90, SBP>150\nHYDROmorphone (Dilaudid) 0.125-1 mg IV Q3H:PRN\nBowel meds\nInsulin sliding scale\nALLERGIES: NKDA\nSOCIAL HISTORY: Unavailable\nFAMILY HISTORY: Unavailable\nREVIEW OF SYSTEMS: Unable to obtain\nPHYSICAL EXAMINATION\nVitals: T: 100.6 degrees Farenheit, BP: 93-120/50s mmHg supine,\nHR 78-80 bpm, CVP 12, RR 24 bpm, O2: 98 % on PSV 13/10 @ 0.5, TV\n~ 500.\nCONSTITUTIONAL: Intubated, sedated.\nEYES: No conjunctival pallor. No icterus.\nENT/Mouth: ETT in place. OP clear.\nTHYROID: No thyromegaly or thyroid nodules.\nCV: Nondisplaced PMI. Normal rate. Regular rhythm. nl S1, S2. No\nextra heart sounds. No appreciable murmurs. No JVD.\nLUNGS: Rhonchorous breath sounds bilaterally.\nGI: NABS. Soft, NT, ND. No HSM. No abdominal bruits.\nMUSCULO: Limited exam. Normal muscle tone.\nHEME/LYMPH: No palpable LAD. + pitting edema. Scrotal edeam\nwith overlying ecchymoses. Full distal pulses bilaterally. SKIN:\nWarm extremities. Significant ecchymoses along trunk.\nNEURO: Sedated.\nPSYCH: Deferred.\nTELEMETRY: Aflutter at 80s. No other events. Not available > 24\nhours ago, but per report, in sinus on .\nECG (): Aflutter with A rate ~300, VR regular at 86 with\n3:1 AV block. L axis. Nonspecific TW flattening inferior leads.\nCompared to prior ECG from , flutter is more organized.\nOne ECG from (5:56) shows atrial tach.\nTRANSTHORACIC ECHOCARDIOGRAM ():\nThe left atrium and right atrium are normal in cavity size. Left\nventricular wall thickness, cavity size and regional/global\nsystolic function are normal (LVEF >55%). Transmitral and tissue\nDoppler imaging suggests normal diastolic function, and a normal\nleft ventricular filling pressure (PCWP<12mmHg). Right\nventricular chamber size is mildly dilated with normal free wall\nmotion. The aortic root is mildly dilated at the sinus level. The\naortic valve leaflets (3) appear structurally normal with good\nleaflet excursion and no aortic stenosis. Trace aortic\nregurgitation is seen. The mitral valve appears structurally\nnormal with trivial mitral regurgitation. There is no mitral\nvalve prolapse. There is mild pulmonary artery systolic\nhypertension. There is no pericardial effusion. Compared with the\nprior study (images reviewed) of , the right\nventricular cavity is now smaller, the severity of tricuspid\nregurgitation is now reduced, and the estimated pulmonary artery\nsystolic pressure is now lower (previously overestimated on\nreview of the prior study).\nOTHER TESTING:\nCXR : The ET tube tip is 6.2 cm above the carina. The NG\ntube tip is in the proximal stomach. The right subclavian line\ntip is at the level of superior SVC. Cardiomediastinal silhouette\nis unchanged as well as there is no change in mild bilateral\npulmonary edema and parenchymal opacities and there is no pleural\neffusion. There is no clear evidence of pneumothorax, although\nminimal amount cannot be excluded on the left. Multiple rib\nfractures are redemonstrated.\nIliac angiography :\n1. Pelvic arteriography: Multiple arteriographic runs performed\nof distal\naorta, external iliac, internal iliac, lateral sacral and\nsuperior gluteal\narteries. Active contrast extravasation noted from branches of\nthe lateral\nsacral artery and superior gluteal arteries. Successful Gelfoam\nembolization\nof lateral sacral artery and branches of the superior gluteal\nartery.\n2. Hepatic angiography: Multiple arteriographic runs of common\nhepatic and\nright hepatic arteries. Some active contrast extravasation was\nnoted from\nperipheral branches of right hepatic artery. Gelfoam embolization\nof distal\nright hepatic artery branches performed.\nCT Head \nThere is no intracranial hemorrhage, edema, shift of normally\nmidline structures or evidence of major vascular territorial\ninfarct. Ventricles and sulci are normal in size and\nconfiguration. The -white matter differentiation is\npreserved. The basilar cisterns are symmetric. A small mucous\nretention cyst, and a small amount of fluid are noted within the\nright maxillary sinus. Remaining paranasal sinuses are well\naerated. Mastoid air cells are well aerated\nCT C spine \n1. No fracture or malalignment of the cervical spine.\n2. Large posterior disc bulge at C4-5, acuity unknown, resulting\nin deformity of the thecal sac. If neural deficits are\nlocalizable to this level, MRI can be obtained to assess for\nspinal cord injury.\n3 Bilateral neural foraminal narrowing.\nCT Chest \n1. Multiple rib fractures bilaterally, including right\nanterolateral and posterior, and left posterior ribs as detailed\nabove.\n2. T4 vertebral body inferior corner fracture, with no\nretropulsion or malalignment. Comminuted spinous process\nfractures between T2 and T8.\n3. Non-displaced left T10 transverse process fracture.\n4. Non-displaced left clavicle and left scapula fractures.\n5. Dependent consolidation in the lungs bilaterally, which could\nbe sequela\nof aspiration, or could reflect contusion.\n6. No acute vascular injury.\n7. Calcified pleura bilaterally suggesting prior asbestos\nexposure.\nCT abdomen \n1. Contusion/laceration of the medial aspect of the right hepatic\nlobe, with adjacent small hematoma, without definite evidence of\nactive bleeding. Associated irregularity of an adjacent branch of\nthe right hepatic artery and resultant narrowing of the adjacent\nright hepatic vein and right posterior portal vein branches.\nPosterior right hepatic laceration/contusion, adjacent to a\ncalcified granuloma, with a small hematoma, without evidence of\nactive\nextravasation.\n2. Comminuted left pubic ramus fracture with associated hematoma,\nwhich has increased in size from the prior study of approximately\nsix hours prior. Tiny focus of arterially enhancing material,\nwhich enlarges on venous and delayed images, concerning for\nactive extravasation.\n3. Minimally displaced, comminuted left iliac bone fracture, with\nadjacent iliac muscle hematoma, largely unchanged from the prior\nstudy, without evidence of active extravasation. Fracture extends\ninto the left sacroiliac joint.\n4. Minimally displaced fracture of the right iliac bone,\nextending to the right sacroiliac joint.\n5. Bilateral comminuted, minimally displaced posterior rib\nfractures of the eighth through eleventh ribs. Nondisplaced left\n10th vertebral body transverse process fracture.\n6. Interval increase in bilateral pleural effusions (small), with\nincreased bilateral atelectasis or consolidation which could be\nthe result of aspiration.\n7. Cirrhotic liver. Fluid around the nondistended gallbladder may\nbe related to liver disease.\nMR T spine \nIMPRESSION:\n1. Mild compression deformity of L1 with additional levels of\npotential trabecular contusion at T10-11 also inferiorly at T4\nwith no retropulsion.\n2. Multilevel degenerative changes with moderate canal narrowing\nat T10-11 with cord deformity and no abnormal cord signal.\n3. Extensive edema throughout the paraspinal soft tissues,\npredominantly posteriorly within the interspinous ligaments.\n4. Incompletely evaluated cervical spine demonstrates severe\ncanal narrowing at C4-5 with cord deformity and no abnormal cord\nsignal.\nLABORATORY DATA: Reviewed in OMR\nASSESSMENT AND PLAN:\n74M no significant PMH, s/p tractor accident with pelvic, spine,\nand rib fractures, liver laceration requiring embolization, and\ncoagulopathy requiring multiple FFP transfusions and hematology\nconsult, who p/w aflutter. Although tele is unavailable from >\n24 hours, he was reportedly in sinus on , and thus has been\nin the sustained rhythm for over 24 hours but probably not > 48\nhours. Despite appropriate rate control, his blood pressure does\nappear to drop with the aflutter, requiring higher doses of the\nneo gtt, which is a little unusual given his fairly normal\nappearing TTE. At this point, he may in fact benefit from being\nin sinus rhythm, but it is unclear 1) that he will remain in SR\nafter cardioversion without additional meds since he apparently\nhad been going in and out of Aflutter over the past week, and 2)\nwhether the risk of thromboembolism after possibly > 48 hours of\nflutter following CV outweighs the benefit of establishing sinus\nrhythm urgently, especially since he is unable to have any\nanticoagulation. As the clinical situation will dictate urgent\ncare, TEE is unlikely to be helpful, and flutter ablation is not\nan option. The etiology of the aflutter is likely increased\ncatechols in the setting of stress, and thus beta blockers might\nbe preferred as an of rate control, although he appears to\nhave good rate control on diltiazem.\nRec:\n--Continue dilt at present dose\n--Continue pain control, supportive measures\n--Consider initiation of amiodarone (1mg/min x 6 hours, then 0.5\nmg/min) if benefit of SR is determined to outweigh the risk of\nthromboembolism; which could be followed by DCCV if necessary,\nbut will d/w attending\nThe Assessment and Plan will be reviewed with Dr. in\nmulti- disciplinary rounds. Please see his/her note in the\n medical record for further comments and\nrecommendations. Thank you for allowing us to participate in the\ncare of this patient. Please feel free to contact us with any\nquestions or concerns.\n"},{"category":"Nursing","chartdate":"2175-02-03 00:00:00.000","description":"Nursing Progress Note","row_id":714710,"text":"Respiratory failure, acute (not ARDS/)\n Assessment:\n Following commands. Mouthing words, but incomprehensible.\n Frequently agitated. Administered Ativan/Midazolam and Zyprexa to\n alleve anxiety. Fair results. BP and anxiety slightly improved.\n Febrile. Treated with Tylenol as ordered. MAE x 4 strongly.\n Remains on CPAP. Strong cough. Lungs clear to rhonchi BL\n in upper airways, diminished in bases. Suctioned thick tan/white\n secretions via trach. O2 sat stable, >=95%.\n Hypertensive at times, especially during agitation. BP\n decreased to 130s post Versed bolus. Pulses palpable.\n Abdomen softly distended, non-tender. Positive BS\n throughout abdomen. Small BM (smear) this am. Tube feeds continued at\n goal of 80cc/hr. Tolerating well with little residual noted.\n Foley catheter draining clear amber urine.\n Skin intact. Ecchymosis noted to right flank. Scrotum with\n severe edema.\n Plan:\n Continue to monitor neuro status with improvement in agitation. Wean\n down PEEP/PS as tolerated.\n"},{"category":"Nursing","chartdate":"2175-01-28 00:00:00.000","description":"Nursing Progress Note","row_id":713929,"text":"74M s/p fall with multiple rib fx, pelvis fx, clavicle fx, and thoracic\n fx c/b unstable bleeding s/p IR embo, AF with RVR, hematologic\n abnomalities.\n Atrial fibrillation (Afib)\n Assessment:\n Remains in 1^st degree HB. HR to 120\ns with agitation, anxiety.\n Action:\n Continues on Fentanyl gtt, Receiving Dilaudid IV and Midazolam for\n pain & agitation.\n Response:\n Good response with meds for pain, agitation, and anxiety.\n Plan:\n Cont to asses rhythm, BP. Metoprolol PRN for HR > 90, SBP > 150\n Respiratory failure, acute (not ARDS/)\n Assessment:\n BBS= essentially clear throughout all lung fields.\n Action:\n Rested overnight on CPAP/PS. Lasix gtt initiated for diuresis.\n Suctioned Q1-2 hrs for moderate amounts thick, pale yellow secretions.\n Klebsiella growing from sputum\n Response:\n Appears comfortable, no SOB noted or increased WOB.\n Plan:\n Goal for pt to be -500cc, will move towards extubation this morning as\n pt tolerates.\n Trauma, s/p\n Assessment:\n Mult echymotic areas over head torso, extremities. Scrotum echymotic,\n edematous.\n Action:\n Managing pain with Fentanyl gtt, Dilaudid & Midazolam IV. Scrotum\n elevated\n Response:\n Currently denies pain.\n Plan:\n Fentanyl gtt overnight. Keep scrotum elevated.\n"},{"category":"Respiratory ","chartdate":"2175-01-29 00:00:00.000","description":"Respiratory Care Shift Note","row_id":713943,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 20 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt cont intub with OETT sedated and on mech vent as per\n Metavision. Lung sounds ess clear after suct mod th yellow sput. ABGs\n stable on current vent settings; no vent changes required overnoc. Cont\n PSV.\n"},{"category":"Nursing","chartdate":"2175-01-29 00:00:00.000","description":"Nursing Progress Note","row_id":713947,"text":"74M s/p fall with multiple rib fx, pelvis fx, clavicle fx, and thoracic\n fx c/b unstable bleeding s/p IR embo, AF with RVR, hematologic\n abnomalities.\n Atrial fibrillation (Afib)\n Assessment:\n Remains in 1^st degree HB. HR to 120\ns with agitation, anxiety.\n Action:\n Continues on Fentanyl gtt, Receiving Dilaudid IV and Midazolam for\n pain & agitation.\n Response:\n Good response with meds for pain, agitation, and anxiety.\n Plan:\n Cont to asses rhythm, BP. Metoprolol PRN for HR > 90, SBP > 150\n Respiratory failure, acute (not ARDS/)\n Assessment:\n BBS= essentially clear throughout all lung fields.\n Action:\n Rested overnight on CPAP/PS. Lasix gtt initiated for diuresis.\n Suctioned Q1-2 hrs for moderate amounts thick, pale yellow secretions.\n Klebsiella growing from sputum\n Response:\n Appears comfortable, no SOB noted or increased WOB.\n Plan:\n Goal for pt to be -500cc, will move towards extubation this morning as\n pt tolerates.\n Trauma, s/p\n Assessment:\n Multiple echymotic areas over head torso, extremities. Scrotum\n echymotic, edematous.\n Action:\n Managing pain with Fentanyl gtt, Dilaudid & Midazolam IV. Scrotum\n elevated\n Response:\n Currently denies pain.\n Plan:\n Fentanyl gtt overnight. Keep scrotum elevated.\n"},{"category":"Physician ","chartdate":"2175-01-31 00:00:00.000","description":"Intensivist Note","row_id":714367,"text":"TSICU\n HPI:\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\n checked and 1.5, 1 more unit FFP given.\n Chief complaint:\n Mult rib fx: R anterolateral and post, L posterior\n T4 vert body inf corner fx\n Commin spinous process fx T2-8\n Nondisplaced L T10 transverse process\n Nondispaced L distal clavicle\n Nondisplaced L clavicle fx\n R medial lobe liver contusion w/hematoma\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny focus of arterial\n bleeding/active extravasation, and larger area of venous bleeding\n Nondisplaced, comminuted L iliac bone fx w/adjacent iliac muscle\n hematoma, extends into L SIJ.\n Minimally displaced fx of R iliac bone extending to R SIJ.\n PMHx:\n PMH: None\n PSH: None\n Current medications:\n 1. IV access: Peripheral line Order date: @ 2329 16. Ketamine\n Study Drug Study Med 1 dose IV AS SIR Duration: 24 Hours\n Patient to receive Ketamine/Placebo 0.25mg/kg bolus over 1 hour\n followed by 0.1mg/kg/hr for 23 hours Order date: @ 1338\n 2. Acetaminophen 650 mg PO/NG Q6H:PRN pain Order date: @ 2329\n 17. Lorazepam 2mg Syringe Study Med 1 mg IV Q6H Duration: 4 Doses\n Patient to receive Lorazepam 1mg iv every 6 hours for 4 doses while on\n ketamine study drug Order date: @ 1338\n 3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation Order date: @\n 0823 18. Magnesium Sulfate IV Sliding Scale Order date: @ 2339\n 4. Calcium Gluconate IV Sliding Scale Order date: @ 1657 19.\n Metoprolol Tartrate 5 mg IV Q4H:PRN hr>90, SBP>150\n hold hr<60, SBP<100 Order date: @ 1809\n 5. CeftriaXONE 1 gm IV Q24H Order date: @ 1228 20. Midazolam\n 0.5-1 mg IV Q2H:PRN sedation Order date: @ 0912\n 6. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL Order date:\n @ 2329 21. Midazolam 0.5-10 mg/hr IV DRIP TITRATE TO sedation\n Patient must have adequate airway support prior to administration of\n dose. Order date: @ 0734\n 7. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date: \n @ 0104 22. Ondansetron 4 mg IV Q8H:PRN nausea Order date: @ 2329\n 8. Diltiazem 60 mg PO/NG QID\n hold for HR < 60 or SBP < 100 Order date: @ 23.\n Pantoprazole 40 mg IV Q24H Order date: @ 1321\n 9. Docusate Sodium (Liquid) 100 mg PO/NG Order date: @ 2329\n 24. Phenylephrine 0.5-5 mcg/kg/min IV DRIP TITRATE TO SBP>90 MAP>60\n Order date: @ 2339\n 10. Fentanyl Citrate 25-100 mcg/hr IV DRIP INFUSION\n Please wean with Dilaudid dosing. Thank you. Order date: @ 1136\n 25. Pneumococcal Vac Polyvalent 0.5 ml IM ASDIR Order date: @\n 2316\n 11. Gabapentin 400 mg PO/NG TID Order date: @ 1210 26. Potassium\n Phosphate IV Sliding Scale\n Infuse over 6 hours Order date: @ 2339\n 12. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date:\n @ 0104 27. Potassium Chloride IV Sliding Scale Order date: \n @ 2339\n 13. HYDROmorphone (Dilaudid) 0.125-1 mg IV Q3H:PRN pain Order date:\n @ 0912 28. Senna 1 TAB PO/NG :PRN constipation Order date:\n @ 0823\n 14. Heparin 5000 UNIT SC TID Order date: @ 0931 29. Sodium\n Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ 2329\n 15. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 0104 30. Vancomycin 1000 mg IV\n Q 12H\n ID Approval will be required for this order in 39 hours. Order date:\n @ \n 24 Hour Events:\n Placed on ketamine for study. Continues to be in aflutter and on Neo,\n difficulties weaning, however when pt more awake (ie: turning), he is\n actually HTN. TTE done showing mild TR. RUQ U/S showing mild\n perihepatic fluid collection too small to be drained.\n Post operative day:\n POD#5 - IVC filter via L groin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\n Ceftriaxone - 12:00 PM\n Vancomycin - 08:36 PM\n Infusions:\n Fentanyl (Concentrate) - 100 mcg/hour\n Ketamine - 0.1 mcg/Kg/min\n Phenylephrine - 1.2 mcg/Kg/min\n Midazolam (Versed) - 0.5 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 02:00 PM\n Heparin Sodium (Prophylaxis) - 08:29 PM\n Midazolam (Versed) - 01:15 AM\n Fentanyl - 01:20 AM\n Lorazepam (Ativan) - 02:09 AM\n Other medications:\n Flowsheet Data as of 04:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.2\nC (100.7\n T current: 37.9\nC (100.3\n HR: 78 (75 - 91) bpm\n BP: 103/51(69) {89/48(62) - 152/66(94)} mmHg\n RR: 28 (16 - 29) insp/min\n SPO2: 98%\n Heart rhythm: A Flut (Atrial Flutter)\n Wgt (current): 102 kg (admission): 90 kg\n CVP: 11 (9 - 17) mmHg\n Total In:\n 3,764 mL\n 418 mL\n PO:\n Tube feeding:\n 1,920 mL\n 255 mL\n IV Fluid:\n 1,384 mL\n 163 mL\n Blood products:\n Total out:\n 1,535 mL\n 245 mL\n Urine:\n 1,530 mL\n 245 mL\n NG:\n 5 mL\n Stool:\n Drains:\n Balance:\n 2,229 mL\n 173 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 431 (399 - 596) mL\n PS : 10 cmH2O\n RR (Spontaneous): 25\n PEEP: 10 cmH2O\n FiO2: 50%\n PIP: 20 cmH2O\n SPO2: 98%\n ABG: 7.41/56/91./32/8\n Ve: 11.7 L/min\n PaO2 / FiO2: 184\n Physical Examination\n General Appearance: Overweight / Obese\n Cardiovascular: (Rhythm: No(t) Regular, Irregular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: No(t)\n Crackles : , Rhonchorous : bilaterally)\n Abdominal: Soft, Obese, right flank, right pelvis, and scrotum\n eechymotic\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Skin: right flank, right pelvis, and scrotum eechymotic\n Neurologic: Sedated\n Labs / Radiology\n 153 K/uL\n 10.7 g/dL\n 117 mg/dL\n 0.7 mg/dL\n 32 mEq/L\n 3.9 mEq/L\n 22 mg/dL\n 106 mEq/L\n 143 mEq/L\n 32.1 %\n 8.8 K/uL\n [image002.jpg]\n 02:55 AM\n 04:11 AM\n 09:45 AM\n 04:45 PM\n 12:45 AM\n 01:00 AM\n 05:12 AM\n 02:40 PM\n 01:46 AM\n 01:55 AM\n WBC\n 6.5\n 13.1\n 8.8\n Hct\n 29.3\n 31.6\n 32.1\n Plt\n 86\n 158\n 153\n Creatinine\n 0.8\n 0.8\n 0.7\n 0.7\n TCO2\n 38\n 37\n 35\n 35\n 34\n 37\n Glucose\n 141\n 107\n 131\n 115\n 132\n 122\n 117\n Other labs: PT / PTT / INR:13.7/27.6/1.2, CK / CK-MB / Troponin\n T:128/13/<0.01, ALT / AST:81/93, Alk-Phos / T bili:84/5.8, Amylase /\n Lipase:44/, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic Acid:1.4\n mmol/L, Albumin:2.7 g/dL, LDH:348 IU/L, Ca:8.0 mg/dL, Mg:2.0 mg/dL,\n PO4:3.3 mg/dL\n Imaging: CXR: Cardiac size top nl, interval improvement of\n collapse LLL. Collapse RLL. Atelectasis in lingula unchanged. Mod B\n pleural effusions stable. No PTX.\n CXR: Interval mild incr in cardiac size, b/l pleural effusions,\n and opacities @ bases,c/w overload\n : R foot: Linear density projecting @ expected area of insertion\n of the Achilles to calcaneus, may be min avulsion fx or degenerative\n changes. Otherwise no fx\n CXR: b/l pleural effusions\n CXR: stable.\n RUQ U/S: No perihepatic fluid collection. small amt perihepatic\n free fluid persists. Small contusion in hepatic segment VII. No\n gallstones or significant wall thickening/edema. CBD 4.5 mm\n TTE: LVEF >55%, normal diastolic function, normal left\n ventricular filling pressure (PCWP<12mmHg), Right ventricular chamber\n size is mildly dilated, mild TR\n Microbiology: Ucx no growth final\n Sputum: sparse GNRs, too few to colonize\n Bcx P\n Bcx P\n 12/17 L BAL: Klebsiella Pneumoniae, HAEMOPHILUS SPECIES NOT INFLUENZAE\n R BAL: Klebsiella Pneumoniae, Proteus.\n 12/20 L BAL: gram + cocci pairs on gram stain, GNRs (sparse) on cx\n R BAL: gram + cocci pairs on gram stain, GNRs (10-100K) on cx\n BCX: p\n BCx: P\n UCx: no growth final\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, now\n with AF with RVR/Aflutter, hypotension and presumed PNA.\n Neurologic: Intubated on Fentanyl/Versed gtt. Per ortho spine, no\n surgery; HOB<30, TLSO when OOB (NEOPS will place).\n Neuro checks Q: shift\n Pain: Fentanyl gtt (trying to wean), dilaudid, Midazolam gtt\n switch\n to Precidex. Also on Neurontin, Tylenol\n Cardiovascular: Aflutter on Dilt 60mg PO QID. Reamins o vasopressor\n support (Neo at 1). TTE without e/o cardiac dysfunction. ScVO2 68 so\n cardiogenic shock unlikely. Cortisol 17 which is borderline, although\n scenario not classic for adrenal insufficiency. ? sedation related so\n switch to precidex. Weaning Neo today. .\n Pulmonary: Intubated. Weaning vent. On appropriate abx per BAL cx\n -Vanco and Ceftriaxone. Will need Trach this week.\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin with CT scan\n suggesting cirrhosis - Hepatitis panel NEG. TFs advancing to goal.\n Bowel regimen.\n Nutrition: Tube feeding\n Renal: Foley, monitor UOP.\n Hematology: Hct stable. Plt low but stable (100's); d/c'd H2B with\n increasing plt count. Heme onc consulted - smear nl; no hemolysis. IVC\n filter placed.\n Endocrine: RISS, goal BS<150.\n Infectious Disease: Check cultures, WBC normal, f/u Cx - BAL:\n Klebsiella (b/l)& GNRs (on R)/Haemophilus (on L). Klebsiella\n Pneumoniae, Proteus/Haemophilus. Repeat BAL with gram+ cocci in\n pairs on gram stain, GNRs.\n Lines / Tubes / Drains: R SC CVL (), PIV x2, Foley, L a-line\n (), ETT\n Wounds:\n Imaging: CXR today\n Fluids: KVO\n Consults: Trauma (1o), Ortho Spine, Ortho trauma, Heme\n Billing Diagnosis: Multiple injuries (Trauma)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 04:41 PM\n Arterial Line - 11:30 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin, IVC filter\n Stress ulcer: PPI (? H2B-related thrombocytopenia)\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 32 min\n"},{"category":"Nursing","chartdate":"2175-02-02 00:00:00.000","description":"Nursing Progress Note","row_id":714601,"text":"74M s/p crushing injury d/t falling tree. Injuries sustained include\n multiple R sided rib fxs, grade 2 liver lac (w/ assoc hepatic vessel\n extravasation), stable pelvis fxs (w/ associated extravasation), R\n ramus fx, clavicle fx, and T4 vertebral body fx. Episodes of A.\n Flutter with RVR and aflutter, now with resp failure and newly dx\n pneumonia as of .\n intubated for resp distress\n angio embolization of hepatic and pelvic arterial bleeders\n IVC filter in OR\n self extubated and re-intubated immediately after d/t acute resp.\n failure\n Trach and PEG at bedside\n Atrial fibrillation (Afib)\n Assessment:\n Pt converted to NSR @ 1900 w/ rate 80s-100s.\n Action:\n PO dilt, amioderone gtt continued\n Neo gtt weaned off\n Response:\n HR & BP remain well controlled.\n Plan:\n Continue Amio gtt, switch to PO amio, ? Anticoagulant.\n Monitor hemodynamics, monitor BP\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt w/ trach on CPAP/PS 10/10/50%. LS rhonchorous throughout. Strong\n productive cough, large amounts of thick blood tinged secretions. ABG\n stable. VSS. Low grade temps. WBC 5.9\n Action:\n Pulm hygiene, suction PRN\n Ceftriaxone admistered for pna\n Response:\n Exam unchanged.\n Plan:\n Wean vent settings as tolerated, pulmonary toileting, wean\n sedation.\n"},{"category":"Respiratory ","chartdate":"2175-02-03 00:00:00.000","description":"Respiratory Care Shift Note","row_id":714815,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 10\n Airway\n Known difficult intubation: Yes\n Tracheostomy tube:\n Type: Standard, Cuffed\n Manufacturer: Portex\n Size: 8.0mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"},{"category":"Physician ","chartdate":"2175-02-04 00:00:00.000","description":"Intensivist Note","row_id":714875,"text":"TSICU\n HPI:\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\n checked and 1.5, 1 more unit FFP given.\n Chief complaint:\n Mult rib fx: R anterolateral and post, L posterior\n T4 vert body inf corner fx\n Commin spinous process fx T2-8\n Nondisplaced L T10 transverse process\n Nondispaced L distal clavicle\n Nondisplaced L clavicle fx\n R medial lobe liver contusion w/hematoma\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny focus of arterial\n bleeding/active extravasation, and larger area of venous bleeding\n Nondisplaced, comminuted L iliac bone fx w/adjacent iliac muscle\n hematoma, extends into L SIJ.\n Minimally displaced fx of R iliac bone extending to R SIJ.\n PMHx:\n PMH: cirrhosis and asbestosis dx on CT\n PSH: None\n Current medications:\n 1. 2. 3. Acetaminophen 4. Amiodarone 5. Bisacodyl 6. Calcium Gluconate\n 7. CefePIME 8. Chlorhexidine Gluconate 0.12% Oral Rinse\n 9. Ciprofloxacin HCl 10. Dextrose 50% 11. Diltiazem 12. Docusate Sodium\n (Liquid) 13. Furosemide\n 14. Gabapentin 15. Glucagon 16. Haloperidol 17. Haloperidol 18. Heparin\n 19. Insulin 20. Lactulose\n 21. Lansoprazole Oral Disintegrating Tab 22. Magnesium Sulfate 23.\n Metoprolol Tartrate 24. Metoprolol Tartrate\n 25. Milk of Magnesia 26. Olanzapine (Disintegrating Tablet) 27.\n Ondansetron 28. OxycoDONE Liquid\n 29. Pneumococcal Vac Polyvalent 30. Potassium Phosphate 31. Potassium\n Chloride 32. Senna 33. Sodium Chloride 0.9% Flush\n 34. Sodium Chloride 0.9% Flush 35. Vancomycin\n 24 Hour Events:\n Back to Aflutter with HR in 120's. Stable BP. Given Lopressor with\n adequate rate control but no conversion. Eventually placed on a Dilt\n gtt. Pt converted to NSR. Maintained on Amio PO. TF switched to\n Nutren 2 in order to limit fluids, pt getting Lasix 20 q6 with net neg\n of 1500 cc. US of LE done to r/o clot as cause of fever.\n Post operative day:\n POD#9 - IVC filter via L groin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 03:00 PM\n Vancomycin - 08:09 PM\n Ciprofloxacin - 10:08 PM\n Cefipime - 12:00 AM\n Infusions:\n Other ICU medications:\n Midazolam (Versed) - 12:45 PM\n Lorazepam (Ativan) - 01:39 PM\n Metoprolol - 01:54 PM\n Furosemide (Lasix) - 06:52 PM\n Heparin Sodium (Prophylaxis) - 08:09 PM\n Other medications:\n Flowsheet Data as of 05:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.9\nC (100.3\n T current: 37.7\nC (99.8\n HR: 96 (75 - 125) bpm\n BP: 132/60(83) {121/51(73) - 169/88(115)} mmHg\n RR: 16 (16 - 33) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 104.2 kg (admission): 90 kg\n CVP: 19 (17 - 19) mmHg\n Total In:\n 2,563 mL\n 512 mL\n PO:\n Tube feeding:\n 1,482 mL\n 211 mL\n IV Fluid:\n 821 mL\n 300 mL\n Blood products:\n Total out:\n 4,060 mL\n 635 mL\n Urine:\n 4,055 mL\n 635 mL\n NG:\n 5 mL\n Stool:\n Drains:\n Balance:\n -1,497 mL\n -123 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 554 (380 - 554) mL\n PS : 15 cmH2O\n RR (Spontaneous): 18\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 27 cmH2O\n SPO2: 99%\n ABG: 7.53/39/124/33/9\n Ve: 14.2 L/min\n PaO2 / FiO2: 248\n Physical Examination\n General Appearance: Overweight / Obese, Tracheostomy\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : , Crackles : b/l bases)\n Abdominal: Soft, Non-tender, Obese\n Left Extremities: (Edema: 1+), (Temperature: Warm)\n Right Extremities: (Edema: 1+), (Temperature: Warm)\n Skin: Jaundice\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities, Pt appears to be confused this AM.\n Labs / Radiology\n 124 K/uL\n 9.3 g/dL\n 103 mg/dL\n 0.8 mg/dL\n 33 mEq/L\n 3.9 mEq/L\n 21 mg/dL\n 107 mEq/L\n 144 mEq/L\n 29.0 %\n 6.5 K/uL\n [image002.jpg]\n 01:00 AM\n 01:07 AM\n 01:18 AM\n 02:05 AM\n 03:54 AM\n 05:17 AM\n 01:23 PM\n 07:20 PM\n 12:35 AM\n 01:04 AM\n WBC\n 5.9\n 6.3\n 6.5\n Hct\n 31.3\n 28.9\n 29.0\n Plt\n 109\n 128\n 124\n Creatinine\n 0.8\n 0.8\n 0.8\n 0.8\n TCO2\n 35\n 34\n 35\n 34\n Glucose\n 117\n 110\n 138\n 136\n 130\n 103\n Other labs: PT / PTT / INR:13.7/27.6/1.2, CK / CK-MB / Troponin\n T:128/13/<0.01, ALT / AST:90/122, Alk-Phos / T bili:133/5.4, Amylase /\n Lipase:54/52, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic\n Acid:1.4 mmol/L, Albumin:2.3 g/dL, LDH:348 IU/L, Ca:7.7 mg/dL, Mg:2.2\n mg/dL, PO4:2.7 mg/dL\n Imaging: RUQ U/S: No perihepatic fluid collection. small amt\n perihepatic free fluid persists. Small contusion in hepatic segment\n VII. No\n gallstones or sig wall thickening/edema. CBD 4.5 mm\n TTE: LVEF >55%, NL diastolic function, NL LV filling pressure\n (PCWP<12mmHg), RV chamber size mildly dilated, mild TR\n CXR: mild b/l pulm edema and parenchymal opacities and no\n pl effusion.\n CXR: Persistent b/l pl effusions and bibasilar opacity.\n CXR: Minimal improvement of mod b/l pl effusions. Otherwise\n stable.\n CXR: no relevant change. B/L pleural effusions with basal\n opacities. No evidence of newly appeared focal parenchymal opacities\n suggesting pneumonia.\n : No dvt\n Microbiology: Ucx no growth final\n Sputum: sparse GNRs, too few to colonize\n Bcx x2 no growth final\n 12/17 L BAL: Klebsiella Pneumoniae, HAEMOPHILUS SPECIES NOT INFLUENZAE\n R BAL: Klebsiella Pneumoniae, Proteus.\n 12/20 L &R BAL: Klebsiella Pneumoniae\n BCX: p\n BCx: P\n UCx: no growth final\n BCx: P\n BCx: P\n UCx: P\n SpCx: contamination\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, now\n with AF with RVR/Aflutter, persistant hypotension and PNA.\n Neurologic: Neuro checks Q: 4 hr, s/p trach (). Per ortho spine,\n no surgery; HOB<30, TLSO when OOB. Zyprexa & Haldol PRN (off fent/midaz\n ).\n Pain: Oxycodone, Neurontin, Tylenol.\n Cardiovascular: Aflutter->NSR, on Amio and dilt gtt, will need to\n transition to PO meds. Likely cardiac contusion. Cards for Amio rec\n 400'' x 1wk, then 400'x1 wk, then 200'. Pt cannot be fully\n anticoagulated for now (trauma).\n Pulmonary: Trach, Trach, weaning vent, Vanc/cipro/cefepime for VAP\n (). Increasing pulmonary edema on CXR. consider therapeutic\n thoracentesis 12/26-7 if no improvement on Lasix, lots of secretions,\n consider bronchoscopy\n Gastrointestinal / Abdomen: Unknown elevated LFTs and bilirubin w/CT\n scan suggesting cirrhosis - Hepatitis panel NEG, RUQ U/S r/o\n gallbladder etiology, will continue to trend. On Nutren 2.0 with goal\n 40 cc/hr. Bowel regimen.\n Nutrition: Tube feeding\n Renal: Foley, Foley, monitor UOP, edematous scrotum. Lasix 20 Q6,\n developing contraction alk, consider switching to acetazolamide\n Hematology: Hct stable 28.9->29. Plt stable (100's); d/c'd H2B. Heme\n onc c/s - smear nl; no hemolysis. IVC filter placed.\n Endocrine: RISS, RISS\n Infectious Disease: Check cultures, WBC normal, on Vanc/cipro/cefepime\n for VAP given worsening pulm status, f/u on cx\n Lines / Tubes / Drains: Trach/Peg/foley/L radial a-line/R SCL\n Wounds:\n Imaging: CXR today\n Fluids: KVO\n Consults: Trauma (1o), Ortho Spine, Ortho trauma, Heme\n Billing Diagnosis: Multiple injuries (Trauma)\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 01:00 PM 40 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 04:41 PM\n Arterial Line - 11:30 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin, IVC filter\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent:\n"},{"category":"Nursing","chartdate":"2175-01-30 00:00:00.000","description":"Nursing Progress Note","row_id":714091,"text":"74M s/p crushing injury d/t falling tree. Injuries sustained include\n multiple R sided rib fxs, grade 2 liver lac (w/ assoc hepatic vessel\n extravasation), stable pelvis fxs (w/ associated extravasation), R\n ramus fx, clavicle fx, and T4 vertebral body fx. Episodes of AF with\n RVR and aflutter, hematologic abnormalities, now with resp failure and\n newly dx pneumonia as of .\n intubated for resp distress\n angio embolization of hepatic and pelvic arterial bleeders\n IVC filter in OR\n self extubated and reintubated immediately after d/t acute resp\n failure\n Atrial fibrillation (Afib), aflutter\n Assessment:\n Pt in and out of aflutter with controlled rate on dilt drip,\n predominently aflutter. Hypotensive w/ sbp 80\ns while in aflutter.\n Action:\n Dilt weaned off, po dose increased. Lytes followed, stable. Neo gtt\n to support sbp titrated to map >60 and sbp >100. Pt on low dose midaz\n gtt along with fentanyl for sedation.\n Response:\n Converts to longer periods of NSR w/ higher po dilt dose, drip remains\n off, rate holding 80s. Rate well controlled but remains Neo\n dependent. Tolerating sedation titrated to lowest dose to keep\n comfortable and safe.\n Plan:\n Cont to monitor hemodynamics. Wean neo gtt as tolerated. Cont dilt\n gtt. Optimize lytes ongoing. Cardiology consult in am to determine\n need for amio vs. cardioversion to further manage aflutter.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains fully vented after reintubation yest morning. AC mode, 550x15,\n 50% and 10 peep. Stable abg, improved p02. O2sat 96-98%. Moderate\n amt thick, yellow tenacious secretions. LS coarse, clearing w/\n suctioning. Note: upon reintubation pt found to have signif airway\n edema, required bougie catheter for reintubation).\n Action:\n Remains intubated on ac mode, see settings above, tol well. Pulm\n toileting per routine.\n Response:\n Abg acceptable, note compensated metabolic alkalosis. Pao2 improved on\n higher peep. LS improved as well, clearer, remain diminished,\n especially to R sided fields.\n Plan:\n Cont vanco for pneumonia coverage, await ID approval for zosyn. Pulm\n toilet. Maintain sedated for safety and comfort. Pt may benefit from\n trach in the short term if continuing to require vent support w/\n difficulty weaning.\n Trauma, s/p\n Assessment:\n As above, pt s/p liver laceration and resultant angio procedure to\n embolize few hepatic vessels. LFTs continue to be elevated, although\n slowly improving. Urine icteric, clear.\n Action:\n Following LFTs, hct, coags. Monitor s/s bleeding, visual signs of\n jaundice.\n Response:\n As of this am, enzymes remain elevated, await indirect/direct bili\n levels.\n Plan:\n Continue to follow LFTs, coags, hct, serial belly assessments, s/s\n bleeding.\n"},{"category":"Respiratory ","chartdate":"2175-02-04 00:00:00.000","description":"Respiratory Care Shift Note","row_id":714865,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 11\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes:\n Tube Type\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 8.0mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: PS had to be increased to 15 overnight due to pt tachypnea\n and high BP's and HR\n Assessment of breathing comfort: No claim of dyspnea)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated, Reduce PEEP as tolerated; Comments: wean as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Underlying illness not resolved\n"},{"category":"Nursing","chartdate":"2175-02-04 00:00:00.000","description":"Nursing Progress Note","row_id":714870,"text":"Atrial fibrillation (Afib)\n Assessment:\n Aflutter 70\n 100\ns w/ occasional pvc\ns. Stable bp,\n Action:\n Cont on po amioderone and iv dilt gtt. Lytes repleted.\n Response:\n Converted to nsr w/ occasional pvc\ns. Stable bp.\n Plan:\n Cont to monitor. Change over to po Diltiazem ATC. Wean dilt gtt.\n Cont po amioderone. Replete lytes.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2175-02-04 00:00:00.000","description":"Nursing Progress Note","row_id":714876,"text":"Atrial fibrillation (Afib)\n Assessment:\n Aflutter 70\n 100\ns w/ occasional pvc\ns. Stable bp,\n Action:\n Cont on po amioderone and iv dilt gtt. Lytes repleted.\n Response:\n Converted to nsr w/ occasional pvc\ns. Stable bp.\n Plan:\n Cont to monitor. Change over to po Diltiazem ATC. Wean dilt gtt.\n Cont po amioderone. Replete lytes.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains on PSV. LS rhonci, diminished bilat. Cont w/ copious\n secretions, thick yellow. Stable 02sats. Increasing tachypnea and\n restlessness overnoc. Tmax 100.3 Fluid balance positive for length\n of stay.\n Action:\n Pulm toilet. Increased psv from . Con on iv Vanco, cefepime and\n po cipro. Lasix at 1900 and cont w/ brisk u/o. Lasix held at mn.\n Given haldol and zyprexa for restlessness and oxycodone x1 for pain.\n Response:\n Cont with copious secretions but w/ strong cough. Less agitated but\n still restless after haldol and zyprexa. No sleep. Persistent\n metabolic alkalosis.\n Plan:\n Cont to monitor and cont aggressive pulm toilet. Titrate ventilatory\n support as needed. Monitor abg\ns and 02sats. ?diamox for alkalosis.\n Decrease frequency of lasix. Replete lytes. Cont zyprexa and haldol\n as needed. Pain control. Cont pt and family support.\n"},{"category":"Respiratory ","chartdate":"2175-01-27 00:00:00.000","description":"Respiratory Care Shift Note","row_id":713715,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated\n Plan\n Next 24-48 hours: Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n OR\n 2200\n"},{"category":"Nursing","chartdate":"2175-01-27 00:00:00.000","description":"Nursing Progress Note","row_id":713716,"text":"Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient intubated on CMV 18 x 440. 50%. PEEP 14. Sats 100%. LS clear\n to diminished.\n Action:\n Pulmonary hygiene.\n Response:\n Suctioned for small amounts of thick, yellow secretions. ABG WNL.\n Diminished on R side.\n Plan:\n Continue to monitor respiratory status. Wean vent as tolerated.\n Monitor ABG. Pulmonary hygiene.\n Trauma, s/p\n Assessment:\n Patient sedated on propofol and fentanyl drip. When lightened, patient\n opens eyes to voice and follows commands. MAE on bed. Denies pain.\n Bolus prior to turns. Sent to OR for IVC filter placement. Dsg to L\n groin c/d/i.\n TF restarted post-op.\n Action:\n Monitored CSM of LLE. TF advanced per orders.\n Response:\n No change. TF currently at 20cc/hr.\n Plan:\n Continue to monitor CSM to LLE. Advance TF as ordered/tolerated.\n Assess for pain, titrate fentanyl drip as indicated.\n Atrial fibrillation (Afib)\n Assessment:\n Patient in atrial flutter, HR 70-80s. MAP > 65 on phenylephrine drip.\n PVCs rare.\n Action:\n Diltiazem drip at 5mg/hr, held at . Phenylephrine drip at\n 1.25mcg/kg/min. Patient sent to OR for IVC filter.\n Response:\n Patient hypertensive post-op. Phenylephrine drip weaned to\n 0.5mcg/kg/min. Dilitiazem drip restarted for tachycardia (HR 110\n At 0400, patient converted to sinus bradycardia. Diltiazem drip\n currently off.\n Plan:\n Continue to monitor rhythm. Treat as indicated. Wean phenylephrine as\n tolerated.\n"},{"category":"Nursing","chartdate":"2175-01-28 00:00:00.000","description":"Nursing Progress Note","row_id":713928,"text":"74M s/p fall with multiple rib fx, pelvis fx, clavicle fx, and thoracic\n fx c/b unstable bleeding s/p IR embo, AF with RVR, hematologic\n abnomalities.\n Atrial fibrillation (Afib)\n Assessment:\n Remains in 1^st degree HB. HR to 120\ns with agitation, anxiety as well\n as when sast were dropping to high 80\ns on PS 5, PEEP 5 for several\n hours. Neo off since approx 070\n Action:\n Fentanyl gtt increased, Dilaudid IV m I Midazolam for pain & agitation.\n PS, PEEP increased Lasix 10 mg at 1815.\n Response:\n Good response with meds for pain, agitation, and anxiety. Good response\n with increased vent support.\n Plan:\n Rest on PS 10, PEEP 10 overnight. Start lasix gtt for goal equal to\n 500 cc negative at MN. Cont to asses rhythm, BP. Metoprolol PRN for HT\n > 90, SBP > 150\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Put on PS5, PEEP 5. Suctioned Q1-2 rhs for moderate amounts thick, pale\n yellow secretions this afternoon. Klebsiella growing from sputum\n Action:\n Increased PS 10, PEEP 10 when sats dropping to high 80\n Response:\n Sats improved with increased PS as well as HR, BP\n Plan:\n rest on current vent settings overnight. Asse\n Trauma, s/p\n Assessment:\n Mult echymotic areas over head torso, extremities. Scrotum echymotic,\n edematous. On fent gtt.\n Action:\n Transiently able to decrease fent gtt to 25 mcg hr after starting\n Dilaudid & Midazolam IV. Scrotum elevated\n Response:\n Fent back to 100 mc&pain management. Currently denies pain.\n Plan:\n Fentanyl gtt overnight. Keep scrotum elevated.\n"},{"category":"Physician ","chartdate":"2175-01-29 00:00:00.000","description":"Intensivist Note","row_id":714002,"text":"TSICU\n HPI:\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\n checked and 1.5, 1 more unit FFP given.\n Chief complaint:\n polytrauma\n PMHx:\n none\n Current medications:\n Acetaminophen 3. Bisacodyl 4. CeftriaXONE 5. Chlorhexidine Gluconate\n 0.12% Oral Rinse 6. Dextrose 50% 7. Diltiazem 8. Docusate Sodium\n (Liquid) 9. Fentanyl Citrate 10. Furosemide 11. Furosemide 12.\n Gabapentin\n 13. Glucagon 14. HYDROmorphone (Dilaudid) 15. Insulin 16. Magnesium\n Sulfate 17. Metoprolol Tartrate 18. Midazolam 19. Omeprazole 20.\n Ondansetron 21. Phenylephrine 22. Pneumococcal Vac Polyvalent 23.\n Potassium Phosphate\n 24. Potassium Chloride 25. Propofol 26. Senna 27. Sodium Chloride 0.9%\n Flush\n 24 Hour Events:\n : agitated w/HTN, tachycardia, incr fent/midaz w/some resolution.\n weaned cpap to -->desat-->incr to & improved hr & BP. started\n dilaudid, incr neurontin 300''', d/c'd H2B decr plt. lasix bolus\n 10, gtt. R ankle films (ecchymosis/edema) WNL. BAL: KLEBSIELLA\n PNEUMONIAE & GNRs-ceftriaxone started.\n Before rounds this AM, pt self-extubated using his tongue (hands were\n restrained), emergently re-intubated for resp distress and hypoxia.\n Post operative day:\n POD#3 - IVC filter via L groin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Furosemide (Lasix) - 5 mg/hour\n Fentanyl (Concentrate) - 50 mcg/hour\n Other ICU medications:\n Fentanyl - 02:15 PM\n Furosemide (Lasix) - 06:19 PM\n Labetalol - 07:00 PM\n Midazolam (Versed) - 04:00 AM\n Hydromorphone (Dilaudid) - 04:00 AM\n Other medications:\n Flowsheet Data as of 06:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.2\nC (99\n T current: 36.9\nC (98.4\n HR: 98 (79 - 127) bpm\n BP: 105/51(69) {91/41(58) - 185/74(110)} mmHg\n RR: 0 (0 - 26) insp/min\n SPO2: 95%\n Heart rhythm: 1st AV (First degree AV Block)\n Wgt (current): 102 kg (admission): 90 kg\n CVP: 8 (6 - 15) mmHg\n Total In:\n 1,861 mL\n 741 mL\n PO:\n Tube feeding:\n 1,330 mL\n 521 mL\n IV Fluid:\n 221 mL\n 160 mL\n Blood products:\n Total out:\n 2,010 mL\n 1,195 mL\n Urine:\n 2,010 mL\n 1,195 mL\n NG:\n Stool:\n Drains:\n Balance:\n -149 mL\n -454 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 540 (456 - 634) mL\n PS : 5 cmH2O\n RR (Spontaneous): 14\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 34\n PIP: 11 cmH2O\n SPO2: 95%\n ABG: 7.42/56/114/33/10\n Ve: 8 L/min\n PaO2 / FiO2: 285\n Physical Examination\n General Appearance: No acute distress, Well nourished; intubated on\n vent.\n HEENT: EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: bibasilar)\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present, Obese\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities, Sedated\n Labs / Radiology\n 86 K/uL\n 10.1 g/dL\n 141 mg/dL\n 0.8 mg/dL\n 33 mEq/L\n 3.6 mEq/L\n 19 mg/dL\n 106 mEq/L\n 143 mEq/L\n 29.3 %\n 6.5 K/uL\n [image002.jpg]\n 05:24 AM\n 06:50 AM\n 02:40 PM\n 03:13 PM\n 01:59 AM\n 02:00 AM\n 11:04 AM\n 01:17 PM\n 02:55 AM\n 04:11 AM\n WBC\n 11.0\n 8.0\n 5.6\n 6.5\n Hct\n 30.1\n 29.8\n 28.7\n 29.3\n Plt\n 97\n 80\n 74\n 86\n Creatinine\n 0.8\n 0.8\n 0.8\n TCO2\n 30\n 33\n 35\n 34\n 34\n 38\n Glucose\n 133\n 125\n 128\n 141\n Other labs: PT / PTT / INR:12.9/26.8/1.1, CK / CK-MB / Troponin\n T:1334/13/<0.01, ALT / AST:109/96, Alk-Phos / T bili:66/3.6, Amylase /\n Lipase:44/, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic Acid:1.4\n mmol/L, Albumin:2.7 g/dL, LDH:435 IU/L, Ca:7.7 mg/dL, Mg:1.9 mg/dL,\n PO4:3.0 mg/dL\n Imaging: CT head OSH: Prelim No ICH or fx.\n CT chest OSH: Mult rib fx: R anterolateral and posterior, L\n posterior; Dependent consolidation, possible aspiration; T4 vertebral\n body inf corner fx, no retropulsion; Comminuted spinous process fx\n T2-8; Nondisplaced L T10 transverse process; Nondisplaced L clavicle\n distal fx; Nondisplaced L scapula fx;\n CT c spine OSH: Prelim No fx or malalignment. Multilevel\n degenerative changes w/large post disk bulge at C4-5, narrowing the\n spinal canal and deforming the thecal sac, acuity unknown. Marked\n neuroforamenal narrowing @multiple levels.\n CTA abd/pel Prelim: Medial R liver lobe contusion w/adj\n hematoma, w/o evidence of active bleeding; Comminuted L pubic ramus\n fracture w/assoc hematoma, with tiny focus of arterial bleeding/active\n extravasation, and larger area of venous bleeding. Hematoma somewhat\n larger than on OSH study. Nondisplaced, comminuted L iliac bone fx\n w/adj iliac muscle hematoma, larger than on prior study, w/o active\n extrav. Fx extends into L SIJ. Post R hepatic laceration/contusion\n adjacent to calcified granuloma, w/small hematoma, w/out active\n bleeding. Min displaced fx of R iliac bone extending to R SIJ.\n Cirrhotic liver. Inc B pl effusions (small), w/inc atelectasis.\n MRI: Mild compression deformity of L1 w/additional levels of\n potential trabecular contusion @T10-11 also inf @T4 w/o retropulsion.\n Multilevel degenerative changes with moderate canal narrowing at T10-11\n w/cord deformity and no abnormal cord signal. Extensive edema\n throughout paraspinal soft tissues, predominantly post w/in\n interspinous ligaments. Incompletely eval'ed c-spine w/severe canal\n narrowing @C4-5 w/cord deformity and no abnormal cord signal.\n CTA: no PE.\n CXR: Moderate bilateral pleural effusions are stable.\n CXR: Cardiac size top nl, interval improvement of collapse LLL.\n Collapse RLL. Atelectasis in lingula unchanged. Mod B\n pleural effusions stable. No PTX.\n CXR: Interval mild incr in cardiac size, b/l pleural effusions,\n and opacities @ bases,c/w overload\n : R foot: Linear density projecting @ expected area of insertion\n of the Achilles to calcaneus, may be min avulsion fx or degenerative\n changes. Otherwise no fx\n CXR: ETT in place, + hazy opacities bilaterally\n Microbiology: Ucx no growth final\n Sputum: sparse GNR\n Bcx P\n Bcx P\n 12/17 L BAL: KLEBSIELLA PNEUMONIAE, HAEMOPHILUS SPECIES NOT INFLUENZAE\n R BAL: KLEBSIELLA PNEUMONIAE & GNRs.\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, AF with\n RVR, hematologic abnormalities, now with resp failure.\n Neurologic: Intubated on fentanyl gtt and Midazolam gtt (drops BP with\n Propofol). Per ortho spine, no surgery; HOB<30, TLSO when OOB (NEOPS\n will place).\n Neuro checks Q: shift\n Pain: Fentanyl gtt (trying to wean), dilaudid, Neurontin, Tylenol\n Cardiovascular: NSR currently, occasional tachycardia & HTN improved\n occasionally w/sedation. Metop started prn. Restart Dilt gtt as pt\n hemodynamics best when in sinus. On PO Dilt.\n Pulmonary: Re-uintubated after unexpected self-extubated and failure.\n Intubated with bougie and partial view of the cords. F/U on BAL:\n KLEBSIELLA PNEUMONIAE & GNRs/Haemophilus. Bronch after rounds.\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin with CT scan\n suggesting cirrhosis - Hepatitis panel NEG. TFs advancing to goal.\n Bowel regimen.\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO, Foley, monitor UOP. Cr normalized. Lasix\n gtt started after bolus 10 mg x1 with goal even to neg 500cc.\n Hematology: Hct stable. Plt low but stable (100's); d/c'd H2B. Heme\n onc consulted - smear nl. IVC filter placed.\n Endocrine: RISS, goal BS<150.\n Infectious Disease: Check cultures, WBC normal, f/u Cx - BAL:\n Klebsiella (b/l)& GNRs (on R)/Haemophilus (on L). Started Ceftriaxone\n () x 10 days.\n Lines / Tubes / Drains: R SC CVL (), PIV x2, Foley, L a-line\n (), ETT\n Wounds:\n Imaging: CXR today\n Fluids:\n Consults: Trauma (1o), Ortho Spine, Ortho trauma, Heme\n Billing Diagnosis: Multiple injuries (Trauma)\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 08:40 PM 80 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 04:41 PM\n Arterial Line - 11:30 AM\n Prophylaxis:\n DVT: Boots, IVC filter\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 33 mins\n Patient is critically ill\n"},{"category":"Nursing","chartdate":"2175-01-30 00:00:00.000","description":"Nursing Progress Note","row_id":714089,"text":"74M s/p crushing injury d/t falling tree. Injuries sustained include\n multiple R sided rib fxs, grade 2 liver lac (w/ assoc hepatic vessel\n extravasation), stable pelvis fxs (w/ associated extravasation), R\n ramus fx, clavicle fx, and T4 vertebral body fx. Episodes of AF with\n RVR and aflutter, hematologic abnormalities, now with resp failure and\n newly dx pneumonia as of .\n intubated for resp distress\n angio embolization of hepatic and pelvic arterial bleeders\n IVC filter in OR\n self extubated and reintubated immediately after d/t acute resp\n failure\n Atrial fibrillation (Afib), aflutter\n Assessment:\n Pt in and out of aflutter with controlled rate on dilt drip,\n predominently aflutter. Hypotensive w/ sbp 80\ns while in aflutter.\n Action:\n Dilt weaned off, po dose increased. Lytes followed, stable. Neo gtt\n to support sbp titrated to map >60 and sbp >100. Pt on low dose midaz\n gtt along with fentanyl for sedation.\n Response:\n Converts to longer periods of NSR w/ higher po dilt dose, drip remains\n off, rate holding 80s. Rate well controlled but remains Neo\n dependent. Tolerating sedation titrated to lowest dose to keep\n comfortable and safe.\n Plan:\n Cont to monitor hemodynamics. Wean neo gtt as tolerated. Cont dilt\n gtt. Optimize lytes ongoing. Cardiology consult in am to determine\n need for amio vs. cardioversion to further manage aflutter.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains fully vented after reintubation yest morning. AC mode, 550x15,\n 50% and 10 peep. Stable abg, improved p02. O2sat 96-98%. Moderate\n amt thick, yellow tenacious secretions. LS coarse, clearing w/\n suctioning. Note: upon reintubation pt found to have signif airway\n edema, required bougie catheter for reintubation).\n Action:\n Remains intubated on ac mode, see settings above, tol well. Pulm\n toileting per routine.\n Response:\n Abg acceptable, note compensated metabolic alkalosis. Pao2 improved on\n higher peep. LS improved as well, clearer, remain diminished,\n especially to R sided fields.\n Plan:\n Cont vanco for pneumonia coverage, await ID approval for zosyn. Pulm\n toilet. Maintain sedated for safety and comfort. Pt may benefit from\n trach in the short term if continuing to require vent support w/\n difficulty weaning.\n"},{"category":"Respiratory ","chartdate":"2175-01-30 00:00:00.000","description":"Respiratory Care Shift Note","row_id":714096,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 6\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 20 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt cont intub with OETT sedated and on mech vent as per\n Metavision. Lung sounds ess clear after suct mod th tan sput. ABGs\n metabolic alkalosis with adequate oxygenation on current vent settings;\n no vent changes required overnoc. Cont mech vent support.\n"},{"category":"Nursing","chartdate":"2175-01-30 00:00:00.000","description":"Nursing Progress Note","row_id":714201,"text":"Hypotension (not Shock)\n Assessment:\n Pt continues on neo gtt, BP low 90\ns, neo titrating as needed. BP goal\n MAP 65. Pt continues on Fentanyl gtt at 100mcg/hr and Midazolam at\n 2mg/hr.\n Action:\n Neo weaned as tolerated. Midazolam changed/bolused as needed.\n Response:\n Pt tolerating neo wean gradually, but still requires neo gtt at this\n time.\n Plan:\n Wean neo as tolerated. Study to start this evening at 20:00 with\n ketamine and ativan. See information sheet for details (in room).\n Continue to support pt and family, keep pt sedated/comfortable.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt continues on the vent, requiring frequent suctioning. Lung sounds\n diminished on the right side, occasionally rhonchorous. O2 sat >96%.\n +PNA, continues on antibiotics but Afebrile today.\n Action:\n Settings changed to CPAP/PS this AM. Suctioned frequently as\n needed. Pt repositioned frequently. Zosyn discontinued, ceftriaxone\n started, vanco continues.\n Response:\n Pt tolerating vent wean well, occasionally plugging, waking up through\n sedation and getting agitated. Midazolam weaned as needed.\n Plan:\n Wean vent as tolerated, pulmonary toileting. Continue to support pt\n and family. Suction frequently, VAP care, frequent repositioning.\n"},{"category":"Physician ","chartdate":"2175-01-31 00:00:00.000","description":"Intensivist Note","row_id":714280,"text":"TSICU\n HPI:\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\n checked and 1.5, 1 more unit FFP given.\n Chief complaint:\n Mult rib fx: R anterolateral and post, L posterior\n T4 vert body inf corner fx\n Commin spinous process fx T2-8\n Nondisplaced L T10 transverse process\n Nondispaced L distal clavicle\n Nondisplaced L clavicle fx\n R medial lobe liver contusion w/hematoma\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny focus of arterial\n bleeding/active extravasation, and larger area of venous bleeding\n Nondisplaced, comminuted L iliac bone fx w/adjacent iliac muscle\n hematoma, extends into L SIJ.\n Minimally displaced fx of R iliac bone extending to R SIJ.\n PMHx:\n PMH: None\n PSH: None\n Current medications:\n 1. IV access: Peripheral line Order date: @ 2329 16. Ketamine\n Study Drug Study Med 1 dose IV AS SIR Duration: 24 Hours\n Patient to receive Ketamine/Placebo 0.25mg/kg bolus over 1 hour\n followed by 0.1mg/kg/hr for 23 hours Order date: @ 1338\n 2. Acetaminophen 650 mg PO/NG Q6H:PRN pain Order date: @ 2329\n 17. Lorazepam 2mg Syringe Study Med 1 mg IV Q6H Duration: 4 Doses\n Patient to receive Lorazepam 1mg iv every 6 hours for 4 doses while on\n ketamine study drug Order date: @ 1338\n 3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation Order date: @\n 0823 18. Magnesium Sulfate IV Sliding Scale Order date: @ 2339\n 4. Calcium Gluconate IV Sliding Scale Order date: @ 1657 19.\n Metoprolol Tartrate 5 mg IV Q4H:PRN hr>90, SBP>150\n hold hr<60, SBP<100 Order date: @ 1809\n 5. CeftriaXONE 1 gm IV Q24H Order date: @ 1228 20. Midazolam\n 0.5-1 mg IV Q2H:PRN sedation Order date: @ 0912\n 6. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL Order date:\n @ 2329 21. Midazolam 0.5-10 mg/hr IV DRIP TITRATE TO sedation\n Patient must have adequate airway support prior to administration of\n dose. Order date: @ 0734\n 7. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date: \n @ 0104 22. Ondansetron 4 mg IV Q8H:PRN nausea Order date: @ 2329\n 8. Diltiazem 60 mg PO/NG QID\n hold for HR < 60 or SBP < 100 Order date: @ 23.\n Pantoprazole 40 mg IV Q24H Order date: @ 1321\n 9. Docusate Sodium (Liquid) 100 mg PO/NG Order date: @ 2329\n 24. Phenylephrine 0.5-5 mcg/kg/min IV DRIP TITRATE TO SBP>90 MAP>60\n Order date: @ 2339\n 10. Fentanyl Citrate 25-100 mcg/hr IV DRIP INFUSION\n Please wean with Dilaudid dosing. Thank you. Order date: @ 1136\n 25. Pneumococcal Vac Polyvalent 0.5 ml IM ASDIR Order date: @\n 2316\n 11. Gabapentin 400 mg PO/NG TID Order date: @ 1210 26. Potassium\n Phosphate IV Sliding Scale\n Infuse over 6 hours Order date: @ 2339\n 12. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date:\n @ 0104 27. Potassium Chloride IV Sliding Scale Order date: \n @ 2339\n 13. HYDROmorphone (Dilaudid) 0.125-1 mg IV Q3H:PRN pain Order date:\n @ 0912 28. Senna 1 TAB PO/NG :PRN constipation Order date:\n @ 0823\n 14. Heparin 5000 UNIT SC TID Order date: @ 0931 29. Sodium\n Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ 2329\n 15. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 0104 30. Vancomycin 1000 mg IV\n Q 12H\n ID Approval will be required for this order in 39 hours. Order date:\n @ \n 24 Hour Events:\n Placed on ketamine for study. Continues to be in aflutter and on Neo,\n difficulties weaning, however when pt more awake (ie: turning), he is\n actually HTN. TTE done showing mild TR. RUQ U/S showing mild\n perihepatic fluid collection too small to be drained.\n Post operative day:\n POD#5 - IVC filter via L groin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\n Ceftriaxone - 12:00 PM\n Vancomycin - 08:36 PM\n Infusions:\n Fentanyl (Concentrate) - 100 mcg/hour\n Ketamine - 0.1 mcg/Kg/min\n Phenylephrine - 1.2 mcg/Kg/min\n Midazolam (Versed) - 0.5 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 02:00 PM\n Heparin Sodium (Prophylaxis) - 08:29 PM\n Midazolam (Versed) - 01:15 AM\n Fentanyl - 01:20 AM\n Lorazepam (Ativan) - 02:09 AM\n Other medications:\n Flowsheet Data as of 04:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.2\nC (100.7\n T current: 37.9\nC (100.3\n HR: 78 (75 - 91) bpm\n BP: 103/51(69) {89/48(62) - 152/66(94)} mmHg\n RR: 28 (16 - 29) insp/min\n SPO2: 98%\n Heart rhythm: A Flut (Atrial Flutter)\n Wgt (current): 102 kg (admission): 90 kg\n CVP: 11 (9 - 17) mmHg\n Total In:\n 3,764 mL\n 418 mL\n PO:\n Tube feeding:\n 1,920 mL\n 255 mL\n IV Fluid:\n 1,384 mL\n 163 mL\n Blood products:\n Total out:\n 1,535 mL\n 245 mL\n Urine:\n 1,530 mL\n 245 mL\n NG:\n 5 mL\n Stool:\n Drains:\n Balance:\n 2,229 mL\n 173 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 431 (399 - 596) mL\n PS : 10 cmH2O\n RR (Spontaneous): 25\n PEEP: 10 cmH2O\n FiO2: 50%\n PIP: 20 cmH2O\n SPO2: 98%\n ABG: 7.41/56/91./32/8\n Ve: 11.7 L/min\n PaO2 / FiO2: 184\n Physical Examination\n General Appearance: Overweight / Obese\n Cardiovascular: (Rhythm: No(t) Regular, Irregular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: No(t)\n Crackles : , Rhonchorous : bilaterally)\n Abdominal: Soft, Obese, right flank, right pelvis, and scrotum\n eechymotic\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Skin: right flank, right pelvis, and scrotum eechymotic\n Neurologic: Sedated\n Labs / Radiology\n 153 K/uL\n 10.7 g/dL\n 117 mg/dL\n 0.7 mg/dL\n 32 mEq/L\n 3.9 mEq/L\n 22 mg/dL\n 106 mEq/L\n 143 mEq/L\n 32.1 %\n 8.8 K/uL\n [image002.jpg]\n 02:55 AM\n 04:11 AM\n 09:45 AM\n 04:45 PM\n 12:45 AM\n 01:00 AM\n 05:12 AM\n 02:40 PM\n 01:46 AM\n 01:55 AM\n WBC\n 6.5\n 13.1\n 8.8\n Hct\n 29.3\n 31.6\n 32.1\n Plt\n 86\n 158\n 153\n Creatinine\n 0.8\n 0.8\n 0.7\n 0.7\n TCO2\n 38\n 37\n 35\n 35\n 34\n 37\n Glucose\n 141\n 107\n 131\n 115\n 132\n 122\n 117\n Other labs: PT / PTT / INR:13.7/27.6/1.2, CK / CK-MB / Troponin\n T:128/13/<0.01, ALT / AST:81/93, Alk-Phos / T bili:84/5.8, Amylase /\n Lipase:44/, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic Acid:1.4\n mmol/L, Albumin:2.7 g/dL, LDH:348 IU/L, Ca:8.0 mg/dL, Mg:2.0 mg/dL,\n PO4:3.3 mg/dL\n Imaging: CXR: Cardiac size top nl, interval improvement of\n collapse LLL. Collapse RLL. Atelectasis in lingula unchanged. Mod B\n pleural effusions stable. No PTX.\n CXR: Interval mild incr in cardiac size, b/l pleural effusions,\n and opacities @ bases,c/w overload\n : R foot: Linear density projecting @ expected area of insertion\n of the Achilles to calcaneus, may be min avulsion fx or degenerative\n changes. Otherwise no fx\n CXR: b/l pleural effusions\n CXR: stable.\n RUQ U/S: No perihepatic fluid collection. small amt perihepatic\n free fluid persists. Small contusion in hepatic segment VII. No\n gallstones or significant wall thickening/edema. CBD 4.5 mm\n TTE: LVEF >55%, normal diastolic function, normal left\n ventricular filling pressure (PCWP<12mmHg), Right ventricular chamber\n size is mildly dilated, mild TR\n Microbiology: Ucx no growth final\n Sputum: sparse GNRs, too few to colonize\n Bcx P\n Bcx P\n 12/17 L BAL: Klebsiella Pneumoniae, HAEMOPHILUS SPECIES NOT INFLUENZAE\n R BAL: Klebsiella Pneumoniae, Proteus.\n 12/20 L BAL: gram + cocci pairs on gram stain, GNRs (sparse) on cx\n R BAL: gram + cocci pairs on gram stain, GNRs (10-100K) on cx\n BCX: p\n BCx: P\n UCx: no growth final\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, now\n with AF with RVR/Aflutter, hypotension and presumed PNA.\n Neurologic: Intubated on Fentanyl/Versed gtt. Per ortho spine, no\n surgery; HOB<30, TLSO when OOB (NEOPS will place).\n Neuro checks Q: shift\n Pain: Fentanyl gtt (trying to wean), dilaudid, Midazolam gtt\n switch\n to Precidex. Also on Neurontin, Tylenol\n Cardiovascular: Aflutter on Dilt 60mg PO QID. Weaning Neo.\n Pulmonary: Intubated. Weaning to extubate. On appropriate abx per BAL\n cx -Vanco and Ceftriaxone. Will need Trach this week.\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin with CT scan\n suggesting cirrhosis - Hepatitis panel NEG. TFs advancing to goal.\n Bowel regimen.\n Nutrition: Tube feeding\n Renal: Foley, monitor UOP.\n Hematology: Hct stable. Plt low but stable (100's); d/c'd H2B with\n increasing plt count. Heme onc consulted - smear nl; no hemolysis. IVC\n filter placed.\n Endocrine: RISS, goal BS<150.\n Infectious Disease: Check cultures, WBC normal, f/u Cx - BAL:\n Klebsiella (b/l)& GNRs (on R)/Haemophilus (on L). Klebsiella\n Pneumoniae, Proteus/Haemophilus. Repeat BAL with gram+ cocci in\n pairs on gram stain, GNRs.\n Lines / Tubes / Drains: R SC CVL (), PIV x2, Foley, L a-line\n (), ETT\n Wounds:\n Imaging: CXR today\n Fluids: KVO\n Consults: Trauma (1o), Ortho Spine, Ortho trauma, Heme\n Billing Diagnosis: Multiple injuries (Trauma)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 04:41 PM\n Arterial Line - 11:30 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin, IVC filter\n Stress ulcer: PPI (? H2B-related thrombocytopenia)\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 32 min\n"},{"category":"Physician ","chartdate":"2175-01-31 00:00:00.000","description":"Intensivist Note","row_id":714282,"text":"TSICU\n HPI:\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\n checked and 1.5, 1 more unit FFP given.\n Chief complaint:\n Mult rib fx: R anterolateral and post, L posterior\n T4 vert body inf corner fx\n Commin spinous process fx T2-8\n Nondisplaced L T10 transverse process\n Nondispaced L distal clavicle\n Nondisplaced L clavicle fx\n R medial lobe liver contusion w/hematoma\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny focus of arterial\n bleeding/active extravasation, and larger area of venous bleeding\n Nondisplaced, comminuted L iliac bone fx w/adjacent iliac muscle\n hematoma, extends into L SIJ.\n Minimally displaced fx of R iliac bone extending to R SIJ.\n PMHx:\n PMH: None\n PSH: None\n Current medications:\n 1. IV access: Peripheral line Order date: @ 2329 16. Ketamine\n Study Drug Study Med 1 dose IV AS SIR Duration: 24 Hours\n Patient to receive Ketamine/Placebo 0.25mg/kg bolus over 1 hour\n followed by 0.1mg/kg/hr for 23 hours Order date: @ 1338\n 2. Acetaminophen 650 mg PO/NG Q6H:PRN pain Order date: @ 2329\n 17. Lorazepam 2mg Syringe Study Med 1 mg IV Q6H Duration: 4 Doses\n Patient to receive Lorazepam 1mg iv every 6 hours for 4 doses while on\n ketamine study drug Order date: @ 1338\n 3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation Order date: @\n 0823 18. Magnesium Sulfate IV Sliding Scale Order date: @ 2339\n 4. Calcium Gluconate IV Sliding Scale Order date: @ 1657 19.\n Metoprolol Tartrate 5 mg IV Q4H:PRN hr>90, SBP>150\n hold hr<60, SBP<100 Order date: @ 1809\n 5. CeftriaXONE 1 gm IV Q24H Order date: @ 1228 20. Midazolam\n 0.5-1 mg IV Q2H:PRN sedation Order date: @ 0912\n 6. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL Order date:\n @ 2329 21. Midazolam 0.5-10 mg/hr IV DRIP TITRATE TO sedation\n Patient must have adequate airway support prior to administration of\n dose. Order date: @ 0734\n 7. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date: \n @ 0104 22. Ondansetron 4 mg IV Q8H:PRN nausea Order date: @ 2329\n 8. Diltiazem 60 mg PO/NG QID\n hold for HR < 60 or SBP < 100 Order date: @ 23.\n Pantoprazole 40 mg IV Q24H Order date: @ 1321\n 9. Docusate Sodium (Liquid) 100 mg PO/NG Order date: @ 2329\n 24. Phenylephrine 0.5-5 mcg/kg/min IV DRIP TITRATE TO SBP>90 MAP>60\n Order date: @ 2339\n 10. Fentanyl Citrate 25-100 mcg/hr IV DRIP INFUSION\n Please wean with Dilaudid dosing. Thank you. Order date: @ 1136\n 25. Pneumococcal Vac Polyvalent 0.5 ml IM ASDIR Order date: @\n 2316\n 11. Gabapentin 400 mg PO/NG TID Order date: @ 1210 26. Potassium\n Phosphate IV Sliding Scale\n Infuse over 6 hours Order date: @ 2339\n 12. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date:\n @ 0104 27. Potassium Chloride IV Sliding Scale Order date: \n @ 2339\n 13. HYDROmorphone (Dilaudid) 0.125-1 mg IV Q3H:PRN pain Order date:\n @ 0912 28. Senna 1 TAB PO/NG :PRN constipation Order date:\n @ 0823\n 14. Heparin 5000 UNIT SC TID Order date: @ 0931 29. Sodium\n Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ 2329\n 15. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 0104 30. Vancomycin 1000 mg IV\n Q 12H\n ID Approval will be required for this order in 39 hours. Order date:\n @ \n 24 Hour Events:\n Placed on ketamine for study. Continues to be in aflutter and on Neo,\n difficulties weaning, however when pt more awake (ie: turning), he is\n actually HTN. TTE done showing mild TR. RUQ U/S showing mild\n perihepatic fluid collection too small to be drained.\n Post operative day:\n POD#5 - IVC filter via L groin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\n Ceftriaxone - 12:00 PM\n Vancomycin - 08:36 PM\n Infusions:\n Fentanyl (Concentrate) - 100 mcg/hour\n Ketamine - 0.1 mcg/Kg/min\n Phenylephrine - 1.2 mcg/Kg/min\n Midazolam (Versed) - 0.5 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 02:00 PM\n Heparin Sodium (Prophylaxis) - 08:29 PM\n Midazolam (Versed) - 01:15 AM\n Fentanyl - 01:20 AM\n Lorazepam (Ativan) - 02:09 AM\n Other medications:\n Flowsheet Data as of 04:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.2\nC (100.7\n T current: 37.9\nC (100.3\n HR: 78 (75 - 91) bpm\n BP: 103/51(69) {89/48(62) - 152/66(94)} mmHg\n RR: 28 (16 - 29) insp/min\n SPO2: 98%\n Heart rhythm: A Flut (Atrial Flutter)\n Wgt (current): 102 kg (admission): 90 kg\n CVP: 11 (9 - 17) mmHg\n Total In:\n 3,764 mL\n 418 mL\n PO:\n Tube feeding:\n 1,920 mL\n 255 mL\n IV Fluid:\n 1,384 mL\n 163 mL\n Blood products:\n Total out:\n 1,535 mL\n 245 mL\n Urine:\n 1,530 mL\n 245 mL\n NG:\n 5 mL\n Stool:\n Drains:\n Balance:\n 2,229 mL\n 173 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 431 (399 - 596) mL\n PS : 10 cmH2O\n RR (Spontaneous): 25\n PEEP: 10 cmH2O\n FiO2: 50%\n PIP: 20 cmH2O\n SPO2: 98%\n ABG: 7.41/56/91./32/8\n Ve: 11.7 L/min\n PaO2 / FiO2: 184\n Physical Examination\n General Appearance: Overweight / Obese\n Cardiovascular: (Rhythm: No(t) Regular, Irregular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: No(t)\n Crackles : , Rhonchorous : bilaterally)\n Abdominal: Soft, Obese, right flank, right pelvis, and scrotum\n eechymotic\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Skin: right flank, right pelvis, and scrotum eechymotic\n Neurologic: Sedated\n Labs / Radiology\n 153 K/uL\n 10.7 g/dL\n 117 mg/dL\n 0.7 mg/dL\n 32 mEq/L\n 3.9 mEq/L\n 22 mg/dL\n 106 mEq/L\n 143 mEq/L\n 32.1 %\n 8.8 K/uL\n [image002.jpg]\n 02:55 AM\n 04:11 AM\n 09:45 AM\n 04:45 PM\n 12:45 AM\n 01:00 AM\n 05:12 AM\n 02:40 PM\n 01:46 AM\n 01:55 AM\n WBC\n 6.5\n 13.1\n 8.8\n Hct\n 29.3\n 31.6\n 32.1\n Plt\n 86\n 158\n 153\n Creatinine\n 0.8\n 0.8\n 0.7\n 0.7\n TCO2\n 38\n 37\n 35\n 35\n 34\n 37\n Glucose\n 141\n 107\n 131\n 115\n 132\n 122\n 117\n Other labs: PT / PTT / INR:13.7/27.6/1.2, CK / CK-MB / Troponin\n T:128/13/<0.01, ALT / AST:81/93, Alk-Phos / T bili:84/5.8, Amylase /\n Lipase:44/, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic Acid:1.4\n mmol/L, Albumin:2.7 g/dL, LDH:348 IU/L, Ca:8.0 mg/dL, Mg:2.0 mg/dL,\n PO4:3.3 mg/dL\n Imaging: CXR: Cardiac size top nl, interval improvement of\n collapse LLL. Collapse RLL. Atelectasis in lingula unchanged. Mod B\n pleural effusions stable. No PTX.\n CXR: Interval mild incr in cardiac size, b/l pleural effusions,\n and opacities @ bases,c/w overload\n : R foot: Linear density projecting @ expected area of insertion\n of the Achilles to calcaneus, may be min avulsion fx or degenerative\n changes. Otherwise no fx\n CXR: b/l pleural effusions\n CXR: stable.\n RUQ U/S: No perihepatic fluid collection. small amt perihepatic\n free fluid persists. Small contusion in hepatic segment VII. No\n gallstones or significant wall thickening/edema. CBD 4.5 mm\n TTE: LVEF >55%, normal diastolic function, normal left\n ventricular filling pressure (PCWP<12mmHg), Right ventricular chamber\n size is mildly dilated, mild TR\n Microbiology: Ucx no growth final\n Sputum: sparse GNRs, too few to colonize\n Bcx P\n Bcx P\n 12/17 L BAL: Klebsiella Pneumoniae, HAEMOPHILUS SPECIES NOT INFLUENZAE\n R BAL: Klebsiella Pneumoniae, Proteus.\n 12/20 L BAL: gram + cocci pairs on gram stain, GNRs (sparse) on cx\n R BAL: gram + cocci pairs on gram stain, GNRs (10-100K) on cx\n BCX: p\n BCx: P\n UCx: no growth final\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, now\n with AF with RVR/Aflutter, hypotension and presumed PNA.\n Neurologic: Intubated on Fentanyl/Versed gtt. Per ortho spine, no\n surgery; HOB<30, TLSO when OOB (NEOPS will place).\n Neuro checks Q: shift\n Pain: Fentanyl gtt (trying to wean), dilaudid, Midazolam gtt\n switch\n to Precidex. Also on Neurontin, Tylenol\n Cardiovascular: Aflutter on Dilt 60mg PO QID. Reamins o vasopressor\n support (Neo at 1). TTE without e/o cardiac dysfunction. ScVO2 68 so\n cardiogenic shock unlikely. Cortisol 17 which is borderline, although\n scenario not classic for adrenal insufficiency. ? sedation related so\n switch to precidex. Weaning Neo today. .\n Pulmonary: Intubated. Weaning vent. On appropriate abx per BAL cx\n -Vanco and Ceftriaxone. Will need Trach this week.\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin with CT scan\n suggesting cirrhosis - Hepatitis panel NEG. TFs advancing to goal.\n Bowel regimen.\n Nutrition: Tube feeding\n Renal: Foley, monitor UOP.\n Hematology: Hct stable. Plt low but stable (100's); d/c'd H2B with\n increasing plt count. Heme onc consulted - smear nl; no hemolysis. IVC\n filter placed.\n Endocrine: RISS, goal BS<150.\n Infectious Disease: Check cultures, WBC normal, f/u Cx - BAL:\n Klebsiella (b/l)& GNRs (on R)/Haemophilus (on L). Klebsiella\n Pneumoniae, Proteus/Haemophilus. Repeat BAL with gram+ cocci in\n pairs on gram stain, GNRs.\n Lines / Tubes / Drains: R SC CVL (), PIV x2, Foley, L a-line\n (), ETT\n Wounds:\n Imaging: CXR today\n Fluids: KVO\n Consults: Trauma (1o), Ortho Spine, Ortho trauma, Heme\n Billing Diagnosis: Multiple injuries (Trauma)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 04:41 PM\n Arterial Line - 11:30 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin, IVC filter\n Stress ulcer: PPI (? H2B-related thrombocytopenia)\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 32 min\n"},{"category":"General","chartdate":"2175-01-29 00:00:00.000","description":"ICU Event Note","row_id":713987,"text":"Clinician: Fellow\n Called to bedside of patient, who had self-extubated (dislodged ETT\n with his tongue). Pt rapidly developed tachypnea, hypoxia, poor mental\n status. Notified Anesthesia but given dropping SaO2 and respiratory\n distress we positioned pt, pre-oxygenated but difficult to get SaO2>80,\n RSI with Etom 20mg and Succ 100mg, on DL there was notable supraglottic\n edema, with a partial view of the cords (Grade II-III), passed bougie,\n passed ETT over bougie, + EtCO2 color change x 5 breaths, + chest rise,\n + BS bilaterally, + mist in tube. SaO2 rapidly improved to 95%. Pt\n remained HD stable throughout. ETT secured. CXR ordered. Rhonchorous\n breath sounds at bases, will plan for bronch this AM.\n Total time spent: 20 minutes\n Patient is critically ill.\n"},{"category":"Physician ","chartdate":"2175-01-29 00:00:00.000","description":"Intensivist Note","row_id":713996,"text":"TSICU\n HPI:\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\n checked and 1.5, 1 more unit FFP given.\n Chief complaint:\n polytrauma\n PMHx:\n none\n Current medications:\n Acetaminophen 3. Bisacodyl 4. CeftriaXONE 5. Chlorhexidine Gluconate\n 0.12% Oral Rinse 6. Dextrose 50% 7. Diltiazem 8. Docusate Sodium\n (Liquid) 9. Fentanyl Citrate 10. Furosemide 11. Furosemide 12.\n Gabapentin\n 13. Glucagon 14. HYDROmorphone (Dilaudid) 15. Insulin 16. Magnesium\n Sulfate 17. Metoprolol Tartrate 18. Midazolam 19. Omeprazole 20.\n Ondansetron 21. Phenylephrine 22. Pneumococcal Vac Polyvalent 23.\n Potassium Phosphate\n 24. Potassium Chloride 25. Propofol 26. Senna 27. Sodium Chloride 0.9%\n Flush\n 24 Hour Events:\n : agitated w/HTN, tachycardia, incr fent/midaz w/some resolution.\n weaned cpap to -->desat-->incr to & improved hr & BP. started\n dilaudid, incr neurontin 300''', d/c'd H2B decr plt. lasix bolus\n 10, gtt. R ankle films (ecchymosis/edema) WNL. BAL: KLEBSIELLA\n PNEUMONIAE & GNRs-ceftriaxone started.\n Before rounds this AM, pt self-extubated using his tongue (hands were\n restrained), emergently re-intubated for resp distress and hypoxia.\n Post operative day:\n POD#3 - IVC filter via L groin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Furosemide (Lasix) - 5 mg/hour\n Fentanyl (Concentrate) - 50 mcg/hour\n Other ICU medications:\n Fentanyl - 02:15 PM\n Furosemide (Lasix) - 06:19 PM\n Labetalol - 07:00 PM\n Midazolam (Versed) - 04:00 AM\n Hydromorphone (Dilaudid) - 04:00 AM\n Other medications:\n Flowsheet Data as of 06:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.2\nC (99\n T current: 36.9\nC (98.4\n HR: 98 (79 - 127) bpm\n BP: 105/51(69) {91/41(58) - 185/74(110)} mmHg\n RR: 0 (0 - 26) insp/min\n SPO2: 95%\n Heart rhythm: 1st AV (First degree AV Block)\n Wgt (current): 102 kg (admission): 90 kg\n CVP: 8 (6 - 15) mmHg\n Total In:\n 1,861 mL\n 741 mL\n PO:\n Tube feeding:\n 1,330 mL\n 521 mL\n IV Fluid:\n 221 mL\n 160 mL\n Blood products:\n Total out:\n 2,010 mL\n 1,195 mL\n Urine:\n 2,010 mL\n 1,195 mL\n NG:\n Stool:\n Drains:\n Balance:\n -149 mL\n -454 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 540 (456 - 634) mL\n PS : 5 cmH2O\n RR (Spontaneous): 14\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 34\n PIP: 11 cmH2O\n SPO2: 95%\n ABG: 7.42/56/114/33/10\n Ve: 8 L/min\n PaO2 / FiO2: 285\n Physical Examination\n General Appearance: No acute distress, Well nourished; intubated on\n vent.\n HEENT: EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: bibasilar)\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present, Obese\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities, Sedated\n Labs / Radiology\n 86 K/uL\n 10.1 g/dL\n 141 mg/dL\n 0.8 mg/dL\n 33 mEq/L\n 3.6 mEq/L\n 19 mg/dL\n 106 mEq/L\n 143 mEq/L\n 29.3 %\n 6.5 K/uL\n [image002.jpg]\n 05:24 AM\n 06:50 AM\n 02:40 PM\n 03:13 PM\n 01:59 AM\n 02:00 AM\n 11:04 AM\n 01:17 PM\n 02:55 AM\n 04:11 AM\n WBC\n 11.0\n 8.0\n 5.6\n 6.5\n Hct\n 30.1\n 29.8\n 28.7\n 29.3\n Plt\n 97\n 80\n 74\n 86\n Creatinine\n 0.8\n 0.8\n 0.8\n TCO2\n 30\n 33\n 35\n 34\n 34\n 38\n Glucose\n 133\n 125\n 128\n 141\n Other labs: PT / PTT / INR:12.9/26.8/1.1, CK / CK-MB / Troponin\n T:1334/13/<0.01, ALT / AST:109/96, Alk-Phos / T bili:66/3.6, Amylase /\n Lipase:44/, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic Acid:1.4\n mmol/L, Albumin:2.7 g/dL, LDH:435 IU/L, Ca:7.7 mg/dL, Mg:1.9 mg/dL,\n PO4:3.0 mg/dL\n Imaging: CT head OSH: Prelim No ICH or fx.\n CT chest OSH: Mult rib fx: R anterolateral and posterior, L\n posterior; Dependent consolidation, possible aspiration; T4 vertebral\n body inf corner fx, no retropulsion; Comminuted spinous process fx\n T2-8; Nondisplaced L T10 transverse process; Nondisplaced L clavicle\n distal fx; Nondisplaced L scapula fx;\n CT c spine OSH: Prelim No fx or malalignment. Multilevel\n degenerative changes w/large post disk bulge at C4-5, narrowing the\n spinal canal and deforming the thecal sac, acuity unknown. Marked\n neuroforamenal narrowing @multiple levels.\n CTA abd/pel Prelim: Medial R liver lobe contusion w/adj\n hematoma, w/o evidence of active bleeding; Comminuted L pubic ramus\n fracture w/assoc hematoma, with tiny focus of arterial bleeding/active\n extravasation, and larger area of venous bleeding. Hematoma somewhat\n larger than on OSH study. Nondisplaced, comminuted L iliac bone fx\n w/adj iliac muscle hematoma, larger than on prior study, w/o active\n extrav. Fx extends into L SIJ. Post R hepatic laceration/contusion\n adjacent to calcified granuloma, w/small hematoma, w/out active\n bleeding. Min displaced fx of R iliac bone extending to R SIJ.\n Cirrhotic liver. Inc B pl effusions (small), w/inc atelectasis.\n MRI: Mild compression deformity of L1 w/additional levels of\n potential trabecular contusion @T10-11 also inf @T4 w/o retropulsion.\n Multilevel degenerative changes with moderate canal narrowing at T10-11\n w/cord deformity and no abnormal cord signal. Extensive edema\n throughout paraspinal soft tissues, predominantly post w/in\n interspinous ligaments. Incompletely eval'ed c-spine w/severe canal\n narrowing @C4-5 w/cord deformity and no abnormal cord signal.\n CTA: no PE.\n CXR: Moderate bilateral pleural effusions are stable.\n CXR: Cardiac size top nl, interval improvement of collapse LLL.\n Collapse RLL. Atelectasis in lingula unchanged. Mod B\n pleural effusions stable. No PTX.\n CXR: Interval mild incr in cardiac size, b/l pleural effusions,\n and opacities @ bases,c/w overload\n : R foot: Linear density projecting @ expected area of insertion\n of the Achilles to calcaneus, may be min avulsion fx or degenerative\n changes. Otherwise no fx\n CXR: ETT in place, + hazy opacities bilaterally\n Microbiology: Ucx no growth final\n Sputum: sparse GNR\n Bcx P\n Bcx P\n 12/17 L BAL: KLEBSIELLA PNEUMONIAE, HAEMOPHILUS SPECIES NOT INFLUENZAE\n R BAL: KLEBSIELLA PNEUMONIAE & GNRs.\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, AF with\n RVR, hematologic abnormalities, now with resp failure.\n Neurologic: Intubated on fentanyl gtt and Midazolam gtt (drops BP with\n Propofol). Per ortho spine, no surgery; HOB<30, TLSO when OOB (NEOPS\n will place).\n Neuro checks Q: shift\n Pain: Fentanyl gtt (trying to wean), dilaudid, Neurontin, Tylenol\n Cardiovascular: NSR currently, occasional tachycardia & HTN improved\n occasionally w/sedation. Metop started prn. Restart Dilt gtt as pt\n hemodynamics best when in sinus. On PO Dilt.\n Pulmonary: Re-uintubated after unexpected self-extubated and failure.\n Intubated with bougie and partial view of the cords. F/U on BAL:\n KLEBSIELLA PNEUMONIAE & GNRs/Haemophilus. Bronch after rounds.\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin with CT scan\n suggesting cirrhosis - Hepatitis panel NEG. TFs advancing to goal.\n Bowel regimen.\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO, Foley, monitor UOP. Cr normalized. Lasix\n gtt started after bolus 10 mg x1 with goal even to neg 500cc.\n Hematology: Hct stable. Plt low but stable (100's); d/c'd H2B. Heme\n onc consulted - smear nl. IVC filter placed.\n Endocrine: RISS, goal BS<150.\n Infectious Disease: Check cultures, WBC normal, f/u Cx - BAL:\n Klebsiella (b/l)& GNRs (on R)/Haemophilus (on L). Started Ceftriaxone\n () x 10 days.\n Lines / Tubes / Drains: R SC CVL (), PIV x2, Foley, L a-line\n (), ETT\n Wounds:\n Imaging: CXR today\n Fluids:\n Consults: Trauma (1o), Ortho Spine, Ortho trauma, Heme\n Billing Diagnosis: Multiple injuries (Trauma)\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 08:40 PM 80 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 04:41 PM\n Arterial Line - 11:30 AM\n Prophylaxis:\n DVT: Boots, IVC filter\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 33 mins\n Patient is critically ill\n"},{"category":"Nursing","chartdate":"2175-02-02 00:00:00.000","description":"Nursing Progress Note","row_id":714594,"text":"74M s/p crushing injury d/t falling tree. Injuries sustained include\n multiple R sided rib fxs, grade 2 liver lac (w/ assoc hepatic vessel\n extravasation), stable pelvis fxs (w/ associated extravasation), R\n ramus fx, clavicle fx, and T4 vertebral body fx. Episodes of A.\n Flutter with RVR and aflutter, now with resp failure and newly dx\n pneumonia as of .\n intubated for resp distress\n angio embolization of hepatic and pelvic arterial bleeders\n IVC filter in OR\n self extubated and re-intubated immediately after d/t acute resp.\n failure\n Trach and PEG at bedside\n Atrial fibrillation (Afib)\n Assessment:\n Pt converted to NSR @ 1900 w/ rate 80s-100s.\n Action:\n PO dilt, amioderone gtt continued\n Neo gtt weaned off\n Response:\n HR & BP remain well controlled. Pt\n :\n Continue Amio gtt, switch to PO amio, ? Anticoagulant.\n Monitor hemodynamics, monitor BP\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt w/ trach on CPAP/PS 10/10/50%. LS rhonchorous throughout. Strong\n productive cough, large amounts of thick blood tinged secretions. ABG\n stable. VSS. Low grade temps. WBC 5.9\n Action:\n Pulm hygiene, suction PRN\n Ceftriaxone admistered for pna\n Response:\n Exam unchanged.\n Plan:\n Wean vent settings as tolerated, pulmonary toileting, wean\n sedation.\n"},{"category":"Nursing","chartdate":"2175-01-27 00:00:00.000","description":"Nursing Progress Note","row_id":713708,"text":"Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient intubated on CMV 18 x 440. 50%. PEEP 14. Sats 100%. LS clear\n to diminished.\n Action:\n Pulmonary hygiene.\n Response:\n Suctioned for small amounts of thick, yellow secretions. ABG WNL.\n Very diminished on R side.\n Plan:\n Continue to monitor respiratory status. Wean vent as tolerated.\n Monitor ABG. Pulmonary hygiene.\n Trauma, s/p\n Assessment:\n Patient sedated on propofol and fentanyl drip. When lightened, patient\n opens eyes to voice and follows commands. MAE on bed. Denies pain.\n Bolused prior to turns. Sent to OR for IVC filter placement. Dsg to L\n groin c/d/i.\n TF restarted post-op.\n Action:\n Monitored CSM of LLE. TF advanced per orders.\n Response:\n No change. TF currently at 20cc/hr.\n Plan:\n Continue to monitor CSM to LLE. Advance TF as ordered/tolerated.\n Assess for pain, titrate fentanyl drip as indicated.\n Atrial fibrillation (Afib)\n Assessment:\n Patient in atrial flutter, HR 70-80s. MAP > 65 on phenylephrine drip.\n PVCs rare.\n Action:\n Diltiazem drip at 5mg/hr, held at . Phenylephrine drip at\n 1.25mcg/kg/min. Patient sent to OR for IVC filter.\n Response:\n Patient hypertensive post-op. Phenylephrine drip weaned to\n 0.5mcg/kg/min. Dilitiazem drip restarted for tachycardia (HR 110\n At 0400, patient converted to sinus bradycardia. Diltiazem drip\n currently off.\n Plan:\n Continue to monitor rhythm. Treat as indicated. Wean phenylephrine as\n tolerated.\n"},{"category":"Nursing","chartdate":"2175-01-28 00:00:00.000","description":"Nursing Progress Note","row_id":713926,"text":"74M s/p fall with multiple rib fx, pelvis fx, clavicle fx, and thoracic\n fx c/b unstable bleeding s/p IR embo, AF with RVR, hematologic\n abnomalities.\n"},{"category":"Physician ","chartdate":"2175-01-29 00:00:00.000","description":"Intensivist Note","row_id":713985,"text":"TSICU\n HPI:\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\n checked and 1.5, 1 more unit FFP given.\n Chief complaint:\n pain\n PMHx:\n none\n Current medications:\n Acetaminophen 3. Bisacodyl 4. CeftriaXONE 5. Chlorhexidine Gluconate\n 0.12% Oral Rinse 6. Dextrose 50%\n 7. Diltiazem 8. Docusate Sodium (Liquid) 9. Fentanyl Citrate 10.\n Furosemide 11. Furosemide 12. Gabapentin\n 13. Glucagon 14. HYDROmorphone (Dilaudid) 15. Insulin 16. Magnesium\n Sulfate 17. Metoprolol Tartrate\n 18. Midazolam 19. Omeprazole 20. Ondansetron 21. Phenylephrine 22.\n Pneumococcal Vac Polyvalent 23. Potassium Phosphate\n 24. Potassium Chloride 25. Propofol 26. Senna 27. Sodium Chloride 0.9%\n Flush\n 24 Hour Events:\n : agitated w/HTN, tachycardia, incr fent/midaz w/some resolution.\n weaned cpap to -->desat-->incr to & improved hr & BP. started\n dilaudid, incr neurontin 300''', d/c'd H2B decr plt. lasix bolus\n 10, gtt. R ankle films (ecchymosis/edema) WNL. BAL: KLEBSIELLA\n PNEUMONIAE & GNRs-ceftriaxone started\n Post operative day:\n POD#3 - IVC filter via L groin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Furosemide (Lasix) - 5 mg/hour\n Fentanyl (Concentrate) - 50 mcg/hour\n Other ICU medications:\n Fentanyl - 02:15 PM\n Furosemide (Lasix) - 06:19 PM\n Labetalol - 07:00 PM\n Midazolam (Versed) - 04:00 AM\n Hydromorphone (Dilaudid) - 04:00 AM\n Other medications:\n Flowsheet Data as of 06:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.2\nC (99\n T current: 36.9\nC (98.4\n HR: 98 (79 - 127) bpm\n BP: 105/51(69) {91/41(58) - 185/74(110)} mmHg\n RR: 0 (0 - 26) insp/min\n SPO2: 95%\n Heart rhythm: 1st AV (First degree AV Block)\n Wgt (current): 102 kg (admission): 90 kg\n CVP: 8 (6 - 15) mmHg\n Total In:\n 1,861 mL\n 741 mL\n PO:\n Tube feeding:\n 1,330 mL\n 521 mL\n IV Fluid:\n 221 mL\n 160 mL\n Blood products:\n Total out:\n 2,010 mL\n 1,195 mL\n Urine:\n 2,010 mL\n 1,195 mL\n NG:\n Stool:\n Drains:\n Balance:\n -149 mL\n -454 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 540 (456 - 634) mL\n PS : 5 cmH2O\n RR (Spontaneous): 14\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 34\n PIP: 11 cmH2O\n SPO2: 95%\n ABG: 7.42/56/114/33/10\n Ve: 8 L/min\n PaO2 / FiO2: 285\n Physical Examination\n General Appearance: No acute distress, Well nourished\n HEENT: EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: bibasilar)\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present, Obese\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities, Sedated\n Labs / Radiology\n 86 K/uL\n 10.1 g/dL\n 141 mg/dL\n 0.8 mg/dL\n 33 mEq/L\n 3.6 mEq/L\n 19 mg/dL\n 106 mEq/L\n 143 mEq/L\n 29.3 %\n 6.5 K/uL\n [image002.jpg]\n 05:24 AM\n 06:50 AM\n 02:40 PM\n 03:13 PM\n 01:59 AM\n 02:00 AM\n 11:04 AM\n 01:17 PM\n 02:55 AM\n 04:11 AM\n WBC\n 11.0\n 8.0\n 5.6\n 6.5\n Hct\n 30.1\n 29.8\n 28.7\n 29.3\n Plt\n 97\n 80\n 74\n 86\n Creatinine\n 0.8\n 0.8\n 0.8\n TCO2\n 30\n 33\n 35\n 34\n 34\n 38\n Glucose\n 133\n 125\n 128\n 141\n Other labs: PT / PTT / INR:12.9/26.8/1.1, CK / CK-MB / Troponin\n T:1334/13/<0.01, ALT / AST:109/96, Alk-Phos / T bili:66/3.6, Amylase /\n Lipase:44/, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic Acid:1.4\n mmol/L, Albumin:2.7 g/dL, LDH:435 IU/L, Ca:7.7 mg/dL, Mg:1.9 mg/dL,\n PO4:3.0 mg/dL\n Imaging: CT head OSH: Prelim No ICH or fx.\n CT chest OSH: Mult rib fx: R anterolateral and posterior, L\n posterior; Dependent consolidation, possible aspiration; T4 vertebral\n body inf corner fx, no retropulsion; Comminuted spinous process fx\n T2-8; Nondisplaced L T10 transverse process; Nondisplaced L clavicle\n distal fx; Nondisplaced L scapula fx;\n CT c spine OSH: Prelim No fx or malalignment. Multilevel\n degenerative changes w/large post disk bulge at C4-5, narrowing the\n spinal canal and deforming the thecal sac, acuity unknown. Marked\n neuroforamenal narrowing @multiple levels.\n CTA abd/pel Prelim: Medial R liver lobe contusion w/adj\n hematoma, w/o evidence of active bleeding; Comminuted L pubic ramus\n fracture w/assoc hematoma, with tiny focus of arterial bleeding/active\n extravasation, and larger area of venous bleeding. Hematoma somewhat\n larger than on OSH study. Nondisplaced, comminuted L iliac bone fx\n w/adj iliac muscle hematoma, larger than on prior study, w/o active\n extrav. Fx extends into L SIJ. Post R hepatic laceration/contusion\n adjacent to calcified granuloma, w/small hematoma, w/out active\n bleeding. Min displaced fx of R iliac bone extending to R SIJ.\n Cirrhotic liver. Inc B pl effusions (small), w/inc atelectasis.\n MRI: Mild compression deformity of L1 w/additional levels of\n potential trabecular contusion @T10-11 also inf @T4 w/o retropulsion.\n Multilevel degenerative changes with moderate canal narrowing at T10-11\n w/cord deformity and no abnormal cord signal. Extensive edema\n throughout paraspinal soft tissues, predominantly post w/in\n interspinous ligaments. Incompletely eval'ed c-spine w/severe canal\n narrowing @C4-5 w/cord deformity and no abnormal cord signal.\n CTA: no PE.\n CXR: Moderate bilateral pleural effusions are stable.\n CXR: Cardiac size top nl, interval improvement of collapse LLL.\n Collapse RLL. Atelectasis in lingula unchanged. Mod B\n pleural effusions stable. No PTX.\n CXR: Interval mild incr in cardiac size, b/l pleural effusions,\n and opacities @ bases,c/w overload\n : R foot: Linear density projecting @ expected area of insertion\n of the Achilles to calcaneus, may be min avulsion fx or degenerative\n changes. Otherwise no fx\n Microbiology: Ucx no growth final\n Sputum: sparse GNR\n Bcx P\n Bcx P\n 12/17 L BAL: KLEBSIELLA PNEUMONIAE, HAEMOPHILUS SPECIES NOT INFLUENZAE\n R BAL: KLEBSIELLA PNEUMONIAE & GNRs.\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, AF with\n RVR, hematologic abnomalities.\n Neurologic: Intubated on fentanyl gtt and Midazolam PRN (have not been\n giving). Per ortho spine, no surgery; HOB<30, TLSO when OOB (NEOPS will\n place).\n Neuro checks Q: shift\n Pain: Fentanyl gtt (trying to wean), dilaudid, Midazolam prn,\n Neurontin, Tylenol\n Cardiovascular: NSR currently, occasional tachycardia & HTN improved\n occasionally w/sedation. Metop started prn.\n Pulmonary: Intubated. Weaning to extubate (was on throughout\n , changed to 10/10 after desat). F/U on BAL: KLEBSIELLA PNEUMONIAE\n & GNRs/Haemophilus.\n SElf extubated , reintubated (increased edema, blind intubation\n w/bougie)\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin with CT scan\n suggesting cirrhosis - Hepatitis panel NEG. TFs advancing to goal.\n Bowel regimen.\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO, Foley, monitor UOP. Cr normalized. Lasix\n gtt started after bolus 10 mg x1 with goal even to neg 500cc.\n Hematology: Hct stable. Plt low but stable (100's); d/c'd H2B. Heme\n onc consulted - smear nl. IVC filter placed.\n Endocrine: RISS\n Infectious Disease: Check cultures, WBC normal, f/u Cx - BAL:\n Klebsiella (b/l)& GNRs (on R)/Haemophilus (on L). Started Ceftriaxone\n ()\n Lines / Tubes / Drains: R SC CVL (), PIV x2, Foley, L a-line\n (), ETT\n Wounds:\n Imaging: CXR today\n Fluids:\n Consults: Trauma (1o), Ortho Spine, Ortho trauma, Heme\n Billing Diagnosis: Multiple injuries (Trauma)\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 08:40 PM 80 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 04:41 PM\n Arterial Line - 11:30 AM\n Prophylaxis:\n DVT: Boots, IVC filter\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent:\n Patient is critically ill\n"},{"category":"Physician ","chartdate":"2175-01-30 00:00:00.000","description":"Intensivist Note","row_id":714085,"text":"TSICU\n HPI:\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\n checked and 1.5, 1 more unit FFP given.\n Chief complaint:\n Mult rib fx: R anterolateral and post, L posterior\n T4 vert body inf corner fx\n Commin spinous process fx T2-8\n Nondisplaced L T10 transverse process\n Nondispaced L distal clavicle\n Nondisplaced L clavicle fx\n R medial lobe liver contusion w/hematoma\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny focus of arterial\n bleeding/active extravasation, and larger area of venous bleeding\n Nondisplaced, comminuted L iliac bone fx w/adjacent iliac muscle\n hematoma, extends into L SIJ.\n Minimally displaced fx of R iliac bone extending to R SIJ.\n PMHx:\n None\n Current medications:\n Chlorhexidine Gluconate 0.12% Oral Rinse\n Diltiazem\n Furosemide\n Gabapentin\n Metoprolol Tartrate\n Ondansetron\n Phenylephrine\n 24 Hour Events:\n self-extubated in the AM, re-intubated over bougie, NGT replaced, \n with bilateral BALs sent, plan for trach later this week. T spike to\n 101.8 - u/a, urine cx, blood cxs sent. Diltiazem titrated to 60mg PO\n QID. ABX coverage broadened to Vanc/Zosyn. Tbili up to 6.8 (other LFTs\n trending down)\n Post operative day:\n POD#4 - IVC filter via L groin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 11:00 AM\n Piperacillin/Tazobactam (Zosyn) - 08:19 PM\n Vancomycin - 08:56 PM\n Infusions:\n Fentanyl (Concentrate) - 100 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Hydromorphone (Dilaudid) - 04:00 AM\n Metoprolol - 06:33 AM\n Pantoprazole (Protonix) - 02:00 PM\n Midazolam (Versed) - 12:30 AM\n Other medications:\n Flowsheet Data as of 02:07 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.8\nC (101.8\n T current: 37.2\nC (98.9\n HR: 76 (76 - 103) bpm\n BP: 97/51(67) {86/47(62) - 121/858(84)} mmHg\n RR: 18 (0 - 25) insp/min\n SPO2: 99%\n Heart rhythm: A Flut (Atrial Flutter)\n Wgt (current): 102 kg (admission): 90 kg\n CVP: 11 (6 - 18) mmHg\n Total In:\n 3,114 mL\n 207 mL\n PO:\n Tube feeding:\n 1,301 mL\n 148 mL\n IV Fluid:\n 1,682 mL\n 59 mL\n Blood products:\n Total out:\n 2,500 mL\n 180 mL\n Urine:\n 2,500 mL\n 180 mL\n NG:\n Stool:\n Drains:\n Balance:\n 614 mL\n 27 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 540 (540 - 540) mL\n PS : 5 cmH2O\n RR (Set): 15\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI: 34\n PIP: 26 cmH2O\n Plateau: 23 cmH2O\n Compliance: 42.3 cmH2O/mL\n SPO2: 99%\n ABG: 7.44/50/127/34/8\n Ve: 9.5 L/min\n PaO2 / FiO2: 254\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: Aflutter\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present,\n Stable scrotal edema/hematoma, soft, no crepitus\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: Follows simple commands, Moves all extremities, Sedated\n Labs / Radiology\n 158 K/uL\n 10.7 g/dL\n 115 mg/dL\n 0.8 mg/dL\n 34 mEq/L\n 4.0 mEq/L\n 20 mg/dL\n 111 mEq/L\n 148 mEq/L\n 31.6 %\n 13.1 K/uL\n [image002.jpg]\n 01:59 AM\n 02:00 AM\n 11:04 AM\n 01:17 PM\n 02:55 AM\n 04:11 AM\n 09:45 AM\n 04:45 PM\n 12:45 AM\n 01:00 AM\n WBC\n 5.6\n 6.5\n 13.1\n Hct\n 28.7\n 29.3\n 31.6\n Plt\n 74\n 86\n 158\n Creatinine\n 0.8\n 0.8\n 0.8\n TCO2\n 35\n 34\n 34\n 38\n 37\n 35\n 35\n Glucose\n 125\n 128\n 141\n 107\n 131\n 115\n Other labs: PT / PTT / INR:13.9/26.9/1.2, CK / CK-MB / Troponin\n T:1334/13/<0.01, ALT / AST:90/88, Alk-Phos / T bili:63/6.8, Amylase /\n Lipase:44/, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic Acid:1.2\n mmol/L, Albumin:2.7 g/dL, LDH:348 IU/L, Ca:8.4 mg/dL, Mg:2.1 mg/dL,\n PO4:2.9 mg/dL\n Imaging: CT head OSH: Prelim No ICH or fx.\n CT chest OSH: Mult rib fx: R anterolateral and posterior, L\n posterior; Dependent consolidation, possible aspiration; T4 vertebral\n body inf corner fx, no retropulsion; Comminuted spinous process fx\n T2-8; Nondisplaced L T10 transverse process; Nondisplaced L clavicle\n distal fx; Nondisplaced L scapula fx;\n CT c spine OSH: Prelim No fx or malalignment. Multilevel\n degenerative changes w/large post disk bulge at C4-5, narrowing the\n spinal canal and deforming the thecal sac, acuity unknown. Marked\n neuroforamenal narrowing @multiple levels.\n CTA abd/pel Prelim: Medial R liver lobe contusion w/adj\n hematoma, w/o evidence of active bleeding; Comminuted L pubic ramus\n fracture w/assoc hematoma, with tiny focus of arterial bleeding/active\n extravasation, and larger area of venous bleeding. Hematoma somewhat\n larger than on OSH study. Nondisplaced, comminuted L iliac bone fx\n w/adj iliac muscle hematoma, larger than on prior study, w/o active\n extrav. Fx extends into L SIJ. Post R hepatic laceration/contusion\n adjacent to calcified granuloma, w/small hematoma, w/out active\n bleeding. Min displaced fx of R iliac bone extending to R SIJ.\n Cirrhotic liver. Inc B pl effusions (small), w/inc atelectasis.\n MRI: Mild compression deformity of L1 w/additional levels of\n potential trabecular contusion @T10-11 also inf @T4 w/o retropulsion.\n Multilevel degenerative changes with moderate canal narrowing at T10-11\n w/cord deformity and no abnormal cord signal. Extensive edema\n throughout paraspinal soft tissues, predominantly post w/in\n interspinous ligaments. Incompletely eval'ed c-spine w/severe canal\n narrowing @C4-5 w/cord deformity and no abnormal cord signal.\n CTA: no PE.\n CXR: Moderate bilateral pleural effusions are stable.\n CXR: Cardiac size top nl, interval improvement of collapse LLL.\n Collapse RLL. Atelectasis in lingula unchanged. Mod B\n pleural effusions stable. No PTX.\n CXR: Interval mild incr in cardiac size, b/l pleural effusions,\n and opacities @ bases,c/w overload\n : R foot: Linear density projecting @ expected area of insertion\n of the Achilles to calcaneus, may be min avulsion fx or degenerative\n changes. Otherwise no fx\n CXR: bilateral pleural effusions\n Microbiology: Ucx no growth final\n Sputum: sparse GNR\n Bcx P\n Bcx P\n 12/17 L BAL: KLEBSIELLA PNEUMONIAE, HAEMOPHILUS SPECIES NOT INFLUENZAE\n R BAL: KLEBSIELLA PNEUMONIAE & GNRs.\n 12/20 L BAL: gram + cocci pairs on gram stain\n R BAL: gram + cocci pairs on gram stain\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, AF with\n RVR, hematologic abnomalities.\n Neurologic: Intubated on Fentanyl/Versed gtt. Per ortho spine, no\n surgery; HOB<30, TLSO when OOB (NEOPS will place). Neuro checks q\n shift.\n Cardiovascular: Aflutter on Dilt 60mg PO QID. Still on Neo. Likely\n needs chemical/electrical cardioversion to improve atrial contribution\n to CO\n Pulmonary: Intubated. Weaning to extubate (was on throughout\n , changed to 10/10 after desat, but self-extubated and reintubated\n am). F/U on BAL: KLEBSIELLA PNEUMONIAE & GNRs/Haemophilus. Repeat\n BAL with gram+ cocci in pairs on gram stain. Ceftriaxone ()\n changed to Vancomycin/Zosyn (). Plan for Trach early this week.\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin with CT scan\n suggesting cirrhosis - Hepatitis panel NEG. TFs advancing to goal.\n Bowel regimen. Tbili trending up (6.8), other LFTs improving.\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO, Foley, monitor UOP. Cr normalized.\n Hematology: Hct and Plt stable; d/c'd H2B\n Endocrine: RISS\n Infectious Disease: WBC increasing to 13.1, f/u Cx - BAL: Klebsiella\n (b/l)& GNRs (on R)/Haemophilus (on L). Started Ceftriaxone (),\n broadened to Zosyn/Vanc () for continued fevers and gram+ on BAL\n Lines / Tubes / Drains: R SC CVL (), PIV x2, Foley, L a-line\n (), ETT\n Wounds:\n Imaging: CXR today\n Fluids: KVO\n Consults: Trauma surgery, Ortho, Ortho-spine, Heme\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 01:00 PM 80 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 04:41 PM\n Arterial Line - 11:30 AM\n Prophylaxis:\n DVT: (IVC filter, SCDs)\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n"},{"category":"Respiratory ","chartdate":"2175-01-30 00:00:00.000","description":"Respiratory Care Shift Note","row_id":714188,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 6\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: pt weaned to PSV 10/10 tolerated well all shift abgs wnl\n Assessment of breathing comfort: No claim of dyspnea)\n Plan\n Next 24-48 hours: Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n"},{"category":"Nursing","chartdate":"2175-02-01 00:00:00.000","description":"Nursing Progress Note","row_id":714542,"text":"74M s/p crushing injury d/t falling tree. Injuries sustained include\n multiple R sided rib fxs, grade 2 liver lac (w/ assoc hepatic vessel\n extravasation), stable pelvis fxs (w/ associated extravasation), R\n ramus fx, clavicle fx, and T4 vertebral body fx. Episodes of A.\n Flutter with RVR and aflutter, now with resp failure and newly dx\n pneumonia as of .\n intubated for resp distress\n angio embolization of hepatic and pelvic arterial bleeders\n IVC filter in OR\n self extubated and re-intubated immediately after d/t acute resp.\n failure\n Trach and PEG at bedside\n Atrial fibrillation (Afib)\n Assessment:\n Atrial flutter continues, RVR up to 130s this AM. Now rate controlled\n <100.\n Action:\n PO dilt, amioderone gtt continued, Neo gtt titrated for adequate BP\n control.\n Response:\n Rate controlled after PO Dilt.\n Plan:\n Continue Amio gtt, switch to PO amio, ? Cardio version,? Anticoagulant.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Post trach pt back on CPAP 10/10/50%. Ls clear to diminish at bases.\n Strong productive cough, suctioned for copious amounts of thick blood\n tinged secretions. ABG stable.\n Action:\n Trach and PEG at bedside, continue pulmonary toileting.\n Response:\n Tolerated procedure without issue.\n Plan:\n Wean vent settings as tolerated, pulmonary toileting, wean sedation.\n"},{"category":"Physician ","chartdate":"2175-02-04 00:00:00.000","description":"Intensivist Note","row_id":714930,"text":"TSICU\n HPI:\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\n checked and 1.5, 1 more unit FFP given.\n Chief complaint:\n Mult rib fx: R anterolateral and post, L posterior\n T4 vert body inf corner fx\n Commin spinous process fx T2-8\n Nondisplaced L T10 transverse process\n Nondispaced L distal clavicle\n Nondisplaced L clavicle fx\n R medial lobe liver contusion w/hematoma\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny focus of arterial\n bleeding/active extravasation, and larger area of venous bleeding\n Nondisplaced, comminuted L iliac bone fx w/adjacent iliac muscle\n hematoma, extends into L SIJ.\n Minimally displaced fx of R iliac bone extending to R SIJ.\n PMHx:\n PMH: cirrhosis and asbestosis dx on CT\n PSH: None\n Current medications:\n 1. 2. 3. Acetaminophen 4. Amiodarone 5. Bisacodyl 6. Calcium Gluconate\n 7. CefePIME 8. Chlorhexidine Gluconate 0.12% Oral Rinse\n 9. Ciprofloxacin HCl 10. Dextrose 50% 11. Diltiazem 12. Docusate Sodium\n (Liquid) 13. Furosemide\n 14. Gabapentin 15. Glucagon 16. Haloperidol 17. Haloperidol 18. Heparin\n 19. Insulin 20. Lactulose\n 21. Lansoprazole Oral Disintegrating Tab 22. Magnesium Sulfate 23.\n Metoprolol Tartrate 24. Metoprolol Tartrate\n 25. Milk of Magnesia 26. Olanzapine (Disintegrating Tablet) 27.\n Ondansetron 28. OxycoDONE Liquid\n 29. Pneumococcal Vac Polyvalent 30. Potassium Phosphate 31. Potassium\n Chloride 32. Senna 33. Sodium Chloride 0.9% Flush\n 34. Sodium Chloride 0.9% Flush 35. Vancomycin\n 24 Hour Events:\n Back to Aflutter with HR in 120's. Stable BP. Given Lopressor with\n adequate rate control but no conversion. Eventually placed on a Dilt\n gtt. Pt converted to NSR. Maintained on Amio PO. TF switched to\n Nutren 2 in order to limit fluids, pt getting Lasix 20 q6 with net neg\n of 1500 cc. US of LE done to r/o clot as cause of fever.\n Post operative day:\n POD#9 - IVC filter via L groin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 03:00 PM\n Vancomycin - 08:09 PM\n Ciprofloxacin - 10:08 PM\n Cefipime - 12:00 AM\n Infusions:\n Other ICU medications:\n Midazolam (Versed) - 12:45 PM\n Lorazepam (Ativan) - 01:39 PM\n Metoprolol - 01:54 PM\n Furosemide (Lasix) - 06:52 PM\n Heparin Sodium (Prophylaxis) - 08:09 PM\n Other medications:\n Flowsheet Data as of 05:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.9\nC (100.3\n T current: 37.7\nC (99.8\n HR: 96 (75 - 125) bpm\n BP: 132/60(83) {121/51(73) - 169/88(115)} mmHg\n RR: 16 (16 - 33) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 104.2 kg (admission): 90 kg\n CVP: 19 (17 - 19) mmHg\n Total In:\n 2,563 mL\n 512 mL\n PO:\n Tube feeding:\n 1,482 mL\n 211 mL\n IV Fluid:\n 821 mL\n 300 mL\n Blood products:\n Total out:\n 4,060 mL\n 635 mL\n Urine:\n 4,055 mL\n 635 mL\n NG:\n 5 mL\n Stool:\n Drains:\n Balance:\n -1,497 mL\n -123 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 554 (380 - 554) mL\n PS : 15 cmH2O\n RR (Spontaneous): 18\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 27 cmH2O\n SPO2: 99%\n ABG: 7.53/39/124/33/9\n Ve: 14.2 L/min\n PaO2 / FiO2: 248\n Physical Examination\n General Appearance: Overweight / Obese, Tracheostomy\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : , Crackles : b/l bases)\n Abdominal: Soft, Non-tender, Obese\n Left Extremities: (Edema: 1+), (Temperature: Warm)\n Right Extremities: (Edema: 1+), (Temperature: Warm)\n Skin: Jaundice\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities, Pt appears to be confused this AM.\n Labs / Radiology\n 124 K/uL\n 9.3 g/dL\n 103 mg/dL\n 0.8 mg/dL\n 33 mEq/L\n 3.9 mEq/L\n 21 mg/dL\n 107 mEq/L\n 144 mEq/L\n 29.0 %\n 6.5 K/uL\n [image002.jpg]\n 01:00 AM\n 01:07 AM\n 01:18 AM\n 02:05 AM\n 03:54 AM\n 05:17 AM\n 01:23 PM\n 07:20 PM\n 12:35 AM\n 01:04 AM\n WBC\n 5.9\n 6.3\n 6.5\n Hct\n 31.3\n 28.9\n 29.0\n Plt\n 109\n 128\n 124\n Creatinine\n 0.8\n 0.8\n 0.8\n 0.8\n TCO2\n 35\n 34\n 35\n 34\n Glucose\n 117\n 110\n 138\n 136\n 130\n 103\n Other labs: PT / PTT / INR:13.7/27.6/1.2, CK / CK-MB / Troponin\n T:128/13/<0.01, ALT / AST:90/122, Alk-Phos / T bili:133/5.4, Amylase /\n Lipase:54/52, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic\n Acid:1.4 mmol/L, Albumin:2.3 g/dL, LDH:348 IU/L, Ca:7.7 mg/dL, Mg:2.2\n mg/dL, PO4:2.7 mg/dL\n Imaging: RUQ U/S: No perihepatic fluid collection. small amt\n perihepatic free fluid persists. Small contusion in hepatic segment\n VII. No\n gallstones or sig wall thickening/edema. CBD 4.5 mm\n TTE: LVEF >55%, NL diastolic function, NL LV filling pressure\n (PCWP<12mmHg), RV chamber size mildly dilated, mild TR\n CXR: mild b/l pulm edema and parenchymal opacities and no\n pl effusion.\n CXR: Persistent b/l pl effusions and bibasilar opacity.\n CXR: Minimal improvement of mod b/l pl effusions. Otherwise\n stable.\n CXR: no relevant change. B/L pleural effusions with basal\n opacities. No evidence of newly appeared focal parenchymal opacities\n suggesting pneumonia.\n : No dvt\n Microbiology: Ucx no growth final\n Sputum: sparse GNRs, too few to colonize\n Bcx x2 no growth final\n 12/17 L BAL: Klebsiella Pneumoniae, HAEMOPHILUS SPECIES NOT INFLUENZAE\n R BAL: Klebsiella Pneumoniae, Proteus.\n 12/20 L &R BAL: Klebsiella Pneumoniae\n BCX: p\n BCx: P\n UCx: no growth final\n BCx: P\n BCx: P\n UCx: P\n SpCx: contamination\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, now\n with AF with RVR/Aflutter, persistant hypotension and PNA.\n Neurologic: Neuro checks Q: 4 hr, s/p trach (). Per ortho spine,\n no surgery; HOB<30, TLSO when OOB. Zyprexa & Haldol PRN (off fent/midaz\n ).\n Pain: Oxycodone, Neurontin, Tylenol.\n Cardiovascular: Aflutter->NSR, on Amio and dilt gtt, will need to\n transition to PO meds. Likely cardiac contusion. Cards for Amio rec\n 400'' x 1wk, then 400'x1 wk, then 200'. Pt cannot be fully\n anticoagulated for now (trauma).\n Pulmonary: Trach, Trach, weaning vent, Vanc/cipro/cefepime for VAP\n (). Increasing pulmonary edema on CXR. consider therapeutic\n thoracentesis 12/26-7 if no improvement on Lasix, lots of secretions,\n consider bronchoscopy\n Gastrointestinal / Abdomen: Unknown elevated LFTs and bilirubin w/CT\n scan suggesting cirrhosis - Hepatitis panel NEG, RUQ U/S r/o\n gallbladder etiology, will continue to trend. On Nutren 2.0 with goal\n 40 cc/hr. Bowel regimen.\n Nutrition: Tube feeding\n Renal: Foley, Foley, monitor UOP, edematous scrotum. Lasix 20 Q6,\n developing contraction alk, consider switching to acetazolamide\n Hematology: Hct stable 28.9->29. Plt stable (100's); d/c'd H2B. Heme\n onc c/s - smear nl; no hemolysis. IVC filter placed.\n Endocrine: RISS, RISS\n Infectious Disease: Check cultures, WBC normal, on Vanc/cipro/cefepime\n for VAP given worsening pulm status, f/u on cx\n Lines / Tubes / Drains: Trach/Peg/foley/L radial a-line/R SCL\n Wounds:\n Imaging: CXR today\n Fluids: KVO\n Consults: Trauma (1o), Ortho Spine, Ortho trauma, Heme\n Billing Diagnosis: Multiple injuries (Trauma)\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 01:00 PM 40 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 04:41 PM\n Arterial Line - 11:30 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin, IVC filter\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n"},{"category":"Nursing","chartdate":"2175-01-27 00:00:00.000","description":"Nursing Progress Note","row_id":713792,"text":"Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains orally intubated and vented. Pt was on CMV this AM. Lung\n sounds clear in the upper lobes, diminished at the bases bilaterally.\n Daily CXR continue. ABGs show fully compensated metabolic alkalosis.\n Suctioned for thick, yellow/white secretions. Pt has strong,\n productive/congested cough. O2 sat 99-100%.\n Action:\n Vent changed from CMV to MMV 12/12/40%. Pt suctioned as needed. Pt\n repositioned frequently. Tube feeds increased to goal (Replete with\n Fiber FS).\n Response:\n Pt tolerating vent setting, remains afebrile.\n Plan:\n Continue to wean vent as tolerated. Follow up with BAL cultures sent\n on . Start antibiotics? Continue to support pt and family. PT\n consulted, plan to visit pt over the weekend in the event that he is\n extubated.\n Hypotension (not Shock)\n Assessment:\n BP low 80\ns when off neo, on low doses of neo throughout the day.\n Propofol gtt continues for sedation. Pt is uncomfortable being awake\n and off propofol, he is agitated, anxious, and reaches for the ET tube\n as well as sits up in bed. HR converted to NSR early this AM,\n diltiazem gtt stopped. Pt having PAC\ns in the afternoon, electrolytes\n WNL when checked. Pt is edematous throughout, CVP 13, PPV .\n Scrotum is edematous and purple since OR trip last evening (? From IVC\n filter placement?). HCT remains stable. UO marginal, clear, icteric.\n Tube feeds started at midnight.\n Action:\n Heme consulted, recommended starting vitamin K and possibly antibiotics\n for gram negative rods found in sputum. Neo gtt titrated throughout\n the day. Pt remains sedated on propofol, titrated as tolerated.\n Diltiazem 30mg QID PO started. Fluid challenge done this AM with\n little effect. Tube feeds increasing to goal, IV fluids turned off\n when tube feeds reached goal.\n Response:\n Pt becoming more awake on current doses of propofol, had to increase\n gtt to adequately sedate pt. HR remains NSR but with PAC\ns. BP\n remains low and requiring small doses of neo. Pt tolerating goal tube\n feeds well, minimal residuals.\n Plan:\n Start vitamin K (per heme)? Wean neo as tolerated. Consider albumin\n or hespan to draw in fluid from extravascular spaces. Continue goal\n tube feeds. Monitor coags. Continue to support pt and family.\n"},{"category":"Nursing","chartdate":"2175-01-29 00:00:00.000","description":"Nursing Progress Note","row_id":713986,"text":"74M s/p fall with multiple rib fx, pelvis fx, clavicle fx, and thoracic\n fx c/b unstable bleeding s/p IR embo, AF with RVR, hematologic\n abnomalities.\n Atrial fibrillation (Afib)\n Assessment:\n Remains in 1^st degree HB. HR to 120\ns with agitation, anxiety.\n Action:\n Continues on Fentanyl gtt, Receiving Dilaudid IV and Midazolam for\n pain & agitation.\n Response:\n Good response with meds for pain, agitation, and anxiety.\n Plan:\n Cont to asses rhythm, BP. Metoprolol PRN for HR > 90, SBP > 150\n Respiratory failure, acute (not ARDS/)\n Assessment:\n BBS= essentially clear throughout all lung fields.\n Action:\n Rested overnight on CPAP/PS. Lasix gtt initiated for diuresis.\n Suctioned Q1-2 hrs for moderate amounts thick, pale yellow secretions.\n Klebsiella growing from sputum\n Response:\n Appears comfortable, no SOB noted or increased WOB.\n Plan:\n Goal for pt to be -500cc, will move towards extubation this morning as\n pt tolerates.\n Trauma, s/p\n Assessment:\n Multiple echymotic areas over head torso, extremities. Scrotum\n echymotic, edematous.\n Action:\n Managing pain with Fentanyl gtt, Dilaudid & Midazolam IV. Scrotum\n elevated\n Response:\n Currently denies pain.\n Plan:\n Fentanyl gtt overnight. Keep scrotum elevated.\n ------ Protected Section ------\n At 630 pt tongued ETT and self extubated. Unable to maintain sats or\n protect airway- emergently reintubated. Pt tolerated well.\n ------ Protected Section Addendum Entered By: , RN\n on: 06:54 ------\n"},{"category":"Physician ","chartdate":"2175-01-30 00:00:00.000","description":"Intensivist Note","row_id":714190,"text":"TSICU\n HPI:\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\n checked and 1.5, 1 more unit FFP given.\n Chief complaint:\n Mult rib fx: R anterolateral and post, L posterior\n T4 vert body inf corner fx\n Commin spinous process fx T2-8\n Nondisplaced L T10 transverse process\n Nondispaced L distal clavicle\n Nondisplaced L clavicle fx\n R medial lobe liver contusion w/hematoma\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny focus of arterial\n bleeding/active extravasation, and larger area of venous bleeding\n Nondisplaced, comminuted L iliac bone fx w/adjacent iliac muscle\n hematoma, extends into L SIJ.\n Minimally displaced fx of R iliac bone extending to R SIJ.\n PMHx:\n None\n Current medications:\n Chlorhexidine Gluconate 0.12% Oral Rinse\n Diltiazem\n Furosemide\n Gabapentin\n Metoprolol Tartrate\n Ondansetron\n Phenylephrine\n 24 Hour Events:\n Self-extubated in the AM, re-intubated over bougie, NGT replaced,\n bronch with bilateral BALs sent, plan for trach later this week. T\n spike to 101.8 - u/a, urine cx, blood cxs sent. Diltiazem titrated to\n 60mg PO QID. ABX coverage broadened to Vanc/Zosyn. Tbili up to 6.8\n (other LFTs trending down)\n Post operative day:\n POD#4 - IVC filter via L groin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 11:00 AM\n Piperacillin/Tazobactam (Zosyn) - 08:19 PM\n Vancomycin - 08:56 PM\n Infusions:\n Fentanyl (Concentrate) - 100 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Hydromorphone (Dilaudid) - 04:00 AM\n Metoprolol - 06:33 AM\n Pantoprazole (Protonix) - 02:00 PM\n Midazolam (Versed) - 12:30 AM\n Other medications:\n Flowsheet Data as of 02:07 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.8\nC (101.8\n T current: 37.2\nC (98.9\n HR: 76 (76 - 103) bpm\n BP: 97/51(67) {86/47(62) - 121/858(84)} mmHg\n RR: 18 (0 - 25) insp/min\n SPO2: 99%\n Heart rhythm: A Flut (Atrial Flutter)\n Wgt (current): 102 kg (admission): 90 kg\n CVP: 11 (6 - 18) mmHg\n Total In:\n 3,114 mL\n 207 mL\n PO:\n Tube feeding:\n 1,301 mL\n 148 mL\n IV Fluid:\n 1,682 mL\n 59 mL\n Blood products:\n Total out:\n 2,500 mL\n 180 mL\n Urine:\n 2,500 mL\n 180 mL\n NG:\n Stool:\n Drains:\n Balance:\n 614 mL\n 27 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 540 (540 - 540) mL\n PS : 5 cmH2O\n RR (Set): 15\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI: 34\n PIP: 26 cmH2O\n Plateau: 23 cmH2O\n Compliance: 42.3 cmH2O/mL\n SPO2: 99%\n ABG: 7.44/50/127/34/8\n Ve: 9.5 L/min\n PaO2 / FiO2: 254\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: Aflutter\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present,\n Stable scrotal edema/hematoma, soft, no crepitus\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: Follows simple commands, Moves all extremities, Sedated\n Labs / Radiology\n 158 K/uL\n 10.7 g/dL\n 115 mg/dL\n 0.8 mg/dL\n 34 mEq/L\n 4.0 mEq/L\n 20 mg/dL\n 111 mEq/L\n 148 mEq/L\n 31.6 %\n 13.1 K/uL\n [image002.jpg]\n 01:59 AM\n 02:00 AM\n 11:04 AM\n 01:17 PM\n 02:55 AM\n 04:11 AM\n 09:45 AM\n 04:45 PM\n 12:45 AM\n 01:00 AM\n WBC\n 5.6\n 6.5\n 13.1\n Hct\n 28.7\n 29.3\n 31.6\n Plt\n 74\n 86\n 158\n Creatinine\n 0.8\n 0.8\n 0.8\n TCO2\n 35\n 34\n 34\n 38\n 37\n 35\n 35\n Glucose\n 125\n 128\n 141\n 107\n 131\n 115\n Other labs: PT / PTT / INR:13.9/26.9/1.2, CK / CK-MB / Troponin\n T:1334/13/<0.01, ALT / AST:90/88, Alk-Phos / T bili:63/6.8, Amylase /\n Lipase:44/, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic Acid:1.2\n mmol/L, Albumin:2.7 g/dL, LDH:348 IU/L, Ca:8.4 mg/dL, Mg:2.1 mg/dL,\n PO4:2.9 mg/dL\n Imaging: CT head OSH: Prelim No ICH or fx.\n CT chest OSH: Mult rib fx: R anterolateral and posterior, L\n posterior; Dependent consolidation, possible aspiration; T4 vertebral\n body inf corner fx, no retropulsion; Comminuted spinous process fx\n T2-8; Nondisplaced L T10 transverse process; Nondisplaced L clavicle\n distal fx; Nondisplaced L scapula fx;\n CT c spine OSH: Prelim No fx or malalignment. Multilevel\n degenerative changes w/large post disk bulge at C4-5, narrowing the\n spinal canal and deforming the thecal sac, acuity unknown. Marked\n neuroforamenal narrowing @multiple levels.\n CTA abd/pel Prelim: Medial R liver lobe contusion w/adj\n hematoma, w/o evidence of active bleeding; Comminuted L pubic ramus\n fracture w/assoc hematoma, with tiny focus of arterial bleeding/active\n extravasation, and larger area of venous bleeding. Hematoma somewhat\n larger than on OSH study. Nondisplaced, comminuted L iliac bone fx\n w/adj iliac muscle hematoma, larger than on prior study, w/o active\n extrav. Fx extends into L SIJ. Post R hepatic laceration/contusion\n adjacent to calcified granuloma, w/small hematoma, w/out active\n bleeding. Min displaced fx of R iliac bone extending to R SIJ.\n Cirrhotic liver. Inc B pl effusions (small), w/inc atelectasis.\n MRI: Mild compression deformity of L1 w/additional levels of\n potential trabecular contusion @T10-11 also inf @T4 w/o retropulsion.\n Multilevel degenerative changes with moderate canal narrowing at T10-11\n w/cord deformity and no abnormal cord signal. Extensive edema\n throughout paraspinal soft tissues, predominantly post w/in\n interspinous ligaments. Incompletely eval'ed c-spine w/severe canal\n narrowing @C4-5 w/cord deformity and no abnormal cord signal.\n CTA: no PE.\n CXR: Moderate bilateral pleural effusions are stable.\n CXR: Cardiac size top nl, interval improvement of collapse LLL.\n Collapse RLL. Atelectasis in lingula unchanged. Mod B\n pleural effusions stable. No PTX.\n CXR: Interval mild incr in cardiac size, b/l pleural effusions,\n and opacities @ bases,c/w overload\n : R foot: Linear density projecting @ expected area of insertion\n of the Achilles to calcaneus, may be min avulsion fx or degenerative\n changes. Otherwise no fx\n CXR: bilateral pleural effusions\n Microbiology: Ucx no growth final\n Sputum: sparse GNR\n Bcx P\n Bcx P\n 12/17 L BAL: KLEBSIELLA PNEUMONIAE, HAEMOPHILUS SPECIES NOT INFLUENZAE\n R BAL: KLEBSIELLA PNEUMONIAE & GNRs.\n 12/20 L BAL: gram + cocci pairs on gram stain\n R BAL: gram + cocci pairs on gram stain\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, AF with\n RVR, hematologic abnomalities.\n Neurologic: Intubated on Fentanyl/Versed gtt. Per ortho spine, no\n surgery; HOB<30, TLSO when OOB (NEOPS will place). Neuro checks q\n shift.\n Cardiovascular: Aflutter on Dilt 60mg PO QID. Still on Neo. Likely\n needs chemical/electrical cardioversion to improve atrial contribution\n to CO\n Pulmonary: Intubated. Weaning to extubate (was on throughout\n , changed to 10/10 after desat, but self-extubated and reintubated\n am). F/U on BAL: KLEBSIELLA PNEUMONIAE & GNRs/Haemophilus. Repeat\n BAL with gram+ cocci in pairs on gram stain. Ceftriaxone ()\n changed to Vancomycin/Zosyn (). Plan for Trach early this week.\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin with CT scan\n suggesting cirrhosis - Hepatitis panel NEG. TFs advancing to goal.\n Bowel regimen. Tbili trending up (6.8), other LFTs improving.\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO, Foley, monitor UOP. Cr normalized.\n Hematology: Hct and Plt stable; d/c'd H2B\n Endocrine: RISS\n Infectious Disease: WBC increasing to 13.1, f/u Cx - BAL: Klebsiella\n (b/l)& GNRs (on R)/Haemophilus (on L). Started Ceftriaxone (),\n broadened to Zosyn/Vanc () for continued fevers and gram+ on BAL\n Lines / Tubes / Drains: R SC CVL (), PIV x2, Foley, L a-line\n (), ETT\n Wounds:\n Imaging: CXR today\n Fluids: KVO\n Consults: Trauma surgery, Ortho, Ortho-spine, Heme\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 01:00 PM 80 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 04:41 PM\n Arterial Line - 11:30 AM\n Prophylaxis:\n DVT: (IVC filter, SCDs)\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 32 minutes\n"},{"category":"Nursing","chartdate":"2175-01-31 00:00:00.000","description":"Nursing Progress Note","row_id":714356,"text":"Atrial fibrillation (Afib)\n Assessment:\n Pt continues in aflutter, controlled rate 70\ns-80\ns, rare PVCs noted.\n Pt continues on diltiazem 60mg PO tid. Atrial flutter thought to be\n from cardiac contusion as a result of the pt\ns injury.\n Action:\n Cardiology consult obtained as well as electrophysiology consult to\n discuss possibility of cardioversion to correct pt\ns aflutter. Pt\n ultimately started on amiodarone gtt without bolus as recommended by\n cards team and ordered by ICU team.\n Response:\n Pt continues on diltiazem PO while on amiodarone gtt. Pt remains in\n atrial flutter at time of note. HR remains in the 70-80\n Plan:\n Continue amiodarone, change dose to .5mg/hr at 17:45 tonight per order\n for 18 hrs. Monitor HR and rhythm closely and attempt to wean neo as\n tolerated to support heart.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lung sounds clear in the upper lobes, diminished at the bases\n bilaterally. Suctioned frequently for thick, white secretions-moderate\n amounts. Pt remains orally intubated on CPAP/PS 50% FiO2. Pt\n requiring sedation while orally intubated because he is unsafely\n agitated when he wakes-tonguing/biting ET tube, reaching for ET tube,\n sitting up in bed. Pt continues to be lightly sedated (easily\n arousable, follows commands) on midazolam and Fentanyl for sedation\n with boluses as needed. +PNA, low grade temp today (Tmax 100.6),\n antibiotics continue (vanco, ceftriaxone).\n Action:\n Tracheostomy (and PEG procedure) brought up to pt and family today by\n Trauma team and ICU team. Family agreed to got forth with procedure\n but formal consent still needed by son (spokesperson, ). Pt\n suctioned frequently, ET tube inserted by RT further (2cm) per ICU team\n this evening.\n Response:\n Pt continues to have moderate amount of secretions, no weaning of vent\n done today, ABG unchanged.\n Plan:\n Trach and PEG procedures planned for tomorrow per Trauma team, no\n consents done- in room v. OR? Continue to educate family regarding\n plan and rationale for treatment. Pulmonary toileting, frequent\n repositioning, VAP care to continue. Consider diuresis once BP more\n stable?\n Hypotension (not Shock)\n Assessment:\n Pt continues to have low BP, requiring neo gtt for several days now.\n Neo gtt titrating daily as tolerated but ultimately still necessary for\n adequate BP. Pt on midazolam gtt and Fentanyl gtt for sedation. Pt\n able to nod yes/no when he has pain.\n Action:\n Ketamine study continues today, will stop at 20:00 tonight, at which\n point 2 corvac tubes should be drawn for lab tests. Fentanyl gtt\n decreased to assist with BP control, PO pain meds started and given as\n needed today. Midazolam gtt lowered to 1mg/hr as tolerated. Haldol PO\n initially given to assist with sedation, but then stopped d/t\n amiodarone gtt started per pharmacy because of prolonged QTC risk.\n Response:\n Pt tolerating sedation changes, very lightly sedated and encouraging\n minimal simulation to family members who are visiting. Pt is easily\n stimulated and becomes uncomfortable with ET tube and agitated. Pt\n denying pain at this time.\n Plan:\n Pt continues on Fentanyl and midaz gtts since the plan is for him to\n have a trach placed tomorrow, which means sedation can be removed, and\n therefore BP should improve. Continue to keep pt safely sedated and\n comfortable. Wean neo gtt as tolerated. BP goal MAP >60-65. Continue\n to support pt and family. Trach/PEG tomorrow by trauma team, remove\n sedation after procedure.\n"},{"category":"Physician ","chartdate":"2175-02-02 00:00:00.000","description":"Intensivist Note","row_id":714592,"text":"TSICU\n HPI:\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\n checked and 1.5, 1 more unit FFP given.\n .\n Injuries\n Mult rib fx: R anterolateral and post, L posterior\n T4 vert body inf corner fx\n Commin spinous process fx T2-8\n Nondisplaced L T10 transverse process\n Nondispaced L distal clavicle\n Nondisplaced L clavicle fx\n R medial lobe liver contusion w/hematoma\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny focus of arterial\n bleeding/active extravasation, and larger area of venous bleeding\n Nondisplaced, comminuted L iliac bone fx w/adjacent iliac muscle\n hematoma, extends into L SIJ.\n Minimally displaced fx of R iliac bone extending to R SIJ.\n Chief complaint:\n Trauma\n PMHx:\n PMH: None\n PSH: None\n : None\n Current medications:\n 24 Hour Events:\n Trach/PEG. Pt's BP dropped to 80/40 off pressors, sats 88. restarted\n neo. Overnight, pt reverted to sinus, off pressors, weaning sedation.\n PERCUTANEOUS TRACHEOSTOMY - At 12:00 PM\n PEG INSERTION - At 12:00 PM\n Post operative day:\n POD#7 - IVC filter via L groin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\n Vancomycin - 08:00 AM\n Ceftriaxone - 03:00 PM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Amiodarone - 0.5 mg/min\n Fentanyl (Concentrate) - 50 mcg/hour\n Other ICU medications:\n Fentanyl - 01:23 PM\n Pantoprazole (Protonix) - 02:00 PM\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Other medications:\n Flowsheet Data as of 04:33 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.7\nC (99.9\n T current: 37.1\nC (98.8\n HR: 94 (68 - 101) bpm\n BP: 140/66(91) {89/46(63) - 154/68(94)} mmHg\n RR: 26 (11 - 30) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 102 kg (admission): 90 kg\n CVP: 9 (6 - 16) mmHg\n Total In:\n 1,764 mL\n 142 mL\n PO:\n Tube feeding:\n 424 mL\n IV Fluid:\n 1,000 mL\n 82 mL\n Blood products:\n Total out:\n 1,630 mL\n 290 mL\n Urine:\n 1,630 mL\n 290 mL\n NG:\n Stool:\n Drains:\n Balance:\n 134 mL\n -148 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 483 (404 - 506) mL\n PS : 15 cmH2O\n RR (Spontaneous): 16\n PEEP: 10 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10\n PIP: 25 cmH2O\n SPO2: 98%\n ABG: 7.45/49/98./31/8\n Ve: 8.5 L/min\n PaO2 / FiO2: 163\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: Crackles : )\n Abdominal: Soft\n Left Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present)\n Right Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present)\n Neurologic: Follows simple commands, Moves all extremities, Sedated\n Labs / Radiology\n 109 K/uL\n 10.2 g/dL\n 110 mg/dL\n 0.8 mg/dL\n 31 mEq/L\n 4.5 mEq/L\n 24 mg/dL\n 105 mEq/L\n 144 mEq/L\n 31.3 %\n 5.9 K/uL\n [image002.jpg]\n 12:07 AM\n 02:18 AM\n 08:00 AM\n 02:00 PM\n 05:04 PM\n 08:00 PM\n 09:20 PM\n 01:00 AM\n 01:07 AM\n 01:18 AM\n WBC\n 4.2\n 5.9\n Hct\n 29.7\n 31.3\n Plt\n 104\n 109\n Creatinine\n 0.7\n 0.8\n TCO2\n 32\n 36\n 34\n 35\n Glucose\n 129\n 100\n 111\n 105\n 117\n 110\n Other labs: PT / PTT / INR:13.7/27.6/1.2, CK / CK-MB / Troponin\n T:128/13/<0.01, ALT / AST:90/113, Alk-Phos / T bili:99/5.1, Amylase /\n Lipase:58/39, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic\n Acid:1.4 mmol/L, Albumin:2.3 g/dL, LDH:348 IU/L, Ca:8.1 mg/dL, Mg:2.1\n mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, now\n with AF with RVR/Aflutter, persistant hypotension and PNA.\n Neurologic: s/p trach. Per ortho spine, no surgery; HOB<30, TLSO when\n OOB (NEOPS will place). Wean sedation as may be causing hypotension.\n Change pain meds to PO.\n Neuro checks Q: shift\n Pain: Oxycodone, Neurontin, Tylenol. Wean fentanyl gtt, midazolam gtt\n Cardiovascular: Aflutter, now reverted to sinus. Likely cardiac\n contusion. On Dilt 60mg PO QID. Cards rec amio gtt. Neo off. Pt cannot\n be fully anticoagulated for now (trauma).\n Pulmonary: Intubated, weaning, tachypneic likely abd distension. On\n appropriate abx per BAL cx - Ceftriaxone. If pt continues to spike or\n have signs of focal infection, breaden abx.\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin (declining 6.8\n max ->5.0) w/CT scan suggesting cirrhosis - Hepatitis panel NEG. TFs on\n hold for PEG. Bowel regimen.\n Nutrition:\n Renal: Foley, monitor UOP, edematous scrotum.\n Hematology: Hct stable 32.1->29.7. Plt stable (100's); d/c'd H2B with\n increasing plt count. Heme onc c/s - smear nl; no hemolysis. IVC\n filter placed.\n Endocrine: RISS\n Infectious Disease: WBC droppping 13.1->8.8->4.2, f/u Cx - BAL:\n pansensitive Klebsiella - continue ceftriaxone; consider broadning\n coverage if indicated.v\n Lines / Tubes / Drains: R SC CVL (), Foley, L a-line (),\n trach/PEG\n Wounds: SCDs, IVC filter, SQH\n Imaging:\n Fluids:\n Consults: Trauma surgery\n Billing Diagnosis: Multiple injuries (Trauma)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 04:41 PM\n Arterial Line - 11:30 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n"},{"category":"Respiratory ","chartdate":"2175-01-27 00:00:00.000","description":"Respiratory Care Shift Note","row_id":713782,"text":"Demographics\n Day of mechanical ventilation: 3\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Pt placed on MMV this a.m.; has tolerated well breathing over\n MMV of 5L on PSV settings as charted.\n Assessment of breathing comfort: No response (sleeping / sedated)\n Plan\n Next 24-48 hours: Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n"},{"category":"Respiratory ","chartdate":"2175-01-28 00:00:00.000","description":"Respiratory Care Shift Note","row_id":713901,"text":"Demographics\n Day of mechanical ventilation: 4\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Pt continues on PSV settings as charted; weaned on settings.\n Assessment of breathing comfort: No claim of dyspnea\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Cannot manage\n secretions, Underlying illness not resolved\n"},{"category":"Nursing","chartdate":"2175-01-29 00:00:00.000","description":"Nursing Progress Note","row_id":714065,"text":"74M s/p fall with multiple rib fx, pelvis fx, clavicle fx, and thoracic\n fx c/b unstable bleeding s/p IR embo, AF with RVR, hematologic\n abnormalities, now with resp failure.\n Atrial fibrillation (Afib), aflutter\n Assessment:\n Pt in and out of aflutter with controlled rate. Predominently\n aflutter. Hypotensive w/ sbp 80\ns while in aflutter.\n Action:\n Pt started dilt gtt 5-10mg/hr. K=3.5 and lytes repleted. Neo gtt to\n support sbp titrated to map >60 and sbp >100\n Propofol off due to hypotension. Pt started on low dose midaz gtt\n along with fentanyl.\n Response:\n Remains on dilt now at 5mg/hr. Briefly converted to nsr and then back\n to aflutter. Rate well controlled but remains neo dependent.\n Tolerating sedation titrated to lowest dose to keep comfortable and\n safe.\n Plan:\n Cont to monitor hemodynamics. Wean neo gtt as tolerated. Cont dilt\n gtt. Replete lytes. ?amio bolus or if persists possible electrical\n cardioversion. Hold off on Lasix for now.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains fully vented after reintubation ithis am, cmv 550x15, 50% and\n 10 peep. Stable abg, improved p02 this afternoon. O2sat 96-98%.\n Moderate amt thick, tenacious secretions. LS coarse, diminished.\n Clears with sxning.\n Action:\n Pt maintained intubated and bronch done this am. Sxned for thick\n secretions. BAL sent. Cont on abx for klebsiella pna. (febrile to\n 101.8 on abx) cultures sent and pnd.\n Response:\n Stable abg\ns . Cont with tenacious secretions. Cont with failure to\n wean.\n Plan:\n Cont abx for pna. Pulm toilet. Maintain sedated for safety and\n comfort. ? need for trach in future.\n"},{"category":"Nutrition","chartdate":"2175-01-30 00:00:00.000","description":"Clinical Nutrition Note","row_id":714171,"text":"Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n cm\n 90 kg\n 102 kg ( 12:00 AM)\n Pertinent medications: fetanyl, versed, phenylephrone.normal saline,\n heparin, IV abx, others noted\n Labs:\n Value\n Date\n Glucose\n 132 mg/dL\n 05:12 AM\n Glucose Finger Stick\n 153\n 08:00 AM\n BUN\n 19 mg/dL\n 05:12 AM\n Creatinine\n 0.7 mg/dL\n 05:12 AM\n Sodium\n 143 mEq/L\n 05:12 AM\n Potassium\n 4.0 mEq/L\n 05:12 AM\n Chloride\n 108 mEq/L\n 05:12 AM\n TCO2\n 32 mEq/L\n 05:12 AM\n PO2 (arterial)\n 127 mm Hg\n 01:00 AM\n PCO2 (arterial)\n 50 mm Hg\n 01:00 AM\n pH (arterial)\n 7.44 units\n 01:00 AM\n pH (urine)\n 5.0 units\n 04:25 PM\n CO2 (Calc) arterial\n 35 mEq/L\n 01:00 AM\n Albumin\n 2.7 g/dL\n 12:14 AM\n Calcium non-ionized\n 8.2 mg/dL\n 05:12 AM\n Phosphorus\n 2.8 mg/dL\n 05:12 AM\n Ionized Calcium\n 1.12 mmol/L\n 01:00 AM\n Magnesium\n 2.0 mg/dL\n 05:12 AM\n ALT\n 90 IU/L\n 12:45 AM\n Alkaline Phosphate\n 63 IU/L\n 12:45 AM\n AST\n 88 IU/L\n 12:45 AM\n Amylase\n 44 IU/L\n 06:01 AM\n Total Bilirubin\n 6.8 mg/dL\n 12:45 AM\n WBC\n 13.1 K/uL\n 12:45 AM\n Hgb\n 10.7 g/dL\n 12:45 AM\n Hematocrit\n 31.6 %\n 12:45 AM\n Current diet order / nutrition support: Replete wtih Fiber @ 80 ml/hr =\n kcals/ 119 g protein\n GI: soft, distended, +bowel sounds\n Assessment of Nutritional Status\n Specifics: 74 year old male s/p fall fromo tractor and crushed by tree\n branch now with multiple fx. Tube feedings started on . Patient\n tolerating tube feedings at goal which provide 100% of nutritional\n needs.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. Continue with goal tube feeding\n 2. Check chemistry 10 daily and replete prn\n 3. Will follow page with questions\n"},{"category":"Nursing","chartdate":"2175-02-02 00:00:00.000","description":"Nursing Progress Note","row_id":714590,"text":"74M s/p crushing injury d/t falling tree. Injuries sustained include\n multiple R sided rib fxs, grade 2 liver lac (w/ assoc hepatic vessel\n extravasation), stable pelvis fxs (w/ associated extravasation), R\n ramus fx, clavicle fx, and T4 vertebral body fx. Episodes of A.\n Flutter with RVR and aflutter, now with resp failure and newly dx\n pneumonia as of .\n intubated for resp distress\n angio embolization of hepatic and pelvic arterial bleeders\n IVC filter in OR\n self extubated and re-intubated immediately after d/t acute resp.\n failure\n Trach and PEG at bedside\n Atrial fibrillation (Afib)\n Assessment:\n Pt converted to NSR @ 1900 w/ rate 80s-100s.\n Action:\n PO dilt, amioderone gtt continued\n Neo gtt weaned off\n Response:\n HR & BP remain well controlled. Pt\n :\n Continue Amio gtt, switch to PO amio, ? Anticoagulant.\n Monitor hemodynamics, monitor BP\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt w/ trach on CPAP/PS 10/10/50%. LS rhonchorous throughout. Strong\n productive cough, large amounts of thick blood tinged secretions. ABG\n stable. VSS. Low grade temps\n Action:\n Pulm hygiene, suction PRN\n Ceftriaxone admistered for pna\n Response:\n Exam unchanged.\n Plan:\n Wean vent settings as tolerated, pulmonary toileting, wean\n sedation.\n"},{"category":"Physician ","chartdate":"2175-01-28 00:00:00.000","description":"Intensivist Note","row_id":713870,"text":"TSICU\n HPI:\n 74M s/p fall with multiple rib fx, pelvis fx, clavicle fx, and thoracic\n fx c/b unstable bleeding s/p IR embo, AF with RVR, hematologic\n abnomalities.\n Chief complaint:\n fall\n PMHx:\n none\n Current medications:\n 1. Acetaminophen 2. Bisacodyl 3. Chlorhexidine Gluconate 0.12% Oral\n Rinse 4. Dextrose 50% 5. Diltiazem 6. Docusate Sodium (Liquid) 7.\n Famotidine 8. Fentanyl Citrate 9. Fentanyl Citrate 10. Gabapentin 11.\n Glucagon 12. Insulin 13. Magnesium Sulfate 14. Midazolam 15.\n Ondansetron 16. Phenylephrine 17. Pneumococcal Vac Polyvalent 18.\n Potassium Phosphate 19. Potassium Chloride 20. Propofol 21. Senna 22.\n Sodium Chloride 0.9% Flush\n 24 Hour Events:\n ARTERIAL LINE - STOP 11:05 AM\n ARTERIAL LINE - START 11:30 AM\n Heme c/s- smear nl. Wean vent, started on po diltiazem for atrial\n ectopy.\n Post operative day:\n POD#2 - IVC filter via L groin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Fentanyl (Concentrate) - 100 mcg/hour\n Propofol - 20 mcg/Kg/min\n Phenylephrine - 0.3 mcg/Kg/min\n Other ICU medications:\n Fentanyl - 08:00 PM\n Other medications:\n Flowsheet Data as of 04:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.6\nC (99.7\n T current: 37.5\nC (99.5\n HR: 69 (62 - 97) bpm\n BP: 102/51(66) {89/48(63) - 135/71(94)} mmHg\n RR: 13 (8 - 20) insp/min\n SPO2: 98%\n Heart rhythm: 1st AV (First degree AV Block)\n Wgt (current): 102 kg (admission): 90 kg\n CVP: 15 (11 - 24) mmHg\n Total In:\n 2,899 mL\n 385 mL\n PO:\n Tube feeding:\n 908 mL\n 228 mL\n IV Fluid:\n 1,471 mL\n 96 mL\n Blood products:\n 50 mL\n Total out:\n 1,050 mL\n 90 mL\n Urine:\n 1,050 mL\n 90 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,849 mL\n 295 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (440 - 500) mL\n Vt (Spontaneous): 495 (495 - 680) mL\n PS : 12 cmH2O\n RR (Set): 10\n RR (Spontaneous): 12\n PEEP: 12 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 25 cmH2O\n SPO2: 98%\n ABG: 7.40/54/92./31/6\n Ve: 7.2 L/min\n PaO2 / FiO2: 232\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: No(t) Regular, Irregular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: 3+), (Temperature: Warm)\n Right Extremities: (Edema: 3+), (Temperature: Warm)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities, Sedated\n Labs / Radiology\n 74 K/uL\n 9.7 g/dL\n 128 mg/dL\n 0.8 mg/dL\n 31 mEq/L\n 3.9 mEq/L\n 19 mg/dL\n 108 mEq/L\n 141 mEq/L\n 28.7 %\n 5.6 K/uL\n [image002.jpg]\n 02:16 PM\n 05:17 PM\n 12:14 AM\n 12:20 AM\n 05:24 AM\n 06:50 AM\n 02:40 PM\n 03:13 PM\n 01:59 AM\n 02:00 AM\n WBC\n 11.0\n 11.0\n 8.0\n 5.6\n Hct\n 30.6\n 30.1\n 29.8\n 28.7\n Plt\n 99\n 97\n 80\n 74\n Creatinine\n 0.9\n 0.8\n 0.8\n TCO2\n 34\n 33\n 32\n 30\n 33\n 35\n Glucose\n 96\n 133\n 125\n 128\n Other labs: PT / PTT / INR:13.7/28.7/1.2, CK / CK-MB / Troponin\n T:1334/13/<0.01, ALT / AST:147/126, Alk-Phos / T bili:52/2.6, Amylase /\n Lipase:44/, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic Acid:1.4\n mmol/L, Albumin:2.7 g/dL, LDH:435 IU/L, Ca:8.0 mg/dL, Mg:2.2 mg/dL,\n PO4:2.8 mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, AF with\n RVR, hematologic abnormalities.\n Neurologic: Intubated on Propofol gtt and Midazolam PRN (have not been\n giving). Per ortho spine, no surgery; HOB<30, TLSO when OOB (NEOPS will\n place).\n Neuro checks Q: shift\n Pain: Fentanyl 100mcg/hr, start Dilaudid, Neurontin, Tylenol\n Cardiovascular: Now back in NSR with occasional PACs, off dilt gtt,\n started po diltiazem 30 qid, and currently weaning Neo gtt. Fluid\n challenge and PPV 6. Also given 25% albumin x1.\n Pulmonary: Intubated. Pt developing early ARDS, placed on MMV. F/U on\n bronch cx.\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin with CT scan\n suggesting cirrhosis - Hepatitis panel NEG. TFs advancing to goal.\n Bowel regimen.\n Nutrition: Tube feeding\n Renal: Foley, monitor UOP. Cr normalized. Consider diuresis if remains\n off Neo, goal even.\n Hematology: Hct stable at 29-30-28.7. Plt low but stable (100's).\n Heme onc consulted - smear nl, no further recs. H2B stopped in case\n contributing factor. IVC filter placed.\n Endocrine: RISS, goal BS<150.\n Infectious Disease: WBC normal, f/u Cx - GNR in sputum and BAL, but\n afebrile, monitor for now, WBC trending down to 5.6 today, vent support\n decreasing; may start abx if spikes.\n Lines / Tubes / Drains: R SC CVL (), PIV x2, Foley, L a-line\n (), ETT\n Wounds:\n Imaging: CXR today\n Fluids: none\n Consults: Trauma (1o), Ortho Spine, Ortho trauma, Heme\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 01:48 AM 50 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 04:41 PM\n Arterial Line - 11:30 AM\n Prophylaxis:\n DVT: Boots, IVC filter\n Stress ulcer: PPI (changed from H2B)\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 32 min\n"},{"category":"Physician ","chartdate":"2175-01-28 00:00:00.000","description":"Intensivist Note","row_id":713872,"text":"TSICU\n HPI:\n 74M s/p fall with multiple rib fx, pelvis fx, clavicle fx, and thoracic\n fx c/b unstable bleeding s/p IR embo, AF with RVR, hematologic\n abnomalities.\n Chief complaint:\n fall\n PMHx:\n none\n Current medications:\n 1. Acetaminophen 2. Bisacodyl 3. Chlorhexidine Gluconate 0.12% Oral\n Rinse 4. Dextrose 50% 5. Diltiazem 6. Docusate Sodium (Liquid) 7.\n Famotidine 8. Fentanyl Citrate 9. Fentanyl Citrate 10. Gabapentin 11.\n Glucagon 12. Insulin 13. Magnesium Sulfate 14. Midazolam 15.\n Ondansetron 16. Phenylephrine 17. Pneumococcal Vac Polyvalent 18.\n Potassium Phosphate 19. Potassium Chloride 20. Propofol 21. Senna 22.\n Sodium Chloride 0.9% Flush\n 24 Hour Events:\n ARTERIAL LINE - STOP 11:05 AM\n ARTERIAL LINE - START 11:30 AM\n Heme c/s- smear nl. Wean vent, started on po diltiazem for atrial\n ectopy.\n Post operative day:\n POD#2 - IVC filter via L groin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Fentanyl (Concentrate) - 100 mcg/hour\n Propofol - 20 mcg/Kg/min\n Phenylephrine - 0.3 mcg/Kg/min\n Other ICU medications:\n Fentanyl - 08:00 PM\n Other medications:\n Flowsheet Data as of 04:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.6\nC (99.7\n T current: 37.5\nC (99.5\n HR: 69 (62 - 97) bpm\n BP: 102/51(66) {89/48(63) - 135/71(94)} mmHg\n RR: 13 (8 - 20) insp/min\n SPO2: 98%\n Heart rhythm: 1st AV (First degree AV Block)\n Wgt (current): 102 kg (admission): 90 kg\n CVP: 15 (11 - 24) mmHg\n Total In:\n 2,899 mL\n 385 mL\n PO:\n Tube feeding:\n 908 mL\n 228 mL\n IV Fluid:\n 1,471 mL\n 96 mL\n Blood products:\n 50 mL\n Total out:\n 1,050 mL\n 90 mL\n Urine:\n 1,050 mL\n 90 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,849 mL\n 295 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (440 - 500) mL\n Vt (Spontaneous): 495 (495 - 680) mL\n PS : 12 cmH2O\n RR (Set): 10\n RR (Spontaneous): 12\n PEEP: 12 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 25 cmH2O\n SPO2: 98%\n ABG: 7.40/54/92./31/6\n Ve: 7.2 L/min\n PaO2 / FiO2: 232\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: No(t) Regular, Irregular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: 3+), (Temperature: Warm)\n Right Extremities: (Edema: 3+), (Temperature: Warm)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities, Sedated\n Labs / Radiology\n 74 K/uL\n 9.7 g/dL\n 128 mg/dL\n 0.8 mg/dL\n 31 mEq/L\n 3.9 mEq/L\n 19 mg/dL\n 108 mEq/L\n 141 mEq/L\n 28.7 %\n 5.6 K/uL\n [image002.jpg]\n 02:16 PM\n 05:17 PM\n 12:14 AM\n 12:20 AM\n 05:24 AM\n 06:50 AM\n 02:40 PM\n 03:13 PM\n 01:59 AM\n 02:00 AM\n WBC\n 11.0\n 11.0\n 8.0\n 5.6\n Hct\n 30.6\n 30.1\n 29.8\n 28.7\n Plt\n 99\n 97\n 80\n 74\n Creatinine\n 0.9\n 0.8\n 0.8\n TCO2\n 34\n 33\n 32\n 30\n 33\n 35\n Glucose\n 96\n 133\n 125\n 128\n Other labs: PT / PTT / INR:13.7/28.7/1.2, CK / CK-MB / Troponin\n T:1334/13/<0.01, ALT / AST:147/126, Alk-Phos / T bili:52/2.6, Amylase /\n Lipase:44/, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic Acid:1.4\n mmol/L, Albumin:2.7 g/dL, LDH:435 IU/L, Ca:8.0 mg/dL, Mg:2.2 mg/dL,\n PO4:2.8 mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, AF with\n RVR, hematologic abnormalities.\n Neurologic: Intubated on Propofol gtt and Midazolam PRN (have not been\n giving). Per ortho spine, no surgery; HOB<30, TLSO when OOB (NEOPS will\n place).\n Neuro checks Q: shift\n Pain: Fentanyl 100mcg/hr, start Dilaudid, Neurontin, Tylenol\n Cardiovascular: Now back in NSR with occasional PACs, off dilt gtt,\n started po diltiazem 30 qid, and currently weaning Neo gtt. Fluid\n challenge and PPV 6. Also given 25% albumin x1.\n Pulmonary: Intubated. Pt developing early ARDS, placed on MMV. F/U on\n bronch cx.\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin with CT scan\n suggesting cirrhosis - Hepatitis panel NEG. TFs advancing to goal.\n Bowel regimen.\n Nutrition: Tube feeding\n Renal: Foley, monitor UOP. Cr normalized. Consider diuresis if remains\n off Neo, goal even.\n Hematology: Hct stable at 29-30-28.7. Plt low but stable (100's).\n Heme onc consulted - smear nl, no further recs. H2B stopped in case\n contributing factor. IVC filter placed.\n Endocrine: RISS, goal BS<150.\n Infectious Disease: WBC normal, f/u Cx - GNR in sputum and BAL, but\n afebrile, monitor for now, WBC trending down to 5.6 today, vent support\n decreasing; may start abx if spikes.\n Lines / Tubes / Drains: R SC CVL (), PIV x2, Foley, L a-line\n (), ETT\n Wounds:\n Imaging: CXR today\n Fluids: none\n Consults: Trauma (1o), Ortho Spine, Ortho trauma, Heme\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 01:48 AM 50 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 04:41 PM\n Arterial Line - 11:30 AM\n Prophylaxis:\n DVT: Boots, IVC filter\n Stress ulcer: PPI (changed from H2B)\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 32 min\n"},{"category":"Nursing","chartdate":"2175-02-01 00:00:00.000","description":"Nursing Progress Note","row_id":714415,"text":"74M s/p crushing injury d/t falling tree. Injuries sustained include\n multiple R sided rib fxs, grade 2 liver lac (w/ assoc hepatic vessel\n extravasation), stable pelvis fxs (w/ associated extravasation), R\n ramus fx, clavicle fx, and T4 vertebral body fx. Episodes of AF with\n RVR and aflutter, hematologic abnormalities, now with resp failure and\n newly dx pneumonia as of .\n intubated for resp distress\n angio embolization of hepatic and pelvic arterial bleeders\n IVC filter in OR\n self extubated and reintubated immediately after d/t acute resp\n failure\n Atrial fibrillation (Afib), aflutter\n Assessment:\n Pt in aflutter with controlled rate most of time, w/ stimulation HR\n jumps to 100s-110s. weaned off neo since last evening, BP stable.\n Action:\n Amio drip continues, dose weaned to 0.5mg/min per 18 hr protocol.\n Standing po dose dilt continued, lytes followed, repleted as needed.\n Pt on low dose midaz gtt along with fentanyl for sedation.\n Response:\n Remains in afib despite amio infusion, rate 70s-80s when calm,\n tachycardic when pt agitated. BP remains soft w/ sedation/pain med\n dosing, when stimulated, BP adequate. Urine output remains brisk.\n Tolerating sedation titrated to lowest dose to keep comfortable and\n safe.\n Plan:\n Cont to monitor hemodynamics. Continue amio drip for full 18 hrs, will\n need to be d/c\nd 1400 unless team decides to continue. Optimize\n lytes ongoing. Cardiology consult team following.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Weaned to cpap mode vent support yesterday, 10 psv, 50% and 10 peep.\n Stable abg, improved p02. At rest RR mid to high 20s, when agitated,\n increasingly tachypneic to 30s. abg wnl. Moderate amt thick,\n yellow/white secretions. LS improving, diminished to all fields, less\n rhonchi.\n Action:\n Remains intubated on cpap, signif peep. see settings above, tol well.\n Pulm toileting per routine. Increased sedation overnoc w/ cessation of\n ketamine study drug, pt noted to be increasingly tachypneic,\n hyperdynamic. Midaz increased substantially, requires bolus dosing for\n any care. Given po as well as IV drip pain meds as written to\n potentiate benzo effect.\n Response:\n Abg acceptable, Pao2 improved on higher peep. LS improved as well,\n clearer, remain diminished throughout, more so to R side. Cough\n remains weak w/ sedation. Pt denies pain when asked, nods adamantly\n yes to question of discomfort w/ ett w/ any stimulation at all.\n Remains agitated w/ any physical care or stimulus.\n Plan:\n Cont Vanco, ceftriaxone for hflu and klebsiella pneumonia coverage,\n Pulm toilet. Maintain sedation for safety and comfort until trach\n placement, likely to be today.\n Trauma, s/p\n Assessment:\n As above, pt s/p liver laceration and resultant angio procedure to\n embolize several extravsating hepatic and pelvic vessels. LFTs\n continue to be elevated, tbili from 6.8 w/ direct 5.2. INR\n stable. Urine icteric, clear, pt jaundiced. R hip/flank/torso\n hematoma appears larger than in previous days\n Action:\n Following LFTs, hct, coags. Monitor s/s bleeding, hematoma expansion\n to R hip/flank/torso areas.\n Response:\n WBC 4.2, plts 104 this am, significant drops from last 24h values,\n trauma and ICU teams aware. LFTs added on to this am\ns labs.\n Plan:\n Continue to follow LFTs, coags, hct, serial belly assessments, s/s\n further bleeding.\n"},{"category":"Respiratory ","chartdate":"2175-02-01 00:00:00.000","description":"Respiratory Care Shift Note","row_id":714525,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 8\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Tube Type\n Tracheostomy tube:\n Type: Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Comments: trach placed on \n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Blood Tinged / Thin\n Sputum source/amount: Suctioned / Scant\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Bedside Procedures:\n Bedside tracheostomy (11:00)\n Comments: uneventfull trach placement at bedside\n"},{"category":"Nursing","chartdate":"2175-02-01 00:00:00.000","description":"Nursing Progress Note","row_id":714528,"text":"74M s/p crushing injury d/t falling tree. Injuries sustained include\n multiple R sided rib fxs, grade 2 liver lac (w/ assoc hepatic vessel\n extravasation), stable pelvis fxs (w/ associated extravasation), R\n ramus fx, clavicle fx, and T4 vertebral body fx. Episodes of A.\n Flutter with RVR and aflutter, hematologic abnormalities, now with resp\n failure and newly dx pneumonia as of .\n intubated for resp distress\n angio embolization of hepatic and pelvic arterial bleeders\n IVC filter in OR\n self extubated and re-intubated immediately after d/t acute resp.\n failure\n Trach and PEG at bedside\n Atrial fibrillation (Afib)\n Assessment:\n Atrial flutter continues, RVR up to 130s this AM.\n Action:\n PO dilt, amioderone gtt continued, Neo gtt titrated for adequate BP\n control.\n Response:\n Rate controlled after PO Dilt.\n Plan:\n Continue Amio gtt, ? Switch to PO amio, ? Cardio version,?\n Anticoagulant.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Post trach pt back on CPAP 10/10/50%. Ls clear to diminish at bases.\n Strong productive cough, suctioned for copious amounts of thick blood\n tinged secretions.\n Action:\n Trach and PEG at bedside, continue pulmonary toileting.\n Response:\n Tolerated procedure without issue.\n Plan:\n Wean vent settings as tolerated, pulmonary toileting, wean sedation as\n tolerated,\n"},{"category":"Physician ","chartdate":"2175-02-03 00:00:00.000","description":"Intensivist Note","row_id":714765,"text":"TSICU\n HPI:\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\n checked and 1.5, 1 more unit FFP given.\n Chief complaint:\n PMHx:\n Current medications:\n Acetaminophen 4. Amiodarone 5. Bisacodyl 6. Calcium Gluconate 7.\n CefePIME 8. CefePIME\n 9. Chlorhexidine Gluconate 0.12% Oral Rinse 10. Ciprofloxacin HCl 11.\n Dextrose 50% 12. Docusate Sodium (Liquid)\n 13. Fentanyl Citrate 14. Furosemide 15. Furosemide 16. Furosemide 17.\n Gabapentin 18. Glucagon 19. Heparin\n 20. Insulin 21. Lactulose 22. Lansoprazole Oral Disintegrating Tab 23.\n Lorazepam 24. Magnesium Sulfate\n 25. Metoprolol Tartrate 26. Metoprolol Tartrate 27. Midazolam 28.\n Midazolam 29. Milk of Magnesia\n 30. Olanzapine (Disintegrating Tablet) 31. Ondansetron 32. OxycoDONE\n Liquid 33. Phenylephrine 34. Pneumococcal Vac Polyvalent\n 35. Potassium Phosphate 36. Potassium Chloride 37. Senna 38. Sodium\n Chloride 0.9% Flush 39. Sodium Chloride 0.9% Flush\n 40. Vancomycin 41. Vancomycin\n 24 Hour Events:\n EKG - At 09:07 PM\n FEVER - 101.1\nF - 12:00 AM\n : TFs increased. Lasix 10x3 with good result. Zyprexa for\n sedation, weaned off versed, fentanyl. Cards rec 400'' x 1wk, then\n 400'x1 wk, then 200'. also rec changing dilt to metop succinate 25''.\n Vanc/cipro/cefepime for VAP.\n : pan cx for temp 101.1\n Post operative day:\n POD#8 - IVC filter via L groin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 03:00 PM\n Ciprofloxacin - 12:00 PM\n Vancomycin - 07:33 PM\n Cefipime - 11:15 PM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 02:00 PM\n Lorazepam (Ativan) - 11:41 PM\n Midazolam (Versed) - 02:16 AM\n Furosemide (Lasix) - 03:55 AM\n Heparin Sodium (Prophylaxis) - 04:02 AM\n Metoprolol - 06:27 AM\n Other medications:\n Flowsheet Data as of 08:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.4\nC (101.1\n T current: 37.7\nC (99.8\n HR: 97 (81 - 111) bpm\n BP: 160/81(110) {111/59(80) - 166/81(110)} mmHg\n RR: 30 (17 - 30) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 104.2 kg (admission): 90 kg\n CVP: 19 (12 - 26) mmHg\n Total In:\n 2,674 mL\n 727 mL\n PO:\n Tube feeding:\n 660 mL\n 637 mL\n IV Fluid:\n 895 mL\n 90 mL\n Blood products:\n Total out:\n 2,485 mL\n 1,055 mL\n Urine:\n 2,485 mL\n 1,055 mL\n NG:\n Stool:\n Drains:\n Balance:\n 189 mL\n -328 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 510 (502 - 660) mL\n PS : 12 cmH2O\n RR (Spontaneous): 28\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 28 cmH2O\n SPO2: 99%\n ABG: 7.50/43/150/31/9\n Ve: 11.8 L/min\n PaO2 / FiO2: 300\n Physical Examination\n General Appearance: Anxious, Well nourished\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: Crackles : , Rhonchorous : ,\n Diminished: )\n Abdominal: Soft, Distended\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities\n Labs / Radiology\n 128 K/uL\n 9.3 g/dL\n 138 mg/dL\n 0.8 mg/dL\n 31 mEq/L\n 3.8 mEq/L\n 23 mg/dL\n 105 mEq/L\n 142 mEq/L\n 28.9 %\n 6.3 K/uL\n [image002.jpg]\n 02:00 PM\n 05:04 PM\n 08:00 PM\n 09:20 PM\n 01:00 AM\n 01:07 AM\n 01:18 AM\n 02:05 AM\n 03:54 AM\n 05:17 AM\n WBC\n 5.9\n 6.3\n Hct\n 31.3\n 28.9\n Plt\n 109\n 128\n Creatinine\n 0.8\n 0.8\n TCO2\n 36\n 34\n 35\n 34\n 35\n Glucose\n 111\n 105\n 117\n 110\n 138\n Other labs: PT / PTT / INR:13.7/27.6/1.2, CK / CK-MB / Troponin\n T:128/13/<0.01, ALT / AST:90/122, Alk-Phos / T bili:133/5.4, Amylase /\n Lipase:54/52, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic\n Acid:1.4 mmol/L, Albumin:2.3 g/dL, LDH:348 IU/L, Ca:8.0 mg/dL, Mg:2.2\n mg/dL, PO4:2.8 mg/dL\n Imaging: CT head OSH: Prelim No ICH or fx.\n CT chest OSH: Mult rib fx: R anterolateral and posterior, L\n posterior; Dependent consolidation, possible aspiration; T4 vertebral\n body inf corner fx, no retropulsion; Comminuted spinous process fx\n T2-8; Nondisplaced L T10 transverse process; Nondisplaced L clavicle\n distal fx; Nondisplaced L scapula fx;\n CT c spine OSH: Prelim No fx or malalignment. Multilevel\n degenerative changes w/large post disk bulge at C4-5, narrowing the\n spinal canal and deforming the thecal sac, acuity unknown. Marked\n neuroforamenal narrowing @multiple levels.\n CTA abd/pel Prelim: Medial R liver lobe contusion w/adj\n hematoma, w/o evidence of active bleeding; Comminuted L pubic ramus\n fracture w/assoc hematoma, with tiny focus of arterial bleeding/active\n extravasation, and larger area of venous bleeding. Hematoma somewhat\n larger than on OSH study. Nondisplaced, comminuted L iliac bone fx\n w/adj iliac muscle hematoma, larger than on prior study, w/o active\n extrav. Fx extends into L SIJ. Post R hepatic laceration/contusion\n adjacent to calcified granuloma, w/small hematoma, w/out active\n bleeding. Min displaced fx of R iliac bone extending to R SIJ.\n Cirrhotic liver. Inc B pl effusions (small), w/inc atelectasis.\n MRI: Mild compression deformity of L1 w/additional levels of\n potential trabecular contusion @T10-11 also inf @T4 w/o retropulsion.\n Multilevel degenerative changes w/moderate canal narrowing @T10-11\n w/cord deformity & no abnl cord signal. Extensive edema throughout\n paraspinal soft tissues, predominantly post w/in interspinous\n ligaments. Incompletely eval'ed c-spine w/severe canal narrowing @C4-5\n w/cord deformity and no abn cord signal.\n CTA: no PE.\n CXR: Moderate b/l pleural effusions are stable.\n CXR: Cardiac size top nl, interval improvement of collapse LLL.\n Collapse RLL. Atelectasis in lingula unchanged. Mod B pleural effusions\n stable. No PTX.\n CXR: Interval mild incr in cardiac size, b/l pl effusions,\n & opacities @ bases,c/w overload\n : R foot: Linear density projecting @ expected area of insertion\n of Achilles to calcaneus, may be min avulsion fx or degenerative\n changes. Otherwise no fx\n CXR: b/l pl effusions\n CXR: stable.\n RUQ U/S: No perihepatic fluid collection. small amt perihepatic\n free fluid persists. Small contusion in hepatic segment VII. No\n gallstones or sig wall thickening/edema. CBD 4.5 mm\n TTE: LVEF >55%, NL diastolic function, NL LV filling pressure\n (PCWP<12mmHg), RV chamber size mildly dilated, mild TR\n CXR: mild b/l pulm edema and parenchymal opacities and no\n pl effusion.\n CXR: Persistent b/l pl effusions and bibasilar opacity.\n CXR: Minimal improvement of mod b/l pl effusions. Otherwise\n stable.\n Microbiology: Ucx no growth final\n Sputum: sparse GNRs, too few to colonize\n Bcx x2 no growth final\n 12/17 L BAL: Klebsiella Pneumoniae, HAEMOPHILUS SPECIES NOT INFLUENZAE\n R BAL: Klebsiella Pneumoniae, Proteus.\n 12/20 L &R BAL: Klebsiella Pneumoniae\n BCX: p\n BCx: P\n UCx: no growth final\n BCx: P\n BCx: P\n UCx: P\n SpCx: P\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, now\n with AF with RVR/Aflutter, persistant hypotension and PNA.\n Neurologic: s/p trach (). Per ortho spine, no surgery; HOB<30,\n TLSO when OOB. Zyprexa & Ativan PRN (off fent/midaz ).\n Neuro checks Q: shift\n Pain: Oxycodone, Neurontin, Tylenol.\n Cardiovascular: Aflutter, now reverted to sinus w/1st deg AVB. Likely\n cardiac contusion. Cards rec 400'' x 1wk, then 400'x1 wk, then\n 200'. also rec changing dilt to metop 25''. Pt cannot be fully\n anticoagulated for now (trauma).\n Pulmonary: Intubated, weaning, Vanc/cipro/cefepime for VAP ().\n Increasing pulmonary edema on CXR (lasix x 2 on , lasix x1 ).\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin (declining 6.8\n max ->5.0) w/CT scan suggesting cirrhosis - Hepatitis panel NEG. TFs\n restarted, increasing to goal . Bowel regimen.\n Nutrition: Tube feeding\n Renal: Foley, monitor UOP, edematous scrotum. Lasix 10 x2 on ,\n lasix x1 .\n Hematology: Hct stable 32.1->29.7. Plt stable (100's); d/c'd H2B. Heme\n onc c/s - smear nl; no hemolysis. IVC filter placed.\n Endocrine: RISS\n Infectious Disease: Check cultures, WBC droppping\n 13.1->8.8->4.2->5.9->6.3, Vanc/cipro/cefepime for VAP given worsening\n pulm status\n Lines / Tubes / Drains: Trach/Peg/foley/L radial a-line/R SCL\n Wounds:\n Imaging: CXR today\n Fluids: KVO\n Consults: Trauma (1o), Ortho Spine, Ortho trauma, Heme\n Billing Diagnosis: (Respiratory distress: Failure), (Shock: Traumatic),\n Multiple injuries (Trauma)\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 04:12 AM 80 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 04:41 PM\n Arterial Line - 11:30 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting planning, ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 33 minutes\n Patient is critically ill\n"},{"category":"Respiratory ","chartdate":"2175-01-29 00:00:00.000","description":"Respiratory Care Shift Note","row_id":714050,"text":"Demographics\n Day of mechanical ventilation: 5\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Crackles\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Crackles\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Cannot protect\n airway, Underlying illness not resolved\n Respiratory Care Shift Procedures\n Bedside Procedures:\n Bronchoscopy (1000)\n Comments: BAL collected & sent.\n"},{"category":"Physician ","chartdate":"2175-01-30 00:00:00.000","description":"Intensivist Note","row_id":714145,"text":"TSICU\n HPI:\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\n checked and 1.5, 1 more unit FFP given.\n Chief complaint:\n Mult rib fx: R anterolateral and post, L posterior\n T4 vert body inf corner fx\n Commin spinous process fx T2-8\n Nondisplaced L T10 transverse process\n Nondispaced L distal clavicle\n Nondisplaced L clavicle fx\n R medial lobe liver contusion w/hematoma\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny focus of arterial\n bleeding/active extravasation, and larger area of venous bleeding\n Nondisplaced, comminuted L iliac bone fx w/adjacent iliac muscle\n hematoma, extends into L SIJ.\n Minimally displaced fx of R iliac bone extending to R SIJ.\n PMHx:\n None\n Current medications:\n Chlorhexidine Gluconate 0.12% Oral Rinse\n Diltiazem\n Furosemide\n Gabapentin\n Metoprolol Tartrate\n Ondansetron\n Phenylephrine\n 24 Hour Events:\n Self-extubated in the AM, re-intubated over bougie, NGT replaced,\n bronch with bilateral BALs sent, plan for trach later this week. T\n spike to 101.8 - u/a, urine cx, blood cxs sent. Diltiazem titrated to\n 60mg PO QID. ABX coverage broadened to Vanc/Zosyn. Tbili up to 6.8\n (other LFTs trending down)\n Post operative day:\n POD#4 - IVC filter via L groin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 11:00 AM\n Piperacillin/Tazobactam (Zosyn) - 08:19 PM\n Vancomycin - 08:56 PM\n Infusions:\n Fentanyl (Concentrate) - 100 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Hydromorphone (Dilaudid) - 04:00 AM\n Metoprolol - 06:33 AM\n Pantoprazole (Protonix) - 02:00 PM\n Midazolam (Versed) - 12:30 AM\n Other medications:\n Flowsheet Data as of 02:07 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.8\nC (101.8\n T current: 37.2\nC (98.9\n HR: 76 (76 - 103) bpm\n BP: 97/51(67) {86/47(62) - 121/858(84)} mmHg\n RR: 18 (0 - 25) insp/min\n SPO2: 99%\n Heart rhythm: A Flut (Atrial Flutter)\n Wgt (current): 102 kg (admission): 90 kg\n CVP: 11 (6 - 18) mmHg\n Total In:\n 3,114 mL\n 207 mL\n PO:\n Tube feeding:\n 1,301 mL\n 148 mL\n IV Fluid:\n 1,682 mL\n 59 mL\n Blood products:\n Total out:\n 2,500 mL\n 180 mL\n Urine:\n 2,500 mL\n 180 mL\n NG:\n Stool:\n Drains:\n Balance:\n 614 mL\n 27 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 540 (540 - 540) mL\n PS : 5 cmH2O\n RR (Set): 15\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI: 34\n PIP: 26 cmH2O\n Plateau: 23 cmH2O\n Compliance: 42.3 cmH2O/mL\n SPO2: 99%\n ABG: 7.44/50/127/34/8\n Ve: 9.5 L/min\n PaO2 / FiO2: 254\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: Aflutter\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present,\n Stable scrotal edema/hematoma, soft, no crepitus\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: Follows simple commands, Moves all extremities, Sedated\n Labs / Radiology\n 158 K/uL\n 10.7 g/dL\n 115 mg/dL\n 0.8 mg/dL\n 34 mEq/L\n 4.0 mEq/L\n 20 mg/dL\n 111 mEq/L\n 148 mEq/L\n 31.6 %\n 13.1 K/uL\n [image002.jpg]\n 01:59 AM\n 02:00 AM\n 11:04 AM\n 01:17 PM\n 02:55 AM\n 04:11 AM\n 09:45 AM\n 04:45 PM\n 12:45 AM\n 01:00 AM\n WBC\n 5.6\n 6.5\n 13.1\n Hct\n 28.7\n 29.3\n 31.6\n Plt\n 74\n 86\n 158\n Creatinine\n 0.8\n 0.8\n 0.8\n TCO2\n 35\n 34\n 34\n 38\n 37\n 35\n 35\n Glucose\n 125\n 128\n 141\n 107\n 131\n 115\n Other labs: PT / PTT / INR:13.9/26.9/1.2, CK / CK-MB / Troponin\n T:1334/13/<0.01, ALT / AST:90/88, Alk-Phos / T bili:63/6.8, Amylase /\n Lipase:44/, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic Acid:1.2\n mmol/L, Albumin:2.7 g/dL, LDH:348 IU/L, Ca:8.4 mg/dL, Mg:2.1 mg/dL,\n PO4:2.9 mg/dL\n Imaging: CT head OSH: Prelim No ICH or fx.\n CT chest OSH: Mult rib fx: R anterolateral and posterior, L\n posterior; Dependent consolidation, possible aspiration; T4 vertebral\n body inf corner fx, no retropulsion; Comminuted spinous process fx\n T2-8; Nondisplaced L T10 transverse process; Nondisplaced L clavicle\n distal fx; Nondisplaced L scapula fx;\n CT c spine OSH: Prelim No fx or malalignment. Multilevel\n degenerative changes w/large post disk bulge at C4-5, narrowing the\n spinal canal and deforming the thecal sac, acuity unknown. Marked\n neuroforamenal narrowing @multiple levels.\n CTA abd/pel Prelim: Medial R liver lobe contusion w/adj\n hematoma, w/o evidence of active bleeding; Comminuted L pubic ramus\n fracture w/assoc hematoma, with tiny focus of arterial bleeding/active\n extravasation, and larger area of venous bleeding. Hematoma somewhat\n larger than on OSH study. Nondisplaced, comminuted L iliac bone fx\n w/adj iliac muscle hematoma, larger than on prior study, w/o active\n extrav. Fx extends into L SIJ. Post R hepatic laceration/contusion\n adjacent to calcified granuloma, w/small hematoma, w/out active\n bleeding. Min displaced fx of R iliac bone extending to R SIJ.\n Cirrhotic liver. Inc B pl effusions (small), w/inc atelectasis.\n MRI: Mild compression deformity of L1 w/additional levels of\n potential trabecular contusion @T10-11 also inf @T4 w/o retropulsion.\n Multilevel degenerative changes with moderate canal narrowing at T10-11\n w/cord deformity and no abnormal cord signal. Extensive edema\n throughout paraspinal soft tissues, predominantly post w/in\n interspinous ligaments. Incompletely eval'ed c-spine w/severe canal\n narrowing @C4-5 w/cord deformity and no abnormal cord signal.\n CTA: no PE.\n CXR: Moderate bilateral pleural effusions are stable.\n CXR: Cardiac size top nl, interval improvement of collapse LLL.\n Collapse RLL. Atelectasis in lingula unchanged. Mod B\n pleural effusions stable. No PTX.\n CXR: Interval mild incr in cardiac size, b/l pleural effusions,\n and opacities @ bases,c/w overload\n : R foot: Linear density projecting @ expected area of insertion\n of the Achilles to calcaneus, may be min avulsion fx or degenerative\n changes. Otherwise no fx\n CXR: bilateral pleural effusions\n Microbiology: Ucx no growth final\n Sputum: sparse GNR\n Bcx P\n Bcx P\n 12/17 L BAL: KLEBSIELLA PNEUMONIAE, HAEMOPHILUS SPECIES NOT INFLUENZAE\n R BAL: KLEBSIELLA PNEUMONIAE & GNRs.\n 12/20 L BAL: gram + cocci pairs on gram stain\n R BAL: gram + cocci pairs on gram stain\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, AF with\n RVR, hematologic abnomalities.\n Neurologic: Intubated on Fentanyl/Versed gtt. Per ortho spine, no\n surgery; HOB<30, TLSO when OOB (NEOPS will place). Neuro checks q\n shift.\n Cardiovascular: Aflutter on Dilt 60mg PO QID. Still on Neo. Likely\n needs chemical/electrical cardioversion to improve atrial contribution\n to CO\n Pulmonary: Intubated. Weaning to extubate (was on throughout\n , changed to 10/10 after desat, but self-extubated and reintubated\n am). F/U on BAL: KLEBSIELLA PNEUMONIAE & GNRs/Haemophilus. Repeat\n BAL with gram+ cocci in pairs on gram stain. Ceftriaxone ()\n changed to Vancomycin/Zosyn (). Plan for Trach early this week.\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin with CT scan\n suggesting cirrhosis - Hepatitis panel NEG. TFs advancing to goal.\n Bowel regimen. Tbili trending up (6.8), other LFTs improving.\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO, Foley, monitor UOP. Cr normalized.\n Hematology: Hct and Plt stable; d/c'd H2B\n Endocrine: RISS\n Infectious Disease: WBC increasing to 13.1, f/u Cx - BAL: Klebsiella\n (b/l)& GNRs (on R)/Haemophilus (on L). Started Ceftriaxone (),\n broadened to Zosyn/Vanc () for continued fevers and gram+ on BAL\n Lines / Tubes / Drains: R SC CVL (), PIV x2, Foley, L a-line\n (), ETT\n Wounds:\n Imaging: CXR today\n Fluids: KVO\n Consults: Trauma surgery, Ortho, Ortho-spine, Heme\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 01:00 PM 80 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 04:41 PM\n Arterial Line - 11:30 AM\n Prophylaxis:\n DVT: (IVC filter, SCDs)\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n"},{"category":"General","chartdate":"2175-01-30 00:00:00.000","description":"Generic Note","row_id":714146,"text":"TITLE:\n TSICU\n HPI:\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\n checked and 1.5, 1 more unit FFP given.\n Chief complaint:\n Mult rib fx: R anterolateral and post, L posterior\n T4 vert body inf corner fx\n Commin spinous process fx T2-8\n Nondisplaced L T10 transverse process\n Nondispaced L distal clavicle\n Nondisplaced L clavicle fx\n R medial lobe liver contusion w/hematoma\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny focus of arterial\n bleeding/active extravasation, and larger area of venous bleeding\n Nondisplaced, comminuted L iliac bone fx w/adjacent iliac muscle\n hematoma, extends into L SIJ.\n Minimally displaced fx of R iliac bone extending to R SIJ.\n PMHx:\n None\n Current medications:\n Chlorhexidine Gluconate 0.12% Oral Rinse\n Diltiazem\n Furosemide\n Gabapentin\n Metoprolol Tartrate\n Ondansetron\n Phenylephrine\n 24 Hour Events:\n Self-extubated in the AM, re-intubated over bougie, NGT replaced,\n bronch with bilateral BALs sent, plan for trach later this week. T\n spike to 101.8 - u/a, urine cx, blood cxs sent. Diltiazem titrated to\n 60mg PO QID. ABX coverage broadened to Vanc/Zosyn. Tbili up to 6.8\n (other LFTs trending down)\n Post operative day:\n POD#4 - IVC filter via L groin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 11:00 AM\n Piperacillin/Tazobactam (Zosyn) - 08:19 PM\n Vancomycin - 08:56 PM\n Infusions:\n Fentanyl (Concentrate) - 100 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Hydromorphone (Dilaudid) - 04:00 AM\n Metoprolol - 06:33 AM\n Pantoprazole (Protonix) - 02:00 PM\n Midazolam (Versed) - 12:30 AM\n Other medications:\n Flowsheet Data as of 02:07 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.8\nC (101.8\n T current: 37.2\nC (98.9\n HR: 76 (76 - 103) bpm\n BP: 97/51(67) {86/47(62) - 121/858(84)} mmHg\n RR: 18 (0 - 25) insp/min\n SPO2: 99%\n Heart rhythm: A Flut (Atrial Flutter)\n Wgt (current): 102 kg (admission): 90 kg\n CVP: 11 (6 - 18) mmHg\n Total In:\n 3,114 mL\n 207 mL\n PO:\n Tube feeding:\n 1,301 mL\n 148 mL\n IV Fluid:\n 1,682 mL\n 59 mL\n Blood products:\n Total out:\n 2,500 mL\n 180 mL\n Urine:\n 2,500 mL\n 180 mL\n NG:\n Stool:\n Drains:\n Balance:\n 614 mL\n 27 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 540 (540 - 540) mL\n PS : 5 cmH2O\n RR (Set): 15\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI: 34\n PIP: 26 cmH2O\n Plateau: 23 cmH2O\n Compliance: 42.3 cmH2O/mL\n SPO2: 99%\n ABG: 7.44/50/127/34/8\n Ve: 9.5 L/min\n PaO2 / FiO2: 254\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: Aflutter\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present,\n Stable scrotal edema/hematoma, soft, no crepitus\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: Follows simple commands, Moves all extremities, Sedated\n Labs / Radiology\n 158 K/uL\n 10.7 g/dL\n 115 mg/dL\n 0.8 mg/dL\n 34 mEq/L\n 4.0 mEq/L\n 20 mg/dL\n 111 mEq/L\n 148 mEq/L\n 31.6 %\n 13.1 K/uL\n [image002.jpg]\n 01:59 AM\n 02:00 AM\n 11:04 AM\n 01:17 PM\n 02:55 AM\n 04:11 AM\n 09:45 AM\n 04:45 PM\n 12:45 AM\n 01:00 AM\n WBC\n 5.6\n 6.5\n 13.1\n Hct\n 28.7\n 29.3\n 31.6\n Plt\n 74\n 86\n 158\n Creatinine\n 0.8\n 0.8\n 0.8\n TCO2\n 35\n 34\n 34\n 38\n 37\n 35\n 35\n Glucose\n 125\n 128\n 141\n 107\n 131\n 115\n Other labs: PT / PTT / INR:13.9/26.9/1.2, CK / CK-MB / Troponin\n T:1334/13/<0.01, ALT / AST:90/88, Alk-Phos / T bili:63/6.8, Amylase /\n Lipase:44/, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic Acid:1.2\n mmol/L, Albumin:2.7 g/dL, LDH:348 IU/L, Ca:8.4 mg/dL, Mg:2.1 mg/dL,\n PO4:2.9 mg/dL\n Imaging: CT head OSH: Prelim No ICH or fx.\n CT chest OSH: Mult rib fx: R anterolateral and posterior, L\n posterior; Dependent consolidation, possible aspiration; T4 vertebral\n body inf corner fx, no retropulsion; Comminuted spinous process fx\n T2-8; Nondisplaced L T10 transverse process; Nondisplaced L clavicle\n distal fx; Nondisplaced L scapula fx;\n CT c spine OSH: Prelim No fx or malalignment. Multilevel\n degenerative changes w/large post disk bulge at C4-5, narrowing the\n spinal canal and deforming the thecal sac, acuity unknown. Marked\n neuroforamenal narrowing @multiple levels.\n CTA abd/pel Prelim: Medial R liver lobe contusion w/adj\n hematoma, w/o evidence of active bleeding; Comminuted L pubic ramus\n fracture w/assoc hematoma, with tiny focus of arterial bleeding/active\n extravasation, and larger area of venous bleeding. Hematoma somewhat\n larger than on OSH study. Nondisplaced, comminuted L iliac bone fx\n w/adj iliac muscle hematoma, larger than on prior study, w/o active\n extrav. Fx extends into L SIJ. Post R hepatic laceration/contusion\n adjacent to calcified granuloma, w/small hematoma, w/out active\n bleeding. Min displaced fx of R iliac bone extending to R SIJ.\n Cirrhotic liver. Inc B pl effusions (small), w/inc atelectasis.\n MRI: Mild compression deformity of L1 w/additional levels of\n potential trabecular contusion @T10-11 also inf @T4 w/o retropulsion.\n Multilevel degenerative changes with moderate canal narrowing at T10-11\n w/cord deformity and no abnormal cord signal. Extensive edema\n throughout paraspinal soft tissues, predominantly post w/in\n interspinous ligaments. Incompletely eval'ed c-spine w/severe canal\n narrowing @C4-5 w/cord deformity and no abnormal cord signal.\n CTA: no PE.\n CXR: Moderate bilateral pleural effusions are stable.\n CXR: Cardiac size top nl, interval improvement of collapse LLL.\n Collapse RLL. Atelectasis in lingula unchanged. Mod B\n pleural effusions stable. No PTX.\n CXR: Interval mild incr in cardiac size, b/l pleural effusions,\n and opacities @ bases,c/w overload\n : R foot: Linear density projecting @ expected area of insertion\n of the Achilles to calcaneus, may be min avulsion fx or degenerative\n changes. Otherwise no fx\n CXR: bilateral pleural effusions\n Microbiology: Ucx no growth final\n Sputum: sparse GNR\n Bcx P\n Bcx P\n 12/17 L BAL: KLEBSIELLA PNEUMONIAE, HAEMOPHILUS SPECIES NOT INFLUENZAE\n R BAL: KLEBSIELLA PNEUMONIAE & GNRs.\n 12/20 L BAL: gram + cocci pairs on gram stain\n R BAL: gram + cocci pairs on gram stain\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, AF with\n RVR, hematologic abnomalities.\n Neurologic: Intubated on Fentanyl/Versed gtt. Per ortho spine, no\n surgery; HOB<30, TLSO when OOB (NEOPS will place). Neuro checks q\n shift.\n Cardiovascular: Aflutter on Dilt 60mg PO QID. Still on Neo (was off\n Neof or a time while in NSR). Likely needs chemical/electrical\n cardioversion to improve atrial contribution to CO. Repeat TTE today to\n evaluate function while in flutter.\n Pulmonary: Intubated. Weaning to extubate (was on throughout\n , changed to 10/10 after desat, but self-extubated and reintubated\n am). F/U on BAL: KLEBSIELLA PNEUMONIAE & GNRs/Haemophilus. Repeat\n BAL with gram+ cocci in pairs on gram stain. Ceftriaxone ()\n changed to Vancomycin/Zosyn (). Plan for Trach early this week.\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin with CT scan\n suggesting cirrhosis - Hepatitis panel NEG. TFs advancing to goal.\n Bowel regimen. Tbili trending up (6.8), other LFTs improving. Obtain\n RUQ U/S today to evaluate for acalculous cholecystitis as well as bile\n leak given recent trauma. Plan for PEG this week.\n Nutrition: Tube feeding at goal.\n Renal: Foley, Adequate UO, monitor UOP. Cr normalized.\n Hematology: Hct and Plt stable; d/c'd H2B. F/u Heme recs.\n Endocrine: RISS, goa,l BS<150, adequate control.\n Infectious Disease: WBC increasing to 13.1, f/u Cx - BAL: Klebsiella\n (b/l)& GNRs (on R)/Haemophilus (on L). Started Ceftriaxone (),\n broadened to Zosyn/Vanc () for continued fevers and gram+ on BAL.\n Will add cipor for additional antipseudomonal coverage if deteriorates\n clinically.\n Lines / Tubes / Drains: R SC CVL (), PIV x2, Foley, L a-line\n (), ETT\n Wounds:\n Imaging: CXR today\n Fluids: KVO\n Consults: Trauma surgery, Ortho, Ortho-spine, Heme\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 01:00 PM 80 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 04:41 PM\n Arterial Line - 11:30 AM\n Prophylaxis:\n DVT: (IVC filter, SCDs); start heparin sq\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 mins\n"},{"category":"Physician ","chartdate":"2175-01-31 00:00:00.000","description":"Intensivist Note","row_id":714239,"text":"TSICU\n HPI:\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\n checked and 1.5, 1 more unit FFP given.\n Chief complaint:\n Mult rib fx: R anterolateral and post, L posterior\n T4 vert body inf corner fx\n Commin spinous process fx T2-8\n Nondisplaced L T10 transverse process\n Nondispaced L distal clavicle\n Nondisplaced L clavicle fx\n R medial lobe liver contusion w/hematoma\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny focus of arterial\n bleeding/active extravasation, and larger area of venous bleeding\n Nondisplaced, comminuted L iliac bone fx w/adjacent iliac muscle\n hematoma, extends into L SIJ.\n Minimally displaced fx of R iliac bone extending to R SIJ.\n PMHx:\n PMH: None\n PSH: None\n Current medications:\n 1. IV access: Peripheral line Order date: @ 2329 16. Ketamine\n Study Drug Study Med 1 dose IV AS SIR Duration: 24 Hours\n Patient to receive Ketamine/Placebo 0.25mg/kg bolus over 1 hour\n followed by 0.1mg/kg/hr for 23 hours Order date: @ 1338\n 2. Acetaminophen 650 mg PO/NG Q6H:PRN pain Order date: @ 2329\n 17. Lorazepam 2mg Syringe Study Med 1 mg IV Q6H Duration: 4 Doses\n Patient to receive Lorazepam 1mg iv every 6 hours for 4 doses while on\n ketamine study drug Order date: @ 1338\n 3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation Order date: @\n 0823 18. Magnesium Sulfate IV Sliding Scale Order date: @ 2339\n 4. Calcium Gluconate IV Sliding Scale Order date: @ 1657 19.\n Metoprolol Tartrate 5 mg IV Q4H:PRN hr>90, SBP>150\n hold hr<60, SBP<100 Order date: @ 1809\n 5. CeftriaXONE 1 gm IV Q24H Order date: @ 1228 20. Midazolam\n 0.5-1 mg IV Q2H:PRN sedation Order date: @ 0912\n 6. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL Order date:\n @ 2329 21. Midazolam 0.5-10 mg/hr IV DRIP TITRATE TO sedation\n Patient must have adequate airway support prior to administration of\n dose. Order date: @ 0734\n 7. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date: \n @ 0104 22. Ondansetron 4 mg IV Q8H:PRN nausea Order date: @ 2329\n 8. Diltiazem 60 mg PO/NG QID\n hold for HR < 60 or SBP < 100 Order date: @ 23.\n Pantoprazole 40 mg IV Q24H Order date: @ 1321\n 9. Docusate Sodium (Liquid) 100 mg PO/NG Order date: @ 2329\n 24. Phenylephrine 0.5-5 mcg/kg/min IV DRIP TITRATE TO SBP>90 MAP>60\n Order date: @ 2339\n 10. Fentanyl Citrate 25-100 mcg/hr IV DRIP INFUSION\n Please wean with Dilaudid dosing. Thank you. Order date: @ 1136\n 25. Pneumococcal Vac Polyvalent 0.5 ml IM ASDIR Order date: @\n 2316\n 11. Gabapentin 400 mg PO/NG TID Order date: @ 1210 26. Potassium\n Phosphate IV Sliding Scale\n Infuse over 6 hours Order date: @ 2339\n 12. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date:\n @ 0104 27. Potassium Chloride IV Sliding Scale Order date: \n @ 2339\n 13. HYDROmorphone (Dilaudid) 0.125-1 mg IV Q3H:PRN pain Order date:\n @ 0912 28. Senna 1 TAB PO/NG :PRN constipation Order date:\n @ 0823\n 14. Heparin 5000 UNIT SC TID Order date: @ 0931 29. Sodium\n Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ 2329\n 15. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 0104 30. Vancomycin 1000 mg IV\n Q 12H\n ID Approval will be required for this order in 39 hours. Order date:\n @ \n 24 Hour Events:\n Placed on ketamine for study. Continues to be in aflutter and on Neo,\n difficulties weaning, however when pt more awake (ie: turning), he is\n actually HTN. TTE done showing mild TR. RUQ U/S showing mild\n perihepatic fluid collection too small to be drained.\n Post operative day:\n POD#5 - IVC filter via L groin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\n Ceftriaxone - 12:00 PM\n Vancomycin - 08:36 PM\n Infusions:\n Fentanyl (Concentrate) - 100 mcg/hour\n Ketamine - 0.1 mcg/Kg/min\n Phenylephrine - 1.2 mcg/Kg/min\n Midazolam (Versed) - 0.5 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 02:00 PM\n Heparin Sodium (Prophylaxis) - 08:29 PM\n Midazolam (Versed) - 01:15 AM\n Fentanyl - 01:20 AM\n Lorazepam (Ativan) - 02:09 AM\n Other medications:\n Flowsheet Data as of 04:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.2\nC (100.7\n T current: 37.9\nC (100.3\n HR: 78 (75 - 91) bpm\n BP: 103/51(69) {89/48(62) - 152/66(94)} mmHg\n RR: 28 (16 - 29) insp/min\n SPO2: 98%\n Heart rhythm: A Flut (Atrial Flutter)\n Wgt (current): 102 kg (admission): 90 kg\n CVP: 11 (9 - 17) mmHg\n Total In:\n 3,764 mL\n 418 mL\n PO:\n Tube feeding:\n 1,920 mL\n 255 mL\n IV Fluid:\n 1,384 mL\n 163 mL\n Blood products:\n Total out:\n 1,535 mL\n 245 mL\n Urine:\n 1,530 mL\n 245 mL\n NG:\n 5 mL\n Stool:\n Drains:\n Balance:\n 2,229 mL\n 173 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 431 (399 - 596) mL\n PS : 10 cmH2O\n RR (Spontaneous): 25\n PEEP: 10 cmH2O\n FiO2: 50%\n PIP: 20 cmH2O\n SPO2: 98%\n ABG: 7.41/56/91./32/8\n Ve: 11.7 L/min\n PaO2 / FiO2: 184\n Physical Examination\n General Appearance: Overweight / Obese\n Cardiovascular: (Rhythm: No(t) Regular, Irregular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: No(t)\n Crackles : , Rhonchorous : bilaterally)\n Abdominal: Soft, Obese, right flank, right pelvis, and scrotum\n eechymotic\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Skin: right flank, right pelvis, and scrotum eechymotic\n Neurologic: Sedated\n Labs / Radiology\n 153 K/uL\n 10.7 g/dL\n 117 mg/dL\n 0.7 mg/dL\n 32 mEq/L\n 3.9 mEq/L\n 22 mg/dL\n 106 mEq/L\n 143 mEq/L\n 32.1 %\n 8.8 K/uL\n [image002.jpg]\n 02:55 AM\n 04:11 AM\n 09:45 AM\n 04:45 PM\n 12:45 AM\n 01:00 AM\n 05:12 AM\n 02:40 PM\n 01:46 AM\n 01:55 AM\n WBC\n 6.5\n 13.1\n 8.8\n Hct\n 29.3\n 31.6\n 32.1\n Plt\n 86\n 158\n 153\n Creatinine\n 0.8\n 0.8\n 0.7\n 0.7\n TCO2\n 38\n 37\n 35\n 35\n 34\n 37\n Glucose\n 141\n 107\n 131\n 115\n 132\n 122\n 117\n Other labs: PT / PTT / INR:13.7/27.6/1.2, CK / CK-MB / Troponin\n T:128/13/<0.01, ALT / AST:81/93, Alk-Phos / T bili:84/5.8, Amylase /\n Lipase:44/, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic Acid:1.4\n mmol/L, Albumin:2.7 g/dL, LDH:348 IU/L, Ca:8.0 mg/dL, Mg:2.0 mg/dL,\n PO4:3.3 mg/dL\n Imaging: CXR: Cardiac size top nl, interval improvement of\n collapse LLL. Collapse RLL. Atelectasis in lingula unchanged. Mod B\n pleural effusions stable. No PTX.\n CXR: Interval mild incr in cardiac size, b/l pleural effusions,\n and opacities @ bases,c/w overload\n : R foot: Linear density projecting @ expected area of insertion\n of the Achilles to calcaneus, may be min avulsion fx or degenerative\n changes. Otherwise no fx\n CXR: b/l pleural effusions\n CXR: stable.\n RUQ U/S: No perihepatic fluid collection. small amt perihepatic\n free fluid persists. Small contusion in hepatic segment VII. No\n gallstones or significant wall thickening/edema. CBD 4.5 mm\n TTE: LVEF >55%, normal diastolic function, normal left\n ventricular filling pressure (PCWP<12mmHg), Right ventricular chamber\n size is mildly dilated, mild TR\n Microbiology: Ucx no growth final\n Sputum: sparse GNRs, too few to colonize\n Bcx P\n Bcx P\n 12/17 L BAL: Klebsiella Pneumoniae, HAEMOPHILUS SPECIES NOT INFLUENZAE\n R BAL: Klebsiella Pneumoniae, Proteus.\n 12/20 L BAL: gram + cocci pairs on gram stain, GNRs (sparse) on cx\n R BAL: gram + cocci pairs on gram stain, GNRs (10-100K) on cx\n BCX: p\n BCx: P\n UCx: no growth final\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, now\n with AF with RVR/Aflutter, hypotension and presumed PNA.\n Neurologic: Intubated on Fentanyl/Versed gtt. Per ortho spine, no\n surgery; HOB<30, TLSO when OOB (NEOPS will place).\n Neuro checks Q: shift\n Pain: Fentanyl gtt (trying to wean), dilaudid, Midazolam gtt,\n Neurontin, Tylenol\n Cardiovascular: Aflutter on Dilt 60mg PO QID. Weaning Neo.\n Pulmonary: Intubated. Weaning to extubate. On appropriate abx per BAL\n cx -Vanco and Ceftriaxone. Will need Trach this week.\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin with CT scan\n suggesting cirrhosis - Hepatitis panel NEG. TFs advancing to goal.\n Bowel regimen.\n Nutrition: Tube feeding\n Renal: Foley, Foley, monitor UOP.\n Hematology: Hct stable. Plt low but stable (100's); d/c'd H2B with\n increasing plt count. Heme onc consulted - smear nl; no hemolysis. IVC\n filter placed.\n Endocrine: RISS\n Infectious Disease: Check cultures, WBC normal, f/u Cx - BAL:\n Klebsiella (b/l)& GNRs (on R)/Haemophilus (on L). Klebsiella\n Pneumoniae, Proteus/Haemophilus. Repeat BAL with gram+ cocci in\n pairs on gram stain, GNRs.\n Lines / Tubes / Drains: R SC CVL (), PIV x2, Foley, L a-line\n (), ETT\n Wounds:\n Imaging: CXR today\n Fluids: KVO\n Consults: Trauma (1o), Ortho Spine, Ortho trauma, Heme\n Billing Diagnosis: Multiple injuries (Trauma)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 04:41 PM\n Arterial Line - 11:30 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin, IVC filter\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent:\n"},{"category":"Respiratory ","chartdate":"2175-02-01 00:00:00.000","description":"Respiratory Care Shift Note","row_id":714416,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 8\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Tube Type\n ETT:\n Position: 25 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 30 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Tracheostomy planned\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Underlying illness not resolved\n Comments: Pt. remains intubated on IPS overnoc. Plan trach today.\n"},{"category":"Physician ","chartdate":"2175-02-03 00:00:00.000","description":"Intensivist Note","row_id":714779,"text":"TSICU\n HPI:\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\n checked and 1.5, 1 more unit FFP given.\n Chief complaint:\n PMHx:\n Current medications:\n Acetaminophen 4. Amiodarone 5. Bisacodyl 6. Calcium Gluconate 7.\n CefePIME 8. CefePIME\n 9. Chlorhexidine Gluconate 0.12% Oral Rinse 10. Ciprofloxacin HCl 11.\n Dextrose 50% 12. Docusate Sodium (Liquid)\n 13. Fentanyl Citrate 14. Furosemide 15. Furosemide 16. Furosemide 17.\n Gabapentin 18. Glucagon 19. Heparin\n 20. Insulin 21. Lactulose 22. Lansoprazole Oral Disintegrating Tab 23.\n Lorazepam 24. Magnesium Sulfate\n 25. Metoprolol Tartrate 26. Metoprolol Tartrate 27. Midazolam 28.\n Midazolam 29. Milk of Magnesia\n 30. Olanzapine (Disintegrating Tablet) 31. Ondansetron 32. OxycoDONE\n Liquid 33. Phenylephrine 34. Pneumococcal Vac Polyvalent\n 35. Potassium Phosphate 36. Potassium Chloride 37. Senna 38. Sodium\n Chloride 0.9% Flush 39. Sodium Chloride 0.9% Flush\n 40. Vancomycin 41. Vancomycin\n 24 Hour Events:\n EKG - At 09:07 PM\n FEVER - 101.1\nF - 12:00 AM\n : TFs increased. Lasix 10x3 with good result. Zyprexa for\n sedation, weaned off versed, fentanyl. Cards rec 400'' x 1wk, then\n 400'x1 wk, then 200'. also rec changing dilt to metop 25''.\n Vanc/cipro/cefepime for VAP.\n : pan cx for temp 101.1\n Post operative day:\n POD#8 - IVC filter via L groin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 03:00 PM\n Ciprofloxacin - 12:00 PM\n Vancomycin - 07:33 PM\n Cefipime - 11:15 PM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 02:00 PM\n Lorazepam (Ativan) - 11:41 PM\n Midazolam (Versed) - 02:16 AM\n Furosemide (Lasix) - 03:55 AM\n Heparin Sodium (Prophylaxis) - 04:02 AM\n Metoprolol - 06:27 AM\n Other medications:\n Flowsheet Data as of 08:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.4\nC (101.1\n T current: 37.7\nC (99.8\n HR: 97 (81 - 111) bpm\n BP: 160/81(110) {111/59(80) - 166/81(110)} mmHg\n RR: 30 (17 - 30) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 104.2 kg (admission): 90 kg\n CVP: 19 (12 - 26) mmHg\n Total In:\n 2,674 mL\n 727 mL\n PO:\n Tube feeding:\n 660 mL\n 637 mL\n IV Fluid:\n 895 mL\n 90 mL\n Blood products:\n Total out:\n 2,485 mL\n 1,055 mL\n Urine:\n 2,485 mL\n 1,055 mL\n NG:\n Stool:\n Drains:\n Balance:\n 189 mL\n -328 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 510 (502 - 660) mL\n PS : 12 cmH2O\n RR (Spontaneous): 28\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 28 cmH2O\n SPO2: 99%\n ABG: 7.50/43/150/31/9\n Ve: 11.8 L/min\n PaO2 / FiO2: 300\n Physical Examination\n General Appearance: Anxious, Well nourished\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: Crackles : , Rhonchorous : ,\n Diminished: )\n Abdominal: Soft, Distended\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities\n Labs / Radiology\n 128 K/uL\n 9.3 g/dL\n 138 mg/dL\n 0.8 mg/dL\n 31 mEq/L\n 3.8 mEq/L\n 23 mg/dL\n 105 mEq/L\n 142 mEq/L\n 28.9 %\n 6.3 K/uL\n [image002.jpg]\n 02:00 PM\n 05:04 PM\n 08:00 PM\n 09:20 PM\n 01:00 AM\n 01:07 AM\n 01:18 AM\n 02:05 AM\n 03:54 AM\n 05:17 AM\n WBC\n 5.9\n 6.3\n Hct\n 31.3\n 28.9\n Plt\n 109\n 128\n Creatinine\n 0.8\n 0.8\n TCO2\n 36\n 34\n 35\n 34\n 35\n Glucose\n 111\n 105\n 117\n 110\n 138\n Other labs: PT / PTT / INR:13.7/27.6/1.2, CK / CK-MB / Troponin\n T:128/13/<0.01, ALT / AST:90/122, Alk-Phos / T bili:133/5.4, Amylase /\n Lipase:54/52, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic\n Acid:1.4 mmol/L, Albumin:2.3 g/dL, LDH:348 IU/L, Ca:8.0 mg/dL, Mg:2.2\n mg/dL, PO4:2.8 mg/dL\n Imaging: CT head OSH: Prelim No ICH or fx.\n CT chest OSH: Mult rib fx: R anterolateral and posterior, L\n posterior; Dependent consolidation, possible aspiration; T4 vertebral\n body inf corner fx, no retropulsion; Comminuted spinous process fx\n T2-8; Nondisplaced L T10 transverse process; Nondisplaced L clavicle\n distal fx; Nondisplaced L scapula fx;\n CT c spine OSH: Prelim No fx or malalignment. Multilevel\n degenerative changes w/large post disk bulge at C4-5, narrowing the\n spinal canal and deforming the thecal sac, acuity unknown. Marked\n neuroforamenal narrowing @multiple levels.\n CTA abd/pel Prelim: Medial R liver lobe contusion w/adj\n hematoma, w/o evidence of active bleeding; Comminuted L pubic ramus\n fracture w/assoc hematoma, with tiny focus of arterial bleeding/active\n extravasation, and larger area of venous bleeding. Hematoma somewhat\n larger than on OSH study. Nondisplaced, comminuted L iliac bone fx\n w/adj iliac muscle hematoma, larger than on prior study, w/o active\n extrav. Fx extends into L SIJ. Post R hepatic laceration/contusion\n adjacent to calcified granuloma, w/small hematoma, w/out active\n bleeding. Min displaced fx of R iliac bone extending to R SIJ.\n Cirrhotic liver. Inc B pl effusions (small), w/inc atelectasis.\n MRI: Mild compression deformity of L1 w/additional levels of\n potential trabecular contusion @T10-11 also inf @T4 w/o retropulsion.\n Multilevel degenerative changes w/moderate canal narrowing @T10-11\n w/cord deformity & no abnl cord signal. Extensive edema throughout\n paraspinal soft tissues, predominantly post w/in interspinous\n ligaments. Incompletely eval'ed c-spine w/severe canal narrowing @C4-5\n w/cord deformity and no abn cord signal.\n CTA: no PE.\n CXR: Moderate b/l pleural effusions are stable.\n CXR: Cardiac size top nl, interval improvement of collapse LLL.\n Collapse RLL. Atelectasis in lingula unchanged. Mod B pleural effusions\n stable. No PTX.\n CXR: Interval mild incr in cardiac size, b/l pl effusions,\n & opacities @ bases,c/w overload\n : R foot: Linear density projecting @ expected area of insertion\n of Achilles to calcaneus, may be min avulsion fx or degenerative\n changes. Otherwise no fx\n CXR: b/l pl effusions\n CXR: stable.\n RUQ U/S: No perihepatic fluid collection. small amt perihepatic\n free fluid persists. Small contusion in hepatic segment VII. No\n gallstones or sig wall thickening/edema. CBD 4.5 mm\n TTE: LVEF >55%, NL diastolic function, NL LV filling pressure\n (PCWP<12mmHg), RV chamber size mildly dilated, mild TR\n CXR: mild b/l pulm edema and parenchymal opacities and no\n pl effusion.\n CXR: Persistent b/l pl effusions and bibasilar opacity.\n CXR: Minimal improvement of mod b/l pl effusions. Otherwise\n stable.\n Microbiology: Ucx no growth final\n Sputum: sparse GNRs, too few to colonize\n Bcx x2 no growth final\n 12/17 L BAL: Klebsiella Pneumoniae, HAEMOPHILUS SPECIES NOT INFLUENZAE\n R BAL: Klebsiella Pneumoniae, Proteus.\n 12/20 L &R BAL: Klebsiella Pneumoniae\n BCX: p\n BCx: P\n UCx: no growth final\n BCx: P\n BCx: P\n UCx: P\n SpCx: P\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, now\n with AF with RVR/Aflutter, persistant hypotension and PNA.\n Neurologic: s/p trach (). Per ortho spine, no surgery; HOB<30,\n TLSO when OOB. Zyprexa & Ativan PRN (off fent/midaz ).\n Neuro checks Q: shift\n Pain: Oxycodone, Neurontin, Tylenol.\n Cardiovascular: Aflutter, now reverted to sinus w/1st deg AVB. Likely\n cardiac contusion. Cards rec 400'' x 1wk, then 400'x1 wk, then\n 200'. also rec changing dilt to metop 25''. Pt cannot be fully\n anticoagulated for now (trauma). Will concentrate meds.\n Pulmonary: Intubated, weaning, Vanc/cipro/cefepime for VAP ().\n Increasing pulmonary edema on CXR (lasix x 2 on , lasix x1 ).\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin (declining 6.8\n max ->5.0) w/CT scan suggesting cirrhosis - Hepatitis panel NEG. TFs\n restarted, increasing to goal . Bowel regimen. Will concentrate\n TFs or change to a different type.\n Nutrition: Tube feeding\n Renal: Foley, monitor UOP, edematous scrotum. Lasix 10 x2 on ,\n lasix x1 . Lasix 20 x1 , if tolerates 20 Q6.\n Hematology: Hct stable 32.1->29.7. Plt stable (100's); d/c'd H2B. Heme\n onc c/s - smear nl; no hemolysis. IVC filter placed.\n Endocrine: RISS\n Infectious Disease: Check cultures, WBC droppping\n 13.1->8.8->4.2->5.9->6.3, Vanc/cipro/cefepime for VAP given worsening\n pulm status. B/l LENIS to r/o DVT as source. Fever 101.1 o/n, re-pan\n cx.\n Lines / Tubes / Drains: Trach/Peg/foley/L radial a-line/R SCL\n Wounds:\n Imaging: CXR today\n Fluids: KVO\n Consults: Trauma (1o), Ortho Spine, Ortho trauma, Heme\n Billing Diagnosis: (Respiratory distress: Failure), (Shock: Traumatic),\n Multiple injuries (Trauma)\n ICU Care\n Nutrition: Replete with Fiber (Full) - 04:12 AM 80 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 04:41 PM\n Arterial Line - 11:30 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting planning, ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 33 minutes\n Patient is critically ill\n"},{"category":"Physician ","chartdate":"2175-02-03 00:00:00.000","description":"Intensivist Note","row_id":714794,"text":"TSICU\n HPI:\n 74M s/p fall with multiple rib fx, pelvis fx, clavicle fx, and thoracic\n fx c/b unstable bleeding s/p IR embo, now with AF with RVR/Aflutter,\n persistant hypotension and presumed PNA.\n Chief complaint:\n fall\n PMHx:\n none\n Current medications:\n 1. Acetaminophen 2. Amiodarone 3. Bisacodyl 4. Calcium Gluconate 5.\n CeftriaXONE 6. Chlorhexidine Gluconate 0.12% Oral Rinse 7. Dextrose 50%\n 8. Diltiazem 9. Docusate Sodium (Liquid) 10. Fentanyl Citrate 11.\n Gabapentin 12. Glucagon 13. Heparin 14. Insulin 15. Lactulose 16.\n Magnesium Sulfate 17. Metoprolol Tartrate 18. Midazolam 19. Midazolam\n 20. Milk of Magnesia 21. Ondansetron 22. OxycoDONE Liquid 23.\n Pantoprazole 24. Phenylephrine\n 25. Pneumococcal Vac Polyvalent 26. Potassium Phosphate 27. Potassium\n Chloride 28. Senna 29. Sodium Chloride 0.9% Flush\n 24 Hour Events:\n Changed sedation to po Oxycodone, wean fentanyl gtt, wean Midazolam,\n and start Haldol prn, but stopped due to QTc. Cards consult, started\n amiodarone.\n Post operative day:\n POD#6 - IVC filter via L groin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\n Vancomycin - 08:00 AM\n Ceftriaxone - 12:00 PM\n Infusions:\n Midazolam (Versed) - 5 mg/hour\n Fentanyl (Concentrate) - 50 mcg/hour\n Amiodarone - 0.5 mg/min\n Other ICU medications:\n Haloperidol (Haldol) - 10:45 AM\n Lorazepam (Ativan) - 02:00 PM\n Midazolam (Versed) - 03:25 AM\n Fentanyl - 03:25 AM\n Heparin Sodium (Prophylaxis) - 05:33 AM\n Other medications:\n Flowsheet Data as of 06:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.1\nC (100.6\n T current: 37.2\nC (98.9\n HR: 76 (74 - 104) bpm\n BP: 125/62(81) {90/49(62) - 152/67(89)} mmHg\n RR: 25 (18 - 31) insp/min\n SPO2: 98%\n Heart rhythm: A Flut (Atrial Flutter)\n Wgt (current): 102 kg (admission): 90 kg\n CVP: 12 (10 - 19) mmHg\n Total In:\n 3,718 mL\n 759 mL\n PO:\n Tube feeding:\n 1,920 mL\n 424 mL\n IV Fluid:\n 1,078 mL\n 245 mL\n Blood products:\n Total out:\n 1,755 mL\n 350 mL\n Urine:\n 1,755 mL\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,963 mL\n 409 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 480 (400 - 540) mL\n PS : 10 cmH2O\n RR (Spontaneous): 29\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 21 cmH2O\n SPO2: 98%\n ABG: 7.44/45/119/31/6\n Ve: 11.8 L/min\n PaO2 / FiO2: 238\n Physical Examination\n General Appearance: No acute distress, intubated\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), shallow respirations\n Abdominal: Soft, No(t) Non-distended, Bowel sounds present, Distended\n Left Extremities: (Edema: 1+), (Temperature: Warm)\n Right Extremities: (Edema: 1+), (Temperature: Warm)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities, Sedated\n Labs / Radiology\n 104 K/uL\n 9.5 g/dL\n 129 mg/dL\n 0.7 mg/dL\n 31 mEq/L\n 4.2 mEq/L\n 24 mg/dL\n 106 mEq/L\n 142 mEq/L\n 29.7 %\n 4.2 K/uL\n [image002.jpg]\n 04:45 PM\n 12:45 AM\n 01:00 AM\n 05:12 AM\n 02:40 PM\n 01:46 AM\n 01:55 AM\n 03:40 PM\n 12:07 AM\n 02:18 AM\n WBC\n 13.1\n 8.8\n 4.2\n Hct\n 31.6\n 32.1\n 29.7\n Plt\n 158\n 153\n 104\n Creatinine\n 0.8\n 0.7\n 0.7\n 0.7\n TCO2\n 35\n 35\n 34\n 37\n 35\n 32\n Glucose\n 131\n 115\n 132\n 122\n 117\n 129\n Other labs:\n PT / PTT / INR:13.7/27.6/1.2, CK / CK-MB / Troponin T:128/13/<0.01,\n ALT / AST:87/109, Alk-Phos / T bili:115/5.0, Amylase / Lipase:44/,\n D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic Acid:1.4 mmol/L,\n Albumin:2.7 g/dL, LDH:348 IU/L, Ca:7.9 mg/dL, Mg:2.0 mg/dL, PO4:3.4\n mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, now\n with AF with RVR/Aflutter, persistant hypotension and presumed PNA.\n Neurologic: Intubated. Per ortho spine, no surgery; HOB<30, TLSO when\n OOB (NEOPS will place). Wean sedation as may be causing hypotension.\n Change pain meds to PO. Wean versed.\n Neuro checks Q: shift\n Pain: Oxycodone, Fentanyl gtt (weaning), Midazolam gtt (weaning),\n Neurontin, Tylenol\n Cardiovascular: Aflutter on Dilt 60mg PO QID. Neo off since this AM.\n Cards yesterday rec Amiodarone. Pressor requirements may be related to\n AFib/flutter. No plan for electrical cardioversion right now. As pt\n cannot be anticoagulated (recent major trauma), had TTE w/o thrombus,\n Cards would like anticoagulation, will hold on heparin per Trauma\n surgery.\n Pulmonary: Intubated, weaning, tachypneic likely abd distension. On\n appropriate abx per BAL cx\n Ceftriaxone. Plan for trach today.\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin (declining 6.8\n max\n 5.0) with CT scan suggesting cirrhosis - Hepatitis panel NEG. TFs\n on hold for PEG. Bowel regimen, no BM since admission MOM and Lactulose\n added, will try Methylnaltrexone.\n Nutrition: NPO pre-op.\n Renal: Foley, monitor UOP, edematous scrotum but soft, eccymosis\n improving.\n Hematology: Hct stable 32.1->29.7. Plt low but stable (100's); d/c'd\n H2B with increasing plt count. Heme onc consulted - smear nl; no\n hemolysis. IVC filter placed.\n Endocrine: RISS, goal BS<150, adequate control.\n Infectious Disease: WBC dropping 13.1->8.8->4.2, f/u Cx - BAL:\n Klebsiella\n Ceftriaxone. Will add Vanco back for GPCs coverage if\n patient worsens.\n Lines / Tubes / Drains: R SC CVL (), Foley, L a-line (), ETT\n Imaging: CXR today\n Fluids: KVO\n Consults: Trauma (1o), Ortho Spine, Ortho trauma, Heme\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 04:41 PM\n Arterial Line - 11:30 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin, IVC filter\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 33 min\n"},{"category":"Physician ","chartdate":"2175-02-03 00:00:00.000","description":"Intensivist Note","row_id":714795,"text":"TSICU\n HPI:\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\n checked and 1.5, 1 more unit FFP given.\n .\n Injuries\n Mult rib fx: R anterolateral and post, L posterior\n T4 vert body inf corner fx\n Commin spinous process fx T2-8\n Nondisplaced L T10 transverse process\n Nondispaced L distal clavicle\n Nondisplaced L clavicle fx\n R medial lobe liver contusion w/hematoma\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny focus of arterial\n bleeding/active extravasation, and larger area of venous bleeding\n Nondisplaced, comminuted L iliac bone fx w/adjacent iliac muscle\n hematoma, extends into L SIJ.\n Minimally displaced fx of R iliac bone extending to R SIJ.\n Chief complaint:\n Trauma\n PMHx:\n PMH: None\n PSH: None\n : None\n Current medications:\n 24 Hour Events:\n Trach/PEG. Pt's BP dropped to 80/40 off pressors, sats 88. restarted\n neo. Overnight, pt reverted to sinus, off pressors, weaning sedation.\n PERCUTANEOUS TRACHEOSTOMY - At 12:00 PM\n PEG INSERTION - At 12:00 PM\n Post operative day:\n POD#7 - IVC filter via L groin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\n Vancomycin - 08:00 AM\n Ceftriaxone - 03:00 PM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Amiodarone - 0.5 mg/min\n Fentanyl (Concentrate) - 50 mcg/hour\n Other ICU medications:\n Fentanyl - 01:23 PM\n Pantoprazole (Protonix) - 02:00 PM\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Other medications:\n Flowsheet Data as of 04:33 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.7\nC (99.9\n T current: 37.1\nC (98.8\n HR: 94 (68 - 101) bpm\n BP: 140/66(91) {89/46(63) - 154/68(94)} mmHg\n RR: 26 (11 - 30) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 102 kg (admission): 90 kg\n CVP: 9 (6 - 16) mmHg\n Total In:\n 1,764 mL\n 142 mL\n PO:\n Tube feeding:\n 424 mL\n IV Fluid:\n 1,000 mL\n 82 mL\n Blood products:\n Total out:\n 1,630 mL\n 290 mL\n Urine:\n 1,630 mL\n 290 mL\n NG:\n Stool:\n Drains:\n Balance:\n 134 mL\n -148 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 483 (404 - 506) mL\n PS : 15 cmH2O\n RR (Spontaneous): 16\n PEEP: 10 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10\n PIP: 25 cmH2O\n SPO2: 98%\n ABG: 7.45/49/98./31/8\n Ve: 8.5 L/min\n PaO2 / FiO2: 163\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: Crackles : )\n Abdominal: Soft\n Left Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present)\n Right Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present)\n Neurologic: Follows simple commands, Moves all extremities, Sedated\n Labs / Radiology\n 109 K/uL\n 10.2 g/dL\n 110 mg/dL\n 0.8 mg/dL\n 31 mEq/L\n 4.5 mEq/L\n 24 mg/dL\n 105 mEq/L\n 144 mEq/L\n 31.3 %\n 5.9 K/uL\n [image002.jpg]\n 12:07 AM\n 02:18 AM\n 08:00 AM\n 02:00 PM\n 05:04 PM\n 08:00 PM\n 09:20 PM\n 01:00 AM\n 01:07 AM\n 01:18 AM\n WBC\n 4.2\n 5.9\n Hct\n 29.7\n 31.3\n Plt\n 104\n 109\n Creatinine\n 0.7\n 0.8\n TCO2\n 32\n 36\n 34\n 35\n Glucose\n 129\n 100\n 111\n 105\n 117\n 110\n Other labs: PT / PTT / INR:13.7/27.6/1.2, CK / CK-MB / Troponin\n T:128/13/<0.01, ALT / AST:90/113, Alk-Phos / T bili:99/5.1, Amylase /\n Lipase:58/39, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic\n Acid:1.4 mmol/L, Albumin:2.3 g/dL, LDH:348 IU/L, Ca:8.1 mg/dL, Mg:2.1\n mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, now\n with AF with RVR/Aflutter, persistant hypotension and PNA.\n Neurologic: s/p trach. Per ortho spine, no surgery; HOB<30, TLSO when\n OOB (NEOPS will place). Wean sedation as may be causing hypotension.\n Change pain meds to PO. Will try Geodon today for agitation.\n Neuro checks Q: shift\n Pain: Oxycodone, Neurontin, Tylenol. Wean fentanyl gtt, midazolam\n gtt\n Cardiovascular: Aflutter, now reverted to sinus. Likely cardiac\n contusion. On Dilt 60mg PO QID. Cards rec amio gtt. Neo off. Pt cannot\n be fully anticoagulated for now (trauma). Start PO amio.\n Pulmonary: Intubated, weaning, tachypneic likely abd distension. On\n appropriate abx per BAL cx - Ceftriaxone. Now that pulm status is\n worsening, will broaden coverage with V/C/C.\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin (declining 6.8\n max ->5.0) w/CT scan suggesting cirrhosis - Hepatitis panel NEG. TFs.\n Bowel regimen.\n Nutrition: TF\n Renal: Foley, monitor UOP, edematous scrotum. Diurese with lasix 10mg\n IV. Goal 1 L negative today.\n Hematology: Hct stable 32.1->29.7. Plt stable (100's); d/c'd H2B with\n increasing plt count. Heme onc c/s - smear nl; no hemolysis. IVC\n filter placed.\n Endocrine: RISS, goal BS<150.\n Infectious Disease: WBC dropping 13.1->8.8->4.2, f/u Cx - BAL:\n pan-sensitive Klebsiella\n broaden coverage for VAP.\n Lines / Tubes / Drains: R SC CVL (), Foley, L a-line (),\n trach/PEG\n Wounds: SCDs, IVC filter, SQH\n Imaging:\n Fluids:\n Consults: Trauma surgery\n Billing Diagnosis: Multiple injuries (Trauma)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 04:41 PM\n Arterial Line - 11:30 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 32 min\n"},{"category":"Physician ","chartdate":"2175-02-03 00:00:00.000","description":"Intensivist Note","row_id":714796,"text":"TSICU\n HPI:\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\n checked and 1.5, 1 more unit FFP given.\n Chief complaint:\n PMHx:\n Current medications:\n Acetaminophen 4. Amiodarone 5. Bisacodyl 6. Calcium Gluconate 7.\n CefePIME 8. CefePIME\n 9. Chlorhexidine Gluconate 0.12% Oral Rinse 10. Ciprofloxacin HCl 11.\n Dextrose 50% 12. Docusate Sodium (Liquid)\n 13. Fentanyl Citrate 14. Furosemide 15. Furosemide 16. Furosemide 17.\n Gabapentin 18. Glucagon 19. Heparin\n 20. Insulin 21. Lactulose 22. Lansoprazole Oral Disintegrating Tab 23.\n Lorazepam 24. Magnesium Sulfate\n 25. Metoprolol Tartrate 26. Metoprolol Tartrate 27. Midazolam 28.\n Midazolam 29. Milk of Magnesia\n 30. Olanzapine (Disintegrating Tablet) 31. Ondansetron 32. OxycoDONE\n Liquid 33. Phenylephrine 34. Pneumococcal Vac Polyvalent\n 35. Potassium Phosphate 36. Potassium Chloride 37. Senna 38. Sodium\n Chloride 0.9% Flush 39. Sodium Chloride 0.9% Flush\n 40. Vancomycin 41. Vancomycin\n 24 Hour Events:\n EKG - At 09:07 PM\n FEVER - 101.1\nF - 12:00 AM\n : TFs increased. Lasix 10x3 with good result. Zyprexa for\n sedation, weaned off versed, fentanyl. Cards rec 400'' x 1wk, then\n 400'x1 wk, then 200'. also rec changing dilt to metop 25''.\n Vanc/cipro/cefepime for VAP.\n : pan cx for temp 101.1\n Post operative day:\n POD#8 - IVC filter via L groin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 03:00 PM\n Ciprofloxacin - 12:00 PM\n Vancomycin - 07:33 PM\n Cefipime - 11:15 PM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 02:00 PM\n Lorazepam (Ativan) - 11:41 PM\n Midazolam (Versed) - 02:16 AM\n Furosemide (Lasix) - 03:55 AM\n Heparin Sodium (Prophylaxis) - 04:02 AM\n Metoprolol - 06:27 AM\n Other medications:\n Flowsheet Data as of 08:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.4\nC (101.1\n T current: 37.7\nC (99.8\n HR: 97 (81 - 111) bpm\n BP: 160/81(110) {111/59(80) - 166/81(110)} mmHg\n RR: 30 (17 - 30) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 104.2 kg (admission): 90 kg\n CVP: 19 (12 - 26) mmHg\n Total In:\n 2,674 mL\n 727 mL\n PO:\n Tube feeding:\n 660 mL\n 637 mL\n IV Fluid:\n 895 mL\n 90 mL\n Blood products:\n Total out:\n 2,485 mL\n 1,055 mL\n Urine:\n 2,485 mL\n 1,055 mL\n NG:\n Stool:\n Drains:\n Balance:\n 189 mL\n -328 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 510 (502 - 660) mL\n PS : 12 cmH2O\n RR (Spontaneous): 28\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 28 cmH2O\n SPO2: 99%\n ABG: 7.50/43/150/31/9\n Ve: 11.8 L/min\n PaO2 / FiO2: 300\n Physical Examination\n General Appearance: Anxious, Well nourished\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: Crackles : , Rhonchorous : ,\n Diminished: )\n Abdominal: Soft, Distended\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities\n Labs / Radiology\n 128 K/uL\n 9.3 g/dL\n 138 mg/dL\n 0.8 mg/dL\n 31 mEq/L\n 3.8 mEq/L\n 23 mg/dL\n 105 mEq/L\n 142 mEq/L\n 28.9 %\n 6.3 K/uL\n 02:00 PM\n 05:04 PM\n 08:00 PM\n 09:20 PM\n 01:00 AM\n 01:07 AM\n 01:18 AM\n 02:05 AM\n 03:54 AM\n 05:17 AM\n WBC\n 5.9\n 6.3\n Hct\n 31.3\n 28.9\n Plt\n 109\n 128\n Creatinine\n 0.8\n 0.8\n TCO2\n 36\n 34\n 35\n 34\n 35\n Glucose\n 111\n 105\n 117\n 110\n 138\n Other labs: PT / PTT / INR:13.7/27.6/1.2, CK / CK-MB / Troponin\n T:128/13/<0.01, ALT / AST:90/122, Alk-Phos / T bili:133/5.4, Amylase /\n Lipase:54/52, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic\n Acid:1.4 mmol/L, Albumin:2.3 g/dL, LDH:348 IU/L, Ca:8.0 mg/dL, Mg:2.2\n mg/dL, PO4:2.8 mg/dL\n Imaging: CT head OSH: Prelim No ICH or fx.\n CT chest OSH: Mult rib fx: R anterolateral and posterior, L\n posterior; Dependent consolidation, possible aspiration; T4 vertebral\n body inf corner fx, no retropulsion; Comminuted spinous process fx\n T2-8; Nondisplaced L T10 transverse process; Nondisplaced L clavicle\n distal fx; Nondisplaced L scapula fx;\n CT c spine OSH: Prelim No fx or malalignment. Multilevel\n degenerative changes w/large post disk bulge at C4-5, narrowing the\n spinal canal and deforming the thecal sac, acuity unknown. Marked\n neuroforamenal narrowing @multiple levels.\n CTA abd/pel Prelim: Medial R liver lobe contusion w/adj\n hematoma, w/o evidence of active bleeding; Comminuted L pubic ramus\n fracture w/assoc hematoma, with tiny focus of arterial bleeding/active\n extravasation, and larger area of venous bleeding. Hematoma somewhat\n larger than on OSH study. Nondisplaced, comminuted L iliac bone fx\n w/adj iliac muscle hematoma, larger than on prior study, w/o active\n extrav. Fx extends into L SIJ. Post R hepatic laceration/contusion\n adjacent to calcified granuloma, w/small hematoma, w/out active\n bleeding. Min displaced fx of R iliac bone extending to R SIJ.\n Cirrhotic liver. Inc B pl effusions (small), w/inc atelectasis.\n MRI: Mild compression deformity of L1 w/additional levels of\n potential trabecular contusion @T10-11 also inf @T4 w/o retropulsion.\n Multilevel degenerative changes w/moderate canal narrowing @T10-11\n w/cord deformity & no abnl cord signal. Extensive edema throughout\n paraspinal soft tissues, predominantly post w/in interspinous\n ligaments. Incompletely eval'ed c-spine w/severe canal narrowing @C4-5\n w/cord deformity and no abn cord signal.\n CTA: no PE.\n CXR: Moderate b/l pleural effusions are stable.\n CXR: Cardiac size top nl, interval improvement of collapse LLL.\n Collapse RLL. Atelectasis in lingula unchanged. Mod B pleural effusions\n stable. No PTX.\n CXR: Interval mild incr in cardiac size, b/l pl effusions,\n & opacities @ bases,c/w overload\n : R foot: Linear density projecting @ expected area of insertion\n of Achilles to calcaneus, may be min avulsion fx or degenerative\n changes. Otherwise no fx\n CXR: b/l pl effusions\n CXR: stable.\n RUQ U/S: No perihepatic fluid collection. small amt perihepatic\n free fluid persists. Small contusion in hepatic segment VII. No\n gallstones or sig wall thickening/edema. CBD 4.5 mm\n TTE: LVEF >55%, NL diastolic function, NL LV filling pressure\n (PCWP<12mmHg), RV chamber size mildly dilated, mild TR\n CXR: mild b/l pulm edema and parenchymal opacities and no\n pl effusion.\n CXR: Persistent b/l pl effusions and bibasilar opacity.\n CXR: Minimal improvement of mod b/l pl effusions. Otherwise\n stable.\n Microbiology: Ucx no growth final\n Sputum: sparse GNRs, too few to colonize\n Bcx x2 no growth final\n 12/17 L BAL: Klebsiella Pneumoniae, HAEMOPHILUS SPECIES NOT INFLUENZAE\n R BAL: Klebsiella Pneumoniae, Proteus.\n 12/20 L &R BAL: Klebsiella Pneumoniae\n BCX: p\n BCx: P\n UCx: no growth final\n BCx: P\n BCx: P\n UCx: P\n SpCx: P\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, now\n with AF with RVR/Aflutter, persistant hypotension and PNA.\n Neurologic: s/p trach (). Per ortho spine, no surgery; HOB<30,\n TLSO when OOB. Zyprexa & Ativan PRN (off fent/midaz ).\n Neuro checks Q: shift\n Pain: Oxycodone, Neurontin, Tylenol.\n Cardiovascular: Aflutter, now reverted to sinus w/1st deg AVB. Likely\n cardiac contusion. Cards rec 400'' x 1wk, then 400'x1 wk, then\n 200'. also rec changing dilt to metop 25''. Pt cannot be fully\n anticoagulated for now (trauma). Will concentrate meds.\n Pulmonary: Intubated, weaning, Vanc/cipro/cefepime for VAP ().\n Increasing pulmonary edema on CXR (lasix x 2 on , lasix x1\n ).\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin (declining 6.8\n max ->5.0) w/CT scan suggesting cirrhosis - Hepatitis panel NEG. TFs\n restarted, increasing to goal . Bowel regimen. Will concentrate\n TFs or change to a different type.\n Nutrition: Tube feeding\n Renal: Foley, monitor UOP, edematous scrotum. Lasix 10 x2 on ,\n lasix x1 . Lasix 20 x1 , if tolerates 20 Q6.\n Hematology: Hct stable 32.1->29.7. Plt stable (100's); d/c'd H2B. Heme\n onc c/s - smear nl; no hemolysis. IVC filter placed.\n Endocrine: RISS\n Infectious Disease: Check cultures, WBC droppping\n 13.1->8.8->4.2->5.9->6.3, Vanc/cipro/cefepime for VAP given worsening\n pulm status. B/l LENIS to r/o DVT as source. Fever 101.1 o/n, re-pan\n cx.\n Lines / Tubes / Drains: Trach/Peg/foley/L radial a-line/R SCL\n Wounds:\n Imaging: CXR today\n Fluids: KVO\n Consults: Trauma (1o), Ortho Spine, Ortho trauma, Heme\n Billing Diagnosis: (Respiratory distress: Failure), (Shock: Traumatic),\n Multiple injuries (Trauma)\n ICU Care\n Nutrition: Replete with Fiber (Full) - 04:12 AM 80 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 04:41 PM\n Arterial Line - 11:30 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting planning, ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 33 minutes\n Patient is critically ill\n"},{"category":"Nursing","chartdate":"2175-02-06 00:00:00.000","description":"Nursing Progress Note","row_id":715198,"text":"Respiratory failure, acute (not ARDS/)\n Assessment:\n Trached. Vent settings as charted in metavision. LS rhonchorous at\n times. Sats WNL. Afebrile. WBC count trending down.\n Action:\n Pulmonary hygiene. Cefepime, cipro, and vanco administered as\n ordered. Vent weaned to . ABG drawn. Diamox administered as\n ordered.\n Response:\n Moderate amounts of thick, tan secretions. ABG WNL. Diamox to\n continue for two more doses. Diuresing well, -3L for yesterday\n ().\n Plan:\n ? trach mask today. Begin rehab screening. Administer abx as\n ordered. Monitor I/O\n IV access: PICC placed on currently midline, NOT central.\n Patient did not want IV team to change it; patient preferred them to\n come later today (). HO aware. Discontinue subclavian line once\n PICC placement is confirmed.\n"},{"category":"Nursing","chartdate":"2175-01-31 00:00:00.000","description":"Nursing Progress Note","row_id":714237,"text":"Hypotension (not Shock)\n Assessment:\n Cont in aflutter with controlled rate. SBP remains > 90 on neo gtt.\n Gd csm. Adequate u/o.\n Action:\n Neo gtt titrated to support sbp. Remains on dilt 60mg po qid.\n Response:\n Stable sbp on neo gtt. Remains in aflutter of diltiazem. Lytes wnl.\n Stable hct.\n Plan:\n Cont to monitor hemodynamics and titrate neo to SBP >90. Monitor u/o,\n lytes.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains on psv 10/10peep w/ no change in abg\ns. Stable 02sats. Sxned\n for moderate amt thick yellow and white secretions. LS clear,\n diminished. SRR 20\ns. Poor toleration of ett. Pt cont on midaz and\n Fentanyl and is now on ketamine for a study protocol w/ ATC ativan x4\n doses. Midaz briefly weaned off and pt lightened enough to open eyes\n and follow simple commands and then became increasingly agitated and\n unable to focus.\n Attempting to bite ETT and tongue out ETT. Unable to ventilate at that\n time.\n Action:\n Resedated and maintained sedated for safety overnoc. Pulm toilet.\n Response:\n More heavily sedated until ativan wore off. Sedation adjusted\n accordingly. Cont to open eyes and MAE but agitated when light and\n airway at risk. Stable on present vent settings.\n Plan:\n Cont pulm toilet. Monitor 02sats and abg\ns. Cont sedation for airway\n protection. Possibility of Trach to be discussed with family.\n"},{"category":"Nursing","chartdate":"2175-02-06 00:00:00.000","description":"Nursing Progress Note","row_id":715192,"text":"Respiratory failure, acute (not ARDS/)\n Assessment:\n Trached. Vent settings as charted in metavision. LS rhonchorous at\n times. Sats WNL. Afebrile. WBC count trending down.\n Action:\n Pulmonary hygiene. Cefepime, cipro, and vanco administered as\n ordered. Vent weaned to . ABG drawn. Diamox given.\n Response:\n Moderate amounts of thick, tan secretions. ABG WNL. Diamox to\n continue for two more doses. Diuresing well, -3L for yesterday\n ().\n Plan:\n ? trach mask today. Begin rehab screening. Administer abx as ordered.\n IV access: PICC placed on currently midline, NOT central.\n Patient did not want IV team to change it; patient preferred them to\n come later today (). HO aware. Discontinue subclavian line once\n PICC placement is confirmed.\n"},{"category":"Respiratory ","chartdate":"2175-02-07 00:00:00.000","description":"Respiratory Care Shift Note","row_id":715347,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 14\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Tube Type\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 8.0mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 27 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: pt continues to require frequent suctioning\n Assessment of breathing comfort: No claim of dyspnea)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: attempt to wean off vent to trach collar as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Underlying illness not resolved\n"},{"category":"Physician ","chartdate":"2175-02-06 00:00:00.000","description":"Intensivist Note","row_id":715177,"text":"TSICU\n HPI:\n 74M s/p fall from tractor and crush injury from tree branch. +Loc.\n Chief complaint:\n ventilator dependance\n PMHx:\n PMH: cirrhosis and asbestosis dx on CT\n Current medications:\n Acetaminophen 4. AcetaZOLamide 5. Amiodarone 6. Bisacodyl 7. Calcium\n Gluconate 8. CefePIME\n 9. Chlorhexidine Gluconate 0.12% Oral Rinse 10. Ciprofloxacin HCl 11.\n Dextrose 50% 12. Diltiazem\n 13. Docusate Sodium (Liquid) 14. Furosemide 15. Furosemide 16.\n Gabapentin 17. Glucagon 18. Heparin\n 19. Heparin Flush (10 units/ml) 20. 21. Insulin 22. Lactulose 23.\n Lansoprazole Oral Disintegrating Tab\n 24. Magnesium Sulfate 25. Metoprolol Tartrate 26. Milk of Magnesia 27.\n Olanzapine (Disintegrating Tablet)\n 28. Ondansetron 29. OxycoDONE Liquid 30. Pneumococcal Vac Polyvalent\n 31. Potassium Phosphate 32. Potassium Chloride\n 33. Senna 34. Sodium Chloride 0.9% Flush 35. Sodium Chloride 0.9% Flush\n 36. Vancomycin\n 24 Hour Events:\n : Diamox continued. Lasix 20x2 with good result. PICC. Diamox decr\n w/iatrogenic hyperchloremia, hypernatremia.\n Post operative day:\n POD#11 - IVC filter via L groin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 07:41 PM\n Ciprofloxacin - 09:44 PM\n Cefipime - 12:13 AM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 02:24 PM\n Furosemide (Lasix) - 05:14 PM\n Heparin Sodium (Prophylaxis) - 07:35 PM\n Other medications:\n Flowsheet Data as of 03:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.3\nC (99.2\n T current: 37.1\nC (98.7\n HR: 77 (73 - 98) bpm\n BP: 103/42(60) {86/40(55) - 152/70(97)} mmHg\n RR: 29 (20 - 34) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 104.2 kg (admission): 90 kg\n Total In:\n 2,020 mL\n 451 mL\n PO:\n Tube feeding:\n 960 mL\n 152 mL\n IV Fluid:\n 470 mL\n 119 mL\n Blood products:\n Total out:\n 5,030 mL\n 470 mL\n Urine:\n 5,030 mL\n 470 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,010 mL\n -19 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 442 (421 - 612) mL\n PS : 5 cmH2O\n RR (Spontaneous): 29\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 65\n PIP: 16 cmH2O\n SPO2: 98%\n ABG: 7.40/32/123/21/-3\n Ve: 13.5 L/min\n PaO2 / FiO2: 308\n Physical Examination\n General Appearance: No acute distress, Anxious at times\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n bibasilar, occasional, Diminished: bibasilar), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Obese\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities\n Labs / Radiology\n 196 K/uL\n 8.9 g/dL\n 122 mg/dL\n 1.1 mg/dL\n 21 mEq/L\n 3.6 mEq/L\n 25 mg/dL\n 117 mEq/L\n 144 mEq/L\n 28.2 %\n 4.6 K/uL\n [image002.jpg]\n 06:07 PM\n 01:55 AM\n 02:04 AM\n 08:00 AM\n 11:35 AM\n 03:56 PM\n 05:09 PM\n 08:00 PM\n 01:36 AM\n 02:16 AM\n WBC\n 5.2\n 4.6\n Hct\n 28.4\n 28.2\n Plt\n 178\n 196\n Creatinine\n 1.0\n 1.0\n 1.1\n TCO2\n 29\n 25\n 25\n 26\n 21\n Glucose\n 119\n 108\n 120\n 120\n 138\n 122\n Other labs: PT / PTT / INR:14.0/28.1/1.2, CK / CK-MB / Troponin\n T:128/13/<0.01, ALT / AST:104/137, Alk-Phos / T bili:204/4.8, Amylase /\n Lipase:54/52, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic\n Acid:1.1 mmol/L, Albumin:2.3 g/dL, LDH:348 IU/L, Ca:8.1 mg/dL, Mg:2.4\n mg/dL, PO4:3.5 mg/dL\n Imaging: CT head OSH: Prelim No ICH or fx.\n CT chest OSH: Mult rib fx: R anterolateral and posterior, L\n posterior; Dependent consolidation, possible aspiration; T4 vertebral\n body inf corner fx, no retropulsion; Comminuted spinous process fx\n T2-8; Nondisplaced L T10 transverse process; Nondisplaced L clavicle\n distal fx; Nondisplaced L scapula fx;\n CT c spine OSH: Prelim No fx or malalignment. Multilevel\n degenerative changes w/large post disk bulge at C4-5, narrowing the\n spinal canal and deforming the thecal sac, acuity unknown. Marked\n neuroforamenal narrowing @multiple levels.\n CTA abd/pel Prelim: Medial R liver lobe contusion w/adj\n hematoma, w/o evidence of active bleeding; Comminuted L pubic ramus\n fracture w/assoc hematoma, with tiny focus of arterial bleeding/active\n extravasation, and larger area of venous bleeding. Hematoma somewhat\n larger than on OSH study. Nondisplaced, comminuted L iliac bone fx\n w/adj iliac muscle hematoma, larger than on prior study, w/o active\n extrav. Fx extends into L SIJ. Post R hepatic laceration/contusion\n adjacent to calcified granuloma, w/small hematoma, w/out active\n bleeding. Min displaced fx of R iliac bone extending to R SIJ.\n Cirrhotic liver. Inc B pl effusions (small), w/inc atelectasis.\n MRI: Mild compression deformity of L1 w/additional levels of\n potential trabecular contusion @T10-11 also inf @T4 w/o retropulsion.\n Multilevel degenerative changes w/moderate canal narrowing @T10-11\n w/cord deformity & no abnl cord signal. Extensive edema throughout\n paraspinal soft tissues, predominantly post w/in interspinous\n ligaments. Incompletely eval'ed c-spine w/severe canal narrowing @C4-5\n w/cord deformity and no abn cord signal.\n CTA: no PE.\n CXR: Moderate b/l pleural effusions are stable.\n CXR: Cardiac size top nl, interval improvement of collapse LLL.\n Collapse RLL. Atelectasis in lingula unchanged. Mod B pleural effusions\n stable. No PTX.\n CXR: Interval mild incr in cardiac size, b/l pl effusions,\n & opacities @ bases,c/w overload\n : R foot: Linear density projecting @ expected area of insertion\n of Achilles to calcaneus, may be min avulsion fx or degenerative\n changes. Otherwise no fx\n CXR: b/l pl effusions\n CXR: stable.\n RUQ U/S: No perihepatic fluid collection. small amt perihepatic\n free fluid persists. Small contusion in hepatic segment VII. No\n gallstones or sig wall thickening/edema. CBD 4.5 mm\n TTE: LVEF >55%, NL diastolic function, NL LV filling pressure\n (PCWP<12mmHg), RV chamber size mildly dilated, mild TR\n CXR: mild b/l pulm edema and parenchymal opacities and no\n pl effusion.\n CXR: Persistent b/l pl effusions and bibasilar opacity.\n CXR: Minimal improvement of mod b/l pl effusions. Otherwise\n stable.\n CXR: no relevant change. B/L pleural effusions with basal\n opacities. No evidence of newly appeared focal parenchymal opacities\n suggesting pneumonia.\n : No dvt\n CXR: No change, B pleural effusions, no new infiltrates\n CXR: stable\n Microbiology: Ucx neg\n Sputum: sparse GNRs, too few to colonize\n Bcx x2 neg\n 12/17 L BAL: Klebsiella Pneumoniae, HAEMOPHILUS SPECIES NOT INFLUENZAE\n R BAL: Klebsiella Pneumoniae, Proteus.\n 12/20 L &R BAL: Klebsiella Pneumoniae\n BCX: neg\n BCx: neg\n UCx: neg\n BCx: P\n BCx: P\n UCx: neg\n SpCx: contamination\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, AF with\n RVR/Aflutter, now in sinus, and PNA, s/p trach/PEG (), IVC filter\n Neurologic: HOB<30, TLSO when OOB. Zyprexa 10'''\n Neuro checks Q: shift\n Pain: Oxycodone, Neurontin, Tylenol. Pain adequately controlled.\n Cardiovascular: Aflutter->NSR, on Amio and diltizem 60 QID. Likely \n cardiac contusion. Cards for Amio rec 400'' x 1wk, then 400'x1 wk, then\n 200'. Pt cannot be fully anticoagulated for now (trauma).\n Pulmonary: Trach, weaning vent ( currently), Vanc/cipro/cefepime for\n VAP (). Improving pulmonary edema. Continued diuresis.\n Gastrointestinal / Abdomen: Unknown elevated LFTs and bilirubin w/CT\n scan suggesting cirrhosis - Hepatitis panel NEG, RUQ U/S r/o\n gallbladder etiology, will continue to trend. Nutren 2.0 @ goal 40\n cc/hr. Bowel regimen.\n Nutrition: Tube feeding\n Renal: Foley, monitor UOP, edematous scrotum. Diamox 250 q12 for\n contraction alkalosis. Lasix 20x2 on . Hypernatremia,\n hyperchloremia.\n Hematology: Hct stable (28.2). Plt stable (178-196); d/c'd H2B. Heme\n onc c/s - smear nl; no hemolysis. IVC filter.\n Endocrine: RISS\n Infectious Disease: WBC normal, on Vanc/cipro/cefepime for VAP given\n worsening pulm status, f/u on cx\n Lines / Tubes / Drains: Trach/Peg/foley/L radial a-line/L basilic PICC,\n SCL (will d/c SCL once midline)\n Wounds:\n Imaging: CXR today\n Fluids: KVO\n Consults: Trauma (1o), Ortho Spine, Ortho trauma, Heme\n Billing Diagnosis: (Shock: Unspecified), Multiple injuries (Trauma)\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 07:46 PM 40 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 04:41 PM\n Arterial Line - 11:30 AM\n PICC Line - 06:02 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin, IVC filter\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 33 minutes\n Patient is critically ill\n"},{"category":"Physician ","chartdate":"2175-02-06 00:00:00.000","description":"Intensivist Note","row_id":715182,"text":"TSICU\n HPI:\n 74M s/p fall from bed/standing? tx from osh () with\n acetabular fracture. On w/u in ER, pt found to be increasingly\n tachycardic with abdominal distention and hypotension; found to have\n acetabular fracture, iliac crest fracture, increasing pelvic and\n retroperitoneal hematomas. Coffee ground emesis x1 in ED.\n Chief complaint:\n pain\n PMHx:\n PMH: PVD, emphysema/COPD, dementia, seizure d/o, HTN, anemia, ?aortic\n dissection in past; pureed food diet with honey thick liquids\n PSH: s/p fem-fem bypass, c1-c2 fusion\n Current medications:\n 1000 mL NS 3. Acetaminophen 4. Albuterol 0.083% Neb Soln 5. Bisacodyl\n 6. Calcium Gluconate\n 7. Citalopram Hydrobromide 8. Clozapine 9. Clozapine 10. Dextrose 50%\n 11. Docusate Sodium 12. Glucagon\n 13. HYDROmorphone (Dilaudid) 14. Heparin 15. Insulin 16. Ipratropium\n Bromide Neb 17. LeVETiracetam\n 18. Magnesium Sulfate 19. Magnesium Sulfate 20. Metoprolol Tartrate 21.\n Metoprolol Tartrate 22. Metoprolol Tartrate\n 23. Metoprolol Tartrate 24. Multiple Vitamins Liq. 25. Olanzapine\n (Disintegrating Tablet) 26. Ondansetron\n 27. OxycoDONE (Immediate Release) 28. Pantoprazole 29. Pneumococcal Vac\n Polyvalent 30. Potassium Chloride\n 31. Potassium Chloride 32. Senna 33. Sodium Phosphate 34. Sodium\n Chloride 0.9% Flush\n 24 Hour Events:\n : Persistent tachycardia. Metop inc to 37.5''-->50. Metop 5-10 mg\n IV PRN hr>110 (ST w/PACs, PVCs), 2 mg Mg. SQH started. Chest PT, nebs.\n NPO p MN for ORIF.\n Post operative day:\n POD#11 - IVC filter via L groin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 07:41 PM\n Ciprofloxacin - 09:44 PM\n Cefipime - 12:13 AM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 02:24 PM\n Furosemide (Lasix) - 05:14 PM\n Heparin Sodium (Prophylaxis) - 03:52 AM\n Other medications:\n Flowsheet Data as of 04:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.3\nC (99.2\n T current: 37.1\nC (98.7\n HR: 77 (73 - 98) bpm\n BP: 103/42(60) {86/40(55) - 152/70(97)} mmHg\n RR: 29 (20 - 34) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 104.2 kg (admission): 90 kg\n Total In:\n 2,020 mL\n 456 mL\n PO:\n Tube feeding:\n 960 mL\n 157 mL\n IV Fluid:\n 470 mL\n 120 mL\n Blood products:\n Total out:\n 5,030 mL\n 470 mL\n Urine:\n 5,030 mL\n 470 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,010 mL\n -14 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 442 (421 - 612) mL\n PS : 5 cmH2O\n RR (Spontaneous): 29\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 65\n PIP: 16 cmH2O\n SPO2: 98%\n ABG: 7.40/32/123/21/-3\n Ve: 13.5 L/min\n PaO2 / FiO2: 308\n Physical Examination\n General Appearance: No acute distress, confused at times\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: No(t)\n Resonant : ), (Breath Sounds: Rhonchorous : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 1), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 196 K/uL\n 8.9 g/dL\n 122 mg/dL\n 1.1 mg/dL\n 21 mEq/L\n 3.6 mEq/L\n 25 mg/dL\n 117 mEq/L\n 144 mEq/L\n 28.2 %\n 4.6 K/uL\n [image002.jpg]\n 06:07 PM\n 01:55 AM\n 02:04 AM\n 08:00 AM\n 11:35 AM\n 03:56 PM\n 05:09 PM\n 08:00 PM\n 01:36 AM\n 02:16 AM\n WBC\n 5.2\n 4.6\n Hct\n 28.4\n 28.2\n Plt\n 178\n 196\n Creatinine\n 1.0\n 1.0\n 1.1\n TCO2\n 29\n 25\n 25\n 26\n 21\n Glucose\n 119\n 108\n 120\n 120\n 138\n 122\n Other labs: PT / PTT / INR:14.0/28.1/1.2, CK / CK-MB / Troponin\n T:128/13/<0.01, ALT / AST:104/137, Alk-Phos / T bili:204/4.8, Amylase /\n Lipase:54/52, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic\n Acid:1.1 mmol/L, Albumin:2.3 g/dL, LDH:348 IU/L, Ca:8.1 mg/dL, Mg:2.4\n mg/dL, PO4:3.5 mg/dL\n Imaging: CT c-spine: s/p post c1-c2 fusion. metallic nail\n through L lat C2 extends w/tip in retropharnyngeal/prevertebral jxn\n soft tissues ant to C1. mild anterolisthesis of C4 over C5. very min\n retrolisthesis C5 over C6. mult-level change. no acute fx seen.\n pulmonary emphysema. coarse vertebral and carotid artery calcs. 6mm R\n thyroid lobe hypodensity.\n CT torso: 1.6 x 1.2 cm focal hypodensity in ant mediastinum\n (S2:im15). ?focal hematoma vs thymic cystic lesion. No overlying\n sternal fx or aortic injury. dense aortic calcs. LLL atelect/scarring.\n comminuted, intra-art L acetabular fx involv ant &post columns and ext\n to L sup pubic ramus. adj mod pelvic hematoma w/out active extrav.\n hematoma crosses midline, extends superiorly ant to L psoas muscle and\n iliacus. mild loss of ht of L2 & L3 vert bodies. Grade 1\n spondylolisthesis L5/S1. bladder diverticula .\n CT head: No acute ICH. opacification of inf L maxillary\n sinus w/focal loss of ant inf L max sinus/ant L alveolar bone, adj soft\n tissue swelling and foci of gas. ?infectious process involving L\n alveolar process of maxilla, dental in nature vs chronic sinusitis vs\n injury. recommend direct visualization.\n CXR: No consolidation\n CXR (pm): Increased lung volumes c/w emphysema. Peribronchial\n cuffing and predominantly R-sided interstitial opacities likely fluid\n overload. Subtle opacity @R apex ?superimposition of external\n ventilator apparatus vs. consolidation.\n Microbiology: SCx: contaminated\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, AF with\n RVR/Aflutter, now in sinus, and PNA, s/p trach/PEG (), IVC filter.\n Neurologic: HOB<30, TLSO when OOB. Zyprexa 10'''\n Neuro checks Q: shift\n Pain: Oxycodone, Neurontin, Tylenol. Pain adequately controlled.\n Cardiovascular: Aflutter->NSR, on Amio and diltizem 60 QID. Likely \n cardiac contusion. Cards for Amio rec 400'' x 1wk, then 400'x1 wk, then\n 200'. Pt cannot be fully anticoagulated for now (trauma).\n Pulmonary: Trach, weaning vent ( currently), Vanc/cipro/cefepime for\n VAP (). Improving pulmonary edema. Continued diuresis.\n Gastrointestinal / Abdomen: Unknown elevated LFTs and bilirubin w/CT\n scan suggesting cirrhosis - Hepatitis panel NEG, RUQ U/S r/o\n gallbladder etiology, will continue to trend. Nutren 2.0 @ goal 40\n cc/hr. Bowel regimen.\n RENAL: Foley, monitor UOP, edematous scrotum. Diamox 250 q12 for\n contraction alkalosis. Lasix 20x2 on . Hypernatremia,\n hyperchloremia.\n Nutrition: Tube feeding\n Renal: Foley\n Hematology: Hct stable (28.2). Plt stable (178-196); d/c'd H2B. Heme\n onc c/s - smear nl; no hemolysis. IVC filter.\n Endocrine: RISS\n Infectious Disease: Check cultures, WBC normal (4.6), on\n Vanc/cipro/cefepime for VAP given worsening pulm status, f/u on cx\n Lines / Tubes / Drains: Trach/Peg/foley/L radial a-line/L basilic PICC,\n SCL (will d/c SCL once midline)\n Wounds:\n Imaging: CXR today\n Fluids: KVO\n Consults: Trauma (1o), Ortho Spine, Ortho trauma, Heme\n Billing Diagnosis: (Shock: Unspecified), Multiple injuries (Trauma)\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 07:46 PM 40 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 04:41 PM\n Arterial Line - 11:30 AM\n PICC Line - 06:02 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin, IVC filter\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting planning, ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 33 minutes\n Patient is critically ill\n"},{"category":"Nursing","chartdate":"2175-02-06 00:00:00.000","description":"Nursing Progress Note","row_id":715190,"text":"Respiratory failure, acute (not ARDS/)\n Assessment:\n Trached. Vent settings as charted in metavision. LS rhonchorous at\n times. Sats WNL. Afebrile. WBC count trending down.\n Action:\n Pulmonary hygiene. Cefepime, cipro, and vanco administered as\n ordered. Vent weaned to . ABG drawn.\n Response:\n Moderate amounts of thick, tan secretions. ABG WNL.\n Plan:\n ? trach mask today. Begin rehab screening. Administer abx as ordered.\n IV access: PICC placed on currently midline, NOT central.\n Patient did not want IV team to change it; patient preferred them to\n come later today (). HO aware. Discontinue subclavian line once\n PICC placement is confirmed.\n"},{"category":"Nursing","chartdate":"2175-02-06 00:00:00.000","description":"Nursing Progress Note","row_id":715281,"text":"74M s/p crushing injury d/t falling tree. Injuries sustained include\n multiple R sided rib fxs, grade 2 liver lac (w/ assoc hepatic vessel\n extravasation), stable pelvis fxs (w/ associated extravasation), R\n ramus fx, clavicle fx, and T4 vertebral body fx. Episodes of A.\n Flutter with RVR and aflutter, now with resp failure and newly dx\n pneumonia as of .\n intubated for resp distress\n angio embolization of hepatic and pelvic arterial bleeders\n IVC filter in OR\n self extubated and re-intubated immediately after d/t acute resp.\n failure\n Trach and PEG at bedside\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Respiratory ","chartdate":"2175-02-06 00:00:00.000","description":"Respiratory Care Shift Note","row_id":715187,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 13\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Tube Type\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 8.0mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 26 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: wean off ventilator to trach mask as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Underlying illness not resolved\n"},{"category":"Respiratory ","chartdate":"2175-02-05 00:00:00.000","description":"Respiratory Care Shift Note","row_id":715129,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 12\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason:\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: pt weaned to PSV 10/5 tolerated well\n Assessment of breathing comfort: No claim of dyspnea)\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: plan to continue to wean toward TM as tolerated\n"},{"category":"Nursing","chartdate":"2175-02-07 00:00:00.000","description":"Nursing Progress Note","row_id":715332,"text":"Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains on psv 10, 5peep and 40% with stable abg and 02sats. Remains\n tachypneic, 30\ns but denies distress. LS w/ rhonci throughout.\n Copious thick yellow secretions. Strong productive cough but cannot\n clear.\n Action:\n Pulm toilet, Frequent suctioning required.\n Response:\n Stable on psv 10/5 but cont with copious secretions despite frequent\n sxning.\n Plan:\n Will attempt psv 5 in am and recheck ABG. Not ready for TM due to\n copious secretions and tachpynea. Cont w/ oob to chair as tolerated.\n Cont pulm toilet.\n"},{"category":"Respiratory ","chartdate":"2175-02-05 00:00:00.000","description":"Respiratory Care Shift Note","row_id":715024,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 12\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Tube Type\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 8.0mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated, Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Underlying illness not resolved\n"},{"category":"Nursing","chartdate":"2175-02-06 00:00:00.000","description":"Nursing Progress Note","row_id":715171,"text":"Respiratory failure, acute (not ARDS/)\n Assessment:\n Trached. Vent settings as charted in metavision. LS rhonchorous at\n times. Sats WNL. Afebrile. WBC count trending down.\n Action:\n Pulmonary hygiene. Cefepime, cipro, and vanco administered as\n ordered. ABG drawn.\n Response:\n Plan:\n Continue to wean vent settings. ? trach mask today. Begin rehab\n screening. Administer abx as ordered.\n IV access: PICC placed on currently midline, NOT central.\n Patient did not want IV team to change it; patient preferred them to\n come later today (). HO aware. Discontinue subclavian line once\n PICC placement is confirmed.\n"},{"category":"Physician ","chartdate":"2175-02-07 00:00:00.000","description":"Intensivist Note","row_id":715325,"text":"TSICU\n HPI:\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\n checked and 1.5, 1 more unit FFP given\n Chief complaint:\n Mult rib fx: R anterolateral and post, L posterior\n T4 vert body inf corner fx\n Commin spinous process fx T2-8\n Nondisplaced L T10 transverse process\n Nondispaced L distal clavicle\n Nondisplaced L clavicle fx\n R medial lobe liver contusion w/hematoma\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny focus of arterial\n bleeding/active extravasation, and larger area of venous bleeding\n Nondisplaced, comminuted L iliac bone fx w/adjacent iliac muscle\n hematoma, extends into L SIJ.\n Minimally displaced fx of R iliac bone extending to R SIJ.\n PMHx:\n cirrhosis and asbestosis dx on CT\n Current medications:\n Acetaminophen\n Amiodarone\n Bisacodyl\n Chlorhexidine Gluconate 0.12% Oral Rinse\n Diltiazem\n Docusate Sodium (Liquid)\n Furosemide\n Gabapentin\n Lansoprazole Oral Disintegrating Tab\n Metoprolol Tartrate\n Milk of Magnesia\n Olanzapine (Disintegrating Tablet)\n Ondansetron\n OxycoDONE Liquid\n 24 Hour Events:\n MIDLINE - START 11:37 AM\n Post operative day:\n POD#12 - IVC filter via L groin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 07:41 PM\n Ciprofloxacin - 09:44 PM\n Cefipime - 12:31 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:04 PM\n Other medications:\n Flowsheet Data as of 03:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.1\nC (100.6\n T current: 37.6\nC (99.6\n HR: 70 (70 - 106) bpm\n BP: 92/42(58) {87/42(57) - 158/70(98)} mmHg\n RR: 27 (22 - 38) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 96 kg (admission): 90 kg\n Total In:\n 1,686 mL\n 134 mL\n PO:\n Tube feeding:\n 854 mL\n 134 mL\n IV Fluid:\n 202 mL\n Blood products:\n Total out:\n 2,930 mL\n 280 mL\n Urine:\n 2,930 mL\n 280 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,244 mL\n -145 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 417 (413 - 534) mL\n PS : 10 cmH2O\n RR (Spontaneous): 33\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 16 cmH2O\n SPO2: 99%\n ABG: 7.42/35/85./22/0\n Ve: 15 L/min\n PaO2 / FiO2: 213\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : Bilateral)\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 201 K/uL\n 8.6 g/dL\n 112 mg/dL\n 1.1 mg/dL\n 22 mEq/L\n 4.0 mEq/L\n 28 mg/dL\n 123 mEq/L\n 150 mEq/L\n 26.7 %\n 4.6 K/uL\n [image002.jpg]\n 03:56 PM\n 05:09 PM\n 08:00 PM\n 01:36 AM\n 02:16 AM\n 04:51 AM\n 08:00 AM\n 02:19 PM\n 07:31 PM\n 02:23 AM\n WBC\n 4.6\n 4.6\n 4.6\n Hct\n 28.2\n 28.2\n 26.7\n Plt\n 196\n 196\n 201\n Creatinine\n 1.0\n 1.1\n 1.1\n TCO2\n 26\n 21\n 22\n 23\n Glucose\n 120\n 138\n 122\n 169\n 112\n Other labs: PT / PTT / INR:14.0/28.1/1.2, CK / CK-MB / Troponin\n T:30/13/<0.01, ALT / AST:89/100, Alk-Phos / T bili:250/2.7, Amylase /\n Lipase:54/52, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic\n Acid:1.1 mmol/L, Albumin:2.3 g/dL, LDH:348 IU/L, Ca:7.7 mg/dL, Mg:2.4\n mg/dL, PO4:2.8 mg/dL\n Imaging: CXR: stable\n CXR: stable\n LUE U/S: neg\n Microbiology: Ucx neg\n Sputum: sparse GNRs, too few to colonize\n Bcx x2 neg\n 12/17 L BAL: Klebsiella Pneumoniae, HAEMOPHILUS SPECIES NOT INFLUENZAE\n R BAL: Klebsiella Pneumoniae, Proteus.\n 12/20 L &R BAL: Klebsiella Pneumoniae\n BCX: neg\n BCx: neg\n UCx: neg\n BCx: P\n BCx: P\n UCx: neg\n SpCx: contamination\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, AF with\n RVR/Aflutter, now in sinus, and PNA, s/p trach/PEG (), IVC filter.\n Neurologic: HOB<30, TLSO when OOB. Zyprexa '''\n Neuro checks Q shift\n Cardiovascular: Aflutter->NSR, on Amio and diltizem 60 QID. Likely \n cardiac contusion. Cards rec'd Amio 400'' x 1wk, then 400'x1 wk, then\n 200'. Pt cannot be fully anticoagulated for now (trauma).\n Will consider electrical cardioversion if goes back into Aflutter/AF\n and difficult to control.\n Pulmonary: Trach, weaning vent ( currently), continue TM trials,\n Cipro/cefepime for VAP () tx for 7 days. Vanc d/c().\n Continue diuresis.\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin w/CT scan\n suggesting cirrhosis - Hepatitis panel NEG, RUQ U/S neg for GB\n etiology, will continue to trend. Nutren 2.0 @ goal 40 cc/hr. Bowel\n regimen.\n Nutrition: Tube feeding\n Renal: Foley, monitor UOP, edematous scrotum. Goal 1-1.5 L neg.\n Hypernatremic to 150, approx. free H20 deficit 3.2L, treating with D5W\n @150cc/hr, will check Na Q6.\n Hematology: Hct stable. Plt stable (178-196); d/c'd H2B. Heme onc c/s\n - smear nl; no hemolysis. IVC filter.\n Endocrine: RISS\n Infectious Disease: WBC normal, on cipro/cefepime for VAP () x 7\n days, Vanc .\n Lines / Tubes / Drains: Trach/PEG/foley/L radial a-line/L basilic\n Midline\n Wounds:\n Imaging: CXR today\n Fluids: KVO\n Consults: Trauma surgery, Ortho, Ortho-spine, Hem / Onc\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 03:41 PM 40 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 11:30 AM\n Midline - 11:37 AM\n Prophylaxis:\n DVT: SQ UF Heparin, IVC filter\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: Transfer to rehab / long term facility\n Total time spent:\n"},{"category":"Physician ","chartdate":"2175-02-07 00:00:00.000","description":"Intensivist Note","row_id":715382,"text":"TSICU\n HPI:\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\n checked and 1.5, 1 more unit FFP given\n Chief complaint:\n Mult rib fx: R anterolateral and post, L posterior\n T4 vert body inf corner fx\n Commin spinous process fx T2-8\n Nondisplaced L T10 transverse process\n Nondispaced L distal clavicle\n Nondisplaced L clavicle fx\n R medial lobe liver contusion w/hematoma\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny focus of arterial\n bleeding/active extravasation, and larger area of venous bleeding\n Nondisplaced, comminuted L iliac bone fx w/adjacent iliac muscle\n hematoma, extends into L SIJ.\n Minimally displaced fx of R iliac bone extending to R SIJ.\n PMHx:\n cirrhosis and asbestosis dx on CT\n Current medications:\n Acetaminophen\n Amiodarone\n Bisacodyl\n Chlorhexidine Gluconate 0.12% Oral Rinse\n Diltiazem\n Docusate Sodium (Liquid)\n Furosemide\n Gabapentin\n Lansoprazole Oral Disintegrating Tab\n Metoprolol Tartrate\n Milk of Magnesia\n Olanzapine (Disintegrating Tablet)\n Ondansetron\n OxycoDONE Liquid\n 24 Hour Events:\n MIDLINE - START 11:37 AM\n - U/S neg for DVT in UE. Diuresed 1.2 L. On free water for\n hypernatremia. Failed TM trial yesterday. Overnight on .\n Post operative day:\n POD#12 - IVC filter via L groin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 07:41 PM\n Ciprofloxacin - 09:44 PM\n Cefipime - 12:31 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:04 PM\n Other medications:\n Flowsheet Data as of 03:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.1\nC (100.6\n T current: 37.6\nC (99.6\n HR: 70 (70 - 106) bpm\n BP: 92/42(58) {87/42(57) - 158/70(98)} mmHg\n RR: 27 (22 - 38) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 96 kg (admission): 90 kg\n Total In:\n 1,686 mL\n 134 mL\n PO:\n Tube feeding:\n 854 mL\n 134 mL\n IV Fluid:\n 202 mL\n Blood products:\n Total out:\n 2,930 mL\n 280 mL\n Urine:\n 2,930 mL\n 280 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,244 mL\n -145 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 417 (413 - 534) mL\n PS : 10 cmH2O\n RR (Spontaneous): 33\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 16 cmH2O\n SPO2: 99%\n ABG: 7.42/35/85./22/0\n Ve: 15 L/min\n PaO2 / FiO2: 213\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : Bilateral)\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 201 K/uL\n 8.6 g/dL\n 112 mg/dL\n 1.1 mg/dL\n 22 mEq/L\n 4.0 mEq/L\n 28 mg/dL\n 123 mEq/L\n 150 mEq/L\n 26.7 %\n 4.6 K/uL\n [image002.jpg]\n 03:56 PM\n 05:09 PM\n 08:00 PM\n 01:36 AM\n 02:16 AM\n 04:51 AM\n 08:00 AM\n 02:19 PM\n 07:31 PM\n 02:23 AM\n WBC\n 4.6\n 4.6\n 4.6\n Hct\n 28.2\n 28.2\n 26.7\n Plt\n 196\n 196\n 201\n Creatinine\n 1.0\n 1.1\n 1.1\n TCO2\n 26\n 21\n 22\n 23\n Glucose\n 120\n 138\n 122\n 169\n 112\n Other labs: PT / PTT / INR:14.0/28.1/1.2, CK / CK-MB / Troponin\n T:30/13/<0.01, ALT / AST:89/100, Alk-Phos / T bili:250/2.7, Amylase /\n Lipase:54/52, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic\n Acid:1.1 mmol/L, Albumin:2.3 g/dL, LDH:348 IU/L, Ca:7.7 mg/dL, Mg:2.4\n mg/dL, PO4:2.8 mg/dL\n Imaging:\n CXR: stable\n CXR: stable\n LUE U/S: neg\n Microbiology: Ucx neg\n Sputum: sparse GNRs, too few to colonize\n Bcx x2 neg\n 12/17 L BAL: Klebsiella Pneumoniae, HAEMOPHILUS SPECIES NOT INFLUENZAE\n R BAL: Klebsiella Pneumoniae, Proteus.\n 12/20 L &R BAL: Klebsiella Pneumoniae\n BCX: neg\n BCx: neg\n UCx: neg\n BCx: P\n BCx: P\n UCx: neg\n SpCx: contamination\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, AF with\n RVR/Aflutter, now in sinus, and PNA, s/p trach/PEG (), IVC filter.\n Neurologic: HOB<30, TLSO when OOB. Zyprexa '''\n Neuro checks Q shift. Pain well-controlled on regimen.\n Cardiovascular: Aflutter->NSR, on Amio and diltizem 60 QID. Likely \n cardiac contusion. Cards rec'd Amio 400'' x 1wk, then 400'x1 wk, then\n 200'. Pt cannot be fully anticoagulated for now (trauma).\n Remains in sinus, continue meds.\n Pulmonary: Trach, weaning vent ( currently), continue TM trials,\n Cipro/cefepime for VAP () tx for 7 days. Vanc d/c().\n Continue diuresis as tolerated by hypernatremia.\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin w/CT scan\n suggesting cirrhosis - Hepatitis panel NEG, RUQ U/S neg for GB\n etiology, will continue to trend. Nutren 2.0 @ goal 40 cc/hr. Increase\n free water flushes to 100 q8. Bowel regimen.\n Nutrition: Tube feeding\n Renal: Foley, monitor UOP, edematous scrotum. Goal 1-1.5 L neg.\n Hypernatremic to 150, approx. free H20 deficit 3.2L, treating with D5W\n @150cc/hr, will check Na Q6\n decrease IV free water as increase\n flushes.\n Hematology: Hct stable. Plt stable (178-196); d/c'd H2B. Heme onc c/s\n - smear nl; no hemolysis. IVC filter.\n Endocrine: RISS, goal BS<150.\n Infectious Disease: WBC normal, on cipro/cefepime for VAP () x 7\n days, Vanc .\n Lines / Tubes / Drains: Trach/PEG/foley/L radial a-line/L basilic\n Midline; attempt to obtain PIVs.\n Wounds:\n Imaging: CXR today\n Fluids: KVO\n Consults: Trauma surgery, Ortho, Ortho-spine, Hem / Onc\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 03:41 PM 40 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 11:30 AM\n Midline - 11:37 AM\n Prophylaxis:\n DVT: SQ UF Heparin, IVC filter\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: Transfer to rehab / long term facility\n Total time spent: 32 mins\n"},{"category":"Rehab Services","chartdate":"2175-02-07 00:00:00.000","description":"Physical Therapy Progress Note","row_id":715393,"text":"Subjective:\n Objective:\n Follow up PT visit to address goals of: . Patient seen today\n for balance training, patient education\n Updated medical status: UE US - No evidence of deep vein\n thrombosis in the left arm; CXR pending\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Rolling:\n\n\n\n T\n\n Supine/\n Sidelying to Sit:\n\n\n\n T\n\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n\n\n\n X2\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Aerobic Activity Response:\n Position\n HR\n BP\n RR\n O[2] sat\n RPE\n Rest\n Supine\n 88\n 134/64\n 20\n 98% on CPAP\n Activity\n Sit\n 108\n 127/69\n 45\n 92% on CPAP\n Recovery\n Sit\n 95\n 145/71\n 30\n 96% on CPAP\n Total distance walked:\n Minutes:\n Gait: able to stand and shift weight minimally in standing. Unable to\n take any steps\n Balance: S static sitting at edge of bed. Min A static standing with\n posterior bias, able to anterior weight shift and laterally weight\n shift. Tolerated static standing x3-4 minutes.\n Education / Communication: Reviewed PT and d/c planning.\n Communicated with nsg re: status.\n Other: Total assist slide transfer to stretcher chair.\n On CPAP 5/10 PEEP/PS, 40% FIO2\n Denies pain\n Assessment: 74 yo M s/p crush injury making excellent progress in PT\n with mobility and endurance, continues to be limited by general\n weakness a/w prolonged and complicated hospitalization. He is\n demonstrating great motivation and has excellent rehab potential to\n return to prior independent level of function. PT to continue to\n follow daily at acute level\n Anticipated Discharge: Rehab\n Plan: continue with \n"},{"category":"Nursing","chartdate":"2175-02-05 00:00:00.000","description":"Nursing Progress Note","row_id":715018,"text":"Trauma, s/p\n Assessment:\n N; Pt more alert and seems oriented, MAE and following commands.\n Attempting to participate in care. Denies pain. Less restless.\n CV: Remains in nsr, no ectopy. HR 70\ns-90. Stable bp.\n Resp: Sxned for copious thick secretions requiring lavage. Strong\n productive cough. Cont on psv 12, 10 peep with stable abg. LS coarse\n throughout.\n Renal: Diuresing well from 1x dose lasix and cont on diamox. Brisk u/o\n with negative body balance.\n GI: tol tf at goal. No stool overnoc.\n Heme: Stable\n ID: cont on abx. Remains Afebrile.\n Skin: Intact\n Social: Family called, updated.\n Action:\n Zyprexa ATC. Cont on dilt and amioderone. Vigorous pulm toilet. Cont\n on colace and lactulose.\n Response:\n Calmer and more appropriate. Intermittent sleep. Hemodynamically\n stable. No stool, abd soft. Stable abg on psv, less tachypneic.\n Diuresing well, alkalosis improved.\n Plan:\n Cont to monitor. Cont zyprexa, dilt and amio. OOB-chair as\n tolerated. Pulm toilet. Wean as tolerated from vent. Diamox and\n diurese as tolerated. Monitor temp, cont abx. Pt and family support.\n"},{"category":"Respiratory ","chartdate":"2175-01-26 00:00:00.000","description":"Respiratory Care Shift Note","row_id":713565,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Plan\n Next 24-48 hours: Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Underlying illness not resolved\n PEEP increased overnight due to low Pao2, pt responded well. Will wean\n as tolerated.\n"},{"category":"Physician ","chartdate":"2175-02-05 00:00:00.000","description":"Intensivist Note","row_id":715101,"text":"TSICU\n HPI:\n 74M s/p fall with multiple rib fx, pelvis fx, clavicle fx, and thoracic\n fx c/b unstable bleeding s/p IR embo, AF with RVR/Aflutter, now in\n sinus, and PNA.\n Chief complaint:\n Fall\n PMHx:\n none\n Current medications:\n 1. Acetaminophen 4. AcetaZOLamide 2. Amiodarone 3. Bisacodyl 4. Calcium\n Gluconate 5. CefePIME 6. Chlorhexidine Gluconate 0.12% Oral Rinse 7.\n Ciprofloxacin HCl 8. Dextrose 50% 9. Diltiazem 10. Docusate Sodium\n (Liquid) 11. Furosemide 12. Gabapentin 13. Glucagon 14. Heparin 15.\n Insulin\n 16. Lactulose 17. Lansoprazole Oral Disintegrating Tab 18. Magnesium\n Sulfate 19. Metoprolol Tartrate 20. Milk of Magnesia 21. Olanzapine\n (Disintegrating Tablet) 22. Ondansetron 23. OxycoDONE Liquid 24.\n Pneumococcal Vac Polyvalent 25. Potassium Chloride 26. Potassium\n Phosphate 27. Potassium Chloride 28. Senna 32. Sodium Chloride 0.9%\n Flush 30. Sodium Chloride 0.9% Flush 31. Vancomycin\n 24 Hour Events:\n Started Diamox 500 x4 for contraction alkalosis due to Lasix, also\n given Lasix 20 IV x1 with 1774 off.\n Diltiazem gtt stopped and restarted po.\n d/c'd Haldol and started standing Zyprexa.\n Post operative day:\n POD#10 - IVC filter via L groin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:26 PM\n Ciprofloxacin - 10:48 PM\n Cefipime - 12:48 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 06:00 PM\n Heparin Sodium (Prophylaxis) - 03:48 AM\n Other medications:\n Flowsheet Data as of 05:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38\nC (100.4\n T current: 37.4\nC (99.4\n HR: 87 (71 - 104) bpm\n BP: 143/60(85) {83/38(59) - 158/63(90)} mmHg\n RR: 27 (17 - 32) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 104.2 kg (admission): 90 kg\n Total In:\n 1,956 mL\n 136 mL\n PO:\n Tube feeding:\n 560 mL\n IV Fluid:\n 1,006 mL\n 76 mL\n Blood products:\n Total out:\n 3,730 mL\n 1,140 mL\n Urine:\n 3,730 mL\n 1,140 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,774 mL\n -1,004 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 379 (379 - 713) mL\n PS : 12 cmH2O\n RR (Spontaneous): 33\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 24 cmH2O\n SPO2: 99%\n ABG: 7.45/35/169/24/1\n Ve: 15.2 L/min\n PaO2 / FiO2: 422\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm)\n Right Extremities: (Edema: Trace), (Temperature: Warm)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities\n Labs / Radiology\n 178 K/uL\n 8.8 g/dL\n 108 mg/dL\n 1.0 mg/dL\n 24 mEq/L\n 3.8 mEq/L\n 23 mg/dL\n 113 mEq/L\n 143 mEq/L\n 28.4 %\n 5.2 K/uL\n [image002.jpg]\n 07:20 PM\n 12:35 AM\n 01:04 AM\n 06:28 AM\n 08:00 AM\n 01:10 PM\n 05:03 PM\n 06:07 PM\n 01:55 AM\n 02:04 AM\n WBC\n 6.5\n 5.2\n Hct\n 29.0\n 28.4\n Plt\n 124\n 178\n Creatinine\n 0.8\n 0.9\n 1.0\n TCO2\n 34\n 32\n 30\n 29\n 25\n Glucose\n 130\n 103\n 121\n 130\n 113\n 119\n 108\n Other labs: PT / PTT / INR:14.0/28.1/1.2, CK / CK-MB / Troponin\n T:128/13/<0.01, ALT / AST:104/137, Alk-Phos / T bili:204/4.8, Amylase /\n Lipase:54/52, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic\n Acid:1.1 mmol/L, Albumin:2.3 g/dL, LDH:348 IU/L, Ca:8.3 mg/dL, Mg:2.4\n mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, AF with\n RVR/Aflutter, now in sinus, and PNA.\n Neurologic: s/p trach (). Per ortho spine, no surgery; HOB<30,\n TLSO when OOB. Zyprexa 10 TID (off fent/midaz ).\n Neuro checks Q: shift\n Pain: Oxycodone, Neurontin, Tylenol.\n Cardiovascular: Aflutter->NSR, on Amio and diltizem 60 QID. Likely \n cardiac contusion. Cards for Amio rec 400'' x 1wk, then 400'x1 wk, then\n 200'. Pt cannot be fully anticoagulated for now (trauma).\n Pulmonary: Trach, weaning vent, Vanc/cipro/cefepime for VAP ().\n Improving pulmonary edema.\n Gastrointestinal / Abdomen: Unknown elevated LFTs and bilirubin w/CT\n scan suggesting cirrhosis - Hepatitis panel NEG, RUQ U/S r/o\n gallbladder etiology, will continue to trend. On Nutren 2.0 with goal\n 40 cc/hr. Bowel regimen.\n Nutrition: Tube feeding\n Renal: Foley, monitor UOP, edematous scrotum. Diamox 500 q12 x 4doses\n for contraction alkalosis and Lasix 20 x1.\n Hematology: Hct stable 28.9->29. Plt stable (100's); d/c'd H2B. Heme\n onc c/s - smear nl; no hemolysis. IVC filter placed.\n Endocrine: RISS\n Infectious Disease: WBC normal, on Vanc/cipro/cefepime for VAP given\n worsening pulm status, f/u on cx\n Lines / Tubes / Drains: Trach/Peg/foley/L radial a-line/R SCL\n Wounds:\n Imaging: CXR today\n Fluids: KVO\n Consults: Trauma (1o), Ortho Spine, Ortho trauma, Heme\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 04:41 PM\n Arterial Line - 11:30 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin, IVC filter\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 33 minutes\n"},{"category":"Physician ","chartdate":"2175-02-05 00:00:00.000","description":"Intensivist Note","row_id":715092,"text":"TSICU\n HPI:\n 74M s/p fall with multiple rib fx, pelvis fx, clavicle fx, and thoracic\n fx c/b unstable bleeding s/p IR embo, AF with RVR/Aflutter, now in\n sinus, and PNA.\n Chief complaint:\n Fall\n PMHx:\n none\n Current medications:\n 1. Acetaminophen 4. AcetaZOLamide 2. Amiodarone 3. Bisacodyl 4. Calcium\n Gluconate 5. CefePIME 6. Chlorhexidine Gluconate 0.12% Oral Rinse 7.\n Ciprofloxacin HCl 8. Dextrose 50% 9. Diltiazem 10. Docusate Sodium\n (Liquid) 11. Furosemide 12. Gabapentin 13. Glucagon 14. Heparin 15.\n Insulin\n 16. Lactulose 17. Lansoprazole Oral Disintegrating Tab 18. Magnesium\n Sulfate 19. Metoprolol Tartrate 20. Milk of Magnesia 21. Olanzapine\n (Disintegrating Tablet) 22. Ondansetron 23. OxycoDONE Liquid 24.\n Pneumococcal Vac Polyvalent 25. Potassium Chloride 26. Potassium\n Phosphate 27. Potassium Chloride 28. Senna 32. Sodium Chloride 0.9%\n Flush 30. Sodium Chloride 0.9% Flush 31. Vancomycin\n 24 Hour Events:\n Started Diamox 500 x4 for contraction alkalosis due to Lasix, also\n given Lasix 20 IV x1 with 1774 off.\n Diltiazem gtt stopped and restarted po.\n d/c'd Haldol and started standing Zyprexa.\n Post operative day:\n POD#10 - IVC filter via L groin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:26 PM\n Ciprofloxacin - 10:48 PM\n Cefipime - 12:48 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 06:00 PM\n Heparin Sodium (Prophylaxis) - 03:48 AM\n Other medications:\n Flowsheet Data as of 05:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38\nC (100.4\n T current: 37.4\nC (99.4\n HR: 87 (71 - 104) bpm\n BP: 143/60(85) {83/38(59) - 158/63(90)} mmHg\n RR: 27 (17 - 32) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 104.2 kg (admission): 90 kg\n Total In:\n 1,956 mL\n 136 mL\n PO:\n Tube feeding:\n 560 mL\n IV Fluid:\n 1,006 mL\n 76 mL\n Blood products:\n Total out:\n 3,730 mL\n 1,140 mL\n Urine:\n 3,730 mL\n 1,140 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,774 mL\n -1,004 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 379 (379 - 713) mL\n PS : 12 cmH2O\n RR (Spontaneous): 33\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 24 cmH2O\n SPO2: 99%\n ABG: 7.45/35/169/24/1\n Ve: 15.2 L/min\n PaO2 / FiO2: 422\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm)\n Right Extremities: (Edema: Trace), (Temperature: Warm)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities\n Labs / Radiology\n 178 K/uL\n 8.8 g/dL\n 108 mg/dL\n 1.0 mg/dL\n 24 mEq/L\n 3.8 mEq/L\n 23 mg/dL\n 113 mEq/L\n 143 mEq/L\n 28.4 %\n 5.2 K/uL\n [image002.jpg]\n 07:20 PM\n 12:35 AM\n 01:04 AM\n 06:28 AM\n 08:00 AM\n 01:10 PM\n 05:03 PM\n 06:07 PM\n 01:55 AM\n 02:04 AM\n WBC\n 6.5\n 5.2\n Hct\n 29.0\n 28.4\n Plt\n 124\n 178\n Creatinine\n 0.8\n 0.9\n 1.0\n TCO2\n 34\n 32\n 30\n 29\n 25\n Glucose\n 130\n 103\n 121\n 130\n 113\n 119\n 108\n Other labs: PT / PTT / INR:14.0/28.1/1.2, CK / CK-MB / Troponin\n T:128/13/<0.01, ALT / AST:104/137, Alk-Phos / T bili:204/4.8, Amylase /\n Lipase:54/52, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic\n Acid:1.1 mmol/L, Albumin:2.3 g/dL, LDH:348 IU/L, Ca:8.3 mg/dL, Mg:2.4\n mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, AF with\n RVR/Aflutter, now in sinus, and PNA.\n Neurologic: s/p trach (). Per ortho spine, no surgery; HOB<30,\n TLSO when OOB. Zyprexa 10 TID (off fent/midaz ).\n Neuro checks Q: shift\n Pain: Oxycodone, Neurontin, Tylenol.\n Cardiovascular: Aflutter->NSR, on Amio and diltizem 60 QID. Likely \n cardiac contusion. Cards for Amio rec 400'' x 1wk, then 400'x1 wk, then\n 200'. Pt cannot be fully anticoagulated for now (trauma).\n Pulmonary: Trach, weaning vent, Vanc/cipro/cefepime for VAP ().\n Improving pulmonary edema.\n Gastrointestinal / Abdomen: Unknown elevated LFTs and bilirubin w/CT\n scan suggesting cirrhosis - Hepatitis panel NEG, RUQ U/S r/o\n gallbladder etiology, will continue to trend. On Nutren 2.0 with goal\n 40 cc/hr. Bowel regimen.\n Nutrition: Tube feeding\n Renal: Foley, monitor UOP, edematous scrotum. Diamox 500 q12 x 4doses\n for contraction alkalosis and Lasix 20 x1.\n Hematology: Hct stable 28.9->29. Plt stable (100's); d/c'd H2B. Heme\n onc c/s - smear nl; no hemolysis. IVC filter placed.\n Endocrine: RISS\n Infectious Disease: WBC normal, on Vanc/cipro/cefepime for VAP given\n worsening pulm status, f/u on cx\n Lines / Tubes / Drains: Trach/Peg/foley/L radial a-line/R SCL\n Wounds:\n Imaging: CXR today\n Fluids: KVO\n Consults: Trauma (1o), Ortho Spine, Ortho trauma, Heme\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 04:41 PM\n Arterial Line - 11:30 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin, IVC filter\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n"},{"category":"Nursing","chartdate":"2175-02-06 00:00:00.000","description":"Nursing Progress Note","row_id":715164,"text":"Respiratory failure, acute (not ARDS/)\n Assessment:\n Trached. Vent settings as charted in metavision. LS rhonchorous at\n times. Sats WNL. Afebrile.\n Action:\n Pulmonary hygiene. Cefepime, cipro, and vanco administered as\n ordered. ABG drawn.\n Response:\n Plan:\n Continue to wean vent settings. ? trach mask today. Begin rehab\n screening. Administer abx as ordered.\n IV access: PICC placed on currently midline, NOT central.\n Patient did not want IV to change it; patient preferred them to come\n later today (). HO aware. Discontinue subclavian line once PICC\n placement is confirmed.\n"},{"category":"Nursing","chartdate":"2175-02-06 00:00:00.000","description":"Nursing Progress Note","row_id":715167,"text":"Respiratory failure, acute (not ARDS/)\n Assessment:\n Trached. Vent settings as charted in metavision. LS rhonchorous at\n times. Sats WNL. Afebrile. WBC count trending down.\n Action:\n Pulmonary hygiene. Cefepime, cipro, and vanco administered as\n ordered. ABG drawn.\n Response:\n Plan:\n Continue to wean vent settings. ? trach mask today. Begin rehab\n screening. Administer abx as ordered.\n IV access: PICC placed on currently midline, NOT central.\n Patient did not want IV to change it; patient preferred them to come\n later today (). HO aware. Discontinue subclavian line once PICC\n placement is confirmed.\n"},{"category":"Respiratory ","chartdate":"2175-02-06 00:00:00.000","description":"Respiratory Care Shift Note","row_id":715258,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 13\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 26 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Tachypneic (RR> 35 b/min);\n Comments: pt vent support increased to due to tachypnia into 40s\n on \n Assessment of breathing comfort: No claim of dyspnea)\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: plan to wean vent support as tolerated down to trach mask\n trials\n Reason for continuing current ventilatory support:\n"},{"category":"Nursing","chartdate":"2175-02-04 00:00:00.000","description":"Nursing Progress Note","row_id":714991,"text":"Atrial fibrillation (Afib)\n Assessment:\n Rate controlled all shift in sinus rhythm, Bp stable.\n Action:\n Diltiazem gtt weaned off and PO Dilt restarted.\n Response:\n HR and BP stable, no arrhythmias. Electrolytes checked and replaced as\n needed.\n Plan:\n Continue PO medication regimen, taper Amio as ordered.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS clear to rhonchi but remain diminished at the bases. Strong\n productive cough, expectorating and suctioning out thick yellow\n secretions. ABG stable. SaO2 100%, RR WNL. UOP excellent with\n dieresis.\n Action:\n Cont pulm toileting. OOB to chair for 4 hours today tolerated very\n well. Diamox with Lasix times 1.\n Response:\n Mental status clearing. Weaned vent settings, ABG to be drawn.\n Plan:\n Continue to Dieresis, pulm toileting, wean vent settings as tolerated,\n AM CXR ordered.\n"},{"category":"Nursing","chartdate":"2175-02-07 00:00:00.000","description":"Nursing Progress Note","row_id":715368,"text":"Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains on psv 10, 5peep and 40% with stable abg and 02sats. Remains\n tachypneic, 30\ns but denies distress. LS w/ rhonci throughout.\n Copious thick yellow secretions. Strong productive cough but cannot\n clear.\n Action:\n Pulm toilet, Frequent suctioning . Weaned to psv 5 at 0600\n Response:\n Stable on psv 10/5 but cont with copious secretions despite frequent\n sxning. More tachypneic on psv 5 pc02 28. denies sob, dyspnea.\n Plan:\n Placed back on psv 10 . recheck ABG. Not ready for TM due to copious\n secretions and tachpynea. Cont w/ oob to chair as tolerated. Cont\n pulm toilet.\n Activity Intolerance\n Assessment: Pt assisting with movement and aable to use swabs\n independently with supervision. Washing face independently.\n Action: Encourage pt to increase participation in care.\n Response: More interactive and asking to do things for himself.\n Plan: Increase activity as tolerated. Encourage participation in\n care. Have pt assist with bath when oob-chair during the day.\n Encourage normal sleep pattern.\n"},{"category":"Respiratory ","chartdate":"2175-02-04 00:00:00.000","description":"Respiratory Care Shift Note","row_id":714993,"text":"Day of mechanical ventilation: 11\n Airway Placement Data\n Known difficult intubation: Yes\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 8.0mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: CPAP/PSV\n Assessment of breathing comfort: GOOD\n Invasive ventilation assessment:\n Trigger work assessment: GOOD\n Dysynchrony assessment: LITTLE\n Plan\n Next 24-48 hours: Wean as tolerated\n"},{"category":"Nursing","chartdate":"2175-02-04 00:00:00.000","description":"Nursing Progress Note","row_id":715001,"text":"Atrial fibrillation (Afib)\n Assessment:\n Rate controlled all shift in sinus rhythm, Bp stable.\n Action:\n Diltiazem gtt weaned off and PO Dilt restarted.\n Response:\n HR and BP stable, no arrhythmias. Electrolytes checked and replaced as\n needed.\n Plan:\n Continue PO medication regimen, taper Amio as ordered.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS clear to rhonchi but remain diminished at the bases. Strong\n productive cough, expectorating and suctioning out thick yellow\n secretions. ABG stable. SaO2 100%, RR WNL. UOP excellent with\n dieresis.\n Action:\n Cont pulm toileting. OOB to chair for 4 hours today tolerated very\n well. Diamox with Lasix times 1.\n Response:\n Mental status clearing. Weaned vent settings, ABG to be drawn.\n Plan:\n Continue to Dieresis, pulm toileting, wean vent settings as tolerated,\n AM CXR ordered.\n"},{"category":"Rehab Services","chartdate":"2175-02-06 00:00:00.000","description":"Occupational Therapy Evaluation Note","row_id":715246,"text":"History\n Attending M.D.: \n Referral Date: \n Reason for Referral: evaluation and treatment\n Medical Dx / ICD - 9: polytrauma/959.9\n Activity Orders: activity as tolerated, TLSO when OOB\n HPI / Subjective Complaint: 74 yo M admitted s/p fall from\n tractor and crush injury from tree branch. Sustained multiple fib fxs\n (R anterolateral and L posterior), R pulmonary contusion, T4 vertebral\n teardrop fx, T2-T8 spinous process fx, nondisplaced L T10 transverse\n process fx, nondisplaced L distal clavicle fx, R medial lobe liver\n contusion with hematoma, comminuted L pubic ramus fx with hematoma,\n nondisplaced comminuted L iliac bone fx extending into L SI joint with\n adjacent iliac muscle hematoma, minimally displaced fx of R iliac bone\n extending to R SI joint. Pt intubated for tachycardia and\n increasing O2 requirement. Underwent angio on for embolization\n of pelvic and hepatic vessels, IVC filter placed , and trach/peg\n placement .\n Past Medical / Surgical History: cirrhosis and asbestosis via imaging,\n none per pt report\n Medications: acetaminophen, cipro, cefepime, amiodarone, diltiazem,\n oxycodone, gabapentin, metoprolol\n Labs\n Hematocrit (serum): 28.2 ...\n Hemoglobin: 8.9 ... g/dl\n WBC: 4.6 ...\n Platelet Count: 196 ...\n Radiology\n Radiology: MRI t-spine: C4-5 cord deformity, otherwise imaging as\n above\n Occupational History\n Occupational Profile: retired pipefitter, enjoys doing things around\n the house\n Performance Patterns: lives w/ wife, supportive family\n Baseline Occupational Performance: I PTA, +driving\n Environmental History: unable to assess difficulty communicating\n via writing or mouthing words\n Current Activities of Daily Living\n Grooming: (min A)\n UE Dressing: (mod A)\n Toileting: (Dependent)\n Specify: pt able to swab mouth and comb hair w/ min assist to sustain\n activity due to UE fatigue. decreased grasp noted B. pt up in\n stretcher chair, LE ADLs not assessed\n Current Instrumental Activities of Daily Living\n Home Management: Dependent\n Money Management: Assist\n Community Integration: Dependent\n Performance Skills\n Process Skills: alert and oriented to person, place, situation, month,\n year, time. following 1-step commands\n Communication / Interactive Skills: mouthing words w/ fair\n intelligibility, unable to communicate via written words given\n tremulousness and illegibility. provided communication board but did\n not attempt to use.\n Motor Skills - Functional Transfers\n Functional Transfers Clarification: pt just gotten OOB w/ PT, TBA\n Functional Balance: pt reclined in stretcher chair\n Aerobic Capacity: Rest\n Rest HR: 90\n Rest BP: 117/47\n Rest RR: 34\n Rest O2 sat: 98 %\n Supplemental O2: on CPAP\n Aerobic Capacity: Activity\n Activity HR: 86\n Activity BP: 116/48\n Activity RR: 35\n Activity O2 sat: 98 %\n Supplemental O2: on CPAP\n Aerobic Capacity: Recovery\n Recovery HR: 87\n Recovery BP: 107/48\n Recovery RR: 32\n Recovery O2 sat: 97 %\n Supplemental O2: on CPAP\n Range of Motion\n Range of Motion: full PROM R UE, unable to tolerate >100degress\n shoulder flexion on L, otherwise WNL\n Muscle Performance: strength, power, endurance\n Muscle Performance: R UE , grip 4-/5\n L UE: shoulder flexion, otherwise , grip 4-/5\n Additional Performance Skills\n Motor Control: moving B UE in isolation, significant tremors w/ gross\n and fine motor movements\n Coordination: impaired B due to mm fatigue and deconditioning\n Pain (0 - 10): 2 / 10\n Limiting Symptoms: discomfort. unable to tolerate full L shoulder\n range 2/2 c/o pain further PROM deferred w/ pain resolved.\n Sensation: intact LT b UE\n Integumentary: trach, peg, foley, tele, PIV, TLSO, R eyebrow lac w/\n sutures in place\n Team Communication: RN aware of pt functional status and recs for\n encouragement of self care and use of L UE.\n Patient Education: role of OT, d/c recs for rehab, recs for self care\n as able and to increase use of L UE as tolerated.\n Other: pt and call bell in reach\n Diagnosis\n Diagnosis 1: impaired ADL function\n Diagnosis 2: impaired B UE strength\n Diagnosis 3: impaired communication\n Diagnosis 4: impaired coordination\n Clinical Impression / Prognosis\n Clinical Impression / Prognosis: Pt is a 74 y.o male w/ mult fx now s/p\n trach and peg and on vent support. Pt presents w/ severe\n deconditioning and demonstrates above impairments. Pt would benefit\n from skilled OT services to maximize functional independence w/ rehab\n potential excellent given current med status, prior level of function\n and health.\n Goals: patient / family, objective, measurable\n Patient Goals: to be able to walk to the bathroom myself\n Goal 1: perform UE adls w/ min assist\n Goal 2: improve B UE strength 1/2 mm grade to improve adl independence\n Goal 3: use communication board to express needs w/ min assist\n Goal 4: write short responses with fair legibility\n Time Frame (expected attainment): 1 week\n Anticipated Discharge: Rehab\n Treatment Plan: Interventions; patient / family education, community\n resources\n Treatment Plan: adls, EOB and OOB assessment, coordination/handwriting,\n communication board d/c planning\n Frequency / Duration: 1-5x/wk\n Recommendations for Nursing: encourage participation w/ self care and\n use L UE as able\n Therapist Information\n Patient agrees with the above goals and is willing to participate in\n the rehabilitation program\n Therapist's Name: /L\n Date: \n Time: 12:50-13:20\n Pager #: \n"},{"category":"Nursing","chartdate":"2175-02-05 00:00:00.000","description":"Nursing Progress Note","row_id":715149,"text":"PICC placed.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Ls clear to diminished, strong productive cough, suctioned for large\n amounts of thick yellow sputum. Afebrile all day. Remains in a NSR.\n Pt refused to get OOB due to having to wear TLSO brace.\n Action:\n Continuing diamox and Lasix for diuresis. Electrolytes replaced.\n Response:\n UOP good. Neuro status intact, appropriate.\n Plan:\n PM CXR pending. Continue to wean vent settings. Diuresis per orders.\n Screen for rehab in AM.\n"},{"category":"Physician ","chartdate":"2175-02-06 00:00:00.000","description":"Intensivist Note","row_id":715211,"text":"TSICU\n HPI:\n 74M s/p fall from bed/standing? tx from osh () with\n acetabular fracture. On w/u in ER, pt found to be increasingly\n tachycardic with abdominal distention and hypotension; found to have\n acetabular fracture, iliac crest fracture, increasing pelvic and\n retroperitoneal hematomas. Coffee ground emesis x1 in ED.\n Chief complaint:\n pain\n PMHx:\n PMH: PVD, emphysema/COPD, dementia, seizure d/o, HTN, anemia, ?aortic\n dissection in past; pureed food diet with honey thick liquids\n PSH: s/p fem-fem bypass, c1-c2 fusion\n Current medications:\n 1000 mL NS 3. Acetaminophen 4. Albuterol 0.083% Neb Soln 5. Bisacodyl\n 6. Calcium Gluconate\n 7. Citalopram Hydrobromide 8. Clozapine 9. Clozapine 10. Dextrose 50%\n 11. Docusate Sodium 12. Glucagon\n 13. HYDROmorphone (Dilaudid) 14. Heparin 15. Insulin 16. Ipratropium\n Bromide Neb 17. LeVETiracetam\n 18. Magnesium Sulfate 19. Magnesium Sulfate 20. Metoprolol Tartrate 21.\n Metoprolol Tartrate 22. Metoprolol Tartrate\n 23. Metoprolol Tartrate 24. Multiple Vitamins Liq. 25. Olanzapine\n (Disintegrating Tablet) 26. Ondansetron\n 27. OxycoDONE (Immediate Release) 28. Pantoprazole 29. Pneumococcal Vac\n Polyvalent 30. Potassium Chloride\n 31. Potassium Chloride 32. Senna 33. Sodium Phosphate 34. Sodium\n Chloride 0.9% Flush\n 24 Hour Events:\n : Persistent tachycardia. Metop inc to 37.5''-->50. Metop 5-10 mg\n IV PRN hr>110 (ST w/PACs, PVCs), 2 mg Mg. SQH started. Chest PT, nebs.\n NPO p MN for ORIF.\n Post operative day:\n POD#11 - IVC filter via L groin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 07:41 PM\n Ciprofloxacin - 09:44 PM\n Cefipime - 12:13 AM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 02:24 PM\n Furosemide (Lasix) - 05:14 PM\n Heparin Sodium (Prophylaxis) - 03:52 AM\n Other medications:\n Flowsheet Data as of 04:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.3\nC (99.2\n T current: 37.1\nC (98.7\n HR: 77 (73 - 98) bpm\n BP: 103/42(60) {86/40(55) - 152/70(97)} mmHg\n RR: 29 (20 - 34) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 104.2 kg (admission): 90 kg\n Total In:\n 2,020 mL\n 456 mL\n PO:\n Tube feeding:\n 960 mL\n 157 mL\n IV Fluid:\n 470 mL\n 120 mL\n Blood products:\n Total out:\n 5,030 mL\n 470 mL\n Urine:\n 5,030 mL\n 470 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,010 mL\n -14 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 442 (421 - 612) mL\n PS : 5 cmH2O\n RR (Spontaneous): 29\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 65\n PIP: 16 cmH2O\n SPO2: 98%\n ABG: 7.40/32/123/21/-3\n Ve: 13.5 L/min\n PaO2 / FiO2: 308\n Physical Examination\n General Appearance: No acute distress, confused at times\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: No(t)\n Resonant : ), (Breath Sounds: Rhonchorous : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 1), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 196 K/uL\n 8.9 g/dL\n 122 mg/dL\n 1.1 mg/dL\n 21 mEq/L\n 3.6 mEq/L\n 25 mg/dL\n 117 mEq/L\n 144 mEq/L\n 28.2 %\n 4.6 K/uL\n [image002.jpg]\n 06:07 PM\n 01:55 AM\n 02:04 AM\n 08:00 AM\n 11:35 AM\n 03:56 PM\n 05:09 PM\n 08:00 PM\n 01:36 AM\n 02:16 AM\n WBC\n 5.2\n 4.6\n Hct\n 28.4\n 28.2\n Plt\n 178\n 196\n Creatinine\n 1.0\n 1.0\n 1.1\n TCO2\n 29\n 25\n 25\n 26\n 21\n Glucose\n 119\n 108\n 120\n 120\n 138\n 122\n Other labs: PT / PTT / INR:14.0/28.1/1.2, CK / CK-MB / Troponin\n T:128/13/<0.01, ALT / AST:104/137, Alk-Phos / T bili:204/4.8, Amylase /\n Lipase:54/52, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic\n Acid:1.1 mmol/L, Albumin:2.3 g/dL, LDH:348 IU/L, Ca:8.1 mg/dL, Mg:2.4\n mg/dL, PO4:3.5 mg/dL\n Imaging: CT c-spine: s/p post c1-c2 fusion. metallic nail\n through L lat C2 extends w/tip in retropharnyngeal/prevertebral jxn\n soft tissues ant to C1. mild anterolisthesis of C4 over C5. very min\n retrolisthesis C5 over C6. mult-level change. no acute fx seen.\n pulmonary emphysema. coarse vertebral and carotid artery calcs. 6mm R\n thyroid lobe hypodensity.\n CT torso: 1.6 x 1.2 cm focal hypodensity in ant mediastinum\n (S2:im15). ?focal hematoma vs thymic cystic lesion. No overlying\n sternal fx or aortic injury. dense aortic calcs. LLL atelect/scarring.\n comminuted, intra-art L acetabular fx involv ant &post columns and ext\n to L sup pubic ramus. adj mod pelvic hematoma w/out active extrav.\n hematoma crosses midline, extends superiorly ant to L psoas muscle and\n iliacus. mild loss of ht of L2 & L3 vert bodies. Grade 1\n spondylolisthesis L5/S1. bladder diverticula .\n CT head: No acute ICH. opacification of inf L maxillary\n sinus w/focal loss of ant inf L max sinus/ant L alveolar bone, adj soft\n tissue swelling and foci of gas. ?infectious process involving L\n alveolar process of maxilla, dental in nature vs chronic sinusitis vs\n injury. recommend direct visualization.\n CXR: No consolidation\n CXR (pm): Increased lung volumes c/w emphysema. Peribronchial\n cuffing and predominantly R-sided interstitial opacities likely fluid\n overload. Subtle opacity @R apex ?superimposition of external\n ventilator apparatus vs. consolidation.\n Microbiology: SCx: contaminated\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, AF with\n RVR/Aflutter, now in sinus, and PNA, s/p trach/PEG (), IVC filter.\n Neurologic: HOB<30, TLSO when OOB. Zyprexa 10'''\n Neuro checks Q: shift\n Pain: Oxycodone, Neurontin, Tylenol. Pain adequately controlled.\n Cardiovascular: Aflutter->NSR, on Amio and diltizem 60 QID. Likely \n cardiac contusion. Cards for Amio rec 400'' x 1wk, then 400'x1 wk, then\n 200'. Pt cannot be fully anticoagulated for now (trauma).\n Pulmonary: Trach, weaning vent ( currently), Vanc/cipro/cefepime for\n VAP (). Improving pulmonary edema. Continued diuresis.\n Gastrointestinal / Abdomen: Unknown elevated LFTs and bilirubin w/CT\n scan suggesting cirrhosis - Hepatitis panel NEG, RUQ U/S r/o\n gallbladder etiology, will continue to trend. Nutren 2.0 @ goal 40\n cc/hr. Bowel regimen.\n RENAL: Foley, monitor UOP, edematous scrotum. Diamox 250 q12 for\n contraction alkalosis. Lasix 20x2 on . Hypernatremia,\n hyperchloremia.\n Nutrition: Tube feeding\n Renal: Foley\n Hematology: Hct stable (28.2). Plt stable (178-196); d/c'd H2B. Heme\n onc c/s - smear nl; no hemolysis. IVC filter.\n Endocrine: RISS\n Infectious Disease: Check cultures, WBC normal (4.6), on\n Vanc/cipro/cefepime for VAP given worsening pulm status, f/u on cx\n Lines / Tubes / Drains: Trach/Peg/foley/L radial a-line/L basilic PICC,\n SCL (will d/c SCL once midline)\n Wounds:\n Imaging: CXR today\n Fluids: KVO\n Consults: Trauma (1o), Ortho Spine, Ortho trauma, Heme\n Billing Diagnosis: (Shock: Unspecified), Multiple injuries (Trauma)\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 07:46 PM 40 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 04:41 PM\n Arterial Line - 11:30 AM\n PICC Line - 06:02 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin, IVC filter\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting planning, ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 33 minutes\n Patient is critically ill\n"},{"category":"Physician ","chartdate":"2175-02-06 00:00:00.000","description":"Intensivist Note","row_id":715214,"text":"TSICU\n HPI:\n 74M s/p fall from tractor and crush injury from tree branch. +Loc.\n Chief complaint:\n ventilator dependance\n PMHx:\n PMH: cirrhosis and asbestosis dx on CT\n Current medications:\n Acetaminophen 4. AcetaZOLamide 5. Amiodarone 6. Bisacodyl 7. Calcium\n Gluconate 8. CefePIME 9. Chlorhexidine Gluconate 0.12% Oral Rinse 10.\n Ciprofloxacin HCl 11. Dextrose 50% 12. Diltiazem 13. Docusate Sodium\n (Liquid) 14. Furosemide 15. Furosemide 16. Gabapentin 17. Glucagon 18.\n Heparin\n 19. Heparin Flush (10 units/ml) 20. 21. Insulin 22. Lactulose 23.\n Lansoprazole Oral Disintegrating Tab 24. Magnesium Sulfate 25.\n Metoprolol Tartrate 26. Milk of Magnesia 27. Olanzapine (Disintegrating\n Tablet) 28. Ondansetron 29. OxycoDONE Liquid 30. Pneumococcal Vac\n Polyvalent 31. Potassium Phosphate 32. Potassium Chloride 33. Senna 34.\n Sodium Chloride 0.9% Flush 35. Sodium Chloride 0.9% Flush 36.\n Vancomycin\n 24 Hour Events:\n : Diamox continued. Lasix 20x2 with good result. PICC. Diamox decr\n w/iatrogenic hyperchloremia, hypernatremia.\n Post operative day:\n POD#11 - IVC filter via L groin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 07:41 PM\n Ciprofloxacin - 09:44 PM\n Cefipime - 12:13 AM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 02:24 PM\n Furosemide (Lasix) - 05:14 PM\n Heparin Sodium (Prophylaxis) - 07:35 PM\n Other medications:\n Flowsheet Data as of 03:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.3\nC (99.2\n T current: 37.1\nC (98.7\n HR: 77 (73 - 98) bpm\n BP: 103/42(60) {86/40(55) - 152/70(97)} mmHg\n RR: 29 (20 - 34) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 104.2 kg (admission): 90 kg\n Total In:\n 2,020 mL\n 451 mL\n PO:\n Tube feeding:\n 960 mL\n 152 mL\n IV Fluid:\n 470 mL\n 119 mL\n Blood products:\n Total out:\n 5,030 mL\n 470 mL\n Urine:\n 5,030 mL\n 470 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,010 mL\n -19 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 442 (421 - 612) mL\n PS : 5 cmH2O\n RR (Spontaneous): 29\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 65\n PIP: 16 cmH2O\n SPO2: 98%\n ABG: 7.40/32/123/21/-3\n Ve: 13.5 L/min\n PaO2 / FiO2: 308\n Physical Examination\n General Appearance: No acute distress, Anxious at times\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n bibasilar, occasional, Diminished: bibasilar), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Obese\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities\n Labs / Radiology\n 196 K/uL\n 8.9 g/dL\n 122 mg/dL\n 1.1 mg/dL\n 21 mEq/L\n 3.6 mEq/L\n 25 mg/dL\n 117 mEq/L\n 144 mEq/L\n 28.2 %\n 4.6 K/uL\n [image002.jpg]\n 06:07 PM\n 01:55 AM\n 02:04 AM\n 08:00 AM\n 11:35 AM\n 03:56 PM\n 05:09 PM\n 08:00 PM\n 01:36 AM\n 02:16 AM\n WBC\n 5.2\n 4.6\n Hct\n 28.4\n 28.2\n Plt\n 178\n 196\n Creatinine\n 1.0\n 1.0\n 1.1\n TCO2\n 29\n 25\n 25\n 26\n 21\n Glucose\n 119\n 108\n 120\n 120\n 138\n 122\n Other labs: PT / PTT / INR:14.0/28.1/1.2, CK / CK-MB / Troponin\n T:128/13/<0.01, ALT / AST:104/137, Alk-Phos / T bili:204/4.8, Amylase /\n Lipase:54/52, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic\n Acid:1.1 mmol/L, Albumin:2.3 g/dL, LDH:348 IU/L, Ca:8.1 mg/dL, Mg:2.4\n mg/dL, PO4:3.5 mg/dL\n Imaging: CT head OSH: Prelim No ICH or fx.\n CT chest OSH: Mult rib fx: R anterolateral and posterior, L\n posterior; Dependent consolidation, possible aspiration; T4 vertebral\n body inf corner fx, no retropulsion; Comminuted spinous process fx\n T2-8; Nondisplaced L T10 transverse process; Nondisplaced L clavicle\n distal fx; Nondisplaced L scapula fx;\n CT c spine OSH: Prelim No fx or malalignment. Multilevel\n degenerative changes w/large post disk bulge at C4-5, narrowing the\n spinal canal and deforming the thecal sac, acuity unknown. Marked\n neuroforamenal narrowing @multiple levels.\n CTA abd/pel Prelim: Medial R liver lobe contusion w/adj\n hematoma, w/o evidence of active bleeding; Comminuted L pubic ramus\n fracture w/assoc hematoma, with tiny focus of arterial bleeding/active\n extravasation, and larger area of venous bleeding. Hematoma somewhat\n larger than on OSH study. Nondisplaced, comminuted L iliac bone fx\n w/adj iliac muscle hematoma, larger than on prior study, w/o active\n extrav. Fx extends into L SIJ. Post R hepatic laceration/contusion\n adjacent to calcified granuloma, w/small hematoma, w/out active\n bleeding. Min displaced fx of R iliac bone extending to R SIJ.\n Cirrhotic liver. Inc B pl effusions (small), w/inc atelectasis.\n MRI: Mild compression deformity of L1 w/additional levels of\n potential trabecular contusion @T10-11 also inf @T4 w/o retropulsion.\n Multilevel degenerative changes w/moderate canal narrowing @T10-11\n w/cord deformity & no abnl cord signal. Extensive edema throughout\n paraspinal soft tissues, predominantly post w/in interspinous\n ligaments. Incompletely eval'ed c-spine w/severe canal narrowing @C4-5\n w/cord deformity and no abn cord signal.\n CTA: no PE.\n CXR: Moderate b/l pleural effusions are stable.\n CXR: Cardiac size top nl, interval improvement of collapse LLL.\n Collapse RLL. Atelectasis in lingula unchanged. Mod B pleural effusions\n stable. No PTX.\n CXR: Interval mild incr in cardiac size, b/l pl effusions,\n & opacities @ bases,c/w overload\n : R foot: Linear density projecting @ expected area of insertion\n of Achilles to calcaneus, may be min avulsion fx or degenerative\n changes. Otherwise no fx\n CXR: b/l pl effusions\n CXR: stable.\n RUQ U/S: No perihepatic fluid collection. small amt perihepatic\n free fluid persists. Small contusion in hepatic segment VII. No\n gallstones or sig wall thickening/edema. CBD 4.5 mm\n TTE: LVEF >55%, NL diastolic function, NL LV filling pressure\n (PCWP<12mmHg), RV chamber size mildly dilated, mild TR\n CXR: mild b/l pulm edema and parenchymal opacities and no\n pl effusion.\n CXR: Persistent b/l pl effusions and bibasilar opacity.\n CXR: Minimal improvement of mod b/l pl effusions. Otherwise\n stable.\n CXR: no relevant change. B/L pleural effusions with basal\n opacities. No evidence of newly appeared focal parenchymal opacities\n suggesting pneumonia.\n : No dvt\n CXR: No change, B pleural effusions, no new infiltrates\n CXR: stable\n Microbiology: Ucx neg\n Sputum: sparse GNRs, too few to colonize\n Bcx x2 neg\n 12/17 L BAL: Klebsiella Pneumoniae, HAEMOPHILUS SPECIES NOT INFLUENZAE\n R BAL: Klebsiella Pneumoniae, Proteus.\n 12/20 L &R BAL: Klebsiella Pneumoniae\n BCX: neg\n BCx: neg\n UCx: neg\n BCx: P\n BCx: P\n UCx: neg\n SpCx: contamination\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, AF with\n RVR/Aflutter, now in sinus, and PNA, s/p trach/PEG (), IVC filter\n Neurologic: HOB<30, TLSO when OOB. Zyprexa 10'''\n Neuro checks Q: shift\n Pain: Oxycodone, Neurontin, Tylenol. Pain adequately controlled.\n Cardiovascular: Aflutter->NSR, on Amio and diltizem 60 QID. Likely \n cardiac contusion. Cards for Amio rec 400'' x 1wk, then 400'x1 wk, then\n 200'. Pt cannot be fully anticoagulated for now (trauma). Now in sinus\n so continue Amio.\n Pulmonary: Trach, weaning vent ( currently), Vanc/cipro/cefepime for\n VAP (). Improving pulmonary edema. Continued diuresis. TM trial\n today, follow ABGs. Aggressive chest Pt as e/o collapse on RLL.\n Gastrointestinal / Abdomen: Unknown elevated LFTs and bilirubin w/CT\n scan suggesting cirrhosis - Hepatitis panel NEG, RUQ U/S r/o\n gallbladder etiology, will continue to trend. Nutren 2.0 @ goal 40\n cc/hr. Bowel regimen (d/c Lactulose). C diff negative x 3.\n Nutrition: Tube feeding, Nutren. At goal.\n Renal: Foley, monitor UOP, edematous scrotum. Diamox 250 q12 for\n contraction alkalosis. Lasix 20x2 on . Hypernatremia,\n hyperchloremia. Goal 1.5 L negative today as total volume up from\n admission.\n Hematology: Hct stable (28.2). Plt stable (178-196); d/c'd H2B. Heme\n onc c/s - smear nl; no hemolysis. IVC filter.\n Endocrine: RISS, goal BS<150. Adequate control.\n Infectious Disease: WBC normal, on Vanc/cipro/cefepime for VAP given\n worsening pulm status, f/u on cx. Plan for total 7 days of abx, given\n only GNRs in cx data will d/c Vanco.\n Lines / Tubes / Drains: Trach/Peg/foley/L radial a-line/L basilic PICC,\n SCL (will d/c SCL once midline)\n Wounds:\n Imaging: CXR today\n Fluids: KVO\n Consults: Trauma (1o), Ortho Spine, Ortho trauma, Heme, PT/OT.\n Billing Diagnosis: (Shock: Unspecified), Multiple injuries (Trauma)\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 07:46 PM 40 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 04:41 PM\n Arterial Line - 11:30 AM\n PICC Line - 06:02 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin, IVC filter\n Stress ulcer: PPI (thrombocytopenia possibly from H2B)\n VAP bundle: HOB elevation, Mouth care\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n rehab screen\n Total time spent: 33 minutes\n Patient is critically ill\n"},{"category":"Physician ","chartdate":"2175-02-06 00:00:00.000","description":"Intensivist Note","row_id":715215,"text":"TSICU\n HPI:\n 74M s/p fall from tractor and crush injury from tree branch. +Loc.\n Chief complaint:\n ventilator dependance\n PMHx:\n PMH: cirrhosis and asbestosis dx on CT\n Current medications:\n Acetaminophen 4. AcetaZOLamide 5. Amiodarone 6. Bisacodyl 7. Calcium\n Gluconate 8. CefePIME 9. Chlorhexidine Gluconate 0.12% Oral Rinse 10.\n Ciprofloxacin HCl 11. Dextrose 50% 12. Diltiazem 13. Docusate Sodium\n (Liquid) 14. Furosemide 15. Furosemide 16. Gabapentin 17. Glucagon 18.\n Heparin\n 19. Heparin Flush (10 units/ml) 20. 21. Insulin 22. Lactulose 23.\n Lansoprazole Oral Disintegrating Tab 24. Magnesium Sulfate 25.\n Metoprolol Tartrate 26. Milk of Magnesia 27. Olanzapine (Disintegrating\n Tablet) 28. Ondansetron 29. OxycoDONE Liquid 30. Pneumococcal Vac\n Polyvalent 31. Potassium Phosphate 32. Potassium Chloride 33. Senna 34.\n Sodium Chloride 0.9% Flush 35. Sodium Chloride 0.9% Flush 36.\n Vancomycin\n 24 Hour Events:\n : Diamox continued. Lasix 20x2 with good result. PICC. Diamox decr\n w/iatrogenic hyperchloremia, hypernatremia.\n Post operative day:\n POD#11 - IVC filter via L groin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 07:41 PM\n Ciprofloxacin - 09:44 PM\n Cefipime - 12:13 AM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 02:24 PM\n Furosemide (Lasix) - 05:14 PM\n Heparin Sodium (Prophylaxis) - 07:35 PM\n Other medications:\n Flowsheet Data as of 03:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.3\nC (99.2\n T current: 37.1\nC (98.7\n HR: 77 (73 - 98) bpm\n BP: 103/42(60) {86/40(55) - 152/70(97)} mmHg\n RR: 29 (20 - 34) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 104.2 kg (admission): 90 kg\n Total In:\n 2,020 mL\n 451 mL\n PO:\n Tube feeding:\n 960 mL\n 152 mL\n IV Fluid:\n 470 mL\n 119 mL\n Blood products:\n Total out:\n 5,030 mL\n 470 mL\n Urine:\n 5,030 mL\n 470 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,010 mL\n -19 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 442 (421 - 612) mL\n PS : 5 cmH2O\n RR (Spontaneous): 29\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 65\n PIP: 16 cmH2O\n SPO2: 98%\n ABG: 7.40/32/123/21/-3\n Ve: 13.5 L/min\n PaO2 / FiO2: 308\n Physical Examination\n General Appearance: No acute distress, Anxious at times\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n bibasilar, occasional, Diminished: bibasilar), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Obese\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities\n Labs / Radiology\n 196 K/uL\n 8.9 g/dL\n 122 mg/dL\n 1.1 mg/dL\n 21 mEq/L\n 3.6 mEq/L\n 25 mg/dL\n 117 mEq/L\n 144 mEq/L\n 28.2 %\n 4.6 K/uL\n [image002.jpg]\n 06:07 PM\n 01:55 AM\n 02:04 AM\n 08:00 AM\n 11:35 AM\n 03:56 PM\n 05:09 PM\n 08:00 PM\n 01:36 AM\n 02:16 AM\n WBC\n 5.2\n 4.6\n Hct\n 28.4\n 28.2\n Plt\n 178\n 196\n Creatinine\n 1.0\n 1.0\n 1.1\n TCO2\n 29\n 25\n 25\n 26\n 21\n Glucose\n 119\n 108\n 120\n 120\n 138\n 122\n Other labs: PT / PTT / INR:14.0/28.1/1.2, CK / CK-MB / Troponin\n T:128/13/<0.01, ALT / AST:104/137, Alk-Phos / T bili:204/4.8, Amylase /\n Lipase:54/52, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic\n Acid:1.1 mmol/L, Albumin:2.3 g/dL, LDH:348 IU/L, Ca:8.1 mg/dL, Mg:2.4\n mg/dL, PO4:3.5 mg/dL\n Imaging: CT head OSH: Prelim No ICH or fx.\n CT chest OSH: Mult rib fx: R anterolateral and posterior, L\n posterior; Dependent consolidation, possible aspiration; T4 vertebral\n body inf corner fx, no retropulsion; Comminuted spinous process fx\n T2-8; Nondisplaced L T10 transverse process; Nondisplaced L clavicle\n distal fx; Nondisplaced L scapula fx;\n CT c spine OSH: Prelim No fx or malalignment. Multilevel\n degenerative changes w/large post disk bulge at C4-5, narrowing the\n spinal canal and deforming the thecal sac, acuity unknown. Marked\n neuroforamenal narrowing @multiple levels.\n CTA abd/pel Prelim: Medial R liver lobe contusion w/adj\n hematoma, w/o evidence of active bleeding; Comminuted L pubic ramus\n fracture w/assoc hematoma, with tiny focus of arterial bleeding/active\n extravasation, and larger area of venous bleeding. Hematoma somewhat\n larger than on OSH study. Nondisplaced, comminuted L iliac bone fx\n w/adj iliac muscle hematoma, larger than on prior study, w/o active\n extrav. Fx extends into L SIJ. Post R hepatic laceration/contusion\n adjacent to calcified granuloma, w/small hematoma, w/out active\n bleeding. Min displaced fx of R iliac bone extending to R SIJ.\n Cirrhotic liver. Inc B pl effusions (small), w/inc atelectasis.\n MRI: Mild compression deformity of L1 w/additional levels of\n potential trabecular contusion @T10-11 also inf @T4 w/o retropulsion.\n Multilevel degenerative changes w/moderate canal narrowing @T10-11\n w/cord deformity & no abnl cord signal. Extensive edema throughout\n paraspinal soft tissues, predominantly post w/in interspinous\n ligaments. Incompletely eval'ed c-spine w/severe canal narrowing @C4-5\n w/cord deformity and no abn cord signal.\n CTA: no PE.\n CXR: Moderate b/l pleural effusions are stable.\n CXR: Cardiac size top nl, interval improvement of collapse LLL.\n Collapse RLL. Atelectasis in lingula unchanged. Mod B pleural effusions\n stable. No PTX.\n CXR: Interval mild incr in cardiac size, b/l pl effusions,\n & opacities @ bases,c/w overload\n : R foot: Linear density projecting @ expected area of insertion\n of Achilles to calcaneus, may be min avulsion fx or degenerative\n changes. Otherwise no fx\n CXR: b/l pl effusions\n CXR: stable.\n RUQ U/S: No perihepatic fluid collection. small amt perihepatic\n free fluid persists. Small contusion in hepatic segment VII. No\n gallstones or sig wall thickening/edema. CBD 4.5 mm\n TTE: LVEF >55%, NL diastolic function, NL LV filling pressure\n (PCWP<12mmHg), RV chamber size mildly dilated, mild TR\n CXR: mild b/l pulm edema and parenchymal opacities and no\n pl effusion.\n CXR: Persistent b/l pl effusions and bibasilar opacity.\n CXR: Minimal improvement of mod b/l pl effusions. Otherwise\n stable.\n CXR: no relevant change. B/L pleural effusions with basal\n opacities. No evidence of newly appeared focal parenchymal opacities\n suggesting pneumonia.\n : No dvt\n CXR: No change, B pleural effusions, no new infiltrates\n CXR: stable\n Microbiology: Ucx neg\n Sputum: sparse GNRs, too few to colonize\n Bcx x2 neg\n 12/17 L BAL: Klebsiella Pneumoniae, HAEMOPHILUS SPECIES NOT INFLUENZAE\n R BAL: Klebsiella Pneumoniae, Proteus.\n 12/20 L &R BAL: Klebsiella Pneumoniae\n BCX: neg\n BCx: neg\n UCx: neg\n BCx: P\n BCx: P\n UCx: neg\n SpCx: contamination\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, AF with\n RVR/Aflutter, now in sinus, and PNA, s/p trach/PEG (), IVC filter\n Neurologic: HOB<30, TLSO when OOB. Zyprexa 10'''\n Neuro checks Q: shift\n Pain: Oxycodone, Neurontin, Tylenol. Pain adequately controlled.\n Cardiovascular: Aflutter->NSR, on Amio and diltizem 60 QID. Likely \n cardiac contusion. Cards for Amio rec 400'' x 1wk, then 400'x1 wk, then\n 200'. Pt cannot be fully anticoagulated for now (trauma). Now in sinus\n so continue Amio.\n Pulmonary: Trach, weaning vent ( currently), Vanc/cipro/cefepime for\n VAP (). Improving pulmonary edema. Continued diuresis. TM trial\n today, follow ABGs. Aggressive chest Pt as e/o collapse on RLL.\n Gastrointestinal / Abdomen: Unknown elevated LFTs and bilirubin w/CT\n scan suggesting cirrhosis - Hepatitis panel NEG, RUQ U/S r/o\n gallbladder etiology, will continue to trend. Nutren 2.0 @ goal 40\n cc/hr. Bowel regimen (d/c Lactulose). C diff negative x 3.\n Nutrition: Tube feeding, Nutren. At goal.\n Renal: Foley, monitor UOP, edematous scrotum. Diamox 250 q12 for\n contraction alkalosis. Lasix 20x2 on . Hypernatremia,\n hyperchloremia. Goal 1.5 L negative today as total volume up from\n admission.\n Hematology: Hct stable (28.2). Plt stable (178-196); d/c'd H2B. Heme\n onc c/s - smear nl; no hemolysis. IVC filter.\n Endocrine: RISS, goal BS<150. Adequate control.\n Infectious Disease: WBC normal, on Vanc/cipro/cefepime for VAP given\n worsening pulm status, f/u on cx. Plan for total 7 days of abx, given\n only GNRs in cx data will d/c Vanco.\n Lines / Tubes / Drains: Trach/Peg/foley/L radial a-line/L basilic PICC,\n SCL (will d/c SCL once midline)\n Wounds:\n Imaging: CXR today\n Fluids: KVO\n Consults: Trauma (1o), Ortho Spine, Ortho trauma, Heme, PT/OT.\n Billing Diagnosis: (Shock: Unspecified), Multiple injuries (Trauma)\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 07:46 PM 40 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 04:41 PM\n Arterial Line - 11:30 AM\n PICC Line - 06:02 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin, IVC filter\n Stress ulcer: PPI (thrombocytopenia possibly from H2B)\n VAP bundle: HOB elevation, Mouth care\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n rehab screen\n Total time spent: 33 minutes\n Patient is critically ill\n"},{"category":"Nursing","chartdate":"2175-02-06 00:00:00.000","description":"Nursing Progress Note","row_id":715230,"text":"Nursing 0700-1100\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt. s/p crush injury/multiple trauma. Trach in place, received pt. on\n PSV 5/5 with RR 28-35. \n pt. remains in SR with PRI.27.\n Action:\n Pt. turned, CPT\nd Q2hrs. Suctioned hourly for moderate amts pale\n yellowish-white creamy thick secretions. Antibiotics as ordered, Vanco\n d/c\nd this a.m. CVL d/c\n Response:\n Pt. presently restful and less tachypneic. When awake, RR remains 30,\n and after turning RR towards 40 with long recovery time.\n Plan:\n OOB today with TLSO brace. ??Trach mask trial when in chair if\n clinincal picture allows. Rehab screening in progress.\n"},{"category":"Rehab Services","chartdate":"2175-02-06 00:00:00.000","description":"Physical Therapy Progress Note","row_id":715237,"text":"Subjective:\n Objective:\n Follow up PT visit to address goals of: . Patient seen today\n for balance training, patient education\n Updated medical status: CXR - Bibasilar opacification persists,\n consistent with atelectasis and effusion; UE US pending\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Rolling:\n\n\n\n\n T\n Supine/\n Sidelying to Sit:\n\n\n\n T\n\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n\n\n\n X2\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Aerobic Activity Response:\n Position\n HR\n BP\n RR\n O[2] sat\n RPE\n Rest\n Supine\n 90\n 134/58\n 26\n 100% on CPAP\n Activity\n Sit\n 98\n 126/50\n 34\n 90% on CPAP\n Recovery\n Sit\n 92\n 130/51\n 28\n 100% on CPAP\n Total distance walked: 0\n Minutes:\n Gait: able to attain full upright standing with max verbal and tactile\n cues to extend hips and trunk.\n Balance: able to maintain static sitting at edge once positioned, able\n to weight shift anteriorly and laterally with min A. Able to attain\n static standing with max A x2, and maintain x10-15 sec with increased\n hip flexion and forward trunk flexion.\n Education / Communication: Reviewed PT and encouraged OOB.\n Communicated with nsg re: status and MD re: bracing.\n Other: On CPAP 5/10 PEEP/PS, 40% FiO2\n c/o R>L hip/thigh pain with standing\n Assessment: 74 yo M s/p crush injury with multiple fractures, making\n good progress in PT with mobility and strength, continues to be limited\n by general weakness and deconditioning a/w prolonged hospitalization.\n He continues to be well below his baseline but has excellent rehab\n potential given his prior level of function.\n Anticipated Discharge: Rehab\n Plan: continue with \n"},{"category":"Rehab Services","chartdate":"2175-02-06 00:00:00.000","description":"Physical Therapy Progress Note","row_id":715238,"text":"Subjective:\n Objective:\n Follow up PT visit to address goals of: . Patient seen today\n for balance training, patient education\n Updated medical status: CXR - Bibasilar opacification persists,\n consistent with atelectasis and effusion; UE US pending\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Rolling:\n\n\n\n\n T\n Supine/\n Sidelying to Sit:\n\n\n\n T\n\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n\n\n\n X2\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Aerobic Activity Response:\n Position\n HR\n BP\n RR\n O[2] sat\n RPE\n Rest\n Supine\n 90\n 134/58\n 26\n 100% on CPAP\n Activity\n Sit\n 98\n 126/50\n 34\n 90% on CPAP\n Recovery\n Sit\n 92\n 130/51\n 28\n 100% on CPAP\n Total distance walked: 0\n Minutes:\n Gait: able to attain full upright standing with max verbal and tactile\n cues to extend hips and trunk.\n Balance: able to maintain static sitting at edge once positioned, able\n to weight shift anteriorly and laterally with min A. Able to attain\n static standing with max A x2, and maintain x10-15 sec with increased\n hip flexion and forward trunk flexion.\n Education / Communication: Reviewed PT and encouraged OOB.\n Communicated with nsg re: status and MD re: bracing.\n Other: On CPAP 5/10 PEEP/PS, 40% FiO2\n c/o R>L hip/thigh pain with standing\n Assessment: 74 yo M s/p crush injury with multiple fractures, making\n good progress in PT with mobility and strength, continues to be limited\n by general weakness and deconditioning a/w prolonged hospitalization.\n He continues to be well below his baseline but has excellent rehab\n potential given his prior level of function.\n Anticipated Discharge: Rehab\n Plan: continue with \n"},{"category":"Physician ","chartdate":"2175-02-05 00:00:00.000","description":"Intensivist Note","row_id":715034,"text":"TSICU\n HPI:\n 74M s/p fall with multiple rib fx, pelvis fx, clavicle fx, and thoracic\n fx c/b unstable bleeding s/p IR embo, AF with RVR/Aflutter, now in\n sinus, and PNA.\n Chief complaint:\n Fall\n PMHx:\n none\n Current medications:\n 1. Acetaminophen 4. AcetaZOLamide 2. Amiodarone 3. Bisacodyl 4. Calcium\n Gluconate 5. CefePIME 6. Chlorhexidine Gluconate 0.12% Oral Rinse 7.\n Ciprofloxacin HCl 8. Dextrose 50% 9. Diltiazem 10. Docusate Sodium\n (Liquid) 11. Furosemide 12. Gabapentin 13. Glucagon 14. Heparin 15.\n Insulin\n 16. Lactulose 17. Lansoprazole Oral Disintegrating Tab 18. Magnesium\n Sulfate 19. Metoprolol Tartrate 20. Milk of Magnesia 21. Olanzapine\n (Disintegrating Tablet) 22. Ondansetron 23. OxycoDONE Liquid 24.\n Pneumococcal Vac Polyvalent 25. Potassium Chloride 26. Potassium\n Phosphate 27. Potassium Chloride 28. Senna 32. Sodium Chloride 0.9%\n Flush 30. Sodium Chloride 0.9% Flush 31. Vancomycin\n 24 Hour Events:\n Started Diamox 500 x4 for contraction alkalosis due to Lasix, also\n given Lasix 20 IV x1 with 1774 off.\n Diltiazem gtt stopped and restarted po.\n d/c'd Haldol and started standing Zyprexa.\n Post operative day:\n POD#10 - IVC filter via L groin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:26 PM\n Ciprofloxacin - 10:48 PM\n Cefipime - 12:48 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 06:00 PM\n Heparin Sodium (Prophylaxis) - 03:48 AM\n Other medications:\n Flowsheet Data as of 05:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38\nC (100.4\n T current: 37.4\nC (99.4\n HR: 87 (71 - 104) bpm\n BP: 143/60(85) {83/38(59) - 158/63(90)} mmHg\n RR: 27 (17 - 32) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 104.2 kg (admission): 90 kg\n Total In:\n 1,956 mL\n 136 mL\n PO:\n Tube feeding:\n 560 mL\n IV Fluid:\n 1,006 mL\n 76 mL\n Blood products:\n Total out:\n 3,730 mL\n 1,140 mL\n Urine:\n 3,730 mL\n 1,140 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,774 mL\n -1,004 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 379 (379 - 713) mL\n PS : 12 cmH2O\n RR (Spontaneous): 33\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 24 cmH2O\n SPO2: 99%\n ABG: 7.45/35/169/24/1\n Ve: 15.2 L/min\n PaO2 / FiO2: 422\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm)\n Right Extremities: (Edema: Trace), (Temperature: Warm)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities\n Labs / Radiology\n 178 K/uL\n 8.8 g/dL\n 108 mg/dL\n 1.0 mg/dL\n 24 mEq/L\n 3.8 mEq/L\n 23 mg/dL\n 113 mEq/L\n 143 mEq/L\n 28.4 %\n 5.2 K/uL\n [image002.jpg]\n 07:20 PM\n 12:35 AM\n 01:04 AM\n 06:28 AM\n 08:00 AM\n 01:10 PM\n 05:03 PM\n 06:07 PM\n 01:55 AM\n 02:04 AM\n WBC\n 6.5\n 5.2\n Hct\n 29.0\n 28.4\n Plt\n 124\n 178\n Creatinine\n 0.8\n 0.9\n 1.0\n TCO2\n 34\n 32\n 30\n 29\n 25\n Glucose\n 130\n 103\n 121\n 130\n 113\n 119\n 108\n Other labs: PT / PTT / INR:14.0/28.1/1.2, CK / CK-MB / Troponin\n T:128/13/<0.01, ALT / AST:104/137, Alk-Phos / T bili:204/4.8, Amylase /\n Lipase:54/52, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic\n Acid:1.1 mmol/L, Albumin:2.3 g/dL, LDH:348 IU/L, Ca:8.3 mg/dL, Mg:2.4\n mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, AF with\n RVR/Aflutter, now in sinus, and PNA.\n Neurologic: s/p trach (). Per ortho spine, no surgery; HOB<30,\n TLSO when OOB. Zyprexa 10 TID (off fent/midaz ).\n Neuro checks Q: shift\n Pain: Oxycodone, Neurontin, Tylenol.\n Cardiovascular: Aflutter->NSR, on Amio and diltizem 60 QID. Likely \n cardiac contusion. Cards for Amio rec 400'' x 1wk, then 400'x1 wk, then\n 200'. Pt cannot be fully anticoagulated for now (trauma).\n Pulmonary: Trach, weaning vent, Vanc/cipro/cefepime for VAP ().\n Improving pulmonary edema. consider therapeutic thoracentesis \n if no improvement with diuresis, lots of secretions, consider\n bronchoscopy\n Gastrointestinal / Abdomen: Unknown elevated LFTs and bilirubin w/CT\n scan suggesting cirrhosis - Hepatitis panel NEG, RUQ U/S r/o\n gallbladder etiology, will continue to trend. On Nutren 2.0 with goal\n 40 cc/hr. Bowel regimen.\n Nutrition: Tube feeding\n Renal: Foley, monitor UOP, edematous scrotum. Diamox 500 q12 for\n contraction alkalosis.\n Hematology: Hct stable 28.9->29. Plt stable (100's); d/c'd H2B. Heme\n onc c/s - smear nl; no hemolysis. IVC filter placed.\n Endocrine: RISS\n Infectious Disease: WBC normal, on Vanc/cipro/cefepime for VAP given\n worsening pulm status, f/u on cx\n Lines / Tubes / Drains: Trach/Peg/foley/L radial a-line/R SCL\n Wounds:\n Imaging: CXR today\n Fluids: KVO\n Consults: Trauma (1o), Ortho Spine, Ortho trauma, Heme\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 04:41 PM\n Arterial Line - 11:30 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin, IVC filter\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n"},{"category":"Nursing","chartdate":"2175-02-05 00:00:00.000","description":"Nursing Progress Note","row_id":715142,"text":"PICC placed.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Ls clear to diminished, strong productive cough, suctioned for large\n amounts of thick yellow sputum. Afebrile all day. Remains in a NSR.\n Pt refused to get OOB due to having to wear TLSO brace.\n Action:\n Continuing diamox and Lasix for diuresis. Electrolytes replaced.\n Response:\n UOP good. Neuro status intact, appropriate.\n Plan:\n PM CXR pending. Screen for rehab in AM.\n"},{"category":"Nursing","chartdate":"2175-02-06 00:00:00.000","description":"Nursing Progress Note","row_id":715284,"text":"74M s/p crushing injury d/t falling tree. Injuries sustained include\n multiple R sided rib fxs, grade 2 liver lac (w/ assoc hepatic vessel\n extravasation), stable pelvis fxs (w/ associated extravasation), R\n ramus fx, clavicle fx, and T4 vertebral body fx. Episodes of A.\n Flutter with RVR and aflutter, now with resp failure and newly dx\n pneumonia as of .\n intubated for resp distress\n angio embolization of hepatic and pelvic arterial bleeders\n IVC filter in OR\n self extubated and re-intubated immediately after d/t acute resp.\n failure\n Trach and PEG at bedside\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt alert, follows commands, MAE\ns purposefully. Nods yes to R sided\n rib discomfort, but mouths that it is tolerable, currently declining\n pain meds.\n Pt remains in SR, conts. Diltiazem via PEG. DL midline intact with\n 25cm coiled outside of skin; +blood return, flushes easily.\n LS with rhonchi throughout, suctioned for sm. to moderate amts. Thick\n white secretions. RR remains in 30\n Abd soft, NT/D, BS present, incontinent sm. to medium soft, brown BM.\n Conts. TF at goal 40cc/hr with no residuals.\n Foley patent draining adequate amts. Yellow urine.\n Endo: BS 128, no coverage per sliding scale.\n Tmax 100.6po, conts. Cefipime as ordered.\n Mulitple areas of ecchymosis, see metavision.\n Pt\ns companion in this afternoon, pt\ns son also telephoned\n for update.\n Action:\n Frequent repositioning/pulmonary hygiene provided. Cons. Dilt. As\n ordered.\n Midline dsg changed.\n and updated by this RN; plan for son to touch base\n with case management tomorrow regarding rehab\n possibilities.\n Pt dangled a edge of bed and stood at edge of bed with PT, see PT\n note. OOB to chair for approx. 3hours, tolerated well.\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2175-02-06 00:00:00.000","description":"Nursing Progress Note","row_id":715287,"text":"74M s/p crushing injury d/t falling tree. Injuries sustained include\n multiple R sided rib fxs, grade 2 liver lac (w/ assoc hepatic vessel\n extravasation), stable pelvis fxs (w/ associated extravasation), R\n ramus fx, clavicle fx, and T4 vertebral body fx. Episodes of A.\n Flutter with RVR and aflutter, now with resp failure and newly dx\n pneumonia as of .\n intubated for resp distress\n angio embolization of hepatic and pelvic arterial bleeders\n IVC filter in OR\n self extubated and re-intubated immediately after d/t acute resp.\n failure\n Trach and PEG at bedside\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt alert, follows commands, MAE\ns purposefully. Nods yes to R sided\n rib discomfort, but mouths that it is tolerable, currently declining\n pain meds.\n Pt remains in SR, conts. Diltiazem via PEG. DL midline intact with\n 25cm coiled outside of skin; +blood return, flushes easily.\n LS with rhonchi throughout, suctioned for sm. to moderate amts. Thick\n white secretions. RR remains in 30\n Abd soft, NT/D, BS present, incontinent sm. to medium soft, brown BM.\n Conts. TF at goal 40cc/hr with no residuals.\n Foley patent draining adequate amts. Yellow urine.\n Endo: BS 128, no coverage per sliding scale.\n Tmax 100.6po, conts. Cefipime as ordered.\n Mulitple areas of ecchymosis, see metavision.\n Pt\ns companion in this afternoon, pt\ns son also telephoned\n for update.\n Action:\n Frequent repositioning/pulmonary hygiene provided. Cons. Dilt. As\n ordered.\n Midline dsg changed.\n and updated by this RN; plan for son to touch base\n with case management tomorrow regarding rehab\n possibilities.\n Pt dangled a edge of bed and stood at edge of bed with PT, see PT\n note. OOB to chair for approx. 3hours, tolerated well.\n Response:\n Pt tachypneic with RR up to 40\ns after turning activity with prolonged\n recovery time.\n Currently on 10PS/5 PEEP/40%.\n Plan:\n Monitor VS, hemodynamics, I/O, labs. Cont. aggressive pulmonary\n hygiene, frequent repositioning.\n Wean vent as able, attempt trach mask trial if/when appropriate. Cont.\n rehab screening process.\n Double lumen midline remains coiled outside skin. ?antibiotic course\n complete in next few days. If there is a need for prolonged abx\n course, ? IR for PICC replacement. Follow up with case management and\n family regarding specific rehabs on . Cont. ongoing open\n communication, comfort, and support to pt and family.\n"},{"category":"Nursing","chartdate":"2175-02-07 00:00:00.000","description":"Nursing Progress Note","row_id":715352,"text":"Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains on psv 10, 5peep and 40% with stable abg and 02sats. Remains\n tachypneic, 30\ns but denies distress. LS w/ rhonci throughout.\n Copious thick yellow secretions. Strong productive cough but cannot\n clear.\n Action:\n Pulm toilet, Frequent suctioning required.\n Response:\n Stable on psv 10/5 but cont with copious secretions despite frequent\n sxning.\n Plan:\n Will attempt psv 5 in am and recheck ABG. Not ready for TM due to\n copious secretions and tachpynea. Cont w/ oob to chair as tolerated.\n Cont pulm toilet.\n Activity Intolerance\n Assessment: Pt assisting with movement and aable to use swabs\n independently with supervision. Washing face independently.\n Action: Encourage pt to increase participation in care.\n Response: More interactive and asking to do things for himself.\n Plan: Increase activity as tolerated. Encourage participation in\n care. Have pt assist with bath when oob-chair during the day.\n Encourage normal sleep pattern.\n"},{"category":"Nursing","chartdate":"2175-01-25 00:00:00.000","description":"Nursing Progress Note","row_id":713466,"text":"s/p hit by falling tree, crushing injury to right chest, pelvis,\n thorasic fx, liver lac.\n Trauma, s/p\n Assessment:\n Patient sleeping comfortably all night. Pain well controlled with\n Dilaudid PCA using IS frequently with TV 1000. Cough weak but\n productive. NPO overnight for ? OR today. UOP marginal with increasing\n Creatinine, responding slightly to IVF bolus. Afebrile, blood sugars\n requiring minimal insulin coverage. At 0600 HR 150s, ST with poor\n respiratory status. ABG showing worsening acidosis. Pt was increasingly\n lethargic but remained oriented times 3. LS very diminished which was a\n change from being clear over night. HR not responding it intervention\n and became hypotensive. Pt was intubated at 0630 successfully. Hct\n drifting to 23.\n Action:\n Fluid bolus for UOP. EKG done, esmolol bolus given, 1 unit PRBC, Lasix\n bolus given, patient intubated at 0630.\n Response:\n Cough improving post intubation suctioning copious amounts of tenacious\n yellow secretions.\n Plan:\n Bicarb gtt prior to IR. Emergently to IR this am, ? CTA of chest to R/O\n PE. Maintain hemodynamic stability with blood product transfusions and\n vasopressors as needed. Awaiting TLSO brace must be less than 30\n degrees without brace.\n"},{"category":"Physician ","chartdate":"2175-01-25 00:00:00.000","description":"Intensivist Note","row_id":713469,"text":"TSICU\n HPI:\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\n checked and 1.5, 1 more unit FFP given.\n Injuries\n Mult rib fx: R anterolateral and post, L posterior\n T4 vert body inf corner fx\n Commin spinous process fx T2-8\n Nondisplaced left T10 transverse process\n Nondispaced L distal clavicle\n Nondisplaced L clavicle fx\n R medial lobe liver contusion with hematoma\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny\n focus of arterial bleeding/active extravasation, and larger area\n of venous bleeding\n Nondisplaced, comminuted L iliac bone fracture w/adjacent iliac muscle\n hematoma, Fracture extends into left SI joint.\n Minimally displaced fracture of the right iliac bone extending to right\n SI joint.\n Chief complaint:\n pain\n PMHx:\n none\n Current medications:\n Acetaminophen 5. Calcium Gluconate 6. Dextrose 50% 7. Docusate Sodium\n (Liquid)\n 8. Famotidine 9. Gabapentin 10. Glucagon 11. HYDROmorphone (Dilaudid)\n 12. Insulin 13. Magnesium Sulfate\n 14. Ondansetron 15. Pneumococcal Vac Polyvalent 16. Potassium Chloride\n 17. Sodium Chloride 0.9% Flush\n 18. Sodium Phosphate\n 24 Hour Events:\n ARTERIAL LINE - START 10:59 AM\n : Hct stable. APS c/s for possible epidural--awaiting ortho spine\n plan. Tylenol, neurontin, dilaudid for pain. Ortho non op, will\n reassess . Per ortho spine, no surgical intervention; HOB<30, TLSO\n when OOB.\n : CR increased to 1.6, LFTs elevated in 500s. Bolused 500c x2 for\n low urine output\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 PM\n Other medications:\n Flowsheet Data as of 04:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.3\nC (97.3\n T current: 35.9\nC (96.6\n HR: 99 (80 - 102) bpm\n BP: 96/45(61) {94/45(61) - 126/65(84)} mmHg\n RR: 18 (10 - 25) insp/min\n SPO2: 90%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 90 kg (admission): 90 kg\n Total In:\n 3,960 mL\n 1,473 mL\n PO:\n 510 mL\n Tube feeding:\n IV Fluid:\n 3,450 mL\n 1,473 mL\n Blood products:\n Total out:\n 855 mL\n 195 mL\n Urine:\n 855 mL\n 195 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,105 mL\n 1,278 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SPO2: 90%\n ABG: 7.29/54/77./25/-1\n PaO2 / FiO2: 156\n Physical Examination\n General Appearance: No acute distress, Well nourished\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: Diminished: at bases), (Sternum:\n Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 89 K/uL\n 8.2 g/dL\n 123 mg/dL\n 1.6 mg/dL\n 25 mEq/L\n 5.1 mEq/L\n 36 mg/dL\n 110 mEq/L\n 140 mEq/L\n 24.1 %\n 15.5 K/uL\n [image002.jpg]\n 02:00 AM\n 04:29 AM\n 07:36 AM\n 10:54 AM\n 04:13 PM\n 05:25 PM\n 10:38 PM\n 10:56 PM\n 03:24 AM\n 03:44 AM\n WBC\n 13.7\n 15.5\n Hct\n 31.9\n 28.3\n 28.9\n 27.7\n 25.7\n 24.1\n Plt\n 127\n 89\n Creatinine\n 1.2\n 1.6\n 1.6\n TCO2\n 27\n 28\n 27\n Glucose\n 140\n 181\n 130\n 123\n Other labs: PT / PTT / INR:14.7/27.7/1.3, CK / CK-MB / Troponin\n T:1349//, ALT / AST:559/522, Alk-Phos / T bili:39/0.9, Lactic Acid:1.7\n mmol/L, LDH:616 IU/L, Ca:8.0 mg/dL, Mg:2.3 mg/dL, PO4:5.7 mg/dL\n Imaging: CXR Pend\n Pelvis Pend\n CT head OSH: Prelim No ICH or fracture.\n CT chest OSH: Mult rib fx: R anterolateral and posterior, L\n posterior; Dependent consolidation, possible aspiration; T4 vertebral\n body inf corner fx, no retropulsion; Comminuted spinous process fx\n T2-8; Nondisplaced L T10 transverse process; Nondisplaced L clavicle\n distal fx; Nondisplaced L scapula fx;\n CT c spine OSH: Prelim No fx or malalignment. Multilevel\n degenerative changes w/large post disk bulge at C4-5, narrowing the\n spinal canal and deforming the thecal sac, acuity unknown. Marked\n neuroforamenal narrowing @multiple levels.\n CTA abd/pel Prelim: Medial R liver lobe contusion w/adj\n hematoma, w/o evidence of active bleeding; Comminuted L pubic ramus\n fracture w/assoc hematoma, with tiny focus of arterial bleeding/active\n extravasation, and larger area of venous bleeding. Hematoma somewhat\n larger than on OSH study. Nondisplaced, comminuted L iliac bone fx\n w/adj iliac muscle hematoma, larger than on prior study, w/o active\n extrav. Fx extends into L SI joint. Post R hepatic laceration/contusion\n adjacent to calcified granuloma, w/small hematoma, without active\n bleeding. Min displaced fx of R iliac bone extending to R SI joint.\n Cirrhotic liver. Inc B pleural effusions (small), w/inc atelectasis.\n MRI: Mild compression deformity of L1 with additional levels of\n potential trabecular contusion @T10-11 also inf @T4 w/o retropulsion.\n Multilevel degenerative changes with moderate canal narrowing at T10-11\n w/cord deformity and no abnormal cord signal. Extensive edema\n throughout the paraspinal soft tissues, predominantly\n post w/in interspinous ligaments. Incompletely evaluated c-spine w/\n severe canal narrowing @C4-5 w/cord deformity and no abnormal cord\n signal.\n Assessment and Plan\n TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx.\n Neurologic: Neuro checks Q: 4 hr, Pain controlled, C-spine cleared. Per\n ortho spine, no surgical intervention; HOB<30, TLSO when OOB. Use\n ativan and fentanyl for sedation.\n Neuro checks Q: shift\n Pain: Dilaudid PCA 0.25/2.5, may require epidural (APS awaiting ortho\n spine plan)\n changed to fentanyl while now intubated. Neurontin,\n Tylenol. Will place paravetebral catheters for analgesia.\n Cardiovascular: Stable currently, SBP into 90s on , but in 120s\n after a-line placed. TTE with adequate CO, low SVR state, e/o RV\n pressure overload but good contractility. Place Vigileo.\n Pulmonary: IS, On face tent 70% O2, monitor, may require intubation.\n f/u CXR . Excellent tidal volumes of > 1L. Early this am\n developed progressive respiratory acidosis. Will obtain pulm\n angiogram as well.\n Gastrointestinal / Abdomen: NPO after MN for possible OR (pelvis).\n Increasing LFTs (in 500s on ); h/o cirrhosis.\n Nutrition: Regular diet, Advance diet as tolerated\n Renal: Foley, Adequate UO, Foley, monitor UOP, f/u lytes, and trend\n Cr. Given ~1L bolus o/n for decreasing uop.\n Hematology: Serial Hct, Monitor Hct q6\n 35.1-32.2-31.9-28.3-28.9-27.7-25.7-24.1, Monitor coags INR 1.3. If\n actively bleeding may need Angio.\n Endocrine: RISS, goal BS<150.\n Infectious Disease: Check cultures, afebrile, but elevated wbc to\n 15.5.\n Lines / Tubes / Drains: Foley, RIJ CVL (d/c if stable), PIV x2,\n Foley, a-line (). Will change CVL now.\n Wounds:\n Imaging: CXR today\n Fluids: LR, LR@100 currently, KVO if taking POs\n Consults: Trauma surgery, Ortho, Ortho-spine, Trauma (1o), Ortho Spine,\n Ortho trauma\n Billing Diagnosis: Multiple injuries (Trauma)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 09:00 PM\n 18 Gauge - 09:00 PM\n 20 Gauge - 09:00 PM\n Arterial Line - 10:59 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition:\n Total time spent:\n Patient is critically ill\n"},{"category":"Physician ","chartdate":"2175-01-25 00:00:00.000","description":"Intensivist Note","row_id":713488,"text":"TSICU\n HPI:\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\n checked and 1.5, 1 more unit FFP given.\n Injuries\n Mult rib fx: R anterolateral and post, L posterior\n T4 vert body inf corner fx\n Commin spinous process fx T2-8\n Nondisplaced left T10 transverse process\n Nondispaced L distal clavicle\n Nondisplaced L clavicle fx\n R medial lobe liver contusion with hematoma\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny\n focus of arterial bleeding/active extravasation, and larger area\n of venous bleeding\n Nondisplaced, comminuted L iliac bone fracture w/adjacent iliac muscle\n hematoma, Fracture extends into left SI joint.\n Minimally displaced fracture of the right iliac bone extending to right\n SI joint.\n Chief complaint:\n pain\n PMHx:\n none\n Current medications:\n Acetaminophen 5. Calcium Gluconate 6. Dextrose 50% 7. Docusate Sodium\n (Liquid)\n 8. Famotidine 9. Gabapentin 10. Glucagon 11. HYDROmorphone (Dilaudid)\n 12. Insulin 13. Magnesium Sulfate\n 14. Ondansetron 15. Pneumococcal Vac Polyvalent 16. Potassium Chloride\n 17. Sodium Chloride 0.9% Flush\n 18. Sodium Phosphate\n 24 Hour Events:\n ARTERIAL LINE - START 10:59 AM\n : Hct stable. APS c/s for possible epidural--awaiting ortho spine\n plan. Tylenol, neurontin, dilaudid for pain. Ortho non op, will\n reassess . Per ortho spine, no surgical intervention; HOB<30, TLSO\n when OOB.\n : CR increased to 1.6, LFTs elevated in 500s. Bolused 500c x2 for\n low urine output\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 PM\n Other medications:\n Flowsheet Data as of 04:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.3\nC (97.3\n T current: 35.9\nC (96.6\n HR: 99 (80 - 102) bpm\n BP: 96/45(61) {94/45(61) - 126/65(84)} mmHg\n RR: 18 (10 - 25) insp/min\n SPO2: 90%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 90 kg (admission): 90 kg\n Total In:\n 3,960 mL\n 1,473 mL\n PO:\n 510 mL\n Tube feeding:\n IV Fluid:\n 3,450 mL\n 1,473 mL\n Blood products:\n Total out:\n 855 mL\n 195 mL\n Urine:\n 855 mL\n 195 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,105 mL\n 1,278 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SPO2: 90%\n ABG: 7.29/54/77./25/-1\n PaO2 / FiO2: 156\n Physical Examination\n General Appearance: No acute distress, Well nourished\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: Diminished: at bases), (Sternum:\n Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 89 K/uL\n 8.2 g/dL\n 123 mg/dL\n 1.6 mg/dL\n 25 mEq/L\n 5.1 mEq/L\n 36 mg/dL\n 110 mEq/L\n 140 mEq/L\n 24.1 %\n 15.5 K/uL\n [image002.jpg]\n 02:00 AM\n 04:29 AM\n 07:36 AM\n 10:54 AM\n 04:13 PM\n 05:25 PM\n 10:38 PM\n 10:56 PM\n 03:24 AM\n 03:44 AM\n WBC\n 13.7\n 15.5\n Hct\n 31.9\n 28.3\n 28.9\n 27.7\n 25.7\n 24.1\n Plt\n 127\n 89\n Creatinine\n 1.2\n 1.6\n 1.6\n TCO2\n 27\n 28\n 27\n Glucose\n 140\n 181\n 130\n 123\n Other labs: PT / PTT / INR:14.7/27.7/1.3, CK / CK-MB / Troponin\n T:1349//, ALT / AST:559/522, Alk-Phos / T bili:39/0.9, Lactic Acid:1.7\n mmol/L, LDH:616 IU/L, Ca:8.0 mg/dL, Mg:2.3 mg/dL, PO4:5.7 mg/dL\n Imaging: CXR Pend\n Pelvis Pend\n CT head OSH: Prelim No ICH or fracture.\n CT chest OSH: Mult rib fx: R anterolateral and posterior, L\n posterior; Dependent consolidation, possible aspiration; T4 vertebral\n body inf corner fx, no retropulsion; Comminuted spinous process fx\n T2-8; Nondisplaced L T10 transverse process; Nondisplaced L clavicle\n distal fx; Nondisplaced L scapula fx;\n CT c spine OSH: Prelim No fx or malalignment. Multilevel\n degenerative changes w/large post disk bulge at C4-5, narrowing the\n spinal canal and deforming the thecal sac, acuity unknown. Marked\n neuroforamenal narrowing @multiple levels.\n CTA abd/pel Prelim: Medial R liver lobe contusion w/adj\n hematoma, w/o evidence of active bleeding; Comminuted L pubic ramus\n fracture w/assoc hematoma, with tiny focus of arterial bleeding/active\n extravasation, and larger area of venous bleeding. Hematoma somewhat\n larger than on OSH study. Nondisplaced, comminuted L iliac bone fx\n w/adj iliac muscle hematoma, larger than on prior study, w/o active\n extrav. Fx extends into L SI joint. Post R hepatic laceration/contusion\n adjacent to calcified granuloma, w/small hematoma, without active\n bleeding. Min displaced fx of R iliac bone extending to R SI joint.\n Cirrhotic liver. Inc B pleural effusions (small), w/inc atelectasis.\n MRI: Mild compression deformity of L1 with additional levels of\n potential trabecular contusion @T10-11 also inf @T4 w/o retropulsion.\n Multilevel degenerative changes with moderate canal narrowing at T10-11\n w/cord deformity and no abnormal cord signal. Extensive edema\n throughout the paraspinal soft tissues, predominantly\n post w/in interspinous ligaments. Incompletely evaluated c-spine w/\n severe canal narrowing @C4-5 w/cord deformity and no abnormal cord\n signal.\n Assessment and Plan\n TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx.\n Neurologic: Neuro checks Q: 4 hr, Pain controlled, C-spine cleared. Per\n ortho spine, no surgical intervention; HOB<30, TLSO when OOB. Use\n ativan and fentanyl for sedation.\n Neuro checks Q: shift\n Pain: Dilaudid PCA 0.25/2.5, may require epidural (APS awaiting ortho\n spine plan)\n changed to fentanyl while now intubated. Neurontin,\n Tylenol. may place paravetebral catheters for analgesia.\n Cardiovascular: Stable currently, SBP into 90s on , but in 120s\n after a-line placed. TTE with adequate CO, low SVR state, e/o RV\n pressure overload but good contractility. place the or\n Vigilleo. Hypotension/shock on phenylephrine. Normal LV function,\n dilated RV. Could be from PE (See below). Currently on phenylephrine.\n Will re-evaluate post IR procedure.\n Pulmonary:. Early this am developed progressive respiratory acidosis\n and hypotension. Given signs of RV dilatation (although no classical\n sign of PE) will send for CTA (Torso, given continued bleeding).\n Gastrointestinal / Abdomen: NPO after MN for possible OR (pelvis).\n Increasing LFTs (in 500s on ); h/o cirrhosis.\n Nutrition: NPO for now\n Renal: Foley, Adequate UO, Foley, monitor UOP, f/u lytes, and trend\n Cr. Given ~1L bolus o/n for decreasing uop. CRI appears to slightly\n improve. Will hydrate with bicarb gtt for anticipated dye load.\n Hematology: Serial Hct, Monitor Hct q6\n 35.1-32.2-31.9-28.3-28.9-27.7-25.7-24.1, Monitor coags INR 1.3. If\n actively bleeding may need Angio.\n Endocrine: RISS, goal BS<150.\n Infectious Disease: Check cultures, afebrile, but elevated wbc to\n 15.5.\n Lines / Tubes / Drains: Foley, RIJ CVL (d/c if stable), PIV x2,\n Foley, a-line (). Will change CVL today.\n Wounds:\n Imaging: CXR today\n Fluids: LR, LR@100 currently, KVO if taking POs\n Consults: Trauma surgery, Ortho, Ortho-spine, Trauma (1o), Ortho Spine,\n Ortho trauma\n Billing Diagnosis: Multiple injuries (Trauma)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 09:00 PM\n 18 Gauge - 09:00 PM\n 20 Gauge - 09:00 PM\n Arterial Line - 10:59 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 40 min\n Patient is critically ill\n"},{"category":"Physician ","chartdate":"2175-01-24 00:00:00.000","description":"Intensivist Note","row_id":713330,"text":"TSICU\n HPI:\n 74 yo male s/p fall from tractor and crush injury from tree branch.\n +Loc. At OSH received 4 units prbcs, 1 unit FFP for INR 4. +HD stable\n here. INR checked and 1.5, 1 more unit FFP given.\n Injuries\n Mult rib fx: R anterolateral and post, L posterior\n T4 vert body inf corner fx\n Commin spinous process fx T2-8\n Nondisplaced left T10 transverse process\n Nondispaced L distal clavicle\n R medial lobe liver contusion with hematoma\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny\n focus of arterial bleeding/active extravasation, and larger area of\n venous bleeding\n Nondisplaced, comminuted L iliac bone fracture w/adjacent iliac muscle\n hematoma, Fracture extends into left SI joint.\n Minimally displaced fracture of the right iliac bone extending to right\n SI joint.\n Chief complaint:\n fall\n PMHx:\n None\n Current medications:\n 1. Calcium Gluconate 2. Dextrose 50% 3. Docusate Sodium (Liquid) 4.\n Famotidine 5. Glucagon 6. HYDROmorphone (Dilaudid) 7. Insulin 8.\n Magnesium Sulfate 9. Pneumococcal Vac Polyvalent 10. Potassium Chloride\n 11. Sodium Chloride 0.9% Flush 12. Sodium Phosphate\n 24 Hour Events:\n MULTI LUMEN - START 09:00 PM\n NASAL SWAB - At 12:00 AM\n C-SPINE CLEARANCE - At 12:00 AM\n MAGNETIC RESONANCE IMAGING - At 02:17 AM Thoracic spine\n - Started on Dilaudid PCA with good effect, breathing improved. Weaned\n down oxygen to face tent. Remained HD stable overnight, although SBP\n dropped to 70s transiently this AM\n bolused 1 L NS. Thoracic MRI\n performed.\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 10:00 PM\n Fentanyl - 12:00 AM\n Other medications:\n Flowsheet Data as of 06:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.7\nC (98\n T current: 35.7\nC (96.2\n HR: 88 (88 - 99) bpm\n BP: 91/65(71) {91/52(66) - 135/72(89)} mmHg\n RR: 25 (24 - 35) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 90 kg (admission): 90 kg\n Total In:\n 6,105 mL\n 593 mL\n PO:\n Tube feeding:\n IV Fluid:\n 305 mL\n 593 mL\n Blood products:\n Total out:\n 595 mL\n 300 mL\n Urine:\n 395 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,510 mL\n 293 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SPO2: 100%\n ABG: 7.35/41/112/23/-2\n PaO2 / FiO2: 160\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: shallow respirations)\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: No(t) Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 127 K/uL\n 10.5 g/dL\n 181 mg/dL\n 1.2 mg/dL\n 23 mEq/L\n 5.2 mEq/L\n 21 mg/dL\n 110 mEq/L\n 140 mEq/L\n 31.9 %\n 13.7 K/uL\n [image002.jpg]\n 09:00 PM\n 11:04 PM\n 11:22 PM\n 04:29 AM\n WBC\n 13.7\n Hct\n 32.2\n 31.9\n Plt\n 127\n Creatinine\n 1.2\n TCO2\n 23\n 24\n Glucose\n 181\n Other labs: PT / PTT / INR:15.0/26.4/1.3, Lactic Acid:2.8 mmol/L,\n LDH:616 IU/L, Ca:8.1 mg/dL, Mg:1.8 mg/dL, PO4:4.9 mg/dL\n Assessment and Plan\n TRAUMA, S/P fall from tractor.\n Assessment and Plan: 74 yo M s/p fall with multiple rib fractures,\n pelvis fractures, clavicle fx, and thoracic fractures.\n Neurologic: A&Ox 3. Using PCA with effect. C-spine cleared. Thoracic\n MRI done per ortho spine, logroll precautions.\n Neuro checks Q: shift\n Pain: Dilaudid PCA 0.25/2.5; start Tylenol as Neurontin once taking\n POs.\n require epidural vs paravertebral catheter, will discuss with APS.\n Cardiovascular: Stable but transient hypoTN this AM. Will place aline.\n Pt has access, type and crossed. need angio if ongoing bleeding.\n Pulmonary: On face tent 70% O2, monitor, may require intubation.\n Splinting due to pain.\n Gastrointestinal / Abdomen: NPO x meds. Elevated transaminases, ? liver\n contusion related. Follow and trend LFTs.\n Nutrition: NPO\n Renal: Foley, Adequate UO\n Hematology: Monitor Hct q6 35.1-32.2-31.9-28.3, Monitor coags INR 1.3.\n If actively bleeding may need Angio, follow Hct closely, recheck 11 AM.\n Endocrine: RISS, goal BS <150. Tighten RISS.\n Infectious Disease: Afebrile.\n Lines / Tubes / Drains: RIJ CVL, PIV, Foley\n will d/c OSH CVL and\n replace CVL.\n Wounds: c/d/i\n Imaging:\n Fluids: LR @ 100.\n Consults: Trauma, Ortho Spine, Ortho trauma\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 09:00 PM\n 18 Gauge - 09:00 PM\n 20 Gauge - 09:00 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: n/a\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 33 min\n"},{"category":"Physician ","chartdate":"2175-01-24 00:00:00.000","description":"Intensivist Note","row_id":713343,"text":"TSICU\n HPI:\n 74 yo male s/p fall from tractor and crush injury from tree branch.\n +Loc. At OSH received 4 units prbcs, 1 unit FFP for INR 4. +HD stable\n here. INR checked and 1.5, 1 more unit FFP given.\n Injuries\n Mult rib fx: R anterolateral and post, L posterior\n T4 vert body inf corner fx\n Commin spinous process fx T2-8\n Nondisplaced left T10 transverse process\n Nondispaced L distal clavicle\n R medial lobe liver contusion with hematoma\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny\n focus of arterial bleeding/active extravasation, and larger area of\n venous bleeding\n Nondisplaced, comminuted L iliac bone fracture w/adjacent iliac muscle\n hematoma, Fracture extends into left SI joint.\n Minimally displaced fracture of the right iliac bone extending to right\n SI joint.\n Chief complaint:\n fall\n PMHx:\n None\n Current medications:\n 1. Calcium Gluconate 2. Dextrose 50% 3. Docusate Sodium (Liquid) 4.\n Famotidine 5. Glucagon 6. HYDROmorphone (Dilaudid) 7. Insulin 8.\n Magnesium Sulfate 9. Pneumococcal Vac Polyvalent 10. Potassium Chloride\n 11. Sodium Chloride 0.9% Flush 12. Sodium Phosphate\n 24 Hour Events:\n MULTI LUMEN - START 09:00 PM\n NASAL SWAB - At 12:00 AM\n C-SPINE CLEARANCE - At 12:00 AM\n MAGNETIC RESONANCE IMAGING - At 02:17 AM Thoracic spine\n - Started on Dilaudid PCA with good effect, breathing improved. Weaned\n down oxygen to face tent. Remained HD stable overnight, although SBP\n dropped to 70s transiently this AM\n bolused 1 L NS. Thoracic MRI\n performed.\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 10:00 PM\n Fentanyl - 12:00 AM\n Other medications:\n Flowsheet Data as of 06:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.7\nC (98\n T current: 35.7\nC (96.2\n HR: 88 (88 - 99) bpm\n BP: 91/65(71) {91/52(66) - 135/72(89)} mmHg\n RR: 25 (24 - 35) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 90 kg (admission): 90 kg\n Total In:\n 6,105 mL\n 593 mL\n PO:\n Tube feeding:\n IV Fluid:\n 305 mL\n 593 mL\n Blood products:\n Total out:\n 595 mL\n 300 mL\n Urine:\n 395 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,510 mL\n 293 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SPO2: 100%\n ABG: 7.35/41/112/23/-2\n PaO2 / FiO2: 160\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: shallow respirations)\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: No(t) Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 127 K/uL\n 10.5 g/dL\n 181 mg/dL\n 1.2 mg/dL\n 23 mEq/L\n 5.2 mEq/L\n 21 mg/dL\n 110 mEq/L\n 140 mEq/L\n 31.9 %\n 13.7 K/uL\n [image002.jpg]\n 09:00 PM\n 11:04 PM\n 11:22 PM\n 04:29 AM\n WBC\n 13.7\n Hct\n 32.2\n 31.9\n Plt\n 127\n Creatinine\n 1.2\n TCO2\n 23\n 24\n Glucose\n 181\n Other labs: PT / PTT / INR:15.0/26.4/1.3, Lactic Acid:2.8 mmol/L,\n LDH:616 IU/L, Ca:8.1 mg/dL, Mg:1.8 mg/dL, PO4:4.9 mg/dL\n Assessment and Plan\n TRAUMA, S/P fall from tractor.\n Assessment and Plan: 74 yo M s/p fall with multiple rib fractures,\n pelvis fractures, clavicle fx, and thoracic fractures.\n Neurologic: A&Ox 3. Using PCA with good effect. C-spine cleared.\n Thoracic MRI done per ortho spine, continue logroll precautions.\n Awaiting input from ortho-spine re: surgery vs. TLSO\n Neuro checks Q:4 shift\n Pain: Dilaudid PCA 0.25/2.5; start Tylenol as Neurontin once taking\n POs.\n require epidural vs paravertebral catheter, will discuss with APS.\n Cardiovascular: Stable, but transient hypotension this AM. Will place\n aline. Pt has access, type and crossed. need angio if ongoing\n bleeding. Will do a focused TTE to eval C.O and function.\n Pulmonary: On face tent 70% O2, monitor, may require intubation.\n Splinting due to pain.\n Gastrointestinal / Abdomen: NPO x meds. Elevated transaminases, ? liver\n contusion related. Follow and trend LFTs.\n Nutrition: NPO\n Renal: Foley, Adequate UO\n Hematology: Monitor Hct q6 35.1-32.2-31.9-28.3, Monitor coags INR 1.3.\n If actively bleeding may need Angio, follow Hct closely, recheck 11 AM.\n Endocrine: RISS, goal BS <150. Tighten RISS as slightly hyperglycemic.\n Infectious Disease: Afebrile.\n Lines / Tubes / Drains: RIJ CVL, PIV, Foley. Will keep OSH CVL for now\n and may re-site it tomorrow, as the risk of placing a CVL in this\n respiratory tenuous patient outweighs the benefit today.\n Wounds: c/d/i\n Imaging:\n Fluids: LR @ 100.\n Consults: Trauma, Ortho Spine, Ortho trauma\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 09:00 PM\n 18 Gauge - 09:00 PM\n 20 Gauge - 09:00 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: n/a\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 33 min\n"},{"category":"Physician ","chartdate":"2175-01-25 00:00:00.000","description":"Intensivist Note","row_id":713436,"text":"TSICU\n HPI:\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\n checked and 1.5, 1 more unit FFP given.\n Injuries\n Mult rib fx: R anterolateral and post, L posterior\n T4 vert body inf corner fx\n Commin spinous process fx T2-8\n Nondisplaced left T10 transverse process\n Nondispaced L distal clavicle\n Nondisplaced L clavicle fx\n R medial lobe liver contusion with hematoma\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny\n focus of arterial bleeding/active extravasation, and larger area\n of venous bleeding\n Nondisplaced, comminuted L iliac bone fracture w/adjacent iliac muscle\n hematoma, Fracture extends into left SI joint.\n Minimally displaced fracture of the right iliac bone extending to right\n SI joint.\n Chief complaint:\n pain\n PMHx:\n none\n Current medications:\n Acetaminophen 5. Calcium Gluconate 6. Dextrose 50% 7. Docusate Sodium\n (Liquid)\n 8. Famotidine 9. Gabapentin 10. Glucagon 11. HYDROmorphone (Dilaudid)\n 12. Insulin 13. Magnesium Sulfate\n 14. Ondansetron 15. Pneumococcal Vac Polyvalent 16. Potassium Chloride\n 17. Sodium Chloride 0.9% Flush\n 18. Sodium Phosphate\n 24 Hour Events:\n ARTERIAL LINE - START 10:59 AM\n : Hct stable. APS c/s for possible epidural--awaiting ortho spine\n plan. Tylenol, neurontin, dilaudid for pain. Ortho non op, will\n reassess . Per ortho spine, no surgical intervention; HOB<30, TLSO\n when OOB.\n : CR increased to 1.6, LFTs elevated in 500s. Bolused 500c x2 for\n low urine output\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 PM\n Other medications:\n Flowsheet Data as of 04:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.3\nC (97.3\n T current: 35.9\nC (96.6\n HR: 99 (80 - 102) bpm\n BP: 96/45(61) {94/45(61) - 126/65(84)} mmHg\n RR: 18 (10 - 25) insp/min\n SPO2: 90%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 90 kg (admission): 90 kg\n Total In:\n 3,960 mL\n 1,473 mL\n PO:\n 510 mL\n Tube feeding:\n IV Fluid:\n 3,450 mL\n 1,473 mL\n Blood products:\n Total out:\n 855 mL\n 195 mL\n Urine:\n 855 mL\n 195 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,105 mL\n 1,278 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SPO2: 90%\n ABG: 7.29/54/77./25/-1\n PaO2 / FiO2: 156\n Physical Examination\n General Appearance: No acute distress, Well nourished\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: Diminished: at bases), (Sternum:\n Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 89 K/uL\n 8.2 g/dL\n 123 mg/dL\n 1.6 mg/dL\n 25 mEq/L\n 5.1 mEq/L\n 36 mg/dL\n 110 mEq/L\n 140 mEq/L\n 24.1 %\n 15.5 K/uL\n [image002.jpg]\n 02:00 AM\n 04:29 AM\n 07:36 AM\n 10:54 AM\n 04:13 PM\n 05:25 PM\n 10:38 PM\n 10:56 PM\n 03:24 AM\n 03:44 AM\n WBC\n 13.7\n 15.5\n Hct\n 31.9\n 28.3\n 28.9\n 27.7\n 25.7\n 24.1\n Plt\n 127\n 89\n Creatinine\n 1.2\n 1.6\n 1.6\n TCO2\n 27\n 28\n 27\n Glucose\n 140\n 181\n 130\n 123\n Other labs: PT / PTT / INR:14.7/27.7/1.3, CK / CK-MB / Troponin\n T:1349//, ALT / AST:559/522, Alk-Phos / T bili:39/0.9, Lactic Acid:1.7\n mmol/L, LDH:616 IU/L, Ca:8.0 mg/dL, Mg:2.3 mg/dL, PO4:5.7 mg/dL\n Imaging: CXR Pend\n Pelvis Pend\n CT head OSH: Prelim No ICH or fracture.\n CT chest OSH: Mult rib fx: R anterolateral and posterior, L\n posterior; Dependent consolidation, possible aspiration; T4 vertebral\n body inf corner fx, no retropulsion; Comminuted spinous process fx\n T2-8; Nondisplaced L T10 transverse process; Nondisplaced L clavicle\n distal fx; Nondisplaced L scapula fx;\n CT c spine OSH: Prelim No fx or malalignment. Multilevel\n degenerative changes w/large post disk bulge at C4-5, narrowing the\n spinal canal and deforming the thecal sac, acuity unknown. Marked\n neuroforamenal narrowing @multiple levels.\n CTA abd/pel Prelim: Medial R liver lobe contusion w/adj\n hematoma, w/o evidence of active bleeding; Comminuted L pubic ramus\n fracture w/assoc hematoma, with tiny focus of arterial bleeding/active\n extravasation, and larger area of venous bleeding. Hematoma somewhat\n larger than on OSH study. Nondisplaced, comminuted L iliac bone fx\n w/adj iliac muscle hematoma, larger than on prior study, w/o active\n extrav. Fx extends into L SI joint. Post R hepatic laceration/contusion\n adjacent to calcified granuloma, w/small hematoma, without active\n bleeding. Min displaced fx of R iliac bone extending to R SI joint.\n Cirrhotic liver. Inc B pleural effusions (small), w/inc atelectasis.\n MRI: Mild compression deformity of L1 with additional levels of\n potential trabecular contusion @T10-11 also inf @T4 w/o retropulsion.\n Multilevel degenerative changes with moderate canal narrowing at T10-11\n w/cord deformity and no abnormal cord signal. Extensive edema\n throughout the paraspinal soft tissues, predominantly\n post w/in interspinous ligaments. Incompletely evaluated c-spine w/\n severe canal narrowing @C4-5 w/cord deformity and no abnormal cord\n signal.\n Assessment and Plan\n TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx.\n Neurologic: Neuro checks Q: 4 hr, Pain controlled, C-spine cleared. Per\n ortho spine, no surgical intervention; HOB<30, TLSO when OOB.\n Neuro checks Q: shift\n Pain: Dilaudid PCA 0.25/2.5, may require epidural (APS awaiting ortho\n spine plan). Neurontin, Tylenol\n Cardiovascular: Stable currently, SBP into 90s on , but in 120s\n after a-line placed.\n Pulmonary: IS, On face tent 70% O2, monitor, may require intubation.\n f/u CXR . Excellent tidal volumes of > 1L.\n Gastrointestinal / Abdomen: NPO after MN for possible OR (pelvis).\n Increasing LFTs (in 500s on ); h/o cirrhosis.\n Nutrition: Regular diet, Advance diet as tolerated\n Renal: Foley, Adequate UO, Foley, monitor UOP, f/u lytes, and trend\n Cr. Given ~1L bolus o/n for decreasing uop.\n Hematology: Serial Hct, Monitor Hct q6\n 35.1-32.2-31.9-28.3-28.9-27.7-25.7-24.1, Monitor coags INR 1.3. If\n actively bleeding may need Angio.\n Endocrine: RISS\n Infectious Disease: Check cultures, afebrile, no issues\n Lines / Tubes / Drains: Foley, RIJ CVL (d/c if stable), PIV x2,\n Foley, a-line ()\n Wounds:\n Imaging: CXR today\n Fluids: LR, LR@100 currently, KVO if taking POs\n Consults: Trauma surgery, Ortho, Ortho-spine, Trauma (1o), Ortho Spine,\n Ortho trauma\n Billing Diagnosis: Multiple injuries (Trauma)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 09:00 PM\n 18 Gauge - 09:00 PM\n 20 Gauge - 09:00 PM\n Arterial Line - 10:59 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition:\n Total time spent:\n Patient is critically ill\n"},{"category":"Nursing","chartdate":"2175-01-25 00:00:00.000","description":"Nursing Progress Note","row_id":713538,"text":"Anemia\n Assessment:\n This AM at 06:00 reportedly pt\ns HR suddenly went to 140\ns, pt\n experienced respiratory distress and poor ABG, was intubated for airway\n protection. HCT was trending down, seen as low as 23.1 today. At the\n beginning of this shift, pt\ns HR converted to NSR, 80-90\ns. BP low and\n neo started at 07:00. Fluid boluses were given on the previous shift.\n Event suggested possible bleeding v. PE but unknown etiology of\n tachycardia and resp distress this AM.\n Action:\n OGT placed this AM for PO meds. HCT checked frequently, total of 6\n units PRBCs given, 1 unit FFP, 1 unit platelets throughout the shift.\n Neo titrated as needed. Propofol gtt titrated to sedation/BP, \n gtt started for pain control. Pt had transthoracic echo done to\n evaluate work of the heart and fluid status. Pt went to IR for\n embolization and gel foam of pelvic/gluteal bleeding from traumatic\n injury (see IR note for procedure details). Pt went directly from IR\n for CTA of chest to rule out PE. Upon arrival back to ,\n subclavian central line placed to replace old OSH central line. CXR\n done to determine placement. Pt lying flat on back (logroll, reverse\n Tberg, side to side flat with pillows). Frequent right femoral checks\n done to evaluate for bleeding.\n Response:\n HCT increasing, BP improved-able to wean propofol, neo. Pt still\n experiencing some pain (able to express this with lightened sedation),\n boluses given. Pt more hemodynamicaly stable, femoral site\n intact, tolerating neo wean well.\n Plan:\n Discontinue old OSH central line and PIVs tonight since central line is\n approved for use per CXR. Continue frequent HCT checks. Wean propofol\n and neo as tolerated; per attending MD /midazolam\n boluses instead of increasing midazolam for sedation/comfort. Consider\n IVC filter? Follow up with blood cultures/urine culture and CTA for\n rule out PE. Consider getting sputum culture tonight d/t large amount\n of secretions. Continue to support pt and family.\n"},{"category":"Physician ","chartdate":"2175-01-26 00:00:00.000","description":"Intensivist Note","row_id":713619,"text":"TSICU\n HPI:\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\n checked and 1.5, 1 more unit FFP given.\n Chief complaint:\n Mult rib fx: R anterolateral and post, L posterior\n T4 vert body inf corner fx\n Commin spinous process fx T2-8\n Nondisplaced left T10 transverse process\n Nondispaced L distal clavicle\n Nondisplaced L clavicle fx\n R medial lobe liver contusion with hematoma\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny\n focus of arterial bleeding/active extravasation, and larger area\n of venous bleeding\n Nondisplaced, comminuted L iliac bone fracture w/adjacent iliac muscle\n hematoma, Fracture extends into left SI joint.\n Minimally displaced fracture of the right iliac bone extending to right\n SI joint.\n PMHx:\n Cirrhosis\n Current medications:\n Acetylcysteine 20%\n Chlorhexidine Gluconate 0.12% Oral Rinse\n Docusate Sodium (Liquid)\n Famotidine\n Fentanyl Citrate\n Gabapentin\n 24 Hour Events:\n CR increased to 1.6, LFTs elevated in 500s. Bolused 500c x2 for low\n urine output, which improved up to 100cc/h. @6am, hr incr acutely to\n 140s, ST on ECG. Progressive acidosis. No resp decompensation\n w/continued good tidal volumes w/effort but hypoventilated. CXR\n w/pleural effusion, vasc congestion. Hct gradually decreasing to 23\n @6am. 2u prbcs tx -> 24.3, 20 IV lasix. IR embolization x2 and gelfoam\n x2. CTA neg for large PE. Received another 2u prbcs -> 25.8. 2u\n prbcs -> 29.2. Intermittently on Neo.\n CMV 50/15/550/14.\n Weaning prop & Neo. Had bigeminy overnight. This AM went into AF with\n RVR. Transitioning to PS trial. Transfused unit 50\n 86. No\n hematoma at femoral site. Febrile to 101.3 this AM.\n Post operative day:\n POD1 s/p angio embolization\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Fentanyl (Concentrate) - 75 mcg/hour\n Phenylephrine - 0.5 mcg/Kg/min\n Propofol - 20 mcg/Kg/min\n Other ICU medications:\n Furosemide (Lasix) - 06:00 AM\n Fentanyl - 07:00 PM\n Famotidine (Pepcid) - 08:29 PM\n Other medications:\n Flowsheet Data as of 06:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.3\nC (100.9\n T current: 37.9\nC (100.2\n HR: 82 (63 - 146) bpm\n BP: 99/53(67) {86/49(61) - 133/69(90)} mmHg\n RR: 18 (15 - 23) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 100.9 kg (admission): 90 kg\n CVP: 12 (12 - 30) mmHg\n Total In:\n 9,459 mL\n 1,174 mL\n PO:\n Tube feeding:\n IV Fluid:\n 6,222 mL\n 1,174 mL\n Blood products:\n 2,877 mL\n Total out:\n 2,325 mL\n 285 mL\n Urine:\n 2,325 mL\n 285 mL\n NG:\n Stool:\n Drains:\n Balance:\n 7,134 mL\n 889 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (500 - 550) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 14 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 32 cmH2O\n Plateau: 27 cmH2O\n Compliance: 42.3 cmH2O/mL\n SPO2: 100%\n ABG: 7.50/42/204/30/8\n Ve: 9.4 L/min\n PaO2 / FiO2: 408\n Physical Examination\n General Appearance: No acute distress, intubated\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), Regular Irregular\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: Follows simple commands, Moves all extremities, Sedated\n Labs / Radiology\n 86 K/uL\n 10.6 g/dL\n 116 mg/dL\n 1.1 mg/dL\n 30 mEq/L\n 3.7 mEq/L\n 23 mg/dL\n 105 mEq/L\n 141 mEq/L\n 29.6 %\n 9.5 K/uL\n [image002.jpg]\n 10:40 AM\n 02:00 PM\n 03:41 PM\n 04:11 PM\n 07:14 PM\n 09:29 PM\n 09:59 PM\n 11:10 PM\n 01:19 AM\n 01:38 AM\n WBC\n 9.2\n 6.8\n 9.5\n Hct\n 25.8\n 29.2\n 29.6\n Plt\n 79\n 52\n 86\n Creatinine\n 1.2\n 1.1\n TCO2\n 31\n 32\n 30\n 32\n 30\n 34\n Glucose\n 104\n 99\n 116\n Other labs: PT / PTT / INR:14.1/29.7/1.2, CK / CK-MB / Troponin\n T:1334/13/<0.01, ALT / AST:345/278, Alk-Phos / T bili:49/3.0, Amylase /\n Lipase:44/, Lactic Acid:1.6 mmol/L, LDH:616 IU/L, Ca:8.2 mg/dL, Mg:2.1\n mg/dL, PO4:1.9 mg/dL\n Imaging: CXR Pend\n Pelvis Pend\n CT head OSH: Prelim No ICH or fracture.\n CT chest OSH: Mult rib fx: R anterolateral and posterior, L\n posterior; Dependent consolidation, possible aspiration; T4 vertebral\n body inf corner fx, no retropulsion; Comminuted spinous process fx\n T2-8; Nondisplaced L T10 transverse process; Nondisplaced L clavicle\n distal fx; Nondisplaced L scapula fx;\n CT c spine OSH: Prelim No fx or malalignment. Multilevel\n degenerative changes w/large post disk bulge at C4-5, narrowing the\n spinal canal and deforming the thecal sac, acuity unknown. Marked\n neuroforamenal narrowing @multiple levels.\n CTA abd/pel Prelim: Medial R liver lobe contusion w/adj\n hematoma, w/o evidence of active bleeding; Comminuted L pubic ramus\n fracture w/assoc hematoma, with tiny focus of arterial bleeding/active\n extravasation, and larger area of venous bleeding. Hematoma somewhat\n larger than on OSH study. Nondisplaced, comminuted L iliac bone fx\n w/adj iliac muscle hematoma, larger than on prior study, w/o active\n extrav. Fx extends into L SI joint. Post R hepatic laceration/contusion\n adjacent to calcified granuloma, w/small hematoma, without active\n bleeding. Min displaced fx of R iliac bone extending to R SI joint.\n Cirrhotic liver. Inc B pleural effusions (small), w/inc atelectasis.\n MRI: Mild compression deformity of L1 with additional levels of\n potential trabecular contusion @T10-11 also inf @T4 w/o retropulsion.\n Multilevel degenerative changes with moderate canal narrowing at T10-11\n w/cord deformity and no abnormal cord signal. Extensive edema\n throughout the paraspinal soft tissues, predominantly\n post w/in interspinous ligaments. Incompletely evaluated c-spine w/\n severe canal narrowing @C4-5 w/cord deformity and no abnormal cord\n signal.\n CTA: no PE.\n Microbiology: Ucx P\n Sputum P\n Bcx P\n Bcx P\n Assessment and Plan\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx.\n Neurologic: C-spine cleared. Per ortho spine, no surgical intervention;\n HOB<30, TLSO when OOB. Awake off sedation, follows commands. Midaz prn\n for sedation, please increase dose and frequency and if need put on gtt\n to adequately sedate patient given new AF and ARDS/ . Pain: on\n fentanyl.\n Cardiovascular: Bedside ECHO shows TR and elevated PA pressures but\n adequate contractility. CVP 20s. Wean Neo gtt. Went into AF with RVR\n this AM. Maintaining BP. Start Dilt gtt, use Neo as needed. Would not\n use amiodaron at this point given chronic lung disease with probable\n asbstosis and in addition liver cirrhocis. If cannot rate control,\n though, would bolus with amio for one day\n Pulmonary: Cont ETT, Intubated . /ARDS type picture given\n bilat opacities and P/F ratio < 300. Will use low tidal volume\n ventilation. Will need adequate sedation for this. Also, chronic lung\n dz as demonstrated by CT yesterday.\n Gastrointestinal / Abdomen: Elevated LFTs (in 500s on ). h/o\n cirrhosis - liver panel sent. T bili elevated to 3.0, other LFTs\n trending down. Send Direct bili. Bowel regimen.\n Nutrition: ADAT\n Renal: Foley, monitor UOP, f/u lytes, and trend Cr (1.1). Received\n bicarb gtt and Mucomyst. Monitor creatinine. Check PM lytes.\n Hematology: Monitor Hct q6\n 35.1-32.2-31.9-28.3-28.9-27.7-25.7-24.1-23.1; tx 2u prbcs, 1 plt,\n 1uFFP, (INR 1.3) -> 24.3; Angio embolization. 2u prbcs -> 25.8; 2u\n prbcs -> 29.6 (). Elevated bili could be hematoma resolution, but\n given dropping , ask Heme for consult, sent smear, DIC labs\n this AM. Plt (peak 175) -86. Check PM CBC. Thrombocytopenia\n -- HIT negative. Could be baseline as patient has liver cirrhocis.\n Endocrine: RISS, adequate control, goal BS<150.\n Infectious Disease: f/u pan cx. No abx right now, will bronch.\n Lines / Tubes / Drains: R SC CVL (), PIV x2, Foley, a-line\n (), ETT\n Wounds:\n Imaging: CXR today\n Fluids: maintenance fluids\n Consults: Trauma surgery, Ortho, Ortho-spine, Heme\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Comments: ADAT\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 09:00 PM\n 20 Gauge - 09:00 PM\n Arterial Line - 10:59 AM\n Multi Lumen - 04:41 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker PO\n VAP bundle: HOB elevation, Mouth care, Daily wake up\n Comments:\n Communication: Comments: ICU consent obtained. Discussed in\n multidisciplinary rounds\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 min\n"},{"category":"Nursing","chartdate":"2175-01-24 00:00:00.000","description":"Nursing Progress Note","row_id":713301,"text":"s/p crush injury from tree while riding on tractor. At Hospital\n patient was hTN and had dropping HCT, tx to . Injuries include: T4\n vertebral body fracture, grade 2 Liver lac, multiple right side rib\n fracture, lung contusions, right ramous and bilateral pelvic \n fracture.\n No PMH\n NKDA\n Events:\n Abdominal and pelvic CTA\n Thoracic MRI\n Trauma, s/p\n Assessment:\n Alert and oriented times three, MAE with normal strength and has normal\n sensation throughout. Hemodynamics stable. Hct stable at 32. LS clear\n but diminished in right base, sa02 100% 70% face-tent, de-saturating to\n low 90\ns off O2, using IS well but has weak cough. Pain poorly\n controlled upon admission but doing better with PCA. Abdomen soft with\n normal BS, non tender.\n Action:\n Dilaudid PCA, abd/pelvic CTA and thoracic MR, Q 4 hr Hct checks, IS per\n orders.\n Response:\n Pain control improving and pt stating it is easier to breathe now.\n Plan:\n Continue Q 4 hct and coag checks, transfuse as needed, and maintain\n hemodynamic stability, awaiting MRI results for further POC re: spinal\n fractures. Continue to provide emotional support for patient and\n family.\n"},{"category":"Physician ","chartdate":"2175-01-24 00:00:00.000","description":"Intensivist Note","row_id":713303,"text":"TSICU\n HPI:\n 74 yo male s/p fall from tractor and crush injury from tree branch.\n +Loc. At OSH received 4 units prbcs, 1 unit FFP for INR 4. +HD stable\n here. INR checked and 1.5, 1 more unit FFP given.\n Injuries\n Mult rib fx: R anterolateral and post, L posterior\n T4 vert body inf corner fx\n Commin spinous process fx T2-8\n Nondisplaced left T10 transverse process\n Nondispaced L distal clavicle\n Nondisplaced L clavicle fx\n R medial lobe liver contusion with hematoma\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny\n focus of arterial bleeding/active extravasation, and larger area\n of venous bleeding\n Nondisplaced, comminuted L iliac bone fracture w/adjacent iliac muscle\n hematoma, Fracture extends into left SI joint.\n Minimally displaced fracture of the right iliac bone extending to right\n SI joint.\n Chief complaint:\n fall\n PMHx:\n None\n Current medications:\n 1. Calcium Gluconate 2. Dextrose 50% 3. Docusate Sodium (Liquid) 4.\n Famotidine 5. Glucagon 6. HYDROmorphone (Dilaudid) 7. Insulin 8.\n Magnesium Sulfate 9. Pneumococcal Vac Polyvalent 10. Potassium Chloride\n 11. Sodium Chloride 0.9% Flush 12. Sodium Phosphate\n 24 Hour Events:\n MULTI LUMEN - START 09:00 PM\n NASAL SWAB - At 12:00 AM\n C-SPINE CLEARANCE - At 12:00 AM\n MAGNETIC RESONANCE IMAGING - At 02:17 AM Thoracic spine\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 10:00 PM\n Fentanyl - 12:00 AM\n Other medications:\n Flowsheet Data as of 06:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.7\nC (98\n T current: 35.7\nC (96.2\n HR: 88 (88 - 99) bpm\n BP: 91/65(71) {91/52(66) - 135/72(89)} mmHg\n RR: 25 (24 - 35) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 90 kg (admission): 90 kg\n Total In:\n 6,105 mL\n 593 mL\n PO:\n Tube feeding:\n IV Fluid:\n 305 mL\n 593 mL\n Blood products:\n Total out:\n 595 mL\n 300 mL\n Urine:\n 395 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,510 mL\n 293 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SPO2: 100%\n ABG: 7.35/41/112/23/-2\n PaO2 / FiO2: 160\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: shallow respirations)\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: No(t) Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 127 K/uL\n 10.5 g/dL\n 181 mg/dL\n 1.2 mg/dL\n 23 mEq/L\n 5.2 mEq/L\n 21 mg/dL\n 110 mEq/L\n 140 mEq/L\n 31.9 %\n 13.7 K/uL\n [image002.jpg]\n 09:00 PM\n 11:04 PM\n 11:22 PM\n 04:29 AM\n WBC\n 13.7\n Hct\n 32.2\n 31.9\n Plt\n 127\n Creatinine\n 1.2\n TCO2\n 23\n 24\n Glucose\n 181\n Other labs: PT / PTT / INR:15.0/26.4/1.3, Lactic Acid:2.8 mmol/L,\n LDH:616 IU/L, Ca:8.1 mg/dL, Mg:1.8 mg/dL, PO4:4.9 mg/dL\n Assessment and Plan\n TRAUMA, S/P\n Assessment and Plan: 74 yo M s/p fall with multiple rib fractures,\n pelvis fractures, clavicle fx, and thoracic fractures.\n Neurologic: C-spine cleared. Thoracic MRI done per ortho spine, logroll\n precautions.\n Neuro checks Q: shift\n Pain: Dilaudid PCA 0.25/2. require epidural vs paravertebral catheter.\n Cardiovascular: Stable\n Pulmonary: On face tent 70% O2, monitor, may require intubation.\n Gastrointestinal / Abdomen: NPO x meds\n Nutrition: NPO\n Renal: Foley, Adequate UO\n Hematology: Monitor Hct q6 35.1-32.2-31.9, Monitor coags INR 1.3. If\n actively bleeding may need Angio.\n Endocrine: RISS\n Infectious Disease:\n Lines / Tubes / Drains: RIJ CVL, PIV, Foley\n Wounds:\n Imaging:\n Fluids: LR @ 100.\n Consults: Trauma, Ortho Spine, Ortho trauma\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 09:00 PM\n 18 Gauge - 09:00 PM\n 20 Gauge - 09:00 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n"},{"category":"Physician ","chartdate":"2175-01-26 00:00:00.000","description":"Intensivist Note","row_id":713612,"text":"TSICU\n HPI:\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\n checked and 1.5, 1 more unit FFP given.\n Chief complaint:\n Mult rib fx: R anterolateral and post, L posterior\n T4 vert body inf corner fx\n Commin spinous process fx T2-8\n Nondisplaced left T10 transverse process\n Nondispaced L distal clavicle\n Nondisplaced L clavicle fx\n R medial lobe liver contusion with hematoma\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny\n focus of arterial bleeding/active extravasation, and larger area\n of venous bleeding\n Nondisplaced, comminuted L iliac bone fracture w/adjacent iliac muscle\n hematoma, Fracture extends into left SI joint.\n Minimally displaced fracture of the right iliac bone extending to right\n SI joint.\n PMHx:\n Cirrhosis\n Current medications:\n Acetylcysteine 20%\n Chlorhexidine Gluconate 0.12% Oral Rinse\n Docusate Sodium (Liquid)\n Famotidine\n Fentanyl Citrate\n Gabapentin\n 24 Hour Events:\n CR increased to 1.6, LFTs elevated in 500s. Bolused 500c x2 for low\n urine output, which improved up to 100cc/h. @6am, hr incr acutely to\n 140s, ST on ECG. Progressive acidosis. No resp decompensation\n w/continued good tidal volumes w/effort but hypoventilated. CXR\n w/pleural effusion, vasc congestion. Hct gradually decreasing to 23\n @6am. 2u prbcs tx -> 24.3, 20 IV lasix. IR embolization x2 and gelfoam\n x2. CTA neg for large PE. Received another 2u prbcs -> 25.8. 2u\n prbcs -> 29.2. Intermittently on Neo.\n CMV 50/15/550/14.\n Weaning prop & Neo. Had bigeminy overnight. This AM went into AF with\n RVR. Transitioning to PS trial. Transfused unit 50\n 86. No\n hematoma at femoral site. Febrile to 101.3 this AM.\n Post operative day:\n POD1 s/p angio embolization\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Fentanyl (Concentrate) - 75 mcg/hour\n Phenylephrine - 0.5 mcg/Kg/min\n Propofol - 20 mcg/Kg/min\n Other ICU medications:\n Furosemide (Lasix) - 06:00 AM\n Fentanyl - 07:00 PM\n Famotidine (Pepcid) - 08:29 PM\n Other medications:\n Flowsheet Data as of 06:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.3\nC (100.9\n T current: 37.9\nC (100.2\n HR: 82 (63 - 146) bpm\n BP: 99/53(67) {86/49(61) - 133/69(90)} mmHg\n RR: 18 (15 - 23) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 100.9 kg (admission): 90 kg\n CVP: 12 (12 - 30) mmHg\n Total In:\n 9,459 mL\n 1,174 mL\n PO:\n Tube feeding:\n IV Fluid:\n 6,222 mL\n 1,174 mL\n Blood products:\n 2,877 mL\n Total out:\n 2,325 mL\n 285 mL\n Urine:\n 2,325 mL\n 285 mL\n NG:\n Stool:\n Drains:\n Balance:\n 7,134 mL\n 889 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (500 - 550) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 14 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 32 cmH2O\n Plateau: 27 cmH2O\n Compliance: 42.3 cmH2O/mL\n SPO2: 100%\n ABG: 7.50/42/204/30/8\n Ve: 9.4 L/min\n PaO2 / FiO2: 408\n Physical Examination\n General Appearance: No acute distress, intubated\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), Regular Irregular\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: Follows simple commands, Moves all extremities, Sedated\n Labs / Radiology\n 86 K/uL\n 10.6 g/dL\n 116 mg/dL\n 1.1 mg/dL\n 30 mEq/L\n 3.7 mEq/L\n 23 mg/dL\n 105 mEq/L\n 141 mEq/L\n 29.6 %\n 9.5 K/uL\n [image002.jpg]\n 10:40 AM\n 02:00 PM\n 03:41 PM\n 04:11 PM\n 07:14 PM\n 09:29 PM\n 09:59 PM\n 11:10 PM\n 01:19 AM\n 01:38 AM\n WBC\n 9.2\n 6.8\n 9.5\n Hct\n 25.8\n 29.2\n 29.6\n Plt\n 79\n 52\n 86\n Creatinine\n 1.2\n 1.1\n TCO2\n 31\n 32\n 30\n 32\n 30\n 34\n Glucose\n 104\n 99\n 116\n Other labs: PT / PTT / INR:14.1/29.7/1.2, CK / CK-MB / Troponin\n T:1334/13/<0.01, ALT / AST:345/278, Alk-Phos / T bili:49/3.0, Amylase /\n Lipase:44/, Lactic Acid:1.6 mmol/L, LDH:616 IU/L, Ca:8.2 mg/dL, Mg:2.1\n mg/dL, PO4:1.9 mg/dL\n Imaging: CXR Pend\n Pelvis Pend\n CT head OSH: Prelim No ICH or fracture.\n CT chest OSH: Mult rib fx: R anterolateral and posterior, L\n posterior; Dependent consolidation, possible aspiration; T4 vertebral\n body inf corner fx, no retropulsion; Comminuted spinous process fx\n T2-8; Nondisplaced L T10 transverse process; Nondisplaced L clavicle\n distal fx; Nondisplaced L scapula fx;\n CT c spine OSH: Prelim No fx or malalignment. Multilevel\n degenerative changes w/large post disk bulge at C4-5, narrowing the\n spinal canal and deforming the thecal sac, acuity unknown. Marked\n neuroforamenal narrowing @multiple levels.\n CTA abd/pel Prelim: Medial R liver lobe contusion w/adj\n hematoma, w/o evidence of active bleeding; Comminuted L pubic ramus\n fracture w/assoc hematoma, with tiny focus of arterial bleeding/active\n extravasation, and larger area of venous bleeding. Hematoma somewhat\n larger than on OSH study. Nondisplaced, comminuted L iliac bone fx\n w/adj iliac muscle hematoma, larger than on prior study, w/o active\n extrav. Fx extends into L SI joint. Post R hepatic laceration/contusion\n adjacent to calcified granuloma, w/small hematoma, without active\n bleeding. Min displaced fx of R iliac bone extending to R SI joint.\n Cirrhotic liver. Inc B pleural effusions (small), w/inc atelectasis.\n MRI: Mild compression deformity of L1 with additional levels of\n potential trabecular contusion @T10-11 also inf @T4 w/o retropulsion.\n Multilevel degenerative changes with moderate canal narrowing at T10-11\n w/cord deformity and no abnormal cord signal. Extensive edema\n throughout the paraspinal soft tissues, predominantly\n post w/in interspinous ligaments. Incompletely evaluated c-spine w/\n severe canal narrowing @C4-5 w/cord deformity and no abnormal cord\n signal.\n CTA: no PE.\n Microbiology: Ucx P\n Sputum P\n Bcx P\n Bcx P\n Assessment and Plan\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx.\n Neurologic: C-spine cleared. Per ortho spine, no surgical intervention;\n HOB<30, TLSO when OOB. Awake off sedation, follows commands. Midaz prn\n sedation needs while intubated. Pain: on fentanyl. Will plan to\n transition to Oxycodone. Will discuss with APS again today.\n Cardiovascular: Bedside ECHO shows TR and elevated PA pressures but\n adequate contractility. CVP 20s. Wean Neo gtt. AF with RVR this AM.\n Maintaining BP. Start Dilt gtt, use Neo as needed.\n Pulmonary: Cont ETT, Intubated . Wean as tolerated (improve pain\n control). 50%, checking ABG. Thick secretions, now febrile.\n Bronch today, send BAL.\n Gastrointestinal / Abdomen: Elevated LFTs (in 500s on ). h/o\n cirrhosis - liver panel sent. T bili elevated to 3.0, other LFTs\n trending down. Send Direct bili. Bowel regimen.\n Nutrition: ADAT\n Renal: Foley, monitor UOP, f/u lytes, and trend Cr (1.1). Received\n bicarb gtt and Mucomyst. Monitor creatinine. Check PM lytes.\n Hematology: Monitor Hct q6\n 35.1-32.2-31.9-28.3-28.9-27.7-25.7-24.1-23.1; tx 2u prbcs, 1 plt,\n 1uFFP, (INR 1.3) -> 24.3; Angio embolization. 2u prbcs -> 25.8; 2u\n prbcs -> 29.6 (). Elevated bili could be hematoma resolution, but\n given dropping , ask Heme for consult, sent smear, DIC labs\n this AM. Plt (peak 175) -86. Check PM CBC.\n Endocrine: RISS, adequate control, goal BS<150.\n Infectious Disease: f/u pan cx. No abx right now, will bronch.\n Lines / Tubes / Drains: R SC CVL (), PIV x2, Foley, a-line\n (), ETT\n Wounds:\n Imaging: CXR today\n Fluids: maintenance fluids\n Consults: Trauma surgery, Ortho, Ortho-spine, Heme\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Comments: ADAT\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 09:00 PM\n 20 Gauge - 09:00 PM\n Arterial Line - 10:59 AM\n Multi Lumen - 04:41 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker PO\n VAP bundle: HOB elevation, Mouth care, Daily wake up\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 33 min\n"},{"category":"Nutrition","chartdate":"2175-01-26 00:00:00.000","description":"Clinical Nutrition Note","row_id":713631,"text":"Subjective\n Intubated, no family present\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 175 cm\n 90 kg\n 100.9 kg ( 12:00 AM)\n +10.9 kg due to fluid\n 29.2\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 72.6 kg\n 124%\n 77 kg\n Diagnosis: polytrauma\n PMHx: cirrhosis\n Food allergies and intolerances: none noted\n Pertinent medications: RISS, phenylephrine, propofol, fentanyl,\n famotidine, Ca gluconate (2 g repletion), KPhos (15 mmol repletion),\n diltiazem, others noted\n Labs:\n Value\n Date\n Glucose\n 84\n 08:00 AM\n Glucose Finger Stick\n 137\n 08:00 PM\n BUN\n 23 mg/dL\n 01:19 AM\n Creatinine\n 1.1 mg/dL\n 01:19 AM\n Sodium\n 141 mEq/L\n 01:19 AM\n Potassium\n 3.7 mEq/L\n 01:19 AM\n Chloride\n 105 mEq/L\n 01:19 AM\n TCO2\n 30 mEq/L\n 01:19 AM\n PO2 (arterial)\n 138 mm Hg\n 10:22 AM\n PCO2 (arterial)\n 47 mm Hg\n 10:22 AM\n pH (arterial)\n 7.44 units\n 10:22 AM\n pH (urine)\n 6.5 units\n 07:00 PM\n CO2 (Calc) arterial\n 33 mEq/L\n 10:22 AM\n Calcium non-ionized\n 8.2 mg/dL\n 01:19 AM\n Phosphorus\n 1.9 mg/dL\n 01:19 AM\n Ionized Calcium\n 1.15 mmol/L\n 01:38 AM\n Magnesium\n 2.1 mg/dL\n 01:19 AM\n ALT\n 345 IU/L\n 01:19 AM\n Alkaline Phosphate\n 49 IU/L\n 01:19 AM\n AST\n 278 IU/L\n 01:19 AM\n Amylase\n 44 IU/L\n 06:01 AM\n Total Bilirubin\n 3.0 mg/dL\n 01:19 AM\n WBC\n 9.5 K/uL\n 01:19 AM\n Hgb\n 10.6 g/dL\n 01:19 AM\n Hematocrit\n 29.1 %\n 07:26 AM\n Current diet order / nutrition support: Replete with fiber Full\n strength;\n Starting rate: 10 ml/hr; Advance rate by 10 ml q4h Goal rate: 50 ml/hr\n = 1200 kcals/ 74 g protein\n Residual Check: q4h Hold feeding for residual >= : 200 ml\n Flush w/ 50 ml water q8h\n GI: soft, distended, +bowel sounds\n Assessment of Nutritional Status\n At risk for malnutrition\n Patient at risk due to: NPO / hypocaloric diet, trauma\n Estimated Nutritional Needs\n Calories: -2156 (BEE x or / 25-28 cal/kg)\n Protein: 92-116 (1.2-1.5 g/kg)\n Fluid: per team\n Calculations based on: Adjusted weight\n Estimation of previous intake: likely adequate\n Estimation of current intake: Inadequate\n Specifics: 74 year old male s/p fall from tractor and crush injury from\n tree branch. +Loc. Transferred from outside hospital, patient with\n multiple injuries :Mult rib fx: R anterolateral and post, L\n posterior,T4 vert body inf corner fx, Commin spinous process fx T2-8,\n Nondisplaced left T10 transverse process, Nondispaced L distal \n clavicle, Nondisplaced L clavicle fx, R medial lobe liver contusion\n with hematoma, Comminuted L pubic ramus fx w/assoc hematoma, w/tiny\n focus of arterial bleeding/active extravasation, and larger area of\n venous bleeding, Nondisplaced, comminuted L iliac bone fracture\n w/adjacent iliac muscle hematoma, Fracture extends into left SI joint.\n Tube feeding ordered, not yet started. At goal tube feeding underfeeds\n patient. Agree with plan for nutrition support. Propofol is running at\n 13.5 ml/hr which provides 356 kcals/day. Will need to adjust tube\n feeding. Noted repletions.\n Medical Nutrition Therapy Plan - Recommend the Following\n Tube feeding / TPN recommendations: while on current rate of\n propofol recommend Replete with Fiber @ 55 ml/hr = 1320 kcals/ 82 g\n protein\n While off propofol recommend Replete with Fiber @ 80 ml/hr =\n kcals/ 119 g protein\n Multivitamin / Mineral supplement: via tube feeding\n Check chemistry 10 panel daily and replete prn\n Will follow page with questions\n"},{"category":"Nursing","chartdate":"2175-01-24 00:00:00.000","description":"Nursing Progress Note","row_id":713404,"text":"Trauma, s/p\n Assessment:\n Patient alert, oriented x3. Pupils 3mm, equal, reactive.\n Moves upper extremities w/ normal strength. Lower extremities move on\n bed, splinted by pain.\n Complaining of pain to R side, constant w/ and w/o\n movement. At worst, . Patient on Dilaudid PCA 02.5mg/dose.\n LS diminished on R side. Clear to diminished on L side.\n Sats WNL on 12L 70% fact tent and 3L NC.\n Hypotensive at beginning of shift, SBP in 70\ns. HR 90\n +PP.\n Denies abdominal pain. Abdomen soft, BS present.\n UOP marginal.\n Action:\n Q4h neuro exams. Encouraged use of PCA prior to activity.\n Tylenol and gabapentin administered.\n Logroll precautions cleared. TLSO brace ordered. NEOPS\n came by to measure for brace this afternoon.\n Encouraged CDB and IS. Oxygen weaned to 12L 50% face tent,\n 2L NC.\n 1L LR fluid bolus administered for hypotension\n Patient ordered for clear diet\n Response:\n Pain decreased to with use of PCA and oral pain\n medications.\n Reaches up to 1000ml with IS. Patient has weak cough,\n splinted by pain.\n Patient may sit up to 30 degrees but will need brace when\n OOB.\n VSS. Hct remains stable. Lactate trending down.\n Plan:\n Continue to assess for pain, medicate as needed. Wean oxygen as\n tolerated. Pulmonary toileting. CXR tomorrow a.m. Patient to be NPO\n after midnight for ? OR tomorrow for pelvis (awaiting final word from\n ortho).\n"},{"category":"Nursing","chartdate":"2175-01-24 00:00:00.000","description":"Nursing Progress Note","row_id":713406,"text":"Trauma, s/p\n Assessment:\n Patient alert, oriented x3. Pupils 3mm, equal, reactive.\n Moves upper extremities w/ normal strength. Lower extremities move on\n bed, splinted by pain.\n Complaining of pain to R side, constant w/ and w/o\n movement. At worst, . Patient on Dilaudid PCA 02.5mg/dose.\n LS diminished on R side. Clear to diminished on L side.\n Sats WNL on 12L 70% fact tent and 3L NC.\n Hypotensive at beginning of shift, SBP in 70\ns. HR 90\n +PP.\n Denies abdominal pain. Abdomen soft, BS present.\n UOP marginal.\n Action:\n Q4h neuro exams. Encouraged use of PCA prior to activity.\n Tylenol and gabapentin administered.\n Logroll precautions cleared. TLSO brace ordered. NEOPS\n came by to measure for brace this afternoon.\n Encouraged CDB and IS. Oxygen weaned to 12L 50% face tent,\n 2L NC.\n 1L LR fluid bolus administered for hypotension\n Patient ordered for clear diet\n Response:\n Pain decreased to with use of PCA and oral pain\n medications.\n Reaches up to 1000ml with IS. Patient has weak cough,\n splinted by pain.\n Patient may sit up to 30 degrees but will need brace when\n OOB.\n VSS. Hct remains stable. Lactate trending down.\n Plan:\n Continue to assess for pain, medicate as needed. Wean oxygen as\n tolerated. Pulmonary toileting. CXR tomorrow a.m. Patient to be NPO\n after midnight for ? OR tomorrow for pelvis (awaiting final word from\n ortho).\n ------ Protected Section ------\n IV: Patient has OSH central line and PIV x2. Attempt to place PIV,\n unsuccessful. IV team aware, will come place two new PIV. Per policy,\n OSH central line to be pulled within 24 hour. ICU team aware.\n ------ Protected Section Addendum Entered By: , RN\n on: 18:13 ------\n"},{"category":"Nursing","chartdate":"2175-01-26 00:00:00.000","description":"Nursing Progress Note","row_id":713588,"text":"Trauma, s/p\n Assessment:\n Patient sedated on propofol and Fentanyl gtt for pain, able to wake and\n follows commands. MAE. Peripheral pulses present. Right groin site\n soft, no hematoma, dsg CDI. Sinus arrhythmia, BP supported overnight\n with Neo gtt. LS diminished at bases with moderate amounts of thick\n white secretions. Vent support increased per metavision for decreased\n PaO2. Hct stable times 2.\n Action:\n Pulmonary toileting, plt tx, pain control, maintained hemodynamic\n stability.\n Response:\n Remains stable, physical exam unchanged. ABG improved.\n Plan:\n Monitor hct and ABGs. Continue pain control and pulmonary toileting.\n Titrate vasopressor to maintain BP. Wean sedation and vent settings\n towards extubation.\n"},{"category":"Nursing","chartdate":"2175-01-26 00:00:00.000","description":"Nursing Progress Note","row_id":713566,"text":"Trauma, s/p\n Assessment:\n Patient sedated on propofol and Fentanyl gtt for pain, able to wake and\n follows commands. MAE. Peripheral pulses present. Right groin site\n soft, no hematoma, dsg CDI. Sinus arrhythmia, BP supported overnight\n with Neo gtt. LS diminished at bases with moderate amounts of thick\n white secretions. Vent support increased per metavision for decreased\n PaO2. Hct stable times 2.\n Action:\n Pulmonary toileting, plt tx, pain control, maintained hemodynamic\n stability.\n Response:\n Remains stable, physical exam unchanged. ABG improved.\n Plan:\n Monitor hct and ABGs. Continue pain control and pulmonary toileting.\n Titrate vasopressor to maintain BP. Wean sedation and vent settings\n towards extubation.\n"},{"category":"Physician ","chartdate":"2175-01-26 00:00:00.000","description":"Intensivist Note","row_id":713582,"text":"TSICU\n HPI:\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\n checked and 1.5, 1 more unit FFP given.\n Chief complaint:\n Mult rib fx: R anterolateral and post, L posterior\n T4 vert body inf corner fx\n Commin spinous process fx T2-8\n Nondisplaced left T10 transverse process\n Nondispaced L distal clavicle\n Nondisplaced L clavicle fx\n R medial lobe liver contusion with hematoma\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny\n focus of arterial bleeding/active extravasation, and larger area\n of venous bleeding\n Nondisplaced, comminuted L iliac bone fracture w/adjacent iliac muscle\n hematoma, Fracture extends into left SI joint.\n Minimally displaced fracture of the right iliac bone extending to right\n SI joint.\n PMHx:\n Cirrhosis\n Current medications:\n Acetylcysteine 20%\n Chlorhexidine Gluconate 0.12% Oral Rinse\n Docusate Sodium (Liquid)\n Famotidine\n Fentanyl Citrate\n Gabapentin\n 24 Hour Events:\n CR increased to 1.6, LFTs elevated in 500s. Bolused 500c x2 for low\n urine output, which improved up to 100cc/h. @6am, hr incr acutely to\n 140s, ST on ECG. Progressive acidosis. No resp decompensation\n w/continued good tidal volumes w/effort but hypoventilated. CXR\n w/pleural effusion, vasc congestion. Hct gradually decreasing to 23\n @6am. 2u prbcs tx -> 24.3, 20 IV lasix. IR embolization x2 and gelfoam\n x2. CTA neg for large PE. Received another 2u prbcs -> 25.8. 2u\n prbcs -> 29.2. Intermittently on Neo.\n CMV 50/15/550/14\n Post operative day:\n POD1 s/p angio embolization\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Fentanyl (Concentrate) - 75 mcg/hour\n Phenylephrine - 0.5 mcg/Kg/min\n Propofol - 20 mcg/Kg/min\n Other ICU medications:\n Furosemide (Lasix) - 06:00 AM\n Fentanyl - 07:00 PM\n Famotidine (Pepcid) - 08:29 PM\n Other medications:\n Flowsheet Data as of 06:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.3\nC (100.9\n T current: 37.9\nC (100.2\n HR: 82 (63 - 146) bpm\n BP: 99/53(67) {86/49(61) - 133/69(90)} mmHg\n RR: 18 (15 - 23) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 100.9 kg (admission): 90 kg\n CVP: 12 (12 - 30) mmHg\n Total In:\n 9,459 mL\n 1,174 mL\n PO:\n Tube feeding:\n IV Fluid:\n 6,222 mL\n 1,174 mL\n Blood products:\n 2,877 mL\n Total out:\n 2,325 mL\n 285 mL\n Urine:\n 2,325 mL\n 285 mL\n NG:\n Stool:\n Drains:\n Balance:\n 7,134 mL\n 889 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (500 - 550) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 14 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 32 cmH2O\n Plateau: 27 cmH2O\n Compliance: 42.3 cmH2O/mL\n SPO2: 100%\n ABG: 7.50/42/204/30/8\n Ve: 9.4 L/min\n PaO2 / FiO2: 408\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), Regular Irregular\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: Follows simple commands, Moves all extremities, Sedated\n Labs / Radiology\n 86 K/uL\n 10.6 g/dL\n 116 mg/dL\n 1.1 mg/dL\n 30 mEq/L\n 3.7 mEq/L\n 23 mg/dL\n 105 mEq/L\n 141 mEq/L\n 29.6 %\n 9.5 K/uL\n [image002.jpg]\n 10:40 AM\n 02:00 PM\n 03:41 PM\n 04:11 PM\n 07:14 PM\n 09:29 PM\n 09:59 PM\n 11:10 PM\n 01:19 AM\n 01:38 AM\n WBC\n 9.2\n 6.8\n 9.5\n Hct\n 25.8\n 29.2\n 29.6\n Plt\n 79\n 52\n 86\n Creatinine\n 1.2\n 1.1\n TCO2\n 31\n 32\n 30\n 32\n 30\n 34\n Glucose\n 104\n 99\n 116\n Other labs: PT / PTT / INR:14.1/29.7/1.2, CK / CK-MB / Troponin\n T:1334/13/<0.01, ALT / AST:345/278, Alk-Phos / T bili:49/3.0, Amylase /\n Lipase:44/, Lactic Acid:1.6 mmol/L, LDH:616 IU/L, Ca:8.2 mg/dL, Mg:2.1\n mg/dL, PO4:1.9 mg/dL\n Imaging: CXR Pend\n Pelvis Pend\n CT head OSH: Prelim No ICH or fracture.\n CT chest OSH: Mult rib fx: R anterolateral and posterior, L\n posterior; Dependent consolidation, possible aspiration; T4 vertebral\n body inf corner fx, no retropulsion; Comminuted spinous process fx\n T2-8; Nondisplaced L T10 transverse process; Nondisplaced L clavicle\n distal fx; Nondisplaced L scapula fx;\n CT c spine OSH: Prelim No fx or malalignment. Multilevel\n degenerative changes w/large post disk bulge at C4-5, narrowing the\n spinal canal and deforming the thecal sac, acuity unknown. Marked\n neuroforamenal narrowing @multiple levels.\n CTA abd/pel Prelim: Medial R liver lobe contusion w/adj\n hematoma, w/o evidence of active bleeding; Comminuted L pubic ramus\n fracture w/assoc hematoma, with tiny focus of arterial bleeding/active\n extravasation, and larger area of venous bleeding. Hematoma somewhat\n larger than on OSH study. Nondisplaced, comminuted L iliac bone fx\n w/adj iliac muscle hematoma, larger than on prior study, w/o active\n extrav. Fx extends into L SI joint. Post R hepatic laceration/contusion\n adjacent to calcified granuloma, w/small hematoma, without active\n bleeding. Min displaced fx of R iliac bone extending to R SI joint.\n Cirrhotic liver. Inc B pleural effusions (small), w/inc atelectasis.\n MRI: Mild compression deformity of L1 with additional levels of\n potential trabecular contusion @T10-11 also inf @T4 w/o retropulsion.\n Multilevel degenerative changes with moderate canal narrowing at T10-11\n w/cord deformity and no abnormal cord signal. Extensive edema\n throughout the paraspinal soft tissues, predominantly\n post w/in interspinous ligaments. Incompletely evaluated c-spine w/\n severe canal narrowing @C4-5 w/cord deformity and no abnormal cord\n signal.\n CTA: no PE.\n Microbiology: Ucx P\n Sputum P\n Bcx P\n Bcx P\n Assessment and Plan\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx.\n Neurologic: C-spine cleared. Per ortho spine, no surgical intervention;\n HOB<30, TLSO when OOB.\n Cardiovascular: Bedside ECHO shows TR and elevated PA pressures but\n adequate contractility. CVP 20s. Wean phenylephrine gtt\n Pulmonary: Cont ETT, Intubated . Wean as tolerated (improve pain\n control)\n Gastrointestinal / Abdomen: Elevated LFTs (in 500s on ). h/o\n cirrhosis - liver panel sent. T bili elevated to 3.0, other LFTs\n trending down\n Nutrition: ADAT\n Renal: Foley, monitor UOP, f/u lytes, and trend Cr (1.1). Received\n bicarb gtt and Mucomyst\n Hematology: Monitor Hct q6\n 35.1-32.2-31.9-28.3-28.9-27.7-25.7-24.1-23.1; tx 2u prbcs, 1 plt,\n 1uFFP, (INR 1.3) -> 24.3; Angio embolization. 2u prbcs -> 25.8; 2u\n prbcs -> 29.6 ()\n Plt (peak 175) -86\n Endocrine: RISS\n Infectious Disease: f/u pan cx.\n Lines / Tubes / Drains: R SC CVL (), PIV x2, Foley, a-line\n (), ETT\n Wounds:\n Imaging: CXR today\n Fluids: LR, KVO when tolerating PO intake\n Consults: Trauma surgery, Ortho, Ortho-spine\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Comments: ADAT\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 09:00 PM\n 20 Gauge - 09:00 PM\n Arterial Line - 10:59 AM\n Multi Lumen - 04:41 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n"},{"category":"Nursing","chartdate":"2175-01-26 00:00:00.000","description":"Nursing Progress Note","row_id":713668,"text":"Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains vented throughout the day, AM CXR showed some lower lobe\n consolidation and fluid. ABGs were poor overnight-alkalotic. Pt\n received total of 6 units PRBCs, 2 units platelets, 1 unit FFP\n yesterday and is more fluid overloaded today, general edema, CVP 13-20,\n 10kg heavier this AM. Lung sounds clear in upper lobes, slightly\n diminished in bases. Pt has multiple rib fractures and is currently\n sedated on propofol/fentanyl and on bedrest <30 degrees until TLSO\n brace arrives. Pt febrile today-101.3. Suctioned for thick, yellow\n secretions frequently.\n Action:\n Bronchoscopy done this AM, BAL sent from right and left mainstems\n (sputum culture also pending from last evening). Sedation turned off\n this AM as tolerated then neo was turned off d/t BP WNL. Vent weaned\n to CPAP/PS and pt tolerated breathing well. Pt was wide awake and\n uncomfortable off sedation, requesting more pain medication as well as\n sedation. Fentanyl gtt increased to 100mcg/hr from 75mcg/hr. Pt was\n sedated more for the bronchoscopy and sedation left on after procedure\n per team d/t possible ARDS risk. Team wanted pt to be adequately\n sedated to allow vent to provide PEEP/volume with the intention of\n improving pt\ns ABGs. Fever reduced without intervention, team aware,\n cultures pending from . Vent changed back to CMV PEEP 14, 50%\n FiO2, RR 18, TV 440 based on weight/height for bronch and remainder of\n the shift. VAP care per protocol, repositioned frequently. Bilateral\n CPT performed. Tube feeds started but then stopped for IVC filter\n placement scheduled as add-on tonight.\n Response:\n Pt sedated but arouses to voice, neuro exam remains intact and\n unchanged as evidenced by when pt is awake. Neo required while pt is\n more sedated, titrating as needed, see metavision for details. Pt more\n comfortable with additional sedation and pain medication. Suctioned\n for thick, yellow secretions.\n Plan:\n Continue to monitor ABGs, follow up with cultures. Suction as needed.\n Monitor respiratory status closely, VAP care, daily CXRs. Provide IV\n fluid for when tube feeds off, monitor kidney and liver function.\n Restart tube feeds post-op. Continue to support pt and family.\n Atrial fibrillation (Afib)\n Assessment:\n Pt went into rapid afib this AM, HR seen as high as 149. Change in\n rhythm was abrupt, unknown cause but possibly d/t cardiac contusion?\n Action:\n EKG done immediately which showed afib. Monitor EKG showing atrial\n flutter for the rest of the day. TTEcho done this evening by team in\n room. Diltiazem bolus given per HO this am (20mg over 2min) before\n starting 5mg/hr gtt.\n Response:\n Pt\ns rate better controlled (70\ns), continues in atrial flutter. BP\n lower, neo gtt continues to be titrated as needed d/t dilt gtt and\n propofol gtt.\n Plan:\n IVC filter to be placed this evening in OR by Dr. as add-on\n case. Consider converting this pt to NSR with Amiodarone since it is\n new afib? Continue to support pt and family. Change dilt gtt to PO\n when able.\n"},{"category":"Respiratory ","chartdate":"2175-01-26 00:00:00.000","description":"Respiratory Care Shift Note","row_id":713662,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Maintain PEEP at current level and reduce FiO2 as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Intolerant of weaning attempts, Underlying illness not resolved\n Respiratory Care Shift Procedures\n Bedside Procedures:\n Bronchoscopy (1100)\n Comments: removed large amounts of thick yellow secretions.\n"},{"category":"Nursing","chartdate":"2175-01-24 00:00:00.000","description":"Nursing Progress Note","row_id":713280,"text":"s/p crush injury from tree while riding on tractor. At Hospital\n patient was hTN and had dropping HCT, tx to . Injuries include: T4\n vertebral body fracture, grade 2 Liver lac, multiple right side rib\n fracture, lung contusions, right ramous and bilateral pelvic \n fracture.\n No PMH\n NKDA\n Events:\n Abdominal and pelvic CTA\n Thoracic MRI\n Trauma, s/p\n Assessment:\n Alert and oriented times three, MAE with normal strength and has normal\n sensation throughout. Hemodynamics stable. Hct stable at 32. LS clear\n but diminished in right base, sa02 100% on NRB, de-saturating to low\n 90\ns off O2, using IS well but has very weak cough. Pain poorly\n controlled upon admission but doing better with PCA. Abdomen soft with\n normal BS, non tender.\n Action:\n Dilaudid PCA, abd/pelvic CTA and thoracic MR, Q 4 hr Hct checks, IS per\n orders.\n Response:\n Pain control improving and pt stating it is easier to breathe now.\n Plan:\n Continue Q 4 hct and coag checks, transfuse as needed, maintain\n hemodynamic stability, awaiting MRI results for further POC re: spinal\n fractures. Continue to provide emotional support for patient and\n family.\n"},{"category":"Nursing","chartdate":"2175-01-24 00:00:00.000","description":"Nursing Progress Note","row_id":713289,"text":"s/p crush injury from tree while riding on tractor. At Hospital\n patient was hTN and had dropping HCT, tx to . Injuries include: T4\n vertebral body fracture, grade 2 Liver lac, multiple right side rib\n fracture, lung contusions, right ramous and bilateral pelvic \n fracture.\n No PMH\n NKDA\n Events:\n Abdominal and pelvic CTA\n Thoracic MRI\n Trauma, s/p\n Assessment:\n Alert and oriented times three, MAE with normal strength and has normal\n sensation throughout. Hemodynamics stable. Hct stable at 32. LS clear\n but diminished in right base, sa02 100% 70% face-tent, de-saturating to\n low 90\ns off O2, using IS well but has weak cough. Pain poorly\n controlled upon admission but doing better with PCA. Abdomen soft with\n normal BS, non tender.\n Action:\n Dilaudid PCA, abd/pelvic CTA and thoracic MR, Q 4 hr Hct checks, IS per\n orders.\n Response:\n Pain control improving and pt stating it is easier to breathe now.\n Plan:\n Continue Q 4 hct and coag checks, transfuse as needed, and maintain\n hemodynamic stability, awaiting MRI results for further POC re: spinal\n fractures. Continue to provide emotional support for patient and\n family.\n"},{"category":"Nursing","chartdate":"2175-01-24 00:00:00.000","description":"Nursing Progress Note","row_id":713393,"text":"Trauma, s/p\n Assessment:\n Patient alert, oriented x3. Pupils 3mm, equal, reactive.\n Moves upper extremities w/ normal strength. Lower extremities move on\n bed, splinted by pain.\n Complaining of pain to R side, constant w/ and w/o\n movement. At worst, . Patient on Dilaudid PCA 02.5mg/dose.\n LS diminished on R side. Clear to diminished on L side.\n Sats WNL on 12L 70% fact tent and 3L NC.\n Hypotensive at beginning of shift, SBP in 70\ns. HR 90\n +PP.\n Denies abdominal pain. Abdomen soft, BS present.\n UOP marginal.\n Action:\n Q4h neuro exams. Encouraged use of PCA prior to activity.\n Tylenol and gabapentin administered.\n Logroll precautions cleared. TLSO brace ordered. NEOPS\n came by to measure for brace this afternoon.\n Encouraged CDB and IS. Oxygen weaned to 12L 50% face tent,\n 2L NC.\n 1L LR fluid bolus administered for hypotension\n Patient ordered for clear liquid diet\n Response:\n Pain decreased to with use of PCA and oral pain\n medications.\n Reaches up to 1000ml with IS. Patient has weak cough,\n splinted by pain.\n Patient may sit up to 30 degrees but will need brace when\n OOB.\n VSS\n Plan:\n Continue to assess for pain, medicate as needed. Wean oxygen as\n tolerated. Pulmonary toileting. CXR tomorrow a.m. Patient to be NPO\n after midnight for ? OR tomorrow for pelvis (awaiting final word from\n ortho).\n"},{"category":"ECG","chartdate":"2175-02-02 00:00:00.000","description":"Report","row_id":233689,"text":"Resting sinus tachycardia with frequent atrial premature beats. Prolonged\nP-R interval at about 230 milliseconds. Left atrial abnormality. Borderline\nlow limb lead voltage. Non-specific ST-T wave changes. Relatively early\nR wave progression, a non-diagnostic finding. Compared to the previous tracing\nof atrial flutter is no longer present.\n\n"},{"category":"ECG","chartdate":"2175-01-29 00:00:00.000","description":"Report","row_id":233690,"text":"Atrial flutter with predominant 3:1 A-V block, atrial rate approximately 260,\nventricular rate approximately 86. There is some variability in ventricular\nresponse suggesting dual level block. Probable inferior myocardial infarction\nof indeterminate age. Compared to the previous tracing of overall\nventricular rate has fallen from 114 to 86.\n\n"},{"category":"ECG","chartdate":"2175-01-26 00:00:00.000","description":"Report","row_id":233910,"text":"Atrial fibrillation, rate 114. Early transition. Leftward axis at\nminus 31 degrees. Compared to the previous tracing of no diagnostic\ninterval change.\n\n"},{"category":"ECG","chartdate":"2175-01-25 00:00:00.000","description":"Report","row_id":233911,"text":"Atrial flutter. Modest left axis deviation. Early precordial QRS transition.\nFindings are non-specific. No previous tracing available for comparison.\n\n"},{"category":"Radiology","chartdate":"2175-02-07 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1114102,"text":" 5:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?atelectasis, effusion, consolidation\n Admitting Diagnosis: POLYTAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with trach\n REASON FOR THIS EXAMINATION:\n ?atelectasis, effusion, consolidation\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Tracheostomy, to evaluate for effusions and consolidation.\n\n FINDINGS: In comparison with the study of , there is continued\n enlargement of the cardiac silhouette with pulmonary vascular congestion and\n bilateral pleural effusions. The possibility of supervening pneumonia still\n be considered.\n\n Tracheostomy tube remains in place.\n\n\n"},{"category":"Radiology","chartdate":"2175-01-25 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":1112506,"text":" 4:57 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: ?PTX, line placement\n Admitting Diagnosis: POLYTAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man s/p R subclavian placement\n REASON FOR THIS EXAMINATION:\n ?PTX, line placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Right subclavian line placement.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, a right subclavian vein\n catheter has been newly introduced. The tip of the line projects over the mid\n SVC. There is no evidence of complication, notably no pneumothorax. The\n other monitoring and support devices are in unchanged position. The extent of\n the pre-existing right-sided pleural effusion could have mildly decreased.\n\n\n"},{"category":"Radiology","chartdate":"2175-01-26 00:00:00.000","description":"VENOGRAPHY IVC S&I","row_id":1112703,"text":" 10:46 PM\n VENOGRAPHY IVC S&I; -52 REDUCED SERVICES Clip # \n Reason: IVC FILTER PLACEMENT AND VENOCAVAGRAM\n Admitting Diagnosis: POLYTAUMA\n ______________________________________________________________________________\n FINAL REPORT\n \"Please see CareWeb Notes for the complete operative report.\"\n\n"},{"category":"Radiology","chartdate":"2175-01-25 00:00:00.000","description":"CTA CHEST W&W/O C&RECONS, NON-CORONARY","row_id":1112483,"text":" 2:58 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: r/o PE\n Admitting Diagnosis: POLYTAUMA\n Contrast: VISAPAQUE Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with pelvic fractures and concern for PE\n REASON FOR THIS EXAMINATION:\n r/o PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SHfd WED 7:04 PM\n No evidence of central pulmonary embolism. The subsegmental arteries cannot\n be evaluated due to technique. No aortic dissection.\n\n Multiple bilateral rib fractures and T4 vertebral body fracture, grossly\n stable.\n\n Bilateral lower lobe pneumonia - atelectasis. Mildly increased small\n bilateral pleural effusions.\n\n Enlarged main pulmonary artery may represent underlying pulmonary\n hypertension.\n\n Liver contusion and laceration, grossly stable, incompletely evaluated.\n\n Probable cirrhosis and mild splenomegaly, stable. Bilateral pulmonary\n reticular opacities in the subpleural region with minimal fibrotic changes and\n honeycombing may be chronic in nature.\n\n Calcified pleural plaques compatible with prior asbestos exposure.\n\n Followup chest CT when acute symptoms resolve is recommended to evaluate the\n pulmonary parenchyma.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: 74-year-old man with pelvic fractures and concern for\n pulmonary embolism.\n\n COMPARISON: Chest radiograph from , CT abdomen and pelvis\n from , CT chest without contrast from .\n\n TECHNIQUE: Contiguous multidetector CT images of the chest before and after\n administration of IV contrast with coronal, sagittal and oblique reformats\n were submitted for interpretation.\n\n FINDINGS:\n\n NON-CONTRAST CHEST CT: There is no intramural hematoma. Atherosclerotic\n calcifications of the aorta and coronary arteries are mild-to-moderate. Heart\n is upper limits of normal in size. There is no pericardial effusion. An\n endotracheal tube with the tip above the carina and an NG tube with the tip\n (Over)\n\n 2:58 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: r/o PE\n Admitting Diagnosis: POLYTAUMA\n Contrast: VISAPAQUE Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n within the stomach are noted.\n\n POST-CONTRAST CHEST CT: Study is limited due to patient motion. There is no\n evidence of pulmonary embolism in the main, primary or secondary branches of\n the pulmonary arteries. The subsegmental branches are suboptimally evaluated.\n The main pulmonary artery is dilated, measuring up to 3.5 cm (3:24). Both\n right and left pulmonary arteries are also dilated, right more than left.\n There is no evidence of aortic dissection. Heart is borderline in size.\n There is no pericardial effusion. There is no pathologically enlarged\n mediastinal, hilar, or axial lymphadenopathy. Localized soft tissue\n attenuation area at the rigt aspect of the mediastinum is likely a hematoma\n adjacent to fractured T4 vertebral body.\n\n There has been interval increase in small bilateral pleural effusions with\n associated lower lobe collapse and probable underlying aspiration or\n contusion. Pleural thickening especially in the right hemithorax is likely\n related to adjacent rib fractures and pleural hemorrhage. Calcified pleural\n plaques are most compatible with asbestos exposure, grossly stable. Bilateral\n pulmonary reticular opacities in the subpleural region with minimal\n honeycombing is likely fibrotic.\n\n Suboptimally evaluated and partially imaged upper abdominal organs demonstrate\n an area of hypodensity in the medial aspect of the posterior right lobe\n adjacent to a large vertebral osteophyte compatible with contusion, slightly\n decreased in size, however, incompletely evaluated. Laceration-contusion\n along the posterolateral surface of the liver is partially imaged and grossly\n stable. 12-mm stable hyperdense, likely calcified structure in the posterior\n right lobe of the liver likely represents a calcified granuloma. Spleen is\n upper limit of normal in size. Previously seen nodular contour of the liver\n is not as conspicuous as prior study.\n\n Multiple bilateral rib fractures are again noted. There is also grossly\n stable anterior inferior fracture of one of T4 thoracic vertebral bodies.\n Degenerative changes of the vertebral body are severe. Previously seen\n non-displaced left T10 transverse is not as well seen on the current study,\n likely due to motion artifact.\n\n IMPRESSION:\n 1. No evidence of central pulmonary embolism. The subsegmental arteries\n cannot be evaluated due to motion arifact.\n\n 2. Multiple bilateral rib fractures and T4 vertebral body fracture with\n associated mediastinal hematoma, grossly stable.\n\n 3. Mildly increased small bilateral pleural effusions and adjacent bilateral\n (Over)\n\n 2:58 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: r/o PE\n Admitting Diagnosis: POLYTAUMA\n Contrast: VISAPAQUE Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n lower lobe atelectasis with likely underlying aspiration or contusion.\n\n 4. Enlarged main pulmonary artery may represent underlying pulmonary\n hypertension.\n\n 5. Liver contusion and laceration, grossly stable, incompletely evaluated.\n\n 6. Calcified pleural plaques compatible with prior asbestos exposure. Probable\n mild paranchymal subpleural fibrotic changes may represent asbestosis.\n Followup chest CT when acute symptoms resolve is recommended to evaluate the\n pulmonary parenchyma.\n\n"},{"category":"Radiology","chartdate":"2175-01-25 00:00:00.000","description":"CTA CHEST W&W/O C&RECONS, NON-CORONARY","row_id":1112484,"text":", R. TSICU 2:58 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: r/o PE\n Admitting Diagnosis: POLYTAUMA\n Contrast: VISAPAQUE Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with pelvic fractures and concern for PE\n REASON FOR THIS EXAMINATION:\n r/o PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n No evidence of central pulmonary embolism. The subsegmental arteries cannot\n be evaluated due to technique. No aortic dissection.\n\n Multiple bilateral rib fractures and T4 vertebral body fracture, grossly\n stable.\n\n Bilateral lower lobe pneumonia - atelectasis. Mildly increased small\n bilateral pleural effusions.\n\n Enlarged main pulmonary artery may represent underlying pulmonary\n hypertension.\n\n Liver contusion and laceration, grossly stable, incompletely evaluated.\n\n Probable cirrhosis and mild splenomegaly, stable. Bilateral pulmonary\n reticular opacities in the subpleural region with minimal fibrotic changes and\n honeycombing may be chronic in nature.\n\n Calcified pleural plaques compatible with prior asbestos exposure.\n\n Followup chest CT when acute symptoms resolve is recommended to evaluate the\n pulmonary parenchyma.\n\n"},{"category":"Radiology","chartdate":"2175-01-31 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1113231,"text":" 5:05 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for progression\n Admitting Diagnosis: POLYTAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with multiple rib fx and pulm contusions\n REASON FOR THIS EXAMINATION:\n eval for progression\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of the patient with multiple rib fractures\n and pulmonary contusions.\n\n Portable AP chest radiograph was compared to .\n\n The ET tube tip is 6.2 cm above the carina. The NG tube tip is in the\n proximal stomach. The right subclavian line tip is at the level of superior\n SVC. Cardiomediastinal silhouette is unchanged as well as there is no change\n in mild bilateral pulmonary edema and parenchymal opacities and there is no\n pleural effusion. There is no clear evidence of pneumothorax, although\n minimal amount cannot be excluded on the left. Multiple rib fractures are\n redemonstrated.\n\n\n"},{"category":"Radiology","chartdate":"2175-01-25 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1112413,"text":" 7:24 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: eval ETT placement\n Admitting Diagnosis: POLYTAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with recent intubation\n REASON FOR THIS EXAMINATION:\n eval ETT placement\n ______________________________________________________________________________\n WET READ: RSRc WED 9:02 AM\n ETT terminates 5.5 cm above carina otherwise similar to prior with atelectasis\n and likely small effusions at both bases. Superimposed\n aspiration/consolidation difficult to exclude. Multiple fractures better\n evaluated on previous CT. (called by Dr. - anesthesia resident\n 8:20 am ).\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of the patient after recent intubation.\n\n Portable AP chest radiograph was compared to prior study obtained the same day\n earlier at 06:13 a.m.\n\n The ET tube tip is 5.5 cm above the carina. The right internal jugular line\n tip is at the level of low SVC. There is interval improvement of pulmonary\n edema which is currently mild. Bilateral pleural effusions and bibasal\n atelectasis are unchanged in the short-term interval.\n\n\n"},{"category":"Radiology","chartdate":"2175-02-05 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":1113890,"text":" 5:36 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: 50cm DL L basilic PICC placed ? tip\n Admitting Diagnosis: POLYTAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with new PICC\n REASON FOR THIS EXAMINATION:\n 50cm DL L basilic PICC placed ? tip\n ______________________________________________________________________________\n WET READ: DLrc SUN 6:09 PM\n Left PICC at brachiocephalic junction. Recommend repositioning. Findings\n discussed with at 6:10PM. Otherwise unchanged appearance of the\n lungs.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST \n\n COMPARISON: Radiograph of earlier the same date.\n\n INDICATION: PICC placement.\n\n FINDINGS: Left PICC is visualized to the level of the junction of the left\n brachiocephalic vein and superior vena cava. An opaque external monitoring\n lead overlies this region, and it is difficult to determine whether the\n catheter extends slightly below this level into the proximal SVC. With the\n exception of PICC placement, there has not been a substantial change in the\n appearance of the chest since the recent radiograph of earlier the same date.\n\n\n"},{"category":"Radiology","chartdate":"2175-02-06 00:00:00.000","description":"LP UNILAT UP EXT VEINS US LEFT PORT","row_id":1113934,"text":" 8:39 AM\n UNILAT UP EXT VEINS US LEFT PORT Clip # \n Reason: Eval for DVT\n Admitting Diagnosis: POLYTAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with new PICC, and LUE swelling\n REASON FOR THIS EXAMINATION:\n Eval for DVT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 74-year-old man with left upper extremity swelling and new PICC\n line.\n\n COMPARISON: No previous exam for comparison.\n\n FINDINGS: Grayscale, color and Doppler son of the left IJ, subclavian,\n axillary, brachial, and basilic veins were performed. Note is made that the\n left cephalic vein could not be identified. There is normal flow, compression\n and augmentation seen in all of the vessels.\n\n IMPRESSION: No evidence of deep vein thrombosis in the left arm.\n\n\n"},{"category":"Radiology","chartdate":"2175-02-04 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1113735,"text":" 5:17 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for PNA\n Admitting Diagnosis: POLYTAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with VAP, recent trach, s/p crush injury w/mult rib fx\n REASON FOR THIS EXAMINATION:\n eval for PNA\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Ventilatory associated pneumonia, recent tracheostomy,\n evaluation.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the patient has changed in\n body position. Overall, there is little change. The tracheostomy tube and\n the right-sided central venous access line are in unchanged position. Also\n unchanged are the bilateral pleural effusions as well as the bilateral patchy\n areas of opacity. The size of the cardiac silhouette and the extent of the\n retrocardiac atelectasis are also constant. In the well-ventilated portions\n of the lung parenchyma, there is no evidence of newly appeared focal\n parenchymal opacity suggesting pneumonia.\n\n\n"},{"category":"Radiology","chartdate":"2175-01-25 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1112403,"text":" 5:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for progression\n Admitting Diagnosis: POLYTAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with multiple broken ribs and pulmonary contusion\n REASON FOR THIS EXAMINATION:\n eval for progression\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of the patient after trauma.\n\n COMPARISON: Chest CT from .\n\n Multiple rib fractures involving the right hemithorax are seen although better\n evaluated by the recent CT of the chest. There is interval development of a\n pulmonary edema that was not seen on the prior studies accompanied by\n bilateral increase of pleural effusions. The cardiomediastinal silhouette is\n grossly unchanged although the comparison is difficult between the chest\n radiograph and the chest CT. The small amount of pneumothorax on the right is\n difficult to appreciate on the chest radiograph.\n\n Overall the significant change is interval development of moderate to severe\n pulmonary edema and increase in bilateral pleural effusions.\n\n\n"},{"category":"Radiology","chartdate":"2175-02-01 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1113401,"text":" 5:37 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for PNA, edema, interval change\n Admitting Diagnosis: POLYTAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with PNA\n REASON FOR THIS EXAMINATION:\n Evaluate for PNA, edema, interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 74-year-old male with pneumonia, followup chest x-ray for\n interval change.\n\n COMPARISON: Chest radiographs available from through .\n\n SEMI-UPRIGHT AP VIEW OF THE CHEST: A right-sided central venous catheter,\n endotracheal tube, and gastric tube are unchanged in position since , . Cardiomediastinal silhouette is unchanged. There is no change of\n mild bilateral pulmonary edema and parenchymal opacities. There are no new\n focal opacities. There is no pneumothorax.\n\n IMPRESSION: No significant radiographic change since .\n\n"},{"category":"Radiology","chartdate":"2175-01-24 00:00:00.000","description":"MR THORACIC SPINE W/O CONTRAST","row_id":1112259,"text":" 1:59 AM\n MR THORACIC SPINE W/O CONTRAST Clip # \n Reason: please do MRI T-spine to further characterize fractures\n Admitting Diagnosis: POLYTAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with fall with thoracic spine fractures\n REASON FOR THIS EXAMINATION:\n please do MRI T-spine to further characterize fractures\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): BLjb TUE 11:55 AM\n 1. Mild compression deformity of L1 with additional levels of potential\n trabecular contusion at T10-11 also inferiorly at T4 with no retropulsion.\n\n 2. Multilevel degenerative changes with moderate canal narrowing at T10-11\n with cord deformity and no abnormal cord signal.\n\n 3. Extensive edema throughout the paraspinal soft tissues, predominantly\n posteriorly within the interspinous ligaments.\n\n 4. Incompletely evaluated cervical spine demonstrates severe canal narrowing\n at C4-5 with cord deformity and no abnormal cord signal.\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: Thoracic spine MRI.\n\n HISTORY: 74-year-old male presents with fall and thoracic spine fractures.\n\n COMPARISON: Abdominal CT scan one day prior.\n\n TECHNIQUE: Sagittal T1, T2 FSE, STIR, axial T2-weighted sequences through the\n thoracic spine were obtained.\n\n FINDINGS: Sagittal alignment is satisfactory. There is a mild compression\n deformity of L1 with minimal loss of vertebral body height. Bone marrow edema\n extends horizontally into the posterior elements. There is mild bone marrow\n edema surrounding the T10-11 disc space and to a lesser extent involving the\n inferior right posterolateral corner of the T4 vertebral body. There is\n extensive edema throughout the paraspinal soft tissues, predominantly within\n the interspinous ligaments within the mid-to-lower thoracic spine.\n\n Multilevel degenerative changes are present, including multilevel Schmorl's\n nodes and central disc herniations. The largest disc herniation is present at\n T10-11 where there is additional facet arthropathy and ligamentum flavum\n mineralization resulting in moderate canal narrowing with slight cord\n deformity, though no abnormal cord signal. The conus terminates at T12.\n\n The known multilevel rib fractures are not well visualized on this\n examination. There are bilateral pleural effusions. Limited views of the\n cervical spine demonstrate multilevel spondylosis with a central disc\n herniation at C4-5 which appears to result in severe canal narrowing with cord\n deformity, though no convincing abnormal cord signal.\n (Over)\n\n 1:59 AM\n MR THORACIC SPINE W/O CONTRAST Clip # \n Reason: please do MRI T-spine to further characterize fractures\n Admitting Diagnosis: POLYTAUMA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n IMPRESSION:\n 1. Mild compression deformity of L1 with additional levels of potential\n trabecular contusion at T10-11 also inferiorly at T4 with no retropulsion.\n\n 2. Multilevel degenerative changes with moderate canal narrowing at T10-11\n with cord deformity and no abnormal cord signal.\n\n 3. Extensive edema throughout the paraspinal soft tissues, predominantly\n posteriorly within the interspinous ligaments.\n\n 4. Incompletely evaluated cervical spine demonstrates severe canal narrowing\n at C4-5 with cord deformity and no abnormal cord signal.\n\n\n"},{"category":"Radiology","chartdate":"2175-01-28 00:00:00.000","description":"RP FOOT AP,LAT & OBL RIGHT PORT","row_id":1112908,"text":" 11:43 AM\n FOOT AP,LAT & OBL RIGHT PORT Clip # \n Reason: eval for fracture\n Admitting Diagnosis: POLYTAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man s/p crush injury/trauma with ecchymosis on RLE.\n REASON FOR THIS EXAMINATION:\n eval for fracture\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of the patient with crush injury with\n ecchymosis of right lower extremity.\n\n Three views of the right foot were reviewed. There is no clear evidence of\n fracture. There is no evidence of lytic or sclerotic lesion worrisome for\n neoplasm or infectious process. There is no appreciable soft tissue swelling.\n Minimal degenerative changes are present as well as hallux valgus.\n\n Linear density projecting at the expected area of insertion of the Achilles\n tendon to the calcaneus is noted and might represent either minimal avulsion\n fracture or degenerative changes, correlation with clinical findings is\n recommended.\n\n\n"},{"category":"Radiology","chartdate":"2175-01-29 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1112982,"text":" 7:03 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Newly intubated\n Admitting Diagnosis: POLYTAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with new intubated\n REASON FOR THIS EXAMINATION:\n Newly intubated\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST.\n\n REASON FOR EXAM: Intubated patient.\n\n Comparison is made with prior study performed one hour earlier.\n\n ET tube tip is 5.6 cm above the carina. No other change\n\n"},{"category":"Radiology","chartdate":"2175-01-24 00:00:00.000","description":"MR THORACIC SPINE W/O CONTRAST","row_id":1112260,"text":", R. TSICU 1:59 AM\n MR THORACIC SPINE W/O CONTRAST Clip # \n Reason: please do MRI T-spine to further characterize fractures\n Admitting Diagnosis: POLYTAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with fall with thoracic spine fractures\n REASON FOR THIS EXAMINATION:\n please do MRI T-spine to further characterize fractures\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n 1. Mild compression deformity of L1 with additional levels of potential\n trabecular contusion at T10-11 also inferiorly at T4 with no retropulsion.\n\n 2. Multilevel degenerative changes with moderate canal narrowing at T10-11\n with cord deformity and no abnormal cord signal.\n\n 3. Extensive edema throughout the paraspinal soft tissues, predominantly\n posteriorly within the interspinous ligaments.\n\n 4. Incompletely evaluated cervical spine demonstrates severe canal narrowing\n at C4-5 with cord deformity and no abnormal cord signal.\n\n"},{"category":"Radiology","chartdate":"2175-01-23 00:00:00.000","description":"CT C-SPINE W/O CONTRAST","row_id":1112230,"text":" 7:52 PM\n CT C-SPINE W/O CONTRAST; OUTSIDE FILMS READ ONLY Clip # \n Reason: eval CT C-Spine for acute traumatic injuries.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man hit by tree.\n REASON FOR THIS EXAMINATION:\n eval CT C-Spine for acute traumatic injuries.\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: CXWc MON 9:09 PM\n No fracture or malalignment. Multilevel degenerative changes with large\n posterior disk bulge at C4-5, narrowing the spinal canal and deforming the\n thecal sac, acuity unknown. Marked neuroforamenal narrowing at multiple\n levels.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Transfer for pelvic fracture.\n\n TECHNIQUE: A non-contrast cervical spine CT was obtained earlier today at\n Hospital, at 1600 hours on . A second opinion is requested by\n the referring clinician. No official report is available at the time of\n interpretation.\n\n FINDINGS: There is no fracture or malalignment of the cervical spine.\n Vertebral body heights are preserved. There is loss of intervertebral disc\n height between C5 and C7. Prevertebral soft tissues are not thickened.\n\n At C4-5, a large posterior disc bulge moderately narrows the spinal canal,\n deforming the thecal sac. The acuity is unknown. Posterior disc osteophyte\n complexes at C5-6 and C6-7 results in mild narrowing of the spinal canal.\n Pronounced uncovertebral hypertrophy results in neural foraminal narrowing\n bilaterally at multiple levels.\n\n The visualized lung apices demonstrate atelectasis bilaterally.\n\n IMPRESSIONS:\n\n 1. No fracture or malalignment of the cervical spine.\n\n 2. Large posterior disc bulge at C4-5, acuity unknown, resulting in deformity\n of the thecal sac. If neural deficits are localizable to this level, MRI can\n be obtained to assess for spinal cord injury.\n\n 3. Bilateral neural foraminal narrowing.\n\n"},{"category":"Radiology","chartdate":"2175-01-23 00:00:00.000","description":"CT CHEST W/O CONTRAST","row_id":1112231,"text":" 7:53 PM\n CT CHEST W/O CONTRAST; OUTSIDE FILMS READ ONLY Clip # \n Reason: eval CT Chest for acute traumatic injuries.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man hit by tree.\n REASON FOR THIS EXAMINATION:\n eval CT Chest for acute traumatic injuries.\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: CXWc MON 11:06 PM\n 1. Multiple rib fractures: right anterolateral and posterior, left posterior\n 2. Dependent consolidation which could be sequela of aspiration\n 3. T4 vertebral body inferior corner fracture, no retropulsion\n 4. Comminuted spinous process fractures T2-8\n 5. Nondisplaced left T10 transverse process\n 6. Nondisplaced left clavicle distal fracture\n 7. Nondisplaced left scapula fracture\n WET READ VERSION #1 CXWc MON 10:17 PM\n 1. Multiple rib fractures: right anterolateral and posterior\n 2. Dependent consolidation which could be sequela of aspiration\n 3. T4 vertebral body inferior corner fracture, no retropulsion\n 4. Comminuted spinous process fractures T2-8\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Transfer for multiple fractures. Hit by tree.\n\n TECHNIQUE: A contrast-enhanced chest CT was obtained earlier today at \n Hospital, at 1620 hours on . A second opinion was requested by the\n referring physician. formal report of that study is available at the time\n of interpretation. By verbal report from the referring physician, is\n concern for rib fractures.\n\n COMPARISON: None.\n\n FINDINGS: The aorta is normal in caliber, without dissection, pseudoaneurysm,\n or other acute abnormality. Atherosclerotic calcification is noted. There is\n no segmental or central pulmonary embolus. The heart size is normal without\n pericardial effusion. Atherosclerotic calcifications are noted. There is no\n mediastinal, hilar, or axillary lymphadenopathy by size criteria.\n\n Lungs demonstrate bilateral, dependent consolidation, which could reflect\n sequela of aspiration, or could indicate atelectasis. Additionally, there are\n peripherally based heterogeneous areas of opacity that could reflect\n contusion. There is no pleural effusion. The tracheobronchial tree is patent\n to subsegmental levels. Bilateral pleural calcifications suggest prior\n asbestos exposure.\n\n In the included portion of the upper abdomen, there is a focal linear area of\n hypodensity in the posterior right lobe of the liver, with adjacent\n intermediate attenuation fluid closely opposed to the hepatic parenchyma and\n extending to the posterior chest wall. In this location in the hepatic\n parenchyma, there is a calcified granuloma. This is concerning for\n (Over)\n\n 7:53 PM\n CT CHEST W/O CONTRAST; OUTSIDE FILMS READ ONLY Clip # \n Reason: eval CT Chest for acute traumatic injuries.\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n laceration/contusion, and is further assessed on the subsequent abdominopelvic\n CT.\n\n OSSEOUS STRUCTURES: Multiple fractures are present. The T4 vertebral body\n demonstrates a nondisplaced anterior inferior corner fracture. There is no\n retropulsion of the main fracture fragment. The remaining vertebral bodies\n are preserved in height. There are multiple comminuted fractures through the\n spinous processes spanning T2 through T8. Additionally, there are multiple\n rib fractures. On the right, there are anterolateral fractures of the third\n through eighth ribs, with extensively comminuted fractures of the seventh and\n eighth ribs. Posteriorly, there are non-displaced fractures through the fifth\n through eleventh ribs. On the left, there are minimally displaced fractures\n through the posterior third through eleventh ribs. There is a minimally\n displaced fracture through the left tenth transverse process. Additionally,\n there are non-displaced fractures through the distal one-third of the left\n clavicle, and through the body of the left scapula.\n\n IMPRESSION:\n 1. Multiple rib fractures bilaterally, including right anterolateral and\n posterior, and left posterior ribs as detailed above.\n 2. T4 vertebral body inferior corner fracture, with no retropulsion or\n malalignment. Comminuted spinous process fractures between T2 and T8.\n 3. Non-displaced left T10 transverse process fracture.\n 4. Non-displaced left clavicle and left scapula fractures.\n 5. Dependent consolidation in the lungs bilaterally, which could be sequela\n of aspiration, or could reflect contusion.\n 6. No acute vascular injury.\n 7. Calcified pleura bilaterally suggesting prior asbestos exposure.\n\n"},{"category":"Radiology","chartdate":"2175-01-29 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1112980,"text":" 5:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for acute process\n Admitting Diagnosis: POLYTAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man s/p crush trauma\n REASON FOR THIS EXAMINATION:\n eval for acute process\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: S/P crush trauma, intubated patient.\n\n Comparison is made with prior study performed a day earlier.\n\n ET tube tip is 6.4 cm above the carina. Moderate right and small left pleural\n effusions are unchanged. There are low lung volumes. Cardiomediastinal\n silhouette is unchanged with mild cardiomegaly. Right subclavian catheter and\n NG tube remain in place. Mild fluid overload is unchanged.\n\n\n"},{"category":"Radiology","chartdate":"2175-01-30 00:00:00.000","description":"LIVER OR GALLBLADDER US (SINGLE ORGAN)","row_id":1113099,"text":" 9:35 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: ? acalculous chole vs biloma\n Admitting Diagnosis: POLYTAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with hyperbilirubinemia s/p fall\n REASON FOR THIS EXAMINATION:\n ? acalculous chole vs biloma\n ______________________________________________________________________________\n WET READ: ARHb MON 11:37 AM\n No perihepatic fluid collection. Only a small amount of perihepatic free fluid\n persists. Small contusion in hepatic segment VII again noted. No\n gallstones or significant wall thickening/edema.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 74-year-old male with liver injury and hyperbilirubinemia, status\n post fall.\n\n COMPARISON: CTA abdomen/pelvis .\n\n FINDINGS: The hepatic echotexture and contour is diffusely echogenic without\n intra- or extra-hepatic biliary ductal dilatation. The extrahepatic duct\n measures 5 mm. A small ill-defined focus of hypoechogenicity measuring up to\n approximately 2.3 cm in the posterior right hepatic lobe is consistent with\n the intrahepatic contusion/laceration seen on CT. The main portal vein\n demonstrates normal hepatopedal flow. The gallbladder is mildly distended,\n without significant wall edema, stones, or sludge. Son sign\n cannot be evaluated for in this intubated patient. A small amount of\n perihepatic free fluid has not increased since the recent CT.\n\n IMPRESSION:\n 1. No son evidence for cholecystitis. No cholelithiasis or wall\n edema.\n 2. Small perihepatic free fluid, without focal collection.\n 3. Cirrhotic liver with small contusion noted in the posterior right hepatic\n lobe, as seen on recent CT.\n\n\n"},{"category":"Radiology","chartdate":"2175-02-03 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1113654,"text":" 5:46 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: POLYTAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with VAP, recent trach, s/p crush injury w/mult rib fx\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Ventilator-associated pneumonia, recent tracheostomy, crush\n injury, evaluation for interval change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous examination, there is no relevant\n change. Tracheostomy, right-sided central venous access line. Bilateral\n pleural effusions with bilateral basal opacities. Unchanged size of the\n cardiac silhouette. No evidence of newly appeared focal parenchymal opacities\n suggesting pneumonia.\n\n\n"},{"category":"Radiology","chartdate":"2175-01-29 00:00:00.000","description":"BY SAME PHYSICIAN","row_id":1112994,"text":" 11:04 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: eval for infiltrates s/p brocnh, also eval plaecemnt of NGT\n Admitting Diagnosis: POLYTAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with new NGT\n REASON FOR THIS EXAMINATION:\n eval for infiltrates s/p brocnh, also eval plaecemnt of NGT\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Evaluate NG tube.\n\n Prior exam was performed four hours earlier.\n\n NG tube tip is in the stomach. No other interval change.\n\n\n"},{"category":"Radiology","chartdate":"2175-01-25 00:00:00.000","description":"PELVIS SEL/SUPERSEL A-GRAM","row_id":1112438,"text":" 9:37 AM\n ILIAC Clip # \n Reason: eval for bleed\n Admitting Diagnosis: POLYTAUMA\n Contrast: OPTIRAY Amt: 130\n ********************************* CPT Codes ********************************\n * EMBO NON NEURO INITAL 3RD ORDER ABD/PEL/LOWER *\n * -51 MULTI-PROCEDURE SAME DAY INITAL 3RD ORDER ABD/PEL/LOWER *\n * -59 DISTINCT PROCEDURAL SERVICE ADD'L 2ND/3RD ORDER ABD/PEL/LO *\n * -59 DISTINCT PROCEDURAL SERVICE PELVIS SEL/SUPERSEL A-GRAM *\n * -59 DISTINCT PROCEDURAL SERVICE VISERAL SEL/SUPERSEL A-GRAM *\n * -59 DISTINCT PROCEDURAL SERVICE VISERAL SEL/SUPERSEL A-GRAM *\n * -59 DISTINCT PROCEDURAL SERVICE TRANCATHETER EMBOLIZATION *\n * EA ADD'L VESSEL AFTER BASIC A- EA ADD'L VESSEL AFTER BASIC A- *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with acutely dropping Hct s/p trauma with crush injury\n REASON FOR THIS EXAMINATION:\n eval for bleed\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): MGRc WED 8:45 PM\n PFI.\n\n 1. Pelvic arteriography: Multiple arteriographic runs performed of distal\n aorta, external iliac, internal iliac, lateral sacral and superior gluteal\n arteries. Active contrast extravasation noted from branches of the lateral\n sacral artery and superior gluteal arteries. Successful Gelfoam embolization\n of lateral sacral artery and branches of the superior gluteal artery.\n 2. Hepatic angiography: Multiple arteriographic runs of common hepatic and\n right hepatic arteries. Some active contrast extravasation was noted from\n peripheral branches of right hepatic artery. Gelfoam embolization of distal\n right hepatic artery branches performed.\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n MEDICAL HISTORY: 74-year-old man with polytrauma with pelvic fracture and\n liver injury. Patient has been acutely dropping hematocrit and contrast CT\n scan of abdomen and pelvis showed some active extravasation around the left\n superior pubic ramus fracture as well as liver contusion. A request was\n placed for pelvic and hepatic arteriography with embolization of any bleeding\n vessels.\n\n CLINICIANS: Dr. , Dr. and Dr. . Dr. \n is the attending radiologist who was present and supervising throughout.\n\n ANESTHESIA: The patient was brought down from the ICU intubated and sedated .\n Local anesthesia with 1% lidocaine.\n\n PROCEDURE AND FINDINGS: A written informed consent was obtained after\n explaining the procedure, benefits and risks involved. The patient was\n brought to angiography suite and placed supine on the imaging table. The\n right groin was prepped and draped in the usual sterile fashion. A\n preprocedural huddle and timeout were performed as per protocol.\n (Over)\n\n 9:37 AM\n ILIAC Clip # \n Reason: eval for bleed\n Admitting Diagnosis: POLYTAUMA\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n (Cont)\n\n Under palpatory and fluoroscopic guidance the right common femoral artery was\n accessed with a micropuncture needle. A 0.018 guidewire was placed through\n the needle and needle exchanged for a micropuncture sheath which in turn was\n used to upsize the wire to wire. The wire was advanced into\n abdominal aorta under fluoroscopic guidance. The micropuncture sheath was\n removed and replaced with a 5 French vascular sheath, the side arm of which\n was connected to a continuous saline flush. Over the wire, a 5 French\n Omni Flush catheter was placed into the distal aorta and an angiogram\n performed with power injection. Then the Omni Flush catheter was advanced\n into left common iliac artery over a guidewire and Left external iliac\n arteriogram was performed. Then the the catheter exchanged for a C2 cobra\n catheter and a left internal iliac arteriogram was performed. The internal\n iliac arteriogram showed some contrast extravasation from the branches of\n lateral sacral and superior gluteal arteries. There was no contrast\n extravasation seen in the vicinity of the left superior pubic ramus fracture.\n Depending upon these diagnostic findings, it was felt that the patient would\n benefit from embolization of the bleeding vessels. Using a C2 Cobra catheter\n and Renegade high-flow microcatheter and an 0.018 gold glidewire, the left\n lateral sacral artery was selectively catheterized and an arteriogram at this\n level demonstrated multiple small clusters of contrast or micro-extravasations\n from the small peripheral branches. Therefore, the lateral sacral artery was\n embolized using Gelfoam slurry with good angiographic result. The C2 catheter\n was then withdrawn from the lateral sacral artery the superior gluteal artery\n was selectively catheterized and angiogram at this level again demonstrated\n similar small contrast collctions. These branches of the superior gluteal\n artery were therefore embolized with Gelfoam slurry with good angiographic\n result.\n\n Then the C2 Cobra catheter was pulled back into the aorta and the celiac\n artery was cannulated. Using a Glidewire the hepatic artery was cannulated\n and angiography of the hepatic artery demonstrated some small peripheral\n contrast areas of hypervascvlarity supplied from the right hepatic artery\n branches. These were in the region of the hepatic and subcapsular hemorrhage\n from the right lobe. The C2 catheter was advanced distal to origin of the\n cystic artery and the peripheral branches were embolized with Gelfoam slurry\n with good angiographic result. Post- embolization arteriography demonstrated\n no further visible contrast extravasation. The catheter and vascular sheaths\n were pulled out and hemostasis was achieved with digital compression for 20\n minutes. Sterile dressings were applied. The patient tolerated the procedure\n well with no immediate complications.\n\n IMPRESSION:\n 1. Pelvic angiography with multiple arteriographic runs of the distal aorta,\n left external iliac, left internal iliac, left lateral sacral and superior\n (Over)\n\n 9:37 AM\n ILIAC Clip # \n Reason: eval for bleed\n Admitting Diagnosis: POLYTAUMA\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n (Cont)\n gluteal arteries. Abnormal clusters of contrast, ? active contrast\n extravasation noted from branches of lateral sacral artery and superior\n gluteal artery on the left. These arteries were successfully embolized with\n Gelfoam slurry.\n 2. Hepatic angiography with multiple arteriographic runs of common and right\n hepatic arteries demonstrating similar contrast collections in peripheral\n branches of right hepatic artery, adjacent to the known hepatic and\n subcapsular hematomas. These peripheral branches of the right hepatic artery\n were successfully embolized with Gelfoam slurry.\n\n\n\n\n"},{"category":"Radiology","chartdate":"2175-01-23 00:00:00.000","description":"CTA ABD W&W/O C & RECONS","row_id":1112248,"text":" 9:51 PM\n CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # \n Reason: CTA Abd Pelvis with 5 minute delayed venous imaging to asses\n Admitting Diagnosis: POLYTAUMA\n Field of view: 40 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with fall and pelvis fractures\n REASON FOR THIS EXAMINATION:\n CTA Abd Pelvis with 5 minute delayed venous imaging to assess for active\n bleeding\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: CXWc MON 10:41 PM\n 1. Medial right liver lobe contusion with adjacent hematoma, without evidence\n of active bleeding\n 2. Comminuted left pubic ramus fracture with associated hematoma, with tiny\n focus of arterial bleeding/active extravasation, and larger area of venous\n bleeding. Hematoma somewhat larger than on OSH study.\n 3. Nondisplaced, comminuted left iliac bone fracture with adjacent iliac\n muscle hematoma, larger than on prior study, without active extrav. Fracture\n extends into left SI joint.\n 4. Posterior right hepatic laceration/contusion adjacent to calcified\n granuloma, with small hematoma, without active bleeding\n 5. Minimally displaced fracture of the right iliac bone extending to right SI\n joint.\n 6. Cirrhotic liver. Fluid around nondistended gallbladder likely related to\n liver disease.\n 7. Increased pleural effusions (small), bilaterally, with increased\n atelectasis.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 74-year-old man status post trauma, with pelvic fractures.\n Concern for active bleeding.\n\n COMPARISON: CT abdomen and pelvis obtained at Hospital at\n approximately 1615 hours on .\n\n TECHNIQUE: MDCT-acquired axial images were obtained through the abdomen and\n pelvis before and after administration of intravenous contrast material.\n Post-contrast images were obtained in arterial, venous and delayed phases.\n Multiplanar reformatted images were generated.\n\n CT ABDOMEN WITH IV CONTRAST: At the lung bases, there has been an interval\n increase/development of bilateral pleural effusions, now small. Additionally,\n there is increased consolidation dependently, which could reflect atelectasis\n or the sequela of aspiration. The heart size remains normal, without\n pericardial effusion. Coronary artery calcifications are again noted.\n Pleural calcifications bilaterally suggest prior asbestos exposure.\n\n Within the abdomen, the liver demonstrates multiple abnormalities. Along the\n medial aspect of the posterior right lobe, there is an area of\n hypoattenuation, somewhat irregular in contour, measuring approximately 4.9 x\n (Over)\n\n 9:51 PM\n CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # \n Reason: CTA Abd Pelvis with 5 minute delayed venous imaging to asses\n Admitting Diagnosis: POLYTAUMA\n Field of view: 40 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 4.4 cm. This area lies adjacent to a large protruding vertebral body\n osteophyte, and is consistent with contusion. The area of contusion results\n in narrowing of the adjacent right hepatic vein and the right posterior portal\n vein branches. Additionally, on arterial phase, a branch of the right hepatic\n artery is slightly irregular, although there is no definite evidence of acute\n active extravasation at this time. This area of contusion abuts the inferior\n vena cava, which has improved in caliber since the prior study. There is a\n small degree of fluid and fat stranding along the inferior margin of the liver\n and tracking around the IVC to the level of the renal veins.\n\n Along the posterolateral surface of the right lobe of the liver, there is a\n linear region of hypodensity that could reflect contusion or laceration. This\n is associated with a 12-mm hyperdense structure, most likely a calcified\n granuloma. There is a moderate amount of adjacent fluid or stranding, with\n intermediate density fluid suggesting hematoma. Surrounding this area, there\n is inflammatory stranding.\n\n The liver is shrunken, with a nodular contour, consistent with cirrhosis. No\n worrisome arterially enhancing lesions are identified. The gallbladder is\n decompressed, but demonstrates a small amount of pericholecystic fluid or wall\n thickening, which may be related to chronic liver disease. The main portal\n vein and its branches are patent.\n\n The pancreas, spleen, adrenal glands and duodenum are unremarkable. The\n stomach is within normal limits, with a moderate hiatal hernia. The kidneys\n enhance and excrete contrast symmetrically, with a hypodense lesion at the\n lower pole of the left kidney, too small to accurately characterize.\n\n The abdominal aorta and its major branches are patent, with atherosclerotic\n calcifications. The aorta is normal in caliber. There is no free air in the\n abdomen. There is no mesenteric or retroperitoneal lymphadenopathy by size\n criteria.\n\n CT PELVIS WITH IV CONTRAST: In the anterior pelvis, associated with a\n comminuted pubic ramus fracture (to be described in the next section), there\n has been an interval increase in a multifocal hematoma, now extending more\n cranially into the peritoneal cavity than on the prior study. On arterial\n phase, there is a tiny hyperdense linear focus, extending a few millimeters,\n concerning for active extravasation. On venous phase, this area increases in\n density and size, to 7 x 5 mm. On delayed images, hyperdense material spans a\n larger area measuring roughly 23 x 14 mm. This is concerning for a small\n amount of active, or venous bleeding.\n\n Additionally, there is a retroperitoneal hematoma involving the left iliac\n muscle, associated with an iliac bone fracture (to be described in the next\n (Over)\n\n 9:51 PM\n CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # \n Reason: CTA Abd Pelvis with 5 minute delayed venous imaging to asses\n Admitting Diagnosis: POLYTAUMA\n Field of view: 40 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n section). This hematoma has also increased in size from the prior study. It\n now measures roughly 8.8 x 5.6 cm, previously 9.6 x 5.9 cm. There is no\n evidence of active extravasation at this time. Hyperdense material noted\n within this region on the prior study is no longer seen.\n\n Multiple loops of large and small bowel are notable for sigmoid\n diverticulosis, without diverticulitis. There is no bowel wall thickening,\n evidence of obstruction, or mesenteric fluid to suggest bowel injury. The\n urinary bladder is decompressed around a Foley catheter. Distal ureters and\n prostate gland are within normal limits. There is no pelvic or inguinal\n lymphadenopathy by size criteria.\n\n OSSEOUS STRUCTURES: There is a comminuted fracture of the left superior pubic\n ramus, and a minimally displaced fracture of the left inferior pubic ramus.\n This is associated with a large hematoma containing hyperdense material\n concerning for active extravasation, as described in the previous section.\n\n There is a minimally displaced fracture through the left iliac bone, extending\n from the crest to the sacroiliac joint, and extending into the joint space on\n the left. This is associated with an iliac muscle hematoma, as described in\n the previous section. Additionally, there is a nondisplaced fracture through\n the right iliac bone, extending from the iliac crest to the sacroiliac joint,\n and into the joint space.\n\n Degenerative changes are noted of both hips and the lumbar spine. No\n vertebral body fractures are identified. Posterior rib fractures involving\n the bilateral eleventh, tenth, ninth and eighth ribs are again visualized. A\n nondisplaced 10th vertebral body left transverse process fracture is noted.\n\n IMPRESSIONS:\n\n 1. Contusion/laceration of the medial aspect of the right hepatic lobe, with\n adjacent small hematoma, without definite evidence of active bleeding.\n Associated irregularity of an adjacent branch of the right hepatic artery and\n resultant narrowing of the adjacent right hepatic vein and right posterior\n portal vein branches. Posterior right hepatic laceration/contusion, adjacent\n to a calcified granuloma, with a small hematoma, without evidence of active\n extravasation.\n\n 2. Comminuted left pubic ramus fracture with associated hematoma, which has\n increased in size from the prior study of approximately six hours prior. Tiny\n focus of arterially enhancing material, which enlarges on venous and delayed\n images, concerning for active extravasation.\n\n 3. Minimally displaced, comminuted left iliac bone fracture, with adjacent\n (Over)\n\n 9:51 PM\n CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # \n Reason: CTA Abd Pelvis with 5 minute delayed venous imaging to asses\n Admitting Diagnosis: POLYTAUMA\n Field of view: 40 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n iliac muscle hematoma, largely unchanged from the prior study, without\n evidence of active extravasation. Fracture extends into the left sacroiliac\n joint.\n\n 4. Minimally displaced fracture of the right iliac bone, extending to the\n right sacroiliac joint.\n\n 5. Bilateral comminuted, minimally displaced posterior rib fractures of the\n eighth through eleventh ribs. Nondisplaced left 10th vertebral body\n transverse process fracture.\n\n 6. Interval increase in bilateral pleural effusions (small), with increased\n bilateral atelectasis or consolidation which could be the result of\n aspiration.\n\n 7. Cirrhotic liver. Fluid around the nondistended gallbladder may be related\n to liver disease.\n\n\n\n"},{"category":"Radiology","chartdate":"2175-01-25 00:00:00.000","description":"PELVIS SEL/SUPERSEL A-GRAM","row_id":1112439,"text":", R. TSICU 9:37 AM\n ILIAC Clip # \n Reason: eval for bleed\n Admitting Diagnosis: POLYTAUMA\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with acutely dropping Hct s/p trauma with crush injury\n REASON FOR THIS EXAMINATION:\n eval for bleed\n ______________________________________________________________________________\n PFI REPORT (REVISED)\n PFI.\n\n 1. Pelvic arteriography: Multiple arteriographic runs performed of distal\n aorta, external iliac, internal iliac, lateral sacral and superior gluteal\n arteries. Active contrast extravasation noted from branches of the lateral\n sacral artery and superior gluteal arteries. Successful Gelfoam embolization\n of lateral sacral artery and branches of the superior gluteal artery.\n 2. Hepatic angiography: Multiple arteriographic runs of common hepatic and\n right hepatic arteries. Some active contrast extravasation was noted from\n peripheral branches of right hepatic artery. Gelfoam embolization of distal\n right hepatic artery branches performed.\n\n"},{"category":"Radiology","chartdate":"2175-02-01 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1113503,"text":" 7:14 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ? change pulm path\n Admitting Diagnosis: POLYTAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with desats, PNA\n REASON FOR THIS EXAMINATION:\n ? change pulm path\n ______________________________________________________________________________\n WET READ: EAGg WED 8:36 PM\n Persistent bilateral pleural effusions and bibasilar opacity, likely\n atelectasis but underlying infection not excluded.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 74-year-old male with desats and pneumonia.\n\n COMPARISON: Chest radiographs available from at 1:37 p.m.\n\n SEMI-UPRIGHT AP VIEW OF THE CHEST: The right-sided central venous catheter\n and tracheostomy tube are unchanged in position. Moderate bilateral pleural\n effusions and bibasilar opacities are stable. There has been interval\n resolution of the previously seen pneumoperitoneum. There is no pneumothorax.\n The cardiac and mediastinal contours are unchanged.\n\n IMPRESSION: Interval resolution of pneumoperitoneum, otherwise, unchanged\n radiograph.\n\n"},{"category":"Radiology","chartdate":"2175-01-23 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":1112229,"text":" 7:52 PM\n CT HEAD W/O CONTRAST; OUTSIDE FILMS READ ONLY Clip # \n Reason: eval CT Head for acute traumatic injuries.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man hit by tree.\n REASON FOR THIS EXAMINATION:\n eval CT Head for acute traumatic injuries.\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: CXWc MON 9:10 PM\n No ICH or fracture.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Transfer for pelvic fractures.\n\n TECHNIQUE: A non-contrast head CT was obtained earlier today at \n Hospital, at 1600 hours . A second opinion is requested by the\n referring clinician. No official report is available at the time of\n interpretation.\n\n FINDINGS: There is no intracranial hemorrhage, edema, shift of normally\n midline structures or evidence of major vascular territorial infarct.\n Ventricles and sulci are normal in size and configuration. The -white\n matter differentiation is preserved. The basilar cisterns are symmetric. A\n small mucous retention cyst, and a small amount of fluid are noted within the\n right maxillary sinus. Remaining paranasal sinuses are well aerated. Mastoid\n air cells are well aerated.\n\n IMPRESSIONS:\n\n No acute intracranial abnormality.\n\n\n\n"},{"category":"Radiology","chartdate":"2175-02-01 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1113440,"text":" 1:06 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ? change pulm path\n Admitting Diagnosis: POLYTAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with PNA, desat, hypotension\n REASON FOR THIS EXAMINATION:\n ? change pulm path\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 74-year-old male with pneumonia, continued desats, and\n hypertension.\n\n COMPARISON: Chest radiographs available from through .\n\n UPRIGHT AP VIEW OF THE CHEST:\n The upper mediastinal contour is unchanged since 5:48 a.m. The patient is\n status post tracheostomy. New pneumomediastinum is compatible with recent\n surgery, likely PEG placement, given removal of the NGT. The left-sided PICC\n is unchanged in position. There has been no change in moderate bilateral\n pleural effusions, with significant compressive atelectasis at the bases.\n There is no pneumothorax. Mild pulmonary edema is unchanged.\n\n IMPRESSION:\n 1. Status post tracheostomy. Pneumoperitoneum compatible with PEG placement\n (confirmed with TICU team).\n 2. Stable moderate bilateral pleural effusions and mild pulmonary edema.\n 3. Persistent compressive bibasilar atalectasis.\n\n"},{"category":"Radiology","chartdate":"2175-01-28 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1112875,"text":" 5:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?effusion, atelectasis, pneumonia\n Admitting Diagnosis: POLYTAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with ETT, multiple rib fractures\n REASON FOR THIS EXAMINATION:\n ?effusion, atelectasis, pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: Chest one view at 05:49 hours.\n\n COMPARISON: at 05:59 hours.\n\n HISTORY: A 74-year-old male with endotracheal tube and multiple rib\n fractures, status post trauma.\n\n TECHNIQUE: Single semi-upright portable chest x-ray was obtained.\n\n FINDINGS:\n\n Endotracheal tube is identified with its tip just above the level of the\n thoracic inlet. Nasogastric tube is identified with its tip in the stomach.\n Right subclavian central venous catheter is identified with its tip in the\n cavoatrial junction. There is an IVC filter noted.\n\n Multiple rib fractures are present, and not well appreciated on this portable\n examination.\n\n Cardiopericardial silhouette appears somewhat enlarged, although this may be\n related to low lung volumes. In the interval, there is increasing perihilar\n opacities with an indistinct appearance of interstitium, consistent with\n cephalization of the pulmonary vasculature. Also seen are bibasilar linear\n and hazy opacities, likely related to a combination of pleural effusions and\n associated underlying edema or atelectasis. Opacity in the retrocardiac\n region may be related to atelectasis or edema.\n\n IMPRESSION:\n\n 1. Interval mild increase in cardiac size, cephalization of the vessels\n within indistinct appearance of the interstitium, bilateral pleural effusions,\n and opacities at the lung bases, which may represent edema or atelectasis. The\n constellation of these findings is likely related to fluid overload/congestive\n heart failure.\n\n"},{"category":"Radiology","chartdate":"2175-02-02 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1113544,"text":" 5:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for acute process\n Admitting Diagnosis: POLYTAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with VAP\n REASON FOR THIS EXAMINATION:\n eval for acute process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: This is a 74-year-old male with VAP.\n\n COMPARISON: Chest radiographs available from .\n\n SEMI-UPRIGHT AP VIEW OF THE CHEST: The tracheostomy tube and right-sided\n central venous catheter are unchanged in position. Cardiac and mediastinal\n contours are unchanged. There remains persistent mild pulmonary edema.\n Moderate-sized bilateral pleural effusions have minimally improved. Bibasilar\n opacities remain present, compatible with atelectasis and/or pneumonia.\n\n IMPRESSION:\n 1. Minimal improvement of moderate-sized bilateral pleural effusions.\n 2. Stable mild pulmonary edema.\n 3. Stable bibasilar opacities compatible with atelectasis with possible\n superimposed infection.\n\n\n"},{"category":"Radiology","chartdate":"2175-01-30 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1113074,"text":" 4:34 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pna, pleural effusions\n Admitting Diagnosis: POLYTAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with pna and pleural effusions, s/p crush injury\n REASON FOR THIS EXAMINATION:\n eval for pna, pleural effusions\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Pneumonia and pleural effusions, status post crush injury.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous examination, there is no relevant\n change. Unchanged monitoring and support devices, unchanged bilateral pleural\n effusions, unchanged size of the cardiac silhouette, unchanged retrocardiac\n and left basal atelectasis. No evidence of pneumothorax.\n\n\n"},{"category":"Radiology","chartdate":"2175-01-26 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1112561,"text":" 5:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?edema, pneumonia, ETT\n Admitting Diagnosis: POLYTAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with multiple rib fxs, intubated\n REASON FOR THIS EXAMINATION:\n ?edema, pneumonia, ETT\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Multiple rib fractures and intubated.\n\n Comparison is made with prior study, .\n\n ET tube is in standard position. NG tube tip is out of view below the\n diaphragm. Right central catheter tip is in the SVC. There are low lung\n volumes. Moderate bilateral pleural effusions are stable. Collapse of the\n lower lobes bilaterally is better seen in the prior CT from the day before.\n Atelectases in the lingula and in the right upper lobe are better seen in\n prior CT.\n\n\n"},{"category":"Radiology","chartdate":"2175-02-03 00:00:00.000","description":"BILAT LOWER EXT VEINS","row_id":1113681,"text":" 10:49 AM\n BILAT LOWER EXT VEINS Clip # \n Reason: eval for DVTs\n Admitting Diagnosis: POLYTAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with persistent fevers despite adequate pna coverage. eval for\n other sources.\n REASON FOR THIS EXAMINATION:\n eval for DVTs\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): RSRc FRI 12:22 PM\n No DVT\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 74-year-old male with pneumonia on treatment, persistent fever.\n Evaluate for DVT as occult second cause for fever.\n\n COMPARISON: None available.\n\n BILATERAL LOWER EXTREMITY VENOUS ULTRASOUND: The common femoral veins,\n superficial femoral veins, deep femoral veins, greater saphenous veins,\n popliteal veins, and calf veins demonstrate normal color flow. There is\n respiratory phasicity, compressibility, and appropriate response to\n augmentation and Valsalva maneuvers.\n\n IMPRESSION: No evidence of DVT in the lower extremities.\n\n"},{"category":"Radiology","chartdate":"2175-01-27 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1112729,"text":" 5:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: POLYTAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with multiple broken ribs. Intubated.\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Multiple rib fractures and intubated patient.\n\n Comparison is made with prior study performed a day earlier.\n\n ET tube tip is 6.3 cm above the carina. NG tube tip is out of view below the\n diaphragm. Cardiac size is top normal, is partially obscured by lung\n abnormality. There has been interval improvement of collapse in the left\n lower lobe. Collapse of the right lower lobe is persistent. Atelectasis in\n the lingula is unchanged. Cardiomediastinum is midline. Moderate bilateral\n pleural effusions are stable. There is no pneumothorax.\n\n\n"},{"category":"Radiology","chartdate":"2175-02-03 00:00:00.000","description":"BILAT LOWER EXT VEINS","row_id":1113682,"text":", R. TSICU 10:49 AM\n BILAT LOWER EXT VEINS Clip # \n Reason: eval for DVTs\n Admitting Diagnosis: POLYTAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with persistent fevers despite adequate pna coverage. eval for\n other sources.\n REASON FOR THIS EXAMINATION:\n eval for DVTs\n ______________________________________________________________________________\n PFI REPORT\n No DVT\n\n"},{"category":"Radiology","chartdate":"2175-02-05 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1113838,"text":" 5:05 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for infiltrates, edema, interval change\n Admitting Diagnosis: POLYTAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with multiple trauma and PNA, volume overload\n REASON FOR THIS EXAMINATION:\n Evaluate for infiltrates, edema, interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST \n\n COMPARISON: \n\n INDICATION: Volume overload.\n\n FINDINGS: Allowing for technical differences between the studies, there has\n not been a substantial change in appearance of the chest since the recent\n radiograph of one day earlier.\n\n\n"},{"category":"Radiology","chartdate":"2175-02-06 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1113917,"text":" 4:55 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: POLYTAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with multi-trauma\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Multiple trauma, to evaluate for change.\n\n FINDINGS: In comparison with the study of , the patient may have taken a\n slightly better inspiration. The left PICC line is not seen in the\n hemithorax, though it may be present in the soft tissues at the edge of the\n film in the axillary region. Bibasilar opacification persists, consistent\n with atelectasis and effusion. Some degree of pulmonary contusion and even\n supervening pneumonia must be considered.\n\n\n"},{"category":"Radiology","chartdate":"2175-01-23 00:00:00.000","description":"TRAUMA #2 (AP CXR & PELVIS PORT)","row_id":1112226,"text":" 7:26 PM\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \n Reason: rib fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with fall\n REASON FOR THIS EXAMINATION:\n rib fx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 74-year-old man status post fall.\n\n COMPARISON: None.\n\n SINGLE SUPINE VIEW OF THE CHEST AT HOURS: Underlying trauma board limits\n evaluation. Lung volumes are low. There are heterogeneous parenchymal\n opacities bilaterally, suggesting multifocal contusion and/or atelectasis.\n There is no large pleural effusion. The heart size is normal. There is no\n hilar or mediastinal enlargement. Multiple displaced rib fractures are noted,\n particularly along the right lateral chest wall.\n\n SINGLE FRONTAL VIEW OF THE PELVIS: Underlying trauma board limits evaluation.\n There are minimally displaced fractures of the superior and anterior pubic\n rami on the left. Degenerative changes and fragmented osteophytes are noted\n of both hips. No other displaced fractures are definitively identified. The\n femoral heads are well seated in the acetabuli.\n\n IMPRESSIONS:\n\n 1. Heterogeneous pulmonary opacities suggestive of contusion and/or\n aspiration.\n\n 2. Multiple minimally displaced right lateral rib fractures.\n\n 3. Left pubic rami fractures.\n\n Please refer to concurrently obtained CT abdomen/pelvis, and OSH chest CT for\n further assessment.\n\n"}],"string":"[\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2175-01-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 88102,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Right ventricular function. Atrial flutter. Hypotension. S/p trauma.\\nHeight: (in) 70\\nWeight (lb): 198\\nBSA (m2): 2.08 m2\\nBP (mm Hg): 111/57\\nHR (bpm): 84\\nStatus: Inpatient\\nDate/Time: at 15:32\\nTest: Portable TTE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nThis study was compared to the prior study of .\\n\\n\\nLEFT ATRIUM: Normal LA and RA cavity sizes.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The patient is mechanically ventilated.\\nCannot assess RA pressure.\\n\\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\\nsystolic function (LVEF >55%). False LV tendon (normal variant). Transmitral\\nDoppler E>A and TDI E/e' <8 suggesting normal diastolic function, and normal\\nLV filling pressure (PCWP<12mmHg). No resting LVOT gradient.\\n\\nRIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic function.\\n\\nAORTA: Mildly dilated aortic sinus. Normal ascending aorta diameter.\\n\\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. Trace AR.\\n\\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. of the\\nmitral chordae (normal variant). No resting LVOT gradient.\\n\\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Mild PA\\nsystolic hypertension.\\n\\nPERICARDIUM: No pericardial effusion.\\n\\nConclusions:\\nThe left atrium and right atrium are normal in cavity size. Left ventricular\\nwall thickness, cavity size and regional/global systolic function are normal\\n(LVEF >55%). Transmitral and tissue Doppler imaging suggests normal diastolic\\nfunction, and a normal left ventricular filling pressure (PCWP<12mmHg). Right\\nventricular chamber size is mildly dilated with normal free wall motion. The\\naortic root is mildly dilated at the sinus level. The aortic valve leaflets\\n(3) appear structurally normal with good leaflet excursion and no aortic\\nstenosis. Trace aortic regurgitation is seen. The mitral valve appears\\nstructurally normal with trivial mitral regurgitation. There is no mitral\\nvalve prolapse. There is mild pulmonary artery systolic hypertension. There is\\nno pericardial effusion.\\n\\nCompared with the prior study (images reviewed) of , the right\\nventricular cavity is now smaller, the severity of tricuspid regurgitation is\\nnow reduced, and the estimated pulmonary artery systolic pressure is now lower\\n(previously overestimated on review of the prior study).\\n\\nCLINICAL IMPLICATIONS:\\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\\nindicate prophylaxis is NOT recommended. Clinical decisions regarding the need\\nfor prophylaxis should be based on clinical and echocardiographic data.\\n\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2175-01-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 88133,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Left ventricular function. Right ventricular function. Shortness of breath.\\nHeight: (in) 70\\nWeight (lb): 198\\nBSA (m2): 2.08 m2\\nBP (mm Hg): 114/54\\nHR (bpm): 78\\nStatus: Inpatient\\nDate/Time: at 16:51\\nTest: Portable TTE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nPatient hypotensive on phenylephrine drip at 1.5 mcg/kg/min\\nLEFT ATRIUM: Normal LA size.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\\n\\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\\nsystolic function (LVEF >55%). Normal regional LV systolic function.\\n\\nRIGHT VENTRICLE: Moderately dilated RV cavity. Borderline normal RV systolic\\nfunction.\\n\\nAORTIC VALVE: Three aortic valve leaflets. Moderately thickened aortic valve\\nleaflets. No AS. No AR.\\n\\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\\n\\nTRICUSPID VALVE: Moderate [2+] TR. Severe PA systolic hypertension.\\n\\nPERICARDIUM: No pericardial effusion.\\n\\nGENERAL COMMENTS: The patient appears to be in sinus rhythm. Results were\\npersonally reviewed with the MD caring for the patient.\\n\\nConclusions:\\nThe left atrium is normal in size. Left ventricular wall thickness, cavity\\nsize and regional/global systolic function are normal (LVEF >55%). Regional\\nleft ventricular wall motion is normal. The right ventricular cavity is\\nmoderately dilated with borderline normal free wall function. Septal motion is\\nindicative of right ventricular pressure overload. There are three aortic\\nvalve leaflets. The aortic valve leaflets are moderately thickened. There is\\nno aortic valve stenosis. No aortic regurgitation is seen. The mitral valve\\nappears structurally normal with trivial mitral regurgitation. Moderate [2+]\\ntricuspid regurgitation is seen. There is severe pulmonary artery systolic\\nhypertension. There is no pericardial effusion.\\n\\nIMPRESSION: Preserved left ventricular systolic function. Dilated right\\nventricule with borderline normal function with evidence of right ventricular\\npressure overload. 2+ tricuspid regurgitation. Severe pulmonary artery\\nsystolic pressure\\n\\nDr. was notified in person of the results on at 17:27.\\n\\n\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2175-02-02 00:00:00.000\",\n \"description\": \"EP NOTE\",\n \"row_id\": 714687,\n \"text\": \"Cardiac Electrophysiology Note:\\n History of Present Illness\\n Date: \\n Subsequent care\\n Events / History of present illness: 74M no known PMH, presented on\\n s/p fall from tractor and crush injury with right ribs and pelvic\\n fractures and T4 vertebral body fracture. He was given 4 U PRBC, 1 unit\\n FFP, and underwent arteriogram on with embolization to the liver\\n and pelvis and IVC filter placement for concern of high likelihood of\\n development of DVT and inability to anticoagulate. We were consulted\\n d/t paroxysmal atrial flutter which has started on the morning of\\n . He was started on Amiodarone drip, with subsequent conversion to\\n sinus rhythm last evening. He is currently post PEG and tracheostomy,\\n awake and alert. He is in sinus rhythm at the 90s, on Amiodarone P.O.\\n Medications\\n Unchanged\\n Physical Exam\\n Tmax C last 24 hours: 37.7 C\\n Tmax F last 24 hours: 99.9 F\\n T current C: 36.3 C\\n T current F: 97.4 F\\n Previous day:\\n Intake: 1,764 mL\\n Output: 1,630 mL\\n Fluid balance: 134 mL\\n Today:\\n Intake: 863 mL\\n Output: 1,115 mL\\n Fluid balance: -252 mL\\n General: Awake and alert. Sitting in a chair. No acute distress\\n Cardiovascular: (Auscultation: RRR, no murmurs)\\n Respiratory: (Auscultation: Limited exam: clear to auscultation, no\\n rales or wheezes)\\n Abdomen: (Limited exam: Could not appreciate organomegaly )\\n Neurological: (Orientation: Awake and alert)\\n Labs\\n 109\\n 10.2\\n 110\\n 0.8\\n 31\\n 4.5\\n 24\\n 105\\n 144\\n 31.3\\n 5.9\\n [image002.jpg]\\n 01:00 AM\\n 05:12 AM\\n 01:46 AM\\n 01:55 AM\\n 02:18 AM\\n 08:00 AM\\n 02:00 PM\\n 08:00 PM\\n 01:00 AM\\n 01:07 AM\\n WBC\\n 8.8\\n 4.2\\n 5.9\\n Hgb\\n 10.7\\n 9.5\\n 10.2\\n Hct (Serum)\\n 32.1\\n 29.7\\n 31.3\\n Plt\\n 153\\n 104\\n 109\\n INR\\n 1.2\\n PTT\\n 27.6\\n Na+\\n 143\\n 143\\n 142\\n 144\\n K + (Serum)\\n 4.0\\n 3.9\\n 4.2\\n 4.5\\n Cl\\n 108\\n 106\\n 106\\n 105\\n HCO3\\n 32\\n 32\\n 31\\n 31\\n BUN\\n 19\\n 22\\n 24\\n 24\\n Creatinine\\n 0.7\\n 0.7\\n 0.7\\n 0.8\\n Glucose\\n 115\\n 132\\n 122\\n 117\\n 129\\n 100\\n 111\\n 105\\n 117\\n 110\\n CK\\n 225\\n 128\\n ABG: 7.45 / 49 / 98 / / 8 Values as of 01:18 AM\\n Assessment and Plan\\n ATRIAL FLUTTER: converted to sinus yesterday evening with I.V\\n amiodarome. Would recommend:\\n 1. Amiodarone PO 400 mg .\\n 2. Metoprolol Succinate PO 25 mg .\\n 3. Discontinue Diltiazem P.O.\\n 4. Discontinue I.V Metoprolol\\n 5. Consider Heparin I.V with a goal of PTT between 60-80 seconds\\n if it is not contra-indicated from his trauma standpoint\\n ------ Protected Section ------\\n 1. Would also recommend liver enzymes follow up given his\\n elevated LFT\\ns and Amiodarone treatment\\n 2. Amiodarone 400mg for 1 week followed by Amiodarone 400 mg\\n daily for 1 week, and then Amiodarone 200 mg daily.\\n 3. ------ Protected Section Addendum Entered By:\\n , MD on: 13:00 ------\\n 4.\\n 5.\\n 6. Electronically signed by , MD \\n 13:00\\n 7.\\n Cardiology Teaching Physician Note\\n have seen and examined the patient. I have reviewed the above note\\n and plans.\\n I would add the following remarks:\\n Physical Examination\\n bp incr and sinus \\n Medical Decision Making\\n transition diltiazem to beta blocker and ace inhibitor, they both will\\n help prevent atrial tachyarrhythmias. if any concerns about amiodarone\\n liver toxicity since in sinus tach can cut back dose\\n 8.\\n 9. ------ Protected Section Addendum Entered By: \\n on: 17:29 ------\\n 10.\\n 11.\\n 12. Electronically signed by 17:29\\n 13.\\n 14.\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2175-01-31 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 714230,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 7\\n Ideal body weight: 0 None\\n Ideal tidal volume: 0 / 0 / 0 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: Yes\\n Procedure location:\\n Reason:\\n Tube Type\\n ETT:\\n Position: cm at teeth\\n Route:\\n Type: Standard\\n Size: 7.5mm\\n Tracheostomy tube:\\n Type:\\n Manufacturer:\\n Size:\\n PMV:\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 20 cmH2O\\n Cuff volume: mL /\\n Airway problems:\\n Comments:\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Diminished\\n Comments:\\n Secretions\\n Sputum color / consistency: Yellow / Thick\\n Sputum source/amount: Suctioned / Moderate\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance:\\n Visual assessment of breathing pattern:\\n Assessment of breathing comfort:\\n Non-invasive ventilation assessment:\\n Invasive ventilation assessment:\\n Trigger work assessment:\\n Dysynchrony assessment:\\n Comments:\\n Plan\\n Next 24-48 hours:\\n Reason for continuing current ventilatory support:\\n Respiratory Care Shift Procedures\\n Transports:\\n Destination (R/T)\\n Time\\n Complications\\n Comments\\n Bedside Procedures:\\n Comments: Pt cont intub with OETT sedated and on mech vent as per\\n Metavision. Lung sounds ess clear after suct mod th tan sput. ABGs\\n metabolic alkalosis with adequate oxygenation on current vent settings;\\n no vent changes required overnoc. Cont PSV.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2175-01-31 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 714234,\n \"text\": \"Hypotension (not Shock)\\n Assessment:\\n Cont in aflutter with controlled rate. SBP remains > 90 on neo gtt.\\n Action:\\n Response:\\n Plan:\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2175-01-31 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 714336,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 7\\n Ideal body weight: 0 None\\n Ideal tidal volume: 0 / 0 / 0 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: Yes\\n Procedure location:\\n Reason:\\n Tube Type\\n ETT:\\n Position: 25 cm at teeth\\n Route: Oral\\n Type: Standard\\n Size: 7.5mm\\n Tracheostomy tube:\\n Type:\\n Manufacturer:\\n Size:\\n PMV:\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 25 cmH2O\\n Cuff volume: mL / Air\\n Airway problems:\\n Comments:\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Diminished\\n Comments:\\n Secretions\\n Sputum color / consistency: White / Thick\\n Sputum source/amount: Suctioned / Moderate\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance: Intermittent invasive ventilation\\n Visual assessment of breathing pattern: Normal quiet breathing\\n Assessment of breathing comfort: No response (sleeping / sedated)\\n Non-invasive ventilation assessment:\\n Invasive ventilation assessment:\\n Trigger work assessment:\\n Dysynchrony assessment:\\n Comments:\\n Plan\\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\\n Reason for continuing current ventilatory support: Pending procedure /\\n OR\\n Respiratory Care Shift Procedures\\n Transports:\\n Destination (R/T)\\n Time\\n Complications\\n Comments\\n Bedside Procedures:\\n Comments:\\n Patient remains on ventilator support. Tracheostomy planned for\\n tomorrow.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2175-01-29 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 714041,\n \"text\": \"74M s/p fall with multiple rib fx, pelvis fx, clavicle fx, and thoracic\\n fx c/b unstable bleeding s/p IR embo, AF with RVR, hematologic\\n abnormalities, now with resp failure.\\n Atrial fibrillation (Afib), aflutter\\n Assessment:\\n Pt in and out of aflutter with controlled rate. Predominently\\n aflutter. Hypotensive w/ sbp 80\\ns while in aflutter.\\n Action:\\n Pt started dilt gtt 5-10mg/hr. K=3.5 and lytes repleted. Neo gtt to\\n support sbp titrated to map >60 and sbp >100\\n Response:\\n Remains on dilt now at 10mg/hr. Briefly converted to nsr and then back\\n to aflutter. Sbp 90-115 w/ neo gtt.\\n Plan:\\n Cont to monitor hemodynamics. Wean neo gtt as tolerated. Cont dilt\\n gtt. PRN Lopressor. Replete lytes.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2175-01-28 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 713846,\n \"text\": \"Atrial fibrillation (Afib)\\n Assessment:\\n HR 60s-80s SR with 1^st degree AV block.\\n Action:\\n Continues on diltiazem.\\n Response:\\n HR stable. Continue on neo for BP.\\n Plan:\\n Continue to monitor HR and BP.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n On PS 12/12/40%. LS clear and diminished.\\n Action:\\n Sx\\nd for minimal secretions.\\n Response:\\n O2 Sat stable. ABG marginal and no attempts to wean further at this\\n time.\\n Plan:\\n Continue to attempt to wean vent when able.\\n Hypotension (not Shock)\\n Assessment:\\n Continues on neo gtt to maintain goal map >65. Urine output\\n 30-40cc/hr.\\n Action:\\n Able to wean neo down to 0.3mcg/kg/min. Gave albumin last pm and pt\\n BP increased for awhile.\\n Response:\\n Continues grossly edematous.\\n Plan:\\n Plan for possible albumin/lasix combination- to be decided.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2175-01-28 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 713848,\n \"text\": \"Atrial fibrillation (Afib)\\n Assessment:\\n HR 60s-80s SR with 1^st degree AV block.\\n Action:\\n Continues on diltiazem.\\n Response:\\n HR stable. Continue on neo for BP.\\n Plan:\\n Continue to monitor HR and BP.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n On PS 12/12/40%. LS clear and diminished.\\n Action:\\n Sx\\nd for minimal secretions.\\n Response:\\n O2 Sat stable. ABG marginal and no attempts to wean further at this\\n time.\\n Plan:\\n Continue to attempt to wean vent when able.\\n Hypotension (not Shock)\\n Assessment:\\n Continues on neo gtt to maintain goal map >65. Urine output\\n 30-40cc/hr. On 25mcg propofol and when off propofol follows commands\\n and denies pain. Very agitated off propofol and placed back on lowest\\n dose possible.\\n Action:\\n Able to wean neo down to 0.3mcg/kg/min. Gave albumin last pm and pt\\n BP increased for awhile.\\n Response:\\n Continues grossly edematous.\\n Plan:\\n Plan for possible albumin/lasix combination- to be decided.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2175-02-01 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 714462,\n \"text\": \"TSICU\\n HPI:\\n 74M s/p fall with multiple rib fx, pelvis fx, clavicle fx, and thoracic\\n fx c/b unstable bleeding s/p IR embo, now with AF with RVR/Aflutter,\\n persistant hypotension and presumed PNA.\\n Chief complaint:\\n fall\\n PMHx:\\n none\\n Current medications:\\n 1. Acetaminophen 2. Amiodarone 3. Bisacodyl 4. Calcium Gluconate 5.\\n CeftriaXONE 6. Chlorhexidine Gluconate 0.12% Oral Rinse 7. Dextrose 50%\\n 8. Diltiazem 9. Docusate Sodium (Liquid) 10. Fentanyl Citrate 11.\\n Gabapentin 12. Glucagon 13. Heparin 14. Insulin 15. Lactulose 16.\\n Magnesium Sulfate 17. Metoprolol Tartrate 18. Midazolam 19. Midazolam\\n 20. Milk of Magnesia 21. Ondansetron 22. OxycoDONE Liquid 23.\\n Pantoprazole 24. Phenylephrine\\n 25. Pneumococcal Vac Polyvalent 26. Potassium Phosphate 27. Potassium\\n Chloride 28. Senna 29. Sodium Chloride 0.9% Flush\\n 24 Hour Events:\\n Changed sedation to po Oxycodone, wean fentanyl gtt, wean Midazolam,\\n and start Haldol prn, but stopped due to QTc. Cards consult, started\\n amiodarone.\\n Post operative day:\\n POD#6 - IVC filter via L groin\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\\n Vancomycin - 08:00 AM\\n Ceftriaxone - 12:00 PM\\n Infusions:\\n Midazolam (Versed) - 5 mg/hour\\n Fentanyl (Concentrate) - 50 mcg/hour\\n Amiodarone - 0.5 mg/min\\n Other ICU medications:\\n Haloperidol (Haldol) - 10:45 AM\\n Lorazepam (Ativan) - 02:00 PM\\n Midazolam (Versed) - 03:25 AM\\n Fentanyl - 03:25 AM\\n Heparin Sodium (Prophylaxis) - 05:33 AM\\n Other medications:\\n Flowsheet Data as of 06:27 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 38.1\\nC (100.6\\n T current: 37.2\\nC (98.9\\n HR: 76 (74 - 104) bpm\\n BP: 125/62(81) {90/49(62) - 152/67(89)} mmHg\\n RR: 25 (18 - 31) insp/min\\n SPO2: 98%\\n Heart rhythm: A Flut (Atrial Flutter)\\n Wgt (current): 102 kg (admission): 90 kg\\n CVP: 12 (10 - 19) mmHg\\n Total In:\\n 3,718 mL\\n 759 mL\\n PO:\\n Tube feeding:\\n 1,920 mL\\n 424 mL\\n IV Fluid:\\n 1,078 mL\\n 245 mL\\n Blood products:\\n Total out:\\n 1,755 mL\\n 350 mL\\n Urine:\\n 1,755 mL\\n 350 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,963 mL\\n 409 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 480 (400 - 540) mL\\n PS : 10 cmH2O\\n RR (Spontaneous): 29\\n PEEP: 10 cmH2O\\n FiO2: 50%\\n RSBI Deferred: PEEP > 10\\n PIP: 21 cmH2O\\n SPO2: 98%\\n ABG: 7.44/45/119/31/6\\n Ve: 11.8 L/min\\n PaO2 / FiO2: 238\\n Physical Examination\\n General Appearance: No acute distress, intubated\\n HEENT: PERRL\\n Cardiovascular: (Rhythm: Regular)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\\n bilateral : ), shallow respirations\\n Abdominal: Soft, No(t) Non-distended, Bowel sounds present, Distended\\n Left Extremities: (Edema: 1+), (Temperature: Warm)\\n Right Extremities: (Edema: 1+), (Temperature: Warm)\\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\\n Moves all extremities, Sedated\\n Labs / Radiology\\n 104 K/uL\\n 9.5 g/dL\\n 129 mg/dL\\n 0.7 mg/dL\\n 31 mEq/L\\n 4.2 mEq/L\\n 24 mg/dL\\n 106 mEq/L\\n 142 mEq/L\\n 29.7 %\\n 4.2 K/uL\\n [image002.jpg]\\n 04:45 PM\\n 12:45 AM\\n 01:00 AM\\n 05:12 AM\\n 02:40 PM\\n 01:46 AM\\n 01:55 AM\\n 03:40 PM\\n 12:07 AM\\n 02:18 AM\\n WBC\\n 13.1\\n 8.8\\n 4.2\\n Hct\\n 31.6\\n 32.1\\n 29.7\\n Plt\\n 158\\n 153\\n 104\\n Creatinine\\n 0.8\\n 0.7\\n 0.7\\n 0.7\\n TCO2\\n 35\\n 35\\n 34\\n 37\\n 35\\n 32\\n Glucose\\n 131\\n 115\\n 132\\n 122\\n 117\\n 129\\n Other labs: PT / PTT / INR:13.7/27.6/1.2, CK / CK-MB / Troponin\\n T:128/13/<0.01, ALT / AST:87/109, Alk-Phos / T bili:115/5.0, Amylase /\\n Lipase:44/, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic Acid:1.4\\n mmol/L, Albumin:2.7 g/dL, LDH:348 IU/L, Ca:7.9 mg/dL, Mg:2.0 mg/dL,\\n PO4:3.4 mg/dL\\n Assessment and Plan\\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, now\\n with AF with RVR/Aflutter, persistant hypotension and presumed PNA.\\n Neurologic: Intubated. Per ortho spine, no surgery; HOB<30, TLSO when\\n OOB (NEOPS will place). Wean sedation as may be causing hypotension.\\n Change pain meds to PO. Wean versed.\\n Neuro checks Q: shift\\n Pain: Oxycodone, Fentanyl gtt (weaning), Midazolam gtt (weaning),\\n Neurontin, Tylenol\\n Cardiovascular: Aflutter on Dilt 60mg PO QID. Neo off since this AM.\\n Cards yesterday rec Amio Pressor requirements may be related to\\n AFib/flutter. No plan for electrical cardioversion right now. As pt\\n cannot be anticoagulated (recent major trauma), had TTE w/o thrombus,\\n Cards would like anticoagulation, will hold on heparin per Trauma\\n surgery.\\n Pulmonary: Intubated, weaning, tachypneic likely abd distension. On\\n appropriate abx per BAL cx\\n Ceftriaxone. Plan for trach today.\\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin (declining 6.8\\n max ->5.0) with CT scan suggesting cirrhosis - Hepatitis panel NEG. TFs\\n on hold for PEG. Bowel regimen, no B29.7. Plt low but stable (100's); d/c'd\\n H2B with increasing plt count. Heme onc consulted - smear nl; no\\n hemolysis. IVC filter placed.\\n Endocrine: RISS\\n Infectious Disease: WBC droppping 13.1->8.8->4.2, f/u Cx - BAL:\\n Klebsiella - Ceftriaxone\\n Lines / Tubes / Drains: R SC CVL (), PIV x2, Foley, L a-line\\n (), ETT\\n Imaging: CXR today\\n Fluids: -\\n Consults: Trauma (1o), Ortho Spine, Ortho trauma, Heme\\n Billing Diagnosis:\\n ICU Care\\n Nutrition:\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n Multi Lumen - 04:41 PM\\n Arterial Line - 11:30 AM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin, IVC filter\\n Stress ulcer: PPI\\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\\n Comments:\\n Communication: ICU consent signed Comments:\\n Code status: Full code\\n Disposition: ICU\\n Total time spent: 33 min\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2175-02-01 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 714464,\n \"text\": \"TSICU\\n HPI:\\n 74M s/p fall with multiple rib fx, pelvis fx, clavicle fx, and thoracic\\n fx c/b unstable bleeding s/p IR embo, now with AF with RVR/Aflutter,\\n persistant hypotension and presumed PNA.\\n Chief complaint:\\n fall\\n PMHx:\\n none\\n Current medications:\\n 1. Acetaminophen 2. Amiodarone 3. Bisacodyl 4. Calcium Gluconate 5.\\n CeftriaXONE 6. Chlorhexidine Gluconate 0.12% Oral Rinse 7. Dextrose 50%\\n 8. Diltiazem 9. Docusate Sodium (Liquid) 10. Fentanyl Citrate 11.\\n Gabapentin 12. Glucagon 13. Heparin 14. Insulin 15. Lactulose 16.\\n Magnesium Sulfate 17. Metoprolol Tartrate 18. Midazolam 19. Midazolam\\n 20. Milk of Magnesia 21. Ondansetron 22. OxycoDONE Liquid 23.\\n Pantoprazole 24. Phenylephrine\\n 25. Pneumococcal Vac Polyvalent 26. Potassium Phosphate 27. Potassium\\n Chloride 28. Senna 29. Sodium Chloride 0.9% Flush\\n 24 Hour Events:\\n Changed sedation to po Oxycodone, wean fentanyl gtt, wean Midazolam,\\n and start Haldol prn, but stopped due to QTc. Cards consult, started\\n amiodarone.\\n Post operative day:\\n POD#6 - IVC filter via L groin\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\\n Vancomycin - 08:00 AM\\n Ceftriaxone - 12:00 PM\\n Infusions:\\n Midazolam (Versed) - 5 mg/hour\\n Fentanyl (Concentrate) - 50 mcg/hour\\n Amiodarone - 0.5 mg/min\\n Other ICU medications:\\n Haloperidol (Haldol) - 10:45 AM\\n Lorazepam (Ativan) - 02:00 PM\\n Midazolam (Versed) - 03:25 AM\\n Fentanyl - 03:25 AM\\n Heparin Sodium (Prophylaxis) - 05:33 AM\\n Other medications:\\n Flowsheet Data as of 06:27 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 38.1\\nC (100.6\\n T current: 37.2\\nC (98.9\\n HR: 76 (74 - 104) bpm\\n BP: 125/62(81) {90/49(62) - 152/67(89)} mmHg\\n RR: 25 (18 - 31) insp/min\\n SPO2: 98%\\n Heart rhythm: A Flut (Atrial Flutter)\\n Wgt (current): 102 kg (admission): 90 kg\\n CVP: 12 (10 - 19) mmHg\\n Total In:\\n 3,718 mL\\n 759 mL\\n PO:\\n Tube feeding:\\n 1,920 mL\\n 424 mL\\n IV Fluid:\\n 1,078 mL\\n 245 mL\\n Blood products:\\n Total out:\\n 1,755 mL\\n 350 mL\\n Urine:\\n 1,755 mL\\n 350 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,963 mL\\n 409 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 480 (400 - 540) mL\\n PS : 10 cmH2O\\n RR (Spontaneous): 29\\n PEEP: 10 cmH2O\\n FiO2: 50%\\n RSBI Deferred: PEEP > 10\\n PIP: 21 cmH2O\\n SPO2: 98%\\n ABG: 7.44/45/119/31/6\\n Ve: 11.8 L/min\\n PaO2 / FiO2: 238\\n Physical Examination\\n General Appearance: No acute distress, intubated\\n HEENT: PERRL\\n Cardiovascular: (Rhythm: Regular)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\\n bilateral : ), shallow respirations\\n Abdominal: Soft, No(t) Non-distended, Bowel sounds present, Distended\\n Left Extremities: (Edema: 1+), (Temperature: Warm)\\n Right Extremities: (Edema: 1+), (Temperature: Warm)\\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\\n Moves all extremities, Sedated\\n Labs / Radiology\\n 104 K/uL\\n 9.5 g/dL\\n 129 mg/dL\\n 0.7 mg/dL\\n 31 mEq/L\\n 4.2 mEq/L\\n 24 mg/dL\\n 106 mEq/L\\n 142 mEq/L\\n 29.7 %\\n 4.2 K/uL\\n [image002.jpg]\\n 04:45 PM\\n 12:45 AM\\n 01:00 AM\\n 05:12 AM\\n 02:40 PM\\n 01:46 AM\\n 01:55 AM\\n 03:40 PM\\n 12:07 AM\\n 02:18 AM\\n WBC\\n 13.1\\n 8.8\\n 4.2\\n Hct\\n 31.6\\n 32.1\\n 29.7\\n Plt\\n 158\\n 153\\n 104\\n Creatinine\\n 0.8\\n 0.7\\n 0.7\\n 0.7\\n TCO2\\n 35\\n 35\\n 34\\n 37\\n 35\\n 32\\n Glucose\\n 131\\n 115\\n 132\\n 122\\n 117\\n 129\\n Other labs:\\n PT / PTT / INR:13.7/27.6/1.2, CK / CK-MB / Troponin T:128/13/<0.01,\\n ALT / AST:87/109, Alk-Phos / T bili:115/5.0, Amylase / Lipase:44/,\\n D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic Acid:1.4 mmol/L,\\n Albumin:2.7 g/dL, LDH:348 IU/L, Ca:7.9 mg/dL, Mg:2.0 mg/dL, PO4:3.4\\n mg/dL\\n Assessment and Plan\\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, now\\n with AF with RVR/Aflutter, persistant hypotension and presumed PNA.\\n Neurologic: Intubated. Per ortho spine, no surgery; HOB<30, TLSO when\\n OOB (NEOPS will place). Wean sedation as may be causing hypotension.\\n Change pain meds to PO. Wean versed.\\n Neuro checks Q: shift\\n Pain: Oxycodone, Fentanyl gtt (weaning), Midazolam gtt (weaning),\\n Neurontin, Tylenol\\n Cardiovascular: Aflutter on Dilt 60mg PO QID. Neo off since this AM.\\n Cards yesterday rec Amiodarone. Pressor requirements may be related to\\n AFib/flutter. No plan for electrical cardioversion right now. As pt\\n cannot be anticoagulated (recent major trauma), had TTE w/o thrombus,\\n Cards would like anticoagulation, will hold on heparin per Trauma\\n surgery.\\n Pulmonary: Intubated, weaning, tachypneic likely abd distension. On\\n appropriate abx per BAL cx\\n Ceftriaxone. Plan for trach today.\\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin (declining 6.8\\n max\\n 5.0) with CT scan suggesting cirrhosis - Hepatitis panel NEG. TFs\\n on hold for PEG. Bowel regimen, no BM since admission MOM and Lactulose\\n added, will try Methylnaltrexone.\\n Nutrition: NPO pre-op.\\n Renal: Foley, monitor UOP, edematous scrotum but soft, eccymosis\\n improving.\\n Hematology: Hct stable 32.1->29.7. Plt low but stable (100's); d/c'd\\n H2B with increasing plt count. Heme onc consulted - smear nl; no\\n hemolysis. IVC filter placed.\\n Endocrine: RISS, goal BS<150, adequate control.\\n Infectious Disease: WBC dropping 13.1->8.8->4.2, f/u Cx - BAL:\\n Klebsiella\\n Ceftriaxone. Will add Vanco back for GPCs coverage if\\n patient worsens.\\n Lines / Tubes / Drains: R SC CVL (), Foley, L a-line (), ETT\\n Imaging: CXR today\\n Fluids: KVO\\n Consults: Trauma (1o), Ortho Spine, Ortho trauma, Heme\\n Billing Diagnosis:\\n ICU Care\\n Nutrition:\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n Multi Lumen - 04:41 PM\\n Arterial Line - 11:30 AM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin, IVC filter\\n Stress ulcer: PPI\\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\\n Comments:\\n Communication: ICU consent signed Comments:\\n Code status: Full code\\n Disposition: ICU\\n Total time spent: 33 min\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2175-02-01 00:00:00.000\",\n \"description\": \"Cardiology Physician Note\",\n \"row_id\": 714493,\n \"text\": \"TITLE:\\n History of Present Illness\\n Date: \\n Subsequent care\\n Seen and examined with: Dr. \\n Events / History of present illness: Started amiodarone gtt, weaned off\\n neo yesterday. This AM, dropped his sats and hypotensive. Neo\\n restarted.\\n Medications\\n Unchanged\\n Dilt 60 QID\\n Amio gtt at 0.5\\n Neo at 0.8\\n Physical Exam\\n General appearance: Intubated, sedated\\n BP: 105 / 57 mmHg\\n HR: 75 bpm\\n RR: 24 insp/min\\n Tmax C last 24 hours: 37.6 C\\n Tmax F last 24 hours: 99.6 F\\n T current C: 37.5 C\\n T current F: 99.5 F\\n Previous day:\\n Intake: 3,716 mL\\n Output: 1,755 mL\\n Fluid balance: 1,961 mL\\n Today:\\n Intake: 940 mL\\n Output: 650 mL\\n Fluid balance: 290 mL\\n HEENT: (Conjunctiva and lids: NL), (Jugular veins: ~8cm)\\n Cardiovascular: (Auscultation: RR, NR, no murmurs)\\n Respiratory: (Auscultation: rhonchorous)\\n Abdomen: (Palpation: Soft)\\n Extremities:\\n Right: (Edema: 2+)\\n Left: (Edema: 2+)\\n Other: Diffuse edema\\n Labs\\n 104\\n 9.5\\n 100\\n 0.7\\n 31\\n 4.2\\n 24\\n 106\\n 142\\n 29.7\\n 4.2\\n [image002.jpg]\\n 02:55 AM\\n 09:45 AM\\n 04:21 PM\\n 12:45 AM\\n 01:00 AM\\n 05:12 AM\\n 01:46 AM\\n 01:55 AM\\n 02:18 AM\\n 08:00 AM\\n WBC\\n 6.5\\n 13.1\\n 8.8\\n 4.2\\n Hgb\\n 10.1\\n 10.7\\n 10.7\\n 9.5\\n Hct (Serum)\\n 29.3\\n 31.6\\n 32.1\\n 29.7\\n Plt\\n 86\\n 158\\n 153\\n 104\\n INR\\n 1.1\\n 1.2\\n 1.2\\n PTT\\n 26.8\\n 26.9\\n 27.6\\n Na+\\n 143\\n 148\\n 143\\n 143\\n 142\\n K + (Serum)\\n 3.6\\n 4.1\\n 4.0\\n 4.0\\n 3.9\\n 4.2\\n K + (Whole blood)\\n 3.5\\n Cl\\n 106\\n 111\\n 108\\n 106\\n 106\\n HCO3\\n 33\\n 34\\n 32\\n 32\\n 31\\n BUN\\n 19\\n 20\\n 19\\n 22\\n 24\\n Creatinine\\n 0.8\\n 0.8\\n 0.7\\n 0.7\\n 0.7\\n Glucose\\n 141\\n 107\\n 131\\n 115\\n 132\\n 122\\n 117\\n 129\\n 100\\n CK\\n 225\\n 128\\n ABG: / / / 31 / Values as of 02:18 AM\\n Tests\\n Telemetry: Aflutter at 70s, 3-4:1 up to 2:1 this AM.\\n Assessment and Plan\\n Continues to be in Aflutter on amio gtt. Able to wean down on neo\\n yesterday, but restarted this AM. As mentioned yesterday, very\\n unlikely that hypotension is a result of aflutter itself (loss of\\n atrial kick) based on echocardiogram (Normal E/A ratio) and he was able\\n to be weaned off the drip yesterday despite continued Aflutter. Would\\n search for other etiologies of hypotension (infection, hypovolemia); he\\n appears to have a large amount of third spacing on my exam, so he may\\n be intravascularly deplete despite being total body fluid overloaded.\\n Can increase Dilt to 90 QID if necessary for better rate control if BP\\n tolerates, but at this point would search for other causes of\\n hypotension.\\n Recs:\\n --Continue amiodarone gtt at 0.5\\n --Continue diltiazem\\n --Cont to monitor, consider IVFs to wean off neo\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2175-02-02 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 714574,\n \"text\": \"Demographics\\n Day of intubation: \\n Day of mechanical ventilation: 9\\n Ideal body weight: 0 None\\n Ideal tidal volume: 0 / 0 / 0 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: Yes\\n Tube Type\\n Tracheostomy tube:\\n Type: Perc Trach\\n Manufacturer: Portex\\n Size: 8.0mm\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 25 cmH2O\\n Lung sounds\\n RLL Lung Sounds: Clear\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Clear\\n Secretions\\n Sputum color / consistency: Rusty / Thick\\n Sputum source/amount: Suctioned / Moderate\\n Ventilation Assessment\\n Level of breathing assistance: Continuous invasive ventilation\\n Visual assessment of breathing pattern: Normal quiet breathing\\n Assessment of breathing comfort: No response (sleeping / sedated)\\n Invasive ventilation assessment:\\n Trigger work assessment: Triggering synchronously\\n Plan\\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\\n Reason for continuing current ventilatory support: Intolerant of\\n weaning attempts\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2175-02-03 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 714840,\n \"text\": \"Atrial fibrillation (Afib)\\n Assessment:\\n Atrial flutter with RVR up to 120\\ns. BP stable. Not responding to IV\\n beta blockers.\\n Action:\\n Cont PO lopressor and Amioderone, started Diltiazem gtt and titrating\\n up for HR <100.\\n Response:\\n A flutter continues, rate better controlled.\\n Plan:\\n Maintain rate control, monitor hemodynamics, titrate dilt gtt for HR.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n LS rhonchi, SaO2 100%, copious amounts of thick white secretions.\\n Patient becoming very agitated and confused at times.\\n Action:\\n No change in vent settings. PRN anxiety meds given.\\n Response:\\n Patient responding well to haldol.\\n Plan:\\n Wean vent settings as tolerated, CXR in AM. Improve confusion.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2175-02-03 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 714844,\n \"text\": \"Atrial fibrillation (Afib)\\n Assessment:\\n Atrial flutter with RVR up to 120\\ns. BP stable. Not responding to IV\\n beta blockers.\\n Action:\\n Cont PO lopressor and Amioderone, started Diltiazem gtt and titrating\\n up for HR <100.\\n Response:\\n A flutter continues, rate better controlled.\\n Plan:\\n Maintain rate control, monitor hemodynamics, titrate dilt gtt for HR.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n LS rhonchi, SaO2 100%, copious amounts of thick white secretions.\\n Patient becoming very agitated and confused at times.\\n Action:\\n No change in vent settings. PRN anxiety meds given.\\n Response:\\n Patient responding well to haldol.\\n Plan:\\n Wean vent settings as tolerated, CXR in AM. Improve confusion.\\n\"\n },\n {\n \"category\": \"Rehab Services\",\n \"chartdate\": \"2175-02-02 00:00:00.000\",\n \"description\": \"Physical Therapy Evaluation Note\",\n \"row_id\": 714650,\n \"text\": \"Attending Physician: \\n Referral date: \\n Medical Diagnosis / ICD 9: crush injury / 959.9\\n Reason of referral: Eval & treat\\n History of Present Illness / Subjective Complaint: 74 yo M admitted\\n s/p fall from tractor and crush injury from tree branch.\\n Sustained multiple fib fxs (R anterolateral and L posterior), R\\n pulmonary contusion, T4 vertebral teardrop fx, T2-T8 spinous process\\n fx, nondisplaced L T10 transverse process fx, nondisplaced L distal \\n clavicle fx, R medial lobe liver contusion with hematoma, comminuted L\\n pubic ramus fx with hematoma, nondisplaced comminuted L iliac bone fx\\n extending into L SI joint with adjacent iliac muscle hematoma,\\n minimally displaced fx of R iliac bone extending to R SI joint.\\n Underwent angio on for embolization of pelvic and hepatic\\n vessels, IVC filter placed , and trach/peg placement .\\n Past Medical / Surgical History: none\\n Medications: tylenol, midazolam, metoprolol, diltiazem, gabapentin,\\n heparin, oxycodone, fentanyl, lactulose, cefepime, ciprofloxacin,\\n lorazepam, vancomycin, amiodarone\\n Radiology: CXR - Persistent bilateral pleural effusions and\\n bibasilar opacity, likely atelectasis but underlying infection not\\n excluded\\n Labs:\\n 31.3\\n 10.2\\n 109\\n 5.9\\n [image002.jpg]\\n Other labs:\\n Activity Orders: Activity as tolerated, TLSO for OOB\\n Social / Occupational History: lives with wife, supportive family at\\n bedside\\n Living Environment:\\n Prior Functional Status / Activity Level: I pta, no DME\\n Objective Test\\n Arousal / Attention / Cognition / Communication: alert, oriented to\\n self and place, follows all simple commands. Mouths words with some\\n effectiveness.\\n Aerobic Capacity\\n HR\\n BP\\n RR\\n O[2] sat\\n RPE\\n Rest\\n 80\\n 102/50\\n 14\\n 97% on CPAP\\n Activity\\n 94\\n 160/74\\n 32\\n Recovery\\n 90\\n 154/72\\n 20\\n 99% on CPAP\\n Total distance walked: 0\\n Minutes:\\n Pulmonary Status: coarse upper BS with congested cough, incline suction\\n small amount thin yellow secretions. On CPAP 10/15 PEEP/PS, 60% FiO2.\\n Integumentary / Vascular: L radial a-line, R subclavian multi-lumen,\\n foley, tele, trach, TLSO\\n Sensory Integrity: B LE's intact to light touch\\n Pain / Limiting Symptoms: denies pain\\n Posture: denies pain\\n Range of Motion\\n Muscle Performance\\n B LE's WNL\\n B UE/LE's grossly t/o\\n Motor Function: no abnormal movement patterns\\n Functional Status:\\n Activity\\n Clarification\\n I\\n S\\n CG\\n Min\\n Mod\\n Max\\n Gait, Locomotion: total assist slide transfers from bed to stretcher\\n chair.\\n Rolling:\\n\\n\\n\\n\\n\\n T\\n Supine /\\n Sidelying to Sit:\\n\\n\\n\\n\\n X2\\n Transfer:\\n\\n\\n\\n\\n\\n Sit to Stand:\\n\\n\\n\\n\\n\\n Ambulation:\\n\\n\\n\\n\\n\\n Stairs:\\n\\n\\n\\n\\n\\n Balance: initially max A to maintain static sitting but was able to\\n progress to CG for several seconds at a time and mostly min A. Able to\\n weight shift anteriorly and laterally with mod A. Tolerated sitting at\\n edge of bed 5-10 min.\\n Education / Communication: Reviewed PT , positioning and use of\\n TLSO, d/c planning. Communicated with nsg re: status.\\n Intervention:\\n Diagnosis:\\n 1.\\n Impaired functional mobility\\n 2.\\n Impaired endurance\\n 3.\\n Impaired balance\\n 4.\\n Impaired strength\\n 5.\\n Impaired pulmonary hygiene\\n Clinical impression / Prognosis: 74 yo M s/p crush injury p/w above\\n impairments a/w bony fractures. He is most limited by general weakness\\n a/w prolonged icu hospitalization with intubation and sedation, as well\\n as ventilator dependency. He is significantly below his baseline, but\\n given his age and prior level of function, would anticipate a good\\n prognosis and excellent rehab potential to return to independent level\\n of function. PT to continue to follow and progress as able at acute\\n level.\\n Goals\\n Time frame: 1 week\\n 1.\\n Mod A bed mobility, assess sit-to-stand and transfers\\n 2.\\n Tolerate OOB >/= 3 hours/day\\n 3.\\n Static/dynamic sitting balance with CG, assess standing balance\\n 4.\\n Tolerate daily UE/LE strengthening\\n 5.\\n Tolerates trach mask t/o PT session\\n 6.\\n Anticipated Discharge: Rehab\\n Treatment Plan:\\n Frequency / Duration: 3-5x/wk\\n bed mobility, transfers, balance, endurance, strengthening, education,\\n d/c planning\\n T Patient agrees with the above goals and is willing to participate in\\n the rehabilitation program.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2175-02-02 00:00:00.000\",\n \"description\": \"EP NOTE\",\n \"row_id\": 714651,\n \"text\": \"Cardiac Electrophysiology Note:\\n History of Present Illness\\n Date: \\n Subsequent care\\n Events / History of present illness: 74M no known PMH, presented on\\n s/p fall from tractor and crush injury with right ribs and pelvic\\n fractures and T4 vertebral body fracture. He was given 4 U PRBC, 1 unit\\n FFP, and underwent arteriogram on with embolization to the liver\\n and pelvis and IVC filter placement for concern of high likelihood of\\n development of DVT and inability to anticoagulate. We were consulted\\n d/t paroxysmal atrial flutter which has started on the morning of\\n . He was started on Amiodarone drip, with subsequent conversion to\\n sinus rhythm last evening. He is currently post PEG and tracheostomy,\\n awake and alert. He is in sinus rhythm at the 90s, on Amiodarone P.O.\\n Medications\\n Unchanged\\n Physical Exam\\n Tmax C last 24 hours: 37.7 C\\n Tmax F last 24 hours: 99.9 F\\n T current C: 36.3 C\\n T current F: 97.4 F\\n Previous day:\\n Intake: 1,764 mL\\n Output: 1,630 mL\\n Fluid balance: 134 mL\\n Today:\\n Intake: 863 mL\\n Output: 1,115 mL\\n Fluid balance: -252 mL\\n General: Awake and alert. Sitting in a chair. No acute distress\\n Cardiovascular: (Auscultation: RRR, no murmurs)\\n Respiratory: (Auscultation: Limited exam: clear to auscultation, no\\n rales or wheezes)\\n Abdomen: (Limited exam: Could not appreciate organomegaly )\\n Neurological: (Orientation: Awake and alert)\\n Labs\\n 109\\n 10.2\\n 110\\n 0.8\\n 31\\n 4.5\\n 24\\n 105\\n 144\\n 31.3\\n 5.9\\n [image002.jpg]\\n 01:00 AM\\n 05:12 AM\\n 01:46 AM\\n 01:55 AM\\n 02:18 AM\\n 08:00 AM\\n 02:00 PM\\n 08:00 PM\\n 01:00 AM\\n 01:07 AM\\n WBC\\n 8.8\\n 4.2\\n 5.9\\n Hgb\\n 10.7\\n 9.5\\n 10.2\\n Hct (Serum)\\n 32.1\\n 29.7\\n 31.3\\n Plt\\n 153\\n 104\\n 109\\n INR\\n 1.2\\n PTT\\n 27.6\\n Na+\\n 143\\n 143\\n 142\\n 144\\n K + (Serum)\\n 4.0\\n 3.9\\n 4.2\\n 4.5\\n Cl\\n 108\\n 106\\n 106\\n 105\\n HCO3\\n 32\\n 32\\n 31\\n 31\\n BUN\\n 19\\n 22\\n 24\\n 24\\n Creatinine\\n 0.7\\n 0.7\\n 0.7\\n 0.8\\n Glucose\\n 115\\n 132\\n 122\\n 117\\n 129\\n 100\\n 111\\n 105\\n 117\\n 110\\n CK\\n 225\\n 128\\n ABG: 7.45 / 49 / 98 / / 8 Values as of 01:18 AM\\n Assessment and Plan\\n ATRIAL FLUTTER: converted to sinus yesterday evening with I.V\\n amiodarome. Would recommend:\\n 1. Amiodarone PO 400 mg .\\n 2. Metoprolol Succinate PO 25 mg .\\n 3. Discontinue Diltiazem P.O.\\n 4. Discontinue I.V Metoprolol\\n 5. Consider Heparin I.V with a goal of PTT between 60-80 seconds\\n if it is not contra-indicated from his trauma standpoint\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2175-02-02 00:00:00.000\",\n \"description\": \"EP NOTE\",\n \"row_id\": 714652,\n \"text\": \"Cardiac Electrophysiology Note:\\n History of Present Illness\\n Date: \\n Subsequent care\\n Events / History of present illness: 74M no known PMH, presented on\\n s/p fall from tractor and crush injury with right ribs and pelvic\\n fractures and T4 vertebral body fracture. He was given 4 U PRBC, 1 unit\\n FFP, and underwent arteriogram on with embolization to the liver\\n and pelvis and IVC filter placement for concern of high likelihood of\\n development of DVT and inability to anticoagulate. We were consulted\\n d/t paroxysmal atrial flutter which has started on the morning of\\n . He was started on Amiodarone drip, with subsequent conversion to\\n sinus rhythm last evening. He is currently post PEG and tracheostomy,\\n awake and alert. He is in sinus rhythm at the 90s, on Amiodarone P.O.\\n Medications\\n Unchanged\\n Physical Exam\\n Tmax C last 24 hours: 37.7 C\\n Tmax F last 24 hours: 99.9 F\\n T current C: 36.3 C\\n T current F: 97.4 F\\n Previous day:\\n Intake: 1,764 mL\\n Output: 1,630 mL\\n Fluid balance: 134 mL\\n Today:\\n Intake: 863 mL\\n Output: 1,115 mL\\n Fluid balance: -252 mL\\n General: Awake and alert. Sitting in a chair. No acute distress\\n Cardiovascular: (Auscultation: RRR, no murmurs)\\n Respiratory: (Auscultation: Limited exam: clear to auscultation, no\\n rales or wheezes)\\n Abdomen: (Limited exam: Could not appreciate organomegaly )\\n Neurological: (Orientation: Awake and alert)\\n Labs\\n 109\\n 10.2\\n 110\\n 0.8\\n 31\\n 4.5\\n 24\\n 105\\n 144\\n 31.3\\n 5.9\\n [image002.jpg]\\n 01:00 AM\\n 05:12 AM\\n 01:46 AM\\n 01:55 AM\\n 02:18 AM\\n 08:00 AM\\n 02:00 PM\\n 08:00 PM\\n 01:00 AM\\n 01:07 AM\\n WBC\\n 8.8\\n 4.2\\n 5.9\\n Hgb\\n 10.7\\n 9.5\\n 10.2\\n Hct (Serum)\\n 32.1\\n 29.7\\n 31.3\\n Plt\\n 153\\n 104\\n 109\\n INR\\n 1.2\\n PTT\\n 27.6\\n Na+\\n 143\\n 143\\n 142\\n 144\\n K + (Serum)\\n 4.0\\n 3.9\\n 4.2\\n 4.5\\n Cl\\n 108\\n 106\\n 106\\n 105\\n HCO3\\n 32\\n 32\\n 31\\n 31\\n BUN\\n 19\\n 22\\n 24\\n 24\\n Creatinine\\n 0.7\\n 0.7\\n 0.7\\n 0.8\\n Glucose\\n 115\\n 132\\n 122\\n 117\\n 129\\n 100\\n 111\\n 105\\n 117\\n 110\\n CK\\n 225\\n 128\\n ABG: 7.45 / 49 / 98 / / 8 Values as of 01:18 AM\\n Assessment and Plan\\n ATRIAL FLUTTER: converted to sinus yesterday evening with I.V\\n amiodarome. Would recommend:\\n 1. Amiodarone PO 400 mg .\\n 2. Metoprolol Succinate PO 25 mg .\\n 3. Discontinue Diltiazem P.O.\\n 4. Discontinue I.V Metoprolol\\n 5. Consider Heparin I.V with a goal of PTT between 60-80 seconds\\n if it is not contra-indicated from his trauma standpoint\\n ------ Protected Section ------\\n 1. Would also recommend liver enzymes follow up given his\\n elevated LFT\\ns and Amiodarone treatment\\n 2. Amiodarone 400mg for 1 week followed by Amiodarone 400 mg\\n daily for 1 week, and then Amiodarone 200 mg daily.\\n 3. ------ Protected Section Addendum Entered By:\\n , MD on: 13:00 ------\\n 4.\\n 5.\\n 6. Electronically signed by , MD \\n 13:00\\n 7.\\n 8.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2175-02-02 00:00:00.000\",\n \"description\": \"Cardiology Physician Note\",\n \"row_id\": 714655,\n \"text\": \"TITLE:\\n History of Present Illness\\n Date: \\n Subsequent care\\n Events / History of present illness: Trach/PEG yesterday. Converted to\\n sinus rhythm yesterday at 7PM. Off pressors.\\n Medications\\n Unchanged\\n Physical Exam\\n General appearance: NAD\\n BP: 147 / 73 mmHg\\n HR: 93 bpm\\n RR: 17 insp/min\\n Tmax C last 24 hours: 37.7 C\\n Tmax F last 24 hours: 99.9 F\\n T current C: 36.3 C\\n T current F: 97.4 F\\n O2 sat: 98 % on Supplemental oxygen: PSV 16/10 on 60% O2\\n Previous day:\\n Intake: 1,764 mL\\n Output: 1,630 mL\\n Fluid balance: 134 mL\\n Today:\\n Intake: 619 mL\\n Output: 1,020 mL\\n Fluid balance: -401 mL\\n HEENT: (Conjunctiva and lids: NL), (Jugular veins: ~8-10cm)\\n Cardiovascular: (Auscultation: RR, NR, No murmurs), (Palpation: NL PMI)\\n Respiratory: (Auscultation: rhonchorous bs)\\n Abdomen: (Palpation: Soft, No R/G)\\n Neurological: (Orientation: Responds to voice)\\n Extremities:\\n Right: (Edema: 2+)\\n Left: (Edema: 2+)\\n Other: + diffuse edema with overlying ecchymoses\\n Labs\\n 109\\n 10.2\\n 110\\n 0.8\\n 31\\n 4.5\\n 24\\n 105\\n 144\\n 31.3\\n 5.9\\n [image002.jpg]\\n 01:00 AM\\n 05:12 AM\\n 01:46 AM\\n 01:55 AM\\n 02:18 AM\\n 08:00 AM\\n 02:00 PM\\n 08:00 PM\\n 01:00 AM\\n 01:07 AM\\n WBC\\n 8.8\\n 4.2\\n 5.9\\n Hgb\\n 10.7\\n 9.5\\n 10.2\\n Hct (Serum)\\n 32.1\\n 29.7\\n 31.3\\n Plt\\n 153\\n 104\\n 109\\n INR\\n 1.2\\n PTT\\n 27.6\\n Na+\\n 143\\n 143\\n 142\\n 144\\n K + (Serum)\\n 4.0\\n 3.9\\n 4.2\\n 4.5\\n Cl\\n 108\\n 106\\n 106\\n 105\\n HCO3\\n 32\\n 32\\n 31\\n 31\\n BUN\\n 19\\n 22\\n 24\\n 24\\n Creatinine\\n 0.7\\n 0.7\\n 0.7\\n 0.8\\n Glucose\\n 115\\n 132\\n 122\\n 117\\n 129\\n 100\\n 111\\n 105\\n 117\\n 110\\n CK\\n 225\\n 128\\n ABG: 7.45 / 49 / 98 / / 8 Values as of 01:18 AM\\n Tests\\n Telemetry: Converted to sinus yesterday at 7PM with brief pause. Sinus\\n at 90s since.\\n Assessment and Plan\\n Sinus rhythm currently; off pressors with BP slightly hypertensive.\\n Okay to transition to PO amio. Would recommend a baby aspirin if\\n possible from a bleeding risk. Would continue diltiazem for now at\\n present dose; could increase if desired, although his sinus tachycardia\\n is most likely due to pain and/or his acute illness and is thus\\n appropriate. Once acute issues improved, should follow up in\\n cardiology clinic for further management of AF ().\\n Recs:\\n --Change to PO amiodarone (400mg TID x 2 weeks, then 400mg daily x 1\\n week, then 200mg daily)\\n --Monitor LFTs (likely resolving from liver lac, but if increase\\n significantly may need to change to a different )\\n --Initiate ASA 81mg daily if okay from bleed risk\\n --Continue dilt for now (sinus tachy likely from acute illness/pain)\\n --Follow up in cardiology clinic as an outpatient\\n ------ Protected Section ------\\n Spoke with Dr. (EP attending). Please modify above plan as\\n following:\\n --Would transition to amiodarone 200mg given his liver lacs, prior\\n elevated LFTs, and sufficient IV load thus far\\n --Would recommend d/c of dilatiazem and initiation of metoprolol 25mg\\n \\n ------ Protected Section Addendum Entered By: , MD\\n on: 13:32 ------\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2175-02-02 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 714664,\n \"text\": \"Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt trached and continues on vent, with settings: CPAP: 60%.\\n Lung sounds rhonchorous in upper lobes, diminished at bases\\n bilaterally. Pt requiring frequent suctioning for thick, tan/white\\n secretions. Pt has strong, productive, cough. Pt was minimally\\n sedated this AM on Fentanyl and midaz gtts. CXR showed fluid overload.\\n Action:\\n Fentanyl stopped, midaz stopped, PO roxicodone given for pain. Zyprexa\\n given for comfort/anxiety. IV ativan ordered for anxiety but not\\n given at time of note. Tube feeds restarted. Pt seen by PT, did ROM\\n and dangling at bedside. Pt OOB to stretcher chair this afternoon for\\n 3 hours. Pt diuresed with 10mg lasix this AM. Suctioned frequently,\\n trach care provided. IV antibiotics ordered and given for suspected\\n VAP PNA; ceftriaxone discontinued.\\n Response:\\n Pt tolerated sitting in the chair well, felt slightly uncomfortable\\n with TLSO brace but managed well. Lasix put out ~350cc UO. Pt\\n tolerating tube feeds, advancing to goal. Pt unrestrained and\\n appropriate. Pt tolerating activity/repositioning, appears to be\\n comfortable. Pt remains Afebrile, WBC low.\\n Plan:\\n Continue to support pt and family, provide disease process education as\\n needed. TLSO brace when >30 degrees or OOB to chair. Advance tube\\n feeds to goal today as tolerated. Zyprexa/ativan/roxicodone for pain\\n as needed. Daily OOB to chair and work with PT. Wean vent as\\n tolerated. Pulmonary toileting and diurese as able.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2175-02-01 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 714556,\n \"text\": \"74M s/p crushing injury d/t falling tree. Injuries sustained include\\n multiple R sided rib fxs, grade 2 liver lac (w/ assoc hepatic vessel\\n extravasation), stable pelvis fxs (w/ associated extravasation), R\\n ramus fx, clavicle fx, and T4 vertebral body fx. Episodes of A.\\n Flutter with RVR and aflutter, now with resp failure and newly dx\\n pneumonia as of .\\n intubated for resp distress\\n angio embolization of hepatic and pelvic arterial bleeders\\n IVC filter in OR\\n self extubated and re-intubated immediately after d/t acute resp.\\n failure\\n Trach and PEG at bedside\\n Atrial fibrillation (Afib)\\n Assessment:\\n Atrial flutter continues, RVR up to 130s this AM. Now rate controlled\\n <100.\\n Action:\\n PO dilt, amioderone gtt continued, Neo gtt titrated for adequate BP\\n control.\\n Response:\\n Rate controlled after PO Dilt.\\n Plan:\\n Continue Amio gtt, switch to PO amio, ? Cardio version,? Anticoagulant.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Post trach pt back on CPAP 10/10/50%. Ls clear to diminish at bases.\\n Strong productive cough, suctioned for copious amounts of thick blood\\n tinged secretions. ABG stable.\\n Action:\\n Trach and PEG at bedside, continue pulmonary toileting.\\n Response:\\n Tolerated procedure without issue.\\n Plan:\\n Wean vent settings as tolerated, pulmonary toileting, wean sedation.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2175-02-01 00:00:00.000\",\n \"description\": \"Cardiology Physician Note\",\n \"row_id\": 714562,\n \"text\": \"TITLE:\\n History of Present Illness\\n Date: \\n Subsequent care\\n Seen and examined with: Dr. \\n Events / History of present illness: Started amiodarone gtt, weaned off\\n neo yesterday. This AM, dropped his sats and hypotensive. Neo\\n restarted.\\n Medications\\n Unchanged\\n Dilt 60 QID\\n Amio gtt at 0.5\\n Neo at 0.8\\n Physical Exam\\n General appearance: Intubated, sedated\\n BP: 105 / 57 mmHg\\n HR: 75 bpm\\n RR: 24 insp/min\\n Tmax C last 24 hours: 37.6 C\\n Tmax F last 24 hours: 99.6 F\\n T current C: 37.5 C\\n T current F: 99.5 F\\n Previous day:\\n Intake: 3,716 mL\\n Output: 1,755 mL\\n Fluid balance: 1,961 mL\\n Today:\\n Intake: 940 mL\\n Output: 650 mL\\n Fluid balance: 290 mL\\n HEENT: (Conjunctiva and lids: NL), (Jugular veins: ~8cm)\\n Cardiovascular: (Auscultation: RR, NR, no murmurs)\\n Respiratory: (Auscultation: rhonchorous)\\n Abdomen: (Palpation: Soft)\\n Extremities:\\n Right: (Edema: 2+)\\n Left: (Edema: 2+)\\n Other: Diffuse edema\\n Labs\\n 104\\n 9.5\\n 100\\n 0.7\\n 31\\n 4.2\\n 24\\n 106\\n 142\\n 29.7\\n 4.2\\n [image002.jpg]\\n 02:55 AM\\n 09:45 AM\\n 04:21 PM\\n 12:45 AM\\n 01:00 AM\\n 05:12 AM\\n 01:46 AM\\n 01:55 AM\\n 02:18 AM\\n 08:00 AM\\n WBC\\n 6.5\\n 13.1\\n 8.8\\n 4.2\\n Hgb\\n 10.1\\n 10.7\\n 10.7\\n 9.5\\n Hct (Serum)\\n 29.3\\n 31.6\\n 32.1\\n 29.7\\n Plt\\n 86\\n 158\\n 153\\n 104\\n INR\\n 1.1\\n 1.2\\n 1.2\\n PTT\\n 26.8\\n 26.9\\n 27.6\\n Na+\\n 143\\n 148\\n 143\\n 143\\n 142\\n K + (Serum)\\n 3.6\\n 4.1\\n 4.0\\n 4.0\\n 3.9\\n 4.2\\n K + (Whole blood)\\n 3.5\\n Cl\\n 106\\n 111\\n 108\\n 106\\n 106\\n HCO3\\n 33\\n 34\\n 32\\n 32\\n 31\\n BUN\\n 19\\n 20\\n 19\\n 22\\n 24\\n Creatinine\\n 0.8\\n 0.8\\n 0.7\\n 0.7\\n 0.7\\n Glucose\\n 141\\n 107\\n 131\\n 115\\n 132\\n 122\\n 117\\n 129\\n 100\\n CK\\n 225\\n 128\\n ABG: / / / 31 / Values as of 02:18 AM\\n Tests\\n Telemetry: Aflutter at 70s, 3-4:1 up to 2:1 this AM.\\n Assessment and Plan\\n Continues to be in Aflutter on amio gtt. Able to wean down on neo\\n yesterday, but restarted this AM. As mentioned yesterday, very\\n unlikely that hypotension is a result of aflutter itself (loss of\\n atrial kick) based on echocardiogram (Normal E/A ratio) and he was able\\n to be weaned off the drip yesterday despite continued Aflutter. Would\\n search for other etiologies of hypotension (infection, hypovolemia); he\\n appears to have a large amount of third spacing on my exam, so he may\\n be intravascularly deplete despite being total body fluid overloaded.\\n Can increase Dilt to 90 QID if necessary for better rate control if BP\\n tolerates, but at this point would search for other causes of\\n hypotension.\\n Recs:\\n --Continue amiodarone gtt at 0.5\\n --Continue diltiazem\\n --Cont to monitor, consider IVFs to wean off neo\\n ------ Protected Section ------\\n Cardiology Teaching Physician Note\\n have seen and examined the patient. I have reviewed the above note\\n and plans.\\n I would add the following remarks:\\n History\\n 7 pm conv to st. now bp 120.\\n Physical Examination\\n more alert, follows commands\\n Medical Decision Making\\n consider taper diltiazem\\n ------ Protected Section Addendum Entered By: \\n on: 09:33 PM ------\\n\"\n },\n {\n \"category\": \"Nutrition\",\n \"chartdate\": \"2175-02-02 00:00:00.000\",\n \"description\": \"Clinical Nutrition Note\",\n \"row_id\": 714631,\n \"text\": \"Subjective\\n intubated\\n Objective\\n Height\\n Admit weight\\n Daily weight\\n Weight change\\n BMI\\n cm\\n 90 kg\\n 102 kg ( 12:00 AM)\\n Pertinent medications: amidoarone, fentanyl, normal saline, HISS,\\n protonix, heparin, IV abx, others noted\\n Labs:\\n Value\\n Date\\n Glucose\\n 110 mg/dL\\n 01:07 AM\\n Glucose Finger Stick\\n 124\\n 08:00 AM\\n BUN\\n 24 mg/dL\\n 01:07 AM\\n Creatinine\\n 0.8 mg/dL\\n 01:07 AM\\n Sodium\\n 144 mEq/L\\n 01:07 AM\\n Potassium\\n 4.5 mEq/L\\n 01:07 AM\\n Chloride\\n 105 mEq/L\\n 01:07 AM\\n TCO2\\n 31 mEq/L\\n 01:07 AM\\n PO2 (arterial)\\n 98. mm Hg\\n 01:18 AM\\n PCO2 (arterial)\\n 49 mm Hg\\n 01:18 AM\\n pH (arterial)\\n 7.45 units\\n 01:18 AM\\n pH (urine)\\n 5.0 units\\n 04:25 PM\\n CO2 (Calc) arterial\\n 35 mEq/L\\n 01:18 AM\\n Albumin\\n 2.3 g/dL\\n 02:18 AM\\n Calcium non-ionized\\n 8.1 mg/dL\\n 01:07 AM\\n Phosphorus\\n 3.8 mg/dL\\n 01:07 AM\\n Ionized Calcium\\n 1.17 mmol/L\\n 01:18 AM\\n Magnesium\\n 2.1 mg/dL\\n 01:07 AM\\n ALT\\n 90 IU/L\\n 01:07 AM\\n Alkaline Phosphate\\n 99 IU/L\\n 01:07 AM\\n AST\\n 113 IU/L\\n 01:07 AM\\n Amylase\\n 58 IU/L\\n 01:07 AM\\n Total Bilirubin\\n 5.1 mg/dL\\n 01:07 AM\\n WBC\\n 5.9 K/uL\\n 01:07 AM\\n Hgb\\n 10.2 g/dL\\n 01:07 AM\\n Hematocrit\\n 31.3 %\\n 01:07 AM\\n Current diet order / nutrition support: (ON HOLD) replete with fiber @\\n 80 ml/hr\\n GI: soft, nontender, nondistended\\n Assessment of Nutritional Status\\n Specifics: Patient s/p PEG/trach on . Tube feedings on hold since\\n 4am on for procedure. Plan to resume tube feedings today. At goal\\n tube feedings provide kcals/ 119 g protein, which is 100% of\\n estimated nutritional needs.\\n Medical Nutrition Therapy Plan - Recommend the Following\\n 1. Resume tube feedings when able\\n 2. Check chemistry 10 daily\\n 3. Will follow page with questions\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2175-02-02 00:00:00.000\",\n \"description\": \"Cardiology Physician Note\",\n \"row_id\": 714634,\n \"text\": \"TITLE:\\n History of Present Illness\\n Date: \\n Subsequent care\\n Events / History of present illness: Trach/PEG yesterday. Converted to\\n sinus rhythm yesterday at 7PM. Off pressors.\\n Medications\\n Unchanged\\n Physical Exam\\n General appearance: NAD\\n BP: 147 / 73 mmHg\\n HR: 93 bpm\\n RR: 17 insp/min\\n Tmax C last 24 hours: 37.7 C\\n Tmax F last 24 hours: 99.9 F\\n T current C: 36.3 C\\n T current F: 97.4 F\\n O2 sat: 98 % on Supplemental oxygen: PSV 16/10 on 60% O2\\n Previous day:\\n Intake: 1,764 mL\\n Output: 1,630 mL\\n Fluid balance: 134 mL\\n Today:\\n Intake: 619 mL\\n Output: 1,020 mL\\n Fluid balance: -401 mL\\n HEENT: (Conjunctiva and lids: NL), (Jugular veins: ~8-10cm)\\n Cardiovascular: (Auscultation: RR, NR, No murmurs), (Palpation: NL PMI)\\n Respiratory: (Auscultation: rhonchorous bs)\\n Abdomen: (Palpation: Soft, No R/G)\\n Neurological: (Orientation: Responds to voice)\\n Extremities:\\n Right: (Edema: 2+)\\n Left: (Edema: 2+)\\n Other: + diffuse edema with overlying ecchymoses\\n Labs\\n 109\\n 10.2\\n 110\\n 0.8\\n 31\\n 4.5\\n 24\\n 105\\n 144\\n 31.3\\n 5.9\\n [image002.jpg]\\n 01:00 AM\\n 05:12 AM\\n 01:46 AM\\n 01:55 AM\\n 02:18 AM\\n 08:00 AM\\n 02:00 PM\\n 08:00 PM\\n 01:00 AM\\n 01:07 AM\\n WBC\\n 8.8\\n 4.2\\n 5.9\\n Hgb\\n 10.7\\n 9.5\\n 10.2\\n Hct (Serum)\\n 32.1\\n 29.7\\n 31.3\\n Plt\\n 153\\n 104\\n 109\\n INR\\n 1.2\\n PTT\\n 27.6\\n Na+\\n 143\\n 143\\n 142\\n 144\\n K + (Serum)\\n 4.0\\n 3.9\\n 4.2\\n 4.5\\n Cl\\n 108\\n 106\\n 106\\n 105\\n HCO3\\n 32\\n 32\\n 31\\n 31\\n BUN\\n 19\\n 22\\n 24\\n 24\\n Creatinine\\n 0.7\\n 0.7\\n 0.7\\n 0.8\\n Glucose\\n 115\\n 132\\n 122\\n 117\\n 129\\n 100\\n 111\\n 105\\n 117\\n 110\\n CK\\n 225\\n 128\\n ABG: 7.45 / 49 / 98 / / 8 Values as of 01:18 AM\\n Tests\\n Telemetry: Converted to sinus yesterday at 7PM with brief pause. Sinus\\n at 90s since.\\n Assessment and Plan\\n Sinus rhythm currently; off pressors with BP slightly hypertensive.\\n Okay to transition to PO amio. Would recommend a baby aspirin if\\n possible from a bleeding risk. Would continue diltiazem for now at\\n present dose; could increase if desired, although his sinus tachycardia\\n is most likely due to pain and/or his acute illness and is thus\\n appropriate. Once acute issues improved, should follow up in\\n cardiology clinic for further management of AF ().\\n Recs:\\n --Change to PO amiodarone (400mg TID x 2 weeks, then 400mg daily x 1\\n week, then 200mg daily)\\n --Monitor LFTs (likely resolving from liver lac, but if increase\\n significantly may need to change to a different )\\n --Initiate ASA 81mg daily if okay from bleed risk\\n --Continue dilt for now (sinus tachy likely from acute illness/pain)\\n --Follow up in cardiology clinic as an outpatient\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2175-02-02 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 714661,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 9\\n Airway\\n Airway Placement Data\\n Known difficult intubation: Yes\\n Procedure location:\\n Reason:\\n Tube Type\\n Tracheostomy tube:\\n Type: Standard, Cuffed, Inner Cannula\\n Manufacturer: Portex\\n Size: 8.0mm\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 30 cmH2O\\n Cuff volume: mL /\\n Airway problems:\\n Comments:\\n Lung sounds\\n RLL Lung Sounds: Crackles\\n RUL Lung Sounds: Crackles\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Diminished\\n Comments:\\n Secretions\\n Sputum color / consistency: White / Thick\\n Sputum source/amount: Suctioned / Moderate\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance: Continuous invasive ventilation\\n Visual assessment of breathing pattern: Normal quiet breathing\\n Assessment of breathing comfort: No claim of dyspnea)\\n Non-invasive ventilation assessment:\\n Invasive ventilation assessment:\\n Trigger work assessment: Triggering synchronously\\n Plan\\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\\n tolerated\\n Reason for continuing current ventilatory support: Underlying illness\\n not resolved\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2175-02-03 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 714729,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 10\\n Ideal body weight: 0 None\\n Ideal tidal volume: 0 / 0 / 0 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: Yes\\n Tube Type\\n Tracheostomy tube:\\n Type: Standard, Cuffed\\n Manufacturer: Portex\\n Size: 8.0mm\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 28 cmH2O\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Rhonchi\\n LUL Lung Sounds: Rhonchi\\n LLL Lung Sounds: Diminished\\n Secretions\\n Sputum color / consistency: White / Thin\\n Sputum source/amount: Suctioned / Moderate\\n Ventilation Assessment\\n Level of breathing assistance: Continuous invasive ventilation\\n Visual assessment of breathing pattern: Normal quiet breathing\\n Assessment of breathing comfort: No claim of dyspnea)\\n Invasive ventilation assessment:\\n Trigger work assessment: Triggering synchronously\\n Plan\\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\\n tolerated, Reduce PEEP as tolerated; Comments: continue to wean pt as\\n tolerated\\n Reason for continuing current ventilatory support: Intolerant of\\n weaning attempts, Underlying illness not resolved\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2175-02-03 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 714835,\n \"text\": \"Atrial fibrillation (Afib)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2175-01-27 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 713743,\n \"text\": \"TSICU\\n HPI:\\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\\n checked and 1.5, 1 more unit FFP given.\\n Chief complaint:\\n Mult rib fx: R anterolateral and post, L posterior\\n T4 vert body inf corner fx\\n Commin spinous process fx T2-8\\n Nondisplaced L T10 transverse process\\n Nondispaced L distal clavicle\\n Nondisplaced L clavicle fx\\n R medial lobe liver contusion w/hematoma\\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny focus of arterial\\n bleeding/active extravasation, and larger area of venous bleeding\\n Nondisplaced, comminuted L iliac bone fx w/adjacent iliac muscle\\n hematoma, extends into L SIJ.\\n Minimally displaced fx of R iliac bone extending to R SIJ.\\n PMHx:\\n None\\n Current medications:\\n 1. IV access: Peripheral line Order date: @ 2329 12. Glucagon 1\\n mg IM Q15MIN:PRN hypoglycemia protocol Order date: @ 0104\\n 2. 1000 mL LR\\n Continuous at 60 ml/hr\\n LR + TF = 60 cc/hr Order date: @ 0103 13. Insulin SC (per\\n Insulin Flowsheet)\\n Sliding Scale Order date: @ 0104\\n 3. Acetaminophen 650 mg PO/NG Q6H:PRN pain Order date: @ 2329\\n 14. Magnesium Sulfate IV Sliding Scale Order date: @ 2339\\n 4. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL Order date:\\n @ 2329 15. Midazolam 2-4 mg IV Q2H:PRN sedation Order date:\\n @ 2329\\n 5. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date: \\n @ 0104 16. Ondansetron 4 mg IV Q8H:PRN nausea Order date: @ 2329\\n 6. Diltiazem 5-15 mg/hr IV INFUSION Afib\\n titrate titrate to HR<100 Order date: @ 2339 17. Phenylephrine\\n 0.5-5 mcg/kg/min IV DRIP TITRATE TO SBP>90 MAP>60 Order date: @\\n 2339\\n 7. Docusate Sodium (Liquid) 100 mg PO/NG Order date: @ 2329\\n 18. Pneumococcal Vac Polyvalent 0.5 ml IM ASDIR Order date: @\\n 2316\\n 8. Famotidine 20 mg PO/NG Order date: @ 2329 19. Potassium\\n Phosphate IV Sliding Scale\\n Infuse over 6 hours Order date: @ 2339\\n 9. Fentanyl Citrate 25-100 mcg IV Q2H:PRN pain, agitation Order date:\\n @ 2329 20. Potassium Chloride IV Sliding Scale Order date: \\n @ 2339\\n 10. Fentanyl Citrate 25-100 mcg/hr IV DRIP INFUSION Order date: \\n @ 2339 21. Propofol 5-20 mcg/kg/min IV DRIP TITRATE TO sedation Order\\n date: @ 2339\\n 11. Gabapentin 100 mg PO/NG TID Order date: @ 2329 22. Sodium\\n Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush\\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\\n Order date: @ 2329\\n 24 Hour Events:\\n Febrile yesterday AM to 101.3. Pan cx. Placed on Dilt gtt for Afib\\n with RVR but since has converted to sinus and is off the dilt gtt.\\n Continues to wean off the Neo gtt. Tube feeds started. Bronchoscopy\\n performed. IVC filter placed late last PM.\\n Post operative day:\\n POD#1 - IVC filter via L groin\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Fentanyl (Concentrate) - 100 mcg/hour\\n Propofol - 20 mcg/Kg/min\\n Phenylephrine - 0.5 mcg/Kg/min\\n Other ICU medications:\\n Famotidine (Pepcid) - 08:00 AM\\n Diltiazem - 10:07 AM\\n Fentanyl - 02:45 AM\\n Other medications:\\n Flowsheet Data as of 06:19 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 38.5\\nC (101.3\\n T current: 36.7\\nC (98.1\\n HR: 75 (57 - 147) bpm\\n BP: 107/59(76) {92/49(64) - 153/81(106)} mmHg\\n RR: 8 (0 - 22) insp/min\\n SPO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 102 kg (admission): 90 kg\\n CVP: 19 (9 - 27) mmHg\\n Total In:\\n 2,767 mL\\n 520 mL\\n PO:\\n Tube feeding:\\n 52 mL\\n 82 mL\\n IV Fluid:\\n 2,425 mL\\n 438 mL\\n Blood products:\\n Total out:\\n 1,078 mL\\n 380 mL\\n Urine:\\n 1,078 mL\\n 380 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,689 mL\\n 140 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 440 (440 - 440) mL\\n Vt (Spontaneous): 612 (612 - 612) mL\\n PS : 15 cmH2O\\n RR (Set): 18\\n RR (Spontaneous): 3\\n PEEP: 14 cmH2O\\n FiO2: 40%\\n RSBI Deferred: PEEP > 10\\n PIP: 27 cmH2O\\n Plateau: 19 cmH2O\\n SPO2: 100%\\n ABG: 7.39/47/154/28/3\\n Ve: 9.6 L/min\\n PaO2 / FiO2: 385\\n Physical Examination\\n General Appearance: Intubated\\n HEENT: PERRL, Jaundiced\\n Cardiovascular: (Rhythm: Regular)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\\n bilateral : )\\n Abdominal: Soft, Non-distended\\n Left Extremities: (Edema: 1+), (Temperature: Warm)\\n Right Extremities: (Edema: 1+), (Temperature: Warm)\\n Skin: scrotum eechymotic\\n Neurologic: Sedated\\n Labs / Radiology\\n 99 K/uL\\n 10.9 g/dL\\n 96 mg/dL\\n 0.9 mg/dL\\n 28 mEq/L\\n 3.8 mEq/L\\n 18 mg/dL\\n 107 mEq/L\\n 141 mEq/L\\n 30.6 %\\n 11.0 K/uL\\n [image002.jpg]\\n 07:39 AM\\n 08:00 AM\\n 10:22 AM\\n 01:57 PM\\n 02:00 PM\\n 02:16 PM\\n 05:17 PM\\n 12:14 AM\\n 12:20 AM\\n 05:24 AM\\n WBC\\n 12.1\\n 11.0\\n Hct\\n 30.5\\n 30.6\\n Plt\\n 105\\n 99\\n Creatinine\\n 1.0\\n 0.9\\n TCO2\\n 32\\n 33\\n 34\\n 33\\n 32\\n 30\\n Glucose\\n 84\\n 105\\n 101\\n 96\\n Other labs: PT / PTT / INR:13.7/28.7/1.2, CK / CK-MB / Troponin\\n T:1334/13/<0.01, ALT / AST:345/278, Alk-Phos / T bili:49/3.0, Amylase /\\n Lipase:44/, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic Acid:1.4\\n mmol/L, LDH:435 IU/L, Ca:7.8 mg/dL, Mg:2.2 mg/dL, PO4:2.8 mg/dL\\n Imaging: MRI: Mild compression deformity of L1 w/additional\\n levels of potential trabecular contusion @T10-11 also inf @T4 w/o\\n retropulsion. Multilevel degenerative changes with moderate canal\\n narrowing at T10-11 w/cord deformity and no abnormal cord signal.\\n Extensive edema throughout paraspinal soft tissues, predominantly post\\n w/in interspinous ligaments. Incompletely eval'ed c-spine w/severe\\n canal narrowing @C4-5 w/cord deformity and no abnormal cord signal.\\n CTA: no PE.\\n CXR: Moderate bilateral pleural effusions are stable.\\n Microbiology: Ucx no growth final\\n Sputum: sparse GNR\\n Bcx P\\n Bcx P\\n BAL: GS shows 1+ normal flora\\n BAL: GS shows 1+ normal flora\\n Assessment and Plan\\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, AF with\\n RVR, hematologic abnormalities.\\n Neurologic: Neuro checks Q: 4 hr, Intubated on Propofol gtt and\\n Midazolam PRN. Per ortho spine, no surgery; HOB<30, TLSO when OOB\\n (NEOPS will place).\\n Pain: Fentanyl PRN, Midazolam prn, Neurontin, Tylenol, APS c/s for\\n paravertebral catheters.\\n Cardiovascular: Now back in NSR, off dilt gtt and currently weaning Neo\\n gtt. Give fluid bolus now and assess response. Will check PPV on\\n bedside monitor to help assess volume status.\\n Pulmonary: Cont ETT, Intubated. Pt developing early ARDS, keep on rate\\n with low tidal volumes. Sats 100% on FiO2 40% so will wean down PEEP\\n this AM. F/U CXR this AM. F/U on bronch cx. Today will try to\\n transition over to pressure support, keep Vt in 6cc/kg range if\\n possible with sedation.\\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin with CT scan\\n suggesting cirrhosis - Hepatitis panel sent. Starting TF and advancing\\n to goal. Increase bowel regimen.\\n Nutrition: Tube feeding.\\n Renal: Foley, Foley, monitor UOP. Cr normalized. Monitoring for\\n contrast induced nephropathy.\\n Hematology: Hct stable anemia at 29-30. Plt low but stable (100's).\\n Heme onc consulted - f/u on hemolysis labs and smear read, Heme recs.\\n IVC filter placed.\\n Endocrine: RISS, goal BS<150, adequate control.\\n Infectious Disease: Check cultures, WBC normal, f/u Cx\\n Lines / Tubes / Drains: R SC CVL (), PIV x2, Foley, a-line\\n (), ETT\\n Wounds: left groin site is c/d/i, no hematoma or pseudoaneurysm\\n Imaging:\\n Fluids: TF + IVF = 60 cc/hr\\n Consults: Trauma surgery, Ortho, Ortho-spine, Heme/Onc\\n Billing Diagnosis: Multiple injuries (Trauma)\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 11:52 PM 20 mL/hour\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n Arterial Line - 10:59 AM\\n Multi Lumen - 04:41 PM\\n Prophylaxis:\\n DVT: Boots, IVC filter\\n Stress ulcer: H2 blocker\\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds , ICU\\n Code status: Full code\\n Disposition: ICU\\n Total time spent: 32 mins\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2175-01-27 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 713750,\n \"text\": \"TSICU\\n HPI:\\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\\n checked and 1.5, 1 more unit FFP given.\\n Chief complaint:\\n Mult rib fx: R anterolateral and post, L posterior\\n T4 vert body inf corner fx\\n Commin spinous process fx T2-8\\n Nondisplaced L T10 transverse process\\n Nondispaced L distal clavicle\\n Nondisplaced L clavicle fx\\n R medial lobe liver contusion w/hematoma\\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny focus of arterial\\n bleeding/active extravasation, and larger area of venous bleeding\\n Nondisplaced, comminuted L iliac bone fx w/adjacent iliac muscle\\n hematoma, extends into L SIJ.\\n Minimally displaced fx of R iliac bone extending to R SIJ.\\n PMHx:\\n None\\n Current medications:\\n 1. IV access: Peripheral line Order date: @ 2329 12. Glucagon 1\\n mg IM Q15MIN:PRN hypoglycemia protocol Order date: @ 0104\\n 2. 1000 mL LR\\n Continuous at 60 ml/hr\\n LR + TF = 60 cc/hr Order date: @ 0103 13. Insulin SC (per\\n Insulin Flowsheet)\\n Sliding Scale Order date: @ 0104\\n 3. Acetaminophen 650 mg PO/NG Q6H:PRN pain Order date: @ 2329\\n 14. Magnesium Sulfate IV Sliding Scale Order date: @ 2339\\n 4. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL Order date:\\n @ 2329 15. Midazolam 2-4 mg IV Q2H:PRN sedation Order date:\\n @ 2329\\n 5. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date: \\n @ 0104 16. Ondansetron 4 mg IV Q8H:PRN nausea Order date: @ 2329\\n 6. Diltiazem 5-15 mg/hr IV INFUSION Afib\\n titrate titrate to HR<100 Order date: @ 2339 17. Phenylephrine\\n 0.5-5 mcg/kg/min IV DRIP TITRATE TO SBP>90 MAP>60 Order date: @\\n 2339\\n 7. Docusate Sodium (Liquid) 100 mg PO/NG Order date: @ 2329\\n 18. Pneumococcal Vac Polyvalent 0.5 ml IM ASDIR Order date: @\\n 2316\\n 8. Famotidine 20 mg PO/NG Order date: @ 2329 19. Potassium\\n Phosphate IV Sliding Scale\\n Infuse over 6 hours Order date: @ 2339\\n 9. Fentanyl Citrate 25-100 mcg IV Q2H:PRN pain, agitation Order date:\\n @ 2329 20. Potassium Chloride IV Sliding Scale Order date: \\n @ 2339\\n 10. Fentanyl Citrate 25-100 mcg/hr IV DRIP INFUSION Order date: \\n @ 2339 21. Propofol 5-20 mcg/kg/min IV DRIP TITRATE TO sedation Order\\n date: @ 2339\\n 11. Gabapentin 100 mg PO/NG TID Order date: @ 2329 22. Sodium\\n Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush\\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\\n Order date: @ 2329\\n 24 Hour Events:\\n Febrile yesterday AM to 101.3. Pan cx. Placed on Dilt gtt for Afib\\n with RVR but since has converted to sinus and is off the dilt gtt.\\n Continues to wean off the Neo gtt. Tube feeds started. Bronchoscopy\\n performed. IVC filter placed late last PM.\\n Post operative day:\\n POD#1 - IVC filter via L groin\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Fentanyl (Concentrate) - 100 mcg/hour\\n Propofol - 20 mcg/Kg/min\\n Phenylephrine - 0.5 mcg/Kg/min\\n Other ICU medications:\\n Famotidine (Pepcid) - 08:00 AM\\n Diltiazem - 10:07 AM\\n Fentanyl - 02:45 AM\\n Other medications:\\n Flowsheet Data as of 06:19 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 38.5\\nC (101.3\\n T current: 36.7\\nC (98.1\\n HR: 75 (57 - 147) bpm\\n BP: 107/59(76) {92/49(64) - 153/81(106)} mmHg\\n RR: 8 (0 - 22) insp/min\\n SPO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 102 kg (admission): 90 kg\\n CVP: 19 (9 - 27) mmHg\\n Total In:\\n 2,767 mL\\n 520 mL\\n PO:\\n Tube feeding:\\n 52 mL\\n 82 mL\\n IV Fluid:\\n 2,425 mL\\n 438 mL\\n Blood products:\\n Total out:\\n 1,078 mL\\n 380 mL\\n Urine:\\n 1,078 mL\\n 380 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,689 mL\\n 140 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 440 (440 - 440) mL\\n Vt (Spontaneous): 612 (612 - 612) mL\\n PS : 15 cmH2O\\n RR (Set): 18\\n RR (Spontaneous): 3\\n PEEP: 14 cmH2O\\n FiO2: 40%\\n RSBI Deferred: PEEP > 10\\n PIP: 27 cmH2O\\n Plateau: 19 cmH2O\\n SPO2: 100%\\n ABG: 7.39/47/154/28/3\\n Ve: 9.6 L/min\\n PaO2 / FiO2: 385\\n Physical Examination\\n General Appearance: Intubated\\n HEENT: PERRL, Jaundiced\\n Cardiovascular: (Rhythm: Regular)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\\n bilateral : )\\n Abdominal: Soft, Non-distended\\n Left Extremities: (Edema: 1+), (Temperature: Warm)\\n Right Extremities: (Edema: 1+), (Temperature: Warm)\\n Skin: scrotum eechymotic\\n Neurologic: Sedated\\n Labs / Radiology\\n 99 K/uL\\n 10.9 g/dL\\n 96 mg/dL\\n 0.9 mg/dL\\n 28 mEq/L\\n 3.8 mEq/L\\n 18 mg/dL\\n 107 mEq/L\\n 141 mEq/L\\n 30.6 %\\n 11.0 K/uL\\n [image002.jpg]\\n 07:39 AM\\n 08:00 AM\\n 10:22 AM\\n 01:57 PM\\n 02:00 PM\\n 02:16 PM\\n 05:17 PM\\n 12:14 AM\\n 12:20 AM\\n 05:24 AM\\n WBC\\n 12.1\\n 11.0\\n Hct\\n 30.5\\n 30.6\\n Plt\\n 105\\n 99\\n Creatinine\\n 1.0\\n 0.9\\n TCO2\\n 32\\n 33\\n 34\\n 33\\n 32\\n 30\\n Glucose\\n 84\\n 105\\n 101\\n 96\\n Other labs: PT / PTT / INR:13.7/28.7/1.2, CK / CK-MB / Troponin\\n T:1334/13/<0.01, ALT / AST:345/278, Alk-Phos / T bili:49/3.0, Amylase /\\n Lipase:44/, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic Acid:1.4\\n mmol/L, LDH:435 IU/L, Ca:7.8 mg/dL, Mg:2.2 mg/dL, PO4:2.8 mg/dL\\n Imaging: MRI: Mild compression deformity of L1 w/additional\\n levels of potential trabecular contusion @T10-11 also inf @T4 w/o\\n retropulsion. Multilevel degenerative changes with moderate canal\\n narrowing at T10-11 w/cord deformity and no abnormal cord signal.\\n Extensive edema throughout paraspinal soft tissues, predominantly post\\n w/in interspinous ligaments. Incompletely eval'ed c-spine w/severe\\n canal narrowing @C4-5 w/cord deformity and no abnormal cord signal.\\n CTA: no PE.\\n CXR: Moderate bilateral pleural effusions are stable.\\n Microbiology: Ucx no growth final\\n Sputum: sparse GNR\\n Bcx P\\n Bcx P\\n BAL: GS shows 1+ normal flora\\n BAL: GS shows 1+ normal flora\\n Assessment and Plan\\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, AF with\\n RVR, hematologic abnormalities.\\n Neurologic: Neuro checks Q: 4 hr, Intubated on Propofol gtt and\\n Midazolam PRN. Per ortho spine, no surgery; HOB<30, TLSO when OOB\\n (NEOPS will place).\\n Pain: Fentanyl drip, propofol gtt for sedation, Neurontin, Tylenol.\\n Adequate pain control at this point\\n Cardiovascular: Now back in NSR, off dilt gtt and currently weaning Neo\\n gtt. Please start PO dilt as appears to be irritable. Will check PPV on\\n bedside monitor to help assess volume status.\\n Pulmonary: Cont ETT, Intubated. /ARDS\\n type picture improving with\\n improve CXR and oxygenation,. Sats 100% on FiO2 40% so will wean down\\n PEEP this AM. F/U CXR this AM. F/U on bronch cx. Today will try to\\n transition over to pressure support, keep Vt in 6cc/kg range if\\n possible with sedation.\\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin with CT scan\\n suggesting cirrhosis - Hepatitis panel sent. Starting TF and advancing\\n to goal. Increase bowel regimen.\\n Nutrition: Tube feeding.\\n Renal: Foley, Foley, monitor UOP. Cr normalized. Monitoring for\\n contrast induced nephropathy.\\n Hematology: Hct stable anemia at 29-30. Plt low but stable (100's).\\n Heme onc consulted - f/u on hemolysis labs and smear read, Heme recs.\\n IVC filter placed.\\n Endocrine: RISS, goal BS<150, adequate control.\\n Infectious Disease: Check cultures, WBC normal, f/u Cx. No signs of\\n infection. No Abx started\\n Lines / Tubes / Drains: R SC CVL (), PIV x2, Foley, a-line\\n (), ETT\\n Wounds: left groin site is c/d/i, no hematoma or pseudoaneurysm\\n Imaging:\\n Fluids: TF + IVF = 60 cc/hr\\n Consults: Trauma surgery, Ortho, Ortho-spine, Heme/Onc\\n Billing Diagnosis: Multiple injuries (Trauma)\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 11:52 PM 20 mL/hour\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n Arterial Line - 10:59 AM\\n Multi Lumen - 04:41 PM\\n Prophylaxis:\\n DVT: Boots, IVC filter\\n Stress ulcer: H2 blocker\\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds , ICU\\n Code status: Full code\\n Disposition: ICU\\n Total time spent: 32 mins\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2175-02-01 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 714438,\n \"text\": \"TSICU\\n HPI:\\n 74M s/p fall with multiple rib fx, pelvis fx, clavicle fx, and thoracic\\n fx c/b unstable bleeding s/p IR embo, now with AF with RVR/Aflutter,\\n persistant hypotension and presumed PNA.\\n Chief complaint:\\n fall\\n PMHx:\\n none\\n Current medications:\\n 1. Acetaminophen 2. Amiodarone 3. Bisacodyl 4. Calcium Gluconate 5.\\n CeftriaXONE 6. Chlorhexidine Gluconate 0.12% Oral Rinse 7. Dextrose 50%\\n 8. Diltiazem 9. Docusate Sodium (Liquid) 10. Fentanyl Citrate 11.\\n Gabapentin 12. Glucagon 13. Heparin 14. Insulin 15. Lactulose 16.\\n Magnesium Sulfate 17. Metoprolol Tartrate 18. Midazolam 19. Midazolam\\n 20. Milk of Magnesia 21. Ondansetron 22. OxycoDONE Liquid 23.\\n Pantoprazole 24. Phenylephrine\\n 25. Pneumococcal Vac Polyvalent 26. Potassium Phosphate 27. Potassium\\n Chloride 28. Senna 29. Sodium Chloride 0.9% Flush\\n 24 Hour Events:\\n Changed sedation to po Oxycodone, wean fentanyl gtt, wean Midazolam,\\n and start Haldol prn, but stopped due to QTc. Cards consult, started\\n amiodarone.\\n Post operative day:\\n POD#6 - IVC filter via L groin\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\\n Vancomycin - 08:00 AM\\n Ceftriaxone - 12:00 PM\\n Infusions:\\n Midazolam (Versed) - 5 mg/hour\\n Fentanyl (Concentrate) - 50 mcg/hour\\n Amiodarone - 0.5 mg/min\\n Other ICU medications:\\n Haloperidol (Haldol) - 10:45 AM\\n Lorazepam (Ativan) - 02:00 PM\\n Midazolam (Versed) - 03:25 AM\\n Fentanyl - 03:25 AM\\n Heparin Sodium (Prophylaxis) - 05:33 AM\\n Other medications:\\n Flowsheet Data as of 06:27 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 38.1\\nC (100.6\\n T current: 37.2\\nC (98.9\\n HR: 76 (74 - 104) bpm\\n BP: 125/62(81) {90/49(62) - 152/67(89)} mmHg\\n RR: 25 (18 - 31) insp/min\\n SPO2: 98%\\n Heart rhythm: A Flut (Atrial Flutter)\\n Wgt (current): 102 kg (admission): 90 kg\\n CVP: 12 (10 - 19) mmHg\\n Total In:\\n 3,718 mL\\n 759 mL\\n PO:\\n Tube feeding:\\n 1,920 mL\\n 424 mL\\n IV Fluid:\\n 1,078 mL\\n 245 mL\\n Blood products:\\n Total out:\\n 1,755 mL\\n 350 mL\\n Urine:\\n 1,755 mL\\n 350 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,963 mL\\n 409 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 480 (400 - 540) mL\\n PS : 10 cmH2O\\n RR (Spontaneous): 29\\n PEEP: 10 cmH2O\\n FiO2: 50%\\n RSBI Deferred: PEEP > 10\\n PIP: 21 cmH2O\\n SPO2: 98%\\n ABG: 7.44/45/119/31/6\\n Ve: 11.8 L/min\\n PaO2 / FiO2: 238\\n Physical Examination\\n General Appearance: No acute distress\\n HEENT: PERRL\\n Cardiovascular: (Rhythm: Regular)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\\n bilateral : ), shallow respirations\\n Abdominal: Soft, No(t) Non-distended, Bowel sounds present, Distended\\n Left Extremities: (Edema: 1+), (Temperature: Warm)\\n Right Extremities: (Edema: 1+), (Temperature: Warm)\\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\\n Moves all extremities, Sedated\\n Labs / Radiology\\n 104 K/uL\\n 9.5 g/dL\\n 129 mg/dL\\n 0.7 mg/dL\\n 31 mEq/L\\n 4.2 mEq/L\\n 24 mg/dL\\n 106 mEq/L\\n 142 mEq/L\\n 29.7 %\\n 4.2 K/uL\\n [image002.jpg]\\n 04:45 PM\\n 12:45 AM\\n 01:00 AM\\n 05:12 AM\\n 02:40 PM\\n 01:46 AM\\n 01:55 AM\\n 03:40 PM\\n 12:07 AM\\n 02:18 AM\\n WBC\\n 13.1\\n 8.8\\n 4.2\\n Hct\\n 31.6\\n 32.1\\n 29.7\\n Plt\\n 158\\n 153\\n 104\\n Creatinine\\n 0.8\\n 0.7\\n 0.7\\n 0.7\\n TCO2\\n 35\\n 35\\n 34\\n 37\\n 35\\n 32\\n Glucose\\n 131\\n 115\\n 132\\n 122\\n 117\\n 129\\n Other labs: PT / PTT / INR:13.7/27.6/1.2, CK / CK-MB / Troponin\\n T:128/13/<0.01, ALT / AST:87/109, Alk-Phos / T bili:115/5.0, Amylase /\\n Lipase:44/, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic Acid:1.4\\n mmol/L, Albumin:2.7 g/dL, LDH:348 IU/L, Ca:7.9 mg/dL, Mg:2.0 mg/dL,\\n PO4:3.4 mg/dL\\n Assessment and Plan\\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, now\\n with AF with RVR/Aflutter, persistant hypotension and presumed PNA.\\n Neurologic: Intubated. Per ortho spine, no surgery; HOB<30, TLSO when\\n OOB (NEOPS will place). Wean sedation as may be causing hypotension.\\n Change pain meds to PO. Wean versed.\\n Neuro checks Q: shift\\n Pain: Oxycodone, Fentanyl gtt (weaning), Midazolam gtt (weaning),\\n Neurontin, Tylenol\\n Cardiovascular: Aflutter on Dilt 60mg PO QID. Neo off. Consulting\\n cards to assess for cardioversion, rec starting amiodarone. Pressor\\n requirements may be related to AFib/flutter. As pt cannot be\\n anticoagulated (trauma), will need TEE b/f cardioversion.\\n Pulmonary: Intubated, weaning, tachypneic likely abd distension. On\\n appropriate abx per BAL cx -Ceftriaxone, will need trach this week\\n (likely )\\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin (declining 6.8\\n max ->5.0) with CT scan suggesting cirrhosis - Hepatitis panel NEG. TFs\\n on hold for PEG. Bowel regimen, no B29.7. Plt low but stable (100's); d/c'd\\n H2B with increasing plt count. Heme onc consulted - smear nl; no\\n hemolysis. IVC filter placed.\\n Endocrine: RISS\\n Infectious Disease: WBC droppping 13.1->8.8->4.2, f/u Cx - BAL:\\n Klebsiella - Ceftriaxone\\n Lines / Tubes / Drains: R SC CVL (), PIV x2, Foley, L a-line\\n (), ETT\\n Imaging: CXR today\\n Fluids: -\\n Consults: Trauma (1o), Ortho Spine, Ortho trauma, Heme\\n Billing Diagnosis:\\n ICU Care\\n Nutrition:\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n Multi Lumen - 04:41 PM\\n Arterial Line - 11:30 AM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin, IVC filter\\n Stress ulcer: PPI\\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\\n Comments:\\n Communication: ICU consent signed Comments:\\n Code status: Full code\\n Disposition: ICU\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2175-02-02 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 714642,\n \"text\": \"TSICU\\n HPI:\\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\\n checked and 1.5, 1 more unit FFP given.\\n .\\n Injuries\\n Mult rib fx: R anterolateral and post, L posterior\\n T4 vert body inf corner fx\\n Commin spinous process fx T2-8\\n Nondisplaced L T10 transverse process\\n Nondispaced L distal clavicle\\n Nondisplaced L clavicle fx\\n R medial lobe liver contusion w/hematoma\\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny focus of arterial\\n bleeding/active extravasation, and larger area of venous bleeding\\n Nondisplaced, comminuted L iliac bone fx w/adjacent iliac muscle\\n hematoma, extends into L SIJ.\\n Minimally displaced fx of R iliac bone extending to R SIJ.\\n Chief complaint:\\n Trauma\\n PMHx:\\n PMH: None\\n PSH: None\\n : None\\n Current medications:\\n 24 Hour Events:\\n Trach/PEG. Pt's BP dropped to 80/40 off pressors, sats 88. restarted\\n neo. Overnight, pt reverted to sinus, off pressors, weaning sedation.\\n PERCUTANEOUS TRACHEOSTOMY - At 12:00 PM\\n PEG INSERTION - At 12:00 PM\\n Post operative day:\\n POD#7 - IVC filter via L groin\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\\n Vancomycin - 08:00 AM\\n Ceftriaxone - 03:00 PM\\n Infusions:\\n Midazolam (Versed) - 1 mg/hour\\n Amiodarone - 0.5 mg/min\\n Fentanyl (Concentrate) - 50 mcg/hour\\n Other ICU medications:\\n Fentanyl - 01:23 PM\\n Pantoprazole (Protonix) - 02:00 PM\\n Heparin Sodium (Prophylaxis) - 04:00 AM\\n Other medications:\\n Flowsheet Data as of 04:33 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 37.7\\nC (99.9\\n T current: 37.1\\nC (98.8\\n HR: 94 (68 - 101) bpm\\n BP: 140/66(91) {89/46(63) - 154/68(94)} mmHg\\n RR: 26 (11 - 30) insp/min\\n SPO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 102 kg (admission): 90 kg\\n CVP: 9 (6 - 16) mmHg\\n Total In:\\n 1,764 mL\\n 142 mL\\n PO:\\n Tube feeding:\\n 424 mL\\n IV Fluid:\\n 1,000 mL\\n 82 mL\\n Blood products:\\n Total out:\\n 1,630 mL\\n 290 mL\\n Urine:\\n 1,630 mL\\n 290 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 134 mL\\n -148 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 483 (404 - 506) mL\\n PS : 15 cmH2O\\n RR (Spontaneous): 16\\n PEEP: 10 cmH2O\\n FiO2: 60%\\n RSBI Deferred: PEEP > 10\\n PIP: 25 cmH2O\\n SPO2: 98%\\n ABG: 7.45/49/98./31/8\\n Ve: 8.5 L/min\\n PaO2 / FiO2: 163\\n Physical Examination\\n General Appearance: No acute distress\\n HEENT: PERRL\\n Cardiovascular: (Rhythm: Regular)\\n Respiratory / Chest: (Breath Sounds: Crackles : )\\n Abdominal: Soft\\n Left Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present)\\n Right Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present)\\n Neurologic: Follows simple commands, Moves all extremities, Sedated\\n Labs / Radiology\\n 109 K/uL\\n 10.2 g/dL\\n 110 mg/dL\\n 0.8 mg/dL\\n 31 mEq/L\\n 4.5 mEq/L\\n 24 mg/dL\\n 105 mEq/L\\n 144 mEq/L\\n 31.3 %\\n 5.9 K/uL\\n [image002.jpg]\\n 12:07 AM\\n 02:18 AM\\n 08:00 AM\\n 02:00 PM\\n 05:04 PM\\n 08:00 PM\\n 09:20 PM\\n 01:00 AM\\n 01:07 AM\\n 01:18 AM\\n WBC\\n 4.2\\n 5.9\\n Hct\\n 29.7\\n 31.3\\n Plt\\n 104\\n 109\\n Creatinine\\n 0.7\\n 0.8\\n TCO2\\n 32\\n 36\\n 34\\n 35\\n Glucose\\n 129\\n 100\\n 111\\n 105\\n 117\\n 110\\n Other labs: PT / PTT / INR:13.7/27.6/1.2, CK / CK-MB / Troponin\\n T:128/13/<0.01, ALT / AST:90/113, Alk-Phos / T bili:99/5.1, Amylase /\\n Lipase:58/39, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic\\n Acid:1.4 mmol/L, Albumin:2.3 g/dL, LDH:348 IU/L, Ca:8.1 mg/dL, Mg:2.1\\n mg/dL, PO4:3.8 mg/dL\\n Assessment and Plan\\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, now\\n with AF with RVR/Aflutter, persistant hypotension and PNA.\\n Neurologic: s/p trach. Per ortho spine, no surgery; HOB<30, TLSO when\\n OOB (NEOPS will place). Wean sedation as may be causing hypotension.\\n Change pain meds to PO. Will try Geodon today for agitation.\\n Neuro checks Q: shift\\n Pain: Oxycodone, Neurontin, Tylenol. Wean fentanyl gtt, midazolam\\n gtt\\n Cardiovascular: Aflutter, now reverted to sinus. Likely cardiac\\n contusion. On Dilt 60mg PO QID. Cards rec amio gtt. Neo off. Pt cannot\\n be fully anticoagulated for now (trauma). Start PO amio.\\n Pulmonary: Intubated, weaning, tachypneic likely abd distension. On\\n appropriate abx per BAL cx - Ceftriaxone. Now that pulm status is\\n worsening, will broaden coverage with V/C/C.\\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin (declining 6.8\\n max ->5.0) w/CT scan suggesting cirrhosis - Hepatitis panel NEG. TFs.\\n Bowel regimen.\\n Nutrition: TF\\n Renal: Foley, monitor UOP, edematous scrotum. Diurese with lasix 10mg\\n IV. Goal 1 L negative today.\\n Hematology: Hct stable 32.1->29.7. Plt stable (100's); d/c'd H2B with\\n increasing plt count. Heme onc c/s - smear nl; no hemolysis. IVC\\n filter placed.\\n Endocrine: RISS, goal BS<150.\\n Infectious Disease: WBC dropping 13.1->8.8->4.2, f/u Cx - BAL:\\n pan-sensitive Klebsiella\\n broaden coverage for VAP.\\n Lines / Tubes / Drains: R SC CVL (), Foley, L a-line (),\\n trach/PEG\\n Wounds: SCDs, IVC filter, SQH\\n Imaging:\\n Fluids:\\n Consults: Trauma surgery\\n Billing Diagnosis: Multiple injuries (Trauma)\\n ICU Care\\n Nutrition:\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n Multi Lumen - 04:41 PM\\n Arterial Line - 11:30 AM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin\\n Stress ulcer: PPI\\n VAP bundle:\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds Comments:\\n Code status: Full code\\n Disposition: ICU\\n Total time spent: 32 min\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2175-02-02 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 714643,\n \"text\": \"TSICU\\n HPI:\\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\\n checked and 1.5, 1 more unit FFP given.\\n .\\n Injuries\\n Mult rib fx: R anterolateral and post, L posterior\\n T4 vert body inf corner fx\\n Commin spinous process fx T2-8\\n Nondisplaced L T10 transverse process\\n Nondispaced L distal clavicle\\n Nondisplaced L clavicle fx\\n R medial lobe liver contusion w/hematoma\\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny focus of arterial\\n bleeding/active extravasation, and larger area of venous bleeding\\n Nondisplaced, comminuted L iliac bone fx w/adjacent iliac muscle\\n hematoma, extends into L SIJ.\\n Minimally displaced fx of R iliac bone extending to R SIJ.\\n Chief complaint:\\n Trauma\\n PMHx:\\n PMH: None\\n PSH: None\\n : None\\n Current medications:\\n 24 Hour Events:\\n Trach/PEG. Pt's BP dropped to 80/40 off pressors, sats 88. restarted\\n neo. Overnight, pt reverted to sinus, off pressors, weaning sedation.\\n PERCUTANEOUS TRACHEOSTOMY - At 12:00 PM\\n PEG INSERTION - At 12:00 PM\\n Post operative day:\\n POD#7 - IVC filter via L groin\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\\n Vancomycin - 08:00 AM\\n Ceftriaxone - 03:00 PM\\n Infusions:\\n Midazolam (Versed) - 1 mg/hour\\n Amiodarone - 0.5 mg/min\\n Fentanyl (Concentrate) - 50 mcg/hour\\n Other ICU medications:\\n Fentanyl - 01:23 PM\\n Pantoprazole (Protonix) - 02:00 PM\\n Heparin Sodium (Prophylaxis) - 04:00 AM\\n Other medications:\\n Flowsheet Data as of 04:33 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 37.7\\nC (99.9\\n T current: 37.1\\nC (98.8\\n HR: 94 (68 - 101) bpm\\n BP: 140/66(91) {89/46(63) - 154/68(94)} mmHg\\n RR: 26 (11 - 30) insp/min\\n SPO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 102 kg (admission): 90 kg\\n CVP: 9 (6 - 16) mmHg\\n Total In:\\n 1,764 mL\\n 142 mL\\n PO:\\n Tube feeding:\\n 424 mL\\n IV Fluid:\\n 1,000 mL\\n 82 mL\\n Blood products:\\n Total out:\\n 1,630 mL\\n 290 mL\\n Urine:\\n 1,630 mL\\n 290 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 134 mL\\n -148 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 483 (404 - 506) mL\\n PS : 15 cmH2O\\n RR (Spontaneous): 16\\n PEEP: 10 cmH2O\\n FiO2: 60%\\n RSBI Deferred: PEEP > 10\\n PIP: 25 cmH2O\\n SPO2: 98%\\n ABG: 7.45/49/98./31/8\\n Ve: 8.5 L/min\\n PaO2 / FiO2: 163\\n Physical Examination\\n General Appearance: No acute distress\\n HEENT: PERRL\\n Cardiovascular: (Rhythm: Regular)\\n Respiratory / Chest: (Breath Sounds: Crackles : )\\n Abdominal: Soft\\n Left Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present)\\n Right Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present)\\n Neurologic: Follows simple commands, Moves all extremities, Sedated\\n Labs / Radiology\\n 109 K/uL\\n 10.2 g/dL\\n 110 mg/dL\\n 0.8 mg/dL\\n 31 mEq/L\\n 4.5 mEq/L\\n 24 mg/dL\\n 105 mEq/L\\n 144 mEq/L\\n 31.3 %\\n 5.9 K/uL\\n [image002.jpg]\\n 12:07 AM\\n 02:18 AM\\n 08:00 AM\\n 02:00 PM\\n 05:04 PM\\n 08:00 PM\\n 09:20 PM\\n 01:00 AM\\n 01:07 AM\\n 01:18 AM\\n WBC\\n 4.2\\n 5.9\\n Hct\\n 29.7\\n 31.3\\n Plt\\n 104\\n 109\\n Creatinine\\n 0.7\\n 0.8\\n TCO2\\n 32\\n 36\\n 34\\n 35\\n Glucose\\n 129\\n 100\\n 111\\n 105\\n 117\\n 110\\n Other labs: PT / PTT / INR:13.7/27.6/1.2, CK / CK-MB / Troponin\\n T:128/13/<0.01, ALT / AST:90/113, Alk-Phos / T bili:99/5.1, Amylase /\\n Lipase:58/39, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic\\n Acid:1.4 mmol/L, Albumin:2.3 g/dL, LDH:348 IU/L, Ca:8.1 mg/dL, Mg:2.1\\n mg/dL, PO4:3.8 mg/dL\\n Assessment and Plan\\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, now\\n with AF with RVR/Aflutter, persistant hypotension and PNA.\\n Neurologic: s/p trach. Per ortho spine, no surgery; HOB<30, TLSO when\\n OOB (NEOPS will place). Wean sedation as may be causing hypotension.\\n Change pain meds to PO. Will try Geodon today for agitation.\\n Neuro checks Q: shift\\n Pain: Oxycodone, Neurontin, Tylenol. Wean fentanyl gtt, midazolam\\n gtt\\n Cardiovascular: Aflutter, now reverted to sinus. Likely cardiac\\n contusion. On Dilt 60mg PO QID. Cards rec amio gtt. Neo off. Pt cannot\\n be fully anticoagulated for now (trauma). Start PO amio.\\n Pulmonary: Intubated, weaning, tachypneic likely abd distension. On\\n appropriate abx per BAL cx - Ceftriaxone. Now that pulm status is\\n worsening, will broaden coverage with V/C/C.\\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin (declining 6.8\\n max ->5.0) w/CT scan suggesting cirrhosis - Hepatitis panel NEG. TFs.\\n Bowel regimen.\\n Nutrition: TF\\n Renal: Foley, monitor UOP, edematous scrotum. Diurese with lasix 10mg\\n IV. Goal 1 L negative today.\\n Hematology: Hct stable 32.1->29.7. Plt stable (100's); d/c'd H2B with\\n increasing plt count. Heme onc c/s - smear nl; no hemolysis. IVC\\n filter placed.\\n Endocrine: RISS, goal BS<150.\\n Infectious Disease: WBC dropping 13.1->8.8->4.2, f/u Cx - BAL:\\n pan-sensitive Klebsiella\\n broaden coverage for VAP.\\n Lines / Tubes / Drains: R SC CVL (), Foley, L a-line (),\\n trach/PEG\\n Wounds: SCDs, IVC filter, SQH\\n Imaging:\\n Fluids:\\n Consults: Trauma surgery\\n Billing Diagnosis: Multiple injuries (Trauma)\\n ICU Care\\n Nutrition:\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n Multi Lumen - 04:41 PM\\n Arterial Line - 11:30 AM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin\\n Stress ulcer: PPI\\n VAP bundle:\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds Comments:\\n Code status: Full code\\n Disposition: ICU\\n Total time spent: 32 min\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2175-02-02 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 714644,\n \"text\": \"TSICU\\n HPI:\\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\\n checked and 1.5, 1 more unit FFP given.\\n .\\n Injuries\\n Mult rib fx: R anterolateral and post, L posterior\\n T4 vert body inf corner fx\\n Commin spinous process fx T2-8\\n Nondisplaced L T10 transverse process\\n Nondispaced L distal clavicle\\n Nondisplaced L clavicle fx\\n R medial lobe liver contusion w/hematoma\\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny focus of arterial\\n bleeding/active extravasation, and larger area of venous bleeding\\n Nondisplaced, comminuted L iliac bone fx w/adjacent iliac muscle\\n hematoma, extends into L SIJ.\\n Minimally displaced fx of R iliac bone extending to R SIJ.\\n Chief complaint:\\n Trauma\\n PMHx:\\n PMH: None\\n PSH: None\\n : None\\n Current medications:\\n 24 Hour Events:\\n Trach/PEG. Pt's BP dropped to 80/40 off pressors, sats 88. restarted\\n neo. Overnight, pt reverted to sinus, off pressors, weaning sedation.\\n PERCUTANEOUS TRACHEOSTOMY - At 12:00 PM\\n PEG INSERTION - At 12:00 PM\\n Post operative day:\\n POD#7 - IVC filter via L groin\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\\n Vancomycin - 08:00 AM\\n Ceftriaxone - 03:00 PM\\n Infusions:\\n Midazolam (Versed) - 1 mg/hour\\n Amiodarone - 0.5 mg/min\\n Fentanyl (Concentrate) - 50 mcg/hour\\n Other ICU medications:\\n Fentanyl - 01:23 PM\\n Pantoprazole (Protonix) - 02:00 PM\\n Heparin Sodium (Prophylaxis) - 04:00 AM\\n Other medications:\\n Flowsheet Data as of 04:33 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 37.7\\nC (99.9\\n T current: 37.1\\nC (98.8\\n HR: 94 (68 - 101) bpm\\n BP: 140/66(91) {89/46(63) - 154/68(94)} mmHg\\n RR: 26 (11 - 30) insp/min\\n SPO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 102 kg (admission): 90 kg\\n CVP: 9 (6 - 16) mmHg\\n Total In:\\n 1,764 mL\\n 142 mL\\n PO:\\n Tube feeding:\\n 424 mL\\n IV Fluid:\\n 1,000 mL\\n 82 mL\\n Blood products:\\n Total out:\\n 1,630 mL\\n 290 mL\\n Urine:\\n 1,630 mL\\n 290 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 134 mL\\n -148 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 483 (404 - 506) mL\\n PS : 15 cmH2O\\n RR (Spontaneous): 16\\n PEEP: 10 cmH2O\\n FiO2: 60%\\n RSBI Deferred: PEEP > 10\\n PIP: 25 cmH2O\\n SPO2: 98%\\n ABG: 7.45/49/98./31/8\\n Ve: 8.5 L/min\\n PaO2 / FiO2: 163\\n Physical Examination\\n General Appearance: No acute distress\\n HEENT: PERRL\\n Cardiovascular: (Rhythm: Regular)\\n Respiratory / Chest: (Breath Sounds: Crackles : )\\n Abdominal: Soft\\n Left Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present)\\n Right Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present)\\n Neurologic: Follows simple commands, Moves all extremities, Sedated\\n Labs / Radiology\\n 109 K/uL\\n 10.2 g/dL\\n 110 mg/dL\\n 0.8 mg/dL\\n 31 mEq/L\\n 4.5 mEq/L\\n 24 mg/dL\\n 105 mEq/L\\n 144 mEq/L\\n 31.3 %\\n 5.9 K/uL\\n [image002.jpg]\\n 12:07 AM\\n 02:18 AM\\n 08:00 AM\\n 02:00 PM\\n 05:04 PM\\n 08:00 PM\\n 09:20 PM\\n 01:00 AM\\n 01:07 AM\\n 01:18 AM\\n WBC\\n 4.2\\n 5.9\\n Hct\\n 29.7\\n 31.3\\n Plt\\n 104\\n 109\\n Creatinine\\n 0.7\\n 0.8\\n TCO2\\n 32\\n 36\\n 34\\n 35\\n Glucose\\n 129\\n 100\\n 111\\n 105\\n 117\\n 110\\n Other labs: PT / PTT / INR:13.7/27.6/1.2, CK / CK-MB / Troponin\\n T:128/13/<0.01, ALT / AST:90/113, Alk-Phos / T bili:99/5.1, Amylase /\\n Lipase:58/39, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic\\n Acid:1.4 mmol/L, Albumin:2.3 g/dL, LDH:348 IU/L, Ca:8.1 mg/dL, Mg:2.1\\n mg/dL, PO4:3.8 mg/dL\\n Assessment and Plan\\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, now\\n with AF with RVR/Aflutter, persistant hypotension and PNA.\\n Neurologic: s/p trach. Per ortho spine, no surgery; HOB<30, TLSO when\\n OOB (NEOPS will place). Wean sedation as may be causing hypotension.\\n Change pain meds to PO. Will try Geodon today for agitation.\\n Neuro checks Q: shift\\n Pain: Oxycodone, Neurontin, Tylenol. Wean fentanyl gtt, midazolam\\n gtt\\n Cardiovascular: Aflutter, now reverted to sinus. Likely cardiac\\n contusion. On Dilt 60mg PO QID. Cards rec amio gtt. Neo off. Pt cannot\\n be fully anticoagulated for now (trauma). Start PO amio.\\n Pulmonary: Intubated, weaning, tachypneic likely abd distension. On\\n appropriate abx per BAL cx - Ceftriaxone. Now that pulm status is\\n worsening, will broaden coverage with V/C/C.\\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin (declining 6.8\\n max ->5.0) w/CT scan suggesting cirrhosis - Hepatitis panel NEG. TFs.\\n Bowel regimen.\\n Nutrition: TF\\n Renal: Foley, monitor UOP, edematous scrotum. Diurese with lasix 10mg\\n IV. Goal 1 L negative today.\\n Hematology: Hct stable 32.1->29.7. Plt stable (100's); d/c'd H2B with\\n increasing plt count. Heme onc c/s - smear nl; no hemolysis. IVC\\n filter placed.\\n Endocrine: RISS, goal BS<150.\\n Infectious Disease: WBC dropping 13.1->8.8->4.2, f/u Cx - BAL:\\n pan-sensitive Klebsiella\\n broaden coverage for VAP.\\n Lines / Tubes / Drains: R SC CVL (), Foley, L a-line (),\\n trach/PEG\\n Wounds: SCDs, IVC filter, SQH\\n Imaging:\\n Fluids:\\n Consults: Trauma surgery\\n Billing Diagnosis: Multiple injuries (Trauma)\\n ICU Care\\n Nutrition:\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n Multi Lumen - 04:41 PM\\n Arterial Line - 11:30 AM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin\\n Stress ulcer: PPI\\n VAP bundle:\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds Comments:\\n Code status: Full code\\n Disposition: ICU\\n Total time spent: 32 min\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2175-02-03 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 714721,\n \"text\": \"Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Following commands. Mouthing words, but incomprehensible.\\n Frequently agitated. Administered Ativan/Midazolam and Zyprexa to\\n alleve anxiety. Fair results. BP and anxiety slightly improved.\\n Febrile. Treated with Tylenol as ordered. MAE x 4 strongly.\\n Remains on CPAP. Strong cough. Lungs clear to rhonchi BL\\n in upper airways, diminished in bases. Suctioned thick tan/white\\n secretions via trach. O2 sat stable, >=95%. AM ABG showed metabolic\\n alkalosis. No new orders received. Weaned down PS to 12.\\n Hypertensive at times, especially during agitation. BP\\n decreased to 130s post Versed bolus. Pulses palpable.\\n Abdomen softly distended, non-tender. Positive BS\\n throughout abdomen. Small BM (smear) this am. Tube feeds continued at\\n goal of 80cc/hr. Tolerating well with little residual noted.\\n Foley catheter draining clear amber urine.\\n Skin intact. Ecchymosis noted to right flank. Scrotum with\\n severe edema.\\n Plan:\\n Continue to monitor neuro status with improvement in agitation. Wean\\n down PEEP/PS as tolerated.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2175-01-27 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 713731,\n \"text\": \"TSICU\\n HPI:\\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\\n checked and 1.5, 1 more unit FFP given.\\n Chief complaint:\\n Mult rib fx: R anterolateral and post, L posterior\\n T4 vert body inf corner fx\\n Commin spinous process fx T2-8\\n Nondisplaced L T10 transverse process\\n Nondispaced L distal clavicle\\n Nondisplaced L clavicle fx\\n R medial lobe liver contusion w/hematoma\\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny focus of arterial\\n bleeding/active extravasation, and larger area of venous bleeding\\n Nondisplaced, comminuted L iliac bone fx w/adjacent iliac muscle\\n hematoma, extends into L SIJ.\\n Minimally displaced fx of R iliac bone extending to R SIJ.\\n PMHx:\\n None\\n Current medications:\\n 1. IV access: Peripheral line Order date: @ 2329 12. Glucagon 1\\n mg IM Q15MIN:PRN hypoglycemia protocol Order date: @ 0104\\n 2. 1000 mL LR\\n Continuous at 60 ml/hr\\n LR + TF = 60 cc/hr Order date: @ 0103 13. Insulin SC (per\\n Insulin Flowsheet)\\n Sliding Scale Order date: @ 0104\\n 3. Acetaminophen 650 mg PO/NG Q6H:PRN pain Order date: @ 2329\\n 14. Magnesium Sulfate IV Sliding Scale Order date: @ 2339\\n 4. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL Order date:\\n @ 2329 15. Midazolam 2-4 mg IV Q2H:PRN sedation Order date:\\n @ 2329\\n 5. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date: \\n @ 0104 16. Ondansetron 4 mg IV Q8H:PRN nausea Order date: @ 2329\\n 6. Diltiazem 5-15 mg/hr IV INFUSION Afib\\n titrate titrate to HR<100 Order date: @ 2339 17. Phenylephrine\\n 0.5-5 mcg/kg/min IV DRIP TITRATE TO SBP>90 MAP>60 Order date: @\\n 2339\\n 7. Docusate Sodium (Liquid) 100 mg PO/NG Order date: @ 2329\\n 18. Pneumococcal Vac Polyvalent 0.5 ml IM ASDIR Order date: @\\n 2316\\n 8. Famotidine 20 mg PO/NG Order date: @ 2329 19. Potassium\\n Phosphate IV Sliding Scale\\n Infuse over 6 hours Order date: @ 2339\\n 9. Fentanyl Citrate 25-100 mcg IV Q2H:PRN pain, agitation Order date:\\n @ 2329 20. Potassium Chloride IV Sliding Scale Order date: \\n @ 2339\\n 10. Fentanyl Citrate 25-100 mcg/hr IV DRIP INFUSION Order date: \\n @ 2339 21. Propofol 5-20 mcg/kg/min IV DRIP TITRATE TO sedation Order\\n date: @ 2339\\n 11. Gabapentin 100 mg PO/NG TID Order date: @ 2329 22. Sodium\\n Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush\\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\\n Order date: @ 2329\\n 24 Hour Events:\\n Febrile yesterday AM to 101.3. Pan cx. Placed on Dilt gtt for Afib\\n with RVR but since has converted and is off the dilt gtt. Continues to\\n wean off the Neo gtt. Tube feeds started. Bronchoscopy performed.\\n IVC filter placed late last PM.\\n Post operative day:\\n POD#1 - IVC filter via L groin\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Fentanyl (Concentrate) - 100 mcg/hour\\n Propofol - 20 mcg/Kg/min\\n Phenylephrine - 0.5 mcg/Kg/min\\n Other ICU medications:\\n Famotidine (Pepcid) - 08:00 AM\\n Diltiazem - 10:07 AM\\n Fentanyl - 02:45 AM\\n Other medications:\\n Flowsheet Data as of 06:19 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 38.5\\nC (101.3\\n T current: 36.7\\nC (98.1\\n HR: 75 (57 - 147) bpm\\n BP: 107/59(76) {92/49(64) - 153/81(106)} mmHg\\n RR: 8 (0 - 22) insp/min\\n SPO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 102 kg (admission): 90 kg\\n CVP: 19 (9 - 27) mmHg\\n Total In:\\n 2,767 mL\\n 520 mL\\n PO:\\n Tube feeding:\\n 52 mL\\n 82 mL\\n IV Fluid:\\n 2,425 mL\\n 438 mL\\n Blood products:\\n Total out:\\n 1,078 mL\\n 380 mL\\n Urine:\\n 1,078 mL\\n 380 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,689 mL\\n 140 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 440 (440 - 440) mL\\n Vt (Spontaneous): 612 (612 - 612) mL\\n PS : 15 cmH2O\\n RR (Set): 18\\n RR (Spontaneous): 3\\n PEEP: 14 cmH2O\\n FiO2: 40%\\n RSBI Deferred: PEEP > 10\\n PIP: 27 cmH2O\\n Plateau: 19 cmH2O\\n SPO2: 100%\\n ABG: 7.39/47/154/28/3\\n Ve: 9.6 L/min\\n PaO2 / FiO2: 385\\n Physical Examination\\n General Appearance: Intubated\\n HEENT: PERRL, Jaundiced\\n Cardiovascular: (Rhythm: Regular)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\\n bilateral : )\\n Abdominal: Soft, Non-distended\\n Left Extremities: (Edema: 1+), (Temperature: Warm)\\n Right Extremities: (Edema: 1+), (Temperature: Warm)\\n Skin: scrotum eechymotic\\n Neurologic: Sedated\\n Labs / Radiology\\n 99 K/uL\\n 10.9 g/dL\\n 96 mg/dL\\n 0.9 mg/dL\\n 28 mEq/L\\n 3.8 mEq/L\\n 18 mg/dL\\n 107 mEq/L\\n 141 mEq/L\\n 30.6 %\\n 11.0 K/uL\\n [image002.jpg]\\n 07:39 AM\\n 08:00 AM\\n 10:22 AM\\n 01:57 PM\\n 02:00 PM\\n 02:16 PM\\n 05:17 PM\\n 12:14 AM\\n 12:20 AM\\n 05:24 AM\\n WBC\\n 12.1\\n 11.0\\n Hct\\n 30.5\\n 30.6\\n Plt\\n 105\\n 99\\n Creatinine\\n 1.0\\n 0.9\\n TCO2\\n 32\\n 33\\n 34\\n 33\\n 32\\n 30\\n Glucose\\n 84\\n 105\\n 101\\n 96\\n Other labs: PT / PTT / INR:13.7/28.7/1.2, CK / CK-MB / Troponin\\n T:1334/13/<0.01, ALT / AST:345/278, Alk-Phos / T bili:49/3.0, Amylase /\\n Lipase:44/, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic Acid:1.4\\n mmol/L, LDH:435 IU/L, Ca:7.8 mg/dL, Mg:2.2 mg/dL, PO4:2.8 mg/dL\\n Imaging: MRI: Mild compression deformity of L1 w/additional\\n levels of potential trabecular contusion @T10-11 also inf @T4 w/o\\n retropulsion. Multilevel degenerative changes with moderate canal\\n narrowing at T10-11 w/cord deformity and no abnormal cord signal.\\n Extensive edema throughout paraspinal soft tissues, predominantly post\\n w/in interspinous ligaments. Incompletely eval'ed c-spine w/severe\\n canal narrowing @C4-5 w/cord deformity and no abnormal cord signal.\\n CTA: no PE.\\n CXR: Moderate bilateral pleural effusions are stable.\\n Microbiology: Ucx no growth final\\n Sputum: sparse GNR\\n Bcx P\\n Bcx P\\n BAL: GS shows 1+ normal flora\\n BAL: GS shows 1+ normal flora\\n Assessment and Plan\\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, AF with\\n RVR, hematologic abnomalities\\n Neurologic: Neuro checks Q: 4 hr, Intubated on Propofol gtt and\\n Midazolam PRN. Per ortho spine, no surgery; HOB<30, TLSO when OOB\\n (NEOPS will place).\\n Pain: Fentanyl PRN, Midazolam prn, Neurontin, Tylenol, APS c/s for\\n paravertebral catheters\\n Cardiovascular: Now back in NSR, off dilt gtt and currently weaning Neo\\n gtt.\\n Pulmonary: Cont ETT, Intubated. Pt developing early ARDS, keep on rate\\n with low tidal volumes. F/U CXR this AM. F/U on bronch cx.\\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin with CT scan\\n suggesting cirrhosis - Hepatitis panel sent. Starting TF and advancing\\n to goal.\\n Nutrition: Tube feeding\\n Renal: Foley, Foley, monitor UOP. Cr normalized.\\n Hematology: Hct stable at 29-30. Plt low but stable (100's). Heme onc\\n consulted - f/u on hemolysis labs. IVC filter placed.\\n Endocrine: RISS\\n Infectious Disease: Check cultures, WBC normal, f/u Cx\\n Lines / Tubes / Drains: R SC CVL (), PIV x2, Foley, a-line\\n (), ETT\\n Wounds: left groin site is c/d/i, no hematoma or pseudoaneurysm\\n Imaging:\\n Fluids: TF + IVF = 60 cc/hr\\n Consults: Trauma surgery, Ortho, Ortho-spine, Heme/Onc\\n Billing Diagnosis: Multiple injuries (Trauma)\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 11:52 PM 20 mL/hour\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n Arterial Line - 10:59 AM\\n Multi Lumen - 04:41 PM\\n Prophylaxis:\\n DVT: Boots, IVC filter\\n Stress ulcer: H2 blocker\\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds , ICU\\n Code status: Full code\\n Disposition: ICU\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2175-01-28 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 713834,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 4\\n Ideal body weight: 0 None\\n Ideal tidal volume: 0 / 0 / 0 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: No\\n Procedure location:\\n Reason:\\n Tube Type\\n ETT:\\n Position: cm at teeth\\n Route:\\n Type: Standard\\n Size: 7.5mm\\n Tracheostomy tube:\\n Type:\\n Manufacturer:\\n Size:\\n PMV:\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 20 cmH2O\\n Cuff volume: mL /\\n Airway problems:\\n Comments:\\n Lung sounds\\n RLL Lung Sounds: Clear\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Clear\\n Comments:\\n Secretions\\n Sputum color / consistency: Yellow / Thick\\n Sputum source/amount: Suctioned / Moderate\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance:\\n Visual assessment of breathing pattern:\\n Assessment of breathing comfort:\\n Non-invasive ventilation assessment:\\n Invasive ventilation assessment:\\n Trigger work assessment:\\n Dysynchrony assessment:\\n Comments:\\n Plan\\n Next 24-48 hours:\\n Reason for continuing current ventilatory support:\\n Respiratory Care Shift Procedures\\n Transports:\\n Destination (R/T)\\n Time\\n Complications\\n Comments\\n Bedside Procedures:\\n Comments: Pt cont intub with OETT sedated and on mech vent as per\\n Metavision. Lung sounds ess clear after suct mod th yellow sput. ABGs\\n stable on current vent settings; no vent changes required overnoc. Cont\\n PSV.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2175-01-28 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 713835,\n \"text\": \"TSICU\\n HPI:\\n 74M s/p fall with multiple rib fx, pelvis fx, clavicle fx, and thoracic\\n fx c/b unstable bleeding s/p IR embo, AF with RVR, hematologic\\n abnomalities.\\n Chief complaint:\\n fall\\n PMHx:\\n none\\n Current medications:\\n 1. Acetaminophen 2. Bisacodyl 3. Chlorhexidine Gluconate 0.12% Oral\\n Rinse 4. Dextrose 50% 5. Diltiazem 6. Docusate Sodium (Liquid) 7.\\n Famotidine 8. Fentanyl Citrate 9. Fentanyl Citrate 10. Gabapentin 11.\\n Glucagon 12. Insulin 13. Magnesium Sulfate 14. Midazolam 15.\\n Ondansetron 16. Phenylephrine 17. Pneumococcal Vac Polyvalent 18.\\n Potassium Phosphate 19. Potassium Chloride 20. Propofol 21. Senna 22.\\n Sodium Chloride 0.9% Flush\\n 24 Hour Events:\\n ARTERIAL LINE - STOP 11:05 AM\\n ARTERIAL LINE - START 11:30 AM\\n Heme c/s- smear nl. Wean vent, started on po diltiazem for atrial\\n ectopy.\\n Post operative day:\\n POD#2 - IVC filter via L groin\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Fentanyl (Concentrate) - 100 mcg/hour\\n Propofol - 20 mcg/Kg/min\\n Phenylephrine - 0.3 mcg/Kg/min\\n Other ICU medications:\\n Fentanyl - 08:00 PM\\n Other medications:\\n Flowsheet Data as of 04:42 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 37.6\\nC (99.7\\n T current: 37.5\\nC (99.5\\n HR: 69 (62 - 97) bpm\\n BP: 102/51(66) {89/48(63) - 135/71(94)} mmHg\\n RR: 13 (8 - 20) insp/min\\n SPO2: 98%\\n Heart rhythm: 1st AV (First degree AV Block)\\n Wgt (current): 102 kg (admission): 90 kg\\n CVP: 15 (11 - 24) mmHg\\n Total In:\\n 2,899 mL\\n 385 mL\\n PO:\\n Tube feeding:\\n 908 mL\\n 228 mL\\n IV Fluid:\\n 1,471 mL\\n 96 mL\\n Blood products:\\n 50 mL\\n Total out:\\n 1,050 mL\\n 90 mL\\n Urine:\\n 1,050 mL\\n 90 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,849 mL\\n 295 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CPAP/PSV\\n Vt (Set): 500 (440 - 500) mL\\n Vt (Spontaneous): 495 (495 - 680) mL\\n PS : 12 cmH2O\\n RR (Set): 10\\n RR (Spontaneous): 12\\n PEEP: 12 cmH2O\\n FiO2: 40%\\n RSBI Deferred: PEEP > 10\\n PIP: 25 cmH2O\\n SPO2: 98%\\n ABG: 7.40/54/92./31/6\\n Ve: 7.2 L/min\\n PaO2 / FiO2: 232\\n Physical Examination\\n General Appearance: No acute distress\\n HEENT: PERRL\\n Cardiovascular: (Rhythm: No(t) Regular, Irregular)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\\n bilateral : )\\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\\n Left Extremities: (Edema: 3+), (Temperature: Warm)\\n Right Extremities: (Edema: 3+), (Temperature: Warm)\\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\\n Moves all extremities, Sedated\\n Labs / Radiology\\n 74 K/uL\\n 9.7 g/dL\\n 128 mg/dL\\n 0.8 mg/dL\\n 31 mEq/L\\n 3.9 mEq/L\\n 19 mg/dL\\n 108 mEq/L\\n 141 mEq/L\\n 28.7 %\\n 5.6 K/uL\\n [image002.jpg]\\n 02:16 PM\\n 05:17 PM\\n 12:14 AM\\n 12:20 AM\\n 05:24 AM\\n 06:50 AM\\n 02:40 PM\\n 03:13 PM\\n 01:59 AM\\n 02:00 AM\\n WBC\\n 11.0\\n 11.0\\n 8.0\\n 5.6\\n Hct\\n 30.6\\n 30.1\\n 29.8\\n 28.7\\n Plt\\n 99\\n 97\\n 80\\n 74\\n Creatinine\\n 0.9\\n 0.8\\n 0.8\\n TCO2\\n 34\\n 33\\n 32\\n 30\\n 33\\n 35\\n Glucose\\n 96\\n 133\\n 125\\n 128\\n Other labs: PT / PTT / INR:13.7/28.7/1.2, CK / CK-MB / Troponin\\n T:1334/13/<0.01, ALT / AST:147/126, Alk-Phos / T bili:52/2.6, Amylase /\\n Lipase:44/, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic Acid:1.4\\n mmol/L, Albumin:2.7 g/dL, LDH:435 IU/L, Ca:8.0 mg/dL, Mg:2.2 mg/dL,\\n PO4:2.8 mg/dL\\n Assessment and Plan\\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, AF with\\n RVR, hematologic abnomalities.\\n Neurologic: Intubated on Propofol gtt and Midazolam PRN (have not been\\n giving). Per ortho spine, no surgery; HOB<30, TLSO when OOB (NEOPS will\\n place).\\n Neuro checks Q: shift\\n Pain: Fentanyl 100mcg/hr, Midazolam prn, Neurontin, Tylenol\\n Cardiovascular: Now back in NSR with occasional PACs, off dilt gtt,\\n started po diltiazem 30 qid, and currently weaning Neo gtt. Fluid\\n challenge and PPV 6. Also given 25% albumin x1\\n Pulmonary: Intubated. Pt developing early ARDS, placed on MMV. F/U on\\n bronch cx.\\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin with CT scan\\n suggesting cirrhosis - Hepatitis panel NEG. TFs advancing to goal.\\n Bowel regimen.\\n Nutrition: Tube feeding\\n Renal: Foley, monitor UOP. Cr normalized.\\n Hematology: Hct stable at 29-30-28.7. Plt low but stable (100's).\\n Heme onc consulted - smear nl. IVC filter placed.\\n Endocrine: RISS\\n Infectious Disease: WBC normal, f/u Cx - GNR in sputum and BAL, but\\n afebrile, monitor for now, may start abx if spikes.\\n Lines / Tubes / Drains: R SC CVL (), PIV x2, Foley, L a-line\\n (), ETT\\n Wounds:\\n Imaging: CXR today\\n Fluids: none\\n Consults: Trauma (1o), Ortho Spine, Ortho trauma, Heme\\n Billing Diagnosis:\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 01:48 AM 50 mL/hour\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n Multi Lumen - 04:41 PM\\n Arterial Line - 11:30 AM\\n Prophylaxis:\\n DVT: Boots, IVC filter\\n Stress ulcer: H2 blocker\\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\\n Comments:\\n Communication: ICU consent signed Comments:\\n Code status: Full code\\n Disposition: ICU\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2175-01-28 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 713836,\n \"text\": \"Atrial fibrillation (Afib)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Hypotension (not Shock)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2175-01-28 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 713837,\n \"text\": \"Atrial fibrillation (Afib)\\n Assessment:\\n HR 60s-80s SR with 1^st degree AV block.\\n Action:\\n Response:\\n Plan:\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Hypotension (not Shock)\\n Assessment:\\n Continues on neo gtt to maintain goal map >65.\\n Action:\\n Able to wean neo down to 0.3mcg/kg/min. Gave albumin last pm and pt\\n BP increased for awhile.\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2175-01-31 00:00:00.000\",\n \"description\": \"Cardiology Consult\",\n \"row_id\": 714298,\n \"text\": \"TITLE: Cardiology Consult\\n DIVISION OF CARDIOLOGY\\n COMPREHENSIVE CONSULTATION NOTE\\nCHIEF COMPLAINT: Patient is seen in consultation today at the\\nrequest of Dr. . We are asked to give consultative advice\\nregarding evaluation and management of Aflutter with RVR.\\nHISTORY OF PRESENT ILLNESS:\\n74M no known PMH, who originally presented on s/p fall from\\ntractor and crush injury from tree branch. He was initially\\nbrought to hospital where he was found to have numerous\\nright sided rib fractures and t4 vertebral body fracture. He was\\nhypotensive, but in sinus rhythm with HR in the 80s. He was\\ntransferred to where he was found to have a complex\\nfracture of the left iliac , non displaced fracture of the\\nright iliac , complex fracture t2-8, nondisplaced distal left\\nclavicle fracture. He was given 4 U PRBC, 1 unit FFP, and\\nunderwent arteriogram on with embolization to the liver and\\npelvis and IVC filter placement for concern of high likelihood of\\ndevelopment of dvt and inability to anticoagulate. In the\\nmorning of , he developed aflutter into the 140s, which was\\ntreated with diltiazem PO. Over the next 4 days, he continued to\\ngo into and out of AFlutter with HRs controlled in the 80s in\\nflutter and 60s in sinus. His SBP was noted to drop into the 80s\\nwhile in flutter requiring increase in the neosynephrine drip,\\nand so we were consulted about DCCV.\\nThe patient is intubated and sedated, and could not provide any\\nhistory. His family notes that he had no activity limitations\\nprior to the accident, and he no known cardiac history of which\\nthey were aware. He apparently is followed by his physician, \\nper the family, was told he was 'healthy as a horse' when seen\\nthe week prior to the accident.\\nCardiac ROS could not be obtained.\\nPAST MEDICAL HISTORY:\\nNone noted\\nCardiac Risk Factors include none.\\nHOME MEDICATIONS:\\nUnknown; reportedly acid reflux pill and sleep medication\\nCURRENT MEDICATIONS:\\nHaloperidol 2-5 mg PO Q2H:PRN\\nMidazolam 0.5-2 mg/hr IV DRIP\\nFentanyl Citrate 12.5-50 mcg/hr IV DRIP\\nOxycoDONE Liquid 10 mg PO/NG Q3H:PRN pain\\nLorazepam 2mg Syringe Study Med 1 mg IV Q6H Duration: 4 Doses\\nKetamine Study Drug Study Med 1 dose IV AS SIR Duration: 24 Hours\\nCeftriaXONE 1 gm IV Q24H\\nGabapentin 400 mg PO/NG TID\\nHeparin 5000 UNIT SC TID\\nVancomycin 1000 mg IV Q 12H\\nDiltiazem 60 mg PO/NG QID\\nCalcium Gluconate IV Sliding Scale\\nPantoprazole 40 mg IV Q24H\\nMetoprolol Tartrate 5 mg IV Q4H:PRN hr>90, SBP>150\\nHYDROmorphone (Dilaudid) 0.125-1 mg IV Q3H:PRN\\nBowel meds\\nInsulin sliding scale\\nALLERGIES: NKDA\\nSOCIAL HISTORY: Unavailable\\nFAMILY HISTORY: Unavailable\\nREVIEW OF SYSTEMS: Unable to obtain\\nPHYSICAL EXAMINATION\\nVitals: T: 100.6 degrees Farenheit, BP: 93-120/50s mmHg supine,\\nHR 78-80 bpm, CVP 12, RR 24 bpm, O2: 98 % on PSV 13/10 @ 0.5, TV\\n~ 500.\\nCONSTITUTIONAL: Intubated, sedated.\\nEYES: No conjunctival pallor. No icterus.\\nENT/Mouth: ETT in place. OP clear.\\nTHYROID: No thyromegaly or thyroid nodules.\\nCV: Nondisplaced PMI. Normal rate. Regular rhythm. nl S1, S2. No\\nextra heart sounds. No appreciable murmurs. No JVD.\\nLUNGS: Rhonchorous breath sounds bilaterally.\\nGI: NABS. Soft, NT, ND. No HSM. No abdominal bruits.\\nMUSCULO: Limited exam. Normal muscle tone.\\nHEME/LYMPH: No palpable LAD. + pitting edema. Scrotal edeam\\nwith overlying ecchymoses. Full distal pulses bilaterally. SKIN:\\nWarm extremities. Significant ecchymoses along trunk.\\nNEURO: Sedated.\\nPSYCH: Deferred.\\nTELEMETRY: Aflutter at 80s. No other events. Not available > 24\\nhours ago, but per report, in sinus on .\\nECG (): Aflutter with A rate ~300, VR regular at 86 with\\n3:1 AV block. L axis. Nonspecific TW flattening inferior leads.\\nCompared to prior ECG from , flutter is more organized.\\nOne ECG from (5:56) shows atrial tach.\\nTRANSTHORACIC ECHOCARDIOGRAM ():\\nThe left atrium and right atrium are normal in cavity size. Left\\nventricular wall thickness, cavity size and regional/global\\nsystolic function are normal (LVEF >55%). Transmitral and tissue\\nDoppler imaging suggests normal diastolic function, and a normal\\nleft ventricular filling pressure (PCWP<12mmHg). Right\\nventricular chamber size is mildly dilated with normal free wall\\nmotion. The aortic root is mildly dilated at the sinus level. The\\naortic valve leaflets (3) appear structurally normal with good\\nleaflet excursion and no aortic stenosis. Trace aortic\\nregurgitation is seen. The mitral valve appears structurally\\nnormal with trivial mitral regurgitation. There is no mitral\\nvalve prolapse. There is mild pulmonary artery systolic\\nhypertension. There is no pericardial effusion. Compared with the\\nprior study (images reviewed) of , the right\\nventricular cavity is now smaller, the severity of tricuspid\\nregurgitation is now reduced, and the estimated pulmonary artery\\nsystolic pressure is now lower (previously overestimated on\\nreview of the prior study).\\nOTHER TESTING:\\nCXR : The ET tube tip is 6.2 cm above the carina. The NG\\ntube tip is in the proximal stomach. The right subclavian line\\ntip is at the level of superior SVC. Cardiomediastinal silhouette\\nis unchanged as well as there is no change in mild bilateral\\npulmonary edema and parenchymal opacities and there is no pleural\\neffusion. There is no clear evidence of pneumothorax, although\\nminimal amount cannot be excluded on the left. Multiple rib\\nfractures are redemonstrated.\\nIliac angiography :\\n1. Pelvic arteriography: Multiple arteriographic runs performed\\nof distal\\naorta, external iliac, internal iliac, lateral sacral and\\nsuperior gluteal\\narteries. Active contrast extravasation noted from branches of\\nthe lateral\\nsacral artery and superior gluteal arteries. Successful Gelfoam\\nembolization\\nof lateral sacral artery and branches of the superior gluteal\\nartery.\\n2. Hepatic angiography: Multiple arteriographic runs of common\\nhepatic and\\nright hepatic arteries. Some active contrast extravasation was\\nnoted from\\nperipheral branches of right hepatic artery. Gelfoam embolization\\nof distal\\nright hepatic artery branches performed.\\nCT Head \\nThere is no intracranial hemorrhage, edema, shift of normally\\nmidline structures or evidence of major vascular territorial\\ninfarct. Ventricles and sulci are normal in size and\\nconfiguration. The -white matter differentiation is\\npreserved. The basilar cisterns are symmetric. A small mucous\\nretention cyst, and a small amount of fluid are noted within the\\nright maxillary sinus. Remaining paranasal sinuses are well\\naerated. Mastoid air cells are well aerated\\nCT C spine \\n1. No fracture or malalignment of the cervical spine.\\n2. Large posterior disc bulge at C4-5, acuity unknown, resulting\\nin deformity of the thecal sac. If neural deficits are\\nlocalizable to this level, MRI can be obtained to assess for\\nspinal cord injury.\\n3 Bilateral neural foraminal narrowing.\\nCT Chest \\n1. Multiple rib fractures bilaterally, including right\\nanterolateral and posterior, and left posterior ribs as detailed\\nabove.\\n2. T4 vertebral body inferior corner fracture, with no\\nretropulsion or malalignment. Comminuted spinous process\\nfractures between T2 and T8.\\n3. Non-displaced left T10 transverse process fracture.\\n4. Non-displaced left clavicle and left scapula fractures.\\n5. Dependent consolidation in the lungs bilaterally, which could\\nbe sequela\\nof aspiration, or could reflect contusion.\\n6. No acute vascular injury.\\n7. Calcified pleura bilaterally suggesting prior asbestos\\nexposure.\\nCT abdomen \\n1. Contusion/laceration of the medial aspect of the right hepatic\\nlobe, with adjacent small hematoma, without definite evidence of\\nactive bleeding. Associated irregularity of an adjacent branch of\\nthe right hepatic artery and resultant narrowing of the adjacent\\nright hepatic vein and right posterior portal vein branches.\\nPosterior right hepatic laceration/contusion, adjacent to a\\ncalcified granuloma, with a small hematoma, without evidence of\\nactive\\nextravasation.\\n2. Comminuted left pubic ramus fracture with associated hematoma,\\nwhich has increased in size from the prior study of approximately\\nsix hours prior. Tiny focus of arterially enhancing material,\\nwhich enlarges on venous and delayed images, concerning for\\nactive extravasation.\\n3. Minimally displaced, comminuted left iliac bone fracture, with\\nadjacent iliac muscle hematoma, largely unchanged from the prior\\nstudy, without evidence of active extravasation. Fracture extends\\ninto the left sacroiliac joint.\\n4. Minimally displaced fracture of the right iliac bone,\\nextending to the right sacroiliac joint.\\n5. Bilateral comminuted, minimally displaced posterior rib\\nfractures of the eighth through eleventh ribs. Nondisplaced left\\n10th vertebral body transverse process fracture.\\n6. Interval increase in bilateral pleural effusions (small), with\\nincreased bilateral atelectasis or consolidation which could be\\nthe result of aspiration.\\n7. Cirrhotic liver. Fluid around the nondistended gallbladder may\\nbe related to liver disease.\\nMR T spine \\nIMPRESSION:\\n1. Mild compression deformity of L1 with additional levels of\\npotential trabecular contusion at T10-11 also inferiorly at T4\\nwith no retropulsion.\\n2. Multilevel degenerative changes with moderate canal narrowing\\nat T10-11 with cord deformity and no abnormal cord signal.\\n3. Extensive edema throughout the paraspinal soft tissues,\\npredominantly posteriorly within the interspinous ligaments.\\n4. Incompletely evaluated cervical spine demonstrates severe\\ncanal narrowing at C4-5 with cord deformity and no abnormal cord\\nsignal.\\nLABORATORY DATA: Reviewed in OMR\\nASSESSMENT AND PLAN:\\n74M no significant PMH, s/p tractor accident with pelvic, spine,\\nand rib fractures, liver laceration requiring embolization, and\\ncoagulopathy requiring multiple FFP transfusions and hematology\\nconsult, who p/w aflutter. Although tele is unavailable from >\\n24 hours, he was reportedly in sinus on , and thus has been\\nin the sustained rhythm for over 24 hours but probably not > 48\\nhours. Despite appropriate rate control, his blood pressure does\\nappear to drop with the aflutter, requiring higher doses of the\\nneo gtt, which is a little unusual given his fairly normal\\nappearing TTE. At this point, he may in fact benefit from being\\nin sinus rhythm, but it is unclear 1) that he will remain in SR\\nafter cardioversion without additional meds since he apparently\\nhad been going in and out of Aflutter over the past week, and 2)\\nwhether the risk of thromboembolism after possibly > 48 hours of\\nflutter following CV outweighs the benefit of establishing sinus\\nrhythm urgently, especially since he is unable to have any\\nanticoagulation. As the clinical situation will dictate urgent\\ncare, TEE is unlikely to be helpful, and flutter ablation is not\\nan option. The etiology of the aflutter is likely increased\\ncatechols in the setting of stress, and thus beta blockers might\\nbe preferred as an of rate control, although he appears to\\nhave good rate control on diltiazem.\\nRec:\\n--Continue dilt at present dose\\n--Continue pain control, supportive measures\\n--Consider initiation of amiodarone (1mg/min x 6 hours, then 0.5\\nmg/min) if benefit of SR is determined to outweigh the risk of\\nthromboembolism; which could be followed by DCCV if necessary,\\nbut will d/w attending\\nThe Assessment and Plan will be reviewed with Dr. in\\nmulti- disciplinary rounds. Please see his/her note in the\\n medical record for further comments and\\nrecommendations. Thank you for allowing us to participate in the\\ncare of this patient. Please feel free to contact us with any\\nquestions or concerns.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2175-02-03 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 714710,\n \"text\": \"Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Following commands. Mouthing words, but incomprehensible.\\n Frequently agitated. Administered Ativan/Midazolam and Zyprexa to\\n alleve anxiety. Fair results. BP and anxiety slightly improved.\\n Febrile. Treated with Tylenol as ordered. MAE x 4 strongly.\\n Remains on CPAP. Strong cough. Lungs clear to rhonchi BL\\n in upper airways, diminished in bases. Suctioned thick tan/white\\n secretions via trach. O2 sat stable, >=95%.\\n Hypertensive at times, especially during agitation. BP\\n decreased to 130s post Versed bolus. Pulses palpable.\\n Abdomen softly distended, non-tender. Positive BS\\n throughout abdomen. Small BM (smear) this am. Tube feeds continued at\\n goal of 80cc/hr. Tolerating well with little residual noted.\\n Foley catheter draining clear amber urine.\\n Skin intact. Ecchymosis noted to right flank. Scrotum with\\n severe edema.\\n Plan:\\n Continue to monitor neuro status with improvement in agitation. Wean\\n down PEEP/PS as tolerated.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2175-01-28 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 713929,\n \"text\": \"74M s/p fall with multiple rib fx, pelvis fx, clavicle fx, and thoracic\\n fx c/b unstable bleeding s/p IR embo, AF with RVR, hematologic\\n abnomalities.\\n Atrial fibrillation (Afib)\\n Assessment:\\n Remains in 1^st degree HB. HR to 120\\ns with agitation, anxiety.\\n Action:\\n Continues on Fentanyl gtt, Receiving Dilaudid IV and Midazolam for\\n pain & agitation.\\n Response:\\n Good response with meds for pain, agitation, and anxiety.\\n Plan:\\n Cont to asses rhythm, BP. Metoprolol PRN for HR > 90, SBP > 150\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n BBS= essentially clear throughout all lung fields.\\n Action:\\n Rested overnight on CPAP/PS. Lasix gtt initiated for diuresis.\\n Suctioned Q1-2 hrs for moderate amounts thick, pale yellow secretions.\\n Klebsiella growing from sputum\\n Response:\\n Appears comfortable, no SOB noted or increased WOB.\\n Plan:\\n Goal for pt to be -500cc, will move towards extubation this morning as\\n pt tolerates.\\n Trauma, s/p\\n Assessment:\\n Mult echymotic areas over head torso, extremities. Scrotum echymotic,\\n edematous.\\n Action:\\n Managing pain with Fentanyl gtt, Dilaudid & Midazolam IV. Scrotum\\n elevated\\n Response:\\n Currently denies pain.\\n Plan:\\n Fentanyl gtt overnight. Keep scrotum elevated.\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2175-01-29 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 713943,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 5\\n Ideal body weight: 0 None\\n Ideal tidal volume: 0 / 0 / 0 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: No\\n Procedure location:\\n Reason:\\n Tube Type\\n ETT:\\n Position: cm at teeth\\n Route:\\n Type: Standard\\n Size: 7.5mm\\n Tracheostomy tube:\\n Type:\\n Manufacturer:\\n Size:\\n PMV:\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 20 cmH2O\\n Cuff volume: mL /\\n Airway problems:\\n Comments:\\n Lung sounds\\n RLL Lung Sounds: Clear\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Clear\\n Comments:\\n Secretions\\n Sputum color / consistency: Yellow / Thick\\n Sputum source/amount: Suctioned / Small\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance:\\n Visual assessment of breathing pattern:\\n Assessment of breathing comfort:\\n Non-invasive ventilation assessment:\\n Invasive ventilation assessment:\\n Trigger work assessment:\\n Dysynchrony assessment:\\n Comments:\\n Plan\\n Next 24-48 hours:\\n Reason for continuing current ventilatory support:\\n Respiratory Care Shift Procedures\\n Transports:\\n Destination (R/T)\\n Time\\n Complications\\n Comments\\n Bedside Procedures:\\n Comments: Pt cont intub with OETT sedated and on mech vent as per\\n Metavision. Lung sounds ess clear after suct mod th yellow sput. ABGs\\n stable on current vent settings; no vent changes required overnoc. Cont\\n PSV.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2175-01-29 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 713947,\n \"text\": \"74M s/p fall with multiple rib fx, pelvis fx, clavicle fx, and thoracic\\n fx c/b unstable bleeding s/p IR embo, AF with RVR, hematologic\\n abnomalities.\\n Atrial fibrillation (Afib)\\n Assessment:\\n Remains in 1^st degree HB. HR to 120\\ns with agitation, anxiety.\\n Action:\\n Continues on Fentanyl gtt, Receiving Dilaudid IV and Midazolam for\\n pain & agitation.\\n Response:\\n Good response with meds for pain, agitation, and anxiety.\\n Plan:\\n Cont to asses rhythm, BP. Metoprolol PRN for HR > 90, SBP > 150\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n BBS= essentially clear throughout all lung fields.\\n Action:\\n Rested overnight on CPAP/PS. Lasix gtt initiated for diuresis.\\n Suctioned Q1-2 hrs for moderate amounts thick, pale yellow secretions.\\n Klebsiella growing from sputum\\n Response:\\n Appears comfortable, no SOB noted or increased WOB.\\n Plan:\\n Goal for pt to be -500cc, will move towards extubation this morning as\\n pt tolerates.\\n Trauma, s/p\\n Assessment:\\n Multiple echymotic areas over head torso, extremities. Scrotum\\n echymotic, edematous.\\n Action:\\n Managing pain with Fentanyl gtt, Dilaudid & Midazolam IV. Scrotum\\n elevated\\n Response:\\n Currently denies pain.\\n Plan:\\n Fentanyl gtt overnight. Keep scrotum elevated.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2175-01-31 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 714367,\n \"text\": \"TSICU\\n HPI:\\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\\n checked and 1.5, 1 more unit FFP given.\\n Chief complaint:\\n Mult rib fx: R anterolateral and post, L posterior\\n T4 vert body inf corner fx\\n Commin spinous process fx T2-8\\n Nondisplaced L T10 transverse process\\n Nondispaced L distal clavicle\\n Nondisplaced L clavicle fx\\n R medial lobe liver contusion w/hematoma\\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny focus of arterial\\n bleeding/active extravasation, and larger area of venous bleeding\\n Nondisplaced, comminuted L iliac bone fx w/adjacent iliac muscle\\n hematoma, extends into L SIJ.\\n Minimally displaced fx of R iliac bone extending to R SIJ.\\n PMHx:\\n PMH: None\\n PSH: None\\n Current medications:\\n 1. IV access: Peripheral line Order date: @ 2329 16. Ketamine\\n Study Drug Study Med 1 dose IV AS SIR Duration: 24 Hours\\n Patient to receive Ketamine/Placebo 0.25mg/kg bolus over 1 hour\\n followed by 0.1mg/kg/hr for 23 hours Order date: @ 1338\\n 2. Acetaminophen 650 mg PO/NG Q6H:PRN pain Order date: @ 2329\\n 17. Lorazepam 2mg Syringe Study Med 1 mg IV Q6H Duration: 4 Doses\\n Patient to receive Lorazepam 1mg iv every 6 hours for 4 doses while on\\n ketamine study drug Order date: @ 1338\\n 3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation Order date: @\\n 0823 18. Magnesium Sulfate IV Sliding Scale Order date: @ 2339\\n 4. Calcium Gluconate IV Sliding Scale Order date: @ 1657 19.\\n Metoprolol Tartrate 5 mg IV Q4H:PRN hr>90, SBP>150\\n hold hr<60, SBP<100 Order date: @ 1809\\n 5. CeftriaXONE 1 gm IV Q24H Order date: @ 1228 20. Midazolam\\n 0.5-1 mg IV Q2H:PRN sedation Order date: @ 0912\\n 6. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL Order date:\\n @ 2329 21. Midazolam 0.5-10 mg/hr IV DRIP TITRATE TO sedation\\n Patient must have adequate airway support prior to administration of\\n dose. Order date: @ 0734\\n 7. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date: \\n @ 0104 22. Ondansetron 4 mg IV Q8H:PRN nausea Order date: @ 2329\\n 8. Diltiazem 60 mg PO/NG QID\\n hold for HR < 60 or SBP < 100 Order date: @ 23.\\n Pantoprazole 40 mg IV Q24H Order date: @ 1321\\n 9. Docusate Sodium (Liquid) 100 mg PO/NG Order date: @ 2329\\n 24. Phenylephrine 0.5-5 mcg/kg/min IV DRIP TITRATE TO SBP>90 MAP>60\\n Order date: @ 2339\\n 10. Fentanyl Citrate 25-100 mcg/hr IV DRIP INFUSION\\n Please wean with Dilaudid dosing. Thank you. Order date: @ 1136\\n 25. Pneumococcal Vac Polyvalent 0.5 ml IM ASDIR Order date: @\\n 2316\\n 11. Gabapentin 400 mg PO/NG TID Order date: @ 1210 26. Potassium\\n Phosphate IV Sliding Scale\\n Infuse over 6 hours Order date: @ 2339\\n 12. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date:\\n @ 0104 27. Potassium Chloride IV Sliding Scale Order date: \\n @ 2339\\n 13. HYDROmorphone (Dilaudid) 0.125-1 mg IV Q3H:PRN pain Order date:\\n @ 0912 28. Senna 1 TAB PO/NG :PRN constipation Order date:\\n @ 0823\\n 14. Heparin 5000 UNIT SC TID Order date: @ 0931 29. Sodium\\n Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush\\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\\n Order date: @ 2329\\n 15. Insulin SC (per Insulin Flowsheet)\\n Sliding Scale Order date: @ 0104 30. Vancomycin 1000 mg IV\\n Q 12H\\n ID Approval will be required for this order in 39 hours. Order date:\\n @ \\n 24 Hour Events:\\n Placed on ketamine for study. Continues to be in aflutter and on Neo,\\n difficulties weaning, however when pt more awake (ie: turning), he is\\n actually HTN. TTE done showing mild TR. RUQ U/S showing mild\\n perihepatic fluid collection too small to be drained.\\n Post operative day:\\n POD#5 - IVC filter via L groin\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\\n Ceftriaxone - 12:00 PM\\n Vancomycin - 08:36 PM\\n Infusions:\\n Fentanyl (Concentrate) - 100 mcg/hour\\n Ketamine - 0.1 mcg/Kg/min\\n Phenylephrine - 1.2 mcg/Kg/min\\n Midazolam (Versed) - 0.5 mg/hour\\n Other ICU medications:\\n Pantoprazole (Protonix) - 02:00 PM\\n Heparin Sodium (Prophylaxis) - 08:29 PM\\n Midazolam (Versed) - 01:15 AM\\n Fentanyl - 01:20 AM\\n Lorazepam (Ativan) - 02:09 AM\\n Other medications:\\n Flowsheet Data as of 04:48 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 38.2\\nC (100.7\\n T current: 37.9\\nC (100.3\\n HR: 78 (75 - 91) bpm\\n BP: 103/51(69) {89/48(62) - 152/66(94)} mmHg\\n RR: 28 (16 - 29) insp/min\\n SPO2: 98%\\n Heart rhythm: A Flut (Atrial Flutter)\\n Wgt (current): 102 kg (admission): 90 kg\\n CVP: 11 (9 - 17) mmHg\\n Total In:\\n 3,764 mL\\n 418 mL\\n PO:\\n Tube feeding:\\n 1,920 mL\\n 255 mL\\n IV Fluid:\\n 1,384 mL\\n 163 mL\\n Blood products:\\n Total out:\\n 1,535 mL\\n 245 mL\\n Urine:\\n 1,530 mL\\n 245 mL\\n NG:\\n 5 mL\\n Stool:\\n Drains:\\n Balance:\\n 2,229 mL\\n 173 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 431 (399 - 596) mL\\n PS : 10 cmH2O\\n RR (Spontaneous): 25\\n PEEP: 10 cmH2O\\n FiO2: 50%\\n PIP: 20 cmH2O\\n SPO2: 98%\\n ABG: 7.41/56/91./32/8\\n Ve: 11.7 L/min\\n PaO2 / FiO2: 184\\n Physical Examination\\n General Appearance: Overweight / Obese\\n Cardiovascular: (Rhythm: No(t) Regular, Irregular)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: No(t)\\n Crackles : , Rhonchorous : bilaterally)\\n Abdominal: Soft, Obese, right flank, right pelvis, and scrotum\\n eechymotic\\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\\n pedis: Present)\\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\\n pedis: Present)\\n Skin: right flank, right pelvis, and scrotum eechymotic\\n Neurologic: Sedated\\n Labs / Radiology\\n 153 K/uL\\n 10.7 g/dL\\n 117 mg/dL\\n 0.7 mg/dL\\n 32 mEq/L\\n 3.9 mEq/L\\n 22 mg/dL\\n 106 mEq/L\\n 143 mEq/L\\n 32.1 %\\n 8.8 K/uL\\n [image002.jpg]\\n 02:55 AM\\n 04:11 AM\\n 09:45 AM\\n 04:45 PM\\n 12:45 AM\\n 01:00 AM\\n 05:12 AM\\n 02:40 PM\\n 01:46 AM\\n 01:55 AM\\n WBC\\n 6.5\\n 13.1\\n 8.8\\n Hct\\n 29.3\\n 31.6\\n 32.1\\n Plt\\n 86\\n 158\\n 153\\n Creatinine\\n 0.8\\n 0.8\\n 0.7\\n 0.7\\n TCO2\\n 38\\n 37\\n 35\\n 35\\n 34\\n 37\\n Glucose\\n 141\\n 107\\n 131\\n 115\\n 132\\n 122\\n 117\\n Other labs: PT / PTT / INR:13.7/27.6/1.2, CK / CK-MB / Troponin\\n T:128/13/<0.01, ALT / AST:81/93, Alk-Phos / T bili:84/5.8, Amylase /\\n Lipase:44/, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic Acid:1.4\\n mmol/L, Albumin:2.7 g/dL, LDH:348 IU/L, Ca:8.0 mg/dL, Mg:2.0 mg/dL,\\n PO4:3.3 mg/dL\\n Imaging: CXR: Cardiac size top nl, interval improvement of\\n collapse LLL. Collapse RLL. Atelectasis in lingula unchanged. Mod B\\n pleural effusions stable. No PTX.\\n CXR: Interval mild incr in cardiac size, b/l pleural effusions,\\n and opacities @ bases,c/w overload\\n : R foot: Linear density projecting @ expected area of insertion\\n of the Achilles to calcaneus, may be min avulsion fx or degenerative\\n changes. Otherwise no fx\\n CXR: b/l pleural effusions\\n CXR: stable.\\n RUQ U/S: No perihepatic fluid collection. small amt perihepatic\\n free fluid persists. Small contusion in hepatic segment VII. No\\n gallstones or significant wall thickening/edema. CBD 4.5 mm\\n TTE: LVEF >55%, normal diastolic function, normal left\\n ventricular filling pressure (PCWP<12mmHg), Right ventricular chamber\\n size is mildly dilated, mild TR\\n Microbiology: Ucx no growth final\\n Sputum: sparse GNRs, too few to colonize\\n Bcx P\\n Bcx P\\n 12/17 L BAL: Klebsiella Pneumoniae, HAEMOPHILUS SPECIES NOT INFLUENZAE\\n R BAL: Klebsiella Pneumoniae, Proteus.\\n 12/20 L BAL: gram + cocci pairs on gram stain, GNRs (sparse) on cx\\n R BAL: gram + cocci pairs on gram stain, GNRs (10-100K) on cx\\n BCX: p\\n BCx: P\\n UCx: no growth final\\n Assessment and Plan\\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, now\\n with AF with RVR/Aflutter, hypotension and presumed PNA.\\n Neurologic: Intubated on Fentanyl/Versed gtt. Per ortho spine, no\\n surgery; HOB<30, TLSO when OOB (NEOPS will place).\\n Neuro checks Q: shift\\n Pain: Fentanyl gtt (trying to wean), dilaudid, Midazolam gtt\\n switch\\n to Precidex. Also on Neurontin, Tylenol\\n Cardiovascular: Aflutter on Dilt 60mg PO QID. Reamins o vasopressor\\n support (Neo at 1). TTE without e/o cardiac dysfunction. ScVO2 68 so\\n cardiogenic shock unlikely. Cortisol 17 which is borderline, although\\n scenario not classic for adrenal insufficiency. ? sedation related so\\n switch to precidex. Weaning Neo today. .\\n Pulmonary: Intubated. Weaning vent. On appropriate abx per BAL cx\\n -Vanco and Ceftriaxone. Will need Trach this week.\\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin with CT scan\\n suggesting cirrhosis - Hepatitis panel NEG. TFs advancing to goal.\\n Bowel regimen.\\n Nutrition: Tube feeding\\n Renal: Foley, monitor UOP.\\n Hematology: Hct stable. Plt low but stable (100's); d/c'd H2B with\\n increasing plt count. Heme onc consulted - smear nl; no hemolysis. IVC\\n filter placed.\\n Endocrine: RISS, goal BS<150.\\n Infectious Disease: Check cultures, WBC normal, f/u Cx - BAL:\\n Klebsiella (b/l)& GNRs (on R)/Haemophilus (on L). Klebsiella\\n Pneumoniae, Proteus/Haemophilus. Repeat BAL with gram+ cocci in\\n pairs on gram stain, GNRs.\\n Lines / Tubes / Drains: R SC CVL (), PIV x2, Foley, L a-line\\n (), ETT\\n Wounds:\\n Imaging: CXR today\\n Fluids: KVO\\n Consults: Trauma (1o), Ortho Spine, Ortho trauma, Heme\\n Billing Diagnosis: Multiple injuries (Trauma)\\n ICU Care\\n Nutrition:\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n Multi Lumen - 04:41 PM\\n Arterial Line - 11:30 AM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin, IVC filter\\n Stress ulcer: PPI (? H2B-related thrombocytopenia)\\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds , ICU\\n Code status: Full code\\n Disposition: ICU\\n Total time spent: 32 min\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2175-02-02 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 714601,\n \"text\": \"74M s/p crushing injury d/t falling tree. Injuries sustained include\\n multiple R sided rib fxs, grade 2 liver lac (w/ assoc hepatic vessel\\n extravasation), stable pelvis fxs (w/ associated extravasation), R\\n ramus fx, clavicle fx, and T4 vertebral body fx. Episodes of A.\\n Flutter with RVR and aflutter, now with resp failure and newly dx\\n pneumonia as of .\\n intubated for resp distress\\n angio embolization of hepatic and pelvic arterial bleeders\\n IVC filter in OR\\n self extubated and re-intubated immediately after d/t acute resp.\\n failure\\n Trach and PEG at bedside\\n Atrial fibrillation (Afib)\\n Assessment:\\n Pt converted to NSR @ 1900 w/ rate 80s-100s.\\n Action:\\n PO dilt, amioderone gtt continued\\n Neo gtt weaned off\\n Response:\\n HR & BP remain well controlled.\\n Plan:\\n Continue Amio gtt, switch to PO amio, ? Anticoagulant.\\n Monitor hemodynamics, monitor BP\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt w/ trach on CPAP/PS 10/10/50%. LS rhonchorous throughout. Strong\\n productive cough, large amounts of thick blood tinged secretions. ABG\\n stable. VSS. Low grade temps. WBC 5.9\\n Action:\\n Pulm hygiene, suction PRN\\n Ceftriaxone admistered for pna\\n Response:\\n Exam unchanged.\\n Plan:\\n Wean vent settings as tolerated, pulmonary toileting, wean\\n sedation.\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2175-02-03 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 714815,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 10\\n Airway\\n Known difficult intubation: Yes\\n Tracheostomy tube:\\n Type: Standard, Cuffed\\n Manufacturer: Portex\\n Size: 8.0mm\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 28 cmH2O\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Rhonchi\\n LUL Lung Sounds: Rhonchi\\n LLL Lung Sounds: Diminished\\n Comments:\\n Secretions\\n Sputum color / consistency: White / Thick\\n Sputum source/amount: Suctioned / Moderate\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance: Continuous invasive ventilation\\n Visual assessment of breathing pattern: Normal quiet breathing\\n Assessment of breathing comfort: No claim of dyspnea)\\n Plan\\n Next 24-48 hours:\\n Reason for continuing current ventilatory support:\\n Respiratory Care Shift Procedures\\n Transports:\\n Destination (R/T)\\n Time\\n Complications\\n Comments\\n Bedside Procedures:\\n Comments:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2175-02-04 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 714875,\n \"text\": \"TSICU\\n HPI:\\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\\n checked and 1.5, 1 more unit FFP given.\\n Chief complaint:\\n Mult rib fx: R anterolateral and post, L posterior\\n T4 vert body inf corner fx\\n Commin spinous process fx T2-8\\n Nondisplaced L T10 transverse process\\n Nondispaced L distal clavicle\\n Nondisplaced L clavicle fx\\n R medial lobe liver contusion w/hematoma\\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny focus of arterial\\n bleeding/active extravasation, and larger area of venous bleeding\\n Nondisplaced, comminuted L iliac bone fx w/adjacent iliac muscle\\n hematoma, extends into L SIJ.\\n Minimally displaced fx of R iliac bone extending to R SIJ.\\n PMHx:\\n PMH: cirrhosis and asbestosis dx on CT\\n PSH: None\\n Current medications:\\n 1. 2. 3. Acetaminophen 4. Amiodarone 5. Bisacodyl 6. Calcium Gluconate\\n 7. CefePIME 8. Chlorhexidine Gluconate 0.12% Oral Rinse\\n 9. Ciprofloxacin HCl 10. Dextrose 50% 11. Diltiazem 12. Docusate Sodium\\n (Liquid) 13. Furosemide\\n 14. Gabapentin 15. Glucagon 16. Haloperidol 17. Haloperidol 18. Heparin\\n 19. Insulin 20. Lactulose\\n 21. Lansoprazole Oral Disintegrating Tab 22. Magnesium Sulfate 23.\\n Metoprolol Tartrate 24. Metoprolol Tartrate\\n 25. Milk of Magnesia 26. Olanzapine (Disintegrating Tablet) 27.\\n Ondansetron 28. OxycoDONE Liquid\\n 29. Pneumococcal Vac Polyvalent 30. Potassium Phosphate 31. Potassium\\n Chloride 32. Senna 33. Sodium Chloride 0.9% Flush\\n 34. Sodium Chloride 0.9% Flush 35. Vancomycin\\n 24 Hour Events:\\n Back to Aflutter with HR in 120's. Stable BP. Given Lopressor with\\n adequate rate control but no conversion. Eventually placed on a Dilt\\n gtt. Pt converted to NSR. Maintained on Amio PO. TF switched to\\n Nutren 2 in order to limit fluids, pt getting Lasix 20 q6 with net neg\\n of 1500 cc. US of LE done to r/o clot as cause of fever.\\n Post operative day:\\n POD#9 - IVC filter via L groin\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Ceftriaxone - 03:00 PM\\n Vancomycin - 08:09 PM\\n Ciprofloxacin - 10:08 PM\\n Cefipime - 12:00 AM\\n Infusions:\\n Other ICU medications:\\n Midazolam (Versed) - 12:45 PM\\n Lorazepam (Ativan) - 01:39 PM\\n Metoprolol - 01:54 PM\\n Furosemide (Lasix) - 06:52 PM\\n Heparin Sodium (Prophylaxis) - 08:09 PM\\n Other medications:\\n Flowsheet Data as of 05:24 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 37.9\\nC (100.3\\n T current: 37.7\\nC (99.8\\n HR: 96 (75 - 125) bpm\\n BP: 132/60(83) {121/51(73) - 169/88(115)} mmHg\\n RR: 16 (16 - 33) insp/min\\n SPO2: 99%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 104.2 kg (admission): 90 kg\\n CVP: 19 (17 - 19) mmHg\\n Total In:\\n 2,563 mL\\n 512 mL\\n PO:\\n Tube feeding:\\n 1,482 mL\\n 211 mL\\n IV Fluid:\\n 821 mL\\n 300 mL\\n Blood products:\\n Total out:\\n 4,060 mL\\n 635 mL\\n Urine:\\n 4,055 mL\\n 635 mL\\n NG:\\n 5 mL\\n Stool:\\n Drains:\\n Balance:\\n -1,497 mL\\n -123 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 554 (380 - 554) mL\\n PS : 15 cmH2O\\n RR (Spontaneous): 18\\n PEEP: 10 cmH2O\\n FiO2: 50%\\n RSBI Deferred: PEEP > 10\\n PIP: 27 cmH2O\\n SPO2: 99%\\n ABG: 7.53/39/124/33/9\\n Ve: 14.2 L/min\\n PaO2 / FiO2: 248\\n Physical Examination\\n General Appearance: Overweight / Obese, Tracheostomy\\n HEENT: PERRL\\n Cardiovascular: (Rhythm: Regular)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\\n bilateral : , Crackles : b/l bases)\\n Abdominal: Soft, Non-tender, Obese\\n Left Extremities: (Edema: 1+), (Temperature: Warm)\\n Right Extremities: (Edema: 1+), (Temperature: Warm)\\n Skin: Jaundice\\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\\n Moves all extremities, Pt appears to be confused this AM.\\n Labs / Radiology\\n 124 K/uL\\n 9.3 g/dL\\n 103 mg/dL\\n 0.8 mg/dL\\n 33 mEq/L\\n 3.9 mEq/L\\n 21 mg/dL\\n 107 mEq/L\\n 144 mEq/L\\n 29.0 %\\n 6.5 K/uL\\n [image002.jpg]\\n 01:00 AM\\n 01:07 AM\\n 01:18 AM\\n 02:05 AM\\n 03:54 AM\\n 05:17 AM\\n 01:23 PM\\n 07:20 PM\\n 12:35 AM\\n 01:04 AM\\n WBC\\n 5.9\\n 6.3\\n 6.5\\n Hct\\n 31.3\\n 28.9\\n 29.0\\n Plt\\n 109\\n 128\\n 124\\n Creatinine\\n 0.8\\n 0.8\\n 0.8\\n 0.8\\n TCO2\\n 35\\n 34\\n 35\\n 34\\n Glucose\\n 117\\n 110\\n 138\\n 136\\n 130\\n 103\\n Other labs: PT / PTT / INR:13.7/27.6/1.2, CK / CK-MB / Troponin\\n T:128/13/<0.01, ALT / AST:90/122, Alk-Phos / T bili:133/5.4, Amylase /\\n Lipase:54/52, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic\\n Acid:1.4 mmol/L, Albumin:2.3 g/dL, LDH:348 IU/L, Ca:7.7 mg/dL, Mg:2.2\\n mg/dL, PO4:2.7 mg/dL\\n Imaging: RUQ U/S: No perihepatic fluid collection. small amt\\n perihepatic free fluid persists. Small contusion in hepatic segment\\n VII. No\\n gallstones or sig wall thickening/edema. CBD 4.5 mm\\n TTE: LVEF >55%, NL diastolic function, NL LV filling pressure\\n (PCWP<12mmHg), RV chamber size mildly dilated, mild TR\\n CXR: mild b/l pulm edema and parenchymal opacities and no\\n pl effusion.\\n CXR: Persistent b/l pl effusions and bibasilar opacity.\\n CXR: Minimal improvement of mod b/l pl effusions. Otherwise\\n stable.\\n CXR: no relevant change. B/L pleural effusions with basal\\n opacities. No evidence of newly appeared focal parenchymal opacities\\n suggesting pneumonia.\\n : No dvt\\n Microbiology: Ucx no growth final\\n Sputum: sparse GNRs, too few to colonize\\n Bcx x2 no growth final\\n 12/17 L BAL: Klebsiella Pneumoniae, HAEMOPHILUS SPECIES NOT INFLUENZAE\\n R BAL: Klebsiella Pneumoniae, Proteus.\\n 12/20 L &R BAL: Klebsiella Pneumoniae\\n BCX: p\\n BCx: P\\n UCx: no growth final\\n BCx: P\\n BCx: P\\n UCx: P\\n SpCx: contamination\\n Assessment and Plan\\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, now\\n with AF with RVR/Aflutter, persistant hypotension and PNA.\\n Neurologic: Neuro checks Q: 4 hr, s/p trach (). Per ortho spine,\\n no surgery; HOB<30, TLSO when OOB. Zyprexa & Haldol PRN (off fent/midaz\\n ).\\n Pain: Oxycodone, Neurontin, Tylenol.\\n Cardiovascular: Aflutter->NSR, on Amio and dilt gtt, will need to\\n transition to PO meds. Likely cardiac contusion. Cards for Amio rec\\n 400'' x 1wk, then 400'x1 wk, then 200'. Pt cannot be fully\\n anticoagulated for now (trauma).\\n Pulmonary: Trach, Trach, weaning vent, Vanc/cipro/cefepime for VAP\\n (). Increasing pulmonary edema on CXR. consider therapeutic\\n thoracentesis 12/26-7 if no improvement on Lasix, lots of secretions,\\n consider bronchoscopy\\n Gastrointestinal / Abdomen: Unknown elevated LFTs and bilirubin w/CT\\n scan suggesting cirrhosis - Hepatitis panel NEG, RUQ U/S r/o\\n gallbladder etiology, will continue to trend. On Nutren 2.0 with goal\\n 40 cc/hr. Bowel regimen.\\n Nutrition: Tube feeding\\n Renal: Foley, Foley, monitor UOP, edematous scrotum. Lasix 20 Q6,\\n developing contraction alk, consider switching to acetazolamide\\n Hematology: Hct stable 28.9->29. Plt stable (100's); d/c'd H2B. Heme\\n onc c/s - smear nl; no hemolysis. IVC filter placed.\\n Endocrine: RISS, RISS\\n Infectious Disease: Check cultures, WBC normal, on Vanc/cipro/cefepime\\n for VAP given worsening pulm status, f/u on cx\\n Lines / Tubes / Drains: Trach/Peg/foley/L radial a-line/R SCL\\n Wounds:\\n Imaging: CXR today\\n Fluids: KVO\\n Consults: Trauma (1o), Ortho Spine, Ortho trauma, Heme\\n Billing Diagnosis: Multiple injuries (Trauma)\\n ICU Care\\n Nutrition:\\n Nutren 2.0 (Full) - 01:00 PM 40 mL/hour\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n Multi Lumen - 04:41 PM\\n Arterial Line - 11:30 AM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin, IVC filter\\n Stress ulcer: PPI\\n VAP bundle:\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds , ICU\\n Code status: Full code\\n Disposition: ICU\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2175-01-30 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 714091,\n \"text\": \"74M s/p crushing injury d/t falling tree. Injuries sustained include\\n multiple R sided rib fxs, grade 2 liver lac (w/ assoc hepatic vessel\\n extravasation), stable pelvis fxs (w/ associated extravasation), R\\n ramus fx, clavicle fx, and T4 vertebral body fx. Episodes of AF with\\n RVR and aflutter, hematologic abnormalities, now with resp failure and\\n newly dx pneumonia as of .\\n intubated for resp distress\\n angio embolization of hepatic and pelvic arterial bleeders\\n IVC filter in OR\\n self extubated and reintubated immediately after d/t acute resp\\n failure\\n Atrial fibrillation (Afib), aflutter\\n Assessment:\\n Pt in and out of aflutter with controlled rate on dilt drip,\\n predominently aflutter. Hypotensive w/ sbp 80\\ns while in aflutter.\\n Action:\\n Dilt weaned off, po dose increased. Lytes followed, stable. Neo gtt\\n to support sbp titrated to map >60 and sbp >100. Pt on low dose midaz\\n gtt along with fentanyl for sedation.\\n Response:\\n Converts to longer periods of NSR w/ higher po dilt dose, drip remains\\n off, rate holding 80s. Rate well controlled but remains Neo\\n dependent. Tolerating sedation titrated to lowest dose to keep\\n comfortable and safe.\\n Plan:\\n Cont to monitor hemodynamics. Wean neo gtt as tolerated. Cont dilt\\n gtt. Optimize lytes ongoing. Cardiology consult in am to determine\\n need for amio vs. cardioversion to further manage aflutter.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Remains fully vented after reintubation yest morning. AC mode, 550x15,\\n 50% and 10 peep. Stable abg, improved p02. O2sat 96-98%. Moderate\\n amt thick, yellow tenacious secretions. LS coarse, clearing w/\\n suctioning. Note: upon reintubation pt found to have signif airway\\n edema, required bougie catheter for reintubation).\\n Action:\\n Remains intubated on ac mode, see settings above, tol well. Pulm\\n toileting per routine.\\n Response:\\n Abg acceptable, note compensated metabolic alkalosis. Pao2 improved on\\n higher peep. LS improved as well, clearer, remain diminished,\\n especially to R sided fields.\\n Plan:\\n Cont vanco for pneumonia coverage, await ID approval for zosyn. Pulm\\n toilet. Maintain sedated for safety and comfort. Pt may benefit from\\n trach in the short term if continuing to require vent support w/\\n difficulty weaning.\\n Trauma, s/p\\n Assessment:\\n As above, pt s/p liver laceration and resultant angio procedure to\\n embolize few hepatic vessels. LFTs continue to be elevated, although\\n slowly improving. Urine icteric, clear.\\n Action:\\n Following LFTs, hct, coags. Monitor s/s bleeding, visual signs of\\n jaundice.\\n Response:\\n As of this am, enzymes remain elevated, await indirect/direct bili\\n levels.\\n Plan:\\n Continue to follow LFTs, coags, hct, serial belly assessments, s/s\\n bleeding.\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2175-02-04 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 714865,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 11\\n Ideal body weight: 0 None\\n Ideal tidal volume: 0 / 0 / 0 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: Yes:\\n Tube Type\\n Tracheostomy tube:\\n Type: Standard\\n Manufacturer: Portex\\n Size: 8.0mm\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 28 cmH2O\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Rhonchi\\n LUL Lung Sounds: Rhonchi\\n LLL Lung Sounds: Diminished\\n Secretions\\n Sputum color / consistency: Yellow / Thick\\n Sputum source/amount: Suctioned / Moderate\\n Ventilation Assessment\\n Level of breathing assistance: Continuous invasive ventilation\\n Visual assessment of breathing pattern: Normal quiet breathing;\\n Comments: PS had to be increased to 15 overnight due to pt tachypnea\\n and high BP's and HR\\n Assessment of breathing comfort: No claim of dyspnea)\\n Invasive ventilation assessment:\\n Trigger work assessment: Triggering synchronously\\n Plan\\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\\n tolerated, Reduce PEEP as tolerated; Comments: wean as tolerated\\n Reason for continuing current ventilatory support: Intolerant of\\n weaning attempts, Underlying illness not resolved\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2175-02-04 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 714870,\n \"text\": \"Atrial fibrillation (Afib)\\n Assessment:\\n Aflutter 70\\n 100\\ns w/ occasional pvc\\ns. Stable bp,\\n Action:\\n Cont on po amioderone and iv dilt gtt. Lytes repleted.\\n Response:\\n Converted to nsr w/ occasional pvc\\ns. Stable bp.\\n Plan:\\n Cont to monitor. Change over to po Diltiazem ATC. Wean dilt gtt.\\n Cont po amioderone. Replete lytes.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2175-02-04 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 714876,\n \"text\": \"Atrial fibrillation (Afib)\\n Assessment:\\n Aflutter 70\\n 100\\ns w/ occasional pvc\\ns. Stable bp,\\n Action:\\n Cont on po amioderone and iv dilt gtt. Lytes repleted.\\n Response:\\n Converted to nsr w/ occasional pvc\\ns. Stable bp.\\n Plan:\\n Cont to monitor. Change over to po Diltiazem ATC. Wean dilt gtt.\\n Cont po amioderone. Replete lytes.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Remains on PSV. LS rhonci, diminished bilat. Cont w/ copious\\n secretions, thick yellow. Stable 02sats. Increasing tachypnea and\\n restlessness overnoc. Tmax 100.3 Fluid balance positive for length\\n of stay.\\n Action:\\n Pulm toilet. Increased psv from . Con on iv Vanco, cefepime and\\n po cipro. Lasix at 1900 and cont w/ brisk u/o. Lasix held at mn.\\n Given haldol and zyprexa for restlessness and oxycodone x1 for pain.\\n Response:\\n Cont with copious secretions but w/ strong cough. Less agitated but\\n still restless after haldol and zyprexa. No sleep. Persistent\\n metabolic alkalosis.\\n Plan:\\n Cont to monitor and cont aggressive pulm toilet. Titrate ventilatory\\n support as needed. Monitor abg\\ns and 02sats. ?diamox for alkalosis.\\n Decrease frequency of lasix. Replete lytes. Cont zyprexa and haldol\\n as needed. Pain control. Cont pt and family support.\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2175-01-27 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 713715,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 3\\n Ideal body weight: 0 None\\n Ideal tidal volume: 0 / 0 / 0 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: No\\n Tube Type\\n ETT:\\n Position: 23 cm at teeth\\n Route: Oral\\n Type: Standard\\n Size: 7.5mm\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 28 cmH2O\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Diminished\\n Comments:\\n Secretions\\n Sputum color / consistency: Yellow / Thick\\n Sputum source/amount: Suctioned / Moderate\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance: Continuous invasive ventilation\\n Visual assessment of breathing pattern: Normal quiet breathing\\n Assessment of breathing comfort: No response (sleeping / sedated\\n Plan\\n Next 24-48 hours: Reduce PEEP as tolerated\\n Reason for continuing current ventilatory support: Intolerant of\\n weaning attempts, Underlying illness not resolved\\n Respiratory Care Shift Procedures\\n Transports:\\n Destination (R/T)\\n Time\\n Complications\\n Comments\\n OR\\n 2200\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2175-01-27 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 713716,\n \"text\": \"Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Patient intubated on CMV 18 x 440. 50%. PEEP 14. Sats 100%. LS clear\\n to diminished.\\n Action:\\n Pulmonary hygiene.\\n Response:\\n Suctioned for small amounts of thick, yellow secretions. ABG WNL.\\n Diminished on R side.\\n Plan:\\n Continue to monitor respiratory status. Wean vent as tolerated.\\n Monitor ABG. Pulmonary hygiene.\\n Trauma, s/p\\n Assessment:\\n Patient sedated on propofol and fentanyl drip. When lightened, patient\\n opens eyes to voice and follows commands. MAE on bed. Denies pain.\\n Bolus prior to turns. Sent to OR for IVC filter placement. Dsg to L\\n groin c/d/i.\\n TF restarted post-op.\\n Action:\\n Monitored CSM of LLE. TF advanced per orders.\\n Response:\\n No change. TF currently at 20cc/hr.\\n Plan:\\n Continue to monitor CSM to LLE. Advance TF as ordered/tolerated.\\n Assess for pain, titrate fentanyl drip as indicated.\\n Atrial fibrillation (Afib)\\n Assessment:\\n Patient in atrial flutter, HR 70-80s. MAP > 65 on phenylephrine drip.\\n PVCs rare.\\n Action:\\n Diltiazem drip at 5mg/hr, held at . Phenylephrine drip at\\n 1.25mcg/kg/min. Patient sent to OR for IVC filter.\\n Response:\\n Patient hypertensive post-op. Phenylephrine drip weaned to\\n 0.5mcg/kg/min. Dilitiazem drip restarted for tachycardia (HR 110\\n At 0400, patient converted to sinus bradycardia. Diltiazem drip\\n currently off.\\n Plan:\\n Continue to monitor rhythm. Treat as indicated. Wean phenylephrine as\\n tolerated.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2175-01-28 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 713928,\n \"text\": \"74M s/p fall with multiple rib fx, pelvis fx, clavicle fx, and thoracic\\n fx c/b unstable bleeding s/p IR embo, AF with RVR, hematologic\\n abnomalities.\\n Atrial fibrillation (Afib)\\n Assessment:\\n Remains in 1^st degree HB. HR to 120\\ns with agitation, anxiety as well\\n as when sast were dropping to high 80\\ns on PS 5, PEEP 5 for several\\n hours. Neo off since approx 070\\n Action:\\n Fentanyl gtt increased, Dilaudid IV m I Midazolam for pain & agitation.\\n PS, PEEP increased Lasix 10 mg at 1815.\\n Response:\\n Good response with meds for pain, agitation, and anxiety. Good response\\n with increased vent support.\\n Plan:\\n Rest on PS 10, PEEP 10 overnight. Start lasix gtt for goal equal to\\n 500 cc negative at MN. Cont to asses rhythm, BP. Metoprolol PRN for HT\\n > 90, SBP > 150\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Put on PS5, PEEP 5. Suctioned Q1-2 rhs for moderate amounts thick, pale\\n yellow secretions this afternoon. Klebsiella growing from sputum\\n Action:\\n Increased PS 10, PEEP 10 when sats dropping to high 80\\n Response:\\n Sats improved with increased PS as well as HR, BP\\n Plan:\\n rest on current vent settings overnight. Asse\\n Trauma, s/p\\n Assessment:\\n Mult echymotic areas over head torso, extremities. Scrotum echymotic,\\n edematous. On fent gtt.\\n Action:\\n Transiently able to decrease fent gtt to 25 mcg hr after starting\\n Dilaudid & Midazolam IV. Scrotum elevated\\n Response:\\n Fent back to 100 mc&pain management. Currently denies pain.\\n Plan:\\n Fentanyl gtt overnight. Keep scrotum elevated.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2175-01-29 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 714002,\n \"text\": \"TSICU\\n HPI:\\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\\n checked and 1.5, 1 more unit FFP given.\\n Chief complaint:\\n polytrauma\\n PMHx:\\n none\\n Current medications:\\n Acetaminophen 3. Bisacodyl 4. CeftriaXONE 5. Chlorhexidine Gluconate\\n 0.12% Oral Rinse 6. Dextrose 50% 7. Diltiazem 8. Docusate Sodium\\n (Liquid) 9. Fentanyl Citrate 10. Furosemide 11. Furosemide 12.\\n Gabapentin\\n 13. Glucagon 14. HYDROmorphone (Dilaudid) 15. Insulin 16. Magnesium\\n Sulfate 17. Metoprolol Tartrate 18. Midazolam 19. Omeprazole 20.\\n Ondansetron 21. Phenylephrine 22. Pneumococcal Vac Polyvalent 23.\\n Potassium Phosphate\\n 24. Potassium Chloride 25. Propofol 26. Senna 27. Sodium Chloride 0.9%\\n Flush\\n 24 Hour Events:\\n : agitated w/HTN, tachycardia, incr fent/midaz w/some resolution.\\n weaned cpap to -->desat-->incr to & improved hr & BP. started\\n dilaudid, incr neurontin 300''', d/c'd H2B decr plt. lasix bolus\\n 10, gtt. R ankle films (ecchymosis/edema) WNL. BAL: KLEBSIELLA\\n PNEUMONIAE & GNRs-ceftriaxone started.\\n Before rounds this AM, pt self-extubated using his tongue (hands were\\n restrained), emergently re-intubated for resp distress and hypoxia.\\n Post operative day:\\n POD#3 - IVC filter via L groin\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Furosemide (Lasix) - 5 mg/hour\\n Fentanyl (Concentrate) - 50 mcg/hour\\n Other ICU medications:\\n Fentanyl - 02:15 PM\\n Furosemide (Lasix) - 06:19 PM\\n Labetalol - 07:00 PM\\n Midazolam (Versed) - 04:00 AM\\n Hydromorphone (Dilaudid) - 04:00 AM\\n Other medications:\\n Flowsheet Data as of 06:45 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 37.2\\nC (99\\n T current: 36.9\\nC (98.4\\n HR: 98 (79 - 127) bpm\\n BP: 105/51(69) {91/41(58) - 185/74(110)} mmHg\\n RR: 0 (0 - 26) insp/min\\n SPO2: 95%\\n Heart rhythm: 1st AV (First degree AV Block)\\n Wgt (current): 102 kg (admission): 90 kg\\n CVP: 8 (6 - 15) mmHg\\n Total In:\\n 1,861 mL\\n 741 mL\\n PO:\\n Tube feeding:\\n 1,330 mL\\n 521 mL\\n IV Fluid:\\n 221 mL\\n 160 mL\\n Blood products:\\n Total out:\\n 2,010 mL\\n 1,195 mL\\n Urine:\\n 2,010 mL\\n 1,195 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -149 mL\\n -454 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 540 (456 - 634) mL\\n PS : 5 cmH2O\\n RR (Spontaneous): 14\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n RSBI: 34\\n PIP: 11 cmH2O\\n SPO2: 95%\\n ABG: 7.42/56/114/33/10\\n Ve: 8 L/min\\n PaO2 / FiO2: 285\\n Physical Examination\\n General Appearance: No acute distress, Well nourished; intubated on\\n vent.\\n HEENT: EOMI\\n Cardiovascular: (Rhythm: Regular)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\\n Diminished: bibasilar)\\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present, Obese\\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\\n Skin: (Incision: Clean / Dry / Intact)\\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\\n Moves all extremities, Sedated\\n Labs / Radiology\\n 86 K/uL\\n 10.1 g/dL\\n 141 mg/dL\\n 0.8 mg/dL\\n 33 mEq/L\\n 3.6 mEq/L\\n 19 mg/dL\\n 106 mEq/L\\n 143 mEq/L\\n 29.3 %\\n 6.5 K/uL\\n [image002.jpg]\\n 05:24 AM\\n 06:50 AM\\n 02:40 PM\\n 03:13 PM\\n 01:59 AM\\n 02:00 AM\\n 11:04 AM\\n 01:17 PM\\n 02:55 AM\\n 04:11 AM\\n WBC\\n 11.0\\n 8.0\\n 5.6\\n 6.5\\n Hct\\n 30.1\\n 29.8\\n 28.7\\n 29.3\\n Plt\\n 97\\n 80\\n 74\\n 86\\n Creatinine\\n 0.8\\n 0.8\\n 0.8\\n TCO2\\n 30\\n 33\\n 35\\n 34\\n 34\\n 38\\n Glucose\\n 133\\n 125\\n 128\\n 141\\n Other labs: PT / PTT / INR:12.9/26.8/1.1, CK / CK-MB / Troponin\\n T:1334/13/<0.01, ALT / AST:109/96, Alk-Phos / T bili:66/3.6, Amylase /\\n Lipase:44/, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic Acid:1.4\\n mmol/L, Albumin:2.7 g/dL, LDH:435 IU/L, Ca:7.7 mg/dL, Mg:1.9 mg/dL,\\n PO4:3.0 mg/dL\\n Imaging: CT head OSH: Prelim No ICH or fx.\\n CT chest OSH: Mult rib fx: R anterolateral and posterior, L\\n posterior; Dependent consolidation, possible aspiration; T4 vertebral\\n body inf corner fx, no retropulsion; Comminuted spinous process fx\\n T2-8; Nondisplaced L T10 transverse process; Nondisplaced L clavicle\\n distal fx; Nondisplaced L scapula fx;\\n CT c spine OSH: Prelim No fx or malalignment. Multilevel\\n degenerative changes w/large post disk bulge at C4-5, narrowing the\\n spinal canal and deforming the thecal sac, acuity unknown. Marked\\n neuroforamenal narrowing @multiple levels.\\n CTA abd/pel Prelim: Medial R liver lobe contusion w/adj\\n hematoma, w/o evidence of active bleeding; Comminuted L pubic ramus\\n fracture w/assoc hematoma, with tiny focus of arterial bleeding/active\\n extravasation, and larger area of venous bleeding. Hematoma somewhat\\n larger than on OSH study. Nondisplaced, comminuted L iliac bone fx\\n w/adj iliac muscle hematoma, larger than on prior study, w/o active\\n extrav. Fx extends into L SIJ. Post R hepatic laceration/contusion\\n adjacent to calcified granuloma, w/small hematoma, w/out active\\n bleeding. Min displaced fx of R iliac bone extending to R SIJ.\\n Cirrhotic liver. Inc B pl effusions (small), w/inc atelectasis.\\n MRI: Mild compression deformity of L1 w/additional levels of\\n potential trabecular contusion @T10-11 also inf @T4 w/o retropulsion.\\n Multilevel degenerative changes with moderate canal narrowing at T10-11\\n w/cord deformity and no abnormal cord signal. Extensive edema\\n throughout paraspinal soft tissues, predominantly post w/in\\n interspinous ligaments. Incompletely eval'ed c-spine w/severe canal\\n narrowing @C4-5 w/cord deformity and no abnormal cord signal.\\n CTA: no PE.\\n CXR: Moderate bilateral pleural effusions are stable.\\n CXR: Cardiac size top nl, interval improvement of collapse LLL.\\n Collapse RLL. Atelectasis in lingula unchanged. Mod B\\n pleural effusions stable. No PTX.\\n CXR: Interval mild incr in cardiac size, b/l pleural effusions,\\n and opacities @ bases,c/w overload\\n : R foot: Linear density projecting @ expected area of insertion\\n of the Achilles to calcaneus, may be min avulsion fx or degenerative\\n changes. Otherwise no fx\\n CXR: ETT in place, + hazy opacities bilaterally\\n Microbiology: Ucx no growth final\\n Sputum: sparse GNR\\n Bcx P\\n Bcx P\\n 12/17 L BAL: KLEBSIELLA PNEUMONIAE, HAEMOPHILUS SPECIES NOT INFLUENZAE\\n R BAL: KLEBSIELLA PNEUMONIAE & GNRs.\\n Assessment and Plan\\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, AF with\\n RVR, hematologic abnormalities, now with resp failure.\\n Neurologic: Intubated on fentanyl gtt and Midazolam gtt (drops BP with\\n Propofol). Per ortho spine, no surgery; HOB<30, TLSO when OOB (NEOPS\\n will place).\\n Neuro checks Q: shift\\n Pain: Fentanyl gtt (trying to wean), dilaudid, Neurontin, Tylenol\\n Cardiovascular: NSR currently, occasional tachycardia & HTN improved\\n occasionally w/sedation. Metop started prn. Restart Dilt gtt as pt\\n hemodynamics best when in sinus. On PO Dilt.\\n Pulmonary: Re-uintubated after unexpected self-extubated and failure.\\n Intubated with bougie and partial view of the cords. F/U on BAL:\\n KLEBSIELLA PNEUMONIAE & GNRs/Haemophilus. Bronch after rounds.\\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin with CT scan\\n suggesting cirrhosis - Hepatitis panel NEG. TFs advancing to goal.\\n Bowel regimen.\\n Nutrition: Tube feeding\\n Renal: Foley, Adequate UO, Foley, monitor UOP. Cr normalized. Lasix\\n gtt started after bolus 10 mg x1 with goal even to neg 500cc.\\n Hematology: Hct stable. Plt low but stable (100's); d/c'd H2B. Heme\\n onc consulted - smear nl. IVC filter placed.\\n Endocrine: RISS, goal BS<150.\\n Infectious Disease: Check cultures, WBC normal, f/u Cx - BAL:\\n Klebsiella (b/l)& GNRs (on R)/Haemophilus (on L). Started Ceftriaxone\\n () x 10 days.\\n Lines / Tubes / Drains: R SC CVL (), PIV x2, Foley, L a-line\\n (), ETT\\n Wounds:\\n Imaging: CXR today\\n Fluids:\\n Consults: Trauma (1o), Ortho Spine, Ortho trauma, Heme\\n Billing Diagnosis: Multiple injuries (Trauma)\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 08:40 PM 80 mL/hour\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n Multi Lumen - 04:41 PM\\n Arterial Line - 11:30 AM\\n Prophylaxis:\\n DVT: Boots, IVC filter\\n Stress ulcer: PPI\\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds , ICU\\n Code status: Full code\\n Disposition: ICU\\n Total time spent: 33 mins\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2175-01-30 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 714089,\n \"text\": \"74M s/p crushing injury d/t falling tree. Injuries sustained include\\n multiple R sided rib fxs, grade 2 liver lac (w/ assoc hepatic vessel\\n extravasation), stable pelvis fxs (w/ associated extravasation), R\\n ramus fx, clavicle fx, and T4 vertebral body fx. Episodes of AF with\\n RVR and aflutter, hematologic abnormalities, now with resp failure and\\n newly dx pneumonia as of .\\n intubated for resp distress\\n angio embolization of hepatic and pelvic arterial bleeders\\n IVC filter in OR\\n self extubated and reintubated immediately after d/t acute resp\\n failure\\n Atrial fibrillation (Afib), aflutter\\n Assessment:\\n Pt in and out of aflutter with controlled rate on dilt drip,\\n predominently aflutter. Hypotensive w/ sbp 80\\ns while in aflutter.\\n Action:\\n Dilt weaned off, po dose increased. Lytes followed, stable. Neo gtt\\n to support sbp titrated to map >60 and sbp >100. Pt on low dose midaz\\n gtt along with fentanyl for sedation.\\n Response:\\n Converts to longer periods of NSR w/ higher po dilt dose, drip remains\\n off, rate holding 80s. Rate well controlled but remains Neo\\n dependent. Tolerating sedation titrated to lowest dose to keep\\n comfortable and safe.\\n Plan:\\n Cont to monitor hemodynamics. Wean neo gtt as tolerated. Cont dilt\\n gtt. Optimize lytes ongoing. Cardiology consult in am to determine\\n need for amio vs. cardioversion to further manage aflutter.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Remains fully vented after reintubation yest morning. AC mode, 550x15,\\n 50% and 10 peep. Stable abg, improved p02. O2sat 96-98%. Moderate\\n amt thick, yellow tenacious secretions. LS coarse, clearing w/\\n suctioning. Note: upon reintubation pt found to have signif airway\\n edema, required bougie catheter for reintubation).\\n Action:\\n Remains intubated on ac mode, see settings above, tol well. Pulm\\n toileting per routine.\\n Response:\\n Abg acceptable, note compensated metabolic alkalosis. Pao2 improved on\\n higher peep. LS improved as well, clearer, remain diminished,\\n especially to R sided fields.\\n Plan:\\n Cont vanco for pneumonia coverage, await ID approval for zosyn. Pulm\\n toilet. Maintain sedated for safety and comfort. Pt may benefit from\\n trach in the short term if continuing to require vent support w/\\n difficulty weaning.\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2175-01-30 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 714096,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 6\\n Ideal body weight: 0 None\\n Ideal tidal volume: 0 / 0 / 0 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: Yes\\n Procedure location:\\n Reason:\\n Tube Type\\n ETT:\\n Position: cm at teeth\\n Route:\\n Type: Standard\\n Size: 7.5mm\\n Tracheostomy tube:\\n Type:\\n Manufacturer:\\n Size:\\n PMV:\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 20 cmH2O\\n Cuff volume: mL /\\n Airway problems:\\n Comments:\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Diminished\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Diminished\\n Comments:\\n Secretions\\n Sputum color / consistency: Tan / Thick\\n Sputum source/amount: Suctioned / Moderate\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance:\\n Visual assessment of breathing pattern:\\n Assessment of breathing comfort:\\n Non-invasive ventilation assessment:\\n Invasive ventilation assessment:\\n Trigger work assessment:\\n Dysynchrony assessment:\\n Comments:\\n Plan\\n Next 24-48 hours:\\n Reason for continuing current ventilatory support:\\n Respiratory Care Shift Procedures\\n Transports:\\n Destination (R/T)\\n Time\\n Complications\\n Comments\\n Bedside Procedures:\\n Comments: Pt cont intub with OETT sedated and on mech vent as per\\n Metavision. Lung sounds ess clear after suct mod th tan sput. ABGs\\n metabolic alkalosis with adequate oxygenation on current vent settings;\\n no vent changes required overnoc. Cont mech vent support.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2175-01-30 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 714201,\n \"text\": \"Hypotension (not Shock)\\n Assessment:\\n Pt continues on neo gtt, BP low 90\\ns, neo titrating as needed. BP goal\\n MAP 65. Pt continues on Fentanyl gtt at 100mcg/hr and Midazolam at\\n 2mg/hr.\\n Action:\\n Neo weaned as tolerated. Midazolam changed/bolused as needed.\\n Response:\\n Pt tolerating neo wean gradually, but still requires neo gtt at this\\n time.\\n Plan:\\n Wean neo as tolerated. Study to start this evening at 20:00 with\\n ketamine and ativan. See information sheet for details (in room).\\n Continue to support pt and family, keep pt sedated/comfortable.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt continues on the vent, requiring frequent suctioning. Lung sounds\\n diminished on the right side, occasionally rhonchorous. O2 sat >96%.\\n +PNA, continues on antibiotics but Afebrile today.\\n Action:\\n Settings changed to CPAP/PS this AM. Suctioned frequently as\\n needed. Pt repositioned frequently. Zosyn discontinued, ceftriaxone\\n started, vanco continues.\\n Response:\\n Pt tolerating vent wean well, occasionally plugging, waking up through\\n sedation and getting agitated. Midazolam weaned as needed.\\n Plan:\\n Wean vent as tolerated, pulmonary toileting. Continue to support pt\\n and family. Suction frequently, VAP care, frequent repositioning.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2175-01-31 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 714280,\n \"text\": \"TSICU\\n HPI:\\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\\n checked and 1.5, 1 more unit FFP given.\\n Chief complaint:\\n Mult rib fx: R anterolateral and post, L posterior\\n T4 vert body inf corner fx\\n Commin spinous process fx T2-8\\n Nondisplaced L T10 transverse process\\n Nondispaced L distal clavicle\\n Nondisplaced L clavicle fx\\n R medial lobe liver contusion w/hematoma\\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny focus of arterial\\n bleeding/active extravasation, and larger area of venous bleeding\\n Nondisplaced, comminuted L iliac bone fx w/adjacent iliac muscle\\n hematoma, extends into L SIJ.\\n Minimally displaced fx of R iliac bone extending to R SIJ.\\n PMHx:\\n PMH: None\\n PSH: None\\n Current medications:\\n 1. IV access: Peripheral line Order date: @ 2329 16. Ketamine\\n Study Drug Study Med 1 dose IV AS SIR Duration: 24 Hours\\n Patient to receive Ketamine/Placebo 0.25mg/kg bolus over 1 hour\\n followed by 0.1mg/kg/hr for 23 hours Order date: @ 1338\\n 2. Acetaminophen 650 mg PO/NG Q6H:PRN pain Order date: @ 2329\\n 17. Lorazepam 2mg Syringe Study Med 1 mg IV Q6H Duration: 4 Doses\\n Patient to receive Lorazepam 1mg iv every 6 hours for 4 doses while on\\n ketamine study drug Order date: @ 1338\\n 3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation Order date: @\\n 0823 18. Magnesium Sulfate IV Sliding Scale Order date: @ 2339\\n 4. Calcium Gluconate IV Sliding Scale Order date: @ 1657 19.\\n Metoprolol Tartrate 5 mg IV Q4H:PRN hr>90, SBP>150\\n hold hr<60, SBP<100 Order date: @ 1809\\n 5. CeftriaXONE 1 gm IV Q24H Order date: @ 1228 20. Midazolam\\n 0.5-1 mg IV Q2H:PRN sedation Order date: @ 0912\\n 6. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL Order date:\\n @ 2329 21. Midazolam 0.5-10 mg/hr IV DRIP TITRATE TO sedation\\n Patient must have adequate airway support prior to administration of\\n dose. Order date: @ 0734\\n 7. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date: \\n @ 0104 22. Ondansetron 4 mg IV Q8H:PRN nausea Order date: @ 2329\\n 8. Diltiazem 60 mg PO/NG QID\\n hold for HR < 60 or SBP < 100 Order date: @ 23.\\n Pantoprazole 40 mg IV Q24H Order date: @ 1321\\n 9. Docusate Sodium (Liquid) 100 mg PO/NG Order date: @ 2329\\n 24. Phenylephrine 0.5-5 mcg/kg/min IV DRIP TITRATE TO SBP>90 MAP>60\\n Order date: @ 2339\\n 10. Fentanyl Citrate 25-100 mcg/hr IV DRIP INFUSION\\n Please wean with Dilaudid dosing. Thank you. Order date: @ 1136\\n 25. Pneumococcal Vac Polyvalent 0.5 ml IM ASDIR Order date: @\\n 2316\\n 11. Gabapentin 400 mg PO/NG TID Order date: @ 1210 26. Potassium\\n Phosphate IV Sliding Scale\\n Infuse over 6 hours Order date: @ 2339\\n 12. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date:\\n @ 0104 27. Potassium Chloride IV Sliding Scale Order date: \\n @ 2339\\n 13. HYDROmorphone (Dilaudid) 0.125-1 mg IV Q3H:PRN pain Order date:\\n @ 0912 28. Senna 1 TAB PO/NG :PRN constipation Order date:\\n @ 0823\\n 14. Heparin 5000 UNIT SC TID Order date: @ 0931 29. Sodium\\n Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush\\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\\n Order date: @ 2329\\n 15. Insulin SC (per Insulin Flowsheet)\\n Sliding Scale Order date: @ 0104 30. Vancomycin 1000 mg IV\\n Q 12H\\n ID Approval will be required for this order in 39 hours. Order date:\\n @ \\n 24 Hour Events:\\n Placed on ketamine for study. Continues to be in aflutter and on Neo,\\n difficulties weaning, however when pt more awake (ie: turning), he is\\n actually HTN. TTE done showing mild TR. RUQ U/S showing mild\\n perihepatic fluid collection too small to be drained.\\n Post operative day:\\n POD#5 - IVC filter via L groin\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\\n Ceftriaxone - 12:00 PM\\n Vancomycin - 08:36 PM\\n Infusions:\\n Fentanyl (Concentrate) - 100 mcg/hour\\n Ketamine - 0.1 mcg/Kg/min\\n Phenylephrine - 1.2 mcg/Kg/min\\n Midazolam (Versed) - 0.5 mg/hour\\n Other ICU medications:\\n Pantoprazole (Protonix) - 02:00 PM\\n Heparin Sodium (Prophylaxis) - 08:29 PM\\n Midazolam (Versed) - 01:15 AM\\n Fentanyl - 01:20 AM\\n Lorazepam (Ativan) - 02:09 AM\\n Other medications:\\n Flowsheet Data as of 04:48 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 38.2\\nC (100.7\\n T current: 37.9\\nC (100.3\\n HR: 78 (75 - 91) bpm\\n BP: 103/51(69) {89/48(62) - 152/66(94)} mmHg\\n RR: 28 (16 - 29) insp/min\\n SPO2: 98%\\n Heart rhythm: A Flut (Atrial Flutter)\\n Wgt (current): 102 kg (admission): 90 kg\\n CVP: 11 (9 - 17) mmHg\\n Total In:\\n 3,764 mL\\n 418 mL\\n PO:\\n Tube feeding:\\n 1,920 mL\\n 255 mL\\n IV Fluid:\\n 1,384 mL\\n 163 mL\\n Blood products:\\n Total out:\\n 1,535 mL\\n 245 mL\\n Urine:\\n 1,530 mL\\n 245 mL\\n NG:\\n 5 mL\\n Stool:\\n Drains:\\n Balance:\\n 2,229 mL\\n 173 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 431 (399 - 596) mL\\n PS : 10 cmH2O\\n RR (Spontaneous): 25\\n PEEP: 10 cmH2O\\n FiO2: 50%\\n PIP: 20 cmH2O\\n SPO2: 98%\\n ABG: 7.41/56/91./32/8\\n Ve: 11.7 L/min\\n PaO2 / FiO2: 184\\n Physical Examination\\n General Appearance: Overweight / Obese\\n Cardiovascular: (Rhythm: No(t) Regular, Irregular)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: No(t)\\n Crackles : , Rhonchorous : bilaterally)\\n Abdominal: Soft, Obese, right flank, right pelvis, and scrotum\\n eechymotic\\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\\n pedis: Present)\\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\\n pedis: Present)\\n Skin: right flank, right pelvis, and scrotum eechymotic\\n Neurologic: Sedated\\n Labs / Radiology\\n 153 K/uL\\n 10.7 g/dL\\n 117 mg/dL\\n 0.7 mg/dL\\n 32 mEq/L\\n 3.9 mEq/L\\n 22 mg/dL\\n 106 mEq/L\\n 143 mEq/L\\n 32.1 %\\n 8.8 K/uL\\n [image002.jpg]\\n 02:55 AM\\n 04:11 AM\\n 09:45 AM\\n 04:45 PM\\n 12:45 AM\\n 01:00 AM\\n 05:12 AM\\n 02:40 PM\\n 01:46 AM\\n 01:55 AM\\n WBC\\n 6.5\\n 13.1\\n 8.8\\n Hct\\n 29.3\\n 31.6\\n 32.1\\n Plt\\n 86\\n 158\\n 153\\n Creatinine\\n 0.8\\n 0.8\\n 0.7\\n 0.7\\n TCO2\\n 38\\n 37\\n 35\\n 35\\n 34\\n 37\\n Glucose\\n 141\\n 107\\n 131\\n 115\\n 132\\n 122\\n 117\\n Other labs: PT / PTT / INR:13.7/27.6/1.2, CK / CK-MB / Troponin\\n T:128/13/<0.01, ALT / AST:81/93, Alk-Phos / T bili:84/5.8, Amylase /\\n Lipase:44/, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic Acid:1.4\\n mmol/L, Albumin:2.7 g/dL, LDH:348 IU/L, Ca:8.0 mg/dL, Mg:2.0 mg/dL,\\n PO4:3.3 mg/dL\\n Imaging: CXR: Cardiac size top nl, interval improvement of\\n collapse LLL. Collapse RLL. Atelectasis in lingula unchanged. Mod B\\n pleural effusions stable. No PTX.\\n CXR: Interval mild incr in cardiac size, b/l pleural effusions,\\n and opacities @ bases,c/w overload\\n : R foot: Linear density projecting @ expected area of insertion\\n of the Achilles to calcaneus, may be min avulsion fx or degenerative\\n changes. Otherwise no fx\\n CXR: b/l pleural effusions\\n CXR: stable.\\n RUQ U/S: No perihepatic fluid collection. small amt perihepatic\\n free fluid persists. Small contusion in hepatic segment VII. No\\n gallstones or significant wall thickening/edema. CBD 4.5 mm\\n TTE: LVEF >55%, normal diastolic function, normal left\\n ventricular filling pressure (PCWP<12mmHg), Right ventricular chamber\\n size is mildly dilated, mild TR\\n Microbiology: Ucx no growth final\\n Sputum: sparse GNRs, too few to colonize\\n Bcx P\\n Bcx P\\n 12/17 L BAL: Klebsiella Pneumoniae, HAEMOPHILUS SPECIES NOT INFLUENZAE\\n R BAL: Klebsiella Pneumoniae, Proteus.\\n 12/20 L BAL: gram + cocci pairs on gram stain, GNRs (sparse) on cx\\n R BAL: gram + cocci pairs on gram stain, GNRs (10-100K) on cx\\n BCX: p\\n BCx: P\\n UCx: no growth final\\n Assessment and Plan\\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, now\\n with AF with RVR/Aflutter, hypotension and presumed PNA.\\n Neurologic: Intubated on Fentanyl/Versed gtt. Per ortho spine, no\\n surgery; HOB<30, TLSO when OOB (NEOPS will place).\\n Neuro checks Q: shift\\n Pain: Fentanyl gtt (trying to wean), dilaudid, Midazolam gtt\\n switch\\n to Precidex. Also on Neurontin, Tylenol\\n Cardiovascular: Aflutter on Dilt 60mg PO QID. Weaning Neo.\\n Pulmonary: Intubated. Weaning to extubate. On appropriate abx per BAL\\n cx -Vanco and Ceftriaxone. Will need Trach this week.\\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin with CT scan\\n suggesting cirrhosis - Hepatitis panel NEG. TFs advancing to goal.\\n Bowel regimen.\\n Nutrition: Tube feeding\\n Renal: Foley, monitor UOP.\\n Hematology: Hct stable. Plt low but stable (100's); d/c'd H2B with\\n increasing plt count. Heme onc consulted - smear nl; no hemolysis. IVC\\n filter placed.\\n Endocrine: RISS, goal BS<150.\\n Infectious Disease: Check cultures, WBC normal, f/u Cx - BAL:\\n Klebsiella (b/l)& GNRs (on R)/Haemophilus (on L). Klebsiella\\n Pneumoniae, Proteus/Haemophilus. Repeat BAL with gram+ cocci in\\n pairs on gram stain, GNRs.\\n Lines / Tubes / Drains: R SC CVL (), PIV x2, Foley, L a-line\\n (), ETT\\n Wounds:\\n Imaging: CXR today\\n Fluids: KVO\\n Consults: Trauma (1o), Ortho Spine, Ortho trauma, Heme\\n Billing Diagnosis: Multiple injuries (Trauma)\\n ICU Care\\n Nutrition:\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n Multi Lumen - 04:41 PM\\n Arterial Line - 11:30 AM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin, IVC filter\\n Stress ulcer: PPI (? H2B-related thrombocytopenia)\\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds , ICU\\n Code status: Full code\\n Disposition: ICU\\n Total time spent: 32 min\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2175-01-31 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 714282,\n \"text\": \"TSICU\\n HPI:\\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\\n checked and 1.5, 1 more unit FFP given.\\n Chief complaint:\\n Mult rib fx: R anterolateral and post, L posterior\\n T4 vert body inf corner fx\\n Commin spinous process fx T2-8\\n Nondisplaced L T10 transverse process\\n Nondispaced L distal clavicle\\n Nondisplaced L clavicle fx\\n R medial lobe liver contusion w/hematoma\\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny focus of arterial\\n bleeding/active extravasation, and larger area of venous bleeding\\n Nondisplaced, comminuted L iliac bone fx w/adjacent iliac muscle\\n hematoma, extends into L SIJ.\\n Minimally displaced fx of R iliac bone extending to R SIJ.\\n PMHx:\\n PMH: None\\n PSH: None\\n Current medications:\\n 1. IV access: Peripheral line Order date: @ 2329 16. Ketamine\\n Study Drug Study Med 1 dose IV AS SIR Duration: 24 Hours\\n Patient to receive Ketamine/Placebo 0.25mg/kg bolus over 1 hour\\n followed by 0.1mg/kg/hr for 23 hours Order date: @ 1338\\n 2. Acetaminophen 650 mg PO/NG Q6H:PRN pain Order date: @ 2329\\n 17. Lorazepam 2mg Syringe Study Med 1 mg IV Q6H Duration: 4 Doses\\n Patient to receive Lorazepam 1mg iv every 6 hours for 4 doses while on\\n ketamine study drug Order date: @ 1338\\n 3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation Order date: @\\n 0823 18. Magnesium Sulfate IV Sliding Scale Order date: @ 2339\\n 4. Calcium Gluconate IV Sliding Scale Order date: @ 1657 19.\\n Metoprolol Tartrate 5 mg IV Q4H:PRN hr>90, SBP>150\\n hold hr<60, SBP<100 Order date: @ 1809\\n 5. CeftriaXONE 1 gm IV Q24H Order date: @ 1228 20. Midazolam\\n 0.5-1 mg IV Q2H:PRN sedation Order date: @ 0912\\n 6. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL Order date:\\n @ 2329 21. Midazolam 0.5-10 mg/hr IV DRIP TITRATE TO sedation\\n Patient must have adequate airway support prior to administration of\\n dose. Order date: @ 0734\\n 7. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date: \\n @ 0104 22. Ondansetron 4 mg IV Q8H:PRN nausea Order date: @ 2329\\n 8. Diltiazem 60 mg PO/NG QID\\n hold for HR < 60 or SBP < 100 Order date: @ 23.\\n Pantoprazole 40 mg IV Q24H Order date: @ 1321\\n 9. Docusate Sodium (Liquid) 100 mg PO/NG Order date: @ 2329\\n 24. Phenylephrine 0.5-5 mcg/kg/min IV DRIP TITRATE TO SBP>90 MAP>60\\n Order date: @ 2339\\n 10. Fentanyl Citrate 25-100 mcg/hr IV DRIP INFUSION\\n Please wean with Dilaudid dosing. Thank you. Order date: @ 1136\\n 25. Pneumococcal Vac Polyvalent 0.5 ml IM ASDIR Order date: @\\n 2316\\n 11. Gabapentin 400 mg PO/NG TID Order date: @ 1210 26. Potassium\\n Phosphate IV Sliding Scale\\n Infuse over 6 hours Order date: @ 2339\\n 12. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date:\\n @ 0104 27. Potassium Chloride IV Sliding Scale Order date: \\n @ 2339\\n 13. HYDROmorphone (Dilaudid) 0.125-1 mg IV Q3H:PRN pain Order date:\\n @ 0912 28. Senna 1 TAB PO/NG :PRN constipation Order date:\\n @ 0823\\n 14. Heparin 5000 UNIT SC TID Order date: @ 0931 29. Sodium\\n Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush\\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\\n Order date: @ 2329\\n 15. Insulin SC (per Insulin Flowsheet)\\n Sliding Scale Order date: @ 0104 30. Vancomycin 1000 mg IV\\n Q 12H\\n ID Approval will be required for this order in 39 hours. Order date:\\n @ \\n 24 Hour Events:\\n Placed on ketamine for study. Continues to be in aflutter and on Neo,\\n difficulties weaning, however when pt more awake (ie: turning), he is\\n actually HTN. TTE done showing mild TR. RUQ U/S showing mild\\n perihepatic fluid collection too small to be drained.\\n Post operative day:\\n POD#5 - IVC filter via L groin\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\\n Ceftriaxone - 12:00 PM\\n Vancomycin - 08:36 PM\\n Infusions:\\n Fentanyl (Concentrate) - 100 mcg/hour\\n Ketamine - 0.1 mcg/Kg/min\\n Phenylephrine - 1.2 mcg/Kg/min\\n Midazolam (Versed) - 0.5 mg/hour\\n Other ICU medications:\\n Pantoprazole (Protonix) - 02:00 PM\\n Heparin Sodium (Prophylaxis) - 08:29 PM\\n Midazolam (Versed) - 01:15 AM\\n Fentanyl - 01:20 AM\\n Lorazepam (Ativan) - 02:09 AM\\n Other medications:\\n Flowsheet Data as of 04:48 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 38.2\\nC (100.7\\n T current: 37.9\\nC (100.3\\n HR: 78 (75 - 91) bpm\\n BP: 103/51(69) {89/48(62) - 152/66(94)} mmHg\\n RR: 28 (16 - 29) insp/min\\n SPO2: 98%\\n Heart rhythm: A Flut (Atrial Flutter)\\n Wgt (current): 102 kg (admission): 90 kg\\n CVP: 11 (9 - 17) mmHg\\n Total In:\\n 3,764 mL\\n 418 mL\\n PO:\\n Tube feeding:\\n 1,920 mL\\n 255 mL\\n IV Fluid:\\n 1,384 mL\\n 163 mL\\n Blood products:\\n Total out:\\n 1,535 mL\\n 245 mL\\n Urine:\\n 1,530 mL\\n 245 mL\\n NG:\\n 5 mL\\n Stool:\\n Drains:\\n Balance:\\n 2,229 mL\\n 173 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 431 (399 - 596) mL\\n PS : 10 cmH2O\\n RR (Spontaneous): 25\\n PEEP: 10 cmH2O\\n FiO2: 50%\\n PIP: 20 cmH2O\\n SPO2: 98%\\n ABG: 7.41/56/91./32/8\\n Ve: 11.7 L/min\\n PaO2 / FiO2: 184\\n Physical Examination\\n General Appearance: Overweight / Obese\\n Cardiovascular: (Rhythm: No(t) Regular, Irregular)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: No(t)\\n Crackles : , Rhonchorous : bilaterally)\\n Abdominal: Soft, Obese, right flank, right pelvis, and scrotum\\n eechymotic\\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\\n pedis: Present)\\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\\n pedis: Present)\\n Skin: right flank, right pelvis, and scrotum eechymotic\\n Neurologic: Sedated\\n Labs / Radiology\\n 153 K/uL\\n 10.7 g/dL\\n 117 mg/dL\\n 0.7 mg/dL\\n 32 mEq/L\\n 3.9 mEq/L\\n 22 mg/dL\\n 106 mEq/L\\n 143 mEq/L\\n 32.1 %\\n 8.8 K/uL\\n [image002.jpg]\\n 02:55 AM\\n 04:11 AM\\n 09:45 AM\\n 04:45 PM\\n 12:45 AM\\n 01:00 AM\\n 05:12 AM\\n 02:40 PM\\n 01:46 AM\\n 01:55 AM\\n WBC\\n 6.5\\n 13.1\\n 8.8\\n Hct\\n 29.3\\n 31.6\\n 32.1\\n Plt\\n 86\\n 158\\n 153\\n Creatinine\\n 0.8\\n 0.8\\n 0.7\\n 0.7\\n TCO2\\n 38\\n 37\\n 35\\n 35\\n 34\\n 37\\n Glucose\\n 141\\n 107\\n 131\\n 115\\n 132\\n 122\\n 117\\n Other labs: PT / PTT / INR:13.7/27.6/1.2, CK / CK-MB / Troponin\\n T:128/13/<0.01, ALT / AST:81/93, Alk-Phos / T bili:84/5.8, Amylase /\\n Lipase:44/, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic Acid:1.4\\n mmol/L, Albumin:2.7 g/dL, LDH:348 IU/L, Ca:8.0 mg/dL, Mg:2.0 mg/dL,\\n PO4:3.3 mg/dL\\n Imaging: CXR: Cardiac size top nl, interval improvement of\\n collapse LLL. Collapse RLL. Atelectasis in lingula unchanged. Mod B\\n pleural effusions stable. No PTX.\\n CXR: Interval mild incr in cardiac size, b/l pleural effusions,\\n and opacities @ bases,c/w overload\\n : R foot: Linear density projecting @ expected area of insertion\\n of the Achilles to calcaneus, may be min avulsion fx or degenerative\\n changes. Otherwise no fx\\n CXR: b/l pleural effusions\\n CXR: stable.\\n RUQ U/S: No perihepatic fluid collection. small amt perihepatic\\n free fluid persists. Small contusion in hepatic segment VII. No\\n gallstones or significant wall thickening/edema. CBD 4.5 mm\\n TTE: LVEF >55%, normal diastolic function, normal left\\n ventricular filling pressure (PCWP<12mmHg), Right ventricular chamber\\n size is mildly dilated, mild TR\\n Microbiology: Ucx no growth final\\n Sputum: sparse GNRs, too few to colonize\\n Bcx P\\n Bcx P\\n 12/17 L BAL: Klebsiella Pneumoniae, HAEMOPHILUS SPECIES NOT INFLUENZAE\\n R BAL: Klebsiella Pneumoniae, Proteus.\\n 12/20 L BAL: gram + cocci pairs on gram stain, GNRs (sparse) on cx\\n R BAL: gram + cocci pairs on gram stain, GNRs (10-100K) on cx\\n BCX: p\\n BCx: P\\n UCx: no growth final\\n Assessment and Plan\\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, now\\n with AF with RVR/Aflutter, hypotension and presumed PNA.\\n Neurologic: Intubated on Fentanyl/Versed gtt. Per ortho spine, no\\n surgery; HOB<30, TLSO when OOB (NEOPS will place).\\n Neuro checks Q: shift\\n Pain: Fentanyl gtt (trying to wean), dilaudid, Midazolam gtt\\n switch\\n to Precidex. Also on Neurontin, Tylenol\\n Cardiovascular: Aflutter on Dilt 60mg PO QID. Reamins o vasopressor\\n support (Neo at 1). TTE without e/o cardiac dysfunction. ScVO2 68 so\\n cardiogenic shock unlikely. Cortisol 17 which is borderline, although\\n scenario not classic for adrenal insufficiency. ? sedation related so\\n switch to precidex. Weaning Neo today. .\\n Pulmonary: Intubated. Weaning vent. On appropriate abx per BAL cx\\n -Vanco and Ceftriaxone. Will need Trach this week.\\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin with CT scan\\n suggesting cirrhosis - Hepatitis panel NEG. TFs advancing to goal.\\n Bowel regimen.\\n Nutrition: Tube feeding\\n Renal: Foley, monitor UOP.\\n Hematology: Hct stable. Plt low but stable (100's); d/c'd H2B with\\n increasing plt count. Heme onc consulted - smear nl; no hemolysis. IVC\\n filter placed.\\n Endocrine: RISS, goal BS<150.\\n Infectious Disease: Check cultures, WBC normal, f/u Cx - BAL:\\n Klebsiella (b/l)& GNRs (on R)/Haemophilus (on L). Klebsiella\\n Pneumoniae, Proteus/Haemophilus. Repeat BAL with gram+ cocci in\\n pairs on gram stain, GNRs.\\n Lines / Tubes / Drains: R SC CVL (), PIV x2, Foley, L a-line\\n (), ETT\\n Wounds:\\n Imaging: CXR today\\n Fluids: KVO\\n Consults: Trauma (1o), Ortho Spine, Ortho trauma, Heme\\n Billing Diagnosis: Multiple injuries (Trauma)\\n ICU Care\\n Nutrition:\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n Multi Lumen - 04:41 PM\\n Arterial Line - 11:30 AM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin, IVC filter\\n Stress ulcer: PPI (? H2B-related thrombocytopenia)\\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds , ICU\\n Code status: Full code\\n Disposition: ICU\\n Total time spent: 32 min\\n\"\n },\n {\n \"category\": \"General\",\n \"chartdate\": \"2175-01-29 00:00:00.000\",\n \"description\": \"ICU Event Note\",\n \"row_id\": 713987,\n \"text\": \"Clinician: Fellow\\n Called to bedside of patient, who had self-extubated (dislodged ETT\\n with his tongue). Pt rapidly developed tachypnea, hypoxia, poor mental\\n status. Notified Anesthesia but given dropping SaO2 and respiratory\\n distress we positioned pt, pre-oxygenated but difficult to get SaO2>80,\\n RSI with Etom 20mg and Succ 100mg, on DL there was notable supraglottic\\n edema, with a partial view of the cords (Grade II-III), passed bougie,\\n passed ETT over bougie, + EtCO2 color change x 5 breaths, + chest rise,\\n + BS bilaterally, + mist in tube. SaO2 rapidly improved to 95%. Pt\\n remained HD stable throughout. ETT secured. CXR ordered. Rhonchorous\\n breath sounds at bases, will plan for bronch this AM.\\n Total time spent: 20 minutes\\n Patient is critically ill.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2175-01-29 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 713996,\n \"text\": \"TSICU\\n HPI:\\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\\n checked and 1.5, 1 more unit FFP given.\\n Chief complaint:\\n polytrauma\\n PMHx:\\n none\\n Current medications:\\n Acetaminophen 3. Bisacodyl 4. CeftriaXONE 5. Chlorhexidine Gluconate\\n 0.12% Oral Rinse 6. Dextrose 50% 7. Diltiazem 8. Docusate Sodium\\n (Liquid) 9. Fentanyl Citrate 10. Furosemide 11. Furosemide 12.\\n Gabapentin\\n 13. Glucagon 14. HYDROmorphone (Dilaudid) 15. Insulin 16. Magnesium\\n Sulfate 17. Metoprolol Tartrate 18. Midazolam 19. Omeprazole 20.\\n Ondansetron 21. Phenylephrine 22. Pneumococcal Vac Polyvalent 23.\\n Potassium Phosphate\\n 24. Potassium Chloride 25. Propofol 26. Senna 27. Sodium Chloride 0.9%\\n Flush\\n 24 Hour Events:\\n : agitated w/HTN, tachycardia, incr fent/midaz w/some resolution.\\n weaned cpap to -->desat-->incr to & improved hr & BP. started\\n dilaudid, incr neurontin 300''', d/c'd H2B decr plt. lasix bolus\\n 10, gtt. R ankle films (ecchymosis/edema) WNL. BAL: KLEBSIELLA\\n PNEUMONIAE & GNRs-ceftriaxone started.\\n Before rounds this AM, pt self-extubated using his tongue (hands were\\n restrained), emergently re-intubated for resp distress and hypoxia.\\n Post operative day:\\n POD#3 - IVC filter via L groin\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Furosemide (Lasix) - 5 mg/hour\\n Fentanyl (Concentrate) - 50 mcg/hour\\n Other ICU medications:\\n Fentanyl - 02:15 PM\\n Furosemide (Lasix) - 06:19 PM\\n Labetalol - 07:00 PM\\n Midazolam (Versed) - 04:00 AM\\n Hydromorphone (Dilaudid) - 04:00 AM\\n Other medications:\\n Flowsheet Data as of 06:45 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 37.2\\nC (99\\n T current: 36.9\\nC (98.4\\n HR: 98 (79 - 127) bpm\\n BP: 105/51(69) {91/41(58) - 185/74(110)} mmHg\\n RR: 0 (0 - 26) insp/min\\n SPO2: 95%\\n Heart rhythm: 1st AV (First degree AV Block)\\n Wgt (current): 102 kg (admission): 90 kg\\n CVP: 8 (6 - 15) mmHg\\n Total In:\\n 1,861 mL\\n 741 mL\\n PO:\\n Tube feeding:\\n 1,330 mL\\n 521 mL\\n IV Fluid:\\n 221 mL\\n 160 mL\\n Blood products:\\n Total out:\\n 2,010 mL\\n 1,195 mL\\n Urine:\\n 2,010 mL\\n 1,195 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -149 mL\\n -454 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 540 (456 - 634) mL\\n PS : 5 cmH2O\\n RR (Spontaneous): 14\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n RSBI: 34\\n PIP: 11 cmH2O\\n SPO2: 95%\\n ABG: 7.42/56/114/33/10\\n Ve: 8 L/min\\n PaO2 / FiO2: 285\\n Physical Examination\\n General Appearance: No acute distress, Well nourished; intubated on\\n vent.\\n HEENT: EOMI\\n Cardiovascular: (Rhythm: Regular)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\\n Diminished: bibasilar)\\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present, Obese\\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\\n Skin: (Incision: Clean / Dry / Intact)\\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\\n Moves all extremities, Sedated\\n Labs / Radiology\\n 86 K/uL\\n 10.1 g/dL\\n 141 mg/dL\\n 0.8 mg/dL\\n 33 mEq/L\\n 3.6 mEq/L\\n 19 mg/dL\\n 106 mEq/L\\n 143 mEq/L\\n 29.3 %\\n 6.5 K/uL\\n [image002.jpg]\\n 05:24 AM\\n 06:50 AM\\n 02:40 PM\\n 03:13 PM\\n 01:59 AM\\n 02:00 AM\\n 11:04 AM\\n 01:17 PM\\n 02:55 AM\\n 04:11 AM\\n WBC\\n 11.0\\n 8.0\\n 5.6\\n 6.5\\n Hct\\n 30.1\\n 29.8\\n 28.7\\n 29.3\\n Plt\\n 97\\n 80\\n 74\\n 86\\n Creatinine\\n 0.8\\n 0.8\\n 0.8\\n TCO2\\n 30\\n 33\\n 35\\n 34\\n 34\\n 38\\n Glucose\\n 133\\n 125\\n 128\\n 141\\n Other labs: PT / PTT / INR:12.9/26.8/1.1, CK / CK-MB / Troponin\\n T:1334/13/<0.01, ALT / AST:109/96, Alk-Phos / T bili:66/3.6, Amylase /\\n Lipase:44/, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic Acid:1.4\\n mmol/L, Albumin:2.7 g/dL, LDH:435 IU/L, Ca:7.7 mg/dL, Mg:1.9 mg/dL,\\n PO4:3.0 mg/dL\\n Imaging: CT head OSH: Prelim No ICH or fx.\\n CT chest OSH: Mult rib fx: R anterolateral and posterior, L\\n posterior; Dependent consolidation, possible aspiration; T4 vertebral\\n body inf corner fx, no retropulsion; Comminuted spinous process fx\\n T2-8; Nondisplaced L T10 transverse process; Nondisplaced L clavicle\\n distal fx; Nondisplaced L scapula fx;\\n CT c spine OSH: Prelim No fx or malalignment. Multilevel\\n degenerative changes w/large post disk bulge at C4-5, narrowing the\\n spinal canal and deforming the thecal sac, acuity unknown. Marked\\n neuroforamenal narrowing @multiple levels.\\n CTA abd/pel Prelim: Medial R liver lobe contusion w/adj\\n hematoma, w/o evidence of active bleeding; Comminuted L pubic ramus\\n fracture w/assoc hematoma, with tiny focus of arterial bleeding/active\\n extravasation, and larger area of venous bleeding. Hematoma somewhat\\n larger than on OSH study. Nondisplaced, comminuted L iliac bone fx\\n w/adj iliac muscle hematoma, larger than on prior study, w/o active\\n extrav. Fx extends into L SIJ. Post R hepatic laceration/contusion\\n adjacent to calcified granuloma, w/small hematoma, w/out active\\n bleeding. Min displaced fx of R iliac bone extending to R SIJ.\\n Cirrhotic liver. Inc B pl effusions (small), w/inc atelectasis.\\n MRI: Mild compression deformity of L1 w/additional levels of\\n potential trabecular contusion @T10-11 also inf @T4 w/o retropulsion.\\n Multilevel degenerative changes with moderate canal narrowing at T10-11\\n w/cord deformity and no abnormal cord signal. Extensive edema\\n throughout paraspinal soft tissues, predominantly post w/in\\n interspinous ligaments. Incompletely eval'ed c-spine w/severe canal\\n narrowing @C4-5 w/cord deformity and no abnormal cord signal.\\n CTA: no PE.\\n CXR: Moderate bilateral pleural effusions are stable.\\n CXR: Cardiac size top nl, interval improvement of collapse LLL.\\n Collapse RLL. Atelectasis in lingula unchanged. Mod B\\n pleural effusions stable. No PTX.\\n CXR: Interval mild incr in cardiac size, b/l pleural effusions,\\n and opacities @ bases,c/w overload\\n : R foot: Linear density projecting @ expected area of insertion\\n of the Achilles to calcaneus, may be min avulsion fx or degenerative\\n changes. Otherwise no fx\\n CXR: ETT in place, + hazy opacities bilaterally\\n Microbiology: Ucx no growth final\\n Sputum: sparse GNR\\n Bcx P\\n Bcx P\\n 12/17 L BAL: KLEBSIELLA PNEUMONIAE, HAEMOPHILUS SPECIES NOT INFLUENZAE\\n R BAL: KLEBSIELLA PNEUMONIAE & GNRs.\\n Assessment and Plan\\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, AF with\\n RVR, hematologic abnormalities, now with resp failure.\\n Neurologic: Intubated on fentanyl gtt and Midazolam gtt (drops BP with\\n Propofol). Per ortho spine, no surgery; HOB<30, TLSO when OOB (NEOPS\\n will place).\\n Neuro checks Q: shift\\n Pain: Fentanyl gtt (trying to wean), dilaudid, Neurontin, Tylenol\\n Cardiovascular: NSR currently, occasional tachycardia & HTN improved\\n occasionally w/sedation. Metop started prn. Restart Dilt gtt as pt\\n hemodynamics best when in sinus. On PO Dilt.\\n Pulmonary: Re-uintubated after unexpected self-extubated and failure.\\n Intubated with bougie and partial view of the cords. F/U on BAL:\\n KLEBSIELLA PNEUMONIAE & GNRs/Haemophilus. Bronch after rounds.\\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin with CT scan\\n suggesting cirrhosis - Hepatitis panel NEG. TFs advancing to goal.\\n Bowel regimen.\\n Nutrition: Tube feeding\\n Renal: Foley, Adequate UO, Foley, monitor UOP. Cr normalized. Lasix\\n gtt started after bolus 10 mg x1 with goal even to neg 500cc.\\n Hematology: Hct stable. Plt low but stable (100's); d/c'd H2B. Heme\\n onc consulted - smear nl. IVC filter placed.\\n Endocrine: RISS, goal BS<150.\\n Infectious Disease: Check cultures, WBC normal, f/u Cx - BAL:\\n Klebsiella (b/l)& GNRs (on R)/Haemophilus (on L). Started Ceftriaxone\\n () x 10 days.\\n Lines / Tubes / Drains: R SC CVL (), PIV x2, Foley, L a-line\\n (), ETT\\n Wounds:\\n Imaging: CXR today\\n Fluids:\\n Consults: Trauma (1o), Ortho Spine, Ortho trauma, Heme\\n Billing Diagnosis: Multiple injuries (Trauma)\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 08:40 PM 80 mL/hour\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n Multi Lumen - 04:41 PM\\n Arterial Line - 11:30 AM\\n Prophylaxis:\\n DVT: Boots, IVC filter\\n Stress ulcer: PPI\\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds , ICU\\n Code status: Full code\\n Disposition: ICU\\n Total time spent: 33 mins\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2175-02-02 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 714594,\n \"text\": \"74M s/p crushing injury d/t falling tree. Injuries sustained include\\n multiple R sided rib fxs, grade 2 liver lac (w/ assoc hepatic vessel\\n extravasation), stable pelvis fxs (w/ associated extravasation), R\\n ramus fx, clavicle fx, and T4 vertebral body fx. Episodes of A.\\n Flutter with RVR and aflutter, now with resp failure and newly dx\\n pneumonia as of .\\n intubated for resp distress\\n angio embolization of hepatic and pelvic arterial bleeders\\n IVC filter in OR\\n self extubated and re-intubated immediately after d/t acute resp.\\n failure\\n Trach and PEG at bedside\\n Atrial fibrillation (Afib)\\n Assessment:\\n Pt converted to NSR @ 1900 w/ rate 80s-100s.\\n Action:\\n PO dilt, amioderone gtt continued\\n Neo gtt weaned off\\n Response:\\n HR & BP remain well controlled. Pt\\n :\\n Continue Amio gtt, switch to PO amio, ? Anticoagulant.\\n Monitor hemodynamics, monitor BP\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt w/ trach on CPAP/PS 10/10/50%. LS rhonchorous throughout. Strong\\n productive cough, large amounts of thick blood tinged secretions. ABG\\n stable. VSS. Low grade temps. WBC 5.9\\n Action:\\n Pulm hygiene, suction PRN\\n Ceftriaxone admistered for pna\\n Response:\\n Exam unchanged.\\n Plan:\\n Wean vent settings as tolerated, pulmonary toileting, wean\\n sedation.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2175-01-27 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 713708,\n \"text\": \"Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Patient intubated on CMV 18 x 440. 50%. PEEP 14. Sats 100%. LS clear\\n to diminished.\\n Action:\\n Pulmonary hygiene.\\n Response:\\n Suctioned for small amounts of thick, yellow secretions. ABG WNL.\\n Very diminished on R side.\\n Plan:\\n Continue to monitor respiratory status. Wean vent as tolerated.\\n Monitor ABG. Pulmonary hygiene.\\n Trauma, s/p\\n Assessment:\\n Patient sedated on propofol and fentanyl drip. When lightened, patient\\n opens eyes to voice and follows commands. MAE on bed. Denies pain.\\n Bolused prior to turns. Sent to OR for IVC filter placement. Dsg to L\\n groin c/d/i.\\n TF restarted post-op.\\n Action:\\n Monitored CSM of LLE. TF advanced per orders.\\n Response:\\n No change. TF currently at 20cc/hr.\\n Plan:\\n Continue to monitor CSM to LLE. Advance TF as ordered/tolerated.\\n Assess for pain, titrate fentanyl drip as indicated.\\n Atrial fibrillation (Afib)\\n Assessment:\\n Patient in atrial flutter, HR 70-80s. MAP > 65 on phenylephrine drip.\\n PVCs rare.\\n Action:\\n Diltiazem drip at 5mg/hr, held at . Phenylephrine drip at\\n 1.25mcg/kg/min. Patient sent to OR for IVC filter.\\n Response:\\n Patient hypertensive post-op. Phenylephrine drip weaned to\\n 0.5mcg/kg/min. Dilitiazem drip restarted for tachycardia (HR 110\\n At 0400, patient converted to sinus bradycardia. Diltiazem drip\\n currently off.\\n Plan:\\n Continue to monitor rhythm. Treat as indicated. Wean phenylephrine as\\n tolerated.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2175-01-28 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 713926,\n \"text\": \"74M s/p fall with multiple rib fx, pelvis fx, clavicle fx, and thoracic\\n fx c/b unstable bleeding s/p IR embo, AF with RVR, hematologic\\n abnomalities.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2175-01-29 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 713985,\n \"text\": \"TSICU\\n HPI:\\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\\n checked and 1.5, 1 more unit FFP given.\\n Chief complaint:\\n pain\\n PMHx:\\n none\\n Current medications:\\n Acetaminophen 3. Bisacodyl 4. CeftriaXONE 5. Chlorhexidine Gluconate\\n 0.12% Oral Rinse 6. Dextrose 50%\\n 7. Diltiazem 8. Docusate Sodium (Liquid) 9. Fentanyl Citrate 10.\\n Furosemide 11. Furosemide 12. Gabapentin\\n 13. Glucagon 14. HYDROmorphone (Dilaudid) 15. Insulin 16. Magnesium\\n Sulfate 17. Metoprolol Tartrate\\n 18. Midazolam 19. Omeprazole 20. Ondansetron 21. Phenylephrine 22.\\n Pneumococcal Vac Polyvalent 23. Potassium Phosphate\\n 24. Potassium Chloride 25. Propofol 26. Senna 27. Sodium Chloride 0.9%\\n Flush\\n 24 Hour Events:\\n : agitated w/HTN, tachycardia, incr fent/midaz w/some resolution.\\n weaned cpap to -->desat-->incr to & improved hr & BP. started\\n dilaudid, incr neurontin 300''', d/c'd H2B decr plt. lasix bolus\\n 10, gtt. R ankle films (ecchymosis/edema) WNL. BAL: KLEBSIELLA\\n PNEUMONIAE & GNRs-ceftriaxone started\\n Post operative day:\\n POD#3 - IVC filter via L groin\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Furosemide (Lasix) - 5 mg/hour\\n Fentanyl (Concentrate) - 50 mcg/hour\\n Other ICU medications:\\n Fentanyl - 02:15 PM\\n Furosemide (Lasix) - 06:19 PM\\n Labetalol - 07:00 PM\\n Midazolam (Versed) - 04:00 AM\\n Hydromorphone (Dilaudid) - 04:00 AM\\n Other medications:\\n Flowsheet Data as of 06:45 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 37.2\\nC (99\\n T current: 36.9\\nC (98.4\\n HR: 98 (79 - 127) bpm\\n BP: 105/51(69) {91/41(58) - 185/74(110)} mmHg\\n RR: 0 (0 - 26) insp/min\\n SPO2: 95%\\n Heart rhythm: 1st AV (First degree AV Block)\\n Wgt (current): 102 kg (admission): 90 kg\\n CVP: 8 (6 - 15) mmHg\\n Total In:\\n 1,861 mL\\n 741 mL\\n PO:\\n Tube feeding:\\n 1,330 mL\\n 521 mL\\n IV Fluid:\\n 221 mL\\n 160 mL\\n Blood products:\\n Total out:\\n 2,010 mL\\n 1,195 mL\\n Urine:\\n 2,010 mL\\n 1,195 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -149 mL\\n -454 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 540 (456 - 634) mL\\n PS : 5 cmH2O\\n RR (Spontaneous): 14\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n RSBI: 34\\n PIP: 11 cmH2O\\n SPO2: 95%\\n ABG: 7.42/56/114/33/10\\n Ve: 8 L/min\\n PaO2 / FiO2: 285\\n Physical Examination\\n General Appearance: No acute distress, Well nourished\\n HEENT: EOMI\\n Cardiovascular: (Rhythm: Regular)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\\n Diminished: bibasilar)\\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present, Obese\\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\\n Skin: (Incision: Clean / Dry / Intact)\\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\\n Moves all extremities, Sedated\\n Labs / Radiology\\n 86 K/uL\\n 10.1 g/dL\\n 141 mg/dL\\n 0.8 mg/dL\\n 33 mEq/L\\n 3.6 mEq/L\\n 19 mg/dL\\n 106 mEq/L\\n 143 mEq/L\\n 29.3 %\\n 6.5 K/uL\\n [image002.jpg]\\n 05:24 AM\\n 06:50 AM\\n 02:40 PM\\n 03:13 PM\\n 01:59 AM\\n 02:00 AM\\n 11:04 AM\\n 01:17 PM\\n 02:55 AM\\n 04:11 AM\\n WBC\\n 11.0\\n 8.0\\n 5.6\\n 6.5\\n Hct\\n 30.1\\n 29.8\\n 28.7\\n 29.3\\n Plt\\n 97\\n 80\\n 74\\n 86\\n Creatinine\\n 0.8\\n 0.8\\n 0.8\\n TCO2\\n 30\\n 33\\n 35\\n 34\\n 34\\n 38\\n Glucose\\n 133\\n 125\\n 128\\n 141\\n Other labs: PT / PTT / INR:12.9/26.8/1.1, CK / CK-MB / Troponin\\n T:1334/13/<0.01, ALT / AST:109/96, Alk-Phos / T bili:66/3.6, Amylase /\\n Lipase:44/, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic Acid:1.4\\n mmol/L, Albumin:2.7 g/dL, LDH:435 IU/L, Ca:7.7 mg/dL, Mg:1.9 mg/dL,\\n PO4:3.0 mg/dL\\n Imaging: CT head OSH: Prelim No ICH or fx.\\n CT chest OSH: Mult rib fx: R anterolateral and posterior, L\\n posterior; Dependent consolidation, possible aspiration; T4 vertebral\\n body inf corner fx, no retropulsion; Comminuted spinous process fx\\n T2-8; Nondisplaced L T10 transverse process; Nondisplaced L clavicle\\n distal fx; Nondisplaced L scapula fx;\\n CT c spine OSH: Prelim No fx or malalignment. Multilevel\\n degenerative changes w/large post disk bulge at C4-5, narrowing the\\n spinal canal and deforming the thecal sac, acuity unknown. Marked\\n neuroforamenal narrowing @multiple levels.\\n CTA abd/pel Prelim: Medial R liver lobe contusion w/adj\\n hematoma, w/o evidence of active bleeding; Comminuted L pubic ramus\\n fracture w/assoc hematoma, with tiny focus of arterial bleeding/active\\n extravasation, and larger area of venous bleeding. Hematoma somewhat\\n larger than on OSH study. Nondisplaced, comminuted L iliac bone fx\\n w/adj iliac muscle hematoma, larger than on prior study, w/o active\\n extrav. Fx extends into L SIJ. Post R hepatic laceration/contusion\\n adjacent to calcified granuloma, w/small hematoma, w/out active\\n bleeding. Min displaced fx of R iliac bone extending to R SIJ.\\n Cirrhotic liver. Inc B pl effusions (small), w/inc atelectasis.\\n MRI: Mild compression deformity of L1 w/additional levels of\\n potential trabecular contusion @T10-11 also inf @T4 w/o retropulsion.\\n Multilevel degenerative changes with moderate canal narrowing at T10-11\\n w/cord deformity and no abnormal cord signal. Extensive edema\\n throughout paraspinal soft tissues, predominantly post w/in\\n interspinous ligaments. Incompletely eval'ed c-spine w/severe canal\\n narrowing @C4-5 w/cord deformity and no abnormal cord signal.\\n CTA: no PE.\\n CXR: Moderate bilateral pleural effusions are stable.\\n CXR: Cardiac size top nl, interval improvement of collapse LLL.\\n Collapse RLL. Atelectasis in lingula unchanged. Mod B\\n pleural effusions stable. No PTX.\\n CXR: Interval mild incr in cardiac size, b/l pleural effusions,\\n and opacities @ bases,c/w overload\\n : R foot: Linear density projecting @ expected area of insertion\\n of the Achilles to calcaneus, may be min avulsion fx or degenerative\\n changes. Otherwise no fx\\n Microbiology: Ucx no growth final\\n Sputum: sparse GNR\\n Bcx P\\n Bcx P\\n 12/17 L BAL: KLEBSIELLA PNEUMONIAE, HAEMOPHILUS SPECIES NOT INFLUENZAE\\n R BAL: KLEBSIELLA PNEUMONIAE & GNRs.\\n Assessment and Plan\\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, AF with\\n RVR, hematologic abnomalities.\\n Neurologic: Intubated on fentanyl gtt and Midazolam PRN (have not been\\n giving). Per ortho spine, no surgery; HOB<30, TLSO when OOB (NEOPS will\\n place).\\n Neuro checks Q: shift\\n Pain: Fentanyl gtt (trying to wean), dilaudid, Midazolam prn,\\n Neurontin, Tylenol\\n Cardiovascular: NSR currently, occasional tachycardia & HTN improved\\n occasionally w/sedation. Metop started prn.\\n Pulmonary: Intubated. Weaning to extubate (was on throughout\\n , changed to 10/10 after desat). F/U on BAL: KLEBSIELLA PNEUMONIAE\\n & GNRs/Haemophilus.\\n SElf extubated , reintubated (increased edema, blind intubation\\n w/bougie)\\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin with CT scan\\n suggesting cirrhosis - Hepatitis panel NEG. TFs advancing to goal.\\n Bowel regimen.\\n Nutrition: Tube feeding\\n Renal: Foley, Adequate UO, Foley, monitor UOP. Cr normalized. Lasix\\n gtt started after bolus 10 mg x1 with goal even to neg 500cc.\\n Hematology: Hct stable. Plt low but stable (100's); d/c'd H2B. Heme\\n onc consulted - smear nl. IVC filter placed.\\n Endocrine: RISS\\n Infectious Disease: Check cultures, WBC normal, f/u Cx - BAL:\\n Klebsiella (b/l)& GNRs (on R)/Haemophilus (on L). Started Ceftriaxone\\n ()\\n Lines / Tubes / Drains: R SC CVL (), PIV x2, Foley, L a-line\\n (), ETT\\n Wounds:\\n Imaging: CXR today\\n Fluids:\\n Consults: Trauma (1o), Ortho Spine, Ortho trauma, Heme\\n Billing Diagnosis: Multiple injuries (Trauma)\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 08:40 PM 80 mL/hour\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n Multi Lumen - 04:41 PM\\n Arterial Line - 11:30 AM\\n Prophylaxis:\\n DVT: Boots, IVC filter\\n Stress ulcer: PPI\\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds , ICU\\n Code status: Full code\\n Disposition: ICU\\n Total time spent:\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2175-01-30 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 714085,\n \"text\": \"TSICU\\n HPI:\\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\\n checked and 1.5, 1 more unit FFP given.\\n Chief complaint:\\n Mult rib fx: R anterolateral and post, L posterior\\n T4 vert body inf corner fx\\n Commin spinous process fx T2-8\\n Nondisplaced L T10 transverse process\\n Nondispaced L distal clavicle\\n Nondisplaced L clavicle fx\\n R medial lobe liver contusion w/hematoma\\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny focus of arterial\\n bleeding/active extravasation, and larger area of venous bleeding\\n Nondisplaced, comminuted L iliac bone fx w/adjacent iliac muscle\\n hematoma, extends into L SIJ.\\n Minimally displaced fx of R iliac bone extending to R SIJ.\\n PMHx:\\n None\\n Current medications:\\n Chlorhexidine Gluconate 0.12% Oral Rinse\\n Diltiazem\\n Furosemide\\n Gabapentin\\n Metoprolol Tartrate\\n Ondansetron\\n Phenylephrine\\n 24 Hour Events:\\n self-extubated in the AM, re-intubated over bougie, NGT replaced, \\n with bilateral BALs sent, plan for trach later this week. T spike to\\n 101.8 - u/a, urine cx, blood cxs sent. Diltiazem titrated to 60mg PO\\n QID. ABX coverage broadened to Vanc/Zosyn. Tbili up to 6.8 (other LFTs\\n trending down)\\n Post operative day:\\n POD#4 - IVC filter via L groin\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Ceftriaxone - 11:00 AM\\n Piperacillin/Tazobactam (Zosyn) - 08:19 PM\\n Vancomycin - 08:56 PM\\n Infusions:\\n Fentanyl (Concentrate) - 100 mcg/hour\\n Midazolam (Versed) - 1 mg/hour\\n Other ICU medications:\\n Hydromorphone (Dilaudid) - 04:00 AM\\n Metoprolol - 06:33 AM\\n Pantoprazole (Protonix) - 02:00 PM\\n Midazolam (Versed) - 12:30 AM\\n Other medications:\\n Flowsheet Data as of 02:07 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 38.8\\nC (101.8\\n T current: 37.2\\nC (98.9\\n HR: 76 (76 - 103) bpm\\n BP: 97/51(67) {86/47(62) - 121/858(84)} mmHg\\n RR: 18 (0 - 25) insp/min\\n SPO2: 99%\\n Heart rhythm: A Flut (Atrial Flutter)\\n Wgt (current): 102 kg (admission): 90 kg\\n CVP: 11 (6 - 18) mmHg\\n Total In:\\n 3,114 mL\\n 207 mL\\n PO:\\n Tube feeding:\\n 1,301 mL\\n 148 mL\\n IV Fluid:\\n 1,682 mL\\n 59 mL\\n Blood products:\\n Total out:\\n 2,500 mL\\n 180 mL\\n Urine:\\n 2,500 mL\\n 180 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 614 mL\\n 27 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 550 (550 - 550) mL\\n Vt (Spontaneous): 540 (540 - 540) mL\\n PS : 5 cmH2O\\n RR (Set): 15\\n RR (Spontaneous): 0\\n PEEP: 10 cmH2O\\n FiO2: 50%\\n RSBI: 34\\n PIP: 26 cmH2O\\n Plateau: 23 cmH2O\\n Compliance: 42.3 cmH2O/mL\\n SPO2: 99%\\n ABG: 7.44/50/127/34/8\\n Ve: 9.5 L/min\\n PaO2 / FiO2: 254\\n Physical Examination\\n General Appearance: No acute distress\\n HEENT: PERRL\\n Cardiovascular: Aflutter\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\\n Rhonchorous : )\\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present,\\n Stable scrotal edema/hematoma, soft, no crepitus\\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\\n Neurologic: Follows simple commands, Moves all extremities, Sedated\\n Labs / Radiology\\n 158 K/uL\\n 10.7 g/dL\\n 115 mg/dL\\n 0.8 mg/dL\\n 34 mEq/L\\n 4.0 mEq/L\\n 20 mg/dL\\n 111 mEq/L\\n 148 mEq/L\\n 31.6 %\\n 13.1 K/uL\\n [image002.jpg]\\n 01:59 AM\\n 02:00 AM\\n 11:04 AM\\n 01:17 PM\\n 02:55 AM\\n 04:11 AM\\n 09:45 AM\\n 04:45 PM\\n 12:45 AM\\n 01:00 AM\\n WBC\\n 5.6\\n 6.5\\n 13.1\\n Hct\\n 28.7\\n 29.3\\n 31.6\\n Plt\\n 74\\n 86\\n 158\\n Creatinine\\n 0.8\\n 0.8\\n 0.8\\n TCO2\\n 35\\n 34\\n 34\\n 38\\n 37\\n 35\\n 35\\n Glucose\\n 125\\n 128\\n 141\\n 107\\n 131\\n 115\\n Other labs: PT / PTT / INR:13.9/26.9/1.2, CK / CK-MB / Troponin\\n T:1334/13/<0.01, ALT / AST:90/88, Alk-Phos / T bili:63/6.8, Amylase /\\n Lipase:44/, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic Acid:1.2\\n mmol/L, Albumin:2.7 g/dL, LDH:348 IU/L, Ca:8.4 mg/dL, Mg:2.1 mg/dL,\\n PO4:2.9 mg/dL\\n Imaging: CT head OSH: Prelim No ICH or fx.\\n CT chest OSH: Mult rib fx: R anterolateral and posterior, L\\n posterior; Dependent consolidation, possible aspiration; T4 vertebral\\n body inf corner fx, no retropulsion; Comminuted spinous process fx\\n T2-8; Nondisplaced L T10 transverse process; Nondisplaced L clavicle\\n distal fx; Nondisplaced L scapula fx;\\n CT c spine OSH: Prelim No fx or malalignment. Multilevel\\n degenerative changes w/large post disk bulge at C4-5, narrowing the\\n spinal canal and deforming the thecal sac, acuity unknown. Marked\\n neuroforamenal narrowing @multiple levels.\\n CTA abd/pel Prelim: Medial R liver lobe contusion w/adj\\n hematoma, w/o evidence of active bleeding; Comminuted L pubic ramus\\n fracture w/assoc hematoma, with tiny focus of arterial bleeding/active\\n extravasation, and larger area of venous bleeding. Hematoma somewhat\\n larger than on OSH study. Nondisplaced, comminuted L iliac bone fx\\n w/adj iliac muscle hematoma, larger than on prior study, w/o active\\n extrav. Fx extends into L SIJ. Post R hepatic laceration/contusion\\n adjacent to calcified granuloma, w/small hematoma, w/out active\\n bleeding. Min displaced fx of R iliac bone extending to R SIJ.\\n Cirrhotic liver. Inc B pl effusions (small), w/inc atelectasis.\\n MRI: Mild compression deformity of L1 w/additional levels of\\n potential trabecular contusion @T10-11 also inf @T4 w/o retropulsion.\\n Multilevel degenerative changes with moderate canal narrowing at T10-11\\n w/cord deformity and no abnormal cord signal. Extensive edema\\n throughout paraspinal soft tissues, predominantly post w/in\\n interspinous ligaments. Incompletely eval'ed c-spine w/severe canal\\n narrowing @C4-5 w/cord deformity and no abnormal cord signal.\\n CTA: no PE.\\n CXR: Moderate bilateral pleural effusions are stable.\\n CXR: Cardiac size top nl, interval improvement of collapse LLL.\\n Collapse RLL. Atelectasis in lingula unchanged. Mod B\\n pleural effusions stable. No PTX.\\n CXR: Interval mild incr in cardiac size, b/l pleural effusions,\\n and opacities @ bases,c/w overload\\n : R foot: Linear density projecting @ expected area of insertion\\n of the Achilles to calcaneus, may be min avulsion fx or degenerative\\n changes. Otherwise no fx\\n CXR: bilateral pleural effusions\\n Microbiology: Ucx no growth final\\n Sputum: sparse GNR\\n Bcx P\\n Bcx P\\n 12/17 L BAL: KLEBSIELLA PNEUMONIAE, HAEMOPHILUS SPECIES NOT INFLUENZAE\\n R BAL: KLEBSIELLA PNEUMONIAE & GNRs.\\n 12/20 L BAL: gram + cocci pairs on gram stain\\n R BAL: gram + cocci pairs on gram stain\\n Assessment and Plan\\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, AF with\\n RVR, hematologic abnomalities.\\n Neurologic: Intubated on Fentanyl/Versed gtt. Per ortho spine, no\\n surgery; HOB<30, TLSO when OOB (NEOPS will place). Neuro checks q\\n shift.\\n Cardiovascular: Aflutter on Dilt 60mg PO QID. Still on Neo. Likely\\n needs chemical/electrical cardioversion to improve atrial contribution\\n to CO\\n Pulmonary: Intubated. Weaning to extubate (was on throughout\\n , changed to 10/10 after desat, but self-extubated and reintubated\\n am). F/U on BAL: KLEBSIELLA PNEUMONIAE & GNRs/Haemophilus. Repeat\\n BAL with gram+ cocci in pairs on gram stain. Ceftriaxone ()\\n changed to Vancomycin/Zosyn (). Plan for Trach early this week.\\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin with CT scan\\n suggesting cirrhosis - Hepatitis panel NEG. TFs advancing to goal.\\n Bowel regimen. Tbili trending up (6.8), other LFTs improving.\\n Nutrition: Tube feeding\\n Renal: Foley, Adequate UO, Foley, monitor UOP. Cr normalized.\\n Hematology: Hct and Plt stable; d/c'd H2B\\n Endocrine: RISS\\n Infectious Disease: WBC increasing to 13.1, f/u Cx - BAL: Klebsiella\\n (b/l)& GNRs (on R)/Haemophilus (on L). Started Ceftriaxone (),\\n broadened to Zosyn/Vanc () for continued fevers and gram+ on BAL\\n Lines / Tubes / Drains: R SC CVL (), PIV x2, Foley, L a-line\\n (), ETT\\n Wounds:\\n Imaging: CXR today\\n Fluids: KVO\\n Consults: Trauma surgery, Ortho, Ortho-spine, Heme\\n Billing Diagnosis:\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 01:00 PM 80 mL/hour\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n Multi Lumen - 04:41 PM\\n Arterial Line - 11:30 AM\\n Prophylaxis:\\n DVT: (IVC filter, SCDs)\\n Stress ulcer: PPI\\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition: ICU\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2175-01-30 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 714188,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 6\\n Ideal body weight: 0 None\\n Ideal tidal volume: 0 / 0 / 0 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: Yes\\n Procedure location:\\n Reason:\\n Tube Type\\n ETT:\\n Position: 23 cm at teeth\\n Route: Oral\\n Type: Standard\\n Size: 7.5mm\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 25 cmH2O\\n Lung sounds\\n RLL Lung Sounds: Rhonchi\\n RUL Lung Sounds: Rhonchi\\n LUL Lung Sounds: Rhonchi\\n LLL Lung Sounds: Rhonchi\\n Comments:\\n Secretions\\n Sputum color / consistency: Tan / Thick\\n Sputum source/amount: Suctioned / Moderate\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance: Continuous invasive ventilation\\n Visual assessment of breathing pattern: Normal quiet breathing;\\n Comments: pt weaned to PSV 10/10 tolerated well all shift abgs wnl\\n Assessment of breathing comfort: No claim of dyspnea)\\n Plan\\n Next 24-48 hours: Reduce PEEP as tolerated\\n Reason for continuing current ventilatory support: Underlying illness\\n not resolved\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2175-02-01 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 714542,\n \"text\": \"74M s/p crushing injury d/t falling tree. Injuries sustained include\\n multiple R sided rib fxs, grade 2 liver lac (w/ assoc hepatic vessel\\n extravasation), stable pelvis fxs (w/ associated extravasation), R\\n ramus fx, clavicle fx, and T4 vertebral body fx. Episodes of A.\\n Flutter with RVR and aflutter, now with resp failure and newly dx\\n pneumonia as of .\\n intubated for resp distress\\n angio embolization of hepatic and pelvic arterial bleeders\\n IVC filter in OR\\n self extubated and re-intubated immediately after d/t acute resp.\\n failure\\n Trach and PEG at bedside\\n Atrial fibrillation (Afib)\\n Assessment:\\n Atrial flutter continues, RVR up to 130s this AM. Now rate controlled\\n <100.\\n Action:\\n PO dilt, amioderone gtt continued, Neo gtt titrated for adequate BP\\n control.\\n Response:\\n Rate controlled after PO Dilt.\\n Plan:\\n Continue Amio gtt, switch to PO amio, ? Cardio version,? Anticoagulant.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Post trach pt back on CPAP 10/10/50%. Ls clear to diminish at bases.\\n Strong productive cough, suctioned for copious amounts of thick blood\\n tinged secretions. ABG stable.\\n Action:\\n Trach and PEG at bedside, continue pulmonary toileting.\\n Response:\\n Tolerated procedure without issue.\\n Plan:\\n Wean vent settings as tolerated, pulmonary toileting, wean sedation.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2175-02-04 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 714930,\n \"text\": \"TSICU\\n HPI:\\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\\n checked and 1.5, 1 more unit FFP given.\\n Chief complaint:\\n Mult rib fx: R anterolateral and post, L posterior\\n T4 vert body inf corner fx\\n Commin spinous process fx T2-8\\n Nondisplaced L T10 transverse process\\n Nondispaced L distal clavicle\\n Nondisplaced L clavicle fx\\n R medial lobe liver contusion w/hematoma\\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny focus of arterial\\n bleeding/active extravasation, and larger area of venous bleeding\\n Nondisplaced, comminuted L iliac bone fx w/adjacent iliac muscle\\n hematoma, extends into L SIJ.\\n Minimally displaced fx of R iliac bone extending to R SIJ.\\n PMHx:\\n PMH: cirrhosis and asbestosis dx on CT\\n PSH: None\\n Current medications:\\n 1. 2. 3. Acetaminophen 4. Amiodarone 5. Bisacodyl 6. Calcium Gluconate\\n 7. CefePIME 8. Chlorhexidine Gluconate 0.12% Oral Rinse\\n 9. Ciprofloxacin HCl 10. Dextrose 50% 11. Diltiazem 12. Docusate Sodium\\n (Liquid) 13. Furosemide\\n 14. Gabapentin 15. Glucagon 16. Haloperidol 17. Haloperidol 18. Heparin\\n 19. Insulin 20. Lactulose\\n 21. Lansoprazole Oral Disintegrating Tab 22. Magnesium Sulfate 23.\\n Metoprolol Tartrate 24. Metoprolol Tartrate\\n 25. Milk of Magnesia 26. Olanzapine (Disintegrating Tablet) 27.\\n Ondansetron 28. OxycoDONE Liquid\\n 29. Pneumococcal Vac Polyvalent 30. Potassium Phosphate 31. Potassium\\n Chloride 32. Senna 33. Sodium Chloride 0.9% Flush\\n 34. Sodium Chloride 0.9% Flush 35. Vancomycin\\n 24 Hour Events:\\n Back to Aflutter with HR in 120's. Stable BP. Given Lopressor with\\n adequate rate control but no conversion. Eventually placed on a Dilt\\n gtt. Pt converted to NSR. Maintained on Amio PO. TF switched to\\n Nutren 2 in order to limit fluids, pt getting Lasix 20 q6 with net neg\\n of 1500 cc. US of LE done to r/o clot as cause of fever.\\n Post operative day:\\n POD#9 - IVC filter via L groin\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Ceftriaxone - 03:00 PM\\n Vancomycin - 08:09 PM\\n Ciprofloxacin - 10:08 PM\\n Cefipime - 12:00 AM\\n Infusions:\\n Other ICU medications:\\n Midazolam (Versed) - 12:45 PM\\n Lorazepam (Ativan) - 01:39 PM\\n Metoprolol - 01:54 PM\\n Furosemide (Lasix) - 06:52 PM\\n Heparin Sodium (Prophylaxis) - 08:09 PM\\n Other medications:\\n Flowsheet Data as of 05:24 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 37.9\\nC (100.3\\n T current: 37.7\\nC (99.8\\n HR: 96 (75 - 125) bpm\\n BP: 132/60(83) {121/51(73) - 169/88(115)} mmHg\\n RR: 16 (16 - 33) insp/min\\n SPO2: 99%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 104.2 kg (admission): 90 kg\\n CVP: 19 (17 - 19) mmHg\\n Total In:\\n 2,563 mL\\n 512 mL\\n PO:\\n Tube feeding:\\n 1,482 mL\\n 211 mL\\n IV Fluid:\\n 821 mL\\n 300 mL\\n Blood products:\\n Total out:\\n 4,060 mL\\n 635 mL\\n Urine:\\n 4,055 mL\\n 635 mL\\n NG:\\n 5 mL\\n Stool:\\n Drains:\\n Balance:\\n -1,497 mL\\n -123 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 554 (380 - 554) mL\\n PS : 15 cmH2O\\n RR (Spontaneous): 18\\n PEEP: 10 cmH2O\\n FiO2: 50%\\n RSBI Deferred: PEEP > 10\\n PIP: 27 cmH2O\\n SPO2: 99%\\n ABG: 7.53/39/124/33/9\\n Ve: 14.2 L/min\\n PaO2 / FiO2: 248\\n Physical Examination\\n General Appearance: Overweight / Obese, Tracheostomy\\n HEENT: PERRL\\n Cardiovascular: (Rhythm: Regular)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\\n bilateral : , Crackles : b/l bases)\\n Abdominal: Soft, Non-tender, Obese\\n Left Extremities: (Edema: 1+), (Temperature: Warm)\\n Right Extremities: (Edema: 1+), (Temperature: Warm)\\n Skin: Jaundice\\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\\n Moves all extremities, Pt appears to be confused this AM.\\n Labs / Radiology\\n 124 K/uL\\n 9.3 g/dL\\n 103 mg/dL\\n 0.8 mg/dL\\n 33 mEq/L\\n 3.9 mEq/L\\n 21 mg/dL\\n 107 mEq/L\\n 144 mEq/L\\n 29.0 %\\n 6.5 K/uL\\n [image002.jpg]\\n 01:00 AM\\n 01:07 AM\\n 01:18 AM\\n 02:05 AM\\n 03:54 AM\\n 05:17 AM\\n 01:23 PM\\n 07:20 PM\\n 12:35 AM\\n 01:04 AM\\n WBC\\n 5.9\\n 6.3\\n 6.5\\n Hct\\n 31.3\\n 28.9\\n 29.0\\n Plt\\n 109\\n 128\\n 124\\n Creatinine\\n 0.8\\n 0.8\\n 0.8\\n 0.8\\n TCO2\\n 35\\n 34\\n 35\\n 34\\n Glucose\\n 117\\n 110\\n 138\\n 136\\n 130\\n 103\\n Other labs: PT / PTT / INR:13.7/27.6/1.2, CK / CK-MB / Troponin\\n T:128/13/<0.01, ALT / AST:90/122, Alk-Phos / T bili:133/5.4, Amylase /\\n Lipase:54/52, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic\\n Acid:1.4 mmol/L, Albumin:2.3 g/dL, LDH:348 IU/L, Ca:7.7 mg/dL, Mg:2.2\\n mg/dL, PO4:2.7 mg/dL\\n Imaging: RUQ U/S: No perihepatic fluid collection. small amt\\n perihepatic free fluid persists. Small contusion in hepatic segment\\n VII. No\\n gallstones or sig wall thickening/edema. CBD 4.5 mm\\n TTE: LVEF >55%, NL diastolic function, NL LV filling pressure\\n (PCWP<12mmHg), RV chamber size mildly dilated, mild TR\\n CXR: mild b/l pulm edema and parenchymal opacities and no\\n pl effusion.\\n CXR: Persistent b/l pl effusions and bibasilar opacity.\\n CXR: Minimal improvement of mod b/l pl effusions. Otherwise\\n stable.\\n CXR: no relevant change. B/L pleural effusions with basal\\n opacities. No evidence of newly appeared focal parenchymal opacities\\n suggesting pneumonia.\\n : No dvt\\n Microbiology: Ucx no growth final\\n Sputum: sparse GNRs, too few to colonize\\n Bcx x2 no growth final\\n 12/17 L BAL: Klebsiella Pneumoniae, HAEMOPHILUS SPECIES NOT INFLUENZAE\\n R BAL: Klebsiella Pneumoniae, Proteus.\\n 12/20 L &R BAL: Klebsiella Pneumoniae\\n BCX: p\\n BCx: P\\n UCx: no growth final\\n BCx: P\\n BCx: P\\n UCx: P\\n SpCx: contamination\\n Assessment and Plan\\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, now\\n with AF with RVR/Aflutter, persistant hypotension and PNA.\\n Neurologic: Neuro checks Q: 4 hr, s/p trach (). Per ortho spine,\\n no surgery; HOB<30, TLSO when OOB. Zyprexa & Haldol PRN (off fent/midaz\\n ).\\n Pain: Oxycodone, Neurontin, Tylenol.\\n Cardiovascular: Aflutter->NSR, on Amio and dilt gtt, will need to\\n transition to PO meds. Likely cardiac contusion. Cards for Amio rec\\n 400'' x 1wk, then 400'x1 wk, then 200'. Pt cannot be fully\\n anticoagulated for now (trauma).\\n Pulmonary: Trach, Trach, weaning vent, Vanc/cipro/cefepime for VAP\\n (). Increasing pulmonary edema on CXR. consider therapeutic\\n thoracentesis 12/26-7 if no improvement on Lasix, lots of secretions,\\n consider bronchoscopy\\n Gastrointestinal / Abdomen: Unknown elevated LFTs and bilirubin w/CT\\n scan suggesting cirrhosis - Hepatitis panel NEG, RUQ U/S r/o\\n gallbladder etiology, will continue to trend. On Nutren 2.0 with goal\\n 40 cc/hr. Bowel regimen.\\n Nutrition: Tube feeding\\n Renal: Foley, Foley, monitor UOP, edematous scrotum. Lasix 20 Q6,\\n developing contraction alk, consider switching to acetazolamide\\n Hematology: Hct stable 28.9->29. Plt stable (100's); d/c'd H2B. Heme\\n onc c/s - smear nl; no hemolysis. IVC filter placed.\\n Endocrine: RISS, RISS\\n Infectious Disease: Check cultures, WBC normal, on Vanc/cipro/cefepime\\n for VAP given worsening pulm status, f/u on cx\\n Lines / Tubes / Drains: Trach/Peg/foley/L radial a-line/R SCL\\n Wounds:\\n Imaging: CXR today\\n Fluids: KVO\\n Consults: Trauma (1o), Ortho Spine, Ortho trauma, Heme\\n Billing Diagnosis: Multiple injuries (Trauma)\\n ICU Care\\n Nutrition:\\n Nutren 2.0 (Full) - 01:00 PM 40 mL/hour\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n Multi Lumen - 04:41 PM\\n Arterial Line - 11:30 AM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin, IVC filter\\n Stress ulcer: PPI\\n VAP bundle:\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds , ICU\\n Code status: Full code\\n Disposition: ICU\\n Total time spent: 31 minutes\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2175-01-27 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 713792,\n \"text\": \"Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt remains orally intubated and vented. Pt was on CMV this AM. Lung\\n sounds clear in the upper lobes, diminished at the bases bilaterally.\\n Daily CXR continue. ABGs show fully compensated metabolic alkalosis.\\n Suctioned for thick, yellow/white secretions. Pt has strong,\\n productive/congested cough. O2 sat 99-100%.\\n Action:\\n Vent changed from CMV to MMV 12/12/40%. Pt suctioned as needed. Pt\\n repositioned frequently. Tube feeds increased to goal (Replete with\\n Fiber FS).\\n Response:\\n Pt tolerating vent setting, remains afebrile.\\n Plan:\\n Continue to wean vent as tolerated. Follow up with BAL cultures sent\\n on . Start antibiotics? Continue to support pt and family. PT\\n consulted, plan to visit pt over the weekend in the event that he is\\n extubated.\\n Hypotension (not Shock)\\n Assessment:\\n BP low 80\\ns when off neo, on low doses of neo throughout the day.\\n Propofol gtt continues for sedation. Pt is uncomfortable being awake\\n and off propofol, he is agitated, anxious, and reaches for the ET tube\\n as well as sits up in bed. HR converted to NSR early this AM,\\n diltiazem gtt stopped. Pt having PAC\\ns in the afternoon, electrolytes\\n WNL when checked. Pt is edematous throughout, CVP 13, PPV .\\n Scrotum is edematous and purple since OR trip last evening (? From IVC\\n filter placement?). HCT remains stable. UO marginal, clear, icteric.\\n Tube feeds started at midnight.\\n Action:\\n Heme consulted, recommended starting vitamin K and possibly antibiotics\\n for gram negative rods found in sputum. Neo gtt titrated throughout\\n the day. Pt remains sedated on propofol, titrated as tolerated.\\n Diltiazem 30mg QID PO started. Fluid challenge done this AM with\\n little effect. Tube feeds increasing to goal, IV fluids turned off\\n when tube feeds reached goal.\\n Response:\\n Pt becoming more awake on current doses of propofol, had to increase\\n gtt to adequately sedate pt. HR remains NSR but with PAC\\ns. BP\\n remains low and requiring small doses of neo. Pt tolerating goal tube\\n feeds well, minimal residuals.\\n Plan:\\n Start vitamin K (per heme)? Wean neo as tolerated. Consider albumin\\n or hespan to draw in fluid from extravascular spaces. Continue goal\\n tube feeds. Monitor coags. Continue to support pt and family.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2175-01-29 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 713986,\n \"text\": \"74M s/p fall with multiple rib fx, pelvis fx, clavicle fx, and thoracic\\n fx c/b unstable bleeding s/p IR embo, AF with RVR, hematologic\\n abnomalities.\\n Atrial fibrillation (Afib)\\n Assessment:\\n Remains in 1^st degree HB. HR to 120\\ns with agitation, anxiety.\\n Action:\\n Continues on Fentanyl gtt, Receiving Dilaudid IV and Midazolam for\\n pain & agitation.\\n Response:\\n Good response with meds for pain, agitation, and anxiety.\\n Plan:\\n Cont to asses rhythm, BP. Metoprolol PRN for HR > 90, SBP > 150\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n BBS= essentially clear throughout all lung fields.\\n Action:\\n Rested overnight on CPAP/PS. Lasix gtt initiated for diuresis.\\n Suctioned Q1-2 hrs for moderate amounts thick, pale yellow secretions.\\n Klebsiella growing from sputum\\n Response:\\n Appears comfortable, no SOB noted or increased WOB.\\n Plan:\\n Goal for pt to be -500cc, will move towards extubation this morning as\\n pt tolerates.\\n Trauma, s/p\\n Assessment:\\n Multiple echymotic areas over head torso, extremities. Scrotum\\n echymotic, edematous.\\n Action:\\n Managing pain with Fentanyl gtt, Dilaudid & Midazolam IV. Scrotum\\n elevated\\n Response:\\n Currently denies pain.\\n Plan:\\n Fentanyl gtt overnight. Keep scrotum elevated.\\n ------ Protected Section ------\\n At 630 pt tongued ETT and self extubated. Unable to maintain sats or\\n protect airway- emergently reintubated. Pt tolerated well.\\n ------ Protected Section Addendum Entered By: , RN\\n on: 06:54 ------\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2175-01-30 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 714190,\n \"text\": \"TSICU\\n HPI:\\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\\n checked and 1.5, 1 more unit FFP given.\\n Chief complaint:\\n Mult rib fx: R anterolateral and post, L posterior\\n T4 vert body inf corner fx\\n Commin spinous process fx T2-8\\n Nondisplaced L T10 transverse process\\n Nondispaced L distal clavicle\\n Nondisplaced L clavicle fx\\n R medial lobe liver contusion w/hematoma\\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny focus of arterial\\n bleeding/active extravasation, and larger area of venous bleeding\\n Nondisplaced, comminuted L iliac bone fx w/adjacent iliac muscle\\n hematoma, extends into L SIJ.\\n Minimally displaced fx of R iliac bone extending to R SIJ.\\n PMHx:\\n None\\n Current medications:\\n Chlorhexidine Gluconate 0.12% Oral Rinse\\n Diltiazem\\n Furosemide\\n Gabapentin\\n Metoprolol Tartrate\\n Ondansetron\\n Phenylephrine\\n 24 Hour Events:\\n Self-extubated in the AM, re-intubated over bougie, NGT replaced,\\n bronch with bilateral BALs sent, plan for trach later this week. T\\n spike to 101.8 - u/a, urine cx, blood cxs sent. Diltiazem titrated to\\n 60mg PO QID. ABX coverage broadened to Vanc/Zosyn. Tbili up to 6.8\\n (other LFTs trending down)\\n Post operative day:\\n POD#4 - IVC filter via L groin\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Ceftriaxone - 11:00 AM\\n Piperacillin/Tazobactam (Zosyn) - 08:19 PM\\n Vancomycin - 08:56 PM\\n Infusions:\\n Fentanyl (Concentrate) - 100 mcg/hour\\n Midazolam (Versed) - 1 mg/hour\\n Other ICU medications:\\n Hydromorphone (Dilaudid) - 04:00 AM\\n Metoprolol - 06:33 AM\\n Pantoprazole (Protonix) - 02:00 PM\\n Midazolam (Versed) - 12:30 AM\\n Other medications:\\n Flowsheet Data as of 02:07 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 38.8\\nC (101.8\\n T current: 37.2\\nC (98.9\\n HR: 76 (76 - 103) bpm\\n BP: 97/51(67) {86/47(62) - 121/858(84)} mmHg\\n RR: 18 (0 - 25) insp/min\\n SPO2: 99%\\n Heart rhythm: A Flut (Atrial Flutter)\\n Wgt (current): 102 kg (admission): 90 kg\\n CVP: 11 (6 - 18) mmHg\\n Total In:\\n 3,114 mL\\n 207 mL\\n PO:\\n Tube feeding:\\n 1,301 mL\\n 148 mL\\n IV Fluid:\\n 1,682 mL\\n 59 mL\\n Blood products:\\n Total out:\\n 2,500 mL\\n 180 mL\\n Urine:\\n 2,500 mL\\n 180 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 614 mL\\n 27 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 550 (550 - 550) mL\\n Vt (Spontaneous): 540 (540 - 540) mL\\n PS : 5 cmH2O\\n RR (Set): 15\\n RR (Spontaneous): 0\\n PEEP: 10 cmH2O\\n FiO2: 50%\\n RSBI: 34\\n PIP: 26 cmH2O\\n Plateau: 23 cmH2O\\n Compliance: 42.3 cmH2O/mL\\n SPO2: 99%\\n ABG: 7.44/50/127/34/8\\n Ve: 9.5 L/min\\n PaO2 / FiO2: 254\\n Physical Examination\\n General Appearance: No acute distress\\n HEENT: PERRL\\n Cardiovascular: Aflutter\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\\n Rhonchorous : )\\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present,\\n Stable scrotal edema/hematoma, soft, no crepitus\\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\\n Neurologic: Follows simple commands, Moves all extremities, Sedated\\n Labs / Radiology\\n 158 K/uL\\n 10.7 g/dL\\n 115 mg/dL\\n 0.8 mg/dL\\n 34 mEq/L\\n 4.0 mEq/L\\n 20 mg/dL\\n 111 mEq/L\\n 148 mEq/L\\n 31.6 %\\n 13.1 K/uL\\n [image002.jpg]\\n 01:59 AM\\n 02:00 AM\\n 11:04 AM\\n 01:17 PM\\n 02:55 AM\\n 04:11 AM\\n 09:45 AM\\n 04:45 PM\\n 12:45 AM\\n 01:00 AM\\n WBC\\n 5.6\\n 6.5\\n 13.1\\n Hct\\n 28.7\\n 29.3\\n 31.6\\n Plt\\n 74\\n 86\\n 158\\n Creatinine\\n 0.8\\n 0.8\\n 0.8\\n TCO2\\n 35\\n 34\\n 34\\n 38\\n 37\\n 35\\n 35\\n Glucose\\n 125\\n 128\\n 141\\n 107\\n 131\\n 115\\n Other labs: PT / PTT / INR:13.9/26.9/1.2, CK / CK-MB / Troponin\\n T:1334/13/<0.01, ALT / AST:90/88, Alk-Phos / T bili:63/6.8, Amylase /\\n Lipase:44/, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic Acid:1.2\\n mmol/L, Albumin:2.7 g/dL, LDH:348 IU/L, Ca:8.4 mg/dL, Mg:2.1 mg/dL,\\n PO4:2.9 mg/dL\\n Imaging: CT head OSH: Prelim No ICH or fx.\\n CT chest OSH: Mult rib fx: R anterolateral and posterior, L\\n posterior; Dependent consolidation, possible aspiration; T4 vertebral\\n body inf corner fx, no retropulsion; Comminuted spinous process fx\\n T2-8; Nondisplaced L T10 transverse process; Nondisplaced L clavicle\\n distal fx; Nondisplaced L scapula fx;\\n CT c spine OSH: Prelim No fx or malalignment. Multilevel\\n degenerative changes w/large post disk bulge at C4-5, narrowing the\\n spinal canal and deforming the thecal sac, acuity unknown. Marked\\n neuroforamenal narrowing @multiple levels.\\n CTA abd/pel Prelim: Medial R liver lobe contusion w/adj\\n hematoma, w/o evidence of active bleeding; Comminuted L pubic ramus\\n fracture w/assoc hematoma, with tiny focus of arterial bleeding/active\\n extravasation, and larger area of venous bleeding. Hematoma somewhat\\n larger than on OSH study. Nondisplaced, comminuted L iliac bone fx\\n w/adj iliac muscle hematoma, larger than on prior study, w/o active\\n extrav. Fx extends into L SIJ. Post R hepatic laceration/contusion\\n adjacent to calcified granuloma, w/small hematoma, w/out active\\n bleeding. Min displaced fx of R iliac bone extending to R SIJ.\\n Cirrhotic liver. Inc B pl effusions (small), w/inc atelectasis.\\n MRI: Mild compression deformity of L1 w/additional levels of\\n potential trabecular contusion @T10-11 also inf @T4 w/o retropulsion.\\n Multilevel degenerative changes with moderate canal narrowing at T10-11\\n w/cord deformity and no abnormal cord signal. Extensive edema\\n throughout paraspinal soft tissues, predominantly post w/in\\n interspinous ligaments. Incompletely eval'ed c-spine w/severe canal\\n narrowing @C4-5 w/cord deformity and no abnormal cord signal.\\n CTA: no PE.\\n CXR: Moderate bilateral pleural effusions are stable.\\n CXR: Cardiac size top nl, interval improvement of collapse LLL.\\n Collapse RLL. Atelectasis in lingula unchanged. Mod B\\n pleural effusions stable. No PTX.\\n CXR: Interval mild incr in cardiac size, b/l pleural effusions,\\n and opacities @ bases,c/w overload\\n : R foot: Linear density projecting @ expected area of insertion\\n of the Achilles to calcaneus, may be min avulsion fx or degenerative\\n changes. Otherwise no fx\\n CXR: bilateral pleural effusions\\n Microbiology: Ucx no growth final\\n Sputum: sparse GNR\\n Bcx P\\n Bcx P\\n 12/17 L BAL: KLEBSIELLA PNEUMONIAE, HAEMOPHILUS SPECIES NOT INFLUENZAE\\n R BAL: KLEBSIELLA PNEUMONIAE & GNRs.\\n 12/20 L BAL: gram + cocci pairs on gram stain\\n R BAL: gram + cocci pairs on gram stain\\n Assessment and Plan\\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, AF with\\n RVR, hematologic abnomalities.\\n Neurologic: Intubated on Fentanyl/Versed gtt. Per ortho spine, no\\n surgery; HOB<30, TLSO when OOB (NEOPS will place). Neuro checks q\\n shift.\\n Cardiovascular: Aflutter on Dilt 60mg PO QID. Still on Neo. Likely\\n needs chemical/electrical cardioversion to improve atrial contribution\\n to CO\\n Pulmonary: Intubated. Weaning to extubate (was on throughout\\n , changed to 10/10 after desat, but self-extubated and reintubated\\n am). F/U on BAL: KLEBSIELLA PNEUMONIAE & GNRs/Haemophilus. Repeat\\n BAL with gram+ cocci in pairs on gram stain. Ceftriaxone ()\\n changed to Vancomycin/Zosyn (). Plan for Trach early this week.\\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin with CT scan\\n suggesting cirrhosis - Hepatitis panel NEG. TFs advancing to goal.\\n Bowel regimen. Tbili trending up (6.8), other LFTs improving.\\n Nutrition: Tube feeding\\n Renal: Foley, Adequate UO, Foley, monitor UOP. Cr normalized.\\n Hematology: Hct and Plt stable; d/c'd H2B\\n Endocrine: RISS\\n Infectious Disease: WBC increasing to 13.1, f/u Cx - BAL: Klebsiella\\n (b/l)& GNRs (on R)/Haemophilus (on L). Started Ceftriaxone (),\\n broadened to Zosyn/Vanc () for continued fevers and gram+ on BAL\\n Lines / Tubes / Drains: R SC CVL (), PIV x2, Foley, L a-line\\n (), ETT\\n Wounds:\\n Imaging: CXR today\\n Fluids: KVO\\n Consults: Trauma surgery, Ortho, Ortho-spine, Heme\\n Billing Diagnosis:\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 01:00 PM 80 mL/hour\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n Multi Lumen - 04:41 PM\\n Arterial Line - 11:30 AM\\n Prophylaxis:\\n DVT: (IVC filter, SCDs)\\n Stress ulcer: PPI\\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition: ICU\\n Total time spent: 32 minutes\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2175-01-31 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 714356,\n \"text\": \"Atrial fibrillation (Afib)\\n Assessment:\\n Pt continues in aflutter, controlled rate 70\\ns-80\\ns, rare PVCs noted.\\n Pt continues on diltiazem 60mg PO tid. Atrial flutter thought to be\\n from cardiac contusion as a result of the pt\\ns injury.\\n Action:\\n Cardiology consult obtained as well as electrophysiology consult to\\n discuss possibility of cardioversion to correct pt\\ns aflutter. Pt\\n ultimately started on amiodarone gtt without bolus as recommended by\\n cards team and ordered by ICU team.\\n Response:\\n Pt continues on diltiazem PO while on amiodarone gtt. Pt remains in\\n atrial flutter at time of note. HR remains in the 70-80\\n Plan:\\n Continue amiodarone, change dose to .5mg/hr at 17:45 tonight per order\\n for 18 hrs. Monitor HR and rhythm closely and attempt to wean neo as\\n tolerated to support heart.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Lung sounds clear in the upper lobes, diminished at the bases\\n bilaterally. Suctioned frequently for thick, white secretions-moderate\\n amounts. Pt remains orally intubated on CPAP/PS 50% FiO2. Pt\\n requiring sedation while orally intubated because he is unsafely\\n agitated when he wakes-tonguing/biting ET tube, reaching for ET tube,\\n sitting up in bed. Pt continues to be lightly sedated (easily\\n arousable, follows commands) on midazolam and Fentanyl for sedation\\n with boluses as needed. +PNA, low grade temp today (Tmax 100.6),\\n antibiotics continue (vanco, ceftriaxone).\\n Action:\\n Tracheostomy (and PEG procedure) brought up to pt and family today by\\n Trauma team and ICU team. Family agreed to got forth with procedure\\n but formal consent still needed by son (spokesperson, ). Pt\\n suctioned frequently, ET tube inserted by RT further (2cm) per ICU team\\n this evening.\\n Response:\\n Pt continues to have moderate amount of secretions, no weaning of vent\\n done today, ABG unchanged.\\n Plan:\\n Trach and PEG procedures planned for tomorrow per Trauma team, no\\n consents done- in room v. OR? Continue to educate family regarding\\n plan and rationale for treatment. Pulmonary toileting, frequent\\n repositioning, VAP care to continue. Consider diuresis once BP more\\n stable?\\n Hypotension (not Shock)\\n Assessment:\\n Pt continues to have low BP, requiring neo gtt for several days now.\\n Neo gtt titrating daily as tolerated but ultimately still necessary for\\n adequate BP. Pt on midazolam gtt and Fentanyl gtt for sedation. Pt\\n able to nod yes/no when he has pain.\\n Action:\\n Ketamine study continues today, will stop at 20:00 tonight, at which\\n point 2 corvac tubes should be drawn for lab tests. Fentanyl gtt\\n decreased to assist with BP control, PO pain meds started and given as\\n needed today. Midazolam gtt lowered to 1mg/hr as tolerated. Haldol PO\\n initially given to assist with sedation, but then stopped d/t\\n amiodarone gtt started per pharmacy because of prolonged QTC risk.\\n Response:\\n Pt tolerating sedation changes, very lightly sedated and encouraging\\n minimal simulation to family members who are visiting. Pt is easily\\n stimulated and becomes uncomfortable with ET tube and agitated. Pt\\n denying pain at this time.\\n Plan:\\n Pt continues on Fentanyl and midaz gtts since the plan is for him to\\n have a trach placed tomorrow, which means sedation can be removed, and\\n therefore BP should improve. Continue to keep pt safely sedated and\\n comfortable. Wean neo gtt as tolerated. BP goal MAP >60-65. Continue\\n to support pt and family. Trach/PEG tomorrow by trauma team, remove\\n sedation after procedure.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2175-02-02 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 714592,\n \"text\": \"TSICU\\n HPI:\\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\\n checked and 1.5, 1 more unit FFP given.\\n .\\n Injuries\\n Mult rib fx: R anterolateral and post, L posterior\\n T4 vert body inf corner fx\\n Commin spinous process fx T2-8\\n Nondisplaced L T10 transverse process\\n Nondispaced L distal clavicle\\n Nondisplaced L clavicle fx\\n R medial lobe liver contusion w/hematoma\\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny focus of arterial\\n bleeding/active extravasation, and larger area of venous bleeding\\n Nondisplaced, comminuted L iliac bone fx w/adjacent iliac muscle\\n hematoma, extends into L SIJ.\\n Minimally displaced fx of R iliac bone extending to R SIJ.\\n Chief complaint:\\n Trauma\\n PMHx:\\n PMH: None\\n PSH: None\\n : None\\n Current medications:\\n 24 Hour Events:\\n Trach/PEG. Pt's BP dropped to 80/40 off pressors, sats 88. restarted\\n neo. Overnight, pt reverted to sinus, off pressors, weaning sedation.\\n PERCUTANEOUS TRACHEOSTOMY - At 12:00 PM\\n PEG INSERTION - At 12:00 PM\\n Post operative day:\\n POD#7 - IVC filter via L groin\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\\n Vancomycin - 08:00 AM\\n Ceftriaxone - 03:00 PM\\n Infusions:\\n Midazolam (Versed) - 1 mg/hour\\n Amiodarone - 0.5 mg/min\\n Fentanyl (Concentrate) - 50 mcg/hour\\n Other ICU medications:\\n Fentanyl - 01:23 PM\\n Pantoprazole (Protonix) - 02:00 PM\\n Heparin Sodium (Prophylaxis) - 04:00 AM\\n Other medications:\\n Flowsheet Data as of 04:33 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 37.7\\nC (99.9\\n T current: 37.1\\nC (98.8\\n HR: 94 (68 - 101) bpm\\n BP: 140/66(91) {89/46(63) - 154/68(94)} mmHg\\n RR: 26 (11 - 30) insp/min\\n SPO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 102 kg (admission): 90 kg\\n CVP: 9 (6 - 16) mmHg\\n Total In:\\n 1,764 mL\\n 142 mL\\n PO:\\n Tube feeding:\\n 424 mL\\n IV Fluid:\\n 1,000 mL\\n 82 mL\\n Blood products:\\n Total out:\\n 1,630 mL\\n 290 mL\\n Urine:\\n 1,630 mL\\n 290 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 134 mL\\n -148 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 483 (404 - 506) mL\\n PS : 15 cmH2O\\n RR (Spontaneous): 16\\n PEEP: 10 cmH2O\\n FiO2: 60%\\n RSBI Deferred: PEEP > 10\\n PIP: 25 cmH2O\\n SPO2: 98%\\n ABG: 7.45/49/98./31/8\\n Ve: 8.5 L/min\\n PaO2 / FiO2: 163\\n Physical Examination\\n General Appearance: No acute distress\\n HEENT: PERRL\\n Cardiovascular: (Rhythm: Regular)\\n Respiratory / Chest: (Breath Sounds: Crackles : )\\n Abdominal: Soft\\n Left Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present)\\n Right Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present)\\n Neurologic: Follows simple commands, Moves all extremities, Sedated\\n Labs / Radiology\\n 109 K/uL\\n 10.2 g/dL\\n 110 mg/dL\\n 0.8 mg/dL\\n 31 mEq/L\\n 4.5 mEq/L\\n 24 mg/dL\\n 105 mEq/L\\n 144 mEq/L\\n 31.3 %\\n 5.9 K/uL\\n [image002.jpg]\\n 12:07 AM\\n 02:18 AM\\n 08:00 AM\\n 02:00 PM\\n 05:04 PM\\n 08:00 PM\\n 09:20 PM\\n 01:00 AM\\n 01:07 AM\\n 01:18 AM\\n WBC\\n 4.2\\n 5.9\\n Hct\\n 29.7\\n 31.3\\n Plt\\n 104\\n 109\\n Creatinine\\n 0.7\\n 0.8\\n TCO2\\n 32\\n 36\\n 34\\n 35\\n Glucose\\n 129\\n 100\\n 111\\n 105\\n 117\\n 110\\n Other labs: PT / PTT / INR:13.7/27.6/1.2, CK / CK-MB / Troponin\\n T:128/13/<0.01, ALT / AST:90/113, Alk-Phos / T bili:99/5.1, Amylase /\\n Lipase:58/39, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic\\n Acid:1.4 mmol/L, Albumin:2.3 g/dL, LDH:348 IU/L, Ca:8.1 mg/dL, Mg:2.1\\n mg/dL, PO4:3.8 mg/dL\\n Assessment and Plan\\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, now\\n with AF with RVR/Aflutter, persistant hypotension and PNA.\\n Neurologic: s/p trach. Per ortho spine, no surgery; HOB<30, TLSO when\\n OOB (NEOPS will place). Wean sedation as may be causing hypotension.\\n Change pain meds to PO.\\n Neuro checks Q: shift\\n Pain: Oxycodone, Neurontin, Tylenol. Wean fentanyl gtt, midazolam gtt\\n Cardiovascular: Aflutter, now reverted to sinus. Likely cardiac\\n contusion. On Dilt 60mg PO QID. Cards rec amio gtt. Neo off. Pt cannot\\n be fully anticoagulated for now (trauma).\\n Pulmonary: Intubated, weaning, tachypneic likely abd distension. On\\n appropriate abx per BAL cx - Ceftriaxone. If pt continues to spike or\\n have signs of focal infection, breaden abx.\\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin (declining 6.8\\n max ->5.0) w/CT scan suggesting cirrhosis - Hepatitis panel NEG. TFs on\\n hold for PEG. Bowel regimen.\\n Nutrition:\\n Renal: Foley, monitor UOP, edematous scrotum.\\n Hematology: Hct stable 32.1->29.7. Plt stable (100's); d/c'd H2B with\\n increasing plt count. Heme onc c/s - smear nl; no hemolysis. IVC\\n filter placed.\\n Endocrine: RISS\\n Infectious Disease: WBC droppping 13.1->8.8->4.2, f/u Cx - BAL:\\n pansensitive Klebsiella - continue ceftriaxone; consider broadning\\n coverage if indicated.v\\n Lines / Tubes / Drains: R SC CVL (), Foley, L a-line (),\\n trach/PEG\\n Wounds: SCDs, IVC filter, SQH\\n Imaging:\\n Fluids:\\n Consults: Trauma surgery\\n Billing Diagnosis: Multiple injuries (Trauma)\\n ICU Care\\n Nutrition:\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n Multi Lumen - 04:41 PM\\n Arterial Line - 11:30 AM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin\\n Stress ulcer: PPI\\n VAP bundle:\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds Comments:\\n Code status: Full code\\n Disposition: ICU\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2175-01-27 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 713782,\n \"text\": \"Demographics\\n Day of mechanical ventilation: 3\\n Airway\\n Airway Placement Data\\n Known difficult intubation: No\\n Tube Type\\n ETT:\\n Route: Oral\\n Type: Standard\\n Size: 7.5mm\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 28 cmH2O\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Diminished\\n Comments:\\n Secretions\\n Sputum color / consistency: White / Thick\\n Sputum source/amount: Suctioned / Small\\n Ventilation Assessment\\n Level of breathing assistance: Continuous invasive ventilation\\n Visual assessment of breathing pattern: Normal quiet breathing;\\n Comments: Pt placed on MMV this a.m.; has tolerated well breathing over\\n MMV of 5L on PSV settings as charted.\\n Assessment of breathing comfort: No response (sleeping / sedated)\\n Plan\\n Next 24-48 hours: Reduce PEEP as tolerated\\n Reason for continuing current ventilatory support: Underlying illness\\n not resolved\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2175-01-28 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 713901,\n \"text\": \"Demographics\\n Day of mechanical ventilation: 4\\n Airway\\n Airway Placement Data\\n Known difficult intubation: No\\n Tube Type\\n ETT:\\n Route: Oral\\n Type: Standard\\n Size: 7.5mm\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 25 cmH2O\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Diminished\\n Secretions\\n Sputum color / consistency: Yellow / Thick\\n Sputum source/amount: Suctioned / Moderate\\n Ventilation Assessment\\n Level of breathing assistance: Continuous invasive ventilation\\n Visual assessment of breathing pattern: Normal quiet breathing;\\n Comments: Pt continues on PSV settings as charted; weaned on settings.\\n Assessment of breathing comfort: No claim of dyspnea\\n Plan\\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\\n Reason for continuing current ventilatory support: Cannot manage\\n secretions, Underlying illness not resolved\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2175-01-29 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 714065,\n \"text\": \"74M s/p fall with multiple rib fx, pelvis fx, clavicle fx, and thoracic\\n fx c/b unstable bleeding s/p IR embo, AF with RVR, hematologic\\n abnormalities, now with resp failure.\\n Atrial fibrillation (Afib), aflutter\\n Assessment:\\n Pt in and out of aflutter with controlled rate. Predominently\\n aflutter. Hypotensive w/ sbp 80\\ns while in aflutter.\\n Action:\\n Pt started dilt gtt 5-10mg/hr. K=3.5 and lytes repleted. Neo gtt to\\n support sbp titrated to map >60 and sbp >100\\n Propofol off due to hypotension. Pt started on low dose midaz gtt\\n along with fentanyl.\\n Response:\\n Remains on dilt now at 5mg/hr. Briefly converted to nsr and then back\\n to aflutter. Rate well controlled but remains neo dependent.\\n Tolerating sedation titrated to lowest dose to keep comfortable and\\n safe.\\n Plan:\\n Cont to monitor hemodynamics. Wean neo gtt as tolerated. Cont dilt\\n gtt. Replete lytes. ?amio bolus or if persists possible electrical\\n cardioversion. Hold off on Lasix for now.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Remains fully vented after reintubation ithis am, cmv 550x15, 50% and\\n 10 peep. Stable abg, improved p02 this afternoon. O2sat 96-98%.\\n Moderate amt thick, tenacious secretions. LS coarse, diminished.\\n Clears with sxning.\\n Action:\\n Pt maintained intubated and bronch done this am. Sxned for thick\\n secretions. BAL sent. Cont on abx for klebsiella pna. (febrile to\\n 101.8 on abx) cultures sent and pnd.\\n Response:\\n Stable abg\\ns . Cont with tenacious secretions. Cont with failure to\\n wean.\\n Plan:\\n Cont abx for pna. Pulm toilet. Maintain sedated for safety and\\n comfort. ? need for trach in future.\\n\"\n },\n {\n \"category\": \"Nutrition\",\n \"chartdate\": \"2175-01-30 00:00:00.000\",\n \"description\": \"Clinical Nutrition Note\",\n \"row_id\": 714171,\n \"text\": \"Objective\\n Height\\n Admit weight\\n Daily weight\\n Weight change\\n BMI\\n cm\\n 90 kg\\n 102 kg ( 12:00 AM)\\n Pertinent medications: fetanyl, versed, phenylephrone.normal saline,\\n heparin, IV abx, others noted\\n Labs:\\n Value\\n Date\\n Glucose\\n 132 mg/dL\\n 05:12 AM\\n Glucose Finger Stick\\n 153\\n 08:00 AM\\n BUN\\n 19 mg/dL\\n 05:12 AM\\n Creatinine\\n 0.7 mg/dL\\n 05:12 AM\\n Sodium\\n 143 mEq/L\\n 05:12 AM\\n Potassium\\n 4.0 mEq/L\\n 05:12 AM\\n Chloride\\n 108 mEq/L\\n 05:12 AM\\n TCO2\\n 32 mEq/L\\n 05:12 AM\\n PO2 (arterial)\\n 127 mm Hg\\n 01:00 AM\\n PCO2 (arterial)\\n 50 mm Hg\\n 01:00 AM\\n pH (arterial)\\n 7.44 units\\n 01:00 AM\\n pH (urine)\\n 5.0 units\\n 04:25 PM\\n CO2 (Calc) arterial\\n 35 mEq/L\\n 01:00 AM\\n Albumin\\n 2.7 g/dL\\n 12:14 AM\\n Calcium non-ionized\\n 8.2 mg/dL\\n 05:12 AM\\n Phosphorus\\n 2.8 mg/dL\\n 05:12 AM\\n Ionized Calcium\\n 1.12 mmol/L\\n 01:00 AM\\n Magnesium\\n 2.0 mg/dL\\n 05:12 AM\\n ALT\\n 90 IU/L\\n 12:45 AM\\n Alkaline Phosphate\\n 63 IU/L\\n 12:45 AM\\n AST\\n 88 IU/L\\n 12:45 AM\\n Amylase\\n 44 IU/L\\n 06:01 AM\\n Total Bilirubin\\n 6.8 mg/dL\\n 12:45 AM\\n WBC\\n 13.1 K/uL\\n 12:45 AM\\n Hgb\\n 10.7 g/dL\\n 12:45 AM\\n Hematocrit\\n 31.6 %\\n 12:45 AM\\n Current diet order / nutrition support: Replete wtih Fiber @ 80 ml/hr =\\n kcals/ 119 g protein\\n GI: soft, distended, +bowel sounds\\n Assessment of Nutritional Status\\n Specifics: 74 year old male s/p fall fromo tractor and crushed by tree\\n branch now with multiple fx. Tube feedings started on . Patient\\n tolerating tube feedings at goal which provide 100% of nutritional\\n needs.\\n Medical Nutrition Therapy Plan - Recommend the Following\\n 1. Continue with goal tube feeding\\n 2. Check chemistry 10 daily and replete prn\\n 3. Will follow page with questions\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2175-02-02 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 714590,\n \"text\": \"74M s/p crushing injury d/t falling tree. Injuries sustained include\\n multiple R sided rib fxs, grade 2 liver lac (w/ assoc hepatic vessel\\n extravasation), stable pelvis fxs (w/ associated extravasation), R\\n ramus fx, clavicle fx, and T4 vertebral body fx. Episodes of A.\\n Flutter with RVR and aflutter, now with resp failure and newly dx\\n pneumonia as of .\\n intubated for resp distress\\n angio embolization of hepatic and pelvic arterial bleeders\\n IVC filter in OR\\n self extubated and re-intubated immediately after d/t acute resp.\\n failure\\n Trach and PEG at bedside\\n Atrial fibrillation (Afib)\\n Assessment:\\n Pt converted to NSR @ 1900 w/ rate 80s-100s.\\n Action:\\n PO dilt, amioderone gtt continued\\n Neo gtt weaned off\\n Response:\\n HR & BP remain well controlled. Pt\\n :\\n Continue Amio gtt, switch to PO amio, ? Anticoagulant.\\n Monitor hemodynamics, monitor BP\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt w/ trach on CPAP/PS 10/10/50%. LS rhonchorous throughout. Strong\\n productive cough, large amounts of thick blood tinged secretions. ABG\\n stable. VSS. Low grade temps\\n Action:\\n Pulm hygiene, suction PRN\\n Ceftriaxone admistered for pna\\n Response:\\n Exam unchanged.\\n Plan:\\n Wean vent settings as tolerated, pulmonary toileting, wean\\n sedation.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2175-01-28 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 713870,\n \"text\": \"TSICU\\n HPI:\\n 74M s/p fall with multiple rib fx, pelvis fx, clavicle fx, and thoracic\\n fx c/b unstable bleeding s/p IR embo, AF with RVR, hematologic\\n abnomalities.\\n Chief complaint:\\n fall\\n PMHx:\\n none\\n Current medications:\\n 1. Acetaminophen 2. Bisacodyl 3. Chlorhexidine Gluconate 0.12% Oral\\n Rinse 4. Dextrose 50% 5. Diltiazem 6. Docusate Sodium (Liquid) 7.\\n Famotidine 8. Fentanyl Citrate 9. Fentanyl Citrate 10. Gabapentin 11.\\n Glucagon 12. Insulin 13. Magnesium Sulfate 14. Midazolam 15.\\n Ondansetron 16. Phenylephrine 17. Pneumococcal Vac Polyvalent 18.\\n Potassium Phosphate 19. Potassium Chloride 20. Propofol 21. Senna 22.\\n Sodium Chloride 0.9% Flush\\n 24 Hour Events:\\n ARTERIAL LINE - STOP 11:05 AM\\n ARTERIAL LINE - START 11:30 AM\\n Heme c/s- smear nl. Wean vent, started on po diltiazem for atrial\\n ectopy.\\n Post operative day:\\n POD#2 - IVC filter via L groin\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Fentanyl (Concentrate) - 100 mcg/hour\\n Propofol - 20 mcg/Kg/min\\n Phenylephrine - 0.3 mcg/Kg/min\\n Other ICU medications:\\n Fentanyl - 08:00 PM\\n Other medications:\\n Flowsheet Data as of 04:42 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 37.6\\nC (99.7\\n T current: 37.5\\nC (99.5\\n HR: 69 (62 - 97) bpm\\n BP: 102/51(66) {89/48(63) - 135/71(94)} mmHg\\n RR: 13 (8 - 20) insp/min\\n SPO2: 98%\\n Heart rhythm: 1st AV (First degree AV Block)\\n Wgt (current): 102 kg (admission): 90 kg\\n CVP: 15 (11 - 24) mmHg\\n Total In:\\n 2,899 mL\\n 385 mL\\n PO:\\n Tube feeding:\\n 908 mL\\n 228 mL\\n IV Fluid:\\n 1,471 mL\\n 96 mL\\n Blood products:\\n 50 mL\\n Total out:\\n 1,050 mL\\n 90 mL\\n Urine:\\n 1,050 mL\\n 90 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,849 mL\\n 295 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CPAP/PSV\\n Vt (Set): 500 (440 - 500) mL\\n Vt (Spontaneous): 495 (495 - 680) mL\\n PS : 12 cmH2O\\n RR (Set): 10\\n RR (Spontaneous): 12\\n PEEP: 12 cmH2O\\n FiO2: 40%\\n RSBI Deferred: PEEP > 10\\n PIP: 25 cmH2O\\n SPO2: 98%\\n ABG: 7.40/54/92./31/6\\n Ve: 7.2 L/min\\n PaO2 / FiO2: 232\\n Physical Examination\\n General Appearance: No acute distress\\n HEENT: PERRL\\n Cardiovascular: (Rhythm: No(t) Regular, Irregular)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\\n bilateral : )\\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\\n Left Extremities: (Edema: 3+), (Temperature: Warm)\\n Right Extremities: (Edema: 3+), (Temperature: Warm)\\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\\n Moves all extremities, Sedated\\n Labs / Radiology\\n 74 K/uL\\n 9.7 g/dL\\n 128 mg/dL\\n 0.8 mg/dL\\n 31 mEq/L\\n 3.9 mEq/L\\n 19 mg/dL\\n 108 mEq/L\\n 141 mEq/L\\n 28.7 %\\n 5.6 K/uL\\n [image002.jpg]\\n 02:16 PM\\n 05:17 PM\\n 12:14 AM\\n 12:20 AM\\n 05:24 AM\\n 06:50 AM\\n 02:40 PM\\n 03:13 PM\\n 01:59 AM\\n 02:00 AM\\n WBC\\n 11.0\\n 11.0\\n 8.0\\n 5.6\\n Hct\\n 30.6\\n 30.1\\n 29.8\\n 28.7\\n Plt\\n 99\\n 97\\n 80\\n 74\\n Creatinine\\n 0.9\\n 0.8\\n 0.8\\n TCO2\\n 34\\n 33\\n 32\\n 30\\n 33\\n 35\\n Glucose\\n 96\\n 133\\n 125\\n 128\\n Other labs: PT / PTT / INR:13.7/28.7/1.2, CK / CK-MB / Troponin\\n T:1334/13/<0.01, ALT / AST:147/126, Alk-Phos / T bili:52/2.6, Amylase /\\n Lipase:44/, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic Acid:1.4\\n mmol/L, Albumin:2.7 g/dL, LDH:435 IU/L, Ca:8.0 mg/dL, Mg:2.2 mg/dL,\\n PO4:2.8 mg/dL\\n Assessment and Plan\\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, AF with\\n RVR, hematologic abnormalities.\\n Neurologic: Intubated on Propofol gtt and Midazolam PRN (have not been\\n giving). Per ortho spine, no surgery; HOB<30, TLSO when OOB (NEOPS will\\n place).\\n Neuro checks Q: shift\\n Pain: Fentanyl 100mcg/hr, start Dilaudid, Neurontin, Tylenol\\n Cardiovascular: Now back in NSR with occasional PACs, off dilt gtt,\\n started po diltiazem 30 qid, and currently weaning Neo gtt. Fluid\\n challenge and PPV 6. Also given 25% albumin x1.\\n Pulmonary: Intubated. Pt developing early ARDS, placed on MMV. F/U on\\n bronch cx.\\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin with CT scan\\n suggesting cirrhosis - Hepatitis panel NEG. TFs advancing to goal.\\n Bowel regimen.\\n Nutrition: Tube feeding\\n Renal: Foley, monitor UOP. Cr normalized. Consider diuresis if remains\\n off Neo, goal even.\\n Hematology: Hct stable at 29-30-28.7. Plt low but stable (100's).\\n Heme onc consulted - smear nl, no further recs. H2B stopped in case\\n contributing factor. IVC filter placed.\\n Endocrine: RISS, goal BS<150.\\n Infectious Disease: WBC normal, f/u Cx - GNR in sputum and BAL, but\\n afebrile, monitor for now, WBC trending down to 5.6 today, vent support\\n decreasing; may start abx if spikes.\\n Lines / Tubes / Drains: R SC CVL (), PIV x2, Foley, L a-line\\n (), ETT\\n Wounds:\\n Imaging: CXR today\\n Fluids: none\\n Consults: Trauma (1o), Ortho Spine, Ortho trauma, Heme\\n Billing Diagnosis:\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 01:48 AM 50 mL/hour\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n Multi Lumen - 04:41 PM\\n Arterial Line - 11:30 AM\\n Prophylaxis:\\n DVT: Boots, IVC filter\\n Stress ulcer: PPI (changed from H2B)\\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\\n Comments:\\n Communication: ICU consent signed Comments:\\n Code status: Full code\\n Disposition: ICU\\n Total time spent: 32 min\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2175-01-28 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 713872,\n \"text\": \"TSICU\\n HPI:\\n 74M s/p fall with multiple rib fx, pelvis fx, clavicle fx, and thoracic\\n fx c/b unstable bleeding s/p IR embo, AF with RVR, hematologic\\n abnomalities.\\n Chief complaint:\\n fall\\n PMHx:\\n none\\n Current medications:\\n 1. Acetaminophen 2. Bisacodyl 3. Chlorhexidine Gluconate 0.12% Oral\\n Rinse 4. Dextrose 50% 5. Diltiazem 6. Docusate Sodium (Liquid) 7.\\n Famotidine 8. Fentanyl Citrate 9. Fentanyl Citrate 10. Gabapentin 11.\\n Glucagon 12. Insulin 13. Magnesium Sulfate 14. Midazolam 15.\\n Ondansetron 16. Phenylephrine 17. Pneumococcal Vac Polyvalent 18.\\n Potassium Phosphate 19. Potassium Chloride 20. Propofol 21. Senna 22.\\n Sodium Chloride 0.9% Flush\\n 24 Hour Events:\\n ARTERIAL LINE - STOP 11:05 AM\\n ARTERIAL LINE - START 11:30 AM\\n Heme c/s- smear nl. Wean vent, started on po diltiazem for atrial\\n ectopy.\\n Post operative day:\\n POD#2 - IVC filter via L groin\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Fentanyl (Concentrate) - 100 mcg/hour\\n Propofol - 20 mcg/Kg/min\\n Phenylephrine - 0.3 mcg/Kg/min\\n Other ICU medications:\\n Fentanyl - 08:00 PM\\n Other medications:\\n Flowsheet Data as of 04:42 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 37.6\\nC (99.7\\n T current: 37.5\\nC (99.5\\n HR: 69 (62 - 97) bpm\\n BP: 102/51(66) {89/48(63) - 135/71(94)} mmHg\\n RR: 13 (8 - 20) insp/min\\n SPO2: 98%\\n Heart rhythm: 1st AV (First degree AV Block)\\n Wgt (current): 102 kg (admission): 90 kg\\n CVP: 15 (11 - 24) mmHg\\n Total In:\\n 2,899 mL\\n 385 mL\\n PO:\\n Tube feeding:\\n 908 mL\\n 228 mL\\n IV Fluid:\\n 1,471 mL\\n 96 mL\\n Blood products:\\n 50 mL\\n Total out:\\n 1,050 mL\\n 90 mL\\n Urine:\\n 1,050 mL\\n 90 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,849 mL\\n 295 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CPAP/PSV\\n Vt (Set): 500 (440 - 500) mL\\n Vt (Spontaneous): 495 (495 - 680) mL\\n PS : 12 cmH2O\\n RR (Set): 10\\n RR (Spontaneous): 12\\n PEEP: 12 cmH2O\\n FiO2: 40%\\n RSBI Deferred: PEEP > 10\\n PIP: 25 cmH2O\\n SPO2: 98%\\n ABG: 7.40/54/92./31/6\\n Ve: 7.2 L/min\\n PaO2 / FiO2: 232\\n Physical Examination\\n General Appearance: No acute distress\\n HEENT: PERRL\\n Cardiovascular: (Rhythm: No(t) Regular, Irregular)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\\n bilateral : )\\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\\n Left Extremities: (Edema: 3+), (Temperature: Warm)\\n Right Extremities: (Edema: 3+), (Temperature: Warm)\\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\\n Moves all extremities, Sedated\\n Labs / Radiology\\n 74 K/uL\\n 9.7 g/dL\\n 128 mg/dL\\n 0.8 mg/dL\\n 31 mEq/L\\n 3.9 mEq/L\\n 19 mg/dL\\n 108 mEq/L\\n 141 mEq/L\\n 28.7 %\\n 5.6 K/uL\\n [image002.jpg]\\n 02:16 PM\\n 05:17 PM\\n 12:14 AM\\n 12:20 AM\\n 05:24 AM\\n 06:50 AM\\n 02:40 PM\\n 03:13 PM\\n 01:59 AM\\n 02:00 AM\\n WBC\\n 11.0\\n 11.0\\n 8.0\\n 5.6\\n Hct\\n 30.6\\n 30.1\\n 29.8\\n 28.7\\n Plt\\n 99\\n 97\\n 80\\n 74\\n Creatinine\\n 0.9\\n 0.8\\n 0.8\\n TCO2\\n 34\\n 33\\n 32\\n 30\\n 33\\n 35\\n Glucose\\n 96\\n 133\\n 125\\n 128\\n Other labs: PT / PTT / INR:13.7/28.7/1.2, CK / CK-MB / Troponin\\n T:1334/13/<0.01, ALT / AST:147/126, Alk-Phos / T bili:52/2.6, Amylase /\\n Lipase:44/, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic Acid:1.4\\n mmol/L, Albumin:2.7 g/dL, LDH:435 IU/L, Ca:8.0 mg/dL, Mg:2.2 mg/dL,\\n PO4:2.8 mg/dL\\n Assessment and Plan\\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, AF with\\n RVR, hematologic abnormalities.\\n Neurologic: Intubated on Propofol gtt and Midazolam PRN (have not been\\n giving). Per ortho spine, no surgery; HOB<30, TLSO when OOB (NEOPS will\\n place).\\n Neuro checks Q: shift\\n Pain: Fentanyl 100mcg/hr, start Dilaudid, Neurontin, Tylenol\\n Cardiovascular: Now back in NSR with occasional PACs, off dilt gtt,\\n started po diltiazem 30 qid, and currently weaning Neo gtt. Fluid\\n challenge and PPV 6. Also given 25% albumin x1.\\n Pulmonary: Intubated. Pt developing early ARDS, placed on MMV. F/U on\\n bronch cx.\\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin with CT scan\\n suggesting cirrhosis - Hepatitis panel NEG. TFs advancing to goal.\\n Bowel regimen.\\n Nutrition: Tube feeding\\n Renal: Foley, monitor UOP. Cr normalized. Consider diuresis if remains\\n off Neo, goal even.\\n Hematology: Hct stable at 29-30-28.7. Plt low but stable (100's).\\n Heme onc consulted - smear nl, no further recs. H2B stopped in case\\n contributing factor. IVC filter placed.\\n Endocrine: RISS, goal BS<150.\\n Infectious Disease: WBC normal, f/u Cx - GNR in sputum and BAL, but\\n afebrile, monitor for now, WBC trending down to 5.6 today, vent support\\n decreasing; may start abx if spikes.\\n Lines / Tubes / Drains: R SC CVL (), PIV x2, Foley, L a-line\\n (), ETT\\n Wounds:\\n Imaging: CXR today\\n Fluids: none\\n Consults: Trauma (1o), Ortho Spine, Ortho trauma, Heme\\n Billing Diagnosis:\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 01:48 AM 50 mL/hour\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n Multi Lumen - 04:41 PM\\n Arterial Line - 11:30 AM\\n Prophylaxis:\\n DVT: Boots, IVC filter\\n Stress ulcer: PPI (changed from H2B)\\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\\n Comments:\\n Communication: ICU consent signed Comments:\\n Code status: Full code\\n Disposition: ICU\\n Total time spent: 32 min\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2175-02-01 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 714415,\n \"text\": \"74M s/p crushing injury d/t falling tree. Injuries sustained include\\n multiple R sided rib fxs, grade 2 liver lac (w/ assoc hepatic vessel\\n extravasation), stable pelvis fxs (w/ associated extravasation), R\\n ramus fx, clavicle fx, and T4 vertebral body fx. Episodes of AF with\\n RVR and aflutter, hematologic abnormalities, now with resp failure and\\n newly dx pneumonia as of .\\n intubated for resp distress\\n angio embolization of hepatic and pelvic arterial bleeders\\n IVC filter in OR\\n self extubated and reintubated immediately after d/t acute resp\\n failure\\n Atrial fibrillation (Afib), aflutter\\n Assessment:\\n Pt in aflutter with controlled rate most of time, w/ stimulation HR\\n jumps to 100s-110s. weaned off neo since last evening, BP stable.\\n Action:\\n Amio drip continues, dose weaned to 0.5mg/min per 18 hr protocol.\\n Standing po dose dilt continued, lytes followed, repleted as needed.\\n Pt on low dose midaz gtt along with fentanyl for sedation.\\n Response:\\n Remains in afib despite amio infusion, rate 70s-80s when calm,\\n tachycardic when pt agitated. BP remains soft w/ sedation/pain med\\n dosing, when stimulated, BP adequate. Urine output remains brisk.\\n Tolerating sedation titrated to lowest dose to keep comfortable and\\n safe.\\n Plan:\\n Cont to monitor hemodynamics. Continue amio drip for full 18 hrs, will\\n need to be d/c\\nd 1400 unless team decides to continue. Optimize\\n lytes ongoing. Cardiology consult team following.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Weaned to cpap mode vent support yesterday, 10 psv, 50% and 10 peep.\\n Stable abg, improved p02. At rest RR mid to high 20s, when agitated,\\n increasingly tachypneic to 30s. abg wnl. Moderate amt thick,\\n yellow/white secretions. LS improving, diminished to all fields, less\\n rhonchi.\\n Action:\\n Remains intubated on cpap, signif peep. see settings above, tol well.\\n Pulm toileting per routine. Increased sedation overnoc w/ cessation of\\n ketamine study drug, pt noted to be increasingly tachypneic,\\n hyperdynamic. Midaz increased substantially, requires bolus dosing for\\n any care. Given po as well as IV drip pain meds as written to\\n potentiate benzo effect.\\n Response:\\n Abg acceptable, Pao2 improved on higher peep. LS improved as well,\\n clearer, remain diminished throughout, more so to R side. Cough\\n remains weak w/ sedation. Pt denies pain when asked, nods adamantly\\n yes to question of discomfort w/ ett w/ any stimulation at all.\\n Remains agitated w/ any physical care or stimulus.\\n Plan:\\n Cont Vanco, ceftriaxone for hflu and klebsiella pneumonia coverage,\\n Pulm toilet. Maintain sedation for safety and comfort until trach\\n placement, likely to be today.\\n Trauma, s/p\\n Assessment:\\n As above, pt s/p liver laceration and resultant angio procedure to\\n embolize several extravsating hepatic and pelvic vessels. LFTs\\n continue to be elevated, tbili from 6.8 w/ direct 5.2. INR\\n stable. Urine icteric, clear, pt jaundiced. R hip/flank/torso\\n hematoma appears larger than in previous days\\n Action:\\n Following LFTs, hct, coags. Monitor s/s bleeding, hematoma expansion\\n to R hip/flank/torso areas.\\n Response:\\n WBC 4.2, plts 104 this am, significant drops from last 24h values,\\n trauma and ICU teams aware. LFTs added on to this am\\ns labs.\\n Plan:\\n Continue to follow LFTs, coags, hct, serial belly assessments, s/s\\n further bleeding.\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2175-02-01 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 714525,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 8\\n Ideal body weight: 0 None\\n Ideal tidal volume: 0 / 0 / 0 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: Yes\\n Tube Type\\n Tracheostomy tube:\\n Type: Perc Trach\\n Manufacturer: Portex\\n Size: 8.0mm\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 25 cmH2O\\n Comments: trach placed on \\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Diminished\\n Secretions\\n Sputum color / consistency: Blood Tinged / Thin\\n Sputum source/amount: Suctioned / Scant\\n Ventilation Assessment\\n Level of breathing assistance: Continuous invasive ventilation\\n Visual assessment of breathing pattern: Normal quiet breathing\\n Assessment of breathing comfort: No response (sleeping / sedated)\\n Invasive ventilation assessment:\\n Trigger work assessment: Triggering synchronously\\n Plan\\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\\n Reason for continuing current ventilatory support: Underlying illness\\n not resolved\\n Respiratory Care Shift Procedures\\n Bedside Procedures:\\n Bedside tracheostomy (11:00)\\n Comments: uneventfull trach placement at bedside\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2175-02-01 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 714528,\n \"text\": \"74M s/p crushing injury d/t falling tree. Injuries sustained include\\n multiple R sided rib fxs, grade 2 liver lac (w/ assoc hepatic vessel\\n extravasation), stable pelvis fxs (w/ associated extravasation), R\\n ramus fx, clavicle fx, and T4 vertebral body fx. Episodes of A.\\n Flutter with RVR and aflutter, hematologic abnormalities, now with resp\\n failure and newly dx pneumonia as of .\\n intubated for resp distress\\n angio embolization of hepatic and pelvic arterial bleeders\\n IVC filter in OR\\n self extubated and re-intubated immediately after d/t acute resp.\\n failure\\n Trach and PEG at bedside\\n Atrial fibrillation (Afib)\\n Assessment:\\n Atrial flutter continues, RVR up to 130s this AM.\\n Action:\\n PO dilt, amioderone gtt continued, Neo gtt titrated for adequate BP\\n control.\\n Response:\\n Rate controlled after PO Dilt.\\n Plan:\\n Continue Amio gtt, ? Switch to PO amio, ? Cardio version,?\\n Anticoagulant.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Post trach pt back on CPAP 10/10/50%. Ls clear to diminish at bases.\\n Strong productive cough, suctioned for copious amounts of thick blood\\n tinged secretions.\\n Action:\\n Trach and PEG at bedside, continue pulmonary toileting.\\n Response:\\n Tolerated procedure without issue.\\n Plan:\\n Wean vent settings as tolerated, pulmonary toileting, wean sedation as\\n tolerated,\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2175-02-03 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 714765,\n \"text\": \"TSICU\\n HPI:\\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\\n checked and 1.5, 1 more unit FFP given.\\n Chief complaint:\\n PMHx:\\n Current medications:\\n Acetaminophen 4. Amiodarone 5. Bisacodyl 6. Calcium Gluconate 7.\\n CefePIME 8. CefePIME\\n 9. Chlorhexidine Gluconate 0.12% Oral Rinse 10. Ciprofloxacin HCl 11.\\n Dextrose 50% 12. Docusate Sodium (Liquid)\\n 13. Fentanyl Citrate 14. Furosemide 15. Furosemide 16. Furosemide 17.\\n Gabapentin 18. Glucagon 19. Heparin\\n 20. Insulin 21. Lactulose 22. Lansoprazole Oral Disintegrating Tab 23.\\n Lorazepam 24. Magnesium Sulfate\\n 25. Metoprolol Tartrate 26. Metoprolol Tartrate 27. Midazolam 28.\\n Midazolam 29. Milk of Magnesia\\n 30. Olanzapine (Disintegrating Tablet) 31. Ondansetron 32. OxycoDONE\\n Liquid 33. Phenylephrine 34. Pneumococcal Vac Polyvalent\\n 35. Potassium Phosphate 36. Potassium Chloride 37. Senna 38. Sodium\\n Chloride 0.9% Flush 39. Sodium Chloride 0.9% Flush\\n 40. Vancomycin 41. Vancomycin\\n 24 Hour Events:\\n EKG - At 09:07 PM\\n FEVER - 101.1\\nF - 12:00 AM\\n : TFs increased. Lasix 10x3 with good result. Zyprexa for\\n sedation, weaned off versed, fentanyl. Cards rec 400'' x 1wk, then\\n 400'x1 wk, then 200'. also rec changing dilt to metop succinate 25''.\\n Vanc/cipro/cefepime for VAP.\\n : pan cx for temp 101.1\\n Post operative day:\\n POD#8 - IVC filter via L groin\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Ceftriaxone - 03:00 PM\\n Ciprofloxacin - 12:00 PM\\n Vancomycin - 07:33 PM\\n Cefipime - 11:15 PM\\n Infusions:\\n Other ICU medications:\\n Lansoprazole (Prevacid) - 02:00 PM\\n Lorazepam (Ativan) - 11:41 PM\\n Midazolam (Versed) - 02:16 AM\\n Furosemide (Lasix) - 03:55 AM\\n Heparin Sodium (Prophylaxis) - 04:02 AM\\n Metoprolol - 06:27 AM\\n Other medications:\\n Flowsheet Data as of 08:02 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 38.4\\nC (101.1\\n T current: 37.7\\nC (99.8\\n HR: 97 (81 - 111) bpm\\n BP: 160/81(110) {111/59(80) - 166/81(110)} mmHg\\n RR: 30 (17 - 30) insp/min\\n SPO2: 99%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 104.2 kg (admission): 90 kg\\n CVP: 19 (12 - 26) mmHg\\n Total In:\\n 2,674 mL\\n 727 mL\\n PO:\\n Tube feeding:\\n 660 mL\\n 637 mL\\n IV Fluid:\\n 895 mL\\n 90 mL\\n Blood products:\\n Total out:\\n 2,485 mL\\n 1,055 mL\\n Urine:\\n 2,485 mL\\n 1,055 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 189 mL\\n -328 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 510 (502 - 660) mL\\n PS : 12 cmH2O\\n RR (Spontaneous): 28\\n PEEP: 10 cmH2O\\n FiO2: 50%\\n RSBI Deferred: PEEP > 10\\n PIP: 28 cmH2O\\n SPO2: 99%\\n ABG: 7.50/43/150/31/9\\n Ve: 11.8 L/min\\n PaO2 / FiO2: 300\\n Physical Examination\\n General Appearance: Anxious, Well nourished\\n HEENT: PERRL, EOMI\\n Cardiovascular: (Rhythm: Regular)\\n Respiratory / Chest: (Breath Sounds: Crackles : , Rhonchorous : ,\\n Diminished: )\\n Abdominal: Soft, Distended\\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\\n pedis: Present)\\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\\n pedis: Present)\\n Skin: (Incision: Clean / Dry / Intact)\\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\\n Moves all extremities\\n Labs / Radiology\\n 128 K/uL\\n 9.3 g/dL\\n 138 mg/dL\\n 0.8 mg/dL\\n 31 mEq/L\\n 3.8 mEq/L\\n 23 mg/dL\\n 105 mEq/L\\n 142 mEq/L\\n 28.9 %\\n 6.3 K/uL\\n [image002.jpg]\\n 02:00 PM\\n 05:04 PM\\n 08:00 PM\\n 09:20 PM\\n 01:00 AM\\n 01:07 AM\\n 01:18 AM\\n 02:05 AM\\n 03:54 AM\\n 05:17 AM\\n WBC\\n 5.9\\n 6.3\\n Hct\\n 31.3\\n 28.9\\n Plt\\n 109\\n 128\\n Creatinine\\n 0.8\\n 0.8\\n TCO2\\n 36\\n 34\\n 35\\n 34\\n 35\\n Glucose\\n 111\\n 105\\n 117\\n 110\\n 138\\n Other labs: PT / PTT / INR:13.7/27.6/1.2, CK / CK-MB / Troponin\\n T:128/13/<0.01, ALT / AST:90/122, Alk-Phos / T bili:133/5.4, Amylase /\\n Lipase:54/52, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic\\n Acid:1.4 mmol/L, Albumin:2.3 g/dL, LDH:348 IU/L, Ca:8.0 mg/dL, Mg:2.2\\n mg/dL, PO4:2.8 mg/dL\\n Imaging: CT head OSH: Prelim No ICH or fx.\\n CT chest OSH: Mult rib fx: R anterolateral and posterior, L\\n posterior; Dependent consolidation, possible aspiration; T4 vertebral\\n body inf corner fx, no retropulsion; Comminuted spinous process fx\\n T2-8; Nondisplaced L T10 transverse process; Nondisplaced L clavicle\\n distal fx; Nondisplaced L scapula fx;\\n CT c spine OSH: Prelim No fx or malalignment. Multilevel\\n degenerative changes w/large post disk bulge at C4-5, narrowing the\\n spinal canal and deforming the thecal sac, acuity unknown. Marked\\n neuroforamenal narrowing @multiple levels.\\n CTA abd/pel Prelim: Medial R liver lobe contusion w/adj\\n hematoma, w/o evidence of active bleeding; Comminuted L pubic ramus\\n fracture w/assoc hematoma, with tiny focus of arterial bleeding/active\\n extravasation, and larger area of venous bleeding. Hematoma somewhat\\n larger than on OSH study. Nondisplaced, comminuted L iliac bone fx\\n w/adj iliac muscle hematoma, larger than on prior study, w/o active\\n extrav. Fx extends into L SIJ. Post R hepatic laceration/contusion\\n adjacent to calcified granuloma, w/small hematoma, w/out active\\n bleeding. Min displaced fx of R iliac bone extending to R SIJ.\\n Cirrhotic liver. Inc B pl effusions (small), w/inc atelectasis.\\n MRI: Mild compression deformity of L1 w/additional levels of\\n potential trabecular contusion @T10-11 also inf @T4 w/o retropulsion.\\n Multilevel degenerative changes w/moderate canal narrowing @T10-11\\n w/cord deformity & no abnl cord signal. Extensive edema throughout\\n paraspinal soft tissues, predominantly post w/in interspinous\\n ligaments. Incompletely eval'ed c-spine w/severe canal narrowing @C4-5\\n w/cord deformity and no abn cord signal.\\n CTA: no PE.\\n CXR: Moderate b/l pleural effusions are stable.\\n CXR: Cardiac size top nl, interval improvement of collapse LLL.\\n Collapse RLL. Atelectasis in lingula unchanged. Mod B pleural effusions\\n stable. No PTX.\\n CXR: Interval mild incr in cardiac size, b/l pl effusions,\\n & opacities @ bases,c/w overload\\n : R foot: Linear density projecting @ expected area of insertion\\n of Achilles to calcaneus, may be min avulsion fx or degenerative\\n changes. Otherwise no fx\\n CXR: b/l pl effusions\\n CXR: stable.\\n RUQ U/S: No perihepatic fluid collection. small amt perihepatic\\n free fluid persists. Small contusion in hepatic segment VII. No\\n gallstones or sig wall thickening/edema. CBD 4.5 mm\\n TTE: LVEF >55%, NL diastolic function, NL LV filling pressure\\n (PCWP<12mmHg), RV chamber size mildly dilated, mild TR\\n CXR: mild b/l pulm edema and parenchymal opacities and no\\n pl effusion.\\n CXR: Persistent b/l pl effusions and bibasilar opacity.\\n CXR: Minimal improvement of mod b/l pl effusions. Otherwise\\n stable.\\n Microbiology: Ucx no growth final\\n Sputum: sparse GNRs, too few to colonize\\n Bcx x2 no growth final\\n 12/17 L BAL: Klebsiella Pneumoniae, HAEMOPHILUS SPECIES NOT INFLUENZAE\\n R BAL: Klebsiella Pneumoniae, Proteus.\\n 12/20 L &R BAL: Klebsiella Pneumoniae\\n BCX: p\\n BCx: P\\n UCx: no growth final\\n BCx: P\\n BCx: P\\n UCx: P\\n SpCx: P\\n Assessment and Plan\\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, now\\n with AF with RVR/Aflutter, persistant hypotension and PNA.\\n Neurologic: s/p trach (). Per ortho spine, no surgery; HOB<30,\\n TLSO when OOB. Zyprexa & Ativan PRN (off fent/midaz ).\\n Neuro checks Q: shift\\n Pain: Oxycodone, Neurontin, Tylenol.\\n Cardiovascular: Aflutter, now reverted to sinus w/1st deg AVB. Likely\\n cardiac contusion. Cards rec 400'' x 1wk, then 400'x1 wk, then\\n 200'. also rec changing dilt to metop 25''. Pt cannot be fully\\n anticoagulated for now (trauma).\\n Pulmonary: Intubated, weaning, Vanc/cipro/cefepime for VAP ().\\n Increasing pulmonary edema on CXR (lasix x 2 on , lasix x1 ).\\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin (declining 6.8\\n max ->5.0) w/CT scan suggesting cirrhosis - Hepatitis panel NEG. TFs\\n restarted, increasing to goal . Bowel regimen.\\n Nutrition: Tube feeding\\n Renal: Foley, monitor UOP, edematous scrotum. Lasix 10 x2 on ,\\n lasix x1 .\\n Hematology: Hct stable 32.1->29.7. Plt stable (100's); d/c'd H2B. Heme\\n onc c/s - smear nl; no hemolysis. IVC filter placed.\\n Endocrine: RISS\\n Infectious Disease: Check cultures, WBC droppping\\n 13.1->8.8->4.2->5.9->6.3, Vanc/cipro/cefepime for VAP given worsening\\n pulm status\\n Lines / Tubes / Drains: Trach/Peg/foley/L radial a-line/R SCL\\n Wounds:\\n Imaging: CXR today\\n Fluids: KVO\\n Consults: Trauma (1o), Ortho Spine, Ortho trauma, Heme\\n Billing Diagnosis: (Respiratory distress: Failure), (Shock: Traumatic),\\n Multiple injuries (Trauma)\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 04:12 AM 80 mL/hour\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n Multi Lumen - 04:41 PM\\n Arterial Line - 11:30 AM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin\\n Stress ulcer: PPI\\n VAP bundle: HOB elevation, Mouth care\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds , Family\\n meeting planning, ICU consent signed Comments:\\n Code status: Full code\\n Disposition: ICU\\n Total time spent: 33 minutes\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2175-01-29 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 714050,\n \"text\": \"Demographics\\n Day of mechanical ventilation: 5\\n Airway\\n Airway Placement Data\\n Known difficult intubation: No\\n Tube Type\\n ETT:\\n Route: Oral\\n Type: Standard\\n Size: 7.5mm\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 25 cmH2O\\n Lung sounds\\n RLL Lung Sounds: Crackles\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Crackles\\n Secretions\\n Sputum color / consistency: White / Thick\\n Sputum source/amount: Suctioned / Moderate\\n Ventilation Assessment\\n Level of breathing assistance: Continuous invasive ventilation\\n Visual assessment of breathing pattern: Normal quiet breathing\\n Assessment of breathing comfort: No response (sleeping / sedated)\\n Invasive ventilation assessment:\\n Trigger work assessment: Triggering synchronously\\n Plan\\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\\n Reason for continuing current ventilatory support: Cannot protect\\n airway, Underlying illness not resolved\\n Respiratory Care Shift Procedures\\n Bedside Procedures:\\n Bronchoscopy (1000)\\n Comments: BAL collected & sent.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2175-01-30 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 714145,\n \"text\": \"TSICU\\n HPI:\\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\\n checked and 1.5, 1 more unit FFP given.\\n Chief complaint:\\n Mult rib fx: R anterolateral and post, L posterior\\n T4 vert body inf corner fx\\n Commin spinous process fx T2-8\\n Nondisplaced L T10 transverse process\\n Nondispaced L distal clavicle\\n Nondisplaced L clavicle fx\\n R medial lobe liver contusion w/hematoma\\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny focus of arterial\\n bleeding/active extravasation, and larger area of venous bleeding\\n Nondisplaced, comminuted L iliac bone fx w/adjacent iliac muscle\\n hematoma, extends into L SIJ.\\n Minimally displaced fx of R iliac bone extending to R SIJ.\\n PMHx:\\n None\\n Current medications:\\n Chlorhexidine Gluconate 0.12% Oral Rinse\\n Diltiazem\\n Furosemide\\n Gabapentin\\n Metoprolol Tartrate\\n Ondansetron\\n Phenylephrine\\n 24 Hour Events:\\n Self-extubated in the AM, re-intubated over bougie, NGT replaced,\\n bronch with bilateral BALs sent, plan for trach later this week. T\\n spike to 101.8 - u/a, urine cx, blood cxs sent. Diltiazem titrated to\\n 60mg PO QID. ABX coverage broadened to Vanc/Zosyn. Tbili up to 6.8\\n (other LFTs trending down)\\n Post operative day:\\n POD#4 - IVC filter via L groin\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Ceftriaxone - 11:00 AM\\n Piperacillin/Tazobactam (Zosyn) - 08:19 PM\\n Vancomycin - 08:56 PM\\n Infusions:\\n Fentanyl (Concentrate) - 100 mcg/hour\\n Midazolam (Versed) - 1 mg/hour\\n Other ICU medications:\\n Hydromorphone (Dilaudid) - 04:00 AM\\n Metoprolol - 06:33 AM\\n Pantoprazole (Protonix) - 02:00 PM\\n Midazolam (Versed) - 12:30 AM\\n Other medications:\\n Flowsheet Data as of 02:07 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 38.8\\nC (101.8\\n T current: 37.2\\nC (98.9\\n HR: 76 (76 - 103) bpm\\n BP: 97/51(67) {86/47(62) - 121/858(84)} mmHg\\n RR: 18 (0 - 25) insp/min\\n SPO2: 99%\\n Heart rhythm: A Flut (Atrial Flutter)\\n Wgt (current): 102 kg (admission): 90 kg\\n CVP: 11 (6 - 18) mmHg\\n Total In:\\n 3,114 mL\\n 207 mL\\n PO:\\n Tube feeding:\\n 1,301 mL\\n 148 mL\\n IV Fluid:\\n 1,682 mL\\n 59 mL\\n Blood products:\\n Total out:\\n 2,500 mL\\n 180 mL\\n Urine:\\n 2,500 mL\\n 180 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 614 mL\\n 27 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 550 (550 - 550) mL\\n Vt (Spontaneous): 540 (540 - 540) mL\\n PS : 5 cmH2O\\n RR (Set): 15\\n RR (Spontaneous): 0\\n PEEP: 10 cmH2O\\n FiO2: 50%\\n RSBI: 34\\n PIP: 26 cmH2O\\n Plateau: 23 cmH2O\\n Compliance: 42.3 cmH2O/mL\\n SPO2: 99%\\n ABG: 7.44/50/127/34/8\\n Ve: 9.5 L/min\\n PaO2 / FiO2: 254\\n Physical Examination\\n General Appearance: No acute distress\\n HEENT: PERRL\\n Cardiovascular: Aflutter\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\\n Rhonchorous : )\\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present,\\n Stable scrotal edema/hematoma, soft, no crepitus\\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\\n Neurologic: Follows simple commands, Moves all extremities, Sedated\\n Labs / Radiology\\n 158 K/uL\\n 10.7 g/dL\\n 115 mg/dL\\n 0.8 mg/dL\\n 34 mEq/L\\n 4.0 mEq/L\\n 20 mg/dL\\n 111 mEq/L\\n 148 mEq/L\\n 31.6 %\\n 13.1 K/uL\\n [image002.jpg]\\n 01:59 AM\\n 02:00 AM\\n 11:04 AM\\n 01:17 PM\\n 02:55 AM\\n 04:11 AM\\n 09:45 AM\\n 04:45 PM\\n 12:45 AM\\n 01:00 AM\\n WBC\\n 5.6\\n 6.5\\n 13.1\\n Hct\\n 28.7\\n 29.3\\n 31.6\\n Plt\\n 74\\n 86\\n 158\\n Creatinine\\n 0.8\\n 0.8\\n 0.8\\n TCO2\\n 35\\n 34\\n 34\\n 38\\n 37\\n 35\\n 35\\n Glucose\\n 125\\n 128\\n 141\\n 107\\n 131\\n 115\\n Other labs: PT / PTT / INR:13.9/26.9/1.2, CK / CK-MB / Troponin\\n T:1334/13/<0.01, ALT / AST:90/88, Alk-Phos / T bili:63/6.8, Amylase /\\n Lipase:44/, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic Acid:1.2\\n mmol/L, Albumin:2.7 g/dL, LDH:348 IU/L, Ca:8.4 mg/dL, Mg:2.1 mg/dL,\\n PO4:2.9 mg/dL\\n Imaging: CT head OSH: Prelim No ICH or fx.\\n CT chest OSH: Mult rib fx: R anterolateral and posterior, L\\n posterior; Dependent consolidation, possible aspiration; T4 vertebral\\n body inf corner fx, no retropulsion; Comminuted spinous process fx\\n T2-8; Nondisplaced L T10 transverse process; Nondisplaced L clavicle\\n distal fx; Nondisplaced L scapula fx;\\n CT c spine OSH: Prelim No fx or malalignment. Multilevel\\n degenerative changes w/large post disk bulge at C4-5, narrowing the\\n spinal canal and deforming the thecal sac, acuity unknown. Marked\\n neuroforamenal narrowing @multiple levels.\\n CTA abd/pel Prelim: Medial R liver lobe contusion w/adj\\n hematoma, w/o evidence of active bleeding; Comminuted L pubic ramus\\n fracture w/assoc hematoma, with tiny focus of arterial bleeding/active\\n extravasation, and larger area of venous bleeding. Hematoma somewhat\\n larger than on OSH study. Nondisplaced, comminuted L iliac bone fx\\n w/adj iliac muscle hematoma, larger than on prior study, w/o active\\n extrav. Fx extends into L SIJ. Post R hepatic laceration/contusion\\n adjacent to calcified granuloma, w/small hematoma, w/out active\\n bleeding. Min displaced fx of R iliac bone extending to R SIJ.\\n Cirrhotic liver. Inc B pl effusions (small), w/inc atelectasis.\\n MRI: Mild compression deformity of L1 w/additional levels of\\n potential trabecular contusion @T10-11 also inf @T4 w/o retropulsion.\\n Multilevel degenerative changes with moderate canal narrowing at T10-11\\n w/cord deformity and no abnormal cord signal. Extensive edema\\n throughout paraspinal soft tissues, predominantly post w/in\\n interspinous ligaments. Incompletely eval'ed c-spine w/severe canal\\n narrowing @C4-5 w/cord deformity and no abnormal cord signal.\\n CTA: no PE.\\n CXR: Moderate bilateral pleural effusions are stable.\\n CXR: Cardiac size top nl, interval improvement of collapse LLL.\\n Collapse RLL. Atelectasis in lingula unchanged. Mod B\\n pleural effusions stable. No PTX.\\n CXR: Interval mild incr in cardiac size, b/l pleural effusions,\\n and opacities @ bases,c/w overload\\n : R foot: Linear density projecting @ expected area of insertion\\n of the Achilles to calcaneus, may be min avulsion fx or degenerative\\n changes. Otherwise no fx\\n CXR: bilateral pleural effusions\\n Microbiology: Ucx no growth final\\n Sputum: sparse GNR\\n Bcx P\\n Bcx P\\n 12/17 L BAL: KLEBSIELLA PNEUMONIAE, HAEMOPHILUS SPECIES NOT INFLUENZAE\\n R BAL: KLEBSIELLA PNEUMONIAE & GNRs.\\n 12/20 L BAL: gram + cocci pairs on gram stain\\n R BAL: gram + cocci pairs on gram stain\\n Assessment and Plan\\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, AF with\\n RVR, hematologic abnomalities.\\n Neurologic: Intubated on Fentanyl/Versed gtt. Per ortho spine, no\\n surgery; HOB<30, TLSO when OOB (NEOPS will place). Neuro checks q\\n shift.\\n Cardiovascular: Aflutter on Dilt 60mg PO QID. Still on Neo. Likely\\n needs chemical/electrical cardioversion to improve atrial contribution\\n to CO\\n Pulmonary: Intubated. Weaning to extubate (was on throughout\\n , changed to 10/10 after desat, but self-extubated and reintubated\\n am). F/U on BAL: KLEBSIELLA PNEUMONIAE & GNRs/Haemophilus. Repeat\\n BAL with gram+ cocci in pairs on gram stain. Ceftriaxone ()\\n changed to Vancomycin/Zosyn (). Plan for Trach early this week.\\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin with CT scan\\n suggesting cirrhosis - Hepatitis panel NEG. TFs advancing to goal.\\n Bowel regimen. Tbili trending up (6.8), other LFTs improving.\\n Nutrition: Tube feeding\\n Renal: Foley, Adequate UO, Foley, monitor UOP. Cr normalized.\\n Hematology: Hct and Plt stable; d/c'd H2B\\n Endocrine: RISS\\n Infectious Disease: WBC increasing to 13.1, f/u Cx - BAL: Klebsiella\\n (b/l)& GNRs (on R)/Haemophilus (on L). Started Ceftriaxone (),\\n broadened to Zosyn/Vanc () for continued fevers and gram+ on BAL\\n Lines / Tubes / Drains: R SC CVL (), PIV x2, Foley, L a-line\\n (), ETT\\n Wounds:\\n Imaging: CXR today\\n Fluids: KVO\\n Consults: Trauma surgery, Ortho, Ortho-spine, Heme\\n Billing Diagnosis:\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 01:00 PM 80 mL/hour\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n Multi Lumen - 04:41 PM\\n Arterial Line - 11:30 AM\\n Prophylaxis:\\n DVT: (IVC filter, SCDs)\\n Stress ulcer: PPI\\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition: ICU\\n Total time spent:\\n\"\n },\n {\n \"category\": \"General\",\n \"chartdate\": \"2175-01-30 00:00:00.000\",\n \"description\": \"Generic Note\",\n \"row_id\": 714146,\n \"text\": \"TITLE:\\n TSICU\\n HPI:\\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\\n checked and 1.5, 1 more unit FFP given.\\n Chief complaint:\\n Mult rib fx: R anterolateral and post, L posterior\\n T4 vert body inf corner fx\\n Commin spinous process fx T2-8\\n Nondisplaced L T10 transverse process\\n Nondispaced L distal clavicle\\n Nondisplaced L clavicle fx\\n R medial lobe liver contusion w/hematoma\\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny focus of arterial\\n bleeding/active extravasation, and larger area of venous bleeding\\n Nondisplaced, comminuted L iliac bone fx w/adjacent iliac muscle\\n hematoma, extends into L SIJ.\\n Minimally displaced fx of R iliac bone extending to R SIJ.\\n PMHx:\\n None\\n Current medications:\\n Chlorhexidine Gluconate 0.12% Oral Rinse\\n Diltiazem\\n Furosemide\\n Gabapentin\\n Metoprolol Tartrate\\n Ondansetron\\n Phenylephrine\\n 24 Hour Events:\\n Self-extubated in the AM, re-intubated over bougie, NGT replaced,\\n bronch with bilateral BALs sent, plan for trach later this week. T\\n spike to 101.8 - u/a, urine cx, blood cxs sent. Diltiazem titrated to\\n 60mg PO QID. ABX coverage broadened to Vanc/Zosyn. Tbili up to 6.8\\n (other LFTs trending down)\\n Post operative day:\\n POD#4 - IVC filter via L groin\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Ceftriaxone - 11:00 AM\\n Piperacillin/Tazobactam (Zosyn) - 08:19 PM\\n Vancomycin - 08:56 PM\\n Infusions:\\n Fentanyl (Concentrate) - 100 mcg/hour\\n Midazolam (Versed) - 1 mg/hour\\n Other ICU medications:\\n Hydromorphone (Dilaudid) - 04:00 AM\\n Metoprolol - 06:33 AM\\n Pantoprazole (Protonix) - 02:00 PM\\n Midazolam (Versed) - 12:30 AM\\n Other medications:\\n Flowsheet Data as of 02:07 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 38.8\\nC (101.8\\n T current: 37.2\\nC (98.9\\n HR: 76 (76 - 103) bpm\\n BP: 97/51(67) {86/47(62) - 121/858(84)} mmHg\\n RR: 18 (0 - 25) insp/min\\n SPO2: 99%\\n Heart rhythm: A Flut (Atrial Flutter)\\n Wgt (current): 102 kg (admission): 90 kg\\n CVP: 11 (6 - 18) mmHg\\n Total In:\\n 3,114 mL\\n 207 mL\\n PO:\\n Tube feeding:\\n 1,301 mL\\n 148 mL\\n IV Fluid:\\n 1,682 mL\\n 59 mL\\n Blood products:\\n Total out:\\n 2,500 mL\\n 180 mL\\n Urine:\\n 2,500 mL\\n 180 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 614 mL\\n 27 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 550 (550 - 550) mL\\n Vt (Spontaneous): 540 (540 - 540) mL\\n PS : 5 cmH2O\\n RR (Set): 15\\n RR (Spontaneous): 0\\n PEEP: 10 cmH2O\\n FiO2: 50%\\n RSBI: 34\\n PIP: 26 cmH2O\\n Plateau: 23 cmH2O\\n Compliance: 42.3 cmH2O/mL\\n SPO2: 99%\\n ABG: 7.44/50/127/34/8\\n Ve: 9.5 L/min\\n PaO2 / FiO2: 254\\n Physical Examination\\n General Appearance: No acute distress\\n HEENT: PERRL\\n Cardiovascular: Aflutter\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\\n Rhonchorous : )\\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present,\\n Stable scrotal edema/hematoma, soft, no crepitus\\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\\n Neurologic: Follows simple commands, Moves all extremities, Sedated\\n Labs / Radiology\\n 158 K/uL\\n 10.7 g/dL\\n 115 mg/dL\\n 0.8 mg/dL\\n 34 mEq/L\\n 4.0 mEq/L\\n 20 mg/dL\\n 111 mEq/L\\n 148 mEq/L\\n 31.6 %\\n 13.1 K/uL\\n [image002.jpg]\\n 01:59 AM\\n 02:00 AM\\n 11:04 AM\\n 01:17 PM\\n 02:55 AM\\n 04:11 AM\\n 09:45 AM\\n 04:45 PM\\n 12:45 AM\\n 01:00 AM\\n WBC\\n 5.6\\n 6.5\\n 13.1\\n Hct\\n 28.7\\n 29.3\\n 31.6\\n Plt\\n 74\\n 86\\n 158\\n Creatinine\\n 0.8\\n 0.8\\n 0.8\\n TCO2\\n 35\\n 34\\n 34\\n 38\\n 37\\n 35\\n 35\\n Glucose\\n 125\\n 128\\n 141\\n 107\\n 131\\n 115\\n Other labs: PT / PTT / INR:13.9/26.9/1.2, CK / CK-MB / Troponin\\n T:1334/13/<0.01, ALT / AST:90/88, Alk-Phos / T bili:63/6.8, Amylase /\\n Lipase:44/, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic Acid:1.2\\n mmol/L, Albumin:2.7 g/dL, LDH:348 IU/L, Ca:8.4 mg/dL, Mg:2.1 mg/dL,\\n PO4:2.9 mg/dL\\n Imaging: CT head OSH: Prelim No ICH or fx.\\n CT chest OSH: Mult rib fx: R anterolateral and posterior, L\\n posterior; Dependent consolidation, possible aspiration; T4 vertebral\\n body inf corner fx, no retropulsion; Comminuted spinous process fx\\n T2-8; Nondisplaced L T10 transverse process; Nondisplaced L clavicle\\n distal fx; Nondisplaced L scapula fx;\\n CT c spine OSH: Prelim No fx or malalignment. Multilevel\\n degenerative changes w/large post disk bulge at C4-5, narrowing the\\n spinal canal and deforming the thecal sac, acuity unknown. Marked\\n neuroforamenal narrowing @multiple levels.\\n CTA abd/pel Prelim: Medial R liver lobe contusion w/adj\\n hematoma, w/o evidence of active bleeding; Comminuted L pubic ramus\\n fracture w/assoc hematoma, with tiny focus of arterial bleeding/active\\n extravasation, and larger area of venous bleeding. Hematoma somewhat\\n larger than on OSH study. Nondisplaced, comminuted L iliac bone fx\\n w/adj iliac muscle hematoma, larger than on prior study, w/o active\\n extrav. Fx extends into L SIJ. Post R hepatic laceration/contusion\\n adjacent to calcified granuloma, w/small hematoma, w/out active\\n bleeding. Min displaced fx of R iliac bone extending to R SIJ.\\n Cirrhotic liver. Inc B pl effusions (small), w/inc atelectasis.\\n MRI: Mild compression deformity of L1 w/additional levels of\\n potential trabecular contusion @T10-11 also inf @T4 w/o retropulsion.\\n Multilevel degenerative changes with moderate canal narrowing at T10-11\\n w/cord deformity and no abnormal cord signal. Extensive edema\\n throughout paraspinal soft tissues, predominantly post w/in\\n interspinous ligaments. Incompletely eval'ed c-spine w/severe canal\\n narrowing @C4-5 w/cord deformity and no abnormal cord signal.\\n CTA: no PE.\\n CXR: Moderate bilateral pleural effusions are stable.\\n CXR: Cardiac size top nl, interval improvement of collapse LLL.\\n Collapse RLL. Atelectasis in lingula unchanged. Mod B\\n pleural effusions stable. No PTX.\\n CXR: Interval mild incr in cardiac size, b/l pleural effusions,\\n and opacities @ bases,c/w overload\\n : R foot: Linear density projecting @ expected area of insertion\\n of the Achilles to calcaneus, may be min avulsion fx or degenerative\\n changes. Otherwise no fx\\n CXR: bilateral pleural effusions\\n Microbiology: Ucx no growth final\\n Sputum: sparse GNR\\n Bcx P\\n Bcx P\\n 12/17 L BAL: KLEBSIELLA PNEUMONIAE, HAEMOPHILUS SPECIES NOT INFLUENZAE\\n R BAL: KLEBSIELLA PNEUMONIAE & GNRs.\\n 12/20 L BAL: gram + cocci pairs on gram stain\\n R BAL: gram + cocci pairs on gram stain\\n Assessment and Plan\\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, AF with\\n RVR, hematologic abnomalities.\\n Neurologic: Intubated on Fentanyl/Versed gtt. Per ortho spine, no\\n surgery; HOB<30, TLSO when OOB (NEOPS will place). Neuro checks q\\n shift.\\n Cardiovascular: Aflutter on Dilt 60mg PO QID. Still on Neo (was off\\n Neof or a time while in NSR). Likely needs chemical/electrical\\n cardioversion to improve atrial contribution to CO. Repeat TTE today to\\n evaluate function while in flutter.\\n Pulmonary: Intubated. Weaning to extubate (was on throughout\\n , changed to 10/10 after desat, but self-extubated and reintubated\\n am). F/U on BAL: KLEBSIELLA PNEUMONIAE & GNRs/Haemophilus. Repeat\\n BAL with gram+ cocci in pairs on gram stain. Ceftriaxone ()\\n changed to Vancomycin/Zosyn (). Plan for Trach early this week.\\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin with CT scan\\n suggesting cirrhosis - Hepatitis panel NEG. TFs advancing to goal.\\n Bowel regimen. Tbili trending up (6.8), other LFTs improving. Obtain\\n RUQ U/S today to evaluate for acalculous cholecystitis as well as bile\\n leak given recent trauma. Plan for PEG this week.\\n Nutrition: Tube feeding at goal.\\n Renal: Foley, Adequate UO, monitor UOP. Cr normalized.\\n Hematology: Hct and Plt stable; d/c'd H2B. F/u Heme recs.\\n Endocrine: RISS, goa,l BS<150, adequate control.\\n Infectious Disease: WBC increasing to 13.1, f/u Cx - BAL: Klebsiella\\n (b/l)& GNRs (on R)/Haemophilus (on L). Started Ceftriaxone (),\\n broadened to Zosyn/Vanc () for continued fevers and gram+ on BAL.\\n Will add cipor for additional antipseudomonal coverage if deteriorates\\n clinically.\\n Lines / Tubes / Drains: R SC CVL (), PIV x2, Foley, L a-line\\n (), ETT\\n Wounds:\\n Imaging: CXR today\\n Fluids: KVO\\n Consults: Trauma surgery, Ortho, Ortho-spine, Heme\\n Billing Diagnosis:\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 01:00 PM 80 mL/hour\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n Multi Lumen - 04:41 PM\\n Arterial Line - 11:30 AM\\n Prophylaxis:\\n DVT: (IVC filter, SCDs); start heparin sq\\n Stress ulcer: PPI\\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition: ICU\\n Total time spent: 35 mins\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2175-01-31 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 714239,\n \"text\": \"TSICU\\n HPI:\\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\\n checked and 1.5, 1 more unit FFP given.\\n Chief complaint:\\n Mult rib fx: R anterolateral and post, L posterior\\n T4 vert body inf corner fx\\n Commin spinous process fx T2-8\\n Nondisplaced L T10 transverse process\\n Nondispaced L distal clavicle\\n Nondisplaced L clavicle fx\\n R medial lobe liver contusion w/hematoma\\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny focus of arterial\\n bleeding/active extravasation, and larger area of venous bleeding\\n Nondisplaced, comminuted L iliac bone fx w/adjacent iliac muscle\\n hematoma, extends into L SIJ.\\n Minimally displaced fx of R iliac bone extending to R SIJ.\\n PMHx:\\n PMH: None\\n PSH: None\\n Current medications:\\n 1. IV access: Peripheral line Order date: @ 2329 16. Ketamine\\n Study Drug Study Med 1 dose IV AS SIR Duration: 24 Hours\\n Patient to receive Ketamine/Placebo 0.25mg/kg bolus over 1 hour\\n followed by 0.1mg/kg/hr for 23 hours Order date: @ 1338\\n 2. Acetaminophen 650 mg PO/NG Q6H:PRN pain Order date: @ 2329\\n 17. Lorazepam 2mg Syringe Study Med 1 mg IV Q6H Duration: 4 Doses\\n Patient to receive Lorazepam 1mg iv every 6 hours for 4 doses while on\\n ketamine study drug Order date: @ 1338\\n 3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation Order date: @\\n 0823 18. Magnesium Sulfate IV Sliding Scale Order date: @ 2339\\n 4. Calcium Gluconate IV Sliding Scale Order date: @ 1657 19.\\n Metoprolol Tartrate 5 mg IV Q4H:PRN hr>90, SBP>150\\n hold hr<60, SBP<100 Order date: @ 1809\\n 5. CeftriaXONE 1 gm IV Q24H Order date: @ 1228 20. Midazolam\\n 0.5-1 mg IV Q2H:PRN sedation Order date: @ 0912\\n 6. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL Order date:\\n @ 2329 21. Midazolam 0.5-10 mg/hr IV DRIP TITRATE TO sedation\\n Patient must have adequate airway support prior to administration of\\n dose. Order date: @ 0734\\n 7. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date: \\n @ 0104 22. Ondansetron 4 mg IV Q8H:PRN nausea Order date: @ 2329\\n 8. Diltiazem 60 mg PO/NG QID\\n hold for HR < 60 or SBP < 100 Order date: @ 23.\\n Pantoprazole 40 mg IV Q24H Order date: @ 1321\\n 9. Docusate Sodium (Liquid) 100 mg PO/NG Order date: @ 2329\\n 24. Phenylephrine 0.5-5 mcg/kg/min IV DRIP TITRATE TO SBP>90 MAP>60\\n Order date: @ 2339\\n 10. Fentanyl Citrate 25-100 mcg/hr IV DRIP INFUSION\\n Please wean with Dilaudid dosing. Thank you. Order date: @ 1136\\n 25. Pneumococcal Vac Polyvalent 0.5 ml IM ASDIR Order date: @\\n 2316\\n 11. Gabapentin 400 mg PO/NG TID Order date: @ 1210 26. Potassium\\n Phosphate IV Sliding Scale\\n Infuse over 6 hours Order date: @ 2339\\n 12. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date:\\n @ 0104 27. Potassium Chloride IV Sliding Scale Order date: \\n @ 2339\\n 13. HYDROmorphone (Dilaudid) 0.125-1 mg IV Q3H:PRN pain Order date:\\n @ 0912 28. Senna 1 TAB PO/NG :PRN constipation Order date:\\n @ 0823\\n 14. Heparin 5000 UNIT SC TID Order date: @ 0931 29. Sodium\\n Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush\\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\\n Order date: @ 2329\\n 15. Insulin SC (per Insulin Flowsheet)\\n Sliding Scale Order date: @ 0104 30. Vancomycin 1000 mg IV\\n Q 12H\\n ID Approval will be required for this order in 39 hours. Order date:\\n @ \\n 24 Hour Events:\\n Placed on ketamine for study. Continues to be in aflutter and on Neo,\\n difficulties weaning, however when pt more awake (ie: turning), he is\\n actually HTN. TTE done showing mild TR. RUQ U/S showing mild\\n perihepatic fluid collection too small to be drained.\\n Post operative day:\\n POD#5 - IVC filter via L groin\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\\n Ceftriaxone - 12:00 PM\\n Vancomycin - 08:36 PM\\n Infusions:\\n Fentanyl (Concentrate) - 100 mcg/hour\\n Ketamine - 0.1 mcg/Kg/min\\n Phenylephrine - 1.2 mcg/Kg/min\\n Midazolam (Versed) - 0.5 mg/hour\\n Other ICU medications:\\n Pantoprazole (Protonix) - 02:00 PM\\n Heparin Sodium (Prophylaxis) - 08:29 PM\\n Midazolam (Versed) - 01:15 AM\\n Fentanyl - 01:20 AM\\n Lorazepam (Ativan) - 02:09 AM\\n Other medications:\\n Flowsheet Data as of 04:48 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 38.2\\nC (100.7\\n T current: 37.9\\nC (100.3\\n HR: 78 (75 - 91) bpm\\n BP: 103/51(69) {89/48(62) - 152/66(94)} mmHg\\n RR: 28 (16 - 29) insp/min\\n SPO2: 98%\\n Heart rhythm: A Flut (Atrial Flutter)\\n Wgt (current): 102 kg (admission): 90 kg\\n CVP: 11 (9 - 17) mmHg\\n Total In:\\n 3,764 mL\\n 418 mL\\n PO:\\n Tube feeding:\\n 1,920 mL\\n 255 mL\\n IV Fluid:\\n 1,384 mL\\n 163 mL\\n Blood products:\\n Total out:\\n 1,535 mL\\n 245 mL\\n Urine:\\n 1,530 mL\\n 245 mL\\n NG:\\n 5 mL\\n Stool:\\n Drains:\\n Balance:\\n 2,229 mL\\n 173 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 431 (399 - 596) mL\\n PS : 10 cmH2O\\n RR (Spontaneous): 25\\n PEEP: 10 cmH2O\\n FiO2: 50%\\n PIP: 20 cmH2O\\n SPO2: 98%\\n ABG: 7.41/56/91./32/8\\n Ve: 11.7 L/min\\n PaO2 / FiO2: 184\\n Physical Examination\\n General Appearance: Overweight / Obese\\n Cardiovascular: (Rhythm: No(t) Regular, Irregular)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: No(t)\\n Crackles : , Rhonchorous : bilaterally)\\n Abdominal: Soft, Obese, right flank, right pelvis, and scrotum\\n eechymotic\\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\\n pedis: Present)\\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\\n pedis: Present)\\n Skin: right flank, right pelvis, and scrotum eechymotic\\n Neurologic: Sedated\\n Labs / Radiology\\n 153 K/uL\\n 10.7 g/dL\\n 117 mg/dL\\n 0.7 mg/dL\\n 32 mEq/L\\n 3.9 mEq/L\\n 22 mg/dL\\n 106 mEq/L\\n 143 mEq/L\\n 32.1 %\\n 8.8 K/uL\\n [image002.jpg]\\n 02:55 AM\\n 04:11 AM\\n 09:45 AM\\n 04:45 PM\\n 12:45 AM\\n 01:00 AM\\n 05:12 AM\\n 02:40 PM\\n 01:46 AM\\n 01:55 AM\\n WBC\\n 6.5\\n 13.1\\n 8.8\\n Hct\\n 29.3\\n 31.6\\n 32.1\\n Plt\\n 86\\n 158\\n 153\\n Creatinine\\n 0.8\\n 0.8\\n 0.7\\n 0.7\\n TCO2\\n 38\\n 37\\n 35\\n 35\\n 34\\n 37\\n Glucose\\n 141\\n 107\\n 131\\n 115\\n 132\\n 122\\n 117\\n Other labs: PT / PTT / INR:13.7/27.6/1.2, CK / CK-MB / Troponin\\n T:128/13/<0.01, ALT / AST:81/93, Alk-Phos / T bili:84/5.8, Amylase /\\n Lipase:44/, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic Acid:1.4\\n mmol/L, Albumin:2.7 g/dL, LDH:348 IU/L, Ca:8.0 mg/dL, Mg:2.0 mg/dL,\\n PO4:3.3 mg/dL\\n Imaging: CXR: Cardiac size top nl, interval improvement of\\n collapse LLL. Collapse RLL. Atelectasis in lingula unchanged. Mod B\\n pleural effusions stable. No PTX.\\n CXR: Interval mild incr in cardiac size, b/l pleural effusions,\\n and opacities @ bases,c/w overload\\n : R foot: Linear density projecting @ expected area of insertion\\n of the Achilles to calcaneus, may be min avulsion fx or degenerative\\n changes. Otherwise no fx\\n CXR: b/l pleural effusions\\n CXR: stable.\\n RUQ U/S: No perihepatic fluid collection. small amt perihepatic\\n free fluid persists. Small contusion in hepatic segment VII. No\\n gallstones or significant wall thickening/edema. CBD 4.5 mm\\n TTE: LVEF >55%, normal diastolic function, normal left\\n ventricular filling pressure (PCWP<12mmHg), Right ventricular chamber\\n size is mildly dilated, mild TR\\n Microbiology: Ucx no growth final\\n Sputum: sparse GNRs, too few to colonize\\n Bcx P\\n Bcx P\\n 12/17 L BAL: Klebsiella Pneumoniae, HAEMOPHILUS SPECIES NOT INFLUENZAE\\n R BAL: Klebsiella Pneumoniae, Proteus.\\n 12/20 L BAL: gram + cocci pairs on gram stain, GNRs (sparse) on cx\\n R BAL: gram + cocci pairs on gram stain, GNRs (10-100K) on cx\\n BCX: p\\n BCx: P\\n UCx: no growth final\\n Assessment and Plan\\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, now\\n with AF with RVR/Aflutter, hypotension and presumed PNA.\\n Neurologic: Intubated on Fentanyl/Versed gtt. Per ortho spine, no\\n surgery; HOB<30, TLSO when OOB (NEOPS will place).\\n Neuro checks Q: shift\\n Pain: Fentanyl gtt (trying to wean), dilaudid, Midazolam gtt,\\n Neurontin, Tylenol\\n Cardiovascular: Aflutter on Dilt 60mg PO QID. Weaning Neo.\\n Pulmonary: Intubated. Weaning to extubate. On appropriate abx per BAL\\n cx -Vanco and Ceftriaxone. Will need Trach this week.\\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin with CT scan\\n suggesting cirrhosis - Hepatitis panel NEG. TFs advancing to goal.\\n Bowel regimen.\\n Nutrition: Tube feeding\\n Renal: Foley, Foley, monitor UOP.\\n Hematology: Hct stable. Plt low but stable (100's); d/c'd H2B with\\n increasing plt count. Heme onc consulted - smear nl; no hemolysis. IVC\\n filter placed.\\n Endocrine: RISS\\n Infectious Disease: Check cultures, WBC normal, f/u Cx - BAL:\\n Klebsiella (b/l)& GNRs (on R)/Haemophilus (on L). Klebsiella\\n Pneumoniae, Proteus/Haemophilus. Repeat BAL with gram+ cocci in\\n pairs on gram stain, GNRs.\\n Lines / Tubes / Drains: R SC CVL (), PIV x2, Foley, L a-line\\n (), ETT\\n Wounds:\\n Imaging: CXR today\\n Fluids: KVO\\n Consults: Trauma (1o), Ortho Spine, Ortho trauma, Heme\\n Billing Diagnosis: Multiple injuries (Trauma)\\n ICU Care\\n Nutrition:\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n Multi Lumen - 04:41 PM\\n Arterial Line - 11:30 AM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin, IVC filter\\n Stress ulcer: H2 blocker\\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds , ICU\\n Code status: Full code\\n Disposition: ICU\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2175-02-01 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 714416,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 8\\n Ideal body weight: 0 None\\n Ideal tidal volume: 0 / 0 / 0 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: Yes\\n Tube Type\\n ETT:\\n Position: 25 cm at teeth\\n Route: Oral\\n Type: Standard\\n Size: 7.5mm\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 30 cmH2O\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Diminished\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Diminished\\n Comments:\\n Secretions\\n Sputum color / consistency: White / Thick\\n Sputum source/amount: Suctioned / Small\\n Ventilation Assessment\\n Level of breathing assistance: Continuous invasive ventilation\\n Invasive ventilation assessment:\\n Trigger work assessment: Triggering synchronously\\n Plan\\n Next 24-48 hours: Tracheostomy planned\\n Reason for continuing current ventilatory support: Intolerant of\\n weaning attempts, Underlying illness not resolved\\n Comments: Pt. remains intubated on IPS overnoc. Plan trach today.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2175-02-03 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 714779,\n \"text\": \"TSICU\\n HPI:\\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\\n checked and 1.5, 1 more unit FFP given.\\n Chief complaint:\\n PMHx:\\n Current medications:\\n Acetaminophen 4. Amiodarone 5. Bisacodyl 6. Calcium Gluconate 7.\\n CefePIME 8. CefePIME\\n 9. Chlorhexidine Gluconate 0.12% Oral Rinse 10. Ciprofloxacin HCl 11.\\n Dextrose 50% 12. Docusate Sodium (Liquid)\\n 13. Fentanyl Citrate 14. Furosemide 15. Furosemide 16. Furosemide 17.\\n Gabapentin 18. Glucagon 19. Heparin\\n 20. Insulin 21. Lactulose 22. Lansoprazole Oral Disintegrating Tab 23.\\n Lorazepam 24. Magnesium Sulfate\\n 25. Metoprolol Tartrate 26. Metoprolol Tartrate 27. Midazolam 28.\\n Midazolam 29. Milk of Magnesia\\n 30. Olanzapine (Disintegrating Tablet) 31. Ondansetron 32. OxycoDONE\\n Liquid 33. Phenylephrine 34. Pneumococcal Vac Polyvalent\\n 35. Potassium Phosphate 36. Potassium Chloride 37. Senna 38. Sodium\\n Chloride 0.9% Flush 39. Sodium Chloride 0.9% Flush\\n 40. Vancomycin 41. Vancomycin\\n 24 Hour Events:\\n EKG - At 09:07 PM\\n FEVER - 101.1\\nF - 12:00 AM\\n : TFs increased. Lasix 10x3 with good result. Zyprexa for\\n sedation, weaned off versed, fentanyl. Cards rec 400'' x 1wk, then\\n 400'x1 wk, then 200'. also rec changing dilt to metop 25''.\\n Vanc/cipro/cefepime for VAP.\\n : pan cx for temp 101.1\\n Post operative day:\\n POD#8 - IVC filter via L groin\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Ceftriaxone - 03:00 PM\\n Ciprofloxacin - 12:00 PM\\n Vancomycin - 07:33 PM\\n Cefipime - 11:15 PM\\n Infusions:\\n Other ICU medications:\\n Lansoprazole (Prevacid) - 02:00 PM\\n Lorazepam (Ativan) - 11:41 PM\\n Midazolam (Versed) - 02:16 AM\\n Furosemide (Lasix) - 03:55 AM\\n Heparin Sodium (Prophylaxis) - 04:02 AM\\n Metoprolol - 06:27 AM\\n Other medications:\\n Flowsheet Data as of 08:02 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 38.4\\nC (101.1\\n T current: 37.7\\nC (99.8\\n HR: 97 (81 - 111) bpm\\n BP: 160/81(110) {111/59(80) - 166/81(110)} mmHg\\n RR: 30 (17 - 30) insp/min\\n SPO2: 99%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 104.2 kg (admission): 90 kg\\n CVP: 19 (12 - 26) mmHg\\n Total In:\\n 2,674 mL\\n 727 mL\\n PO:\\n Tube feeding:\\n 660 mL\\n 637 mL\\n IV Fluid:\\n 895 mL\\n 90 mL\\n Blood products:\\n Total out:\\n 2,485 mL\\n 1,055 mL\\n Urine:\\n 2,485 mL\\n 1,055 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 189 mL\\n -328 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 510 (502 - 660) mL\\n PS : 12 cmH2O\\n RR (Spontaneous): 28\\n PEEP: 10 cmH2O\\n FiO2: 50%\\n RSBI Deferred: PEEP > 10\\n PIP: 28 cmH2O\\n SPO2: 99%\\n ABG: 7.50/43/150/31/9\\n Ve: 11.8 L/min\\n PaO2 / FiO2: 300\\n Physical Examination\\n General Appearance: Anxious, Well nourished\\n HEENT: PERRL, EOMI\\n Cardiovascular: (Rhythm: Regular)\\n Respiratory / Chest: (Breath Sounds: Crackles : , Rhonchorous : ,\\n Diminished: )\\n Abdominal: Soft, Distended\\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\\n pedis: Present)\\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\\n pedis: Present)\\n Skin: (Incision: Clean / Dry / Intact)\\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\\n Moves all extremities\\n Labs / Radiology\\n 128 K/uL\\n 9.3 g/dL\\n 138 mg/dL\\n 0.8 mg/dL\\n 31 mEq/L\\n 3.8 mEq/L\\n 23 mg/dL\\n 105 mEq/L\\n 142 mEq/L\\n 28.9 %\\n 6.3 K/uL\\n [image002.jpg]\\n 02:00 PM\\n 05:04 PM\\n 08:00 PM\\n 09:20 PM\\n 01:00 AM\\n 01:07 AM\\n 01:18 AM\\n 02:05 AM\\n 03:54 AM\\n 05:17 AM\\n WBC\\n 5.9\\n 6.3\\n Hct\\n 31.3\\n 28.9\\n Plt\\n 109\\n 128\\n Creatinine\\n 0.8\\n 0.8\\n TCO2\\n 36\\n 34\\n 35\\n 34\\n 35\\n Glucose\\n 111\\n 105\\n 117\\n 110\\n 138\\n Other labs: PT / PTT / INR:13.7/27.6/1.2, CK / CK-MB / Troponin\\n T:128/13/<0.01, ALT / AST:90/122, Alk-Phos / T bili:133/5.4, Amylase /\\n Lipase:54/52, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic\\n Acid:1.4 mmol/L, Albumin:2.3 g/dL, LDH:348 IU/L, Ca:8.0 mg/dL, Mg:2.2\\n mg/dL, PO4:2.8 mg/dL\\n Imaging: CT head OSH: Prelim No ICH or fx.\\n CT chest OSH: Mult rib fx: R anterolateral and posterior, L\\n posterior; Dependent consolidation, possible aspiration; T4 vertebral\\n body inf corner fx, no retropulsion; Comminuted spinous process fx\\n T2-8; Nondisplaced L T10 transverse process; Nondisplaced L clavicle\\n distal fx; Nondisplaced L scapula fx;\\n CT c spine OSH: Prelim No fx or malalignment. Multilevel\\n degenerative changes w/large post disk bulge at C4-5, narrowing the\\n spinal canal and deforming the thecal sac, acuity unknown. Marked\\n neuroforamenal narrowing @multiple levels.\\n CTA abd/pel Prelim: Medial R liver lobe contusion w/adj\\n hematoma, w/o evidence of active bleeding; Comminuted L pubic ramus\\n fracture w/assoc hematoma, with tiny focus of arterial bleeding/active\\n extravasation, and larger area of venous bleeding. Hematoma somewhat\\n larger than on OSH study. Nondisplaced, comminuted L iliac bone fx\\n w/adj iliac muscle hematoma, larger than on prior study, w/o active\\n extrav. Fx extends into L SIJ. Post R hepatic laceration/contusion\\n adjacent to calcified granuloma, w/small hematoma, w/out active\\n bleeding. Min displaced fx of R iliac bone extending to R SIJ.\\n Cirrhotic liver. Inc B pl effusions (small), w/inc atelectasis.\\n MRI: Mild compression deformity of L1 w/additional levels of\\n potential trabecular contusion @T10-11 also inf @T4 w/o retropulsion.\\n Multilevel degenerative changes w/moderate canal narrowing @T10-11\\n w/cord deformity & no abnl cord signal. Extensive edema throughout\\n paraspinal soft tissues, predominantly post w/in interspinous\\n ligaments. Incompletely eval'ed c-spine w/severe canal narrowing @C4-5\\n w/cord deformity and no abn cord signal.\\n CTA: no PE.\\n CXR: Moderate b/l pleural effusions are stable.\\n CXR: Cardiac size top nl, interval improvement of collapse LLL.\\n Collapse RLL. Atelectasis in lingula unchanged. Mod B pleural effusions\\n stable. No PTX.\\n CXR: Interval mild incr in cardiac size, b/l pl effusions,\\n & opacities @ bases,c/w overload\\n : R foot: Linear density projecting @ expected area of insertion\\n of Achilles to calcaneus, may be min avulsion fx or degenerative\\n changes. Otherwise no fx\\n CXR: b/l pl effusions\\n CXR: stable.\\n RUQ U/S: No perihepatic fluid collection. small amt perihepatic\\n free fluid persists. Small contusion in hepatic segment VII. No\\n gallstones or sig wall thickening/edema. CBD 4.5 mm\\n TTE: LVEF >55%, NL diastolic function, NL LV filling pressure\\n (PCWP<12mmHg), RV chamber size mildly dilated, mild TR\\n CXR: mild b/l pulm edema and parenchymal opacities and no\\n pl effusion.\\n CXR: Persistent b/l pl effusions and bibasilar opacity.\\n CXR: Minimal improvement of mod b/l pl effusions. Otherwise\\n stable.\\n Microbiology: Ucx no growth final\\n Sputum: sparse GNRs, too few to colonize\\n Bcx x2 no growth final\\n 12/17 L BAL: Klebsiella Pneumoniae, HAEMOPHILUS SPECIES NOT INFLUENZAE\\n R BAL: Klebsiella Pneumoniae, Proteus.\\n 12/20 L &R BAL: Klebsiella Pneumoniae\\n BCX: p\\n BCx: P\\n UCx: no growth final\\n BCx: P\\n BCx: P\\n UCx: P\\n SpCx: P\\n Assessment and Plan\\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, now\\n with AF with RVR/Aflutter, persistant hypotension and PNA.\\n Neurologic: s/p trach (). Per ortho spine, no surgery; HOB<30,\\n TLSO when OOB. Zyprexa & Ativan PRN (off fent/midaz ).\\n Neuro checks Q: shift\\n Pain: Oxycodone, Neurontin, Tylenol.\\n Cardiovascular: Aflutter, now reverted to sinus w/1st deg AVB. Likely\\n cardiac contusion. Cards rec 400'' x 1wk, then 400'x1 wk, then\\n 200'. also rec changing dilt to metop 25''. Pt cannot be fully\\n anticoagulated for now (trauma). Will concentrate meds.\\n Pulmonary: Intubated, weaning, Vanc/cipro/cefepime for VAP ().\\n Increasing pulmonary edema on CXR (lasix x 2 on , lasix x1 ).\\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin (declining 6.8\\n max ->5.0) w/CT scan suggesting cirrhosis - Hepatitis panel NEG. TFs\\n restarted, increasing to goal . Bowel regimen. Will concentrate\\n TFs or change to a different type.\\n Nutrition: Tube feeding\\n Renal: Foley, monitor UOP, edematous scrotum. Lasix 10 x2 on ,\\n lasix x1 . Lasix 20 x1 , if tolerates 20 Q6.\\n Hematology: Hct stable 32.1->29.7. Plt stable (100's); d/c'd H2B. Heme\\n onc c/s - smear nl; no hemolysis. IVC filter placed.\\n Endocrine: RISS\\n Infectious Disease: Check cultures, WBC droppping\\n 13.1->8.8->4.2->5.9->6.3, Vanc/cipro/cefepime for VAP given worsening\\n pulm status. B/l LENIS to r/o DVT as source. Fever 101.1 o/n, re-pan\\n cx.\\n Lines / Tubes / Drains: Trach/Peg/foley/L radial a-line/R SCL\\n Wounds:\\n Imaging: CXR today\\n Fluids: KVO\\n Consults: Trauma (1o), Ortho Spine, Ortho trauma, Heme\\n Billing Diagnosis: (Respiratory distress: Failure), (Shock: Traumatic),\\n Multiple injuries (Trauma)\\n ICU Care\\n Nutrition: Replete with Fiber (Full) - 04:12 AM 80 mL/hour\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n Multi Lumen - 04:41 PM\\n Arterial Line - 11:30 AM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin\\n Stress ulcer: PPI\\n VAP bundle: HOB elevation, Mouth care\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds , Family\\n meeting planning, ICU consent signed Comments:\\n Code status: Full code\\n Disposition: ICU\\n Total time spent: 33 minutes\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2175-02-03 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 714794,\n \"text\": \"TSICU\\n HPI:\\n 74M s/p fall with multiple rib fx, pelvis fx, clavicle fx, and thoracic\\n fx c/b unstable bleeding s/p IR embo, now with AF with RVR/Aflutter,\\n persistant hypotension and presumed PNA.\\n Chief complaint:\\n fall\\n PMHx:\\n none\\n Current medications:\\n 1. Acetaminophen 2. Amiodarone 3. Bisacodyl 4. Calcium Gluconate 5.\\n CeftriaXONE 6. Chlorhexidine Gluconate 0.12% Oral Rinse 7. Dextrose 50%\\n 8. Diltiazem 9. Docusate Sodium (Liquid) 10. Fentanyl Citrate 11.\\n Gabapentin 12. Glucagon 13. Heparin 14. Insulin 15. Lactulose 16.\\n Magnesium Sulfate 17. Metoprolol Tartrate 18. Midazolam 19. Midazolam\\n 20. Milk of Magnesia 21. Ondansetron 22. OxycoDONE Liquid 23.\\n Pantoprazole 24. Phenylephrine\\n 25. Pneumococcal Vac Polyvalent 26. Potassium Phosphate 27. Potassium\\n Chloride 28. Senna 29. Sodium Chloride 0.9% Flush\\n 24 Hour Events:\\n Changed sedation to po Oxycodone, wean fentanyl gtt, wean Midazolam,\\n and start Haldol prn, but stopped due to QTc. Cards consult, started\\n amiodarone.\\n Post operative day:\\n POD#6 - IVC filter via L groin\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\\n Vancomycin - 08:00 AM\\n Ceftriaxone - 12:00 PM\\n Infusions:\\n Midazolam (Versed) - 5 mg/hour\\n Fentanyl (Concentrate) - 50 mcg/hour\\n Amiodarone - 0.5 mg/min\\n Other ICU medications:\\n Haloperidol (Haldol) - 10:45 AM\\n Lorazepam (Ativan) - 02:00 PM\\n Midazolam (Versed) - 03:25 AM\\n Fentanyl - 03:25 AM\\n Heparin Sodium (Prophylaxis) - 05:33 AM\\n Other medications:\\n Flowsheet Data as of 06:27 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 38.1\\nC (100.6\\n T current: 37.2\\nC (98.9\\n HR: 76 (74 - 104) bpm\\n BP: 125/62(81) {90/49(62) - 152/67(89)} mmHg\\n RR: 25 (18 - 31) insp/min\\n SPO2: 98%\\n Heart rhythm: A Flut (Atrial Flutter)\\n Wgt (current): 102 kg (admission): 90 kg\\n CVP: 12 (10 - 19) mmHg\\n Total In:\\n 3,718 mL\\n 759 mL\\n PO:\\n Tube feeding:\\n 1,920 mL\\n 424 mL\\n IV Fluid:\\n 1,078 mL\\n 245 mL\\n Blood products:\\n Total out:\\n 1,755 mL\\n 350 mL\\n Urine:\\n 1,755 mL\\n 350 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,963 mL\\n 409 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 480 (400 - 540) mL\\n PS : 10 cmH2O\\n RR (Spontaneous): 29\\n PEEP: 10 cmH2O\\n FiO2: 50%\\n RSBI Deferred: PEEP > 10\\n PIP: 21 cmH2O\\n SPO2: 98%\\n ABG: 7.44/45/119/31/6\\n Ve: 11.8 L/min\\n PaO2 / FiO2: 238\\n Physical Examination\\n General Appearance: No acute distress, intubated\\n HEENT: PERRL\\n Cardiovascular: (Rhythm: Regular)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\\n bilateral : ), shallow respirations\\n Abdominal: Soft, No(t) Non-distended, Bowel sounds present, Distended\\n Left Extremities: (Edema: 1+), (Temperature: Warm)\\n Right Extremities: (Edema: 1+), (Temperature: Warm)\\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\\n Moves all extremities, Sedated\\n Labs / Radiology\\n 104 K/uL\\n 9.5 g/dL\\n 129 mg/dL\\n 0.7 mg/dL\\n 31 mEq/L\\n 4.2 mEq/L\\n 24 mg/dL\\n 106 mEq/L\\n 142 mEq/L\\n 29.7 %\\n 4.2 K/uL\\n [image002.jpg]\\n 04:45 PM\\n 12:45 AM\\n 01:00 AM\\n 05:12 AM\\n 02:40 PM\\n 01:46 AM\\n 01:55 AM\\n 03:40 PM\\n 12:07 AM\\n 02:18 AM\\n WBC\\n 13.1\\n 8.8\\n 4.2\\n Hct\\n 31.6\\n 32.1\\n 29.7\\n Plt\\n 158\\n 153\\n 104\\n Creatinine\\n 0.8\\n 0.7\\n 0.7\\n 0.7\\n TCO2\\n 35\\n 35\\n 34\\n 37\\n 35\\n 32\\n Glucose\\n 131\\n 115\\n 132\\n 122\\n 117\\n 129\\n Other labs:\\n PT / PTT / INR:13.7/27.6/1.2, CK / CK-MB / Troponin T:128/13/<0.01,\\n ALT / AST:87/109, Alk-Phos / T bili:115/5.0, Amylase / Lipase:44/,\\n D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic Acid:1.4 mmol/L,\\n Albumin:2.7 g/dL, LDH:348 IU/L, Ca:7.9 mg/dL, Mg:2.0 mg/dL, PO4:3.4\\n mg/dL\\n Assessment and Plan\\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, now\\n with AF with RVR/Aflutter, persistant hypotension and presumed PNA.\\n Neurologic: Intubated. Per ortho spine, no surgery; HOB<30, TLSO when\\n OOB (NEOPS will place). Wean sedation as may be causing hypotension.\\n Change pain meds to PO. Wean versed.\\n Neuro checks Q: shift\\n Pain: Oxycodone, Fentanyl gtt (weaning), Midazolam gtt (weaning),\\n Neurontin, Tylenol\\n Cardiovascular: Aflutter on Dilt 60mg PO QID. Neo off since this AM.\\n Cards yesterday rec Amiodarone. Pressor requirements may be related to\\n AFib/flutter. No plan for electrical cardioversion right now. As pt\\n cannot be anticoagulated (recent major trauma), had TTE w/o thrombus,\\n Cards would like anticoagulation, will hold on heparin per Trauma\\n surgery.\\n Pulmonary: Intubated, weaning, tachypneic likely abd distension. On\\n appropriate abx per BAL cx\\n Ceftriaxone. Plan for trach today.\\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin (declining 6.8\\n max\\n 5.0) with CT scan suggesting cirrhosis - Hepatitis panel NEG. TFs\\n on hold for PEG. Bowel regimen, no BM since admission MOM and Lactulose\\n added, will try Methylnaltrexone.\\n Nutrition: NPO pre-op.\\n Renal: Foley, monitor UOP, edematous scrotum but soft, eccymosis\\n improving.\\n Hematology: Hct stable 32.1->29.7. Plt low but stable (100's); d/c'd\\n H2B with increasing plt count. Heme onc consulted - smear nl; no\\n hemolysis. IVC filter placed.\\n Endocrine: RISS, goal BS<150, adequate control.\\n Infectious Disease: WBC dropping 13.1->8.8->4.2, f/u Cx - BAL:\\n Klebsiella\\n Ceftriaxone. Will add Vanco back for GPCs coverage if\\n patient worsens.\\n Lines / Tubes / Drains: R SC CVL (), Foley, L a-line (), ETT\\n Imaging: CXR today\\n Fluids: KVO\\n Consults: Trauma (1o), Ortho Spine, Ortho trauma, Heme\\n Billing Diagnosis:\\n ICU Care\\n Nutrition:\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n Multi Lumen - 04:41 PM\\n Arterial Line - 11:30 AM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin, IVC filter\\n Stress ulcer: PPI\\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\\n Comments:\\n Communication: ICU consent signed Comments:\\n Code status: Full code\\n Disposition: ICU\\n Total time spent: 33 min\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2175-02-03 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 714795,\n \"text\": \"TSICU\\n HPI:\\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\\n checked and 1.5, 1 more unit FFP given.\\n .\\n Injuries\\n Mult rib fx: R anterolateral and post, L posterior\\n T4 vert body inf corner fx\\n Commin spinous process fx T2-8\\n Nondisplaced L T10 transverse process\\n Nondispaced L distal clavicle\\n Nondisplaced L clavicle fx\\n R medial lobe liver contusion w/hematoma\\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny focus of arterial\\n bleeding/active extravasation, and larger area of venous bleeding\\n Nondisplaced, comminuted L iliac bone fx w/adjacent iliac muscle\\n hematoma, extends into L SIJ.\\n Minimally displaced fx of R iliac bone extending to R SIJ.\\n Chief complaint:\\n Trauma\\n PMHx:\\n PMH: None\\n PSH: None\\n : None\\n Current medications:\\n 24 Hour Events:\\n Trach/PEG. Pt's BP dropped to 80/40 off pressors, sats 88. restarted\\n neo. Overnight, pt reverted to sinus, off pressors, weaning sedation.\\n PERCUTANEOUS TRACHEOSTOMY - At 12:00 PM\\n PEG INSERTION - At 12:00 PM\\n Post operative day:\\n POD#7 - IVC filter via L groin\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\\n Vancomycin - 08:00 AM\\n Ceftriaxone - 03:00 PM\\n Infusions:\\n Midazolam (Versed) - 1 mg/hour\\n Amiodarone - 0.5 mg/min\\n Fentanyl (Concentrate) - 50 mcg/hour\\n Other ICU medications:\\n Fentanyl - 01:23 PM\\n Pantoprazole (Protonix) - 02:00 PM\\n Heparin Sodium (Prophylaxis) - 04:00 AM\\n Other medications:\\n Flowsheet Data as of 04:33 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 37.7\\nC (99.9\\n T current: 37.1\\nC (98.8\\n HR: 94 (68 - 101) bpm\\n BP: 140/66(91) {89/46(63) - 154/68(94)} mmHg\\n RR: 26 (11 - 30) insp/min\\n SPO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 102 kg (admission): 90 kg\\n CVP: 9 (6 - 16) mmHg\\n Total In:\\n 1,764 mL\\n 142 mL\\n PO:\\n Tube feeding:\\n 424 mL\\n IV Fluid:\\n 1,000 mL\\n 82 mL\\n Blood products:\\n Total out:\\n 1,630 mL\\n 290 mL\\n Urine:\\n 1,630 mL\\n 290 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 134 mL\\n -148 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 483 (404 - 506) mL\\n PS : 15 cmH2O\\n RR (Spontaneous): 16\\n PEEP: 10 cmH2O\\n FiO2: 60%\\n RSBI Deferred: PEEP > 10\\n PIP: 25 cmH2O\\n SPO2: 98%\\n ABG: 7.45/49/98./31/8\\n Ve: 8.5 L/min\\n PaO2 / FiO2: 163\\n Physical Examination\\n General Appearance: No acute distress\\n HEENT: PERRL\\n Cardiovascular: (Rhythm: Regular)\\n Respiratory / Chest: (Breath Sounds: Crackles : )\\n Abdominal: Soft\\n Left Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present)\\n Right Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present)\\n Neurologic: Follows simple commands, Moves all extremities, Sedated\\n Labs / Radiology\\n 109 K/uL\\n 10.2 g/dL\\n 110 mg/dL\\n 0.8 mg/dL\\n 31 mEq/L\\n 4.5 mEq/L\\n 24 mg/dL\\n 105 mEq/L\\n 144 mEq/L\\n 31.3 %\\n 5.9 K/uL\\n [image002.jpg]\\n 12:07 AM\\n 02:18 AM\\n 08:00 AM\\n 02:00 PM\\n 05:04 PM\\n 08:00 PM\\n 09:20 PM\\n 01:00 AM\\n 01:07 AM\\n 01:18 AM\\n WBC\\n 4.2\\n 5.9\\n Hct\\n 29.7\\n 31.3\\n Plt\\n 104\\n 109\\n Creatinine\\n 0.7\\n 0.8\\n TCO2\\n 32\\n 36\\n 34\\n 35\\n Glucose\\n 129\\n 100\\n 111\\n 105\\n 117\\n 110\\n Other labs: PT / PTT / INR:13.7/27.6/1.2, CK / CK-MB / Troponin\\n T:128/13/<0.01, ALT / AST:90/113, Alk-Phos / T bili:99/5.1, Amylase /\\n Lipase:58/39, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic\\n Acid:1.4 mmol/L, Albumin:2.3 g/dL, LDH:348 IU/L, Ca:8.1 mg/dL, Mg:2.1\\n mg/dL, PO4:3.8 mg/dL\\n Assessment and Plan\\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, now\\n with AF with RVR/Aflutter, persistant hypotension and PNA.\\n Neurologic: s/p trach. Per ortho spine, no surgery; HOB<30, TLSO when\\n OOB (NEOPS will place). Wean sedation as may be causing hypotension.\\n Change pain meds to PO. Will try Geodon today for agitation.\\n Neuro checks Q: shift\\n Pain: Oxycodone, Neurontin, Tylenol. Wean fentanyl gtt, midazolam\\n gtt\\n Cardiovascular: Aflutter, now reverted to sinus. Likely cardiac\\n contusion. On Dilt 60mg PO QID. Cards rec amio gtt. Neo off. Pt cannot\\n be fully anticoagulated for now (trauma). Start PO amio.\\n Pulmonary: Intubated, weaning, tachypneic likely abd distension. On\\n appropriate abx per BAL cx - Ceftriaxone. Now that pulm status is\\n worsening, will broaden coverage with V/C/C.\\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin (declining 6.8\\n max ->5.0) w/CT scan suggesting cirrhosis - Hepatitis panel NEG. TFs.\\n Bowel regimen.\\n Nutrition: TF\\n Renal: Foley, monitor UOP, edematous scrotum. Diurese with lasix 10mg\\n IV. Goal 1 L negative today.\\n Hematology: Hct stable 32.1->29.7. Plt stable (100's); d/c'd H2B with\\n increasing plt count. Heme onc c/s - smear nl; no hemolysis. IVC\\n filter placed.\\n Endocrine: RISS, goal BS<150.\\n Infectious Disease: WBC dropping 13.1->8.8->4.2, f/u Cx - BAL:\\n pan-sensitive Klebsiella\\n broaden coverage for VAP.\\n Lines / Tubes / Drains: R SC CVL (), Foley, L a-line (),\\n trach/PEG\\n Wounds: SCDs, IVC filter, SQH\\n Imaging:\\n Fluids:\\n Consults: Trauma surgery\\n Billing Diagnosis: Multiple injuries (Trauma)\\n ICU Care\\n Nutrition:\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n Multi Lumen - 04:41 PM\\n Arterial Line - 11:30 AM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin\\n Stress ulcer: PPI\\n VAP bundle:\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds Comments:\\n Code status: Full code\\n Disposition: ICU\\n Total time spent: 32 min\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2175-02-03 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 714796,\n \"text\": \"TSICU\\n HPI:\\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\\n checked and 1.5, 1 more unit FFP given.\\n Chief complaint:\\n PMHx:\\n Current medications:\\n Acetaminophen 4. Amiodarone 5. Bisacodyl 6. Calcium Gluconate 7.\\n CefePIME 8. CefePIME\\n 9. Chlorhexidine Gluconate 0.12% Oral Rinse 10. Ciprofloxacin HCl 11.\\n Dextrose 50% 12. Docusate Sodium (Liquid)\\n 13. Fentanyl Citrate 14. Furosemide 15. Furosemide 16. Furosemide 17.\\n Gabapentin 18. Glucagon 19. Heparin\\n 20. Insulin 21. Lactulose 22. Lansoprazole Oral Disintegrating Tab 23.\\n Lorazepam 24. Magnesium Sulfate\\n 25. Metoprolol Tartrate 26. Metoprolol Tartrate 27. Midazolam 28.\\n Midazolam 29. Milk of Magnesia\\n 30. Olanzapine (Disintegrating Tablet) 31. Ondansetron 32. OxycoDONE\\n Liquid 33. Phenylephrine 34. Pneumococcal Vac Polyvalent\\n 35. Potassium Phosphate 36. Potassium Chloride 37. Senna 38. Sodium\\n Chloride 0.9% Flush 39. Sodium Chloride 0.9% Flush\\n 40. Vancomycin 41. Vancomycin\\n 24 Hour Events:\\n EKG - At 09:07 PM\\n FEVER - 101.1\\nF - 12:00 AM\\n : TFs increased. Lasix 10x3 with good result. Zyprexa for\\n sedation, weaned off versed, fentanyl. Cards rec 400'' x 1wk, then\\n 400'x1 wk, then 200'. also rec changing dilt to metop 25''.\\n Vanc/cipro/cefepime for VAP.\\n : pan cx for temp 101.1\\n Post operative day:\\n POD#8 - IVC filter via L groin\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Ceftriaxone - 03:00 PM\\n Ciprofloxacin - 12:00 PM\\n Vancomycin - 07:33 PM\\n Cefipime - 11:15 PM\\n Infusions:\\n Other ICU medications:\\n Lansoprazole (Prevacid) - 02:00 PM\\n Lorazepam (Ativan) - 11:41 PM\\n Midazolam (Versed) - 02:16 AM\\n Furosemide (Lasix) - 03:55 AM\\n Heparin Sodium (Prophylaxis) - 04:02 AM\\n Metoprolol - 06:27 AM\\n Other medications:\\n Flowsheet Data as of 08:02 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 38.4\\nC (101.1\\n T current: 37.7\\nC (99.8\\n HR: 97 (81 - 111) bpm\\n BP: 160/81(110) {111/59(80) - 166/81(110)} mmHg\\n RR: 30 (17 - 30) insp/min\\n SPO2: 99%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 104.2 kg (admission): 90 kg\\n CVP: 19 (12 - 26) mmHg\\n Total In:\\n 2,674 mL\\n 727 mL\\n PO:\\n Tube feeding:\\n 660 mL\\n 637 mL\\n IV Fluid:\\n 895 mL\\n 90 mL\\n Blood products:\\n Total out:\\n 2,485 mL\\n 1,055 mL\\n Urine:\\n 2,485 mL\\n 1,055 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 189 mL\\n -328 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 510 (502 - 660) mL\\n PS : 12 cmH2O\\n RR (Spontaneous): 28\\n PEEP: 10 cmH2O\\n FiO2: 50%\\n RSBI Deferred: PEEP > 10\\n PIP: 28 cmH2O\\n SPO2: 99%\\n ABG: 7.50/43/150/31/9\\n Ve: 11.8 L/min\\n PaO2 / FiO2: 300\\n Physical Examination\\n General Appearance: Anxious, Well nourished\\n HEENT: PERRL, EOMI\\n Cardiovascular: (Rhythm: Regular)\\n Respiratory / Chest: (Breath Sounds: Crackles : , Rhonchorous : ,\\n Diminished: )\\n Abdominal: Soft, Distended\\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\\n pedis: Present)\\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\\n pedis: Present)\\n Skin: (Incision: Clean / Dry / Intact)\\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\\n Moves all extremities\\n Labs / Radiology\\n 128 K/uL\\n 9.3 g/dL\\n 138 mg/dL\\n 0.8 mg/dL\\n 31 mEq/L\\n 3.8 mEq/L\\n 23 mg/dL\\n 105 mEq/L\\n 142 mEq/L\\n 28.9 %\\n 6.3 K/uL\\n 02:00 PM\\n 05:04 PM\\n 08:00 PM\\n 09:20 PM\\n 01:00 AM\\n 01:07 AM\\n 01:18 AM\\n 02:05 AM\\n 03:54 AM\\n 05:17 AM\\n WBC\\n 5.9\\n 6.3\\n Hct\\n 31.3\\n 28.9\\n Plt\\n 109\\n 128\\n Creatinine\\n 0.8\\n 0.8\\n TCO2\\n 36\\n 34\\n 35\\n 34\\n 35\\n Glucose\\n 111\\n 105\\n 117\\n 110\\n 138\\n Other labs: PT / PTT / INR:13.7/27.6/1.2, CK / CK-MB / Troponin\\n T:128/13/<0.01, ALT / AST:90/122, Alk-Phos / T bili:133/5.4, Amylase /\\n Lipase:54/52, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic\\n Acid:1.4 mmol/L, Albumin:2.3 g/dL, LDH:348 IU/L, Ca:8.0 mg/dL, Mg:2.2\\n mg/dL, PO4:2.8 mg/dL\\n Imaging: CT head OSH: Prelim No ICH or fx.\\n CT chest OSH: Mult rib fx: R anterolateral and posterior, L\\n posterior; Dependent consolidation, possible aspiration; T4 vertebral\\n body inf corner fx, no retropulsion; Comminuted spinous process fx\\n T2-8; Nondisplaced L T10 transverse process; Nondisplaced L clavicle\\n distal fx; Nondisplaced L scapula fx;\\n CT c spine OSH: Prelim No fx or malalignment. Multilevel\\n degenerative changes w/large post disk bulge at C4-5, narrowing the\\n spinal canal and deforming the thecal sac, acuity unknown. Marked\\n neuroforamenal narrowing @multiple levels.\\n CTA abd/pel Prelim: Medial R liver lobe contusion w/adj\\n hematoma, w/o evidence of active bleeding; Comminuted L pubic ramus\\n fracture w/assoc hematoma, with tiny focus of arterial bleeding/active\\n extravasation, and larger area of venous bleeding. Hematoma somewhat\\n larger than on OSH study. Nondisplaced, comminuted L iliac bone fx\\n w/adj iliac muscle hematoma, larger than on prior study, w/o active\\n extrav. Fx extends into L SIJ. Post R hepatic laceration/contusion\\n adjacent to calcified granuloma, w/small hematoma, w/out active\\n bleeding. Min displaced fx of R iliac bone extending to R SIJ.\\n Cirrhotic liver. Inc B pl effusions (small), w/inc atelectasis.\\n MRI: Mild compression deformity of L1 w/additional levels of\\n potential trabecular contusion @T10-11 also inf @T4 w/o retropulsion.\\n Multilevel degenerative changes w/moderate canal narrowing @T10-11\\n w/cord deformity & no abnl cord signal. Extensive edema throughout\\n paraspinal soft tissues, predominantly post w/in interspinous\\n ligaments. Incompletely eval'ed c-spine w/severe canal narrowing @C4-5\\n w/cord deformity and no abn cord signal.\\n CTA: no PE.\\n CXR: Moderate b/l pleural effusions are stable.\\n CXR: Cardiac size top nl, interval improvement of collapse LLL.\\n Collapse RLL. Atelectasis in lingula unchanged. Mod B pleural effusions\\n stable. No PTX.\\n CXR: Interval mild incr in cardiac size, b/l pl effusions,\\n & opacities @ bases,c/w overload\\n : R foot: Linear density projecting @ expected area of insertion\\n of Achilles to calcaneus, may be min avulsion fx or degenerative\\n changes. Otherwise no fx\\n CXR: b/l pl effusions\\n CXR: stable.\\n RUQ U/S: No perihepatic fluid collection. small amt perihepatic\\n free fluid persists. Small contusion in hepatic segment VII. No\\n gallstones or sig wall thickening/edema. CBD 4.5 mm\\n TTE: LVEF >55%, NL diastolic function, NL LV filling pressure\\n (PCWP<12mmHg), RV chamber size mildly dilated, mild TR\\n CXR: mild b/l pulm edema and parenchymal opacities and no\\n pl effusion.\\n CXR: Persistent b/l pl effusions and bibasilar opacity.\\n CXR: Minimal improvement of mod b/l pl effusions. Otherwise\\n stable.\\n Microbiology: Ucx no growth final\\n Sputum: sparse GNRs, too few to colonize\\n Bcx x2 no growth final\\n 12/17 L BAL: Klebsiella Pneumoniae, HAEMOPHILUS SPECIES NOT INFLUENZAE\\n R BAL: Klebsiella Pneumoniae, Proteus.\\n 12/20 L &R BAL: Klebsiella Pneumoniae\\n BCX: p\\n BCx: P\\n UCx: no growth final\\n BCx: P\\n BCx: P\\n UCx: P\\n SpCx: P\\n Assessment and Plan\\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, now\\n with AF with RVR/Aflutter, persistant hypotension and PNA.\\n Neurologic: s/p trach (). Per ortho spine, no surgery; HOB<30,\\n TLSO when OOB. Zyprexa & Ativan PRN (off fent/midaz ).\\n Neuro checks Q: shift\\n Pain: Oxycodone, Neurontin, Tylenol.\\n Cardiovascular: Aflutter, now reverted to sinus w/1st deg AVB. Likely\\n cardiac contusion. Cards rec 400'' x 1wk, then 400'x1 wk, then\\n 200'. also rec changing dilt to metop 25''. Pt cannot be fully\\n anticoagulated for now (trauma). Will concentrate meds.\\n Pulmonary: Intubated, weaning, Vanc/cipro/cefepime for VAP ().\\n Increasing pulmonary edema on CXR (lasix x 2 on , lasix x1\\n ).\\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin (declining 6.8\\n max ->5.0) w/CT scan suggesting cirrhosis - Hepatitis panel NEG. TFs\\n restarted, increasing to goal . Bowel regimen. Will concentrate\\n TFs or change to a different type.\\n Nutrition: Tube feeding\\n Renal: Foley, monitor UOP, edematous scrotum. Lasix 10 x2 on ,\\n lasix x1 . Lasix 20 x1 , if tolerates 20 Q6.\\n Hematology: Hct stable 32.1->29.7. Plt stable (100's); d/c'd H2B. Heme\\n onc c/s - smear nl; no hemolysis. IVC filter placed.\\n Endocrine: RISS\\n Infectious Disease: Check cultures, WBC droppping\\n 13.1->8.8->4.2->5.9->6.3, Vanc/cipro/cefepime for VAP given worsening\\n pulm status. B/l LENIS to r/o DVT as source. Fever 101.1 o/n, re-pan\\n cx.\\n Lines / Tubes / Drains: Trach/Peg/foley/L radial a-line/R SCL\\n Wounds:\\n Imaging: CXR today\\n Fluids: KVO\\n Consults: Trauma (1o), Ortho Spine, Ortho trauma, Heme\\n Billing Diagnosis: (Respiratory distress: Failure), (Shock: Traumatic),\\n Multiple injuries (Trauma)\\n ICU Care\\n Nutrition: Replete with Fiber (Full) - 04:12 AM 80 mL/hour\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n Multi Lumen - 04:41 PM\\n Arterial Line - 11:30 AM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin\\n Stress ulcer: PPI\\n VAP bundle: HOB elevation, Mouth care\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds , Family\\n meeting planning, ICU consent signed Comments:\\n Code status: Full code\\n Disposition: ICU\\n Total time spent: 33 minutes\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2175-02-06 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 715198,\n \"text\": \"Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Trached. Vent settings as charted in metavision. LS rhonchorous at\\n times. Sats WNL. Afebrile. WBC count trending down.\\n Action:\\n Pulmonary hygiene. Cefepime, cipro, and vanco administered as\\n ordered. Vent weaned to . ABG drawn. Diamox administered as\\n ordered.\\n Response:\\n Moderate amounts of thick, tan secretions. ABG WNL. Diamox to\\n continue for two more doses. Diuresing well, -3L for yesterday\\n ().\\n Plan:\\n ? trach mask today. Begin rehab screening. Administer abx as\\n ordered. Monitor I/O\\n IV access: PICC placed on currently midline, NOT central.\\n Patient did not want IV team to change it; patient preferred them to\\n come later today (). HO aware. Discontinue subclavian line once\\n PICC placement is confirmed.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2175-01-31 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 714237,\n \"text\": \"Hypotension (not Shock)\\n Assessment:\\n Cont in aflutter with controlled rate. SBP remains > 90 on neo gtt.\\n Gd csm. Adequate u/o.\\n Action:\\n Neo gtt titrated to support sbp. Remains on dilt 60mg po qid.\\n Response:\\n Stable sbp on neo gtt. Remains in aflutter of diltiazem. Lytes wnl.\\n Stable hct.\\n Plan:\\n Cont to monitor hemodynamics and titrate neo to SBP >90. Monitor u/o,\\n lytes.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Remains on psv 10/10peep w/ no change in abg\\ns. Stable 02sats. Sxned\\n for moderate amt thick yellow and white secretions. LS clear,\\n diminished. SRR 20\\ns. Poor toleration of ett. Pt cont on midaz and\\n Fentanyl and is now on ketamine for a study protocol w/ ATC ativan x4\\n doses. Midaz briefly weaned off and pt lightened enough to open eyes\\n and follow simple commands and then became increasingly agitated and\\n unable to focus.\\n Attempting to bite ETT and tongue out ETT. Unable to ventilate at that\\n time.\\n Action:\\n Resedated and maintained sedated for safety overnoc. Pulm toilet.\\n Response:\\n More heavily sedated until ativan wore off. Sedation adjusted\\n accordingly. Cont to open eyes and MAE but agitated when light and\\n airway at risk. Stable on present vent settings.\\n Plan:\\n Cont pulm toilet. Monitor 02sats and abg\\ns. Cont sedation for airway\\n protection. Possibility of Trach to be discussed with family.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2175-02-06 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 715192,\n \"text\": \"Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Trached. Vent settings as charted in metavision. LS rhonchorous at\\n times. Sats WNL. Afebrile. WBC count trending down.\\n Action:\\n Pulmonary hygiene. Cefepime, cipro, and vanco administered as\\n ordered. Vent weaned to . ABG drawn. Diamox given.\\n Response:\\n Moderate amounts of thick, tan secretions. ABG WNL. Diamox to\\n continue for two more doses. Diuresing well, -3L for yesterday\\n ().\\n Plan:\\n ? trach mask today. Begin rehab screening. Administer abx as ordered.\\n IV access: PICC placed on currently midline, NOT central.\\n Patient did not want IV team to change it; patient preferred them to\\n come later today (). HO aware. Discontinue subclavian line once\\n PICC placement is confirmed.\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2175-02-07 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 715347,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 14\\n Ideal body weight: 0 None\\n Ideal tidal volume: 0 / 0 / 0 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: Yes\\n Tube Type\\n Tracheostomy tube:\\n Type: Standard\\n Manufacturer: Portex\\n Size: 8.0mm\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 27 cmH2O\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Diminished\\n Secretions\\n Sputum color / consistency: Yellow / Thick\\n Sputum source/amount: Suctioned / Moderate\\n Ventilation Assessment\\n Level of breathing assistance: Continuous invasive ventilation\\n Visual assessment of breathing pattern: Normal quiet breathing;\\n Comments: pt continues to require frequent suctioning\\n Assessment of breathing comfort: No claim of dyspnea)\\n Invasive ventilation assessment:\\n Trigger work assessment: Triggering synchronously\\n Plan\\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\\n Comments: attempt to wean off vent to trach collar as tolerated\\n Reason for continuing current ventilatory support: Intolerant of\\n weaning attempts, Underlying illness not resolved\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2175-02-06 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 715177,\n \"text\": \"TSICU\\n HPI:\\n 74M s/p fall from tractor and crush injury from tree branch. +Loc.\\n Chief complaint:\\n ventilator dependance\\n PMHx:\\n PMH: cirrhosis and asbestosis dx on CT\\n Current medications:\\n Acetaminophen 4. AcetaZOLamide 5. Amiodarone 6. Bisacodyl 7. Calcium\\n Gluconate 8. CefePIME\\n 9. Chlorhexidine Gluconate 0.12% Oral Rinse 10. Ciprofloxacin HCl 11.\\n Dextrose 50% 12. Diltiazem\\n 13. Docusate Sodium (Liquid) 14. Furosemide 15. Furosemide 16.\\n Gabapentin 17. Glucagon 18. Heparin\\n 19. Heparin Flush (10 units/ml) 20. 21. Insulin 22. Lactulose 23.\\n Lansoprazole Oral Disintegrating Tab\\n 24. Magnesium Sulfate 25. Metoprolol Tartrate 26. Milk of Magnesia 27.\\n Olanzapine (Disintegrating Tablet)\\n 28. Ondansetron 29. OxycoDONE Liquid 30. Pneumococcal Vac Polyvalent\\n 31. Potassium Phosphate 32. Potassium Chloride\\n 33. Senna 34. Sodium Chloride 0.9% Flush 35. Sodium Chloride 0.9% Flush\\n 36. Vancomycin\\n 24 Hour Events:\\n : Diamox continued. Lasix 20x2 with good result. PICC. Diamox decr\\n w/iatrogenic hyperchloremia, hypernatremia.\\n Post operative day:\\n POD#11 - IVC filter via L groin\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Vancomycin - 07:41 PM\\n Ciprofloxacin - 09:44 PM\\n Cefipime - 12:13 AM\\n Infusions:\\n Other ICU medications:\\n Lansoprazole (Prevacid) - 02:24 PM\\n Furosemide (Lasix) - 05:14 PM\\n Heparin Sodium (Prophylaxis) - 07:35 PM\\n Other medications:\\n Flowsheet Data as of 03:54 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 37.3\\nC (99.2\\n T current: 37.1\\nC (98.7\\n HR: 77 (73 - 98) bpm\\n BP: 103/42(60) {86/40(55) - 152/70(97)} mmHg\\n RR: 29 (20 - 34) insp/min\\n SPO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 104.2 kg (admission): 90 kg\\n Total In:\\n 2,020 mL\\n 451 mL\\n PO:\\n Tube feeding:\\n 960 mL\\n 152 mL\\n IV Fluid:\\n 470 mL\\n 119 mL\\n Blood products:\\n Total out:\\n 5,030 mL\\n 470 mL\\n Urine:\\n 5,030 mL\\n 470 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -3,010 mL\\n -19 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 442 (421 - 612) mL\\n PS : 5 cmH2O\\n RR (Spontaneous): 29\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n RSBI: 65\\n PIP: 16 cmH2O\\n SPO2: 98%\\n ABG: 7.40/32/123/21/-3\\n Ve: 13.5 L/min\\n PaO2 / FiO2: 308\\n Physical Examination\\n General Appearance: No acute distress, Anxious at times\\n HEENT: PERRL, EOMI\\n Cardiovascular: (Rhythm: Regular)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\\n bibasilar, occasional, Diminished: bibasilar), (Sternum: Stable )\\n Abdominal: Soft, Non-distended, Non-tender, Obese\\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present)\\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present)\\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\\n Moves all extremities\\n Labs / Radiology\\n 196 K/uL\\n 8.9 g/dL\\n 122 mg/dL\\n 1.1 mg/dL\\n 21 mEq/L\\n 3.6 mEq/L\\n 25 mg/dL\\n 117 mEq/L\\n 144 mEq/L\\n 28.2 %\\n 4.6 K/uL\\n [image002.jpg]\\n 06:07 PM\\n 01:55 AM\\n 02:04 AM\\n 08:00 AM\\n 11:35 AM\\n 03:56 PM\\n 05:09 PM\\n 08:00 PM\\n 01:36 AM\\n 02:16 AM\\n WBC\\n 5.2\\n 4.6\\n Hct\\n 28.4\\n 28.2\\n Plt\\n 178\\n 196\\n Creatinine\\n 1.0\\n 1.0\\n 1.1\\n TCO2\\n 29\\n 25\\n 25\\n 26\\n 21\\n Glucose\\n 119\\n 108\\n 120\\n 120\\n 138\\n 122\\n Other labs: PT / PTT / INR:14.0/28.1/1.2, CK / CK-MB / Troponin\\n T:128/13/<0.01, ALT / AST:104/137, Alk-Phos / T bili:204/4.8, Amylase /\\n Lipase:54/52, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic\\n Acid:1.1 mmol/L, Albumin:2.3 g/dL, LDH:348 IU/L, Ca:8.1 mg/dL, Mg:2.4\\n mg/dL, PO4:3.5 mg/dL\\n Imaging: CT head OSH: Prelim No ICH or fx.\\n CT chest OSH: Mult rib fx: R anterolateral and posterior, L\\n posterior; Dependent consolidation, possible aspiration; T4 vertebral\\n body inf corner fx, no retropulsion; Comminuted spinous process fx\\n T2-8; Nondisplaced L T10 transverse process; Nondisplaced L clavicle\\n distal fx; Nondisplaced L scapula fx;\\n CT c spine OSH: Prelim No fx or malalignment. Multilevel\\n degenerative changes w/large post disk bulge at C4-5, narrowing the\\n spinal canal and deforming the thecal sac, acuity unknown. Marked\\n neuroforamenal narrowing @multiple levels.\\n CTA abd/pel Prelim: Medial R liver lobe contusion w/adj\\n hematoma, w/o evidence of active bleeding; Comminuted L pubic ramus\\n fracture w/assoc hematoma, with tiny focus of arterial bleeding/active\\n extravasation, and larger area of venous bleeding. Hematoma somewhat\\n larger than on OSH study. Nondisplaced, comminuted L iliac bone fx\\n w/adj iliac muscle hematoma, larger than on prior study, w/o active\\n extrav. Fx extends into L SIJ. Post R hepatic laceration/contusion\\n adjacent to calcified granuloma, w/small hematoma, w/out active\\n bleeding. Min displaced fx of R iliac bone extending to R SIJ.\\n Cirrhotic liver. Inc B pl effusions (small), w/inc atelectasis.\\n MRI: Mild compression deformity of L1 w/additional levels of\\n potential trabecular contusion @T10-11 also inf @T4 w/o retropulsion.\\n Multilevel degenerative changes w/moderate canal narrowing @T10-11\\n w/cord deformity & no abnl cord signal. Extensive edema throughout\\n paraspinal soft tissues, predominantly post w/in interspinous\\n ligaments. Incompletely eval'ed c-spine w/severe canal narrowing @C4-5\\n w/cord deformity and no abn cord signal.\\n CTA: no PE.\\n CXR: Moderate b/l pleural effusions are stable.\\n CXR: Cardiac size top nl, interval improvement of collapse LLL.\\n Collapse RLL. Atelectasis in lingula unchanged. Mod B pleural effusions\\n stable. No PTX.\\n CXR: Interval mild incr in cardiac size, b/l pl effusions,\\n & opacities @ bases,c/w overload\\n : R foot: Linear density projecting @ expected area of insertion\\n of Achilles to calcaneus, may be min avulsion fx or degenerative\\n changes. Otherwise no fx\\n CXR: b/l pl effusions\\n CXR: stable.\\n RUQ U/S: No perihepatic fluid collection. small amt perihepatic\\n free fluid persists. Small contusion in hepatic segment VII. No\\n gallstones or sig wall thickening/edema. CBD 4.5 mm\\n TTE: LVEF >55%, NL diastolic function, NL LV filling pressure\\n (PCWP<12mmHg), RV chamber size mildly dilated, mild TR\\n CXR: mild b/l pulm edema and parenchymal opacities and no\\n pl effusion.\\n CXR: Persistent b/l pl effusions and bibasilar opacity.\\n CXR: Minimal improvement of mod b/l pl effusions. Otherwise\\n stable.\\n CXR: no relevant change. B/L pleural effusions with basal\\n opacities. No evidence of newly appeared focal parenchymal opacities\\n suggesting pneumonia.\\n : No dvt\\n CXR: No change, B pleural effusions, no new infiltrates\\n CXR: stable\\n Microbiology: Ucx neg\\n Sputum: sparse GNRs, too few to colonize\\n Bcx x2 neg\\n 12/17 L BAL: Klebsiella Pneumoniae, HAEMOPHILUS SPECIES NOT INFLUENZAE\\n R BAL: Klebsiella Pneumoniae, Proteus.\\n 12/20 L &R BAL: Klebsiella Pneumoniae\\n BCX: neg\\n BCx: neg\\n UCx: neg\\n BCx: P\\n BCx: P\\n UCx: neg\\n SpCx: contamination\\n Assessment and Plan\\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, AF with\\n RVR/Aflutter, now in sinus, and PNA, s/p trach/PEG (), IVC filter\\n Neurologic: HOB<30, TLSO when OOB. Zyprexa 10'''\\n Neuro checks Q: shift\\n Pain: Oxycodone, Neurontin, Tylenol. Pain adequately controlled.\\n Cardiovascular: Aflutter->NSR, on Amio and diltizem 60 QID. Likely \\n cardiac contusion. Cards for Amio rec 400'' x 1wk, then 400'x1 wk, then\\n 200'. Pt cannot be fully anticoagulated for now (trauma).\\n Pulmonary: Trach, weaning vent ( currently), Vanc/cipro/cefepime for\\n VAP (). Improving pulmonary edema. Continued diuresis.\\n Gastrointestinal / Abdomen: Unknown elevated LFTs and bilirubin w/CT\\n scan suggesting cirrhosis - Hepatitis panel NEG, RUQ U/S r/o\\n gallbladder etiology, will continue to trend. Nutren 2.0 @ goal 40\\n cc/hr. Bowel regimen.\\n Nutrition: Tube feeding\\n Renal: Foley, monitor UOP, edematous scrotum. Diamox 250 q12 for\\n contraction alkalosis. Lasix 20x2 on . Hypernatremia,\\n hyperchloremia.\\n Hematology: Hct stable (28.2). Plt stable (178-196); d/c'd H2B. Heme\\n onc c/s - smear nl; no hemolysis. IVC filter.\\n Endocrine: RISS\\n Infectious Disease: WBC normal, on Vanc/cipro/cefepime for VAP given\\n worsening pulm status, f/u on cx\\n Lines / Tubes / Drains: Trach/Peg/foley/L radial a-line/L basilic PICC,\\n SCL (will d/c SCL once midline)\\n Wounds:\\n Imaging: CXR today\\n Fluids: KVO\\n Consults: Trauma (1o), Ortho Spine, Ortho trauma, Heme\\n Billing Diagnosis: (Shock: Unspecified), Multiple injuries (Trauma)\\n ICU Care\\n Nutrition:\\n Nutren 2.0 (Full) - 07:46 PM 40 mL/hour\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n Multi Lumen - 04:41 PM\\n Arterial Line - 11:30 AM\\n PICC Line - 06:02 PM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin, IVC filter\\n Stress ulcer: PPI\\n VAP bundle: HOB elevation, Mouth care\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds , ICU\\n Code status: Full code\\n Disposition: ICU\\n Total time spent: 33 minutes\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2175-02-06 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 715182,\n \"text\": \"TSICU\\n HPI:\\n 74M s/p fall from bed/standing? tx from osh () with\\n acetabular fracture. On w/u in ER, pt found to be increasingly\\n tachycardic with abdominal distention and hypotension; found to have\\n acetabular fracture, iliac crest fracture, increasing pelvic and\\n retroperitoneal hematomas. Coffee ground emesis x1 in ED.\\n Chief complaint:\\n pain\\n PMHx:\\n PMH: PVD, emphysema/COPD, dementia, seizure d/o, HTN, anemia, ?aortic\\n dissection in past; pureed food diet with honey thick liquids\\n PSH: s/p fem-fem bypass, c1-c2 fusion\\n Current medications:\\n 1000 mL NS 3. Acetaminophen 4. Albuterol 0.083% Neb Soln 5. Bisacodyl\\n 6. Calcium Gluconate\\n 7. Citalopram Hydrobromide 8. Clozapine 9. Clozapine 10. Dextrose 50%\\n 11. Docusate Sodium 12. Glucagon\\n 13. HYDROmorphone (Dilaudid) 14. Heparin 15. Insulin 16. Ipratropium\\n Bromide Neb 17. LeVETiracetam\\n 18. Magnesium Sulfate 19. Magnesium Sulfate 20. Metoprolol Tartrate 21.\\n Metoprolol Tartrate 22. Metoprolol Tartrate\\n 23. Metoprolol Tartrate 24. Multiple Vitamins Liq. 25. Olanzapine\\n (Disintegrating Tablet) 26. Ondansetron\\n 27. OxycoDONE (Immediate Release) 28. Pantoprazole 29. Pneumococcal Vac\\n Polyvalent 30. Potassium Chloride\\n 31. Potassium Chloride 32. Senna 33. Sodium Phosphate 34. Sodium\\n Chloride 0.9% Flush\\n 24 Hour Events:\\n : Persistent tachycardia. Metop inc to 37.5''-->50. Metop 5-10 mg\\n IV PRN hr>110 (ST w/PACs, PVCs), 2 mg Mg. SQH started. Chest PT, nebs.\\n NPO p MN for ORIF.\\n Post operative day:\\n POD#11 - IVC filter via L groin\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Vancomycin - 07:41 PM\\n Ciprofloxacin - 09:44 PM\\n Cefipime - 12:13 AM\\n Infusions:\\n Other ICU medications:\\n Lansoprazole (Prevacid) - 02:24 PM\\n Furosemide (Lasix) - 05:14 PM\\n Heparin Sodium (Prophylaxis) - 03:52 AM\\n Other medications:\\n Flowsheet Data as of 04:15 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 37.3\\nC (99.2\\n T current: 37.1\\nC (98.7\\n HR: 77 (73 - 98) bpm\\n BP: 103/42(60) {86/40(55) - 152/70(97)} mmHg\\n RR: 29 (20 - 34) insp/min\\n SPO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 104.2 kg (admission): 90 kg\\n Total In:\\n 2,020 mL\\n 456 mL\\n PO:\\n Tube feeding:\\n 960 mL\\n 157 mL\\n IV Fluid:\\n 470 mL\\n 120 mL\\n Blood products:\\n Total out:\\n 5,030 mL\\n 470 mL\\n Urine:\\n 5,030 mL\\n 470 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -3,010 mL\\n -14 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 442 (421 - 612) mL\\n PS : 5 cmH2O\\n RR (Spontaneous): 29\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n RSBI: 65\\n PIP: 16 cmH2O\\n SPO2: 98%\\n ABG: 7.40/32/123/21/-3\\n Ve: 13.5 L/min\\n PaO2 / FiO2: 308\\n Physical Examination\\n General Appearance: No acute distress, confused at times\\n HEENT: PERRL, EOMI\\n Cardiovascular: (Rhythm: Regular)\\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: No(t)\\n Resonant : ), (Breath Sounds: Rhonchorous : ), (Sternum: Stable )\\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present)\\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present)\\n Skin: (Incision: Clean / Dry / Intact)\\n Neurologic: (Awake / Alert / Oriented: x 1), Follows simple commands,\\n (Responds to: Verbal stimuli), Moves all extremities\\n Labs / Radiology\\n 196 K/uL\\n 8.9 g/dL\\n 122 mg/dL\\n 1.1 mg/dL\\n 21 mEq/L\\n 3.6 mEq/L\\n 25 mg/dL\\n 117 mEq/L\\n 144 mEq/L\\n 28.2 %\\n 4.6 K/uL\\n [image002.jpg]\\n 06:07 PM\\n 01:55 AM\\n 02:04 AM\\n 08:00 AM\\n 11:35 AM\\n 03:56 PM\\n 05:09 PM\\n 08:00 PM\\n 01:36 AM\\n 02:16 AM\\n WBC\\n 5.2\\n 4.6\\n Hct\\n 28.4\\n 28.2\\n Plt\\n 178\\n 196\\n Creatinine\\n 1.0\\n 1.0\\n 1.1\\n TCO2\\n 29\\n 25\\n 25\\n 26\\n 21\\n Glucose\\n 119\\n 108\\n 120\\n 120\\n 138\\n 122\\n Other labs: PT / PTT / INR:14.0/28.1/1.2, CK / CK-MB / Troponin\\n T:128/13/<0.01, ALT / AST:104/137, Alk-Phos / T bili:204/4.8, Amylase /\\n Lipase:54/52, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic\\n Acid:1.1 mmol/L, Albumin:2.3 g/dL, LDH:348 IU/L, Ca:8.1 mg/dL, Mg:2.4\\n mg/dL, PO4:3.5 mg/dL\\n Imaging: CT c-spine: s/p post c1-c2 fusion. metallic nail\\n through L lat C2 extends w/tip in retropharnyngeal/prevertebral jxn\\n soft tissues ant to C1. mild anterolisthesis of C4 over C5. very min\\n retrolisthesis C5 over C6. mult-level change. no acute fx seen.\\n pulmonary emphysema. coarse vertebral and carotid artery calcs. 6mm R\\n thyroid lobe hypodensity.\\n CT torso: 1.6 x 1.2 cm focal hypodensity in ant mediastinum\\n (S2:im15). ?focal hematoma vs thymic cystic lesion. No overlying\\n sternal fx or aortic injury. dense aortic calcs. LLL atelect/scarring.\\n comminuted, intra-art L acetabular fx involv ant &post columns and ext\\n to L sup pubic ramus. adj mod pelvic hematoma w/out active extrav.\\n hematoma crosses midline, extends superiorly ant to L psoas muscle and\\n iliacus. mild loss of ht of L2 & L3 vert bodies. Grade 1\\n spondylolisthesis L5/S1. bladder diverticula .\\n CT head: No acute ICH. opacification of inf L maxillary\\n sinus w/focal loss of ant inf L max sinus/ant L alveolar bone, adj soft\\n tissue swelling and foci of gas. ?infectious process involving L\\n alveolar process of maxilla, dental in nature vs chronic sinusitis vs\\n injury. recommend direct visualization.\\n CXR: No consolidation\\n CXR (pm): Increased lung volumes c/w emphysema. Peribronchial\\n cuffing and predominantly R-sided interstitial opacities likely fluid\\n overload. Subtle opacity @R apex ?superimposition of external\\n ventilator apparatus vs. consolidation.\\n Microbiology: SCx: contaminated\\n Assessment and Plan\\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, AF with\\n RVR/Aflutter, now in sinus, and PNA, s/p trach/PEG (), IVC filter.\\n Neurologic: HOB<30, TLSO when OOB. Zyprexa 10'''\\n Neuro checks Q: shift\\n Pain: Oxycodone, Neurontin, Tylenol. Pain adequately controlled.\\n Cardiovascular: Aflutter->NSR, on Amio and diltizem 60 QID. Likely \\n cardiac contusion. Cards for Amio rec 400'' x 1wk, then 400'x1 wk, then\\n 200'. Pt cannot be fully anticoagulated for now (trauma).\\n Pulmonary: Trach, weaning vent ( currently), Vanc/cipro/cefepime for\\n VAP (). Improving pulmonary edema. Continued diuresis.\\n Gastrointestinal / Abdomen: Unknown elevated LFTs and bilirubin w/CT\\n scan suggesting cirrhosis - Hepatitis panel NEG, RUQ U/S r/o\\n gallbladder etiology, will continue to trend. Nutren 2.0 @ goal 40\\n cc/hr. Bowel regimen.\\n RENAL: Foley, monitor UOP, edematous scrotum. Diamox 250 q12 for\\n contraction alkalosis. Lasix 20x2 on . Hypernatremia,\\n hyperchloremia.\\n Nutrition: Tube feeding\\n Renal: Foley\\n Hematology: Hct stable (28.2). Plt stable (178-196); d/c'd H2B. Heme\\n onc c/s - smear nl; no hemolysis. IVC filter.\\n Endocrine: RISS\\n Infectious Disease: Check cultures, WBC normal (4.6), on\\n Vanc/cipro/cefepime for VAP given worsening pulm status, f/u on cx\\n Lines / Tubes / Drains: Trach/Peg/foley/L radial a-line/L basilic PICC,\\n SCL (will d/c SCL once midline)\\n Wounds:\\n Imaging: CXR today\\n Fluids: KVO\\n Consults: Trauma (1o), Ortho Spine, Ortho trauma, Heme\\n Billing Diagnosis: (Shock: Unspecified), Multiple injuries (Trauma)\\n ICU Care\\n Nutrition:\\n Nutren 2.0 (Full) - 07:46 PM 40 mL/hour\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n Multi Lumen - 04:41 PM\\n Arterial Line - 11:30 AM\\n PICC Line - 06:02 PM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin, IVC filter\\n Stress ulcer: PPI\\n VAP bundle:\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds , Family\\n meeting planning, ICU consent signed Comments:\\n Code status: Full code\\n Disposition: ICU\\n Total time spent: 33 minutes\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2175-02-06 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 715190,\n \"text\": \"Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Trached. Vent settings as charted in metavision. LS rhonchorous at\\n times. Sats WNL. Afebrile. WBC count trending down.\\n Action:\\n Pulmonary hygiene. Cefepime, cipro, and vanco administered as\\n ordered. Vent weaned to . ABG drawn.\\n Response:\\n Moderate amounts of thick, tan secretions. ABG WNL.\\n Plan:\\n ? trach mask today. Begin rehab screening. Administer abx as ordered.\\n IV access: PICC placed on currently midline, NOT central.\\n Patient did not want IV team to change it; patient preferred them to\\n come later today (). HO aware. Discontinue subclavian line once\\n PICC placement is confirmed.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2175-02-06 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 715281,\n \"text\": \"74M s/p crushing injury d/t falling tree. Injuries sustained include\\n multiple R sided rib fxs, grade 2 liver lac (w/ assoc hepatic vessel\\n extravasation), stable pelvis fxs (w/ associated extravasation), R\\n ramus fx, clavicle fx, and T4 vertebral body fx. Episodes of A.\\n Flutter with RVR and aflutter, now with resp failure and newly dx\\n pneumonia as of .\\n intubated for resp distress\\n angio embolization of hepatic and pelvic arterial bleeders\\n IVC filter in OR\\n self extubated and re-intubated immediately after d/t acute resp.\\n failure\\n Trach and PEG at bedside\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2175-02-06 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 715187,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 13\\n Ideal body weight: 0 None\\n Ideal tidal volume: 0 / 0 / 0 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: Yes\\n Tube Type\\n Tracheostomy tube:\\n Type: Standard\\n Manufacturer: Portex\\n Size: 8.0mm\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 26 cmH2O\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Rhonchi\\n LUL Lung Sounds: Rhonchi\\n LLL Lung Sounds: Diminished\\n Secretions\\n Sputum color / consistency: Tan / Thick\\n Sputum source/amount: Suctioned / Moderate\\n Ventilation Assessment\\n Level of breathing assistance: Continuous invasive ventilation\\n Visual assessment of breathing pattern: Normal quiet breathing\\n Assessment of breathing comfort: No claim of dyspnea)\\n Invasive ventilation assessment:\\n Trigger work assessment: Triggering synchronously\\n Plan\\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\\n Comments: wean off ventilator to trach mask as tolerated\\n Reason for continuing current ventilatory support: Intolerant of\\n weaning attempts, Underlying illness not resolved\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2175-02-05 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 715129,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 12\\n Ideal body weight: 0 None\\n Ideal tidal volume: 0 / 0 / 0 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: Yes\\n Procedure location:\\n Reason:\\n Tracheostomy tube:\\n Type: Standard\\n Manufacturer: Portex\\n Size: 8.0mm\\n PMV:\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 28 cmH2O\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Diminished\\n Comments:\\n Secretions\\n Sputum color / consistency: Tan / Thick\\n Sputum source/amount: Suctioned / Moderate\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance: Continuous invasive ventilation\\n Visual assessment of breathing pattern: Normal quiet breathing;\\n Comments: pt weaned to PSV 10/5 tolerated well\\n Assessment of breathing comfort: No claim of dyspnea)\\n Plan\\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\\n Comments: plan to continue to wean toward TM as tolerated\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2175-02-07 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 715332,\n \"text\": \"Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Remains on psv 10, 5peep and 40% with stable abg and 02sats. Remains\\n tachypneic, 30\\ns but denies distress. LS w/ rhonci throughout.\\n Copious thick yellow secretions. Strong productive cough but cannot\\n clear.\\n Action:\\n Pulm toilet, Frequent suctioning required.\\n Response:\\n Stable on psv 10/5 but cont with copious secretions despite frequent\\n sxning.\\n Plan:\\n Will attempt psv 5 in am and recheck ABG. Not ready for TM due to\\n copious secretions and tachpynea. Cont w/ oob to chair as tolerated.\\n Cont pulm toilet.\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2175-02-05 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 715024,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 12\\n Ideal body weight: 0 None\\n Ideal tidal volume: 0 / 0 / 0 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: Yes\\n Tube Type\\n Tracheostomy tube:\\n Type: Standard\\n Manufacturer: Portex\\n Size: 8.0mm\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 28 cmH2O\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Diminished\\n Secretions\\n Sputum color / consistency: Yellow / Thick\\n Sputum source/amount: Suctioned / Moderate\\n Ventilation Assessment\\n Level of breathing assistance: Continuous invasive ventilation\\n Visual assessment of breathing pattern: Normal quiet breathing\\n Assessment of breathing comfort: No claim of dyspnea)\\n Invasive ventilation assessment:\\n Trigger work assessment: Triggering synchronously\\n Plan\\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\\n tolerated, Reduce PEEP as tolerated\\n Reason for continuing current ventilatory support: Intolerant of\\n weaning attempts, Underlying illness not resolved\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2175-02-06 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 715171,\n \"text\": \"Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Trached. Vent settings as charted in metavision. LS rhonchorous at\\n times. Sats WNL. Afebrile. WBC count trending down.\\n Action:\\n Pulmonary hygiene. Cefepime, cipro, and vanco administered as\\n ordered. ABG drawn.\\n Response:\\n Plan:\\n Continue to wean vent settings. ? trach mask today. Begin rehab\\n screening. Administer abx as ordered.\\n IV access: PICC placed on currently midline, NOT central.\\n Patient did not want IV team to change it; patient preferred them to\\n come later today (). HO aware. Discontinue subclavian line once\\n PICC placement is confirmed.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2175-02-07 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 715325,\n \"text\": \"TSICU\\n HPI:\\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\\n checked and 1.5, 1 more unit FFP given\\n Chief complaint:\\n Mult rib fx: R anterolateral and post, L posterior\\n T4 vert body inf corner fx\\n Commin spinous process fx T2-8\\n Nondisplaced L T10 transverse process\\n Nondispaced L distal clavicle\\n Nondisplaced L clavicle fx\\n R medial lobe liver contusion w/hematoma\\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny focus of arterial\\n bleeding/active extravasation, and larger area of venous bleeding\\n Nondisplaced, comminuted L iliac bone fx w/adjacent iliac muscle\\n hematoma, extends into L SIJ.\\n Minimally displaced fx of R iliac bone extending to R SIJ.\\n PMHx:\\n cirrhosis and asbestosis dx on CT\\n Current medications:\\n Acetaminophen\\n Amiodarone\\n Bisacodyl\\n Chlorhexidine Gluconate 0.12% Oral Rinse\\n Diltiazem\\n Docusate Sodium (Liquid)\\n Furosemide\\n Gabapentin\\n Lansoprazole Oral Disintegrating Tab\\n Metoprolol Tartrate\\n Milk of Magnesia\\n Olanzapine (Disintegrating Tablet)\\n Ondansetron\\n OxycoDONE Liquid\\n 24 Hour Events:\\n MIDLINE - START 11:37 AM\\n Post operative day:\\n POD#12 - IVC filter via L groin\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Vancomycin - 07:41 PM\\n Ciprofloxacin - 09:44 PM\\n Cefipime - 12:31 PM\\n Infusions:\\n Other ICU medications:\\n Heparin Sodium (Prophylaxis) - 08:04 PM\\n Other medications:\\n Flowsheet Data as of 03:31 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 38.1\\nC (100.6\\n T current: 37.6\\nC (99.6\\n HR: 70 (70 - 106) bpm\\n BP: 92/42(58) {87/42(57) - 158/70(98)} mmHg\\n RR: 27 (22 - 38) insp/min\\n SPO2: 99%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 96 kg (admission): 90 kg\\n Total In:\\n 1,686 mL\\n 134 mL\\n PO:\\n Tube feeding:\\n 854 mL\\n 134 mL\\n IV Fluid:\\n 202 mL\\n Blood products:\\n Total out:\\n 2,930 mL\\n 280 mL\\n Urine:\\n 2,930 mL\\n 280 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,244 mL\\n -145 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 417 (413 - 534) mL\\n PS : 10 cmH2O\\n RR (Spontaneous): 33\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n PIP: 16 cmH2O\\n SPO2: 99%\\n ABG: 7.42/35/85./22/0\\n Ve: 15 L/min\\n PaO2 / FiO2: 213\\n Physical Examination\\n General Appearance: No acute distress\\n HEENT: PERRL, EOMI\\n Cardiovascular: (Rhythm: Regular)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\\n Rhonchorous : Bilateral)\\n Abdominal: Soft, Non-distended, Non-tender\\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\\n pedis: Present), (Pulse - Posterior tibial: Present)\\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\\n pedis: Present), (Pulse - Posterior tibial: Present)\\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\\n (Responds to: Verbal stimuli), Moves all extremities\\n Labs / Radiology\\n 201 K/uL\\n 8.6 g/dL\\n 112 mg/dL\\n 1.1 mg/dL\\n 22 mEq/L\\n 4.0 mEq/L\\n 28 mg/dL\\n 123 mEq/L\\n 150 mEq/L\\n 26.7 %\\n 4.6 K/uL\\n [image002.jpg]\\n 03:56 PM\\n 05:09 PM\\n 08:00 PM\\n 01:36 AM\\n 02:16 AM\\n 04:51 AM\\n 08:00 AM\\n 02:19 PM\\n 07:31 PM\\n 02:23 AM\\n WBC\\n 4.6\\n 4.6\\n 4.6\\n Hct\\n 28.2\\n 28.2\\n 26.7\\n Plt\\n 196\\n 196\\n 201\\n Creatinine\\n 1.0\\n 1.1\\n 1.1\\n TCO2\\n 26\\n 21\\n 22\\n 23\\n Glucose\\n 120\\n 138\\n 122\\n 169\\n 112\\n Other labs: PT / PTT / INR:14.0/28.1/1.2, CK / CK-MB / Troponin\\n T:30/13/<0.01, ALT / AST:89/100, Alk-Phos / T bili:250/2.7, Amylase /\\n Lipase:54/52, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic\\n Acid:1.1 mmol/L, Albumin:2.3 g/dL, LDH:348 IU/L, Ca:7.7 mg/dL, Mg:2.4\\n mg/dL, PO4:2.8 mg/dL\\n Imaging: CXR: stable\\n CXR: stable\\n LUE U/S: neg\\n Microbiology: Ucx neg\\n Sputum: sparse GNRs, too few to colonize\\n Bcx x2 neg\\n 12/17 L BAL: Klebsiella Pneumoniae, HAEMOPHILUS SPECIES NOT INFLUENZAE\\n R BAL: Klebsiella Pneumoniae, Proteus.\\n 12/20 L &R BAL: Klebsiella Pneumoniae\\n BCX: neg\\n BCx: neg\\n UCx: neg\\n BCx: P\\n BCx: P\\n UCx: neg\\n SpCx: contamination\\n Assessment and Plan\\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, AF with\\n RVR/Aflutter, now in sinus, and PNA, s/p trach/PEG (), IVC filter.\\n Neurologic: HOB<30, TLSO when OOB. Zyprexa '''\\n Neuro checks Q shift\\n Cardiovascular: Aflutter->NSR, on Amio and diltizem 60 QID. Likely \\n cardiac contusion. Cards rec'd Amio 400'' x 1wk, then 400'x1 wk, then\\n 200'. Pt cannot be fully anticoagulated for now (trauma).\\n Will consider electrical cardioversion if goes back into Aflutter/AF\\n and difficult to control.\\n Pulmonary: Trach, weaning vent ( currently), continue TM trials,\\n Cipro/cefepime for VAP () tx for 7 days. Vanc d/c().\\n Continue diuresis.\\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin w/CT scan\\n suggesting cirrhosis - Hepatitis panel NEG, RUQ U/S neg for GB\\n etiology, will continue to trend. Nutren 2.0 @ goal 40 cc/hr. Bowel\\n regimen.\\n Nutrition: Tube feeding\\n Renal: Foley, monitor UOP, edematous scrotum. Goal 1-1.5 L neg.\\n Hypernatremic to 150, approx. free H20 deficit 3.2L, treating with D5W\\n @150cc/hr, will check Na Q6.\\n Hematology: Hct stable. Plt stable (178-196); d/c'd H2B. Heme onc c/s\\n - smear nl; no hemolysis. IVC filter.\\n Endocrine: RISS\\n Infectious Disease: WBC normal, on cipro/cefepime for VAP () x 7\\n days, Vanc .\\n Lines / Tubes / Drains: Trach/PEG/foley/L radial a-line/L basilic\\n Midline\\n Wounds:\\n Imaging: CXR today\\n Fluids: KVO\\n Consults: Trauma surgery, Ortho, Ortho-spine, Hem / Onc\\n Billing Diagnosis:\\n ICU Care\\n Nutrition:\\n Nutren 2.0 (Full) - 03:41 PM 40 mL/hour\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n Arterial Line - 11:30 AM\\n Midline - 11:37 AM\\n Prophylaxis:\\n DVT: SQ UF Heparin, IVC filter\\n Stress ulcer: PPI\\n VAP bundle: HOB elevation, Mouth care, Daily wake up\\n Comments:\\n Communication: ICU consent signed Comments:\\n Code status: Full code\\n Disposition: Transfer to rehab / long term facility\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2175-02-07 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 715382,\n \"text\": \"TSICU\\n HPI:\\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\\n checked and 1.5, 1 more unit FFP given\\n Chief complaint:\\n Mult rib fx: R anterolateral and post, L posterior\\n T4 vert body inf corner fx\\n Commin spinous process fx T2-8\\n Nondisplaced L T10 transverse process\\n Nondispaced L distal clavicle\\n Nondisplaced L clavicle fx\\n R medial lobe liver contusion w/hematoma\\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny focus of arterial\\n bleeding/active extravasation, and larger area of venous bleeding\\n Nondisplaced, comminuted L iliac bone fx w/adjacent iliac muscle\\n hematoma, extends into L SIJ.\\n Minimally displaced fx of R iliac bone extending to R SIJ.\\n PMHx:\\n cirrhosis and asbestosis dx on CT\\n Current medications:\\n Acetaminophen\\n Amiodarone\\n Bisacodyl\\n Chlorhexidine Gluconate 0.12% Oral Rinse\\n Diltiazem\\n Docusate Sodium (Liquid)\\n Furosemide\\n Gabapentin\\n Lansoprazole Oral Disintegrating Tab\\n Metoprolol Tartrate\\n Milk of Magnesia\\n Olanzapine (Disintegrating Tablet)\\n Ondansetron\\n OxycoDONE Liquid\\n 24 Hour Events:\\n MIDLINE - START 11:37 AM\\n - U/S neg for DVT in UE. Diuresed 1.2 L. On free water for\\n hypernatremia. Failed TM trial yesterday. Overnight on .\\n Post operative day:\\n POD#12 - IVC filter via L groin\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Vancomycin - 07:41 PM\\n Ciprofloxacin - 09:44 PM\\n Cefipime - 12:31 PM\\n Infusions:\\n Other ICU medications:\\n Heparin Sodium (Prophylaxis) - 08:04 PM\\n Other medications:\\n Flowsheet Data as of 03:31 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 38.1\\nC (100.6\\n T current: 37.6\\nC (99.6\\n HR: 70 (70 - 106) bpm\\n BP: 92/42(58) {87/42(57) - 158/70(98)} mmHg\\n RR: 27 (22 - 38) insp/min\\n SPO2: 99%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 96 kg (admission): 90 kg\\n Total In:\\n 1,686 mL\\n 134 mL\\n PO:\\n Tube feeding:\\n 854 mL\\n 134 mL\\n IV Fluid:\\n 202 mL\\n Blood products:\\n Total out:\\n 2,930 mL\\n 280 mL\\n Urine:\\n 2,930 mL\\n 280 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,244 mL\\n -145 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 417 (413 - 534) mL\\n PS : 10 cmH2O\\n RR (Spontaneous): 33\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n PIP: 16 cmH2O\\n SPO2: 99%\\n ABG: 7.42/35/85./22/0\\n Ve: 15 L/min\\n PaO2 / FiO2: 213\\n Physical Examination\\n General Appearance: No acute distress\\n HEENT: PERRL, EOMI\\n Cardiovascular: (Rhythm: Regular)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\\n Rhonchorous : Bilateral)\\n Abdominal: Soft, Non-distended, Non-tender\\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\\n pedis: Present), (Pulse - Posterior tibial: Present)\\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\\n pedis: Present), (Pulse - Posterior tibial: Present)\\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\\n (Responds to: Verbal stimuli), Moves all extremities\\n Labs / Radiology\\n 201 K/uL\\n 8.6 g/dL\\n 112 mg/dL\\n 1.1 mg/dL\\n 22 mEq/L\\n 4.0 mEq/L\\n 28 mg/dL\\n 123 mEq/L\\n 150 mEq/L\\n 26.7 %\\n 4.6 K/uL\\n [image002.jpg]\\n 03:56 PM\\n 05:09 PM\\n 08:00 PM\\n 01:36 AM\\n 02:16 AM\\n 04:51 AM\\n 08:00 AM\\n 02:19 PM\\n 07:31 PM\\n 02:23 AM\\n WBC\\n 4.6\\n 4.6\\n 4.6\\n Hct\\n 28.2\\n 28.2\\n 26.7\\n Plt\\n 196\\n 196\\n 201\\n Creatinine\\n 1.0\\n 1.1\\n 1.1\\n TCO2\\n 26\\n 21\\n 22\\n 23\\n Glucose\\n 120\\n 138\\n 122\\n 169\\n 112\\n Other labs: PT / PTT / INR:14.0/28.1/1.2, CK / CK-MB / Troponin\\n T:30/13/<0.01, ALT / AST:89/100, Alk-Phos / T bili:250/2.7, Amylase /\\n Lipase:54/52, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic\\n Acid:1.1 mmol/L, Albumin:2.3 g/dL, LDH:348 IU/L, Ca:7.7 mg/dL, Mg:2.4\\n mg/dL, PO4:2.8 mg/dL\\n Imaging:\\n CXR: stable\\n CXR: stable\\n LUE U/S: neg\\n Microbiology: Ucx neg\\n Sputum: sparse GNRs, too few to colonize\\n Bcx x2 neg\\n 12/17 L BAL: Klebsiella Pneumoniae, HAEMOPHILUS SPECIES NOT INFLUENZAE\\n R BAL: Klebsiella Pneumoniae, Proteus.\\n 12/20 L &R BAL: Klebsiella Pneumoniae\\n BCX: neg\\n BCx: neg\\n UCx: neg\\n BCx: P\\n BCx: P\\n UCx: neg\\n SpCx: contamination\\n Assessment and Plan\\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, AF with\\n RVR/Aflutter, now in sinus, and PNA, s/p trach/PEG (), IVC filter.\\n Neurologic: HOB<30, TLSO when OOB. Zyprexa '''\\n Neuro checks Q shift. Pain well-controlled on regimen.\\n Cardiovascular: Aflutter->NSR, on Amio and diltizem 60 QID. Likely \\n cardiac contusion. Cards rec'd Amio 400'' x 1wk, then 400'x1 wk, then\\n 200'. Pt cannot be fully anticoagulated for now (trauma).\\n Remains in sinus, continue meds.\\n Pulmonary: Trach, weaning vent ( currently), continue TM trials,\\n Cipro/cefepime for VAP () tx for 7 days. Vanc d/c().\\n Continue diuresis as tolerated by hypernatremia.\\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin w/CT scan\\n suggesting cirrhosis - Hepatitis panel NEG, RUQ U/S neg for GB\\n etiology, will continue to trend. Nutren 2.0 @ goal 40 cc/hr. Increase\\n free water flushes to 100 q8. Bowel regimen.\\n Nutrition: Tube feeding\\n Renal: Foley, monitor UOP, edematous scrotum. Goal 1-1.5 L neg.\\n Hypernatremic to 150, approx. free H20 deficit 3.2L, treating with D5W\\n @150cc/hr, will check Na Q6\\n decrease IV free water as increase\\n flushes.\\n Hematology: Hct stable. Plt stable (178-196); d/c'd H2B. Heme onc c/s\\n - smear nl; no hemolysis. IVC filter.\\n Endocrine: RISS, goal BS<150.\\n Infectious Disease: WBC normal, on cipro/cefepime for VAP () x 7\\n days, Vanc .\\n Lines / Tubes / Drains: Trach/PEG/foley/L radial a-line/L basilic\\n Midline; attempt to obtain PIVs.\\n Wounds:\\n Imaging: CXR today\\n Fluids: KVO\\n Consults: Trauma surgery, Ortho, Ortho-spine, Hem / Onc\\n Billing Diagnosis:\\n ICU Care\\n Nutrition:\\n Nutren 2.0 (Full) - 03:41 PM 40 mL/hour\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n Arterial Line - 11:30 AM\\n Midline - 11:37 AM\\n Prophylaxis:\\n DVT: SQ UF Heparin, IVC filter\\n Stress ulcer: PPI\\n VAP bundle: HOB elevation, Mouth care\\n Comments:\\n Communication: ICU consent signed Comments:\\n Code status: Full code\\n Disposition: Transfer to rehab / long term facility\\n Total time spent: 32 mins\\n\"\n },\n {\n \"category\": \"Rehab Services\",\n \"chartdate\": \"2175-02-07 00:00:00.000\",\n \"description\": \"Physical Therapy Progress Note\",\n \"row_id\": 715393,\n \"text\": \"Subjective:\\n Objective:\\n Follow up PT visit to address goals of: . Patient seen today\\n for balance training, patient education\\n Updated medical status: UE US - No evidence of deep vein\\n thrombosis in the left arm; CXR pending\\n Activity\\n Clarification\\n I\\n S\\n CG\\n Min\\n Mod\\n Max\\n Rolling:\\n\\n\\n\\n T\\n\\n Supine/\\n Sidelying to Sit:\\n\\n\\n\\n T\\n\\n Transfer:\\n\\n\\n\\n\\n\\n Sit to Stand:\\n\\n\\n\\n\\n X2\\n Ambulation:\\n\\n\\n\\n\\n\\n Stairs:\\n\\n\\n\\n\\n\\n Aerobic Activity Response:\\n Position\\n HR\\n BP\\n RR\\n O[2] sat\\n RPE\\n Rest\\n Supine\\n 88\\n 134/64\\n 20\\n 98% on CPAP\\n Activity\\n Sit\\n 108\\n 127/69\\n 45\\n 92% on CPAP\\n Recovery\\n Sit\\n 95\\n 145/71\\n 30\\n 96% on CPAP\\n Total distance walked:\\n Minutes:\\n Gait: able to stand and shift weight minimally in standing. Unable to\\n take any steps\\n Balance: S static sitting at edge of bed. Min A static standing with\\n posterior bias, able to anterior weight shift and laterally weight\\n shift. Tolerated static standing x3-4 minutes.\\n Education / Communication: Reviewed PT and d/c planning.\\n Communicated with nsg re: status.\\n Other: Total assist slide transfer to stretcher chair.\\n On CPAP 5/10 PEEP/PS, 40% FIO2\\n Denies pain\\n Assessment: 74 yo M s/p crush injury making excellent progress in PT\\n with mobility and endurance, continues to be limited by general\\n weakness a/w prolonged and complicated hospitalization. He is\\n demonstrating great motivation and has excellent rehab potential to\\n return to prior independent level of function. PT to continue to\\n follow daily at acute level\\n Anticipated Discharge: Rehab\\n Plan: continue with \\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2175-02-05 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 715018,\n \"text\": \"Trauma, s/p\\n Assessment:\\n N; Pt more alert and seems oriented, MAE and following commands.\\n Attempting to participate in care. Denies pain. Less restless.\\n CV: Remains in nsr, no ectopy. HR 70\\ns-90. Stable bp.\\n Resp: Sxned for copious thick secretions requiring lavage. Strong\\n productive cough. Cont on psv 12, 10 peep with stable abg. LS coarse\\n throughout.\\n Renal: Diuresing well from 1x dose lasix and cont on diamox. Brisk u/o\\n with negative body balance.\\n GI: tol tf at goal. No stool overnoc.\\n Heme: Stable\\n ID: cont on abx. Remains Afebrile.\\n Skin: Intact\\n Social: Family called, updated.\\n Action:\\n Zyprexa ATC. Cont on dilt and amioderone. Vigorous pulm toilet. Cont\\n on colace and lactulose.\\n Response:\\n Calmer and more appropriate. Intermittent sleep. Hemodynamically\\n stable. No stool, abd soft. Stable abg on psv, less tachypneic.\\n Diuresing well, alkalosis improved.\\n Plan:\\n Cont to monitor. Cont zyprexa, dilt and amio. OOB-chair as\\n tolerated. Pulm toilet. Wean as tolerated from vent. Diamox and\\n diurese as tolerated. Monitor temp, cont abx. Pt and family support.\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2175-01-26 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 713565,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 2\\n Ideal body weight: 0 None\\n Ideal tidal volume: 0 / 0 / 0 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: No\\n Tube Type\\n ETT:\\n Position: 23 cm at teeth\\n Route: Oral\\n Type: Standard\\n Size: 7.5mm\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 25 cmH2O\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Diminished\\n Comments:\\n Secretions\\n Sputum color / consistency: White / Thick\\n Sputum source/amount: Suctioned / Small\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance: Continuous invasive ventilation\\n Visual assessment of breathing pattern: Normal quiet breathing\\n Assessment of breathing comfort: No response (sleeping / sedated)\\n Plan\\n Next 24-48 hours: Reduce PEEP as tolerated\\n Reason for continuing current ventilatory support: Intolerant of\\n weaning attempts, Underlying illness not resolved\\n PEEP increased overnight due to low Pao2, pt responded well. Will wean\\n as tolerated.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2175-02-05 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 715101,\n \"text\": \"TSICU\\n HPI:\\n 74M s/p fall with multiple rib fx, pelvis fx, clavicle fx, and thoracic\\n fx c/b unstable bleeding s/p IR embo, AF with RVR/Aflutter, now in\\n sinus, and PNA.\\n Chief complaint:\\n Fall\\n PMHx:\\n none\\n Current medications:\\n 1. Acetaminophen 4. AcetaZOLamide 2. Amiodarone 3. Bisacodyl 4. Calcium\\n Gluconate 5. CefePIME 6. Chlorhexidine Gluconate 0.12% Oral Rinse 7.\\n Ciprofloxacin HCl 8. Dextrose 50% 9. Diltiazem 10. Docusate Sodium\\n (Liquid) 11. Furosemide 12. Gabapentin 13. Glucagon 14. Heparin 15.\\n Insulin\\n 16. Lactulose 17. Lansoprazole Oral Disintegrating Tab 18. Magnesium\\n Sulfate 19. Metoprolol Tartrate 20. Milk of Magnesia 21. Olanzapine\\n (Disintegrating Tablet) 22. Ondansetron 23. OxycoDONE Liquid 24.\\n Pneumococcal Vac Polyvalent 25. Potassium Chloride 26. Potassium\\n Phosphate 27. Potassium Chloride 28. Senna 32. Sodium Chloride 0.9%\\n Flush 30. Sodium Chloride 0.9% Flush 31. Vancomycin\\n 24 Hour Events:\\n Started Diamox 500 x4 for contraction alkalosis due to Lasix, also\\n given Lasix 20 IV x1 with 1774 off.\\n Diltiazem gtt stopped and restarted po.\\n d/c'd Haldol and started standing Zyprexa.\\n Post operative day:\\n POD#10 - IVC filter via L groin\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Vancomycin - 08:26 PM\\n Ciprofloxacin - 10:48 PM\\n Cefipime - 12:48 AM\\n Infusions:\\n Other ICU medications:\\n Furosemide (Lasix) - 06:00 PM\\n Heparin Sodium (Prophylaxis) - 03:48 AM\\n Other medications:\\n Flowsheet Data as of 05:16 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 38\\nC (100.4\\n T current: 37.4\\nC (99.4\\n HR: 87 (71 - 104) bpm\\n BP: 143/60(85) {83/38(59) - 158/63(90)} mmHg\\n RR: 27 (17 - 32) insp/min\\n SPO2: 99%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 104.2 kg (admission): 90 kg\\n Total In:\\n 1,956 mL\\n 136 mL\\n PO:\\n Tube feeding:\\n 560 mL\\n IV Fluid:\\n 1,006 mL\\n 76 mL\\n Blood products:\\n Total out:\\n 3,730 mL\\n 1,140 mL\\n Urine:\\n 3,730 mL\\n 1,140 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,774 mL\\n -1,004 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 379 (379 - 713) mL\\n PS : 12 cmH2O\\n RR (Spontaneous): 33\\n PEEP: 10 cmH2O\\n FiO2: 40%\\n RSBI Deferred: PEEP > 10\\n PIP: 24 cmH2O\\n SPO2: 99%\\n ABG: 7.45/35/169/24/1\\n Ve: 15.2 L/min\\n PaO2 / FiO2: 422\\n Physical Examination\\n General Appearance: No acute distress\\n HEENT: PERRL\\n Cardiovascular: (Rhythm: Regular)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\\n bilateral : )\\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\\n Left Extremities: (Edema: Trace), (Temperature: Warm)\\n Right Extremities: (Edema: Trace), (Temperature: Warm)\\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\\n Moves all extremities\\n Labs / Radiology\\n 178 K/uL\\n 8.8 g/dL\\n 108 mg/dL\\n 1.0 mg/dL\\n 24 mEq/L\\n 3.8 mEq/L\\n 23 mg/dL\\n 113 mEq/L\\n 143 mEq/L\\n 28.4 %\\n 5.2 K/uL\\n [image002.jpg]\\n 07:20 PM\\n 12:35 AM\\n 01:04 AM\\n 06:28 AM\\n 08:00 AM\\n 01:10 PM\\n 05:03 PM\\n 06:07 PM\\n 01:55 AM\\n 02:04 AM\\n WBC\\n 6.5\\n 5.2\\n Hct\\n 29.0\\n 28.4\\n Plt\\n 124\\n 178\\n Creatinine\\n 0.8\\n 0.9\\n 1.0\\n TCO2\\n 34\\n 32\\n 30\\n 29\\n 25\\n Glucose\\n 130\\n 103\\n 121\\n 130\\n 113\\n 119\\n 108\\n Other labs: PT / PTT / INR:14.0/28.1/1.2, CK / CK-MB / Troponin\\n T:128/13/<0.01, ALT / AST:104/137, Alk-Phos / T bili:204/4.8, Amylase /\\n Lipase:54/52, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic\\n Acid:1.1 mmol/L, Albumin:2.3 g/dL, LDH:348 IU/L, Ca:8.3 mg/dL, Mg:2.4\\n mg/dL, PO4:3.5 mg/dL\\n Assessment and Plan\\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, AF with\\n RVR/Aflutter, now in sinus, and PNA.\\n Neurologic: s/p trach (). Per ortho spine, no surgery; HOB<30,\\n TLSO when OOB. Zyprexa 10 TID (off fent/midaz ).\\n Neuro checks Q: shift\\n Pain: Oxycodone, Neurontin, Tylenol.\\n Cardiovascular: Aflutter->NSR, on Amio and diltizem 60 QID. Likely \\n cardiac contusion. Cards for Amio rec 400'' x 1wk, then 400'x1 wk, then\\n 200'. Pt cannot be fully anticoagulated for now (trauma).\\n Pulmonary: Trach, weaning vent, Vanc/cipro/cefepime for VAP ().\\n Improving pulmonary edema.\\n Gastrointestinal / Abdomen: Unknown elevated LFTs and bilirubin w/CT\\n scan suggesting cirrhosis - Hepatitis panel NEG, RUQ U/S r/o\\n gallbladder etiology, will continue to trend. On Nutren 2.0 with goal\\n 40 cc/hr. Bowel regimen.\\n Nutrition: Tube feeding\\n Renal: Foley, monitor UOP, edematous scrotum. Diamox 500 q12 x 4doses\\n for contraction alkalosis and Lasix 20 x1.\\n Hematology: Hct stable 28.9->29. Plt stable (100's); d/c'd H2B. Heme\\n onc c/s - smear nl; no hemolysis. IVC filter placed.\\n Endocrine: RISS\\n Infectious Disease: WBC normal, on Vanc/cipro/cefepime for VAP given\\n worsening pulm status, f/u on cx\\n Lines / Tubes / Drains: Trach/Peg/foley/L radial a-line/R SCL\\n Wounds:\\n Imaging: CXR today\\n Fluids: KVO\\n Consults: Trauma (1o), Ortho Spine, Ortho trauma, Heme\\n Billing Diagnosis:\\n ICU Care\\n Nutrition:\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n Multi Lumen - 04:41 PM\\n Arterial Line - 11:30 AM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin, IVC filter\\n Stress ulcer: PPI\\n VAP bundle:\\n Comments:\\n Communication: ICU consent signed Comments:\\n Code status: Full code\\n Disposition: ICU\\n Total time spent: 33 minutes\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2175-02-05 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 715092,\n \"text\": \"TSICU\\n HPI:\\n 74M s/p fall with multiple rib fx, pelvis fx, clavicle fx, and thoracic\\n fx c/b unstable bleeding s/p IR embo, AF with RVR/Aflutter, now in\\n sinus, and PNA.\\n Chief complaint:\\n Fall\\n PMHx:\\n none\\n Current medications:\\n 1. Acetaminophen 4. AcetaZOLamide 2. Amiodarone 3. Bisacodyl 4. Calcium\\n Gluconate 5. CefePIME 6. Chlorhexidine Gluconate 0.12% Oral Rinse 7.\\n Ciprofloxacin HCl 8. Dextrose 50% 9. Diltiazem 10. Docusate Sodium\\n (Liquid) 11. Furosemide 12. Gabapentin 13. Glucagon 14. Heparin 15.\\n Insulin\\n 16. Lactulose 17. Lansoprazole Oral Disintegrating Tab 18. Magnesium\\n Sulfate 19. Metoprolol Tartrate 20. Milk of Magnesia 21. Olanzapine\\n (Disintegrating Tablet) 22. Ondansetron 23. OxycoDONE Liquid 24.\\n Pneumococcal Vac Polyvalent 25. Potassium Chloride 26. Potassium\\n Phosphate 27. Potassium Chloride 28. Senna 32. Sodium Chloride 0.9%\\n Flush 30. Sodium Chloride 0.9% Flush 31. Vancomycin\\n 24 Hour Events:\\n Started Diamox 500 x4 for contraction alkalosis due to Lasix, also\\n given Lasix 20 IV x1 with 1774 off.\\n Diltiazem gtt stopped and restarted po.\\n d/c'd Haldol and started standing Zyprexa.\\n Post operative day:\\n POD#10 - IVC filter via L groin\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Vancomycin - 08:26 PM\\n Ciprofloxacin - 10:48 PM\\n Cefipime - 12:48 AM\\n Infusions:\\n Other ICU medications:\\n Furosemide (Lasix) - 06:00 PM\\n Heparin Sodium (Prophylaxis) - 03:48 AM\\n Other medications:\\n Flowsheet Data as of 05:16 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 38\\nC (100.4\\n T current: 37.4\\nC (99.4\\n HR: 87 (71 - 104) bpm\\n BP: 143/60(85) {83/38(59) - 158/63(90)} mmHg\\n RR: 27 (17 - 32) insp/min\\n SPO2: 99%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 104.2 kg (admission): 90 kg\\n Total In:\\n 1,956 mL\\n 136 mL\\n PO:\\n Tube feeding:\\n 560 mL\\n IV Fluid:\\n 1,006 mL\\n 76 mL\\n Blood products:\\n Total out:\\n 3,730 mL\\n 1,140 mL\\n Urine:\\n 3,730 mL\\n 1,140 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,774 mL\\n -1,004 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 379 (379 - 713) mL\\n PS : 12 cmH2O\\n RR (Spontaneous): 33\\n PEEP: 10 cmH2O\\n FiO2: 40%\\n RSBI Deferred: PEEP > 10\\n PIP: 24 cmH2O\\n SPO2: 99%\\n ABG: 7.45/35/169/24/1\\n Ve: 15.2 L/min\\n PaO2 / FiO2: 422\\n Physical Examination\\n General Appearance: No acute distress\\n HEENT: PERRL\\n Cardiovascular: (Rhythm: Regular)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\\n bilateral : )\\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\\n Left Extremities: (Edema: Trace), (Temperature: Warm)\\n Right Extremities: (Edema: Trace), (Temperature: Warm)\\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\\n Moves all extremities\\n Labs / Radiology\\n 178 K/uL\\n 8.8 g/dL\\n 108 mg/dL\\n 1.0 mg/dL\\n 24 mEq/L\\n 3.8 mEq/L\\n 23 mg/dL\\n 113 mEq/L\\n 143 mEq/L\\n 28.4 %\\n 5.2 K/uL\\n [image002.jpg]\\n 07:20 PM\\n 12:35 AM\\n 01:04 AM\\n 06:28 AM\\n 08:00 AM\\n 01:10 PM\\n 05:03 PM\\n 06:07 PM\\n 01:55 AM\\n 02:04 AM\\n WBC\\n 6.5\\n 5.2\\n Hct\\n 29.0\\n 28.4\\n Plt\\n 124\\n 178\\n Creatinine\\n 0.8\\n 0.9\\n 1.0\\n TCO2\\n 34\\n 32\\n 30\\n 29\\n 25\\n Glucose\\n 130\\n 103\\n 121\\n 130\\n 113\\n 119\\n 108\\n Other labs: PT / PTT / INR:14.0/28.1/1.2, CK / CK-MB / Troponin\\n T:128/13/<0.01, ALT / AST:104/137, Alk-Phos / T bili:204/4.8, Amylase /\\n Lipase:54/52, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic\\n Acid:1.1 mmol/L, Albumin:2.3 g/dL, LDH:348 IU/L, Ca:8.3 mg/dL, Mg:2.4\\n mg/dL, PO4:3.5 mg/dL\\n Assessment and Plan\\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, AF with\\n RVR/Aflutter, now in sinus, and PNA.\\n Neurologic: s/p trach (). Per ortho spine, no surgery; HOB<30,\\n TLSO when OOB. Zyprexa 10 TID (off fent/midaz ).\\n Neuro checks Q: shift\\n Pain: Oxycodone, Neurontin, Tylenol.\\n Cardiovascular: Aflutter->NSR, on Amio and diltizem 60 QID. Likely \\n cardiac contusion. Cards for Amio rec 400'' x 1wk, then 400'x1 wk, then\\n 200'. Pt cannot be fully anticoagulated for now (trauma).\\n Pulmonary: Trach, weaning vent, Vanc/cipro/cefepime for VAP ().\\n Improving pulmonary edema.\\n Gastrointestinal / Abdomen: Unknown elevated LFTs and bilirubin w/CT\\n scan suggesting cirrhosis - Hepatitis panel NEG, RUQ U/S r/o\\n gallbladder etiology, will continue to trend. On Nutren 2.0 with goal\\n 40 cc/hr. Bowel regimen.\\n Nutrition: Tube feeding\\n Renal: Foley, monitor UOP, edematous scrotum. Diamox 500 q12 x 4doses\\n for contraction alkalosis and Lasix 20 x1.\\n Hematology: Hct stable 28.9->29. Plt stable (100's); d/c'd H2B. Heme\\n onc c/s - smear nl; no hemolysis. IVC filter placed.\\n Endocrine: RISS\\n Infectious Disease: WBC normal, on Vanc/cipro/cefepime for VAP given\\n worsening pulm status, f/u on cx\\n Lines / Tubes / Drains: Trach/Peg/foley/L radial a-line/R SCL\\n Wounds:\\n Imaging: CXR today\\n Fluids: KVO\\n Consults: Trauma (1o), Ortho Spine, Ortho trauma, Heme\\n Billing Diagnosis:\\n ICU Care\\n Nutrition:\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n Multi Lumen - 04:41 PM\\n Arterial Line - 11:30 AM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin, IVC filter\\n Stress ulcer: PPI\\n VAP bundle:\\n Comments:\\n Communication: ICU consent signed Comments:\\n Code status: Full code\\n Disposition: ICU\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2175-02-06 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 715164,\n \"text\": \"Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Trached. Vent settings as charted in metavision. LS rhonchorous at\\n times. Sats WNL. Afebrile.\\n Action:\\n Pulmonary hygiene. Cefepime, cipro, and vanco administered as\\n ordered. ABG drawn.\\n Response:\\n Plan:\\n Continue to wean vent settings. ? trach mask today. Begin rehab\\n screening. Administer abx as ordered.\\n IV access: PICC placed on currently midline, NOT central.\\n Patient did not want IV to change it; patient preferred them to come\\n later today (). HO aware. Discontinue subclavian line once PICC\\n placement is confirmed.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2175-02-06 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 715167,\n \"text\": \"Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Trached. Vent settings as charted in metavision. LS rhonchorous at\\n times. Sats WNL. Afebrile. WBC count trending down.\\n Action:\\n Pulmonary hygiene. Cefepime, cipro, and vanco administered as\\n ordered. ABG drawn.\\n Response:\\n Plan:\\n Continue to wean vent settings. ? trach mask today. Begin rehab\\n screening. Administer abx as ordered.\\n IV access: PICC placed on currently midline, NOT central.\\n Patient did not want IV to change it; patient preferred them to come\\n later today (). HO aware. Discontinue subclavian line once PICC\\n placement is confirmed.\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2175-02-06 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 715258,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 13\\n Ideal body weight: 0 None\\n Ideal tidal volume: 0 / 0 / 0 mL/kg\\n Airway\\n Tracheostomy tube:\\n Type: Standard\\n Manufacturer: Portex\\n Size: 8.0mm\\n PMV:\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 26 cmH2O\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Rhonchi\\n LUL Lung Sounds: Rhonchi\\n LLL Lung Sounds: Diminished\\n Comments:\\n Secretions\\n Sputum color / consistency: White / Thick\\n Sputum source/amount: Suctioned / Moderate\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance: Continuous invasive ventilation\\n Visual assessment of breathing pattern: Tachypneic (RR> 35 b/min);\\n Comments: pt vent support increased to due to tachypnia into 40s\\n on \\n Assessment of breathing comfort: No claim of dyspnea)\\n Plan\\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\\n Comments: plan to wean vent support as tolerated down to trach mask\\n trials\\n Reason for continuing current ventilatory support:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2175-02-04 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 714991,\n \"text\": \"Atrial fibrillation (Afib)\\n Assessment:\\n Rate controlled all shift in sinus rhythm, Bp stable.\\n Action:\\n Diltiazem gtt weaned off and PO Dilt restarted.\\n Response:\\n HR and BP stable, no arrhythmias. Electrolytes checked and replaced as\\n needed.\\n Plan:\\n Continue PO medication regimen, taper Amio as ordered.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n LS clear to rhonchi but remain diminished at the bases. Strong\\n productive cough, expectorating and suctioning out thick yellow\\n secretions. ABG stable. SaO2 100%, RR WNL. UOP excellent with\\n dieresis.\\n Action:\\n Cont pulm toileting. OOB to chair for 4 hours today tolerated very\\n well. Diamox with Lasix times 1.\\n Response:\\n Mental status clearing. Weaned vent settings, ABG to be drawn.\\n Plan:\\n Continue to Dieresis, pulm toileting, wean vent settings as tolerated,\\n AM CXR ordered.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2175-02-07 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 715368,\n \"text\": \"Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Remains on psv 10, 5peep and 40% with stable abg and 02sats. Remains\\n tachypneic, 30\\ns but denies distress. LS w/ rhonci throughout.\\n Copious thick yellow secretions. Strong productive cough but cannot\\n clear.\\n Action:\\n Pulm toilet, Frequent suctioning . Weaned to psv 5 at 0600\\n Response:\\n Stable on psv 10/5 but cont with copious secretions despite frequent\\n sxning. More tachypneic on psv 5 pc02 28. denies sob, dyspnea.\\n Plan:\\n Placed back on psv 10 . recheck ABG. Not ready for TM due to copious\\n secretions and tachpynea. Cont w/ oob to chair as tolerated. Cont\\n pulm toilet.\\n Activity Intolerance\\n Assessment: Pt assisting with movement and aable to use swabs\\n independently with supervision. Washing face independently.\\n Action: Encourage pt to increase participation in care.\\n Response: More interactive and asking to do things for himself.\\n Plan: Increase activity as tolerated. Encourage participation in\\n care. Have pt assist with bath when oob-chair during the day.\\n Encourage normal sleep pattern.\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2175-02-04 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 714993,\n \"text\": \"Day of mechanical ventilation: 11\\n Airway Placement Data\\n Known difficult intubation: Yes\\n Tracheostomy tube:\\n Type: Standard\\n Manufacturer: Portex\\n Size: 8.0mm\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 28 cmH2O\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Diminished\\n Secretions\\n Sputum color / consistency: Yellow / Thick\\n Sputum source/amount: Suctioned / Moderate\\n Ventilation Assessment\\n Level of breathing assistance: CPAP/PSV\\n Assessment of breathing comfort: GOOD\\n Invasive ventilation assessment:\\n Trigger work assessment: GOOD\\n Dysynchrony assessment: LITTLE\\n Plan\\n Next 24-48 hours: Wean as tolerated\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2175-02-04 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 715001,\n \"text\": \"Atrial fibrillation (Afib)\\n Assessment:\\n Rate controlled all shift in sinus rhythm, Bp stable.\\n Action:\\n Diltiazem gtt weaned off and PO Dilt restarted.\\n Response:\\n HR and BP stable, no arrhythmias. Electrolytes checked and replaced as\\n needed.\\n Plan:\\n Continue PO medication regimen, taper Amio as ordered.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n LS clear to rhonchi but remain diminished at the bases. Strong\\n productive cough, expectorating and suctioning out thick yellow\\n secretions. ABG stable. SaO2 100%, RR WNL. UOP excellent with\\n dieresis.\\n Action:\\n Cont pulm toileting. OOB to chair for 4 hours today tolerated very\\n well. Diamox with Lasix times 1.\\n Response:\\n Mental status clearing. Weaned vent settings, ABG to be drawn.\\n Plan:\\n Continue to Dieresis, pulm toileting, wean vent settings as tolerated,\\n AM CXR ordered.\\n\"\n },\n {\n \"category\": \"Rehab Services\",\n \"chartdate\": \"2175-02-06 00:00:00.000\",\n \"description\": \"Occupational Therapy Evaluation Note\",\n \"row_id\": 715246,\n \"text\": \"History\\n Attending M.D.: \\n Referral Date: \\n Reason for Referral: evaluation and treatment\\n Medical Dx / ICD - 9: polytrauma/959.9\\n Activity Orders: activity as tolerated, TLSO when OOB\\n HPI / Subjective Complaint: 74 yo M admitted s/p fall from\\n tractor and crush injury from tree branch. Sustained multiple fib fxs\\n (R anterolateral and L posterior), R pulmonary contusion, T4 vertebral\\n teardrop fx, T2-T8 spinous process fx, nondisplaced L T10 transverse\\n process fx, nondisplaced L distal clavicle fx, R medial lobe liver\\n contusion with hematoma, comminuted L pubic ramus fx with hematoma,\\n nondisplaced comminuted L iliac bone fx extending into L SI joint with\\n adjacent iliac muscle hematoma, minimally displaced fx of R iliac bone\\n extending to R SI joint. Pt intubated for tachycardia and\\n increasing O2 requirement. Underwent angio on for embolization\\n of pelvic and hepatic vessels, IVC filter placed , and trach/peg\\n placement .\\n Past Medical / Surgical History: cirrhosis and asbestosis via imaging,\\n none per pt report\\n Medications: acetaminophen, cipro, cefepime, amiodarone, diltiazem,\\n oxycodone, gabapentin, metoprolol\\n Labs\\n Hematocrit (serum): 28.2 ...\\n Hemoglobin: 8.9 ... g/dl\\n WBC: 4.6 ...\\n Platelet Count: 196 ...\\n Radiology\\n Radiology: MRI t-spine: C4-5 cord deformity, otherwise imaging as\\n above\\n Occupational History\\n Occupational Profile: retired pipefitter, enjoys doing things around\\n the house\\n Performance Patterns: lives w/ wife, supportive family\\n Baseline Occupational Performance: I PTA, +driving\\n Environmental History: unable to assess difficulty communicating\\n via writing or mouthing words\\n Current Activities of Daily Living\\n Grooming: (min A)\\n UE Dressing: (mod A)\\n Toileting: (Dependent)\\n Specify: pt able to swab mouth and comb hair w/ min assist to sustain\\n activity due to UE fatigue. decreased grasp noted B. pt up in\\n stretcher chair, LE ADLs not assessed\\n Current Instrumental Activities of Daily Living\\n Home Management: Dependent\\n Money Management: Assist\\n Community Integration: Dependent\\n Performance Skills\\n Process Skills: alert and oriented to person, place, situation, month,\\n year, time. following 1-step commands\\n Communication / Interactive Skills: mouthing words w/ fair\\n intelligibility, unable to communicate via written words given\\n tremulousness and illegibility. provided communication board but did\\n not attempt to use.\\n Motor Skills - Functional Transfers\\n Functional Transfers Clarification: pt just gotten OOB w/ PT, TBA\\n Functional Balance: pt reclined in stretcher chair\\n Aerobic Capacity: Rest\\n Rest HR: 90\\n Rest BP: 117/47\\n Rest RR: 34\\n Rest O2 sat: 98 %\\n Supplemental O2: on CPAP\\n Aerobic Capacity: Activity\\n Activity HR: 86\\n Activity BP: 116/48\\n Activity RR: 35\\n Activity O2 sat: 98 %\\n Supplemental O2: on CPAP\\n Aerobic Capacity: Recovery\\n Recovery HR: 87\\n Recovery BP: 107/48\\n Recovery RR: 32\\n Recovery O2 sat: 97 %\\n Supplemental O2: on CPAP\\n Range of Motion\\n Range of Motion: full PROM R UE, unable to tolerate >100degress\\n shoulder flexion on L, otherwise WNL\\n Muscle Performance: strength, power, endurance\\n Muscle Performance: R UE , grip 4-/5\\n L UE: shoulder flexion, otherwise , grip 4-/5\\n Additional Performance Skills\\n Motor Control: moving B UE in isolation, significant tremors w/ gross\\n and fine motor movements\\n Coordination: impaired B due to mm fatigue and deconditioning\\n Pain (0 - 10): 2 / 10\\n Limiting Symptoms: discomfort. unable to tolerate full L shoulder\\n range 2/2 c/o pain further PROM deferred w/ pain resolved.\\n Sensation: intact LT b UE\\n Integumentary: trach, peg, foley, tele, PIV, TLSO, R eyebrow lac w/\\n sutures in place\\n Team Communication: RN aware of pt functional status and recs for\\n encouragement of self care and use of L UE.\\n Patient Education: role of OT, d/c recs for rehab, recs for self care\\n as able and to increase use of L UE as tolerated.\\n Other: pt and call bell in reach\\n Diagnosis\\n Diagnosis 1: impaired ADL function\\n Diagnosis 2: impaired B UE strength\\n Diagnosis 3: impaired communication\\n Diagnosis 4: impaired coordination\\n Clinical Impression / Prognosis\\n Clinical Impression / Prognosis: Pt is a 74 y.o male w/ mult fx now s/p\\n trach and peg and on vent support. Pt presents w/ severe\\n deconditioning and demonstrates above impairments. Pt would benefit\\n from skilled OT services to maximize functional independence w/ rehab\\n potential excellent given current med status, prior level of function\\n and health.\\n Goals: patient / family, objective, measurable\\n Patient Goals: to be able to walk to the bathroom myself\\n Goal 1: perform UE adls w/ min assist\\n Goal 2: improve B UE strength 1/2 mm grade to improve adl independence\\n Goal 3: use communication board to express needs w/ min assist\\n Goal 4: write short responses with fair legibility\\n Time Frame (expected attainment): 1 week\\n Anticipated Discharge: Rehab\\n Treatment Plan: Interventions; patient / family education, community\\n resources\\n Treatment Plan: adls, EOB and OOB assessment, coordination/handwriting,\\n communication board d/c planning\\n Frequency / Duration: 1-5x/wk\\n Recommendations for Nursing: encourage participation w/ self care and\\n use L UE as able\\n Therapist Information\\n Patient agrees with the above goals and is willing to participate in\\n the rehabilitation program\\n Therapist's Name: /L\\n Date: \\n Time: 12:50-13:20\\n Pager #: \\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2175-02-05 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 715149,\n \"text\": \"PICC placed.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Ls clear to diminished, strong productive cough, suctioned for large\\n amounts of thick yellow sputum. Afebrile all day. Remains in a NSR.\\n Pt refused to get OOB due to having to wear TLSO brace.\\n Action:\\n Continuing diamox and Lasix for diuresis. Electrolytes replaced.\\n Response:\\n UOP good. Neuro status intact, appropriate.\\n Plan:\\n PM CXR pending. Continue to wean vent settings. Diuresis per orders.\\n Screen for rehab in AM.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2175-02-06 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 715211,\n \"text\": \"TSICU\\n HPI:\\n 74M s/p fall from bed/standing? tx from osh () with\\n acetabular fracture. On w/u in ER, pt found to be increasingly\\n tachycardic with abdominal distention and hypotension; found to have\\n acetabular fracture, iliac crest fracture, increasing pelvic and\\n retroperitoneal hematomas. Coffee ground emesis x1 in ED.\\n Chief complaint:\\n pain\\n PMHx:\\n PMH: PVD, emphysema/COPD, dementia, seizure d/o, HTN, anemia, ?aortic\\n dissection in past; pureed food diet with honey thick liquids\\n PSH: s/p fem-fem bypass, c1-c2 fusion\\n Current medications:\\n 1000 mL NS 3. Acetaminophen 4. Albuterol 0.083% Neb Soln 5. Bisacodyl\\n 6. Calcium Gluconate\\n 7. Citalopram Hydrobromide 8. Clozapine 9. Clozapine 10. Dextrose 50%\\n 11. Docusate Sodium 12. Glucagon\\n 13. HYDROmorphone (Dilaudid) 14. Heparin 15. Insulin 16. Ipratropium\\n Bromide Neb 17. LeVETiracetam\\n 18. Magnesium Sulfate 19. Magnesium Sulfate 20. Metoprolol Tartrate 21.\\n Metoprolol Tartrate 22. Metoprolol Tartrate\\n 23. Metoprolol Tartrate 24. Multiple Vitamins Liq. 25. Olanzapine\\n (Disintegrating Tablet) 26. Ondansetron\\n 27. OxycoDONE (Immediate Release) 28. Pantoprazole 29. Pneumococcal Vac\\n Polyvalent 30. Potassium Chloride\\n 31. Potassium Chloride 32. Senna 33. Sodium Phosphate 34. Sodium\\n Chloride 0.9% Flush\\n 24 Hour Events:\\n : Persistent tachycardia. Metop inc to 37.5''-->50. Metop 5-10 mg\\n IV PRN hr>110 (ST w/PACs, PVCs), 2 mg Mg. SQH started. Chest PT, nebs.\\n NPO p MN for ORIF.\\n Post operative day:\\n POD#11 - IVC filter via L groin\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Vancomycin - 07:41 PM\\n Ciprofloxacin - 09:44 PM\\n Cefipime - 12:13 AM\\n Infusions:\\n Other ICU medications:\\n Lansoprazole (Prevacid) - 02:24 PM\\n Furosemide (Lasix) - 05:14 PM\\n Heparin Sodium (Prophylaxis) - 03:52 AM\\n Other medications:\\n Flowsheet Data as of 04:15 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 37.3\\nC (99.2\\n T current: 37.1\\nC (98.7\\n HR: 77 (73 - 98) bpm\\n BP: 103/42(60) {86/40(55) - 152/70(97)} mmHg\\n RR: 29 (20 - 34) insp/min\\n SPO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 104.2 kg (admission): 90 kg\\n Total In:\\n 2,020 mL\\n 456 mL\\n PO:\\n Tube feeding:\\n 960 mL\\n 157 mL\\n IV Fluid:\\n 470 mL\\n 120 mL\\n Blood products:\\n Total out:\\n 5,030 mL\\n 470 mL\\n Urine:\\n 5,030 mL\\n 470 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -3,010 mL\\n -14 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 442 (421 - 612) mL\\n PS : 5 cmH2O\\n RR (Spontaneous): 29\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n RSBI: 65\\n PIP: 16 cmH2O\\n SPO2: 98%\\n ABG: 7.40/32/123/21/-3\\n Ve: 13.5 L/min\\n PaO2 / FiO2: 308\\n Physical Examination\\n General Appearance: No acute distress, confused at times\\n HEENT: PERRL, EOMI\\n Cardiovascular: (Rhythm: Regular)\\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: No(t)\\n Resonant : ), (Breath Sounds: Rhonchorous : ), (Sternum: Stable )\\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present)\\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present)\\n Skin: (Incision: Clean / Dry / Intact)\\n Neurologic: (Awake / Alert / Oriented: x 1), Follows simple commands,\\n (Responds to: Verbal stimuli), Moves all extremities\\n Labs / Radiology\\n 196 K/uL\\n 8.9 g/dL\\n 122 mg/dL\\n 1.1 mg/dL\\n 21 mEq/L\\n 3.6 mEq/L\\n 25 mg/dL\\n 117 mEq/L\\n 144 mEq/L\\n 28.2 %\\n 4.6 K/uL\\n [image002.jpg]\\n 06:07 PM\\n 01:55 AM\\n 02:04 AM\\n 08:00 AM\\n 11:35 AM\\n 03:56 PM\\n 05:09 PM\\n 08:00 PM\\n 01:36 AM\\n 02:16 AM\\n WBC\\n 5.2\\n 4.6\\n Hct\\n 28.4\\n 28.2\\n Plt\\n 178\\n 196\\n Creatinine\\n 1.0\\n 1.0\\n 1.1\\n TCO2\\n 29\\n 25\\n 25\\n 26\\n 21\\n Glucose\\n 119\\n 108\\n 120\\n 120\\n 138\\n 122\\n Other labs: PT / PTT / INR:14.0/28.1/1.2, CK / CK-MB / Troponin\\n T:128/13/<0.01, ALT / AST:104/137, Alk-Phos / T bili:204/4.8, Amylase /\\n Lipase:54/52, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic\\n Acid:1.1 mmol/L, Albumin:2.3 g/dL, LDH:348 IU/L, Ca:8.1 mg/dL, Mg:2.4\\n mg/dL, PO4:3.5 mg/dL\\n Imaging: CT c-spine: s/p post c1-c2 fusion. metallic nail\\n through L lat C2 extends w/tip in retropharnyngeal/prevertebral jxn\\n soft tissues ant to C1. mild anterolisthesis of C4 over C5. very min\\n retrolisthesis C5 over C6. mult-level change. no acute fx seen.\\n pulmonary emphysema. coarse vertebral and carotid artery calcs. 6mm R\\n thyroid lobe hypodensity.\\n CT torso: 1.6 x 1.2 cm focal hypodensity in ant mediastinum\\n (S2:im15). ?focal hematoma vs thymic cystic lesion. No overlying\\n sternal fx or aortic injury. dense aortic calcs. LLL atelect/scarring.\\n comminuted, intra-art L acetabular fx involv ant &post columns and ext\\n to L sup pubic ramus. adj mod pelvic hematoma w/out active extrav.\\n hematoma crosses midline, extends superiorly ant to L psoas muscle and\\n iliacus. mild loss of ht of L2 & L3 vert bodies. Grade 1\\n spondylolisthesis L5/S1. bladder diverticula .\\n CT head: No acute ICH. opacification of inf L maxillary\\n sinus w/focal loss of ant inf L max sinus/ant L alveolar bone, adj soft\\n tissue swelling and foci of gas. ?infectious process involving L\\n alveolar process of maxilla, dental in nature vs chronic sinusitis vs\\n injury. recommend direct visualization.\\n CXR: No consolidation\\n CXR (pm): Increased lung volumes c/w emphysema. Peribronchial\\n cuffing and predominantly R-sided interstitial opacities likely fluid\\n overload. Subtle opacity @R apex ?superimposition of external\\n ventilator apparatus vs. consolidation.\\n Microbiology: SCx: contaminated\\n Assessment and Plan\\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, AF with\\n RVR/Aflutter, now in sinus, and PNA, s/p trach/PEG (), IVC filter.\\n Neurologic: HOB<30, TLSO when OOB. Zyprexa 10'''\\n Neuro checks Q: shift\\n Pain: Oxycodone, Neurontin, Tylenol. Pain adequately controlled.\\n Cardiovascular: Aflutter->NSR, on Amio and diltizem 60 QID. Likely \\n cardiac contusion. Cards for Amio rec 400'' x 1wk, then 400'x1 wk, then\\n 200'. Pt cannot be fully anticoagulated for now (trauma).\\n Pulmonary: Trach, weaning vent ( currently), Vanc/cipro/cefepime for\\n VAP (). Improving pulmonary edema. Continued diuresis.\\n Gastrointestinal / Abdomen: Unknown elevated LFTs and bilirubin w/CT\\n scan suggesting cirrhosis - Hepatitis panel NEG, RUQ U/S r/o\\n gallbladder etiology, will continue to trend. Nutren 2.0 @ goal 40\\n cc/hr. Bowel regimen.\\n RENAL: Foley, monitor UOP, edematous scrotum. Diamox 250 q12 for\\n contraction alkalosis. Lasix 20x2 on . Hypernatremia,\\n hyperchloremia.\\n Nutrition: Tube feeding\\n Renal: Foley\\n Hematology: Hct stable (28.2). Plt stable (178-196); d/c'd H2B. Heme\\n onc c/s - smear nl; no hemolysis. IVC filter.\\n Endocrine: RISS\\n Infectious Disease: Check cultures, WBC normal (4.6), on\\n Vanc/cipro/cefepime for VAP given worsening pulm status, f/u on cx\\n Lines / Tubes / Drains: Trach/Peg/foley/L radial a-line/L basilic PICC,\\n SCL (will d/c SCL once midline)\\n Wounds:\\n Imaging: CXR today\\n Fluids: KVO\\n Consults: Trauma (1o), Ortho Spine, Ortho trauma, Heme\\n Billing Diagnosis: (Shock: Unspecified), Multiple injuries (Trauma)\\n ICU Care\\n Nutrition:\\n Nutren 2.0 (Full) - 07:46 PM 40 mL/hour\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n Multi Lumen - 04:41 PM\\n Arterial Line - 11:30 AM\\n PICC Line - 06:02 PM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin, IVC filter\\n Stress ulcer: PPI\\n VAP bundle:\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds , Family\\n meeting planning, ICU consent signed Comments:\\n Code status: Full code\\n Disposition: ICU\\n Total time spent: 33 minutes\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2175-02-06 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 715214,\n \"text\": \"TSICU\\n HPI:\\n 74M s/p fall from tractor and crush injury from tree branch. +Loc.\\n Chief complaint:\\n ventilator dependance\\n PMHx:\\n PMH: cirrhosis and asbestosis dx on CT\\n Current medications:\\n Acetaminophen 4. AcetaZOLamide 5. Amiodarone 6. Bisacodyl 7. Calcium\\n Gluconate 8. CefePIME 9. Chlorhexidine Gluconate 0.12% Oral Rinse 10.\\n Ciprofloxacin HCl 11. Dextrose 50% 12. Diltiazem 13. Docusate Sodium\\n (Liquid) 14. Furosemide 15. Furosemide 16. Gabapentin 17. Glucagon 18.\\n Heparin\\n 19. Heparin Flush (10 units/ml) 20. 21. Insulin 22. Lactulose 23.\\n Lansoprazole Oral Disintegrating Tab 24. Magnesium Sulfate 25.\\n Metoprolol Tartrate 26. Milk of Magnesia 27. Olanzapine (Disintegrating\\n Tablet) 28. Ondansetron 29. OxycoDONE Liquid 30. Pneumococcal Vac\\n Polyvalent 31. Potassium Phosphate 32. Potassium Chloride 33. Senna 34.\\n Sodium Chloride 0.9% Flush 35. Sodium Chloride 0.9% Flush 36.\\n Vancomycin\\n 24 Hour Events:\\n : Diamox continued. Lasix 20x2 with good result. PICC. Diamox decr\\n w/iatrogenic hyperchloremia, hypernatremia.\\n Post operative day:\\n POD#11 - IVC filter via L groin\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Vancomycin - 07:41 PM\\n Ciprofloxacin - 09:44 PM\\n Cefipime - 12:13 AM\\n Infusions:\\n Other ICU medications:\\n Lansoprazole (Prevacid) - 02:24 PM\\n Furosemide (Lasix) - 05:14 PM\\n Heparin Sodium (Prophylaxis) - 07:35 PM\\n Other medications:\\n Flowsheet Data as of 03:54 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 37.3\\nC (99.2\\n T current: 37.1\\nC (98.7\\n HR: 77 (73 - 98) bpm\\n BP: 103/42(60) {86/40(55) - 152/70(97)} mmHg\\n RR: 29 (20 - 34) insp/min\\n SPO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 104.2 kg (admission): 90 kg\\n Total In:\\n 2,020 mL\\n 451 mL\\n PO:\\n Tube feeding:\\n 960 mL\\n 152 mL\\n IV Fluid:\\n 470 mL\\n 119 mL\\n Blood products:\\n Total out:\\n 5,030 mL\\n 470 mL\\n Urine:\\n 5,030 mL\\n 470 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -3,010 mL\\n -19 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 442 (421 - 612) mL\\n PS : 5 cmH2O\\n RR (Spontaneous): 29\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n RSBI: 65\\n PIP: 16 cmH2O\\n SPO2: 98%\\n ABG: 7.40/32/123/21/-3\\n Ve: 13.5 L/min\\n PaO2 / FiO2: 308\\n Physical Examination\\n General Appearance: No acute distress, Anxious at times\\n HEENT: PERRL, EOMI\\n Cardiovascular: (Rhythm: Regular)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\\n bibasilar, occasional, Diminished: bibasilar), (Sternum: Stable )\\n Abdominal: Soft, Non-distended, Non-tender, Obese\\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present)\\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present)\\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\\n Moves all extremities\\n Labs / Radiology\\n 196 K/uL\\n 8.9 g/dL\\n 122 mg/dL\\n 1.1 mg/dL\\n 21 mEq/L\\n 3.6 mEq/L\\n 25 mg/dL\\n 117 mEq/L\\n 144 mEq/L\\n 28.2 %\\n 4.6 K/uL\\n [image002.jpg]\\n 06:07 PM\\n 01:55 AM\\n 02:04 AM\\n 08:00 AM\\n 11:35 AM\\n 03:56 PM\\n 05:09 PM\\n 08:00 PM\\n 01:36 AM\\n 02:16 AM\\n WBC\\n 5.2\\n 4.6\\n Hct\\n 28.4\\n 28.2\\n Plt\\n 178\\n 196\\n Creatinine\\n 1.0\\n 1.0\\n 1.1\\n TCO2\\n 29\\n 25\\n 25\\n 26\\n 21\\n Glucose\\n 119\\n 108\\n 120\\n 120\\n 138\\n 122\\n Other labs: PT / PTT / INR:14.0/28.1/1.2, CK / CK-MB / Troponin\\n T:128/13/<0.01, ALT / AST:104/137, Alk-Phos / T bili:204/4.8, Amylase /\\n Lipase:54/52, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic\\n Acid:1.1 mmol/L, Albumin:2.3 g/dL, LDH:348 IU/L, Ca:8.1 mg/dL, Mg:2.4\\n mg/dL, PO4:3.5 mg/dL\\n Imaging: CT head OSH: Prelim No ICH or fx.\\n CT chest OSH: Mult rib fx: R anterolateral and posterior, L\\n posterior; Dependent consolidation, possible aspiration; T4 vertebral\\n body inf corner fx, no retropulsion; Comminuted spinous process fx\\n T2-8; Nondisplaced L T10 transverse process; Nondisplaced L clavicle\\n distal fx; Nondisplaced L scapula fx;\\n CT c spine OSH: Prelim No fx or malalignment. Multilevel\\n degenerative changes w/large post disk bulge at C4-5, narrowing the\\n spinal canal and deforming the thecal sac, acuity unknown. Marked\\n neuroforamenal narrowing @multiple levels.\\n CTA abd/pel Prelim: Medial R liver lobe contusion w/adj\\n hematoma, w/o evidence of active bleeding; Comminuted L pubic ramus\\n fracture w/assoc hematoma, with tiny focus of arterial bleeding/active\\n extravasation, and larger area of venous bleeding. Hematoma somewhat\\n larger than on OSH study. Nondisplaced, comminuted L iliac bone fx\\n w/adj iliac muscle hematoma, larger than on prior study, w/o active\\n extrav. Fx extends into L SIJ. Post R hepatic laceration/contusion\\n adjacent to calcified granuloma, w/small hematoma, w/out active\\n bleeding. Min displaced fx of R iliac bone extending to R SIJ.\\n Cirrhotic liver. Inc B pl effusions (small), w/inc atelectasis.\\n MRI: Mild compression deformity of L1 w/additional levels of\\n potential trabecular contusion @T10-11 also inf @T4 w/o retropulsion.\\n Multilevel degenerative changes w/moderate canal narrowing @T10-11\\n w/cord deformity & no abnl cord signal. Extensive edema throughout\\n paraspinal soft tissues, predominantly post w/in interspinous\\n ligaments. Incompletely eval'ed c-spine w/severe canal narrowing @C4-5\\n w/cord deformity and no abn cord signal.\\n CTA: no PE.\\n CXR: Moderate b/l pleural effusions are stable.\\n CXR: Cardiac size top nl, interval improvement of collapse LLL.\\n Collapse RLL. Atelectasis in lingula unchanged. Mod B pleural effusions\\n stable. No PTX.\\n CXR: Interval mild incr in cardiac size, b/l pl effusions,\\n & opacities @ bases,c/w overload\\n : R foot: Linear density projecting @ expected area of insertion\\n of Achilles to calcaneus, may be min avulsion fx or degenerative\\n changes. Otherwise no fx\\n CXR: b/l pl effusions\\n CXR: stable.\\n RUQ U/S: No perihepatic fluid collection. small amt perihepatic\\n free fluid persists. Small contusion in hepatic segment VII. No\\n gallstones or sig wall thickening/edema. CBD 4.5 mm\\n TTE: LVEF >55%, NL diastolic function, NL LV filling pressure\\n (PCWP<12mmHg), RV chamber size mildly dilated, mild TR\\n CXR: mild b/l pulm edema and parenchymal opacities and no\\n pl effusion.\\n CXR: Persistent b/l pl effusions and bibasilar opacity.\\n CXR: Minimal improvement of mod b/l pl effusions. Otherwise\\n stable.\\n CXR: no relevant change. B/L pleural effusions with basal\\n opacities. No evidence of newly appeared focal parenchymal opacities\\n suggesting pneumonia.\\n : No dvt\\n CXR: No change, B pleural effusions, no new infiltrates\\n CXR: stable\\n Microbiology: Ucx neg\\n Sputum: sparse GNRs, too few to colonize\\n Bcx x2 neg\\n 12/17 L BAL: Klebsiella Pneumoniae, HAEMOPHILUS SPECIES NOT INFLUENZAE\\n R BAL: Klebsiella Pneumoniae, Proteus.\\n 12/20 L &R BAL: Klebsiella Pneumoniae\\n BCX: neg\\n BCx: neg\\n UCx: neg\\n BCx: P\\n BCx: P\\n UCx: neg\\n SpCx: contamination\\n Assessment and Plan\\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, AF with\\n RVR/Aflutter, now in sinus, and PNA, s/p trach/PEG (), IVC filter\\n Neurologic: HOB<30, TLSO when OOB. Zyprexa 10'''\\n Neuro checks Q: shift\\n Pain: Oxycodone, Neurontin, Tylenol. Pain adequately controlled.\\n Cardiovascular: Aflutter->NSR, on Amio and diltizem 60 QID. Likely \\n cardiac contusion. Cards for Amio rec 400'' x 1wk, then 400'x1 wk, then\\n 200'. Pt cannot be fully anticoagulated for now (trauma). Now in sinus\\n so continue Amio.\\n Pulmonary: Trach, weaning vent ( currently), Vanc/cipro/cefepime for\\n VAP (). Improving pulmonary edema. Continued diuresis. TM trial\\n today, follow ABGs. Aggressive chest Pt as e/o collapse on RLL.\\n Gastrointestinal / Abdomen: Unknown elevated LFTs and bilirubin w/CT\\n scan suggesting cirrhosis - Hepatitis panel NEG, RUQ U/S r/o\\n gallbladder etiology, will continue to trend. Nutren 2.0 @ goal 40\\n cc/hr. Bowel regimen (d/c Lactulose). C diff negative x 3.\\n Nutrition: Tube feeding, Nutren. At goal.\\n Renal: Foley, monitor UOP, edematous scrotum. Diamox 250 q12 for\\n contraction alkalosis. Lasix 20x2 on . Hypernatremia,\\n hyperchloremia. Goal 1.5 L negative today as total volume up from\\n admission.\\n Hematology: Hct stable (28.2). Plt stable (178-196); d/c'd H2B. Heme\\n onc c/s - smear nl; no hemolysis. IVC filter.\\n Endocrine: RISS, goal BS<150. Adequate control.\\n Infectious Disease: WBC normal, on Vanc/cipro/cefepime for VAP given\\n worsening pulm status, f/u on cx. Plan for total 7 days of abx, given\\n only GNRs in cx data will d/c Vanco.\\n Lines / Tubes / Drains: Trach/Peg/foley/L radial a-line/L basilic PICC,\\n SCL (will d/c SCL once midline)\\n Wounds:\\n Imaging: CXR today\\n Fluids: KVO\\n Consults: Trauma (1o), Ortho Spine, Ortho trauma, Heme, PT/OT.\\n Billing Diagnosis: (Shock: Unspecified), Multiple injuries (Trauma)\\n ICU Care\\n Nutrition:\\n Nutren 2.0 (Full) - 07:46 PM 40 mL/hour\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n Multi Lumen - 04:41 PM\\n Arterial Line - 11:30 AM\\n PICC Line - 06:02 PM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin, IVC filter\\n Stress ulcer: PPI (thrombocytopenia possibly from H2B)\\n VAP bundle: HOB elevation, Mouth care\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds , ICU\\n Code status: Full code\\n Disposition: ICU\\n rehab screen\\n Total time spent: 33 minutes\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2175-02-06 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 715215,\n \"text\": \"TSICU\\n HPI:\\n 74M s/p fall from tractor and crush injury from tree branch. +Loc.\\n Chief complaint:\\n ventilator dependance\\n PMHx:\\n PMH: cirrhosis and asbestosis dx on CT\\n Current medications:\\n Acetaminophen 4. AcetaZOLamide 5. Amiodarone 6. Bisacodyl 7. Calcium\\n Gluconate 8. CefePIME 9. Chlorhexidine Gluconate 0.12% Oral Rinse 10.\\n Ciprofloxacin HCl 11. Dextrose 50% 12. Diltiazem 13. Docusate Sodium\\n (Liquid) 14. Furosemide 15. Furosemide 16. Gabapentin 17. Glucagon 18.\\n Heparin\\n 19. Heparin Flush (10 units/ml) 20. 21. Insulin 22. Lactulose 23.\\n Lansoprazole Oral Disintegrating Tab 24. Magnesium Sulfate 25.\\n Metoprolol Tartrate 26. Milk of Magnesia 27. Olanzapine (Disintegrating\\n Tablet) 28. Ondansetron 29. OxycoDONE Liquid 30. Pneumococcal Vac\\n Polyvalent 31. Potassium Phosphate 32. Potassium Chloride 33. Senna 34.\\n Sodium Chloride 0.9% Flush 35. Sodium Chloride 0.9% Flush 36.\\n Vancomycin\\n 24 Hour Events:\\n : Diamox continued. Lasix 20x2 with good result. PICC. Diamox decr\\n w/iatrogenic hyperchloremia, hypernatremia.\\n Post operative day:\\n POD#11 - IVC filter via L groin\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Vancomycin - 07:41 PM\\n Ciprofloxacin - 09:44 PM\\n Cefipime - 12:13 AM\\n Infusions:\\n Other ICU medications:\\n Lansoprazole (Prevacid) - 02:24 PM\\n Furosemide (Lasix) - 05:14 PM\\n Heparin Sodium (Prophylaxis) - 07:35 PM\\n Other medications:\\n Flowsheet Data as of 03:54 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 37.3\\nC (99.2\\n T current: 37.1\\nC (98.7\\n HR: 77 (73 - 98) bpm\\n BP: 103/42(60) {86/40(55) - 152/70(97)} mmHg\\n RR: 29 (20 - 34) insp/min\\n SPO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 104.2 kg (admission): 90 kg\\n Total In:\\n 2,020 mL\\n 451 mL\\n PO:\\n Tube feeding:\\n 960 mL\\n 152 mL\\n IV Fluid:\\n 470 mL\\n 119 mL\\n Blood products:\\n Total out:\\n 5,030 mL\\n 470 mL\\n Urine:\\n 5,030 mL\\n 470 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -3,010 mL\\n -19 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 442 (421 - 612) mL\\n PS : 5 cmH2O\\n RR (Spontaneous): 29\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n RSBI: 65\\n PIP: 16 cmH2O\\n SPO2: 98%\\n ABG: 7.40/32/123/21/-3\\n Ve: 13.5 L/min\\n PaO2 / FiO2: 308\\n Physical Examination\\n General Appearance: No acute distress, Anxious at times\\n HEENT: PERRL, EOMI\\n Cardiovascular: (Rhythm: Regular)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\\n bibasilar, occasional, Diminished: bibasilar), (Sternum: Stable )\\n Abdominal: Soft, Non-distended, Non-tender, Obese\\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present)\\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present)\\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\\n Moves all extremities\\n Labs / Radiology\\n 196 K/uL\\n 8.9 g/dL\\n 122 mg/dL\\n 1.1 mg/dL\\n 21 mEq/L\\n 3.6 mEq/L\\n 25 mg/dL\\n 117 mEq/L\\n 144 mEq/L\\n 28.2 %\\n 4.6 K/uL\\n [image002.jpg]\\n 06:07 PM\\n 01:55 AM\\n 02:04 AM\\n 08:00 AM\\n 11:35 AM\\n 03:56 PM\\n 05:09 PM\\n 08:00 PM\\n 01:36 AM\\n 02:16 AM\\n WBC\\n 5.2\\n 4.6\\n Hct\\n 28.4\\n 28.2\\n Plt\\n 178\\n 196\\n Creatinine\\n 1.0\\n 1.0\\n 1.1\\n TCO2\\n 29\\n 25\\n 25\\n 26\\n 21\\n Glucose\\n 119\\n 108\\n 120\\n 120\\n 138\\n 122\\n Other labs: PT / PTT / INR:14.0/28.1/1.2, CK / CK-MB / Troponin\\n T:128/13/<0.01, ALT / AST:104/137, Alk-Phos / T bili:204/4.8, Amylase /\\n Lipase:54/52, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic\\n Acid:1.1 mmol/L, Albumin:2.3 g/dL, LDH:348 IU/L, Ca:8.1 mg/dL, Mg:2.4\\n mg/dL, PO4:3.5 mg/dL\\n Imaging: CT head OSH: Prelim No ICH or fx.\\n CT chest OSH: Mult rib fx: R anterolateral and posterior, L\\n posterior; Dependent consolidation, possible aspiration; T4 vertebral\\n body inf corner fx, no retropulsion; Comminuted spinous process fx\\n T2-8; Nondisplaced L T10 transverse process; Nondisplaced L clavicle\\n distal fx; Nondisplaced L scapula fx;\\n CT c spine OSH: Prelim No fx or malalignment. Multilevel\\n degenerative changes w/large post disk bulge at C4-5, narrowing the\\n spinal canal and deforming the thecal sac, acuity unknown. Marked\\n neuroforamenal narrowing @multiple levels.\\n CTA abd/pel Prelim: Medial R liver lobe contusion w/adj\\n hematoma, w/o evidence of active bleeding; Comminuted L pubic ramus\\n fracture w/assoc hematoma, with tiny focus of arterial bleeding/active\\n extravasation, and larger area of venous bleeding. Hematoma somewhat\\n larger than on OSH study. Nondisplaced, comminuted L iliac bone fx\\n w/adj iliac muscle hematoma, larger than on prior study, w/o active\\n extrav. Fx extends into L SIJ. Post R hepatic laceration/contusion\\n adjacent to calcified granuloma, w/small hematoma, w/out active\\n bleeding. Min displaced fx of R iliac bone extending to R SIJ.\\n Cirrhotic liver. Inc B pl effusions (small), w/inc atelectasis.\\n MRI: Mild compression deformity of L1 w/additional levels of\\n potential trabecular contusion @T10-11 also inf @T4 w/o retropulsion.\\n Multilevel degenerative changes w/moderate canal narrowing @T10-11\\n w/cord deformity & no abnl cord signal. Extensive edema throughout\\n paraspinal soft tissues, predominantly post w/in interspinous\\n ligaments. Incompletely eval'ed c-spine w/severe canal narrowing @C4-5\\n w/cord deformity and no abn cord signal.\\n CTA: no PE.\\n CXR: Moderate b/l pleural effusions are stable.\\n CXR: Cardiac size top nl, interval improvement of collapse LLL.\\n Collapse RLL. Atelectasis in lingula unchanged. Mod B pleural effusions\\n stable. No PTX.\\n CXR: Interval mild incr in cardiac size, b/l pl effusions,\\n & opacities @ bases,c/w overload\\n : R foot: Linear density projecting @ expected area of insertion\\n of Achilles to calcaneus, may be min avulsion fx or degenerative\\n changes. Otherwise no fx\\n CXR: b/l pl effusions\\n CXR: stable.\\n RUQ U/S: No perihepatic fluid collection. small amt perihepatic\\n free fluid persists. Small contusion in hepatic segment VII. No\\n gallstones or sig wall thickening/edema. CBD 4.5 mm\\n TTE: LVEF >55%, NL diastolic function, NL LV filling pressure\\n (PCWP<12mmHg), RV chamber size mildly dilated, mild TR\\n CXR: mild b/l pulm edema and parenchymal opacities and no\\n pl effusion.\\n CXR: Persistent b/l pl effusions and bibasilar opacity.\\n CXR: Minimal improvement of mod b/l pl effusions. Otherwise\\n stable.\\n CXR: no relevant change. B/L pleural effusions with basal\\n opacities. No evidence of newly appeared focal parenchymal opacities\\n suggesting pneumonia.\\n : No dvt\\n CXR: No change, B pleural effusions, no new infiltrates\\n CXR: stable\\n Microbiology: Ucx neg\\n Sputum: sparse GNRs, too few to colonize\\n Bcx x2 neg\\n 12/17 L BAL: Klebsiella Pneumoniae, HAEMOPHILUS SPECIES NOT INFLUENZAE\\n R BAL: Klebsiella Pneumoniae, Proteus.\\n 12/20 L &R BAL: Klebsiella Pneumoniae\\n BCX: neg\\n BCx: neg\\n UCx: neg\\n BCx: P\\n BCx: P\\n UCx: neg\\n SpCx: contamination\\n Assessment and Plan\\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, AF with\\n RVR/Aflutter, now in sinus, and PNA, s/p trach/PEG (), IVC filter\\n Neurologic: HOB<30, TLSO when OOB. Zyprexa 10'''\\n Neuro checks Q: shift\\n Pain: Oxycodone, Neurontin, Tylenol. Pain adequately controlled.\\n Cardiovascular: Aflutter->NSR, on Amio and diltizem 60 QID. Likely \\n cardiac contusion. Cards for Amio rec 400'' x 1wk, then 400'x1 wk, then\\n 200'. Pt cannot be fully anticoagulated for now (trauma). Now in sinus\\n so continue Amio.\\n Pulmonary: Trach, weaning vent ( currently), Vanc/cipro/cefepime for\\n VAP (). Improving pulmonary edema. Continued diuresis. TM trial\\n today, follow ABGs. Aggressive chest Pt as e/o collapse on RLL.\\n Gastrointestinal / Abdomen: Unknown elevated LFTs and bilirubin w/CT\\n scan suggesting cirrhosis - Hepatitis panel NEG, RUQ U/S r/o\\n gallbladder etiology, will continue to trend. Nutren 2.0 @ goal 40\\n cc/hr. Bowel regimen (d/c Lactulose). C diff negative x 3.\\n Nutrition: Tube feeding, Nutren. At goal.\\n Renal: Foley, monitor UOP, edematous scrotum. Diamox 250 q12 for\\n contraction alkalosis. Lasix 20x2 on . Hypernatremia,\\n hyperchloremia. Goal 1.5 L negative today as total volume up from\\n admission.\\n Hematology: Hct stable (28.2). Plt stable (178-196); d/c'd H2B. Heme\\n onc c/s - smear nl; no hemolysis. IVC filter.\\n Endocrine: RISS, goal BS<150. Adequate control.\\n Infectious Disease: WBC normal, on Vanc/cipro/cefepime for VAP given\\n worsening pulm status, f/u on cx. Plan for total 7 days of abx, given\\n only GNRs in cx data will d/c Vanco.\\n Lines / Tubes / Drains: Trach/Peg/foley/L radial a-line/L basilic PICC,\\n SCL (will d/c SCL once midline)\\n Wounds:\\n Imaging: CXR today\\n Fluids: KVO\\n Consults: Trauma (1o), Ortho Spine, Ortho trauma, Heme, PT/OT.\\n Billing Diagnosis: (Shock: Unspecified), Multiple injuries (Trauma)\\n ICU Care\\n Nutrition:\\n Nutren 2.0 (Full) - 07:46 PM 40 mL/hour\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n Multi Lumen - 04:41 PM\\n Arterial Line - 11:30 AM\\n PICC Line - 06:02 PM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin, IVC filter\\n Stress ulcer: PPI (thrombocytopenia possibly from H2B)\\n VAP bundle: HOB elevation, Mouth care\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds , ICU\\n Code status: Full code\\n Disposition: ICU\\n rehab screen\\n Total time spent: 33 minutes\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2175-02-06 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 715230,\n \"text\": \"Nursing 0700-1100\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt. s/p crush injury/multiple trauma. Trach in place, received pt. on\\n PSV 5/5 with RR 28-35. \\n pt. remains in SR with PRI.27.\\n Action:\\n Pt. turned, CPT\\nd Q2hrs. Suctioned hourly for moderate amts pale\\n yellowish-white creamy thick secretions. Antibiotics as ordered, Vanco\\n d/c\\nd this a.m. CVL d/c\\n Response:\\n Pt. presently restful and less tachypneic. When awake, RR remains 30,\\n and after turning RR towards 40 with long recovery time.\\n Plan:\\n OOB today with TLSO brace. ??Trach mask trial when in chair if\\n clinincal picture allows. Rehab screening in progress.\\n\"\n },\n {\n \"category\": \"Rehab Services\",\n \"chartdate\": \"2175-02-06 00:00:00.000\",\n \"description\": \"Physical Therapy Progress Note\",\n \"row_id\": 715237,\n \"text\": \"Subjective:\\n Objective:\\n Follow up PT visit to address goals of: . Patient seen today\\n for balance training, patient education\\n Updated medical status: CXR - Bibasilar opacification persists,\\n consistent with atelectasis and effusion; UE US pending\\n Activity\\n Clarification\\n I\\n S\\n CG\\n Min\\n Mod\\n Max\\n Rolling:\\n\\n\\n\\n\\n T\\n Supine/\\n Sidelying to Sit:\\n\\n\\n\\n T\\n\\n Transfer:\\n\\n\\n\\n\\n\\n Sit to Stand:\\n\\n\\n\\n\\n X2\\n Ambulation:\\n\\n\\n\\n\\n\\n Stairs:\\n\\n\\n\\n\\n\\n Aerobic Activity Response:\\n Position\\n HR\\n BP\\n RR\\n O[2] sat\\n RPE\\n Rest\\n Supine\\n 90\\n 134/58\\n 26\\n 100% on CPAP\\n Activity\\n Sit\\n 98\\n 126/50\\n 34\\n 90% on CPAP\\n Recovery\\n Sit\\n 92\\n 130/51\\n 28\\n 100% on CPAP\\n Total distance walked: 0\\n Minutes:\\n Gait: able to attain full upright standing with max verbal and tactile\\n cues to extend hips and trunk.\\n Balance: able to maintain static sitting at edge once positioned, able\\n to weight shift anteriorly and laterally with min A. Able to attain\\n static standing with max A x2, and maintain x10-15 sec with increased\\n hip flexion and forward trunk flexion.\\n Education / Communication: Reviewed PT and encouraged OOB.\\n Communicated with nsg re: status and MD re: bracing.\\n Other: On CPAP 5/10 PEEP/PS, 40% FiO2\\n c/o R>L hip/thigh pain with standing\\n Assessment: 74 yo M s/p crush injury with multiple fractures, making\\n good progress in PT with mobility and strength, continues to be limited\\n by general weakness and deconditioning a/w prolonged hospitalization.\\n He continues to be well below his baseline but has excellent rehab\\n potential given his prior level of function.\\n Anticipated Discharge: Rehab\\n Plan: continue with \\n\"\n },\n {\n \"category\": \"Rehab Services\",\n \"chartdate\": \"2175-02-06 00:00:00.000\",\n \"description\": \"Physical Therapy Progress Note\",\n \"row_id\": 715238,\n \"text\": \"Subjective:\\n Objective:\\n Follow up PT visit to address goals of: . Patient seen today\\n for balance training, patient education\\n Updated medical status: CXR - Bibasilar opacification persists,\\n consistent with atelectasis and effusion; UE US pending\\n Activity\\n Clarification\\n I\\n S\\n CG\\n Min\\n Mod\\n Max\\n Rolling:\\n\\n\\n\\n\\n T\\n Supine/\\n Sidelying to Sit:\\n\\n\\n\\n T\\n\\n Transfer:\\n\\n\\n\\n\\n\\n Sit to Stand:\\n\\n\\n\\n\\n X2\\n Ambulation:\\n\\n\\n\\n\\n\\n Stairs:\\n\\n\\n\\n\\n\\n Aerobic Activity Response:\\n Position\\n HR\\n BP\\n RR\\n O[2] sat\\n RPE\\n Rest\\n Supine\\n 90\\n 134/58\\n 26\\n 100% on CPAP\\n Activity\\n Sit\\n 98\\n 126/50\\n 34\\n 90% on CPAP\\n Recovery\\n Sit\\n 92\\n 130/51\\n 28\\n 100% on CPAP\\n Total distance walked: 0\\n Minutes:\\n Gait: able to attain full upright standing with max verbal and tactile\\n cues to extend hips and trunk.\\n Balance: able to maintain static sitting at edge once positioned, able\\n to weight shift anteriorly and laterally with min A. Able to attain\\n static standing with max A x2, and maintain x10-15 sec with increased\\n hip flexion and forward trunk flexion.\\n Education / Communication: Reviewed PT and encouraged OOB.\\n Communicated with nsg re: status and MD re: bracing.\\n Other: On CPAP 5/10 PEEP/PS, 40% FiO2\\n c/o R>L hip/thigh pain with standing\\n Assessment: 74 yo M s/p crush injury with multiple fractures, making\\n good progress in PT with mobility and strength, continues to be limited\\n by general weakness and deconditioning a/w prolonged hospitalization.\\n He continues to be well below his baseline but has excellent rehab\\n potential given his prior level of function.\\n Anticipated Discharge: Rehab\\n Plan: continue with \\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2175-02-05 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 715034,\n \"text\": \"TSICU\\n HPI:\\n 74M s/p fall with multiple rib fx, pelvis fx, clavicle fx, and thoracic\\n fx c/b unstable bleeding s/p IR embo, AF with RVR/Aflutter, now in\\n sinus, and PNA.\\n Chief complaint:\\n Fall\\n PMHx:\\n none\\n Current medications:\\n 1. Acetaminophen 4. AcetaZOLamide 2. Amiodarone 3. Bisacodyl 4. Calcium\\n Gluconate 5. CefePIME 6. Chlorhexidine Gluconate 0.12% Oral Rinse 7.\\n Ciprofloxacin HCl 8. Dextrose 50% 9. Diltiazem 10. Docusate Sodium\\n (Liquid) 11. Furosemide 12. Gabapentin 13. Glucagon 14. Heparin 15.\\n Insulin\\n 16. Lactulose 17. Lansoprazole Oral Disintegrating Tab 18. Magnesium\\n Sulfate 19. Metoprolol Tartrate 20. Milk of Magnesia 21. Olanzapine\\n (Disintegrating Tablet) 22. Ondansetron 23. OxycoDONE Liquid 24.\\n Pneumococcal Vac Polyvalent 25. Potassium Chloride 26. Potassium\\n Phosphate 27. Potassium Chloride 28. Senna 32. Sodium Chloride 0.9%\\n Flush 30. Sodium Chloride 0.9% Flush 31. Vancomycin\\n 24 Hour Events:\\n Started Diamox 500 x4 for contraction alkalosis due to Lasix, also\\n given Lasix 20 IV x1 with 1774 off.\\n Diltiazem gtt stopped and restarted po.\\n d/c'd Haldol and started standing Zyprexa.\\n Post operative day:\\n POD#10 - IVC filter via L groin\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Vancomycin - 08:26 PM\\n Ciprofloxacin - 10:48 PM\\n Cefipime - 12:48 AM\\n Infusions:\\n Other ICU medications:\\n Furosemide (Lasix) - 06:00 PM\\n Heparin Sodium (Prophylaxis) - 03:48 AM\\n Other medications:\\n Flowsheet Data as of 05:16 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 38\\nC (100.4\\n T current: 37.4\\nC (99.4\\n HR: 87 (71 - 104) bpm\\n BP: 143/60(85) {83/38(59) - 158/63(90)} mmHg\\n RR: 27 (17 - 32) insp/min\\n SPO2: 99%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 104.2 kg (admission): 90 kg\\n Total In:\\n 1,956 mL\\n 136 mL\\n PO:\\n Tube feeding:\\n 560 mL\\n IV Fluid:\\n 1,006 mL\\n 76 mL\\n Blood products:\\n Total out:\\n 3,730 mL\\n 1,140 mL\\n Urine:\\n 3,730 mL\\n 1,140 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,774 mL\\n -1,004 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 379 (379 - 713) mL\\n PS : 12 cmH2O\\n RR (Spontaneous): 33\\n PEEP: 10 cmH2O\\n FiO2: 40%\\n RSBI Deferred: PEEP > 10\\n PIP: 24 cmH2O\\n SPO2: 99%\\n ABG: 7.45/35/169/24/1\\n Ve: 15.2 L/min\\n PaO2 / FiO2: 422\\n Physical Examination\\n General Appearance: No acute distress\\n HEENT: PERRL\\n Cardiovascular: (Rhythm: Regular)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\\n bilateral : )\\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\\n Left Extremities: (Edema: Trace), (Temperature: Warm)\\n Right Extremities: (Edema: Trace), (Temperature: Warm)\\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\\n Moves all extremities\\n Labs / Radiology\\n 178 K/uL\\n 8.8 g/dL\\n 108 mg/dL\\n 1.0 mg/dL\\n 24 mEq/L\\n 3.8 mEq/L\\n 23 mg/dL\\n 113 mEq/L\\n 143 mEq/L\\n 28.4 %\\n 5.2 K/uL\\n [image002.jpg]\\n 07:20 PM\\n 12:35 AM\\n 01:04 AM\\n 06:28 AM\\n 08:00 AM\\n 01:10 PM\\n 05:03 PM\\n 06:07 PM\\n 01:55 AM\\n 02:04 AM\\n WBC\\n 6.5\\n 5.2\\n Hct\\n 29.0\\n 28.4\\n Plt\\n 124\\n 178\\n Creatinine\\n 0.8\\n 0.9\\n 1.0\\n TCO2\\n 34\\n 32\\n 30\\n 29\\n 25\\n Glucose\\n 130\\n 103\\n 121\\n 130\\n 113\\n 119\\n 108\\n Other labs: PT / PTT / INR:14.0/28.1/1.2, CK / CK-MB / Troponin\\n T:128/13/<0.01, ALT / AST:104/137, Alk-Phos / T bili:204/4.8, Amylase /\\n Lipase:54/52, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic\\n Acid:1.1 mmol/L, Albumin:2.3 g/dL, LDH:348 IU/L, Ca:8.3 mg/dL, Mg:2.4\\n mg/dL, PO4:3.5 mg/dL\\n Assessment and Plan\\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, AF with\\n RVR/Aflutter, now in sinus, and PNA.\\n Neurologic: s/p trach (). Per ortho spine, no surgery; HOB<30,\\n TLSO when OOB. Zyprexa 10 TID (off fent/midaz ).\\n Neuro checks Q: shift\\n Pain: Oxycodone, Neurontin, Tylenol.\\n Cardiovascular: Aflutter->NSR, on Amio and diltizem 60 QID. Likely \\n cardiac contusion. Cards for Amio rec 400'' x 1wk, then 400'x1 wk, then\\n 200'. Pt cannot be fully anticoagulated for now (trauma).\\n Pulmonary: Trach, weaning vent, Vanc/cipro/cefepime for VAP ().\\n Improving pulmonary edema. consider therapeutic thoracentesis \\n if no improvement with diuresis, lots of secretions, consider\\n bronchoscopy\\n Gastrointestinal / Abdomen: Unknown elevated LFTs and bilirubin w/CT\\n scan suggesting cirrhosis - Hepatitis panel NEG, RUQ U/S r/o\\n gallbladder etiology, will continue to trend. On Nutren 2.0 with goal\\n 40 cc/hr. Bowel regimen.\\n Nutrition: Tube feeding\\n Renal: Foley, monitor UOP, edematous scrotum. Diamox 500 q12 for\\n contraction alkalosis.\\n Hematology: Hct stable 28.9->29. Plt stable (100's); d/c'd H2B. Heme\\n onc c/s - smear nl; no hemolysis. IVC filter placed.\\n Endocrine: RISS\\n Infectious Disease: WBC normal, on Vanc/cipro/cefepime for VAP given\\n worsening pulm status, f/u on cx\\n Lines / Tubes / Drains: Trach/Peg/foley/L radial a-line/R SCL\\n Wounds:\\n Imaging: CXR today\\n Fluids: KVO\\n Consults: Trauma (1o), Ortho Spine, Ortho trauma, Heme\\n Billing Diagnosis:\\n ICU Care\\n Nutrition:\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n Multi Lumen - 04:41 PM\\n Arterial Line - 11:30 AM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin, IVC filter\\n Stress ulcer: PPI\\n VAP bundle:\\n Comments:\\n Communication: ICU consent signed Comments:\\n Code status: Full code\\n Disposition: ICU\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2175-02-05 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 715142,\n \"text\": \"PICC placed.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Ls clear to diminished, strong productive cough, suctioned for large\\n amounts of thick yellow sputum. Afebrile all day. Remains in a NSR.\\n Pt refused to get OOB due to having to wear TLSO brace.\\n Action:\\n Continuing diamox and Lasix for diuresis. Electrolytes replaced.\\n Response:\\n UOP good. Neuro status intact, appropriate.\\n Plan:\\n PM CXR pending. Screen for rehab in AM.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2175-02-06 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 715284,\n \"text\": \"74M s/p crushing injury d/t falling tree. Injuries sustained include\\n multiple R sided rib fxs, grade 2 liver lac (w/ assoc hepatic vessel\\n extravasation), stable pelvis fxs (w/ associated extravasation), R\\n ramus fx, clavicle fx, and T4 vertebral body fx. Episodes of A.\\n Flutter with RVR and aflutter, now with resp failure and newly dx\\n pneumonia as of .\\n intubated for resp distress\\n angio embolization of hepatic and pelvic arterial bleeders\\n IVC filter in OR\\n self extubated and re-intubated immediately after d/t acute resp.\\n failure\\n Trach and PEG at bedside\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt alert, follows commands, MAE\\ns purposefully. Nods yes to R sided\\n rib discomfort, but mouths that it is tolerable, currently declining\\n pain meds.\\n Pt remains in SR, conts. Diltiazem via PEG. DL midline intact with\\n 25cm coiled outside of skin; +blood return, flushes easily.\\n LS with rhonchi throughout, suctioned for sm. to moderate amts. Thick\\n white secretions. RR remains in 30\\n Abd soft, NT/D, BS present, incontinent sm. to medium soft, brown BM.\\n Conts. TF at goal 40cc/hr with no residuals.\\n Foley patent draining adequate amts. Yellow urine.\\n Endo: BS 128, no coverage per sliding scale.\\n Tmax 100.6po, conts. Cefipime as ordered.\\n Mulitple areas of ecchymosis, see metavision.\\n Pt\\ns companion in this afternoon, pt\\ns son also telephoned\\n for update.\\n Action:\\n Frequent repositioning/pulmonary hygiene provided. Cons. Dilt. As\\n ordered.\\n Midline dsg changed.\\n and updated by this RN; plan for son to touch base\\n with case management tomorrow regarding rehab\\n possibilities.\\n Pt dangled a edge of bed and stood at edge of bed with PT, see PT\\n note. OOB to chair for approx. 3hours, tolerated well.\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2175-02-06 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 715287,\n \"text\": \"74M s/p crushing injury d/t falling tree. Injuries sustained include\\n multiple R sided rib fxs, grade 2 liver lac (w/ assoc hepatic vessel\\n extravasation), stable pelvis fxs (w/ associated extravasation), R\\n ramus fx, clavicle fx, and T4 vertebral body fx. Episodes of A.\\n Flutter with RVR and aflutter, now with resp failure and newly dx\\n pneumonia as of .\\n intubated for resp distress\\n angio embolization of hepatic and pelvic arterial bleeders\\n IVC filter in OR\\n self extubated and re-intubated immediately after d/t acute resp.\\n failure\\n Trach and PEG at bedside\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt alert, follows commands, MAE\\ns purposefully. Nods yes to R sided\\n rib discomfort, but mouths that it is tolerable, currently declining\\n pain meds.\\n Pt remains in SR, conts. Diltiazem via PEG. DL midline intact with\\n 25cm coiled outside of skin; +blood return, flushes easily.\\n LS with rhonchi throughout, suctioned for sm. to moderate amts. Thick\\n white secretions. RR remains in 30\\n Abd soft, NT/D, BS present, incontinent sm. to medium soft, brown BM.\\n Conts. TF at goal 40cc/hr with no residuals.\\n Foley patent draining adequate amts. Yellow urine.\\n Endo: BS 128, no coverage per sliding scale.\\n Tmax 100.6po, conts. Cefipime as ordered.\\n Mulitple areas of ecchymosis, see metavision.\\n Pt\\ns companion in this afternoon, pt\\ns son also telephoned\\n for update.\\n Action:\\n Frequent repositioning/pulmonary hygiene provided. Cons. Dilt. As\\n ordered.\\n Midline dsg changed.\\n and updated by this RN; plan for son to touch base\\n with case management tomorrow regarding rehab\\n possibilities.\\n Pt dangled a edge of bed and stood at edge of bed with PT, see PT\\n note. OOB to chair for approx. 3hours, tolerated well.\\n Response:\\n Pt tachypneic with RR up to 40\\ns after turning activity with prolonged\\n recovery time.\\n Currently on 10PS/5 PEEP/40%.\\n Plan:\\n Monitor VS, hemodynamics, I/O, labs. Cont. aggressive pulmonary\\n hygiene, frequent repositioning.\\n Wean vent as able, attempt trach mask trial if/when appropriate. Cont.\\n rehab screening process.\\n Double lumen midline remains coiled outside skin. ?antibiotic course\\n complete in next few days. If there is a need for prolonged abx\\n course, ? IR for PICC replacement. Follow up with case management and\\n family regarding specific rehabs on . Cont. ongoing open\\n communication, comfort, and support to pt and family.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2175-02-07 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 715352,\n \"text\": \"Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Remains on psv 10, 5peep and 40% with stable abg and 02sats. Remains\\n tachypneic, 30\\ns but denies distress. LS w/ rhonci throughout.\\n Copious thick yellow secretions. Strong productive cough but cannot\\n clear.\\n Action:\\n Pulm toilet, Frequent suctioning required.\\n Response:\\n Stable on psv 10/5 but cont with copious secretions despite frequent\\n sxning.\\n Plan:\\n Will attempt psv 5 in am and recheck ABG. Not ready for TM due to\\n copious secretions and tachpynea. Cont w/ oob to chair as tolerated.\\n Cont pulm toilet.\\n Activity Intolerance\\n Assessment: Pt assisting with movement and aable to use swabs\\n independently with supervision. Washing face independently.\\n Action: Encourage pt to increase participation in care.\\n Response: More interactive and asking to do things for himself.\\n Plan: Increase activity as tolerated. Encourage participation in\\n care. Have pt assist with bath when oob-chair during the day.\\n Encourage normal sleep pattern.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2175-01-25 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 713466,\n \"text\": \"s/p hit by falling tree, crushing injury to right chest, pelvis,\\n thorasic fx, liver lac.\\n Trauma, s/p\\n Assessment:\\n Patient sleeping comfortably all night. Pain well controlled with\\n Dilaudid PCA using IS frequently with TV 1000. Cough weak but\\n productive. NPO overnight for ? OR today. UOP marginal with increasing\\n Creatinine, responding slightly to IVF bolus. Afebrile, blood sugars\\n requiring minimal insulin coverage. At 0600 HR 150s, ST with poor\\n respiratory status. ABG showing worsening acidosis. Pt was increasingly\\n lethargic but remained oriented times 3. LS very diminished which was a\\n change from being clear over night. HR not responding it intervention\\n and became hypotensive. Pt was intubated at 0630 successfully. Hct\\n drifting to 23.\\n Action:\\n Fluid bolus for UOP. EKG done, esmolol bolus given, 1 unit PRBC, Lasix\\n bolus given, patient intubated at 0630.\\n Response:\\n Cough improving post intubation suctioning copious amounts of tenacious\\n yellow secretions.\\n Plan:\\n Bicarb gtt prior to IR. Emergently to IR this am, ? CTA of chest to R/O\\n PE. Maintain hemodynamic stability with blood product transfusions and\\n vasopressors as needed. Awaiting TLSO brace must be less than 30\\n degrees without brace.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2175-01-25 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 713469,\n \"text\": \"TSICU\\n HPI:\\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\\n checked and 1.5, 1 more unit FFP given.\\n Injuries\\n Mult rib fx: R anterolateral and post, L posterior\\n T4 vert body inf corner fx\\n Commin spinous process fx T2-8\\n Nondisplaced left T10 transverse process\\n Nondispaced L distal clavicle\\n Nondisplaced L clavicle fx\\n R medial lobe liver contusion with hematoma\\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny\\n focus of arterial bleeding/active extravasation, and larger area\\n of venous bleeding\\n Nondisplaced, comminuted L iliac bone fracture w/adjacent iliac muscle\\n hematoma, Fracture extends into left SI joint.\\n Minimally displaced fracture of the right iliac bone extending to right\\n SI joint.\\n Chief complaint:\\n pain\\n PMHx:\\n none\\n Current medications:\\n Acetaminophen 5. Calcium Gluconate 6. Dextrose 50% 7. Docusate Sodium\\n (Liquid)\\n 8. Famotidine 9. Gabapentin 10. Glucagon 11. HYDROmorphone (Dilaudid)\\n 12. Insulin 13. Magnesium Sulfate\\n 14. Ondansetron 15. Pneumococcal Vac Polyvalent 16. Potassium Chloride\\n 17. Sodium Chloride 0.9% Flush\\n 18. Sodium Phosphate\\n 24 Hour Events:\\n ARTERIAL LINE - START 10:59 AM\\n : Hct stable. APS c/s for possible epidural--awaiting ortho spine\\n plan. Tylenol, neurontin, dilaudid for pain. Ortho non op, will\\n reassess . Per ortho spine, no surgical intervention; HOB<30, TLSO\\n when OOB.\\n : CR increased to 1.6, LFTs elevated in 500s. Bolused 500c x2 for\\n low urine output\\n Allergies:\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Famotidine (Pepcid) - 08:00 PM\\n Other medications:\\n Flowsheet Data as of 04:51 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 36.3\\nC (97.3\\n T current: 35.9\\nC (96.6\\n HR: 99 (80 - 102) bpm\\n BP: 96/45(61) {94/45(61) - 126/65(84)} mmHg\\n RR: 18 (10 - 25) insp/min\\n SPO2: 90%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 90 kg (admission): 90 kg\\n Total In:\\n 3,960 mL\\n 1,473 mL\\n PO:\\n 510 mL\\n Tube feeding:\\n IV Fluid:\\n 3,450 mL\\n 1,473 mL\\n Blood products:\\n Total out:\\n 855 mL\\n 195 mL\\n Urine:\\n 855 mL\\n 195 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 3,105 mL\\n 1,278 mL\\n Respiratory support\\n O2 Delivery Device: Face tent\\n SPO2: 90%\\n ABG: 7.29/54/77./25/-1\\n PaO2 / FiO2: 156\\n Physical Examination\\n General Appearance: No acute distress, Well nourished\\n HEENT: PERRL, EOMI\\n Cardiovascular: (Rhythm: Regular)\\n Respiratory / Chest: (Breath Sounds: Diminished: at bases), (Sternum:\\n Stable )\\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present)\\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present)\\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\\n (Responds to: Verbal stimuli), Moves all extremities\\n Labs / Radiology\\n 89 K/uL\\n 8.2 g/dL\\n 123 mg/dL\\n 1.6 mg/dL\\n 25 mEq/L\\n 5.1 mEq/L\\n 36 mg/dL\\n 110 mEq/L\\n 140 mEq/L\\n 24.1 %\\n 15.5 K/uL\\n [image002.jpg]\\n 02:00 AM\\n 04:29 AM\\n 07:36 AM\\n 10:54 AM\\n 04:13 PM\\n 05:25 PM\\n 10:38 PM\\n 10:56 PM\\n 03:24 AM\\n 03:44 AM\\n WBC\\n 13.7\\n 15.5\\n Hct\\n 31.9\\n 28.3\\n 28.9\\n 27.7\\n 25.7\\n 24.1\\n Plt\\n 127\\n 89\\n Creatinine\\n 1.2\\n 1.6\\n 1.6\\n TCO2\\n 27\\n 28\\n 27\\n Glucose\\n 140\\n 181\\n 130\\n 123\\n Other labs: PT / PTT / INR:14.7/27.7/1.3, CK / CK-MB / Troponin\\n T:1349//, ALT / AST:559/522, Alk-Phos / T bili:39/0.9, Lactic Acid:1.7\\n mmol/L, LDH:616 IU/L, Ca:8.0 mg/dL, Mg:2.3 mg/dL, PO4:5.7 mg/dL\\n Imaging: CXR Pend\\n Pelvis Pend\\n CT head OSH: Prelim No ICH or fracture.\\n CT chest OSH: Mult rib fx: R anterolateral and posterior, L\\n posterior; Dependent consolidation, possible aspiration; T4 vertebral\\n body inf corner fx, no retropulsion; Comminuted spinous process fx\\n T2-8; Nondisplaced L T10 transverse process; Nondisplaced L clavicle\\n distal fx; Nondisplaced L scapula fx;\\n CT c spine OSH: Prelim No fx or malalignment. Multilevel\\n degenerative changes w/large post disk bulge at C4-5, narrowing the\\n spinal canal and deforming the thecal sac, acuity unknown. Marked\\n neuroforamenal narrowing @multiple levels.\\n CTA abd/pel Prelim: Medial R liver lobe contusion w/adj\\n hematoma, w/o evidence of active bleeding; Comminuted L pubic ramus\\n fracture w/assoc hematoma, with tiny focus of arterial bleeding/active\\n extravasation, and larger area of venous bleeding. Hematoma somewhat\\n larger than on OSH study. Nondisplaced, comminuted L iliac bone fx\\n w/adj iliac muscle hematoma, larger than on prior study, w/o active\\n extrav. Fx extends into L SI joint. Post R hepatic laceration/contusion\\n adjacent to calcified granuloma, w/small hematoma, without active\\n bleeding. Min displaced fx of R iliac bone extending to R SI joint.\\n Cirrhotic liver. Inc B pleural effusions (small), w/inc atelectasis.\\n MRI: Mild compression deformity of L1 with additional levels of\\n potential trabecular contusion @T10-11 also inf @T4 w/o retropulsion.\\n Multilevel degenerative changes with moderate canal narrowing at T10-11\\n w/cord deformity and no abnormal cord signal. Extensive edema\\n throughout the paraspinal soft tissues, predominantly\\n post w/in interspinous ligaments. Incompletely evaluated c-spine w/\\n severe canal narrowing @C4-5 w/cord deformity and no abnormal cord\\n signal.\\n Assessment and Plan\\n TRAUMA, S/P\\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\\n clavicle fx, and thoracic fx.\\n Neurologic: Neuro checks Q: 4 hr, Pain controlled, C-spine cleared. Per\\n ortho spine, no surgical intervention; HOB<30, TLSO when OOB. Use\\n ativan and fentanyl for sedation.\\n Neuro checks Q: shift\\n Pain: Dilaudid PCA 0.25/2.5, may require epidural (APS awaiting ortho\\n spine plan)\\n changed to fentanyl while now intubated. Neurontin,\\n Tylenol. Will place paravetebral catheters for analgesia.\\n Cardiovascular: Stable currently, SBP into 90s on , but in 120s\\n after a-line placed. TTE with adequate CO, low SVR state, e/o RV\\n pressure overload but good contractility. Place Vigileo.\\n Pulmonary: IS, On face tent 70% O2, monitor, may require intubation.\\n f/u CXR . Excellent tidal volumes of > 1L. Early this am\\n developed progressive respiratory acidosis. Will obtain pulm\\n angiogram as well.\\n Gastrointestinal / Abdomen: NPO after MN for possible OR (pelvis).\\n Increasing LFTs (in 500s on ); h/o cirrhosis.\\n Nutrition: Regular diet, Advance diet as tolerated\\n Renal: Foley, Adequate UO, Foley, monitor UOP, f/u lytes, and trend\\n Cr. Given ~1L bolus o/n for decreasing uop.\\n Hematology: Serial Hct, Monitor Hct q6\\n 35.1-32.2-31.9-28.3-28.9-27.7-25.7-24.1, Monitor coags INR 1.3. If\\n actively bleeding may need Angio.\\n Endocrine: RISS, goal BS<150.\\n Infectious Disease: Check cultures, afebrile, but elevated wbc to\\n 15.5.\\n Lines / Tubes / Drains: Foley, RIJ CVL (d/c if stable), PIV x2,\\n Foley, a-line (). Will change CVL now.\\n Wounds:\\n Imaging: CXR today\\n Fluids: LR, LR@100 currently, KVO if taking POs\\n Consults: Trauma surgery, Ortho, Ortho-spine, Trauma (1o), Ortho Spine,\\n Ortho trauma\\n Billing Diagnosis: Multiple injuries (Trauma)\\n ICU Care\\n Nutrition:\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n Multi Lumen - 09:00 PM\\n 18 Gauge - 09:00 PM\\n 20 Gauge - 09:00 PM\\n Arterial Line - 10:59 AM\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer: H2 blocker\\n VAP bundle: HOB elevation\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds , ICU\\n Code status: Full code\\n Disposition:\\n Total time spent:\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2175-01-25 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 713488,\n \"text\": \"TSICU\\n HPI:\\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\\n checked and 1.5, 1 more unit FFP given.\\n Injuries\\n Mult rib fx: R anterolateral and post, L posterior\\n T4 vert body inf corner fx\\n Commin spinous process fx T2-8\\n Nondisplaced left T10 transverse process\\n Nondispaced L distal clavicle\\n Nondisplaced L clavicle fx\\n R medial lobe liver contusion with hematoma\\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny\\n focus of arterial bleeding/active extravasation, and larger area\\n of venous bleeding\\n Nondisplaced, comminuted L iliac bone fracture w/adjacent iliac muscle\\n hematoma, Fracture extends into left SI joint.\\n Minimally displaced fracture of the right iliac bone extending to right\\n SI joint.\\n Chief complaint:\\n pain\\n PMHx:\\n none\\n Current medications:\\n Acetaminophen 5. Calcium Gluconate 6. Dextrose 50% 7. Docusate Sodium\\n (Liquid)\\n 8. Famotidine 9. Gabapentin 10. Glucagon 11. HYDROmorphone (Dilaudid)\\n 12. Insulin 13. Magnesium Sulfate\\n 14. Ondansetron 15. Pneumococcal Vac Polyvalent 16. Potassium Chloride\\n 17. Sodium Chloride 0.9% Flush\\n 18. Sodium Phosphate\\n 24 Hour Events:\\n ARTERIAL LINE - START 10:59 AM\\n : Hct stable. APS c/s for possible epidural--awaiting ortho spine\\n plan. Tylenol, neurontin, dilaudid for pain. Ortho non op, will\\n reassess . Per ortho spine, no surgical intervention; HOB<30, TLSO\\n when OOB.\\n : CR increased to 1.6, LFTs elevated in 500s. Bolused 500c x2 for\\n low urine output\\n Allergies:\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Famotidine (Pepcid) - 08:00 PM\\n Other medications:\\n Flowsheet Data as of 04:51 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 36.3\\nC (97.3\\n T current: 35.9\\nC (96.6\\n HR: 99 (80 - 102) bpm\\n BP: 96/45(61) {94/45(61) - 126/65(84)} mmHg\\n RR: 18 (10 - 25) insp/min\\n SPO2: 90%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 90 kg (admission): 90 kg\\n Total In:\\n 3,960 mL\\n 1,473 mL\\n PO:\\n 510 mL\\n Tube feeding:\\n IV Fluid:\\n 3,450 mL\\n 1,473 mL\\n Blood products:\\n Total out:\\n 855 mL\\n 195 mL\\n Urine:\\n 855 mL\\n 195 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 3,105 mL\\n 1,278 mL\\n Respiratory support\\n O2 Delivery Device: Face tent\\n SPO2: 90%\\n ABG: 7.29/54/77./25/-1\\n PaO2 / FiO2: 156\\n Physical Examination\\n General Appearance: No acute distress, Well nourished\\n HEENT: PERRL, EOMI\\n Cardiovascular: (Rhythm: Regular)\\n Respiratory / Chest: (Breath Sounds: Diminished: at bases), (Sternum:\\n Stable )\\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present)\\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present)\\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\\n (Responds to: Verbal stimuli), Moves all extremities\\n Labs / Radiology\\n 89 K/uL\\n 8.2 g/dL\\n 123 mg/dL\\n 1.6 mg/dL\\n 25 mEq/L\\n 5.1 mEq/L\\n 36 mg/dL\\n 110 mEq/L\\n 140 mEq/L\\n 24.1 %\\n 15.5 K/uL\\n [image002.jpg]\\n 02:00 AM\\n 04:29 AM\\n 07:36 AM\\n 10:54 AM\\n 04:13 PM\\n 05:25 PM\\n 10:38 PM\\n 10:56 PM\\n 03:24 AM\\n 03:44 AM\\n WBC\\n 13.7\\n 15.5\\n Hct\\n 31.9\\n 28.3\\n 28.9\\n 27.7\\n 25.7\\n 24.1\\n Plt\\n 127\\n 89\\n Creatinine\\n 1.2\\n 1.6\\n 1.6\\n TCO2\\n 27\\n 28\\n 27\\n Glucose\\n 140\\n 181\\n 130\\n 123\\n Other labs: PT / PTT / INR:14.7/27.7/1.3, CK / CK-MB / Troponin\\n T:1349//, ALT / AST:559/522, Alk-Phos / T bili:39/0.9, Lactic Acid:1.7\\n mmol/L, LDH:616 IU/L, Ca:8.0 mg/dL, Mg:2.3 mg/dL, PO4:5.7 mg/dL\\n Imaging: CXR Pend\\n Pelvis Pend\\n CT head OSH: Prelim No ICH or fracture.\\n CT chest OSH: Mult rib fx: R anterolateral and posterior, L\\n posterior; Dependent consolidation, possible aspiration; T4 vertebral\\n body inf corner fx, no retropulsion; Comminuted spinous process fx\\n T2-8; Nondisplaced L T10 transverse process; Nondisplaced L clavicle\\n distal fx; Nondisplaced L scapula fx;\\n CT c spine OSH: Prelim No fx or malalignment. Multilevel\\n degenerative changes w/large post disk bulge at C4-5, narrowing the\\n spinal canal and deforming the thecal sac, acuity unknown. Marked\\n neuroforamenal narrowing @multiple levels.\\n CTA abd/pel Prelim: Medial R liver lobe contusion w/adj\\n hematoma, w/o evidence of active bleeding; Comminuted L pubic ramus\\n fracture w/assoc hematoma, with tiny focus of arterial bleeding/active\\n extravasation, and larger area of venous bleeding. Hematoma somewhat\\n larger than on OSH study. Nondisplaced, comminuted L iliac bone fx\\n w/adj iliac muscle hematoma, larger than on prior study, w/o active\\n extrav. Fx extends into L SI joint. Post R hepatic laceration/contusion\\n adjacent to calcified granuloma, w/small hematoma, without active\\n bleeding. Min displaced fx of R iliac bone extending to R SI joint.\\n Cirrhotic liver. Inc B pleural effusions (small), w/inc atelectasis.\\n MRI: Mild compression deformity of L1 with additional levels of\\n potential trabecular contusion @T10-11 also inf @T4 w/o retropulsion.\\n Multilevel degenerative changes with moderate canal narrowing at T10-11\\n w/cord deformity and no abnormal cord signal. Extensive edema\\n throughout the paraspinal soft tissues, predominantly\\n post w/in interspinous ligaments. Incompletely evaluated c-spine w/\\n severe canal narrowing @C4-5 w/cord deformity and no abnormal cord\\n signal.\\n Assessment and Plan\\n TRAUMA, S/P\\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\\n clavicle fx, and thoracic fx.\\n Neurologic: Neuro checks Q: 4 hr, Pain controlled, C-spine cleared. Per\\n ortho spine, no surgical intervention; HOB<30, TLSO when OOB. Use\\n ativan and fentanyl for sedation.\\n Neuro checks Q: shift\\n Pain: Dilaudid PCA 0.25/2.5, may require epidural (APS awaiting ortho\\n spine plan)\\n changed to fentanyl while now intubated. Neurontin,\\n Tylenol. may place paravetebral catheters for analgesia.\\n Cardiovascular: Stable currently, SBP into 90s on , but in 120s\\n after a-line placed. TTE with adequate CO, low SVR state, e/o RV\\n pressure overload but good contractility. place the or\\n Vigilleo. Hypotension/shock on phenylephrine. Normal LV function,\\n dilated RV. Could be from PE (See below). Currently on phenylephrine.\\n Will re-evaluate post IR procedure.\\n Pulmonary:. Early this am developed progressive respiratory acidosis\\n and hypotension. Given signs of RV dilatation (although no classical\\n sign of PE) will send for CTA (Torso, given continued bleeding).\\n Gastrointestinal / Abdomen: NPO after MN for possible OR (pelvis).\\n Increasing LFTs (in 500s on ); h/o cirrhosis.\\n Nutrition: NPO for now\\n Renal: Foley, Adequate UO, Foley, monitor UOP, f/u lytes, and trend\\n Cr. Given ~1L bolus o/n for decreasing uop. CRI appears to slightly\\n improve. Will hydrate with bicarb gtt for anticipated dye load.\\n Hematology: Serial Hct, Monitor Hct q6\\n 35.1-32.2-31.9-28.3-28.9-27.7-25.7-24.1, Monitor coags INR 1.3. If\\n actively bleeding may need Angio.\\n Endocrine: RISS, goal BS<150.\\n Infectious Disease: Check cultures, afebrile, but elevated wbc to\\n 15.5.\\n Lines / Tubes / Drains: Foley, RIJ CVL (d/c if stable), PIV x2,\\n Foley, a-line (). Will change CVL today.\\n Wounds:\\n Imaging: CXR today\\n Fluids: LR, LR@100 currently, KVO if taking POs\\n Consults: Trauma surgery, Ortho, Ortho-spine, Trauma (1o), Ortho Spine,\\n Ortho trauma\\n Billing Diagnosis: Multiple injuries (Trauma)\\n ICU Care\\n Nutrition:\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n Multi Lumen - 09:00 PM\\n 18 Gauge - 09:00 PM\\n 20 Gauge - 09:00 PM\\n Arterial Line - 10:59 AM\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer: H2 blocker\\n VAP bundle: HOB elevation\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds , ICU\\n Code status: Full code\\n Disposition: ICU\\n Total time spent: 40 min\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2175-01-24 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 713330,\n \"text\": \"TSICU\\n HPI:\\n 74 yo male s/p fall from tractor and crush injury from tree branch.\\n +Loc. At OSH received 4 units prbcs, 1 unit FFP for INR 4. +HD stable\\n here. INR checked and 1.5, 1 more unit FFP given.\\n Injuries\\n Mult rib fx: R anterolateral and post, L posterior\\n T4 vert body inf corner fx\\n Commin spinous process fx T2-8\\n Nondisplaced left T10 transverse process\\n Nondispaced L distal clavicle\\n R medial lobe liver contusion with hematoma\\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny\\n focus of arterial bleeding/active extravasation, and larger area of\\n venous bleeding\\n Nondisplaced, comminuted L iliac bone fracture w/adjacent iliac muscle\\n hematoma, Fracture extends into left SI joint.\\n Minimally displaced fracture of the right iliac bone extending to right\\n SI joint.\\n Chief complaint:\\n fall\\n PMHx:\\n None\\n Current medications:\\n 1. Calcium Gluconate 2. Dextrose 50% 3. Docusate Sodium (Liquid) 4.\\n Famotidine 5. Glucagon 6. HYDROmorphone (Dilaudid) 7. Insulin 8.\\n Magnesium Sulfate 9. Pneumococcal Vac Polyvalent 10. Potassium Chloride\\n 11. Sodium Chloride 0.9% Flush 12. Sodium Phosphate\\n 24 Hour Events:\\n MULTI LUMEN - START 09:00 PM\\n NASAL SWAB - At 12:00 AM\\n C-SPINE CLEARANCE - At 12:00 AM\\n MAGNETIC RESONANCE IMAGING - At 02:17 AM Thoracic spine\\n - Started on Dilaudid PCA with good effect, breathing improved. Weaned\\n down oxygen to face tent. Remained HD stable overnight, although SBP\\n dropped to 70s transiently this AM\\n bolused 1 L NS. Thoracic MRI\\n performed.\\n Allergies:\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Famotidine (Pepcid) - 10:00 PM\\n Fentanyl - 12:00 AM\\n Other medications:\\n Flowsheet Data as of 06:09 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 36.7\\nC (98\\n T current: 35.7\\nC (96.2\\n HR: 88 (88 - 99) bpm\\n BP: 91/65(71) {91/52(66) - 135/72(89)} mmHg\\n RR: 25 (24 - 35) insp/min\\n SPO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 90 kg (admission): 90 kg\\n Total In:\\n 6,105 mL\\n 593 mL\\n PO:\\n Tube feeding:\\n IV Fluid:\\n 305 mL\\n 593 mL\\n Blood products:\\n Total out:\\n 595 mL\\n 300 mL\\n Urine:\\n 395 mL\\n 300 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 5,510 mL\\n 293 mL\\n Respiratory support\\n O2 Delivery Device: Face tent\\n SPO2: 100%\\n ABG: 7.35/41/112/23/-2\\n PaO2 / FiO2: 160\\n Physical Examination\\n General Appearance: No acute distress\\n HEENT: PERRL\\n Cardiovascular: (Rhythm: Regular)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\\n Diminished: shallow respirations)\\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: No(t) Present)\\n Right Extremities: (Edema: Absent), (Temperature: Warm)\\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\\n (Responds to: Verbal stimuli), Moves all extremities\\n Labs / Radiology\\n 127 K/uL\\n 10.5 g/dL\\n 181 mg/dL\\n 1.2 mg/dL\\n 23 mEq/L\\n 5.2 mEq/L\\n 21 mg/dL\\n 110 mEq/L\\n 140 mEq/L\\n 31.9 %\\n 13.7 K/uL\\n [image002.jpg]\\n 09:00 PM\\n 11:04 PM\\n 11:22 PM\\n 04:29 AM\\n WBC\\n 13.7\\n Hct\\n 32.2\\n 31.9\\n Plt\\n 127\\n Creatinine\\n 1.2\\n TCO2\\n 23\\n 24\\n Glucose\\n 181\\n Other labs: PT / PTT / INR:15.0/26.4/1.3, Lactic Acid:2.8 mmol/L,\\n LDH:616 IU/L, Ca:8.1 mg/dL, Mg:1.8 mg/dL, PO4:4.9 mg/dL\\n Assessment and Plan\\n TRAUMA, S/P fall from tractor.\\n Assessment and Plan: 74 yo M s/p fall with multiple rib fractures,\\n pelvis fractures, clavicle fx, and thoracic fractures.\\n Neurologic: A&Ox 3. Using PCA with effect. C-spine cleared. Thoracic\\n MRI done per ortho spine, logroll precautions.\\n Neuro checks Q: shift\\n Pain: Dilaudid PCA 0.25/2.5; start Tylenol as Neurontin once taking\\n POs.\\n require epidural vs paravertebral catheter, will discuss with APS.\\n Cardiovascular: Stable but transient hypoTN this AM. Will place aline.\\n Pt has access, type and crossed. need angio if ongoing bleeding.\\n Pulmonary: On face tent 70% O2, monitor, may require intubation.\\n Splinting due to pain.\\n Gastrointestinal / Abdomen: NPO x meds. Elevated transaminases, ? liver\\n contusion related. Follow and trend LFTs.\\n Nutrition: NPO\\n Renal: Foley, Adequate UO\\n Hematology: Monitor Hct q6 35.1-32.2-31.9-28.3, Monitor coags INR 1.3.\\n If actively bleeding may need Angio, follow Hct closely, recheck 11 AM.\\n Endocrine: RISS, goal BS <150. Tighten RISS.\\n Infectious Disease: Afebrile.\\n Lines / Tubes / Drains: RIJ CVL, PIV, Foley\\n will d/c OSH CVL and\\n replace CVL.\\n Wounds: c/d/i\\n Imaging:\\n Fluids: LR @ 100.\\n Consults: Trauma, Ortho Spine, Ortho trauma\\n Billing Diagnosis:\\n ICU Care\\n Nutrition:\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n Multi Lumen - 09:00 PM\\n 18 Gauge - 09:00 PM\\n 20 Gauge - 09:00 PM\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer: H2 blocker\\n VAP bundle: n/a\\n Comments:\\n Communication: ICU consent signed Comments:\\n Code status: Full code\\n Disposition: ICU\\n Total time spent: 33 min\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2175-01-24 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 713343,\n \"text\": \"TSICU\\n HPI:\\n 74 yo male s/p fall from tractor and crush injury from tree branch.\\n +Loc. At OSH received 4 units prbcs, 1 unit FFP for INR 4. +HD stable\\n here. INR checked and 1.5, 1 more unit FFP given.\\n Injuries\\n Mult rib fx: R anterolateral and post, L posterior\\n T4 vert body inf corner fx\\n Commin spinous process fx T2-8\\n Nondisplaced left T10 transverse process\\n Nondispaced L distal clavicle\\n R medial lobe liver contusion with hematoma\\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny\\n focus of arterial bleeding/active extravasation, and larger area of\\n venous bleeding\\n Nondisplaced, comminuted L iliac bone fracture w/adjacent iliac muscle\\n hematoma, Fracture extends into left SI joint.\\n Minimally displaced fracture of the right iliac bone extending to right\\n SI joint.\\n Chief complaint:\\n fall\\n PMHx:\\n None\\n Current medications:\\n 1. Calcium Gluconate 2. Dextrose 50% 3. Docusate Sodium (Liquid) 4.\\n Famotidine 5. Glucagon 6. HYDROmorphone (Dilaudid) 7. Insulin 8.\\n Magnesium Sulfate 9. Pneumococcal Vac Polyvalent 10. Potassium Chloride\\n 11. Sodium Chloride 0.9% Flush 12. Sodium Phosphate\\n 24 Hour Events:\\n MULTI LUMEN - START 09:00 PM\\n NASAL SWAB - At 12:00 AM\\n C-SPINE CLEARANCE - At 12:00 AM\\n MAGNETIC RESONANCE IMAGING - At 02:17 AM Thoracic spine\\n - Started on Dilaudid PCA with good effect, breathing improved. Weaned\\n down oxygen to face tent. Remained HD stable overnight, although SBP\\n dropped to 70s transiently this AM\\n bolused 1 L NS. Thoracic MRI\\n performed.\\n Allergies:\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Famotidine (Pepcid) - 10:00 PM\\n Fentanyl - 12:00 AM\\n Other medications:\\n Flowsheet Data as of 06:09 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 36.7\\nC (98\\n T current: 35.7\\nC (96.2\\n HR: 88 (88 - 99) bpm\\n BP: 91/65(71) {91/52(66) - 135/72(89)} mmHg\\n RR: 25 (24 - 35) insp/min\\n SPO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 90 kg (admission): 90 kg\\n Total In:\\n 6,105 mL\\n 593 mL\\n PO:\\n Tube feeding:\\n IV Fluid:\\n 305 mL\\n 593 mL\\n Blood products:\\n Total out:\\n 595 mL\\n 300 mL\\n Urine:\\n 395 mL\\n 300 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 5,510 mL\\n 293 mL\\n Respiratory support\\n O2 Delivery Device: Face tent\\n SPO2: 100%\\n ABG: 7.35/41/112/23/-2\\n PaO2 / FiO2: 160\\n Physical Examination\\n General Appearance: No acute distress\\n HEENT: PERRL\\n Cardiovascular: (Rhythm: Regular)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\\n Diminished: shallow respirations)\\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: No(t) Present)\\n Right Extremities: (Edema: Absent), (Temperature: Warm)\\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\\n (Responds to: Verbal stimuli), Moves all extremities\\n Labs / Radiology\\n 127 K/uL\\n 10.5 g/dL\\n 181 mg/dL\\n 1.2 mg/dL\\n 23 mEq/L\\n 5.2 mEq/L\\n 21 mg/dL\\n 110 mEq/L\\n 140 mEq/L\\n 31.9 %\\n 13.7 K/uL\\n [image002.jpg]\\n 09:00 PM\\n 11:04 PM\\n 11:22 PM\\n 04:29 AM\\n WBC\\n 13.7\\n Hct\\n 32.2\\n 31.9\\n Plt\\n 127\\n Creatinine\\n 1.2\\n TCO2\\n 23\\n 24\\n Glucose\\n 181\\n Other labs: PT / PTT / INR:15.0/26.4/1.3, Lactic Acid:2.8 mmol/L,\\n LDH:616 IU/L, Ca:8.1 mg/dL, Mg:1.8 mg/dL, PO4:4.9 mg/dL\\n Assessment and Plan\\n TRAUMA, S/P fall from tractor.\\n Assessment and Plan: 74 yo M s/p fall with multiple rib fractures,\\n pelvis fractures, clavicle fx, and thoracic fractures.\\n Neurologic: A&Ox 3. Using PCA with good effect. C-spine cleared.\\n Thoracic MRI done per ortho spine, continue logroll precautions.\\n Awaiting input from ortho-spine re: surgery vs. TLSO\\n Neuro checks Q:4 shift\\n Pain: Dilaudid PCA 0.25/2.5; start Tylenol as Neurontin once taking\\n POs.\\n require epidural vs paravertebral catheter, will discuss with APS.\\n Cardiovascular: Stable, but transient hypotension this AM. Will place\\n aline. Pt has access, type and crossed. need angio if ongoing\\n bleeding. Will do a focused TTE to eval C.O and function.\\n Pulmonary: On face tent 70% O2, monitor, may require intubation.\\n Splinting due to pain.\\n Gastrointestinal / Abdomen: NPO x meds. Elevated transaminases, ? liver\\n contusion related. Follow and trend LFTs.\\n Nutrition: NPO\\n Renal: Foley, Adequate UO\\n Hematology: Monitor Hct q6 35.1-32.2-31.9-28.3, Monitor coags INR 1.3.\\n If actively bleeding may need Angio, follow Hct closely, recheck 11 AM.\\n Endocrine: RISS, goal BS <150. Tighten RISS as slightly hyperglycemic.\\n Infectious Disease: Afebrile.\\n Lines / Tubes / Drains: RIJ CVL, PIV, Foley. Will keep OSH CVL for now\\n and may re-site it tomorrow, as the risk of placing a CVL in this\\n respiratory tenuous patient outweighs the benefit today.\\n Wounds: c/d/i\\n Imaging:\\n Fluids: LR @ 100.\\n Consults: Trauma, Ortho Spine, Ortho trauma\\n Billing Diagnosis:\\n ICU Care\\n Nutrition:\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n Multi Lumen - 09:00 PM\\n 18 Gauge - 09:00 PM\\n 20 Gauge - 09:00 PM\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer: H2 blocker\\n VAP bundle: n/a\\n Comments:\\n Communication: ICU consent signed Comments:\\n Code status: Full code\\n Disposition: ICU\\n Total time spent: 33 min\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2175-01-25 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 713436,\n \"text\": \"TSICU\\n HPI:\\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\\n checked and 1.5, 1 more unit FFP given.\\n Injuries\\n Mult rib fx: R anterolateral and post, L posterior\\n T4 vert body inf corner fx\\n Commin spinous process fx T2-8\\n Nondisplaced left T10 transverse process\\n Nondispaced L distal clavicle\\n Nondisplaced L clavicle fx\\n R medial lobe liver contusion with hematoma\\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny\\n focus of arterial bleeding/active extravasation, and larger area\\n of venous bleeding\\n Nondisplaced, comminuted L iliac bone fracture w/adjacent iliac muscle\\n hematoma, Fracture extends into left SI joint.\\n Minimally displaced fracture of the right iliac bone extending to right\\n SI joint.\\n Chief complaint:\\n pain\\n PMHx:\\n none\\n Current medications:\\n Acetaminophen 5. Calcium Gluconate 6. Dextrose 50% 7. Docusate Sodium\\n (Liquid)\\n 8. Famotidine 9. Gabapentin 10. Glucagon 11. HYDROmorphone (Dilaudid)\\n 12. Insulin 13. Magnesium Sulfate\\n 14. Ondansetron 15. Pneumococcal Vac Polyvalent 16. Potassium Chloride\\n 17. Sodium Chloride 0.9% Flush\\n 18. Sodium Phosphate\\n 24 Hour Events:\\n ARTERIAL LINE - START 10:59 AM\\n : Hct stable. APS c/s for possible epidural--awaiting ortho spine\\n plan. Tylenol, neurontin, dilaudid for pain. Ortho non op, will\\n reassess . Per ortho spine, no surgical intervention; HOB<30, TLSO\\n when OOB.\\n : CR increased to 1.6, LFTs elevated in 500s. Bolused 500c x2 for\\n low urine output\\n Allergies:\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Famotidine (Pepcid) - 08:00 PM\\n Other medications:\\n Flowsheet Data as of 04:51 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 36.3\\nC (97.3\\n T current: 35.9\\nC (96.6\\n HR: 99 (80 - 102) bpm\\n BP: 96/45(61) {94/45(61) - 126/65(84)} mmHg\\n RR: 18 (10 - 25) insp/min\\n SPO2: 90%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 90 kg (admission): 90 kg\\n Total In:\\n 3,960 mL\\n 1,473 mL\\n PO:\\n 510 mL\\n Tube feeding:\\n IV Fluid:\\n 3,450 mL\\n 1,473 mL\\n Blood products:\\n Total out:\\n 855 mL\\n 195 mL\\n Urine:\\n 855 mL\\n 195 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 3,105 mL\\n 1,278 mL\\n Respiratory support\\n O2 Delivery Device: Face tent\\n SPO2: 90%\\n ABG: 7.29/54/77./25/-1\\n PaO2 / FiO2: 156\\n Physical Examination\\n General Appearance: No acute distress, Well nourished\\n HEENT: PERRL, EOMI\\n Cardiovascular: (Rhythm: Regular)\\n Respiratory / Chest: (Breath Sounds: Diminished: at bases), (Sternum:\\n Stable )\\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present)\\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present)\\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\\n (Responds to: Verbal stimuli), Moves all extremities\\n Labs / Radiology\\n 89 K/uL\\n 8.2 g/dL\\n 123 mg/dL\\n 1.6 mg/dL\\n 25 mEq/L\\n 5.1 mEq/L\\n 36 mg/dL\\n 110 mEq/L\\n 140 mEq/L\\n 24.1 %\\n 15.5 K/uL\\n [image002.jpg]\\n 02:00 AM\\n 04:29 AM\\n 07:36 AM\\n 10:54 AM\\n 04:13 PM\\n 05:25 PM\\n 10:38 PM\\n 10:56 PM\\n 03:24 AM\\n 03:44 AM\\n WBC\\n 13.7\\n 15.5\\n Hct\\n 31.9\\n 28.3\\n 28.9\\n 27.7\\n 25.7\\n 24.1\\n Plt\\n 127\\n 89\\n Creatinine\\n 1.2\\n 1.6\\n 1.6\\n TCO2\\n 27\\n 28\\n 27\\n Glucose\\n 140\\n 181\\n 130\\n 123\\n Other labs: PT / PTT / INR:14.7/27.7/1.3, CK / CK-MB / Troponin\\n T:1349//, ALT / AST:559/522, Alk-Phos / T bili:39/0.9, Lactic Acid:1.7\\n mmol/L, LDH:616 IU/L, Ca:8.0 mg/dL, Mg:2.3 mg/dL, PO4:5.7 mg/dL\\n Imaging: CXR Pend\\n Pelvis Pend\\n CT head OSH: Prelim No ICH or fracture.\\n CT chest OSH: Mult rib fx: R anterolateral and posterior, L\\n posterior; Dependent consolidation, possible aspiration; T4 vertebral\\n body inf corner fx, no retropulsion; Comminuted spinous process fx\\n T2-8; Nondisplaced L T10 transverse process; Nondisplaced L clavicle\\n distal fx; Nondisplaced L scapula fx;\\n CT c spine OSH: Prelim No fx or malalignment. Multilevel\\n degenerative changes w/large post disk bulge at C4-5, narrowing the\\n spinal canal and deforming the thecal sac, acuity unknown. Marked\\n neuroforamenal narrowing @multiple levels.\\n CTA abd/pel Prelim: Medial R liver lobe contusion w/adj\\n hematoma, w/o evidence of active bleeding; Comminuted L pubic ramus\\n fracture w/assoc hematoma, with tiny focus of arterial bleeding/active\\n extravasation, and larger area of venous bleeding. Hematoma somewhat\\n larger than on OSH study. Nondisplaced, comminuted L iliac bone fx\\n w/adj iliac muscle hematoma, larger than on prior study, w/o active\\n extrav. Fx extends into L SI joint. Post R hepatic laceration/contusion\\n adjacent to calcified granuloma, w/small hematoma, without active\\n bleeding. Min displaced fx of R iliac bone extending to R SI joint.\\n Cirrhotic liver. Inc B pleural effusions (small), w/inc atelectasis.\\n MRI: Mild compression deformity of L1 with additional levels of\\n potential trabecular contusion @T10-11 also inf @T4 w/o retropulsion.\\n Multilevel degenerative changes with moderate canal narrowing at T10-11\\n w/cord deformity and no abnormal cord signal. Extensive edema\\n throughout the paraspinal soft tissues, predominantly\\n post w/in interspinous ligaments. Incompletely evaluated c-spine w/\\n severe canal narrowing @C4-5 w/cord deformity and no abnormal cord\\n signal.\\n Assessment and Plan\\n TRAUMA, S/P\\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\\n clavicle fx, and thoracic fx.\\n Neurologic: Neuro checks Q: 4 hr, Pain controlled, C-spine cleared. Per\\n ortho spine, no surgical intervention; HOB<30, TLSO when OOB.\\n Neuro checks Q: shift\\n Pain: Dilaudid PCA 0.25/2.5, may require epidural (APS awaiting ortho\\n spine plan). Neurontin, Tylenol\\n Cardiovascular: Stable currently, SBP into 90s on , but in 120s\\n after a-line placed.\\n Pulmonary: IS, On face tent 70% O2, monitor, may require intubation.\\n f/u CXR . Excellent tidal volumes of > 1L.\\n Gastrointestinal / Abdomen: NPO after MN for possible OR (pelvis).\\n Increasing LFTs (in 500s on ); h/o cirrhosis.\\n Nutrition: Regular diet, Advance diet as tolerated\\n Renal: Foley, Adequate UO, Foley, monitor UOP, f/u lytes, and trend\\n Cr. Given ~1L bolus o/n for decreasing uop.\\n Hematology: Serial Hct, Monitor Hct q6\\n 35.1-32.2-31.9-28.3-28.9-27.7-25.7-24.1, Monitor coags INR 1.3. If\\n actively bleeding may need Angio.\\n Endocrine: RISS\\n Infectious Disease: Check cultures, afebrile, no issues\\n Lines / Tubes / Drains: Foley, RIJ CVL (d/c if stable), PIV x2,\\n Foley, a-line ()\\n Wounds:\\n Imaging: CXR today\\n Fluids: LR, LR@100 currently, KVO if taking POs\\n Consults: Trauma surgery, Ortho, Ortho-spine, Trauma (1o), Ortho Spine,\\n Ortho trauma\\n Billing Diagnosis: Multiple injuries (Trauma)\\n ICU Care\\n Nutrition:\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n Multi Lumen - 09:00 PM\\n 18 Gauge - 09:00 PM\\n 20 Gauge - 09:00 PM\\n Arterial Line - 10:59 AM\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer: H2 blocker\\n VAP bundle: HOB elevation\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds , ICU\\n Code status: Full code\\n Disposition:\\n Total time spent:\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2175-01-25 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 713538,\n \"text\": \"Anemia\\n Assessment:\\n This AM at 06:00 reportedly pt\\ns HR suddenly went to 140\\ns, pt\\n experienced respiratory distress and poor ABG, was intubated for airway\\n protection. HCT was trending down, seen as low as 23.1 today. At the\\n beginning of this shift, pt\\ns HR converted to NSR, 80-90\\ns. BP low and\\n neo started at 07:00. Fluid boluses were given on the previous shift.\\n Event suggested possible bleeding v. PE but unknown etiology of\\n tachycardia and resp distress this AM.\\n Action:\\n OGT placed this AM for PO meds. HCT checked frequently, total of 6\\n units PRBCs given, 1 unit FFP, 1 unit platelets throughout the shift.\\n Neo titrated as needed. Propofol gtt titrated to sedation/BP, \\n gtt started for pain control. Pt had transthoracic echo done to\\n evaluate work of the heart and fluid status. Pt went to IR for\\n embolization and gel foam of pelvic/gluteal bleeding from traumatic\\n injury (see IR note for procedure details). Pt went directly from IR\\n for CTA of chest to rule out PE. Upon arrival back to ,\\n subclavian central line placed to replace old OSH central line. CXR\\n done to determine placement. Pt lying flat on back (logroll, reverse\\n Tberg, side to side flat with pillows). Frequent right femoral checks\\n done to evaluate for bleeding.\\n Response:\\n HCT increasing, BP improved-able to wean propofol, neo. Pt still\\n experiencing some pain (able to express this with lightened sedation),\\n boluses given. Pt more hemodynamicaly stable, femoral site\\n intact, tolerating neo wean well.\\n Plan:\\n Discontinue old OSH central line and PIVs tonight since central line is\\n approved for use per CXR. Continue frequent HCT checks. Wean propofol\\n and neo as tolerated; per attending MD /midazolam\\n boluses instead of increasing midazolam for sedation/comfort. Consider\\n IVC filter? Follow up with blood cultures/urine culture and CTA for\\n rule out PE. Consider getting sputum culture tonight d/t large amount\\n of secretions. Continue to support pt and family.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2175-01-26 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 713619,\n \"text\": \"TSICU\\n HPI:\\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\\n checked and 1.5, 1 more unit FFP given.\\n Chief complaint:\\n Mult rib fx: R anterolateral and post, L posterior\\n T4 vert body inf corner fx\\n Commin spinous process fx T2-8\\n Nondisplaced left T10 transverse process\\n Nondispaced L distal clavicle\\n Nondisplaced L clavicle fx\\n R medial lobe liver contusion with hematoma\\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny\\n focus of arterial bleeding/active extravasation, and larger area\\n of venous bleeding\\n Nondisplaced, comminuted L iliac bone fracture w/adjacent iliac muscle\\n hematoma, Fracture extends into left SI joint.\\n Minimally displaced fracture of the right iliac bone extending to right\\n SI joint.\\n PMHx:\\n Cirrhosis\\n Current medications:\\n Acetylcysteine 20%\\n Chlorhexidine Gluconate 0.12% Oral Rinse\\n Docusate Sodium (Liquid)\\n Famotidine\\n Fentanyl Citrate\\n Gabapentin\\n 24 Hour Events:\\n CR increased to 1.6, LFTs elevated in 500s. Bolused 500c x2 for low\\n urine output, which improved up to 100cc/h. @6am, hr incr acutely to\\n 140s, ST on ECG. Progressive acidosis. No resp decompensation\\n w/continued good tidal volumes w/effort but hypoventilated. CXR\\n w/pleural effusion, vasc congestion. Hct gradually decreasing to 23\\n @6am. 2u prbcs tx -> 24.3, 20 IV lasix. IR embolization x2 and gelfoam\\n x2. CTA neg for large PE. Received another 2u prbcs -> 25.8. 2u\\n prbcs -> 29.2. Intermittently on Neo.\\n CMV 50/15/550/14.\\n Weaning prop & Neo. Had bigeminy overnight. This AM went into AF with\\n RVR. Transitioning to PS trial. Transfused unit 50\\n 86. No\\n hematoma at femoral site. Febrile to 101.3 this AM.\\n Post operative day:\\n POD1 s/p angio embolization\\n Allergies:\\n Last dose of Antibiotics:\\n Infusions:\\n Fentanyl (Concentrate) - 75 mcg/hour\\n Phenylephrine - 0.5 mcg/Kg/min\\n Propofol - 20 mcg/Kg/min\\n Other ICU medications:\\n Furosemide (Lasix) - 06:00 AM\\n Fentanyl - 07:00 PM\\n Famotidine (Pepcid) - 08:29 PM\\n Other medications:\\n Flowsheet Data as of 06:14 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 38.3\\nC (100.9\\n T current: 37.9\\nC (100.2\\n HR: 82 (63 - 146) bpm\\n BP: 99/53(67) {86/49(61) - 133/69(90)} mmHg\\n RR: 18 (15 - 23) insp/min\\n SPO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 100.9 kg (admission): 90 kg\\n CVP: 12 (12 - 30) mmHg\\n Total In:\\n 9,459 mL\\n 1,174 mL\\n PO:\\n Tube feeding:\\n IV Fluid:\\n 6,222 mL\\n 1,174 mL\\n Blood products:\\n 2,877 mL\\n Total out:\\n 2,325 mL\\n 285 mL\\n Urine:\\n 2,325 mL\\n 285 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 7,134 mL\\n 889 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 550 (500 - 550) mL\\n RR (Set): 18\\n RR (Spontaneous): 0\\n PEEP: 14 cmH2O\\n FiO2: 50%\\n RSBI Deferred: PEEP > 10\\n PIP: 32 cmH2O\\n Plateau: 27 cmH2O\\n Compliance: 42.3 cmH2O/mL\\n SPO2: 100%\\n ABG: 7.50/42/204/30/8\\n Ve: 9.4 L/min\\n PaO2 / FiO2: 408\\n Physical Examination\\n General Appearance: No acute distress, intubated\\n HEENT: PERRL\\n Cardiovascular: (Rhythm: Regular), Regular Irregular\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\\n Rhonchorous : )\\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\\n Neurologic: Follows simple commands, Moves all extremities, Sedated\\n Labs / Radiology\\n 86 K/uL\\n 10.6 g/dL\\n 116 mg/dL\\n 1.1 mg/dL\\n 30 mEq/L\\n 3.7 mEq/L\\n 23 mg/dL\\n 105 mEq/L\\n 141 mEq/L\\n 29.6 %\\n 9.5 K/uL\\n [image002.jpg]\\n 10:40 AM\\n 02:00 PM\\n 03:41 PM\\n 04:11 PM\\n 07:14 PM\\n 09:29 PM\\n 09:59 PM\\n 11:10 PM\\n 01:19 AM\\n 01:38 AM\\n WBC\\n 9.2\\n 6.8\\n 9.5\\n Hct\\n 25.8\\n 29.2\\n 29.6\\n Plt\\n 79\\n 52\\n 86\\n Creatinine\\n 1.2\\n 1.1\\n TCO2\\n 31\\n 32\\n 30\\n 32\\n 30\\n 34\\n Glucose\\n 104\\n 99\\n 116\\n Other labs: PT / PTT / INR:14.1/29.7/1.2, CK / CK-MB / Troponin\\n T:1334/13/<0.01, ALT / AST:345/278, Alk-Phos / T bili:49/3.0, Amylase /\\n Lipase:44/, Lactic Acid:1.6 mmol/L, LDH:616 IU/L, Ca:8.2 mg/dL, Mg:2.1\\n mg/dL, PO4:1.9 mg/dL\\n Imaging: CXR Pend\\n Pelvis Pend\\n CT head OSH: Prelim No ICH or fracture.\\n CT chest OSH: Mult rib fx: R anterolateral and posterior, L\\n posterior; Dependent consolidation, possible aspiration; T4 vertebral\\n body inf corner fx, no retropulsion; Comminuted spinous process fx\\n T2-8; Nondisplaced L T10 transverse process; Nondisplaced L clavicle\\n distal fx; Nondisplaced L scapula fx;\\n CT c spine OSH: Prelim No fx or malalignment. Multilevel\\n degenerative changes w/large post disk bulge at C4-5, narrowing the\\n spinal canal and deforming the thecal sac, acuity unknown. Marked\\n neuroforamenal narrowing @multiple levels.\\n CTA abd/pel Prelim: Medial R liver lobe contusion w/adj\\n hematoma, w/o evidence of active bleeding; Comminuted L pubic ramus\\n fracture w/assoc hematoma, with tiny focus of arterial bleeding/active\\n extravasation, and larger area of venous bleeding. Hematoma somewhat\\n larger than on OSH study. Nondisplaced, comminuted L iliac bone fx\\n w/adj iliac muscle hematoma, larger than on prior study, w/o active\\n extrav. Fx extends into L SI joint. Post R hepatic laceration/contusion\\n adjacent to calcified granuloma, w/small hematoma, without active\\n bleeding. Min displaced fx of R iliac bone extending to R SI joint.\\n Cirrhotic liver. Inc B pleural effusions (small), w/inc atelectasis.\\n MRI: Mild compression deformity of L1 with additional levels of\\n potential trabecular contusion @T10-11 also inf @T4 w/o retropulsion.\\n Multilevel degenerative changes with moderate canal narrowing at T10-11\\n w/cord deformity and no abnormal cord signal. Extensive edema\\n throughout the paraspinal soft tissues, predominantly\\n post w/in interspinous ligaments. Incompletely evaluated c-spine w/\\n severe canal narrowing @C4-5 w/cord deformity and no abnormal cord\\n signal.\\n CTA: no PE.\\n Microbiology: Ucx P\\n Sputum P\\n Bcx P\\n Bcx P\\n Assessment and Plan\\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\\n clavicle fx, and thoracic fx.\\n Neurologic: C-spine cleared. Per ortho spine, no surgical intervention;\\n HOB<30, TLSO when OOB. Awake off sedation, follows commands. Midaz prn\\n for sedation, please increase dose and frequency and if need put on gtt\\n to adequately sedate patient given new AF and ARDS/ . Pain: on\\n fentanyl.\\n Cardiovascular: Bedside ECHO shows TR and elevated PA pressures but\\n adequate contractility. CVP 20s. Wean Neo gtt. Went into AF with RVR\\n this AM. Maintaining BP. Start Dilt gtt, use Neo as needed. Would not\\n use amiodaron at this point given chronic lung disease with probable\\n asbstosis and in addition liver cirrhocis. If cannot rate control,\\n though, would bolus with amio for one day\\n Pulmonary: Cont ETT, Intubated . /ARDS type picture given\\n bilat opacities and P/F ratio < 300. Will use low tidal volume\\n ventilation. Will need adequate sedation for this. Also, chronic lung\\n dz as demonstrated by CT yesterday.\\n Gastrointestinal / Abdomen: Elevated LFTs (in 500s on ). h/o\\n cirrhosis - liver panel sent. T bili elevated to 3.0, other LFTs\\n trending down. Send Direct bili. Bowel regimen.\\n Nutrition: ADAT\\n Renal: Foley, monitor UOP, f/u lytes, and trend Cr (1.1). Received\\n bicarb gtt and Mucomyst. Monitor creatinine. Check PM lytes.\\n Hematology: Monitor Hct q6\\n 35.1-32.2-31.9-28.3-28.9-27.7-25.7-24.1-23.1; tx 2u prbcs, 1 plt,\\n 1uFFP, (INR 1.3) -> 24.3; Angio embolization. 2u prbcs -> 25.8; 2u\\n prbcs -> 29.6 (). Elevated bili could be hematoma resolution, but\\n given dropping , ask Heme for consult, sent smear, DIC labs\\n this AM. Plt (peak 175) -86. Check PM CBC. Thrombocytopenia\\n -- HIT negative. Could be baseline as patient has liver cirrhocis.\\n Endocrine: RISS, adequate control, goal BS<150.\\n Infectious Disease: f/u pan cx. No abx right now, will bronch.\\n Lines / Tubes / Drains: R SC CVL (), PIV x2, Foley, a-line\\n (), ETT\\n Wounds:\\n Imaging: CXR today\\n Fluids: maintenance fluids\\n Consults: Trauma surgery, Ortho, Ortho-spine, Heme\\n Billing Diagnosis:\\n ICU Care\\n Nutrition:\\n Comments: ADAT\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n 18 Gauge - 09:00 PM\\n 20 Gauge - 09:00 PM\\n Arterial Line - 10:59 AM\\n Multi Lumen - 04:41 PM\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer: H2 blocker PO\\n VAP bundle: HOB elevation, Mouth care, Daily wake up\\n Comments:\\n Communication: Comments: ICU consent obtained. Discussed in\\n multidisciplinary rounds\\n Code status: Full code\\n Disposition: ICU\\n Total time spent: 35 min\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2175-01-24 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 713301,\n \"text\": \"s/p crush injury from tree while riding on tractor. At Hospital\\n patient was hTN and had dropping HCT, tx to . Injuries include: T4\\n vertebral body fracture, grade 2 Liver lac, multiple right side rib\\n fracture, lung contusions, right ramous and bilateral pelvic \\n fracture.\\n No PMH\\n NKDA\\n Events:\\n Abdominal and pelvic CTA\\n Thoracic MRI\\n Trauma, s/p\\n Assessment:\\n Alert and oriented times three, MAE with normal strength and has normal\\n sensation throughout. Hemodynamics stable. Hct stable at 32. LS clear\\n but diminished in right base, sa02 100% 70% face-tent, de-saturating to\\n low 90\\ns off O2, using IS well but has weak cough. Pain poorly\\n controlled upon admission but doing better with PCA. Abdomen soft with\\n normal BS, non tender.\\n Action:\\n Dilaudid PCA, abd/pelvic CTA and thoracic MR, Q 4 hr Hct checks, IS per\\n orders.\\n Response:\\n Pain control improving and pt stating it is easier to breathe now.\\n Plan:\\n Continue Q 4 hct and coag checks, transfuse as needed, and maintain\\n hemodynamic stability, awaiting MRI results for further POC re: spinal\\n fractures. Continue to provide emotional support for patient and\\n family.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2175-01-24 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 713303,\n \"text\": \"TSICU\\n HPI:\\n 74 yo male s/p fall from tractor and crush injury from tree branch.\\n +Loc. At OSH received 4 units prbcs, 1 unit FFP for INR 4. +HD stable\\n here. INR checked and 1.5, 1 more unit FFP given.\\n Injuries\\n Mult rib fx: R anterolateral and post, L posterior\\n T4 vert body inf corner fx\\n Commin spinous process fx T2-8\\n Nondisplaced left T10 transverse process\\n Nondispaced L distal clavicle\\n Nondisplaced L clavicle fx\\n R medial lobe liver contusion with hematoma\\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny\\n focus of arterial bleeding/active extravasation, and larger area\\n of venous bleeding\\n Nondisplaced, comminuted L iliac bone fracture w/adjacent iliac muscle\\n hematoma, Fracture extends into left SI joint.\\n Minimally displaced fracture of the right iliac bone extending to right\\n SI joint.\\n Chief complaint:\\n fall\\n PMHx:\\n None\\n Current medications:\\n 1. Calcium Gluconate 2. Dextrose 50% 3. Docusate Sodium (Liquid) 4.\\n Famotidine 5. Glucagon 6. HYDROmorphone (Dilaudid) 7. Insulin 8.\\n Magnesium Sulfate 9. Pneumococcal Vac Polyvalent 10. Potassium Chloride\\n 11. Sodium Chloride 0.9% Flush 12. Sodium Phosphate\\n 24 Hour Events:\\n MULTI LUMEN - START 09:00 PM\\n NASAL SWAB - At 12:00 AM\\n C-SPINE CLEARANCE - At 12:00 AM\\n MAGNETIC RESONANCE IMAGING - At 02:17 AM Thoracic spine\\n Allergies:\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Famotidine (Pepcid) - 10:00 PM\\n Fentanyl - 12:00 AM\\n Other medications:\\n Flowsheet Data as of 06:09 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 36.7\\nC (98\\n T current: 35.7\\nC (96.2\\n HR: 88 (88 - 99) bpm\\n BP: 91/65(71) {91/52(66) - 135/72(89)} mmHg\\n RR: 25 (24 - 35) insp/min\\n SPO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 90 kg (admission): 90 kg\\n Total In:\\n 6,105 mL\\n 593 mL\\n PO:\\n Tube feeding:\\n IV Fluid:\\n 305 mL\\n 593 mL\\n Blood products:\\n Total out:\\n 595 mL\\n 300 mL\\n Urine:\\n 395 mL\\n 300 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 5,510 mL\\n 293 mL\\n Respiratory support\\n O2 Delivery Device: Face tent\\n SPO2: 100%\\n ABG: 7.35/41/112/23/-2\\n PaO2 / FiO2: 160\\n Physical Examination\\n General Appearance: No acute distress\\n HEENT: PERRL\\n Cardiovascular: (Rhythm: Regular)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\\n Diminished: shallow respirations)\\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: No(t) Present)\\n Right Extremities: (Edema: Absent), (Temperature: Warm)\\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\\n (Responds to: Verbal stimuli), Moves all extremities\\n Labs / Radiology\\n 127 K/uL\\n 10.5 g/dL\\n 181 mg/dL\\n 1.2 mg/dL\\n 23 mEq/L\\n 5.2 mEq/L\\n 21 mg/dL\\n 110 mEq/L\\n 140 mEq/L\\n 31.9 %\\n 13.7 K/uL\\n [image002.jpg]\\n 09:00 PM\\n 11:04 PM\\n 11:22 PM\\n 04:29 AM\\n WBC\\n 13.7\\n Hct\\n 32.2\\n 31.9\\n Plt\\n 127\\n Creatinine\\n 1.2\\n TCO2\\n 23\\n 24\\n Glucose\\n 181\\n Other labs: PT / PTT / INR:15.0/26.4/1.3, Lactic Acid:2.8 mmol/L,\\n LDH:616 IU/L, Ca:8.1 mg/dL, Mg:1.8 mg/dL, PO4:4.9 mg/dL\\n Assessment and Plan\\n TRAUMA, S/P\\n Assessment and Plan: 74 yo M s/p fall with multiple rib fractures,\\n pelvis fractures, clavicle fx, and thoracic fractures.\\n Neurologic: C-spine cleared. Thoracic MRI done per ortho spine, logroll\\n precautions.\\n Neuro checks Q: shift\\n Pain: Dilaudid PCA 0.25/2. require epidural vs paravertebral catheter.\\n Cardiovascular: Stable\\n Pulmonary: On face tent 70% O2, monitor, may require intubation.\\n Gastrointestinal / Abdomen: NPO x meds\\n Nutrition: NPO\\n Renal: Foley, Adequate UO\\n Hematology: Monitor Hct q6 35.1-32.2-31.9, Monitor coags INR 1.3. If\\n actively bleeding may need Angio.\\n Endocrine: RISS\\n Infectious Disease:\\n Lines / Tubes / Drains: RIJ CVL, PIV, Foley\\n Wounds:\\n Imaging:\\n Fluids: LR @ 100.\\n Consults: Trauma, Ortho Spine, Ortho trauma\\n Billing Diagnosis:\\n ICU Care\\n Nutrition:\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n Multi Lumen - 09:00 PM\\n 18 Gauge - 09:00 PM\\n 20 Gauge - 09:00 PM\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer: H2 blocker\\n VAP bundle:\\n Comments:\\n Communication: ICU consent signed Comments:\\n Code status: Full code\\n Disposition: ICU\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2175-01-26 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 713612,\n \"text\": \"TSICU\\n HPI:\\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\\n checked and 1.5, 1 more unit FFP given.\\n Chief complaint:\\n Mult rib fx: R anterolateral and post, L posterior\\n T4 vert body inf corner fx\\n Commin spinous process fx T2-8\\n Nondisplaced left T10 transverse process\\n Nondispaced L distal clavicle\\n Nondisplaced L clavicle fx\\n R medial lobe liver contusion with hematoma\\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny\\n focus of arterial bleeding/active extravasation, and larger area\\n of venous bleeding\\n Nondisplaced, comminuted L iliac bone fracture w/adjacent iliac muscle\\n hematoma, Fracture extends into left SI joint.\\n Minimally displaced fracture of the right iliac bone extending to right\\n SI joint.\\n PMHx:\\n Cirrhosis\\n Current medications:\\n Acetylcysteine 20%\\n Chlorhexidine Gluconate 0.12% Oral Rinse\\n Docusate Sodium (Liquid)\\n Famotidine\\n Fentanyl Citrate\\n Gabapentin\\n 24 Hour Events:\\n CR increased to 1.6, LFTs elevated in 500s. Bolused 500c x2 for low\\n urine output, which improved up to 100cc/h. @6am, hr incr acutely to\\n 140s, ST on ECG. Progressive acidosis. No resp decompensation\\n w/continued good tidal volumes w/effort but hypoventilated. CXR\\n w/pleural effusion, vasc congestion. Hct gradually decreasing to 23\\n @6am. 2u prbcs tx -> 24.3, 20 IV lasix. IR embolization x2 and gelfoam\\n x2. CTA neg for large PE. Received another 2u prbcs -> 25.8. 2u\\n prbcs -> 29.2. Intermittently on Neo.\\n CMV 50/15/550/14.\\n Weaning prop & Neo. Had bigeminy overnight. This AM went into AF with\\n RVR. Transitioning to PS trial. Transfused unit 50\\n 86. No\\n hematoma at femoral site. Febrile to 101.3 this AM.\\n Post operative day:\\n POD1 s/p angio embolization\\n Allergies:\\n Last dose of Antibiotics:\\n Infusions:\\n Fentanyl (Concentrate) - 75 mcg/hour\\n Phenylephrine - 0.5 mcg/Kg/min\\n Propofol - 20 mcg/Kg/min\\n Other ICU medications:\\n Furosemide (Lasix) - 06:00 AM\\n Fentanyl - 07:00 PM\\n Famotidine (Pepcid) - 08:29 PM\\n Other medications:\\n Flowsheet Data as of 06:14 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 38.3\\nC (100.9\\n T current: 37.9\\nC (100.2\\n HR: 82 (63 - 146) bpm\\n BP: 99/53(67) {86/49(61) - 133/69(90)} mmHg\\n RR: 18 (15 - 23) insp/min\\n SPO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 100.9 kg (admission): 90 kg\\n CVP: 12 (12 - 30) mmHg\\n Total In:\\n 9,459 mL\\n 1,174 mL\\n PO:\\n Tube feeding:\\n IV Fluid:\\n 6,222 mL\\n 1,174 mL\\n Blood products:\\n 2,877 mL\\n Total out:\\n 2,325 mL\\n 285 mL\\n Urine:\\n 2,325 mL\\n 285 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 7,134 mL\\n 889 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 550 (500 - 550) mL\\n RR (Set): 18\\n RR (Spontaneous): 0\\n PEEP: 14 cmH2O\\n FiO2: 50%\\n RSBI Deferred: PEEP > 10\\n PIP: 32 cmH2O\\n Plateau: 27 cmH2O\\n Compliance: 42.3 cmH2O/mL\\n SPO2: 100%\\n ABG: 7.50/42/204/30/8\\n Ve: 9.4 L/min\\n PaO2 / FiO2: 408\\n Physical Examination\\n General Appearance: No acute distress, intubated\\n HEENT: PERRL\\n Cardiovascular: (Rhythm: Regular), Regular Irregular\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\\n Rhonchorous : )\\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\\n Neurologic: Follows simple commands, Moves all extremities, Sedated\\n Labs / Radiology\\n 86 K/uL\\n 10.6 g/dL\\n 116 mg/dL\\n 1.1 mg/dL\\n 30 mEq/L\\n 3.7 mEq/L\\n 23 mg/dL\\n 105 mEq/L\\n 141 mEq/L\\n 29.6 %\\n 9.5 K/uL\\n [image002.jpg]\\n 10:40 AM\\n 02:00 PM\\n 03:41 PM\\n 04:11 PM\\n 07:14 PM\\n 09:29 PM\\n 09:59 PM\\n 11:10 PM\\n 01:19 AM\\n 01:38 AM\\n WBC\\n 9.2\\n 6.8\\n 9.5\\n Hct\\n 25.8\\n 29.2\\n 29.6\\n Plt\\n 79\\n 52\\n 86\\n Creatinine\\n 1.2\\n 1.1\\n TCO2\\n 31\\n 32\\n 30\\n 32\\n 30\\n 34\\n Glucose\\n 104\\n 99\\n 116\\n Other labs: PT / PTT / INR:14.1/29.7/1.2, CK / CK-MB / Troponin\\n T:1334/13/<0.01, ALT / AST:345/278, Alk-Phos / T bili:49/3.0, Amylase /\\n Lipase:44/, Lactic Acid:1.6 mmol/L, LDH:616 IU/L, Ca:8.2 mg/dL, Mg:2.1\\n mg/dL, PO4:1.9 mg/dL\\n Imaging: CXR Pend\\n Pelvis Pend\\n CT head OSH: Prelim No ICH or fracture.\\n CT chest OSH: Mult rib fx: R anterolateral and posterior, L\\n posterior; Dependent consolidation, possible aspiration; T4 vertebral\\n body inf corner fx, no retropulsion; Comminuted spinous process fx\\n T2-8; Nondisplaced L T10 transverse process; Nondisplaced L clavicle\\n distal fx; Nondisplaced L scapula fx;\\n CT c spine OSH: Prelim No fx or malalignment. Multilevel\\n degenerative changes w/large post disk bulge at C4-5, narrowing the\\n spinal canal and deforming the thecal sac, acuity unknown. Marked\\n neuroforamenal narrowing @multiple levels.\\n CTA abd/pel Prelim: Medial R liver lobe contusion w/adj\\n hematoma, w/o evidence of active bleeding; Comminuted L pubic ramus\\n fracture w/assoc hematoma, with tiny focus of arterial bleeding/active\\n extravasation, and larger area of venous bleeding. Hematoma somewhat\\n larger than on OSH study. Nondisplaced, comminuted L iliac bone fx\\n w/adj iliac muscle hematoma, larger than on prior study, w/o active\\n extrav. Fx extends into L SI joint. Post R hepatic laceration/contusion\\n adjacent to calcified granuloma, w/small hematoma, without active\\n bleeding. Min displaced fx of R iliac bone extending to R SI joint.\\n Cirrhotic liver. Inc B pleural effusions (small), w/inc atelectasis.\\n MRI: Mild compression deformity of L1 with additional levels of\\n potential trabecular contusion @T10-11 also inf @T4 w/o retropulsion.\\n Multilevel degenerative changes with moderate canal narrowing at T10-11\\n w/cord deformity and no abnormal cord signal. Extensive edema\\n throughout the paraspinal soft tissues, predominantly\\n post w/in interspinous ligaments. Incompletely evaluated c-spine w/\\n severe canal narrowing @C4-5 w/cord deformity and no abnormal cord\\n signal.\\n CTA: no PE.\\n Microbiology: Ucx P\\n Sputum P\\n Bcx P\\n Bcx P\\n Assessment and Plan\\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\\n clavicle fx, and thoracic fx.\\n Neurologic: C-spine cleared. Per ortho spine, no surgical intervention;\\n HOB<30, TLSO when OOB. Awake off sedation, follows commands. Midaz prn\\n sedation needs while intubated. Pain: on fentanyl. Will plan to\\n transition to Oxycodone. Will discuss with APS again today.\\n Cardiovascular: Bedside ECHO shows TR and elevated PA pressures but\\n adequate contractility. CVP 20s. Wean Neo gtt. AF with RVR this AM.\\n Maintaining BP. Start Dilt gtt, use Neo as needed.\\n Pulmonary: Cont ETT, Intubated . Wean as tolerated (improve pain\\n control). 50%, checking ABG. Thick secretions, now febrile.\\n Bronch today, send BAL.\\n Gastrointestinal / Abdomen: Elevated LFTs (in 500s on ). h/o\\n cirrhosis - liver panel sent. T bili elevated to 3.0, other LFTs\\n trending down. Send Direct bili. Bowel regimen.\\n Nutrition: ADAT\\n Renal: Foley, monitor UOP, f/u lytes, and trend Cr (1.1). Received\\n bicarb gtt and Mucomyst. Monitor creatinine. Check PM lytes.\\n Hematology: Monitor Hct q6\\n 35.1-32.2-31.9-28.3-28.9-27.7-25.7-24.1-23.1; tx 2u prbcs, 1 plt,\\n 1uFFP, (INR 1.3) -> 24.3; Angio embolization. 2u prbcs -> 25.8; 2u\\n prbcs -> 29.6 (). Elevated bili could be hematoma resolution, but\\n given dropping , ask Heme for consult, sent smear, DIC labs\\n this AM. Plt (peak 175) -86. Check PM CBC.\\n Endocrine: RISS, adequate control, goal BS<150.\\n Infectious Disease: f/u pan cx. No abx right now, will bronch.\\n Lines / Tubes / Drains: R SC CVL (), PIV x2, Foley, a-line\\n (), ETT\\n Wounds:\\n Imaging: CXR today\\n Fluids: maintenance fluids\\n Consults: Trauma surgery, Ortho, Ortho-spine, Heme\\n Billing Diagnosis:\\n ICU Care\\n Nutrition:\\n Comments: ADAT\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n 18 Gauge - 09:00 PM\\n 20 Gauge - 09:00 PM\\n Arterial Line - 10:59 AM\\n Multi Lumen - 04:41 PM\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer: H2 blocker PO\\n VAP bundle: HOB elevation, Mouth care, Daily wake up\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition: ICU\\n Total time spent: 33 min\\n\"\n },\n {\n \"category\": \"Nutrition\",\n \"chartdate\": \"2175-01-26 00:00:00.000\",\n \"description\": \"Clinical Nutrition Note\",\n \"row_id\": 713631,\n \"text\": \"Subjective\\n Intubated, no family present\\n Objective\\n Height\\n Admit weight\\n Daily weight\\n Weight change\\n BMI\\n 175 cm\\n 90 kg\\n 100.9 kg ( 12:00 AM)\\n +10.9 kg due to fluid\\n 29.2\\n Ideal body weight\\n % Ideal body weight\\n Adjusted weight\\n Usual body weight\\n % Usual body weight\\n 72.6 kg\\n 124%\\n 77 kg\\n Diagnosis: polytrauma\\n PMHx: cirrhosis\\n Food allergies and intolerances: none noted\\n Pertinent medications: RISS, phenylephrine, propofol, fentanyl,\\n famotidine, Ca gluconate (2 g repletion), KPhos (15 mmol repletion),\\n diltiazem, others noted\\n Labs:\\n Value\\n Date\\n Glucose\\n 84\\n 08:00 AM\\n Glucose Finger Stick\\n 137\\n 08:00 PM\\n BUN\\n 23 mg/dL\\n 01:19 AM\\n Creatinine\\n 1.1 mg/dL\\n 01:19 AM\\n Sodium\\n 141 mEq/L\\n 01:19 AM\\n Potassium\\n 3.7 mEq/L\\n 01:19 AM\\n Chloride\\n 105 mEq/L\\n 01:19 AM\\n TCO2\\n 30 mEq/L\\n 01:19 AM\\n PO2 (arterial)\\n 138 mm Hg\\n 10:22 AM\\n PCO2 (arterial)\\n 47 mm Hg\\n 10:22 AM\\n pH (arterial)\\n 7.44 units\\n 10:22 AM\\n pH (urine)\\n 6.5 units\\n 07:00 PM\\n CO2 (Calc) arterial\\n 33 mEq/L\\n 10:22 AM\\n Calcium non-ionized\\n 8.2 mg/dL\\n 01:19 AM\\n Phosphorus\\n 1.9 mg/dL\\n 01:19 AM\\n Ionized Calcium\\n 1.15 mmol/L\\n 01:38 AM\\n Magnesium\\n 2.1 mg/dL\\n 01:19 AM\\n ALT\\n 345 IU/L\\n 01:19 AM\\n Alkaline Phosphate\\n 49 IU/L\\n 01:19 AM\\n AST\\n 278 IU/L\\n 01:19 AM\\n Amylase\\n 44 IU/L\\n 06:01 AM\\n Total Bilirubin\\n 3.0 mg/dL\\n 01:19 AM\\n WBC\\n 9.5 K/uL\\n 01:19 AM\\n Hgb\\n 10.6 g/dL\\n 01:19 AM\\n Hematocrit\\n 29.1 %\\n 07:26 AM\\n Current diet order / nutrition support: Replete with fiber Full\\n strength;\\n Starting rate: 10 ml/hr; Advance rate by 10 ml q4h Goal rate: 50 ml/hr\\n = 1200 kcals/ 74 g protein\\n Residual Check: q4h Hold feeding for residual >= : 200 ml\\n Flush w/ 50 ml water q8h\\n GI: soft, distended, +bowel sounds\\n Assessment of Nutritional Status\\n At risk for malnutrition\\n Patient at risk due to: NPO / hypocaloric diet, trauma\\n Estimated Nutritional Needs\\n Calories: -2156 (BEE x or / 25-28 cal/kg)\\n Protein: 92-116 (1.2-1.5 g/kg)\\n Fluid: per team\\n Calculations based on: Adjusted weight\\n Estimation of previous intake: likely adequate\\n Estimation of current intake: Inadequate\\n Specifics: 74 year old male s/p fall from tractor and crush injury from\\n tree branch. +Loc. Transferred from outside hospital, patient with\\n multiple injuries :Mult rib fx: R anterolateral and post, L\\n posterior,T4 vert body inf corner fx, Commin spinous process fx T2-8,\\n Nondisplaced left T10 transverse process, Nondispaced L distal \\n clavicle, Nondisplaced L clavicle fx, R medial lobe liver contusion\\n with hematoma, Comminuted L pubic ramus fx w/assoc hematoma, w/tiny\\n focus of arterial bleeding/active extravasation, and larger area of\\n venous bleeding, Nondisplaced, comminuted L iliac bone fracture\\n w/adjacent iliac muscle hematoma, Fracture extends into left SI joint.\\n Tube feeding ordered, not yet started. At goal tube feeding underfeeds\\n patient. Agree with plan for nutrition support. Propofol is running at\\n 13.5 ml/hr which provides 356 kcals/day. Will need to adjust tube\\n feeding. Noted repletions.\\n Medical Nutrition Therapy Plan - Recommend the Following\\n Tube feeding / TPN recommendations: while on current rate of\\n propofol recommend Replete with Fiber @ 55 ml/hr = 1320 kcals/ 82 g\\n protein\\n While off propofol recommend Replete with Fiber @ 80 ml/hr =\\n kcals/ 119 g protein\\n Multivitamin / Mineral supplement: via tube feeding\\n Check chemistry 10 panel daily and replete prn\\n Will follow page with questions\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2175-01-24 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 713404,\n \"text\": \"Trauma, s/p\\n Assessment:\\n Patient alert, oriented x3. Pupils 3mm, equal, reactive.\\n Moves upper extremities w/ normal strength. Lower extremities move on\\n bed, splinted by pain.\\n Complaining of pain to R side, constant w/ and w/o\\n movement. At worst, . Patient on Dilaudid PCA 02.5mg/dose.\\n LS diminished on R side. Clear to diminished on L side.\\n Sats WNL on 12L 70% fact tent and 3L NC.\\n Hypotensive at beginning of shift, SBP in 70\\ns. HR 90\\n +PP.\\n Denies abdominal pain. Abdomen soft, BS present.\\n UOP marginal.\\n Action:\\n Q4h neuro exams. Encouraged use of PCA prior to activity.\\n Tylenol and gabapentin administered.\\n Logroll precautions cleared. TLSO brace ordered. NEOPS\\n came by to measure for brace this afternoon.\\n Encouraged CDB and IS. Oxygen weaned to 12L 50% face tent,\\n 2L NC.\\n 1L LR fluid bolus administered for hypotension\\n Patient ordered for clear diet\\n Response:\\n Pain decreased to with use of PCA and oral pain\\n medications.\\n Reaches up to 1000ml with IS. Patient has weak cough,\\n splinted by pain.\\n Patient may sit up to 30 degrees but will need brace when\\n OOB.\\n VSS. Hct remains stable. Lactate trending down.\\n Plan:\\n Continue to assess for pain, medicate as needed. Wean oxygen as\\n tolerated. Pulmonary toileting. CXR tomorrow a.m. Patient to be NPO\\n after midnight for ? OR tomorrow for pelvis (awaiting final word from\\n ortho).\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2175-01-24 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 713406,\n \"text\": \"Trauma, s/p\\n Assessment:\\n Patient alert, oriented x3. Pupils 3mm, equal, reactive.\\n Moves upper extremities w/ normal strength. Lower extremities move on\\n bed, splinted by pain.\\n Complaining of pain to R side, constant w/ and w/o\\n movement. At worst, . Patient on Dilaudid PCA 02.5mg/dose.\\n LS diminished on R side. Clear to diminished on L side.\\n Sats WNL on 12L 70% fact tent and 3L NC.\\n Hypotensive at beginning of shift, SBP in 70\\ns. HR 90\\n +PP.\\n Denies abdominal pain. Abdomen soft, BS present.\\n UOP marginal.\\n Action:\\n Q4h neuro exams. Encouraged use of PCA prior to activity.\\n Tylenol and gabapentin administered.\\n Logroll precautions cleared. TLSO brace ordered. NEOPS\\n came by to measure for brace this afternoon.\\n Encouraged CDB and IS. Oxygen weaned to 12L 50% face tent,\\n 2L NC.\\n 1L LR fluid bolus administered for hypotension\\n Patient ordered for clear diet\\n Response:\\n Pain decreased to with use of PCA and oral pain\\n medications.\\n Reaches up to 1000ml with IS. Patient has weak cough,\\n splinted by pain.\\n Patient may sit up to 30 degrees but will need brace when\\n OOB.\\n VSS. Hct remains stable. Lactate trending down.\\n Plan:\\n Continue to assess for pain, medicate as needed. Wean oxygen as\\n tolerated. Pulmonary toileting. CXR tomorrow a.m. Patient to be NPO\\n after midnight for ? OR tomorrow for pelvis (awaiting final word from\\n ortho).\\n ------ Protected Section ------\\n IV: Patient has OSH central line and PIV x2. Attempt to place PIV,\\n unsuccessful. IV team aware, will come place two new PIV. Per policy,\\n OSH central line to be pulled within 24 hour. ICU team aware.\\n ------ Protected Section Addendum Entered By: , RN\\n on: 18:13 ------\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2175-01-26 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 713588,\n \"text\": \"Trauma, s/p\\n Assessment:\\n Patient sedated on propofol and Fentanyl gtt for pain, able to wake and\\n follows commands. MAE. Peripheral pulses present. Right groin site\\n soft, no hematoma, dsg CDI. Sinus arrhythmia, BP supported overnight\\n with Neo gtt. LS diminished at bases with moderate amounts of thick\\n white secretions. Vent support increased per metavision for decreased\\n PaO2. Hct stable times 2.\\n Action:\\n Pulmonary toileting, plt tx, pain control, maintained hemodynamic\\n stability.\\n Response:\\n Remains stable, physical exam unchanged. ABG improved.\\n Plan:\\n Monitor hct and ABGs. Continue pain control and pulmonary toileting.\\n Titrate vasopressor to maintain BP. Wean sedation and vent settings\\n towards extubation.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2175-01-26 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 713566,\n \"text\": \"Trauma, s/p\\n Assessment:\\n Patient sedated on propofol and Fentanyl gtt for pain, able to wake and\\n follows commands. MAE. Peripheral pulses present. Right groin site\\n soft, no hematoma, dsg CDI. Sinus arrhythmia, BP supported overnight\\n with Neo gtt. LS diminished at bases with moderate amounts of thick\\n white secretions. Vent support increased per metavision for decreased\\n PaO2. Hct stable times 2.\\n Action:\\n Pulmonary toileting, plt tx, pain control, maintained hemodynamic\\n stability.\\n Response:\\n Remains stable, physical exam unchanged. ABG improved.\\n Plan:\\n Monitor hct and ABGs. Continue pain control and pulmonary toileting.\\n Titrate vasopressor to maintain BP. Wean sedation and vent settings\\n towards extubation.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2175-01-26 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 713582,\n \"text\": \"TSICU\\n HPI:\\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\\n checked and 1.5, 1 more unit FFP given.\\n Chief complaint:\\n Mult rib fx: R anterolateral and post, L posterior\\n T4 vert body inf corner fx\\n Commin spinous process fx T2-8\\n Nondisplaced left T10 transverse process\\n Nondispaced L distal clavicle\\n Nondisplaced L clavicle fx\\n R medial lobe liver contusion with hematoma\\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny\\n focus of arterial bleeding/active extravasation, and larger area\\n of venous bleeding\\n Nondisplaced, comminuted L iliac bone fracture w/adjacent iliac muscle\\n hematoma, Fracture extends into left SI joint.\\n Minimally displaced fracture of the right iliac bone extending to right\\n SI joint.\\n PMHx:\\n Cirrhosis\\n Current medications:\\n Acetylcysteine 20%\\n Chlorhexidine Gluconate 0.12% Oral Rinse\\n Docusate Sodium (Liquid)\\n Famotidine\\n Fentanyl Citrate\\n Gabapentin\\n 24 Hour Events:\\n CR increased to 1.6, LFTs elevated in 500s. Bolused 500c x2 for low\\n urine output, which improved up to 100cc/h. @6am, hr incr acutely to\\n 140s, ST on ECG. Progressive acidosis. No resp decompensation\\n w/continued good tidal volumes w/effort but hypoventilated. CXR\\n w/pleural effusion, vasc congestion. Hct gradually decreasing to 23\\n @6am. 2u prbcs tx -> 24.3, 20 IV lasix. IR embolization x2 and gelfoam\\n x2. CTA neg for large PE. Received another 2u prbcs -> 25.8. 2u\\n prbcs -> 29.2. Intermittently on Neo.\\n CMV 50/15/550/14\\n Post operative day:\\n POD1 s/p angio embolization\\n Allergies:\\n Last dose of Antibiotics:\\n Infusions:\\n Fentanyl (Concentrate) - 75 mcg/hour\\n Phenylephrine - 0.5 mcg/Kg/min\\n Propofol - 20 mcg/Kg/min\\n Other ICU medications:\\n Furosemide (Lasix) - 06:00 AM\\n Fentanyl - 07:00 PM\\n Famotidine (Pepcid) - 08:29 PM\\n Other medications:\\n Flowsheet Data as of 06:14 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 38.3\\nC (100.9\\n T current: 37.9\\nC (100.2\\n HR: 82 (63 - 146) bpm\\n BP: 99/53(67) {86/49(61) - 133/69(90)} mmHg\\n RR: 18 (15 - 23) insp/min\\n SPO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 100.9 kg (admission): 90 kg\\n CVP: 12 (12 - 30) mmHg\\n Total In:\\n 9,459 mL\\n 1,174 mL\\n PO:\\n Tube feeding:\\n IV Fluid:\\n 6,222 mL\\n 1,174 mL\\n Blood products:\\n 2,877 mL\\n Total out:\\n 2,325 mL\\n 285 mL\\n Urine:\\n 2,325 mL\\n 285 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 7,134 mL\\n 889 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 550 (500 - 550) mL\\n RR (Set): 18\\n RR (Spontaneous): 0\\n PEEP: 14 cmH2O\\n FiO2: 50%\\n RSBI Deferred: PEEP > 10\\n PIP: 32 cmH2O\\n Plateau: 27 cmH2O\\n Compliance: 42.3 cmH2O/mL\\n SPO2: 100%\\n ABG: 7.50/42/204/30/8\\n Ve: 9.4 L/min\\n PaO2 / FiO2: 408\\n Physical Examination\\n General Appearance: No acute distress\\n HEENT: PERRL\\n Cardiovascular: (Rhythm: Regular), Regular Irregular\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\\n Rhonchorous : )\\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\\n Neurologic: Follows simple commands, Moves all extremities, Sedated\\n Labs / Radiology\\n 86 K/uL\\n 10.6 g/dL\\n 116 mg/dL\\n 1.1 mg/dL\\n 30 mEq/L\\n 3.7 mEq/L\\n 23 mg/dL\\n 105 mEq/L\\n 141 mEq/L\\n 29.6 %\\n 9.5 K/uL\\n [image002.jpg]\\n 10:40 AM\\n 02:00 PM\\n 03:41 PM\\n 04:11 PM\\n 07:14 PM\\n 09:29 PM\\n 09:59 PM\\n 11:10 PM\\n 01:19 AM\\n 01:38 AM\\n WBC\\n 9.2\\n 6.8\\n 9.5\\n Hct\\n 25.8\\n 29.2\\n 29.6\\n Plt\\n 79\\n 52\\n 86\\n Creatinine\\n 1.2\\n 1.1\\n TCO2\\n 31\\n 32\\n 30\\n 32\\n 30\\n 34\\n Glucose\\n 104\\n 99\\n 116\\n Other labs: PT / PTT / INR:14.1/29.7/1.2, CK / CK-MB / Troponin\\n T:1334/13/<0.01, ALT / AST:345/278, Alk-Phos / T bili:49/3.0, Amylase /\\n Lipase:44/, Lactic Acid:1.6 mmol/L, LDH:616 IU/L, Ca:8.2 mg/dL, Mg:2.1\\n mg/dL, PO4:1.9 mg/dL\\n Imaging: CXR Pend\\n Pelvis Pend\\n CT head OSH: Prelim No ICH or fracture.\\n CT chest OSH: Mult rib fx: R anterolateral and posterior, L\\n posterior; Dependent consolidation, possible aspiration; T4 vertebral\\n body inf corner fx, no retropulsion; Comminuted spinous process fx\\n T2-8; Nondisplaced L T10 transverse process; Nondisplaced L clavicle\\n distal fx; Nondisplaced L scapula fx;\\n CT c spine OSH: Prelim No fx or malalignment. Multilevel\\n degenerative changes w/large post disk bulge at C4-5, narrowing the\\n spinal canal and deforming the thecal sac, acuity unknown. Marked\\n neuroforamenal narrowing @multiple levels.\\n CTA abd/pel Prelim: Medial R liver lobe contusion w/adj\\n hematoma, w/o evidence of active bleeding; Comminuted L pubic ramus\\n fracture w/assoc hematoma, with tiny focus of arterial bleeding/active\\n extravasation, and larger area of venous bleeding. Hematoma somewhat\\n larger than on OSH study. Nondisplaced, comminuted L iliac bone fx\\n w/adj iliac muscle hematoma, larger than on prior study, w/o active\\n extrav. Fx extends into L SI joint. Post R hepatic laceration/contusion\\n adjacent to calcified granuloma, w/small hematoma, without active\\n bleeding. Min displaced fx of R iliac bone extending to R SI joint.\\n Cirrhotic liver. Inc B pleural effusions (small), w/inc atelectasis.\\n MRI: Mild compression deformity of L1 with additional levels of\\n potential trabecular contusion @T10-11 also inf @T4 w/o retropulsion.\\n Multilevel degenerative changes with moderate canal narrowing at T10-11\\n w/cord deformity and no abnormal cord signal. Extensive edema\\n throughout the paraspinal soft tissues, predominantly\\n post w/in interspinous ligaments. Incompletely evaluated c-spine w/\\n severe canal narrowing @C4-5 w/cord deformity and no abnormal cord\\n signal.\\n CTA: no PE.\\n Microbiology: Ucx P\\n Sputum P\\n Bcx P\\n Bcx P\\n Assessment and Plan\\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\\n clavicle fx, and thoracic fx.\\n Neurologic: C-spine cleared. Per ortho spine, no surgical intervention;\\n HOB<30, TLSO when OOB.\\n Cardiovascular: Bedside ECHO shows TR and elevated PA pressures but\\n adequate contractility. CVP 20s. Wean phenylephrine gtt\\n Pulmonary: Cont ETT, Intubated . Wean as tolerated (improve pain\\n control)\\n Gastrointestinal / Abdomen: Elevated LFTs (in 500s on ). h/o\\n cirrhosis - liver panel sent. T bili elevated to 3.0, other LFTs\\n trending down\\n Nutrition: ADAT\\n Renal: Foley, monitor UOP, f/u lytes, and trend Cr (1.1). Received\\n bicarb gtt and Mucomyst\\n Hematology: Monitor Hct q6\\n 35.1-32.2-31.9-28.3-28.9-27.7-25.7-24.1-23.1; tx 2u prbcs, 1 plt,\\n 1uFFP, (INR 1.3) -> 24.3; Angio embolization. 2u prbcs -> 25.8; 2u\\n prbcs -> 29.6 ()\\n Plt (peak 175) -86\\n Endocrine: RISS\\n Infectious Disease: f/u pan cx.\\n Lines / Tubes / Drains: R SC CVL (), PIV x2, Foley, a-line\\n (), ETT\\n Wounds:\\n Imaging: CXR today\\n Fluids: LR, KVO when tolerating PO intake\\n Consults: Trauma surgery, Ortho, Ortho-spine\\n Billing Diagnosis:\\n ICU Care\\n Nutrition:\\n Comments: ADAT\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n 18 Gauge - 09:00 PM\\n 20 Gauge - 09:00 PM\\n Arterial Line - 10:59 AM\\n Multi Lumen - 04:41 PM\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer: H2 blocker\\n VAP bundle: HOB elevation, Mouth care, Daily wake up\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition: ICU\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2175-01-26 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 713668,\n \"text\": \"Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt remains vented throughout the day, AM CXR showed some lower lobe\\n consolidation and fluid. ABGs were poor overnight-alkalotic. Pt\\n received total of 6 units PRBCs, 2 units platelets, 1 unit FFP\\n yesterday and is more fluid overloaded today, general edema, CVP 13-20,\\n 10kg heavier this AM. Lung sounds clear in upper lobes, slightly\\n diminished in bases. Pt has multiple rib fractures and is currently\\n sedated on propofol/fentanyl and on bedrest <30 degrees until TLSO\\n brace arrives. Pt febrile today-101.3. Suctioned for thick, yellow\\n secretions frequently.\\n Action:\\n Bronchoscopy done this AM, BAL sent from right and left mainstems\\n (sputum culture also pending from last evening). Sedation turned off\\n this AM as tolerated then neo was turned off d/t BP WNL. Vent weaned\\n to CPAP/PS and pt tolerated breathing well. Pt was wide awake and\\n uncomfortable off sedation, requesting more pain medication as well as\\n sedation. Fentanyl gtt increased to 100mcg/hr from 75mcg/hr. Pt was\\n sedated more for the bronchoscopy and sedation left on after procedure\\n per team d/t possible ARDS risk. Team wanted pt to be adequately\\n sedated to allow vent to provide PEEP/volume with the intention of\\n improving pt\\ns ABGs. Fever reduced without intervention, team aware,\\n cultures pending from . Vent changed back to CMV PEEP 14, 50%\\n FiO2, RR 18, TV 440 based on weight/height for bronch and remainder of\\n the shift. VAP care per protocol, repositioned frequently. Bilateral\\n CPT performed. Tube feeds started but then stopped for IVC filter\\n placement scheduled as add-on tonight.\\n Response:\\n Pt sedated but arouses to voice, neuro exam remains intact and\\n unchanged as evidenced by when pt is awake. Neo required while pt is\\n more sedated, titrating as needed, see metavision for details. Pt more\\n comfortable with additional sedation and pain medication. Suctioned\\n for thick, yellow secretions.\\n Plan:\\n Continue to monitor ABGs, follow up with cultures. Suction as needed.\\n Monitor respiratory status closely, VAP care, daily CXRs. Provide IV\\n fluid for when tube feeds off, monitor kidney and liver function.\\n Restart tube feeds post-op. Continue to support pt and family.\\n Atrial fibrillation (Afib)\\n Assessment:\\n Pt went into rapid afib this AM, HR seen as high as 149. Change in\\n rhythm was abrupt, unknown cause but possibly d/t cardiac contusion?\\n Action:\\n EKG done immediately which showed afib. Monitor EKG showing atrial\\n flutter for the rest of the day. TTEcho done this evening by team in\\n room. Diltiazem bolus given per HO this am (20mg over 2min) before\\n starting 5mg/hr gtt.\\n Response:\\n Pt\\ns rate better controlled (70\\ns), continues in atrial flutter. BP\\n lower, neo gtt continues to be titrated as needed d/t dilt gtt and\\n propofol gtt.\\n Plan:\\n IVC filter to be placed this evening in OR by Dr. as add-on\\n case. Consider converting this pt to NSR with Amiodarone since it is\\n new afib? Continue to support pt and family. Change dilt gtt to PO\\n when able.\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2175-01-26 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 713662,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 2\\n Ideal body weight: 0 None\\n Ideal tidal volume: 0 / 0 / 0 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: No\\n Procedure location:\\n Reason:\\n Tube Type\\n ETT:\\n Position: 21 cm at teeth\\n Route: Oral\\n Type: Standard\\n Size: 7.5mm\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 25 cmH2O\\n Cuff volume: mL /\\n Airway problems:\\n Comments:\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Diminished\\n Comments:\\n Secretions\\n Sputum color / consistency: Yellow / Thick\\n Sputum source/amount: Suctioned / Small\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance: Continuous invasive ventilation\\n Visual assessment of breathing pattern: Normal quiet breathing\\n Assessment of breathing comfort: No response (sleeping / sedated)\\n Invasive ventilation assessment:\\n Trigger work assessment: Not triggering\\n Dysynchrony assessment:\\n Comments:\\n Plan\\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\\n Maintain PEEP at current level and reduce FiO2 as tolerated\\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\\n Intolerant of weaning attempts, Underlying illness not resolved\\n Respiratory Care Shift Procedures\\n Bedside Procedures:\\n Bronchoscopy (1100)\\n Comments: removed large amounts of thick yellow secretions.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2175-01-24 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 713280,\n \"text\": \"s/p crush injury from tree while riding on tractor. At Hospital\\n patient was hTN and had dropping HCT, tx to . Injuries include: T4\\n vertebral body fracture, grade 2 Liver lac, multiple right side rib\\n fracture, lung contusions, right ramous and bilateral pelvic \\n fracture.\\n No PMH\\n NKDA\\n Events:\\n Abdominal and pelvic CTA\\n Thoracic MRI\\n Trauma, s/p\\n Assessment:\\n Alert and oriented times three, MAE with normal strength and has normal\\n sensation throughout. Hemodynamics stable. Hct stable at 32. LS clear\\n but diminished in right base, sa02 100% on NRB, de-saturating to low\\n 90\\ns off O2, using IS well but has very weak cough. Pain poorly\\n controlled upon admission but doing better with PCA. Abdomen soft with\\n normal BS, non tender.\\n Action:\\n Dilaudid PCA, abd/pelvic CTA and thoracic MR, Q 4 hr Hct checks, IS per\\n orders.\\n Response:\\n Pain control improving and pt stating it is easier to breathe now.\\n Plan:\\n Continue Q 4 hct and coag checks, transfuse as needed, maintain\\n hemodynamic stability, awaiting MRI results for further POC re: spinal\\n fractures. Continue to provide emotional support for patient and\\n family.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2175-01-24 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 713289,\n \"text\": \"s/p crush injury from tree while riding on tractor. At Hospital\\n patient was hTN and had dropping HCT, tx to . Injuries include: T4\\n vertebral body fracture, grade 2 Liver lac, multiple right side rib\\n fracture, lung contusions, right ramous and bilateral pelvic \\n fracture.\\n No PMH\\n NKDA\\n Events:\\n Abdominal and pelvic CTA\\n Thoracic MRI\\n Trauma, s/p\\n Assessment:\\n Alert and oriented times three, MAE with normal strength and has normal\\n sensation throughout. Hemodynamics stable. Hct stable at 32. LS clear\\n but diminished in right base, sa02 100% 70% face-tent, de-saturating to\\n low 90\\ns off O2, using IS well but has weak cough. Pain poorly\\n controlled upon admission but doing better with PCA. Abdomen soft with\\n normal BS, non tender.\\n Action:\\n Dilaudid PCA, abd/pelvic CTA and thoracic MR, Q 4 hr Hct checks, IS per\\n orders.\\n Response:\\n Pain control improving and pt stating it is easier to breathe now.\\n Plan:\\n Continue Q 4 hct and coag checks, transfuse as needed, and maintain\\n hemodynamic stability, awaiting MRI results for further POC re: spinal\\n fractures. Continue to provide emotional support for patient and\\n family.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2175-01-24 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 713393,\n \"text\": \"Trauma, s/p\\n Assessment:\\n Patient alert, oriented x3. Pupils 3mm, equal, reactive.\\n Moves upper extremities w/ normal strength. Lower extremities move on\\n bed, splinted by pain.\\n Complaining of pain to R side, constant w/ and w/o\\n movement. At worst, . Patient on Dilaudid PCA 02.5mg/dose.\\n LS diminished on R side. Clear to diminished on L side.\\n Sats WNL on 12L 70% fact tent and 3L NC.\\n Hypotensive at beginning of shift, SBP in 70\\ns. HR 90\\n +PP.\\n Denies abdominal pain. Abdomen soft, BS present.\\n UOP marginal.\\n Action:\\n Q4h neuro exams. Encouraged use of PCA prior to activity.\\n Tylenol and gabapentin administered.\\n Logroll precautions cleared. TLSO brace ordered. NEOPS\\n came by to measure for brace this afternoon.\\n Encouraged CDB and IS. Oxygen weaned to 12L 50% face tent,\\n 2L NC.\\n 1L LR fluid bolus administered for hypotension\\n Patient ordered for clear liquid diet\\n Response:\\n Pain decreased to with use of PCA and oral pain\\n medications.\\n Reaches up to 1000ml with IS. Patient has weak cough,\\n splinted by pain.\\n Patient may sit up to 30 degrees but will need brace when\\n OOB.\\n VSS\\n Plan:\\n Continue to assess for pain, medicate as needed. Wean oxygen as\\n tolerated. Pulmonary toileting. CXR tomorrow a.m. Patient to be NPO\\n after midnight for ? OR tomorrow for pelvis (awaiting final word from\\n ortho).\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2175-02-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 233689,\n \"text\": \"Resting sinus tachycardia with frequent atrial premature beats. Prolonged\\nP-R interval at about 230 milliseconds. Left atrial abnormality. Borderline\\nlow limb lead voltage. Non-specific ST-T wave changes. Relatively early\\nR wave progression, a non-diagnostic finding. Compared to the previous tracing\\nof atrial flutter is no longer present.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2175-01-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 233690,\n \"text\": \"Atrial flutter with predominant 3:1 A-V block, atrial rate approximately 260,\\nventricular rate approximately 86. There is some variability in ventricular\\nresponse suggesting dual level block. Probable inferior myocardial infarction\\nof indeterminate age. Compared to the previous tracing of overall\\nventricular rate has fallen from 114 to 86.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2175-01-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 233910,\n \"text\": \"Atrial fibrillation, rate 114. Early transition. Leftward axis at\\nminus 31 degrees. Compared to the previous tracing of no diagnostic\\ninterval change.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2175-01-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 233911,\n \"text\": \"Atrial flutter. Modest left axis deviation. Early precordial QRS transition.\\nFindings are non-specific. No previous tracing available for comparison.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2175-02-07 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1114102,\n \"text\": \" 5:13 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ?atelectasis, effusion, consolidation\\n Admitting Diagnosis: POLYTAUMA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 74 year old man with trach\\n REASON FOR THIS EXAMINATION:\\n ?atelectasis, effusion, consolidation\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Tracheostomy, to evaluate for effusions and consolidation.\\n\\n FINDINGS: In comparison with the study of , there is continued\\n enlargement of the cardiac silhouette with pulmonary vascular congestion and\\n bilateral pleural effusions. The possibility of supervening pneumonia still\\n be considered.\\n\\n Tracheostomy tube remains in place.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2175-01-25 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 1112506,\n \"text\": \" 4:57 PM\\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \\n Reason: ?PTX, line placement\\n Admitting Diagnosis: POLYTAUMA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 74 year old man s/p R subclavian placement\\n REASON FOR THIS EXAMINATION:\\n ?PTX, line placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST RADIOGRAPH\\n\\n INDICATION: Right subclavian line placement.\\n\\n COMPARISON: .\\n\\n FINDINGS: As compared to the previous radiograph, a right subclavian vein\\n catheter has been newly introduced. The tip of the line projects over the mid\\n SVC. There is no evidence of complication, notably no pneumothorax. The\\n other monitoring and support devices are in unchanged position. The extent of\\n the pre-existing right-sided pleural effusion could have mildly decreased.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2175-01-26 00:00:00.000\",\n \"description\": \"VENOGRAPHY IVC S&I\",\n \"row_id\": 1112703,\n \"text\": \" 10:46 PM\\n VENOGRAPHY IVC S&I; -52 REDUCED SERVICES Clip # \\n Reason: IVC FILTER PLACEMENT AND VENOCAVAGRAM\\n Admitting Diagnosis: POLYTAUMA\\n ______________________________________________________________________________\\n FINAL REPORT\\n \\\"Please see CareWeb Notes for the complete operative report.\\\"\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2175-01-25 00:00:00.000\",\n \"description\": \"CTA CHEST W&W/O C&RECONS, NON-CORONARY\",\n \"row_id\": 1112483,\n \"text\": \" 2:58 PM\\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \\n Reason: r/o PE\\n Admitting Diagnosis: POLYTAUMA\\n Contrast: VISAPAQUE Amt: 100\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 74 year old man with pelvic fractures and concern for PE\\n REASON FOR THIS EXAMINATION:\\n r/o PE\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): SHfd WED 7:04 PM\\n No evidence of central pulmonary embolism. The subsegmental arteries cannot\\n be evaluated due to technique. No aortic dissection.\\n\\n Multiple bilateral rib fractures and T4 vertebral body fracture, grossly\\n stable.\\n\\n Bilateral lower lobe pneumonia - atelectasis. Mildly increased small\\n bilateral pleural effusions.\\n\\n Enlarged main pulmonary artery may represent underlying pulmonary\\n hypertension.\\n\\n Liver contusion and laceration, grossly stable, incompletely evaluated.\\n\\n Probable cirrhosis and mild splenomegaly, stable. Bilateral pulmonary\\n reticular opacities in the subpleural region with minimal fibrotic changes and\\n honeycombing may be chronic in nature.\\n\\n Calcified pleural plaques compatible with prior asbestos exposure.\\n\\n Followup chest CT when acute symptoms resolve is recommended to evaluate the\\n pulmonary parenchyma.\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAM: 74-year-old man with pelvic fractures and concern for\\n pulmonary embolism.\\n\\n COMPARISON: Chest radiograph from , CT abdomen and pelvis\\n from , CT chest without contrast from .\\n\\n TECHNIQUE: Contiguous multidetector CT images of the chest before and after\\n administration of IV contrast with coronal, sagittal and oblique reformats\\n were submitted for interpretation.\\n\\n FINDINGS:\\n\\n NON-CONTRAST CHEST CT: There is no intramural hematoma. Atherosclerotic\\n calcifications of the aorta and coronary arteries are mild-to-moderate. Heart\\n is upper limits of normal in size. There is no pericardial effusion. An\\n endotracheal tube with the tip above the carina and an NG tube with the tip\\n (Over)\\n\\n 2:58 PM\\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \\n Reason: r/o PE\\n Admitting Diagnosis: POLYTAUMA\\n Contrast: VISAPAQUE Amt: 100\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n within the stomach are noted.\\n\\n POST-CONTRAST CHEST CT: Study is limited due to patient motion. There is no\\n evidence of pulmonary embolism in the main, primary or secondary branches of\\n the pulmonary arteries. The subsegmental branches are suboptimally evaluated.\\n The main pulmonary artery is dilated, measuring up to 3.5 cm (3:24). Both\\n right and left pulmonary arteries are also dilated, right more than left.\\n There is no evidence of aortic dissection. Heart is borderline in size.\\n There is no pericardial effusion. There is no pathologically enlarged\\n mediastinal, hilar, or axial lymphadenopathy. Localized soft tissue\\n attenuation area at the rigt aspect of the mediastinum is likely a hematoma\\n adjacent to fractured T4 vertebral body.\\n\\n There has been interval increase in small bilateral pleural effusions with\\n associated lower lobe collapse and probable underlying aspiration or\\n contusion. Pleural thickening especially in the right hemithorax is likely\\n related to adjacent rib fractures and pleural hemorrhage. Calcified pleural\\n plaques are most compatible with asbestos exposure, grossly stable. Bilateral\\n pulmonary reticular opacities in the subpleural region with minimal\\n honeycombing is likely fibrotic.\\n\\n Suboptimally evaluated and partially imaged upper abdominal organs demonstrate\\n an area of hypodensity in the medial aspect of the posterior right lobe\\n adjacent to a large vertebral osteophyte compatible with contusion, slightly\\n decreased in size, however, incompletely evaluated. Laceration-contusion\\n along the posterolateral surface of the liver is partially imaged and grossly\\n stable. 12-mm stable hyperdense, likely calcified structure in the posterior\\n right lobe of the liver likely represents a calcified granuloma. Spleen is\\n upper limit of normal in size. Previously seen nodular contour of the liver\\n is not as conspicuous as prior study.\\n\\n Multiple bilateral rib fractures are again noted. There is also grossly\\n stable anterior inferior fracture of one of T4 thoracic vertebral bodies.\\n Degenerative changes of the vertebral body are severe. Previously seen\\n non-displaced left T10 transverse is not as well seen on the current study,\\n likely due to motion artifact.\\n\\n IMPRESSION:\\n 1. No evidence of central pulmonary embolism. The subsegmental arteries\\n cannot be evaluated due to motion arifact.\\n\\n 2. Multiple bilateral rib fractures and T4 vertebral body fracture with\\n associated mediastinal hematoma, grossly stable.\\n\\n 3. Mildly increased small bilateral pleural effusions and adjacent bilateral\\n (Over)\\n\\n 2:58 PM\\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \\n Reason: r/o PE\\n Admitting Diagnosis: POLYTAUMA\\n Contrast: VISAPAQUE Amt: 100\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n lower lobe atelectasis with likely underlying aspiration or contusion.\\n\\n 4. Enlarged main pulmonary artery may represent underlying pulmonary\\n hypertension.\\n\\n 5. Liver contusion and laceration, grossly stable, incompletely evaluated.\\n\\n 6. Calcified pleural plaques compatible with prior asbestos exposure. Probable\\n mild paranchymal subpleural fibrotic changes may represent asbestosis.\\n Followup chest CT when acute symptoms resolve is recommended to evaluate the\\n pulmonary parenchyma.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2175-01-25 00:00:00.000\",\n \"description\": \"CTA CHEST W&W/O C&RECONS, NON-CORONARY\",\n \"row_id\": 1112484,\n \"text\": \", R. TSICU 2:58 PM\\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \\n Reason: r/o PE\\n Admitting Diagnosis: POLYTAUMA\\n Contrast: VISAPAQUE Amt: 100\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 74 year old man with pelvic fractures and concern for PE\\n REASON FOR THIS EXAMINATION:\\n r/o PE\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n PFI REPORT\\n No evidence of central pulmonary embolism. The subsegmental arteries cannot\\n be evaluated due to technique. No aortic dissection.\\n\\n Multiple bilateral rib fractures and T4 vertebral body fracture, grossly\\n stable.\\n\\n Bilateral lower lobe pneumonia - atelectasis. Mildly increased small\\n bilateral pleural effusions.\\n\\n Enlarged main pulmonary artery may represent underlying pulmonary\\n hypertension.\\n\\n Liver contusion and laceration, grossly stable, incompletely evaluated.\\n\\n Probable cirrhosis and mild splenomegaly, stable. Bilateral pulmonary\\n reticular opacities in the subpleural region with minimal fibrotic changes and\\n honeycombing may be chronic in nature.\\n\\n Calcified pleural plaques compatible with prior asbestos exposure.\\n\\n Followup chest CT when acute symptoms resolve is recommended to evaluate the\\n pulmonary parenchyma.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2175-01-31 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1113231,\n \"text\": \" 5:05 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for progression\\n Admitting Diagnosis: POLYTAUMA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 74 year old man with multiple rib fx and pulm contusions\\n REASON FOR THIS EXAMINATION:\\n eval for progression\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAMINATION: Followup of the patient with multiple rib fractures\\n and pulmonary contusions.\\n\\n Portable AP chest radiograph was compared to .\\n\\n The ET tube tip is 6.2 cm above the carina. The NG tube tip is in the\\n proximal stomach. The right subclavian line tip is at the level of superior\\n SVC. Cardiomediastinal silhouette is unchanged as well as there is no change\\n in mild bilateral pulmonary edema and parenchymal opacities and there is no\\n pleural effusion. There is no clear evidence of pneumothorax, although\\n minimal amount cannot be excluded on the left. Multiple rib fractures are\\n redemonstrated.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2175-01-25 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1112413,\n \"text\": \" 7:24 AM\\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \\n Reason: eval ETT placement\\n Admitting Diagnosis: POLYTAUMA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 74 year old man with recent intubation\\n REASON FOR THIS EXAMINATION:\\n eval ETT placement\\n ______________________________________________________________________________\\n WET READ: RSRc WED 9:02 AM\\n ETT terminates 5.5 cm above carina otherwise similar to prior with atelectasis\\n and likely small effusions at both bases. Superimposed\\n aspiration/consolidation difficult to exclude. Multiple fractures better\\n evaluated on previous CT. (called by Dr. - anesthesia resident\\n 8:20 am ).\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAMINATION: Followup of the patient after recent intubation.\\n\\n Portable AP chest radiograph was compared to prior study obtained the same day\\n earlier at 06:13 a.m.\\n\\n The ET tube tip is 5.5 cm above the carina. The right internal jugular line\\n tip is at the level of low SVC. There is interval improvement of pulmonary\\n edema which is currently mild. Bilateral pleural effusions and bibasal\\n atelectasis are unchanged in the short-term interval.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2175-02-05 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 1113890,\n \"text\": \" 5:36 PM\\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \\n Reason: 50cm DL L basilic PICC placed ? tip\\n Admitting Diagnosis: POLYTAUMA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 74 year old man with new PICC\\n REASON FOR THIS EXAMINATION:\\n 50cm DL L basilic PICC placed ? tip\\n ______________________________________________________________________________\\n WET READ: DLrc SUN 6:09 PM\\n Left PICC at brachiocephalic junction. Recommend repositioning. Findings\\n discussed with at 6:10PM. Otherwise unchanged appearance of the\\n lungs.\\n ______________________________________________________________________________\\n FINAL REPORT\\n PORTABLE CHEST \\n\\n COMPARISON: Radiograph of earlier the same date.\\n\\n INDICATION: PICC placement.\\n\\n FINDINGS: Left PICC is visualized to the level of the junction of the left\\n brachiocephalic vein and superior vena cava. An opaque external monitoring\\n lead overlies this region, and it is difficult to determine whether the\\n catheter extends slightly below this level into the proximal SVC. With the\\n exception of PICC placement, there has not been a substantial change in the\\n appearance of the chest since the recent radiograph of earlier the same date.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2175-02-06 00:00:00.000\",\n \"description\": \"LP UNILAT UP EXT VEINS US LEFT PORT\",\n \"row_id\": 1113934,\n \"text\": \" 8:39 AM\\n UNILAT UP EXT VEINS US LEFT PORT Clip # \\n Reason: Eval for DVT\\n Admitting Diagnosis: POLYTAUMA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 74 year old man with new PICC, and LUE swelling\\n REASON FOR THIS EXAMINATION:\\n Eval for DVT\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: A 74-year-old man with left upper extremity swelling and new PICC\\n line.\\n\\n COMPARISON: No previous exam for comparison.\\n\\n FINDINGS: Grayscale, color and Doppler son of the left IJ, subclavian,\\n axillary, brachial, and basilic veins were performed. Note is made that the\\n left cephalic vein could not be identified. There is normal flow, compression\\n and augmentation seen in all of the vessels.\\n\\n IMPRESSION: No evidence of deep vein thrombosis in the left arm.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2175-02-04 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1113735,\n \"text\": \" 5:17 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for PNA\\n Admitting Diagnosis: POLYTAUMA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 74 year old man with VAP, recent trach, s/p crush injury w/mult rib fx\\n REASON FOR THIS EXAMINATION:\\n eval for PNA\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST RADIOGRAPH\\n\\n INDICATION: Ventilatory associated pneumonia, recent tracheostomy,\\n evaluation.\\n\\n COMPARISON: .\\n\\n FINDINGS: As compared to the previous radiograph, the patient has changed in\\n body position. Overall, there is little change. The tracheostomy tube and\\n the right-sided central venous access line are in unchanged position. Also\\n unchanged are the bilateral pleural effusions as well as the bilateral patchy\\n areas of opacity. The size of the cardiac silhouette and the extent of the\\n retrocardiac atelectasis are also constant. In the well-ventilated portions\\n of the lung parenchyma, there is no evidence of newly appeared focal\\n parenchymal opacity suggesting pneumonia.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2175-01-25 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1112403,\n \"text\": \" 5:06 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for progression\\n Admitting Diagnosis: POLYTAUMA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 74 year old man with multiple broken ribs and pulmonary contusion\\n REASON FOR THIS EXAMINATION:\\n eval for progression\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAMINATION: Followup of the patient after trauma.\\n\\n COMPARISON: Chest CT from .\\n\\n Multiple rib fractures involving the right hemithorax are seen although better\\n evaluated by the recent CT of the chest. There is interval development of a\\n pulmonary edema that was not seen on the prior studies accompanied by\\n bilateral increase of pleural effusions. The cardiomediastinal silhouette is\\n grossly unchanged although the comparison is difficult between the chest\\n radiograph and the chest CT. The small amount of pneumothorax on the right is\\n difficult to appreciate on the chest radiograph.\\n\\n Overall the significant change is interval development of moderate to severe\\n pulmonary edema and increase in bilateral pleural effusions.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2175-02-01 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1113401,\n \"text\": \" 5:37 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Evaluate for PNA, edema, interval change\\n Admitting Diagnosis: POLYTAUMA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 74 year old man with PNA\\n REASON FOR THIS EXAMINATION:\\n Evaluate for PNA, edema, interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 74-year-old male with pneumonia, followup chest x-ray for\\n interval change.\\n\\n COMPARISON: Chest radiographs available from through .\\n\\n SEMI-UPRIGHT AP VIEW OF THE CHEST: A right-sided central venous catheter,\\n endotracheal tube, and gastric tube are unchanged in position since , . Cardiomediastinal silhouette is unchanged. There is no change of\\n mild bilateral pulmonary edema and parenchymal opacities. There are no new\\n focal opacities. There is no pneumothorax.\\n\\n IMPRESSION: No significant radiographic change since .\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2175-01-24 00:00:00.000\",\n \"description\": \"MR THORACIC SPINE W/O CONTRAST\",\n \"row_id\": 1112259,\n \"text\": \" 1:59 AM\\n MR THORACIC SPINE W/O CONTRAST Clip # \\n Reason: please do MRI T-spine to further characterize fractures\\n Admitting Diagnosis: POLYTAUMA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 74 year old man with fall with thoracic spine fractures\\n REASON FOR THIS EXAMINATION:\\n please do MRI T-spine to further characterize fractures\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): BLjb TUE 11:55 AM\\n 1. Mild compression deformity of L1 with additional levels of potential\\n trabecular contusion at T10-11 also inferiorly at T4 with no retropulsion.\\n\\n 2. Multilevel degenerative changes with moderate canal narrowing at T10-11\\n with cord deformity and no abnormal cord signal.\\n\\n 3. Extensive edema throughout the paraspinal soft tissues, predominantly\\n posteriorly within the interspinous ligaments.\\n\\n 4. Incompletely evaluated cervical spine demonstrates severe canal narrowing\\n at C4-5 with cord deformity and no abnormal cord signal.\\n ______________________________________________________________________________\\n FINAL REPORT\\n EXAMINATION: Thoracic spine MRI.\\n\\n HISTORY: 74-year-old male presents with fall and thoracic spine fractures.\\n\\n COMPARISON: Abdominal CT scan one day prior.\\n\\n TECHNIQUE: Sagittal T1, T2 FSE, STIR, axial T2-weighted sequences through the\\n thoracic spine were obtained.\\n\\n FINDINGS: Sagittal alignment is satisfactory. There is a mild compression\\n deformity of L1 with minimal loss of vertebral body height. Bone marrow edema\\n extends horizontally into the posterior elements. There is mild bone marrow\\n edema surrounding the T10-11 disc space and to a lesser extent involving the\\n inferior right posterolateral corner of the T4 vertebral body. There is\\n extensive edema throughout the paraspinal soft tissues, predominantly within\\n the interspinous ligaments within the mid-to-lower thoracic spine.\\n\\n Multilevel degenerative changes are present, including multilevel Schmorl's\\n nodes and central disc herniations. The largest disc herniation is present at\\n T10-11 where there is additional facet arthropathy and ligamentum flavum\\n mineralization resulting in moderate canal narrowing with slight cord\\n deformity, though no abnormal cord signal. The conus terminates at T12.\\n\\n The known multilevel rib fractures are not well visualized on this\\n examination. There are bilateral pleural effusions. Limited views of the\\n cervical spine demonstrate multilevel spondylosis with a central disc\\n herniation at C4-5 which appears to result in severe canal narrowing with cord\\n deformity, though no convincing abnormal cord signal.\\n (Over)\\n\\n 1:59 AM\\n MR THORACIC SPINE W/O CONTRAST Clip # \\n Reason: please do MRI T-spine to further characterize fractures\\n Admitting Diagnosis: POLYTAUMA\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n IMPRESSION:\\n 1. Mild compression deformity of L1 with additional levels of potential\\n trabecular contusion at T10-11 also inferiorly at T4 with no retropulsion.\\n\\n 2. Multilevel degenerative changes with moderate canal narrowing at T10-11\\n with cord deformity and no abnormal cord signal.\\n\\n 3. Extensive edema throughout the paraspinal soft tissues, predominantly\\n posteriorly within the interspinous ligaments.\\n\\n 4. Incompletely evaluated cervical spine demonstrates severe canal narrowing\\n at C4-5 with cord deformity and no abnormal cord signal.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2175-01-28 00:00:00.000\",\n \"description\": \"RP FOOT AP,LAT & OBL RIGHT PORT\",\n \"row_id\": 1112908,\n \"text\": \" 11:43 AM\\n FOOT AP,LAT & OBL RIGHT PORT Clip # \\n Reason: eval for fracture\\n Admitting Diagnosis: POLYTAUMA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 74 year old man s/p crush injury/trauma with ecchymosis on RLE.\\n REASON FOR THIS EXAMINATION:\\n eval for fracture\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAMINATION: Followup of the patient with crush injury with\\n ecchymosis of right lower extremity.\\n\\n Three views of the right foot were reviewed. There is no clear evidence of\\n fracture. There is no evidence of lytic or sclerotic lesion worrisome for\\n neoplasm or infectious process. There is no appreciable soft tissue swelling.\\n Minimal degenerative changes are present as well as hallux valgus.\\n\\n Linear density projecting at the expected area of insertion of the Achilles\\n tendon to the calcaneus is noted and might represent either minimal avulsion\\n fracture or degenerative changes, correlation with clinical findings is\\n recommended.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2175-01-29 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1112982,\n \"text\": \" 7:03 AM\\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \\n Reason: Newly intubated\\n Admitting Diagnosis: POLYTAUMA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 74 year old man with new intubated\\n REASON FOR THIS EXAMINATION:\\n Newly intubated\\n ______________________________________________________________________________\\n FINAL REPORT\\n SINGLE AP PORTABLE VIEW OF THE CHEST.\\n\\n REASON FOR EXAM: Intubated patient.\\n\\n Comparison is made with prior study performed one hour earlier.\\n\\n ET tube tip is 5.6 cm above the carina. No other change\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2175-01-24 00:00:00.000\",\n \"description\": \"MR THORACIC SPINE W/O CONTRAST\",\n \"row_id\": 1112260,\n \"text\": \", R. TSICU 1:59 AM\\n MR THORACIC SPINE W/O CONTRAST Clip # \\n Reason: please do MRI T-spine to further characterize fractures\\n Admitting Diagnosis: POLYTAUMA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 74 year old man with fall with thoracic spine fractures\\n REASON FOR THIS EXAMINATION:\\n please do MRI T-spine to further characterize fractures\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n PFI REPORT\\n 1. Mild compression deformity of L1 with additional levels of potential\\n trabecular contusion at T10-11 also inferiorly at T4 with no retropulsion.\\n\\n 2. Multilevel degenerative changes with moderate canal narrowing at T10-11\\n with cord deformity and no abnormal cord signal.\\n\\n 3. Extensive edema throughout the paraspinal soft tissues, predominantly\\n posteriorly within the interspinous ligaments.\\n\\n 4. Incompletely evaluated cervical spine demonstrates severe canal narrowing\\n at C4-5 with cord deformity and no abnormal cord signal.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2175-01-23 00:00:00.000\",\n \"description\": \"CT C-SPINE W/O CONTRAST\",\n \"row_id\": 1112230,\n \"text\": \" 7:52 PM\\n CT C-SPINE W/O CONTRAST; OUTSIDE FILMS READ ONLY Clip # \\n Reason: eval CT C-Spine for acute traumatic injuries.\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 74 year old man hit by tree.\\n REASON FOR THIS EXAMINATION:\\n eval CT C-Spine for acute traumatic injuries.\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: CXWc MON 9:09 PM\\n No fracture or malalignment. Multilevel degenerative changes with large\\n posterior disk bulge at C4-5, narrowing the spinal canal and deforming the\\n thecal sac, acuity unknown. Marked neuroforamenal narrowing at multiple\\n levels.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Transfer for pelvic fracture.\\n\\n TECHNIQUE: A non-contrast cervical spine CT was obtained earlier today at\\n Hospital, at 1600 hours on . A second opinion is requested by\\n the referring clinician. No official report is available at the time of\\n interpretation.\\n\\n FINDINGS: There is no fracture or malalignment of the cervical spine.\\n Vertebral body heights are preserved. There is loss of intervertebral disc\\n height between C5 and C7. Prevertebral soft tissues are not thickened.\\n\\n At C4-5, a large posterior disc bulge moderately narrows the spinal canal,\\n deforming the thecal sac. The acuity is unknown. Posterior disc osteophyte\\n complexes at C5-6 and C6-7 results in mild narrowing of the spinal canal.\\n Pronounced uncovertebral hypertrophy results in neural foraminal narrowing\\n bilaterally at multiple levels.\\n\\n The visualized lung apices demonstrate atelectasis bilaterally.\\n\\n IMPRESSIONS:\\n\\n 1. No fracture or malalignment of the cervical spine.\\n\\n 2. Large posterior disc bulge at C4-5, acuity unknown, resulting in deformity\\n of the thecal sac. If neural deficits are localizable to this level, MRI can\\n be obtained to assess for spinal cord injury.\\n\\n 3. Bilateral neural foraminal narrowing.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2175-01-23 00:00:00.000\",\n \"description\": \"CT CHEST W/O CONTRAST\",\n \"row_id\": 1112231,\n \"text\": \" 7:53 PM\\n CT CHEST W/O CONTRAST; OUTSIDE FILMS READ ONLY Clip # \\n Reason: eval CT Chest for acute traumatic injuries.\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 74 year old man hit by tree.\\n REASON FOR THIS EXAMINATION:\\n eval CT Chest for acute traumatic injuries.\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: CXWc MON 11:06 PM\\n 1. Multiple rib fractures: right anterolateral and posterior, left posterior\\n 2. Dependent consolidation which could be sequela of aspiration\\n 3. T4 vertebral body inferior corner fracture, no retropulsion\\n 4. Comminuted spinous process fractures T2-8\\n 5. Nondisplaced left T10 transverse process\\n 6. Nondisplaced left clavicle distal fracture\\n 7. Nondisplaced left scapula fracture\\n WET READ VERSION #1 CXWc MON 10:17 PM\\n 1. Multiple rib fractures: right anterolateral and posterior\\n 2. Dependent consolidation which could be sequela of aspiration\\n 3. T4 vertebral body inferior corner fracture, no retropulsion\\n 4. Comminuted spinous process fractures T2-8\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Transfer for multiple fractures. Hit by tree.\\n\\n TECHNIQUE: A contrast-enhanced chest CT was obtained earlier today at \\n Hospital, at 1620 hours on . A second opinion was requested by the\\n referring physician. formal report of that study is available at the time\\n of interpretation. By verbal report from the referring physician, is\\n concern for rib fractures.\\n\\n COMPARISON: None.\\n\\n FINDINGS: The aorta is normal in caliber, without dissection, pseudoaneurysm,\\n or other acute abnormality. Atherosclerotic calcification is noted. There is\\n no segmental or central pulmonary embolus. The heart size is normal without\\n pericardial effusion. Atherosclerotic calcifications are noted. There is no\\n mediastinal, hilar, or axillary lymphadenopathy by size criteria.\\n\\n Lungs demonstrate bilateral, dependent consolidation, which could reflect\\n sequela of aspiration, or could indicate atelectasis. Additionally, there are\\n peripherally based heterogeneous areas of opacity that could reflect\\n contusion. There is no pleural effusion. The tracheobronchial tree is patent\\n to subsegmental levels. Bilateral pleural calcifications suggest prior\\n asbestos exposure.\\n\\n In the included portion of the upper abdomen, there is a focal linear area of\\n hypodensity in the posterior right lobe of the liver, with adjacent\\n intermediate attenuation fluid closely opposed to the hepatic parenchyma and\\n extending to the posterior chest wall. In this location in the hepatic\\n parenchyma, there is a calcified granuloma. This is concerning for\\n (Over)\\n\\n 7:53 PM\\n CT CHEST W/O CONTRAST; OUTSIDE FILMS READ ONLY Clip # \\n Reason: eval CT Chest for acute traumatic injuries.\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n laceration/contusion, and is further assessed on the subsequent abdominopelvic\\n CT.\\n\\n OSSEOUS STRUCTURES: Multiple fractures are present. The T4 vertebral body\\n demonstrates a nondisplaced anterior inferior corner fracture. There is no\\n retropulsion of the main fracture fragment. The remaining vertebral bodies\\n are preserved in height. There are multiple comminuted fractures through the\\n spinous processes spanning T2 through T8. Additionally, there are multiple\\n rib fractures. On the right, there are anterolateral fractures of the third\\n through eighth ribs, with extensively comminuted fractures of the seventh and\\n eighth ribs. Posteriorly, there are non-displaced fractures through the fifth\\n through eleventh ribs. On the left, there are minimally displaced fractures\\n through the posterior third through eleventh ribs. There is a minimally\\n displaced fracture through the left tenth transverse process. Additionally,\\n there are non-displaced fractures through the distal one-third of the left\\n clavicle, and through the body of the left scapula.\\n\\n IMPRESSION:\\n 1. Multiple rib fractures bilaterally, including right anterolateral and\\n posterior, and left posterior ribs as detailed above.\\n 2. T4 vertebral body inferior corner fracture, with no retropulsion or\\n malalignment. Comminuted spinous process fractures between T2 and T8.\\n 3. Non-displaced left T10 transverse process fracture.\\n 4. Non-displaced left clavicle and left scapula fractures.\\n 5. Dependent consolidation in the lungs bilaterally, which could be sequela\\n of aspiration, or could reflect contusion.\\n 6. No acute vascular injury.\\n 7. Calcified pleura bilaterally suggesting prior asbestos exposure.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2175-01-29 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1112980,\n \"text\": \" 5:21 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for acute process\\n Admitting Diagnosis: POLYTAUMA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 74 year old man s/p crush trauma\\n REASON FOR THIS EXAMINATION:\\n eval for acute process\\n ______________________________________________________________________________\\n FINAL REPORT\\n SINGLE AP PORTABLE VIEW OF THE CHEST\\n\\n REASON FOR EXAM: S/P crush trauma, intubated patient.\\n\\n Comparison is made with prior study performed a day earlier.\\n\\n ET tube tip is 6.4 cm above the carina. Moderate right and small left pleural\\n effusions are unchanged. There are low lung volumes. Cardiomediastinal\\n silhouette is unchanged with mild cardiomegaly. Right subclavian catheter and\\n NG tube remain in place. Mild fluid overload is unchanged.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2175-01-30 00:00:00.000\",\n \"description\": \"LIVER OR GALLBLADDER US (SINGLE ORGAN)\",\n \"row_id\": 1113099,\n \"text\": \" 9:35 AM\\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \\n Reason: ? acalculous chole vs biloma\\n Admitting Diagnosis: POLYTAUMA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 74 year old man with hyperbilirubinemia s/p fall\\n REASON FOR THIS EXAMINATION:\\n ? acalculous chole vs biloma\\n ______________________________________________________________________________\\n WET READ: ARHb MON 11:37 AM\\n No perihepatic fluid collection. Only a small amount of perihepatic free fluid\\n persists. Small contusion in hepatic segment VII again noted. No\\n gallstones or significant wall thickening/edema.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 74-year-old male with liver injury and hyperbilirubinemia, status\\n post fall.\\n\\n COMPARISON: CTA abdomen/pelvis .\\n\\n FINDINGS: The hepatic echotexture and contour is diffusely echogenic without\\n intra- or extra-hepatic biliary ductal dilatation. The extrahepatic duct\\n measures 5 mm. A small ill-defined focus of hypoechogenicity measuring up to\\n approximately 2.3 cm in the posterior right hepatic lobe is consistent with\\n the intrahepatic contusion/laceration seen on CT. The main portal vein\\n demonstrates normal hepatopedal flow. The gallbladder is mildly distended,\\n without significant wall edema, stones, or sludge. Son sign\\n cannot be evaluated for in this intubated patient. A small amount of\\n perihepatic free fluid has not increased since the recent CT.\\n\\n IMPRESSION:\\n 1. No son evidence for cholecystitis. No cholelithiasis or wall\\n edema.\\n 2. Small perihepatic free fluid, without focal collection.\\n 3. Cirrhotic liver with small contusion noted in the posterior right hepatic\\n lobe, as seen on recent CT.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2175-02-03 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1113654,\n \"text\": \" 5:46 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: interval change\\n Admitting Diagnosis: POLYTAUMA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 74 year old man with VAP, recent trach, s/p crush injury w/mult rib fx\\n REASON FOR THIS EXAMINATION:\\n interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST RADIOGRAPH\\n\\n INDICATION: Ventilator-associated pneumonia, recent tracheostomy, crush\\n injury, evaluation for interval change.\\n\\n COMPARISON: .\\n\\n FINDINGS: As compared to the previous examination, there is no relevant\\n change. Tracheostomy, right-sided central venous access line. Bilateral\\n pleural effusions with bilateral basal opacities. Unchanged size of the\\n cardiac silhouette. No evidence of newly appeared focal parenchymal opacities\\n suggesting pneumonia.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2175-01-29 00:00:00.000\",\n \"description\": \"BY SAME PHYSICIAN\",\n \"row_id\": 1112994,\n \"text\": \" 11:04 AM\\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \\n Reason: eval for infiltrates s/p brocnh, also eval plaecemnt of NGT\\n Admitting Diagnosis: POLYTAUMA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 74 year old man with new NGT\\n REASON FOR THIS EXAMINATION:\\n eval for infiltrates s/p brocnh, also eval plaecemnt of NGT\\n ______________________________________________________________________________\\n FINAL REPORT\\n SINGLE AP PORTABLE VIEW OF THE CHEST\\n\\n REASON FOR EXAM: Evaluate NG tube.\\n\\n Prior exam was performed four hours earlier.\\n\\n NG tube tip is in the stomach. No other interval change.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2175-01-25 00:00:00.000\",\n \"description\": \"PELVIS SEL/SUPERSEL A-GRAM\",\n \"row_id\": 1112438,\n \"text\": \" 9:37 AM\\n ILIAC Clip # \\n Reason: eval for bleed\\n Admitting Diagnosis: POLYTAUMA\\n Contrast: OPTIRAY Amt: 130\\n ********************************* CPT Codes ********************************\\n * EMBO NON NEURO INITAL 3RD ORDER ABD/PEL/LOWER *\\n * -51 MULTI-PROCEDURE SAME DAY INITAL 3RD ORDER ABD/PEL/LOWER *\\n * -59 DISTINCT PROCEDURAL SERVICE ADD'L 2ND/3RD ORDER ABD/PEL/LO *\\n * -59 DISTINCT PROCEDURAL SERVICE PELVIS SEL/SUPERSEL A-GRAM *\\n * -59 DISTINCT PROCEDURAL SERVICE VISERAL SEL/SUPERSEL A-GRAM *\\n * -59 DISTINCT PROCEDURAL SERVICE VISERAL SEL/SUPERSEL A-GRAM *\\n * -59 DISTINCT PROCEDURAL SERVICE TRANCATHETER EMBOLIZATION *\\n * EA ADD'L VESSEL AFTER BASIC A- EA ADD'L VESSEL AFTER BASIC A- *\\n ****************************************************************************\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 74 year old man with acutely dropping Hct s/p trauma with crush injury\\n REASON FOR THIS EXAMINATION:\\n eval for bleed\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): MGRc WED 8:45 PM\\n PFI.\\n\\n 1. Pelvic arteriography: Multiple arteriographic runs performed of distal\\n aorta, external iliac, internal iliac, lateral sacral and superior gluteal\\n arteries. Active contrast extravasation noted from branches of the lateral\\n sacral artery and superior gluteal arteries. Successful Gelfoam embolization\\n of lateral sacral artery and branches of the superior gluteal artery.\\n 2. Hepatic angiography: Multiple arteriographic runs of common hepatic and\\n right hepatic arteries. Some active contrast extravasation was noted from\\n peripheral branches of right hepatic artery. Gelfoam embolization of distal\\n right hepatic artery branches performed.\\n ______________________________________________________________________________\\n FINAL REPORT (REVISED)\\n MEDICAL HISTORY: 74-year-old man with polytrauma with pelvic fracture and\\n liver injury. Patient has been acutely dropping hematocrit and contrast CT\\n scan of abdomen and pelvis showed some active extravasation around the left\\n superior pubic ramus fracture as well as liver contusion. A request was\\n placed for pelvic and hepatic arteriography with embolization of any bleeding\\n vessels.\\n\\n CLINICIANS: Dr. , Dr. and Dr. . Dr. \\n is the attending radiologist who was present and supervising throughout.\\n\\n ANESTHESIA: The patient was brought down from the ICU intubated and sedated .\\n Local anesthesia with 1% lidocaine.\\n\\n PROCEDURE AND FINDINGS: A written informed consent was obtained after\\n explaining the procedure, benefits and risks involved. The patient was\\n brought to angiography suite and placed supine on the imaging table. The\\n right groin was prepped and draped in the usual sterile fashion. A\\n preprocedural huddle and timeout were performed as per protocol.\\n (Over)\\n\\n 9:37 AM\\n ILIAC Clip # \\n Reason: eval for bleed\\n Admitting Diagnosis: POLYTAUMA\\n Contrast: OPTIRAY Amt: 130\\n ______________________________________________________________________________\\n FINAL REPORT (REVISED)\\n (Cont)\\n\\n Under palpatory and fluoroscopic guidance the right common femoral artery was\\n accessed with a micropuncture needle. A 0.018 guidewire was placed through\\n the needle and needle exchanged for a micropuncture sheath which in turn was\\n used to upsize the wire to wire. The wire was advanced into\\n abdominal aorta under fluoroscopic guidance. The micropuncture sheath was\\n removed and replaced with a 5 French vascular sheath, the side arm of which\\n was connected to a continuous saline flush. Over the wire, a 5 French\\n Omni Flush catheter was placed into the distal aorta and an angiogram\\n performed with power injection. Then the Omni Flush catheter was advanced\\n into left common iliac artery over a guidewire and Left external iliac\\n arteriogram was performed. Then the the catheter exchanged for a C2 cobra\\n catheter and a left internal iliac arteriogram was performed. The internal\\n iliac arteriogram showed some contrast extravasation from the branches of\\n lateral sacral and superior gluteal arteries. There was no contrast\\n extravasation seen in the vicinity of the left superior pubic ramus fracture.\\n Depending upon these diagnostic findings, it was felt that the patient would\\n benefit from embolization of the bleeding vessels. Using a C2 Cobra catheter\\n and Renegade high-flow microcatheter and an 0.018 gold glidewire, the left\\n lateral sacral artery was selectively catheterized and an arteriogram at this\\n level demonstrated multiple small clusters of contrast or micro-extravasations\\n from the small peripheral branches. Therefore, the lateral sacral artery was\\n embolized using Gelfoam slurry with good angiographic result. The C2 catheter\\n was then withdrawn from the lateral sacral artery the superior gluteal artery\\n was selectively catheterized and angiogram at this level again demonstrated\\n similar small contrast collctions. These branches of the superior gluteal\\n artery were therefore embolized with Gelfoam slurry with good angiographic\\n result.\\n\\n Then the C2 Cobra catheter was pulled back into the aorta and the celiac\\n artery was cannulated. Using a Glidewire the hepatic artery was cannulated\\n and angiography of the hepatic artery demonstrated some small peripheral\\n contrast areas of hypervascvlarity supplied from the right hepatic artery\\n branches. These were in the region of the hepatic and subcapsular hemorrhage\\n from the right lobe. The C2 catheter was advanced distal to origin of the\\n cystic artery and the peripheral branches were embolized with Gelfoam slurry\\n with good angiographic result. Post- embolization arteriography demonstrated\\n no further visible contrast extravasation. The catheter and vascular sheaths\\n were pulled out and hemostasis was achieved with digital compression for 20\\n minutes. Sterile dressings were applied. The patient tolerated the procedure\\n well with no immediate complications.\\n\\n IMPRESSION:\\n 1. Pelvic angiography with multiple arteriographic runs of the distal aorta,\\n left external iliac, left internal iliac, left lateral sacral and superior\\n (Over)\\n\\n 9:37 AM\\n ILIAC Clip # \\n Reason: eval for bleed\\n Admitting Diagnosis: POLYTAUMA\\n Contrast: OPTIRAY Amt: 130\\n ______________________________________________________________________________\\n FINAL REPORT (REVISED)\\n (Cont)\\n gluteal arteries. Abnormal clusters of contrast, ? active contrast\\n extravasation noted from branches of lateral sacral artery and superior\\n gluteal artery on the left. These arteries were successfully embolized with\\n Gelfoam slurry.\\n 2. Hepatic angiography with multiple arteriographic runs of common and right\\n hepatic arteries demonstrating similar contrast collections in peripheral\\n branches of right hepatic artery, adjacent to the known hepatic and\\n subcapsular hematomas. These peripheral branches of the right hepatic artery\\n were successfully embolized with Gelfoam slurry.\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2175-01-23 00:00:00.000\",\n \"description\": \"CTA ABD W&W/O C & RECONS\",\n \"row_id\": 1112248,\n \"text\": \" 9:51 PM\\n CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # \\n Reason: CTA Abd Pelvis with 5 minute delayed venous imaging to asses\\n Admitting Diagnosis: POLYTAUMA\\n Field of view: 40 Contrast: OPTIRAY Amt: 150\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 74 year old man with fall and pelvis fractures\\n REASON FOR THIS EXAMINATION:\\n CTA Abd Pelvis with 5 minute delayed venous imaging to assess for active\\n bleeding\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: CXWc MON 10:41 PM\\n 1. Medial right liver lobe contusion with adjacent hematoma, without evidence\\n of active bleeding\\n 2. Comminuted left pubic ramus fracture with associated hematoma, with tiny\\n focus of arterial bleeding/active extravasation, and larger area of venous\\n bleeding. Hematoma somewhat larger than on OSH study.\\n 3. Nondisplaced, comminuted left iliac bone fracture with adjacent iliac\\n muscle hematoma, larger than on prior study, without active extrav. Fracture\\n extends into left SI joint.\\n 4. Posterior right hepatic laceration/contusion adjacent to calcified\\n granuloma, with small hematoma, without active bleeding\\n 5. Minimally displaced fracture of the right iliac bone extending to right SI\\n joint.\\n 6. Cirrhotic liver. Fluid around nondistended gallbladder likely related to\\n liver disease.\\n 7. Increased pleural effusions (small), bilaterally, with increased\\n atelectasis.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 74-year-old man status post trauma, with pelvic fractures.\\n Concern for active bleeding.\\n\\n COMPARISON: CT abdomen and pelvis obtained at Hospital at\\n approximately 1615 hours on .\\n\\n TECHNIQUE: MDCT-acquired axial images were obtained through the abdomen and\\n pelvis before and after administration of intravenous contrast material.\\n Post-contrast images were obtained in arterial, venous and delayed phases.\\n Multiplanar reformatted images were generated.\\n\\n CT ABDOMEN WITH IV CONTRAST: At the lung bases, there has been an interval\\n increase/development of bilateral pleural effusions, now small. Additionally,\\n there is increased consolidation dependently, which could reflect atelectasis\\n or the sequela of aspiration. The heart size remains normal, without\\n pericardial effusion. Coronary artery calcifications are again noted.\\n Pleural calcifications bilaterally suggest prior asbestos exposure.\\n\\n Within the abdomen, the liver demonstrates multiple abnormalities. Along the\\n medial aspect of the posterior right lobe, there is an area of\\n hypoattenuation, somewhat irregular in contour, measuring approximately 4.9 x\\n (Over)\\n\\n 9:51 PM\\n CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # \\n Reason: CTA Abd Pelvis with 5 minute delayed venous imaging to asses\\n Admitting Diagnosis: POLYTAUMA\\n Field of view: 40 Contrast: OPTIRAY Amt: 150\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n 4.4 cm. This area lies adjacent to a large protruding vertebral body\\n osteophyte, and is consistent with contusion. The area of contusion results\\n in narrowing of the adjacent right hepatic vein and the right posterior portal\\n vein branches. Additionally, on arterial phase, a branch of the right hepatic\\n artery is slightly irregular, although there is no definite evidence of acute\\n active extravasation at this time. This area of contusion abuts the inferior\\n vena cava, which has improved in caliber since the prior study. There is a\\n small degree of fluid and fat stranding along the inferior margin of the liver\\n and tracking around the IVC to the level of the renal veins.\\n\\n Along the posterolateral surface of the right lobe of the liver, there is a\\n linear region of hypodensity that could reflect contusion or laceration. This\\n is associated with a 12-mm hyperdense structure, most likely a calcified\\n granuloma. There is a moderate amount of adjacent fluid or stranding, with\\n intermediate density fluid suggesting hematoma. Surrounding this area, there\\n is inflammatory stranding.\\n\\n The liver is shrunken, with a nodular contour, consistent with cirrhosis. No\\n worrisome arterially enhancing lesions are identified. The gallbladder is\\n decompressed, but demonstrates a small amount of pericholecystic fluid or wall\\n thickening, which may be related to chronic liver disease. The main portal\\n vein and its branches are patent.\\n\\n The pancreas, spleen, adrenal glands and duodenum are unremarkable. The\\n stomach is within normal limits, with a moderate hiatal hernia. The kidneys\\n enhance and excrete contrast symmetrically, with a hypodense lesion at the\\n lower pole of the left kidney, too small to accurately characterize.\\n\\n The abdominal aorta and its major branches are patent, with atherosclerotic\\n calcifications. The aorta is normal in caliber. There is no free air in the\\n abdomen. There is no mesenteric or retroperitoneal lymphadenopathy by size\\n criteria.\\n\\n CT PELVIS WITH IV CONTRAST: In the anterior pelvis, associated with a\\n comminuted pubic ramus fracture (to be described in the next section), there\\n has been an interval increase in a multifocal hematoma, now extending more\\n cranially into the peritoneal cavity than on the prior study. On arterial\\n phase, there is a tiny hyperdense linear focus, extending a few millimeters,\\n concerning for active extravasation. On venous phase, this area increases in\\n density and size, to 7 x 5 mm. On delayed images, hyperdense material spans a\\n larger area measuring roughly 23 x 14 mm. This is concerning for a small\\n amount of active, or venous bleeding.\\n\\n Additionally, there is a retroperitoneal hematoma involving the left iliac\\n muscle, associated with an iliac bone fracture (to be described in the next\\n (Over)\\n\\n 9:51 PM\\n CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # \\n Reason: CTA Abd Pelvis with 5 minute delayed venous imaging to asses\\n Admitting Diagnosis: POLYTAUMA\\n Field of view: 40 Contrast: OPTIRAY Amt: 150\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n section). This hematoma has also increased in size from the prior study. It\\n now measures roughly 8.8 x 5.6 cm, previously 9.6 x 5.9 cm. There is no\\n evidence of active extravasation at this time. Hyperdense material noted\\n within this region on the prior study is no longer seen.\\n\\n Multiple loops of large and small bowel are notable for sigmoid\\n diverticulosis, without diverticulitis. There is no bowel wall thickening,\\n evidence of obstruction, or mesenteric fluid to suggest bowel injury. The\\n urinary bladder is decompressed around a Foley catheter. Distal ureters and\\n prostate gland are within normal limits. There is no pelvic or inguinal\\n lymphadenopathy by size criteria.\\n\\n OSSEOUS STRUCTURES: There is a comminuted fracture of the left superior pubic\\n ramus, and a minimally displaced fracture of the left inferior pubic ramus.\\n This is associated with a large hematoma containing hyperdense material\\n concerning for active extravasation, as described in the previous section.\\n\\n There is a minimally displaced fracture through the left iliac bone, extending\\n from the crest to the sacroiliac joint, and extending into the joint space on\\n the left. This is associated with an iliac muscle hematoma, as described in\\n the previous section. Additionally, there is a nondisplaced fracture through\\n the right iliac bone, extending from the iliac crest to the sacroiliac joint,\\n and into the joint space.\\n\\n Degenerative changes are noted of both hips and the lumbar spine. No\\n vertebral body fractures are identified. Posterior rib fractures involving\\n the bilateral eleventh, tenth, ninth and eighth ribs are again visualized. A\\n nondisplaced 10th vertebral body left transverse process fracture is noted.\\n\\n IMPRESSIONS:\\n\\n 1. Contusion/laceration of the medial aspect of the right hepatic lobe, with\\n adjacent small hematoma, without definite evidence of active bleeding.\\n Associated irregularity of an adjacent branch of the right hepatic artery and\\n resultant narrowing of the adjacent right hepatic vein and right posterior\\n portal vein branches. Posterior right hepatic laceration/contusion, adjacent\\n to a calcified granuloma, with a small hematoma, without evidence of active\\n extravasation.\\n\\n 2. Comminuted left pubic ramus fracture with associated hematoma, which has\\n increased in size from the prior study of approximately six hours prior. Tiny\\n focus of arterially enhancing material, which enlarges on venous and delayed\\n images, concerning for active extravasation.\\n\\n 3. Minimally displaced, comminuted left iliac bone fracture, with adjacent\\n (Over)\\n\\n 9:51 PM\\n CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # \\n Reason: CTA Abd Pelvis with 5 minute delayed venous imaging to asses\\n Admitting Diagnosis: POLYTAUMA\\n Field of view: 40 Contrast: OPTIRAY Amt: 150\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n iliac muscle hematoma, largely unchanged from the prior study, without\\n evidence of active extravasation. Fracture extends into the left sacroiliac\\n joint.\\n\\n 4. Minimally displaced fracture of the right iliac bone, extending to the\\n right sacroiliac joint.\\n\\n 5. Bilateral comminuted, minimally displaced posterior rib fractures of the\\n eighth through eleventh ribs. Nondisplaced left 10th vertebral body\\n transverse process fracture.\\n\\n 6. Interval increase in bilateral pleural effusions (small), with increased\\n bilateral atelectasis or consolidation which could be the result of\\n aspiration.\\n\\n 7. Cirrhotic liver. Fluid around the nondistended gallbladder may be related\\n to liver disease.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2175-01-25 00:00:00.000\",\n \"description\": \"PELVIS SEL/SUPERSEL A-GRAM\",\n \"row_id\": 1112439,\n \"text\": \", R. TSICU 9:37 AM\\n ILIAC Clip # \\n Reason: eval for bleed\\n Admitting Diagnosis: POLYTAUMA\\n Contrast: OPTIRAY Amt: 130\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 74 year old man with acutely dropping Hct s/p trauma with crush injury\\n REASON FOR THIS EXAMINATION:\\n eval for bleed\\n ______________________________________________________________________________\\n PFI REPORT (REVISED)\\n PFI.\\n\\n 1. Pelvic arteriography: Multiple arteriographic runs performed of distal\\n aorta, external iliac, internal iliac, lateral sacral and superior gluteal\\n arteries. Active contrast extravasation noted from branches of the lateral\\n sacral artery and superior gluteal arteries. Successful Gelfoam embolization\\n of lateral sacral artery and branches of the superior gluteal artery.\\n 2. Hepatic angiography: Multiple arteriographic runs of common hepatic and\\n right hepatic arteries. Some active contrast extravasation was noted from\\n peripheral branches of right hepatic artery. Gelfoam embolization of distal\\n right hepatic artery branches performed.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2175-02-01 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1113503,\n \"text\": \" 7:14 PM\\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \\n Reason: ? change pulm path\\n Admitting Diagnosis: POLYTAUMA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 74 year old man with desats, PNA\\n REASON FOR THIS EXAMINATION:\\n ? change pulm path\\n ______________________________________________________________________________\\n WET READ: EAGg WED 8:36 PM\\n Persistent bilateral pleural effusions and bibasilar opacity, likely\\n atelectasis but underlying infection not excluded.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 74-year-old male with desats and pneumonia.\\n\\n COMPARISON: Chest radiographs available from at 1:37 p.m.\\n\\n SEMI-UPRIGHT AP VIEW OF THE CHEST: The right-sided central venous catheter\\n and tracheostomy tube are unchanged in position. Moderate bilateral pleural\\n effusions and bibasilar opacities are stable. There has been interval\\n resolution of the previously seen pneumoperitoneum. There is no pneumothorax.\\n The cardiac and mediastinal contours are unchanged.\\n\\n IMPRESSION: Interval resolution of pneumoperitoneum, otherwise, unchanged\\n radiograph.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2175-01-23 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 1112229,\n \"text\": \" 7:52 PM\\n CT HEAD W/O CONTRAST; OUTSIDE FILMS READ ONLY Clip # \\n Reason: eval CT Head for acute traumatic injuries.\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 74 year old man hit by tree.\\n REASON FOR THIS EXAMINATION:\\n eval CT Head for acute traumatic injuries.\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: CXWc MON 9:10 PM\\n No ICH or fracture.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Transfer for pelvic fractures.\\n\\n TECHNIQUE: A non-contrast head CT was obtained earlier today at \\n Hospital, at 1600 hours . A second opinion is requested by the\\n referring clinician. No official report is available at the time of\\n interpretation.\\n\\n FINDINGS: There is no intracranial hemorrhage, edema, shift of normally\\n midline structures or evidence of major vascular territorial infarct.\\n Ventricles and sulci are normal in size and configuration. The -white\\n matter differentiation is preserved. The basilar cisterns are symmetric. A\\n small mucous retention cyst, and a small amount of fluid are noted within the\\n right maxillary sinus. Remaining paranasal sinuses are well aerated. Mastoid\\n air cells are well aerated.\\n\\n IMPRESSIONS:\\n\\n No acute intracranial abnormality.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2175-02-01 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1113440,\n \"text\": \" 1:06 PM\\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \\n Reason: ? change pulm path\\n Admitting Diagnosis: POLYTAUMA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 74 year old man with PNA, desat, hypotension\\n REASON FOR THIS EXAMINATION:\\n ? change pulm path\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 74-year-old male with pneumonia, continued desats, and\\n hypertension.\\n\\n COMPARISON: Chest radiographs available from through .\\n\\n UPRIGHT AP VIEW OF THE CHEST:\\n The upper mediastinal contour is unchanged since 5:48 a.m. The patient is\\n status post tracheostomy. New pneumomediastinum is compatible with recent\\n surgery, likely PEG placement, given removal of the NGT. The left-sided PICC\\n is unchanged in position. There has been no change in moderate bilateral\\n pleural effusions, with significant compressive atelectasis at the bases.\\n There is no pneumothorax. Mild pulmonary edema is unchanged.\\n\\n IMPRESSION:\\n 1. Status post tracheostomy. Pneumoperitoneum compatible with PEG placement\\n (confirmed with TICU team).\\n 2. Stable moderate bilateral pleural effusions and mild pulmonary edema.\\n 3. Persistent compressive bibasilar atalectasis.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2175-01-28 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1112875,\n \"text\": \" 5:23 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ?effusion, atelectasis, pneumonia\\n Admitting Diagnosis: POLYTAUMA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 74 year old man with ETT, multiple rib fractures\\n REASON FOR THIS EXAMINATION:\\n ?effusion, atelectasis, pneumonia\\n ______________________________________________________________________________\\n FINAL REPORT\\n EXAM: Chest one view at 05:49 hours.\\n\\n COMPARISON: at 05:59 hours.\\n\\n HISTORY: A 74-year-old male with endotracheal tube and multiple rib\\n fractures, status post trauma.\\n\\n TECHNIQUE: Single semi-upright portable chest x-ray was obtained.\\n\\n FINDINGS:\\n\\n Endotracheal tube is identified with its tip just above the level of the\\n thoracic inlet. Nasogastric tube is identified with its tip in the stomach.\\n Right subclavian central venous catheter is identified with its tip in the\\n cavoatrial junction. There is an IVC filter noted.\\n\\n Multiple rib fractures are present, and not well appreciated on this portable\\n examination.\\n\\n Cardiopericardial silhouette appears somewhat enlarged, although this may be\\n related to low lung volumes. In the interval, there is increasing perihilar\\n opacities with an indistinct appearance of interstitium, consistent with\\n cephalization of the pulmonary vasculature. Also seen are bibasilar linear\\n and hazy opacities, likely related to a combination of pleural effusions and\\n associated underlying edema or atelectasis. Opacity in the retrocardiac\\n region may be related to atelectasis or edema.\\n\\n IMPRESSION:\\n\\n 1. Interval mild increase in cardiac size, cephalization of the vessels\\n within indistinct appearance of the interstitium, bilateral pleural effusions,\\n and opacities at the lung bases, which may represent edema or atelectasis. The\\n constellation of these findings is likely related to fluid overload/congestive\\n heart failure.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2175-02-02 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1113544,\n \"text\": \" 5:22 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for acute process\\n Admitting Diagnosis: POLYTAUMA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 74 year old man with VAP\\n REASON FOR THIS EXAMINATION:\\n eval for acute process\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: This is a 74-year-old male with VAP.\\n\\n COMPARISON: Chest radiographs available from .\\n\\n SEMI-UPRIGHT AP VIEW OF THE CHEST: The tracheostomy tube and right-sided\\n central venous catheter are unchanged in position. Cardiac and mediastinal\\n contours are unchanged. There remains persistent mild pulmonary edema.\\n Moderate-sized bilateral pleural effusions have minimally improved. Bibasilar\\n opacities remain present, compatible with atelectasis and/or pneumonia.\\n\\n IMPRESSION:\\n 1. Minimal improvement of moderate-sized bilateral pleural effusions.\\n 2. Stable mild pulmonary edema.\\n 3. Stable bibasilar opacities compatible with atelectasis with possible\\n superimposed infection.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2175-01-30 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1113074,\n \"text\": \" 4:34 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for pna, pleural effusions\\n Admitting Diagnosis: POLYTAUMA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 74 year old man with pna and pleural effusions, s/p crush injury\\n REASON FOR THIS EXAMINATION:\\n eval for pna, pleural effusions\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST RADIOGRAPH\\n\\n INDICATION: Pneumonia and pleural effusions, status post crush injury.\\n\\n COMPARISON: .\\n\\n FINDINGS: As compared to the previous examination, there is no relevant\\n change. Unchanged monitoring and support devices, unchanged bilateral pleural\\n effusions, unchanged size of the cardiac silhouette, unchanged retrocardiac\\n and left basal atelectasis. No evidence of pneumothorax.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2175-01-26 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1112561,\n \"text\": \" 5:56 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ?edema, pneumonia, ETT\\n Admitting Diagnosis: POLYTAUMA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 74 year old man with multiple rib fxs, intubated\\n REASON FOR THIS EXAMINATION:\\n ?edema, pneumonia, ETT\\n ______________________________________________________________________________\\n FINAL REPORT\\n SINGLE AP PORTABLE VIEW OF THE CHEST\\n\\n REASON FOR EXAM: Multiple rib fractures and intubated.\\n\\n Comparison is made with prior study, .\\n\\n ET tube is in standard position. NG tube tip is out of view below the\\n diaphragm. Right central catheter tip is in the SVC. There are low lung\\n volumes. Moderate bilateral pleural effusions are stable. Collapse of the\\n lower lobes bilaterally is better seen in the prior CT from the day before.\\n Atelectases in the lingula and in the right upper lobe are better seen in\\n prior CT.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2175-02-03 00:00:00.000\",\n \"description\": \"BILAT LOWER EXT VEINS\",\n \"row_id\": 1113681,\n \"text\": \" 10:49 AM\\n BILAT LOWER EXT VEINS Clip # \\n Reason: eval for DVTs\\n Admitting Diagnosis: POLYTAUMA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 74 year old man with persistent fevers despite adequate pna coverage. eval for\\n other sources.\\n REASON FOR THIS EXAMINATION:\\n eval for DVTs\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): RSRc FRI 12:22 PM\\n No DVT\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 74-year-old male with pneumonia on treatment, persistent fever.\\n Evaluate for DVT as occult second cause for fever.\\n\\n COMPARISON: None available.\\n\\n BILATERAL LOWER EXTREMITY VENOUS ULTRASOUND: The common femoral veins,\\n superficial femoral veins, deep femoral veins, greater saphenous veins,\\n popliteal veins, and calf veins demonstrate normal color flow. There is\\n respiratory phasicity, compressibility, and appropriate response to\\n augmentation and Valsalva maneuvers.\\n\\n IMPRESSION: No evidence of DVT in the lower extremities.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2175-01-27 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1112729,\n \"text\": \" 5:22 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for interval change\\n Admitting Diagnosis: POLYTAUMA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 74 year old man with multiple broken ribs. Intubated.\\n REASON FOR THIS EXAMINATION:\\n eval for interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n SINGLE AP PORTABLE VIEW OF THE CHEST\\n\\n REASON FOR EXAM: Multiple rib fractures and intubated patient.\\n\\n Comparison is made with prior study performed a day earlier.\\n\\n ET tube tip is 6.3 cm above the carina. NG tube tip is out of view below the\\n diaphragm. Cardiac size is top normal, is partially obscured by lung\\n abnormality. There has been interval improvement of collapse in the left\\n lower lobe. Collapse of the right lower lobe is persistent. Atelectasis in\\n the lingula is unchanged. Cardiomediastinum is midline. Moderate bilateral\\n pleural effusions are stable. There is no pneumothorax.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2175-02-03 00:00:00.000\",\n \"description\": \"BILAT LOWER EXT VEINS\",\n \"row_id\": 1113682,\n \"text\": \", R. TSICU 10:49 AM\\n BILAT LOWER EXT VEINS Clip # \\n Reason: eval for DVTs\\n Admitting Diagnosis: POLYTAUMA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 74 year old man with persistent fevers despite adequate pna coverage. eval for\\n other sources.\\n REASON FOR THIS EXAMINATION:\\n eval for DVTs\\n ______________________________________________________________________________\\n PFI REPORT\\n No DVT\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2175-02-05 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1113838,\n \"text\": \" 5:05 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Evaluate for infiltrates, edema, interval change\\n Admitting Diagnosis: POLYTAUMA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 74 year old man with multiple trauma and PNA, volume overload\\n REASON FOR THIS EXAMINATION:\\n Evaluate for infiltrates, edema, interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n PORTABLE CHEST \\n\\n COMPARISON: \\n\\n INDICATION: Volume overload.\\n\\n FINDINGS: Allowing for technical differences between the studies, there has\\n not been a substantial change in appearance of the chest since the recent\\n radiograph of one day earlier.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2175-02-06 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1113917,\n \"text\": \" 4:55 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for interval change\\n Admitting Diagnosis: POLYTAUMA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 74 year old man with multi-trauma\\n REASON FOR THIS EXAMINATION:\\n eval for interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Multiple trauma, to evaluate for change.\\n\\n FINDINGS: In comparison with the study of , the patient may have taken a\\n slightly better inspiration. The left PICC line is not seen in the\\n hemithorax, though it may be present in the soft tissues at the edge of the\\n film in the axillary region. Bibasilar opacification persists, consistent\\n with atelectasis and effusion. Some degree of pulmonary contusion and even\\n supervening pneumonia must be considered.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2175-01-23 00:00:00.000\",\n \"description\": \"TRAUMA #2 (AP CXR & PELVIS PORT)\",\n \"row_id\": 1112226,\n \"text\": \" 7:26 PM\\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \\n Reason: rib fx\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 74 year old man with fall\\n REASON FOR THIS EXAMINATION:\\n rib fx\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 74-year-old man status post fall.\\n\\n COMPARISON: None.\\n\\n SINGLE SUPINE VIEW OF THE CHEST AT HOURS: Underlying trauma board limits\\n evaluation. Lung volumes are low. There are heterogeneous parenchymal\\n opacities bilaterally, suggesting multifocal contusion and/or atelectasis.\\n There is no large pleural effusion. The heart size is normal. There is no\\n hilar or mediastinal enlargement. Multiple displaced rib fractures are noted,\\n particularly along the right lateral chest wall.\\n\\n SINGLE FRONTAL VIEW OF THE PELVIS: Underlying trauma board limits evaluation.\\n There are minimally displaced fractures of the superior and anterior pubic\\n rami on the left. Degenerative changes and fragmented osteophytes are noted\\n of both hips. No other displaced fractures are definitively identified. The\\n femoral heads are well seated in the acetabuli.\\n\\n IMPRESSIONS:\\n\\n 1. Heterogeneous pulmonary opacities suggestive of contusion and/or\\n aspiration.\\n\\n 2. Multiple minimally displaced right lateral rib fractures.\\n\\n 3. Left pubic rami fractures.\\n\\n Please refer to concurrently obtained CT abdomen/pelvis, and OSH chest CT for\\n further assessment.\\n\\n\"\n }\n]"}}},{"rowIdx":369,"cells":{"subject_id":{"kind":"number","value":54592,"string":"54,592"},"hadm_id":{"kind":"number","value":154299,"string":"154,299"},"target_text":{"kind":"string","value":"50 year old woman with a history of HIV, Hepatitis C, and opiate abuse admitted with narcotic overdose. She left against medical advice on hospital day X 2."},"extractive_notes_summ":{"kind":"string","value":"Right mastoid tip air cells and left lateral mastoid air cells are partially opacified. IMPRESSION: Minimal streaky opacities in the lung bases which could reflect atelectasis. Left lateral mastoid air cells and right mastoid tip air cells are partially opacified. Thereis mild mucosal thickening in a right anterior ethmoid air cell. Concurrent head CT is reported separately. Minimal streaky opacities are noted within the lung bases. The frontal sinuses are not pneumatized. Sinus rhythm and frequent atrial ectopy. TECHNIQUE: Semi-upright AP view of the chest. The pulmonary vascularity is not engorged. Coronal and sagittal reformatted images were reviewed. TECHNIQUE: Axial CT images through the head were acquired without intravenous contrast. Clinicalcorrelation is suggested. The mediastinal and hilar contours are unremarkable. COMPARISON: Chest radiograph . Scarring and emphysema is again noted at the right lung apex. DFDkq DFDkq The basal cisterns appear patent. A 4 x 4 mm osteoma is again seen in a left middle ethmoid air cell. Cervical degenerative disease. IMPRESSION: No CT evidence for acute intracranial injury. TECHNIQUE: Axial CT images through the cervical spine were acquired without intravenous contrast. There is disc space narrowing and disc osteophyte complexes indenting the thecal sac at C4-5, C5-C6, and C6-C7, as before. FINDINGS: There is no acute fracture or malalignment. Concern for trauma. The ventricles and sulci are normal in size. IMPRESSION: No fracture or malalignment. DFDdp There is preservation of -white matter differentiation. FINDINGS: The heart size is normal. There is also uncovertebral arthropathy with neural foraminal narrowing at these levels, as before. COMPARISON: . COMPARISON: . This could reflect atelectasis. Clips are noted in the right upper quadrant of the abdomen denoting prior cholecystectomy. There is no calvarial fracture. FINDINGS: There is no evidence for acute intracranial hemorrhage, mass effect, edema. 4:59 PM CHEST (PORTABLE AP) Clip # Reason: eval for acute pathology MEDICAL CONDITION: History: 50F with found down REASON FOR THIS EXAMINATION: eval for acute pathology No contraindications for IV contrast FINAL REPORT HISTORY: Found down. There is no prevertebral soft tissue swelling. No pleural effusion, focal consolidation or pneumothorax is identified. Prominent nipple shadow is seen on the left. Coronal, sagittal, and thin slice bone reconstructed images were created and reviewed. Compared to the previous tracingof the rate has increased and there is frequent atrial ectopy as wellas new ST segment flattening and slight depression in leads V4-V6 in thecontext of delayed precordial R wave transition previously recorded. 2 additional clips are also seen projecting over the right inferior hemithorax. 5:16 PM CT HEAD W/O CONTRAST Clip # Reason: eval for acute process/injury to cause hypotension Admitting Diagnosis: OVERDOSE MEDICAL CONDITION: History: 50F with likely OD but hypotensive, r/o traumatic injury, PE REASON FOR THIS EXAMINATION: eval for acute process/injury to cause hypotension No contraindications for IV contrast WET READ: EHAb SUN 8:28 PM No CT evidence for acute intracranial process. 6:06 PM CT C-SPINE W/O CONTRAST Clip # Reason: eval for acute process/injury to cause hypotension Admitting Diagnosis: OVERDOSE MEDICAL CONDITION: History: 50F with likely OD but hypotensive, r/o traumatic injury, PE REASON FOR THIS EXAMINATION: eval for acute process/injury to cause hypotension No contraindications for IV contrast WET READ: EHAb SUN 8:34 PM No CT evidence for acute cervical spine fracture. WET READ VERSION #1 FINAL REPORT INDICATION: 50-year-old female who was found down, with likely overdose, hypotension, and concern for traumatic injury."},"n_notes":{"kind":"number","value":4,"string":"4"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2153-07-22 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1252895,"text":" 4:59 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for acute pathology\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 50F with found down\n REASON FOR THIS EXAMINATION:\n eval for acute pathology\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Found down.\n\n TECHNIQUE: Semi-upright AP view of the chest.\n\n COMPARISON: Chest radiograph .\n\n FINDINGS:\n\n The heart size is normal. The mediastinal and hilar contours are\n unremarkable. The pulmonary vascularity is not engorged. Minimal streaky\n opacities are noted within the lung bases. This could reflect atelectasis.\n Prominent nipple shadow is seen on the left. No pleural effusion, focal\n consolidation or pneumothorax is identified. Clips are noted in the right\n upper quadrant of the abdomen denoting prior cholecystectomy. 2 additional\n clips are also seen projecting over the right inferior hemithorax.\n\n IMPRESSION:\n\n Minimal streaky opacities in the lung bases which could reflect atelectasis.\n\n DFDdp\n\n"},{"category":"ECG","chartdate":"2153-07-22 00:00:00.000","description":"Report","row_id":167299,"text":"Sinus rhythm and frequent atrial ectopy. Compared to the previous tracing\nof the rate has increased and there is frequent atrial ectopy as well\nas new ST segment flattening and slight depression in leads V4-V6 in the\ncontext of delayed precordial R wave transition previously recorded. Clinical\ncorrelation is suggested.\n\n"},{"category":"Radiology","chartdate":"2153-07-22 00:00:00.000","description":"CT C-SPINE W/O CONTRAST","row_id":1252901,"text":" 6:06 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: eval for acute process/injury to cause hypotension\n Admitting Diagnosis: OVERDOSE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 50F with likely OD but hypotensive, r/o traumatic injury, PE\n REASON FOR THIS EXAMINATION:\n eval for acute process/injury to cause hypotension\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: EHAb SUN 8:34 PM\n No CT evidence for acute cervical spine fracture.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 50-year-old female who was found down, with likely overdose,\n hypotension, and concern for traumatic injury.\n\n COMPARISON: .\n\n TECHNIQUE: Axial CT images through the cervical spine were acquired without\n intravenous contrast. Coronal and sagittal reformatted images were reviewed.\n\n FINDINGS: There is no acute fracture or malalignment. There is no\n prevertebral soft tissue swelling. There is disc space narrowing and disc\n osteophyte complexes indenting the thecal sac at C4-5, C5-C6, and C6-C7, as\n before. There is also uncovertebral arthropathy with neural foraminal\n narrowing at these levels, as before.\n\n Scarring and emphysema is again noted at the right lung apex.\n\n Right mastoid tip air cells and left lateral mastoid air cells are partially\n opacified. Concurrent head CT is reported separately.\n\n IMPRESSION: No fracture or malalignment. Cervical degenerative disease.\n DFDkq\n\n"},{"category":"Radiology","chartdate":"2153-07-22 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":1252899,"text":" 5:16 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for acute process/injury to cause hypotension\n Admitting Diagnosis: OVERDOSE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 50F with likely OD but hypotensive, r/o traumatic injury, PE\n REASON FOR THIS EXAMINATION:\n eval for acute process/injury to cause hypotension\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: EHAb SUN 8:28 PM\n No CT evidence for acute intracranial process.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 50-year-old female who was found down, likely overdose,\n hypotensive. Concern for trauma.\n\n COMPARISON: .\n\n TECHNIQUE: Axial CT images through the head were acquired without intravenous\n contrast. Coronal, sagittal, and thin slice bone reconstructed images were\n created and reviewed.\n\n FINDINGS: There is no evidence for acute intracranial hemorrhage, mass\n effect, edema. There is preservation of -white matter differentiation.\n The basal cisterns appear patent. The ventricles and sulci are normal in size.\n\n There is no calvarial fracture.\n\n A 4 x 4 mm osteoma is again seen in a left middle ethmoid air cell. The\n frontal sinuses are not pneumatized. Thereis mild mucosal thickening in a\n right anterior ethmoid air cell. Left lateral mastoid air cells and right\n mastoid tip air cells are partially opacified.\n\n IMPRESSION: No CT evidence for acute intracranial injury.\n DFDkq\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2153-07-22 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1252895,\n \"text\": \" 4:59 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for acute pathology\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n History: 50F with found down\\n REASON FOR THIS EXAMINATION:\\n eval for acute pathology\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Found down.\\n\\n TECHNIQUE: Semi-upright AP view of the chest.\\n\\n COMPARISON: Chest radiograph .\\n\\n FINDINGS:\\n\\n The heart size is normal. The mediastinal and hilar contours are\\n unremarkable. The pulmonary vascularity is not engorged. Minimal streaky\\n opacities are noted within the lung bases. This could reflect atelectasis.\\n Prominent nipple shadow is seen on the left. No pleural effusion, focal\\n consolidation or pneumothorax is identified. Clips are noted in the right\\n upper quadrant of the abdomen denoting prior cholecystectomy. 2 additional\\n clips are also seen projecting over the right inferior hemithorax.\\n\\n IMPRESSION:\\n\\n Minimal streaky opacities in the lung bases which could reflect atelectasis.\\n\\n DFDdp\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2153-07-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 167299,\n \"text\": \"Sinus rhythm and frequent atrial ectopy. Compared to the previous tracing\\nof the rate has increased and there is frequent atrial ectopy as well\\nas new ST segment flattening and slight depression in leads V4-V6 in the\\ncontext of delayed precordial R wave transition previously recorded. Clinical\\ncorrelation is suggested.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2153-07-22 00:00:00.000\",\n \"description\": \"CT C-SPINE W/O CONTRAST\",\n \"row_id\": 1252901,\n \"text\": \" 6:06 PM\\n CT C-SPINE W/O CONTRAST Clip # \\n Reason: eval for acute process/injury to cause hypotension\\n Admitting Diagnosis: OVERDOSE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n History: 50F with likely OD but hypotensive, r/o traumatic injury, PE\\n REASON FOR THIS EXAMINATION:\\n eval for acute process/injury to cause hypotension\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: EHAb SUN 8:34 PM\\n No CT evidence for acute cervical spine fracture.\\n\\n WET READ VERSION #1\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 50-year-old female who was found down, with likely overdose,\\n hypotension, and concern for traumatic injury.\\n\\n COMPARISON: .\\n\\n TECHNIQUE: Axial CT images through the cervical spine were acquired without\\n intravenous contrast. Coronal and sagittal reformatted images were reviewed.\\n\\n FINDINGS: There is no acute fracture or malalignment. There is no\\n prevertebral soft tissue swelling. There is disc space narrowing and disc\\n osteophyte complexes indenting the thecal sac at C4-5, C5-C6, and C6-C7, as\\n before. There is also uncovertebral arthropathy with neural foraminal\\n narrowing at these levels, as before.\\n\\n Scarring and emphysema is again noted at the right lung apex.\\n\\n Right mastoid tip air cells and left lateral mastoid air cells are partially\\n opacified. Concurrent head CT is reported separately.\\n\\n IMPRESSION: No fracture or malalignment. Cervical degenerative disease.\\n DFDkq\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2153-07-22 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 1252899,\n \"text\": \" 5:16 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: eval for acute process/injury to cause hypotension\\n Admitting Diagnosis: OVERDOSE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n History: 50F with likely OD but hypotensive, r/o traumatic injury, PE\\n REASON FOR THIS EXAMINATION:\\n eval for acute process/injury to cause hypotension\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: EHAb SUN 8:28 PM\\n No CT evidence for acute intracranial process.\\n\\n WET READ VERSION #1\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 50-year-old female who was found down, likely overdose,\\n hypotensive. Concern for trauma.\\n\\n COMPARISON: .\\n\\n TECHNIQUE: Axial CT images through the head were acquired without intravenous\\n contrast. Coronal, sagittal, and thin slice bone reconstructed images were\\n created and reviewed.\\n\\n FINDINGS: There is no evidence for acute intracranial hemorrhage, mass\\n effect, edema. There is preservation of -white matter differentiation.\\n The basal cisterns appear patent. The ventricles and sulci are normal in size.\\n\\n There is no calvarial fracture.\\n\\n A 4 x 4 mm osteoma is again seen in a left middle ethmoid air cell. The\\n frontal sinuses are not pneumatized. Thereis mild mucosal thickening in a\\n right anterior ethmoid air cell. Left lateral mastoid air cells and right\\n mastoid tip air cells are partially opacified.\\n\\n IMPRESSION: No CT evidence for acute intracranial injury.\\n DFDkq\\n\\n\"\n }\n]"}}},{"rowIdx":370,"cells":{"subject_id":{"kind":"number","value":28534,"string":"28,534"},"hadm_id":{"kind":"number","value":145987,"string":"145,987"},"target_text":{"kind":"string","value":"She was admitted to Trauma Service. Neurosurgery, Orthopedics and Plastics were consulted because of her injuries. Her intracranial bleed was nonoperative; she was loaded with Dilantin and started on 100 mg tid; she will remain on this for a total of 4 weeks and will follow up with Dr. at that time for repeat head imaging. Serial head CT scans were followed while in the hospital and were stable. She was seen by Plastics for right thumb laceration; this was irrigated and sutured closed. OT was consulted for a thumb splint. She will follow up as an outpatient in Plastics/Hand Clinic. Orthopedics was consulted for the left clavicle fracture; this injury was also non operative. She was made non weight bearing on that extremity; a sling was provided for comfort. She will follow up as an outpatient in Clinic. She was noted to have a hematocrit drop; likely secondary to a left gluteal hematoma that was noted on exam and on imaging studies. Hematocrit on day of admission was 38; down to 28 on the following day and then several days later down to 21. She was transfused with 2 units PRBC's. Post transfusion Hct was 25. Physical and Occupational therapy were consulted and have recommended rehab following acute hospitalization."},"extractive_notes_summ":{"kind":"string","value":"Marked degenerative changes of the thoracolumbar spine with stable, mild superior endplate compression at the L1 level. Left gluteal soft tissue hematoma. Tiny foci of scattered hyperattenuation within the left cerebral hemisphere are consistent with hemorrhagic contusion. NON-CONTRAST HEAD CT: Subdural hematomas along the bilateral cerebral convexities (left greater than right) and adjacent to the falx are redemonstrated. Tiny foci scattered hypoattenuation within the left cerebral hemisphere is consistent with hemorrhagic contusions, unchanged. CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The rectum, sigmoid colon, and bladder are within normal limits. Subcutaneous edema and small left gluteal hematoma. There is a left gluteal soft tissue hematoma. Small scattered foci of hypoattenuation are again seen scattered throughout the left cerebral hemisphere consistent with hemorrhagic contusions. The patient is status post bilateral hip arthroplasty, incompletely assessed. COMPARISON: None NON-CONTRAST HEAD CT: Subdural hematomas are noted along bilateral cerebral convexity (left greater than right) and adjacent to the falx. IMPRESSION: Stable appearance of bilateral cerebral convexity and parasagittal subdural hematoma. Admitting Diagnosis: SUBDURAL HEMATOMA Contrast: OPTIRAY Amt: 130 FINAL REPORT (Cont) drainable collection. Small punctate foci of hyperattenuation are seen scattered throughout the left cerebral hemisphere consistent with hemorrhagic contusions. A moderate- sized left parietal scalp hematoma is present. Large left renal cyst and multiple smaller left renal hypodensities are unchanged. U/O adequate via foleyA: Stable s/p fall with Fx clavicale and ribs. IMPRESSION: Bilateral cerebral convexity (left greater than right) and parasagittal subdural hematoma. The previously described left parietal scalp hematoma has improved. Degenerative changes of the left glenohumeral joint are again noted with surrounding subcutaneous hematoma laterally as well as along the periscapular region. The abdominal aorta shows diffuse calcification. Notes is made of focal ectasia of the infrarenal aorta, proximal celiac and bilateral iliac arteries. FINDINGS: Cervical spine shows an exaggerated lordosis with multilevel degenerative changes. Atherosclerotic calcifications and aortoiliac ectasia again noted. The comminuted left clavicle fracture and non-displaced left rib fractures are again noted. Left apical capping/pleural fluid. No contraindications for IV contrast FINAL REPORT CT TORSO ON CLINICAL HISTORY: Recent trauma, now with decreased hematocrit, question hemorrhage. AP PELVIS: Trauma board obscures fine detail. AP CHEST: Trauma board obscures fine detail. The patient is status post bilateral hip arthroplasty. The remainder of the visualized paranasal sinuses and mastoid air cells remain normally aerated. Patient is status post bilateral hip arthroplasties with cemented femoral stem component. The heart and pericardium are within normal limits. Remainder of the visualized paranasal sinuses and mastoid air cells remain normally aerated. Patient has significant ecchymosis over L shoulder. Left apical pleural fluid/thickening. CT OF THE CHEST WITH INTRAVENOUS CONTRAST: The lungs demonstrate bilateral dependent atelectasis. The thoracic aorta is normal in caliber without evidence of dissection. The gallbladder, spleen, adrenal glands, and pancreas are within normal limits. Deformity over L clavical and bruising over left upper arm present. R thumb laceration with dsd in place. Post-traumatic changes in the left hemithorax including stable rib and clavicle fractures, slightly increased left pleural fluid, not compatible with hemothorax, however, subcutaneous edema and hematomas without a focal (Over) 11:47 AM CT CHEST W&W/O C ; CT ABD W&W/O C Clip # CT PELVIS W&W/O C Reason: Please evaluate for source of bleeding. Extensive degenerative changes are seen involving the left glenohumeral joint. Extensive degenerative changes are seen involving the left glenohumeral joint. Restarted on po antihypertensives.Pulses present. Post-surgical changes related to bilateral hip arthroplasties. Repeat CT of head done. There is increased pleural fluid, low in density and not likely hemothorax. 11:47 AM CT CHEST W&W/O C ; CT ABD W&W/O C Clip # CT PELVIS W&W/O C Reason: Please evaluate for source of bleeding. Also on colace.Heme: hct stable, venodynes in useID: t max 99.4, wbc flat, on no antibiotics.Lines: new 20 g angio placed L forearm, also has 16g angio L antecubital.skin: bruising progressing on L shoulder and L hip. Multilevel degenerative changes are seen involving the thoracolumbar spine. Multilevel degenerative changes are seen involving the thoracolumbar spine. In the left lung apex shows pleural thickening/fluid. The right lobe of the thyroid is not visualized. Extensive degenerative changes are seen involving the glenohumeral joint. Irrigated by Dr and dressed with dsd. ?tendon exposed. The celiac artery, SMA and are patent. TECHNIQUE: Helical acquisition of CT images performed from the thoracic inlet through the ischial tuberosities following administration of 130 cc of intravenous nonionic contrast. The prevertebral soft tissues are within normal limits. Mild mucosal thickening is seen within the left maxillary sinus. CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: The liver shows no focal lesion. Interstial abnormality is likely related to edema. Two views of the left shoulder demonstrate displaced fracture involving the mid left clavicle."},"n_notes":{"kind":"number","value":11,"string":"11"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2176-06-23 00:00:00.000","description":"L SHOULDER 1 VIEW LEFT","row_id":1014891,"text":" 4:10 AM\n SHOULDER 1 VIEW LEFT; HUMERUS (AP & LAT) LEFT Clip # \n HAND (AP, LAT & OBLIQUE) LEFT\n Reason: evaluate for fx/dislocation\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman with left shoulder pain s/p fall\n REASON FOR THIS EXAMINATION:\n evaluate for fx/dislocation\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 76-year-old female with left shoulder pain status post\n fall. Evaluate for fracture, dislocation.\n\n Two views of the left shoulder demonstrate displaced fracture involving the\n mid left clavicle. Extensive degenerative changes are seen involving the\n glenohumeral joint. Multiple left-sided rib fractures are noted, better\n assessed on concurrent chest CT.\n\n Three views of the left hand show degenerative changes involving the first CMC\n and second MCP joints. There is exuberant mineralization of the TFC and about\n the MCP joints, which is likely represents chondrocalcinosis. There is\n cortical irregularity along the radial side of the distal radius, suspicious\n for fracture. Dedicated wrist radiographs are recommended.\n\n"},{"category":"Radiology","chartdate":"2176-06-23 00:00:00.000","description":"PELVIS (AP ONLY)","row_id":1014892,"text":" 4:10 AM\n PELVIS (AP ONLY); -76 BY SAME PHYSICIAN # \n Reason: TO SEE END OF PROSTHES.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman with b/l THR s/p fall\n REASON FOR THIS EXAMINATION:\n r/o fracture\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 76-year-old female with bilateral total hip replacement.\n\n AP pelvis shows no fracture or dislocation. Patient is status post bilateral\n hip arthroplasties with cemented femoral stem component. There is no evidence\n of hardware- related complication. Contrast is noted within the bladder.\n\n"},{"category":"Radiology","chartdate":"2176-06-23 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":1014887,"text":" 3:47 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o trauma\n ______________________________________________________________________________\n FINAL ADDENDUM\n The foci in left frontal lobe could also be due to subarachnoid blood.\n\n\n 3:47 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o trauma\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman s/p fall\n REASON FOR THIS EXAMINATION:\n r/o trauma\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 26-year-old female status post fall downstairs.\n\n COMPARISON: None\n\n NON-CONTRAST HEAD CT: Subdural hematomas are noted along bilateral cerebral\n convexity (left greater than right) and adjacent to the falx. Small punctate\n foci of hyperattenuation are seen scattered throughout the left cerebral\n hemisphere consistent with hemorrhagic contusions. No shift of normally\n midline structures. The - white matter differentiation is preserved. No\n hydrocephalus or evidence of major vascular territorial infarct. A moderate-\n sized left parietal scalp hematoma is present. No fracture is identified.\n Small air-fluid level is seen within the left maxillary sinus. Remainder of\n the visualized paranasal sinuses and mastoid air cells remain normally\n aerated. Dense vascular calcifications are noted.\n\n IMPRESSION: Bilateral cerebral convexity (left greater than right) and\n parasagittal subdural hematoma. Tiny foci of scattered hyperattenuation within\n the left cerebral hemisphere are consistent with hemorrhagic contusion.\n\n"},{"category":"Radiology","chartdate":"2176-06-23 00:00:00.000","description":"CT C-SPINE W/O CONTRAST","row_id":1014888,"text":" 3:48 AM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: r/o trauma\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman s/p fall\n REASON FOR THIS EXAMINATION:\n r/o trauma\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 76 year old female status post fall down stairs.\n\n TECHNIQUE: Non-contrast MDCT-acquired axial images of the cervical spine from\n the skull base to the level of T3. Multiplanar reformatted images were\n obtained.\n\n FINDINGS: Cervical spine shows an exaggerated lordosis with multilevel\n degenerative changes. No evidence of subluxation. Fractures are identified\n involving the left T1 transverse process/superior articulating facet;\n bilateral first ribs; left second and third ribs. In the left lung apex shows\n pleural thickening/fluid. The prevertebral soft tissues are within normal\n limits.\n\n IMPRESSION:\n 1. Fractures involving the left T1 transverse process/superior articulating\n surface as well as bilateral first ribs; left second and third ribs; and left\n clavicle.\n\n 2. Multilevel degenerative changes involving the cervical spine.\n\n 3. Left apical pleural fluid/thickening.\n\n"},{"category":"Radiology","chartdate":"2176-06-23 00:00:00.000","description":"CT CHEST W/CONTRAST","row_id":1014889,"text":" 4:02 AM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: eval fractures\n Field of view: 46\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman s/p fall with multiple rib fractures\n REASON FOR THIS EXAMINATION:\n eval fractures\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Status post fall downstairs.\n\n TECHNIQUE: Contrast-enhanced MDCT acquired axial images of the chest, abdomen\n and pelvis from the thoracic inlet to the pubic symphysis. Multiplanar\n reformatted images were obtained.\n\n CT OF THE CHEST WITH INTRAVENOUS CONTRAST: The lungs demonstrate bilateral\n dependent atelectasis. No consolidation, pneumothorax or worrisome pulmonary\n nodule is identified. Left clavicle and multiple left-sided rib fractures are\n identified with accompanying left apical capping/pleural fluid. Note is also\n made of right first rib fracture (better seen on previous cervical spine CT).\n\n The heart and pericardium are within normal limits. The thoracic aorta is\n normal in caliber without evidence of dissection. No mediastinal or axillary\n lymphadenopathy is appreciated. The right lobe of the thyroid is not\n visualized.\n\n CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: The liver shows no focal lesion.\n The gallbladder, spleen, adrenal glands, and pancreas are within normal\n limits. The kidneys enhance and excrete contrast symmetrically. A large cyst\n is seen within the upper pole of the left kidney. The intra-abdominal loops of\n large and small bowel maintain a normal caliber without evidence of\n obstruction. No free air, free fluid or lymphadenopathy is appreciated. The\n abdominal aorta shows diffuse calcification. Notes is made of focal ectasia of\n the infrarenal aorta, proximal celiac and bilateral iliac arteries. The celiac\n artery, SMA and are patent.\n\n CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The rectum, sigmoid colon, and\n bladder are within normal limits. No free fluid or lymphadenopathy is\n appreciated.\n\n BONE WINDOWS AND SOFT TISSUES: Fractures are identified involving multiple\n left-sided ribs, right first rib, and left clavicle. Extensive degenerative\n changes are seen involving the left glenohumeral joint. The patient is status\n post bilateral hip arthroplasty. Multilevel degenerative changes are seen\n involving the thoracolumbar spine. There is a left gluteal soft tissue\n hematoma.\n\n IMPRESSION:\n 1. Fractures involving multiple left-sided ribs, right first rib and and left\n (Over)\n\n 4:02 AM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: eval fractures\n Field of view: 46\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n clavicle. Left apical capping/pleural fluid.\n\n 2. Post-surgical changes related to bilateral hip arthroplasties. Extensive\n degenerative changes are seen involving the left glenohumeral joint.\n\n 3. Multilevel degenerative changes are seen involving the thoracolumbar\n spine.\n\n 4. Multiple hypodensities within bilateral kidneys, the largest of which\n likely represents a cyst. The remainder are too small to characterize.\n\n 5. Left gluteal soft tissue hematoma.\n\n"},{"category":"Radiology","chartdate":"2176-06-25 00:00:00.000","description":"CT PELVIS W&W/O C","row_id":1015154,"text":" 11:47 AM\n CT CHEST W&W/O C ; CT ABD W&W/O C Clip # \n CT PELVIS W&W/O C\n Reason: Please evaluate for source of bleeding.\n Admitting Diagnosis: SUBDURAL HEMATOMA\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman s/p multi injury trauma with falling hct. Patient has\n significant ecchymosis over L shoulder. She is hemodynamically stable\n REASON FOR THIS EXAMINATION:\n Please evaluate for source of bleeding.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT TORSO ON \n\n CLINICAL HISTORY: Recent trauma, now with decreased hematocrit, question\n hemorrhage.\n\n TECHNIQUE: Helical acquisition of CT images performed from the thoracic inlet\n through the ischial tuberosities following administration of 130 cc of\n intravenous nonionic contrast. Comparison made to prior examination of two\n days earlier.\n\n FINDINGS: There has been minimal interval change. The comminuted left\n clavicle fracture and non-displaced left rib fractures are again noted. No\n new fractures are seen. There is increased pleural fluid, low in density and\n not likely hemothorax. There is associated atelectasis of the left lower\n lobe. No pneumothorax or focal airspace disease. Degenerative changes of the\n left glenohumeral joint are again noted with surrounding subcutaneous hematoma\n laterally as well as along the periscapular region. No drainable hematoma or\n collection.\n\n ABDOMEN:\n Within the abdomen, the solid organs are intact. Large left renal cyst and\n multiple smaller left renal hypodensities are unchanged. No vascular injury\n is evident.\n\n PELVIS: Bowel loops are unremarkable and non-dilated. Atherosclerotic\n calcifications and aortoiliac ectasia again noted. No free pelvic fluid. No\n new bony injury. Bilateral hip prostheses. Subcutaneous edema and small left\n gluteal hematoma. There is a focus of gas within the bladder, likely related\n to recent instrumentation. No Foley catheter is present. Clinical\n correlation is necessary.\n\n Marked degenerative changes of the thoracolumbar spine with stable, mild\n superior endplate compression at the L1 level.\n\n IMPRESSION:\n 1. Post-traumatic changes in the left hemithorax including stable rib and\n clavicle fractures, slightly increased left pleural fluid, not compatible with\n hemothorax, however, subcutaneous edema and hematomas without a focal\n (Over)\n\n 11:47 AM\n CT CHEST W&W/O C ; CT ABD W&W/O C Clip # \n CT PELVIS W&W/O C\n Reason: Please evaluate for source of bleeding.\n Admitting Diagnosis: SUBDURAL HEMATOMA\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n drainable collection.\n 2. No solid organ injury or evident source of significant change in\n hematocrit.\n\n\n"},{"category":"Radiology","chartdate":"2176-06-23 00:00:00.000","description":"TRAUMA #2 (AP CXR & PELVIS PORT)","row_id":1014886,"text":" 3:47 AM\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \n Reason: eval for fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman with 2 stairs\n REASON FOR THIS EXAMINATION:\n eval for fx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 76-year-old female status post fall down 12 flights of stair.\n Evaluate for fracture.\n\n AP CHEST: Trauma board obscures fine detail. The lung volumes are low. No\n consolidation or pneumothorax is detected. The heart is moderately enlarged.\n Interstial abnormality is likely related to edema. Note is made of left apical\n capping, which is likely related to the multiple left- sided rib fractures.\n The left clavicle is fractured in its mid portion.\n\n AP PELVIS: Trauma board obscures fine detail. No fracture or dislocation.\n The patient is status post bilateral hip arthroplasty, incompletely assessed.\n\n"},{"category":"Radiology","chartdate":"2176-06-24 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":1014990,"text":" 3:14 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: evaluated for evolution of SDH. Please do at 4am\n Admitting Diagnosis: SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman with bilateral SDH and sm left frontal contusion.\n REASON FOR THIS EXAMINATION:\n evaluated for evolution of SDH. Please do at 4am\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 76-year-old female with bilateral subdural hematoma and\n small left frontal contusion. Evaluate for evolution of hematoma.\n\n COMPARISON: .\n\n NON-CONTRAST HEAD CT: Subdural hematomas along the bilateral cerebral\n convexities (left greater than right) and adjacent to the falx are\n redemonstrated. Compared to prior exam, there is no appreciable change. Small\n scattered foci of hypoattenuation are again seen scattered throughout the left\n cerebral hemisphere consistent with hemorrhagic contusions. No new focus of\n hemorrhage is identified. There is no shift of normally midline structures.\n The -white matter differentiation is preserved. No hydrocephalus or\n evidence of major vascular territorial infarct. The previously described left\n parietal scalp hematoma has improved. No fracture is identified. Mild\n mucosal thickening is seen within the left maxillary sinus. The remainder of\n the visualized paranasal sinuses and mastoid air cells remain normally\n aerated.\n\n IMPRESSION: Stable appearance of bilateral cerebral convexity and\n parasagittal subdural hematoma. Tiny foci scattered hypoattenuation within\n the left cerebral hemisphere is consistent with hemorrhagic contusions,\n unchanged. No new focus of hemorrhage is identified.\n\n"},{"category":"Nursing/other","chartdate":"2176-06-23 00:00:00.000","description":"Report","row_id":1634396,"text":"T/SICU Brief Admission note\nMrs. is a 76 year old woman admitted to T/SICU from the EW at 05:30 this morning. She was caring for her grandchilden in when she got up to go to the bathroom and fell down approximately 10 stairs. Her injuries include: several small subdural hematomas (one may be a week old from a prior fall), ??cervical fracture, L clavicular fracture, and 4 rib fractures, and a R thumb laceration (with possible tendon exposure).\nPMH: arthritis (s/p bilateral hip replacements), hypertension, hyperlipidemia, hypothyroidism\nMeds: simvatastatin, diovan, synthyroid, norvasc\nReview of systems:\nNeuro: awake, alert, orient, moves all extremities equally, perrla. c/o pain in L shoulder and back. PCA morphine instituted and pt with good understanding.\nCVS: sinus rhythm, rate 80's, bp 120-140/60-70, peripheral pulses present, venodynes initiated\nRESP: breath sounds diminished, on 2L np with sats 99-100%\nRENAL: foley placed in EW, adequate light yellow urine, receiving fluids of ns @ 60/hr. K=3.5\nGI: c/o nausea. Pepcid ordered, belly soft with bowel sounds present\nHeme: INR 1.1 hct 37.9\nendo: fs in er 184, pt takes synthroid at home\nID: cold on arrival, temp 96.4, wbc 15.7, no antibiotics ordered\nskin: Laceration noted on surface of her R thumb with ??tendon exposed. Irrigated by Dr and dressed with dsd. Plastics to evaluate. Deformity over L clavical and bruising over left upper arm present. Cervical collar in place.\nLines: r antecubital iv in place\nSocial: daughter arrived and updated with injuries by Dr. .\nA: 76 year old s/p fall with multiple injuries, currently stable\nP: neuro checks for sdh, ??follow up CT. Radiologist will evaluate possible neck fracture, Reassess movement restrictions. Attempt to achieve excellent pain control either with pca or ??epidural catheter for rib fx to prevent atelectasis. Support family with information as appropriate.\n"},{"category":"Nursing/other","chartdate":"2176-06-23 00:00:00.000","description":"Report","row_id":1634397,"text":"Tsicu NPN\nS: It only hurts a little Its a \"2\"\nO: Initially hypertensive, BP down to 90/60 after PCA medication and norvasc which pt takes at home. Temp flat. Adm K+ 3.5, Rechecked this pm. Alert and oriented with no defecits throughout day. OOB to chair X2 H. IS q1-2 HR with volumes 1000-1500. Lungs clear with diminished bases. Tol reg diet, good fluid intake but poor appetite. No BM On colace. U/O adequate via foley\nA: Stable s/p fall with Fx clavicale and ribs. Neck cleared by Dr this am, collar removed\nP: OOB to chair TID, IS q1-2 Hr. Rigorous pulmonary assessment and rx as indicated\n"},{"category":"Nursing/other","chartdate":"2176-06-24 00:00:00.000","description":"Report","row_id":1634398,"text":"T/SICU Nursing Progress Note\nS:\"I want to get better so I can go to my granddaughter's dance recital\"\nO: Review of systems\nneuro: awake, alert, oriented, motor intact. Repeat CT of head done. Using pca morphine (1.5mg q 6 min) for good pain control. Able to turn side to side with pain level stated as \"4\". Continues on po dilantin\nCVS: stable heart rate and rhythm. Restarted on po antihypertensives.\nPulses present. Venodynes in use.\nRESP: sats excellent on 2L np. Uses IS up to 1200cc, breath sounds decreased in bases. non productive cough.\nRENAL: D51/2ns @ 60/hr, urine output adequate. Lytes wnl except calcium elevated.\nGI: tolerating liquids, no appetite for other food at present. On prevacid for prophylaxis. Also on colace.\nHeme: hct stable, venodynes in use\nID: t max 99.4, wbc flat, on no antibiotics.\nLines: new 20 g angio placed L forearm, also has 16g angio L antecubital.\nskin: bruising progressing on L shoulder and L hip. R thumb laceration with dsd in place. Also has significant bruising and swelling over L wrist\nsocial: daughters all visited during the evening and were updated with plan and all questions answered.\nA: 76 y/o woman s/p fall with fractured L clavicle, l sided ribs, sdh stable post fall\nP: continue vigorous pulmonary hygiene, mobilize pt as much as possible. Regular diet, restart paxil, asa ? Consider switching to po pain medicine (??torodol).\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2176-06-23 00:00:00.000\",\n \"description\": \"L SHOULDER 1 VIEW LEFT\",\n \"row_id\": 1014891,\n \"text\": \" 4:10 AM\\n SHOULDER 1 VIEW LEFT; HUMERUS (AP & LAT) LEFT Clip # \\n HAND (AP, LAT & OBLIQUE) LEFT\\n Reason: evaluate for fx/dislocation\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 76 year old woman with left shoulder pain s/p fall\\n REASON FOR THIS EXAMINATION:\\n evaluate for fx/dislocation\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL HISTORY: 76-year-old female with left shoulder pain status post\\n fall. Evaluate for fracture, dislocation.\\n\\n Two views of the left shoulder demonstrate displaced fracture involving the\\n mid left clavicle. Extensive degenerative changes are seen involving the\\n glenohumeral joint. Multiple left-sided rib fractures are noted, better\\n assessed on concurrent chest CT.\\n\\n Three views of the left hand show degenerative changes involving the first CMC\\n and second MCP joints. There is exuberant mineralization of the TFC and about\\n the MCP joints, which is likely represents chondrocalcinosis. There is\\n cortical irregularity along the radial side of the distal radius, suspicious\\n for fracture. Dedicated wrist radiographs are recommended.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2176-06-23 00:00:00.000\",\n \"description\": \"PELVIS (AP ONLY)\",\n \"row_id\": 1014892,\n \"text\": \" 4:10 AM\\n PELVIS (AP ONLY); -76 BY SAME PHYSICIAN # \\n Reason: TO SEE END OF PROSTHES.\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 76 year old woman with b/l THR s/p fall\\n REASON FOR THIS EXAMINATION:\\n r/o fracture\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL HISTORY: 76-year-old female with bilateral total hip replacement.\\n\\n AP pelvis shows no fracture or dislocation. Patient is status post bilateral\\n hip arthroplasties with cemented femoral stem component. There is no evidence\\n of hardware- related complication. Contrast is noted within the bladder.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2176-06-23 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 1014887,\n \"text\": \" 3:47 AM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: r/o trauma\\n ______________________________________________________________________________\\n FINAL ADDENDUM\\n The foci in left frontal lobe could also be due to subarachnoid blood.\\n\\n\\n 3:47 AM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: r/o trauma\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 76 year old woman s/p fall\\n REASON FOR THIS EXAMINATION:\\n r/o trauma\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL HISTORY: 26-year-old female status post fall downstairs.\\n\\n COMPARISON: None\\n\\n NON-CONTRAST HEAD CT: Subdural hematomas are noted along bilateral cerebral\\n convexity (left greater than right) and adjacent to the falx. Small punctate\\n foci of hyperattenuation are seen scattered throughout the left cerebral\\n hemisphere consistent with hemorrhagic contusions. No shift of normally\\n midline structures. The - white matter differentiation is preserved. No\\n hydrocephalus or evidence of major vascular territorial infarct. A moderate-\\n sized left parietal scalp hematoma is present. No fracture is identified.\\n Small air-fluid level is seen within the left maxillary sinus. Remainder of\\n the visualized paranasal sinuses and mastoid air cells remain normally\\n aerated. Dense vascular calcifications are noted.\\n\\n IMPRESSION: Bilateral cerebral convexity (left greater than right) and\\n parasagittal subdural hematoma. Tiny foci of scattered hyperattenuation within\\n the left cerebral hemisphere are consistent with hemorrhagic contusion.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2176-06-23 00:00:00.000\",\n \"description\": \"CT C-SPINE W/O CONTRAST\",\n \"row_id\": 1014888,\n \"text\": \" 3:48 AM\\n CT C-SPINE W/O CONTRAST Clip # \\n Reason: r/o trauma\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 76 year old woman s/p fall\\n REASON FOR THIS EXAMINATION:\\n r/o trauma\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL HISTORY: 76 year old female status post fall down stairs.\\n\\n TECHNIQUE: Non-contrast MDCT-acquired axial images of the cervical spine from\\n the skull base to the level of T3. Multiplanar reformatted images were\\n obtained.\\n\\n FINDINGS: Cervical spine shows an exaggerated lordosis with multilevel\\n degenerative changes. No evidence of subluxation. Fractures are identified\\n involving the left T1 transverse process/superior articulating facet;\\n bilateral first ribs; left second and third ribs. In the left lung apex shows\\n pleural thickening/fluid. The prevertebral soft tissues are within normal\\n limits.\\n\\n IMPRESSION:\\n 1. Fractures involving the left T1 transverse process/superior articulating\\n surface as well as bilateral first ribs; left second and third ribs; and left\\n clavicle.\\n\\n 2. Multilevel degenerative changes involving the cervical spine.\\n\\n 3. Left apical pleural fluid/thickening.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2176-06-23 00:00:00.000\",\n \"description\": \"CT CHEST W/CONTRAST\",\n \"row_id\": 1014889,\n \"text\": \" 4:02 AM\\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \\n CT PELVIS W/CONTRAST\\n Reason: eval fractures\\n Field of view: 46\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 76 year old woman s/p fall with multiple rib fractures\\n REASON FOR THIS EXAMINATION:\\n eval fractures\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL HISTORY: Status post fall downstairs.\\n\\n TECHNIQUE: Contrast-enhanced MDCT acquired axial images of the chest, abdomen\\n and pelvis from the thoracic inlet to the pubic symphysis. Multiplanar\\n reformatted images were obtained.\\n\\n CT OF THE CHEST WITH INTRAVENOUS CONTRAST: The lungs demonstrate bilateral\\n dependent atelectasis. No consolidation, pneumothorax or worrisome pulmonary\\n nodule is identified. Left clavicle and multiple left-sided rib fractures are\\n identified with accompanying left apical capping/pleural fluid. Note is also\\n made of right first rib fracture (better seen on previous cervical spine CT).\\n\\n The heart and pericardium are within normal limits. The thoracic aorta is\\n normal in caliber without evidence of dissection. No mediastinal or axillary\\n lymphadenopathy is appreciated. The right lobe of the thyroid is not\\n visualized.\\n\\n CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: The liver shows no focal lesion.\\n The gallbladder, spleen, adrenal glands, and pancreas are within normal\\n limits. The kidneys enhance and excrete contrast symmetrically. A large cyst\\n is seen within the upper pole of the left kidney. The intra-abdominal loops of\\n large and small bowel maintain a normal caliber without evidence of\\n obstruction. No free air, free fluid or lymphadenopathy is appreciated. The\\n abdominal aorta shows diffuse calcification. Notes is made of focal ectasia of\\n the infrarenal aorta, proximal celiac and bilateral iliac arteries. The celiac\\n artery, SMA and are patent.\\n\\n CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The rectum, sigmoid colon, and\\n bladder are within normal limits. No free fluid or lymphadenopathy is\\n appreciated.\\n\\n BONE WINDOWS AND SOFT TISSUES: Fractures are identified involving multiple\\n left-sided ribs, right first rib, and left clavicle. Extensive degenerative\\n changes are seen involving the left glenohumeral joint. The patient is status\\n post bilateral hip arthroplasty. Multilevel degenerative changes are seen\\n involving the thoracolumbar spine. There is a left gluteal soft tissue\\n hematoma.\\n\\n IMPRESSION:\\n 1. Fractures involving multiple left-sided ribs, right first rib and and left\\n (Over)\\n\\n 4:02 AM\\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \\n CT PELVIS W/CONTRAST\\n Reason: eval fractures\\n Field of view: 46\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n clavicle. Left apical capping/pleural fluid.\\n\\n 2. Post-surgical changes related to bilateral hip arthroplasties. Extensive\\n degenerative changes are seen involving the left glenohumeral joint.\\n\\n 3. Multilevel degenerative changes are seen involving the thoracolumbar\\n spine.\\n\\n 4. Multiple hypodensities within bilateral kidneys, the largest of which\\n likely represents a cyst. The remainder are too small to characterize.\\n\\n 5. Left gluteal soft tissue hematoma.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2176-06-25 00:00:00.000\",\n \"description\": \"CT PELVIS W&W/O C\",\n \"row_id\": 1015154,\n \"text\": \" 11:47 AM\\n CT CHEST W&W/O C ; CT ABD W&W/O C Clip # \\n CT PELVIS W&W/O C\\n Reason: Please evaluate for source of bleeding.\\n Admitting Diagnosis: SUBDURAL HEMATOMA\\n Contrast: OPTIRAY Amt: 130\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 76 year old woman s/p multi injury trauma with falling hct. Patient has\\n significant ecchymosis over L shoulder. She is hemodynamically stable\\n REASON FOR THIS EXAMINATION:\\n Please evaluate for source of bleeding.\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n CT TORSO ON \\n\\n CLINICAL HISTORY: Recent trauma, now with decreased hematocrit, question\\n hemorrhage.\\n\\n TECHNIQUE: Helical acquisition of CT images performed from the thoracic inlet\\n through the ischial tuberosities following administration of 130 cc of\\n intravenous nonionic contrast. Comparison made to prior examination of two\\n days earlier.\\n\\n FINDINGS: There has been minimal interval change. The comminuted left\\n clavicle fracture and non-displaced left rib fractures are again noted. No\\n new fractures are seen. There is increased pleural fluid, low in density and\\n not likely hemothorax. There is associated atelectasis of the left lower\\n lobe. No pneumothorax or focal airspace disease. Degenerative changes of the\\n left glenohumeral joint are again noted with surrounding subcutaneous hematoma\\n laterally as well as along the periscapular region. No drainable hematoma or\\n collection.\\n\\n ABDOMEN:\\n Within the abdomen, the solid organs are intact. Large left renal cyst and\\n multiple smaller left renal hypodensities are unchanged. No vascular injury\\n is evident.\\n\\n PELVIS: Bowel loops are unremarkable and non-dilated. Atherosclerotic\\n calcifications and aortoiliac ectasia again noted. No free pelvic fluid. No\\n new bony injury. Bilateral hip prostheses. Subcutaneous edema and small left\\n gluteal hematoma. There is a focus of gas within the bladder, likely related\\n to recent instrumentation. No Foley catheter is present. Clinical\\n correlation is necessary.\\n\\n Marked degenerative changes of the thoracolumbar spine with stable, mild\\n superior endplate compression at the L1 level.\\n\\n IMPRESSION:\\n 1. Post-traumatic changes in the left hemithorax including stable rib and\\n clavicle fractures, slightly increased left pleural fluid, not compatible with\\n hemothorax, however, subcutaneous edema and hematomas without a focal\\n (Over)\\n\\n 11:47 AM\\n CT CHEST W&W/O C ; CT ABD W&W/O C Clip # \\n CT PELVIS W&W/O C\\n Reason: Please evaluate for source of bleeding.\\n Admitting Diagnosis: SUBDURAL HEMATOMA\\n Contrast: OPTIRAY Amt: 130\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n drainable collection.\\n 2. No solid organ injury or evident source of significant change in\\n hematocrit.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2176-06-23 00:00:00.000\",\n \"description\": \"TRAUMA #2 (AP CXR & PELVIS PORT)\",\n \"row_id\": 1014886,\n \"text\": \" 3:47 AM\\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \\n Reason: eval for fx\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 76 year old woman with 2 stairs\\n REASON FOR THIS EXAMINATION:\\n eval for fx\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 76-year-old female status post fall down 12 flights of stair.\\n Evaluate for fracture.\\n\\n AP CHEST: Trauma board obscures fine detail. The lung volumes are low. No\\n consolidation or pneumothorax is detected. The heart is moderately enlarged.\\n Interstial abnormality is likely related to edema. Note is made of left apical\\n capping, which is likely related to the multiple left- sided rib fractures.\\n The left clavicle is fractured in its mid portion.\\n\\n AP PELVIS: Trauma board obscures fine detail. No fracture or dislocation.\\n The patient is status post bilateral hip arthroplasty, incompletely assessed.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2176-06-24 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 1014990,\n \"text\": \" 3:14 AM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: evaluated for evolution of SDH. Please do at 4am\\n Admitting Diagnosis: SUBDURAL HEMATOMA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 76 year old woman with bilateral SDH and sm left frontal contusion.\\n REASON FOR THIS EXAMINATION:\\n evaluated for evolution of SDH. Please do at 4am\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL HISTORY: 76-year-old female with bilateral subdural hematoma and\\n small left frontal contusion. Evaluate for evolution of hematoma.\\n\\n COMPARISON: .\\n\\n NON-CONTRAST HEAD CT: Subdural hematomas along the bilateral cerebral\\n convexities (left greater than right) and adjacent to the falx are\\n redemonstrated. Compared to prior exam, there is no appreciable change. Small\\n scattered foci of hypoattenuation are again seen scattered throughout the left\\n cerebral hemisphere consistent with hemorrhagic contusions. No new focus of\\n hemorrhage is identified. There is no shift of normally midline structures.\\n The -white matter differentiation is preserved. No hydrocephalus or\\n evidence of major vascular territorial infarct. The previously described left\\n parietal scalp hematoma has improved. No fracture is identified. Mild\\n mucosal thickening is seen within the left maxillary sinus. The remainder of\\n the visualized paranasal sinuses and mastoid air cells remain normally\\n aerated.\\n\\n IMPRESSION: Stable appearance of bilateral cerebral convexity and\\n parasagittal subdural hematoma. Tiny foci scattered hypoattenuation within\\n the left cerebral hemisphere is consistent with hemorrhagic contusions,\\n unchanged. No new focus of hemorrhage is identified.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2176-06-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1634396,\n \"text\": \"T/SICU Brief Admission note\\nMrs. is a 76 year old woman admitted to T/SICU from the EW at 05:30 this morning. She was caring for her grandchilden in when she got up to go to the bathroom and fell down approximately 10 stairs. Her injuries include: several small subdural hematomas (one may be a week old from a prior fall), ??cervical fracture, L clavicular fracture, and 4 rib fractures, and a R thumb laceration (with possible tendon exposure).\\nPMH: arthritis (s/p bilateral hip replacements), hypertension, hyperlipidemia, hypothyroidism\\nMeds: simvatastatin, diovan, synthyroid, norvasc\\nReview of systems:\\nNeuro: awake, alert, orient, moves all extremities equally, perrla. c/o pain in L shoulder and back. PCA morphine instituted and pt with good understanding.\\nCVS: sinus rhythm, rate 80's, bp 120-140/60-70, peripheral pulses present, venodynes initiated\\nRESP: breath sounds diminished, on 2L np with sats 99-100%\\nRENAL: foley placed in EW, adequate light yellow urine, receiving fluids of ns @ 60/hr. K=3.5\\nGI: c/o nausea. Pepcid ordered, belly soft with bowel sounds present\\nHeme: INR 1.1 hct 37.9\\nendo: fs in er 184, pt takes synthroid at home\\nID: cold on arrival, temp 96.4, wbc 15.7, no antibiotics ordered\\nskin: Laceration noted on surface of her R thumb with ??tendon exposed. Irrigated by Dr and dressed with dsd. Plastics to evaluate. Deformity over L clavical and bruising over left upper arm present. Cervical collar in place.\\nLines: r antecubital iv in place\\nSocial: daughter arrived and updated with injuries by Dr. .\\nA: 76 year old s/p fall with multiple injuries, currently stable\\nP: neuro checks for sdh, ??follow up CT. Radiologist will evaluate possible neck fracture, Reassess movement restrictions. Attempt to achieve excellent pain control either with pca or ??epidural catheter for rib fx to prevent atelectasis. Support family with information as appropriate.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2176-06-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1634397,\n \"text\": \"Tsicu NPN\\nS: It only hurts a little Its a \\\"2\\\"\\nO: Initially hypertensive, BP down to 90/60 after PCA medication and norvasc which pt takes at home. Temp flat. Adm K+ 3.5, Rechecked this pm. Alert and oriented with no defecits throughout day. OOB to chair X2 H. IS q1-2 HR with volumes 1000-1500. Lungs clear with diminished bases. Tol reg diet, good fluid intake but poor appetite. No BM On colace. U/O adequate via foley\\nA: Stable s/p fall with Fx clavicale and ribs. Neck cleared by Dr this am, collar removed\\nP: OOB to chair TID, IS q1-2 Hr. Rigorous pulmonary assessment and rx as indicated\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2176-06-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1634398,\n \"text\": \"T/SICU Nursing Progress Note\\nS:\\\"I want to get better so I can go to my granddaughter's dance recital\\\"\\nO: Review of systems\\nneuro: awake, alert, oriented, motor intact. Repeat CT of head done. Using pca morphine (1.5mg q 6 min) for good pain control. Able to turn side to side with pain level stated as \\\"4\\\". Continues on po dilantin\\nCVS: stable heart rate and rhythm. Restarted on po antihypertensives.\\nPulses present. Venodynes in use.\\nRESP: sats excellent on 2L np. Uses IS up to 1200cc, breath sounds decreased in bases. non productive cough.\\nRENAL: D51/2ns @ 60/hr, urine output adequate. Lytes wnl except calcium elevated.\\nGI: tolerating liquids, no appetite for other food at present. On prevacid for prophylaxis. Also on colace.\\nHeme: hct stable, venodynes in use\\nID: t max 99.4, wbc flat, on no antibiotics.\\nLines: new 20 g angio placed L forearm, also has 16g angio L antecubital.\\nskin: bruising progressing on L shoulder and L hip. R thumb laceration with dsd in place. Also has significant bruising and swelling over L wrist\\nsocial: daughters all visited during the evening and were updated with plan and all questions answered.\\nA: 76 y/o woman s/p fall with fractured L clavicle, l sided ribs, sdh stable post fall\\nP: continue vigorous pulmonary hygiene, mobilize pt as much as possible. Regular diet, restart paxil, asa ? Consider switching to po pain medicine (??torodol).\\n\"\n }\n]"}}},{"rowIdx":371,"cells":{"subject_id":{"kind":"number","value":6917,"string":"6,917"},"hadm_id":{"kind":"number","value":133450,"string":"133,450"},"target_text":{"kind":"string","value":"The patient was admitted to the CVICU and was briefly on levophed and neo. She had benign abdominal studies and had a swallowing evaluation which she passed successfully. She was transferred to the floor on HD#1 and was aggressively diuresed. Her foley was discontinued and she had urinary retention and it was replaced. She grew yeast from her urine and was treated with vaginal miconazole cream. She was followed by physical therapy. Her son told us that she always complains of abdominal pain and it is related to when she has gas. She was started on simethicone PRN. Her hypotension recurred and her blood pressure in her right arm was much higher than her left arm. She was mentating well during what we thought we hypotensive episodes. She had a large left pleural effusion and interventional pulmonology placed a pigtail catheter and obtained 400 cc and it drained another liter of fluid overnight. She continued to improve and was discharged to House rehab on HD# 9 in stable condition."},"extractive_notes_summ":{"kind":"string","value":"There is mild pulmonary artery systolic hypertension.There is a trivial echodense pericardial effusion.IMPRESSION: No clinically-significant pericardial effusion seen.Normally-functioning composite aortic root/aortic valve prosthesis. There is a small reaccumulation of left pleural fluid, without definite pneumothorax. There is mild symmetric leftventricular hypertrophy. FINDINGS: Compared to the prior radiograph, the left pleural effusion has decreased, still with some associated atelectasis. Mild PAsystolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.PERICARDIUM: Trivial/physiologic pericardial effusion.Conclusions:The left atrium is moderately dilated. There is persistent retrocardiac opacity with a moderate-sized left pleural effusion. Diffuse calcification of the aorta is present which is also ectatic. Retrocardiac opacification is consistent with effusion and atelectasis, with a smaller effusion and compressive atelectasis on the right. Small andhypertrophied LV with normal biventricular systolic function.Compared with the prior study (images reviewed) of , the findingsare similar. Right internal jugular and transvenous right atrial and right ventricular pacer leads are unchanged in their respective positions. There is mild pulmonary edema, which is similar to the prior study. Mild tomoderate (+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Mild congestive heart failure persists. Unchanged right-sided central venous access line, unchanged left pectoral pacemaker. Heavy mitral annulus calcifications are unchanged. Right-sided central venous catheter has been removed. Vascular congestion and perhaps mild pulmonary edema are still present. The inferior sternal wires appear unremarkable, post-surgical change is noted adjacent to the sternum. Left-sided dual-chamber pacemaker with leads terminating in the right atrium and right ventricle are in unchanged positions. The heart remains moderately enlarged, but unchanged. IMPRESSION: No significant interval change in mild congestive heart failure, retrocardiac opacification which is likely atelectasis, and left pleural effusion. The left ventricular cavity is unusually small.Regional left ventricular wall motion is normal. PATIENT/TEST INFORMATION:Indication: Pericardial effusion.Height: (in) 62Weight (lb): 160BSA (m2): 1.74 m2BP (mm Hg): 109/50HR (bpm): 80Status: InpatientDate/Time: at 12:41Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Moderate LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. An area of apparent narrowing is noted in the sigmoid colon (series 2, image 46), no associated mucosal thickening is present and there is no proximal obstruction, this is likely related to peristalsis. PELVIS: Visualized loops of large and small bowel are normal. A right internal jugular line and pacemaker are in unchanged position. Moderate mitralannular calcification. IMPRESSION: Decreased left pleural effusion and associated atelectasis. Mild to moderate (+) mitralregurgitation is seen. Enlargement of the cardiac silhouette is stable. The effusion and atelectasis at the right base are less prominent. The cardiomediastinal silhouette and hilar contours are stable. Perihilar haze suggests coexisting mild pulmonary edema. UPRIGHT AP VIEW OF THE CHEST: The patient is status post median sternotomy and CABG. IMPRESSION: Right internal jugular central venous catheter tip terminates in the proximal right atrium. Right ventricular chamber size andfree wall motion are normal. A catheter or pacing wireis seen in the RA and extending into the RV.LEFT VENTRICLE: Mild symmetric LVH. etiology Admitting Diagnosis: HYPOTENSION;UTI FINAL REPORT (Cont) 2. Normal regional LVsystolic function. Diffuse pancreatic atrophy is present. IMPRESSION: AP and lateral chest compared to : Left pleural pigtail catheter has been removed. Moderate-to-severe cardiomegaly with substantial pleural effusions, left more than right. Prior median sternotomy. AVR well seated,normal leaflet/disc motion and transvalvular gradients.MITRAL VALVE: Moderately thickened mitral valve leaflets. UPRIGHT AP VIEW OF THE CHEST: Right internal jugular central venous catheter tip terminates in the proximal right atrium. The aortic valve prosthesis appears well seated,with normal leaflet motion and transvalvular gradients. There has been no reaccumulation of left pleural effusion or pneumothorax, but small-to-moderate right pleural effusion is larger and there is greater opacification at the base of the right lung probably atelectasis. The median sternotomy wires as are the pacing wires remain in unchanged positions. A small right pleural effusion and associated atelectasis are slightly improved or the patient is more upright. A layering small right pleural effusion is also evident. A left chest tube is in place. The degree of pulmonary vascular congestion has decreased. Overall normal LVEF (>55%).RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level. Calcified subcutaneous nodules are noted, likely related to previous injections. etiology CONTRAINDICATIONS for IV CONTRAST: creat PFI REPORT PFI: There is no evidence of bowel obstruction. FINDINGS: As compared to the previous radiograph, there is no relevant change. The spleen, adrenal glands, and kidneys are normal on this non contrast examination. Moderate cardiomegaly is longstanding and the extensive heavy mitral annulus calcification is again seen. Compared to tracing #1 there is no significantdiagnostic change.TRACING #2 This is incompletely imaged without contrast, however, is unchanged since the imaging from . The tip of the right jugular catheter is at the mid portion of the SVC. Overall left ventricularsystolic function is normal (LVEF>55%). Moderate cardiomegaly is longstanding. TECHNIQUE: MDCT images were acquired from the lung bases to pubic symphysis without IV contrast. CT ABDOMEN: An 11-mm low density nodule is noted peripherally within segment VI of the liver. FINDINGS: In comparison with the study of , there is little overall change. Again there is enlargement of the cardiac silhouette in a patient with intact midline sternal wires and dual-channel pacemaker device in place. IMPRESSION: Little overall change. Normal ascending aortadiameter.AORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR). A left pleural effusion is also similar. Large bilateral pleural effusions with associated atelectasis are noted."},"n_notes":{"kind":"number","value":13,"string":"13"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2125-11-18 00:00:00.000","description":"CT ABDOMEN W/O CONTRAST","row_id":1166427,"text":" 2:14 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: recurrent nausea/vomiting- ? etiology\n Admitting Diagnosis: HYPOTENSION;UTI\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman Bentall/CABG\n REASON FOR THIS EXAMINATION:\n recurrent nausea/vomiting- ? etiology\n CONTRAINDICATIONS for IV CONTRAST:\n creat\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): PJBj SUN 6:56 PM\n PFI: There is no evidence of bowel obstruction. Large bilateral pleural\n effusions with associated atelectasis are noted.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 79-year-old woman with previous CABG. Recurrent nausea and\n vomiting. Query etiology.\n\n Comparison is made to previous imaging from .\n\n TECHNIQUE: MDCT images were acquired from the lung bases to pubic symphysis\n without IV contrast. Multiplanar reformatted images were obtained for\n evaluation.\n\n CT ABDOMEN: An 11-mm low density nodule is noted peripherally within segment\n VI of the liver. This is incompletely imaged without contrast, however, is\n unchanged since the imaging from . Mild fatty infiltration is present\n within the liver. Diffuse pancreatic atrophy is present. The spleen, adrenal\n glands, and kidneys are normal on this non contrast examination. Extensive\n aortic atheroma is present and calcified atheroma is noted within the celiac,\n SMA and renal arteries.\n\n PELVIS: Visualized loops of large and small bowel are normal. An area of\n apparent narrowing is noted in the sigmoid colon (series 2, image 46), no\n associated mucosal thickening is present and there is no proximal obstruction,\n this is likely related to peristalsis. There is air within the bladder and no\n catheter is noted, has the patient had a recent catheterization or bladder\n instrumentation? If not, this finding should be further evaluated. No\n enlarged pelvic lymph nodes. Calcified subcutaneous nodules are noted, likely\n related to previous injections.\n\n LUNG BASES: There are large bilateral pleural effusions with associated\n atelectasis, particularly in the left lung base. Extensive mitral valve and\n coronary artery calcification is noted as well as a pacemaker wire. The\n inferior sternal wires appear unremarkable, post-surgical change is noted\n adjacent to the sternum.\n\n Bone review is unremarkable. Prior median sternotomy.\n\n IMPRESSION:\n 1. There is no evidence of bowel obstruction.\n (Over)\n\n 2:14 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: recurrent nausea/vomiting- ? etiology\n Admitting Diagnosis: HYPOTENSION;UTI\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 2. Large bilateral pleural effusions with associated atelectasis.\n\n"},{"category":"Radiology","chartdate":"2125-11-18 00:00:00.000","description":"CT ABDOMEN W/O CONTRAST","row_id":1166428,"text":", C. CSURG FA6A 2:14 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: recurrent nausea/vomiting- ? etiology\n Admitting Diagnosis: HYPOTENSION;UTI\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman Bentall/CABG\n REASON FOR THIS EXAMINATION:\n recurrent nausea/vomiting- ? etiology\n CONTRAINDICATIONS for IV CONTRAST:\n creat\n ______________________________________________________________________________\n PFI REPORT\n PFI: There is no evidence of bowel obstruction. Large bilateral pleural\n effusions with associated atelectasis are noted.\n\n"},{"category":"Radiology","chartdate":"2125-11-15 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1165904,"text":" 11:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval chf or pna\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with respiratory distress\n REASON FOR THIS EXAMINATION:\n eval chf or pna\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Respiratory distress.\n\n COMPARISON: .\n\n UPRIGHT AP VIEW OF THE CHEST: The patient is status post median sternotomy\n and CABG. Left-sided dual-chamber pacemaker with leads terminating in the\n right atrium and right ventricle are in unchanged positions. There are\n extensive mitral annular calcifications. The heart remains moderately\n enlarged, but unchanged. Diffuse calcification of the aorta is present which\n is also ectatic. There is mild pulmonary edema, which is similar to the prior\n study. Retrocardiac opacification may reflect atelectasis. A left pleural\n effusion is also similar. No pneumothorax is identified. No acute osseous\n findings are seen. Right-sided central venous catheter has been removed.\n\n IMPRESSION: No significant interval change in mild congestive heart failure,\n retrocardiac opacification which is likely atelectasis, and left pleural\n effusion.\n DFDdp\n\n"},{"category":"Radiology","chartdate":"2125-11-15 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":1165935,"text":" 1:25 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: new RT IJ line placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with SOB, recent cardiac surgery\n REASON FOR THIS EXAMINATION:\n new RT IJ line placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Shortness of breath and recent cardiac surgery with new right\n internal jugular central line placement.\n\n COMPARISON: at 11:17.\n\n UPRIGHT AP VIEW OF THE CHEST: Right internal jugular central venous catheter\n tip terminates in the proximal right atrium. No pneumothorax is identified.\n Mild congestive heart failure persists. There is persistent retrocardiac\n opacity with a moderate-sized left pleural effusion. A layering small right\n pleural effusion is also evident. The median sternotomy wires as are the\n pacing wires remain in unchanged positions.\n\n IMPRESSION: Right internal jugular central venous catheter tip terminates in\n the proximal right atrium. No pneumothorax. Findings discussed with Dr.\n at 2 p.m., .\n\n\n"},{"category":"Radiology","chartdate":"2125-11-19 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1166648,"text":" 8:05 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: s/p AVR w/worsening respiratory status r/o effusions\n Admitting Diagnosis: HYPOTENSION;UTI\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with as above\n REASON FOR THIS EXAMINATION:\n s/p AVR w/worsening respiratory status r/o effusions\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Worsening respiratory status, rule out pleural effusions.\n\n COMPARISON: , 8 a.m.\n\n FINDINGS: As compared to the previous radiograph, there is no relevant\n change. Moderate-to-severe cardiomegaly with substantial pleural effusions,\n left more than right. The effusions cause relatively extensive basal areas of\n atelectasis. Perihilar haze suggests coexisting mild pulmonary edema. No\n newly appeared focal parenchymal opacities. Unchanged right-sided central\n venous access line, unchanged left pectoral pacemaker.\n\n\n"},{"category":"Radiology","chartdate":"2125-11-22 00:00:00.000","description":"CHEST (PA & LAT)","row_id":1167186,"text":" 3:55 PM\n CHEST (PA & LAT) Clip # \n Reason: eval for effusion\n Admitting Diagnosis: HYPOTENSION;UTI\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman s/p bentall\n REASON FOR THIS EXAMINATION:\n eval for effusion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post cardiac surgery, to assess for change.\n\n FINDINGS:\n\n In comparison with the study of , the monitoring and support devices\n remain in place. There is a small reaccumulation of left pleural fluid,\n without definite pneumothorax. The effusion and atelectasis at the right base\n are less prominent. The degree of pulmonary vascular congestion has\n decreased. Moderate cardiomegaly is longstanding and the extensive heavy\n mitral annulus calcification is again seen.\n\n\n"},{"category":"Radiology","chartdate":"2125-11-23 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1167274,"text":" 8:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for effusion\n Admitting Diagnosis: HYPOTENSION;UTI\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman s/p bentall\n REASON FOR THIS EXAMINATION:\n eval for effusion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Cardiac surgery.\n\n FINDINGS: In comparison with the study of , there appears to be slight\n increase in indistinctness of the pulmonary vessels, suggesting some elevation\n of pulmonary venous pressure. Monitoring and support devices remain in place.\n Enlargement of the cardiac silhouette is stable.\n\n\n"},{"category":"Radiology","chartdate":"2125-11-19 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1166502,"text":" 7:18 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for effusions\n Admitting Diagnosis: HYPOTENSION;UTI\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman s/p avr/cabg\n REASON FOR THIS EXAMINATION:\n assess for effusions\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Cardiac surgery, post-operative.\n\n FINDINGS: In comparison with the study of , there is little overall\n change. Again there is enlargement of the cardiac silhouette in a patient\n with intact midline sternal wires and dual-channel pacemaker device in place.\n Retrocardiac opacification is consistent with effusion and atelectasis, with a\n smaller effusion and compressive atelectasis on the right. The tip of the\n right jugular catheter is at the mid portion of the SVC.\n\n IMPRESSION: Little overall change.\n\n\n"},{"category":"Radiology","chartdate":"2125-11-21 00:00:00.000","description":"CHEST (PA & LAT)","row_id":1166924,"text":" 10:41 AM\n CHEST (PA & LAT) Clip # \n Reason: eval for effusion\n Admitting Diagnosis: HYPOTENSION;UTI\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman s/p pigtail\n REASON FOR THIS EXAMINATION:\n eval for effusion\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST, \n\n HISTORY: Pigtail catheter, evaluate effusion.\n\n IMPRESSION: AP and lateral chest compared to :\n\n Left pleural pigtail catheter has been removed. There has been no\n reaccumulation of left pleural effusion or pneumothorax, but small-to-moderate\n right pleural effusion is larger and there is greater opacification at the\n base of the right lung probably atelectasis. Vascular congestion and perhaps\n mild pulmonary edema are still present. Moderate cardiomegaly is\n longstanding. Right internal jugular and transvenous right atrial and right\n ventricular pacer leads are unchanged in their respective positions.\n Extremely heavy mitral annulus calcification is longstanding finding.\n\n\n"},{"category":"Radiology","chartdate":"2125-11-20 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1166817,"text":" 2:58 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for pneumothorax\n Admitting Diagnosis: HYPOTENSION;UTI\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with bilateral pleural effusions, s/p drainage of left with\n chest tube.\n REASON FOR THIS EXAMINATION:\n please eval for pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Bilateral pleural effusion status post drainage of the\n left.\n\n COMPARISON: CXR .\n\n FINDINGS: Compared to the prior radiograph, the left pleural effusion has\n decreased, still with some associated atelectasis. There is no pneumothorax.\n A small right pleural effusion and associated atelectasis are slightly\n improved or the patient is more upright. The cardiomediastinal silhouette and\n hilar contours are stable. A right internal jugular line and pacemaker are in\n unchanged position. A left chest tube is in place. A tracheal stent extends\n to the left bronchus. Heavy mitral annulus calcifications are unchanged.\n\n IMPRESSION: Decreased left pleural effusion and associated atelectasis. No\n pneumothorax.\n\n"},{"category":"Echo","chartdate":"2125-11-16 00:00:00.000","description":"Report","row_id":62262,"text":"PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion.\nHeight: (in) 62\nWeight (lb): 160\nBSA (m2): 1.74 m2\nBP (mm Hg): 109/50\nHR (bpm): 80\nStatus: Inpatient\nDate/Time: at 12:41\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. A catheter or pacing wire\nis seen in the RA and extending into the RV.\n\nLEFT VENTRICLE: Mild symmetric LVH. Small LV cavity. Normal regional LV\nsystolic function. Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR). AVR well seated,\nnormal leaflet/disc motion and transvalvular gradients.\n\nMITRAL VALVE: Moderately thickened mitral valve leaflets. Moderate mitral\nannular calcification. Calcified tips of papillary muscles. No MS. Mild to\nmoderate (+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Mild PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nConclusions:\nThe left atrium is moderately dilated. There is mild symmetric left\nventricular hypertrophy. The left ventricular cavity is unusually small.\nRegional left ventricular wall motion is normal. Overall left ventricular\nsystolic function is normal (LVEF>55%). Right ventricular chamber size and\nfree wall motion are normal. A composite bioprosthetic aortic valve /aortic\nroot prosthesis is present. The aortic valve prosthesis appears well seated,\nwith normal leaflet motion and transvalvular gradients. The mitral valve\nleaflets are moderately thickened. Mild to moderate (+) mitral\nregurgitation is seen. There is mild pulmonary artery systolic hypertension.\nThere is a trivial echodense pericardial effusion.\n\nIMPRESSION: No clinically-significant pericardial effusion seen.\nNormally-functioning composite aortic root/aortic valve prosthesis. Small and\nhypertrophied LV with normal biventricular systolic function.\n\nCompared with the prior study (images reviewed) of , the findings\nare similar.\n\n\n"},{"category":"ECG","chartdate":"2125-11-15 00:00:00.000","description":"Report","row_id":121940,"text":"Ventricularly paced rhythm. Compared to tracing #1 there is no significant\ndiagnostic change.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2125-11-15 00:00:00.000","description":"Report","row_id":121941,"text":"Baseline artifact. Ventricularly paced rhythm. Underlying rhythm is difficult\nto discern but may be sinus rhythm. Compared to the previous tracing\nof ventricularly paced rhythm is new.\nTRACING #1\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2125-11-18 00:00:00.000\",\n \"description\": \"CT ABDOMEN W/O CONTRAST\",\n \"row_id\": 1166427,\n \"text\": \" 2:14 PM\\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \\n Reason: recurrent nausea/vomiting- ? etiology\\n Admitting Diagnosis: HYPOTENSION;UTI\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old woman Bentall/CABG\\n REASON FOR THIS EXAMINATION:\\n recurrent nausea/vomiting- ? etiology\\n CONTRAINDICATIONS for IV CONTRAST:\\n creat\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): PJBj SUN 6:56 PM\\n PFI: There is no evidence of bowel obstruction. Large bilateral pleural\\n effusions with associated atelectasis are noted.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 79-year-old woman with previous CABG. Recurrent nausea and\\n vomiting. Query etiology.\\n\\n Comparison is made to previous imaging from .\\n\\n TECHNIQUE: MDCT images were acquired from the lung bases to pubic symphysis\\n without IV contrast. Multiplanar reformatted images were obtained for\\n evaluation.\\n\\n CT ABDOMEN: An 11-mm low density nodule is noted peripherally within segment\\n VI of the liver. This is incompletely imaged without contrast, however, is\\n unchanged since the imaging from . Mild fatty infiltration is present\\n within the liver. Diffuse pancreatic atrophy is present. The spleen, adrenal\\n glands, and kidneys are normal on this non contrast examination. Extensive\\n aortic atheroma is present and calcified atheroma is noted within the celiac,\\n SMA and renal arteries.\\n\\n PELVIS: Visualized loops of large and small bowel are normal. An area of\\n apparent narrowing is noted in the sigmoid colon (series 2, image 46), no\\n associated mucosal thickening is present and there is no proximal obstruction,\\n this is likely related to peristalsis. There is air within the bladder and no\\n catheter is noted, has the patient had a recent catheterization or bladder\\n instrumentation? If not, this finding should be further evaluated. No\\n enlarged pelvic lymph nodes. Calcified subcutaneous nodules are noted, likely\\n related to previous injections.\\n\\n LUNG BASES: There are large bilateral pleural effusions with associated\\n atelectasis, particularly in the left lung base. Extensive mitral valve and\\n coronary artery calcification is noted as well as a pacemaker wire. The\\n inferior sternal wires appear unremarkable, post-surgical change is noted\\n adjacent to the sternum.\\n\\n Bone review is unremarkable. Prior median sternotomy.\\n\\n IMPRESSION:\\n 1. There is no evidence of bowel obstruction.\\n (Over)\\n\\n 2:14 PM\\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \\n Reason: recurrent nausea/vomiting- ? etiology\\n Admitting Diagnosis: HYPOTENSION;UTI\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n 2. Large bilateral pleural effusions with associated atelectasis.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2125-11-18 00:00:00.000\",\n \"description\": \"CT ABDOMEN W/O CONTRAST\",\n \"row_id\": 1166428,\n \"text\": \", C. CSURG FA6A 2:14 PM\\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \\n Reason: recurrent nausea/vomiting- ? etiology\\n Admitting Diagnosis: HYPOTENSION;UTI\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old woman Bentall/CABG\\n REASON FOR THIS EXAMINATION:\\n recurrent nausea/vomiting- ? etiology\\n CONTRAINDICATIONS for IV CONTRAST:\\n creat\\n ______________________________________________________________________________\\n PFI REPORT\\n PFI: There is no evidence of bowel obstruction. Large bilateral pleural\\n effusions with associated atelectasis are noted.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2125-11-15 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1165904,\n \"text\": \" 11:10 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval chf or pna\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old woman with respiratory distress\\n REASON FOR THIS EXAMINATION:\\n eval chf or pna\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Respiratory distress.\\n\\n COMPARISON: .\\n\\n UPRIGHT AP VIEW OF THE CHEST: The patient is status post median sternotomy\\n and CABG. Left-sided dual-chamber pacemaker with leads terminating in the\\n right atrium and right ventricle are in unchanged positions. There are\\n extensive mitral annular calcifications. The heart remains moderately\\n enlarged, but unchanged. Diffuse calcification of the aorta is present which\\n is also ectatic. There is mild pulmonary edema, which is similar to the prior\\n study. Retrocardiac opacification may reflect atelectasis. A left pleural\\n effusion is also similar. No pneumothorax is identified. No acute osseous\\n findings are seen. Right-sided central venous catheter has been removed.\\n\\n IMPRESSION: No significant interval change in mild congestive heart failure,\\n retrocardiac opacification which is likely atelectasis, and left pleural\\n effusion.\\n DFDdp\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2125-11-15 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 1165935,\n \"text\": \" 1:25 PM\\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \\n Reason: new RT IJ line placement\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old woman with SOB, recent cardiac surgery\\n REASON FOR THIS EXAMINATION:\\n new RT IJ line placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Shortness of breath and recent cardiac surgery with new right\\n internal jugular central line placement.\\n\\n COMPARISON: at 11:17.\\n\\n UPRIGHT AP VIEW OF THE CHEST: Right internal jugular central venous catheter\\n tip terminates in the proximal right atrium. No pneumothorax is identified.\\n Mild congestive heart failure persists. There is persistent retrocardiac\\n opacity with a moderate-sized left pleural effusion. A layering small right\\n pleural effusion is also evident. The median sternotomy wires as are the\\n pacing wires remain in unchanged positions.\\n\\n IMPRESSION: Right internal jugular central venous catheter tip terminates in\\n the proximal right atrium. No pneumothorax. Findings discussed with Dr.\\n at 2 p.m., .\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2125-11-19 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1166648,\n \"text\": \" 8:05 PM\\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \\n Reason: s/p AVR w/worsening respiratory status r/o effusions\\n Admitting Diagnosis: HYPOTENSION;UTI\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old woman with as above\\n REASON FOR THIS EXAMINATION:\\n s/p AVR w/worsening respiratory status r/o effusions\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST RADIOGRAPH\\n\\n INDICATION: Worsening respiratory status, rule out pleural effusions.\\n\\n COMPARISON: , 8 a.m.\\n\\n FINDINGS: As compared to the previous radiograph, there is no relevant\\n change. Moderate-to-severe cardiomegaly with substantial pleural effusions,\\n left more than right. The effusions cause relatively extensive basal areas of\\n atelectasis. Perihilar haze suggests coexisting mild pulmonary edema. No\\n newly appeared focal parenchymal opacities. Unchanged right-sided central\\n venous access line, unchanged left pectoral pacemaker.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2125-11-22 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 1167186,\n \"text\": \" 3:55 PM\\n CHEST (PA & LAT) Clip # \\n Reason: eval for effusion\\n Admitting Diagnosis: HYPOTENSION;UTI\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old woman s/p bentall\\n REASON FOR THIS EXAMINATION:\\n eval for effusion\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Status post cardiac surgery, to assess for change.\\n\\n FINDINGS:\\n\\n In comparison with the study of , the monitoring and support devices\\n remain in place. There is a small reaccumulation of left pleural fluid,\\n without definite pneumothorax. The effusion and atelectasis at the right base\\n are less prominent. The degree of pulmonary vascular congestion has\\n decreased. Moderate cardiomegaly is longstanding and the extensive heavy\\n mitral annulus calcification is again seen.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2125-11-23 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1167274,\n \"text\": \" 8:06 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for effusion\\n Admitting Diagnosis: HYPOTENSION;UTI\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old woman s/p bentall\\n REASON FOR THIS EXAMINATION:\\n eval for effusion\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Cardiac surgery.\\n\\n FINDINGS: In comparison with the study of , there appears to be slight\\n increase in indistinctness of the pulmonary vessels, suggesting some elevation\\n of pulmonary venous pressure. Monitoring and support devices remain in place.\\n Enlargement of the cardiac silhouette is stable.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2125-11-19 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1166502,\n \"text\": \" 7:18 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: assess for effusions\\n Admitting Diagnosis: HYPOTENSION;UTI\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old woman s/p avr/cabg\\n REASON FOR THIS EXAMINATION:\\n assess for effusions\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Cardiac surgery, post-operative.\\n\\n FINDINGS: In comparison with the study of , there is little overall\\n change. Again there is enlargement of the cardiac silhouette in a patient\\n with intact midline sternal wires and dual-channel pacemaker device in place.\\n Retrocardiac opacification is consistent with effusion and atelectasis, with a\\n smaller effusion and compressive atelectasis on the right. The tip of the\\n right jugular catheter is at the mid portion of the SVC.\\n\\n IMPRESSION: Little overall change.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2125-11-21 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 1166924,\n \"text\": \" 10:41 AM\\n CHEST (PA & LAT) Clip # \\n Reason: eval for effusion\\n Admitting Diagnosis: HYPOTENSION;UTI\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old woman s/p pigtail\\n REASON FOR THIS EXAMINATION:\\n eval for effusion\\n ______________________________________________________________________________\\n FINAL REPORT\\n PA AND LATERAL CHEST, \\n\\n HISTORY: Pigtail catheter, evaluate effusion.\\n\\n IMPRESSION: AP and lateral chest compared to :\\n\\n Left pleural pigtail catheter has been removed. There has been no\\n reaccumulation of left pleural effusion or pneumothorax, but small-to-moderate\\n right pleural effusion is larger and there is greater opacification at the\\n base of the right lung probably atelectasis. Vascular congestion and perhaps\\n mild pulmonary edema are still present. Moderate cardiomegaly is\\n longstanding. Right internal jugular and transvenous right atrial and right\\n ventricular pacer leads are unchanged in their respective positions.\\n Extremely heavy mitral annulus calcification is longstanding finding.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2125-11-20 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1166817,\n \"text\": \" 2:58 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: please eval for pneumothorax\\n Admitting Diagnosis: HYPOTENSION;UTI\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old woman with bilateral pleural effusions, s/p drainage of left with\\n chest tube.\\n REASON FOR THIS EXAMINATION:\\n please eval for pneumothorax\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL HISTORY: Bilateral pleural effusion status post drainage of the\\n left.\\n\\n COMPARISON: CXR .\\n\\n FINDINGS: Compared to the prior radiograph, the left pleural effusion has\\n decreased, still with some associated atelectasis. There is no pneumothorax.\\n A small right pleural effusion and associated atelectasis are slightly\\n improved or the patient is more upright. The cardiomediastinal silhouette and\\n hilar contours are stable. A right internal jugular line and pacemaker are in\\n unchanged position. A left chest tube is in place. A tracheal stent extends\\n to the left bronchus. Heavy mitral annulus calcifications are unchanged.\\n\\n IMPRESSION: Decreased left pleural effusion and associated atelectasis. No\\n pneumothorax.\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2125-11-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 62262,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Pericardial effusion.\\nHeight: (in) 62\\nWeight (lb): 160\\nBSA (m2): 1.74 m2\\nBP (mm Hg): 109/50\\nHR (bpm): 80\\nStatus: Inpatient\\nDate/Time: at 12:41\\nTest: Portable TTE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nThis study was compared to the prior study of .\\n\\n\\nLEFT ATRIUM: Moderate LA enlargement.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. A catheter or pacing wire\\nis seen in the RA and extending into the RV.\\n\\nLEFT VENTRICLE: Mild symmetric LVH. Small LV cavity. Normal regional LV\\nsystolic function. Overall normal LVEF (>55%).\\n\\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\\n\\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\\ndiameter.\\n\\nAORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR). AVR well seated,\\nnormal leaflet/disc motion and transvalvular gradients.\\n\\nMITRAL VALVE: Moderately thickened mitral valve leaflets. Moderate mitral\\nannular calcification. Calcified tips of papillary muscles. No MS. Mild to\\nmoderate (+) MR.\\n\\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Mild PA\\nsystolic hypertension.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\\n\\nPERICARDIUM: Trivial/physiologic pericardial effusion.\\n\\nConclusions:\\nThe left atrium is moderately dilated. There is mild symmetric left\\nventricular hypertrophy. The left ventricular cavity is unusually small.\\nRegional left ventricular wall motion is normal. Overall left ventricular\\nsystolic function is normal (LVEF>55%). Right ventricular chamber size and\\nfree wall motion are normal. A composite bioprosthetic aortic valve /aortic\\nroot prosthesis is present. The aortic valve prosthesis appears well seated,\\nwith normal leaflet motion and transvalvular gradients. The mitral valve\\nleaflets are moderately thickened. Mild to moderate (+) mitral\\nregurgitation is seen. There is mild pulmonary artery systolic hypertension.\\nThere is a trivial echodense pericardial effusion.\\n\\nIMPRESSION: No clinically-significant pericardial effusion seen.\\nNormally-functioning composite aortic root/aortic valve prosthesis. Small and\\nhypertrophied LV with normal biventricular systolic function.\\n\\nCompared with the prior study (images reviewed) of , the findings\\nare similar.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2125-11-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 121940,\n \"text\": \"Ventricularly paced rhythm. Compared to tracing #1 there is no significant\\ndiagnostic change.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2125-11-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 121941,\n \"text\": \"Baseline artifact. Ventricularly paced rhythm. Underlying rhythm is difficult\\nto discern but may be sinus rhythm. Compared to the previous tracing\\nof ventricularly paced rhythm is new.\\nTRACING #1\\n\\n\"\n }\n]"}}},{"rowIdx":372,"cells":{"subject_id":{"kind":"number","value":1154,"string":"1,154"},"hadm_id":{"kind":"number","value":199657,"string":"199,657"},"target_text":{"kind":"string","value":"(By systems including pertinent laboratory data. 1. Respiratory - Initially was placed on continuous positive airway pressure for her respiratory distress. She developed increased work of breathing. She was intubated and received two doses of Survanta. She was extubated to continuous positive airway pressure on day of life #1. She weaned to room nasal cannula oxygen by day of life #2 and was in room air by day of life #4. She remained in room air for the rest of her Neonatal Intensive Care Unit admission. she had many episodes of apnea and bradycardia. She was treated with caffeine citrate. The caffeine was discontinued on . She continued to have intermittent episodes of apnea, her last occurred on . At the time of discharge, she was breathing comfortably in room air with a respiratory rate in the 30s to 50s. 2. Cardiovascular - required a normal saline bolus for a low blood pressure shortly after addition to the Neonatal Intensive Care Unit. She maintained normal heart rates and blood pressures from that time. No murmurs have been noted during admission. 3. Fluids, electrolytes and nutrition - was initially NPO on intravenous fluids. She started on parenteral nutrition on day of life #1. Enteral feeds were started on day of life #2 and gradually advanced to full volume. She received calorie supplementation, to a maximum of 26 cal/oz with added ProMod. She has been on p.o. feeds since . At the time of discharge she is taking breast milk or Enfamil 20, 24 cal/oz breast milk with 4 cal by Enfamil powder. Serum electrolytes were within normal limits during admission. Discharge weight is 2.610 kg with a length of 47 cm and a head circumference of 34 cm. 4. Infectious disease - Due to her respiratory distress and prematurity, was evaluated for sepsis shortly after admission to the Neonatal Intensive Care Unit. A blood culture was obtained prior to starting intravenous ampicillin and gentamicin. The blood culture was no growth at 48 hours and the antibiotics were discontinued. 5. Gastrointestinal - Peak serum bilirubin was 8.0 total/0.3 mg/dl direct, with an indirect of 7.7. On day of life #2, phototherapy was started and continued for six days. Rebound bilirubin was 5.3/0.2 with an indirect of 5.1. 6. Hematology - Hematocrit at birth was 53.2%. did not receive any transfusions of blood products. Most recent hematocrit was on at 31.5%. 7. Neurology - Head ultrasounds were performed on day of life #7 and at one month of age and both were within normal limits. 8. Sensory - Hearing, screening was performed with automated auditory brain stem responses, passed in both ears. Ophthalmology, retinas were most recently examined on and were found to be immature, Zone 3 with a recommended follow up the week of . 9. Social - Parents have been involved and visited regularly. The other triplet siblings have been discharged home."},"extractive_notes_summ":{"kind":"string","value":"BSCEbilat. PO/PG feeds as tolerated,gavaged over 1hr. noincreased wob noted. Min asp. LS CLEAR ANFD EQUAL. A/G stable. Tolfeeds well. COLOR JAUDICE/ AND WELL PERFUSED. Mildretractions noted. Respiratory O: Pt. Current feeds + supps meeting weaned recs for kcals/pro/vits and mins. mild subcostal retractions. Mild subcostal retractions. is stable in RA. ABD SOFT, WITH STABLE GIRTH AND +BS. ABD SOFT, WITH STABLE GIRTH AND +BS. P: cont tofollow.Adv feeds as tolerated.GDO: Temp stable in air isolette, swaddled with hat, tshirtand blanket. Tolerating PN with good BS control. Tol proceduresfairly well.7. A: stable. Calms with containmentand pacifier. Nospits and minimal aspirates noted. aBdoinal exam benign. : No contact thus far this shift.G/D: O/A-Temp stable in . Burped well. : No contact with so far this shift.DEV: Temps stable, swaddled in . Mild S/Cretractions. Abd benign. P-Continue with current regimen. Fontssoft/flat. RR stable. A/G stable. Infant remains on adlibdemand schedule with BM24. AFOF.Lungs CTA, heart rrr s m, abd soft, extr well perfused. Abdomen , soft, round,+BS, no loops. Ag stable. Nospells or desats noted. Abdsoft, +, no loops. Hem neg. F&N: TF remain at 150cc/k/d of PE26. A: Well appereance. Update given. ABD SOFT, WITH STABLE GIRTH AND +BS. A: stable in RA, ?reflux. Elec to be checked .BILI: Single Phx. Abd soft, ND, + BS. A: Stable.P: cont to follow.fENO: TF of 140cc/k/d, ivf PN D10 w/ IL at 70cc/k/d and enteralfeeds at 70cc/k/d. RR40-70s, LS clear/=, mild intercostal rtxns. Abd benign, noloops, active bs. min asp. MIn asp. Min asp. Neonatology AttendingAddendum: PESleeping quietly s/p feed; appropriate tone; . Minimal aspirates, small spitx1so far this shift. given asordered. : No contact with so far this shift.G+D: Temps stable, swaddled in . O: Ls clear. P: cont tofollow.GDO: Temp stable swaddled in an air isolette, active and with cares. Ext and well perfused. Respstatus stable. P-Continue with current regimen asordered. Abdomen benign,bowel sounds active. Respiratory O: Pt. Abdomen benign, active BS, girthstable. noincreased wob noted. is stable in RA. LSclear/=. A: Pt. A: Pt. RR 30-60s, LS clear/=, mild ic rtxns. BS cl and =. Continues onIron. Abd soft, +BS. A: AGA. P: Continue tomonitor respiratory status. Tol well. Nospells or desats noted. mild subcostal retractions. 2 Resp. aga. AGA. Cobedding withsiblings. are activeand independent in cares. Lungs CTA, =. Asking appropriatequestions. : No contact thus far this shift.G/D: O/A-Temp stable in . Min asp. MildSC retractions. Grwoth/Development O: Pt. Stable temp cobedding with sibs. Resp. is stable inRA. Respiratory O: Pt. Respiratory O: Pt. Transitioned to open cribwith stable temps. A/ Stable. Continue tomonitor FEN status. A: Pt. A: Pt. A: Pt. A: Pt. Gaining wt. is stable in RA. BSCE bilat. Abd soft, ND, +BS. , well perfused. G&D. Extrem WWP. P:cont. P:cont. P:cont. Min. Pt. to supportnutritional needs.4no known contact thus far.5infant remains swaddled in OAC, temp. neg. Cl and = BS. Continue to support/educatefamily.G+D: Temps stable, swaddled in . P: Cont to assess.#8 O: Temp stable. Updated at the bedside.Independent with cares. 2. remains in RA, RR30-60, mild sc retractions, sats90-99, BBSclear, equal, one brief self-resolving brady P:continue to monitor.3. Abdomin softand round. tosupport nutritional needs.4no known contact thus far.5infant remains swaddled in air isolette, temp. Respiratory O: Pt. Respiratory O: Pt. A; AGA P; cont devsupport. is stable in RA. is stable in RA. +b.s. LSclear/=. A: Pt. A: Pt. A: Pt. Will continue to monitor.FEN: Abd benign, NTND, no HSM. stable, a/awith cares, settles well in between, fonts soft/flat, bringshands to mouth. BSCEbilat. DEV O/A is in an off isolette with stable temp.A/A w/cares. Mildsc ret. Min asp. BBS cl and equal. Temp stable. Abdomen , soft, round, +BS, noloops. Cont to supportfamily.G+D: Temps 97.8-98.0. Girthstable. ABd benign. Abd benign. 1 A/B. BSCE bilat. sepsis: Pt. Updated r/t positivebld cx from . BBS =/clear. Neonatology AttendingAddendum: PEActive, appropriate, . BP STABLE. NNPnotified. Inf voiding, stooling guiac neg. MBM26/PE26 Alt po/pg. soundsclear with mild retractions.#3O: Wt. Resp O/A Rec'd inf in RA. NPN continued3. Pt. Pt. Pt. Br. Mild SCR noted. Inf remains in RA. Mildsc ret. Mildsc ret. Lrgfamily support. Monitor andsupport G/D. Continue to supportG+D. Abd benign. A/G stable. ,well perfused. Mild S/Cretractions. AG stable. Neonatology-NNP Physical ExamInfant remains in RA. : No contact with so far this shift.G+D: Temps stable, swaddled in . BSCE bilat. A:stable. A: stable. A: stable. A: Stable. Cont to suport toward discharge. Girth stable. BS+. Educate and support .G/DInfant cobedding with sibs. HOBelev. Maintainingtemp well. Uses pacifier with support. Abdomen benign. Tol well. Abdomen ,soft, round, +BS, no loops. A: AGA P: contto follow and support dev. Nursing D/C noteInfant ready for d/c. NPN7a7pRespInfant in RA with adeq sats. Settles withpacifier. Mommet with LC. F/U WITH SPELLCOUNTDOWN. Mild S/C rtxs.Caffiene dcd today. Remains NPO on d10w. Abdsoft, lrg round. is stable inRA. noincreased wob noted. NOINCREASED WOB NOTED. LSclear/=. Update given. sounds clear withmild retractions.#3O: wt. LS clear andequal. A: Pt. A: Pt. TO SUPPORT G/D. BSCE bilat. Respiratory O: Pt. Abd soft, ND, +BS. Lrg benign asps overnight and this am(see careview) and lrg spit. Cont to support and educate .G/DInfant in OAC with stable temps. Extrem WWP. Monitor and support G/D. Lytes 139/4.0/108/17. Murmer notaudible. NNP aware of BP 44/28 M34. Intubated and surv x 1 given. A:Stable on CPAP. CXR done. RESP RATE44-72 WITH MILD IC/SC RETRACTIONS. NOT YET ONCAFFEINE.A:STABLE IN LOW NC, STARTING TO SPELLP:CONTINUE TO MONITOR RESP STATUS, MONITOR FOR NEED FORCAFFEINE BS CLEAR, SLDIMINISHED. AP stable, BP stable--see flowsheet. infusing PN D10 andIL at 70/k/d. Diffunshifted. A: beginning to wean P: Followresp status very closely#3 TF's 80cc/k. Remains NPO with at 80cc/k/d. NNP Ambrosine aware. BBS clearand =. RR 60-70, mild ic/scretractions. CBG:7.44/27/31/19/-4. Check bilitonight. LS clear andequal. On ampi and gent. Temp stable. Abd soft, ND, +BS. Remains onAmp and Gent. Temp. Respiratory Care NotePt off CPAP today."},"n_notes":{"kind":"number","value":199,"string":"199"},"notes":{"kind":"list like","value":[{"category":"Nursing/other","chartdate":"2128-03-08 00:00:00.000","description":"Report","row_id":1695787,"text":"Clinical Nutrition\nO:\n30 wk gestational age BG, AGA, now on DOL 4.\nBirthwt: 1345 g(~25th to 50th %ile); current wt: 1250 g (~25th %ile); wt currently down ~7% from birth wt.\nHC at birth: 29 cm (~50th %ile); current HC: 27.5 cm (~10th to 25th %ile)\nLN at birth: 39 cm (~25th %ile); current LN: 38 cm (~10th to 25th %ile)\nLabs noted.\nNutrition: TF @ 140 cc/kg/day. EN started on DOL 2, currently @ 50 cc/kg/day PE/BM 20, increasing 10 cc/kg/. PN started on DOL 1; lipids added on DOL 2. Remainder of fluids as PN via ; projected intake for next 24 hrs from PN ~47 kcal/kg/day, ~2.1 g pro/kg/day, and ~1.4 g fat/kg/day. From EN: ~40 kcal/kg/day, ~0.6 to 1.2 g pro/kg/day, and ~2 to 2.3 g pro/kg/day.\nGI: Abdomen benign.\n\nA/Goals:\nTolerating feeds without GI problems. Tolerating PN with good BS control. Labs noted and PN adjusted accordingly. Initial goal for feeds is ~150 cc/kg/day PE/BM 24, providing ~120 kcal/kg/day and ~3.2 to 3.6 g pro/kg/day. Further increases in feeds as per growth and tolerance. Appropriate to add Fe and Vit E supps when feeds reach initial goal. PN will be supplemental to feeds and taper off as EN increases. Growth goals after initial diuresis are ~15 to 20 g/kg/day for wt gain, ~0.5 to 1 cm/wk for HC gain, and ~ 1 cm/wk for LN gain. Will follow w/ team and participate in nutrition plans.\n"},{"category":"Nursing/other","chartdate":"2128-03-08 00:00:00.000","description":"Report","row_id":1695788,"text":"NPN\n\n\n2. Received infant in RA on CVR and O2 sat. VS as noted on\nflow sheet. Noted to have 2 bradycardic episodes, one\nneeding mild stim. Both episodes around feeding. Mild\nretractions noted. No murmur. Slight jaundice.\nCont to monitor.\n3. TF increased to 140cc/kg today. Currently on PN D10W\nwith IL at 80cc/kg and NG feeds at 60cc/kg MBM/PE20. Tol\nfeeds well. Abd soft, no asp or spits. A/G stable. No stool\nthis shift. Voiding qs, see flow sheet.\nCont to advance feeds as tol 10cc/kg as ordered.\n4. Parents in for feeds. Handling the infant with assist.\nKangaroo x1. Asking appropriate questions. Discussed common\npreemie issues etc and criteria for discharge. Mom pumping.\nDad also handling infant well. Family meeting postponed\nuntil tomorrow.\n5.In air isolette maintaining temp. Tol 30 min of kangaroo\ncare but decreased temp and returned to . Sucks on\npacifier. Nested and boundries applied. Tol procedures\nfairly well.\n7. Reduced to single phototherapy lights today. Bili and\nlytes ordered for Wed. Mask secure. Voiding qs. No stool\nthis shift.\n\n\n"},{"category":"Radiology","chartdate":"2128-03-11 00:00:00.000","description":"NEONATAL HEAD PORTABLE","row_id":820067,"text":" 7:26 AM\n NEONATAL HEAD PORTABLE Clip # \n Reason: TRIPLET BORN AT 30 WEEKS GESTATION, RULE OUT INTRACRANIAL HEMORRHAGE OR OTHER ABNORMALITY\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant born at 30 weeks gestation\n REASON FOR THIS EXAMINATION:\n rule out intracranial hemorrhage or other abnormality\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Initial study on baby born at 30 weeks who is one of triplets.\n\n Scans through the anterior fontanelle with limited views through the mastoid\n foramen do not demonstrate any abnormalities. There is no evidence of\n hemorrhage or ventriculomegaly.\n\n"},{"category":"Radiology","chartdate":"2128-03-05 00:00:00.000","description":"BABYGRAM (CHEST ONLY)","row_id":819462,"text":" 1:13 AM\n BABYGRAM (CHEST ONLY) Clip # \n Reason: verify ETT placement\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with prematurity, RDS\n REASON FOR THIS EXAMINATION:\n verify ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST\n\n Comparison is made with the examination performed earlier in the day. Since\n that time, the patient has been intubated and the endotrachial tip ends above\n the carina. The lungs are much clearer, compatible with improving hyaline\n membrane disease.\n\n"},{"category":"Radiology","chartdate":"2128-03-04 00:00:00.000","description":"BABYGRAM (CHEST ONLY)","row_id":819458,"text":" 10:44 PM\n BABYGRAM (CHEST ONLY) Clip # \n Reason: evaluate lung fields\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with prematurity at 31 weeks\n REASON FOR THIS EXAMINATION:\n evaluate lung fields\n ______________________________________________________________________________\n FINAL REPORT\n CHEST\n\n This is our initial x-ray on this baby born prematurely, who is one of\n triplets. The lungs are nearly opaque, and the lung volumes very low,\n compatible with severe hyaline membrane disease. No other abnormalities are\n apparent.\n\n"},{"category":"Radiology","chartdate":"2128-04-06 00:00:00.000","description":"NEONATAL HEAD PORTABLE","row_id":822576,"text":" 7:07 AM\n NEONATAL HEAD PORTABLE Clip # \n Reason: PREMATURE INFANT BORN AT 30 WEEKS, FOLLOW UP PREVIOUS NORMAL STUDY; RULE OUT PVL\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant born at 30 weeks gestation, now 1 month old\n REASON FOR THIS EXAMINATION:\n follow up previous normal study; rule out PVL\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Infant born at 30 week gestation, now 1 month old.\n\n COMPARISON: Study on \n\n The ventricles, sulci and cisterns are normal. There is no evidence of\n intracranial hemorrhage. There is no evidence of periventricular\n leukomalacia. Grey/white matter differentiation is normal for the patient's\n age.\n\n IMPRESSION: Normal head ultrasound.\n\n"},{"category":"Nursing/other","chartdate":"2128-03-28 00:00:00.000","description":"Report","row_id":1695872,"text":"PCA Note:\n\n\nResp: O: Infant in RA, sats within limits (>94%). Lung\nsounds are cl/= bilaterally. Mild subcostal retractions. No\nspells, no drifts. A: Infant breathing comfortably. P:\nContinue to monitor respiratory status.\n\nFEN: O: TF 150cc/kg BM/PE26. PO/PG feeds as tolerated,\ngavaged over 1hr. Infant bottled this afternoon, taking in\n45cc. No spits, minimal aspirates. Infant's abdomen is soft,\n+bowel sounds, no loops. Girths stable @25cm. Infant is\nvoiding, no stool. A: Tolerating feeds well. Eager to\nbottle, well coordinated, strong suck. P: Continue ot offer\nPO feeds. Continue to support nutritional needs of infant.\n\n: O: Mom, and big brother in this afternoon. A:\nAppropriate, comfortable, . Big brother very\nexcited about new siblings. P: Continue to support, teach\nand prepare for discharge.\n\nDEV: O: Infant is swaddled, cobedded with brother and sister\nin ; HOB elevated. Infant maintaining stable temps. \nsleeps well between cares, wakes with cares, remains \nand active throughout cares. Calms with pacifier. A:\nDevelopmentally appropriate. P: Continue to support\ndevelopmental needs of infant.\n\n\n"},{"category":"Nursing/other","chartdate":"2128-03-28 00:00:00.000","description":"Report","row_id":1695873,"text":"agree with above note and assessment by , PCA.\n"},{"category":"Nursing/other","chartdate":"2128-03-29 00:00:00.000","description":"Report","row_id":1695874,"text":"npn 1900-0700\n\n\n2: resp\nremains in ra. no spells and no dsats. RR 30-60's. Lung\nsounds clear and equal. mild subcostal retractions. no\nincreased wob noted. sats remain in the high 90%.\n\n3: fen\ncurrent weight 1975gms up 65. total fluids remain at\n150cc/kilo/day of bm/pe 26. no breastmilk available this\nshift. infant po'd her whole volume at 2400. continuing to\nwatch feeding cues. tolerating feeds well. no spits. minimal\naspirates. stable girths. nutritional drawn this shift.\nsee flowsheet.\n\n4: \nno contact this shift.\n\n5: g/d\ntemps stable in an open air crib. and active with\ncares. sleeps well inbetween. sucks on pacifier. brings\nhands to face. aga. continue to monitor for developmental\nmilestones.\n\n\n"},{"category":"Nursing/other","chartdate":"2128-03-29 00:00:00.000","description":"Report","row_id":1695875,"text":"Neonatology-NNP PRogress Note\n\nPE: Remains in room air, cobedding with her siblings, well perfused, bbs cl=, rrr s1s2 no murmur, abd soft, nontender, V&S, afso, bundled\n\nSee attending note for plan\n"},{"category":"Nursing/other","chartdate":"2128-03-29 00:00:00.000","description":"Report","row_id":1695876,"text":"Neonatology Attending\n is 25do, 34 wks corrected.\nRA, open crib cobedding with sibs\nNo a/b or desats\nWt up 65 on TF150 MM26/PE26 pg>po, did take 2 full-volume bottles past 24hrs. Not waking for feeds\n\nMeds Fe, vit E, Desitin\n\n: Ca 10.2/phos 6.9/alk phos 292\n\nImp/ age-appropriate feeding immaturity.\n\nPlan/ continue to monitor cvr status, growth & development. D/c planning in progress contingent upon further evidence of maturity. Eye exam today.\n"},{"category":"Nursing/other","chartdate":"2128-04-14 00:00:00.000","description":"Report","row_id":1695941,"text":"#2 RA. LS CLEAR ANFD EQUAL. NO SPELLS.\n#3 PT PO FEEDING Q4-5HR. PO FEEDING WELL, >140CC/KG OF\nE24. WEIGHT INCREASE 40GM. VOIDING AND STOOLING.\n#4 NO CONTACT FROM FAMILY ON THIS SHIFT.\n#5 WAKING TO FEED. AND ACTIVE. NO SPELLS AT THIS\nTIME IN SHIFT.\n\n\n"},{"category":"Nursing/other","chartdate":"2128-04-14 00:00:00.000","description":"Report","row_id":1695942,"text":"neonatology Attending\n is 41do, 36 wks\nRA, open crib\nDay without a/b\nWt 2490 up 40g on ad TF140 MM/E24 po.\n\nMeds Fe\n\nimp/ age-appropriate immaturity of cvr coordination\nPlan/ continue to monitor cvr status, growth/development. D/c planning ongoing pending evidence of further maturation...\n"},{"category":"Nursing/other","chartdate":"2128-04-14 00:00:00.000","description":"Report","row_id":1695943,"text":"Clinical Nutrition\nO:\n~36 wk CGA BG on DOL 41.\nWt: 2490 g(+40)(~25th %ile); birth wt: 1345 g. Average wt gain over past wk ~37 g/day.\nHC: 33 cm (~50th to 75th %ile); last: 32 cm\nLN: 45 cm (~25th %ile); last: 44 cm\nMeds include Fe.\n not needed\nNutrition: Ad po, minimum 140 cc/kg/day, E 24 or BM 24 w/ 4 kcal/oz Enfamil powder. Infant gets mostly formula. Average of past 3 day intake ~190 cc/kg/day, providing ~152 kcal/kg/day and ~2.5 to 3.2 g pro/kg/day.\nGI: Abdomen benign.\n\nA/Goals:\nTolerating feeds without GI problems; taking all po feeds. not needed. Current feeds + supps meeting weaned recs for kcals/pro/vits and mins. Growth is meeting recs for HC and LN gain. Wt gain is slightly exceeding recommended ~20 to 35 g/day; will monitor daily gains and consider decreasing kcals before d/c if indicated. Will continue to follow w/ team and participate in nutrition plans.\n"},{"category":"Nursing/other","chartdate":"2128-04-14 00:00:00.000","description":"Report","row_id":1695944,"text":"Nursing NICU Note\n\n\n#2. Respiratory O: Pt. remains in RA, O2 sats >95%. LS\nclear/=, no increase work of breathing noted. No A&B's\nnoted this shift thus far. This is day #2 of 5 for a spell\ncount. A: Pt. is stable in RA. P: Continue to monitor\nrespiratory status. Monitor for A&B's.\n\n#3. FEN O: Pt. is ad 140cc/kg/d of E24. She\ntakes ~70-90cc PO Q feed every 4-5hrs. She is wakeing for\nfeeds and bottleing well. Abdomen is soft, , +BS, no\nloops/spits noted. She is voiding/ no stool noted this\nshift thus far. A: Pt. is tolerating current nutritional\nplan. P: Continue w/ current feeding plan. Monitor for\ns/s of intolerance.\n\n#4. O: in this afternoon to take home \nsister. was updated at bedside on pt's current status\nand daily plan of care. A: Family is and involved.\nP: Continue to update, support and educate. Continue w/\ndischarge teaching/planning.\n\n#5. Growth/Development O: Pt. remains in an open crib,\nswaddled w/ stable temps. She is and active w/ cares,\nsleeps well in between. Fontanelle soft/flat. She loves to\nuse her pacifier, brings hands to face. A: AGA P:\nContinue to provide environment appropriate for growth and\ndevelopment.\n\n\n"},{"category":"Nursing/other","chartdate":"2128-03-11 00:00:00.000","description":"Report","row_id":1695798,"text":"NURSING PROGRESS NOTE\n\nRESP/CV: REMAINS IN RA WITH 02 SATS >95% ALL NIGHT. NO A&B'S OR DESATS NOTED. BS CL&= WITH MINIMAL RETRACTIONS AND NO MURMER AUDIBLE. COLOR JAUDICE/ AND WELL PERFUSED. REBOUND BILI SENT THIS AM, RESULTS PNDING. BP 64/38-46.\n\nFEN: TOTAL FLUIDS MAINTAINED AT 140CC/KG/D. ENTERAL FEEDS ADVANCED TO 130CC/KG/D TONIGHT. INFILTRATED AT 0400 AND NOT RESTARTED. WILL ADVANCE TO FULL FEEDS AT 1200. D-STICK 89. ABD SOFT, WITH STABLE GIRTH AND +BS. PASSED MODERATE MECONIUM STOOL TONIGHT. NO RESIDUALS AND ONLY ONE SMALL EMESIS.\n\nDEV: TEMP STABLE IN AIR CONTROLLED ISOLETTE. AND ACTIVE WITH CARES. SUCKING INTERMITANTLY ON PACIFIER.\n\nSOCIAL: DAD VISITING TONIGHT. DID TEMP AND DIAPER CHANGE. PLEASED WITH PROGRESS. HELD SISTER.\n"},{"category":"Nursing/other","chartdate":"2128-03-11 00:00:00.000","description":"Report","row_id":1695799,"text":"Neonatology note\n7 d.o\nin RA, on caffein, no spells.\nRR with no murmur\nclear lungs\nabdomen soft\nAFOF\njaundice\nbili= 5.3\nwt= 1305 gm +15, off IV, feeding at 130 cc/kg/d with PE/EBM 20.\nnormal tone.\nHUS: normal today.\nA: ex 30 wks GA, resolved RDS, AOP, jaundice.\nP: advance feeding, monitor for episodes on caffeine.\n"},{"category":"Nursing/other","chartdate":"2128-03-11 00:00:00.000","description":"Report","row_id":1695800,"text":"NICU nursing progress note\n\n\nPlease refer to flowsheet for specific info.\nResp\nO: remains in room air, RR 40-70's, sat's >93%. BSCE\nbilat. A: Breathing comfortably. Stable. P: Cont to follow.\nFEN\no: TF at 150cc/k/d, currently PG enteral feedings are at\n130cc/k/d. Adv. feeds 15cc/k as tolerated. Abd , no\nloops, active bs. Voiding/ no stool thus far today. One\nsmall spit. Min asp. HOB elev. A: stable. P: cont to\nfollow.Adv feeds as tolerated.\nGD\nO: Temp stable in air isolette, swaddled with hat, tshirt\nand blanket. MAE. Fonts, soft, flat. Calms with containment\nand pacifier. Dark Blanket over the top of isolette. HUS\ndone this morning, please see Dr. note.A: AGA P: Cont\nto support dev. milestones.\nParenting\nO: Mom planning on visiting at noon cares. Dad called and\nupdated, verbalizing understanding. A: Involved and loving\n. P: cont to update, support, educate.\n\n\n\n"},{"category":"Nursing/other","chartdate":"2128-03-12 00:00:00.000","description":"Report","row_id":1695801,"text":"NURSING PROGRESS NOTE\n\nRESP/CV: REMAINS IN RA WITH 02 SATS >95%. 2 A&B'S NOTED TONIGHT. NO DESATS. REMAINS ON CAFFEINE. VSS IN ISOLETTE. BS CL&=, NO MURMER.\n\nFEN: WEIGHT 1335GMS, UP 30GMS. TOTAL FLUIDS ADVANCED TO 150CC/KG/D OF PE20CAL. ABD SOFT, WITH STABLE GIRTH AND +BS. PASSING MECONIUM AND VOIDING LG AMTS. NO RESIDUALS AND ONLY SMALL EMESIS X1. HOB ELEVATED AND FEEDS INFUSING OVER 1HR.\n\nDEV: TEMP STABLE IN ISOLETTE. ACTIVE AND WITH INTERVENTIONS AND SLEEPING QUIETLY BETWEEN CARES. SUCKING VIGOROUSLY ON PACIFIER.\n\nSOCIAL: MOM X1 FOR UPDATE. WILL VISIT AT 11AM TODAY.\n"},{"category":"Nursing/other","chartdate":"2128-03-12 00:00:00.000","description":"Report","row_id":1695802,"text":"Neonatology note\n8 d.o\nin RA, on caffeine, 2 episodes\nRR with no murmur\nclear lungs\nAFOF\nwt= 1335 gm +30, 150 cc/kg/d with EBM/PE 20\nabdomen soft\nnormal tone\n\nA: ex 30 wks GA, AOP, growing preemie\nP: advance calorie density\n\n"},{"category":"Nursing/other","chartdate":"2128-03-29 00:00:00.000","description":"Report","row_id":1695877,"text":"NPN 7a-7p\n\n\n#2: remains in Ra, breathing comfortably with mild SC\nretractions. RR stable. Sats >/= 96%. Rare drift noted to\nmid 80's x2, during mid feed. Infant corrected on her own.\nNo other drifts noted. BBS cl/=. No apnea/brady spells\nnoted thus far. A: stable in RA P:Cont to monitor and\nprovide support as needed.\n\n#3: TF: 150cc/k/d. conts on BM26/PE26, 49cc q4hrs\ngavaged over 1hr10mins. Bottled 20cc at noon feed for Mom.\nDid well with coordinating suck/swallow/breathe pattern, but\ntired out easily. Burped well. No spits, no asps. Abd\nsoft, +, no loops. Ag stable. Voiding qs. No stool\nthus far. A: tol'ing feeds well, learing to bottle P:Cont\nto follow wt and exam. Monitor tol to feeds. Offer bottle\nqshift as tol'ed.\n\n#4: Mom in for noon care. Update given. Indep with temp\nand diaper. Working on bottling infant. Using good\npositioining. Mom was present for eye exam. Did speak with\nDr. regarding results. Aware of need for F/U in\n3wks. Case manager spoke with Mom regarding\n/insurance coverage. A: Involved, parent\nP:Cont to support and educate.\n\n#5: is maintaining stable temps while swaddled in an\nopen crib. She is and active with cares, but not\nwaking on own for feeds. Tol'ed eye exam well. MAE. Fonts\nsoft/flat. Sucks on pacifier. A: AGA P:Cont to support\ndev needs.\n\n\n\n\n"},{"category":"Nursing/other","chartdate":"2128-03-30 00:00:00.000","description":"Report","row_id":1695878,"text":"NPN\n\n\n#2 Resp- Remains in RA w/o2 sats 95-100%. BS clear.RR=40-70.\nMild retractions.\n#3 F/N- Abd soft,+bs, no loops. Tolerating feeds of BM/PE 26\ncals w/o spits. Minimal asps.Bottled 30cc out of 49cc x1. NG\nfeeds given on a pump over 1 hr+ 10mins. voiding in adeq\namts. No stool yet tonight.Wt up 15gms.TF= 150cc/kg/day.\n#4 - no contact yet tonight.\n#5 Dev- + active w/cares. Temp stable swaddled in open\ncrib.\n\n\n"},{"category":"Nursing/other","chartdate":"2128-03-30 00:00:00.000","description":"Report","row_id":1695879,"text":"Neonatology NP Note\nPE\n swaddled in crib, cobedding with siblings\nAFOF, sutures opposed\nrespirations comfortable in room air, lungs clear/=\nRRR, no murmur, and well perfused\nabdomen soft, nontender and nondistended, active bowel sounds\ngood tone.\n"},{"category":"Nursing/other","chartdate":"2128-03-31 00:00:00.000","description":"Report","row_id":1695880,"text":"1900-0700 NPN\n\n\nRESP: Infant remains in RA, O2 sats=96-100%. RR=40-60's.\nBreath sounds clear and equal bilaterally, mild SCR noted.\nNo desats/no bradys so far this shift. Continue to monitor\nresp status.\n\nFEN: Weight tonight=1.990 kg (no change). TF=150cc/kg/d of\nBM26/PE26 PO/PG q4hr. Attempting to bottle feed infant\nqshift. Infant bottled 15cc at 0000. Gavage feedings given\nover 1hr 10min/tolerated well. Abdomen , soft, round,\n+BS, no loops. No spits, no aspirates so far this shift.\nVoiding, no stool. Continue to monitor FEN status.\n\n: No contact with so far this shift.\n\nDEV: Temps stable, swaddled in . Cobedding with brother\nand sister. Active and with cares, sleeps well in\nbetween cares. Infant not waking for feeds. Brings hands to\nface, sucks on pacifier for comfort. MAE. Continue to\nsupport DEV.\n\n\n"},{"category":"Nursing/other","chartdate":"2128-03-31 00:00:00.000","description":"Report","row_id":1695881,"text":"1900-0700 NPN\nPlease disregard the above note. This note was written on the wrong patient.\n"},{"category":"Nursing/other","chartdate":"2128-04-15 00:00:00.000","description":"Report","row_id":1695945,"text":"PCA NOTE\n\n\nRESP: O/A-In RA. Breathing 40-60's. Sats high 90's. No\nspells or desats noted. No drifts. No issues. P-Continue to\nmonitor.\n\nFEN: Current weight 2.520, ^30gm. TF of 140. E 20. PO.\nTotal 24 hour intake 161 cc/ is voiding and\nstooling. Hem neg. Active bowel sounds. Abdomen is\nunremarkable. No spits. P-Continue with current regimen.\n\n: No contact thus far this shift.\n\nG/D: O/A-Temp stable in . Waking q 2-5 hours for feeds.\n and active. Sleeps peacefully. MAE. Awake for longer\nperiods of time. Curious disposition. P-Continue to monitor\nfor developmental milestones.\n\n ****See flowsheet for further information****\n\n\n"},{"category":"Nursing/other","chartdate":"2128-04-15 00:00:00.000","description":"Report","row_id":1695946,"text":"NPN 1900-0730\nI have examined this infant and agree with the above note written by , PCA.\n"},{"category":"Nursing/other","chartdate":"2128-04-15 00:00:00.000","description":"Report","row_id":1695947,"text":"Neonatology-NNP Physical Exam\n\n remains in RA. Active, in an open crib, AFOF, sutures opposed, good tone. BBS clear and equal with good air entry. No murmur, pulses +2, , RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds. Please refer to attending progress note for detailed plan.\n"},{"category":"Nursing/other","chartdate":"2128-04-15 00:00:00.000","description":"Report","row_id":1695948,"text":"Neonatology Attending\n is 42do, 36 wks corrected.\nRA, open crib alone ( went home yesterday)\nNo a/b day \nWt 2520 up 30g on ad po E24/MM24 minTF140 (took 161cc/kg/24hrs)\n\nMeds Fe\n\nImp/ age appropriate cvr immaturity...\nPlan/ continue to monitor cvr status, growth/development. D/C planning in progress for as early as Sat contingent upon evidence of maturity.\n"},{"category":"Nursing/other","chartdate":"2128-04-15 00:00:00.000","description":"Report","row_id":1695949,"text":"NPN 0700-1900\n\n\n#2: O: Infant remains in room air. Saturations 96-100%.\nRespiratory rate 30's-40's with no retractions. No spells or\ndrifts this shift. Day 3 out of 5 of a spell countdown. Lung\nsounds clear and equal. A: Infant stable in room air. P:\nContinue to monitor infant for spells.\n\n#3: O: Total fluid minimum 140cc/kg/day of E24 or breastmilk\n24 with enfamil powder, 59cc q4 hours. Infant is ad \nfeeding and took 90cc and 75cc so far this shift. Abdomen\nbenign, voiding, no stools. One small spit. A: Infant\ntolerating feeds P: Continue with current feeding plan.\n\n#4: O: called this shift, will be in this evening.\n\n#5: O: Temperature stable in . Infant wakes for feeds,\n and active with cares. Brings hands to face for\ncomfort and calms with pacifier. Sleeps well between cares\nand remains swaddled in crib. A: AGA. P: Continue to support\ngrowth and development.\n\n\n"},{"category":"Nursing/other","chartdate":"2128-04-15 00:00:00.000","description":"Report","row_id":1695950,"text":"Nrsg Progress Note\nAgree with above note fromPCa with fdg witnessed by this RN at 1700 with uncoordinated sucking noted periodically with sucking spilling approx 10 cc's from \"dribbling\"of formula. Abd soft with no stool at 1700. No loops noted this shift. phoned with complete update. No a's or b's noted as of this writing. Report to night RN planned for 1900. Infant remains on cvr and 02 sat monitor.\n"},{"category":"Nursing/other","chartdate":"2128-03-26 00:00:00.000","description":"Report","row_id":1695861,"text":"NPN 1900-0700\n\n\n2. RESP: pt reains in RA with RR 40-60's. Mild S/C\nretractions. Sats >94%. No spells noted. Will monitor.\n\n3. F&N: TF remain at 150cc/k/d of PE26. She bottled her\nwhole feed at 2400. Abd benign. BS+. A/G stable. No\nspits and minimal aspirates noted. Voiding well. No stool\nnoted. Weight gain 50 grams.\n\n4. PAR: No contact from so far this shift.\n\n5. DEV: is active and during her cares. Temp\nstable swaddled in crib, cobedding with her siblings. Mild\ngen edema noted.\n\n\n\n\n"},{"category":"Nursing/other","chartdate":"2128-03-26 00:00:00.000","description":"Report","row_id":1695862,"text":"Neonatology Attending\nAddendum\n\nPE: active sleep, appropriate tone/activity. . AFOF.\nLungs CTA, heart rrr s m, abd soft, extr well perfused.\n"},{"category":"Nursing/other","chartdate":"2128-03-26 00:00:00.000","description":"Report","row_id":1695863,"text":"Neonatology Attending\n22do, 34 wks corrected\nRA, open crib cobedding with sibs\nNo a/b\nWt 1840 up 50 on TF150 PE26 pg>> po (took full bottle overnight!); no spits\n\nMeds Fe, vit E, Desitin\n\nImp/ age-appropriate immaturity of feeding skills, making appropriate progress, growing well.\n\nPlan/ continue to monitor cvr status, growth/development\n"},{"category":"Nursing/other","chartdate":"2128-03-26 00:00:00.000","description":"Report","row_id":1695864,"text":"NPN days\n\n\nRESP: Infant in room air, RR 30-60's, O2 sats 93% and\ngreater, lungs are clear and equal, mild SC retractions. No\nspell, no desats. Will continue to monitor closely.\n\nFEN: total fluids 150cc/k/d of PE/BM 26 po/pg feeds Q4hours\n48cc. Bottled X1 today and took in 35cc!, remainder\ngavaged. Infant to breast today , latched well and sucked\nintermittently for approx 5min. Abdomen is soft, ,\nactive bowel sounds, AG stable, minimal residuals, no spits.\nvoiding , no stool this shift. Will continue to offer\nbottle once per shift, and monitor closely.\n\nParenting: Mother in today for 12 and 4p cares, involved\nand mother, participates in cares, attempted to\nbreastfeed, lactation consult appt. made for at noon.\nWill continue to support and update family.\n\nG/D: Temps are stable in open crib (co bedding). and\nactive with cares, does not wake for all feeds, MAE, sucks\non pacifier /hands. AGA. Will continue to support\ndevelopmetnal needs.\n\n\n"},{"category":"Nursing/other","chartdate":"2128-03-27 00:00:00.000","description":"Report","row_id":1695865,"text":"NURSING PROGRESS NOTE\n\nRESP/CV: REMAINS IN RA WITH NO A&B'S OR DESATS NOTED. BS CL&=, NO MURMER. COLOR AND WELL PERFUSED. BP 70/42-52.\n\nFEN: WEIGHT 1880GMS, UP 40GMS. TOTAL FLUIDS REMAIN AT 150CC/KG/D OF BM/PE26CAL. BOTTLED FULL FEEDING VIGOROUSLY WITH GOOD COORDINATION X1 TONIGHT. VOIDING & STOOLING WNL. ABD SOFT, WITH STABLE GIRTH AND +BS. NO EMESIS OR RESIDUALS NOTED.\n\nSOCIAL: MOM WILL BE IN AT 8AM THIS AM.\n"},{"category":"Nursing/other","chartdate":"2128-03-27 00:00:00.000","description":"Report","row_id":1695866,"text":"Attending Note\nDay of life 23 CGA 34 \nstable in room air 30-60\nHR 140-170 BP 70/42 mean 52\n1880 up 40 150 cc/kg/day BM or PE 26\ntaking mostly pg but some po\nvoiding and stooling\n\nA/P doing well\nwill have nutrition on Monday\nwill continue current plan\n\n"},{"category":"Nursing/other","chartdate":"2128-04-11 00:00:00.000","description":"Report","row_id":1695929,"text":"Neonatology Attending\n\nDOL 38 CGA 36 2/7 weeks\n\nStable in RA. No A/B.\n\nOn ad lib feeds. Took 156 cc/kg BM/E 24 yesterday. Voiding. Stooling. Wt 2340 grams (up 30).\n\nCobedding with sister.\n\n in and up to date.\n\nA: Stable. On countdown D2.\n\nP: Monitor\n Home when 5 day spell free\n\n"},{"category":"Nursing/other","chartdate":"2128-04-11 00:00:00.000","description":"Report","row_id":1695930,"text":"Nursing Progress Note:\n#2 - RESP: REmains in room air. Lungs clear and equal. No\nspells/drifts today. Day . Last spell on the 16th. Not\nbeing fed on the monitor. RR (30-50). O2Sats >96%.\n#3 - F&N: Ad lib demand feeder with min of 140cc/kilo.\nBottling well over that. Bottling about 80cc's at each\nfeeding. aBdoinal exam benign. Voiding. No stool thus far\ntoday. Remains on iron.\n#4 - : Mom called this am. in this afternoon.\nUpdated. Independent with cares. Bottled and fed both girls.\n\n#5 - G&D: TEmps stable in open crib. and active with\ncares. MAE. AFSF. Bottling all feeds. Waking for feeds q4-6\nhours.\n\n\n"},{"category":"Nursing/other","chartdate":"2128-04-12 00:00:00.000","description":"Report","row_id":1695931,"text":"NICU NURSING PROGRESS NOTE:\nRESP.O: Infant remains in RA. RR: 40-60. Lungs sound clear\nand equal. No retractions. Infant has had 2x spells to the\ntime of note. 1x with bottling, HR went down to 77 with sats\n88%, bottle was taken out of her mouth, and mild to moderate\nstim for shallow breathing. The second spell was at rest,\nabout 30 min after she ate, HR:56, sat was 70%, her color\ngot dusky. Reguired mode stim for shallow breathing.\nA: Occasionally spells. P: Continue to monitor for spells\nand assess.\n\nFEN.O: Weight=2.385kg, ^45gms. Infant remains on adlib\ndemand schedule with BM24. Bottling slightly uncoordinated.\nTaking 80-90cc. Abd exam is soft, no loops. BS active.\nVoiding, no stools. No spits. Tolerating feeds and gaining\nweight. Continue to support PO feedings.\n\nParenting: No contact from to the time of note. Cont\nto support.\nG/G.O: is cobedding with her twin sister in open crib.\nTemps are stbale. Swaddled. Active and with cares.\nSleeps well in between cares. Wakes for feeds. Likes her\npacifier. A: Well appereance. P: Continue to support\ndevelopmentally needs.\n\n\n"},{"category":"Nursing/other","chartdate":"2128-04-12 00:00:00.000","description":"Report","row_id":1695932,"text":"I am in agreement with documentation done by . Infant had an uneventul night. Brady x2, one at rest and one with when feeding.\n\n"},{"category":"Nursing/other","chartdate":"2128-04-12 00:00:00.000","description":"Report","row_id":1695933,"text":"Neonatology Attending Note\nDay 39\nCGA 36 3\n\nRA. RR40-60s. 2 A&Bs overnight, 1 w feed. No murmur. HR 140-170s. , well perfused. BP 79/47, 59.\n\nWt 2385, up 45. PO ad , 140cc/k/d, BM/E24. TFI: 170. Nl voiding and stooling.\n\nIn open crib.\n\nA/P: Immature cardioresp control, plus some po dyscoordination. Cont to monitor. No changes to current medical plan.\n"},{"category":"Nursing/other","chartdate":"2128-03-10 00:00:00.000","description":"Report","row_id":1695793,"text":"NICU NPN 1500-0700\n\n\nRESP O: Baby remains in nco2 100%, 13-25c's during the\nnight. O2 sats 91-99%, rr50-70's, with baseline mild ic/sc\nretractions. No spont bradys noted, received caffeine bolus.\nLungs are clear. Hr 130-160's, color -jaundiced, bp's\nare stable, no audible murmur.\n\nFEN O: Current weight 1290g, up 10g. Tolerating advancing\nenteral feeds of pe20 well. Abdominal exam benign, voiding\nand stooling, ag stable, no loops, min ngt aspirates, no\nspits. D stick stable. IVF of PN, and IL are infusing\nthrough well.\n\nParenting O: Mom and dad in for cares, asking appropriate\nquestions. Family meeting held at 1500. Mom held.\n\nG&D O: temps are stable, nested on sheepskin, in servo\nisolette. baby is and active irritable with cares.\nSettles with pacifier and containment. Fontanells are soft\nand flat.\n\nBili O: Bili todat 5.0/0.2. She remains under single\nphototherapy\n\n\n"},{"category":"Nursing/other","chartdate":"2128-03-10 00:00:00.000","description":"Report","row_id":1695794,"text":"NICU NPN ADDENDUM\nError on above note, baby is in room air, and has been throughout the night. rr 40-60's, lungs are clear, with o2 sats 94-100%. One brady, noted, no caffeine bolus.\n"},{"category":"Nursing/other","chartdate":"2128-03-10 00:00:00.000","description":"Report","row_id":1695795,"text":"Neonatology note\n6 d.o\nin RA, on caffeine, 2 bradycardia.\nRR with no murmur\nclear lungs\nabdomen soft\nwt= 1290 gm +10, 140 cc/kg/d with feeding at 100 cc/kg/d with PE 20\njaundice\nbili= 5\n\nA: ex 30 wks GA, resolved RDS, jaundice, AOP\nP: advance feeding, d/c phototherapy and f/u bili.\n"},{"category":"Nursing/other","chartdate":"2128-03-10 00:00:00.000","description":"Report","row_id":1695796,"text":"Fellow note; physical exam\n and active in isolette. Breathing comfortably in RA. Mild jaundice. AFOF. Lungs with good aeration and clear breath sounds bilaterally. RRR. Nl S1, S2. No murmur. Normal femoral pulses. Abd soft, ND, + BS. Extrem WWP. Normal tone.\n\nFamily meeting yesterday with mom, dad, nurse, social worker and myself. Discussed course so far and goals for coming weeks. Discussed criteria for discharge home. Also discussed possible transfer to next week. well-informed and asking good questions.\n\n"},{"category":"Nursing/other","chartdate":"2128-03-10 00:00:00.000","description":"Report","row_id":1695797,"text":"NICU nursing progress note\n\n\nPlease refer to flowsheet for specific info.\nResp\nO: remains in room air, RR 40-70's, sat's >91%, BSCE\nbilat. A: Stable. P: Cont to follow. On caffeine, no spells\ntoday.\nFEN\nO: TF of 140cc/k/d. IVF currently at 25cc/k/d of D10 2 meq\nNacl, 1 meq Kcl. Enteral feeds are currently at 115cc/k/d of\npe 20 gavaged over 40\". well tolerated. MIn asp. NO spits.\nAbd , no loops, active bs. voiding/ no stool today. UO\n3.5cc/k/hour for last 12 hours. A: stable. P: cont to\nfollow.\nGD\nO: Temp stable swaddled in an air isolette, active and \nwith cares. MAE. fonts, soft, flat. Calms with containment\nand pacifier. A:AGA P: cont to support dev milestones.\nbili\nO: Off photo tx. Check rebound in am.\nParenting\nO: mom and dad in and updated, verbalizing understanding. A:\nInvolved and loving .\n\n\n\n"},{"category":"Nursing/other","chartdate":"2128-03-09 00:00:00.000","description":"Report","row_id":1695789,"text":"NPN:\n\nRESP: Sats 94-98% in RA. RR=50-76 with sl SC retraction. BBS =/clear. Occasional brief sat-drifts w/quick recovery. A&B x 1 tonight; x 3 over past 24 h -> QSR or stim. Remains on Caffeine.\n\nCV: No murmur. HR=140-150s. BP=50/23 (33). Color w/jaundice. Perfusion good.\n\nFEN: Wt=1280g (+ 30g). TF=140cc/kg/d. Enteral feeds at 70cc/kg/d; tolertaing 16cc PE-20 well q 4 h via NG. PN (D-10) and IL at 70cc/kg/d. No spits; abd soft, rounded, active bs, no loops. U/O=3cc/kg/h over 24-h period yesterday. Voiding well tonight. No stool recorded since birth. To increase enteral fdgs 10cc/kg as tolerated. Elec to be checked .\n\nBILI: Single Phx. Bili 5.3/0.3 (). Bili to be done .\n\nG&D: CGA=31 wk. Temp stable in air-controlled isolette. Active and alert w/cares. Small lesion rt actecubital space -> cleansed and open to air. Nested in sheepskin and resting well.\n\nSOCIAL: No contact w/. Family meeting today at 1330.\n"},{"category":"Nursing/other","chartdate":"2128-03-09 00:00:00.000","description":"Report","row_id":1695790,"text":"Neonatology note\n5 d.o\nin RA, no spells, on caffeine.\nRR with no murmur\nclear lungs\nabdomen soft\njaundice.\nAFOF\nnormal tone\nwt= 1280 gm +30, 140 cc/kg/d with feeding at 70 cc/kg/d with PE 20/EBM 20\nA: ex 30 wks GA, resolved RDS, Jaundice, AOP\nP: advance feeding, f/u bili.\n"},{"category":"Nursing/other","chartdate":"2128-03-31 00:00:00.000","description":"Report","row_id":1695882,"text":"1900-0700 NPN\n\n\nRESP: Infant remains in RA, O2 sats=95-100%. RR=30-60's.\nBreath sounds clear and equal bilaterally, mild SCR noted.\nNo bradys, no desats so far this shift. Will continue to\nmonitor resp status.\n\nFEN: Weight tonight=2.065kg (+5grams). TF=150cc/kg/d of\nPE26/BM26 po/pg q4hr. Attempting to bottle infant qshift.\nInfant bottled 52cc at with good coordination. Gavage\nfeedings given over 1hr 10min/tolerated well. Abdomen ,\nsoft, round, +BS, no loops. Minimal aspirates, small spitx1\nso far this shift. Voiding/no stool. Continue to monitor FEN\nstatus.\n\n: No contact with so far this shift.\n\nG+D: Temps stable, swaddled in . Cobedding with sister\nand brother. Active and with cares, sleeps well in\nbetween cares. Infant does not wake independently for feeds.\nBrings hands to face, sucks on pacifier for comfort. MAE.\nYellow drainage noted to both eyes/warm soaks applied.\nContinue to support G+D.\n\n\n"},{"category":"Nursing/other","chartdate":"2128-03-31 00:00:00.000","description":"Report","row_id":1695883,"text":"Neonatology Attending\nAddendum: PE\nSleeping quietly s/p feed; appropriate tone; . AFOF.\nLungs CTA, heart RRR s murmur, abd soft, extr well perfused.\n"},{"category":"Nursing/other","chartdate":"2128-03-31 00:00:00.000","description":"Report","row_id":1695884,"text":"Neonatology Attending\n is 27do, 34 wks corrected.\nRA, open crib\nNo a/b; occ desats mostly with feeds, some with bradycardia all self-resolved\nwt unchanged on TF150 MM/PE26 pg>>po\n\nMeds Fe, vit E\n\nImp/ age-appropriate cvr & feeding immaturity\nPlan/ continue to monitor cvr status, growth/development.\n"},{"category":"Nursing/other","chartdate":"2128-03-31 00:00:00.000","description":"Report","row_id":1695885,"text":"NPN 7a-7p\n\n\n#2: remains in RA, sating >/= 96%. RR stable.\nBreathing comfortably with mild SC retractions. BBS cl/=.\nNo apnea/brady spells noted. Did have 2 brief drifts with\nbottling to high 80's- QSR. Also had desat at rest to 76%,\nwith HR drop to 86. Occurred after gavage feed had finished.\nQSR. Team aware. A: stable in RA, ?reflux. P:Cont to\nmonitor resp status and provide support as needed.\n\n#3: TF: 150cc/k/d. Conts on BM26/PE26, tol'ing 50cc q4hrs\ngavaged over 1hr10mins. No asps. No spits thus far. HOB\nslighlty elevated. Bottled at 12 feed, taking 32cc. Fair-\ngood coordination. Tires toward end of feed. Abd soft,\n+, no loops. Voiding qs. No stool thus far. A: tol'ing\nfeeds. P:Cont to follow wt and exam. Monitor tol to feeds.\nOffer bottle qshift as tol'ed.\n\n#4: Mom in for noon care. Indep with care and bottling.\nUpdated on infant's status. Rescheduled her LC appt for Sat\nand Mon. A: Involved, parent P:Cont to support and\neducate.\n\n#5: Temps stable while swaddled in an open crib. Molyy\nloves co-bedding with her siblings. MAE. Fonts soft/flat.\nBrings hands to face. Sucks on fingers and pacifier.\nSleeps well in btw cares. A: AGA P:Cont to support dev\nneeds.\n\n\n"},{"category":"Nursing/other","chartdate":"2128-03-09 00:00:00.000","description":"Report","row_id":1695791,"text":"NICU nursing progress note\n\n\nPLease refer to flowsheet for specific info.\nResp\nO: remains in room air, RR 40-70's, sat's 94-98%, occ\ndrift in sat to high 80 's then quickly returns to baseline.\nBSCE bilat. ic/sc ret. On caffeine , no brady's. A: Stable.\nP: cont to follow.\nfEN\nO: TF of 140cc/k/d, ivf PN D10 w/ IL at 70cc/k/d and enteral\nfeeds at 70cc/k/d. NO spits, min. asp. Abd benign, no\nloops, active bs. voiding/ no stool. Glycerin supp. given as\nordered. No results. No spits. min asp. A: Stable. P: Plan\nfor adv of feeds 15cc/k at 1600, cont to follow.\nGD\nO: TEmp stable in air isolette, active and alert with cares,\nocc irritable though calms with containment and pacifier.\nMAE. Font soft, flat. A: AGA P: cont to support dev.\nmilestones.\nBIli\nO: Under single photo tx, eye in place. A: Labs on\nWeds.\nParenting\nPlease see trip #3 note.\n\n\n"},{"category":"Nursing/other","chartdate":"2128-03-09 00:00:00.000","description":"Report","row_id":1695792,"text":"PT/OT\n was observed during her cares. Noted stress signals, strengths and techniques for comfort. Met with and explained role of PT and OT, and initiated education regarding developmental care, stress signs, handling and comfort techniques. were very receptive and demonstrated good understanding of all education. Will continue to f/u for developmental care and parent education.\n"},{"category":"Nursing/other","chartdate":"2128-03-27 00:00:00.000","description":"Report","row_id":1695867,"text":"PCA Note:\n\n\nResp: O: Infant in RA, sats within limits. Lung sounds are\nclear and equal, mild subcostal retractions. No drifts, no\nspells. A: Infant breathing comfortably, no apparent\nrespiratory distress. P: Continue to monitor infant's\nrespiratory status.\n\nFEN: O: TF 150cc/kg BM or PE26. PO/PG feeds as tolerated\nq4h, gavaged over 1hr 10min. Infant bottled 33cc this\nmorning for Mom; well coordinated, eager, strong suck. No\nspits. Infant's abdomen is soft, nontender, +bowel sounds,\nno loops. Girths stable @ 25cm. Max aspirate = 4cc. Infant\nis voiding, no stool thus far. A: Infant tolerating feeds\nwell. P: Continue to offer PO feeds as tolerated. Continue\nto support nutritional needs of infant.\n\n: O: Mom and Dad in this morning. Mom assisted with\ncares, bottled and held infant. A: appear\ncomfortable, appropriate and very . P: Continue to\nsupport, teach and prepare for discharge.\n\nDEV: O: is swaddled, cobedded with brother and sister\nin an , maintaining stable temps. sleeps well\nbetween cares. Infant wakes with cares and remains and\nactive throughout cares. calms with her pacifier. A:\nDevelopmentally appropriate. P: Continue to support\ndevelopmental needs of infant.\n\n\n"},{"category":"Nursing/other","chartdate":"2128-03-27 00:00:00.000","description":"Report","row_id":1695868,"text":"Neonatology NP note\nPe\nAFOF, sutures opposed\nrespirations comfortable in room air, lungs clear/=\nRRR, no murmur, and well perfused\nabdomen soft\ngood tone.\n"},{"category":"Nursing/other","chartdate":"2128-03-12 00:00:00.000","description":"Report","row_id":1695803,"text":"Nursing Progress Note\n\n\nRESP O/A: Infant remains in RA; maintaining O2 sats >95%. RR\n40-70s, LS clear/=, mild intercostal rtxns. No spells/desats\nnoted thus far today. Continues on pg caffeine qd. P: Cont\nto monitor resp status.\n\nFEN O/A: TF @ 150cc/k/d. Calories increased to BM/PE22.\nInfant receives 33cc q4h pg. Tolerating feeds well; no\nspits, minimal aspirates. Abodomen benign, active BS. Girth\nstable. Voiding/mec stooling. P: Cont to monitor for s/s of\nfeeding intolerance.\n\nPAR O/A: Mom in @ 1230 to visit. Very affectionate towards\ndaughter. Asking appropriate questions. P: Cont to support\nNICU family.\n\nDEV O/A: is swaddled in an Air isolette; temps stable.\nSleeps well b/t feeds, A/A with cares. Likes pacifier. P:\nCont to support developmental needs.\n\nBILI O/A: Infant appears slightly juandice. Problem\nresolved.\n\n\n\n"},{"category":"Nursing/other","chartdate":"2128-03-13 00:00:00.000","description":"Report","row_id":1695804,"text":"NPN Nights\n\n\n2. O: Ls clear. RR 40-60's. Mild intercostal retractions. No\nspells/ desats. On Caffeine. RA. A/P: Cont to monitor resp\nstatus.\n\n3. O: Wt 1360gms, up 25. Tf 150cc/kg of BM/PE22 via ngt. 3\nsmall spits. Min asp. Voiding. +bs. No stool. A/P: Cont to\nmonitor wt,a bd, and tol of feeds.\n\n4. O: Mom called X1. MOm asking appropriate questions. Rn\nupdated Mom. A/P: Cont to educate and support.\n\n5. O: Temp 99.4 X1. Removed hat. Otherwise, temp stable.\n and active with cares. Occ Sucking on pacifier. A/p:\nCont to monitor temp. Cont to cluster cares.\n\n\n"},{"category":"Nursing/other","chartdate":"2128-03-13 00:00:00.000","description":"Report","row_id":1695805,"text":"7 Bili\n\nREVISIONS TO PATHWAY:\n\n 7 Bili; resolved\n\n"},{"category":"Nursing/other","chartdate":"2128-03-13 00:00:00.000","description":"Report","row_id":1695806,"text":"Neonatology\nRemains in rA. Comfortable apepairng. Single spell ove course of evening.\n\nWT 1360 up 25. TF at 150 cc/k/d of 22 cal. Abdomen benign. Will advance to 24 cal. Few spits overnight.\n\nTemp stable in isollette.\n\nSl jaundiced. Rbd bili ok.\n\n investigating retrotransfer to area.\n\nHUS for Tuesday.\n\nContinue current monitoring and feed advancement as tolerated.\n"},{"category":"Nursing/other","chartdate":"2128-03-13 00:00:00.000","description":"Report","row_id":1695807,"text":"Nursing Progress Note\n\n\nRESP O/A: Infant remains stable in RA; maintaining O2 sats\n>94%. RR 30-60s, LS clear/=, mild ic rtxns. One spell noted\n@ 0900: HR 74, no desat, QSR. Continues on caffeine. Resp\nstatus stable. P: Cont to monitor for As & Bs.\n\nFEN O/A: TF @ 150cc/k/d; calories increased to BM/PE24.\nInfant receives ~34cc q4h, gavaged over 70 minutes. Minimal\naspirates, no spits. Abdomen benign, active BS, girth\nstable. Voiding/transitional stooling. Started on Vit E & Fe\ntoday. P: Cont to monitor for s/s of feeding intolerance.\n\nPAR O/A: Mom in for 1200 cares, independent. Held \nduring gavage feed. Very loving. Asking appropriate\nquestions. Dad plans to be in for afternoon cares. P: Cont\nto support NICU .\n\nG&D O/A: Infant is swaddled in an Air isolette; temps\nstable. Sleeps well b/t feeds, A/A with cares. Likes\npacifier. MAE, brings hands to face, AFSF. P: Cont to\nsupport developmental needs.\n\n\n"},{"category":"Nursing/other","chartdate":"2128-03-13 00:00:00.000","description":"Report","row_id":1695808,"text":"Neonatology NP Note\nPE\nswaddled in isolette\nAFOF, sutures opposed\ncomfortable respirations in room air, lungs clear/=\nRRR, no murmur, and well perfused\nabdomen sfot, nontender and nondistended, active bowel sounds\ngood tone.\n"},{"category":"Nursing/other","chartdate":"2128-04-16 00:00:00.000","description":"Report","row_id":1695951,"text":"PCA NOTE\n\n\nRESP: O/A-In RA. Breathing 30-50's. Sats High 90's. No\nspells or desats noted. No drifts. No issues. P-Continue to\nmonitor.\n\nFEN: O/A-Current weight 2.545, ^ 25gm. TF 140cc/k/d. E\n24. PO. Exceeding required amount. Total 24 is 191 cc/\n is voiding, no stool thus far. Abdomen is\nunremarkable. Active bowel sounds. Small spit noted.\nTolerating feeds. P-Continue with current regimen as\nordered.\n\n: No contact thus far this shift.\n\nG/D: O/A-Temp stable in . Waking Q4-5 hours for feeds.\n and active with cares. Sleeping peacefully. Curious\ndisposition. Adores being held. Awake for longer periods of\ntime. MAE. AGA. P-Continue to monitor for developmental\nmilestones.\n\n ****See flowsheet for specifics****\n\n\n"},{"category":"Nursing/other","chartdate":"2128-04-16 00:00:00.000","description":"Report","row_id":1695952,"text":"NPN 1900-0730\nI have examined the infant and agree with the above note by , PCA.\n"},{"category":"Nursing/other","chartdate":"2128-04-16 00:00:00.000","description":"Report","row_id":1695953,"text":"Neonatology Attending\n is 43do, 37 wks corrected\nRA, open crib alone (sibs have been d/c'd)\nNo a/b day \nWt 2545 up 45 on ad TF140 E/MM24 po\n\nMeds Fe\n\nImp/ age appropriate cvr immaturity, approaching readiness for d/c.\n\nPlan/ continue to monitor cvr status, growth/development. D/c planning in progress for tomorrow contingent upon further evidence of maturity.\n"},{"category":"Nursing/other","chartdate":"2128-04-16 00:00:00.000","description":"Report","row_id":1695954,"text":"Neonatology - NP Physical Exam\nAwake and with cares, temp stable in open crib. BS clear and equal, color . RRR, without murmur, pulses 2+ and symmetrical. Active bowel sounds, without loops, without HSM, tolerating feeds well. Normal female genitalia. Without rashes. Good tone, AFSF, PFSF, +suck, +, +plantar reflexes. Please see attending neonatologist note for detailed plan of care.\n"},{"category":"Nursing/other","chartdate":"2128-04-16 00:00:00.000","description":"Report","row_id":1695955,"text":"Nursing NICU Note\n\n\n#2. Respiratory O: Pt. remains in RA, O2 sats >96%. LS\nclear/=. RR ~30-50's, no increase work of breathing noted.\nNo A&B's this shift thus far. Today is Day #4 of a 5 day\nspell count. A: Pt. is stable in RA. P: Continue to\nmonitor respiratory status. Monitor for A&B's.\n\n#3. FEN O: Ad 140cc/kg/d of BM24/E24. She takes\n~70-90cc PO q feed. She wakes for feeds and bottles well.\nAbdomen is soft, , +BS, no loops/spits noted. She is\nvoiding/ no stool passed this shift thus far. A: Pt. is\ntolerateing current nutritional plan. P: Continue w/\ncurrrent feeding plan. Monitor for s/s of intolerance.\n\n#4. O: Mom called this am and was updated on pt's\ncurrent status and daily plan of care. are active\nand independent in cares. A: are lvoing and\ninvolved. P: Continue to update, support and educate.\nContinue w/ discharge teaching/planning.\n\n#5. Growth/Development O: Pt. remains in an open crib,\nswaddled w/ stable temps. She is and active w/ cares,\nsleeps well in between. Fontanelle soft/flat. She loves to\nuse her pacifier, brings hands to face. A: AGA P:\nContinue to provide environment appropriate for growth and\ndevelopment.\n\n\n"},{"category":"Nursing/other","chartdate":"2128-03-28 00:00:00.000","description":"Report","row_id":1695869,"text":"npn 1900-0700\n\n\n2: resp\n\nRemains in ra. no spells and no dsats. RR 30-70's. Lung\nsounds clear and equal. mild subcostal retractions. no\nincreased wob noted. continue to monitor for changes in resp\nstatus.\n\n3: fen\ncurrent weight 1910gms up 30gms. total fluids remain at\n150cc/kilo/day of bm/pe 26. tolerating feeds well. no spits.\nminimal aspirates. abd soft with no loops. alt po/pg feeds.\ninfant took whole volume at 2400 care. girths stable.\nvoiding, no stool thus far this shift. continue to encourage\npo feeds.\n\n\n4: :\nNo contact thus far this shift.\n\n5: G/D\ntemp stable in an open crib. and active with cares.\nsleeps well inbetween. brings hands to face. sucks on\npacifier. brings hands to face. aga. continue to monitor for\ndevelopmental milestones.\n\n\n"},{"category":"Nursing/other","chartdate":"2128-03-28 00:00:00.000","description":"Report","row_id":1695870,"text":"Neonatology Attending Note\nDay 24\nCGA 34 2\n\nRA. RR30-50s. No A&Bs. BS cl and =. Mild sc rtxns.\n\nWt , up 30 gms. TF 150 cc/k/day PE26 po/pg. Tol well. Nl voiding and stooling.\n\nStable temps in open crib.\n\nA/P:\nGrowing preterm infant learning how to po feed. Will cont to encourage feeding skills and monitor.\n"},{"category":"Nursing/other","chartdate":"2128-03-28 00:00:00.000","description":"Report","row_id":1695871,"text":"Neonatology Attending Note\nExam:\n\nResting comfortably in open crib. AFSF. Lungs CTA, =. CV RRR, no murmur. 2+FP. Abd soft, +BS. Ext and well perfused.\n"},{"category":"Nursing/other","chartdate":"2128-04-12 00:00:00.000","description":"Report","row_id":1695934,"text":"NPN 0700-1900\n\n\n#2: O: Infant remains in room air. Saturations greater than\n95%. Respiratory rate 30's-50's with no retractions. Lung\nsounds clear and equal. No spells. A: Infant stable in room\nair. P: Continue to monitor infant for spells.\n\n#3: O: Infant is feeding ad demand, breastmilk or E24.\nBottled 90cc each feed so far this shift. Abdomen benign,\nbowel sounds active. Voiding, no stools this shift. One\nsmall spit. A: Infant tolerating feeds. P: Continue with\ncurrent feeding plan.\n\n#4: O: called this shift.\n\n#5: O: Temperature stable in . Wakes for feeds, and\nactive with cares. Brings hands to face for comfort and\ncalms with pacifier. A: AGA. P: Continue to support growth\nand development.\n\n\n"},{"category":"Nursing/other","chartdate":"2128-04-12 00:00:00.000","description":"Report","row_id":1695935,"text":"0700-1900 NPN\nI have read and agree with the above note written by , PCA.\n\n: Mom called this am, updated on patient's current status by this RN. Mom states she will be in for the evening care. Continue to support family.\n"},{"category":"Nursing/other","chartdate":"2128-04-13 00:00:00.000","description":"Report","row_id":1695936,"text":"2 Resp.\n Infant remains in room air with sats over 95.No spells so\nfar tonight.Lungs clear and equal.continue to monitor and\nrecord any changes.\n3 F/N\n Abdomen soft, + bowel sounds, 0 loops, 0 distention,\nbottled well all shift. Total fluids in last 24 hours were\n205cc per K.Voiding, stooling.Wt up 65gms to 2.450. Continue\nper plans.\n4 \n called early part of shift, given updates. Plan to\nkeep family informed.\n\n\n"},{"category":"Nursing/other","chartdate":"2128-04-13 00:00:00.000","description":"Report","row_id":1695937,"text":"Neonatology Attending\naddendum: PE\n\nActive sleep, appropriate activity, . AFOF. Lungs cta, heart rrr s murmur, abd soft, extr well perfused.\n"},{"category":"Nursing/other","chartdate":"2128-04-13 00:00:00.000","description":"Report","row_id":1695938,"text":"Neonatology Attending\n is 40do, 36 wks\nRA, open crib cobedding with \n a/b day \nwt 2450 up 65g on adlib minTF140 Mm24/E24\n\nMeds Fe\n\nImp/ age appropriate cvr immaturity, improving; demonstrating mature feeding skills. Had late (~48hr) +Bcx for S epi last week, repeat cx negative, likely contaminant.\n\nPlan/ continue to monitor cvr status, growth/development\n"},{"category":"Nursing/other","chartdate":"2128-04-13 00:00:00.000","description":"Report","row_id":1695939,"text":"Neonatology Attending\naddendum: PE\n\nActive sleep, appropriate activity, . AFOF. Lungs cta, heart rrr s murmur, abd soft, extr well perfused.\n"},{"category":"Nursing/other","chartdate":"2128-04-13 00:00:00.000","description":"Report","row_id":1695940,"text":"0700-1900 NPN\n\n\nRESP: Infant remains in RA, O2 sats=96-100%. RR=30=60's.\nBreath sounds clear and equal bilaterally, no retractions\nnoted. No bradys, no desats so far this shift. Continue to\nto monitor resp status.\n\nFEN: Ad with a minimum of 140cc/kg/d of BM24 with\nenfamil powder/E24, all PO's. Infant has bottled 90cc and\n55cc with good coordination so far this shift. Waking approx\nq4hr for feeds. Abdomen , soft, round, +BS, no loops. No\nspits. Voiding and stooling (guiac negative). Continues on\nIron. Continue to monitor FEN status.\n\n: Mom called this afternoon,, updated on patient's\ncurrent status by this RN. Mom states she will be in later\ntoday. Continue to support family.\n\nG+D: Temps stable, swaddled in . Cobedding with sister.\nActive and with cares, sleeps well in between cares.\nBrings hands to face, sucks on pacifier for comfort.\nContinue to support G+D.\n\n\n"},{"category":"Nursing/other","chartdate":"2128-04-06 00:00:00.000","description":"Report","row_id":1695908,"text":"NPN 1900-0700\n\n\nRESP: Infant remains in RA. O2sat 97-100%. RR 30-50's.\nOccasional mild IC/SC rtx. LS clear and equal. No spells, no\ndesats. Did have some HR and sat drifts when choking with\nfeed or spits.\n\nFEN: wt2200g (up 45g). TFmin 140cc/kg of BM/E24. Yest\nTFI=174cc/kg. Bottling adequate volumes with good\ncoordination. Abdomen soft, +BS, no loops, spits X2,\nvoiding, no stool. On Fe.\n\n: Mom called X1, updated over the phone. Asking about\nrepeat hearing screen. Will be in later today.\n\nG&D: Temps stable, swaddled in open crib. Cobedding with\nsiblings. and active with cares. Occasionally wakes\nfor feeds. Hands to face. Continues with small amt of\nyellow/green right eye drainage, warm soaks done every care.\n\n\n\n"},{"category":"Nursing/other","chartdate":"2128-04-06 00:00:00.000","description":"Report","row_id":1695909,"text":"Neonatology Attending\n is 33do, 35 wks corrected\nRA, open crib cobedding with sibs\nDay without a/b (last episode at 4am)\nDesat to 85 post feed this am - selfresolved\n\nWt 2200 up 45 on ad lib minTF140 MM/E24 po\n\nMeds Fe\n\nHead u/s this am prelim nl\nPassed hearing screen\n\nImp/ age appropriate cvr/feeding immaturity, approaching readiness for d/c\nPlan/ continue to monitor cvr status, growth/development. D/c planning in progress for as early as Thurs contingent upon further evidence of maturity.\n\n"},{"category":"Nursing/other","chartdate":"2128-04-06 00:00:00.000","description":"Report","row_id":1695910,"text":"Neonatology - NNP Progress Note\n\n is active with good tone. AFOF. She is , well perfused, no murmur auscultated. She is comfortable in room air. No spells today. Breath sounds clear and equal. She is tolerating full volume po feeds. Abd soft, active bowel sounds, no loops. Voiding and stooling. Stable temp cobedding with sibs. Head ultrasound today normal. Please refer to neonatology attending note for detailed plan.\n"},{"category":"Nursing/other","chartdate":"2128-04-06 00:00:00.000","description":"Report","row_id":1695911,"text":"NPN 0700-\n\n\n2. In RA with sats 95-100%. Lungs clear, RR 30-60's. Mild\nSC retractions. One desat to 85% after 0830 feed, QSR. No\nA&B's thus far. Day brady countdown. Cont to monitor\nfor A&B's or desats.\n\n3. Infant on ad lib with min. 140cc/k/d BM24 or E24. Abd\nbenign. Voiding and no stool thus far. Min. Tf intake 51cc\nevery 4hrs and infant able to bottle 65 and 67cc Q4hr well.\nOne small spit thus far. Tolerating all PO's. Cont to\nmonitor ability to take bottles or breast feed.\n\n4. Mother called and updated on plan of care. Mother\nunable to visit today and plans to visit tomorrow at noon.\nSpoke with mother about possible D/C date for Thursday.\nFather is out of town on business in and is trying\nto get home for Thursday. Mother aware that we may be able\nto D/C triplets on Friday if Father is unable to get home by\nThurs. Cont to support, update, and prepare for D/C.\n\n5. Temp stable swaddled in open crib. Infant is cobedding\nwith siblings. and active with cares, resting well\ninbetween. MAE, suckles well on pacifier. Cont to promote\nG&D.\n\n\n\n\n"},{"category":"Nursing/other","chartdate":"2128-03-19 00:00:00.000","description":"Report","row_id":1695828,"text":"PCA 1900-0700\n\n\n2\ninfant remains in RA, RR 20-60, SATing 93-99%, lung sounds\ncl=, sc retractions, no spells. P:cont. to monitor.\n\n3\ninfant's current weight 1580g up 20g, remains on TF min of\n150cc/kg/d of BM/PE 26 with promod=40cc q4h gavaged over 90\nminutes. abd full/soft, bs+, no loops, ag stable 23.5-24.5,\nmax asp. 5.2cc partially digested BM, small spit X1,\nvoiding/stooling qs heme. neg. P:cont. to support\nnutritional needs.\n\n4\nno known contact thus far.\n\n5\ninfant remains swaddled in OAC, temp. stable, and\nquietly active during cares,settles well in between, likes\npacifier, fonts soft/flat. P:cont. to support dev. needs.\n\n\n"},{"category":"Nursing/other","chartdate":"2128-03-19 00:00:00.000","description":"Report","row_id":1695829,"text":"PCA 1900-0700\n#3 Infant's AG remains stable at 24.5cm, active bowel soundAddendum to above: I have examined this infant and agree wis, soft abdomen, non tender (no guarding), transient soft loth note above, see above correction for additional information. ops noted at 4am, residual at this time 8.2cc. No spits. Discussed with NNP, residual refed, and regualr feeding given. Will Contnue to monitor abdominal exam very closely.\n\n\n"},{"category":"Nursing/other","chartdate":"2128-03-19 00:00:00.000","description":"Report","row_id":1695830,"text":"PCA 1900-0700\n#3 Infant's AG remains stable at 24.5cm, active bowel soundAddendum to above: I have examined this infant and agree wis, soft abdomen, non tender (no guarding), transient soft loth note above, see above correction for additional information. ops noted at 4am, residual at this time 8.2cc. No spits. Discussed with NNP, residual refed, and regualr feeding given. Will Contnue to monitor abdominal exam very closely.\n\n\n"},{"category":"Nursing/other","chartdate":"2128-03-19 00:00:00.000","description":"Report","row_id":1695831,"text":"Neonatology Attending Note\nDay 15\nCGA 33\n\nRA. RR20-60s. Cl and = BS. +SC/IC rtxns. On caffeine. No A&Bs. HR 160-180s. No murmur. , well perfused. BP 66/39, 49.\n\nWt 1580, up 20 gms. TF 150 cc/k/day PE/BM26 w promod. PG over 90 minutes. Small spits.\nPassing stool. Nl voiding.\n\nIn open crib.\n\nA/P:\nGrowing preterm infant with resolving , learning how to po feed. Will try smaller feedings at closer intervals to reduce degree of spitting.\n\nImproved , will d/c caffeine which may also improve spitting.\n\n"},{"category":"Nursing/other","chartdate":"2128-04-05 00:00:00.000","description":"Report","row_id":1695902,"text":"1900-0700 NPN\n\n\nRESP: Infant remains in RA, O2 sats=95-100%. RR=30-50's.\nBreath sounds clear and equal, no retractions noted. No\nbradys, no desats so far this shift. Continue to monitor\nresp status.\n\n: Mom called this evening, updated on patient's\nstatus by this RN. Mom states she will be in for afternoon\ncares. Continue to support/educate family.\n\nG+D: Temps stable, swaddled in . Cobedding with sister\nand brother. Active and with cares, sleeps well in\nbetween cares. Brings hands to face, sucks on pacifier for\ncomfort. Continue to support G+D.\n\nFEN: Weight tonight=2.155kg (-10grams). Ad lib on demand\nwith a min of 140cc/kg/d of BM24 with enfamil powder/E24.\nInfant has taken all PO's so far this shift. Infant has\nbottled 55cc and 54cc so far this shift with good\ncoordination. Waking q4hr for feeds. Abdomen , soft,\nround, +BS, no loops. Minimal aspirates, no spits. Voiding,\nno stool. Continue to support FEN status.\n\n\n"},{"category":"Nursing/other","chartdate":"2128-03-18 00:00:00.000","description":"Report","row_id":1695823,"text":"NICU NSG NOTE\n\n\n#2. Resp. O/ RA. LS clear and equal. RR 30-60's. Baseline\nretractions. No spells. A/ Stable. P/ Cont to monitor.\n\n#3. FEN. O/ Wt up 50g. TF 150cc/k/d BM26 with PM. Receiving\nq4h volumes via gavage over 90 mins for hx spits. No spits\nthus far. Abd soft. No loops. +BS. Voiding and stooling. A/\nTolerating feeds. Gaining wt. P/ Cont to monitor for feeding\nintolerances. Daily wts.\n\n#4. Parenting. No contact with family thus far this shift.\n\n#5. G&D. O/ Warm in off isolette. Transitioned to open crib\nwith stable temps. and active for cares. Not waking on\nown for feeds. Nested and swaddled on sheepskin. A/ AGA. P/\nCont to support developmental needs of infant.\n\n\n"},{"category":"Nursing/other","chartdate":"2128-03-18 00:00:00.000","description":"Report","row_id":1695824,"text":"NICU nursing progress note\n\n\nPlease refer to flowsheet for specific info.\nResp\nO: remains in room air, RR 40-60's occ 70's. Sat's\n>97%, mild sc ret. BSCE bilat. NO brady's, on caffeine. A:\nStable P: cont to follow.\nFEN\nO: TF are 150cc/k/d of PE or BM 26 with promod. Abd , no\nloops, active bs Voiding/ stooling. Feedings are gavaged\nover 90\" due to hx of spits. Min asp. A: Stable. P: cont to\nfollow.\nGD\nO: Temps stable in oac cobedding with trip #3 brother,\nactive and with cares, does not wake for feeds. MAE.\nFonts soft, flat. Brings hands to face. Calms with\ncontainment and pacifier. A: AGA P: cont to support\ndev.milestones.\nParenting\nO: Mom planning on visiting at 12pm, also awaiting transfer\nto Hosp. when beds are avail. for triplets.\nA: and invested with extensive family support\nsystem on mother's side. P: cont to update, support,\neducate. D/C planning is ongoing. Will transfer to when beds are avail.\n\n\n"},{"category":"Nursing/other","chartdate":"2128-04-05 00:00:00.000","description":"Report","row_id":1695903,"text":"Neonatology Attending\n i s 32do, 35 /47 wks\nDay without a/b\nWt 2155 down 10 on ad lib minTF140 MM/E24 -- took 160cc/kg/24hrs\n\nPE active, appropriate, . AFOF. Lungs cta, heart rrr s murmur, abd soft, extr well perfused.\n\nImp/ approaching readiness for d/c\nPlan/ continue to monitor cvr status, growth/development. Tentative d/c Thurs contingent upon further evidence of maturity.\n"},{"category":"Nursing/other","chartdate":"2128-04-05 00:00:00.000","description":"Report","row_id":1695904,"text":"Nursing NICU Note\n\n\n#2. Respiratory O: Pt. remains in RA, O2 sats >95%. RR\n~30-50's, no increase work of breathing noted. LS clear/=.\nNo A&B's or sat drifts noted this shift thus far. This is\nDay #2 of 5 for a spell count. A: Pt. is stable in RA. P:\n Continue to monitor respiratory status. Monitor for A&B's.\n\n#3. FEN O: Pt. is ad lib Min 140cc/kg/d of BM24 w/Enfamil\npowder or E24 =50cc Q 4hrs. She is takeing all PO feeds\n45-70cc PO in addition to breastfeeding x1. Abdomen is\nsoft, , +BS, no loops/spits noted. A: Pt. is\ntolerating current nutritional plan. P: Continue w/\ncurrent feeding plan. Monitor for s/s of intolerance.\nEncourage PO feeds.\n\n#4. O: Mom in to visit this afternoon and was\nupdated on pt's current status and daily plan of care.\n are active and involved in cares, asking appropriate\nquestions. A: Family is and involved. P: Continue\nto udpate, support and educate. Continue w/ discharge\nteaching/planning.\n\n#5. Grwoth/Development O: Pt. remains in an open crib,\nco-bedding w/ her siblings. She is and active w/\ncares, sleeps well in between. Fontanelle soft/flat. She\nloves to use her pacifier, brings hands to face. A: AGA\nP: Continue to provide environment appropriate for growth\nand development.\n\n\n"},{"category":"Nursing/other","chartdate":"2128-04-05 00:00:00.000","description":"Report","row_id":1695905,"text":"PT\n seen for developmental evaluation. She was positioned in prone and supported sitting positions. She tolerated them well. She is able to clear her airway in prone but is unable to turn her head. Talked to Mom briefly and will meet with her later in week to discuss discharge teaching and developmental play.\n"},{"category":"Nursing/other","chartdate":"2128-04-06 00:00:00.000","description":"Report","row_id":1695906,"text":"NPN 1900-0700\nInfant passed hearing screen.\n"},{"category":"Nursing/other","chartdate":"2128-04-06 00:00:00.000","description":"Report","row_id":1695907,"text":"NPN 1900-0700\nInfant passed hearing screen.\n"},{"category":"Nursing/other","chartdate":"2128-03-18 00:00:00.000","description":"Report","row_id":1695825,"text":"Neonatology Attending Note\nDay 14\nCGA 36 2\n\nRA. RR50-60s. No A&Bs. No murmur. On caffeine.\n\nWt 1560, up 50 g. TF 150 cc/k/day BM/PE26 w promod. PG over 90 min. Nl voiding and stooling.\nOn Fe and Fe.\n\nIn open crib.\n\nA/P:\nGrowing preterm infant learning how to po feed.\n"},{"category":"Nursing/other","chartdate":"2128-03-18 00:00:00.000","description":"Report","row_id":1695826,"text":"Clinical Nutrition\nO:\n~33 wk CGA BG on DOL 14.\nWT: 1560g(+50); birth wt: 1345g. Average wt gain over past wk ~23g/kg/day.\nHC: 28.75cm( %ile); last wk: 27.5cm\nLN: 38cm(<10 %ile); last wk: 38cm\nMeds include Fe & Vit.E\nLabs noted.\nNutrition: 150cc/kg/day as PE/BM 26 w/promod, all pg over 90 mins. Average of past 3-day intake ~141cc/kg/day, providing ~122kcal/kg/day & ~3.8-4.1g pro/kg/day.\nGI: Abdomen benign.\n\nA/Goals:\nTolerating feeds w/o GI problems over extended feeding times d/t h/o spits; all pg. Labs noted & within acceptable range. Current feeds & supps meeting recs for kcal/pro/vits/mins. Growth is exceeding recs for WT/HC gains of ~15-20g/kg/day for WT gain & of ~0.5-1cm/wk for HC gain. LN gain is not meeting recs of ~1cm/wk. Will monitor long term trends. Will continue to follow w/ team & participate in nutrition plans.\n"},{"category":"Nursing/other","chartdate":"2128-03-18 00:00:00.000","description":"Report","row_id":1695827,"text":"Fellow note; physical exam\n and active in open crib. Breathing comfortably in RA. SKin . AFOF. Lungs clear. No murmur. Abd soft, ND, +BS. Extrem WWP. Good tone.\n\n"},{"category":"Nursing/other","chartdate":"2128-04-04 00:00:00.000","description":"Report","row_id":1695899,"text":"1900-0700 NPN\n\n\nRESP: Infant remains in RA, O2 sats=96-100%. RR=30-50's.\nBreath sounds clear and equal, occasional mild SCR noted. No\nbradys, no desats so far this shift. Continue to monitor\nresp status.\n\nFEN: Weight tonight=2.165kg (+30 grams). TF=150cc/kg/d of\nBM26/PE26 alternating PO/PG q4hr. Infant bottled 35cc at\n0000 with good coordination but does tire easily. Abdomen\n, soft, round, +BS, no loops. Minimal aspirates, small\nspit x 1 so far this shift. Voiding/no stool. Continue to\nmonitor FEN status.\n\n: Mom called this evening, updated on patient's\ncurrent status by this RN. Mom states she will be in\ntomorrow for the afternoon care. Continue to support/educate\nfamily.\n\nG+D: Temps stable, swaddled in . Cobedding with sister\nand brother. Active and with cares, sleeps well in\nbetween cares. Brings hands to face, sucks on pacifier for\ncomfort. MAE. Continue to support G+D.\n\n\n"},{"category":"Nursing/other","chartdate":"2128-04-04 00:00:00.000","description":"Report","row_id":1695900,"text":"Newborn Med Attending\n\nDOL#31. Cont in RA, no spells. AF flat, clear BS, no murmur, abd soft, MAE. WT=2165 up 30, on 150 cc/kg/d BM26 PO/PG.\nA/P: Growing infant working up on PO feeds.\n"},{"category":"Nursing/other","chartdate":"2128-04-04 00:00:00.000","description":"Report","row_id":1695901,"text":"Nursing NICU Note\n\n\n#2. Respiratory O: Pt. remains in RA, O2 sats >96%. RR\n~40-70's, no increase work of breathing noted. LS clear/=.\nNo A&B's noted this shift thus far. A: Pt. is stable in\nRA. P: Continue to monitor respiratory status. Monitor\nfor A&B's.\n\n#3. FEN O: Pt. is now ad lib Min 140cc/kg/d of BM24\nw/Enfamil powder or E24 =51cc Q 4hrs. She has taken all PO\nfeeds this shift thus far ~48-54cc PO Q feed. Pt. requires\nfrequent burping. Abdomen is soft, , +BS, no\nloops/spits noted. She is voiding/ no stool noted this\nshift thus far. A: Pt. is tolerating current nutritional\nplan. P: Continue w/ current feeding plan. Monitor for s/s\nof intolerance. Continue to encourage PO feeds as pt. looks\ninterested and tolerates.\n\n#4. O: Mom called this am and was updated on pt's\ncurrent status and daily plan of care. are active\nand involved in cares. A: Family is and involved.\nP: Continue to update, support and educate. Continue w/\ndischarge teaching/planning.\n\n#5. Growth/Development O: Pt. remains in an open crib,\nswaddled and co-bedding w/ siblings. Temps stable. She is\n and active w/ cares, sleeps well in between.\nFontanelle soft/flat. She loves to use her pacifier, brings\nhands to face. A: AGA P: Continue to provide environment\nappropriate for growth and development.\n\n\n"},{"category":"Nursing/other","chartdate":"2128-03-25 00:00:00.000","description":"Report","row_id":1695856,"text":"npn 1900-0700\n\n\n\n2: resp\nremains in ra. no spells. no dsats. RR 30-50's. Lung sounds\nclear and equal. mild subcostal retractions. no increased\nwob noted. continue to monitor for changes in resp status.\n\n3: fen\ncurrent weight 1790gms up 20gms. total fluids remain at\n150cc/kilo/day of pe 26. tolerating feeds well. no spits\nthus far this shift. minimal aspirates. abd soft with no\nloops. stable girths. voiding, stooled x's 1 hem negative.\ncontinues on vit e and iron. hob elevated for spiting.\n\n4: \nmom called this shift x's 1. updated by this rn. very \nand involved. asking appropriate questions. continue to\nsupport family needs.\n\n\n5: G/D\ntemps stable in an open crib. co-bedded with sibblings.\n and active with cares. sleeps well inbetween.\nsucks vigorously on pacifier. brings hands to face. continue\nto monitor for developmental milestones.\n\n\n"},{"category":"Nursing/other","chartdate":"2128-03-17 00:00:00.000","description":"Report","row_id":1695820,"text":"NPN 1900-0700\n\n\n2.Resp: Infant remains in room air with RRs 20s-50s, 02\nsats> 98%. Lung sounds are clear and equal with mild\nsubcostal retractions. She remains on caffeine, no spells\nthus far this shift. Continue to monitor respiratory status.\n\n3.FEN: Infant's weight tonight 1510g (up 60g). She remains\non TF 150cc/kg/day of PE/BM 26cal/oz with Promod via NGT\nover 1 hr 30 minutes. Infant is tolerating feeds well with\none small spit, max aspirate 2.4cc of non-bilious, partially\ndigested formula. Abdomen is soft and round with active\nbowel sounds, no loops. Abdominal girth consistent 22-23cm.\nShe is voiding, one trace stool thus far this shift.\nRemains on vitamin E and Fe+ dietary supplements. Vitamin E\ngiven this shift. Continue to monitor FEN status and weight\ngain.\n\n4.: Dad in to visit this evening, updated at bedside.\n He participated in the care of this infant and then held\nfor one hour. Dad is and appropriate, asking\nappropriate questions. Mother is planning to visit\ntomorrow, will call to confirm. Possible transfer to . Transfer paperwork on front of chart.\n need to sign consent for transfer. Continue to\nsupport and keep informed.\n\n5.DEV: Infant remains in an off isolette with stable temps.\nShe is swaddled with head of bed at 45 degrees. She is \nand active with cares, irritable at times. She brings hands\nto face and sucks vigorously on pacifier. Mom wants to\nbathe tomorrow. Continue to support growth and development.\n\n\n\n\n"},{"category":"Nursing/other","chartdate":"2128-03-17 00:00:00.000","description":"Report","row_id":1695821,"text":"Neonatology Attending Note\nDay 13\nCGA 32 5\n\nRA. RR20-50s. Cl and =. Mild sc retractions. >96% sats. On caffeine. No A&Bs. No murmur. HR 140-160s. BP 57/39, 44.\n\nWt 1510, up 60 gms. TF 150 cc/k/day BM/PE26 w promod. PG over 1.5 hrs. Tol well. Nl voiding and stooling, g-.\n\nOn Vit E and Fe.\n\nIn off warmer.\n\nA/P:\nGrowing preterm infant.\n- monitor AOP\n- cont to monitor growth on current nutrition\n- awaiting bed availability at Hospital\n"},{"category":"Nursing/other","chartdate":"2128-03-17 00:00:00.000","description":"Report","row_id":1695822,"text":"Nursing NICU Note\n\n\n#2. Respiratory O: Pt. remains in RA, O2 sats ~ 97-99%.\nRR ~50-60's. No increase work of breathing noted. LS\nclear/=. She has mild SC retractions noted. No A&B's noted\nthis shift thus far. A: Pt. is stable in RA. P: Continue\nto monitor respiratory status. Monitor for A&B's.\n\n#3. FEN O: TF 150cc/kg/d of BM26 w/PM or PE26w/PM =38cc Q\n4hrs, gavaged over 1hr 30min, tolerated well. Abdomen is\nsoft, , +BS, no loops/spits noted. Abdominal girth is\n22.5-23cm. She is voiding/ passed tiny amount of stool x1.\nA: Pt. is tolerateing current nutritioanl plan. P:\nContinue w/ current feeding plan. Monitor for s/s of\nintolerance.\n\n#4. O: Mom and grandmom in to visit for 1200\ncares. They were updated at bedside on pt's current status\nand daily plan of care. Mom is actively participateing in\ncares, asking appropriate questions. A: Family is \nand involved. P: Continue to update, support and educate.\n\n#5. Growth/Development O: Pt. remains in an off Isolette,\nswaddled w/ stable temps. She is and active w/ cares,\nsleeps well in between. Fontanelle soft/flat. She uses her\npacifier on occasion, brings hands to face. A: AGA P:\nContinue to provide environment appropriate for growth and\ndevelopment. Plan to transition infant into crib later\ntoday.\n\n\n"},{"category":"Nursing/other","chartdate":"2128-03-25 00:00:00.000","description":"Report","row_id":1695857,"text":"Clinical Nutrition\nO:\n~34 wk CGA BG on DOL 21\nWT: 1790 g (+20)(~25th %ile); birth wt: 1345 g. Average wt gain over past wk ~18 g/kg/day.\nHC: 30 cm (~25th %ile); last: 28.75 cm\nLN: 41.5 cm (~10th to 25th %ile); last: 38 cm\nMeds include Fea dn Vit E\n not due yet\nNutrition: 150 cc/kg/day PE 26 (no BM for now due to mom dumping since she is on medication). Average of past 3 day intake ~150 cc/kg/day, providing ~130 kcal/kg/day and ~3.6 g pro/kg/day.\nGI: Abdomen benign.\n\nA/Goals:\nTolerating feeds without GI problems. not due. Current feeds + supps meeting recs for kcals/pro/vits and mins. Growth is meeting recs for wt gain. HC and LN gain are exceeding recommended ~0.5 to 1 cm/wk for HC gain and ~1 cm /wk for LN gain. Will follow long term trends. Will continue to follow w/ team and participate in nutrition plans.\n"},{"category":"Nursing/other","chartdate":"2128-03-25 00:00:00.000","description":"Report","row_id":1695858,"text":"Neonatology-NNP Physical Exam\n\n remains in RA. Active, in an open crib, AFOF, sutures opposed, good tone. BBS clear and equal with good air entry. No murmur, pulses +2, , RRR. Abdomen soft, non-distended, tolerating feeds. Please refer to attending progress note for detailed plan.\n"},{"category":"Nursing/other","chartdate":"2128-03-25 00:00:00.000","description":"Report","row_id":1695859,"text":"Neonatology Attending\n21do, 33 wks corrected.\n remains in RA, open crib cobedding with sibs.\nNo a/b.\nWt up 20g to 1790 on TF150 PE26 pg\n\nMeds vit E, Fe\n\nImp/ age-appropriate feeding immaturity; growing well.\nPlan/ continue to monitor cvr status, growth & development.\n\n"},{"category":"Nursing/other","chartdate":"2128-03-25 00:00:00.000","description":"Report","row_id":1695860,"text":"2. remains in RA, RR30-60, mild sc retractions, sats\n90-99, BBSclear, equal, one brief self-resolving brady P:\ncontinue to monitor.\n3. TF 150cc/k/d PE26 45cc pg over 80 min, abd soft, no\nloops, active bowel sounds, minimal aspirates, no spits,\nvoiding, no stool.\n4. Mom here at 1300, held babies, planning to bring in\nbreast milk tommorrow A: very involved and concerned P:\ncontinue to update and offer support.\n5. temp stable swaddled in open crib with siblings, active\nwith cares, soon to try po feedings P: continue to support\ngrowth and development.\n\n\n"},{"category":"Nursing/other","chartdate":"2128-04-10 00:00:00.000","description":"Report","row_id":1695925,"text":"Nursing progress note\n\n\n #2 O: Remains in room air with equal & clear breath sounds\n& no retractions. No A's, B's or desats noted. A: Stable. P:\nCont to assess.\n#3 O: Wgt up 65 gms. Waking for feeds & feeding well with\nyel nipple. Voidng with diaper changes. No stool. Abd soft\nwith active bowel sounds & no loops. No spits. A: Tolerating\nfeeds & gaining wgt. P: Cont to assess.\n#5 O: Temp stable, co-beeding with twin. Waking for feeds &\nbottling well. with cares. A: AGA. P: Cont to assess.\n#8 O: Temp stable. with cares. No spells. A: No signs\nof sepsis. P: Cont to assess.\n\n\n\n"},{"category":"Nursing/other","chartdate":"2128-04-03 00:00:00.000","description":"Report","row_id":1695897,"text":"NICU Attending Note\n\nDOL # 30 = 35 1/7 weeks CGA with resolving A/B learning to PO feed.\n\nAll interval hx and data reviewed, patient examined, care discussed.\n\nCVR/RESP: RRR without murmur, and well perfused, no increaased WOB, BS clear/=, remains in RA, occasional O2 drifts with bottles, day of spell countdown. Will continue to monitor.\n\nFEN: Abd benign, NTND, no HSM. Weight 2135 gm, up 60 gm on 150 cc/kg/d MM/PE 26, PO/PG. Will continue to encourage PO intake.\n\nNEURO: AFSOF, appropriate tone and strength, active and .\nHead U/S Tuesday.\n"},{"category":"Nursing/other","chartdate":"2128-04-03 00:00:00.000","description":"Report","row_id":1695898,"text":"Nursing NICU Note\n\n\n#2. Respiratory O: Pt. remains in RA, O2 sats ~91-100%.\nLS clear/=. RR ~30-60's, no increase work of breathing\nnoted. She has occasional sat drifts w/ feeds that self\nresolve. No A&B's noted this shift thus far. This is Day\n#1 of 5 day spell count. A: Pt. is stable in RA. P:\nContinue to monitor respiratory status. Monitor for A&B's.\n\n#3. FEN O: TF 150cc/kg/d of BM26/PE26 =53cc Q 4hrs\nalternateing PO/PG feeds. She has taken 50cc and 35cc w/\nthe remainder gavaged. Pt. tireing out easily by the end of\nher last feed. Abdomen is soft, , +BS, no loops/spits\nnoted. She is voiding/ sm. stool passed x1. A: Pt. is\ntolerating current nutritional plan. P: Continue w/\ncurrent feeding plan. Montor for s/s of intolerance.\nContinue to encourage PO feeds as pt. looks interested and\ntolerates.\n\n#4. O: Mom in to visit for afternoon cares. She\nwas updated at bedside on pt's current status and daily plan\nof care. are active and involved in cares, asking\nappropriate questions. A: Family is and involved.\nP: Continue to update, support and educate. Continue w/\ndischarge teaching.\n\n#5. Growth/Development O: Pt. remains in an open crib,\nswaddled and co-bedding w/ her siblings. Temps stable. She\nis and active w/ cares, sleeps well in between.\nFontanelle soft/flat. She loves to use her pacifier, brings\nhands to face. A: AGA P: Continue to provide environment\nappropriate for growth and development.\n\n\n\n\n\n\n"},{"category":"Nursing/other","chartdate":"2128-04-10 00:00:00.000","description":"Report","row_id":1695926,"text":"Neonatology Attending Progress Note:\n\nDOL #37, CGA 36 1/7 weeks\nRA, RR=30-60's, one brady yesterday with feeds (Day #1 of 5)\nHR=150-160's\nsepsis eval this week for decreased temp, blood culture #1 GPC pairs/chains and repeat blood culture off antibiotics negative\n2310g (inc 65g), ad lib min 140cc/kg/d (taking 161 in past 24 hours)\nvoiding, stooling\nco-bedding\n\nPE: well appearing, AFOF, normal S1S2, no murmur, breath sounds clear, abdomen soft, nontender, nondistended, ext warm, well perfused. tone aga.\n\nImp/Plan: premie twin with and positive blood culture probable contaminant.\n--monitor for spells\n--check second blood culture, if change in symptoms or positive blood culture, will have low threshold for starting antibiotics.\n"},{"category":"Nursing/other","chartdate":"2128-04-10 00:00:00.000","description":"Report","row_id":1695927,"text":"8 Infant with Potential Sepsis\n\nNursing PRogress Note:\n#2 - RESP: REmains in room air. Lungs clear and equal. RR\n30-50. O2Sat > 93%. No spells/desats today. Not being fed\non monitor. Day brady count.\n\n#3 - F&N: Ad lib demand feeder with min of 140cc/kilo =\n54cc's q 4 hours. Bottling between 65-80cc's of E24/BM24.\nOccassionally small spits or wet burps noted. Abdomin soft\nand round. Voiding good amount. Stooling with each diaper\nchange. Iron given.\n\n#4 - : Mom in this afternoon. Updated at the bedside.\nIndependent with cares. Holding and feeding babies.\nEncouraged to get help set up for when the babies are all\nhome. Mom states that plenty of people in the community\noffered to help when needed. All ready setting up dinners\nfor the family for the next 2 months.\n\n#5 - G&D: Temps stable in open crib. Co-bedding with\nsibling. and active with cares. MAE> AFSF. Bottling\nall feeds. Hx of normal head US.\n\n#8 - Potential sepsis: 2nd blood culture neg. Believe first\npositive culture to be a contaminent. Problem resolved.\n\n\nREVISIONS TO PATHWAY:\n\n 8 Infant with Potential Sepsis; resolved\n\n"},{"category":"Nursing/other","chartdate":"2128-04-11 00:00:00.000","description":"Report","row_id":1695928,"text":"NPN 2300-0700\n\n\n2. O: Infant remains in room air. O2 sats 98-100%. RR\n40-50's. No A&B's thus far. Last A&B . A: brady\ncountdown continues.P: Continue to assess.\n\n3. O: Wt.+30g 2340g. Yesterday received 156cc/kg/d. Infant\nbottling 75cc every 4-5 hours. Abdomen soft. +b.s. No loops\nnoted. No spits noted. Wet burps noted. vdg & stooling q.s.\nA; Bottling well. P: Continue to assess weight gain.\n\n4. O : No parental contact noted thus far.\n\n5. O: co-bedding with sister. Maintaining temperature.\nMAE. Brings hands to face. Active & . Waking for feeds.\nNested with boundaries. A: AGA P: Continue to support\ndevelopment.\n\n\n"},{"category":"Nursing/other","chartdate":"2128-03-15 00:00:00.000","description":"Report","row_id":1695815,"text":"NPNOte;\n\n\n#2. Remains in R air, BBS clear, equal, easy resp effort, no\nspells thus far this shift. On Caffine given as ordered.A;\nNo spells thus far this shift. P; cont to monitor.\n\n#3. TF=150cc/kg/day,MBM26/PE26 with promod, pg fed over 1hr\n30mts, no spits, BS+, no loops, voided, no stool thus far\nthis shift. A; Feeds tolerated. P; cont current feeding\nplan.\n\n#5.,active with care, temp stable in a air mode\nisolette, swaddled with blanket, mae. A; AGA P; cont dev\nsupport.\n\n\n"},{"category":"Nursing/other","chartdate":"2128-03-16 00:00:00.000","description":"Report","row_id":1695816,"text":"PCA 1900-0700\n\n\n2\ninfant remains in RA, RR 30-50, lung sounds cl=, sc\nretractions, no spells, P:cont. to monitor.\n\n3\ninfant's CW 1450g up 70g, remains on TF min. 150cc/kg/d of\nPE/BM 26 with promod=36cc q4h gavaged over 90 minutes. abd\nsoft, bs+, no loops, ag stable 22.5-23.5 cm, min. asp.,\nsmall spit X1, voiding stooling qs heme. neg. P:cont. to\nsupport nutritional needs.\n\n4\nno known contact thus far.\n\n5\ninfant remains swaddled in air isolette, temp. stable, a/a\nwith cares, settles well in between, fonts soft/flat, brings\nhands to mouth. P:cont. to support dev needs\n\n\n"},{"category":"Nursing/other","chartdate":"2128-03-16 00:00:00.000","description":"Report","row_id":1695817,"text":"Addendum NPN\nI have examined this infant and agree with the above written statement by , PCA.\n"},{"category":"Nursing/other","chartdate":"2128-03-16 00:00:00.000","description":"Report","row_id":1695818,"text":"Neonatology note\n12 d.o\nin , caffeine, no spells.\nAFOF\nRR with no mumrur\nclear lungs\nwt= 1450 gm +70, 150 cc/klg/d with EBM 26 + promod.\nabdomen osft\nnormal tone\nmild jaundice.\nA: ex 30 wks GA, AOP, growing preemie.\nP: continue current management.\n"},{"category":"Nursing/other","chartdate":"2128-03-24 00:00:00.000","description":"Report","row_id":1695850,"text":"npn 1900-0700\n\n\n2: resp\nremains in ra. one spell thus far this shift. see flow\nsheet. rr 40-70's. sats >93%. Lung sounds clear and equal.\nmild subcostal retractions. no increased wob noted. continue\nto monitor for changes in resp status.\n\n3: fen\ncurrent weight 1770gms up 40gms. total fluids remain at\n150cc/kilo/day of PE 26. tolerating feeds well. no spits\nthus far. minimal aspirates. voiding and stooling. stable\ngirths. abd soft with no loops. feeds run over 1hr 15min for\nhx of spits.\n\n4: \nno contact thus far this shift.\n\n5: g/d\ntemps stable in an open crib. and active with cares.\nsleeps well inbetween. co-bedded with sibblings. brings\nhands to face. aga. continue to monitor for developmental\nmilestones.\n\n\n\n"},{"category":"Nursing/other","chartdate":"2128-03-24 00:00:00.000","description":"Report","row_id":1695851,"text":"Neonatology\nRA. Comfortable. SIngle spell over night. Off caffeine.\n\nWt 1760 up 40. TF at 150 cc/k/d of 26 cal. Abdomen benign. STill requiring gavage. Extended infusion time for spits. Abdomen benign.\n\nLeg slightly swollen last night, b ut this am looks normal to exam. No swelling or tenderness. Hips normal.\n\nDiaper rash improved. Will dc local rx.\n\nAwaiuting maturation of resp control and feeds.\n"},{"category":"Nursing/other","chartdate":"2128-03-24 00:00:00.000","description":"Report","row_id":1695852,"text":"Neonatology-NNP Physical Exam\nNo edema in lower extremities.\n"},{"category":"Nursing/other","chartdate":"2128-03-24 00:00:00.000","description":"Report","row_id":1695853,"text":"Neonatology-NNP Physical Exam\n\n remains in RA. Active, in an open crib, AFOF, sutures opposed, good tone, nevus simplex on left eyelid. BBS clear and equal with good air entry. No murmur, pulses +2, , RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds. Please refer to attending progress note for detailed plan.\n"},{"category":"Nursing/other","chartdate":"2128-03-24 00:00:00.000","description":"Report","row_id":1695854,"text":"NICU nursing progress note\n\n\nPLease refer to flowsheet for specific info.\nResp\nO: remains in room air, RR 20-50's, sat's 94%. BSCE\nbilat. NO brady's. Off of caffeine. A: Stable. P: cont to\nfollow.\nFEN\nO: Tf of 150cc/k/d of PE 26 gavaged over 80\" due to hx of\nspits. No spits. Min asp. Abd soft, , no loops, active\nbs. Voiding/ no stool thus far today. HOB ^15 degrees due to\nhx of spits and placed prone. A: Stable. P: Infant HOB\n^15degrees and place prone to prevent spits. Follow.\nGD\nO: Temp stable in oac, co-bedding with siblings, active and\n with cares. MaE. Fonts, soft, flat. Calms with\ncontainment and pacifier. Left eye with elevated and\npossibly ^ vascularization making more . Cont to follow.\nA: AGA P: cont to follow.\nParenting\nMom is pumping and discarding bm due to cytotec med. Please\nrefer to Trip 32 note.\n\n\n"},{"category":"Nursing/other","chartdate":"2128-03-24 00:00:00.000","description":"Report","row_id":1695855,"text":"NICU nursing progress note\n referred to is #2.\n"},{"category":"Nursing/other","chartdate":"2128-03-16 00:00:00.000","description":"Report","row_id":1695819,"text":"NICU nursing progress note\n\n\nPLease refer to flowsheet for specific info.\nResp\nO: remains in room air, rr 30-50's, sat's >97%. Mild\nsc ret. BSCE bilat. On caffeine, no brady's. A: Stable. P:\ncont to follow.\nFEN\nO: TF of 150cc/k/d of PE or BM 26 w/ promod, gavaged over\n90\". No spits. Max asp of 3cc partially digested formula.\nAbd , no loops, active bs. Voiding/ stooling. Girth\nstable at 22cm. A: stable. P: cont to follow.\nGD\nO: Temp stable in off isolette. Active and with cares.\nMAE. Fonts soft, flat. A: AGA P: cont to support dev.\nmilestones.\nParenting\nO: Mom in and updated at bedside, verbalizing understanding.\n Agreeable to transfer to SCN\nwhen beds are available. A: Mom and dad are and\ninvested with large network of family support on\nmom's side. P: cont to update, support, educate.\n\n\n"},{"category":"Nursing/other","chartdate":"2128-04-02 00:00:00.000","description":"Report","row_id":1695891,"text":"Nursing\n\n\n#2O: In room air with o2 sats> 94% with occ. rare desat;\nhad 1 spell with apnea and desat, self-resolved. Br. sounds\nclear with mild retractions.\n#3O: Wt. up 40g on 150cc/kg, BM26, q 4 hr. feeds. Belly\nsoft, voids qs, 1 stool. Bottled 1 feed well, 1 feed fair,\nand gav. x 1. Minimal asp. and no spits.\n#4O: Mom visited and is independent with cares. Handles\nwell and competently.\n#5O: Co-bedding with siblings. Active with cares, likes\nbeing swaddled.\n\n\n"},{"category":"Nursing/other","chartdate":"2128-04-02 00:00:00.000","description":"Report","row_id":1695892,"text":"Neonatology Attending\n is 29do, 35 wks corrected\nRA, open crib cobedding with sibs\nHas had one spont a/b episode with stim (1hr after eating); one feed-associated\nWt 2075 up 40 on TF150MM/PE24 pg/po (getting close to 50% po)\nMeds Fe, vit E\n\nImp/ age-appropriate feeding & cvr immaturity.\nPlan/ continue to monitor cvr status, growth/development. Will need at least 5 days more for \"apnea countdown\".\n"},{"category":"Nursing/other","chartdate":"2128-04-02 00:00:00.000","description":"Report","row_id":1695893,"text":"Neonatology Attending\nAddendum: PE\nActive, appropriate, . AFOF. Lungs cta, heart rrr s murmur, abd soft, extr well-perfused.\n"},{"category":"Nursing/other","chartdate":"2128-04-02 00:00:00.000","description":"Report","row_id":1695894,"text":"NPN\n\n\n2. Infant in RA on O2sat and CVR monitor. VSS as charted on\nflow sheet. and well perfused. BBS cl and equal. No\nmurmur. Brady x1 with HR 66/ O2sat 72% requiring mild stim.\nStable in RA. Cont to have occ apnea/bradycardia.\nCont to monitor.\n3.TF 150cc/kg/day. MBM26/PE26 Alt po/pg. Attempted po at\n1200 and required supplemental pg to meet min. requirement.\n\n\n"},{"category":"Nursing/other","chartdate":"2128-04-02 00:00:00.000","description":"Report","row_id":1695895,"text":"NPN continued\n\n\n3. ABd benign. Soft no loops. Voiding and stooling.\nInfant attempting to advance on po feeds. Still requiring\npg.\nCont to attempt po as tol. PG as necessary.\n4. in for 1200 feeding. Held infant comfortably and\noffered po feeding. Discussed discharge criteria and plan\nfor support when infants go home. will be in \nfrom Mon through Friday next week. Mat grandmother plans to\nbe with mom.\nIntact involved family. Cont to support.\n5. In open crib cobedding with siblings. Temp stable. Sucks\nvigorously on pacifier. Settles with swaddling and\nboundries.\nCont to promote optimal growth and development.\n\n\n"},{"category":"Nursing/other","chartdate":"2128-04-09 00:00:00.000","description":"Report","row_id":1695921,"text":"1900-0700 NPN\n\n\nRESP: Infant remains in RA, O2 sats=97-100%. RR=30-50's.\nBreath sounds clear and equal bilaterally, no retractions\nnoted. Brady x2 with feeds so far this shift (see flowsheet\nfor details). Continue to monitor resp status.\n\nFEN: Weight=2.245 (-5 grams). Ad lib with a min of\n140cc/kg/d of BM24 with enfamil powder/E24/ all PO's. Infant\nhas bottled 56cc and 60cc with fair coordination so far this\nshift (brady x2 with feeds, see flowsheet). Waking approx\nq4-4.5hrs for feeds. Abdomen , soft, round, +BS, no\nloops. No spits. Voiding and stooling (guiac negative).\nContinue to monitor FEN status.\n\n: Mom called this evening, updated on patient's\ncurrent status by this RN. Mom states she does not want to\ntransfer girls to at this time. Cont to support\nfamily.\n\nG+D: Temps 97.8-98.0. Infant swaddled in , cobedding with\nsister. Active and with cares, sleeps well in between\ncares. Brings hands to face, sucks on pacifier for comfort.\nMAE. Continue to support G+D.\n\n\n"},{"category":"Nursing/other","chartdate":"2128-04-09 00:00:00.000","description":"Report","row_id":1695922,"text":"Neonatology NP Exam Note\nPlease refer to attending note for deatils of evalaution and plan.\n\nPE: small infant cobedding in open crib. and well perfused, and active.\nAFOF, eyes clear, MMMP\nChest clear and equal.\nCV: RRR, no murmru, pulses+2=.\nAbd: soft, active BS, NTND\nGU: normal external female genitalia\nExt: MEA, WWP\nNeuro: symmetric tone and reflexes\n"},{"category":"Nursing/other","chartdate":"2128-04-09 00:00:00.000","description":"Report","row_id":1695923,"text":"Neonatology Attending\n is 36do, 36wks corrected\nRA, open crib cobedding with \n without spont a/b; 3 bradycardic episodes with bottling overnight\nWt 2245 down 5 on minTF140 MM/E24 po -- taking well over minimum\n\nImp/ age-appropriate cvr/feeding immaturity\nPlan/ continue to monitor cvr status, growth/development; d/c planning in progress contingent upon further evidence of maturity.\n"},{"category":"Nursing/other","chartdate":"2128-04-09 00:00:00.000","description":"Report","row_id":1695924,"text":"NPN 0700-1900\n\n8 Infant with Potential Sepsis\n\n#2Resp: Pt. remains on RA, RR 30-50's, sats > 96%. No\nretractions. Lungs clear bilaterally. No spells so far\nthis shift. Pt. is on day#2 of a 5 day spell count. P:\ncontinue to monitor resp status.\n\n#3FEN: Pt remains adlib w/ min 140cc/kg/day of BM 24cal/oz\nor E 24cal/oz. Pt. is taking 55-60cc po Q 4hrs. Abd soft &\nround, +BS, no loops. Spit X 1. Pt. voiding. No stool so\nfar this shift. D/S 88. P: continue to monitor FEN.\n\n#4Parenting: called this am. Updated r/t positive\nbld cx from . asking questions. P:\ncontinue to support & update.\n\n#5G&D: Temps stable swaddled cobedding w/ sister. Awake &\n for cares. Wakes quietly for feeds. MAE's .\nLikes pacifier. P: continue to support dev needs.\n\n#8Pot. sepsis: Pt. had positive bld cx from . NNP\nnotified. CBC & bld cx drawn NNP. No abx started @\nthis time. P: continue to monitor.\nSee flowsheet for further details.\n\n\n\nREVISIONS TO PATHWAY:\n\n 8 Infant with Potential Sepsis; added\n Start date: \n\n"},{"category":"Nursing/other","chartdate":"2128-03-14 00:00:00.000","description":"Report","row_id":1695809,"text":"NPN:\n\nRESP: Sats 95-100% in RA. RR=40-70 w/SC retraction. BBS =/clear. No A&Bs thus far tonight; x 1 over past 24 h. Remains on Caffeine.\n\nCV: No murmur. HR=130-150s. BP=65/54 (59). Color w/jaundice. Perfusion good.\n\nFEN: Wt=1370g (+ 10g). TF=150c/kg/d; 34cc BM/PE-24 q 4 h via NG over 70 min. Tolertating fdgs well w/o spits; minimal residuals. Abd benign. Voiding qs; sm stool. Vit E and FeS04 to begin today.\n\nG&D: CGA=32 wk. Temp stable in air-controlled isolette. Active and w/cares. Nested in sheepskin and resting well. AF soft, flat. HUS planned for .\n\nSOCIAL: No contact w/. Possible transfer to w/i near future; live in Canterbury, NH.\n"},{"category":"Nursing/other","chartdate":"2128-04-03 00:00:00.000","description":"Report","row_id":1695896,"text":"NPN 1900-0700\n\n\n #1 RESP S/O: Infant in RA, rr 40-70's. Lungs are clear with\nno retractions. O2 sats >95% with some drifting with\nbottling into the high 80's. No spells. A: Stable P:\nContinue to support.\n\n#2 FEN S/O: TF 150cc/k/d. Infant to get bm or pe 26, 53cc\nq4h po/pg. Infant bottled 60cc x1 so far this shift. Abdomen\nis benign, voiding. Desitin applied to bottom. No asp, one\nsmall spit. A: Tolerating feeds. P: Continue to support.\n\n#4 Parenting S/O: No contact.\n\n#5 DEV S/O: Infant cobedding with siblings in . and\nactive. Waking for cares. Clear eye drainage both eyes, warm\nsoaks. A: AGA P: Continue to support dev.\n\n\n\n\n"},{"category":"Nursing/other","chartdate":"2128-03-14 00:00:00.000","description":"Report","row_id":1695810,"text":"Neonatology Attending\n\nDOL 10 CGA 32 2/7 weeks\n\nStable in RA. 1 A/B. On caffeine.\n\nBP 65/54 mean 59\n\nOn 150 cc/kg/d BM/PE 24 pg over 1 hr 10 min. Voiding. Stooling. Wt 1370 grams (up 10).\n\n visiting and up to date.\n\nA: Doing well. Spells controlled on caffeine. Tolerating feeds.\n\nP: Monitor\n Advance to 26 cal\n\n\n"},{"category":"Nursing/other","chartdate":"2128-03-14 00:00:00.000","description":"Report","row_id":1695811,"text":"Neonatology Attending\nExam AF soft, flat, clear bs, no murmur, benign abd, and comfortable in RA, active and responsive to exam\n"},{"category":"Nursing/other","chartdate":"2128-03-14 00:00:00.000","description":"Report","row_id":1695812,"text":"Nursing Progress Note\n\n\n2. Resp O/A Rec'd inf in RA. Inf remains in RA. 1X\nspell thus far, see flowsheet. Mild SCR noted. Inf\ncontinues on caffeine. P cont to assess resp needs.\n3. FEN O/A TF=150cc/kg/day. Cal increased today to BM or\nPE26. All feedings PG over 1 hr 10 min. Tol feedings well,\nmin asp, sm spit thus far. Belly soft, no loops. Girth\nstable. Inf voiding, stooling guiac neg. P cont to assess\nFEN needs.\n4. O/A Mom in for visit and cares. Held all 3\ntriplets. Mom independent with temp taking, diapering\ninfants. Dad in for visit. Updates to both paretns. P\ncont to support, educate. ? transfer to .\n5. DEV O/A is in an off isolette with stable temp.\nA/A w/cares. Sleeping well between cares. P cont to assess\ndev needs.\nSee flowsheet for further details.\n\n\n"},{"category":"Nursing/other","chartdate":"2128-03-15 00:00:00.000","description":"Report","row_id":1695813,"text":"NURSING PROGRESS NOTE\n\nRESP/CV: REMAINS IN RA WITH 02 SATS >94%. BS CL&=, NO MURMER. COLOR AND WELL PERFUSED. BP STABLE. NO A&B'S OR DESATS NOTED THIS SHIFT. REMAINS ON CAFFEINE.\n\nFEN: WEIGHT UP 10GMS TO 1380GMS. TOTAL FLUIDS REMAIN AT 150CC/KG/D OF PE26CAL. ABD SOFT, WITH STABLE GIRTH AND +BS. VOIDING AND STOOLING WNL. NO SIGNIFICANT RESIDUALS AND OCCAS EMESIS NOTED.\n\nDEV: TEMP STABLE IN HEATED ISOLETTE. ACTIVE AN WITH INTERVENTIONS.\n\nSOCIAL: MOM X 1, WILL VISIT IN AM.\n"},{"category":"Nursing/other","chartdate":"2128-03-15 00:00:00.000","description":"Report","row_id":1695814,"text":"Neonatology note\n11 d.o\nin RA, 1 spells, on caffeine\nRR with no murmur\nclear lungs\nabdomen soft\nwt= 1380 gm +10, 150 cc/kg/d with PE 26\nAFOF\nnormal tone\nA: ex 30 wks GA, AOP, growing preemie\nP: consider transfering to if acceptable to , add promod.\n\n"},{"category":"Nursing/other","chartdate":"2128-04-01 00:00:00.000","description":"Report","row_id":1695886,"text":"1900-0700 NPN\n\n\nRESP: Infant remains in RA, O2 sats=97-100%. RR=40-60's.\nBreath sounds clear and equal bilaterally, mild SCR noted.\nNo bradys, no desats so far this shift. Continue to monitor\nresp status.\n\nFEN: Weight tonight=2.035kg (+45 grams). TF=150cc/kg/d of\nPE26/BM26 PO/PG q4hr. Attempting to bottle feed infant\nqshift. Infant bottled 50cc at with good coordination.\nGavage feedings given over 1hr/tolerated well. Abdomen ,\nsoft, round, +BS, no loops. No spits, no aspirates.\nVoiding/no stool. Continue to monitor fen status.\n\n: No contact with so far this shift.\n\nG+D: Temps stable, swaddled in . Cobedding with sister\nand brother. Active and with cares, sleeps well in\nbetween. Brings hands to face, sucks on pacifier for\ncomfort. MAE. Hepatitis B vaccine given (see\nflowsheet/patient's chart for details). Continue to support\nG+D.\n\n\n"},{"category":"Nursing/other","chartdate":"2128-04-01 00:00:00.000","description":"Report","row_id":1695887,"text":"Clinical Nutrition\nO:\n~35 wk CGA BG on DOL 28\nWt: 2035 g (+45)(~25th to 50th %ile); birthwt: 1345 g. Average wt gain over past wk ~17 g/kg/day.\nHC: 30 cm (~10th to 25th %ile); last: 30 cm\nLN: 42.5 cm (~10th to 25th %ile); last: 41.5 cm\nMeds include Fe and Vit E\n noted\nNutrition: 150 cc/kg/day BM/PE 26, po/pg. Infant po feeds ~1x per shift, takes ~ volume po. Average of past 3 day intake ~150 cc/kg/day, providing ~130 kcal/kg/day and ~3.2 to 3.6 g pro/kg/day.\nGI: Abdomen benign.\n\nA/Goals:\nTolerating feeds without GI problems. noted and within acceptable range. Current feeds + supps meeting recs for kcals/pro/vits and mins. Growth is meeting recs for wt gain and LN gain. HC shows no change over past wk; will follow long term trends. Will continue to follow w/ team and participate in nutrition plans.\n"},{"category":"Nursing/other","chartdate":"2128-04-01 00:00:00.000","description":"Report","row_id":1695888,"text":"Neonatology Attending\n is 28do, 34 wks corrected.\nRA, open crib cobedding with sibs\nNo a/b; occ desat with feeds\nWt 2035 up 45 on TF150 MM/PE24 pg>po - did take full bottle this am!\n\nMeds Fe, vit E\nGot HBV this am\n\nImp/ age-appropriate cvr/feeding immaturity; making good progress.\nPlan/ continue to monitor cvr status, growth/development. D/C planning in progress contingent upon further evidence of maturity.\n"},{"category":"Nursing/other","chartdate":"2128-04-01 00:00:00.000","description":"Report","row_id":1695889,"text":"Neonatology Attending\nAddendum: PE\nActive sleep, appropriate activity, s distress. AFOF.\nLungs CTA, heart RRR s murmur, abd soft, extr well perfused.\n"},{"category":"Nursing/other","chartdate":"2128-04-01 00:00:00.000","description":"Report","row_id":1695890,"text":"NPN .\n\n\n# Received infant in RA on CVR and O2sat monitors. VSS as\ncharted on flow sheet. BBS clear and equal. No murmur. ,\nwell perfused. No A's or B's at this time. Abd soft, no\nloops. Active bowel sounds. A/G stable. Tol full volume of\n150cc/kg/day. No spits, no asp. PO full volume x1, ng fed\nx1. Mom due in for next feed at 1600. Currently on MBM26/PE\n26. Will approach mom about attempting BF. Plan to request\n to bring in carseat soon for testing prior to\ndischarge. Cobedding with siblings. Tol well. Maintaining\ntemp well. Needs hearing screen.\nStable growing preemie advancing on po feedings. \ninvolved.\nCont to monitor for apnea and bradycardia. Cont to suport\n toward discharge. Cont to offer po as tol. NG feed\nas necessary. Encourage mom to put infant to breast.\n\n\n"},{"category":"Nursing/other","chartdate":"2128-04-17 00:00:00.000","description":"Report","row_id":1695956,"text":"NURSING PROGRESS NOTE\n\n\n2. RESPIRATORY\nNO ISSUES. NO SPELLS.\n3. F/N\nTONIGHT'S WEIGHT UP 65 GRAMS TO 2.61KG. TOOK IN 189CC/KG.\nVOIDING AND STOOLING.\n4. \nNO CONTACT.\n5. G&D\nREADY FOR DISCHARGE.\n\n\n"},{"category":"Nursing/other","chartdate":"2128-04-17 00:00:00.000","description":"Report","row_id":1695957,"text":"Neonatology Attending Progress Note\n\nAddendum - PE\nSee Physician Exam form.\n"},{"category":"Nursing/other","chartdate":"2128-04-17 00:00:00.000","description":"Report","row_id":1695958,"text":"Neonatology Attending Progress Note\n\nAddendum - PE\nSee Physician Exam form.\n"},{"category":"Nursing/other","chartdate":"2128-04-17 00:00:00.000","description":"Report","row_id":1695959,"text":"Neonatology Attending Progress Note\n\nNow day of life 44, CA 1/7 weeks.\nIn RA with RR 40-60s.\nNo apnea and bradycardia since .\nHR - 140-160s.\n\nWt. 2610gm up 65gm on ad volumes of feedings - took in 189cc/kg/d yesterday.\nFeedings well tolerated.\nNormal urine and stool output.\n\nAssessment/plan:\nBaby is doing very well.\nReady for discharge to home today.\nAppointment wtih pediatrician to be set for early this week.\n\n\n"},{"category":"Nursing/other","chartdate":"2128-03-22 00:00:00.000","description":"Report","row_id":1695845,"text":"NICU nursing progress note\n\n\nPlease refer to flowsheet for specific info.\nResp\nO: remains in room air, RR 40-60's, sat's >95%. Mild\nsc ret. Off of caffeine, no brady's for >48 hours. A:\nstable. Breathing comfortably. P: cont to follow.\nFEN\nO: TF of 150c/k/d of pe 26 or bm 26 gavaged over 75\". HOB\nelev. feedings well tolerated, though does wake at times and\ncry, then falls back asleep most likely refluxing. Abd ,\nno loops, active bs. voiding/ no stool today. No spits min\nasp. A: stable. P: follow.\nGD\nO: TEmp stable in oac co-bedding with siblings. Active and\n with cares. MAE. Fonts soft, flat. Left eye with\nslightly more raised area? Examined by Dr. , no\nnew orders at this time/ monitor for changes. A: AGA P: cont\nto follow and support dev. milestones.\n\n\n"},{"category":"Nursing/other","chartdate":"2128-03-23 00:00:00.000","description":"Report","row_id":1695846,"text":"NPN 1900-0700\n\n\n2. RESP: pt remains in RA with RR 30-50's. Mild S/C\nretractions. Sats >95%. No spells noted so far this shift.\nWill monitor closely.\n\n3. F&N: TF remain at 150cc/k/dof BM/PE26. Feeds gavaged\nin over 1 hour 15 minutes. Abd benign. BS+. A/G stable.\nNo spits and minimal aspirates noted. Voiding and passing\nlarge green guiac negative stool. Weight gain 25 grams.\n\n4. PAR: No contact from so far this shift.\n\n5. DEV: is active and during her cares. Temp\nstable swaddled in open crib. Red non-draining area noted\non her right eye lid. Will monitor. Micostatin powder to\nbuttocks as ordered.\n\n\n\n"},{"category":"Nursing/other","chartdate":"2128-03-23 00:00:00.000","description":"Report","row_id":1695847,"text":"Neonatology\nRA. Comfortable apeparing. Spells not a problem.\n\nWt 1730 up 25. toleraing feeds at 150 cc/k/d of 26 cal. Abdomen benign. Still requiring gavage.\n\nOn mycostatin for diaper rash. Will contiunue through tomorrow as is improving.\n\nLeft eye drainage noted w/o signs of infection.\n\nContinue to await maturation of feeds.\n"},{"category":"Nursing/other","chartdate":"2128-03-23 00:00:00.000","description":"Report","row_id":1695848,"text":"Neonatology-NNP Physical Exam\n\nInfant remains in RA. Active, in an open crib, AFOF, sutures opposed, good tone. BBS clear and equal with good air entry. No murmur, pulses +2, , RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds. Left eye slightly edematous, miost likely dependent edema. Please refer to attending progress note for detailed plan.\n"},{"category":"Nursing/other","chartdate":"2128-03-23 00:00:00.000","description":"Report","row_id":1695849,"text":"NPN7a7p\n\n\nResp\nInfant in RA with adeq sats. LSC. No bradys. Monitor and\nsupport resp status.\nFen\nInfant on TF 150 cc/k/d of BM or PE26. BM on hold until\nthursday (2nd to Moms medication) Abd soft, round with\nactive BS. No spits today. Max asp of 4 cc partially\ndigested formula. AG stable. Voiding. No stool. Monitor\nweight and exam.\nParenting\nSee #3 note for details. invested and . Lrg\nfamily support. Educate and support .\nG/D\nInfant cobedding with sibs. Stable temps. Warm this\nafternoon with hat on. No evidence of yeast in groin.\nTomorrow will be day 5, prob DC nystatin powder then. Infant\nwith some dependent edema of eyes and limbs. Edema of left\nlower leg not improved with different position. Pitting. Dr\n aware and assessed, cont to monitor. A/A for cares.\nSleeps quietly in between. Does not disturb easily by sibs.\nMAEs. FS&F. Uses pacifier with support. AGA. Monitor and\nsupport G/D.\n\n\n\n"},{"category":"Nursing/other","chartdate":"2128-04-17 00:00:00.000","description":"Report","row_id":1695960,"text":"Nursing D/C note\n\n\nInfant ready for d/c. Vitals stable this shift, now day \nof spell countdown (no spells since ).\nInfant bottling well on E24, taking > than minimum\nrequirements, voiding and stooling. Will be d/c'd home on\niron.\nVNA and pedi appt scheduled. All other d/c requirements\ncompleted. Currently awaiting : plan to review car\nseat positioning and any other infant care topics they might\nwant to review.\n\n\n\n"},{"category":"Nursing/other","chartdate":"2128-03-20 00:00:00.000","description":"Report","row_id":1695836,"text":"NICU nursing progress note\n\n\nPlease refer to flowsheet for specific info,\nResp\nO: remains in room air, RR 30-60's, sat's >95%. Mild\nsc ret. BSCE bilat. A: stable. breathing comfortably. No\nbrady's off of caffeine. P: cont to follow.\nFEN\nO: TF of 150cc/ k/ d of PE or bm 26 with promod, gavaged\nover 80\", and fed q 4 hours. Abd , no loops, active bs.\nVoiding/ stooling heme (-). Girth stable. Max asp of 5cc\npartially digested formula. No spits. A: Stable. P: cont to\nfollow.\nGD\nO: Temp stable in oac co-bedding with brother and .\nActive and with cares, though does not wake for feeds.\nMAE. Fonts soft, flat. Brings hands to face. A: AGA P: cont\nto support dev.milestones.\nParenting\nO: Mom, dad and older brother in and visited at bedside.\n updated and verbalizing understanding. A: Involved\nand invested . P: cont to update, support, educate.\nPlan is to transfer to Gen. Hospital when beds are\navailable for triplets.\n\n\n"},{"category":"Nursing/other","chartdate":"2128-03-20 00:00:00.000","description":"Report","row_id":1695837,"text":"Neonatology NP EXAM NOTE\nPLease refer to Dr note for detials of evaluation and plan,\n\n\nPE: samll infant in open crib cobedded with sibs.\nHEENT: AFOF, ng in place MMMP\nChest is clear with comfortable resp pattern\nCVB: RRR, nio murmu, pulses +2=\nABD: soft, active BS\nGU: deferred\nEXT: MAE< WWP\nNeuro: active and responsive, good tone\n"},{"category":"Nursing/other","chartdate":"2128-04-08 00:00:00.000","description":"Report","row_id":1695918,"text":"Neonatology - NNP Progress Note\n\n is active, with her exam today. AFOF. She is , well perfused, no murmur auscultated. She is comfortable in room air. Breath sounds clear and equal. She had some desats associated with apnea overnight - spell countdown restarted. She is tolerating full volume feeds, abd soft, active bowel sounds, no loops. Not quite as vigorous with po feeds yesterday and had moderate drop in temp to 97.5 while cobedding with sibs. In light of temp drop, decrease in feeding efforts and apnea, CBC with diff and blood culture sent. CBC: WBC 11.2, Hct-31.5, plt-671, 26% polys, 0% bands.\n\nA/P Active, well appearing infant this am, but some mild symptoms that may be suggestive of infection. Will continue to monitor closely. Will consider antibiotics if clinical picture deteriorates. Please refer to neonatology attending note for detailed plan.\n"},{"category":"Nursing/other","chartdate":"2128-04-08 00:00:00.000","description":"Report","row_id":1695919,"text":"Neonatology Attending\n is 35do, 35 wks corrected\nRA, open crib; occ sat drifts at rest and with bottles\nApnea/desat episode last pm, apparently obstructive (tongue at roof of mouth); now day 0-1/5\nAlso had temp drop (97.5 with good response to swaddling) - sepsis eval as noted by NNP Rivers\n\nWt 2250 up 20 on min TF130 MM/E24; not consistently waking for feeds\n\nMeds Fe\n\nImp/ immaturity of feeding/cvr/thermoregulation -- vs infection. Appears well overall.\n\nPlan/ continue to monitor cvr status, temp, growth/development. Will start abx if increased clinical suspicion.\n"},{"category":"Nursing/other","chartdate":"2128-04-08 00:00:00.000","description":"Report","row_id":1695920,"text":"NPN 7a-7p\n\n\n#2: remains in RA, sating >/= 94%. Occ drift in sat\nto mid 80's noted with QSR. RR stable. Rare intermittent\nSC retraction. BBS cl/=. Did have brady x1 with bottling\nfor Mom. responded appropriately and infant recovered\nwith removal of bottle and stim. Also had brady at rest.\nA: Stable in RA, Restart brady countdown. P:Cont to monitor\nand provide support as needed.\n\n#3: TF:min140cc/k/d. Conts on BM24 with Enfamil powder/E24.\nFeeding ~q4hrs, taking 54-70cc, with fair to good\ncoordination. Abd soft, +, no loops. Voiding qs.\nStooled x1. Small spits/wet burps at times. FeSO4 given.\nMom correctly drew up and administered dose. A: tol'ing all\nPO feeds, working on coordination P:Cont with current\nfeeding plan. Follow wt and exam. Monitor tol to feeds.\n\n#4: in for most of the afternoon. Update given. Mom\nmet with LC. Has scheduled for appt this weekend on Sat.\nA: Involved family, indep with care P:Cont to support and\neducate.\n\n#5: has been very /active today with cares. MAE.\nFonts soft/flat. Temps stable while swaddled in an open\ncrib. She is co-bedding with her sibling. A:AGA P:Cont to\nsupport dev needs.\n\n\n"},{"category":"Nursing/other","chartdate":"2128-03-21 00:00:00.000","description":"Report","row_id":1695838,"text":"NPN\n\n\n#2\nInfant remains in RA with sats >94% BS clear= with mild\nretractions. Color is ; well perfused. Murmer not\naudible. Infant has had one spell after a feed that was\nQSR.\n\n#3\nInfant remains on TF=150cc/k of BM/PE26 with promad q4\nhours. Infant has tolerated feeds via gavage over 80\nminutes without spits and only scant aspirates. Abd is soft\nand round; voiding well. Hypoactive/active BS. Trace/small\ngreen stools(g-) x2. Wt is up 30gms-1650.\n\n#4\nNo contact thus far from the .\n\n#5\nInfant remains in an open crib cobedding with her siblings.\nInfant is with cares; sucks on the pacifier. Fussy at\ntimes while feeding is infusing (?gassy)..settles once feed\nis complete.\n\n\n"},{"category":"Nursing/other","chartdate":"2128-03-21 00:00:00.000","description":"Report","row_id":1695839,"text":"Neonatology Attending\nDOL 17 / CGA 33-2/7 weeks\n\n remains in room air with no distress and one bradycardia in 24 hours (off caffeine).\n\nNo murmur. BP normal.\n\nWt 1650 (+30) on TFI 150 cc/kg/day BM26PM/PE26PM, tolerating by gavage over 75 minutes. Voiding and stooling normally. Abdomen benign.\n\nTemperature stable in open crib.\n\nFather and sibling have viral gastroenteritis.\n\nA&P\n30-6/7 week GA infant with respiratory and feeding immaturity\n-Continue to await maturation of oral feeding skills and respiratory drive\n-No changes in management as detailed above.\n"},{"category":"Nursing/other","chartdate":"2128-04-07 00:00:00.000","description":"Report","row_id":1695912,"text":"nursing\n\n\n#2O: In room air with O2 sats > 90% even with car seat\ntest. No spells or desats noted. br. sounds clear with\nmild retractions.\n#3O: wt. up 30g on BM24/B24. Wakes on own about every 4\nhrs. and bottles fairly well. Took in 188cc/kg . Belly\nsoft, voiding and stooling.\n#4O: No contact, mom will be into visit later and lactation\nappt. scheduled for today.\n#5O: Co-bedding with siblings, stable temp. Active with\ncares. Passed car seat screen.\n\n\n"},{"category":"Nursing/other","chartdate":"2128-04-07 00:00:00.000","description":"Report","row_id":1695913,"text":"Neonatology-NNP Physical Exam\n\nInfant remains in RA. Active, in an open crib, AFOF, sutures opposed, good tone. BBS clear and equal with good air entry. No murmur, pulses +2, , RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds. Please refer to attending progress note for detailed plan.\n"},{"category":"Nursing/other","chartdate":"2128-04-07 00:00:00.000","description":"Report","row_id":1695914,"text":"Neonatology Attending\n is 34do, 35 wks corrected\nRA, open crib cobedding with sibs\nDay s a/b\nWt 2230 up 30 g on ad lib min TF130 MM/E24 po\n\nMeds Fe\n\nImp/ age appropriate cvr immaturity, approaching readiness for d/c\nPlan/ continue to monitor cvr status, growth/development. Potential d/c tomorrow\n"},{"category":"Nursing/other","chartdate":"2128-03-21 00:00:00.000","description":"Report","row_id":1695840,"text":"NICU nursing progress note\n\n\nPlease refer to flowsheet for specific info.\nResp\nO: remains in room air, 30-70's, sat's >96%. Mild sc\nret. BSCE bilat. A: stable. breathing comfortably. No spells\noff of caffeine today.P: cont to follow.\nFEN\nO: TF of 150cc/k/d of PE or bm 26 w/ promod. GAvage fed\nover 75\" well tolerated. Abd , no loops, active bs.\nStable girth. No spits. Max asp of 2.2cc and benign.\nVoiding/ stooling heme (-). A: stable. P: cont to support\ndev.milestones.\nGD\nO: Temp stable in oac co-bedding with siblings. MAE. active\nand with cares. Font soft, flat. Brings hands to face.\nCalms with containment and pacifier. Irritable during\nfeedings/ waking, then crying and falls back asleep. A: AGA\nP: cont to follow and support dev.milestones.\nParenting\nO: Mom called and updated, sibling and dad have viral\ngastroenteritis. Mom states that she feels well, but will\ncall later instead of coming in to hospital. First night and\nfull day back in home in Canterbury NH. Plan is to transfer\ntriplets to when beds available. A:\n and invested . P: cont to update, support,\neducate.\n\n\n"},{"category":"Nursing/other","chartdate":"2128-03-21 00:00:00.000","description":"Report","row_id":1695841,"text":"Neonatology NP Exam NOte\nPE: small well appearing infant in open crib, cobedding with sibs.\nHEENT: AFOF, eyes with clear drainage, MMMP, ng in place.\nChest is clear,comfortable\nCV: RRR, pulses +2=, no murmur\nABd: soft active BS\nGU immature female genoitalia\nEXT, lean MAE, WWp\nNeuro: active and responsive symmetric tone and reflexes\n"},{"category":"Nursing/other","chartdate":"2128-03-22 00:00:00.000","description":"Report","row_id":1695842,"text":"NICU Nursing Note 1900-0700\n\n\n#1 RESP\nRA, RR 30-60's,clear and equal with mild subcostal\nretracitons. No spells.\nStable in room air, continue to follow.\n\n#3 FEN\nWeight tonight 1705gm (+55). TF 150 cc/kg/day of PE26PM. PG\nfed over 1hr 15min. No spits, minimal aspirates. Voiding and\nstooling. No loops. Tolerating feeds well. Continue to\nfollow.\n\n#4 Parenting\nNo contact.\n\n#5 G&D\nTemp stable cobedding with siblings in open crib. and\nactive with cares, irritable at times. Settles with\npacifier. MAE, symmetrical tone. AFSF. AGA. Continue to\npromote developmental growth.\n\n\n\n"},{"category":"Nursing/other","chartdate":"2128-03-22 00:00:00.000","description":"Report","row_id":1695843,"text":"Neonatology note\n18 d.o\nin RA, no spells, off caffeine.\nAFOF\n\nwt= 1705 gm +55, 150 cc/kg/d with 26 cal/oz\nRR with no murmur\nclear lungs\nabdomen soft\nMRSA(+) on skin\n\nA: ex 30 wks GA, growing preemie\nP: continue current management.\n"},{"category":"Nursing/other","chartdate":"2128-03-22 00:00:00.000","description":"Report","row_id":1695844,"text":"Neonatology note\ncorrection for above: skin culture negative.\n"},{"category":"Nursing/other","chartdate":"2128-03-19 00:00:00.000","description":"Report","row_id":1695832,"text":"NPN 7a7p\n\n\nRESP\nInfant in RA with adeq sats. No bradys. LSC. Mild S/C rtxs.\nCaffiene dcd today. Monitor and support resp status.\nFEN\nInfant on TF 150 cc/k/d of PE or BM26PM. Had been gavaging\nover 1.5 hrs q 4 hrs. Lrg benign asps overnight and this am\n(see careview) and lrg spit. Attempt to change feeds to q 3\nhrs per fellow. Next asp was 14 cc, benign, undigested\nformula, refed to infant and will wait 1 hr. Resume q 3 hr\nfeeds, changing gavage time to only 1 hr, per fellow. Abd\nsoft, lrg round. AG 24-25 cm, consistant. Some soft loops on\noccasion. Lrg loose liquid green stool, heme -. Infant with\nlrg benign asps, not tolerating TF regime presently. Cont to\nmonitor, maintain reflux precautions.\n\nMom and uncle came to visit and participate in cares. Mom\nindependent with cares. and appropiate with infants.\nAwaiting word on transfer to Hosp, maybe Monday.\nSigned up for CPR for Tuesday if infants are still here.\nPlans to drive home, NH this weekend. Anxious as this is her\n1st time back home since early . She is unsure if\nshe will visit tomorrow. She hopes to come in early before\nheading north. Mom had a number of hospital staff visitors\nshe became friendly with during her bedrest stay, come to\nsay hello and see babies. Mom appears to enjoy the attention\nand support. Cont to support and educate .\nG/D\nInfant in OAC with stable temps. Bedding alone without sibs\npresently due to need of lrger crib. A/A with cares. MAES.\nFS&F. Has new yeast rash in groin, ordered for nystatin\npowder. AGA. Monitor and support G/D.\n\n\n\n"},{"category":"Nursing/other","chartdate":"2128-03-19 00:00:00.000","description":"Report","row_id":1695833,"text":"Fellow note; physical exam\nSleeping comfortably in open crib. In RA. Skin . AFOF. Eyes clear. Lungs clear. RRR. No murmur. Normal femoral pulses. Abd soft, ND, +BS. Extrem WWP. Good tone.\n\nPossible transfer to on Monday.\n\n"},{"category":"Nursing/other","chartdate":"2128-03-20 00:00:00.000","description":"Report","row_id":1695834,"text":"npn 1900-0700\n\n\n2: resp\nremains in ra. no spells and no dsats. Rr 30-60's. Lung\nsounds clear and equal. mild subcostal retractions. no\nincreased wob noted. caffeine dc'd on day shift.\n\n3: fen\ncurrent weight 1620gms up 40gms. total fluids remain at\n150cc/kilo/day of pe/bm 26 with prom. infant having\naspirates of 4-6cc's. no spits. infant changed back to q 4\nhour feeds after 1am care. At 0100 infant had a 6cc aspirate\nof partially digested formula. 6cc's refed and subtracted to\nthe total feeding. abd soft with no loops. voiding, no stool\nthus far this shift. positive bowel sounds. stable girths.\ncontinue to monitor for changes in nutritional status.\n\n4: \nno contact thus far this shift.\n\n\n5: G/D\ntemps stable in an open crib. co-bedded with sister and\nbrother. and active with cares. sleeps well inbetween.\n\nbrings hands to face. aga. sucks vigorously on pacifier.\ncontinue to monitor for developmental milestones.\n\n\n"},{"category":"Nursing/other","chartdate":"2128-03-20 00:00:00.000","description":"Report","row_id":1695835,"text":"Neonatology Attending\n\nDay 16- CGA 33 1/7 weeks\n\nRemains in RA. RR 30-60. Mild retractions. No bradycardia- now off caffeine. BP mean 58. Weight 1620 gms (+40). TF at 150 cc/kg/d- PE 26 with Promod. Minimal aspirates overnight. Gavage fed every four hours. No spits. Benign abdomen. On iron, vitamin E. Stable temperature- co-bedding.\n\nDoing well overall. Monitoring closely. Gaining weight well. Tolerating feeds well. No changes for now. Mother up to date.\n\n"},{"category":"Nursing/other","chartdate":"2128-04-07 00:00:00.000","description":"Report","row_id":1695915,"text":"Clinical Nutrition\nO:\n~35 wk CGA BG on DOL 34\nWT: 2230 g (+30)(~25th %ile); birthwt: 1345 g. Average wt gain over past wk ~34 g/day.\nHC: 32 cm (~25th to 50th %ile); last: 30 cm\nLN: 44 cm (~10th to 25th %ile); last: 42.5 cm\nMeds include Fe\n not needed\nNutrition: Ad lib po's, minimum 140 cc/kg/day E24/BM 24 w/ Enfamil powder. Average of past 3 day intake ~164 cc/kg/day, providing ~2.2 to 2.8 g pro/kg/day and ~131 kcal/kg/day.\nGI: Abdomen benign.\n\nA/Goals:\nTolerating feeds without GI problems. not needed. Current feeds + supps meeting weaned recs for kcals/pro/vits and mins. Growth is meeting recs for wt gain. HC and LN gain are exceeding recommended ~0.5 to 1 cm/wk for HC gain and ~1 cm/wk for LN gain. Will follow long term trends. Will continue to follow w/ team and participate in nutrition plans.\n"},{"category":"Nursing/other","chartdate":"2128-04-07 00:00:00.000","description":"Report","row_id":1695916,"text":"Nursing NICU Note\n\n\n#2. Respiratory O: Pt. remains in RA, O2 sats >95%. LS\nclear/=. RR ~ 30-50's, no increase work of breathing noted.\n No A&B's noted this shfit thus far. A: Pt. is stable in\nRA. P: Continue to monitor respiratory status. Monitor\nfor A&B's.\n\n#3. FEN O: Ad lib w/ Min 140cc/kg/d of E24 or BM24w/\nEnfamil powder. She takes ~56-70cc PO Q feed, starting to\nwake more for feeds now. Abdomen is soft, , +BS, no\nloops, occasional wet burps/sm.spits noted. She is\nvoiding/ no stool noted this shfit. A: Pt. is tolerating\ncurrent nutritional plan. P: Continue w/ current feeding\nplan. Monitor for s/s of intolerance. Encourage PO feeds.\n\n#4. O: Mom in to visit and called in this am.\n Both updated on pt's current status and daily plan\nof care. are active and independent in cares. A:\nFamily is and involved. P: continue to update,\nsupport and educate. Continue w/ discharge\nteaching/planning.\n\n#5. Growth/Developement O: Pt. remains in an open crib,\nswaddled and co-bedding w/ her siblings. Temps stable. She\nis and active w/ cares, sleeps well in betweeen.\nFontanelle soft/flat. She loves to use her pacifier, brings\nhands to face. A: AGA P: Continue to provide environment\nappropriate for growth and development.\n\n\n"},{"category":"Nursing/other","chartdate":"2128-04-08 00:00:00.000","description":"Report","row_id":1695917,"text":"NPN 1900-0730\n\n\n2. RECEIVED INFANT IN RA. SAO2 B/T 93-99%. RR 50'S-60'S. NO\nINCREASED WOB NOTED. SPONTANOUS DESAT AT WITH SAO2 DOWN\nTO 61. NO CHANGE IN HR. +COLOR CHANGE. MILD STIM PROVIDED\nD/T APNEA. NOW STARTING DAY COUNT DOWN. MOTHER AWARE.\nSOME DRIFTING WITH FEEDS. WILL OBTAIN BCX, CBC PER ORDER OF\nNNP. PLAN; MONITOR FOR S/SX RESP/ DISTRESS. F/U WITH SPELL\nCOUNTDOWN. MONITOR CBC AND BCX.\n\n3. WT. 2.250GMS UP 20GMS FROM YESTEDAY. CONT. ADLIB WITH\n140CC MIN. TAKING B/T 45-55CC Q 4HR FEEDING. TOTAL IN 24HRS,\n136CC/K/D. STILL APPEARS SLIGHTLY UNCOORDINATED THIS SHIFT.\nABD SOFT, NO LOOPS, +BS. VOIDING, STOOLING GREENISH BROWN\nGUIAC- STOOL. PLAN; CONT. TO MONITOR INTAKE ON ADLIB\nSCHEDULE. BCX, CBC TO BE DRAWN.\n\n4. RN NOTIFIED MOM OF INFANT DESAT EPISODE AND THAT 5 DAY\nCOUNTDOWN WILL START AGAIN. MOM SOUNDING AND\nCONCERNED BUT ALSO RELEIVED THAT INFANT IS IN HOSPITAL WHEN\nEPISODE HAPPENED. PLAN; CONT. TO SUPPORT AND EDUCATE \n\n\n5. CONT. SWADDLED. CO-BEDDING WITH SIBLINGS. TEMP DOWN TO\n97.5. EXTRA BLANKET AND HAT ADDED. TEMP UP TO 98.1 WITHIN 10\nMINUTES. APPEARING UNCOORDINATED WITH FEEDS. SOME DRIFTING\nWITH SAO2. NP. BCX, CBC TO BE OBTAINED. MOVING ALL\nEXTREMETIES. WAKING FOR CARES. PLAN; F/U WITH BLOOD WORK.\nCONT. TO SUPPORT G/D.\n\n\n"},{"category":"Nursing/other","chartdate":"2128-03-05 00:00:00.000","description":"Report","row_id":1695771,"text":"Neonatology\nOn SIMV after second dose of surfactant this am. Mainly in RA, but increases with crying. Single bolus of NS last night. Will wean PIP again this am and recheck CBG. No evidence of PDA.\n\nWt 1345. Remains NPO on d10w. Abdomen benign. BS in good range.\n\nOn abx for 48 h r/o.\n\nBili to be checked with lytes later today.\n\nHUS for beginning of next week.\n"},{"category":"Nursing/other","chartdate":"2128-03-05 00:00:00.000","description":"Report","row_id":1695772,"text":"NPN DAYS\n\n\nInfant with Potential Sepsis: Blood cx pending. Remains on\nAmpicillin and Gent for 48 hr r/o. Will repeat CBC in the\nam.\n\nAlt in Resp: Received baby on settings of 20/5 rate 22.\nSurf'd for the 2nd time. Weaned to 18/5 rate 20 where she\nremains at this time. FiO2 21%. Occasional desats to the\n70's and 80's needing temporary increase of O2. LS clear and\nequal. Mild retractions. Sxn'd for small amounts cloudy\nsecretions. Will check blood gas with next set of cares to\nsee if vent settings can be weaned some more.\n\nAlt in FEN: NPO. TF 80cc/kg/day D10 via , change to\nPN this evening. Voiding. No stool. Belly benign. No spits.\nD/S 93. Lytes 139/4.0/108/17. Bili 4.2/0.2. Will continue\nwith current plan of care.\n\nAlt in Parenting: Dad up to visit several times during the\nday. Mom up x1 so far. Parents may hold this afternoon or\nevening. Updated them on the babies day. Will continue to\nprovide teaching and support.\n\nAlt in Growth and Dev: Temp up and down on warmer, ? r/t\nenvironmental temp changes. Awake and alert with cares.\nNested on sheepskin with boundaries in place. Will place in\nisolette this eve to try to regulate temp.\n\nAlt in CV: No murmur. Color pink and well perfused. BP\nstable, see flow sheet. NNP aware of BP 44/28 M34. Will\ncontinue to monitor closely.\n\n\n"},{"category":"Nursing/other","chartdate":"2128-03-05 00:00:00.000","description":"Report","row_id":1695773,"text":"Respiratory Care Note\nReceived pt on SIMV 20/5, RR 22, 21% Second dose of 5cc's of Survanta given at 0730. Given per protocol. Tol well. Weaned to 18/5, RR 20. CBG:7.44/27/31/19/-4. Extubated and placed on +5 prong CPAP, FiO2 25%. BS clear. RR 40-70's. Will follow on CPAP.\n"},{"category":"Nursing/other","chartdate":"2128-03-05 00:00:00.000","description":"Report","row_id":1695774,"text":"Fellow note; physical exam\nAlert and active. Breathing comfortably on SIMV. Skin pink. AFOF. Lungs with good aeration on vented and spontaneous breaths. RRR. Nl S1, S2. No murmur. Normal femoral pulses. Abd soft, ND, +BS. Normal female external genitalia. Extremities WWP. Good tone.\n\n"},{"category":"Nursing/other","chartdate":"2128-03-06 00:00:00.000","description":"Report","row_id":1695775,"text":"Respiratory Care\nBaby remains on cpap 5 21%.BS clear throughout.RR 30-70's.No spells documented thus far this shift.\n"},{"category":"Nursing/other","chartdate":"2128-03-06 00:00:00.000","description":"Report","row_id":1695776,"text":"Nursing progress note\n\n1 Infant with Potential Sepsis\n\n#2 O: Remains on 5cm prong CPAP, 21% O2. Breath sounds equal\n& clear with mild SC retractions. No A's, B's or desats. A:\nStable on CPAP. Cont to assess.\n#3 O: Wgt down 15gms. Remains NPO with at 80cc/k/d. DS\n82. UOP for previous 24 hrs was 2.8cc/k/h. No stool. Abd\nsoft with active bowel sounds & no loops. A: Receiving\nfluids as ordered. P: Cont to assess.\n#4 O: Parents up for visit. Mom held & Dad took\npictures. Parents spoke with Dr at bedside. A:\nInvolved parents. P: Supprot.\n#5 O: Received baby on warmer. Transferred to servo\nisolette. Temp stable. Nested in sheepskin. Alert with cares\n& irritable at times. A: Easily stressed. P: Cluster cares.\nCont to assess.\n#6 O: Mild gen edema. No murmur heard. BP mean was 38. Ruddy\n& well perfused. A: Stable. P: Cont to assess.\n\nOUTCOME EVALUATION:\n\n 1 Infant with Potential Sepsis\n MET [1] Infant will be free of signs and\n symptoms of sepsis.;\n Blood cultures neg to date.\n Remains on antibiotics. Repeat CBC\n & diff sent.\n\n\n"},{"category":"Nursing/other","chartdate":"2128-03-06 00:00:00.000","description":"Report","row_id":1695777,"text":"Neonatology Attending\n\nNow day of life 2 for this 30 week gestation .\nBaby remains stable on CPAP of 5 and in RA.\nRR - 50-60s.\nNo apnea and bradycardia.\n\nHR 130-150s BP 47/33 38\n\nWt. 1330gm down 15gm on PN/IL 80cc/kg/d\nNPO\nDS 82\nUO 2.8cc/kg/hr, no stool.\n\nID - repeat cbc pending - FU for neutropenia.\nOn amp and gent.\n\nBili - 4.2/0.2\n\nAssessment/plan\nVery nice progress.\nWill trial off CPAP today.\nFeedings to be initiated with PE.\nWill continue antibiotics while awaiting results of cbc.\n\n\n"},{"category":"Nursing/other","chartdate":"2128-03-06 00:00:00.000","description":"Report","row_id":1695778,"text":"Respiratory Care Note\nPt off CPAP today. Briefly on a 23%, 100cc nasal cannula. BS clear. RR 40-60's. No bradys or desats noted. IC/SubC retractions.\n"},{"category":"Nursing/other","chartdate":"2128-03-06 00:00:00.000","description":"Report","row_id":1695779,"text":"NPN DAYS\n\n6 ALt in CV d/t prematurity\n7 Bili\n\nInfant with Potential Sepsis: Blood cx pending. Remains on\nAmp and Gent. CBC with diff repeated today, see lab results.\n? d/c antibiotics if blood cx at 48hrs remains negative.\n\nAlt in Resp: CPAP removed at 12pm and baby placed on NC\n100cc flow, 21% FiO2. LS clear and equal. Mild retractions.\nNo spells. Tolerating NC without problems. Continue to\nmonitor.\n\nAlt in FEN: TF 80cc/kg/day. Enteral feeds of BM20 at\n20cc/kg/day, increasing 10cc/kg/ as tolerated. PND10 and\nlipids currently infusing via at 60cc/kg/day. D/S 79.\nVoiding, no stool. Belly benign. No spits. Will continue to\nincrease feeds as tolerated .\n\nAlt in Parenting: Parents up to visit and dad participated\nin cares. Updated them on the babies day. Family meeting to\nbe held 2pm Monday. Will continue to provide support and\nteaching.\n\nAlt in Growth and Dev: Temp stable in servo isolette until\nphototherapy started and then temp of isolette needed to be\nweaned, see flow sheet. Nested on sheepskin with boundaries\nin place. Will continue to monitor temp closely.\n\nAlt in CV: No murmur noted. Pink and well perfused, BP\nstable. Problem resolved.\n\nBili: Bili this afternoon 8.0/0.3 up from 4.2/0.2. Placed\nunder double phototherapy.\n\nREVISIONS TO PATHWAY:\n\n 6 ALt in CV d/t prematurity; resolved\n 7 Bili; added\n Start date: \n\n"},{"category":"Nursing/other","chartdate":"2128-03-05 00:00:00.000","description":"Report","row_id":1695767,"text":"Neonatology-NNP Procedure Note\n\nProcedure: Endotracheal intubation\nIndication: Respiratory distress\n\nInfant placed in supine position with cardio-respiratory monitor in place. Under direct laryngoscopy, the vocal cords were visualized using a size 0 blade. A 3.0 Fr ETT was inserted through the vocal cords and secured at 7cm. BBS were equal on auscultation. The infant tolerated the procedure without incident. A CXR will be obtained to confirm placement.\n"},{"category":"Nursing/other","chartdate":"2128-03-05 00:00:00.000","description":"Report","row_id":1695768,"text":"Nursing Admission Note\n\nInfant is a 30 week triplet (#1) born via c-section. Apgars 8,9.\nPlease refer to Dr. note for complete maternal history and\ndelivery room course. Infant admitted to NICU at 2150; G/F/R on admission, required BBO2 and then placed on nasal prong CPAP 6cm with\nFiO2 28-42% in order to maintain O2 sats in the 90's. RR 40-60's, LSC=, mild inter/subcostal retractions noted. AP stable, BP stable--\nsee flowsheet. No murmur. Capillary refill brisk, color ruddy. Infant\nalert and active, MAE, AFOF. CBC,diff. and blood cx drawn and sent\nto lab. Infant started on Ampicillin and Gentamicin as ordered.\nReceived baby care meds as per flowsheet. Infant's wt.1345 gms. NPO.\nPIV placed in infant's (R) hand; IVf infusing without incident; D10W\nat 80cc/k/day. Blood sugar 139. No void or stool output. Abd. soft,\nbowel sounds hypoactive. Temp. stable on open warmer with infant on\nservo control mode. CXR done.\n"},{"category":"Nursing/other","chartdate":"2128-03-05 00:00:00.000","description":"Report","row_id":1695769,"text":"NPN 11p-7a\n\n\n#1 Temp max 100.6x. On ampi and gent. Blood cx pending. Diff\nunshifted. Tone and activity level wnl. A: r/o sepsis P:\nfollow cx and exam\n\n#2 Received infant on CPAP 6cm but moderate amt resp\ndistress persisted. Intubated and surv x 1 given. Placement\nconfirmed via xray. Initial settings weaned from 22/5 x 25\nto 20/5 x 22 after CBG: 7.39,32. Mainly in RA. BBS clear\nand =. Mild IC/SC retractions evident. Suctioned for\nsmall-mod amt secretions. A: beginning to wean P: Follow\nresp status very closely\n\n#3 TF's 80cc/k. Receiving D10W via PIV without incident. DS\n106. Abdominal exam unremarkable. Beginning to void. No\nstool since birth. A: npo with ivf P; Follow hydration\nstatus and weight, 24hr lytes and bili\n\n#4 Mom and Dad in to visit on way down to floor, Update\nprovided and questions answered. A: impaired parenting\nP:Cont to support and educate through nicu stay\n\n#5 Temp max 100.6x. Warmer weaned. Fiesty with and between\ncares. Nested on sheepskin with boundaries in place.\nRepositioned with cares and prn. A: AGA P: Support\ndeveklopmental needs\n\n#6 BP maps drifting to 28-29. Received NS bolus x 1 with\nimprovement to 30-34. NNP Ambrosine aware. Color is ruddy.\nWell perfused. A: low maps P:Follow serial BP's to watch\nfor trends\n\n\n"},{"category":"Nursing/other","chartdate":"2128-03-05 00:00:00.000","description":"Report","row_id":1695770,"text":"Respiratory Care\nBaby is # 1 of 30 week .Please see M.D admit note for hx.Apgars .Received facial cpap in d.r..trans to nicu,placed on cpap 6 fio2 req ^ to ~ 45%,and continued to grunt on cpap.cxr revealed\"white out\".Decsion made to intubate,and give surf.Intubated with 3.0 ett taped @ 7cm,given 5.2 cc survanta @ 0130,tol well.Initial settings R 25 22/5,cbg 7.39/32,weaned R 22 pip to 20.Mainly in 21%.BS = clear.\n"},{"category":"Nursing/other","chartdate":"2128-03-04 00:00:00.000","description":"Report","row_id":1695766,"text":"NICU Attending Admission Note\n\nID: 30 week gestation female triplet #1, delivered by repeat C section due to progressive PTL, triplet gestation.\n\nPre/perinatal Hx: Mother is 29 y.o. G4 P now 2 (2 deliveries, 4 children), IUI triplet conception, EDC . PNS: 0+, Ab-, RPRNR, RI, HepBSAg-, reportedly GBS- (all PNS redrawn on and pending). Pregnancy complicated by GDM, then ? PTL (abdominal discomfort and vaginal pressure) at 23 1/7 weeks, admitted, receiveed complete course of beta at 24 weeks, in house since. Tonight presented with PTL, cervical dilation therefore delivered by repeat C section. Clear fluid. This triplet emerged with spontaneous cry, required only BBO2 and routine care in DR, apgars 8 and 9, but demonstrated mild increased WOB, needed supplemental O2, transported to NICU without incident.\n\nAdmission PEx: Weight 1455 gm (50%), L 41.5 cm (50%), HC 29.25 cm (50%), nondysmorphic with overall appearance c/w known gestational age, AFSOF, RR present bilaterally, palate intact, intermittent grunting, moderate intercostal retractions, diminished air entry bilaterally, RRR without murmur, 2+ femoral pulses, abdomen benign with no HSM, no masses, normal female external genitalia for g.a. normal back and ext with stable hips, appropriate tone, skin pink with fair perfusion.\n\nA/P: 30 week gestation AGA triplet #2, moderate respiratory distress, likely surfactant deficiency +/- component of retained fetal lung fluid, can not rule out pneumonia/sepsis with only perinatal risk factor of preterm labor (not unexpected in setting of triplet gestation). Also at risk of other complications of moderate prematurity including A/B, hypoglycemia, fluid and electrolyte imbalance, suck swallow dyscoordination, hyperbilirubinemia, feeding intolerance/nec, IVH/PVL, ROP.\n\n-CPAP, supplemental O2, monitor, CXR, may need intubation and exogenous surfactant tx.\n-NPO for now, D10W at 80 cc/kg/d, PN/IL asap, monitor glucose, lytes, bili, treat as indicated,\n- CBC, blood cx, amp and gent pending clinicla course and 48 horu blood bulture results\n- Follow up on repeat pending PNS results.\n- Head U/S and eye exam per routine\n\nI updated parents in OR. will keep informed/supported.\n\n"},{"category":"Nursing/other","chartdate":"2128-03-06 00:00:00.000","description":"Report","row_id":1695780,"text":"Addendum - PE\n\nBaby is /jaundiced breathing comfortably in nasal cannula O2.\nAF soft and flat.\nLungs clear and equal, no retractions.\nCVS - S1 S2 normal - no murmur, perfusion good\nAbd - soft with normal bowel sounds, slightly full.\nGU- normal female\nNeuro - tone appropriate, symmetrical movements\n"},{"category":"Nursing/other","chartdate":"2128-03-07 00:00:00.000","description":"Report","row_id":1695781,"text":"1900-0700 NPN\n\n\n#1SEPSIS\nO:BLOOD CX NGTD AT 48HR OF AGE. ANTIBIOTICS D/ MD\nORDER\nA:SEPSIS RULED OUT\nP:D/C PROBLEM\n\n#2RESPIRATORY\nO:REMAINS IN NC 100CC 21% W/SATS 92-97%. BS CLEAR, SL\nDIMINISHED. INTERMITTENT GRUNTING NOTED AT START OF\nSHIFT--MD AWARE AND HAS SUBSEQUENTLY RESOLVED. RESP RATE\n44-72 WITH MILD IC/SC RETRACTIONS. HAS HAD 4 SPELLS THUS\nFAR, ALL MILD STIM WITHOUT DESATS--MD AWARE. NOT YET ON\nCAFFEINE.\nA:STABLE IN LOW NC, STARTING TO SPELL\nP:CONTINUE TO MONITOR RESP STATUS, MONITOR FOR NEED FOR\nCAFFEINE\n\n\n\n\n"},{"category":"Nursing/other","chartdate":"2128-03-07 00:00:00.000","description":"Report","row_id":1695784,"text":"NPN DAYS\n\n\nAlt in Resp: Received Caffeine loading dose at change of\nshift this am r/t 11 spells overnight. Remains on NC 100cc\nflow 21% FiO2, no further spells this shift. LS clear and\nequal. Mild retractions. Continue with current plan of care.\n\nAlt in FEN: TF increased to 120cc/kg/day. PND10 and lipids\ncurrently infusing at 60cc/kg/day via . D10 infusing at\n30cc/kg/day. Feeds of BM20/Pe20 at 30cc/kg/day. Increasing\nfeeds by 10cc/kg/ at 4/4. Belly soft and round with\nactive bowel sounds. No spits or aspirates. No stool since\nbirth. Urine out 1.9cc/kg/hr. Will continue to increase\nfeeds as tolerated.\n\nAlt in Parenting: Parents in to visit and participating in\nall cares. Updated them on day. Family meeting\nscheduled for Monday at 2pm. Will continue to provide\nsupport and teaching.\n\nAlt in Growth and Dev: Temp stable in air isolette. Nested\non sheepskin with boundaries in place. Passivley sucks on\npacifier. Awake and alert with cares, settles well between\ncares. Will continue to provide for developmental needs.\n\nBili: Remains under double phototherapy for bili. Check bili\ntonight.\n\n\n"},{"category":"Nursing/other","chartdate":"2128-03-08 00:00:00.000","description":"Report","row_id":1695785,"text":"NPN\n\n\n#2RESP:\nO; Weaned to RA with sats in high 90's. RR 60-70, mild ic/sc\nretractions. Lungs cl=, no spells\nA/P; Cont to monitor. Caffeine as ordered.\n\n#3FEN:\no: Advanced feeds PE20 to 50cc/k/d. infusing PN D10 and\nIL at 70/k/d. Ad soft, round, no asp or spits. Voiding\n1.7cc/k/h. no stools\nA: Tol feeds\np: Cont to advance as tol. check labs.\n\n#4Parenting:\no: Mom in to visit, happy with progress. dad unable to\nvisit.\nA/P: Cont to support and inform, family mtg today at 1400\n\n#5G@D:\nO: Temps stable in heated isolette with temp adjustments.\nAlert and active with cares, MAE. Opening eyes. sucking on\npacifier.\nA/p: Cont to support dev.\n\n#7Bili:\no: Under double photherapy with eye patches in place.Bili\ndrawn.\nA/p: Cont with tx. check lab results.\n\n\n"},{"category":"Nursing/other","chartdate":"2128-03-08 00:00:00.000","description":"Report","row_id":1695786,"text":"Neonatology note\n4 d.o\nin RA now, off NC O2 last night.\nAFOF, jaundice\nNormal tone for preemie\nRR with no murmur\nclear lungs\nabdomen soft\nwt= 1250 gm +5, 120 cc/kg/d with PN+Il, feeding at 50 cc/kg/d\nbili= 5.3\n\nA: ex 30 wks GA, resolved RDS, jaundice\nP: advancing feeding, monitor jaundice and possible immaturity of breathing.-\n"},{"category":"Nursing/other","chartdate":"2128-03-07 00:00:00.000","description":"Report","row_id":1695782,"text":"1900-0700 NPN\n\n\n#2RESPIRATORY\nO:BABY HAS HAD AN ADDITIONAL 4 SPELLS SINCE MD NOTIFIED\n~2400. NNP NOTIFIED OF ADDITIONAL 4 SPELLS-->8 IN 12HR.\nORDER RECEIVED TO BEGIN CAFFEINE.\nA:INCREASED SPELLS\nP:START CAFFEINE, MONITOR CLOSELY FOR NEED FOR CPAP\n\n#3F/E/N\nO:TF INCREASED TO 100CC/KG. INCREASED ENTERAL FEEDS TO\n30CC/KG BM/PE 6.7CC Q4HR GAVAGE AND IVF D10PN/IL AT 60CC/KG\nAND D1OW IVPB INTO LINE AT 10CC/KG. ABDOMEN SOFT WITH GOOD\nBS. NO LOOPS AND NO SPITS, MINIMAL ASPIRATES. AG 20-20.5CM.\nVOIDING 1.8CC/KG X12HR; NO STOOL. WT DOWN 85GM. DS 63. LYTES\nTHIS AM 145/4.3/113/20\nA:STABLE\nP:CONTINUE TO MONITOR TOLERANCE TO FEEDS, FOLLOW U/O AND DS\n\n#4PARENTING\nO:PARENTS EACH CALLED THIS AM FOR UPDATE ON BABIES. SEE\nSIBLINGS #3 NOTE\nA:INVOLVED, INVESTED\nP:CONTINUE TO SUPPORT, EDUCATE AND KEEP UP TO DATE\n\n#5G&D\nO:IN AIR CONTROL ISOLETTE WITH STABLE TEMPEDRATURE. TEMP\nDROP WITH KC-->PLACED UNDER WARMING LIGHTS WITH RESOLUTION.\nACTIVE/MAE WITH CARES; SLEEPING WELL BETWEEN\nA:AGA\nP:CONTINUE TO SUPPORT AND MONITOR\n\n#7BILI\nO:REMAINS UNDER DOUBLE PHOTOTHERAPY WITH BILIMASK IN PLACE.\nBILI THIS AM 7.8/0.3\nA:HYPERBILI\nP:CONTINUE PHOTOTHERAPY, CHECK BILI AS ORDERED\n\n\n"},{"category":"Nursing/other","chartdate":"2128-03-07 00:00:00.000","description":"Report","row_id":1695783,"text":"Neonatology Attending Note\nDay 3\n\nNC 100cc, 21%. RR40-70s. 11 A&Bs last pm, started caffeine this am. No spells since. No murmur. HR 120-150s. BP 55/41, 45. Mild gen edema.\n\nBili 7.8/0.3\nUnder double photot.\n\nWt 1245, down 85 gms. TF 100 cc/k/day BM/PE20 at 30, remainder PN/IL. Tol well. Nl voiding and stooling.\n145/4.3/11/20\nd/s 63\n\nNow off abx.\n\nIn isolette.\n\nExam: Infant active, alert with exam. AFOF. She is , well perfused, no murmur auscultated. She is comfortable in NCO2. Breath sounds clear and equal. Abd soft, active bowel sounds, no loops. Stable temp in air isolette.\n\nA/P:\n - wean O2 as tol\n - monitor AOP on caffeine\n - adv TF\n - adv enteral feedings\n - cont photot and follow bili levels\n"}],"string":"[\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695787,\n \"text\": \"Clinical Nutrition\\nO:\\n30 wk gestational age BG, AGA, now on DOL 4.\\nBirthwt: 1345 g(~25th to 50th %ile); current wt: 1250 g (~25th %ile); wt currently down ~7% from birth wt.\\nHC at birth: 29 cm (~50th %ile); current HC: 27.5 cm (~10th to 25th %ile)\\nLN at birth: 39 cm (~25th %ile); current LN: 38 cm (~10th to 25th %ile)\\nLabs noted.\\nNutrition: TF @ 140 cc/kg/day. EN started on DOL 2, currently @ 50 cc/kg/day PE/BM 20, increasing 10 cc/kg/. PN started on DOL 1; lipids added on DOL 2. Remainder of fluids as PN via ; projected intake for next 24 hrs from PN ~47 kcal/kg/day, ~2.1 g pro/kg/day, and ~1.4 g fat/kg/day. From EN: ~40 kcal/kg/day, ~0.6 to 1.2 g pro/kg/day, and ~2 to 2.3 g pro/kg/day.\\nGI: Abdomen benign.\\n\\nA/Goals:\\nTolerating feeds without GI problems. Tolerating PN with good BS control. Labs noted and PN adjusted accordingly. Initial goal for feeds is ~150 cc/kg/day PE/BM 24, providing ~120 kcal/kg/day and ~3.2 to 3.6 g pro/kg/day. Further increases in feeds as per growth and tolerance. Appropriate to add Fe and Vit E supps when feeds reach initial goal. PN will be supplemental to feeds and taper off as EN increases. Growth goals after initial diuresis are ~15 to 20 g/kg/day for wt gain, ~0.5 to 1 cm/wk for HC gain, and ~ 1 cm/wk for LN gain. Will follow w/ team and participate in nutrition plans.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695788,\n \"text\": \"NPN\\n\\n\\n2. Received infant in RA on CVR and O2 sat. VS as noted on\\nflow sheet. Noted to have 2 bradycardic episodes, one\\nneeding mild stim. Both episodes around feeding. Mild\\nretractions noted. No murmur. Slight jaundice.\\nCont to monitor.\\n3. TF increased to 140cc/kg today. Currently on PN D10W\\nwith IL at 80cc/kg and NG feeds at 60cc/kg MBM/PE20. Tol\\nfeeds well. Abd soft, no asp or spits. A/G stable. No stool\\nthis shift. Voiding qs, see flow sheet.\\nCont to advance feeds as tol 10cc/kg as ordered.\\n4. Parents in for feeds. Handling the infant with assist.\\nKangaroo x1. Asking appropriate questions. Discussed common\\npreemie issues etc and criteria for discharge. Mom pumping.\\nDad also handling infant well. Family meeting postponed\\nuntil tomorrow.\\n5.In air isolette maintaining temp. Tol 30 min of kangaroo\\ncare but decreased temp and returned to . Sucks on\\npacifier. Nested and boundries applied. Tol procedures\\nfairly well.\\n7. Reduced to single phototherapy lights today. Bili and\\nlytes ordered for Wed. Mask secure. Voiding qs. No stool\\nthis shift.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2128-03-11 00:00:00.000\",\n \"description\": \"NEONATAL HEAD PORTABLE\",\n \"row_id\": 820067,\n \"text\": \" 7:26 AM\\n NEONATAL HEAD PORTABLE Clip # \\n Reason: TRIPLET BORN AT 30 WEEKS GESTATION, RULE OUT INTRACRANIAL HEMORRHAGE OR OTHER ABNORMALITY\\n Admitting Diagnosis: NEWBORN\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n Infant born at 30 weeks gestation\\n REASON FOR THIS EXAMINATION:\\n rule out intracranial hemorrhage or other abnormality\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Initial study on baby born at 30 weeks who is one of triplets.\\n\\n Scans through the anterior fontanelle with limited views through the mastoid\\n foramen do not demonstrate any abnormalities. There is no evidence of\\n hemorrhage or ventriculomegaly.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2128-03-05 00:00:00.000\",\n \"description\": \"BABYGRAM (CHEST ONLY)\",\n \"row_id\": 819462,\n \"text\": \" 1:13 AM\\n BABYGRAM (CHEST ONLY) Clip # \\n Reason: verify ETT placement\\n Admitting Diagnosis: NEWBORN\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n Infant with prematurity, RDS\\n REASON FOR THIS EXAMINATION:\\n verify ETT placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST\\n\\n Comparison is made with the examination performed earlier in the day. Since\\n that time, the patient has been intubated and the endotrachial tip ends above\\n the carina. The lungs are much clearer, compatible with improving hyaline\\n membrane disease.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2128-03-04 00:00:00.000\",\n \"description\": \"BABYGRAM (CHEST ONLY)\",\n \"row_id\": 819458,\n \"text\": \" 10:44 PM\\n BABYGRAM (CHEST ONLY) Clip # \\n Reason: evaluate lung fields\\n Admitting Diagnosis: NEWBORN\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n Infant with prematurity at 31 weeks\\n REASON FOR THIS EXAMINATION:\\n evaluate lung fields\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST\\n\\n This is our initial x-ray on this baby born prematurely, who is one of\\n triplets. The lungs are nearly opaque, and the lung volumes very low,\\n compatible with severe hyaline membrane disease. No other abnormalities are\\n apparent.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2128-04-06 00:00:00.000\",\n \"description\": \"NEONATAL HEAD PORTABLE\",\n \"row_id\": 822576,\n \"text\": \" 7:07 AM\\n NEONATAL HEAD PORTABLE Clip # \\n Reason: PREMATURE INFANT BORN AT 30 WEEKS, FOLLOW UP PREVIOUS NORMAL STUDY; RULE OUT PVL\\n Admitting Diagnosis: NEWBORN\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n Infant born at 30 weeks gestation, now 1 month old\\n REASON FOR THIS EXAMINATION:\\n follow up previous normal study; rule out PVL\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Infant born at 30 week gestation, now 1 month old.\\n\\n COMPARISON: Study on \\n\\n The ventricles, sulci and cisterns are normal. There is no evidence of\\n intracranial hemorrhage. There is no evidence of periventricular\\n leukomalacia. Grey/white matter differentiation is normal for the patient's\\n age.\\n\\n IMPRESSION: Normal head ultrasound.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695872,\n \"text\": \"PCA Note:\\n\\n\\nResp: O: Infant in RA, sats within limits (>94%). Lung\\nsounds are cl/= bilaterally. Mild subcostal retractions. No\\nspells, no drifts. A: Infant breathing comfortably. P:\\nContinue to monitor respiratory status.\\n\\nFEN: O: TF 150cc/kg BM/PE26. PO/PG feeds as tolerated,\\ngavaged over 1hr. Infant bottled this afternoon, taking in\\n45cc. No spits, minimal aspirates. Infant's abdomen is soft,\\n+bowel sounds, no loops. Girths stable @25cm. Infant is\\nvoiding, no stool. A: Tolerating feeds well. Eager to\\nbottle, well coordinated, strong suck. P: Continue ot offer\\nPO feeds. Continue to support nutritional needs of infant.\\n\\n: O: Mom, and big brother in this afternoon. A:\\nAppropriate, comfortable, . Big brother very\\nexcited about new siblings. P: Continue to support, teach\\nand prepare for discharge.\\n\\nDEV: O: Infant is swaddled, cobedded with brother and sister\\nin ; HOB elevated. Infant maintaining stable temps. \\nsleeps well between cares, wakes with cares, remains \\nand active throughout cares. Calms with pacifier. A:\\nDevelopmentally appropriate. P: Continue to support\\ndevelopmental needs of infant.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695873,\n \"text\": \"agree with above note and assessment by , PCA.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695874,\n \"text\": \"npn 1900-0700\\n\\n\\n2: resp\\nremains in ra. no spells and no dsats. RR 30-60's. Lung\\nsounds clear and equal. mild subcostal retractions. no\\nincreased wob noted. sats remain in the high 90%.\\n\\n3: fen\\ncurrent weight 1975gms up 65. total fluids remain at\\n150cc/kilo/day of bm/pe 26. no breastmilk available this\\nshift. infant po'd her whole volume at 2400. continuing to\\nwatch feeding cues. tolerating feeds well. no spits. minimal\\naspirates. stable girths. nutritional drawn this shift.\\nsee flowsheet.\\n\\n4: \\nno contact this shift.\\n\\n5: g/d\\ntemps stable in an open air crib. and active with\\ncares. sleeps well inbetween. sucks on pacifier. brings\\nhands to face. aga. continue to monitor for developmental\\nmilestones.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695875,\n \"text\": \"Neonatology-NNP PRogress Note\\n\\nPE: Remains in room air, cobedding with her siblings, well perfused, bbs cl=, rrr s1s2 no murmur, abd soft, nontender, V&S, afso, bundled\\n\\nSee attending note for plan\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695876,\n \"text\": \"Neonatology Attending\\n is 25do, 34 wks corrected.\\nRA, open crib cobedding with sibs\\nNo a/b or desats\\nWt up 65 on TF150 MM26/PE26 pg>po, did take 2 full-volume bottles past 24hrs. Not waking for feeds\\n\\nMeds Fe, vit E, Desitin\\n\\n: Ca 10.2/phos 6.9/alk phos 292\\n\\nImp/ age-appropriate feeding immaturity.\\n\\nPlan/ continue to monitor cvr status, growth & development. D/c planning in progress contingent upon further evidence of maturity. Eye exam today.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-04-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695941,\n \"text\": \"#2 RA. LS CLEAR ANFD EQUAL. NO SPELLS.\\n#3 PT PO FEEDING Q4-5HR. PO FEEDING WELL, >140CC/KG OF\\nE24. WEIGHT INCREASE 40GM. VOIDING AND STOOLING.\\n#4 NO CONTACT FROM FAMILY ON THIS SHIFT.\\n#5 WAKING TO FEED. AND ACTIVE. NO SPELLS AT THIS\\nTIME IN SHIFT.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-04-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695942,\n \"text\": \"neonatology Attending\\n is 41do, 36 wks\\nRA, open crib\\nDay without a/b\\nWt 2490 up 40g on ad TF140 MM/E24 po.\\n\\nMeds Fe\\n\\nimp/ age-appropriate immaturity of cvr coordination\\nPlan/ continue to monitor cvr status, growth/development. D/c planning ongoing pending evidence of further maturation...\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-04-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695943,\n \"text\": \"Clinical Nutrition\\nO:\\n~36 wk CGA BG on DOL 41.\\nWt: 2490 g(+40)(~25th %ile); birth wt: 1345 g. Average wt gain over past wk ~37 g/day.\\nHC: 33 cm (~50th to 75th %ile); last: 32 cm\\nLN: 45 cm (~25th %ile); last: 44 cm\\nMeds include Fe.\\n not needed\\nNutrition: Ad po, minimum 140 cc/kg/day, E 24 or BM 24 w/ 4 kcal/oz Enfamil powder. Infant gets mostly formula. Average of past 3 day intake ~190 cc/kg/day, providing ~152 kcal/kg/day and ~2.5 to 3.2 g pro/kg/day.\\nGI: Abdomen benign.\\n\\nA/Goals:\\nTolerating feeds without GI problems; taking all po feeds. not needed. Current feeds + supps meeting weaned recs for kcals/pro/vits and mins. Growth is meeting recs for HC and LN gain. Wt gain is slightly exceeding recommended ~20 to 35 g/day; will monitor daily gains and consider decreasing kcals before d/c if indicated. Will continue to follow w/ team and participate in nutrition plans.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-04-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695944,\n \"text\": \"Nursing NICU Note\\n\\n\\n#2. Respiratory O: Pt. remains in RA, O2 sats >95%. LS\\nclear/=, no increase work of breathing noted. No A&B's\\nnoted this shift thus far. This is day #2 of 5 for a spell\\ncount. A: Pt. is stable in RA. P: Continue to monitor\\nrespiratory status. Monitor for A&B's.\\n\\n#3. FEN O: Pt. is ad 140cc/kg/d of E24. She\\ntakes ~70-90cc PO Q feed every 4-5hrs. She is wakeing for\\nfeeds and bottleing well. Abdomen is soft, , +BS, no\\nloops/spits noted. She is voiding/ no stool noted this\\nshift thus far. A: Pt. is tolerating current nutritional\\nplan. P: Continue w/ current feeding plan. Monitor for\\ns/s of intolerance.\\n\\n#4. O: in this afternoon to take home \\nsister. was updated at bedside on pt's current status\\nand daily plan of care. A: Family is and involved.\\nP: Continue to update, support and educate. Continue w/\\ndischarge teaching/planning.\\n\\n#5. Growth/Development O: Pt. remains in an open crib,\\nswaddled w/ stable temps. She is and active w/ cares,\\nsleeps well in between. Fontanelle soft/flat. She loves to\\nuse her pacifier, brings hands to face. A: AGA P:\\nContinue to provide environment appropriate for growth and\\ndevelopment.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695798,\n \"text\": \"NURSING PROGRESS NOTE\\n\\nRESP/CV: REMAINS IN RA WITH 02 SATS >95% ALL NIGHT. NO A&B'S OR DESATS NOTED. BS CL&= WITH MINIMAL RETRACTIONS AND NO MURMER AUDIBLE. COLOR JAUDICE/ AND WELL PERFUSED. REBOUND BILI SENT THIS AM, RESULTS PNDING. BP 64/38-46.\\n\\nFEN: TOTAL FLUIDS MAINTAINED AT 140CC/KG/D. ENTERAL FEEDS ADVANCED TO 130CC/KG/D TONIGHT. INFILTRATED AT 0400 AND NOT RESTARTED. WILL ADVANCE TO FULL FEEDS AT 1200. D-STICK 89. ABD SOFT, WITH STABLE GIRTH AND +BS. PASSED MODERATE MECONIUM STOOL TONIGHT. NO RESIDUALS AND ONLY ONE SMALL EMESIS.\\n\\nDEV: TEMP STABLE IN AIR CONTROLLED ISOLETTE. AND ACTIVE WITH CARES. SUCKING INTERMITANTLY ON PACIFIER.\\n\\nSOCIAL: DAD VISITING TONIGHT. DID TEMP AND DIAPER CHANGE. PLEASED WITH PROGRESS. HELD SISTER.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695799,\n \"text\": \"Neonatology note\\n7 d.o\\nin RA, on caffein, no spells.\\nRR with no murmur\\nclear lungs\\nabdomen soft\\nAFOF\\njaundice\\nbili= 5.3\\nwt= 1305 gm +15, off IV, feeding at 130 cc/kg/d with PE/EBM 20.\\nnormal tone.\\nHUS: normal today.\\nA: ex 30 wks GA, resolved RDS, AOP, jaundice.\\nP: advance feeding, monitor for episodes on caffeine.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695800,\n \"text\": \"NICU nursing progress note\\n\\n\\nPlease refer to flowsheet for specific info.\\nResp\\nO: remains in room air, RR 40-70's, sat's >93%. BSCE\\nbilat. A: Breathing comfortably. Stable. P: Cont to follow.\\nFEN\\no: TF at 150cc/k/d, currently PG enteral feedings are at\\n130cc/k/d. Adv. feeds 15cc/k as tolerated. Abd , no\\nloops, active bs. Voiding/ no stool thus far today. One\\nsmall spit. Min asp. HOB elev. A: stable. P: cont to\\nfollow.Adv feeds as tolerated.\\nGD\\nO: Temp stable in air isolette, swaddled with hat, tshirt\\nand blanket. MAE. Fonts, soft, flat. Calms with containment\\nand pacifier. Dark Blanket over the top of isolette. HUS\\ndone this morning, please see Dr. note.A: AGA P: Cont\\nto support dev. milestones.\\nParenting\\nO: Mom planning on visiting at noon cares. Dad called and\\nupdated, verbalizing understanding. A: Involved and loving\\n. P: cont to update, support, educate.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695801,\n \"text\": \"NURSING PROGRESS NOTE\\n\\nRESP/CV: REMAINS IN RA WITH 02 SATS >95%. 2 A&B'S NOTED TONIGHT. NO DESATS. REMAINS ON CAFFEINE. VSS IN ISOLETTE. BS CL&=, NO MURMER.\\n\\nFEN: WEIGHT 1335GMS, UP 30GMS. TOTAL FLUIDS ADVANCED TO 150CC/KG/D OF PE20CAL. ABD SOFT, WITH STABLE GIRTH AND +BS. PASSING MECONIUM AND VOIDING LG AMTS. NO RESIDUALS AND ONLY SMALL EMESIS X1. HOB ELEVATED AND FEEDS INFUSING OVER 1HR.\\n\\nDEV: TEMP STABLE IN ISOLETTE. ACTIVE AND WITH INTERVENTIONS AND SLEEPING QUIETLY BETWEEN CARES. SUCKING VIGOROUSLY ON PACIFIER.\\n\\nSOCIAL: MOM X1 FOR UPDATE. WILL VISIT AT 11AM TODAY.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695802,\n \"text\": \"Neonatology note\\n8 d.o\\nin RA, on caffeine, 2 episodes\\nRR with no murmur\\nclear lungs\\nAFOF\\nwt= 1335 gm +30, 150 cc/kg/d with EBM/PE 20\\nabdomen soft\\nnormal tone\\n\\nA: ex 30 wks GA, AOP, growing preemie\\nP: advance calorie density\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695877,\n \"text\": \"NPN 7a-7p\\n\\n\\n#2: remains in Ra, breathing comfortably with mild SC\\nretractions. RR stable. Sats >/= 96%. Rare drift noted to\\nmid 80's x2, during mid feed. Infant corrected on her own.\\nNo other drifts noted. BBS cl/=. No apnea/brady spells\\nnoted thus far. A: stable in RA P:Cont to monitor and\\nprovide support as needed.\\n\\n#3: TF: 150cc/k/d. conts on BM26/PE26, 49cc q4hrs\\ngavaged over 1hr10mins. Bottled 20cc at noon feed for Mom.\\nDid well with coordinating suck/swallow/breathe pattern, but\\ntired out easily. Burped well. No spits, no asps. Abd\\nsoft, +, no loops. Ag stable. Voiding qs. No stool\\nthus far. A: tol'ing feeds well, learing to bottle P:Cont\\nto follow wt and exam. Monitor tol to feeds. Offer bottle\\nqshift as tol'ed.\\n\\n#4: Mom in for noon care. Update given. Indep with temp\\nand diaper. Working on bottling infant. Using good\\npositioining. Mom was present for eye exam. Did speak with\\nDr. regarding results. Aware of need for F/U in\\n3wks. Case manager spoke with Mom regarding\\n/insurance coverage. A: Involved, parent\\nP:Cont to support and educate.\\n\\n#5: is maintaining stable temps while swaddled in an\\nopen crib. She is and active with cares, but not\\nwaking on own for feeds. Tol'ed eye exam well. MAE. Fonts\\nsoft/flat. Sucks on pacifier. A: AGA P:Cont to support\\ndev needs.\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695878,\n \"text\": \"NPN\\n\\n\\n#2 Resp- Remains in RA w/o2 sats 95-100%. BS clear.RR=40-70.\\nMild retractions.\\n#3 F/N- Abd soft,+bs, no loops. Tolerating feeds of BM/PE 26\\ncals w/o spits. Minimal asps.Bottled 30cc out of 49cc x1. NG\\nfeeds given on a pump over 1 hr+ 10mins. voiding in adeq\\namts. No stool yet tonight.Wt up 15gms.TF= 150cc/kg/day.\\n#4 - no contact yet tonight.\\n#5 Dev- + active w/cares. Temp stable swaddled in open\\ncrib.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695879,\n \"text\": \"Neonatology NP Note\\nPE\\n swaddled in crib, cobedding with siblings\\nAFOF, sutures opposed\\nrespirations comfortable in room air, lungs clear/=\\nRRR, no murmur, and well perfused\\nabdomen soft, nontender and nondistended, active bowel sounds\\ngood tone.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-31 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695880,\n \"text\": \"1900-0700 NPN\\n\\n\\nRESP: Infant remains in RA, O2 sats=96-100%. RR=40-60's.\\nBreath sounds clear and equal bilaterally, mild SCR noted.\\nNo desats/no bradys so far this shift. Continue to monitor\\nresp status.\\n\\nFEN: Weight tonight=1.990 kg (no change). TF=150cc/kg/d of\\nBM26/PE26 PO/PG q4hr. Attempting to bottle feed infant\\nqshift. Infant bottled 15cc at 0000. Gavage feedings given\\nover 1hr 10min/tolerated well. Abdomen , soft, round,\\n+BS, no loops. No spits, no aspirates so far this shift.\\nVoiding, no stool. Continue to monitor FEN status.\\n\\n: No contact with so far this shift.\\n\\nDEV: Temps stable, swaddled in . Cobedding with brother\\nand sister. Active and with cares, sleeps well in\\nbetween cares. Infant not waking for feeds. Brings hands to\\nface, sucks on pacifier for comfort. MAE. Continue to\\nsupport DEV.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-31 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695881,\n \"text\": \"1900-0700 NPN\\nPlease disregard the above note. This note was written on the wrong patient.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-04-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695945,\n \"text\": \"PCA NOTE\\n\\n\\nRESP: O/A-In RA. Breathing 40-60's. Sats high 90's. No\\nspells or desats noted. No drifts. No issues. P-Continue to\\nmonitor.\\n\\nFEN: Current weight 2.520, ^30gm. TF of 140. E 20. PO.\\nTotal 24 hour intake 161 cc/ is voiding and\\nstooling. Hem neg. Active bowel sounds. Abdomen is\\nunremarkable. No spits. P-Continue with current regimen.\\n\\n: No contact thus far this shift.\\n\\nG/D: O/A-Temp stable in . Waking q 2-5 hours for feeds.\\n and active. Sleeps peacefully. MAE. Awake for longer\\nperiods of time. Curious disposition. P-Continue to monitor\\nfor developmental milestones.\\n\\n ****See flowsheet for further information****\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-04-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695946,\n \"text\": \"NPN 1900-0730\\nI have examined this infant and agree with the above note written by , PCA.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-04-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695947,\n \"text\": \"Neonatology-NNP Physical Exam\\n\\n remains in RA. Active, in an open crib, AFOF, sutures opposed, good tone. BBS clear and equal with good air entry. No murmur, pulses +2, , RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds. Please refer to attending progress note for detailed plan.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-04-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695948,\n \"text\": \"Neonatology Attending\\n is 42do, 36 wks corrected.\\nRA, open crib alone ( went home yesterday)\\nNo a/b day \\nWt 2520 up 30g on ad po E24/MM24 minTF140 (took 161cc/kg/24hrs)\\n\\nMeds Fe\\n\\nImp/ age appropriate cvr immaturity...\\nPlan/ continue to monitor cvr status, growth/development. D/C planning in progress for as early as Sat contingent upon evidence of maturity.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-04-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695949,\n \"text\": \"NPN 0700-1900\\n\\n\\n#2: O: Infant remains in room air. Saturations 96-100%.\\nRespiratory rate 30's-40's with no retractions. No spells or\\ndrifts this shift. Day 3 out of 5 of a spell countdown. Lung\\nsounds clear and equal. A: Infant stable in room air. P:\\nContinue to monitor infant for spells.\\n\\n#3: O: Total fluid minimum 140cc/kg/day of E24 or breastmilk\\n24 with enfamil powder, 59cc q4 hours. Infant is ad \\nfeeding and took 90cc and 75cc so far this shift. Abdomen\\nbenign, voiding, no stools. One small spit. A: Infant\\ntolerating feeds P: Continue with current feeding plan.\\n\\n#4: O: called this shift, will be in this evening.\\n\\n#5: O: Temperature stable in . Infant wakes for feeds,\\n and active with cares. Brings hands to face for\\ncomfort and calms with pacifier. Sleeps well between cares\\nand remains swaddled in crib. A: AGA. P: Continue to support\\ngrowth and development.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-04-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695950,\n \"text\": \"Nrsg Progress Note\\nAgree with above note fromPCa with fdg witnessed by this RN at 1700 with uncoordinated sucking noted periodically with sucking spilling approx 10 cc's from \\\"dribbling\\\"of formula. Abd soft with no stool at 1700. No loops noted this shift. phoned with complete update. No a's or b's noted as of this writing. Report to night RN planned for 1900. Infant remains on cvr and 02 sat monitor.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695861,\n \"text\": \"NPN 1900-0700\\n\\n\\n2. RESP: pt reains in RA with RR 40-60's. Mild S/C\\nretractions. Sats >94%. No spells noted. Will monitor.\\n\\n3. F&N: TF remain at 150cc/k/d of PE26. She bottled her\\nwhole feed at 2400. Abd benign. BS+. A/G stable. No\\nspits and minimal aspirates noted. Voiding well. No stool\\nnoted. Weight gain 50 grams.\\n\\n4. PAR: No contact from so far this shift.\\n\\n5. DEV: is active and during her cares. Temp\\nstable swaddled in crib, cobedding with her siblings. Mild\\ngen edema noted.\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695862,\n \"text\": \"Neonatology Attending\\nAddendum\\n\\nPE: active sleep, appropriate tone/activity. . AFOF.\\nLungs CTA, heart rrr s m, abd soft, extr well perfused.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695863,\n \"text\": \"Neonatology Attending\\n22do, 34 wks corrected\\nRA, open crib cobedding with sibs\\nNo a/b\\nWt 1840 up 50 on TF150 PE26 pg>> po (took full bottle overnight!); no spits\\n\\nMeds Fe, vit E, Desitin\\n\\nImp/ age-appropriate immaturity of feeding skills, making appropriate progress, growing well.\\n\\nPlan/ continue to monitor cvr status, growth/development\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695864,\n \"text\": \"NPN days\\n\\n\\nRESP: Infant in room air, RR 30-60's, O2 sats 93% and\\ngreater, lungs are clear and equal, mild SC retractions. No\\nspell, no desats. Will continue to monitor closely.\\n\\nFEN: total fluids 150cc/k/d of PE/BM 26 po/pg feeds Q4hours\\n48cc. Bottled X1 today and took in 35cc!, remainder\\ngavaged. Infant to breast today , latched well and sucked\\nintermittently for approx 5min. Abdomen is soft, ,\\nactive bowel sounds, AG stable, minimal residuals, no spits.\\nvoiding , no stool this shift. Will continue to offer\\nbottle once per shift, and monitor closely.\\n\\nParenting: Mother in today for 12 and 4p cares, involved\\nand mother, participates in cares, attempted to\\nbreastfeed, lactation consult appt. made for at noon.\\nWill continue to support and update family.\\n\\nG/D: Temps are stable in open crib (co bedding). and\\nactive with cares, does not wake for all feeds, MAE, sucks\\non pacifier /hands. AGA. Will continue to support\\ndevelopmetnal needs.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695865,\n \"text\": \"NURSING PROGRESS NOTE\\n\\nRESP/CV: REMAINS IN RA WITH NO A&B'S OR DESATS NOTED. BS CL&=, NO MURMER. COLOR AND WELL PERFUSED. BP 70/42-52.\\n\\nFEN: WEIGHT 1880GMS, UP 40GMS. TOTAL FLUIDS REMAIN AT 150CC/KG/D OF BM/PE26CAL. BOTTLED FULL FEEDING VIGOROUSLY WITH GOOD COORDINATION X1 TONIGHT. VOIDING & STOOLING WNL. ABD SOFT, WITH STABLE GIRTH AND +BS. NO EMESIS OR RESIDUALS NOTED.\\n\\nSOCIAL: MOM WILL BE IN AT 8AM THIS AM.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695866,\n \"text\": \"Attending Note\\nDay of life 23 CGA 34 \\nstable in room air 30-60\\nHR 140-170 BP 70/42 mean 52\\n1880 up 40 150 cc/kg/day BM or PE 26\\ntaking mostly pg but some po\\nvoiding and stooling\\n\\nA/P doing well\\nwill have nutrition on Monday\\nwill continue current plan\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-04-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695929,\n \"text\": \"Neonatology Attending\\n\\nDOL 38 CGA 36 2/7 weeks\\n\\nStable in RA. No A/B.\\n\\nOn ad lib feeds. Took 156 cc/kg BM/E 24 yesterday. Voiding. Stooling. Wt 2340 grams (up 30).\\n\\nCobedding with sister.\\n\\n in and up to date.\\n\\nA: Stable. On countdown D2.\\n\\nP: Monitor\\n Home when 5 day spell free\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-04-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695930,\n \"text\": \"Nursing Progress Note:\\n#2 - RESP: REmains in room air. Lungs clear and equal. No\\nspells/drifts today. Day . Last spell on the 16th. Not\\nbeing fed on the monitor. RR (30-50). O2Sats >96%.\\n#3 - F&N: Ad lib demand feeder with min of 140cc/kilo.\\nBottling well over that. Bottling about 80cc's at each\\nfeeding. aBdoinal exam benign. Voiding. No stool thus far\\ntoday. Remains on iron.\\n#4 - : Mom called this am. in this afternoon.\\nUpdated. Independent with cares. Bottled and fed both girls.\\n\\n#5 - G&D: TEmps stable in open crib. and active with\\ncares. MAE. AFSF. Bottling all feeds. Waking for feeds q4-6\\nhours.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-04-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695931,\n \"text\": \"NICU NURSING PROGRESS NOTE:\\nRESP.O: Infant remains in RA. RR: 40-60. Lungs sound clear\\nand equal. No retractions. Infant has had 2x spells to the\\ntime of note. 1x with bottling, HR went down to 77 with sats\\n88%, bottle was taken out of her mouth, and mild to moderate\\nstim for shallow breathing. The second spell was at rest,\\nabout 30 min after she ate, HR:56, sat was 70%, her color\\ngot dusky. Reguired mode stim for shallow breathing.\\nA: Occasionally spells. P: Continue to monitor for spells\\nand assess.\\n\\nFEN.O: Weight=2.385kg, ^45gms. Infant remains on adlib\\ndemand schedule with BM24. Bottling slightly uncoordinated.\\nTaking 80-90cc. Abd exam is soft, no loops. BS active.\\nVoiding, no stools. No spits. Tolerating feeds and gaining\\nweight. Continue to support PO feedings.\\n\\nParenting: No contact from to the time of note. Cont\\nto support.\\nG/G.O: is cobedding with her twin sister in open crib.\\nTemps are stbale. Swaddled. Active and with cares.\\nSleeps well in between cares. Wakes for feeds. Likes her\\npacifier. A: Well appereance. P: Continue to support\\ndevelopmentally needs.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-04-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695932,\n \"text\": \"I am in agreement with documentation done by . Infant had an uneventul night. Brady x2, one at rest and one with when feeding.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-04-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695933,\n \"text\": \"Neonatology Attending Note\\nDay 39\\nCGA 36 3\\n\\nRA. RR40-60s. 2 A&Bs overnight, 1 w feed. No murmur. HR 140-170s. , well perfused. BP 79/47, 59.\\n\\nWt 2385, up 45. PO ad , 140cc/k/d, BM/E24. TFI: 170. Nl voiding and stooling.\\n\\nIn open crib.\\n\\nA/P: Immature cardioresp control, plus some po dyscoordination. Cont to monitor. No changes to current medical plan.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695793,\n \"text\": \"NICU NPN 1500-0700\\n\\n\\nRESP O: Baby remains in nco2 100%, 13-25c's during the\\nnight. O2 sats 91-99%, rr50-70's, with baseline mild ic/sc\\nretractions. No spont bradys noted, received caffeine bolus.\\nLungs are clear. Hr 130-160's, color -jaundiced, bp's\\nare stable, no audible murmur.\\n\\nFEN O: Current weight 1290g, up 10g. Tolerating advancing\\nenteral feeds of pe20 well. Abdominal exam benign, voiding\\nand stooling, ag stable, no loops, min ngt aspirates, no\\nspits. D stick stable. IVF of PN, and IL are infusing\\nthrough well.\\n\\nParenting O: Mom and dad in for cares, asking appropriate\\nquestions. Family meeting held at 1500. Mom held.\\n\\nG&D O: temps are stable, nested on sheepskin, in servo\\nisolette. baby is and active irritable with cares.\\nSettles with pacifier and containment. Fontanells are soft\\nand flat.\\n\\nBili O: Bili todat 5.0/0.2. She remains under single\\nphototherapy\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695794,\n \"text\": \"NICU NPN ADDENDUM\\nError on above note, baby is in room air, and has been throughout the night. rr 40-60's, lungs are clear, with o2 sats 94-100%. One brady, noted, no caffeine bolus.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695795,\n \"text\": \"Neonatology note\\n6 d.o\\nin RA, on caffeine, 2 bradycardia.\\nRR with no murmur\\nclear lungs\\nabdomen soft\\nwt= 1290 gm +10, 140 cc/kg/d with feeding at 100 cc/kg/d with PE 20\\njaundice\\nbili= 5\\n\\nA: ex 30 wks GA, resolved RDS, jaundice, AOP\\nP: advance feeding, d/c phototherapy and f/u bili.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695796,\n \"text\": \"Fellow note; physical exam\\n and active in isolette. Breathing comfortably in RA. Mild jaundice. AFOF. Lungs with good aeration and clear breath sounds bilaterally. RRR. Nl S1, S2. No murmur. Normal femoral pulses. Abd soft, ND, + BS. Extrem WWP. Normal tone.\\n\\nFamily meeting yesterday with mom, dad, nurse, social worker and myself. Discussed course so far and goals for coming weeks. Discussed criteria for discharge home. Also discussed possible transfer to next week. well-informed and asking good questions.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695797,\n \"text\": \"NICU nursing progress note\\n\\n\\nPlease refer to flowsheet for specific info.\\nResp\\nO: remains in room air, RR 40-70's, sat's >91%, BSCE\\nbilat. A: Stable. P: Cont to follow. On caffeine, no spells\\ntoday.\\nFEN\\nO: TF of 140cc/k/d. IVF currently at 25cc/k/d of D10 2 meq\\nNacl, 1 meq Kcl. Enteral feeds are currently at 115cc/k/d of\\npe 20 gavaged over 40\\\". well tolerated. MIn asp. NO spits.\\nAbd , no loops, active bs. voiding/ no stool today. UO\\n3.5cc/k/hour for last 12 hours. A: stable. P: cont to\\nfollow.\\nGD\\nO: Temp stable swaddled in an air isolette, active and \\nwith cares. MAE. fonts, soft, flat. Calms with containment\\nand pacifier. A:AGA P: cont to support dev milestones.\\nbili\\nO: Off photo tx. Check rebound in am.\\nParenting\\nO: mom and dad in and updated, verbalizing understanding. A:\\nInvolved and loving .\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695789,\n \"text\": \"NPN:\\n\\nRESP: Sats 94-98% in RA. RR=50-76 with sl SC retraction. BBS =/clear. Occasional brief sat-drifts w/quick recovery. A&B x 1 tonight; x 3 over past 24 h -> QSR or stim. Remains on Caffeine.\\n\\nCV: No murmur. HR=140-150s. BP=50/23 (33). Color w/jaundice. Perfusion good.\\n\\nFEN: Wt=1280g (+ 30g). TF=140cc/kg/d. Enteral feeds at 70cc/kg/d; tolertaing 16cc PE-20 well q 4 h via NG. PN (D-10) and IL at 70cc/kg/d. No spits; abd soft, rounded, active bs, no loops. U/O=3cc/kg/h over 24-h period yesterday. Voiding well tonight. No stool recorded since birth. To increase enteral fdgs 10cc/kg as tolerated. Elec to be checked .\\n\\nBILI: Single Phx. Bili 5.3/0.3 (). Bili to be done .\\n\\nG&D: CGA=31 wk. Temp stable in air-controlled isolette. Active and alert w/cares. Small lesion rt actecubital space -> cleansed and open to air. Nested in sheepskin and resting well.\\n\\nSOCIAL: No contact w/. Family meeting today at 1330.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695790,\n \"text\": \"Neonatology note\\n5 d.o\\nin RA, no spells, on caffeine.\\nRR with no murmur\\nclear lungs\\nabdomen soft\\njaundice.\\nAFOF\\nnormal tone\\nwt= 1280 gm +30, 140 cc/kg/d with feeding at 70 cc/kg/d with PE 20/EBM 20\\nA: ex 30 wks GA, resolved RDS, Jaundice, AOP\\nP: advance feeding, f/u bili.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-31 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695882,\n \"text\": \"1900-0700 NPN\\n\\n\\nRESP: Infant remains in RA, O2 sats=95-100%. RR=30-60's.\\nBreath sounds clear and equal bilaterally, mild SCR noted.\\nNo bradys, no desats so far this shift. Will continue to\\nmonitor resp status.\\n\\nFEN: Weight tonight=2.065kg (+5grams). TF=150cc/kg/d of\\nPE26/BM26 po/pg q4hr. Attempting to bottle infant qshift.\\nInfant bottled 52cc at with good coordination. Gavage\\nfeedings given over 1hr 10min/tolerated well. Abdomen ,\\nsoft, round, +BS, no loops. Minimal aspirates, small spitx1\\nso far this shift. Voiding/no stool. Continue to monitor FEN\\nstatus.\\n\\n: No contact with so far this shift.\\n\\nG+D: Temps stable, swaddled in . Cobedding with sister\\nand brother. Active and with cares, sleeps well in\\nbetween cares. Infant does not wake independently for feeds.\\nBrings hands to face, sucks on pacifier for comfort. MAE.\\nYellow drainage noted to both eyes/warm soaks applied.\\nContinue to support G+D.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-31 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695883,\n \"text\": \"Neonatology Attending\\nAddendum: PE\\nSleeping quietly s/p feed; appropriate tone; . AFOF.\\nLungs CTA, heart RRR s murmur, abd soft, extr well perfused.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-31 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695884,\n \"text\": \"Neonatology Attending\\n is 27do, 34 wks corrected.\\nRA, open crib\\nNo a/b; occ desats mostly with feeds, some with bradycardia all self-resolved\\nwt unchanged on TF150 MM/PE26 pg>>po\\n\\nMeds Fe, vit E\\n\\nImp/ age-appropriate cvr & feeding immaturity\\nPlan/ continue to monitor cvr status, growth/development.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-31 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695885,\n \"text\": \"NPN 7a-7p\\n\\n\\n#2: remains in RA, sating >/= 96%. RR stable.\\nBreathing comfortably with mild SC retractions. BBS cl/=.\\nNo apnea/brady spells noted. Did have 2 brief drifts with\\nbottling to high 80's- QSR. Also had desat at rest to 76%,\\nwith HR drop to 86. Occurred after gavage feed had finished.\\nQSR. Team aware. A: stable in RA, ?reflux. P:Cont to\\nmonitor resp status and provide support as needed.\\n\\n#3: TF: 150cc/k/d. Conts on BM26/PE26, tol'ing 50cc q4hrs\\ngavaged over 1hr10mins. No asps. No spits thus far. HOB\\nslighlty elevated. Bottled at 12 feed, taking 32cc. Fair-\\ngood coordination. Tires toward end of feed. Abd soft,\\n+, no loops. Voiding qs. No stool thus far. A: tol'ing\\nfeeds. P:Cont to follow wt and exam. Monitor tol to feeds.\\nOffer bottle qshift as tol'ed.\\n\\n#4: Mom in for noon care. Indep with care and bottling.\\nUpdated on infant's status. Rescheduled her LC appt for Sat\\nand Mon. A: Involved, parent P:Cont to support and\\neducate.\\n\\n#5: Temps stable while swaddled in an open crib. Molyy\\nloves co-bedding with her siblings. MAE. Fonts soft/flat.\\nBrings hands to face. Sucks on fingers and pacifier.\\nSleeps well in btw cares. A: AGA P:Cont to support dev\\nneeds.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695791,\n \"text\": \"NICU nursing progress note\\n\\n\\nPLease refer to flowsheet for specific info.\\nResp\\nO: remains in room air, RR 40-70's, sat's 94-98%, occ\\ndrift in sat to high 80 's then quickly returns to baseline.\\nBSCE bilat. ic/sc ret. On caffeine , no brady's. A: Stable.\\nP: cont to follow.\\nfEN\\nO: TF of 140cc/k/d, ivf PN D10 w/ IL at 70cc/k/d and enteral\\nfeeds at 70cc/k/d. NO spits, min. asp. Abd benign, no\\nloops, active bs. voiding/ no stool. Glycerin supp. given as\\nordered. No results. No spits. min asp. A: Stable. P: Plan\\nfor adv of feeds 15cc/k at 1600, cont to follow.\\nGD\\nO: TEmp stable in air isolette, active and alert with cares,\\nocc irritable though calms with containment and pacifier.\\nMAE. Font soft, flat. A: AGA P: cont to support dev.\\nmilestones.\\nBIli\\nO: Under single photo tx, eye in place. A: Labs on\\nWeds.\\nParenting\\nPlease see trip #3 note.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695792,\n \"text\": \"PT/OT\\n was observed during her cares. Noted stress signals, strengths and techniques for comfort. Met with and explained role of PT and OT, and initiated education regarding developmental care, stress signs, handling and comfort techniques. were very receptive and demonstrated good understanding of all education. Will continue to f/u for developmental care and parent education.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695867,\n \"text\": \"PCA Note:\\n\\n\\nResp: O: Infant in RA, sats within limits. Lung sounds are\\nclear and equal, mild subcostal retractions. No drifts, no\\nspells. A: Infant breathing comfortably, no apparent\\nrespiratory distress. P: Continue to monitor infant's\\nrespiratory status.\\n\\nFEN: O: TF 150cc/kg BM or PE26. PO/PG feeds as tolerated\\nq4h, gavaged over 1hr 10min. Infant bottled 33cc this\\nmorning for Mom; well coordinated, eager, strong suck. No\\nspits. Infant's abdomen is soft, nontender, +bowel sounds,\\nno loops. Girths stable @ 25cm. Max aspirate = 4cc. Infant\\nis voiding, no stool thus far. A: Infant tolerating feeds\\nwell. P: Continue to offer PO feeds as tolerated. Continue\\nto support nutritional needs of infant.\\n\\n: O: Mom and Dad in this morning. Mom assisted with\\ncares, bottled and held infant. A: appear\\ncomfortable, appropriate and very . P: Continue to\\nsupport, teach and prepare for discharge.\\n\\nDEV: O: is swaddled, cobedded with brother and sister\\nin an , maintaining stable temps. sleeps well\\nbetween cares. Infant wakes with cares and remains and\\nactive throughout cares. calms with her pacifier. A:\\nDevelopmentally appropriate. P: Continue to support\\ndevelopmental needs of infant.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695868,\n \"text\": \"Neonatology NP note\\nPe\\nAFOF, sutures opposed\\nrespirations comfortable in room air, lungs clear/=\\nRRR, no murmur, and well perfused\\nabdomen soft\\ngood tone.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695803,\n \"text\": \"Nursing Progress Note\\n\\n\\nRESP O/A: Infant remains in RA; maintaining O2 sats >95%. RR\\n40-70s, LS clear/=, mild intercostal rtxns. No spells/desats\\nnoted thus far today. Continues on pg caffeine qd. P: Cont\\nto monitor resp status.\\n\\nFEN O/A: TF @ 150cc/k/d. Calories increased to BM/PE22.\\nInfant receives 33cc q4h pg. Tolerating feeds well; no\\nspits, minimal aspirates. Abodomen benign, active BS. Girth\\nstable. Voiding/mec stooling. P: Cont to monitor for s/s of\\nfeeding intolerance.\\n\\nPAR O/A: Mom in @ 1230 to visit. Very affectionate towards\\ndaughter. Asking appropriate questions. P: Cont to support\\nNICU family.\\n\\nDEV O/A: is swaddled in an Air isolette; temps stable.\\nSleeps well b/t feeds, A/A with cares. Likes pacifier. P:\\nCont to support developmental needs.\\n\\nBILI O/A: Infant appears slightly juandice. Problem\\nresolved.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695804,\n \"text\": \"NPN Nights\\n\\n\\n2. O: Ls clear. RR 40-60's. Mild intercostal retractions. No\\nspells/ desats. On Caffeine. RA. A/P: Cont to monitor resp\\nstatus.\\n\\n3. O: Wt 1360gms, up 25. Tf 150cc/kg of BM/PE22 via ngt. 3\\nsmall spits. Min asp. Voiding. +bs. No stool. A/P: Cont to\\nmonitor wt,a bd, and tol of feeds.\\n\\n4. O: Mom called X1. MOm asking appropriate questions. Rn\\nupdated Mom. A/P: Cont to educate and support.\\n\\n5. O: Temp 99.4 X1. Removed hat. Otherwise, temp stable.\\n and active with cares. Occ Sucking on pacifier. A/p:\\nCont to monitor temp. Cont to cluster cares.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695805,\n \"text\": \"7 Bili\\n\\nREVISIONS TO PATHWAY:\\n\\n 7 Bili; resolved\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695806,\n \"text\": \"Neonatology\\nRemains in rA. Comfortable apepairng. Single spell ove course of evening.\\n\\nWT 1360 up 25. TF at 150 cc/k/d of 22 cal. Abdomen benign. Will advance to 24 cal. Few spits overnight.\\n\\nTemp stable in isollette.\\n\\nSl jaundiced. Rbd bili ok.\\n\\n investigating retrotransfer to area.\\n\\nHUS for Tuesday.\\n\\nContinue current monitoring and feed advancement as tolerated.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695807,\n \"text\": \"Nursing Progress Note\\n\\n\\nRESP O/A: Infant remains stable in RA; maintaining O2 sats\\n>94%. RR 30-60s, LS clear/=, mild ic rtxns. One spell noted\\n@ 0900: HR 74, no desat, QSR. Continues on caffeine. Resp\\nstatus stable. P: Cont to monitor for As & Bs.\\n\\nFEN O/A: TF @ 150cc/k/d; calories increased to BM/PE24.\\nInfant receives ~34cc q4h, gavaged over 70 minutes. Minimal\\naspirates, no spits. Abdomen benign, active BS, girth\\nstable. Voiding/transitional stooling. Started on Vit E & Fe\\ntoday. P: Cont to monitor for s/s of feeding intolerance.\\n\\nPAR O/A: Mom in for 1200 cares, independent. Held \\nduring gavage feed. Very loving. Asking appropriate\\nquestions. Dad plans to be in for afternoon cares. P: Cont\\nto support NICU .\\n\\nG&D O/A: Infant is swaddled in an Air isolette; temps\\nstable. Sleeps well b/t feeds, A/A with cares. Likes\\npacifier. MAE, brings hands to face, AFSF. P: Cont to\\nsupport developmental needs.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695808,\n \"text\": \"Neonatology NP Note\\nPE\\nswaddled in isolette\\nAFOF, sutures opposed\\ncomfortable respirations in room air, lungs clear/=\\nRRR, no murmur, and well perfused\\nabdomen sfot, nontender and nondistended, active bowel sounds\\ngood tone.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-04-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695951,\n \"text\": \"PCA NOTE\\n\\n\\nRESP: O/A-In RA. Breathing 30-50's. Sats High 90's. No\\nspells or desats noted. No drifts. No issues. P-Continue to\\nmonitor.\\n\\nFEN: O/A-Current weight 2.545, ^ 25gm. TF 140cc/k/d. E\\n24. PO. Exceeding required amount. Total 24 is 191 cc/\\n is voiding, no stool thus far. Abdomen is\\nunremarkable. Active bowel sounds. Small spit noted.\\nTolerating feeds. P-Continue with current regimen as\\nordered.\\n\\n: No contact thus far this shift.\\n\\nG/D: O/A-Temp stable in . Waking Q4-5 hours for feeds.\\n and active with cares. Sleeping peacefully. Curious\\ndisposition. Adores being held. Awake for longer periods of\\ntime. MAE. AGA. P-Continue to monitor for developmental\\nmilestones.\\n\\n ****See flowsheet for specifics****\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-04-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695952,\n \"text\": \"NPN 1900-0730\\nI have examined the infant and agree with the above note by , PCA.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-04-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695953,\n \"text\": \"Neonatology Attending\\n is 43do, 37 wks corrected\\nRA, open crib alone (sibs have been d/c'd)\\nNo a/b day \\nWt 2545 up 45 on ad TF140 E/MM24 po\\n\\nMeds Fe\\n\\nImp/ age appropriate cvr immaturity, approaching readiness for d/c.\\n\\nPlan/ continue to monitor cvr status, growth/development. D/c planning in progress for tomorrow contingent upon further evidence of maturity.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-04-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695954,\n \"text\": \"Neonatology - NP Physical Exam\\nAwake and with cares, temp stable in open crib. BS clear and equal, color . RRR, without murmur, pulses 2+ and symmetrical. Active bowel sounds, without loops, without HSM, tolerating feeds well. Normal female genitalia. Without rashes. Good tone, AFSF, PFSF, +suck, +, +plantar reflexes. Please see attending neonatologist note for detailed plan of care.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-04-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695955,\n \"text\": \"Nursing NICU Note\\n\\n\\n#2. Respiratory O: Pt. remains in RA, O2 sats >96%. LS\\nclear/=. RR ~30-50's, no increase work of breathing noted.\\nNo A&B's this shift thus far. Today is Day #4 of a 5 day\\nspell count. A: Pt. is stable in RA. P: Continue to\\nmonitor respiratory status. Monitor for A&B's.\\n\\n#3. FEN O: Ad 140cc/kg/d of BM24/E24. She takes\\n~70-90cc PO q feed. She wakes for feeds and bottles well.\\nAbdomen is soft, , +BS, no loops/spits noted. She is\\nvoiding/ no stool passed this shift thus far. A: Pt. is\\ntolerateing current nutritional plan. P: Continue w/\\ncurrrent feeding plan. Monitor for s/s of intolerance.\\n\\n#4. O: Mom called this am and was updated on pt's\\ncurrent status and daily plan of care. are active\\nand independent in cares. A: are lvoing and\\ninvolved. P: Continue to update, support and educate.\\nContinue w/ discharge teaching/planning.\\n\\n#5. Growth/Development O: Pt. remains in an open crib,\\nswaddled w/ stable temps. She is and active w/ cares,\\nsleeps well in between. Fontanelle soft/flat. She loves to\\nuse her pacifier, brings hands to face. A: AGA P:\\nContinue to provide environment appropriate for growth and\\ndevelopment.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695869,\n \"text\": \"npn 1900-0700\\n\\n\\n2: resp\\n\\nRemains in ra. no spells and no dsats. RR 30-70's. Lung\\nsounds clear and equal. mild subcostal retractions. no\\nincreased wob noted. continue to monitor for changes in resp\\nstatus.\\n\\n3: fen\\ncurrent weight 1910gms up 30gms. total fluids remain at\\n150cc/kilo/day of bm/pe 26. tolerating feeds well. no spits.\\nminimal aspirates. abd soft with no loops. alt po/pg feeds.\\ninfant took whole volume at 2400 care. girths stable.\\nvoiding, no stool thus far this shift. continue to encourage\\npo feeds.\\n\\n\\n4: :\\nNo contact thus far this shift.\\n\\n5: G/D\\ntemp stable in an open crib. and active with cares.\\nsleeps well inbetween. brings hands to face. sucks on\\npacifier. brings hands to face. aga. continue to monitor for\\ndevelopmental milestones.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695870,\n \"text\": \"Neonatology Attending Note\\nDay 24\\nCGA 34 2\\n\\nRA. RR30-50s. No A&Bs. BS cl and =. Mild sc rtxns.\\n\\nWt , up 30 gms. TF 150 cc/k/day PE26 po/pg. Tol well. Nl voiding and stooling.\\n\\nStable temps in open crib.\\n\\nA/P:\\nGrowing preterm infant learning how to po feed. Will cont to encourage feeding skills and monitor.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695871,\n \"text\": \"Neonatology Attending Note\\nExam:\\n\\nResting comfortably in open crib. AFSF. Lungs CTA, =. CV RRR, no murmur. 2+FP. Abd soft, +BS. Ext and well perfused.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-04-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695934,\n \"text\": \"NPN 0700-1900\\n\\n\\n#2: O: Infant remains in room air. Saturations greater than\\n95%. Respiratory rate 30's-50's with no retractions. Lung\\nsounds clear and equal. No spells. A: Infant stable in room\\nair. P: Continue to monitor infant for spells.\\n\\n#3: O: Infant is feeding ad demand, breastmilk or E24.\\nBottled 90cc each feed so far this shift. Abdomen benign,\\nbowel sounds active. Voiding, no stools this shift. One\\nsmall spit. A: Infant tolerating feeds. P: Continue with\\ncurrent feeding plan.\\n\\n#4: O: called this shift.\\n\\n#5: O: Temperature stable in . Wakes for feeds, and\\nactive with cares. Brings hands to face for comfort and\\ncalms with pacifier. A: AGA. P: Continue to support growth\\nand development.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-04-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695935,\n \"text\": \"0700-1900 NPN\\nI have read and agree with the above note written by , PCA.\\n\\n: Mom called this am, updated on patient's current status by this RN. Mom states she will be in for the evening care. Continue to support family.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-04-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695936,\n \"text\": \"2 Resp.\\n Infant remains in room air with sats over 95.No spells so\\nfar tonight.Lungs clear and equal.continue to monitor and\\nrecord any changes.\\n3 F/N\\n Abdomen soft, + bowel sounds, 0 loops, 0 distention,\\nbottled well all shift. Total fluids in last 24 hours were\\n205cc per K.Voiding, stooling.Wt up 65gms to 2.450. Continue\\nper plans.\\n4 \\n called early part of shift, given updates. Plan to\\nkeep family informed.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-04-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695937,\n \"text\": \"Neonatology Attending\\naddendum: PE\\n\\nActive sleep, appropriate activity, . AFOF. Lungs cta, heart rrr s murmur, abd soft, extr well perfused.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-04-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695938,\n \"text\": \"Neonatology Attending\\n is 40do, 36 wks\\nRA, open crib cobedding with \\n a/b day \\nwt 2450 up 65g on adlib minTF140 Mm24/E24\\n\\nMeds Fe\\n\\nImp/ age appropriate cvr immaturity, improving; demonstrating mature feeding skills. Had late (~48hr) +Bcx for S epi last week, repeat cx negative, likely contaminant.\\n\\nPlan/ continue to monitor cvr status, growth/development\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-04-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695939,\n \"text\": \"Neonatology Attending\\naddendum: PE\\n\\nActive sleep, appropriate activity, . AFOF. Lungs cta, heart rrr s murmur, abd soft, extr well perfused.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-04-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695940,\n \"text\": \"0700-1900 NPN\\n\\n\\nRESP: Infant remains in RA, O2 sats=96-100%. RR=30=60's.\\nBreath sounds clear and equal bilaterally, no retractions\\nnoted. No bradys, no desats so far this shift. Continue to\\nto monitor resp status.\\n\\nFEN: Ad with a minimum of 140cc/kg/d of BM24 with\\nenfamil powder/E24, all PO's. Infant has bottled 90cc and\\n55cc with good coordination so far this shift. Waking approx\\nq4hr for feeds. Abdomen , soft, round, +BS, no loops. No\\nspits. Voiding and stooling (guiac negative). Continues on\\nIron. Continue to monitor FEN status.\\n\\n: Mom called this afternoon,, updated on patient's\\ncurrent status by this RN. Mom states she will be in later\\ntoday. Continue to support family.\\n\\nG+D: Temps stable, swaddled in . Cobedding with sister.\\nActive and with cares, sleeps well in between cares.\\nBrings hands to face, sucks on pacifier for comfort.\\nContinue to support G+D.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-04-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695908,\n \"text\": \"NPN 1900-0700\\n\\n\\nRESP: Infant remains in RA. O2sat 97-100%. RR 30-50's.\\nOccasional mild IC/SC rtx. LS clear and equal. No spells, no\\ndesats. Did have some HR and sat drifts when choking with\\nfeed or spits.\\n\\nFEN: wt2200g (up 45g). TFmin 140cc/kg of BM/E24. Yest\\nTFI=174cc/kg. Bottling adequate volumes with good\\ncoordination. Abdomen soft, +BS, no loops, spits X2,\\nvoiding, no stool. On Fe.\\n\\n: Mom called X1, updated over the phone. Asking about\\nrepeat hearing screen. Will be in later today.\\n\\nG&D: Temps stable, swaddled in open crib. Cobedding with\\nsiblings. and active with cares. Occasionally wakes\\nfor feeds. Hands to face. Continues with small amt of\\nyellow/green right eye drainage, warm soaks done every care.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-04-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695909,\n \"text\": \"Neonatology Attending\\n is 33do, 35 wks corrected\\nRA, open crib cobedding with sibs\\nDay without a/b (last episode at 4am)\\nDesat to 85 post feed this am - selfresolved\\n\\nWt 2200 up 45 on ad lib minTF140 MM/E24 po\\n\\nMeds Fe\\n\\nHead u/s this am prelim nl\\nPassed hearing screen\\n\\nImp/ age appropriate cvr/feeding immaturity, approaching readiness for d/c\\nPlan/ continue to monitor cvr status, growth/development. D/c planning in progress for as early as Thurs contingent upon further evidence of maturity.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-04-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695910,\n \"text\": \"Neonatology - NNP Progress Note\\n\\n is active with good tone. AFOF. She is , well perfused, no murmur auscultated. She is comfortable in room air. No spells today. Breath sounds clear and equal. She is tolerating full volume po feeds. Abd soft, active bowel sounds, no loops. Voiding and stooling. Stable temp cobedding with sibs. Head ultrasound today normal. Please refer to neonatology attending note for detailed plan.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-04-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695911,\n \"text\": \"NPN 0700-\\n\\n\\n2. In RA with sats 95-100%. Lungs clear, RR 30-60's. Mild\\nSC retractions. One desat to 85% after 0830 feed, QSR. No\\nA&B's thus far. Day brady countdown. Cont to monitor\\nfor A&B's or desats.\\n\\n3. Infant on ad lib with min. 140cc/k/d BM24 or E24. Abd\\nbenign. Voiding and no stool thus far. Min. Tf intake 51cc\\nevery 4hrs and infant able to bottle 65 and 67cc Q4hr well.\\nOne small spit thus far. Tolerating all PO's. Cont to\\nmonitor ability to take bottles or breast feed.\\n\\n4. Mother called and updated on plan of care. Mother\\nunable to visit today and plans to visit tomorrow at noon.\\nSpoke with mother about possible D/C date for Thursday.\\nFather is out of town on business in and is trying\\nto get home for Thursday. Mother aware that we may be able\\nto D/C triplets on Friday if Father is unable to get home by\\nThurs. Cont to support, update, and prepare for D/C.\\n\\n5. Temp stable swaddled in open crib. Infant is cobedding\\nwith siblings. and active with cares, resting well\\ninbetween. MAE, suckles well on pacifier. Cont to promote\\nG&D.\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695828,\n \"text\": \"PCA 1900-0700\\n\\n\\n2\\ninfant remains in RA, RR 20-60, SATing 93-99%, lung sounds\\ncl=, sc retractions, no spells. P:cont. to monitor.\\n\\n3\\ninfant's current weight 1580g up 20g, remains on TF min of\\n150cc/kg/d of BM/PE 26 with promod=40cc q4h gavaged over 90\\nminutes. abd full/soft, bs+, no loops, ag stable 23.5-24.5,\\nmax asp. 5.2cc partially digested BM, small spit X1,\\nvoiding/stooling qs heme. neg. P:cont. to support\\nnutritional needs.\\n\\n4\\nno known contact thus far.\\n\\n5\\ninfant remains swaddled in OAC, temp. stable, and\\nquietly active during cares,settles well in between, likes\\npacifier, fonts soft/flat. P:cont. to support dev. needs.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695829,\n \"text\": \"PCA 1900-0700\\n#3 Infant's AG remains stable at 24.5cm, active bowel soundAddendum to above: I have examined this infant and agree wis, soft abdomen, non tender (no guarding), transient soft loth note above, see above correction for additional information. ops noted at 4am, residual at this time 8.2cc. No spits. Discussed with NNP, residual refed, and regualr feeding given. Will Contnue to monitor abdominal exam very closely.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695830,\n \"text\": \"PCA 1900-0700\\n#3 Infant's AG remains stable at 24.5cm, active bowel soundAddendum to above: I have examined this infant and agree wis, soft abdomen, non tender (no guarding), transient soft loth note above, see above correction for additional information. ops noted at 4am, residual at this time 8.2cc. No spits. Discussed with NNP, residual refed, and regualr feeding given. Will Contnue to monitor abdominal exam very closely.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695831,\n \"text\": \"Neonatology Attending Note\\nDay 15\\nCGA 33\\n\\nRA. RR20-60s. Cl and = BS. +SC/IC rtxns. On caffeine. No A&Bs. HR 160-180s. No murmur. , well perfused. BP 66/39, 49.\\n\\nWt 1580, up 20 gms. TF 150 cc/k/day PE/BM26 w promod. PG over 90 minutes. Small spits.\\nPassing stool. Nl voiding.\\n\\nIn open crib.\\n\\nA/P:\\nGrowing preterm infant with resolving , learning how to po feed. Will try smaller feedings at closer intervals to reduce degree of spitting.\\n\\nImproved , will d/c caffeine which may also improve spitting.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-04-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695902,\n \"text\": \"1900-0700 NPN\\n\\n\\nRESP: Infant remains in RA, O2 sats=95-100%. RR=30-50's.\\nBreath sounds clear and equal, no retractions noted. No\\nbradys, no desats so far this shift. Continue to monitor\\nresp status.\\n\\n: Mom called this evening, updated on patient's\\nstatus by this RN. Mom states she will be in for afternoon\\ncares. Continue to support/educate family.\\n\\nG+D: Temps stable, swaddled in . Cobedding with sister\\nand brother. Active and with cares, sleeps well in\\nbetween cares. Brings hands to face, sucks on pacifier for\\ncomfort. Continue to support G+D.\\n\\nFEN: Weight tonight=2.155kg (-10grams). Ad lib on demand\\nwith a min of 140cc/kg/d of BM24 with enfamil powder/E24.\\nInfant has taken all PO's so far this shift. Infant has\\nbottled 55cc and 54cc so far this shift with good\\ncoordination. Waking q4hr for feeds. Abdomen , soft,\\nround, +BS, no loops. Minimal aspirates, no spits. Voiding,\\nno stool. Continue to support FEN status.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695823,\n \"text\": \"NICU NSG NOTE\\n\\n\\n#2. Resp. O/ RA. LS clear and equal. RR 30-60's. Baseline\\nretractions. No spells. A/ Stable. P/ Cont to monitor.\\n\\n#3. FEN. O/ Wt up 50g. TF 150cc/k/d BM26 with PM. Receiving\\nq4h volumes via gavage over 90 mins for hx spits. No spits\\nthus far. Abd soft. No loops. +BS. Voiding and stooling. A/\\nTolerating feeds. Gaining wt. P/ Cont to monitor for feeding\\nintolerances. Daily wts.\\n\\n#4. Parenting. No contact with family thus far this shift.\\n\\n#5. G&D. O/ Warm in off isolette. Transitioned to open crib\\nwith stable temps. and active for cares. Not waking on\\nown for feeds. Nested and swaddled on sheepskin. A/ AGA. P/\\nCont to support developmental needs of infant.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695824,\n \"text\": \"NICU nursing progress note\\n\\n\\nPlease refer to flowsheet for specific info.\\nResp\\nO: remains in room air, RR 40-60's occ 70's. Sat's\\n>97%, mild sc ret. BSCE bilat. NO brady's, on caffeine. A:\\nStable P: cont to follow.\\nFEN\\nO: TF are 150cc/k/d of PE or BM 26 with promod. Abd , no\\nloops, active bs Voiding/ stooling. Feedings are gavaged\\nover 90\\\" due to hx of spits. Min asp. A: Stable. P: cont to\\nfollow.\\nGD\\nO: Temps stable in oac cobedding with trip #3 brother,\\nactive and with cares, does not wake for feeds. MAE.\\nFonts soft, flat. Brings hands to face. Calms with\\ncontainment and pacifier. A: AGA P: cont to support\\ndev.milestones.\\nParenting\\nO: Mom planning on visiting at 12pm, also awaiting transfer\\nto Hosp. when beds are avail. for triplets.\\nA: and invested with extensive family support\\nsystem on mother's side. P: cont to update, support,\\neducate. D/C planning is ongoing. Will transfer to when beds are avail.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-04-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695903,\n \"text\": \"Neonatology Attending\\n i s 32do, 35 /47 wks\\nDay without a/b\\nWt 2155 down 10 on ad lib minTF140 MM/E24 -- took 160cc/kg/24hrs\\n\\nPE active, appropriate, . AFOF. Lungs cta, heart rrr s murmur, abd soft, extr well perfused.\\n\\nImp/ approaching readiness for d/c\\nPlan/ continue to monitor cvr status, growth/development. Tentative d/c Thurs contingent upon further evidence of maturity.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-04-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695904,\n \"text\": \"Nursing NICU Note\\n\\n\\n#2. Respiratory O: Pt. remains in RA, O2 sats >95%. RR\\n~30-50's, no increase work of breathing noted. LS clear/=.\\nNo A&B's or sat drifts noted this shift thus far. This is\\nDay #2 of 5 for a spell count. A: Pt. is stable in RA. P:\\n Continue to monitor respiratory status. Monitor for A&B's.\\n\\n#3. FEN O: Pt. is ad lib Min 140cc/kg/d of BM24 w/Enfamil\\npowder or E24 =50cc Q 4hrs. She is takeing all PO feeds\\n45-70cc PO in addition to breastfeeding x1. Abdomen is\\nsoft, , +BS, no loops/spits noted. A: Pt. is\\ntolerating current nutritional plan. P: Continue w/\\ncurrent feeding plan. Monitor for s/s of intolerance.\\nEncourage PO feeds.\\n\\n#4. O: Mom in to visit this afternoon and was\\nupdated on pt's current status and daily plan of care.\\n are active and involved in cares, asking appropriate\\nquestions. A: Family is and involved. P: Continue\\nto udpate, support and educate. Continue w/ discharge\\nteaching/planning.\\n\\n#5. Grwoth/Development O: Pt. remains in an open crib,\\nco-bedding w/ her siblings. She is and active w/\\ncares, sleeps well in between. Fontanelle soft/flat. She\\nloves to use her pacifier, brings hands to face. A: AGA\\nP: Continue to provide environment appropriate for growth\\nand development.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-04-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695905,\n \"text\": \"PT\\n seen for developmental evaluation. She was positioned in prone and supported sitting positions. She tolerated them well. She is able to clear her airway in prone but is unable to turn her head. Talked to Mom briefly and will meet with her later in week to discuss discharge teaching and developmental play.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-04-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695906,\n \"text\": \"NPN 1900-0700\\nInfant passed hearing screen.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-04-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695907,\n \"text\": \"NPN 1900-0700\\nInfant passed hearing screen.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695825,\n \"text\": \"Neonatology Attending Note\\nDay 14\\nCGA 36 2\\n\\nRA. RR50-60s. No A&Bs. No murmur. On caffeine.\\n\\nWt 1560, up 50 g. TF 150 cc/k/day BM/PE26 w promod. PG over 90 min. Nl voiding and stooling.\\nOn Fe and Fe.\\n\\nIn open crib.\\n\\nA/P:\\nGrowing preterm infant learning how to po feed.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695826,\n \"text\": \"Clinical Nutrition\\nO:\\n~33 wk CGA BG on DOL 14.\\nWT: 1560g(+50); birth wt: 1345g. Average wt gain over past wk ~23g/kg/day.\\nHC: 28.75cm( %ile); last wk: 27.5cm\\nLN: 38cm(<10 %ile); last wk: 38cm\\nMeds include Fe & Vit.E\\nLabs noted.\\nNutrition: 150cc/kg/day as PE/BM 26 w/promod, all pg over 90 mins. Average of past 3-day intake ~141cc/kg/day, providing ~122kcal/kg/day & ~3.8-4.1g pro/kg/day.\\nGI: Abdomen benign.\\n\\nA/Goals:\\nTolerating feeds w/o GI problems over extended feeding times d/t h/o spits; all pg. Labs noted & within acceptable range. Current feeds & supps meeting recs for kcal/pro/vits/mins. Growth is exceeding recs for WT/HC gains of ~15-20g/kg/day for WT gain & of ~0.5-1cm/wk for HC gain. LN gain is not meeting recs of ~1cm/wk. Will monitor long term trends. Will continue to follow w/ team & participate in nutrition plans.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695827,\n \"text\": \"Fellow note; physical exam\\n and active in open crib. Breathing comfortably in RA. SKin . AFOF. Lungs clear. No murmur. Abd soft, ND, +BS. Extrem WWP. Good tone.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-04-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695899,\n \"text\": \"1900-0700 NPN\\n\\n\\nRESP: Infant remains in RA, O2 sats=96-100%. RR=30-50's.\\nBreath sounds clear and equal, occasional mild SCR noted. No\\nbradys, no desats so far this shift. Continue to monitor\\nresp status.\\n\\nFEN: Weight tonight=2.165kg (+30 grams). TF=150cc/kg/d of\\nBM26/PE26 alternating PO/PG q4hr. Infant bottled 35cc at\\n0000 with good coordination but does tire easily. Abdomen\\n, soft, round, +BS, no loops. Minimal aspirates, small\\nspit x 1 so far this shift. Voiding/no stool. Continue to\\nmonitor FEN status.\\n\\n: Mom called this evening, updated on patient's\\ncurrent status by this RN. Mom states she will be in\\ntomorrow for the afternoon care. Continue to support/educate\\nfamily.\\n\\nG+D: Temps stable, swaddled in . Cobedding with sister\\nand brother. Active and with cares, sleeps well in\\nbetween cares. Brings hands to face, sucks on pacifier for\\ncomfort. MAE. Continue to support G+D.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-04-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695900,\n \"text\": \"Newborn Med Attending\\n\\nDOL#31. Cont in RA, no spells. AF flat, clear BS, no murmur, abd soft, MAE. WT=2165 up 30, on 150 cc/kg/d BM26 PO/PG.\\nA/P: Growing infant working up on PO feeds.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-04-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695901,\n \"text\": \"Nursing NICU Note\\n\\n\\n#2. Respiratory O: Pt. remains in RA, O2 sats >96%. RR\\n~40-70's, no increase work of breathing noted. LS clear/=.\\nNo A&B's noted this shift thus far. A: Pt. is stable in\\nRA. P: Continue to monitor respiratory status. Monitor\\nfor A&B's.\\n\\n#3. FEN O: Pt. is now ad lib Min 140cc/kg/d of BM24\\nw/Enfamil powder or E24 =51cc Q 4hrs. She has taken all PO\\nfeeds this shift thus far ~48-54cc PO Q feed. Pt. requires\\nfrequent burping. Abdomen is soft, , +BS, no\\nloops/spits noted. She is voiding/ no stool noted this\\nshift thus far. A: Pt. is tolerating current nutritional\\nplan. P: Continue w/ current feeding plan. Monitor for s/s\\nof intolerance. Continue to encourage PO feeds as pt. looks\\ninterested and tolerates.\\n\\n#4. O: Mom called this am and was updated on pt's\\ncurrent status and daily plan of care. are active\\nand involved in cares. A: Family is and involved.\\nP: Continue to update, support and educate. Continue w/\\ndischarge teaching/planning.\\n\\n#5. Growth/Development O: Pt. remains in an open crib,\\nswaddled and co-bedding w/ siblings. Temps stable. She is\\n and active w/ cares, sleeps well in between.\\nFontanelle soft/flat. She loves to use her pacifier, brings\\nhands to face. A: AGA P: Continue to provide environment\\nappropriate for growth and development.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695856,\n \"text\": \"npn 1900-0700\\n\\n\\n\\n2: resp\\nremains in ra. no spells. no dsats. RR 30-50's. Lung sounds\\nclear and equal. mild subcostal retractions. no increased\\nwob noted. continue to monitor for changes in resp status.\\n\\n3: fen\\ncurrent weight 1790gms up 20gms. total fluids remain at\\n150cc/kilo/day of pe 26. tolerating feeds well. no spits\\nthus far this shift. minimal aspirates. abd soft with no\\nloops. stable girths. voiding, stooled x's 1 hem negative.\\ncontinues on vit e and iron. hob elevated for spiting.\\n\\n4: \\nmom called this shift x's 1. updated by this rn. very \\nand involved. asking appropriate questions. continue to\\nsupport family needs.\\n\\n\\n5: G/D\\ntemps stable in an open crib. co-bedded with sibblings.\\n and active with cares. sleeps well inbetween.\\nsucks vigorously on pacifier. brings hands to face. continue\\nto monitor for developmental milestones.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695820,\n \"text\": \"NPN 1900-0700\\n\\n\\n2.Resp: Infant remains in room air with RRs 20s-50s, 02\\nsats> 98%. Lung sounds are clear and equal with mild\\nsubcostal retractions. She remains on caffeine, no spells\\nthus far this shift. Continue to monitor respiratory status.\\n\\n3.FEN: Infant's weight tonight 1510g (up 60g). She remains\\non TF 150cc/kg/day of PE/BM 26cal/oz with Promod via NGT\\nover 1 hr 30 minutes. Infant is tolerating feeds well with\\none small spit, max aspirate 2.4cc of non-bilious, partially\\ndigested formula. Abdomen is soft and round with active\\nbowel sounds, no loops. Abdominal girth consistent 22-23cm.\\nShe is voiding, one trace stool thus far this shift.\\nRemains on vitamin E and Fe+ dietary supplements. Vitamin E\\ngiven this shift. Continue to monitor FEN status and weight\\ngain.\\n\\n4.: Dad in to visit this evening, updated at bedside.\\n He participated in the care of this infant and then held\\nfor one hour. Dad is and appropriate, asking\\nappropriate questions. Mother is planning to visit\\ntomorrow, will call to confirm. Possible transfer to . Transfer paperwork on front of chart.\\n need to sign consent for transfer. Continue to\\nsupport and keep informed.\\n\\n5.DEV: Infant remains in an off isolette with stable temps.\\nShe is swaddled with head of bed at 45 degrees. She is \\nand active with cares, irritable at times. She brings hands\\nto face and sucks vigorously on pacifier. Mom wants to\\nbathe tomorrow. Continue to support growth and development.\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695821,\n \"text\": \"Neonatology Attending Note\\nDay 13\\nCGA 32 5\\n\\nRA. RR20-50s. Cl and =. Mild sc retractions. >96% sats. On caffeine. No A&Bs. No murmur. HR 140-160s. BP 57/39, 44.\\n\\nWt 1510, up 60 gms. TF 150 cc/k/day BM/PE26 w promod. PG over 1.5 hrs. Tol well. Nl voiding and stooling, g-.\\n\\nOn Vit E and Fe.\\n\\nIn off warmer.\\n\\nA/P:\\nGrowing preterm infant.\\n- monitor AOP\\n- cont to monitor growth on current nutrition\\n- awaiting bed availability at Hospital\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695822,\n \"text\": \"Nursing NICU Note\\n\\n\\n#2. Respiratory O: Pt. remains in RA, O2 sats ~ 97-99%.\\nRR ~50-60's. No increase work of breathing noted. LS\\nclear/=. She has mild SC retractions noted. No A&B's noted\\nthis shift thus far. A: Pt. is stable in RA. P: Continue\\nto monitor respiratory status. Monitor for A&B's.\\n\\n#3. FEN O: TF 150cc/kg/d of BM26 w/PM or PE26w/PM =38cc Q\\n4hrs, gavaged over 1hr 30min, tolerated well. Abdomen is\\nsoft, , +BS, no loops/spits noted. Abdominal girth is\\n22.5-23cm. She is voiding/ passed tiny amount of stool x1.\\nA: Pt. is tolerateing current nutritioanl plan. P:\\nContinue w/ current feeding plan. Monitor for s/s of\\nintolerance.\\n\\n#4. O: Mom and grandmom in to visit for 1200\\ncares. They were updated at bedside on pt's current status\\nand daily plan of care. Mom is actively participateing in\\ncares, asking appropriate questions. A: Family is \\nand involved. P: Continue to update, support and educate.\\n\\n#5. Growth/Development O: Pt. remains in an off Isolette,\\nswaddled w/ stable temps. She is and active w/ cares,\\nsleeps well in between. Fontanelle soft/flat. She uses her\\npacifier on occasion, brings hands to face. A: AGA P:\\nContinue to provide environment appropriate for growth and\\ndevelopment. Plan to transition infant into crib later\\ntoday.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695857,\n \"text\": \"Clinical Nutrition\\nO:\\n~34 wk CGA BG on DOL 21\\nWT: 1790 g (+20)(~25th %ile); birth wt: 1345 g. Average wt gain over past wk ~18 g/kg/day.\\nHC: 30 cm (~25th %ile); last: 28.75 cm\\nLN: 41.5 cm (~10th to 25th %ile); last: 38 cm\\nMeds include Fea dn Vit E\\n not due yet\\nNutrition: 150 cc/kg/day PE 26 (no BM for now due to mom dumping since she is on medication). Average of past 3 day intake ~150 cc/kg/day, providing ~130 kcal/kg/day and ~3.6 g pro/kg/day.\\nGI: Abdomen benign.\\n\\nA/Goals:\\nTolerating feeds without GI problems. not due. Current feeds + supps meeting recs for kcals/pro/vits and mins. Growth is meeting recs for wt gain. HC and LN gain are exceeding recommended ~0.5 to 1 cm/wk for HC gain and ~1 cm /wk for LN gain. Will follow long term trends. Will continue to follow w/ team and participate in nutrition plans.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695858,\n \"text\": \"Neonatology-NNP Physical Exam\\n\\n remains in RA. Active, in an open crib, AFOF, sutures opposed, good tone. BBS clear and equal with good air entry. No murmur, pulses +2, , RRR. Abdomen soft, non-distended, tolerating feeds. Please refer to attending progress note for detailed plan.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695859,\n \"text\": \"Neonatology Attending\\n21do, 33 wks corrected.\\n remains in RA, open crib cobedding with sibs.\\nNo a/b.\\nWt up 20g to 1790 on TF150 PE26 pg\\n\\nMeds vit E, Fe\\n\\nImp/ age-appropriate feeding immaturity; growing well.\\nPlan/ continue to monitor cvr status, growth & development.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695860,\n \"text\": \"2. remains in RA, RR30-60, mild sc retractions, sats\\n90-99, BBSclear, equal, one brief self-resolving brady P:\\ncontinue to monitor.\\n3. TF 150cc/k/d PE26 45cc pg over 80 min, abd soft, no\\nloops, active bowel sounds, minimal aspirates, no spits,\\nvoiding, no stool.\\n4. Mom here at 1300, held babies, planning to bring in\\nbreast milk tommorrow A: very involved and concerned P:\\ncontinue to update and offer support.\\n5. temp stable swaddled in open crib with siblings, active\\nwith cares, soon to try po feedings P: continue to support\\ngrowth and development.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-04-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695925,\n \"text\": \"Nursing progress note\\n\\n\\n #2 O: Remains in room air with equal & clear breath sounds\\n& no retractions. No A's, B's or desats noted. A: Stable. P:\\nCont to assess.\\n#3 O: Wgt up 65 gms. Waking for feeds & feeding well with\\nyel nipple. Voidng with diaper changes. No stool. Abd soft\\nwith active bowel sounds & no loops. No spits. A: Tolerating\\nfeeds & gaining wgt. P: Cont to assess.\\n#5 O: Temp stable, co-beeding with twin. Waking for feeds &\\nbottling well. with cares. A: AGA. P: Cont to assess.\\n#8 O: Temp stable. with cares. No spells. A: No signs\\nof sepsis. P: Cont to assess.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-04-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695897,\n \"text\": \"NICU Attending Note\\n\\nDOL # 30 = 35 1/7 weeks CGA with resolving A/B learning to PO feed.\\n\\nAll interval hx and data reviewed, patient examined, care discussed.\\n\\nCVR/RESP: RRR without murmur, and well perfused, no increaased WOB, BS clear/=, remains in RA, occasional O2 drifts with bottles, day of spell countdown. Will continue to monitor.\\n\\nFEN: Abd benign, NTND, no HSM. Weight 2135 gm, up 60 gm on 150 cc/kg/d MM/PE 26, PO/PG. Will continue to encourage PO intake.\\n\\nNEURO: AFSOF, appropriate tone and strength, active and .\\nHead U/S Tuesday.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-04-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695898,\n \"text\": \"Nursing NICU Note\\n\\n\\n#2. Respiratory O: Pt. remains in RA, O2 sats ~91-100%.\\nLS clear/=. RR ~30-60's, no increase work of breathing\\nnoted. She has occasional sat drifts w/ feeds that self\\nresolve. No A&B's noted this shift thus far. This is Day\\n#1 of 5 day spell count. A: Pt. is stable in RA. P:\\nContinue to monitor respiratory status. Monitor for A&B's.\\n\\n#3. FEN O: TF 150cc/kg/d of BM26/PE26 =53cc Q 4hrs\\nalternateing PO/PG feeds. She has taken 50cc and 35cc w/\\nthe remainder gavaged. Pt. tireing out easily by the end of\\nher last feed. Abdomen is soft, , +BS, no loops/spits\\nnoted. She is voiding/ sm. stool passed x1. A: Pt. is\\ntolerating current nutritional plan. P: Continue w/\\ncurrent feeding plan. Montor for s/s of intolerance.\\nContinue to encourage PO feeds as pt. looks interested and\\ntolerates.\\n\\n#4. O: Mom in to visit for afternoon cares. She\\nwas updated at bedside on pt's current status and daily plan\\nof care. are active and involved in cares, asking\\nappropriate questions. A: Family is and involved.\\nP: Continue to update, support and educate. Continue w/\\ndischarge teaching.\\n\\n#5. Growth/Development O: Pt. remains in an open crib,\\nswaddled and co-bedding w/ her siblings. Temps stable. She\\nis and active w/ cares, sleeps well in between.\\nFontanelle soft/flat. She loves to use her pacifier, brings\\nhands to face. A: AGA P: Continue to provide environment\\nappropriate for growth and development.\\n\\n\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-04-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695926,\n \"text\": \"Neonatology Attending Progress Note:\\n\\nDOL #37, CGA 36 1/7 weeks\\nRA, RR=30-60's, one brady yesterday with feeds (Day #1 of 5)\\nHR=150-160's\\nsepsis eval this week for decreased temp, blood culture #1 GPC pairs/chains and repeat blood culture off antibiotics negative\\n2310g (inc 65g), ad lib min 140cc/kg/d (taking 161 in past 24 hours)\\nvoiding, stooling\\nco-bedding\\n\\nPE: well appearing, AFOF, normal S1S2, no murmur, breath sounds clear, abdomen soft, nontender, nondistended, ext warm, well perfused. tone aga.\\n\\nImp/Plan: premie twin with and positive blood culture probable contaminant.\\n--monitor for spells\\n--check second blood culture, if change in symptoms or positive blood culture, will have low threshold for starting antibiotics.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-04-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695927,\n \"text\": \"8 Infant with Potential Sepsis\\n\\nNursing PRogress Note:\\n#2 - RESP: REmains in room air. Lungs clear and equal. RR\\n30-50. O2Sat > 93%. No spells/desats today. Not being fed\\non monitor. Day brady count.\\n\\n#3 - F&N: Ad lib demand feeder with min of 140cc/kilo =\\n54cc's q 4 hours. Bottling between 65-80cc's of E24/BM24.\\nOccassionally small spits or wet burps noted. Abdomin soft\\nand round. Voiding good amount. Stooling with each diaper\\nchange. Iron given.\\n\\n#4 - : Mom in this afternoon. Updated at the bedside.\\nIndependent with cares. Holding and feeding babies.\\nEncouraged to get help set up for when the babies are all\\nhome. Mom states that plenty of people in the community\\noffered to help when needed. All ready setting up dinners\\nfor the family for the next 2 months.\\n\\n#5 - G&D: Temps stable in open crib. Co-bedding with\\nsibling. and active with cares. MAE> AFSF. Bottling\\nall feeds. Hx of normal head US.\\n\\n#8 - Potential sepsis: 2nd blood culture neg. Believe first\\npositive culture to be a contaminent. Problem resolved.\\n\\n\\nREVISIONS TO PATHWAY:\\n\\n 8 Infant with Potential Sepsis; resolved\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-04-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695928,\n \"text\": \"NPN 2300-0700\\n\\n\\n2. O: Infant remains in room air. O2 sats 98-100%. RR\\n40-50's. No A&B's thus far. Last A&B . A: brady\\ncountdown continues.P: Continue to assess.\\n\\n3. O: Wt.+30g 2340g. Yesterday received 156cc/kg/d. Infant\\nbottling 75cc every 4-5 hours. Abdomen soft. +b.s. No loops\\nnoted. No spits noted. Wet burps noted. vdg & stooling q.s.\\nA; Bottling well. P: Continue to assess weight gain.\\n\\n4. O : No parental contact noted thus far.\\n\\n5. O: co-bedding with sister. Maintaining temperature.\\nMAE. Brings hands to face. Active & . Waking for feeds.\\nNested with boundaries. A: AGA P: Continue to support\\ndevelopment.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695815,\n \"text\": \"NPNOte;\\n\\n\\n#2. Remains in R air, BBS clear, equal, easy resp effort, no\\nspells thus far this shift. On Caffine given as ordered.A;\\nNo spells thus far this shift. P; cont to monitor.\\n\\n#3. TF=150cc/kg/day,MBM26/PE26 with promod, pg fed over 1hr\\n30mts, no spits, BS+, no loops, voided, no stool thus far\\nthis shift. A; Feeds tolerated. P; cont current feeding\\nplan.\\n\\n#5.,active with care, temp stable in a air mode\\nisolette, swaddled with blanket, mae. A; AGA P; cont dev\\nsupport.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695816,\n \"text\": \"PCA 1900-0700\\n\\n\\n2\\ninfant remains in RA, RR 30-50, lung sounds cl=, sc\\nretractions, no spells, P:cont. to monitor.\\n\\n3\\ninfant's CW 1450g up 70g, remains on TF min. 150cc/kg/d of\\nPE/BM 26 with promod=36cc q4h gavaged over 90 minutes. abd\\nsoft, bs+, no loops, ag stable 22.5-23.5 cm, min. asp.,\\nsmall spit X1, voiding stooling qs heme. neg. P:cont. to\\nsupport nutritional needs.\\n\\n4\\nno known contact thus far.\\n\\n5\\ninfant remains swaddled in air isolette, temp. stable, a/a\\nwith cares, settles well in between, fonts soft/flat, brings\\nhands to mouth. P:cont. to support dev needs\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695817,\n \"text\": \"Addendum NPN\\nI have examined this infant and agree with the above written statement by , PCA.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695818,\n \"text\": \"Neonatology note\\n12 d.o\\nin , caffeine, no spells.\\nAFOF\\nRR with no mumrur\\nclear lungs\\nwt= 1450 gm +70, 150 cc/klg/d with EBM 26 + promod.\\nabdomen osft\\nnormal tone\\nmild jaundice.\\nA: ex 30 wks GA, AOP, growing preemie.\\nP: continue current management.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695850,\n \"text\": \"npn 1900-0700\\n\\n\\n2: resp\\nremains in ra. one spell thus far this shift. see flow\\nsheet. rr 40-70's. sats >93%. Lung sounds clear and equal.\\nmild subcostal retractions. no increased wob noted. continue\\nto monitor for changes in resp status.\\n\\n3: fen\\ncurrent weight 1770gms up 40gms. total fluids remain at\\n150cc/kilo/day of PE 26. tolerating feeds well. no spits\\nthus far. minimal aspirates. voiding and stooling. stable\\ngirths. abd soft with no loops. feeds run over 1hr 15min for\\nhx of spits.\\n\\n4: \\nno contact thus far this shift.\\n\\n5: g/d\\ntemps stable in an open crib. and active with cares.\\nsleeps well inbetween. co-bedded with sibblings. brings\\nhands to face. aga. continue to monitor for developmental\\nmilestones.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695851,\n \"text\": \"Neonatology\\nRA. Comfortable. SIngle spell over night. Off caffeine.\\n\\nWt 1760 up 40. TF at 150 cc/k/d of 26 cal. Abdomen benign. STill requiring gavage. Extended infusion time for spits. Abdomen benign.\\n\\nLeg slightly swollen last night, b ut this am looks normal to exam. No swelling or tenderness. Hips normal.\\n\\nDiaper rash improved. Will dc local rx.\\n\\nAwaiuting maturation of resp control and feeds.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695852,\n \"text\": \"Neonatology-NNP Physical Exam\\nNo edema in lower extremities.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695853,\n \"text\": \"Neonatology-NNP Physical Exam\\n\\n remains in RA. Active, in an open crib, AFOF, sutures opposed, good tone, nevus simplex on left eyelid. BBS clear and equal with good air entry. No murmur, pulses +2, , RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds. Please refer to attending progress note for detailed plan.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695854,\n \"text\": \"NICU nursing progress note\\n\\n\\nPLease refer to flowsheet for specific info.\\nResp\\nO: remains in room air, RR 20-50's, sat's 94%. BSCE\\nbilat. NO brady's. Off of caffeine. A: Stable. P: cont to\\nfollow.\\nFEN\\nO: Tf of 150cc/k/d of PE 26 gavaged over 80\\\" due to hx of\\nspits. No spits. Min asp. Abd soft, , no loops, active\\nbs. Voiding/ no stool thus far today. HOB ^15 degrees due to\\nhx of spits and placed prone. A: Stable. P: Infant HOB\\n^15degrees and place prone to prevent spits. Follow.\\nGD\\nO: Temp stable in oac, co-bedding with siblings, active and\\n with cares. MaE. Fonts, soft, flat. Calms with\\ncontainment and pacifier. Left eye with elevated and\\npossibly ^ vascularization making more . Cont to follow.\\nA: AGA P: cont to follow.\\nParenting\\nMom is pumping and discarding bm due to cytotec med. Please\\nrefer to Trip 32 note.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695855,\n \"text\": \"NICU nursing progress note\\n referred to is #2.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695819,\n \"text\": \"NICU nursing progress note\\n\\n\\nPLease refer to flowsheet for specific info.\\nResp\\nO: remains in room air, rr 30-50's, sat's >97%. Mild\\nsc ret. BSCE bilat. On caffeine, no brady's. A: Stable. P:\\ncont to follow.\\nFEN\\nO: TF of 150cc/k/d of PE or BM 26 w/ promod, gavaged over\\n90\\\". No spits. Max asp of 3cc partially digested formula.\\nAbd , no loops, active bs. Voiding/ stooling. Girth\\nstable at 22cm. A: stable. P: cont to follow.\\nGD\\nO: Temp stable in off isolette. Active and with cares.\\nMAE. Fonts soft, flat. A: AGA P: cont to support dev.\\nmilestones.\\nParenting\\nO: Mom in and updated at bedside, verbalizing understanding.\\n Agreeable to transfer to SCN\\nwhen beds are available. A: Mom and dad are and\\ninvested with large network of family support on\\nmom's side. P: cont to update, support, educate.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-04-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695891,\n \"text\": \"Nursing\\n\\n\\n#2O: In room air with o2 sats> 94% with occ. rare desat;\\nhad 1 spell with apnea and desat, self-resolved. Br. sounds\\nclear with mild retractions.\\n#3O: Wt. up 40g on 150cc/kg, BM26, q 4 hr. feeds. Belly\\nsoft, voids qs, 1 stool. Bottled 1 feed well, 1 feed fair,\\nand gav. x 1. Minimal asp. and no spits.\\n#4O: Mom visited and is independent with cares. Handles\\nwell and competently.\\n#5O: Co-bedding with siblings. Active with cares, likes\\nbeing swaddled.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-04-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695892,\n \"text\": \"Neonatology Attending\\n is 29do, 35 wks corrected\\nRA, open crib cobedding with sibs\\nHas had one spont a/b episode with stim (1hr after eating); one feed-associated\\nWt 2075 up 40 on TF150MM/PE24 pg/po (getting close to 50% po)\\nMeds Fe, vit E\\n\\nImp/ age-appropriate feeding & cvr immaturity.\\nPlan/ continue to monitor cvr status, growth/development. Will need at least 5 days more for \\\"apnea countdown\\\".\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-04-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695893,\n \"text\": \"Neonatology Attending\\nAddendum: PE\\nActive, appropriate, . AFOF. Lungs cta, heart rrr s murmur, abd soft, extr well-perfused.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-04-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695894,\n \"text\": \"NPN\\n\\n\\n2. Infant in RA on O2sat and CVR monitor. VSS as charted on\\nflow sheet. and well perfused. BBS cl and equal. No\\nmurmur. Brady x1 with HR 66/ O2sat 72% requiring mild stim.\\nStable in RA. Cont to have occ apnea/bradycardia.\\nCont to monitor.\\n3.TF 150cc/kg/day. MBM26/PE26 Alt po/pg. Attempted po at\\n1200 and required supplemental pg to meet min. requirement.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-04-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695895,\n \"text\": \"NPN continued\\n\\n\\n3. ABd benign. Soft no loops. Voiding and stooling.\\nInfant attempting to advance on po feeds. Still requiring\\npg.\\nCont to attempt po as tol. PG as necessary.\\n4. in for 1200 feeding. Held infant comfortably and\\noffered po feeding. Discussed discharge criteria and plan\\nfor support when infants go home. will be in \\nfrom Mon through Friday next week. Mat grandmother plans to\\nbe with mom.\\nIntact involved family. Cont to support.\\n5. In open crib cobedding with siblings. Temp stable. Sucks\\nvigorously on pacifier. Settles with swaddling and\\nboundries.\\nCont to promote optimal growth and development.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-04-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695921,\n \"text\": \"1900-0700 NPN\\n\\n\\nRESP: Infant remains in RA, O2 sats=97-100%. RR=30-50's.\\nBreath sounds clear and equal bilaterally, no retractions\\nnoted. Brady x2 with feeds so far this shift (see flowsheet\\nfor details). Continue to monitor resp status.\\n\\nFEN: Weight=2.245 (-5 grams). Ad lib with a min of\\n140cc/kg/d of BM24 with enfamil powder/E24/ all PO's. Infant\\nhas bottled 56cc and 60cc with fair coordination so far this\\nshift (brady x2 with feeds, see flowsheet). Waking approx\\nq4-4.5hrs for feeds. Abdomen , soft, round, +BS, no\\nloops. No spits. Voiding and stooling (guiac negative).\\nContinue to monitor FEN status.\\n\\n: Mom called this evening, updated on patient's\\ncurrent status by this RN. Mom states she does not want to\\ntransfer girls to at this time. Cont to support\\nfamily.\\n\\nG+D: Temps 97.8-98.0. Infant swaddled in , cobedding with\\nsister. Active and with cares, sleeps well in between\\ncares. Brings hands to face, sucks on pacifier for comfort.\\nMAE. Continue to support G+D.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-04-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695922,\n \"text\": \"Neonatology NP Exam Note\\nPlease refer to attending note for deatils of evalaution and plan.\\n\\nPE: small infant cobedding in open crib. and well perfused, and active.\\nAFOF, eyes clear, MMMP\\nChest clear and equal.\\nCV: RRR, no murmru, pulses+2=.\\nAbd: soft, active BS, NTND\\nGU: normal external female genitalia\\nExt: MEA, WWP\\nNeuro: symmetric tone and reflexes\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-04-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695923,\n \"text\": \"Neonatology Attending\\n is 36do, 36wks corrected\\nRA, open crib cobedding with \\n without spont a/b; 3 bradycardic episodes with bottling overnight\\nWt 2245 down 5 on minTF140 MM/E24 po -- taking well over minimum\\n\\nImp/ age-appropriate cvr/feeding immaturity\\nPlan/ continue to monitor cvr status, growth/development; d/c planning in progress contingent upon further evidence of maturity.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-04-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695924,\n \"text\": \"NPN 0700-1900\\n\\n8 Infant with Potential Sepsis\\n\\n#2Resp: Pt. remains on RA, RR 30-50's, sats > 96%. No\\nretractions. Lungs clear bilaterally. No spells so far\\nthis shift. Pt. is on day#2 of a 5 day spell count. P:\\ncontinue to monitor resp status.\\n\\n#3FEN: Pt remains adlib w/ min 140cc/kg/day of BM 24cal/oz\\nor E 24cal/oz. Pt. is taking 55-60cc po Q 4hrs. Abd soft &\\nround, +BS, no loops. Spit X 1. Pt. voiding. No stool so\\nfar this shift. D/S 88. P: continue to monitor FEN.\\n\\n#4Parenting: called this am. Updated r/t positive\\nbld cx from . asking questions. P:\\ncontinue to support & update.\\n\\n#5G&D: Temps stable swaddled cobedding w/ sister. Awake &\\n for cares. Wakes quietly for feeds. MAE's .\\nLikes pacifier. P: continue to support dev needs.\\n\\n#8Pot. sepsis: Pt. had positive bld cx from . NNP\\nnotified. CBC & bld cx drawn NNP. No abx started @\\nthis time. P: continue to monitor.\\nSee flowsheet for further details.\\n\\n\\n\\nREVISIONS TO PATHWAY:\\n\\n 8 Infant with Potential Sepsis; added\\n Start date: \\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695809,\n \"text\": \"NPN:\\n\\nRESP: Sats 95-100% in RA. RR=40-70 w/SC retraction. BBS =/clear. No A&Bs thus far tonight; x 1 over past 24 h. Remains on Caffeine.\\n\\nCV: No murmur. HR=130-150s. BP=65/54 (59). Color w/jaundice. Perfusion good.\\n\\nFEN: Wt=1370g (+ 10g). TF=150c/kg/d; 34cc BM/PE-24 q 4 h via NG over 70 min. Tolertating fdgs well w/o spits; minimal residuals. Abd benign. Voiding qs; sm stool. Vit E and FeS04 to begin today.\\n\\nG&D: CGA=32 wk. Temp stable in air-controlled isolette. Active and w/cares. Nested in sheepskin and resting well. AF soft, flat. HUS planned for .\\n\\nSOCIAL: No contact w/. Possible transfer to w/i near future; live in Canterbury, NH.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-04-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695896,\n \"text\": \"NPN 1900-0700\\n\\n\\n #1 RESP S/O: Infant in RA, rr 40-70's. Lungs are clear with\\nno retractions. O2 sats >95% with some drifting with\\nbottling into the high 80's. No spells. A: Stable P:\\nContinue to support.\\n\\n#2 FEN S/O: TF 150cc/k/d. Infant to get bm or pe 26, 53cc\\nq4h po/pg. Infant bottled 60cc x1 so far this shift. Abdomen\\nis benign, voiding. Desitin applied to bottom. No asp, one\\nsmall spit. A: Tolerating feeds. P: Continue to support.\\n\\n#4 Parenting S/O: No contact.\\n\\n#5 DEV S/O: Infant cobedding with siblings in . and\\nactive. Waking for cares. Clear eye drainage both eyes, warm\\nsoaks. A: AGA P: Continue to support dev.\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695810,\n \"text\": \"Neonatology Attending\\n\\nDOL 10 CGA 32 2/7 weeks\\n\\nStable in RA. 1 A/B. On caffeine.\\n\\nBP 65/54 mean 59\\n\\nOn 150 cc/kg/d BM/PE 24 pg over 1 hr 10 min. Voiding. Stooling. Wt 1370 grams (up 10).\\n\\n visiting and up to date.\\n\\nA: Doing well. Spells controlled on caffeine. Tolerating feeds.\\n\\nP: Monitor\\n Advance to 26 cal\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695811,\n \"text\": \"Neonatology Attending\\nExam AF soft, flat, clear bs, no murmur, benign abd, and comfortable in RA, active and responsive to exam\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695812,\n \"text\": \"Nursing Progress Note\\n\\n\\n2. Resp O/A Rec'd inf in RA. Inf remains in RA. 1X\\nspell thus far, see flowsheet. Mild SCR noted. Inf\\ncontinues on caffeine. P cont to assess resp needs.\\n3. FEN O/A TF=150cc/kg/day. Cal increased today to BM or\\nPE26. All feedings PG over 1 hr 10 min. Tol feedings well,\\nmin asp, sm spit thus far. Belly soft, no loops. Girth\\nstable. Inf voiding, stooling guiac neg. P cont to assess\\nFEN needs.\\n4. O/A Mom in for visit and cares. Held all 3\\ntriplets. Mom independent with temp taking, diapering\\ninfants. Dad in for visit. Updates to both paretns. P\\ncont to support, educate. ? transfer to .\\n5. DEV O/A is in an off isolette with stable temp.\\nA/A w/cares. Sleeping well between cares. P cont to assess\\ndev needs.\\nSee flowsheet for further details.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695813,\n \"text\": \"NURSING PROGRESS NOTE\\n\\nRESP/CV: REMAINS IN RA WITH 02 SATS >94%. BS CL&=, NO MURMER. COLOR AND WELL PERFUSED. BP STABLE. NO A&B'S OR DESATS NOTED THIS SHIFT. REMAINS ON CAFFEINE.\\n\\nFEN: WEIGHT UP 10GMS TO 1380GMS. TOTAL FLUIDS REMAIN AT 150CC/KG/D OF PE26CAL. ABD SOFT, WITH STABLE GIRTH AND +BS. VOIDING AND STOOLING WNL. NO SIGNIFICANT RESIDUALS AND OCCAS EMESIS NOTED.\\n\\nDEV: TEMP STABLE IN HEATED ISOLETTE. ACTIVE AN WITH INTERVENTIONS.\\n\\nSOCIAL: MOM X 1, WILL VISIT IN AM.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695814,\n \"text\": \"Neonatology note\\n11 d.o\\nin RA, 1 spells, on caffeine\\nRR with no murmur\\nclear lungs\\nabdomen soft\\nwt= 1380 gm +10, 150 cc/kg/d with PE 26\\nAFOF\\nnormal tone\\nA: ex 30 wks GA, AOP, growing preemie\\nP: consider transfering to if acceptable to , add promod.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-04-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695886,\n \"text\": \"1900-0700 NPN\\n\\n\\nRESP: Infant remains in RA, O2 sats=97-100%. RR=40-60's.\\nBreath sounds clear and equal bilaterally, mild SCR noted.\\nNo bradys, no desats so far this shift. Continue to monitor\\nresp status.\\n\\nFEN: Weight tonight=2.035kg (+45 grams). TF=150cc/kg/d of\\nPE26/BM26 PO/PG q4hr. Attempting to bottle feed infant\\nqshift. Infant bottled 50cc at with good coordination.\\nGavage feedings given over 1hr/tolerated well. Abdomen ,\\nsoft, round, +BS, no loops. No spits, no aspirates.\\nVoiding/no stool. Continue to monitor fen status.\\n\\n: No contact with so far this shift.\\n\\nG+D: Temps stable, swaddled in . Cobedding with sister\\nand brother. Active and with cares, sleeps well in\\nbetween. Brings hands to face, sucks on pacifier for\\ncomfort. MAE. Hepatitis B vaccine given (see\\nflowsheet/patient's chart for details). Continue to support\\nG+D.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-04-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695887,\n \"text\": \"Clinical Nutrition\\nO:\\n~35 wk CGA BG on DOL 28\\nWt: 2035 g (+45)(~25th to 50th %ile); birthwt: 1345 g. Average wt gain over past wk ~17 g/kg/day.\\nHC: 30 cm (~10th to 25th %ile); last: 30 cm\\nLN: 42.5 cm (~10th to 25th %ile); last: 41.5 cm\\nMeds include Fe and Vit E\\n noted\\nNutrition: 150 cc/kg/day BM/PE 26, po/pg. Infant po feeds ~1x per shift, takes ~ volume po. Average of past 3 day intake ~150 cc/kg/day, providing ~130 kcal/kg/day and ~3.2 to 3.6 g pro/kg/day.\\nGI: Abdomen benign.\\n\\nA/Goals:\\nTolerating feeds without GI problems. noted and within acceptable range. Current feeds + supps meeting recs for kcals/pro/vits and mins. Growth is meeting recs for wt gain and LN gain. HC shows no change over past wk; will follow long term trends. Will continue to follow w/ team and participate in nutrition plans.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-04-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695888,\n \"text\": \"Neonatology Attending\\n is 28do, 34 wks corrected.\\nRA, open crib cobedding with sibs\\nNo a/b; occ desat with feeds\\nWt 2035 up 45 on TF150 MM/PE24 pg>po - did take full bottle this am!\\n\\nMeds Fe, vit E\\nGot HBV this am\\n\\nImp/ age-appropriate cvr/feeding immaturity; making good progress.\\nPlan/ continue to monitor cvr status, growth/development. D/C planning in progress contingent upon further evidence of maturity.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-04-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695889,\n \"text\": \"Neonatology Attending\\nAddendum: PE\\nActive sleep, appropriate activity, s distress. AFOF.\\nLungs CTA, heart RRR s murmur, abd soft, extr well perfused.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-04-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695890,\n \"text\": \"NPN .\\n\\n\\n# Received infant in RA on CVR and O2sat monitors. VSS as\\ncharted on flow sheet. BBS clear and equal. No murmur. ,\\nwell perfused. No A's or B's at this time. Abd soft, no\\nloops. Active bowel sounds. A/G stable. Tol full volume of\\n150cc/kg/day. No spits, no asp. PO full volume x1, ng fed\\nx1. Mom due in for next feed at 1600. Currently on MBM26/PE\\n26. Will approach mom about attempting BF. Plan to request\\n to bring in carseat soon for testing prior to\\ndischarge. Cobedding with siblings. Tol well. Maintaining\\ntemp well. Needs hearing screen.\\nStable growing preemie advancing on po feedings. \\ninvolved.\\nCont to monitor for apnea and bradycardia. Cont to suport\\n toward discharge. Cont to offer po as tol. NG feed\\nas necessary. Encourage mom to put infant to breast.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-04-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695956,\n \"text\": \"NURSING PROGRESS NOTE\\n\\n\\n2. RESPIRATORY\\nNO ISSUES. NO SPELLS.\\n3. F/N\\nTONIGHT'S WEIGHT UP 65 GRAMS TO 2.61KG. TOOK IN 189CC/KG.\\nVOIDING AND STOOLING.\\n4. \\nNO CONTACT.\\n5. G&D\\nREADY FOR DISCHARGE.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-04-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695957,\n \"text\": \"Neonatology Attending Progress Note\\n\\nAddendum - PE\\nSee Physician Exam form.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-04-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695958,\n \"text\": \"Neonatology Attending Progress Note\\n\\nAddendum - PE\\nSee Physician Exam form.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-04-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695959,\n \"text\": \"Neonatology Attending Progress Note\\n\\nNow day of life 44, CA 1/7 weeks.\\nIn RA with RR 40-60s.\\nNo apnea and bradycardia since .\\nHR - 140-160s.\\n\\nWt. 2610gm up 65gm on ad volumes of feedings - took in 189cc/kg/d yesterday.\\nFeedings well tolerated.\\nNormal urine and stool output.\\n\\nAssessment/plan:\\nBaby is doing very well.\\nReady for discharge to home today.\\nAppointment wtih pediatrician to be set for early this week.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695845,\n \"text\": \"NICU nursing progress note\\n\\n\\nPlease refer to flowsheet for specific info.\\nResp\\nO: remains in room air, RR 40-60's, sat's >95%. Mild\\nsc ret. Off of caffeine, no brady's for >48 hours. A:\\nstable. Breathing comfortably. P: cont to follow.\\nFEN\\nO: TF of 150c/k/d of pe 26 or bm 26 gavaged over 75\\\". HOB\\nelev. feedings well tolerated, though does wake at times and\\ncry, then falls back asleep most likely refluxing. Abd ,\\nno loops, active bs. voiding/ no stool today. No spits min\\nasp. A: stable. P: follow.\\nGD\\nO: TEmp stable in oac co-bedding with siblings. Active and\\n with cares. MAE. Fonts soft, flat. Left eye with\\nslightly more raised area? Examined by Dr. , no\\nnew orders at this time/ monitor for changes. A: AGA P: cont\\nto follow and support dev. milestones.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695846,\n \"text\": \"NPN 1900-0700\\n\\n\\n2. RESP: pt remains in RA with RR 30-50's. Mild S/C\\nretractions. Sats >95%. No spells noted so far this shift.\\nWill monitor closely.\\n\\n3. F&N: TF remain at 150cc/k/dof BM/PE26. Feeds gavaged\\nin over 1 hour 15 minutes. Abd benign. BS+. A/G stable.\\nNo spits and minimal aspirates noted. Voiding and passing\\nlarge green guiac negative stool. Weight gain 25 grams.\\n\\n4. PAR: No contact from so far this shift.\\n\\n5. DEV: is active and during her cares. Temp\\nstable swaddled in open crib. Red non-draining area noted\\non her right eye lid. Will monitor. Micostatin powder to\\nbuttocks as ordered.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695847,\n \"text\": \"Neonatology\\nRA. Comfortable apeparing. Spells not a problem.\\n\\nWt 1730 up 25. toleraing feeds at 150 cc/k/d of 26 cal. Abdomen benign. Still requiring gavage.\\n\\nOn mycostatin for diaper rash. Will contiunue through tomorrow as is improving.\\n\\nLeft eye drainage noted w/o signs of infection.\\n\\nContinue to await maturation of feeds.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695848,\n \"text\": \"Neonatology-NNP Physical Exam\\n\\nInfant remains in RA. Active, in an open crib, AFOF, sutures opposed, good tone. BBS clear and equal with good air entry. No murmur, pulses +2, , RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds. Left eye slightly edematous, miost likely dependent edema. Please refer to attending progress note for detailed plan.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695849,\n \"text\": \"NPN7a7p\\n\\n\\nResp\\nInfant in RA with adeq sats. LSC. No bradys. Monitor and\\nsupport resp status.\\nFen\\nInfant on TF 150 cc/k/d of BM or PE26. BM on hold until\\nthursday (2nd to Moms medication) Abd soft, round with\\nactive BS. No spits today. Max asp of 4 cc partially\\ndigested formula. AG stable. Voiding. No stool. Monitor\\nweight and exam.\\nParenting\\nSee #3 note for details. invested and . Lrg\\nfamily support. Educate and support .\\nG/D\\nInfant cobedding with sibs. Stable temps. Warm this\\nafternoon with hat on. No evidence of yeast in groin.\\nTomorrow will be day 5, prob DC nystatin powder then. Infant\\nwith some dependent edema of eyes and limbs. Edema of left\\nlower leg not improved with different position. Pitting. Dr\\n aware and assessed, cont to monitor. A/A for cares.\\nSleeps quietly in between. Does not disturb easily by sibs.\\nMAEs. FS&F. Uses pacifier with support. AGA. Monitor and\\nsupport G/D.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-04-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695960,\n \"text\": \"Nursing D/C note\\n\\n\\nInfant ready for d/c. Vitals stable this shift, now day \\nof spell countdown (no spells since ).\\nInfant bottling well on E24, taking > than minimum\\nrequirements, voiding and stooling. Will be d/c'd home on\\niron.\\nVNA and pedi appt scheduled. All other d/c requirements\\ncompleted. Currently awaiting : plan to review car\\nseat positioning and any other infant care topics they might\\nwant to review.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695836,\n \"text\": \"NICU nursing progress note\\n\\n\\nPlease refer to flowsheet for specific info,\\nResp\\nO: remains in room air, RR 30-60's, sat's >95%. Mild\\nsc ret. BSCE bilat. A: stable. breathing comfortably. No\\nbrady's off of caffeine. P: cont to follow.\\nFEN\\nO: TF of 150cc/ k/ d of PE or bm 26 with promod, gavaged\\nover 80\\\", and fed q 4 hours. Abd , no loops, active bs.\\nVoiding/ stooling heme (-). Girth stable. Max asp of 5cc\\npartially digested formula. No spits. A: Stable. P: cont to\\nfollow.\\nGD\\nO: Temp stable in oac co-bedding with brother and .\\nActive and with cares, though does not wake for feeds.\\nMAE. Fonts soft, flat. Brings hands to face. A: AGA P: cont\\nto support dev.milestones.\\nParenting\\nO: Mom, dad and older brother in and visited at bedside.\\n updated and verbalizing understanding. A: Involved\\nand invested . P: cont to update, support, educate.\\nPlan is to transfer to Gen. Hospital when beds are\\navailable for triplets.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695837,\n \"text\": \"Neonatology NP EXAM NOTE\\nPLease refer to Dr note for detials of evaluation and plan,\\n\\n\\nPE: samll infant in open crib cobedded with sibs.\\nHEENT: AFOF, ng in place MMMP\\nChest is clear with comfortable resp pattern\\nCVB: RRR, nio murmu, pulses +2=\\nABD: soft, active BS\\nGU: deferred\\nEXT: MAE< WWP\\nNeuro: active and responsive, good tone\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-04-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695918,\n \"text\": \"Neonatology - NNP Progress Note\\n\\n is active, with her exam today. AFOF. She is , well perfused, no murmur auscultated. She is comfortable in room air. Breath sounds clear and equal. She had some desats associated with apnea overnight - spell countdown restarted. She is tolerating full volume feeds, abd soft, active bowel sounds, no loops. Not quite as vigorous with po feeds yesterday and had moderate drop in temp to 97.5 while cobedding with sibs. In light of temp drop, decrease in feeding efforts and apnea, CBC with diff and blood culture sent. CBC: WBC 11.2, Hct-31.5, plt-671, 26% polys, 0% bands.\\n\\nA/P Active, well appearing infant this am, but some mild symptoms that may be suggestive of infection. Will continue to monitor closely. Will consider antibiotics if clinical picture deteriorates. Please refer to neonatology attending note for detailed plan.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-04-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695919,\n \"text\": \"Neonatology Attending\\n is 35do, 35 wks corrected\\nRA, open crib; occ sat drifts at rest and with bottles\\nApnea/desat episode last pm, apparently obstructive (tongue at roof of mouth); now day 0-1/5\\nAlso had temp drop (97.5 with good response to swaddling) - sepsis eval as noted by NNP Rivers\\n\\nWt 2250 up 20 on min TF130 MM/E24; not consistently waking for feeds\\n\\nMeds Fe\\n\\nImp/ immaturity of feeding/cvr/thermoregulation -- vs infection. Appears well overall.\\n\\nPlan/ continue to monitor cvr status, temp, growth/development. Will start abx if increased clinical suspicion.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-04-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695920,\n \"text\": \"NPN 7a-7p\\n\\n\\n#2: remains in RA, sating >/= 94%. Occ drift in sat\\nto mid 80's noted with QSR. RR stable. Rare intermittent\\nSC retraction. BBS cl/=. Did have brady x1 with bottling\\nfor Mom. responded appropriately and infant recovered\\nwith removal of bottle and stim. Also had brady at rest.\\nA: Stable in RA, Restart brady countdown. P:Cont to monitor\\nand provide support as needed.\\n\\n#3: TF:min140cc/k/d. Conts on BM24 with Enfamil powder/E24.\\nFeeding ~q4hrs, taking 54-70cc, with fair to good\\ncoordination. Abd soft, +, no loops. Voiding qs.\\nStooled x1. Small spits/wet burps at times. FeSO4 given.\\nMom correctly drew up and administered dose. A: tol'ing all\\nPO feeds, working on coordination P:Cont with current\\nfeeding plan. Follow wt and exam. Monitor tol to feeds.\\n\\n#4: in for most of the afternoon. Update given. Mom\\nmet with LC. Has scheduled for appt this weekend on Sat.\\nA: Involved family, indep with care P:Cont to support and\\neducate.\\n\\n#5: has been very /active today with cares. MAE.\\nFonts soft/flat. Temps stable while swaddled in an open\\ncrib. She is co-bedding with her sibling. A:AGA P:Cont to\\nsupport dev needs.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695838,\n \"text\": \"NPN\\n\\n\\n#2\\nInfant remains in RA with sats >94% BS clear= with mild\\nretractions. Color is ; well perfused. Murmer not\\naudible. Infant has had one spell after a feed that was\\nQSR.\\n\\n#3\\nInfant remains on TF=150cc/k of BM/PE26 with promad q4\\nhours. Infant has tolerated feeds via gavage over 80\\nminutes without spits and only scant aspirates. Abd is soft\\nand round; voiding well. Hypoactive/active BS. Trace/small\\ngreen stools(g-) x2. Wt is up 30gms-1650.\\n\\n#4\\nNo contact thus far from the .\\n\\n#5\\nInfant remains in an open crib cobedding with her siblings.\\nInfant is with cares; sucks on the pacifier. Fussy at\\ntimes while feeding is infusing (?gassy)..settles once feed\\nis complete.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695839,\n \"text\": \"Neonatology Attending\\nDOL 17 / CGA 33-2/7 weeks\\n\\n remains in room air with no distress and one bradycardia in 24 hours (off caffeine).\\n\\nNo murmur. BP normal.\\n\\nWt 1650 (+30) on TFI 150 cc/kg/day BM26PM/PE26PM, tolerating by gavage over 75 minutes. Voiding and stooling normally. Abdomen benign.\\n\\nTemperature stable in open crib.\\n\\nFather and sibling have viral gastroenteritis.\\n\\nA&P\\n30-6/7 week GA infant with respiratory and feeding immaturity\\n-Continue to await maturation of oral feeding skills and respiratory drive\\n-No changes in management as detailed above.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-04-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695912,\n \"text\": \"nursing\\n\\n\\n#2O: In room air with O2 sats > 90% even with car seat\\ntest. No spells or desats noted. br. sounds clear with\\nmild retractions.\\n#3O: wt. up 30g on BM24/B24. Wakes on own about every 4\\nhrs. and bottles fairly well. Took in 188cc/kg . Belly\\nsoft, voiding and stooling.\\n#4O: No contact, mom will be into visit later and lactation\\nappt. scheduled for today.\\n#5O: Co-bedding with siblings, stable temp. Active with\\ncares. Passed car seat screen.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-04-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695913,\n \"text\": \"Neonatology-NNP Physical Exam\\n\\nInfant remains in RA. Active, in an open crib, AFOF, sutures opposed, good tone. BBS clear and equal with good air entry. No murmur, pulses +2, , RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds. Please refer to attending progress note for detailed plan.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-04-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695914,\n \"text\": \"Neonatology Attending\\n is 34do, 35 wks corrected\\nRA, open crib cobedding with sibs\\nDay s a/b\\nWt 2230 up 30 g on ad lib min TF130 MM/E24 po\\n\\nMeds Fe\\n\\nImp/ age appropriate cvr immaturity, approaching readiness for d/c\\nPlan/ continue to monitor cvr status, growth/development. Potential d/c tomorrow\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695840,\n \"text\": \"NICU nursing progress note\\n\\n\\nPlease refer to flowsheet for specific info.\\nResp\\nO: remains in room air, 30-70's, sat's >96%. Mild sc\\nret. BSCE bilat. A: stable. breathing comfortably. No spells\\noff of caffeine today.P: cont to follow.\\nFEN\\nO: TF of 150cc/k/d of PE or bm 26 w/ promod. GAvage fed\\nover 75\\\" well tolerated. Abd , no loops, active bs.\\nStable girth. No spits. Max asp of 2.2cc and benign.\\nVoiding/ stooling heme (-). A: stable. P: cont to support\\ndev.milestones.\\nGD\\nO: Temp stable in oac co-bedding with siblings. MAE. active\\nand with cares. Font soft, flat. Brings hands to face.\\nCalms with containment and pacifier. Irritable during\\nfeedings/ waking, then crying and falls back asleep. A: AGA\\nP: cont to follow and support dev.milestones.\\nParenting\\nO: Mom called and updated, sibling and dad have viral\\ngastroenteritis. Mom states that she feels well, but will\\ncall later instead of coming in to hospital. First night and\\nfull day back in home in Canterbury NH. Plan is to transfer\\ntriplets to when beds available. A:\\n and invested . P: cont to update, support,\\neducate.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695841,\n \"text\": \"Neonatology NP Exam NOte\\nPE: small well appearing infant in open crib, cobedding with sibs.\\nHEENT: AFOF, eyes with clear drainage, MMMP, ng in place.\\nChest is clear,comfortable\\nCV: RRR, pulses +2=, no murmur\\nABd: soft active BS\\nGU immature female genoitalia\\nEXT, lean MAE, WWp\\nNeuro: active and responsive symmetric tone and reflexes\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695842,\n \"text\": \"NICU Nursing Note 1900-0700\\n\\n\\n#1 RESP\\nRA, RR 30-60's,clear and equal with mild subcostal\\nretracitons. No spells.\\nStable in room air, continue to follow.\\n\\n#3 FEN\\nWeight tonight 1705gm (+55). TF 150 cc/kg/day of PE26PM. PG\\nfed over 1hr 15min. No spits, minimal aspirates. Voiding and\\nstooling. No loops. Tolerating feeds well. Continue to\\nfollow.\\n\\n#4 Parenting\\nNo contact.\\n\\n#5 G&D\\nTemp stable cobedding with siblings in open crib. and\\nactive with cares, irritable at times. Settles with\\npacifier. MAE, symmetrical tone. AFSF. AGA. Continue to\\npromote developmental growth.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695843,\n \"text\": \"Neonatology note\\n18 d.o\\nin RA, no spells, off caffeine.\\nAFOF\\n\\nwt= 1705 gm +55, 150 cc/kg/d with 26 cal/oz\\nRR with no murmur\\nclear lungs\\nabdomen soft\\nMRSA(+) on skin\\n\\nA: ex 30 wks GA, growing preemie\\nP: continue current management.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695844,\n \"text\": \"Neonatology note\\ncorrection for above: skin culture negative.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695832,\n \"text\": \"NPN 7a7p\\n\\n\\nRESP\\nInfant in RA with adeq sats. No bradys. LSC. Mild S/C rtxs.\\nCaffiene dcd today. Monitor and support resp status.\\nFEN\\nInfant on TF 150 cc/k/d of PE or BM26PM. Had been gavaging\\nover 1.5 hrs q 4 hrs. Lrg benign asps overnight and this am\\n(see careview) and lrg spit. Attempt to change feeds to q 3\\nhrs per fellow. Next asp was 14 cc, benign, undigested\\nformula, refed to infant and will wait 1 hr. Resume q 3 hr\\nfeeds, changing gavage time to only 1 hr, per fellow. Abd\\nsoft, lrg round. AG 24-25 cm, consistant. Some soft loops on\\noccasion. Lrg loose liquid green stool, heme -. Infant with\\nlrg benign asps, not tolerating TF regime presently. Cont to\\nmonitor, maintain reflux precautions.\\n\\nMom and uncle came to visit and participate in cares. Mom\\nindependent with cares. and appropiate with infants.\\nAwaiting word on transfer to Hosp, maybe Monday.\\nSigned up for CPR for Tuesday if infants are still here.\\nPlans to drive home, NH this weekend. Anxious as this is her\\n1st time back home since early . She is unsure if\\nshe will visit tomorrow. She hopes to come in early before\\nheading north. Mom had a number of hospital staff visitors\\nshe became friendly with during her bedrest stay, come to\\nsay hello and see babies. Mom appears to enjoy the attention\\nand support. Cont to support and educate .\\nG/D\\nInfant in OAC with stable temps. Bedding alone without sibs\\npresently due to need of lrger crib. A/A with cares. MAES.\\nFS&F. Has new yeast rash in groin, ordered for nystatin\\npowder. AGA. Monitor and support G/D.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695833,\n \"text\": \"Fellow note; physical exam\\nSleeping comfortably in open crib. In RA. Skin . AFOF. Eyes clear. Lungs clear. RRR. No murmur. Normal femoral pulses. Abd soft, ND, +BS. Extrem WWP. Good tone.\\n\\nPossible transfer to on Monday.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695834,\n \"text\": \"npn 1900-0700\\n\\n\\n2: resp\\nremains in ra. no spells and no dsats. Rr 30-60's. Lung\\nsounds clear and equal. mild subcostal retractions. no\\nincreased wob noted. caffeine dc'd on day shift.\\n\\n3: fen\\ncurrent weight 1620gms up 40gms. total fluids remain at\\n150cc/kilo/day of pe/bm 26 with prom. infant having\\naspirates of 4-6cc's. no spits. infant changed back to q 4\\nhour feeds after 1am care. At 0100 infant had a 6cc aspirate\\nof partially digested formula. 6cc's refed and subtracted to\\nthe total feeding. abd soft with no loops. voiding, no stool\\nthus far this shift. positive bowel sounds. stable girths.\\ncontinue to monitor for changes in nutritional status.\\n\\n4: \\nno contact thus far this shift.\\n\\n\\n5: G/D\\ntemps stable in an open crib. co-bedded with sister and\\nbrother. and active with cares. sleeps well inbetween.\\n\\nbrings hands to face. aga. sucks vigorously on pacifier.\\ncontinue to monitor for developmental milestones.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695835,\n \"text\": \"Neonatology Attending\\n\\nDay 16- CGA 33 1/7 weeks\\n\\nRemains in RA. RR 30-60. Mild retractions. No bradycardia- now off caffeine. BP mean 58. Weight 1620 gms (+40). TF at 150 cc/kg/d- PE 26 with Promod. Minimal aspirates overnight. Gavage fed every four hours. No spits. Benign abdomen. On iron, vitamin E. Stable temperature- co-bedding.\\n\\nDoing well overall. Monitoring closely. Gaining weight well. Tolerating feeds well. No changes for now. Mother up to date.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-04-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695915,\n \"text\": \"Clinical Nutrition\\nO:\\n~35 wk CGA BG on DOL 34\\nWT: 2230 g (+30)(~25th %ile); birthwt: 1345 g. Average wt gain over past wk ~34 g/day.\\nHC: 32 cm (~25th to 50th %ile); last: 30 cm\\nLN: 44 cm (~10th to 25th %ile); last: 42.5 cm\\nMeds include Fe\\n not needed\\nNutrition: Ad lib po's, minimum 140 cc/kg/day E24/BM 24 w/ Enfamil powder. Average of past 3 day intake ~164 cc/kg/day, providing ~2.2 to 2.8 g pro/kg/day and ~131 kcal/kg/day.\\nGI: Abdomen benign.\\n\\nA/Goals:\\nTolerating feeds without GI problems. not needed. Current feeds + supps meeting weaned recs for kcals/pro/vits and mins. Growth is meeting recs for wt gain. HC and LN gain are exceeding recommended ~0.5 to 1 cm/wk for HC gain and ~1 cm/wk for LN gain. Will follow long term trends. Will continue to follow w/ team and participate in nutrition plans.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-04-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695916,\n \"text\": \"Nursing NICU Note\\n\\n\\n#2. Respiratory O: Pt. remains in RA, O2 sats >95%. LS\\nclear/=. RR ~ 30-50's, no increase work of breathing noted.\\n No A&B's noted this shfit thus far. A: Pt. is stable in\\nRA. P: Continue to monitor respiratory status. Monitor\\nfor A&B's.\\n\\n#3. FEN O: Ad lib w/ Min 140cc/kg/d of E24 or BM24w/\\nEnfamil powder. She takes ~56-70cc PO Q feed, starting to\\nwake more for feeds now. Abdomen is soft, , +BS, no\\nloops, occasional wet burps/sm.spits noted. She is\\nvoiding/ no stool noted this shfit. A: Pt. is tolerating\\ncurrent nutritional plan. P: Continue w/ current feeding\\nplan. Monitor for s/s of intolerance. Encourage PO feeds.\\n\\n#4. O: Mom in to visit and called in this am.\\n Both updated on pt's current status and daily plan\\nof care. are active and independent in cares. A:\\nFamily is and involved. P: continue to update,\\nsupport and educate. Continue w/ discharge\\nteaching/planning.\\n\\n#5. Growth/Developement O: Pt. remains in an open crib,\\nswaddled and co-bedding w/ her siblings. Temps stable. She\\nis and active w/ cares, sleeps well in betweeen.\\nFontanelle soft/flat. She loves to use her pacifier, brings\\nhands to face. A: AGA P: Continue to provide environment\\nappropriate for growth and development.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-04-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695917,\n \"text\": \"NPN 1900-0730\\n\\n\\n2. RECEIVED INFANT IN RA. SAO2 B/T 93-99%. RR 50'S-60'S. NO\\nINCREASED WOB NOTED. SPONTANOUS DESAT AT WITH SAO2 DOWN\\nTO 61. NO CHANGE IN HR. +COLOR CHANGE. MILD STIM PROVIDED\\nD/T APNEA. NOW STARTING DAY COUNT DOWN. MOTHER AWARE.\\nSOME DRIFTING WITH FEEDS. WILL OBTAIN BCX, CBC PER ORDER OF\\nNNP. PLAN; MONITOR FOR S/SX RESP/ DISTRESS. F/U WITH SPELL\\nCOUNTDOWN. MONITOR CBC AND BCX.\\n\\n3. WT. 2.250GMS UP 20GMS FROM YESTEDAY. CONT. ADLIB WITH\\n140CC MIN. TAKING B/T 45-55CC Q 4HR FEEDING. TOTAL IN 24HRS,\\n136CC/K/D. STILL APPEARS SLIGHTLY UNCOORDINATED THIS SHIFT.\\nABD SOFT, NO LOOPS, +BS. VOIDING, STOOLING GREENISH BROWN\\nGUIAC- STOOL. PLAN; CONT. TO MONITOR INTAKE ON ADLIB\\nSCHEDULE. BCX, CBC TO BE DRAWN.\\n\\n4. RN NOTIFIED MOM OF INFANT DESAT EPISODE AND THAT 5 DAY\\nCOUNTDOWN WILL START AGAIN. MOM SOUNDING AND\\nCONCERNED BUT ALSO RELEIVED THAT INFANT IS IN HOSPITAL WHEN\\nEPISODE HAPPENED. PLAN; CONT. TO SUPPORT AND EDUCATE \\n\\n\\n5. CONT. SWADDLED. CO-BEDDING WITH SIBLINGS. TEMP DOWN TO\\n97.5. EXTRA BLANKET AND HAT ADDED. TEMP UP TO 98.1 WITHIN 10\\nMINUTES. APPEARING UNCOORDINATED WITH FEEDS. SOME DRIFTING\\nWITH SAO2. NP. BCX, CBC TO BE OBTAINED. MOVING ALL\\nEXTREMETIES. WAKING FOR CARES. PLAN; F/U WITH BLOOD WORK.\\nCONT. TO SUPPORT G/D.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695771,\n \"text\": \"Neonatology\\nOn SIMV after second dose of surfactant this am. Mainly in RA, but increases with crying. Single bolus of NS last night. Will wean PIP again this am and recheck CBG. No evidence of PDA.\\n\\nWt 1345. Remains NPO on d10w. Abdomen benign. BS in good range.\\n\\nOn abx for 48 h r/o.\\n\\nBili to be checked with lytes later today.\\n\\nHUS for beginning of next week.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695772,\n \"text\": \"NPN DAYS\\n\\n\\nInfant with Potential Sepsis: Blood cx pending. Remains on\\nAmpicillin and Gent for 48 hr r/o. Will repeat CBC in the\\nam.\\n\\nAlt in Resp: Received baby on settings of 20/5 rate 22.\\nSurf'd for the 2nd time. Weaned to 18/5 rate 20 where she\\nremains at this time. FiO2 21%. Occasional desats to the\\n70's and 80's needing temporary increase of O2. LS clear and\\nequal. Mild retractions. Sxn'd for small amounts cloudy\\nsecretions. Will check blood gas with next set of cares to\\nsee if vent settings can be weaned some more.\\n\\nAlt in FEN: NPO. TF 80cc/kg/day D10 via , change to\\nPN this evening. Voiding. No stool. Belly benign. No spits.\\nD/S 93. Lytes 139/4.0/108/17. Bili 4.2/0.2. Will continue\\nwith current plan of care.\\n\\nAlt in Parenting: Dad up to visit several times during the\\nday. Mom up x1 so far. Parents may hold this afternoon or\\nevening. Updated them on the babies day. Will continue to\\nprovide teaching and support.\\n\\nAlt in Growth and Dev: Temp up and down on warmer, ? r/t\\nenvironmental temp changes. Awake and alert with cares.\\nNested on sheepskin with boundaries in place. Will place in\\nisolette this eve to try to regulate temp.\\n\\nAlt in CV: No murmur. Color pink and well perfused. BP\\nstable, see flow sheet. NNP aware of BP 44/28 M34. Will\\ncontinue to monitor closely.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695773,\n \"text\": \"Respiratory Care Note\\nReceived pt on SIMV 20/5, RR 22, 21% Second dose of 5cc's of Survanta given at 0730. Given per protocol. Tol well. Weaned to 18/5, RR 20. CBG:7.44/27/31/19/-4. Extubated and placed on +5 prong CPAP, FiO2 25%. BS clear. RR 40-70's. Will follow on CPAP.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695774,\n \"text\": \"Fellow note; physical exam\\nAlert and active. Breathing comfortably on SIMV. Skin pink. AFOF. Lungs with good aeration on vented and spontaneous breaths. RRR. Nl S1, S2. No murmur. Normal femoral pulses. Abd soft, ND, +BS. Normal female external genitalia. Extremities WWP. Good tone.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695775,\n \"text\": \"Respiratory Care\\nBaby remains on cpap 5 21%.BS clear throughout.RR 30-70's.No spells documented thus far this shift.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695776,\n \"text\": \"Nursing progress note\\n\\n1 Infant with Potential Sepsis\\n\\n#2 O: Remains on 5cm prong CPAP, 21% O2. Breath sounds equal\\n& clear with mild SC retractions. No A's, B's or desats. A:\\nStable on CPAP. Cont to assess.\\n#3 O: Wgt down 15gms. Remains NPO with at 80cc/k/d. DS\\n82. UOP for previous 24 hrs was 2.8cc/k/h. No stool. Abd\\nsoft with active bowel sounds & no loops. A: Receiving\\nfluids as ordered. P: Cont to assess.\\n#4 O: Parents up for visit. Mom held & Dad took\\npictures. Parents spoke with Dr at bedside. A:\\nInvolved parents. P: Supprot.\\n#5 O: Received baby on warmer. Transferred to servo\\nisolette. Temp stable. Nested in sheepskin. Alert with cares\\n& irritable at times. A: Easily stressed. P: Cluster cares.\\nCont to assess.\\n#6 O: Mild gen edema. No murmur heard. BP mean was 38. Ruddy\\n& well perfused. A: Stable. P: Cont to assess.\\n\\nOUTCOME EVALUATION:\\n\\n 1 Infant with Potential Sepsis\\n MET [1] Infant will be free of signs and\\n symptoms of sepsis.;\\n Blood cultures neg to date.\\n Remains on antibiotics. Repeat CBC\\n & diff sent.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695777,\n \"text\": \"Neonatology Attending\\n\\nNow day of life 2 for this 30 week gestation .\\nBaby remains stable on CPAP of 5 and in RA.\\nRR - 50-60s.\\nNo apnea and bradycardia.\\n\\nHR 130-150s BP 47/33 38\\n\\nWt. 1330gm down 15gm on PN/IL 80cc/kg/d\\nNPO\\nDS 82\\nUO 2.8cc/kg/hr, no stool.\\n\\nID - repeat cbc pending - FU for neutropenia.\\nOn amp and gent.\\n\\nBili - 4.2/0.2\\n\\nAssessment/plan\\nVery nice progress.\\nWill trial off CPAP today.\\nFeedings to be initiated with PE.\\nWill continue antibiotics while awaiting results of cbc.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695778,\n \"text\": \"Respiratory Care Note\\nPt off CPAP today. Briefly on a 23%, 100cc nasal cannula. BS clear. RR 40-60's. No bradys or desats noted. IC/SubC retractions.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695779,\n \"text\": \"NPN DAYS\\n\\n6 ALt in CV d/t prematurity\\n7 Bili\\n\\nInfant with Potential Sepsis: Blood cx pending. Remains on\\nAmp and Gent. CBC with diff repeated today, see lab results.\\n? d/c antibiotics if blood cx at 48hrs remains negative.\\n\\nAlt in Resp: CPAP removed at 12pm and baby placed on NC\\n100cc flow, 21% FiO2. LS clear and equal. Mild retractions.\\nNo spells. Tolerating NC without problems. Continue to\\nmonitor.\\n\\nAlt in FEN: TF 80cc/kg/day. Enteral feeds of BM20 at\\n20cc/kg/day, increasing 10cc/kg/ as tolerated. PND10 and\\nlipids currently infusing via at 60cc/kg/day. D/S 79.\\nVoiding, no stool. Belly benign. No spits. Will continue to\\nincrease feeds as tolerated .\\n\\nAlt in Parenting: Parents up to visit and dad participated\\nin cares. Updated them on the babies day. Family meeting to\\nbe held 2pm Monday. Will continue to provide support and\\nteaching.\\n\\nAlt in Growth and Dev: Temp stable in servo isolette until\\nphototherapy started and then temp of isolette needed to be\\nweaned, see flow sheet. Nested on sheepskin with boundaries\\nin place. Will continue to monitor temp closely.\\n\\nAlt in CV: No murmur noted. Pink and well perfused, BP\\nstable. Problem resolved.\\n\\nBili: Bili this afternoon 8.0/0.3 up from 4.2/0.2. Placed\\nunder double phototherapy.\\n\\nREVISIONS TO PATHWAY:\\n\\n 6 ALt in CV d/t prematurity; resolved\\n 7 Bili; added\\n Start date: \\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695767,\n \"text\": \"Neonatology-NNP Procedure Note\\n\\nProcedure: Endotracheal intubation\\nIndication: Respiratory distress\\n\\nInfant placed in supine position with cardio-respiratory monitor in place. Under direct laryngoscopy, the vocal cords were visualized using a size 0 blade. A 3.0 Fr ETT was inserted through the vocal cords and secured at 7cm. BBS were equal on auscultation. The infant tolerated the procedure without incident. A CXR will be obtained to confirm placement.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695768,\n \"text\": \"Nursing Admission Note\\n\\nInfant is a 30 week triplet (#1) born via c-section. Apgars 8,9.\\nPlease refer to Dr. note for complete maternal history and\\ndelivery room course. Infant admitted to NICU at 2150; G/F/R on admission, required BBO2 and then placed on nasal prong CPAP 6cm with\\nFiO2 28-42% in order to maintain O2 sats in the 90's. RR 40-60's, LSC=, mild inter/subcostal retractions noted. AP stable, BP stable--\\nsee flowsheet. No murmur. Capillary refill brisk, color ruddy. Infant\\nalert and active, MAE, AFOF. CBC,diff. and blood cx drawn and sent\\nto lab. Infant started on Ampicillin and Gentamicin as ordered.\\nReceived baby care meds as per flowsheet. Infant's wt.1345 gms. NPO.\\nPIV placed in infant's (R) hand; IVf infusing without incident; D10W\\nat 80cc/k/day. Blood sugar 139. No void or stool output. Abd. soft,\\nbowel sounds hypoactive. Temp. stable on open warmer with infant on\\nservo control mode. CXR done.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695769,\n \"text\": \"NPN 11p-7a\\n\\n\\n#1 Temp max 100.6x. On ampi and gent. Blood cx pending. Diff\\nunshifted. Tone and activity level wnl. A: r/o sepsis P:\\nfollow cx and exam\\n\\n#2 Received infant on CPAP 6cm but moderate amt resp\\ndistress persisted. Intubated and surv x 1 given. Placement\\nconfirmed via xray. Initial settings weaned from 22/5 x 25\\nto 20/5 x 22 after CBG: 7.39,32. Mainly in RA. BBS clear\\nand =. Mild IC/SC retractions evident. Suctioned for\\nsmall-mod amt secretions. A: beginning to wean P: Follow\\nresp status very closely\\n\\n#3 TF's 80cc/k. Receiving D10W via PIV without incident. DS\\n106. Abdominal exam unremarkable. Beginning to void. No\\nstool since birth. A: npo with ivf P; Follow hydration\\nstatus and weight, 24hr lytes and bili\\n\\n#4 Mom and Dad in to visit on way down to floor, Update\\nprovided and questions answered. A: impaired parenting\\nP:Cont to support and educate through nicu stay\\n\\n#5 Temp max 100.6x. Warmer weaned. Fiesty with and between\\ncares. Nested on sheepskin with boundaries in place.\\nRepositioned with cares and prn. A: AGA P: Support\\ndeveklopmental needs\\n\\n#6 BP maps drifting to 28-29. Received NS bolus x 1 with\\nimprovement to 30-34. NNP Ambrosine aware. Color is ruddy.\\nWell perfused. A: low maps P:Follow serial BP's to watch\\nfor trends\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695770,\n \"text\": \"Respiratory Care\\nBaby is # 1 of 30 week .Please see M.D admit note for hx.Apgars .Received facial cpap in d.r..trans to nicu,placed on cpap 6 fio2 req ^ to ~ 45%,and continued to grunt on cpap.cxr revealed\\\"white out\\\".Decsion made to intubate,and give surf.Intubated with 3.0 ett taped @ 7cm,given 5.2 cc survanta @ 0130,tol well.Initial settings R 25 22/5,cbg 7.39/32,weaned R 22 pip to 20.Mainly in 21%.BS = clear.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695766,\n \"text\": \"NICU Attending Admission Note\\n\\nID: 30 week gestation female triplet #1, delivered by repeat C section due to progressive PTL, triplet gestation.\\n\\nPre/perinatal Hx: Mother is 29 y.o. G4 P now 2 (2 deliveries, 4 children), IUI triplet conception, EDC . PNS: 0+, Ab-, RPRNR, RI, HepBSAg-, reportedly GBS- (all PNS redrawn on and pending). Pregnancy complicated by GDM, then ? PTL (abdominal discomfort and vaginal pressure) at 23 1/7 weeks, admitted, receiveed complete course of beta at 24 weeks, in house since. Tonight presented with PTL, cervical dilation therefore delivered by repeat C section. Clear fluid. This triplet emerged with spontaneous cry, required only BBO2 and routine care in DR, apgars 8 and 9, but demonstrated mild increased WOB, needed supplemental O2, transported to NICU without incident.\\n\\nAdmission PEx: Weight 1455 gm (50%), L 41.5 cm (50%), HC 29.25 cm (50%), nondysmorphic with overall appearance c/w known gestational age, AFSOF, RR present bilaterally, palate intact, intermittent grunting, moderate intercostal retractions, diminished air entry bilaterally, RRR without murmur, 2+ femoral pulses, abdomen benign with no HSM, no masses, normal female external genitalia for g.a. normal back and ext with stable hips, appropriate tone, skin pink with fair perfusion.\\n\\nA/P: 30 week gestation AGA triplet #2, moderate respiratory distress, likely surfactant deficiency +/- component of retained fetal lung fluid, can not rule out pneumonia/sepsis with only perinatal risk factor of preterm labor (not unexpected in setting of triplet gestation). Also at risk of other complications of moderate prematurity including A/B, hypoglycemia, fluid and electrolyte imbalance, suck swallow dyscoordination, hyperbilirubinemia, feeding intolerance/nec, IVH/PVL, ROP.\\n\\n-CPAP, supplemental O2, monitor, CXR, may need intubation and exogenous surfactant tx.\\n-NPO for now, D10W at 80 cc/kg/d, PN/IL asap, monitor glucose, lytes, bili, treat as indicated,\\n- CBC, blood cx, amp and gent pending clinicla course and 48 horu blood bulture results\\n- Follow up on repeat pending PNS results.\\n- Head U/S and eye exam per routine\\n\\nI updated parents in OR. will keep informed/supported.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695780,\n \"text\": \"Addendum - PE\\n\\nBaby is /jaundiced breathing comfortably in nasal cannula O2.\\nAF soft and flat.\\nLungs clear and equal, no retractions.\\nCVS - S1 S2 normal - no murmur, perfusion good\\nAbd - soft with normal bowel sounds, slightly full.\\nGU- normal female\\nNeuro - tone appropriate, symmetrical movements\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695781,\n \"text\": \"1900-0700 NPN\\n\\n\\n#1SEPSIS\\nO:BLOOD CX NGTD AT 48HR OF AGE. ANTIBIOTICS D/ MD\\nORDER\\nA:SEPSIS RULED OUT\\nP:D/C PROBLEM\\n\\n#2RESPIRATORY\\nO:REMAINS IN NC 100CC 21% W/SATS 92-97%. BS CLEAR, SL\\nDIMINISHED. INTERMITTENT GRUNTING NOTED AT START OF\\nSHIFT--MD AWARE AND HAS SUBSEQUENTLY RESOLVED. RESP RATE\\n44-72 WITH MILD IC/SC RETRACTIONS. HAS HAD 4 SPELLS THUS\\nFAR, ALL MILD STIM WITHOUT DESATS--MD AWARE. NOT YET ON\\nCAFFEINE.\\nA:STABLE IN LOW NC, STARTING TO SPELL\\nP:CONTINUE TO MONITOR RESP STATUS, MONITOR FOR NEED FOR\\nCAFFEINE\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695784,\n \"text\": \"NPN DAYS\\n\\n\\nAlt in Resp: Received Caffeine loading dose at change of\\nshift this am r/t 11 spells overnight. Remains on NC 100cc\\nflow 21% FiO2, no further spells this shift. LS clear and\\nequal. Mild retractions. Continue with current plan of care.\\n\\nAlt in FEN: TF increased to 120cc/kg/day. PND10 and lipids\\ncurrently infusing at 60cc/kg/day via . D10 infusing at\\n30cc/kg/day. Feeds of BM20/Pe20 at 30cc/kg/day. Increasing\\nfeeds by 10cc/kg/ at 4/4. Belly soft and round with\\nactive bowel sounds. No spits or aspirates. No stool since\\nbirth. Urine out 1.9cc/kg/hr. Will continue to increase\\nfeeds as tolerated.\\n\\nAlt in Parenting: Parents in to visit and participating in\\nall cares. Updated them on day. Family meeting\\nscheduled for Monday at 2pm. Will continue to provide\\nsupport and teaching.\\n\\nAlt in Growth and Dev: Temp stable in air isolette. Nested\\non sheepskin with boundaries in place. Passivley sucks on\\npacifier. Awake and alert with cares, settles well between\\ncares. Will continue to provide for developmental needs.\\n\\nBili: Remains under double phototherapy for bili. Check bili\\ntonight.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695785,\n \"text\": \"NPN\\n\\n\\n#2RESP:\\nO; Weaned to RA with sats in high 90's. RR 60-70, mild ic/sc\\nretractions. Lungs cl=, no spells\\nA/P; Cont to monitor. Caffeine as ordered.\\n\\n#3FEN:\\no: Advanced feeds PE20 to 50cc/k/d. infusing PN D10 and\\nIL at 70/k/d. Ad soft, round, no asp or spits. Voiding\\n1.7cc/k/h. no stools\\nA: Tol feeds\\np: Cont to advance as tol. check labs.\\n\\n#4Parenting:\\no: Mom in to visit, happy with progress. dad unable to\\nvisit.\\nA/P: Cont to support and inform, family mtg today at 1400\\n\\n#5G@D:\\nO: Temps stable in heated isolette with temp adjustments.\\nAlert and active with cares, MAE. Opening eyes. sucking on\\npacifier.\\nA/p: Cont to support dev.\\n\\n#7Bili:\\no: Under double photherapy with eye patches in place.Bili\\ndrawn.\\nA/p: Cont with tx. check lab results.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695786,\n \"text\": \"Neonatology note\\n4 d.o\\nin RA now, off NC O2 last night.\\nAFOF, jaundice\\nNormal tone for preemie\\nRR with no murmur\\nclear lungs\\nabdomen soft\\nwt= 1250 gm +5, 120 cc/kg/d with PN+Il, feeding at 50 cc/kg/d\\nbili= 5.3\\n\\nA: ex 30 wks GA, resolved RDS, jaundice\\nP: advancing feeding, monitor jaundice and possible immaturity of breathing.-\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695782,\n \"text\": \"1900-0700 NPN\\n\\n\\n#2RESPIRATORY\\nO:BABY HAS HAD AN ADDITIONAL 4 SPELLS SINCE MD NOTIFIED\\n~2400. NNP NOTIFIED OF ADDITIONAL 4 SPELLS-->8 IN 12HR.\\nORDER RECEIVED TO BEGIN CAFFEINE.\\nA:INCREASED SPELLS\\nP:START CAFFEINE, MONITOR CLOSELY FOR NEED FOR CPAP\\n\\n#3F/E/N\\nO:TF INCREASED TO 100CC/KG. INCREASED ENTERAL FEEDS TO\\n30CC/KG BM/PE 6.7CC Q4HR GAVAGE AND IVF D10PN/IL AT 60CC/KG\\nAND D1OW IVPB INTO LINE AT 10CC/KG. ABDOMEN SOFT WITH GOOD\\nBS. NO LOOPS AND NO SPITS, MINIMAL ASPIRATES. AG 20-20.5CM.\\nVOIDING 1.8CC/KG X12HR; NO STOOL. WT DOWN 85GM. DS 63. LYTES\\nTHIS AM 145/4.3/113/20\\nA:STABLE\\nP:CONTINUE TO MONITOR TOLERANCE TO FEEDS, FOLLOW U/O AND DS\\n\\n#4PARENTING\\nO:PARENTS EACH CALLED THIS AM FOR UPDATE ON BABIES. SEE\\nSIBLINGS #3 NOTE\\nA:INVOLVED, INVESTED\\nP:CONTINUE TO SUPPORT, EDUCATE AND KEEP UP TO DATE\\n\\n#5G&D\\nO:IN AIR CONTROL ISOLETTE WITH STABLE TEMPEDRATURE. TEMP\\nDROP WITH KC-->PLACED UNDER WARMING LIGHTS WITH RESOLUTION.\\nACTIVE/MAE WITH CARES; SLEEPING WELL BETWEEN\\nA:AGA\\nP:CONTINUE TO SUPPORT AND MONITOR\\n\\n#7BILI\\nO:REMAINS UNDER DOUBLE PHOTOTHERAPY WITH BILIMASK IN PLACE.\\nBILI THIS AM 7.8/0.3\\nA:HYPERBILI\\nP:CONTINUE PHOTOTHERAPY, CHECK BILI AS ORDERED\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-03-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1695783,\n \"text\": \"Neonatology Attending Note\\nDay 3\\n\\nNC 100cc, 21%. RR40-70s. 11 A&Bs last pm, started caffeine this am. No spells since. No murmur. HR 120-150s. BP 55/41, 45. Mild gen edema.\\n\\nBili 7.8/0.3\\nUnder double photot.\\n\\nWt 1245, down 85 gms. TF 100 cc/k/day BM/PE20 at 30, remainder PN/IL. Tol well. Nl voiding and stooling.\\n145/4.3/11/20\\nd/s 63\\n\\nNow off abx.\\n\\nIn isolette.\\n\\nExam: Infant active, alert with exam. AFOF. She is , well perfused, no murmur auscultated. She is comfortable in NCO2. Breath sounds clear and equal. Abd soft, active bowel sounds, no loops. Stable temp in air isolette.\\n\\nA/P:\\n - wean O2 as tol\\n - monitor AOP on caffeine\\n - adv TF\\n - adv enteral feedings\\n - cont photot and follow bili levels\\n\"\n }\n]"}}},{"rowIdx":373,"cells":{"subject_id":{"kind":"number","value":45393,"string":"45,393"},"hadm_id":{"kind":"number","value":173107,"string":"173,107"},"target_text":{"kind":"string","value":"# Patient expired on from hypoxic respiratory failure secondary to multifactorial etiologies including aspiration, HAP, mucus plugging, chronic COPD and atelectasis. Patient coughed and began to have increased work of breathing and the team was called for evaluation. The patient initially had rapid, shallowing breath, followed by agonal breathing. Additional supplemental O2 were given. Patient was DNR/DNI and goals of care were reviewed with patient's daughter and family at bedside. As consistent with their wishes, no invasive interventions were performed and patient was not transferred to the ICU. The patient subsequently expired. . # Hypoxic respiratory distress/HAP: Patient developed multiple episodes of hypoxic respiratory distress throughout her hospitalization, likely secondary to multifactorial etiologies including mucus plugging, COPD, chronic atelectasis and aspiration event/pneumonia. CXR showed bibasilar opacities. She was treated for HAP with 7-day course of Vancomycin, Aztreonam, and Levaquin (patient with documented penicillin and clindamycin). Per family wishes, patient was DNR/DNI, and O2 desaturations were managed with repositioning, suction, and supplemental O2 with goal O2 sat>90. . # Coag neg Staph bacteremia: Positive cultures from and , but subsequent cultures have been negative. Source believed to be from PICC. TTE negative for vegetations. Patient was treated with a 7-day course of vancomycin. Infectious diseases agreed with management. . # Abdominal Distension/Pain: Found to have an SBO on CT scan. Also, found to have large amounts of stool in rectal vault and distal colon. G-tube placed to suction with decompression. Disimpacted and given aggressive bowel regimen with good results, decreased pain, and decreased distension. After bowel movements had repeat KUB which showed an interval decrease in bowel distension and resolution of ileus. Patient's symptoms improved. She failed a speech and swallow evaluation with video fibroscopy, which revealed aspiration. Following family meeting, decision was made to keep NGT and tube feeds given intermittently as tolerated. . # Afib w/ RVR: On diltiazem and metoprolol at home. Not anticoagulated given fall risk. Originally placed on diltiazem gtt given NPO status on admission per above. Rate controlled with discontinuation of diltiazem gtt. Transitioned to IV metoprolol 5 mg q4hrs with PO diltiazem after patient showd signs of improving obstruction. She had one episode of AFib with RVR to 140s with stable hemodynamics. She was transitioned to PO metoprolol 50 qid and diltiazem 30 qid with good rate control in 90-100s . # Acute Kidney Injury: BUN to Cr ratio> 20:1 on admission most consistent with prerenal azotemia secondary to dehydration. Resolved with IVF's. . # Delirium: Likely multifactorial due to constipation/ileus, dehydration, afib w/ RVR, and pneumonia/bacteremia. Treated with low dose Zyprexa in the evening. Throughout her hospitalization, her baseline deteriorated and became unresponsive to voice and pain the day prior to passing away. Her family understook the deterioration of her status, and wished to continue with DNR/DNI status. . # Chronic C2 fracture: Stable for some time and pt does not need collar for stability but used it for management of cervical disk disease and upper extremity symptoms. . # Lumbar fracture: Incidental L1 compression fracture seen on CT scan of unknown chroniciity. Patient without symptoms. Likely due to osteoporosis."},"extractive_notes_summ":{"kind":"string","value":"Moderate (2+) aortic regurgitation isseen. Moderate aortic andmitral regurgitation. Mild symmetric left ventricularhypertrophy with normal global biventricular systolic function. Probable normal sinus rhythm with atrial prematurebeats. No PS.Physiologic PR.PERICARDIUM: No pericardial effusion.Conclusions:The left atrium is moderately dilated. There is mild aorticvalve stenosis (valve area 1.2-1.9cm2). Mild mitral annular calcification. There is mild pulmonary artery systolichypertension. Moderate (2+)mitral regurgitation is seen. There is mild symmetric leftventricular hypertrophy with normal cavity size. Mild to moderate [+] TR.Mild PA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. Mild aortic stenosis. Moderate (2+)MR.TRICUSPID VALVE: Normal tricuspid valve leaflets. Since the previous tracingof ventricular rate is slower and irregular, atrial wave forms aresuggested of atrial fibrillation and further left axis deviation is present. Moderate (2+) AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Mildly dilated ascendingaorta.AORTIC VALVE: Moderately thickened aortic valve leaflets. Left anterior fascicular block. Moderate baseline artifact. The ascendingaorta is mildly dilated. Mild AS (area 1.2-1.9cm2). Noresting LVOT gradient.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level. Consider prior inferior andanterior myocardial infarctions of undetermined age. Compared to the previoustracing of probably no diagnostic interval change.TRACING #1 Mitral valve disease.Height: (in) 60Weight (lb): 126BSA (m2): 1.54 m2BP (mm Hg): 136/81HR (bpm): 100Status: InpatientDate/Time: at 14:41Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Moderate LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Delayed R waveprogression may be due to left anterior fascicular block but cannot excludepossible prior septal myocardial infarction. Poor R wave progression. The aortic valve leaflets are moderately thickened.No masses or vegetations are seen on the aortic valve. Atrial fibrillation. Atrial fibrillation. Tissue Dopplerimaging suggests an increased left ventricular filling pressure (PCWP>18mmHg).Right ventricular chamber size and free wall motion are normal. Baseline is not steady butthere may be ST segment depressions in the precordial leads V2-V5 which arenew. Suboptimaltechnical quality, a focal LV wall motion abnormality cannot be fullyexcluded. Supraventricular tachycardia at a rateof 153. P waves are not clearly enough seen to determine the exactmechanism but there appears to be a P wave in the ST segment, perhapssuggesting catrialv flutter with 2:1 A-V block. The mitral valve leaflets are mildly thickened. Endocarditis. There is no mitral valveprolapse. Hypertrophic cardiomyopathy. Leftward axis. Due to suboptimal technicalquality, a focal wall motion abnormality cannot be fully excluded. No masses orvegetations on aortic valve. Overallleft ventricular systolic function is normal (LVEF>55%). No mass orvegetation on mitral valve. Marked baseline artifact. No MVP. There is no pericardial effusion.IMPRESSION: No echocardiographic evidence of endocarditis. Compared to tracing #1 and compared to .TRACING #2 PATIENT/TEST INFORMATION:Indication: Aortic valve disease. Overall normal LVEF (>55%). Elevatedestimated PCWP.If clinically indicated, a transesophageal echocardiogram may better assessfor valvular vegetations. TDI E/e' >15, suggesting PCWP>18mmHg."},"n_notes":{"kind":"number","value":4,"string":"4"},"notes":{"kind":"list like","value":[{"category":"Echo","chartdate":"2198-05-28 00:00:00.000","description":"Report","row_id":88552,"text":"PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease. Atrial fibrillation. Endocarditis. Hypertrophic cardiomyopathy. Mitral valve disease.\nHeight: (in) 60\nWeight (lb): 126\nBSA (m2): 1.54 m2\nBP (mm Hg): 136/81\nHR (bpm): 100\nStatus: Inpatient\nDate/Time: at 14:41\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Suboptimal\ntechnical quality, a focal LV wall motion abnormality cannot be fully\nexcluded. Overall normal LVEF (>55%). TDI E/e' >15, suggesting PCWP>18mmHg. No\nresting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Mildly dilated ascending\naorta.\n\nAORTIC VALVE: Moderately thickened aortic valve leaflets. No masses or\nvegetations on aortic valve. Mild AS (area 1.2-1.9cm2). Moderate (2+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. No mass or\nvegetation on mitral valve. Mild mitral annular calcification. Moderate (2+)\nMR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to moderate [+] TR.\nMild PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is moderately dilated. There is mild symmetric left\nventricular hypertrophy with normal cavity size. Due to suboptimal technical\nquality, a focal wall motion abnormality cannot be fully excluded. Overall\nleft ventricular systolic function is normal (LVEF>55%). Tissue Doppler\nimaging suggests an increased left ventricular filling pressure (PCWP>18mmHg).\nRight ventricular chamber size and free wall motion are normal. The ascending\naorta is mildly dilated. The aortic valve leaflets are moderately thickened.\nNo masses or vegetations are seen on the aortic valve. There is mild aortic\nvalve stenosis (valve area 1.2-1.9cm2). Moderate (2+) aortic regurgitation is\nseen. The mitral valve leaflets are mildly thickened. There is no mitral valve\nprolapse. No mass or vegetation is seen on the mitral valve. Moderate (2+)\nmitral regurgitation is seen. There is mild pulmonary artery systolic\nhypertension. There is no pericardial effusion.\n\nIMPRESSION: No echocardiographic evidence of endocarditis. Moderate aortic and\nmitral regurgitation. Mild aortic stenosis. Mild symmetric left ventricular\nhypertrophy with normal global biventricular systolic function. Elevated\nestimated PCWP.\n\nIf clinically indicated, a transesophageal echocardiogram may better assess\nfor valvular vegetations.\n\n\n"},{"category":"ECG","chartdate":"2198-05-29 00:00:00.000","description":"Report","row_id":231629,"text":"Atrial fibrillation. Left anterior fascicular block. Delayed R wave\nprogression may be due to left anterior fascicular block but cannot exclude\npossible prior septal myocardial infarction. Since the previous tracing\nof ventricular rate is slower and irregular, atrial wave forms are\nsuggested of atrial fibrillation and further left axis deviation is present.\n\n"},{"category":"ECG","chartdate":"2198-05-23 00:00:00.000","description":"Report","row_id":231859,"text":"Moderate baseline artifact. Supraventricular tachycardia at a rate\nof 153. P waves are not clearly enough seen to determine the exact\nmechanism but there appears to be a P wave in the ST segment, perhaps\nsuggesting catrialv flutter with 2:1 A-V block. Baseline is not steady but\nthere may be ST segment depressions in the precordial leads V2-V5 which are\nnew. Compared to tracing #1 and compared to .\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2198-05-23 00:00:00.000","description":"Report","row_id":231860,"text":"Marked baseline artifact. Probable normal sinus rhythm with atrial premature\nbeats. Leftward axis. Poor R wave progression. Consider prior inferior and\nanterior myocardial infarctions of undetermined age. Compared to the previous\ntracing of probably no diagnostic interval change.\nTRACING #1\n\n"}],"string":"[\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2198-05-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 88552,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Aortic valve disease. Atrial fibrillation. Endocarditis. Hypertrophic cardiomyopathy. Mitral valve disease.\\nHeight: (in) 60\\nWeight (lb): 126\\nBSA (m2): 1.54 m2\\nBP (mm Hg): 136/81\\nHR (bpm): 100\\nStatus: Inpatient\\nDate/Time: at 14:41\\nTest: TTE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT ATRIUM: Moderate LA enlargement.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\\n\\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Suboptimal\\ntechnical quality, a focal LV wall motion abnormality cannot be fully\\nexcluded. Overall normal LVEF (>55%). TDI E/e' >15, suggesting PCWP>18mmHg. No\\nresting LVOT gradient.\\n\\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\\n\\nAORTA: Normal aortic diameter at the sinus level. Mildly dilated ascending\\naorta.\\n\\nAORTIC VALVE: Moderately thickened aortic valve leaflets. No masses or\\nvegetations on aortic valve. Mild AS (area 1.2-1.9cm2). Moderate (2+) AR.\\n\\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. No mass or\\nvegetation on mitral valve. Mild mitral annular calcification. Moderate (2+)\\nMR.\\n\\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to moderate [+] TR.\\nMild PA systolic hypertension.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS.\\nPhysiologic PR.\\n\\nPERICARDIUM: No pericardial effusion.\\n\\nConclusions:\\nThe left atrium is moderately dilated. There is mild symmetric left\\nventricular hypertrophy with normal cavity size. Due to suboptimal technical\\nquality, a focal wall motion abnormality cannot be fully excluded. Overall\\nleft ventricular systolic function is normal (LVEF>55%). Tissue Doppler\\nimaging suggests an increased left ventricular filling pressure (PCWP>18mmHg).\\nRight ventricular chamber size and free wall motion are normal. The ascending\\naorta is mildly dilated. The aortic valve leaflets are moderately thickened.\\nNo masses or vegetations are seen on the aortic valve. There is mild aortic\\nvalve stenosis (valve area 1.2-1.9cm2). Moderate (2+) aortic regurgitation is\\nseen. The mitral valve leaflets are mildly thickened. There is no mitral valve\\nprolapse. No mass or vegetation is seen on the mitral valve. Moderate (2+)\\nmitral regurgitation is seen. There is mild pulmonary artery systolic\\nhypertension. There is no pericardial effusion.\\n\\nIMPRESSION: No echocardiographic evidence of endocarditis. Moderate aortic and\\nmitral regurgitation. Mild aortic stenosis. Mild symmetric left ventricular\\nhypertrophy with normal global biventricular systolic function. Elevated\\nestimated PCWP.\\n\\nIf clinically indicated, a transesophageal echocardiogram may better assess\\nfor valvular vegetations.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2198-05-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 231629,\n \"text\": \"Atrial fibrillation. Left anterior fascicular block. Delayed R wave\\nprogression may be due to left anterior fascicular block but cannot exclude\\npossible prior septal myocardial infarction. Since the previous tracing\\nof ventricular rate is slower and irregular, atrial wave forms are\\nsuggested of atrial fibrillation and further left axis deviation is present.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2198-05-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 231859,\n \"text\": \"Moderate baseline artifact. Supraventricular tachycardia at a rate\\nof 153. P waves are not clearly enough seen to determine the exact\\nmechanism but there appears to be a P wave in the ST segment, perhaps\\nsuggesting catrialv flutter with 2:1 A-V block. Baseline is not steady but\\nthere may be ST segment depressions in the precordial leads V2-V5 which are\\nnew. Compared to tracing #1 and compared to .\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2198-05-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 231860,\n \"text\": \"Marked baseline artifact. Probable normal sinus rhythm with atrial premature\\nbeats. Leftward axis. Poor R wave progression. Consider prior inferior and\\nanterior myocardial infarctions of undetermined age. Compared to the previous\\ntracing of probably no diagnostic interval change.\\nTRACING #1\\n\\n\"\n }\n]"}}},{"rowIdx":374,"cells":{"subject_id":{"kind":"number","value":60431,"string":"60,431"},"hadm_id":{"kind":"number","value":116904,"string":"116,904"},"target_text":{"kind":"string","value":"Brief Hospital Course: . #R hip injury s/p fall Pt suffered multiple injuries during her fall. In addition to broken teeth (some cemented in the ED) and ecchymoses over her chin and R temple, there was persistent concern for R hip fracture given limited range of motion on exam. Therefore, despite initial negative plain films of her R hip and leg in the ED, a follow-up CT was obtained and showed a peri-prosthetic proximal femur fracture. Ortho trauma recommended non-operative management of her right hip fracture, with outpatient follow-up with in weeks with repeat x-rays of her right hip. Pain was controlled with standing tylenol and a lidocaine patch. Initially anticoagulated with Sq heparin alone, changed to lovenox per discussions with ortho. . #Small Bowel Obstruction On the medicine service on hospital day 4 the pt developed acute epigastric pain associated with nausea, nonbloody vomiting, and dyspnea. Abdominal x-ray showed a distended stomach and small bowel with multiple air-fluid levels with no free air, consistent with possible small bowel obstruction. In the ICU, an NGT tube was placed (required left lateral decubitus positioning given known Zenker's diverticulum) with >2L bilious gastric fluid drainage. Surgery was consulted to evaluate her recurrent small bowel obstruction; they recommended non-operative management, keeping patient NPO with NGT/IV fluids. She also received an agressive bowel regimen to relieve obstruction, and was passing gas within 24 hours. Her symptoms improved, NGT was removed on and her diet advanced to regular. #Acute Hypoxia/severe atelectasis with lung collapse. Vital signs obtained at the onset of nausea/vomiting showed oxygen desaturation to 84% with tachypnea to RR 24. Pt denied chest pain and palpitations. ABG pH 7.43 pCO2 42 pO2 65. Supplemental oxygen via non-rebreather improved O2sats to 91-94%. SErial EKG's were monitored. EKG performed at 3am on morning prior to hypoxic episode showed possible STE in v3-v4 (performed as pre-op for possible OR but not reviewed by overnight physician). Repeat EKG at 6am did not show this finding. However, serial cardiac enzymes ruled out MI. Reviewed EKG with cardiology. Pt was empirically started on heparin gtt, PR aspirin, statin and beta-blocker and transferred to the ICU for stabilization of her respiratory status. She was afebrile, without elevated WBC or consolidation/infiltration on CXR or cough. Negative CTA ruled out pulmonary emboli, but showed bilateral lower lobe collapse due to lobar atelectasis. Echo showed normal biventricular function and no evidence of pulmonary hypertension. Cardiac enzymes were negative. As ACS and PE were ruled out, BB, statin, heparin were discontinued. After transfer to the ICU she denied SOB but continued to require 5-6L supplemental oxygen to keep O2 sats>90%. Used frequent incentive spirometry to promote re-inflation of collapsed lower lobes. Pt required no further oxygen on day of discharge and had clinical improvement in crackles in right base *******PT SHOULD HAVE STRESS TESTING AS AN OUTPT GIVEN ISOLATED TRANSIENT V3-4 STE ON EKG*** . # Hypothyroid - Treated with home levothyroxine. . # GERD - Treated with home omeprazole. #UTI-s/p course of PO cipro x3 days. Cx with mixed flora. . #osteoporosis-continued calcium . FEN:adat to clears . PPX: hep SC, bowel regimen (PR dulcolax/enemas) . #CODE: Full (confirmed) . #Contact: (handicapped. per patient he is not able to make decisions for the patient. Patient has no one who she says can make decisions for her."},"extractive_notes_summ":{"kind":"string","value":"Moderate mitral annularcalcification. Trivial mitral regurgitationis seen. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. The P-R interval is prolonged.Non-specific ST-T wave changes. Non-specific ST-T wave changes. Probable left atrial abnormality.Non-specific anterolateral ST-T wave changes. No aortic regurgitation is seen.The mitral valve leaflets are mildly thickened. Diffuse T wave flatteningwhich is non-specific. Trivial MR.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. The estimatedpulmonary artery systolic pressure is normal. Mild [1+] TR.Normal PA systolic pressure.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.PERICARDIUM: No pericardial effusion.Conclusions:The left atrium is normal in size. No change compared to . Low voltage in the precordialleads. Borderline P-R interval prolongation. First degree A-V delay. First degree A-V delay. Sinus rhythm. Sinus rhythm. Sinus rhythm. Sinus rhythm. Sinus rhythm. Compared tothe previous tracing of there is no change. Right ventricular chambersize and free wall motion are normal. Nopulmonary hypertension or pathologic valvular disease seen.Compared with the resting images of the prior study of , the findingsare similar. Compared to the previous tracing of there is no significant change. Compared to the previous tracingof precordial lead voltage is much less. Theestimated cardiac index is normal (>=2.5L/min/m2). The diameters of aorta at the sinus,ascending and arch levels are normal. There is no pericardialeffusion.IMPRESSION: Normal global and regional biventricular systolic function. Estimated cardiac index is normal(>=2.5L/min/m2). Compared to the previous tracing of there is nosignificant diagnostic change. No resting LVOT gradient.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal diameter of aorta at the sinus, ascending and arch levels.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). The aortic valve leaflets (3) are mildlythickened but aortic stenosis is not present. Anterior T wave inversion. The tricuspid valve leaflets are mildly thickened. Evaluate valves, right and left ventricular function.Height: (in) 60Weight (lb): 112BSA (m2): 1.46 m2BP (mm Hg): 130/67HR (bpm): 72Status: InpatientDate/Time: at 11:30Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/globalsystolic function (LVEF >55%). No AS. There is a late transitionconsistent with possible myocardial infarction. The P-R interval is prolonged. Left ventricular wall thickness, cavitysize and regional/global systolic function are normal (LVEF >55%). Artifact is present."},"n_notes":{"kind":"number","value":6,"string":"6"},"notes":{"kind":"list like","value":[{"category":"Echo","chartdate":"2137-06-12 00:00:00.000","description":"Report","row_id":96538,"text":"PATIENT/TEST INFORMATION:\nIndication: Unexplained hypoxia, dyspnea. Evaluate valves, right and left ventricular function.\nHeight: (in) 60\nWeight (lb): 112\nBSA (m2): 1.46 m2\nBP (mm Hg): 130/67\nHR (bpm): 72\nStatus: Inpatient\nDate/Time: at 11:30\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). Estimated cardiac index is normal\n(>=2.5L/min/m2). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate mitral annular\ncalcification. Trivial MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR.\nNormal PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thickness, cavity\nsize and regional/global systolic function are normal (LVEF >55%). The\nestimated cardiac index is normal (>=2.5L/min/m2). Right ventricular chamber\nsize and free wall motion are normal. The diameters of aorta at the sinus,\nascending and arch levels are normal. The aortic valve leaflets (3) are mildly\nthickened but aortic stenosis is not present. No aortic regurgitation is seen.\nThe mitral valve leaflets are mildly thickened. Trivial mitral regurgitation\nis seen. The tricuspid valve leaflets are mildly thickened. The estimated\npulmonary artery systolic pressure is normal. There is no pericardial\neffusion.\n\nIMPRESSION: Normal global and regional biventricular systolic function. No\npulmonary hypertension or pathologic valvular disease seen.\n\nCompared with the resting images of the prior study of , the findings\nare similar.\n\n\n"},{"category":"ECG","chartdate":"2137-06-12 00:00:00.000","description":"Report","row_id":262899,"text":"Sinus rhythm. The P-R interval is prolonged. There is a late transition\nconsistent with possible myocardial infarction. Low voltage in the precordial\nleads. Non-specific ST-T wave changes. Compared to the previous tracing\nof precordial lead voltage is much less.\n\n"},{"category":"ECG","chartdate":"2137-06-11 00:00:00.000","description":"Report","row_id":262900,"text":"Artifact is present. Sinus rhythm. The P-R interval is prolonged.\nNon-specific ST-T wave changes. Compared to the previous tracing of \nthere is no significant change.\n\n"},{"category":"ECG","chartdate":"2137-06-08 00:00:00.000","description":"Report","row_id":262901,"text":"Sinus rhythm. First degree A-V delay. Probable left atrial abnormality.\nNon-specific anterolateral ST-T wave changes. No change compared to .\n\n"},{"category":"ECG","chartdate":"2137-06-14 00:00:00.000","description":"Report","row_id":262897,"text":"Sinus rhythm. Anterior T wave inversion. First degree A-V delay. Compared to\nthe previous tracing of there is no change.\n\n"},{"category":"ECG","chartdate":"2137-06-13 00:00:00.000","description":"Report","row_id":262898,"text":"Sinus rhythm. Borderline P-R interval prolongation. Diffuse T wave flattening\nwhich is non-specific. Compared to the previous tracing of there is no\nsignificant diagnostic change.\n\n"}],"string":"[\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2137-06-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 96538,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Unexplained hypoxia, dyspnea. Evaluate valves, right and left ventricular function.\\nHeight: (in) 60\\nWeight (lb): 112\\nBSA (m2): 1.46 m2\\nBP (mm Hg): 130/67\\nHR (bpm): 72\\nStatus: Inpatient\\nDate/Time: at 11:30\\nTest: Portable TTE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nThis study was compared to the prior study of .\\n\\n\\nLEFT ATRIUM: Normal LA size.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\\n\\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\\nsystolic function (LVEF >55%). Estimated cardiac index is normal\\n(>=2.5L/min/m2). No resting LVOT gradient.\\n\\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\\n\\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels.\\n\\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\\n\\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate mitral annular\\ncalcification. Trivial MR.\\n\\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR.\\nNormal PA systolic pressure.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\\n\\nPERICARDIUM: No pericardial effusion.\\n\\nConclusions:\\nThe left atrium is normal in size. Left ventricular wall thickness, cavity\\nsize and regional/global systolic function are normal (LVEF >55%). The\\nestimated cardiac index is normal (>=2.5L/min/m2). Right ventricular chamber\\nsize and free wall motion are normal. The diameters of aorta at the sinus,\\nascending and arch levels are normal. The aortic valve leaflets (3) are mildly\\nthickened but aortic stenosis is not present. No aortic regurgitation is seen.\\nThe mitral valve leaflets are mildly thickened. Trivial mitral regurgitation\\nis seen. The tricuspid valve leaflets are mildly thickened. The estimated\\npulmonary artery systolic pressure is normal. There is no pericardial\\neffusion.\\n\\nIMPRESSION: Normal global and regional biventricular systolic function. No\\npulmonary hypertension or pathologic valvular disease seen.\\n\\nCompared with the resting images of the prior study of , the findings\\nare similar.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2137-06-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 262899,\n \"text\": \"Sinus rhythm. The P-R interval is prolonged. There is a late transition\\nconsistent with possible myocardial infarction. Low voltage in the precordial\\nleads. Non-specific ST-T wave changes. Compared to the previous tracing\\nof precordial lead voltage is much less.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2137-06-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 262900,\n \"text\": \"Artifact is present. Sinus rhythm. The P-R interval is prolonged.\\nNon-specific ST-T wave changes. Compared to the previous tracing of \\nthere is no significant change.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2137-06-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 262901,\n \"text\": \"Sinus rhythm. First degree A-V delay. Probable left atrial abnormality.\\nNon-specific anterolateral ST-T wave changes. No change compared to .\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2137-06-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 262897,\n \"text\": \"Sinus rhythm. Anterior T wave inversion. First degree A-V delay. Compared to\\nthe previous tracing of there is no change.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2137-06-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 262898,\n \"text\": \"Sinus rhythm. Borderline P-R interval prolongation. Diffuse T wave flattening\\nwhich is non-specific. Compared to the previous tracing of there is no\\nsignificant diagnostic change.\\n\\n\"\n }\n]"}}},{"rowIdx":375,"cells":{"subject_id":{"kind":"number","value":11947,"string":"11,947"},"hadm_id":{"kind":"number","value":199058,"string":"199,058"},"target_text":{"kind":"string","value":"The patient was admitted on , and underwent a coronary artery bypass graft times three with left internal mammary artery to the left anterior descending, reversed saphenous vein graft to the obtuse marginal and right coronary artery, cross-plant time 44 minutes, total bypass time 70 minutes. He was transferred to the CSRU on Neo-Synephrine and Propofol in stable condition. He did have labile blood pressure swings immediately postoperative and required volume for this. He was extubated on postoperative night. Postoperative day number one, his chest tubes were discontinued and he remained on Neo-Synephrine. This was slowly weaned off and on postoperative day three, he was transferred to the floor in stable condition. He had his epicardial pacing wires discontinued. He continued to have a stable postoperative course. He did have some tachycardia which responded well to beta blocker. He got very anxious and got combative and was seen by psychiatry who recommended low dose Ativan which eventually his anxiety subsided. He continued to progress and, on postoperative day number eight, he was discharged to home in stable condition. His laboratories on discharge included a hematocrit of 32.4, white blood cell count 7.2, platelet count 390,000. Sodium 141, potassium 4.1, chloride 105, CO2 25, blood urea nitrogen 13, creatinine 0.9, blood sugar 95."},"extractive_notes_summ":{"kind":"string","value":"Resp alkolotic. volume,weaning neo as tolerated. REPLETE K+ PRN. Weaned neo gtt off. Hypoactive bs. Titrated to NBP. Pt requested percocet. Rehab: As above.A: Less neo. ID: Tmax 100.7, down after percocet. IMPRESSION: Small pleural effusions and focal left basilar atelectasis following CABG. Pt w/ low PAP's and CVP. Encouraged pt to CDB and IS. Palpable dp, dopplerable pt pulses. SPo2 100 2L Np.GU: Brisk Uop >100c qhr.GI: Soft abd. Endo: SSRI. Continue to wean neo. Restarted Neo. Rule out pneumothorax. Patient is s/p median sternotomy and CABG. Notified Dr. . PT. PT. IMPRESSION: 1) Tubes and lines as described. COMPARISON made to cxr. + periph pulses, trace edema, hands cool.Resp: R/A w/ 02sat 95-98%. extubated to np's w/o incident. Tolerating clear liquids.A/P Labile bp in the setting of low filling pressures and autodiurese.Wean Neo as tol. Clinical correlation issuggested. DELINE CORDIS & ALINE. Periph line and dc cordis. 2) Possible tiny right apical pneumothorax. Monitor BP off neo. A/P Continuing to require neo. CSRU Progress NoteS/O: Neuro: A+O, med with percocet. Effect pending at this time.CV: Remains on Neo gtt for bp. Poor exercise tolerance.P: Cont efforts to wean neo. Pao2 65. cuff leak + w vocalization around ett cuff. darvocet given.importance of pain control reiterated.bp stabilizing after signif. DENIES NEED FOR PAIN MED.DIURESING WELL; K+ REPLETED.PLAN: WEAN NEO TO OFF & TRANSFER TO FLOOR IF STABLE. Heme: Aspirin. Pulm toilet. Pulm toilet. s/p cabg x 3 csru npn 7a-7ps-\"i'm anxious about getting up\"o-neuro-intactcv-bp remains labile 60's-110's on neo gtt 1.5-2mcg/k/min.+dp/pt ble,hr 80's-100's nsr->st no vea.mediastinal/pleural ct's dc'd this pm,pa cath dc'd this pm.resp-ls cta decreased @ bases,c+db well w/ enc,o2 weaned to off,ra o2 sats97-99%.rr 18-20's nard.flovent mdi this pm.gi/gu-pt tol clear w/o diff,ate some fruit for lunch,u/o adeq amts clear yellow urine via foley cath.pt abd soft +hypoactive bs.skin-pt back and buttock grossly intact.soc-pt wife and son visited this pm.endo-fsbs99-110id-afebrilea-labile bp on neo gttp-vs,neo prn to maint sbp>90 map>60/tm,monitor resp status qs and prn,enc c+db wa,i+o,monitor skin integrity qs and prn,fsbs. amts crystalloid.discussed w team,lr to continue for now. 2 Given. COMPARISON: AP SUPINE SINGLE VIEW OF THE CHEST: ET tube is in good position. There is a possible tiny right apical pneumothorax. ENCOURAGE PULM TOILET. Pain mgmt. ct's w scant sero sang. remains on neo as recorded. There are post operative changes of CABG with sternal wires and mediastinal clips. Sinus rhythmNonspecific T wave flattening ( lll, aVL, V4-5 )Poor R wave progressionSince previous tracing, T wave changes Using IS to 1250.GU/GI: Abd soft, +BS, no BM. There is a left chest tube. The heart size and mediastinal contours are within normal limits. Med prn for incisional discomfort.Access: RIJ cordic d/cl'd. Hr St 100's. ? Interval improvement in degree of atelectasis with prior postoperative radiograph. A+Ox3, pleasantly following commands. There has been interval removal of various lines and tubes. There is interval improvement in degree of left lower lobe atelectasis with residual area of atelectasis remaining in the retrocardiac region. Sinus tachycardia. hct essentially unchanged despite lg. Resp: Room air. ST 100-115. CV: Neo .25 with BP 90s. NEURO: A+Ox3. c & r thick blood tinged tan.advanced to clear liqs,tolerated well. HR 90's. Following commands. CI 3.03-3.19.RESP: Lungs are clear. #20PIV placed in RFA. incisional splinting w cough pillow reinforced. Small pleural effusions are noted bilaterally, left greater than right. At 1330, Pt ambulated again w/o any difficulties. Medicated w/ 2 darvocet for pain. There are T wave inversions in leads V3-V4. The NG tube is in the stomach. Taking diet fair, po fluids well. Renal: Foley out, voiding large amts. dng sespite ooziness intra op.exrubation deferred,no cuff leak detected.lethargic,appropriate when awakened.telephone update to wife given. Continue to monitor cardiac/resp/neuro status. Medicated w/ 2 percocet for pain. Nontender. Continues to autodiurese >100cc hr. BP at this time = 125/70. Maintained BP, no sx. FULL CODE Universal Precautions NKDANeuro/Cardiac: AAOx3, MAEx4 - OOB to chair, ambulated in hallx2. Pt continued to have pain 2hours following darcocet. extremely labile bp w wide swings from high 60's to mid 160's w increasing hr,continued low filling pressures w huge dilute appearing huo.multiple lr boluses given w transient effect.cuff correlates well. Since the previous tracing of the heart rate hasincreased. Advance activity as tol, but monitor closely. cuff now ~ 10 mm hg higher in lt. arm. more volume. Stable transfer bed-chair. But pt is very anxious and will tell you so! He sat in the chair and BP back to 90-100/ and he felt ok. Neo was not restarted. reluctant to take pain med but w incisional splinting/grimacing noted. Spo2 > 96%. Pleasant. Bp dropped to 82/51 Map 50's. No ectopy. No ectopy. Raising small amts thick tan secretions. Med w/ Percocet for insisional discomfort when back to bed after ambulating and RIJ cordis and chest dreassings redressed/pacer d/c'd. NEO BEING WEANED SLOWLY TO MAP> 60.TAKING PO'S (PILLS) WITHOUT DIFFICULTY. The pulmonary vascularity is normal. Voids in urinal. Pt raised thick tan blood tinged secretions. The Swan- Ganz catheter tip is located in the right pulmonary artery. Lungs clear bilat, Good cough effort producing clear white sputum. The first time he walked this am w/ PT, SBP down to 80/ (from 98-100s), but he became light-headed. Neo had been off since 7am. refusing percocet & mso4 as he states it makes him \"loopy\". 11:09 AM CHEST (PA & LAT) Clip # Reason: s/p CABG w/decreased BS-r/o effusion/atelectasis Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT/SDA MEDICAL CONDITION: 63 year old man with as above REASON FOR THIS EXAMINATION: s/p CABG w/decreased BS-r/o effusion/atelectasis FINAL REPORT TWO VIEWS CHEST: INDICATION: Decreased breath sounds following CABG."},"n_notes":{"kind":"number","value":12,"string":"12"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2144-01-07 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":814752,"text":" 10:25 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ro ptx\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with\n REASON FOR THIS EXAMINATION:\n ro ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 63 y/o male status post CABG. Rule out pneumothorax.\n\n COMPARISON: \n\n AP SUPINE SINGLE VIEW OF THE CHEST: ET tube is in good position. The Swan-\n Ganz catheter tip is located in the right pulmonary artery. There is a left\n chest tube. There are post operative changes of CABG with sternal wires and\n mediastinal clips.\n\n There is a possible tiny right apical pneumothorax. There is no evidence of a\n left pneumothorax. The NG tube is in the stomach.\n\n IMPRESSION:\n\n 1) Tubes and lines as described.\n 2) Possible tiny right apical pneumothorax. No evidence of a left\n pneumothorax.\n\n"},{"category":"Radiology","chartdate":"2144-01-14 00:00:00.000","description":"CHEST (PA & LAT)","row_id":815456,"text":" 11:09 AM\n CHEST (PA & LAT) Clip # \n Reason: s/p CABG w/decreased BS-r/o effusion/atelectasis\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with as above\n REASON FOR THIS EXAMINATION:\n s/p CABG w/decreased BS-r/o effusion/atelectasis\n ______________________________________________________________________________\n FINAL REPORT\n\n TWO VIEWS CHEST:\n\n INDICATION: Decreased breath sounds following CABG.\n\n COMPARISON made to cxr.\n\n There has been interval removal of various lines and tubes. Patient is s/p\n median sternotomy and CABG. The heart size and mediastinal contours are\n within normal limits. The pulmonary vascularity is normal. There is\n interval improvement in degree of left lower lobe atelectasis with residual\n area of atelectasis remaining in the retrocardiac region. Small pleural\n effusions are noted bilaterally, left greater than right. No pneumothorax is\n identified.\n\n IMPRESSION: Small pleural effusions and focal left basilar atelectasis\n following CABG. Interval improvement in degree of atelectasis with prior\n postoperative radiograph.\n\n\n\n"},{"category":"ECG","chartdate":"2144-01-12 00:00:00.000","description":"Report","row_id":261696,"text":"Sinus tachycardia. Since the previous tracing of the heart rate has\nincreased. There are T wave inversions in leads V3-V4. Clinical correlation is\nsuggested.\n\n"},{"category":"ECG","chartdate":"2144-01-07 00:00:00.000","description":"Report","row_id":261697,"text":"Sinus rhythm\nNonspecific T wave flattening ( lll, aVL, V4-5 )\nPoor R wave progression\nSince previous tracing, T wave changes\n\n"},{"category":"Nursing/other","chartdate":"2144-01-10 00:00:00.000","description":"Report","row_id":1418990,"text":"A+Ox3, pleasantly following commands. Medicated w/ 2 percocet for pain. Weaned neo gtt off. Bp dropped to 82/51 Map 50's. Restarted Neo. Hr St 100's. No ectopy. Resp alkolotic. Pao2 65. Spo2 > 96%. Encouraged pt to CDB and IS. Raising small amts thick tan secretions. Voids in urinal. A/P Continuing to require neo. Continue to wean neo. Pulm toilet.\n"},{"category":"Nursing/other","chartdate":"2144-01-10 00:00:00.000","description":"Report","row_id":1418991,"text":"FULL CODE Universal Precautions NKDA\n\n\nNeuro/Cardiac: AAOx3, MAEx4 - OOB to chair, ambulated in hallx2. The first time he walked this am w/ PT, SBP down to 80/ (from 98-100s), but he became light-headed. Neo had been off since 7am. He sat in the chair and BP back to 90-100/ and he felt ok. Neo was not restarted. At 1330, Pt ambulated again w/o any difficulties. Maintained BP, no sx. BP at this time = 125/70. But pt is very anxious and will tell you so! Med w/ Percocet for insisional discomfort when back to bed after ambulating and RIJ cordis and chest dreassings redressed/pacer d/c'd. + periph pulses, trace edema, hands cool.\n\nResp: R/A w/ 02sat 95-98%. Lungs clear bilat, Good cough effort producing clear white sputum. Using IS to 1250.\n\nGU/GI: Abd soft, +BS, no BM. Taking diet fair, po fluids well. Voiding 400cc at a time via urinal.\n\nPlan: TX to floor when bed available. Continue to monitor cardiac/resp/neuro status. Monitor BP off neo. Med prn for incisional discomfort.\n\nAccess: RIJ cordic d/cl'd. #20PIV placed in RFA.\n\n\n"},{"category":"Nursing/other","chartdate":"2144-01-07 00:00:00.000","description":"Report","row_id":1418984,"text":"extremely labile bp w wide swings from high 60's to mid 160's w increasing hr,continued low filling pressures w huge dilute appearing huo.multiple lr boluses given w transient effect.cuff correlates well. remains on neo as recorded. hct essentially unchanged despite lg. amts crystalloid.discussed w team,lr to continue for now. ct's w scant sero sang. dng sespite ooziness intra op.exrubation deferred,no cuff leak detected.lethargic,appropriate when awakened.telephone update to wife given.\n"},{"category":"Nursing/other","chartdate":"2144-01-07 00:00:00.000","description":"Report","row_id":1418985,"text":"cuff leak + w vocalization around ett cuff. extubated to np's w/o incident. incisional splinting w cough pillow reinforced. c & r thick blood tinged tan.advanced to clear liqs,tolerated well. reluctant to take pain med but w incisional splinting/grimacing noted. refusing percocet & mso4 as he states it makes him \"loopy\". darvocet given.importance of pain control reiterated.bp stabilizing after signif. volume,weaning neo as tolerated. cuff now ~ 10 mm hg higher in lt. arm.\n"},{"category":"Nursing/other","chartdate":"2144-01-08 00:00:00.000","description":"Report","row_id":1418986,"text":"NEURO: A+Ox3. Pleasant. Following commands. Medicated w/ 2 darvocet for pain. Pt continued to have pain 2hours following darcocet. Pt requested percocet. 2 Given. Effect pending at this time.\n\nCV: Remains on Neo gtt for bp. Titrated to NBP. Pt w/ low PAP's and CVP. Continues to autodiurese >100cc hr. Notified Dr. . HR 90's. No ectopy. Palpable dp, dopplerable pt pulses. CI 3.03-3.19.\n\nRESP: Lungs are clear. Pt raised thick tan blood tinged secretions. SPo2 100 2L Np.\n\nGU: Brisk Uop >100c qhr.\n\nGI: Soft abd. Hypoactive bs. Nontender. Tolerating clear liquids.\n\nA/P Labile bp in the setting of low filling pressures and autodiurese.\n\nWean Neo as tol. ? more volume. Pulm toilet. Pain mgmt.\n\n"},{"category":"Nursing/other","chartdate":"2144-01-08 00:00:00.000","description":"Report","row_id":1418987,"text":"s/p cabg x 3 csru npn 7a-7p\ns-\"i'm anxious about getting up\"\no-neuro-intact\ncv-bp remains labile 60's-110's on neo gtt 1.5-2mcg/k/min.+dp/pt ble,hr 80's-100's nsr->st no vea.mediastinal/pleural ct's dc'd this pm,pa cath dc'd this pm.\nresp-ls cta decreased @ bases,c+db well w/ enc,o2 weaned to off,ra o2 sats97-99%.rr 18-20's nard.flovent mdi this pm.\ngi/gu-pt tol clear w/o diff,ate some fruit for lunch,u/o adeq amts clear yellow urine via foley cath.pt abd soft +hypoactive bs.\nskin-pt back and buttock grossly intact.\nsoc-pt wife and son visited this pm.\nendo-fsbs99-110\nid-afebrile\na-labile bp on neo gtt\np-vs,neo prn to maint sbp>90 map>60/tm,monitor resp status qs and prn,enc c+db wa,i+o,monitor skin integrity qs and prn,fsbs.\n"},{"category":"Nursing/other","chartdate":"2144-01-09 00:00:00.000","description":"Report","row_id":1418988,"text":"PT. SLEPT MOST OF THE NIGHT. NEO BEING WEANED SLOWLY TO MAP> 60.\nTAKING PO'S (PILLS) WITHOUT DIFFICULTY. PT. DENIES NEED FOR PAIN MED.\nDIURESING WELL; K+ REPLETED.\nPLAN: WEAN NEO TO OFF & TRANSFER TO FLOOR IF STABLE. DELINE CORDIS & ALINE. REPLETE K+ PRN. ENCOURAGE PULM TOILET.\n"},{"category":"Nursing/other","chartdate":"2144-01-09 00:00:00.000","description":"Report","row_id":1418989,"text":"CSRU Progress Note\nS/O: Neuro: A+O, med with percocet.\n CV: Neo .25 with BP 90s. ST 100-115. Walked with physical therapists, c/o dizziness with mom LOC, sat in chair with instant recovery. Stable transfer bed-chair.\n Resp: Room air.\n Renal: Foley out, voiding large amts.\n Heme: Aspirin.\n ID: Tmax 100.7, down after percocet.\n GI: Eating small amts.\n Endo: SSRI.\n Rehab: As above.\nA: Less neo. Poor exercise tolerance.\nP: Cont efforts to wean neo. Advance activity as tol, but monitor closely. Periph line and dc cordis.\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2144-01-07 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 814752,\n \"text\": \" 10:25 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ro ptx\\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\\\CORONARY ARTERY BYPASS GRAFT/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 63 year old man with\\n REASON FOR THIS EXAMINATION:\\n ro ptx\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 63 y/o male status post CABG. Rule out pneumothorax.\\n\\n COMPARISON: \\n\\n AP SUPINE SINGLE VIEW OF THE CHEST: ET tube is in good position. The Swan-\\n Ganz catheter tip is located in the right pulmonary artery. There is a left\\n chest tube. There are post operative changes of CABG with sternal wires and\\n mediastinal clips.\\n\\n There is a possible tiny right apical pneumothorax. There is no evidence of a\\n left pneumothorax. The NG tube is in the stomach.\\n\\n IMPRESSION:\\n\\n 1) Tubes and lines as described.\\n 2) Possible tiny right apical pneumothorax. No evidence of a left\\n pneumothorax.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2144-01-14 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 815456,\n \"text\": \" 11:09 AM\\n CHEST (PA & LAT) Clip # \\n Reason: s/p CABG w/decreased BS-r/o effusion/atelectasis\\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\\\CORONARY ARTERY BYPASS GRAFT/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 63 year old man with as above\\n REASON FOR THIS EXAMINATION:\\n s/p CABG w/decreased BS-r/o effusion/atelectasis\\n ______________________________________________________________________________\\n FINAL REPORT\\n\\n TWO VIEWS CHEST:\\n\\n INDICATION: Decreased breath sounds following CABG.\\n\\n COMPARISON made to cxr.\\n\\n There has been interval removal of various lines and tubes. Patient is s/p\\n median sternotomy and CABG. The heart size and mediastinal contours are\\n within normal limits. The pulmonary vascularity is normal. There is\\n interval improvement in degree of left lower lobe atelectasis with residual\\n area of atelectasis remaining in the retrocardiac region. Small pleural\\n effusions are noted bilaterally, left greater than right. No pneumothorax is\\n identified.\\n\\n IMPRESSION: Small pleural effusions and focal left basilar atelectasis\\n following CABG. Interval improvement in degree of atelectasis with prior\\n postoperative radiograph.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2144-01-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 261696,\n \"text\": \"Sinus tachycardia. Since the previous tracing of the heart rate has\\nincreased. There are T wave inversions in leads V3-V4. Clinical correlation is\\nsuggested.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2144-01-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 261697,\n \"text\": \"Sinus rhythm\\nNonspecific T wave flattening ( lll, aVL, V4-5 )\\nPoor R wave progression\\nSince previous tracing, T wave changes\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2144-01-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1418990,\n \"text\": \"A+Ox3, pleasantly following commands. Medicated w/ 2 percocet for pain. Weaned neo gtt off. Bp dropped to 82/51 Map 50's. Restarted Neo. Hr St 100's. No ectopy. Resp alkolotic. Pao2 65. Spo2 > 96%. Encouraged pt to CDB and IS. Raising small amts thick tan secretions. Voids in urinal. A/P Continuing to require neo. Continue to wean neo. Pulm toilet.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2144-01-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1418991,\n \"text\": \"FULL CODE Universal Precautions NKDA\\n\\n\\nNeuro/Cardiac: AAOx3, MAEx4 - OOB to chair, ambulated in hallx2. The first time he walked this am w/ PT, SBP down to 80/ (from 98-100s), but he became light-headed. Neo had been off since 7am. He sat in the chair and BP back to 90-100/ and he felt ok. Neo was not restarted. At 1330, Pt ambulated again w/o any difficulties. Maintained BP, no sx. BP at this time = 125/70. But pt is very anxious and will tell you so! Med w/ Percocet for insisional discomfort when back to bed after ambulating and RIJ cordis and chest dreassings redressed/pacer d/c'd. + periph pulses, trace edema, hands cool.\\n\\nResp: R/A w/ 02sat 95-98%. Lungs clear bilat, Good cough effort producing clear white sputum. Using IS to 1250.\\n\\nGU/GI: Abd soft, +BS, no BM. Taking diet fair, po fluids well. Voiding 400cc at a time via urinal.\\n\\nPlan: TX to floor when bed available. Continue to monitor cardiac/resp/neuro status. Monitor BP off neo. Med prn for incisional discomfort.\\n\\nAccess: RIJ cordic d/cl'd. #20PIV placed in RFA.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2144-01-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1418984,\n \"text\": \"extremely labile bp w wide swings from high 60's to mid 160's w increasing hr,continued low filling pressures w huge dilute appearing huo.multiple lr boluses given w transient effect.cuff correlates well. remains on neo as recorded. hct essentially unchanged despite lg. amts crystalloid.discussed w team,lr to continue for now. ct's w scant sero sang. dng sespite ooziness intra op.exrubation deferred,no cuff leak detected.lethargic,appropriate when awakened.telephone update to wife given.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2144-01-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1418985,\n \"text\": \"cuff leak + w vocalization around ett cuff. extubated to np's w/o incident. incisional splinting w cough pillow reinforced. c & r thick blood tinged tan.advanced to clear liqs,tolerated well. reluctant to take pain med but w incisional splinting/grimacing noted. refusing percocet & mso4 as he states it makes him \\\"loopy\\\". darvocet given.importance of pain control reiterated.bp stabilizing after signif. volume,weaning neo as tolerated. cuff now ~ 10 mm hg higher in lt. arm.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2144-01-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1418986,\n \"text\": \"NEURO: A+Ox3. Pleasant. Following commands. Medicated w/ 2 darvocet for pain. Pt continued to have pain 2hours following darcocet. Pt requested percocet. 2 Given. Effect pending at this time.\\n\\nCV: Remains on Neo gtt for bp. Titrated to NBP. Pt w/ low PAP's and CVP. Continues to autodiurese >100cc hr. Notified Dr. . HR 90's. No ectopy. Palpable dp, dopplerable pt pulses. CI 3.03-3.19.\\n\\nRESP: Lungs are clear. Pt raised thick tan blood tinged secretions. SPo2 100 2L Np.\\n\\nGU: Brisk Uop >100c qhr.\\n\\nGI: Soft abd. Hypoactive bs. Nontender. Tolerating clear liquids.\\n\\nA/P Labile bp in the setting of low filling pressures and autodiurese.\\n\\nWean Neo as tol. ? more volume. Pulm toilet. Pain mgmt.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2144-01-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1418987,\n \"text\": \"s/p cabg x 3 csru npn 7a-7p\\ns-\\\"i'm anxious about getting up\\\"\\no-neuro-intact\\ncv-bp remains labile 60's-110's on neo gtt 1.5-2mcg/k/min.+dp/pt ble,hr 80's-100's nsr->st no vea.mediastinal/pleural ct's dc'd this pm,pa cath dc'd this pm.\\nresp-ls cta decreased @ bases,c+db well w/ enc,o2 weaned to off,ra o2 sats97-99%.rr 18-20's nard.flovent mdi this pm.\\ngi/gu-pt tol clear w/o diff,ate some fruit for lunch,u/o adeq amts clear yellow urine via foley cath.pt abd soft +hypoactive bs.\\nskin-pt back and buttock grossly intact.\\nsoc-pt wife and son visited this pm.\\nendo-fsbs99-110\\nid-afebrile\\na-labile bp on neo gtt\\np-vs,neo prn to maint sbp>90 map>60/tm,monitor resp status qs and prn,enc c+db wa,i+o,monitor skin integrity qs and prn,fsbs.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2144-01-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1418988,\n \"text\": \"PT. SLEPT MOST OF THE NIGHT. NEO BEING WEANED SLOWLY TO MAP> 60.\\nTAKING PO'S (PILLS) WITHOUT DIFFICULTY. PT. DENIES NEED FOR PAIN MED.\\nDIURESING WELL; K+ REPLETED.\\nPLAN: WEAN NEO TO OFF & TRANSFER TO FLOOR IF STABLE. DELINE CORDIS & ALINE. REPLETE K+ PRN. ENCOURAGE PULM TOILET.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2144-01-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1418989,\n \"text\": \"CSRU Progress Note\\nS/O: Neuro: A+O, med with percocet.\\n CV: Neo .25 with BP 90s. ST 100-115. Walked with physical therapists, c/o dizziness with mom LOC, sat in chair with instant recovery. Stable transfer bed-chair.\\n Resp: Room air.\\n Renal: Foley out, voiding large amts.\\n Heme: Aspirin.\\n ID: Tmax 100.7, down after percocet.\\n GI: Eating small amts.\\n Endo: SSRI.\\n Rehab: As above.\\nA: Less neo. Poor exercise tolerance.\\nP: Cont efforts to wean neo. Advance activity as tol, but monitor closely. Periph line and dc cordis.\\n\\n\"\n }\n]"}}},{"rowIdx":376,"cells":{"subject_id":{"kind":"number","value":2365,"string":"2,365"},"hadm_id":{"kind":"number","value":198301,"string":"198,301"},"target_text":{"kind":"string","value":"The patient is a 48-year- old female with a history of HIV diagnosed on and HCV confection, since complicated by cirrhosis, portal hypertension and esophagovariceal hemorrhage. The patient underwent a prior transhepatic intraportal systemic shunt(TIPS) procedure and has had severe hepatic encephalopathy and recent recurrent hemorrhage. The patient was evaluated for a liver transplantation and was found to be a suitable candidate. She was brought to the operating room on /5 for an OLT. During the procedure It was difficult and ultimately not possible to fit the donor liver into the abdominal cavity of the patient. The decision to perform a portal caval shunt was made. And At this point, the patient was listed as a status 1 for liver transplantation. She remained in the operating room, receiving blood and blood products. During this time, she was oxygenating well and remained hemodynamically stable. Her coagulopathy was able to be corrected and maintained. A donor liver was made available and ultimately brought to the operating room. Successful OLT was perform patient was to the ICU, with no neurological deficit. Was extuated on transfered to the floor 2 days after. And this point is stable tolerating regular diet and tube feedings."},"extractive_notes_summ":{"kind":"string","value":"An inferior vena cava filter is again noted in an infrarenal position. Suboptimal evaluation of the hepatic vasculature. Stable appearance of right lower lobe collapse/consolidation and small right pleural effusion. Right pleural effusion with associated right lower zone atelectasis. A perihepatic drain exits in the right lower quadrant. Again note is made of bilateral pleural effusions with right lower lobe atelectasis. A right internal jugular venous access catheter is in place with the tip terminating at the level of the SVC/RA junction. FINDINGS: An endotracheal tube is in place with the tip terminating 3.1 cm from the carina. A Swan-Ganz catheter has been removed, and a right internal jugular catheter terminates in the superior vena cava. CT OF THE PELVIS WITH IV CONTRAST: A small amount of free fluid is noted within the pelvis. A nasogastric tube is present, and an IVC filter is noted. A small caliber left subclavian central venous catheter is present with the tip overlying the distal SVC. There is new hazy opacity at the right base with relative preservation of the right hemidiaphragm, findings that could be related to layering small pleural effusion at the right base. Mild (1+) aorticregurgitation is seen. FINDINGS: The endotracheal tube, left subclavian venous line, and right-sided drainage tube are unchanged compared to the prior study. SUPINE AP CHEST: The endotracheal tube, left internal jugular central venous catheter sheath, left subclavian central venous catheter, and NG tubes are unchanged in position. A right pleural effusion remains with associated compression atelectasis of the right lower lobe. A right internal jugular vascular catheter is unchanged in position. On the current study, a right pleural effusion layering posteriorly is well visualized. The right subdiaphragmatic drainage tube has been removed. Cardiac and mediastinal contours are within normal limits. SUPINE AP CHEST: The endotracheal tube, left internal jugular catheter sheath, right internal jugular Swan-Ganz catheter, left subclavian central line, NG tube, surgical drains, and IVC filter are unchanged in position compared to the prior exam. The cardiac and mediastinal contours are within normal limits. IMPRESSION: 1) Low position of right internal jugular vascular catheter, terminating within the lower portion of the right atrium. bp stable, tolerating ^ dose lopressor.resp status: weaned to cpap peep8 ps 18. bbs coarse to slt coarse after suctioning. CONDITION UPDATEPLEASE SEE CAREVUE FLOWSHEET FOR SPECIFICS.NEURO: PROPOFOL AND FENT GTT'S WEANED DOWN. SCANT SECRETIONS, CLEAR.CV: TMAX 100.9 THIS SHIFT. Incision C/D/I. FLUID BAL SL POS SINCE MN.GI: SBD SOFT. Tube feeding restarted through NG. Cont wean PSV. F/U CXR, U/S, CT RESULTS. INFORMED, PAN CX.ENDO: REMAINS ON INS GTT FOR FS CONTROL.PLAN: MONIOTR VS, LABS, RESP STATUS, NEURO STATUS. Plan to extub if am mechanics acceptable. Cont PSV/wean. Resp Care Note:Pt cont intub with OETT and on mech vent as per Carevue. Resp Care Note:Pt cont intub with OETT and on mech vent as per Carevue. Resp Care Note:Pt cont intub with OETT and on mech vent as per Carevue. Pt episode of ^RR/HR/BP and dropped Vt; increased PSV with good result; later returned to previous settings. TACHYCARDIC TO 130S. PA CATH CHANGED TO NON-HEPARIN COATED AND PLACEMENT CONFIRMED BY CXR MD . Scleral jaundice.ETT tube intact; tape changed. PROPOFOL RESUMED WITH IMPROVED VS. SEDATION WITH EFFECT.LUNGS COARSE BILAT. PERRL.RESP: LS CTA. BS coarse R>L. NGT WITH SM AMT CLEAR O/P. PRECEDEX DISCONTINUED D/T POOR EFFECT. COAGS STABLE.GI: ABD SOFT. Resp CarePt. FOCUS: STATUS UPDATEDATA:PT SEDATED ON PROPOFOL. SM AMT SECRETIONS VIA ETT SUCTION.CV: AFEBRILE. HYPOACTIVE BS. SUCTIONED FOR MODERATE AMOUNTS CLEAR SECRETIONS. LSC dual-lumen and left rad. HR 115-130, BP 110-120/80-85, and temp 38.4 oral (cooling blanket still on). WEAN OFF PROPOFOL AS ABLE. HYPOACTIVE BS.CONTINUES ON LASIX WITH GOOD EFFECT.PLAN:CONTINUE TO WEAN OFF VENT AS ABLE. Temp 99.9 oral. T-tube intact and draining moderate amounts bilious. D/C ALL HEPARIN. Resp. T-tube intact and draining bilious. CONTINUES ON CPAP WITH PS. Last ABG 730/36/159/18/-7/100. a-line extremely positional; going by cuff pressure.ETT intact. HCT stable. CONDITION UPDATEPLEASE SEE CAREVUE FLOWSHEET FOR SPECIFICS.NEURO: PT SEDATED ON PROPOFOL AND FENTANYL GTTS. to wean from vent and wean from propofol. FOCUS: STATUS UPDATEDATA:PT LIGHTLY SEDATED ON PROPOFOL DRIP. ABG STABLE.CONTINUES ON LASIX WITH GOOD EFFECT. CONDITION UPDATED.AFEBRILE,SR-ST,RR16-26,O2 SAT=99 ON 2L NP,BP 117-140/60. POSSIBLE EXTUBATION THIS AM.GI: ABD SOFT, NT/ND, +HYPO BOWEL SOUNDS, REMAINS NPO FOR POSSIBLE EXTUBATION THIS AM. SBP 90S-130.HCT 25.7 DR. STRTED ON IVF FOR U/O AND DUE TO PT REMAINING NPO. SVO2 RECAL'D. Resp CarePt. MEDS RESUMED (EXCEPT HEPARIN). NS 250CC X 2 GIVEN WITH MINIMAL EFFECT.ENDO-BS QID WITH SC COVERAGESKIN- TMAX 98.6 ABD STAPLES C/D/I OTA, T-TUBE DSG C/D/I, RLQ DSG INATCT ? care note - Pt. care note - Pt. secreations minimal thick.Plan: continue current support. NO DISTRESS NOTED.GI-ABD SOFT, SLIGHTLY DISTENDED, (+) BSX4, LG LOOSE BM X2, T-TUBE IN PLACE AND PATENT. ?POST-PYLORIC DOBHOFF PLACEMENT FOR TF TODAY. OLD DRAIN SITE.COMFORT-DENIES PAIN/DISC.A/P-CONTINUE WITH CURRENT CARE PLAN. Dr notified. INCISION REMAINS C/D/I W/ CLIPS. TOL CLRS (30CC/HR) WITHOUT DIFF. WEAN OFF O2 AS TOL. Respiratory Care:Pt. NO C/O OF PAIN EXCEPT AT 0400,PT C/O ABD PAIN AND CONFIRMED ABD CRAMPS..PT HAD STOOL,LOOSE X2 THRU THE NITE.A. remaines intubated and vented, transffered to CT and back to SICUB without incident. Last ABG: pH 7.38, PaCO2 51, PaO2 102, bicarb 31, BE 3. CXR TO BE DONE IN AM.GI: ABD SOFT NT/ND, HYPO BOWEL SOUNDS, TF IMPACT W/ FIBER AT 60CC/HR W/ GOAL RATE 90CC/HR, MINIMAL RESIDUALS. RESPONSE TO DIAMOX PENDING.ENDO: FSBG COVERED PER RISS.SKIN: SURGICAL ABD DSG INTACT. MDI'S Q4, SUCTIONING MINIMAL SECRECTIONS. Q4 CBC, Fibrinogen, PT, PTT, and ABG's. DUIRESE WITH DIAMOX AS ORDERED. Left femoral A-line tip sent for cx. SMA MT OLD SEROUS DRG. ARRIVED TO SICU, INTUBATED ON PROPOFOL AND NTG. LAST ABG 7.38/52/132/32/4/98. lungs exp wheeze/coarse/clear sx sm amt of thick tan secretions albuterol tx given cxr taken to determine reason for decreasing o2 sat, adjustments made as aboveCVS HR 127-107 ST without ectopy PAP s/D 61/36-50/31 CO 9.1 CI 5.2 CVP 16 bp 161/87-137/75 lopressor 5mg IV given x2 skin w+d pp+4 Hct 36.4GI abd soft BS absent Dsg D+I JP lat 70cc, T 75cc, JP med 22, ngt 200cc bilious, amylase 111, LDH 659, AST 735, ALT 927, alk phos 119."},"n_notes":{"kind":"number","value":102,"string":"102"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2179-03-11 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":857753,"text":" 3:24 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: confirm line positioning\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48F s/p liver txp, now s/p line replacment\n REASON FOR THIS EXAMINATION:\n confirm line positioning\n ______________________________________________________________________________\n FINAL REPORT\n Portable supine chest compared to previous study of earlier the same\n date.\n\n CLINICAL INDICATION: Line repositioning.\n\n FINDINGS:\n\n The examination is limited due to exclusion of the extreme lung apices from\n the radiograph.\n\n A left subclavian catheter has been advanced in the interval into the superior\n vena cava. A Swan-Ganz catheter has been removed, and a right internal\n jugular catheter terminates in the superior vena cava. Endotracheal tube\n remains in satisfactory position. A nasogastric tube is notable for the\n sideport above the GE junction level although the distal tip is in the\n stomach. There is patchy right lower lobe opacity, most suggestive of\n atelectasis. A drain is seen in the upper abdomen. No pneumothorax is\n identified on the supine study although exclusion of the extreme apices limits\n assessment for this finding.\n\n IMPRESSION:\n\n 1) Satisfactory position of vascular catheter. No pneumothorax on this\n limited study.\n\n 2) Proximal location of NG tube sideport, which should be advanced for more\n optimal placement.\n\n\n"},{"category":"Radiology","chartdate":"2179-03-07 00:00:00.000","description":"CTA ABD W&W/O C & RECONS","row_id":857175,"text":" 10:01 AM\n CTA ABD W&W/O C & RECONS; 200CC NON IONIC CONTRAST SUPPLY Clip # \n Reason: SPIKING TEMPS, OPEN FASCIA, S/P LIVER TRANSPLANT, EVALUATE FOR HEPATIC FLOW IN PHASES\n Admitting Diagnosis: LIVER FAILURE\n Field of view: 40 Contrast: OPTIRAY Amt: 200\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman with\n REASON FOR THIS EXAMINATION:\n CT abdomen ANGIOGRAM to evalaute for heptic flow in phases.ALSO CT abdomen to\n r/o abcess or collection.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Spiking fevers. Status post liver transplant.\n\n TECHNIQUE: Multidetector, multiphasic, helical axial imaging of the abdomen\n and pelvis before and after the administration of intravenous contrast.\n Coronal and sagittal reformatting.\n\n CONTRAST: 200 cc of Optiray intravenously. Nonionic contrast was administered\n due to the fast bolus requirement.\n\n COMPARISON: Direct comparison is made with the prior study dated . The\n most recent studies of and are unavailable for direct\n comparison at this time. The reports were reviewed. That are no comparison\n studies since the patient's liver transplant.\n\n CTA ABDOMEN WITH AND WITHOUT CONTRAST:\n\n The patient had suboptimal intravenous access, and a suitable peripheral IV\n could not be obtained. As a result, there is suboptimal timing of the\n contrast bolus, limiting the evaluation of the hepatic vascularture and\n particulary the hepatic artery. The celiac axis is grossly patent proximally.\n The hepatic and portal veins are grossly patent. There is a triangular\n irregularity in the region of the hepatic vein confluence, but this appearance\n may be projectional given the fact that it appears normal on the coronal and\n sagittal reconstructions. There is no hepatic perfusion defect detected. The\n periportal edema is a common post-transplant finding. The spleen remains\n enlarged. The pancreas, adrenal glands and kidneys are unremarkable. Small\n retroperitoneal nodes are present. There is no abnormal bowel wall thickening\n or bowel loop dilatation. There are minor scattered amounts of fluid without\n discrete collections. There is no free air.\n\n A perihepatic drain exits in the right lower quadrant. Another drain,\n possibly biliary, extends from the region of the porta and exits the anterior\n abdomen near the midline below the umbilicus. A nasogastric tube is present,\n and an IVC filter is noted.\n\n Limited imaging of the lung bases shows consolidation with air bronchograms in\n the right lung base, possibly representing pneumonia, particularly in the\n given clinical setting. A small right pleural effusion has developed.\n\n (Over)\n\n 10:01 AM\n CTA ABD W&W/O C & RECONS; 200CC NON IONIC CONTRAST SUPPLY Clip # \n Reason: SPIKING TEMPS, OPEN FASCIA, S/P LIVER TRANSPLANT, EVALUATE FOR HEPATIC FLOW IN PHASES\n Admitting Diagnosis: LIVER FAILURE\n Field of view: 40 Contrast: OPTIRAY Amt: 200\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n CT PELVIS WITH CONTRAST: A Foley catheter is present in the mostly\n decompressed bladder. There is mild presacral edema. The pelvic viscera are\n unremarkable. No pelvic mass, lymphadenopathy or fluid collection is detected.\n\n CT RECONSTRUCTIONS: Coronal and sagittal reformatting was performed for\n additional assessment of the abdominal and pelvic viscera. As stated above,\n the suboptimal intravenous access and bolus timing limits the evaluation of\n the hepatic vasculature. There is minimal scattered fluid without discrete\n collection.\n\n BONE WINDOWS: No suspicious lytic or blastic lesions are detected.\n\n IMPRESSION:\n 1. Suboptimal evaluation of the hepatic vasculature.\n 2. Persistent splenomegaly.\n 3. A small right pleural effusion. Right basilar consolidation may represent\n pneumonia, particularly in the given clinical scenario.\n\n\n"},{"category":"Radiology","chartdate":"2179-03-17 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":858446,"text":" 1:56 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate, plugging\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48F s/p liver txp, now with desats\n REASON FOR THIS EXAMINATION:\n eval for infiltrate, plugging\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE AP FILM:\n\n HISTORY: Liver transplant with oxygen desaturation.\n\n Endotracheal tube is 3 cm above the carina. Right jugular CV line is in right\n atrium. Suggest withdrawal 3-4 cm. NG tube is in stomach with distal\n end not included on the film. No pneumothorax. Allowing for technique, the\n heart size is normal. No evidence for CHF. There is a right sided pleural\n effusion with associated atelectasis in the right lower zone.\n\n IMPRESSION:\n\n Jugular CV line is in right atrium. No pneumothorax. Right pleural effusion\n with associated right lower zone atelectasis.\n\n\n"},{"category":"Radiology","chartdate":"2179-03-16 00:00:00.000","description":"BILAT LOWER EXT VEINS","row_id":858317,"text":" 2:08 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: please evaluate for DVT\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman with\n REASON FOR THIS EXAMINATION:\n please evaluate for DVT\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: Lower extremity swelling, assess for DVT.\n\n BILATERAL LOWER EXTREMITY VEINS ULTRASOUND: Grayscale and color Doppler\n images of both common femoral, superficial femoral, and popliteal veins were\n obtained. Normal waveforms, compressibility and augmentation are\n demonstrated. No intraluminal thrombus is identified.\n\n IMPRESSION: No evidence of lower extremity DVT.\n\n\n\n"},{"category":"Radiology","chartdate":"2179-03-17 00:00:00.000","description":"LIVER OR GALLBLADDER US (SINGLE ORGAN)","row_id":858492,"text":" 8:40 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOPP ABD/PEL\n Reason: ELEV LFTS, LIVER TX, ASSESS VASCULAR STRUCTURES\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman with HCV cirrhosis and varices admitted with hematemisis\n - now s/p redo tips - would like to re-eval tips to obtain baseline flow\n velocities\n REASON FOR THIS EXAMINATION:\n sp liver transplant asesse vascular structures\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post liver transplant with elevated LFTs.\n\n COMPARISON: Comparison is made to .\n\n TRANSPLANT ULTRASOUND WITH COLOR DOPPLER: -scale images show no focal or\n diffuse hepatic abnormalities. There is no evidence of intrahepatic bile duct\n dilatation. Trace amount of fluid around the liver in the Morison's pouch.\n\n Color Doppler images of the liver were obtained. The main, right, and left\n portal veins are patent with blood flow in the appropriate direction. The\n intrahepatic portions of the left and right hepatic arteries are also\n demonstrated with normal appearing waveforms. Resistive indices are\n 0.83-0.84. The main hepatic artery is patent. The hepatic veins and the\n inferior vena cava are patent.\n\n IMPRESSION:\n 1) The hepatic vessels are patent.\n 2) Trace amount of fluid around the liver.\n\n\n"},{"category":"Radiology","chartdate":"2179-03-16 00:00:00.000","description":"CT ABDOMEN W/CONTRAST","row_id":858349,"text":" 4:54 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: SP Liver tx please eval for intraabdominal abscess\n Admitting Diagnosis: LIVER FAILURE\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman with\n\n REASON FOR THIS EXAMINATION:\n SP Liver tx please eval for intraabdominal abscess\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post liver transplant. Evaluate for intraabdominal abscess.\n\n COMPARISON: .\n\n TECHNIQUE: MDCT acquired contiguous axial images from the lung bases to the\n pubic symphysis were obtained following the administration of 150 cc of IV\n Optiray. Nonionic contrast was administered secondary to patient request.\n\n CT OF THE ABDOMEN WITH IV CONTRAST: Again demonstrated is right lower lobe\n collapse/consolidation with air bronchograms, not significantly changed since\n the prior examination, along with a small right pleural effusion.\n Additionally, within the periphery of the right middle lobe, there is an ill-\n defined nodular opacity seen measuring approximately 1 cm. A second nodular,\n peripherally based opacity is also demonstrated within the right lower lobe\n which measures approximately 1.1 cm. Minor atelectatic changes are noted\n within the left lower lobe.\n\n Again, demonstrated within the transplanted liver are several tiny\n hypodensities, unchanged since the prior examination, too small to fully\n characterize. A mild amount of periportal edema is again noted. The portal\n vein is patent. There is no intrahepatic biliary ductal dilatation seen. A\n catheter is again noted, likely representing a biliary drain, extending from\n the region of the porta and exiting via the anterior abdomen near the\n umbilicus. The gallbladder is not visualized. Small amount of perihepatic\n fluid is present as well as fluid within pouch extending anterior\n to the duodenum; the amount of fluid has mildly increased since the prior\n exam. No focal fluid collections are identified. The spleen is stablely\n enlarged. The adrenal glands, kidneys, ureters, stomach, and loops of large\n and small bowel, all appear within normal limits. A nasogastric tube is\n identified with tip in the stomach. Multiple surgical clips are noted within\n the pericaval region, they are unchanged since the prior examination. An\n inferior vena cava filter is again noted in an infrarenal position. There is\n no definite evidence for bowel obstruction.\n\n CT OF THE PELVIS WITH IV CONTRAST: A small amount of free fluid is noted\n within the pelvis. The ureters, rectum, sigmoid colon are all within normal\n limits. A Foley catheter is again visualized within the bladder with a small\n amount of air. There is no pelvic or inguinal lymphadenopathy.\n (Over)\n\n 4:54 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: SP Liver tx please eval for intraabdominal abscess\n Admitting Diagnosis: LIVER FAILURE\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n Some soft tissue stranding is demonstrated along the right lateral\n subcutaneous tissues, likely related to postoperative changes.\n\n BONE WINDOWS: No suspicious lytic or sclerotic lesions are seen.\n\n IMPRESSION:\n 1. No definite focal fluid collections identified to suggest an abscess.\n\n 2. Stable appearance of right lower lobe collapse/consolidation and small\n right pleural effusion.\n\n 3. Two ill-defined nodular opacities identified within the right middle lobe\n and right lower lobe peripherally, which may represent an infectious etiology.\n\n 4. Mildly increased amount of fluid within pouch and anterior to\n the duodenum.\n\n 5. Stable splenomegaly.\n\n\n\n\n\n DFDdp\n\n"},{"category":"Radiology","chartdate":"2179-03-12 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":857820,"text":" 8:11 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pneumonia\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48F s/p liver txp, now s/p swan replacement\n\n REASON FOR THIS EXAMINATION:\n r/o pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 48-year-old female status post liver transplant. Please\n evaluate Swan-Ganz catheter placement.\n\n FINDINGS:\n\n Single AP view of the chest dated is compared with a single AP view\n of the chest dated . Endotracheal tube is 2.5 cm above the carina.\n The right internal jugular line terminates in the right atrium. The new left\n subclavian central line also terminates in the right atrium. The NG tube has\n been advanced, and its sideport is now located 3 cm distal to the GE junction.\n NG tube tip is in the body of the stomach. A drain remains in the right upper\n quadrant. There are skin staples overlying the mid abdomen. Clips and an IVC\n filter are seen in the mid abdomen.\n\n The lung volumes are low, likely secondary to technique. The lungs are clear\n without focal consolidation. There is no significant pulmonary venous\n congestion. There are no pleural effusions or pneumothorax. Heart and\n mediastinal contours remain unchanged.\n\n IMPRESSION:\n\n New left subclavian central line with its tip terminating in the right atrium.\n No pneumothorax. The lung fields are clear.\n\n\n\n"},{"category":"Radiology","chartdate":"2179-03-21 00:00:00.000","description":"NASO-INTESTINAL TUBE PLACEMENT (W/FLUORO)","row_id":858896,"text":" 3:29 PM\n -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # \n Reason: post pyloric tube\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n please place post piloric tube this am for feedings sp liver transplant\n\n REASON FOR THIS EXAMINATION:\n post pyloric tube\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Dobbhoff tube placed. Please advance to postpyloric position for\n feeding status post liver transplant. The patient has a history of\n aspiration.\n\n COMPARISON: Portable abdomen dated .\n\n The patient arrived in the department with a Dobbhoff tube in place, with the\n tip located within the stomach at the pylorus. Under fluoroscopic guidance,\n the tip of the tube was advanced into the postpyloric position, approximately\n into the third portion of the duodenum. Approximately 10 cc of nonionic\n contrast was instilled, confirming the tube's positioning within the duodenum.\n Surgical staples overly the skin of the abdomen, and there are surgical clips\n located within the right upper quadrant.\n\n IMPRESSION: Successful advancement of the Dobbhoff feeding tube into the\n third portion of the duodenum.\n\n"},{"category":"Radiology","chartdate":"2179-03-12 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":857906,"text":" 7:35 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval R TLC position\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48F s/p liver txp, now s/p line replacment\n\n REASON FOR THIS EXAMINATION:\n eval R TLC position\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post line replacement, evaluate triple lumen catheter\n position.\n\n COMPARISON: .\n\n TECHNIQUE: Single AP portable semiupright chest.\n\n FINDINGS: An endotracheal tube is in place with the tip terminating 3.1 cm\n from the carina. A nasogastric tube extends below the diaphragm, with the tip\n terminating below the borders of the radiograph. A right internal jugular\n venous access catheter is in place with the tip terminating at the level of\n the SVC/RA junction. Left subclavian venous access catheter with tip in the\n distal SVC. JP drain in the right upper quadrant. Surgical clips in the\n right upper quadrant. Inferior vena cava filter. Surgical skin staples\n overlying the mid abdomen. The heart size and mediastinal contours are\n unchanged. There is new hazy opacity at the right base with relative\n preservation of the right hemidiaphragm, findings that could be related to\n layering small pleural effusion at the right base. No pneumothorax. The\n osseous structures are unchanged.\n\n IMPRESSION:\n\n 1) Right internal jugular venous access catheter tip at the RA/SVC junction.\n The nasogastric tube has been advanced. Other lines and tubes are in\n unchanged position.\n\n 2) New hazy opacity at the right base, consistent with layering right pleural\n effusion.\n\n\n\n"},{"category":"Radiology","chartdate":"2179-03-19 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":858735,"text":" 3:17 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval tip position\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48F s/p liver txp, now S/P LINE EXCHANGE\n REASON FOR THIS EXAMINATION:\n eval tip position\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 48-year-old woman status post liver transplant, line exchange.\n\n TECHNIQUE: Portable AP chest radiograph.\n\n Comparison is made with the prior chest radiograph dated .\n\n FINDINGS: Right IJ line terminates at the junction of SVC and right atrium.\n No pneumothorax is identified. The patient has been extubated. The cardiac\n and mediastinal contours are unchanged. Again note is made of bilateral\n pleural effusions with right lower lobe atelectasis.\n\n IMPRESSION:\n\n Tubes and lines as described above. Persistent pleural effusion with right\n lower lobe atelectasis.\n\n"},{"category":"Radiology","chartdate":"2179-03-02 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":856645,"text":" 2:40 PM\n CHEST (PORTABLE AP) Clip # \n Reason: line placement\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year s/p liver transplant\n REASON FOR THIS EXAMINATION:\n line placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post liver transplant. Line placement.\n\n COMPARISON: .\n\n SUPINE AP CHEST: There is interval placement of an endotracheal tube, with\n the tip located approximately 5 cm from the carina. A right internal jugular\n Swan-Ganz catheter has been placed, with the tip overlying the expected main\n pulmonary artery. A left internal jugular central venous catheter sheath is\n present, with the tip overlying the left brachiocephalic vein. A small\n caliber left subclavian central venous catheter is present with the tip\n overlying the distal SVC. An NG tube is seen with the tip in the expected\n stomach. The cardiac and mediastinal contours are unchanged. There are\n bilateral effusions layering posteriorly, with associated left lower lobe\n atelectasis. Within the abdomen, there is a surgical drain within the right\n upper quadrant. There is also an inferior vena cava filter. No pneumothorax\n is detected on this supine radiograph.\n\n IMPRESSION:\n\n Status post liver transplant. Multiple tubes and lines as described. No\n pneumothorax detected.\n\n\n"},{"category":"Radiology","chartdate":"2179-03-01 00:00:00.000","description":"CHEST (PRE-OP PA & LAT)","row_id":856461,"text":" 7:28 AM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: LIVER FAILURE\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman with\n REASON FOR THIS EXAMINATION:\n pre-op\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: Preoperative assessment.\n\n Comparison is made to previous chest radiograph of .\n\n The heart size, mediastinal, and hilar contours are normal. Previously noted\n pulmonary vascular redistribution and perihilar haziness have resolved in the\n interval. There are no pleural effusions. Scoliosis is noted.\n\n IMPRESSION:\n\n No evidence of acute cardiopulmonary process.\n\n\n"},{"category":"Radiology","chartdate":"2179-03-06 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":857086,"text":" 9:01 AM\n CHEST (PORTABLE AP) Clip # \n Reason: follow up chf\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year s/p liver transplant\n\n REASON FOR THIS EXAMINATION:\n follow up chf\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 48-year-old female with status post liver transplant, follow up\n CHF.\n\n COMPARISON: .\n\n TECHNIQUE: AP upright single view of the chest.\n\n FINDINGS:\n\n There is a right IJ Swan-Ganz catheter with the tip in the pulmonary artery\n trunk. There is interval removal of the left IJ Cordis. The ET tube is\n located at the level of the thoracic inlet. There is an NG tube with the tip\n in the stomach. There is a left subclavian central line with the tip in the\n SVC. Cardiac, mediastinal, and hilar contours are unchanged when compared to\n prior study. There is interval slight improvement in the pulmonary edema.\n There is a right effusion. There is no evidence of pneumothorax. There are\n skin staples overlying the upper abdomen. There are multiple surgical clips\n in the right upper quadrant.\n\n IMPRESSION:\n Slight improvement of pulmonary edema. Lines and tubes as described above.\n\n\n"},{"category":"Radiology","chartdate":"2179-03-02 00:00:00.000","description":"DUPLEX DOP ABD/PEL LIMITED","row_id":856634,"text":" 1:53 PM\n DUPLEX DOP ABD/PEL LIMITED Clip # \n Reason: liver transplant duplex: hepatic artery, hepatic veins, port\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman with HCV cirrhosis and varices admitted with hematemisis -\n now s/p redo tips - would like to re-eval tips to obtain baseline flow\n velocities\n REASON FOR THIS EXAMINATION:\n liver transplant duplex: hepatic artery, hepatic veins, portal vein, blie duct\n dil, peri hepatic fluid\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: A 48-year-old woman with HCV cirrhosis and varices, status post\n liver transplant, for evaluation.\n\n TECHNIQUE: Duplex Doppler examination of the liver.\n\n FINDINGS: The echotexture of the liver is somewhat coarse. The main, right,\n and left hepatic arteries are patent with appropriate arterial flow, and\n resistive indices ranging from 0.53-0.61. The main, left, and right portal\n veins are patent and show appropriate hepatpetal flow on Doppler color and\n waveform examinations. The right, middle, and left hepatic veins are patent\n with appropriate directional flow.\n\n IMPRESSION: Appropriate flow in the major hepatic arteries and veins, and in\n major portal veins.\n\n"},{"category":"Radiology","chartdate":"2179-03-09 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":857456,"text":" 12:01 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval tip position\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48F s/p liver txp, now s/p swan replacement\n REASON FOR THIS EXAMINATION:\n eval tip position\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 48-year-old female status post liver transplant with placement\n of Swan-Ganz catheter. Please evaluate position of tip.\n\n FINDINGS:\n\n Single AP view of the chest dated is compared with the previous\n exam dated , also a single AP view. The tip of the Swan-Ganz\n catheter is positioned in the right lower lobe pulmonary artery. There has\n been interval improvement in the right pleural effusion. Overall, the degree\n of congestive heart failure has improved. The endotracheal tube is\n approximately 3 cm above the carina. The left subclavian central line tip\n terminates in the mid SVC. The NG tube terminates in the mid stomach. The\n cardiac, mediastinal, and hilar contours are essentially unchanged from the\n prior exam. There is a drain within the right upper quadrant. Skin staples\n overlie the upper abdomen.\n\n IMPRESSION:\n\n Swan-Ganz catheter in the right pulmonary artery. Interval improvement in the\n right pleural effusion. Improved CHF.\n\n\n"},{"category":"Radiology","chartdate":"2179-03-21 00:00:00.000","description":"PORTABLE ABDOMEN","row_id":858870,"text":" 2:01 PM\n PORTABLE ABDOMEN; -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: eval tip position\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48F s/p dobhoff placement\n REASON FOR THIS EXAMINATION:\n eval tip position\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Chest, single view.\n\n HISTORY: Status post Dobbhoff placement.\n\n FINDINGS: Feeding tube is present with tip probably in the first portion of\n the duodenum. Skin staples are present. There is some prominent loops of\n bowel that measure up to 5 cm. It is unclear if these are small or large\n bowel. There is a right pleural effusion.\n\n\n"},{"category":"Radiology","chartdate":"2179-03-10 00:00:00.000","description":"CHALNAGIOGRAPHY VIA EXISTING CATHETER","row_id":857613,"text":" 2:35 PM\n CHALNAGIOGRAPHY VIA EXISTING CATHETER Clip # \n Reason: evaluate biliary tree, please do to gravity, page with\n Admitting Diagnosis: LIVER FAILURE\n Contrast: OPTIRAY Amt: 15\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman s/p liver transplant with rising bilirubin\n REASON FOR THIS EXAMINATION:\n evaluate biliary tree, please do to gravity, page with questions\n ______________________________________________________________________________\n FINAL REPORT\n\n\n\n\n\n HISTORY: 48 year-old female status post liver transplant with elevated liver\n function tests. Please performe gravity injection tube cholangiogram.\n\n PROCEDURE/FINDINGS: The procedure was performed by Dr. and Dr.\n . Dr. , the staff radiologist, was present and supervising\n throughout. The patient was placed supine on the angiography table. Her\n abdomen was prepped and draped in the standard sterile fashion. A\n fluoroscopic spot film of the abdomen was obtained, demonstrating multiple\n surgical clips within the abdominal cavity, along with an IVC filter. A tube\n cholangiogram was then performed via gravity injection of nonionic contrast.\n This revealed opacification of the left and right hepatic ducts. The left\n hepatic duct appears mildly prominent. Upon further imaging, there was free\n but slow filling of the bowel lumen beyond the choledocho-jejunal anastomosis.\n No leak or stricture was identified. Following the cholangiogram, the\n contrast was gently aspirated from the catheter and the catheter was again\n placed to external bag drainage.\n\n COMPLICATIONS: None.\n\n CONTRAST: 15 cc of 60% Optiray.\n\n IMPRESSION: Tube cholangiography via the indwelling surgical T-tube\n demonstrates normal common and right hepatic ducts. There is mild prominence\n of the left hepatic duct. There was free but delayed emptying into the bowel\n lumen beyond the choledocho-jejunal anastomosis without evidence of narrowing\n or leak.\n\n These findings were discussed with the transplant surgery service at the time\n of the procedure.\n\n\n"},{"category":"Radiology","chartdate":"2179-03-04 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":856850,"text":" 10:40 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p OLT, ? fluid overload\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year s/p liver transplant\n\n REASON FOR THIS EXAMINATION:\n s/p OLT, ? fluid overload\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post liver transplant. Question fluid overload.\n\n COMPARISON: .\n\n SUPINE AP CHEST: The endotracheal tube, left internal jugular catheter\n sheath, right internal jugular Swan-Ganz catheter, left subclavian central\n line, NG tube, surgical drains, and IVC filter are unchanged in position\n compared to the prior exam. The Swan-Ganz catheter tip may be slightly\n retracted and within the main pulmonary artery. No pneumothorax is detected\n on this supine radiograph. The cardiac and mediastinal contours are stable.\n The lungs are relatively clear, without frank vascular congestion or\n consolidation present. The right pleural effusion is not as prominent on the\n current study.\n\n IMPRESSION:\n\n Relatively unchanged appearance of the chest compared to 12 hours previous.\n No evidence of frank fluid overload.\n\n\n"},{"category":"Radiology","chartdate":"2179-03-22 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":859003,"text":" 2:05 PM\n CHEST (PORTABLE AP) Clip # \n Reason: UPRIGHT FILM to eval right effusion\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48F s/p liver txp\n REASON FOR THIS EXAMINATION:\n UPRIGHT FILM to eval right effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 48-year-old female status post liver transplant. Single AP view\n of the chest dated , is compared to the same examination on\n . The right internal jugular central venous catheter is again\n seen terminating at the junction of the superior vena cava and right atrium.\n There is no pneumothorax. A Dobhoff nasogastric tube terminates in the third\n part of the duodenum. Cardiac and mediastinal contours are unchanged. There\n is interval improvement in the bilateral small pleural effusions. Right\n basilar atelectasis remains. There are no focal areas of opacity to suggest a\n consolidation. Splenomegaly.\n\n IMPRESSION:\n 1. Interval improvement in bilateral pleural effusions. Right basilar\n atelectasis.\n 2. No focal consolidations noted.\n 3. Splenomegaly.\n\n"},{"category":"Radiology","chartdate":"2179-03-05 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":856965,"text":" 7:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: monitor ? pleural effusion\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year s/p liver transplant\n\n REASON FOR THIS EXAMINATION:\n monitor ? pleural effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post liver transplant. Assess pleural effusion.\n\n COMPARISON: .\n\n SUPINE AP CHEST: The endotracheal tube, left internal jugular central venous\n catheter sheath, left subclavian central venous catheter, NG tube, and\n surgical drains are unchanged in position. The right internal jugular\n Swan-Ganz catheter tip has been advanced into the right main pulmonary artery.\n The cardiac and mediastinal contours are stable. On the current study, a\n right pleural effusion layering posteriorly is well visualized. Differences\n in the appearance of the right pleural effusion in the recent preceding exams\n is likely related to differences in patient positioning. No evidence of left\n effusion. The lungs are relatively well aerated, without vascular congestion\n or consolidation.\n\n IMPRESSION:\n\n Right pleural effusion. Differences in recent examinations likely reflects\n differences in patient positioning.\n\n\n"},{"category":"Radiology","chartdate":"2179-03-03 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":856811,"text":" 10:50 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: dropping sats\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year s/p liver transplant\n\n REASON FOR THIS EXAMINATION:\n dropping sats\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Portable chest .\n\n COMPARISON: To previous study of earlier the same date.\n\n INDICATION: Liver transplantation. Dropping oxygen saturation.\n\n FINDINGS:\n\n Various lines and tubes are in satisfactory position. Cardiac and mediastinal\n contours appear stable. Bilateral perihilar haziness is again demonstrated.\n There is an increasing pleural effusion on the right, small to moderate in\n size. Atelectatic changes are noted at the lung bases. With the exception of\n increasing pleural effusion on the right, there has otherwise been no\n significant change. Postoperative changes are noted in the abdomen.\n\n IMPRESSION:\n\n Increasing right pleural effusion with otherwise stable chest radiographic\n appearance.\n\n\n"},{"category":"Radiology","chartdate":"2179-03-18 00:00:00.000","description":"BX-NEEDLE LIVER BY RADIOLOGIST","row_id":858555,"text":" 9:32 AM\n BX-NEEDLE LIVER BY RADIOLOGIST Clip # \n Reason: r/o rejection\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48F HCV cirrhosis s/p OLT with rising LFTs\n REASON FOR THIS EXAMINATION:\n r/o rejection\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: Status post liver transplant, now with rising liver\n function tests. The patient presents for ultrasound-guided liver biopsy.\n\n The proposed procedure was explained in detail with the patient's sister, who\n serves as her healthcare proxy. The potential risks and benefits of the\n procedure were discussed. Signed consent was then obtained from the patient's\n sister. timeout was employed to verify the patient's identity\n and the planned biopsy site.\n\n LIVER BIOPSY BY RADIOLOGIST: The procedure took place within the surgical\n intensive care unit. An appropriate spot was marked on the skin of the\n patient's anterior abdomen, overlying the anterior aspect of the liver\n transplant, using son localization. The area was then prepped and\n draped in the standard sterile fashion. Local anesthesia was achieved with 1%\n lidocaine. Using continuous son guidance, a single 18-gauge core\n biopsy of the transplanted liver was obtained. The patient tolerated the\n procedure well without any immediate post-procedure complications. The\n specimen was immediately transported to pathology for further analysis.\n\n Dr. , the staff radiologist, was present and supervised the entire\n procedure.\n\n IMPRESSION: Successful 18-gauge core biopsy of a transplanted liver.\n\n\n\n"},{"category":"Radiology","chartdate":"2179-03-16 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":858249,"text":" 9:01 AM\n CHEST (PORTABLE AP) Clip # \n Reason: slow weaning off vent. ? pna\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48F s/p liver txp, now s/p line replacment\n\n REASON FOR THIS EXAMINATION:\n slow weaning off vent. ? pna\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 48-year-old woman status post liver transplant with replacement\n of central line. Difficulty weaning off the ventilator.\n\n Single AP view of the chest dated is compared with a single AP\n view of the chest from . An endotracheal tube terminates 3.5 cm\n above the carina. The NG tube terminates below the diaphragm, however, the\n tip courses off the imaged portion of the film. The left subclavian central\n line has been removed. A right interval jugular central line terminates in\n the right atrium. The right subdiaphragmatic drainage tube has been removed.\n Clips are present in the mid-right abdomen. Skin staples are seen overlying\n the mid-abdomen.\n\n There are no focal areas of opacity to suggest consolidation. A right pleural\n effusion remains with associated compression atelectasis of the right lower\n lobe. The heart size and mediastinal contours are unchanged. There is no\n pneumothorax. The osseous structures are unchanged.\n\n IMPRESSION:\n 1. Persistent right-sided pleural effusion with associated right lower lobe\n compression atelectasis. No focal areas of consolidation to suggest\n pneumonia.\n 2. Tubes and lines changed as above.\n\n\n"},{"category":"Radiology","chartdate":"2179-03-11 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":857687,"text":" 7:30 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval changes\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48F s/p liver txp, now s/p swan replacement\n REASON FOR THIS EXAMINATION:\n interval changes\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 48-year-old female with liver transplant. Swan-Ganz catheter\n placement.\n\n TECHNIQUE: Portable AP chest radiograph.\n\n The comparison is made with a prior chest radiograph dated .\n\n FINDINGS:\n\n The endotracheal tube, left subclavian venous line, and right-sided drainage\n tube are unchanged compared to the prior study. Swan-Ganz catheter is\n terminating in the right interlobar pulmonary artery. Left apex is not\n included in the present study; however, no pneumothorax is noted. The cardiac\n and mediastinal contours are within normal limits. No consolidation noted.\n\n IMPRESSION:\n\n Tubes and lines as described above. Swan-Ganz catheter terminating in the\n right interlobar pulmonary artery. Left apex is not included in the present\n study.\n\n\n"},{"category":"Radiology","chartdate":"2179-03-04 00:00:00.000","description":"P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT","row_id":856846,"text":" 9:11 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT; -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOPP ABD/PEL\n Reason: transplant liver. assess portal vein, hepatic vein, hepatic\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman with HCV cirrhosis and varices admitted with hematemisis -\n now s/p redo tips - would like to re-eval tips to obtain baseline flow\n velocities\n REASON FOR THIS EXAMINATION:\n transplant liver. assess portal vein, hepatic vein, hepatic artery, and bile\n ducts.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: Recent history of a liver transplant, assess bile ducts\n and blood flow.\n\n COMPARISONS: Liver ultrasound of .\n\n LIVER ULTRASOUND WITH COLOR DOPPLER: Grayscale images show no focal or\n diffuse hepatic abnormalities. There is no evidence of intrahepatic ductal\n dilatation. No perihepatic fluid collections are identified.\n\n Color Doppler images of the liver were also obtained. The main, right, and\n left portal veins are patent, with blood flow in the appropriate direction.\n Velocities within the main portal vein ranged from 60-80 cm/sec. The\n intrahepatic portions of the left and right hepatic arteries also demonstrate\n normal-appearing waveforms, with brisk upstrokes. The resistive indices range\n from 0.62-0.77. The main hepatic artery is patent. The hepatic veins and\n inferior vena cava are also patent, with flow in the appropriate direction.\n\n IMPRESSION: Son appearance of the transplant liver is within normal\n limits. Patent intrahepatic vasculature, as discussed above.\n\n These findings were discussed with the surgical house staff caring for the\n patient at the time of the exam on .\n\n\n\n"},{"category":"Radiology","chartdate":"2179-03-03 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":856711,"text":" 7:49 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for pulm edema\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year s/p liver transplant\n\n REASON FOR THIS EXAMINATION:\n evaluate for pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post liver transplant. Evaluate for pulmonary edema.\n\n COMPARISON: .\n\n SUPINE AP CHEST: The endotracheal tube, left internal jugular central venous\n catheter sheath, left subclavian central venous catheter, and NG tubes are\n unchanged in position. The right internal jugular Swan-Ganz catheter is\n probably unchanged in position, though multiple wires overlie the region of\n interest on this exam. The surgical clips and drain are unchanged as well.\n The cardiac and mediastinal contours are stable. There is no definite\n evidence of pulmonary edema, appearance of the lungs and vasculature is\n unchanged from one day ago. No pleural effusions identified. No pneumothorax\n identified.\n\n IMPRESSION:\n\n No evidence of pulmonary edema. The appearance of the chest is unchanged from\n one day ago.\n\n\n"},{"category":"Radiology","chartdate":"2179-03-24 00:00:00.000","description":"NASO-INTESTINAL TUBE PLACEMENT (W/FLUORO)","row_id":859326,"text":" 4:25 PM\n -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # \n Reason: please plase post-pyloric Dobhoff on AM.\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman s/p OLT, needing post-pyloric Dobhoff\n REASON FOR THIS EXAMINATION:\n please plase post-pyloric Dobhoff on AM.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: A 48-year-old woman status post liver transplant requiring\n postpyloric feeding tube.\n\n PROCEDURE AND FINDINGS: After coating the weighted feeding tube with\n lidocaine jelly, the tube was advanced through the right nostril into the\n stomach. Air and 5 cc of Conray were infused to elucidate the gastric\n anatomy. The wire was then replaced and the tube was advanced into the\n duodenum and past the ligament of Treitz. The wire was removed. Final\n injection of contrast demonstrated appropriate positioning of the tube tip in\n the proximal jejunum. The tube was secured with tape. The patient tolerated\n the procedure well and there are no immediate post-procedural complications.\n\n IMPRESSION: Successful placement of nasojejunal feeding tube.\n\n\n"},{"category":"Radiology","chartdate":"2179-03-30 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":859975,"text":" 9:27 AM\n CHEST (PORTABLE AP) Clip # \n Reason: sp guide wire line\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n sp liver tx/ wire line\n REASON FOR THIS EXAMINATION:\n sp guide wire line\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Guide wire line placement.\n\n Comparison .\n\n A right internal jugular vascular catheter is present, terminating in the\n lower portion of the right atrium. There is no pneumothorax. A feeding tube\n terminates in the duodenum. Cardiac and mediastinal contours are within\n normal limits. There is improving opacity at the right base with minimal\n residual patchy opacity remaining. The lungs are otherwise clear.\n\n IMPRESSION:\n\n 1) Low position of right internal jugular vascular catheter, terminating\n within the lower portion of the right atrium. No pneumothorax.\n\n 2) Resolving right basilar opacity, most likely due to atelectasis.\n\n\n"},{"category":"Radiology","chartdate":"2179-03-30 00:00:00.000","description":"ABDOMEN (SUPINE & ERECT)","row_id":860053,"text":" 4:46 PM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: assess for obstruction\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman with diarrhea s/p liver transplant\n REASON FOR THIS EXAMINATION:\n assess for obstruction\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 48-year-old woman with diarrhea status post liver transplant.\n\n SUPINE AND UPRIGHT ABDOMEN: There is a normal bowel gas pattern without\n evidence of dilatation or obstruction. There is no free intraperitoneal air.\n A feeding tube is seen with the tip in the third portion of the duodenum. A\n TrapEase IVC filter is noted. Surgical clips are seen within the right upper\n quadrant of the abdomen. A surgical tube is seen with the tip terminating in\n the right upper quadrant. Osseous structures are remarkable for degenerative\n changes at the lower lumbar spine.\n\n IMPRESSION: Normal bowel gas pattern without evidence of obstruction.\n\n\n"},{"category":"Radiology","chartdate":"2179-03-29 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":859804,"text":" 6:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please perform a thoracoabdominal film. For feeding tube pos\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48F s/p liver txp\n\n REASON FOR THIS EXAMINATION:\n please perform a thoracoabdominal film. For feeding tube position\n ______________________________________________________________________________\n FINAL REPORT\n This is a portable chest .\n\n COMPARISON: .\n\n INDICATION: Feeding tube placement.\n\n The radiograph was obtained centered at the thoracoabdominal junction for\n feeding tube assessment. It demonstrates a feeding tube within the duodenum.\n A right internal jugular vascular catheter is unchanged in position. Cardiac\n and mediastinal contours are stable. A small right pleural effusion and\n patchy right basilar opacity are unchanged allowing for positional\n differences.\n\n IMPRESSION: Feeding tube terminates within the duodenum.\n\n\n"},{"category":"Echo","chartdate":"2179-03-05 00:00:00.000","description":"Report","row_id":100266,"text":"PATIENT/TEST INFORMATION:\nIndication: Tachycardia. Assess left ventricular function.\nHeight: (in) 62\nWeight (lb): 165\nBSA (m2): 1.76 m2\nBP (mm Hg): 123/74\nHR (bpm): 142\nStatus: Inpatient\nDate/Time: at 13:57\nTest: Portable TTE (Complete)\nDoppler: Full doppler and color doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or pacing wire is\nseen in the RA and/or RV.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function\n(LVEF>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No valvular\nAS. The increased transaortic gradient related to high cardiac output. Mild\n(1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Trivial MR.\n\nTRICUSPID VALVE: Tricuspid valve not well visualized.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Resting\ntachycardia (HR>100bpm).\n\nConclusions:\nThe patient is tachycardic. The left atrium is normal in size. Left\nventricular wall thickness, cavity size, and systolic function are normal\n(LVEF>55%). Right ventricular chamber size and free wall motion are normal.\nThe aortic valve leaflets (3) are mildly thickened but aortic stenosis is not\npresent. There is no valvular aortic stenosis. The increased transaortic\ngradient is likely related to high cardiac output. Mild (1+) aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. There\nis no mitral valve prolapse. Trivial mitral regurgitation is seen. There is no\npericardial effusion.\n\nCompared with the findings of the prior study (tape reviewed) of , other\nthan the tachycardia, probably no significant change.\n\n\n"},{"category":"ECG","chartdate":"2179-03-12 00:00:00.000","description":"Report","row_id":276275,"text":"Sinus tachycardia. Borderline low voltage in the limb leads. Compared to the\nprevious tracing of the rate has slowed. Although, tachycardia persists.\n\n"},{"category":"ECG","chartdate":"2179-03-11 00:00:00.000","description":"Report","row_id":276276,"text":"Sinus tachycardia. Otherwise, probably normal ECG. Since the previous tracing\nof sinus tachycardia rate has increased.\n\n\n"},{"category":"ECG","chartdate":"2179-03-08 00:00:00.000","description":"Report","row_id":276277,"text":"Sinus tachycardia\nNormal ECG except for rate\nSince previous tracing of , increased heart rate\n\n"},{"category":"ECG","chartdate":"2179-03-01 00:00:00.000","description":"Report","row_id":276278,"text":"Normal sinus rhythm. Normal ECG. Compared to the previous tracing of \nno significant change.\n\n"},{"category":"Nursing/other","chartdate":"2179-03-09 00:00:00.000","description":"Report","row_id":1293270,"text":"D:See carevue flowsheets for specifics\nNeuro:Pt remains unresponsive on propofol and fentynal drips. Both increased overnoc for resp inconsistent MVs and Hypertensive and tachycardic.\nCV:Hyperdynamic state with temp max 102.4. Pt pan cultured (Blood line and venipuncture, urine and sputum). Hypothermia blanket on at 0300. SBP 200+ and tachy up to 140, lopressor given as ordered.\nResp:No vent changes overnoc. Increased sedation to prevent MV inconsistencies with vent despite suctioning.\nGI:BS hypoactive s/p closure of fascia . Abd dsg reinforcedx1, small am't of serosang drg.\nGU:Additional lasix 40mg IVP for elevated PA#s and cvp #s.\nFamily: called and wanted to know what time pt would be weaned from sedation today. He will call this am. Do not weaning sedation as SBP hypertensive if prop is decreased.\nPlan/Goals:Normothermic-Use hypothermia blanket, tepid baths.\nNormotensive: Lopressor as ordered. Maintain fluid balance even.\nFamily coping-provide explanation concerning realistic expectations while pt in ICU.\n"},{"category":"Nursing/other","chartdate":"2179-03-09 00:00:00.000","description":"Report","row_id":1293271,"text":"CONDITION UPDATE\nPLEASE SEE CAREVUE FLOWSHEET FOR SPECIFICS.\nNEURO: PROPOFOL AND FENT GTT'S WEANED DOWN. WITH PROP NEARLY OFF, PT OPENED EYES TO VOICE. DID NOT FOLLOW COMMANDS. PERRL. LOCALIZED WITH ALL EXTREMTITIED ON BED TO TRAP SQUEEZE. PROPOFOL INCREASED THIS EVE FOR PT COMFORT ON VENT.\nRESP: LS CTA. VENT CHANGED TO CPAP WITH 8PEEP AND 16 PS, BUT PT DID NOT TOL, BECOMMING TACHYPNEIC, LABORED, LOW TV'S, TACHYCARDIC AND HYPERTENSIVE TO 200S SYS. PROPOFOL INCREASED AND VENT RETURNED TO CMV. REATTEMPTING PS THIS EVE WITH LIGHTER PROPOFOL THAN THIS AM. BP, HR AND RR STABLE, PA NUMBERS DECREASED WITH 16 PS, AND TV'S > 450. ABG PENDING. PT THIS AFTERNOON. SCANT SECRETIONS, CLEAR.\nCV: TMAX 100.9 THIS SHIFT. COOLING BLANKET REMOVED D/T SL MOTTLING OF SKIN AT LEGS. SICU TEAM WITNESSED. ICE TO AXILLA FOR TEMP CONTROL. TACHYCARDIC TO 130S. METOPROLOL STARTED AND DOSE INCREASED TO EFFECT. PA CATH CHANGED TO NON-HEPARIN COATED AND PLACEMENT CONFIRMED BY CXR MD . CO DECREASED AS COMPARED WITH LAST SEVERAL DAYS. LASIX DOSE INCREASED WITH SOME EFFECT ON U/O AND MIN EFFECT ON PA#S. FLUID BAL SL POS SINCE MN.\nGI: SBD SOFT. NO BM. CLEAR OUTPUT VIA NGT.\nGU: CLEAR AMBER U/O.\nSKIN: DRESSING INTACT WITH OLD STAINING. T-TUBE WITH MOD AMTS DK AMBER O/P. JP WITH SM AMTS DK MAROON O/P. NO S/S BREAKDOWN AT PT'S BACK OR HEELS.\nPLAN: ASSESS TOLERANCE OF CPAP. AWAIT ABG RESULTS. WEAN SEDATIONAS TOLERATED. ? EXTUBATE TOMORROW. MONITOR HEMODYNAMICS. TREAT TACHYCARDIA AND HTN WITH LOPRESSOR. DIURESE AS ORDERED. EXPECT FLUID MOBILIZATION ON NEXT 2 DAYS. EMOTIONAL SUPPORT TO FAMILY.\n"},{"category":"Nursing/other","chartdate":"2179-03-16 00:00:00.000","description":"Report","row_id":1293294,"text":"PLEASE REFER TO CAREVUE FOR COMPLETE ASSESSMENT AND SPECIFICS.\n\nNEURO: PROPOFOL STOPPED THIS AM AND REMAINS OFF FOR THE REST OF THE DAY. PT ALERT, FOLLOWING SIMPLE COMMANDS, MAE SPONT/PURP, PERL. DOZING INTERMITTENTLY.\n\nCV: HR 101-121 ST, NO ECTOPY. SBP 124-157 W/ MAP>60. CVP 4-6. BIL LE'S U/S OBTAINED TO R/O DVT, F/U REPORT.\n\nRESP: LUNG SOUNDS COARSE, SXN AS NEDED FOR THICK YELLOW SECRETIONS. VENT SETTINGS CURRENTLY CPAP+PS 5PEEP /10 PS( PS WEANED FROM 15-10),RR 14-22, FIO2 40%, TV 400'S. ABG 7.38/46/148/28/1/98. O2 SAT 99-100%. CXR DONE, F/U RESULTS.\n\nGI: ABD SOFTLY DISTENDED, HYPO BOWEL SOUNDS, TF STARTED IMPACT W/ FIBER AT 20CC/HR W/ GOAL 90CC/HR, INC BY 20CC/HR Q6 HRS, NO RESIDUALS.\nT-TUBE DRAINING CLEAR DARK AMBER FLUID. CT ABD AND PELVIS DONE, F/U RESULTS.\n\nGU: FOLEY DRAINING CLEAR AMBER URINE, LASIX 20MG IVP X2 W/ GOOD DIURESIS.\n\nID: TMAX 101.7, DR. INFORMED, PAN CX.\n\nENDO: REMAINS ON INS GTT FOR FS CONTROL.\n\nPLAN: MONIOTR VS, LABS, RESP STATUS, NEURO STATUS. F/U CXR, U/S, CT RESULTS. ADVANCE TF TO GOAL. ?ATTEMPT TO WEAN VENT DOWN FOR POSSIBLE EXTUBATION TOMORROW AND STOP TF AT 4AM. CONT CURRENT MGMT.\n"},{"category":"Nursing/other","chartdate":"2179-03-17 00:00:00.000","description":"Report","row_id":1293295,"text":"Resp Care Note:\n\nPt cont intub with OETT and on mech vent as per Carevue. Lung sounds coarse with rhonchi improving with suct for mod th sput. Pt in NARD on current vent settings; no vent changes made overnoc. Cont wean PSV.\n"},{"category":"Nursing/other","chartdate":"2179-03-17 00:00:00.000","description":"Report","row_id":1293296,"text":"FOCUS: STATUS UPDATE\nDATA:\nPT ALERT AND RESPONDING TO HER NAME. FOLLOWING COMMANDS AND MOVING ALL EXTREMITIES IN BED WITH UPPER EXTREMITIES VERY WEAK.\n\nLUNGS COARSE BILATERALLY WITH SCATTERED RHONCHI IMPROVING WITH SUCTIONING OF THICK SPUTUM. CONTINUES ON 10 PS, NO VENT CHANGES OVERNIGHT.\n\nABDOMEN SOFT WITH HYPOACTIVE BOWEL SOUNDS. TOLERATED TUBE FEEDS WITH MINIMAL RESIDUALS UNTIL 0400. STOPPED IN PREPERATION FOR POSSIBLE AM EXTUBATION. INCISIONAL ABD STAPLES DRY AND INTACT, OPEN TO AIR. T TUBE WITH BILIOUS OUTPUT.\n\nLASIX X1 OVERNIGHT FOR NEGATIVE I/O GOAL OF 1L WHICH WAS ATTAINED.\n\nPLAN:\nWEAN AND EXTUBATE IF POSSIBLE, OTHERWISE TRACH TO BE CONSIDERED. F/U CT SCAN RESULTS.\n"},{"category":"Nursing/other","chartdate":"2179-03-17 00:00:00.000","description":"Report","row_id":1293297,"text":"Respiratory Care\n\n Pt continues on PSV weaned as documented. In NARD. B/S equal dim at bases. Suctioned for min amount thick yellow. Plan ? extubation in A.M. Will continue to follow closely.\n"},{"category":"Nursing/other","chartdate":"2179-03-17 00:00:00.000","description":"Report","row_id":1293298,"text":"Nursing\nSee flowsheet for details.\n\nPt. had uneventful day. HR remained 100-115 NSR, no ectopy. BP 115-150/75. T. max 99.9 oral. Tube feeding restarted through NG. Hypoactive BS; max residual 30cc. TPN d/c. Insulin gtt cont. Incision C/D/I. Good urine output. Goal of -1000cc fluid balance; received two doses of lasix. Cont. to medicate prn with fentanyl. Family in to visit today.\n\nPlan to cont. to wean for possible extubation in a.m. Also plan for pt. to be NPO after midnight.\n"},{"category":"Nursing/other","chartdate":"2179-03-13 00:00:00.000","description":"Report","row_id":1293281,"text":"Resp Care Note:\n\nPt cont intub with OETT sedated and on mech vent as per Carevue. Lung sounds coarse with rhonchi improving with suct for mod th tan/brown sput. ABGs metabolic acidosis with good oxygenation; adjusting vent to help increase pH. Cont mech vent support.\n"},{"category":"Nursing/other","chartdate":"2179-03-13 00:00:00.000","description":"Report","row_id":1293282,"text":"STATUS\nD: REMAINS ON FENT/PROPOFOL/INSULIN GTT'S..OPENS EYES TO NAME..WILL FOLLOW SOME SIMPLE COMMANDS\nA: FENT GTT DC'D & STARTED ON PRN DOSE..TOL WELL..JP DC'D SITE OOZING SEROUS DSD APPLIED..LF SUBCL LINE DC'D & TIP SENT FOR CULT..PROPOFOL @ 30MCG..INSULIN GTT @ 5-7U TO KEEP BS <120..LASIX GIVEN X1 WITH GOOD EFFECT..INCT MOD AMT MUCOID STOOL..FIB PLACED..STARTED ON TF'S @ 10CC/H INITIALLY WILL CHECK RESIDUALS Q6H..NO VENT CHANGES ABG'S ACIDOTIC GIVEN 2 AMPS BICARB GIVEN WITH IMPROVEMENT\nR: STABLE\nP: WILL ATTEMPT VENT WEAN IN AM..MONITOR LABS Q6..BS'S Q1-2H REGULATE INSULIN GTT ACCORDINGLY\n\n"},{"category":"Nursing/other","chartdate":"2179-03-14 00:00:00.000","description":"Report","row_id":1293283,"text":"Resp Care Note:\n\nPt cont intub with OETT and on mech vent as per Carevue. Lung sounds coarse with rhonchi improving with suct sm=>mod th tan sput. Pt switched to PSV and tol well on present settings; ABGs ess unchanged on PSV. Cont PSV/wean.\n"},{"category":"Nursing/other","chartdate":"2179-03-14 00:00:00.000","description":"Report","row_id":1293284,"text":"Update\nO: cv status: to sr w lopressor ^'d to 50mg . bp stable, tolerating ^ dose lopressor.\n\nresp status: weaned to cpap peep8 ps 18. bbs coarse to slt coarse after suctioning. abg unchanged mild acidosis\n\nneuro status: sedated on propfol, arousable to voice and following simple commands.perl 2-3mm.\n\ngi status: tol tf's ^ to 20cc/hr w min resids . incont loose mucoid stool-> fib bag.\nglucoses managed w insulin gtt.\ngu status: huo qs amber urine via foley.\n\nheme/id: am labs sent results pending.\n sin: mid abd incision site dry. oozy around old jp site-> ostomy bag to measure and contain drng. ttube to w bilious drng.\nA/P: weaning from vent wean peep and ps as tol.\ncheck am lab results & rx as ordered any lyte imbalance.titrate tf toward goal 45 cc/hr nepro.\n"},{"category":"Nursing/other","chartdate":"2179-03-14 00:00:00.000","description":"Report","row_id":1293285,"text":"STATUS\nD: REMAINS ON PROPOFOL & INSULIN GTT'S..EASILY AROUSED FOLLOWS SIMPLE COMMANDS WITH MUCH ENCOURAGEMENT..MOVES ALL EXTREM'S\nA: PROPOFOL DECREASED TO 20MCG..VENT WEANED TO C-PAP WITH 0 IPS TOL WELL FOR FEW HOURS BUT THEN TIRED WITH RR 30'S..BP 150/'S..HR 120-130'S PLACED BACK ON IPS 5..GOOD SAT'S & ABG'S..RESTING COMF NOW.. SUCTIONED FOR MOD AMT THIN /YELLOW..SUCTIONED FOR COPIOUS AMT ORAL SECREATIONS..TF'S ON HOLD FOR HIGH RESIDUALS..FIB INTACT SM AMT MUCOID STOOL..ADQUATE HUO'S..OOZING LGE AMT FROM JP SITE STITCH PLACED BY HO..NO FURTHER OOZING NOTED..T TUBE DRAINING MOD AMT BILIOUS\nR: STABLE\nP: CONTINUE TO WEAN AS TOL..? EXTUBATE IN NEXT COUPLE OF DAYS\n"},{"category":"Nursing/other","chartdate":"2179-03-14 00:00:00.000","description":"Report","row_id":1293286,"text":"Respiratory Care\nPt spent a few hours on SBT, back on for increased rr, and hr. Suctioning large amts of thick yellow.\n"},{"category":"Nursing/other","chartdate":"2179-03-15 00:00:00.000","description":"Report","row_id":1293287,"text":"Resp Care Note:\n\nPt cont intub with OETT and on mech vent as per Carevue. Lung sounds coarse suct sm=>mod th off sput. ABGs resp acidosis with good oxygenation. Pt episode of ^RR/HR/BP and dropped Vt; increased PSV with good result; later returned to previous settings. Plan to extub if am mechanics acceptable.\n"},{"category":"Nursing/other","chartdate":"2179-03-15 00:00:00.000","description":"Report","row_id":1293288,"text":"Update\nO: Arousable,follows simple commands w stim. mae to command. w htn improved w ^ lopressor dosing & fentanyl for pain/discomfort.GI: abd soft no active bowel snds,Tf's on hold for potential extubation this a.m.Glucoses managed w insulin gtt. huo qs amber urine w brisk diuresis w lasix 20 iv.\n\nA/P: Wean vent? extub today.Follow glucoses and titrate insulin gtt. Hr/bp still ^,? ^ lopressor dose/frequency.\n"},{"category":"Nursing/other","chartdate":"2179-03-15 00:00:00.000","description":"Report","row_id":1293289,"text":"Respiratory Care:\nPt. was to be extubated today if at all possible, however, she developed a rather high RR and had an episode of respiratory distress\nwith increased WOB and decreasing O2 sat. to 90-91%. She was rested on 50% PSV 20/5peep. This has been weaned down to 40% and a PS of over the course of this shift, and presently is slowly increasing her RR, and ? WOB...\n"},{"category":"Nursing/other","chartdate":"2179-03-15 00:00:00.000","description":"Report","row_id":1293290,"text":"Nursing\nSee flowsheet for details.\n\nAttempted to wean from vent with no success. Propofol turned off at 0700 and by 0930 pt. was alert and following commands consistently. Pt. remained on and 40% until 1300 when propofol had to be restarted to help the pt. to be less anxious. Dr. stated that pt. would not be extubated due to possible anxiety/pain and low tidal volumes.\n\nAt this time pt. is on and 40% sa02 99%. Sxn small amounts of thick clear from ETT and large amounts thick clear from mouth. HR 125 NSR with no ectopy. BP 139/77. Temp 99.9 oral. Propofol at 30mcg/kg/min and insulin at 4units/hr. Urinary output remains adequate. T-tube intact and draining bilious. Abdominal incision C/D/I.\n\nPlan to cont. to wean from vent and keep pt. comfortable.\n"},{"category":"Nursing/other","chartdate":"2179-03-16 00:00:00.000","description":"Report","row_id":1293291,"text":"FOCUS: STATUS UPDATE\nDATA:\nPT LIGHTLY SEDATED ON PROPOFOL DRIP. FOLLOWING COMMANDS INCONSISTENTLY, OPENING EYES SPONT AND TO COMMAND.\n\nLUNGS COARSE BILAT LOWER LOBES. SUCTIONED FOR THICK YELLOW SPUTUM. PS INCREASED TO 20 DUE TO RR IN THE 40'S AND LOWER TV. NOW WITH TV >500 AND RR <20. PT ALSO CALMER ON THIS SETTING ALLOWING WEANING DOWN OF PROPOFOL.\n\nABD SOFT AND NONTENDER. HYPOACTIVE BS. INCISION WITH STAPLES INTACT AND OPEN TO AIR.\n\nPLAN:\nMAINTAIN INTUBATED ON HIGHER PS REQUIREMENT AND REEVALUATE WEANING IN AM. WEAN OFF PROPOFOL AS ABLE.\n\n"},{"category":"Nursing/other","chartdate":"2179-03-16 00:00:00.000","description":"Report","row_id":1293292,"text":"Resp Care Note:\n\nPt cont intub with OETT and on mech vent as per Carevue. Lung sounds coarse suct sm=>mod th off sput.ABGs ess same however pt requiring higher levels of PSV to maintain adequate Vt/RR. PSV increased overnoc to a high of 22 to present value of 15cm to stabilize Ve. Pt does not appear ready for extub even though RSBIs have been consistantly < 100. Cont PSV; ? trach soon.\n"},{"category":"Nursing/other","chartdate":"2179-03-16 00:00:00.000","description":"Report","row_id":1293293,"text":"Respiratory Care:\nPt began shift on PSV 15/5. she was slowly weaned to @ 40%.\nRR inc some but not excessively w/a good MV. At ~ 16:30 she went to CT for a scan of her Abdomen, looking for a collection that may be causing her temp. spikes and complicating her wean off the Vent.\nThe plan is to try extubation soon (tomorrow) to see if she will do well. If not we will reintubate and trach sometime in the next 2-3 days. Please check CareVue for details and ABG's.\n"},{"category":"Nursing/other","chartdate":"2179-03-12 00:00:00.000","description":"Report","row_id":1293276,"text":"Resp Care Note:\n\nPt cont intub on mech vent as per Carevue. Lung sounds coarse bilat suct sm th tan sput. Pt appears comfortable on A/C though she cont to overbreathe vent but in NARD; no vent changes required overnoc. Cont mech vent support.\n"},{"category":"Nursing/other","chartdate":"2179-03-12 00:00:00.000","description":"Report","row_id":1293277,"text":"Condition Update\nPlease see carevue for specifics.\n\nNeuro: PPF gtt at 80 mcqs/hour. Off the gtt, pt did not follow commands. Only would open her eyes to voice. Fentanyl gtt at 100mcs/hour. PERRL.\n\nCV: SR - ST. No ectopy noted. HR 96-119. Aline dampened, used cuff for pressures. Temperature down to 97.7 Cooling blanket off.\n\nResp: No vent changes made. o2 sats 97-100% Pt sxn'd several times for small amts of thick tan sputum. LS coarse b/L.\n\nGI/GU: Foley is patent and draining amber urine. Decreased u/o approx 25-35 cc hour. FIB bag intact. Immeasureable amt of liquid brown stool out. TPN infusing for nutrition. NGT to low continuous sxn and draining brown fluid. Left T tube intact, right jp drain to bulb sxn and draining dark brown fluid.\n\nEndo: Pt on a regular insulin gtt. BS checked q hour and gtt titrated accordingly.\n\nInteg: s/p Liver tx. abdominal staples intact. Incision is reddened. Small amt of drainage noted. DSD to cover.\n"},{"category":"Nursing/other","chartdate":"2179-03-12 00:00:00.000","description":"Report","row_id":1293278,"text":"Nursing\nSee flowsheet for details.\n\nPt. sedated on 40mcg/kg propofol. Opens eyes and moves all extremities on propofol holiday; not following commands. PERRLA 2-3mm, brisk, scleral jaundice.\n\nHR 100-120 NST, no ectopy. BP low this a.m. and all antihypertensive meds d/c. CVP connected and read 15-17 throughout day. Given 500cc NS . BP 95-125/65. Temp 97.1 ax. Pulses weakly palpable. /hr, Fentanyl at 100mcg/hr and Insulin gtt on. Left rad. a-line extremely positional; going by cuff pressure.\n\nETT intact. CMV 40%, 500Vt, 5PEEP, sa02 95-100%. Lungs coarse in upper lobes and diminished at times in lower lobes. Not sxn much from tube. Sxn moderate amounts clear from mouth.\n\nAbdomen soft/non-distended with pos. BS. Incision C/D with staples intact; no drainage, no dressing. T-tube intact and draining moderate amounts bilious. JP intact and draining small amounts brown. NG to LCWS with brown output. Fecal bag intact with tan mucous foul-smelling drainage.\n\nFoley intact with clear yellow urine. Output increased significantly after NS .\n\nPt. potassium high. Received 4 units Hum. Reg. insulin IV and 25gm D50 IV. Also receieved 2gm calcium gluconate.\n\nFamily updated several times throughout the by RN.\n\nPlan to cont. to monitor lab values and resp. status.\n"},{"category":"Nursing/other","chartdate":"2179-03-12 00:00:00.000","description":"Report","row_id":1293279,"text":"Respiratory Care\nPt. remains on a/c with increased tidal volume to 500cc. Last ABG 730/36/159/18/-7/100. BS coarse R>L.\n"},{"category":"Nursing/other","chartdate":"2179-03-13 00:00:00.000","description":"Report","row_id":1293280,"text":" 19/07\n PT REMAINS ON FENT WITH PROPOFOL DRIP FOR MILD SEDATION PLEASE SEE CAREVIEW FOR DETAILS ON NEURO STATUS PT WILL OPEN EYES AND TRIES TO FOLLOW COMANDS\n RESP CMV RATE 20 FIO2 .40 PEEP5 T/V 500 SPUTUM BROWN IN COLOR RHONCHI THRU OUT\n HEART S1S2 PULSES POS 2 THRU OUT M EDEMA THRU OUT ST 110 TO 120\n GI HYPOACTIVE B/S SCANT STOOL SOFT ABD T TUBE AND JP IN PLACE U/O QS\n NOTE ELEVATED LEVELS MD AWARE SEE ORDERS\n SUPPORTIVE CARE MONITOR LYTES AND HCT SKIN CARE T/P WITH ROM\n"},{"category":"Nursing/other","chartdate":"2179-03-10 00:00:00.000","description":"Report","row_id":1293272,"text":"FOCUS: STATUS UPDATE\nDATA:\nPT SEDATED ON PROPOFOL. ALERT AND FOLLOWING COMMANDS OFF SEDATION BUT WITH HYPERTENSION, TACHYCARDIA AND AGITATION. CONTINUES ON FENTANYL DRIP.\n\nHYPERTENSION TO >200SYS WITH STIMULATION SUCH AS BATHING. TACHYCARDIA TO 130'S, IMPROVED WITH INCREASE IN LOPRESSOR.\n\nLUNGS BILATERALLY CLEAR. CONTINUES ON CPAP WITH PS. PS INCREASED THIS AM D/T PCO2 55. SUCTIONED FOR MODERATE AMOUNTS CLEAR SECRETIONS. LESS FEBRILE O/N.\n\nABDOMINAL SL DISTENDED, SOFT AND WITH STAPLES INTACT. HYPOACTIVE BS.\n\nCONTINUES ON LASIX WITH GOOD EFFECT.\n\nPLAN:\nCONTINUE TO WEAN OFF VENT AS ABLE. DECREASE SEDATION AS TOLERATED.\n"},{"category":"Nursing/other","chartdate":"2179-03-10 00:00:00.000","description":"Report","row_id":1293273,"text":"Nursing\nSee flowsheet for details.\nPt. hard to wean from propofol; becomes very restless and . Propofol currently at 50mcg/kg; Fentanyl at 50mcg/hr. Insulin gtt currently at 7units/hr.\nWent for cholangiogram for elevated bilirubin; found no problems with tube.\nIncision intact with no drainage. T-tube with good output. JP with small amounts brown drainage.\nPlan to cont. to wean from vent and wean from propofol.\n"},{"category":"Nursing/other","chartdate":"2179-03-11 00:00:00.000","description":"Report","row_id":1293274,"text":"FOCUS: STATUS UPDATE\nDATA:\nEXTREME AGITATION OFF PROPOFOL, MOSTLY EVIDENT BY HYPERTENSION AT TIMES TO >200 SYSTOLIC, TACHYCARDIA TO 120'S AND INCREASED RESPIRATORY EFFORT, RATE TO 40'S. PRECEDEX DISCONTINUED D/T POOR EFFECT. HALDOL AND FENTANYL PRN WITH SOME EFFECT. PROPOFOL RESUMED WITH IMPROVED VS. FOLLOWING COMAMNDS AND MOVING ALL EXTREMITIES OFF SEDATION.\n\nHYPERTENSION WITH AGITATION. HYDRALAZINE WITH MINIMAL EFFECT. SEDATION WITH EFFECT.\n\nLUNGS COARSE BILAT. SUCTIONED FOR THICK CLEAR SECRETIONS OCCAS. PLACED BACK ON AC WITH RATE OF 18 D/T TIRING WITH INCREASED RESPIRATORY EFFORT. ABG STABLE.\n\nCONTINUES ON LASIX WITH GOOD EFFECT. +3 PITTING EDEMA BILAT HANDS.\n\nPLAN:\nWEAN OFF VENT AND EXTUBATE IF POSSIBLE.\n\n\n\n"},{"category":"Nursing/other","chartdate":"2179-03-11 00:00:00.000","description":"Report","row_id":1293275,"text":"Nursing\nSee flowsheet for details.\n\nAt beginning of shift pt. HR 150-160, BP 160-180 systolic and temp 39C (blood). Propofol increased to 80mcg/kg, fentanyl gtt restarted at 100mcg/hr and cooling blanket placed on pt. Pt. pan-cultured to include all lines and fungal cx. Right IJ swan changed to quad-lumen. LSC dual-lumen and left rad. a-line intact. Insulin gtt between 7-10units/hr.\n\nCurrently, pt. HR 115-130, BP 110-120/80-85, and temp 38.4 oral (cooling blanket still on). Extremities with +3 edema. Weakly palpable peripheral pulses.\n\nPt. will open eyes to pain when propofol decreased. Moves all extremities. Follows commands inconsistently. PERRLA 3mm brisk. Scleral jaundice.\n\nETT tube intact; tape changed. Currently on CMV VT450, 8PEEP, 40%. Sa02 95-98%. Sxn scant amounts thick clear. Sxn moderate amounts from mouth thin tan. Thrush on tongue noted.\n\nNG to LCWS and draining moderate amounts dark brown. Pos. BS. Abdomen soft and slightly distended. Abdominal incision intact/approximated with no drainage; DSD intact. T-tube with moderate amounts of bilious drainage; intact. RLQ JP intact with dark brown drainage approx. 10cc for 12 hours. Fecal bag reinforced with small amount of mucoid stool present.\n\nFamily updated several times throughout day.\n\nPlan to cont. to monitor HR and BP. Also plan to monitor temp and to keep cooling blanket on until temp. decreases.\n"},{"category":"Nursing/other","chartdate":"2179-03-08 00:00:00.000","description":"Report","row_id":1293264,"text":"Resp Care\nPt. remains intubated sedated on ventilator w/o change overnight.\nBs: coarse sxn'd for sm. amts. of thick.\nabgs: mild metabolic alkalosis with hyperoxia.\nPlan: scheduled to have fascia closed in OR today.\n"},{"category":"Nursing/other","chartdate":"2179-03-08 00:00:00.000","description":"Report","row_id":1293265,"text":"D:Pt is PODS#6 and 7 s/p OLT for ESLD. See carevue flowsheets for specifics.\nNeuro:Pt sedated on propofol and fentynal and does not respond to verbal or tactile stimuli. PERRLA.\nCV:VSS, CO stable at 7.5 CVP 11-12, PAD 20. SR to ST 90s-100 no ectopics. Ulnar arterial line left wrist patent and is 20mm higher than NBP.\nResp:Pt remains intubated on ventilator FIO2 40%. O2 sats 97-99. ABGs improving.\nGI:NGT draing BRB in small am'ts started around 0500. H.O. notified. HCT stable. Platlets 70.\nGU:foley to BSD draining small am'ts of hematuria.\nSkin with the exception of incisions intact. Eccymotic areas lt groin abd near incisions (old).\nLab:K repeted for 3.5 level. BS treated by titrating insulin gtt.\nA:Stable s/p OLT.\nP:Check cyclosporin level at 10:30.\n check vanco level at 11:30\n Pt expected to go to the OR for closure today TF.\n Provide emotional support to pt and family.\n\n"},{"category":"Nursing/other","chartdate":"2179-03-08 00:00:00.000","description":"Report","row_id":1293266,"text":"Resp. Care Note\nPt remains intubated and vented on settings as charted on resp flowsheet. No vent changes made this shift. Pt back to OR for abd. closure.\n"},{"category":"Nursing/other","chartdate":"2179-03-08 00:00:00.000","description":"Report","row_id":1293267,"text":"CONDITION UPDATE\nPLEASE SEE CAREVUE FLOWSHEET FOR SPECIFICS.\nNEURO: PT SEDATED ON PROPOFOL AND FENTANYL GTTS. OCCASIONALLY OPENS EYES TO STIM. MOVES ALL EXTREMITIES ON BED TO STIM. PERRL.\nRESP: LS CTA. ABG STABLE. NO VENT CHANGES. SM AMT SECRETIONS VIA ETT SUCTION.\nCV: AFEBRILE. HEMODYNAMICALLY STABLE. FLUID BAL NEG 180CC SINCE MN. PLT GIVEN FOR 70, POST 105. HIT PANEL SENT AND POS PER BLOOD BANK. SICU AND TRANSPLANT TEAMS INFORMED. COAGS STABLE.\nGI: ABD SOFT. NGT WITH SM AMT CLEAR O/P. NO BM.\nGU: CLEAR AMBER U/O. SM RESPONSE TO AM LASIX.\nENDO: INSULIN GTT TITRATED TO FSBG.\nSKIN: T-TUBE WITH MOD AMTS DK AMBER DRG. JP WITH SM AMTS DK MAROON DRG. ABD INC DSG CDI.\nMISC: CYCLO GTT CONTS AT 2MG/HOUR. PT SENT TO OR FOR FASCIA CLOSURE AT 1600 WITH ANESTHESIA. SENT ON PPF AND CYCLO GTTS.\nPLAN: AWAIT RETURN FROM OR. D/C ALL HEPARIN.\n"},{"category":"Nursing/other","chartdate":"2179-03-08 00:00:00.000","description":"Report","row_id":1293268,"text":"CONDITION UPDATE\nPT RETURNED FROM OR AT 1800 S/P FASCIA CLOSURE. PT STABLE. ALL TUBES AND LINES INTACT. MEDS RESUMED (EXCEPT HEPARIN). SVO2 RECAL'D. LABS SENT. REPEAT HIT TO BE SENT.\n"},{"category":"Nursing/other","chartdate":"2179-03-09 00:00:00.000","description":"Report","row_id":1293269,"text":"Resp Care\nPt. remains intubated/sedated overnight. No changes made abg's within normal parameters.\nBs: coarse bilat. secreations minimal thick.\nPlan: continue current support.\n"},{"category":"Nursing/other","chartdate":"2179-03-21 00:00:00.000","description":"Report","row_id":1293308,"text":"CONDITION UPDATE\nD.AFEBRILE,SR-ST,RR16-26,O2 SAT=99 ON 2L NP,BP 117-140/60.\n PT WAS GIVEN LASIX THIS EVENING.DESPITE MOD. DIURESIS,PT REMAINED POSITIVE BY 1700ML/24 HRS.\n PT CONFUSED AT TIMES TO TIME AND PLACE BUT COOPERATIVE.PT DID NOT SLEEP ALL NITE.\n NO C/O OF PAIN EXCEPT AT 0400,PT C/O ABD PAIN AND CONFIRMED ABD CRAMPS..PT HAD STOOL,LOOSE X2 THRU THE NITE.\nA.?NEED TO DECREASE TF RATE..?NEED FOR FT PLACMENT TODAY.\nR. STABLE\n"},{"category":"Nursing/other","chartdate":"2179-03-21 00:00:00.000","description":"Report","row_id":1293309,"text":"please see carevue for specifics:\nNeuro: pt alert and oriented to person. able to follow directions,but confused when answering questions.\nCV: afebrile, HR 90-110's sinus tach with no ectopy, SBP 120-150's, CVP 9-13. extremities warm with +PP. lytes repleated.\nRESP: lungs clear to dim at bases, On room air O2 sats >96%.\nGI: tube feed at 70cc/hr via dopoff tube (post pyloric). Having frequent loose stool.\nGU: foley draining adequate amounts of amber clear urine.\nENDO: blood sugars SLightly elevated, covered with RISS.\nPLAN: continue to monitor VS, monitor labs for LFT's, ? transfer to floor monday.\n"},{"category":"Nursing/other","chartdate":"2179-03-22 00:00:00.000","description":"Report","row_id":1293310,"text":"See flowsheet for specifics\nD:Pt confused oriented to name only. One leg over side rail x1. Pt awakwe all night, finally fell asleep at 0600. No changes overnight. Pt continues to complain of abd cramping. Liquid stool via mushroom rectal tube-intact. C-diff specimen sent last night.\nA:Pt improving s/p LTX.\nP:Advance to floorcare if alright with attending. \n\n"},{"category":"Nursing/other","chartdate":"2179-03-06 00:00:00.000","description":"Report","row_id":1293257,"text":"Respiratory Care:\nPatient remains on ventilatory support (A/C) with no parameter changes made throughout the night. Morning abg results were compatible with a partially compensated metabolic alkalemia with excellent oxygenation on the current settings (see CareVue).\n\nNo RSBI performed due to lack of spontaneous respiration.\n"},{"category":"Nursing/other","chartdate":"2179-03-06 00:00:00.000","description":"Report","row_id":1293258,"text":"Resp. care note - Pt. remaines intubated and vented, no vent changes made at this time, BS clear.\n"},{"category":"Nursing/other","chartdate":"2179-03-06 00:00:00.000","description":"Report","row_id":1293259,"text":"npn\nNeuro- propofol gtt weaning, cont fentanyl, pearl, no response to stim/+ cough with suction.\n\nResp- AC vent with acceptable abg pr md, lungs clear uper/ lower, suction thin sec.\n\nHemodynmics- PA in place- see flow sheet for all #'s, lasix gtt dc , currently + 2 liters- sicu md aware.\n\nHeme_ hct 32-35, platelet count decrease to 61- sicu aware- awaiting transplant service. (transplant intern notified).\n\nID- temp max 101.5- blood cx done\n\n\n"},{"category":"Nursing/other","chartdate":"2179-03-07 00:00:00.000","description":"Report","row_id":1293260,"text":"D:TPN changed to D5Aminosyn 4.5% due to elevated K. Insulin drip titrated to maintain BS < 120. Pain control maintained with Fentynal drip, sedation maintained with propofol drip which was increased when pt was having inconsistent MV with ventilator due to stimulation. No vent changes overnoc. ABGs improved. Coffee ground NGT secretions changed to tan overnight. HCT stable at 32. Frank blood noted in stool. 2 medium stools both with frank blood in small am't. Dr notified. Pt had positive fluid balance, Lasix 20 mg IVP given per d.o.. Response to lasix 450ml then 380ml. u/o dwindled down x 1hr to 22ml h.o. aware. Cyclosporin drip started in addition to ngt cyclosporin per Dr and Dr . Cyclo level to be drawn at 0800.\nA:Pt stable overnoc.\nPlan:OR today for probable liver biopsy and closure of fascia.\n \n"},{"category":"Nursing/other","chartdate":"2179-03-07 00:00:00.000","description":"Report","row_id":1293261,"text":"Respiratory Care:\nPt. well oxygenated with essentially normal range acid-base. Pt. very tenuous to stimulation (Suctioning, turning, etc.)>>recovers slowly to baseline, and has required increased sedation. Pt. going to O.R. today for ? closure of Abd. Will follow compliance closely post-op.\n"},{"category":"Nursing/other","chartdate":"2179-03-07 00:00:00.000","description":"Report","row_id":1293262,"text":"Resp. care note - Pt. remaines intubated and vented, transffered to CT and back to SICUB without incident.\n"},{"category":"Nursing/other","chartdate":"2179-03-07 00:00:00.000","description":"Report","row_id":1293263,"text":"npn\nNeuro- sedated with propofol and fentanyl gtts, fent decrease to 100 mcg, facial grimace with suction, no ext movement noted, not foll command.\n\nResp- ac vent, fio2 decrease to .40 with good abg, lungs decreased right upper/lower, suction thin copiuos secretions- ett and oral.\n\nGI- + c diff from stool, po flagyl started, cont tpn, (over noc tpn change to quick fix as kcl in ordered bag 100 meq kcl and pts k 5.4).\n\nHeme- platelet count decreaseing to 58- received 2 6 pack platelet this shift- current count 88. hct stable.\n\nGen- abd/pelvis ct this am to r/o abcess- (neg) plan OR for closure of fascia.\n\nHemodynamics- in place- see flow sheet for #'s, temp max 100.1, hr 90's to 110. new left ulna a line placed this pm by md.\n"},{"category":"Nursing/other","chartdate":"2179-03-05 00:00:00.000","description":"Report","row_id":1293255,"text":"npn\nNeuro- sedated with propofol and fentanyl gtts, cista gtt dc this am 1030, inc cough after dc, pearl but no ext movement noted yet.\n\nResp- Tol fio2 .40 and peep decrease to 5, abg metabolic alk, lungs diminished right upper/lower, suction thick secretions, sputum cx sent.\n\nHemodynimics- temp max 102 via pa- pan cx done, hr cont up to 150's with occasional pvc's- lytes wnl, lasix gtt initially decrease to 5 from 8 mg- then dc 6pm, currently 800 neg. pa advanced by md waveform- looking like wedge and then right vent, adv to 48. see flow sheet for all pa#'s.\n\nendocrine- cont insulin gtt 7-9u/hr, glu 110-157. tpn cont.\n\nID- temp max 102- cx done. cont vanco, merepenum, fluconazole, gangcylovir, ID stated due to + antibodies pt at high risk delayed transfusion reaction- coombs and sed rate sent this am. stool sent for c diff this pm.\n\nHeme- hct stable- see labs- platelet count 69- 1 6 pk givin- repaet count 83- md - to notify transplant and ? give additional 6 pack. inr 1.0.\n"},{"category":"Nursing/other","chartdate":"2179-03-19 00:00:00.000","description":"Report","row_id":1293304,"text":"PLEASE REFER TO CAREVUE FOR COMPLETE ASSESSMENT AND SPECIFICS.\n\nNEURO: PT ALERT MOST OF NIGHT, ABLE TO TRACK, . FOLLOWS COMMANDS CONSISTENTLY, MAE SPONT/PURP.\n\nCV: HR 101-124 ST, SBP 94-155. CVP 6-16.\n\nRESP: LUNG SOUNDS CLEAR BUT COARSE AT BASES. SXN PRN FOR THICK WHITISH/YELLOWISH SECRETIONS. VENT SETTINGS CPAP+PS W/ 5PEEP/10PS, FIO2 40%, TV 400'S, RR 11-23, O2 SAT 100%, ABG 7.39/52/119/33/5/98. POSSIBLE EXTUBATION THIS AM.\n\nGI: ABD SOFT, NT/ND, +HYPO BOWEL SOUNDS, REMAINS NPO FOR POSSIBLE EXTUBATION THIS AM. STRTED ON IVF FOR U/O AND DUE TO PT REMAINING NPO. INCISION REMAINS C/D/I W/ CLIPS. ?CLIP REMOVAL. T-TUBE DRAINING CLEAR DARK AMBER FLUID.\n\nGU: FOLEY DRAINING CLEAR AMBER URINE, PT RECEIVED NS 250CC W/ POSITIVE EFFECT.\n\nID: TMAX 101.9, PAN CX.\n\nPLAN: MONIOTR VS, LABS, RESP STATUS, NEURO STATUS, U/O. ?EXTUBATE THIS MORNING. ?POST-PYLORIC DOBHOFF PLACEMENT FOR TF TODAY. PHYSICAL THERAPY CONSULT.\n"},{"category":"Nursing/other","chartdate":"2179-03-19 00:00:00.000","description":"Report","row_id":1293305,"text":"see carevue for details\nfocus data update.\n\ntol extubation well, talking, tol sips of clears, ivf d/c impact with fiber started @ 20/hr with minimal residual, foley changed per infectious disease, wire change over on right central line, family into visit, medicated q2h with fentanyl\n"},{"category":"Nursing/other","chartdate":"2179-03-06 00:00:00.000","description":"Report","row_id":1293256,"text":"focus update note\ntemperature improving overnight currently 100.1, heart rate decreased from 130-140s to 115 with decreasing temperature, sbp 105/60, cvp 9, pa pressures 29/20- swan advanced by icu resident and recalabrated at approx 0100. pt transfused with 1 pack platlets for plat count 82 post plat count 97, to transfuse with 1 unit prbc awaiting unit from blood bank. current hct 33. pt possibly volume depleted- lasix gtt now off since 1830 last night uo 30-100cc/hr dark amber clear. please see flowsheet for hemodynamic cco swan values\n\npain/neuro: pt cont on fentanyl gtt at 200 mcq/hr, sedated with propofol at 120 mcq/kg/min. pt very sedated, no movement on exam or spontaneous, pupils 2mm brisk, pt does not open eyes or follow commands.\n\nresp: no vent changes overnight, lsc dim at right base, o2sat 95%.\n\nabdomen:soft/distended, bs hypoactive, small stool X 2 soft brown, surgical dressing changed c/d/i, medial JP removed by transplant surgery overnight, lateral jp drainage 35 cc brown sero sang fluid q 2-4 hours, some drainage at insertion site liver transplant team and icu team made aware. T tube bag exhibits bilious drainage, ngt drainage scant pink/blood tinged drainage transplant team aware\n\ninsulin gtt cont with hourly finger sticks- goal fs 70-110 currently insulin gtt at 6 units /hr\n\nnutrition: tpn continues\n\nplan: continue to monitor hemodynamic status closly using cco swan, pt to go back to OR for closure ? sunday, monitor for sepsis, control blood sugar with insulin gtt, pain and sedation with fentanyl and propofol gtt, monitor resp staus closely\n\n\n"},{"category":"Nursing/other","chartdate":"2179-03-20 00:00:00.000","description":"Report","row_id":1293306,"text":"NURSING NOTE\nSEE CAREVUE FOR SPECIFICS:\n\nNEURO-A&OX2(SELF&HOSPITAL),PERRLA AT 2-3MM WITH BRISK RX. FOLLOWS COMMANDS CONSISTANTLY. DROWSY AT BEGINNING OF SHIFT, INCREASE ALERTNESS THROUGHOUT NOC. NON-SENSICAL TALK AT TIMES EASILY REDIRECTED.\n\nCV-HR 90S-LOW 100S, NSR, NO ECTOPY. SBP 90S-130.HCT 25.7 DR. AWARE. CVP 2-8.\n\nRESP-FT AT 50%, LS COARSE AND SLIGHTLY DIMINISHED AT BASES. SPO2 95-100%. NO DISTRESS NOTED.\n\nGI-ABD SOFT, SLIGHTLY DISTENDED, (+) BSX4, LG LOOSE BM X2, T-TUBE IN PLACE AND PATENT. DRNG MOD AMTS OF BILIOUS DRAINAGE. TOL CLRS (30CC/HR) WITHOUT DIFF. NO N&V NOTED. NGT IN PLACE WITH TFs BEING TITRATED UP TO GOAL OF 90 (CURRENTLY AT 60), MININMAL RESIDUALS NOTED.\n\nGU-FOLEY WITH BOARDERLINE U/O. 20-50CC/HR. NS 250CC X 2 GIVEN WITH MINIMAL EFFECT.\n\nENDO-BS QID WITH SC COVERAGE\n\nSKIN- TMAX 98.6 ABD STAPLES C/D/I OTA, T-TUBE DSG C/D/I, RLQ DSG INATCT ? OLD DRAIN SITE.\n\nCOMFORT-DENIES PAIN/DISC.\n\nA/P-CONTINUE WITH CURRENT CARE PLAN. MONITOR LABS, HEMODYNAMICS & RESP STATUS. WEAN OFF O2 AS TOL. ? ADVANCE DIET. PROVIDE EMOTIONAL SUPPORT.\n\n\n"},{"category":"Nursing/other","chartdate":"2179-03-20 00:00:00.000","description":"Report","row_id":1293307,"text":"Neuro: Pt alert and oriented to self. Answering questions inappropriately, but able to follow directions. Having generalized pain, med with fentanyl with minimal effect.\nCV: low grade temp 99.9, HR 100-110's sinus tach with no ectopy, SBP 100-130's. extremities warm with +PP. HCT 25.7, treated with 2units or PRBC's.\nRESP: lungs clear to dim at bases. requiring 2l via N/C.\nGI: tol tube feed at goal, having numerous liquid stool, incontinent.\nGU: foley draining adequate amounts of amber clear urine.\nENDO: blood sugars elevated this eve. med with 11u regular insulin will recheck in one hour.\nPLAN: monitor HCT, awaiting transfer to floor\n"},{"category":"Nursing/other","chartdate":"2179-03-04 00:00:00.000","description":"Report","row_id":1293250,"text":"Respiratory Care:\nPatient required vent changes due to increased hypoxia. FIO2 increased to 80% and PEEP to 7 cm. RR decreased to 20. FIO2 titrated down to 60%. Morning abg results revealed a compensated respiratory acidosis with good oxygenation on 70% with 7 cm PSV (see CareVue).\n\nNo RSBI due to required vent settings.\n"},{"category":"Nursing/other","chartdate":"2179-03-04 00:00:00.000","description":"Report","row_id":1293251,"text":"CONDITION UPDATE (7A-3P)\nASSESSMENT:\n PT SEDATED AND PARALYZED ON PPF/FENTANYL/CISATRACURIUM GTTS. PT NOT MOVING OR OVERBREATHING VENTILATOR, BUT BP AND HR INCREASE WITH SUCTIONING AND MOVEMENT. PUPILS EQUAL AND BRISK BILATERALLY.\n HR ~ 120, TEMP DECREASING, FOLLOWED BY INFECTIOUS DISEASE TEAM. SBP RANGING 140'S-170'S. PA PRESSURES REMAIN HIGH (GOAL PAD IN 20'S). LASIX GTT CONTINUES FOR GOAL OF NEGATIVE 2 LITERS BY MIDNIGHT (CURRENTLY -1 L). SV02 79-80 AND PATIENT REMAINS HYPERDYNAMIC (SEE FLOWSHEET). FOLLOWING LABS EVERY 4 HOURS, NO BLOOD PRODUCTS GIVEN.\n PT ON ASSIST CONTROL 20 X 550, 60% FI02 AND 7 PEEP THIS MORNING. DESATTING TO 90% IN AFTERNOON AFTER BEING REPOSITIONED. FI02 INCREASED TO 70%, RR UP TO 28 WITH DECREASED TV TO 450 TO IMPROVE OXYGENATION BUT NOT EXERT MORE PRESSURE ON VENA CAVA. UNABLE TO OBTAIN REPEAT ABG AFTER CHANGE, A-LINE NOT DRAWING. LUNG SOUNDS OCCASIONALLY RHONCHOROUS, MINIMAL SECRETIONS.\n ABDOMEN SOFT, NONDISTENDED, DRESSING OP DRESSING INTACT. JPS X 2 TO SELF SUCTION; T-TUBE DRAINING HEALTHY BILE. TPN INFUSING, INSULIN GTT STARTED FOR BLOOD SUGARS > 150. LIVER US DONE, ADEQUATE FLOW EVERYWHERE EXCEPT ? HEPATIC ARTERY.\nPLAN:\n A-LINE TO BE REWIRED BY DR. (ICU). FOLLOW FREQUENT ABGS AND OTHER LABS. CONTINUE WITH DIURESIS FOR GOAL - 2LITERS. POSSIBLE RETURN TO OR THIS WEEKEND.\n"},{"category":"Nursing/other","chartdate":"2179-03-04 00:00:00.000","description":"Report","row_id":1293252,"text":"RESPIRATORY CARE\nPT REMAINS ON A/C VENT. WITH TIDAL VOLUMES 450 X 25 7PEEP 60%, PT REQUIRED INCREASED FIO2 FOR DESAT. DURING TURNING. TEAM DOES NOT WANT PEEP INCREASED, INCREASE FIO2 IF DESAT. MDI'S Q4, SUCTIONING MINIMAL SECRECTIONS.\n"},{"category":"Nursing/other","chartdate":"2179-03-05 00:00:00.000","description":"Report","row_id":1293253,"text":"Respiratory Care:\nPatient's rr increased from 25 to 27 to accomodate increased PCO2. Repeat abg results determined little change. Results consistent with a compensated respiratory acidosis with good oxygenation on the current settings.\n\nNo RSBI performed due to the patient's hemodynamic instability.\n"},{"category":"Nursing/other","chartdate":"2179-03-05 00:00:00.000","description":"Report","row_id":1293254,"text":"Nursing Progress Note:\nPlease refer to CareVue for details.\n\nNeuro: Pt remains sedated and paralyzed on Ppf/fentanyl/Cist. No spontaneous movement noted. PERRLA (2-3mm; brisk). TOF q2hr ( twitches of left eye noted). Per Dr. (transplant team), ? d/c Cist in AM.\n\nCV: Febrile overnight (Tmax 38.5; svc aware). Per Dr. , blood cx sent. Left femoral A-line tip sent for cx. HR 140s-sinus tach, no ectopy noted (Dr. , Dr. , and Dr. aware); Ppf gtt rate increased to 120mcg/kg/min to ?decrease HR without effect. ABP 130-150s/70-80s. PAP 38-50/21-32. CVP 7-12. CO down to 7.7 towards end of shift (CO was 8.6-12.4 at beginning of shift). SV down to 50s (Per Dr. , no IVB ordered). Cont to monitor. DP/PT pulses strongly palpable. Generalized edema. Q4hr blood draws. Plt 60; transfused with 1unit platelet. No electrolyte replacements ordered.\n\nPulm: Lungs sound CTA, diminished at bases. CMV: FiO2 decreased to 40%, Vt 450, freq increased to 27 to blow off CO2 (without much effect), PEEP 7. Last ABG: pH 7.38, PaCO2 51, PaO2 102, bicarb 31, BE 3. Pt not breathing over vent. O2 sat >/= 93%. O2 sat down to 92% during T&R.\n\nGI: Abdomen soft w/ +BS. NGT to LWS; drainage was dark brown at beginning of shift, but became bright red (Dr. , Dr. , and Dr. aware; Protonix increased to q12hr). Insulin gtt to keep BS<120. BS checked q1hr.\n\nGU: Foley intact w/ clear, yellow urine. Lasix gtt decreased to 8mg/hr to keep I's and O's even (per Dr. and Dr. .\n\nInteg: Primary dsg to abd removed and replaced w/ DSD. Abd staples intact; no drainage noted. DSD applied over drains. JPx2 to bulb suction. Medial JP w/ serous drainage; lateral JP w/ dark brown drainage. T-tube w/ bilious drainage.\n\nSocial: sister called x1 overnight; updated w/ pt's plan of care.\n\nPlan: Continue ICU care and treatments. Monitor VS, I's and O's (keep even). Blood draw and ABG q4hr; replace lytes/blood products as needed. Monitor resp status, TOF. Cont drips. Plan to take pt back to OR for fascia closure (?date). Maintain skin integrity. Discuss plan of care w/ pt's sister.\n"},{"category":"Nursing/other","chartdate":"2179-03-18 00:00:00.000","description":"Report","row_id":1293299,"text":"PLEASE REFER TO CAREVUE FOR COMPLETE ASSESSMENT AND SPECIFICS.\n\nNEURO: PT ALERT, FOLLOWING SIMPLE COMMANDS, ABLE TO TRACK AND , SPONT/PURP BUT VERY WEAK, NODS APPROPRIATELY TO SIMPLE COMMANDS.\n\nCV: HR 98-122, NSR-ST, NO ECTOPY, SBP 10-135. CVP 3-7.\n\nRESP: LUNG SOUNDS COARSE, SXN FOR SMALL AMT THICK WHITISH SECRETIONS. VENT SETTINGS CURRENTLY CPAP+PS, 5PEEP/10PS (PS INC FROM 5 TO 10)40% FIO2, RR 12-27, TV 300-400. LAST ABG 7.38/52/132/32/4/98. CXR TO BE DONE IN AM.\n\nGI: ABD SOFT NT/ND, HYPO BOWEL SOUNDS, TF IMPACT W/ FIBER AT 60CC/HR W/ GOAL RATE 90CC/HR, MINIMAL RESIDUALS. TF TO BE STOPPED AT 4AM FOR POSSIBLE EXTUBATION. INC W/ CLIPS C/D/I, DRAIN W/ LRG AMT DARK CLEAR BILIOUS FLUID. LIVER U/S DONE, F/U RESULTS.\n\nGU: FOLEY DRAINING 80-300CC/HR POST LASIX DOSE, CLEAR AMBER TO YELLOW URINE. I/O BALANCE GOA IS FOR PT TO BE NEG 1L, BY 7AM.\n\nID: TMAX 101.7 DOWN TO 99.8\n\nENDO: PR REMAINS ON INS GTT FOR FS CONTROL.\n\nPLAN: MONIOTR VS, LABS, RESP STATUS, NEURO STATUS. PHYS THERAPY TO FOLLOW PT. FOLLOW UP U/S RESULTS. AWAITING CXR. STOP TF AT 4AM FOR ? EXTUBATIN THIS AM. CONT CURRENT MGMT.\n"},{"category":"Nursing/other","chartdate":"2179-03-18 00:00:00.000","description":"Report","row_id":1293300,"text":"Respiratory Care:\nPt. continues on low level PS ventilation. Increased PS level overnight to decrease WOB. ABG's well oxygenated with a fully compensated respiratory acidosis. RSBI was 69 this a.m.>>started on SBT 04:10. B/S scattered course>>ETS small to moderate, thick, pale yellow. Good gag, excellent cough. Team to eval for extubation on rounds.\n"},{"category":"Nursing/other","chartdate":"2179-03-18 00:00:00.000","description":"Report","row_id":1293301,"text":"Nursing\nSee flowsheet for details.\n\nPt. fairly calm and cooperative today. Following commands and strength increasing. Remained on minimal vent settings all day. Prior to liver bx this afternoon, pt. placed back on propofol. Procedure was unremarkable and propofol d/c. Insulin gtt on.\n\nCont. to receive fentanyl prn with good results. Abdomen soft and slightly tender. Good BS. Stool thick, brown and moderate amounts. NG clamped. Cont. to receive lasix for -1000cc fluid balance.\n\nPlan to rest over night for pending extubation tomorrow. Also plan for post-pyloric tube placement tomorrow.\n"},{"category":"Nursing/other","chartdate":"2179-03-18 00:00:00.000","description":"Report","row_id":1293302,"text":"Resp Care\nPt remains on vent. Required increased in support for lung biospy. Plan to wean to extubate tomorrow.\n"},{"category":"Nursing/other","chartdate":"2179-03-19 00:00:00.000","description":"Report","row_id":1293303,"text":"Respiratory Care:\nPt. continues on low level PS settings per flowsheet. Increased PS level from 5 to 10 overnight to \"rest\". B/S with course crackles>>ETS small to moderate secretions ranging from pale yellow to . Sputum sample \"cross contaminated with oralpharyngeal secretions\" per lab. ABG's well oxygenated with a fully compensated respiratory acidosis. RSBI was 71 this a.m. (done with ATC off, 0 peep, 0 PS). Pt. has good gag/cough. Starting SBT ~ 04:30. Evaluate for extubation on rounds.\n"},{"category":"Nursing/other","chartdate":"2179-03-03 00:00:00.000","description":"Report","row_id":1293248,"text":"7a-7p nursing note:\nNursing Assessment:\n\nNeuro: Currently 2 twitches on cisatracurium Besylate, Propofol, and Fentanyl gtts. Pupils equal and reactive.\n\nCV/GU: PAD to try to keep low 20's. HIght 20's to low 30's for shift, Nitro off and Dr. is aware. Tachycardic in 120's. Lasix gtt for goal 1 liter negative for day. FC putting out large amounts clear yellow urine.\n\nResp: CMV decreased to FiO2 .60, O2 sats 92% and frequent blood gases with vent changes, otherwise Q 4 hour gases and labs as ordered. Dr. is aware of oxygenation issues. Please see flowsheet for specifics. Tidal volume 500 X 25 with 5 of PEEP. Lung sounds clear to coarse. Only scant amounts of thick secretions on suctioning.\n\nSkin/GI: Abdominal incisions with DSD's CD&I. Bowel sounds absent, abdomen soft. NGT to suction with brown drainage. TPN initiated.\n\nPlan: Titrate all gtts as required. Monitor PAD pressures and O2 sats. Q4 CBC, Fibrinogen, PT, PTT, and ABG's. Chem 10 and LFT's Q 8.\n\nPlease see nursing flowsheet for all specifics.\n\n\n"},{"category":"Nursing/other","chartdate":"2179-03-04 00:00:00.000","description":"Report","row_id":1293249,"text":"Neuro sedated fentanyl 100mcg and propofol 100mcg/kg/min paralyzed cisatracurium .14mg/kg/hr TOF 1/lid, pupils equal and reactive\nResp 70%/550/20/7peep abg 7.37/53/136/32/4 fio2 dropped to 60% hydrochloric acid gtt d/c. lungs exp wheeze/coarse/clear sx sm amt of thick tan secretions albuterol tx given cxr taken to determine reason for decreasing o2 sat, adjustments made as above\nCVS HR 127-107 ST without ectopy PAP s/D 61/36-50/31 CO 9.1 CI 5.2 CVP 16 bp 161/87-137/75 lopressor 5mg IV given x2 skin w+d pp+4 Hct 36.4\nGI abd soft BS absent Dsg D+I JP lat 70cc, T 75cc, JP med 22, ngt 200cc bilious, amylase 111, LDH 659, AST 735, ALT 927, alk phos 119. Sm amt soft brown stool\nGU u/o > 200cc neg 652 mn to 0500 lasix gtt 4mg IV q hr cr .9\nID temp max 100.8 core lact acid 2.6 wbc 7.7 on vanco fluconazole zoysn, bactrium\nendo BS > 200\nTPN\nA. s/p liver transplant HIV+ HCV cirrohois esophageal varices hx liver enzymes relatively unchanged overnight, IVDU, asthma + smoker 1ppd ? rt pleural effusion by cxr\np. keep sedated paralyzed, wean fi02 as tol albuterol tx prn, monitor labs q 4, keep u/o > 100cc titrate lasix monitor lytes replete prn, goal pap diastolic <20, needs peak cyclosporine level after 0800 dose, Blood bank requests direct coomb's antiglobulin and antibody screen be sent to bld bank today. Monitor s/s blding. Add insulin to TPN cont SS q 4hr tx per scale,\n\n"},{"category":"Nursing/other","chartdate":"2179-03-02 00:00:00.000","description":"Report","row_id":1293244,"text":"FOCUS: CONDITION UPDATE/ADMISSION NOTE\nSEE CAREVUE FOR SPECIFIC VITAL SIGNS/LAB VALUES/ASSESSMENT\nD: PATIENT ADMITTED TO SICU FROM OR AT 1300, S/P LIVER TRANSPLANT--STARTED ON , UNABLE TO ANASTAMOSE FIRST LIVER, WAS ANAHEPATIC FOR APPROX. 14 HOURS, RECEIVED 2ND LIVER THIS AM, CASE FINISHING AROUND 1230. RECEIVED MASSIVE AMOUNTS OF COLLOIDS (SEE FLOW SHEET FOR EXACT NUMBERS). ARRIVED TO SICU, INTUBATED ON PROPOFOL AND NTG. DID AWAKE IN THAT SHE MOVES EVERYTHING, RESPONDS APPROPRIATELY TO PAINFUL STIMULATION (WITHDRAWS, NOT POSTURING), AND PUPILS EQUAL AND REACTIVE TO LIGHT. DOES NOT FOLLOW COMMANDS, AND IS BEING KEPT PRETTY SEDATED ON PROPOFOL 50 MCG/ AND PRN MSO4.\nRECEIVED 1 U PRBC SINCE ADMISSION , NO OTHER COLLOIDS. LABS PER FLOW SHEET.HAS BEEN TACHYCARDIC SINCE ADMISSION, PA / CARDIAC NUMBERS PER FLOW SHEET. HO AWARE.\nBELLY COVERED WITH POSTOP DRESSING AND COVERED WITH LARGE OPSITE, SKIN IS CLOSED, YET FASCIA REMAINS OPENED, AS COULD NOT CLOSE IN OR DUE TO HIGH PA NUMBERS AND HIGH PIP ON VENTILATOR.\nJPS DRAINING MINMAL AMOUNTS DARK FLUID, T TUBE DRAINING SMALL AMOUNT OF LIGHT COLORED BILE. NGT +PLACEMENT, DRAINING OLD BLOODY DRAINAGE.\nRECEIVED LASIX 20 MG AND DIURESED WELL, ON IV NTG TO LOWER PAD (CURRENTLY AROUND 24-25 WHICH SHOULD BE GOAL).\nFAMILY IN, SPOKE WITH DR. , AWARE OF SITUATION.\nULTRA SOUND DONE, +FLOW ALL VESSELS.,\nCULTURED FOR BLOOD/SPUTUM FOR TEM>38.0\nP: CONTINUE TO DRAW LABS Q 4/8 HRS. AS ORDERED.\nTRY TO WEAN FIO2, YET PO2 LOW ON HIGH FIO2, CXRAY DONE, TEAM AWARE.\nCONTINUE WITH PLAN, CALL HO WITH ANY CHANGES.\n"},{"category":"Nursing/other","chartdate":"2179-03-02 00:00:00.000","description":"Report","row_id":1293245,"text":"Pt remains on current vent settings, see carevue for details.Will follow.\n"},{"category":"Nursing/other","chartdate":"2179-03-03 00:00:00.000","description":"Report","row_id":1293246,"text":"RESP CARE: Pt remains intubated/on vent on AC 550/15/.70/5 PEEP. Lungs coarse bilat R>L. No RSBI at this time due to high FI02. Will continue to wean FI02 as tol.\n"},{"category":"Nursing/other","chartdate":"2179-03-03 00:00:00.000","description":"Report","row_id":1293247,"text":"CONDITION UPDATE\nPLEASE SEE CAREVUE FLOWSHEET FOR SPECIFICS.\nNEURO: PT SEDATED WITH PROPOFOL AND FENTANYL GTTS, PARALYZED WITH CISATRICURIUM. CIS GTT TITRATED UP FOR RR, 0-1 THUMB TWITCH WITH 40MA STIM TO ULNAR NERVE. SEDATION INCREASED WHILE PARALYZED BASED ON CHANGES IN VS WITH STIMULATION. PERRL. PRIOR TO INCREASE IN SEDATION AND START OF PARALYTIC, PT MOVING SPONT AND IN RESPONSE TO PAIN. LOCALIZED WITH BUE TO TRAP SQUEEZE.\nRESP: LS CTA. SCANT SECRETIONS VIA ETT SUCTION. ABG'S WITH INCREASING PCO2 DESPITE DECREASED RR WITH ADEQUATE SEDATION/PARALYSIS. PH STABLE WITH INCREASE IN HCO3. DIAMOX ORDERED FOR DIURESIS THIS AM. FIO2 WEANED TO 70% WITH STABLE O2 SATS.\nCV: LOW GRADE TEMPS. CONTS TACHYCARDIC, HYPERDYNAMIC. PULMONARY HTN CONTINUES DESPITE DIURESIS WITH LASIX, INCREASE IN NTG GTT PER DISCUSSION WITH MD . K AND MAG REPLETED AS ORDERED. CBC AND COAGS STABLE.\nGI: NGT TO LCWS WITH SM AMT O/P, BROWN TO BLOODY AT TIMES. MD INFORMED.\nGU: POS DIURETIC RESPONSE TO LASIX. RESPONSE TO DIAMOX PENDING.\nENDO: FSBG COVERED PER RISS.\nSKIN: SURGICAL ABD DSG INTACT. SMA MT OLD SEROUS DRG. MEDIAL JP WITH SMAMT SEROSANG O/P. LATERAL JP WITH SMA MT MAROON O/P. T-TUBE WITH SM AMT DK AMBER O/P.\nPLAN: MAINTAIN ADEQUATE SEDATION WHILE PARALYZED. CONT TO MONITOR LABS Q4H AS ORDERED. MONITOR HEMODYNAMICS CLOSELY. DUIRESE WITH DIAMOX AS ORDERED. EMOTIONAL SUPPORT TO FAMILY. AWAIT RETURN TO OR FOR FACIA CLOSURE.\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2179-03-11 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 857753,\n \"text\": \" 3:24 PM\\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \\n Reason: confirm line positioning\\n Admitting Diagnosis: LIVER FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 48F s/p liver txp, now s/p line replacment\\n REASON FOR THIS EXAMINATION:\\n confirm line positioning\\n ______________________________________________________________________________\\n FINAL REPORT\\n Portable supine chest compared to previous study of earlier the same\\n date.\\n\\n CLINICAL INDICATION: Line repositioning.\\n\\n FINDINGS:\\n\\n The examination is limited due to exclusion of the extreme lung apices from\\n the radiograph.\\n\\n A left subclavian catheter has been advanced in the interval into the superior\\n vena cava. A Swan-Ganz catheter has been removed, and a right internal\\n jugular catheter terminates in the superior vena cava. Endotracheal tube\\n remains in satisfactory position. A nasogastric tube is notable for the\\n sideport above the GE junction level although the distal tip is in the\\n stomach. There is patchy right lower lobe opacity, most suggestive of\\n atelectasis. A drain is seen in the upper abdomen. No pneumothorax is\\n identified on the supine study although exclusion of the extreme apices limits\\n assessment for this finding.\\n\\n IMPRESSION:\\n\\n 1) Satisfactory position of vascular catheter. No pneumothorax on this\\n limited study.\\n\\n 2) Proximal location of NG tube sideport, which should be advanced for more\\n optimal placement.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2179-03-07 00:00:00.000\",\n \"description\": \"CTA ABD W&W/O C & RECONS\",\n \"row_id\": 857175,\n \"text\": \" 10:01 AM\\n CTA ABD W&W/O C & RECONS; 200CC NON IONIC CONTRAST SUPPLY Clip # \\n Reason: SPIKING TEMPS, OPEN FASCIA, S/P LIVER TRANSPLANT, EVALUATE FOR HEPATIC FLOW IN PHASES\\n Admitting Diagnosis: LIVER FAILURE\\n Field of view: 40 Contrast: OPTIRAY Amt: 200\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 48 year old woman with\\n REASON FOR THIS EXAMINATION:\\n CT abdomen ANGIOGRAM to evalaute for heptic flow in phases.ALSO CT abdomen to\\n r/o abcess or collection.\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Spiking fevers. Status post liver transplant.\\n\\n TECHNIQUE: Multidetector, multiphasic, helical axial imaging of the abdomen\\n and pelvis before and after the administration of intravenous contrast.\\n Coronal and sagittal reformatting.\\n\\n CONTRAST: 200 cc of Optiray intravenously. Nonionic contrast was administered\\n due to the fast bolus requirement.\\n\\n COMPARISON: Direct comparison is made with the prior study dated . The\\n most recent studies of and are unavailable for direct\\n comparison at this time. The reports were reviewed. That are no comparison\\n studies since the patient's liver transplant.\\n\\n CTA ABDOMEN WITH AND WITHOUT CONTRAST:\\n\\n The patient had suboptimal intravenous access, and a suitable peripheral IV\\n could not be obtained. As a result, there is suboptimal timing of the\\n contrast bolus, limiting the evaluation of the hepatic vascularture and\\n particulary the hepatic artery. The celiac axis is grossly patent proximally.\\n The hepatic and portal veins are grossly patent. There is a triangular\\n irregularity in the region of the hepatic vein confluence, but this appearance\\n may be projectional given the fact that it appears normal on the coronal and\\n sagittal reconstructions. There is no hepatic perfusion defect detected. The\\n periportal edema is a common post-transplant finding. The spleen remains\\n enlarged. The pancreas, adrenal glands and kidneys are unremarkable. Small\\n retroperitoneal nodes are present. There is no abnormal bowel wall thickening\\n or bowel loop dilatation. There are minor scattered amounts of fluid without\\n discrete collections. There is no free air.\\n\\n A perihepatic drain exits in the right lower quadrant. Another drain,\\n possibly biliary, extends from the region of the porta and exits the anterior\\n abdomen near the midline below the umbilicus. A nasogastric tube is present,\\n and an IVC filter is noted.\\n\\n Limited imaging of the lung bases shows consolidation with air bronchograms in\\n the right lung base, possibly representing pneumonia, particularly in the\\n given clinical setting. A small right pleural effusion has developed.\\n\\n (Over)\\n\\n 10:01 AM\\n CTA ABD W&W/O C & RECONS; 200CC NON IONIC CONTRAST SUPPLY Clip # \\n Reason: SPIKING TEMPS, OPEN FASCIA, S/P LIVER TRANSPLANT, EVALUATE FOR HEPATIC FLOW IN PHASES\\n Admitting Diagnosis: LIVER FAILURE\\n Field of view: 40 Contrast: OPTIRAY Amt: 200\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n CT PELVIS WITH CONTRAST: A Foley catheter is present in the mostly\\n decompressed bladder. There is mild presacral edema. The pelvic viscera are\\n unremarkable. No pelvic mass, lymphadenopathy or fluid collection is detected.\\n\\n CT RECONSTRUCTIONS: Coronal and sagittal reformatting was performed for\\n additional assessment of the abdominal and pelvic viscera. As stated above,\\n the suboptimal intravenous access and bolus timing limits the evaluation of\\n the hepatic vasculature. There is minimal scattered fluid without discrete\\n collection.\\n\\n BONE WINDOWS: No suspicious lytic or blastic lesions are detected.\\n\\n IMPRESSION:\\n 1. Suboptimal evaluation of the hepatic vasculature.\\n 2. Persistent splenomegaly.\\n 3. A small right pleural effusion. Right basilar consolidation may represent\\n pneumonia, particularly in the given clinical scenario.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2179-03-17 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 858446,\n \"text\": \" 1:56 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for infiltrate, plugging\\n Admitting Diagnosis: LIVER FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 48F s/p liver txp, now with desats\\n REASON FOR THIS EXAMINATION:\\n eval for infiltrate, plugging\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST SINGLE AP FILM:\\n\\n HISTORY: Liver transplant with oxygen desaturation.\\n\\n Endotracheal tube is 3 cm above the carina. Right jugular CV line is in right\\n atrium. Suggest withdrawal 3-4 cm. NG tube is in stomach with distal\\n end not included on the film. No pneumothorax. Allowing for technique, the\\n heart size is normal. No evidence for CHF. There is a right sided pleural\\n effusion with associated atelectasis in the right lower zone.\\n\\n IMPRESSION:\\n\\n Jugular CV line is in right atrium. No pneumothorax. Right pleural effusion\\n with associated right lower zone atelectasis.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2179-03-16 00:00:00.000\",\n \"description\": \"BILAT LOWER EXT VEINS\",\n \"row_id\": 858317,\n \"text\": \" 2:08 PM\\n BILAT LOWER EXT VEINS Clip # \\n Reason: please evaluate for DVT\\n Admitting Diagnosis: LIVER FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 48 year old woman with\\n REASON FOR THIS EXAMINATION:\\n please evaluate for DVT\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL INDICATION: Lower extremity swelling, assess for DVT.\\n\\n BILATERAL LOWER EXTREMITY VEINS ULTRASOUND: Grayscale and color Doppler\\n images of both common femoral, superficial femoral, and popliteal veins were\\n obtained. Normal waveforms, compressibility and augmentation are\\n demonstrated. No intraluminal thrombus is identified.\\n\\n IMPRESSION: No evidence of lower extremity DVT.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2179-03-17 00:00:00.000\",\n \"description\": \"LIVER OR GALLBLADDER US (SINGLE ORGAN)\",\n \"row_id\": 858492,\n \"text\": \" 8:40 PM\\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \\n DUPLEX DOPP ABD/PEL\\n Reason: ELEV LFTS, LIVER TX, ASSESS VASCULAR STRUCTURES\\n Admitting Diagnosis: LIVER FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 48 year old woman with HCV cirrhosis and varices admitted with hematemisis\\n - now s/p redo tips - would like to re-eval tips to obtain baseline flow\\n velocities\\n REASON FOR THIS EXAMINATION:\\n sp liver transplant asesse vascular structures\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Status post liver transplant with elevated LFTs.\\n\\n COMPARISON: Comparison is made to .\\n\\n TRANSPLANT ULTRASOUND WITH COLOR DOPPLER: -scale images show no focal or\\n diffuse hepatic abnormalities. There is no evidence of intrahepatic bile duct\\n dilatation. Trace amount of fluid around the liver in the Morison's pouch.\\n\\n Color Doppler images of the liver were obtained. The main, right, and left\\n portal veins are patent with blood flow in the appropriate direction. The\\n intrahepatic portions of the left and right hepatic arteries are also\\n demonstrated with normal appearing waveforms. Resistive indices are\\n 0.83-0.84. The main hepatic artery is patent. The hepatic veins and the\\n inferior vena cava are patent.\\n\\n IMPRESSION:\\n 1) The hepatic vessels are patent.\\n 2) Trace amount of fluid around the liver.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2179-03-16 00:00:00.000\",\n \"description\": \"CT ABDOMEN W/CONTRAST\",\n \"row_id\": 858349,\n \"text\": \" 4:54 PM\\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \\n CT 150CC NONIONIC CONTRAST\\n Reason: SP Liver tx please eval for intraabdominal abscess\\n Admitting Diagnosis: LIVER FAILURE\\n Field of view: 36 Contrast: OPTIRAY Amt: 150\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 48 year old woman with\\n\\n REASON FOR THIS EXAMINATION:\\n SP Liver tx please eval for intraabdominal abscess\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Status post liver transplant. Evaluate for intraabdominal abscess.\\n\\n COMPARISON: .\\n\\n TECHNIQUE: MDCT acquired contiguous axial images from the lung bases to the\\n pubic symphysis were obtained following the administration of 150 cc of IV\\n Optiray. Nonionic contrast was administered secondary to patient request.\\n\\n CT OF THE ABDOMEN WITH IV CONTRAST: Again demonstrated is right lower lobe\\n collapse/consolidation with air bronchograms, not significantly changed since\\n the prior examination, along with a small right pleural effusion.\\n Additionally, within the periphery of the right middle lobe, there is an ill-\\n defined nodular opacity seen measuring approximately 1 cm. A second nodular,\\n peripherally based opacity is also demonstrated within the right lower lobe\\n which measures approximately 1.1 cm. Minor atelectatic changes are noted\\n within the left lower lobe.\\n\\n Again, demonstrated within the transplanted liver are several tiny\\n hypodensities, unchanged since the prior examination, too small to fully\\n characterize. A mild amount of periportal edema is again noted. The portal\\n vein is patent. There is no intrahepatic biliary ductal dilatation seen. A\\n catheter is again noted, likely representing a biliary drain, extending from\\n the region of the porta and exiting via the anterior abdomen near the\\n umbilicus. The gallbladder is not visualized. Small amount of perihepatic\\n fluid is present as well as fluid within pouch extending anterior\\n to the duodenum; the amount of fluid has mildly increased since the prior\\n exam. No focal fluid collections are identified. The spleen is stablely\\n enlarged. The adrenal glands, kidneys, ureters, stomach, and loops of large\\n and small bowel, all appear within normal limits. A nasogastric tube is\\n identified with tip in the stomach. Multiple surgical clips are noted within\\n the pericaval region, they are unchanged since the prior examination. An\\n inferior vena cava filter is again noted in an infrarenal position. There is\\n no definite evidence for bowel obstruction.\\n\\n CT OF THE PELVIS WITH IV CONTRAST: A small amount of free fluid is noted\\n within the pelvis. The ureters, rectum, sigmoid colon are all within normal\\n limits. A Foley catheter is again visualized within the bladder with a small\\n amount of air. There is no pelvic or inguinal lymphadenopathy.\\n (Over)\\n\\n 4:54 PM\\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \\n CT 150CC NONIONIC CONTRAST\\n Reason: SP Liver tx please eval for intraabdominal abscess\\n Admitting Diagnosis: LIVER FAILURE\\n Field of view: 36 Contrast: OPTIRAY Amt: 150\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n Some soft tissue stranding is demonstrated along the right lateral\\n subcutaneous tissues, likely related to postoperative changes.\\n\\n BONE WINDOWS: No suspicious lytic or sclerotic lesions are seen.\\n\\n IMPRESSION:\\n 1. No definite focal fluid collections identified to suggest an abscess.\\n\\n 2. Stable appearance of right lower lobe collapse/consolidation and small\\n right pleural effusion.\\n\\n 3. Two ill-defined nodular opacities identified within the right middle lobe\\n and right lower lobe peripherally, which may represent an infectious etiology.\\n\\n 4. Mildly increased amount of fluid within pouch and anterior to\\n the duodenum.\\n\\n 5. Stable splenomegaly.\\n\\n\\n\\n\\n\\n DFDdp\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2179-03-12 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 857820,\n \"text\": \" 8:11 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: r/o pneumonia\\n Admitting Diagnosis: LIVER FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 48F s/p liver txp, now s/p swan replacement\\n\\n REASON FOR THIS EXAMINATION:\\n r/o pneumonia\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: A 48-year-old female status post liver transplant. Please\\n evaluate Swan-Ganz catheter placement.\\n\\n FINDINGS:\\n\\n Single AP view of the chest dated is compared with a single AP view\\n of the chest dated . Endotracheal tube is 2.5 cm above the carina.\\n The right internal jugular line terminates in the right atrium. The new left\\n subclavian central line also terminates in the right atrium. The NG tube has\\n been advanced, and its sideport is now located 3 cm distal to the GE junction.\\n NG tube tip is in the body of the stomach. A drain remains in the right upper\\n quadrant. There are skin staples overlying the mid abdomen. Clips and an IVC\\n filter are seen in the mid abdomen.\\n\\n The lung volumes are low, likely secondary to technique. The lungs are clear\\n without focal consolidation. There is no significant pulmonary venous\\n congestion. There are no pleural effusions or pneumothorax. Heart and\\n mediastinal contours remain unchanged.\\n\\n IMPRESSION:\\n\\n New left subclavian central line with its tip terminating in the right atrium.\\n No pneumothorax. The lung fields are clear.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2179-03-21 00:00:00.000\",\n \"description\": \"NASO-INTESTINAL TUBE PLACEMENT (W/FLUORO)\",\n \"row_id\": 858896,\n \"text\": \" 3:29 PM\\n -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # \\n Reason: post pyloric tube\\n Admitting Diagnosis: LIVER FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n please place post piloric tube this am for feedings sp liver transplant\\n\\n REASON FOR THIS EXAMINATION:\\n post pyloric tube\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Dobbhoff tube placed. Please advance to postpyloric position for\\n feeding status post liver transplant. The patient has a history of\\n aspiration.\\n\\n COMPARISON: Portable abdomen dated .\\n\\n The patient arrived in the department with a Dobbhoff tube in place, with the\\n tip located within the stomach at the pylorus. Under fluoroscopic guidance,\\n the tip of the tube was advanced into the postpyloric position, approximately\\n into the third portion of the duodenum. Approximately 10 cc of nonionic\\n contrast was instilled, confirming the tube's positioning within the duodenum.\\n Surgical staples overly the skin of the abdomen, and there are surgical clips\\n located within the right upper quadrant.\\n\\n IMPRESSION: Successful advancement of the Dobbhoff feeding tube into the\\n third portion of the duodenum.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2179-03-12 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 857906,\n \"text\": \" 7:35 PM\\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \\n Reason: eval R TLC position\\n Admitting Diagnosis: LIVER FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 48F s/p liver txp, now s/p line replacment\\n\\n REASON FOR THIS EXAMINATION:\\n eval R TLC position\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Status post line replacement, evaluate triple lumen catheter\\n position.\\n\\n COMPARISON: .\\n\\n TECHNIQUE: Single AP portable semiupright chest.\\n\\n FINDINGS: An endotracheal tube is in place with the tip terminating 3.1 cm\\n from the carina. A nasogastric tube extends below the diaphragm, with the tip\\n terminating below the borders of the radiograph. A right internal jugular\\n venous access catheter is in place with the tip terminating at the level of\\n the SVC/RA junction. Left subclavian venous access catheter with tip in the\\n distal SVC. JP drain in the right upper quadrant. Surgical clips in the\\n right upper quadrant. Inferior vena cava filter. Surgical skin staples\\n overlying the mid abdomen. The heart size and mediastinal contours are\\n unchanged. There is new hazy opacity at the right base with relative\\n preservation of the right hemidiaphragm, findings that could be related to\\n layering small pleural effusion at the right base. No pneumothorax. The\\n osseous structures are unchanged.\\n\\n IMPRESSION:\\n\\n 1) Right internal jugular venous access catheter tip at the RA/SVC junction.\\n The nasogastric tube has been advanced. Other lines and tubes are in\\n unchanged position.\\n\\n 2) New hazy opacity at the right base, consistent with layering right pleural\\n effusion.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2179-03-19 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 858735,\n \"text\": \" 3:17 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval tip position\\n Admitting Diagnosis: LIVER FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 48F s/p liver txp, now S/P LINE EXCHANGE\\n REASON FOR THIS EXAMINATION:\\n eval tip position\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 48-year-old woman status post liver transplant, line exchange.\\n\\n TECHNIQUE: Portable AP chest radiograph.\\n\\n Comparison is made with the prior chest radiograph dated .\\n\\n FINDINGS: Right IJ line terminates at the junction of SVC and right atrium.\\n No pneumothorax is identified. The patient has been extubated. The cardiac\\n and mediastinal contours are unchanged. Again note is made of bilateral\\n pleural effusions with right lower lobe atelectasis.\\n\\n IMPRESSION:\\n\\n Tubes and lines as described above. Persistent pleural effusion with right\\n lower lobe atelectasis.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2179-03-02 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 856645,\n \"text\": \" 2:40 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: line placement\\n Admitting Diagnosis: LIVER FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 48 year s/p liver transplant\\n REASON FOR THIS EXAMINATION:\\n line placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Status post liver transplant. Line placement.\\n\\n COMPARISON: .\\n\\n SUPINE AP CHEST: There is interval placement of an endotracheal tube, with\\n the tip located approximately 5 cm from the carina. A right internal jugular\\n Swan-Ganz catheter has been placed, with the tip overlying the expected main\\n pulmonary artery. A left internal jugular central venous catheter sheath is\\n present, with the tip overlying the left brachiocephalic vein. A small\\n caliber left subclavian central venous catheter is present with the tip\\n overlying the distal SVC. An NG tube is seen with the tip in the expected\\n stomach. The cardiac and mediastinal contours are unchanged. There are\\n bilateral effusions layering posteriorly, with associated left lower lobe\\n atelectasis. Within the abdomen, there is a surgical drain within the right\\n upper quadrant. There is also an inferior vena cava filter. No pneumothorax\\n is detected on this supine radiograph.\\n\\n IMPRESSION:\\n\\n Status post liver transplant. Multiple tubes and lines as described. No\\n pneumothorax detected.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2179-03-01 00:00:00.000\",\n \"description\": \"CHEST (PRE-OP PA & LAT)\",\n \"row_id\": 856461,\n \"text\": \" 7:28 AM\\n CHEST (PRE-OP PA & LAT) Clip # \\n Reason: LIVER FAILURE\\n Admitting Diagnosis: LIVER FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 48 year old woman with\\n REASON FOR THIS EXAMINATION:\\n pre-op\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL INDICATION: Preoperative assessment.\\n\\n Comparison is made to previous chest radiograph of .\\n\\n The heart size, mediastinal, and hilar contours are normal. Previously noted\\n pulmonary vascular redistribution and perihilar haziness have resolved in the\\n interval. There are no pleural effusions. Scoliosis is noted.\\n\\n IMPRESSION:\\n\\n No evidence of acute cardiopulmonary process.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2179-03-06 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 857086,\n \"text\": \" 9:01 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: follow up chf\\n Admitting Diagnosis: LIVER FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 48 year s/p liver transplant\\n\\n REASON FOR THIS EXAMINATION:\\n follow up chf\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: A 48-year-old female with status post liver transplant, follow up\\n CHF.\\n\\n COMPARISON: .\\n\\n TECHNIQUE: AP upright single view of the chest.\\n\\n FINDINGS:\\n\\n There is a right IJ Swan-Ganz catheter with the tip in the pulmonary artery\\n trunk. There is interval removal of the left IJ Cordis. The ET tube is\\n located at the level of the thoracic inlet. There is an NG tube with the tip\\n in the stomach. There is a left subclavian central line with the tip in the\\n SVC. Cardiac, mediastinal, and hilar contours are unchanged when compared to\\n prior study. There is interval slight improvement in the pulmonary edema.\\n There is a right effusion. There is no evidence of pneumothorax. There are\\n skin staples overlying the upper abdomen. There are multiple surgical clips\\n in the right upper quadrant.\\n\\n IMPRESSION:\\n Slight improvement of pulmonary edema. Lines and tubes as described above.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2179-03-02 00:00:00.000\",\n \"description\": \"DUPLEX DOP ABD/PEL LIMITED\",\n \"row_id\": 856634,\n \"text\": \" 1:53 PM\\n DUPLEX DOP ABD/PEL LIMITED Clip # \\n Reason: liver transplant duplex: hepatic artery, hepatic veins, port\\n Admitting Diagnosis: LIVER FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 48 year old woman with HCV cirrhosis and varices admitted with hematemisis -\\n now s/p redo tips - would like to re-eval tips to obtain baseline flow\\n velocities\\n REASON FOR THIS EXAMINATION:\\n liver transplant duplex: hepatic artery, hepatic veins, portal vein, blie duct\\n dil, peri hepatic fluid\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATIONS: A 48-year-old woman with HCV cirrhosis and varices, status post\\n liver transplant, for evaluation.\\n\\n TECHNIQUE: Duplex Doppler examination of the liver.\\n\\n FINDINGS: The echotexture of the liver is somewhat coarse. The main, right,\\n and left hepatic arteries are patent with appropriate arterial flow, and\\n resistive indices ranging from 0.53-0.61. The main, left, and right portal\\n veins are patent and show appropriate hepatpetal flow on Doppler color and\\n waveform examinations. The right, middle, and left hepatic veins are patent\\n with appropriate directional flow.\\n\\n IMPRESSION: Appropriate flow in the major hepatic arteries and veins, and in\\n major portal veins.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2179-03-09 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 857456,\n \"text\": \" 12:01 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval tip position\\n Admitting Diagnosis: LIVER FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 48F s/p liver txp, now s/p swan replacement\\n REASON FOR THIS EXAMINATION:\\n eval tip position\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: A 48-year-old female status post liver transplant with placement\\n of Swan-Ganz catheter. Please evaluate position of tip.\\n\\n FINDINGS:\\n\\n Single AP view of the chest dated is compared with the previous\\n exam dated , also a single AP view. The tip of the Swan-Ganz\\n catheter is positioned in the right lower lobe pulmonary artery. There has\\n been interval improvement in the right pleural effusion. Overall, the degree\\n of congestive heart failure has improved. The endotracheal tube is\\n approximately 3 cm above the carina. The left subclavian central line tip\\n terminates in the mid SVC. The NG tube terminates in the mid stomach. The\\n cardiac, mediastinal, and hilar contours are essentially unchanged from the\\n prior exam. There is a drain within the right upper quadrant. Skin staples\\n overlie the upper abdomen.\\n\\n IMPRESSION:\\n\\n Swan-Ganz catheter in the right pulmonary artery. Interval improvement in the\\n right pleural effusion. Improved CHF.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2179-03-21 00:00:00.000\",\n \"description\": \"PORTABLE ABDOMEN\",\n \"row_id\": 858870,\n \"text\": \" 2:01 PM\\n PORTABLE ABDOMEN; -59 DISTINCT PROCEDURAL SERVICE Clip # \\n Reason: eval tip position\\n Admitting Diagnosis: LIVER FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 48F s/p dobhoff placement\\n REASON FOR THIS EXAMINATION:\\n eval tip position\\n ______________________________________________________________________________\\n FINAL REPORT\\n STUDY: Chest, single view.\\n\\n HISTORY: Status post Dobbhoff placement.\\n\\n FINDINGS: Feeding tube is present with tip probably in the first portion of\\n the duodenum. Skin staples are present. There is some prominent loops of\\n bowel that measure up to 5 cm. It is unclear if these are small or large\\n bowel. There is a right pleural effusion.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2179-03-10 00:00:00.000\",\n \"description\": \"CHALNAGIOGRAPHY VIA EXISTING CATHETER\",\n \"row_id\": 857613,\n \"text\": \" 2:35 PM\\n CHALNAGIOGRAPHY VIA EXISTING CATHETER Clip # \\n Reason: evaluate biliary tree, please do to gravity, page with\\n Admitting Diagnosis: LIVER FAILURE\\n Contrast: OPTIRAY Amt: 15\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 48 year old woman s/p liver transplant with rising bilirubin\\n REASON FOR THIS EXAMINATION:\\n evaluate biliary tree, please do to gravity, page with questions\\n ______________________________________________________________________________\\n FINAL REPORT\\n\\n\\n\\n\\n\\n HISTORY: 48 year-old female status post liver transplant with elevated liver\\n function tests. Please performe gravity injection tube cholangiogram.\\n\\n PROCEDURE/FINDINGS: The procedure was performed by Dr. and Dr.\\n . Dr. , the staff radiologist, was present and supervising\\n throughout. The patient was placed supine on the angiography table. Her\\n abdomen was prepped and draped in the standard sterile fashion. A\\n fluoroscopic spot film of the abdomen was obtained, demonstrating multiple\\n surgical clips within the abdominal cavity, along with an IVC filter. A tube\\n cholangiogram was then performed via gravity injection of nonionic contrast.\\n This revealed opacification of the left and right hepatic ducts. The left\\n hepatic duct appears mildly prominent. Upon further imaging, there was free\\n but slow filling of the bowel lumen beyond the choledocho-jejunal anastomosis.\\n No leak or stricture was identified. Following the cholangiogram, the\\n contrast was gently aspirated from the catheter and the catheter was again\\n placed to external bag drainage.\\n\\n COMPLICATIONS: None.\\n\\n CONTRAST: 15 cc of 60% Optiray.\\n\\n IMPRESSION: Tube cholangiography via the indwelling surgical T-tube\\n demonstrates normal common and right hepatic ducts. There is mild prominence\\n of the left hepatic duct. There was free but delayed emptying into the bowel\\n lumen beyond the choledocho-jejunal anastomosis without evidence of narrowing\\n or leak.\\n\\n These findings were discussed with the transplant surgery service at the time\\n of the procedure.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2179-03-04 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 856850,\n \"text\": \" 10:40 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: s/p OLT, ? fluid overload\\n Admitting Diagnosis: LIVER FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 48 year s/p liver transplant\\n\\n REASON FOR THIS EXAMINATION:\\n s/p OLT, ? fluid overload\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Status post liver transplant. Question fluid overload.\\n\\n COMPARISON: .\\n\\n SUPINE AP CHEST: The endotracheal tube, left internal jugular catheter\\n sheath, right internal jugular Swan-Ganz catheter, left subclavian central\\n line, NG tube, surgical drains, and IVC filter are unchanged in position\\n compared to the prior exam. The Swan-Ganz catheter tip may be slightly\\n retracted and within the main pulmonary artery. No pneumothorax is detected\\n on this supine radiograph. The cardiac and mediastinal contours are stable.\\n The lungs are relatively clear, without frank vascular congestion or\\n consolidation present. The right pleural effusion is not as prominent on the\\n current study.\\n\\n IMPRESSION:\\n\\n Relatively unchanged appearance of the chest compared to 12 hours previous.\\n No evidence of frank fluid overload.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2179-03-22 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 859003,\n \"text\": \" 2:05 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: UPRIGHT FILM to eval right effusion\\n Admitting Diagnosis: LIVER FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 48F s/p liver txp\\n REASON FOR THIS EXAMINATION:\\n UPRIGHT FILM to eval right effusion\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 48-year-old female status post liver transplant. Single AP view\\n of the chest dated , is compared to the same examination on\\n . The right internal jugular central venous catheter is again\\n seen terminating at the junction of the superior vena cava and right atrium.\\n There is no pneumothorax. A Dobhoff nasogastric tube terminates in the third\\n part of the duodenum. Cardiac and mediastinal contours are unchanged. There\\n is interval improvement in the bilateral small pleural effusions. Right\\n basilar atelectasis remains. There are no focal areas of opacity to suggest a\\n consolidation. Splenomegaly.\\n\\n IMPRESSION:\\n 1. Interval improvement in bilateral pleural effusions. Right basilar\\n atelectasis.\\n 2. No focal consolidations noted.\\n 3. Splenomegaly.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2179-03-05 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 856965,\n \"text\": \" 7:31 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: monitor ? pleural effusion\\n Admitting Diagnosis: LIVER FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 48 year s/p liver transplant\\n\\n REASON FOR THIS EXAMINATION:\\n monitor ? pleural effusion\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Status post liver transplant. Assess pleural effusion.\\n\\n COMPARISON: .\\n\\n SUPINE AP CHEST: The endotracheal tube, left internal jugular central venous\\n catheter sheath, left subclavian central venous catheter, NG tube, and\\n surgical drains are unchanged in position. The right internal jugular\\n Swan-Ganz catheter tip has been advanced into the right main pulmonary artery.\\n The cardiac and mediastinal contours are stable. On the current study, a\\n right pleural effusion layering posteriorly is well visualized. Differences\\n in the appearance of the right pleural effusion in the recent preceding exams\\n is likely related to differences in patient positioning. No evidence of left\\n effusion. The lungs are relatively well aerated, without vascular congestion\\n or consolidation.\\n\\n IMPRESSION:\\n\\n Right pleural effusion. Differences in recent examinations likely reflects\\n differences in patient positioning.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2179-03-03 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 856811,\n \"text\": \" 10:50 PM\\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \\n Reason: dropping sats\\n Admitting Diagnosis: LIVER FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 48 year s/p liver transplant\\n\\n REASON FOR THIS EXAMINATION:\\n dropping sats\\n ______________________________________________________________________________\\n FINAL REPORT\\n STUDY: Portable chest .\\n\\n COMPARISON: To previous study of earlier the same date.\\n\\n INDICATION: Liver transplantation. Dropping oxygen saturation.\\n\\n FINDINGS:\\n\\n Various lines and tubes are in satisfactory position. Cardiac and mediastinal\\n contours appear stable. Bilateral perihilar haziness is again demonstrated.\\n There is an increasing pleural effusion on the right, small to moderate in\\n size. Atelectatic changes are noted at the lung bases. With the exception of\\n increasing pleural effusion on the right, there has otherwise been no\\n significant change. Postoperative changes are noted in the abdomen.\\n\\n IMPRESSION:\\n\\n Increasing right pleural effusion with otherwise stable chest radiographic\\n appearance.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2179-03-18 00:00:00.000\",\n \"description\": \"BX-NEEDLE LIVER BY RADIOLOGIST\",\n \"row_id\": 858555,\n \"text\": \" 9:32 AM\\n BX-NEEDLE LIVER BY RADIOLOGIST Clip # \\n Reason: r/o rejection\\n Admitting Diagnosis: LIVER FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 48F HCV cirrhosis s/p OLT with rising LFTs\\n REASON FOR THIS EXAMINATION:\\n r/o rejection\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL INDICATION: Status post liver transplant, now with rising liver\\n function tests. The patient presents for ultrasound-guided liver biopsy.\\n\\n The proposed procedure was explained in detail with the patient's sister, who\\n serves as her healthcare proxy. The potential risks and benefits of the\\n procedure were discussed. Signed consent was then obtained from the patient's\\n sister. timeout was employed to verify the patient's identity\\n and the planned biopsy site.\\n\\n LIVER BIOPSY BY RADIOLOGIST: The procedure took place within the surgical\\n intensive care unit. An appropriate spot was marked on the skin of the\\n patient's anterior abdomen, overlying the anterior aspect of the liver\\n transplant, using son localization. The area was then prepped and\\n draped in the standard sterile fashion. Local anesthesia was achieved with 1%\\n lidocaine. Using continuous son guidance, a single 18-gauge core\\n biopsy of the transplanted liver was obtained. The patient tolerated the\\n procedure well without any immediate post-procedure complications. The\\n specimen was immediately transported to pathology for further analysis.\\n\\n Dr. , the staff radiologist, was present and supervised the entire\\n procedure.\\n\\n IMPRESSION: Successful 18-gauge core biopsy of a transplanted liver.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2179-03-16 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 858249,\n \"text\": \" 9:01 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: slow weaning off vent. ? pna\\n Admitting Diagnosis: LIVER FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 48F s/p liver txp, now s/p line replacment\\n\\n REASON FOR THIS EXAMINATION:\\n slow weaning off vent. ? pna\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: A 48-year-old woman status post liver transplant with replacement\\n of central line. Difficulty weaning off the ventilator.\\n\\n Single AP view of the chest dated is compared with a single AP\\n view of the chest from . An endotracheal tube terminates 3.5 cm\\n above the carina. The NG tube terminates below the diaphragm, however, the\\n tip courses off the imaged portion of the film. The left subclavian central\\n line has been removed. A right interval jugular central line terminates in\\n the right atrium. The right subdiaphragmatic drainage tube has been removed.\\n Clips are present in the mid-right abdomen. Skin staples are seen overlying\\n the mid-abdomen.\\n\\n There are no focal areas of opacity to suggest consolidation. A right pleural\\n effusion remains with associated compression atelectasis of the right lower\\n lobe. The heart size and mediastinal contours are unchanged. There is no\\n pneumothorax. The osseous structures are unchanged.\\n\\n IMPRESSION:\\n 1. Persistent right-sided pleural effusion with associated right lower lobe\\n compression atelectasis. No focal areas of consolidation to suggest\\n pneumonia.\\n 2. Tubes and lines changed as above.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2179-03-11 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 857687,\n \"text\": \" 7:30 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: interval changes\\n Admitting Diagnosis: LIVER FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 48F s/p liver txp, now s/p swan replacement\\n REASON FOR THIS EXAMINATION:\\n interval changes\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: A 48-year-old female with liver transplant. Swan-Ganz catheter\\n placement.\\n\\n TECHNIQUE: Portable AP chest radiograph.\\n\\n The comparison is made with a prior chest radiograph dated .\\n\\n FINDINGS:\\n\\n The endotracheal tube, left subclavian venous line, and right-sided drainage\\n tube are unchanged compared to the prior study. Swan-Ganz catheter is\\n terminating in the right interlobar pulmonary artery. Left apex is not\\n included in the present study; however, no pneumothorax is noted. The cardiac\\n and mediastinal contours are within normal limits. No consolidation noted.\\n\\n IMPRESSION:\\n\\n Tubes and lines as described above. Swan-Ganz catheter terminating in the\\n right interlobar pulmonary artery. Left apex is not included in the present\\n study.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2179-03-04 00:00:00.000\",\n \"description\": \"P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT\",\n \"row_id\": 856846,\n \"text\": \" 9:11 AM\\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT; -59 DISTINCT PROCEDURAL SERVICEClip # \\n DUPLEX DOPP ABD/PEL\\n Reason: transplant liver. assess portal vein, hepatic vein, hepatic\\n Admitting Diagnosis: LIVER FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 48 year old woman with HCV cirrhosis and varices admitted with hematemisis -\\n now s/p redo tips - would like to re-eval tips to obtain baseline flow\\n velocities\\n REASON FOR THIS EXAMINATION:\\n transplant liver. assess portal vein, hepatic vein, hepatic artery, and bile\\n ducts.\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL INDICATION: Recent history of a liver transplant, assess bile ducts\\n and blood flow.\\n\\n COMPARISONS: Liver ultrasound of .\\n\\n LIVER ULTRASOUND WITH COLOR DOPPLER: Grayscale images show no focal or\\n diffuse hepatic abnormalities. There is no evidence of intrahepatic ductal\\n dilatation. No perihepatic fluid collections are identified.\\n\\n Color Doppler images of the liver were also obtained. The main, right, and\\n left portal veins are patent, with blood flow in the appropriate direction.\\n Velocities within the main portal vein ranged from 60-80 cm/sec. The\\n intrahepatic portions of the left and right hepatic arteries also demonstrate\\n normal-appearing waveforms, with brisk upstrokes. The resistive indices range\\n from 0.62-0.77. The main hepatic artery is patent. The hepatic veins and\\n inferior vena cava are also patent, with flow in the appropriate direction.\\n\\n IMPRESSION: Son appearance of the transplant liver is within normal\\n limits. Patent intrahepatic vasculature, as discussed above.\\n\\n These findings were discussed with the surgical house staff caring for the\\n patient at the time of the exam on .\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2179-03-03 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 856711,\n \"text\": \" 7:49 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: evaluate for pulm edema\\n Admitting Diagnosis: LIVER FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 48 year s/p liver transplant\\n\\n REASON FOR THIS EXAMINATION:\\n evaluate for pulm edema\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Status post liver transplant. Evaluate for pulmonary edema.\\n\\n COMPARISON: .\\n\\n SUPINE AP CHEST: The endotracheal tube, left internal jugular central venous\\n catheter sheath, left subclavian central venous catheter, and NG tubes are\\n unchanged in position. The right internal jugular Swan-Ganz catheter is\\n probably unchanged in position, though multiple wires overlie the region of\\n interest on this exam. The surgical clips and drain are unchanged as well.\\n The cardiac and mediastinal contours are stable. There is no definite\\n evidence of pulmonary edema, appearance of the lungs and vasculature is\\n unchanged from one day ago. No pleural effusions identified. No pneumothorax\\n identified.\\n\\n IMPRESSION:\\n\\n No evidence of pulmonary edema. The appearance of the chest is unchanged from\\n one day ago.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2179-03-24 00:00:00.000\",\n \"description\": \"NASO-INTESTINAL TUBE PLACEMENT (W/FLUORO)\",\n \"row_id\": 859326,\n \"text\": \" 4:25 PM\\n -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # \\n Reason: please plase post-pyloric Dobhoff on AM.\\n Admitting Diagnosis: LIVER FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 48 year old woman s/p OLT, needing post-pyloric Dobhoff\\n REASON FOR THIS EXAMINATION:\\n please plase post-pyloric Dobhoff on AM.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: A 48-year-old woman status post liver transplant requiring\\n postpyloric feeding tube.\\n\\n PROCEDURE AND FINDINGS: After coating the weighted feeding tube with\\n lidocaine jelly, the tube was advanced through the right nostril into the\\n stomach. Air and 5 cc of Conray were infused to elucidate the gastric\\n anatomy. The wire was then replaced and the tube was advanced into the\\n duodenum and past the ligament of Treitz. The wire was removed. Final\\n injection of contrast demonstrated appropriate positioning of the tube tip in\\n the proximal jejunum. The tube was secured with tape. The patient tolerated\\n the procedure well and there are no immediate post-procedural complications.\\n\\n IMPRESSION: Successful placement of nasojejunal feeding tube.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2179-03-30 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 859975,\n \"text\": \" 9:27 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: sp guide wire line\\n Admitting Diagnosis: LIVER FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n sp liver tx/ wire line\\n REASON FOR THIS EXAMINATION:\\n sp guide wire line\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Guide wire line placement.\\n\\n Comparison .\\n\\n A right internal jugular vascular catheter is present, terminating in the\\n lower portion of the right atrium. There is no pneumothorax. A feeding tube\\n terminates in the duodenum. Cardiac and mediastinal contours are within\\n normal limits. There is improving opacity at the right base with minimal\\n residual patchy opacity remaining. The lungs are otherwise clear.\\n\\n IMPRESSION:\\n\\n 1) Low position of right internal jugular vascular catheter, terminating\\n within the lower portion of the right atrium. No pneumothorax.\\n\\n 2) Resolving right basilar opacity, most likely due to atelectasis.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2179-03-30 00:00:00.000\",\n \"description\": \"ABDOMEN (SUPINE & ERECT)\",\n \"row_id\": 860053,\n \"text\": \" 4:46 PM\\n ABDOMEN (SUPINE & ERECT) Clip # \\n Reason: assess for obstruction\\n Admitting Diagnosis: LIVER FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 48 year old woman with diarrhea s/p liver transplant\\n REASON FOR THIS EXAMINATION:\\n assess for obstruction\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 48-year-old woman with diarrhea status post liver transplant.\\n\\n SUPINE AND UPRIGHT ABDOMEN: There is a normal bowel gas pattern without\\n evidence of dilatation or obstruction. There is no free intraperitoneal air.\\n A feeding tube is seen with the tip in the third portion of the duodenum. A\\n TrapEase IVC filter is noted. Surgical clips are seen within the right upper\\n quadrant of the abdomen. A surgical tube is seen with the tip terminating in\\n the right upper quadrant. Osseous structures are remarkable for degenerative\\n changes at the lower lumbar spine.\\n\\n IMPRESSION: Normal bowel gas pattern without evidence of obstruction.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2179-03-29 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 859804,\n \"text\": \" 6:06 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: please perform a thoracoabdominal film. For feeding tube pos\\n Admitting Diagnosis: LIVER FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 48F s/p liver txp\\n\\n REASON FOR THIS EXAMINATION:\\n please perform a thoracoabdominal film. For feeding tube position\\n ______________________________________________________________________________\\n FINAL REPORT\\n This is a portable chest .\\n\\n COMPARISON: .\\n\\n INDICATION: Feeding tube placement.\\n\\n The radiograph was obtained centered at the thoracoabdominal junction for\\n feeding tube assessment. It demonstrates a feeding tube within the duodenum.\\n A right internal jugular vascular catheter is unchanged in position. Cardiac\\n and mediastinal contours are stable. A small right pleural effusion and\\n patchy right basilar opacity are unchanged allowing for positional\\n differences.\\n\\n IMPRESSION: Feeding tube terminates within the duodenum.\\n\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2179-03-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 100266,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Tachycardia. Assess left ventricular function.\\nHeight: (in) 62\\nWeight (lb): 165\\nBSA (m2): 1.76 m2\\nBP (mm Hg): 123/74\\nHR (bpm): 142\\nStatus: Inpatient\\nDate/Time: at 13:57\\nTest: Portable TTE (Complete)\\nDoppler: Full doppler and color doppler\\nContrast: None\\nTechnical Quality: Suboptimal\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT ATRIUM: Normal LA size.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or pacing wire is\\nseen in the RA and/or RV.\\n\\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function\\n(LVEF>55%).\\n\\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\\n\\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No valvular\\nAS. The increased transaortic gradient related to high cardiac output. Mild\\n(1+) AR.\\n\\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Trivial MR.\\n\\nTRICUSPID VALVE: Tricuspid valve not well visualized.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\\n\\nPERICARDIUM: No pericardial effusion.\\n\\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Resting\\ntachycardia (HR>100bpm).\\n\\nConclusions:\\nThe patient is tachycardic. The left atrium is normal in size. Left\\nventricular wall thickness, cavity size, and systolic function are normal\\n(LVEF>55%). Right ventricular chamber size and free wall motion are normal.\\nThe aortic valve leaflets (3) are mildly thickened but aortic stenosis is not\\npresent. There is no valvular aortic stenosis. The increased transaortic\\ngradient is likely related to high cardiac output. Mild (1+) aortic\\nregurgitation is seen. The mitral valve leaflets are mildly thickened. There\\nis no mitral valve prolapse. Trivial mitral regurgitation is seen. There is no\\npericardial effusion.\\n\\nCompared with the findings of the prior study (tape reviewed) of , other\\nthan the tachycardia, probably no significant change.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2179-03-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 276275,\n \"text\": \"Sinus tachycardia. Borderline low voltage in the limb leads. Compared to the\\nprevious tracing of the rate has slowed. Although, tachycardia persists.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2179-03-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 276276,\n \"text\": \"Sinus tachycardia. Otherwise, probably normal ECG. Since the previous tracing\\nof sinus tachycardia rate has increased.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2179-03-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 276277,\n \"text\": \"Sinus tachycardia\\nNormal ECG except for rate\\nSince previous tracing of , increased heart rate\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2179-03-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 276278,\n \"text\": \"Normal sinus rhythm. Normal ECG. Compared to the previous tracing of \\nno significant change.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2179-03-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1293270,\n \"text\": \"D:See carevue flowsheets for specifics\\nNeuro:Pt remains unresponsive on propofol and fentynal drips. Both increased overnoc for resp inconsistent MVs and Hypertensive and tachycardic.\\nCV:Hyperdynamic state with temp max 102.4. Pt pan cultured (Blood line and venipuncture, urine and sputum). Hypothermia blanket on at 0300. SBP 200+ and tachy up to 140, lopressor given as ordered.\\nResp:No vent changes overnoc. Increased sedation to prevent MV inconsistencies with vent despite suctioning.\\nGI:BS hypoactive s/p closure of fascia . Abd dsg reinforcedx1, small am't of serosang drg.\\nGU:Additional lasix 40mg IVP for elevated PA#s and cvp #s.\\nFamily: called and wanted to know what time pt would be weaned from sedation today. He will call this am. Do not weaning sedation as SBP hypertensive if prop is decreased.\\nPlan/Goals:Normothermic-Use hypothermia blanket, tepid baths.\\nNormotensive: Lopressor as ordered. Maintain fluid balance even.\\nFamily coping-provide explanation concerning realistic expectations while pt in ICU.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2179-03-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1293271,\n \"text\": \"CONDITION UPDATE\\nPLEASE SEE CAREVUE FLOWSHEET FOR SPECIFICS.\\nNEURO: PROPOFOL AND FENT GTT'S WEANED DOWN. WITH PROP NEARLY OFF, PT OPENED EYES TO VOICE. DID NOT FOLLOW COMMANDS. PERRL. LOCALIZED WITH ALL EXTREMTITIED ON BED TO TRAP SQUEEZE. PROPOFOL INCREASED THIS EVE FOR PT COMFORT ON VENT.\\nRESP: LS CTA. VENT CHANGED TO CPAP WITH 8PEEP AND 16 PS, BUT PT DID NOT TOL, BECOMMING TACHYPNEIC, LABORED, LOW TV'S, TACHYCARDIC AND HYPERTENSIVE TO 200S SYS. PROPOFOL INCREASED AND VENT RETURNED TO CMV. REATTEMPTING PS THIS EVE WITH LIGHTER PROPOFOL THAN THIS AM. BP, HR AND RR STABLE, PA NUMBERS DECREASED WITH 16 PS, AND TV'S > 450. ABG PENDING. PT THIS AFTERNOON. SCANT SECRETIONS, CLEAR.\\nCV: TMAX 100.9 THIS SHIFT. COOLING BLANKET REMOVED D/T SL MOTTLING OF SKIN AT LEGS. SICU TEAM WITNESSED. ICE TO AXILLA FOR TEMP CONTROL. TACHYCARDIC TO 130S. METOPROLOL STARTED AND DOSE INCREASED TO EFFECT. PA CATH CHANGED TO NON-HEPARIN COATED AND PLACEMENT CONFIRMED BY CXR MD . CO DECREASED AS COMPARED WITH LAST SEVERAL DAYS. LASIX DOSE INCREASED WITH SOME EFFECT ON U/O AND MIN EFFECT ON PA#S. FLUID BAL SL POS SINCE MN.\\nGI: SBD SOFT. NO BM. CLEAR OUTPUT VIA NGT.\\nGU: CLEAR AMBER U/O.\\nSKIN: DRESSING INTACT WITH OLD STAINING. T-TUBE WITH MOD AMTS DK AMBER O/P. JP WITH SM AMTS DK MAROON O/P. NO S/S BREAKDOWN AT PT'S BACK OR HEELS.\\nPLAN: ASSESS TOLERANCE OF CPAP. AWAIT ABG RESULTS. WEAN SEDATIONAS TOLERATED. ? EXTUBATE TOMORROW. MONITOR HEMODYNAMICS. TREAT TACHYCARDIA AND HTN WITH LOPRESSOR. DIURESE AS ORDERED. EXPECT FLUID MOBILIZATION ON NEXT 2 DAYS. EMOTIONAL SUPPORT TO FAMILY.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2179-03-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1293294,\n \"text\": \"PLEASE REFER TO CAREVUE FOR COMPLETE ASSESSMENT AND SPECIFICS.\\n\\nNEURO: PROPOFOL STOPPED THIS AM AND REMAINS OFF FOR THE REST OF THE DAY. PT ALERT, FOLLOWING SIMPLE COMMANDS, MAE SPONT/PURP, PERL. DOZING INTERMITTENTLY.\\n\\nCV: HR 101-121 ST, NO ECTOPY. SBP 124-157 W/ MAP>60. CVP 4-6. BIL LE'S U/S OBTAINED TO R/O DVT, F/U REPORT.\\n\\nRESP: LUNG SOUNDS COARSE, SXN AS NEDED FOR THICK YELLOW SECRETIONS. VENT SETTINGS CURRENTLY CPAP+PS 5PEEP /10 PS( PS WEANED FROM 15-10),RR 14-22, FIO2 40%, TV 400'S. ABG 7.38/46/148/28/1/98. O2 SAT 99-100%. CXR DONE, F/U RESULTS.\\n\\nGI: ABD SOFTLY DISTENDED, HYPO BOWEL SOUNDS, TF STARTED IMPACT W/ FIBER AT 20CC/HR W/ GOAL 90CC/HR, INC BY 20CC/HR Q6 HRS, NO RESIDUALS.\\nT-TUBE DRAINING CLEAR DARK AMBER FLUID. CT ABD AND PELVIS DONE, F/U RESULTS.\\n\\nGU: FOLEY DRAINING CLEAR AMBER URINE, LASIX 20MG IVP X2 W/ GOOD DIURESIS.\\n\\nID: TMAX 101.7, DR. INFORMED, PAN CX.\\n\\nENDO: REMAINS ON INS GTT FOR FS CONTROL.\\n\\nPLAN: MONIOTR VS, LABS, RESP STATUS, NEURO STATUS. F/U CXR, U/S, CT RESULTS. ADVANCE TF TO GOAL. ?ATTEMPT TO WEAN VENT DOWN FOR POSSIBLE EXTUBATION TOMORROW AND STOP TF AT 4AM. CONT CURRENT MGMT.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2179-03-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1293295,\n \"text\": \"Resp Care Note:\\n\\nPt cont intub with OETT and on mech vent as per Carevue. Lung sounds coarse with rhonchi improving with suct for mod th sput. Pt in NARD on current vent settings; no vent changes made overnoc. Cont wean PSV.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2179-03-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1293296,\n \"text\": \"FOCUS: STATUS UPDATE\\nDATA:\\nPT ALERT AND RESPONDING TO HER NAME. FOLLOWING COMMANDS AND MOVING ALL EXTREMITIES IN BED WITH UPPER EXTREMITIES VERY WEAK.\\n\\nLUNGS COARSE BILATERALLY WITH SCATTERED RHONCHI IMPROVING WITH SUCTIONING OF THICK SPUTUM. CONTINUES ON 10 PS, NO VENT CHANGES OVERNIGHT.\\n\\nABDOMEN SOFT WITH HYPOACTIVE BOWEL SOUNDS. TOLERATED TUBE FEEDS WITH MINIMAL RESIDUALS UNTIL 0400. STOPPED IN PREPERATION FOR POSSIBLE AM EXTUBATION. INCISIONAL ABD STAPLES DRY AND INTACT, OPEN TO AIR. T TUBE WITH BILIOUS OUTPUT.\\n\\nLASIX X1 OVERNIGHT FOR NEGATIVE I/O GOAL OF 1L WHICH WAS ATTAINED.\\n\\nPLAN:\\nWEAN AND EXTUBATE IF POSSIBLE, OTHERWISE TRACH TO BE CONSIDERED. F/U CT SCAN RESULTS.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2179-03-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1293297,\n \"text\": \"Respiratory Care\\n\\n Pt continues on PSV weaned as documented. In NARD. B/S equal dim at bases. Suctioned for min amount thick yellow. Plan ? extubation in A.M. Will continue to follow closely.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2179-03-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1293298,\n \"text\": \"Nursing\\nSee flowsheet for details.\\n\\nPt. had uneventful day. HR remained 100-115 NSR, no ectopy. BP 115-150/75. T. max 99.9 oral. Tube feeding restarted through NG. Hypoactive BS; max residual 30cc. TPN d/c. Insulin gtt cont. Incision C/D/I. Good urine output. Goal of -1000cc fluid balance; received two doses of lasix. Cont. to medicate prn with fentanyl. Family in to visit today.\\n\\nPlan to cont. to wean for possible extubation in a.m. Also plan for pt. to be NPO after midnight.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2179-03-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1293281,\n \"text\": \"Resp Care Note:\\n\\nPt cont intub with OETT sedated and on mech vent as per Carevue. Lung sounds coarse with rhonchi improving with suct for mod th tan/brown sput. ABGs metabolic acidosis with good oxygenation; adjusting vent to help increase pH. Cont mech vent support.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2179-03-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1293282,\n \"text\": \"STATUS\\nD: REMAINS ON FENT/PROPOFOL/INSULIN GTT'S..OPENS EYES TO NAME..WILL FOLLOW SOME SIMPLE COMMANDS\\nA: FENT GTT DC'D & STARTED ON PRN DOSE..TOL WELL..JP DC'D SITE OOZING SEROUS DSD APPLIED..LF SUBCL LINE DC'D & TIP SENT FOR CULT..PROPOFOL @ 30MCG..INSULIN GTT @ 5-7U TO KEEP BS <120..LASIX GIVEN X1 WITH GOOD EFFECT..INCT MOD AMT MUCOID STOOL..FIB PLACED..STARTED ON TF'S @ 10CC/H INITIALLY WILL CHECK RESIDUALS Q6H..NO VENT CHANGES ABG'S ACIDOTIC GIVEN 2 AMPS BICARB GIVEN WITH IMPROVEMENT\\nR: STABLE\\nP: WILL ATTEMPT VENT WEAN IN AM..MONITOR LABS Q6..BS'S Q1-2H REGULATE INSULIN GTT ACCORDINGLY\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2179-03-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1293283,\n \"text\": \"Resp Care Note:\\n\\nPt cont intub with OETT and on mech vent as per Carevue. Lung sounds coarse with rhonchi improving with suct sm=>mod th tan sput. Pt switched to PSV and tol well on present settings; ABGs ess unchanged on PSV. Cont PSV/wean.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2179-03-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1293284,\n \"text\": \"Update\\nO: cv status: to sr w lopressor ^'d to 50mg . bp stable, tolerating ^ dose lopressor.\\n\\nresp status: weaned to cpap peep8 ps 18. bbs coarse to slt coarse after suctioning. abg unchanged mild acidosis\\n\\nneuro status: sedated on propfol, arousable to voice and following simple commands.perl 2-3mm.\\n\\ngi status: tol tf's ^ to 20cc/hr w min resids . incont loose mucoid stool-> fib bag.\\nglucoses managed w insulin gtt.\\ngu status: huo qs amber urine via foley.\\n\\nheme/id: am labs sent results pending.\\n sin: mid abd incision site dry. oozy around old jp site-> ostomy bag to measure and contain drng. ttube to w bilious drng.\\nA/P: weaning from vent wean peep and ps as tol.\\ncheck am lab results & rx as ordered any lyte imbalance.titrate tf toward goal 45 cc/hr nepro.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2179-03-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1293285,\n \"text\": \"STATUS\\nD: REMAINS ON PROPOFOL & INSULIN GTT'S..EASILY AROUSED FOLLOWS SIMPLE COMMANDS WITH MUCH ENCOURAGEMENT..MOVES ALL EXTREM'S\\nA: PROPOFOL DECREASED TO 20MCG..VENT WEANED TO C-PAP WITH 0 IPS TOL WELL FOR FEW HOURS BUT THEN TIRED WITH RR 30'S..BP 150/'S..HR 120-130'S PLACED BACK ON IPS 5..GOOD SAT'S & ABG'S..RESTING COMF NOW.. SUCTIONED FOR MOD AMT THIN /YELLOW..SUCTIONED FOR COPIOUS AMT ORAL SECREATIONS..TF'S ON HOLD FOR HIGH RESIDUALS..FIB INTACT SM AMT MUCOID STOOL..ADQUATE HUO'S..OOZING LGE AMT FROM JP SITE STITCH PLACED BY HO..NO FURTHER OOZING NOTED..T TUBE DRAINING MOD AMT BILIOUS\\nR: STABLE\\nP: CONTINUE TO WEAN AS TOL..? EXTUBATE IN NEXT COUPLE OF DAYS\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2179-03-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1293286,\n \"text\": \"Respiratory Care\\nPt spent a few hours on SBT, back on for increased rr, and hr. Suctioning large amts of thick yellow.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2179-03-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1293287,\n \"text\": \"Resp Care Note:\\n\\nPt cont intub with OETT and on mech vent as per Carevue. Lung sounds coarse suct sm=>mod th off sput. ABGs resp acidosis with good oxygenation. Pt episode of ^RR/HR/BP and dropped Vt; increased PSV with good result; later returned to previous settings. Plan to extub if am mechanics acceptable.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2179-03-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1293288,\n \"text\": \"Update\\nO: Arousable,follows simple commands w stim. mae to command. w htn improved w ^ lopressor dosing & fentanyl for pain/discomfort.GI: abd soft no active bowel snds,Tf's on hold for potential extubation this a.m.Glucoses managed w insulin gtt. huo qs amber urine w brisk diuresis w lasix 20 iv.\\n\\nA/P: Wean vent? extub today.Follow glucoses and titrate insulin gtt. Hr/bp still ^,? ^ lopressor dose/frequency.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2179-03-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1293289,\n \"text\": \"Respiratory Care:\\nPt. was to be extubated today if at all possible, however, she developed a rather high RR and had an episode of respiratory distress\\nwith increased WOB and decreasing O2 sat. to 90-91%. She was rested on 50% PSV 20/5peep. This has been weaned down to 40% and a PS of over the course of this shift, and presently is slowly increasing her RR, and ? WOB...\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2179-03-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1293290,\n \"text\": \"Nursing\\nSee flowsheet for details.\\n\\nAttempted to wean from vent with no success. Propofol turned off at 0700 and by 0930 pt. was alert and following commands consistently. Pt. remained on and 40% until 1300 when propofol had to be restarted to help the pt. to be less anxious. Dr. stated that pt. would not be extubated due to possible anxiety/pain and low tidal volumes.\\n\\nAt this time pt. is on and 40% sa02 99%. Sxn small amounts of thick clear from ETT and large amounts thick clear from mouth. HR 125 NSR with no ectopy. BP 139/77. Temp 99.9 oral. Propofol at 30mcg/kg/min and insulin at 4units/hr. Urinary output remains adequate. T-tube intact and draining bilious. Abdominal incision C/D/I.\\n\\nPlan to cont. to wean from vent and keep pt. comfortable.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2179-03-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1293291,\n \"text\": \"FOCUS: STATUS UPDATE\\nDATA:\\nPT LIGHTLY SEDATED ON PROPOFOL DRIP. FOLLOWING COMMANDS INCONSISTENTLY, OPENING EYES SPONT AND TO COMMAND.\\n\\nLUNGS COARSE BILAT LOWER LOBES. SUCTIONED FOR THICK YELLOW SPUTUM. PS INCREASED TO 20 DUE TO RR IN THE 40'S AND LOWER TV. NOW WITH TV >500 AND RR <20. PT ALSO CALMER ON THIS SETTING ALLOWING WEANING DOWN OF PROPOFOL.\\n\\nABD SOFT AND NONTENDER. HYPOACTIVE BS. INCISION WITH STAPLES INTACT AND OPEN TO AIR.\\n\\nPLAN:\\nMAINTAIN INTUBATED ON HIGHER PS REQUIREMENT AND REEVALUATE WEANING IN AM. WEAN OFF PROPOFOL AS ABLE.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2179-03-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1293292,\n \"text\": \"Resp Care Note:\\n\\nPt cont intub with OETT and on mech vent as per Carevue. Lung sounds coarse suct sm=>mod th off sput.ABGs ess same however pt requiring higher levels of PSV to maintain adequate Vt/RR. PSV increased overnoc to a high of 22 to present value of 15cm to stabilize Ve. Pt does not appear ready for extub even though RSBIs have been consistantly < 100. Cont PSV; ? trach soon.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2179-03-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1293293,\n \"text\": \"Respiratory Care:\\nPt began shift on PSV 15/5. she was slowly weaned to @ 40%.\\nRR inc some but not excessively w/a good MV. At ~ 16:30 she went to CT for a scan of her Abdomen, looking for a collection that may be causing her temp. spikes and complicating her wean off the Vent.\\nThe plan is to try extubation soon (tomorrow) to see if she will do well. If not we will reintubate and trach sometime in the next 2-3 days. Please check CareVue for details and ABG's.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2179-03-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1293276,\n \"text\": \"Resp Care Note:\\n\\nPt cont intub on mech vent as per Carevue. Lung sounds coarse bilat suct sm th tan sput. Pt appears comfortable on A/C though she cont to overbreathe vent but in NARD; no vent changes required overnoc. Cont mech vent support.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2179-03-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1293277,\n \"text\": \"Condition Update\\nPlease see carevue for specifics.\\n\\nNeuro: PPF gtt at 80 mcqs/hour. Off the gtt, pt did not follow commands. Only would open her eyes to voice. Fentanyl gtt at 100mcs/hour. PERRL.\\n\\nCV: SR - ST. No ectopy noted. HR 96-119. Aline dampened, used cuff for pressures. Temperature down to 97.7 Cooling blanket off.\\n\\nResp: No vent changes made. o2 sats 97-100% Pt sxn'd several times for small amts of thick tan sputum. LS coarse b/L.\\n\\nGI/GU: Foley is patent and draining amber urine. Decreased u/o approx 25-35 cc hour. FIB bag intact. Immeasureable amt of liquid brown stool out. TPN infusing for nutrition. NGT to low continuous sxn and draining brown fluid. Left T tube intact, right jp drain to bulb sxn and draining dark brown fluid.\\n\\nEndo: Pt on a regular insulin gtt. BS checked q hour and gtt titrated accordingly.\\n\\nInteg: s/p Liver tx. abdominal staples intact. Incision is reddened. Small amt of drainage noted. DSD to cover.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2179-03-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1293278,\n \"text\": \"Nursing\\nSee flowsheet for details.\\n\\nPt. sedated on 40mcg/kg propofol. Opens eyes and moves all extremities on propofol holiday; not following commands. PERRLA 2-3mm, brisk, scleral jaundice.\\n\\nHR 100-120 NST, no ectopy. BP low this a.m. and all antihypertensive meds d/c. CVP connected and read 15-17 throughout day. Given 500cc NS . BP 95-125/65. Temp 97.1 ax. Pulses weakly palpable. /hr, Fentanyl at 100mcg/hr and Insulin gtt on. Left rad. a-line extremely positional; going by cuff pressure.\\n\\nETT intact. CMV 40%, 500Vt, 5PEEP, sa02 95-100%. Lungs coarse in upper lobes and diminished at times in lower lobes. Not sxn much from tube. Sxn moderate amounts clear from mouth.\\n\\nAbdomen soft/non-distended with pos. BS. Incision C/D with staples intact; no drainage, no dressing. T-tube intact and draining moderate amounts bilious. JP intact and draining small amounts brown. NG to LCWS with brown output. Fecal bag intact with tan mucous foul-smelling drainage.\\n\\nFoley intact with clear yellow urine. Output increased significantly after NS .\\n\\nPt. potassium high. Received 4 units Hum. Reg. insulin IV and 25gm D50 IV. Also receieved 2gm calcium gluconate.\\n\\nFamily updated several times throughout the by RN.\\n\\nPlan to cont. to monitor lab values and resp. status.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2179-03-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1293279,\n \"text\": \"Respiratory Care\\nPt. remains on a/c with increased tidal volume to 500cc. Last ABG 730/36/159/18/-7/100. BS coarse R>L.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2179-03-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1293280,\n \"text\": \" 19/07\\n PT REMAINS ON FENT WITH PROPOFOL DRIP FOR MILD SEDATION PLEASE SEE CAREVIEW FOR DETAILS ON NEURO STATUS PT WILL OPEN EYES AND TRIES TO FOLLOW COMANDS\\n RESP CMV RATE 20 FIO2 .40 PEEP5 T/V 500 SPUTUM BROWN IN COLOR RHONCHI THRU OUT\\n HEART S1S2 PULSES POS 2 THRU OUT M EDEMA THRU OUT ST 110 TO 120\\n GI HYPOACTIVE B/S SCANT STOOL SOFT ABD T TUBE AND JP IN PLACE U/O QS\\n NOTE ELEVATED LEVELS MD AWARE SEE ORDERS\\n SUPPORTIVE CARE MONITOR LYTES AND HCT SKIN CARE T/P WITH ROM\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2179-03-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1293272,\n \"text\": \"FOCUS: STATUS UPDATE\\nDATA:\\nPT SEDATED ON PROPOFOL. ALERT AND FOLLOWING COMMANDS OFF SEDATION BUT WITH HYPERTENSION, TACHYCARDIA AND AGITATION. CONTINUES ON FENTANYL DRIP.\\n\\nHYPERTENSION TO >200SYS WITH STIMULATION SUCH AS BATHING. TACHYCARDIA TO 130'S, IMPROVED WITH INCREASE IN LOPRESSOR.\\n\\nLUNGS BILATERALLY CLEAR. CONTINUES ON CPAP WITH PS. PS INCREASED THIS AM D/T PCO2 55. SUCTIONED FOR MODERATE AMOUNTS CLEAR SECRETIONS. LESS FEBRILE O/N.\\n\\nABDOMINAL SL DISTENDED, SOFT AND WITH STAPLES INTACT. HYPOACTIVE BS.\\n\\nCONTINUES ON LASIX WITH GOOD EFFECT.\\n\\nPLAN:\\nCONTINUE TO WEAN OFF VENT AS ABLE. DECREASE SEDATION AS TOLERATED.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2179-03-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1293273,\n \"text\": \"Nursing\\nSee flowsheet for details.\\nPt. hard to wean from propofol; becomes very restless and . Propofol currently at 50mcg/kg; Fentanyl at 50mcg/hr. Insulin gtt currently at 7units/hr.\\nWent for cholangiogram for elevated bilirubin; found no problems with tube.\\nIncision intact with no drainage. T-tube with good output. JP with small amounts brown drainage.\\nPlan to cont. to wean from vent and wean from propofol.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2179-03-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1293274,\n \"text\": \"FOCUS: STATUS UPDATE\\nDATA:\\nEXTREME AGITATION OFF PROPOFOL, MOSTLY EVIDENT BY HYPERTENSION AT TIMES TO >200 SYSTOLIC, TACHYCARDIA TO 120'S AND INCREASED RESPIRATORY EFFORT, RATE TO 40'S. PRECEDEX DISCONTINUED D/T POOR EFFECT. HALDOL AND FENTANYL PRN WITH SOME EFFECT. PROPOFOL RESUMED WITH IMPROVED VS. FOLLOWING COMAMNDS AND MOVING ALL EXTREMITIES OFF SEDATION.\\n\\nHYPERTENSION WITH AGITATION. HYDRALAZINE WITH MINIMAL EFFECT. SEDATION WITH EFFECT.\\n\\nLUNGS COARSE BILAT. SUCTIONED FOR THICK CLEAR SECRETIONS OCCAS. PLACED BACK ON AC WITH RATE OF 18 D/T TIRING WITH INCREASED RESPIRATORY EFFORT. ABG STABLE.\\n\\nCONTINUES ON LASIX WITH GOOD EFFECT. +3 PITTING EDEMA BILAT HANDS.\\n\\nPLAN:\\nWEAN OFF VENT AND EXTUBATE IF POSSIBLE.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2179-03-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1293275,\n \"text\": \"Nursing\\nSee flowsheet for details.\\n\\nAt beginning of shift pt. HR 150-160, BP 160-180 systolic and temp 39C (blood). Propofol increased to 80mcg/kg, fentanyl gtt restarted at 100mcg/hr and cooling blanket placed on pt. Pt. pan-cultured to include all lines and fungal cx. Right IJ swan changed to quad-lumen. LSC dual-lumen and left rad. a-line intact. Insulin gtt between 7-10units/hr.\\n\\nCurrently, pt. HR 115-130, BP 110-120/80-85, and temp 38.4 oral (cooling blanket still on). Extremities with +3 edema. Weakly palpable peripheral pulses.\\n\\nPt. will open eyes to pain when propofol decreased. Moves all extremities. Follows commands inconsistently. PERRLA 3mm brisk. Scleral jaundice.\\n\\nETT tube intact; tape changed. Currently on CMV VT450, 8PEEP, 40%. Sa02 95-98%. Sxn scant amounts thick clear. Sxn moderate amounts from mouth thin tan. Thrush on tongue noted.\\n\\nNG to LCWS and draining moderate amounts dark brown. Pos. BS. Abdomen soft and slightly distended. Abdominal incision intact/approximated with no drainage; DSD intact. T-tube with moderate amounts of bilious drainage; intact. RLQ JP intact with dark brown drainage approx. 10cc for 12 hours. Fecal bag reinforced with small amount of mucoid stool present.\\n\\nFamily updated several times throughout day.\\n\\nPlan to cont. to monitor HR and BP. Also plan to monitor temp and to keep cooling blanket on until temp. decreases.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2179-03-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1293264,\n \"text\": \"Resp Care\\nPt. remains intubated sedated on ventilator w/o change overnight.\\nBs: coarse sxn'd for sm. amts. of thick.\\nabgs: mild metabolic alkalosis with hyperoxia.\\nPlan: scheduled to have fascia closed in OR today.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2179-03-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1293265,\n \"text\": \"D:Pt is PODS#6 and 7 s/p OLT for ESLD. See carevue flowsheets for specifics.\\nNeuro:Pt sedated on propofol and fentynal and does not respond to verbal or tactile stimuli. PERRLA.\\nCV:VSS, CO stable at 7.5 CVP 11-12, PAD 20. SR to ST 90s-100 no ectopics. Ulnar arterial line left wrist patent and is 20mm higher than NBP.\\nResp:Pt remains intubated on ventilator FIO2 40%. O2 sats 97-99. ABGs improving.\\nGI:NGT draing BRB in small am'ts started around 0500. H.O. notified. HCT stable. Platlets 70.\\nGU:foley to BSD draining small am'ts of hematuria.\\nSkin with the exception of incisions intact. Eccymotic areas lt groin abd near incisions (old).\\nLab:K repeted for 3.5 level. BS treated by titrating insulin gtt.\\nA:Stable s/p OLT.\\nP:Check cyclosporin level at 10:30.\\n check vanco level at 11:30\\n Pt expected to go to the OR for closure today TF.\\n Provide emotional support to pt and family.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2179-03-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1293266,\n \"text\": \"Resp. Care Note\\nPt remains intubated and vented on settings as charted on resp flowsheet. No vent changes made this shift. Pt back to OR for abd. closure.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2179-03-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1293267,\n \"text\": \"CONDITION UPDATE\\nPLEASE SEE CAREVUE FLOWSHEET FOR SPECIFICS.\\nNEURO: PT SEDATED ON PROPOFOL AND FENTANYL GTTS. OCCASIONALLY OPENS EYES TO STIM. MOVES ALL EXTREMITIES ON BED TO STIM. PERRL.\\nRESP: LS CTA. ABG STABLE. NO VENT CHANGES. SM AMT SECRETIONS VIA ETT SUCTION.\\nCV: AFEBRILE. HEMODYNAMICALLY STABLE. FLUID BAL NEG 180CC SINCE MN. PLT GIVEN FOR 70, POST 105. HIT PANEL SENT AND POS PER BLOOD BANK. SICU AND TRANSPLANT TEAMS INFORMED. COAGS STABLE.\\nGI: ABD SOFT. NGT WITH SM AMT CLEAR O/P. NO BM.\\nGU: CLEAR AMBER U/O. SM RESPONSE TO AM LASIX.\\nENDO: INSULIN GTT TITRATED TO FSBG.\\nSKIN: T-TUBE WITH MOD AMTS DK AMBER DRG. JP WITH SM AMTS DK MAROON DRG. ABD INC DSG CDI.\\nMISC: CYCLO GTT CONTS AT 2MG/HOUR. PT SENT TO OR FOR FASCIA CLOSURE AT 1600 WITH ANESTHESIA. SENT ON PPF AND CYCLO GTTS.\\nPLAN: AWAIT RETURN FROM OR. D/C ALL HEPARIN.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2179-03-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1293268,\n \"text\": \"CONDITION UPDATE\\nPT RETURNED FROM OR AT 1800 S/P FASCIA CLOSURE. PT STABLE. ALL TUBES AND LINES INTACT. MEDS RESUMED (EXCEPT HEPARIN). SVO2 RECAL'D. LABS SENT. REPEAT HIT TO BE SENT.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2179-03-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1293269,\n \"text\": \"Resp Care\\nPt. remains intubated/sedated overnight. No changes made abg's within normal parameters.\\nBs: coarse bilat. secreations minimal thick.\\nPlan: continue current support.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2179-03-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1293308,\n \"text\": \"CONDITION UPDATE\\nD.AFEBRILE,SR-ST,RR16-26,O2 SAT=99 ON 2L NP,BP 117-140/60.\\n PT WAS GIVEN LASIX THIS EVENING.DESPITE MOD. DIURESIS,PT REMAINED POSITIVE BY 1700ML/24 HRS.\\n PT CONFUSED AT TIMES TO TIME AND PLACE BUT COOPERATIVE.PT DID NOT SLEEP ALL NITE.\\n NO C/O OF PAIN EXCEPT AT 0400,PT C/O ABD PAIN AND CONFIRMED ABD CRAMPS..PT HAD STOOL,LOOSE X2 THRU THE NITE.\\nA.?NEED TO DECREASE TF RATE..?NEED FOR FT PLACMENT TODAY.\\nR. STABLE\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2179-03-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1293309,\n \"text\": \"please see carevue for specifics:\\nNeuro: pt alert and oriented to person. able to follow directions,but confused when answering questions.\\nCV: afebrile, HR 90-110's sinus tach with no ectopy, SBP 120-150's, CVP 9-13. extremities warm with +PP. lytes repleated.\\nRESP: lungs clear to dim at bases, On room air O2 sats >96%.\\nGI: tube feed at 70cc/hr via dopoff tube (post pyloric). Having frequent loose stool.\\nGU: foley draining adequate amounts of amber clear urine.\\nENDO: blood sugars SLightly elevated, covered with RISS.\\nPLAN: continue to monitor VS, monitor labs for LFT's, ? transfer to floor monday.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2179-03-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1293310,\n \"text\": \"See flowsheet for specifics\\nD:Pt confused oriented to name only. One leg over side rail x1. Pt awakwe all night, finally fell asleep at 0600. No changes overnight. Pt continues to complain of abd cramping. Liquid stool via mushroom rectal tube-intact. C-diff specimen sent last night.\\nA:Pt improving s/p LTX.\\nP:Advance to floorcare if alright with attending. \\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2179-03-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1293257,\n \"text\": \"Respiratory Care:\\nPatient remains on ventilatory support (A/C) with no parameter changes made throughout the night. Morning abg results were compatible with a partially compensated metabolic alkalemia with excellent oxygenation on the current settings (see CareVue).\\n\\nNo RSBI performed due to lack of spontaneous respiration.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2179-03-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1293258,\n \"text\": \"Resp. care note - Pt. remaines intubated and vented, no vent changes made at this time, BS clear.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2179-03-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1293259,\n \"text\": \"npn\\nNeuro- propofol gtt weaning, cont fentanyl, pearl, no response to stim/+ cough with suction.\\n\\nResp- AC vent with acceptable abg pr md, lungs clear uper/ lower, suction thin sec.\\n\\nHemodynmics- PA in place- see flow sheet for all #'s, lasix gtt dc , currently + 2 liters- sicu md aware.\\n\\nHeme_ hct 32-35, platelet count decrease to 61- sicu aware- awaiting transplant service. (transplant intern notified).\\n\\nID- temp max 101.5- blood cx done\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2179-03-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1293260,\n \"text\": \"D:TPN changed to D5Aminosyn 4.5% due to elevated K. Insulin drip titrated to maintain BS < 120. Pain control maintained with Fentynal drip, sedation maintained with propofol drip which was increased when pt was having inconsistent MV with ventilator due to stimulation. No vent changes overnoc. ABGs improved. Coffee ground NGT secretions changed to tan overnight. HCT stable at 32. Frank blood noted in stool. 2 medium stools both with frank blood in small am't. Dr notified. Pt had positive fluid balance, Lasix 20 mg IVP given per d.o.. Response to lasix 450ml then 380ml. u/o dwindled down x 1hr to 22ml h.o. aware. Cyclosporin drip started in addition to ngt cyclosporin per Dr and Dr . Cyclo level to be drawn at 0800.\\nA:Pt stable overnoc.\\nPlan:OR today for probable liver biopsy and closure of fascia.\\n \\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2179-03-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1293261,\n \"text\": \"Respiratory Care:\\nPt. well oxygenated with essentially normal range acid-base. Pt. very tenuous to stimulation (Suctioning, turning, etc.)>>recovers slowly to baseline, and has required increased sedation. Pt. going to O.R. today for ? closure of Abd. Will follow compliance closely post-op.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2179-03-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1293262,\n \"text\": \"Resp. care note - Pt. remaines intubated and vented, transffered to CT and back to SICUB without incident.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2179-03-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1293263,\n \"text\": \"npn\\nNeuro- sedated with propofol and fentanyl gtts, fent decrease to 100 mcg, facial grimace with suction, no ext movement noted, not foll command.\\n\\nResp- ac vent, fio2 decrease to .40 with good abg, lungs decreased right upper/lower, suction thin copiuos secretions- ett and oral.\\n\\nGI- + c diff from stool, po flagyl started, cont tpn, (over noc tpn change to quick fix as kcl in ordered bag 100 meq kcl and pts k 5.4).\\n\\nHeme- platelet count decreaseing to 58- received 2 6 pack platelet this shift- current count 88. hct stable.\\n\\nGen- abd/pelvis ct this am to r/o abcess- (neg) plan OR for closure of fascia.\\n\\nHemodynamics- in place- see flow sheet for #'s, temp max 100.1, hr 90's to 110. new left ulna a line placed this pm by md.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2179-03-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1293255,\n \"text\": \"npn\\nNeuro- sedated with propofol and fentanyl gtts, cista gtt dc this am 1030, inc cough after dc, pearl but no ext movement noted yet.\\n\\nResp- Tol fio2 .40 and peep decrease to 5, abg metabolic alk, lungs diminished right upper/lower, suction thick secretions, sputum cx sent.\\n\\nHemodynimics- temp max 102 via pa- pan cx done, hr cont up to 150's with occasional pvc's- lytes wnl, lasix gtt initially decrease to 5 from 8 mg- then dc 6pm, currently 800 neg. pa advanced by md waveform- looking like wedge and then right vent, adv to 48. see flow sheet for all pa#'s.\\n\\nendocrine- cont insulin gtt 7-9u/hr, glu 110-157. tpn cont.\\n\\nID- temp max 102- cx done. cont vanco, merepenum, fluconazole, gangcylovir, ID stated due to + antibodies pt at high risk delayed transfusion reaction- coombs and sed rate sent this am. stool sent for c diff this pm.\\n\\nHeme- hct stable- see labs- platelet count 69- 1 6 pk givin- repaet count 83- md - to notify transplant and ? give additional 6 pack. inr 1.0.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2179-03-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1293304,\n \"text\": \"PLEASE REFER TO CAREVUE FOR COMPLETE ASSESSMENT AND SPECIFICS.\\n\\nNEURO: PT ALERT MOST OF NIGHT, ABLE TO TRACK, . FOLLOWS COMMANDS CONSISTENTLY, MAE SPONT/PURP.\\n\\nCV: HR 101-124 ST, SBP 94-155. CVP 6-16.\\n\\nRESP: LUNG SOUNDS CLEAR BUT COARSE AT BASES. SXN PRN FOR THICK WHITISH/YELLOWISH SECRETIONS. VENT SETTINGS CPAP+PS W/ 5PEEP/10PS, FIO2 40%, TV 400'S, RR 11-23, O2 SAT 100%, ABG 7.39/52/119/33/5/98. POSSIBLE EXTUBATION THIS AM.\\n\\nGI: ABD SOFT, NT/ND, +HYPO BOWEL SOUNDS, REMAINS NPO FOR POSSIBLE EXTUBATION THIS AM. STRTED ON IVF FOR U/O AND DUE TO PT REMAINING NPO. INCISION REMAINS C/D/I W/ CLIPS. ?CLIP REMOVAL. T-TUBE DRAINING CLEAR DARK AMBER FLUID.\\n\\nGU: FOLEY DRAINING CLEAR AMBER URINE, PT RECEIVED NS 250CC W/ POSITIVE EFFECT.\\n\\nID: TMAX 101.9, PAN CX.\\n\\nPLAN: MONIOTR VS, LABS, RESP STATUS, NEURO STATUS, U/O. ?EXTUBATE THIS MORNING. ?POST-PYLORIC DOBHOFF PLACEMENT FOR TF TODAY. PHYSICAL THERAPY CONSULT.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2179-03-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1293305,\n \"text\": \"see carevue for details\\nfocus data update.\\n\\ntol extubation well, talking, tol sips of clears, ivf d/c impact with fiber started @ 20/hr with minimal residual, foley changed per infectious disease, wire change over on right central line, family into visit, medicated q2h with fentanyl\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2179-03-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1293256,\n \"text\": \"focus update note\\ntemperature improving overnight currently 100.1, heart rate decreased from 130-140s to 115 with decreasing temperature, sbp 105/60, cvp 9, pa pressures 29/20- swan advanced by icu resident and recalabrated at approx 0100. pt transfused with 1 pack platlets for plat count 82 post plat count 97, to transfuse with 1 unit prbc awaiting unit from blood bank. current hct 33. pt possibly volume depleted- lasix gtt now off since 1830 last night uo 30-100cc/hr dark amber clear. please see flowsheet for hemodynamic cco swan values\\n\\npain/neuro: pt cont on fentanyl gtt at 200 mcq/hr, sedated with propofol at 120 mcq/kg/min. pt very sedated, no movement on exam or spontaneous, pupils 2mm brisk, pt does not open eyes or follow commands.\\n\\nresp: no vent changes overnight, lsc dim at right base, o2sat 95%.\\n\\nabdomen:soft/distended, bs hypoactive, small stool X 2 soft brown, surgical dressing changed c/d/i, medial JP removed by transplant surgery overnight, lateral jp drainage 35 cc brown sero sang fluid q 2-4 hours, some drainage at insertion site liver transplant team and icu team made aware. T tube bag exhibits bilious drainage, ngt drainage scant pink/blood tinged drainage transplant team aware\\n\\ninsulin gtt cont with hourly finger sticks- goal fs 70-110 currently insulin gtt at 6 units /hr\\n\\nnutrition: tpn continues\\n\\nplan: continue to monitor hemodynamic status closly using cco swan, pt to go back to OR for closure ? sunday, monitor for sepsis, control blood sugar with insulin gtt, pain and sedation with fentanyl and propofol gtt, monitor resp staus closely\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2179-03-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1293306,\n \"text\": \"NURSING NOTE\\nSEE CAREVUE FOR SPECIFICS:\\n\\nNEURO-A&OX2(SELF&HOSPITAL),PERRLA AT 2-3MM WITH BRISK RX. FOLLOWS COMMANDS CONSISTANTLY. DROWSY AT BEGINNING OF SHIFT, INCREASE ALERTNESS THROUGHOUT NOC. NON-SENSICAL TALK AT TIMES EASILY REDIRECTED.\\n\\nCV-HR 90S-LOW 100S, NSR, NO ECTOPY. SBP 90S-130.HCT 25.7 DR. AWARE. CVP 2-8.\\n\\nRESP-FT AT 50%, LS COARSE AND SLIGHTLY DIMINISHED AT BASES. SPO2 95-100%. NO DISTRESS NOTED.\\n\\nGI-ABD SOFT, SLIGHTLY DISTENDED, (+) BSX4, LG LOOSE BM X2, T-TUBE IN PLACE AND PATENT. DRNG MOD AMTS OF BILIOUS DRAINAGE. TOL CLRS (30CC/HR) WITHOUT DIFF. NO N&V NOTED. NGT IN PLACE WITH TFs BEING TITRATED UP TO GOAL OF 90 (CURRENTLY AT 60), MININMAL RESIDUALS NOTED.\\n\\nGU-FOLEY WITH BOARDERLINE U/O. 20-50CC/HR. NS 250CC X 2 GIVEN WITH MINIMAL EFFECT.\\n\\nENDO-BS QID WITH SC COVERAGE\\n\\nSKIN- TMAX 98.6 ABD STAPLES C/D/I OTA, T-TUBE DSG C/D/I, RLQ DSG INATCT ? OLD DRAIN SITE.\\n\\nCOMFORT-DENIES PAIN/DISC.\\n\\nA/P-CONTINUE WITH CURRENT CARE PLAN. MONITOR LABS, HEMODYNAMICS & RESP STATUS. WEAN OFF O2 AS TOL. ? ADVANCE DIET. PROVIDE EMOTIONAL SUPPORT.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2179-03-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1293307,\n \"text\": \"Neuro: Pt alert and oriented to self. Answering questions inappropriately, but able to follow directions. Having generalized pain, med with fentanyl with minimal effect.\\nCV: low grade temp 99.9, HR 100-110's sinus tach with no ectopy, SBP 100-130's. extremities warm with +PP. HCT 25.7, treated with 2units or PRBC's.\\nRESP: lungs clear to dim at bases. requiring 2l via N/C.\\nGI: tol tube feed at goal, having numerous liquid stool, incontinent.\\nGU: foley draining adequate amounts of amber clear urine.\\nENDO: blood sugars elevated this eve. med with 11u regular insulin will recheck in one hour.\\nPLAN: monitor HCT, awaiting transfer to floor\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2179-03-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1293250,\n \"text\": \"Respiratory Care:\\nPatient required vent changes due to increased hypoxia. FIO2 increased to 80% and PEEP to 7 cm. RR decreased to 20. FIO2 titrated down to 60%. Morning abg results revealed a compensated respiratory acidosis with good oxygenation on 70% with 7 cm PSV (see CareVue).\\n\\nNo RSBI due to required vent settings.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2179-03-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1293251,\n \"text\": \"CONDITION UPDATE (7A-3P)\\nASSESSMENT:\\n PT SEDATED AND PARALYZED ON PPF/FENTANYL/CISATRACURIUM GTTS. PT NOT MOVING OR OVERBREATHING VENTILATOR, BUT BP AND HR INCREASE WITH SUCTIONING AND MOVEMENT. PUPILS EQUAL AND BRISK BILATERALLY.\\n HR ~ 120, TEMP DECREASING, FOLLOWED BY INFECTIOUS DISEASE TEAM. SBP RANGING 140'S-170'S. PA PRESSURES REMAIN HIGH (GOAL PAD IN 20'S). LASIX GTT CONTINUES FOR GOAL OF NEGATIVE 2 LITERS BY MIDNIGHT (CURRENTLY -1 L). SV02 79-80 AND PATIENT REMAINS HYPERDYNAMIC (SEE FLOWSHEET). FOLLOWING LABS EVERY 4 HOURS, NO BLOOD PRODUCTS GIVEN.\\n PT ON ASSIST CONTROL 20 X 550, 60% FI02 AND 7 PEEP THIS MORNING. DESATTING TO 90% IN AFTERNOON AFTER BEING REPOSITIONED. FI02 INCREASED TO 70%, RR UP TO 28 WITH DECREASED TV TO 450 TO IMPROVE OXYGENATION BUT NOT EXERT MORE PRESSURE ON VENA CAVA. UNABLE TO OBTAIN REPEAT ABG AFTER CHANGE, A-LINE NOT DRAWING. LUNG SOUNDS OCCASIONALLY RHONCHOROUS, MINIMAL SECRETIONS.\\n ABDOMEN SOFT, NONDISTENDED, DRESSING OP DRESSING INTACT. JPS X 2 TO SELF SUCTION; T-TUBE DRAINING HEALTHY BILE. TPN INFUSING, INSULIN GTT STARTED FOR BLOOD SUGARS > 150. LIVER US DONE, ADEQUATE FLOW EVERYWHERE EXCEPT ? HEPATIC ARTERY.\\nPLAN:\\n A-LINE TO BE REWIRED BY DR. (ICU). FOLLOW FREQUENT ABGS AND OTHER LABS. CONTINUE WITH DIURESIS FOR GOAL - 2LITERS. POSSIBLE RETURN TO OR THIS WEEKEND.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2179-03-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1293252,\n \"text\": \"RESPIRATORY CARE\\nPT REMAINS ON A/C VENT. WITH TIDAL VOLUMES 450 X 25 7PEEP 60%, PT REQUIRED INCREASED FIO2 FOR DESAT. DURING TURNING. TEAM DOES NOT WANT PEEP INCREASED, INCREASE FIO2 IF DESAT. MDI'S Q4, SUCTIONING MINIMAL SECRECTIONS.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2179-03-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1293253,\n \"text\": \"Respiratory Care:\\nPatient's rr increased from 25 to 27 to accomodate increased PCO2. Repeat abg results determined little change. Results consistent with a compensated respiratory acidosis with good oxygenation on the current settings.\\n\\nNo RSBI performed due to the patient's hemodynamic instability.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2179-03-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1293254,\n \"text\": \"Nursing Progress Note:\\nPlease refer to CareVue for details.\\n\\nNeuro: Pt remains sedated and paralyzed on Ppf/fentanyl/Cist. No spontaneous movement noted. PERRLA (2-3mm; brisk). TOF q2hr ( twitches of left eye noted). Per Dr. (transplant team), ? d/c Cist in AM.\\n\\nCV: Febrile overnight (Tmax 38.5; svc aware). Per Dr. , blood cx sent. Left femoral A-line tip sent for cx. HR 140s-sinus tach, no ectopy noted (Dr. , Dr. , and Dr. aware); Ppf gtt rate increased to 120mcg/kg/min to ?decrease HR without effect. ABP 130-150s/70-80s. PAP 38-50/21-32. CVP 7-12. CO down to 7.7 towards end of shift (CO was 8.6-12.4 at beginning of shift). SV down to 50s (Per Dr. , no IVB ordered). Cont to monitor. DP/PT pulses strongly palpable. Generalized edema. Q4hr blood draws. Plt 60; transfused with 1unit platelet. No electrolyte replacements ordered.\\n\\nPulm: Lungs sound CTA, diminished at bases. CMV: FiO2 decreased to 40%, Vt 450, freq increased to 27 to blow off CO2 (without much effect), PEEP 7. Last ABG: pH 7.38, PaCO2 51, PaO2 102, bicarb 31, BE 3. Pt not breathing over vent. O2 sat >/= 93%. O2 sat down to 92% during T&R.\\n\\nGI: Abdomen soft w/ +BS. NGT to LWS; drainage was dark brown at beginning of shift, but became bright red (Dr. , Dr. , and Dr. aware; Protonix increased to q12hr). Insulin gtt to keep BS<120. BS checked q1hr.\\n\\nGU: Foley intact w/ clear, yellow urine. Lasix gtt decreased to 8mg/hr to keep I's and O's even (per Dr. and Dr. .\\n\\nInteg: Primary dsg to abd removed and replaced w/ DSD. Abd staples intact; no drainage noted. DSD applied over drains. JPx2 to bulb suction. Medial JP w/ serous drainage; lateral JP w/ dark brown drainage. T-tube w/ bilious drainage.\\n\\nSocial: sister called x1 overnight; updated w/ pt's plan of care.\\n\\nPlan: Continue ICU care and treatments. Monitor VS, I's and O's (keep even). Blood draw and ABG q4hr; replace lytes/blood products as needed. Monitor resp status, TOF. Cont drips. Plan to take pt back to OR for fascia closure (?date). Maintain skin integrity. Discuss plan of care w/ pt's sister.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2179-03-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1293299,\n \"text\": \"PLEASE REFER TO CAREVUE FOR COMPLETE ASSESSMENT AND SPECIFICS.\\n\\nNEURO: PT ALERT, FOLLOWING SIMPLE COMMANDS, ABLE TO TRACK AND , SPONT/PURP BUT VERY WEAK, NODS APPROPRIATELY TO SIMPLE COMMANDS.\\n\\nCV: HR 98-122, NSR-ST, NO ECTOPY, SBP 10-135. CVP 3-7.\\n\\nRESP: LUNG SOUNDS COARSE, SXN FOR SMALL AMT THICK WHITISH SECRETIONS. VENT SETTINGS CURRENTLY CPAP+PS, 5PEEP/10PS (PS INC FROM 5 TO 10)40% FIO2, RR 12-27, TV 300-400. LAST ABG 7.38/52/132/32/4/98. CXR TO BE DONE IN AM.\\n\\nGI: ABD SOFT NT/ND, HYPO BOWEL SOUNDS, TF IMPACT W/ FIBER AT 60CC/HR W/ GOAL RATE 90CC/HR, MINIMAL RESIDUALS. TF TO BE STOPPED AT 4AM FOR POSSIBLE EXTUBATION. INC W/ CLIPS C/D/I, DRAIN W/ LRG AMT DARK CLEAR BILIOUS FLUID. LIVER U/S DONE, F/U RESULTS.\\n\\nGU: FOLEY DRAINING 80-300CC/HR POST LASIX DOSE, CLEAR AMBER TO YELLOW URINE. I/O BALANCE GOA IS FOR PT TO BE NEG 1L, BY 7AM.\\n\\nID: TMAX 101.7 DOWN TO 99.8\\n\\nENDO: PR REMAINS ON INS GTT FOR FS CONTROL.\\n\\nPLAN: MONIOTR VS, LABS, RESP STATUS, NEURO STATUS. PHYS THERAPY TO FOLLOW PT. FOLLOW UP U/S RESULTS. AWAITING CXR. STOP TF AT 4AM FOR ? EXTUBATIN THIS AM. CONT CURRENT MGMT.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2179-03-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1293300,\n \"text\": \"Respiratory Care:\\nPt. continues on low level PS ventilation. Increased PS level overnight to decrease WOB. ABG's well oxygenated with a fully compensated respiratory acidosis. RSBI was 69 this a.m.>>started on SBT 04:10. B/S scattered course>>ETS small to moderate, thick, pale yellow. Good gag, excellent cough. Team to eval for extubation on rounds.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2179-03-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1293301,\n \"text\": \"Nursing\\nSee flowsheet for details.\\n\\nPt. fairly calm and cooperative today. Following commands and strength increasing. Remained on minimal vent settings all day. Prior to liver bx this afternoon, pt. placed back on propofol. Procedure was unremarkable and propofol d/c. Insulin gtt on.\\n\\nCont. to receive fentanyl prn with good results. Abdomen soft and slightly tender. Good BS. Stool thick, brown and moderate amounts. NG clamped. Cont. to receive lasix for -1000cc fluid balance.\\n\\nPlan to rest over night for pending extubation tomorrow. Also plan for post-pyloric tube placement tomorrow.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2179-03-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1293302,\n \"text\": \"Resp Care\\nPt remains on vent. Required increased in support for lung biospy. Plan to wean to extubate tomorrow.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2179-03-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1293303,\n \"text\": \"Respiratory Care:\\nPt. continues on low level PS settings per flowsheet. Increased PS level from 5 to 10 overnight to \\\"rest\\\". B/S with course crackles>>ETS small to moderate secretions ranging from pale yellow to . Sputum sample \\\"cross contaminated with oralpharyngeal secretions\\\" per lab. ABG's well oxygenated with a fully compensated respiratory acidosis. RSBI was 71 this a.m. (done with ATC off, 0 peep, 0 PS). Pt. has good gag/cough. Starting SBT ~ 04:30. Evaluate for extubation on rounds.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2179-03-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1293248,\n \"text\": \"7a-7p nursing note:\\nNursing Assessment:\\n\\nNeuro: Currently 2 twitches on cisatracurium Besylate, Propofol, and Fentanyl gtts. Pupils equal and reactive.\\n\\nCV/GU: PAD to try to keep low 20's. HIght 20's to low 30's for shift, Nitro off and Dr. is aware. Tachycardic in 120's. Lasix gtt for goal 1 liter negative for day. FC putting out large amounts clear yellow urine.\\n\\nResp: CMV decreased to FiO2 .60, O2 sats 92% and frequent blood gases with vent changes, otherwise Q 4 hour gases and labs as ordered. Dr. is aware of oxygenation issues. Please see flowsheet for specifics. Tidal volume 500 X 25 with 5 of PEEP. Lung sounds clear to coarse. Only scant amounts of thick secretions on suctioning.\\n\\nSkin/GI: Abdominal incisions with DSD's CD&I. Bowel sounds absent, abdomen soft. NGT to suction with brown drainage. TPN initiated.\\n\\nPlan: Titrate all gtts as required. Monitor PAD pressures and O2 sats. Q4 CBC, Fibrinogen, PT, PTT, and ABG's. Chem 10 and LFT's Q 8.\\n\\nPlease see nursing flowsheet for all specifics.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2179-03-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1293249,\n \"text\": \"Neuro sedated fentanyl 100mcg and propofol 100mcg/kg/min paralyzed cisatracurium .14mg/kg/hr TOF 1/lid, pupils equal and reactive\\nResp 70%/550/20/7peep abg 7.37/53/136/32/4 fio2 dropped to 60% hydrochloric acid gtt d/c. lungs exp wheeze/coarse/clear sx sm amt of thick tan secretions albuterol tx given cxr taken to determine reason for decreasing o2 sat, adjustments made as above\\nCVS HR 127-107 ST without ectopy PAP s/D 61/36-50/31 CO 9.1 CI 5.2 CVP 16 bp 161/87-137/75 lopressor 5mg IV given x2 skin w+d pp+4 Hct 36.4\\nGI abd soft BS absent Dsg D+I JP lat 70cc, T 75cc, JP med 22, ngt 200cc bilious, amylase 111, LDH 659, AST 735, ALT 927, alk phos 119. Sm amt soft brown stool\\nGU u/o > 200cc neg 652 mn to 0500 lasix gtt 4mg IV q hr cr .9\\nID temp max 100.8 core lact acid 2.6 wbc 7.7 on vanco fluconazole zoysn, bactrium\\nendo BS > 200\\nTPN\\nA. s/p liver transplant HIV+ HCV cirrohois esophageal varices hx liver enzymes relatively unchanged overnight, IVDU, asthma + smoker 1ppd ? rt pleural effusion by cxr\\np. keep sedated paralyzed, wean fi02 as tol albuterol tx prn, monitor labs q 4, keep u/o > 100cc titrate lasix monitor lytes replete prn, goal pap diastolic <20, needs peak cyclosporine level after 0800 dose, Blood bank requests direct coomb's antiglobulin and antibody screen be sent to bld bank today. Monitor s/s blding. Add insulin to TPN cont SS q 4hr tx per scale,\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2179-03-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1293244,\n \"text\": \"FOCUS: CONDITION UPDATE/ADMISSION NOTE\\nSEE CAREVUE FOR SPECIFIC VITAL SIGNS/LAB VALUES/ASSESSMENT\\nD: PATIENT ADMITTED TO SICU FROM OR AT 1300, S/P LIVER TRANSPLANT--STARTED ON , UNABLE TO ANASTAMOSE FIRST LIVER, WAS ANAHEPATIC FOR APPROX. 14 HOURS, RECEIVED 2ND LIVER THIS AM, CASE FINISHING AROUND 1230. RECEIVED MASSIVE AMOUNTS OF COLLOIDS (SEE FLOW SHEET FOR EXACT NUMBERS). ARRIVED TO SICU, INTUBATED ON PROPOFOL AND NTG. DID AWAKE IN THAT SHE MOVES EVERYTHING, RESPONDS APPROPRIATELY TO PAINFUL STIMULATION (WITHDRAWS, NOT POSTURING), AND PUPILS EQUAL AND REACTIVE TO LIGHT. DOES NOT FOLLOW COMMANDS, AND IS BEING KEPT PRETTY SEDATED ON PROPOFOL 50 MCG/ AND PRN MSO4.\\nRECEIVED 1 U PRBC SINCE ADMISSION , NO OTHER COLLOIDS. LABS PER FLOW SHEET.HAS BEEN TACHYCARDIC SINCE ADMISSION, PA / CARDIAC NUMBERS PER FLOW SHEET. HO AWARE.\\nBELLY COVERED WITH POSTOP DRESSING AND COVERED WITH LARGE OPSITE, SKIN IS CLOSED, YET FASCIA REMAINS OPENED, AS COULD NOT CLOSE IN OR DUE TO HIGH PA NUMBERS AND HIGH PIP ON VENTILATOR.\\nJPS DRAINING MINMAL AMOUNTS DARK FLUID, T TUBE DRAINING SMALL AMOUNT OF LIGHT COLORED BILE. NGT +PLACEMENT, DRAINING OLD BLOODY DRAINAGE.\\nRECEIVED LASIX 20 MG AND DIURESED WELL, ON IV NTG TO LOWER PAD (CURRENTLY AROUND 24-25 WHICH SHOULD BE GOAL).\\nFAMILY IN, SPOKE WITH DR. , AWARE OF SITUATION.\\nULTRA SOUND DONE, +FLOW ALL VESSELS.,\\nCULTURED FOR BLOOD/SPUTUM FOR TEM>38.0\\nP: CONTINUE TO DRAW LABS Q 4/8 HRS. AS ORDERED.\\nTRY TO WEAN FIO2, YET PO2 LOW ON HIGH FIO2, CXRAY DONE, TEAM AWARE.\\nCONTINUE WITH PLAN, CALL HO WITH ANY CHANGES.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2179-03-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1293245,\n \"text\": \"Pt remains on current vent settings, see carevue for details.Will follow.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2179-03-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1293246,\n \"text\": \"RESP CARE: Pt remains intubated/on vent on AC 550/15/.70/5 PEEP. Lungs coarse bilat R>L. No RSBI at this time due to high FI02. Will continue to wean FI02 as tol.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2179-03-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1293247,\n \"text\": \"CONDITION UPDATE\\nPLEASE SEE CAREVUE FLOWSHEET FOR SPECIFICS.\\nNEURO: PT SEDATED WITH PROPOFOL AND FENTANYL GTTS, PARALYZED WITH CISATRICURIUM. CIS GTT TITRATED UP FOR RR, 0-1 THUMB TWITCH WITH 40MA STIM TO ULNAR NERVE. SEDATION INCREASED WHILE PARALYZED BASED ON CHANGES IN VS WITH STIMULATION. PERRL. PRIOR TO INCREASE IN SEDATION AND START OF PARALYTIC, PT MOVING SPONT AND IN RESPONSE TO PAIN. LOCALIZED WITH BUE TO TRAP SQUEEZE.\\nRESP: LS CTA. SCANT SECRETIONS VIA ETT SUCTION. ABG'S WITH INCREASING PCO2 DESPITE DECREASED RR WITH ADEQUATE SEDATION/PARALYSIS. PH STABLE WITH INCREASE IN HCO3. DIAMOX ORDERED FOR DIURESIS THIS AM. FIO2 WEANED TO 70% WITH STABLE O2 SATS.\\nCV: LOW GRADE TEMPS. CONTS TACHYCARDIC, HYPERDYNAMIC. PULMONARY HTN CONTINUES DESPITE DIURESIS WITH LASIX, INCREASE IN NTG GTT PER DISCUSSION WITH MD . K AND MAG REPLETED AS ORDERED. CBC AND COAGS STABLE.\\nGI: NGT TO LCWS WITH SM AMT O/P, BROWN TO BLOODY AT TIMES. MD INFORMED.\\nGU: POS DIURETIC RESPONSE TO LASIX. RESPONSE TO DIAMOX PENDING.\\nENDO: FSBG COVERED PER RISS.\\nSKIN: SURGICAL ABD DSG INTACT. SMA MT OLD SEROUS DRG. MEDIAL JP WITH SMAMT SEROSANG O/P. LATERAL JP WITH SMA MT MAROON O/P. T-TUBE WITH SM AMT DK AMBER O/P.\\nPLAN: MAINTAIN ADEQUATE SEDATION WHILE PARALYZED. CONT TO MONITOR LABS Q4H AS ORDERED. MONITOR HEMODYNAMICS CLOSELY. DUIRESE WITH DIAMOX AS ORDERED. EMOTIONAL SUPPORT TO FAMILY. AWAIT RETURN TO OR FOR FACIA CLOSURE.\\n\"\n }\n]"}}},{"rowIdx":377,"cells":{"subject_id":{"kind":"number","value":5307,"string":"5,307"},"hadm_id":{"kind":"number","value":168261,"string":"168,261"},"target_text":{"kind":"string","value":"The patient was admitted to the neuro ICU. Blood pressure was controlled with Labetalol drip to maintain systolic blood pressure 140's to 160's. He was given FFP for a total of 6 units to reverse elevated INR. Head of bed was kept 30 degrees. Frequent neuro checks were done to watch for any sign of hydrocephalus. He was placed on gentle hydration with IV fluids at 50 cc per hour. He was evaluated by neurosurgery who felt that his intraparenchymal bleed was not operable. Throughout his hospital course his neurologic exam did not significantly change. He remained with flaccid right arm and leg and with good spontaneous movements on his left arm and leg. He remained intubated and sedated. The sedation was withdrawn on with no significant change in his neurologic status or responsiveness other than opening his eyes to stimulation. Repeat head CT was done on to evaluate for any change in hemorrhage or mass effect or hydrocephalus. Repeat head CT showed a stable hemorrhage with no significant change from the prior study. It continued to require aggressive blood pressure control. He again had a repeat head CT done on for question of decreased responsiveness and again no significant change was seen in the hemorrhage or small amount of shift. His ventilatory requirements continued to be weaned. He was weaned to pressure support and C-pap, though continued to require intubation for airway protection. After discussion with the family it was decided to place tracheostomy as well as PEG tube which was done on . He did become febrile over his hospital course with cultures showing an enterococcus UTI and MSSA in his sputum. He was started on antibiotics including Levaquin and Oxacillin. He received a total course of a 7 day course of Levaquin and is to continue for a total of 7 days of Oxacillin requiring one more day, to be discontinued after dose. He did have an episode of acute respiratory distress on . At that time the episode resolved spontaneously. Chest x-ray at that time showed mild CHF, the episode was felt to possibly be a PE. Lower extremity dopplers were done which were negative. The patient had been on boots for DVT prophylaxis and was started on subcu Heparin. Neurologic exam on discharge remained not significantly changed. The patient is awake, alert, opens eyes to verbal stimuli. He does not follow commands. he does squeeze with his left hand but not consistently to command. He continues with a left gaze deviation, both eyes sometimes do cross midline. He does not track with his eyes, his pupils are equal, round and reactive to light. The left gaze deviation is able to be overcome by dolls. He continues with a dense right hemiplegia. He has good spontaneous movements on the left arm and leg. He withdraws his left arm and leg to painful stimuli. There is occasionally triple flexion response to painful stimuli of the right leg. There is no withdrawal on the right arm."},"extractive_notes_summ":{"kind":"string","value":"SETTING UNCHGED-AM ABG SENT. MD notified and pt again placed on Labetolol gtt. Weaned labetolol gtt to off with SBP <110. CV=HEMODY STABLE. AM ABG-7.43/40/139/27/2BREATH SOUNDS=COURSE THROUGHOUT. PULM=TRACHED & VENTED. WO MOVEMENT OF R EXTREM. ID=LOW GRADE T. LABS=AM SENT.A:FRESH TRACH & PEG.P:CONTIN PRESENT RX. LASIX PO W GD RESPONSE. OPENS EYES TO STIM-?TRACTS/FOLLOWS. ?WEAN TO EXTUBATE. PULM=TRACHED. BP, HR and RR began trending down back to baseline. K REPLACED.A:UNCHGED.P:CONTIN PRESENT MED MANAGEMENT. Suction prn. Conts on levo and oxacillin for coverage. PULM=REMAINS /VENTED. WO BM. CCU NSG PROGRESS NOTE-NSICU BORDER.O:NEURO=UNCHGED. BUN 51 creat 1.4. SX FREQ. +BS Abd softly distended. ABG 7.35/49/97/28. ABG 7.43/42/173/29. begining vemt wean as tolerated. CV=CONTIN ON LOPRESSOR/HYDRAL FOR RATE/BP CONTROL. Tolerating well, ABG confirms. ?trach. GU=CONDOM CATH. TLC in R subclavian flushing w/o incidence. Abluterol/Atrovent mdi given as ordered. ?LBM. FS QID. TREATED X1 THIS SHIFT. CCU NSG NOTE: THALMIC BLEEDO: For complete VS see CCU flow sheet.ID: T-max 100.6.NEURO: Pt remains minimally responsive. CCU NSG PROGRESS NOTE 7P-7A/ S/P THALMIC BLEED.S- , SEDATED, NONRESPONSIVE.O- SEE FLOWSHEET FOR OBJECTIVE DATA.CV- VS REMAIN STABLE- BP LABILE ACCORDING TO AGITATION/SEDATION LEVEL.MOSTLY B/T 100/50- 150/70.GOAL- SPB- 120-140/. Started on LEVOFLOXACIN IV qd.RESP: LS coarse. s/c Heparin and pneumoboots.ID: Tmax 100.6 PO, 101.5 rectal today. suction q3-4h and prn. AMBUED & SUCTIONED & SEDATED WITH VERSED 1MG VP WITH GOOD EFFECT.CARDIAC: HR 87-109 AF, NO ECTOPICS. Respir. abd soft, +BS. placed back on PS 12/ peep 5 w/ good effect. ON IV LEVOFLOX.ENDO: BS 173->166. reverting back into above respiratory pattern. excellant cough. BP-115/- 160/REMAINS ON LOPRESSOR/NTP/CLONIDINE/HYDRALAZINE. purposful movements L side. TV- 800'S,.ABG EXCELLENT.PLAN TO EXTUBATE THIS AM.NPO EXCEPT FOR MEDS.RR- .MIN SECRETIONS.ID- AFEBRILE.GU- FAIR UO- 20-60/HOUR- RESUMED ON LASIX PO.I/O CLOSE TO EVEN AS OF 12 AM.GI- OGT IN PLACE - NPO FOR POSSIBLE EXTUBATION.MINIMAL ASPIRATES. EPISODES OF TACHIPNEA & LABORED RESPIRATIONS-RXED W HALDOL PRN W LIMITED EFFECT. CV=NTG WEANED & DCED. ?RESUME TF-IF NOT EXTUBATABLE. b/s +/cta/dim bilat. PULM= & VENTED. generalized +edema.RESP: remains on PS today. ID=FEBRILE W T MAX 100.4 PO. HAS HX MI, HTN, AFIB. OVER DIURESIS ...? Abd +BS, distended soft. ABG'S SDEQUATE. pneumoboots on. sxn thk wh. TF WELL WITH MIN RESIDUAL. BP 120-160/60-70s.GI: Pt had lg soft G- bm. RT gave inhalers.CVS: BP 97 -178/60 - 80. ?HEAD CT REDO. abg 7.43/44/116/30. current abg 7.40/42/131/27. ?WEAN VENT TO EXTUBATE (FREQ SX & COUPIOUS SECRETIONS). c/w tc as tolerates. Cont TF overnight.Keep R arm elevated. CK AM LABS-REPLACE AS INDICATED. status, BS, tube feedings off in am. TEGADEM APPLIED. admin albuterol/atrovent q4-6 with mdi/. Suction prn. BP STABLE ON LABETOLOL GTT. MDI/neb treaments per RESP.GI/GU: abd soft, distended. +generalized edema.ACCESS: R PIV d/c'd. TMAX 101.4 rectally. Resp.---- Pt. C/W TRACH MASK AS TOLERATES. admin albuterol/atrovent mdi q6h. Albuterol/Atrovent MDI's given Q6hr. ADMIN ALBUTEROL/ATROVENT MDI X3. advance to GR as tolerated. SXNED AS NEEDED. NTP has been D/C'd. OXACILLIN D/C. CCU NSG PROGRESS NOTE 7P-7A/ S/P THALMIC BLEEDS- O- SEE FLOWSHEET FOR OBJECTIVE DATA.CV- VS REMAIN AT BASELINE.HR- 108-112 AF. of tan sputum.I.D. Sx for lrg amts. : Pt. : Pt. : Pt. Suctioned for a mod. Receiving albuterol and atrovent MDI as needed. TOLERATING VERY WELL, CUFF IS DEFLATED. : afebrile. Pt. Pt. Pt. Pt. Pt. Pt. ABG: compensated metabolic alkalosis. Plan is to cont. PSV, weaned to 10/5/0.40. Continues on oxa.CVS: BP labile 140 - 180's/70's. TOLERATING WELL. RN AWARE. u/a and CS sent.PLAN: sent sputum spec. amt. DOES NOT FOLLOW COMANDSCV: HR 85-115 A FIB, BP 140-180/60-70, ^ TO 190/100 W/ ATTEMPT TO LOWER PS.RESP: REMAINS ON PS 14, PEEP5. Pt rxd t/o shift with Albuterol/atrovent mdis. +generalized edema.ACCESS: R radial Aline. CXR done. Tolerating TF. ABG 7.45/37/119/2. Resp CarePt. ABG ->60/7.43/43/29. AM ABG-7.39/48/117/30/3. Pulm toliet. +Flatus today. REPLACED X1.ID: T 97.7->98.8(PO).PLAN: TO REHAB THIS AM. Started on Vancomycin today.RESP: LS clear, dim bases. placement confirmed by CXR. Pt with +cough reflex but w/o gag reflex.CV: NTG gtt at 115mcg to maintain SBp<160. BUN 32 Creat 1.4. ETT.ID: Febrile today. +corneals. REMAINS ON LABETALOL GTT.P:CONTIN PRESENT MANAGEMENT. : Pt. con't w/ +generalized edema.RESP: LS Diminished to bases, generally clear upper. Pt tol current settings fairly. ?ADUMENT DIURESIS W PRN LASIX-?SOME COMPONENT OM HTN RELATED TO FL STATUS. Tmax today 100.7 oral. LBM. remains flaccid on R side. ?ATTEMPT TO WEAN & DC LABETOLAL. BS+. +1393 LOS.ID: tmax 99.6.SKIN: intactENDO: FS 127 and 147. Pt. Pt. Pt. Pt. Pt. Pt. +BS. Resp Care,pt. DUODERM TO BUTTOCKS INTACT.DISPOSITION: DNRA: STABLEP: BEDSIDE TRACH TODAY. Right subclavian CV line is in mid SVC. pt tol procedure well. DIURESING WELL FROM LASIX. DIURESING WELL FROM LASIX.GI: + BOWEL SOUNDS. IMPRESSION: PICC tip in proximal SVC. Pt tol PSV well. r hemiparesis. NSG NOTECV: REMAINS IN A-FIB. cont on oxacillin. cont po lasix.id: afeb. pt tol well. tol well.p: begin vent wean as tol. sxn'd for sm amt bld tinged secretions. continues very bronchospastic to SXN. Respiratory Care:Pt. RESPIRATORY CARE:Pt. ABG 7.47/40/151/30. PT BECOMING WITH SUCTIONING. ABG'S ADEQUATE.GU: FOLEY PATENT. bp 130-150/70 via r rad aline. has note visited.act: pt and ot eval pt. ABD SOFT WITH + BS. moves l hand to face/tubes and req soft wrist restraint.cv: hr 80s afib. Rec'g IV lasix . FOLLOWS WITH EYES.CV: CONT ON LABETOLOL GTT. IMPRESSION: Stable left basal ganglionic and intraventricular hemorrhage. There is edema associated with the left basal ganglia hemorrhage that does not appear significantly changed. There is a calcified extra-axial mass off the higher convexities on the right which is unchanged and probably represents a calcified meningioma. There has been interval removal of the right subclavian central venous line. Mild ventricular dilatation. There is a tiny amount of hemorrhage seen within the posterior of the right lateral ventricle as well as in the left temporal and third ventricle. There is a stable old right temporal lobe infarct. There is a stable old right temporal lobe infarct. Mild congestive failure and probably a right-sided effusion. The calcified presumed meningioma in the right frontal region is unchanged. Interval removal of the right subclavian central venous line. There has been decreased interval perihilar haziness and patchy bibasilar opacities."},"n_notes":{"kind":"number","value":127,"string":"127"},"notes":{"kind":"list like","value":[{"category":"Nursing/other","chartdate":"2147-12-11 00:00:00.000","description":"Report","row_id":1332335,"text":"No ABG drawn over night,yesterday abg was normal. Patient head scan from yesterday is unchanged. Remains on mechanical ventilation PS 8/5 with FI02 40% sat 98%,HR 100, BP179/82 BS diminished, not much secretion present on ventolin and atrovent inhalers.\n"},{"category":"Nursing/other","chartdate":"2147-12-11 00:00:00.000","description":"Report","row_id":1332336,"text":"CCU NSG PROGRESS NOTE-NSICU BORDER.\nO:NEURO=STABLE. MOVING L ARM-?PURPOSEFULLY. MOVES L LEG ON BED. WO MOVEMENT R SIDE. OPENS EYES TO STIM-?TRACTS/FOLLOWS. SEE FLOW SHEET FOR FURTHER NEURO CKS.\n PULM=REMAINS /VENTED. SETTING UNCHGED-AM ABG SENT. BREATH SOUNDS=COURSE THROUGHOUT. SX-THICK TANNISH SECRETIONS.\n CV=CONTIN ON LOPRESSOR/HYDRAL FOR RATE/BP CONTROL.\n GI=TF @ GOAL W MINIMAL RESIDUALS. WO STOOL.\n ID=LOW GRADE T.\n LABS=AM SENT.\n\nA:UNCHGED NEURO ASSESSMENT.\n\nP:?ADD MILD SEDATION-HEPL W ?ANXIETY & W HYPERTENSION. ?WEAN TO EXTUBATE. SUPPORT PT/FAMILY AS NEEDED.\n"},{"category":"Nursing/other","chartdate":"2147-12-18 00:00:00.000","description":"Report","row_id":1332359,"text":"CCU Nursing Progress Note 3p-7p:\n\nNeuro: Pt opening eyes spontaneously. Moving neck and LUE frequently wrasping side rails. No spontaneous movement of lower extremities notes. PT consulted today regaring increasing pt's activity, please see eval for details.\n\nCV: Afib HR 90's w/o ectopy. SBP 119-125. Pt conts on cardiac regimen 2in NTP,lopressor and hydralazine. IVF changed to d51/2 NS 40meq KCL at 80cc/hr.\n\nPULM: Mechanically ventilated via trach on PS 14 5 peep 40% fi02 with tv 460. ABG 7.43/42/173/29. Pt with strong spontaneous cough. Pt sxn'd for small to moderate amts of blood tinged sputum. Await RT to locate in line sxn for trach. Pt rec'd last dose of diamox for metabolic alkalosis.\n\nGI: Abd soft +BS. No stool this shift. Peg tube site c/d/i. Place check done with bilious aspirate. Pt rec'd meds crushed w/o incidence.\n\nGU: Foley cath patent draining cyu in adequate amts. -140cc since mn + LOS.\n\nLINES: A-line removed today. TLC in R subclavian flushing w/o incidence. Pt evaluated by IV for PICC placement per IV pt with marginal access secondary to edema. IV team will reevaluate they are also concerned with recent temps and would like line order checked out with ID.\n\nENDO: FS 115 no reg insulin coverage indicated.\n\nID: Afebrile. Rec'd last dose of levo po. Conts on oxacillin iv atc.\n\nSOCIAL: wife and friend in to visit this evening.\n\nDISPO: DNR\n\n\nA: s/p trach and peg placement today. VSS.\nPeg tube flushing w/o incidence.\n\nP: Follow for neuro status changes.\n monitor bp on current regimen.\n ? begining vemt wean as tolerated.\n NPO except meds, start TF in am \n skin care.\n follow u/o.\n\n\n"},{"category":"Nursing/other","chartdate":"2147-12-19 00:00:00.000","description":"Report","row_id":1332360,"text":"CCU NSG PROGRESS NOTE-NSICU BORDER.\nO:NEURO=OPENS EYES & TURNS HEAD TO NOISE, BUT DOES NOT FOCUS, TRACT OR FOLLOW W EYES-APPEARS TO LOOK RIGHT THROUGH YOU!\n PULM=TRACHED. VENTED W SETTINGS-CPAP/PS, 40%, 490-700 STV, 20-30 RR, 5 PEEP, & 14 PRESSURE SUPPORT. BREATH SOUNDS=COURSE THROUGHOUT. SX-LT PINKISH SECRETIONS. TRACH CARE DONE.\n CV=HEMODY STABLE.\n GI=PEG. MEDS WO DIFFICULTLY-?INCREASE AMT OF AIR PRESENT.\n GU=FOLEY. LASIX PO W GD RESPONSE.\n ID=LOW GRADE T.\n LABS=AM SENT.\nA:FRESH TRACH & PEG.\nP:CONTIN PRESENT RX. ?PICC LINE PLACEMENT. ?SCREEN FOR PLACEMENT. SUPPORT AS NEEDED.\n\n"},{"category":"Nursing/other","chartdate":"2147-12-19 00:00:00.000","description":"Report","row_id":1332361,"text":"CCU Nursing Progress Note 7a-7p:\n\nNeuro: Pt alert moving LUE up and down off bed and holding side rail. RUE w/o movement, RLE moves toes and LLE moves on bed. Pt turning head side to side but does not track.\n\nCV: Pt rec'd ADL's, MDI's and was sxn'd at appox 9:30am pt's BP increased to 190-200's, RR high 30's to 40 and HR AFib to 115. Team notified EKG and CXR obtained CK sent. During this event pt appeared air hungry and Diaphoretic. pt w/o difficulty. Dr. was in unit evlauated pt less than 24 hour post trach insertion. Dr not find any issues with trach. Pt rec'd a total of 4mg mso4 with effect. BP, HR and RR began trending down back to baseline. ? PE so pt rec'd duplex US of lower extremities to r/o DVT, await results. rec'd 40mg iv lasix with +diuresis.\nPt conts on current cardiac regimen. HCT 32.7\n\nPULM: Mechanically ventilated via trach on ps 14 5 peep 505 fi02 with tv 700-900. ABG 7.35/49/97/28. Ls course throughout. Sxn'd via trach for yellow sputum. Trach site clean and intact.\n\nGI: Peg tube patent flushing w/o incidence. +BS Abd softly distended. Pt conts on bowel regimen with no stool this shift. TF at goal 65cc/hr.\n\nGU: Foley cath patent draining cyu in adequate amts s/p lasix dose. -952 since mn +1102 LOS.\n\nID: t max 100.0 orally. WBC 19.7. Conts on levo and oxacillin for coverage. + enterococcus in urine on . Sputum on with gram +cocci and gram neg rods.\n\nENDO: FS QID with reg insulin coverage. FS <200.\n\nSKIN: Blister on R heel, remains elevated off bed.\n\nLINES: R radial a-line placed today. R TLC cath flushing w/o incidence.\n\nDISPO: DNR\n\nSOCIAL: wife in to visit today. Sister in law phoned from .\n\nA: resp event this am ?etiology.\n VS now stable.\n TF at goal.\n No change in neuro status.\n\nP: Cont current cardiac regimen. Follow for neuro changes.\n Follow ABG's begin vent wean when indicated.\n Provide support. Await picc line placement when less edematous.\n"},{"category":"Nursing/other","chartdate":"2147-12-11 00:00:00.000","description":"Report","row_id":1332337,"text":"CCU Nursing Progress Note 7a-7p:\n\nNeuro: Pt awake looking around the room and up at the tv. Pt with minimal tracking. No gag reflex and impaired cough reflex. Responding to commands ie opening eyes and sqeexzing left hand. Purposeful movement noted of LUE, moving LLE on bed. No spontaneous movement noted on the R side. HOB 30 degrees. Pt rec'd haldol 2mg IV with minimal effect.\n\nCV: Afib HR 80-100 w/o ectopy. Pt hypertensive throughout the day, Res aware. SBP 160-180's trending to 200 with nursing interventions. Hydralazine dose increased to 30mg po and lopressor dose increased to 125mg po, please follow effect. K+ 4.3 HCT 35.1\nHead CT from neg.\n\nPULM: Mechanically ventilated on PS 8 5 peep 40% fi02. Spont tv 390-490. RR 20's trending into the 30's with sxning and turning. LS coarse throughout. Pt sxn'd q2 hr for thick yellow secretions in moderate amts at times requiring lavage. MDI's by RT. Secondary to no gag reflex pt to be consulted for a trach per team await team to discuss with pt's wife.\nIf pt spikes team with aquire at CXR.\n\nGI: Abd soflty distended +BS + flatus. Pt reached goal of TF impact with fiber today 80cc/hr. Minimal residuals to 25cc.\n\nGU: Foley cath patent draining cyu in adequate amts. BUN 51 creat 1.4. +2455 LOS. Pt with 50cc/hr u/o. Urine with enteroccus.\n\nID: low grade temp to 100.9 Res. aware. WBC 13.2. No abx indicated at this time, follow temps.\n\nSKIN: R heel blister, multipodus boots in place.\nButtocks redened w/o breakdown.\n\nENDO: FS QID <160 reg ss insulin for coverage.\n\nDISPO: Full Code\n\nSOCIAL: wife in to visit today.\n\nA: Improved neuro exam\n resp status stable on current vent settings\n hypertensive\n Tolerating TF at goal\n\nP: Follow neuro assessment. Await effects of increased cardiac regimen. Follow resp status no changes in vent settings. ?trach. TF at goal. ?LBM. Provide support to pt and family.\n\n\n"},{"category":"Nursing/other","chartdate":"2147-12-11 00:00:00.000","description":"Report","row_id":1332338,"text":"Respiratory Care\nPt remains and mechanically ventilated, please see carevue flowsheet for specific info, no vent changes made this shift,no ABG's, 02 sats stable. Suctioning thick yellow, plan to continue with mechanical support.\n"},{"category":"Nursing/other","chartdate":"2147-12-31 00:00:00.000","description":"Report","row_id":1332402,"text":"CCU NSG NOTE: ALT IN NEURO\nO: For complete VS see CCU flow sheet.\nID: Pt afebrile.\nNEURO: Pt conts to have no movement seen on R side of body. He was very alert much of the day, making eye contact and intermittently, and occasionally following commands.\nCV: Stable with hr 80-90s a-fib and bp better controlled in 125-160/60-80s. Pt lifted out of bed to chair for ~2.5 hrs.\nRESP: Pt off the vent for over 48hrs now. He still requires suctioning ~Q3hr for lt yellow sputum. His cough is strong cough and he get much up on his own. Breath sounds are course.\n GI: Pt had lg soft G- BM in am. He continues on replete with fiber from 4p until 8am at 120cc/hr.\nGU: Pt voiding thru condom cath without problem.\nELECTROLYTES: up to 145 today and D5W boluses decreased to 200cc Q6.\nENDO: Blood sugars 162 st noon and 134 at 6p. Pt received 5u NPH at 6p\nA: Decreasing secretion/off vent >48hr\nP: ? transfer to neuro floor tomorrow. Monitor for change. Suction prn. Monitor for change.\n"},{"category":"Nursing/other","chartdate":"2147-12-12 00:00:00.000","description":"Report","row_id":1332339,"text":"SICU Nursing Progress Note\nNeuro: Pt responsive to voice. Pt will open eyes and track for a short period. Pt will follow very simple commands inconsistantly. Pt able to move LUE freely, I have not observed any movement of other extremeties. Neuro checks q2 hours. Pt inconsistantly responds to painful sensation. Pupils PEARL. Pt has -gag reflex, and impaired cough reflex.\n\nCardiac: Pt in controlled AF in 80-90's. BP hypertensive in 180's-190's. MD notified and pt again placed on Labetolol gtt. Started at 2345, initially at 4mg/min, decreased to 2 mg/min. Where he remains currently. BP decreased to about 160's sys. Pt con't on large doses of cardiac meds, lopressor and hydralizine. BP dramaticaly improved with am lopressor and tylenol. BP currently 118/55.\n\nResp: Pt , ? trach at some point, (has not been discussed with wife...will need to be, MD's notified). Pt on CPAP .4%, . Tolerating well, ABG confirms. Pts BS are decreased. Pt has moderate amt of thick yellow sputum, needs lavage.\n\nGI: Pt has OGT, TF, impact with fiber tolerating well minimal residual, at goal of 80. Pts abd is soft and distended, +BS, -BM? how long?\n\nGU: Pt has f/c, with 50-100 cc/hr out. Amber in color and has slight sediment. Pt gets 100 cc of free H2O q8/hr. Lasix is being held. Pt has eneerococcus in urine.\n\nID: Tmax 101.8 pt pan cultured at 0400, pt given tylenol with good response. MD's wanted pt to have CXR with spike, MD notified and decided to have CXR in am.\n\nSkin: Pt has sheepskin boots on bilaterally placed for R heel blister, pneumo sleeves on. Pt turned q3/hr.\n\nEndo: Pt covered with R insulin for BG of 159.\n\nAccess: Pt has R SC TL, and R rad .\n"},{"category":"Nursing/other","chartdate":"2147-12-20 00:00:00.000","description":"Report","row_id":1332362,"text":"Respiratory care:\nPatient remains trached with a # 8 portex and mechanically vented. Vent checked and alarms functioning. Settings CPap/PS with IP 14\npeep 5. Abluterol/Atrovent mdi given as ordered. Please see respiratory Section of carevue for further data.\nPlan: Continue mechanical ventilation. Wean PS as tolerated.\n"},{"category":"Nursing/other","chartdate":"2147-12-20 00:00:00.000","description":"Report","row_id":1332363,"text":"CCU NSG PROGRESS NOTE-NSICU BORDER.\nO:NEURO=REMAINS UNCHANGED. RESPONDS TO NOISE-TURNS HEAD TOWARDS, BUT DOES NOR ENGAGE W EYES.\n PULM=TRACHED & VENTED. SETTINGS-CPAP/PRESSURE SUPPORT, FIO2 50%, STV 640-730, RR 12-20, PEEP 5, & PRESS SUPPORT 14. AM ABG-7.43/40/139/27/2\nBREATH SOUNDS=COURSE THROUGHOUT. SX-THICK TANNISH SECRETIONS. TRACH CARE DONE.\n CV=BORDERLINE HYPERTENSIVE DESPITE RX W HYDRALAZINE, LOPRESSOR, & NTP.\n GI=TF-PROMOTE W FIBER @ 65ML/HR W MINIMAL RESIDUALS. WO BM.\n GU=I&O -.9L @ 2300 & -.8L @ 0600.\n ID=LOW GRADE T.\n LABS=AM SENT. K REPLACED.\nA:UNCHGED.\nP:CONTIN PRESENT MED MANAGEMENT. ?PICC LINE. ?START EVALUATION FOR PLACEMENT.\n"},{"category":"Nursing/other","chartdate":"2147-12-07 00:00:00.000","description":"Report","row_id":1332319,"text":"CCU Nursing Progress Note 7p-7a:\n\nNeuro: Pt sedated on propofol gtt at 25mcg. Pt responding to sternal rub and nail bed pressure. Pt moving all extremities on bed. Pupils pinpoint, reactivity sluggish. No gag or cough reflex. Lightened sedation w/o change. Await results from CT scan.\n\nCV: Afib HR 70-80's w/o ectopy. Goal SBP <120. Weaned labetolol gtt to off with SBP <110. Am hydralazine iv held per parameters. Conts on lopressor 12.5mg . HCT 35.5.\n\nPULM: Mechanically ventilated on PS 5 last evening with RR in high 30's, tv 310-380 with pt diaphoretic. Team notified PS increased to 15 and within 5 min pt's RR down to the teens and tv increased to the 700's. Pt appeared more comfortable. Began PS wean this am currently at 13 7.5 peep 40% fi02 RR 13 and Tv 600. ABG 7.43/40/118/2.\nPt sxn'd q2hr for small amts of thick yellow secretions.\n\nGI: Abd softly distended with hypoactive BS. OGT clamped. +bile in stomach. No stool this shift. Pt remains NPO on maintainence IVF for posible extubation.\n\nGU: Foley cath patent draining concentrated yellow urine in adequate amts 30cc/hr. +305 since mn +1128 LOS.\n\nSKIN: intact\n\nENDO: FS 189 and 134. Reg insulin ss for coverage.\n\nPROPH: Pneumoboots and protonix.\n\nLINES: L radial a-line and PIV.\n\nDISPO: Full Code\n\nSOCIAL: No phone calls this shift.\n\nA: stable BP off labetalol gtt\n neuro status stable\n requiring increased PS.\n\nP: Maintain SBP <120.\n Follow Afib. Wean PS as tolerated.\n NPO. Follow u/o.\n Neuro checks q1hr.\n FS QID. Provide support to family.\n"},{"category":"Nursing/other","chartdate":"2147-12-07 00:00:00.000","description":"Report","row_id":1332320,"text":"Respiratory Care note: Pt is on CPAP 7.5. PSV decreased from 13 to 11. Tidal Volumes= 500-650ml. RR= 17. Spo2= 97% on an Fio2= .40. When ETT was placed at 20cm at lip, there was an enormous air leak that would not go away with the administration of air to the cuff. As a result, we had to advance the ETT to a level that below the vocal cords. Currently the ETT is placed at 26 cm. A CXR has beendered to check tube placement. Suctioned pt after repositioning for a large amount of thick, yellow sputum.\n"},{"category":"Nursing/other","chartdate":"2147-12-07 00:00:00.000","description":"Report","row_id":1332321,"text":"N SICU NPN\nNEURO: PROPOFOL D/C 09:00, PT RESPONSIVE TO NOXIOUS STIMULI. OPENS EYES, OCC SPONTANEOUSLY HOWEVER DOES NOT TRACK. PUPILS 2MM AND SLUGGISH. MOVING L SIDE OCCASIONALLY, VERY SLIGHT MOVEMENT OF R HAND AND FOOT NOTED THIS AM. + COUGH GAG ABSENT.\n\nCV: HEMODYNAMICALLY STABLE IN A FIB 80-90'S, BP 110-160/50-70.\n\nRESP: PS DECREASED TO 11, TV 400-500.RR 14-20. APPEARS VERY COMFORTABLE. SECRETIONS BECAME COPIOUS THIS AFTERNOON, THICK, TAN. SPECIMENT SENT FOR CULTRE. LG AMTS ORAL SECRETIONS. LESS PAST 2 HRS. ETT REPOSITIONED BY SICU RESIDENT. PLACEMENT CONFIRMED BY X RAY.\n\nGI: IMPACT W/ FIBER STARTED AT 16:00 AT 10CC/HR. NO STOOL THS SHIFT.\n\nGU: U/O 15-25CC/HR, CURRENTLY ~ 800CC +. CURRENTLY BEING GIVEN 500CC NS BOLUS.\n\nID: TM 100.2 R.\n\nSOCIAL: WIFE, BROTHER AND SISTER IN LAW IN ALL AFTERNOON, UPDATED BY MD.\n\nA: NEURO STATUS UNCHANGED, HEMODYNAMICALLY STABLE OFF LABATELOL, TOLERATING DECREASED PS.\n\nP: MONITOR NEURO STATUS, KEEP SBP > 120, FOLLOW U/O, ? SWAN.\nEMOTIONAL SUPPORT TO FAMILY.\n"},{"category":"Nursing/other","chartdate":"2147-12-07 00:00:00.000","description":"Report","row_id":1332322,"text":"NPN ADDENDUM\nBP ^ 190'S/ STARTED ON NTG GTT AT 40 MCG/MIN AT 18:00,INCREASED TO 60 MCG/MIN. ALSO LOPRESSOR ^ TO 25MG , AND DOSE GIVEN AT 18:00.\nCURRENTLY HR 108 A FIB, BP 140/73.\n"},{"category":"Nursing/other","chartdate":"2148-01-01 00:00:00.000","description":"Report","row_id":1332403,"text":"CCU NSG PROGRESS NOTE-NSICU BORDER.\nO:NEURO=RESPONSIVE. APPROPRIATE TO SIMPLE QUESTIONS-\"ARE YOU OK?\"- SHAKES HEAD NO & SAYS \"HELP\". CONTIN TO MOVE LUE PURPOSEFULLY-TAKING TRACH MASK OFF, PLAYING W COMDOM CATH, & SCRATHCHING NOSE. WO MOVEMENT OF R EXTREM.\n PULM=TRACH MASK-50% W ADEQ SATS. SX-THICK WHITEISH SECRETIONS. BREATH SOUNDS=COURSE THROUGHOUT.\n GI=TF @ GOAL. WO STOOL.\n GU=CONDOM CATH. GD RESPONSE TO LASIX.\n LABS=AM SENT. EXTREMELY DIFFICULT STICK-POOR ACCESS.\nA:SLOWLY IMPROVING NEURO STATUS.\nP:CONTIN PRESENT MED MANAGEMENT. ?CALL-OUT.\n\n"},{"category":"Nursing/other","chartdate":"2148-01-01 00:00:00.000","description":"Report","row_id":1332404,"text":"ccu nursing progress note\nremains on trach mask\nO: see flowsheet for objective data. VSS with BP good on current meds.\nremains in afib without vea. resp: remains on .5 trach mask with good sats. requiring suctioning q2-3hr for thick yellow/white secretions with occassional plugs. lungs coarse. afebrile. u/o qs via condom cath. cont tube feeds at goal rate, no BM today. PEG site d/i, PICC site D/I , coccyx reddened, duoderm intact. pt. oob-chair with 4 assists for 2 hours, tolerated well. neuro: pt. alert at times, following simple commands inconsistently, moving LUE purposefully, moving LLE on bed, right side remains flacid. wife called x 2, updated on condition. turned q2hr.\nA: stable, cont with secretions\nP: cont pulm toilet, follow neuro status, cont supportive care. ?Placement on per resident to \n"},{"category":"Nursing/other","chartdate":"2148-01-02 00:00:00.000","description":"Report","row_id":1332405,"text":"CCU NSG PROGRESS NOTE-NSICU BORDER.\nO:NEURO=UNCHGED.\n PULM=THICK SECRETIONS. SX FREQ.\n LABS=UNABLE TO OBTAIN. PICC LINE DOES NOT DRAW BACK.\nA:UNCHGED.\nP:CONTIN PRESENT MED MANAGEMENT. ?TRANSFER TO REHAB.\n\n"},{"category":"Nursing/other","chartdate":"2148-01-02 00:00:00.000","description":"Report","row_id":1332406,"text":"RESPIRATORY CARE:\nPATIENT FOLLOWED FOR ALBUTEROL/ATROVENT NEBS. TREATED X1 THIS SHIFT. TOLERATED WELL. BS COARSE.\nWILL CONTINUE TO FOLLOW. PATIENT WITH 50% COOL AEROSOL ON.\n"},{"category":"Nursing/other","chartdate":"2148-01-02 00:00:00.000","description":"Report","row_id":1332407,"text":"ccu nursing progress note\nS' remains trached\nO: see flowsheet for objective data. VSS on current meds. cont on .5 trach mask with good sats, suctioned frequently for thick white secretions, lungs remain coarse with upper airway exp. wheezing, cont nebs per RT, afebrile, GI: tube feeds restarted at goal rate at 4pm, BS+, no BM today, GU: voiding via condom cath, neuro: more alert his am, at times following commands but not consistently, moving LUE purposefully, moving LLE in bed, right side remains flacid. sent for head CT this am, pnd RUE remains edemetous, elevated on pillow. turned q2hr, skin intact. PICC line cont, able to flush but not draw blood, pt. extremely difficult to stick for bloods.\nA: stable\nP: to be eval for tx to , cont to follow neuro status, cont pulm toilet\n"},{"category":"Nursing/other","chartdate":"2148-01-02 00:00:00.000","description":"Report","row_id":1332408,"text":"Resp Care\nadmin albuterol/atrovent 4 puffs each q4h via trach/. sxning sm amts clear to white secretions. good cough. cuff deflated. occas.audible wheezing ?from tracheal irritation vs.bronchospasm.\nremains on 50% trach collar in nard.\n"},{"category":"Nursing/other","chartdate":"2148-01-03 00:00:00.000","description":"Report","row_id":1332409,"text":"CCU progress note\nNEURO: no changes noted. PERLA 2mm reactive. no movement R side. +sensation. purposful movements L side. pt sleeping most of nite. not obeying verbal or gestured commands tonite.\n\nCARDIAC: AFIB 90s. SBP stable.\n\nRESP: remains on Trach collar 50%. suctioned for small amts thin white secretions. no resp distress. RR 6-40s varying, sats >98%.\n\nGI/GU: voiding in condom cath. incontinent x 1 large amt urine when condom fell off. abd soft. +BS. Large soft formed BM tonite. TF overnite via peg.\n\nPLAN: ?rehab placement. cont' to monitor neuro and VS.\n"},{"category":"Nursing/other","chartdate":"2148-01-03 00:00:00.000","description":"Report","row_id":1332410,"text":"Respir. Care Note\nFollowed overnight with q 4 Albuterol/Atrovent MDIs via trach. Breath sounds are coarse bilaterally, suctioned for thick white/tan secretions. O2 sat 97-99% on 50% trach mask.\n"},{"category":"Nursing/other","chartdate":"2148-01-03 00:00:00.000","description":"Report","row_id":1332411,"text":"Resp care\nc/w 40% trch collar/cuff deflated. excellant cough. prod sm amts green sputum. less wheezing today. mdi's changed to prn. awaiting transfer to rehab facility.\n"},{"category":"Nursing/other","chartdate":"2148-01-03 00:00:00.000","description":"Report","row_id":1332412,"text":"N SICU NPN\nNEURO: NO MOVEMENT R SIDE. MOVING L SIDE IN PURPOSEFUL MANNER. FOLLOWING COMMANDS INCONSISTENTLY. OCCASIONALLY WILL SPEAK WORD OR TWO, ANSWERING SIMPLE QUESTIONS.\nCV: HEMODYNAMICALLY STABLE\nRESP: DOING WELL ON TRACH MASK AT 50%.W/ CUFF DOWN. SEEN BY SPEECH AND FITTED W/ PASSEY MUIR VALVE. (DO NOT HAVE ON WHILE PT IS COUGH PRODUCTIVE FOR THICK YEL SPUTUM, NEB RX HAVE BEEN CHANGED TO PRN.\nGI: TOLERATING TF. NO STOOL TODAY\nGU: CONDOM CATH DRAINING CL YEL URINE QS.\nID: AFEBRILE\nEND: BS 179 AT 6PM.\nACTIVITY: SEEN BY PT TODAY. OOB TO CHAIR, SAT ON EDGE OF CHAIR BALANCING W/ L HAND, ATTEMPTED TO STAND.\nDISPO: PT HAS BED AT OLYMPUS/ FOR , AT 9AM.\n"},{"category":"Nursing/other","chartdate":"2147-12-27 00:00:00.000","description":"Report","row_id":1332387,"text":"Respiratory care:\nPt. remained on vent overnight. SPO2 high 90's to 100%, with RR generally mid teens. B/S course>>ETS for moderate amounts of thick, tan/yellow. MDI's given for induced bronchospasm with good effect. Will continue pulmonary hygiene and TM trials in a.m.\n"},{"category":"Nursing/other","chartdate":"2147-12-27 00:00:00.000","description":"Report","row_id":1332388,"text":"NEURO: AWAKE & ALERT. FOCUSES BUT DOES NOT TRACK. PERL. FOLLOWS SIMPLE\n COMMANDS, BUT NOT CONSISTENTLY. NO MOVEMENT ON R. SIDE. L. ARM\n LIFTS & HOLDS OFF BED. L. LEG LIFTS & FALLS. DOES NOT ATTEMPT\n TO COMMUNICATE.\nRESP: TRACHED & ON VENT: 50% 14 IPS 5 PEEP. BS COARSE THROUGHOUT, &\n SLIGHTLY DIMINISHED AT BASES. RR 8-15. O2 SATS 98-100%. SX FOR\n SM.-MOD. AMTS. THICK YELLOW-TAN SECRETIONS. ONE EPISODE EARLY\n IN SHIFT WHEN BECAME TACHYPNEIC TO RR 40-50. AMBUED & SUCTIONED\n & SEDATED WITH VERSED 1MG VP WITH GOOD EFFECT.\nCARDIAC: HR 87-109 AF, NO ECTOPICS. BP 111-139/42-70. CONT. ON NTP,\n LOPRESSOR, & IV HYDRALAZINE.\nGI: TF:FS PROMOTE WITH FIBER AT 65CC/HR. ABD. SL. DISTENDED. BS+. NO\n STOOL. RECEIVING FREE H2O 300CC Q4HRS FOR ELEVATED NA 160.\nGU: FOLEY->CD PATENT & DRAINING CLEAR YELLOW URINE. U/O 60-235CC/HR.\nID: T 99.8->100.1(PO). CONT. ON IV LEVOFLOX.\nENDO: BS 173->166. RECEIVED REG. HUMALIN INSULIN 2U SC X2 PER SLIDING\n SCALE.\nLABS: WBC 12.8, HCT 33.6, PLAT CT 198K, NA 156, K 3.9, BUN/CREAT 44/\n 1.1, CA 8.3, MG 2.3, & PO4 2.5.\nAWAITING REHAB!!!!!!!\n"},{"category":"Nursing/other","chartdate":"2147-12-27 00:00:00.000","description":"Report","row_id":1332389,"text":"CCU progress note 7a-7p\nNEURO: unchanged. inconsistently obeying verbal + gestured commands. pt brushed teeth today and washed face w/ encouragement. pt helped to place glasses on face. pt occasionally doing arm curls w/ 1lb weight. Moves L side well. No movement to R side. +sensation to all extremieites. pupils 2mm brisk. started on serax 10mg TID. ?start antidepressant? ?increase serax if not noted to have good effect on anxiety levels.\n\nCARDIAC: no change in hypertensive meds. BP 120-180 today. AFIB 80-100s.\n\nRESP: attempted to trach collar today, but pt became stridorous and agitated today. placed back on PS 12/ peep 5 w/ good effect. has had episodes of tachypnea on vent this afternoon. settled on own. sats remains >97%. Sx small amts yellow thin secretions.\n\nGI/GU: foley patent. good u/o. on lasix 20mg . On free water 300cc Q6h. TF increased to 80cc/hr GR. PEG intact to abd.\n\nSKIN: duoderm changed to coccyx, stage II ulcerated area to R buttock, new duoderm applied. Ordered first step air mattress. heels intact. old blister to R heel healing well. multipodus boots on. peg site looks healthy, dsg changed today. trach site slightly reddened, cleansed w/ H2O2.\n\nPLAN: con't to monitor VS and neuro status. keep pt comfortable. Awaiting PLACEMENT TO REHAB.\n"},{"category":"Nursing/other","chartdate":"2147-12-06 00:00:00.000","description":"Report","row_id":1332315,"text":"addendum to day note\npt's breathing appears more labored than this am. rr is 28 but much more abd breathing irregular. stroke team in to assess.\n"},{"category":"Nursing/other","chartdate":"2147-12-06 00:00:00.000","description":"Report","row_id":1332316,"text":"Patient went to CT Scan today plan to extubate aborted on PSV 5/7.5 with spy VT 500. Large IPH not improved from previous film.\n"},{"category":"Nursing/other","chartdate":"2147-12-06 00:00:00.000","description":"Report","row_id":1332317,"text":"CCU NSG NOTE: THALMIC BLEED\nO: For complete VS see CCU flow sheet.\nID: T-max 100.6.\nNEURO: Pt remains minimally responsive. With sternal rub some movement of L arm seen. Early in shiftmoving left arm pulling against restaint. Some movements of L leg also seen. R sid showed some minimal ?flexor activity. Pupil small and minmimally reactive. When oral suctioning done no gag observed. Pt has tachypnic abnormal breathing pattern with rr 22-30.\nCV: Pt has remained on 2mg/min labetalol with bp varying between 1-teens to 140/50-60. He is also received lopressor 12.5 and hydralazine 10mg IV Q6.\nRESP: Pt remains on c-pap 40%, 7.5 PEEP and 5 PS with last gas on that setting 7.39/ 46/ 108/ 29. He has very decreased breath sounds. He is useing accesory muscles to breath and even with sedation appears to be working hard at breathing. He does have history of COPD, though does not seem to have used inhalors. He requires suctioning ~Q2hr for thick lt yellow secretions. One lg plug was aspirated.\nGU: Urine output remains poor, between 12-35cc/hr. He received 40mg ng lasix at 8pm with minimal response. He is presently 2500+ cc pos for the day. HO notified about poor output. He had received 250NS bolus earlier today with minimal response. Creatinine up to 1.4 today from 1.0 yesterday.\nGI: Pt has OG tube. He has small amt green G+ bile in stomach. Bowels sounds are very decreased. No BM.\nSEDATION: Pt restless early in shift with swings in blood pressure. Propofol increased from 20mic/kilo to 25mic/kilo with pt appearing more comfortable with less aggitated movements.\nENDO: FS at 6p was 159 and pt received ss reg insulin per order.\nFAMILY: Family in to visit. They remains appopriately concerned.\nA: Minimally responsive/poor urine output/bizaare resp pattern\nP: Monitor I & O closely. Wean labetalol as tolerated. Monitor for change in MS.\n"},{"category":"Nursing/other","chartdate":"2147-12-07 00:00:00.000","description":"Report","row_id":1332318,"text":"Respiratory Care:\nPt. with a very dysynchronous respiratory pattern (gasping inspiration with forced expiration), and VT's decreasing with RR increased to mid 30's. Obtained PS order to titrate for VT 450-550cc. Increased to 15 to finally capture, then slowly weaned through the course of the shift. Unable to make larger decreases due to Pt. reverting back into above respiratory pattern. ABG's throughout have remained well oxygenated with a slight resp. alkalosis. Will continue support as needed.\n"},{"category":"Nursing/other","chartdate":"2147-12-25 00:00:00.000","description":"Report","row_id":1332382,"text":"NPN\n7 PM - 7 AM\nS/O\nPLS SEE CAREVIEW FLOWSHEET FOR ALL OBJ/NUMERICAL DATA\nCV HEMODYN STABLE .....\nRESP ON 50% TRACH MASK THROUGHOUT THE NITE...LUNGS COARSE ...RR 36-44...ABLE TO COUGH THIN CREAMY YELLOW SXNS INTO TRACH COLLAR ...AND SXD'D Q3 ...\nGI ON TF VIA G-TUBE ON PROMOTE AT 65 CC/HR ..INC SMALL AMOUNT OF SOFT STOOL\nGU U/O GD\nNEURO GIVEN VERSED 1 MG Q4 ...DURING THE NITE ..BUT PT AWAKE ALL NITE\nA STABLE\nP CONTINUE TO ASSESS NUERO STATUS CLOSELY\n\n"},{"category":"Nursing/other","chartdate":"2147-12-25 00:00:00.000","description":"Report","row_id":1332383,"text":"CCU progress note 7a-7p\nNEURO: Pt very tired today, to recieve ?serax or ativan for sleep tonite (pt did not sleep at all last nite). Slept in short naps today. Obeyed gestured commands. Will shake/hold hand when you indicated for him to reach and hold it. Pt attempted to brush his teeth and use electric today (still weak). Pt holds washcloth and lightly washed L side of face. Pt helped to place glasses on face. Pt sometimes nods to actions. Will look at people and activities outside room, does not always track. Seems withdrawn at times ?angry/depressed? Continues to lift and move L arm and leg. No movement to R side. R side neglect, no vision noted on R side. +sensation to R side.\n\nCARDIAC: AFIB 90-110s. SBP 130-170s today. On hydralazine 50mg IV q6h, Lopressor 150mg TID, Norvasc 10mg, NTP 2inches q6h, clonodine 0.3mg . s/c Heparin and pneumoboots.\n\nID: Tmax 100.6 PO, 101.5 rectal today. PAN CULTURED BCx1, sputum + urine cx sent. CXR obtained. Tylenol given x 1. Started on LEVOFLOXACIN IV qd.\n\nRESP: LS coarse. Remains on Trach collar 50% humidified. Pt has productive cough for thick tan sputum. CX sent. trach suctioned for mod amts secretions also. RR ranges from 14 to 40s, but sats maintained >96% at all times, even when pt occasionally moved trach mask off trach, RA sats >96%. No decrease in sats noted w/ suctioning either.\n\nGI/GU: foley patent, good amts urine. remains on LASIX 20mg PO BID. abd soft, +BS. had large formed BM this afternoon. TF promote w/ fibre at goal rate @ 65cc/hr. PEG intact to abd.\n\nSKIN: duoderm intact to coccyx. duoderm placed on shin area on R leg (some skin breakdown noted ?from pneumoboots). R heel blister healed, both heels remain elevated off bed. placed in multipodus boots occasionally - rotating schedule.\n\n\nPLAN: cont' to monitor neuro signs. attempt to give gestured commands as pt may not be able to understand language d/t stroke. give sleep medication tonite. suction q3-4h and prn. pt is in the process of being rescreened by rehab today (pt improved - is off ventilator and is able to follow gestured commands and perform some small ADLs).\n"},{"category":"Nursing/other","chartdate":"2147-12-26 00:00:00.000","description":"Report","row_id":1332384,"text":"Respiratory Care:\nPt. had been TM trial for >24hours. Increasing RR with severe bronchospasm>>attempted MDI's with limited success, but Pt. responded well to manual ventilation. Pt. then placed back on the vent with IPS=14 cmH20, 5 peep, and FIO2 of 50%. Pt. immediately had decrease bronchospasm, decreased RR, and VT's up to 850cc. Will continue on PS vent for the remainder of the shift, then attempt to TM trial again in the a.m.\n"},{"category":"Nursing/other","chartdate":"2147-12-26 00:00:00.000","description":"Report","row_id":1332385,"text":"CCU NSG PROGRESS NOTE 7P-7A/ S/P THALMIC BLEED\n\nS- TRACHED, NOT VERBAL\n\n0 SEE FLOWSHEET FOR OBJECTIVE DATA.\n\n PT REMAINS HEMODYNAMICALLY UNCHANGED.\nHR- 90-100'S AF. BP-115/- 160/\nREMAINS ON LOPRESSOR/NTP/CLONIDINE/HYDRALAZINE.\n\n PT ON TRACH MASK- 50%, TOLERATED WELL UNITL 2:30 AM- MUCH I/E WHEEZE, REPS DISTRESS, WITH RATE 40'S. COMFORTED BY BAGGING, BUT NOT IMPROVED AFTER INHALERS. SWITCHED OVER TO 14 PRESSURE SUPPORT AND CURRENTLY GOOD SATS AND APPEARING STABLE/COMFORTABLE.\n\nID- AFEBRILE- TO LOW GRADE.\n\nGI- REMAINS ON TUBE FEEDS- 65 CC/HOUR- (+) BOWEL SOUNDS- NO STOOL THIS SHIFT- ABD SOFT/DISTENDED.\n\nGU- FAIR UO- 50-80/HOUR.\nNO ISSUES.\n\n PT AWAKE AND ALERT- NOT CONSISTENTLY OBEYING COMMANDS OR WITH PURPOSEFUL ACTIONS.\nSEE FLOWSHEET.\n\nA/ PT S/P LARGE HEAD BLEED/RESP FX- ON/OFF TRACH MASK- DEVELOPING SOME RESP DISTRESS AND NEEDING PRESSURE SUPPORT AGAIN.\n\nCONTINUE TO CLOSELY FOLLOW RESP STATUS AND MAINTAIN AIRWAY- SUCTIONING/NEBS.\nCONSIDER ADDITION OF STEROID NEB PER RT.\nCONTINUE TO CONTROL RPP WITH CV MEDS, AND OBSERVE FOR ANY IMPROVEMENT OF NEURO STATUS.\nCONTINUE SCREENING PROCESS FOR REHAB/LONG TERM FACILITY.\n"},{"category":"Nursing/other","chartdate":"2147-12-26 00:00:00.000","description":"Report","row_id":1332386,"text":"CCU progress note 7a-7p\nNEURO: neuro's unchanged. purposful movement of L arm and leg. looks at subjects, occasionally tracks. does not obey verbal commands. will occasionally obey gestured commands. pt very tired today, not really interacting much. did attempt to brush teeth with alot of encouragement.\n\nCARDIAC: SBP 110-150s. remains on same BP meds. given MSO4 this afternoon w/ decrease in BP to 90s, noon BP meds held. resumed this evening.\n\nRESP: LS coarse, sx creamy tan secretions. small amts. Pt kept having episodes of tachypnea 40-60s this morning after being taken off vent to trach collar. sats remained 100%. Attempted to sedate w/ 2mg MSO4 per HO, w/ no effect. Placed back on PS 14/ Peep 5 50%, RR 6-40s w/ episodes of 20-30sec periods of apnea. TV 600-1000cc. sats 100%.\n\nID: Tmax 100.2. remains on LEVO IV.\n\nGI/GU: foley patent, good u/o. remains on lasix 20mg po. abd soft. +BS. had large soft formed BM this afternoon. On free water boluses 300cc QID. TF promote w/ fibre @ 65cc/hr. PEG intact.\n\nPLAN: con't to monitor neuro and resp status. monitor vs. keep pt comfortable.\n"},{"category":"Nursing/other","chartdate":"2147-12-06 00:00:00.000","description":"Report","row_id":1332313,"text":"CCU NSG PROGRESS NOTE 7P-7A/ S/P THALMIC BLEED.\n\nS- , SEDATED, NONRESPONSIVE.\n\nO- SEE FLOWSHEET FOR OBJECTIVE DATA.\n\nCV- VS REMAIN STABLE- BP LABILE ACCORDING TO AGITATION/SEDATION LEVEL.\nMOSTLY B/T 100/50- 150/70.\nGOAL- SPB- 120-140/. CURRENTLY OFF 1 LABETELOL GTT FOR BP <110.\nTOLERATING HYDRALAZINE 10 QID AND LOW DOSE LOPRESSOR PO.\nREMAINS OFF NIPRIDE GTT.\n\nRESP- REMAINS FOR AIRWAY PROTECTION- 40% WITH 15 PS AND 7.5 PEEP. TV- 800'S,.ABG EXCELLENT.\nPLAN TO EXTUBATE THIS AM.\nNPO EXCEPT FOR MEDS.\nRR- .\nMIN SECRETIONS.\n\nID- AFEBRILE.\n\nGU- FAIR UO- 20-60/HOUR- RESUMED ON LASIX PO.\nI/O CLOSE TO EVEN AS OF 12 AM.\n\nGI- OGT IN PLACE - NPO FOR POSSIBLE EXTUBATION.\nMINIMAL ASPIRATES. NO STOOL.\n\nHEME- S/P VIT K AND 6 U FFP ON ADMIT- AWAIT REPEAT COAGS.\n\nMS/NEURO- NO CHANGE IN NEURO VS- REQUIRING PROPOFOL GTT TO REMAIN SAFELY AND VENTILATED.\nSEE FLOWSHEET FOR DETAIL.\nPROPOFOL GTT REMAINS AT 10-30 MCG, WITH NEEDS FOR BOLUS WITH AGITATION EPISODES AND REACHING FOR ETT.\n\nA/ PT ADMITTED TO CCU FOR NEURO EVENT/BLEED.\nCURRENTLY STATUS QUO ON CURRENT CV MEDS ON VENTILATORY SUPPORT WITH NO CHANGE IN NEURO VS OR EVIDENCE OF WORSENED BLEED.\n\nCONTINUE TO CLOSELY MONITOR, CALL NEURO WITH ANY CHANGE IN SIGNS FOR EMERGENT REPEAT CT SCAN/POSSIBLE INTERVENTION.\nAWAIT COAGS- REPEAT VIT K AND FFP AS NEEDED/ORDERED.\nKEEP BP WITHIN GOAL RANGE OF 120-140.\nKEEP FAMILY AWARE OF PLAN OF CARE AND PROGRESS.\n"},{"category":"Nursing/other","chartdate":"2147-12-10 00:00:00.000","description":"Report","row_id":1332331,"text":"NURSING PROGRESS NOTE 7P-7A\nS: \n\nO: NEURO: DOES NOT RESPOND TO COMMANDS. WILL OCC OPEN EYES TO STIMULI. NO PURPOSEFUL MOVEMENT. PUPILS 2MM BILAT, SLUGGISH TO REACT. DOES NOT MOVE RIGHT SIDE. ABLE TO PICK UP LEFT ARM, FALLS TO BED. MOVES LEFT LEG ON BED. UNABLE TO GRASP HANDS.\n\nCV: HR 80'S A-FIB NO VEA NOTED. BP STABLE ON LABETOLOL GTT. BP RANGE 120-140'S. RECEIVING HYDRALAZINE IV.\n\nRESP: VENTED. SUCTIONING FOR MIN WHITE, THIN SECRETIONS. VENT SETTINGS OVERNIGHT FIO2 40%, PEEP 5, PS 5 CPAP. BECOMING TACHYPNEIC EARLIER THIS AM. RESTED FOR 2 HRS ON IMV. NOW BACK ON ORIGINAL SETTINGS. RR NOW 37 LABORED BREATHING. ABG'S SDEQUATE. LUNGS COARSE IN BASES.\n\nGU: FOLEY DRAINING AMBER COLORED URINE 30-50 CC/HR. IV FLUIDS AT KVO. RECEIVING FREE WATER BOLUS Q 8 HRS.\n\nGI; NO BM. BOWEL SOUNDS PRESENT, ABD SOFT, DISTENDED. TOL. TF WELL WITH MIN RESIDUAL. RECEIVING PROMOTE W/ FIBER. RATE 30 CC/HR.(GOAL 80 CC/HR)\n\nSKIN INTACT. 2 PIV'S PATENT.\n"},{"category":"Nursing/other","chartdate":"2147-12-10 00:00:00.000","description":"Report","row_id":1332332,"text":"Continue to wean patient on psv5/5-40% . Patient occasionally went into rapid RR , rested for 1 hr on A/C to slow down rythm. ABG 7.45-41.115-29- 4-98% sputum induced for lab will continue to follow\n"},{"category":"Nursing/other","chartdate":"2147-12-10 00:00:00.000","description":"Report","row_id":1332333,"text":"resp care\n\npt remains and mech ventilated. ps 8 peep 5 fio2 40%. ps ^ to 8 to maintain vt 500-600 w/good effect. rr ess 20's occ teens. b/s coarse. sxn thk wh. mdi's given x3. current abg 7.40/42/131/27. pt tx w/o incident to ct scan. pt ambu 100% o2 to/from. plan: cont w/mech support. wean ps as tolerated.\n"},{"category":"Nursing/other","chartdate":"2147-12-10 00:00:00.000","description":"Report","row_id":1332334,"text":"CCU progress note 7a-7p\nNEURO: pt was obtunded this morning, not responding to stimuli except for suctioning ETT. Pupils remained 2mm sluggish. no movement R side. lifts/falls on L arm, no random squeezing of L hand noted, slight movement/withdraw from pain L foot. Repeat CT scan done this afternoon, no changes or new bleed noted. Pt noted to be 'waking' up this evening, opening eyes at times to tactile stimuli and having increased RR. Noting to hold siderail w/ L hand. given 30mg (3cc) of Propofol for light sedation during central line insertion this evening.\n\nCARDIAC: AFIB 90s. Labetolol gtt d/c'd this morning. Lopressor 100mg restarted at TID dosing. remains on Hydralazine 20mg QID. SBP 120-150s today. generalized +edema.\n\nRESP: remains on PS today. increased RR this morning w/ TV 300-400s. Increased PS to 8 w/ noted decrease to 18-20 RR, and TV 600s. Sats >97%. good abgs. Sx small amts yellow/tan secretions. CPT given with turns. sputum spec sent early this am.\n\nID: TMAX 99.8 po. no abx. remains diaphoretic all day.\n\nGI/GU: foley had decreased u/o this morning. given IVF x 6hrs today and increased TF to 60cc/hr Promote w/ fibre. Noted increase to ~30cc/hr urine. Abd +BS, distended soft. OGT patent. NO BM. no stools since admission. pt may need bowel regimin!!\n\nSKIN: mulipodus boots ordered for pt. L heel has blister on outer heel. otherwise skin intact.\n\nACCESS: R s/c TLC placed this evening. both peripheral IVs intersticial and d/c'd.\n\nPLAN: con't to monitor Neuro status. need bowel meds ordered in am. monitor temp (BC for temp >102). keep L heel elevated. place mulitpodus boots on pt when they arrive on floor (ordered). awaiting CXR and confirmation of placement of R s/c TLC.\n\n"},{"category":"Nursing/other","chartdate":"2147-12-06 00:00:00.000","description":"Report","row_id":1332314,"text":"NURSING PROGRESS NOTE 0700-1500\nNEURO---PT LIGHTLY SEDATED ON PROPOFOL AT 20 MCG/KG/MIN. WHEN GTT TURNED OFF TO ASSESS NEURO STATUS, PT DOES NOT FOLLOW COMMANDS. PUPILS AT 1MM AND REACT SLOWLY. R ARM NO MOVEMENT. R LEG WITHDRAWS TO NOXIOUS STIMULI BUT ? WHETHER THIS IS REFLEXIVE PER NEURO. L ARM WILL HAVE SOME PURPOSEFUL MOVEMENT AND ATTEMPT TO PULL ETT OUT. NO FINE MOTOR MOVEMENT OBSERVED IN EITHER UPPER EXT. L LEG WILL FLEX AND WITHDRAW TO NOXIOUS STIMULI. DOWN FOR CT OF HEAD WITHOUT CONTRAST AT 1200. RESULTS PENDING.\n\nCARDIAC--HTN AND RESTARTED ON LABETALOL GTT AT 2MG. PT BECOMES AGITATED WITH NON-PURPOSEFUL FLAILING OF LUE AND LLE. ON IVF AT 50 CC HR. IN A-FIB AT 80'S . OCCASIONAL UNIFOCAL PVC'S.\n\nRESP--BREATHING APPEARS LABORED WHEN PT IS LIGHT. RR INCREASES TO 38-44 WHEN LIGHT. SAO2 98%. ABG'S OK ON 5PEEP AND 7.5 IPS. PLAN IS TO WEAN TO EXTUBATE. IT IS UNCLEAR IF PT WILL BE ABLE TO PROTECT AIRWAY AS HE HAS A WEAK GAG AND WEAK COUGH.\n\nGI--NGT TO LCS DRAINING BILIOUS DRAINAGE. NO STOOL.\n\nGU--FOLEY CATH PATENT DRAINING CONCENTRATED URINE IN ~30 CC HR.\n\nENDO--UNREMARKABLE AT PRESENT.\n\nSKIN-- BUTTOCKS INTACT WITHOUT BREAKDOWN. SMALL RASH IN R GROIN.\n\nA--HTN NEEDING INCREASE IN LABETOLOL.\n\nP--PLAN TO EXTUBATE. CON'T Q1HR NEURO CHECKS. ? ANTIHTN THERAPY.\n\nLINES--PT HAS 2 PERIPHERAL IV'S.\n\n AND WIFE FLEW IN FROM CALIF TODAY. WIFE IS .\n"},{"category":"Nursing/other","chartdate":"2147-12-23 00:00:00.000","description":"Report","row_id":1332375,"text":"NPN\n11 PM - 7 AM\nS/P LARGE THALMIC BLD\nS/O\nPLS SEE CAREVIEW FLOWSHEET FOR ALL OBJ/NUMERICAL DATA\nCV HR 90-100'S..AFIB....SBP LABILE 190'S-80'S/40-80'S....DROPPING SBP TO THE 80'S...AFTER .3 MG OF CLONIDINE ...SLOW HYDRALAZINE INFUSION STOPPED ...NTP WIPED OFF ...ABLE TO TOLERATE 150 MG OF PO LOPRESSOR ...\nRESP CONTINUES ON CPAP AND PS OF 15..5 PEEP...50%...TV 700...FREQUENT EPISODES OF TACHYPNEA WITH RATES IN THE 40'S..TV 190-260 ..SUCTIONED Q3 FOR SMALL AMOUNT OF THICK YELLOW SPUTUM..MINIMAL ORAL SXNS....LUNGS COARSE ....RESPONDING TO 2 MG OF IV VERSED ..\n\nGI ON PROMOTE WITH FIBER ..AT 65 CC/HR ..SMALL AMOUNT OF SOFT STOOL ...OB NEG...\n\nGU U/O GD\n\nTURNED Q3...RIGHT ARM ELEVATED ON PILLOWS ..\n\nACCESS...DOUBLE LUMEN PIC LINE FLUSHED WITH HEPARIN AND SALINE ..BUT UNABLE TO OBTAIN AM LABS ...NO PERIPHERAL ACCESS ...\n\nNEURO..SLEEPY,..INTER OPENS EYES TO VOICE ...LEFT GAZE ...RIGHT HEMIPLEGIA ..OCCAS DRAWS UP LEFT LEG ...SQUEEZING LEFT HAND BUT NOT TO COMMAND ...\n\nA LABILE BP/RESP STATUS\n\nP CAUTION WITH CARDIAC DRUGS ...? OVER DIURESIS ...? ALINE\n"},{"category":"Nursing/other","chartdate":"2147-12-23 00:00:00.000","description":"Report","row_id":1332376,"text":"CCU progress note : 7a-7p\nEVENTS OF DAY:: NEURO CHANGEs NOTED!!! PT OFF VENTILATOR, on TRACH collar 50% w/ good sats.\n\n\nNEURO: Pt had episode of agitation this morning, ^BP^HR^RR 40s, NEURO team in to assess at this time ?neuro agitation or ?agitation d/t ventilator. Attempt bagging which pt relaxed with, then post would go back to ^RR again. tried pt off vent on trach collar and pt settled. kept off ventilator. No further episodes of ?neuro agitation noted. PERLA 2mm brisk. alert most of time, occasionally rests/sleeps in naps. Tracks and looks at people, to voice and movements outside room. occasionally looks at TV. Sometimes nods head to questions. inconsisently obeys simple gestured/voiced commands to take objects or wash face w/ washcloth. if you hold out your hand to shake, he will lift his hand and hold your hand. if you show him something interesting to him , he will take it from your hand and hold it properly (keys, comb, toothbrush, washcloth), and will give it back to you if you hold out your hand and ask for it. Wife assisted pt to place eyeglasses on face. NEURO team and NSICU team notified of changes. Wife in this afternoon and aware of changes.\nPt still moves only L limbs, but no movement on R side, +sensation to R, noting some reflexive movements on R leg to painful stimuli. nothing to R arm. R side neglect, R vision defecit. +gag +cough.\n\nCARDIAC: AF 100-110s, SBP 120-170s today. On Hydralazine 50mg IV q6h, NTP 2\" CW Q6H, Lopressor 150mg TID ngt, Norvasc 10mg qd. generalized edema +, 3+edema to R arm.\n\nRESP: pt had episode of TACHYPNEA 40s, on vent settings early this morning 15 PS/ 5 Peep. Sats remained 100% the whole time. attempted changing PS settings from PS 15 to higher w/ no results, when 'd pt RR went to 12 w/ periods of apnea and seemed to sleep, then after 'ing pt woke and went back to rapid RR 40s again. attempted to take off vent, room air, sats remained 100% with some decrease in RR. placed on Trach collar w/ cuff down, 50% FIO2 w/ decrease in RR to 14-30s the rest of the day. No extreme agitation noted. having neuro respiratory periods, some occasional apnea noted w/ some 'panting' to normal breathing cycled. Sx'd trach for small amts tan secretions. pt has PRODUCTIVE cough. LS coarse bilat. MDI/neb treaments per RESP.\n\nGI/GU: abd soft, distended. no BM, last BM last nite. TF promote w/ fibre. minimal residuals. PEG tube intact. FOLEY patent good amts urine. Lasix decreased to 20mg po.\n\nSKIN: old R heel blister healing well. multipodus boots on. pneumoboots on. old skin tear healing on L outer hip, cleansed w/ NS and new opsite placed over site. Duoderm intact to coccyx. Sat in Chair today for a few hours.\n\n\nPLAN: con't to monitor neuro status.con't to monitor VS. wife to bring in pictures of his favorite cat at home, and stuffed animal (cat), ?1-2lb dumbbell weight to see if he uses it, to bring in his electric in to shave. Plan to have Case Manager rehab facilities to re-evaluate pt's eligibility/rehabi\n"},{"category":"Nursing/other","chartdate":"2147-12-23 00:00:00.000","description":"Report","row_id":1332377,"text":"CCU progress note : 7a-7p\n(Continued)\nbility.\n\n\n"},{"category":"Nursing/other","chartdate":"2147-12-23 00:00:00.000","description":"Report","row_id":1332378,"text":"Resp Care\npt changed to 50% trach collar.. tolerating very well with cuff deflated. has cyclical episodes of tachypnea..usually self-limiting. seems to do better with cuff deflated. when inflated requires lg amt air to seal. sxning sm amts tan. good strong cough. admin albuterol/atrovent q4-6 with mdi/. c/w tc as tolerates. vent on standby.\n"},{"category":"Nursing/other","chartdate":"2147-12-09 00:00:00.000","description":"Report","row_id":1332329,"text":"CCU NSG PROGRESS NOTE-NSICU BORDER.\n73 YO MALE ADMITTED W R-SIDED WEAKNESS. HEAD CT SCAN-LARGE BASAL GANGLIA HEMMORRHAGE W EXTENSION INTO VENTRICLES & POS MASS EFFECT W SM AMT OF HERNIATION.\n\nO:NEURO=OPENS EYES SPONTANEOUSLY-TRACKING/FOLLOWING. SQUEEZES W L HAND ON COMMAND. NOT ABLE TO HOLD L SIDED EXTREM UP ON OWN-MOVING L SIDE ON BED. SL WDRAWL TO NOXIOUS STIM ON R. PERL-SLUGGISHLY.\n PULM= & VENTED. SETTING=CPAP/PS, FIO2 40%, SPONTAN TV 450-550, RR 24-36, MIV 11.6-13.6, PEEP 5, & PRESSURT SUPPORT 5. BREATH SOUNDS=COURSE THROUGHOUT. SX-THICK COUPIOUS SECRETIONS @ X'S-REQUIRING LEAVAGING. SATS UPPER 90'S. AM ABG PENDING. EPISODES OF TACHIPNEA & LABORED RESPIRATIONS-RXED W HALDOL PRN W LIMITED EFFECT.\n CV=NTG WEANED & DCED. LOPRESSOR 100MG & HYDRAL 10MG QID-CONTIN TO BE TACHYCARDIC & @ X'S HYPERTENSIVE @ X'S--?MORE RELATED TO AGITATION.\n GI=TF CHGED TO PROMOTE W FIBER. STOPPED @ 0000.\n GU=FOLEY. ADEQ UO.\n ID=FEBRILE W T MAX 100.4 PO.\n LABS=AM SENT.\n\nA:STABLE NEURO EXAM. REQUIRING FREQ SX FOR THICK COUPIOUS SECRETIONS. ?TACHYCARDIA & HYPERTENSION RELATED TO AGITATION/FRUSTRATION.\n\nP:CONTIN FREQ NEURO CKS. ?HEAD CT REDO. HALDO PRN. PULM TOILET. ?WEAN VENT TO EXTUBATE (FREQ SX & COUPIOUS SECRETIONS). ?ADD MILD TRANQUILIZER-AGITATION/FRUSTRATION. ?RESUME TF-IF NOT EXTUBATABLE. FOLLOW T-CULTURE W SPIKE. CK AM LABS-REPLACE AS INDICATED. SUPPORT PT/FAMILY AS NEEDED.\n"},{"category":"Nursing/other","chartdate":"2147-12-30 00:00:00.000","description":"Report","row_id":1332397,"text":"NEURO-ALERT TO SURROUNDINGS,TRACKES VOICES,INCONSISTENTLY FOLLOWS COMMANDS WITH NON-PURPOSEFUL AND OCCASIONALLY PURPSOEFUL MOVEMENT.PERLA (4mm). RESTLESS AT TIMES. MEDICATED WITH 0.5MG VERSED IV X1 WITH LITTLE RELIEF.\n.\n\n\nCV-REMAINS IN AFIB 85-95 WITH NO ECTOPY. BP INCREASING THROUGHOUT NOC. 135->160/85.+PP.\n\nRESP-50% TRACH-COLLOR,SATS=100%.LS WTIH OCC. EXP. WHEEZE.DIMINISHED\n THROUGHOUT. STRONG COUGH WITH THICK YELLOW SPUTUM &\n SXD FOR S.AMT. THICK YELLOW SPUTUM.\n\nG.I.-TOLERATING PROMOTE WITH FIBER AT 120CC/HR. +BS. NO STOOL.\n\nG.U.-CONDOM CATH WITH CLEAR YELLOW URINE.\n\nSKIN-RT POSTERIOR THIGH WITH CLEAN PINK ABRAIN. TEGADEM APPLIED. RT OUTE HEEL WITH 4/4CM RED BLISTER WITH BROWN DRY CENTER. COCCYX WITH 6X6CM ULCER. DUODERM INTACT.\n\nENDO-SSC PRN. LABS-REPLACED PRN.\n\nA/P-AS ABOVE. CONTINUE MONITORING HEMODYNAMICS,NEUR0\n/RESP/G.I/G.U.\n\n\n\n\n\n"},{"category":"Nursing/other","chartdate":"2147-12-30 00:00:00.000","description":"Report","row_id":1332398,"text":"CCU NSG NOTE: ALT IN NEURO\nO: For complete VS see CCU flow sheet.\nID: Pt afebrile.\nNEURO: Pt alert much of the day. At times trying to talk, will follow some commands. No movement seen on R side. Using L arm purposefully.\nCV: HR 80s-90s a-fib on lopressor 150. BP 120-160/60-70s.\nGI: Pt had lg soft G- bm. Tube feed of replete with fiber off at 8am and restarted at 4pm at 120cc/hr. Tolerating well.\nGU:Pt voiding thru condom. He is ~1700cc positive for the day and ~ 5L positive LOS.\nRESP: Pt remains on trach mask at 50%. He is sating 97-100%. He does require suctioning ~Q3-4 hrs for thick lt yellow sputum. Some wheezing heard. Pt getting nebs Q 4 hrs.\nELECTROLYTES: Na up to 149. D5W boluses decreased to 300cc QID.\nENDO: BS 147-151. 2u Reg given twice and 5u NPH given at 6p.\nA: Stable on trach mask/ alert\nP: Continue to turn Q3 hour. Suction prn. Cont TF overnight.Keep R arm elevated. Support pt and family.\n"},{"category":"Nursing/other","chartdate":"2147-12-30 00:00:00.000","description":"Report","row_id":1332399,"text":"Patient remains on T-Mask all day suctioned PRN for sign of resp distress. BS wheezy, treated with albuterol/atrvent neb Q4. More alert follow commands today will continue frequent bronchial hygien and neb Rx Q4. HR now 84,BP 154/70, Sat 98%.\n"},{"category":"Nursing/other","chartdate":"2147-12-31 00:00:00.000","description":"Report","row_id":1332400,"text":"CCu NPN 7pm - 7am\nS/O: Resp: Pt. continues on trach mask at 50%. O2sats are 97 - 100%. Suctioned Q3 hours for small to moderate amount of light yellow sputum. RR 20 - 30 slightly labored at times. RT gave inhalers.\nCVS: BP 97 -178/60 - 80. HR 70 - 100afib. Continues on lopressor, hydralazine, norvasc.\nG.I.: tube feedings at 120 cc/hr from 7pm - 7 am.\nD.M: FS 145, 109. SS insulin as written.\nF/E:continues 300 cc free H2O boluses Q 6 hours.\nA: s/p thalmic bleed, tolerating trach mask\nP: continue pulmonary toilet, monitor resp. status, BS, tube feedings off in am.\n"},{"category":"Nursing/other","chartdate":"2147-12-31 00:00:00.000","description":"Report","row_id":1332401,"text":"PATIENT CONTINUES TO DO WELL ON T-COLLAR. SAT 100%,BP 147/65, HR 96,BS COARSE. DEEPLY SUCTIONED Q4HRS WILL CONTINUE NEB TREATMENT IN LIEU OF MDIS.\n"},{"category":"Nursing/other","chartdate":"2147-12-05 00:00:00.000","description":"Report","row_id":1332309,"text":"DEEP INTERCRANIAL HEMMORHAGE\n72 YR OLD GENTLEMAN AWOKE 4 AM C R SIDED WKNESS, ,SLURRED SPEECH ,COLLAPSED ,BROUGHT TO HOSPITAL ,INTUBATED.HAS BEEN HYPERTENSIVE ,ON IV NIPRIDE,LABETOLOL IN ER. HAS HX MI, HTN, AFIB. ON COUMADIN .ADMITTING INR 4.2.GIVEN 6 FFP ,VIT K.HAS BEEN SEDATED FOR RESTLESSNESS C ATIVAN, 150 SUC,30 ETOMADATE, 10 VEC FOR INTUBATION.\n"},{"category":"Nursing/other","chartdate":"2147-12-05 00:00:00.000","description":"Report","row_id":1332310,"text":"oett pulled back 1.5cm md s/p cxr . resecured at 20cm @lip. post change + bilat b/s.\n"},{"category":"Nursing/other","chartdate":"2147-12-05 00:00:00.000","description":"Report","row_id":1332311,"text":"resp care\n\npt arrived to ccu intubated w/# 7.5 oett secured 22cm @lip. pt placed on mech vent ps 15 peep 7.5 fio2 50%. b/s +/cta/dim bilat. spont vt 600's rr teens. pt appears comfortable. abg 7.43/44/116/30. fio2 to 40%. plan: cont w/mech support. wean as tolerated.\n"},{"category":"Nursing/other","chartdate":"2147-12-05 00:00:00.000","description":"Report","row_id":1332312,"text":"LARGE L THALMIC BLEED\nSR 60S TO 70S. BP 100 TO 180. ON NIPRIDE,LABETOLOL GTTS .IV HYDRALAZINE GIVEN .NIPRIDE D/C.WEANING LABETOLOLTO OFF IF POSSIBLE .\n\nVENTED , CPAP 15 PS/PEEP7.5 ,FIO2 40% RR 14 TO 17 C TV 6OO TO 8OO. SAT 98. BS DISTANT ,HX EMPHYSEMA .\n\nINR 1.4 P 6U FFP .VIT K IV GIVEN\n\nOG DRAINING CL GREEN ,HYPOACTIVE BS .ABD SOFT DISTENDED .\n\nCONCENTRATED BLOOD TINGED URINE 20CC HR VIA FOLEY\n\nPT RESTLESS ON ADMISSION, TRIED TO EXTUBATE SELF C L HAND.KICKING C L LEG . MOVES R ARM AND LEG ON BED TO PAINFUL STIMULI. PT STARTED ON PROPOFOL LOW DOSE STARTED TO KEEP PT ,WILL WEAN IF POSSIBLE.\n\nGOAL BP 120 TO 160\nWEAN LABETOLOL TO OFF\nWEAN PROPOFOL TO OFF IF POSSIBLE\n"},{"category":"Nursing/other","chartdate":"2147-12-21 00:00:00.000","description":"Report","row_id":1332370,"text":"NSICU PNP\nNEURO: NO CHANGE IN NEURO STATUS. OPENS EYES SPONTANEOUSLY, MOVES L SIDE. DOES NOT FOLLOW COMANDS\nCV: HR 85-115 A FIB, BP 140-180/60-70, ^ TO 190/100 W/ ATTEMPT TO LOWER PS.\nRESP: REMAINS ON PS 14, PEEP5. ATTEMPTED TO LOWER PS, TV DOWN, ^ RR TO 40'S, ^ BP. SX FOR MOD AMTS THICK TAN SECRETIONS.\nID: TM 99.4, CONT ON OXACILLIN\nGI: TF CONT AT 65CC/HR, TOL WELL, SM BRN FORMED STOOL\nGU: FOLEY DRAINING DK YEL URINE QS.\nSOCIAL: WIFE CALLED, HAS NOT BEEN IN TO VISIT TODAY.\nDISPO: IS BEING SCREENED FOR REHAB.\n"},{"category":"Nursing/other","chartdate":"2147-12-22 00:00:00.000","description":"Report","row_id":1332371,"text":"Pt. maintained on psv ventilation with mostly a comfortable night except for these intermittent spikes in BP and RR. Sats are good. Sx for lrg amts. Plan is to cont. with current management with eventual rehab placement.\n"},{"category":"Nursing/other","chartdate":"2147-12-24 00:00:00.000","description":"Report","row_id":1332379,"text":"NPN\n7 PM - 7 AM\nS/O PLS SEE CAREVIEW FLOWSHEET FOR ALL OBJ/NUMERICAL DATA\nLOW GRADE 100.2...\nCV HEMODYN STABLE ..TOLERATING BETABLOCKERS AND ANTI-HYPERTENSIVES WELL\nRESP ..INITIALLY RR IN THE 40'S...TV IN THE LOW 200'S...WITH DIFFUSE EXP WHEEZES ...AMBUED AND SUCTIONED ...BUT RR REMAINED IN THE 40'S...AND PT LOOKING VERY UNCOMFORTABLE ....PLACED BACK ON VENT PS15/5PEEP..FI02 OF 50%...AND GIVEN VERSED 1 MG Q4-5 H...WITH BETTER TIDAL VOLUMES ...\nNEURO..OPENS EYES TO VOICE ..SQUEEZING LEFT HAND BUT INCONSIST TO COMMAND\nGI/GU TOLERATING TUBE FEEDS ..U/O GD\nA STABLE\nP CONSIDER INCREASING VERSED MED...OR ATIVAN ORDER ROUND THE CLOCK..TO KEEP PT COMFORTABLE ..\n"},{"category":"Nursing/other","chartdate":"2147-12-24 00:00:00.000","description":"Report","row_id":1332380,"text":"N SICU NPN\nNEURO: SLEEPING MOST OF MORNING, MORE AWAKE THIS AFTERNOON.TRACKING, MOVING L ARM TO FACE, SCRATCHING EAR, BUT NOT FOLLOWING COMMANDS.NOT MOVING R SIDE.\nCV: HEMODYNAMICALLY STABLE\nRESP: ON TRACH MASK ALL DAY. SATS 97-98%, RR 12-24, APPEARS VERY COMFORTABLE. SX Q3-4HR FOR SM-MOD AMTS YELLOW/TAN THICK SECRETIONS.\nGI: TOL TF, NO STOOL\nGU: FLOLEY DRAINING CL, DK YEL URINE, CURRENTLY ~ 500CC NEG.\nEND: BS 186 AT 6PM, COVERED PER SS\nSKIN: DUODERM ON COCCYX, R HEEL BLISTER HEALING, OP XITE ON R HIP.\nACTIVITY: OOB TO CHAIR, USING SLIDE BOARD. TOLERATED WELL.\nSOCIAL: WIFE AND COUSIN IN TO VISIT MOST OF AFTERNOON.\n"},{"category":"Nursing/other","chartdate":"2147-12-24 00:00:00.000","description":"Report","row_id":1332381,"text":"RESP CARE\nPT CHANGED TO TRACH COLLAR AT BEGINNING OF SHIFT. TOLERATING VERY WELL, CUFF IS DEFLATED. STRONG COUGH. SXNED AS NEEDED. ADMIN ALBUTEROL/ATROVENT MDI X3. C/W TRACH MASK AS TOLERATES. VENT ON SB.\n"},{"category":"Nursing/other","chartdate":"2147-12-09 00:00:00.000","description":"Report","row_id":1332330,"text":"CCU progress note: 7a-7p\nNEURO: neuro signs unchanged. unable to move R side. able to lift and fall/withdraw from painful stimuli w/ L arm, moves L foot on bed. Pupils 2mm equal and sluggish reaction. opens eyes to verbal stimuli. +tracking. inconsistent squeezing of L hand to command ?reflex. non-purposful movement. ?agitation today w/ ^BP 200s, given multiple doses of haldol w/ little effect.\n\nSOCIAL: family in to visit today. talked w/ nurse and house staff re pt condition.\n\nID: WBC count elevated to 17. repeat WBC pending tonite w/ diff. no abx ordered. TMAX 101.4 rectally. to culture w/ temp>102 per HO. urine culture sent today.\n\nCARDIAC: AFIB 90-100s. no ectopy noted. SBP 170-200s during the day, given hydralazine 20mg QID IV and was on Lopressor 100mg , but this afternoon started on LABETOLOL gtt titrated to 5mg/min for SBP 130-150. +generalized edema.\n\nACCESS: R PIV d/c'd. New access LLA #20g and old LLA #20g intact but reddened at site, but patent. HO aware. NEED CENTRAL ACCESS. IV therapy in to start new access w/ difficutly.\n\nRESP: Remains on CPAP/PS 40% TV 300-500. Peep 5/ PS 5. RR24-36. LS coarse. CXR worsening. WBC elevated. Thick tenacious secretions - yellow tan, needing instillation of saline and ambu for good suctioning. sats > 96%. PM ABG: 134/43/7.43.\n\nGI/GU: no BM. TF restarted promote w/ fibre @ 20cc/hr. advance to GR as tolerated. on Free water boluses 100cc TID. FOley draining good amts clear yellow urine. u/a and CS sent.\n\nPLAN: sent sputum spec. monitor temps blood cultures for >102. need central access. titrate labetolol for ABP 130-150 goal.\n"},{"category":"Nursing/other","chartdate":"2147-12-28 00:00:00.000","description":"Report","row_id":1332392,"text":"Respiratory Therapy\nTrached with an 8.0 Portex. PSV, weaned to 10/5/0.40. ABG: compensated metabolic alkalosis. Had to pt this afternoon for low Vt and increased WOB. Suctioned pink frothy secretions at that time. Pt does have periods of apnea lasting about 5sec which are self resolved. Receiving albuterol and atrovent MDI as needed. Plan to continue with PSV as tolerated and TM when ready.\n"},{"category":"Nursing/other","chartdate":"2147-12-28 00:00:00.000","description":"Report","row_id":1332393,"text":"NSICU NPN\nNEURO: VERY LETHARGIC TODAY. OPENS EYES TO VOICE, OCC SPONTANEOUSLY. NOT FOLLOWING COMMANDS. LIFTS L ARM AND MOVES IN ? PURPOSEFUL MANNER, MOVES L LEG ON BED. NOT MOVING R ARM.\nCV: HEMODYNAMICALLY STABLE\nRESP: PS 14, PEEP 5 THIS AM DOWN TO 10/5, UNABLE TO WEAN FURTHER D/T ^ TACHYPNEA, LOW TV, GENERAL DISTRESS.\nGI: TF CHANGED TO CYCLE FROM 4P->8AM AT 120CC/HR. TOLERATING WELL. SOFT BRN STOOL.\nGU: FOLEY PULLED AT 17:00, CONDOM CATH PLACED.\nID: AFEBRILE\nEND: WNL\nACTIVITY: OOB TO CHAIR, FULL LIFT, PT HERE.\nPT BEING SCREENED FOR REHAB.\n\n"},{"category":"Nursing/other","chartdate":"2147-12-22 00:00:00.000","description":"Report","row_id":1332372,"text":"CCU NSG PROGRESS NOTE 7P-7A/ S/P THALMIC BLEED\n\n\nS- \n\nO- SEE FLOWSHEET FOR OBJECTIVE DATA.\n\nCV- VS REMAIN AT BASELINE.\nHR- 108-112 AF. BP- 120-180/.\nREMAINS ON SAME CV MEDS.\n\n PT ON PRESSURE SUPPORT 14/40%.\nO2 SATS 99-100%.\nSUCTIONED FOR THICK WHITISH SPUTUM.\nCOARSE BREATH SOUNDS.\n\nID- AFEBRILE.\nREMAINS ON OXACILLIN .\n\nGU- GOOD UO VIA FOLEY/LASIX AS ORDERED.\nI/O EVEN.\n\nGI- PROMOTE AT 65/HOUR.\nLARGE FORMED STOOL X 1 G (-).\n\nMS- NO SIGNIFICANT NEURO CHANGES.\nSEE FLOWSHEET.\n\nA/ PT STATUS S/P THALMIC BLEED, ON VENTILATORY SUPPORT.\nAWAITING PLACEMENT.\nCONTINUE PULM TOILET/NUTRITION/BP CONTROL.\n"},{"category":"Nursing/other","chartdate":"2147-12-22 00:00:00.000","description":"Report","row_id":1332373,"text":"NSICU NPN\nS: TRACHED\nO: SEE CAREVUE FOR ALL OBJECTIVE DATA.\n\nNEURO: NO CHANGES\nCV: HEMODYNAMICALLY STABLE A FIB 90-110, BP 115-180/60-70, NO CHANGES MADE TO CV MED REGIME.\nRESP: UNABLE TO WEAN PS, PT BECAME , DISTRESSED AND W/ LOW TV. REQUIRING PS ^20 BRIEFLY. SX FOR SM-MOD AMTS THICK TAN SECRETIONS. LUNG SOUNDS COARSE.\nID: TM 100.5 PO, BLOOD, URINE AND SPUTUM CX SENT. OXACILLIN D/C. TLC D/C AND TIP CX.\nGU: FOLEY DRAINING DK YEL URINE, 50-70CC/HR.\nGI: TOLERATING PROMOTE W/ FIBER AT GOAL, 65CC/HR. NO STOOL TODAY.\nLINES: PICC PLACED L ARM, PLACEMENT CONFIRMED BY X RAY, TLC AND A LINE D/C.\nSOCIAL: WIFE IN TO VISIT.\nDISPO: REHAB PLACEMENT.\n"},{"category":"Nursing/other","chartdate":"2147-12-23 00:00:00.000","description":"Report","row_id":1332374,"text":"Respiratory Care:\n\nPatient trached with 8.0 Portex. Current vent settings Psv 15, Cpap 5, Fio2 50%, with Flowby . Spont vols 500-700's with RR 11-16. Bs slightly coarse bilaterally. Sx'd/lavaged for sm amounts of thick tan sputum. Albuterol/Atrovent MDI's given Q6hr. O2 sats 98-100%. No further changes made. Continue to wean Psv as tolerated.\n\n"},{"category":"Nursing/other","chartdate":"2147-12-29 00:00:00.000","description":"Report","row_id":1332394,"text":"CCU NSG PROGRESS NOTE 7P-7A/ S/P THALMIC BLEED\n\nS- TRACHED\n\nO- SEE FLOWSHEET FOR OBJECTIVE DATA.\n\n PT REMAINS WELL CONTROLED ON CURRENT CV MEDS.\n\nHR- 80-90'S AFIB.\nBP- 120/- 150/\nNO CHANGES IN CV MED REGIMEN.\nAM LABS PENDING.\n\n PT REMAINS ON VENT SUPPORT:\n50%/PRESSURE SUPPORT- 14, 5 PEEP.\nSUCTIONED FOR YELLOWISH THIN SPUTUM.\nFAIR AMOUNT VIA TRACH.\nSITE CLEAN.\n\nID- AFEBRILE- 99 T MAX.\nREMAINS ON PO LEVO.\n\nGU- CHANGED FOLEY TO CONDOM CATH- 600CC/HOUR.\nREMAINS ON 300CC H20 EVERY 4 HOURS.\n\nGI- SWITCHED TO TUBE FEED OVERNT ONLY- 4P-8A- 120CC/HOUR.\n(+) BOWEL SOUNDS- NO STOOL THIS SHIFT.\nREMAINS ON COLACE.\n\nSKIN- HEEL WITH BLISTER AND COCCYX WITH OPEN ABRASION AREA- DUODERM ON PLACE, AREA CLEAN.\nMULTIPODIS BOOTS/SLEEVES IN PLACE.\n\nNEURO= NO SIGNIFICANT CHANGES IN NEURO STATUS.\nWATCHING AND ALERT, BUT NO RESPONSE VERBALLY AND INCONSISTENT FOLLOW OF COMMANDS.\n\nA/ PT S/P LARGE CVA ON VENTILATOR SUPPORT- AWAITING PLACEMENT.\n\nCONTINUE TO ADMINISTER CV MEDS/MAINTAIN STABLE HEMODYNAMICS.\nNEURO VITAL SIGNS, SKIN CARE/COMFORT.\nCONTINUE NUTRITION/INCREASE ACTIVITY AS TOLERATED.\nKEEP FAMILY AWARE OF PLAN OF CARE/CURRENT PROGRESS.\n\n"},{"category":"Nursing/other","chartdate":"2147-12-29 00:00:00.000","description":"Report","row_id":1332395,"text":"7am - 7 pm\nS/O: Resp.: Pt. trached and vented initially. Put on a trach mask at 50% and tolerating it well so far. Pt. has a strong productive cough and has been able to clear secretions fairly well. Lung sounds are coarse. Pt. had 1 episode of tachypnea this morning which resolved with cuff deflation and 100% O2. Continues on levaquin.\nCVS: Continues on lopressor, hydralazine, norvasc and clonidine patch to control HTN. NTP has been D/C'd. BP 106 -140's/50 - 60. HR 90 - 110's.\nG.I.: Pt. tolerating TF at 120 cc/hr. Started at 4 pm and continue until 8 am. Pt. continues on free H2O for Na of 154 today.\nG.U.: Pt. voiding via condom catheter.\nDM: FS 130 this morning. Pt. received 2 units of regular insulin.\n\nA: s/p thalmic bleed\nP: monitor response to trach mask, continue aggressive pulm toilet, antibx.\n"},{"category":"Nursing/other","chartdate":"2147-12-29 00:00:00.000","description":"Report","row_id":1332396,"text":"Resp Care\nchanged to trach collar with cuff deflated...actually seems more relaxed with no episodes of tachypnea/diaphoresis. sxning sm amts yellow thick. strong cough. admin albuterol/atrovent mdi q6h. plan to leave on trach collar as tolerates. clearly looks better on trach collar with cuff down vs. on vent with cuff inflated. ?air trapping.\n\n"},{"category":"Nursing/other","chartdate":"2147-12-20 00:00:00.000","description":"Report","row_id":1332364,"text":"SICU NPN\nNEURO: NEURO STATUS REMAINS UNCHANGED. OPENS EYES SPONTANEOUSLY, MOVES LEFT SIDE W/ ? PURPOSEFUL MOVEMEMT. RLE WITHDRAWS TO PAINFUL STIMULI OTHERWISE NO MOVEMENT ON R SIDE. PERRL.\nCV: HEMODYNAMICALLY STABLE W/ HR 80-100 A FIB, BP 140-170/50-80 ON CURENT MED REGEIME. NO CHANGES MADE TODAY.\nRESP: TRACH AREA CLEAN W/O SSI, SX Q3 HR FOR MOD AMT THICK TAN SECRETIONS., LUNG SOUNDS COARSE. PS DOWN TO 5/5, TOLERATING WELL, TO HAVE TRIAL W/ TRACH MASK.\nGI: PEG IN PLACE, TOLERATING PROMOTE W/ FIBER AT 65CC/HR, NO STOOL TODAY.\nGU: FOLEY DRAINING CL YEL URINE. CURRENTLY ~1000CC NEG, (GOAL FOR DAY)\nID: TM 100.1 PO, CONT ON OXACILLIN, LEVO D/C AFTER THIS AFTERNOON'S DOSE.\nSKIN: BLISTER ON R HEEL, OPEN ABRASION ON COCCYX, DUODERM APPLIED.\nSOCIAL: WIFE IN MOST OF AFTERNOON. PT HAS BEEN ACCEPTED AT AND GO IF BED AVAILABLE, WIFE AWARE.\n"},{"category":"Nursing/other","chartdate":"2147-12-20 00:00:00.000","description":"Report","row_id":1332365,"text":"ATTEMPTED TRACH COLLAR TRIAL. AFTER APPROX. 15 MINS PT'S RR UP TO 30'S, BP UP, LOOKED UNCOMFORTABLE... PLACED BACK ON VENT. RN AWARE.\n"},{"category":"Nursing/other","chartdate":"2147-12-20 00:00:00.000","description":"Report","row_id":1332366,"text":"PT PLACED ON IPS 14 TO REST. TOLERATED IPS 5 FOR 8 HOURS WELL. WILL ATTEMPT AGAIN IN AM\n"},{"category":"Nursing/other","chartdate":"2147-12-20 00:00:00.000","description":"Report","row_id":1332367,"text":"CCU NPN 7PM - 11PM\nS/O:RESP: Pt. remains trached and vented. Changed back to 14 PS from 5. due to tachypnea. Suctioned for a mod. amt. of tan sputum.\nI.D.: afebrile. Continues on oxa.\nCVS: BP labile 140 - 180's/70's. HR 100's.\nG.I.: PEG. continues on TF. Please see careview for specific data.\nA: s/p thalmic bleed, awaits placement for tomorrow.\nP: continue pulm. toilet, monitor neuro signs, meds for HTN.\n\n"},{"category":"Nursing/other","chartdate":"2147-12-21 00:00:00.000","description":"Report","row_id":1332368,"text":"Resp.---- Pt. maintained on psv ventilation of 14 overnight with good oxygenation. Pt. had episode of hypertension and tachypnea that was relieved by placing pt on a/c ventilation for brief period followed by mdi administration and sx. Returned to psv with no pt distress. Plan is to cont with current status.\n"},{"category":"Nursing/other","chartdate":"2147-12-21 00:00:00.000","description":"Report","row_id":1332369,"text":"CCU NSG PROGRESS NOTE 11P-7A/ S/P THALMIC BLEED\n\nS- TRACH/NONVERBAL OR RESPONSIVE\n\nO- SEE FLOWSHEET FOR OBJECTIVE DATA.\n\n PT REMAINS WITH LABILE HEMODYNAMICS- BP-110-130/ AT REST WITH\nINCREASE TO 220-180/ WITH ANY SORT OF AGITATION.\nREMAINS ON LOPRESSOR/HYDRAL/CLON/NTP.\nHR- 90-110 AF, NO VEA.\nAM LYTES PENDING.\n\nRESP- REMAINS ON VENTILATORY SUPPORT- TRACH WITH 50%/CPAP- 14 PRESSURE SUPPORT/5 PEEP.\nRESP RATE SPONTANEOUSLY- 12-36- RESTING/AGITATED.\nSUCTIONED FOR THICK YELLOWISH SPUTUM, MINIMAL AMT.\nO2 SATS 100-99%\n\nID- AFEBRILE- REMAINS ON OXACILLIN.\n\nGU- FAIR TO GOOD UO= 40-130/HOUR.\nI/O (-) 1200CC.\n\nGI- PEG IN PLACE- RECEIVING PROMOTE WITH FIBER 65/HOUR.\nNO STOOL THIS SHIFT., (+) BOWEL SOUNDS.\n\n PT AWAKE/ALERT, BUT NOT PURPOSEFUL IN BEHAVIOR.\nTRACKING WITH EYES BUT NO EVIDENCE OF UNDERSTANDING/ORIENTATION.\nNO SIGNIFICANT CHANGES.\n\nA/ PT S/P THALMIC BLEED REMAINS WITH NEED FOR VENTILATORY SUPPORT.\nLABILE HEMODYNAMICS PERSISTS IN SPITE OF HIGH DOSE CV MEDS.\n\nPLAN TO D/C TO REHAB TODAY.\nCONTINUE TO ATTEMPT TO CONTROL HEMODYNAMICS .\nPULM TOILET.\nKEEP FAMILY AWARE OF PLAN OF CARE AND PROGRESS.\n"},{"category":"Nursing/other","chartdate":"2147-12-12 00:00:00.000","description":"Report","row_id":1332340,"text":"CCU progress note 7a-7p\nNEURO: no neuro changes noted. does not respond to commands. non-purposful movements of L arm and L foot. R side resists movement/stiff and non-moving. Opens eyes to stimuli occasionally and has R sided neglect, pt does not seem to track. Pupils 2-3mm brisk reactive. +corneals. NO GAG. +cough with suctioning. +sensation to L side.\n\nCARDIAC: AF 80-90s. SBP remains labile 130-170s today. LABETOLOL gtt remains on, decreased from 5mg to 2mg/min this evening. Remains on Lopressor 125mg TID, Hydralazine 40mg QID and VASOTEC 5mg started today for pressure con't. Con't to wean labetolol as tolerated. con't w/ +generalized edema.\n\nRESP: LS Diminished to bases, generally clear upper. Sx small amts thick tan/yellow secretions. PS 8/Peep 5 40% all day, decreasing TV this evening, increased RR 30s, increased PS to 14 w/ good improvement in TV to 600s. Sats >97%.\n\nID: pan cultured overnite, cx pending. Tmax today 100.7 oral. R S/C TLC changed overwire , cath tip sent for cx, new R s/c DL line placed. placement confirmed by CXR. No abx as yet.\n\nGI/GU: foley patent, clear yellow urine good amts. abd soft/distended. +BS. started on colace . +Flatus today. rectal check by HO showed soft stool in rectum, not impaced. no bm as yet. TF goal of promote w/ fibre @ 65cc/hr. OGT intact, patent.\n\nSKIN: R outer heel blister intact. mulitpodus boots on. opsite on coccyx redened area. no breakdown noted.\n\nSOCIAL: wife would like family meeting (to discuss code status, ?pt outcome, trach/peg, long term care, what to expect?) with NSICU team, NEURO team and STROKE team and Social worker ?maybe tomorrow afternoon (wife will be in anyways). to attempt to plan in am.\n\nCODE STATUS: FULL\n\nPLAN: Con't to monitor neuro status for changes. ?trach/peg, cont' to wean off Labetolol.\n\n"},{"category":"Nursing/other","chartdate":"2147-12-13 00:00:00.000","description":"Report","row_id":1332341,"text":"Resp Care: Pt continues and on ventilatory support with psv14/fio2 .4/+5 peep maintaining Vt 3-600 ml with Vt 9-12 L, spo2 98%; BS coarse, sxn thick tan secretions, rx with mdi albuterol/atrovent, see carevue for details.\n"},{"category":"Nursing/other","chartdate":"2147-12-13 00:00:00.000","description":"Report","row_id":1332342,"text":"CCU NSG PROGRESS NOTE 7P-7A/ S/P THALMIC BLEED\n\nS- INUTBATED\n\nO- SEE FLOWSHEET FOR OBJECTIVE DATA.\n\nCV- HR REMAINS AFIB, 80-90'S, NO VEA.\nBP- 140-150/ WITH OCCASIONAL INCREASES TO 160/- 170 WITH AGITATION/STIMULATION- INCREASED LABETELOL TO 2 MG, REMAINS ON LOPRESSOR AND HYDRALAZINE FOR BP CONTROL.\n\nRESP- REMAINS INUTUBATED FOR AIRWAY PROTECTION, NO GAG REFLEX.\nSUCTIONED FOR THICK WHITISH SPUTUM, MUCH ORAL SECRETIONS.\nPRESSURE SUPORT- 14, FI02- 40%.\nABG WML.\n\nID- AFBRILE AFTER T AMX- 101-\nTYLENOL, PAN CULTURED ON .\nAWAIT RESULTS.\n\nGI- TUBE FEEDS AT 65/HOUR, STARTED D5 AT 30/HOUR.\nNO STOOL AS OF YET, MIN RESID, COLACE TID.\n\nGU- UO- 40-60/HOUR VIA FOLEY CATHETER.\n\nMS/NEURO- NO CHANGES IN NEURO STATUS- REMAINS WITH OPEN EYES, NO FOLLOWING COMANDS, USING LEFT SIDE, NOT RIGHT SIDE.\nNO ACUTE CHANGES.\n\nA/ PT S/P HEAD BLEED REMAINS FOR AIRWAY PROTECTION, FUO AND LABILE BP ON/OFF LABETELOL GTT.\n\nCONTINUE TO MANAGE BP WITH MULTIPLE MEDS- ATTEMPT TO MAX PO MEDS TO WEAN OFF IV LABETELOL.\nWATCH FOR FURTHER FEVER/AWAIT CULTURE RESULTS.\nCOMFORT/SAFETY/FREQ NEURO CHECKS.\nKEEP FAMILY AWARE OF PLAN OF CARE.\nD/C PLANNING, ?PLAN TRACH.\n\n"},{"category":"Nursing/other","chartdate":"2147-12-13 00:00:00.000","description":"Report","row_id":1332343,"text":"CCU progress note 7a-7p\nFAMILY MEETING this afternoon. Discussed pt's prognosis, possiblity of trach/peg, ?rehab rehab/nsg home, and discussed with wife pt's wishes. Wife decided to make him a DNR at this point, but needs to talk to brother-in-law in and have him talk to Dr . She hopes to have a decision re: ?extuabtion or ?trach/peg after brother-in-law talks to Dr and she talks again to the brother.\n\nNEURO: no changes noted. More alert today. opens eyes to verbal stimuli. R sided neglect, not noted to track. remains flaccid on R side. +sensation to R side noted at times to painful stimuli (reacting w/ lifting of L leg). pt restless and moving L knee up in bed and trying to lift up restrained L arm. Pt noted to hold onto side rail at times and inconsistently squeezes hand, but not to command. Pupils remain 2mm brisk.\n\nCARDIAC: AFib 70-90s. SBP 140-170s today. Remains on Lopressor 125mg TID, Hydralazine 40mg po QID, Norvasc increased to 10mg QD, and Clonodin patch 0.3mg added. On LABETOLOL gtt titrating between 2-5mg/min. +generalized edema.\n\nACCESS: R radial Aline. R s/c DL central line. OGT. ETT.\n\nID: Febrile today. Gram + cocci pairs/clusters in sputum, BC anaerobic culture growing + cocci clusters. Started on Vancomycin today.\n\nRESP: LS clear, dim bases. Sx small amt thick tan/yellow sputum. Gram + cocci. pm ABG 7.40/44/186 on PS 12/Peep 5/ 40% TV 300-400s, RR 20-30s. Pt RR in high 30s-40s on PS 12 and has frothy tan sputum large amts, suctioned and placed back on PS 14. RR back to high 20s, TV 300-400s. CPT today/Pulm toliet.\n\nGI/GU: foley patent, good amts urine. abd soft, +BS. TF GR 65cc/hr Promote w/ fibre via OGT. on colace . given Dulcolax PR today w/ good results, soft brown BM.\n\nSKIN: R outer heel blister remains intact, healing well, elevated off bed or in multipodus boots. coccyx slightly reddened tegaderm intact. no other breakdown noted.\n\nPLAN: con't to monitor neuro status. con't to give wife emotional support and keep her informed of pt status/changes. Pulm toliet. titrate PS for good tidal volumes. titrate Labetolol for goal SBP 130-150s.\n"},{"category":"Nursing/other","chartdate":"2148-01-04 00:00:00.000","description":"Report","row_id":1332413,"text":"NEURO: AWAKE & ALERT. FOLLOWS SIMPLE COMMANDS, BUT NOT CONSISTENTLY.\n DOES NOT MOVE R. SIDE. LIFTS & HOLDS L. ARM UP OFF BED. L. LEG\n LIFTS & FALLS. PERL.\nRESP: 50% TRACH COLLAR. O2 SATS 97-100%. RR 23-28. SX FOR THICK YELLOW\n ->THIN WHITE SECRETIONS Q4HRS. BS COARSE BUT DIMINISHED AT\n BASES.\nCARDIAC: HR 85-93 AF, NO ECTOPY. BP 112-140/54-69.\nGI: CYCLED TF: FS PROMOTE WITH FIBER AT 120CC/HR VIA PEG TOLERATED\n WELL. ABD. SL. DISTENDED. BS+. NO STOOL. FREE H2O 150CC Q8HRS.\nGU: CONDOM CATH DRAINING CLEAR YELLOW URINE. REPLACED X1.\nID: T 97.7->98.8(PO).\nPLAN: TO REHAB THIS AM.\n"},{"category":"Nursing/other","chartdate":"2148-01-04 00:00:00.000","description":"Report","row_id":1332414,"text":"N SICU NPN\nPT ACCEPTED AT OLYMPUS/. WIFE AWARE OF TRANSFER. PT TRANSFERRED AT 09:00 W/ MULTIPOSUS BOOTS, GLASSES, ELECTRIC RAZOR, PICTURES AND WEIGHTS. PT IN STABLE CONDITION.\n"},{"category":"Nursing/other","chartdate":"2147-12-08 00:00:00.000","description":"Report","row_id":1332323,"text":"CCU Nursing Progress Note 7p-7a:\n\nNeuro: Pt opening eyes to name tracking inconsistently. Pupils equal and reactive. Sqeezing left hand on command. Moving L side on bed. R hand and leg responding to painful stimuli. Pt with +cough reflex but w/o gag reflex.\n\nCV: NTG gtt at 115mcg to maintain SBp<160. SBP 130-150's. Afib HR 92-108. Pt conts on lopressor 25mg and hydralazine 10mg IV. H.O. aware of VS ? increasing lopressor this am.\nHCT 34.5 K+4.0\n\nRESP: Mechanically ventilated decreased to PS 10 with Tv 500 40% fi02 and 7.4 peep. ABG 7.45/37/119/2. Pt did not tolerate PS 8 per RT, tv dropped into the 300's.\nLS coarse. Sxn'd for thick yellow sputum in small amts. Sputum cx pending from .\nNo peripheral edema.\n\nGI: Abd softly distended with hypoactive BS. ? LBM. OGT in place with impact with fiber infusing at 30cc/hr. Minimal residuals advance as tolerated for goal rate of 70cc/hr.\n\nGU: Foley cath patent draining yellow urine in good amts. u/o 500cc/hr. BUN 32 Creat 1.4. Fluid balance -43cc since mn. +1393 LOS.\n\nID: tmax 99.6.\n\nSKIN: intact\n\nENDO: FS 127 and 147. No regular insulin required per SS.\n\nPROPH: protonix iv and pneumoboots.\n\nLINES: R radial a-line and 2 piv.\n\nSOCIAL: No phone calls this shift.\n\nDISPO: Full Code\n\nA: cont on ntg gtt to maintian sbp <160.\n increased spontaneous movement on L side.\n Tolerating TF.\n good u/o.\nP: Follow neuro checks q2hr.\n maintain SBP <160.\n ? increasing lopressor dose\n increase TF rate to reach goal as tolerated.\n Wean PS as tv improve.\n Provide support to pt and family.\n"},{"category":"Nursing/other","chartdate":"2147-12-08 00:00:00.000","description":"Report","row_id":1332324,"text":"n micu npn\nNeuro: pt opens eyes to voice, occasionally spontaneously. Moves l side in non purposeful manner, only withdraws from pain on r side. PEARL.\nCV: Continures on ntg gtt at 113 mcg/min, lopressor ^ to 50 mg pngt tid, and hydralazine ^ to 20 mg . hr90- low 100's sr-st, occ pvc. bp 130-165/50-70.\nResp: ps to 8, 5 peep w/ good abg. Mod -lg amts thick yellow/tan secretions. lung sounds coarse.\nGI: tf ^ to 60cc/hr w/ goal 70cc/hr. tolerating well w/ 5cc residuals. No stooo today.\nGU: foley draining dk yel urine\n"},{"category":"Nursing/other","chartdate":"2147-12-08 00:00:00.000","description":"Report","row_id":1332325,"text":"Pt remains on vent, CPAP mode. Changes to the vent settings: decrease in PSV from 10 to 8. Fio2= .40 with spo2= 98%. Suctioned pt several times throughout shift for mod amts of thick yellow sputum.\n"},{"category":"Nursing/other","chartdate":"2147-12-08 00:00:00.000","description":"Report","row_id":1332326,"text":"n sicu nsg addendum\nCurrently +240cc.\n\nid: tm 100.4 po\n\nend: bs wnl\n\nsocial: wife and brother in to visit most of day.\n"},{"category":"Nursing/other","chartdate":"2147-12-08 00:00:00.000","description":"Report","row_id":1332327,"text":"Pt PSV decreased to 5 and Peep decreased to 5 at 1840. Fio2 still= .40. VT= 450ml. RR= 25.\n"},{"category":"Nursing/other","chartdate":"2147-12-09 00:00:00.000","description":"Report","row_id":1332328,"text":"Resp Care\nPt. continues on CPAP 5/5 with VTs 350-550. BS coarse bilaterally, ambued sxn'd x2 for copious thick yellow. Pt. had periods of agitation, diaphoresis, increased BP, desats to 87%. Would not recommend extubation this morning, secreations too thick\n"},{"category":"Nursing/other","chartdate":"2147-12-28 00:00:00.000","description":"Report","row_id":1332390,"text":"Respiratory Care:\nPt. remains on IPS=14, peep=5, and FIO2 of 50%. At times, Pt. becomes very tachypneac and agitated, and appears to become very bronchospastic. He responds well to manual ventilation and/or brief periods on A/C until FRC is restored. Pt. also has periods of bradypnea, with increased VT's ~1L and RR in single digits. This would lead me to want ot wean IPS, but when this is attempted (with targetted VT's ~ 600cc), Pt. soon reverts to tachypnea and agitation. B/S course and at times very wheezy. ETS for small to moderate, thick, yellow. Alb./Atr MDI's given with good effect. Will continue on present settings, and perform as outlined above when needed. Pt. may also benefit from the addition of inhaled steroids. Will follow.\n"},{"category":"Nursing/other","chartdate":"2147-12-28 00:00:00.000","description":"Report","row_id":1332391,"text":"CCU NSG PROGRESS NOTE 7P-7A-S/P HEAD BLEED;FX WEAN\n\nS- TRACHED\n\nO- SEE FLOWSHEET FOR OBJECTIVE DATA.\n\n PT REMAINS ON MULTIPLE MEDS FOR BP/HR.\nCURRENTLY- HR- 90'S AFIB WITH BP- 120-140/.\nNO VEA. AM LYTES PENDING.\n\n PT ON VENTILATORY SUPPORT- 50%/14PRESSURE SUPPORT/5 PEEP.\nSUCTIONED FOR FAIR TO MINIMAL AMT WHITISH/YELLOW SPUTUM.\nCOARSE BREATH SOUNDS.\nIRREGULAR BREATHING PATTERN PERSISTS.\nAT TIMES PERIODS OF APNEA, AT TIMES PERIODS OF TACHYPNEA TO 30'S.\nIMPROVING WITH .\nRECEIVING NEBS AS ORDERED.\nPER RESP- SUGGESTS ADDITION OF STEROIDAL BASED NEBS TO PREVENT\nBRONCHOSPASM/EPISODES OF TACHYPNEA.\n\nID- AFEBRILE- LOW GRADE.\nLEVOQUIN IV.\n\nGI- REMAINS ON TUBE FEEDS AS ORDERED.\nABD DISTENDED BUT SOFT.\nSMALL AMT STOOL G (-). SOFT FORMED.\n\nGU- FAIR AMT URINE VIA CATHETER.\nREMAINS ON LASIX AS ORDERED.\n\nSKIN- LEFT BUTTOCK/AT COCCYX WITH ABRASION/STAGE 11- COVERED AND PROTECTED WITH DUODERM\nHEELS ALSO WITH (+) BLISTER. MULTIPODUS BOOTS ON AS WELL AS ANTIEMB SLEEVES.\nPUT PT ON FIRST STEP BED 12 AM FOR SKIN PROTECTION,\n\n PT AT TIMES ALERT, TRACKING= REPSONDING TO STIMULI SLIGHTLY.\nOTHER TIMES NOT.\nSEE FLOWSHEET FOR DATA RE: NEURO VS- UNCHANGED.\n\nENDO- BS<180'S- NO SS REG INSULIN COVERAGE.\n\nA/ PT S/P HEAD BLEED REMAINS IN NEED OF VENTILATORY SUPPORT.\nCONTINUE PULM TOILET AND SKIN CARE AS WELL AS CLOSE ASSESSMENT OF NEURO STATUS.\nKEEP PT AND FAMILY AWARE OF PLAN OF CARE.\nPLACEMENT.\n"},{"category":"Nursing/other","chartdate":"2147-12-13 00:00:00.000","description":"Report","row_id":1332344,"text":"Respiratory Care Note\n\nPt currently on CPAP 5 PSV 14. Pt tol current settings fairly. ? increasing PSV. Pt rxd t/o shift with Albuterol/atrovent mdis. Will continue to support and wean as tolerated\n"},{"category":"Nursing/other","chartdate":"2147-12-14 00:00:00.000","description":"Report","row_id":1332345,"text":"CCU NSG PROGRESS NOTE-SICU BORDER.\nO:NEURO=WO CHG-SEE FLOW SHEET.\n PULM=REMAINS /VENTED W SETTINGS-CPAP/PS, 40%, STV 350-500, RR 20-32, PEEP 5, & PS 14. BREATH SOUNDS=COURSE THROUGHOUT. SX-THICK TANNISH SECRETIONS.\n GI=LABETOLAL GTT @ 5MG/MIN W SBP 110-150.\n GU=TF @ GOAL (65ML/HR). LAST BM .\n GU=FOLEY. POSITIVE I&0 SINCE ADMISSION.\n ID=LOW GRADE T.\n LABS=AM SENT.\n SOCIAL=PT MADE DNR BY WIFE ON . FURTHER DISCUSSION RE:LONG TERM CARE CONTINUES.\n\nA:UNCHGED.\n\nP:CONTIN PRESENT MANAGEMENT. ?ATTEMPT TO WEAN & DC LABETOLAL. ?ADUMENT DIURESIS W PRN LASIX-?SOME COMPONENT OM HTN RELATED TO FL STATUS. CK AM LABS-REPLACE AS INDICATED. SUPPORT PT WIFE IN DECISION MAKING REGARDING LONG TERM OPTIONS.\n\n"},{"category":"Nursing/other","chartdate":"2147-12-14 00:00:00.000","description":"Report","row_id":1332346,"text":"CCU NPN 7am - 7pm\nS/O: Resp: Pt. remains . PS was decreased to 12. Pt. tolerated this well for a couple of hours with ABG of 132/7.40/45/29. RR 24-30 slightly labored. At 1630 O2sats dropped to 89%and pt. looked more labored. PS was increased back to 14. ABG ->60/7.43/43/29. Pt. was agressively suctioned and CPT was done. O2 sat up to 96%. CXR done. Suctioning done Q2 hours for moderate amount of tan secretions.\nI.D: T max 100 rectal. Vanco D/C'd and levoquin was started per OGT.\nCVS: HR 70 - 80's afib. BP 140-160/70's. Continues on labetelol drip, lopressor, hydralazine, and norvasc.\nG.U.: voiding via foley catheter. sediment noted. urine dark and concentrated. Pt. received 20 mg of lasix pOGT.\nG.I.: Pt. continues on TF at 65cc/hr. residuals are less than 50cc. Aspirates are negative. BM x2.\nA: s/p thalmic bleed\nP: continue antihypertensive measures, aggressive pulm toilet, antibx as written, monitor neuro status for changes.\n\n"},{"category":"Nursing/other","chartdate":"2147-12-15 00:00:00.000","description":"Report","row_id":1332347,"text":"CCU NSG PROGRESS NOTE-NSICU BORDER.\nO:NEURO=PERIODS OF APPROPRIATENESS-FOLLOWS SIMPLE COMMANDS (RISES ARM & SQUEEZES HAND L-SIDE ONLY-NODS HEAD TO ?'S-FOLLOWS W EYES). PURPOSEFUL MOVEMENT OF L ARM-ATTEMPTS TO SCRATCH HEAD-MOVES HAND TOWARDS ETT.\n PULM:VENT SETTINGS UNCHGED-CPAP/PS, FIO2 40%, STV 350-48-, RR 16-32, PEEP 5, * PS 14. SATS UPPER 90'S. AM ABG-7.39/48/117/30/3. BREATH SOUNDS=COURSE THROUGHOUT. SX-THICK TANNISH SECRETIONS.\n CV=ON LABETALOL GTT @ 4MG/MIN. SBP <150.\n GI=TF @ GOAL-65ML/HR W MINIMAL RESIDUALS.\n GU=FOLEY. LASIX X2 ON DAY/EVES -REMAINS POS @ 2300-1.9L.\n ID=LOW GRADE T.\n LABS=AM SENT. WNL.\n\nA:?SL IMPROVING NEURO STATUS. REMAINS ON LABETALOL GTT.\n\nP:CONTIN PRESENT MANAGEMENT. CONTIN ATTEMPT @ WEANING PRESSURE SUPPORT. SUPPORT AS NEEDED.\n\n"},{"category":"Nursing/other","chartdate":"2147-12-15 00:00:00.000","description":"Report","row_id":1332348,"text":"Resp Care Note:\n\nPt cont intub on mech vent as per Carevue. Lung sounds coarse suct mod th tan sput. Pt tol PSV well. No changes made overnoc. Cont wean from mech vent with PSV.\n"},{"category":"Nursing/other","chartdate":"2147-12-18 00:00:00.000","description":"Report","row_id":1332356,"text":"NSG NOTE\n\nCV: REMAINS IN A-FIB. RATE CONTROLLED 83-90. SBP 126-150. CON'T ON NTG TP 2\",HYDRALAZINE 50MG AND LOPRESSOR. NO VEA NOTED.\n\nRESP: CPAP/PS-14,PEEP 5, 40%, VT 710-940. 7.47,40,151,30,5,99%. METABOLIC ALKALOSIS BEING TX WITH DIAMOX X4 DOSES.PT HAS ALREADY RECEIVED 3 DOSES. SUCTIONED FOR SM AMT TAN SECRETIONS.\n\nNEURO: OPENS EYES SPONTANEOUSLY. 2MM/2MM BRISK. BOTH RUE/RLE NO MOVEMENT. LUE LIFTS AND HOLDS,LLE MOVES ON BED. HE FOLLOWS COMMANDS IN CONSISTENTLY.\n\nGI: PT WAS ON TF @ GOAL RATE 65. TOL WELL WITH LOW RESIDUALS. ABD SOFT WITH + BS. NO STOOL THIS SHIFT. TF D/CD @ 0400 IN PREP FOR TRACH TODAY. LAST BM \n\nLABS: BS 168- RECEIVED 2 UNITS REG PER SSI\n\nID: TEMP MAX 99.5 PT IS ON . AND OXACILLIN IV FOR COVERAGE\n\nSKIN: HAS BLISTER ON R LATERAL ASPECT OF HEEL. LEG AND FOOT ELEVATED ON PILLOW. DUODERM TO BUTTOCKS INTACT.\n\nDISPOSITION: DNR\n\nA: STABLE\n\nP: BEDSIDE TRACH TODAY. KIT AT BEDSIDE\n SUGGEST PICC LINE. IV NEEDS TO BE NOTIFIED.\n\n\n"},{"category":"Nursing/other","chartdate":"2147-12-18 00:00:00.000","description":"Report","row_id":1332357,"text":"Resp Care,\npt. remains on CPAP IPS 14/.4/5peep. Vt 600's, RR15. Plan to today. ABG 7.47/40/151/30. See vent flowsheet.\n"},{"category":"Nursing/other","chartdate":"2147-12-18 00:00:00.000","description":"Report","row_id":1332358,"text":"ccu nursing progress note\ns/o: pls see carevue flowsheet for complete vs/data/events\nneuro: opens eyes spon. occ appears to track. r hemiparesis. withdraws rle to pain but not upper. l moves spon but not to command. moves l hand to face/tubes and req soft wrist restraint.\ncv: hr 80s afib. bp 130-150/70 via r rad aline. no changes to bp/cardiac meds. k repleted 80meq for k 3.1.\nresp: cont on ps 14. rr low 20s. tv 500-800. sats >96% on .4 fio2. percutaneous trach placed at bedside. pt tol procedure well. sxn'd for sm amt bld tinged secretions. bs scatt coarse.\ngi: npo. peg placed at bedside. pt tol well. will remain npo until tomorrow am but peg may be used for essential meds. rec'ing ns at 80cc/hr while tf on hold.\ngu: good uop. cont po lasix.\nid: afeb. cont on oxacillin. levo to be dc'd after today's dose.\ncultures from pend.\naccess: rsc double lumen. iv team contact to eval for picc line. (pt may need 1 more week of oxacillin for mssa in sputum.) r rad aline will be pulled this afternoon.\nsocial: wife called this am. has note visited.\nact: pt and ot eval pt. will require full lift to get oob.\na: s/p trach and peg. tol well.\np: begin vent wean as tol. pulm toilet. neuro rehab. follow temp. f/u w/ iv team re: picc. ready for screening for rehab placement.\nsupport to family and pt.\n"},{"category":"Nursing/other","chartdate":"2147-12-17 00:00:00.000","description":"Report","row_id":1332353,"text":"Respiratory Care:\nPt. initially tachypneac to 30's, VT's ~400cc, and appearing diaphoretic and agitated>>increased IPS to 14cmH20>>RR slowly decreased over course of the shift to mid teens, with VT's increasing to 6-800cc. ABG's essentially unchanged on both settings. Well oxygenated with a slight metabolic alkalosis. B/S continue course>>ETS for small to moderate yellow. Pt. continues very bronchospastic to SXN. Good relief with MDI's. Will continue pulmonary hygiene and attempts to wean as tolerated.\n"},{"category":"Nursing/other","chartdate":"2147-12-17 00:00:00.000","description":"Report","row_id":1332354,"text":"NURSING PROGRESS NOTE 7P-7A\nS/O: PT. MECH VENTILATED.\n\nNEURO: OPENS EYES SPONTANEOUSLY, MOVES LEFT ARM LIFTS AND HOLDS, MOVES LEFT LEG ON BED. NO MOVEMENT ON RIGHT SIDE. FOLLOWS SIMPLE COMMANDS. SQUEEZES WITH LEFT HAND. FOLLOWS WITH EYES.\n\nCV: CONT ON LABETOLOL GTT. NEEDED TO INCREASE GTT RATE TO 3 MG FOR PERIOD OF TIME D/T BP 160-170'S. LABETOLOL GTT NOW AT 1 MG. CLONIDINE DOSE INCREASED AND TOL WELL. HR 90'S AFIB.\n\nRESP: SEE PROGRESS NOTE FROM RESP THERAPY. PRESENT VENT SETTINGS FIO2 40%, TV 800, PS 14 CPAP SUCTIONING FOR THICK WHITE SPUTUM. PT BECOMING WITH SUCTIONING. O2 SATS 97%. ABG UNCHANGED. SL. ALKALOTIC, RECEIVING DIAMOX 250 MG IV X 2 DOSES.\n\nGI: REMAINS ON TF PROMOTE WITH FIBER AT GOAL RATE OF 65 CC/HR. MIN RESIDUALS. + BOWEL SOUNDS, HOWEVER NO BM. ON COLACE . ? NEED FOR LAXATIVE TODAY.\n\nGU: FOLEY PATENT AND DRAINING CLEAR YELLOW URINE. DIURESING WELL FROM LASIX. CONT ON ABX FOR UTI.\n\nSKIN: SMALL QUARTER SIZE BLISTER NOTED ON RIGHT HEEL. BLISTER INTACT. MULTIPODUS SPLINTS ON. SMALL ABRSSION ON COCCYX COVERED WITH TEGADERM. SMALL SKIN ABRASION NOTED ON RIGHT FLANK. LEFT OPEN TO AIR. WASHED WITH SOAP AND WATER.\n"},{"category":"Nursing/other","chartdate":"2147-12-17 00:00:00.000","description":"Report","row_id":1332355,"text":"CCU NURSING PROGRESS NOTE 7A-7P\n\nNEURO: Pt awake and moving head side to side, however does not appear to be tracking with his eyes. PERL. Will squeeze left hand, however does not let go when asked. ?reflex vs. purposeful movement. No movement of right side.\n\nRESP: Remains vented on PSV 14/ peep 5. RR 20's most of the day. Sats maintained >97%. Suctioned q4 hrs for small-> mod amt thick white sputum. No plans to wean today given febrile state. Scheduled for trach Monday morning ~10am.\n\nCARDIAC: BP range 120-160's. Hydralazine and clonidine increased; able to d/c labetolol gtt while maintaining SBP 140-160 range. Remains in afib with rate 80-90's.\n\nGI: Abd soft distended with +BS. Given dulcolax suppository this am with good effect. Passed small amt soft brown stool. Tolerating goal tube feeds at 65cc/hr. To be NPO after 4am for trach and peg in am.\n\nGU: foley draining clear yellow urine. Pt is +435cc this evening. Conts on lasix and diamox.\n\nID: T max 102.2. Was fully cultured. Right SC DL was changed over a wire and tip was sent for cx. Pt may be a candidate for PICC given potential need for 10-14 days of IV abx. COnts on po levo and IV oxacillin for MSSA in urine and sputum. WBC up to 20 today. Given tylenol x2 today with temp down to 100.8 this evening.\n\nA/P: New temp spike on abx-> follow up with cx results.\n Awaiting trach and peg in am. D/C tube feeds at 4am\n Consult IV team for PICC placement.\n Cont to assess for acute neuro changes\n\n"},{"category":"Nursing/other","chartdate":"2147-12-15 00:00:00.000","description":"Report","row_id":1332349,"text":"SICU NPN\nNEURO: OPENS EYES TO VOICE, AT TIMES SEEMS TO TRACK. VERY OCCASIONALLY FOLLOWING COMMANDS SUCH AS WIGGLING TOES (L SIDE ONLY), LIFTS L HAND, MOVES L LEG ON BED. NO MOVEMENT I R SIDE EXCEPT WITHDRAWAL OF R LEG TO PAINFUL STIMULI.\n\nCV: LABATELOL WEANED TO 1 MG/MIN. LOPRESSOR ^ TO 150MG TID, CLONIDINE .2MG , HYDRALAZINE REMAINS AT 40MG QID, NTP 1\" Q6HR. BP 137-160/58-70. (GOAL <160) HR 70'S A FIB.\n\nRESP: PS TO 10 (FROM 14) TV 400-500, RR 20'S, APPEARS COMFORTABLE.\nSX Q 3 HRS FOT SM/MOD AMTS YEL SECRETIONS. LUNG SOUNDS COARSE.\n\nID: LOW GRADE TEMP, CONT ON LEVOQUIN\n\nGU: FOLEY DRAINING YEL URINE. GIVEN LASIX 40MG IV W/ EXCELLENT RESPONSE.\n\nGI: TOLERATING TF AT GOAL, NO STOOL TODAY. MINIMAL RESIDUALS.\n\nSOCIAL: WIFE MET W/ DR. THIS AFTERNOON. PLAN IS FOR PT TO HAVE TRACH AND PEG PLACEMENT MON OR TUES.\n"},{"category":"Nursing/other","chartdate":"2147-12-16 00:00:00.000","description":"Report","row_id":1332350,"text":"RESPIRATORY CARE:\nPt. remains on unchanged vent support. RR low to high 20's, VT's 4-500cc on IPS=10cmH20. ABG was well oxygenated with with normal range acid-base. B/S continue course>>ETS for moderate to large amounts of thick yellow. Pt. very bronchospastic to SXN>>MDI's given post with good effect. Pt. appears to be tolerating present level of support. Will continue pulmonary hygiene.\n"},{"category":"Nursing/other","chartdate":"2147-12-16 00:00:00.000","description":"Report","row_id":1332351,"text":"NURSING PROGRESS NOTE 7P-7A\nNEURO: PT. OPENS EYES TO COMMAND. FOLLOWS WITH EYES. MOVING LEFT ARM OFF BED AND ABLE TO HOLD. MOVING LEFT LEG ON BED. NO MOVEMENT OF RIGHT SIDE. WILL FOLLOW SOME SIMPLE COMMANDS. NO SEIZURE ACTIVITY NOTED.\n\nCV: CONT IN AFIB. RATE 80'S NO VEA BP STABLE ON LABETOLOL I MG. BP RANGE 150-160'S. TOL CARDIAC MEDS WELL.\n\nRESP: SEE FLOWSHEET FOR VENT SETTINGS. SUCTIONING FOR THICK YELLOW SPUTUM. LUNGS SOUNDS COARSE. O2 SATS 96-98%. ABG'S ADEQUATE.\n\nGU: FOLEY PATENT. DRAINING CLEAR YELLOW URINE. GIVEN LASIX AS ORDERED. DIURESING WELL FROM LASIX.\n\nGI: + BOWEL SOUNDS. TOL TF AT GOAL RATE OF 65 CC/HR. MIN RESIDUALS. NO BM OVERNIGHT. ABD SOFT, DISTENDED.\n\nSKIN: SMALL BLISTER NOTED ON RIGHT HEEL. OPEN TO AIR. SMALL ABRASION NOTED ON COCCYX.\n\nSTABLE OVERNIGHT, WAITING FOR TRACH AND PEG PLACEMENT NEXT WEEK.\n"},{"category":"Nursing/other","chartdate":"2147-12-16 00:00:00.000","description":"Report","row_id":1332352,"text":"CCU NURSING PROGRESS NOTE 7A-7P\n\nNEURO: Pt awake and following simple commands intermittently. Moving left arm and left leg; no movements noted of right side. PERL.\n\nRESP: LS coarse. Sxn'd q2-4 hrs for moderate amt thick white sputum. Attempted to decrease PSV to 8 however pt's rr increased to high 30's\n(ABG essentially unchanged: 115/44/7.47). Placed back on PSV 10/5 with RR 27 Vt 400's. Awaiting trach and peg on Mon or Tues.\n\nCARDIAC: Bp 140-160's most of the day (which is goal range). Conts on labetolol gtt as well as multiple po cardiac meds. Tolerating well.\n\nGI: Tolerating tube feeds at goal rate of 65cc/hr. Abd soft distended. +BS. no stool this shift.\n\nGU: foley draining clear yellow urine. Rec'g IV lasix . Pt is >500cc negative this evening. Bun 36/ Creat 1.2.\n\nID: T max 99.8. WBC 12.1. Conts on po levo for UTI and started on IV oxacillin for MSSA in sputum.\n\nA/P: Stable day. Awaiting trach and peg\n Maintain SBP 140-160 range.\n Follow t-curve on abx.\n Assess for acute neuro changes.\n\n"},{"category":"ECG","chartdate":"2147-12-28 00:00:00.000","description":"Report","row_id":150624,"text":"Atrial fibrillation\nSince last ECG, , no significant change\n\n"},{"category":"ECG","chartdate":"2147-12-05 00:00:00.000","description":"Report","row_id":150625,"text":"Atrial fibrillation\nEarly R wave progressing\n\n"},{"category":"Radiology","chartdate":"2147-12-22 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":748454,"text":" 1:23 PM\n CHEST (PORTABLE AP) Clip # \n Reason: PLEASE CONFIRM PICC TIP PLACEMENT TO RIGHT ARM; PAGE \n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with ICH.\n temp spike r/o PNA\n for central line position check\n temp spike today- rt subclavian line changed over a wire today\n for correct placement check\n REASON FOR THIS EXAMINATION:\n PLEASE CONFIRM PICC TIP PLACEMENT TO RIGHT ARM; PAGE WITH RESULTS.\n THANKS..\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Intracranial hemorrhage and temperature spike, PICC placement.\n\n COMPARISON: .\n\n PORTABLE AP CHEST: The left PICC line terminates with tip in the proximal\n SVC. The right subclavian central venous line and endotracheal tube are\n unchanged. There are bibasilar nonspecific opacities, which could represent\n atelectasis or alternatively, aspiration. The cardiomediastinal silhouette\n and pulmonary vasculature are stable.\n\n IMPRESSION:\n PICC tip in proximal SVC. Nonsecific patchy bibasilar opacities could\n represent atelectasis or aspiration.\n\n\n"},{"category":"Radiology","chartdate":"2147-12-14 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":747902,"text":" 5:00 PM\n CHEST (PORTABLE AP) Clip # \n Reason: desatting on vent. on levoquin ? pneumonia\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with ICH.\n temp spike r/o PNA\n for central line position check\n REASON FOR THIS EXAMINATION:\n desatting on vent. on levoquin ? pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Intracranial hemorrhage with new temperature spike.\n\n COMPARISON: .\n\n PORTABLE AP CHEST: Allowing for lordotic position, the ETT and right\n subclavian central venous catheter and NG tube are in unchanged and\n satisfactory position. The lung volumes are low but there is no consolidation.\n There is continued improvement in patchy left basilar opacity likely related\n to atelectasis.\n\n IMPRESSION: No evidence of pneumonia.\n\n"},{"category":"Radiology","chartdate":"2147-12-17 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":748083,"text":" 1:39 PM\n CHEST (PORTABLE AP) Clip # \n Reason: post line change\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with ICH.\n temp spike r/o PNA\n for central line position check\n temp spike today- rt subclavian line changed over a wire today\n for correct placement check\n REASON FOR THIS EXAMINATION:\n post line change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE AP FILM.\n\n HISTORY: Fever with change in right CV line. Evaluate for location and\n pneumothorax.\n\n Endotracheal tube is 3 cm above carina. Right subclavian CV line is in mid\n SVC. No pneumothorax. Apart from discoid atelectasis in the left lower zone\n and linear atelectasis in the right midzone, the lungs are grossly clear.\n\n\n"},{"category":"Radiology","chartdate":"2147-12-18 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":748174,"text":" 9:57 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p trach, please eval lung volumes; infiltrates\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with ICH.\n temp spike r/o PNA\n for central line position check\n temp spike today- rt subclavian line changed over a wire today\n for correct placement check\n REASON FOR THIS EXAMINATION:\n s/p trach\n please eval lung volumes; infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post tracheostomy with fever, check line placement.\n\n AP radiograph dated is compared with AP radiograph dated .\n The ET tube has been removed. A tracheostomy tube is in proper position. The\n right subclavian central venous catheter tip is located in the mid SVC. There\n are adequate lung volumes. There is discoid atelectasis in the left lower lung\n Zone. The lungs are otherwise clear.\n\n IMPRESSION: Satisfactory position of tracheostomy and right subclavian\n central venous catheter. Adequate expansion of the lungs. No evidence of\n infiltrate.\n\n"},{"category":"Radiology","chartdate":"2147-12-19 00:00:00.000","description":"VEN DUP EXTEXT BIL (MAP/DVT)","row_id":748219,"text":" 12:54 PM\n DUP EXTEXT BIL (MAP/DVT) Clip # \n Reason: ACUTELY DESATTED AND HYPERTENSIVE WITH RESIDUAL LOWER O/2 SATURATION,SOB ,EVAL FOR DVT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with BASAL GANGLIA CVA\n REASON FOR THIS EXAMINATION:\n ACUTELY DESATTED AND HYPERTENSIVE WITH RESIDUAL LOWER O2 SATS\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Basal ganglia CVA, acutely desated and hypertensive with\n bilateral lower extremity swelling.\n\n BILATERAL DVT STUDY:\n\n scale and Doppler son of both common femoral, superficial femoral,\n and popliteal veins were performed. Normal flow, augmentation and\n compressibility and wave forms are demonstrated. Intraluminal thrombus is not\n identified.\n\n IMPRESSION: No evidence of DVT in either leg.\n\n"},{"category":"Radiology","chartdate":"2147-12-19 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":748200,"text":" 9:49 AM\n CHEST (PORTABLE AP) Clip # \n Reason: hemodynamics unsteady w/ decreased sats\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with ICH.\n temp spike r/o PNA\n for central line position check\n temp spike today- rt subclavian line changed over a wire today\n for correct placement check\n REASON FOR THIS EXAMINATION:\n hemodynamics unsteady w/ decreased sats\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Unsteady hemodynamics with decreased sats and fever.\n\n AP radiograph dated is compared with the radiograph dated .\n\n The heart size is normal. The mediastinal and hilar contours are normal. The\n right subclavian central venous catheter tip is i proper position. The\n endotracheal tube is in proper position. There is increased interstitial\n pattern of opacification in the bases bilaterally. This likely represents\n pulmonary edema. There are no pleural effusions. The soft tissues and\n osseous structures are unremarkable.\n\n IMPRESSION: Though it is difficult to assess the pulmonary vasculature in\n this supine radiograph, the increased interstitial pattern of pulmonary\n opacity is suggestive of evolving pulmonary edema.\n\n"},{"category":"Radiology","chartdate":"2147-12-09 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":747547,"text":" 2:28 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pt has elevated WBC count and increased secretions., rule ou\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with ICH.\n eval ETT position\n REASON FOR THIS EXAMINATION:\n pt has elevated WBC count and increased secretions.\n rule out infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Elevated white count and increased secretions. Rule out infiltrate.\n\n CHEST, SINGLE AP PORTABLE VIEW.\n\n Lordotic positioning and low inspiratory volumes. Allowing for this, no\n definite infiltrate. There is bibasilar atelectasis, presumably related to\n low lung volumes. An ET tube is present, tip approximately 1.3 cm above the\n carina, relatively low. An NG tube is present, tip obscured due to\n underpenetration.\n\n IMPRESSION: Low lung volumes. Allowing for this, no definite infiltrate.\n Attention to ET tube is recommended, as the positioning on today's exam seems\n relatively low compared with 11/29.\n\n\n"},{"category":"Radiology","chartdate":"2147-12-28 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":748839,"text":" 10:15 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o infiltrate, chf\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with ICH. prolonged resp failure w/ trach, now w/ inc WBC,\n agitation, need to go back on vent\n REASON FOR THIS EXAMINATION:\n r/o infiltrate, chf\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 73 year old man with history of intracerebral hemorrhage and\n prolonged respiratory failure, now with increasing white blood cell count,\n aggitation and respiratory distress.\n\n AP portable radiograph of the chest dated , compared with prior AP\n portable on .\n\n There is stable cardiomegaly. The mediastinal and hilar contours are\n unchanged. There is a possible small left pleural effusion with atelectasis\n at the left lung base. The remainder of the lung fields are clear. A\n tracheostomy tube is seen in good position. The soft tissue and osseous\n structures are unremarkable.\n\n IMPRESSION: Small left pleural effusion with left lower lobe atelectasis.\n\n"},{"category":"Radiology","chartdate":"2148-01-02 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":749159,"text":" 9:50 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o progression of previous hemorrhage\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with left hemisphere hemorrhage. No significant change in his\n neurological status over the last weeks. Resorption of hemorrhage?\n REASON FOR THIS EXAMINATION:\n r/o progression of previous hemorrhage\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Intraparenchymal hemorrhage, assess change. There has been interval\n change in neurological status.\n\n There is a prior study dated .\n\n TECHNIQUE: Contiguous axial images were obtained from skull base to higher\n convexities. No intravenous contrast was administered.\n\n FINDINGS: There is evolution of the left basal ganglia hemorrhage and\n currently measures 3.1 x 1.7 cm with surrounding hypodensity consistent with\n vasogenic edema. There was mild left-to-right midline shift of the normally\n midline structures. This is decreased in comparison to the prior examination.\n There is mass effect upon the left lateral ventricle. There is a small amount\n of hemorrhage within the occipital horns bilaterally. There are no other areas\n of hemorrhage. There is a stable old right temporal lobe infarct. There is a\n calcified extra-axial mass off the higher convexities on the right which is\n unchanged and probably represents a calcified meningioma. The bony calvarium\n and paranasal sinuses are clear. The bony calvarium is intact.\n\n IMPRESSION: Evolution of the left basal ganglia hemorrhage. There is no\n evidence of new hemorrhage.\n\n There is a small amount of intraventricular hemorrhage, as well.\n\n\n"},{"category":"Radiology","chartdate":"2147-12-06 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":747344,"text":" 12:01 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: known intraparenchymal hem, eval interval extension, shift,\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man transferred for ICH with mass effect. Intubated.\n REASON FOR THIS EXAMINATION:\n known intraparenchymal hem, eval interval extension, shift, hydrocephalus\n ______________________________________________________________________________\n FINAL REPORT\n CT SCAN OF THE BRAIN, :\n\n INDICATION: Follow up intracranial hemorrhage, assess for shift and\n hydrocephalus.\n\n TECHNIQUE: Axial noncontrast CT scans of the brain were obtained.\n\n FINDINGS:\n Comparison is made to the previous study of .\n\n There has been no extension of the large left basal ganglionic hemorrhage.\n there is an intraventricular component of the hemorrhage, which is also\n stable. The lateral ventricles are mildly dilated, but not significantly\n changed in size, compared to the previous study. There is mild midline shift\n to the right. This is not changed. The basal cisterns remain well visualized.\n\n There are no other changes in the appearance of the brain. Again noted is an\n old right temporal lobe infarction and a high right frontal region calcified\n mass, presumably a meningioma.\n\n IMPRESSION: Stable left basal ganglionic and intraventricular hemorrhage.\n Mild ventricular dilatation.\n\n\n\n"},{"category":"Radiology","chartdate":"2147-12-07 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":747437,"text":" 2:38 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval ETT position\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with ICH.\n eval ETT position\n REASON FOR THIS EXAMINATION:\n eval ETT position\n ______________________________________________________________________________\n FINAL REPORT\n\n CHEST, SINGLE AP FILM.\n\n ET Tube is 4 cm above carina. NG tube is in proximal stomach. There are\n bibasilar subsegmental atelectases. No pneumothorax.\n\n\n"},{"category":"Radiology","chartdate":"2147-12-10 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":747605,"text":" 6:14 PM\n CHEST (PORTABLE AP) Clip # \n Reason: status post right subclavian catheter\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with ICH.\n eval ETT position\n for position of right subclavian catheter\n REASON FOR THIS EXAMINATION:\n status post right subclavian catheter\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 73 y/o man with intracranial hemorrhage, s/p ETT placement and\n subclavian catheter placement.\n\n Portable AP radiograph of the chest dated at 6:28 P.M. is compared\n with a portable AP radiograph of the chest dated .\n\n The ETT is approximately 3 cm above the carina. The right subclavian central\n venous catheter tip is at the distal superior vena cava. There is lordotic\n positioning and low lung volumes. Allowing for this, the cardiomediastinal\n silhouette is within normal limits and stable. There is no consolidation,\n effusion, or pneumothorax.\n\n IMPRESSION: ETT and right subclavian central venous catheter in satisfactory\n position.\n\n"},{"category":"Radiology","chartdate":"2147-12-10 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":747597,"text":" 1:37 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: change in mental status, s/p intracranial bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man transferred for ICH with mass effect. Intubated.\n REASON FOR THIS EXAMINATION:\n change in mental status\n s/p intracranial bleed\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Intracranial hemorrhage with mass effect, intubated with change\n in mental status.\n\n COMPARISON: .\n\n TECHNIQUE: CT of the head without IV contrast.\n\n FINDINGS: Again seen is a left basal ganglia hemorrhage with a large amount\n of hemorrhage present within the left lateral ventricle as well as hemorrhage\n within the occipital of the right lateral ventricle. There is a stable\n old right temporal lobe infarct. The calcified presumed meningioma in the\n right frontal region is unchanged. Compared with the prior study there does\n not appear to be a significant interval change in the ventricular size. The\n hemorrhage within the third ventricle is less apparent on the present study.\n There continues to be a small amount of shift of normal midline structures\n which are not significantly changed from the prior study. There is edema\n associated with the left basal ganglia hemorrhage that does not appear\n significantly changed.\n\n IMPRESSION: No significant change from the prior study.\n\n\n"},{"category":"Radiology","chartdate":"2147-12-12 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":747678,"text":" 7:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: TEMP SPIKE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with ICH.\n temp spike r/o PNA\n REASON FOR THIS EXAMINATION:\n r/o infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 73 y/o man with intracranial hemorrhage and fever spike.\n\n COMPARISON: .\n\n PORTABLE SUPINE AP CHEST: The ETT, NG tube, and right subclavian line remain\n in stable and satisfactory position. There are low lung volumes. The\n cardiomediastinal silhouette is stable. There is no consolidation, CHF, or\n effusion.\n\n IMPRESSION: No evidence of pneumonia.\n\n"},{"category":"Radiology","chartdate":"2147-12-12 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":747715,"text":" 1:47 PM\n CHEST (PORTABLE AP) Clip # \n Reason: post change of central venous catheter over a wire- for posi\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with ICH.\n temp spike r/o PNA\n for central line position check\n REASON FOR THIS EXAMINATION:\n post change of central venous catheter over a wire- for position of central\n venous catheter\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: Central line catheter placement.\n\n Comparison is made to previous radiograph of earlier the same day.\n\n A right subclavian central venous catheter has been placed and terminates in\n the distal superior vena cava. No pneumothorax is identified. However,\n exclusion of the right costophrenic angle area from the radiograph limits\n assessment for basilar pneumothorax.\n\n An endotracheal tube is in satisfactory position, allowing for flexed position\n of the patient's neck. The nasogastric tube courses below the diaphragm.\n\n Cardiac and mediastinal contours are stable. A patchy left lower lobe opacity\n shows some interval improvement. The right lung is grossly clear, allowing\n for low lung volumes.\n\n IMPRESSION:\n 1. Satisfactory placement of central venous catheter. No pneumothorax is\n detected, but additional view to include entire right lung base would be\n helpful to exclude basilar pneumothorax.\n\n 2. Improving left lower lobe opacity, likely due to atelectasis.\n\n"},{"category":"Radiology","chartdate":"2147-12-05 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":747283,"text":" 3:15 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/o intubation....distant BS on left...r/o PTX, ET tube migr\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with ICH.\n REASON FOR THIS EXAMINATION:\n s/o intubation....distant BS on left...r/o PTX, ET tube migration\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Intracranial hemorrhage, status post intubation with decreased\n breath sounds on the left.\n\n FINDINGS: Single frontal view of the chest. Enotracheal tube tip resides 2.4\n cm above the carina. There is bibasilar atelectasis which appears more\n pronounced when compared with the prior study from five hours prior. There is\n no congestive heart failure or dense consolidations. No pneumothoraces seen.\n\n IMPRESSION: Increased atelectasis at the bases bilaterally.\n\n"},{"category":"Radiology","chartdate":"2147-12-05 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":747242,"text":" 10:01 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval position of EG and OG\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with ICH.\n REASON FOR THIS EXAMINATION:\n eval position of EG and OG\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Tube check.\n\n Portable AP chest radiograph was performed. No prior studies.\n\n The ETT and OGT are appropriately positioned. There is tortuosity and\n calcification of the aorta. The heart is difficult to assess but appears\n slightly enlarged. There is vascular redistribution suggesting mild\n congestive failure. There is a hazy opacity involving the entire right lung,\n which may represent layering pleural effusion. There is no pneumothorax. The\n osseous structures are unremarkable.\n\n IMPRESSION: Appropriately positioned ET and OG tube. Mild congestive failure\n and probably a right-sided effusion.\n\n"},{"category":"Radiology","chartdate":"2147-12-05 00:00:00.000","description":"CT EMERGENCY HEAD W/O CONTRAST","row_id":747238,"text":" 9:25 AM\n CT EMERGENCY HEAD W/O CONTRAST Clip # \n Reason: eval ICH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man transferred for ICH with mass effect. Intubated.\n REASON FOR THIS EXAMINATION:\n eval ICH\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Intracranial hemorrhage.\n\n TECHNIQUE: Noncontrast head CT.\n\n HEAD CT WITHOUT CONTRAST: There is a large intraparenchymal hemorrhage\n centered in the left basal ganglia extending superiorly to the left corona\n radiata and centrum semiovale and inferiorly to the posterior limb of the\n internal capsule and thalamus. There is significant amount of\n intraventricular blood, predominantly involving the left lateral ventricle.\n There is a tiny amount of hemorrhage seen within the posterior of the\n right lateral ventricle as well as in the left temporal and third\n ventricle. There is some shift of normally midline structures to the right\n with some subfalcine herniation. There is no evidence of uncal displacement.\n\n There is an area of hypodensity within the right temporal lobe with loss of\n -white differentiation consistent with an old infarct. There is a large\n calcified right frontal convexity meningioma measuring 2.8 cm.\n\n Mild mucosal thickening is noted within the ethmoid air cells.\n\n IMPRESSION: Large intraparenchymal hemorrhage centered in the left basal\n ganglia, slight subfalcine herniation and intraventricular hemorrhage.\n\n"},{"category":"Radiology","chartdate":"2147-12-25 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":748626,"text":" 1:34 PM\n CHEST (PORTABLE AP) Clip # \n Reason: fever work up- r/o pnuemonia\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with ICH.\n temp spike r/o PNA\n for central line position check\n temp spike today- rt subclavian line changed over a wire today\n for correct placement check\n fever work up r/o pneumonia\n REASON FOR THIS EXAMINATION:\n fever work up- r/o pnuemonia\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 73 YEAR OLD MAN WITH INTRACRANIAL HEMORRHAGE AND FEVER. EVALUATE\n FOR PNEUMONIA.\n\n FINDINGS: The heart, mediastinal and hilar contours are unremarkable. There\n has been decreased interval perihilar haziness and patchy bibasilar opacities.\n There are no pleural effusions. A tracheostomy tube is seen with its tip\n approximately 5 cm above the carina. The soft tissues and osseous structures\n are unremarkable. There has been interval removal of the right subclavian\n central venous line.\n\n IMPRESSION:\n 1. Interval improvement in perihilar haziness and bibasilar patchy opacities.\n 2. Interval removal of the right subclavian central venous line.\n\n"}],"string":"[\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332335,\n \"text\": \"No ABG drawn over night,yesterday abg was normal. Patient head scan from yesterday is unchanged. Remains on mechanical ventilation PS 8/5 with FI02 40% sat 98%,HR 100, BP179/82 BS diminished, not much secretion present on ventolin and atrovent inhalers.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332336,\n \"text\": \"CCU NSG PROGRESS NOTE-NSICU BORDER.\\nO:NEURO=STABLE. MOVING L ARM-?PURPOSEFULLY. MOVES L LEG ON BED. WO MOVEMENT R SIDE. OPENS EYES TO STIM-?TRACTS/FOLLOWS. SEE FLOW SHEET FOR FURTHER NEURO CKS.\\n PULM=REMAINS /VENTED. SETTING UNCHGED-AM ABG SENT. BREATH SOUNDS=COURSE THROUGHOUT. SX-THICK TANNISH SECRETIONS.\\n CV=CONTIN ON LOPRESSOR/HYDRAL FOR RATE/BP CONTROL.\\n GI=TF @ GOAL W MINIMAL RESIDUALS. WO STOOL.\\n ID=LOW GRADE T.\\n LABS=AM SENT.\\n\\nA:UNCHGED NEURO ASSESSMENT.\\n\\nP:?ADD MILD SEDATION-HEPL W ?ANXIETY & W HYPERTENSION. ?WEAN TO EXTUBATE. SUPPORT PT/FAMILY AS NEEDED.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332359,\n \"text\": \"CCU Nursing Progress Note 3p-7p:\\n\\nNeuro: Pt opening eyes spontaneously. Moving neck and LUE frequently wrasping side rails. No spontaneous movement of lower extremities notes. PT consulted today regaring increasing pt's activity, please see eval for details.\\n\\nCV: Afib HR 90's w/o ectopy. SBP 119-125. Pt conts on cardiac regimen 2in NTP,lopressor and hydralazine. IVF changed to d51/2 NS 40meq KCL at 80cc/hr.\\n\\nPULM: Mechanically ventilated via trach on PS 14 5 peep 40% fi02 with tv 460. ABG 7.43/42/173/29. Pt with strong spontaneous cough. Pt sxn'd for small to moderate amts of blood tinged sputum. Await RT to locate in line sxn for trach. Pt rec'd last dose of diamox for metabolic alkalosis.\\n\\nGI: Abd soft +BS. No stool this shift. Peg tube site c/d/i. Place check done with bilious aspirate. Pt rec'd meds crushed w/o incidence.\\n\\nGU: Foley cath patent draining cyu in adequate amts. -140cc since mn + LOS.\\n\\nLINES: A-line removed today. TLC in R subclavian flushing w/o incidence. Pt evaluated by IV for PICC placement per IV pt with marginal access secondary to edema. IV team will reevaluate they are also concerned with recent temps and would like line order checked out with ID.\\n\\nENDO: FS 115 no reg insulin coverage indicated.\\n\\nID: Afebrile. Rec'd last dose of levo po. Conts on oxacillin iv atc.\\n\\nSOCIAL: wife and friend in to visit this evening.\\n\\nDISPO: DNR\\n\\n\\nA: s/p trach and peg placement today. VSS.\\nPeg tube flushing w/o incidence.\\n\\nP: Follow for neuro status changes.\\n monitor bp on current regimen.\\n ? begining vemt wean as tolerated.\\n NPO except meds, start TF in am \\n skin care.\\n follow u/o.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332360,\n \"text\": \"CCU NSG PROGRESS NOTE-NSICU BORDER.\\nO:NEURO=OPENS EYES & TURNS HEAD TO NOISE, BUT DOES NOT FOCUS, TRACT OR FOLLOW W EYES-APPEARS TO LOOK RIGHT THROUGH YOU!\\n PULM=TRACHED. VENTED W SETTINGS-CPAP/PS, 40%, 490-700 STV, 20-30 RR, 5 PEEP, & 14 PRESSURE SUPPORT. BREATH SOUNDS=COURSE THROUGHOUT. SX-LT PINKISH SECRETIONS. TRACH CARE DONE.\\n CV=HEMODY STABLE.\\n GI=PEG. MEDS WO DIFFICULTLY-?INCREASE AMT OF AIR PRESENT.\\n GU=FOLEY. LASIX PO W GD RESPONSE.\\n ID=LOW GRADE T.\\n LABS=AM SENT.\\nA:FRESH TRACH & PEG.\\nP:CONTIN PRESENT RX. ?PICC LINE PLACEMENT. ?SCREEN FOR PLACEMENT. SUPPORT AS NEEDED.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332361,\n \"text\": \"CCU Nursing Progress Note 7a-7p:\\n\\nNeuro: Pt alert moving LUE up and down off bed and holding side rail. RUE w/o movement, RLE moves toes and LLE moves on bed. Pt turning head side to side but does not track.\\n\\nCV: Pt rec'd ADL's, MDI's and was sxn'd at appox 9:30am pt's BP increased to 190-200's, RR high 30's to 40 and HR AFib to 115. Team notified EKG and CXR obtained CK sent. During this event pt appeared air hungry and Diaphoretic. pt w/o difficulty. Dr. was in unit evlauated pt less than 24 hour post trach insertion. Dr not find any issues with trach. Pt rec'd a total of 4mg mso4 with effect. BP, HR and RR began trending down back to baseline. ? PE so pt rec'd duplex US of lower extremities to r/o DVT, await results. rec'd 40mg iv lasix with +diuresis.\\nPt conts on current cardiac regimen. HCT 32.7\\n\\nPULM: Mechanically ventilated via trach on ps 14 5 peep 505 fi02 with tv 700-900. ABG 7.35/49/97/28. Ls course throughout. Sxn'd via trach for yellow sputum. Trach site clean and intact.\\n\\nGI: Peg tube patent flushing w/o incidence. +BS Abd softly distended. Pt conts on bowel regimen with no stool this shift. TF at goal 65cc/hr.\\n\\nGU: Foley cath patent draining cyu in adequate amts s/p lasix dose. -952 since mn +1102 LOS.\\n\\nID: t max 100.0 orally. WBC 19.7. Conts on levo and oxacillin for coverage. + enterococcus in urine on . Sputum on with gram +cocci and gram neg rods.\\n\\nENDO: FS QID with reg insulin coverage. FS <200.\\n\\nSKIN: Blister on R heel, remains elevated off bed.\\n\\nLINES: R radial a-line placed today. R TLC cath flushing w/o incidence.\\n\\nDISPO: DNR\\n\\nSOCIAL: wife in to visit today. Sister in law phoned from .\\n\\nA: resp event this am ?etiology.\\n VS now stable.\\n TF at goal.\\n No change in neuro status.\\n\\nP: Cont current cardiac regimen. Follow for neuro changes.\\n Follow ABG's begin vent wean when indicated.\\n Provide support. Await picc line placement when less edematous.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332337,\n \"text\": \"CCU Nursing Progress Note 7a-7p:\\n\\nNeuro: Pt awake looking around the room and up at the tv. Pt with minimal tracking. No gag reflex and impaired cough reflex. Responding to commands ie opening eyes and sqeexzing left hand. Purposeful movement noted of LUE, moving LLE on bed. No spontaneous movement noted on the R side. HOB 30 degrees. Pt rec'd haldol 2mg IV with minimal effect.\\n\\nCV: Afib HR 80-100 w/o ectopy. Pt hypertensive throughout the day, Res aware. SBP 160-180's trending to 200 with nursing interventions. Hydralazine dose increased to 30mg po and lopressor dose increased to 125mg po, please follow effect. K+ 4.3 HCT 35.1\\nHead CT from neg.\\n\\nPULM: Mechanically ventilated on PS 8 5 peep 40% fi02. Spont tv 390-490. RR 20's trending into the 30's with sxning and turning. LS coarse throughout. Pt sxn'd q2 hr for thick yellow secretions in moderate amts at times requiring lavage. MDI's by RT. Secondary to no gag reflex pt to be consulted for a trach per team await team to discuss with pt's wife.\\nIf pt spikes team with aquire at CXR.\\n\\nGI: Abd soflty distended +BS + flatus. Pt reached goal of TF impact with fiber today 80cc/hr. Minimal residuals to 25cc.\\n\\nGU: Foley cath patent draining cyu in adequate amts. BUN 51 creat 1.4. +2455 LOS. Pt with 50cc/hr u/o. Urine with enteroccus.\\n\\nID: low grade temp to 100.9 Res. aware. WBC 13.2. No abx indicated at this time, follow temps.\\n\\nSKIN: R heel blister, multipodus boots in place.\\nButtocks redened w/o breakdown.\\n\\nENDO: FS QID <160 reg ss insulin for coverage.\\n\\nDISPO: Full Code\\n\\nSOCIAL: wife in to visit today.\\n\\nA: Improved neuro exam\\n resp status stable on current vent settings\\n hypertensive\\n Tolerating TF at goal\\n\\nP: Follow neuro assessment. Await effects of increased cardiac regimen. Follow resp status no changes in vent settings. ?trach. TF at goal. ?LBM. Provide support to pt and family.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332338,\n \"text\": \"Respiratory Care\\nPt remains and mechanically ventilated, please see carevue flowsheet for specific info, no vent changes made this shift,no ABG's, 02 sats stable. Suctioning thick yellow, plan to continue with mechanical support.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-31 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332402,\n \"text\": \"CCU NSG NOTE: ALT IN NEURO\\nO: For complete VS see CCU flow sheet.\\nID: Pt afebrile.\\nNEURO: Pt conts to have no movement seen on R side of body. He was very alert much of the day, making eye contact and intermittently, and occasionally following commands.\\nCV: Stable with hr 80-90s a-fib and bp better controlled in 125-160/60-80s. Pt lifted out of bed to chair for ~2.5 hrs.\\nRESP: Pt off the vent for over 48hrs now. He still requires suctioning ~Q3hr for lt yellow sputum. His cough is strong cough and he get much up on his own. Breath sounds are course.\\n GI: Pt had lg soft G- BM in am. He continues on replete with fiber from 4p until 8am at 120cc/hr.\\nGU: Pt voiding thru condom cath without problem.\\nELECTROLYTES: up to 145 today and D5W boluses decreased to 200cc Q6.\\nENDO: Blood sugars 162 st noon and 134 at 6p. Pt received 5u NPH at 6p\\nA: Decreasing secretion/off vent >48hr\\nP: ? transfer to neuro floor tomorrow. Monitor for change. Suction prn. Monitor for change.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332339,\n \"text\": \"SICU Nursing Progress Note\\nNeuro: Pt responsive to voice. Pt will open eyes and track for a short period. Pt will follow very simple commands inconsistantly. Pt able to move LUE freely, I have not observed any movement of other extremeties. Neuro checks q2 hours. Pt inconsistantly responds to painful sensation. Pupils PEARL. Pt has -gag reflex, and impaired cough reflex.\\n\\nCardiac: Pt in controlled AF in 80-90's. BP hypertensive in 180's-190's. MD notified and pt again placed on Labetolol gtt. Started at 2345, initially at 4mg/min, decreased to 2 mg/min. Where he remains currently. BP decreased to about 160's sys. Pt con't on large doses of cardiac meds, lopressor and hydralizine. BP dramaticaly improved with am lopressor and tylenol. BP currently 118/55.\\n\\nResp: Pt , ? trach at some point, (has not been discussed with wife...will need to be, MD's notified). Pt on CPAP .4%, . Tolerating well, ABG confirms. Pts BS are decreased. Pt has moderate amt of thick yellow sputum, needs lavage.\\n\\nGI: Pt has OGT, TF, impact with fiber tolerating well minimal residual, at goal of 80. Pts abd is soft and distended, +BS, -BM? how long?\\n\\nGU: Pt has f/c, with 50-100 cc/hr out. Amber in color and has slight sediment. Pt gets 100 cc of free H2O q8/hr. Lasix is being held. Pt has eneerococcus in urine.\\n\\nID: Tmax 101.8 pt pan cultured at 0400, pt given tylenol with good response. MD's wanted pt to have CXR with spike, MD notified and decided to have CXR in am.\\n\\nSkin: Pt has sheepskin boots on bilaterally placed for R heel blister, pneumo sleeves on. Pt turned q3/hr.\\n\\nEndo: Pt covered with R insulin for BG of 159.\\n\\nAccess: Pt has R SC TL, and R rad .\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332362,\n \"text\": \"Respiratory care:\\nPatient remains trached with a # 8 portex and mechanically vented. Vent checked and alarms functioning. Settings CPap/PS with IP 14\\npeep 5. Abluterol/Atrovent mdi given as ordered. Please see respiratory Section of carevue for further data.\\nPlan: Continue mechanical ventilation. Wean PS as tolerated.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332363,\n \"text\": \"CCU NSG PROGRESS NOTE-NSICU BORDER.\\nO:NEURO=REMAINS UNCHANGED. RESPONDS TO NOISE-TURNS HEAD TOWARDS, BUT DOES NOR ENGAGE W EYES.\\n PULM=TRACHED & VENTED. SETTINGS-CPAP/PRESSURE SUPPORT, FIO2 50%, STV 640-730, RR 12-20, PEEP 5, & PRESS SUPPORT 14. AM ABG-7.43/40/139/27/2\\nBREATH SOUNDS=COURSE THROUGHOUT. SX-THICK TANNISH SECRETIONS. TRACH CARE DONE.\\n CV=BORDERLINE HYPERTENSIVE DESPITE RX W HYDRALAZINE, LOPRESSOR, & NTP.\\n GI=TF-PROMOTE W FIBER @ 65ML/HR W MINIMAL RESIDUALS. WO BM.\\n GU=I&O -.9L @ 2300 & -.8L @ 0600.\\n ID=LOW GRADE T.\\n LABS=AM SENT. K REPLACED.\\nA:UNCHGED.\\nP:CONTIN PRESENT MED MANAGEMENT. ?PICC LINE. ?START EVALUATION FOR PLACEMENT.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332319,\n \"text\": \"CCU Nursing Progress Note 7p-7a:\\n\\nNeuro: Pt sedated on propofol gtt at 25mcg. Pt responding to sternal rub and nail bed pressure. Pt moving all extremities on bed. Pupils pinpoint, reactivity sluggish. No gag or cough reflex. Lightened sedation w/o change. Await results from CT scan.\\n\\nCV: Afib HR 70-80's w/o ectopy. Goal SBP <120. Weaned labetolol gtt to off with SBP <110. Am hydralazine iv held per parameters. Conts on lopressor 12.5mg . HCT 35.5.\\n\\nPULM: Mechanically ventilated on PS 5 last evening with RR in high 30's, tv 310-380 with pt diaphoretic. Team notified PS increased to 15 and within 5 min pt's RR down to the teens and tv increased to the 700's. Pt appeared more comfortable. Began PS wean this am currently at 13 7.5 peep 40% fi02 RR 13 and Tv 600. ABG 7.43/40/118/2.\\nPt sxn'd q2hr for small amts of thick yellow secretions.\\n\\nGI: Abd softly distended with hypoactive BS. OGT clamped. +bile in stomach. No stool this shift. Pt remains NPO on maintainence IVF for posible extubation.\\n\\nGU: Foley cath patent draining concentrated yellow urine in adequate amts 30cc/hr. +305 since mn +1128 LOS.\\n\\nSKIN: intact\\n\\nENDO: FS 189 and 134. Reg insulin ss for coverage.\\n\\nPROPH: Pneumoboots and protonix.\\n\\nLINES: L radial a-line and PIV.\\n\\nDISPO: Full Code\\n\\nSOCIAL: No phone calls this shift.\\n\\nA: stable BP off labetalol gtt\\n neuro status stable\\n requiring increased PS.\\n\\nP: Maintain SBP <120.\\n Follow Afib. Wean PS as tolerated.\\n NPO. Follow u/o.\\n Neuro checks q1hr.\\n FS QID. Provide support to family.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332320,\n \"text\": \"Respiratory Care note: Pt is on CPAP 7.5. PSV decreased from 13 to 11. Tidal Volumes= 500-650ml. RR= 17. Spo2= 97% on an Fio2= .40. When ETT was placed at 20cm at lip, there was an enormous air leak that would not go away with the administration of air to the cuff. As a result, we had to advance the ETT to a level that below the vocal cords. Currently the ETT is placed at 26 cm. A CXR has beendered to check tube placement. Suctioned pt after repositioning for a large amount of thick, yellow sputum.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332321,\n \"text\": \"N SICU NPN\\nNEURO: PROPOFOL D/C 09:00, PT RESPONSIVE TO NOXIOUS STIMULI. OPENS EYES, OCC SPONTANEOUSLY HOWEVER DOES NOT TRACK. PUPILS 2MM AND SLUGGISH. MOVING L SIDE OCCASIONALLY, VERY SLIGHT MOVEMENT OF R HAND AND FOOT NOTED THIS AM. + COUGH GAG ABSENT.\\n\\nCV: HEMODYNAMICALLY STABLE IN A FIB 80-90'S, BP 110-160/50-70.\\n\\nRESP: PS DECREASED TO 11, TV 400-500.RR 14-20. APPEARS VERY COMFORTABLE. SECRETIONS BECAME COPIOUS THIS AFTERNOON, THICK, TAN. SPECIMENT SENT FOR CULTRE. LG AMTS ORAL SECRETIONS. LESS PAST 2 HRS. ETT REPOSITIONED BY SICU RESIDENT. PLACEMENT CONFIRMED BY X RAY.\\n\\nGI: IMPACT W/ FIBER STARTED AT 16:00 AT 10CC/HR. NO STOOL THS SHIFT.\\n\\nGU: U/O 15-25CC/HR, CURRENTLY ~ 800CC +. CURRENTLY BEING GIVEN 500CC NS BOLUS.\\n\\nID: TM 100.2 R.\\n\\nSOCIAL: WIFE, BROTHER AND SISTER IN LAW IN ALL AFTERNOON, UPDATED BY MD.\\n\\nA: NEURO STATUS UNCHANGED, HEMODYNAMICALLY STABLE OFF LABATELOL, TOLERATING DECREASED PS.\\n\\nP: MONITOR NEURO STATUS, KEEP SBP > 120, FOLLOW U/O, ? SWAN.\\nEMOTIONAL SUPPORT TO FAMILY.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332322,\n \"text\": \"NPN ADDENDUM\\nBP ^ 190'S/ STARTED ON NTG GTT AT 40 MCG/MIN AT 18:00,INCREASED TO 60 MCG/MIN. ALSO LOPRESSOR ^ TO 25MG , AND DOSE GIVEN AT 18:00.\\nCURRENTLY HR 108 A FIB, BP 140/73.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2148-01-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332403,\n \"text\": \"CCU NSG PROGRESS NOTE-NSICU BORDER.\\nO:NEURO=RESPONSIVE. APPROPRIATE TO SIMPLE QUESTIONS-\\\"ARE YOU OK?\\\"- SHAKES HEAD NO & SAYS \\\"HELP\\\". CONTIN TO MOVE LUE PURPOSEFULLY-TAKING TRACH MASK OFF, PLAYING W COMDOM CATH, & SCRATHCHING NOSE. WO MOVEMENT OF R EXTREM.\\n PULM=TRACH MASK-50% W ADEQ SATS. SX-THICK WHITEISH SECRETIONS. BREATH SOUNDS=COURSE THROUGHOUT.\\n GI=TF @ GOAL. WO STOOL.\\n GU=CONDOM CATH. GD RESPONSE TO LASIX.\\n LABS=AM SENT. EXTREMELY DIFFICULT STICK-POOR ACCESS.\\nA:SLOWLY IMPROVING NEURO STATUS.\\nP:CONTIN PRESENT MED MANAGEMENT. ?CALL-OUT.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2148-01-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332404,\n \"text\": \"ccu nursing progress note\\nremains on trach mask\\nO: see flowsheet for objective data. VSS with BP good on current meds.\\nremains in afib without vea. resp: remains on .5 trach mask with good sats. requiring suctioning q2-3hr for thick yellow/white secretions with occassional plugs. lungs coarse. afebrile. u/o qs via condom cath. cont tube feeds at goal rate, no BM today. PEG site d/i, PICC site D/I , coccyx reddened, duoderm intact. pt. oob-chair with 4 assists for 2 hours, tolerated well. neuro: pt. alert at times, following simple commands inconsistently, moving LUE purposefully, moving LLE on bed, right side remains flacid. wife called x 2, updated on condition. turned q2hr.\\nA: stable, cont with secretions\\nP: cont pulm toilet, follow neuro status, cont supportive care. ?Placement on per resident to \\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2148-01-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332405,\n \"text\": \"CCU NSG PROGRESS NOTE-NSICU BORDER.\\nO:NEURO=UNCHGED.\\n PULM=THICK SECRETIONS. SX FREQ.\\n LABS=UNABLE TO OBTAIN. PICC LINE DOES NOT DRAW BACK.\\nA:UNCHGED.\\nP:CONTIN PRESENT MED MANAGEMENT. ?TRANSFER TO REHAB.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2148-01-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332406,\n \"text\": \"RESPIRATORY CARE:\\nPATIENT FOLLOWED FOR ALBUTEROL/ATROVENT NEBS. TREATED X1 THIS SHIFT. TOLERATED WELL. BS COARSE.\\nWILL CONTINUE TO FOLLOW. PATIENT WITH 50% COOL AEROSOL ON.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2148-01-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332407,\n \"text\": \"ccu nursing progress note\\nS' remains trached\\nO: see flowsheet for objective data. VSS on current meds. cont on .5 trach mask with good sats, suctioned frequently for thick white secretions, lungs remain coarse with upper airway exp. wheezing, cont nebs per RT, afebrile, GI: tube feeds restarted at goal rate at 4pm, BS+, no BM today, GU: voiding via condom cath, neuro: more alert his am, at times following commands but not consistently, moving LUE purposefully, moving LLE in bed, right side remains flacid. sent for head CT this am, pnd RUE remains edemetous, elevated on pillow. turned q2hr, skin intact. PICC line cont, able to flush but not draw blood, pt. extremely difficult to stick for bloods.\\nA: stable\\nP: to be eval for tx to , cont to follow neuro status, cont pulm toilet\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2148-01-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332408,\n \"text\": \"Resp Care\\nadmin albuterol/atrovent 4 puffs each q4h via trach/. sxning sm amts clear to white secretions. good cough. cuff deflated. occas.audible wheezing ?from tracheal irritation vs.bronchospasm.\\nremains on 50% trach collar in nard.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2148-01-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332409,\n \"text\": \"CCU progress note\\nNEURO: no changes noted. PERLA 2mm reactive. no movement R side. +sensation. purposful movements L side. pt sleeping most of nite. not obeying verbal or gestured commands tonite.\\n\\nCARDIAC: AFIB 90s. SBP stable.\\n\\nRESP: remains on Trach collar 50%. suctioned for small amts thin white secretions. no resp distress. RR 6-40s varying, sats >98%.\\n\\nGI/GU: voiding in condom cath. incontinent x 1 large amt urine when condom fell off. abd soft. +BS. Large soft formed BM tonite. TF overnite via peg.\\n\\nPLAN: ?rehab placement. cont' to monitor neuro and VS.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2148-01-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332410,\n \"text\": \"Respir. Care Note\\nFollowed overnight with q 4 Albuterol/Atrovent MDIs via trach. Breath sounds are coarse bilaterally, suctioned for thick white/tan secretions. O2 sat 97-99% on 50% trach mask.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2148-01-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332411,\n \"text\": \"Resp care\\nc/w 40% trch collar/cuff deflated. excellant cough. prod sm amts green sputum. less wheezing today. mdi's changed to prn. awaiting transfer to rehab facility.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2148-01-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332412,\n \"text\": \"N SICU NPN\\nNEURO: NO MOVEMENT R SIDE. MOVING L SIDE IN PURPOSEFUL MANNER. FOLLOWING COMMANDS INCONSISTENTLY. OCCASIONALLY WILL SPEAK WORD OR TWO, ANSWERING SIMPLE QUESTIONS.\\nCV: HEMODYNAMICALLY STABLE\\nRESP: DOING WELL ON TRACH MASK AT 50%.W/ CUFF DOWN. SEEN BY SPEECH AND FITTED W/ PASSEY MUIR VALVE. (DO NOT HAVE ON WHILE PT IS COUGH PRODUCTIVE FOR THICK YEL SPUTUM, NEB RX HAVE BEEN CHANGED TO PRN.\\nGI: TOLERATING TF. NO STOOL TODAY\\nGU: CONDOM CATH DRAINING CL YEL URINE QS.\\nID: AFEBRILE\\nEND: BS 179 AT 6PM.\\nACTIVITY: SEEN BY PT TODAY. OOB TO CHAIR, SAT ON EDGE OF CHAIR BALANCING W/ L HAND, ATTEMPTED TO STAND.\\nDISPO: PT HAS BED AT OLYMPUS/ FOR , AT 9AM.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332387,\n \"text\": \"Respiratory care:\\nPt. remained on vent overnight. SPO2 high 90's to 100%, with RR generally mid teens. B/S course>>ETS for moderate amounts of thick, tan/yellow. MDI's given for induced bronchospasm with good effect. Will continue pulmonary hygiene and TM trials in a.m.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332388,\n \"text\": \"NEURO: AWAKE & ALERT. FOCUSES BUT DOES NOT TRACK. PERL. FOLLOWS SIMPLE\\n COMMANDS, BUT NOT CONSISTENTLY. NO MOVEMENT ON R. SIDE. L. ARM\\n LIFTS & HOLDS OFF BED. L. LEG LIFTS & FALLS. DOES NOT ATTEMPT\\n TO COMMUNICATE.\\nRESP: TRACHED & ON VENT: 50% 14 IPS 5 PEEP. BS COARSE THROUGHOUT, &\\n SLIGHTLY DIMINISHED AT BASES. RR 8-15. O2 SATS 98-100%. SX FOR\\n SM.-MOD. AMTS. THICK YELLOW-TAN SECRETIONS. ONE EPISODE EARLY\\n IN SHIFT WHEN BECAME TACHYPNEIC TO RR 40-50. AMBUED & SUCTIONED\\n & SEDATED WITH VERSED 1MG VP WITH GOOD EFFECT.\\nCARDIAC: HR 87-109 AF, NO ECTOPICS. BP 111-139/42-70. CONT. ON NTP,\\n LOPRESSOR, & IV HYDRALAZINE.\\nGI: TF:FS PROMOTE WITH FIBER AT 65CC/HR. ABD. SL. DISTENDED. BS+. NO\\n STOOL. RECEIVING FREE H2O 300CC Q4HRS FOR ELEVATED NA 160.\\nGU: FOLEY->CD PATENT & DRAINING CLEAR YELLOW URINE. U/O 60-235CC/HR.\\nID: T 99.8->100.1(PO). CONT. ON IV LEVOFLOX.\\nENDO: BS 173->166. RECEIVED REG. HUMALIN INSULIN 2U SC X2 PER SLIDING\\n SCALE.\\nLABS: WBC 12.8, HCT 33.6, PLAT CT 198K, NA 156, K 3.9, BUN/CREAT 44/\\n 1.1, CA 8.3, MG 2.3, & PO4 2.5.\\nAWAITING REHAB!!!!!!!\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332389,\n \"text\": \"CCU progress note 7a-7p\\nNEURO: unchanged. inconsistently obeying verbal + gestured commands. pt brushed teeth today and washed face w/ encouragement. pt helped to place glasses on face. pt occasionally doing arm curls w/ 1lb weight. Moves L side well. No movement to R side. +sensation to all extremieites. pupils 2mm brisk. started on serax 10mg TID. ?start antidepressant? ?increase serax if not noted to have good effect on anxiety levels.\\n\\nCARDIAC: no change in hypertensive meds. BP 120-180 today. AFIB 80-100s.\\n\\nRESP: attempted to trach collar today, but pt became stridorous and agitated today. placed back on PS 12/ peep 5 w/ good effect. has had episodes of tachypnea on vent this afternoon. settled on own. sats remains >97%. Sx small amts yellow thin secretions.\\n\\nGI/GU: foley patent. good u/o. on lasix 20mg . On free water 300cc Q6h. TF increased to 80cc/hr GR. PEG intact to abd.\\n\\nSKIN: duoderm changed to coccyx, stage II ulcerated area to R buttock, new duoderm applied. Ordered first step air mattress. heels intact. old blister to R heel healing well. multipodus boots on. peg site looks healthy, dsg changed today. trach site slightly reddened, cleansed w/ H2O2.\\n\\nPLAN: con't to monitor VS and neuro status. keep pt comfortable. Awaiting PLACEMENT TO REHAB.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332315,\n \"text\": \"addendum to day note\\npt's breathing appears more labored than this am. rr is 28 but much more abd breathing irregular. stroke team in to assess.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332316,\n \"text\": \"Patient went to CT Scan today plan to extubate aborted on PSV 5/7.5 with spy VT 500. Large IPH not improved from previous film.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332317,\n \"text\": \"CCU NSG NOTE: THALMIC BLEED\\nO: For complete VS see CCU flow sheet.\\nID: T-max 100.6.\\nNEURO: Pt remains minimally responsive. With sternal rub some movement of L arm seen. Early in shiftmoving left arm pulling against restaint. Some movements of L leg also seen. R sid showed some minimal ?flexor activity. Pupil small and minmimally reactive. When oral suctioning done no gag observed. Pt has tachypnic abnormal breathing pattern with rr 22-30.\\nCV: Pt has remained on 2mg/min labetalol with bp varying between 1-teens to 140/50-60. He is also received lopressor 12.5 and hydralazine 10mg IV Q6.\\nRESP: Pt remains on c-pap 40%, 7.5 PEEP and 5 PS with last gas on that setting 7.39/ 46/ 108/ 29. He has very decreased breath sounds. He is useing accesory muscles to breath and even with sedation appears to be working hard at breathing. He does have history of COPD, though does not seem to have used inhalors. He requires suctioning ~Q2hr for thick lt yellow secretions. One lg plug was aspirated.\\nGU: Urine output remains poor, between 12-35cc/hr. He received 40mg ng lasix at 8pm with minimal response. He is presently 2500+ cc pos for the day. HO notified about poor output. He had received 250NS bolus earlier today with minimal response. Creatinine up to 1.4 today from 1.0 yesterday.\\nGI: Pt has OG tube. He has small amt green G+ bile in stomach. Bowels sounds are very decreased. No BM.\\nSEDATION: Pt restless early in shift with swings in blood pressure. Propofol increased from 20mic/kilo to 25mic/kilo with pt appearing more comfortable with less aggitated movements.\\nENDO: FS at 6p was 159 and pt received ss reg insulin per order.\\nFAMILY: Family in to visit. They remains appopriately concerned.\\nA: Minimally responsive/poor urine output/bizaare resp pattern\\nP: Monitor I & O closely. Wean labetalol as tolerated. Monitor for change in MS.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332318,\n \"text\": \"Respiratory Care:\\nPt. with a very dysynchronous respiratory pattern (gasping inspiration with forced expiration), and VT's decreasing with RR increased to mid 30's. Obtained PS order to titrate for VT 450-550cc. Increased to 15 to finally capture, then slowly weaned through the course of the shift. Unable to make larger decreases due to Pt. reverting back into above respiratory pattern. ABG's throughout have remained well oxygenated with a slight resp. alkalosis. Will continue support as needed.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332382,\n \"text\": \"NPN\\n7 PM - 7 AM\\nS/O\\nPLS SEE CAREVIEW FLOWSHEET FOR ALL OBJ/NUMERICAL DATA\\nCV HEMODYN STABLE .....\\nRESP ON 50% TRACH MASK THROUGHOUT THE NITE...LUNGS COARSE ...RR 36-44...ABLE TO COUGH THIN CREAMY YELLOW SXNS INTO TRACH COLLAR ...AND SXD'D Q3 ...\\nGI ON TF VIA G-TUBE ON PROMOTE AT 65 CC/HR ..INC SMALL AMOUNT OF SOFT STOOL\\nGU U/O GD\\nNEURO GIVEN VERSED 1 MG Q4 ...DURING THE NITE ..BUT PT AWAKE ALL NITE\\nA STABLE\\nP CONTINUE TO ASSESS NUERO STATUS CLOSELY\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332383,\n \"text\": \"CCU progress note 7a-7p\\nNEURO: Pt very tired today, to recieve ?serax or ativan for sleep tonite (pt did not sleep at all last nite). Slept in short naps today. Obeyed gestured commands. Will shake/hold hand when you indicated for him to reach and hold it. Pt attempted to brush his teeth and use electric today (still weak). Pt holds washcloth and lightly washed L side of face. Pt helped to place glasses on face. Pt sometimes nods to actions. Will look at people and activities outside room, does not always track. Seems withdrawn at times ?angry/depressed? Continues to lift and move L arm and leg. No movement to R side. R side neglect, no vision noted on R side. +sensation to R side.\\n\\nCARDIAC: AFIB 90-110s. SBP 130-170s today. On hydralazine 50mg IV q6h, Lopressor 150mg TID, Norvasc 10mg, NTP 2inches q6h, clonodine 0.3mg . s/c Heparin and pneumoboots.\\n\\nID: Tmax 100.6 PO, 101.5 rectal today. PAN CULTURED BCx1, sputum + urine cx sent. CXR obtained. Tylenol given x 1. Started on LEVOFLOXACIN IV qd.\\n\\nRESP: LS coarse. Remains on Trach collar 50% humidified. Pt has productive cough for thick tan sputum. CX sent. trach suctioned for mod amts secretions also. RR ranges from 14 to 40s, but sats maintained >96% at all times, even when pt occasionally moved trach mask off trach, RA sats >96%. No decrease in sats noted w/ suctioning either.\\n\\nGI/GU: foley patent, good amts urine. remains on LASIX 20mg PO BID. abd soft, +BS. had large formed BM this afternoon. TF promote w/ fibre at goal rate @ 65cc/hr. PEG intact to abd.\\n\\nSKIN: duoderm intact to coccyx. duoderm placed on shin area on R leg (some skin breakdown noted ?from pneumoboots). R heel blister healed, both heels remain elevated off bed. placed in multipodus boots occasionally - rotating schedule.\\n\\n\\nPLAN: cont' to monitor neuro signs. attempt to give gestured commands as pt may not be able to understand language d/t stroke. give sleep medication tonite. suction q3-4h and prn. pt is in the process of being rescreened by rehab today (pt improved - is off ventilator and is able to follow gestured commands and perform some small ADLs).\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332384,\n \"text\": \"Respiratory Care:\\nPt. had been TM trial for >24hours. Increasing RR with severe bronchospasm>>attempted MDI's with limited success, but Pt. responded well to manual ventilation. Pt. then placed back on the vent with IPS=14 cmH20, 5 peep, and FIO2 of 50%. Pt. immediately had decrease bronchospasm, decreased RR, and VT's up to 850cc. Will continue on PS vent for the remainder of the shift, then attempt to TM trial again in the a.m.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332385,\n \"text\": \"CCU NSG PROGRESS NOTE 7P-7A/ S/P THALMIC BLEED\\n\\nS- TRACHED, NOT VERBAL\\n\\n0 SEE FLOWSHEET FOR OBJECTIVE DATA.\\n\\n PT REMAINS HEMODYNAMICALLY UNCHANGED.\\nHR- 90-100'S AF. BP-115/- 160/\\nREMAINS ON LOPRESSOR/NTP/CLONIDINE/HYDRALAZINE.\\n\\n PT ON TRACH MASK- 50%, TOLERATED WELL UNITL 2:30 AM- MUCH I/E WHEEZE, REPS DISTRESS, WITH RATE 40'S. COMFORTED BY BAGGING, BUT NOT IMPROVED AFTER INHALERS. SWITCHED OVER TO 14 PRESSURE SUPPORT AND CURRENTLY GOOD SATS AND APPEARING STABLE/COMFORTABLE.\\n\\nID- AFEBRILE- TO LOW GRADE.\\n\\nGI- REMAINS ON TUBE FEEDS- 65 CC/HOUR- (+) BOWEL SOUNDS- NO STOOL THIS SHIFT- ABD SOFT/DISTENDED.\\n\\nGU- FAIR UO- 50-80/HOUR.\\nNO ISSUES.\\n\\n PT AWAKE AND ALERT- NOT CONSISTENTLY OBEYING COMMANDS OR WITH PURPOSEFUL ACTIONS.\\nSEE FLOWSHEET.\\n\\nA/ PT S/P LARGE HEAD BLEED/RESP FX- ON/OFF TRACH MASK- DEVELOPING SOME RESP DISTRESS AND NEEDING PRESSURE SUPPORT AGAIN.\\n\\nCONTINUE TO CLOSELY FOLLOW RESP STATUS AND MAINTAIN AIRWAY- SUCTIONING/NEBS.\\nCONSIDER ADDITION OF STEROID NEB PER RT.\\nCONTINUE TO CONTROL RPP WITH CV MEDS, AND OBSERVE FOR ANY IMPROVEMENT OF NEURO STATUS.\\nCONTINUE SCREENING PROCESS FOR REHAB/LONG TERM FACILITY.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332386,\n \"text\": \"CCU progress note 7a-7p\\nNEURO: neuro's unchanged. purposful movement of L arm and leg. looks at subjects, occasionally tracks. does not obey verbal commands. will occasionally obey gestured commands. pt very tired today, not really interacting much. did attempt to brush teeth with alot of encouragement.\\n\\nCARDIAC: SBP 110-150s. remains on same BP meds. given MSO4 this afternoon w/ decrease in BP to 90s, noon BP meds held. resumed this evening.\\n\\nRESP: LS coarse, sx creamy tan secretions. small amts. Pt kept having episodes of tachypnea 40-60s this morning after being taken off vent to trach collar. sats remained 100%. Attempted to sedate w/ 2mg MSO4 per HO, w/ no effect. Placed back on PS 14/ Peep 5 50%, RR 6-40s w/ episodes of 20-30sec periods of apnea. TV 600-1000cc. sats 100%.\\n\\nID: Tmax 100.2. remains on LEVO IV.\\n\\nGI/GU: foley patent, good u/o. remains on lasix 20mg po. abd soft. +BS. had large soft formed BM this afternoon. On free water boluses 300cc QID. TF promote w/ fibre @ 65cc/hr. PEG intact.\\n\\nPLAN: con't to monitor neuro and resp status. monitor vs. keep pt comfortable.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332313,\n \"text\": \"CCU NSG PROGRESS NOTE 7P-7A/ S/P THALMIC BLEED.\\n\\nS- , SEDATED, NONRESPONSIVE.\\n\\nO- SEE FLOWSHEET FOR OBJECTIVE DATA.\\n\\nCV- VS REMAIN STABLE- BP LABILE ACCORDING TO AGITATION/SEDATION LEVEL.\\nMOSTLY B/T 100/50- 150/70.\\nGOAL- SPB- 120-140/. CURRENTLY OFF 1 LABETELOL GTT FOR BP <110.\\nTOLERATING HYDRALAZINE 10 QID AND LOW DOSE LOPRESSOR PO.\\nREMAINS OFF NIPRIDE GTT.\\n\\nRESP- REMAINS FOR AIRWAY PROTECTION- 40% WITH 15 PS AND 7.5 PEEP. TV- 800'S,.ABG EXCELLENT.\\nPLAN TO EXTUBATE THIS AM.\\nNPO EXCEPT FOR MEDS.\\nRR- .\\nMIN SECRETIONS.\\n\\nID- AFEBRILE.\\n\\nGU- FAIR UO- 20-60/HOUR- RESUMED ON LASIX PO.\\nI/O CLOSE TO EVEN AS OF 12 AM.\\n\\nGI- OGT IN PLACE - NPO FOR POSSIBLE EXTUBATION.\\nMINIMAL ASPIRATES. NO STOOL.\\n\\nHEME- S/P VIT K AND 6 U FFP ON ADMIT- AWAIT REPEAT COAGS.\\n\\nMS/NEURO- NO CHANGE IN NEURO VS- REQUIRING PROPOFOL GTT TO REMAIN SAFELY AND VENTILATED.\\nSEE FLOWSHEET FOR DETAIL.\\nPROPOFOL GTT REMAINS AT 10-30 MCG, WITH NEEDS FOR BOLUS WITH AGITATION EPISODES AND REACHING FOR ETT.\\n\\nA/ PT ADMITTED TO CCU FOR NEURO EVENT/BLEED.\\nCURRENTLY STATUS QUO ON CURRENT CV MEDS ON VENTILATORY SUPPORT WITH NO CHANGE IN NEURO VS OR EVIDENCE OF WORSENED BLEED.\\n\\nCONTINUE TO CLOSELY MONITOR, CALL NEURO WITH ANY CHANGE IN SIGNS FOR EMERGENT REPEAT CT SCAN/POSSIBLE INTERVENTION.\\nAWAIT COAGS- REPEAT VIT K AND FFP AS NEEDED/ORDERED.\\nKEEP BP WITHIN GOAL RANGE OF 120-140.\\nKEEP FAMILY AWARE OF PLAN OF CARE AND PROGRESS.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332331,\n \"text\": \"NURSING PROGRESS NOTE 7P-7A\\nS: \\n\\nO: NEURO: DOES NOT RESPOND TO COMMANDS. WILL OCC OPEN EYES TO STIMULI. NO PURPOSEFUL MOVEMENT. PUPILS 2MM BILAT, SLUGGISH TO REACT. DOES NOT MOVE RIGHT SIDE. ABLE TO PICK UP LEFT ARM, FALLS TO BED. MOVES LEFT LEG ON BED. UNABLE TO GRASP HANDS.\\n\\nCV: HR 80'S A-FIB NO VEA NOTED. BP STABLE ON LABETOLOL GTT. BP RANGE 120-140'S. RECEIVING HYDRALAZINE IV.\\n\\nRESP: VENTED. SUCTIONING FOR MIN WHITE, THIN SECRETIONS. VENT SETTINGS OVERNIGHT FIO2 40%, PEEP 5, PS 5 CPAP. BECOMING TACHYPNEIC EARLIER THIS AM. RESTED FOR 2 HRS ON IMV. NOW BACK ON ORIGINAL SETTINGS. RR NOW 37 LABORED BREATHING. ABG'S SDEQUATE. LUNGS COARSE IN BASES.\\n\\nGU: FOLEY DRAINING AMBER COLORED URINE 30-50 CC/HR. IV FLUIDS AT KVO. RECEIVING FREE WATER BOLUS Q 8 HRS.\\n\\nGI; NO BM. BOWEL SOUNDS PRESENT, ABD SOFT, DISTENDED. TOL. TF WELL WITH MIN RESIDUAL. RECEIVING PROMOTE W/ FIBER. RATE 30 CC/HR.(GOAL 80 CC/HR)\\n\\nSKIN INTACT. 2 PIV'S PATENT.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332332,\n \"text\": \"Continue to wean patient on psv5/5-40% . Patient occasionally went into rapid RR , rested for 1 hr on A/C to slow down rythm. ABG 7.45-41.115-29- 4-98% sputum induced for lab will continue to follow\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332333,\n \"text\": \"resp care\\n\\npt remains and mech ventilated. ps 8 peep 5 fio2 40%. ps ^ to 8 to maintain vt 500-600 w/good effect. rr ess 20's occ teens. b/s coarse. sxn thk wh. mdi's given x3. current abg 7.40/42/131/27. pt tx w/o incident to ct scan. pt ambu 100% o2 to/from. plan: cont w/mech support. wean ps as tolerated.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332334,\n \"text\": \"CCU progress note 7a-7p\\nNEURO: pt was obtunded this morning, not responding to stimuli except for suctioning ETT. Pupils remained 2mm sluggish. no movement R side. lifts/falls on L arm, no random squeezing of L hand noted, slight movement/withdraw from pain L foot. Repeat CT scan done this afternoon, no changes or new bleed noted. Pt noted to be 'waking' up this evening, opening eyes at times to tactile stimuli and having increased RR. Noting to hold siderail w/ L hand. given 30mg (3cc) of Propofol for light sedation during central line insertion this evening.\\n\\nCARDIAC: AFIB 90s. Labetolol gtt d/c'd this morning. Lopressor 100mg restarted at TID dosing. remains on Hydralazine 20mg QID. SBP 120-150s today. generalized +edema.\\n\\nRESP: remains on PS today. increased RR this morning w/ TV 300-400s. Increased PS to 8 w/ noted decrease to 18-20 RR, and TV 600s. Sats >97%. good abgs. Sx small amts yellow/tan secretions. CPT given with turns. sputum spec sent early this am.\\n\\nID: TMAX 99.8 po. no abx. remains diaphoretic all day.\\n\\nGI/GU: foley had decreased u/o this morning. given IVF x 6hrs today and increased TF to 60cc/hr Promote w/ fibre. Noted increase to ~30cc/hr urine. Abd +BS, distended soft. OGT patent. NO BM. no stools since admission. pt may need bowel regimin!!\\n\\nSKIN: mulipodus boots ordered for pt. L heel has blister on outer heel. otherwise skin intact.\\n\\nACCESS: R s/c TLC placed this evening. both peripheral IVs intersticial and d/c'd.\\n\\nPLAN: con't to monitor Neuro status. need bowel meds ordered in am. monitor temp (BC for temp >102). keep L heel elevated. place mulitpodus boots on pt when they arrive on floor (ordered). awaiting CXR and confirmation of placement of R s/c TLC.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332314,\n \"text\": \"NURSING PROGRESS NOTE 0700-1500\\nNEURO---PT LIGHTLY SEDATED ON PROPOFOL AT 20 MCG/KG/MIN. WHEN GTT TURNED OFF TO ASSESS NEURO STATUS, PT DOES NOT FOLLOW COMMANDS. PUPILS AT 1MM AND REACT SLOWLY. R ARM NO MOVEMENT. R LEG WITHDRAWS TO NOXIOUS STIMULI BUT ? WHETHER THIS IS REFLEXIVE PER NEURO. L ARM WILL HAVE SOME PURPOSEFUL MOVEMENT AND ATTEMPT TO PULL ETT OUT. NO FINE MOTOR MOVEMENT OBSERVED IN EITHER UPPER EXT. L LEG WILL FLEX AND WITHDRAW TO NOXIOUS STIMULI. DOWN FOR CT OF HEAD WITHOUT CONTRAST AT 1200. RESULTS PENDING.\\n\\nCARDIAC--HTN AND RESTARTED ON LABETALOL GTT AT 2MG. PT BECOMES AGITATED WITH NON-PURPOSEFUL FLAILING OF LUE AND LLE. ON IVF AT 50 CC HR. IN A-FIB AT 80'S . OCCASIONAL UNIFOCAL PVC'S.\\n\\nRESP--BREATHING APPEARS LABORED WHEN PT IS LIGHT. RR INCREASES TO 38-44 WHEN LIGHT. SAO2 98%. ABG'S OK ON 5PEEP AND 7.5 IPS. PLAN IS TO WEAN TO EXTUBATE. IT IS UNCLEAR IF PT WILL BE ABLE TO PROTECT AIRWAY AS HE HAS A WEAK GAG AND WEAK COUGH.\\n\\nGI--NGT TO LCS DRAINING BILIOUS DRAINAGE. NO STOOL.\\n\\nGU--FOLEY CATH PATENT DRAINING CONCENTRATED URINE IN ~30 CC HR.\\n\\nENDO--UNREMARKABLE AT PRESENT.\\n\\nSKIN-- BUTTOCKS INTACT WITHOUT BREAKDOWN. SMALL RASH IN R GROIN.\\n\\nA--HTN NEEDING INCREASE IN LABETOLOL.\\n\\nP--PLAN TO EXTUBATE. CON'T Q1HR NEURO CHECKS. ? ANTIHTN THERAPY.\\n\\nLINES--PT HAS 2 PERIPHERAL IV'S.\\n\\n AND WIFE FLEW IN FROM CALIF TODAY. WIFE IS .\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332375,\n \"text\": \"NPN\\n11 PM - 7 AM\\nS/P LARGE THALMIC BLD\\nS/O\\nPLS SEE CAREVIEW FLOWSHEET FOR ALL OBJ/NUMERICAL DATA\\nCV HR 90-100'S..AFIB....SBP LABILE 190'S-80'S/40-80'S....DROPPING SBP TO THE 80'S...AFTER .3 MG OF CLONIDINE ...SLOW HYDRALAZINE INFUSION STOPPED ...NTP WIPED OFF ...ABLE TO TOLERATE 150 MG OF PO LOPRESSOR ...\\nRESP CONTINUES ON CPAP AND PS OF 15..5 PEEP...50%...TV 700...FREQUENT EPISODES OF TACHYPNEA WITH RATES IN THE 40'S..TV 190-260 ..SUCTIONED Q3 FOR SMALL AMOUNT OF THICK YELLOW SPUTUM..MINIMAL ORAL SXNS....LUNGS COARSE ....RESPONDING TO 2 MG OF IV VERSED ..\\n\\nGI ON PROMOTE WITH FIBER ..AT 65 CC/HR ..SMALL AMOUNT OF SOFT STOOL ...OB NEG...\\n\\nGU U/O GD\\n\\nTURNED Q3...RIGHT ARM ELEVATED ON PILLOWS ..\\n\\nACCESS...DOUBLE LUMEN PIC LINE FLUSHED WITH HEPARIN AND SALINE ..BUT UNABLE TO OBTAIN AM LABS ...NO PERIPHERAL ACCESS ...\\n\\nNEURO..SLEEPY,..INTER OPENS EYES TO VOICE ...LEFT GAZE ...RIGHT HEMIPLEGIA ..OCCAS DRAWS UP LEFT LEG ...SQUEEZING LEFT HAND BUT NOT TO COMMAND ...\\n\\nA LABILE BP/RESP STATUS\\n\\nP CAUTION WITH CARDIAC DRUGS ...? OVER DIURESIS ...? ALINE\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332376,\n \"text\": \"CCU progress note : 7a-7p\\nEVENTS OF DAY:: NEURO CHANGEs NOTED!!! PT OFF VENTILATOR, on TRACH collar 50% w/ good sats.\\n\\n\\nNEURO: Pt had episode of agitation this morning, ^BP^HR^RR 40s, NEURO team in to assess at this time ?neuro agitation or ?agitation d/t ventilator. Attempt bagging which pt relaxed with, then post would go back to ^RR again. tried pt off vent on trach collar and pt settled. kept off ventilator. No further episodes of ?neuro agitation noted. PERLA 2mm brisk. alert most of time, occasionally rests/sleeps in naps. Tracks and looks at people, to voice and movements outside room. occasionally looks at TV. Sometimes nods head to questions. inconsisently obeys simple gestured/voiced commands to take objects or wash face w/ washcloth. if you hold out your hand to shake, he will lift his hand and hold your hand. if you show him something interesting to him , he will take it from your hand and hold it properly (keys, comb, toothbrush, washcloth), and will give it back to you if you hold out your hand and ask for it. Wife assisted pt to place eyeglasses on face. NEURO team and NSICU team notified of changes. Wife in this afternoon and aware of changes.\\nPt still moves only L limbs, but no movement on R side, +sensation to R, noting some reflexive movements on R leg to painful stimuli. nothing to R arm. R side neglect, R vision defecit. +gag +cough.\\n\\nCARDIAC: AF 100-110s, SBP 120-170s today. On Hydralazine 50mg IV q6h, NTP 2\\\" CW Q6H, Lopressor 150mg TID ngt, Norvasc 10mg qd. generalized edema +, 3+edema to R arm.\\n\\nRESP: pt had episode of TACHYPNEA 40s, on vent settings early this morning 15 PS/ 5 Peep. Sats remained 100% the whole time. attempted changing PS settings from PS 15 to higher w/ no results, when 'd pt RR went to 12 w/ periods of apnea and seemed to sleep, then after 'ing pt woke and went back to rapid RR 40s again. attempted to take off vent, room air, sats remained 100% with some decrease in RR. placed on Trach collar w/ cuff down, 50% FIO2 w/ decrease in RR to 14-30s the rest of the day. No extreme agitation noted. having neuro respiratory periods, some occasional apnea noted w/ some 'panting' to normal breathing cycled. Sx'd trach for small amts tan secretions. pt has PRODUCTIVE cough. LS coarse bilat. MDI/neb treaments per RESP.\\n\\nGI/GU: abd soft, distended. no BM, last BM last nite. TF promote w/ fibre. minimal residuals. PEG tube intact. FOLEY patent good amts urine. Lasix decreased to 20mg po.\\n\\nSKIN: old R heel blister healing well. multipodus boots on. pneumoboots on. old skin tear healing on L outer hip, cleansed w/ NS and new opsite placed over site. Duoderm intact to coccyx. Sat in Chair today for a few hours.\\n\\n\\nPLAN: con't to monitor neuro status.con't to monitor VS. wife to bring in pictures of his favorite cat at home, and stuffed animal (cat), ?1-2lb dumbbell weight to see if he uses it, to bring in his electric in to shave. Plan to have Case Manager rehab facilities to re-evaluate pt's eligibility/rehabi\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332377,\n \"text\": \"CCU progress note : 7a-7p\\n(Continued)\\nbility.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332378,\n \"text\": \"Resp Care\\npt changed to 50% trach collar.. tolerating very well with cuff deflated. has cyclical episodes of tachypnea..usually self-limiting. seems to do better with cuff deflated. when inflated requires lg amt air to seal. sxning sm amts tan. good strong cough. admin albuterol/atrovent q4-6 with mdi/. c/w tc as tolerates. vent on standby.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332329,\n \"text\": \"CCU NSG PROGRESS NOTE-NSICU BORDER.\\n73 YO MALE ADMITTED W R-SIDED WEAKNESS. HEAD CT SCAN-LARGE BASAL GANGLIA HEMMORRHAGE W EXTENSION INTO VENTRICLES & POS MASS EFFECT W SM AMT OF HERNIATION.\\n\\nO:NEURO=OPENS EYES SPONTANEOUSLY-TRACKING/FOLLOWING. SQUEEZES W L HAND ON COMMAND. NOT ABLE TO HOLD L SIDED EXTREM UP ON OWN-MOVING L SIDE ON BED. SL WDRAWL TO NOXIOUS STIM ON R. PERL-SLUGGISHLY.\\n PULM= & VENTED. SETTING=CPAP/PS, FIO2 40%, SPONTAN TV 450-550, RR 24-36, MIV 11.6-13.6, PEEP 5, & PRESSURT SUPPORT 5. BREATH SOUNDS=COURSE THROUGHOUT. SX-THICK COUPIOUS SECRETIONS @ X'S-REQUIRING LEAVAGING. SATS UPPER 90'S. AM ABG PENDING. EPISODES OF TACHIPNEA & LABORED RESPIRATIONS-RXED W HALDOL PRN W LIMITED EFFECT.\\n CV=NTG WEANED & DCED. LOPRESSOR 100MG & HYDRAL 10MG QID-CONTIN TO BE TACHYCARDIC & @ X'S HYPERTENSIVE @ X'S--?MORE RELATED TO AGITATION.\\n GI=TF CHGED TO PROMOTE W FIBER. STOPPED @ 0000.\\n GU=FOLEY. ADEQ UO.\\n ID=FEBRILE W T MAX 100.4 PO.\\n LABS=AM SENT.\\n\\nA:STABLE NEURO EXAM. REQUIRING FREQ SX FOR THICK COUPIOUS SECRETIONS. ?TACHYCARDIA & HYPERTENSION RELATED TO AGITATION/FRUSTRATION.\\n\\nP:CONTIN FREQ NEURO CKS. ?HEAD CT REDO. HALDO PRN. PULM TOILET. ?WEAN VENT TO EXTUBATE (FREQ SX & COUPIOUS SECRETIONS). ?ADD MILD TRANQUILIZER-AGITATION/FRUSTRATION. ?RESUME TF-IF NOT EXTUBATABLE. FOLLOW T-CULTURE W SPIKE. CK AM LABS-REPLACE AS INDICATED. SUPPORT PT/FAMILY AS NEEDED.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332397,\n \"text\": \"NEURO-ALERT TO SURROUNDINGS,TRACKES VOICES,INCONSISTENTLY FOLLOWS COMMANDS WITH NON-PURPOSEFUL AND OCCASIONALLY PURPSOEFUL MOVEMENT.PERLA (4mm). RESTLESS AT TIMES. MEDICATED WITH 0.5MG VERSED IV X1 WITH LITTLE RELIEF.\\n.\\n\\n\\nCV-REMAINS IN AFIB 85-95 WITH NO ECTOPY. BP INCREASING THROUGHOUT NOC. 135->160/85.+PP.\\n\\nRESP-50% TRACH-COLLOR,SATS=100%.LS WTIH OCC. EXP. WHEEZE.DIMINISHED\\n THROUGHOUT. STRONG COUGH WITH THICK YELLOW SPUTUM &\\n SXD FOR S.AMT. THICK YELLOW SPUTUM.\\n\\nG.I.-TOLERATING PROMOTE WITH FIBER AT 120CC/HR. +BS. NO STOOL.\\n\\nG.U.-CONDOM CATH WITH CLEAR YELLOW URINE.\\n\\nSKIN-RT POSTERIOR THIGH WITH CLEAN PINK ABRAIN. TEGADEM APPLIED. RT OUTE HEEL WITH 4/4CM RED BLISTER WITH BROWN DRY CENTER. COCCYX WITH 6X6CM ULCER. DUODERM INTACT.\\n\\nENDO-SSC PRN. LABS-REPLACED PRN.\\n\\nA/P-AS ABOVE. CONTINUE MONITORING HEMODYNAMICS,NEUR0\\n/RESP/G.I/G.U.\\n\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332398,\n \"text\": \"CCU NSG NOTE: ALT IN NEURO\\nO: For complete VS see CCU flow sheet.\\nID: Pt afebrile.\\nNEURO: Pt alert much of the day. At times trying to talk, will follow some commands. No movement seen on R side. Using L arm purposefully.\\nCV: HR 80s-90s a-fib on lopressor 150. BP 120-160/60-70s.\\nGI: Pt had lg soft G- bm. Tube feed of replete with fiber off at 8am and restarted at 4pm at 120cc/hr. Tolerating well.\\nGU:Pt voiding thru condom. He is ~1700cc positive for the day and ~ 5L positive LOS.\\nRESP: Pt remains on trach mask at 50%. He is sating 97-100%. He does require suctioning ~Q3-4 hrs for thick lt yellow sputum. Some wheezing heard. Pt getting nebs Q 4 hrs.\\nELECTROLYTES: Na up to 149. D5W boluses decreased to 300cc QID.\\nENDO: BS 147-151. 2u Reg given twice and 5u NPH given at 6p.\\nA: Stable on trach mask/ alert\\nP: Continue to turn Q3 hour. Suction prn. Cont TF overnight.Keep R arm elevated. Support pt and family.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332399,\n \"text\": \"Patient remains on T-Mask all day suctioned PRN for sign of resp distress. BS wheezy, treated with albuterol/atrvent neb Q4. More alert follow commands today will continue frequent bronchial hygien and neb Rx Q4. HR now 84,BP 154/70, Sat 98%.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-31 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332400,\n \"text\": \"CCu NPN 7pm - 7am\\nS/O: Resp: Pt. continues on trach mask at 50%. O2sats are 97 - 100%. Suctioned Q3 hours for small to moderate amount of light yellow sputum. RR 20 - 30 slightly labored at times. RT gave inhalers.\\nCVS: BP 97 -178/60 - 80. HR 70 - 100afib. Continues on lopressor, hydralazine, norvasc.\\nG.I.: tube feedings at 120 cc/hr from 7pm - 7 am.\\nD.M: FS 145, 109. SS insulin as written.\\nF/E:continues 300 cc free H2O boluses Q 6 hours.\\nA: s/p thalmic bleed, tolerating trach mask\\nP: continue pulmonary toilet, monitor resp. status, BS, tube feedings off in am.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-31 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332401,\n \"text\": \"PATIENT CONTINUES TO DO WELL ON T-COLLAR. SAT 100%,BP 147/65, HR 96,BS COARSE. DEEPLY SUCTIONED Q4HRS WILL CONTINUE NEB TREATMENT IN LIEU OF MDIS.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332309,\n \"text\": \"DEEP INTERCRANIAL HEMMORHAGE\\n72 YR OLD GENTLEMAN AWOKE 4 AM C R SIDED WKNESS, ,SLURRED SPEECH ,COLLAPSED ,BROUGHT TO HOSPITAL ,INTUBATED.HAS BEEN HYPERTENSIVE ,ON IV NIPRIDE,LABETOLOL IN ER. HAS HX MI, HTN, AFIB. ON COUMADIN .ADMITTING INR 4.2.GIVEN 6 FFP ,VIT K.HAS BEEN SEDATED FOR RESTLESSNESS C ATIVAN, 150 SUC,30 ETOMADATE, 10 VEC FOR INTUBATION.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332310,\n \"text\": \"oett pulled back 1.5cm md s/p cxr . resecured at 20cm @lip. post change + bilat b/s.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332311,\n \"text\": \"resp care\\n\\npt arrived to ccu intubated w/# 7.5 oett secured 22cm @lip. pt placed on mech vent ps 15 peep 7.5 fio2 50%. b/s +/cta/dim bilat. spont vt 600's rr teens. pt appears comfortable. abg 7.43/44/116/30. fio2 to 40%. plan: cont w/mech support. wean as tolerated.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332312,\n \"text\": \"LARGE L THALMIC BLEED\\nSR 60S TO 70S. BP 100 TO 180. ON NIPRIDE,LABETOLOL GTTS .IV HYDRALAZINE GIVEN .NIPRIDE D/C.WEANING LABETOLOLTO OFF IF POSSIBLE .\\n\\nVENTED , CPAP 15 PS/PEEP7.5 ,FIO2 40% RR 14 TO 17 C TV 6OO TO 8OO. SAT 98. BS DISTANT ,HX EMPHYSEMA .\\n\\nINR 1.4 P 6U FFP .VIT K IV GIVEN\\n\\nOG DRAINING CL GREEN ,HYPOACTIVE BS .ABD SOFT DISTENDED .\\n\\nCONCENTRATED BLOOD TINGED URINE 20CC HR VIA FOLEY\\n\\nPT RESTLESS ON ADMISSION, TRIED TO EXTUBATE SELF C L HAND.KICKING C L LEG . MOVES R ARM AND LEG ON BED TO PAINFUL STIMULI. PT STARTED ON PROPOFOL LOW DOSE STARTED TO KEEP PT ,WILL WEAN IF POSSIBLE.\\n\\nGOAL BP 120 TO 160\\nWEAN LABETOLOL TO OFF\\nWEAN PROPOFOL TO OFF IF POSSIBLE\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332370,\n \"text\": \"NSICU PNP\\nNEURO: NO CHANGE IN NEURO STATUS. OPENS EYES SPONTANEOUSLY, MOVES L SIDE. DOES NOT FOLLOW COMANDS\\nCV: HR 85-115 A FIB, BP 140-180/60-70, ^ TO 190/100 W/ ATTEMPT TO LOWER PS.\\nRESP: REMAINS ON PS 14, PEEP5. ATTEMPTED TO LOWER PS, TV DOWN, ^ RR TO 40'S, ^ BP. SX FOR MOD AMTS THICK TAN SECRETIONS.\\nID: TM 99.4, CONT ON OXACILLIN\\nGI: TF CONT AT 65CC/HR, TOL WELL, SM BRN FORMED STOOL\\nGU: FOLEY DRAINING DK YEL URINE QS.\\nSOCIAL: WIFE CALLED, HAS NOT BEEN IN TO VISIT TODAY.\\nDISPO: IS BEING SCREENED FOR REHAB.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332371,\n \"text\": \"Pt. maintained on psv ventilation with mostly a comfortable night except for these intermittent spikes in BP and RR. Sats are good. Sx for lrg amts. Plan is to cont. with current management with eventual rehab placement.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332379,\n \"text\": \"NPN\\n7 PM - 7 AM\\nS/O PLS SEE CAREVIEW FLOWSHEET FOR ALL OBJ/NUMERICAL DATA\\nLOW GRADE 100.2...\\nCV HEMODYN STABLE ..TOLERATING BETABLOCKERS AND ANTI-HYPERTENSIVES WELL\\nRESP ..INITIALLY RR IN THE 40'S...TV IN THE LOW 200'S...WITH DIFFUSE EXP WHEEZES ...AMBUED AND SUCTIONED ...BUT RR REMAINED IN THE 40'S...AND PT LOOKING VERY UNCOMFORTABLE ....PLACED BACK ON VENT PS15/5PEEP..FI02 OF 50%...AND GIVEN VERSED 1 MG Q4-5 H...WITH BETTER TIDAL VOLUMES ...\\nNEURO..OPENS EYES TO VOICE ..SQUEEZING LEFT HAND BUT INCONSIST TO COMMAND\\nGI/GU TOLERATING TUBE FEEDS ..U/O GD\\nA STABLE\\nP CONSIDER INCREASING VERSED MED...OR ATIVAN ORDER ROUND THE CLOCK..TO KEEP PT COMFORTABLE ..\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332380,\n \"text\": \"N SICU NPN\\nNEURO: SLEEPING MOST OF MORNING, MORE AWAKE THIS AFTERNOON.TRACKING, MOVING L ARM TO FACE, SCRATCHING EAR, BUT NOT FOLLOWING COMMANDS.NOT MOVING R SIDE.\\nCV: HEMODYNAMICALLY STABLE\\nRESP: ON TRACH MASK ALL DAY. SATS 97-98%, RR 12-24, APPEARS VERY COMFORTABLE. SX Q3-4HR FOR SM-MOD AMTS YELLOW/TAN THICK SECRETIONS.\\nGI: TOL TF, NO STOOL\\nGU: FLOLEY DRAINING CL, DK YEL URINE, CURRENTLY ~ 500CC NEG.\\nEND: BS 186 AT 6PM, COVERED PER SS\\nSKIN: DUODERM ON COCCYX, R HEEL BLISTER HEALING, OP XITE ON R HIP.\\nACTIVITY: OOB TO CHAIR, USING SLIDE BOARD. TOLERATED WELL.\\nSOCIAL: WIFE AND COUSIN IN TO VISIT MOST OF AFTERNOON.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332381,\n \"text\": \"RESP CARE\\nPT CHANGED TO TRACH COLLAR AT BEGINNING OF SHIFT. TOLERATING VERY WELL, CUFF IS DEFLATED. STRONG COUGH. SXNED AS NEEDED. ADMIN ALBUTEROL/ATROVENT MDI X3. C/W TRACH MASK AS TOLERATES. VENT ON SB.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332330,\n \"text\": \"CCU progress note: 7a-7p\\nNEURO: neuro signs unchanged. unable to move R side. able to lift and fall/withdraw from painful stimuli w/ L arm, moves L foot on bed. Pupils 2mm equal and sluggish reaction. opens eyes to verbal stimuli. +tracking. inconsistent squeezing of L hand to command ?reflex. non-purposful movement. ?agitation today w/ ^BP 200s, given multiple doses of haldol w/ little effect.\\n\\nSOCIAL: family in to visit today. talked w/ nurse and house staff re pt condition.\\n\\nID: WBC count elevated to 17. repeat WBC pending tonite w/ diff. no abx ordered. TMAX 101.4 rectally. to culture w/ temp>102 per HO. urine culture sent today.\\n\\nCARDIAC: AFIB 90-100s. no ectopy noted. SBP 170-200s during the day, given hydralazine 20mg QID IV and was on Lopressor 100mg , but this afternoon started on LABETOLOL gtt titrated to 5mg/min for SBP 130-150. +generalized edema.\\n\\nACCESS: R PIV d/c'd. New access LLA #20g and old LLA #20g intact but reddened at site, but patent. HO aware. NEED CENTRAL ACCESS. IV therapy in to start new access w/ difficutly.\\n\\nRESP: Remains on CPAP/PS 40% TV 300-500. Peep 5/ PS 5. RR24-36. LS coarse. CXR worsening. WBC elevated. Thick tenacious secretions - yellow tan, needing instillation of saline and ambu for good suctioning. sats > 96%. PM ABG: 134/43/7.43.\\n\\nGI/GU: no BM. TF restarted promote w/ fibre @ 20cc/hr. advance to GR as tolerated. on Free water boluses 100cc TID. FOley draining good amts clear yellow urine. u/a and CS sent.\\n\\nPLAN: sent sputum spec. monitor temps blood cultures for >102. need central access. titrate labetolol for ABP 130-150 goal.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332392,\n \"text\": \"Respiratory Therapy\\nTrached with an 8.0 Portex. PSV, weaned to 10/5/0.40. ABG: compensated metabolic alkalosis. Had to pt this afternoon for low Vt and increased WOB. Suctioned pink frothy secretions at that time. Pt does have periods of apnea lasting about 5sec which are self resolved. Receiving albuterol and atrovent MDI as needed. Plan to continue with PSV as tolerated and TM when ready.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332393,\n \"text\": \"NSICU NPN\\nNEURO: VERY LETHARGIC TODAY. OPENS EYES TO VOICE, OCC SPONTANEOUSLY. NOT FOLLOWING COMMANDS. LIFTS L ARM AND MOVES IN ? PURPOSEFUL MANNER, MOVES L LEG ON BED. NOT MOVING R ARM.\\nCV: HEMODYNAMICALLY STABLE\\nRESP: PS 14, PEEP 5 THIS AM DOWN TO 10/5, UNABLE TO WEAN FURTHER D/T ^ TACHYPNEA, LOW TV, GENERAL DISTRESS.\\nGI: TF CHANGED TO CYCLE FROM 4P->8AM AT 120CC/HR. TOLERATING WELL. SOFT BRN STOOL.\\nGU: FOLEY PULLED AT 17:00, CONDOM CATH PLACED.\\nID: AFEBRILE\\nEND: WNL\\nACTIVITY: OOB TO CHAIR, FULL LIFT, PT HERE.\\nPT BEING SCREENED FOR REHAB.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332372,\n \"text\": \"CCU NSG PROGRESS NOTE 7P-7A/ S/P THALMIC BLEED\\n\\n\\nS- \\n\\nO- SEE FLOWSHEET FOR OBJECTIVE DATA.\\n\\nCV- VS REMAIN AT BASELINE.\\nHR- 108-112 AF. BP- 120-180/.\\nREMAINS ON SAME CV MEDS.\\n\\n PT ON PRESSURE SUPPORT 14/40%.\\nO2 SATS 99-100%.\\nSUCTIONED FOR THICK WHITISH SPUTUM.\\nCOARSE BREATH SOUNDS.\\n\\nID- AFEBRILE.\\nREMAINS ON OXACILLIN .\\n\\nGU- GOOD UO VIA FOLEY/LASIX AS ORDERED.\\nI/O EVEN.\\n\\nGI- PROMOTE AT 65/HOUR.\\nLARGE FORMED STOOL X 1 G (-).\\n\\nMS- NO SIGNIFICANT NEURO CHANGES.\\nSEE FLOWSHEET.\\n\\nA/ PT STATUS S/P THALMIC BLEED, ON VENTILATORY SUPPORT.\\nAWAITING PLACEMENT.\\nCONTINUE PULM TOILET/NUTRITION/BP CONTROL.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332373,\n \"text\": \"NSICU NPN\\nS: TRACHED\\nO: SEE CAREVUE FOR ALL OBJECTIVE DATA.\\n\\nNEURO: NO CHANGES\\nCV: HEMODYNAMICALLY STABLE A FIB 90-110, BP 115-180/60-70, NO CHANGES MADE TO CV MED REGIME.\\nRESP: UNABLE TO WEAN PS, PT BECAME , DISTRESSED AND W/ LOW TV. REQUIRING PS ^20 BRIEFLY. SX FOR SM-MOD AMTS THICK TAN SECRETIONS. LUNG SOUNDS COARSE.\\nID: TM 100.5 PO, BLOOD, URINE AND SPUTUM CX SENT. OXACILLIN D/C. TLC D/C AND TIP CX.\\nGU: FOLEY DRAINING DK YEL URINE, 50-70CC/HR.\\nGI: TOLERATING PROMOTE W/ FIBER AT GOAL, 65CC/HR. NO STOOL TODAY.\\nLINES: PICC PLACED L ARM, PLACEMENT CONFIRMED BY X RAY, TLC AND A LINE D/C.\\nSOCIAL: WIFE IN TO VISIT.\\nDISPO: REHAB PLACEMENT.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332374,\n \"text\": \"Respiratory Care:\\n\\nPatient trached with 8.0 Portex. Current vent settings Psv 15, Cpap 5, Fio2 50%, with Flowby . Spont vols 500-700's with RR 11-16. Bs slightly coarse bilaterally. Sx'd/lavaged for sm amounts of thick tan sputum. Albuterol/Atrovent MDI's given Q6hr. O2 sats 98-100%. No further changes made. Continue to wean Psv as tolerated.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332394,\n \"text\": \"CCU NSG PROGRESS NOTE 7P-7A/ S/P THALMIC BLEED\\n\\nS- TRACHED\\n\\nO- SEE FLOWSHEET FOR OBJECTIVE DATA.\\n\\n PT REMAINS WELL CONTROLED ON CURRENT CV MEDS.\\n\\nHR- 80-90'S AFIB.\\nBP- 120/- 150/\\nNO CHANGES IN CV MED REGIMEN.\\nAM LABS PENDING.\\n\\n PT REMAINS ON VENT SUPPORT:\\n50%/PRESSURE SUPPORT- 14, 5 PEEP.\\nSUCTIONED FOR YELLOWISH THIN SPUTUM.\\nFAIR AMOUNT VIA TRACH.\\nSITE CLEAN.\\n\\nID- AFEBRILE- 99 T MAX.\\nREMAINS ON PO LEVO.\\n\\nGU- CHANGED FOLEY TO CONDOM CATH- 600CC/HOUR.\\nREMAINS ON 300CC H20 EVERY 4 HOURS.\\n\\nGI- SWITCHED TO TUBE FEED OVERNT ONLY- 4P-8A- 120CC/HOUR.\\n(+) BOWEL SOUNDS- NO STOOL THIS SHIFT.\\nREMAINS ON COLACE.\\n\\nSKIN- HEEL WITH BLISTER AND COCCYX WITH OPEN ABRASION AREA- DUODERM ON PLACE, AREA CLEAN.\\nMULTIPODIS BOOTS/SLEEVES IN PLACE.\\n\\nNEURO= NO SIGNIFICANT CHANGES IN NEURO STATUS.\\nWATCHING AND ALERT, BUT NO RESPONSE VERBALLY AND INCONSISTENT FOLLOW OF COMMANDS.\\n\\nA/ PT S/P LARGE CVA ON VENTILATOR SUPPORT- AWAITING PLACEMENT.\\n\\nCONTINUE TO ADMINISTER CV MEDS/MAINTAIN STABLE HEMODYNAMICS.\\nNEURO VITAL SIGNS, SKIN CARE/COMFORT.\\nCONTINUE NUTRITION/INCREASE ACTIVITY AS TOLERATED.\\nKEEP FAMILY AWARE OF PLAN OF CARE/CURRENT PROGRESS.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332395,\n \"text\": \"7am - 7 pm\\nS/O: Resp.: Pt. trached and vented initially. Put on a trach mask at 50% and tolerating it well so far. Pt. has a strong productive cough and has been able to clear secretions fairly well. Lung sounds are coarse. Pt. had 1 episode of tachypnea this morning which resolved with cuff deflation and 100% O2. Continues on levaquin.\\nCVS: Continues on lopressor, hydralazine, norvasc and clonidine patch to control HTN. NTP has been D/C'd. BP 106 -140's/50 - 60. HR 90 - 110's.\\nG.I.: Pt. tolerating TF at 120 cc/hr. Started at 4 pm and continue until 8 am. Pt. continues on free H2O for Na of 154 today.\\nG.U.: Pt. voiding via condom catheter.\\nDM: FS 130 this morning. Pt. received 2 units of regular insulin.\\n\\nA: s/p thalmic bleed\\nP: monitor response to trach mask, continue aggressive pulm toilet, antibx.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332396,\n \"text\": \"Resp Care\\nchanged to trach collar with cuff deflated...actually seems more relaxed with no episodes of tachypnea/diaphoresis. sxning sm amts yellow thick. strong cough. admin albuterol/atrovent mdi q6h. plan to leave on trach collar as tolerates. clearly looks better on trach collar with cuff down vs. on vent with cuff inflated. ?air trapping.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332364,\n \"text\": \"SICU NPN\\nNEURO: NEURO STATUS REMAINS UNCHANGED. OPENS EYES SPONTANEOUSLY, MOVES LEFT SIDE W/ ? PURPOSEFUL MOVEMEMT. RLE WITHDRAWS TO PAINFUL STIMULI OTHERWISE NO MOVEMENT ON R SIDE. PERRL.\\nCV: HEMODYNAMICALLY STABLE W/ HR 80-100 A FIB, BP 140-170/50-80 ON CURENT MED REGEIME. NO CHANGES MADE TODAY.\\nRESP: TRACH AREA CLEAN W/O SSI, SX Q3 HR FOR MOD AMT THICK TAN SECRETIONS., LUNG SOUNDS COARSE. PS DOWN TO 5/5, TOLERATING WELL, TO HAVE TRIAL W/ TRACH MASK.\\nGI: PEG IN PLACE, TOLERATING PROMOTE W/ FIBER AT 65CC/HR, NO STOOL TODAY.\\nGU: FOLEY DRAINING CL YEL URINE. CURRENTLY ~1000CC NEG, (GOAL FOR DAY)\\nID: TM 100.1 PO, CONT ON OXACILLIN, LEVO D/C AFTER THIS AFTERNOON'S DOSE.\\nSKIN: BLISTER ON R HEEL, OPEN ABRASION ON COCCYX, DUODERM APPLIED.\\nSOCIAL: WIFE IN MOST OF AFTERNOON. PT HAS BEEN ACCEPTED AT AND GO IF BED AVAILABLE, WIFE AWARE.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332365,\n \"text\": \"ATTEMPTED TRACH COLLAR TRIAL. AFTER APPROX. 15 MINS PT'S RR UP TO 30'S, BP UP, LOOKED UNCOMFORTABLE... PLACED BACK ON VENT. RN AWARE.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332366,\n \"text\": \"PT PLACED ON IPS 14 TO REST. TOLERATED IPS 5 FOR 8 HOURS WELL. WILL ATTEMPT AGAIN IN AM\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332367,\n \"text\": \"CCU NPN 7PM - 11PM\\nS/O:RESP: Pt. remains trached and vented. Changed back to 14 PS from 5. due to tachypnea. Suctioned for a mod. amt. of tan sputum.\\nI.D.: afebrile. Continues on oxa.\\nCVS: BP labile 140 - 180's/70's. HR 100's.\\nG.I.: PEG. continues on TF. Please see careview for specific data.\\nA: s/p thalmic bleed, awaits placement for tomorrow.\\nP: continue pulm. toilet, monitor neuro signs, meds for HTN.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332368,\n \"text\": \"Resp.---- Pt. maintained on psv ventilation of 14 overnight with good oxygenation. Pt. had episode of hypertension and tachypnea that was relieved by placing pt on a/c ventilation for brief period followed by mdi administration and sx. Returned to psv with no pt distress. Plan is to cont with current status.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332369,\n \"text\": \"CCU NSG PROGRESS NOTE 11P-7A/ S/P THALMIC BLEED\\n\\nS- TRACH/NONVERBAL OR RESPONSIVE\\n\\nO- SEE FLOWSHEET FOR OBJECTIVE DATA.\\n\\n PT REMAINS WITH LABILE HEMODYNAMICS- BP-110-130/ AT REST WITH\\nINCREASE TO 220-180/ WITH ANY SORT OF AGITATION.\\nREMAINS ON LOPRESSOR/HYDRAL/CLON/NTP.\\nHR- 90-110 AF, NO VEA.\\nAM LYTES PENDING.\\n\\nRESP- REMAINS ON VENTILATORY SUPPORT- TRACH WITH 50%/CPAP- 14 PRESSURE SUPPORT/5 PEEP.\\nRESP RATE SPONTANEOUSLY- 12-36- RESTING/AGITATED.\\nSUCTIONED FOR THICK YELLOWISH SPUTUM, MINIMAL AMT.\\nO2 SATS 100-99%\\n\\nID- AFEBRILE- REMAINS ON OXACILLIN.\\n\\nGU- FAIR TO GOOD UO= 40-130/HOUR.\\nI/O (-) 1200CC.\\n\\nGI- PEG IN PLACE- RECEIVING PROMOTE WITH FIBER 65/HOUR.\\nNO STOOL THIS SHIFT., (+) BOWEL SOUNDS.\\n\\n PT AWAKE/ALERT, BUT NOT PURPOSEFUL IN BEHAVIOR.\\nTRACKING WITH EYES BUT NO EVIDENCE OF UNDERSTANDING/ORIENTATION.\\nNO SIGNIFICANT CHANGES.\\n\\nA/ PT S/P THALMIC BLEED REMAINS WITH NEED FOR VENTILATORY SUPPORT.\\nLABILE HEMODYNAMICS PERSISTS IN SPITE OF HIGH DOSE CV MEDS.\\n\\nPLAN TO D/C TO REHAB TODAY.\\nCONTINUE TO ATTEMPT TO CONTROL HEMODYNAMICS .\\nPULM TOILET.\\nKEEP FAMILY AWARE OF PLAN OF CARE AND PROGRESS.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332340,\n \"text\": \"CCU progress note 7a-7p\\nNEURO: no neuro changes noted. does not respond to commands. non-purposful movements of L arm and L foot. R side resists movement/stiff and non-moving. Opens eyes to stimuli occasionally and has R sided neglect, pt does not seem to track. Pupils 2-3mm brisk reactive. +corneals. NO GAG. +cough with suctioning. +sensation to L side.\\n\\nCARDIAC: AF 80-90s. SBP remains labile 130-170s today. LABETOLOL gtt remains on, decreased from 5mg to 2mg/min this evening. Remains on Lopressor 125mg TID, Hydralazine 40mg QID and VASOTEC 5mg started today for pressure con't. Con't to wean labetolol as tolerated. con't w/ +generalized edema.\\n\\nRESP: LS Diminished to bases, generally clear upper. Sx small amts thick tan/yellow secretions. PS 8/Peep 5 40% all day, decreasing TV this evening, increased RR 30s, increased PS to 14 w/ good improvement in TV to 600s. Sats >97%.\\n\\nID: pan cultured overnite, cx pending. Tmax today 100.7 oral. R S/C TLC changed overwire , cath tip sent for cx, new R s/c DL line placed. placement confirmed by CXR. No abx as yet.\\n\\nGI/GU: foley patent, clear yellow urine good amts. abd soft/distended. +BS. started on colace . +Flatus today. rectal check by HO showed soft stool in rectum, not impaced. no bm as yet. TF goal of promote w/ fibre @ 65cc/hr. OGT intact, patent.\\n\\nSKIN: R outer heel blister intact. mulitpodus boots on. opsite on coccyx redened area. no breakdown noted.\\n\\nSOCIAL: wife would like family meeting (to discuss code status, ?pt outcome, trach/peg, long term care, what to expect?) with NSICU team, NEURO team and STROKE team and Social worker ?maybe tomorrow afternoon (wife will be in anyways). to attempt to plan in am.\\n\\nCODE STATUS: FULL\\n\\nPLAN: Con't to monitor neuro status for changes. ?trach/peg, cont' to wean off Labetolol.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332341,\n \"text\": \"Resp Care: Pt continues and on ventilatory support with psv14/fio2 .4/+5 peep maintaining Vt 3-600 ml with Vt 9-12 L, spo2 98%; BS coarse, sxn thick tan secretions, rx with mdi albuterol/atrovent, see carevue for details.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332342,\n \"text\": \"CCU NSG PROGRESS NOTE 7P-7A/ S/P THALMIC BLEED\\n\\nS- INUTBATED\\n\\nO- SEE FLOWSHEET FOR OBJECTIVE DATA.\\n\\nCV- HR REMAINS AFIB, 80-90'S, NO VEA.\\nBP- 140-150/ WITH OCCASIONAL INCREASES TO 160/- 170 WITH AGITATION/STIMULATION- INCREASED LABETELOL TO 2 MG, REMAINS ON LOPRESSOR AND HYDRALAZINE FOR BP CONTROL.\\n\\nRESP- REMAINS INUTUBATED FOR AIRWAY PROTECTION, NO GAG REFLEX.\\nSUCTIONED FOR THICK WHITISH SPUTUM, MUCH ORAL SECRETIONS.\\nPRESSURE SUPORT- 14, FI02- 40%.\\nABG WML.\\n\\nID- AFBRILE AFTER T AMX- 101-\\nTYLENOL, PAN CULTURED ON .\\nAWAIT RESULTS.\\n\\nGI- TUBE FEEDS AT 65/HOUR, STARTED D5 AT 30/HOUR.\\nNO STOOL AS OF YET, MIN RESID, COLACE TID.\\n\\nGU- UO- 40-60/HOUR VIA FOLEY CATHETER.\\n\\nMS/NEURO- NO CHANGES IN NEURO STATUS- REMAINS WITH OPEN EYES, NO FOLLOWING COMANDS, USING LEFT SIDE, NOT RIGHT SIDE.\\nNO ACUTE CHANGES.\\n\\nA/ PT S/P HEAD BLEED REMAINS FOR AIRWAY PROTECTION, FUO AND LABILE BP ON/OFF LABETELOL GTT.\\n\\nCONTINUE TO MANAGE BP WITH MULTIPLE MEDS- ATTEMPT TO MAX PO MEDS TO WEAN OFF IV LABETELOL.\\nWATCH FOR FURTHER FEVER/AWAIT CULTURE RESULTS.\\nCOMFORT/SAFETY/FREQ NEURO CHECKS.\\nKEEP FAMILY AWARE OF PLAN OF CARE.\\nD/C PLANNING, ?PLAN TRACH.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332343,\n \"text\": \"CCU progress note 7a-7p\\nFAMILY MEETING this afternoon. Discussed pt's prognosis, possiblity of trach/peg, ?rehab rehab/nsg home, and discussed with wife pt's wishes. Wife decided to make him a DNR at this point, but needs to talk to brother-in-law in and have him talk to Dr . She hopes to have a decision re: ?extuabtion or ?trach/peg after brother-in-law talks to Dr and she talks again to the brother.\\n\\nNEURO: no changes noted. More alert today. opens eyes to verbal stimuli. R sided neglect, not noted to track. remains flaccid on R side. +sensation to R side noted at times to painful stimuli (reacting w/ lifting of L leg). pt restless and moving L knee up in bed and trying to lift up restrained L arm. Pt noted to hold onto side rail at times and inconsistently squeezes hand, but not to command. Pupils remain 2mm brisk.\\n\\nCARDIAC: AFib 70-90s. SBP 140-170s today. Remains on Lopressor 125mg TID, Hydralazine 40mg po QID, Norvasc increased to 10mg QD, and Clonodin patch 0.3mg added. On LABETOLOL gtt titrating between 2-5mg/min. +generalized edema.\\n\\nACCESS: R radial Aline. R s/c DL central line. OGT. ETT.\\n\\nID: Febrile today. Gram + cocci pairs/clusters in sputum, BC anaerobic culture growing + cocci clusters. Started on Vancomycin today.\\n\\nRESP: LS clear, dim bases. Sx small amt thick tan/yellow sputum. Gram + cocci. pm ABG 7.40/44/186 on PS 12/Peep 5/ 40% TV 300-400s, RR 20-30s. Pt RR in high 30s-40s on PS 12 and has frothy tan sputum large amts, suctioned and placed back on PS 14. RR back to high 20s, TV 300-400s. CPT today/Pulm toliet.\\n\\nGI/GU: foley patent, good amts urine. abd soft, +BS. TF GR 65cc/hr Promote w/ fibre via OGT. on colace . given Dulcolax PR today w/ good results, soft brown BM.\\n\\nSKIN: R outer heel blister remains intact, healing well, elevated off bed or in multipodus boots. coccyx slightly reddened tegaderm intact. no other breakdown noted.\\n\\nPLAN: con't to monitor neuro status. con't to give wife emotional support and keep her informed of pt status/changes. Pulm toliet. titrate PS for good tidal volumes. titrate Labetolol for goal SBP 130-150s.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2148-01-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332413,\n \"text\": \"NEURO: AWAKE & ALERT. FOLLOWS SIMPLE COMMANDS, BUT NOT CONSISTENTLY.\\n DOES NOT MOVE R. SIDE. LIFTS & HOLDS L. ARM UP OFF BED. L. LEG\\n LIFTS & FALLS. PERL.\\nRESP: 50% TRACH COLLAR. O2 SATS 97-100%. RR 23-28. SX FOR THICK YELLOW\\n ->THIN WHITE SECRETIONS Q4HRS. BS COARSE BUT DIMINISHED AT\\n BASES.\\nCARDIAC: HR 85-93 AF, NO ECTOPY. BP 112-140/54-69.\\nGI: CYCLED TF: FS PROMOTE WITH FIBER AT 120CC/HR VIA PEG TOLERATED\\n WELL. ABD. SL. DISTENDED. BS+. NO STOOL. FREE H2O 150CC Q8HRS.\\nGU: CONDOM CATH DRAINING CLEAR YELLOW URINE. REPLACED X1.\\nID: T 97.7->98.8(PO).\\nPLAN: TO REHAB THIS AM.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2148-01-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332414,\n \"text\": \"N SICU NPN\\nPT ACCEPTED AT OLYMPUS/. WIFE AWARE OF TRANSFER. PT TRANSFERRED AT 09:00 W/ MULTIPOSUS BOOTS, GLASSES, ELECTRIC RAZOR, PICTURES AND WEIGHTS. PT IN STABLE CONDITION.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332323,\n \"text\": \"CCU Nursing Progress Note 7p-7a:\\n\\nNeuro: Pt opening eyes to name tracking inconsistently. Pupils equal and reactive. Sqeezing left hand on command. Moving L side on bed. R hand and leg responding to painful stimuli. Pt with +cough reflex but w/o gag reflex.\\n\\nCV: NTG gtt at 115mcg to maintain SBp<160. SBP 130-150's. Afib HR 92-108. Pt conts on lopressor 25mg and hydralazine 10mg IV. H.O. aware of VS ? increasing lopressor this am.\\nHCT 34.5 K+4.0\\n\\nRESP: Mechanically ventilated decreased to PS 10 with Tv 500 40% fi02 and 7.4 peep. ABG 7.45/37/119/2. Pt did not tolerate PS 8 per RT, tv dropped into the 300's.\\nLS coarse. Sxn'd for thick yellow sputum in small amts. Sputum cx pending from .\\nNo peripheral edema.\\n\\nGI: Abd softly distended with hypoactive BS. ? LBM. OGT in place with impact with fiber infusing at 30cc/hr. Minimal residuals advance as tolerated for goal rate of 70cc/hr.\\n\\nGU: Foley cath patent draining yellow urine in good amts. u/o 500cc/hr. BUN 32 Creat 1.4. Fluid balance -43cc since mn. +1393 LOS.\\n\\nID: tmax 99.6.\\n\\nSKIN: intact\\n\\nENDO: FS 127 and 147. No regular insulin required per SS.\\n\\nPROPH: protonix iv and pneumoboots.\\n\\nLINES: R radial a-line and 2 piv.\\n\\nSOCIAL: No phone calls this shift.\\n\\nDISPO: Full Code\\n\\nA: cont on ntg gtt to maintian sbp <160.\\n increased spontaneous movement on L side.\\n Tolerating TF.\\n good u/o.\\nP: Follow neuro checks q2hr.\\n maintain SBP <160.\\n ? increasing lopressor dose\\n increase TF rate to reach goal as tolerated.\\n Wean PS as tv improve.\\n Provide support to pt and family.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332324,\n \"text\": \"n micu npn\\nNeuro: pt opens eyes to voice, occasionally spontaneously. Moves l side in non purposeful manner, only withdraws from pain on r side. PEARL.\\nCV: Continures on ntg gtt at 113 mcg/min, lopressor ^ to 50 mg pngt tid, and hydralazine ^ to 20 mg . hr90- low 100's sr-st, occ pvc. bp 130-165/50-70.\\nResp: ps to 8, 5 peep w/ good abg. Mod -lg amts thick yellow/tan secretions. lung sounds coarse.\\nGI: tf ^ to 60cc/hr w/ goal 70cc/hr. tolerating well w/ 5cc residuals. No stooo today.\\nGU: foley draining dk yel urine\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332325,\n \"text\": \"Pt remains on vent, CPAP mode. Changes to the vent settings: decrease in PSV from 10 to 8. Fio2= .40 with spo2= 98%. Suctioned pt several times throughout shift for mod amts of thick yellow sputum.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332326,\n \"text\": \"n sicu nsg addendum\\nCurrently +240cc.\\n\\nid: tm 100.4 po\\n\\nend: bs wnl\\n\\nsocial: wife and brother in to visit most of day.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332327,\n \"text\": \"Pt PSV decreased to 5 and Peep decreased to 5 at 1840. Fio2 still= .40. VT= 450ml. RR= 25.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332328,\n \"text\": \"Resp Care\\nPt. continues on CPAP 5/5 with VTs 350-550. BS coarse bilaterally, ambued sxn'd x2 for copious thick yellow. Pt. had periods of agitation, diaphoresis, increased BP, desats to 87%. Would not recommend extubation this morning, secreations too thick\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332390,\n \"text\": \"Respiratory Care:\\nPt. remains on IPS=14, peep=5, and FIO2 of 50%. At times, Pt. becomes very tachypneac and agitated, and appears to become very bronchospastic. He responds well to manual ventilation and/or brief periods on A/C until FRC is restored. Pt. also has periods of bradypnea, with increased VT's ~1L and RR in single digits. This would lead me to want ot wean IPS, but when this is attempted (with targetted VT's ~ 600cc), Pt. soon reverts to tachypnea and agitation. B/S course and at times very wheezy. ETS for small to moderate, thick, yellow. Alb./Atr MDI's given with good effect. Will continue on present settings, and perform as outlined above when needed. Pt. may also benefit from the addition of inhaled steroids. Will follow.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332391,\n \"text\": \"CCU NSG PROGRESS NOTE 7P-7A-S/P HEAD BLEED;FX WEAN\\n\\nS- TRACHED\\n\\nO- SEE FLOWSHEET FOR OBJECTIVE DATA.\\n\\n PT REMAINS ON MULTIPLE MEDS FOR BP/HR.\\nCURRENTLY- HR- 90'S AFIB WITH BP- 120-140/.\\nNO VEA. AM LYTES PENDING.\\n\\n PT ON VENTILATORY SUPPORT- 50%/14PRESSURE SUPPORT/5 PEEP.\\nSUCTIONED FOR FAIR TO MINIMAL AMT WHITISH/YELLOW SPUTUM.\\nCOARSE BREATH SOUNDS.\\nIRREGULAR BREATHING PATTERN PERSISTS.\\nAT TIMES PERIODS OF APNEA, AT TIMES PERIODS OF TACHYPNEA TO 30'S.\\nIMPROVING WITH .\\nRECEIVING NEBS AS ORDERED.\\nPER RESP- SUGGESTS ADDITION OF STEROIDAL BASED NEBS TO PREVENT\\nBRONCHOSPASM/EPISODES OF TACHYPNEA.\\n\\nID- AFEBRILE- LOW GRADE.\\nLEVOQUIN IV.\\n\\nGI- REMAINS ON TUBE FEEDS AS ORDERED.\\nABD DISTENDED BUT SOFT.\\nSMALL AMT STOOL G (-). SOFT FORMED.\\n\\nGU- FAIR AMT URINE VIA CATHETER.\\nREMAINS ON LASIX AS ORDERED.\\n\\nSKIN- LEFT BUTTOCK/AT COCCYX WITH ABRASION/STAGE 11- COVERED AND PROTECTED WITH DUODERM\\nHEELS ALSO WITH (+) BLISTER. MULTIPODUS BOOTS ON AS WELL AS ANTIEMB SLEEVES.\\nPUT PT ON FIRST STEP BED 12 AM FOR SKIN PROTECTION,\\n\\n PT AT TIMES ALERT, TRACKING= REPSONDING TO STIMULI SLIGHTLY.\\nOTHER TIMES NOT.\\nSEE FLOWSHEET FOR DATA RE: NEURO VS- UNCHANGED.\\n\\nENDO- BS<180'S- NO SS REG INSULIN COVERAGE.\\n\\nA/ PT S/P HEAD BLEED REMAINS IN NEED OF VENTILATORY SUPPORT.\\nCONTINUE PULM TOILET AND SKIN CARE AS WELL AS CLOSE ASSESSMENT OF NEURO STATUS.\\nKEEP PT AND FAMILY AWARE OF PLAN OF CARE.\\nPLACEMENT.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332344,\n \"text\": \"Respiratory Care Note\\n\\nPt currently on CPAP 5 PSV 14. Pt tol current settings fairly. ? increasing PSV. Pt rxd t/o shift with Albuterol/atrovent mdis. Will continue to support and wean as tolerated\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332345,\n \"text\": \"CCU NSG PROGRESS NOTE-SICU BORDER.\\nO:NEURO=WO CHG-SEE FLOW SHEET.\\n PULM=REMAINS /VENTED W SETTINGS-CPAP/PS, 40%, STV 350-500, RR 20-32, PEEP 5, & PS 14. BREATH SOUNDS=COURSE THROUGHOUT. SX-THICK TANNISH SECRETIONS.\\n GI=LABETOLAL GTT @ 5MG/MIN W SBP 110-150.\\n GU=TF @ GOAL (65ML/HR). LAST BM .\\n GU=FOLEY. POSITIVE I&0 SINCE ADMISSION.\\n ID=LOW GRADE T.\\n LABS=AM SENT.\\n SOCIAL=PT MADE DNR BY WIFE ON . FURTHER DISCUSSION RE:LONG TERM CARE CONTINUES.\\n\\nA:UNCHGED.\\n\\nP:CONTIN PRESENT MANAGEMENT. ?ATTEMPT TO WEAN & DC LABETOLAL. ?ADUMENT DIURESIS W PRN LASIX-?SOME COMPONENT OM HTN RELATED TO FL STATUS. CK AM LABS-REPLACE AS INDICATED. SUPPORT PT WIFE IN DECISION MAKING REGARDING LONG TERM OPTIONS.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332346,\n \"text\": \"CCU NPN 7am - 7pm\\nS/O: Resp: Pt. remains . PS was decreased to 12. Pt. tolerated this well for a couple of hours with ABG of 132/7.40/45/29. RR 24-30 slightly labored. At 1630 O2sats dropped to 89%and pt. looked more labored. PS was increased back to 14. ABG ->60/7.43/43/29. Pt. was agressively suctioned and CPT was done. O2 sat up to 96%. CXR done. Suctioning done Q2 hours for moderate amount of tan secretions.\\nI.D: T max 100 rectal. Vanco D/C'd and levoquin was started per OGT.\\nCVS: HR 70 - 80's afib. BP 140-160/70's. Continues on labetelol drip, lopressor, hydralazine, and norvasc.\\nG.U.: voiding via foley catheter. sediment noted. urine dark and concentrated. Pt. received 20 mg of lasix pOGT.\\nG.I.: Pt. continues on TF at 65cc/hr. residuals are less than 50cc. Aspirates are negative. BM x2.\\nA: s/p thalmic bleed\\nP: continue antihypertensive measures, aggressive pulm toilet, antibx as written, monitor neuro status for changes.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332347,\n \"text\": \"CCU NSG PROGRESS NOTE-NSICU BORDER.\\nO:NEURO=PERIODS OF APPROPRIATENESS-FOLLOWS SIMPLE COMMANDS (RISES ARM & SQUEEZES HAND L-SIDE ONLY-NODS HEAD TO ?'S-FOLLOWS W EYES). PURPOSEFUL MOVEMENT OF L ARM-ATTEMPTS TO SCRATCH HEAD-MOVES HAND TOWARDS ETT.\\n PULM:VENT SETTINGS UNCHGED-CPAP/PS, FIO2 40%, STV 350-48-, RR 16-32, PEEP 5, * PS 14. SATS UPPER 90'S. AM ABG-7.39/48/117/30/3. BREATH SOUNDS=COURSE THROUGHOUT. SX-THICK TANNISH SECRETIONS.\\n CV=ON LABETALOL GTT @ 4MG/MIN. SBP <150.\\n GI=TF @ GOAL-65ML/HR W MINIMAL RESIDUALS.\\n GU=FOLEY. LASIX X2 ON DAY/EVES -REMAINS POS @ 2300-1.9L.\\n ID=LOW GRADE T.\\n LABS=AM SENT. WNL.\\n\\nA:?SL IMPROVING NEURO STATUS. REMAINS ON LABETALOL GTT.\\n\\nP:CONTIN PRESENT MANAGEMENT. CONTIN ATTEMPT @ WEANING PRESSURE SUPPORT. SUPPORT AS NEEDED.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332348,\n \"text\": \"Resp Care Note:\\n\\nPt cont intub on mech vent as per Carevue. Lung sounds coarse suct mod th tan sput. Pt tol PSV well. No changes made overnoc. Cont wean from mech vent with PSV.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332356,\n \"text\": \"NSG NOTE\\n\\nCV: REMAINS IN A-FIB. RATE CONTROLLED 83-90. SBP 126-150. CON'T ON NTG TP 2\\\",HYDRALAZINE 50MG AND LOPRESSOR. NO VEA NOTED.\\n\\nRESP: CPAP/PS-14,PEEP 5, 40%, VT 710-940. 7.47,40,151,30,5,99%. METABOLIC ALKALOSIS BEING TX WITH DIAMOX X4 DOSES.PT HAS ALREADY RECEIVED 3 DOSES. SUCTIONED FOR SM AMT TAN SECRETIONS.\\n\\nNEURO: OPENS EYES SPONTANEOUSLY. 2MM/2MM BRISK. BOTH RUE/RLE NO MOVEMENT. LUE LIFTS AND HOLDS,LLE MOVES ON BED. HE FOLLOWS COMMANDS IN CONSISTENTLY.\\n\\nGI: PT WAS ON TF @ GOAL RATE 65. TOL WELL WITH LOW RESIDUALS. ABD SOFT WITH + BS. NO STOOL THIS SHIFT. TF D/CD @ 0400 IN PREP FOR TRACH TODAY. LAST BM \\n\\nLABS: BS 168- RECEIVED 2 UNITS REG PER SSI\\n\\nID: TEMP MAX 99.5 PT IS ON . AND OXACILLIN IV FOR COVERAGE\\n\\nSKIN: HAS BLISTER ON R LATERAL ASPECT OF HEEL. LEG AND FOOT ELEVATED ON PILLOW. DUODERM TO BUTTOCKS INTACT.\\n\\nDISPOSITION: DNR\\n\\nA: STABLE\\n\\nP: BEDSIDE TRACH TODAY. KIT AT BEDSIDE\\n SUGGEST PICC LINE. IV NEEDS TO BE NOTIFIED.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332357,\n \"text\": \"Resp Care,\\npt. remains on CPAP IPS 14/.4/5peep. Vt 600's, RR15. Plan to today. ABG 7.47/40/151/30. See vent flowsheet.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332358,\n \"text\": \"ccu nursing progress note\\ns/o: pls see carevue flowsheet for complete vs/data/events\\nneuro: opens eyes spon. occ appears to track. r hemiparesis. withdraws rle to pain but not upper. l moves spon but not to command. moves l hand to face/tubes and req soft wrist restraint.\\ncv: hr 80s afib. bp 130-150/70 via r rad aline. no changes to bp/cardiac meds. k repleted 80meq for k 3.1.\\nresp: cont on ps 14. rr low 20s. tv 500-800. sats >96% on .4 fio2. percutaneous trach placed at bedside. pt tol procedure well. sxn'd for sm amt bld tinged secretions. bs scatt coarse.\\ngi: npo. peg placed at bedside. pt tol well. will remain npo until tomorrow am but peg may be used for essential meds. rec'ing ns at 80cc/hr while tf on hold.\\ngu: good uop. cont po lasix.\\nid: afeb. cont on oxacillin. levo to be dc'd after today's dose.\\ncultures from pend.\\naccess: rsc double lumen. iv team contact to eval for picc line. (pt may need 1 more week of oxacillin for mssa in sputum.) r rad aline will be pulled this afternoon.\\nsocial: wife called this am. has note visited.\\nact: pt and ot eval pt. will require full lift to get oob.\\na: s/p trach and peg. tol well.\\np: begin vent wean as tol. pulm toilet. neuro rehab. follow temp. f/u w/ iv team re: picc. ready for screening for rehab placement.\\nsupport to family and pt.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332353,\n \"text\": \"Respiratory Care:\\nPt. initially tachypneac to 30's, VT's ~400cc, and appearing diaphoretic and agitated>>increased IPS to 14cmH20>>RR slowly decreased over course of the shift to mid teens, with VT's increasing to 6-800cc. ABG's essentially unchanged on both settings. Well oxygenated with a slight metabolic alkalosis. B/S continue course>>ETS for small to moderate yellow. Pt. continues very bronchospastic to SXN. Good relief with MDI's. Will continue pulmonary hygiene and attempts to wean as tolerated.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332354,\n \"text\": \"NURSING PROGRESS NOTE 7P-7A\\nS/O: PT. MECH VENTILATED.\\n\\nNEURO: OPENS EYES SPONTANEOUSLY, MOVES LEFT ARM LIFTS AND HOLDS, MOVES LEFT LEG ON BED. NO MOVEMENT ON RIGHT SIDE. FOLLOWS SIMPLE COMMANDS. SQUEEZES WITH LEFT HAND. FOLLOWS WITH EYES.\\n\\nCV: CONT ON LABETOLOL GTT. NEEDED TO INCREASE GTT RATE TO 3 MG FOR PERIOD OF TIME D/T BP 160-170'S. LABETOLOL GTT NOW AT 1 MG. CLONIDINE DOSE INCREASED AND TOL WELL. HR 90'S AFIB.\\n\\nRESP: SEE PROGRESS NOTE FROM RESP THERAPY. PRESENT VENT SETTINGS FIO2 40%, TV 800, PS 14 CPAP SUCTIONING FOR THICK WHITE SPUTUM. PT BECOMING WITH SUCTIONING. O2 SATS 97%. ABG UNCHANGED. SL. ALKALOTIC, RECEIVING DIAMOX 250 MG IV X 2 DOSES.\\n\\nGI: REMAINS ON TF PROMOTE WITH FIBER AT GOAL RATE OF 65 CC/HR. MIN RESIDUALS. + BOWEL SOUNDS, HOWEVER NO BM. ON COLACE . ? NEED FOR LAXATIVE TODAY.\\n\\nGU: FOLEY PATENT AND DRAINING CLEAR YELLOW URINE. DIURESING WELL FROM LASIX. CONT ON ABX FOR UTI.\\n\\nSKIN: SMALL QUARTER SIZE BLISTER NOTED ON RIGHT HEEL. BLISTER INTACT. MULTIPODUS SPLINTS ON. SMALL ABRSSION ON COCCYX COVERED WITH TEGADERM. SMALL SKIN ABRASION NOTED ON RIGHT FLANK. LEFT OPEN TO AIR. WASHED WITH SOAP AND WATER.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332355,\n \"text\": \"CCU NURSING PROGRESS NOTE 7A-7P\\n\\nNEURO: Pt awake and moving head side to side, however does not appear to be tracking with his eyes. PERL. Will squeeze left hand, however does not let go when asked. ?reflex vs. purposeful movement. No movement of right side.\\n\\nRESP: Remains vented on PSV 14/ peep 5. RR 20's most of the day. Sats maintained >97%. Suctioned q4 hrs for small-> mod amt thick white sputum. No plans to wean today given febrile state. Scheduled for trach Monday morning ~10am.\\n\\nCARDIAC: BP range 120-160's. Hydralazine and clonidine increased; able to d/c labetolol gtt while maintaining SBP 140-160 range. Remains in afib with rate 80-90's.\\n\\nGI: Abd soft distended with +BS. Given dulcolax suppository this am with good effect. Passed small amt soft brown stool. Tolerating goal tube feeds at 65cc/hr. To be NPO after 4am for trach and peg in am.\\n\\nGU: foley draining clear yellow urine. Pt is +435cc this evening. Conts on lasix and diamox.\\n\\nID: T max 102.2. Was fully cultured. Right SC DL was changed over a wire and tip was sent for cx. Pt may be a candidate for PICC given potential need for 10-14 days of IV abx. COnts on po levo and IV oxacillin for MSSA in urine and sputum. WBC up to 20 today. Given tylenol x2 today with temp down to 100.8 this evening.\\n\\nA/P: New temp spike on abx-> follow up with cx results.\\n Awaiting trach and peg in am. D/C tube feeds at 4am\\n Consult IV team for PICC placement.\\n Cont to assess for acute neuro changes\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332349,\n \"text\": \"SICU NPN\\nNEURO: OPENS EYES TO VOICE, AT TIMES SEEMS TO TRACK. VERY OCCASIONALLY FOLLOWING COMMANDS SUCH AS WIGGLING TOES (L SIDE ONLY), LIFTS L HAND, MOVES L LEG ON BED. NO MOVEMENT I R SIDE EXCEPT WITHDRAWAL OF R LEG TO PAINFUL STIMULI.\\n\\nCV: LABATELOL WEANED TO 1 MG/MIN. LOPRESSOR ^ TO 150MG TID, CLONIDINE .2MG , HYDRALAZINE REMAINS AT 40MG QID, NTP 1\\\" Q6HR. BP 137-160/58-70. (GOAL <160) HR 70'S A FIB.\\n\\nRESP: PS TO 10 (FROM 14) TV 400-500, RR 20'S, APPEARS COMFORTABLE.\\nSX Q 3 HRS FOT SM/MOD AMTS YEL SECRETIONS. LUNG SOUNDS COARSE.\\n\\nID: LOW GRADE TEMP, CONT ON LEVOQUIN\\n\\nGU: FOLEY DRAINING YEL URINE. GIVEN LASIX 40MG IV W/ EXCELLENT RESPONSE.\\n\\nGI: TOLERATING TF AT GOAL, NO STOOL TODAY. MINIMAL RESIDUALS.\\n\\nSOCIAL: WIFE MET W/ DR. THIS AFTERNOON. PLAN IS FOR PT TO HAVE TRACH AND PEG PLACEMENT MON OR TUES.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332350,\n \"text\": \"RESPIRATORY CARE:\\nPt. remains on unchanged vent support. RR low to high 20's, VT's 4-500cc on IPS=10cmH20. ABG was well oxygenated with with normal range acid-base. B/S continue course>>ETS for moderate to large amounts of thick yellow. Pt. very bronchospastic to SXN>>MDI's given post with good effect. Pt. appears to be tolerating present level of support. Will continue pulmonary hygiene.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332351,\n \"text\": \"NURSING PROGRESS NOTE 7P-7A\\nNEURO: PT. OPENS EYES TO COMMAND. FOLLOWS WITH EYES. MOVING LEFT ARM OFF BED AND ABLE TO HOLD. MOVING LEFT LEG ON BED. NO MOVEMENT OF RIGHT SIDE. WILL FOLLOW SOME SIMPLE COMMANDS. NO SEIZURE ACTIVITY NOTED.\\n\\nCV: CONT IN AFIB. RATE 80'S NO VEA BP STABLE ON LABETOLOL I MG. BP RANGE 150-160'S. TOL CARDIAC MEDS WELL.\\n\\nRESP: SEE FLOWSHEET FOR VENT SETTINGS. SUCTIONING FOR THICK YELLOW SPUTUM. LUNGS SOUNDS COARSE. O2 SATS 96-98%. ABG'S ADEQUATE.\\n\\nGU: FOLEY PATENT. DRAINING CLEAR YELLOW URINE. GIVEN LASIX AS ORDERED. DIURESING WELL FROM LASIX.\\n\\nGI: + BOWEL SOUNDS. TOL TF AT GOAL RATE OF 65 CC/HR. MIN RESIDUALS. NO BM OVERNIGHT. ABD SOFT, DISTENDED.\\n\\nSKIN: SMALL BLISTER NOTED ON RIGHT HEEL. OPEN TO AIR. SMALL ABRASION NOTED ON COCCYX.\\n\\nSTABLE OVERNIGHT, WAITING FOR TRACH AND PEG PLACEMENT NEXT WEEK.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-12-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332352,\n \"text\": \"CCU NURSING PROGRESS NOTE 7A-7P\\n\\nNEURO: Pt awake and following simple commands intermittently. Moving left arm and left leg; no movements noted of right side. PERL.\\n\\nRESP: LS coarse. Sxn'd q2-4 hrs for moderate amt thick white sputum. Attempted to decrease PSV to 8 however pt's rr increased to high 30's\\n(ABG essentially unchanged: 115/44/7.47). Placed back on PSV 10/5 with RR 27 Vt 400's. Awaiting trach and peg on Mon or Tues.\\n\\nCARDIAC: Bp 140-160's most of the day (which is goal range). Conts on labetolol gtt as well as multiple po cardiac meds. Tolerating well.\\n\\nGI: Tolerating tube feeds at goal rate of 65cc/hr. Abd soft distended. +BS. no stool this shift.\\n\\nGU: foley draining clear yellow urine. Rec'g IV lasix . Pt is >500cc negative this evening. Bun 36/ Creat 1.2.\\n\\nID: T max 99.8. WBC 12.1. Conts on po levo for UTI and started on IV oxacillin for MSSA in sputum.\\n\\nA/P: Stable day. Awaiting trach and peg\\n Maintain SBP 140-160 range.\\n Follow t-curve on abx.\\n Assess for acute neuro changes.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2147-12-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 150624,\n \"text\": \"Atrial fibrillation\\nSince last ECG, , no significant change\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2147-12-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 150625,\n \"text\": \"Atrial fibrillation\\nEarly R wave progressing\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2147-12-22 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 748454,\n \"text\": \" 1:23 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: PLEASE CONFIRM PICC TIP PLACEMENT TO RIGHT ARM; PAGE \\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 73 year old man with ICH.\\n temp spike r/o PNA\\n for central line position check\\n temp spike today- rt subclavian line changed over a wire today\\n for correct placement check\\n REASON FOR THIS EXAMINATION:\\n PLEASE CONFIRM PICC TIP PLACEMENT TO RIGHT ARM; PAGE WITH RESULTS.\\n THANKS..\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Intracranial hemorrhage and temperature spike, PICC placement.\\n\\n COMPARISON: .\\n\\n PORTABLE AP CHEST: The left PICC line terminates with tip in the proximal\\n SVC. The right subclavian central venous line and endotracheal tube are\\n unchanged. There are bibasilar nonspecific opacities, which could represent\\n atelectasis or alternatively, aspiration. The cardiomediastinal silhouette\\n and pulmonary vasculature are stable.\\n\\n IMPRESSION:\\n PICC tip in proximal SVC. Nonsecific patchy bibasilar opacities could\\n represent atelectasis or aspiration.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2147-12-14 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 747902,\n \"text\": \" 5:00 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: desatting on vent. on levoquin ? pneumonia\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 73 year old man with ICH.\\n temp spike r/o PNA\\n for central line position check\\n REASON FOR THIS EXAMINATION:\\n desatting on vent. on levoquin ? pneumonia\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Intracranial hemorrhage with new temperature spike.\\n\\n COMPARISON: .\\n\\n PORTABLE AP CHEST: Allowing for lordotic position, the ETT and right\\n subclavian central venous catheter and NG tube are in unchanged and\\n satisfactory position. The lung volumes are low but there is no consolidation.\\n There is continued improvement in patchy left basilar opacity likely related\\n to atelectasis.\\n\\n IMPRESSION: No evidence of pneumonia.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2147-12-17 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 748083,\n \"text\": \" 1:39 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: post line change\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 73 year old man with ICH.\\n temp spike r/o PNA\\n for central line position check\\n temp spike today- rt subclavian line changed over a wire today\\n for correct placement check\\n REASON FOR THIS EXAMINATION:\\n post line change\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST SINGLE AP FILM.\\n\\n HISTORY: Fever with change in right CV line. Evaluate for location and\\n pneumothorax.\\n\\n Endotracheal tube is 3 cm above carina. Right subclavian CV line is in mid\\n SVC. No pneumothorax. Apart from discoid atelectasis in the left lower zone\\n and linear atelectasis in the right midzone, the lungs are grossly clear.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2147-12-18 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 748174,\n \"text\": \" 9:57 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: s/p trach, please eval lung volumes; infiltrates\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 73 year old man with ICH.\\n temp spike r/o PNA\\n for central line position check\\n temp spike today- rt subclavian line changed over a wire today\\n for correct placement check\\n REASON FOR THIS EXAMINATION:\\n s/p trach\\n please eval lung volumes; infiltrates\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Status post tracheostomy with fever, check line placement.\\n\\n AP radiograph dated is compared with AP radiograph dated .\\n The ET tube has been removed. A tracheostomy tube is in proper position. The\\n right subclavian central venous catheter tip is located in the mid SVC. There\\n are adequate lung volumes. There is discoid atelectasis in the left lower lung\\n Zone. The lungs are otherwise clear.\\n\\n IMPRESSION: Satisfactory position of tracheostomy and right subclavian\\n central venous catheter. Adequate expansion of the lungs. No evidence of\\n infiltrate.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2147-12-19 00:00:00.000\",\n \"description\": \"VEN DUP EXTEXT BIL (MAP/DVT)\",\n \"row_id\": 748219,\n \"text\": \" 12:54 PM\\n DUP EXTEXT BIL (MAP/DVT) Clip # \\n Reason: ACUTELY DESATTED AND HYPERTENSIVE WITH RESIDUAL LOWER O/2 SATURATION,SOB ,EVAL FOR DVT\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 73 year old man with BASAL GANGLIA CVA\\n REASON FOR THIS EXAMINATION:\\n ACUTELY DESATTED AND HYPERTENSIVE WITH RESIDUAL LOWER O2 SATS\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Basal ganglia CVA, acutely desated and hypertensive with\\n bilateral lower extremity swelling.\\n\\n BILATERAL DVT STUDY:\\n\\n scale and Doppler son of both common femoral, superficial femoral,\\n and popliteal veins were performed. Normal flow, augmentation and\\n compressibility and wave forms are demonstrated. Intraluminal thrombus is not\\n identified.\\n\\n IMPRESSION: No evidence of DVT in either leg.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2147-12-19 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 748200,\n \"text\": \" 9:49 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: hemodynamics unsteady w/ decreased sats\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 73 year old man with ICH.\\n temp spike r/o PNA\\n for central line position check\\n temp spike today- rt subclavian line changed over a wire today\\n for correct placement check\\n REASON FOR THIS EXAMINATION:\\n hemodynamics unsteady w/ decreased sats\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Unsteady hemodynamics with decreased sats and fever.\\n\\n AP radiograph dated is compared with the radiograph dated .\\n\\n The heart size is normal. The mediastinal and hilar contours are normal. The\\n right subclavian central venous catheter tip is i proper position. The\\n endotracheal tube is in proper position. There is increased interstitial\\n pattern of opacification in the bases bilaterally. This likely represents\\n pulmonary edema. There are no pleural effusions. The soft tissues and\\n osseous structures are unremarkable.\\n\\n IMPRESSION: Though it is difficult to assess the pulmonary vasculature in\\n this supine radiograph, the increased interstitial pattern of pulmonary\\n opacity is suggestive of evolving pulmonary edema.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2147-12-09 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 747547,\n \"text\": \" 2:28 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: pt has elevated WBC count and increased secretions., rule ou\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 73 year old man with ICH.\\n eval ETT position\\n REASON FOR THIS EXAMINATION:\\n pt has elevated WBC count and increased secretions.\\n rule out infiltrate\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Elevated white count and increased secretions. Rule out infiltrate.\\n\\n CHEST, SINGLE AP PORTABLE VIEW.\\n\\n Lordotic positioning and low inspiratory volumes. Allowing for this, no\\n definite infiltrate. There is bibasilar atelectasis, presumably related to\\n low lung volumes. An ET tube is present, tip approximately 1.3 cm above the\\n carina, relatively low. An NG tube is present, tip obscured due to\\n underpenetration.\\n\\n IMPRESSION: Low lung volumes. Allowing for this, no definite infiltrate.\\n Attention to ET tube is recommended, as the positioning on today's exam seems\\n relatively low compared with 11/29.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2147-12-28 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 748839,\n \"text\": \" 10:15 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: r/o infiltrate, chf\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 73 year old man with ICH. prolonged resp failure w/ trach, now w/ inc WBC,\\n agitation, need to go back on vent\\n REASON FOR THIS EXAMINATION:\\n r/o infiltrate, chf\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 73 year old man with history of intracerebral hemorrhage and\\n prolonged respiratory failure, now with increasing white blood cell count,\\n aggitation and respiratory distress.\\n\\n AP portable radiograph of the chest dated , compared with prior AP\\n portable on .\\n\\n There is stable cardiomegaly. The mediastinal and hilar contours are\\n unchanged. There is a possible small left pleural effusion with atelectasis\\n at the left lung base. The remainder of the lung fields are clear. A\\n tracheostomy tube is seen in good position. The soft tissue and osseous\\n structures are unremarkable.\\n\\n IMPRESSION: Small left pleural effusion with left lower lobe atelectasis.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2148-01-02 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 749159,\n \"text\": \" 9:50 AM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: r/o progression of previous hemorrhage\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 73 year old man with left hemisphere hemorrhage. No significant change in his\\n neurological status over the last weeks. Resorption of hemorrhage?\\n REASON FOR THIS EXAMINATION:\\n r/o progression of previous hemorrhage\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Intraparenchymal hemorrhage, assess change. There has been interval\\n change in neurological status.\\n\\n There is a prior study dated .\\n\\n TECHNIQUE: Contiguous axial images were obtained from skull base to higher\\n convexities. No intravenous contrast was administered.\\n\\n FINDINGS: There is evolution of the left basal ganglia hemorrhage and\\n currently measures 3.1 x 1.7 cm with surrounding hypodensity consistent with\\n vasogenic edema. There was mild left-to-right midline shift of the normally\\n midline structures. This is decreased in comparison to the prior examination.\\n There is mass effect upon the left lateral ventricle. There is a small amount\\n of hemorrhage within the occipital horns bilaterally. There are no other areas\\n of hemorrhage. There is a stable old right temporal lobe infarct. There is a\\n calcified extra-axial mass off the higher convexities on the right which is\\n unchanged and probably represents a calcified meningioma. The bony calvarium\\n and paranasal sinuses are clear. The bony calvarium is intact.\\n\\n IMPRESSION: Evolution of the left basal ganglia hemorrhage. There is no\\n evidence of new hemorrhage.\\n\\n There is a small amount of intraventricular hemorrhage, as well.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2147-12-06 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 747344,\n \"text\": \" 12:01 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: known intraparenchymal hem, eval interval extension, shift,\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 73 year old man transferred for ICH with mass effect. Intubated.\\n REASON FOR THIS EXAMINATION:\\n known intraparenchymal hem, eval interval extension, shift, hydrocephalus\\n ______________________________________________________________________________\\n FINAL REPORT\\n CT SCAN OF THE BRAIN, :\\n\\n INDICATION: Follow up intracranial hemorrhage, assess for shift and\\n hydrocephalus.\\n\\n TECHNIQUE: Axial noncontrast CT scans of the brain were obtained.\\n\\n FINDINGS:\\n Comparison is made to the previous study of .\\n\\n There has been no extension of the large left basal ganglionic hemorrhage.\\n there is an intraventricular component of the hemorrhage, which is also\\n stable. The lateral ventricles are mildly dilated, but not significantly\\n changed in size, compared to the previous study. There is mild midline shift\\n to the right. This is not changed. The basal cisterns remain well visualized.\\n\\n There are no other changes in the appearance of the brain. Again noted is an\\n old right temporal lobe infarction and a high right frontal region calcified\\n mass, presumably a meningioma.\\n\\n IMPRESSION: Stable left basal ganglionic and intraventricular hemorrhage.\\n Mild ventricular dilatation.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2147-12-07 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 747437,\n \"text\": \" 2:38 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval ETT position\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 73 year old man with ICH.\\n eval ETT position\\n REASON FOR THIS EXAMINATION:\\n eval ETT position\\n ______________________________________________________________________________\\n FINAL REPORT\\n\\n CHEST, SINGLE AP FILM.\\n\\n ET Tube is 4 cm above carina. NG tube is in proximal stomach. There are\\n bibasilar subsegmental atelectases. No pneumothorax.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2147-12-10 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 747605,\n \"text\": \" 6:14 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: status post right subclavian catheter\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 73 year old man with ICH.\\n eval ETT position\\n for position of right subclavian catheter\\n REASON FOR THIS EXAMINATION:\\n status post right subclavian catheter\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 73 y/o man with intracranial hemorrhage, s/p ETT placement and\\n subclavian catheter placement.\\n\\n Portable AP radiograph of the chest dated at 6:28 P.M. is compared\\n with a portable AP radiograph of the chest dated .\\n\\n The ETT is approximately 3 cm above the carina. The right subclavian central\\n venous catheter tip is at the distal superior vena cava. There is lordotic\\n positioning and low lung volumes. Allowing for this, the cardiomediastinal\\n silhouette is within normal limits and stable. There is no consolidation,\\n effusion, or pneumothorax.\\n\\n IMPRESSION: ETT and right subclavian central venous catheter in satisfactory\\n position.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2147-12-10 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 747597,\n \"text\": \" 1:37 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: change in mental status, s/p intracranial bleed\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 73 year old man transferred for ICH with mass effect. Intubated.\\n REASON FOR THIS EXAMINATION:\\n change in mental status\\n s/p intracranial bleed\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Intracranial hemorrhage with mass effect, intubated with change\\n in mental status.\\n\\n COMPARISON: .\\n\\n TECHNIQUE: CT of the head without IV contrast.\\n\\n FINDINGS: Again seen is a left basal ganglia hemorrhage with a large amount\\n of hemorrhage present within the left lateral ventricle as well as hemorrhage\\n within the occipital of the right lateral ventricle. There is a stable\\n old right temporal lobe infarct. The calcified presumed meningioma in the\\n right frontal region is unchanged. Compared with the prior study there does\\n not appear to be a significant interval change in the ventricular size. The\\n hemorrhage within the third ventricle is less apparent on the present study.\\n There continues to be a small amount of shift of normal midline structures\\n which are not significantly changed from the prior study. There is edema\\n associated with the left basal ganglia hemorrhage that does not appear\\n significantly changed.\\n\\n IMPRESSION: No significant change from the prior study.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2147-12-12 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 747678,\n \"text\": \" 7:22 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: TEMP SPIKE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 73 year old man with ICH.\\n temp spike r/o PNA\\n REASON FOR THIS EXAMINATION:\\n r/o infiltrate\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 73 y/o man with intracranial hemorrhage and fever spike.\\n\\n COMPARISON: .\\n\\n PORTABLE SUPINE AP CHEST: The ETT, NG tube, and right subclavian line remain\\n in stable and satisfactory position. There are low lung volumes. The\\n cardiomediastinal silhouette is stable. There is no consolidation, CHF, or\\n effusion.\\n\\n IMPRESSION: No evidence of pneumonia.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2147-12-12 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 747715,\n \"text\": \" 1:47 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: post change of central venous catheter over a wire- for posi\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 73 year old man with ICH.\\n temp spike r/o PNA\\n for central line position check\\n REASON FOR THIS EXAMINATION:\\n post change of central venous catheter over a wire- for position of central\\n venous catheter\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL INDICATION: Central line catheter placement.\\n\\n Comparison is made to previous radiograph of earlier the same day.\\n\\n A right subclavian central venous catheter has been placed and terminates in\\n the distal superior vena cava. No pneumothorax is identified. However,\\n exclusion of the right costophrenic angle area from the radiograph limits\\n assessment for basilar pneumothorax.\\n\\n An endotracheal tube is in satisfactory position, allowing for flexed position\\n of the patient's neck. The nasogastric tube courses below the diaphragm.\\n\\n Cardiac and mediastinal contours are stable. A patchy left lower lobe opacity\\n shows some interval improvement. The right lung is grossly clear, allowing\\n for low lung volumes.\\n\\n IMPRESSION:\\n 1. Satisfactory placement of central venous catheter. No pneumothorax is\\n detected, but additional view to include entire right lung base would be\\n helpful to exclude basilar pneumothorax.\\n\\n 2. Improving left lower lobe opacity, likely due to atelectasis.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2147-12-05 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 747283,\n \"text\": \" 3:15 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: s/o intubation....distant BS on left...r/o PTX, ET tube migr\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 73 year old man with ICH.\\n REASON FOR THIS EXAMINATION:\\n s/o intubation....distant BS on left...r/o PTX, ET tube migration\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Intracranial hemorrhage, status post intubation with decreased\\n breath sounds on the left.\\n\\n FINDINGS: Single frontal view of the chest. Enotracheal tube tip resides 2.4\\n cm above the carina. There is bibasilar atelectasis which appears more\\n pronounced when compared with the prior study from five hours prior. There is\\n no congestive heart failure or dense consolidations. No pneumothoraces seen.\\n\\n IMPRESSION: Increased atelectasis at the bases bilaterally.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2147-12-05 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 747242,\n \"text\": \" 10:01 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval position of EG and OG\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 73 year old man with ICH.\\n REASON FOR THIS EXAMINATION:\\n eval position of EG and OG\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Tube check.\\n\\n Portable AP chest radiograph was performed. No prior studies.\\n\\n The ETT and OGT are appropriately positioned. There is tortuosity and\\n calcification of the aorta. The heart is difficult to assess but appears\\n slightly enlarged. There is vascular redistribution suggesting mild\\n congestive failure. There is a hazy opacity involving the entire right lung,\\n which may represent layering pleural effusion. There is no pneumothorax. The\\n osseous structures are unremarkable.\\n\\n IMPRESSION: Appropriately positioned ET and OG tube. Mild congestive failure\\n and probably a right-sided effusion.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2147-12-05 00:00:00.000\",\n \"description\": \"CT EMERGENCY HEAD W/O CONTRAST\",\n \"row_id\": 747238,\n \"text\": \" 9:25 AM\\n CT EMERGENCY HEAD W/O CONTRAST Clip # \\n Reason: eval ICH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 73 year old man transferred for ICH with mass effect. Intubated.\\n REASON FOR THIS EXAMINATION:\\n eval ICH\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Intracranial hemorrhage.\\n\\n TECHNIQUE: Noncontrast head CT.\\n\\n HEAD CT WITHOUT CONTRAST: There is a large intraparenchymal hemorrhage\\n centered in the left basal ganglia extending superiorly to the left corona\\n radiata and centrum semiovale and inferiorly to the posterior limb of the\\n internal capsule and thalamus. There is significant amount of\\n intraventricular blood, predominantly involving the left lateral ventricle.\\n There is a tiny amount of hemorrhage seen within the posterior of the\\n right lateral ventricle as well as in the left temporal and third\\n ventricle. There is some shift of normally midline structures to the right\\n with some subfalcine herniation. There is no evidence of uncal displacement.\\n\\n There is an area of hypodensity within the right temporal lobe with loss of\\n -white differentiation consistent with an old infarct. There is a large\\n calcified right frontal convexity meningioma measuring 2.8 cm.\\n\\n Mild mucosal thickening is noted within the ethmoid air cells.\\n\\n IMPRESSION: Large intraparenchymal hemorrhage centered in the left basal\\n ganglia, slight subfalcine herniation and intraventricular hemorrhage.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2147-12-25 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 748626,\n \"text\": \" 1:34 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: fever work up- r/o pnuemonia\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 73 year old man with ICH.\\n temp spike r/o PNA\\n for central line position check\\n temp spike today- rt subclavian line changed over a wire today\\n for correct placement check\\n fever work up r/o pneumonia\\n REASON FOR THIS EXAMINATION:\\n fever work up- r/o pnuemonia\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 73 YEAR OLD MAN WITH INTRACRANIAL HEMORRHAGE AND FEVER. EVALUATE\\n FOR PNEUMONIA.\\n\\n FINDINGS: The heart, mediastinal and hilar contours are unremarkable. There\\n has been decreased interval perihilar haziness and patchy bibasilar opacities.\\n There are no pleural effusions. A tracheostomy tube is seen with its tip\\n approximately 5 cm above the carina. The soft tissues and osseous structures\\n are unremarkable. There has been interval removal of the right subclavian\\n central venous line.\\n\\n IMPRESSION:\\n 1. Interval improvement in perihilar haziness and bibasilar patchy opacities.\\n 2. Interval removal of the right subclavian central venous line.\\n\\n\"\n }\n]"}}},{"rowIdx":378,"cells":{"subject_id":{"kind":"number","value":84629,"string":"84,629"},"hadm_id":{"kind":"number","value":111966,"string":"111,966"},"target_text":{"kind":"string","value":"51yoW h/o prior R basal ganglia stroke, syncope, HTN, PFO/ASD, and prior left cerebellar mass p/w right arm and leg weakness, dysarthria and dysphagia, subsequently developing a basilar artery occlusion which was removed via mechanical clot retrieval. [] Acute Cerebral Infarction - The patient presented initially with right-sided weakness, dysarthria and dysphagia with an NIHSS of more than 12 hours after the onset of symptoms after an initial evaluation at an outside hospital. She was not eligible for intravenous tPA or for mechanical thrombectomy initially. The patient said that her code status should be DNR/DNI. She was initially going to be uptitrated from Aspirin to Clopidogrel, but her MRI/MRA brain and MRA neck showed multiple bilateral posterior circulation strokes with flow voids in the basilar artery and poor flow in the vertebral arteries. The patient was placed on a Heparin infusion instead of Clopidogrel and was transferred to the Neuro ICU. The patient was asked by Dr. if she would agree to a clot retrieval procedure if it became necessary at a later time. The patient said that she might potentially agree to a clot retrieval procedure. Later at 3pm on , the patient started drooling and had nystagmus in all directions. She deteriorated rapidly. She became anarthric and quadiparetic. Given her contrast allergy, she was premedicated before she underwent CTA head and neck. The CTA subsequently showed a basilar artery occlusion. The patient was unable to give consent at this time. Her daughter gave consent for a clot retrieval and/or balloon angioplasty and/or stenting procedure. The daughter agreed that her mother's code status could be reversed to FULL code during the procedure. She was intubated and brought to the angiography suite for emergent mechanical clot retrieval which resulted in partial recanalization. After two passes with the MERCI clot retrieval device, the proximal half of the basilar artery was partially opened up. However, the basilar artery reoccluded twice and required intra-arterial tPA, eptifibatide, and balloon angioplasty to remain patent. She was brought back to the Neuro ICU for further stabilization and management. Her daughter asked that her code status be changed to DNR at that time. Her exam improved and stabilized. On while still intubated, she was alert, oriented to year and place. She was able to show two fingers with the left hand. She had 3/5 strength of the left forearm, 2/5 strength of the right arm, and 2/5 strength of both legs. MRA head, CTA head, and conventional angiogram showed a severe distal V4 segment stenosis of the left vertebral artery. This stenosis likely served as the nidus from which the proximal basilar artery thrombosis and occlusion evolved. There were multiple emboli from the proximal basilar artery to distal parts of the posterior circulation. Unfortunately, there was no prior vessel imaging from her or admissions for our review. Her prior HgbA1c and lipid panel from were relatively unremarkable. TTE with bubble study did not reveal significant valvular disease or an intracardiac shunt. She had autoimmmune and coagulopathy studies sent. During conversation with her daughter , said that once her mother was extubated, that her code status should be DNR/DNI. Given her stable clinical status, she was extubated just before 5pm on , but about 25 minutes later she suddenly became bradycardic and hypotensive. Code status was reconfirmed as DNR/DNI by the patient's daughter who was at the bedside. Attempts were made with IV fluids and three pressor agents to improve her hemodynamic status, but this never recovered, and the patient was declared deceased at 7:20PM. The family agreed to an autopsy."},"extractive_notes_summ":{"kind":"string","value":"There is thrombus sitting in the basilar artery with occlusion of the right PCA. The axial T2-weighted images demonstrate a loss of the normal flow void in the basilar artery. A check angiogram showed persistent partial occlusion of the basilar artery. Unchanged 1-cm left pontine hypodensity representing infarct seen on MRI of . A firm Merci 2 2.5 self-retrieval device was then deployed, and withdrawn under roadmap guidance into the right vertebral artery. Susceptibility artifact in the left mid brain and left cerebellum indicated petechial hemorrhages. CTA demonstrated occlusion of the basilar artery. MRI c/w distal vertebral and basilar artery thrombosis. Interval small amount of subarachnoid hemorrhage layering along the left parietal sulci. COMPARISON: MRI/MRA head dated . A preliminary report was issued that read \"no enhancement of distal bilateral V4 segments and basilar artery presumably secondary to distal vertebral and basilar artery thrombosis. FINDINGS: HEAD CT: There is a vague hypodensity in the left paramedian pontine region indicative of an infarct seen on the previous MRI. FINAL REPORT MRI AND MRA BRAIN AND NECK WITHOUT AND WITH CONTRAST HISTORY: Prior infarction. Scattered small acute infarcts in the left occipital lobe, right cerebellum, right pons, and possibly left pons. Scattered small acute infarcts in the left occipital lobe, right cerebellum, right pons, and possibly left pons. Right vertebral artery angiogram. A repeat right vertebral artery angiogram was then performed. Head CT shows a left paramedian pontine hypodensity indicative of infarcts seen on the MR done earlier. Left thalamic and bilateral cerebellar infarcts are seen and some extension in the left pontine infarct is noted. FINDINGS: Single portable view of the chest shows a right upper extremity PICC line whose tip terminates within the atriocaval junction. Right posterior cerebral artery angiogram. Right basilar artery angiogram. Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK Contrast: OPTIRAY Amt: 70 FINAL REPORT (Cont) Right ventricular chamber size and free wall motion arenormal. FINDINGS: Single portable frontal view of the chest shows a right upper extremity PICC line which courses into the left brachiocephalic. A selective arteriogram through the right vertebral artery was performed, and confirmed placement. CT angiography of the head demonstrates high-grade stenosis of the distal left vertebral artery and proximal basilar artery with diminished flow distally as described above. FINDINGS: Right vertebral arteriogram showed a dominant right vertebral artery. Right superior cerebellar artery angiogram. There has been placement of an endotracheal tube whose distal tip is 3.4 cm above the carina, appropriately sited. A repeat angiogram showed persistent occlusion. Susceptibility abnormalities are seen in left side of midbrain and left cerebellum indicating petechial hemorrhages. Merci thrombectomy of basilar artery thrombus. These findings are indicative of stenosis or clot within the basilar artery. PATIENT/TEST INFORMATION:Indication: ?PFO LV/RV FunctionHeight: (in) 69Weight (lb): 175BSA (m2): 1.95 m2BP (mm Hg): 108/49HR (bpm): 61Status: InpatientDate/Time: at 10:19Test: Portable TTE (Congenital, complete)Doppler: Full Doppler and color DopplerContrast: SalineTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. INDICATION: For reperfusion and recanalization of the vertebrobasilar system. A repeat arteriogram through the right vertebral artery was then performed, and this showed persistent clot in the basilar artery. Following this, the right common femoral artery arteriogram was done. Petechial hemorrhages are seen in the left mid brain and left cerebellum. Petechial hemorrhages are seen in the left mid brain and left cerebellum. CONCLUSION: Apparent mid basilar severe stenosis or occlusion with multiple posterior circulation infarctions. Incidental note is made of right maxillary sinus opacification. Following recanalization of the basilar artery, the vessel demonstrates flow-related enhancement with high-grade irregularity of the lumen diameter, which is difficult to evaluate with regard to motion artifacts, but most likely represents residual stenosis. REASON FOR THIS EXAMINATION: s/p clot retrieval. The superior cerebellar artery was patent. A Merci retriever V 3.0 firm device was then deployed across the thrombus in the proximal basilar artery, and withdrawn into the (Over) 5:07 PM CAROT/CEREB Clip # Reason: New vascular insult Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK Contrast: OPTIRAY Amt: 241 FINAL REPORT (Cont) right vertebral artery under constant suction with a Penumbra System. Right superior cerebellar artery arteriogram showed a patent right superior cerebellar artery. Minor T wave abnormalities. MRA NECK: (Over) 3:09 PM MR HEAD W/O CONTRAST; MRA NECK W/O CONTRAST Clip # Reason: evaluate evolution Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK FINAL REPORT (Cont) The neck MRA demonstrates normal flow in the carotid and vertebral arteries without stenosis or occlusion."},"n_notes":{"kind":"number","value":15,"string":"15"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2195-07-11 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1203713,"text":" 3:59 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ETT position\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman s/p intubation\n REASON FOR THIS EXAMINATION:\n ETT position\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest, .\n\n CLINICAL HISTORY: Patient with endotracheal tube placement.\n\n FINDINGS: Comparison is made to previous study from .\n\n There has been placement of an endotracheal tube whose distal tip is 3.4 cm\n above the carina, appropriately sited. There is a feeding tube whose distal\n tip and sideport are below the gastroesophageal junction. The cardiac\n silhouette and mediastinum are normal. There is focal consolidation in the\n right upper lobe which may represent pneumonia. Followup to resolution is\n recommended. There are no signs of pulmonary edema or pleural effusions.\n\n"},{"category":"Radiology","chartdate":"2195-07-13 00:00:00.000","description":"BILAT LOWER EXT VEINS","row_id":1203913,"text":" 11:04 AM\n BILAT LOWER EXT VEINS Clip # \n Reason: assess for DVT\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman with stroke.\n REASON FOR THIS EXAMINATION:\n assess for DVT\n ______________________________________________________________________________\n WET READ: KKgc MON 4:42 PM\n No DVT in both lower extremities.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 51-year-old woman with stroke, to evaluate for DVT.\n\n COMPARISON: None available.\n\n TECHNIQUE: Grayscale and Doppler son of bilateral common femoral,\n superficial femoral, deep femoral, popliteal and proximal calf veins were\n performed. There is normal compressibility, flow and augmentation throughout.\n\n IMPRESSION: No DVT in both lower extremities.\n\n\n"},{"category":"Radiology","chartdate":"2195-07-12 00:00:00.000","description":"MR HEAD W/O CONTRAST","row_id":1203810,"text":" 3:09 PM\n MR HEAD W/O CONTRAST; MRA NECK W/O CONTRAST Clip # \n Reason: evaluate evolution\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman with vertebral and basilar artery thrombosis s/p clot removal\n REASON FOR THIS EXAMINATION:\n evaluate evolution\n CONTRAINDICATIONS for IV CONTRAST:\n lack of IV access\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AFSN SUN 5:19 PM\n PFI: Since the previous MRI, there have been multiple new small infarcts in\n both cerebellar hemispheres and in the left thalamus as well as some extension\n of the left pontine infarct. Petechial hemorrhages are seen in the left mid\n brain and left cerebellum. MRA of the neck is unremarkable.\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: MRI BRAIN AND MRA OF THE NECK.\n\n CLINICAL INFORMATION: Patient with vertebrobasilar thrombosis status post\n clot retraction, for further evaluation.\n\n TECHNIQUE: T1 sagittal and T2 susceptibility and diffusion axial images\n of the brain were acquired. 2D and 3D time-of-flight MRA of the neck vessels\n were obtained. Gadolinium-enhanced MRA of the neck was not obtained as per\n the clinical request as the patient has no IV access.\n\n FINDINGS: BRAIN MRI:\n\n Comparison was made with the previous MRI examination of .\n\n There are now multiple new infarcts seen in the posterior circulation.\n Several new cerebellar infarcts are identified in both hemispheres. A left\n thalamic infarct is also now apparent, as well as the previously seen left\n paramedian pontine infarct has slightly increased in size. Susceptibility\n abnormalities are seen in left side of midbrain and left cerebellum indicating\n petechial hemorrhages. There is no midline shift or hydrocephalus. There are\n soft tissue changes in the left maxillary sinus and mucosal thickening in the\n remaining sinuses with retained secretions in the nasopharynx.\n\n Note is made of increased signal within the left transverse sinus on\n T2-weighted images could be secondary to slow flow as this sinus was well\n visualized on the previous MRA study.\n\n IMPRESSION: Multiple new infarcts are now identified since the previous MRI\n examination of . Left thalamic and bilateral cerebellar infarcts are\n seen and some extension in the left pontine infarct is noted. Susceptibility\n artifact in the left mid brain and left cerebellum indicated petechial\n hemorrhages.\n\n MRA NECK:\n (Over)\n\n 3:09 PM\n MR HEAD W/O CONTRAST; MRA NECK W/O CONTRAST Clip # \n Reason: evaluate evolution\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n The neck MRA demonstrates normal flow in the carotid and vertebral arteries\n without stenosis or occlusion.\n\n IMPRESSION: Normal MRA of the neck.\n\n"},{"category":"Radiology","chartdate":"2195-07-12 00:00:00.000","description":"MR HEAD W/O CONTRAST","row_id":1203811,"text":", C. NMED SICU-B 3:09 PM\n MR HEAD W/O CONTRAST; MRA NECK W/O CONTRAST Clip # \n Reason: evaluate evolution\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman with vertebral and basilar artery thrombosis s/p clot removal\n REASON FOR THIS EXAMINATION:\n evaluate evolution\n CONTRAINDICATIONS for IV CONTRAST:\n lack of IV access\n ______________________________________________________________________________\n PFI REPORT\n PFI: Since the previous MRI, there have been multiple new small infarcts in\n both cerebellar hemispheres and in the left thalamus as well as some extension\n of the left pontine infarct. Petechial hemorrhages are seen in the left mid\n brain and left cerebellum. MRA of the neck is unremarkable.\n\n"},{"category":"Radiology","chartdate":"2195-07-13 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":1203924,"text":" 12:30 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: 44cm DL R brachial PICC placed ? tip - \n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman with new R PICC\n REASON FOR THIS EXAMINATION:\n 44cm DL R brachial PICC placed ? tip - \n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: PICC placement.\n\n FINDINGS: Single portable frontal view of the chest shows a right upper\n extremity PICC line which courses into the left brachiocephalic. Withdrawal\n and repositioning is recommended. The ET tube and feeding tube are in\n standard position. There is atelectasis of the left lung base. Otherwise,\n the lungs are unchanged.\n\n IMPRESSION: Poorly positioned. Right upper extremity PICC.\n\n These findings were discussed with by telephone at the time of this\n dictation.\n\n"},{"category":"Radiology","chartdate":"2195-07-13 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1203979,"text":" 5:33 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: evidence of consolidation?\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman recently extubated with productive cough\n REASON FOR THIS EXAMINATION:\n evidence of consolidation?\n ______________________________________________________________________________\n WET READ: DLrc MON 8:24 PM\n Right upper lobe consolidation is improving since . No new areas of\n consolidation.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 6:22 P.M. ON \n\n HISTORY: Recently extubated patient with a productive cough, question\n consolidation.\n\n IMPRESSION: AP chest compared to through 22 at 1:55 p.m.:\n\n There is the suggestion of a region of greater opacity in the right mid lung,\n but I am hesitant to call at pneumonia. PA and lateral view should really be\n obtained to see if there is any pulmonary abnormality. Lungs are otherwise\n clear and there is no pleural effusion. Heart size is normal and there is no\n pleural effusion. Right PIC line ends in the right atrium at least 5 cm\n beyond the estimated location of the superior cavoatrial junction. No\n endotracheal tube visible on the imaged portion of the trachea below the level\n of C7.\n\n\n"},{"category":"Radiology","chartdate":"2195-07-12 00:00:00.000","description":"MRA BRAIN W/O CONTRAST","row_id":1203836,"text":" 9:15 PM\n MRA BRAIN W/O CONTRAST Clip # \n Reason: eval evolution\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman with basal ganglia infarct s/p clot removal + tPA, integrelin\n REASON FOR THIS EXAMINATION:\n eval evolution\n CONTRAINDICATIONS for IV CONTRAST:\n lack of IV access\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 51-year-old man with basilar artery occlusion and interventional\n recanalization.\n\n COMPARISON: MRI/MRA head dated .\n\n TECHNIQUE: Axial 3D TOF of the intracranial vessels was obtained without\n contrast and multiple MIP reconstructions were displayed.\n\n FINDINGS: The image quality of the current study is somewhat degraded by\n motion artifacts.\n Following recanalization of the basilar artery, the vessel demonstrates\n flow-related enhancement with high-grade irregularity of the lumen diameter,\n which is difficult to evaluate with regard to motion artifacts, but most\n likely represents residual stenosis.\n\n Diffuse atherosclerotic changes are, moreover, seen in the posterior cerebral\n arteries as well as the anterior circulation, most notably the intracranial\n carotid arteries at the level of the cavernous and ophthalmic segments.\n Otherwise, the anterior and middle cerebral arteries demonstrate normal\n flow-related enhancement with no evidence of occlusion.\n\n Incidental note is made of right maxillary sinus opacification.\n\n IMPRESSION: High-grade lumen irregularity of the recanalized basilar artery\n which is difficult to evaluate in the setting of extensive motion artifacts,\n but may represent persistent stenosis.Suggest follow up imaging evaluation\n with CTA.\n\n"},{"category":"Radiology","chartdate":"2195-07-10 00:00:00.000","description":"MR HEAD W & W/O CONTRAST","row_id":1203627,"text":" 10:10 PM\n MR HEAD W & W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n MRA NECK W&W/O CONTRAST\n Reason: Infarct versus mass versus evidence of infection versus vasc\n Contrast: MAGNEVIST Amt: 18\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51F status post CVA in , went to outside hospital this morning, complaints\n of worsened dysarthria and right-sided weakness of the arm and leg since she\n awoke this morning. Also complained of generalized weakness since yesterday. He\n head CT is outside hospital negative for bleed, concerning for possible\n subacute infarct, transferred to for neurologic evaluation.\n REASON FOR THIS EXAMINATION:\n Infarct versus mass versus evidence of infection versus vasculitis\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: SAT 3:07 AM\n 1. No enhancement of distal bilateral V4 segments and basilar artery\n presumably secondary to distal vertebral and basilar artery thrombosis. The\n right P1 segment is vaguely seen, but the remaining portions of the PCAs\n bilaterally are not visualized. Small PCOMMs are seen bilaterally.\n 2. Left A1 segment is narrowed, could be due to hypoplasia and/or\n atherosclerosis.\n 3. Scattered small acute infarcts in the left occipital lobe, right\n cerebellum, right pons, and possibly left pons.\n 4. Complete opacification of the left maxillary sinus.\n ______________________________________________________________________________\n FINAL REPORT\n MRI AND MRA BRAIN AND NECK WITHOUT AND WITH CONTRAST \n\n HISTORY: Prior infarction. Now with worsening dysarthria and right-sided\n weakness.\n\n Sagittal short TR, short TE spin echo imaging was performed through the brain.\n Axial imaging was performed with , TR, long TE fast spin echo,\n gradient echo, diffusion, and 3D time-of-flight MRA technique.\n Gadolinium-enhanced MRA was performed through the neck. Comparison to a brain\n MR .\n\n FINDINGS: There are multiple areas of new infarction since the prior study.\n These are most prominent in the pons, predominantly on the left, where there\n is associated hemorrhage. There are also small infarctions in the right\n cerebellar hemisphere of the left occipital lobe, and the right cerebral\n peduncle. These all implicate posterior circulation abnormalities. The brain\n MRA demonstrates very poor signal arising from the basilar artery and its\n branches. The distal vertebral arteries are visualized on the non-contrast\n MRA but the vertebrobasilar junction is not. The axial T2-weighted images\n demonstrate a loss of the normal flow void in the basilar artery. The\n gadolinium-enhanced neck MRA source images demonstrate the distal vertebral\n arteries, the vertebrobasilar junction, and the distal basilar artery. This\n suggests that these vessels are patent but experiencing extremely slow flow,\n responsible for the poor visualization on the non-contrast time-of-flight\n images. However, the mid basilar is not opacified on the gadolinium MRA.\n (Over)\n\n 10:10 PM\n MR HEAD W & W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n MRA NECK W&W/O CONTRAST\n Reason: Infarct versus mass versus evidence of infection versus vasc\n Contrast: MAGNEVIST Amt: 18\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Overall, these findings suggest a focal area of severe stenosis or thrombosis\n in the mid basilar artery with poor runoff for the vertebral arteries and\n reduced flow through the superior cerebellar and posterior cerebral arteries.\n This would explain the distribution of infarction seen on the diffusion\n images.\n\n The MRA also demonstrates loss of the A1 segment of the left anterior cerebral\n artery, which was present on the MR examination of . There is\n no evidence of infarction in the A1 distribution.\n\n Images of the remainder of the brain demonstrate no other areas of hemorrhage\n or infarction. The remainder of the intracranial branches appear normal.\n\n A preliminary report was issued that read \"no enhancement of distal bilateral\n V4 segments and basilar artery presumably secondary to distal vertebral and\n basilar artery thrombosis. The right P1 segment is vaguely seen, but\n remaining portions of the PCAs bilaterally are not well visualized. Small\n posterior communicating arteries are seen bilaterally.\n\n 2. Left A1 segment is narrowed, could be due to hypoplasia or\n atherosclerosis.\n\n 3. Scattered small acute infarcts in the left occipital lobe, right\n cerebellum, right pons, and possibly left pons.\n\n 4. Complete opacification of the left maxillary sinus.\n\n discussed with Dr. at 3:03 a.m. via telephone on .\"\n\n CONCLUSION: Apparent mid basilar severe stenosis or occlusion with multiple\n posterior circulation infarctions. There is a small amount of hemorrhage in\n the pons associated with these infarctions.\n\n\n"},{"category":"Radiology","chartdate":"2195-07-11 00:00:00.000","description":"CTA HEAD W&W/O C & RECONS","row_id":1203717,"text":" 4:30 PM\n CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # \n Reason: bleeding?\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n Contrast: OPTIRAY Amt: 70\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman with basilar clot with acute decompensation.\n REASON FOR THIS EXAMINATION:\n bleeding?\n CONTRAINDICATIONS for IV CONTRAST:\n allergic;stat - confirmed with rads attending\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: CTA of the head and neck.\n\n CLINICAL INFORMATION: Patient with basilar artery clot, for further\n evaluation.\n\n TECHNIQUE: Axial images of the head were obtained without contrast.\n Following this using departmental protocol CT angiography of the head and neck\n acquired. 3D reformatted images were obtained on independent workstation.\n\n FINDINGS:\n\n HEAD CT: There is a vague hypodensity in the left paramedian pontine region\n indicative of an infarct seen on the previous MRI. No hemorrhage seen.\n\n CT ANGIOGRAPHY NECK: CT angiography of the neck demonstrates normal flow in\n the carotid and vertebral arteries. The left vertebral artery is smaller in\n size compared to the right which could be a variation. The V1, V2, and V3\n segments of the vertebral arteries are patent without stenosis or occlusion.\n\n CT ANGIOGRAPHY HEAD: The CT angiography of the head demonstrates narrowing of\n the distal left vertebral artery prior to the vertebrobasilar junction. In\n addition, the proximal one-half of the basilar artery is markedly narrowed\n with diminished flow. There is also diminished flow seen in the distal\n basilar artery. The right posterior cerebral artery is not well visualized\n and the left posterior cerebral artery flow is markedly diminished. These\n findings are indicative of stenosis or clot within the basilar artery.\n\n The anterior circulation is patent without stenosis or occlusion. Both A1\n segments of the anterior cerebral arteries are seen although the left side is\n slightly smaller than the right, in variation.\n\n IMPRESSION:\n 1. Head CT shows a left paramedian pontine hypodensity indicative of infarcts\n seen on the MR done earlier.\n 2. CT angiography of the neck demonstrates no evidence of dissection,\n stenosis, or occlusion in the neck vessels.\n 3. CT angiography of the head demonstrates high-grade stenosis of the distal\n left vertebral artery and proximal basilar artery with diminished flow\n distally as described above.\n (Over)\n\n 4:30 PM\n CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # \n Reason: bleeding?\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n Contrast: OPTIRAY Amt: 70\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"},{"category":"Radiology","chartdate":"2195-07-12 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":1203753,"text":" 2:10 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: s/p clot retrieval. Please perform at 0200 on .\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman with basilar clot s/p clot retrieval.\n REASON FOR THIS EXAMINATION:\n s/p clot retrieval. Please perform at 0200 on .\n CONTRAINDICATIONS for IV CONTRAST:\n not indicated\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 51-year-old woman, with basilar clot. Status post clot retrieval.\n\n COMPARISON: Multiple prior studies including CTA head on and\n cerebral on at 1707.\n\n TECHNIQUE: Non-contrast MDCT images were acquired through the brain.\n Multiplanar reformatted images were obtained for evaluation.\n\n FINDINGS: Small amount of subarachnoid layering in the high parietal sulci is\n new. There is no evidence of intraventricular hemorrhagic extension. No\n acute major vascular territorial infarct is noted. The -white matter\n differentiation is well preserved. The ventricles and sulci remained normal\n in size and symmetric in configuration. There is no shift of normally midline\n structure. A 10 mm rounded hypodensity (image 2:8) in the left pons is\n unchanged, likely represent an old infarct. There is no acute fracture.\n\n IMPRESSION:\n 1. Interval small amount of subarachnoid hemorrhage layering along the left\n parietal sulci. No intraventricular hemorrhagic extension. No evidence of\n developing hydrocephalus.\n 2. Unchanged 1-cm left pontine hypodensity representing infarct seen on MRI\n of .\n\n"},{"category":"Radiology","chartdate":"2195-07-11 00:00:00.000","description":"PRIMARY MECH THROMBECTOMY ART/BPG; INITIAL VESSEL","row_id":1203723,"text":" 5:07 PM\n CAROT/CEREB Clip # \n Reason: New vascular insult\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n Contrast: OPTIRAY Amt: 241\n ********************************* CPT Codes ********************************\n * PRIMARY MECH THROMBECTOMY ART/ SEL CATH 3RD ORDER *\n * -51 MULTI-PROCEDURE SAME DAY VERT/CAROTID A-GRAM *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 RHF with precent right basal ganglia infarct in , transferred from\n an outside hospital more than 12 hours after new onset right sided weakness in\n arm and leg, dysarthria and dysphagia. MRI c/w distal vertebral and basilar\n artery thrombosis.\n REASON FOR THIS EXAMINATION:\n New vascular insult\n ______________________________________________________________________________\n FINAL REPORT\n DATE OF SERVICE: .\n\n PREOPERATIVE DIAGNOSIS: Acute stroke with basilar artery occlusion.\n\n INDICATION: For reperfusion and recanalization of the vertebrobasilar system.\n The patient had presented with a significant stroke. CTA demonstrated\n occlusion of the basilar artery. We felt it would be worthwhile to reopen the\n basilar artery which was occluded with thrombus.\n\n PROCEDURE PERFORMED:\n\n 1. Right vertebral artery angiogram.\n 2. Right superior cerebellar artery angiogram.\n 3. Right posterior cerebral artery angiogram.\n 4. Right basilar artery angiogram.\n 5. Merci thrombectomy of basilar artery thrombus.\n 6. Chemical thrombolysis of right posterior cerebral artery and basilar\n artery.\n\n DETAILS OF PROCEDURE:\n\n The patient was brought to the angiography suite. Following this, a safety\n timeout was obtained. The entire procedure was performed under general\n anesthesia. We gained access to the right common femoral artery using a\n Seldinger technique, and an 8 French long vascular sheath was advanced into\n the right common femoral artery. Subsequently, a 5 French 2 catheter\n was advanced, and the right vertebral artery was selected. On CTA, this was\n the dominant vertebral artery. Over a long exchange glidewire, the 2\n catheter was exchanged for an 8 French Merci sheath, which was placed in the\n right vertebral artery. The basilar artery was then selected. It was\n catheterized with an 18 L microcatheter, and an X-Pedion 014 wire. A\n selective arteriogram through the right vertebral artery was performed, and\n confirmed placement. A Merci retriever V 3.0 firm device was then deployed\n across the thrombus in the proximal basilar artery, and withdrawn into the\n (Over)\n\n 5:07 PM\n CAROT/CEREB Clip # \n Reason: New vascular insult\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n Contrast: OPTIRAY Amt: 241\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n right vertebral artery under constant suction with a Penumbra System.\n Following this, a check arteriogram was performed. This demonstrated\n non-filling of the right PCA. The microcatheter was advanced into the right\n PCA, and this was injected with approximately 3 mg of TPA. A repeat\n arteriogram through the right vertebral artery was then performed, and this\n showed persistent clot in the basilar artery. A firm Merci 2 2.5\n self-retrieval device was then deployed, and withdrawn under roadmap guidance\n into the right vertebral artery. A repeat angiogram showed persistent\n occlusion. A further 4 mg of TPA was injected into the basilar artery.\n\n A repeat right vertebral artery angiogram was then performed. There was\n persistent clot formation in the basilar artery. A discussion was held with\n the neurologist, and a decision was made to administer further TPA into the\n basilar artery. However, there was persistent irregularity of the basilar\n artery, and this was felt to be due to endothelial denudation. A Sprinter\n Legend RX 2.5 mm x 20 mm balloon was then advanced into the basilar artery,\n and this was angioplastied. The balloon was inflated with an insufflation\n device, and held at 8 atmospheres for approximately 30 seconds. The balloon\n catheter was then withdrawn. A check angiogram showed persistent partial\n occlusion of the basilar artery. A decision was then made to administer 15 mg\n of Integrilin, and a repeat right vertebral arteriogram was performed after\n five minutes. This showed relative patency of the basilar artery with\n improved flow. The consideration towards placement of a stent was\n subsequently abandoned. An OGT was then placed, and the patient was given 600\n mg of Plavix. Following this, the right common femoral artery arteriogram was\n done. This showed a widely patent right common femoral artery. At this\n point, an 8 French Angio-Seal was used for closure, and to secure hemostasis.\n\n FINDINGS: Right vertebral arteriogram showed a dominant right vertebral\n artery. There is thrombus sitting in the basilar artery with occlusion of the\n right PCA. The superior cerebellar artery was patent.\n\n Right superior cerebellar artery arteriogram showed a patent right superior\n cerebellar artery.\n\n Right posterior cerebral artery arteriogram showed an occluded right posterior\n cerebral artery, which was subsequently recanalized with 3 mg of TPA.\n\n IMPRESSION:\n\n Basilar artery thrombus was treated with successful recanalization of the\n basilar artery. The patient underwent TPA administration into the basilar\n artery, as well as the right posterior cerebral artery. She was also\n angioplastied with a 2.5 mm balloon, and 15 mg of Integrilin was administered\n iv. The patient was placed on 600 mg of Plavix. The neurologist was present\n (Over)\n\n 5:07 PM\n CAROT/CEREB Clip # \n Reason: New vascular insult\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n Contrast: OPTIRAY Amt: 241\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n throughout the entire procedure.\n\n"},{"category":"Radiology","chartdate":"2195-07-13 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1203939,"text":" 1:48 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: rue picc powerflushed x 4: re-assess tip #\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman with right picc crossing midline. powerflushed x 4 to help\n re-position picc\n REASON FOR THIS EXAMINATION:\n rue picc powerflushed x 4: re-assess tip #\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: PICC re-positioning.\n\n FINDINGS: Single portable view of the chest shows a right upper extremity\n PICC line whose tip terminates within the atriocaval junction. The ET tube is\n approximately 3 cm above the carina. Feeding tube is within the stomach.\n Lungs are unchanged. No pneumothorax.\n\n IMPRESSION: Properly positioned right upper extremity PICC.\n\n\n"},{"category":"Radiology","chartdate":"2195-07-11 00:00:00.000","description":"R KNEE (2 VIEWS) RIGHT","row_id":1203650,"text":" 7:35 AM\n KNEE (2 VIEWS) RIGHT Clip # \n Reason: fracture? effusion? arthritis?\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman with CVA who is complaining of right knee pain.\n REASON FOR THIS EXAMINATION:\n fracture? effusion? arthritis?\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Right knee, two views, .\n\n CLINICAL HISTORY: 51-year-old woman with CVA with complaint of right knee\n pain. Evaluate for fracture.\n\n FINDINGS: There are no signs for acute fractures or dislocations. There is\n minimal spurring involving the medial compartment as well as the inferior\n aspect of the patella. There is no joint effusion. There are no focal lytic\n or blastic lesions.\n\n IMPRESSION:\n\n Mild spurring without signs for acute bony injury.\n\n"},{"category":"Echo","chartdate":"2195-07-11 00:00:00.000","description":"Report","row_id":65171,"text":"PATIENT/TEST INFORMATION:\nIndication: ?PFO LV/RV Function\nHeight: (in) 69\nWeight (lb): 175\nBSA (m2): 1.95 m2\nBP (mm Hg): 108/49\nHR (bpm): 61\nStatus: Inpatient\nDate/Time: at 10:19\nTest: Portable TTE (Congenital, complete)\nDoppler: Full Doppler and color Doppler\nContrast: Saline\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD or PFO by 2D, color\nDoppler or saline contrast with maneuvers.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. Normal mitral\nvalve supporting structures. No MS. Trivial MR. Normal LV inflow pattern for\nage.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal\ntricuspid valve supporting structures. No TS. Normal PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR. Normal main PA. No Doppler evidence for PDA\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Contrast study was performed with 3 iv injections of 8 ccs\nof agitated normal saline, at rest, with cough and post-Valsalva maneuver.\n\nConclusions:\nThe left atrium is normal in size. No atrial septal defect or patent foramen\novale is seen by 2D, color Doppler or saline contrast with maneuvers. Left\nventricular wall thickness, cavity size and regional/global systolic function\nare normal (LVEF 70%). Right ventricular chamber size and free wall motion are\nnormal. The aortic valve leaflets (3) appear structurally normal with good\nleaflet excursion and no aortic stenosis or aortic regurgitation. The mitral\nvalve appears structurally normal with trivial mitral regurgitation. Trivial\nmitral regurgitation is seen. The estimated pulmonary artery systolic pressure\nis normal. There is no pericardial effusion.\n\nCompared with the findings of the prior transesophageal study with agitated\nsaline contrast infusion (images reviewed) of , once again no\nevidence of an intracardiac shunt is found during agitated saline contrast\ninfusion.\n\n\n"},{"category":"ECG","chartdate":"2195-07-13 00:00:00.000","description":"Report","row_id":130689,"text":"Sinus rhythm. Short P-R interval. Minor T wave abnormalities. Since the\nprevious tracing of probably no significant change.\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2195-07-11 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1203713,\n \"text\": \" 3:59 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ETT position\\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51 year old woman s/p intubation\\n REASON FOR THIS EXAMINATION:\\n ETT position\\n ______________________________________________________________________________\\n FINAL REPORT\\n STUDY: AP chest, .\\n\\n CLINICAL HISTORY: Patient with endotracheal tube placement.\\n\\n FINDINGS: Comparison is made to previous study from .\\n\\n There has been placement of an endotracheal tube whose distal tip is 3.4 cm\\n above the carina, appropriately sited. There is a feeding tube whose distal\\n tip and sideport are below the gastroesophageal junction. The cardiac\\n silhouette and mediastinum are normal. There is focal consolidation in the\\n right upper lobe which may represent pneumonia. Followup to resolution is\\n recommended. There are no signs of pulmonary edema or pleural effusions.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2195-07-13 00:00:00.000\",\n \"description\": \"BILAT LOWER EXT VEINS\",\n \"row_id\": 1203913,\n \"text\": \" 11:04 AM\\n BILAT LOWER EXT VEINS Clip # \\n Reason: assess for DVT\\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51 year old woman with stroke.\\n REASON FOR THIS EXAMINATION:\\n assess for DVT\\n ______________________________________________________________________________\\n WET READ: KKgc MON 4:42 PM\\n No DVT in both lower extremities.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 51-year-old woman with stroke, to evaluate for DVT.\\n\\n COMPARISON: None available.\\n\\n TECHNIQUE: Grayscale and Doppler son of bilateral common femoral,\\n superficial femoral, deep femoral, popliteal and proximal calf veins were\\n performed. There is normal compressibility, flow and augmentation throughout.\\n\\n IMPRESSION: No DVT in both lower extremities.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2195-07-12 00:00:00.000\",\n \"description\": \"MR HEAD W/O CONTRAST\",\n \"row_id\": 1203810,\n \"text\": \" 3:09 PM\\n MR HEAD W/O CONTRAST; MRA NECK W/O CONTRAST Clip # \\n Reason: evaluate evolution\\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51 year old woman with vertebral and basilar artery thrombosis s/p clot removal\\n REASON FOR THIS EXAMINATION:\\n evaluate evolution\\n CONTRAINDICATIONS for IV CONTRAST:\\n lack of IV access\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): AFSN SUN 5:19 PM\\n PFI: Since the previous MRI, there have been multiple new small infarcts in\\n both cerebellar hemispheres and in the left thalamus as well as some extension\\n of the left pontine infarct. Petechial hemorrhages are seen in the left mid\\n brain and left cerebellum. MRA of the neck is unremarkable.\\n ______________________________________________________________________________\\n FINAL REPORT\\n EXAM: MRI BRAIN AND MRA OF THE NECK.\\n\\n CLINICAL INFORMATION: Patient with vertebrobasilar thrombosis status post\\n clot retraction, for further evaluation.\\n\\n TECHNIQUE: T1 sagittal and T2 susceptibility and diffusion axial images\\n of the brain were acquired. 2D and 3D time-of-flight MRA of the neck vessels\\n were obtained. Gadolinium-enhanced MRA of the neck was not obtained as per\\n the clinical request as the patient has no IV access.\\n\\n FINDINGS: BRAIN MRI:\\n\\n Comparison was made with the previous MRI examination of .\\n\\n There are now multiple new infarcts seen in the posterior circulation.\\n Several new cerebellar infarcts are identified in both hemispheres. A left\\n thalamic infarct is also now apparent, as well as the previously seen left\\n paramedian pontine infarct has slightly increased in size. Susceptibility\\n abnormalities are seen in left side of midbrain and left cerebellum indicating\\n petechial hemorrhages. There is no midline shift or hydrocephalus. There are\\n soft tissue changes in the left maxillary sinus and mucosal thickening in the\\n remaining sinuses with retained secretions in the nasopharynx.\\n\\n Note is made of increased signal within the left transverse sinus on\\n T2-weighted images could be secondary to slow flow as this sinus was well\\n visualized on the previous MRA study.\\n\\n IMPRESSION: Multiple new infarcts are now identified since the previous MRI\\n examination of . Left thalamic and bilateral cerebellar infarcts are\\n seen and some extension in the left pontine infarct is noted. Susceptibility\\n artifact in the left mid brain and left cerebellum indicated petechial\\n hemorrhages.\\n\\n MRA NECK:\\n (Over)\\n\\n 3:09 PM\\n MR HEAD W/O CONTRAST; MRA NECK W/O CONTRAST Clip # \\n Reason: evaluate evolution\\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n The neck MRA demonstrates normal flow in the carotid and vertebral arteries\\n without stenosis or occlusion.\\n\\n IMPRESSION: Normal MRA of the neck.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2195-07-12 00:00:00.000\",\n \"description\": \"MR HEAD W/O CONTRAST\",\n \"row_id\": 1203811,\n \"text\": \", C. NMED SICU-B 3:09 PM\\n MR HEAD W/O CONTRAST; MRA NECK W/O CONTRAST Clip # \\n Reason: evaluate evolution\\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51 year old woman with vertebral and basilar artery thrombosis s/p clot removal\\n REASON FOR THIS EXAMINATION:\\n evaluate evolution\\n CONTRAINDICATIONS for IV CONTRAST:\\n lack of IV access\\n ______________________________________________________________________________\\n PFI REPORT\\n PFI: Since the previous MRI, there have been multiple new small infarcts in\\n both cerebellar hemispheres and in the left thalamus as well as some extension\\n of the left pontine infarct. Petechial hemorrhages are seen in the left mid\\n brain and left cerebellum. MRA of the neck is unremarkable.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2195-07-13 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 1203924,\n \"text\": \" 12:30 PM\\n CHEST PORT. LINE PLACEMENT Clip # \\n Reason: 44cm DL R brachial PICC placed ? tip - \\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51 year old woman with new R PICC\\n REASON FOR THIS EXAMINATION:\\n 44cm DL R brachial PICC placed ? tip - \\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL HISTORY: PICC placement.\\n\\n FINDINGS: Single portable frontal view of the chest shows a right upper\\n extremity PICC line which courses into the left brachiocephalic. Withdrawal\\n and repositioning is recommended. The ET tube and feeding tube are in\\n standard position. There is atelectasis of the left lung base. Otherwise,\\n the lungs are unchanged.\\n\\n IMPRESSION: Poorly positioned. Right upper extremity PICC.\\n\\n These findings were discussed with by telephone at the time of this\\n dictation.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2195-07-13 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1203979,\n \"text\": \" 5:33 PM\\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \\n Reason: evidence of consolidation?\\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51 year old woman recently extubated with productive cough\\n REASON FOR THIS EXAMINATION:\\n evidence of consolidation?\\n ______________________________________________________________________________\\n WET READ: DLrc MON 8:24 PM\\n Right upper lobe consolidation is improving since . No new areas of\\n consolidation.\\n ______________________________________________________________________________\\n FINAL REPORT\\n AP CHEST 6:22 P.M. ON \\n\\n HISTORY: Recently extubated patient with a productive cough, question\\n consolidation.\\n\\n IMPRESSION: AP chest compared to through 22 at 1:55 p.m.:\\n\\n There is the suggestion of a region of greater opacity in the right mid lung,\\n but I am hesitant to call at pneumonia. PA and lateral view should really be\\n obtained to see if there is any pulmonary abnormality. Lungs are otherwise\\n clear and there is no pleural effusion. Heart size is normal and there is no\\n pleural effusion. Right PIC line ends in the right atrium at least 5 cm\\n beyond the estimated location of the superior cavoatrial junction. No\\n endotracheal tube visible on the imaged portion of the trachea below the level\\n of C7.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2195-07-12 00:00:00.000\",\n \"description\": \"MRA BRAIN W/O CONTRAST\",\n \"row_id\": 1203836,\n \"text\": \" 9:15 PM\\n MRA BRAIN W/O CONTRAST Clip # \\n Reason: eval evolution\\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51 year old woman with basal ganglia infarct s/p clot removal + tPA, integrelin\\n REASON FOR THIS EXAMINATION:\\n eval evolution\\n CONTRAINDICATIONS for IV CONTRAST:\\n lack of IV access\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 51-year-old man with basilar artery occlusion and interventional\\n recanalization.\\n\\n COMPARISON: MRI/MRA head dated .\\n\\n TECHNIQUE: Axial 3D TOF of the intracranial vessels was obtained without\\n contrast and multiple MIP reconstructions were displayed.\\n\\n FINDINGS: The image quality of the current study is somewhat degraded by\\n motion artifacts.\\n Following recanalization of the basilar artery, the vessel demonstrates\\n flow-related enhancement with high-grade irregularity of the lumen diameter,\\n which is difficult to evaluate with regard to motion artifacts, but most\\n likely represents residual stenosis.\\n\\n Diffuse atherosclerotic changes are, moreover, seen in the posterior cerebral\\n arteries as well as the anterior circulation, most notably the intracranial\\n carotid arteries at the level of the cavernous and ophthalmic segments.\\n Otherwise, the anterior and middle cerebral arteries demonstrate normal\\n flow-related enhancement with no evidence of occlusion.\\n\\n Incidental note is made of right maxillary sinus opacification.\\n\\n IMPRESSION: High-grade lumen irregularity of the recanalized basilar artery\\n which is difficult to evaluate in the setting of extensive motion artifacts,\\n but may represent persistent stenosis.Suggest follow up imaging evaluation\\n with CTA.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2195-07-10 00:00:00.000\",\n \"description\": \"MR HEAD W & W/O CONTRAST\",\n \"row_id\": 1203627,\n \"text\": \" 10:10 PM\\n MR HEAD W & W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \\n MRA NECK W&W/O CONTRAST\\n Reason: Infarct versus mass versus evidence of infection versus vasc\\n Contrast: MAGNEVIST Amt: 18\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51F status post CVA in , went to outside hospital this morning, complaints\\n of worsened dysarthria and right-sided weakness of the arm and leg since she\\n awoke this morning. Also complained of generalized weakness since yesterday. He\\n head CT is outside hospital negative for bleed, concerning for possible\\n subacute infarct, transferred to for neurologic evaluation.\\n REASON FOR THIS EXAMINATION:\\n Infarct versus mass versus evidence of infection versus vasculitis\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: SAT 3:07 AM\\n 1. No enhancement of distal bilateral V4 segments and basilar artery\\n presumably secondary to distal vertebral and basilar artery thrombosis. The\\n right P1 segment is vaguely seen, but the remaining portions of the PCAs\\n bilaterally are not visualized. Small PCOMMs are seen bilaterally.\\n 2. Left A1 segment is narrowed, could be due to hypoplasia and/or\\n atherosclerosis.\\n 3. Scattered small acute infarcts in the left occipital lobe, right\\n cerebellum, right pons, and possibly left pons.\\n 4. Complete opacification of the left maxillary sinus.\\n ______________________________________________________________________________\\n FINAL REPORT\\n MRI AND MRA BRAIN AND NECK WITHOUT AND WITH CONTRAST \\n\\n HISTORY: Prior infarction. Now with worsening dysarthria and right-sided\\n weakness.\\n\\n Sagittal short TR, short TE spin echo imaging was performed through the brain.\\n Axial imaging was performed with , TR, long TE fast spin echo,\\n gradient echo, diffusion, and 3D time-of-flight MRA technique.\\n Gadolinium-enhanced MRA was performed through the neck. Comparison to a brain\\n MR .\\n\\n FINDINGS: There are multiple areas of new infarction since the prior study.\\n These are most prominent in the pons, predominantly on the left, where there\\n is associated hemorrhage. There are also small infarctions in the right\\n cerebellar hemisphere of the left occipital lobe, and the right cerebral\\n peduncle. These all implicate posterior circulation abnormalities. The brain\\n MRA demonstrates very poor signal arising from the basilar artery and its\\n branches. The distal vertebral arteries are visualized on the non-contrast\\n MRA but the vertebrobasilar junction is not. The axial T2-weighted images\\n demonstrate a loss of the normal flow void in the basilar artery. The\\n gadolinium-enhanced neck MRA source images demonstrate the distal vertebral\\n arteries, the vertebrobasilar junction, and the distal basilar artery. This\\n suggests that these vessels are patent but experiencing extremely slow flow,\\n responsible for the poor visualization on the non-contrast time-of-flight\\n images. However, the mid basilar is not opacified on the gadolinium MRA.\\n (Over)\\n\\n 10:10 PM\\n MR HEAD W & W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \\n MRA NECK W&W/O CONTRAST\\n Reason: Infarct versus mass versus evidence of infection versus vasc\\n Contrast: MAGNEVIST Amt: 18\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n Overall, these findings suggest a focal area of severe stenosis or thrombosis\\n in the mid basilar artery with poor runoff for the vertebral arteries and\\n reduced flow through the superior cerebellar and posterior cerebral arteries.\\n This would explain the distribution of infarction seen on the diffusion\\n images.\\n\\n The MRA also demonstrates loss of the A1 segment of the left anterior cerebral\\n artery, which was present on the MR examination of . There is\\n no evidence of infarction in the A1 distribution.\\n\\n Images of the remainder of the brain demonstrate no other areas of hemorrhage\\n or infarction. The remainder of the intracranial branches appear normal.\\n\\n A preliminary report was issued that read \\\"no enhancement of distal bilateral\\n V4 segments and basilar artery presumably secondary to distal vertebral and\\n basilar artery thrombosis. The right P1 segment is vaguely seen, but\\n remaining portions of the PCAs bilaterally are not well visualized. Small\\n posterior communicating arteries are seen bilaterally.\\n\\n 2. Left A1 segment is narrowed, could be due to hypoplasia or\\n atherosclerosis.\\n\\n 3. Scattered small acute infarcts in the left occipital lobe, right\\n cerebellum, right pons, and possibly left pons.\\n\\n 4. Complete opacification of the left maxillary sinus.\\n\\n discussed with Dr. at 3:03 a.m. via telephone on .\\\"\\n\\n CONCLUSION: Apparent mid basilar severe stenosis or occlusion with multiple\\n posterior circulation infarctions. There is a small amount of hemorrhage in\\n the pons associated with these infarctions.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2195-07-11 00:00:00.000\",\n \"description\": \"CTA HEAD W&W/O C & RECONS\",\n \"row_id\": 1203717,\n \"text\": \" 4:30 PM\\n CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # \\n Reason: bleeding?\\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\\n Contrast: OPTIRAY Amt: 70\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51 year old woman with basilar clot with acute decompensation.\\n REASON FOR THIS EXAMINATION:\\n bleeding?\\n CONTRAINDICATIONS for IV CONTRAST:\\n allergic;stat - confirmed with rads attending\\n ______________________________________________________________________________\\n FINAL REPORT\\n EXAM: CTA of the head and neck.\\n\\n CLINICAL INFORMATION: Patient with basilar artery clot, for further\\n evaluation.\\n\\n TECHNIQUE: Axial images of the head were obtained without contrast.\\n Following this using departmental protocol CT angiography of the head and neck\\n acquired. 3D reformatted images were obtained on independent workstation.\\n\\n FINDINGS:\\n\\n HEAD CT: There is a vague hypodensity in the left paramedian pontine region\\n indicative of an infarct seen on the previous MRI. No hemorrhage seen.\\n\\n CT ANGIOGRAPHY NECK: CT angiography of the neck demonstrates normal flow in\\n the carotid and vertebral arteries. The left vertebral artery is smaller in\\n size compared to the right which could be a variation. The V1, V2, and V3\\n segments of the vertebral arteries are patent without stenosis or occlusion.\\n\\n CT ANGIOGRAPHY HEAD: The CT angiography of the head demonstrates narrowing of\\n the distal left vertebral artery prior to the vertebrobasilar junction. In\\n addition, the proximal one-half of the basilar artery is markedly narrowed\\n with diminished flow. There is also diminished flow seen in the distal\\n basilar artery. The right posterior cerebral artery is not well visualized\\n and the left posterior cerebral artery flow is markedly diminished. These\\n findings are indicative of stenosis or clot within the basilar artery.\\n\\n The anterior circulation is patent without stenosis or occlusion. Both A1\\n segments of the anterior cerebral arteries are seen although the left side is\\n slightly smaller than the right, in variation.\\n\\n IMPRESSION:\\n 1. Head CT shows a left paramedian pontine hypodensity indicative of infarcts\\n seen on the MR done earlier.\\n 2. CT angiography of the neck demonstrates no evidence of dissection,\\n stenosis, or occlusion in the neck vessels.\\n 3. CT angiography of the head demonstrates high-grade stenosis of the distal\\n left vertebral artery and proximal basilar artery with diminished flow\\n distally as described above.\\n (Over)\\n\\n 4:30 PM\\n CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # \\n Reason: bleeding?\\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\\n Contrast: OPTIRAY Amt: 70\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2195-07-12 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 1203753,\n \"text\": \" 2:10 AM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: s/p clot retrieval. Please perform at 0200 on .\\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51 year old woman with basilar clot s/p clot retrieval.\\n REASON FOR THIS EXAMINATION:\\n s/p clot retrieval. Please perform at 0200 on .\\n CONTRAINDICATIONS for IV CONTRAST:\\n not indicated\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 51-year-old woman, with basilar clot. Status post clot retrieval.\\n\\n COMPARISON: Multiple prior studies including CTA head on and\\n cerebral on at 1707.\\n\\n TECHNIQUE: Non-contrast MDCT images were acquired through the brain.\\n Multiplanar reformatted images were obtained for evaluation.\\n\\n FINDINGS: Small amount of subarachnoid layering in the high parietal sulci is\\n new. There is no evidence of intraventricular hemorrhagic extension. No\\n acute major vascular territorial infarct is noted. The -white matter\\n differentiation is well preserved. The ventricles and sulci remained normal\\n in size and symmetric in configuration. There is no shift of normally midline\\n structure. A 10 mm rounded hypodensity (image 2:8) in the left pons is\\n unchanged, likely represent an old infarct. There is no acute fracture.\\n\\n IMPRESSION:\\n 1. Interval small amount of subarachnoid hemorrhage layering along the left\\n parietal sulci. No intraventricular hemorrhagic extension. No evidence of\\n developing hydrocephalus.\\n 2. Unchanged 1-cm left pontine hypodensity representing infarct seen on MRI\\n of .\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2195-07-11 00:00:00.000\",\n \"description\": \"PRIMARY MECH THROMBECTOMY ART/BPG; INITIAL VESSEL\",\n \"row_id\": 1203723,\n \"text\": \" 5:07 PM\\n CAROT/CEREB Clip # \\n Reason: New vascular insult\\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\\n Contrast: OPTIRAY Amt: 241\\n ********************************* CPT Codes ********************************\\n * PRIMARY MECH THROMBECTOMY ART/ SEL CATH 3RD ORDER *\\n * -51 MULTI-PROCEDURE SAME DAY VERT/CAROTID A-GRAM *\\n ****************************************************************************\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51 RHF with precent right basal ganglia infarct in , transferred from\\n an outside hospital more than 12 hours after new onset right sided weakness in\\n arm and leg, dysarthria and dysphagia. MRI c/w distal vertebral and basilar\\n artery thrombosis.\\n REASON FOR THIS EXAMINATION:\\n New vascular insult\\n ______________________________________________________________________________\\n FINAL REPORT\\n DATE OF SERVICE: .\\n\\n PREOPERATIVE DIAGNOSIS: Acute stroke with basilar artery occlusion.\\n\\n INDICATION: For reperfusion and recanalization of the vertebrobasilar system.\\n The patient had presented with a significant stroke. CTA demonstrated\\n occlusion of the basilar artery. We felt it would be worthwhile to reopen the\\n basilar artery which was occluded with thrombus.\\n\\n PROCEDURE PERFORMED:\\n\\n 1. Right vertebral artery angiogram.\\n 2. Right superior cerebellar artery angiogram.\\n 3. Right posterior cerebral artery angiogram.\\n 4. Right basilar artery angiogram.\\n 5. Merci thrombectomy of basilar artery thrombus.\\n 6. Chemical thrombolysis of right posterior cerebral artery and basilar\\n artery.\\n\\n DETAILS OF PROCEDURE:\\n\\n The patient was brought to the angiography suite. Following this, a safety\\n timeout was obtained. The entire procedure was performed under general\\n anesthesia. We gained access to the right common femoral artery using a\\n Seldinger technique, and an 8 French long vascular sheath was advanced into\\n the right common femoral artery. Subsequently, a 5 French 2 catheter\\n was advanced, and the right vertebral artery was selected. On CTA, this was\\n the dominant vertebral artery. Over a long exchange glidewire, the 2\\n catheter was exchanged for an 8 French Merci sheath, which was placed in the\\n right vertebral artery. The basilar artery was then selected. It was\\n catheterized with an 18 L microcatheter, and an X-Pedion 014 wire. A\\n selective arteriogram through the right vertebral artery was performed, and\\n confirmed placement. A Merci retriever V 3.0 firm device was then deployed\\n across the thrombus in the proximal basilar artery, and withdrawn into the\\n (Over)\\n\\n 5:07 PM\\n CAROT/CEREB Clip # \\n Reason: New vascular insult\\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\\n Contrast: OPTIRAY Amt: 241\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n right vertebral artery under constant suction with a Penumbra System.\\n Following this, a check arteriogram was performed. This demonstrated\\n non-filling of the right PCA. The microcatheter was advanced into the right\\n PCA, and this was injected with approximately 3 mg of TPA. A repeat\\n arteriogram through the right vertebral artery was then performed, and this\\n showed persistent clot in the basilar artery. A firm Merci 2 2.5\\n self-retrieval device was then deployed, and withdrawn under roadmap guidance\\n into the right vertebral artery. A repeat angiogram showed persistent\\n occlusion. A further 4 mg of TPA was injected into the basilar artery.\\n\\n A repeat right vertebral artery angiogram was then performed. There was\\n persistent clot formation in the basilar artery. A discussion was held with\\n the neurologist, and a decision was made to administer further TPA into the\\n basilar artery. However, there was persistent irregularity of the basilar\\n artery, and this was felt to be due to endothelial denudation. A Sprinter\\n Legend RX 2.5 mm x 20 mm balloon was then advanced into the basilar artery,\\n and this was angioplastied. The balloon was inflated with an insufflation\\n device, and held at 8 atmospheres for approximately 30 seconds. The balloon\\n catheter was then withdrawn. A check angiogram showed persistent partial\\n occlusion of the basilar artery. A decision was then made to administer 15 mg\\n of Integrilin, and a repeat right vertebral arteriogram was performed after\\n five minutes. This showed relative patency of the basilar artery with\\n improved flow. The consideration towards placement of a stent was\\n subsequently abandoned. An OGT was then placed, and the patient was given 600\\n mg of Plavix. Following this, the right common femoral artery arteriogram was\\n done. This showed a widely patent right common femoral artery. At this\\n point, an 8 French Angio-Seal was used for closure, and to secure hemostasis.\\n\\n FINDINGS: Right vertebral arteriogram showed a dominant right vertebral\\n artery. There is thrombus sitting in the basilar artery with occlusion of the\\n right PCA. The superior cerebellar artery was patent.\\n\\n Right superior cerebellar artery arteriogram showed a patent right superior\\n cerebellar artery.\\n\\n Right posterior cerebral artery arteriogram showed an occluded right posterior\\n cerebral artery, which was subsequently recanalized with 3 mg of TPA.\\n\\n IMPRESSION:\\n\\n Basilar artery thrombus was treated with successful recanalization of the\\n basilar artery. The patient underwent TPA administration into the basilar\\n artery, as well as the right posterior cerebral artery. She was also\\n angioplastied with a 2.5 mm balloon, and 15 mg of Integrilin was administered\\n iv. The patient was placed on 600 mg of Plavix. The neurologist was present\\n (Over)\\n\\n 5:07 PM\\n CAROT/CEREB Clip # \\n Reason: New vascular insult\\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\\n Contrast: OPTIRAY Amt: 241\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n throughout the entire procedure.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2195-07-13 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1203939,\n \"text\": \" 1:48 PM\\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \\n Reason: rue picc powerflushed x 4: re-assess tip #\\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51 year old woman with right picc crossing midline. powerflushed x 4 to help\\n re-position picc\\n REASON FOR THIS EXAMINATION:\\n rue picc powerflushed x 4: re-assess tip #\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL HISTORY: PICC re-positioning.\\n\\n FINDINGS: Single portable view of the chest shows a right upper extremity\\n PICC line whose tip terminates within the atriocaval junction. The ET tube is\\n approximately 3 cm above the carina. Feeding tube is within the stomach.\\n Lungs are unchanged. No pneumothorax.\\n\\n IMPRESSION: Properly positioned right upper extremity PICC.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2195-07-11 00:00:00.000\",\n \"description\": \"R KNEE (2 VIEWS) RIGHT\",\n \"row_id\": 1203650,\n \"text\": \" 7:35 AM\\n KNEE (2 VIEWS) RIGHT Clip # \\n Reason: fracture? effusion? arthritis?\\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51 year old woman with CVA who is complaining of right knee pain.\\n REASON FOR THIS EXAMINATION:\\n fracture? effusion? arthritis?\\n ______________________________________________________________________________\\n FINAL REPORT\\n STUDY: Right knee, two views, .\\n\\n CLINICAL HISTORY: 51-year-old woman with CVA with complaint of right knee\\n pain. Evaluate for fracture.\\n\\n FINDINGS: There are no signs for acute fractures or dislocations. There is\\n minimal spurring involving the medial compartment as well as the inferior\\n aspect of the patella. There is no joint effusion. There are no focal lytic\\n or blastic lesions.\\n\\n IMPRESSION:\\n\\n Mild spurring without signs for acute bony injury.\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2195-07-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 65171,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: ?PFO LV/RV Function\\nHeight: (in) 69\\nWeight (lb): 175\\nBSA (m2): 1.95 m2\\nBP (mm Hg): 108/49\\nHR (bpm): 61\\nStatus: Inpatient\\nDate/Time: at 10:19\\nTest: Portable TTE (Congenital, complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: Saline\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT ATRIUM: Normal LA size.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD or PFO by 2D, color\\nDoppler or saline contrast with maneuvers.\\n\\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\\nsystolic function (LVEF >55%). No resting LVOT gradient.\\n\\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\\n\\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\\ndiameter.\\n\\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\\n\\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. Normal mitral\\nvalve supporting structures. No MS. Trivial MR. Normal LV inflow pattern for\\nage.\\n\\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal\\ntricuspid valve supporting structures. No TS. Normal PA systolic pressure.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\\nPhysiologic PR. Normal main PA. No Doppler evidence for PDA\\n\\nPERICARDIUM: No pericardial effusion.\\n\\nGENERAL COMMENTS: Contrast study was performed with 3 iv injections of 8 ccs\\nof agitated normal saline, at rest, with cough and post-Valsalva maneuver.\\n\\nConclusions:\\nThe left atrium is normal in size. No atrial septal defect or patent foramen\\novale is seen by 2D, color Doppler or saline contrast with maneuvers. Left\\nventricular wall thickness, cavity size and regional/global systolic function\\nare normal (LVEF 70%). Right ventricular chamber size and free wall motion are\\nnormal. The aortic valve leaflets (3) appear structurally normal with good\\nleaflet excursion and no aortic stenosis or aortic regurgitation. The mitral\\nvalve appears structurally normal with trivial mitral regurgitation. Trivial\\nmitral regurgitation is seen. The estimated pulmonary artery systolic pressure\\nis normal. There is no pericardial effusion.\\n\\nCompared with the findings of the prior transesophageal study with agitated\\nsaline contrast infusion (images reviewed) of , once again no\\nevidence of an intracardiac shunt is found during agitated saline contrast\\ninfusion.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2195-07-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 130689,\n \"text\": \"Sinus rhythm. Short P-R interval. Minor T wave abnormalities. Since the\\nprevious tracing of probably no significant change.\\n\\n\"\n }\n]"}}},{"rowIdx":379,"cells":{"subject_id":{"kind":"number","value":29770,"string":"29,770"},"hadm_id":{"kind":"number","value":197088,"string":"197,088"},"target_text":{"kind":"string","value":"As mentioned in the HPI, Mrs. was admitted for cardiac cath which showed severe coronary disease. She was evaluated for bypass surgery and appropriately worked up. She remained medically managed for several days awaiting Plavix washout. On she was brought to the operating room where she underwent a coronary artery bypass graft x 5. Please see operative report for surgical details. Following surgery she was transferred to the CVICU for invasive monitoring in stable condition. She remained intubated until post-op day two when she was weaned from sedation, awoke neurologically intact and extubated. On post-op day one she was started on IV Lasix and gently diuresed towards her pre-op weight. On post-op day two she had episodes of atrial fibrillation and she was started on Amiodarone. On post-op day three her chest tubes were removed. She remained in the CVICU until post-op day five when she was transferred to the telemetry floor for further care. On post-op day six her epicardial pacing wires were removed. She worked with physical therapy during her post-op course for strength and mobility. On post-op day eight she was discharged to home with the appropriate medications and follow-up appointments."},"extractive_notes_summ":{"kind":"string","value":"Mild (1+) mitral regurgitationis seen. Mild (1+) MR. LV inflow pattern c/w impairedrelaxation.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal descending aortadiameter. Mild mitral regurgitation. Normal ascending aorta diameter. Normal aortic arch diameter. Normal aortic arch diameter. Moderateregional LV systolic dysfunction. Mild mitralannular calcification. Mild (1+) MR.TRICUSPID VALVE: Mild [1+] TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: A TEE was performed in the location listed above. Mild to moderate (+) aortic regurgitation is seen. BS COURSE UPPER, DIMINISHED BIBASILAR. Mild tomoderate (+) AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild to moderate aorticregurgitation. Mildly dilated ascending aorta. Mildly thickened aortic valveleaflets. Mitral valve disease.Height: (in) 62Weight (lb): 159BSA (m2): 1.74 m2BP (mm Hg): 130/88HR (bpm): 54Status: InpatientDate/Time: at 11:52Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA and RA cavity sizes.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.LEFT VENTRICLE: Normal LV wall thickness. No VSD.LV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior- hypo; mid inferior - hypo; basal inferolateral - hypo; mid inferolateral -hypo; septal apex - hypo; inferior apex - hypo; apex - akinetic;RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level. The left ventricular cavity sizeis normal. There is an anterior space which mostlikely represents a fat pad, though a loculated anterior pericardial effusioncannot be excluded.Conclusions:The left atrium and right atrium are normal in cavity size. Probable small, if present, left pleural effusion. Sternal dressing CDI. There is unchanged mild pulmonary edema. BorderlinePA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR.PERICARDIUM: No pericardial effusion. Mildly dilated LV cavity. The left ventricular cavity is mildly dilated.There is moderate regional left ventricular systolic dysfunction withhypokinesis of the basal to mid inferolateral segments, inferior wall andseptal apex. Moderate regional LV systolic dysfunction.LV WALL MOTION: Regional LV wall motion abnormalities include: mid anterior -hypo; mid anteroseptal - hypo; mid inferoseptal - hypo; anterior apex - hypo;septal apex - hypo; apex - akinetic;RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level. The left hemidiaphragm is now obscured by a small-to-moderate left pleural effusion with associated atelectasis. Mild to moderate (+) AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild to moderate (+) aortic regurgitation is seen.The mitral valve leaflets are mildly thickened. There is moderate regionalleft ventricular systolic dysfunction with hypokinesis notable in the LADdistribution.Right ventricular chamber size and free wall motion are normal.There are simple atheroma in the descending thoracic aorta.The aortic valve leaflets (3) are mildly thickened but aortic stenosis is notpresent. Rule out pneumothorax. ABD SOFT+DISTENDED, ABSENT BOWEL SOUNDS. No2D or Doppler evidence of distal arch coarctation.AORTIC VALVE: ?# aortic valve leaflets. IMPRESSION: Small left pleural effusion with associated atelectasis. Mild pulmonary edema, small, if present, left pleural effusion, status post CABG. c/o pain , Given dilaudid PO with good relief.CV: Pt in NSR 60s-70s with no ectopy noted. +palpable pulses.Resp: LS clear diminished bases. 2+ generalized edema. chest tubes with serosang, drainage slowing overnoc. ?need precedex for extubation.CV: sinus rhythm 80's few PVC noted overnoc. To go by FICk per PA . Albuterol MDI given as ordered. VENODYNES AND SC HEPARIN PER DR. . continue diuresis. UPDATED A STO PLAN.A: CI IMPROVED WITH DOBUTAMINE,CXR WET, DIURESING WITH LASIX GTT, PO2 ^ WITH ^ PEEP AND FIO2, ^ AGITATION WITH LIGHTENING ,P: MONITOR COMFORT, HR AND RYTHYM, SBP-USE LEVO IF NEED TO SUPPORT BP, CI-CONTINUE DOBUTAMINE, MVO2, CT DRAINAGE, DSGS, PP, RESP STATUS-WEAN FIO2 AND PEEP, NEURO STATUS-CONTINUE PROPOFOL-?PRECEDEX WHEN ABLE TO WEAN, I+O-CONTINUE LASIX GTT GOAL UO 100-150 ML/HR, LABS PENDING. CXR REVEALS WET-HOPE TO IMPROVE WITH IV LASIX GTT.BS COURSE TO CLEAR UPPER, DIMINISHED BIBASILAR. PA aware, CI>2 via FICK. Pain med changed to dilaudid po w/ effect. LLE with hemovacscant sang drainage, steristrips intact dsd changed and ace re-wrapped. Most recent ABG: 7.45/38/103/27/2. On Diamox(one more dose), Lasix Labs- lytes repleted, no RISS coverage Hct 28 Plan- SBP<140 Pain control ^ act as tolerated Monitor resp. + BOWEL SOUNDS-HYPOACTIVE. Bringing up thick tannish secretions small amts.GI/GU: Abd softly distended. CARAFATE AND ZANTAC GIVEN. CPT done. Non-specific ST-T wave changes.Compared to the previous tracing of Q-T interval is no longerprolonged. continues on dobutamine, lasix gtts, diureseing well, weight down, -600 since midnoc. CREAT WNL. Pao2 improved on subsqueint abg's. PEEP 10, fio2 50. getting alkalotic from diuresis. lungs clear with diminished bases bilat. CI> 2 via thermodilution w/ HR 80. DSGS REMAIN D+I. REPEAT ABG PO2 86. ABG AND VENT SETTINGS PER FLOW. +BS. Tolerating clears. Sinus rhythm. Sinus rhythm. Morphine 2mg ivp w/fair effect, given x4 CVMP Apaced at 80, BP<140 ion NTG up to 3mcg/kg/min,presently off.Hydralazine 10mg iv x2 w/effect. HCT 31. Perrla. SUCTIONED FOR A SMALL AMOUNT OF THICK BLOOD TINGED SPUTUM X1. Pulmonary hygeine.Encourage po intake. 7a-7pneuro: received sedated on propofol, not following commands; now rouses to voice, oriented x2 (reoriented to time), follows commands, mae, good pain control w/ morphine 1mg ivp q1-2hcv: sr 85-97 no ectopy, sbp 95-140, ntg gtt to keep map<90/sbp<120, ci 2.1-2.6, dobutamine gtt weaned off, swan left in place md, cvp 7-15, pad 17-25, ct draining small/moderate amts s/s drainage, max temp 38.2resp: lungs cta, dim to left base, extubated at 1430 to nc 4L & face tent at 50%, now sats >95% on 5L nc & face tent 70%, strong non-productive cough, w/ extubation pt expectorated large bloody/mucoid sputum (md aware, no further bleeding noted), is to 250mlgi: abdomen soft/distended, hypoactive bowel sounds, tolerating ice chips, fingersticks ssrigu: foley to gravity, copious diuresis this am w/ lasix gtt, lasix gtt weaned off & pt continues to autodiurese, pt currently -3L for dayassess: stableplan: start po metoprolol, wean ntg as tolerated to keep sbp<120, map<90, pulmonary toilet, deline and transfer to 6 in am"},"n_notes":{"kind":"number","value":30,"string":"30"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2176-04-27 00:00:00.000","description":"CHEST (PA & LAT)","row_id":1006803,"text":" 9:03 AM\n CHEST (PA & LAT) Clip # \n Reason: eval pleural effusions\n Admitting Diagnosis: ANGINA\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman s/p CABG\n REASON FOR THIS EXAMINATION:\n eval pleural effusions\n ______________________________________________________________________________\n FINAL REPORT\n TWO-VIEW CHEST, \n\n COMPARISON: .\n\n INDICATION: Status post coronary bypass surgery.\n\n Cardiac silhouette is mildly enlarged but stable in size from the prior\n post-operative radiograph. Areas of patchy and linear atelectasis in the\n lower lobes have slightly improved, and small bilateral pleural effusions are\n not substantially changed.\n\n IMPRESSION: Persistent small bilateral pleural effusions. Improving\n bibasilar atelectasis.\n\n\n"},{"category":"Radiology","chartdate":"2176-04-19 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1005724,"text":" 11:47 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: overload\n Admitting Diagnosis: ANGINA\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman with increasing lactate\n REASON FOR THIS EXAMINATION:\n overload\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Followup.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous examination, there are no major\n changes. The monitoring and support devices are in unchanged position. There\n is unchanged mild pulmonary edema. The size of the cardiac silhouette is also\n unchanged.\n\n\n"},{"category":"Radiology","chartdate":"2176-04-22 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1006017,"text":" 9:41 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o ptx s/p ct's removed\n Admitting Diagnosis: ANGINA\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman with\n REASON FOR THIS EXAMINATION:\n r/o ptx s/p ct's removed\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 76-year-old female status post chest tube removal. Rule out\n pneumothorax.\n\n COMPARISON: .\n\n UPRIGHT CHEST RADIOGRAPH: Patient is status post CABG and median sternotomy\n wires are intact. The right-sided Swan-Ganz catheter is in unchanged\n position. Left-sided chest tubes have been removed and there is no evidence\n of pneumothorax. Left basilar atelectasis has increased at the site of prior\n chest tube removal. The remainder of this examination is unchanged.\n\n IMPRESSION: Status post removal of left-sided chest tubes with no evidence of\n pneumothorax.\n\n\n"},{"category":"Radiology","chartdate":"2176-04-19 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":1005660,"text":" 1:16 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: ptx\n Admitting Diagnosis: ANGINA\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman with s/p CABG\n REASON FOR THIS EXAMINATION:\n ptx\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest portable for line placement on .\n\n COMPARISON: chest radiograph.\n\n HISTORY: 76-year-old woman status post CABG, evaluate for pneumothorax.\n\n FINDINGS: Baseline postoperative examination showing multiple median\n sternotomy wires with no wire complications. The lungs are mildly edematous.\n Two chest drainage catheters are seen projecting over the left lower\n hemithorax.\n\n A feeding tube distal tip is in the stomach. An endotracheal tube distal tip\n is only 1.5 cm above the carina. A right internal jugular Swan-Ganz catheter\n terminates in the main pulmonary outflow tract. No right pleural effusion.\n Probable small, if present, left pleural effusion. No pneumothorax.\n\n IMPRESSION:\n 1. No radiographic evidence of pneumothorax.\n 2. Mild pulmonary edema, small, if present, left pleural effusion, status\n post CABG.\n 3. The endotracheal tube distal tip is approximately 1.5 cm above the carina\n bifurcation.\n\n The information was delivered by phone to for Dr. \n . Dr. to inform her about the position of the\n endotracheal tube.\n\n\n"},{"category":"Radiology","chartdate":"2176-04-21 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1005876,"text":" 7:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p cabg CHF\n Admitting Diagnosis: ANGINA\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman with\n REASON FOR THIS EXAMINATION:\n s/p cabg CHF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Followup.\n\n COMPARISON: , 00:10 a.m.\n\n FINDINGS: As compared to the previous examination, there is no relevant\n change. The monitoring and support devices are in unchanged position. The\n size of the cardiac silhouette is unchanged. There are no signs suggestive of\n pneumonia and no signs suggestive of relevant overhydration. Pleural\n effusions cannot be detected. No evidence of pneumothorax.\n\n\n"},{"category":"Radiology","chartdate":"2176-04-25 00:00:00.000","description":"CHEST (PA & LAT)","row_id":1006520,"text":" 1:02 PM\n CHEST (PA & LAT) Clip # \n Reason: eval for pleural effusions\n Admitting Diagnosis: ANGINA\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman s/p cabgx5\n REASON FOR THIS EXAMINATION:\n eval for pleural effusions\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 76-year-old woman with five vessel CABG.\n\n COMPARISON: .\n\n PA AND LATERAL VIEWS OF THE CHEST: There has been interval removal of a Swan-\n Ganz catheter via a right internal jugular approach. Median sternotomy wires\n are intact. The left hemidiaphragm is now obscured by a small-to-moderate\n left pleural effusion with associated atelectasis. Elsewhere, the lungs are\n well expanded with no foci of consolidation. There may be a tiny right\n pleural effusion. There is no pneumothorax. The mild cardiomegaly is\n unchanged. Pulmonary vasculature is normal.\n\n IMPRESSION: Small left pleural effusion with associated atelectasis.\n\n"},{"category":"Radiology","chartdate":"2176-04-17 00:00:00.000","description":"CHEST (PRE-OP PA & LAT)","row_id":1005376,"text":" 2:42 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: ANGINA\\CATH\n Admitting Diagnosis: ANGINA\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman with 3VD, unstable angina awaiting CABG \n REASON FOR THIS EXAMINATION:\n evaluate for infiltrates/CHF\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Unstable engine awaiting CABG.\n\n FINDINGS: No previous images. There is enlargement of the cardiac silhouette\n with tortuosity of the aorta. Some prominence of interstitial markings could\n reflect elevated pulmonary venous pressure, chronic lung disease, or both. No\n acute focal pneumonia.\n\n\n"},{"category":"Echo","chartdate":"2176-04-19 00:00:00.000","description":"Report","row_id":78950,"text":"PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease;\nHeight: (in) 62\nWeight (lb): 159\nBSA (m2): 1.74 m2\nBP (mm Hg): 110/70\nHR (bpm): 74\nStatus: Inpatient\nDate/Time: at 11:07\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Dilated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or color\nDoppler.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. No LV\naneurysm. Moderate regional LV systolic dysfunction.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: mid anterior -\nhypo; mid anteroseptal - hypo; mid inferoseptal - hypo; anterior apex - hypo;\nseptal apex - hypo; apex - akinetic;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root. Normal ascending aorta diameter. Focal calcifications in\nascending aorta. Normal aortic arch diameter. Normal descending aorta\ndiameter. Simple atheroma in descending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild to\nmoderate (+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR.\n\nTRICUSPID VALVE: Mild [1+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was under\ngeneral anesthesia throughout the procedure. No TEE related complications. The\npatient appears to be in sinus rhythm. Results were personally reviewed with\nthe MD caring for the patient.\n\nConclusions:\nPRE-BYPASS:\nThe left atrium is dilated. No atrial septal defect is seen by 2D or color\nDoppler.\nLeft ventricular wall thicknesses are normal. The left ventricular cavity size\nis normal. No left ventricular aneurysm is seen. There is moderate regional\nleft ventricular systolic dysfunction with hypokinesis notable in the LAD\ndistribution.\nRight ventricular chamber size and free wall motion are normal.\nThere are simple atheroma in the descending thoracic aorta.\nThe aortic valve leaflets (3) are mildly thickened but aortic stenosis is not\npresent. Mild to moderate (+) aortic regurgitation is seen.\nThe mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation\nis seen. There is no pericardial effusion. Dr. was notified in person\nof the results on at 8AM on .\n\nPOST_BYPASS:\nLVEF 45% on no inotropic support.\nMild AI, Mild MR and Mild TR.\nNormal RV systolic function.\nAscending aortic contour is intact.\nLAD terriotry WMA is the same.\n\n\n"},{"category":"Echo","chartdate":"2176-04-17 00:00:00.000","description":"Report","row_id":78951,"text":"PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease. Mitral valve disease.\nHeight: (in) 62\nWeight (lb): 159\nBSA (m2): 1.74 m2\nBP (mm Hg): 130/88\nHR (bpm): 54\nStatus: Inpatient\nDate/Time: at 11:52\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA and RA cavity sizes.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Normal LV wall thickness. Mildly dilated LV cavity. Moderate\nregional LV systolic dysfunction. No resting LVOT gradient. No VSD.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior\n- hypo; mid inferior - hypo; basal inferolateral - hypo; mid inferolateral -\nhypo; septal apex - hypo; inferior apex - hypo; apex - akinetic;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root. Mildly dilated ascending aorta. Normal aortic arch diameter. No\n2D or Doppler evidence of distal arch coarctation.\n\nAORTIC VALVE: ?# aortic valve leaflets. Mildly thickened aortic valve\nleaflets. No AS. Mild to moderate (+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Mild (1+) MR. LV inflow pattern c/w impaired\nrelaxation.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Borderline\nPA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion. There is an anterior space which most\nlikely represents a fat pad, though a loculated anterior pericardial effusion\ncannot be excluded.\n\nConclusions:\nThe left atrium and right atrium are normal in cavity size. Left ventricular\nwall thicknesses are normal. The left ventricular cavity is mildly dilated.\nThere is moderate regional left ventricular systolic dysfunction with\nhypokinesis of the basal to mid inferolateral segments, inferior wall and\nseptal apex. The apex is akinetic. There is no ventricular septal defect.\nRight ventricular chamber size and free wall motion are normal. The ascending\naorta is mildly dilated. The number of aortic valve leaflets cannot be\ndetermined. The aortic valve leaflets are mildly thickened. There is no aortic\nvalve stenosis. Mild to moderate (+) aortic regurgitation is seen. The\nmitral valve leaflets are mildly thickened. Mild mitral regurgitation is seen.\nThere is no mitral valve prolapse. The left ventricular inflow pattern\nsuggests impaired relaxation. There is borderline pulmonary artery systolic\nhypertension. There is no pericardial effusion. There is an anterior space\nwhich most likely represents a fat pad.\n\nIMPRESSION: Mildly dilated left ventricular cavity with moderate focal left\nventricular systolic dysfunction likely due to multi-vessel CAD. Probable\ndiastolic dysfunction. Mild mitral regurgitation. Mild to moderate aortic\nregurgitation. Borderline pulmonary artery systolic hypertension.\n\n\n"},{"category":"Nursing/other","chartdate":"2176-04-19 00:00:00.000","description":"Report","row_id":1647214,"text":"Resp Care\n\nPt received from OR and placed on full vent support. BS were bilateral. Mode was changed to a/c. OETT pulled back 2cm. Will wean fast wean appropriate.\n"},{"category":"Nursing/other","chartdate":"2176-04-24 00:00:00.000","description":"Report","row_id":1647229,"text":"2300-0700\n\nNEURO: Pt slept most of shift. Ox3 when awake, followed commands, MAE, assists with turning. c/o pain , Given dilaudid PO with good relief.\n\nCV: Pt in NSR 60s-70s with no ectopy noted. 2As/2Vs, pacer turned off. Both sense and capture. SBP 110s-140s, MAP 70s-80s. Captopril ^ 50mg TID. PP palpable. Hct 32.9.\n\nRESP: Pt on 2L NC, sats>96%. LS clear, little dim in bases. Pt well, producing sputum on own, thick yellow sputum.\n\nGI/GU: + BS; pt denies nausea, no appetite. Pt on PO lasix , diuresing well. K+ pnd. Lytes repleated prn.\n\nENDO: BS tx per RISS. BS WNL.\n\nID: Afebrile, skin cool to touch- warm blankets. WBC 10.9\n\nPLAN: Peripheral access and d/c cordus. ^ diet, ^ activity. pulm toilet & comfort/support. transfer to 6 in am.\n\n\n\n"},{"category":"Nursing/other","chartdate":"2176-04-19 00:00:00.000","description":"Report","row_id":1647215,"text":"S/P CABG X 5\nO: CARDIAC: A PACED WITH UNDERLYING RYTHYM 70-60'S. SR 70'S PRESENTLY A PACED @88 DUE TO HYPOTENSION. SBP REQUIRED NEO WITH LABILE BP/ NTG WHEN AWAKE AND . BOTH OFF. CI <2 RECEIVED 5L LR THEREFORE EPI STARTED @.O2 MCQ ^ .O3 MCQ.CI>2. RECEIVED 1UPC FOR HCT 27 REPEAT 32-36. MVO2 55-63. EXTREMITIES DRY BUT COOL. PALP PP. DSGS D+I. JP FROM LEFT UPPER LEG. REPEAT HCT 32-36. PH 7.28 WITH -7 RECEIVED AN ADDITIONAL 2L LR , REPEAT LABS PENDING. CT OOZY WITH ACT 162 RECEIVED 50 MG PROTAMINE. K,CALCIUM + MAG REPLACED. PACS NOTED INFREQUENTLY.LACTATE 3-5.7.\n RESP: VENT SETTINGS AND ABG PER FLOW.ABG PRIOR TO CPAP SENT AND PH 7.29 WITH -7 THEREFORE RESEDATED AND PLACED BACK ON RATE (ONCPAP PT .) BS COURSE UPPER, DIMINISHED BIBASILAR. ETT PULLED BACK 2 CM AS PER ABOVE. INTEMITTENT CT LEAK. SUCTIONED FOR A MOD AMOUNT OF BLOOD TINGED TO YELLOW SPUTUM. LAVAGED.\n NEURO: SEDATED ON PROPOFOL 50 AND PT . DID FOLLOW COMMANDS +MAE, RESEDATED ON 60 MCQ. PERL,\n GI+ + OGT PLACEMENT DRAINED 100ML. ABD SOFT+DISTENDED, ABSENT BOWEL SOUNDS.\n GU: AUTODIURESING HAS SLOWED.\n ENDO: INSULIN GTT AT 8 UNITS/HR.\n ID: VANCO AT .\n PAIN: WHEN AWAKE PT ADMITTED TO PAIN. RECEIVED 2 MG MORPHINE X2. 2 MG MORPHINE PREVIOUSLY PRIOR TO BEING AWAKE DUE TO CHANGE IN SBP.\n SKIN: INTACT. NOTED NOSE BLLED. NP INTO ASSESS.HAS STOPPED SINCE ARRIVAL FROM OR/\n SOCIAL: SPOKE TO DAUGHTER WHO IS THE SPOKESPERSON AND UPDATED.\nA: CI LOW REQUIRING LR,UPC,AUTODIURESING, WITH AWAKENING, ^ LACTATE? ETIOLOGY.\nP: MONITOR COMFORT, HR AND RYTHYM, SBP, CI, MVO2,CONTINUE EPI,CT DRAINAGE, DSGS, PP, RESP STATUS-TO REMAIN INTUBATED OVERNIGHT, NEURO STATUS-PROPOFOL, I+O, LABS PENDING, IF STABLE THROUGHTOUT THE NIGHT/ WAKE AND WEAN. AS PER ORDERS\n"},{"category":"Nursing/other","chartdate":"2176-04-20 00:00:00.000","description":"Report","row_id":1647216,"text":"Resp Care: Pt continues on mechanical ventilation: AC 450x20 60%+8. Most recent ABG: 7.39/35/79/22/-2-> PEEP briefly inreased to 10-> returned to 8 MD. Pt fluid overloaded. LS coarse bilaterally. Sxn'd small amounts of thick yellow secretions. MDI's given as ordered. PLAN: continue current support.\n"},{"category":"Nursing/other","chartdate":"2176-04-20 00:00:00.000","description":"Report","row_id":1647217,"text":"Nursing Progress Note\nNeuro: sedated propofol at 25 mcg/kg/min. Awoke at 5 am off sedation, followed commands, gag and cough intact, perla 4 brisk. Resedated for resp compromise while awake.\n\nCVS: t max 98.1, hr 95 apaced underlying 70's sr. pa 25/18, co 4.08/ci 2.25, mvo2 63. EPI gtt off at 0130, on/off neo overnight, currently prop as above and insulin at 8 units/hour. Pacer ademand rate of 94, appropriately sensing and pacing a and V, skin warm, pale, dry. Pedal pulses doppler, right weaker than left. Troponin .53, EKG no significant changes from post op. Right Ij introducer with thermo swan, right radial a line and 3 peripheral iv's. Left leg ace wrap changed, echymosis and edema knee and calf, hemovac left groin with scant sang drainage. Sternal dressing CDI. Chest tubes to suction with serosang drainage. Initially acidosis, after 2 amps sodium bicarb acidosis is resolving.\n\nResp: ls coarse in uppers to dim throughout. Intubated, vent on AC .6/450/20/peep 8 now 10 after desat episode. ABG on 8 peep 7.39/35/79/22/-2/95% When waking from sedation attempted CPAP became bronchospastic, desating to 90-91, placed on 100 fio2 with no change, returned to cmv with sedation sats now 96%. Suctioned x 1 for thick blood tinged, otherwise no seretions with suction.\n\nGI: abdomen obese, distended, bs hypo. OGT with brown to golden secretions with coffee ground. 450 cc overnight. Appeared to be wretching with waking, given reglan IVP with relief.\n\nGU: Foley catheter draining clear yellow urien to gravity.\n\nEndo: fs bs covered with insulin drip per cvicu guidelines.\n\nPain: Grimacing and crying when awake, morphine 2 mg ivp with sleep as relief.\n\nLabs: lactate initially 6.8, down to 2.8 at 0500.\n\nSocial: no calls or family contact this shift.\n\nActivity: right side lying not well tolerated, numbers improve on back or left side.\n\nPlan: Wean ventilator support as tolerated. Wean pacing and sedation as numbers and hemodynamics tolerate.\n\n\n\n"},{"category":"Nursing/other","chartdate":"2176-04-21 00:00:00.000","description":"Report","row_id":1647224,"text":" 7a-7p addendum\nat ~ 1730 pt went into RAF 110-180, lopressor 5mg iv x2 and amio 150mg iv bolus w/out return to nsr, RAF continues 110-145, md aware, awaiting amio gtt to arrive\n"},{"category":"Nursing/other","chartdate":"2176-04-22 00:00:00.000","description":"Report","row_id":1647225,"text":"Neuro: pt oriented x 1 to name only she does know she is in a hospital but not where, and she thinks it is . pt reoriented but does not remember when asked again. MOving all extremities weakly.\nResp: pt found on 70& FIO@ face tent with sats of 98% weaned down to 50% pt did well with this until about 0200 when sats started to fall. FIO@ increased and NP but sats remained low. pt coughing and raising moderate amounts of thick tan secretions. CPT done. Albuterol inhalers given but pt did not take well so changed to neb. BReath sounds clear with crackes in left base. Cough was tight and wheezy. ABG sent with po2 returning 60 pt placed on hiflow 95% with plan to wean as tolerated.\nC/V: pt was in afib at the begining of shift rate 120-150 with stable BP and borderline CI. pt given additional 10mg IVP lopressor without effect., Amiodarone drip at 1mg started and pt given additional bolus of amio when pt did not slow down. Hemodynamics rechecked and CI by thermodilution had dropped to 1.5 SVO2 came backat 47% which gave a CI of 1.99. Hct check was stable at 28. Resdient notified Dr and additional Amio bolus of 150mg given and Diltiazem drip was ordered but before drip was ready but converted to sinus rhythm of 60. Hemodynamic rechecked and CI remained low with HR of 60 pt apaced at rate of 80 with SVO@ increased to 53% and CI >2.0 HO aware to monitor for now. Repeat SVO@ pending. SBP increasing throughout evening pt required nitro to be started presently on 2.5mcg with SBP 138/67.\nPedal pulses present. Chest tubes continue to drainig small to moderate amounts of serous sangunious drainage.\nGI: pt tolerating sips of clear liquids.\nEndo: Blood sugars treated with sliding scale.\nGU: adequate urine outputs off lasix drip.\nPain: pt complaining of pain in chest and leg last evening medicated with percocet 1 tab with good effect except pt seemed alittle more confused and lethargic after taking. THis am compalianing of pain so pt trying tylenol 650mg.\\\nskin: Incisions clean and dry no redness or drainage.\nPlan: Wean nitro as tolerated. OOB to chair CPT and IS\n"},{"category":"Nursing/other","chartdate":"2176-04-22 00:00:00.000","description":"Report","row_id":1647226,"text":"3*24 7a-7p\nneuro: a+ox2, reoriented to place, mae, follows commands, up with PT to chair w/ assist x1, steady on feet, perrlaa, darvocet started for incisional pain w/ good response\n\ncv: a paced 70-80, underlying rhythm sb/sr high 50s-low 60s, sbp 15-145, ntg gtt to keep sbp <140, lopressor/captopril po for bp control, ci 1.7-2.8, pt a paced for ci support, amio gtt turned off this am, amio po started, afeb, ct d/ced this am\n\nresp: lungs cta, dim to bases, weaned o2 to nc 4L, sats currently>95%, is to 375ml, strong cough productive of clear/tan secretions\n\ngi: abdomen soft/distended, tolerating clear liquid diet, fingersticks ssri\n\ngu: foley to gravity draining clear yellow urine\n\nlabs: HIT panel from negative, heparin sc given this pm\n\nassess: improving respiratory status\n\nplan: wean ntg to off, goal sbp<140, pace as needed to keep ci>2.1, pulmonary toilet, increase activity\n"},{"category":"Nursing/other","chartdate":"2176-04-23 00:00:00.000","description":"Report","row_id":1647227,"text":"TSICU Progress Note 1900-0700\n See carevue for exact data\n ROS_\n Neuro- alert, ox2, MAE equally. C/o significant incisional pain,Darvocet 2tabs given w/poor efect. N/V x2, ? form pain med. Morphine 2mg ivp w/fair effect, given x4\n CV_MP Apaced at 80, BP<140 ion NTG up to 3mcg/kg/min,presently off.Hydralazine 10mg iv x2 w/effect. Hct 28 s/p 2u PC's, last CO4.31,CI 2.38. Generalized edema persists, pulses+, SCD's off part of night for comfort, moving legs frequently.Excellent diuresis form Diamox.\n Resp- NC4lpm, desat briefly after vomiting to mid 80's, improved w/ Db+C, raising mod amts thick tan sputum\n GI- water taken well overnight, intermittent N/V. BS+, no stool\n GU-Foley, u/o clear yellow. On Diamox(one more dose), Lasix\n Labs- lytes repleted, no RISS coverage Hct 28\n Plan-\n SBP<140\n Pain control\n ^ act as tolerated\n\n"},{"category":"Nursing/other","chartdate":"2176-04-23 00:00:00.000","description":"Report","row_id":1647228,"text":"7A-7P\nNeuro: Pt alert and oriented, forgetful at times. Perrla. MAE. Pain med changed to dilaudid po w/ effect. See flowsheet.\n\nCV: Received pt via epicardial wires at 80. CI> 2 via thermodilution w/ HR 80. To go by FICk per PA . Epicardial wires turned off per PA. SVO2 sent, resulted as 59. PA aware, CI>2 via FICK. Ok to dc swan per PA . See flowsheet for filling pressures. Captorpil increased to 37.5mg tid. GOAL SBP <140. Hydralazine iv prn ordered for SBP>140. 2+ generalized edema. +palpable pulses.\n\nResp: LS clear diminished bases. Sats >94% on 4Lnc. Encouraged coughing and deep breathing. Bringing up thick tannish secretions small amts.\n\nGI/GU: Abd softly distended. +BS. Tolerating clears. Poor appetite. Foley draining clear yellow urine adequate amts, see flowsheet.\n\nEndo: RISS.\n\nPlan: Monitor hemodynamics. Monitor resp. status. Pulmonary hygeine.\nEncourage po intake. Transfer to floor in am.\n"},{"category":"Nursing/other","chartdate":"2176-04-20 00:00:00.000","description":"Report","row_id":1647218,"text":"S/P CABG X 5\nO: CARDIAC: A PACED 94-80 TO SR 60'S HOWEVER SBP DROPS TO HIGH 80'S THEREFORE A PACED. PRESENTLY A PACED AT 80. ISOLATED PVC'S NOTED. K 4.1 RECEIVED 20 MEQ WITH K 4.7. MAGNESIUM 2 GM X1. SBP HIGH 80'S TO 140 WITH AGITATION.CI<2 AT 1000 DOBUTAMINE BEGAN AT 1100 WITH CI>2.MVO2 61-66. PADS LOW TWENTIES,CVP LOW TEENS. CT DRAINAGE 10-50ML/HR. DSGS REMAIN D+I. EXTREMITIES COOL TO TOUCH. WEAK PALP PP. JP DRAINED 30 ML SANGUINOUS DRAINAGE AT 0900. HCT 31. VENODYNES AND SC HEPARIN PER DR. .\n RESP: PO2 68 FIO2 ^ TO 70% AND PEEP ^ TO 12. REPEAT ABG PO2 86. ABG AND VENT SETTINGS PER FLOW. SUCTIONED FOR A SMALL AMOUNT OF THICK BLOOD TINGED SPUTUM X1. CXR REVEALS WET-HOPE TO IMPROVE WITH IV LASIX GTT.BS COURSE TO CLEAR UPPER, DIMINISHED BIBASILAR. NO CHEST TUBE LEAK NOTED THIS SHIFT.\n NEURO: MAE NOT TO COMMAND, PROPOFOL ^ FROM 25 MCQ TO 40 MCQ WITH AGITATION AND HTN. PERL, TO REMAIN SEDATED AND INTUBATED UNTIL FLUID REMOVED.\n GI: +PLACEMENT OF OGT, ABD DISTENDED NOT AS SOFT AS LAST NIGHT. + BOWEL SOUNDS-HYPOACTIVE. NO STOOL. CARAFATE AND ZANTAC GIVEN. 75 ML BROWN DRAINAGE NOTED.\n GU: RECEIVED 10 MG IV LASIX WITH BRISK 840 ML DIURESIS, IV LASIX GTT STARTED AT 2 MG ^ TO 3 MG AT 1530 DUE TO UO <100ML/HR. GOAL 100-150 ML /HR. CREAT WNL.\n ID: RECEIVED VANCO AT 0830. WBC 10. AFEBRILE.\n ENDO: INSULIN GTT DC'D AT 1100. 1400 GLUCOSE 95.\n PAIN: 2 MG MORPHINE PRIOR TO MOVEMENT OR CHANGE IN VS.\n SKIN: INTACT- NOTED BRUISING OF LEFT ANKLE WITH EDEMA.\n SOCIAL: DAUGHTER INTO VISIT ASKING QUESTIONS. UPDATED A STO PLAN.\nA: CI IMPROVED WITH DOBUTAMINE,CXR WET, DIURESING WITH LASIX GTT, PO2 ^ WITH ^ PEEP AND FIO2, ^ AGITATION WITH LIGHTENING ,\nP: MONITOR COMFORT, HR AND RYTHYM, SBP-USE LEVO IF NEED TO SUPPORT BP, CI-CONTINUE DOBUTAMINE, MVO2, CT DRAINAGE, DSGS, PP, RESP STATUS-WEAN FIO2 AND PEEP, NEURO STATUS-CONTINUE PROPOFOL-?PRECEDEX WHEN ABLE TO WEAN, I+O-CONTINUE LASIX GTT GOAL UO 100-150 ML/HR, LABS PENDING. AS PER ORDERS.\n"},{"category":"Nursing/other","chartdate":"2176-04-20 00:00:00.000","description":"Report","row_id":1647219,"text":"Resp care\n\nFio2 to 70% and peep to 12 after am abg with pao2 of 68. Pao2 improved on subsqueint abg's. Cxr being read as pulmonary edema. Bs are generally clear. Suctioning scant white sputum.\n\n\n"},{"category":"Nursing/other","chartdate":"2176-04-21 00:00:00.000","description":"Report","row_id":1647220,"text":"Resp Care: Pt continues on mechanical ventilation: AC 450x18 60%+10. Most recent ABG: 7.45/38/103/27/2. LS diminished bilaterally. Pt suctioned for small amounts of blood-tinged secretions. Albuterol MDI given as ordered. RSBI not done secondary to high oxygen and PEEP requirements. PLAN: continue mechanical ventilation. Wean as tolerated.\n"},{"category":"Nursing/other","chartdate":"2176-04-21 00:00:00.000","description":"Report","row_id":1647221,"text":"NEURO: sedated on propofol. opens eyes, MAE, PERRL. not following commands but becomes with any stimulation. treated with morphine IV for pain with turning/moving. ?need precedex for extubation.\nCV: sinus rhythm 80's few PVC noted overnoc. continues on dobutamine, lasix gtts, diureseing well, weight down, -600 since midnoc. CI>2 and CO>4 by thermodilution. sov2 70. a and v wires in place both sense and pace, a demand some pacing spikes noted so sensitivity turned up, resolved. sbp >100 map>60 so no need to start levo. warm and dry +palp pedal pulses.\nRESP: remains orally intubated PEEP and fio2 weaned overnoc with good oxygenation on abg. PEEP 10, fio2 50. getting alkalotic from diuresis. lungs clear with diminished bases bilat. suctioned for scant yellow thick secretions. chest tubes with serosang, drainage slowing overnoc. no leak or crepitus.\nGI/GU: abd obese, +bowel sounds- hypoactive. OGT draining coffee grounds-->brown drainage. +placement. foley with clear yellow urine.\nENDO: CVICU RISS\nID: vanco\nSKIN: sternal incision with operative dressing intact. mediastinal chest tube site clean, no drainage dsd changed. LLE with hemovacscant sang drainage, steristrips intact dsd changed and ace re-wrapped. back and buttocks intact.\nA/P: continue to monitor cv, resp. continue diuresis. to remain intubated until fluid balance improves. ?need precedex to extubate. ?need diamox for matabolic alkalosis. ?nutrition consult.\n"},{"category":"Nursing/other","chartdate":"2176-04-21 00:00:00.000","description":"Report","row_id":1647222,"text":"Respiratory Care:\nPt extubated to a 50% cool neb plus 4L/M NC Sat = 94% HR = 99,\nRR = 22, BP = 129/56. Seems to be OK at present.\n"},{"category":"Nursing/other","chartdate":"2176-04-21 00:00:00.000","description":"Report","row_id":1647223,"text":" 7a-7p\nneuro: received sedated on propofol, not following commands; now rouses to voice, oriented x2 (reoriented to time), follows commands, mae, good pain control w/ morphine 1mg ivp q1-2h\n\ncv: sr 85-97 no ectopy, sbp 95-140, ntg gtt to keep map<90/sbp<120, ci 2.1-2.6, dobutamine gtt weaned off, swan left in place md, cvp 7-15, pad 17-25, ct draining small/moderate amts s/s drainage, max temp 38.2\n\nresp: lungs cta, dim to left base, extubated at 1430 to nc 4L & face tent at 50%, now sats >95% on 5L nc & face tent 70%, strong non-productive cough, w/ extubation pt expectorated large bloody/mucoid sputum (md aware, no further bleeding noted), is to 250ml\n\ngi: abdomen soft/distended, hypoactive bowel sounds, tolerating ice chips, fingersticks ssri\n\ngu: foley to gravity, copious diuresis this am w/ lasix gtt, lasix gtt weaned off & pt continues to autodiurese, pt currently -3L for day\n\nassess: stable\n\nplan: start po metoprolol, wean ntg as tolerated to keep sbp<120, map<90, pulmonary toilet, deline and transfer to 6 in am\n"},{"category":"ECG","chartdate":"2176-04-26 00:00:00.000","description":"Report","row_id":192589,"text":"Sinus rhythm. Left anterior fascicular block. Non-specific ST-T wave changes.\nCompared to the previous tracing of Q-T interval is no longer\nprolonged.\n\n"},{"category":"ECG","chartdate":"2176-04-25 00:00:00.000","description":"Report","row_id":192590,"text":"Sinus rhythm\nLeft anterior fascicular block\nAnterolateral T wave changes are nonspecific\nQT interval prolonged for rate\nSince previous tracing of , QT interval prolonged, T wave abnormalities\nmore marked\n\n"},{"category":"ECG","chartdate":"2176-04-20 00:00:00.000","description":"Report","row_id":192591,"text":"Sinus rhythm. Left anterior fascicular block. Compared to the previous\ntracing pacing is no longer seen.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2176-04-19 00:00:00.000","description":"Report","row_id":192592,"text":"Atrial paced rhythm. Compared to the previous tracing of pacing\nis new.\nTRACING #1\n\n"},{"category":"ECG","chartdate":"2176-04-16 00:00:00.000","description":"Report","row_id":192593,"text":"Sinus bradycardia\nLeft anterior fascicular block\nPossible anterior myocardial infarction - age undetermined\nInferior/lateral T changes may be due to ischemia\nNo previous tracing available for comparison\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2176-04-27 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 1006803,\n \"text\": \" 9:03 AM\\n CHEST (PA & LAT) Clip # \\n Reason: eval pleural effusions\\n Admitting Diagnosis: ANGINA\\\\CATH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 76 year old woman s/p CABG\\n REASON FOR THIS EXAMINATION:\\n eval pleural effusions\\n ______________________________________________________________________________\\n FINAL REPORT\\n TWO-VIEW CHEST, \\n\\n COMPARISON: .\\n\\n INDICATION: Status post coronary bypass surgery.\\n\\n Cardiac silhouette is mildly enlarged but stable in size from the prior\\n post-operative radiograph. Areas of patchy and linear atelectasis in the\\n lower lobes have slightly improved, and small bilateral pleural effusions are\\n not substantially changed.\\n\\n IMPRESSION: Persistent small bilateral pleural effusions. Improving\\n bibasilar atelectasis.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2176-04-19 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1005724,\n \"text\": \" 11:47 PM\\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \\n Reason: overload\\n Admitting Diagnosis: ANGINA\\\\CATH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 76 year old woman with increasing lactate\\n REASON FOR THIS EXAMINATION:\\n overload\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Followup.\\n\\n COMPARISON: .\\n\\n FINDINGS: As compared to the previous examination, there are no major\\n changes. The monitoring and support devices are in unchanged position. There\\n is unchanged mild pulmonary edema. The size of the cardiac silhouette is also\\n unchanged.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2176-04-22 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1006017,\n \"text\": \" 9:41 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: r/o ptx s/p ct's removed\\n Admitting Diagnosis: ANGINA\\\\CATH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 76 year old woman with\\n REASON FOR THIS EXAMINATION:\\n r/o ptx s/p ct's removed\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 76-year-old female status post chest tube removal. Rule out\\n pneumothorax.\\n\\n COMPARISON: .\\n\\n UPRIGHT CHEST RADIOGRAPH: Patient is status post CABG and median sternotomy\\n wires are intact. The right-sided Swan-Ganz catheter is in unchanged\\n position. Left-sided chest tubes have been removed and there is no evidence\\n of pneumothorax. Left basilar atelectasis has increased at the site of prior\\n chest tube removal. The remainder of this examination is unchanged.\\n\\n IMPRESSION: Status post removal of left-sided chest tubes with no evidence of\\n pneumothorax.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2176-04-19 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 1005660,\n \"text\": \" 1:16 PM\\n CHEST PORT. LINE PLACEMENT Clip # \\n Reason: ptx\\n Admitting Diagnosis: ANGINA\\\\CATH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 76 year old woman with s/p CABG\\n REASON FOR THIS EXAMINATION:\\n ptx\\n ______________________________________________________________________________\\n FINAL REPORT\\n PROCEDURE: Chest portable for line placement on .\\n\\n COMPARISON: chest radiograph.\\n\\n HISTORY: 76-year-old woman status post CABG, evaluate for pneumothorax.\\n\\n FINDINGS: Baseline postoperative examination showing multiple median\\n sternotomy wires with no wire complications. The lungs are mildly edematous.\\n Two chest drainage catheters are seen projecting over the left lower\\n hemithorax.\\n\\n A feeding tube distal tip is in the stomach. An endotracheal tube distal tip\\n is only 1.5 cm above the carina. A right internal jugular Swan-Ganz catheter\\n terminates in the main pulmonary outflow tract. No right pleural effusion.\\n Probable small, if present, left pleural effusion. No pneumothorax.\\n\\n IMPRESSION:\\n 1. No radiographic evidence of pneumothorax.\\n 2. Mild pulmonary edema, small, if present, left pleural effusion, status\\n post CABG.\\n 3. The endotracheal tube distal tip is approximately 1.5 cm above the carina\\n bifurcation.\\n\\n The information was delivered by phone to for Dr. \\n . Dr. to inform her about the position of the\\n endotracheal tube.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2176-04-21 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1005876,\n \"text\": \" 7:29 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: s/p cabg CHF\\n Admitting Diagnosis: ANGINA\\\\CATH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 76 year old woman with\\n REASON FOR THIS EXAMINATION:\\n s/p cabg CHF\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Followup.\\n\\n COMPARISON: , 00:10 a.m.\\n\\n FINDINGS: As compared to the previous examination, there is no relevant\\n change. The monitoring and support devices are in unchanged position. The\\n size of the cardiac silhouette is unchanged. There are no signs suggestive of\\n pneumonia and no signs suggestive of relevant overhydration. Pleural\\n effusions cannot be detected. No evidence of pneumothorax.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2176-04-25 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 1006520,\n \"text\": \" 1:02 PM\\n CHEST (PA & LAT) Clip # \\n Reason: eval for pleural effusions\\n Admitting Diagnosis: ANGINA\\\\CATH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 76 year old woman s/p cabgx5\\n REASON FOR THIS EXAMINATION:\\n eval for pleural effusions\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 76-year-old woman with five vessel CABG.\\n\\n COMPARISON: .\\n\\n PA AND LATERAL VIEWS OF THE CHEST: There has been interval removal of a Swan-\\n Ganz catheter via a right internal jugular approach. Median sternotomy wires\\n are intact. The left hemidiaphragm is now obscured by a small-to-moderate\\n left pleural effusion with associated atelectasis. Elsewhere, the lungs are\\n well expanded with no foci of consolidation. There may be a tiny right\\n pleural effusion. There is no pneumothorax. The mild cardiomegaly is\\n unchanged. Pulmonary vasculature is normal.\\n\\n IMPRESSION: Small left pleural effusion with associated atelectasis.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2176-04-17 00:00:00.000\",\n \"description\": \"CHEST (PRE-OP PA & LAT)\",\n \"row_id\": 1005376,\n \"text\": \" 2:42 PM\\n CHEST (PRE-OP PA & LAT) Clip # \\n Reason: ANGINA\\\\CATH\\n Admitting Diagnosis: ANGINA\\\\CATH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 76 year old woman with 3VD, unstable angina awaiting CABG \\n REASON FOR THIS EXAMINATION:\\n evaluate for infiltrates/CHF\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Unstable engine awaiting CABG.\\n\\n FINDINGS: No previous images. There is enlargement of the cardiac silhouette\\n with tortuosity of the aorta. Some prominence of interstitial markings could\\n reflect elevated pulmonary venous pressure, chronic lung disease, or both. No\\n acute focal pneumonia.\\n\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2176-04-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 78950,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Coronary artery disease;\\nHeight: (in) 62\\nWeight (lb): 159\\nBSA (m2): 1.74 m2\\nBP (mm Hg): 110/70\\nHR (bpm): 74\\nStatus: Inpatient\\nDate/Time: at 11:07\\nTest: TEE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT ATRIUM: Dilated LA.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or color\\nDoppler.\\n\\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. No LV\\naneurysm. Moderate regional LV systolic dysfunction.\\n\\nLV WALL MOTION: Regional LV wall motion abnormalities include: mid anterior -\\nhypo; mid anteroseptal - hypo; mid inferoseptal - hypo; anterior apex - hypo;\\nseptal apex - hypo; apex - akinetic;\\n\\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\\n\\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\\naortic root. Normal ascending aorta diameter. Focal calcifications in\\nascending aorta. Normal aortic arch diameter. Normal descending aorta\\ndiameter. Simple atheroma in descending aorta.\\n\\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild to\\nmoderate (+) AR.\\n\\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR.\\n\\nTRICUSPID VALVE: Mild [1+] TR.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\\nphysiologic PR.\\n\\nPERICARDIUM: No pericardial effusion.\\n\\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\\nI was present in compliance with HCFA regulations. The patient was under\\ngeneral anesthesia throughout the procedure. No TEE related complications. The\\npatient appears to be in sinus rhythm. Results were personally reviewed with\\nthe MD caring for the patient.\\n\\nConclusions:\\nPRE-BYPASS:\\nThe left atrium is dilated. No atrial septal defect is seen by 2D or color\\nDoppler.\\nLeft ventricular wall thicknesses are normal. The left ventricular cavity size\\nis normal. No left ventricular aneurysm is seen. There is moderate regional\\nleft ventricular systolic dysfunction with hypokinesis notable in the LAD\\ndistribution.\\nRight ventricular chamber size and free wall motion are normal.\\nThere are simple atheroma in the descending thoracic aorta.\\nThe aortic valve leaflets (3) are mildly thickened but aortic stenosis is not\\npresent. Mild to moderate (+) aortic regurgitation is seen.\\nThe mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation\\nis seen. There is no pericardial effusion. Dr. was notified in person\\nof the results on at 8AM on .\\n\\nPOST_BYPASS:\\nLVEF 45% on no inotropic support.\\nMild AI, Mild MR and Mild TR.\\nNormal RV systolic function.\\nAscending aortic contour is intact.\\nLAD terriotry WMA is the same.\\n\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2176-04-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 78951,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Coronary artery disease. Mitral valve disease.\\nHeight: (in) 62\\nWeight (lb): 159\\nBSA (m2): 1.74 m2\\nBP (mm Hg): 130/88\\nHR (bpm): 54\\nStatus: Inpatient\\nDate/Time: at 11:52\\nTest: TTE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT ATRIUM: Normal LA and RA cavity sizes.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\\n\\nLEFT VENTRICLE: Normal LV wall thickness. Mildly dilated LV cavity. Moderate\\nregional LV systolic dysfunction. No resting LVOT gradient. No VSD.\\n\\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior\\n- hypo; mid inferior - hypo; basal inferolateral - hypo; mid inferolateral -\\nhypo; septal apex - hypo; inferior apex - hypo; apex - akinetic;\\n\\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\\n\\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\\naortic root. Mildly dilated ascending aorta. Normal aortic arch diameter. No\\n2D or Doppler evidence of distal arch coarctation.\\n\\nAORTIC VALVE: ?# aortic valve leaflets. Mildly thickened aortic valve\\nleaflets. No AS. Mild to moderate (+) AR.\\n\\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\\nannular calcification. Mild (1+) MR. LV inflow pattern c/w impaired\\nrelaxation.\\n\\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Borderline\\nPA systolic hypertension.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\\nphysiologic PR.\\n\\nPERICARDIUM: No pericardial effusion. There is an anterior space which most\\nlikely represents a fat pad, though a loculated anterior pericardial effusion\\ncannot be excluded.\\n\\nConclusions:\\nThe left atrium and right atrium are normal in cavity size. Left ventricular\\nwall thicknesses are normal. The left ventricular cavity is mildly dilated.\\nThere is moderate regional left ventricular systolic dysfunction with\\nhypokinesis of the basal to mid inferolateral segments, inferior wall and\\nseptal apex. The apex is akinetic. There is no ventricular septal defect.\\nRight ventricular chamber size and free wall motion are normal. The ascending\\naorta is mildly dilated. The number of aortic valve leaflets cannot be\\ndetermined. The aortic valve leaflets are mildly thickened. There is no aortic\\nvalve stenosis. Mild to moderate (+) aortic regurgitation is seen. The\\nmitral valve leaflets are mildly thickened. Mild mitral regurgitation is seen.\\nThere is no mitral valve prolapse. The left ventricular inflow pattern\\nsuggests impaired relaxation. There is borderline pulmonary artery systolic\\nhypertension. There is no pericardial effusion. There is an anterior space\\nwhich most likely represents a fat pad.\\n\\nIMPRESSION: Mildly dilated left ventricular cavity with moderate focal left\\nventricular systolic dysfunction likely due to multi-vessel CAD. Probable\\ndiastolic dysfunction. Mild mitral regurgitation. Mild to moderate aortic\\nregurgitation. Borderline pulmonary artery systolic hypertension.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2176-04-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1647214,\n \"text\": \"Resp Care\\n\\nPt received from OR and placed on full vent support. BS were bilateral. Mode was changed to a/c. OETT pulled back 2cm. Will wean fast wean appropriate.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2176-04-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1647229,\n \"text\": \"2300-0700\\n\\nNEURO: Pt slept most of shift. Ox3 when awake, followed commands, MAE, assists with turning. c/o pain , Given dilaudid PO with good relief.\\n\\nCV: Pt in NSR 60s-70s with no ectopy noted. 2As/2Vs, pacer turned off. Both sense and capture. SBP 110s-140s, MAP 70s-80s. Captopril ^ 50mg TID. PP palpable. Hct 32.9.\\n\\nRESP: Pt on 2L NC, sats>96%. LS clear, little dim in bases. Pt well, producing sputum on own, thick yellow sputum.\\n\\nGI/GU: + BS; pt denies nausea, no appetite. Pt on PO lasix , diuresing well. K+ pnd. Lytes repleated prn.\\n\\nENDO: BS tx per RISS. BS WNL.\\n\\nID: Afebrile, skin cool to touch- warm blankets. WBC 10.9\\n\\nPLAN: Peripheral access and d/c cordus. ^ diet, ^ activity. pulm toilet & comfort/support. transfer to 6 in am.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2176-04-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1647215,\n \"text\": \"S/P CABG X 5\\nO: CARDIAC: A PACED WITH UNDERLYING RYTHYM 70-60'S. SR 70'S PRESENTLY A PACED @88 DUE TO HYPOTENSION. SBP REQUIRED NEO WITH LABILE BP/ NTG WHEN AWAKE AND . BOTH OFF. CI <2 RECEIVED 5L LR THEREFORE EPI STARTED @.O2 MCQ ^ .O3 MCQ.CI>2. RECEIVED 1UPC FOR HCT 27 REPEAT 32-36. MVO2 55-63. EXTREMITIES DRY BUT COOL. PALP PP. DSGS D+I. JP FROM LEFT UPPER LEG. REPEAT HCT 32-36. PH 7.28 WITH -7 RECEIVED AN ADDITIONAL 2L LR , REPEAT LABS PENDING. CT OOZY WITH ACT 162 RECEIVED 50 MG PROTAMINE. K,CALCIUM + MAG REPLACED. PACS NOTED INFREQUENTLY.LACTATE 3-5.7.\\n RESP: VENT SETTINGS AND ABG PER FLOW.ABG PRIOR TO CPAP SENT AND PH 7.29 WITH -7 THEREFORE RESEDATED AND PLACED BACK ON RATE (ONCPAP PT .) BS COURSE UPPER, DIMINISHED BIBASILAR. ETT PULLED BACK 2 CM AS PER ABOVE. INTEMITTENT CT LEAK. SUCTIONED FOR A MOD AMOUNT OF BLOOD TINGED TO YELLOW SPUTUM. LAVAGED.\\n NEURO: SEDATED ON PROPOFOL 50 AND PT . DID FOLLOW COMMANDS +MAE, RESEDATED ON 60 MCQ. PERL,\\n GI+ + OGT PLACEMENT DRAINED 100ML. ABD SOFT+DISTENDED, ABSENT BOWEL SOUNDS.\\n GU: AUTODIURESING HAS SLOWED.\\n ENDO: INSULIN GTT AT 8 UNITS/HR.\\n ID: VANCO AT .\\n PAIN: WHEN AWAKE PT ADMITTED TO PAIN. RECEIVED 2 MG MORPHINE X2. 2 MG MORPHINE PREVIOUSLY PRIOR TO BEING AWAKE DUE TO CHANGE IN SBP.\\n SKIN: INTACT. NOTED NOSE BLLED. NP INTO ASSESS.HAS STOPPED SINCE ARRIVAL FROM OR/\\n SOCIAL: SPOKE TO DAUGHTER WHO IS THE SPOKESPERSON AND UPDATED.\\nA: CI LOW REQUIRING LR,UPC,AUTODIURESING, WITH AWAKENING, ^ LACTATE? ETIOLOGY.\\nP: MONITOR COMFORT, HR AND RYTHYM, SBP, CI, MVO2,CONTINUE EPI,CT DRAINAGE, DSGS, PP, RESP STATUS-TO REMAIN INTUBATED OVERNIGHT, NEURO STATUS-PROPOFOL, I+O, LABS PENDING, IF STABLE THROUGHTOUT THE NIGHT/ WAKE AND WEAN. AS PER ORDERS\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2176-04-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1647216,\n \"text\": \"Resp Care: Pt continues on mechanical ventilation: AC 450x20 60%+8. Most recent ABG: 7.39/35/79/22/-2-> PEEP briefly inreased to 10-> returned to 8 MD. Pt fluid overloaded. LS coarse bilaterally. Sxn'd small amounts of thick yellow secretions. MDI's given as ordered. PLAN: continue current support.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2176-04-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1647217,\n \"text\": \"Nursing Progress Note\\nNeuro: sedated propofol at 25 mcg/kg/min. Awoke at 5 am off sedation, followed commands, gag and cough intact, perla 4 brisk. Resedated for resp compromise while awake.\\n\\nCVS: t max 98.1, hr 95 apaced underlying 70's sr. pa 25/18, co 4.08/ci 2.25, mvo2 63. EPI gtt off at 0130, on/off neo overnight, currently prop as above and insulin at 8 units/hour. Pacer ademand rate of 94, appropriately sensing and pacing a and V, skin warm, pale, dry. Pedal pulses doppler, right weaker than left. Troponin .53, EKG no significant changes from post op. Right Ij introducer with thermo swan, right radial a line and 3 peripheral iv's. Left leg ace wrap changed, echymosis and edema knee and calf, hemovac left groin with scant sang drainage. Sternal dressing CDI. Chest tubes to suction with serosang drainage. Initially acidosis, after 2 amps sodium bicarb acidosis is resolving.\\n\\nResp: ls coarse in uppers to dim throughout. Intubated, vent on AC .6/450/20/peep 8 now 10 after desat episode. ABG on 8 peep 7.39/35/79/22/-2/95% When waking from sedation attempted CPAP became bronchospastic, desating to 90-91, placed on 100 fio2 with no change, returned to cmv with sedation sats now 96%. Suctioned x 1 for thick blood tinged, otherwise no seretions with suction.\\n\\nGI: abdomen obese, distended, bs hypo. OGT with brown to golden secretions with coffee ground. 450 cc overnight. Appeared to be wretching with waking, given reglan IVP with relief.\\n\\nGU: Foley catheter draining clear yellow urien to gravity.\\n\\nEndo: fs bs covered with insulin drip per cvicu guidelines.\\n\\nPain: Grimacing and crying when awake, morphine 2 mg ivp with sleep as relief.\\n\\nLabs: lactate initially 6.8, down to 2.8 at 0500.\\n\\nSocial: no calls or family contact this shift.\\n\\nActivity: right side lying not well tolerated, numbers improve on back or left side.\\n\\nPlan: Wean ventilator support as tolerated. Wean pacing and sedation as numbers and hemodynamics tolerate.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2176-04-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1647224,\n \"text\": \" 7a-7p addendum\\nat ~ 1730 pt went into RAF 110-180, lopressor 5mg iv x2 and amio 150mg iv bolus w/out return to nsr, RAF continues 110-145, md aware, awaiting amio gtt to arrive\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2176-04-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1647225,\n \"text\": \"Neuro: pt oriented x 1 to name only she does know she is in a hospital but not where, and she thinks it is . pt reoriented but does not remember when asked again. MOving all extremities weakly.\\nResp: pt found on 70& FIO@ face tent with sats of 98% weaned down to 50% pt did well with this until about 0200 when sats started to fall. FIO@ increased and NP but sats remained low. pt coughing and raising moderate amounts of thick tan secretions. CPT done. Albuterol inhalers given but pt did not take well so changed to neb. BReath sounds clear with crackes in left base. Cough was tight and wheezy. ABG sent with po2 returning 60 pt placed on hiflow 95% with plan to wean as tolerated.\\nC/V: pt was in afib at the begining of shift rate 120-150 with stable BP and borderline CI. pt given additional 10mg IVP lopressor without effect., Amiodarone drip at 1mg started and pt given additional bolus of amio when pt did not slow down. Hemodynamics rechecked and CI by thermodilution had dropped to 1.5 SVO2 came backat 47% which gave a CI of 1.99. Hct check was stable at 28. Resdient notified Dr and additional Amio bolus of 150mg given and Diltiazem drip was ordered but before drip was ready but converted to sinus rhythm of 60. Hemodynamic rechecked and CI remained low with HR of 60 pt apaced at rate of 80 with SVO@ increased to 53% and CI >2.0 HO aware to monitor for now. Repeat SVO@ pending. SBP increasing throughout evening pt required nitro to be started presently on 2.5mcg with SBP 138/67.\\nPedal pulses present. Chest tubes continue to drainig small to moderate amounts of serous sangunious drainage.\\nGI: pt tolerating sips of clear liquids.\\nEndo: Blood sugars treated with sliding scale.\\nGU: adequate urine outputs off lasix drip.\\nPain: pt complaining of pain in chest and leg last evening medicated with percocet 1 tab with good effect except pt seemed alittle more confused and lethargic after taking. THis am compalianing of pain so pt trying tylenol 650mg.\\\\\\nskin: Incisions clean and dry no redness or drainage.\\nPlan: Wean nitro as tolerated. OOB to chair CPT and IS\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2176-04-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1647226,\n \"text\": \"3*24 7a-7p\\nneuro: a+ox2, reoriented to place, mae, follows commands, up with PT to chair w/ assist x1, steady on feet, perrlaa, darvocet started for incisional pain w/ good response\\n\\ncv: a paced 70-80, underlying rhythm sb/sr high 50s-low 60s, sbp 15-145, ntg gtt to keep sbp <140, lopressor/captopril po for bp control, ci 1.7-2.8, pt a paced for ci support, amio gtt turned off this am, amio po started, afeb, ct d/ced this am\\n\\nresp: lungs cta, dim to bases, weaned o2 to nc 4L, sats currently>95%, is to 375ml, strong cough productive of clear/tan secretions\\n\\ngi: abdomen soft/distended, tolerating clear liquid diet, fingersticks ssri\\n\\ngu: foley to gravity draining clear yellow urine\\n\\nlabs: HIT panel from negative, heparin sc given this pm\\n\\nassess: improving respiratory status\\n\\nplan: wean ntg to off, goal sbp<140, pace as needed to keep ci>2.1, pulmonary toilet, increase activity\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2176-04-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1647227,\n \"text\": \"TSICU Progress Note 1900-0700\\n See carevue for exact data\\n ROS_\\n Neuro- alert, ox2, MAE equally. C/o significant incisional pain,Darvocet 2tabs given w/poor efect. N/V x2, ? form pain med. Morphine 2mg ivp w/fair effect, given x4\\n CV_MP Apaced at 80, BP<140 ion NTG up to 3mcg/kg/min,presently off.Hydralazine 10mg iv x2 w/effect. Hct 28 s/p 2u PC's, last CO4.31,CI 2.38. Generalized edema persists, pulses+, SCD's off part of night for comfort, moving legs frequently.Excellent diuresis form Diamox.\\n Resp- NC4lpm, desat briefly after vomiting to mid 80's, improved w/ Db+C, raising mod amts thick tan sputum\\n GI- water taken well overnight, intermittent N/V. BS+, no stool\\n GU-Foley, u/o clear yellow. On Diamox(one more dose), Lasix\\n Labs- lytes repleted, no RISS coverage Hct 28\\n Plan-\\n SBP<140\\n Pain control\\n ^ act as tolerated\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2176-04-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1647228,\n \"text\": \"7A-7P\\nNeuro: Pt alert and oriented, forgetful at times. Perrla. MAE. Pain med changed to dilaudid po w/ effect. See flowsheet.\\n\\nCV: Received pt via epicardial wires at 80. CI> 2 via thermodilution w/ HR 80. To go by FICk per PA . Epicardial wires turned off per PA. SVO2 sent, resulted as 59. PA aware, CI>2 via FICK. Ok to dc swan per PA . See flowsheet for filling pressures. Captorpil increased to 37.5mg tid. GOAL SBP <140. Hydralazine iv prn ordered for SBP>140. 2+ generalized edema. +palpable pulses.\\n\\nResp: LS clear diminished bases. Sats >94% on 4Lnc. Encouraged coughing and deep breathing. Bringing up thick tannish secretions small amts.\\n\\nGI/GU: Abd softly distended. +BS. Tolerating clears. Poor appetite. Foley draining clear yellow urine adequate amts, see flowsheet.\\n\\nEndo: RISS.\\n\\nPlan: Monitor hemodynamics. Monitor resp. status. Pulmonary hygeine.\\nEncourage po intake. Transfer to floor in am.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2176-04-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1647218,\n \"text\": \"S/P CABG X 5\\nO: CARDIAC: A PACED 94-80 TO SR 60'S HOWEVER SBP DROPS TO HIGH 80'S THEREFORE A PACED. PRESENTLY A PACED AT 80. ISOLATED PVC'S NOTED. K 4.1 RECEIVED 20 MEQ WITH K 4.7. MAGNESIUM 2 GM X1. SBP HIGH 80'S TO 140 WITH AGITATION.CI<2 AT 1000 DOBUTAMINE BEGAN AT 1100 WITH CI>2.MVO2 61-66. PADS LOW TWENTIES,CVP LOW TEENS. CT DRAINAGE 10-50ML/HR. DSGS REMAIN D+I. EXTREMITIES COOL TO TOUCH. WEAK PALP PP. JP DRAINED 30 ML SANGUINOUS DRAINAGE AT 0900. HCT 31. VENODYNES AND SC HEPARIN PER DR. .\\n RESP: PO2 68 FIO2 ^ TO 70% AND PEEP ^ TO 12. REPEAT ABG PO2 86. ABG AND VENT SETTINGS PER FLOW. SUCTIONED FOR A SMALL AMOUNT OF THICK BLOOD TINGED SPUTUM X1. CXR REVEALS WET-HOPE TO IMPROVE WITH IV LASIX GTT.BS COURSE TO CLEAR UPPER, DIMINISHED BIBASILAR. NO CHEST TUBE LEAK NOTED THIS SHIFT.\\n NEURO: MAE NOT TO COMMAND, PROPOFOL ^ FROM 25 MCQ TO 40 MCQ WITH AGITATION AND HTN. PERL, TO REMAIN SEDATED AND INTUBATED UNTIL FLUID REMOVED.\\n GI: +PLACEMENT OF OGT, ABD DISTENDED NOT AS SOFT AS LAST NIGHT. + BOWEL SOUNDS-HYPOACTIVE. NO STOOL. CARAFATE AND ZANTAC GIVEN. 75 ML BROWN DRAINAGE NOTED.\\n GU: RECEIVED 10 MG IV LASIX WITH BRISK 840 ML DIURESIS, IV LASIX GTT STARTED AT 2 MG ^ TO 3 MG AT 1530 DUE TO UO <100ML/HR. GOAL 100-150 ML /HR. CREAT WNL.\\n ID: RECEIVED VANCO AT 0830. WBC 10. AFEBRILE.\\n ENDO: INSULIN GTT DC'D AT 1100. 1400 GLUCOSE 95.\\n PAIN: 2 MG MORPHINE PRIOR TO MOVEMENT OR CHANGE IN VS.\\n SKIN: INTACT- NOTED BRUISING OF LEFT ANKLE WITH EDEMA.\\n SOCIAL: DAUGHTER INTO VISIT ASKING QUESTIONS. UPDATED A STO PLAN.\\nA: CI IMPROVED WITH DOBUTAMINE,CXR WET, DIURESING WITH LASIX GTT, PO2 ^ WITH ^ PEEP AND FIO2, ^ AGITATION WITH LIGHTENING ,\\nP: MONITOR COMFORT, HR AND RYTHYM, SBP-USE LEVO IF NEED TO SUPPORT BP, CI-CONTINUE DOBUTAMINE, MVO2, CT DRAINAGE, DSGS, PP, RESP STATUS-WEAN FIO2 AND PEEP, NEURO STATUS-CONTINUE PROPOFOL-?PRECEDEX WHEN ABLE TO WEAN, I+O-CONTINUE LASIX GTT GOAL UO 100-150 ML/HR, LABS PENDING. AS PER ORDERS.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2176-04-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1647219,\n \"text\": \"Resp care\\n\\nFio2 to 70% and peep to 12 after am abg with pao2 of 68. Pao2 improved on subsqueint abg's. Cxr being read as pulmonary edema. Bs are generally clear. Suctioning scant white sputum.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2176-04-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1647220,\n \"text\": \"Resp Care: Pt continues on mechanical ventilation: AC 450x18 60%+10. Most recent ABG: 7.45/38/103/27/2. LS diminished bilaterally. Pt suctioned for small amounts of blood-tinged secretions. Albuterol MDI given as ordered. RSBI not done secondary to high oxygen and PEEP requirements. PLAN: continue mechanical ventilation. Wean as tolerated.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2176-04-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1647221,\n \"text\": \"NEURO: sedated on propofol. opens eyes, MAE, PERRL. not following commands but becomes with any stimulation. treated with morphine IV for pain with turning/moving. ?need precedex for extubation.\\nCV: sinus rhythm 80's few PVC noted overnoc. continues on dobutamine, lasix gtts, diureseing well, weight down, -600 since midnoc. CI>2 and CO>4 by thermodilution. sov2 70. a and v wires in place both sense and pace, a demand some pacing spikes noted so sensitivity turned up, resolved. sbp >100 map>60 so no need to start levo. warm and dry +palp pedal pulses.\\nRESP: remains orally intubated PEEP and fio2 weaned overnoc with good oxygenation on abg. PEEP 10, fio2 50. getting alkalotic from diuresis. lungs clear with diminished bases bilat. suctioned for scant yellow thick secretions. chest tubes with serosang, drainage slowing overnoc. no leak or crepitus.\\nGI/GU: abd obese, +bowel sounds- hypoactive. OGT draining coffee grounds-->brown drainage. +placement. foley with clear yellow urine.\\nENDO: CVICU RISS\\nID: vanco\\nSKIN: sternal incision with operative dressing intact. mediastinal chest tube site clean, no drainage dsd changed. LLE with hemovacscant sang drainage, steristrips intact dsd changed and ace re-wrapped. back and buttocks intact.\\nA/P: continue to monitor cv, resp. continue diuresis. to remain intubated until fluid balance improves. ?need precedex to extubate. ?need diamox for matabolic alkalosis. ?nutrition consult.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2176-04-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1647222,\n \"text\": \"Respiratory Care:\\nPt extubated to a 50% cool neb plus 4L/M NC Sat = 94% HR = 99,\\nRR = 22, BP = 129/56. Seems to be OK at present.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2176-04-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1647223,\n \"text\": \" 7a-7p\\nneuro: received sedated on propofol, not following commands; now rouses to voice, oriented x2 (reoriented to time), follows commands, mae, good pain control w/ morphine 1mg ivp q1-2h\\n\\ncv: sr 85-97 no ectopy, sbp 95-140, ntg gtt to keep map<90/sbp<120, ci 2.1-2.6, dobutamine gtt weaned off, swan left in place md, cvp 7-15, pad 17-25, ct draining small/moderate amts s/s drainage, max temp 38.2\\n\\nresp: lungs cta, dim to left base, extubated at 1430 to nc 4L & face tent at 50%, now sats >95% on 5L nc & face tent 70%, strong non-productive cough, w/ extubation pt expectorated large bloody/mucoid sputum (md aware, no further bleeding noted), is to 250ml\\n\\ngi: abdomen soft/distended, hypoactive bowel sounds, tolerating ice chips, fingersticks ssri\\n\\ngu: foley to gravity, copious diuresis this am w/ lasix gtt, lasix gtt weaned off & pt continues to autodiurese, pt currently -3L for day\\n\\nassess: stable\\n\\nplan: start po metoprolol, wean ntg as tolerated to keep sbp<120, map<90, pulmonary toilet, deline and transfer to 6 in am\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2176-04-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 192589,\n \"text\": \"Sinus rhythm. Left anterior fascicular block. Non-specific ST-T wave changes.\\nCompared to the previous tracing of Q-T interval is no longer\\nprolonged.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2176-04-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 192590,\n \"text\": \"Sinus rhythm\\nLeft anterior fascicular block\\nAnterolateral T wave changes are nonspecific\\nQT interval prolonged for rate\\nSince previous tracing of , QT interval prolonged, T wave abnormalities\\nmore marked\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2176-04-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 192591,\n \"text\": \"Sinus rhythm. Left anterior fascicular block. Compared to the previous\\ntracing pacing is no longer seen.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2176-04-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 192592,\n \"text\": \"Atrial paced rhythm. Compared to the previous tracing of pacing\\nis new.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2176-04-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 192593,\n \"text\": \"Sinus bradycardia\\nLeft anterior fascicular block\\nPossible anterior myocardial infarction - age undetermined\\nInferior/lateral T changes may be due to ischemia\\nNo previous tracing available for comparison\\n\\n\"\n }\n]"}}},{"rowIdx":380,"cells":{"subject_id":{"kind":"number","value":91053,"string":"91,053"},"hadm_id":{"kind":"number","value":144816,"string":"144,816"},"target_text":{"kind":"string","value":"This is a 76 year old male with IPF on prednisone and azathioprine, Bactrim PPX, exertional hypoxia, AS with LVH, AAA, and pulmonary HTN, who was admitted for increased SOB likely due to an exacerbation of his underlying pulmonary fibrosis. . #. SOB- He was admitted to the ICU The patient has end stage pulmonary fibrosis on 5L of NC at home and therefore has poor respiratory functional reserve. The patient has had several CXRs this admission which do not show any signs of infection. It is also likely that his mild leukocytosis was due to an increase in his steroid dosing. His SOB this admission is likely secondary to an IPF exacerbation which responded to increased steroid dosing with a 3 day burst of prednisone 60mg that was decreased down to his home prednisone 20mg dose prior to discharge. He was started on antibiotics on admission to cover a hospital acquired pneumonia and he was continued on his empiric antibiotics despite minimal evidence of infection given that he has poor baseline pulmonary reserve. He therefore was continued on levofloxacin, linezolid, and cefepime to complete an 8 day course at home. Linezolid was chosen after the patient developed an erythemic eruption on his chest and back while being dosed with vancomyin in the ED. He was continued on his home azathioprine and bactrim prohylaxis. He was set up for home PT and home O2 of Liters with a face mask upon discharge. . #. Thrombocytopenia: Felt to be secondary to PPI. Resolved since patient has been switched to H2 blocker. . #. Pancreatic ductal dilation: Per a prior discharge summary, he should be scheduled for an outpatient CT abd/pelvis for further evaluation and monitoring. . #. Aortic Stenosis: It does not seem like his aortic stenosis is contributing to his current symptoms. Continued home ASA and lasix. . #. Anemia- His hematocrit has drifted down from 40 earlier this month to 38 on admission. He would likely benefit from having as high a hematocrit as possible to give him maximal oxygen carrying capacity in the setting of his chronic hypoxia. Continue to monitor closely as an outpatient. . #. Anxiety - When the patient develops anxiety, he becomes short of breath, tachypneic, and tachycardic. It was noted that he responded well to lorazepam 0.5mg PRN which relieved his anxiety and improved his oxygen saturation. He was discharged with a new prescription for lorazepam 0.5mg q8 PRN. . #. Access: Right sided PICC placed . #. Emergency Contact: wife- . #. Code: Confirmed DNR/DNI"},"extractive_notes_summ":{"kind":"string","value":"IMPRESSION: Advanced interstitial pattern bilaterally consistent with diagnosis of idiopathic pulmonary fibrosis. There existed already at that time rather advanced diffuse bilateral interstitial process suggesting the diagnosis of idiopathic pulmonary fibrosis. There are extensive bilateral reticular interstitial markings, compatible with interstitial fibrosis, similar compared to prior. Atelectasis at the right lung base. Additionally, there is mild opacification at the right lung base, which could be dependent atelectasis; however, cannot exclude focal area of consolidation. IMPRESSION: New right PICC with tip in low SVC in satisfactory position. Bilateral interstitial fibrosis. FINDINGS: The new right PICC is with tip in the lower SVC in satisfactory position. There pleural effusions or pneumothorax. COMPARISON: Compared to chest radiograph from . The findings are described in the accompanying report making the diagnosis of rather advanced interstitial fibrosis. EXAMINATION: Single frontal chest radiograph. New right PICC placement. The lung parenchyma is unchanged with diffuse interstitial prominence, compatible with known interstitial lung disease now with superimposed left lower lobe consolidation compatible with pneumonia. FINDINGS: PA and lateral chest views were obtained with patient in upright position. FINDINGS: There is new interval consolidation of the left lobe, which could be atelectasis; however, cannot exclude pneumonia, or pleural effusion. COMPARISONS: and CT from . Comparison is first made with the next preceding AP single view chest examination of . Sinus tachycardia. Cardiomediastinal and hilar contours are unchanged. Occasional atrial premature beats. Otherwise, no change in known chronic interstitial lung disease and left lower lobe pneumonia. Evaluate for worsened lung process. Right bundle-branchblock. Pulmonary vascularity is normal. No new major pleural effusions. TECHNIQUE: Portable upright chest radiograph, single view. New opacity at the left lung base, concerning for pneumonia in appropriate clinical setting; however, atelectasis can have a similar appearance. The lateral and posterior pleural sinuses are free. A previous chest CT of is also reviewed. IMPRESSION: 1. Evaluate for pneumonia. INDICATION: 76-year-old male patient with IPF and worsened pulmonary status. Comparison is extended to multiple previous chest examinations beginning with . No pneumothorax in the apical area. No evidence of new discrete parenchymal infiltrates. Evaluate position. 3. The process may have increased slightly, but again there is no evidence of new discrete additional infiltrates. 1:15 PM CHEST (PA & LAT) Clip # Reason: Evaluation of worsened L lung process Admitting Diagnosis: PNEUMONIA MEDICAL CONDITION: 76 year old man with IPF and worsened pulmonary status REASON FOR THIS EXAMINATION: Evaluation of worsened L lung process FINAL REPORT TYPE OF EXAMINATION: Chest PA and lateral. 2:39 AM CHEST (PORTABLE AP) Clip # Reason: ?PNA MEDICAL CONDITION: 76 year old man with SOB, h/o pulm fibrosis REASON FOR THIS EXAMINATION: ?PNA FINAL REPORT HISTORY: 76-year-old man with shortness of breath, and history of pulmonary fibrosis. FINAL REPORT INDICATION: Patient is a 76-year-old male with pneumonia. 2. Compared to the previous tracing of the rate has increased. There is no evidence of pneumothorax. LINE PLACEMENT Clip # Reason: R picc 48cm Admitting Diagnosis: PNEUMONIA MEDICAL CONDITION: 76 year old man with pneumonia REASON FOR THIS EXAMINATION: R picc 48cm WET READ: IPf WED 12:24 AM Tip of PICC line at the cavoatrial junction. 10:15 PM CHEST PORT."},"n_notes":{"kind":"number","value":4,"string":"4"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2177-06-24 00:00:00.000","description":"CHEST (PA & LAT)","row_id":1137440,"text":" 1:15 PM\n CHEST (PA & LAT) Clip # \n Reason: Evaluation of worsened L lung process\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with IPF and worsened pulmonary status\n REASON FOR THIS EXAMINATION:\n Evaluation of worsened L lung process\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest PA and lateral.\n\n INDICATION: 76-year-old male patient with IPF and worsened pulmonary status.\n Evaluate for worsened lung process.\n\n FINDINGS: PA and lateral chest views were obtained with patient in upright\n position. Comparison is first made with the next preceding AP single view\n chest examination of . No significant interval change can be\n identified, thus no evidence of rapidly progressing processes or new discrete\n infiltrates. Comparison is extended to multiple previous chest examinations\n beginning with . There existed already at that time rather\n advanced diffuse bilateral interstitial process suggesting the diagnosis of\n idiopathic pulmonary fibrosis. The process may have increased slightly, but\n again there is no evidence of new discrete additional infiltrates. The\n lateral and posterior pleural sinuses are free. No pneumothorax in the apical\n area. A previous chest CT of is also reviewed. The findings\n are described in the accompanying report making the diagnosis of rather\n advanced interstitial fibrosis.\n\n IMPRESSION: Advanced interstitial pattern bilaterally consistent with\n diagnosis of idiopathic pulmonary fibrosis. No evidence of new discrete\n parenchymal infiltrates. No new major pleural effusions.\n\n\n"},{"category":"Radiology","chartdate":"2177-06-23 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1137260,"text":" 2:39 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?PNA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with SOB, h/o pulm fibrosis\n REASON FOR THIS EXAMINATION:\n ?PNA\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 76-year-old man with shortness of breath, and history of pulmonary\n fibrosis. Evaluate for pneumonia.\n\n TECHNIQUE: Portable upright chest radiograph, single view.\n\n COMPARISON: Compared to chest radiograph from .\n\n FINDINGS:\n\n There is new interval consolidation of the left lobe, which could be\n atelectasis; however, cannot exclude pneumonia, or pleural effusion.\n Additionally, there is mild opacification at the right lung base, which could\n be dependent atelectasis; however, cannot exclude focal area of consolidation.\n There are extensive bilateral reticular interstitial markings, compatible with\n interstitial fibrosis, similar compared to prior. There is no evidence of\n pneumothorax.\n\n IMPRESSION:\n 1. New opacity at the left lung base, concerning for pneumonia in appropriate\n clinical setting; however, atelectasis can have a similar appearance.\n 2. Atelectasis at the right lung base.\n 3. Bilateral interstitial fibrosis.\n\n\n\n\n"},{"category":"Radiology","chartdate":"2177-06-24 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":1137508,"text":" 10:15 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: R picc 48cm\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with pneumonia\n REASON FOR THIS EXAMINATION:\n R picc 48cm\n ______________________________________________________________________________\n WET READ: IPf WED 12:24 AM\n Tip of PICC line at the cavoatrial junction.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient is a 76-year-old male with pneumonia. New right PICC\n placement. Evaluate position.\n\n EXAMINATION: Single frontal chest radiograph.\n\n COMPARISONS: and CT from .\n\n FINDINGS: The new right PICC is with tip in the lower SVC in satisfactory\n position. The lung parenchyma is unchanged with diffuse interstitial\n prominence, compatible with known interstitial lung disease now with\n superimposed left lower lobe consolidation compatible with pneumonia. There\n pleural effusions or pneumothorax. Cardiomediastinal and hilar contours are\n unchanged. Pulmonary vascularity is normal.\n\n IMPRESSION:\n New right PICC with tip in low SVC in satisfactory position. Otherwise, no\n change in known chronic interstitial lung disease and left lower lobe\n pneumonia.\n\n\n"},{"category":"ECG","chartdate":"2177-06-23 00:00:00.000","description":"Report","row_id":233712,"text":"Sinus tachycardia. Occasional atrial premature beats. Right bundle-branch\nblock. Compared to the previous tracing of the rate has increased.\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2177-06-24 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 1137440,\n \"text\": \" 1:15 PM\\n CHEST (PA & LAT) Clip # \\n Reason: Evaluation of worsened L lung process\\n Admitting Diagnosis: PNEUMONIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 76 year old man with IPF and worsened pulmonary status\\n REASON FOR THIS EXAMINATION:\\n Evaluation of worsened L lung process\\n ______________________________________________________________________________\\n FINAL REPORT\\n TYPE OF EXAMINATION: Chest PA and lateral.\\n\\n INDICATION: 76-year-old male patient with IPF and worsened pulmonary status.\\n Evaluate for worsened lung process.\\n\\n FINDINGS: PA and lateral chest views were obtained with patient in upright\\n position. Comparison is first made with the next preceding AP single view\\n chest examination of . No significant interval change can be\\n identified, thus no evidence of rapidly progressing processes or new discrete\\n infiltrates. Comparison is extended to multiple previous chest examinations\\n beginning with . There existed already at that time rather\\n advanced diffuse bilateral interstitial process suggesting the diagnosis of\\n idiopathic pulmonary fibrosis. The process may have increased slightly, but\\n again there is no evidence of new discrete additional infiltrates. The\\n lateral and posterior pleural sinuses are free. No pneumothorax in the apical\\n area. A previous chest CT of is also reviewed. The findings\\n are described in the accompanying report making the diagnosis of rather\\n advanced interstitial fibrosis.\\n\\n IMPRESSION: Advanced interstitial pattern bilaterally consistent with\\n diagnosis of idiopathic pulmonary fibrosis. No evidence of new discrete\\n parenchymal infiltrates. No new major pleural effusions.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2177-06-23 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1137260,\n \"text\": \" 2:39 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ?PNA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 76 year old man with SOB, h/o pulm fibrosis\\n REASON FOR THIS EXAMINATION:\\n ?PNA\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 76-year-old man with shortness of breath, and history of pulmonary\\n fibrosis. Evaluate for pneumonia.\\n\\n TECHNIQUE: Portable upright chest radiograph, single view.\\n\\n COMPARISON: Compared to chest radiograph from .\\n\\n FINDINGS:\\n\\n There is new interval consolidation of the left lobe, which could be\\n atelectasis; however, cannot exclude pneumonia, or pleural effusion.\\n Additionally, there is mild opacification at the right lung base, which could\\n be dependent atelectasis; however, cannot exclude focal area of consolidation.\\n There are extensive bilateral reticular interstitial markings, compatible with\\n interstitial fibrosis, similar compared to prior. There is no evidence of\\n pneumothorax.\\n\\n IMPRESSION:\\n 1. New opacity at the left lung base, concerning for pneumonia in appropriate\\n clinical setting; however, atelectasis can have a similar appearance.\\n 2. Atelectasis at the right lung base.\\n 3. Bilateral interstitial fibrosis.\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2177-06-24 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 1137508,\n \"text\": \" 10:15 PM\\n CHEST PORT. LINE PLACEMENT Clip # \\n Reason: R picc 48cm\\n Admitting Diagnosis: PNEUMONIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 76 year old man with pneumonia\\n REASON FOR THIS EXAMINATION:\\n R picc 48cm\\n ______________________________________________________________________________\\n WET READ: IPf WED 12:24 AM\\n Tip of PICC line at the cavoatrial junction.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Patient is a 76-year-old male with pneumonia. New right PICC\\n placement. Evaluate position.\\n\\n EXAMINATION: Single frontal chest radiograph.\\n\\n COMPARISONS: and CT from .\\n\\n FINDINGS: The new right PICC is with tip in the lower SVC in satisfactory\\n position. The lung parenchyma is unchanged with diffuse interstitial\\n prominence, compatible with known interstitial lung disease now with\\n superimposed left lower lobe consolidation compatible with pneumonia. There\\n pleural effusions or pneumothorax. Cardiomediastinal and hilar contours are\\n unchanged. Pulmonary vascularity is normal.\\n\\n IMPRESSION:\\n New right PICC with tip in low SVC in satisfactory position. Otherwise, no\\n change in known chronic interstitial lung disease and left lower lobe\\n pneumonia.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2177-06-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 233712,\n \"text\": \"Sinus tachycardia. Occasional atrial premature beats. Right bundle-branch\\nblock. Compared to the previous tracing of the rate has increased.\\n\\n\"\n }\n]"}}},{"rowIdx":381,"cells":{"subject_id":{"kind":"number","value":69370,"string":"69,370"},"hadm_id":{"kind":"number","value":125185,"string":"125,185"},"target_text":{"kind":"string","value":"He was taken to interventional radiology, where an attempt was made to find and embolize the vessel leading to the bleeding. During the course of the procedure he received 27+ units of packed cells and additional units of FFP, cryoprecipitate and platelets. He was found to have extravasation of contrast from the GDA and a duodenal branch of the SMA. Both were coiled to stasis during the procedure and there was no evidence of further extravasation. The L gastric artery was also embolized with gelfoam. He was taken to the MICU afterwards. While in the MICU, he again became hypertensive and continued to have blood come out of his PEG tube and his flexi-seal tube. He was taken emergently to the operating room. While in the operating room, he received an additional unit of packed red cells, but was found to have an intra-operative hematocrit around thirty, so no more units were given. During the course of the exploratory laparotomy, he was found to have a bleeding duodenal ulcer which was oversewn. There were no other sources of bleeding identified and he was closed primarily and taken to the surgical ICU. His post-operative was uncomplicated initially. His hematocrit was stable, he passed some small amounts of melanotic stool post-operatively, but these resolved by POD 1. His trauma line was discontinued on POD 1 as his hematocrit had been stable, and he was transferred out of the SICU on POD 2. His tube feeds through his g-tube were restarted on POD 3 early in the AM. At some point around 7-8am on POD 3 (), he had a large amount of emesis which appeared very similar to tube feed material. He had immidiate respiratory distress and was coughing copiously. He was transferred back to the SICU and he was re-intubated. He had a bronchoscopy which showed a small amounts of fluid in the lungs and erythema consistent with pneumonitis. He was placed on CMV and began having increasing FiO2 and PEEP requirements to maintain even modest PaO2 in the 50s. By POD 4, he was requiring FiO2 of 100% and high PEEP settings up to 20cmH2o, and he was also started on inhaled nitric oxide to attempt to improve his oxygenation. As POD 4 went on, he continued to have very poor PaO2 and was also requiring increasing levels of vasopressors to maintain his systolic pressures adequately. His lactate, which had been 1.8 on and 5.7 a few hours after the aspiration, had now climbed to 11.3, and the decision was made to place the patient on ECMO to attempt to improve his oxygenation. He continued to have PaO2 in the 50s and 40s and was eventually maxed out on norepinepherine, vasopression and neosynepherine. His lactate rose to 23.3 and he began to have episodes of ventricular fibrillation. A code was called during his first episode of ventricular fibrillation but was shortly cancelled after two rounds of epinepherine, bicarbonate and shocks did nothing to alter his heart rhythm. Compressions were not started as the patient was already on ECMO at the time of the code. At roughly 1145pm on , the decision was made to make the patient comfort measures only and he expired shortly thereafter at 0035 ."},"extractive_notes_summ":{"kind":"string","value":"Right internal jugular, check placement. Having achieved this, the catheter was withdrawn from the celiac origin and brought inferiorly into the superior mesenteric artery. There is now a new right internal jugular approach central venous line that terminates in similar position as the subclavian line. Injection of a small volume of contrast at this point no longer demonstrated active extravasation; however, we are concerned inflow from the additional branch to the GDA so this was cannulated using a combination of the microcatheter and wire and additional larger coils and gelfoam slurry were placed in this branch extending up into the origin of the gastroduodenal artery from the common hepatic. Right subclavian catheter tip is in the mid SVC. Mild (1+) mitral regurgitation is seen. Superior mesenteric artery angiography. Right femoral arterial access. Selective GDA angiography. A previously identified NG line is seen unchanged and reaches well below the diaphragm. The inner portion was removed along with nitinol wire and wire was advanced up into the IVC. With some manipulation, we successfully cannulated the inferior pancreaticoduodenal artery, which continued to (Over) 11:31 AM MESSENERTIC Clip # Reason: please embolize bleeder Admitting Diagnosis: UPPER GI BLEED Contrast: OPTIRAY Amt: 214 FINAL REPORT (Cont) demonstrate active extravasation. (Over) 11:31 AM MESSENERTIC Clip # Reason: please embolize bleeder Admitting Diagnosis: UPPER GI BLEED Contrast: OPTIRAY Amt: 214 FINAL REPORT (Cont) Hypoxia,Height: (in) 68Weight (lb): 155BSA (m2): 1.84 m2BP (mm Hg): 96/61HR (bpm): 96Status: InpatientDate/Time: at 14:59Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: SalineTechnical Quality: SuboptimalINTERPRETATION:Findings:This study was compared to the report of the prior study (images notavailable) of .LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Normal LV cavity size. A right subclavian approach central venous line can be identified and appears unchanged in comparison with the previous study. Celiac angiography. Mild-moderate global left ventricularhypokinesis. Left gastric Gelfoam embolization. The aortic root is mildly dilated at the sinus level. From that point, an STC microcatheter and Transend wire were advanced into the common hepatic artery and then to the gastroduodenal artery. Suboptimal image quality - ventilator.Conclusions:The left atrium is normal in size. There is mild pulmonary artery systolichypertension. Mild (1+) MR.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Left ventricular function. Using a combination of palpatory, fluoroscopic and ultrasound guidance, the right femoral artery was accessed with a micropuncture needle. Left gastric arteriography. Contrast was injected via the side arm to confirm adequate positioning with the point of entry overlying the femoral head. The catheter was removed. An 018 nitinol wire was passed via the needle which was removed and exchanged for a 4F micropuncture sheath, the inner portions of which and the nitinol wire were removed and exchanged for wire. AP single view of the chest has been obtained with patient in supine position. A nitinol wire was advanced via the needle which was removed and exchanged for a micropuncture sheath. As per the request of the MICU team, the right femoral arterial sheath was left in situ as an arterial line access point. 11:31 AM MESSENERTIC Clip # Reason: please embolize bleeder Admitting Diagnosis: UPPER GI BLEED Contrast: OPTIRAY Amt: 214 ********************************* CPT Codes ******************************** * EMBO NON NEURO NON-TUNNELED * * INITAL 3RD ORDER ABD/PEL/LOWER -59 DISTINCT PROCEDURAL SERVICE * * INITAL 2ND ORDER ABD/PEL/LOWER -59 DISTINCT PROCEDURAL SERVICE * * VISERAL SEL/SUPERSEL A-GRAM -59 DISTINCT PROCEDURAL SERVICE * * VISERAL SEL/SUPERSEL A-GRAM -59 DISTINCT PROCEDURAL SERVICE * * EA ADD'L VESSEL AFTER BASIC A- -59 DISTINCT PROCEDURAL SERVICE * * EA ADD'L VESSEL AFTER BASIC A- -59 DISTINCT PROCEDURAL SERVICE * * TRANCATHETER EMBOLIZATION * **************************************************************************** MEDICAL CONDITION: 63 year old man with ."},"n_notes":{"kind":"number","value":5,"string":"5"},"notes":{"kind":"list like","value":[{"category":"Echo","chartdate":"2119-10-10 00:00:00.000","description":"Report","row_id":103452,"text":"PATIENT/TEST INFORMATION:\nIndication: Chronic lung disease. Left ventricular function. Hypoxia,\nHeight: (in) 68\nWeight (lb): 155\nBSA (m2): 1.84 m2\nBP (mm Hg): 96/61\nHR (bpm): 96\nStatus: Inpatient\nDate/Time: at 14:59\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: Saline\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the report of the prior study (images not\navailable) of .\n\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV cavity size. Mild-moderate global left ventricular\nhypokinesis. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Mild global RV free wall hypokinesis.\n\nAORTA: Mildy dilated aortic root.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. Mild (1+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR. Mild\nPA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: Very small pericardial effusion. No echocardiographic signs of\ntamponade.\n\nGENERAL COMMENTS: Contrast study was performed with 1 iv injection of 8 ccs of\nagitated normal saline at rest. Suboptimal image quality - ventilator.\n\nConclusions:\nThe left atrium is normal in size. The left ventricular cavity size is normal.\nThere is mild to moderate global left ventricular hypokinesis (LVEF = 40 %).\nThe right ventricle is borderline dilated with mild global free wall\nhypokinesis. The aortic root is mildly dilated at the sinus level. The aortic\nvalve leaflets (3) appear structurally normal with good leaflet excursion and\nno aortic stenosis or aortic regurgitation. The mitral valve leaflets are\nstructurally normal. Mild (1+) mitral regurgitation is seen. The tricuspid\nvalve leaflets are mildly thickened. There is mild pulmonary artery systolic\nhypertension. There is a very small pericardial effusion. There are no\nechocardiographic signs of tamponade.\n\nAgitated saline contrast study at rest revealed no evidence of an intracardiac\nshunt.\n\nCompared with the prior report (images unavailable) of , ventricular\ndysfunction is new.\n\n\n"},{"category":"Radiology","chartdate":"2119-10-05 00:00:00.000","description":"NON-TUNNELED","row_id":1252516,"text":" 11:31 AM\n MESSENERTIC Clip # \n Reason: please embolize bleeder\n Admitting Diagnosis: UPPER GI BLEED\n Contrast: OPTIRAY Amt: 214\n ********************************* CPT Codes ********************************\n * EMBO NON NEURO NON-TUNNELED *\n * INITAL 3RD ORDER ABD/PEL/LOWER -59 DISTINCT PROCEDURAL SERVICE *\n * INITAL 2ND ORDER ABD/PEL/LOWER -59 DISTINCT PROCEDURAL SERVICE *\n * VISERAL SEL/SUPERSEL A-GRAM -59 DISTINCT PROCEDURAL SERVICE *\n * VISERAL SEL/SUPERSEL A-GRAM -59 DISTINCT PROCEDURAL SERVICE *\n * EA ADD'L VESSEL AFTER BASIC A- -59 DISTINCT PROCEDURAL SERVICE *\n * EA ADD'L VESSEL AFTER BASIC A- -59 DISTINCT PROCEDURAL SERVICE *\n * TRANCATHETER EMBOLIZATION *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with . Posterior duodenal bulb artery bleeding\n REASON FOR THIS EXAMINATION:\n please embolize bleeder\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 63-year-old man with posterior duodenal bulb artery bleeding,\n please embolize bleeder.\n\n PHYSICIANS: Dr. Mhuircheartaigh (radiology fellow), Dr. \n , Dr (radiology attending) who was present throughout and\n supervised the procedure.\n\n MEDICATIONS: The patient was intubated and sedated prior to transfer to the\n angiographic suite, please see dedicated ICU note for additional information.\n\n RADIATION: 2900 mGy, 94 minutes fluoroscopy time.\n\n CONTRAST: 214 cc of Optiray 320.\n\n PROCEDURES:\n 1. Right femoral arterial access.\n 2. Celiac angiography.\n 3. Selective GDA angiography.\n 4. Embolization of a branch of the GDA which demonstrated active\n extravasation. In addition, embolization of the GDA was performed.\n 5. Left gastric arteriography.\n 6. Left gastric Gelfoam embolization.\n 7. Superior mesenteric artery angiography.\n 8. Embolization of a bleeding duodenal branch of the SMA.\n 9. Right femoral angiography demonstrating appropriate placement of a 5\n French femoral sheath.\n 10. Placement of a 9 French trauma line into the left common femoral vein.\n\n PROCEDURE DETAILS:\n\n Informed patient consent was waived by the referring physician in view of the\n (Over)\n\n 11:31 AM\n MESSENERTIC Clip # \n Reason: please embolize bleeder\n Admitting Diagnosis: UPPER GI BLEED\n Contrast: OPTIRAY Amt: 214\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n patient's need for emergent interventions. The patient was brought to\n angiographic suite, intubated and sedated and was placed supine on the\n angiographic table. A preprocedure timeout was performed using three patient\n identifiers.\n\n Using a combination of palpatory, fluoroscopic and ultrasound guidance, the\n right femoral artery was accessed with a micropuncture needle. An 018 nitinol\n wire was passed via the needle which was removed and exchanged for a 4F\n micropuncture sheath, the inner portions of which and the nitinol wire were\n removed and exchanged for wire. This was advanced up into the\n abdominal aorta. The micropuncture sheath was exchanged for a 5 French\n -Tip sheath, the side arm of which was kept continuously flushed with\n heparinized saline throughout procedure. catheter was advanced\n over the wire, formed in the aortic arch and brought down to\n successfully cannulate the origin of the celiac artery.\n A hand injection of contrast at this point demonstrated active extravasation\n into the duodenum from a branch of gastroduodenal artery. From that point,\n an STC microcatheter and Transend wire were advanced into the common hepatic\n artery and then to the gastroduodenal artery. With some difficulty, we\n manipulated our wire and microcatheter into the branch which was actively\n extravasating into duodenum. Having achieved this, we rapidly placed two 1 x\n 0.5 cm straight coils into this branch. Injection of a small volume of\n contrast at this point no longer demonstrated active extravasation; however,\n we are concerned inflow from the additional branch to the GDA so this was\n cannulated using a combination of the microcatheter and wire and additional\n larger coils and gelfoam slurry were placed in this branch extending up into\n the origin of the gastroduodenal artery from the common hepatic.\n Approximately, two-thirds of gastroduodenal artery were coiled with only a\n small residual component of the vessel remaining patent at its origin. Having\n achieved this, the microcatheter and wire were withdrawn and repeat celiac\n angiography demonstrated no further extravasation. Because there was concern\n of gastric fundal bleeding on the EGD, we selectively cannulated the left\n gastric artery using our microcatheter and microwire system. An angiographic\n run at this point showed no definite extravasation, but possibly hyperemia\n around the gastroesophageal junction, therefore, we elected to perform Gelfoam\n embolization at this level.\n\n Having achieved this, the catheter was withdrawn from the celiac\n origin and brought inferiorly into the superior mesenteric artery. An\n angiographic run performed at this point demonstrated active extravasation\n from a branch to the duodenal region, feeding into the same area that had been\n bleeding on our celiac interrogation. Our STC microcatheter could not\n successfully cannulated the vessel, therefore, we exchanged for a Merit\n Maestro microcatheter and wire. With some manipulation, we successfully\n cannulated the inferior pancreaticoduodenal artery, which continued to\n (Over)\n\n 11:31 AM\n MESSENERTIC Clip # \n Reason: please embolize bleeder\n Admitting Diagnosis: UPPER GI BLEED\n Contrast: OPTIRAY Amt: 214\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n demonstrate active extravasation. Additional coils and gelfoam slurry were\n placed along the vessel. Following completion of this maneuver, superior\n mesenteric angiography did not demonstrate any further extravasation. The\n catheter was removed. As per the request of the MICU team, the right femoral\n arterial sheath was left in situ as an arterial line access point. Contrast\n was injected via the side arm to confirm adequate positioning with the point\n of entry overlying the femoral head.\n Following completion of the embolisation procedure the patient remained on\n pressor support and had received over 30 units of packed red cells. The\n patient was transferred to the ICU in a critical condition.\n\n PLACEMENT OF LEFT COMMON FEMORAL VEIN TRAUMA LINE\n\n The MICU team in addition requested that we place a left common femoral trauma\n venous line for access. Once again, a preprocedure timeout was performed\n using three patient identifiers. The skin in the left groin had already been\n prepped and draped in usual sterile fashion. Using ultrasound guidance, a\n micropuncture needle was advanced into the left common femoral vein. A\n nitinol wire was advanced via the needle which was removed and exchanged for a\n micropuncture sheath. The inner portion was removed along with nitinol wire\n and wire was advanced up into the IVC. Serial dilatation was\n performed with subsequent placement of a 14 French peel-away sheath and a\n triple-lumen trauma line was advanced over the wire via the peel-away sheath,\n the tip lies in the left common iliac vein. All three lumens were aspirated\n and flushed without difficulty. The catheter was secured to the skin with a\n silk suture and a sterile dressing was applied. There were no immediate\n post-procedure complications.\n\n IMPRESSION:\n 1. Rapid active contrast extravasation from a branch of the gastroduodenal\n artery and from a duodenal branch of the superior mesenteric artery. Both\n vessels have been coiled to stasis with no residual extravasation on\n completion angiography. A total of two 0.5 x 0 coils, fifteen 1 cm x 2 mm\n coils and two 2 cm x 3 mm coils were used in this procedure.\n 2. Gelfoam embolization of the left gastric artery as a potential gastric\n source of bleeding.\n 3. Right femoral arterial sheath has been left in situ, this is a 5 French\n sheath which will need to be continuously flushed with heparinized saline\n while in use.\n 4. Placement of a triple lumen trauma line in the left common femoral vein.\n (Over)\n\n 11:31 AM\n MESSENERTIC Clip # \n Reason: please embolize bleeder\n Admitting Diagnosis: UPPER GI BLEED\n Contrast: OPTIRAY Amt: 214\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"},{"category":"Radiology","chartdate":"2119-10-09 00:00:00.000","description":"BY SAME PHYSICIAN","row_id":1252951,"text":" 12:27 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: Line placement\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with central line\n REASON FOR THIS EXAMINATION:\n Line placement\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE FRONTAL VIEW OF THE CHEST\n\n REASON FOR EXAM: Assess line.\n\n Right subclavian catheter tip is in the mid SVC. There is no evident\n pneumothorax. Moderate right and a small left pleural effusion have increased\n with increasing associated adjacent opacities. It could be atelectasis or\n pneumonia. ET tube is in standard position. NG tube tip is in the stomach.\n Cardiomediastinal contours are normal. There is persistent dilatation of\n small bowel loops visualized in the upper abdomen.\n\n"},{"category":"Radiology","chartdate":"2119-10-10 00:00:00.000","description":"BY DIFFERENT PHYSICIAN","row_id":1253105,"text":" 3:57 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: check placement\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with new line, R IJ\n REASON FOR THIS EXAMINATION:\n check placement\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: 63-year-old male patient with new line. Right internal jugular,\n check placement. Contact , .\n\n AP single view of the chest has been obtained with patient in supine position.\n Comparison is made with the next preceding portable chest examination with the\n patient in semi-erect position obtained 12 hours earlier during the same day.\n The patient remains intubated, the ETT terminating in the trachea 5 cm above\n the level of carina. The position is unchanged compared with the previous\n study. Multiple metallic cables overlying the upper chest. A right subclavian\n approach central venous line can be identified and appears unchanged in\n comparison with the previous study. There is now a new right internal jugular\n approach central venous line that terminates in similar position as the\n subclavian line. Unfortunately, the external cables are overlying the area so\n detail is difficult to see. As, however, there is no line structure lower\n than the carina, inappropriate advancement of the line is excluded. A\n previously identified NG line is seen unchanged and reaches well below the\n diaphragm. An additional line traverses the chest from the upper left to the\n lower right that must be external. Patient's heart size is unaltered;\n however, the previously described multiple patchy densities ascribed to\n aspirations have increased and are more confluenting. No pneumothorax is\n seen. Page to was placed at 4:50 p.m.\n\n"},{"category":"ECG","chartdate":"2119-10-06 00:00:00.000","description":"Report","row_id":297044,"text":"Sinus rhythm. Non-specific ST-T wave changes. Compared to the previous\ntracing of T waves are more flattened. Otherwise, no significant\nchange.\n\n\n"}],"string":"[\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2119-10-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 103452,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Chronic lung disease. Left ventricular function. Hypoxia,\\nHeight: (in) 68\\nWeight (lb): 155\\nBSA (m2): 1.84 m2\\nBP (mm Hg): 96/61\\nHR (bpm): 96\\nStatus: Inpatient\\nDate/Time: at 14:59\\nTest: Portable TTE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: Saline\\nTechnical Quality: Suboptimal\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nThis study was compared to the report of the prior study (images not\\navailable) of .\\n\\n\\nLEFT ATRIUM: Normal LA size.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\\n\\nLEFT VENTRICLE: Normal LV cavity size. Mild-moderate global left ventricular\\nhypokinesis. No resting LVOT gradient.\\n\\nRIGHT VENTRICLE: Mild global RV free wall hypokinesis.\\n\\nAORTA: Mildy dilated aortic root.\\n\\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\\n\\nMITRAL VALVE: Normal mitral valve leaflets. Mild (1+) MR.\\n\\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR. Mild\\nPA systolic hypertension.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\\n\\nPERICARDIUM: Very small pericardial effusion. No echocardiographic signs of\\ntamponade.\\n\\nGENERAL COMMENTS: Contrast study was performed with 1 iv injection of 8 ccs of\\nagitated normal saline at rest. Suboptimal image quality - ventilator.\\n\\nConclusions:\\nThe left atrium is normal in size. The left ventricular cavity size is normal.\\nThere is mild to moderate global left ventricular hypokinesis (LVEF = 40 %).\\nThe right ventricle is borderline dilated with mild global free wall\\nhypokinesis. The aortic root is mildly dilated at the sinus level. The aortic\\nvalve leaflets (3) appear structurally normal with good leaflet excursion and\\nno aortic stenosis or aortic regurgitation. The mitral valve leaflets are\\nstructurally normal. Mild (1+) mitral regurgitation is seen. The tricuspid\\nvalve leaflets are mildly thickened. There is mild pulmonary artery systolic\\nhypertension. There is a very small pericardial effusion. There are no\\nechocardiographic signs of tamponade.\\n\\nAgitated saline contrast study at rest revealed no evidence of an intracardiac\\nshunt.\\n\\nCompared with the prior report (images unavailable) of , ventricular\\ndysfunction is new.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2119-10-05 00:00:00.000\",\n \"description\": \"NON-TUNNELED\",\n \"row_id\": 1252516,\n \"text\": \" 11:31 AM\\n MESSENERTIC Clip # \\n Reason: please embolize bleeder\\n Admitting Diagnosis: UPPER GI BLEED\\n Contrast: OPTIRAY Amt: 214\\n ********************************* CPT Codes ********************************\\n * EMBO NON NEURO NON-TUNNELED *\\n * INITAL 3RD ORDER ABD/PEL/LOWER -59 DISTINCT PROCEDURAL SERVICE *\\n * INITAL 2ND ORDER ABD/PEL/LOWER -59 DISTINCT PROCEDURAL SERVICE *\\n * VISERAL SEL/SUPERSEL A-GRAM -59 DISTINCT PROCEDURAL SERVICE *\\n * VISERAL SEL/SUPERSEL A-GRAM -59 DISTINCT PROCEDURAL SERVICE *\\n * EA ADD'L VESSEL AFTER BASIC A- -59 DISTINCT PROCEDURAL SERVICE *\\n * EA ADD'L VESSEL AFTER BASIC A- -59 DISTINCT PROCEDURAL SERVICE *\\n * TRANCATHETER EMBOLIZATION *\\n ****************************************************************************\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 63 year old man with . Posterior duodenal bulb artery bleeding\\n REASON FOR THIS EXAMINATION:\\n please embolize bleeder\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 63-year-old man with posterior duodenal bulb artery bleeding,\\n please embolize bleeder.\\n\\n PHYSICIANS: Dr. Mhuircheartaigh (radiology fellow), Dr. \\n , Dr (radiology attending) who was present throughout and\\n supervised the procedure.\\n\\n MEDICATIONS: The patient was intubated and sedated prior to transfer to the\\n angiographic suite, please see dedicated ICU note for additional information.\\n\\n RADIATION: 2900 mGy, 94 minutes fluoroscopy time.\\n\\n CONTRAST: 214 cc of Optiray 320.\\n\\n PROCEDURES:\\n 1. Right femoral arterial access.\\n 2. Celiac angiography.\\n 3. Selective GDA angiography.\\n 4. Embolization of a branch of the GDA which demonstrated active\\n extravasation. In addition, embolization of the GDA was performed.\\n 5. Left gastric arteriography.\\n 6. Left gastric Gelfoam embolization.\\n 7. Superior mesenteric artery angiography.\\n 8. Embolization of a bleeding duodenal branch of the SMA.\\n 9. Right femoral angiography demonstrating appropriate placement of a 5\\n French femoral sheath.\\n 10. Placement of a 9 French trauma line into the left common femoral vein.\\n\\n PROCEDURE DETAILS:\\n\\n Informed patient consent was waived by the referring physician in view of the\\n (Over)\\n\\n 11:31 AM\\n MESSENERTIC Clip # \\n Reason: please embolize bleeder\\n Admitting Diagnosis: UPPER GI BLEED\\n Contrast: OPTIRAY Amt: 214\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n patient's need for emergent interventions. The patient was brought to\\n angiographic suite, intubated and sedated and was placed supine on the\\n angiographic table. A preprocedure timeout was performed using three patient\\n identifiers.\\n\\n Using a combination of palpatory, fluoroscopic and ultrasound guidance, the\\n right femoral artery was accessed with a micropuncture needle. An 018 nitinol\\n wire was passed via the needle which was removed and exchanged for a 4F\\n micropuncture sheath, the inner portions of which and the nitinol wire were\\n removed and exchanged for wire. This was advanced up into the\\n abdominal aorta. The micropuncture sheath was exchanged for a 5 French\\n -Tip sheath, the side arm of which was kept continuously flushed with\\n heparinized saline throughout procedure. catheter was advanced\\n over the wire, formed in the aortic arch and brought down to\\n successfully cannulate the origin of the celiac artery.\\n A hand injection of contrast at this point demonstrated active extravasation\\n into the duodenum from a branch of gastroduodenal artery. From that point,\\n an STC microcatheter and Transend wire were advanced into the common hepatic\\n artery and then to the gastroduodenal artery. With some difficulty, we\\n manipulated our wire and microcatheter into the branch which was actively\\n extravasating into duodenum. Having achieved this, we rapidly placed two 1 x\\n 0.5 cm straight coils into this branch. Injection of a small volume of\\n contrast at this point no longer demonstrated active extravasation; however,\\n we are concerned inflow from the additional branch to the GDA so this was\\n cannulated using a combination of the microcatheter and wire and additional\\n larger coils and gelfoam slurry were placed in this branch extending up into\\n the origin of the gastroduodenal artery from the common hepatic.\\n Approximately, two-thirds of gastroduodenal artery were coiled with only a\\n small residual component of the vessel remaining patent at its origin. Having\\n achieved this, the microcatheter and wire were withdrawn and repeat celiac\\n angiography demonstrated no further extravasation. Because there was concern\\n of gastric fundal bleeding on the EGD, we selectively cannulated the left\\n gastric artery using our microcatheter and microwire system. An angiographic\\n run at this point showed no definite extravasation, but possibly hyperemia\\n around the gastroesophageal junction, therefore, we elected to perform Gelfoam\\n embolization at this level.\\n\\n Having achieved this, the catheter was withdrawn from the celiac\\n origin and brought inferiorly into the superior mesenteric artery. An\\n angiographic run performed at this point demonstrated active extravasation\\n from a branch to the duodenal region, feeding into the same area that had been\\n bleeding on our celiac interrogation. Our STC microcatheter could not\\n successfully cannulated the vessel, therefore, we exchanged for a Merit\\n Maestro microcatheter and wire. With some manipulation, we successfully\\n cannulated the inferior pancreaticoduodenal artery, which continued to\\n (Over)\\n\\n 11:31 AM\\n MESSENERTIC Clip # \\n Reason: please embolize bleeder\\n Admitting Diagnosis: UPPER GI BLEED\\n Contrast: OPTIRAY Amt: 214\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n demonstrate active extravasation. Additional coils and gelfoam slurry were\\n placed along the vessel. Following completion of this maneuver, superior\\n mesenteric angiography did not demonstrate any further extravasation. The\\n catheter was removed. As per the request of the MICU team, the right femoral\\n arterial sheath was left in situ as an arterial line access point. Contrast\\n was injected via the side arm to confirm adequate positioning with the point\\n of entry overlying the femoral head.\\n Following completion of the embolisation procedure the patient remained on\\n pressor support and had received over 30 units of packed red cells. The\\n patient was transferred to the ICU in a critical condition.\\n\\n PLACEMENT OF LEFT COMMON FEMORAL VEIN TRAUMA LINE\\n\\n The MICU team in addition requested that we place a left common femoral trauma\\n venous line for access. Once again, a preprocedure timeout was performed\\n using three patient identifiers. The skin in the left groin had already been\\n prepped and draped in usual sterile fashion. Using ultrasound guidance, a\\n micropuncture needle was advanced into the left common femoral vein. A\\n nitinol wire was advanced via the needle which was removed and exchanged for a\\n micropuncture sheath. The inner portion was removed along with nitinol wire\\n and wire was advanced up into the IVC. Serial dilatation was\\n performed with subsequent placement of a 14 French peel-away sheath and a\\n triple-lumen trauma line was advanced over the wire via the peel-away sheath,\\n the tip lies in the left common iliac vein. All three lumens were aspirated\\n and flushed without difficulty. The catheter was secured to the skin with a\\n silk suture and a sterile dressing was applied. There were no immediate\\n post-procedure complications.\\n\\n IMPRESSION:\\n 1. Rapid active contrast extravasation from a branch of the gastroduodenal\\n artery and from a duodenal branch of the superior mesenteric artery. Both\\n vessels have been coiled to stasis with no residual extravasation on\\n completion angiography. A total of two 0.5 x 0 coils, fifteen 1 cm x 2 mm\\n coils and two 2 cm x 3 mm coils were used in this procedure.\\n 2. Gelfoam embolization of the left gastric artery as a potential gastric\\n source of bleeding.\\n 3. Right femoral arterial sheath has been left in situ, this is a 5 French\\n sheath which will need to be continuously flushed with heparinized saline\\n while in use.\\n 4. Placement of a triple lumen trauma line in the left common femoral vein.\\n (Over)\\n\\n 11:31 AM\\n MESSENERTIC Clip # \\n Reason: please embolize bleeder\\n Admitting Diagnosis: UPPER GI BLEED\\n Contrast: OPTIRAY Amt: 214\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2119-10-09 00:00:00.000\",\n \"description\": \"BY SAME PHYSICIAN\",\n \"row_id\": 1252951,\n \"text\": \" 12:27 PM\\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \\n Reason: Line placement\\n Admitting Diagnosis: UPPER GI BLEED\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 63 year old man with central line\\n REASON FOR THIS EXAMINATION:\\n Line placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n SINGLE FRONTAL VIEW OF THE CHEST\\n\\n REASON FOR EXAM: Assess line.\\n\\n Right subclavian catheter tip is in the mid SVC. There is no evident\\n pneumothorax. Moderate right and a small left pleural effusion have increased\\n with increasing associated adjacent opacities. It could be atelectasis or\\n pneumonia. ET tube is in standard position. NG tube tip is in the stomach.\\n Cardiomediastinal contours are normal. There is persistent dilatation of\\n small bowel loops visualized in the upper abdomen.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2119-10-10 00:00:00.000\",\n \"description\": \"BY DIFFERENT PHYSICIAN\",\n \"row_id\": 1253105,\n \"text\": \" 3:57 PM\\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \\n Reason: check placement\\n Admitting Diagnosis: UPPER GI BLEED\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 63 year old man with new line, R IJ\\n REASON FOR THIS EXAMINATION:\\n check placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n TYPE OF EXAMINATION: Chest AP portable single view.\\n\\n INDICATION: 63-year-old male patient with new line. Right internal jugular,\\n check placement. Contact , .\\n\\n AP single view of the chest has been obtained with patient in supine position.\\n Comparison is made with the next preceding portable chest examination with the\\n patient in semi-erect position obtained 12 hours earlier during the same day.\\n The patient remains intubated, the ETT terminating in the trachea 5 cm above\\n the level of carina. The position is unchanged compared with the previous\\n study. Multiple metallic cables overlying the upper chest. A right subclavian\\n approach central venous line can be identified and appears unchanged in\\n comparison with the previous study. There is now a new right internal jugular\\n approach central venous line that terminates in similar position as the\\n subclavian line. Unfortunately, the external cables are overlying the area so\\n detail is difficult to see. As, however, there is no line structure lower\\n than the carina, inappropriate advancement of the line is excluded. A\\n previously identified NG line is seen unchanged and reaches well below the\\n diaphragm. An additional line traverses the chest from the upper left to the\\n lower right that must be external. Patient's heart size is unaltered;\\n however, the previously described multiple patchy densities ascribed to\\n aspirations have increased and are more confluenting. No pneumothorax is\\n seen. Page to was placed at 4:50 p.m.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2119-10-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 297044,\n \"text\": \"Sinus rhythm. Non-specific ST-T wave changes. Compared to the previous\\ntracing of T waves are more flattened. Otherwise, no significant\\nchange.\\n\\n\\n\"\n }\n]"}}},{"rowIdx":382,"cells":{"subject_id":{"kind":"number","value":29458,"string":"29,458"},"hadm_id":{"kind":"number","value":165088,"string":"165,088"},"target_text":{"kind":"string","value":"Patient is a 57 yo M w/ hx of hypercholesterolemia, asthma presenting after positive stress test found to have severe distal left main bifurcation disease. . #. CAD: Severe LMCA and ostial LAD and LCx disease seen on cardiac catheterization. Pt to have emergent CABG in am. No rest pain or sign of MI so no heparin O/N per CT - pre-op for CABG tomorrow - T & S, U/A, CXR - low dose B-blocker, to start after surgery when BP allows - NPO at midnight - monitor on telemetry . #. Pump: Mild systolic dysfunction with preserved EF on cardiac catheterization. Treatment of CAD as above . #. Rhythm: NSR, monitor on telemetry . #. Asthma: Stable with no active sx, cont. flovent inhaler . #. Hypothyroidism: Cont. outpatient dose of Levoxyl . #. FEN: NPO at midnight for CABG tomorrow . #. Access: PIV . #. PPx: to OR in am . #. Code: Full . #. Dispo: pending CABG and recovery . #. Contact: wife cell Underwent urgent cabg x2 on with Dr. .Transferred to the CVICU in stbale condition on phenylephrine and propofol drips.Extubated that afternoon and transferred to the floor on POD #1. Chest tubes and pacing wires removed without incident. Gently diuresed toward his preoperative weight. Cleared for discharge to home with services on POD #3. Pt. is to make all followup visits as per discharge instructions."},"extractive_notes_summ":{"kind":"string","value":"Generalized ST segment elevation and PR segmentdepression with PR segment elevation in lead aVR consistent with pericarditis.Compared to the previous tracing of atrial ectopy is absent. IMPRESSION: Stable mild post-operative widened mediastinum. There is mildsymmetric left ventricular hypertrophy. Trivial MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.GENERAL COMMENTS: A TEE was performed in the location listed above. There is mild regional leftventricular systolic dysfunction with mild anterior and anteroseptal wallhypokinesis. Mild regional LV systolic dysfunction.LV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior- hypo; mid anterior - hypo; basal anteroseptal - hypo; mid anteroseptal -hypo; anterior apex - hypo; septal apex - hypo; remaining LV segments contractnormally.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal descending aorta diameter. Zantac for prophylaxis.GU: adequate huo.SKin: intact: sternal dsg intact. Mild widespread ST segmentelevation of uncertain significance. Right ventricular chamber size and free wall motion are normal.There are simple atheroma in the descending thoracic aorta. The mediastinal drain the left chest tube is in expected position. Trivial mitral regurgitation is seen.POSTBYPASSLV systolic function and regional wall motion abnormalities remain unchangedfrom prebypass. Preoperative assessment.Status: InpatientDate/Time: at 10:00Test: TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.LEFT VENTRICLE: Mild symmetric LVH. Simple atheroma in descending aorta.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Post-operative widened mediastinum is stable. The remaining left ventricular segments contractnormally. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Small pneumopericardium is noted in the lateral view. Left ventricular function. Patient is post median sternotomy and CABG. Patient S/P CABG. Cardiac size is top normal. Sinus rhythm with an atrial premature beat. ekg nsr, no ectopy, rate 90s. There has been interval worsening of left lower atelectasis and less in right lower atelectasis. The cardiomediastinal silhouette is stable. No TEE related complications.Conclusions:PREBYPASSNo atrial septal defect is seen by 2D or color Doppler. There are small bilateral pleural effusions. The cardiomediastinal silhouette and pulmonary vessels are within normal limits and there is no significant pleural effusion (the extreme left CP angle is excluded from the study). DL DR. CI >2.5.Pacer sensing; no pacing required.Pulm: IS reinforced. filling pressures low, pad is 11, cvp is 9, ci 2.53. uo marginal, 35cc this hour, may need more volume. jr DR. This Swan-Ganz catheter tip is at the right ventricle outflow tract. There is persistent widened mediastinum with bulging of the right paramediastinal contour that still is worrisome for postsurgical hematoma. sternal and mediastinal dressings intact, small amts sang ct drainage, no air leak. coverage.Plan: de-line. The aortic valveleaflets (3) are mildly thickened. Cardiac size is normal. updateD: pt underwent CAbg x 2 today--L main - or uneventful-pt to vicu B intubated, on propofol-pt warmed-min ct drainage- pt reversed, weane dpropofol- work crazy x 2- added precedex--still woke agitated- extubated fast.pt groggy-yet c/o mod pain=percocet given prior to extub-and mso4 iv--added toradol for pain.plan: obtain pain relief. Normal sinus rhythm, rate 80. DR. SSRI instituted.ID: kefzol for periop. Portable AP chest radiograph compared to . The patient was undergeneral anesthesia throughout the procedure. breath sounds clear, decreased at bases, encouraged to deep breathe, incentive spirometer introduced, used but only achieved 250-300cc d/t to discomfort. The remaining study is also unchanged from prebypass. Clinical correlation is suggested. Allowing for slight motion-blurring and overlying soft tissues, the lungs appear well-inflated and clear. Possible pericarditis. feet warm, dp and pt pulses palp bilat, ace wrap inatct. New rounded opacity projects in the right lower lobe medially. mainataining spo2 99%, on 4l nc, decreased to 2l, with spo2 99%. Advance DAT and ADL's. Lobulation of the left mediastinal contours are unusual after surgery and might represent postsurgical hematoma. updateD: pt warm- min ct drainage- vvs- on no drips other than sedation. resp careweaned and extubated as per cardiac surgery fast track protocol.refer to flow sheet. The NG tube tip passes below the diaphragm, most likely terminating in the stomach. sbp stable in 100s, no pressors. Discoid atelectasis are in the left lower lobe. Pt. Pt. Pt. percocet given x 1 and morphine 2 mg x 1 for breakthrough pain. FINDINGS: Single bedside AP examination labeled \"upright\" with no comparisons on record. The mitralvalve leaflets are mildly thickened. alert and oriented, conversational, pain control is an issue. Otherwise,no significant change. re-assured that his vital signs are stable and that his labs are wnl and that we will manage his pain and make him as comfortable as possible.CV: aline dampening, therefore NBP recorded as well. I certifyI was present in compliance with HCFA regulations. calciulm rx with 2 gm ca gluc. Transfer to floor. Coronary artery disease. Increase in bibasilar atelectasis, worse in the left side. PATIENT/TEST INFORMATION:Indication: Chest pain. 1:42 PM CHEST PORT. Encourage use of IS. 2lNP.Explained the importance of deep breathing and repositioning.GI: taking pills with water. Overall increase in bilateral perihilar haziness might represent pulmonary edema. reversed, propofol to off-A: pt woke WILD..initially followed commands--then would not not--mae--extremely agitatedA: placed back on propofol intially 20 mcq--had to inc to 50.plan: obtain precedex for extubation Close attention to this area would be recommended to exclude the possibility of growing hematoma. LVEF~ 45%. Comparison is made with prior study . No cough. glucose up to 181, rx with 2 unit bolus and gtt started at 3 units. no n/v. This examination was performed at 11:30. There is no pneumothorax or substantial pleural effusion. Findings were discussed with Dr. at the time of the interpretation of the study. Left leg bruising from medial knee to thigh: ace bandage changed.Endo: insulin drip off for BS 75. able to push to 500cc volume. states that he knows he''s asking a lot of questions.Pt. No aortic regurgitation is seen. There is no pneumothorax or sizable pleural effusion."},"n_notes":{"kind":"number","value":12,"string":"12"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2194-03-03 00:00:00.000","description":"CHEST (PA & LAT)","row_id":1000641,"text":" 11:20 AM\n CHEST (PA & LAT) Clip # \n Reason: widened mediastinum post CT removal\n Admitting Diagnosis: CHEST PAIN;+ ETT\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with post CT removal, had AP / shows questionable widened\n mediastinum, reevaluate mediastinum\n REASON FOR THIS EXAMINATION:\n widened mediastinum post CT removal\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL VIEWS OF THE CHEST\n\n REASON FOR EXAM: Assess widened mediastinum described in prior study.\n\n Comparison is made with prior study performed at 20:00. This\n examination was performed at 11:30.\n\n Post-operative widened mediastinum is stable. There has been interval\n worsening of left lower atelectasis and less in right lower atelectasis. There\n are small bilateral pleural effusions. Patient is post median sternotomy and\n CABG. Small pneumopericardium is noted in the lateral view. Cardiac size is\n normal.\n\n IMPRESSION: Stable mild post-operative widened mediastinum. Increase in\n bibasilar atelectasis, worse in the left side.\n\n jr\n\n DR. \n"},{"category":"Radiology","chartdate":"2194-02-28 00:00:00.000","description":"CHEST (PRE-OP AP ONLY)","row_id":1000380,"text":" 8:32 PM\n CHEST (PRE-OP AP ONLY) Clip # \n Reason: Evaluate for cardiopulm process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with CAD, preop for CABG in am\n REASON FOR THIS EXAMINATION:\n Evaluate for cardiopulm process\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE VIEW OF THE CHEST, \n\n HISTORY: 57-year-old man with CAD, preop for CABG in AM, ; evaluate\n for acute process.\n\n FINDINGS: Single bedside AP examination labeled \"upright\" with no comparisons\n on record. Allowing for slight motion-blurring and overlying soft tissues,\n the lungs appear well-inflated and clear. The cardiomediastinal silhouette\n and pulmonary vessels are within normal limits and there is no significant\n pleural effusion (the extreme left CP angle is excluded from the study).\n\n\n"},{"category":"Radiology","chartdate":"2194-03-01 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":1000451,"text":" 1:42 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: postop film- contact MD # if abnormal\n Admitting Diagnosis: CHEST PAIN;+ ETT\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man s/p urgent cabg x2\n REASON FOR THIS EXAMINATION:\n postop film- contact MD # if abnormal\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of a patient after urgent CABG.\n\n Portable AP chest radiograph compared to .\n\n The ET tube tip is 5 cm above the carina. This Swan-Ganz catheter tip is at\n the right ventricle outflow tract. The mediastinal drain the left chest tube\n is in expected position. The NG tube tip passes below the diaphragm, most\n likely terminating in the stomach. The cardiomediastinal silhouette is\n stable. Overall increase in bilateral perihilar haziness might represent\n pulmonary edema. Lobulation of the left mediastinal contours are unusual\n after surgery and might represent postsurgical hematoma. Close attention to\n this area would be recommended to exclude the possibility of growing hematoma.\n There is no pneumothorax or substantial pleural effusion.\n\n DL\n\n DR. \n"},{"category":"Nursing/other","chartdate":"2194-03-02 00:00:00.000","description":"Report","row_id":1643613,"text":"Pt. alert and pleasant but very talkative. Asking many questions re: care, procedures, asking to be repositioned, wanting to know when pain meds are due. Pt. states that he knows he''s asking a lot of questions.\nPt. re-assured that his vital signs are stable and that his labs are wnl and that we will manage his pain and make him as comfortable as possible.\nCV: aline dampening, therefore NBP recorded as well. CI >2.5.\nPacer sensing; no pacing required.\nPulm: IS reinforced. Pt. able to push to 500cc volume. No cough. 2lNP.\nExplained the importance of deep breathing and repositioning.\nGI: taking pills with water. no n/v. Zantac for prophylaxis.\nGU: adequate huo.\nSKin: intact: sternal dsg intact. Left leg bruising from medial knee to thigh: ace bandage changed.\nEndo: insulin drip off for BS 75. SSRI instituted.\nID: kefzol for periop. coverage.\nPlan: de-line. Advance DAT and ADL's. Encourage use of IS. Transfer to floor.\n\n\n"},{"category":"Nursing/other","chartdate":"2194-03-01 00:00:00.000","description":"Report","row_id":1643609,"text":"update\nD: pt warm- min ct drainage- vvs- on no drips other than sedation. reversed, propofol to off-\nA: pt woke WILD..initially followed commands--then would not not--mae--extremely agitated\nA: placed back on propofol intially 20 mcq--had to inc to 50.\n\nplan: obtain precedex for extubation\n"},{"category":"Nursing/other","chartdate":"2194-03-01 00:00:00.000","description":"Report","row_id":1643610,"text":"resp care\nweaned and extubated as per cardiac surgery fast track protocol.refer to flow sheet.\n"},{"category":"Nursing/other","chartdate":"2194-03-01 00:00:00.000","description":"Report","row_id":1643611,"text":"update\nD: pt underwent CAbg x 2 today--L main - or uneventful-pt to vicu B intubated, on propofol-pt warmed-min ct drainage- pt reversed, weane dpropofol- work crazy x 2- added precedex--still woke agitated- extubated fast.pt groggy-yet c/o mod pain=percocet given prior to extub-and mso4 iv--added toradol for pain.\nplan: obtain pain relief.\n"},{"category":"Nursing/other","chartdate":"2194-03-01 00:00:00.000","description":"Report","row_id":1643612,"text":"ekg nsr, no ectopy, rate 90s. sbp stable in 100s, no pressors. filling pressures low, pad is 11, cvp is 9, ci 2.53. uo marginal, 35cc this hour, may need more volume. calciulm rx with 2 gm ca gluc. glucose up to 181, rx with 2 unit bolus and gtt started at 3 units. breath sounds clear, decreased at bases, encouraged to deep breathe, incentive spirometer introduced, used but only achieved 250-300cc d/t to discomfort. mainataining spo2 99%, on 4l nc, decreased to 2l, with spo2 99%. sternal and mediastinal dressings intact, small amts sang ct drainage, no air leak. feet warm, dp and pt pulses palp bilat, ace wrap inatct. alert and oriented, conversational, pain control is an issue. percocet given x 1 and morphine 2 mg x 1 for breakthrough pain.\n"},{"category":"Radiology","chartdate":"2194-03-02 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1000583,"text":" 7:57 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ?PTX, hemothorax, s/p tube removal\n Admitting Diagnosis: CHEST PAIN;+ ETT\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man pod1 s/p CABG, now s/p chest tube and mediastinal tube removal\n REASON FOR THIS EXAMINATION:\n ?PTX, hemothorax, s/p tube removal\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Assess for pneumothorax S/P tube removal. Patient S/P CABG.\n\n Comparison is made with prior study .\n\n There is no pneumothorax or sizable pleural effusion. There is persistent\n widened mediastinum with bulging of the right paramediastinal contour that\n still is worrisome for postsurgical hematoma. New rounded opacity projects in\n the right lower lobe medially. Cardiac size is top normal. Discoid\n atelectasis are in the left lower lobe.\n\n Findings were discussed with Dr. at the time of the interpretation of\n the study.\n\n\n DR. \n"},{"category":"Echo","chartdate":"2194-03-01 00:00:00.000","description":"Report","row_id":98939,"text":"PATIENT/TEST INFORMATION:\nIndication: Chest pain. Coronary artery disease. Left ventricular function. Preoperative assessment.\nStatus: Inpatient\nDate/Time: at 10:00\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Mild symmetric LVH. Mild regional LV systolic dysfunction.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior\n- hypo; mid anterior - hypo; basal anteroseptal - hypo; mid anteroseptal -\nhypo; anterior apex - hypo; septal apex - hypo; remaining LV segments contract\nnormally.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal descending aorta diameter. Simple atheroma in descending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was under\ngeneral anesthesia throughout the procedure. No TEE related complications.\n\nConclusions:\nPREBYPASS\nNo atrial septal defect is seen by 2D or color Doppler. There is mild\nsymmetric left ventricular hypertrophy. There is mild regional left\nventricular systolic dysfunction with mild anterior and anteroseptal wall\nhypokinesis. LVEF~ 45%. The remaining left ventricular segments contract\nnormally. Right ventricular chamber size and free wall motion are normal.\nThere are simple atheroma in the descending thoracic aorta. The aortic valve\nleaflets (3) are mildly thickened. No aortic regurgitation is seen. The mitral\nvalve leaflets are mildly thickened. Trivial mitral regurgitation is seen.\n\nPOSTBYPASS\nLV systolic function and regional wall motion abnormalities remain unchanged\nfrom prebypass. The remaining study is also unchanged from prebypass.\n\n\n"},{"category":"ECG","chartdate":"2194-03-01 00:00:00.000","description":"Report","row_id":279466,"text":"Normal sinus rhythm, rate 80. Generalized ST segment elevation and PR segment\ndepression with PR segment elevation in lead aVR consistent with pericarditis.\nCompared to the previous tracing of atrial ectopy is absent. Otherwise,\nno significant change.\n\n"},{"category":"ECG","chartdate":"2194-03-02 00:00:00.000","description":"Report","row_id":279467,"text":"Sinus rhythm with an atrial premature beat. Mild widespread ST segment\nelevation of uncertain significance. Possible pericarditis. No previous\ntracing available for comparison. Clinical correlation is suggested.\n\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2194-03-03 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 1000641,\n \"text\": \" 11:20 AM\\n CHEST (PA & LAT) Clip # \\n Reason: widened mediastinum post CT removal\\n Admitting Diagnosis: CHEST PAIN;+ ETT\\\\CATH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 57 year old man with post CT removal, had AP / shows questionable widened\\n mediastinum, reevaluate mediastinum\\n REASON FOR THIS EXAMINATION:\\n widened mediastinum post CT removal\\n ______________________________________________________________________________\\n FINAL REPORT\\n PA AND LATERAL VIEWS OF THE CHEST\\n\\n REASON FOR EXAM: Assess widened mediastinum described in prior study.\\n\\n Comparison is made with prior study performed at 20:00. This\\n examination was performed at 11:30.\\n\\n Post-operative widened mediastinum is stable. There has been interval\\n worsening of left lower atelectasis and less in right lower atelectasis. There\\n are small bilateral pleural effusions. Patient is post median sternotomy and\\n CABG. Small pneumopericardium is noted in the lateral view. Cardiac size is\\n normal.\\n\\n IMPRESSION: Stable mild post-operative widened mediastinum. Increase in\\n bibasilar atelectasis, worse in the left side.\\n\\n jr\\n\\n DR. \\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2194-02-28 00:00:00.000\",\n \"description\": \"CHEST (PRE-OP AP ONLY)\",\n \"row_id\": 1000380,\n \"text\": \" 8:32 PM\\n CHEST (PRE-OP AP ONLY) Clip # \\n Reason: Evaluate for cardiopulm process\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 57 year old man with CAD, preop for CABG in am\\n REASON FOR THIS EXAMINATION:\\n Evaluate for cardiopulm process\\n ______________________________________________________________________________\\n FINAL REPORT\\n SINGLE VIEW OF THE CHEST, \\n\\n HISTORY: 57-year-old man with CAD, preop for CABG in AM, ; evaluate\\n for acute process.\\n\\n FINDINGS: Single bedside AP examination labeled \\\"upright\\\" with no comparisons\\n on record. Allowing for slight motion-blurring and overlying soft tissues,\\n the lungs appear well-inflated and clear. The cardiomediastinal silhouette\\n and pulmonary vessels are within normal limits and there is no significant\\n pleural effusion (the extreme left CP angle is excluded from the study).\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2194-03-01 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 1000451,\n \"text\": \" 1:42 PM\\n CHEST PORT. LINE PLACEMENT Clip # \\n Reason: postop film- contact MD # if abnormal\\n Admitting Diagnosis: CHEST PAIN;+ ETT\\\\CATH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 57 year old man s/p urgent cabg x2\\n REASON FOR THIS EXAMINATION:\\n postop film- contact MD # if abnormal\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAMINATION: Followup of a patient after urgent CABG.\\n\\n Portable AP chest radiograph compared to .\\n\\n The ET tube tip is 5 cm above the carina. This Swan-Ganz catheter tip is at\\n the right ventricle outflow tract. The mediastinal drain the left chest tube\\n is in expected position. The NG tube tip passes below the diaphragm, most\\n likely terminating in the stomach. The cardiomediastinal silhouette is\\n stable. Overall increase in bilateral perihilar haziness might represent\\n pulmonary edema. Lobulation of the left mediastinal contours are unusual\\n after surgery and might represent postsurgical hematoma. Close attention to\\n this area would be recommended to exclude the possibility of growing hematoma.\\n There is no pneumothorax or substantial pleural effusion.\\n\\n DL\\n\\n DR. \\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2194-03-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1643613,\n \"text\": \"Pt. alert and pleasant but very talkative. Asking many questions re: care, procedures, asking to be repositioned, wanting to know when pain meds are due. Pt. states that he knows he''s asking a lot of questions.\\nPt. re-assured that his vital signs are stable and that his labs are wnl and that we will manage his pain and make him as comfortable as possible.\\nCV: aline dampening, therefore NBP recorded as well. CI >2.5.\\nPacer sensing; no pacing required.\\nPulm: IS reinforced. Pt. able to push to 500cc volume. No cough. 2lNP.\\nExplained the importance of deep breathing and repositioning.\\nGI: taking pills with water. no n/v. Zantac for prophylaxis.\\nGU: adequate huo.\\nSKin: intact: sternal dsg intact. Left leg bruising from medial knee to thigh: ace bandage changed.\\nEndo: insulin drip off for BS 75. SSRI instituted.\\nID: kefzol for periop. coverage.\\nPlan: de-line. Advance DAT and ADL's. Encourage use of IS. Transfer to floor.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2194-03-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1643609,\n \"text\": \"update\\nD: pt warm- min ct drainage- vvs- on no drips other than sedation. reversed, propofol to off-\\nA: pt woke WILD..initially followed commands--then would not not--mae--extremely agitated\\nA: placed back on propofol intially 20 mcq--had to inc to 50.\\n\\nplan: obtain precedex for extubation\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2194-03-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1643610,\n \"text\": \"resp care\\nweaned and extubated as per cardiac surgery fast track protocol.refer to flow sheet.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2194-03-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1643611,\n \"text\": \"update\\nD: pt underwent CAbg x 2 today--L main - or uneventful-pt to vicu B intubated, on propofol-pt warmed-min ct drainage- pt reversed, weane dpropofol- work crazy x 2- added precedex--still woke agitated- extubated fast.pt groggy-yet c/o mod pain=percocet given prior to extub-and mso4 iv--added toradol for pain.\\nplan: obtain pain relief.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2194-03-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1643612,\n \"text\": \"ekg nsr, no ectopy, rate 90s. sbp stable in 100s, no pressors. filling pressures low, pad is 11, cvp is 9, ci 2.53. uo marginal, 35cc this hour, may need more volume. calciulm rx with 2 gm ca gluc. glucose up to 181, rx with 2 unit bolus and gtt started at 3 units. breath sounds clear, decreased at bases, encouraged to deep breathe, incentive spirometer introduced, used but only achieved 250-300cc d/t to discomfort. mainataining spo2 99%, on 4l nc, decreased to 2l, with spo2 99%. sternal and mediastinal dressings intact, small amts sang ct drainage, no air leak. feet warm, dp and pt pulses palp bilat, ace wrap inatct. alert and oriented, conversational, pain control is an issue. percocet given x 1 and morphine 2 mg x 1 for breakthrough pain.\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2194-03-02 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1000583,\n \"text\": \" 7:57 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ?PTX, hemothorax, s/p tube removal\\n Admitting Diagnosis: CHEST PAIN;+ ETT\\\\CATH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 57 year old man pod1 s/p CABG, now s/p chest tube and mediastinal tube removal\\n REASON FOR THIS EXAMINATION:\\n ?PTX, hemothorax, s/p tube removal\\n ______________________________________________________________________________\\n FINAL REPORT\\n SINGLE AP PORTABLE VIEW OF THE CHEST\\n\\n REASON FOR EXAM: Assess for pneumothorax S/P tube removal. Patient S/P CABG.\\n\\n Comparison is made with prior study .\\n\\n There is no pneumothorax or sizable pleural effusion. There is persistent\\n widened mediastinum with bulging of the right paramediastinal contour that\\n still is worrisome for postsurgical hematoma. New rounded opacity projects in\\n the right lower lobe medially. Cardiac size is top normal. Discoid\\n atelectasis are in the left lower lobe.\\n\\n Findings were discussed with Dr. at the time of the interpretation of\\n the study.\\n\\n\\n DR. \\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2194-03-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 98939,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Chest pain. Coronary artery disease. Left ventricular function. Preoperative assessment.\\nStatus: Inpatient\\nDate/Time: at 10:00\\nTest: TEE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.\\n\\nLEFT VENTRICLE: Mild symmetric LVH. Mild regional LV systolic dysfunction.\\n\\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior\\n- hypo; mid anterior - hypo; basal anteroseptal - hypo; mid anteroseptal -\\nhypo; anterior apex - hypo; septal apex - hypo; remaining LV segments contract\\nnormally.\\n\\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\\n\\nAORTA: Normal descending aorta diameter. Simple atheroma in descending aorta.\\n\\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AR.\\n\\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR.\\n\\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.\\n\\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\\nI was present in compliance with HCFA regulations. The patient was under\\ngeneral anesthesia throughout the procedure. No TEE related complications.\\n\\nConclusions:\\nPREBYPASS\\nNo atrial septal defect is seen by 2D or color Doppler. There is mild\\nsymmetric left ventricular hypertrophy. There is mild regional left\\nventricular systolic dysfunction with mild anterior and anteroseptal wall\\nhypokinesis. LVEF~ 45%. The remaining left ventricular segments contract\\nnormally. Right ventricular chamber size and free wall motion are normal.\\nThere are simple atheroma in the descending thoracic aorta. The aortic valve\\nleaflets (3) are mildly thickened. No aortic regurgitation is seen. The mitral\\nvalve leaflets are mildly thickened. Trivial mitral regurgitation is seen.\\n\\nPOSTBYPASS\\nLV systolic function and regional wall motion abnormalities remain unchanged\\nfrom prebypass. The remaining study is also unchanged from prebypass.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2194-03-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 279466,\n \"text\": \"Normal sinus rhythm, rate 80. Generalized ST segment elevation and PR segment\\ndepression with PR segment elevation in lead aVR consistent with pericarditis.\\nCompared to the previous tracing of atrial ectopy is absent. Otherwise,\\nno significant change.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2194-03-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 279467,\n \"text\": \"Sinus rhythm with an atrial premature beat. Mild widespread ST segment\\nelevation of uncertain significance. Possible pericarditis. No previous\\ntracing available for comparison. Clinical correlation is suggested.\\n\\n\\n\"\n }\n]"}}},{"rowIdx":383,"cells":{"subject_id":{"kind":"number","value":7632,"string":"7,632"},"hadm_id":{"kind":"number","value":149404,"string":"149,404"},"target_text":{"kind":"string","value":"He was subsequently taken for CT angiogram to assess for possible vascular abnormalities contributing to his bleed. The CT angiogram was suggestive of some venous dilatation in the area of the bleed. Given the CTA findings, he was taken for an angiogram urgently. The angiogram did not show any vascular malformations or abnormalities. In the interim, an A-line was placed for blood pressure control. Blood pressure medications were started to keep the systolic blood pressure less than 140. He received mannitol 50 q six hours. He received a Dilantin load. He also received platelets and DDAVP. After his angiogram, he was immediately taken to the Operating Room for evacuation of the right intraparenchymal hemorrhage. Consent was obtained from the family and the situation was explained. He underwent a right craniotomy with evacuation of the hemorrhage. He tolerated the procedure with no complications. Post procedure, his examination remained unremarkable. He had minimal movement of his extremities. His pupils remained 2.5 mm and unreactive. He did not appear to have a corneal or gag reflex initially. He received another dose of DDAVP at the end of the procedure. On postoperative day one, he was much more responsive. He opened his eyes to stimulation and started lifting his right lower extremity and arm to stimulation. He remained afebrile with stable vital signs during his course in the hospital. His platelet count and coagulopathy labs were normal. He remained in Intensive Care Unit for several days for close monitoring while he was intubated. Again, his course in the hospital remained uneventful. He was afebrile with stable vital signs. He received perioperative Ancef. Repeat CT scans, as well as postoperative CT scans showed good evacuation of the clot with minimal, if any, residual component. He was rapidly weaned off the Dilantin over 2-3 days. Serial CT scans performed during the wean showed no significant change. Ultimately, he was transferred to the floor for further care. He was extubated prior to transfer and tolerated the extubation well. He started following commands and moving his right extremities spontaneously. Over time, he started to move his left extremities as well, initially the leg more than the arm. Currently, he moves all four extremities at least to antigravity. Speech and _______ assessments were completed. Initially, he failed the bedside assessment but video esophageal studies showed that he was able to tolerate thickened and _____ thick food. He has since been placed on ________ solids and allowed to take p.o. intake. He does, however, display a significant left neglect. On over the night, he leaned to the right and banged his head against the railing of the bed. No significant trauma was induced. However, he did have slight drainage from his wound. Upon inspection, there was a dry thin layer of blood with no apparent wound dehiscence. He is being continued to be seen by Occupational Therapy and Physical Therapy for further help in strengthening. He has had good improvement. He has continued to do well. Ultimately, he is discharged to rehabilitation to further strengthen his extremities. He has remained stable and is currently ready for discharge to rehabilitation. He should follow-up with Dr. in two weeks with a repeat head CT prior to his appointment. He should follow-up with his primary care physician in one week for further assessment. He should continue on his Dilantin until seen in follow-up. He should have serial Dilantin levels checked while in rehabilitation to assure that he is at a therapeutic level. His incision requires daily dry dressing changes, as well as antibiotic ointment application daily. Please reassess his ability to take oral food after a few days of rehabilitation."},"extractive_notes_summ":{"kind":"string","value":"COMPARISON: TECHNIQUE: Non-contrast head CT. HEAD CT WITHOUT IV CONTRAST: There has been interval evacuation of the previously identified right temporoparietal intraparenchymal hemorrhage with interval development of gas within the right frontal, temporal, and parietal lobes. The previously seen uncal herniation has resolved. A right parietal craniotomy defect is demonstrated. Small amount of residual blood is seen within the right temporoparietal lobe. HEAD CT: There is postoperative change in the right parietal region. Enlarged left scalp fluid collection. change No contraindications for IV contrast FINAL REPORT NONCONTRAST HEAD CT: INDICATION: Status post fall with ICH, status post evacuation of hematoma, please evaluate status. COMPARISON: Noncontrast head CT of and . ETT is well secured.Hemodynamically:SR 80s, 90s when agitated. FINDINGS: In the area of the previously evacuated right temporoparietal intraparenchymal hemorrhage, there is pneumocephalus and trace areas of high density suggestive of residual blood. There is partial opacification of the ethmoid, sphenoid, and maxillary sinuses bilaterally. TECHNIQUE: Noncontrast head CT. Endotracheal tube and NG tube are unchanged compared with the previous study. cv stable tol lopressor and hydralazine. hr nsrresp sats adequate, congested spont cough breathsounds coarse.gi tol tube feeds at goal. There is cardiomegaly, with a right perihilar infiltrate, and left lower lobe and upper lobe infiltrates. COMPARISON: Head CT, . Started on levofloxacin for same. These findings suggest aspiration vs. left heart failure. Levofloxacin commenced pending sputum cultures.Renal:Urine output declining but still satisfactory.Skin:Essentially intact. IMPRESSION: Aspiration vs. left heart failure. Two peripheral IV's started. Patient is status post right parietal craniotomy. Dosing antihypertensives by , underdamped. IMPRESSION: Interval evacuation of large right temporoparietal intraparenchymal hemorrhage with resolution of uncal herniation and improvement in right to left subfalcine herniation. Normal flow is noted in the intracranial circulation. K repleated.Pulm - Extubated today. The basal cisterns and foramen magnum are patent. L SC TLC dc'd. There is stable layering of hemorrhage within the left lateral ventricle. ETT and left subclavian line satisfactorily positioned. There continues to be mass effect upon the adjacent right lateral and frontal ventricle with minimal right to left subfalcine herniation, much improved since the prior study. CT OF HEAD today--per Dr. . FINDINGS: Single portable AP view of the chest shows an ETT that is well positioned. Bowel sounds present, no BM.GU - Diuresing well with lasix, mannitol.Skin - No areas of pressure, breakdown.A - Hypertensive s/p bleed. Lung fields coarse bilateral upper lobes with diminsihed bases. On lopressor and hydralazine PO--scheduled. There is a stable right scalp fluid collection at the operative site. FREQUENT STOOLING-FORMEDID/LABS: LOW GRADE TEMP, WBC DOWN TO TODAY. There is stable continued mass effect on the right lateral ventricle. Interval development of pneumocephalus within the area of prior hemorrhage. Resolved left scalp fluid collection. CLEARS WITH SXN. LUE WITH OCC WITHDRAWAL AND OCC EXTENSOR POSTURING NOTED. Withdraws to painfull stim. K REPLETED.R: LUNGS OCC COURSE. CXR taken. Cough, gag, and corneal reflex's +. Respiratory Care:Pt. The left scalp fluid collection is resolved. Initially was on labetalol. DP & PT dopplerable only. Interval decrease in the pneumocephalus. There is left lower lobe atelectasis/infiltrate. VENT SETTINGS UNCHANGED.GI: ABD SOFT/DISTENDED WITH +BS. FINDINGS: There are post-operative changes of right parietotemporal craniotomy. Resp assessment as noted above in RT's note.CV: RSR no ectopy noted. extubate. +CORNEALS. OGT to suction with bilious output. b/s coarse, sc rhonchi. Right groin lump unchanged. OS 3MM/SLUGGISH. Femoral line removed by Dr . There are again noted encephalomalacic changes in the right temporoparietal region. The Dobbhoff tube has been repositioned, and there is a loop of tubing in the stomach, but the Dobbhoff tip is back in the distal esophagus, above the GE junction. TECHNIQUE: Noncontrast head CT. DP and PT pulses w/doppler only. To nailbed stimuli, Lt arm rotates internally, moves laterally with elbow bent (unchanged). BRISKLY LOCALIZES WITH RUE TO STERNAL RUB. Has right radial ABP line and right femoral (venous) cortis. + cough,gag, and corneal reflexes. pt currently on cpap+ps 5/5 - tol well. WEAK WITHDRAWAL OF LLE. Pupils = to un= w/left pupil brisk,slugish, to nonreactive, see careview for complete neuro assessment. LIFTS/HOLDS WITH RUE/RLE. Left pupil 3mm and fluctuates b/t sluggish to non reactive. IMPRESSION: Dobbhoff coiled in distal esophagus with tip likely in upper neck or oropharynx. ABG WNL. continues on minimal level vent support. J collar in situ. BS coarse. There is again noted a very slight leftward midline shift, which is unchanged when compared to the prior study. Head midline. Head midline. Labatolol on/off this shift to maintain SBP < 140. Neurologicaly intact post fall. The left upper lobe infiltrate persists. There is patchy left lower lobe atelectasis. Nursing Progress Note: Please see CareVue for details.Pt condition essentially stable today.Events:CT brain.TLS films.New subclavian line placed.Femoral line removed.On exam,Resp:Chest clear, occasionally coarse this am. There was poorly timed airway closure with moderate aspiration with thin liquids. Note is made of likely external tubing overlying the left clavicular region. Surgical area swollen, dressing intact. CPK 1900's w/MB 13.Resp: Orally intubated and on vent. IMPRESSION: Moderate aspiration with thin liquids, intermittent trace aspiration with thickened liquids with adequate clearance. ETT is at 27cm, and was at 27cm at time of CXR.Hemodynamically:Weaned off labetolol infusion. Occasional episodes of SBP mid 90s, spontaneously resolving. 11:45 PM CHEST (PORTABLE AP) Clip # Reason: readjustment of second dobhouf. Radial pulses strong and =. pain.Resp: Remains orally intubated and on vent."},"n_notes":{"kind":"number","value":31,"string":"31"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2200-08-13 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":838576,"text":" 9:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? ETT placement\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man s/p a fall with ICH and evacuation of hematoma\n REASON FOR THIS EXAMINATION:\n ? ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: ?ETT placement.\n\n FINDINGS: Single portable AP view of the chest shows an ETT that is well\n positioned. There is cardiomegaly, with a right perihilar infiltrate, and left\n lower lobe and upper lobe infiltrates. These findings suggest aspiration vs.\n left heart failure. Also noted is an NG tube, the tip of which is in the\n distal stomach.\n\n IMPRESSION: Aspiration vs. left heart failure. ETT well-positioned.\n\n"},{"category":"Radiology","chartdate":"2200-08-14 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":838701,"text":" 7:31 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: BLEED\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man s/p fall with ICH, s/p evacuation of hematoma\n\n REASON FOR THIS EXAMINATION:\n interval changeS?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 56 y/o man status post fall with intracranial hemorrhage, status\n post evacuation of hematoma.\n\n TECHNIQUE: Axial images of the head were obtained from the occiput to the\n vertex without intravenous contrast.\n\n COMPARISON: Head CT, .\n\n HEAD CT: There is postoperative change in the right parietal region.\n Scattered surrounding high-attenuation foci are present and are stable in the\n interval. Several bubbles of gas are present in the right parietal region and\n in the right superior temporal region. The overall appearance of this area is\n unchanged from the prior study. There is stable continued mass effect on the\n right lateral ventricle. There is very slight leftward midline shift. The\n basal cisterns and foramen magnum are patent. There is stable layering of\n hemorrhage within the left lateral ventricle.\n\n There is a left scalp fluid collection measuring 6.3 x 1.3 cm. This has\n increased in size in the interval. There is a stable right scalp fluid\n collection at the operative site. Patient is status post right parietal\n craniotomy.\n\n IMPRESSION:\n\n 1. Stable appearance of the head from one day prior.\n\n 2. Enlarged left scalp fluid collection.\n\n\n"},{"category":"Radiology","chartdate":"2200-08-11 00:00:00.000","description":"CTA HEAD W&W/O C & RECONS","row_id":838424,"text":" 11:56 PM\n CTA HEAD W&W/O C & RECONS; -59 DISTINCT PROCEDURAL SERVICE Clip # \n CT 100CC NON IONIC CONTRAST; -59 DISTINCT PROCEDURAL SERVICE\n Reason: R/O AVM or anuerysm\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with large right temporal parietal bleed\n REASON FOR THIS EXAMINATION:\n R/O AVM or anuerysm\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT ANGIOGRAPHY, \n\n INDICATION: Large right temporal lobe hemorrhage, rule out AVM or aneurysm.\n\n TECHNIQUE: Dynamically-acquired contrast-enhanced CT scans through the brain\n were obtained for acquisition of a CT angiogram of the circle of . The\n superior cervical portion of the vasculature is also included. Two\n dimensional reformatted images are provided for evaluation.\n\n Comparison is made to the previous CT scan of the brain from .\n\n FINDINGS: There is a large hematoma expanding the right temporal lobe and\n elevating the Sylvian branches of the right middle cerebral artery. This is\n grossly unchanged since the previous CT scan.\n\n The right lateral ventricle is flattened and the left lateral ventricle is\n mildly dilated due to right to left subfalcian herniation. The basal\n cisternal spaces are narrowed as the medial right temporal lobe is medially\n displaced.\n\n CT angiographic images demonstrate displacement of vessels around the hematoma\n but no abnormal vascularity is detected. Additionally, no aneurysms are\n detected within the right internal carotid artery or middle cerebral arterial\n branches.\n\n IMPRESSION:\n\n CT angiography reveals no vascular abnormality to explain the presence of\n a right temporal lobe hematoma. Conventional angiography should be\n considered for further evaluation.\n\n"},{"category":"Radiology","chartdate":"2200-08-12 00:00:00.000","description":"SEL CATH 3RD ORDER THOR","row_id":838428,"text":" 2:37 AM\n CAROT/CEREB Clip # \n Reason: HEADACHES\n Contrast: OPTIRAY Amt: 308\n ********************************* CPT Codes ********************************\n * SEL CATH 3RD ORDER SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE ADD'L 2ND/3RD ORDER *\n * ADD'L 2ND/3RD ORDER ADD'L 2ND/3RD ORDER *\n * CAROTID/CEREBRAL BILAT CAROTID/CEREBRAL BILAT *\n * EXT CAROTID BILAT VERT/CAROTID A-GRAM *\n * VERT/CAROTID A-GRAM -59 DISTINCT PROCEDURAL SERVICE *\n ****************************************************************************\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY:\n Intracerebral hemorrhage.\n\n TECHNIQUE:\n Informed consent was obtained from the patient and the patient's family after\n explaining the risks, indications and alternative management. Risks explained\n included stroke, loss of vision and speech, temporary or permanent, with\n possible treatment with stent and coils if needed.\n\n The patient was brought to the Interventional Neuroradiology Theater and\n placed on the biplane table in supine position. Both groins were prepped and\n draped in the usual sterile fashion. Access to the right common femoral artery\n was obtained using a 19-gauge single wall needle, under local anesthesia using\n 1% lidocaine mixed with sodium bicarbonate and with aseptic precautions.\n Through the needle, a 0.35 wire was introduced and the needle taken\n out. Over the wire, a 5 Fr vascular sheath was placed and connected to a\n saline infusion (mixed with heparin 500 units in 500 cc of saline) with a\n continuous drip. Through the sheath, a 4 Fr Berenstein catheter was introduced\n and connected to continuous saline infusion (with mixture of 1000 units of\n heparin in 1000 cc of saline).\n\n The following blood vessels were selectively catherized, and arteriograms were\n performed from these locations.\n\n right common carotid artery:\n\n right internal carotid artery:\n\n right external carotid artery:\n\n left common carotid artery:\n\n left internal carotid artery:\n\n left external carotid artery:\n\n left vertebral artery:\n\n (Over)\n\n 2:37 AM\n CAROT/CEREB Clip # \n Reason: HEADACHES\n Contrast: OPTIRAY Amt: 308\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n right vertebral artery.\n\n Evaluation of the right common carotid artery, right internal carotid artery,\n right external carotid artery, left common carotid artery, left internal\n carotid artery, left external carotid artery, left vertebral artery and right\n vertebral artery demonstrates no evidence of vascular malformation or\n aneurysm. Normal flow is noted in the intracranial circulation. No significant\n atherosclerotic stenosis noted in the carotid bifurcation.\n\n IMPRESSION: No evidence of aneurysm or vascular malformation.\n\n Mild-to-moderate vasospasm noted in the right and middle cerebral artery\n branches and posterior cerebral artery branch may be related to hemorrhage.\n\n If clinically warranted a followup angiogram may be performed in six weeks\n after the hemorrhage has resolved to exclude subtle abnormalities.\n\n\n\n\n\n\n"},{"category":"Radiology","chartdate":"2200-08-12 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":838465,"text":" 9:30 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: s/p right craniotomy for evacuation of hemorrhage\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man s/p fall\n\n REASON FOR THIS EXAMINATION:\n s/p right craniotomy for evacuation of hemorrhage\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: S/P right craniotomy for evacuation of hemorrhage.\n\n COMPARISON: \n\n TECHNIQUE: Non-contrast head CT.\n\n HEAD CT WITHOUT IV CONTRAST: There has been interval evacuation of the\n previously identified right temporoparietal intraparenchymal hemorrhage with\n interval development of gas within the right frontal, temporal, and parietal\n lobes. Minimal high density material is seen within these areas suggestive of\n residual blood. The previously seen uncal herniation has resolved. There\n continues to be mass effect upon the adjacent right lateral and frontal\n ventricle with minimal right to left subfalcine herniation, much improved\n since the prior study. A right parietal craniotomy defect is demonstrated.\n There is partial opacification of the ethmoid, sphenoid, and maxillary sinuses\n bilaterally.\n\n IMPRESSION: Interval evacuation of large right temporoparietal\n intraparenchymal hemorrhage with resolution of uncal herniation and\n improvement in right to left subfalcine herniation. Interval development of\n pneumocephalus within the area of prior hemorrhage. Small amount of residual\n blood is seen within the right temporoparietal lobe.\n\n"},{"category":"Radiology","chartdate":"2200-08-13 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":838614,"text":" 12:48 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval tip position & r/o PTX\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man s/p a fall with ICH and evacuation of hematoma, s/p L SCV line\n plaqcment\n REASON FOR THIS EXAMINATION:\n eval tip position & r/o PTX\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 56 year old man status post fall, intracranial hemorrhage, left\n subclavian vein placement.\n\n TECHNIQUE: Portable AP chest radiograph. Comparison is made with the\n previous chest radiograph dated , 9:00AM.\n\n FINDINGS: The tip of the left subclavian line is terminating in the SVC.\n There is no pneumothorax. Endotracheal tube and NG tube are unchanged\n compared with the previous study.\n\n The heart is mildly enlarged in size.\n\n There is infiltration in left lower lobe, most likely representing atelectasis\n vs. pneumonia. There is a new focal opacity in the left upper lobe, which can\n represent either pneumonia, aspiration, or edema.\n\n The right lung is clear.\n\n There is no evidence of pleural effusion on chest radiograph.\n\n IMPRESSION: Continued left lower lobe infiltration with increased left upper\n lobe infiltration, which can represent pneumonia vs. aspiration.\n\n"},{"category":"Radiology","chartdate":"2200-08-13 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":838620,"text":" 1:43 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? change\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man s/p fall with ICH, s/p evacuation of hematoma\n\n REASON FOR THIS EXAMINATION:\n ? change\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n NONCONTRAST HEAD CT:\n\n INDICATION: Status post fall with ICH, status post evacuation of hematoma,\n please evaluate status.\n\n TECHNIQUE: Noncontrast head CT.\n\n COMPARISON: Noncontrast head CT of and .\n\n FINDINGS: In the area of the previously evacuated right temporoparietal\n intraparenchymal hemorrhage, there is pneumocephalus and trace areas of high\n density suggestive of residual blood. Additionally, there is pneumocephalus in\n the right frontal region. These findings show no change from the previous\n study. There continues to be mild mass effect upon the adjacent right lateral\n and frontal ventricle, with no change from the previous study. On the current\n study, however, due to technical factors during scanning, there is poor\n visualization of the /white interface, which drastically reduces the\n ability of this study to be accurately interpreted. If clinically indicated,\n recommendation is made to repeat the scan.\n\n IMPRESSION: Extremely limited study due to technical factors during scanning\n resulting in extensive blurring of the /white interface. Despite these\n limitations, there is an apparent stable appearance of the drainage bed with\n no significant change in amount of pneumocephalus or residual blood. However,\n a repeat scan is hightly recommended due to the low quality of this scan. Dr.\n covering for referring clinician was paged and given this\n recommendation.\n\n"},{"category":"Radiology","chartdate":"2200-08-13 00:00:00.000","description":"T-SPINE","row_id":838624,"text":" 2:10 PM\n T-SPINE; L-SPINE (AP & LAT) Clip # \n Reason: ? fx or dislocation\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man s/p a fall with ICH\n REASON FOR THIS EXAMINATION:\n ? fx or dislocation\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Fall. Pain.\n\n These two exams consist of AP and lateral views of the thoracic and lumbar\n spine (five images). Normal vertebral body alignment. No fracture identified\n and normal discs. The hips and SI joints are normal. Incidentally noted is\n prominent enthesopathy at multiple sites. Tip of NG tube in distal stomach\n and right inguinal blood access line, tip lying in iliac vessel. Normal bowel\n gas pattern and no ascites. Instantly noted is air space disease in the left\n mid and lower lungs with air bronchograms. ETT and left subclavian line\n satisfactorily positioned.\n\n"},{"category":"Nursing/other","chartdate":"2200-08-17 00:00:00.000","description":"Report","row_id":1364609,"text":"ASSESSMENT AS NOTED\n\nNEURO: FOLLOWS, ANSWERS QUESTIONS, DISORIENTED IN TIME/PLACE(TELLS HE IS IN WEREHOUSE), KNOWS HIS FAMILY. IS SLOW AND UNCLEAR AT TIMES. L ARM POSTURES. R SIDE IS STRONG. STRONG COUGH. REMAINS IN CER COLLAR. CON'T ON MANNITOL AND DILANTIN. NO SEIZURE ACTIVITY\nNO SEDATION WAS GIVEN. DENIES PAIN\n\nRES: COUGHING AND SWALOWING SECRETIONS, LS CLEAR/COARSE , ON RA 100%\n\nCV: TRYING TO MAINTAIN 140-160 SBP, ON LOPRESSOR, HYDRALAZINE. GOT 500CC BOLUS(WAS NEG TOO MUCH )\n\nGU: 100-50 CC/H CLEAR\n\nGI: AT THGE GOAL 85 CC/H T. FEED. FREQUENT STOOLING-FORMED\n\nID/LABS: LOW GRADE TEMP, WBC DOWN TO TODAY. K WAS REPLETED\n BS DOWN TO 109 IN AM- COVERAGE BY RISS.\n\nSOCIAL: FAMILY IN LAST NIGHT\n\nA: ALTERATION IN NEURO STATUS\n\nP: WEAN OFF TRANSFER TO STEPDOWN OR FLOOR. MAINTAIN SBP<160\n"},{"category":"Nursing/other","chartdate":"2200-08-17 00:00:00.000","description":"Report","row_id":1364610,"text":"TSICU NPN (0700-1900)\nREVIEW of SYSTEMS\n\nNeuro....Dozing off and on for most of day. Awakens to voice or light stimuli. When awake, light voice, but answers questions and follows commands. Moves R sided extremities with good strength and purposefully. L leg moves slightly on bed--withdrawl. Extnesor posturing with LUE. R pupil slightly smaller than L, but both briskly reactive. CT OF HEAD today--per Dr. . Mannitol stopped. Continues on dilantin with no seziure activity noted. OOB to chair for almost 4 hours. Tolerated well. No c/o pain.\nFlexion/Extension x-rays done. Not cleared yet per Dr. . J collar remains on.\n\nCV....NSR with no ectopy noted. HR 80-90's. Goal SBP <160 per Dr. . On lopressor and hydralazine PO--scheduled. BP ranging 160-130/60-70's. PRN lopressor dose available if needed. Two peripheral IV's started. L SC TLC dc'd. Dr. did not want tip cultured.\n\nRESP...Stable on RA with sats >94%. Lung fields coarse bilateral upper lobes with diminsihed bases. Strong congested cough--minimally productive thought. NT suctioned x1 this afternoon with moderate amts of thick yellow secretions returned.\n\nGI....Promote with fiber TF's remain at goal of 85cc/hr. Tolerating well. No BM today, but multiple stools overnight. Abd soft with active BS.\n\nGU....Foley to gravity with adequate clear yellow urine. Lytes stable.\n\nENDO...Blood sugars peaked at 406, noon. Given 12U regular and 8U NPH. No effect seen 1hr later. Started on insulin drip--requiring up to 12U/hr in order to bring sugars down. Dropped quickly when NPH peaked, down to 75. 1/2 amp D50 given at 1700. Will continue to check frequently.\n\nHEME...HCT stable. Heparin subq and pneumo boots on.\n\nID...Tmax 99.9. Levofloxacin coverage on board. TLC dc'd.\n\nSKIN...Staples to incision on head with no redness or drg note. Poor dentation with loose teeth noted. Backside intact.\n\nSOCIAL... son and daughter in earlier today. Updated on pt's condition and plan of care. Not aware of events with blood sugars.\n\nPLAN...Pt is possible bump to neuro step down floor if necessary. Would like to keep pt here overnight d/t sugar issues unless bed issues arise. Swallow study ordered for tomorrow. ??Check into flex-ex films tomorrow. Needs encouragement with pulmonary toilet. SBP around 160. Montior blood sugars.\n"},{"category":"Nursing/other","chartdate":"2200-08-18 00:00:00.000","description":"Report","row_id":1364611,"text":"nsg note:\nneuro moving t side to command lt side posturing very spastic answers questions simply slightly confused knows hes in a hospital. cv stable tol lopressor and hydralazine. hr nsr\n\nresp sats adequate, congested spont cough breathsounds coarse.\n\ngi tol tube feeds at goal. given insulin per sliding scale. one lg bm\n\n"},{"category":"Nursing/other","chartdate":"2200-08-18 00:00:00.000","description":"Report","row_id":1364612,"text":"TRAUMA ICU NURSING PROGRESS NOTE\nSEE TRANSFER NOTE....AWAITING BED.\n"},{"category":"Nursing/other","chartdate":"2200-08-15 00:00:00.000","description":"Report","row_id":1364606,"text":"TSICU Nursing Progress Note\nNeuro - Less alert most of today. Opening eyes occasionally to voice. Localizes with left arm with suctioning, stimulation. Right arm with extensor posturing. Moves bilateral LE right>left. Pupils unequal, reactive. Impaired gag, strong cough.\n\nCV - Tachycardic to 100s despite increased Metoprolol. No ectopy noted. Hypertensive requiring PRN Metoprolol, hydralyzine and fentanyl. Dosing antihypertensives by , underdamped. Neurosurgery wants SBP < 150 at all times. Added lasix. K repleated.\n\nPulm - Extubated today. Tolerating 3L NC with face tent for humidification. Strong cough, productive of thick yellow sputum.\n\nGI - OGT discontinued in preparation for extubation. Small bore feeding tube placed, currently in stomach. Maintained NPO until tomorrow. Bowel sounds present, no BM.\n\nGU - Diuresing well with lasix, mannitol.\n\nSkin - No areas of pressure, breakdown.\n\nA - Hypertensive s/p bleed. Tolerating extubation .\n\nP - Maintain SBP< 150 per . Aggressive pulmonary toilet, oral care.\n"},{"category":"Nursing/other","chartdate":"2200-08-16 00:00:00.000","description":"Report","row_id":1364607,"text":"ASSESSMENT AS NOTED\n\nNEURO: FOLLOWS SIMPLE COMMANDS, L. ARM POSTURES. UNCLEAR . ANSWERS QUESTIONS Y/N. STILL IN CERVICAL COLLAR, NO SEIZURE ACTIVITY\nCON'T ON DILANTIN AND MANNITOL\n\nRES: STRONG PROD. COUGH, MAINTAINS S02>9% ON COOL AIRSOLE TENT 35% AND NC2L, LS COARSE T/0.\n\nCV: GOAL TO MAINTAIN SBP 140-160, UNABLE TO CONTROL WITH LOPRESSOR AND HYDRALAZINE AND LABETALLOL GTT WAS STERTED DURING THE NIGHT WITH GOOD SBP CONTROL., REMAINS IN NSR NO ECTOPY.\nA-LINE IS WITH FLING, GOING BY CUFF.\n\nGI: UNREMARCABLE, + BS, FEEDING TUBE IS CLAMPED: WAITING FOR IT TO DROP INTO JEJUNO.\n\nGU: BRISK U/O WITH LASIX AND MANNITOL. ON DOSE OF 5MG ZAROXYLIN WAS GIVEN 2100 LAST NIGHT.\n\nLABS: K WAS REPLACED FOR 3.3, STILL WAITING FOR OSMO SINCE 4AM.\n\nSKIN :INTACT , INCISION INTACT\n\nSOCIAL: FAMILY IS IN ALL NIGHT IN AND OUT\n\nID : NO FEVER\n\nA: FALL, HEAD BLEED-->CRANI, SEVERE HTN\n\nP:CONTROL BP, NEURO, PULM TOILET\n\n\n\n\n"},{"category":"Nursing/other","chartdate":"2200-08-16 00:00:00.000","description":"Report","row_id":1364608,"text":"NSG NOTE:\n\nROS:\n\n CV:LOPRESSOR PO INCREASED,HYDRALIZINE IV ADDED,THEN CHANGED TO PO.SYS BP BELOW 170 ALL DAY,LABETALOL DC'D.CVP - TO 1.\n\n RESP:NOW ON 4L NP WITH SAT 99.HAS STRONG PROD COUGH,SWALLOWS ALL SPUTUM.\n\n NEURO:ANSWERS APPROPIATELY TO YES/NO QUESTIONS.DIFF TO UNDERSTAND WHEN HE SPEAKS IN SENTENCES.MOVES R ARM,LEG NORMALLY.\nPOSTURES WITH L ARM,MOVES L LEG ON BED.PUPILS REACTING BRISKLY.\nOOB IN CHAIR.\n\n GU:GOOD UO,DIURESING WITH 12N DOSE LASIX.\n\n GI:STARTED TF,PROMOTE WITH FIBER.GOAL 85,ON 60CC AT 4PM.\n+ BS,NO STOOL\n\n ID:99+.\n\n ENDO:BS 188-189,GIVEN INSULIN AS ORDERED.\n\n SOCIAL:MULTIPLE FSMILY MEMBERS IN,WIFE IN MOST OF PM.\n\n PLAN:CAN TRANSFER TO 5 STEPDOWN UNIT.BED FACILITATOR AWARE.\n\n\n\n"},{"category":"Nursing/other","chartdate":"2200-08-14 00:00:00.000","description":"Report","row_id":1364604,"text":"Nursing Progress Note.\nPlease see CareVue for specifics.\n\nPt condition improved today.\n\nNeuro:\nPt more alert today, moving Rt side spontaneously, lifting legs spont, shifting position, regarding examiner. Still has episodes where much less alert, rousing to stimuli. Has obeyed commands by squeezing and releasing Rt hand, although does not obey all times. Pupils still Lt > Rt. Fentanyl in CT scan to keep pt still. TLS cleared today. J remains insitu. Strong cough, occasional gag.\nStill weaning mannitol.\n\nResp:\nRemains on PSV 5/5 40%. Very thick secretions. Started on levofloxacin for same. Chest clear. ETT not rotated due to very loose teeth and risk of dislodging one. ETT is well secured.\n\nHemodynamically:\nSR 80s, 90s when agitated. No ectopy. Weaned labetolol infusion off with additional oral metoprolol. Hydralazine very effective. Goal SBP 100-150. Peripherally warm and well pewrfused.\n\nEndocrine:\nBetter control of sugers with tighter sliding scale, but has still needed coverage today.\n\nFluids:\nNS with 20KCl to total input 75mls/hr.\n\nGI:\nAbd soft, non distended.\nTube feeds recommenced.\n\nID:\nAfebrile. Levofloxacin commenced pending sputum cultures.\n\nRenal:\nUrine output declining but still satisfactory.\n\nSkin:\nEssentially intact. See CareVue. No new issues.\n\nSocial:\nFamily very concerned that they have not yet had an update from team. Paged resident and NP, neithor available to speak with family. Social work involved. Also suggested family contact patient relations if they would like another outlet for their concern.\n\nPlan:\nContinue to monitor.\nPlan for extubation tomorrow.\nContinued support for family.\n"},{"category":"Nursing/other","chartdate":"2200-08-13 00:00:00.000","description":"Report","row_id":1364598,"text":"Admit note:\n\nUnwitnessed fall from standing position. Neurologicaly intact post fall. Approx 3 hrs after fall family was unable to arouse for dinner and called 911. Transported here. CT=>right tempral/parietal bleed with IPH and midline shift=> OR for evacuation of hematoma. 4 vessel angio negative, CTA head/neck = AVM\n\nROS:\n\nNeuro: Initially off propofol, would open eyes w/coughing. Right pupil consistanly 3 mm and brisk. Left pupil 3mm and fluctuates b/t sluggish to non reactive. Cough, gag, and corneal reflex's +. Withdraws to painfull stim. Propofol had to be restarted at 40 mcg/kg/min do to coughing against ETT. Bed in Reverse T- at 30 degreees. J collar on. Head midline. On dilantin 100mg q 8 hr. Manitol q 6hr. Crani dressing intact w/ scant amt of red drainage..\n\nCV: RSR no ectopy noted. S1S2. Initially was on labetalol. On admission to unit SBP 88. Labetalol turned off, later resumed and titrated to 1.5 mg/min to keep sbp <140 and > 100 ( ). Has right radial ABP line and right femoral (venous) cortis. Radial pulses palpable. DP and PT pulses w/doppler only. Right DP very difficult to auscultate w/doppler. CPK 1900's w/MB 13.\n\nResp: Orally intubated and on vent. Vent changed to SIMV 600x12, peep 5, PS 5, 40%. Breathing over vent w/RR of 14-22. Lung sound clear upper lung fields. Diminished and coarse in bases. Sx thick light green sputum. Sats 100%. ABGs WNL this AM. No resp distress noted, = rise and fall of chest\n\nGI: Oral sump to LCS draining bile colored fluid. Abd soft w/active Bowel sounds in all four quads af abd. Prophylactic protonix changed to H2 blocker.\n\nGU:Foley patent draining clear yellow urine in QS\n\nLabs: pending at this hour\n\nSocial: Here in working and staying w/daughter . Wife and other children living in (all are here)\n"},{"category":"Nursing/other","chartdate":"2200-08-13 00:00:00.000","description":"Report","row_id":1364599,"text":"Resp care\nWeaned pt to minimal vent support today. ABG's acceptable, well oxygenated and ventilated. BS coarse. Sx mod-lg thick green secretions. Head CT done today, TLS films done. Results pending. Will follow.\n"},{"category":"Nursing/other","chartdate":"2200-08-13 00:00:00.000","description":"Report","row_id":1364600,"text":"Nursing Progress Note: Please see CareVue for details.\n\nPt condition essentially stable today.\n\nEvents:\nCT brain.\nTLS films.\nNew subclavian line placed.\nFemoral line removed.\n\nOn exam,\n\nResp:\nChest clear, occasionally coarse this am. Moving large tidal volumes >500mls. Weaned to Pressure Support 40%. Tolerating well, ABGs improved. Has strong cough, productive of thick greenish sputum. CXR taken. ETT is at 27cm, and was at 27cm at time of CXR.\n\nHemodynamically:\nWeaned off labetolol infusion. Maintaining SBP within goal of 100-140mmHg. Occasional episodes of SBP mid 90s, spontaneously resolving. HR 80s, SR. Peripheries warming. Femoral line removed by Dr . Soft mass in Rt groin unchanged. New subclavian line in use. CVP 13.\n\nNeuro:\nPropofol off except for scans and turns- coughs violently without. Poor exam. Rouses to stimuli, localizes with Rt arm to sternal rub, lifts both legs at knee, Rt more briskly than left, but with essentially equal strength. To nailbed stimuli, Lt arm rotates internally, moves laterally with elbow bent (unchanged). Pupils: Lt>Rt, Rt reactive, Lt sluggish at best. Slight left gaze, pt's head turns to Lt. Corneals present, blink to threat absent. J collar in situ. Surgical area swollen, dressing intact. No new ooze. Mannitol q6 according to osm and Na.\n\nEndocrine:\nCovered with regular insulin per sliding scale.\n\nFluids:\nNS with 20meq KCl at 75/hr.\n\nGI:\nABd soft, non distended, bowel sounds present. OGT to suction with bilious output. For commencement of tube feeds. GI prophylaxis being reviewed in light of pt's history of thrombocytopenia.\n\nID:\nLow grade fever only. Antibiotics complete.\nSputum culture sent.\n\nRenal:\nGood urine output.\n\nSkin:\nIntact except for surgical wound and forehead lac.\nPt has very poor dentition and loose teeth, shown to team.\n\nSocial:\nFamily here. Daughter and wife updated by physician. discarded by family.\n\nPlan:\nContinue to monitor.\nFollow up TLS films.\nTube feeds.\nPossible extubation tomorrow.\nContinued support for family.\n\n"},{"category":"Nursing/other","chartdate":"2200-08-14 00:00:00.000","description":"Report","row_id":1364601,"text":"Respiratory Care:\nPt. continues on minimal level vent support. ABG's well oxygenated with normal range acid-base. B/S with scattered rhonchi>>ETS small to moderate, thick, green. Foul smelling oral secretions. RSBI was 42 this a.m.. Started on SBT. Will follow.\n"},{"category":"Nursing/other","chartdate":"2200-08-15 00:00:00.000","description":"Report","row_id":1364605,"text":"NPN\nN: PT NOT THOUGH PURPOSEFUL WITH RUE TOWARDS GROIN & ETT. BRISKLY LOCALIZES WITH RUE TO STERNAL RUB. LIFTS/HOLDS WITH RUE/RLE. WEAK WITHDRAWAL OF LLE. LUE WITH OCC WITHDRAWAL AND OCC EXTENSOR POSTURING NOTED. PUPILS UNEQUAL. OD 2MM/BRISK. OS 3MM/SLUGGISH. STRONG COUGH/IMPAIRED GAG. +CORNEALS. DILANTIN LEVEL 14. RESTLESS AT TIMES PULLING AT RESTRAINTS/SHIFTING WEIGHT IN BED. GIVEN FENTANYL WITH SOME EFFECT PRN. CONT MANNITOL.\nCV: HYPERDYNAMIC AND REQUIRING INCREASED DOSES OF LOPRESSOR AND USE OF PRN LOPRESSOR/HYDRALAZINE. ALINE WITH SOME FLING. NBP CYCLING AND TREATING BP PER NBP. K REPLETED.\nR: LUNGS OCC COURSE. CLEARS WITH SXN. SXN'D FOR SM AMT THICK TAN. ABG WNL. VENT SETTINGS UNCHANGED.\nGI: ABD SOFT/DISTENDED WITH +BS. TF OFF AT 4AM FOR PROBABLE EXTUBATION. NO STOOL.\nGU: CLEAR YELLOW URINE DRAINING VIA FOLEY IN GOOD AMTS.\nHEME: HCT STABLE\nID: TMAX 100. WBC 15.9\nENDO: GLUCOSE TREATED PER RISS.\nSOC: PT'S DAUGHTER CAME IN LAST EVENING AND GIVEN UPDATE. DAUGHTER VOICING CONCERN.\nA/P: EXTUBATE IF ABLE TODAY.\n"},{"category":"Nursing/other","chartdate":"2200-08-14 00:00:00.000","description":"Report","row_id":1364602,"text":"ROS:\n\nNeuro: Has periods where he is more alert then other times. When he is more alert has eyes open spontaniously and has protective blink reflex. + cough,gag, and corneal reflexes. Pupils = to un= w/left pupil brisk,slugish, to nonreactive, see careview for complete neuro assessment. Bed in Reverse T-. j collar on. Head midline. Dilantin level 16, receiving dilantin 100mg q 8 hr and manitol 25 Gm q 6 hr. Serum osmo trending up as well as Na+. Fentanyl for ? pain.\n\nResp: Remains orally intubated and on vent. Resp assessment as noted above in RT's note.\n\nCV: RSR no ectopy noted. S1S2. Has right radial ABP line and left subclavian MML w/distal port transduced for cvp=8->12. Radial pulses strong and =. DP & PT dopplerable only. Right groin line site clean dry and intact. Right groin lump unchanged. Labatolol on/off this shift to maintain SBP < 140. Metoprolol 12.5mg via ng initiated.\n\nGI: Oral gastric tube w/TF infusing at 30cc/hr w/minimal residuals. Abd soft w/active bowel sounds thoughout.\n\nGU: Foley patent draining clear yellow urine in QS\n\nLabs: Stable\n\nSocial: Children and spouse present this shift for support.\n\nPlan: BP management. ? extubate.\n"},{"category":"Nursing/other","chartdate":"2200-08-14 00:00:00.000","description":"Report","row_id":1364603,"text":"resp care\npt remains intubated and mech ventilated. pt currently on cpap+ps 5/5 - tol well. b/s coarse, sc rhonchi. sxn thk yel>>green secretions. pt tx to/from ct scan w/o incident. plan: cont w/mech support. ? extubation tomorrow.\n"},{"category":"Radiology","chartdate":"2200-08-17 00:00:00.000","description":"C-SPINE FLEX AND EXT ONLY 2 VIEWS","row_id":839022,"text":" 12:42 PM\n C-SPINE FLEX AND EXT ONLY 2 VIEWS Clip # \n Reason: eval c spine for instability\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56M s/p trauma, SDH\n REASON FOR THIS EXAMINATION:\n eval c spine for instability\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 56 year old man status post trauma. Evaluate C-spine for stability.\n\n CERVICAL SPINE FOUR VIEWS. There is no prevertebral soft-tissue swelling.\n There is no evidence of fracture. The cervical vertebral bodies are in normal\n alignment without loss of body or disc height. However, C6, C7 and T1 are not\n well visualized. Alignment is stable in flexion and extension views.\n\n IMPRESSION: No cervical spine fracture. Stable alignment in flexion and\n extension. Somewhat limited study due to poor visualization of C6, C7 and T1.\n\n"},{"category":"Radiology","chartdate":"2200-08-17 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":839021,"text":" 12:37 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval interval changes. please coordinate schedule with flex\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56M with SDH s/p evac\n REASON FOR THIS EXAMINATION:\n eval interval changes. please coordinate schedule with flex-ext films\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 56-year-old male status-post evacuation of subdural hemorrhage.\n\n COMPARISON: .\n\n TECHNIQUE: Noncontrast head CT.\n\n FINDINGS: There are post-operative changes of right parietotemporal\n craniotomy. There are again noted encephalomalacic changes in the right\n temporoparietal region. There is slight decrease in the amount of air. There\n is no new hemorrhage. There is again noted a hyperdense foci in the right\n temporal lobe that is unchanged when compared to the previous studies, and may\n represent blood. The ventricles are unchanged in size. There is still a\n small amount of blood in the occipital of the left lateral ventricle.\n There is again noted a very slight leftward midline shift, which is unchanged\n when compared to the prior study. The left scalp fluid collection is\n resolved.\n\n IMPRESSION\n\n 1. There is no evidence of new hemorrhage.\n 2. Interval decrease in the pneumocephalus.\n 3. Resolved left scalp fluid collection.\n\n\n"},{"category":"Radiology","chartdate":"2200-08-19 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":839278,"text":" 8:14 PM\n CHEST (PORTABLE AP) Clip # \n Reason: post dophouf placement\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man s/p a fall with ICH and evacuation of hematoma, s/p L SCV\n line plaqcment\n REASON FOR THIS EXAMINATION:\n post dophouf placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Dobbhoff and left subclavian central venous line placement.\n\n : Comparison is made to . Dobbhoff tubing is looped\n in the distal esophagus with the tip not visualized, but likely in the upper\n neck or oropharynx. This needs to be repositioned. Note is made of likely\n external tubing overlying the left clavicular region. This is not in the\n region expected for a left subclavian central venous line. The patient's\n previous left subclavian central venous line has been removed. There is patchy\n left lower lobe atelectasis.\n\n IMPRESSION: Dobbhoff coiled in distal esophagus with tip likely in upper neck\n or oropharynx. This needs to be repositioned. Note is made that the patient\n has had multiple subsequent prior films which show repositioning of the tube.\n\n"},{"category":"Radiology","chartdate":"2200-08-20 00:00:00.000","description":"VIDEO OROPHARYNGEAL SWALLOW","row_id":839357,"text":" 1:51 PM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: please eval swallow function per speech and swallow\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56M s/p trauma, SDH\n\n REASON FOR THIS EXAMINATION:\n please eval swallow function per speech and swallow\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 56 year old man status post trauma and subdural hematoma\n presenting for swallowing function evaluation.\n\n COMPARISONS: None.\n\n TECHNIQUE: The study was performed in conjunction with the speech\n pathologist. Various consistencies of barium were administered orally. The\n study was recorded on a video tape.\n\n FINDINGS: The patient exhibited weakness of the oral musculature and bolus\n control. There was some spillover of thick and thin liquids into the\n hypopharynx. There was poorly timed airway closure with moderate aspiration\n with thin liquids. There was also trace aspiration with nectar thick liquids\n intermittently, which cleared, and was improved with the chin tuck technique.\n Please see the report of the speech pathologist for further details.\n\n IMPRESSION: Moderate aspiration with thin liquids, intermittent trace\n aspiration with thickened liquids with adequate clearance.\n\n\n"},{"category":"Radiology","chartdate":"2200-08-19 00:00:00.000","description":"BILAT LOWER EXT VEINS","row_id":839227,"text":" 1:06 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: CEREBRAL ANEURYSM, R/O DVT\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with cerebral hemorrhage\n REASON FOR THIS EXAMINATION:\n r/o dvt\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: Bilateral lower extremity venous Doppler ultrasound.\n\n INDICATION: 56 year old man with cerebral hemorrhage and suspicion for DVT.\n\n COMPARISON: None.\n\n FINDINGS: Doppler son were performed of the left and right common\n femoral veins, superficial femoral veins, popliteal veins. All vessels showed\n normal flow, augmentation, compressibility, and respiratory variation.\n Intraluminal thrombus is not identified.\n\n IMPRESSION: No evidence for deep vein thrombosis in either lower extremity.\n\n\n"},{"category":"Radiology","chartdate":"2200-08-19 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":839283,"text":" 9:56 PM\n CHEST (PORTABLE AP) Clip # \n Reason: second dophouf placement at 75cm\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man s/p a fall with ICH and evacuation of hematoma, s/p L SCV\n line plaqcment\n REASON FOR THIS EXAMINATION:\n second dophouf placement at 75cm\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Dobhoff repositioning.\n\n PORTABLE AP CHEST: Comparison is made to the study from two hours earlier. The\n Dobbhoff tube has been repositioned, and there is a loop of tubing in the\n stomach, but the Dobbhoff tip is back in the distal esophagus, above the GE\n junction. This needs to be repositioned. The heart and lungs are unchanged.\n The previously seen tubing overlying the left clavicular region is no longer\n present.\n\n IMPRESSION: Dobbhoff tubing looped in stomach but tip is in the distal\n esophagus, above the GE junction, requiring repositioning.\n\n"},{"category":"Radiology","chartdate":"2200-08-15 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":838824,"text":" 10:04 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? tube feed placement\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man s/p a fall with ICH and evacuation of hematoma, s/p L SCV\n line plaqcment\n REASON FOR THIS EXAMINATION:\n ? tube feed placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Feeding tube placement check.\n\n FINDINGS: Single AP portable view of the chest show a feeding tube, with the\n tip in the fundus. There is left lower lobe atelectasis/infiltrate. The left\n upper lobe infiltrate persists. Right lung appears clear. The ETT and central\n venous line remain in good position.\n\n IMPRESSION: Feeding tube in fundus of stomach. Otherwise no significant\n interval change.\n\n"},{"category":"Radiology","chartdate":"2200-08-19 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":839290,"text":" 11:45 PM\n CHEST (PORTABLE AP) Clip # \n Reason: readjustment of second dobhouf. this is the third film \n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man s/p a fall with ICH and evacuation of hematoma, s/p L SCV\n line plaqcment\n REASON FOR THIS EXAMINATION:\n readjustment of second dobhouf. this is the third film tonight s/p adjustment\n at 11:20pm\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Dobbhoff repositioning.\n\n PORTABLE AP CHEST: Comparison is made with the study from ,\n approximately 2 hours earlier. The Dobbhoff tubing is now coiled in the\n stomach in satisfactory position. There is residual patchy left lower lobe\n atelectasis, but the appearance of the heart and lungs are unchanged.\n\n IMPRESSION: Successful Dobbhoff tube positioning, coiled in stomach.\n\n\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2200-08-13 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 838576,\n \"text\": \" 9:02 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ? ETT placement\\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old man s/p a fall with ICH and evacuation of hematoma\\n REASON FOR THIS EXAMINATION:\\n ? ETT placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: ?ETT placement.\\n\\n FINDINGS: Single portable AP view of the chest shows an ETT that is well\\n positioned. There is cardiomegaly, with a right perihilar infiltrate, and left\\n lower lobe and upper lobe infiltrates. These findings suggest aspiration vs.\\n left heart failure. Also noted is an NG tube, the tip of which is in the\\n distal stomach.\\n\\n IMPRESSION: Aspiration vs. left heart failure. ETT well-positioned.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2200-08-14 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 838701,\n \"text\": \" 7:31 AM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: BLEED\\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old man s/p fall with ICH, s/p evacuation of hematoma\\n\\n REASON FOR THIS EXAMINATION:\\n interval changeS?\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 56 y/o man status post fall with intracranial hemorrhage, status\\n post evacuation of hematoma.\\n\\n TECHNIQUE: Axial images of the head were obtained from the occiput to the\\n vertex without intravenous contrast.\\n\\n COMPARISON: Head CT, .\\n\\n HEAD CT: There is postoperative change in the right parietal region.\\n Scattered surrounding high-attenuation foci are present and are stable in the\\n interval. Several bubbles of gas are present in the right parietal region and\\n in the right superior temporal region. The overall appearance of this area is\\n unchanged from the prior study. There is stable continued mass effect on the\\n right lateral ventricle. There is very slight leftward midline shift. The\\n basal cisterns and foramen magnum are patent. There is stable layering of\\n hemorrhage within the left lateral ventricle.\\n\\n There is a left scalp fluid collection measuring 6.3 x 1.3 cm. This has\\n increased in size in the interval. There is a stable right scalp fluid\\n collection at the operative site. Patient is status post right parietal\\n craniotomy.\\n\\n IMPRESSION:\\n\\n 1. Stable appearance of the head from one day prior.\\n\\n 2. Enlarged left scalp fluid collection.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2200-08-11 00:00:00.000\",\n \"description\": \"CTA HEAD W&W/O C & RECONS\",\n \"row_id\": 838424,\n \"text\": \" 11:56 PM\\n CTA HEAD W&W/O C & RECONS; -59 DISTINCT PROCEDURAL SERVICE Clip # \\n CT 100CC NON IONIC CONTRAST; -59 DISTINCT PROCEDURAL SERVICE\\n Reason: R/O AVM or anuerysm\\n Contrast: OPTIRAY Amt: 100\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old man with large right temporal parietal bleed\\n REASON FOR THIS EXAMINATION:\\n R/O AVM or anuerysm\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n CT ANGIOGRAPHY, \\n\\n INDICATION: Large right temporal lobe hemorrhage, rule out AVM or aneurysm.\\n\\n TECHNIQUE: Dynamically-acquired contrast-enhanced CT scans through the brain\\n were obtained for acquisition of a CT angiogram of the circle of . The\\n superior cervical portion of the vasculature is also included. Two\\n dimensional reformatted images are provided for evaluation.\\n\\n Comparison is made to the previous CT scan of the brain from .\\n\\n FINDINGS: There is a large hematoma expanding the right temporal lobe and\\n elevating the Sylvian branches of the right middle cerebral artery. This is\\n grossly unchanged since the previous CT scan.\\n\\n The right lateral ventricle is flattened and the left lateral ventricle is\\n mildly dilated due to right to left subfalcian herniation. The basal\\n cisternal spaces are narrowed as the medial right temporal lobe is medially\\n displaced.\\n\\n CT angiographic images demonstrate displacement of vessels around the hematoma\\n but no abnormal vascularity is detected. Additionally, no aneurysms are\\n detected within the right internal carotid artery or middle cerebral arterial\\n branches.\\n\\n IMPRESSION:\\n\\n CT angiography reveals no vascular abnormality to explain the presence of\\n a right temporal lobe hematoma. Conventional angiography should be\\n considered for further evaluation.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2200-08-12 00:00:00.000\",\n \"description\": \"SEL CATH 3RD ORDER THOR\",\n \"row_id\": 838428,\n \"text\": \" 2:37 AM\\n CAROT/CEREB Clip # \\n Reason: HEADACHES\\n Contrast: OPTIRAY Amt: 308\\n ********************************* CPT Codes ********************************\\n * SEL CATH 3RD ORDER SEL CATH 2ND ORDER *\\n * -59 DISTINCT PROCEDURAL SERVICE SEL CATH 2ND ORDER *\\n * -59 DISTINCT PROCEDURAL SERVICE ADD'L 2ND/3RD ORDER *\\n * ADD'L 2ND/3RD ORDER ADD'L 2ND/3RD ORDER *\\n * CAROTID/CEREBRAL BILAT CAROTID/CEREBRAL BILAT *\\n * EXT CAROTID BILAT VERT/CAROTID A-GRAM *\\n * VERT/CAROTID A-GRAM -59 DISTINCT PROCEDURAL SERVICE *\\n ****************************************************************************\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL HISTORY:\\n Intracerebral hemorrhage.\\n\\n TECHNIQUE:\\n Informed consent was obtained from the patient and the patient's family after\\n explaining the risks, indications and alternative management. Risks explained\\n included stroke, loss of vision and speech, temporary or permanent, with\\n possible treatment with stent and coils if needed.\\n\\n The patient was brought to the Interventional Neuroradiology Theater and\\n placed on the biplane table in supine position. Both groins were prepped and\\n draped in the usual sterile fashion. Access to the right common femoral artery\\n was obtained using a 19-gauge single wall needle, under local anesthesia using\\n 1% lidocaine mixed with sodium bicarbonate and with aseptic precautions.\\n Through the needle, a 0.35 wire was introduced and the needle taken\\n out. Over the wire, a 5 Fr vascular sheath was placed and connected to a\\n saline infusion (mixed with heparin 500 units in 500 cc of saline) with a\\n continuous drip. Through the sheath, a 4 Fr Berenstein catheter was introduced\\n and connected to continuous saline infusion (with mixture of 1000 units of\\n heparin in 1000 cc of saline).\\n\\n The following blood vessels were selectively catherized, and arteriograms were\\n performed from these locations.\\n\\n right common carotid artery:\\n\\n right internal carotid artery:\\n\\n right external carotid artery:\\n\\n left common carotid artery:\\n\\n left internal carotid artery:\\n\\n left external carotid artery:\\n\\n left vertebral artery:\\n\\n (Over)\\n\\n 2:37 AM\\n CAROT/CEREB Clip # \\n Reason: HEADACHES\\n Contrast: OPTIRAY Amt: 308\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n right vertebral artery.\\n\\n Evaluation of the right common carotid artery, right internal carotid artery,\\n right external carotid artery, left common carotid artery, left internal\\n carotid artery, left external carotid artery, left vertebral artery and right\\n vertebral artery demonstrates no evidence of vascular malformation or\\n aneurysm. Normal flow is noted in the intracranial circulation. No significant\\n atherosclerotic stenosis noted in the carotid bifurcation.\\n\\n IMPRESSION: No evidence of aneurysm or vascular malformation.\\n\\n Mild-to-moderate vasospasm noted in the right and middle cerebral artery\\n branches and posterior cerebral artery branch may be related to hemorrhage.\\n\\n If clinically warranted a followup angiogram may be performed in six weeks\\n after the hemorrhage has resolved to exclude subtle abnormalities.\\n\\n\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2200-08-12 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 838465,\n \"text\": \" 9:30 AM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: s/p right craniotomy for evacuation of hemorrhage\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old man s/p fall\\n\\n REASON FOR THIS EXAMINATION:\\n s/p right craniotomy for evacuation of hemorrhage\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: S/P right craniotomy for evacuation of hemorrhage.\\n\\n COMPARISON: \\n\\n TECHNIQUE: Non-contrast head CT.\\n\\n HEAD CT WITHOUT IV CONTRAST: There has been interval evacuation of the\\n previously identified right temporoparietal intraparenchymal hemorrhage with\\n interval development of gas within the right frontal, temporal, and parietal\\n lobes. Minimal high density material is seen within these areas suggestive of\\n residual blood. The previously seen uncal herniation has resolved. There\\n continues to be mass effect upon the adjacent right lateral and frontal\\n ventricle with minimal right to left subfalcine herniation, much improved\\n since the prior study. A right parietal craniotomy defect is demonstrated.\\n There is partial opacification of the ethmoid, sphenoid, and maxillary sinuses\\n bilaterally.\\n\\n IMPRESSION: Interval evacuation of large right temporoparietal\\n intraparenchymal hemorrhage with resolution of uncal herniation and\\n improvement in right to left subfalcine herniation. Interval development of\\n pneumocephalus within the area of prior hemorrhage. Small amount of residual\\n blood is seen within the right temporoparietal lobe.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2200-08-13 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 838614,\n \"text\": \" 12:48 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval tip position & r/o PTX\\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old man s/p a fall with ICH and evacuation of hematoma, s/p L SCV line\\n plaqcment\\n REASON FOR THIS EXAMINATION:\\n eval tip position & r/o PTX\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 56 year old man status post fall, intracranial hemorrhage, left\\n subclavian vein placement.\\n\\n TECHNIQUE: Portable AP chest radiograph. Comparison is made with the\\n previous chest radiograph dated , 9:00AM.\\n\\n FINDINGS: The tip of the left subclavian line is terminating in the SVC.\\n There is no pneumothorax. Endotracheal tube and NG tube are unchanged\\n compared with the previous study.\\n\\n The heart is mildly enlarged in size.\\n\\n There is infiltration in left lower lobe, most likely representing atelectasis\\n vs. pneumonia. There is a new focal opacity in the left upper lobe, which can\\n represent either pneumonia, aspiration, or edema.\\n\\n The right lung is clear.\\n\\n There is no evidence of pleural effusion on chest radiograph.\\n\\n IMPRESSION: Continued left lower lobe infiltration with increased left upper\\n lobe infiltration, which can represent pneumonia vs. aspiration.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2200-08-13 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 838620,\n \"text\": \" 1:43 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: ? change\\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old man s/p fall with ICH, s/p evacuation of hematoma\\n\\n REASON FOR THIS EXAMINATION:\\n ? change\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n NONCONTRAST HEAD CT:\\n\\n INDICATION: Status post fall with ICH, status post evacuation of hematoma,\\n please evaluate status.\\n\\n TECHNIQUE: Noncontrast head CT.\\n\\n COMPARISON: Noncontrast head CT of and .\\n\\n FINDINGS: In the area of the previously evacuated right temporoparietal\\n intraparenchymal hemorrhage, there is pneumocephalus and trace areas of high\\n density suggestive of residual blood. Additionally, there is pneumocephalus in\\n the right frontal region. These findings show no change from the previous\\n study. There continues to be mild mass effect upon the adjacent right lateral\\n and frontal ventricle, with no change from the previous study. On the current\\n study, however, due to technical factors during scanning, there is poor\\n visualization of the /white interface, which drastically reduces the\\n ability of this study to be accurately interpreted. If clinically indicated,\\n recommendation is made to repeat the scan.\\n\\n IMPRESSION: Extremely limited study due to technical factors during scanning\\n resulting in extensive blurring of the /white interface. Despite these\\n limitations, there is an apparent stable appearance of the drainage bed with\\n no significant change in amount of pneumocephalus or residual blood. However,\\n a repeat scan is hightly recommended due to the low quality of this scan. Dr.\\n covering for referring clinician was paged and given this\\n recommendation.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2200-08-13 00:00:00.000\",\n \"description\": \"T-SPINE\",\n \"row_id\": 838624,\n \"text\": \" 2:10 PM\\n T-SPINE; L-SPINE (AP & LAT) Clip # \\n Reason: ? fx or dislocation\\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old man s/p a fall with ICH\\n REASON FOR THIS EXAMINATION:\\n ? fx or dislocation\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Fall. Pain.\\n\\n These two exams consist of AP and lateral views of the thoracic and lumbar\\n spine (five images). Normal vertebral body alignment. No fracture identified\\n and normal discs. The hips and SI joints are normal. Incidentally noted is\\n prominent enthesopathy at multiple sites. Tip of NG tube in distal stomach\\n and right inguinal blood access line, tip lying in iliac vessel. Normal bowel\\n gas pattern and no ascites. Instantly noted is air space disease in the left\\n mid and lower lungs with air bronchograms. ETT and left subclavian line\\n satisfactorily positioned.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2200-08-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1364609,\n \"text\": \"ASSESSMENT AS NOTED\\n\\nNEURO: FOLLOWS, ANSWERS QUESTIONS, DISORIENTED IN TIME/PLACE(TELLS HE IS IN WEREHOUSE), KNOWS HIS FAMILY. IS SLOW AND UNCLEAR AT TIMES. L ARM POSTURES. R SIDE IS STRONG. STRONG COUGH. REMAINS IN CER COLLAR. CON'T ON MANNITOL AND DILANTIN. NO SEIZURE ACTIVITY\\nNO SEDATION WAS GIVEN. DENIES PAIN\\n\\nRES: COUGHING AND SWALOWING SECRETIONS, LS CLEAR/COARSE , ON RA 100%\\n\\nCV: TRYING TO MAINTAIN 140-160 SBP, ON LOPRESSOR, HYDRALAZINE. GOT 500CC BOLUS(WAS NEG TOO MUCH )\\n\\nGU: 100-50 CC/H CLEAR\\n\\nGI: AT THGE GOAL 85 CC/H T. FEED. FREQUENT STOOLING-FORMED\\n\\nID/LABS: LOW GRADE TEMP, WBC DOWN TO TODAY. K WAS REPLETED\\n BS DOWN TO 109 IN AM- COVERAGE BY RISS.\\n\\nSOCIAL: FAMILY IN LAST NIGHT\\n\\nA: ALTERATION IN NEURO STATUS\\n\\nP: WEAN OFF TRANSFER TO STEPDOWN OR FLOOR. MAINTAIN SBP<160\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2200-08-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1364610,\n \"text\": \"TSICU NPN (0700-1900)\\nREVIEW of SYSTEMS\\n\\nNeuro....Dozing off and on for most of day. Awakens to voice or light stimuli. When awake, light voice, but answers questions and follows commands. Moves R sided extremities with good strength and purposefully. L leg moves slightly on bed--withdrawl. Extnesor posturing with LUE. R pupil slightly smaller than L, but both briskly reactive. CT OF HEAD today--per Dr. . Mannitol stopped. Continues on dilantin with no seziure activity noted. OOB to chair for almost 4 hours. Tolerated well. No c/o pain.\\nFlexion/Extension x-rays done. Not cleared yet per Dr. . J collar remains on.\\n\\nCV....NSR with no ectopy noted. HR 80-90's. Goal SBP <160 per Dr. . On lopressor and hydralazine PO--scheduled. BP ranging 160-130/60-70's. PRN lopressor dose available if needed. Two peripheral IV's started. L SC TLC dc'd. Dr. did not want tip cultured.\\n\\nRESP...Stable on RA with sats >94%. Lung fields coarse bilateral upper lobes with diminsihed bases. Strong congested cough--minimally productive thought. NT suctioned x1 this afternoon with moderate amts of thick yellow secretions returned.\\n\\nGI....Promote with fiber TF's remain at goal of 85cc/hr. Tolerating well. No BM today, but multiple stools overnight. Abd soft with active BS.\\n\\nGU....Foley to gravity with adequate clear yellow urine. Lytes stable.\\n\\nENDO...Blood sugars peaked at 406, noon. Given 12U regular and 8U NPH. No effect seen 1hr later. Started on insulin drip--requiring up to 12U/hr in order to bring sugars down. Dropped quickly when NPH peaked, down to 75. 1/2 amp D50 given at 1700. Will continue to check frequently.\\n\\nHEME...HCT stable. Heparin subq and pneumo boots on.\\n\\nID...Tmax 99.9. Levofloxacin coverage on board. TLC dc'd.\\n\\nSKIN...Staples to incision on head with no redness or drg note. Poor dentation with loose teeth noted. Backside intact.\\n\\nSOCIAL... son and daughter in earlier today. Updated on pt's condition and plan of care. Not aware of events with blood sugars.\\n\\nPLAN...Pt is possible bump to neuro step down floor if necessary. Would like to keep pt here overnight d/t sugar issues unless bed issues arise. Swallow study ordered for tomorrow. ??Check into flex-ex films tomorrow. Needs encouragement with pulmonary toilet. SBP around 160. Montior blood sugars.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2200-08-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1364611,\n \"text\": \"nsg note:\\nneuro moving t side to command lt side posturing very spastic answers questions simply slightly confused knows hes in a hospital. cv stable tol lopressor and hydralazine. hr nsr\\n\\nresp sats adequate, congested spont cough breathsounds coarse.\\n\\ngi tol tube feeds at goal. given insulin per sliding scale. one lg bm\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2200-08-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1364612,\n \"text\": \"TRAUMA ICU NURSING PROGRESS NOTE\\nSEE TRANSFER NOTE....AWAITING BED.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2200-08-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1364606,\n \"text\": \"TSICU Nursing Progress Note\\nNeuro - Less alert most of today. Opening eyes occasionally to voice. Localizes with left arm with suctioning, stimulation. Right arm with extensor posturing. Moves bilateral LE right>left. Pupils unequal, reactive. Impaired gag, strong cough.\\n\\nCV - Tachycardic to 100s despite increased Metoprolol. No ectopy noted. Hypertensive requiring PRN Metoprolol, hydralyzine and fentanyl. Dosing antihypertensives by , underdamped. Neurosurgery wants SBP < 150 at all times. Added lasix. K repleated.\\n\\nPulm - Extubated today. Tolerating 3L NC with face tent for humidification. Strong cough, productive of thick yellow sputum.\\n\\nGI - OGT discontinued in preparation for extubation. Small bore feeding tube placed, currently in stomach. Maintained NPO until tomorrow. Bowel sounds present, no BM.\\n\\nGU - Diuresing well with lasix, mannitol.\\n\\nSkin - No areas of pressure, breakdown.\\n\\nA - Hypertensive s/p bleed. Tolerating extubation .\\n\\nP - Maintain SBP< 150 per . Aggressive pulmonary toilet, oral care.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2200-08-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1364607,\n \"text\": \"ASSESSMENT AS NOTED\\n\\nNEURO: FOLLOWS SIMPLE COMMANDS, L. ARM POSTURES. UNCLEAR . ANSWERS QUESTIONS Y/N. STILL IN CERVICAL COLLAR, NO SEIZURE ACTIVITY\\nCON'T ON DILANTIN AND MANNITOL\\n\\nRES: STRONG PROD. COUGH, MAINTAINS S02>9% ON COOL AIRSOLE TENT 35% AND NC2L, LS COARSE T/0.\\n\\nCV: GOAL TO MAINTAIN SBP 140-160, UNABLE TO CONTROL WITH LOPRESSOR AND HYDRALAZINE AND LABETALLOL GTT WAS STERTED DURING THE NIGHT WITH GOOD SBP CONTROL., REMAINS IN NSR NO ECTOPY.\\nA-LINE IS WITH FLING, GOING BY CUFF.\\n\\nGI: UNREMARCABLE, + BS, FEEDING TUBE IS CLAMPED: WAITING FOR IT TO DROP INTO JEJUNO.\\n\\nGU: BRISK U/O WITH LASIX AND MANNITOL. ON DOSE OF 5MG ZAROXYLIN WAS GIVEN 2100 LAST NIGHT.\\n\\nLABS: K WAS REPLACED FOR 3.3, STILL WAITING FOR OSMO SINCE 4AM.\\n\\nSKIN :INTACT , INCISION INTACT\\n\\nSOCIAL: FAMILY IS IN ALL NIGHT IN AND OUT\\n\\nID : NO FEVER\\n\\nA: FALL, HEAD BLEED-->CRANI, SEVERE HTN\\n\\nP:CONTROL BP, NEURO, PULM TOILET\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2200-08-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1364608,\n \"text\": \"NSG NOTE:\\n\\nROS:\\n\\n CV:LOPRESSOR PO INCREASED,HYDRALIZINE IV ADDED,THEN CHANGED TO PO.SYS BP BELOW 170 ALL DAY,LABETALOL DC'D.CVP - TO 1.\\n\\n RESP:NOW ON 4L NP WITH SAT 99.HAS STRONG PROD COUGH,SWALLOWS ALL SPUTUM.\\n\\n NEURO:ANSWERS APPROPIATELY TO YES/NO QUESTIONS.DIFF TO UNDERSTAND WHEN HE SPEAKS IN SENTENCES.MOVES R ARM,LEG NORMALLY.\\nPOSTURES WITH L ARM,MOVES L LEG ON BED.PUPILS REACTING BRISKLY.\\nOOB IN CHAIR.\\n\\n GU:GOOD UO,DIURESING WITH 12N DOSE LASIX.\\n\\n GI:STARTED TF,PROMOTE WITH FIBER.GOAL 85,ON 60CC AT 4PM.\\n+ BS,NO STOOL\\n\\n ID:99+.\\n\\n ENDO:BS 188-189,GIVEN INSULIN AS ORDERED.\\n\\n SOCIAL:MULTIPLE FSMILY MEMBERS IN,WIFE IN MOST OF PM.\\n\\n PLAN:CAN TRANSFER TO 5 STEPDOWN UNIT.BED FACILITATOR AWARE.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2200-08-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1364604,\n \"text\": \"Nursing Progress Note.\\nPlease see CareVue for specifics.\\n\\nPt condition improved today.\\n\\nNeuro:\\nPt more alert today, moving Rt side spontaneously, lifting legs spont, shifting position, regarding examiner. Still has episodes where much less alert, rousing to stimuli. Has obeyed commands by squeezing and releasing Rt hand, although does not obey all times. Pupils still Lt > Rt. Fentanyl in CT scan to keep pt still. TLS cleared today. J remains insitu. Strong cough, occasional gag.\\nStill weaning mannitol.\\n\\nResp:\\nRemains on PSV 5/5 40%. Very thick secretions. Started on levofloxacin for same. Chest clear. ETT not rotated due to very loose teeth and risk of dislodging one. ETT is well secured.\\n\\nHemodynamically:\\nSR 80s, 90s when agitated. No ectopy. Weaned labetolol infusion off with additional oral metoprolol. Hydralazine very effective. Goal SBP 100-150. Peripherally warm and well pewrfused.\\n\\nEndocrine:\\nBetter control of sugers with tighter sliding scale, but has still needed coverage today.\\n\\nFluids:\\nNS with 20KCl to total input 75mls/hr.\\n\\nGI:\\nAbd soft, non distended.\\nTube feeds recommenced.\\n\\nID:\\nAfebrile. Levofloxacin commenced pending sputum cultures.\\n\\nRenal:\\nUrine output declining but still satisfactory.\\n\\nSkin:\\nEssentially intact. See CareVue. No new issues.\\n\\nSocial:\\nFamily very concerned that they have not yet had an update from team. Paged resident and NP, neithor available to speak with family. Social work involved. Also suggested family contact patient relations if they would like another outlet for their concern.\\n\\nPlan:\\nContinue to monitor.\\nPlan for extubation tomorrow.\\nContinued support for family.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2200-08-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1364598,\n \"text\": \"Admit note:\\n\\nUnwitnessed fall from standing position. Neurologicaly intact post fall. Approx 3 hrs after fall family was unable to arouse for dinner and called 911. Transported here. CT=>right tempral/parietal bleed with IPH and midline shift=> OR for evacuation of hematoma. 4 vessel angio negative, CTA head/neck = AVM\\n\\nROS:\\n\\nNeuro: Initially off propofol, would open eyes w/coughing. Right pupil consistanly 3 mm and brisk. Left pupil 3mm and fluctuates b/t sluggish to non reactive. Cough, gag, and corneal reflex's +. Withdraws to painfull stim. Propofol had to be restarted at 40 mcg/kg/min do to coughing against ETT. Bed in Reverse T- at 30 degreees. J collar on. Head midline. On dilantin 100mg q 8 hr. Manitol q 6hr. Crani dressing intact w/ scant amt of red drainage..\\n\\nCV: RSR no ectopy noted. S1S2. Initially was on labetalol. On admission to unit SBP 88. Labetalol turned off, later resumed and titrated to 1.5 mg/min to keep sbp <140 and > 100 ( ). Has right radial ABP line and right femoral (venous) cortis. Radial pulses palpable. DP and PT pulses w/doppler only. Right DP very difficult to auscultate w/doppler. CPK 1900's w/MB 13.\\n\\nResp: Orally intubated and on vent. Vent changed to SIMV 600x12, peep 5, PS 5, 40%. Breathing over vent w/RR of 14-22. Lung sound clear upper lung fields. Diminished and coarse in bases. Sx thick light green sputum. Sats 100%. ABGs WNL this AM. No resp distress noted, = rise and fall of chest\\n\\nGI: Oral sump to LCS draining bile colored fluid. Abd soft w/active Bowel sounds in all four quads af abd. Prophylactic protonix changed to H2 blocker.\\n\\nGU:Foley patent draining clear yellow urine in QS\\n\\nLabs: pending at this hour\\n\\nSocial: Here in working and staying w/daughter . Wife and other children living in (all are here)\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2200-08-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1364599,\n \"text\": \"Resp care\\nWeaned pt to minimal vent support today. ABG's acceptable, well oxygenated and ventilated. BS coarse. Sx mod-lg thick green secretions. Head CT done today, TLS films done. Results pending. Will follow.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2200-08-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1364600,\n \"text\": \"Nursing Progress Note: Please see CareVue for details.\\n\\nPt condition essentially stable today.\\n\\nEvents:\\nCT brain.\\nTLS films.\\nNew subclavian line placed.\\nFemoral line removed.\\n\\nOn exam,\\n\\nResp:\\nChest clear, occasionally coarse this am. Moving large tidal volumes >500mls. Weaned to Pressure Support 40%. Tolerating well, ABGs improved. Has strong cough, productive of thick greenish sputum. CXR taken. ETT is at 27cm, and was at 27cm at time of CXR.\\n\\nHemodynamically:\\nWeaned off labetolol infusion. Maintaining SBP within goal of 100-140mmHg. Occasional episodes of SBP mid 90s, spontaneously resolving. HR 80s, SR. Peripheries warming. Femoral line removed by Dr . Soft mass in Rt groin unchanged. New subclavian line in use. CVP 13.\\n\\nNeuro:\\nPropofol off except for scans and turns- coughs violently without. Poor exam. Rouses to stimuli, localizes with Rt arm to sternal rub, lifts both legs at knee, Rt more briskly than left, but with essentially equal strength. To nailbed stimuli, Lt arm rotates internally, moves laterally with elbow bent (unchanged). Pupils: Lt>Rt, Rt reactive, Lt sluggish at best. Slight left gaze, pt's head turns to Lt. Corneals present, blink to threat absent. J collar in situ. Surgical area swollen, dressing intact. No new ooze. Mannitol q6 according to osm and Na.\\n\\nEndocrine:\\nCovered with regular insulin per sliding scale.\\n\\nFluids:\\nNS with 20meq KCl at 75/hr.\\n\\nGI:\\nABd soft, non distended, bowel sounds present. OGT to suction with bilious output. For commencement of tube feeds. GI prophylaxis being reviewed in light of pt's history of thrombocytopenia.\\n\\nID:\\nLow grade fever only. Antibiotics complete.\\nSputum culture sent.\\n\\nRenal:\\nGood urine output.\\n\\nSkin:\\nIntact except for surgical wound and forehead lac.\\nPt has very poor dentition and loose teeth, shown to team.\\n\\nSocial:\\nFamily here. Daughter and wife updated by physician. discarded by family.\\n\\nPlan:\\nContinue to monitor.\\nFollow up TLS films.\\nTube feeds.\\nPossible extubation tomorrow.\\nContinued support for family.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2200-08-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1364601,\n \"text\": \"Respiratory Care:\\nPt. continues on minimal level vent support. ABG's well oxygenated with normal range acid-base. B/S with scattered rhonchi>>ETS small to moderate, thick, green. Foul smelling oral secretions. RSBI was 42 this a.m.. Started on SBT. Will follow.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2200-08-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1364605,\n \"text\": \"NPN\\nN: PT NOT THOUGH PURPOSEFUL WITH RUE TOWARDS GROIN & ETT. BRISKLY LOCALIZES WITH RUE TO STERNAL RUB. LIFTS/HOLDS WITH RUE/RLE. WEAK WITHDRAWAL OF LLE. LUE WITH OCC WITHDRAWAL AND OCC EXTENSOR POSTURING NOTED. PUPILS UNEQUAL. OD 2MM/BRISK. OS 3MM/SLUGGISH. STRONG COUGH/IMPAIRED GAG. +CORNEALS. DILANTIN LEVEL 14. RESTLESS AT TIMES PULLING AT RESTRAINTS/SHIFTING WEIGHT IN BED. GIVEN FENTANYL WITH SOME EFFECT PRN. CONT MANNITOL.\\nCV: HYPERDYNAMIC AND REQUIRING INCREASED DOSES OF LOPRESSOR AND USE OF PRN LOPRESSOR/HYDRALAZINE. ALINE WITH SOME FLING. NBP CYCLING AND TREATING BP PER NBP. K REPLETED.\\nR: LUNGS OCC COURSE. CLEARS WITH SXN. SXN'D FOR SM AMT THICK TAN. ABG WNL. VENT SETTINGS UNCHANGED.\\nGI: ABD SOFT/DISTENDED WITH +BS. TF OFF AT 4AM FOR PROBABLE EXTUBATION. NO STOOL.\\nGU: CLEAR YELLOW URINE DRAINING VIA FOLEY IN GOOD AMTS.\\nHEME: HCT STABLE\\nID: TMAX 100. WBC 15.9\\nENDO: GLUCOSE TREATED PER RISS.\\nSOC: PT'S DAUGHTER CAME IN LAST EVENING AND GIVEN UPDATE. DAUGHTER VOICING CONCERN.\\nA/P: EXTUBATE IF ABLE TODAY.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2200-08-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1364602,\n \"text\": \"ROS:\\n\\nNeuro: Has periods where he is more alert then other times. When he is more alert has eyes open spontaniously and has protective blink reflex. + cough,gag, and corneal reflexes. Pupils = to un= w/left pupil brisk,slugish, to nonreactive, see careview for complete neuro assessment. Bed in Reverse T-. j collar on. Head midline. Dilantin level 16, receiving dilantin 100mg q 8 hr and manitol 25 Gm q 6 hr. Serum osmo trending up as well as Na+. Fentanyl for ? pain.\\n\\nResp: Remains orally intubated and on vent. Resp assessment as noted above in RT's note.\\n\\nCV: RSR no ectopy noted. S1S2. Has right radial ABP line and left subclavian MML w/distal port transduced for cvp=8->12. Radial pulses strong and =. DP & PT dopplerable only. Right groin line site clean dry and intact. Right groin lump unchanged. Labatolol on/off this shift to maintain SBP < 140. Metoprolol 12.5mg via ng initiated.\\n\\nGI: Oral gastric tube w/TF infusing at 30cc/hr w/minimal residuals. Abd soft w/active bowel sounds thoughout.\\n\\nGU: Foley patent draining clear yellow urine in QS\\n\\nLabs: Stable\\n\\nSocial: Children and spouse present this shift for support.\\n\\nPlan: BP management. ? extubate.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2200-08-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1364603,\n \"text\": \"resp care\\npt remains intubated and mech ventilated. pt currently on cpap+ps 5/5 - tol well. b/s coarse, sc rhonchi. sxn thk yel>>green secretions. pt tx to/from ct scan w/o incident. plan: cont w/mech support. ? extubation tomorrow.\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2200-08-17 00:00:00.000\",\n \"description\": \"C-SPINE FLEX AND EXT ONLY 2 VIEWS\",\n \"row_id\": 839022,\n \"text\": \" 12:42 PM\\n C-SPINE FLEX AND EXT ONLY 2 VIEWS Clip # \\n Reason: eval c spine for instability\\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56M s/p trauma, SDH\\n REASON FOR THIS EXAMINATION:\\n eval c spine for instability\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 56 year old man status post trauma. Evaluate C-spine for stability.\\n\\n CERVICAL SPINE FOUR VIEWS. There is no prevertebral soft-tissue swelling.\\n There is no evidence of fracture. The cervical vertebral bodies are in normal\\n alignment without loss of body or disc height. However, C6, C7 and T1 are not\\n well visualized. Alignment is stable in flexion and extension views.\\n\\n IMPRESSION: No cervical spine fracture. Stable alignment in flexion and\\n extension. Somewhat limited study due to poor visualization of C6, C7 and T1.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2200-08-17 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 839021,\n \"text\": \" 12:37 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: eval interval changes. please coordinate schedule with flex\\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56M with SDH s/p evac\\n REASON FOR THIS EXAMINATION:\\n eval interval changes. please coordinate schedule with flex-ext films\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 56-year-old male status-post evacuation of subdural hemorrhage.\\n\\n COMPARISON: .\\n\\n TECHNIQUE: Noncontrast head CT.\\n\\n FINDINGS: There are post-operative changes of right parietotemporal\\n craniotomy. There are again noted encephalomalacic changes in the right\\n temporoparietal region. There is slight decrease in the amount of air. There\\n is no new hemorrhage. There is again noted a hyperdense foci in the right\\n temporal lobe that is unchanged when compared to the previous studies, and may\\n represent blood. The ventricles are unchanged in size. There is still a\\n small amount of blood in the occipital of the left lateral ventricle.\\n There is again noted a very slight leftward midline shift, which is unchanged\\n when compared to the prior study. The left scalp fluid collection is\\n resolved.\\n\\n IMPRESSION\\n\\n 1. There is no evidence of new hemorrhage.\\n 2. Interval decrease in the pneumocephalus.\\n 3. Resolved left scalp fluid collection.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2200-08-19 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 839278,\n \"text\": \" 8:14 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: post dophouf placement\\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old man s/p a fall with ICH and evacuation of hematoma, s/p L SCV\\n line plaqcment\\n REASON FOR THIS EXAMINATION:\\n post dophouf placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Dobbhoff and left subclavian central venous line placement.\\n\\n : Comparison is made to . Dobbhoff tubing is looped\\n in the distal esophagus with the tip not visualized, but likely in the upper\\n neck or oropharynx. This needs to be repositioned. Note is made of likely\\n external tubing overlying the left clavicular region. This is not in the\\n region expected for a left subclavian central venous line. The patient's\\n previous left subclavian central venous line has been removed. There is patchy\\n left lower lobe atelectasis.\\n\\n IMPRESSION: Dobbhoff coiled in distal esophagus with tip likely in upper neck\\n or oropharynx. This needs to be repositioned. Note is made that the patient\\n has had multiple subsequent prior films which show repositioning of the tube.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2200-08-20 00:00:00.000\",\n \"description\": \"VIDEO OROPHARYNGEAL SWALLOW\",\n \"row_id\": 839357,\n \"text\": \" 1:51 PM\\n VIDEO OROPHARYNGEAL SWALLOW Clip # \\n Reason: please eval swallow function per speech and swallow\\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56M s/p trauma, SDH\\n\\n REASON FOR THIS EXAMINATION:\\n please eval swallow function per speech and swallow\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 56 year old man status post trauma and subdural hematoma\\n presenting for swallowing function evaluation.\\n\\n COMPARISONS: None.\\n\\n TECHNIQUE: The study was performed in conjunction with the speech\\n pathologist. Various consistencies of barium were administered orally. The\\n study was recorded on a video tape.\\n\\n FINDINGS: The patient exhibited weakness of the oral musculature and bolus\\n control. There was some spillover of thick and thin liquids into the\\n hypopharynx. There was poorly timed airway closure with moderate aspiration\\n with thin liquids. There was also trace aspiration with nectar thick liquids\\n intermittently, which cleared, and was improved with the chin tuck technique.\\n Please see the report of the speech pathologist for further details.\\n\\n IMPRESSION: Moderate aspiration with thin liquids, intermittent trace\\n aspiration with thickened liquids with adequate clearance.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2200-08-19 00:00:00.000\",\n \"description\": \"BILAT LOWER EXT VEINS\",\n \"row_id\": 839227,\n \"text\": \" 1:06 PM\\n BILAT LOWER EXT VEINS Clip # \\n Reason: CEREBRAL ANEURYSM, R/O DVT\\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old man with cerebral hemorrhage\\n REASON FOR THIS EXAMINATION:\\n r/o dvt\\n ______________________________________________________________________________\\n FINAL REPORT\\n EXAMINATION: Bilateral lower extremity venous Doppler ultrasound.\\n\\n INDICATION: 56 year old man with cerebral hemorrhage and suspicion for DVT.\\n\\n COMPARISON: None.\\n\\n FINDINGS: Doppler son were performed of the left and right common\\n femoral veins, superficial femoral veins, popliteal veins. All vessels showed\\n normal flow, augmentation, compressibility, and respiratory variation.\\n Intraluminal thrombus is not identified.\\n\\n IMPRESSION: No evidence for deep vein thrombosis in either lower extremity.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2200-08-19 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 839283,\n \"text\": \" 9:56 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: second dophouf placement at 75cm\\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old man s/p a fall with ICH and evacuation of hematoma, s/p L SCV\\n line plaqcment\\n REASON FOR THIS EXAMINATION:\\n second dophouf placement at 75cm\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATIONS: Dobhoff repositioning.\\n\\n PORTABLE AP CHEST: Comparison is made to the study from two hours earlier. The\\n Dobbhoff tube has been repositioned, and there is a loop of tubing in the\\n stomach, but the Dobbhoff tip is back in the distal esophagus, above the GE\\n junction. This needs to be repositioned. The heart and lungs are unchanged.\\n The previously seen tubing overlying the left clavicular region is no longer\\n present.\\n\\n IMPRESSION: Dobbhoff tubing looped in stomach but tip is in the distal\\n esophagus, above the GE junction, requiring repositioning.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2200-08-15 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 838824,\n \"text\": \" 10:04 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ? tube feed placement\\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old man s/p a fall with ICH and evacuation of hematoma, s/p L SCV\\n line plaqcment\\n REASON FOR THIS EXAMINATION:\\n ? tube feed placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Feeding tube placement check.\\n\\n FINDINGS: Single AP portable view of the chest show a feeding tube, with the\\n tip in the fundus. There is left lower lobe atelectasis/infiltrate. The left\\n upper lobe infiltrate persists. Right lung appears clear. The ETT and central\\n venous line remain in good position.\\n\\n IMPRESSION: Feeding tube in fundus of stomach. Otherwise no significant\\n interval change.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2200-08-19 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 839290,\n \"text\": \" 11:45 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: readjustment of second dobhouf. this is the third film \\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old man s/p a fall with ICH and evacuation of hematoma, s/p L SCV\\n line plaqcment\\n REASON FOR THIS EXAMINATION:\\n readjustment of second dobhouf. this is the third film tonight s/p adjustment\\n at 11:20pm\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Dobbhoff repositioning.\\n\\n PORTABLE AP CHEST: Comparison is made with the study from ,\\n approximately 2 hours earlier. The Dobbhoff tubing is now coiled in the\\n stomach in satisfactory position. There is residual patchy left lower lobe\\n atelectasis, but the appearance of the heart and lungs are unchanged.\\n\\n IMPRESSION: Successful Dobbhoff tube positioning, coiled in stomach.\\n\\n\\n\\n\"\n }\n]"}}},{"rowIdx":384,"cells":{"subject_id":{"kind":"number","value":55672,"string":"55,672"},"hadm_id":{"kind":"number","value":193172,"string":"193,172"},"target_text":{"kind":"string","value":"55 year old woman with history of EtOH abuse presenting following mechanical fall and traumatic T spine fracture. She was intubated at an outside hospital for unclear etiology and was transferred while intubated. # Respiratory failure and Ventilator Associated PNA: Upon transfer, the patietn was already intubated for initial unclear etiology. With further evaluation, the cause was likely multifactorial and she was found to have a significant pneumonia soon after transfer. Initial blood and sputum cultures were negative. Given poor status, patient was started on Vancomycin, Aztreonam, Flagyl and Levofloxacin. Metronidazole was discontinued. Aztreonam was discontinued. Levofloxacin was discontinued. During this time, she continued to be diuresed and had stress-dose steroids and required vasopressor support. Interventional Pulmonology was consulted to perform bronchoscopy and provide further information regarding difficulty in weaning patient and BAL was performed on . The pansensitive KLEBSIELLA OXYTOCA and KLEBSIELLA PNEUMONIAE grew from BAL. She was optimized with inhalers including Albuterol and Ipratroprium. She continued to be of a marginal respiratory status and given failure to wean from the vent, she underwent tracheostomy on . On she was restarted on Vancomycin 1000 mg IV Q 12H, Aztreonam mg IV Q8H, and Levofloxacin 750 mg IV Q24H for concern for recurrent VAP and aspiration. Aztreonam and Vancomycin were stopped on . On Levofloxacin was changed to Ceftriaxone. Ceftriaxone was discontinued . Given concern for recurrent aspiration, ENT was consulted to evaluate the patient. On VC exam, revealed an inability to adduct the true vocal cords posteriorly, raising concern for high aspiration risk. Despite this, from that point on, Ms. has continued to improve and has tolerated her tubefeeding with minimal residuals. She continues to have intermittent mucous plugging with appropriate desaturations, but these resolve with deep suctioning. the patient had further evaluation for Passe-Muir valve. They left the following recommendations including always deflate cuff prior to placing the Passy-Muir valve; monitor O2 Sats / respiration while valve is in place; do not allow the patient to sleep with the valve in place; patient must be supervised wtih valve in place; and requires frequent suctioning via yankauer with PMV in place. Ultimately, the PMV wear schedule is up to the discretion of then nurse and/or respiratory therapist. Scopalomine was started to decrease secretions but was later discontinued due to possible etiology of delirium. # Hypotension. Patient was hypotensive upon presentation and throughout a large portion of her hospital course. This was intially concerning for hypovolemia and she was responsive to transfusion. There was also concern for sepsis, and she was treated with broad spectrum antibiotics as above. Ultimately, she was successfully weaned from her pressor support on ."},"extractive_notes_summ":{"kind":"string","value":"REASON FOR THIS EXAMINATION: atelectasis vs edema FINAL REPORT HISTORY: Intubated with the recent desaturation. Right IJ catheter terminates in the superior vena cava. ETT terminates in the mid thoracic trachea. There is a 7.5 cm x 3.0 cm tubular fluid density (Over) 4:59 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST Reason: eval structures, bleeding, spinal cord impingement Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA Field of view: 42 Contrast: OPTIRAY Amt: 130 FINAL REPORT (Cont) structure in continuation with the cecum in the anticipated location of the appendix without adjacent inflammatory stranding. REASON FOR THIS EXAMINATION: eval for infiltrate, effusion PFI REPORT Unchanged right middle lobe and right lower lobe collapse and left lower lobe atelectasis. PORTABLE SUPINE ABDOMINAL RADIOGRAPH FINDINGS: Positioning of the J-tube is unchanged with contrast noted to have advanced antegrade into the mid to distal jejunum. Right basal atelectasis and small bilateral pleural effusions unchanged. Resolution of nonocclusive thrombus in the right axillary and basilic veins. Resolution of nonocclusive thrombus in the right axillary and basilic veins. FINAL REPORT INDICATION: History of upper extremity DVT and tachycardia. Compared to the previoustracing of sinus tachycardia with first degree A-V block has givenway to the current rhythm. Compared to the previous tracing of the A-V nodal re-entrant tachycardia is no longer present.TRACING #1 - wean FiO2 as tolerated - attempt wean PS today and hopeful for trach mask trial # Sedation: Continue to have issues with pain/delirium causing tachycardia and hypertension with intermittent hypotension. Deep Venous Thrombosis (DVT), Upper extremity Assessment: Heparin gtt off this am for possible trip to OR. ## Adrenal Insufficency: Minimal response to stim test again. Response: After 1 hr pt became tachycardic and tachypnic. Response: After 1 hr pt became tachycardic and tachypnic. - hydrocortt (day 1 = ), wean per endo recs # Hypotension: Likely adrenal insufficiency and sedation. INR is high and HCT is down; will hold coumadin and guiac stool, confirm BBS and check PM HCT. Bradycardia Assessment: Pt conts with HR 50-70s at rest, 100-140s during care, pt asymptomatic; easily arousable Action: Sedation decreased, Lasix off @0200 Response: HR 60 Plan: Cont to wean sedation, ?cardiac consult Deep Venous Thrombosis (DVT), Upper extremity Assessment: Action: Cont with IV Heparin @ 1500u/hr, Coumadin dcd for? Action: MD notified and valium PO continues. Action: MD notified and valium PO continues. # EKG changes: Sinus bradycardia, responsive to stress. Bradycardia Assessment: Pt conts with HR 50-70s at rest, 100-140s during care, pt asymptomatic; easily arousable Action: Sedation decreased, Lasix off @0200 Response: HR 60 Plan: Cont to wean sedation, ?cardiac consult Deep Venous Thrombosis (DVT), Upper extremity Assessment: Action: Cont with IV Heparin @ 1500u/hr, Coumadin dcd for? - Weaning FiO2 as tolerated # Tachycardia: Pt in ST 120s to 150s. - needs A-line for monitoring - cortisol stim to rule out persistent adrenal insufficiency # RUE DVT: Started on heparin gtt on , now off for trach that was planned for today. - Weaning FiO2 as tolerated # Tachycardia: Pt in ST 120s to 150s. Resp Failure Trach mask trials as tolerating (needing QHS support at present) PMV trials S/P rx for pan Klebs PNA. - Weaning FiO2 as tolerated # Tachycardia: Pt in ST 120s to 150s. - Weaning FiO2 as tolerated - Will attempt trach collar today # Sedation: Pt has pain/delirium causing tachycardia and hypertension with intermittent hypotension. - Weaning FiO2 as tolerated # Tachycardia: Pt in ST 120s to 150s. - Weaning FiO2 as tolerated # Tachycardia: Pt in ST 120s to 150s. - Weaning FiO2 as tolerated # Tachycardia: Pt in ST 120s to 150s. Today pt had a US of LUE to R/O DVT as a source of tachycardia. Today pt had a US of LUE to R/O DVT as a source of tachycardia. Today pt had a US of LUE to R/O DVT as a source of tachycardia. - wean PEEP as tolerated # # Adrenal Insufficency: Minimal response to stim test again. DVT: Treatment dose heparin Ulcer: Ranitidine VAP: Prevention per routine ICU Care Nutrition: Glycemic Control: Lines: PICC Line - 09:19 PM Arterial Line - 02:00 PM Prophylaxis: DVT: Stress ulcer: VAP: Comments: Communication: Comments: Code status: Full code Disposition: Belly: repeat LFTs, KUB OK, check residuals. Belly: repeat LFTs, KUB OK, check residuals. - wean PEEP as tolerated # # Adrenal Insufficency: Minimal response to stim test again. - hold heparin gtt when anticipate trach/peg # Adrenal Insufficency: Minimal response to stim test again. - hold heparin gtt when anticipate trach/peg # Adrenal Insufficency: Minimal response to stim test again. Vanc trough pending today - Also on flagyl for empiric coverage of c. diff - Per CT, unlikely to be abdominal process # Hypotension, requiring Levophed: - Hypovolemia is possibly a factor- responded to a transfusion; HCT had been dropping - Sepsis also a factor- on broad spectrum abs - Central line in place. Vanc trough pending today - Also on flagyl for empiric coverage of c. diff - Per CT, unlikely to be abdominal process # Hypotension, requiring Levophed: - Hypovolemia is possibly a factor- responded to a transfusion; HCT had been dropping - Sepsis also a factor- on broad spectrum abs - Central line in place. Plan: Titrate lasix gtt and sedation as tol by b/p restart levophed if b/p drops and remains low. Bradycardia Assessment: Pt conts with HR 50-70s at rest, 100-140s during care, pt asymptomatic; easily arousable Action: Sedation decreased, Lasix off @0200 Response: HR 60 Plan: Cont to wean sedation, ?cardiac consult Deep Venous Thrombosis (DVT), Upper extremity Assessment: Action: Cont with IV Heparin @ 1500u/hr Response: Pt therapeutic, cont with daily PTT Plan: Cont to labs, adjust per Heparin protocol Respiratory failure, acute (not ARDS/) Assessment: Pt cont on AC 18/400/50%/10, LS clear bilat, occ scat rhonchi Action: Pt suct for sm thin tan secretions Response: Plan: Cont to ABGs, Hypotension (not Shock) Assessment: SBP 140s when pt is agitated, SBP dropping to 70s-80s, UO 200/hr (total 2500 in 2hr) Action: Fent/Versed turned down @ 0000, Lasix gtt on hold, team informed Response: Pt SBPs in 80 Plan: Cardiac consult to further eval SB/ST, re-evalu cont. which lead to VAP most likely with GNR (by one sputum). which lead to VAP most likely with GNR (by one sputum). Action: Levophed gtt weaned off. Response: ABG WNL Plan: Cont to try to wean vent settings as tolerated, cont monitoring ABG Hypotension (not Shock) Assessment: SBP 90-110s MAP 62-66 Goal MAP >65 Levophed gtt @ 0.020 mcg/kg/min. Vanc trough pending today - Also on flagyl for empiric coverage of c. diff - Per CT, unlikely to be abdominal process # Hypotension, requiring Levophed: - Hypovolemia is possibly a factor- responded to a transfusion; HCT had been dropping - Sepsis also a factor- on broad spectrum abs - Central line in place. require further imaging # Transient hypotension: Has been somewhat fluid responsive; UOP ccs/hr. require further imaging # Transient hypotension: Has been somewhat fluid responsive; UOP ccs/hr. - f/u Cards recs # Sedation/Anxiolysis/AlteredMS: Resolved O/N with risperdal. - continue scopolamine patch q72hrs for secretions - Holding sedation with exception of Risperidal 0.5mg PRN - F/u CXR tomorrow # Sedation/Anxiolysis/AlteredMS: Resolved O/N with risperdal. - continue scopolamine patch q72hrs for secretions - Holding sedation with exception of Risperidal 0.5mg PRN - F/u CXR tomorrow # Sedation/Anxiolysis/AlteredMS: Resolved O/N with risperdal. # Sedation/Anxiolysis/AlteredMS: Resolved O/N with risperdal. # Sedation/Anxiolysis/AlteredMS: Resolved O/N with risperdal. # Sedation/Anxiolysis/AlteredMS: Resolving. A-FIB -- rate controlled on amioderone. Continue PT rehab. Scolpolamine patch d/cd d/t mental status. - CXR today - F/u cx data - If remains febrile, send sputum cx. # Fluid Status: Likely approaching euvolemia, though still has mild hypernatramia which may suggest is still intravascularly depleated. - f/u Cards recs # Sedation/Anxiolysis/AlteredMS: Resolved O/N. - f/u Cards recs # Sedation/Anxiolysis/AlteredMS: Resolved O/N with risperdal. - f/u Cards recs # Sedation/Anxiolysis/AlteredMS: Resolved O/N with risperdal. - f/u Cards recs # Sedation/Anxiolysis/AlteredMS: Resolved O/N. - f/u Cards recs # Sedation/Anxiolysis/AlteredMS: Resolved O/N. Today pt had a US of LUE to R/O DVT as a source of tachycardia. - CXR today - F/u cx data - If remains febrile, send sputum cx. # Fluid Status: Likely approaching euvolemia, though still has mild hypernatramia which may suggest is still intravascularly depleated. DVT and coagulopathy: reversed with IV Vit k hold coumadin today 4. DVT and coagulopathy: reversed with IV Vit k hold coumadin today 4. start PPN today if KUB + illeus Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin) Assessment: Tmax this shift 101.4 rectally Action: BC x2 sent and U/A C+S sent . # Code: Full # Dispo: ICU, Will d/w case management re rehab facilities. # Nutrition/Vomiting: Currently receiving TPN;. Will call and f/u psych recs. # UE DVT and elevated INR: Decision made to d/c Coumadin given her labile INR, and start Lovenox ."},"n_notes":{"kind":"number","value":703,"string":"703"},"notes":{"kind":"list like","value":[{"category":"Physician ","chartdate":"2167-10-14 00:00:00.000","description":"Physician Attending Progress Note","row_id":637511,"text":"Chief Complaint: resp failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n s/p t spine fx with resp failure\n 24 Hour Events:\n BLOOD CULTURED - At 02:18 AM\n SPUTUM CULTURE - At 02:18 AM\n URINE CULTURE - At 02:18 AM\n FEVER Pan cx\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Ceftriaxone - 12:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Atrovent/Albuterol, Miralax, Chlorhex, Ceftriaxone, Thiamine Folate\n Valium 5 mg QID COumadin 2.5\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fever\n Flowsheet Data as of 08:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.8\n Tcurrent: 37.2\nC (99\n HR: 137 (120 - 151) bpm\n BP: 125/55(73) {98/41(54) - 202/97(111)} mmHg\n RR: 23 (12 - 39) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,934 mL\n 497 mL\n PO:\n TF:\n 1,104 mL\n 447 mL\n IVF:\n 1,000 mL\n 50 mL\n Blood products:\n Total out:\n 530 mL\n 240 mL\n Urine:\n 530 mL\n 240 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,404 mL\n 257 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 318 (318 - 475) mL\n PS : 10 cmH2O\n RR (Spontaneous): 34\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 171\n SpO2: 98%\n ABG: ///32/\n Ve: 9 L/min\n Physical Examination\n Gen sitting up in , on trach mask, interactive\n CV tachy RRR\n Chest good air movement ANT\n Abd soft NT + NS\n Ext: no edema\n Neuro: alert follows simple commands\n Labs / Radiology\n 8.8 g/dL\n 306 K/uL\n 134 mg/dL\n 0.6 mg/dL\n 32 mEq/L\n 4.0 mEq/L\n 11 mg/dL\n 106 mEq/L\n 146 mEq/L\n 26.8 %\n 7.5 K/uL\n [image002.jpg]\n 03:10 AM\n 03:08 PM\n 03:00 AM\n 03:36 AM\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n 05:00 AM\n 02:06 AM\n WBC\n 11.3\n 7.3\n 6.1\n 7.2\n 5.2\n 5.9\n 7.5\n Hct\n 24.9\n 27.6\n 26.5\n 26.9\n 26.0\n 27.2\n 26.8\n Plt\n 227\n 189\n 209\n 238\n 240\n 296\n 306\n Cr\n 0.7\n 0.6\n 0.6\n 0.9\n 0.7\n 0.6\n 0.7\n 0.6\n TCO2\n 26\n Glucose\n 114\n 99\n 115\n 106\n 100\n 134\n 134\n Other labs: PT / PTT / INR:13.5/23.6/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:27/19, Alk Phos / T Bili:118/0.3,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:243 IU/L, Ca++:9.2 mg/dL, Mg++:2.1 mg/dL, PO4:4.0\n mg/dL\n - Sputum: 3+ GPC cocci in prs and chains\n yeast\n Assessment and Plan 55 yr old alcoholic s/p t spine fx s/p trcah and\n PEG with persistent resp failure\n 1. Resp Failure: currently on trach mask, can do a few hours per\n day, then needs for support. New pan Klebs in sputum, day\n . Re- try. Holding off on stent by IP until after pulm rehab.\n 2. Fevers: DDx - line infection VAP, check LFTs, check blood and\n urine cx, LUE ultrasounds -\n 3 Hemodynamics: persistant simus tachy\n check CTPA to look for\n emboli- has been off on anti coag - tachycardia with slightly decreased\n UOP\n bolus IVF and trend UOP. Watch to see if response with\n tachycardia.\n 4. Anti coag: for upper ext DVT but INR elevated on coumadin +\n quinolone\n repeat inr low- trend with po COumadin\n 5. Adrenal Insufficiency: proper stim this AM, off steroids\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 06:23 AM 60 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n"},{"category":"Physician ","chartdate":"2167-10-23 00:00:00.000","description":"Physician Attending Progress Note","row_id":639169,"text":"Chief Complaint: resp distress\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n UNPLANNED EXTUBATION (PATIENT-INITIATED) - At 03:50 PM\n Pt pulled out her trach tube, tube replaced\n FEVER - 101.4\nF - 12:00 AM\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Amiodarone - 0.5 mg/min\n Other ICU medications:\n Metoprolol - 01:00 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.4\n Tcurrent: 36.8\nC (98.2\n HR: 116 (84 - 142) bpm\n BP: 147/84(96) {86/39(53) - 181/113(137)} mmHg\n RR: 23 (13 - 27) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,127 mL\n 994 mL\n PO:\n TF:\n IVF:\n 2,127 mL\n 994 mL\n Blood products:\n Total out:\n 995 mL\n 900 mL\n Urine:\n 995 mL\n 900 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,132 mL\n 94 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: CPAP/PPS\n Vt (Set): 0 (0 - 0) mL\n Vt (Spontaneous): 360 (208 - 360) mL\n PS : 10 cmH2O\n RR (Set): 0\n RR (Spontaneous): 21\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 0 cmH2O\n SpO2: 99%\n ABG: ///31/\n Physical Examination\n Gen: lying in bed, alert, responding to questions, PMV placed\n CV; tachy RR\n Chest: bibasilar decreased BS, faint exp wheeze\n Abd: soft NT+BS\n Ext: no edema\n Skin: warm\n Neurologic: confused, stating that p[eople are trying to kill kill,\n that a owmna named is coming into her room\n Labs / Radiology\n 8.4 g/dL\n 346 K/uL\n 123 mg/dL\n 0.7 mg/dL\n 31 mEq/L\n 3.8 mEq/L\n 4 mg/dL\n 107 mEq/L\n 144 mEq/L\n 27.3 %\n 7.3 K/uL\n [image002.jpg]\n 02:58 AM\n 03:43 AM\n 05:02 PM\n 03:36 AM\n 02:30 AM\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n 03:00 AM\n WBC\n 7.1\n 7.1\n 6.9\n 7.6\n 9.5\n 5.7\n 7.3\n Hct\n 28.9\n 29.2\n 27.8\n 32.7\n 28.6\n 28.9\n 30.0\n 26.9\n 27.3\n Plt\n 462\n 452\n 467\n 548\n 528\n 356\n 346\n Cr\n 0.6\n 0.7\n 0.8\n 0.7\n 0.8\n 1.0\n 0.7\n 0.7\n Glucose\n 137\n 104\n 108\n 131\n 128\n 121\n 129\n 123\n Other labs: PT / PTT / INR:14.1/23.7/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.8 mg/dL, Mg++:1.9 mg/dL, PO4:3.7\n mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 06:31 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent:\n"},{"category":"Physician ","chartdate":"2167-10-23 00:00:00.000","description":"Physician Attending Progress Note","row_id":639171,"text":"Chief Complaint: resp distress\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n UNPLANNED EXTUBATION (PATIENT-INITIATED) - At 03:50 PM\n Pt pulled out her trach tube, tube replaced\n FEVER - 101.4\nF - 12:00 AM\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Amiodarone - 0.5 mg/min\n Other ICU medications:\n Metoprolol - 01:00 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.4\n Tcurrent: 36.8\nC (98.2\n HR: 116 (84 - 142) bpm\n BP: 147/84(96) {86/39(53) - 181/113(137)} mmHg\n RR: 23 (13 - 27) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,127 mL\n 994 mL\n PO:\n TF:\n IVF:\n 2,127 mL\n 994 mL\n Blood products:\n Total out:\n 995 mL\n 900 mL\n Urine:\n 995 mL\n 900 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,132 mL\n 94 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: CPAP/PPS\n Vt (Set): 0 (0 - 0) mL\n Vt (Spontaneous): 360 (208 - 360) mL\n PS : 10 cmH2O\n RR (Set): 0\n RR (Spontaneous): 21\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 0 cmH2O\n SpO2: 99%\n ABG: ///31/\n Physical Examination\n Gen: lying in bed, alert, responding to questions, PMV placed\n CV; tachy RR\n Chest: bibasilar decreased BS, faint exp wheeze\n Abd: soft NT+BS\n Ext: no edema\n Skin: warm\n Neurologic: confused, stating that p[eople are trying to kill kill,\n that a owmna named is coming into her room\n Labs / Radiology\n 8.4 g/dL\n 346 K/uL\n 123 mg/dL\n 0.7 mg/dL\n 31 mEq/L\n 3.8 mEq/L\n 4 mg/dL\n 107 mEq/L\n 144 mEq/L\n 27.3 %\n 7.3 K/uL\n [image002.jpg]\n 02:58 AM\n 03:43 AM\n 05:02 PM\n 03:36 AM\n 02:30 AM\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n 03:00 AM\n WBC\n 7.1\n 7.1\n 6.9\n 7.6\n 9.5\n 5.7\n 7.3\n Hct\n 28.9\n 29.2\n 27.8\n 32.7\n 28.6\n 28.9\n 30.0\n 26.9\n 27.3\n Plt\n 462\n 452\n 467\n 548\n 528\n 356\n 346\n Cr\n 0.6\n 0.7\n 0.8\n 0.7\n 0.8\n 1.0\n 0.7\n 0.7\n Glucose\n 137\n 104\n 108\n 131\n 128\n 121\n 129\n 123\n Other labs: PT / PTT / INR:14.1/23.7/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.8 mg/dL, Mg++:1.9 mg/dL, PO4:3.7\n mg/dL\n Assessment and Plan\n 1. Tachycardia: runs of attach Appreciate EP consult\n trying IV Amio.\n will increase bblocker. Have to convert to metoprolol 7.5mg IV Q4\n because unable to take pos.\n 2. Persistent Nausea/Vomiting: we have ruled out\n pSBO/SBO, very poor\n bowel sounds, tube study this AM shows contrast not moving out of the\n jejunum. GI consult to discuss any role for EGD. Place PICC for TPN as\n she has not had nutrition.\n 2. Resp Failure\n Trach mask trials all day, PSV\n PMV trials\n Per IP not stent planned as technically not possible to\n place into her airway\n 3. DVT and coagulopathy: reversed with IV Vit k\n hold coumadin today\n 4. Hypernatremia Replete free water.\n Please see today\ns ICU team note for other issues.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 06:31 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent:\n"},{"category":"Physician ","chartdate":"2167-10-29 00:00:00.000","description":"Physician Attending Progress Note","row_id":640089,"text":"Chief Complaint: Delerium\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Remains with delerium.\n Experienced episode of SVT --> responded to extra iv dose metoprolol.\n History obtained from Medical records\n Patient unable to provide history: Encephalopathy\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, Tube feeds, No(t) Parenteral nutrition\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, No(t) Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: No(t) Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 11:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.2\nC (97.2\n HR: 78 (61 - 115) bpm\n BP: 108/48(60) {91/36(50) - 156/79(101)} mmHg\n RR: 24 (17 - 30) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,952 mL\n 760 mL\n PO:\n TF:\n 646 mL\n 685 mL\n IVF:\n 950 mL\n 75 mL\n Blood products:\n Total out:\n 2,430 mL\n 610 mL\n Urine:\n 2,430 mL\n 380 mL\n NG:\n Stool:\n Drains:\n Balance:\n 522 mL\n 150 mL\n Respiratory support\n SpO2: 100%\n ABG: ///35/\n Physical Examination\n General Appearance: No(t) Well nourished, No acute distress, No(t)\n Overweight / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic,\n No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, Paradoxical), (Percussion:\n Resonant : , No(t) Hyperresonant: , No(t) Dullness : ), (Breath Sounds:\n Clear : , No(t) Crackles : , No(t) Bronchial: , No(t) Wheezes : , No(t)\n Diminished: , No(t) Absent : , No(t) Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\n Extremities: No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, No(t) Oriented (to): , Movement: Purposeful, No(t) Sedated,\n No(t) Paralyzed, Tone: Normal\n Labs / Radiology\n 7.2 g/dL\n 187 K/uL\n 105 mg/dL\n 0.5 mg/dL\n 35 mEq/L\n 3.8 mEq/L\n 17 mg/dL\n 108 mEq/L\n 147 mEq/L\n 23.7 %\n 5.1 K/uL\n [image002.jpg]\n 03:00 AM\n 04:00 AM\n 05:45 AM\n 03:51 AM\n 04:45 PM\n 04:00 AM\n 07:37 PM\n 04:05 AM\n 06:05 PM\n 03:23 AM\n WBC\n 7.3\n 8.0\n 8.7\n 5.5\n 5.7\n 5.8\n 5.1\n Hct\n 27.3\n 27.0\n 28.7\n 24.7\n 25.2\n 25.3\n 23.7\n 24.7\n 23.7\n Plt\n 346\n 316\n 271\n 249\n 231\n 203\n 187\n Cr\n 0.7\n 0.7\n 0.7\n 0.5\n 0.4\n 0.5\n 0.5\n 0.5\n Glucose\n 123\n 114\n 112\n 122\n 145\n 137\n 149\n 105\n Other labs: PT / PTT / INR:13.3/32.4/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.8 mg/dL, Mg++:2.1 mg/dL, PO4:3.5\n mg/dL\n Assessment and Plan\n T-spine fracture, delerium.\n DELERIUM -- persistent. Etiology may be related to prior EtOH use,\n contribution of medications. Intermittently oriented. Continue\n respiradol. Avoid medications that have psych complications or side\n effects.\n RESPIRATORY FAILURE -- s/p trach. Maintain trach for pulmonary\n toilet/frequent suctioning.\n TACHYCARDIA -- SVT. Continue amiodarone. Continue beta-blocker, with\n extra doses prn if needed.\n NUTRITIONAL SUPPORT -- TF via PEJ approaching goal.\n T-SPINE FRACTURE -- s/p fall. Tolerating back brace as per ortho\n service. Activity as tolerated (up in chair).\n ASPIRATION RISK -- poor adduction of vocal cords (post. portion).\n Eventually may require intervention.\n TRANCHEOBRONCHOMALACIA -- no interventions planned at present.\n ICU Care\n Nutrition:\n Replete with Fiber () - 09:45 PM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 55 minutes\n Patient is critically ill\n"},{"category":"Physician ","chartdate":"2167-09-24 00:00:00.000","description":"Physician Attending Progress Note","row_id":634562,"text":"Chief Complaint: respiratory failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n BLOOD CULTURED - At 12:24 AM\n URINE CULTURE - At 12:24 AM\n SPUTUM CULTURE - At 03:30 AM\n EKG - At 05:20 AM\n pt in junctional rhythem, holding stable BP, intern aware and came to\n assess pt. HR 47-50.\n Fever spike to 101\n Steroids started\n Antibiotics tailored\n PEEP decreased\n History obtained from Medical records, ICU team\n Patient unable to provide history: Sedated\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Metronidazole - 08:00 AM\n Levofloxacin - 08:39 AM\n Aztreonam - 06:00 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 100 mcg/hour\n Other ICU medications:\n Midazolam (Versed) - 03:50 PM\n Fentanyl - 03:50 PM\n Ranitidine (Prophylaxis) - 08:31 PM\n Other medications:\n versed, fentanyl, colace, H2B, CHG, SQI, MDIs, heparin infusion,\n levoflox, aztreonam, hydrocortisone 50 q6, fludrocort\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (101\n Tcurrent: 37.1\nC (98.8\n HR: 57 (48 - 86) bpm\n BP: 102/48(61) {102/46(61) - 121/52(66)} mmHg\n RR: 22 (17 - 23) insp/min\n SpO2: 99%\n Heart rhythm: JR (Junctional Rhythm)\n Wgt (current): 101 kg (admission): 94.2 kg\n Height: 67 Inch\n CVP: 11 (11 - 20)mmHg\n Bladder pressure: 12 (12 - 12) mmHg\n Total In:\n 1,708 mL\n 460 mL\n PO:\n TF:\n 182 mL\n 138 mL\n IVF:\n 1,267 mL\n 321 mL\n Blood products:\n Total out:\n 877 mL\n 1,305 mL\n Urine:\n 727 mL\n 1,275 mL\n NG:\n 30 mL\n Stool:\n Drains:\n Balance:\n 831 mL\n -845 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 21 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 36 cmH2O\n Plateau: 29 cmH2O\n Compliance: 50 cmH2O/mL\n SpO2: 99%\n ABG: 7.46/38/96./26/2\n Ve: 8.6 L/min\n PaO2 / FiO2: 242\n Physical Examination\n General Appearance: Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear :\n anteriorly)\n Abdominal: Soft, Non-tender, Obese\n Extremities: Right: 1+, Left: 1+\n Musculoskeletal: Unable to stand\n Skin: Warm\n Neurologic: Responds to: Unresponsive, Movement: No spontaneous\n movement, Sedated, Tone: Normal\n Labs / Radiology\n 8.9 g/dL\n 326 K/uL\n 151 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 3.6 mEq/L\n 2 mg/dL\n 108 mEq/L\n 141 mEq/L\n 28.6 %\n 8.9 K/uL\n [image002.jpg]\n 02:02 AM\n 03:59 AM\n 09:14 PM\n 01:04 AM\n 05:54 AM\n 06:11 AM\n 11:07 PM\n 03:51 AM\n 06:17 AM\n 08:18 AM\n WBC\n 8.4\n 8.1\n 8.9\n Hct\n 28.1\n 28.0\n 28.6\n Plt\n 376\n 358\n 326\n Cr\n 0.6\n 0.7\n 0.7\n TCO2\n 25\n 28\n 28\n 26\n 26\n 21\n 28\n Glucose\n 120\n 126\n 151\n Other labs: PT / PTT / INR:24.3/68.6/2.4, CK / CKMB / Troponin-T:24//,\n ALT / AST:24/16, Alk Phos / T Bili:117/0.7, Amylase / Lipase:,\n Differential-Neuts:82.5 %, Lymph:11.6 %, Mono:3.3 %, Eos:2.2 %, Lactic\n Acid:0.7 mmol/L, Albumin:2.4 g/dL, LDH:204 IU/L, Ca++:8.5 mg/dL,\n Mg++:2.1 mg/dL, PO4:2.5 mg/dL\n Imaging: CXR: increased right base opacity\n Microbiology: Sputum from overnight: GPCs with 2+ GPCs in\n pairs/clusters and 2+ GPRs\n Prior sputum growing GNRs\n Assessment and Plan\n Fever\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 01:36 AM\n Arterial Line - 03:00 AM\n Multi Lumen - 11:30 AM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Heparin gtt)\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent:\n Patient is critically ill\n"},{"category":"Physician ","chartdate":"2167-10-14 00:00:00.000","description":"Physician Attending Progress Note","row_id":637507,"text":"Chief Complaint: resp failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n s/p t spine fx with resp failure\n 24 Hour Events:\n BLOOD CULTURED - At 02:18 AM\n SPUTUM CULTURE - At 02:18 AM\n URINE CULTURE - At 02:18 AM\n FEVER Pan cx\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Ceftriaxone - 12:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fever\n Flowsheet Data as of 08:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.8\n Tcurrent: 37.2\nC (99\n HR: 137 (120 - 151) bpm\n BP: 125/55(73) {98/41(54) - 202/97(111)} mmHg\n RR: 23 (12 - 39) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,934 mL\n 497 mL\n PO:\n TF:\n 1,104 mL\n 447 mL\n IVF:\n 1,000 mL\n 50 mL\n Blood products:\n Total out:\n 530 mL\n 240 mL\n Urine:\n 530 mL\n 240 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,404 mL\n 257 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 318 (318 - 475) mL\n PS : 10 cmH2O\n RR (Spontaneous): 34\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 171\n SpO2: 98%\n ABG: ///32/\n Ve: 9 L/min\n Physical Examination\n Labs / Radiology\n 8.8 g/dL\n 306 K/uL\n 134 mg/dL\n 0.6 mg/dL\n 32 mEq/L\n 4.0 mEq/L\n 11 mg/dL\n 106 mEq/L\n 146 mEq/L\n 26.8 %\n 7.5 K/uL\n [image002.jpg]\n 03:10 AM\n 03:08 PM\n 03:00 AM\n 03:36 AM\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n 05:00 AM\n 02:06 AM\n WBC\n 11.3\n 7.3\n 6.1\n 7.2\n 5.2\n 5.9\n 7.5\n Hct\n 24.9\n 27.6\n 26.5\n 26.9\n 26.0\n 27.2\n 26.8\n Plt\n 227\n 189\n 209\n 238\n 240\n 296\n 306\n Cr\n 0.7\n 0.6\n 0.6\n 0.9\n 0.7\n 0.6\n 0.7\n 0.6\n TCO2\n 26\n Glucose\n 114\n 99\n 115\n 106\n 100\n 134\n 134\n Other labs: PT / PTT / INR:13.5/23.6/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:27/19, Alk Phos / T Bili:118/0.3,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:243 IU/L, Ca++:9.2 mg/dL, Mg++:2.1 mg/dL, PO4:4.0\n mg/dL\n Assessment and Plan 55 yr old alcoholic s/p t spine fx s/p trcah and\n PEG with persistent resp failure\n 1. Resp Failure: currently on trach mask, can do a few hours per\n day, then needs for support. New pan Klebs in sputum, day\n . Re- try. Holding off on stent by IP until after pulm rehab.\n 2. Hemodynamics: tachycardia with slightly decreased UOP\n bolus\n IVF and trend UOP. Watch to see if response with tachycardia.\n 3. Anti coag: for upper ext DVT but INR elevated on coumadin +\n quinolone\n repeat inr low- trend with po COumadin\n 4. Adrenal Insufficiency: proper stim this AM, off steroids\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 06:23 AM 60 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n"},{"category":"Physician ","chartdate":"2167-09-29 00:00:00.000","description":"Physician Resident Progress Note","row_id":635064,"text":"Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - STOP 09:00 PM - attempted to re-wire but\n patient was very agitated and re-wire was unsuccessful\n Patient alternated between tachycardia and normotension and hypotension\n in the high-80s/low 90s and HRs in the 50s\n Given haldol, valium, midaz and fentanyl for sedation\n ABG with low paO2 on PEEP 10, had to increase -- went back up to 15 and\n then attempted to re-wean down with goal 8 in anticipation of OR\n To OR for trach and PEG today (thoracics)\n Put on lasix drip and put out >1L in just over an hour\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 08:06 AM\n Infusions:\n Midazolam (Versed) - 1.5 mg/hour\n Fentanyl - 200 mcg/hour\n Other ICU medications:\n Fentanyl - 06:45 PM\n Ranitidine (Prophylaxis) - 08:00 PM\n Haloperidol (Haldol) - 10:00 PM\n Midazolam (Versed) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.7\nC (99.8\n HR: 109 (55 - 134) bpm\n BP: 120/56(70) {80/43(51) - 133/85(94)} mmHg\n RR: 20 (16 - 28) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 101 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 3,064 mL\n 404 mL\n PO:\n TF:\n 1,440 mL\n IVF:\n 1,014 mL\n 314 mL\n Blood products:\n Total out:\n 4,257 mL\n 1,195 mL\n Urine:\n 4,257 mL\n 1,195 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,193 mL\n -791 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 18\n RR (Spontaneous): 10\n PEEP: 15 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10\n PIP: 23 cmH2O\n Plateau: 24 cmH2O\n SpO2: 97%\n ABG: 7.46/48/65/31/8\n Ve: 7.8 L/min\n PaO2 / FiO2: 108\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 320 K/uL\n 8.0 g/dL\n 94 mg/dL\n 0.6 mg/dL\n 31 mEq/L\n 3.6 mEq/L\n 13 mg/dL\n 110 mEq/L\n 147 mEq/L\n 25.8 %\n 9.0 K/uL\n [image002.jpg]\n 10:18 AM\n 02:33 PM\n 02:46 PM\n 03:31 AM\n 02:26 PM\n 05:53 PM\n 05:01 AM\n 03:32 PM\n 10:19 PM\n 02:50 AM\n WBC\n 9.7\n 9.5\n 9.0\n Hct\n 26.0\n 27.6\n 25.8\n Plt\n \n Cr\n 0.5\n 0.5\n 0.5\n 0.6\n 0.6\n TCO2\n 29\n 26\n 27\n 30\n 30\n 35\n Glucose\n 195\n 195\n 163\n 133\n 102\n 94\n Other labs: PT / PTT / INR:14.1/59.6/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:71.2 %, Lymph:22.7 %,\n Mono:4.0 %, Eos:1.7 %, Lactic Acid:1.5 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:8.2 mg/dL, Mg++:2.1 mg/dL, PO4:4.6 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with respiratory failure\n and difficulty weaning from vent.\n # Respiratory failure: Intubated on for resp decompensation.\n Likely VAP. Transferred here for tracheomalacia, but not sure this\n is a component. Will need bronch eval when improved\n - will discuss PEEP goal for trach placement with IP.\n - wean PEEP\n - repeat ABG this AM\n - discuss need for trach with patient and her family\n - Volume overload may be contributing.\n # Volume overload\n Currently with hypernatremia, Cr increase, contract\n alk, but mild\n - continue gentle diuresis\n - FW in TF at 150 cc q4hrs\n - PM lytes.\n # Sedation: On versed 3mg/hr + .5 q 1hr and fentanyl 150 mcg/hr + 50\n bolus q 1hr.\n - Start fentanyl patch and diazepam to provide long acting analgesia\n and wean from drips\n - Haldol 1 mg Q4h PRN agitation\n # Pneumonia: Pansensitive Kleb oxytoca pneumonia and sputum with GPCs\n on gram stain. Afebrile off abx.\n # EKG changes: Sinus bradycardia, responsive to stress. Related to\n sedation, increased vagal tone, possibly related to steroid\n replacement. Atrial EKG shows p-waves and cardiac enzymes normal.\n - Continue to monitor\n # Hypotension: Improved, off levophed for 2-3 days now, with good urine\n output. s/p 5 d course of steroids for adrenal insufficiency. High\n PEEP may have been contributing. Now likely related to sedation and\n decreased intravascular volume,\n -monitor, expect improvement with continual reduction in\n PEEP\n # RUE DVT: Started on heparin gtt on , now therapeutic. Follow\n PTTs. Would hold off on coumadin at least until s/p trach.\n - continue to monitor\n # Adrenal Insufficency: Random cortisol was approx 3 when it should\n have been maximally stimulated.\n - hydrocortisone and florinef for 5 days\n # Anemia: Stable.\n - Trend HCT\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n FEN/GI: Tube feeds @ goal\n DVT: Treatment dose heparin\n Ulcer: Ranitidine\n VAP: Prevention per routine\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2167-10-26 00:00:00.000","description":"Physician Resident Progress Note","row_id":639585,"text":"Chief Complaint:\n 24 Hour Events:\n Pt agitated overnight given extra Risperidone 0.5 mg x 2 overnight.\n (1.5mg total)\n 1000 mL D5W for Hypernatremia\n Changed B-Blocker from IV to PO, Metoprolol Tartrate 25 mg PO TID\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:17 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.7\nC (98\n HR: 120 (67 - 120) bpm\n BP: 110/64(76) {109/47(60) - 141/115(118)} mmHg\n RR: 26 (18 - 30) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 3,820 mL\n 856 mL\n PO:\n TF:\n 117 mL\n 20 mL\n IVF:\n 2,612 mL\n 572 mL\n Blood products:\n Total out:\n 2,460 mL\n 1,180 mL\n Urine:\n 2,460 mL\n 1,180 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,360 mL\n -324 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 100%\n ABG: ///33/\n Physical Examination\n Gen: Awake, Mouthing words, More agitated compared to previous\n mornings.\n HEENT: EOMI, No pallor in conjunctiva, MMM\n Resp: CTAB, no rales, rhonchi, or wheezing, good airway movement.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, decreased bowel sounds,, G-Tube in\n place with no erythema/induration\n Exte: No edema, DP 2+ bil\n NEURO: Gross Motor and Sensation in 4 extremities\n Labs / Radiology\n 249 K/uL\n 8.0 g/dL\n 122 mg/dL\n 0.5 mg/dL\n 33 mEq/L\n 3.7 mEq/L\n 13 mg/dL\n 108 mEq/L\n 146 mEq/L\n 24.7 %\n 5.5 K/uL\n [image002.jpg] CXR: L Picc, trach tip at midline, bibasilar\n opacities, low lung volumes, Bil pleural effusions.\n 03:36 AM\n 02:30 AM\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n 03:00 AM\n 04:00 AM\n 05:45 AM\n 03:51 AM\n WBC\n 6.9\n 7.6\n 9.5\n 5.7\n 7.3\n 8.0\n 8.7\n 5.5\n Hct\n 27.8\n 32.7\n 28.6\n 28.9\n 30.0\n 26.9\n 27.3\n 27.0\n 28.7\n 24.7\n Plt\n 467\n 548\n 528\n 356\n 346\n 316\n 271\n 249\n Cr\n 0.7\n 0.8\n 1.0\n 0.7\n 0.7\n 0.7\n 0.7\n 0.5\n Glucose\n 131\n 128\n 121\n 129\n 123\n 114\n 112\n 122\n Other labs: PT / PTT / INR:13.6/31.1/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:9.0 mg/dL, Mg++:2.2 mg/dL, PO4:3.1\n mg/dL\n Assessment and Plan\n 56yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach/PEG with resolving respiratory failure and HAP.\n .\n # Respiratory failure: s/p intubation/extubation, now on trach mask,\n FiO2 70%. Tolerating well with good O2 sat. No further\n self-decanulations overnight.\n - Tach mask as tolerated.\n - Holding sedation with exception of Risperidal 0.5mg .\n - F/u CXR tomorrow\n .\n # Nutrition/Vomiting: Currently receiving TPN;. One large BM in past\n 24 hrs to indicate potential improvement in ileus.\n - Cont Reglan 20mg IV Q 8 hours; meds via G-J tube,\n - Will obtain recommendations from Nutrition re TPN before starting TPN\n tomorrow\n - Increase TF as tolerated\n - Speech and Swallow eval\n - PICC line in place with TPN given when pt not tolerating TF\n - GI consult, appreciate recs\n .\n # Tachycardia: Improved HR max of 120\ns versus 160s previously;\n elevated this am secondary to agitation. Pt now on PO Amiodarone 200\n TID and PO metoprolol 25mg TID\n - Continue current med regimen. Will continue amiodarone 200 TID for\n three weeks and then switch to qday.\n - Will schedule f/u in 4wks with Dr. upon d/c.\n - f/u Cards recs\n # Sedation/Anxiolysis/AlteredMS: Agitation O/N, continues to be\n agitated most likely secondary to long hospital course and multiple\n psychotropic medications as well as hx of EtOH abuse. Risperdal given\n O/N.\n - started Risperdal 0.5mg PO BID\n - continue to hold all benzos. opiates, and antihistamines\n - Appreciate psych. Will f/u psych recs.\n .\n # Hypernatremia/Fluid Status: Mild hypernatramia with good UOP\n (hypervolemic hypernatremia). On TPN/TF.\n - providing D5W IVF PRN and follow lytes (check Na this afternoon).\n # UE DVT and elevated INR: Decision made to d/c Coumadin given her\n labile INR, and start Lovenox . Current INR 1.2.\n - Will flush L PICC with TPA\n .\n # Spine fracture: Stable\n - Brace for OOB, will discuss with Neurosurgery if current brace is\n optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n .\n # Tracheomalacia. Was initially addressed with IP and they wanted to\n follow up as outpatient. IP reevaluated and does not believe that a\n stent would be feasible.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # ACCESS: PIV x 1, L PICC\n # Ppx: Lovenox, PPi, Bowel Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n - Social Work and Case management involved, have discussed situation\n w/ brother and boyfriend.\n # Code: Full\n # Dispo: ICU, Screening for vent facilities\n"},{"category":"Radiology","chartdate":"2167-10-02 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1034896,"text":" 3:25 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? interval change, ? RLL process\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with respiratory failure\n REASON FOR THIS EXAMINATION:\n ? interval change, ? RLL process\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 3:31 A.M. ON \n\n HISTORY: Respiratory failure, question interval change in right lower lobe\n process.\n\n IMPRESSION: AP chest compared to , 7:58 p.m.\n\n Pulmonary vascular congestion and mild edema have developed. Consolidation in\n the right lower lung has progressed, probably worsening atelectasis. The\n examination is positioned though as to underestimate the distance of the ET\n tube from the carina. It ends above the level of the clavicles, and with the\n chin down, and is at least 5 cm too high.\n\n Dr. was paged to report these at the time of dictation.\n\n"},{"category":"Radiology","chartdate":"2167-09-30 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1034491,"text":", F. MED MICU 7:28 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: please eval ET tube placement\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with respiratory failure, unable to see ET tube and carina on\n film from this AM.\n REASON FOR THIS EXAMINATION:\n please eval ET tube placement\n ______________________________________________________________________________\n PFI REPORT\n ET tube tip 5.5 cm above the carina. Impingement of the left tracheal wall by\n the ET tube that should be re-positioned.\n\n Interval improvement of pulmonary edema.\n\n\n"},{"category":"Radiology","chartdate":"2167-09-27 00:00:00.000","description":"BY SAME PHYSICIAN","row_id":1033999,"text":" 2:21 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: Pt had a left sided picc line placed,51cm and needs tip conf\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with Respiratory Failure who needs picc line for IV access.\n REASON FOR THIS EXAMINATION:\n Pt had a left sided picc line placed,51cm and needs tip confirmation please\n page at with wet read,thanks.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST \n\n CLINICAL INFORMATION: PICC line placement.\n\n FINDINGS:\n\n COMPARISON STUDY: at 04:22 hours.\n\n Left PICC has been placed. The tip terminates at the right atrium. The\n endotracheal tube terminates at the carina and should be pulled back. The\n nasogastric tube terminates in the stomach. Right IJ catheter terminates in\n the superior vena cava. The heart is enlarged. Mediastinum is within normal\n limits. There is a small left pleural effusion with a very small right\n pleural effusion. There is elevation of the right hemidiaphragm. There is\n bibasilar atelectasis.\n\n IMPRESSION:\n\n 1. Left PICC terminates in the right atrium.\n\n 2. Small bilateral pleural effusions with bibasilar atelectasis.\n Cardiomegaly.\n\n\n"},{"category":"Radiology","chartdate":"2167-10-01 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1034678,"text":" 3:43 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval lines/tubes/infiltrates\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with VAP and ARDS\n REASON FOR THIS EXAMINATION:\n eval lines/tubes/infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Ventilator-associated pneumonia and ARDS.\n\n FINDINGS: A semi-upright frontal bedside chest radiograph compared to\n and demonstrates no significant change. The lung volumes\n are low. There are moderate bilateral layering effusions. There is a large\n left retrocardiac atelectasis. There is mild pulmonary overload. The ETT is\n 3 cm above the carina. NG tube is in the stomach. A left central venous\n catheter tip terminates in the SVC.\n\n IMPRESSION: No marked interval change in mild pulmonary edema, bilateral\n effusions, and large left retrocardiac atelectasis.\n\n\n"},{"category":"Radiology","chartdate":"2167-09-27 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1033919,"text":" 1:28 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval lines/tubes/infiltrates\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with respiratory failure with VAP\n REASON FOR THIS EXAMINATION:\n eval lines/tubes/infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST \n\n CLINICAL INFORMATION: Respiratory failure.\n\n FINDINGS:\n\n Endotracheal tube terminates just above the thoracic inlet in appropriate\n position. Nasogastric tube courses below the diaphragm. Right IJ catheter\n terminates in the superior vena cava.\n\n There are moderate bilateral pleural effusions and bibasilar atelectasis.\n There is essentially no change in the appearance of the chest since the prior\n study.\n\n\n"},{"category":"Radiology","chartdate":"2167-09-20 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":1032610,"text":" 7:01 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: position of Left IJ\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with resp failure s/p left IJ placement.\n REASON FOR THIS EXAMINATION:\n position of Left IJ\n ______________________________________________________________________________\n FINAL REPORT\n\n\n HISTORY: Left IJ placement.\n\n FINDINGS: Left IJ central line is malpositioned, coursing towards the left\n axilla. New left apical pleural capping could reflect the re-distribution of\n effusion since the patient was in the Trendelenburg position for the\n procedure, though the possibility of a hematoma complicating the line\n placement must be considered. This information was discussed by the radiology\n resident with Dr. .\n\n"},{"category":"Radiology","chartdate":"2167-09-22 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1032921,"text":" 9:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Assess tube position\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with respiratory distress, intubated. S/P repositioning of\n ET tube.\n REASON FOR THIS EXAMINATION:\n Assess tube position\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Respiratory distress status post re-positioning of endotracheal\n tube.\n\n FINDINGS: In comparison with the study of , the endotracheal tube tip now\n lies approximately 7.4 cm above the carina. There is little overall change in\n the appearance of heart and lungs. Elevation of the right hemidiaphragm\n persists with bibasilar effusions and atelectatic change.\n\n\n"},{"category":"Radiology","chartdate":"2167-09-24 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1033342,"text":" 2:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Assess ET tube placement\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with repiratory failure, intubated\n REASON FOR THIS EXAMINATION:\n Assess ET tube placement\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 9:52 AM\n No change.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Assessment of endotracheal tube placement.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is no relevant\n change. The monitoring and support devices are in unchanged position. The\n tip of the endotracheal tube projects 5.7 cm above the carina.\n\n\n"},{"category":"Radiology","chartdate":"2167-09-24 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1033343,"text":", D. MED MICU 2:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Assess ET tube placement\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with repiratory failure, intubated\n REASON FOR THIS EXAMINATION:\n Assess ET tube placement\n ______________________________________________________________________________\n PFI REPORT\n No change.\n\n\n"},{"category":"Radiology","chartdate":"2167-09-29 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1034241,"text":" 2:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? Interval change\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with recent ARDS\n REASON FOR THIS EXAMINATION:\n ? Interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Desaturation.\n\n FINDINGS: In comparison with study of , there is little overall change.\n Again, there is enlargement of the cardiac silhouette with basilar atelectasis\n and bilateral effusions. Elevation of the right hemidiaphragmatic contour\n persists. Again, it is difficult to evaluate the area behind the heart in the\n absence of a lateral view. Tubes remain in place.\n\n IMPRESSION: Little change.\n\n\n"},{"category":"Radiology","chartdate":"2167-09-28 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1034222,"text":" 10:24 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: atelectasis vs edema\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman intubated with recent desats.\n REASON FOR THIS EXAMINATION:\n atelectasis vs edema\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Intubated with the recent desaturation.\n\n FINDINGS: In comparison with study earlier in this date, there is again\n enlargement of the cardiac silhouette with bilateral pleural effusion and\n bibasilar atelectasis. Elevation of the right hemidiaphragmatic contour\n persists. The area behind the heart is difficult to evaluate in the absence\n of a lateral view. Tubes remain in place.\n\n IMPRESSION: Little change.\n\n\n"},{"category":"Radiology","chartdate":"2167-09-30 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1034454,"text":", F. MED MICU 3:16 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?Interval change\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with respiratory failure\n REASON FOR THIS EXAMINATION:\n ?Interval change\n ______________________________________________________________________________\n PFI REPORT\n Increase in bilateral pleural effusions.\n\n\n"},{"category":"Radiology","chartdate":"2167-09-23 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1033096,"text":" 2:45 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? tube/line position, infiltrates\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with respiratory failure, T8 fracture.\n REASON FOR THIS EXAMINATION:\n ? tube/line position, infiltrates\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): PSS WED 10:36 AM\n ET tube, right jugular line, NG tube okay. Left lower lobe atelectasis\n improved. Mild pulmonary edema improved.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 3 A.M. \n\n HISTORY: Respiratory failure. T8 fracture. Check lines and tubes.\n\n IMPRESSION: AP chest compared to :\n\n ET tube, right jugular line, in standard placements. Nasogastric tube passes\n below the diaphragm and out of view. Mild pulmonary edema has improved,\n previously severe left lower lobe atelectasis and milder right basal\n atelectasis have also improved. No pneumothorax. Small pleural effusion is\n presumed. Heart size normal.\n\n\n"},{"category":"Radiology","chartdate":"2167-09-20 00:00:00.000","description":"PORTABLE ABDOMEN","row_id":1032618,"text":" 8:20 PM\n PORTABLE ABDOMEN Clip # \n Reason: ? ileus v obstruction\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with respiratory failure, distended abdomen.\n REASON FOR THIS EXAMINATION:\n ? ileus v obstruction\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 55-year-old woman with respiratory failure and distended abdomen.\n Concern for ileus versus obstruction.\n\n COMPARISON: Portable abdominal radiograph .\n\n FINDINGS: A single AP supine portable radiograph of the abdomen was obtained\n demonstrating a nasogastric tube with termination in the stomach. There are\n no air-fluid levels or dilated loops of large or small bowel. There is no\n evidence of pneumatosis or pneumoperitoneum. A few surgical clips are noted\n to project over the right sacroiliac joint. Patient is status post left hip\n arthroplasty. Mild convex left thoracolumbar scoliosis may be explained by\n positioning.\n\n IMPRESSION: No obstruction.\n\n"},{"category":"Radiology","chartdate":"2167-09-21 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1032860,"text":" 11:12 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Assess ET tube possition\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with acute respiraotry distress. Acute desaturation.\n REASON FOR THIS EXAMINATION:\n Assess ET tube possition\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: To assess for endotracheal tube position.\n\n FINDINGS: In comparison with earlier study of this date, there are continued\n bilateral pleural effusions with atelectatic changes especially in the\n retrocardiac region. The endotracheal tube tip lies approximately 6.7 cm\n above the carina. Nasogastric tube and right IJ catheter remain in place.\n\n\n"},{"category":"Radiology","chartdate":"2167-09-23 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1033097,"text":", D. MED MICU 2:45 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? tube/line position, infiltrates\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with respiratory failure, T8 fracture.\n REASON FOR THIS EXAMINATION:\n ? tube/line position, infiltrates\n ______________________________________________________________________________\n PFI REPORT\n ET tube, right jugular line, NG tube okay. Left lower lobe atelectasis\n improved. Mild pulmonary edema improved.\n\n\n"},{"category":"Radiology","chartdate":"2167-09-20 00:00:00.000","description":"RP UNILAT UP EXT VEINS US RIGHT PORT","row_id":1032570,"text":" 11:50 AM\n UNILAT UP EXT VEINS US RIGHT PORT Clip # \n Reason: EVAL FOR UPPER EXT DVT, SWELLING\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with PICC with arm swelling\n REASON FOR THIS EXAMINATION:\n eval upper extremity DVT\n ______________________________________________________________________________\n WET READ: DXAe SUN 1:21 PM\n 1. 2 cm Nonocclusive DVT in the right axillary vein\n\n 2. 1 cm superficial nonocclusive thrombus in the basillic vein).\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 55-year-old woman with PICC line and arm swelling, evaluate for\n upper extremity DVT.\n\n COMPARISON: None.\n\n FINDINGS: Grayscale and Doppler imaging of the right superficial and deep\n veins was performed. There is a non-occlusive thrombus in the right axillary\n vein spanning 2 cm. There is also a non-occlusive thrombus in the right\n basilic vein. The other veins including the internal jugular, brachial veins\n demonstrate normal compressibility, augmentation, and waveforms.\n\n IMPRESSION:\n\n 1. Non-occlusive right axillary deep vein thrombus.\n\n 2. Non-occlusive right basilic superficial thrombosis.\n\n"},{"category":"Radiology","chartdate":"2167-09-30 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1034490,"text":" 7:28 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: please eval ET tube placement\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with respiratory failure, unable to see ET tube and carina on\n film from this AM.\n REASON FOR THIS EXAMINATION:\n please eval ET tube placement\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLnc WED 11:20 AM\n ET tube tip 5.5 cm above the carina. Impingement of the left tracheal wall by\n the ET tube that should be re-positioned.\n\n Interval improvement of pulmonary edema.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of ET tube tip.\n\n Portable AP chest radiograph was compared to .\n\n The ET tube tip is impinging the left tracheal wall and should be\n re-positioned. Its tip is approximately 5.5 cm above the carina.\n\n The NG tube tip is in the stomach. The interval improvement in pulmonary\n edema and slight decrease in pleural effusions is demonstrated. There is no\n change in left retrocardiac opacity consistent with atelectasis. There is no\n pneumothorax.\n\n IMPRESSION: ET tube tip 5.5 cm above the carina impinging the left tracheal\n wall and should be re-positioned.\n\n Interval improvement of pulmonary edema and slight decrease in pleural\n effusions.\n\n\n"},{"category":"Radiology","chartdate":"2167-09-26 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1033806,"text":" 3:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate tubes/lines, infiltrates\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with respiratory failure, ARDS, VAP.\n REASON FOR THIS EXAMINATION:\n please evaluate tubes/lines, infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST \n\n CLINICAL INFORMATION: Respiratory failure, ARDS.\n\n FINDINGS:\n\n Since the prior study from , there has been increased bilateral pleural\n effusions, moderate on the right, small to moderate on the left, with\n bilateral lower lobe consolidation. There is cardiomegaly.\n\n Endotracheal tube terminates in the thoracic inlet. Right IJ catheter\n terminates in the superior vena cava. Endotracheal tube courses below the\n diaphragm and the tip is not seen. Multiple lines project over the chest.\n\n IMPRESSION:\n\n Interval worsening, with increased bilateral pleural effusions and bibasilar\n consolidation.\n\n\n"},{"category":"Radiology","chartdate":"2167-09-20 00:00:00.000","description":"BY SAME PHYSICIAN","row_id":1032632,"text":" 10:37 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: ? pneumothorax\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with respiratory failure, s/p attempted right sided CVL.\n REASON FOR THIS EXAMINATION:\n ? pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Respiratory failure status post attempted right central venous\n pressure insertion.\n\n FINDINGS: In comparison with study of , there is little change in the\n appearance of the heart and lungs. Specifically, no evidence of pneumothorax\n after the attempted central line placement.\n\n\n"},{"category":"Radiology","chartdate":"2167-09-21 00:00:00.000","description":"CTA CHEST W&W/O C&RECONS, NON-CORONARY","row_id":1032824,"text":" 4:59 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: eval structures, bleeding, spinal cord impingement\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n Field of view: 42 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with respiratory failure, T5-T8 fracture, hypotension\n REASON FOR THIS EXAMINATION:\n eval structures, bleeding, spinal cord impingement\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AHPb MON 9:28 PM\n Right lower lobe consolidation, and superimposed atelectasis/lower lobe\n collapse, and effusions. Acute T8 compression deformity, with no posterior\n retropulsion of fracture fragments. No associated hematoma.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Respiratory failure, T5 through T8 fracture, hypotension,\n evaluate structures, bleeding, spinal cord impingement.\n\n COMPARISON: None.\n\n TECHNIQUE: MDCT of the chest, abdomen, and pelvis performed before and after\n the uneventful administration of 130 cc Optiray contrast. Multiplanar\n reformatted images were also obtained and reviewed.\n\n CTA CHEST: The pulmonary arteries opacify normally without evidence for\n filling defects. Evaluation of the subsegmental pulmonary arteries is limited\n lower lobe collapse and body habitus. The main pulmonary artery is top normal\n in size which could be secondary to mild pulmonary hypertension. The heart\n and great vessels of the mediastinum are otherwise unremarkable. There are\n coronary artery calcifications. NG tube terminates in the stomach.\n Endotracheal tube terminates in the mid thoracic trachea. The airways are\n patent to the segmental level but collapsed more distally in the right middle\n and lower lobes.\n\n There is total collapse of the right middle and lower lobes. There is\n atelectasis of the right upper lobe and superimposed patchy opacities and most\n prominent in the basal portions of the right upper lobe, consistent with\n aspiration or infection. There is also partial collapse of the left lower lobe\n and left upper lobe. There are small bilateral pleural effusions. There is\n presternal fluid and soft tissue stranding (3:15).\n\n CT ABDOMEN WITH CONTRAST: The liver, gallbladder, pancreas, spleen, stomach,\n adrenal glands, kidneys, and small bowel loops are unremarkable aside from\n small gallstones and right upper pole renal cyst. There is no free air, free\n fluid, or pathologic adenopathy. Incidental note of a small duodenal\n diverticulum.\n\n CT PELVIS WITH CONTRAST: The rectum, sigmoid, and large bowel are remarkable\n for sigmoid diverticulosis. There is a 7.5 cm x 3.0 cm tubular fluid density\n (Over)\n\n 4:59 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: eval structures, bleeding, spinal cord impingement\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n Field of view: 42 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n structure in continuation with the cecum in the anticipated location of the\n appendix without adjacent inflammatory stranding. Surgical sutures are\n present at the tip of this lesion. Foley is present within a collapsed\n bladder. There is mild diffuse anasarca.\n\n OSSEOUS STRUCTURES: There is an acute compression deformity of the T8\n vertebral body with approximately 25% loss of height, and no retropulsion of\n fracture fragments, and no associated hematoma. Evaluation of the contents of\n the spinal canal is limited by CT, but there is no evidence for gross cord\n compression. Please see CT T-spine from today for further details.\n\n IMPRESSION:\n 1. Collapse of the right middle and lower lobes with atelectasis of the right\n upper lobe.\n 2. Superimposed patchy opacities in right upper lobe consistent with\n aspiration, infection, or combination.\n 3. Partial collapse of left lower lobe and upper lobe.\n 4. Acute T8 compression deformity without retropulsion of fracture fragments.\n 5. Incidental appendiceal mucocele versus mucinous cystadenoma. Correlation\n of abdominal surgery recommended given adjacent sutures. Recurrence of\n previously excised lesion is a possibility.\n\n These findings were communicated with Dr. at 6:30 p.m., .\n\n"},{"category":"Radiology","chartdate":"2167-09-21 00:00:00.000","description":"CT PELVIS W/CONTRAST","row_id":1032825,"text":", D. MED MICU 4:59 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: eval structures, bleeding, spinal cord impingement\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n Field of view: 42 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with respiratory failure, T5-T8 fracture, hypotension\n REASON FOR THIS EXAMINATION:\n eval structures, bleeding, spinal cord impingement\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Right lower lobe consolidation, and superimposed atelectasis/lower lobe\n collapse, and effusions. Acute T8 compression deformity, with no posterior\n retropulsion of fracture fragments. No associated hematoma.\n\n"},{"category":"Radiology","chartdate":"2167-09-21 00:00:00.000","description":"CT T-SPINE W/ CONTRAST","row_id":1032826,"text":" 5:00 PM\n CT T-SPINE W/ CONTRAST Clip # \n Reason: eval structures, bleeding, spinal cord impingement\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with respiratory failure, T5-T8 fracture, hypotension\n REASON FOR THIS EXAMINATION:\n eval structures, bleeding, spinal cord impingement\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Respiratory failure, T5 through 8 fracture, hypotension. Please\n evaluate for spinal cord impingement.\n\n TECHNIQUE: MDCT of the thoracic spine without contrast displayed in 3.75 mm\n axial collimation. Coronal and sagittal reformatted images were also obtained\n and reviewed.\n\n COMPARISON: CT chest, abdomen and pelvis from same day.\n\n CT THORACIC SPINE WITHOUT CONTRAST: There is an acute compression deformity\n of the T8 vertebral body with approximately 25% loss of height. There is no\n retropulsion of fracture fragments. Fracture lines do not extend into the\n posterior elements. Although evaluation of the spinal cord is limited by CT,\n there is no evidence for gross cord compression. There is also mild loss of\n height at T5. The remaining thoracic and visualized lumbar vertebrae are\n normal.\n\n Evaluation of the lung fields demonstrates complete collapse of the right\n lower and middle lobes with partial collapse/atelectasis of the right upper\n and left upper lobes. Superimposed patchy opacities in the right upper lobe\n suggest aspiration, infection, or combination. Note is also made of a 1-cm\n calcified granuloma in the left lung. NG tube courses into the stomach. ETT\n terminates in the mid thoracic trachea.\n\n IMPRESSION:\n 1. T8 compression deformity with 25% loss of height and no retropulsion of\n fracture fragments. Mild loss of height at T5.\n 2. Multifocal pumonary collapse and consolidation. Please see the\n accompanying CT chest, abdomen and pelvis for further details.\n\n These findings were communicated with Dr. at the time of this study.\n\n\n"},{"category":"Radiology","chartdate":"2167-10-01 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1034868,"text":" 7:45 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: confirm ETT placement\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman intubated with difficult sedation, pulling at ETT.\n REASON FOR THIS EXAMINATION:\n confirm ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 7:58 P.M., \n\n HISTORY: Difficult intubation. Confirmed tube placement.\n\n IMPRESSION: AP chest compared to and at 4:13 a.m.:\n\n Tip of the ET tube, at the upper margin of the clavicles with the chin down is\n 3 cm above optimal placement. Severe bibasilar atelectasis unchanged. Upper\n lungs clear. Heart is top normal size, remains shifted to the left.\n Nasogastric tube ends in the region of the pylorus.\n\n"},{"category":"Radiology","chartdate":"2167-09-19 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1032505,"text":" 11:37 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval lines/ tubes/infiltrates\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with respiratory failure transfer to for vent wean\n REASON FOR THIS EXAMINATION:\n eval lines/ tubes/infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Transfer to for vent wean. Check lines and tubes.\n\n FINDINGS: There is no old film available for comparison. The endotracheal\n tube tip is 4.5 cm above the carina. The NG tube tip is in the stomach. The\n right hemidiaphragm is mildly elevated. The heart is upper limits normal in\n size. There is pulmonary vascular redistribution with volume loss/infiltrate\n in the right mid lung. The left lateral lung is off the film.\n\n\n"},{"category":"Radiology","chartdate":"2167-09-25 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1033584,"text":" 2:54 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ETT and line loactions\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with respiratory failure of unclear etiology.\n REASON FOR THIS EXAMINATION:\n ETT and line loactions\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Respiratory failure for ET tube and line locations.\n\n FINDINGS: In comparison with the study of , there is little overall\n change. The endotracheal tube lies approximately 5 cm above the carina and\n the right IJ catheter extends to the lower portion of the SVC. Little overall\n change in the appearance of the heart and lungs.\n\n\n"},{"category":"Radiology","chartdate":"2167-09-28 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1034039,"text":", D. MED MICU 3:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval infiltrates, lines\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with respiratory failure, VAP, intubated.\n REASON FOR THIS EXAMINATION:\n please eval infiltrates, lines\n ______________________________________________________________________________\n PFI REPORT\n PFI: No interval change.\n\n"},{"category":"Radiology","chartdate":"2167-09-21 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":1032743,"text":" 11:39 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: placement of right IJ\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with resp failure, hypotension, oliguria. s/p placement of\n right IJ\n REASON FOR THIS EXAMINATION:\n placement of right IJ\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Respiratory failure, for placement of a right IJ catheter.\n\n FINDINGS: In comparison with the study of , there has been placement of a\n right IJ catheter that extends to the lower portion of the SVC. Endotracheal\n and nasogastric tubes remain in place. Overlying artifacts make it very\n difficult to properly evaluate the lungs.\n\n\n"},{"category":"Radiology","chartdate":"2167-09-20 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1032518,"text":" 3:16 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ETT tube placement\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with resp distress s/p intubation transferred from OSH for\n management of weaning.\n REASON FOR THIS EXAMINATION:\n ETT tube placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE VIEW ON .\n\n HISTORY: Check endotracheal tube.\n\n FINDINGS: The endotracheal tube tip is 5 cm above the carina. There is a\n right subclavian line with tip at the SVC/RA junction. The NG tube tip is in\n the stomach. There is a small right effusion. There continues to be\n right-sided volume loss/infiltrate. There is perihilar haze and pulmonary\n vascular redistribution but slightly worse compared to the prior study\n suggesting worsening fluid overload.\n\n\n"},{"category":"Radiology","chartdate":"2167-09-22 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1032944,"text":" 10:31 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: please re-eval tube positioning\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with respiratory failure, s/p tube repositioning.\n REASON FOR THIS EXAMINATION:\n please re-eval tube positioning\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Respiratory failure status post tube repositioning.\n\n FINDINGS: In comparison with the earlier study of this date, the tip of the\n endotracheal tube is approximately 5.2 cm above the carina. Nasogastric tube\n and right IJ line remain in place. The opacification in the retrocardiac\n region persists. There is some increasing opacification at the right base.\n Although some of this could reflect atelectasis, the possibility of\n supervening atelectasis or pneumonia should be considered.\n\n\n"},{"category":"Radiology","chartdate":"2167-09-30 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1034453,"text":" 3:16 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?Interval change\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with respiratory failure\n REASON FOR THIS EXAMINATION:\n ?Interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLnc WED 10:33 AM\n Increase in bilateral pleural effusions.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Interval change in a patient with respiratory\n failure.\n\n Portable AP chest radiograph was compared to obtained at\n 02:59 a.m.\n\n The ET tube tip is 3.8 cm above the carina. The NG tube is in the stomach.\n The cardiomediastinal silhouette is unchanged. Interval increase in bilateral\n pleural effusions is present but no change in bibasal consolidations\n consistent with atelectasis.\n\n IMPRESSION: No significant interval change except for increase in bilateral\n pleural effusions.\n\n\n"},{"category":"Radiology","chartdate":"2167-09-19 00:00:00.000","description":"PORTABLE ABDOMEN","row_id":1032503,"text":" 11:22 PM\n PORTABLE ABDOMEN Clip # \n Reason: eval gas pattern for obstruction\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with respiratory failure and abdominal distension\n REASON FOR THIS EXAMINATION:\n eval gas pattern for obstruction\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMEN FILM ON \n\n HISTORY: Respiratory failure and abdominal distention.\n\n FINDINGS: Patient is status post left total hip replacement. Gas is seen in\n the stomach and a small amount of gas is seen in the colon and in the rectum\n but otherwise there is a paucity of bowel gas. An NG tube is noted in the\n stomach.\n\n IMPRESSION: Nonspecific bowel gas pattern.\n\n\n"},{"category":"Radiology","chartdate":"2167-09-20 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":1032623,"text":" 8:47 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: ? pneumothorax\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with respiratory failure, s/p CVL placement. ? pneumo.\n REASON FOR THIS EXAMINATION:\n ? pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Respiratory failure with central line placement.\n\n FINDINGS: In comparison with the earlier study, the malpositioned left\n subclavian line has been removed.\n\n Little change in the left apical opacification.\n\n"},{"category":"Radiology","chartdate":"2167-09-28 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1034038,"text":" 3:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval infiltrates, lines\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with respiratory failure, VAP, intubated.\n REASON FOR THIS EXAMINATION:\n please eval infiltrates, lines\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AHPb MON 10:51 AM\n PFI: No interval change.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Respiratory failure, ventilator-associated pneumonia.\n\n FINDINGS: Portable semi-upright chest radiograph is compared to at 14:33 and demonstrates no marked interval change in bilateral pleural\n effusions, large bibasilar atelectases (left greater than right),\n cardiomegaly. Lines and tubes are in standard fashion with left PICC\n terminates at the cavoatrial junction.\n\n IMPRESSION: No interval changed in bibasilar pleural effusions and\n atelectasis.\n\n"},{"category":"Echo","chartdate":"2167-09-30 00:00:00.000","description":"Report","row_id":87285,"text":"PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Braddycardia. Hypotension.\nWeight (lb): 235\nBP (mm Hg): 108/56\nHR (bpm): 49\nStatus: Inpatient\nDate/Time: at 15:40\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal interatrial septum.\nNo ASD by 2D or color Doppler. Normal IVC diameter (<2.1cm) with <35% decrease\nduring respiration (estimated RA pressure indeterminate).\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. No MS.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR.\nModerate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: No PS.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nThe left atrium is elongated. No atrial septal defect is seen by 2D or color\nDoppler. The right atrial pressure is indeterminate. Left ventricular wall\nthickness, cavity size and regional/global systolic function are normal (LVEF\n>55%). There is no ventricular septal defect. Right ventricular chamber size\nand free wall motion are normal. The aortic valve leaflets (3) are mildly\nthickened but aortic stenosis is not present. No aortic regurgitation is seen.\nThe mitral valve appears structurally normal with trivial mitral\nregurgitation. There is no mitral valve prolapse. The tricuspid valve leaflets\nare mildly thickened. There is moderate pulmonary artery systolic\nhypertension. There is no pericardial effusion.\n\nCompared with the prior study (images reviewed) of , no change.\n\n\n"},{"category":"Echo","chartdate":"2167-09-21 00:00:00.000","description":"Report","row_id":87286,"text":"PATIENT/TEST INFORMATION:\nIndication: Right ventricular function. Shortness of breath. Hypotension. Bubble study.\nHeight: (in) 68\nWeight (lb): 230\nBSA (m2): 2.17 m2\nBP (mm Hg): 101/67\nHR (bpm): 72\nStatus: Inpatient\nDate/Time: at 15:37\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: Saline\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA and RA cavity sizes.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolic\nfunction (LVEF>55%). Suboptimal technical quality, a focal LV wall motion\nabnormality cannot be fully excluded. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTIC VALVE: Normal aortic valve leaflets. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Mild PA\nsystolic hypertension.\n\nPERICARDIUM: There is an anterior space which most likely represents a fat\npad, though a loculated anterior pericardial effusion cannot be excluded.\n\nGENERAL COMMENTS: Contrast study was performed with 3 iv injections of 8 ccs\nof agitated normal saline, at rest, with cough and post-Valsalva maneuver.\n\nConclusions:\nThe left atrium and right atrium are normal in cavity size. Suboptimal saline\ncontrast study does not suggest an intracardiac shunt. Left ventricular wall\nthickness, cavity size, and global systolic function are normal (LVEF>55%).\nDue to suboptimal technical quality, a focal wall motion abnormality cannot be\nfully excluded. Right ventricular chamber size and free wall motion are\nnormal. The aortic valve leaflets appear structurally normal with good leaflet\nexcursion. No aortic regurgitation is seen. .The mitral valve appears\nstructurally normal with trivial mitral regurgitation. There is mild-moderate\npulmonary artery systolic hypertension. There is an anterior space which most\nlikely represents a fat pad.\n\nIMPRESSION: Suboptimal image quality. Preserved global biventricular systolic\nfunction. Mild-moderate pulmonary artery systolic hypertension.\n\nCLINICAL IMPLICATIONS:\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate prophylaxis is NOT recommended. Clinical decisions regarding the need\nfor prophylaxis should be based on clinical and echocardiographic data.\n\n\n"},{"category":"Radiology","chartdate":"2167-10-28 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1040102,"text":" 3:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? interval change\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with TBM, s/p trach\n REASON FOR THIS EXAMINATION:\n ? interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLnc WED 11:40 AM\n No significant change compared to the prior studies. Extensive basal\n atelectasis.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of a patient with tracheobronchomalacia\n after tracheostomy.\n\n COMPARISON: Chest radiographs from and .\n\n The study is limited due to motion artifact, but overall, there is no change\n in bilateral significant atelectasis involving lower lobes and right middle\n lobe. The upper lungs are ventilated. The tracheostomy is low with its tip\n projecting less than 2 cm above the carina. Pleural effusion cannot be\n excluded.\n\n\n"},{"category":"Radiology","chartdate":"2167-10-28 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1040103,"text":", MED MICU 3:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? interval change\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with TBM, s/p trach\n REASON FOR THIS EXAMINATION:\n ? interval change\n ______________________________________________________________________________\n PFI REPORT\n No significant change compared to the prior studies. Extensive basal\n atelectasis.\n\n\n"},{"category":"Radiology","chartdate":"2167-10-23 00:00:00.000","description":"PICC W/O PORT","row_id":1039213,"text":" 11:27 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: Needs double lumen PICC; has Hx of DVT in upper extremities.\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ********************************* CPT Codes ********************************\n * PICC W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with ilius needs TPN\n REASON FOR THIS EXAMINATION:\n Needs double lumen PICC; has Hx of DVT in upper extremities.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JRCi 3:58 PM\n PICC line ready for use. Non-occlusive thrombus bilateral upper extremity.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: PICC line placement.\n\n INDICATION: Inability to perform bedside PICC line with patient needing TPN.\n\n The procedure was explained to the patient's proxy. A timeout was performed.\n\n RADIOLOGISTS: Dr. performed the procedure. Dr. , the Attending\n Radiologist, was present and supervised the entire procedure.\n\n TECHNIQUE: Using sterile technique and local anesthesia, the left basilic\n vein was punctured under direct ultrasound guidance using a micropuncture set.\n A small focal non-occlusive thrombus was detected within the vein more\n distally. Hard copy of ultrasound images were obtained before and immediately\n after establishing intravenous access. A peel-away sheath was then placed\n over a guidewire and a double-lumen PICC line measuring 41 cm in length was\n then placed through the peel-away sheath with its tip positioned in the SVC\n under fluoroscopic guidance. Position of the catheter was confirmed by a\n fluoroscopic spot film of the chest.\n\n The peel-away sheath and guidewire were then removed. The catheter was\n secured to the skin, flushed, and a sterile dressing applied.\n\n The patient was uncooperative during the procedure. There were no immediate\n post- procedural complications.\n\n IMPRESSION:\n 1. Uncomplicated ultrasound and fluoroscopically guided double-lumen PICC line\n via the left basilic venous approach. Final internal length is 41 cm, with\n the tip positioned in the SVC. The line is ready to use.\n\n 2. Small amount of non-occlusive thrombus was detected within bilateral\n basilic veins.\n\n Findings discussed with Dr. at 4:44 pm the day of examination.\n (Over)\n\n 11:27 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: Needs double lumen PICC; has Hx of DVT in upper extremities.\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"},{"category":"Radiology","chartdate":"2167-10-23 00:00:00.000","description":"FLUORO GUID PLCT/REPLCT/REMOVE CENTRAL LINE","row_id":1039214,"text":", C. MED MICU 11:27 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: Needs double lumen PICC; has Hx of DVT in upper extremities.\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with ilius needs TPN\n REASON FOR THIS EXAMINATION:\n Needs double lumen PICC; has Hx of DVT in upper extremities.\n ______________________________________________________________________________\n PFI REPORT\n PICC line ready for use. Non-occlusive thrombus bilateral upper extremity.\n\n"},{"category":"Radiology","chartdate":"2167-10-19 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1038109,"text":" 3:18 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for change from prior\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with tracheostomy\n REASON FOR THIS EXAMINATION:\n Please eval for change from prior\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Tracheostomy.\n\n COMPARISON: .\n\n PORTABLE CHEST RADIOGRAPH: Tracheostomy tube appears in unchanged position.\n Gastric tube is seen overlying the abdomen. Cardiac and mediastinal contours\n are unchanged. Bibasilar atelectasis and likely small pleural effusions are\n also unchanged. Unusual opacity is seen overlying the left mid lung, possibly\n atelectasis, although attention on followup is recommended.\n\n"},{"category":"Radiology","chartdate":"2167-10-23 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1039135,"text":" 7:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? aspiration, ? PNA\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 yo F, w/ trach and peg, s/p self-extubation, now w/ fever, ? aspiration\n REASON FOR THIS EXAMINATION:\n ? aspiration, ? PNA\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Tracheostomy and PEG status post self-extubation, now with fever and\n possible aspiration.\n\n FINDINGS: In comparison with the study of , there is opacification at the\n left base that again could reflect atelectasis or aspiration. Right lower\n lobe collapse is long-standing. Enlargement of the cardiac silhouette\n persists. No definite vascular congestion, raising the possibility of\n underlying cardiomyopathy.\n\n Tracheostomy tube remains in place.\n\n\n"},{"category":"Radiology","chartdate":"2167-10-22 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1038849,"text":" 2:54 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? Interval change\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with spinal injury, PEG tube in place but vomiting all tube\n feeds and no bowel sounds on exam.\n REASON FOR THIS EXAMINATION:\n ? Interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 2:54 A.M. ON .\n\n HISTORY: Spinal injury, PEG tube in place. Vomiting.\n\n IMPRESSION: AP chest compared to and 8.\n\n Developing opacification in left lower lobe could represent atelectasis or\n aspiration. Right lower lobe collapse is longstanding. Mild cardiomegaly is\n worsened. Tracheostomy tube is turned and has a very short intratracheal\n excursion. Clinical evaluation is advised. No pneumothorax.\n\n\n"},{"category":"Radiology","chartdate":"2167-10-18 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1037930,"text":", C. MED MICU 2:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate, effusion\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with long MICU admission, s/p trach, intermittently\n mechanically ventilated.\n REASON FOR THIS EXAMINATION:\n eval for infiltrate, effusion\n ______________________________________________________________________________\n PFI REPORT\n Unchanged right middle lobe and right lower lobe collapse and left lower lobe\n atelectasis. No enlarging pleural effusions.\n\n"},{"category":"Radiology","chartdate":"2167-10-22 00:00:00.000","description":"UGI SGL CONTRAST W/ KUB","row_id":1038939,"text":" 10:29 AM\n UGI SGL CONTRAST W/ KUB Clip # \n Reason: evaluate for dysmotility\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman s/p t-spine fx, repeated emesis with TFs.\n REASON FOR THIS EXAMINATION:\n evaluate for dysmotility\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 12:25 PM\n PFI: Findings are suggestive of underlying dysmotility with minimal antegrade\n or retrograde movement.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post thoracic spine fracture with repeated emesis, recently\n placed GJ tube with port in jejunum and still not tolerating tube feeds with\n episodes of tube feed vomiting.\n\n Comparison is made to CT examination dated and images from\n recent J-tube placement.\n\n Initial scout radiograph demonstrates appropriately positioned GJ tube with\n inflated balloon. Approximately 30 cc of Optiray contrast was injected\n through the port and was noted to predominantly pool within the loop of\n jejunum at the tube exit site with minimal retro and forward pulsion of\n contents. Intermittent fluoroscopy was performed for approximately 5 minutes\n to evaluate for motility pattern. Subsequently, an additional 10 mL of thin\n barium was instilled and displayed a similar pattern with only mild motility\n noted. No contrast is noted to reflux into the duodenum/stomach. Oral\n contrast is noted within the large bowel from prior CT examination.\n\n IMPRESSION:\n\n Findings are suggestive of underlying intestinal dysmotility with limited\n movement of injected contrast through the J-tube in either antegrade or\n retrograde direction. A repeat KUB is recommended centered over the upper\n abdomen in 15 minutes to evaluate for contrast progression.\n\n Findings discussed with Dr. shortly after exam acquisition.\n\n\n *\n\n"},{"category":"Radiology","chartdate":"2167-10-22 00:00:00.000","description":"UGI SGL CONTRAST W/ KUB","row_id":1038940,"text":", C. MED MICU 10:29 AM\n UGI SGL CONTRAST W/ KUB Clip # \n Reason: evaluate for dysmotility\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman s/p t-spine fx, repeated emesis with TFs.\n REASON FOR THIS EXAMINATION:\n evaluate for dysmotility\n ______________________________________________________________________________\n PFI REPORT\n PFI: Findings are suggestive of underlying dysmotility with minimal antegrade\n or retrograde movement.\n\n"},{"category":"Radiology","chartdate":"2167-10-24 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1039350,"text":" 3:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for change from prior\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with trach, fever, recurrent vomiting, desaturation\n REASON FOR THIS EXAMINATION:\n Please eval for change from prior\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST \n\n COMPARISON: .\n\n INDICATION: Fever.\n\n PICC terminates within the mid superior vena cava. There is otherwise no\n substantial change since the recent radiograph allowing for marked leftward\n patient rotation on the current study.\n\n\n"},{"category":"Radiology","chartdate":"2167-10-25 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1039489,"text":", C. MED MICU 2:55 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for change from prior\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with respiratory failure, trach\n REASON FOR THIS EXAMINATION:\n please eval for change from prior\n ______________________________________________________________________________\n PFI REPORT\n The left PICC line tip is at the junction of brachiocephalic vein and SVC,\n more proximal than on the prior study, otherwise worsening of atelectasis in\n the left lower lung.\n\n"},{"category":"Radiology","chartdate":"2167-10-26 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1039687,"text":" 3:41 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for change from prior\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with trach ?aspiration\n REASON FOR THIS EXAMINATION:\n please eval for change from prior\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLnc MON 9:18 AM\n PFI: No appreciable change.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Suspected aspiration.\n\n Portable AP chest radiograph was compared to prior study obtained on , , at 03:38 a.m.\n\n No appreciable change is demonstrated in this approximately 24 hours interval.\n Bibasilar atelectasis is unchanged, left more than right. The tracheostomy is\n in unchanged position. The upper lungs are aerated. The patient's head\n overlies the apices.\n\n\n"},{"category":"Radiology","chartdate":"2167-10-18 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1037929,"text":" 2:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate, effusion\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with long MICU admission, s/p trach, intermittently\n mechanically ventilated.\n REASON FOR THIS EXAMINATION:\n eval for infiltrate, effusion\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JRld SUN 2:35 PM\n Unchanged right middle lobe and right lower lobe collapse and left lower lobe\n atelectasis. No enlarging pleural effusions.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Intermittently mechanically ventilated, long MICU admission.\n\n Comparison is made with prior studies including most recent one on .\n\n Right middle lobe and right lower lobe collapse are unchanged as are left\n lower lobe atelectasis. If any, there is a small left pleural effusion.\n No PTX. Tracheostomy tube in standard position. Low lung volumes.\n Cardiomediastinal silhouette is unchanged.\n\n DR. \n"},{"category":"Radiology","chartdate":"2167-10-26 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1039688,"text":", C. MED MICU 3:41 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for change from prior\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with trach ?aspiration\n REASON FOR THIS EXAMINATION:\n please eval for change from prior\n ______________________________________________________________________________\n PFI REPORT\n PFI: No appreciable change.\n\n\n"},{"category":"Radiology","chartdate":"2167-10-22 00:00:00.000","description":"PORTABLE ABDOMEN","row_id":1039027,"text":" 3:31 PM\n PORTABLE ABDOMEN; -76 BY SAME PHYSICIAN # \n Reason: eval for movement of contrast\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with GI dysmotility, s/p UGI series this AM\n REASON FOR THIS EXAMINATION:\n eval for movement of contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 4:23 PM\n Continued progression of oral contrast into the distal small bowel/proximal\n large bowel. Findings are again suggestive of underlying intestinal\n dysmotility without evidence of obstruction. No further radiographic followup\n is deemed necessary.\n ______________________________________________________________________________\n FINAL REPORT\n Evaluate for interval movement of contrast in patient with probable underlying\n intestinal dysmotility.\n\n Comparison is made to prior portable abdominal radiograph and upper GI series\n from same date.\n\n There continues to be progression of the oral contrast instilled during the\n fluoroscopy examination from the morning, now in the distal small\n bowel/proximal large bowel. No definite contrast is noted within the\n duodenum/stomach.\n\n IMPRESSION:\n\n Findings again consistent with mild-to-moderate underlying intestinal\n dysmotility but no evidence of retrograde contrast movement into the\n duodenum/stomach was noted on real-time fluoroscopy or initial followup\n radiograph. No further films are deemed necessary.\n\n\n"},{"category":"Radiology","chartdate":"2167-10-22 00:00:00.000","description":"PORTABLE ABDOMEN","row_id":1039028,"text":", C. MED MICU 3:31 PM\n PORTABLE ABDOMEN; -76 BY SAME PHYSICIAN # \n Reason: eval for movement of contrast\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with GI dysmotility, s/p UGI series this AM\n REASON FOR THIS EXAMINATION:\n eval for movement of contrast\n ______________________________________________________________________________\n PFI REPORT\n Continued progression of oral contrast into the distal small bowel/proximal\n large bowel. Findings are again suggestive of underlying intestinal\n dysmotility without evidence of obstruction. No further radiographic followup\n is deemed necessary.\n\n\n"},{"category":"Radiology","chartdate":"2167-10-20 00:00:00.000","description":"CT ABDOMEN W/CONTRAST","row_id":1038473,"text":" 3:39 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: eval for transition point or evidence of obstruction\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with spinal injury, PEG tube in place but vomiting all tube\n feeds and no bowel sounds on exam.\n REASON FOR THIS EXAMINATION:\n eval for transition point or evidence of obstruction\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JXKc TUE 7:51 PM\n No evidence of obstruction. No acute intra-abdominal process.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 56-year-old female with spinal injury, PEG tube in place, but\n vomiting all tube feeds and no bowel sounds on examination. Evaluate for\n evidence of obstruction.\n\n COMPARISON: .\n\n TECHNIQUE: MDCT axial images were obtained from the lung bases symphysis\n pubis with administration of IV and oral contrast. Coronal and sagittal\n reformations were obtained.\n\n CT OF THE ABDOMEN WITH IV CONTRAST: The visualized heart and pericardium are\n unremarkable. There is atelectasis within both lung bases, with the\n visualized airways suggestive of tracheobronchomalacia. A 1- cm rounded\n calcific density within the left atelectatic left lower lobe is of unclear\n etiology, could represent a calcified granuloma, or sequela from prior trauma.\n There is no pleural effusion.\n\n The liver, spleen, adrenal glands, left kidney, and pancreas are unremarkable.\n Gallstones are present, without secondary findings for cholecystitis. There\n is a 3.5-cm cyst within the upper pole of the right kidney. Otherwise, the\n right kidney is unremarkable.\n\n There is a gastrostomy tube in place. The stomach, small bowel, and colon are\n collapsed, without evidence of bowel obstruction. There are scattered\n diverticula throughout the colon, without evidence of diverticulitis. A 2.5 cm\n rounded structure adjacent to the second/third portion of duodenum, likely\n reflects a duodenal diverticulum. There is no free fluid, free air, or\n pathologic adenopathy. Surgical clips are present within the right lower\n quadrant of the abdomen.\n\n CT OF THE PELVIS WITH IV CONTRAST: Foley catheter courses into the bladder.\n Rectum is unremarkable. There is no pelvic free fluid or adenopathy.\n\n OSSEOUS STRUCTURES: Patient is status post left hip replacement. There is a\n compression fracture of the T8 vertebral body as well as likely the T6\n vertebral body, as seen on , with a slightly increased loss\n (Over)\n\n 3:39 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: eval for transition point or evidence of obstruction\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n of vertebral body height.\n\n IMPRESSION:\n\n 1. No acute intra-abdominal process, without evidence of obstruction.\n\n 2. Atelectasis of both lung bases, with suggestion of tracheobronchomalacia,\n which may be related to chronic tracheostomy. This can be further evaluated\n with a CT trachea.\n\n 3. Cholelithiasis.\n\n 4. Diverticulosis without diverticulitis.\n\n\n"},{"category":"Radiology","chartdate":"2167-10-20 00:00:00.000","description":"CT ABDOMEN W/CONTRAST","row_id":1038474,"text":", C. MED MICU 3:39 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: eval for transition point or evidence of obstruction\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with spinal injury, tube in place but vomiting all tube\n feeds and no bowel sounds on exam.\n REASON FOR THIS EXAMINATION:\n eval for transition point or evidence of obstruction\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n No evidence of obstruction. No acute intra-abdominal process.\n\n"},{"category":"Radiology","chartdate":"2167-10-25 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1039488,"text":" 2:55 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for change from prior\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with respiratory failure, trach\n REASON FOR THIS EXAMINATION:\n please eval for change from prior\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLnc SUN 9:26 AM\n The left PICC line tip is at the junction of brachiocephalic vein and SVC,\n more proximal than on the prior study, otherwise worsening of atelectasis in\n the left lower lung.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Interval change in intubated patient with respiratory\n failure and tracheostomy.\n\n Portable AP chest radiograph was compared to and .\n\n The left PICC line tip is at the junction of brachiocephalic vein and SVC,\n slightly more proximal than on the prior study. The tracheostomy tip is at\n the midline. The bibasilar opacities have increased, obscuring the right and\n left heart border. The lung volumes remain low. Bilateral pleural effusion\n is most likely present.\n\n The radiodense opacity projecting over the left lower lobe corresponds to\n known calcified granuloma.\n\n"},{"category":"Radiology","chartdate":"2167-10-21 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1038566,"text":", C. MED MICU 3:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate or effusion\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with trach, concern for aspiration\n REASON FOR THIS EXAMINATION:\n eval for infiltrate or effusion\n ______________________________________________________________________________\n PFI REPORT\n Tracheostomy tube oriented horizontally should be evaluated clinically. Right\n basal atelectasis and small bilateral pleural effusions unchanged. Heart size\n normal. No pneumothorax.\n\n\n"},{"category":"Radiology","chartdate":"2167-10-22 00:00:00.000","description":"PORTABLE ABDOMEN","row_id":1038965,"text":" 11:46 AM\n PORTABLE ABDOMEN; -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: Need f/u study s/p tube study; requested by radiology\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with PEG/TRACH s/p t-spine frx, resp failure, and PNA, w/\n vomitting and now new Jtube via G-tube\n REASON FOR THIS EXAMINATION:\n Need f/u study s/p tube study; requested by radiology\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 2:30 PM\n PFI: Appropriate antegrade movement of injected contrast into the mid and\n distal jejunum. No reflux of contrast noted within the duodenum or stomach.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Evaluate progression of contrast from prior J-tube study.\n\n Comparison is made to J-tube study performed on same date.\n\n PORTABLE SUPINE ABDOMINAL RADIOGRAPH\n\n FINDINGS: Positioning of the J-tube is unchanged with contrast noted to have\n advanced antegrade into the mid to distal jejunum. No contrast is noted\n within the duodenum or stomach. Oral contrast from prior CT examination is\n again noted within the colon.\n\n IMPRESSION:\n\n No reflux contrast noted within the duodenum/stomach. Appropriate antegrade\n movement of the stomach into the loops of mid and distal jejunum.\n\n\n"},{"category":"Radiology","chartdate":"2167-10-22 00:00:00.000","description":"PORTABLE ABDOMEN","row_id":1038966,"text":", C. MED MICU 11:46 AM\n PORTABLE ABDOMEN; -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: Need f/u study s/p tube study; requested by radiology\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with PEG/TRACH s/p t-spine frx, resp failure, and PNA, w/\n vomitting and now new Jtube via G-tube\n REASON FOR THIS EXAMINATION:\n Need f/u study s/p tube study; requested by radiology\n ______________________________________________________________________________\n PFI REPORT\n PFI: Appropriate antegrade movement of injected contrast into the mid and\n distal jejunum. No reflux of contrast noted within the duodenum or stomach.\n\n\n"},{"category":"Radiology","chartdate":"2167-10-21 00:00:00.000","description":"CONVERT G TO GJ, ALL INCL.","row_id":1038769,"text":" 3:49 PM\n PERC G/G-J TUBE PLMT Clip # \n Reason: Please place J tube\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n Contrast: OPTIRAY Amt: 20\n ********************************* CPT Codes ********************************\n * CONVERT G TO GJ, ALL INCL. *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with PEG tube. Please place smaller G-J tube through G tube.\n REASON FOR THIS EXAMINATION:\n Please place J tube\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 56-year-old female with PEG tube. Please convert to J-tube.\n\n RADIOLOGISTS: Dr. , , and attending radiologist, Dr. ,\n who was present and supervised the entire procedure.\n\n PROCEDURE AND FINDINGS: The risks and benefits of the procedure were\n explained to the healthcare proxy and informed consent was obtained.\n A pre-procedure timeout was performed to confirm the identity of the patient\n by name, medical record number, date of birth, and the nature of the procedure\n to be performed. The patient was placed supine on the angiography table and\n the patient's mid abdomen and indwelling G-tube were prepped and draped in\n standard sterile fashion.\n\n Initial fluoroscopic image demonstrates gastrostomy tube located within the\n stomach. Injection of contrast through the indwelling G-tube demonstrates\n passage of contrast. After local anesthesia administration to the existing\n site with 1% lidocaine, a 0.035 wire was passed through the pre-\n existing G-tube and with the aid of a 5 French catheter was advanced\n under fluoroscopic guidance past the pylorus into the jejunum. The \n wire was replaced with a 0.035 Amplatz wire. After removal of the 5 French\n catheter, a 10 French -Alvatecoons gastrojejunostomy catheter was\n advanced over the wire through the indwelling gastrostomy tube with tip\n positioned in the jejunum. Appropriate position of the catheter was confirmed\n by injection of contrast. The wire was removed and the GJ tube secured to the\n skin with 0 silk sutures and a Flexi-Trak device. The patient tolerated the\n procedure well and there were no immediate complications.\n\n MODERATE SEDATION was provided by administering 180 mcg of Fentanyl and 3 mg\n of Versed via divided doses throughout the 43 minute intraservice time with\n continuous hemodynamic monitoring.\n\n IMPRESSION: Successful placement of a GJ tube through existing G-tube with\n tip positioned in the jejunum.\n (Over)\n\n 3:49 PM\n PERC G/G-J TUBE PLMT Clip # \n Reason: Please place J tube\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n Contrast: OPTIRAY Amt: 20\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"},{"category":"Radiology","chartdate":"2167-10-27 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1039854,"text":" 2:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with TBM, s/p trach\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Follow up.\n\n COMPARISON: , 4:18 a.m.\n\n FINDINGS: The current radiograph is markedly impaired by severe motion\n artifacts. On this limited basis, there is no obvious radiological change.\n The tracheostomy tube is in unchanged position. The retrocardiac lung areas\n could be minimally better ventilated.\n\n\n"},{"category":"Radiology","chartdate":"2167-10-21 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1038565,"text":" 3:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate or effusion\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with trach, concern for aspiration\n REASON FOR THIS EXAMINATION:\n eval for infiltrate or effusion\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): PSS WED 2:00 PM\n Tracheostomy tube oriented horizontally should be evaluated clinically. Right\n basal atelectasis and small bilateral pleural effusions unchanged. Heart size\n normal. No pneumothorax.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 3:14 A.M. \n\n HISTORY: Tracheostomy. Concern for aspiration.\n\n IMPRESSION: AP chest compared to and 6:\n\n Tracheostomy tube is oriented horizontally and should be evaluated clinically.\n Heart size normal. Right lower lobe atelectasis persists. Pleural effusion\n is bilateral and small. No pneumothorax.\n\n\n"},{"category":"Radiology","chartdate":"2167-10-04 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1035231,"text":" 3:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: lung fields\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with resp failure\n REASON FOR THIS EXAMINATION:\n lung fields\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DJRX SUN 10:25 AM\n No significant change.\n ______________________________________________________________________________\n FINAL REPORT\n SUPINE PORTABLE CHEST\n\n HISTORY: Respiratory failure, check lungs.\n\n One view. Comparison with . Lung volumes are somewhat low. There is\n continued evidence of pulmonary vascular congestion and bilateral pleural\n effusions unchanged. There is increased density in the retrocardiac area as\n before. Mediastinal structures are stable. A tracheostomy tube remains in\n place.\n\n IMPRESSION: No definite interval change.\n\n\n"},{"category":"Radiology","chartdate":"2167-10-04 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1035232,"text":", F. MED MICU 3:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: lung fields\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with resp failure\n REASON FOR THIS EXAMINATION:\n lung fields\n ______________________________________________________________________________\n PFI REPORT\n No significant change.\n\n\n"},{"category":"Radiology","chartdate":"2167-10-09 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1036271,"text":" 3:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?interval change\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with t-spine frx and respiratory failure, s/p VAP, and\n PEG/trach\n REASON FOR THIS EXAMINATION:\n ?interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLnc FRI 12:08 PM\n No appreciable change during the short-time interval.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of a patient with T-spine fractures and\n respiratory failure.\n\n Portable AP chest radiograph was compared to obtained at\n 8:30 p.m.\n\n The current study demonstrates no significant change in the degree of left\n retrocardiac consolidation, consistent with atelectasis/aspiration. The right\n hemidiaphragm remains high. The upper lungs are grossly unremarkable. The\n position of the tracheostomy is unchanged. The PICC line tip can be followed\n till the cavoatrial junction.\n\n\n"},{"category":"Radiology","chartdate":"2167-10-14 00:00:00.000","description":"L UNILAT UP EXT VEINS US LEFT","row_id":1037258,"text":", C. MED MICU 3:29 PM\n UNILAT UP EXT VEINS US LEFT Clip # \n Reason: Pleas eeval for DVT\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with fever, h/o UE DVT with PICC line\n REASON FOR THIS EXAMINATION:\n Pleas eeval for DVT\n ______________________________________________________________________________\n PFI REPORT\n PFI: Very small segment (1-cm in length) of nonocclusive thrombus in the left\n axillary vein. A PICC catheter is present on the left.\n\n\n"},{"category":"Radiology","chartdate":"2167-10-12 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1036725,"text":" 2:50 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? interval change\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with traumatic T-spine frx, HAP/VAP and respiratory ditress,\n now extubated, but spiking fevers and slowly improving MS\n REASON FOR THIS EXAMINATION:\n ? interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Status post respiratory distress.\n\n COMPARISON: , 12:44 a.m.\n\n FINDINGS: As compared to the previous radiograph, there is little overall\n change. Small newly occurred left-sided atelectasis that project over the\n costophrenic sinus. The right lung base has slightly increased in\n transparency. Unchanged is a small right-sided pleural effusion. The size of\n the cardiac silhouette is unchanged and at the upper range of normal. No\n obvious overhydration. No newly occurred focal parenchymal opacities\n suggestive of pneumonia.\n\n\n"},{"category":"Radiology","chartdate":"2167-10-09 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1036272,"text":", F. MED MICU 3:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?interval change\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with t-spine frx and respiratory failure, s/p VAP, and\n PEG/trach\n REASON FOR THIS EXAMINATION:\n ?interval change\n ______________________________________________________________________________\n PFI REPORT\n No appreciable change during the short-time interval.\n\n\n"},{"category":"Radiology","chartdate":"2167-10-15 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1037316,"text":" 3:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for change\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with elevated diaphragm, ? effusion\n REASON FOR THIS EXAMINATION:\n Please eval for change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 56-year-old woman with question of effusion and interval change.\n\n COMPARISON: Comparison is made to chest radiograph from .\n\n FINDINGS: A tracheostomy tube and left PICC are in good position, unchanged\n from previous study.\n\n Small right pleural effusion is unchanged. There is no left pleural effusion.\n Right middle and lower lobe collapse is unchanged. There is interval increase\n in left lung base opacity, likely progressive atelectasis. Lungs are\n otherwise clear. Cardiac contours are obscured by adjacent atelectasis and\n effusion. Mediastinal contours are normal. Visualized soft tissue structures\n and bony thorax are unremarkable.\n\n IMPRESSION:\n 1. Persistent right middle/lower lobe collapse and progressive left basilar\n atelectasis.\n 2. Unchanged small right pleural effusion.\n\n\n"},{"category":"Radiology","chartdate":"2167-10-11 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1036618,"text":" 12:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o aspiration/infection\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with recent aspiration and fever.\n REASON FOR THIS EXAMINATION:\n r/o aspiration/infection\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Followup.\n\n COMPARISON: , 4:24 a.m.\n\n FINDINGS: As compared to the previous radiograph, the tracheostomy tube is in\n unchanged position. The size of the cardiac silhouette is also unchanged.\n The retrocardiac lung areas are slightly better ventilated than before, the\n right basal opacities are unchanged. There is no evidence of newly occurred\n focal parenchymal opacities. Unchanged moderate cardiomegaly without signs of\n obvious overhydration. No pneumothorax.\n\n\n"},{"category":"Radiology","chartdate":"2167-10-14 00:00:00.000","description":"L UNILAT UP EXT VEINS US LEFT","row_id":1037257,"text":" 3:29 PM\n UNILAT UP EXT VEINS US LEFT Clip # \n Reason: Pleas eeval for DVT\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with fever, h/o UE DVT with PICC line\n REASON FOR THIS EXAMINATION:\n Pleas eeval for DVT\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AHPb WED 7:35 PM\n PFI: Very small segment (1-cm in length) of nonocclusive thrombus in the left\n axillary vein. A PICC catheter is present on the left.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fever, history of upper extremity DVT with PICC line.\n\n FINDINGS: -scale and color Doppler son of the left upper extremity\n including the subclavian, internal jugular, axillary, basilic, and cephalic\n veins demonstrate very small segment of nonocclusive thrombus in the left\n axillary (1-cm in length). Otherwise, there is normal flow, compressibility,\n and waveforms. A PICC catheter is present entering the left basilic.\n\n IMPRESSION: Very small nonocclusive DVT in the left axillary vein.\n\n\n"},{"category":"Radiology","chartdate":"2167-10-05 00:00:00.000","description":"CT CHEST W/O CONTRAST","row_id":1035524,"text":" 5:23 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: ? loculated effusion,\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n Field of view: 40\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with resp failure s/p fall and T-spine frx, now w/ worsening\n bilateral effusions, s/p treated VAP, considering Tap of effusion\n REASON FOR THIS EXAMINATION:\n ? loculated effusion,\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): KCLd TUE 5:10 PM\n 1. Improving bilateral consolidations, atelectasis, and effusions. No\n loculated effusion identified. Persistent smaller bilateral pleural effusions\n and atelectasis/consolidation could be secondary to aspiration.\n 2. Evidence of tracheobronchomalacia.\n 3. Evidence of overinflation of the tracheostomy cuff.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Respiratory failure, status post fall with T-spine fracture,\n worsening bilateral effusions. Evaluate for loculated effusion.\n\n COMPARISON: .\n\n TECHNIQUE: MDCT-acquired axial images of the chest were obtained without\n contrast. 5- and 1.25-mm thin section images were displayed. Coronal and\n sagittal reformatted images were also displayed.\n\n FINDINGS: Patient is status post tracheostomy. Small amount of hematoma is\n seen surrounding the tracheostomy tube. The tracheal cuff appears slightly\n overinflated. Right hypoattenuating thyroid nodule is noted.\n\n Compared to prior study, there is improved aeration of the lungs bilaterally.\n There has been interval decrease in the pleural effusions not atelectasis\n bilaterally. Persistent lower lobe atelectasis is seen bilaterally, with\n small pleural effusions. There is no loculated effusion. There has been\n interval improvement of the patchy nodular densities as well, suggesting\n improving infection. Persistent large calcified granuloma measuring upwards\n of 13 mm again seen in the left lower lobe.\n\n There is a severe collapse of the tracheal and bronchial airways, consistent\n with tracheobronchomalacia. Pulmonary artery appears enlarged measuring\n upwards of 3.5 cm, raising concern for possible pulmonary arterial\n hypertension. Coronary artery calcifications are seen. Heart size appears\n upper limits of normal. No pathologically enlarged mediastinal or hilar\n lymphadenopathy identified. Gastric tube is seen in the stomach. Calcified\n stones seen within the gallbladder. A cystic lesion in the right kidney again\n identified. Otherwise, limited views of the upper abdomen are grossly\n unremarkable.\n\n IMPRESSION:\n (Over)\n\n 5:23 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: ? loculated effusion,\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n Field of view: 40\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 1. Improving bilateral consolidations and effusions. No loculated effusion\n identified. Persistent atelectasis/consolidation at the lower lobes\n bilaterally with small effusions, possibly secondary to aspiration.\n 2. Evidence of tracheobronchomalacia.\n 3. Evidence of slight overinflation of the tracheostomy cuff.\n 4. Cholelithiasis.\n 5. Right thyroid nodule. Ultrasound for further evaluation as clinically\n indicated would be recommended when patient is stable.\n\n"},{"category":"Radiology","chartdate":"2167-10-05 00:00:00.000","description":"CT CHEST W/O CONTRAST","row_id":1035525,"text":", F. MED MICU 5:23 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: ? loculated effusion,\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n Field of view: 40\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with resp failure s/p fall and T-spine frx, now w/ worsening\n bilateral effusions, s/p treated VAP, considering Tap of effusion\n REASON FOR THIS EXAMINATION:\n ? loculated effusion,\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n 1. Improving bilateral consolidations, atelectasis, and effusions. No\n loculated effusion identified. Persistent smaller bilateral pleural effusions\n and atelectasis/consolidation could be secondary to aspiration.\n 2. Evidence of tracheobronchomalacia.\n 3. Evidence of overinflation of the tracheostomy cuff.\n\n"},{"category":"Radiology","chartdate":"2167-10-15 00:00:00.000","description":"CONVERT G TO GJ, ALL INCL.","row_id":1037472,"text":" 5:01 PM\n PERC G/J TUBE CHECK Clip # \n Reason: Please reposition gastric tube into duodenum or jejunum.\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n Contrast: OPTIRAY Amt: 15\n ********************************* CPT Codes ********************************\n * CONVERT G TO GJ, ALL INCL. -52 REDUCED SERVICES *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with PEG and Trach, s/p traumatic T-spine frx and respiratory\n failure, HAP/VAP,now w/ multiple episodes of emesis into oropharynx.\n REASON FOR THIS EXAMINATION:\n Please reposition gastric tube into duodenum or jejunum.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JXXb FRI 10:08 AM\n Exchange of existing G tube for a GJ tube without success.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: The patient is a 56-year-old woman with a PEG and\n tracheostomy, status post traumatic thoracic spinal fracture and respiratory\n failure. A G tube was placed surgically, and multiple episodes reflux. A\n request was made for conversion of G to a gasrto-jejunal feeding tube.\n\n OPERATORS: Dr. and Dr. , the attending radiologist\n who was present and supervised during the whole procedure.\n\n PROCEDURE: G tube injection.\n\n SEDATION: Lidocaine was used for local anesthesia.\n\n PROCEDURE AND FINDINGS: After the risks and benefits of the procedure as well\n as the conscious sedation were explained, informed consent was obtained. The\n patient was brought to the angiographic suite and placed supine on the imaging\n table. The catheter area was prepared and draped in the usual sterile\n fashion.\n\n A scout image and contrast injection verified the existing gastric tube with\n its tip in the gastric lumen. A guide wire from a MIC GJ feeding tube kit was\n advanced into the gastric lumen through the existing G tube. The external\n skin sutures were removed, but the existing G tube could not be removed due to\n the existence of an internal securing disc which could not be removed. A\n portion of the external gastric tube was cut and a connector was placed. Tube\n exchange can be performed only after surgical removal of the existing tube.\n\n The existing gastric tube was sutured to the skin and a sterile dressing was\n applied.\n\n There were no immediate complications.\n\n IMPRESSION:\n 1. Unsuccessful exchange of the existing gastric tube for a jejunal feeding\n tube due to the existence of internal securing disc of the gastric tube that\n (Over)\n\n 5:01 PM\n PERC G/J TUBE CHECK Clip # \n Reason: Please reposition gastric tube into duodenum or jejunum.\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n Contrast: OPTIRAY Amt: 15\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n requires surgical removal.\n 2. Existing tube has it's tip within the gastric lumen.\n\n\n\n"},{"category":"Radiology","chartdate":"2167-10-08 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1035989,"text":" 2:52 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? Interval change\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with tramatic T-spine frx, and respiratory failure\n REASON FOR THIS EXAMINATION:\n ? Interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 9:24 AM\n No relevant change.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Respiratory failure, interval change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there are extensive motion\n artifacts that clearly limits the interpretation. Unchanged moderate\n retrocardiac opacity and elevation of the hemidiaphragm. There could be a\n minimal right-sided pleural effusion. The size of the cardiac silhouette is\n unchanged. No newly occurred focal parenchymal opacity suggestive of\n pneumonia.\n\n\n"},{"category":"Radiology","chartdate":"2167-10-08 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1035990,"text":", F. MED MICU 2:52 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? Interval change\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with tramatic T-spine frx, and respiratory failure\n REASON FOR THIS EXAMINATION:\n ? Interval change\n ______________________________________________________________________________\n PFI REPORT\n No relevant change.\n\n\n"},{"category":"Radiology","chartdate":"2167-10-11 00:00:00.000","description":"P ABDOMEN (SUPINE ONLY) PORT","row_id":1036673,"text":" 11:35 AM\n ABDOMEN (SUPINE ONLY) PORT Clip # \n Reason: Eval for signs of obstruction,\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman s/p T-spine frx, HAP/, and trach w/ episodes of\n vomiting and ?aspiration. Long course of narcotics. ?ileus/obstruction\n REASON FOR THIS EXAMINATION:\n Eval for signs of obstruction,\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Episodes of vomiting, signs of obstruction.\n\n FINDINGS: Normal borders of the psoas muscle. Total hip replacement, left.\n Air in the rectum. tube in situ. No secure evidence of free air. No\n evidence of pathologic air-fluid levels.\n\n\n"},{"category":"Radiology","chartdate":"2167-10-15 00:00:00.000","description":"CONVERT G TO GJ, ALL INCL.","row_id":1037473,"text":", C. MED MICU 5:01 PM\n PERC G/J TUBE CHECK Clip # \n Reason: Please reposition gastric tube into duodenum or jejunum.\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n Contrast: OPTIRAY Amt: 15\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with PEG and Trach, s/p traumatic T-spine frx and respiratory\n failure, HAP/VAP,now w/ multiple episodes of emesis into oropharynx.\n REASON FOR THIS EXAMINATION:\n Please reposition gastric tube into duodenum or jejunum.\n ______________________________________________________________________________\n PFI REPORT\n Exchange of existing G tube for a GJ tube without success.\n\n"},{"category":"Radiology","chartdate":"2167-10-16 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1037530,"text":", C. MED MICU 3:49 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? interval change\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with respiratory failure, s/p traumatic t-spine frx, s/pHAP\n REASON FOR THIS EXAMINATION:\n ? interval change\n ______________________________________________________________________________\n PFI REPORT\n No change since at least in right middle and lower lobe collapse,\n left lower lobe atelectasis, and small bilateral pleural effusions.\n\n\n"},{"category":"Radiology","chartdate":"2167-10-14 00:00:00.000","description":"CTA CHEST W&W/O C&RECONS, NON-CORONARY","row_id":1037218,"text":" 12:55 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: Pleas eevaluate for PE\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with persistent sinus tachycardia, h/o UE DVT, fever,\n abnormal CXR\n REASON FOR THIS EXAMINATION:\n Pleas eevaluate for PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): MLKb WED 3:12 PM\n No PE centrally.\n Study limited due to motion.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 56-year-old female with persistent sinus tachycardia, history of\n upper extremity DVT, fever, abnormal chest x-ray. Please evaluate for PE.\n\n TECHNIQUE: MDCT of the chest was performed before and after administration of\n intravenous contrast. Images were reformatted in the axial, sagittal, coronal\n and oblique planes.\n\n COMPARISON: CT performed .\n\n FINDINGS: No filling defect can be identified in the central pulmonary\n arteries, that could suggest pulmonary embolism. Study is limited due to\n motion and poor contrast enhancement of pulmonary arteries.\n A central line is seen with the tip in the cavoatrial junction. The patient is\n status post tracheostomy. Minimal soft tissue edema is seen surrounding the\n tracheostomy tube at its insertion. Above the level of the tracheal cuff,\n pulling secretions are noted. Stable calcified granuloma in the left lower\n lobe, (measuring 12 mm). Increased in number of borderline size lymph nodes in\n the mediastinum, measuring up to 10 mm in the APW . Air- trapping is noted.\n There is resolution of pleural effusions bilaterally. There is complete\n collapse of the right middle lobe and partial collapse of the right lower\n lobe. Dependent atelectases are seen in the lingula and left lower lobe. A\n wedge-shaped consolidation is seen in the right upper lobe could correspond to\n an area of infarction. There is severe collapsability of the tracheal and\n bronchial airways, as previously described, consistent with\n tracheobronchomalacia. Coronary artery calcifications are seen. Heart size\n appears in the normal limits. Minimal pericardial effusion. Enlarged pulmonary\n arteries measuring up to 30 mm suggest presence of pulmonary hypertension.\n Limited evaluation of abdominal organs represents of calcified stones within\n the gallbladder.\n\n BONE WINDOWS: Multiple collapsed fractures are seen in the thoracic spine.\n\n IMPRESSION:\n\n 1. No evidence of the central pulmonary embolism. The study is limited due\n (Over)\n\n 12:55 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: Pleas eevaluate for PE\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n to motion and poor enhancement of pulmonary artery branches.\n 2. Persistent collapse of the right middle lobe and right lower lobe.\n 3. Evidence of tracheobronchomalacia.\n 4. Cholelithiasis.\n 5. A wedge-shaped opacity in the right upper lobe on today's study but not\n seen in the prior study on , is nonspecific but could\n potentially represent infarction.\n\n"},{"category":"Radiology","chartdate":"2167-10-08 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1036239,"text":" 8:04 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval for infiltrate\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with respiratory failure, recent pneumonia, on mechanical\n vent, now with new fever.\n REASON FOR THIS EXAMINATION:\n eval for infiltrate\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLnc FRI 10:15 AM\n Newly developed left lower lobe retrocardiac opacity most likely consistent\n with atelectasis. Infectious process cannot be excluded.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Respiratory failure in a patient on mechanical\n ventilation.\n\n Portable AP chest radiograph was compared to prior study obtained the same day\n earlier at 03:23 a.m. and .\n\n The tracheostomy is at the midline with the tip terminating 3 cm above the\n carina. The left PICC line tip terminates approximately at the level of\n cavoatrial junction.\n\n The cardiomediastinal silhouette is unchanged. Interval worsening in left\n retrocardiac opacity is demonstrated consistent with a newly developed\n atelectasis. Aspiration is another possibility. Left pleural effusion is\n noted, small, grossly unchanged. The rest of the findings are unchanged.\n\n"},{"category":"Radiology","chartdate":"2167-10-08 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1036240,"text":", F. MED MICU 8:04 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval for infiltrate\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with respiratory failure, recent pneumonia, on mechanical\n vent, now with new fever.\n REASON FOR THIS EXAMINATION:\n eval for infiltrate\n ______________________________________________________________________________\n PFI REPORT\n Newly developed left lower lobe retrocardiac opacity most likely consistent\n with atelectasis. Infectious process cannot be excluded.\n\n"},{"category":"Radiology","chartdate":"2167-10-14 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1037126,"text":" 1:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change. evaluate for new infiltrate\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with traumatic T-spine frx, HAP/VAP and respiratory ditress,\n now extubated, fevers, agitation and tachypnic\n REASON FOR THIS EXAMINATION:\n interval change. evaluate for new infiltrate\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JRld WED 1:03 PM\n Unchanged appearance of the chest with small atelectasis in the left lower\n lobe, small right pleural effusion and right lower lobe atelectasis.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: T-spine fracture, respiratory distress with fever.\n\n Comparison is made with prior study of .\n\n Mildly improved left lower lobe opacities. Likely improving atelectasis.\n There is a small left pleural effusion. Tracheostomy tube is in place.\n Cardiomediastinal contours are unchanged. Small right pleural effusion and\n right lower lobe atelectasis are unchanged.\n\n jr\n\n DR. \n"},{"category":"Radiology","chartdate":"2167-10-14 00:00:00.000","description":"CTA CHEST W&W/O C&RECONS, NON-CORONARY","row_id":1037219,"text":", C. MED MICU 12:55 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: Pleas eevaluate for PE\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with persistent sinus tachycardia, h/o UE DVT, fever,\n abnormal CXR\n REASON FOR THIS EXAMINATION:\n Pleas eevaluate for PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n No PE centrally.\n Study limited due to motion.\n\n"},{"category":"Radiology","chartdate":"2167-10-07 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1035784,"text":" 3:38 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with asp PNA, intubated\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Bedside supine AP chest radiograph.\n\n HISTORY: 56-year-old woman with aspiration pneumonia. Question interval\n change.\n\n COMPARISON: Comparison is made to chest radiograph from .\n\n FINDINGS: There has been interval improvement in the retrocardiac\n consolidation with minimal areas of residual consolidations seen at the left\n lung base and right lung base. Small right and tiny left pleural effusions\n are also improved from the most recent radiograph. The lungs are otherwise\n clear. The right hemidiaphragm is elevated. Cardiomediastinal contours is\n normal. Visualized soft tissue structures and bony thorax are normal. A\n tracheostomy tube and left PICC line are again seen in good position.\n\n IMPRESSION:\n 1. Interval improvement in retrocardiac consolidation with minimal residual\n consolidation.\n 2. Interval improvement in bilateral pleural effusions.\n\n\n\n\n"},{"category":"Radiology","chartdate":"2167-10-14 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1037127,"text":", C. MED MICU 1:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change. evaluate for new infiltrate\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with traumatic T-spine frx, HAP/ and respiratory ditress,\n now extubated, fevers, agitation and tachypnic\n REASON FOR THIS EXAMINATION:\n interval change. evaluate for new infiltrate\n ______________________________________________________________________________\n PFI REPORT\n Unchanged appearance of the chest with small atelectasis in the left lower\n lobe, small right pleural effusion and right lower lobe atelectasis.\n\n"},{"category":"Radiology","chartdate":"2167-10-10 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1036501,"text":" 3:27 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? interval change\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with traumatic T-spine frx, respiratory distress follwed by\n HAP/VAP, resolving, now w/ ? new aspiration vs brewing LLL process.\n REASON FOR THIS EXAMINATION:\n ? interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Traumatic T spine fracture, concern for aspiration or left lower\n lobe pneumonia.\n\n FINDINGS: A single frontal chest radiograph was compared to . No new\n opacities seen. There is improved aeration within the retrocardiac\n space. There is stable elevation of the right hemidiaphragm. There is a\n stable appearance of the cardiac and mediastinal contours. Tracheostomy\n remains in place. The osseous structures are stable.\n\n IMPRESSION: No new opacities identified, as questioned. Improved\n aeration within the retrocardiac space. Stable elevation of the right\n hemidiaphragm.\n\n"},{"category":"Radiology","chartdate":"2167-10-03 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1035114,"text":" 2:50 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Volume status, interval change\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with respiratory distress, s/p trach placement.\n REASON FOR THIS EXAMINATION:\n Volume status, interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 4:02 A.M., \n\n HISTORY: 56-year-old woman with respiratory distress. Trach placement.\n\n IMPRESSION: AP chest compared to , through 19.\n\n Large right pleural effusion and moderate pulmonary edema have worsened since\n . Heart size top normal. Tracheostomy tube midline. No\n pneumothorax. Left pleural effusion is small-to-moderate, but more difficult\n to assess.\n\n\n"},{"category":"Radiology","chartdate":"2167-10-16 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1037529,"text":" 3:49 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? interval change\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with respiratory failure, s/p traumatic t-spine frx, s/pHAP\n REASON FOR THIS EXAMINATION:\n ? interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): PSS 3:34 PM\n No change since at least in right middle and lower lobe collapse,\n left lower lobe atelectasis, and small bilateral pleural effusions.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 4:18 AM \n\n HISTORY: Respiratory failure, spine fracture.\n\n IMPRESSION: AP chest compared to :\n\n Right middle and lower lobe collapse, less severe left lower lobe atelectasis\n and small bilateral pleural effusions unchanged since . Tracheostomy\n tube in standard placement.\n\n\n"},{"category":"Radiology","chartdate":"2167-10-15 00:00:00.000","description":"PR UNILAT UP EXT VEINS US PORT RIGHT","row_id":1037340,"text":" 7:34 AM\n UNILAT UP EXT VEINS US PORT RIGHT Clip # \n Reason: please eval for DVT\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with h/o UE DVT and tachycardia, please eval for clot.\n REASON FOR THIS EXAMINATION:\n please eval for DVT\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 10:09 AM\n No evidence of DVT in the right upper extremity. Resolution of nonocclusive\n thrombus in the right axillary and basilic veins.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of upper extremity DVT and tachycardia. Assess for clot.\n\n COMPARISON: Upper extremity ultrasound of .\n\n RIGHT UPPER EXTREMITY ULTRASOUND: -scale and Doppler son of the\n right internal jugular, subclavian, axillary, basilic, cephalic, and brachial\n veins was performed. Normal flow, compressibility and waveforms were\n demonstrated. No thrombus was identified today, particularly in the axillary\n and basilic veins where nonocclusive thrombus was seen previously. The wall of\n the axillary vein appeared diffusely thickened, possibly an inflammatory\n change related to prior non- occlusive thrombus. Augmentation was not\n performed on this examination due to the concern for clot that was previously\n present.\n\n IMPRESSION: No evidence of DVT in the right upper extremity.\n\n"},{"category":"Radiology","chartdate":"2167-10-15 00:00:00.000","description":"PR UNILAT UP EXT VEINS US PORT RIGHT","row_id":1037341,"text":", C. MED MICU 7:34 AM\n UNILAT UP EXT VEINS US PORT RIGHT Clip # \n Reason: please eval for DVT\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with h/o UE DVT and tachycardia, please eval for clot.\n REASON FOR THIS EXAMINATION:\n please eval for DVT\n ______________________________________________________________________________\n PFI REPORT\n No evidence of DVT in the right upper extremity. Resolution of nonocclusive\n thrombus in the right axillary and basilic veins.\n\n"},{"category":"Radiology","chartdate":"2167-10-02 00:00:00.000","description":"BY DIFFERENT PHYSICIAN","row_id":1035051,"text":" 3:11 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: interval change\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman S/P trach/PEG\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n INDICATION: Status post tracheostomy.\n\n Tracheostomy tube is in standard position with tip terminating about 5 cm\n above the carina. Left PICC terminates in superior vena cava, and nasogastric\n tube has been removed. Cardiomediastinal contour appears slightly less\n widened, and pulmonary edema has slightly improved. Moderate right and small-\n to-moderate left pleural effusion have also slightly decreased. No\n pneumothorax or pneumomediastinum. Incidental left lower lobe granuloma.\n\n\n"},{"category":"ECG","chartdate":"2167-09-29 00:00:00.000","description":"Report","row_id":222651,"text":"Narrow complex tachycardia at rate 123. Atrial mechanism is uncertain.\nThe differential is between sinus tachycardia, supraventricular\ntachy-arrhythmia and accelerated junctional rhythm. Compared to the previous\ntracing of sinus tachycardia with first degree A-V block has given\nway to the current rhythm. Both tracings show borderline low voltage with\ngeneralized non-specific repolarization abnormality.\nTRACING #1\n\n"},{"category":"ECG","chartdate":"2167-10-27 00:00:00.000","description":"Report","row_id":222642,"text":"Normal sinus rhythm with A-V conduction delay. Borderline voltage criteria for\nleft ventricular hypertrophy. Compared to tracing #1 the A-V conduction delay\nis new.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2167-10-26 00:00:00.000","description":"Report","row_id":222643,"text":"Normal sinus rhythm. Voltage criteria for left ventricular hypertrophy with\nsecondary ST-T wave abnormalities. Compared to the previous tracing of \nthe A-V nodal re-entrant tachycardia is no longer present.\nTRACING #1\n\n"},{"category":"ECG","chartdate":"2167-10-18 00:00:00.000","description":"Report","row_id":222644,"text":"Supraventricular tachycardia, probable A-V nodal re-entrant tachycardia.\nCompared to the previous tracing of the supraventricular tachycardia\nis as previously described. There is also delayed R wave transition.\n\n"},{"category":"ECG","chartdate":"2167-10-07 00:00:00.000","description":"Report","row_id":222645,"text":"There is a run of supraventricular tachycardia followed by a premature atrial\ncontraction and then sinus rhythm with probable left atrial abnormality.\nCompared to tracing #3 the premature atrial contraction and sinus rhythm are\nboth new.\nTRACING #4\n\n"},{"category":"ECG","chartdate":"2167-10-07 00:00:00.000","description":"Report","row_id":222646,"text":"Supraventricular tachycardia or sinus tachycardia. Compared to tracing #2\nearlier the same date supraventricular tachycardia is present in the entire\nstrip.\nTRACING #3\n\n"},{"category":"ECG","chartdate":"2167-10-07 00:00:00.000","description":"Report","row_id":222647,"text":"There appears to be a run of supraventricular tachycardia followed by a\npremature atrial contraction and then sinus rhythm with probable left\natrial abnormality and borderline first degree A-V block. Compared to the\nprevious tracing of no significant change.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2167-10-06 00:00:00.000","description":"Report","row_id":222648,"text":"There is a run of supraventricular tachycardia followed by a premature atrial\ncontraction and then sinus rhythm. Consider left atrial abnormality. Compared\nto the previous tracing of supraventricular tachycardia is present.\nTRACING #1\n\n"},{"category":"ECG","chartdate":"2167-10-05 00:00:00.000","description":"Report","row_id":222649,"text":"Narrow complex rhythm with probable low amplitude P waves. A wider complex\nbeat may be supraventricular with aberration or ventricular premature beat.\nThere are probable atrial premature beats of multifocal origin. Borderline\nlow voltage throughout. Since the previous tracing of the rate is\nfaster.\n\n"},{"category":"ECG","chartdate":"2167-10-01 00:00:00.000","description":"Report","row_id":222650,"text":"Compared with the prior tracing undisclosed narrow complex tachycardia has\ngiven way once again to sinus bradycardia with first degree A-V block and\noccasional interpolated ventricular premature beat. Non-specific\nrepolarization change and low voltage. Pericardial disease should be included\nin the differential.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2167-09-21 00:00:00.000","description":"Report","row_id":222871,"text":"Regular supraventricular rhythm. Some semblance of P waves is discerned in\nlead V3 but this is not definite. Borderline low voltage in the limb leads.\nDiffuse non-specific ST-T wave changes. Compared to the previous tracing\nof the findings are similar.\n\n"},{"category":"ECG","chartdate":"2167-09-20 00:00:00.000","description":"Report","row_id":222872,"text":"Sinus rhythm. Non-specific ST-T wave changes. Compared to the previous\ntracing of no significant change.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2167-09-19 00:00:00.000","description":"Report","row_id":222873,"text":"Sinus rhythm. Non-specific ST-T wave changes. No previous tracing available\nfor comparison.\nTRACING #1\n\n"},{"category":"ECG","chartdate":"2167-09-26 00:00:00.000","description":"Report","row_id":222869,"text":"Sinus rhythm. First degree A-V block. Low QRS voltage in the precordial leads\nwith a delayed R wave progression, probably a normal variant. Diffuse\nnon-specific T wave flattening. Compared to the previous tracing of \nno significant change.\n\n"},{"category":"ECG","chartdate":"2167-09-24 00:00:00.000","description":"Report","row_id":222870,"text":"Atrial mechanism is unclear but probable sinus bradycardia with first\ndegree A-V blcok. Generalized low voltage. Generalized non-specific\nrepolarization abnormalities. Consider electrolyte abnormality, consider\npericardial effusion, consider drug effect. A junctional mechanism at\nrate 48 cannot be excluded but is somewhat less likely. Compared to the\nprevious tracing of normal sinus rhythm at rate 80 has given way to\nsinus bradycardia with first degree A-V block.\n\n"},{"category":"Nursing","chartdate":"2167-10-12 00:00:00.000","description":"Nursing Progress Note","row_id":637207,"text":"Tachycardia, Other\n Assessment:\n Pt restless and awake with tachycardia at 140-150. Md notified and in\n to assess. Pt also denies any pain every time asked.\n Action:\n Pt given haldol po and IV, valium po/IV and morphine IVP. Emotional\n support also given w/o effect.\n Response:\n Sedation given with NO effect. MD aware. No more interventions for now.\n HR decreased to 120 once pt back in bed and sleeping.\n Plan:\n Continue to eval tachycardia.\n Hypernatremia (high sodium)\n Assessment:\n NA elevated this am .\n Action:\n H2O flushes increased to 100 cc q 4hrs.\n Response:\n Na level to be drawn in am.\n Plan:\n Continue current plan.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS coarse throughout and slight improved after deep sx.\n Action:\n Pt placed on TC this am at 9am x 8hrs and tol well by pt with O2sat\n 93-96%. Pt was able to have prod cough of now green-yellow secretions.\n Pt placed on CPAP +PS once back in bed in order to rest pt overnight.\n Response:\n Pt tol being on TC very well. Pt was placed on pass\n muir valve, but\n was only able to tol it for 15 min inability to clear secretions.\n Plan:\n Needs sputum sample for culture.\n Altered mental status (not Delirium)\n Assessment:\n Pt awake almost the whole day and has been restless. MD aware.\n Action:\n Pt given haldol, valium and Morphine.\n Response:\n No effect from sedation.\n Plan:\n Continue to eval MS.\n"},{"category":"Nursing","chartdate":"2167-10-06 00:00:00.000","description":"Nursing Progress Note","row_id":636097,"text":"55 yr old transferred from OSH on ^th. Pt with PNA/ARDS and\n T-spine fracture. Pt now with trach and PEG.\n Altered mental status (not Delirium)\n Assessment:\n Versed and fentanyl gtt stopped and pt had PO doses of valium and\n haldol given\n Action:\n Pt lethargic throughout the day, did wake more during the day.\n Response:\n Follows all commands but intermittently, does get very aggited with\n stimulation but PO meds did help\n Plan:\n Try to keep pt off IV sedation meds. And give PO haldol and valium.\n Hypotension (not Shock)\n Assessment:\n Pt lethargic and hypotensive throughout entire day, team aware and\n feels its d/t her being over sedated. Pt SBP will go into the 70\n when asleep and not being stimulated.\n Action:\n Fentanyl and versed gtt turned off, and pt did not have any sedation\n meds until 1400 when she became more alert and her HR went into 130\n and SBP 120-130\n Response:\n As the day went on pt became more awake and her SBP stayed in the 90\n but she will still drop into SBP of low 80\ns when she is asleep.\n Plan:\n Keep pt off IV sedation meds\n Hypernatremia (high sodium)\n Assessment:\n NA level of 147\n Action:\n Free water flushed given 300 Q 4 hr.\n Response:\n NA level 141\n Plan:\n Free water flush decreased to 150 Q4 hr.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Vent settings weaned to Pressure support 12 and Peep 10.\n Action:\n ABG on these settings acceptable to team, O2 sats in 92-94 range and\n team accepting that.\n Response:\n Pt cont to be on this vent setting and doing fine.\n Plan:\n Cont to monitor resp status, wean as tolerated.\n"},{"category":"Physician ","chartdate":"2167-10-07 00:00:00.000","description":"Physician Resident Progress Note","row_id":636204,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n EKG - At 11:53 PM for qrs (<500)\n Continued to have alternating tachy and bradycadia with associated\n pressure swings on adjusted pain regimen. Unable to diurese given\n intermittant hypotension. Finally got one dose lasix when BP in an\n acceptable range.\n Much more anxious than previous nights. Increased Valium back to 10 mg\n QID.\n CT showed cuff distention. Per respiratory, still has a leak, likely\n needs a larger cuff.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,500 units/hour\n Other ICU medications:\n Diazepam (Valium) - 02:00 AM\n Furosemide (Lasix) - 03:56 AM\n Haloperidol (Haldol) - 03:57 AM\n Midazolam (Versed) - 05:11 AM\n Other medications:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37.1\nC (98.7\n HR: 124 (66 - 135) bpm\n BP: 137/67(92) {74/35(48) - 150/81(106)} mmHg\n RR: 15 (7 - 28) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 3,707 mL\n 723 mL\n PO:\n TF:\n 1,457 mL\n 364 mL\n IVF:\n 810 mL\n 150 mL\n Blood products:\n Total out:\n 2,535 mL\n 2,760 mL\n Urine:\n 2,535 mL\n 2,760 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,172 mL\n -2,037 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 964 (260 - 964) mL\n PS : 12 cmH2O\n RR (Set): 10\n RR (Spontaneous): 8\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI Deferred: Agitated\n PIP: 21 cmH2O\n SpO2: 94%\n ABG: 7.41/53/86/35/6\n Ve: 7.8 L/min\n PaO2 / FiO2: 172\n Physical Examination\n General Appearance: Trached and sedated. Responsive, following\n commands, Overweight / Obese, mild agitation but NAD\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\n deviation\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Respiratory / Chest: (Expansion: Symmetric), CTA anteriorly, decreased\n BS\n Abdominal: Obese, soft, Non-tender, no rebound, no guarding, + BS, PEG\n in place with dressing C/D/I\n Extremities: no CCE\n Skin: no rashes or jaundice\n Lines: r brachioceph ART with large amount of bloody drainage and L\n PICC C/D/I\n Labs / Radiology\n 213 K/uL\n 8.3 g/dL\n 118 mg/dL\n 0.6 mg/dL\n 32 mEq/L\n 3.5 mEq/L\n 11 mg/dL\n 108 mEq/L\n 146 mEq/L\n 27.4 %\n 8.2 K/uL\n [image002.jpg]\n 02:47 AM\n 11:01 AM\n 04:40 PM\n 05:08 PM\n 03:44 AM\n 06:04 AM\n 09:09 AM\n 05:07 PM\n 03:31 AM\n 03:46 AM\n WBC\n 11.2\n 9.6\n 8.2\n Hct\n 27.4\n 25.3\n 27.4\n Plt\n 272\n 229\n 213\n Cr\n 0.6\n 0.6\n 0.6\n 0.8\n 0.6\n TCO2\n 31\n 34\n 33\n 32\n 35\n Glucose\n 128\n 138\n 107\n 121\n 118\n Other labs: PT / PTT / INR:18.4/68.9/1.7, Ca++:9.0 mg/dL, Mg++:2.5\n mg/dL, PO4:4.8 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA and\n ARDS intubated since the end of now s/p trach and PEG placement.\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation. Stenting\n unlikely to help for trachiomalacia as airways have poor structure\n diffusely. S/P Trach and PEG on .\n - wean FiO2 as tolerated\n - attempt wean PS today and hopeful for trach mask trial\n # Adrenal Insufficency: Hypotension that resolved with steroids,\n returned as they came off and is now improved again. Possible primary\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\n started on .\n - wean per endo recs, decrease to 20q am and 10 q pm today\n - ok to go to 10 q am and 5 q pm tomorrow ()\n # Volume overloaded in setting of hypernatremia with TBW deficit and\n metabolic alkalosis\n - Lasix boluses with diamox today\n - electrolytes\n - continue tube feeds with free water flushes 300 cc q4\n # Sedation: Sedation control remains somewhat poor although fentanyl\n patch and diazpem are likely therapeutic range today. On Versed 2.0,\n Fentanyl 100, Fentanyl patch, Diazepam standing and haldo 2.5-5 mg\n PRN. QTc increased to 480.\n - Wean versed/fentanyl as tolerated, continue diazepam in\n hopes for vent facility placement\n - Continue diazepam 10 mg q8 with haldol 5 mg q8 with 2.5-5\n prn haldol\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\n coumadin at least until s/p trach. INR 1.7 today.\n - heparin gtt restarted\n - coumadin 5mg G-tube today, INR in am\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n -f/u full trauma spine eval from OSH to determine need for further back\n imaging in-house (to be done )\n #. Thyroid Nodule on CT\n -outpatient follow up\n # Nutrition: Tube feeds with free water flushes, tolerating well,\n continue Replete (Full) - 11:20 AM 30 mL/hour\n # Glycemic control: SSI, well controlled\n # Lines L PICC () and R ART ()\n d/c art and re-site today\n # Ppx: heparin drip until INR therapeutic for 2 days, ranitidine, VAP\n prevention, colace and senna\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n Code: Full\n Dispo: ICU, being screening for vent facilities\n"},{"category":"Nursing","chartdate":"2167-09-30 00:00:00.000","description":"Nursing Progress Note","row_id":635164,"text":"55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP now with prolonged\n hospital course c/o by PNA anxiety,RUE DVD with high PEEP requirement\n .\n Plan : Plan for trach and peg today or the next few days, if pt tol\n peep of 10.\n Hypernatremia (high sodium)\n Assessment:\n Na level elevated\n Action:\n H2O flushes increased to 250 cc q 4hrs.\n Response:\n Na level remains elevated this am at 146 (sl improved).\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains intubated on CMV settings, now at 60%/400x18/10. LS coarse\n to upper resp area with diminished bases. Pt has been deep sx\nd for\n scant amounts of yellow secretions q 2hrs. Pt cont to have copious\n amounts of clear oral secretions and in need of freq oral care. Pt\n noted to have a decrease in O2sat, while she is on her Lt side, but it\n has improved throughout the night.\n Action:\n Peep weaned to 10, and tol well by pt with good ABGs. Fio2 weaned to 50\n %, but pt\ns O2sat decreased to 88% right away.\n Response:\n LS clear to upper resp area after sx.\n Plan:\n Plan for trach and Peg today if p[t cont to tol peep of 10.\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt on heparin gtt protocol for DVT to Rt arm. No signs of bleeding\n noted. Hct stable.\n Action:\n Response:\n PTT drawn q 6hrs; and it has been therapeutic.\n Plan:\n Plan to check PTT now daily.\n"},{"category":"Nursing","chartdate":"2167-09-30 00:00:00.000","description":"Nursing Progress Note","row_id":635166,"text":"55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP now with prolonged\n hospital course c/o by PNA anxiety,RUE DVD with high PEEP requirement\n .\n Plan : Plan for trach and peg today or the next few days, if pt tol\n peep of 10.\n Hypernatremia (high sodium)\n Assessment:\n Na level elevated\n Action:\n H2O flushes increased to 250 cc q 4hrs.\n Response:\n Na level remains elevated this am at 146 (sl improved).\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains intubated on CMV settings, now at 60%/400x18/10. LS coarse\n to upper resp area with diminished bases. Pt has been deep sx\nd for\n scant amounts of yellow secretions q 2hrs. Pt cont to have copious\n amounts of clear oral secretions and in need of freq oral care. Pt\n noted to have a decrease in O2sat, while she is on her Lt side, but it\n has improved throughout the night.\n Action:\n Peep weaned to 10, and tol well by pt with good ABGs. Fio2 weaned to 50\n %, but pt\ns O2sat decreased to 88% right away.\n Response:\n LS clear to upper resp area after sx.\n Plan:\n Plan for trach and Peg today if p[t cont to tol peep of 10.\n Altered mental status (not Delirium)\n Assessment:\n Pt found at 8pm to 10pm to be awake, alert and following commands. Pt\n was slight restless, but appropriate. 10pm, pt became very restless in\n bed, trying to sit up and was reaching for ETT. Once reposition and\n back rubs did not work, MD notified and haldol given and diazepam given\n with only effect for one hr. When pt is awake and restless, her HR will\n increase to 120-130\ns (ST) and BP will increase to 120-130\ns. When pt\n was sleeping (after sedation), Hr will deacrease to 50\ns with a SBP in\n the 80\ns. Fentanyl patch increased and diazepam changed to q6hrs, with\n no effect.\n Action:\n 2:30am, versed gtt was initiated again with good effect. Pt more\n relaxed and fell back to sleep with stable HR and BP.\n Response:\n Plan:\n Continue to evaluate restlessness.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt on heparin gtt protocol for DVT to Rt arm. No signs of bleeding\n noted. Hct stable.\n Action:\n Response:\n PTT drawn q 6hrs; and it has been therapeutic.\n Plan:\n Plan to check PTT now daily.\n"},{"category":"Nursing","chartdate":"2167-10-12 00:00:00.000","description":"Nursing Progress Note","row_id":637018,"text":"56 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\n with prolonged hospital course c/b by PNA, anxiety/altered mental\n status, RUE DVT .\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on PSV 10/5/50%. RR 20-30. )2 sat > 97%\n Action:\n Pt remained on PSV rather than AC overnight. Suctioned ~q 3-4 hrs for\n sm amt yellow bld-tinged secretions. Continues to have copious oral\n secretions\n removed with yankeur.\n Response:\n Tolerated PSV well, no tachypnea or desaturation.\n Plan:\n Attempt trach collar trial again in am. On-going pulm hygiene\n Hypotension (not Shock)\n Assessment:\n BP 90/40 with urine output falling to 10-15ccs/hr via foley. HR remains\n tachycardic (110-140ST) even when pt is not agitated or febrile.\n Action:\n Given 1 500cc d5\n ns fluid bolus\n Response:\n SBP > 90, Urine output improving to >30ccs/hr\n Plan:\n Continue to monitor hemodynamic status and f+e balance.\n Altered mental status (not Delirium)\n Assessment:\n Pt lethargic after receiving benedryl for several hrs but then awoke\n agitated, attempting to climb OOB and pull at trach despite restraints.\n Denies pain ( fentanyl patch in place) or need to go to the bathroom.\n c/o itchiness on back secondary to rash.\n Action:\n Medicated with iv benedryl.\n Response:\n Less agitated. Slept again\n Plan:\n Continue to reorient pt, benedryl for pruritis, safety precautions.\n"},{"category":"Nursing","chartdate":"2167-10-12 00:00:00.000","description":"Nursing Progress Note","row_id":637208,"text":"Tachycardia, Other\n Assessment:\n Pt restless and awake with tachycardia at 140-150. Md notified and in\n to assess. Pt also denies any pain every time asked. ? if pt is\n dehydrated with U/O 15-30cc/hr, but no IVF for now MD. Pt remains\n afebrile.\n Action:\n Pt given haldol po and IV, valium po/IV and morphine IVP. Emotional\n support also given w/o effect.\n Response:\n Sedation given with NO effect. MD aware. No more interventions for now.\n HR decreased to 120 once pt back in bed and sleeping.\n Plan:\n Continue to eval tachycardia.\n Hypernatremia (high sodium)\n Assessment:\n NA elevated this am .\n Action:\n H2O flushes increased to 100 cc q 4hrs.\n Response:\n Na level to be drawn in am.\n Plan:\n Continue current plan.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS coarse throughout and slight improved after deep sx. RR 18-24.\n Action:\n Pt placed on TC this am at 9am x 8hrs and tol well by pt with O2sat\n 93-96%. Pt was able to have prod cough of now green-yellow secretions.\n Pt placed on CPAP +PS once back in bed in order to rest pt overnight.\n Response:\n Pt tol being on TC very well. Pt was placed on pass\n muir valve, but\n was only able to tol it for 15 min inability to clear secretions.\n Plan:\n Needs sputum sample for culture.\n Altered mental status (not Delirium)\n Assessment:\n Pt awake almost the whole day and has been restless. MD aware.\n Action:\n Pt given haldol, valium and Morphine.\n Response:\n No effect from sedation.\n Plan:\n Continue to eval MS.\n"},{"category":"Physician ","chartdate":"2167-10-07 00:00:00.000","description":"Physician Resident/Attending Progress Note - MICU","row_id":636214,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n EKG - At 11:53 PM for qrs (<500)\n Continued to have alternating tachy and bradycadia with associated\n pressure swings on adjusted pain regimen. Unable to diurese given\n intermittant hypotension. Finally got one dose lasix when BP in an\n acceptable range.\n Much more anxious than previous nights. Increased Valium back to 10 mg\n QID.\n CT showed cuff distention. Per respiratory, still has a leak, likely\n needs a larger cuff.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,500 units/hour\n Other ICU medications:\n Diazepam (Valium) - 02:00 AM\n Furosemide (Lasix) - 03:56 AM\n Haloperidol (Haldol) - 03:57 AM\n Midazolam (Versed) - 05:11 AM\n Other medications:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37.1\nC (98.7\n HR: 124 (66 - 135) bpm\n BP: 137/67(92) {74/35(48) - 150/81(106)} mmHg\n RR: 15 (7 - 28) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 3,707 mL\n 723 mL\n PO:\n TF:\n 1,457 mL\n 364 mL\n IVF:\n 810 mL\n 150 mL\n Blood products:\n Total out:\n 2,535 mL\n 2,760 mL\n Urine:\n 2,535 mL\n 2,760 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,172 mL\n -2,037 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 964 (260 - 964) mL\n PS : 12 cmH2O\n RR (Set): 10\n RR (Spontaneous): 8\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI Deferred: Agitated\n PIP: 21 cmH2O\n SpO2: 94%\n ABG: 7.41/53/86/35/6\n Ve: 7.8 L/min\n PaO2 / FiO2: 172\n Physical Examination\n General Appearance: Trached and sedated. Responsive, following\n commands, Overweight / Obese, mild agitation but NAD\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\n deviation\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Respiratory / Chest: (Expansion: Symmetric), CTA anteriorly, decreased\n BS\n Abdominal: Obese, soft, Non-tender, no rebound, no guarding, + BS, PEG\n in place with dressing C/D/I\n Extremities: no CCE\n Skin: no rashes or jaundice\n Lines: r brachioceph ART with large amount of bloody drainage and L\n PICC C/D/I\n Labs / Radiology\n 213 K/uL\n 8.3 g/dL\n 118 mg/dL\n 0.6 mg/dL\n 32 mEq/L\n 3.5 mEq/L\n 11 mg/dL\n 108 mEq/L\n 146 mEq/L\n 27.4 %\n 8.2 K/uL\n [image002.jpg]\n 02:47 AM\n 11:01 AM\n 04:40 PM\n 05:08 PM\n 03:44 AM\n 06:04 AM\n 09:09 AM\n 05:07 PM\n 03:31 AM\n 03:46 AM\n WBC\n 11.2\n 9.6\n 8.2\n Hct\n 27.4\n 25.3\n 27.4\n Plt\n 272\n 229\n 213\n Cr\n 0.6\n 0.6\n 0.6\n 0.8\n 0.6\n TCO2\n 31\n 34\n 33\n 32\n 35\n Glucose\n 128\n 138\n 107\n 121\n 118\n Other labs: PT / PTT / INR:18.4/68.9/1.7, Ca++:9.0 mg/dL, Mg++:2.5\n mg/dL, PO4:4.8 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA and\n ARDS intubated since the end of now s/p trach and PEG placement.\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation. Stenting\n unlikely to help for trachiomalacia as airways have poor structure\n diffusely. S/P Trach and PEG on .\n - wean FiO2 as tolerated\n - attempt wean PS today and hopeful for trach mask trial\n # Adrenal Insufficency: Hypotension that resolved with steroids,\n returned as they came off and is now improved again. Possible primary\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\n started on .\n - wean per endo recs, decrease to 20q am and 10 q pm today\n - ok to go to 10 q am and 5 q pm tomorrow ()\n # Volume overloaded in setting of hypernatremia with TBW deficit and\n metabolic alkalosis\n - Lasix boluses with diamox today\n - electrolytes\n - continue tube feeds with free water flushes 300 cc q4\n # Sedation: Sedation control remains somewhat poor although fentanyl\n patch and diazpem are likely therapeutic range today. On Versed 2.0,\n Fentanyl 100, Fentanyl patch, Diazepam standing and haldo 2.5-5 mg\n PRN. QTc increased to 480.\n - Wean versed/fentanyl as tolerated, continue diazepam in\n hopes for vent facility placement\n - Continue diazepam 10 mg q8 with haldol 5 mg q8 with 2.5-5\n prn haldol\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\n coumadin at least until s/p trach. INR 1.7 today.\n - heparin gtt restarted\n - coumadin 5mg G-tube today, INR in am\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n -f/u full trauma spine eval from OSH to determine need for further back\n imaging in-house (to be done )\n #. Thyroid Nodule on CT\n -outpatient follow up\n # Nutrition: Tube feeds with free water flushes, tolerating well,\n continue Replete (Full) - 11:20 AM 30 mL/hour\n # Glycemic control: SSI, well controlled\n # Lines L PICC () and R ART ()\n d/c art and re-site today\n # Ppx: heparin drip until INR therapeutic for 2 days, ranitidine, VAP\n prevention, colace and senna\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n Code: Full\n Dispo: ICU, being screening for vent facilities\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 55F T5-8 fractures with retropulsion and ARDS\n from klebsiella VAP; on heparin for UE DVT and lasix for volume\n overload.\n Exam notable for Tm 99.6 BP 110/50 HR 110 RR 18-20 with sat 97%\n on PSV 12/8 FiO2 0.5, ABG 7.41/53/86. TBB -3L/8h, +6L/MICU LOS. Eyes\n opens, will squeeze hands and wiggle toes but very drowsy. Clearer BS\n bilaterally with RRR s1s2 SM at base. Abdomen is distended with\n decreased BS. Trace edema in BLE, no cords. Labs notable for WBC 8K,\n HCT 27, K+ 3.5, Na 146, Cr 0.6, INR 1.7. CXR with resolving B LL\n airspace disease and RLL collapse.\n Agree with plan to continue supportive care, wean PSV to , and\n continue diuresis with lasix / diamox as BP allows. Will continue\n fentanyl patch at 150mcg, haldol 5q8h alternating with valium 10q6h at\n lower dose, now off drips. Will use haldol for breakthrough agitation.\n Will wean hydrocortisone 20/10q12 PGT today and will discuss more\n aggressive wean with endocrine as I think she has a component of\n steroid psychosis. Will continue IV heparin for UE DVT and transition\n to anticoagulation with coumadin. Will continue tube feeds and continue\n FW boluses for hypernatremia. Arterial line to be resited today.\n Continue spinal stabilization with brace when OOB and discuss follow-up\n plan with spine surgery. Will eventually need MRI for surgical\n planning; remainder of plan as outlined above.\n Patient is critically ill\n Total time: 50 min\n ------ Protected Section Addendum Entered By: , MD\n on: 03:06 PM ------\n"},{"category":"Respiratory ","chartdate":"2167-10-01 00:00:00.000","description":"Respiratory Care Shift Note","row_id":635396,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 13\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Clear / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments: Patient remains on mechanical ventilation with hypoxemic ABG\n on A/C 400*18-.50-8p.Patient more alert today,BS clear,suctioned for\n minimal to moderate amount of thick tan secretion.Plan to go to OR in\n AM for tracheostomy and PEG procedure.Trial of SBT failed as patient\n quickly desaturated with increase in HR.\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"},{"category":"Physician ","chartdate":"2167-10-02 00:00:00.000","description":"Physician Resident Progress Note","row_id":635495,"text":"Chief Complaint:\n 24 Hour Events:\n Patient agitated and combative overnight - restarted midazolam gtt and\n patient was becoming increasingly tachycardic and hypertensive\n Thoracics to take to OR this am for trach and PEG\n Discussion with patient's boyfriend yesterday - her should be here this\n weekend, wants to be involved, just hard for him to get here\n On lasix drip with excellent response (200 cc urine/hour)\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Fentanyl - 100 mcg/hour\n Furosemide (Lasix) - 1 mg/hour\n Heparin Sodium - 1,700 units/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:07 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.3\nC (99.2\n HR: 118 (45 - 138) bpm\n BP: 155/84(118) {91/38(56) - 177/106(139)} mmHg\n RR: 18 (17 - 27) insp/min\n SpO2: 90%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,604 mL\n 1,447 mL\n PO:\n TF:\n 675 mL\n 17 mL\n IVF:\n 1,089 mL\n 730 mL\n Blood products:\n Total out:\n 4,130 mL\n 2,430 mL\n Urine:\n 4,130 mL\n 2,430 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,526 mL\n -983 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n PS : 5 cmH2O\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n PIP: 22 cmH2O\n Plateau: 19 cmH2O\n Compliance: 48.2 cmH2O/mL\n SpO2: 90%\n ABG: 7.45/50/67/36/8\n Ve: 7.5 L/min\n PaO2 / FiO2: 134\n Physical Examination\n General Appearance: Responsive, following commands, Overweight / Obese,\n NAD\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\n deviation\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Respiratory / Chest: (Expansion: Symmetric), referred breath sounds\n from ETT, mild rhonchi diffusely\n Abdominal: Obese, Soft, Non-tender, no rebound, no guarding\n Extremities: No clubbing or cyanosis, + nonpitting edema of b/l\n hands, anasarca\n Skin: no rashes or jaundice\n Neuro: alert. Strength 4/5 upper and lower extremeties, light touch\n sensation intact bil.\n Lines: r brachioceph ART and L PICC C/D/I\n Labs / Radiology\n 306 K/uL\n 8.5 g/dL\n 165 mg/dL\n 0.7 mg/dL\n 29 mEq/L\n 3.7 mEq/L\n 10 mg/dL\n 108 mEq/L\n 146 mEq/L\n 27.1 %\n 11.2 K/uL\n [image002.jpg]\n WBC 11.2 up from 8.6\n HCT 27.1 up from 25.9\n HCO2 32 up from 29\n 02:18 AM\n 01:27 PM\n 03:06 PM\n 10:04 PM\n 03:00 AM\n 10:47 AM\n 04:10 PM\n 12:13 AM\n 05:08 AM\n 05:20 AM\n WBC\n 8.6\n 11.2\n Hct\n 25.9\n 27.1\n Plt\n 280\n 306\n Cr\n 0.6\n 0.5\n 0.7\n TCO2\n 33\n 32\n 32\n 34\n 36\n 36\n Glucose\n 176\n 136\n 165\n Other labs: PT / PTT / INR:13.2/68.7/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:89.7 %, Lymph:8.7 %, Mono:1.1\n %, Eos:0.4 %, Lactic Acid:0.9 mmol/L, Albumin:2.4 g/dL, LDH:204 IU/L,\n Ca++:10.6 mg/dL, Mg++:2.8 mg/dL, PO4:4.3 mg/dL\n MICRO: sputum Gram stain: 2+ GPC in P/C, 2+ GPR. Cx: sparse\n flora, sparse yeast\n MICRO: MiniBAL: Gram stain: 2+PMNs, Cx: GNR #1, GNR#2, yeast.\n CXR: Poor penetration, hazy opacification of both lung fields R>L,\n patchy opacities in LLL, new. Focal atelectasis vs. PNA\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA and\n ARDS intubated since the end of .\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation.\n Transferred here for airway stenting.\n - attempt SBT yesterday. Failed.\n -To OR today , add-on for trach and PEG with Dr. (tube feeds\n off after MN, heparin off after 6am)\n - Repeat CXR in PM post trach.\n ## Adrenal Insufficency: Minimal response to stim test again.\n Appreciate endocrine recommendations.\n - hydrocort and fludrocort (day 1 = )\n - will continue at current dose until s/p trach and PEG and\n hemodynamically stable for 24 hours\n will then plan to taper\n hydrocortisone to 25mg IV q6 with a slow taper\n - f/u daily endocrine recs\n - Endocrine recs: d/c Fludrocort. Continue Hydrocort for now.\n # Hypotension: Likely adrenal insufficiency and sedation. Goal map\n > 60. Much improved since re-administration of steroids.\n - hydrocortisone as above\n - restart levophed if necessary to maintain MAP > 60\n # Volume overloaded in setting of hypernatremia with TBW deficit.\n - goal -1000cc I/Os yesterday, was -1500cc for last 24 hours.\n - continue FW in TF at 250 cc q4hrs\n - lasix drip (1-5mg/hr) held before surgery, will restart when returns\n to MICU.\n - may have some contraction alkalosis, w/ rising pH and bicarb. Start\n Diamox 500mg TID to decrease bicarb and pH and may improve respiratory\n drive.\n # Sedation: Sedation control remains somewhat poor although fentanyl\n patch and diazpem are likely therapeutic range today. On Versed 2.0,\n Fentanyl 100, Fentanyl patch, Diazepam standing and haldo 2.5-5 mg\n PRN. QTc increased to 480.\n - Wean versed/fentanyl as tolerated, continue diazepam. Avoid haldol\n use if possible to avoid further prolongation of QTc\n - Will reassess sedation/agitation after PEG/Trach.\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\n coumadin at least until s/p trach.\n - hold heparin gtt when anticipate trach/peg\n - will restart heparin gtt per recs from surgery post-op\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n # FEN/GI: Tube feeds with FWF @ goal.\n -held for surgery. Will restart based on post-op recs after PEG\n placement.\n DVT: Treatment dose heparin, holding until post-op recs from PEG/Trach\n Ulcer: Ranitidine\n VAP: Prevention per routine\n # Access: L PICC line, and R brachial a-line\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n - touch base with SW today\n Code: Full\n Dispo: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Arterial Line - 02:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2167-10-02 00:00:00.000","description":"Physician Resident/Attending Progress Note - MICU","row_id":635496,"text":"Chief Complaint:\n 24 Hour Events:\n Patient agitated and combative overnight - restarted midazolam gtt and\n patient was becoming increasingly tachycardic and hypertensive\n Thoracics to take to OR this am for trach and PEG\n Discussion with patient's boyfriend yesterday - her should be here this\n weekend, wants to be involved, just hard for him to get here\n On lasix drip with excellent response (200 cc urine/hour)\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Fentanyl - 100 mcg/hour\n Furosemide (Lasix) - 1 mg/hour\n Heparin Sodium - 1,700 units/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:07 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.3\nC (99.2\n HR: 118 (45 - 138) bpm\n BP: 155/84(118) {91/38(56) - 177/106(139)} mmHg\n RR: 18 (17 - 27) insp/min\n SpO2: 90%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,604 mL\n 1,447 mL\n PO:\n TF:\n 675 mL\n 17 mL\n IVF:\n 1,089 mL\n 730 mL\n Blood products:\n Total out:\n 4,130 mL\n 2,430 mL\n Urine:\n 4,130 mL\n 2,430 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,526 mL\n -983 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n PS : 5 cmH2O\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n PIP: 22 cmH2O\n Plateau: 19 cmH2O\n Compliance: 48.2 cmH2O/mL\n SpO2: 90%\n ABG: 7.45/50/67/36/8\n Ve: 7.5 L/min\n PaO2 / FiO2: 134\n Physical Examination\n General Appearance: Responsive, following commands, Overweight / Obese,\n NAD\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\n deviation\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Respiratory / Chest: (Expansion: Symmetric), referred breath sounds\n from ETT, mild rhonchi diffusely\n Abdominal: Obese, Soft, Non-tender, no rebound, no guarding\n Extremities: No clubbing or cyanosis, + nonpitting edema of b/l\n hands, anasarca\n Skin: no rashes or jaundice\n Neuro: alert. Strength 4/5 upper and lower extremeties, light touch\n sensation intact bil.\n Lines: r brachioceph ART and L PICC C/D/I\n Labs / Radiology\n 306 K/uL\n 8.5 g/dL\n 165 mg/dL\n 0.7 mg/dL\n 29 mEq/L\n 3.7 mEq/L\n 10 mg/dL\n 108 mEq/L\n 146 mEq/L\n 27.1 %\n 11.2 K/uL\n [image002.jpg]\n WBC 11.2 up from 8.6\n HCT 27.1 up from 25.9\n HCO2 32 up from 29\n 02:18 AM\n 01:27 PM\n 03:06 PM\n 10:04 PM\n 03:00 AM\n 10:47 AM\n 04:10 PM\n 12:13 AM\n 05:08 AM\n 05:20 AM\n WBC\n 8.6\n 11.2\n Hct\n 25.9\n 27.1\n Plt\n 280\n 306\n Cr\n 0.6\n 0.5\n 0.7\n TCO2\n 33\n 32\n 32\n 34\n 36\n 36\n Glucose\n 176\n 136\n 165\n Other labs: PT / PTT / INR:13.2/68.7/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:89.7 %, Lymph:8.7 %, Mono:1.1\n %, Eos:0.4 %, Lactic Acid:0.9 mmol/L, Albumin:2.4 g/dL, LDH:204 IU/L,\n Ca++:10.6 mg/dL, Mg++:2.8 mg/dL, PO4:4.3 mg/dL\n MICRO: sputum Gram stain: 2+ GPC in P/C, 2+ GPR. Cx: sparse\n flora, sparse yeast\n MICRO: MiniBAL: Gram stain: 2+PMNs, Cx: GNR #1, GNR#2, yeast.\n CXR: Poor penetration, hazy opacification of both lung fields R>L,\n patchy opacities in LLL, new. Focal atelectasis vs. PNA\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA and\n ARDS intubated since the end of .\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation.\n Transferred here for airway stenting.\n - attempt SBT yesterday. Failed.\n -To OR today , add-on for trach and PEG with Dr. (tube feeds\n off after MN, heparin off after 6am)\n - Repeat CXR in PM post trach.\n ## Adrenal Insufficency: Minimal response to stim test again.\n Appreciate endocrine recommendations.\n - hydrocort and fludrocort (day 1 = )\n - will continue at current dose until s/p trach and PEG and\n hemodynamically stable for 24 hours\n will then plan to taper\n hydrocortisone to 25mg IV q6 with a slow taper\n - f/u daily endocrine recs\n - Endocrine recs: d/c Fludrocort. Continue Hydrocort for now.\n # Hypotension: Likely adrenal insufficiency and sedation. Goal map\n > 60. Much improved since re-administration of steroids.\n - hydrocortisone as above\n - restart levophed if necessary to maintain MAP > 60\n # Volume overloaded in setting of hypernatremia with TBW deficit.\n - goal -1000cc I/Os yesterday, was -1500cc for last 24 hours.\n - continue FW in TF at 250 cc q4hrs\n - lasix drip (1-5mg/hr) held before surgery, will restart when returns\n to MICU.\n - may have some contraction alkalosis, w/ rising pH and bicarb. Start\n Diamox 500mg TID to decrease bicarb and pH and may improve respiratory\n drive.\n # Sedation: Sedation control remains somewhat poor although fentanyl\n patch and diazpem are likely therapeutic range today. On Versed 2.0,\n Fentanyl 100, Fentanyl patch, Diazepam standing and haldo 2.5-5 mg\n PRN. QTc increased to 480.\n - Wean versed/fentanyl as tolerated, continue diazepam. Avoid haldol\n use if possible to avoid further prolongation of QTc\n - Will reassess sedation/agitation after PEG/Trach.\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\n coumadin at least until s/p trach.\n - hold heparin gtt when anticipate trach/peg\n - will restart heparin gtt per recs from surgery post-op\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n # FEN/GI: Tube feeds with FWF @ goal.\n -held for surgery. Will restart based on post-op recs after PEG\n placement.\n DVT: Treatment dose heparin, holding until post-op recs from PEG/Trach\n Ulcer: Ranitidine\n VAP: Prevention per routine\n # Access: L PICC line, and R brachial a-line\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n - touch base with SW today\n Code: Full\n Dispo: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Arterial Line - 02:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 55F T5-8 fractures with retropulsion and ARDS\n from VAP; on heparin for UE DVT. Tolerating slow vent wean but failed\n SBT. Was TBB negative yesterday with lasix drip; sedation remains\n challenging. Plan for T+G today.\n Exam notable for Tm 99.2 BP 105/45 HR 45-120 RR 18-20 with sat 93-96%\n on VAC 400x18 PEEP 8 FiO2 0.5 for 7.45/50/67. TBB -2.6L/24h, +15L/MICU\n LOS. Eyes opens, will squeeze hands and wiggle toes but very\n drowsyBronchial BS bilaterally with RRR s1s2 SM at base. Abdomen is\n distended with decreased BS. 3+ edema in BLE, no cords. Labs notable\n for WBC 11K, HCT 27, K+ 3.8, Na 146, Cr 0.5. CXR with resolving B LL\n airspace disease and effusions.\n Agree with plan to continue supportive care and wean vent after\n procedures today. Needs diamox and aggressive KCl repletion in addition\n to lasix given progressive alkalosis and rising pCO2. Once sedation\n requirements are clarified following T+G, will try PSV. For now,\n continue fentanyl patch and valium 10 TID po in addition to drips. Will\n continue hydrocortisone 50 q6 today and reduce to q8 tomorrow, with\n long term goal for oral prednisone. Will d/c fludrocortisone. Will\n resume IV heparin for UE DVT when cleared from a surgical perspective\n with plan for eventual transition to coumadin. Will restart tube feeds\n and continue FW boluses for hypernatremia once PEG cleared by surgery.\n Continue spinal stabilization with brace when OOB; will eventually need\n MRI for surgical planning; remainder of plan as outlined above.\n Patient is critically ill\n Total time: 40 min\n ------ Protected Section Addendum Entered By: , MD\n on: 02:53 PM ------\n"},{"category":"Respiratory ","chartdate":"2167-10-10 00:00:00.000","description":"Respiratory Care Shift Note","row_id":636796,"text":"TITLE:\n Demographics\n Day of intubation:\n Day of mechanical ventilation: 22\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Cuffed\n Manufacturer: Portex\n Size: 7.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Cannot protect\n airway; Comments: some weaning to trach collar tolerated today\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"},{"category":"Respiratory ","chartdate":"2167-10-11 00:00:00.000","description":"Respiratory Care Shift Note","row_id":636848,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 23\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason:\n Tube Type\n Tracheostomy tube:\n Type: Cuffed\n Manufacturer: Portex\n Size: 7.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thin\n Sputum source/amount: Suctioned / Moderate\n Comments: Pt had excessive coughing all shift\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment: Frequent alarms (High pressure, High rate)\n Comments: Pt coughing all shift, very agitated by thrashing in bed\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Adjust Min. ventilation to control pH, Increase ventilatory support at\n night; Comments: Pt needed to be suctioned many times this shift.\n Sputum culture sent. Pt thrashes in bed, causing tracheostomy to shift\n and causing her cough.\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Cannot protect airway, Cannot manage secretions,\n Underlying illness not resolved\n Bedside RSBI- deferred due to agitation\n"},{"category":"Respiratory ","chartdate":"2167-10-12 00:00:00.000","description":"Respiratory Care Shift Note","row_id":637200,"text":"TITLE:\n Demographics\n Day of intubation:\n Day of mechanical ventilation: 24\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Not applicable\n Size: Not applicable\n Tracheostomy tube:\n Type: Cuffed\n Manufacturer: Portex\n Size: 7.0mm\n PMV: No\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments: PMV eval done today... only partially\n successful\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Cannot protect\n airway, Cannot manage secretions, Underlying illness not resolved;\n Comments: weaning to trach collar as tolerated each day\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"},{"category":"Physician ","chartdate":"2167-10-07 00:00:00.000","description":"Physician Resident Progress Note","row_id":636189,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n EKG - At 11:53 PM for qrs (<500)\n Continued to have alternating tachy and bradycadia with associated\n pressure swings on adjusted pain regimen. Unable to diurese given\n intermittant hypotension. Finally got one dose lasix when BP in an\n acceptable range.\n Much more anxious than previous nights. Increased Valium back to 10 mg\n QID.\n CT showed cuff distention. Per respiratory, still has a leak, likely\n needs a larger cuff.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,500 units/hour\n Other ICU medications:\n Diazepam (Valium) - 02:00 AM\n Furosemide (Lasix) - 03:56 AM\n Haloperidol (Haldol) - 03:57 AM\n Midazolam (Versed) - 05:11 AM\n Other medications:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37.1\nC (98.7\n HR: 124 (66 - 135) bpm\n BP: 137/67(92) {74/35(48) - 150/81(106)} mmHg\n RR: 15 (7 - 28) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 3,707 mL\n 723 mL\n PO:\n TF:\n 1,457 mL\n 364 mL\n IVF:\n 810 mL\n 150 mL\n Blood products:\n Total out:\n 2,535 mL\n 2,760 mL\n Urine:\n 2,535 mL\n 2,760 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,172 mL\n -2,037 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 964 (260 - 964) mL\n PS : 12 cmH2O\n RR (Set): 10\n RR (Spontaneous): 8\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI Deferred: Agitated\n PIP: 21 cmH2O\n SpO2: 94%\n ABG: 7.41/53/86/35/6\n Ve: 7.8 L/min\n PaO2 / FiO2: 172\n Physical Examination\n General Appearance: Trached and sedated. Responsive, following\n commands, Overweight / Obese, mild agitation but NAD\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\n deviation\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Respiratory / Chest: (Expansion: Symmetric), CTA anteriorly, decreased\n BS\n Abdominal: Obese, Firm, Non-tender, no rebound, no guarding, + BS, PEG\n in place with dressing C/D/I\n Extremities: no CCE\n Skin: no rashes or jaundice\n Lines: r brachioceph ART with large amount of bloody drainage and L\n PICC C/D/I\n Labs / Radiology\n 213 K/uL\n 8.3 g/dL\n 118 mg/dL\n 0.6 mg/dL\n 32 mEq/L\n 3.5 mEq/L\n 11 mg/dL\n 108 mEq/L\n 146 mEq/L\n 27.4 %\n 8.2 K/uL\n [image002.jpg]\n 02:47 AM\n 11:01 AM\n 04:40 PM\n 05:08 PM\n 03:44 AM\n 06:04 AM\n 09:09 AM\n 05:07 PM\n 03:31 AM\n 03:46 AM\n WBC\n 11.2\n 9.6\n 8.2\n Hct\n 27.4\n 25.3\n 27.4\n Plt\n 272\n 229\n 213\n Cr\n 0.6\n 0.6\n 0.6\n 0.8\n 0.6\n TCO2\n 31\n 34\n 33\n 32\n 35\n Glucose\n 128\n 138\n 107\n 121\n 118\n Other labs: PT / PTT / INR:18.4/68.9/1.7, Ca++:9.0 mg/dL, Mg++:2.5\n mg/dL, PO4:4.8 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA and\n ARDS intubated since the end of now s/p trach and PEG placement.\n Thyroid nodule on CT\n Watch phos product\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation. Stenting\n unlikely to help for trachiomalacia as airways have poor structure\n diffusely. S/P Trach and PEG on . Increased effusion on recent\n CXR.\n - wean FiO2 as tolerated\n # Adrenal Insufficency: Hypotension that resolved with steroids,\n returned as they came off and is now improved again. Possible primary\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\n started on .\n - wean per endo recs, decrease to 20q am and 10 q pm starting\n tonight\n will maintain this maintenance dose and check am cortisol\n level one week later\n # Volume overloaded in setting of hypernatremia with TBW deficit.\n - Lasix gtt, continue with goal -1-2 L per day\n currently off as\n patient is somewhat hypotensive\n will restart once/if BP increases and\n remains stable for several hours\n - electrolytes\n - continue tube feeds with free water flushes 300 cc q4\n # Sedation: Sedation control remains somewhat poor although fentanyl\n patch and diazpem are likely therapeutic range today. On Versed 2.0,\n Fentanyl 100, Fentanyl patch, Diazepam standing and haldo 2.5-5 mg\n PRN. QTc increased to 480.\n - Wean versed/fentanyl as tolerated, continue diazepam in\n hopes for vent facility placement\n - Change diazepam to 5mg q8 with haldol 5 mg q8\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\n coumadin at least until s/p trach.\n - heparin gtt restarted\n - coumadin 5mg G-tube today, INR in am\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n -f/u full trauma spine eval from OSH to determine need for further back\n imaging in-house (to be done )\n #. Thyroid Nodule\n # Nutrition: Tube feeds with free water flushes, tolerating well,\n continue Replete (Full) - 11:20 AM 30 mL/hour\n # Glycemic control: SSI, well controlled\n # Lines L PICC () and R ART ()\n similarly but will\n keep in setting of hypotension\n # Ppx: heparin drip until INR therapeutic for 2 days, ranitidine, VAP\n prevention, colace and senna\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n Code: Full\n Dispo: ICU, being screening for vent facilities\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 01:39 AM 60 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Arterial Line - 02:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Nutrition","chartdate":"2167-10-07 00:00:00.000","description":"Clinical Nutrition Note","row_id":636190,"text":"Objective\n Pertinent medications: nted\n Labs:\n Value\n Date\n Glucose\n 155 mg/dL\n 10:20 AM\n Glucose Finger Stick\n 115\n 04:00 AM\n BUN\n 12 mg/dL\n 10:20 AM\n Creatinine\n 0.8 mg/dL\n 10:20 AM\n Sodium\n 150 mEq/L\n 10:20 AM\n Potassium\n 4.8 mEq/L\n 10:20 AM\n Chloride\n 109 mEq/L\n 10:20 AM\n TCO2\n 32 mEq/L\n 10:20 AM\n Albumin\n 2.4 g/dL\n 03:59 AM\n Calcium non-ionized\n 10.0 mg/dL\n 10:20 AM\n Phosphorus\n 4.8 mg/dL\n 10:20 AM\n Ionized Calcium\n 1.17 mmol/L\n 03:32 PM\n Magnesium\n 2.8 mg/dL\n 10:20 AM\n Current diet order / nutrition support: Replete c/ Fiber @ 60mL/hr\n (1440 kcals/89 graa) Flush c/ 150mL q4hr per medbook\n GI: Abd: soft/+bs\n Assessment of Nutritional Status\n Estimation of current intake: Adequate\n Specifics:\n Pt continues on TF\ns for full nutrition support via PEG. TF\ns meeting\n 100% estimated nutrition needs. Asked by RN to evaluate TF in relation\n to high Na and PO4. Pt is receiving TF\ns c/ the most free H2O able in\n a standard formula, therefore will need to increase FWB to increase\n free H2O in. A low PO4 formula would also have low K, which is not\n appropriate in this pt given need for frequent K repletions. Would\n consider PO4 binder instead.\n Medical Nutrition Therapy Plan - Recommend the Following\n Increase FWB to 250mL q 4 hr\n Consider CaCO3 500mg daily for high Po4\n"},{"category":"Nursing","chartdate":"2167-10-08 00:00:00.000","description":"Generic Note","row_id":636274,"text":"TITLE:\n 55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\n Now with prolonged hospital course c/b by PNA with high PEEP\n requirement, anxiety, RUE DVT ,continued on heparin qtt.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lungs clear bilat upper lobes and diminished bilat bases with\n occasional scattered rhonchi, prod cough thick yellow/tan sputum, trach\n sx for mod.amt. Placed on MMV for the night with good effect.\n Action:\n Vent changed from CPAP+PS to MMV overnight, Peep @ to 8cm. Freq.\n pulmonary toileting.\n Response:\n Tolerating slow vent wean, requiring pulmonary toileting, good\n diuresis in attempt to wean vent further\n Plan:\n Attempt to wean PS and FI02 down further today as tolerated, Continue\n aggressive pulmonary toileting, Diurese as tolerated.\n Altered mental status (not Delirium)\n Assessment:\n Increased agitation throughout night with pt wriggling in bed and\n attempting to get OOB and attempting to pull at all lines and tubes,\n makes eye contact and follows commands but doesn\nt stay calm for long,\n HR up to 130- with agitation and BP up to 130-150\ns/60-70\n received valium and Haldol as ordered. Prn Midazolam given as per\n orders. dosing in between scheduled doses with poor effect. appears\n generally uncomfortable but denies pain when asked.\n Action:\n Freq. attempts to reorient and calm pt with no effect, Is on Haldol po\n q 8 & also on prn dosing. On po diazepam 10 mgs q 6 & iv versed 0.5 mg\n to 2 mgs q 1 hr. stimulation decreased, bilat soft wrist restraints to\n prevent pt from pulling at lines and tubes\n Response:\n Increased agitation off of continuous IV sedation, poor effect from\n current medical regime, MICU team aware.\n Plan:\n Continue meds to control agitation.\n Hypernatremia (high sodium)\n Assessment:\n No seizure activity noted, Na= 150 yesterday during the day\n Action:\n Free water flushes 300ml Q 4hr\n Response:\n Na --MICU team aware\n Plan:\n Continue free water flushes, address tube feedings with nutrition and\n possible change to a lower sodium tube feeding. monitor Na levels. Will\n follow up on am labs.\n"},{"category":"Physician ","chartdate":"2167-10-08 00:00:00.000","description":"Physician Resident Progress Note","row_id":636396,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - STOP 12:23 PM\n ARTERIAL LINE - START 02:00 PM\n A-line resited, not working again\n tube feed machine not working\n failed SBT - low MV with PSV - switched to MMV overnight\n tachycardic to 140-142\n Ortho spine ok with documented final read of CT trauma from attending\n at OSH and week f/u - faxed request and spoke with med recs at\n Medical re: sending report which was agreed upon.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,500 units/hour\n Other ICU medications:\n Morphine Sulfate - 12:15 PM\n Midazolam (Versed) - 03:50 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:13 AM\n Vital signs\n Cardiac monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.1\nC (98.8\n HR: 105 (70 - 148) bpm\n BP: 85/55(66) {85/41(57) - 158/110(323)} mmHg\n RR: 23 (10 - 31) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n QTc: 411\n Total In:\n 3,562 mL\n 965 mL\n PO:\n TF:\n 1,685 mL\n 150 mL\n IVF:\n 548 mL\n 215 mL\n Blood products:\n Total out:\n 5,695 mL\n 1,740 mL\n Urine:\n 5,695 mL\n 1,740 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,133 mL\n -775 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 359 (137 - 695) mL\n PS : 8 cmH2O\n RR (Set): 10\n RR (Spontaneous): 26\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI: 58\n PIP: 16 cmH2O\n SpO2: 95%\n ABG: 7.40/49/114/32/3\n Ve: 7.2 L/min\n PaO2 / FiO2: 228\n Physical Examination\n General Appearance: Trached and sedated. Responsive, following\n commands, Overweight / Obese, mild agitation but NAD\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\n deviation\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Respiratory / Chest: (Expansion: Symmetric), CTA anteriorly, decreased\n BS\n Abdominal: Obese, soft, Non-tender, no rebound, no guarding, + BS, PEG\n in place with dressing C/D/I\n Extremities: no CCE\n Skin: no rashes or jaundice\n Lines: r brachioceph ART with large amount of bloody drainage and L\n PICC C/D/I\n Labs / Radiology\n 213 K/uL\n 8.8 g/dL\n 123 mg/dL\n 0.6 mg/dL\n 32 mEq/L\n 3.6 mEq/L\n 13 mg/dL\n 107 mEq/L\n 145 mEq/L\n 29.4 %\n 11.1 K/uL\n [image002.jpg]\n 03:44 AM\n 06:04 AM\n 09:09 AM\n 05:07 PM\n 03:31 AM\n 03:46 AM\n 10:20 AM\n 03:46 PM\n 01:37 AM\n 05:32 AM\n WBC\n 9.6\n 8.2\n 11.1\n Hct\n 25.3\n 27.4\n 29.4\n Plt\n \n Cr\n 0.6\n 0.8\n 0.6\n 0.8\n 0.6\n TCO2\n 33\n 32\n 35\n 37\n 31\n Glucose\n 107\n 121\n 118\n 155\n 123\n Other labs: PT / PTT / INR:22.3/69.7/2.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:13.1 %,\n Mono:2.7 %, Eos:0.6 %, Lactic Acid:1.1 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:9.2 mg/dL, Mg++:2.5 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA, and\n ARDS, intubated since the end of now s/p trach and PEG\n placement.\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation. S/P Trach\n and PEG on .\n - wean FiO2 as tolerated\n - attempt wean PS today and hopeful for trach mask trial\n # Sedation: Continue to have issues with pain/delirium causing\n tachycardia and hypertension with intermittent hypotension. On Haldol\n 5 TID, Fentanyl 100-150 mcg TP, Diazapam 10 QID; Haldol, midazolam and\n morphine PRN. Had good response to morphine, minimal response to\n haldol bolus.\n - Will d/c midazolam and haldol PRN and use morphine for now.\n - If stable, would d/c standing Haldol tonight or tomorrow\n # Adrenal Insufficency: Hypotension that resolved with steroids,\n returned as they came off and is now improved again. Possible primary\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\n started on .\n - ok to go to 10 q am and 5 q pm prednisone, will wean to\n maintenance dose as tolerated, in consultation with endo.\n # Volume overloaded in setting of hypernatremia with TBW deficit and\n metabolic alkalosis\n - Lasix boluses, goal -1L today\n - Diamox until HCO3 < 30\n - electrolytes\n - continue tube feeds with free water flushes 300 cc q4\n # RUE DVT: INR now therapeutic on coumadin. Goal \n - stop heparin gtt\n - coumadin 5mg QHS\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - Brace for OOB\n - will f/u full trauma spine eval from OSH to determine need for\n further back imaging in-house.\n # Tracheomalacia: Discussed with IP. Stenting unlikely to help for\n trachiomalacia as airways have poor structure diffusely.\n - Outpatient f/u once off pressure support to assess for possible\n stenting\n #. Thyroid Nodule on CT\n -outpatient follow up\n # Nutrition: Tube feeds with free water flushes, tolerating well,\n continue Replete (Full) - 11:20 AM 30 mL/hour\n # Glycemic control: SSI, well controlled\n # Lines L PICC () and R ART ()\n d/c art today. Correlate ABG\n and VBG.\n # Ppx: INR therapeutic, ranitidine, colace and senna\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n Code: Full\n Dispo: ICU, being screening for vent facilities\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Arterial Line - 02:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2167-10-11 00:00:00.000","description":"Physician Resident Progress Note","row_id":636943,"text":"Chief Complaint:\n 24 Hour Events:\n Spiked to 102.2 after aspiration of tube feeds (only at 10 cc/hr) - pan\n cultured and given tylenol\n INR rising\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Aztreonam - 03:42 AM\n Vancomycin - 09:40 AM\n Levofloxacin - 11:15 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 07:47 AM\n Morphine Sulfate - 05:16 AM\n Other medications:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39\nC (102.2\n Tcurrent: 37.1\nC (98.7\n HR: 129 (86 - 137) bpm\n BP: 102/52(64) {78/26(42) - 155/89(100)} mmHg\n RR: 15 (12 - 65) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,299 mL\n 500 mL\n PO:\n TF:\n 55 mL\n IVF:\n 699 mL\n 500 mL\n Blood products:\n Total out:\n 2,990 mL\n 485 mL\n Urine:\n 2,990 mL\n 485 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,691 mL\n 15 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 513 (328 - 561) mL\n PS : 0 cmH2O\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: Agitated\n PIP: 22 cmH2O\n SpO2: 99%\n ABG: ///26/\n Ve: 6.6 L/min\n Physical Examination\n General Appearance: Trached. Interactive. Responsive, following\n commands, Overweight / Obese, mild agitation but NAD\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\n deviation\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Respiratory / Chest: (Expansion: Symmetric), b/l rhonchi R>L, decreased\n BS\n Abdominal: Obese, soft, Non-tender, no rebound, no guarding, + BS, PEG\n in place with dressing C/D/I\n Extremities: no CCE\n Skin: no rashes or jaundice\n Lines: L PICC C/D/I\n Labs / Radiology\n 238 K/uL\n 8.4 g/dL\n 106 mg/dL\n 0.9 mg/dL\n 26 mEq/L\n 3.9 mEq/L\n 11 mg/dL\n 108 mEq/L\n 143 mEq/L\n 26.9 %\n 7.2 K/uL\n [image002.jpg]\n 02:43 PM\n 03:03 PM\n 08:11 PM\n 02:51 AM\n 03:10 AM\n 03:08 PM\n 03:00 AM\n 03:36 AM\n 04:40 PM\n 03:00 AM\n WBC\n 9.4\n 11.3\n 7.3\n 6.1\n 7.2\n Hct\n 26.6\n 24.9\n 27.6\n 26.5\n 26.9\n Plt\n 09\n 238\n Cr\n 0.9\n 0.7\n 0.6\n 0.6\n 0.9\n TCO2\n 31\n 30\n 29\n 26\n Glucose\n 128\n 114\n 114\n 99\n 115\n 106\n Other labs: PT / PTT / INR:72.4/42.1/9.0, Ca++:9.3 mg/dL, Mg++:2.5\n mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA, and\n ARDS, intubated since the end of now s/p trach and PEG\n placement.\n # Recent Aspiration of tube feeds. Given prolonged hospitalization and\n tenuous respiratory status will treat with antibiotics while cultures\n pending\n - Levoflox for 48 hours while waiting for sputum results.\n - hold tube feeds\n - Follow cultures\n - check tube placement\n .\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation. S/P Trach\n and PEG on .\n - wean FiO2 as tolerated\n - attempt wean PS today and hopeful for trach mask trial\n # Sedation: Continue to have issues with pain/delirium causing\n tachycardia and hypertension with intermittent hypotension. On Haldol\n 5 TID, Fentanyl 75 mcg TP, Diazapam 10 QID; Haldol, midazolam and\n morphine PRN. Had good response to morphine, minimal response to\n haldol bolus.\n - tolerating current regimen well, no changes today\n # Adrenal Insufficency: Hypotension that resolved with steroids,\n returned as they came off and is now improved again. Possible primary\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\n started on .\n - stopped steroids as per endocrine today\n # Volume overloaded in setting of hypernatremia\n Goal even today.\n - monitor urine output\n # RUE DVT: INR super-therapeutic on coumadin. Goal . Hasn\n received coumadin in days yet INR continues to rise. Likely\n contributors are nutritional and antibiotics.\n - will start coumadin 2.5 mg QHS once INR < 3\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - Brace for OOB\n - report from full trauma series from OSH is in chart. No evidence of\n other fracture and no need for further spinal imaging based on this\n report and ortho note.\n # Tracheomalacia: Discussed with IP. Stenting unlikely to help for\n trachiomalacia as airways have poor structure diffusely.\n - Outpatient f/u once off pressure support to assess for possible\n stenting\n #. Thyroid Nodule on CT\n -outpatient follow up\n # Nutrition: Replete (Full)\n hold\n # Glycemic control: SSI, well controlled\n # Lines L PICC\n ().\n # Ppx: INR therapeutic, ranitidine, colace and senna, miralax,\n bisacodyl.\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n Code: Full\n Dispo: ICU, being screening for vent facilities\n ------ Protected Section ------\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 55F T5-8 fractures with retropulsion and ARDS\n from klebsiella VAP; on heparin for UE DVT and lasix for volume\n overload. Overnight spiked to 102.2 after apparent aspiration of TF\n despite low rate (suctioned whitish material from trache).\n On exam:\n Tmax: 39\nC (102.2\n Tcurrent: 37.1\nC (98.7\n HR: 129 (86 - 137) bpm\n BP: 102/52(64) {78/26(42) - 155/89(100)} mmHg\n RR: 15 (12 - 65) insp/min\n SpO2: 99%\n Trached, lightly sedated, following commands.\n CV RRR, distant\n Lungs\n distant bs, otherwise clear\n abd: soft NTND BS+, +PEG site\n Ext- no c/c/e\n 55F h/o EtOH abuse presenting following mech fall -> traumatic T spine\n fracture with K. oxytoca PNA, and ARDS, intubated since the end of\n now s/p trach and PEG placement.\n Cont efforts to wean mech vent including spont breathing trials w/\n monitoring given RR. Resp failure related to ARDS, tracheomalacia,\n VAP (resolved) and component of fluid overload. Now w/ apparent\n aspiration of TF. Check position of FT to ensure intragastric. Hold\n TF until confirmed. SCx/GS. Sedation continues to be challenge given\n delirium, agitation and tolerance for medications. Ortho following re:\n fx. Cont brace. Agree with recs as outlined above.\n Code: FULL\n ------ Protected Section Addendum Entered By: , MD\n on: 04:14 PM ------\n"},{"category":"Physician ","chartdate":"2167-10-08 00:00:00.000","description":"Physician Resident Progress Note","row_id":636389,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - STOP 12:23 PM\n ARTERIAL LINE - START 02:00 PM\n A-line resited, not working again\n tube feed machine not working\n failed SBT - low MV with PSV - switched to MMV overnight\n tachycardic to 140-142\n Ortho spine ok with documented final read of CT trauma from attending\n at OSH and week f/u - faxed request and spoke with med recs at\n Medical re: sending report which was agreed upon.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,500 units/hour\n Other ICU medications:\n Morphine Sulfate - 12:15 PM\n Midazolam (Versed) - 03:50 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:13 AM\n Vital signs\n Cardiac monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.1\nC (98.8\n HR: 105 (70 - 148) bpm\n BP: 85/55(66) {85/41(57) - 158/110(323)} mmHg\n RR: 23 (10 - 31) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n QTc: 411\n Total In:\n 3,562 mL\n 965 mL\n PO:\n TF:\n 1,685 mL\n 150 mL\n IVF:\n 548 mL\n 215 mL\n Blood products:\n Total out:\n 5,695 mL\n 1,740 mL\n Urine:\n 5,695 mL\n 1,740 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,133 mL\n -775 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 359 (137 - 695) mL\n PS : 8 cmH2O\n RR (Set): 10\n RR (Spontaneous): 26\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI: 58\n PIP: 16 cmH2O\n SpO2: 95%\n ABG: 7.40/49/114/32/3\n Ve: 7.2 L/min\n PaO2 / FiO2: 228\n Physical Examination\n General Appearance: Trached and sedated. Responsive, following\n commands, Overweight / Obese, mild agitation but NAD\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\n deviation\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Respiratory / Chest: (Expansion: Symmetric), CTA anteriorly, decreased\n BS\n Abdominal: Obese, soft, Non-tender, no rebound, no guarding, + BS, PEG\n in place with dressing C/D/I\n Extremities: no CCE\n Skin: no rashes or jaundice\n Lines: r brachioceph ART with large amount of bloody drainage and L\n PICC C/D/I\n Labs / Radiology\n 213 K/uL\n 8.8 g/dL\n 123 mg/dL\n 0.6 mg/dL\n 32 mEq/L\n 3.6 mEq/L\n 13 mg/dL\n 107 mEq/L\n 145 mEq/L\n 29.4 %\n 11.1 K/uL\n [image002.jpg]\n 03:44 AM\n 06:04 AM\n 09:09 AM\n 05:07 PM\n 03:31 AM\n 03:46 AM\n 10:20 AM\n 03:46 PM\n 01:37 AM\n 05:32 AM\n WBC\n 9.6\n 8.2\n 11.1\n Hct\n 25.3\n 27.4\n 29.4\n Plt\n \n Cr\n 0.6\n 0.8\n 0.6\n 0.8\n 0.6\n TCO2\n 33\n 32\n 35\n 37\n 31\n Glucose\n 107\n 121\n 118\n 155\n 123\n Other labs: PT / PTT / INR:22.3/69.7/2.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:13.1 %,\n Mono:2.7 %, Eos:0.6 %, Lactic Acid:1.1 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:9.2 mg/dL, Mg++:2.5 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA, and\n ARDS, intubated since the end of now s/p trach and PEG\n placement.\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation. Stenting\n unlikely to help for trachiomalacia as airways have poor structure\n diffusely. S/P Trach and PEG on .\n - wean FiO2 as tolerated\n - attempt wean PS today and hopeful for trach mask trial\n # Sedation: Sedation control remains somewhat poor although fentanyl\n patch and diazpem are likely therapeutic range today. On Versed 2.0,\n Fentanyl 100, Fentanyl patch, Diazepam standing and haldo 2.5-5 mg\n PRN. QTc increased to 480.\n - Wean versed/fentanyl as tolerated, continue diazepam in\n hopes for vent facility placement\n - Continue diazepam 10 mg q8 with haldol 5 mg q8 with 2.5-5\n prn haldol\n # Adrenal Insufficency: Hypotension that resolved with steroids,\n returned as they came off and is now improved again. Possible primary\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\n started on .\n - wean per endo recs, decrease to 20q am and 10 q pm today\n - ok to go to 10 q am and 5 q pm tomorrow ()\n # Volume overloaded in setting of hypernatremia with TBW deficit and\n metabolic alkalosis\n - Lasix boluses with diamox today, goal -1L\n - electrolytes\n - continue tube feeds with free water flushes 300 cc q4\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\n coumadin at least until s/p trach. INR 1.7 today.\n - heparin gtt restarted\n - coumadin 5mg G-tube today, INR in am\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n -f/u full trauma spine eval from OSH to determine need for further back\n imaging in-house (to be done )\n # Tracheomalacia: Discussed with IP.\n - Outpatient f/u once off pressure support to assess for possible\n stenting\n #. Thyroid Nodule on CT\n -outpatient follow up\n # Nutrition: Tube feeds with free water flushes, tolerating well,\n continue Replete (Full) - 11:20 AM 30 mL/hour\n # Glycemic control: SSI, well controlled\n # Lines L PICC () and R ART ()\n d/c art and re-site today\n # Ppx: heparin drip until INR therapeutic for 2 days, ranitidine, VAP\n prevention, colace and senna\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n Code: Full\n Dispo: ICU, being screening for vent facilities\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Arterial Line - 02:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Nursing","chartdate":"2167-10-04 00:00:00.000","description":"Nursing Progress Note","row_id":635675,"text":"55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\n Now with prolonged hospital course c/b by PNA with high PEEP\n requirement, anxiety, RUE DVT on heparin qtt.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt on Vent settings AC 55%/18 X 400/+10 with no overbreathing of\n set RR. O2 sat 92-98%. Lung snds clear, diminished in bases. Pt sxn\n for small-moderate amts thick white secretions. Trach site with small\n amt serosang drainage.\n Action:\n Cont same vent settings\n Response:\n Pt doesn\nt over breath on the vent and never desat.\n Plan:\n Wean from vent as she tolerates,monitor sats,ABG?.\n"},{"category":"Physician ","chartdate":"2167-10-13 00:00:00.000","description":"Physician Resident Progress Note","row_id":637258,"text":"Chief Complaint:\n 24 Hour Events:\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 09:40 AM\n Levofloxacin - 11:15 PM\n Ceftriaxone - 07:50 PM\n Infusions:\n Other ICU medications:\n Haloperidol (Haldol) - 10:26 AM\n Diazepam (Valium) - 11:33 AM\n Morphine Sulfate - 02:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.7\nC (98.1\n HR: 118 (118 - 148) bpm\n BP: 90/37(48) {90/37(48) - 171/111(115)} mmHg\n RR: 14 (12 - 36) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,614 mL\n 439 mL\n PO:\n TF:\n 884 mL\n 279 mL\n IVF:\n 100 mL\n Blood products:\n Total out:\n 834 mL\n 20 mL\n Urine:\n 834 mL\n 20 mL\n NG:\n Stool:\n Drains:\n Balance:\n 780 mL\n 419 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 354 (244 - 376) mL\n PS : 10 cmH2O\n RR (Spontaneous): 12\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 56\n PIP: 15 cmH2O\n SpO2: 95%\n ABG: ////\n Ve: 4.1 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 240 K/uL\n 7.9 g/dL\n 100 mg/dL\n 0.6 mg/dL\n 30 mEq/L\n 3.4 mEq/L\n 12 mg/dL\n 108 mEq/L\n 146 mEq/L\n 26.0 %\n 5.2 K/uL\n [image002.jpg]\n 08:11 PM\n 02:51 AM\n 03:10 AM\n 03:08 PM\n 03:00 AM\n 03:36 AM\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n WBC\n 9.4\n 11.3\n 7.3\n 6.1\n 7.2\n 5.2\n Hct\n 26.6\n 24.9\n 27.6\n 26.5\n 26.9\n 26.0\n Plt\n \n Cr\n 0.9\n 0.7\n 0.6\n 0.6\n 0.9\n 0.7\n 0.6\n TCO2\n 29\n 26\n Glucose\n 128\n 114\n 114\n 99\n 115\n 106\n 100\n Other labs: PT / PTT / INR:17.6/27.4/1.6, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:33/22, Alk Phos / T Bili:143/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:0.5 mmol/L,\n Albumin:3.5 g/dL, LDH:199 IU/L, Ca++:8.9 mg/dL, Mg++:2.4 mg/dL, PO4:4.1\n mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 10:31 PM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n 20 Gauge - 04:59 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2167-10-13 00:00:00.000","description":"Physician Resident Progress Note","row_id":637259,"text":"Chief Complaint:\n 24 Hour Events:\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 09:40 AM\n Levofloxacin - 11:15 PM\n Ceftriaxone - 07:50 PM\n Infusions:\n Other ICU medications:\n Haloperidol (Haldol) - 10:26 AM\n Diazepam (Valium) - 11:33 AM\n Morphine Sulfate - 02:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.7\nC (98.1\n HR: 118 (118 - 148) bpm\n BP: 90/37(48) {90/37(48) - 171/111(115)} mmHg\n RR: 14 (12 - 36) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,614 mL\n 439 mL\n PO:\n TF:\n 884 mL\n 279 mL\n IVF:\n 100 mL\n Blood products:\n Total out:\n 834 mL\n 20 mL\n Urine:\n 834 mL\n 20 mL\n NG:\n Stool:\n Drains:\n Balance:\n 780 mL\n 419 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 354 (244 - 376) mL\n PS : 10 cmH2O\n RR (Spontaneous): 12\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 56\n PIP: 15 cmH2O\n SpO2: 95%\n ABG: ////\n Ve: 4.1 L/min\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n Eyes / Conjunctiva: PERRL, Pupils dilated\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Bowel sounds present, Obese, Patient with thoracic\n brace on\n Skin: Not assessed, No(t) Rash: , Per Nursing: Pt with vesicular rash\n on inferior back.\n Neurologic: Follows simple commands, Responds to: Not assessed,\n Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 240 K/uL\n 7.9 g/dL\n 100 mg/dL\n 0.6 mg/dL\n 30 mEq/L\n 3.4 mEq/L\n 12 mg/dL\n 108 mEq/L\n 146 mEq/L\n 26.0 %\n 5.2 K/uL\n [image002.jpg]\n 08:11 PM\n 02:51 AM\n 03:10 AM\n 03:08 PM\n 03:00 AM\n 03:36 AM\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n WBC\n 9.4\n 11.3\n 7.3\n 6.1\n 7.2\n 5.2\n Hct\n 26.6\n 24.9\n 27.6\n 26.5\n 26.9\n 26.0\n Plt\n \n Cr\n 0.9\n 0.7\n 0.6\n 0.6\n 0.9\n 0.7\n 0.6\n TCO2\n 29\n 26\n Glucose\n 128\n 114\n 114\n 99\n 115\n 106\n 100\n Other labs: PT / PTT / INR:17.6/27.4/1.6, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:33/22, Alk Phos / T Bili:143/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:0.5 mmol/L,\n Albumin:3.5 g/dL, LDH:199 IU/L, Ca++:8.9 mg/dL, Mg++:2.4 mg/dL, PO4:4.1\n mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 10:31 PM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n 20 Gauge - 04:59 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2167-10-13 00:00:00.000","description":"Physician Resident Progress Note","row_id":637260,"text":"Chief Complaint:\n 24 Hour Events:\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 09:40 AM\n Levofloxacin - 11:15 PM\n Ceftriaxone - 07:50 PM\n Infusions:\n Other ICU medications:\n Haloperidol (Haldol) - 10:26 AM\n Diazepam (Valium) - 11:33 AM\n Morphine Sulfate - 02:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.7\nC (98.1\n HR: 118 (118 - 148) bpm\n BP: 90/37(48) {90/37(48) - 171/111(115)} mmHg\n RR: 14 (12 - 36) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,614 mL\n 439 mL\n PO:\n TF:\n 884 mL\n 279 mL\n IVF:\n 100 mL\n Blood products:\n Total out:\n 834 mL\n 20 mL\n Urine:\n 834 mL\n 20 mL\n NG:\n Stool:\n Drains:\n Balance:\n 780 mL\n 419 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 354 (244 - 376) mL\n PS : 10 cmH2O\n RR (Spontaneous): 12\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 56\n PIP: 15 cmH2O\n SpO2: 95%\n ABG: ////\n Ve: 4.1 L/min\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n Eyes / Conjunctiva: PERRL, Pupils dilated\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Bowel sounds present, Obese, Patient with thoracic\n brace on\n Skin: Not assessed, No(t) Rash: , Per Nursing: Pt with vesicular rash\n on inferior back.\n Neurologic: Follows simple commands, Responds to: Not assessed,\n Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 240 K/uL\n 7.9 g/dL\n 100 mg/dL\n 0.6 mg/dL\n 30 mEq/L\n 3.4 mEq/L\n 12 mg/dL\n 108 mEq/L\n 146 mEq/L\n 26.0 %\n 5.2 K/uL\n [image002.jpg]\n 08:11 PM\n 02:51 AM\n 03:10 AM\n 03:08 PM\n 03:00 AM\n 03:36 AM\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n WBC\n 9.4\n 11.3\n 7.3\n 6.1\n 7.2\n 5.2\n Hct\n 26.6\n 24.9\n 27.6\n 26.5\n 26.9\n 26.0\n Plt\n \n Cr\n 0.9\n 0.7\n 0.6\n 0.6\n 0.9\n 0.7\n 0.6\n TCO2\n 29\n 26\n Glucose\n 128\n 114\n 114\n 99\n 115\n 106\n 100\n Other labs: PT / PTT / INR:17.6/27.4/1.6, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:33/22, Alk Phos / T Bili:143/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:0.5 mmol/L,\n Albumin:3.5 g/dL, LDH:199 IU/L, Ca++:8.9 mg/dL, Mg++:2.4 mg/dL, PO4:4.1\n mg/dL\n Assessment and Plan\n 55yoF with history of EtOH abuse presenting following mechanical fall\n and traumatic T spine fracture with K. oxytoca PNA, and ARDS, intubated\n since the end of now s/p trach and PEG placement.\n# Recent Aspiration on Tube Feeds. Cultures growing Klebsiella Oxytoca and Klebs\niella Pneumoniae. Pt received developed rash on Levofloxacin, switched to Ceftri\naxone overnight. Will treat for potential HAP for 8 days.\n - Continue Ceftriaxone day #1.\n - Tube Feeds restarted with goal of 60/hr\n - Follow cultures\n - check tube placement\n .\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation. S/P Trach\n and PEG on .\n - Weaning FiO2 as tolerated\n - Will attempt trach collar today\n # Tachycardia: Pt in ST for most of the day 120\ns to 140s. Etiology\n remains unclear although she has been tachy since admission. Etiologies\n include pain (especially when sitting upright with thoracic brace on),\n infection (pt with known klebsiella, possibly acquired HAP). DDx also\n includes PE, hyperthyroidism.\n - Will keep pt\ns INR therapeutic\n - TSH 2.4 on early , will check free T3, T4.\n - Continue Pain Control\n - Treat underlying infection\n # Sedation: Pt has pain/delirium causing tachycardia and hypertension\n with intermittent hypotension. On Haldol 5 TID, Fentanyl 75 mcg TP,\n Diazapam 10 QID; Haldol, midazolam and morphine PRN. Had good response\n to morphine, minimal response to haldol bolus.\n - tolerating current regimen well, no changes today\n # Adrenal Insufficency: Hypotension that resolved with steroids,\n returned as they came off and is now improved again. Possible primary\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\n started on .\n - stopped steroids as per endocrine today\n # Volume overloaded in prior setting of hypernatremia\n Goal even\n today.\n - Monitoring urine output\n # RUE DVT: INR was super-therapeutic on coumadin. Goal . Hasn\n received coumadin in days yet INR continues to rise. Likely\n contributors are nutritional and antibiotics.\n - will start coumadin 2.5 mg QHS once INR < 3\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - Brace for OOB\n - Report from full trauma series from OSH is in chart.\n - Pt to follow up with Dr. in weeks\n # Tracheomalacia: Discussed with IP. Stenting unlikely to help for\n trachiomalacia as airways have poor structure diffusely.\n - Outpatient f/u once off pressure support to assess for possible\n stenting\n #. Thyroid Nodule on CT\n - Outpatient follow up\n # Nutrition: Replete (Full)\n hold\n # Glycemic control: SSI, well controlled\n # Lines L PICC ().\n # Ppx: INR remains therapeutic, ranitidine, colace and senna, miralax,\n bisacodyl.\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n Code: Full\n Dispo: ICU, being screening for vent facilities\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 11:38 AM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n 20 Gauge - 04:59 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 10:31 PM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n 20 Gauge - 04:59 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Nursing","chartdate":"2167-10-07 00:00:00.000","description":"Nursing Progress Note","row_id":636150,"text":"55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\n Now with prolonged hospital course c/b by PNA with high PEEP\n requirement, anxiety, RUE DVT on heparin qtt.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lungs clear bilat upper lobes and diminished bilat bases with\n occasional scattered rhonchi, prod cough thick yellow/tan sputum, trach\n sx for mod. Amt of same, tolerated CPAP+PS until fell asleep and then\n RR down to 4-5 breaths with MV down to 1-5. Placed on MMV for\n remainder of night with good effect.\n Action:\n Vent changed from CPAP+PS to MMV overnight and weaned back to CPAP+PS\n this am, Peep decreased to 8cm. Freq. pulmonary toileting, diuresing\n with 40mg. IV Lasix dose\n Response:\n Tolerating slow vent wean, ABG: 7.41-53-86, requiring pulmonary\n toileting, good diuresis in attempt to wean vent further\n Plan:\n Attempt to wean PS and FI02 down further today as tolerated, may need\n MMV mode at night or when sedated, Continue aggressive pulmonary\n toileting, Diurese as tolerated.\n Altered mental status (not Delirium)\n Assessment:\n Increased agitation throughout night with pt writhing in bed and\n attempting to get OOB and attempting to pull at all lines and tubes,\n makes eye contact and follows commands but doesn\nt stay calm for long,\n HR up to 130- with agitation and BP up to 130-150\ns/60-70\n received valium and Haldol as ordered with prn dosing in between\n scheduled doses with poor effect, received 4 mg. Iv versed with poor\n effect, appears generally uncomfortable but denies pain when asked.\n Action:\n Freq. attempts to reorient and calm pt, Valium 5mg x 2 with no effect,\n Haldol 5mg po and additional 1 mg. IV with no effect, Versed 4 mg. with\n no effect, stimulation decreased, bilat soft wrist restraints to\n prevent pt from pulling at lines and tubes\n Response:\n Increased agitation off of continuous IV sedation, poor effect from\n current medical regime, MICU team aware and addressing\n Plan:\n Valium dose to be increased, Potential head CT today, obtain psych and\n neuro consults if pt\ns mental status doesn\nt improve\n"},{"category":"Nursing","chartdate":"2167-10-07 00:00:00.000","description":"Nursing Progress Note","row_id":636153,"text":"55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\n Now with prolonged hospital course c/b by PNA with high PEEP\n requirement, anxiety, RUE DVT on heparin qtt.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lungs clear bilat upper lobes and diminished bilat bases with\n occasional scattered rhonchi, prod cough thick yellow/tan sputum, trach\n sx for mod. Amt of same, tolerated CPAP+PS until fell asleep and then\n RR down to 4-5 breaths with MV down to 1-5. Placed on MMV for\n remainder of night with good effect.\n Action:\n Vent changed from CPAP+PS to MMV overnight and weaned back to CPAP+PS\n this am, Peep decreased to 8cm. Freq. pulmonary toileting, diuresing\n with 40mg. IV Lasix dose\n Response:\n Tolerating slow vent wean, ABG: 7.41-53-86, requiring pulmonary\n toileting, good diuresis in attempt to wean vent further\n Plan:\n Attempt to wean PS and FI02 down further today as tolerated, may need\n MMV mode at night or when sedated, Continue aggressive pulmonary\n toileting, Diurese as tolerated.\n Altered mental status (not Delirium)\n Assessment:\n Increased agitation throughout night with pt writhing in bed and\n attempting to get OOB and attempting to pull at all lines and tubes,\n makes eye contact and follows commands but doesn\nt stay calm for long,\n HR up to 130- with agitation and BP up to 130-150\ns/60-70\n received valium and Haldol as ordered with prn dosing in between\n scheduled doses with poor effect, received 4 mg. Iv versed with poor\n effect, appears generally uncomfortable but denies pain when asked.\n Action:\n Freq. attempts to reorient and calm pt, Valium 5mg x 2 with no effect,\n Haldol 5mg po and additional 1 mg. IV with no effect, Versed 4 mg. with\n no effect, stimulation decreased, bilat soft wrist restraints to\n prevent pt from pulling at lines and tubes\n Response:\n Increased agitation off of continuous IV sedation, poor effect from\n current medical regime, MICU team aware and addressing\n Plan:\n Valium dose to be increased, Potential head CT today, obtain psych and\n neuro consults if pt\ns mental status doesn\nt improve\n Hypernatremia (high sodium)\n Assessment:\n No seizure activity noted, Na= 141 last evening\n Action:\n Free water flushes decreased to 150 ml Q4hr from 300ml Q 4hr\n Response:\n Na back up to 146---MICU team aware\n Plan:\n Continue free water flushes, address tube feedings with nutrition and\n possible change to a lower sodium tube feeding, potential need to\n increase free water amts back to 300ml, monitor Na levels\n"},{"category":"Respiratory ","chartdate":"2167-10-08 00:00:00.000","description":"Respiratory Care Shift Note","row_id":636432,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 20\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Cuffed\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments: Patient ewaned to then back on due to increase RR and\n HR.Was oob/chair today for many hours with neck brace on.ABG on \n shows hypoxemia with pao2 66 mmhg and compensated resp acidosis,has # 8\n Portex,suctioned for small thick sputum.\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"},{"category":"Nursing","chartdate":"2167-10-01 00:00:00.000","description":"Nursing Progress Note","row_id":635388,"text":"55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP now with prolonged\n hospital course c/o by PNA anxiety,RUE DVD with high PEEP requirement\n .\n Events:. Failed spont. Breathing trial. pt to go to OR on for\n trach/PEG\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd on AC 400x18 50% +PEEP 8, 02 sat 88-93% ABG last night 7.42/47/87\n Action:\n Pt changed to PSV 5/0 for spontaneous breathing trial,\n Response:\n Pt immediately deatted to the low 80%\ns, sbp increased to the\n 150\ns-160\ns and HR increased to the 120\ns-130\ns. pt placed back on\n above vent settings and VS returned to baseline.\n Plan:\n Pt to have trach placed in the OR in the am.\n Altered mental status (not Delirium)\n Assessment:\n Pt w/ periods of agitation and sleeping at other times, but overall\n more alert, following commands intermittently.\n Action:\n Midazolam remains off, Fentanyl at 100mcg/hr. pt rec\nd Haldol x1 and\n cont on q6hr diazepam.\n Response:\n HR ranging from SB in the 40\ns when asleep to the 120\ns when agitated,\n b/p ranging from 90\ns/40\ns when asleep to 140-150\ns/ 70\ns when\n agitated. When pt awake appropriate and following commands HR\n 80\ns-100\ns and b/p 100\ns-120\ns/ 60-70\n Plan:\n Cont scheduled valium for anxiety w/ haldol for breakthrough, titrate\n Fentanyl for pain control.\n Alteration in Nutrition\n Assessment:\n TF on hold this am for possible procedure in OR, FS 123 this am. Pt\n total body fluid balance remains +~16L for LOS. UOP improving since\n midnight\n Action:\n TF restarted at goal rate 60ml/hr w/ H20 boluses 250ml Q4hrs. when OR\n procedure moved until tomorrow. Lasix gtt continues at 3mg/hr\n Response:\n Pt tol TF well stools x2 this shift, serum Na 146 at 1600. K= 4.1UOP\n 140-540ml/hr on lasix gtt at 3mg/hr\n Plan:\n Cont lasix gtt as b/p tol w/ goal 24 FB neg 1-2L. cont TF and free H20\n boluses until midnight. Pt NPO after midnight for trach/PEG placement\n in am.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Heparin gtt off this am for possible trip to OR. Ptt 26.6 INR 1.1\n Action:\n Heparin gtt restarted at 1700units/hr this am when OR time changed\n until tomorrow.\n Response:\n Repeat PTT pending at the time of this note\n Plan:\n Cont to monitor PTT and titrate heparin gtt per protocol, heparin to be\n shut off at 6am for procedure in OR.\n"},{"category":"Physician ","chartdate":"2167-10-13 00:00:00.000","description":"Physician Resident Progress Note","row_id":637263,"text":"Chief Complaint:\n 24 Hour Events:\n Low UOP. UOP 10-20cc/hr, tachy to 130s\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 09:40 AM\n Levofloxacin - 11:15 PM\n Ceftriaxone - 07:50 PM\n Infusions:\n Other ICU medications:\n Haloperidol (Haldol) - 10:26 AM\n Diazepam (Valium) - 11:33 AM\n Morphine Sulfate - 02:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.7\nC (98.1\n HR: 118 (118 - 148) bpm\n BP: 90/37(48) {90/37(48) - 171/111(115)} mmHg\n RR: 14 (12 - 36) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,614 mL\n 439 mL\n PO:\n TF:\n 884 mL\n 279 mL\n IVF:\n 100 mL\n Blood products:\n Total out:\n 834 mL\n 20 mL\n Urine:\n 834 mL\n 20 mL\n NG:\n Stool:\n Drains:\n Balance:\n 780 mL\n 419 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 354 (244 - 376) mL\n PS : 10 cmH2O\n RR (Spontaneous): 12\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 56\n PIP: 15 cmH2O\n SpO2: 95%\n ABG: ////\n Ve: 4.1 L/min\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n Eyes / Conjunctiva: PERRL, Pupils dilated\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Bowel sounds present, Obese, Patient with thoracic\n brace on\n Skin: Not assessed, No(t) Rash: , Per Nursing: Pt with vesicular rash\n on inferior back.\n Neurologic: Follows simple commands, Responds to: Not assessed,\n Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 240 K/uL\n 7.9 g/dL\n 100 mg/dL\n 0.6 mg/dL\n 30 mEq/L\n 3.4 mEq/L\n 12 mg/dL\n 108 mEq/L\n 146 mEq/L\n 26.0 %\n 5.2 K/uL\n [image002.jpg]\n 08:11 PM\n 02:51 AM\n 03:10 AM\n 03:08 PM\n 03:00 AM\n 03:36 AM\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n WBC\n 9.4\n 11.3\n 7.3\n 6.1\n 7.2\n 5.2\n Hct\n 26.6\n 24.9\n 27.6\n 26.5\n 26.9\n 26.0\n Plt\n \n Cr\n 0.9\n 0.7\n 0.6\n 0.6\n 0.9\n 0.7\n 0.6\n TCO2\n 29\n 26\n Glucose\n 128\n 114\n 114\n 99\n 115\n 106\n 100\n Other labs: PT / PTT / INR:17.6/27.4/1.6, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:33/22, Alk Phos / T Bili:143/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:0.5 mmol/L,\n Albumin:3.5 g/dL, LDH:199 IU/L, Ca++:8.9 mg/dL, Mg++:2.4 mg/dL, PO4:4.1\n mg/dL\n Assessment and Plan\n 55yoF with history of EtOH abuse presenting following mechanical fall\n and traumatic T spine fracture with K. oxytoca PNA, and ARDS, intubated\n since the end of now s/p trach and PEG placement.\n# Recent Aspiration on Tube Feeds. Cultures growing Klebsiella Oxytoca and Klebs\niella Pneumoniae. Pt received developed rash on Levofloxacin, switched to Ceftri\naxone overnight. Will treat for potential HAP for 8 days.\n - Continue Ceftriaxone day #1.\n - Tube Feeds restarted with goal of 60/hr\n - Follow cultures\n - check tube placement\n .\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation. S/P Trach\n and PEG on .\n - Weaning FiO2 as tolerated\n - Will attempt trach collar today\n # Tachycardia: Pt in ST for most of the day 120\ns to 140s. Etiology\n remains unclear although she has been tachy since admission. Etiologies\n include pain (especially when sitting upright with thoracic brace on),\n infection (pt with known klebsiella, possibly acquired HAP). DDx also\n includes PE, hyperthyroidism.\n - Will keep pt\ns INR therapeutic\n - TSH 2.4 on early , will check free T3, T4.\n - Continue Pain Control\n - Treat underlying infection\n # Sedation: Pt has pain/delirium causing tachycardia and hypertension\n with intermittent hypotension. On Haldol 5 TID, Fentanyl 75 mcg TP,\n Diazapam 10 QID; Haldol, midazolam and morphine PRN. Had good response\n to morphine, minimal response to haldol bolus.\n - tolerating current regimen well, no changes today\n # Adrenal Insufficency: Hypotension that resolved with steroids,\n returned as they came off and is now improved again. Possible primary\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\n started on .\n - stopped steroids as per endocrine today\n # Volume overloaded in prior setting of hypernatremia\n Goal even\n today.\n - Monitoring urine output\n # RUE DVT: INR was super-therapeutic on coumadin. Goal . Hasn\n received coumadin in days yet INR continues to rise. Likely\n contributors are nutritional and antibiotics.\n - will start coumadin 2.5 mg QHS once INR < 3\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - Brace for OOB\n - Report from full trauma series from OSH is in chart.\n - Pt to follow up with Dr. in weeks\n # Tracheomalacia: Discussed with IP. Stenting unlikely to help for\n trachiomalacia as airways have poor structure diffusely.\n - Outpatient f/u once off pressure support to assess for possible\n stenting\n #. Thyroid Nodule on CT\n - Outpatient follow up\n # Nutrition: Replete (Full)\n hold\n # Glycemic control: SSI, well controlled\n # Lines L PICC\n ().\n # Ppx: INR remains therapeutic, ranitidine, colace and senna, miralax,\n bisacodyl.\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n Code: Full\n Dispo: ICU, being screening for vent facilities\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 11:38 AM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n 20 Gauge - 04:59 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 10:31 PM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n 20 Gauge - 04:59 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2167-10-07 00:00:00.000","description":"Physician Resident Progress Note","row_id":636133,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n EKG - At 11:53 PM for qrs\n Continued to have alternating tachy and bradycadia with associated\n pressure swings on adjusted pain regimen. Unable to diurese given\n intermittant hypotension. Finally got one dose lasix.\n Much more anxious than previous nights. Increased Valium back to 10 mg\n QID.\n CT showed cuff distention. Per respiratory, still has a leak, likely\n needs a larger cuff.\n Hypernatremia resolved, cut back on FWB\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,500 units/hour\n Other ICU medications:\n Diazepam (Valium) - 02:00 AM\n Furosemide (Lasix) - 03:56 AM\n Haloperidol (Haldol) - 03:57 AM\n Midazolam (Versed) - 05:11 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37.1\nC (98.7\n HR: 124 (66 - 135) bpm\n BP: 137/67(92) {74/35(48) - 150/81(106)} mmHg\n RR: 15 (7 - 28) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 3,707 mL\n 723 mL\n PO:\n TF:\n 1,457 mL\n 364 mL\n IVF:\n 810 mL\n 150 mL\n Blood products:\n Total out:\n 2,535 mL\n 2,760 mL\n Urine:\n 2,535 mL\n 2,760 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,172 mL\n -2,037 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 964 (260 - 964) mL\n PS : 12 cmH2O\n RR (Set): 10\n RR (Spontaneous): 8\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI Deferred: Agitated\n PIP: 21 cmH2O\n SpO2: 94%\n ABG: 7.41/53/86/32/6\n Ve: 7.8 L/min\n PaO2 / FiO2: 172\n Physical Examination\n General Appearance: Trached and sedated. Responsive, following\n commands, Overweight / Obese, mild agitation but NAD\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\n deviation\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Respiratory / Chest: (Expansion: Symmetric), CTA anteriorly, decreased\n BS\n Abdominal: Obese, Firm, Non-tender, no rebound, no guarding, + BS, PEG\n in place with dressing C/D/I\n Extremities: No clubbing or cyanosis, trace edema of b/l hands,\n anasarca\n Skin: no rashes or jaundice\n Lines: r brachioceph ART with small amount of bloody drainage and L\n PICC C/D/I\n Labs / Radiology\n 213 K/uL\n 8.3 g/dL\n 118 mg/dL\n 0.6 mg/dL\n 32 mEq/L\n 3.5 mEq/L\n 11 mg/dL\n 108 mEq/L\n 146 mEq/L\n 27.4 %\n 8.2 K/uL\n [image002.jpg]\n 02:47 AM\n 11:01 AM\n 04:40 PM\n 05:08 PM\n 03:44 AM\n 06:04 AM\n 09:09 AM\n 05:07 PM\n 03:31 AM\n 03:46 AM\n WBC\n 11.2\n 9.6\n 8.2\n Hct\n 27.4\n 25.3\n 27.4\n Plt\n 272\n 229\n 213\n Cr\n 0.6\n 0.6\n 0.6\n 0.8\n 0.6\n TCO2\n 31\n 34\n 33\n 32\n 35\n Glucose\n 128\n 138\n 107\n 121\n 118\n Other labs: PT / PTT / INR:18.4/68.9/1.7, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:13.1 %,\n Mono:2.7 %, Eos:0.6 %, Lactic Acid:1.1 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:9.0 mg/dL, Mg++:2.5 mg/dL, PO4:4.8 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA and\n ARDS intubated since the end of now s/p trach and PEG placement.\n Thyroid nodule on CT\n Watch phos product\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation. Stenting\n unlikely to help for trachiomalacia as airways have poor structure\n diffusely. S/P Trach and PEG on . Increased effusion on recent\n CXR.\n - wean FiO2 as tolerated\n # Adrenal Insufficency: Hypotension that resolved with steroids,\n returned as they came off and is now improved again. Possible primary\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\n started on .\n - wean per endo recs, decrease to 20q am and 10 q pm starting\n tonight\n will maintain this maintenance dose and check am cortisol\n level one week later\n # Volume overloaded in setting of hypernatremia with TBW deficit.\n - Lasix gtt, continue with goal -1-2 L per day\n currently off as\n patient is somewhat hypotensive\n will restart once/if BP increases and\n remains stable for several hours\n - electrolytes\n - continue tube feeds with free water flushes 300 cc q4\n # Sedation: Sedation control remains somewhat poor although fentanyl\n patch and diazpem are likely therapeutic range today. On Versed 2.0,\n Fentanyl 100, Fentanyl patch, Diazepam standing and haldo 2.5-5 mg\n PRN. QTc increased to 480.\n - Wean versed/fentanyl as tolerated, continue diazepam in\n hopes for vent facility placement\n - Change diazepam to 5mg q8 with haldol 5 mg q8\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\n coumadin at least until s/p trach.\n - heparin gtt restarted\n - coumadin 5mg G-tube today, INR in am\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n -f/u full trauma spine eval from OSH to determine need for further back\n imaging in-house (to be done )\n # Nutrition: Tube feeds with free water flushes, tolerating well,\n continue Replete (Full) - 11:20 AM 30 mL/hour\n # Glycemic control: SSI, well controlled\n # Lines L PICC () and R ART ()\n similarly but will\n keep in setting of hypotension\n # Ppx: heparin drip until INR therapeutic for 2 days, ranitidine, VAP\n prevention, colace and senna\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n Code: Full\n Dispo: ICU, being screening for vent facilities\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 01:39 AM 60 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Arterial Line - 02:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Nursing","chartdate":"2167-10-07 00:00:00.000","description":"Nursing Progress Note","row_id":636259,"text":"Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Following commands, but pt with flat affect most of the day. Does at\n times nod to questions of pain. But does not see to understand what I\n am telling her.\n Action:\n Tried to give pain meds for agitation today instead of the valium and\n haldol which see to sedate her. Gave her 2 mg morphine\n Response:\n To 2 mg morhphine pt settles down just as well as when haldol and\n valium are used, but it still seem to sedate her.\n Plan:\n Possibly cont to try pain med for agitation but give lower doses.\n Hypernatremia (high sodium)\n Assessment:\n NA level 150\n Action:\n 300 ml flushes Q 4hr. free water.\n Response:\n Plan:\n Draw AM labs and either increase or decrease flushes depending on NA\n level\n Hypotension (not Shock)\n Assessment:\n Hypotensive SBP in 80/40 when she is sleeping and or given\n pain/sedation meds For her aggitaiton\n Action:\n Tried to give pt pain meds instead of the haldol and valium\n Response:\n 2mg of morphine sedates pt just as much but her BP doesn\nt seem to drop\n as low.\n Plan:\n Cont to try pain meds for agitation but give lower doses.\n"},{"category":"Nursing","chartdate":"2167-10-07 00:00:00.000","description":"Nursing Progress Note","row_id":636260,"text":"Respiratory failure, acute (not ARDS/)\n Assessment:\n Lung sounds clear, thick yellow secretions out of ET tube, O2 sats\n 92-94 team aware.\n Action:\n Pt on MMV mode overnight, changed to CPAP this AM pt with metabolic\n alkolosis ABG and diomox given, pt then weaned to CPAP .\n Response:\n Pt started desaturating into 87-89%, ABG 7.33/68/78, put pt back to\n CPAP \n Plan:\n Possibly put pt back on MMV mode to rest for the night like last night\n and wean again in the AM.\n Altered mental status (not Delirium)\n Assessment:\n Following commands, but pt with flat affect most of the day. Does at\n times nod to questions of pain. But does not see to understand what I\n am telling her.\n Action:\n Tried to give pain meds for agitation today instead of the valium and\n haldol which see to sedate her. Gave her 2 mg morphine\n Response:\n To 2 mg morhphine pt settles down just as well as when haldol and\n valium are used, but it still seem to sedate her.\n Plan:\n Possibly cont to try pain med for agitation but give lower doses.\n Hypernatremia (high sodium)\n Assessment:\n NA level 150\n Action:\n 300 ml flushes Q 4hr. free water.\n Response:\n Plan:\n Draw AM labs and either increase or decrease flushes depending on NA\n level\n Hypotension (not Shock)\n Assessment:\n Hypotensive SBP in 80/40 when she is sleeping and or given\n pain/sedation meds For her aggitaiton\n Action:\n Tried to give pt pain meds instead of the haldol and valium\n Response:\n 2mg of morphine sedates pt just as much but her BP doesn\nt seem to drop\n as low.\n Plan:\n Cont to try pain meds for agitation but give lower doses.\n"},{"category":"Nursing","chartdate":"2167-10-04 00:00:00.000","description":"Nursing Progress Note","row_id":635763,"text":"55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\n Now with prolonged hospital course c/b by PNA with high PEEP\n requirement, anxiety, RUE DVT on heparin qtt.\n Edema, peripheral\n Assessment:\n Fluid balance for previous 24hrs decreased by 3 liters D/T diuresis.\n Rec\nd pt off of Lasix qtt. Urine output decreased to 45ml/hr @1000.\n Action:\n Lasix qtt restarted @ 2mg/hr to maintain urine output 1-2liters/day.\n Response:\n Fluid balance approx -50ml/hr, with 24hr fluid balance -650ml @ 1500.\n However, SBP 78 when pt soundly sleeping/sedated. Lasix qtt stopped @\n 1530.\n Plan:\n Restart Lasix qtt when BP stabilized.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Rec\nd pt on Heparin qtt @ 1500units/hr.\n Action:\n PTT 92.1 @ 1230.\n Response:\n Per goal PTT 60-100, Heparin rate unchanged.\n Plan:\n Repeat PTT @ 1830. Start po Coumadin tonight.\n Altered mental status (not Delirium)\n Assessment:\n Rec\nd pt on Versed @ 2mg/hr, Fentanyl @ 100mcg/hr, as well as Fentanyl\n patches totaling 150mcg in place. Pt also rec\ning Diazepam 10mg po\n Q6hrs, in hope of weaning pt from IV sedation. Pt alternately appears\n very sedated and very restless. When she appears alert, she intermit\n responds to commands approp but not attempting to mouth words or nod to\n communicate. Moving arms purposefully towards trach, so soft wrist\n restraints remain in place. When very sedated @ 1530, SBP to 78 per\n below.\n Action:\n Versed \nd to 1mg/hr, Fentanyl \nd to 75mcg/hr.\n Response:\n Pt restless/squirming in bed when she appears awake. Not responding to\n verbal reassurance.\n Plan:\n Cont to attempt weaning from IV sedation. Cont to freq reorient pt,\n emotional support.\n Hypotension (not Shock)\n Assessment:\n VS generally stable with HR 68-123SR with occas PVC\ns, BP\n 122/65-144/76. However, when pt sleeping/sedated soundly @ 1530 SBP\n remained in high 70\n Action:\n Sedation decreased per above, Lasix qtt stopped. Pt woken and turned\n STS in bed.\n Response:\n VS returned to baseline, with BP presently 133/76.\n Plan:\n Restart Lasix qtt when BP stabilized WNL.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt on vent settings AC 55%/18 X 400/+10, with no over-breathing\n of rate by pt. O2 sat 95-99%. ABG 7.44/42/93. Lung snds clear but\n diminished in lower lobes. Suctionned for mod-lg amts thick white\n secretions.\n Action:\n Vent changed to CMV with PS 8/+10 on 55%.\n Response:\n Pt tolerated PS approx 3hrs, but after rec\ning scheduled dose Diazepam\n @ 1200 began having extended pauses apnea. She was then returned to AC\n 55%/9 X 500/+10.\n Plan:\n Cont wean from vent with PS trials, as well as \ning FiO2.\n"},{"category":"Physician ","chartdate":"2167-10-04 00:00:00.000","description":"Physician Resident Progress Note","row_id":635764,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n Hydrocortisone decreased from 50 to 25 mg Q6 per endocrine recs.\n Lasix drip turned off yesterday after 3L negative.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Heparin Sodium - 1,700 units/hour\n Fentanyl - 125 mcg/hour\n Other ICU medications:\n Ranitidine (Prophylaxis) - 09:00 AM\n Midazolam (Versed) - 07:30 PM\n Other medications:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36.8\nC (98.3\n HR: 66 (50 - 131) bpm\n BP: 103/46(65) {100/46(65) - 157/102(127)} mmHg\n RR: 18 (15 - 21) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,984 mL\n 948 mL\n PO:\n TF:\n 103 mL\n 121 mL\n IVF:\n 747 mL\n 277 mL\n Blood products:\n Total out:\n 5,270 mL\n 1,420 mL\n Urine:\n 5,270 mL\n 1,420 mL\n NG:\n Stool:\n 0\n Drains:\n Balance:\n -3,286 mL\n LOS + 10.5 L\n -472 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 55%\n RSBI Deferred: PEEP > 10\n PIP: 25 cmH2O\n Plateau: 14 cmH2O\n Compliance: 100 cmH2O/mL\n SpO2: 93%\n ABG: 7.44/42/93/29\n Ve: 6.8 L/min\n Physical Examination\n General Appearance: Intubated and sedated. Responsive, following some\n commands, Overweight / Obese, mild agitation but NAD\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\n deviation\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Respiratory / Chest: (Expansion: Symmetric), CTA anteriorly, decreased\n BS\n Abdominal: Obese, Firm, Non-tender, no rebound, no guarding, + BS, PEG\n in place with dressing C/D/I\n Extremities: No clubbing or cyanosis, 1+ nonpitting edema of b/l hands,\n anasarca\n Skin: no rashes or jaundice\n Lines: r brachioceph ART and L PICC C/D/I\n Labs / Radiology\n 279 K/uL\n 8.0 g/dL\n 123 mg/dL\n 0.5 mg/dL\n 27 mEq/L\n 3.6 mEq/L\n 6 mg/dL\n 109 mEq/L\n 143 mEq/L\n 24.6 %\n 8.3 K/uL\n [image002.jpg]\n 04:10 PM\n 12:13 AM\n 05:08 AM\n 05:20 AM\n 05:17 PM\n 11:41 PM\n 03:06 AM\n 03:38 AM\n 04:05 PM\n 03:55 AM\n WBC\n 11.2\n 10.6\n 10.0\n 8.3\n Hct\n 27.1\n 27.3\n 25.8\n 24.6\n Plt\n 79\n Cr\n 0.7\n 0.5\n 0.5\n 0.6\n 0.6\n 0.5\n TCO2\n 36\n 36\n 32\n 31\n Glucose\n 165\n 143\n 110\n 94\n 111\n 106\n 121\n Other labs: PT / PTT / INR:15.9/107.7/1.4, Ca++:8.8 mg/dL, Mg++:3.1\n mg/dL, PO4:4.2 mg/dL\n No new culture data\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA and\n ARDS intubated since the end of now s/p trach and PEG placement.\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation. Stenting\n unlikely to help for trachiomalacia as airways have poor structure\n diffusely. S/P Trach and PEG on .\n - wean FiO2 today\n # Adrenal Insufficency: Hypotension that resolved with steroids,\n returned as they came off and is now improved again. Possible primary\n adrenal insufficency. Appreciate endocrine recommendations. Halved\n dose today.\n - hydrocortt (day 1 = ), wean per endo recs\n # Volume overloaded in setting of hypernatremia with TBW deficit.\n - Lasix gtt, continue with goal -1-2 L per day.\n - electrolytes\n - continue tube feeds with free water flushes 250 cc q4\n # Sedation: Sedation control remains somewhat poor although fentanyl\n patch and diazpem are likely therapeutic range today. On Versed 2.0,\n Fentanyl 100, Fentanyl patch, Diazepam standing and haldo 2.5-5 mg\n PRN. QTc increased to 480.\n - Wean versed/fentanyl as tolerated, continue diazepam. Avoid haldol\n use if possible to avoid further prolongation of QTc\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\n coumadin at least until s/p trach.\n - heparin gtt restarted\n - coumadin 5mg G-tube today\n # Constipation\n current regimen of colace and senna, no BM over last\n 24 hours\n - dulcolax PO/PR today\n - reassess and increase bowel regimen PRN\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n -f/u full trauma spine eval from OSH to determine need for further back\n imaging in-house (to be done )\n # Nutrition: Tube feeds with free water flushes, tolerating well,\n continue Replete (Full) - 11:20 AM 30 mL/hour\n # Glycemic control: SSI, well controlled\n # Lines L PICC () and R ART ()\n both working well, mainitain\n # Ppx: heparin, ranitidine, VAP prevention, colace and senna\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n Code: Full\n Dispo: ICU\n"},{"category":"Respiratory ","chartdate":"2167-10-05 00:00:00.000","description":"Respiratory Care Shift Note","row_id":635822,"text":"TITLE:\n Demographics\n Day of mechanical ventilation: 17\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Tracheostomy tube:\n Type: Cuffed\n Manufacturer: Portex\n Size: 7.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: A/C400x18/+10 peep/.5\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: occ periods of agitation with increased rr\n Assessment of breathing comfort: comf\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment: none noted\n Plan\n Next 24-48 hours: Reduce PEEP as tolerated; Comments: periodic psv\n trials for conditioning\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts\n"},{"category":"Physician ","chartdate":"2167-10-08 00:00:00.000","description":"Physician Resident Progress Note","row_id":636337,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - STOP 12:23 PM\n ARTERIAL LINE - START 02:00 PM\n A-line resited, not working again\n tube feed machine not working\n failed SBT - low MV with PSV - switched to MMV overnight\n tachycardic to 140-142\n Ortho spine ok with documented final read of CT trauma from attending\n at OSH and week f/u - faxed request and spoke with med recs at\n Medical re: sending report which was agreed upon.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,500 units/hour\n Other ICU medications:\n Morphine Sulfate - 12:15 PM\n Midazolam (Versed) - 03:50 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.1\nC (98.8\n HR: 105 (70 - 148) bpm\n BP: 85/55(66) {85/41(57) - 158/110(323)} mmHg\n RR: 23 (10 - 31) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 3,562 mL\n 965 mL\n PO:\n TF:\n 1,685 mL\n 150 mL\n IVF:\n 548 mL\n 215 mL\n Blood products:\n Total out:\n 5,695 mL\n 1,740 mL\n Urine:\n 5,695 mL\n 1,740 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,133 mL\n -775 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 359 (137 - 695) mL\n PS : 8 cmH2O\n RR (Set): 10\n RR (Spontaneous): 26\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI: 58\n PIP: 16 cmH2O\n SpO2: 95%\n ABG: 7.40/49/114/32/3\n Ve: 7.2 L/min\n PaO2 / FiO2: 228\n Physical Examination\n General Appearance: Trached and sedated. Responsive, following\n commands, Overweight / Obese, mild agitation but NAD\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\n deviation\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Respiratory / Chest: (Expansion: Symmetric), CTA anteriorly, decreased\n BS\n Abdominal: Obese, soft, Non-tender, no rebound, no guarding, + BS, PEG\n in place with dressing C/D/I\n Extremities: no CCE\n Skin: no rashes or jaundice\n Lines: r brachioceph ART with large amount of bloody drainage and L\n PICC C/D/I\n Labs / Radiology\n 213 K/uL\n 8.8 g/dL\n 123 mg/dL\n 0.6 mg/dL\n 32 mEq/L\n 3.6 mEq/L\n 13 mg/dL\n 107 mEq/L\n 145 mEq/L\n 29.4 %\n 11.1 K/uL\n [image002.jpg]\n 03:44 AM\n 06:04 AM\n 09:09 AM\n 05:07 PM\n 03:31 AM\n 03:46 AM\n 10:20 AM\n 03:46 PM\n 01:37 AM\n 05:32 AM\n WBC\n 9.6\n 8.2\n 11.1\n Hct\n 25.3\n 27.4\n 29.4\n Plt\n \n Cr\n 0.6\n 0.8\n 0.6\n 0.8\n 0.6\n TCO2\n 33\n 32\n 35\n 37\n 31\n Glucose\n 107\n 121\n 118\n 155\n 123\n Other labs: PT / PTT / INR:22.3/69.7/2.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:13.1 %,\n Mono:2.7 %, Eos:0.6 %, Lactic Acid:1.1 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:9.2 mg/dL, Mg++:2.5 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA and\n ARDS intubated since the end of now s/p trach and PEG placement.\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation. Stenting\n unlikely to help for trachiomalacia as airways have poor structure\n diffusely. S/P Trach and PEG on .\n - wean FiO2 as tolerated\n - attempt wean PS today and hopeful for trach mask trial\n # Adrenal Insufficency: Hypotension that resolved with steroids,\n returned as they came off and is now improved again. Possible primary\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\n started on .\n - wean per endo recs, decrease to 20q am and 10 q pm today\n - ok to go to 10 q am and 5 q pm tomorrow ()\n # Volume overloaded in setting of hypernatremia with TBW deficit and\n metabolic alkalosis\n - Lasix boluses with diamox today\n - electrolytes\n - continue tube feeds with free water flushes 300 cc q4\n # Sedation: Sedation control remains somewhat poor although fentanyl\n patch and diazpem are likely therapeutic range today. On Versed 2.0,\n Fentanyl 100, Fentanyl patch, Diazepam standing and haldo 2.5-5 mg\n PRN. QTc increased to 480.\n - Wean versed/fentanyl as tolerated, continue diazepam in\n hopes for vent facility placement\n - Continue diazepam 10 mg q8 with haldol 5 mg q8 with 2.5-5\n prn haldol\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\n coumadin at least until s/p trach. INR 1.7 today.\n - heparin gtt restarted\n - coumadin 5mg G-tube today, INR in am\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n -f/u full trauma spine eval from OSH to determine need for further back\n imaging in-house (to be done )\n #. Thyroid Nodule on CT\n -outpatient follow up\n # Nutrition: Tube feeds with free water flushes, tolerating well,\n continue Replete (Full) - 11:20 AM 30 mL/hour\n # Glycemic control: SSI, well controlled\n # Lines L PICC () and R ART ()\n d/c art and re-site today\n # Ppx: heparin drip until INR therapeutic for 2 days, ranitidine, VAP\n prevention, colace and senna\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n Code: Full\n Dispo: ICU, being screening for vent facilities\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Arterial Line - 02:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Nursing","chartdate":"2167-10-09 00:00:00.000","description":"Nursing Progress Note","row_id":636607,"text":"Event: Pt had a stable day and was OOB for 4 hrs. VSS throughout the\n day.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt has a clot to RUE and was taken off heparin gtt . inr this am\n 4.4. No signs of bleeding noted.\n Action:\n No interventions done at this time.\n Response:\n Plan:\n F/U coags.\n Hypernatremia (high sodium)\n Assessment:\n Na level increased this am from 140 to 145.\n Action:\n H2O flushes DC\nd NPO and started on D5 IVF at 100 cc/hr x 1 lliter.\n Response:\n Plan:\n Follow up Na level in am.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Pt has been Afebrile throughout the day. IV ABXs to continue for 48hrs\n until cultures back.\n Action:\n No actions done. WBC now WNLs.\n Response:\n Plan:\n Follow up cultures.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LA this am very coarse and was sx\nd for copious amounts of thick tan\n secretions. Aggressive pulm toilet done and resp status improved\n throughout the day. LS now CTA and pt is being deep sx\nd for scant\n amounts of yellow secretions. Pt placed on CPAP this am and weaned down\n to 50/5/5 and was placed on TC. Pt tol it for 2 hrs and was then placed\n back on CPAP. Pt in need of freq oral care for copious amounts of\n clear-white secretions.\n Action:\n As noted above.\n Response:\n Resp status has improved.\n Plan:\n Continue aggressive oral care and pulm toilet and wean vent as tol.\n Altered mental status (not Delirium)\n Assessment:\n Pt found this am to be very awake and follows commands. Pt able to have\n eye contact and tracking people. = strength. Pt noted to have some\n restlessness at times, but no prn meds needed.\n Action:\n Pt given MSo4 for pain while she was OOB in brace with good effect.\n Response:\n Plan:\n Continue to eval MS.\n"},{"category":"Nursing","chartdate":"2167-10-10 00:00:00.000","description":"Nursing Progress Note","row_id":636689,"text":"55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\n Now with prolonged hospital course c/b by PNA with high PEEP\n requirement, anxiety, RUE DVT .\n Altered mental status (not Delirium)\n Assessment:\n Pt more alert, following commands intermittently. Periods of agitation\n with HR rising to 130\n Action:\n Fentanyl patch in place. Valium RTC. MSO4 given x 2 for discomfort.\n Response:\n Pt with less episodes of agitation previously. ? steroid psychosis.\n Plan:\n Check cortisol level in am and wean hydrocortisone MD. Continue to\n reorient pt. MSO4 prn for discomfort.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on PSV 8/5/50%.RR 19-24. Tidal volumes 200-250. 02 sats\n variable 90-100%. LS rhoncherous to clear, diminished at bases.\n Action:\n Pt maintained at current settings given reduced tv\ns and sats. Orally\n suctioned q 2 hrs for copious secretions. Deep suctioned q 3-4 hrs for\n sm amt thick white secretions.\n Response:\n ABG 7.37/40/120/0/26 on PSV. At 0530 pt hypoventilating with RR 4-6,\n changed to AC mode of ventilation (500x 12 x 5 50%)\n Plan:\n Attempt PSV again this am. Pulm hygiene.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt with RUE DVT. Heparin dcd on .\n Action:\n Coags being monitored. INR 4.4 yest. Hct was falling.\n Response:\n Hct 26.5 today, previously 27.6. INR pend.\n Plan:\n Coumadin to be started when INR < 3\n Hypernatremia (high sodium)\n Assessment:\n Na 140. Pt volume overloaded. LOS + ~10,000ccs.\n Action:\n Treated with 1 liter d5w iv.\n Response:\n Urine output 120-400ccs/hr via foley. TFB neg 100cc. Na 145. Goal ~\n even fluid balance.\n Plan:\n Continue to monitor f+e status.\n"},{"category":"Physician ","chartdate":"2167-10-03 00:00:00.000","description":"Physician Resident Progress Note","row_id":635586,"text":"Chief Complaint:\n 24 Hour Events:\n # To OR for Peg and Trach placement\n # Desatted in the evening to 84%, increased PEEP and FiO2\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Furosemide (Lasix) - 2 mg/hour\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.4\nC (97.6\n HR: 111 (44 - 133) bpm\n BP: 127/63(90) {90/46(63) - 165/89(123)} mmHg\n RR: 18 (15 - 24) insp/min\n SpO2: 93%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,751 mL\n 534 mL\n PO:\n TF:\n 17 mL\n IVF:\n 1,834 mL\n 84 mL\n Blood products:\n Total out:\n 6,600 mL\n 950 mL\n Urine:\n 6,600 mL\n 950 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,849 mL\n -416 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 23 cmH2O\n Plateau: 25 cmH2O\n SpO2: 93%\n ABG: 7.45/43/81./29/4\n Ve: 7.6 L/min\n PaO2 / FiO2: 137\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 256 K/uL\n 7.8 g/dL\n 106 mg/dL\n 0.6 mg/dL\n 29 mEq/L\n 4.1 mEq/L\n 7 mg/dL\n 110 mEq/L\n 144 mEq/L\n 25.8 %\n 10.0 K/uL\n [image002.jpg]\n 03:00 AM\n 10:47 AM\n 04:10 PM\n 12:13 AM\n 05:08 AM\n 05:20 AM\n 05:17 PM\n 11:41 PM\n 03:06 AM\n 03:38 AM\n WBC\n 8.6\n 11.2\n 10.6\n 10.0\n Hct\n 25.9\n 27.1\n 27.3\n 25.8\n Plt\n 280\n 306\n 321\n 256\n Cr\n 0.5\n 0.7\n 0.5\n 0.5\n 0.6\n TCO2\n 34\n 36\n 36\n 32\n 31\n Glucose\n 136\n 165\n 143\n 110\n 94\n 111\n 106\n Other labs: PT / PTT / INR:13.6/24.4/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:13.1 %,\n Mono:2.7 %, Eos:0.6 %, Lactic Acid:0.9 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:8.4 mg/dL, Mg++:2.5 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Arterial Line - 02:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2167-10-03 00:00:00.000","description":"Physician Resident Progress Note","row_id":635587,"text":"Chief Complaint:\n 24 Hour Events:\n # To OR for Peg and Trach placement\n # Desatted in the evening to 84%, increased PEEP and FiO2\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Furosemide (Lasix) - 2 mg/hour\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.4\nC (97.6\n HR: 111 (44 - 133) bpm\n BP: 127/63(90) {90/46(63) - 165/89(123)} mmHg\n RR: 18 (15 - 24) insp/min\n SpO2: 93%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,751 mL\n 534 mL\n PO:\n TF:\n 17 mL\n IVF:\n 1,834 mL\n 84 mL\n Blood products:\n Total out:\n 6,600 mL\n 950 mL\n Urine:\n 6,600 mL\n 950 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,849 mL\n -416 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 23 cmH2O\n Plateau: 25 cmH2O\n SpO2: 93%\n ABG: 7.45/43/81./29/4\n Ve: 7.6 L/min\n PaO2 / FiO2: 137\n Physical Examination\n General Appearance: Responsive, following commands, Overweight / Obese,\n NAD\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\n deviation\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Respiratory / Chest: (Expansion: Symmetric), referred breath sounds\n from ETT, mild rhonchi diffusely\n Abdominal: Obese, Soft, Non-tender, no rebound, no guarding\n Extremities: No clubbing or cyanosis, + nonpitting edema of b/l\n hands, anasarca\n Skin: no rashes or jaundice\n Neuro: alert. Strength 4/5 upper and lower extremeties, light touch\n sensation intact bil.\n Lines: r brachioceph ART and L PICC C/D/I\n Labs / Radiology\n 256 K/uL\n 7.8 g/dL\n 106 mg/dL\n 0.6 mg/dL\n 29 mEq/L\n 4.1 mEq/L\n 7 mg/dL\n 110 mEq/L\n 144 mEq/L\n 25.8 %\n 10.0 K/uL\n [image002.jpg]\n 03:00 AM\n 10:47 AM\n 04:10 PM\n 12:13 AM\n 05:08 AM\n 05:20 AM\n 05:17 PM\n 11:41 PM\n 03:06 AM\n 03:38 AM\n WBC\n 8.6\n 11.2\n 10.6\n 10.0\n Hct\n 25.9\n 27.1\n 27.3\n 25.8\n Plt\n 280\n 306\n 321\n 256\n Cr\n 0.5\n 0.7\n 0.5\n 0.5\n 0.6\n TCO2\n 34\n 36\n 36\n 32\n 31\n Glucose\n 136\n 165\n 143\n 110\n 94\n 111\n 106\n Other labs: PT / PTT / INR:13.6/24.4/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:13.1 %,\n Mono:2.7 %, Eos:0.6 %, Lactic Acid:0.9 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:8.4 mg/dL, Mg++:2.5 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Arterial Line - 02:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2167-10-03 00:00:00.000","description":"Physician Resident Progress Note","row_id":635588,"text":"Chief Complaint:\n 24 Hour Events:\n # To OR for Peg and Trach placement\n # Desatted in the evening to 84%, increased PEEP and FiO2\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Furosemide (Lasix) - 2 mg/hour\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.4\nC (97.6\n HR: 111 (44 - 133) bpm\n BP: 127/63(90) {90/46(63) - 165/89(123)} mmHg\n RR: 18 (15 - 24) insp/min\n SpO2: 93%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,751 mL\n 534 mL\n PO:\n TF:\n 17 mL\n IVF:\n 1,834 mL\n 84 mL\n Blood products:\n Total out:\n 6,600 mL\n 950 mL\n Urine:\n 6,600 mL\n 950 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,849 mL\n -416 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 23 cmH2O\n Plateau: 25 cmH2O\n SpO2: 93%\n ABG: 7.45/43/81./29/4\n Ve: 7.6 L/min\n PaO2 / FiO2: 137\n Physical Examination\n General Appearance: Responsive, following commands, Overweight / Obese,\n NAD\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\n deviation\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Respiratory / Chest: (Expansion: Symmetric), referred breath sounds\n from ETT, mild rhonchi diffusely\n Abdominal: Obese, Soft, Non-tender, no rebound, no guarding\n Extremities: No clubbing or cyanosis, + nonpitting edema of b/l\n hands, anasarca\n Skin: no rashes or jaundice\n Neuro: alert. Strength 4/5 upper and lower extremeties, light touch\n sensation intact bil.\n Lines: r brachioceph ART and L PICC C/D/I\n Labs / Radiology\n 256 K/uL\n 7.8 g/dL\n 106 mg/dL\n 0.6 mg/dL\n 29 mEq/L\n 4.1 mEq/L\n 7 mg/dL\n 110 mEq/L\n 144 mEq/L\n 25.8 %\n 10.0 K/uL\n [image002.jpg]\n 03:00 AM\n 10:47 AM\n 04:10 PM\n 12:13 AM\n 05:08 AM\n 05:20 AM\n 05:17 PM\n 11:41 PM\n 03:06 AM\n 03:38 AM\n WBC\n 8.6\n 11.2\n 10.6\n 10.0\n Hct\n 25.9\n 27.1\n 27.3\n 25.8\n Plt\n 280\n 306\n 321\n 256\n Cr\n 0.5\n 0.7\n 0.5\n 0.5\n 0.6\n TCO2\n 34\n 36\n 36\n 32\n 31\n Glucose\n 136\n 165\n 143\n 110\n 94\n 111\n 106\n Other labs: PT / PTT / INR:13.6/24.4/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:13.1 %,\n Mono:2.7 %, Eos:0.6 %, Lactic Acid:0.9 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:8.4 mg/dL, Mg++:2.5 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA and\n ARDS intubated since the end of .\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation.\n Transferred here for airway stenting.\n - attempt SBT yesterday. Failed.\n -To OR today , add-on for trach and PEG with Dr. (tube feeds\n off after MN, heparin off after 6am)\n - Repeat CXR in PM post trach.\n ## Adrenal Insufficency: Minimal response to stim test again.\n Appreciate endocrine recommendations.\n - hydrocort and fludrocort (day 1 = )\n - will continue at current dose until s/p trach and PEG and\n hemodynamically stable for 24 hours\n will then plan to taper\n hydrocortisone to 25mg IV q6 with a slow taper\n - f/u daily endocrine recs\n - Endocrine recs: d/c Fludrocort. Continue Hydrocort for now.\n # Hypotension: Likely adrenal insufficiency and sedation. Goal map\n > 60. Much improved since re-administration of steroids.\n - hydrocortisone as above\n - restart levophed if necessary to maintain MAP > 60\n # Volume overloaded in setting of hypernatremia with TBW deficit.\n - goal -1000cc I/Os yesterday, was -1500cc for last 24 hours.\n - continue FW in TF at 250 cc q4hrs\n - lasix drip (1-5mg/hr) held before surgery, will restart when returns\n to MICU.\n - may have some contraction alkalosis, w/ rising pH and bicarb. Start\n Diamox 500mg TID to decrease bicarb and pH and may improve respiratory\n drive.\n # Sedation: Sedation control remains somewhat poor although fentanyl\n patch and diazpem are likely therapeutic range today. On Versed 2.0,\n Fentanyl 100, Fentanyl patch, Diazepam standing and haldo 2.5-5 mg\n PRN. QTc increased to 480.\n - Wean versed/fentanyl as tolerated, continue diazepam. Avoid haldol\n use if possible to avoid further prolongation of QTc\n - Will reassess sedation/agitation after PEG/Trach.\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\n coumadin at least until s/p trach.\n - hold heparin gtt when anticipate trach/peg\n - will restart heparin gtt per recs from surgery post-op\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n # FEN/GI: Tube feeds with FWF @ goal.\n -held for surgery. Will restart based on post-op recs after PEG\n placement.\n DVT: Treatment dose heparin, holding until post-op recs from PEG/Trach\n Ulcer: Ranitidine\n VAP: Prevention per routine\n # Access: L PICC line, and R brachial a-line\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n - touch base with SW today\n Code: Full\n Dispo: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Arterial Line - 02:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Nursing","chartdate":"2167-10-04 00:00:00.000","description":"Nursing Progress Note","row_id":635759,"text":"55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\n Now with prolonged hospital course c/b by PNA with high PEEP\n requirement, anxiety, RUE DVT on heparin qtt.\n Edema, peripheral\n Assessment:\n Fluid balance for previous 24hrs decreased by 3 liters D/T diuresis.\n Rec\nd pt off of Lasix qtt. Urine output decreased to 45ml/hr @1000.\n Action:\n Lasix qtt restarted @ 2mg/hr to maintain urine output 1-2liters/day.\n Response:\n Fluid balance approx -50ml/hr, with 24hr fluid balance -650ml @ 1500.\n However, SBP 78 when pt soundly sleeping/sedated. Lasix qtt stopped @\n 1530.\n Plan:\n Restart Lasix qtt when BP stabilized.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Rec\nd pt on Heparin qtt @ 1500units/hr.\n Action:\n PTT 92.1 @ 1230.\n Response:\n Per goal PTT 60-100, Heparin rate unchanged.\n Plan:\n Repeat PTT @ 1830. Start po Coumadin tonight.\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Respiratory ","chartdate":"2167-10-07 00:00:00.000","description":"Respiratory Care Shift Note","row_id":636126,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 19\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Tube Type\n Tracheostomy tube:\n Type: Cuffed, Extra Length\n Manufacturer: Portex\n Size: 7.0mm\n PMV: No\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Rhonchi\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Placed on MMV for constant LMV\n alarms/apnea. Weaned PEEp to ~8cmH20.\n Invasive ventilation assessment:\n Trigger work assessment: Frequent failed trigger efforts\n Dysynchrony assessment: Frequent alarms (Low min. ventilation)\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: rsbi deffered for agitation, req sedation\n Reason for continuing current ventilatory support: Sedated / Paralyzed\n"},{"category":"Nursing","chartdate":"2167-10-07 00:00:00.000","description":"Nursing Progress Note","row_id":636127,"text":"55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\n Now with prolonged hospital course c/b by PNA with high PEEP\n requirement, anxiety, RUE DVT on heparin qtt.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lungs clear bilat upper lobes and diminished bilat bases with\n occasional scattered rhonchi, prod cough thick yellow/tan sputum, trach\n sx for mod. Amt of same, tolerated CPAP+PS until fell asleep and then\n RR down to 4-5 breaths with MV down to 1-5. Placed on MMV for\n remainder of night with good effect.\n Action:\n Vent changed from CPAP+PS to MMV overnight and weaned back to CPAP+PS\n this am, Peep decreased to 8cm. Freq. pulmonary toileting, diuresing\n with 40mg. IV Lasix dose\n Response:\n Tolerating slow vent wean, requiring pulmonary toileting, good diuresis\n in attempt to wean vent further\n Plan:\n Attempt to wean PS and FI02 down further today as tolerated, may need\n MMV mode at night or when sedated, Continue aggressive pulmonary\n toileting, Diurese as tolerated.\n Altered mental status (not Delirium)\n Assessment:\n Increased agitation throughout night with pt writhing in bed and\n attempting to get OOB and attempting to pull at all lines and tubes,\n makes eye contact and follows commands but doesn\nt stay calm for long,\n HR up to 130- with agitation and BP up to 130-150\ns/60-70\n received valium and Haldol as ordered with prn dosing in between\n scheduled doses with poor effect, received 4 mg. Iv versed with poor\n effect, appears generally uncomfortable but denies pain when asked.\n Action:\n Freq. attempts to reorient and calm pt, Valium 5mg x 2 with no effect,\n Haldol 5mg po and additional 1 mg. IV with no effect, Versed 4 mg. with\n no effect, stimulation decreased, bilat soft wrist restraints to\n prevent pt from pulling at lines and tubes\n Response:\n Increased agitation off of continuous IV sedation, poor effect from\n current medical regime, MICU team aware and addressing\n Plan:\n Valium dose to be increased, Potential head CT today, obtain psych and\n neuro consults if pt\ns mental status doesn\nt improve\n"},{"category":"Nursing","chartdate":"2167-10-07 00:00:00.000","description":"Nursing Progress Note","row_id":636128,"text":"55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\n Now with prolonged hospital course c/b by PNA with high PEEP\n requirement, anxiety, RUE DVT on heparin qtt.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lungs clear bilat upper lobes and diminished bilat bases with\n occasional scattered rhonchi, prod cough thick yellow/tan sputum, trach\n sx for mod. Amt of same, tolerated CPAP+PS until fell asleep and then\n RR down to 4-5 breaths with MV down to 1-5. Placed on MMV for\n remainder of night with good effect.\n Action:\n Vent changed from CPAP+PS to MMV overnight and weaned back to CPAP+PS\n this am, Peep decreased to 8cm. Freq. pulmonary toileting, diuresing\n with 40mg. IV Lasix dose\n Response:\n Tolerating slow vent wean, ABG: 7.41-53-86, requiring pulmonary\n toileting, good diuresis in attempt to wean vent further\n Plan:\n Attempt to wean PS and FI02 down further today as tolerated, may need\n MMV mode at night or when sedated, Continue aggressive pulmonary\n toileting, Diurese as tolerated.\n Altered mental status (not Delirium)\n Assessment:\n Increased agitation throughout night with pt writhing in bed and\n attempting to get OOB and attempting to pull at all lines and tubes,\n makes eye contact and follows commands but doesn\nt stay calm for long,\n HR up to 130- with agitation and BP up to 130-150\ns/60-70\n received valium and Haldol as ordered with prn dosing in between\n scheduled doses with poor effect, received 4 mg. Iv versed with poor\n effect, appears generally uncomfortable but denies pain when asked.\n Action:\n Freq. attempts to reorient and calm pt, Valium 5mg x 2 with no effect,\n Haldol 5mg po and additional 1 mg. IV with no effect, Versed 4 mg. with\n no effect, stimulation decreased, bilat soft wrist restraints to\n prevent pt from pulling at lines and tubes\n Response:\n Increased agitation off of continuous IV sedation, poor effect from\n current medical regime, MICU team aware and addressing\n Plan:\n Valium dose to be increased, Potential head CT today, obtain psych and\n neuro consults if pt\ns mental status doesn\nt improve\n"},{"category":"Nursing","chartdate":"2167-10-08 00:00:00.000","description":"Nursing Progress Note","row_id":636428,"text":"Alteration in Nutrition\n Assessment:\n Abd dist, soft with hypoactive BS. No BM on this shift.\n Action:\n TF restarted at goal at 60 cc/hr with minimal residuals.\n Response:\n Plan:\n Follow FSBS. ? adding more laxatives until BM.\n Fracture, other\n Assessment:\n Pt out of bed in stretcher chair with brace in place most of day. Pt\n did very well.\n Action:\n Pt tol being OOb well in regards to resp status and MS.\n Response:\n Plan:\n Plan to take pt OOB to cahir tomorrow also.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains on vent via trach in CPAP+PS at 50 %/. LS CTA with\n diminished bases. Pt has been deep sx\nd for sml amounts of tan to thick\n yellow secretions.\n Action:\n Vent changed to 5/5, but was only tolerated for 1 hr.\n Response:\n After 1 hr pt became tachycardic and tachypnic. O2sat decreased to 95%.\n Plan:\n Continue to wean vent settings as tolerated. Plan to IP to follow up\n regarding ? need for stent tomorrow.\n Altered mental status (not Delirium)\n Assessment:\n Pt opens eyes to voice, but will only follow simple commands very\n inconsistently. Pt is very lethargic. Pt found this am to be very\n restless and given versed with no effect.\n Action:\n After pt placed in a chair, and pt more relaxed. Pt was calm, but her\n HR was in the 120-130\ns (while awake). Pt given Morphine with good\n effect. Fentanyl patches weaned down to 100 mcg.\n Response:\n Plan:\n Continue to eval restlessness.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt was on heparin gtt for clot to Rt upper arm. Inr 2.1 . No signs of\n any bleeding.\n Action:\n Heparin was dc\nd this am.\n Response:\n Plan:\n ? coumadin tonight. Continue to eval for bleeding.\n"},{"category":"Nursing","chartdate":"2167-10-08 00:00:00.000","description":"Nursing Progress Note","row_id":636430,"text":"Alteration in Nutrition\n Assessment:\n Abd dist, soft with hypoactive BS. No BM on this shift.\n Action:\n TF restarted at goal at 60 cc/hr with minimal residuals.\n Response:\n Plan:\n Follow FSBS. ? adding more laxatives until BM.\n Fracture, other\n Assessment:\n Pt out of bed in stretcher chair with brace in place most of day. Pt\n did very well.\n Action:\n Pt tol being OOb well in regards to resp status and MS.\n Response:\n Plan:\n Plan to take pt OOB to cahir tomorrow also.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains on vent via trach in CPAP+PS at 50 %/. LS CTA with\n diminished bases. Pt has been deep sx\nd for sml amounts of tan to thick\n yellow secretions.\n Action:\n Vent changed to 5/5, but was only tolerated for 1 hr.\n Response:\n After 1 hr pt became tachycardic and tachypnic. O2sat decreased to 95%.\n Plan:\n Continue to wean vent settings as tolerated. Plan to IP to follow up\n regarding ? need for stent tomorrow.\n Altered mental status (not Delirium)\n Assessment:\n Pt opens eyes to voice, but will only follow simple commands very\n inconsistently. Pt is very lethargic. Pt found this am to be very\n restless and given versed with no effect.\n Action:\n After pt placed in a chair, and pt more relaxed. Pt was calm, but her\n HR was in the 120-130\ns (while awake). Pt given Morphine with good\n effect. Fentanyl patches weaned down to 100 mcg.\n Response:\n Plan:\n Continue to eval restlessness.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt was on heparin gtt for clot to Rt upper arm. Inr 2.1 . No signs of\n any bleeding.\n Action:\n Heparin was dc\nd this am.\n Response:\n Plan:\n ? coumadin tonight. Continue to eval for bleeding.\n"},{"category":"Physician ","chartdate":"2167-10-09 00:00:00.000","description":"Physician Resident Progress Note","row_id":636500,"text":"Chief Complaint:\n 24 Hour Events:\n Arterial line d/c'd\n Spiked a fever of 101.4, blood and urine cultures sent, CXR. Started\n Vanc, Levo, Aztreonam\n Persistently hypotensive to 70s SBP overnight with low urine output and\n poor O2 sats.\n Started on Levophed, and given 1.75L NS. BPs improved to 90-120s SBP,\n and urine output increased significantly.\n Large amount of oral secretions, ?gastric in origin\n Tube feeds held for ? of aspiration.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 11:00 PM\n Levofloxacin - 11:43 PM\n Aztreonam - 04:07 AM\n Infusions:\n Norepinephrine - 0.03 mcg/Kg/min\n Other ICU medications:\n Midazolam (Versed) - 09:30 AM\n Morphine Sulfate - 03:17 PM\n Furosemide (Lasix) - 06:36 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.4\n Tcurrent: 36.7\nC (98.1\n HR: 131 (73 - 142) bpm\n BP: 127/43(60) {71/29(42) - 137/97(101)} mmHg\n RR: 21 (12 - 36) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 4,627 mL\n 1,084 mL\n PO:\n TF:\n 839 mL\n IVF:\n 2,288 mL\n 1,084 mL\n Blood products:\n Total out:\n 2,407 mL\n 2,220 mL\n Urine:\n 2,407 mL\n 2,220 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,220 mL\n -1,136 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 412 (236 - 480) mL\n PS : 8 cmH2O\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI: 126\n PIP: 21 cmH2O\n Plateau: 17 cmH2O\n Compliance: 44.4 cmH2O/mL\n SpO2: 97%\n ABG: 7.35/50/81./26/0\n Ve: 7 L/min\n PaO2 / FiO2: 162\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 227 K/uL\n 7.7 g/dL\n 114 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 4.0 mEq/L\n 16 mg/dL\n 112 mEq/L\n 145 mEq/L\n 24.9 %\n 11.3 K/uL\n [image002.jpg]\n 03:46 AM\n 10:20 AM\n 03:46 PM\n 01:37 AM\n 05:32 AM\n 02:43 PM\n 03:03 PM\n 08:11 PM\n 02:51 AM\n 03:10 AM\n WBC\n 11.1\n 9.4\n 11.3\n Hct\n 29.4\n 26.6\n 24.9\n Plt\n \n Cr\n 0.8\n 0.6\n 0.9\n 0.7\n TCO2\n 35\n 37\n 31\n 31\n 30\n 29\n Glucose\n 155\n 123\n 128\n 114\n 114\n Other labs: PT / PTT / INR:37.2/37.9/4.0, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Lactic Acid:0.5 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:8.7 mg/dL, Mg++:2.6 mg/dL, PO4:4.2 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n 18 Gauge - 08:15 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2167-10-09 00:00:00.000","description":"Physician Resident Progress Note","row_id":636501,"text":"Chief Complaint:\n 24 Hour Events:\n Arterial line d/c'd\n Spiked a fever of 101.4, blood and urine cultures sent, CXR. Started\n Vanc, Levo, Aztreonam\n Persistently hypotensive to 70s SBP overnight with low urine output and\n poor O2 sats.\n Started on Levophed, and given 1.75L NS. BPs improved to 90-120s SBP,\n and urine output increased significantly.\n Large amount of oral secretions, ?gastric in origin\n Tube feeds held for ? of aspiration.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 11:00 PM\n Levofloxacin - 11:43 PM\n Aztreonam - 04:07 AM\n Infusions:\n Norepinephrine - 0.03 mcg/Kg/min\n Other ICU medications:\n Midazolam (Versed) - 09:30 AM\n Morphine Sulfate - 03:17 PM\n Furosemide (Lasix) - 06:36 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.4\n Tcurrent: 36.7\nC (98.1\n HR: 131 (73 - 142) bpm\n BP: 127/43(60) {71/29(42) - 137/97(101)} mmHg\n RR: 21 (12 - 36) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 4,627 mL\n 1,084 mL\n PO:\n TF:\n 839 mL\n IVF:\n 2,288 mL\n 1,084 mL\n Blood products:\n Total out:\n 2,407 mL\n 2,220 mL\n Urine:\n 2,407 mL\n 2,220 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,220 mL\n -1,136 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 412 (236 - 480) mL\n PS : 8 cmH2O\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI: 126\n PIP: 21 cmH2O\n Plateau: 17 cmH2O\n Compliance: 44.4 cmH2O/mL\n SpO2: 97%\n ABG: 7.35/50/81./26/0\n Ve: 7 L/min\n PaO2 / FiO2: 162\n Physical Examination\n General Appearance: Trached and sedated. Responsive, following\n commands, Overweight / Obese, mild agitation but NAD\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\n deviation\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Respiratory / Chest: (Expansion: Symmetric), CTA anteriorly, decreased\n BS\n Abdominal: Obese, soft, Non-tender, no rebound, no guarding, + BS, PEG\n in place with dressing C/D/I\n Extremities: no CCE\n Skin: no rashes or jaundice\n Lines: r brachioceph ART with large amount of bloody drainage and L\n PICC C/D/I\n Labs / Radiology\n 227 K/uL\n 7.7 g/dL\n 114 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 4.0 mEq/L\n 16 mg/dL\n 112 mEq/L\n 145 mEq/L\n 24.9 %\n 11.3 K/uL\n [image002.jpg]\n 03:46 AM\n 10:20 AM\n 03:46 PM\n 01:37 AM\n 05:32 AM\n 02:43 PM\n 03:03 PM\n 08:11 PM\n 02:51 AM\n 03:10 AM\n WBC\n 11.1\n 9.4\n 11.3\n Hct\n 29.4\n 26.6\n 24.9\n Plt\n \n Cr\n 0.8\n 0.6\n 0.9\n 0.7\n TCO2\n 35\n 37\n 31\n 31\n 30\n 29\n Glucose\n 155\n 123\n 128\n 114\n 114\n Other labs: PT / PTT / INR:37.2/37.9/4.0, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Lactic Acid:0.5 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:8.7 mg/dL, Mg++:2.6 mg/dL, PO4:4.2 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA, and\n ARDS, intubated since the end of now s/p trach and PEG\n placement.\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation. S/P Trach\n and PEG on .\n - wean FiO2 as tolerated\n - attempt wean PS today and hopeful for trach mask trial\n # Sedation: Continue to have issues with pain/delirium causing\n tachycardia and hypertension with intermittent hypotension. On Haldol\n 5 TID, Fentanyl 100-150 mcg TP, Diazapam 10 QID; Haldol, midazolam and\n morphine PRN. Had good response to morphine, minimal response to\n haldol bolus.\n - Will d/c midazolam and haldol PRN and use morphine for now.\n - If stable, would d/c standing Haldol tonight or tomorrow\n # Adrenal Insufficency: Hypotension that resolved with steroids,\n returned as they came off and is now improved again. Possible primary\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\n started on .\n - ok to go to 10 q am and 5 q pm prednisone, will wean to\n maintenance dose as tolerated, in consultation with endo.\n # Volume overloaded in setting of hypernatremia with TBW deficit and\n metabolic alkalosis\n - Lasix boluses, goal -1L today\n - Diamox until HCO3 < 30\n - electrolytes\n - continue tube feeds with free water flushes 300 cc q4\n # RUE DVT: INR now therapeutic on coumadin. Goal \n - stop heparin gtt\n - coumadin 5mg QHS\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - Brace for OOB\n - will f/u full trauma spine eval from OSH to determine need for\n further back imaging in-house.\n # Tracheomalacia: Discussed with IP. Stenting unlikely to help for\n trachiomalacia as airways have poor structure diffusely.\n - Outpatient f/u once off pressure support to assess for possible\n stenting\n #. Thyroid Nodule on CT\n -outpatient follow up\n # Nutrition: Tube feeds with free water flushes, tolerating well,\n continue Replete (Full) - 11:20 AM 30 mL/hour\n # Glycemic control: SSI, well controlled\n # Lines L PICC () and R ART ()\n d/c art today. Correlate ABG\n and VBG.\n # Ppx: INR therapeutic, ranitidine, colace and senna\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n Code: Full\n Dispo: ICU, being screening for vent facilities\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n 18 Gauge - 08:15 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Nursing","chartdate":"2167-10-09 00:00:00.000","description":"Nursing Progress Note","row_id":636605,"text":"Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt has a clot to RUE and was taken off heparin gtt . inr this am\n 4.4. No signs of bleeding noted.\n Action:\n No interventions done at this time.\n Response:\n Plan:\n F/U coags.\n Hypernatremia (high sodium)\n Assessment:\n Na level increased this am from 140 to 145.\n Action:\n H2O flushes DC\nd NPO and started on D5 IVF at 100 cc/hr x 1 lliter.\n Response:\n Plan:\n Follow up Na level in am.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Pt has been Afebrile throughout the day. IV ABXs to continue for 48hrs\n until cultures back.\n Action:\n No actions done.\n Response:\n Plan:\n Follow up cultures.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS this am very coarse and sx\nd for copious amounts amount secretions.\n Pt was given aggressive pulm toilet, and respm status improved\n throughout the day\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2167-10-04 00:00:00.000","description":"Nursing Progress Note","row_id":635668,"text":"55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\n Now with prolonged hospital course c/b by PNA with high PEEP\n requirement, anxiety, RUE DVT on heparin qtt.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt on Vent settings AC 60%/18 X 400/+10 with no overbreathing of\n set RR. O2 sat 92-98%. Lung snds clear, diminished in bases. Pt sxn\n for small amts thick white secretions. Trach site with small amt\n serosang drainage.\n Action:\n FiO2 \nd to 55%.\n Response:\n ABG to follow.\n Plan:\n Cont to gently wean from vent.\n"},{"category":"Physician ","chartdate":"2167-10-04 00:00:00.000","description":"Physician Resident Progress Note","row_id":635669,"text":"Chief Complaint:\n 24 Hour Events:\n # To OR for Peg and Trach placement\n # Desatted in the evening to 84%, increased PEEP and FiO2\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Furosemide (Lasix) - 2 mg/hour\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.4\nC (97.6\n HR: 111 (44 - 133) bpm\n BP: 127/63(90) {90/46(63) - 165/89(123)} mmHg\n RR: 18 (15 - 24) insp/min\n SpO2: 93%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,751 mL\n 534 mL\n PO:\n TF:\n 17 mL\n IVF:\n 1,834 mL\n 84 mL\n Blood products:\n Total out:\n 6,600 mL\n 950 mL\n Urine:\n 6,600 mL\n 950 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,849 mL\n -416 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 23 cmH2O\n Plateau: 25 cmH2O\n SpO2: 93%\n ABG: 7.45/43/81./29/4\n Ve: 7.6 L/min\n PaO2 / FiO2: 137\n Physical Examination\n General Appearance: Responsive, following commands, Overweight / Obese,\n NAD\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\n deviation\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Respiratory / Chest: (Expansion: Symmetric), referred breath sounds\n from ETT, mild rhonchi diffusely\n Abdominal: Obese, Soft, Non-tender, no rebound, no guarding\n Extremities: No clubbing or cyanosis, + nonpitting edema of b/l\n hands, anasarca\n Skin: no rashes or jaundice\n Neuro: alert. Strength 4/5 upper and lower extremeties, light touch\n sensation intact bil.\n Lines: r brachioceph ART and L PICC C/D/I\n Labs / Radiology\n 256 K/uL\n 7.8 g/dL\n 106 mg/dL\n 0.6 mg/dL\n 29 mEq/L\n 4.1 mEq/L\n 7 mg/dL\n 110 mEq/L\n 144 mEq/L\n 25.8 %\n 10.0 K/uL\n [image002.jpg]\n 03:00 AM\n 10:47 AM\n 04:10 PM\n 12:13 AM\n 05:08 AM\n 05:20 AM\n 05:17 PM\n 11:41 PM\n 03:06 AM\n 03:38 AM\n WBC\n 8.6\n 11.2\n 10.6\n 10.0\n Hct\n 25.9\n 27.1\n 27.3\n 25.8\n Plt\n 280\n 306\n 321\n 256\n Cr\n 0.5\n 0.7\n 0.5\n 0.5\n 0.6\n TCO2\n 34\n 36\n 36\n 32\n 31\n Glucose\n 136\n 165\n 143\n 110\n 94\n 111\n 106\n Other labs: PT / PTT / INR:13.6/24.4/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:13.1 %,\n Mono:2.7 %, Eos:0.6 %, Lactic Acid:0.9 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:8.4 mg/dL, Mg++:2.5 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA and\n ARDS intubated since the end of .\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation. Stenting\n unlikely to help for trachiomalacia as airways have poor structure\n diffusely. S/P Trach yesterday\n - Continue to wean O2 as tolerated\n # Adrenal Insufficency: Hypotension that resolved with steroids,\n returned as they came off and is now improved again. Possible primary\n adrenal insufficency. Appreciate endocrine recommendations.\n - hydrocortt (day 1 = ), wean per endo recs\n # Hypotension: Likely adrenal insufficiency and sedation. Goal map\n > 60. Much improved since re-administration of steroids.\n - hydrocortisone as above\n - restart levophed if necessary to maintain MAP > 60\n # Volume overloaded in setting of hypernatremia with TBW deficit.\n - Lasix gtt, continue with goal -1L per day.\n - electrolytes\n - may have some contraction alkalosis, w/ rising pH and bicarb. Start\n Diamox 500mg TID to decrease bicarb and pH and may improve respiratory\n drive.\n # Sedation: Sedation control remains somewhat poor although fentanyl\n patch and diazpem are likely therapeutic range today. On Versed 2.0,\n Fentanyl 100, Fentanyl patch, Diazepam standing and haldo 2.5-5 mg\n PRN. QTc increased to 480.\n - Wean versed/fentanyl as tolerated, continue diazepam. Avoid haldol\n use if possible to avoid further prolongation of QTc\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\n coumadin at least until s/p trach.\n - heparin gtt restarted\n - plan to start coumadin night of if stable\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n # FEN/GI: Tube feeds\n DVT: Treatment dose heparin\n Ulcer: Ranitidine\n VAP: Prevention per routine\n # Access: L PICC line, and R brachial a-line\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n - touch base with SW today\n Code: Full\n Dispo: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Arterial Line - 02:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Nursing","chartdate":"2167-10-08 00:00:00.000","description":"Generic Note","row_id":636314,"text":"TITLE:\n 55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\n Now with prolonged hospital course c/b by PNA with high PEEP\n requirement, anxiety, RUE DVT ,continued on heparin qtt.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lungs clear bilat upper lobes and diminished bilat bases with\n occasional scattered rhonchi, prod cough thick yellow/tan sputum, trach\n sx for mod.amt. Placed on MMV for the night with good effect.\n Action:\n Vent changed from CPAP+PS to MMV overnight, Peep @ to 8cm. Freq.\n pulmonary toileting.\n Response:\n Tolerating slow vent wean, requiring pulmonary toileting, Mode\n changed to Cpap+ PS Peep 8, PS 8.\n Plan:\n Attempt to wean PS and FI02 down further today as tolerated, Continue\n aggressive pulmonary toileting.\n Altered mental status (not Delirium)\n Assessment:\n Increased agitation throughout night with pt wriggling in bed and\n attempting to get OOB and attempting to pull at all lines and tubes,\n makes eye contact and follows commands but doesn\nt stay calm for long,\n HR up to 130- with agitation and BP up to 130-150\ns/60-70\n received valium and Haldol as ordered. Prn Midazolam given as per\n orders. dosing in between scheduled doses with poor effect. appears\n generally uncomfortable but denies pain when asked.\n Action:\n Freq. attempts to reorient and calm pt with no effect, Is on Haldol po\n q 8 & also on prn dosing. On po diazepam 10 mgs q 6 & iv versed 0.5 mg\n to 2 mgs q 1 hr. stimulation decreased, bilat soft wrist restraints to\n prevent pt from pulling at lines and tubes\n Response:\n Increased agitation off of continuous IV sedation, poor effect from\n current medical regime, MICU team aware.\n Plan:\n Continue meds to control agitation.\n Hypernatremia (high sodium)\n Assessment:\n NA+ 145 in am labs.\n Action:\n Orders to continue Free water flushes 300ml Q 4hr\n Response:\n Na level has comparatively reduced since yesterday.\n Plan:\n Continue free water flushes. monitor Na levels.\n Arterial line has no return, Team aware. A-line Dressing\n changed. Labs obtained from Picc. ABG done by Intern. Reassess A-line\n ? change A-line .\n Alteration in Nutrition\n Assessment:\n Tube feeds held as per orders . Had problems with priming the new\n tubing. Changed 3 pumps & 2 new tubing set. Tried by 3 RN\ns. Unable to\n prime the tubing in the auto or the manual mode. Orders by team not to\n continue feeds for now, Only to continue the water flushes manually.\n Action:\n Peg Feeds held as of now.\n Response:\n Peg tube flushed & clamped.\n Plan:\n Follow up with the Problem. Monitor Glucose.\n"},{"category":"Respiratory ","chartdate":"2167-10-08 00:00:00.000","description":"Respiratory Care Shift Note","row_id":636320,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 20\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Tube Type\n Tracheostomy tube:\n Type: Cuffed\n Manufacturer: Portex\n Size: 8.0mm\n PMV: No\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: mL /\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Accessory muscle use; Comments:\n Switch to MMV @ beginning of shift till this morning/\n Back to CPAP.\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment: Frequent alarms (Low min. ventilation)\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: Rsbi done ~56.------\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Intolerant of weaning attempts\n"},{"category":"Nursing","chartdate":"2167-10-10 00:00:00.000","description":"Nursing Progress Note","row_id":636671,"text":"55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\n Now with prolonged hospital course c/b by PNA with high PEEP\n requirement, anxiety, RUE DVT .\n Altered mental status (not Delirium)\n Assessment:\n Pt more alert, following commands intermittently. Periods of agitation\n with HR rising to 130\n Action:\n Fentanyl patch in place. Valium RTC. MSO4 given x 1 for discomfort.\n Response:\n Pt with less episodes of agitation previously. ? steroid psychosis.\n Plan:\n Check cortisol level in am and wean hydrocortisone MD. Continue to\n reorient pt. MSO4 prn for discomfort.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on PSV 8/5/50%.RR 19-24. Tidal volumes 200-250. 02 sats\n variable 90-100%. LS rhoncherous to clear, diminished at bases.\n Action:\n Pt maintained at current settings given reduced tv\ns and sats. Orally\n suctioned q 2 hrs for copious secretions. Deep suctioned q 3-4 hrs for\n sm amt thick white secretions.\n Response:\n ABG 7.37/40/120/0/26 on PSV. At 0530 pt hypoventilating with RR 4-6,\n changed to AC mode of ventilation (500x 12 x 5 50%)\n Plan:\n Attempt PSV again this am. Pulm hygiene.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt with RUE DVT. Heparin dcd on .\n Action:\n Coags being monitored. INR 4.4 yest. Hct was falling.\n Response:\n Hct 26.5 today, previously 27.6. INR pend.\n Plan:\n Coumadin to be started when INR < 3\n Hypernatremia (high sodium)\n Assessment:\n Na 140. Pt volume overloaded. LOS + ~10,000ccs.\n Action:\n Treated with 1 liter d5w iv.\n Response:\n Urine output 120-400ccs/hr via foley. TFB neg 100cc. Na 145. Goal ~\n even fluid balance.\n Plan:\n Continue to monitor f+e status.\n"},{"category":"Nursing","chartdate":"2167-10-11 00:00:00.000","description":"Nursing Progress Note","row_id":636837,"text":"Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on trach collar 50%. Sats fell to 78%. Pt ambu\nd and\n lavaged with no plugs detected. RR 30-40 . Pt diaphoretic.\n Action:\n Placed on PSV 10/5/50%\n Response:\n Apneic with RR 3-5\n Plan:\n Rested on AC 500/12/5/50%. No further episodes of desating or\n tachypnea.\n Hypotension (not Shock)\n Assessment:\n BP falling to 78/37. Urine output 5-30ccs/hr via foley\n Action:\n Given 500ccs\n NS fluid bolus\n Response:\n Pt normotensive, improved urine output\n Plan:\n Continue to monitor.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Temp spike to 102.2 po\n Action:\n Blood, urine and sputum cxs sent. Sputum white, not yellow or\n consistant with TF. Chest x-ray taken. Tylenol pr given. Cool cloths\n applied.\n Response:\n Pt normothermic\n Plan:\n Monitor fever curve, cooling measures. Follow-up on cx results.\n Alteration in Nutrition\n Assessment:\n Pt vomiting yellow fluid with coughing and when turned\n Action:\n TF held. Peg to gravity. Medicated with 4 mg zofran iv.\n Response:\n No further episodes of vomiting.\n Plan:\n Continue to monitor. Aspiration precautions. ? need for alternative\n form of nutrition.\n Altered mental status (not Delirium)\n Assessment:\n Onset of shift, pt lethargic, not following commands but MAE. ~ 12 mn\n pt agitated, attempting to climb oob, disconnecting self from vent\n despite restraints\n Action:\n 5 mg valium given q 8hrs\n Response:\n Pt still agitated\n Plan:\n Needs better sedation at bedtime - ? zyprexa or alternative med\n"},{"category":"General","chartdate":"2167-10-04 00:00:00.000","description":"Generic Note","row_id":635747,"text":"TITLE: Addendum to Dr. \ns note\n MICU ATTENDING ADDENDUM \n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points:\n trauma thoracic spine fracture\n intubated\n VAP\n tracheomalacia\n trached\n desaturated and PEEP increased\n Exam notable for Tm 98.5 BP 86/42 HR 91 RR 14 with 94 sat on PS\n /.55\n anasarca\n awake, occasional purposeful movements\n decreased breath sounds ant and lat\n tachy, regular\n abd benign\n 7.39/46/118\n Labs notable for WBC 8 K, HCT 25 , K+ 3.6 , Cr .5 , HCO3 27\n CXR reviewed - bilat effusion, trach ok\n Problems:\n respiratory failure\n airway malacia\n anasarca, effusions\n spine fracture\n agitation\n adrenal insufficiency\n UE DVT\n hypernatremia\n Agree with plan to wean O2 as tolerated, diurese, wean sedation though\n continue pain medications, wean steroids, continue heparin - start\n coumadin, continue H2O\n Remainder of plan as outlined above.\n Patient is critically ill.\n Total time: 36 min\n"},{"category":"Nursing","chartdate":"2167-10-04 00:00:00.000","description":"Nursing Progress Note","row_id":635755,"text":"55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\n Now with prolonged hospital course c/b by PNA with high PEEP\n requirement, anxiety, RUE DVT on heparin qtt.\n Edema, peripheral\n Assessment:\n Action:\n Response:\n Plan:\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Respiratory ","chartdate":"2167-10-05 00:00:00.000","description":"Respiratory Care Shift Note","row_id":635906,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 17\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 7.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Exp Wheeze\n LUL Lung Sounds: Exp Wheeze\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Green / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern:\n Assessment of breathing comfort: No claim of dyspnea)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment: Erratic exhaled Tidal Volumes\n Comments: pt dysynchrones at times though PSV attempted and pt had\n periods of apnea >30 seconds\n Plan\n Next 24-48 hours: Reduce PEEP as tolerated\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n CT\n 1730\n Bedside Procedures:\n Comments:\n"},{"category":"Physician ","chartdate":"2167-10-06 00:00:00.000","description":"Physician Resident Progress Note","row_id":636054,"text":"Chief Complaint:\n 24 Hour Events:\n CT showed small effusions, not amenable for tap and so given warfarin\n (2^nd night)\n Extremely labile pressures over night, trying to wean off Fentanyl and\n use more Haldol.\n Tapering hydrocortisone\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 0.5 mg/hour\n Heparin Sodium - 1,500 units/hour\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:00 AM\n Haloperidol (Haldol) - 01:00 AM\n Other medications:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:12 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.6\n Tcurrent: 37.1\nC (98.8\n HR: 100 (56 - 142) bpm\n BP: 98/47(65) {77/40(53) - 164/93(123)} mmHg\n RR: 18 (15 - 24) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 4,228 mL\n 1,123 mL\n PO:\n TF:\n 1,440 mL\n 360 mL\n IVF:\n 978 mL\n 343 mL\n Blood products:\n Total out:\n 6,725 mL\n 780 mL\n Urine:\n 6,725 mL\n 780 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,497 mL\n 343 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 450 (450 - 450) mL\n PS : 8 cmH2O\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 23 cmH2O\n Plateau: 19 cmH2O\n SpO2: 94%\n ABG: 7.50/41/81./29/7\n Ve: 7.2 L/min\n PaO2 / FiO2: 164\n Physical Examination\n General Appearance: Trached and sedated. Responsive, following\n commands, Overweight / Obese, mild agitation but NAD\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\n deviation\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Respiratory / Chest: (Expansion: Symmetric), CTA anteriorly, decreased\n BS\n Abdominal: Obese, Firm, Non-tender, no rebound, no guarding, + BS, PEG\n in place with dressing C/D/I\n Extremities: No clubbing or cyanosis, trace edema of b/l hands,\n anasarca\n Skin: no rashes or jaundice\n Lines: r brachioceph ART with small amount of bloody drainage and L\n PICC C/D/I\n Labs / Radiology\n 229 K/uL\n 7.9 g/dL\n 107 mg/dL\n 0.6 mg/dL\n 29 mEq/L\n 3.8 mEq/L\n 11 mg/dL\n 109 mEq/L\n 147 mEq/L\n 25.3 %\n 9.6 K/uL\n [image002.jpg]\n 03:55 AM\n 07:19 AM\n 11:24 AM\n 03:18 PM\n 02:47 AM\n 11:01 AM\n 04:40 PM\n 05:08 PM\n 03:44 AM\n 06:04 AM\n WBC\n 8.3\n 11.2\n 9.6\n Hct\n 24.6\n 27.4\n 25.3\n Plt\n 279\n 272\n 229\n Cr\n 0.5\n 0.6\n 0.6\n 0.6\n 0.6\n TCO2\n 29\n 29\n 31\n 34\n 33\n Glucose\n 123\n 137\n 128\n 138\n 107\n Other labs: PT / PTT / INR:16.5/78.5/1.5, Ca++:8.7 mg/dL, Mg++:2.4\n mg/dL, PO4:4.7 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA and\n ARDS intubated since the end of now s/p trach and PEG placement.\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation. Stenting\n unlikely to help for trachiomalacia as airways have poor structure\n diffusely. S/P Trach and PEG on . Increased effusion on recent\n CXR.\n - wean FiO2 as tolerated\n # Adrenal Insufficency: Hypotension that resolved with steroids,\n returned as they came off and is now improved again. Possible primary\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\n started on .\n - wean per endo recs, decrease to 20q am and 10 q pm starting\n tonight\n will maintain this maintenance dose and check am cortisol\n level one week later\n # Volume overloaded in setting of hypernatremia with TBW deficit.\n - Lasix gtt, continue with goal -1-2 L per day\n currently off as\n patient is somewhat hypotensive\n will restart once/if BP increases and\n remains stable for several hours\n - electrolytes\n - continue tube feeds with free water flushes 300 cc q4\n # Sedation: Sedation control remains somewhat poor although fentanyl\n patch and diazpem are likely therapeutic range today. On Versed 2.0,\n Fentanyl 100, Fentanyl patch, Diazepam standing and haldo 2.5-5 mg\n PRN. QTc increased to 480.\n - Wean versed/fentanyl as tolerated, continue diazepam in\n hopes for vent facility placement\n - Change diazepam to 5mg q8 with haldol 5 mg q8\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\n coumadin at least until s/p trach.\n - heparin gtt restarted\n - coumadin 5mg G-tube today, INR in am\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n -f/u full trauma spine eval from OSH to determine need for further back\n imaging in-house (to be done )\n # Nutrition: Tube feeds with free water flushes, tolerating well,\n continue Replete (Full) - 11:20 AM 30 mL/hour\n # Glycemic control: SSI, well controlled\n # Lines L PICC () and R ART ()\n similarly but will\n keep in setting of hypotension\n # Ppx: heparin drip until INR therapeutic for 2 days, ranitidine, VAP\n prevention, colace and senna\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n Code: Full\n Dispo: ICU, being screening for vent facilities\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Arterial Line - 02:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2167-10-06 00:00:00.000","description":"Physician Resident/Attending Progress Note - MICU","row_id":636058,"text":"Chief Complaint:\n 24 Hour Events:\n CT showed small effusions, not amenable for tap and so given warfarin\n (2^nd night)\n Extremely labile pressures over night, trying to wean off Fentanyl and\n use more Haldol.\n Tapering hydrocortisone\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 0.5 mg/hour\n Heparin Sodium - 1,500 units/hour\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:00 AM\n Haloperidol (Haldol) - 01:00 AM\n Other medications:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:12 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.6\n Tcurrent: 37.1\nC (98.8\n HR: 100 (56 - 142) bpm\n BP: 98/47(65) {77/40(53) - 164/93(123)} mmHg\n RR: 18 (15 - 24) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 4,228 mL\n 1,123 mL\n PO:\n TF:\n 1,440 mL\n 360 mL\n IVF:\n 978 mL\n 343 mL\n Blood products:\n Total out:\n 6,725 mL\n 780 mL\n Urine:\n 6,725 mL\n 780 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,497 mL\n 343 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 450 (450 - 450) mL\n PS : 8 cmH2O\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 23 cmH2O\n Plateau: 19 cmH2O\n SpO2: 94%\n ABG: 7.50/41/81./29/7\n Ve: 7.2 L/min\n PaO2 / FiO2: 164\n Physical Examination\n General Appearance: Trached and sedated. Responsive, following\n commands, Overweight / Obese, mild agitation but NAD\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\n deviation\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Respiratory / Chest: (Expansion: Symmetric), CTA anteriorly, decreased\n BS\n Abdominal: Obese, Firm, Non-tender, no rebound, no guarding, + BS, PEG\n in place with dressing C/D/I\n Extremities: No clubbing or cyanosis, trace edema of b/l hands,\n anasarca\n Skin: no rashes or jaundice\n Lines: r brachioceph ART with small amount of bloody drainage and L\n PICC C/D/I\n Labs / Radiology\n 229 K/uL\n 7.9 g/dL\n 107 mg/dL\n 0.6 mg/dL\n 29 mEq/L\n 3.8 mEq/L\n 11 mg/dL\n 109 mEq/L\n 147 mEq/L\n 25.3 %\n 9.6 K/uL\n [image002.jpg]\n 03:55 AM\n 07:19 AM\n 11:24 AM\n 03:18 PM\n 02:47 AM\n 11:01 AM\n 04:40 PM\n 05:08 PM\n 03:44 AM\n 06:04 AM\n WBC\n 8.3\n 11.2\n 9.6\n Hct\n 24.6\n 27.4\n 25.3\n Plt\n 279\n 272\n 229\n Cr\n 0.5\n 0.6\n 0.6\n 0.6\n 0.6\n TCO2\n 29\n 29\n 31\n 34\n 33\n Glucose\n 123\n 137\n 128\n 138\n 107\n Other labs: PT / PTT / INR:16.5/78.5/1.5, Ca++:8.7 mg/dL, Mg++:2.4\n mg/dL, PO4:4.7 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA and\n ARDS intubated since the end of now s/p trach and PEG placement.\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation. Stenting\n unlikely to help for trachiomalacia as airways have poor structure\n diffusely. S/P Trach and PEG on . Increased effusion on recent\n CXR.\n - wean FiO2 as tolerated\n # Adrenal Insufficency: Hypotension that resolved with steroids,\n returned as they came off and is now improved again. Possible primary\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\n started on .\n - wean per endo recs, decrease to 20q am and 10 q pm starting\n tonight\n will maintain this maintenance dose and check am cortisol\n level one week later\n # Volume overloaded in setting of hypernatremia with TBW deficit.\n - Lasix gtt, continue with goal -1-2 L per day\n currently off as\n patient is somewhat hypotensive\n will restart once/if BP increases and\n remains stable for several hours\n - electrolytes\n - continue tube feeds with free water flushes 300 cc q4\n # Sedation: Sedation control remains somewhat poor although fentanyl\n patch and diazpem are likely therapeutic range today. On Versed 2.0,\n Fentanyl 100, Fentanyl patch, Diazepam standing and haldo 2.5-5 mg\n PRN. QTc increased to 480.\n - Wean versed/fentanyl as tolerated, continue diazepam in\n hopes for vent facility placement\n - Change diazepam to 5mg q8 with haldol 5 mg q8\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\n coumadin at least until s/p trach.\n - heparin gtt restarted\n - coumadin 5mg G-tube today, INR in am\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n -f/u full trauma spine eval from OSH to determine need for further back\n imaging in-house (to be done )\n # Nutrition: Tube feeds with free water flushes, tolerating well,\n continue Replete (Full) - 11:20 AM 30 mL/hour\n # Glycemic control: SSI, well controlled\n # Lines L PICC () and R ART ()\n similarly but will\n keep in setting of hypotension\n # Ppx: heparin drip until INR therapeutic for 2 days, ranitidine, VAP\n prevention, colace and senna\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n Code: Full\n Dispo: ICU, being screening for vent facilities\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Arterial Line - 02:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 55F T5-8 fractures with retropulsion and ARDS\n from klebsiella VAP; on heparin for UE DVT and lasix for volume\n overload. Tolerating slow vent wean but failed SBT. Was TBB positive\n yesterday despite lasix drip; sedation remains challenging. CT without\n tappable effusions and resolving airspace disease.\n Exam notable for Tm 100.6 BP 100/50 HR 62 RR 18-20 with sat 97% on VAC\n 400x18 PEEP 8 FiO2 0.5, ABG 7.50/41/82. TBB -2L/24h, +9L/MICU LOS. Eyes\n opens, will squeeze hands and wiggle toes but very drowsy. Bronchial BS\n bilaterally with RRR s1s2 SM at base. Abdomen is distended with\n decreased BS. 1+ edema in BLE, no cords. Labs notable for WBC 9K, HCT\n 25, K+ 3.8, Na 147, Cr 0.6. CXR with resolving B LL airspace disease\n and effusions.\n Agree with plan to continue supportive care, wean vent to PSV, and\n continue diuresis as BP allows. CT without drainable effusions. Will\n continue fentanyl patch at 100mcg, haldol 5q8h alternating with\n valium 5q8h at lower dose, now off drips. Will wean hydrocortisone\n 20/10q12 PGT today. Will continue IV heparin for UE DVT and transition\n to anticoagulation with coumadin. Will continue tube feeds and continue\n FW boluses for hypernatremia. Continue spinal stabilization with brace\n when OOB and discuss followup plan with spine surgery. Will eventually\n need MRI for surgical planning; remainder of plan as outlined above.\n Patient is critically ill\n Total time: 40 min\n ------ Protected Section Addendum Entered By: , MD\n on: 03:04 PM ------\n"},{"category":"Nursing","chartdate":"2167-10-07 00:00:00.000","description":"Nursing Progress Note","row_id":636122,"text":"55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\n Now with prolonged hospital course c/b by PNA with high PEEP\n requirement, anxiety, RUE DVT on heparin qtt.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2167-10-09 00:00:00.000","description":"Generic Note","row_id":636488,"text":"TITLE:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received Pt on vent via trach in CPAP+PS at 50 %/. LS finely\n coarse with diminished bases.. RR 28 to 30/min sats intermittently down\n to 91 %.\n Action:\n Suctioned fro small amts of tan thick mildly blood tinged sputum. Vent\n Mode changed to AC TV 400, RR 10, peep 8 for the night as per\n discussion By Resident & MD to rest for the night.\n Response:\n Sats maintained in Mid 90\ns to high 90\ns. ABG done in am PH\n 7.35/50/81/29/ Sats 96. Set RR ^ to 12 post abg\n Plan:\n Wean vent settings as tolerated. Plan to IP to follow up regarding ?\n need for stent tomorrow.\n Altered mental status (not Delirium)\n Assessment:\n Pt lethargic, arousable to stimuli, Po diazepam dose was held at 1800\n hrs,.haldol po dose was given at hrs to keep the patient calm\n Action:\n HR was in the 120-130\ns (while awake) Fentanyl patch weaned down to 75\n micgs. off fentanyl patch From Midnight till 530am.\n Response:\n Patient wide awake at 4am, Calm & still after being restless for few\n minutes. responds to name & follows commands inconsistently,Tracks\n well. Continues to be lethargic.\n Plan:\n Continue to eval restlessness & treat as needed.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Temp up to 101.4. axillary at hrs .\n Action:\n Tylenol 650 mgs given, Pan cultured, started on vanco, aztreonam &\n Levofloxacin.\n Response:\n Temp down to 98.1 orally at 4 am.\n Plan:\n Continue monitoring temp, continue anbx, follow up on cultures.\n Anemia, other\n Assessment:\n Blood tinged sputum obtained when suctioned via trach. INR 4.0 ( Goal\n INR 2 to 3.0), HCT down to 24.9, HgB 7.7 in am labs, (Total of 2lits NS\n was given at this time)\n Action:\n Coumadin not given on the night of \n Response:\n No other bleeding seen.\n Plan:\n Monitor Labs, S/S bleeding\n Hypotension (not Shock)\n Assessment:\n Received with NIBP systolic in mid 90\ns, maps of mid 50\ns. At \n hrs Sbp\ns 70\ns to 80\ns, Maps in low to high 40\n Action:\n Total 2.25 litres of fluid given, started on Levophed gtt at 0040 hrs.\n Response:\n Sbp\ns in 100\ns to 120\ns, maps in 60\ns to 70\n Plan:\n Continue monitoring BP, I/O\n Alteration in Nutrition\n Assessment:\n Obtained large feed like secretions orally. ? aspiration Abd\n dist, soft with hypoactive BS. No BM on this shift. Pt\ns head needs to\n be lowered down as BP is Low.\n Action:\n TF held . Peg tube flushed & clamped.\n Response:\n Towards morning changed to thick secretions like the color of the\n feeds mixed with saliva. By MD . At 4am obtained tannish\n loose copious amts of oral secretions.\n Plan:\n Hold feeds till am rounds as MD . Intern Discussed about a\n dye test. No plans at present to do the dye study to determine\n aspiration.\n Hypernatremia (high sodium)\n Assessment:\n Na 140 in pm labs. As feeds were held water boluses held too.\n Action:\n Orders to give NS Fluid bolus( discussed about the chances of ^ Na\n levels) . Team would like to go ahead with NS fluid boluses. Total of\n 2250 mls given overnight. Patient diuresed a total of mls.\n Response:\n Na 145 in am labs\n Plan:\n Continue to monitor I/O, Lytes.\n"},{"category":"Nursing","chartdate":"2167-10-09 00:00:00.000","description":"Generic Note","row_id":636494,"text":"TITLE:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received Pt on vent via trach in CPAP+PS at 50 %/. LS coarse\n with diminished bases.. RR 28 to 30/min sats intermittently down to 91\n %.\n Action:\n Suctioned fro small amts of tan thick mildly blood tinged sputum. Vent\n Mode changed to AC TV 400, RR 10, peep 8 for the night as per\n discussion By Resident & MD to rest for the night.\n Response:\n Sats maintained in Mid 90\ns to high 90\ns. ABG done in am PH\n 7.35/50/81/29/ Sats 96. Set RR ^ to 12 post abg\n Plan:\n Wean vent settings as tolerated. Plan to IP to follow up regarding ?\n need for stent tomorrow.\n Altered mental status (not Delirium)\n Assessment:\n Pt lethargic, arousable to stimuli, Po diazepam dose was held at 1800\n hrs, Haldol po dose was given at hrs to continue to rest the\n patient & keep her calm .\n Action:\n Fentanyl patch weaned down to 75 micgs. off fentanyl patch From\n Midnight till 530am.\n Response:\n Patient wide awake at 0345 am, Calm & still after being restless for\n few minutes. responds to name & follows commands inconsistently, Tracks\n well. Continues to be lethargic. Further haldol & diazepam doses held .\n Plan:\n Continue to eval restlessness & treat as needed.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Temp up to 101.4. axillary at hrs . WBC Upto 11.3 in am labs. Was\n 9.4 in pm labs.\n Action:\n Tylenol 650 mgs given, Pan cultured, started on vanco, aztreonam &\n Levofloxacin.\n Response:\n Temp down to 98.1 orally at 4 am.\n Plan:\n Continue monitoring temp, continue anbx, follow up on cultures.\n Anemia, other\n Assessment:\n Blood tinged sputum obtained when suctioned via trach. INR 4.0 ( Goal\n INR 2 to 3.0as MD ), HCT down to 24.9, HgB 7.7 in am labs, (Total\n of 2lits NS was given at this time)\n Action:\n Coumadin not given on the night of \n Response:\n No other bleeding seen.\n Plan:\n Monitor Labs, S/S bleeding\n Hypotension (not Shock)\n Assessment:\n Received with NIBP systolic in mid 90\ns, maps of mid 50\ns. At \n hrs Sbp\ns 70\ns to 80\ns, Maps in low to high 40\n Action:\n Total 2.25 litres of fluid given, started on Levophed gtt at 0040 hrs.\n Response:\n Sbp\ns in 100\ns to 130\ns, maps in 60\ns to 70\ns.Patient diuresing copious\n amts when she is awake & bp is higher Weaned Levophed titrated to\n maintain BP. Currently @ 0.03 mics/kg/min, BP is 119/55(68).\n Plan:\n Continue monitoring BP, I/O.\n Alteration in Nutrition\n Assessment:\n Obtained large feed like secretions orally. ? aspiration Abd\n dist, soft with hypoactive BS. No BM on this shift. Pt\ns head needs to\n be lowered down as BP is Low.\n Action:\n TF held . Peg tube flushed & clamped.\n Response:\n Towards morning changed to thick secretions like the color of the\n feeds mixed with saliva. By MD . At 4am obtained tannish\n loose copious amts of oral secretions.\n Plan:\n Hold feeds till am rounds as MD . Intern Discussed about a\n dye test. No plans at present to do the dye study to determine\n aspiration.\n Hypernatremia (high sodium)\n Assessment:\n Na 140 in pm labs. As feeds were held water boluses held too.\n Action:\n Orders to give NS Fluid bolus( discussed about the chances of ^ Na\n levels) . Team would like to go ahead with NS fluid boluses. Total of\n 2250 mls of Fluid bolus given overnight. Patient diuresed a total of\n 2220 mls from 7pm to 6am.\n Response:\n Na 145 in am labs\n Plan:\n Continue to monitor I/O, Lytes.\n"},{"category":"Nursing","chartdate":"2167-10-10 00:00:00.000","description":"Nursing Progress Note","row_id":636772,"text":"Altered mental status (not Delirium)\n Assessment:\n Rec\nd pt restless, intermit following commands. MAEE with good\n strength. Pt shaking head\n when asked if has pain or SOB.\n Action:\n Torso brace applied\nwith difficulty\nand pt OOB to stretcher/chair with\n transfer via board.\n Response:\n Pt increasingly restless with HR 130-140ST, grimacing. Pt attempting to\n stand and/or exit chair. Pt rec\nd scheduled Valium 5mg po early, as\n well as Morphine Sulfate 2mg IVP without relief of discomfort. Pt\n returned to bed after 45mins. When brace removed, chin noted to be\n abraided from chin rest. Pt cont to be restless all afternoon, freq\n attempting to sit up in bed. Soft wrist restraints in place for pt\n safety.\n Plan:\n Duoderm to chin or chin-rest when brace applied. Attempt OOB to chair\n again tomorrow.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt on vent settings AC 50%/ 12 X 500/+5 with rare over-breathing\n of rate. O2 sat 100%. Lung snds with rhonchi in RUL, clear in LUL, and\n diminished bilat in bases. Pt requiring sxn\ning Q2-4hrs for mod amts\n yellow/white thick secretions. Pt also intermit with copious thick,\n clear oral secretions.\n Action:\n Vent changed to CPAP/PS 8/+5/50% with SRR 14-25 and regular, O2 sat\n remaining 98-100%. Pt then placed on trach mask @ 80%.\n Response:\n Pt has tolerated TM for several hrs, with RR remaining regular @\n 14-25/min, O2 sat 100%.\n Plan:\n"},{"category":"Respiratory ","chartdate":"2167-10-11 00:00:00.000","description":"Respiratory Care Shift Note","row_id":636930,"text":"TITLE:\n Demographics\n Day of intubation:\n Day of mechanical ventilation: 23\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Cuffed\n Manufacturer: Portex\n Size: 7.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments: probable for PMV eval tomorrow by speech\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: pt tolerating trach collar through majority of shift thus\n far, will contiue to eval periodically\n Assessment of breathing comfort: No claim of dyspnea)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: weaning as tolerated\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"},{"category":"Nursing","chartdate":"2167-10-05 00:00:00.000","description":"Nursing Progress Note","row_id":635811,"text":"55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\n Now with prolonged hospital course c/b by PNA with high PEEP\n requirement, anxiety, RUE DVT on heparin qtt.\n Edema, peripheral\n Assessment:\n Fluid balance for previous 24hrs decreased by 3 liters D/T diuresis.\n Rec\nd pt off of Lasix qtt. Urine output decreased to 45ml/hr @1000.\n Action:\n Lasix qtt restarted @ 2mg/hr to maintain urine output 1-2liters/day.\n Response:\n Fluid balance approx -50ml/hr, with 24hr fluid balance -650ml @ 1500.\n However, SBP 78 when pt soundly sleeping/sedated. Lasix qtt stopped @\n 1530.\n Plan:\n Restart Lasix qtt when BP stabilized.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Rec\nd pt on Heparin qtt @ 1500units/hr.\n Action:\n PTT 92.1 @ 1230.\n Response:\n Per goal PTT 60-100, Heparin rate unchanged.\n Plan:\n Repeat PTT @ 1830. Start po Coumadin tonight.\n Altered mental status (not Delirium)\n Assessment:\n Rec\nd pt on Versed @ 2mg/hr, Fentanyl @ 75 mcg/hr, as well as Fentanyl\n patches totaling 150mcg in place. Pt also rec\ning Diazepam 10mg po\n Q6hrs, in hope of weaning pt from IV sedation. Agitated most time\n moving around intermittently following commands. Moving arms\n purposefully towards trach, so soft wrist restraints remain in place..\n Action:\n Pt required bolus sedation x2 with care and activity.\n Response:\n Pt restless/squirming in bed when she appears awake..\n Plan:\n Cont to attempt weaning from IV sedation. emotional support to pt and\n family,reorient pt .\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt on vent settings AC 50%/18 X 400/+10, with no over-breathing\n of rate by pt. O2 sa\\94-96%. ABG done yesterday was 7.44/42/93. Lung\n snds clear but diminished in lower lobes. Suctionned for small-moderate\n amts thick white secretions.\n Action:\n .Cont same Vent settings.\n Response:\n Pts secretions got better\n Plan:\n Cont wean from vent with PS trials,Monitor mental status.\n"},{"category":"Nursing","chartdate":"2167-10-05 00:00:00.000","description":"Nursing Progress Note","row_id":635814,"text":"55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\n Now with prolonged hospital course c/b by PNA with high PEEP\n requirement, anxiety, RUE DVT on heparin qtt.\n Edema, peripheral\n Assessment:\n Fluid balance for previous 24hrs decreased by 3 liters D/T diuresis.\n Rec\nd pt off of Lasix qtt. Urine output decreased to 45ml/hr @1000.\n Action:\n Lasix qtt restarted @ 2mg/hr to maintain urine output 1-2liters/day.\n Response:\n Fluid balance approx -50ml/hr, with 24hr fluid balance -650ml @ 1500.\n However, SBP 78 when pt soundly sleeping/sedated. Lasix qtt stopped @\n 1530.\n Plan:\n Restart Lasix qtt when BP stabilized.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Rec\nd pt on Heparin qtt @ 1500units/hr.\n Action:\n PTT 62,2 @ 0230.\n Response:\n Heparin rate unchanged.pt had 2 therapeutic PTT,started on coumadin\n 5mg at 2200,.\n Plan:\n Cont heparin gtt as well as Coumadin until INR ^ 2.\n Altered mental status (not Delirium)\n Assessment:\n Rec\nd pt on Versed @ 2mg/hr, Fentanyl @ 75 mcg/hr, as well as Fentanyl\n patches totaling 150mcg in place. Pt also rec\ning Diazepam 10mg po\n Q6hrs, in hope of weaning pt from IV sedation. Agitated most time\n moving around intermittently following commands. Moving arms\n purposefully towards trach, so soft wrist restraints remain in place..\n Action:\n Pt required bolus sedation x2 with care and activity.\n Response:\n Pt restless/squirming in bed when she appears awake..\n Plan:\n Cont to attempt weaning from IV sedation. emotional support to pt and\n family,reorient pt .\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt on vent settings AC 50%/18 X 400/+10, with no over-breathing\n of rate by pt. O2 sa\\94-96%. ABG done yesterday was 7.44/42/93. Lung\n snds clear but diminished in lower lobes. Suctionned for small-moderate\n amts thick white secretions.\n Action:\n .Cont same Vent settings.\n Response:\n Pts secretions got better\n Plan:\n Cont wean from vent with PS trials,Monitor mental status.\n"},{"category":"Nursing","chartdate":"2167-10-06 00:00:00.000","description":"Nursing Progress Note","row_id":635952,"text":"Bradycardia\n Assessment:\n Pt conts with HR 50-70\ns at rest, 100-140\ns during care, pt\n asymptomatic; easily arousable\n Action:\n Sedation decreased, Lasix off @0200\n Response:\n HR 60\n Plan:\n Cont to wean sedation, ?cardiac consult\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Action:\n Cont with IV Heparin @ 1500u/hr, Coumadin d\ncd for? thoracentesis\n Response:\n Pt therapeutic, cont with daily PTT\n Plan:\n Cont to labs, cont to wean off Heparin, Coumadin 5mg given x 1dose\n @ 2200, re-eval dosing this am\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt cont on AC 18/400/50%/10, LS clear bilat, occ scat rhonchi\n Action:\n Pt suct for sm thin tan secretions\n Response:\n Plan:\n Cont to ABGs,\n Hypotension (not Shock)\n Assessment:\n SBP 140\ns when pt is agitated, SBP dropping to 70\ns-80\ns, UO 200/hr\n (total 2500 in 2hr)\n Action:\n Fent/Versed turned down @ 0000, Lasix gtt on hold, team informed\n Response:\n Pt SBP\ns in 80\n Plan:\n Cardiac consult to further eval SB/ST, re-evalu cont. Lasix gtt\n Hypernatremia (high sodium)\n Assessment:\n Na 146\n Action:\n Cont with 300cc free water flush Q4hrs\n Response:\n Plan:\n Cont to sodium levels, treat as ordered\n Altered mental status (not Delirium)\n Assessment:\n Pt alert and agitated throughout shift, pt following commands\n inconsistently; sleeping off and off throughout shift\n Action:\n Fent/Versed decreased low SBP\ns, pt recved prn dose of Haldol 1mg @\n 0100; cont with bilat. Wrist restraints for safety\n Response:\n pt sleeping off/on throughout shift, with periods of\n agitation/restlessness\n Plan:\n Cont to wean fent/versed gtt down, cont with scheduled Haldol/Valium;\n cont to QTC intervals daily\n"},{"category":"Nursing","chartdate":"2167-10-06 00:00:00.000","description":"Nursing Progress Note","row_id":635953,"text":"55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\n Now with prolonged hospital course c/b by PNA with high PEEP\n requirement, anxiety, RUE DVT on heparin qtt.\n Bradycardia\n Assessment:\n Pt conts with HR 50-70\ns at rest, 100-140\ns during care, pt\n asymptomatic; easily arousable\n Action:\n Sedation decreased, Lasix off @0200\n Response:\n HR 60\n Plan:\n Cont to wean sedation, ?cardiac consult\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Action:\n Cont with IV Heparin @ 1500u/hr, Coumadin d\ncd for? thoracentesis\n Response:\n Pt therapeutic, cont with daily PTT\n Plan:\n Cont to labs, cont to wean off Heparin, Coumadin 5mg given x 1dose\n @ 2200, re-eval dosing this am\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt cont on AC 18/400/50%/10, LS clear bilat, occ scat rhonchi\n Action:\n Pt suct for sm thin tan secretions\n Response:\n Plan:\n Cont to ABGs,\n Hypotension (not Shock)\n Assessment:\n SBP 140\ns when pt is agitated, SBP dropping to 70\ns-80\ns, UO 200/hr\n (total 2500 in 2hr)\n Action:\n Fent/Versed turned down @ 0000, Lasix gtt on hold, team informed\n Response:\n Pt SBP\ns in 80\n Plan:\n Cardiac consult to further eval SB/ST, re-evalu cont. Lasix gtt\n Hypernatremia (high sodium)\n Assessment:\n Na 146\n Action:\n Cont with 300cc free water flush Q4hrs\n Response:\n Plan:\n Cont to sodium levels, treat as ordered\n Altered mental status (not Delirium)\n Assessment:\n Pt alert and agitated throughout shift, pt following commands\n inconsistently; sleeping off and off throughout shift\n Action:\n Fent/Versed decreased low SBP\ns, pt recved prn dose of Haldol 1mg @\n 0100; cont with bilat. Wrist restraints for safety\n Response:\n pt sleeping off/on throughout shift, with periods of\n agitation/restlessness\n Plan:\n Cont to wean fent/versed gtt down, cont with scheduled Haldol/Valium;\n cont to QTC intervals daily\n"},{"category":"Nursing","chartdate":"2167-10-08 00:00:00.000","description":"Nursing Progress Note","row_id":636425,"text":"Alteration in Nutrition\n Assessment:\n Abd dist, soft with hypoactive BS. No BM on this shift.\n Action:\n TF restarted at goal at 60 cc/hr with minimal residuals.\n Response:\n Plan:\n Follow FSBS. ? adding more laxatives until BM.\n Fracture, other\n Assessment:\n Pt out of bed in stretcher chair with brace in place most of day. Pt\n did very well.\n Action:\n Pt tol being OOb well in regards to resp status and MS.\n Response:\n Plan:\n Plan to take pt OOB to cahir tomorrow also.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains on vent via trach in CPAP+PS at 50 %/. LS CTA with\n diminished bases. Pt has been deep sx\nd for sml amounts of tan to thick\n yellow secretions.\n Action:\n Vent changed to 5/5, but was only tolerated for 1 hr.\n Response:\n After 1 hr pt became tachycardic and tachypnic. O2sat decreased to 95%.\n Plan:\n Continue to wean vent settings as tolerated. Plan to IP to follow up\n regarding ? need for stent tomorrow.\n Altered mental status (not Delirium)\n Assessment:\n Pt opens eyes to voice, but will only follow simple commands very\n inconsistently. Pt is very lethargic. Pt found this am to be very\n restless and given versed with no effect.\n Action:\n After pt placed in a chair, and pt more relaxed. Pt was calm, but her\n HR was in the 120-130\ns (while awake). Pt given Morphine with good\n effect. Fentanyl patches weaned down to 100 mcg.\n Response:\n Plan:\n Continue to eval restlessness.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Respiratory ","chartdate":"2167-10-09 00:00:00.000","description":"Respiratory Care Shift Note","row_id":636480,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 21\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason:\n Tube Type\n Tracheostomy tube:\n Type: Cuffed\n Manufacturer: Portex\n Size: 7.0mm\n PMV: No\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments: Large cuff volume needed for air tight seal\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Copious\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing,\n Frequent desaturation episodes; Comments: Pt had some episodes of\n desaturations after turning and suctioning. Pt was switched to AC as\n MD orders due to lowing SpO2 and increased WOB\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments: Pt is stable on vent (AC settings)as per Expiratory Tv, RR\n and SpO2\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Periodic SBT's for conditioning, Adjust Min. ventilation to control pH;\n Comments: Pt to con't current support. Pt showed poor RSBI trial, due\n to low Tidal volumes.\n Reason for continuing current ventilatory support: Cannot protect\n airway, Cannot manage secretions, Underlying illness not resolved\n BEDSIDE RSBI- 126\n"},{"category":"Nursing","chartdate":"2167-10-09 00:00:00.000","description":"Generic Note","row_id":636485,"text":"TITLE:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received Pt on vent via trach in CPAP+PS at 50 %/. LS finely\n coarse with diminished bases.. RR 28 to 30/min sats intermittently down\n to 91 %.\n Action:\n Suctioned fro small amts of tan thick mildly blood tinged sputum. Vent\n Mode changed to AC TV 400, RR 10, peep 8 for the night as per\n discussion By Resident & MD to rest for the night.\n Response:\n Sats maintained in Mid 90\ns to high 90\ns. ABG done in am PH\n 7.35/50/81/29/ Sats 96. Set RR ^ to 12 post abg\n Plan:\n Wean vent settings as tolerated. Plan to IP to follow up regarding ?\n need for stent tomorrow.\n Altered mental status (not Delirium)\n Assessment:\n Pt lethargic, arousable to stimuli, Po diazepam dose was held at 1800\n hrs,.haldol po dose was given at hrs\n Action:\n HR was in the 120-130\ns (while awake) Fentanyl patches weaned down to\n 75 micgs. Currently off fentanyl patch.\n Response:\n Patient wide awake at 4am, Calm & still after being restless for few\n minutes. responds to name & follows commands inconsistently, continues\n to be lethargic.\n Plan:\n Continue to eval restlessness.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Temp up to 101.4. axillary at hrs .\n Action:\n Tylenol 650 mgs given, Pan cultured, started on vanco, aztreonam &\n Levofloxacin.\n Response:\n Temp down to 98.1 orally at 4 am.\n Plan:\n Continue monitoring temp, continue anbx, follow up on cultures.\n Anemia, other\n Assessment:\n Blood tinged sputum obtained when suctioned via trach. INR 4.0 ,HCT\n down to 24.9, HgB 7.7 in am labs, (Total of 2lits NS was given at this\n time)\n Action:\n Coumadin not given on the night of \n Response:\n No other bleeding seen.\n Plan:\n Monitor Labs, S/S bleeding\n Hypotension (not Shock)\n Assessment:\n Received with NIBP systolic in mid 90\ns, maps of mid 50\ns. At \n hrs Sbp\ns 70\ns to 80\ns, Maps in low to high 40\n Action:\n Total 2.25 litres of fluid given, started on Levophed gtt at 0040 hrs.\n Response:\n Sbp\ns in 100\ns to 120\ns, maps in 60\ns to 70\n Plan:\n Continue monitoring BP, I/O\n Alteration in Nutrition\n Assessment:\n Obtained large feed like secretions orally. ? aspiration Abd\n dist, soft with hypoactive BS. No BM on this shift. Pt\ns head needs to\n be lowered down as BP is Low.\n Action:\n TF held . Peg tube flushed & clamped.\n Response:\n Towards morning changed to thick secretions like the color of the\n feeds mixed with saliva. By MD . At 4am obtained tannish\n loose copious amts of oral secretions.\n Plan:\n Hold feeds till am rounds as MD . Intern Discussed about a\n dye test. No plans at present to do the dye study to determine\n aspiration.\n Hypernatremia (high sodium)\n Assessment:\n Na 140 in pm labs. As feeds were held water boluses held too.\n Action:\n Orders to give NS Fluid bolus( discussed about the chances of ^ Na\n levels) . Team would like to go ahead with NS fluid boluses. Total of\n 2250 mls given overnight. Patient diuresed a total of mls.\n Response:\n Na 145 in am labs\n Plan:\n Continue to monitor I/O, Lytes.\n"},{"category":"Physician ","chartdate":"2167-10-09 00:00:00.000","description":"Physician Resident/Attending Progress Note - MICU","row_id":636590,"text":"Chief Complaint:\n 24 Hour Events:\n Arterial line d/c'd\n Spiked a fever of 101.4, blood and urine cultures sent, CXR. Started\n Vanc, Levo, Aztreonam\n Persistently hypotensive to 70s SBP overnight with low urine output and\n poor O2 sats.\n Started on Levophed, and given 1.75L NS. BPs improved to 90-120s SBP,\n and urine output increased significantly.\n Large amount of oral secretions, ?gastric in origin\n Tube feeds held for ? of aspiration.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 11:00 PM\n Levofloxacin - 11:43 PM\n Aztreonam - 04:07 AM\n Infusions:\n Norepinephrine\n Off at 7:30 AM\n Other ICU medications:\n Midazolam (Versed) - 09:30 AM\n Morphine Sulfate - 03:17 PM\n Furosemide (Lasix) - 06:36 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.4\n Tcurrent: 36.7\nC (98.1\n HR: 131 (73 - 142) bpm\n BP: 127/43(60) {71/29(42) - 137/97(101)} mmHg\n RR: 21 (12 - 36) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 4,627 mL\n 1,084 mL\n PO:\n TF:\n 839 mL\n IVF:\n 2,288 mL\n 1,084 mL\n Blood products:\n Total out:\n 2,407 mL\n 2,220 mL\n Urine:\n 2,407 mL\n 2,220 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,220 mL\n -1,136 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 412 (236 - 480) mL\n PS : 8 cmH2O\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI: 126\n PIP: 21 cmH2O\n Plateau: 17 cmH2O\n Compliance: 44.4 cmH2O/mL\n SpO2: 97%\n ABG: 7.35/50/81./26/0\n Ve: 7 L/min\n PaO2 / FiO2: 162\n Physical Examination\n General Appearance: Trached and sedated. Responsive, following\n commands, Overweight / Obese, mild agitation but NAD\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\n deviation\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Respiratory / Chest: (Expansion: Symmetric), CTA anteriorly, decreased\n BS\n Abdominal: Obese, soft, Non-tender, no rebound, no guarding, + BS, PEG\n in place with dressing C/D/I\n Extremities: no CCE\n Skin: no rashes or jaundice\n Lines: r brachioceph ART with large amount of bloody drainage and L\n PICC C/D/I\n Labs / Radiology\n 227 K/uL\n 7.7 g/dL\n 114 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 4.0 mEq/L\n 16 mg/dL\n 112 mEq/L\n 145 mEq/L\n 24.9 %\n 11.3 K/uL\n [image002.jpg]\n 03:46 AM\n 10:20 AM\n 03:46 PM\n 01:37 AM\n 05:32 AM\n 02:43 PM\n 03:03 PM\n 08:11 PM\n 02:51 AM\n 03:10 AM\n WBC\n 11.1\n 9.4\n 11.3\n Hct\n 29.4\n 26.6\n 24.9\n Plt\n \n Cr\n 0.8\n 0.6\n 0.9\n 0.7\n TCO2\n 35\n 37\n 31\n 31\n 30\n 29\n Glucose\n 155\n 123\n 128\n 114\n 114\n Other labs: PT / PTT / INR:37.2/37.9/4.0, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Lactic Acid:0.5 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:8.7 mg/dL, Mg++:2.6 mg/dL, PO4:4.2 mg/dL\n Blood/Urine/Sputum culture pending\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA, and\n ARDS, intubated since the end of now s/p trach and PEG\n placement.\n # Fever: Likely secondary to aspiration pneumonitis. Given prolonged\n hospitalization and tenuous respiratory status will treat with\n antibiotics while cultures pending\n - Vanc/Cef/Azithro for 48 hours while waiting for sputum results.\n - Hold tube feeds for 24 hours\n - Follow cultures\n - Off levophed\n .\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation. S/P Trach\n and PEG on .\n - wean FiO2 as tolerated\n - attempt wean PS today and hopeful for trach mask trial\n # Sedation: Continue to have issues with pain/delirium causing\n tachycardia and hypertension with intermittent hypotension. On Haldol\n 5 TID, Fentanyl 75 mcg TP, Diazapam 10 QID; Haldol, midazolam and\n morphine PRN. Had good response to morphine, minimal response to\n haldol bolus.\n - Reduce diazepam to 5 q 8hrs.\n - d/c standing Haldol\n # Adrenal Insufficency: Hypotension that resolved with steroids,\n returned as they came off and is now improved again. Possible primary\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\n started on .\n - 10 q am and 5 q pm prednisone day 2 of 3, will wean to\n maintenance dose as tolerated, in consultation with endo.\n # Volume overloaded in setting of hypernatremia with TBW deficit and\n metabolic alkalosis\n - Goal of even in the setting of recent hypotension.\n - Off diamox\n - electrolytes\n - Will give IV free water rather than flushes. D5W 1L@100 cc/hr\n # Falling Hct: Likely dilutional. Concern given elevated INR\n - Recheck in PM\n - Type and screen\n # RUE DVT: INR now therapeutic on coumadin. Goal \n - stop heparin gtt\n - will start coumadin 2.5 mg QHS once INR < 3\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - Brace for OOB\n - report from full trauma series from OSH is in chart. No evidence of\n other fracture and no need for further spinal imaging based on this\n report and ortho note.\n # Tracheomalacia: Discussed with IP. Stenting unlikely to help for\n trachiomalacia as airways have poor structure diffusely.\n - Outpatient f/u once off pressure support to assess for possible\n stenting\n #. Thyroid Nodule on CT\n -outpatient follow up\n # Nutrition: Hold tube feeds x 24 hours, continue Replete (Full)\n will reintroduce slowly\n - advance bowel regimen\n # Glycemic control: SSI, well controlled\n # Lines L PICC (). ABG and VBG correlate well.\n # Ppx: INR therapeutic, ranitidine, colace and senna, miralax,\n bisacodyl.\n # Communication:\n - Boyfriend of 10 \n - Brother is her HCP, also involved\n Code: Full\n Dispo: ICU, being screening for vent facilities\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n 18 Gauge - 08:15 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 55F T5-8 fractures with retropulsion and ARDS\n from klebsiella VAP; on heparin for UE DVT and lasix for volume\n overload. Febrile overnight with ? aspiration, now back on antibiotics\n with HCT drop, hypotensive requiring levophed.\n Exam notable for Tm 101.4 BP 120/43 HR 100-130 RR 18-20 with sat 97% on\n VAC 400x12 PEEP 8, FiO2 0.4, ABG 7.35/50/81. Eyes opens, more alert.\n Clearer BS bilaterally with RRR s1s2 SM at base. Abdomen is\n distended with decreased BS. Trace edema in BLE, no cords. Labs notable\n for WBC 11K, HCT 25, K+ 4.0, Na 145, Cr 0.7, INR 4.0. CXR without\n significant change.\n Agree with plan to transition back from VAC to PSV and to continue\n antibiotics x48 while awaiting cultures. Abdomen is distended; will\n hold tube feeds and increase bowel regimen including possible PO\n narcan. INR is high and HCT is down; will hold coumadin and guiac\n stool, confirm BBS and check PM HCT. Will continue fentanyl patch at\n 150mcg and valium 5q8h. Will change haldol to PRN, and wean\n hydrocortisone per endocrine. Will continue FW boluses for\n hypernatremia. Continue spinal stabilization with brace when OOB; will\n review outside images with spine surgery but no plan for acute\n intervention. Remainder of plan as outlined above.\n Patient is critically ill\n Total time: 45 min\n ------ Protected Section Addendum Entered By: , MD\n on: 05:19 PM ------\n"},{"category":"Nursing","chartdate":"2167-10-11 00:00:00.000","description":"Nursing Progress Note","row_id":636829,"text":"Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on trach collar 50%. Sats fell to 78%. Pt ambu\nd and\n lavaged with no plugs detected. RR 30-40 . Pt diaphoretic.\n Action:\n Placed on PSV 10/5/50%\n Response:\n Apneic with RR 3-5\n Plan:\n Rested on AC 500/12/5/50%. No further episodes of desating or\n tachypnea.\n Hypotension (not Shock)\n Assessment:\n BP falling to 78/37. Urine output 5-30ccs/hr via foley\n Action:\n Given 500ccs\n NS fluid bolus\n Response:\n Plan:\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Temp spike to 102.2 po\n Action:\n Blood, urine and sputum cxs sent. Chest x-ray taken. Tylenol pr given.\n Cool cloths applied.\n Response:\n Temp down to 100.4\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2167-10-11 00:00:00.000","description":"Nursing Progress Note","row_id":636830,"text":"Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on trach collar 50%. Sats fell to 78%. Pt ambu\nd and\n lavaged with no plugs detected. RR 30-40 . Pt diaphoretic.\n Action:\n Placed on PSV 10/5/50%\n Response:\n Apneic with RR 3-5\n Plan:\n Rested on AC 500/12/5/50%. No further episodes of desating or\n tachypnea.\n Hypotension (not Shock)\n Assessment:\n BP falling to 78/37. Urine output 5-30ccs/hr via foley\n Action:\n Given 500ccs\n NS fluid bolus\n Response:\n Pt normotensive, improved urine output\n Plan:\n Continue to monitor.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Temp spike to 102.2 po\n Action:\n Blood, urine and sputum cxs sent. Sputum white, not yellow or\n consistant with TF. Chest x-ray taken. Tylenol pr given. Cool cloths\n applied.\n Response:\n Temp down to 100.4\n Plan:\n Monitor fever curve, cooling measures. Follow-up on cx results.\n Alteration in Nutrition\n Assessment:\n Pt vomiting yellow fluid with coughing and when turned\n Action:\n TF held. Peg to gravity. Medicated with 4 mg zofran iv.\n Response:\n No further episodes of vomiting.\n Plan:\n Continue to monitor. Aspiration precautions.\n"},{"category":"Nursing","chartdate":"2167-10-11 00:00:00.000","description":"Nursing Progress Note","row_id":636833,"text":"Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on trach collar 50%. Sats fell to 78%. Pt ambu\nd and\n lavaged with no plugs detected. RR 30-40 . Pt diaphoretic.\n Action:\n Placed on PSV 10/5/50%\n Response:\n Apneic with RR 3-5\n Plan:\n Rested on AC 500/12/5/50%. No further episodes of desating or\n tachypnea.\n Hypotension (not Shock)\n Assessment:\n BP falling to 78/37. Urine output 5-30ccs/hr via foley\n Action:\n Given 500ccs\n NS fluid bolus\n Response:\n Pt normotensive, improved urine output\n Plan:\n Continue to monitor.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Temp spike to 102.2 po\n Action:\n Blood, urine and sputum cxs sent. Sputum white, not yellow or\n consistant with TF. Chest x-ray taken. Tylenol pr given. Cool cloths\n applied.\n Response:\n Temp down to 100.4\n Plan:\n Monitor fever curve, cooling measures. Follow-up on cx results.\n Alteration in Nutrition\n Assessment:\n Pt vomiting yellow fluid with coughing and when turned\n Action:\n TF held. Peg to gravity. Medicated with 4 mg zofran iv.\n Response:\n No further episodes of vomiting.\n Plan:\n Continue to monitor. Aspiration precautions.\n Altered mental status (not Delirium)\n Assessment:\n Onset of shift, pt lethargic, not following commands but MAE. ~ 12 mn\n pt agitated, attempting to climb oob, disconnecting self from vent\n despite restraints\n Action:\n 5 mg valium given q 8hrs\n Response:\n Pt still agitated\n Plan:\n Needs better sedation at bedtime - ? zyprexa or alternative med\n"},{"category":"Physician ","chartdate":"2167-10-11 00:00:00.000","description":"Physician Resident Progress Note","row_id":636905,"text":"Chief Complaint:\n 24 Hour Events:\n Spiked to 102.2 after aspiration of tube feeds (only at 10 cc/hr) - pan\n cultured and given tylenol\n INR rising\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Aztreonam - 03:42 AM\n Vancomycin - 09:40 AM\n Levofloxacin - 11:15 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 07:47 AM\n Morphine Sulfate - 05:16 AM\n Other medications:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39\nC (102.2\n Tcurrent: 37.1\nC (98.7\n HR: 129 (86 - 137) bpm\n BP: 102/52(64) {78/26(42) - 155/89(100)} mmHg\n RR: 15 (12 - 65) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,299 mL\n 500 mL\n PO:\n TF:\n 55 mL\n IVF:\n 699 mL\n 500 mL\n Blood products:\n Total out:\n 2,990 mL\n 485 mL\n Urine:\n 2,990 mL\n 485 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,691 mL\n 15 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 513 (328 - 561) mL\n PS : 0 cmH2O\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: Agitated\n PIP: 22 cmH2O\n SpO2: 99%\n ABG: ///26/\n Ve: 6.6 L/min\n Physical Examination\n Labs / Radiology\n 238 K/uL\n 8.4 g/dL\n 106 mg/dL\n 0.9 mg/dL\n 26 mEq/L\n 3.9 mEq/L\n 11 mg/dL\n 108 mEq/L\n 143 mEq/L\n 26.9 %\n 7.2 K/uL\n [image002.jpg]\n 02:43 PM\n 03:03 PM\n 08:11 PM\n 02:51 AM\n 03:10 AM\n 03:08 PM\n 03:00 AM\n 03:36 AM\n 04:40 PM\n 03:00 AM\n WBC\n 9.4\n 11.3\n 7.3\n 6.1\n 7.2\n Hct\n 26.6\n 24.9\n 27.6\n 26.5\n 26.9\n Plt\n 09\n 238\n Cr\n 0.9\n 0.7\n 0.6\n 0.6\n 0.9\n TCO2\n 31\n 30\n 29\n 26\n Glucose\n 128\n 114\n 114\n 99\n 115\n 106\n Other labs: PT / PTT / INR:72.4/42.1/9.0, Ca++:9.3 mg/dL, Mg++:2.5\n mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA, and\n ARDS, intubated since the end of now s/p trach and PEG\n placement.\n # Recent Aspiration of tube feeds. Given prolonged hospitalization and\n tenuous respiratory status will treat with antibiotics while cultures\n pending\n - Levoflox for 48 hours while waiting for sputum results.\n - restart tube feeds slowly\n - Follow cultures\n .\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation. S/P Trach\n and PEG on .\n - wean FiO2 as tolerated\n - attempt wean PS today and hopeful for trach mask trial\n # Sedation: Continue to have issues with pain/delirium causing\n tachycardia and hypertension with intermittent hypotension. On Haldol\n 5 TID, Fentanyl 75 mcg TP, Diazapam 10 QID; Haldol, midazolam and\n morphine PRN. Had good response to morphine, minimal response to\n haldol bolus.\n - Reduce diazepam to 5 q 8hrs.\n - d/c standing Haldol\n # Adrenal Insufficency: Hypotension that resolved with steroids,\n returned as they came off and is now improved again. Possible primary\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\n started on .\n - 10 q am and 5 q pm prednisone day 2 of 3, will wean to\n maintenance dose as tolerated, in consultation with endo.\n # Volume overloaded in setting of hypernatremia\n Goal even today.\n - Off diamox\n - electrolytes\n - Free water flushes with tube feeds.\n # Falling Hct: Likely dilutional. Concern given elevated INR. Stable\n today.\n - monitor\n - maintain active type and screen\n # RUE DVT: INR now therapeutic on coumadin. Goal \n - will start coumadin 2.5 mg QHS once INR < 3\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - Brace for OOB\n - report from full trauma series from OSH is in chart. No evidence of\n other fracture and no need for further spinal imaging based on this\n report and ortho note.\n # Tracheomalacia: Discussed with IP. Stenting unlikely to help for\n trachiomalacia as airways have poor structure diffusely.\n - Outpatient f/u once off pressure support to assess for possible\n stenting\n #. Thyroid Nodule on CT\n -outpatient follow up\n # Nutrition: Replete (Full)\n will reintroduce slowly\n - advance bowel regimen\n # Glycemic control: SSI, well controlled\n # Lines L PICC\n ().\n # Ppx: INR therapeutic, ranitidine, colace and senna, miralax,\n bisacodyl.\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n Code: Full\n Dispo: ICU, being screening for vent facilities\n"},{"category":"Physician ","chartdate":"2167-10-11 00:00:00.000","description":"Physician Resident Progress Note","row_id":636906,"text":"Chief Complaint:\n 24 Hour Events:\n Spiked to 102.2 after aspiration of tube feeds (only at 10 cc/hr) - pan\n cultured and given tylenol\n INR rising\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Aztreonam - 03:42 AM\n Vancomycin - 09:40 AM\n Levofloxacin - 11:15 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 07:47 AM\n Morphine Sulfate - 05:16 AM\n Other medications:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39\nC (102.2\n Tcurrent: 37.1\nC (98.7\n HR: 129 (86 - 137) bpm\n BP: 102/52(64) {78/26(42) - 155/89(100)} mmHg\n RR: 15 (12 - 65) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,299 mL\n 500 mL\n PO:\n TF:\n 55 mL\n IVF:\n 699 mL\n 500 mL\n Blood products:\n Total out:\n 2,990 mL\n 485 mL\n Urine:\n 2,990 mL\n 485 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,691 mL\n 15 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 513 (328 - 561) mL\n PS : 0 cmH2O\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: Agitated\n PIP: 22 cmH2O\n SpO2: 99%\n ABG: ///26/\n Ve: 6.6 L/min\n Physical Examination\n General Appearance: Trached. Interactive. Responsive, following\n commands, Overweight / Obese, mild agitation but NAD\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\n deviation\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Respiratory / Chest: (Expansion: Symmetric), b/l rhonchi R>L, decreased\n BS\n Abdominal: Obese, soft, Non-tender, no rebound, no guarding, + BS, PEG\n in place with dressing C/D/I\n Extremities: no CCE\n Skin: no rashes or jaundice\n Lines: L PICC C/D/I\n Labs / Radiology\n 238 K/uL\n 8.4 g/dL\n 106 mg/dL\n 0.9 mg/dL\n 26 mEq/L\n 3.9 mEq/L\n 11 mg/dL\n 108 mEq/L\n 143 mEq/L\n 26.9 %\n 7.2 K/uL\n [image002.jpg]\n 02:43 PM\n 03:03 PM\n 08:11 PM\n 02:51 AM\n 03:10 AM\n 03:08 PM\n 03:00 AM\n 03:36 AM\n 04:40 PM\n 03:00 AM\n WBC\n 9.4\n 11.3\n 7.3\n 6.1\n 7.2\n Hct\n 26.6\n 24.9\n 27.6\n 26.5\n 26.9\n Plt\n 09\n 238\n Cr\n 0.9\n 0.7\n 0.6\n 0.6\n 0.9\n TCO2\n 31\n 30\n 29\n 26\n Glucose\n 128\n 114\n 114\n 99\n 115\n 106\n Other labs: PT / PTT / INR:72.4/42.1/9.0, Ca++:9.3 mg/dL, Mg++:2.5\n mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA, and\n ARDS, intubated since the end of now s/p trach and PEG\n placement.\n # Recent Aspiration of tube feeds. Given prolonged hospitalization and\n tenuous respiratory status will treat with antibiotics while cultures\n pending\n - Levoflox for 48 hours while waiting for sputum results.\n - hold tube feeds\n - Follow cultures\n - check tube placement\n .\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation. S/P Trach\n and PEG on .\n - wean FiO2 as tolerated\n - attempt wean PS today and hopeful for trach mask trial\n # Sedation: Continue to have issues with pain/delirium causing\n tachycardia and hypertension with intermittent hypotension. On Haldol\n 5 TID, Fentanyl 75 mcg TP, Diazapam 10 QID; Haldol, midazolam and\n morphine PRN. Had good response to morphine, minimal response to\n haldol bolus.\n - tolerating current regimen well, no changes today\n # Adrenal Insufficency: Hypotension that resolved with steroids,\n returned as they came off and is now improved again. Possible primary\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\n started on .\n - stopped steroids as per endocrine today\n # Volume overloaded in setting of hypernatremia\n Goal even today.\n - monitor urine output\n # RUE DVT: INR super-therapeutic on coumadin. Goal . Hasn\n received coumadin in days yet INR continues to rise. Likely\n contributors are nutritional and antibiotics.\n - will start coumadin 2.5 mg QHS once INR < 3\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - Brace for OOB\n - report from full trauma series from OSH is in chart. No evidence of\n other fracture and no need for further spinal imaging based on this\n report and ortho note.\n # Tracheomalacia: Discussed with IP. Stenting unlikely to help for\n trachiomalacia as airways have poor structure diffusely.\n - Outpatient f/u once off pressure support to assess for possible\n stenting\n #. Thyroid Nodule on CT\n -outpatient follow up\n # Nutrition: Replete (Full)\n hold\n # Glycemic control: SSI, well controlled\n # Lines L PICC\n ().\n # Ppx: INR therapeutic, ranitidine, colace and senna, miralax,\n bisacodyl.\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n Code: Full\n Dispo: ICU, being screening for vent facilities\n"},{"category":"Physician ","chartdate":"2167-10-09 00:00:00.000","description":"Physician Resident Progress Note","row_id":636576,"text":"Chief Complaint:\n 24 Hour Events:\n Arterial line d/c'd\n Spiked a fever of 101.4, blood and urine cultures sent, CXR. Started\n Vanc, Levo, Aztreonam\n Persistently hypotensive to 70s SBP overnight with low urine output and\n poor O2 sats.\n Started on Levophed, and given 1.75L NS. BPs improved to 90-120s SBP,\n and urine output increased significantly.\n Large amount of oral secretions, ?gastric in origin\n Tube feeds held for ? of aspiration.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 11:00 PM\n Levofloxacin - 11:43 PM\n Aztreonam - 04:07 AM\n Infusions:\n Norepinephrine\n Off at 7:30 AM\n Other ICU medications:\n Midazolam (Versed) - 09:30 AM\n Morphine Sulfate - 03:17 PM\n Furosemide (Lasix) - 06:36 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.4\n Tcurrent: 36.7\nC (98.1\n HR: 131 (73 - 142) bpm\n BP: 127/43(60) {71/29(42) - 137/97(101)} mmHg\n RR: 21 (12 - 36) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 4,627 mL\n 1,084 mL\n PO:\n TF:\n 839 mL\n IVF:\n 2,288 mL\n 1,084 mL\n Blood products:\n Total out:\n 2,407 mL\n 2,220 mL\n Urine:\n 2,407 mL\n 2,220 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,220 mL\n -1,136 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 412 (236 - 480) mL\n PS : 8 cmH2O\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI: 126\n PIP: 21 cmH2O\n Plateau: 17 cmH2O\n Compliance: 44.4 cmH2O/mL\n SpO2: 97%\n ABG: 7.35/50/81./26/0\n Ve: 7 L/min\n PaO2 / FiO2: 162\n Physical Examination\n General Appearance: Trached and sedated. Responsive, following\n commands, Overweight / Obese, mild agitation but NAD\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\n deviation\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Respiratory / Chest: (Expansion: Symmetric), CTA anteriorly, decreased\n BS\n Abdominal: Obese, soft, Non-tender, no rebound, no guarding, + BS, PEG\n in place with dressing C/D/I\n Extremities: no CCE\n Skin: no rashes or jaundice\n Lines: r brachioceph ART with large amount of bloody drainage and L\n PICC C/D/I\n Labs / Radiology\n 227 K/uL\n 7.7 g/dL\n 114 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 4.0 mEq/L\n 16 mg/dL\n 112 mEq/L\n 145 mEq/L\n 24.9 %\n 11.3 K/uL\n [image002.jpg]\n 03:46 AM\n 10:20 AM\n 03:46 PM\n 01:37 AM\n 05:32 AM\n 02:43 PM\n 03:03 PM\n 08:11 PM\n 02:51 AM\n 03:10 AM\n WBC\n 11.1\n 9.4\n 11.3\n Hct\n 29.4\n 26.6\n 24.9\n Plt\n \n Cr\n 0.8\n 0.6\n 0.9\n 0.7\n TCO2\n 35\n 37\n 31\n 31\n 30\n 29\n Glucose\n 155\n 123\n 128\n 114\n 114\n Other labs: PT / PTT / INR:37.2/37.9/4.0, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Lactic Acid:0.5 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:8.7 mg/dL, Mg++:2.6 mg/dL, PO4:4.2 mg/dL\n Blood/Urine/Sputum culture pending\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA, and\n ARDS, intubated since the end of now s/p trach and PEG\n placement.\n # Fever: Likely secondary to aspiration pneumonitis. Given prolonged\n hospitalization and tenuous respiratory status will treat with\n antibiotics while cultures pending\n - Vanc/Cef/Azithro for 48 hours while waiting for sputum results.\n - Hold tube feeds for 24 hours\n - Follow cultures\n - Off levophed\n .\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation. S/P Trach\n and PEG on .\n - wean FiO2 as tolerated\n - attempt wean PS today and hopeful for trach mask trial\n # Sedation: Continue to have issues with pain/delirium causing\n tachycardia and hypertension with intermittent hypotension. On Haldol\n 5 TID, Fentanyl 75 mcg TP, Diazapam 10 QID; Haldol, midazolam and\n morphine PRN. Had good response to morphine, minimal response to\n haldol bolus.\n - Reduce diazepam to 5 q 8hrs.\n - d/c standing Haldol\n # Adrenal Insufficency: Hypotension that resolved with steroids,\n returned as they came off and is now improved again. Possible primary\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\n started on .\n - 10 q am and 5 q pm prednisone day 2 of 3, will wean to\n maintenance dose as tolerated, in consultation with endo.\n # Volume overloaded in setting of hypernatremia with TBW deficit and\n metabolic alkalosis\n - Goal of even in the setting of recent hypotension.\n - Off diamox\n - electrolytes\n - Will give IV free water rather than flushes. D5W 1L@100 cc/hr\n # Falling Hct: Likely dilutional. Concern given elevated INR\n - Recheck in PM\n - Type and screen\n # RUE DVT: INR now therapeutic on coumadin. Goal \n - stop heparin gtt\n - will start coumadin 2.5 mg QHS once INR < 3\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - Brace for OOB\n - report from full trauma series from OSH is in chart. No evidence of\n other fracture and no need for further spinal imaging based on this\n report and ortho note.\n # Tracheomalacia: Discussed with IP. Stenting unlikely to help for\n trachiomalacia as airways have poor structure diffusely.\n - Outpatient f/u once off pressure support to assess for possible\n stenting\n #. Thyroid Nodule on CT\n -outpatient follow up\n # Nutrition: Hold tube feeds x 24 hours, continue Replete (Full)\n will reintroduce slowly\n - advance bowel regimen\n # Glycemic control: SSI, well controlled\n # Lines L PICC (). ABG and VBG correlate well.\n # Ppx: INR therapeutic, ranitidine, colace and senna, miralax,\n bisacodyl.\n # Communication:\n - Boyfriend of 10 \n - Brother is her HCP, also involved\n Code: Full\n Dispo: ICU, being screening for vent facilities\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n 18 Gauge - 08:15 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2167-10-11 00:00:00.000","description":"Physician Resident Progress Note","row_id":636884,"text":"Chief Complaint:\n 24 Hour Events:\n Spiked to 102.2 after aspiration of tube feeds (only at 10 cc/hr) - pan\n cultured and given tylenol\n INR rising\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Aztreonam - 03:42 AM\n Vancomycin - 09:40 AM\n Levofloxacin - 11:15 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 07:47 AM\n Morphine Sulfate - 05:16 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39\nC (102.2\n Tcurrent: 37.1\nC (98.7\n HR: 129 (86 - 137) bpm\n BP: 102/52(64) {78/26(42) - 155/89(100)} mmHg\n RR: 15 (12 - 65) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,299 mL\n 500 mL\n PO:\n TF:\n 55 mL\n IVF:\n 699 mL\n 500 mL\n Blood products:\n Total out:\n 2,990 mL\n 485 mL\n Urine:\n 2,990 mL\n 485 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,691 mL\n 15 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 513 (328 - 561) mL\n PS : 0 cmH2O\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: Agitated\n PIP: 22 cmH2O\n SpO2: 99%\n ABG: ///26/\n Ve: 6.6 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 238 K/uL\n 8.4 g/dL\n 106 mg/dL\n 0.9 mg/dL\n 26 mEq/L\n 3.9 mEq/L\n 11 mg/dL\n 108 mEq/L\n 143 mEq/L\n 26.9 %\n 7.2 K/uL\n [image002.jpg]\n 02:43 PM\n 03:03 PM\n 08:11 PM\n 02:51 AM\n 03:10 AM\n 03:08 PM\n 03:00 AM\n 03:36 AM\n 04:40 PM\n 03:00 AM\n WBC\n 9.4\n 11.3\n 7.3\n 6.1\n 7.2\n Hct\n 26.6\n 24.9\n 27.6\n 26.5\n 26.9\n Plt\n 09\n 238\n Cr\n 0.9\n 0.7\n 0.6\n 0.6\n 0.9\n TCO2\n 31\n 30\n 29\n 26\n Glucose\n 128\n 114\n 114\n 99\n 115\n 106\n Other labs: PT / PTT / INR:72.4/42.1/9.0, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Lactic Acid:0.5 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:9.3 mg/dL, Mg++:2.5 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA, and\n ARDS, intubated since the end of now s/p trach and PEG\n placement.\n # Recent Aspiration of tube feeds. Given prolonged hospitalization and\n tenuous respiratory status will treat with antibiotics while cultures\n pending\n - Levoflox for 48 hours while waiting for sputum results.\n - restart tube feeds slowly\n - Follow cultures\n .\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation. S/P Trach\n and PEG on .\n - wean FiO2 as tolerated\n - attempt wean PS today and hopeful for trach mask trial\n # Sedation: Continue to have issues with pain/delirium causing\n tachycardia and hypertension with intermittent hypotension. On Haldol\n 5 TID, Fentanyl 75 mcg TP, Diazapam 10 QID; Haldol, midazolam and\n morphine PRN. Had good response to morphine, minimal response to\n haldol bolus.\n - Reduce diazepam to 5 q 8hrs.\n - d/c standing Haldol\n # Adrenal Insufficency: Hypotension that resolved with steroids,\n returned as they came off and is now improved again. Possible primary\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\n started on .\n - 10 q am and 5 q pm prednisone day 2 of 3, will wean to\n maintenance dose as tolerated, in consultation with endo.\n # Volume overloaded in setting of hypernatremia\n Goal even today.\n - Off diamox\n - electrolytes\n - Free water flushes with tube feeds.\n # Falling Hct: Likely dilutional. Concern given elevated INR. Stable\n today.\n - monitor\n - maintain active type and screen\n # RUE DVT: INR now therapeutic on coumadin. Goal \n - will start coumadin 2.5 mg QHS once INR < 3\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - Brace for OOB\n - report from full trauma series from OSH is in chart. No evidence of\n other fracture and no need for further spinal imaging based on this\n report and ortho note.\n # Tracheomalacia: Discussed with IP. Stenting unlikely to help for\n trachiomalacia as airways have poor structure diffusely.\n - Outpatient f/u once off pressure support to assess for possible\n stenting\n #. Thyroid Nodule on CT\n -outpatient follow up\n # Nutrition: Replete (Full)\n will reintroduce slowly\n - advance bowel regimen\n # Glycemic control: SSI, well controlled\n # Lines L PICC\n ().\n # Ppx: INR therapeutic, ranitidine, colace and senna, miralax,\n bisacodyl.\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n Code: Full\n Dispo: ICU, being screening for vent facilities\n"},{"category":"Nursing","chartdate":"2167-10-12 00:00:00.000","description":"Nursing Progress Note","row_id":637037,"text":"56 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\n with prolonged hospital course c/b by PNA, anxiety/altered mental\n status, RUE DVT .\n Events\n stim test performed. TF restarted. INR down to 1.6 from 9\n ( pt given vit K yesterday)\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on PSV 10/5/50%. RR 20-30. )2 sat > 97%\n Action:\n Pt remained on PSV rather than AC overnight. Suctioned ~q 3-4 hrs for\n sm amt yellow bld-tinged secretions. Continues to have copious oral\n secretions\n removed with yankeur.\n Response:\n Tolerated PSV well, no tachypnea or desaturation.\n Plan:\n Attempt trach collar trial again in am. On-going pulm hygiene\n Hypotension (not Shock)\n Assessment:\n BP 90/40 with urine output falling to 10-15ccs/hr via foley. HR remains\n tachycardic (110-140ST) even when pt is not agitated or febrile.\n Action:\n Given 1 500cc d5\n ns fluid bolus\n Response:\n SBP > 90, Urine output improving to >30ccs/hr\n Plan:\n Continue to monitor hemodynamic status and f+e balance.\n Altered mental status (not Delirium)\n Assessment:\n Pt lethargic after receiving benedryl for several hrs but then awoke\n agitated, attempting to climb OOB and pull at trach despite restraints.\n Denies pain ( fentanyl patch in place) or need to go to the bathroom.\n c/o itchiness on back secondary to rash.\n Action:\n Medicated with iv benedryl.\n Response:\n Less agitated. Slept again for a few hours.\n Plan:\n Continue to reorient pt, benedryl for pruritis, safety precautions.\n Alteration in Nutrition\n Assessment:\n Pt with previous episodes of vomiting last eve. Kub showed no evidence\n of obstruction. Na 146\n Action:\n TF initiated with 50ccs free h20 boluses q 4hrs\n Response:\n No nausea or vomiting. No residuals.\n Plan:\n Advance TF as tolerated. ? increase free h20 boluses for hypernatremia.\n"},{"category":"Physician ","chartdate":"2167-09-28 00:00:00.000","description":"Physician Resident / Attending Progress Note - MIC","row_id":634984,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n PICC placed, Central line d/c'd\n Lasix 10 mg given with 400 cc UOP in afternoon, pH improved\n Lasix 20 mg given at ~ 4AM.\n Lots of thick sinus secreations\n Delerium/anxiety overnight with periods of hypertension.\n Could not draw of A-line.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Aztreonam - 06:00 AM\n Vancomycin - 09:00 AM\n Levofloxacin - 08:06 AM\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Fentanyl - 150 mcg/hour\n Heparin Sodium - 1,700 units/hour\n Other ICU medications:\n Furosemide (Lasix) - 03:01 AM\n Midazolam (Versed) - 04:36 AM\n Fentanyl - 04:36 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36.4\nC (97.6\n HR: 90 (47 - 92) bpm\n BP: 118/59(80) {80/40(53) - 137/105(111)} mmHg\n RR: 17 (15 - 24) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101 kg (admission): 94.2 kg\n Height: 67 Inch\n CVP: 19 (16 - 19)mmHg\n Total In:\n 2,560 mL\n 543 mL\n PO:\n TF:\n 1,441 mL\n 342 mL\n IVF:\n 1,020 mL\n 201 mL\n Blood products:\n Total out:\n 1,680 mL\n 860 mL\n Urine:\n 1,680 mL\n 860 mL\n NG:\n Stool:\n Drains:\n Balance:\n 880 mL\n -317 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 15 cmH2O\n FiO2: 50%\n PIP: 27 cmH2O\n Plateau: 23 cmH2O\n SpO2: 98%\n ABG: 7.41/45/77./28/2\n Ve: 6.5 L/min\n PaO2 / FiO2: 156\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese, opens eyes\n but no purposeful movement\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric)\n Abdominal: No(t) Soft, Non-tender, Bowel sounds present, Distended\n Extremities: No clubbing or cyanosis, 3+ nonpitting edema of b/l hands,\n LE without edema\n Skin: no rashes or jaundice\n Labs / Radiology\n 411 K/uL\n 8.3 g/dL\n 133 mg/dL\n 0.5 mg/dL\n 28 mEq/L\n 4.1 mEq/L\n 13 mg/dL\n 111 mEq/L\n 145 mEq/L\n 26.0 %\n 9.7 K/uL\n [image002.jpg]\n 04:05 PM\n 01:12 AM\n 04:00 AM\n 04:09 AM\n 10:18 AM\n 02:33 PM\n 02:46 PM\n 03:31 AM\n 02:26 PM\n 05:53 PM\n WBC\n 9.6\n 9.7\n Hct\n 27.8\n 26.0\n Plt\n 374\n 411\n Cr\n 0.5\n 0.5\n 0.5\n 0.5\n TCO2\n 26\n 27\n 28\n 29\n 26\n 27\n 30\n Glucose\n 194\n 195\n 195\n 163\n 133\n Other labs: PT / PTT / INR:15.3/69.9/1.3, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:86.1 %, Lymph:10.3 %,\n Mono:2.8 %, Eos:0.5 %, Lactic Acid:2.0 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:8.3 mg/dL, Mg++:2.2 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with respiratory failure\n and difficulty weaning from vent.\n # Respiratory failure: Intubated on for resp decompensation.\n Likely VAP. Transferred here for tracheomalacia, but not sure this\n is a component. Will need bronch eval when improved\n - will discuss PEEP goal for trach placement with IP.\n - wean PEEP\n - repeat ABG this AM\n - discuss need for trach with patient and her family\n - Volume overload may be contributing.\n # Volume overload\n Currently with hypernatremia, Cr increase, contract\n alk, but mild\n - continue gentle diuresis\n - FW in TF at 150 cc q4hrs\n - PM lytes.\n # Sedation: On versed 3mg/hr + .5 q 1hr and fentanyl 150 mcg/hr + 50\n bolus q 1hr.\n - Start fentanyl patch and diazepam to provide long acting analgesia\n and wean from drips\n - Haldol 1 mg Q4h PRN agitation\n # Pneumonia: Pansensitive Kleb oxytoca pneumonia and sputum with GPCs\n on gram stain. Afebrile off abx.\n # EKG changes: Sinus bradycardia, responsive to stress. Related to\n sedation, increased vagal tone, possibly related to steroid\n replacement. Atrial EKG shows p-waves and cardiac enzymes normal.\n - Continue to monitor\n # Hypotension: Improved, off levophed for 2-3 days now, with good urine\n output. s/p 5 d course of steroids for adrenal insufficiency. High\n PEEP may have been contributing. Now likely related to sedation and\n decreased intravascular volume,\n -monitor, expect improvement with continual reduction in\n PEEP\n # RUE DVT: Started on heparin gtt on , now therapeutic. Follow\n PTTs. Would hold off on coumadin at least until s/p trach.\n - continue to monitor\n # Adrenal Insufficency: Random cortisol was approx 3 when it should\n have been maximally stimulated.\n - hydrocortisone and florinef for 5 days\n # Anemia: Stable.\n - Trend HCT\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n FEN/GI: Tube feeds @ goal\n DVT: Treatment dose heparin\n Ulcer: Ranitidine\n VAP: Prevention per routine\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 08:12 PM 60 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 04:00 PM\n PICC Line - 09:19 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 55F T5-8 fractures with retropulsion and ARDS\n from VAP; on heparin for UE DVT.\n Exam notable for Tm 97.5 BP 90/45 HR 67 RR with sat 95 on VAC 400x18\n PEEP 15 FiO2 0.5 for 7.41/45/78. Eyes opens, will squeeze hands and\n wiggle toes but very drowsy. Bronchial BS bilaterally with RRR s1s2 \n SM at base. Abdomen is mildly distended with decreased BS. 3+ edema in\n BLE, no cords. Labs notable for WBC 9K, HCT 26, K+ 4.1, Cr 0.5. CXR\n with resolving B LL airspace disease and effusions.\n Agree with plan to start fentanyl patch and po valium and wean IV\n sedation while slowly coming down on PEEP. Will start gentle IV lasix\n (drip or bolus) to affect a negative fluid balance and use haldol for\n breakthrough agitiation. In addition, we will continue IV heparin for\n UE DVT; consider transition to coumadin only after tracheostomy and\n feeding tube placement, which will require lower ventilator settings.\n Will ask IP to reevaluate today, given need for tracheostomy and\n possible tracheobronchomalacia. Continue spinal stabilization with\n brace when OOB; will eventually need MRI for surgical planning.\n Continue TF; remainder of plan as outlined above.\n Patient is critically ill\n Total time: 40 min\n ------ Protected Section Addendum Entered By: , MD\n on: 01:45 PM ------\n"},{"category":"Nursing","chartdate":"2167-09-29 00:00:00.000","description":"Nursing Progress Note","row_id":635035,"text":"Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n RUE edematous, warm, red\n Action:\n Heparin gtt WNL\n Response:\n No change\n Plan:\n Heparin off at 0600 for procedure\n Altered mental status (not Delirium)\n Assessment:\n Periods of agitation\n Action:\n Fentanyl and Versed Gtt, haldol and valium started. Fentanyl patch\n Response:\n Calm with increased sedation needed\n Plan:\n Monitor, continue with sedation as tolerates.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt desatted to 87%\n Action:\n Peep increased\n Response:\n O2 sat improved\n Plan:\n Team to attempt to replace aline or will draw am abg. AM RSBI\n Hypotension (not Shock)\n Assessment:\n Sbp 70\n Action:\n Sedation weaned, but pt agitated\n Response:\n Sbp > 90\n Plan:\n Maintain sbp > 90 with adequate sedation\n Bradycardia\n Assessment:\n HR 50\ns with increased sedation\n Action:\n Sedation weaned, but pt agitated\n Response:\n HR 70-130\ns, with decreased sedation\n Plan:\n Maintain sedation, monitor hr\n"},{"category":"Physician ","chartdate":"2167-10-10 00:00:00.000","description":"Physician Resident Progress Note","row_id":636651,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n Discussed imaging with ortho. They do not need further imaging. She\n should wear TLSO for 2 months and f/u with at 2 months\n prior to removal of TLSO.\n Changed to PSV, was stable on trach mask for 1-2 hrs\n Tube feeds held\n Endo recs: check AM cortisol prior to dose\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 10:04 PM\n Levofloxacin - 10:49 PM\n Aztreonam - 03:42 AM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 10:49 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.7\nC (98\n HR: 125 (74 - 151) bpm\n BP: 121/64(77) {89/32(45) - 179/99(120)} mmHg\n RR: 20 (13 - 30) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 5,817 mL\n 457 mL\n PO:\n TF:\n IVF:\n 5,277 mL\n 327 mL\n Blood products:\n Total out:\n 5,205 mL\n 1,460 mL\n Urine:\n 5,205 mL\n 1,460 mL\n NG:\n Stool:\n Drains:\n Balance:\n 612 mL\n -1,003 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 429 (340 - 480) mL\n PS : 8 cmH2O\n RR (Set): 0\n RR (Spontaneous): 25\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 13 cmH2O\n SpO2: 100%\n ABG: 7.37/44/120/25/0\n Ve: 6.3 L/min\n PaO2 / FiO2: 240\n Physical Examination\n General Appearance: Trached and sedated. Responsive, following\n commands, Overweight / Obese, mild agitation but NAD\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\n deviation\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Respiratory / Chest: (Expansion: Symmetric), CTA anteriorly, decreased\n BS\n Abdominal: Obese, soft, Non-tender, no rebound, no guarding, + BS, PEG\n in place with dressing C/D/I\n Extremities: no CCE\n Skin: no rashes or jaundice\n Lines: r brachioceph ART with large amount of bloody drainage and L\n PICC C/D/I\n Labs / Radiology\n 209 K/uL\n 8.3 g/dL\n 99 mg/dL\n 0.6 mg/dL\n 25 mEq/L\n 4.3 mEq/L\n 9 mg/dL\n 111 mEq/L\n 145 mEq/L\n 26.5 %\n 6.1 K/uL\n [image002.jpg]\n 01:37 AM\n 05:32 AM\n 02:43 PM\n 03:03 PM\n 08:11 PM\n 02:51 AM\n 03:10 AM\n 03:08 PM\n 03:00 AM\n 03:36 AM\n WBC\n 11.1\n 9.4\n 11.3\n 7.3\n 6.1\n Hct\n 29.4\n 26.6\n 24.9\n 27.6\n 26.5\n Plt\n 89\n 209\n Cr\n 0.6\n 0.9\n 0.7\n 0.6\n TCO2\n 31\n 31\n 30\n 29\n 26\n Glucose\n 123\n 128\n 114\n 114\n 99\n Other labs: PT / PTT / INR:40.1/40.7/4.4, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Lactic Acid:0.5 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:8.9 mg/dL, Mg++:2.6 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA, and\n ARDS, intubated since the end of now s/p trach and PEG\n placement.\n # Fever: Likely secondary to aspiration pneumonitis. Given prolonged\n hospitalization and tenuous respiratory status will treat with\n antibiotics while cultures pending\n - Vanc/Cef/Azithro for 48 hours while waiting for sputum results.\n - Hold tube feeds for 24 hours\n - Follow cultures\n - Off levophed\n .\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation. S/P Trach\n and PEG on .\n - wean FiO2 as tolerated\n - attempt wean PS today and hopeful for trach mask trial\n # Sedation: Continue to have issues with pain/delirium causing\n tachycardia and hypertension with intermittent hypotension. On Haldol\n 5 TID, Fentanyl 75 mcg TP, Diazapam 10 QID; Haldol, midazolam and\n morphine PRN. Had good response to morphine, minimal response to\n haldol bolus.\n - Reduce diazepam to 5 q 8hrs.\n - d/c standing Haldol\n # Adrenal Insufficency: Hypotension that resolved with steroids,\n returned as they came off and is now improved again. Possible primary\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\n started on .\n - 10 q am and 5 q pm prednisone day 2 of 3, will wean to\n maintenance dose as tolerated, in consultation with endo.\n # Volume overloaded in setting of hypernatremia with TBW deficit and\n metabolic alkalosis\n - Goal of even in the setting of recent hypotension.\n - Off diamox\n - electrolytes\n - Will give IV free water rather than flushes. D5W 1L@100 cc/hr\n # Falling Hct: Likely dilutional. Concern given elevated INR\n - Recheck in PM\n - Type and screen\n # RUE DVT: INR now therapeutic on coumadin. Goal \n - stop heparin gtt\n - will start coumadin 2.5 mg QHS once INR < 3\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - Brace for OOB\n - report from full trauma series from OSH is in chart. No evidence of\n other fracture and no need for further spinal imaging based on this\n report and ortho note.\n # Tracheomalacia: Discussed with IP. Stenting unlikely to help for\n trachiomalacia as airways have poor structure diffusely.\n - Outpatient f/u once off pressure support to assess for possible\n stenting\n #. Thyroid Nodule on CT\n -outpatient follow up\n # Nutrition: Hold tube feeds x 24 hours, continue Replete (Full)\n will reintroduce slowly\n - advance bowel regimen\n # Glycemic control: SSI, well controlled\n # Lines L PICC (). ABG and VBG correlate well.\n # Ppx: INR therapeutic, ranitidine, colace and senna, miralax,\n bisacodyl.\n # Communication:\n - Boyfriend of 10 \n - Brother is her HCP, also involved\n Code: Full\n Dispo: ICU, being screening for vent facilities\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n 18 Gauge - 08:15 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Respiratory ","chartdate":"2167-10-10 00:00:00.000","description":"Respiratory Care Shift Note","row_id":636655,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 22\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason:\n Tube Type\n Tracheostomy tube:\n Type: Cuffed\n Manufacturer: Portex\n Size: 7.0mm\n PMV: No\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Periodic SBT's for conditioning, Adjust Min. ventilation to control pH,\n Increase ventilatory support at night; Comments: During RSBI trial,\n ptwould not breathe in normal pattern, very deep but slow breaths\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Cannot protect airway, Underlying illness not\n resolved\n"},{"category":"Physician ","chartdate":"2167-10-10 00:00:00.000","description":"Physician Resident Progress Note","row_id":636749,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n Discussed imaging with ortho. They do not need further imaging. She\n should wear TLSO for 2 months and f/u with at 2 months\n prior to removal of TLSO.\n Changed to PSV, was stable on trach mask for 1-2 hrs\n Tube feeds held\n Endo recs: check AM cortisol prior to dose\n At 5:45 am --- RR 4, switched from CPAP/PSV to AC\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 10:04 PM\n Levofloxacin - 10:49 PM\n Aztreonam - 03:42 AM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 10:49 PM\n Other medications:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.7\nC (98\n HR: 125 (74 - 151) bpm\n BP: 121/64(77) {89/32(45) - 179/99(120)} mmHg\n RR: 20 (13 - 30) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 5,817 mL\n 457 mL\n PO:\n TF:\n IVF:\n 5,277 mL\n 327 mL\n Blood products:\n Total out:\n 5,205 mL\n 1,460 mL\n Urine:\n 5,205 mL\n 1,460 mL\n NG:\n Stool:\n Drains:\n Balance:\n 612 mL\n -1,003 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 429 (340 - 480) mL\n PS : 8 cmH2O\n RR (Set): 0\n RR (Spontaneous): 25\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 13 cmH2O\n SpO2: 100%\n ABG: 7.37/44/120/25/0\n Ve: 6.3 L/min\n PaO2 / FiO2: 240\n Physical Examination\n On CMV\n Peep 5, FiO2 40%, Vt 500, R 14\n General Appearance: Trached and sedated. Responsive, following\n commands, Overweight / Obese, mild agitation but NAD\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\n deviation\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Respiratory / Chest: (Expansion: Symmetric), CTA anteriorly, decreased\n BS\n Abdominal: Obese, soft, Non-tender, no rebound, no guarding, + BS, PEG\n in place with dressing C/D/I\n Extremities: no CCE\n Skin: no rashes or jaundice\n Lines: L PICC C/D/I\n Labs / Radiology\n 209 K/uL\n 8.3 g/dL\n 99 mg/dL\n 0.6 mg/dL\n 25 mEq/L\n 4.3 mEq/L\n 9 mg/dL\n 111 mEq/L\n 145 mEq/L\n 26.5 %\n 6.1 K/uL\n [image002.jpg]\n 01:37 AM\n 05:32 AM\n 02:43 PM\n 03:03 PM\n 08:11 PM\n 02:51 AM\n 03:10 AM\n 03:08 PM\n 03:00 AM\n 03:36 AM\n WBC\n 11.1\n 9.4\n 11.3\n 7.3\n 6.1\n Hct\n 29.4\n 26.6\n 24.9\n 27.6\n 26.5\n Plt\n 89\n 209\n Cr\n 0.6\n 0.9\n 0.7\n 0.6\n TCO2\n 31\n 31\n 30\n 29\n 26\n Glucose\n 123\n 128\n 114\n 114\n 99\n Other labs: PT / PTT / INR:36.4/38.8/3.9, Ca++:8.9 mg/dL, Mg++:2.6\n mg/dL, PO4:4.1 mg/dL\n Cx: endotrach \n GN diplococci, budding yeast\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA, and\n ARDS, intubated since the end of now s/p trach and PEG\n placement.\n # Recent Aspiration of tube feeds. Given prolonged hospitalization and\n tenuous respiratory status will treat with antibiotics while cultures\n pending\n - Levoflox for 48 hours while waiting for sputum results.\n - restart tube feeds slowly\n - Follow cultures\n .\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation. S/P Trach\n and PEG on .\n - wean FiO2 as tolerated\n - attempt wean PS today and hopeful for trach mask trial\n # Sedation: Continue to have issues with pain/delirium causing\n tachycardia and hypertension with intermittent hypotension. On Haldol\n 5 TID, Fentanyl 75 mcg TP, Diazapam 10 QID; Haldol, midazolam and\n morphine PRN. Had good response to morphine, minimal response to\n haldol bolus.\n - Reduce diazepam to 5 q 8hrs.\n - d/c standing Haldol\n # Adrenal Insufficency: Hypotension that resolved with steroids,\n returned as they came off and is now improved again. Possible primary\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\n started on .\n - 10 q am and 5 q pm prednisone day 2 of 3, will wean to\n maintenance dose as tolerated, in consultation with endo.\n # Volume overloaded in setting of hypernatremia\n Goal even today.\n - Off diamox\n - electrolytes\n - Free water flushes with tube feeds.\n # Falling Hct: Likely dilutional. Concern given elevated INR. Stable\n today.\n - monitor\n - maintain active type and screen\n # RUE DVT: INR now therapeutic on coumadin. Goal \n - will start coumadin 2.5 mg QHS once INR < 3\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - Brace for OOB\n - report from full trauma series from OSH is in chart. No evidence of\n other fracture and no need for further spinal imaging based on this\n report and ortho note.\n # Tracheomalacia: Discussed with IP. Stenting unlikely to help for\n trachiomalacia as airways have poor structure diffusely.\n - Outpatient f/u once off pressure support to assess for possible\n stenting\n #. Thyroid Nodule on CT\n -outpatient follow up\n # Nutrition: Replete (Full)\n will reintroduce slowly\n - advance bowel regimen\n # Glycemic control: SSI, well controlled\n # Lines L PICC ().\n # Ppx: INR therapeutic, ranitidine, colace and senna, miralax,\n bisacodyl.\n # Communication:\n - Boyfriend of 10 \n - Brother is her HCP, also involved\n Code: Full\n Dispo: ICU, being screening for vent facilities\n"},{"category":"Nursing","chartdate":"2167-10-11 00:00:00.000","description":"Nursing Progress Note","row_id":636873,"text":"Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on trach collar 50%. Sats fell to 78%. Pt ambu\nd and\n lavaged with no plugs detected. RR 30-40 . Pt diaphoretic.\n Action:\n Placed on PSV 10/5/50%\n Response:\n Apneic with RR 3-5\n Plan:\n Rested on AC 500/12/5/50%. No further episodes of desating or\n tachypnea.\n Hypotension (not Shock)\n Assessment:\n BP falling to 78/37. Urine output 5-30ccs/hr via foley\n Action:\n Given 500ccs\n NS fluid bolus\n Response:\n Pt normotensive, improved urine output\n Plan:\n Continue to monitor.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Temp spike to 102.2 po\n Action:\n Blood, urine and sputum cxs sent. Sputum white, not yellow or\n consistant with TF. Chest x-ray taken. Tylenol pr given. Cool cloths\n applied.\n Response:\n Pt normothermic. WBC 7.2\n Plan:\n Monitor fever curve, cooling measures. Follow-up on cx results.\n Alteration in Nutrition\n Assessment:\n Pt vomiting yellow fluid with coughing and when turned\n Action:\n TF held. Peg to gravity. Medicated with 4 mg zofran iv.\n Response:\n No further episodes of vomiting.\n Plan:\n Continue to monitor. Aspiration precautions. ? need for alternative\n form of nutrition.\n Altered mental status (not Delirium)\n Assessment:\n Onset of shift, pt lethargic, not following commands but MAE. ~ 12 mn\n pt agitated, attempting to climb oob, disconnecting self from vent\n despite restraints\n Action:\n 5 mg valium given q 8hrs. Haldol 2.5 mg given.\n Response:\n Pt still agitated\n Plan:\n Needs better sedation at bedtime - ? zyprexa or alternative med\n Addendum\n PT and INR rising to 72.4 and 9.0 ( venipuncture, not drawn\n from PIC ). MD notified. No intervention at this time.\n"},{"category":"Physician ","chartdate":"2167-10-12 00:00:00.000","description":"Physician Attending Progress Note","row_id":637162,"text":"Chief Complaint: resp failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n rash- vesicular and d/c l;evoquin and started Ceftriaxone\n More tachycardic this AM - autonomic dysregulation\n Trach Mask for several hours\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Aztreonam - 03:42 AM\n Vancomycin - 09:40 AM\n Levofloxacin - 11:15 PM\n Ceftriaxone - 07:50 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 09:45 AM\n Haloperidol (Haldol) - 10:26 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 36.9\nC (98.5\n HR: 143 (113 - 145) bpm\n BP: 153/89(102) {85/40(50) - 153/89(102)} mmHg\n RR: 24 (9 - 30) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,362 mL\n 537 mL\n PO:\n TF:\n 47 mL\n 287 mL\n IVF:\n 1,061 mL\n 100 mL\n Blood products:\n Total out:\n 1,203 mL\n 615 mL\n Urine:\n 1,203 mL\n 615 mL\n NG:\n Stool:\n Drains:\n Balance:\n 159 mL\n -78 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Set): 0 (0 - 0) mL\n Vt (Spontaneous): 244 (110 - 504) mL\n PS : 10 cmH2O\n RR (Set): 0\n RR (Spontaneous): 19\n PEEP: 5 cmH2O\n FiO2: 70%\n RSBI: 245\n PIP: 16 cmH2O\n SpO2: 98%\n ABG: ///30/\n Ve: 10 L/min\n Physical Examination\n Gen sitting up in , on trach mask, interactive\n CV tachy RRR\n Chest good movement ANT\n Abd soft NT + NS\n Ext: no edema\n Neuroalert follows simple commands\n Labs / Radiology\n 7.9 g/dL\n 240 K/uL\n 100 mg/dL\n 0.6 mg/dL\n 30 mEq/L\n 3.4 mEq/L\n 12 mg/dL\n 108 mEq/L\n 146 mEq/L\n 26.0 %\n 5.2 K/uL\n [image002.jpg]\n 08:11 PM\n 02:51 AM\n 03:10 AM\n 03:08 PM\n 03:00 AM\n 03:36 AM\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n WBC\n 9.4\n 11.3\n 7.3\n 6.1\n 7.2\n 5.2\n Hct\n 26.6\n 24.9\n 27.6\n 26.5\n 26.9\n 26.0\n Plt\n \n Cr\n 0.9\n 0.7\n 0.6\n 0.6\n 0.9\n 0.7\n 0.6\n TCO2\n 29\n 26\n Glucose\n 128\n 114\n 114\n 99\n 115\n 106\n 100\n Other labs: PT / PTT / INR:17.6/27.4/1.6, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:33/22, Alk Phos / T Bili:143/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:0.5 mmol/L,\n Albumin:3.5 g/dL, LDH:199 IU/L, Ca++:8.9 mg/dL, Mg++:2.4 mg/dL, PO4:4.1\n mg/dL\n Assessment and Plan 55 yr old alcoholic s/p t spine fx s/p trcah and\n PEG with persistent resp failure\n 1. Resp Failure: currently on trach mask, can do a few hours per\n day, then needs for support. New pan Klebs in sputum, day\n . Get Speech consult for PMV evaluation. Holding off on stent by IP\n until after pulm rehab.\n 2. Hemodynamics: tachycardia seems most likely due to agitation\n at present, did taper Valium aggressively, may be need to increase\n benzo slightly and see f it helps (haldol and morphione have not helped\n yet this AM)\n 3. Anti coag: for upper ext DVT but INR elevated on coumadin +\n quinolone\n repeat\n 4. Adrenal Insufficny: proper stim this AM, off steroids\n ICU Care\n Nutrition: Replete with Fiber (Full) - 07:46 AM 30 mL/hour\n Glycemic Control:\n Lines: PICC Line - 09:19 PM\n Prophylaxis:\n DVT: inr levetaed recheck, and start coumadin when at 2.0\n Stress ulcer: ppi\n Communication:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n"},{"category":"Nursing","chartdate":"2167-10-13 00:00:00.000","description":"Nursing Progress Note","row_id":637226,"text":"56 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\n with prolonged hospital course c/b by PNA, anxiety/altered mental\n status, RUE DVT .\n Tachycardia, Other\n Assessment:\n HR\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2167-10-06 00:00:00.000","description":"Nursing Progress Note","row_id":636001,"text":"55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\n Now with prolonged hospital course c/b by PNA with high PEEP\n requirement, anxiety, RUE DVT on heparin qtt.\n Bradycardia\n Assessment:\n Pt conts with HR 50-70\ns at rest, 100-140\ns during care, pt\n asymptomatic; easily arousable\n Action:\n Sedation decreased, Lasix off @0200\n Response:\n HR 60\n Plan:\n Cont to wean sedation, ?cardiac consult\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Action:\n Cont with IV Heparin @ 1500u/hr, Coumadin d\ncd for? thoracentesis\n Response:\n Pt therapeutic, cont with daily PTT\n Plan:\n Cont to labs, cont to wean off Heparin, Coumadin 5mg given x 1dose\n @ 2200, re-eval dosing this am\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt cont on AC 18/400/50%/10, LS clear bilat, occ scat rhonchi\n Action:\n Pt suct for sm thin tan secretions\n Response:\n Pt 02 Sats 94-97%,\n Plan:\n Cont to ABGs, Rate decreased to 16 this am to PC02 elevated\n Hypotension (not Shock)\n Assessment:\n SBP 140\ns when pt is agitated, SBP dropping to 70\ns-80\ns, UO 200/hr\n (total 2500 in 2hr) K 3.3\n Action:\n Fent/Versed turned down @ 0000, Lasix gtt on hold, team informed ; pt\n recvd 1x dose of 40meg/Peg, 20meqK/250D5W x 1 dose\n Response:\n Pt SBP\ns in 80\n Plan:\n Cardiac consult to further eval SB/ST, re-evalu cont. Lasix gtt,\n recheck am labs\n Hypernatremia (high sodium)\n Assessment:\n Na 146\n Action:\n Cont with 300cc free water flush Q4hrs\n Response:\n Plan:\n Cont to sodium levels, treat as ordered\n Altered mental status (not Delirium)\n Assessment:\n Pt alert and agitated throughout shift, pt following commands\n inconsistently; sleeping off and off throughout shift\n Action:\n Fent/Versed decreased low SBP\ns, pt recved prn dose of Haldol 1mg @\n 0100; cont with bilat. Wrist restraints for safety\n Response:\n pt sleeping off/on throughout shift, with periods of\n agitation/restlessness\n Plan:\n Cont to wean fent/versed gtt down, cont with scheduled Haldol/Valium;\n cont to QTC intervals daily\n"},{"category":"Physician ","chartdate":"2167-09-28 00:00:00.000","description":"Physician Resident Progress Note","row_id":634960,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n PICC placed, Central line d/c'd\n Lasix 10 mg given with 400 cc UOP in afternoon, pH improved\n Lasix 20 mg given at ~ 4AM.\n Lots of thick sinus secreations\n Delerium/anxiety overnight with periods of hypertension.\n Could not draw of A-line.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Aztreonam - 06:00 AM\n Vancomycin - 09:00 AM\n Levofloxacin - 08:06 AM\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Fentanyl - 150 mcg/hour\n Heparin Sodium - 1,700 units/hour\n Other ICU medications:\n Furosemide (Lasix) - 03:01 AM\n Midazolam (Versed) - 04:36 AM\n Fentanyl - 04:36 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36.4\nC (97.6\n HR: 90 (47 - 92) bpm\n BP: 118/59(80) {80/40(53) - 137/105(111)} mmHg\n RR: 17 (15 - 24) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101 kg (admission): 94.2 kg\n Height: 67 Inch\n CVP: 19 (16 - 19)mmHg\n Total In:\n 2,560 mL\n 543 mL\n PO:\n TF:\n 1,441 mL\n 342 mL\n IVF:\n 1,020 mL\n 201 mL\n Blood products:\n Total out:\n 1,680 mL\n 860 mL\n Urine:\n 1,680 mL\n 860 mL\n NG:\n Stool:\n Drains:\n Balance:\n 880 mL\n -317 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 15 cmH2O\n FiO2: 50%\n PIP: 27 cmH2O\n Plateau: 23 cmH2O\n SpO2: 98%\n ABG: 7.41/45/77./28/2\n Ve: 6.5 L/min\n PaO2 / FiO2: 156\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese, opens eyes\n but no purposeful movement\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric)\n Abdominal: No(t) Soft, Non-tender, Bowel sounds present, Distended\n Extremities: No clubbing or cyanosis, 3+ nonpitting edema of b/l hands,\n LE without edema\n Skin: no rashes or jaundice\n Labs / Radiology\n 411 K/uL\n 8.3 g/dL\n 133 mg/dL\n 0.5 mg/dL\n 28 mEq/L\n 4.1 mEq/L\n 13 mg/dL\n 111 mEq/L\n 145 mEq/L\n 26.0 %\n 9.7 K/uL\n [image002.jpg]\n 04:05 PM\n 01:12 AM\n 04:00 AM\n 04:09 AM\n 10:18 AM\n 02:33 PM\n 02:46 PM\n 03:31 AM\n 02:26 PM\n 05:53 PM\n WBC\n 9.6\n 9.7\n Hct\n 27.8\n 26.0\n Plt\n 374\n 411\n Cr\n 0.5\n 0.5\n 0.5\n 0.5\n TCO2\n 26\n 27\n 28\n 29\n 26\n 27\n 30\n Glucose\n 194\n 195\n 195\n 163\n 133\n Other labs: PT / PTT / INR:15.3/69.9/1.3, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:86.1 %, Lymph:10.3 %,\n Mono:2.8 %, Eos:0.5 %, Lactic Acid:2.0 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:8.3 mg/dL, Mg++:2.2 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with respiratory failure\n and difficulty weaning from vent.\n # Respiratory failure: Intubated on for resp decompensation.\n Likely VAP. Transferred here for tracheomalacia, but not sure this\n is a component. Will need bronch eval when improved\n - wean PEEP\n - repeat ABG this AM\n - discuss need for trach with patient and her family\n - Will continue gentle diuresis once alkalosis resolved\n # Diuresis\n Currently with hypernatremia, Cr increase, contract alk\n suggestive of overdiuresis\n - FW in TF at 150 cc q4hrs\n - PM lytes. Can restart lasix if resolved\n # Pneumonia: Pansensitive Kleb oxytoca pneumonia and sputum with GPCs\n on gram stain. Afebrile off abx.\n # Sedation: On versed 3mg/hr + .5 q 1hr and fentanyl 150 mcg/hr + 50\n bolus q 1hr.\n - seroquil 25 \n # EKG changes: Sinus bradycardia, responsive to stress. Related to\n sedation, increased vagal tone, possibly related to steroid\n replacement. Atrial EKG shows p-waves and cardiac enzymes normal.\n - Continue to monitor\n # Hypotension: Improved, off levophed for 2-3 days now, with good urine\n output. s/p 5 d courserof steroids and getting high PEEP. Now likely\n related to sedation and decreased intravascual volume,\n -monitor, expect improvement with continual reduction in PEEP\n # RUE DVT: Started on heparin gtt on , now therapeutic. Follow\n PTTs. Would hold off on coumadin at least until s/p trach.\n - continue to monitor\n # Adrenal Insufficency: Random cortisol was approx 3 when it should\n have been maximally stimulated.\n - hydrocortisone and florinef for 5 days\n # Anemia: Stable.\n - Trend HCT\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n FEN/GI: Tube feeds @ goal\n DVT: Treatment dose heparin\n Ulcer: Ranitidine\n VAP: Prevention per routine\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 08:12 PM 60 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 04:00 PM\n PICC Line - 09:19 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2167-09-28 00:00:00.000","description":"Physician Resident Progress Note","row_id":634969,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n PICC placed, Central line d/c'd\n Lasix 10 mg given with 400 cc UOP in afternoon, pH improved\n Lasix 20 mg given at ~ 4AM.\n Lots of thick sinus secreations\n Delerium/anxiety overnight with periods of hypertension.\n Could not draw of A-line.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Aztreonam - 06:00 AM\n Vancomycin - 09:00 AM\n Levofloxacin - 08:06 AM\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Fentanyl - 150 mcg/hour\n Heparin Sodium - 1,700 units/hour\n Other ICU medications:\n Furosemide (Lasix) - 03:01 AM\n Midazolam (Versed) - 04:36 AM\n Fentanyl - 04:36 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36.4\nC (97.6\n HR: 90 (47 - 92) bpm\n BP: 118/59(80) {80/40(53) - 137/105(111)} mmHg\n RR: 17 (15 - 24) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101 kg (admission): 94.2 kg\n Height: 67 Inch\n CVP: 19 (16 - 19)mmHg\n Total In:\n 2,560 mL\n 543 mL\n PO:\n TF:\n 1,441 mL\n 342 mL\n IVF:\n 1,020 mL\n 201 mL\n Blood products:\n Total out:\n 1,680 mL\n 860 mL\n Urine:\n 1,680 mL\n 860 mL\n NG:\n Stool:\n Drains:\n Balance:\n 880 mL\n -317 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 15 cmH2O\n FiO2: 50%\n PIP: 27 cmH2O\n Plateau: 23 cmH2O\n SpO2: 98%\n ABG: 7.41/45/77./28/2\n Ve: 6.5 L/min\n PaO2 / FiO2: 156\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese, opens eyes\n but no purposeful movement\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric)\n Abdominal: No(t) Soft, Non-tender, Bowel sounds present, Distended\n Extremities: No clubbing or cyanosis, 3+ nonpitting edema of b/l hands,\n LE without edema\n Skin: no rashes or jaundice\n Labs / Radiology\n 411 K/uL\n 8.3 g/dL\n 133 mg/dL\n 0.5 mg/dL\n 28 mEq/L\n 4.1 mEq/L\n 13 mg/dL\n 111 mEq/L\n 145 mEq/L\n 26.0 %\n 9.7 K/uL\n [image002.jpg]\n 04:05 PM\n 01:12 AM\n 04:00 AM\n 04:09 AM\n 10:18 AM\n 02:33 PM\n 02:46 PM\n 03:31 AM\n 02:26 PM\n 05:53 PM\n WBC\n 9.6\n 9.7\n Hct\n 27.8\n 26.0\n Plt\n 374\n 411\n Cr\n 0.5\n 0.5\n 0.5\n 0.5\n TCO2\n 26\n 27\n 28\n 29\n 26\n 27\n 30\n Glucose\n 194\n 195\n 195\n 163\n 133\n Other labs: PT / PTT / INR:15.3/69.9/1.3, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:86.1 %, Lymph:10.3 %,\n Mono:2.8 %, Eos:0.5 %, Lactic Acid:2.0 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:8.3 mg/dL, Mg++:2.2 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with respiratory failure\n and difficulty weaning from vent.\n # Respiratory failure: Intubated on for resp decompensation.\n Likely VAP. Transferred here for tracheomalacia, but not sure this\n is a component. Will need bronch eval when improved\n - will discuss PEEP goal for trach placement with IP.\n - wean PEEP\n - repeat ABG this AM\n - discuss need for trach with patient and her family\n - Volume overload may be contributing.\n # Volume overload\n Currently with hypernatremia, Cr increase, contract\n alk, but mild\n - continue gentle diuresis\n - FW in TF at 150 cc q4hrs\n - PM lytes.\n # Sedation: On versed 3mg/hr + .5 q 1hr and fentanyl 150 mcg/hr + 50\n bolus q 1hr.\n - Start fentanyl patch and diazepam to provide long acting analgesia\n and wean from drips\n - Haldol 1 mg Q4h PRN agitation\n # Pneumonia: Pansensitive Kleb oxytoca pneumonia and sputum with GPCs\n on gram stain. Afebrile off abx.\n # EKG changes: Sinus bradycardia, responsive to stress. Related to\n sedation, increased vagal tone, possibly related to steroid\n replacement. Atrial EKG shows p-waves and cardiac enzymes normal.\n - Continue to monitor\n # Hypotension: Improved, off levophed for 2-3 days now, with good urine\n output. s/p 5 d course of steroids for adrenal insufficiency. High\n PEEP may have been contributing. Now likely related to sedation and\n decreased intravascular volume,\n -monitor, expect improvement with continual reduction in\n PEEP\n # RUE DVT: Started on heparin gtt on , now therapeutic. Follow\n PTTs. Would hold off on coumadin at least until s/p trach.\n - continue to monitor\n # Adrenal Insufficency: Random cortisol was approx 3 when it should\n have been maximally stimulated.\n - hydrocortisone and florinef for 5 days\n # Anemia: Stable.\n - Trend HCT\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n FEN/GI: Tube feeds @ goal\n DVT: Treatment dose heparin\n Ulcer: Ranitidine\n VAP: Prevention per routine\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 08:12 PM 60 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 04:00 PM\n PICC Line - 09:19 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2167-10-10 00:00:00.000","description":"Physician Resident Progress Note","row_id":636755,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n Discussed imaging with ortho. They do not need further imaging. She\n should wear TLSO for 2 months and f/u with at 2 months\n prior to removal of TLSO.\n Changed to PSV, was stable on trach mask for 1-2 hrs\n Tube feeds held\n Endo recs: check AM cortisol prior to dose\n At 5:45 am --- RR 4, switched from CPAP/PSV to AC\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 10:04 PM\n Levofloxacin - 10:49 PM\n Aztreonam - 03:42 AM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 10:49 PM\n Other medications:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.7\nC (98\n HR: 125 (74 - 151) bpm\n BP: 121/64(77) {89/32(45) - 179/99(120)} mmHg\n RR: 20 (13 - 30) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 5,817 mL\n 457 mL\n PO:\n TF:\n IVF:\n 5,277 mL\n 327 mL\n Blood products:\n Total out:\n 5,205 mL\n 1,460 mL\n Urine:\n 5,205 mL\n 1,460 mL\n NG:\n Stool:\n Drains:\n Balance:\n 612 mL\n -1,003 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 429 (340 - 480) mL\n PS : 8 cmH2O\n RR (Set): 0\n RR (Spontaneous): 25\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 13 cmH2O\n SpO2: 100%\n ABG: 7.37/44/120/25/0\n Ve: 6.3 L/min\n PaO2 / FiO2: 240\n Physical Examination\n On CMV\n Peep 5, FiO2 40%, Vt 500, R 14\n General Appearance: Trached and sedated. Responsive, following\n commands, Overweight / Obese, mild agitation but NAD\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\n deviation\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Respiratory / Chest: (Expansion: Symmetric), CTA anteriorly, decreased\n BS\n Abdominal: Obese, soft, Non-tender, no rebound, no guarding, + BS, PEG\n in place with dressing C/D/I\n Extremities: no CCE\n Skin: no rashes or jaundice\n Lines: L PICC C/D/I\n Labs / Radiology\n 209 K/uL\n 8.3 g/dL\n 99 mg/dL\n 0.6 mg/dL\n 25 mEq/L\n 4.3 mEq/L\n 9 mg/dL\n 111 mEq/L\n 145 mEq/L\n 26.5 %\n 6.1 K/uL\n [image002.jpg]\n 01:37 AM\n 05:32 AM\n 02:43 PM\n 03:03 PM\n 08:11 PM\n 02:51 AM\n 03:10 AM\n 03:08 PM\n 03:00 AM\n 03:36 AM\n WBC\n 11.1\n 9.4\n 11.3\n 7.3\n 6.1\n Hct\n 29.4\n 26.6\n 24.9\n 27.6\n 26.5\n Plt\n 89\n 209\n Cr\n 0.6\n 0.9\n 0.7\n 0.6\n TCO2\n 31\n 31\n 30\n 29\n 26\n Glucose\n 123\n 128\n 114\n 114\n 99\n Other labs: PT / PTT / INR:36.4/38.8/3.9, Ca++:8.9 mg/dL, Mg++:2.6\n mg/dL, PO4:4.1 mg/dL\n Cx: endotrach \n GN diplococci, budding yeast\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA, and\n ARDS, intubated since the end of now s/p trach and PEG\n placement.\n # Recent Aspiration of tube feeds. Given prolonged hospitalization and\n tenuous respiratory status will treat with antibiotics while cultures\n pending\n - Levoflox for 48 hours while waiting for sputum results.\n - restart tube feeds slowly\n - Follow cultures\n .\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation. S/P Trach\n and PEG on .\n - wean FiO2 as tolerated\n - attempt wean PS today and hopeful for trach mask trial\n # Sedation: Continue to have issues with pain/delirium causing\n tachycardia and hypertension with intermittent hypotension. On Haldol\n 5 TID, Fentanyl 75 mcg TP, Diazapam 10 QID; Haldol, midazolam and\n morphine PRN. Had good response to morphine, minimal response to\n haldol bolus.\n - Reduce diazepam to 5 q 8hrs.\n - d/c standing Haldol\n # Adrenal Insufficency: Hypotension that resolved with steroids,\n returned as they came off and is now improved again. Possible primary\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\n started on .\n - 10 q am and 5 q pm prednisone day 2 of 3, will wean to\n maintenance dose as tolerated, in consultation with endo.\n # Volume overloaded in setting of hypernatremia\n Goal even today.\n - Off diamox\n - electrolytes\n - Free water flushes with tube feeds.\n # Falling Hct: Likely dilutional. Concern given elevated INR. Stable\n today.\n - monitor\n - maintain active type and screen\n # RUE DVT: INR now therapeutic on coumadin. Goal \n - will start coumadin 2.5 mg QHS once INR < 3\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - Brace for OOB\n - report from full trauma series from OSH is in chart. No evidence of\n other fracture and no need for further spinal imaging based on this\n report and ortho note.\n # Tracheomalacia: Discussed with IP. Stenting unlikely to help for\n trachiomalacia as airways have poor structure diffusely.\n - Outpatient f/u once off pressure support to assess for possible\n stenting\n #. Thyroid Nodule on CT\n -outpatient follow up\n # Nutrition: Replete (Full)\n will reintroduce slowly\n - advance bowel regimen\n # Glycemic control: SSI, well controlled\n # Lines L PICC ().\n # Ppx: INR therapeutic, ranitidine, colace and senna, miralax,\n bisacodyl.\n # Communication:\n - Boyfriend of 10 \n - Brother is her HCP, also involved\n Code: Full\n Dispo: ICU, being screening for vent facilities\n ------ Protected Section ------\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 55F T5-8 fractures with retropulsion and ARDS\n from klebsiella VAP; on heparin for UE DVT and lasix for volume\n overload. Overnight transitioned to PSV and trial spont breathing\n performed. RR down to 4 terminated trial\n mode changed back to AC.\n On exam:\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.7\nC (98\n HR: 125 (74 - 151) bpm\n BP: 121/64(77) {89/32(45) - 179/99(120)} mmHg\n RR: 20 (13 - 30) insp/min\n SpO2: 100%\n Trached, lightly sedated, following commands.\n CV RRR, distantstant\n Lungs\n distant bs, otherwise clear\n abd: soft NTND BS+, +PEG site\n Ext- no c/c/e\n Data: WBC 6.1 hct 26.5 creat 0.6\n 55F h/o EtOH abuse presenting following mech fall -> traumatic T spine\n fracture with K. oxytoca PNA, and ARDS, intubated since the end of\n now s/p trach and PEG placement. Cont efforts to wean mech vent\n including spont breathing trials w/ monitoring given RR. Check ABG\n prior to d/c to assess adequacy of vent. Tracheomalacia\n indication for intervention per IP. Ortho following re: fx. Cont\n brace. Agree with recs as outlined above.\n ------ Protected Section Addendum Entered By: , MD\n on: 02:09 PM ------\n"},{"category":"Nursing","chartdate":"2167-10-10 00:00:00.000","description":"Nursing Progress Note","row_id":636806,"text":"55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\n with prolonged hospital course c/b by PNA with high PEEP requirement,\n anxiety, RUE DVT .\n Altered mental status (not Delirium)\n Assessment:\n Rec\nd pt restless, intermit following commands. MAEE with good\n strength. Pt shaking head\n when asked if has pain or SOB.\n Action:\n Torso brace applied\nwith difficulty\nand pt OOB to stretcher/chair with\n transfer via board.\n Response:\n Pt increasingly restless with HR 130-140ST, grimacing. Pt attempting to\n stand and/or exit chair. She dislodged her periph IV. Pt rec\n scheduled Valium 5mg po early, as well as Morphine Sulfate 2mg IVP\n without relief of discomfort. Pt returned to bed after 45mins. When\n brace removed, chin noted to be abraided from chin rest. Pt cont to be\n restless until approx 1600, freq attempting to sit up in bed. Soft\n wrist restraints in place for pt safety.\n Plan:\n Duoderm to chin or chin-rest when brace applied. Attempt OOB to chair\n again tomorrow, but meanwhile bed as chair intermit.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt on vent settings AC 50%/ 12 X 500/+5 with rare over-breathing\n of rate. O2 sat 100%. Lung snds with rhonchi in RUL, clear in LUL, and\n diminished bilat in bases. Pt requiring sxn\ning Q2-4hrs for mod amts\n yellow/white thick secretions. Pt also intermit with copious thick,\n clear oral secretions.\n Action:\n Vent changed to CPAP/PS 8/+5/50% with SRR 14-25 and regular, O2 sat\n remaining 98-100%. Pt then placed on trach mask @ 80% at 1230.\n Response:\n Pt has tolerated TM for several hrs, with RR remaining regular @\n 14-25/min, O2 sat generally 100%. However, desated to 70\ns X 2,\n returning to baseline after suctioning and ambu.\n Plan:\n Cont pt on TM as tol, monitoring for ? plugs requiring ambu/suctioning.\n"},{"category":"Respiratory ","chartdate":"2167-10-12 00:00:00.000","description":"Respiratory Care Shift Note","row_id":637021,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 24\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason:\n Tube Type\n Tracheostomy tube:\n Type: Cuffed\n Manufacturer: Portex\n Size: 7.0mm\n PMV: No\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments: Lung sounds are rhonchi, but clear up after suction. Pt has\n consistent cough, but minimal secretions are sucitoned\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Pt has strong, consistent productive cough\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment: Frequent alarms (High pressure)\n Comments: Pt is always coughing, although minimal is suctioned out\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Periodic SBT's for conditioning, Increase ventilatory support at night\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Cannot protect airway, Cannot manage secretions;\n Comments: Pt is stable on current vent settings, switch to trachmask\n during the day, vent usage at night.\n BEDSIDE RSBI FAILED due to small tidal volumes\n"},{"category":"Nursing","chartdate":"2167-10-13 00:00:00.000","description":"Nursing Progress Note","row_id":637228,"text":"56 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\n with prolonged hospital course c/b by PNA, anxiety/altered mental\n status, RUE DVT .\n Tachycardia, Other\n Assessment:\n HR at rest and sleeping 120-130 , when awake pt is very restless and at\n times seems agitated also. When restless HR is 140-155 w/o ectopy.\n Pt shakes head no when asked if in pain. Attempted to reposition pt,\n but wiggles back to her back.\n Action:\n MD notified and valium PO continues. Morphine 2 mg IV given\n Response:\n No effect noted on HR after valium or morphine\n Plan:\n Will discuss in am rounds\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Pt has fungal rash noted under bil breasts\n Action:\n Nystatin powder to affected areas\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2167-09-29 00:00:00.000","description":"Nursing Progress Note","row_id":635033,"text":"Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n RUE edematous, warm, red\n Action:\n Heparin gtt WNL\n Response:\n No change\n Plan:\n Heparin off at 0600 for procedure\n Altered mental status (not Delirium)\n Assessment:\n Periods of agitation\n Action:\n Fentanyl and Versed Gtt, haldol and valium started. Fentanyl patch\n Response:\n Calm with increased sedation needed\n Plan:\n Monitor, continue with sedation as tolerates.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt desatted to 87%\n Action:\n Peep increased\n Response:\n O2 sat improved\n Plan:\n Team to attempt to replace aline or will draw am abg. AM RSBI\n Hypotension (not Shock)\n Assessment:\n Sbp 70\n Action:\n Sedation weaned, but pt agitated\n Response:\n Sbp > 90\n Plan:\n Maintain sbp > 90 with adequate sedation\n Bradycardia\n Assessment:\n HR 50\ns with increased sedation\n Action:\n Sedation weaned, but pt agitated\n Response:\n HR 70-130\ns, with increased sedation noted\n Plan:\n Maintain sedation, monitor hr\n"},{"category":"Nursing","chartdate":"2167-10-10 00:00:00.000","description":"Nursing Progress Note","row_id":636645,"text":"55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\n Now with prolonged hospital course c/b by PNA with high PEEP\n requirement, anxiety, RUE DVT .\n Altered mental status (not Delirium)\n Assessment:\n Pt more alert, following commands intermittently. Periods of agitation\n with HR rising to 130\n Action:\n Fentanyl patch in place. Valium RTC. MSO4 given x 1 for discomfort.\n Response:\n Pt with less episodes of agitation previously. ? steroid psychosis.\n Plan:\n Check cortisol level in am and wean hydrocortisone MD. Continue to\n reorient pt. MSO4 prn for discomfort.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on PSV 8/5/50%.RR 19-24. Tidal volumes 200-250. 02 sats\n variable 90-100%. LS rhoncherous to clear, diminished at bases.\n Action:\n Pt maintained at current settings given reduced tv\ns and sats. Orally\n suctioned q 2 hrs for copious secretions. Deep suctioned q 3-4 hrs for\n sm amt thick white secretions.\n Response:\n Resp status continues to improve. ABG 7.37/40/120/0/26\n Plan:\n Wean fio2 and peep as tolerated. Vigorous pulm hygiene.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt with RUE DVT. Heparin dcd on .\n Action:\n Coags being monitored. INR 4.4 yest. Hct waws falling.\n Response:\n Hct 26.5 today, previously 27.6.\n Plan:\n Coumadin to be started when INR < 3\n Hypernatremia (high sodium)\n Assessment:\n Na 140. Pt volume overloaded. LOS + ~10,000ccs.\n Action:\n Treated with 1 liter d5w iv.\n Response:\n Urine output 120-400ccs/hr via foley. TFB neg 100cc. Na 145. Goal ~\n even fluid balance.\n Plan:\n Continue to monitor f+e status.\n"},{"category":"Nursing","chartdate":"2167-10-10 00:00:00.000","description":"Nursing Progress Note","row_id":636804,"text":"Altered mental status (not Delirium)\n Assessment:\n Rec\nd pt restless, intermit following commands. MAEE with good\n strength. Pt shaking head\n when asked if has pain or SOB.\n Action:\n Torso brace applied\nwith difficulty\nand pt OOB to stretcher/chair with\n transfer via board.\n Response:\n Pt increasingly restless with HR 130-140ST, grimacing. Pt attempting to\n stand and/or exit chair. Pt rec\nd scheduled Valium 5mg po early, as\n well as Morphine Sulfate 2mg IVP without relief of discomfort. Pt\n returned to bed after 45mins. When brace removed, chin noted to be\n abraided from chin rest. Pt cont to be restless until approx 1600, freq\n attempting to sit up in bed. Soft wrist restraints in place for pt\n safety.\n Plan:\n Duoderm to chin or chin-rest when brace applied. Attempt OOB to chair\n again tomorrow, but meanwhile bed as chair intermit.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt on vent settings AC 50%/ 12 X 500/+5 with rare over-breathing\n of rate. O2 sat 100%. Lung snds with rhonchi in RUL, clear in LUL, and\n diminished bilat in bases. Pt requiring sxn\ning Q2-4hrs for mod amts\n yellow/white thick secretions. Pt also intermit with copious thick,\n clear oral secretions.\n Action:\n Vent changed to CPAP/PS 8/+5/50% with SRR 14-25 and regular, O2 sat\n remaining 98-100%. Pt then placed on trach mask @ 80% at 1230.\n Response:\n Pt has tolerated TM for several hrs, with RR remaining regular @\n 14-25/min, O2 sat generally 100%. However, desated to 70\ns X 2,\n returning to baseline after suctioning and ambu.\n Plan:\n Cont pt on TM as tol, monitoring for ? plugs requiring ambu/suctioning.\n"},{"category":"Nursing","chartdate":"2167-10-12 00:00:00.000","description":"Nursing Progress Note","row_id":637026,"text":"56 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\n with prolonged hospital course c/b by PNA, anxiety/altered mental\n status, RUE DVT .\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on PSV 10/5/50%. RR 20-30. )2 sat > 97%\n Action:\n Pt remained on PSV rather than AC overnight. Suctioned ~q 3-4 hrs for\n sm amt yellow bld-tinged secretions. Continues to have copious oral\n secretions\n removed with yankeur.\n Response:\n Tolerated PSV well, no tachypnea or desaturation.\n Plan:\n Attempt trach collar trial again in am. On-going pulm hygiene\n Hypotension (not Shock)\n Assessment:\n BP 90/40 with urine output falling to 10-15ccs/hr via foley. HR remains\n tachycardic (110-140ST) even when pt is not agitated or febrile.\n Action:\n Given 1 500cc d5\n ns fluid bolus\n Response:\n SBP > 90, Urine output improving to >30ccs/hr\n Plan:\n Continue to monitor hemodynamic status and f+e balance.\n Altered mental status (not Delirium)\n Assessment:\n Pt lethargic after receiving benedryl for several hrs but then awoke\n agitated, attempting to climb OOB and pull at trach despite restraints.\n Denies pain ( fentanyl patch in place) or need to go to the bathroom.\n c/o itchiness on back secondary to rash.\n Action:\n Medicated with iv benedryl.\n Response:\n Less agitated. Slept again\n Plan:\n Continue to reorient pt, benedryl for pruritis, safety precautions.\n Alteration in Nutrition\n Assessment:\n Pt with previous episodes of vomiting last eve. Kub showed no evidence\n of obstruction. Na 146\n Action:\n TF initiated with 50ccs free h20 boluses q 4hrs\n Response:\n No nausea or vomiting. No residuals.\n Plan:\n Advance TF as tolerated. ? increase free h20 boluses for hypernatremia.\n"},{"category":"Nursing","chartdate":"2167-10-13 00:00:00.000","description":"Nursing Progress Note","row_id":637220,"text":"Tachycardia, Other\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2167-10-13 00:00:00.000","description":"Nursing Progress Note","row_id":637221,"text":"Tachycardia, Other\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2167-10-13 00:00:00.000","description":"Nursing Progress Note","row_id":637223,"text":"56 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\n with prolonged hospital course c/b by PNA, anxiety/altered mental\n status, RUE DVT .\n Tachycardia, Other\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2167-10-13 00:00:00.000","description":"Nursing Progress Note","row_id":637284,"text":"56 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\n with prolonged hospital course c/b by PNA, anxiety/altered mental\n status, RUE DVT .\n Tachycardia, Other\n Assessment:\n HR at rest and sleeping 120-130 , when awake pt is very restless and at\n times seems agitated also. When restless HR is 140-155 w/o ectopy.\n Pt shakes head no when asked if in pain. Attempted to reposition pt,\n but wiggles back to her back.\n Action:\n MD notified and valium PO continues. Morphine 2 mg IV given\n Response:\n No effect noted on HR after valium or morphine\n Plan:\n Will discuss in am rounds\n Altered mental status (not Delirium)\n Assessment:\n Pt very restless at times and seems not to follow verbal commands at\n times. Pt will nod head appropriately when asked simple questions. Ie\n if she has pain\n Action:\n Pt continues to be reoriented to surrounding\n Response:\n Pt not following commands consistently and not able to use call light\n Plan:\n Continue to reorient\n Alteration in Nutrition\n Assessment:\n Abd distended , TF residuals >50cc and TF held at 6am. BS present, no\n BM\n Action:\n Will continue to assess\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Pt has fungal rash noted under bil breasts\n Action:\n Nystatin powder to affected areas\n Response:\n Plan:\n"},{"category":"Physician ","chartdate":"2167-09-30 00:00:00.000","description":"Physician Resident Progress Note","row_id":635174,"text":"Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - START 02:00 PM - in right brachial atery\n Hypotensive- started on levophed, weaned off over night\n Low cortisol and failed stim test - started on steroids\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 08:06 AM\n Infusions:\n Heparin Sodium - 1,700 units/hour\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 150 mcg/hour\n Other ICU medications:\n Haloperidol (Haldol) - 12:15 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 36.7\nC (98\n HR: 63 (48 - 138) bpm\n BP: 91/41(58) {68/30(49) - 143/78(105)} mmHg\n RR: 18 (13 - 23) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Mixed Venous O2% Sat: 59 - 59\n Total In:\n 3,898 mL\n 1,155 mL\n PO:\n TF:\n 802 mL\n 348 mL\n IVF:\n 2,126 mL\n 247 mL\n Blood products:\n Total out:\n 2,367 mL\n 800 mL\n Urine:\n 2,367 mL\n 800 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,531 mL\n 355 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 401) mL\n RR (Set): 18\n RR (Spontaneous): 1\n PEEP: 10 cmH2O\n FiO2: 60%\n PIP: 23 cmH2O\n Plateau: 19 cmH2O\n Compliance: 57.1 cmH2O/mL\n SpO2: 91%\n ABG: 7.42/49/92./30/5\n Ve: 8.1 L/min\n PaO2 / FiO2: 155\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 355 K/uL\n 9.1 g/dL\n 168 mg/dL\n 0.5 mg/dL\n 30 mEq/L\n 3.9 mEq/L\n 11 mg/dL\n 108 mEq/L\n 146 mEq/L\n 29.9 %\n 11.8 K/uL\n [image002.jpg]\n 03:32 PM\n 10:19 PM\n 02:50 AM\n 02:30 PM\n 02:44 PM\n 03:33 PM\n 07:26 PM\n 07:46 PM\n 02:04 AM\n 02:18 AM\n WBC\n 9.0\n 8.4\n 11.8\n Hct\n 25.8\n 23.0\n 28.1\n 29.9\n Plt\n \n Cr\n 0.6\n 0.7\n 0.5\n TCO2\n 30\n 35\n 33\n 31\n 33\n Glucose\n 94\n 97\n 168\n Other labs: PT / PTT / INR:13.8/70.4/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:89.7 %, Lymph:8.7 %, Mono:1.1\n %, Eos:0.4 %, Lactic Acid:0.9 mmol/L, Albumin:2.4 g/dL, LDH:204 IU/L,\n Ca++:8.5 mg/dL, Mg++:2.2 mg/dL, PO4:5.4 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with respiratory failure\n and difficulty weaning from vent.\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation.\n Transferred here for tracheomalacia, but not sure this is a component.\n Will need bronch eval when improved\n - Thoracics will do trach and PEG once stable on PEEPs around 10. Had\n been planned for today but currently holding as PEEP is 15.\n - wean PEEP as tolerated\n - needs A-line\n # Volume overload\n Currently with hypernatremia, Cr increase, contract\n alk, but mild\n - continue gentle diuresis with goal -1L per day as tolerated by blood\n pressure. IV lasix drip at 1-5 mg/hr.\n - FW in TF at 150 cc q4hrs\n - PM lytes.\n # Sedation: Now well seadated on Versed 1.5, Fentanyl 175, Fentanyl\n patch, Diazepam standing and haldo 2.5-5 mg PRN. QTc stable at .44\n - Wean versed/fentanyl as tolerated\n # HCT\n Has had slow decline while in ICU.\n - Xfuse PRN Hct < 21\n - continue to follow, guiac stools\n # Hypotension: Related to sedation, but high PEEP, adrenial\n insufficiency, sepsis have previously been contributing.\n - needs A-line for monitoring\n - cortisol stim to rule out persistent adrenal insufficiency\n # RUE DVT: Started on heparin gtt on , now off for trach that was\n planned for today. Follow PTTs. Would hold off on coumadin at least\n until s/p trach.\n - restart heparin\n # Adrenal Insufficency: Random cortisol was approx 3 when it should\n have been maximally stimulated. S/P 5 days of hydrocortisone and\n florinef.\n - will recheck as above and start at 50 q8 if needed\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n # FEN/GI: Tube feeds @ goal. No need to be NPO while awaiting stable\n PEEP\n DVT: Treatment dose heparin\n Ulcer: Ranitidine\n VAP: Prevention per routine\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 09:51 PM 60 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Arterial Line - 02:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Respiratory ","chartdate":"2167-10-07 00:00:00.000","description":"Respiratory Care Shift Note","row_id":636226,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 19\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Not applicable\n Size: Not applicable\n Tracheostomy tube:\n Type: Cuffed, Extra Length\n Manufacturer: Portex\n Size: 7.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"},{"category":"Nursing","chartdate":"2167-10-09 00:00:00.000","description":"Generic Note","row_id":636471,"text":"TITLE:\n Alteration in Nutrition\n Assessment:\n Obtained large feed like secretions orally. ? aspiration Abd\n dist, soft with hypoactive BS. No BM on this shift. Pt\ns head needs to\n be lowered down as BP is Low.\n Action:\n TF held .\n Response:\n Continues to have thick secretions like the color of the feeds mixed\n with saliva. By MD .\n Plan:\n Hold feeds till am rounds. Intern Discussed about a dye test. No plans\n at present to do the dye study to determine aspiration.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received Pt on vent via trach in CPAP+PS at 50 %/. LS finely\n coarse with diminished bases.. RR 28 to 30/min sats intermittently down\n to 91 %.\n Action:\n Suctioned fro small amts of tan thick mildly blood tinged sputum. Vent\n Mode changed to AC TV 400, RR 10, peep 8 for the night as per\n discussion By Resident & MD to rest for the night.\n Response:\n Sats maintained in Mid 90\ns to high 90\ns. ABG done in am PH\n 7.35/50/81/29/ Sats 96. Set RR ^ to 12 post abg\n Plan:\n Wean vent settings as tolerated. Plan to IP to follow up regarding ?\n need for stent tomorrow.\n Altered mental status (not Delirium)\n Assessment:\n Pt opens eyes to voice, but will only follow simple commands very\n inconsistently. Pt is very lethargic. Pt found this am to be very\n restless and given versed with no effect.\n Action:\n After pt placed in a chair, and pt more relaxed. Pt was calm, but her\n HR was in the 120-130\ns (while awake). Pt given Morphine with good\n effect. Fentanyl patches weaned down to 100 mcg.\n Response:\n Plan:\n Continue to eval restlessness.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt was on heparin gtt for clot to Rt upper arm. Inr 2.1 . No signs of\n any bleeding.\n Action:\n Heparin was dc\nd this am,\n Response:\n Plan:\n ? coumadin tonight. Continue to eval for bleeding.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Temp up to 101.4. Axillary at hrs\n Action:\n Tylenol 650 mgs given, Pan cultured, started on vanco, aztreonam &\n Levofloxacin.\n Response:\n Temp down to 97.5 axillary.\n Plan:\n Continue monitoring temp, continue anbx, follow up on cultures.\n Alteration in Nutrition\n Assessment:\n Oral secretions large feedlike. Pt\ns head needs to be lowered down as\n BP was Low.\n Action:\n Feeds held . by MD. as BP improved.\n Response:\n Continues to have small amts of the same color mixed with saliva .\n Plan:\n Anemia, other\n Assessment:\n HCT down to\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Physician ","chartdate":"2167-10-15 00:00:00.000","description":"Physician Resident Progress Note","row_id":637663,"text":"Chief Complaint:\n 24 Hour Events:\n ULTRASOUND - At 03:48 PM\n US of Lt arm to R/O DVT. Shows small , nonobstructing clot in axillary\n vein of LEFT arm\n CTA- neg for PE, though study limited by movement artifact\n Coumadin increased to 5mg last night\n Episode of emesis w/ tube gastric contents/ TFs extruding from\n tracheostomy site, around tube. TFs held.\n L PICC line left in place until AM.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Ceftriaxone - 10:00 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 36.3\nC (97.3\n HR: 135 (123 - 146) bpm\n BP: 141/65(82) {106/41(56) - 185/128(142)} mmHg\n RR: 19 (11 - 32) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,888 mL\n 360 mL\n PO:\n TF:\n 1,268 mL\n IVF:\n 100 mL\n Blood products:\n Total out:\n 1,530 mL\n 240 mL\n Urine:\n 1,510 mL\n 240 mL\n NG:\n 20 mL\n Stool:\n Drains:\n Balance:\n 358 mL\n 120 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 227 (227 - 397) mL\n PS : 8 cmH2O\n RR (Spontaneous): 20\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 194\n PIP: 16 cmH2O\n SpO2: 96%\n ABG: ////\n Ve: 6.5 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 306 K/uL\n 8.8 g/dL\n 134 mg/dL\n 0.6 mg/dL\n 32 mEq/L\n 4.0 mEq/L\n 11 mg/dL\n 106 mEq/L\n 146 mEq/L\n 26.8 %\n 7.5 K/uL\n [image002.jpg]\n 03:10 AM\n 03:08 PM\n 03:00 AM\n 03:36 AM\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n 05:00 AM\n 02:06 AM\n WBC\n 11.3\n 7.3\n 6.1\n 7.2\n 5.2\n 5.9\n 7.5\n Hct\n 24.9\n 27.6\n 26.5\n 26.9\n 26.0\n 27.2\n 26.8\n Plt\n 227\n 189\n 209\n 238\n 240\n 296\n 306\n Cr\n 0.7\n 0.6\n 0.6\n 0.9\n 0.7\n 0.6\n 0.7\n 0.6\n TCO2\n 26\n Glucose\n 114\n 99\n 115\n 106\n 100\n 134\n 134\n Other labs: PT / PTT / INR:15.5/24.8/1.4, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:27/19, Alk Phos / T Bili:118/0.3,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:243 IU/L, Ca++:9.2 mg/dL, Mg++:2.1 mg/dL, PO4:4.0\n mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2167-10-15 00:00:00.000","description":"Physician Resident Progress Note","row_id":637665,"text":"Chief Complaint:\n 24 Hour Events:\n ULTRASOUND - At 03:48 PM\n US of Lt arm to R/O DVT. Shows small , nonobstructing clot in axillary\n vein of LEFT arm\n CTA- neg for PE, though study limited by movement artifact\n Coumadin increased to 5mg last night\n Episode of emesis w/ tube gastric contents/ TFs extruding from\n tracheostomy site, around tube. TFs held.\n L PICC line left in place until AM.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Ceftriaxone - 10:00 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 36.3\nC (97.3\n HR: 135 (123 - 146) bpm\n BP: 141/65(82) {106/41(56) - 185/128(142)} mmHg\n RR: 19 (11 - 32) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,888 mL\n 360 mL\n PO:\n TF:\n 1,268 mL\n IVF:\n 100 mL\n Blood products:\n Total out:\n 1,530 mL\n 240 mL\n Urine:\n 1,510 mL\n 240 mL\n NG:\n 20 mL\n Stool:\n Drains:\n Balance:\n 358 mL\n 120 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 227 (227 - 397) mL\n PS : 8 cmH2O\n RR (Spontaneous): 20\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 194\n PIP: 16 cmH2O\n SpO2: 96%\n ABG: ////\n Ve: 6.5 L/min\n Physical Examination\n GEN: Awake, alert, responsive. Sitting in chair, in back brace.\n Following commands.\n HEENT: PERRL\n PULM: CTA anteriorly, no r/r/w\n CARD: tachycardic, regular, ,s1, s2,\n ABD: abdomen, inferior to brace, soft, nontender\n EXT: DP 2+\n NEURO: able to move all extremeties, strength 5/5 upper and lower, R\n hip < L hip.\n Labs / Radiology\n 306 K/uL\n 8.8 g/dL\n 134 mg/dL\n 0.6 mg/dL\n 32 mEq/L\n 4.0 mEq/L\n 11 mg/dL\n 106 mEq/L\n 146 mEq/L\n 26.8 %\n 7.5 K/uL\n [image002.jpg]\n 03:10 AM\n 03:08 PM\n 03:00 AM\n 03:36 AM\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n 05:00 AM\n 02:06 AM\n WBC\n 11.3\n 7.3\n 6.1\n 7.2\n 5.2\n 5.9\n 7.5\n Hct\n 24.9\n 27.6\n 26.5\n 26.9\n 26.0\n 27.2\n 26.8\n Plt\n 227\n 189\n 209\n 238\n 240\n 296\n 306\n Cr\n 0.7\n 0.6\n 0.6\n 0.9\n 0.7\n 0.6\n 0.7\n 0.6\n TCO2\n 26\n Glucose\n 114\n 99\n 115\n 106\n 100\n 134\n 134\n Other labs: PT / PTT / INR:15.5/24.8/1.4, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:27/19, Alk Phos / T Bili:118/0.3,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:243 IU/L, Ca++:9.2 mg/dL, Mg++:2.1 mg/dL, PO4:4.0\n mg/dL\n Assessment and Plan\n 55yoF with history of EtOH abuse presenting following mechanical fall\n and traumatic T spine fracture, now s/p trach, PEG, placement being\n treated for HAP.\n# HAP vs Aspiration PNA: Cultures grew, Klebsiella Oxytoca, Klebsiella Pneumonia\ne, GNR, GP Cocci. Will continue to treat for potential HAP for 8 days.Pt continu\ning to have some fevers, last night 100.8, and new sputum on today w/ gram stain\n showing GPC p/c. New VAP/HAP w/ staph possible, but given no clear infiltrate o\nn CXR and good respiratory status, significant PNA is unlikely, colonization of\ntrach is possible, as is contamination of sputum. Given improving clinical \n, wait until CX data or change in clinical status or CXR to initiate HAP\n/VAP treatment.\n - Continue Ceftriaxone HAP (Day #6 of 8)\n - Continue to f/u cultures\n .\n # Respiratory failure: Improving status. Will continue to increase\n time on trach mask as tolerated.\n - PMV with suctioning.\n - Weaning FiO2 as tolerated\n # Tachycardia: Pt in ST 120\ns to 150s. Etiology remains unclear and\n etiologies include hypovolemia, pain, infection (pt with known\n klebsiella), . DDx also includes PE given hx of RUE DVT, mucus\n plugging given large amount of secretions, and spinal injury.\n - Treating underlying infection\n - Restarting patients Coumadin, last INR 1.2 yesterday, not\n therapeutic, will recheck this PM\n - TSH 2.4 on early , will check free T3, T4.\n - Continue Pain Control\n - Assess for PE w/ CTPA and UE u/s\n # Sedation: Pt has pain/delirium causing tachycardia and hypertension\n with intermittent hypotension. Had good response to morphine, minimal\n response to haldol bolus.\n - Haldol 5 PRN, Fentanyl 75 mcg TP, Diazapam 5 QID;\n - tolerating current regimen well, will continue to wean\n # Adrenal Insufficency: Followed up with endocrine that suggested if\n the patient under goes major stressors such as major surgery, sepsis,\n she may need stress dosed steroids.\n - Will consider MRI at later date for evaluation of pituitary\n # Fluid Status: Volume overloaded in prior setting of Hypernatremia\n Goal even today.\n - Monitoring urine output\n - increasse Free H20, for mild hypernatremia\n # RUE DVT: restarted Coumadin for INR 1.2, will follow INR carefully,\n given Abx.\n - Check INR this PM\n # Spine fracture: Stable\n - Brace for OOB, will discuss with Neurosurgery if current brace is\n optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n # Tracheomalacia?: Discussed with IP.\n - Outpatient f/u once off pressure support to assess for possible\n stenting\n #. Thyroid Nodule on CT\n - Outpatient follow up\n # Nutrition: TFs with goal of 60\n # Glycemic control: SSI, well controlled\n # Lines L PICC\n ().\n # Ppx: Restarting Coumadin, Ranitidine, Bowel Regimen\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n # Code: Full\n # Dispo: ICU, Screening for vent facilities\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Nursing","chartdate":"2167-10-15 00:00:00.000","description":"Nursing Progress Note","row_id":637796,"text":"Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Left hand to elbow area with edema 2mm\nknown DVT to left axillary vein;\n US of right arm\n Action:\n DL PICC d/c\nd; left arm elevated on pillow; US results pnd for right\n arm\n Response:\n PIV placed for access issues to right arm; edema unchanged;\n Plan:\n Cont to monitor left arm status; no BP/blood draws left arm. NIBP cuff\n to right calf. F/U w/ team Re: right arm status\n Hypernatremia (high sodium)\n Assessment:\n hypernatremic\n Action:\n Free water boluses cont; bloused with D5W/500cc\n Response:\n Remains hypernatremic with min improvement\n Plan:\n Cont with free water boluses; check labs am\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Restless, anxious am\n Action:\n Trach collar placed 70% early am--\n Response:\n Brief episode of desaturation to mid 80\ns requiring increase of Fi02 to\n 100% briefly (approx 20min); placed on 70% remainder of shift with\n adequate o2 sats in low 90\n Plan:\n Passer muir valve for brief periods of time with direct supervision by\n nsg or resp as tolerated by patient; keep on trach collar thru night\n and try to avoid PSV; nebs changed to prn status for ?partial cause for\n tachycardia\n Tachycardia, Other\n Assessment:\n Tachy to 130-140\ns continuous while awake; continuous tachy in 120\n while sound asleep\n Action:\n Standing valium decreased; cont with fent patch; morphine and haldol\n prn\n Response:\n No significant change in level of restlessness/anxiety; freq pulling at\n any objects/lines with short term memory issues; no significant\n response to IV morphine; was able to obtain some sleep after 2mg haldol\n ivp\n Plan:\n Cont to closely monitor mental status; maintain safety w/use of\n restraints, soft wrist restraints and bed alarm. Assess degree of\n change with titration of meds\n"},{"category":"Social Work","chartdate":"2167-10-07 00:00:00.000","description":"Social Work Progress Note","row_id":636222,"text":"Social Work:\n Received phone call from pt\ns brother, (c: ).\n He is back at his home in but reports he has been in touch by\n phone with MICU daily for updates and any issues re consent for\n procedures. As previously mentioned, brother is pt\ns legal and\n therefore the primary person to give consent when pt is unable to speak\n for herself re her healthcare wishes. Per brother and pt\ns long-time\n boyfriend, (h: ), pt has not completed a HCP\n form. However, per pt\ns wishes (verbally expressed to MICU team at\n beginning of her admission), boyfriend should also be consulted, if\n possible, re plan of care. In prior discussion with brother and\n boyfriend, both are in agreement with this and seem to have been\n communicating well with each other and with MICU team. Confirmed this\n with brother again today.\n Brother states he is planning on flying in from this Saturday\n () to visit pt in hospital and meet with MICU team. He plans to be\n here from about noon\n 3:00 p.m. before flying back home.\n Brother asks about pt\ns long-term prognosis with regards to how long\n she might not be able to speak for herself or attend to her financial\n matters. Brother is concerned about how pt will pay her bills (i.e.\n new car payments and car insurance, etc.). Discussed with him that\n physicians at hospital can write letter as needed to state that pt is\n unable to attend to her financial matters at this time and that this\n often suffices for a temporary period. Brother understands that\n boyfriend is already assisting with this and has been in touch with a\n lawyer for help around this issue as well. Brother also states he is\n able to pay pt\ns bills temporarily. However, his main concern seems to\n be how long pt might be in this\nlimbo\n place and what her longer-term\n prognosis is. He is wondering if it makes sense to pursue\n conservatorship or guardianship for pt at this time. SW discussed with\n MICU team who report more information re pt\ns prognosis may be\n available in the next few days, and this can be shared with pt\n brother during his meeting with MICU team on Saturday.\n SW discussed with RNCM who will begin to screen pt for rehab facilities\n as appropriate. While brother will remain primary point of contact\n during this process, encouraged him to remain in good communication\n with pt\ns boyfriend around dispo planning issues as well. He clearly\n states his intention to do so. Attempted to call pt\ns boyfriend to\n discuss as well, but was unable to reach him by phone.\n SW will remain available to pt/family for continued emotional support\n and for facilitation re communication with team as needed. Please page\n with any questions or concerns.\n , LCSW, #\n"},{"category":"Nursing","chartdate":"2167-10-15 00:00:00.000","description":"Nursing Progress Note","row_id":637793,"text":"Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Left hand to elbow area with edema 2mm\nknown DVT to left axillary vein;\n US of right arm\n Action:\n DL PICC d/c\nd; left arm elevated on pillow; US results pnd for right\n arm\n Response:\n PIV placed for access issues to right arm; edema unchanged;\n Plan:\n Cont to monitor left arm status; no BP/blood draws left arm. NIBP cuff\n to right calf. F/U w/ team Re: right arm status\n Hypernatremia (high sodium)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Restless, anxious am\n Action:\n Trach collar placed 70% early am--\n Response:\n Brief episode of desaturation to mid 80\ns requiring increase of Fi02 to\n 100% briefly (approx 20min); placed on 70% remainder of shift with\n adequate o2 sats in low 90\n Plan:\n Passer muir valve for brief periods of time with direct supervision by\n nsg or resp as tolerated by patient; keep on trach collar thru night\n and try to avoid PSV; nebs changed to prn status for ?partial cause for\n tachycardia\n Tachycardia, Other\n Assessment:\n Tachy to 130-140\ns continuous while awake; continuous tachy in 120\n while sound asleep\n Action:\n Standing valium decreased; cont with fent patch; morphine and haldol\n prn\n Response:\n No significant change in level of restlessness/anxiety; freq pulling at\n any objects/lines with short term memory issues; no significant\n response to IV morphine; was able to obtain some sleep after 2mg haldol\n ivp\n Plan:\n Cont to closely monitor mental status; maintain safety w/use of\n restraints, soft wrist restraints and bed alarm. Assess degree of\n change with titration of meds\n"},{"category":"Nursing","chartdate":"2167-10-16 00:00:00.000","description":"Nursing Progress Note","row_id":637897,"text":"56 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\n with prolonged hospital course c/b by PNA, anxiety/altered mental\n status, RUE DVT .Pt found to have small non occlusive Clot on her right\n axial vein via Ultrasound.Yesterday Pt went down to IR for Peg revision\n aspiration riskcouldn\nt do it,due the type of peg she has now.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt has known DVT to left axillary vein; US of right arm showed no\n clots.\n Action:\n DL PICC d/c\nd; from left arm and elevated on pillow and received\n Coumadin scheduled dose.\n Response:\n PIV placed for access issues to right arm; edema looks better;\n Plan:\n Cont to monitor left arm status; no BP/blood draws left arm PICC line\n to right arm?.\n Hypernatremia (high sodium)\n Assessment:\n Hypernatremic NA was 146 yesterday evening.\n Action:\n Started on D5 W at 100cc/hr for 1000cc,held free wqater bolus \n aspiration..\n Response:\n Awaiting for AM lab report.\n Plan:\n Cont with D5W,follow up with AM lab,resume Free water bolus via PEG\n tube?.\n Tachycardia, Other\n Assessment:\n Tachy to 130-140\ns continuous while awake; HR stayed 90- 120 sound\n asleep\n Action:\n Standing valium decreased; cont with fent patch; morphine and haldol\n prn.Bilateral restraints on\n Response:\n No significant change in level of restlessness/anxiety; freq pulling at\n any objects/lines with short term memory issues. She keeps\n disconnecting from vent,desat to low 80s within seconds.\n Plan:\n Cont to closely monitor mental status; maintain safety w/use of\n restraints, soft wrist restraints and bed alarm. PRN Haldol or\n Morphine.\n Altered mental status (not Delirium)\n Assessment:\n Pt has been slept most of the time,hard to wake up.responded to deep\n stimuli.\n Action:\n Held Scheduled dose of valium at 2200.Pt has Fentanyl 75 mcg patch on\n her lleft thigh.\n Response:\n Pt start waking up around 0300,got disconnected from vent by\n herself,given valium 2.5 mg at 0315.\n Plan:\n Continue to eval MS,Valium and PRN Morphine and haldol?,cont reorient\n and emotional support to pt .\n"},{"category":"Respiratory ","chartdate":"2167-10-17 00:00:00.000","description":"Respiratory Care Shift Note","row_id":638138,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 29\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type:\n Manufacturer: Portex\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Unassisted spontaneous breathing\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Increase ventilatory support at night\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Maintained on Trach Collar all day, plan to stay on TC as tolerated\n overnoc\n"},{"category":"Physician ","chartdate":"2167-10-17 00:00:00.000","description":"Physician Attending Progress Note","row_id":638116,"text":"Chief Complaint: respiratory distress\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n episode of SVT -- beta blocker begun\n valium decreased, haldol d/c'd, zyprexa started\n c collar removed\n History obtained from Medical records, ICU team\n Patient unable to provide history: Encephalopathy\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Ceftriaxone - 10:00 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:11 AM\n Other medications:\n , , docusate, senna, SQI, thiamine, folate, warfarin,\n lopressor, valium, reglan\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:37 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 36.4\nC (97.5\n HR: 131 (119 - 149) bpm\n BP: 118/95(99) {99/28(50) - 185/99(144)} mmHg\n RR: 28 (11 - 31) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,408 mL\n 370 mL\n PO:\n 50 mL\n TF:\n IVF:\n 2,358 mL\n 210 mL\n Blood products:\n Total out:\n 1,795 mL\n 1,445 mL\n Urine:\n 1,795 mL\n 1,445 mL\n NG:\n Stool:\n Drains:\n Balance:\n 613 mL\n -1,075 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 415 (244 - 415) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 70%\n RSBI Deferred: No Spon Resp\n PIP: 22 cmH2O\n Plateau: 17 cmH2O\n SpO2: 99%\n ABG: ///38/\n Ve: 5.5 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 9.0 g/dL\n 462 K/uL\n 137 mg/dL\n 0.6 mg/dL\n 38 mEq/L\n 3.9 mEq/L\n 5 mg/dL\n 101 mEq/L\n 146 mEq/L\n 28.9 %\n 7.1 K/uL\n [image002.jpg]\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n 05:00 AM\n 02:06 AM\n 07:34 AM\n 03:50 AM\n 06:22 AM\n 02:58 AM\n WBC\n 7.2\n 5.2\n 5.9\n 7.5\n 5.6\n 6.1\n 7.0\n 7.1\n Hct\n 26.9\n 26.0\n 27.2\n 26.8\n 27.0\n 27.0\n 29.7\n 28.9\n Plt\n 238\n 240\n 296\n \n 395\n 462\n Cr\n 0.6\n 0.9\n 0.7\n 0.6\n 0.7\n 0.6\n 0.5\n 0.7\n 0.7\n 0.6\n Glucose\n 115\n 106\n 100\n 134\n 134\n 121\n \n Other labs: PT / PTT / INR:36.6/30.0/3.9, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:9.8 mg/dL, Mg++:2.2 mg/dL, PO4:3.3\n mg/dL\n Assessment and Plan\n 1. Resp Failure: currently on trach mask, can do sevreal hours per\n day and increasing each day, then needs for support QHS. Completed\n Rx for pan Klebs PNA. Per IP not stent planned as technically\n not possible to place into her airway\n 2. Hemodynamics: persistant simus tachy but also has runs of SVT-\n will add low dose bblocker today\n watch MAPs at night as\n she tends to run low. Anticoagulated.\n 3. New L Ext DVT: PICC out, on coumadin\n 4. Emesis: start Reglan, watch qt and restart low dose tf tonight-\n discuss with TSurg role of J prior to hospital d/c\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 08:39 AM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Coumadin)\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent:\n Patient is critically ill\n"},{"category":"Physician ","chartdate":"2167-10-17 00:00:00.000","description":"Physician Resident Progress Note","row_id":638119,"text":"Chief Complaint:\n 24 Hour Events:\n Pt continued on B-Blocker for prior runs of SVT, HR peaked in 135\n Olanzapine 5mg QHS, Haldol d/c\nd, diazepam decreased\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Ceftriaxone - 10:00 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history: None\n Review of systems is unchanged from admission except as noted below\n Review of systems: Pt denies pain in chest, abdomen. Pt unable to\n further communicate,\n Flowsheet Data as of 08:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 36.4\nC (97.5\n HR: 131 (119 - 149) bpm\n BP: 111/53(67) {99/28(50) - 185/99(144)} mmHg\n RR: 11 (11 - 30) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,408 mL\n 200 mL\n PO:\n 50 mL\n TF:\n IVF:\n 2,358 mL\n 200 mL\n Blood products:\n Total out:\n 1,795 mL\n 1,320 mL\n Urine:\n 1,795 mL\n 1,320 mL\n NG:\n Stool:\n Drains:\n Balance:\n 613 mL\n -1,120 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: MMV/PSV/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 415 (244 - 415) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 22 cmH2O\n Plateau: 17 cmH2O\n SpO2: 98%\n ABG: ///38/\n Ve: 5.5 L/min\n Physical Examination\n Gen: NAD, A0X3\n HEENT: PERRLA, EOMI\n Resp: Limited by patients mobility, but CTA anteriorly\n Card: S1S2 tachy\n Abd: Soft, Non-tender, Non-distended, BS+\n Exte: No edema\n Labs / Radiology\n 462 K/uL\n 9.0 g/dL\n 137 mg/dL\n 0.6 mg/dL\n 38 mEq/L\n 3.9 mEq/L\n 5 mg/dL\n 101 mEq/L\n 146 mEq/L\n 28.9 %\n 7.1 K/uL\n [image002.jpg]\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n 05:00 AM\n 02:06 AM\n 07:34 AM\n 03:50 AM\n 06:22 AM\n 02:58 AM\n WBC\n 7.2\n 5.2\n 5.9\n 7.5\n 5.6\n 6.1\n 7.0\n 7.1\n Hct\n 26.9\n 26.0\n 27.2\n 26.8\n 27.0\n 27.0\n 29.7\n 28.9\n Plt\n 238\n 240\n 296\n \n 395\n 462\n Cr\n 0.6\n 0.9\n 0.7\n 0.6\n 0.7\n 0.6\n 0.5\n 0.7\n 0.7\n 0.6\n Glucose\n 115\n 106\n 100\n 134\n 134\n 121\n \n Other labs: PT / PTT / INR:36.6/30.0/3.9, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:9.8 mg/dL, Mg++:2.2 mg/dL, PO4:3.3\n mg/dL\n Assessment and Plan\n 55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach, PEG, placement no with respiratory failure secondary to\n tracheomalacia , resolving HAP.\n .\n # Respiratory failure: Slowly Improving. Pressure support of at\n night.\n - Continue to increase time on trach mask as tolerated.\n - PMV with suctioning.\n .\n # HAP vs Aspiration PNA: Afebrile without leukocytosis\n - Completed course of ceftriaxone\n - Continue to f/u cultures\n - Continue trach mask as tolerated\n .\n # Tachycardia: Sinus Tach with occasional runs of SVT, now on low dose\n b-blocker. . HR decreased overnight with ranges of 115-135. From\n yesterday when pt found had runs of SVT as well as ST 120\ns to 150s.\n SBPs approx 65.\n Had Negative CTA, thyroid fxn WNL,\n - HR became tachy on , will further investigate events surrounding\n the event for further data\n - cont metoprolol 12.5mg TID and up titrate as tolerated\n - monitor on telemetry\n - Continue Pain Control\n .\n # Sedation: Inconsistent response to sedation, unclear what is best\n regime. Will continue to wean overall\n - Started on Olanzapine QHS\n - DC\nd haldol and taper valium to 2.5 mg PRN TID, taper off\n # Nutrition: Pt had emesis overnight. TFs currently held. Given\n Reglan.\n - Restart Nutrition as tolerated\n .\n # Adrenal Insufficency: Endocrine following. Followed Suggesting if\n the patient under goes major stressors such as major surgery, sepsis,\n she may need stress dosed steroids.\n - Endocrine s/o\n no need for steroids currently\n .\n # Fluid Status: Volume overloaded in prior setting of Hypernatremia\n - Monitoring urine output\n - increase Free H20, for mild hypernatremia 200cc Free bolus PEG, and\n - 500cc D5W at 125.\n - PM lytes to assess hypernatremia\n .\n # UE DVT: right has resolved, new non occlusive in left axillary. INR\n supratherapeutic today\n - decrease coumadin to home dose of 2.5mg\n - follow INR\n .\n # Spine fracture: Stable\n - Brace for OOB, will discuss with Neurosurgery if current brace is\n optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n .\n # Tracheomalacia. Was initially addressed with IP and they wanted to\n follow up as outpatient.\n - Consult IP for stent placement given improved clinical status, will\n readdresses\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # PIV x 1\n # Ppx: Coumadin, Ranitidine, Bowel Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n # Code: Full\n # Dispo: ICU, Screening for vent facilities\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:10 AM\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2167-10-17 00:00:00.000","description":"Physician Attending Progress Note","row_id":638123,"text":"Chief Complaint: respiratory distress\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n episode of SVT -- beta blocker begun\n valium decreased, haldol d/c'd, zyprexa started\n c collar removed\n History obtained from Medical records, ICU team\n Patient unable to provide history: Encephalopathy\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Ceftriaxone - 10:00 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:11 AM\n Other medications:\n , , docusate, senna, SQI, thiamine, folate, warfarin,\n lopressor, valium, reglan\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:37 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 36.4\nC (97.5\n HR: 131 (119 - 149) bpm\n BP: 118/95(99) {99/28(50) - 185/99(144)} mmHg\n RR: 28 (11 - 31) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,408 mL\n 370 mL\n PO:\n 50 mL\n TF:\n IVF:\n 2,358 mL\n 210 mL\n Blood products:\n Total out:\n 1,795 mL\n 1,445 mL\n Urine:\n 1,795 mL\n 1,445 mL\n NG:\n Stool:\n Drains:\n Balance:\n 613 mL\n -1,075 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 415 (244 - 415) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 70%\n RSBI Deferred: No Spon Resp\n PIP: 22 cmH2O\n Plateau: 17 cmH2O\n SpO2: 99%\n ABG: ///38/\n Ve: 5.5 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 9.0 g/dL\n 462 K/uL\n 137 mg/dL\n 0.6 mg/dL\n 38 mEq/L\n 3.9 mEq/L\n 5 mg/dL\n 101 mEq/L\n 146 mEq/L\n 28.9 %\n 7.1 K/uL\n [image002.jpg]\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n 05:00 AM\n 02:06 AM\n 07:34 AM\n 03:50 AM\n 06:22 AM\n 02:58 AM\n WBC\n 7.2\n 5.2\n 5.9\n 7.5\n 5.6\n 6.1\n 7.0\n 7.1\n Hct\n 26.9\n 26.0\n 27.2\n 26.8\n 27.0\n 27.0\n 29.7\n 28.9\n Plt\n 238\n 240\n 296\n \n 395\n 462\n Cr\n 0.6\n 0.9\n 0.7\n 0.6\n 0.7\n 0.6\n 0.5\n 0.7\n 0.7\n 0.6\n Glucose\n 115\n 106\n 100\n 134\n 134\n 121\n \n Other labs: PT / PTT / INR:36.6/30.0/3.9, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:9.8 mg/dL, Mg++:2.2 mg/dL, PO4:3.3\n mg/dL\n Assessment and Plan\n Resp Failure\n Trach mask trials as tolerating (needing QHS support at\n present)\n S/P rx for pan Klebs PNA.\n Per IP not stent planned as technically not possible to\n place into her airway\n Tachycardia\n Extensive evaluation. Will test whether BZD or opiate withdrawal might\n be playing a role. Review hx of medication additions that might\n contribute. Otherwise, will continue beta blocker.\n DVT\n On warfarin\n Emesis\n Getting raglan trial. Restart TF\n Hypernatremia\n Replete free water.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 08:39 AM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Coumadin)\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition :ICU. Screen for rehab.\n"},{"category":"Nursing","chartdate":"2167-10-09 00:00:00.000","description":"Generic Note","row_id":636465,"text":"TITLE:\n Alteration in Nutrition\n Assessment:\n Abd dist, soft with hypoactive BS. No BM on this shift.\n Action:\n TF restarted at goal at 60 cc/hr with minimal residuals.\n Response:\n Plan:\n Follow FSBS. ? adding more laxatives until BM.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains on vent via trach in CPAP+PS at 50 %/. LS CTA with\n diminished bases. Pt has been deep sx\nd for sml amounts of tan to thick\n yellow secretions.\n Action:\n Vent changed to 5/5, but was only tolerated for 1 hr.\n Response:\n After 1 hr pt became tachycardic and tachypnic. O2sat decreased to 95%.\n Plan:\n Continue to wean vent settings as tolerated. Plan to IP to follow up\n regarding ? need for stent tomorrow.\n Altered mental status (not Delirium)\n Assessment:\n Pt opens eyes to voice, but will only follow simple commands very\n inconsistently. Pt is very lethargic. Pt found this am to be very\n restless and given versed with no effect.\n Action:\n After pt placed in a chair, and pt more relaxed. Pt was calm, but her\n HR was in the 120-130\ns (while awake). Pt given Morphine with good\n effect. Fentanyl patches weaned down to 100 mcg.\n Response:\n Plan:\n Continue to eval restlessness.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt was on heparin gtt for clot to Rt upper arm. Inr 2.1 . No signs of\n any bleeding.\n Action:\n Heparin was dc\nd this am.\n Response:\n Plan:\n ? coumadin tonight. Continue to eval for bleeding.\n"},{"category":"Nursing","chartdate":"2167-10-16 00:00:00.000","description":"Nursing Progress Note","row_id":637889,"text":"Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Left hand to elbow area with edema 2mm\nknown DVT to left axillary vein;\n US of right arm\n Action:\n DL PICC d/c\nd; left arm elevated on pillow; US results pnd for right\n arm\n Response:\n PIV placed for access issues to right arm; edema unchanged;\n Plan:\n Cont to monitor left arm status; no BP/blood draws left arm. NIBP cuff\n to right calf. F/U w/ team Re: right arm status\n Hypernatremia (high sodium)\n Assessment:\n Hypernatremic NA was 146 yesterday evening.\n Action:\n Started on D5 W at 100cc/hr for 1000cc.\n Response:\n Awaiting for AM lab report.\n Plan:\n Cont with D5W,follow up with AM lab,resume Free water bolus via PEG\n tube\n Tachycardia, Other\n Assessment:\n Tachy to 130-140\ns continuous while awake; Hr stayed 90- 120 sound\n asleep\n Action:\n Standing valium decreased; cont with fent patch; morphine and haldol\n prn.Bilateral restraints on\n Response:\n No significant change in level of restlessness/anxiety; freq pulling at\n any objects/lines with short term memory issues. She keeps\n disconnecting from vent,desat to low 80s within seconds.\n Plan:\n Cont to closely monitor mental status; maintain safety w/use of\n restraints, soft wrist restraints and bed alarm. PRN Haldol or\n Morphine.\n"},{"category":"Nursing","chartdate":"2167-10-16 00:00:00.000","description":"Nursing Progress Note","row_id":637893,"text":"Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt has known DVT to left axillary vein; US of right arm showed no\n clots.\n Action:\n DL PICC d/c\nd; from left arm and elevated on pillow and received\n Coumadin scheduled dose.\n Response:\n PIV placed for access issues to right arm; edema looks better;\n Plan:\n Cont to monitor left arm status; no BP/blood draws left arm PICC line\n to right arm?.\n Hypernatremia (high sodium)\n Assessment:\n Hypernatremic NA was 146 yesterday evening.\n Action:\n Started on D5 W at 100cc/hr for 1000cc.\n Response:\n Awaiting for AM lab report.\n Plan:\n Cont with D5W,follow up with AM lab,resume Free water bolus via PEG\n tube?.\n Tachycardia, Other\n Assessment:\n Tachy to 130-140\ns continuous while awake; HR stayed 90- 120 sound\n asleep\n Action:\n Standing valium decreased; cont with fent patch; morphine and haldol\n prn.Bilateral restraints on\n Response:\n No significant change in level of restlessness/anxiety; freq pulling at\n any objects/lines with short term memory issues. She keeps\n disconnecting from vent,desat to low 80s within seconds.\n Plan:\n Cont to closely monitor mental status; maintain safety w/use of\n restraints, soft wrist restraints and bed alarm. PRN Haldol or\n Morphine.\n Altered mental status (not Delirium)\n Assessment:\n Pt has been slept most of the time,hard to wake up.responded to deep\n stimuli.\n Action:\n Held Scheduled dose of valium at 2200.Pt has Fentanyl 75 mcg patch on\n her lleft thigh.\n Response:\n Pt start waking up around 0300,got disconnected from vent by\n herself,given valium 2.5 mg at 0315.\n Plan:\n Continue to eval MS,Valium and PRN Morphine and haldol?,cont reorient\n and emotional support to pt .\n"},{"category":"Nursing","chartdate":"2167-10-16 00:00:00.000","description":"Nursing Progress Note","row_id":637894,"text":"56 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\n with prolonged hospital course c/b by PNA, anxiety/altered mental\n status, RUE DVT .Pt found to have small non occlusive Clot on her right\n axial vein via Ultrasound.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt has known DVT to left axillary vein; US of right arm showed no\n clots.\n Action:\n DL PICC d/c\nd; from left arm and elevated on pillow and received\n Coumadin scheduled dose.\n Response:\n PIV placed for access issues to right arm; edema looks better;\n Plan:\n Cont to monitor left arm status; no BP/blood draws left arm PICC line\n to right arm?.\n Hypernatremia (high sodium)\n Assessment:\n Hypernatremic NA was 146 yesterday evening.\n Action:\n Started on D5 W at 100cc/hr for 1000cc.\n Response:\n Awaiting for AM lab report.\n Plan:\n Cont with D5W,follow up with AM lab,resume Free water bolus via PEG\n tube?.\n Tachycardia, Other\n Assessment:\n Tachy to 130-140\ns continuous while awake; HR stayed 90- 120 sound\n asleep\n Action:\n Standing valium decreased; cont with fent patch; morphine and haldol\n prn.Bilateral restraints on\n Response:\n No significant change in level of restlessness/anxiety; freq pulling at\n any objects/lines with short term memory issues. She keeps\n disconnecting from vent,desat to low 80s within seconds.\n Plan:\n Cont to closely monitor mental status; maintain safety w/use of\n restraints, soft wrist restraints and bed alarm. PRN Haldol or\n Morphine.\n Altered mental status (not Delirium)\n Assessment:\n Pt has been slept most of the time,hard to wake up.responded to deep\n stimuli.\n Action:\n Held Scheduled dose of valium at 2200.Pt has Fentanyl 75 mcg patch on\n her lleft thigh.\n Response:\n Pt start waking up around 0300,got disconnected from vent by\n herself,given valium 2.5 mg at 0315.\n Plan:\n Continue to eval MS,Valium and PRN Morphine and haldol?,cont reorient\n and emotional support to pt .\n"},{"category":"Nursing","chartdate":"2167-10-18 00:00:00.000","description":"Nursing Progress Note","row_id":638197,"text":"Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Hypernatremia (high sodium)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2167-10-18 00:00:00.000","description":"Nursing Progress Note","row_id":638198,"text":"56 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\n with prolonged hospital course c/b by PNA, anxiety/altered mental\n status, RUE DVT .Pt found to have small non occlusive Clot on her right\n axial vein via Ultrasound.Yesterday Pt went down to IR for Peg revision\n aspiration risk couldn\nt do it due the type of peg she has now.\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Hypernatremia (high sodium)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nutrition","chartdate":"2167-10-14 00:00:00.000","description":"Clinical Nutrition Note","row_id":637523,"text":"Objective\n Pertinent medications: noted\n Labs:\n Value\n Date\n Glucose\n 134 mg/dL\n 02:06 AM\n Glucose Finger Stick\n 139\n 10:00 AM\n BUN\n 11 mg/dL\n 02:06 AM\n Creatinine\n 0.6 mg/dL\n 02:06 AM\n Sodium\n 146 mEq/L\n 02:06 AM\n Potassium\n 4.0 mEq/L\n 02:06 AM\n Chloride\n 106 mEq/L\n 02:06 AM\n TCO2\n 32 mEq/L\n 02:06 AM\n Albumin\n 3.5 g/dL\n 03:00 AM\n Calcium non-ionized\n 9.2 mg/dL\n 02:06 AM\n Phosphorus\n 4.0 mg/dL\n 02:06 AM\n Ionized Calcium\n 1.24 mmol/L\n 02:51 AM\n Magnesium\n 2.1 mg/dL\n 02:06 AM\n Current diet order / nutrition support: Replete c. Fiber @60mL/hr (1440\n kcals/89 gr aa)\n GI: Abd: soft/dist/+bs\n Assessment of Nutritional Status\n Estimation of current intake: Adequate\n Specifics:\n Pt continues on TF\ns for full nutrition support via PEG, currently\n tolerating @ goal s/ problems. (Noted TF\ns were off over weekend / ?\n aspiration event) FWB down to 100mL q 4 hr c/ Na WNL. BG\ns well\n controlled.\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: via TF\n Tube feeding recommendations: Continue TF's @ goal\n Monitor fluid status and adjust FWB prn.\n BG and lyte management as you are\n Please check current wt\n"},{"category":"Nutrition","chartdate":"2167-10-14 00:00:00.000","description":"Clinical Nutrition Note","row_id":637524,"text":"Objective\n Pertinent medications: noted\n Labs:\n Value\n Date\n Glucose\n 134 mg/dL\n 02:06 AM\n Glucose Finger Stick\n 139\n 10:00 AM\n BUN\n 11 mg/dL\n 02:06 AM\n Creatinine\n 0.6 mg/dL\n 02:06 AM\n Sodium\n 146 mEq/L\n 02:06 AM\n Potassium\n 4.0 mEq/L\n 02:06 AM\n Chloride\n 106 mEq/L\n 02:06 AM\n TCO2\n 32 mEq/L\n 02:06 AM\n Albumin\n 3.5 g/dL\n 03:00 AM\n Calcium non-ionized\n 9.2 mg/dL\n 02:06 AM\n Phosphorus\n 4.0 mg/dL\n 02:06 AM\n Ionized Calcium\n 1.24 mmol/L\n 02:51 AM\n Magnesium\n 2.1 mg/dL\n 02:06 AM\n Current diet order / nutrition support: Replete c. Fiber @60mL/hr (1440\n kcals/89 gr aa)\n GI: Abd: soft/dist/+bs\n Assessment of Nutritional Status\n Estimation of current intake: Adequate\n Specifics:\n Pt continues on TF\ns for full nutrition support via PEG, currently\n tolerating @ goal s/ problems. (Noted TF\ns were off over weekend / ?\n aspiration event) FWB down to 100mL q 4 hr c/ Na WNL. BG\ns well\n controlled.\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: via TF\n Tube feeding recommendations: Continue TF's @ goal\n Monitor fluid status and adjust FWB prn.\n BG and lyte management as you are\n Please check current wt\n"},{"category":"Nursing","chartdate":"2167-10-17 00:00:00.000","description":"Nursing Progress Note","row_id":638171,"text":"Airway Clearance, Impaired\n Assessment:\n Pt placed on trach mask this am (on vent o/n). She continues to have\n moderate amts of thick secretions, requiring frequent sxn. Pt does have\n a strong/productive cough.\n Action:\n Sxn prn; chest pt; pt repositioned frequently (including OOB to chair)\n to help mobilize secretions.\n Response:\n Unchanged at this time.\n Plan:\n Continue to sxn prn; chest pt prn; OOB as tolerated.\n Altered mental status (not Delirium)\n Assessment:\n Pt extremely restless/agitated today. Attempting to get OOB/chair. Very\n difficult to redirect.\n Action:\n Pt reoriented frequently; Valium given prn; Morphine given per presumed\n pain.\n Response:\n Pt had no improvement after Valium; however, she appeared more\n calm/comfortable after Morphine administration.\n Plan:\n Medicate for agitation prn; continue to follow exam.\n Alteration in Nutrition\n Assessment:\n Pt NPO for past few days ( recurrent aspiration/risk for of TFs)\n Action:\n Response:\n Plan:\n Tachycardia, Other\n Assessment:\n HR 120\ns-140\ns today (baseline for ~ 1 week).\n Action:\n Lopressor given per orders.\n Response:\n HR in low 120\ns after Morphine, but otherwise unchanged.\n Plan:\n Continue Lopressor; ? need to increase dose.\n"},{"category":"Physician ","chartdate":"2167-10-08 00:00:00.000","description":"Physician Resident/Attending Progress Note - MICU","row_id":636409,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - STOP 12:23 PM\n ARTERIAL LINE - START 02:00 PM\n A-line resited, not working again\n tube feed machine not working\n failed SBT - low MV with PSV - switched to MMV overnight\n tachycardic to 140-142\n Ortho spine ok with documented final read of CT trauma from attending\n at OSH and week f/u - faxed request and spoke with med recs at\n Medical re: sending report which was agreed upon.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,500 units/hour\n Other ICU medications:\n Morphine Sulfate - 12:15 PM\n Midazolam (Versed) - 03:50 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:13 AM\n Vital signs\n Cardiac monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.1\nC (98.8\n HR: 105 (70 - 148) bpm\n BP: 85/55(66) {85/41(57) - 158/110(323)} mmHg\n RR: 23 (10 - 31) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n QTc: 411\n Total In:\n 3,562 mL\n 965 mL\n PO:\n TF:\n 1,685 mL\n 150 mL\n IVF:\n 548 mL\n 215 mL\n Blood products:\n Total out:\n 5,695 mL\n 1,740 mL\n Urine:\n 5,695 mL\n 1,740 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,133 mL\n -775 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 359 (137 - 695) mL\n PS : 8 cmH2O\n RR (Set): 10\n RR (Spontaneous): 26\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI: 58\n PIP: 16 cmH2O\n SpO2: 95%\n ABG: 7.40/49/114/32/3\n Ve: 7.2 L/min\n PaO2 / FiO2: 228\n Physical Examination\n General Appearance: Trached and sedated. Responsive, following\n commands, Overweight / Obese, mild agitation but NAD\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\n deviation\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Respiratory / Chest: (Expansion: Symmetric), CTA anteriorly, decreased\n BS\n Abdominal: Obese, soft, Non-tender, no rebound, no guarding, + BS, PEG\n in place with dressing C/D/I\n Extremities: no CCE\n Skin: no rashes or jaundice\n Lines: r brachioceph ART with large amount of bloody drainage and L\n PICC C/D/I\n Labs / Radiology\n 213 K/uL\n 8.8 g/dL\n 123 mg/dL\n 0.6 mg/dL\n 32 mEq/L\n 3.6 mEq/L\n 13 mg/dL\n 107 mEq/L\n 145 mEq/L\n 29.4 %\n 11.1 K/uL\n [image002.jpg]\n 03:44 AM\n 06:04 AM\n 09:09 AM\n 05:07 PM\n 03:31 AM\n 03:46 AM\n 10:20 AM\n 03:46 PM\n 01:37 AM\n 05:32 AM\n WBC\n 9.6\n 8.2\n 11.1\n Hct\n 25.3\n 27.4\n 29.4\n Plt\n \n Cr\n 0.6\n 0.8\n 0.6\n 0.8\n 0.6\n TCO2\n 33\n 32\n 35\n 37\n 31\n Glucose\n 107\n 121\n 118\n 155\n 123\n Other labs: PT / PTT / INR:22.3/69.7/2.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:13.1 %,\n Mono:2.7 %, Eos:0.6 %, Lactic Acid:1.1 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:9.2 mg/dL, Mg++:2.5 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA, and\n ARDS, intubated since the end of now s/p trach and PEG\n placement.\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation. S/P Trach\n and PEG on .\n - wean FiO2 as tolerated\n - attempt wean PS today and hopeful for trach mask trial\n # Sedation: Continue to have issues with pain/delirium causing\n tachycardia and hypertension with intermittent hypotension. On Haldol\n 5 TID, Fentanyl 100-150 mcg TP, Diazapam 10 QID; Haldol, midazolam and\n morphine PRN. Had good response to morphine, minimal response to\n haldol bolus.\n - Will d/c midazolam and haldol PRN and use morphine for now.\n - If stable, would d/c standing Haldol tonight or tomorrow\n # Adrenal Insufficency: Hypotension that resolved with steroids,\n returned as they came off and is now improved again. Possible primary\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\n started on .\n - ok to go to 10 q am and 5 q pm prednisone, will wean to\n maintenance dose as tolerated, in consultation with endo.\n # Volume overloaded in setting of hypernatremia with TBW deficit and\n metabolic alkalosis\n - Lasix boluses, goal -1L today\n - Diamox until HCO3 < 30\n - electrolytes\n - continue tube feeds with free water flushes 300 cc q4\n # RUE DVT: INR now therapeutic on coumadin. Goal \n - stop heparin gtt\n - coumadin 5mg QHS\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - Brace for OOB\n - will f/u full trauma spine eval from OSH to determine need for\n further back imaging in-house.\n # Tracheomalacia: Discussed with IP. Stenting unlikely to help for\n trachiomalacia as airways have poor structure diffusely.\n - Outpatient f/u once off pressure support to assess for possible\n stenting\n #. Thyroid Nodule on CT\n -outpatient follow up\n # Nutrition: Tube feeds with free water flushes, tolerating well,\n continue Replete (Full) - 11:20 AM 30 mL/hour\n # Glycemic control: SSI, well controlled\n # Lines L PICC () and R ART ()\n d/c art today. Correlate ABG\n and VBG.\n # Ppx: INR therapeutic, ranitidine, colace and senna\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n Code: Full\n Dispo: ICU, being screening for vent facilities\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Arterial Line - 02:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 55F T5-8 fractures with retropulsion and ARDS\n from klebsiella VAP; on heparin for UE DVT and lasix for volume\n overload. Failed SBT but mental status slowly stabilizing off drip\n sedation. Awaiting OSH spine films.\n Exam notable for Tm 99.5 BP 110/50 HR 70-120 RR 18-20 with sat 97%\n on PSV 8/8 FiO2 0.5, 350x 20, ABG 7.41/53/86. TBB -2L/8h, +7L/MICU LOS.\n Eyes opens, will squeeze hands and wiggle toes but very drowsy. Clearer\n BS bilaterally with RRR s1s2 SM at base. Abdomen is distended with\n decreased BS. Trace edema in BLE, no cords. Labs notable for WBC 11K,\n HCT 29, K+ 3.6, Na 145, Cr 0.6, INR 2.1. CXR without significant\n change.\n Agree with plan to continue supportive care, continue PSV at 8/8, and\n continue diuresis with lasix / diamox as BP allows. Will discuss\n management of TBM with IP but would favor supportive care and slow wean\n until she has recovered from her severe pneumonia / ARDS. Will continue\n fentanyl patch at 150mcg, haldol 5q8h alternating with valium 10q6h\n with morphine PRN pain. Will wean hydrocortisone 20/10q12 PGT today and\n will discuss more aggressive wean with endocrine, as I think she has a\n component of steroid psychosis. Will stop IV heparin for UE DVT and\n continue coumadin now that her INR is >2. Will continue tube feeds and\n continue FW boluses for hypernatremia. Continue spinal stabilization\n with brace when OOB; will review outside images with spine surgery but\n no plan for acute intervention. Remainder of plan as outlined above.\n Total time 50 minutes\n Patient is critically ill\n ------ Protected Section Addendum Entered By: , MD\n on: 03:32 PM ------\n"},{"category":"Physician ","chartdate":"2167-10-09 00:00:00.000","description":"Physician Resident Progress Note","row_id":636566,"text":"Chief Complaint:\n 24 Hour Events:\n Arterial line d/c'd\n Spiked a fever of 101.4, blood and urine cultures sent, CXR. Started\n Vanc, Levo, Aztreonam\n Persistently hypotensive to 70s SBP overnight with low urine output and\n poor O2 sats.\n Started on Levophed, and given 1.75L NS. BPs improved to 90-120s SBP,\n and urine output increased significantly.\n Large amount of oral secretions, ?gastric in origin\n Tube feeds held for ? of aspiration.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 11:00 PM\n Levofloxacin - 11:43 PM\n Aztreonam - 04:07 AM\n Infusions:\n Norepinephrine - 0.03 mcg/Kg/min\n Other ICU medications:\n Midazolam (Versed) - 09:30 AM\n Morphine Sulfate - 03:17 PM\n Furosemide (Lasix) - 06:36 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.4\n Tcurrent: 36.7\nC (98.1\n HR: 131 (73 - 142) bpm\n BP: 127/43(60) {71/29(42) - 137/97(101)} mmHg\n RR: 21 (12 - 36) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 4,627 mL\n 1,084 mL\n PO:\n TF:\n 839 mL\n IVF:\n 2,288 mL\n 1,084 mL\n Blood products:\n Total out:\n 2,407 mL\n 2,220 mL\n Urine:\n 2,407 mL\n 2,220 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,220 mL\n -1,136 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 412 (236 - 480) mL\n PS : 8 cmH2O\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI: 126\n PIP: 21 cmH2O\n Plateau: 17 cmH2O\n Compliance: 44.4 cmH2O/mL\n SpO2: 97%\n ABG: 7.35/50/81./26/0\n Ve: 7 L/min\n PaO2 / FiO2: 162\n Physical Examination\n General Appearance: Trached and sedated. Responsive, following\n commands, Overweight / Obese, mild agitation but NAD\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\n deviation\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Respiratory / Chest: (Expansion: Symmetric), CTA anteriorly, decreased\n BS\n Abdominal: Obese, soft, Non-tender, no rebound, no guarding, + BS, PEG\n in place with dressing C/D/I\n Extremities: no CCE\n Skin: no rashes or jaundice\n Lines: r brachioceph ART with large amount of bloody drainage and L\n PICC C/D/I\n Labs / Radiology\n 227 K/uL\n 7.7 g/dL\n 114 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 4.0 mEq/L\n 16 mg/dL\n 112 mEq/L\n 145 mEq/L\n 24.9 %\n 11.3 K/uL\n [image002.jpg]\n 03:46 AM\n 10:20 AM\n 03:46 PM\n 01:37 AM\n 05:32 AM\n 02:43 PM\n 03:03 PM\n 08:11 PM\n 02:51 AM\n 03:10 AM\n WBC\n 11.1\n 9.4\n 11.3\n Hct\n 29.4\n 26.6\n 24.9\n Plt\n \n Cr\n 0.8\n 0.6\n 0.9\n 0.7\n TCO2\n 35\n 37\n 31\n 31\n 30\n 29\n Glucose\n 155\n 123\n 128\n 114\n 114\n Other labs: PT / PTT / INR:37.2/37.9/4.0, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Lactic Acid:0.5 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:8.7 mg/dL, Mg++:2.6 mg/dL, PO4:4.2 mg/dL\n Blood/Urine/Sputum culture pending\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA, and\n ARDS, intubated since the end of now s/p trach and PEG\n placement.\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation. S/P Trach\n and PEG on .\n - wean FiO2 as tolerated\n - attempt wean PS today and hopeful for trach mask trial\n # Sedation: Continue to have issues with pain/delirium causing\n tachycardia and hypertension with intermittent hypotension. On Haldol\n 5 TID, Fentanyl 100-150 mcg TP, Diazapam 10 QID; Haldol, midazolam and\n morphine PRN. Had good response to morphine, minimal response to\n haldol bolus.\n - Will d/c midazolam and haldol PRN and use morphine for now.\n - If stable, would d/c standing Haldol tonight or tomorrow\n # Adrenal Insufficency: Hypotension that resolved with steroids,\n returned as they came off and is now improved again. Possible primary\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\n started on .\n - ok to go to 10 q am and 5 q pm prednisone, will wean to\n maintenance dose as tolerated, in consultation with endo.\n # Volume overloaded in setting of hypernatremia with TBW deficit and\n metabolic alkalosis\n - Lasix boluses, goal -1L today\n - Diamox until HCO3 < 30\n - electrolytes\n - continue tube feeds with free water flushes 300 cc q4\n # RUE DVT: INR now therapeutic on coumadin. Goal \n - stop heparin gtt\n - coumadin 5mg QHS\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - Brace for OOB\n - will f/u full trauma spine eval from OSH to determine need for\n further back imaging in-house.\n # Tracheomalacia: Discussed with IP. Stenting unlikely to help for\n trachiomalacia as airways have poor structure diffusely.\n - Outpatient f/u once off pressure support to assess for possible\n stenting\n #. Thyroid Nodule on CT\n -outpatient follow up\n # Nutrition: Tube feeds with free water flushes, tolerating well,\n continue Replete (Full) - 11:20 AM 30 mL/hour\n # Glycemic control: SSI, well controlled\n # Lines L PICC () and R ART ()\n d/c art today. Correlate ABG\n and VBG.\n # Ppx: INR therapeutic, ranitidine, colace and senna\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n Code: Full\n Dispo: ICU, being screening for vent facilities\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n 18 Gauge - 08:15 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2167-10-18 00:00:00.000","description":"ICU Attending Addendum","row_id":638264,"text":"CRITICAL CARE STAFF ADDENDUM\n 10A\n I saw and physically examined with the ICU team, whose note today\n reflects my input. I would add/emphasize that she had an episode of\n normal heart rate today that allowed further elucidation of her\n rhythm. Her INR is also quite elevated today.\n Tachycardia\n * My examination of telemetry suggests that this was a brisk\n conversion into sinus. Her fast rate is a narrow complex\n tachycardia without obvious p waves. DDx for this is AVNRT, atrial\n tach, AVRT, Aflutter. Suspect AVNRT and atrial tach.\n * Check 12 lead.\n * No response to carotid massage.\n * Will try to increase beta blockade for now. If cannot maintain\n sinus, will consult cardiology. We are already anticoagulating\n her.\n Resp Failure\n Trach mask trials as tolerating (needing QHS support at\n present)\n PMV trials\n S/P rx for pan Klebs PNA.\n Per IP not stent planned as technically not possible to\n place into her airway\n DVT and coagulopathy\n On warfarin. Hold warfarin\n Feeding tube\n Getting reglan trial. See thoracic surgery note for plans if this\n does not succeed.\n Hypernatremia\n Replete free water.\n After feeding tube and tachycardia more settled, will be appropriate\n for rehab.\n Please see today\ns ICU team note for other issues.\n"},{"category":"Physician ","chartdate":"2167-10-18 00:00:00.000","description":"Physician Resident Progress Note","row_id":638270,"text":"Chief Complaint:\n 24 Hour Events:\n Pt was agitated during the day with no response to PRN zyprexa.\n Her sodium was increased to 150 yesterday, and she was given 500cc D5W\n bolus and her FW flushes for her tube feeds were increases from 100 to\n 150.\n Overnight, pt received zyprexa, valium, and was placed back on the\n ventilator, after which she was more sedated and her SBP dropped to the\n 70s and HR remained 120-130s. Her BP came back up to 110s-120s when she\n was woken up.\n She was agitated again until approx 5am when she was given her\n Metoprolol and 2.5 mg valium, after which her HR dropped to the 80s and\n stayed there for 2+ hours.\n Careful examination of telemetry revealed that she has likely been in\n an SVT and that after getting her BB, converted back to a sinus rhythm.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:11 AM\n Morphine Sulfate - 04:00 AM\n Diazepam (Valium) - 05:24 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.4\nC (97.5\n HR: 126 (118 - 140) bpm\n BP: 98/62(70) {74/38(47) - 145/105(114)} mmHg\n RR: 29 (11 - 35) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 959 mL\n 1,250 mL\n PO:\n TF:\n 176 mL\n 140 mL\n IVF:\n 463 mL\n 810 mL\n Blood products:\n Total out:\n 1,980 mL\n 130 mL\n Urine:\n 1,980 mL\n 130 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,021 mL\n 1,120 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: MMV/PSV/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 408 (408 - 499) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 26\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 149\n PIP: 16 cmH2O\n Plateau: 21 cmH2O\n SpO2: 95%\n ABG: ///36/\n Ve: 6.4 L/min\n Physical Examination\n Gen: NAD, difficult to assess orientation as patient is nonverbal on\n trach mask, but she appeared alert, and resonded appropriately to\n questions and followed commands.\n HEENT: PERRLA, EOMI, OP w/o erythema.\n Resp: Limited by patients mobility, but CTA anteriorly and laterally\n Card: S1S2 tachicardic, no m/r/g\n Abd: Soft, Non-tender, Non-distended, BS+\n Exte: No edema, DP 2+, RP2+ bil.\n NEURO: CN II\nXII grossly intact. Strength 4/5 upper and lower\n bilaterally. Reflexes 2+ bilaterally, 3+ at L patellar tendon, with\n mild adductor crossover\n Labs / Radiology\n 452 K/uL\n 8.9 g/dL\n 104 mg/dL\n 0.7 mg/dL\n 36 mEq/L\n 3.5 mEq/L\n 6 mg/dL\n 103 mEq/L\n 145 mEq/L\n 29.2 %\n 7.1 K/uL\n [image002.jpg]\n 03:00 AM\n 07:05 PM\n 03:00 AM\n 05:00 AM\n 02:06 AM\n 07:34 AM\n 03:50 AM\n 06:22 AM\n 02:58 AM\n 03:43 AM\n WBC\n 7.2\n 5.2\n 5.9\n 7.5\n 5.6\n 6.1\n 7.0\n 7.1\n 7.1\n Hct\n 26.9\n 26.0\n 27.2\n 26.8\n 27.0\n 27.0\n 29.7\n 28.9\n 29.2\n Plt\n 238\n 240\n 296\n \n 395\n 462\n 452\n Cr\n 0.9\n 0.7\n 0.6\n 0.7\n 0.6\n 0.5\n 0.7\n 0.7\n 0.6\n 0.7\n Glucose\n 106\n 100\n 134\n 134\n 121\n 619\n 126\n 137\n 104\n Other labs: PT / PTT / INR:66.1/32.7/8.0, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:9.3 mg/dL, Mg++:2.2 mg/dL, PO4:3.8\n mg/dL\n Assessment and Plan\n 55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach, PEG, placement no with respiratory failure secondary to\n tracheomalacia , resolving HAP.\n .\n # Respiratory failure: Slowly Improving. Now remaining on trach mask\n for most of the day and night, with periods of pressure support of \n over night.\n - Continue to increase time on trach mask as tolerated.\n - PMV with suctioning again today.\n .\n # HAP vs Aspiration PNA: Afebrile without leukocytosis\n - Completed course of ceftriaxone\n - Continue to f/u cultures\n - Continue trach mask as tolerated\n .\n # Tachycardia: Previously was assessed as sinus tach with occasional\n runs of SVT and sources such as hypovolemia, PE, infection, and pain\n were assessed as possibly etiologies. But, now appears to be SVT for\n much of time, rhythm,/rate nonresponsive to carotid massage. HR\n decreased to 80s w/ stable BPs for approx 2 hour period overnight that\n seems to be associated with administration of her BB and valium. Rhythm\n strip shows conversion from a narrow complex non-sinus tachycardia to\n normal sinus rhythm.\n - Increase Metroprolol from 25mg TID to 25mg QID\n - Consider further adjustment of BB as tolerated by BP.\n - If not sufficient for rhythm conversion, consult cardiology for\n management.\n .\n # Sedation: Inconsistent response to sedation, unclear what is best\n regime. Will continue to wean overall. Possibly improved level of\n agitation when rhytm returned to sinus.\n - Continue w Olanzapine QHS\n - DC\nd haldol and taper valium to 2.5 mg PRN TID w/ 2.5 mg PRNs.\n # Nutrition: Tube feeds have been restarted and pt started on raglan.\n Has been tolerating feeds well so far.\n - Continue TFs, w/ FW flushes\n - Nutrition recs appreciated.\n .\n # Adrenal Insufficency: Endocrine following. Pt does not appear to be\n adrenally insufficient at baseline. Suggesting if the patient under\n goes major stressors such as major surgery, sepsis, she may need stress\n dosed steroids.\n .\n # Fluid Status: Likely approaching euvolemia, though still has\n hypernatramia which may suggest is still intravascularly depleated.\n - Monitoring urine output\n - FW flushes at 100/hr w/ tube feeds\n - PM lytes to trend Na\n .\n # UE DVT and elevated INR: DVT in right UE has resolved, new\n non-occlusive in left axillary vein. INR supratherapeutic today\n - COumadin held, will restart at low dose when INR approaches\n therapeutic range.\n - follow INR\n .\n # Spine fracture: Stable\n - Brace for OOB, will discuss with Neurosurgery if current brace is\n optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n .\n # Tracheomalacia. Was initially addressed with IP and they wanted to\n follow up as outpatient.\n - Consult IP for stent placement given improved clinical status, will\n readdress\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # PIV x 1\n # Ppx: Coumadin, Ranitidine, Bowel Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n # Code: Full\n # Dispo: ICU, Screening for vent facilities\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 12:38 PM 30 mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 12:35 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Respiratory ","chartdate":"2167-10-15 00:00:00.000","description":"Respiratory Care Shift Note","row_id":637824,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 27\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Known difficult intubation: Yes\n Reason:\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 7.0mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Expectorated / Small\n Ventilation Assessment\n Level of breathing assistance: Unassisted spontaneous breathing\n Visual assessment of breathing pattern: Supra-sternal retractions,\n Accessory muscle use\n Assessment of breathing comfort: No claim of dyspnea)\n Plan to keep pt on trach collar over night. Vent is on stand-by.\n"},{"category":"Nursing","chartdate":"2167-10-10 00:00:00.000","description":"Nursing Progress Note","row_id":636630,"text":"55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\n Now with prolonged hospital course c/b by PNA with high PEEP\n requirement, anxiety, RUE DVT .\n Altered mental status (not Delirium)\n Assessment:\n Pt more alert, following commands intermittently. Periods of agitation\n with HR rising to 130\n Action:\n Fentanyl patch in place. Valium RTC. MSO4 given x 1 for discomfort.\n Response:\n Pt with less episodes of agitation previously. ? steroid psychosis.\n Plan:\n Check cortisol level in am and wean hydrocortisone MD. Continue to\n reorient pt. MSO4 prn for discomfort.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on PSV 8/5/50%.RR 19-24. Tidal volumes 200-250. 02 sats\n variable 90-100%. LS rhoncherous to clear, diminished at bases.\n Action:\n Pt maintained at current settings given reduced tv\ns and sats. Orally\n suctioned q 2 hrs for copious secretions. Deep suctioned q 3-4 hrs for\n sm amt thick white secretions.\n Response:\n Resp status continues to improve\n Plan:\n Wean fio2 and peep as tolerated. Vigorous pulm hygiene.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt with RUE DVT. Heparin dcd on .\n Action:\n Coags being monitored.\n Response:\n Plan:\n Coumadin to be started when INR < 3\n Hypernatremia (high sodium)\n Assessment:\n Na 140. Pt volume overloaded.\n Action:\n Treated with 1 liter d5w iv.\n Response:\n TFB Na Goal ~ even fluid balance.\n Plan:\n"},{"category":"Physician ","chartdate":"2167-10-15 00:00:00.000","description":"Physician Attending Progress Note","row_id":637734,"text":"Chief Complaint: resp failuire\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n ULTRASOUND - At 03:48 PM\n US of Lt arm shows small 1 cm axillary clot non occlusive near PICC\n RUS US shows resolutyion of formal clot\n Vomting tube feeds around trach\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Ceftriaxone - 10:00 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 06:20 AM\n Pantoprazole (Protonix) - 08:12 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Gastrointestinal: Emesis\n Flowsheet Data as of 10:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 36.2\nC (97.1\n HR: 146 (123 - 146) bpm\n BP: 153/129(134) {106/41(56) - 185/129(142)} mmHg\n RR: 26 (11 - 33) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,888 mL\n 520 mL\n PO:\n TF:\n 1,268 mL\n IVF:\n 100 mL\n Blood products:\n Total out:\n 1,530 mL\n 845 mL\n Urine:\n 1,510 mL\n 820 mL\n NG:\n 20 mL\n 25 mL\n Stool:\n Drains:\n Balance:\n 358 mL\n -325 mL\n Respiratory support\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 227 (227 - 397) mL\n PS : 8 cmH2O\n RR (Spontaneous): 20\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 194\n PIP: 16 cmH2O\n SpO2: 96%\n ABG: ///34/\n Ve: 6.5 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 8.5 g/dL\n 335 K/uL\n 121 mg/dL\n 0.5 mg/dL\n 34 mEq/L\n 3.8 mEq/L\n 7 mg/dL\n 107 mEq/L\n 147 mEq/L\n 27.0 %\n 5.6 K/uL\n [image002.jpg]\n 03:08 PM\n 03:00 AM\n 03:36 AM\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n 05:00 AM\n 02:06 AM\n 07:34 AM\n WBC\n 7.3\n 6.1\n 7.2\n 5.2\n 5.9\n 7.5\n 5.6\n Hct\n 27.6\n 26.5\n 26.9\n 26.0\n 27.2\n 26.8\n 27.0\n Plt\n 189\n 209\n 238\n \n 335\n Cr\n 0.6\n 0.6\n 0.9\n 0.7\n 0.6\n 0.7\n 0.6\n 0.5\n TCO2\n 26\n Glucose\n 99\n 115\n 106\n 100\n 134\n 134\n 121\n Other labs: PT / PTT / INR:16.6/25.0/1.5, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:9.3 mg/dL, Mg++:2.3 mg/dL, PO4:4.1\n mg/dL\n Assessment and Plan\n 55 yr old alcoholic s/p t spine fx s/p trcah and PEG with persistent\n resp failure\n 1. Resp Failure: currently on trach mask, can do a few hours per\n day, then needs for support. New pan Klebs in sputum, day\n . Try more vent support and see if it helps her.\n 2. Fevers: did not persist- cultures neg to date.\n 3 Hemodynamics: persistant simus tachy\n CTPA to look for emboli\n negative for proximal clot. IOs the of trach mask and her TB\n malacia too much for her. We will see what happens if we out her on\n 15-20 and 5.\n 4. New L Ext DVT\n 5. Emesis: call IR and get g pushed to a j tube\n ICU Care\n Nutrition: tfs held for vomiting\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Prophylaxis:\n DVT: coumadin\n Stress ulcer: ppi\n Communication: try to reach boyfriend\n status: Full code\n Disposition :ICU\n"},{"category":"Nursing","chartdate":"2167-10-11 00:00:00.000","description":"Nursing Progress Note","row_id":636941,"text":"56 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\n with prolonged hospital course c/b by PNA, anxiety/altered mental\n status, RUE DVT .\n Altered mental status (not Delirium)\n Assessment:\n Rec\nd pt very restless/agitated, repeatedly attempting to sit up in bed\n and pulling at soft wrist restraints. When arms freed, she immediately\n disconnected trach from vent. Agitation did not subside with verbal\n reassurance or scheduled dose valium. Pt follows commands\n inconsistently, has difficulty initiating cough on command. MAEE with\n good strength. Not grimacing and denied pain by mouthing words.\n Action:\n Pt noted to have rash per below, nodded\n to\nDoes you back itch?\n and rec\nd Benadryl 25mg IV @ 1345.\n Response:\n Pt finally sleeping after having been awake most of night and very\n restless all morning.\n Plan:\n Benadryl Q6hrs PRN. Cont freq mental/neuro eval.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt on AC vent settings 50%/12 X 500/+5 with SRR 17-20\ns and\n regular. O2 sat 96-100%. Lungs snds rhonchorous bilat, diminished in\n bases. Pt with weak cough, raising mod amts thick white sputum but not\n fully expectorating it from trach.\n Action:\n Pt placed on TM @ 70% @ 0900. Suctionned PRN for mod amts sputum.\n Response:\n O2 sat stable until pt soundly sleeping and de-sated to 80\ns. TM inc\n to 100% with return of O2 sat to high 90\n Plan:\n Cont to wean from vent as tolerated. Cont to encourage C&DB.\n Tachycardia, Other\n Assessment:\n HR 130\ns @ rest throughout shift, and still > 125 when pt soundly\n sleeping. Pt Afebrile.\n Action:\n Response:\n Plan:\n Rash\n Assessment:\n Pt noted to have raised red rash evenly distributed over mid/lower\n back. Pt has been very restless, and nodded\n to\nDoes your back\n itch?\n. No new meds recently.\n Action:\n Team made aware, and they examined rash. Pt rec\nd Benadryl 25mg IV X 1.\n Response:\n Pt finally able to sleep after very restless night and morning. HR\n 130\ns->125ST. O2 sat \nd to 80\ns with RR inc\nd to high 20\ns and\n shallow.\n Plan:\n Benadryl PRN Q6hrs. ? Sarna lotion. Cont to monitor rash. FiO2 inc\nd to\n 100% on TM while pt sleeping with good response per O2 sat.\n"},{"category":"Physician ","chartdate":"2167-10-19 00:00:00.000","description":"Physician Attending Progress Note","row_id":638411,"text":"Chief Complaint: resp failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Another episode of emesis\n Was on MMV\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Diazepam (Valium) - 12:00 AM\n Furosemide (Lasix) - 01:30 AM\n Morphine Sulfate - 02:00 AM\n Pantoprazole (Protonix) - 08:24 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:35 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.6\nC (97.8\n HR: 101 (74 - 137) bpm\n BP: 105/57(67) {75/42(50) - 130/73(108)} mmHg\n RR: 24 (12 - 28) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 3,165 mL\n 1,720 mL\n PO:\n TF:\n 691 mL\n IVF:\n 1,574 mL\n 1,665 mL\n Blood products:\n Total out:\n 1,670 mL\n 1,020 mL\n Urine:\n 1,470 mL\n 965 mL\n NG:\n 200 mL\n 55 mL\n Stool:\n Drains:\n Balance:\n 1,495 mL\n 700 mL\n Respiratory support\n O2 Delivery Device: Trach mask , Tracheostomy tube\n Ventilator mode: MMV/PSV/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 94 (94 - 450) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n RSBI Deferred: No Spon Resp\n PIP: 20 cmH2O\n SpO2: 97%\n ABG: ///38/\n Ve: 5.6 L/min\n Physical Examination\n Labs / Radiology\n 8.6 g/dL\n 467 K/uL\n 131 mg/dL\n 0.7 mg/dL\n 38 mEq/L\n 3.4 mEq/L\n 8 mg/dL\n 101 mEq/L\n 145 mEq/L\n 27.8 %\n 6.9 K/uL\n [image002.jpg]\n 03:00 AM\n 05:00 AM\n 02:06 AM\n 07:34 AM\n 03:50 AM\n 06:22 AM\n 02:58 AM\n 03:43 AM\n 05:02 PM\n 03:36 AM\n WBC\n 5.2\n 5.9\n 7.5\n 5.6\n 6.1\n 7.0\n 7.1\n 7.1\n 6.9\n Hct\n 26.0\n 27.2\n 26.8\n 27.0\n 27.0\n 29.7\n 28.9\n 29.2\n 27.8\n Plt\n 35\n 52\n 467\n Cr\n 0.6\n 0.7\n 0.6\n 0.5\n 0.7\n 0.7\n 0.6\n 0.7\n 0.8\n 0.7\n Glucose\n 100\n 134\n 134\n 121\n 04\n 108\n 131\n Other labs: PT / PTT / INR:38.8/34.5/4.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:9.4 mg/dL, Mg++:2.3 mg/dL, PO4:4.2\n mg/dL\n Assessment and Plan\n 1. Tachycardia: runs of atach versus AVNRT. On bblocker be not very\n effective- EP cinsult for ? is there an ablatable focus.\n 2. Resp Failure\n Trach mask trials as tolerating (needing QHS support at\n present)\n PMV trials\n S/P rx for pan Klebs PNA.\n Per IP not stent planned as technically not possible to\n place into her airway\n 3. DVT and coagulopathy On warfarin. Hold warfarin\n 4. Feeding tube Getting reglan trial but still with emesis.\n 5. Hypernatremia Replete free water.\n Please see today\ns ICU team note for other issues.\n ICU Care\n Nutrition: TFs\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n Prophylaxis:\n DVT: anti coag\n Stress ulcer: ppi\n Communication: trying to reach boyfriend\n status: Full code\n Disposition : ICU, start screening still need to fix tachycardia\n"},{"category":"Physician ","chartdate":"2167-10-15 00:00:00.000","description":"Physician Resident Progress Note","row_id":637745,"text":"Chief Complaint:\n 24 Hour Events:\n ULTRASOUND - At 03:48 PM\n US of Lt arm to R/O DVT. Shows small , nonobstructing clot in axillary\n vein of LEFT arm\n CTA- wet read neg for PE, though study limited by movement artifact\n Coumadin increased to 5mg last night\n Episode of emesis w/ tube gastric contents/ TFs extruding from\n tracheostomy site, around tube. TFs held.\n L PICC line left in place until AM.\n RUE U/S in am showed no DVT in right arm, resolved old clot.\n Endocrine consult left impressions/recs\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Ceftriaxone - 10:00 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 36.3\nC (97.3\n HR: 135 (123 - 146) bpm\n BP: 141/65(82) {106/41(56) - 185/128(142)} mmHg\n RR: 19 (11 - 32) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,888 mL\n 360 mL\n PO:\n TF:\n 1,268 mL\n IVF:\n 100 mL\n Blood products:\n Total out:\n 1,530 mL\n 240 mL\n Urine:\n 1,510 mL\n 240 mL\n NG:\n 20 mL\n Stool:\n Drains:\n Balance:\n 358 mL\n 120 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 227 (227 - 397) mL\n PS : 8 cmH2O\n RR (Spontaneous): 20\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 194\n PIP: 16 cmH2O\n SpO2: 96%\n ABG: ////\n Ve: 6.5 L/min\n Physical Examination\n GEN: Awake, alert, responsive. Sitting in bed. Indicated that she\n wanted to get out of the hospital. Cooperative.\n HEENT: PERRL, EOMI, no scleral icterus or injections.\n PULM: Large secretions, diffuse loud wet upperairway sounds/rhonchi, no\n wheezes, no rales, but difficult exam w/ poor inspiration.\n CARD: tachycardic, regular, ,s1, s2,\n ABD: abdomen obese, mildly distended, nontender, no rebound, no\n guarding.\n EXT: DP 2+\n NEURO: able to move all extremeties, strength 5/5 upper and 4-5/5\n lower, R hip < L hip.\n Labs / Radiology\n 306 K/uL\n 8.8 g/dL\n 134 mg/dL\n 0.6 mg/dL\n 32 mEq/L\n 4.0 mEq/L\n 11 mg/dL\n 106 mEq/L\n 146 mEq/L\n 26.8 %\n 7.5 K/uL\n [image002.jpg]\n 03:10 AM\n 03:08 PM\n 03:00 AM\n 03:36 AM\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n 05:00 AM\n 02:06 AM\n WBC\n 11.3\n 7.3\n 6.1\n 7.2\n 5.2\n 5.9\n 7.5\n Hct\n 24.9\n 27.6\n 26.5\n 26.9\n 26.0\n 27.2\n 26.8\n Plt\n 227\n 189\n 209\n 238\n 240\n 296\n 306\n Cr\n 0.7\n 0.6\n 0.6\n 0.9\n 0.7\n 0.6\n 0.7\n 0.6\n TCO2\n 26\n Glucose\n 114\n 99\n 115\n 106\n 100\n 134\n 134\n Other labs: PT / PTT / INR:15.5/24.8/1.4, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:27/19, Alk Phos / T Bili:118/0.3,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:243 IU/L, Ca++:9.2 mg/dL, Mg++:2.1 mg/dL, PO4:4.0\n mg/dL\n CXR: no sig change from previous, some R sided infiltrate vs effusion,\n redistrubted from previous\n RUE U/S: (PRELIM) No evidence of DVT in the right upper extremity.\n Resolution of nonocclusive thrombus in the right axillary and basilic\n veins.\n LUE U/S: (PRELIM) Very small segment (1-cm in length) of nonocclusive\n thrombus in the left axillary vein. A PICC catheter is present on the\n left.\n Assessment and Plan\n 55yoF with history of EtOH abuse presenting following mechanical fall\n and traumatic T spine fracture, now s/p trach, PEG, placement being\n treated for HAP.\n# HAP vs Aspiration PNA: Cultures grew, Klebsiella Oxytoca, Klebsiella Pneumonia\ne, GNR, GP Cocci. Has completed 8 day course of Ceftriaxone. Has had occasional\nlow grade fevers, but has continued to improve clinically. Had a sputum gram sta\nin from w/ GPC p/c. a new VAP/HAP w/ staph possible, but given no clear inf\niltrate on CXR and good respiratory status, significant PNA is unlikely, coloniz\nation of tracheostomy tube is more likely, as is contamination of sputum. Given\n improving clinical picture, will wait until CX data or change in clinical statu\ns or CXR to initiate HAP/VAP treatment.\n - D/c Ceftriaxone\n - Continue to f/u cultures\n .\n # Respiratory failure: Improving status. Will continue to increase\n time on trach mask as tolerated.\n - PMV with suctioning.\n - Weaning FiO2 as tolerated\n # Tachycardia: Pt in ST 120\ns to 150s. Etiology remains unclear and\n include hypovolemia, pain, infection (pt with known klebsiella), and\n incrased work of breathing from secretions and tracheomalacia, . DDx\n also includes PE given hx of RUE DVT, mucus plugging given large\n amount of secretions, and spinal injury. Tachycardia is unresponsive to\n IVF, Pt has had a negative CT-PA and has not had sig response to pain\n meds. Has completed treatment for her HAP. Thyroid function was checked\n and had normal TSH and T3 and free T4. Had been on albuterol q4 and\n atrovent , she has not been wheezing, and perhaps she is sensitive to\n the B-agonist.\n - Continue Pain Control\n - Change albuterol to PRN\n - Test if HR decreases when placed on higher pressure support\n for period of time.\n # Sedation: Has had inconsistent response to sedation, unclear what is\n best regime. Will continue to wean overall\n - Change to haldol 2.5 PRN, Fentanyl 75 mcg TP, Morphine PRN,\n Benadryl, Valium 5mg PRN\n # Adrenal Insufficency: Followed up with endocrine that suggested if\n the patient under goes major stressors such as major surgery, sepsis,\n she may need stress dosed steroids.\n - Will consider MRI at later date for evaluation of pituitary\n # Fluid Status: Volume overloaded in prior setting of Hypernatremia\n - Monitoring urine output\n - increasse Free H20, for mild hypernatremia 200cc Free bolus PEG, and\n - 500cc D5W at 125.\n - PM lytes to assess hypernatremia\n # UE DVT: right has resolved, new non occlusive in left axillary. INR\n 1.5\n -continue coumadin\n -follow INR\n - D/c Left PICC line, and place peripheral IVs. If unable, can place a\n R PICC.\n # Spine fracture: Stable\n - Brace for OOB, will discuss with Neurosurgery if current brace is\n optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n # Tracheomalacia?: Was initially addressed with IP and they wanted to\n follow up as outpatient.\n - Consult IP for stent placement given improved clinical status, will\n readdresses\n #. Thyroid Nodule on CT\n - Outpatient follow up\n # Nutrition: Pt had emesis and extrusion of gastric contents through\n tracheostomy site (not through tube).\n - TFs held\n - Consult IR for advancement of her PEG to jejunum.\n # Glycemic control: SSI, well controlled\n # PIV x 1\n # Ppx: Restarting Coumadin, Ranitidine, Bowel Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n # Code: Full\n # Dispo: ICU, Screening for vent facilities\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Nutrition","chartdate":"2167-10-14 00:00:00.000","description":"Clinical Nutrition Note","row_id":637522,"text":"Objective\n Pertinent medications: noted\n Labs:\n Value\n Date\n Glucose\n 134 mg/dL\n 02:06 AM\n Glucose Finger Stick\n 139\n 10:00 AM\n BUN\n 11 mg/dL\n 02:06 AM\n Creatinine\n 0.6 mg/dL\n 02:06 AM\n Sodium\n 146 mEq/L\n 02:06 AM\n Potassium\n 4.0 mEq/L\n 02:06 AM\n Chloride\n 106 mEq/L\n 02:06 AM\n TCO2\n 32 mEq/L\n 02:06 AM\n Albumin\n 3.5 g/dL\n 03:00 AM\n Calcium non-ionized\n 9.2 mg/dL\n 02:06 AM\n Phosphorus\n 4.0 mg/dL\n 02:06 AM\n Ionized Calcium\n 1.24 mmol/L\n 02:51 AM\n Magnesium\n 2.1 mg/dL\n 02:06 AM\n Current diet order / nutrition support: Replete c. Fiber @60mL/hr (1440\n kcals/89 gr aa)\n GI: Abd: soft/dist/+bs\n Assessment of Nutritional Status\n Estimation of current intake: Adequate\n Specifics:\n Pt continues on TF\ns for full nutrition support via PEG, currently\n tolerating @ goal s/ problems. (Noted TF\ns were off over weekend / ?\n aspiration event) FWB down to 100mL q 4 hr c/ Na WNL. BG\ns well\n controlled.\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: via TF\n Tube feeding recommendations: Continue TF's @ goal\n Monitor fluid status and adjust FWB prn.\n BG and lyte management as you are\n Please check current wt\n"},{"category":"Respiratory ","chartdate":"2167-10-16 00:00:00.000","description":"Respiratory Care Shift Note","row_id":637872,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 28\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 7.0mm\n PMV: No\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Increase ventilatory support at night; Comments: Trach Trials as\n tolerated.\n Reason for continuing current ventilatory support:\n Note: rsbi 52\n"},{"category":"Physician ","chartdate":"2167-10-17 00:00:00.000","description":"Physician Resident Progress Note","row_id":638106,"text":"Chief Complaint:\n 24 Hour Events:\n Pt continued on B-Blocker for prior runs of SVT, HR peaked in 135\n Olanzapine 5mg QHS\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Ceftriaxone - 10:00 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 36.4\nC (97.5\n HR: 131 (119 - 149) bpm\n BP: 111/53(67) {99/28(50) - 185/99(144)} mmHg\n RR: 11 (11 - 30) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,408 mL\n 200 mL\n PO:\n 50 mL\n TF:\n IVF:\n 2,358 mL\n 200 mL\n Blood products:\n Total out:\n 1,795 mL\n 1,320 mL\n Urine:\n 1,795 mL\n 1,320 mL\n NG:\n Stool:\n Drains:\n Balance:\n 613 mL\n -1,120 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: MMV/PSV/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 415 (244 - 415) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 22 cmH2O\n Plateau: 17 cmH2O\n SpO2: 98%\n ABG: ///38/\n Ve: 5.5 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 462 K/uL\n 9.0 g/dL\n 137 mg/dL\n 0.6 mg/dL\n 38 mEq/L\n 3.9 mEq/L\n 5 mg/dL\n 101 mEq/L\n 146 mEq/L\n 28.9 %\n 7.1 K/uL\n [image002.jpg]\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n 05:00 AM\n 02:06 AM\n 07:34 AM\n 03:50 AM\n 06:22 AM\n 02:58 AM\n WBC\n 7.2\n 5.2\n 5.9\n 7.5\n 5.6\n 6.1\n 7.0\n 7.1\n Hct\n 26.9\n 26.0\n 27.2\n 26.8\n 27.0\n 27.0\n 29.7\n 28.9\n Plt\n 238\n 240\n 296\n \n 395\n 462\n Cr\n 0.6\n 0.9\n 0.7\n 0.6\n 0.7\n 0.6\n 0.5\n 0.7\n 0.7\n 0.6\n Glucose\n 115\n 106\n 100\n 134\n 134\n 121\n \n Other labs: PT / PTT / INR:36.6/30.0/3.9, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:9.8 mg/dL, Mg++:2.2 mg/dL, PO4:3.3\n mg/dL\n Assessment and Plan\n 55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach, PEG, placement being with respiratory failure secondary to\n tracheomalacia and HAP.\n .\n # Respiratory failure: Improving status. Will continue to increase\n time on trach mask as tolerated.\n - PMV with suctioning.\n - Continue to increase time on trach mask as tolerated.\n .\n # HAP vs Aspiration PNA: Cultures Positive for, Klebsiella Oxytoca,\n Klebsiella Pneumoniae, GNR, GP Cocci. 8 day course of Ceftriaxone\n completed. Occasional low grade fevers, clinically improved. Sputum\n gram stain from w/ GPC p/c. new VAP/HAP w/ staph possible, no\n clear infiltrate on CXR and good respiratory status. Potential\n colonization of tracheostomy and contamination of sputum. Given\n improving clinical picture, will wait until CX data or change in\n clinical status or CXR to initiate HAP/VAP treatment.\n - Completed course of ceftriaxone\n - Continue to f/u cultures\n - Continue trach mask as tolerated\n .\n # Tachycardia: Sinus Tach. HR decreases overnight with ranges of\n 115-135. From yesterday when pt found had runs of SVT as well as ST\n 120\ns to 150s. SBPs approx 65.\n Negative CT to evaluate for DVT, resp failure likely contributing\n - cont metoprolol 12.5mg TID and uptitrate as tolerated\n - monitor on telemetry\n - Continue Pain Control\n - Change albuterol to PRN\n .\n # Mental Status / Sedation: Has had inconsistent response to sedation,\n unclear what is best regime. Will continue to wean overall\n - DC haldol and taper valium to 2.5 mg PRN TID, taper off\n # Adrenal Insufficency: Followed up with endocrine that suggested if\n the patient under goes major stressors such as major surgery, sepsis,\n she may need stress dosed steroids.\n - Endocrine s/o\n no need for steroids currently\n .\n # Fluid Status: Volume overloaded in prior setting of Hypernatremia\n - Monitoring urine output\n - increasse Free H20, for mild hypernatremia 200cc Free bolus PEG, and\n - 500cc D5W at 125.\n - PM lytes to assess hypernatremia\n .\n # UE DVT: right has resolved, new non occlusive in left axillary. INR\n 1.5\n - continue coumadin\n - follow INR\n - PICC lines DC\n .\n # Spine fracture: Stable\n - Brace for OOB, will discuss with Neurosurgery if current brace is\n optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n .\n # Tracheomalacia?: Was initially addressed with IP and they wanted to\n follow up as outpatient.\n - Consult IP for stent placement given improved clinical status, will\n readdresses\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Nutrition: Pt had emesis and extrusion of gastric contents through\n tracheostomy site (not through tube).\n - TFs held\n - Appreciate thoracic\ns recs\n will add reglan 10mg Q6\n .\n # Glycemic control: SSI, well controlled\n # PIV x 1\n # Ppx: Restarting Coumadin, Ranitidine, Bowel Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n # Code: Full\n # Dispo: ICU, Screening for vent facilities\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:10 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Nursing","chartdate":"2167-10-17 00:00:00.000","description":"Nursing Progress Note","row_id":638167,"text":"Airway Clearance, Impaired\n Assessment:\n Pt placed on trach mask this am (on vent o/n). She continues to have\n moderate amts of thick secretions, requiring frequent sxn. Pt does have\n a strong/productive cough.\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n Tachycardia, Other\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2167-10-19 00:00:00.000","description":"Nursing Progress Note","row_id":638356,"text":"Hypernatremia (high sodium)\n Assessment:\n Na 148, pt vomited and tube feeds on hold as well as fluid boluses on\n hold.\n Action:\n Iv fluids of D5w at 125 cc/hr\n Response:\n Na decreased to 145 at 0330 lab check\n Plan:\n Continue with D5w at 125 cc/hr. check with ho in am regarding further\n iv orders and next na level check.\n Altered mental status (not Delirium)\n Assessment:\n Pt restless and moving all over bed.. There are also times when pt\n sleeps. pt nodded yes to generalized pain times once and at another\n time she nodded yes when asked if she was itichy.\n Action:\n Medicated with valium 2.5 mg gtube atc dose. Pt also received one dose\n of 2.5 mg iv for increased restlessness. Medicated with benadryl 25 mg\n iv for the c/o itch. Pt also received a dose of morphine 2 mg iv for\n c/o generalized discomfort.\n Response:\n Pt behaviour continues with episodic agitation followed by a period of\n sleep\n Plan:\n Continue atc valium. Evaluate pt for c/o itch/ pain and medicate\n accordingly\n Alteration in Nutrition\n Assessment:\n Pt vomited large amounts of tube feed. Copious amounts gushing from her\n mouth times three. Tube feeds stopped and hydration with iv fluids\n initiated. Pt continues to gag and have small amounts of brownish\n emesis when she coughs.\n Action:\n Regaln iv ATC, zofran 4 mg iv times 2, gtube to drainage.\n Response:\n Gtube drained 50 cc brownish/bilious.\n Plan:\n Airway Clearance, Impaired\n Assessment:\n Pt vomiting and tube feed gushing from mouth. Later when pt resting o2\n sats decreased to 90 %.\n Action:\n Pt turned to side to prevent aspiration. Suctioned trach for sm/mod\n white and blood tinged time 2 , pt placed on vent for decreased o2\n saturation.\n Response: sats improved to 97-99 % on 50 % mmv\n Plan: monitor sats, follow temp, chest xray done am rounds.. check\n results\n Response:\n [image002.jpg]\n Plan:\n"},{"category":"Physician ","chartdate":"2167-10-12 00:00:00.000","description":"Physician Attending Progress Note","row_id":637102,"text":"Chief Complaint: resp failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n rash- vesicular and d/c l;evoquin and started Ceftriaxone\n More tachycardic this AM - autonomic dysregulation\n Trach Mask for several hours\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Aztreonam - 03:42 AM\n Vancomycin - 09:40 AM\n Levofloxacin - 11:15 PM\n Ceftriaxone - 07:50 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 09:45 AM\n Haloperidol (Haldol) - 10:26 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 36.9\nC (98.5\n HR: 143 (113 - 145) bpm\n BP: 153/89(102) {85/40(50) - 153/89(102)} mmHg\n RR: 24 (9 - 30) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,362 mL\n 537 mL\n PO:\n TF:\n 47 mL\n 287 mL\n IVF:\n 1,061 mL\n 100 mL\n Blood products:\n Total out:\n 1,203 mL\n 615 mL\n Urine:\n 1,203 mL\n 615 mL\n NG:\n Stool:\n Drains:\n Balance:\n 159 mL\n -78 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Set): 0 (0 - 0) mL\n Vt (Spontaneous): 244 (110 - 504) mL\n PS : 10 cmH2O\n RR (Set): 0\n RR (Spontaneous): 19\n PEEP: 5 cmH2O\n FiO2: 70%\n RSBI: 245\n PIP: 16 cmH2O\n SpO2: 98%\n ABG: ///30/\n Ve: 10 L/min\n Physical Examination\n Gen\n Heent\n CV\n Chest\n Abd\n Ext\n Neuro\n Labs / Radiology\n 7.9 g/dL\n 240 K/uL\n 100 mg/dL\n 0.6 mg/dL\n 30 mEq/L\n 3.4 mEq/L\n 12 mg/dL\n 108 mEq/L\n 146 mEq/L\n 26.0 %\n 5.2 K/uL\n [image002.jpg]\n 08:11 PM\n 02:51 AM\n 03:10 AM\n 03:08 PM\n 03:00 AM\n 03:36 AM\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n WBC\n 9.4\n 11.3\n 7.3\n 6.1\n 7.2\n 5.2\n Hct\n 26.6\n 24.9\n 27.6\n 26.5\n 26.9\n 26.0\n Plt\n \n Cr\n 0.9\n 0.7\n 0.6\n 0.6\n 0.9\n 0.7\n 0.6\n TCO2\n 29\n 26\n Glucose\n 128\n 114\n 114\n 99\n 115\n 106\n 100\n Other labs: PT / PTT / INR:17.6/27.4/1.6, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:33/22, Alk Phos / T Bili:143/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:0.5 mmol/L,\n Albumin:3.5 g/dL, LDH:199 IU/L, Ca++:8.9 mg/dL, Mg++:2.4 mg/dL, PO4:4.1\n mg/dL\n Assessment and Plan 55 yr old alcoholic s/p t spine fx s/p trcah and\n PEG with persistent resp failure\n 1. Resp Failure: currently on trach mask, can do a few hours per\n day, then needs for support. New pan Klebs in sputum, day\n . Get Speech consult for PMV evaluation. Holding off on stent by IP\n until after pulm rehab.\n 2. Hemodynamics: tachycardia seems most likely due to agitation\n at present, did taper Valium aggressively, may be need to increase\n benzo slightly and see f it helps (haldol and morphione have not helped\n yet this AM)\n 3.\n ICU Care\n Nutrition: Replete with Fiber (Full) - 07:46 AM 30 mL/hour\n Glycemic Control:\n Lines: PICC Line - 09:19 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n Communication:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n"},{"category":"Physician ","chartdate":"2167-10-12 00:00:00.000","description":"Physician Attending Progress Note","row_id":637104,"text":"Chief Complaint: resp failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n rash- vesicular and d/c l;evoquin and started Ceftriaxone\n More tachycardic this AM - autonomic dysregulation\n Trach Mask for several hours\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Aztreonam - 03:42 AM\n Vancomycin - 09:40 AM\n Levofloxacin - 11:15 PM\n Ceftriaxone - 07:50 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 09:45 AM\n Haloperidol (Haldol) - 10:26 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 36.9\nC (98.5\n HR: 143 (113 - 145) bpm\n BP: 153/89(102) {85/40(50) - 153/89(102)} mmHg\n RR: 24 (9 - 30) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,362 mL\n 537 mL\n PO:\n TF:\n 47 mL\n 287 mL\n IVF:\n 1,061 mL\n 100 mL\n Blood products:\n Total out:\n 1,203 mL\n 615 mL\n Urine:\n 1,203 mL\n 615 mL\n NG:\n Stool:\n Drains:\n Balance:\n 159 mL\n -78 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Set): 0 (0 - 0) mL\n Vt (Spontaneous): 244 (110 - 504) mL\n PS : 10 cmH2O\n RR (Set): 0\n RR (Spontaneous): 19\n PEEP: 5 cmH2O\n FiO2: 70%\n RSBI: 245\n PIP: 16 cmH2O\n SpO2: 98%\n ABG: ///30/\n Ve: 10 L/min\n Physical Examination\n Gen\n Heent\n CV\n Chest\n Abd\n Ext\n Neuro\n Labs / Radiology\n 7.9 g/dL\n 240 K/uL\n 100 mg/dL\n 0.6 mg/dL\n 30 mEq/L\n 3.4 mEq/L\n 12 mg/dL\n 108 mEq/L\n 146 mEq/L\n 26.0 %\n 5.2 K/uL\n [image002.jpg]\n 08:11 PM\n 02:51 AM\n 03:10 AM\n 03:08 PM\n 03:00 AM\n 03:36 AM\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n WBC\n 9.4\n 11.3\n 7.3\n 6.1\n 7.2\n 5.2\n Hct\n 26.6\n 24.9\n 27.6\n 26.5\n 26.9\n 26.0\n Plt\n \n Cr\n 0.9\n 0.7\n 0.6\n 0.6\n 0.9\n 0.7\n 0.6\n TCO2\n 29\n 26\n Glucose\n 128\n 114\n 114\n 99\n 115\n 106\n 100\n Other labs: PT / PTT / INR:17.6/27.4/1.6, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:33/22, Alk Phos / T Bili:143/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:0.5 mmol/L,\n Albumin:3.5 g/dL, LDH:199 IU/L, Ca++:8.9 mg/dL, Mg++:2.4 mg/dL, PO4:4.1\n mg/dL\n Assessment and Plan 55 yr old alcoholic s/p t spine fx s/p trcah and\n PEG with persistent resp failure\n 1. Resp Failure: currently on trach mask, can do a few hours per\n day, then needs for support. New pan Klebs in sputum, day\n . Get Speech consult for PMV evaluation. Holding off on stent by IP\n until after pulm rehab.\n 2. Hemodynamics: tachycardia seems most likely due to agitation\n at present, did taper Valium aggressively, may be need to increase\n benzo slightly and see f it helps (haldol and morphione have not helped\n yet this AM)\n 3. Anti coag: for upper ext DVT but INR elevated on coumadin +\n quinolone\n repeat\n 4. Adrenal Insufficny: proper stim this AM\n ICU Care\n Nutrition: Replete with Fiber (Full) - 07:46 AM 30 mL/hour\n Glycemic Control:\n Lines: PICC Line - 09:19 PM\n Prophylaxis:\n DVT: inr levetaed recheck, and start coumadin when at 2.0\n Stress ulcer: ppi\n Communication:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n"},{"category":"Physician ","chartdate":"2167-10-14 00:00:00.000","description":"Physician Attending Progress Note","row_id":637493,"text":"Chief Complaint: resp failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n s/p t spine fx with resp failure\n 24 Hour Events:\n BLOOD CULTURED - At 02:18 AM\n SPUTUM CULTURE - At 02:18 AM\n URINE CULTURE - At 02:18 AM\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Ceftriaxone - 12:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fever\n Flowsheet Data as of 08:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.8\n Tcurrent: 37.2\nC (99\n HR: 137 (120 - 151) bpm\n BP: 125/55(73) {98/41(54) - 202/97(111)} mmHg\n RR: 23 (12 - 39) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,934 mL\n 497 mL\n PO:\n TF:\n 1,104 mL\n 447 mL\n IVF:\n 1,000 mL\n 50 mL\n Blood products:\n Total out:\n 530 mL\n 240 mL\n Urine:\n 530 mL\n 240 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,404 mL\n 257 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 318 (318 - 475) mL\n PS : 10 cmH2O\n RR (Spontaneous): 34\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 171\n SpO2: 98%\n ABG: ///32/\n Ve: 9 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 8.8 g/dL\n 306 K/uL\n 134 mg/dL\n 0.6 mg/dL\n 32 mEq/L\n 4.0 mEq/L\n 11 mg/dL\n 106 mEq/L\n 146 mEq/L\n 26.8 %\n 7.5 K/uL\n [image002.jpg]\n 03:10 AM\n 03:08 PM\n 03:00 AM\n 03:36 AM\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n 05:00 AM\n 02:06 AM\n WBC\n 11.3\n 7.3\n 6.1\n 7.2\n 5.2\n 5.9\n 7.5\n Hct\n 24.9\n 27.6\n 26.5\n 26.9\n 26.0\n 27.2\n 26.8\n Plt\n 227\n 189\n 209\n 238\n 240\n 296\n 306\n Cr\n 0.7\n 0.6\n 0.6\n 0.9\n 0.7\n 0.6\n 0.7\n 0.6\n TCO2\n 26\n Glucose\n 114\n 99\n 115\n 106\n 100\n 134\n 134\n Other labs: PT / PTT / INR:13.5/23.6/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:27/19, Alk Phos / T Bili:118/0.3,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:243 IU/L, Ca++:9.2 mg/dL, Mg++:2.1 mg/dL, PO4:4.0\n mg/dL\n Assessment and Plan\n Assessment and Plan 55 yr old alcoholic s/p t spine fx s/p trcah and\n PEG with persistent resp failure\n 1. Resp Failure: currently on trach mask, can do a few hours per\n day, then needs for support. New pan Klebs in sputum, day\n . Re- try. Holding off on stent by IP until after pulm rehab.\n 2. Hemodynamics: tachycardia with slightly decreased UOP\n bolus\n IVF and trend UOP. Watch to see if response with tachycardia.\n 3. Anti coag: for upper ext DVT but INR elevated on coumadin +\n quinolone\n repeat inr low- trend with po COumadin\n 4. Adrenal Insufficiency: proper stim this AM, off steroids\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 06:23 AM 60 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n"},{"category":"Nursing","chartdate":"2167-10-15 00:00:00.000","description":"Nursing Progress Note","row_id":637630,"text":"Tachycardia, Other\n Assessment:\n Continues to be Tachycardia in 120-145 (anxiety). SBP has been 100-145\n without ectopy.\n Action:\n No medication given for tachycardia.Pt gets Valium 5 mg scheduled Q6H\n with little effect. CTA done to r/o pe as a source of tachycardia.\n Response:\n Results pending on CTA.\n Plan:\n Continue to evaluate HR and BP for need of treatment.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt has a known DVT to RUE. Today pt had a US of LUEand ruled out small\n non occlusive clot on her left axial vein.\n Action:\n Dr ,pt received ceftriaxone via PICC line.Coumadin dosage\n increased from 2.5 to 5 mg ( INR 1.4).\n Response:\n Repeat ultrasound orderd for right arm to check old clot. Pt received 5\n mg coumadin at 2200.\n Plan:\n Ultrasound today,cont coumadin and closely monitor INR.\n Altered mental status (not Delirium)\n Assessment:\n Pt has been restless most of the night. Pt nodded her head for pain and\n simple yes or no questions.\n Action:\n Pt given scheduled Valium with little effect.\n Response:\n Pt slept for a while,Hr dropped to 120s at the time of rest.\n Plan:\n Continue to eval MS,Valium and PRN Morphine and haldol?.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt rested on CPAP+ PS 50%/,sats stayed upper 90\ns,Pt found to have\n TF coming around Tracheostomy. As well as from her mouth\n Action:\n Cont pulm toilet as needed,Held TF throughout the night .\n Response:\n Pt suctioned for small- moderate amount thick yellow secretions.No more\n leakage noted around the tracheostomy as well as Minimal residuals from\n PEG tube\n Plan:\n Continue to wean pt off vent and place on TC once pt can tol it again\n and frequent pulmonary toileting. Restart TF?\n"},{"category":"Nursing","chartdate":"2167-10-15 00:00:00.000","description":"Nursing Progress Note","row_id":637633,"text":"56 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\n with prolonged hospital course c/b by PNA, anxiety/altered mental\n status, RUE DVT .Pt found to have small non occlusive Clot on her right\n axial vein via Ultrasound.\n Tachycardia, Other\n Assessment:\n Continues to be Tachycardia in 120-145 (anxiety). SBP has been 100-145\n without ectopy.\n Action:\n No medication given for tachycardia.Pt gets Valium 5 mg scheduled Q6H\n with little effect. CTA done to r/o pe as a source of tachycardia.\n Response:\n Results pending on CTA.\n Plan:\n Continue to evaluate HR and BP for need of treatment.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt has a known DVT to RUE. Today pt had a US of LUEand ruled out small\n non occlusive clot on her left axial vein.\n Action:\n Dr ,pt received ceftriaxone via PICC line.Coumadin dosage\n increased from 2.5 to 5 mg ( INR 1.4).\n Response:\n Repeat ultrasound orderd for right arm to check old clot. Pt received 5\n mg coumadin at 2200.\n Plan:\n Ultrasound today,cont coumadin and closely monitor INR.\n Altered mental status (not Delirium)\n Assessment:\n Pt has been restless most of the night. Pt nodded her head for pain and\n simple yes or no questions.\n Action:\n Pt given scheduled Valium with little effect.\n Response:\n Pt slept for a while,Hr dropped to 120s at the time of rest.\n Plan:\n Continue to eval MS,Valium and PRN Morphine and haldol?.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt rested on CPAP+ PS 50%/,sats stayed upper 90\ns,Pt found to have\n TF coming around Tracheostomy. As well as from her mouth\n Action:\n Cont pulm toilet as needed,Held TF throughout the night .\n Response:\n Pt suctioned for small- moderate amount thick yellow secretions.No more\n leakage noted around the tracheostomy as well as Minimal residuals from\n PEG tube\n Plan:\n Continue to wean pt off vent and place on TC once pt can tol it again\n and frequent pulmonary toileting. Restart TF?\n"},{"category":"Physician ","chartdate":"2167-10-16 00:00:00.000","description":"Physician Resident Progress Note","row_id":638014,"text":"Chief Complaint: Tracheomalacia\n 24 Hour Events:\n ULTRASOUND - At 08:11 AM\n right arm - negative for DVT\n PICC LINE - STOP 12:02 PM\n - IR unable to advance PEG\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Ceftriaxone - 10:00 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:12 AM\n Morphine Sulfate - 12:00 PM\n Haloperidol (Haldol) - 02:00 PM\n Diazepam (Valium) - 03:52 PM\n Furosemide (Lasix) - 06:40 AM\n Other medications:\n Changes to medical and family history:\n None\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.2\nC (97.1\n HR: 139 (97 - 146) bpm\n BP: 133/67(84) {93/43(55) - 183/129(134)} mmHg\n RR: 18 (13 - 33) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,220 mL\n 568 mL\n PO:\n TF:\n IVF:\n 500 mL\n 568 mL\n Blood products:\n Total out:\n 1,514 mL\n 150 mL\n Urine:\n 1,439 mL\n 150 mL\n NG:\n 75 mL\n Stool:\n Drains:\n Balance:\n -294 mL\n 418 mL\n Respiratory support\n O2 Delivery Device: Trach mask , Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 384 (311 - 675) mL\n PS : 10 cmH2O\n RR (Spontaneous): 12\n PEEP: 5 cmH2O\n FiO2: 70%\n RSBI: 52\n PIP: 15 cmH2O\n SpO2: 96%\n ABG: ///31/\n Ve: 4.6 L/min\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic,\n No(t) Diastolic), tachy, regular\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Attentive,\n Labs / Radiology\n 395 K/uL\n 9.0 g/dL\n 619 mg/dL\n 0.7 mg/dL\n 31 mEq/L\n 3.3 mEq/L\n 6 mg/dL\n 91 mEq/L\n 129 mEq/L\n 29.7 %\n 7.0 K/uL\n [image002.jpg]\n 03:36 AM\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n 05:00 AM\n 02:06 AM\n 07:34 AM\n 03:50 AM\n 06:22 AM\n WBC\n 7.2\n 5.2\n 5.9\n 7.5\n 5.6\n 6.1\n 7.0\n Hct\n 26.9\n 26.0\n 27.2\n 26.8\n 27.0\n 27.0\n 29.7\n Plt\n 238\n 240\n 296\n \n 395\n Cr\n 0.6\n 0.9\n 0.7\n 0.6\n 0.7\n 0.6\n 0.5\n 0.7\n TCO2\n 26\n Glucose\n 115\n 106\n 100\n 134\n 134\n 121\n 619\n Other labs: PT / PTT / INR:23.4/29.6/2.3, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:8.4 mg/dL, Mg++:1.9 mg/dL, PO4:3.9\n mg/dL\n Microbiology: 7:34 am STOOL CONSISTENCY: FORMED\n Source: Stool.\n **FINAL REPORT **\n CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final ):\n Feces negative for C.difficile toxin A & B by EIA.\n (Reference Range-Negative).\n .\n 7:33 am BLOOD CULTURE Source: Line-picc.\n **FINAL REPORT **\n Blood Culture, Routine (Final ): NO GROWTH\n Assessment and Plan\n Assessment and Plan\n 55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach, PEG, placement being with respiratory failure secondary to\n tracheomalacia and HAP.\n .\n # HAP vs Aspiration PNA: Cultures grew, Klebsiella Oxytoca, Klebsiella\n Pneumoniae, GNR, GP Cocci. Has completed 8 day course of Ceftriaxone.\n Has had occasional low grade fevers, but has continued to improve\n clinically. Had a sputum gram stain from w/ GPC p/c. a new VAP/HAP\n w/ staph possible, but given no clear infiltrate on CXR and good\n respiratory status, significant PNA is unlikely, colonization of\n tracheostomy tube is more likely, as is contamination of sputum. Given\n improving clinical picture, will wait until CX data or change in\n clinical status or CXR to initiate HAP/VAP treatment.\n - Completed course of ceftriaxone\n - Continue to f/u cultures\n - Continue trach mask as tolerated\n .\n # Respiratory failure: Improving status. Will continue to increase\n time on trach mask as tolerated.\n - PMV with suctioning.\n - Tolerating trach mask\n .\n # Tachycardia: Pt found to have runs of SVT as well as ST 120\ns to\n 150s. She had a negative CT to evaluate for DVT, resp failure likely\n contributing\n - start metoprolol 12.5mg TID and uptitrate as tolerated\n - monitor on telemetry\n - Continue Pain Control\n - Change albuterol to PRN\n .\n # Sedation: Has had inconsistent response to sedation, unclear what is\n best regime. Will continue to wean overall\n - DC haldol and taper valium to 2.5 mg PRN TID, taper off\n - .\n # Adrenal Insufficency: Followed up with endocrine that suggested if\n the patient under goes major stressors such as major surgery, sepsis,\n she may need stress dosed steroids.\n - Endocrine s/o\n no need for steroids currently\n .\n # Fluid Status: Volume overloaded in prior setting of Hypernatremia\n - Monitoring urine output\n - increasse Free H20, for mild hypernatremia 200cc Free bolus PEG, and\n - 500cc D5W at 125.\n - PM lytes to assess hypernatremia\n .\n # UE DVT: right has resolved, new non occlusive in left axillary. INR\n 1.5\n -continue coumadin\n -follow INR\n - PICC lines DC\n .\n # Spine fracture: Stable\n - Brace for OOB, will discuss with Neurosurgery if current brace is\n optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n .\n # Tracheomalacia?: Was initially addressed with IP and they wanted to\n follow up as outpatient.\n - Consult IP for stent placement given improved clinical status, will\n readdresses\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Nutrition: Pt had emesis and extrusion of gastric contents through\n tracheostomy site (not through tube).\n - TFs held\n - Appreciate thoracic\ns recs\n will add reglan 10mg Q6\n .\n # Glycemic control: SSI, well controlled\n .\n # PIV x 1\n .\n # Ppx: Restarting Coumadin, Ranitidine, Bowel Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n # Code: Full\n # Dispo: ICU, Screening for vent facilities\n ICU Care\n Nutrition:\n Comments: Tube feeds\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 12:26 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition:ICU\n"},{"category":"Physician ","chartdate":"2167-10-18 00:00:00.000","description":"Physician Resident Progress Note","row_id":638227,"text":"Chief Complaint:\n 24 Hour Events:\n Pt was agitated during the day with no response to PRN zyprexa.\n Her sodium was increased to 150 yesterday, and she was given 500cc D5W\n bolus and her FW flushes for her tube feeds was increases from 100 to\n 150.\n Overnight, pt received zyprexa, valium, and was placed back on the\n ventilator, after which she was more sedated and her SBP dropped to the\n 70s and HR remained 120-130s. Her BP came back up to 110s-120s when she\n was woken up.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:11 AM\n Morphine Sulfate - 04:00 AM\n Diazepam (Valium) - 05:24 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.4\nC (97.5\n HR: 126 (118 - 140) bpm\n BP: 98/62(70) {74/38(47) - 145/105(114)} mmHg\n RR: 29 (11 - 35) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 959 mL\n 1,250 mL\n PO:\n TF:\n 176 mL\n 140 mL\n IVF:\n 463 mL\n 810 mL\n Blood products:\n Total out:\n 1,980 mL\n 130 mL\n Urine:\n 1,980 mL\n 130 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,021 mL\n 1,120 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: MMV/PSV/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 408 (408 - 499) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 26\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 149\n PIP: 16 cmH2O\n Plateau: 21 cmH2O\n SpO2: 95%\n ABG: ///36/\n Ve: 6.4 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 452 K/uL\n 8.9 g/dL\n 104 mg/dL\n 0.7 mg/dL\n 36 mEq/L\n 3.5 mEq/L\n 6 mg/dL\n 103 mEq/L\n 145 mEq/L\n 29.2 %\n 7.1 K/uL\n [image002.jpg]\n 03:00 AM\n 07:05 PM\n 03:00 AM\n 05:00 AM\n 02:06 AM\n 07:34 AM\n 03:50 AM\n 06:22 AM\n 02:58 AM\n 03:43 AM\n WBC\n 7.2\n 5.2\n 5.9\n 7.5\n 5.6\n 6.1\n 7.0\n 7.1\n 7.1\n Hct\n 26.9\n 26.0\n 27.2\n 26.8\n 27.0\n 27.0\n 29.7\n 28.9\n 29.2\n Plt\n 238\n 240\n 296\n \n 395\n 462\n 452\n Cr\n 0.9\n 0.7\n 0.6\n 0.7\n 0.6\n 0.5\n 0.7\n 0.7\n 0.6\n 0.7\n Glucose\n 106\n 100\n 134\n 134\n 121\n 619\n 126\n 137\n 104\n Other labs: PT / PTT / INR:66.1/32.7/8.0, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:9.3 mg/dL, Mg++:2.2 mg/dL, PO4:3.8\n mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 12:38 PM 30 mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 12:35 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2167-10-18 00:00:00.000","description":"Physician Resident Progress Note","row_id":638228,"text":"Chief Complaint:\n 24 Hour Events:\n Pt was agitated during the day with no response to PRN zyprexa.\n Her sodium was increased to 150 yesterday, and she was given 500cc D5W\n bolus and her FW flushes for her tube feeds was increases from 100 to\n 150.\n Overnight, pt received zyprexa, valium, and was placed back on the\n ventilator, after which she was more sedated and her SBP dropped to the\n 70s and HR remained 120-130s. Her BP came back up to 110s-120s when she\n was woken up.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:11 AM\n Morphine Sulfate - 04:00 AM\n Diazepam (Valium) - 05:24 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.4\nC (97.5\n HR: 126 (118 - 140) bpm\n BP: 98/62(70) {74/38(47) - 145/105(114)} mmHg\n RR: 29 (11 - 35) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 959 mL\n 1,250 mL\n PO:\n TF:\n 176 mL\n 140 mL\n IVF:\n 463 mL\n 810 mL\n Blood products:\n Total out:\n 1,980 mL\n 130 mL\n Urine:\n 1,980 mL\n 130 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,021 mL\n 1,120 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: MMV/PSV/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 408 (408 - 499) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 26\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 149\n PIP: 16 cmH2O\n Plateau: 21 cmH2O\n SpO2: 95%\n ABG: ///36/\n Ve: 6.4 L/min\n Physical Examination\n Gen: NAD, A0X3\n HEENT: PERRLA, EOMI\n Resp: Limited by patients mobility, but CTA anteriorly\n Card: S1S2 tachy\n Abd: Soft, Non-tender, Non-distended, BS+\n Exte: No edema\n Labs / Radiology\n 452 K/uL\n 8.9 g/dL\n 104 mg/dL\n 0.7 mg/dL\n 36 mEq/L\n 3.5 mEq/L\n 6 mg/dL\n 103 mEq/L\n 145 mEq/L\n 29.2 %\n 7.1 K/uL\n [image002.jpg]\n 03:00 AM\n 07:05 PM\n 03:00 AM\n 05:00 AM\n 02:06 AM\n 07:34 AM\n 03:50 AM\n 06:22 AM\n 02:58 AM\n 03:43 AM\n WBC\n 7.2\n 5.2\n 5.9\n 7.5\n 5.6\n 6.1\n 7.0\n 7.1\n 7.1\n Hct\n 26.9\n 26.0\n 27.2\n 26.8\n 27.0\n 27.0\n 29.7\n 28.9\n 29.2\n Plt\n 238\n 240\n 296\n \n 395\n 462\n 452\n Cr\n 0.9\n 0.7\n 0.6\n 0.7\n 0.6\n 0.5\n 0.7\n 0.7\n 0.6\n 0.7\n Glucose\n 106\n 100\n 134\n 134\n 121\n 619\n 126\n 137\n 104\n Other labs: PT / PTT / INR:66.1/32.7/8.0, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:9.3 mg/dL, Mg++:2.2 mg/dL, PO4:3.8\n mg/dL\n Assessment and Plan\n 55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach, PEG, placement no with respiratory failure secondary to\n tracheomalacia , resolving HAP.\n .\n # Respiratory failure: Slowly Improving. Pressure support of at\n night.\n - Continue to increase time on trach mask as tolerated.\n - PMV with suctioning.\n .\n # HAP vs Aspiration PNA: Afebrile without leukocytosis\n - Completed course of ceftriaxone\n - Continue to f/u cultures\n - Continue trach mask as tolerated\n .\n # Tachycardia: Sinus Tach with occasional runs of SVT, now on low dose\n b-blocker. . HR decreased overnight with ranges of 115-135. From\n yesterday when pt found had runs of SVT as well as ST 120\ns to 150s.\n SBPs approx 65.\n Had Negative CTA, thyroid fxn WNL,\n - HR became tachy on , will further investigate events surrounding\n the event for further data\n - cont metoprolol 12.5mg TID and up titrate as tolerated\n - monitor on telemetry\n - Continue Pain Control\n .\n # Sedation: Inconsistent response to sedation, unclear what is best\n regime. Will continue to wean overall\n - Started on Olanzapine QHS\n - DC\nd haldol and taper valium to 2.5 mg PRN TID, taper off\n # Nutrition: Pt had emesis overnight. TFs currently held. Given\n Reglan.\n - Restart Nutrition as tolerated\n .\n # Adrenal Insufficency: Endocrine following. Followed Suggesting if\n the patient under goes major stressors such as major surgery, sepsis,\n she may need stress dosed steroids.\n - Endocrine s/o\n no need for steroids currently\n .\n # Fluid Status: Volume overloaded in prior setting of Hypernatremia\n - Monitoring urine output\n - increase Free H20, for mild hypernatremia 200cc Free bolus PEG, and\n - 500cc D5W at 125.\n - PM lytes to assess hypernatremia\n .\n # UE DVT: right has resolved, new non occlusive in left axillary. INR\n supratherapeutic today\n - decrease coumadin to home dose of 2.5mg\n - follow INR\n .\n # Spine fracture: Stable\n - Brace for OOB, will discuss with Neurosurgery if current brace is\n optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n .\n # Tracheomalacia. Was initially addressed with IP and they wanted to\n follow up as outpatient.\n - Consult IP for stent placement given improved clinical status, will\n readdresses\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # PIV x 1\n # Ppx: Coumadin, Ranitidine, Bowel Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n # Code: Full\n # Dispo: ICU, Screening for vent facilities\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 12:38 PM 30 mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 12:35 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Nursing","chartdate":"2167-10-11 00:00:00.000","description":"Nursing Progress Note","row_id":636842,"text":"Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on trach collar 50%. Sats fell to 78%. Pt ambu\nd and\n lavaged with no plugs detected. RR 30-40 . Pt diaphoretic.\n Action:\n Placed on PSV 10/5/50%\n Response:\n Apneic with RR 3-5\n Plan:\n Rested on AC 500/12/5/50%. No further episodes of desating or\n tachypnea.\n Hypotension (not Shock)\n Assessment:\n BP falling to 78/37. Urine output 5-30ccs/hr via foley\n Action:\n Given 500ccs\n NS fluid bolus\n Response:\n Pt normotensive, improved urine output\n Plan:\n Continue to monitor.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Temp spike to 102.2 po\n Action:\n Blood, urine and sputum cxs sent. Sputum white, not yellow or\n consistant with TF. Chest x-ray taken. Tylenol pr given. Cool cloths\n applied.\n Response:\n Pt normothermic. WBC 7.2\n Plan:\n Monitor fever curve, cooling measures. Follow-up on cx results.\n Alteration in Nutrition\n Assessment:\n Pt vomiting yellow fluid with coughing and when turned\n Action:\n TF held. Peg to gravity. Medicated with 4 mg zofran iv.\n Response:\n No further episodes of vomiting.\n Plan:\n Continue to monitor. Aspiration precautions. ? need for alternative\n form of nutrition.\n Altered mental status (not Delirium)\n Assessment:\n Onset of shift, pt lethargic, not following commands but MAE. ~ 12 mn\n pt agitated, attempting to climb oob, disconnecting self from vent\n despite restraints\n Action:\n 5 mg valium given q 8hrs. Haldol 2.5 mg given.\n Response:\n Pt still agitated\n Plan:\n Needs better sedation at bedtime - ? zyprexa or alternative med\n"},{"category":"Nursing","chartdate":"2167-10-11 00:00:00.000","description":"Nursing Progress Note","row_id":636935,"text":"56 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\n with prolonged hospital course c/b by PNA, anxiety/altered mental\n status, RUE DVT .\n Altered mental status (not Delirium)\n Assessment:\n Rec\nd pt very restless/agitated, repeatedly attempting to sit up in bed\n and pulling at soft wrist restraints. When arms freed, she immediately\n disconnected trach from vent. Agitation did not subside with verbal\n reassurance or scheduled dose valium. Pt follows commands\n inconsistently, has difficulty initiating cough on command. MAEE with\n good strength. Not grimacing and denied pain by mouthing words.\n Action:\n Pt noted to have rash per below, nodded\n to\nDoes you back itch?\n and rec\nd Benadryl 25mg IV @ 1345.\n Response:\n Pt finally sleeping after having been awake most of night and very\n restless all morning.\n Plan:\n Benadryl Q6hrs PRN. Cont freq mental/neuro eval.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt on AC vent settings 50%/12 X 500/+5.\n Action:\n Response:\n Plan:\n Tachycardia, Other\n Assessment:\n HR 130\ns @ rest throughout shift, and still > 125 when pt soundly\n sleeping. Pt Afebrile.\n Action:\n Response:\n Plan:\n Rash\n Assessment:\n Pt noted to have raised red rash evenly distributed over mid/lower\n back. Pt has been very restless, and nodded\n to\nDoes your back\n itch?\n. No new meds recently.\n Action:\n Team made aware, and they examined rash. Pt rec\nd Benadryl 25mg IV X 1.\n Response:\n Pt finally able to sleep after very restless night and morning.\n Plan:\n Benadryl PRN Q6hrs. ? Sarna lotion. Cont to monitor rash.\n"},{"category":"Nursing","chartdate":"2167-10-19 00:00:00.000","description":"Nursing Progress Note","row_id":638376,"text":"Addendum:\n Decreased urine ouput:\n Urine ouput decreased to 20 -10 cc/hr. foley catheter flushed easily\n and return clear. D 5 w increased to 125 cc/hr. urine ouput did not\n pick up until after pt given lasix dose of 10 mg iv. Diuresed. 0600\n urine ouput again decreased to 15 cc/hr\n Plan: monitor urine ouput.. notify ho if uo continues < 30 cc/hr.\n Altered rhythm: pt in a sinus tachycardia throughout the night, about\n 6:05 this morning pt converted to a first degree avb. O0600 lopressor\n dose held for sbp 86/\n"},{"category":"Physician ","chartdate":"2167-10-14 00:00:00.000","description":"Physician Resident Progress Note","row_id":637419,"text":"Chief Complaint:\n 24 Hour Events:\n UOP 10-20cc/hr, tachy to 150s while sitting upright, 120s at rest.\n Pt on PMV but had heavy secretions. Trach collar for 5 hours.\n Repeat Sputum Cx + for GNR, fungal, 1+ Gram + Cocci in Pairs.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 09:40 AM\n Levofloxacin - 11:15 PM\n Ceftriaxone - 07:50 PM\n Infusions:\n Other ICU medications:\n Haloperidol (Haldol) - 10:26 AM\n Diazepam (Valium) - 11:33 AM\n Morphine Sulfate - 02:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.7\nC (98.1\n HR: 118 (118 - 148) bpm\n BP: 90/37(48) {90/37(48) - 171/111(115)} mmHg\n RR: 14 (12 - 36) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,614 mL\n 439 mL\n PO:\n TF:\n 884 mL\n 279 mL\n IVF:\n 100 mL\n Blood products:\n Total out:\n 834 mL\n 20 mL\n Urine:\n 834 mL\n 20 mL\n NG:\n Stool:\n Drains:\n Balance:\n 780 mL\n 419 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 354 (244 - 376) mL\n PS : 10 cmH2O\n RR (Spontaneous): 12\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 56\n PIP: 15 cmH2O\n SpO2: 95%\n ABG: ////\n Ve: 4.1 L/min\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n Eyes / Conjunctiva: PERRL, Pupils dilated\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Bowel sounds present, Obese, Patient with thoracic\n brace on\n Skin: Not assessed, No(t) Rash: , Per Nursing: Pt with vesicular rash\n on inferior back.\n Neurologic: Follows simple commands, Responds to: Not assessed,\n Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 240 K/uL\n 7.9 g/dL\n 100 mg/dL\n 0.6 mg/dL\n 30 mEq/L\n 3.4 mEq/L\n 12 mg/dL\n 108 mEq/L\n 146 mEq/L\n 26.0 %\n 5.2 K/uL\n [image002.jpg]\n 08:11 PM\n 02:51 AM\n 03:10 AM\n 03:08 PM\n 03:00 AM\n 03:36 AM\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n WBC\n 9.4\n 11.3\n 7.3\n 6.1\n 7.2\n 5.2\n Hct\n 26.6\n 24.9\n 27.6\n 26.5\n 26.9\n 26.0\n Plt\n \n Cr\n 0.9\n 0.7\n 0.6\n 0.6\n 0.9\n 0.7\n 0.6\n TCO2\n 29\n 26\n Glucose\n 128\n 114\n 114\n 99\n 115\n 106\n 100\n Other labs: PT / PTT / INR:17.6/27.4/1.6, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:33/22, Alk Phos / T Bili:143/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:0.5 mmol/L,\n Albumin:3.5 g/dL, LDH:199 IU/L, Ca++:8.9 mg/dL, Mg++:2.4 mg/dL, PO4:4.1\n mg/dL\n Assessment and Plan\n 55yoF with history of EtOH abuse presenting following mechanical fall\n and traumatic T spine fracture, now s/p trach, PEG, placement being\n treated for HAP.\n# HAP vs Aspiration PNA: Cultures growing Klebsiella Oxytoca, Klebsiella Pneumon\niae, GNR, GP Cocci. Pt received developed rash on Levofloxacin, switched to Ceft\nriaxone overnight. Will treat for potential HAP for 8 days.\n - Continue Ceftriaxone HAP (Day #6 of 8)\n - Tube Feeds now at 50 with goal of 60/hr\n - Following Cultures\n .\n # Respiratory failure: 5 hours on Trach mask yesterday, will assess\n length of tolerance today.\n - PMV with suctioning.\n - Weaning FiO2 as tolerated\n # Tachycardia: Pt in ST 120\ns to 150s. Etiology remains unclear and\n etiologies include hypovolemia, pain, infection (pt with known\n klebsiella), . DDx also includes PE\n - Treating underlying infection\n - Bolus NS 500cc x 2 today and assess HR\n - Restarting patients Coumadin\n - TSH 2.4 on early , will check free T3, T4.\n - Continue Pain Control\n # Sedation: Pt has pain/delirium causing tachycardia and hypertension\n with intermittent hypotension. Had good response to morphine, minimal\n response to haldol bolus.\n - Haldol 5 TID, Fentanyl 75 mcg TP, Diazapam 10 QID;\n - Haldol, midazolam and morphine PRN.\n - tolerating current regimen well\n # Adrenal Insufficency: Followed up with endocrine that suggested if\n the patient under goes major stressors such as major surgery, sepsis,\n she may need stress dosed steroids.\n - Will consider MRI at later date for evaluation of pituitary\n # Fluid Status: Volume overloaded in prior setting of Hypernatremia\n Goal even today.\n - Monitoring urine output\n # RUE DVT: INR was super-therapeutic on coumadin. Goal . Received 5\n of coumadin overnight.\n - Restarting Coumadin 2.5 mg QHS once INR < 3\n # Spine fracture: Stable\n - Brace for OOB, will discuss with Neurosurgery if current brace is\n optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n # Tracheomalacia?: Discussed with IP.\n - Outpatient f/u once off pressure support to assess for possible\n stenting\n #. Thyroid Nodule on CT\n - Outpatient follow up\n # Nutrition: TFs with goal of 60\n # Glycemic control: SSI, well controlled\n # Lines L PICC\n ().\n # Ppx: Restarting Coumadin, Ranitidine, Bowel Regimen\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n # Code: Full\n # Dispo: ICU, Screening for vent facilities\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 11:38 AM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n 20 Gauge - 04:59 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2167-10-15 00:00:00.000","description":"Physician Attending Progress Note","row_id":637728,"text":"Chief Complaint: resp failuire\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n ULTRASOUND - At 03:48 PM\n US of Lt arm shows small 1 cm axillary clot non occlusive near PICC\n RUS US shows resolutyion of formal clot\n Vomting tube feeds around trach\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Ceftriaxone - 10:00 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 06:20 AM\n Pantoprazole (Protonix) - 08:12 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Gastrointestinal: Emesis\n Flowsheet Data as of 10:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 36.2\nC (97.1\n HR: 146 (123 - 146) bpm\n BP: 153/129(134) {106/41(56) - 185/129(142)} mmHg\n RR: 26 (11 - 33) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,888 mL\n 520 mL\n PO:\n TF:\n 1,268 mL\n IVF:\n 100 mL\n Blood products:\n Total out:\n 1,530 mL\n 845 mL\n Urine:\n 1,510 mL\n 820 mL\n NG:\n 20 mL\n 25 mL\n Stool:\n Drains:\n Balance:\n 358 mL\n -325 mL\n Respiratory support\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 227 (227 - 397) mL\n PS : 8 cmH2O\n RR (Spontaneous): 20\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 194\n PIP: 16 cmH2O\n SpO2: 96%\n ABG: ///34/\n Ve: 6.5 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 8.5 g/dL\n 335 K/uL\n 121 mg/dL\n 0.5 mg/dL\n 34 mEq/L\n 3.8 mEq/L\n 7 mg/dL\n 107 mEq/L\n 147 mEq/L\n 27.0 %\n 5.6 K/uL\n [image002.jpg]\n 03:08 PM\n 03:00 AM\n 03:36 AM\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n 05:00 AM\n 02:06 AM\n 07:34 AM\n WBC\n 7.3\n 6.1\n 7.2\n 5.2\n 5.9\n 7.5\n 5.6\n Hct\n 27.6\n 26.5\n 26.9\n 26.0\n 27.2\n 26.8\n 27.0\n Plt\n 189\n 209\n 238\n \n 335\n Cr\n 0.6\n 0.6\n 0.9\n 0.7\n 0.6\n 0.7\n 0.6\n 0.5\n TCO2\n 26\n Glucose\n 99\n 115\n 106\n 100\n 134\n 134\n 121\n Other labs: PT / PTT / INR:16.6/25.0/1.5, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:9.3 mg/dL, Mg++:2.3 mg/dL, PO4:4.1\n mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent:\n"},{"category":"Nursing","chartdate":"2167-10-18 00:00:00.000","description":"Nursing Progress Note","row_id":638220,"text":"56 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\n with prolonged hospital course c/b by PNA, anxiety/altered mental\n status, RUE DVT .Pt found to have small non occlusive Clot on her right\n axial vein via Ultrasound.Yesterday Pt went down to IR for Peg revision\n aspiration risk couldn\nt do it due the type of peg she has now.\n Altered mental status (not Delirium)\n Assessment:\n Restless, attempting to get OOB, kicking and hitting siderails,\n attempting to sit up, attempting to grab at all lines and tubes, bilat\n wrist restraints and waist belt on for pt\ns safety, mouthing words and\n following simple commands, slept soundly for 3-4 hours following\n zyprexa and valium\n Action:\n Morphine 2 mg. IV x 2 with no effect, Zyprexa and valium at bedtime\n with pt asleep for 3-4 hours, Valium 2.5 mg again this am with no\n effect, When pt asleep s BP dips to 70-80\ns---MICU team assessed and pt\n received LR 500ml fluid bolus x 1, scheduled 2am valium dose held d/t\n low BP, freq. reorientation and freq. safety checks\n Response:\n Good response with combination of zyprexa and valium, otherwise no sig.\n improvement with other interventions\n Plan:\n Continue freq. safety checks and reorientation, INR level is 8 this am\n and with pt a high fall risk pt will need to be a 1:1 if gets OOB to\n chair today, continue valium and zyprexa, obtain psych consult to\n assist with management of anxiety issues and for advice on other\n medicines available that may help pt\ns agitation.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Tachypneic but with good Sats on trach mask during eves, Tolerating\n trach mask until received zyprexa and valium and then pt RR drive down\n with apneic periods requiring rest on vent overnight, mod. Amts thick\n secretions continue\n Action:\n Placed on MMV mode overnight, suctioned Q2-3 hours for thick\n tan/bloodtinged sputum, CPT, trach care\n Response:\n Sats >95 % on vent overnight\n Plan:\n Wean back to trach mask this am, continue to rest on vent overnight as\n needed, continue aggressive pulmonary toileting.\n Hypernatremia (high sodium)\n Assessment:\n Na up to 150 during eves, low urine output, low BP when asleep\n Action:\n 500 ml of D5W over 4hours followed by 500 ml LR over 4 hours for both\n high sodium and low urine output, Free water fluid boluses via PEG\n increased to 150ml q 4hrs.\n Response:\n Sodium down to 145 this am, urine output increased from 10-15ml/hr to\n 20-30ml/hr\n Plan:\n Continue free water via PEG, continue to monitor lytes QD.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Good peripheral pulses bilat, no BP on upper extremities, on coumadin\n Action:\n Assessed for evidence of bleeding\n Response:\n No signs of bleeding noted, INR reported as 8.0 this am---MICU team\n aware, Hct stable at 29.2 and platelets WNL\n Plan:\n Hold coumadin dose today and resend coags this evening, send clot to BB\n at next blood draw, monitor for signs of bleeding\n"},{"category":"Nursing","chartdate":"2167-10-12 00:00:00.000","description":"Nursing Progress Note","row_id":637005,"text":"56 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\n with prolonged hospital course c/b by PNA, anxiety/altered mental\n status, RUE DVT .\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on PSV 10/5/50%. RR 20-30. )2 sat > 97%\n Action:\n Pt remained on PSV rather than AC overnight. Suctioned ~q 3-4 hrs for\n sm amt yellow bld-tinged secretions. Continues to have copious oral\n secretions\n removed with yankeur.\n Response:\n Tolerated PSV well, no tachypnea or desaturation.\n Plan:\n Attempt trach collar trial again in am. On-going pulm hygiene\n Hypotension (not Shock)\n Assessment:\n BP 90/40 with urine output falling to 10-15ccs/hr via foley. HR remains\n tachycardic (110-140ST) even when pt is not agitated or febrile.\n Action:\n Given 1 500cc d5\n ns fluid bolus\n Response:\n SBP > 90, Urine output improving to >30ccs/hr\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Pt lethargic after receiving benedryl for several hrs but then awoke\n agitated, attempting to climb OOB and pull at trach despite restraints.\n Denies pain ( fentanyl patch in place) or need to go to the bathroom.\n c/o itchiness on back\n Action:\n Medicated with iv benedryl.\n Response:\n Less agitated. Slept again\n Plan:\n Continue to reorient pt, benedryl for pruritis, safety precautions.\n"},{"category":"Respiratory ","chartdate":"2167-10-13 00:00:00.000","description":"Respiratory Care Shift Note","row_id":637241,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 25\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Cuffed\n Manufacturer: Portex\n Size: 7.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Bronchial\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"},{"category":"Nursing","chartdate":"2167-10-18 00:00:00.000","description":"Nursing Progress Note","row_id":638221,"text":"56 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\n with prolonged hospital course c/b by PNA, anxiety/altered mental\n status, RUE DVT .Pt found to have small non occlusive Clot on her right\n axial vein via Ultrasound.Yesterday Pt went down to IR for Peg revision\n aspiration risk couldn\nt do it due the type of peg she has now.\n Altered mental status (not Delirium)\n Assessment:\n Restless, attempting to get OOB, kicking and hitting siderails,\n attempting to sit up, attempting to grab at all lines and tubes, bilat\n wrist restraints and waist belt on for pt\ns safety, mouthing words and\n following simple commands, slept soundly for 3-4 hours following\n zyprexa and valium\n Action:\n Morphine 2 mg. IV x 2 with no effect, Zyprexa and valium at bedtime\n with pt asleep for 3-4 hours, Valium 2.5 mg again this am with no\n effect, When pt asleep s BP dips to 70-80\ns---MICU team assessed and pt\n received LR 500ml fluid bolus x 1, scheduled 2am valium dose held d/t\n low BP, freq. reorientation and freq. safety checks\n Response:\n Good response with combination of zyprexa and valium, otherwise no sig.\n improvement with other interventions\n Plan:\n Continue freq. safety checks and reorientation, INR level is 8 this am\n and with pt a high fall risk pt will need to be a 1:1 if gets OOB to\n chair today, continue valium and zyprexa, obtain psych consult to\n assist with management of anxiety issues and for advice on other\n medicines available that may help pt\ns agitation.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Tachypneic but with good Sats on trach mask during eves, Tolerating\n trach mask until received zyprexa and valium and then pt RR drive down\n with apneic periods requiring rest on vent overnight, mod. Amts thick\n secretions continue\n Action:\n Placed on MMV mode overnight, suctioned Q2-3 hours for thick\n tan/bloodtinged sputum, CPT, trach care\n Response:\n Sats >95 % on vent overnight\n Plan:\n Wean back to trach mask this am, continue to rest on vent overnight as\n needed, continue aggressive pulmonary toileting.\n Hypernatremia (high sodium)\n Assessment:\n Na up to 150 during eves, low urine output, low BP when asleep\n Action:\n 500 ml of D5W over 4hours followed by 500 ml LR over 4 hours for both\n high sodium and low urine output, Free water fluid boluses via PEG\n increased to 150ml q 4hrs.\n Response:\n Sodium down to 145 this am, urine output increased from 10-15ml/hr to\n 20-30ml/hr\n Plan:\n Continue free water via PEG, continue to monitor lytes QD.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Good peripheral pulses bilat, no BP on upper extremities, on coumadin\n Action:\n Assessed for evidence of bleeding\n Response:\n No signs of bleeding noted, INR reported as 8.0 this am---MICU team\n aware, Hct stable at 29.2 and platelets WNL\n Plan:\n Hold coumadin dose today and resend coags this evening, send clot to BB\n at next blood draw, monitor for signs of bleeding\n"},{"category":"Nursing","chartdate":"2167-10-18 00:00:00.000","description":"Nursing Progress Note","row_id":638222,"text":"56 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\n with prolonged hospital course c/b by PNA, anxiety/altered mental\n status, RUE DVT .Pt found to have small non occlusive Clot on her right\n axial vein via Ultrasound.Yesterday Pt went down to IR for Peg revision\n aspiration risk couldn\nt do it due the type of peg she has now.\n Altered mental status (not Delirium)\n Assessment:\n Restless, attempting to get OOB, kicking and hitting siderails,\n attempting to sit up, attempting to grab at all lines and tubes, bilat\n wrist restraints and waist belt on for pt\ns safety, mouthing words and\n following simple commands, slept soundly for 3-4 hours following\n zyprexa and valium\n Action:\n Morphine 2 mg. IV x 2 with no effect, Zyprexa and valium at bedtime\n with pt asleep for 3-4 hours, Valium 2.5 mg again this am with no\n effect, When pt asleep s BP dips to 70-80\ns---MICU team assessed and pt\n received LR 500ml fluid bolus x 1, scheduled 2am valium dose held d/t\n low BP, freq. reorientation and freq. safety checks\n Response:\n Good response with combination of zyprexa and valium, otherwise no sig.\n improvement with other interventions\n Plan:\n Continue freq. safety checks and reorientation, INR level is 8 this am\n and with pt a high fall risk pt will need to be a 1:1 if gets OOB to\n chair today, continue valium and zyprexa, obtain psych consult to\n assist with management of anxiety issues and for advice on other\n medicines available that may help pt\ns agitation.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Tachypneic but with good Sats on trach mask during eves, Tolerating\n trach mask until received zyprexa and valium and then pt RR drive down\n with apneic periods requiring rest on vent overnight, mod. Amts thick\n secretions continue\n Action:\n Placed on MMV mode overnight, suctioned Q2-3 hours for thick\n tan/bloodtinged sputum, CPT, trach care\n Response:\n Sats >95 % on vent overnight\n Plan:\n Wean back to trach mask this am, continue to rest on vent overnight as\n needed, continue aggressive pulmonary toileting.\n Hypernatremia (high sodium)\n Assessment:\n Na up to 150 during eves, low urine output, low BP when asleep\n Action:\n 500 ml of D5W over 4hours followed by 500 ml LR over 4 hours for both\n high sodium and low urine output, Free water fluid boluses via PEG\n increased to 150ml q 4hrs.\n Response:\n Sodium down to 145 this am, urine output increased from 10-15ml/hr to\n 20-30ml/hr\n Plan:\n Continue free water via PEG, continue to monitor lytes QD.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Good peripheral pulses bilat, no BP on upper extremities, on coumadin\n Action:\n Assessed for evidence of bleeding\n Response:\n No signs of bleeding noted, INR reported as 8.0 this am---MICU team\n aware, Hct stable at 29.2 and platelets WNL\n Plan:\n Hold coumadin dose today and resend coags this evening, send clot to BB\n at next blood draw, monitor for signs of bleeding\n"},{"category":"Nursing","chartdate":"2167-10-11 00:00:00.000","description":"Nursing Progress Note","row_id":636932,"text":"56 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\n with prolonged hospital course c/b by PNA, anxiety/altered mental\n status, RUE DVT .\n Altered mental status (not Delirium)\n Assessment:\n Rec\nd pt very restless/agitated, repeatedly attempting to sit up in bed\n and pulling at soft wrist restraints. When arms freed, she immediately\n disconnected trach from vent. Agitation did not subside with verbal\n reassurance or scheduled dose valium. Pt follows commands\n inconsistently, has difficulty initiating cough on command. MAEE with\n good strength. Not grimacing and denied pain by mouthing words.\n Action:\n Pt noted to have rash per below, nodded\n to\nDoes you back itch?\n and rec\nd Benadryl 25mg IV @ 1345.\n Response:\n Pt finally sleeping after having been awake most of night and very\n restless all morning.\n Plan:\n Benadryl Q6hrs PRN. Cont freq mental/neuro eval.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2167-10-11 00:00:00.000","description":"Nursing Progress Note","row_id":636986,"text":"56 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\n with prolonged hospital course c/b by PNA, anxiety/altered mental\n status, RUE DVT .\n Altered mental status (not Delirium)\n Assessment:\n Rec\nd pt very restless/agitated, repeatedly attempting to sit up in bed\n and pulling at soft wrist restraints. When arms freed, she immediately\n disconnected trach from vent. Agitation did not subside with verbal\n reassurance or scheduled dose valium. Pt follows commands\n inconsistently, has difficulty initiating cough on command. MAEE with\n good strength. Not grimacing and denied pain by mouthing words.\n Action:\n Pt noted to have rash per below, nodded\n to\nDoes you back itch?\n and rec\nd Benadryl 25mg IV @ 1345.\n Response:\n Pt finally slept for 2hrs after having been awake most of night and\n very restless all morning.\n Plan:\n Benadryl Q6hrs PRN. Cont freq mental/neuro eval.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt on AC vent settings 50%/12 X 500/+5 with SRR 17-20\ns and\n regular. O2 sat 96-100%. Lungs snds rhonchorous bilat, diminished in\n bases. Pt with weak cough, raising mod amts thick white sputum but not\n fully expectorating it from trach.\n Action:\n Pt placed on TM @ 70% @ 0900. Suctionned PRN for mod amts sputum.\n Response:\n O2 sat stable until pt soundly sleeping and de-sated to 80\ns. TM inc\n to 100% with return of O2 sat to high 90\ns. However, when she woke @\n 1600 RR inc\nd and HR 140\ns with pt becoming diaphoretic. Pt returned to\n CPAP/PS 8/+5/50% @ 1800. HR presently in 120\ns with pt appearing\n comfortable.\n Plan:\n Cont to wean from vent as tolerated. Cont to encourage C&DB.\n Tachycardia, Other\n Assessment:\n HR 130- without VEA @ rest throughout shift, and still > 125\n when pt soundly sleeping. Pt Afebrile.\n Action:\n MD aware. After being on TM all day, pt returned to CPAP/PS @ 1800.\n Response:\n HR presently in 120\ns with pt looking comfortable.\n Plan:\n ? pt dry->monitor I/O\ns. Cont emotional support.\n Rash\n Assessment:\n Pt noted to have raised red rash evenly distributed over mid/lower\n back. Pt has been very restless, and nodded\n to\nDoes your back\n itch?\n. No new meds recently.\n Action:\n Team made aware, and they examined rash. Pt rec\nd Benadryl 25mg IV X 1.\n Levofloxacin D/C\n Response:\n Pt finally able to sleep after very restless night and morning. HR\n 130\ns->125ST. O2 sat \nd to 80\ns with RR inc\nd to high 20\ns and\n shallow.\n Plan:\n Benadryl PRN Q6hrs. ? Sarna lotion. Cont to monitor rash.\n"},{"category":"Physician ","chartdate":"2167-10-12 00:00:00.000","description":"Physician Resident Progress Note","row_id":637175,"text":"Chief Complaint:\n 24 Hour Events:\n Developed papular rash over entire back, bilaterally in multidermatomal\n distributions, opaque vesicles on erythematous base, non-painful,\n possibly pruritic\n Levofloxacin d/c'd\n Ceftriaxone Initiated for pan-sensitive\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Aztreonam - 03:42 AM\n Vancomycin - 09:40 AM\n Levofloxacin - 11:15 PM\n Ceftriaxone - 07:50 PM\n Infusions:\n Other ICU medications:\n Haloperidol (Haldol) - 10:26 AM\n Diazepam (Valium) - 11:33 AM\n Morphine Sulfate - 02:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Ear, Nose, Throat: Dry mouth\n Cardiovascular: No(t) Chest pain\n Respiratory: No(t) Tachypnea\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea\n Flowsheet Data as of 05:15 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 37.1\nC (98.7\n HR: 129 (113 - 148) bpm\n BP: 100/45(57) {85/40(50) - 171/111(115)} mmHg\n RR: 21 (9 - 36) insp/min\n SpO2: 93%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,362 mL\n 1,102 mL\n PO:\n TF:\n 47 mL\n 532 mL\n IVF:\n 1,061 mL\n 100 mL\n Blood products:\n Total out:\n 1,203 mL\n 755 mL\n Urine:\n 1,203 mL\n 755 mL\n NG:\n Stool:\n Drains:\n Balance:\n 159 mL\n 347 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Set): 0 (0 - 0) mL\n Vt (Spontaneous): 244 (110 - 504) mL\n PS : 10 cmH2O\n RR (Set): 0\n RR (Spontaneous): 19\n PEEP: 5 cmH2O\n FiO2: 70%\n RSBI: 245\n PIP: 16 cmH2O\n SpO2: 93%\n ABG: ///30/\n Ve: 10 L/min\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n Eyes / Conjunctiva: PERRL, Pupils dilated\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Bowel sounds present, Obese, Patient with thoracic\n brace on\n Skin: Not assessed, No(t) Rash: , Per Nursing: Pt with vesicular rash\n on inferior back.\n Neurologic: Follows simple commands, Responds to: Not assessed,\n Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 240 K/uL\n 7.9 g/dL\n 100 mg/dL\n 0.6 mg/dL\n 30 mEq/L\n 3.4 mEq/L\n 12 mg/dL\n 108 mEq/L\n 146 mEq/L\n 26.0 %\n 5.2 K/uL\n [image002.jpg]\n 08:11 PM\n 02:51 AM\n 03:10 AM\n 03:08 PM\n 03:00 AM\n 03:36 AM\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n WBC\n 9.4\n 11.3\n 7.3\n 6.1\n 7.2\n 5.2\n Hct\n 26.6\n 24.9\n 27.6\n 26.5\n 26.9\n 26.0\n Plt\n \n Cr\n 0.9\n 0.7\n 0.6\n 0.6\n 0.9\n 0.7\n 0.6\n TCO2\n 29\n 26\n Glucose\n 128\n 114\n 114\n 99\n 115\n 106\n 100\n Other labs: PT / PTT / INR:17.6/27.4/1.6, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:33/22, Alk Phos / T Bili:143/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:0.5 mmol/L,\n Albumin:3.5 g/dL, LDH:199 IU/L, Ca++:8.9 mg/dL, Mg++:2.4 mg/dL, PO4:4.1\n mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 11:38 AM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n 20 Gauge - 04:59 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2167-10-12 00:00:00.000","description":"Physician Resident Progress Note","row_id":637177,"text":"Chief Complaint:\n 24 Hour Events:\n Developed papular rash over entire back, bilaterally in multidermatomal\n distributions, opaque vesicles on erythematous base, non-painful,\n possibly pruritic\n Levofloxacin d/c'd\n Ceftriaxone Initiated for pan-sensitive\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Aztreonam - 03:42 AM\n Vancomycin - 09:40 AM\n Levofloxacin - 11:15 PM\n Ceftriaxone - 07:50 PM\n Infusions:\n Other ICU medications:\n Haloperidol (Haldol) - 10:26 AM\n Diazepam (Valium) - 11:33 AM\n Morphine Sulfate - 02:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Ear, Nose, Throat: Dry mouth\n Cardiovascular: No(t) Chest pain\n Respiratory: No(t) Tachypnea\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea\n Flowsheet Data as of 05:15 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 37.1\nC (98.7\n HR: 129 (113 - 148) bpm\n BP: 100/45(57) {85/40(50) - 171/111(115)} mmHg\n RR: 21 (9 - 36) insp/min\n SpO2: 93%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,362 mL\n 1,102 mL\n PO:\n TF:\n 47 mL\n 532 mL\n IVF:\n 1,061 mL\n 100 mL\n Blood products:\n Total out:\n 1,203 mL\n 755 mL\n Urine:\n 1,203 mL\n 755 mL\n NG:\n Stool:\n Drains:\n Balance:\n 159 mL\n 347 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Set): 0 (0 - 0) mL\n Vt (Spontaneous): 244 (110 - 504) mL\n PS : 10 cmH2O\n RR (Set): 0\n RR (Spontaneous): 19\n PEEP: 5 cmH2O\n FiO2: 70%\n RSBI: 245\n PIP: 16 cmH2O\n SpO2: 93%\n ABG: ///30/\n Ve: 10 L/min\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n Eyes / Conjunctiva: PERRL, Pupils dilated\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Bowel sounds present, Obese, Patient with thoracic\n brace on\n Skin: Not assessed, No(t) Rash: , Per Nursing: Pt with vesicular rash\n on inferior back.\n Neurologic: Follows simple commands, Responds to: Not assessed,\n Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 240 K/uL\n 7.9 g/dL\n 100 mg/dL\n 0.6 mg/dL\n 30 mEq/L\n 3.4 mEq/L\n 12 mg/dL\n 108 mEq/L\n 146 mEq/L\n 26.0 %\n 5.2 K/uL\n [image002.jpg]\n 08:11 PM\n 02:51 AM\n 03:10 AM\n 03:08 PM\n 03:00 AM\n 03:36 AM\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n WBC\n 9.4\n 11.3\n 7.3\n 6.1\n 7.2\n 5.2\n Hct\n 26.6\n 24.9\n 27.6\n 26.5\n 26.9\n 26.0\n Plt\n \n Cr\n 0.9\n 0.7\n 0.6\n 0.6\n 0.9\n 0.7\n 0.6\n TCO2\n 29\n 26\n Glucose\n 128\n 114\n 114\n 99\n 115\n 106\n 100\n Other labs: PT / PTT / INR:17.6/27.4/1.6, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:33/22, Alk Phos / T Bili:143/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:0.5 mmol/L,\n Albumin:3.5 g/dL, LDH:199 IU/L, Ca++:8.9 mg/dL, Mg++:2.4 mg/dL, PO4:4.1\n mg/dL\n Assessment and Plan\n 55yoF with history of EtOH abuse presenting following mechanical fall\n and traumatic T spine fracture with K. oxytoca PNA, and ARDS, intubated\n since the end of now s/p trach and PEG placement.\n# Recent Aspiration on Tube Feeds. Cultures growing Klebsiella Oxytoca and Klebs\niella Pneumoniae. Pt received developed rash on Levofloxacin, switched to Ceftri\naxone overnight. Will treat for potential HAP for 8 days.\n - Continue Ceftriaxone day #1.\n - Tube Feeds restarted with goal of 60/hr\n - Follow cultures\n - check tube placement\n .\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation. S/P Trach\n and PEG on .\n - Weaning FiO2 as tolerated\n - Will attempt trach collar today\n # Sedation: Pt has pain/delirium causing tachycardia and hypertension\n with intermittent hypotension. On Haldol 5 TID, Fentanyl 75 mcg TP,\n Diazapam 10 QID; Haldol, midazolam and morphine PRN. Had good response\n to morphine, minimal response to haldol bolus.\n - tolerating current regimen well, no changes today\n # Adrenal Insufficency: Hypotension that resolved with steroids,\n returned as they came off and is now improved again. Possible primary\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\n started on .\n - stopped steroids as per endocrine today\n # Volume overloaded in prior setting of hypernatremia\n Goal even\n today.\n - monitor urine output\n # RUE DVT: INR was super-therapeutic on coumadin. Goal . Hasn\n received coumadin in days yet INR continues to rise. Likely\n contributors are nutritional and antibiotics.\n - will start coumadin 2.5 mg QHS once INR < 3\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - Brace for OOB\n - Report from full trauma series from OSH is in chart.\n - No evidence of other fracture and no need for further spinal imaging\n based on this report and ortho note.\n # Tracheomalacia: Discussed with IP. Stenting unlikely to help for\n trachiomalacia as airways have poor structure diffusely.\n - Outpatient f/u once off pressure support to assess for possible\n stenting\n #. Thyroid Nodule on CT\n - Outpatient follow up\n # Nutrition: Replete (Full)\n hold\n # Glycemic control: SSI, well controlled\n # Lines L PICC\n ().\n # Ppx: INR remains therapeutic, ranitidine, colace and senna, miralax,\n bisacodyl.\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n Code: Full\n Dispo: ICU, being screening for vent facilities\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 11:38 AM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n 20 Gauge - 04:59 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2167-10-12 00:00:00.000","description":"Physician Resident Progress Note","row_id":637179,"text":"Chief Complaint:\n 24 Hour Events:\n Developed papular rash over entire back, bilaterally in multidermatomal\n distributions, opaque vesicles on erythematous base, non-painful,\n possibly pruritic\n Levofloxacin d/c'd\n Ceftriaxone Initiated for pan-sensitive\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Aztreonam - 03:42 AM\n Vancomycin - 09:40 AM\n Levofloxacin - 11:15 PM\n Ceftriaxone - 07:50 PM\n Infusions:\n Other ICU medications:\n Haloperidol (Haldol) - 10:26 AM\n Diazepam (Valium) - 11:33 AM\n Morphine Sulfate - 02:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Ear, Nose, Throat: Dry mouth\n Cardiovascular: No(t) Chest pain\n Respiratory: No(t) Tachypnea\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea\n Flowsheet Data as of 05:15 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 37.1\nC (98.7\n HR: 129 (113 - 148) bpm\n BP: 100/45(57) {85/40(50) - 171/111(115)} mmHg\n RR: 21 (9 - 36) insp/min\n SpO2: 93%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,362 mL\n 1,102 mL\n PO:\n TF:\n 47 mL\n 532 mL\n IVF:\n 1,061 mL\n 100 mL\n Blood products:\n Total out:\n 1,203 mL\n 755 mL\n Urine:\n 1,203 mL\n 755 mL\n NG:\n Stool:\n Drains:\n Balance:\n 159 mL\n 347 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Set): 0 (0 - 0) mL\n Vt (Spontaneous): 244 (110 - 504) mL\n PS : 10 cmH2O\n RR (Set): 0\n RR (Spontaneous): 19\n PEEP: 5 cmH2O\n FiO2: 70%\n RSBI: 245\n PIP: 16 cmH2O\n SpO2: 93%\n ABG: ///30/\n Ve: 10 L/min\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n Eyes / Conjunctiva: PERRL, Pupils dilated\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Bowel sounds present, Obese, Patient with thoracic\n brace on\n Skin: Not assessed, No(t) Rash: , Per Nursing: Pt with vesicular rash\n on inferior back.\n Neurologic: Follows simple commands, Responds to: Not assessed,\n Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 240 K/uL\n 7.9 g/dL\n 100 mg/dL\n 0.6 mg/dL\n 30 mEq/L\n 3.4 mEq/L\n 12 mg/dL\n 108 mEq/L\n 146 mEq/L\n 26.0 %\n 5.2 K/uL\n [image002.jpg]\n 08:11 PM\n 02:51 AM\n 03:10 AM\n 03:08 PM\n 03:00 AM\n 03:36 AM\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n WBC\n 9.4\n 11.3\n 7.3\n 6.1\n 7.2\n 5.2\n Hct\n 26.6\n 24.9\n 27.6\n 26.5\n 26.9\n 26.0\n Plt\n \n Cr\n 0.9\n 0.7\n 0.6\n 0.6\n 0.9\n 0.7\n 0.6\n TCO2\n 29\n 26\n Glucose\n 128\n 114\n 114\n 99\n 115\n 106\n 100\n Other labs: PT / PTT / INR:17.6/27.4/1.6, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:33/22, Alk Phos / T Bili:143/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:0.5 mmol/L,\n Albumin:3.5 g/dL, LDH:199 IU/L, Ca++:8.9 mg/dL, Mg++:2.4 mg/dL, PO4:4.1\n mg/dL\n Assessment and Plan\n 55yoF with history of EtOH abuse presenting following mechanical fall\n and traumatic T spine fracture with K. oxytoca PNA, and ARDS, intubated\n since the end of now s/p trach and PEG placement.\n# Recent Aspiration on Tube Feeds. Cultures growing Klebsiella Oxytoca and Klebs\niella Pneumoniae. Pt received developed rash on Levofloxacin, switched to Ceftri\naxone overnight. Will treat for potential HAP for 8 days.\n - Continue Ceftriaxone day #1.\n - Tube Feeds restarted with goal of 60/hr\n - Follow cultures\n - check tube placement\n .\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation. S/P Trach\n and PEG on .\n - Weaning FiO2 as tolerated\n - Will attempt trach collar today\n # Tachycardia: Pt in ST for most of the day 120\ns to 140s. Etiology\n remains unclear although she has been tachy since admission. Etiologies\n include pain (especially when sitting upright with thoracic brace on),\n infection (pt with known klebsiella, possibly acquired HAP). DDx also\n includes PE, hyperthyroidism.\n - Will keep pt\ns INR therapeutic\n - TSH 2.4 on early , will check free T3, T4.\n - Continue Pain Control\n - Treat underlying infection\n # Sedation: Pt has pain/delirium causing tachycardia and hypertension\n with intermittent hypotension. On Haldol 5 TID, Fentanyl 75 mcg TP,\n Diazapam 10 QID; Haldol, midazolam and morphine PRN. Had good response\n to morphine, minimal response to haldol bolus.\n - tolerating current regimen well, no changes today\n # Adrenal Insufficency: Hypotension that resolved with steroids,\n returned as they came off and is now improved again. Possible primary\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\n started on .\n - stopped steroids as per endocrine today\n # Volume overloaded in prior setting of hypernatremia\n Goal even\n today.\n - Monitoring urine output\n # RUE DVT: INR was super-therapeutic on coumadin. Goal . Hasn\n received coumadin in days yet INR continues to rise. Likely\n contributors are nutritional and antibiotics.\n - will start coumadin 2.5 mg QHS once INR < 3\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - Brace for OOB\n - Report from full trauma series from OSH is in chart.\n - Pt to follow up with Dr. in weeks\n # Tracheomalacia: Discussed with IP. Stenting unlikely to help for\n trachiomalacia as airways have poor structure diffusely.\n - Outpatient f/u once off pressure support to assess for possible\n stenting\n #. Thyroid Nodule on CT\n - Outpatient follow up\n # Nutrition: Replete (Full)\n hold\n # Glycemic control: SSI, well controlled\n # Lines L PICC\n ().\n # Ppx: INR remains therapeutic, ranitidine, colace and senna, miralax,\n bisacodyl.\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n Code: Full\n Dispo: ICU, being screening for vent facilities\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 11:38 AM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n 20 Gauge - 04:59 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Respiratory ","chartdate":"2167-10-14 00:00:00.000","description":"Respiratory Care Shift Note","row_id":637595,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 26\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 7.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Periodic SBT's for conditioning\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Cannot manage secretions\n"},{"category":"Physician ","chartdate":"2167-10-12 00:00:00.000","description":"Physician Resident Progress Note","row_id":637047,"text":"Chief Complaint:\n 24 Hour Events:\n Developed papular rash over entire back, bilateraly, in multiple\n dermatomal distributions, opaque vesicles on erythematous base,\n nonpainful, possibly pruritic.\n Levofloxaxin was d/c'd.\n Ceftriaxone started.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Aztreonam - 03:42 AM\n Vancomycin - 09:40 AM\n Levofloxacin - 11:15 PM\n Ceftriaxone - 07:50 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:14 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 37.2\nC (98.9\n HR: 139 (113 - 145) bpm\n BP: 97/61(68) {85/28(50) - 127/86(90)} mmHg\n RR: 12 (9 - 30) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,362 mL\n 302 mL\n PO:\n TF:\n 47 mL\n 152 mL\n IVF:\n 1,061 mL\n 100 mL\n Blood products:\n Total out:\n 1,203 mL\n 460 mL\n Urine:\n 1,203 mL\n 460 mL\n NG:\n Stool:\n Drains:\n Balance:\n 159 mL\n -158 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 0 (0 - 0) mL\n Vt (Spontaneous): 504 (110 - 504) mL\n PS : 10 cmH2O\n RR (Set): 0\n RR (Spontaneous): 14\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 245\n PIP: 16 cmH2O\n SpO2: 100%\n ABG: ///30/\n Ve: 5.9 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 240 K/uL\n 7.9 g/dL\n 100 mg/dL\n 0.6 mg/dL\n 30 mEq/L\n 3.4 mEq/L\n 12 mg/dL\n 108 mEq/L\n 146 mEq/L\n 26.0 %\n 5.2 K/uL\n [image002.jpg]\n 08:11 PM\n 02:51 AM\n 03:10 AM\n 03:08 PM\n 03:00 AM\n 03:36 AM\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n WBC\n 9.4\n 11.3\n 7.3\n 6.1\n 7.2\n 5.2\n Hct\n 26.6\n 24.9\n 27.6\n 26.5\n 26.9\n 26.0\n Plt\n \n Cr\n 0.9\n 0.7\n 0.6\n 0.6\n 0.9\n 0.7\n 0.6\n TCO2\n 29\n 26\n Glucose\n 128\n 114\n 114\n 99\n 115\n 106\n 100\n Other labs: PT / PTT / INR:17.6/27.4/1.6, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:33/22, Alk Phos / T Bili:143/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:0.5 mmol/L,\n Albumin:3.5 g/dL, LDH:199 IU/L, Ca++:8.9 mg/dL, Mg++:2.4 mg/dL, PO4:4.1\n mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 03:36 AM 30 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Respiratory ","chartdate":"2167-10-13 00:00:00.000","description":"Respiratory Care Shift Note","row_id":637399,"text":"TITLE:\n Demographics\n Day of intubation:\n Day of mechanical ventilation: 25\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Not applicable\n Size: Not applicable\n Tracheostomy tube:\n Type: Cuffed\n Manufacturer: Portex\n Size: 7.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: weaning daily to\n trach collar as tolerated\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"},{"category":"Nursing","chartdate":"2167-10-13 00:00:00.000","description":"Nursing Progress Note","row_id":637402,"text":"Tachycardia, Other\n Assessment:\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2167-10-13 00:00:00.000","description":"Nursing Progress Note","row_id":637407,"text":"56 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\n with prolonged hospital course c/b by PNA, anxiety/altered mental\n status, RUE DVT .\n Tachycardia, Other\n Assessment:\n Pt\ns HR was 120\ns this am when asleep. When she woke up her HR went to\n 140\ns. When she was placed in the chair her HR increased to 150\n Her U/O was marginal at 5-10cc/hr. Her B/P 110/70\ns when in bed to\n 160-180/80 when in the chair.\n Action:\n She was given 2 boluses of 500cc NS.\n Response:\n The fluid boluses had no effect on her HR at all. Her U/O increased to\n 35-40cc/hr\n Plan:\n Continue to monitor her HR, B/P and U/O.\n Alteration in Nutrition\n Assessment:\n Tube feeding had been stopped for high residuals.\n Action:\n She was restarted at 8am back at 50cc/hr.\n Response:\n She tolerated the tube feeding with 10 cc residuals, and she had a very\n large stool.\n Plan:\n Continue to monitor TF residuals.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt\ns resp status stable, with RR 18-24 and O2 sats 95-97%.\n Action:\n She was placed in a chair at 10am and then put on the trach collar at\n 10:30.\n Response:\n She tolerated being up in the chair for 8hours and she is still on the\n trach collar\n Plan:\n Place back on PSV 8/5 for the night.\n Pt has been accepted at rehab. They were awaiting insurance\n approval and could have gone today but will probably go tomorrow.\n"},{"category":"Physician ","chartdate":"2167-10-13 00:00:00.000","description":"Physician Resident Progress Note","row_id":637412,"text":"Chief Complaint:\n 24 Hour Events:\n UOP 10-20cc/hr, tachy to 150s while sitting upright, 120s at rest.\n Pt on PMV but had heavy secretions. Trach collar for 5 hours.\n Repeat Sputum Cx + for GNR, fungal, 1+ Gram + Cocci in Pairs.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 09:40 AM\n Levofloxacin - 11:15 PM\n Ceftriaxone - 07:50 PM\n Infusions:\n Other ICU medications:\n Haloperidol (Haldol) - 10:26 AM\n Diazepam (Valium) - 11:33 AM\n Morphine Sulfate - 02:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.7\nC (98.1\n HR: 118 (118 - 148) bpm\n BP: 90/37(48) {90/37(48) - 171/111(115)} mmHg\n RR: 14 (12 - 36) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,614 mL\n 439 mL\n PO:\n TF:\n 884 mL\n 279 mL\n IVF:\n 100 mL\n Blood products:\n Total out:\n 834 mL\n 20 mL\n Urine:\n 834 mL\n 20 mL\n NG:\n Stool:\n Drains:\n Balance:\n 780 mL\n 419 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 354 (244 - 376) mL\n PS : 10 cmH2O\n RR (Spontaneous): 12\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 56\n PIP: 15 cmH2O\n SpO2: 95%\n ABG: ////\n Ve: 4.1 L/min\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n Eyes / Conjunctiva: PERRL, Pupils dilated\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Bowel sounds present, Obese, Patient with thoracic\n brace on\n Skin: Not assessed, No(t) Rash: , Per Nursing: Pt with vesicular rash\n on inferior back.\n Neurologic: Follows simple commands, Responds to: Not assessed,\n Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 240 K/uL\n 7.9 g/dL\n 100 mg/dL\n 0.6 mg/dL\n 30 mEq/L\n 3.4 mEq/L\n 12 mg/dL\n 108 mEq/L\n 146 mEq/L\n 26.0 %\n 5.2 K/uL\n [image002.jpg]\n 08:11 PM\n 02:51 AM\n 03:10 AM\n 03:08 PM\n 03:00 AM\n 03:36 AM\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n WBC\n 9.4\n 11.3\n 7.3\n 6.1\n 7.2\n 5.2\n Hct\n 26.6\n 24.9\n 27.6\n 26.5\n 26.9\n 26.0\n Plt\n \n Cr\n 0.9\n 0.7\n 0.6\n 0.6\n 0.9\n 0.7\n 0.6\n TCO2\n 29\n 26\n Glucose\n 128\n 114\n 114\n 99\n 115\n 106\n 100\n Other labs: PT / PTT / INR:17.6/27.4/1.6, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:33/22, Alk Phos / T Bili:143/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:0.5 mmol/L,\n Albumin:3.5 g/dL, LDH:199 IU/L, Ca++:8.9 mg/dL, Mg++:2.4 mg/dL, PO4:4.1\n mg/dL\n Assessment and Plan\n 55yoF with history of EtOH abuse presenting following mechanical fall\n and traumatic T spine fracture with K. oxytoca PNA, and ARDS, intubated\n since the end of now s/p trach and PEG placement.\n# Recent Aspiration on Tube Feeds. Cultures growing Klebsiella Oxytoca and Klebs\niella Pneumoniae. Pt received developed rash on Levofloxacin, switched to Ceftri\naxone overnight. Will treat for potential HAP for 8 days.\n - Continue Ceftriaxone day #1.\n - Tube Feeds restarted with goal of 60/hr\n - Follow cultures\n - check tube placement\n .\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation. S/P Trach\n and PEG on .\n - Weaning FiO2 as tolerated\n - Will attempt trach collar today\n # Tachycardia: Pt in ST for most of the day 120\ns to 140s. Etiology\n remains unclear although she has been tachy since admission. Etiologies\n include pain (especially when sitting upright with thoracic brace on),\n infection (pt with known klebsiella, possibly acquired HAP). DDx also\n includes PE, hyperthyroidism.\n - Will keep pt\ns INR therapeutic\n - TSH 2.4 on early , will check free T3, T4.\n - Continue Pain Control\n - Treat underlying infection\n # Sedation: Pt has pain/delirium causing tachycardia and hypertension\n with intermittent hypotension. On Haldol 5 TID, Fentanyl 75 mcg TP,\n Diazapam 10 QID; Haldol, midazolam and morphine PRN. Had good response\n to morphine, minimal response to haldol bolus.\n - tolerating current regimen well, no changes today\n # Adrenal Insufficency: Hypotension that resolved with steroids,\n returned as they came off and is now improved again. Possible primary\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\n started on .\n - stopped steroids as per endocrine today\n # Volume overloaded in prior setting of hypernatremia\n Goal even\n today.\n - Monitoring urine output\n # RUE DVT: INR was super-therapeutic on coumadin. Goal . Hasn\n received coumadin in days yet INR continues to rise. Likely\n contributors are nutritional and antibiotics.\n - will start coumadin 2.5 mg QHS once INR < 3\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - Brace for OOB\n - Report from full trauma series from OSH is in chart.\n - Pt to follow up with Dr. in weeks\n # Tracheomalacia: Discussed with IP. Stenting unlikely to help for\n trachiomalacia as airways have poor structure diffusely.\n - Outpatient f/u once off pressure support to assess for possible\n stenting\n #. Thyroid Nodule on CT\n - Outpatient follow up\n # Nutrition: Replete (Full)\n hold\n # Glycemic control: SSI, well controlled\n # Lines L PICC\n ().\n # Ppx: INR remains therapeutic, ranitidine, colace and senna, miralax,\n bisacodyl.\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n Code: Full\n Dispo: ICU, being screening for vent facilities\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 11:38 AM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n 20 Gauge - 04:59 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 10:31 PM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n 20 Gauge - 04:59 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2167-10-13 00:00:00.000","description":"Physician Resident Progress Note","row_id":637413,"text":"Chief Complaint:\n 24 Hour Events:\n UOP 10-20cc/hr, tachy to 150s while sitting upright, 120s at rest.\n Pt on PMV but had heavy secretions. Trach collar for 5 hours.\n Repeat Sputum Cx + for GNR, fungal, 1+ Gram + Cocci in Pairs.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 09:40 AM\n Levofloxacin - 11:15 PM\n Ceftriaxone - 07:50 PM\n Infusions:\n Other ICU medications:\n Haloperidol (Haldol) - 10:26 AM\n Diazepam (Valium) - 11:33 AM\n Morphine Sulfate - 02:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.7\nC (98.1\n HR: 118 (118 - 148) bpm\n BP: 90/37(48) {90/37(48) - 171/111(115)} mmHg\n RR: 14 (12 - 36) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,614 mL\n 439 mL\n PO:\n TF:\n 884 mL\n 279 mL\n IVF:\n 100 mL\n Blood products:\n Total out:\n 834 mL\n 20 mL\n Urine:\n 834 mL\n 20 mL\n NG:\n Stool:\n Drains:\n Balance:\n 780 mL\n 419 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 354 (244 - 376) mL\n PS : 10 cmH2O\n RR (Spontaneous): 12\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 56\n PIP: 15 cmH2O\n SpO2: 95%\n ABG: ////\n Ve: 4.1 L/min\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n Eyes / Conjunctiva: PERRL, Pupils dilated\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Bowel sounds present, Obese, Patient with thoracic\n brace on\n Skin: Not assessed, No(t) Rash: , Per Nursing: Pt with vesicular rash\n on inferior back.\n Neurologic: Follows simple commands, Responds to: Not assessed,\n Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 240 K/uL\n 7.9 g/dL\n 100 mg/dL\n 0.6 mg/dL\n 30 mEq/L\n 3.4 mEq/L\n 12 mg/dL\n 108 mEq/L\n 146 mEq/L\n 26.0 %\n 5.2 K/uL\n [image002.jpg]\n 08:11 PM\n 02:51 AM\n 03:10 AM\n 03:08 PM\n 03:00 AM\n 03:36 AM\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n WBC\n 9.4\n 11.3\n 7.3\n 6.1\n 7.2\n 5.2\n Hct\n 26.6\n 24.9\n 27.6\n 26.5\n 26.9\n 26.0\n Plt\n \n Cr\n 0.9\n 0.7\n 0.6\n 0.6\n 0.9\n 0.7\n 0.6\n TCO2\n 29\n 26\n Glucose\n 128\n 114\n 114\n 99\n 115\n 106\n 100\n Other labs: PT / PTT / INR:17.6/27.4/1.6, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:33/22, Alk Phos / T Bili:143/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:0.5 mmol/L,\n Albumin:3.5 g/dL, LDH:199 IU/L, Ca++:8.9 mg/dL, Mg++:2.4 mg/dL, PO4:4.1\n mg/dL\n Assessment and Plan\n 55yoF with history of EtOH abuse presenting following mechanical fall\n and traumatic T spine fracture, now s/p trach, PEG, placement being\n treated for HAP.\n# HAP vs Aspiration PNA: Cultures growing Klebsiella Oxytoca, Klebsiella Pneumon\niae, GNR, GP Cocci. Pt received developed rash on Levofloxacin, switched to Ceft\nriaxone overnight. Will treat for potential HAP for 8 days.\n - Continue Ceftriaxone HAP (Day #6 of 8)\n - Tube Feeds now at 50 with goal of 60/hr\n - Following Cultures\n .\n # Respiratory failure: 5 hours on Trach mask yesterday, will assess\n length of tolerance today.\n - PMV with suctioning.\n - Weaning FiO2 as tolerated\n # Tachycardia: Pt in ST 120\ns to 150s. Etiology remains unclear and\n etiologies include hypovolemia, pain, infection (pt with known\n klebsiella), . DDx also includes PE\n - Treating underlying infection\n - Bolus NS 500cc x 2 today and assess HR\n - Restarting patients Coumadin\n - TSH 2.4 on early , will check free T3, T4.\n - Continue Pain Control\n # Sedation: Pt has pain/delirium causing tachycardia and hypertension\n with intermittent hypotension. Had good response to morphine, minimal\n response to haldol bolus.\n - Haldol 5 TID, Fentanyl 75 mcg TP, Diazapam 10 QID;\n - Haldol, midazolam and morphine PRN.\n - tolerating current regimen well\n # Adrenal Insufficency: Followed up with endocrine that suggested if\n the patient under goes major stressors such as major surgery, sepsis,\n she may need stress dosed steroids.\n - Will consider MRI at later date for evaluation of pituitary\n # Fluid Status: Volume overloaded in prior setting of Hypernatremia\n Goal even today.\n - Monitoring urine output\n # RUE DVT: INR was super-therapeutic on coumadin. Goal . Received 5\n of coumadin overnight.\n - Restarting Coumadin 2.5 mg QHS once INR < 3\n # Spine fracture: Stable\n - Brace for OOB, will discuss with Neurosurgery if current brace is\n optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n # Tracheomalacia?: Discussed with IP.\n - Outpatient f/u once off pressure support to assess for possible\n stenting\n #. Thyroid Nodule on CT\n - Outpatient follow up\n # Nutrition: TFs with goal of 60\n # Glycemic control: SSI, well controlled\n # Lines L PICC\n ().\n # Ppx: Restarting Coumadin, Ranitidine, Bowel Regimen\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n # Code: Full\n # Dispo: ICU, Screening for vent facilities\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 11:38 AM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n 20 Gauge - 04:59 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Nursing","chartdate":"2167-10-15 00:00:00.000","description":"Nursing Progress Note","row_id":637626,"text":"Tachycardia, Other\n Assessment:\n Continues to be Tachycardia in 120-145 (anxiety). SBP has been 100-145\n without ectopy.\n Action:\n No medication given for tachycardia.Pt gets Valium 5 mg scheduled Q6H\n with little effect. CTA done to r/o pe as a source of tachycardia.\n Response:\n Results pending on CTA.\n Plan:\n Continue to evaluate HR and BP for need of treatment.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt has a known DVT to RUE. Today pt had a US of LUEand ruled out small\n non occlusive clot on her left axial vein.\n Action:\n Dr ,pt received ceftriaxone via PICC line.Coumadin dosage\n increased from 2.5 to 5 mg ( INR 1.4).\n Response:\n Repeat ultrasound orderd for right arm . Pt received 5 mg coumadin at\n 2200.\n Plan:\n Ultrasound today,cont coumadin and closely monitor INR.\n Altered mental status (not Delirium)\n Assessment:\n Pt has been restless most of the night. Pt nodded her head for pain and\n simple yes or no questions.\n Action:\n Pt given scheduled Valium with little effect.\n Response:\n Pt slept for a while,Hr dropped to 120s at the time of rest.\n Plan:\n Continue to eval MS,Valium and Prn Morphine and haldol?.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt rested on CPAP+ PS 50%/,sats stayed upper 90\ns,Pt found to have\n TF coming aroundTracheostomy\n Action:\n Cont pulm toilet as needed. Pt in need of freq oral care.\n Response:\n Plan:\n Continue to wean pt off vent and place on TC once pt can tol it again.\n"},{"category":"Rehab Services","chartdate":"2167-10-16 00:00:00.000","description":"Physical Therapy Evaluation Note","row_id":637950,"text":"Attending Physician:\n date: \n Medical Diagnosis / ICD 9: / e888.9\n Reason of : eval and tx\n History of Present Illness / Subjective Complaint: 55 y/o female with\n h/o obesity admitted to OSH in on after falling down\n stairs at home. She suffered traumatic T8 fx, course was complicated by\n respiratory failure requiring intubation. Respiratory failure was felt\n to be hypoventilation from pain meds. She was transferred to \n on for further intervention after CT chest showed narrowing of\n her central airways. She was evaluated for airway stenting. Course was\n complicated by VAP and became septic. Pt is s/p trach/PEG on . Pt\n has had continues tachycardia and developed B UE DVTs.\n Past Medical / Surgical History: GERD, s/p TAH, s/p appendectomy,\n remote benign breast mass , L THA\n Medications:\n Radiology: Mildly improved left lower lobe opacities. Likely improving\n atelectasis. There is a small left pleural effusion. Small right\n pleural effusion and right lower lobe atelectasis are unchanged.\n Labs:\n 29.7\n 9.0\n 395\n 7.0\n [image002.jpg]\n Other labs:\n Activity Orders:\n Social / Occupational History: Unable to obtain history from pt due to\n mental status per chart pt lives with boyfriend\n Environment:\n Prior Functional Status / Activity Level: Assume pt was I PTA\n Objective Test\n Arousal / Attention / Cognition / Communication: Pt alert, poor\n attention, pt agitated pulling at brace and trach. Pt was able to\n follow 90% of 1 step commands with frequent cues and re-direction. Pt\n nodding \"yes no\" inappropriately to questions. Pt impulsive, trying to\n crawl over bedrails.\n Hemodynamic Response\n Aerobic Capacity\n HR\n BP\n RR\n O[2 ]sat\n HR\n BP\n RR\n O[2] sat\n RPE\n Supine\n 140-150\n 117/85\n 98% TM\n Rest\n /\n Sit\n 130-155\n 110/80\n 98%TM\n Activity\n /\n Stand\n /\n Recovery\n /\n Total distance walked:\n Minutes:\n Pulmonary Status: Strong cough productive of thick yellow sputum\n Integumentary / Vascular: Trach, Peg, foley, , pt has breakdown on\n her chin\n Sensory Integrity: withdraws to pain x 4\n Pain / Limiting Symptoms: Pt appears uncomfortable in bracing, pulling\n at cervical extension\n Posture: unremarkable\n Range of Motion\n Muscle Performance\n B UE and LE \n Pt moving all extremities against gravity\n Motor Function: Purposeful movement patterns\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: Transfer: Pt was able to scoot from bed to stretcher\n chair with Min A\n Rolling:\n\n\n\n T\n\n\n Supine /\n Sidelying to Sit:\n\n\n T\n\n\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n\n\n\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Balance: Fair sitting balance at EOB. Deferred standing due to pts MS\n Education / Communication: Pt status discussed with RN, MDs. Talked to\n Dr. regarding pts current brace. She agrees that a cervical\n extension is not needed. Neops was called and are planning to come\n assess brace today and either remove cervical extension or make a new\n TLSO.\n Intervention:\n Other:\n Diagnosis:\n 1.\n Airway Clearance, Impaired\n 2.\n Arousal, Attention, and Cognition, Impaired\n 3.\n Balance, Impaired\n 4.\n Knowledge, Impaired\n 5.\n Respiration / Gas Exchange, Impaired\n Clinical impression / Prognosis: 55 yo f s/p fall with resultant T8 fx\n and hospital course c/b prolonged intubation, resp failure, and\n tachycardia. Pt is functioning well below baseline, most significantly\n limited by mental status. Feel with new brace, increased time OOB, pts\n pulmonary status should improve. Pts mental status maybe related to\n prolonged ICU stay or medications, if it does not improve may also\n benefit from further w/u given h/o trauma. Pts mobility is good and\n anticipates she will rapidly progress with continued PT in rehab\n setting.\n Goals\n Time frame: 1 wk\n 1.\n follow all 1 step commands\n 2.\n sit at EOB I'ly > 10 mins\n 3.\n tolerate PMV during treatment and maintain SaO2> 95% on 35% TM\n 4.\n transfer goals to follow\n 5.\n 6.\n Anticipated Discharge: Rehab\n Treatment Plan:\n Frequency / Duration: 3-5x/wk\n f/u balance, cognitive training. Progress to transfer training and\n ambulation as appropriate.\n T Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n"},{"category":"Physician ","chartdate":"2167-10-16 00:00:00.000","description":"Physician Attending Progress Note","row_id":637951,"text":"Chief Complaint: resp failuire\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n ULTRASOUND - At 03:48 PM\n US of Lt arm shows small 1 cm axillary clot non occlusive near PICC\n RUS US shows resolution of formal clot\n Vomiting tube feeds around trach\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Ceftriaxone - 10:00 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 06:20 AM\n Pantoprazole (Protonix) - 08:12 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Gastrointestinal: Emesis\n Flowsheet Data as of 10:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 36.2\nC (97.1\n HR: 146 (123 - 146) bpm\n BP: 153/129(134) {106/41(56) - 185/129(142)} mmHg\n RR: 26 (11 - 33) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,888 mL\n 520 mL\n PO:\n TF:\n 1,268 mL\n IVF:\n 100 mL\n Blood products:\n Total out:\n 1,530 mL\n 845 mL\n Urine:\n 1,510 mL\n 820 mL\n NG:\n 20 mL\n 25 mL\n Stool:\n Drains:\n Balance:\n 358 mL\n -325 mL\n Respiratory support\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 227 (227 - 397) mL\n PS : 8 cmH2O\n RR (Spontaneous): 20\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 194\n PIP: 16 cmH2O\n SpO2: 96%\n ABG: ///34/\n Ve: 6.5 L/min\n Physical Examination\n Gen: up in bed, alert, follows simples commands\n Tachy regular\n Fair air movement ant\n No edema\n Labs / Radiology\n 8.5 g/dL\n 335 K/uL\n 121 mg/dL\n 0.5 mg/dL\n 34 mEq/L\n 3.8 mEq/L\n 7 mg/dL\n 107 mEq/L\n 147 mEq/L\n 27.0 %\n 5.6 K/uL\n [image002.jpg]\n 03:08 PM\n 03:00 AM\n 03:36 AM\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n 05:00 AM\n 02:06 AM\n 07:34 AM\n WBC\n 7.3\n 6.1\n 7.2\n 5.2\n 5.9\n 7.5\n 5.6\n Hct\n 27.6\n 26.5\n 26.9\n 26.0\n 27.2\n 26.8\n 27.0\n Plt\n 189\n 209\n 238\n \n 335\n Cr\n 0.6\n 0.6\n 0.9\n 0.7\n 0.6\n 0.7\n 0.6\n 0.5\n TCO2\n 26\n Glucose\n 99\n 115\n 106\n 100\n 134\n 134\n 121\n Other labs: PT / PTT / INR:16.6/25.0/1.5, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:9.3 mg/dL, Mg++:2.3 mg/dL, PO4:4.1\n mg/dL\n Assessment and Plan\n 55 yr old alcoholic s/p t spine fx s/p trcah and PEG with persistent\n resp failure\n 1. Resp Failure: currently on trach mask, can do a few hours per\n day, then needs for support. New pan Klebs in sputum, day\n . Try more vent support and see if it helps her.\n 2. Fevers: did not persist- cultures neg to date.\n 3 Hemodynamics: persistant simus tachy\n CTPA to look for emboli\n negative for proximal clot. IOs the of trach mask and her TB\n malacia too much for her. We will see what happens if we out her on\n 15-20 and 5.\n 4. New L Ext DVT\n 5. Emesis: call IR and get g pushed to a j tube\n ICU Care\n Nutrition: tfs held for vomiting\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Prophylaxis:\n DVT: coumadin\n Stress ulcer: ppi\n Communication: try to reach boyfriend\n status: Full code\n Disposition :ICU\n"},{"category":"Physician ","chartdate":"2167-10-16 00:00:00.000","description":"Physician Attending Progress Note","row_id":637952,"text":"Chief Complaint: resp failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n ULTRASOUND - At 08:11 AM\n right arm\n PICC LINE - STOP 12:02 PM\n PEG INSERTION - At 05:33 PM\n placed PEG which\n cannot be advanced by IR. TSurg by and felt needs to fail Reglan first\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Ceftriaxone - 10:00 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 12:00 PM\n Haloperidol (Haldol) - 02:00 PM\n Diazepam (Valium) - 03:52 PM\n Furosemide (Lasix) - 06:40 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.8\nC (98.3\n HR: 137 (97 - 146) bpm\n BP: 153/66(87) {93/43(55) - 183/129(134)} mmHg\n RR: 18 (13 - 33) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,220 mL\n 807 mL\n PO:\n TF:\n IVF:\n 500 mL\n 807 mL\n Blood products:\n Total out:\n 1,514 mL\n 150 mL\n Urine:\n 1,439 mL\n 150 mL\n NG:\n 75 mL\n Stool:\n Drains:\n Balance:\n -294 mL\n 657 mL\n Respiratory support\n O2 Delivery Device: Trach mask , Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 384 (311 - 675) mL\n PS : 10 cmH2O\n RR (Spontaneous): 12\n PEEP: 5 cmH2O\n FiO2: 70%\n RSBI: 52\n PIP: 15 cmH2O\n SpO2: 95%\n ABG: ///35/\n Ve: 4.6 L/min\n Physical Examination\n Gen: sitting up in bed, answers simples questions\n CV: tachy RR\n Chest: good air moevemtn but long exp time and bibasilar rales\n Abd: soft NT + BS PEG CDI\n Ext: no edema\n Neuro: attentive, mouths answers to words, moving all ext\n Labs / Radiology\n 9.0 g/dL\n 395 K/uL\n 126 mg/dL\n 0.7 mg/dL\n 35 mEq/L\n 4.0 mEq/L\n 7 mg/dL\n 102 mEq/L\n 144 mEq/L\n 29.7 %\n 7.0 K/uL\n [image002.jpg]\n 03:36 AM\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n 05:00 AM\n 02:06 AM\n 07:34 AM\n 03:50 AM\n 06:22 AM\n WBC\n 7.2\n 5.2\n 5.9\n 7.5\n 5.6\n 6.1\n 7.0\n Hct\n 26.9\n 26.0\n 27.2\n 26.8\n 27.0\n 27.0\n 29.7\n Plt\n 238\n 240\n 296\n \n 395\n Cr\n 0.6\n 0.9\n 0.7\n 0.6\n 0.7\n 0.6\n 0.5\n 0.7\n 0.7\n TCO2\n 26\n Glucose\n 115\n 106\n 100\n 134\n 134\n 121\n 619\n 126\n Other labs: PT / PTT / INR:24.2/27.7/2.4, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:9.5 mg/dL, Mg++:2.1 mg/dL, PO4:4.2\n mg/dL\n Assessment and Plan 55 yr old alcoholic s/p t spine fx s/p trcah and\n PEG with persistent resp failure\n 1. Resp Failure: currently on trach mask, can do sevreal hours per\n day and increasing each day, then needs for support QHS. Completed\n Rx for pan Klebs PNA. Per IP not stent planned as technically\n not possible to place into her airway\n 2. Hemodynamics: persistant simus tachy but also has runs of SVT-\n will add low dose bblocker today\n watch MAPs at night as\n she tends to run low. Anticoagulated.\n 3. New L Ext DVT: PICC out, on coumadin\n 4. Emesis: start Reglan, watch qt and restart low dose tf tonight-\n discuss with TSurg role of J prior to hospital d/c\n ICU Care\n Nutrition: restart TFs\n Glycemic Control:\n Lines:\n 20 Gauge - 12:26 PM\n Prophylaxis:\n DVT: couadin\n Stress ulcer: PPI\n Communication: trying to reach boyfriend\n status: Full code\n Disposition :screening for rehab\n"},{"category":"Respiratory ","chartdate":"2167-10-16 00:00:00.000","description":"Respiratory Care Shift Note","row_id":638002,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 28\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type:\n Manufacturer: Portex\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Copious\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Unassisted spontaneous breathing\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Increase ventilatory support at night\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Maintained on Trach Collar all day. Plan to stay as tolerated\n"},{"category":"Physician ","chartdate":"2167-10-19 00:00:00.000","description":"Physician Resident Progress Note","row_id":638347,"text":"Chief Complaint:\n 24 Hour Events:\n 8pm: Vomited tube feeds while receiving free water flushes. Suctioned\n by RT and no apparent aspiration, only blood tinged sputum. O2 sats\n 99-100%. No increased O2 requirement. Held TF, given free water via IV\n 100 cc/hr x 1L since Na 148. Will need to reassess in am, CXR ordered\n for am.\n Thoracics recs: place dophoff post pyloric or have GI place pedi GT\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Diazepam (Valium) - 12:00 AM\n Furosemide (Lasix) - 01:30 AM\n Morphine Sulfate - 02:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:21 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.3\n Tcurrent: 36.8\nC (98.3\n HR: 113 (81 - 137) bpm\n BP: 78/45(52) {78/39(50) - 130/73(108)} mmHg\n RR: 12 (12 - 32) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 3,165 mL\n 700 mL\n PO:\n TF:\n 691 mL\n IVF:\n 1,574 mL\n 700 mL\n Blood products:\n Total out:\n 1,670 mL\n 680 mL\n Urine:\n 1,470 mL\n 680 mL\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n 1,495 mL\n 20 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: MMV/PSV/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 94 (94 - 450) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 7\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 25 cmH2O\n SpO2: 97%\n ABG: ///38/\n Ve: 5.1 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 467 K/uL\n 8.6 g/dL\n 131 mg/dL\n 0.7 mg/dL\n 38 mEq/L\n 3.4 mEq/L\n 8 mg/dL\n 101 mEq/L\n 145 mEq/L\n 27.8 %\n 6.9 K/uL\n [image002.jpg]\n 03:00 AM\n 05:00 AM\n 02:06 AM\n 07:34 AM\n 03:50 AM\n 06:22 AM\n 02:58 AM\n 03:43 AM\n 05:02 PM\n 03:36 AM\n WBC\n 5.2\n 5.9\n 7.5\n 5.6\n 6.1\n 7.0\n 7.1\n 7.1\n 6.9\n Hct\n 26.0\n 27.2\n 26.8\n 27.0\n 27.0\n 29.7\n 28.9\n 29.2\n 27.8\n Plt\n 35\n 52\n 467\n Cr\n 0.6\n 0.7\n 0.6\n 0.5\n 0.7\n 0.7\n 0.6\n 0.7\n 0.8\n 0.7\n Glucose\n 100\n 134\n 134\n 121\n 04\n 108\n 131\n Other labs: PT / PTT / INR:66.1/32.7/8.0, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:9.4 mg/dL, Mg++:2.3 mg/dL, PO4:4.2\n mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2167-10-19 00:00:00.000","description":"Physician Resident Progress Note","row_id":638348,"text":"Chief Complaint:\n 24 Hour Events:\n 8pm: Vomited tube feeds while receiving free water flushes. Suctioned\n by RT and no apparent aspiration, only blood tinged sputum. O2 sats\n 99-100%. No increased O2 requirement. Held TF, given free water via IV\n 100 cc/hr x 1L since Na 148. Will need to reassess in am, CXR ordered\n for am.\n Thoracics recs: place dophoff post pyloric or have GI place pedi GT\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Diazepam (Valium) - 12:00 AM\n Furosemide (Lasix) - 01:30 AM\n Morphine Sulfate - 02:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:21 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.3\n Tcurrent: 36.8\nC (98.3\n HR: 113 (81 - 137) bpm\n BP: 78/45(52) {78/39(50) - 130/73(108)} mmHg\n RR: 12 (12 - 32) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 3,165 mL\n 700 mL\n PO:\n TF:\n 691 mL\n IVF:\n 1,574 mL\n 700 mL\n Blood products:\n Total out:\n 1,670 mL\n 680 mL\n Urine:\n 1,470 mL\n 680 mL\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n 1,495 mL\n 20 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: MMV/PSV/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 94 (94 - 450) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 7\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 25 cmH2O\n SpO2: 97%\n ABG: ///38/\n Ve: 5.1 L/min\n Physical Examination\n Gen: NAD, difficult to assess orientation as patient is nonverbal on\n trach mask, but she appeared alert, and resonded appropriately to\n questions and followed commands.\n HEENT: PERRLA, EOMI, OP w/o erythema.\n Resp: Limited by patients mobility, but CTA anteriorly and laterally\n Card: S1S2 tachicardic, no m/r/g\n Abd: Soft, Non-tender, Non-distended, BS+\n Exte: No edema, DP 2+, RP2+ bil.\n NEURO: CN II\nXII grossly intact. Strength 4/5 upper and lower\n bilaterally. Reflexes 2+ bilaterally, 3+ at L patellar tendon, with\n mild adductor crossover\n Labs / Radiology\n 467 K/uL\n 8.6 g/dL\n 131 mg/dL\n 0.7 mg/dL\n 38 mEq/L\n 3.4 mEq/L\n 8 mg/dL\n 101 mEq/L\n 145 mEq/L\n 27.8 %\n 6.9 K/uL\n [image002.jpg]\n 03:00 AM\n 05:00 AM\n 02:06 AM\n 07:34 AM\n 03:50 AM\n 06:22 AM\n 02:58 AM\n 03:43 AM\n 05:02 PM\n 03:36 AM\n WBC\n 5.2\n 5.9\n 7.5\n 5.6\n 6.1\n 7.0\n 7.1\n 7.1\n 6.9\n Hct\n 26.0\n 27.2\n 26.8\n 27.0\n 27.0\n 29.7\n 28.9\n 29.2\n 27.8\n Plt\n 35\n 52\n 467\n Cr\n 0.6\n 0.7\n 0.6\n 0.5\n 0.7\n 0.7\n 0.6\n 0.7\n 0.8\n 0.7\n Glucose\n 100\n 134\n 134\n 121\n 04\n 108\n 131\n Other labs: PT / PTT / INR:66.1/32.7/8.0, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:9.4 mg/dL, Mg++:2.3 mg/dL, PO4:4.2\n mg/dL\n Assessment and Plan\n 55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach, PEG, placement no with respiratory failure secondary to\n tracheomalacia , resolving HAP.\n .\n # Respiratory failure: Slowly Improving. Now remaining on trach mask\n for most of the day and night, with periods of pressure support of \n over night.\n - Continue to increase time on trach mask as tolerated.\n - PMV with suctioning again today.\n .\n # HAP vs Aspiration PNA: Afebrile without leukocytosis\n - Completed course of ceftriaxone\n - Continue to f/u cultures\n - Continue trach mask as tolerated\n .\n # Tachycardia: Previously was assessed as sinus tach with occasional\n runs of SVT and sources such as hypovolemia, PE, infection, and pain\n were assessed as possibly etiologies. But, now appears to be SVT for\n much of time, rhythm,/rate nonresponsive to carotid massage. HR\n decreased to 80s w/ stable BPs for approx 2 hour period overnight that\n seems to be associated with administration of her BB and valium. Rhythm\n strip shows conversion from a narrow complex non-sinus tachycardia to\n normal sinus rhythm.\n - Increase Metroprolol from 25mg TID to 25mg QID\n - Consider further adjustment of BB as tolerated by BP.\n - If not sufficient for rhythm conversion, consult cardiology for\n management.\n .\n # Sedation: Inconsistent response to sedation, unclear what is best\n regime. Will continue to wean overall. Possibly improved level of\n agitation when rhytm returned to sinus.\n - Continue w Olanzapine QHS\n - DC\nd haldol and taper valium to 2.5 mg PRN TID w/ 2.5 mg PRNs.\n # Nutrition: Tube feeds have been restarted and pt started on raglan.\n Has been tolerating feeds well so far.\n - Continue TFs, w/ FW flushes\n - Nutrition recs appreciated.\n .\n # Adrenal Insufficency: Endocrine following. Pt does not appear to be\n adrenally insufficient at baseline. Suggesting if the patient under\n goes major stressors such as major surgery, sepsis, she may need stress\n dosed steroids.\n .\n # Fluid Status: Likely approaching euvolemia, though still has\n hypernatramia which may suggest is still intravascularly depleated.\n - Monitoring urine output\n - FW flushes at 100/hr w/ tube feeds\n - PM lytes to trend Na\n .\n # UE DVT and elevated INR: DVT in right UE has resolved, new\n non-occlusive in left axillary vein. INR supratherapeutic today\n - COumadin held, will restart at low dose when INR approaches\n therapeutic range.\n - follow INR\n .\n # Spine fracture: Stable\n - Brace for OOB, will discuss with Neurosurgery if current brace is\n optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n .\n # Tracheomalacia. Was initially addressed with IP and they wanted to\n follow up as outpatient.\n - Consult IP for stent placement given improved clinical status, will\n readdress\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # PIV x 1\n # Ppx: Coumadin, Ranitidine, Bowel Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n # Code: Full\n # Dispo: ICU, Screening for vent facilities\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Respiratory ","chartdate":"2167-10-15 00:00:00.000","description":"Respiratory Care Shift Note","row_id":637649,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 27\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Tube Type\n Tracheostomy tube:\n Type: Standard, Cuffed\n Manufacturer: Portex\n Size: 7.0mm\n PMV: No\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Invasive ventilation assessment:\n Dysynchrony assessment: Frequent alarms (Low min. ventilation)\n Comments: with PSV at 10 pt demonstrating frequent periods of decreased\n RR and low minute ventilation, PVS decreased to 8 resulting in more\n consistent RR and minute ventilation. Attempted to further decrease PSV\n to 5 but pt RR increased to 35-40 with very small Vt less then 200ml,\n PS returned to 8, eventually required return to PS 10 due to increasing\n tachypnea.\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated.\n Comments:\n Tol decrease in PS to 8 from 10 for 2 hours eventually becoming\n tachypneac with smaller Vt, PS returned to 10.\n Continue with trach collar trials as tol, return to PSV for rest.\n"},{"category":"Physician ","chartdate":"2167-10-12 00:00:00.000","description":"Physician Resident Progress Note","row_id":637049,"text":"Chief Complaint:\n 24 Hour Events:\n Developed papular rash over entire back, bilateraly, in multiple\n dermatomal distributions, opaque vesicles on erythematous base,\n nonpainful, possibly pruritic.\n Levofloxaxin was d/c'd.\n Ceftriaxone started.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Aztreonam - 03:42 AM\n Vancomycin - 09:40 AM\n Levofloxacin - 11:15 PM\n Ceftriaxone - 07:50 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:14 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 37.2\nC (98.9\n HR: 139 (113 - 145) bpm\n BP: 97/61(68) {85/28(50) - 127/86(90)} mmHg\n RR: 12 (9 - 30) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,362 mL\n 302 mL\n PO:\n TF:\n 47 mL\n 152 mL\n IVF:\n 1,061 mL\n 100 mL\n Blood products:\n Total out:\n 1,203 mL\n 460 mL\n Urine:\n 1,203 mL\n 460 mL\n NG:\n Stool:\n Drains:\n Balance:\n 159 mL\n -158 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 0 (0 - 0) mL\n Vt (Spontaneous): 504 (110 - 504) mL\n PS : 10 cmH2O\n RR (Set): 0\n RR (Spontaneous): 14\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 245\n PIP: 16 cmH2O\n SpO2: 100%\n ABG: ///30/\n Ve: 5.9 L/min\n Physical Examination\n General Appearance: Trached. Interactive. Responsive, following\n commands, Overweight / Obese, mild agitation but NAD\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\n deviation\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Respiratory / Chest: (Expansion: Symmetric), b/l rhonchi R>L, decreased\n BS\n Abdominal: Obese, soft, Non-tender, no rebound, no guarding, + BS, PEG\n in place with dressing C/D/I\n Extremities: no CCE\n Skin: no rashes or jaundice\n Lines: L PICC C/D/I\n Labs / Radiology\n 240 K/uL\n 7.9 g/dL\n 100 mg/dL\n 0.6 mg/dL\n 30 mEq/L\n 3.4 mEq/L\n 12 mg/dL\n 108 mEq/L\n 146 mEq/L\n 26.0 %\n 5.2 K/uL\n [image002.jpg]\n 08:11 PM\n 02:51 AM\n 03:10 AM\n 03:08 PM\n 03:00 AM\n 03:36 AM\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n WBC\n 9.4\n 11.3\n 7.3\n 6.1\n 7.2\n 5.2\n Hct\n 26.6\n 24.9\n 27.6\n 26.5\n 26.9\n 26.0\n Plt\n \n Cr\n 0.9\n 0.7\n 0.6\n 0.6\n 0.9\n 0.7\n 0.6\n TCO2\n 29\n 26\n Glucose\n 128\n 114\n 114\n 99\n 115\n 106\n 100\n Other labs: PT / PTT / INR:17.6/27.4/1.6, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:33/22, Alk Phos / T Bili:143/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:0.5 mmol/L,\n Albumin:3.5 g/dL, LDH:199 IU/L, Ca++:8.9 mg/dL, Mg++:2.4 mg/dL, PO4:4.1\n mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA, and\n ARDS, intubated since the end of now s/p trach and PEG\n placement.\n # Recent Aspiration of tube feeds. Given prolonged hospitalization and\n tenuous respiratory status will treat with antibiotics while cultures\n pending\n - Levoflox for 48 hours while waiting for sputum results.\n - hold tube feeds\n - Follow cultures\n - check tube placement\n .\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation. S/P Trach\n and PEG on .\n - wean FiO2 as tolerated\n - attempt wean PS today and hopeful for trach mask trial\n # Sedation: Continue to have issues with pain/delirium causing\n tachycardia and hypertension with intermittent hypotension. On Haldol\n 5 TID, Fentanyl 75 mcg TP, Diazapam 10 QID; Haldol, midazolam and\n morphine PRN. Had good response to morphine, minimal response to\n haldol bolus.\n - tolerating current regimen well, no changes today\n # Adrenal Insufficency: Hypotension that resolved with steroids,\n returned as they came off and is now improved again. Possible primary\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\n started on .\n - stopped steroids as per endocrine today\n # Volume overloaded in setting of hypernatremia\n Goal even today.\n - monitor urine output\n # RUE DVT: INR super-therapeutic on coumadin. Goal . Hasn\n received coumadin in days yet INR continues to rise. Likely\n contributors are nutritional and antibiotics.\n - will start coumadin 2.5 mg QHS once INR < 3\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - Brace for OOB\n - report from full trauma series from OSH is in chart. No evidence of\n other fracture and no need for further spinal imaging based on this\n report and ortho note.\n # Tracheomalacia: Discussed with IP. Stenting unlikely to help for\n trachiomalacia as airways have poor structure diffusely.\n - Outpatient f/u once off pressure support to assess for possible\n stenting\n #. Thyroid Nodule on CT\n -outpatient follow up\n # Nutrition: Replete (Full)\n hold\n # Glycemic control: SSI, well controlled\n # Lines L PICC ().\n # Ppx: INR therapeutic, ranitidine, colace and senna, miralax,\n bisacodyl.\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n Code: Full\n Dispo: ICU, being screening for vent facilities\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 03:36 AM 30 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2167-10-14 00:00:00.000","description":"Physician Resident Progress Note","row_id":637472,"text":"Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 02:18 AM\n SPUTUM CULTURE - At 02:18 AM\n URINE CULTURE - At 02:18 AM\n Pt tachy to mid 150's yesterday.\n Restarted on Warfarin 2.5mg\n Bolused 500cc x2 without change in HR\n Overnight Tm 100.8, BCx, UCx, CXR\n Tachypnic to high 30's.\n Given Valium 5mg IV x 1, Tylenol\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Ceftriaxone - 12:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.8\n Tcurrent: 37.2\nC (99\n HR: 137 (120 - 151) bpm\n BP: 125/55(73) {91/41(54) - 202/97(111)} mmHg\n RR: 21 (12 - 39) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,934 mL\n 390 mL\n PO:\n TF:\n 1,104 mL\n 340 mL\n IVF:\n 1,000 mL\n 50 mL\n Blood products:\n Total out:\n 530 mL\n 240 mL\n Urine:\n 530 mL\n 240 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,404 mL\n 150 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 318 (318 - 475) mL\n PS : 10 cmH2O\n RR (Spontaneous): 34\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 171\n SpO2: 97%\n ABG: ///32/\n Ve: 9 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 306 K/uL\n 8.8 g/dL\n 134 mg/dL\n 0.6 mg/dL\n 32 mEq/L\n 4.0 mEq/L\n 11 mg/dL\n 106 mEq/L\n 146 mEq/L\n 26.8 %\n 7.5 K/uL\n [image002.jpg]\n 03:10 AM\n 03:08 PM\n 03:00 AM\n 03:36 AM\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n 05:00 AM\n 02:06 AM\n WBC\n 11.3\n 7.3\n 6.1\n 7.2\n 5.2\n 5.9\n 7.5\n Hct\n 24.9\n 27.6\n 26.5\n 26.9\n 26.0\n 27.2\n 26.8\n Plt\n 227\n 189\n 209\n 238\n 240\n 296\n 306\n Cr\n 0.7\n 0.6\n 0.6\n 0.9\n 0.7\n 0.6\n 0.7\n 0.6\n TCO2\n 26\n Glucose\n 114\n 99\n 115\n 106\n 100\n 134\n 134\n Other labs: PT / PTT / INR:13.5/23.6/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:27/19, Alk Phos / T Bili:118/0.3,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:243 IU/L, Ca++:9.2 mg/dL, Mg++:2.1 mg/dL, PO4:4.0\n mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 06:23 AM 60 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2167-10-14 00:00:00.000","description":"Physician Resident Progress Note","row_id":637473,"text":"Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 02:18 AM\n SPUTUM CULTURE - At 02:18 AM\n URINE CULTURE - At 02:18 AM\n Pt tachy to mid 150's yesterday.\n Restarted on Warfarin 2.5mg\n Bolused 500cc x2 without change in HR\n Overnight Tm 100.8, BCx, UCx, CXR\n Tachypnic to high 30's.\n Given Valium 5mg IV x 1, Tylenol\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Ceftriaxone - 12:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.8\n Tcurrent: 37.2\nC (99\n HR: 137 (120 - 151) bpm\n BP: 125/55(73) {91/41(54) - 202/97(111)} mmHg\n RR: 21 (12 - 39) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,934 mL\n 390 mL\n PO:\n TF:\n 1,104 mL\n 340 mL\n IVF:\n 1,000 mL\n 50 mL\n Blood products:\n Total out:\n 530 mL\n 240 mL\n Urine:\n 530 mL\n 240 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,404 mL\n 150 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 318 (318 - 475) mL\n PS : 10 cmH2O\n RR (Spontaneous): 34\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 171\n SpO2: 97%\n ABG: ///32/\n Ve: 9 L/min\n Physical Examination\n GEN:\n HEENT:\n PULM\n CARD:\n ABD:\n EXT:\n NEURO:\n Labs / Radiology\n 306 K/uL\n 8.8 g/dL\n 134 mg/dL\n 0.6 mg/dL\n 32 mEq/L\n 4.0 mEq/L\n 11 mg/dL\n 106 mEq/L\n 146 mEq/L\n 26.8 %\n 7.5 K/uL\n [image002.jpg]\n 03:10 AM\n 03:08 PM\n 03:00 AM\n 03:36 AM\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n 05:00 AM\n 02:06 AM\n WBC\n 11.3\n 7.3\n 6.1\n 7.2\n 5.2\n 5.9\n 7.5\n Hct\n 24.9\n 27.6\n 26.5\n 26.9\n 26.0\n 27.2\n 26.8\n Plt\n 227\n 189\n 209\n 238\n 240\n 296\n 306\n Cr\n 0.7\n 0.6\n 0.6\n 0.9\n 0.7\n 0.6\n 0.7\n 0.6\n TCO2\n 26\n Glucose\n 114\n 99\n 115\n 106\n 100\n 134\n 134\n Other labs: PT / PTT / INR:13.5/23.6/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:27/19, Alk Phos / T Bili:118/0.3,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:243 IU/L, Ca++:9.2 mg/dL, Mg++:2.1 mg/dL, PO4:4.0\n mg/dL\n Assessment and Plan\n 55yoF with history of EtOH abuse presenting following mechanical fall\n and traumatic T spine fracture, now s/p trach, PEG, placement being\n treated for HAP.\n# HAP vs Aspiration PNA: Cultures growing Klebsiella Oxytoca, Klebsiella Pneumon\niae, GNR, GP Cocci. Pt received developed rash on Levofloxacin, switched to Ceft\nriaxone overnight. Will treat for potential HAP for 8 days.\n - Continue Ceftriaxone HAP (Day #6 of 8)\n - Tube Feeds now at 50 with goal of 60/hr\n - Following Cultures\n .\n # Respiratory failure: 5 hours on Trach mask yesterday, will assess\n length of tolerance today.\n - PMV with suctioning.\n - Weaning FiO2 as tolerated\n # Tachycardia: Pt in ST 120\ns to 150s. Etiology remains unclear and\n etiologies include hypovolemia, pain, infection (pt with known\n klebsiella), . DDx also includes PE\n - Treating underlying infection\n - Bolus NS 500cc x 2 today and assess HR\n - Restarting patients Coumadin\n - TSH 2.4 on early , will check free T3, T4.\n - Continue Pain Control\n # Sedation: Pt has pain/delirium causing tachycardia and hypertension\n with intermittent hypotension. Had good response to morphine, minimal\n response to haldol bolus.\n - Haldol 5 TID, Fentanyl 75 mcg TP, Diazapam 10 QID;\n - Haldol, midazolam and morphine PRN.\n - tolerating current regimen well\n # Adrenal Insufficency: Followed up with endocrine that suggested if\n the patient under goes major stressors such as major surgery, sepsis,\n she may need stress dosed steroids.\n - Will consider MRI at later date for evaluation of pituitary\n # Fluid Status: Volume overloaded in prior setting of Hypernatremia\n Goal even today.\n - Monitoring urine output\n # RUE DVT: INR was super-therapeutic on coumadin. Goal . Received 5\n of coumadin overnight.\n - Restarting Coumadin 2.5 mg QHS once INR < 3\n # Spine fracture: Stable\n - Brace for OOB, will discuss with Neurosurgery if current brace is\n optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n # Tracheomalacia?: Discussed with IP.\n - Outpatient f/u once off pressure support to assess for possible\n stenting\n #. Thyroid Nodule on CT\n - Outpatient follow up\n # Nutrition: TFs with goal of 60\n # Glycemic control: SSI, well controlled\n # Lines L PICC\n ().\n # Ppx: Restarting Coumadin, Ranitidine, Bowel Regimen\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n # Code: Full\n # Dispo: ICU, Screening for vent facilities\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 06:23 AM 60 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Nursing","chartdate":"2167-10-18 00:00:00.000","description":"Nursing Progress Note","row_id":638287,"text":"Airway Clearance, Impaired\n Assessment:\n Pt placed TM50% this am, changed to high flow TM 60% @ for low\n O2Sats, cont with mod thick tan secretions.\n Action:\n Suctioned prn, pt repositioned frequently\n Response:\n No s/sx resp distress; pt tolerating trach mask\n Plan:\n Cont prn suctioning; repositioning; monitor CXry as ordered\n Altered mental status (not Delirium)\n Assessment:\n Pt cont with extreme restlessness and periods of agitation, requiring\n frequent redirection\n Action:\n Cont with scheduled valium, prn meds offered, pt oriented to , pt\n given IV morphine for presumed pain\n Response:\n Pt cont with periods of restlessness, minimal effect with valium; pt\n responded well to IV Morphine\n Plan:\n Medicate as needed for agitation; attempt to try PMV when pt secretions\n lessen to initiate communication\n Tachycardia, Other\n Assessment:\n HR 110-140\ns today\n Action:\n Cont with Lopressor as ordered\n Response:\n HR in 110\ns, otherwise unchanged\n Plan:\n Cont. Lopressor, ? cardiology consult\n Alteration in Nutrition\n Assessment:\n Pt cont on Promote w/ Fiber, currently at 50ml/hr goal 60ml, no\n episodes of emesis today\n Action:\n Advanced TF as tolerated for goal 60ml, IV Reglan given per order\n Response:\n No residuals noted, no further emesis\n Plan:\n Advance TF\ns as tolerated, cont IV reglan\n"},{"category":"Physician ","chartdate":"2167-10-13 00:00:00.000","description":"Physician Attending Progress Note","row_id":637378,"text":"Chief Complaint: resp failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Trach Mask x 5 hours\n Tried PMV but had secretions\n History obtained from Patient\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 11:15 PM\n Ceftriaxone - 07:50 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:13 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37\nC (98.6\n HR: 135 (118 - 151) bpm\n BP: 137/78(91) {90/37(48) - 202/96(111)} mmHg\n RR: 37 (13 - 39) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,614 mL\n 2,451 mL\n PO:\n TF:\n 884 mL\n 761 mL\n IVF:\n 100 mL\n 1,000 mL\n Blood products:\n Total out:\n 834 mL\n 320 mL\n Urine:\n 834 mL\n 320 mL\n NG:\n Stool:\n Drains:\n Balance:\n 780 mL\n 2,131 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Spontaneous): 354 (316 - 376) mL\n PS : 10 cmH2O\n RR (Spontaneous): 12\n PEEP: 5 cmH2O\n FiO2: 70%\n RSBI: 56\n PIP: 15 cmH2O\n SpO2: 92%\n ABG: ///32/\n Ve: 4.1 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 8.7 g/dL\n 296 K/uL\n 134 mg/dL\n 0.7 mg/dL\n 32 mEq/L\n 3.8 mEq/L\n 14 mg/dL\n 107 mEq/L\n 147 mEq/L\n 27.2 %\n 5.9 K/uL\n [image002.jpg]\n 02:51 AM\n 03:10 AM\n 03:08 PM\n 03:00 AM\n 03:36 AM\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n 05:00 AM\n WBC\n 11.3\n 7.3\n 6.1\n 7.2\n 5.2\n 5.9\n Hct\n 24.9\n 27.6\n 26.5\n 26.9\n 26.0\n 27.2\n Plt\n 227\n 189\n 209\n 238\n 240\n 296\n Cr\n 0.7\n 0.6\n 0.6\n 0.9\n 0.7\n 0.6\n 0.7\n TCO2\n 29\n 26\n Glucose\n 114\n 114\n 99\n 115\n 106\n 100\n 134\n Other labs: PT / PTT / INR:13.5/23.6/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:27/19, Alk Phos / T Bili:118/0.3,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:0.5 mmol/L,\n Albumin:3.5 g/dL, LDH:178 IU/L, Ca++:9.2 mg/dL, Mg++:2.3 mg/dL, PO4:4.6\n mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 10:29 AM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n 20 Gauge - 04:59 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"},{"category":"Physician ","chartdate":"2167-10-13 00:00:00.000","description":"Physician Attending Progress Note","row_id":637379,"text":"Chief Complaint: resp failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Trach Mask x 5 hours\n Tried PMV but had secretions\n History obtained from Patient\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 11:15 PM\n Ceftriaxone - 07:50 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:13 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37\nC (98.6\n HR: 135 (118 - 151) bpm\n BP: 137/78(91) {90/37(48) - 202/96(111)} mmHg\n RR: 37 (13 - 39) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,614 mL\n 2,451 mL\n PO:\n TF:\n 884 mL\n 761 mL\n IVF:\n 100 mL\n 1,000 mL\n Blood products:\n Total out:\n 834 mL\n 320 mL\n Urine:\n 834 mL\n 320 mL\n NG:\n Stool:\n Drains:\n Balance:\n 780 mL\n 2,131 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Spontaneous): 354 (316 - 376) mL\n PS : 10 cmH2O\n RR (Spontaneous): 12\n PEEP: 5 cmH2O\n FiO2: 70%\n RSBI: 56\n PIP: 15 cmH2O\n SpO2: 92%\n ABG: ///32/\n Ve: 4.1 L/min\n Physical Examination\n Gen sitting up in , on trach mask, interactive\n CV tachy RRR\n Chest good movement ANT\n Abd soft NT + NS\n Ext: no edema\n Neuroalert follows simple commands\n Labs / Radiology\n 8.7 g/dL\n 296 K/uL\n 134 mg/dL\n 0.7 mg/dL\n 32 mEq/L\n 3.8 mEq/L\n 14 mg/dL\n 107 mEq/L\n 147 mEq/L\n 27.2 %\n 5.9 K/uL\n [image002.jpg]\n 02:51 AM\n 03:10 AM\n 03:08 PM\n 03:00 AM\n 03:36 AM\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n 05:00 AM\n WBC\n 11.3\n 7.3\n 6.1\n 7.2\n 5.2\n 5.9\n Hct\n 24.9\n 27.6\n 26.5\n 26.9\n 26.0\n 27.2\n Plt\n 227\n 189\n 209\n 238\n 240\n 296\n Cr\n 0.7\n 0.6\n 0.6\n 0.9\n 0.7\n 0.6\n 0.7\n TCO2\n 29\n 26\n Glucose\n 114\n 114\n 99\n 115\n 106\n 100\n 134\n Other labs: PT / PTT / INR:13.5/23.6/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:27/19, Alk Phos / T Bili:118/0.3,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:0.5 mmol/L,\n Albumin:3.5 g/dL, LDH:178 IU/L, Ca++:9.2 mg/dL, Mg++:2.3 mg/dL, PO4:4.6\n mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 10:29 AM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n 20 Gauge - 04:59 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"},{"category":"Physician ","chartdate":"2167-10-13 00:00:00.000","description":"Physician Attending Progress Note","row_id":637380,"text":"Chief Complaint: resp failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI: 56 yr old with t spine fx, resp failure\n 24 Hour Events:\n Trach Mask x 5 hours\n Tried PMV but had secretions\n History obtained from Patient\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 11:15 PM\n Ceftriaxone - 07:50 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:13 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37\nC (98.6\n HR: 135 (118 - 151) bpm\n BP: 137/78(91) {90/37(48) - 202/96(111)} mmHg\n RR: 37 (13 - 39) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,614 mL\n 2,451 mL\n PO:\n TF:\n 884 mL\n 761 mL\n IVF:\n 100 mL\n 1,000 mL\n Blood products:\n Total out:\n 834 mL\n 320 mL\n Urine:\n 834 mL\n 320 mL\n NG:\n Stool:\n Drains:\n Balance:\n 780 mL\n 2,131 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Spontaneous): 354 (316 - 376) mL\n PS : 10 cmH2O\n RR (Spontaneous): 12\n PEEP: 5 cmH2O\n FiO2: 70%\n RSBI: 56\n PIP: 15 cmH2O\n SpO2: 92%\n ABG: ///32/\n Ve: 4.1 L/min\n Physical Examination\n Gen sitting up in , on trach mask, interactive\n CV tachy RRR\n Chest good air movement ANT\n Abd soft NT + NS\n Ext: no edema\n Neuro: alert follows simple commands\n Labs / Radiology\n 8.7 g/dL\n 296 K/uL\n 134 mg/dL\n 0.7 mg/dL\n 32 mEq/L\n 3.8 mEq/L\n 14 mg/dL\n 107 mEq/L\n 147 mEq/L\n 27.2 %\n 5.9 K/uL\n [image002.jpg]\n 02:51 AM\n 03:10 AM\n 03:08 PM\n 03:00 AM\n 03:36 AM\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n 05:00 AM\n WBC\n 11.3\n 7.3\n 6.1\n 7.2\n 5.2\n 5.9\n Hct\n 24.9\n 27.6\n 26.5\n 26.9\n 26.0\n 27.2\n Plt\n 227\n 189\n 209\n 238\n 240\n 296\n Cr\n 0.7\n 0.6\n 0.6\n 0.9\n 0.7\n 0.6\n 0.7\n TCO2\n 29\n 26\n Glucose\n 114\n 114\n 99\n 115\n 106\n 100\n 134\n Other labs: PT / PTT / INR:13.5/23.6/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:27/19, Alk Phos / T Bili:118/0.3,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:0.5 mmol/L,\n Albumin:3.5 g/dL, LDH:178 IU/L, Ca++:9.2 mg/dL, Mg++:2.3 mg/dL, PO4:4.6\n mg/dL\n Assessment and Plan 55 yr old alcoholic s/p t spine fx s/p trcah and\n PEG with persistent resp failure\n 1. Resp Failure: currently on trach mask, can do a few hours per\n day, then needs for support. New pan Klebs in sputum, day\n . Re- try. Holding off on stent by IP until after pulm rehab.\n 2. Hemodynamics: tachycardia with slightly decreased UOP\n bolus\n IVF and trend UOP. Watch to see if response with tachycardia.\n 3. Anti coag: for upper ext DVT but INR elevated on coumadin +\n quinolone\n repeat inr low- trend with po COumadin\n 4. Adrenal Insufficiency: proper stim this AM, off steroids\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 10:29 AM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n 20 Gauge - 04:59 PM\n Prophylaxis:\n DVT: coumadin\n Stress ulcer: ppi\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"},{"category":"Nursing","chartdate":"2167-10-14 00:00:00.000","description":"Nursing Progress Note","row_id":637594,"text":"Tachycardia, Other\n Assessment:\n Action:\n Response:\n Plan:\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Physician ","chartdate":"2167-10-14 00:00:00.000","description":"Physician Resident Progress Note","row_id":637564,"text":"Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 02:18 AM\n SPUTUM CULTURE - At 02:18 AM\n URINE CULTURE - At 02:18 AM\n Pt tachy to mid 150's yesterday.\n Restarted on Warfarin 2.5mg\n Bolused 500cc x2 without change in HR\n Overnight Tm 100.8, BCx, UCx, CXR\n Tachypnic to high 30's.\n Given Valium 5mg IV x 1, Tylenol\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Ceftriaxone - 12:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.8\n Tcurrent: 37.2\nC (99\n HR: 137 (120 - 151) bpm\n BP: 125/55(73) {91/41(54) - 202/97(111)} mmHg\n RR: 21 (12 - 39) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,934 mL\n 390 mL\n PO:\n TF:\n 1,104 mL\n 340 mL\n IVF:\n 1,000 mL\n 50 mL\n Blood products:\n Total out:\n 530 mL\n 240 mL\n Urine:\n 530 mL\n 240 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,404 mL\n 150 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 318 (318 - 475) mL\n PS : 10 cmH2O\n RR (Spontaneous): 34\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 171\n SpO2: 97%\n ABG: ///32/\n Ve: 9 L/min\n Physical Examination\n GEN: Awake, alert, responsive. Sitting in chair, in back brace.\n Following commands.\n HEENT: PERRL\n PULM: CTA anteriorly, no r/r/w\n CARD: tachycardic, regular, ,s1, s2,\n ABD: abdomen, inferior to brace, soft, nontender\n EXT: DP 2+\n NEURO: able to move all extremeties, strength 5/5 upper and lower, R\n hip < L hip.\n Labs / Radiology\n 306 K/uL\n 8.8 g/dL\n 134 mg/dL\n 0.6 mg/dL\n 32 mEq/L\n 4.0 mEq/L\n 11 mg/dL\n 106 mEq/L\n 146 mEq/L\n 26.8 %\n 7.5 K/uL\n [image002.jpg]\n LACTATE 1.1\n 03:10 AM\n 03:08 PM\n 03:00 AM\n 03:36 AM\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n 05:00 AM\n 02:06 AM\n WBC\n 11.3\n 7.3\n 6.1\n 7.2\n 5.2\n 5.9\n 7.5\n Hct\n 24.9\n 27.6\n 26.5\n 26.9\n 26.0\n 27.2\n 26.8\n Plt\n 227\n 189\n 209\n 238\n 240\n 296\n 306\n Cr\n 0.7\n 0.6\n 0.6\n 0.9\n 0.7\n 0.6\n 0.7\n 0.6\n TCO2\n 26\n Glucose\n 114\n 99\n 115\n 106\n 100\n 134\n 134\n Other labs: PT / PTT / INR:13.5/23.6/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:27/19, Alk Phos / T Bili:118/0.3,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:243 IU/L, Ca++:9.2 mg/dL, Mg++:2.1 mg/dL, PO4:4.0\n mg/dL\n UA: WBC, RBC, EPI, trace bld, trace leuk, few bacter\n CXR: not sig changed from prev, R diaphragm elevated, possibly improved\n L costophrenic angle effusion, PICC line terminus difficult to\n visualize.\n Assessment and Plan\n 55yoF with history of EtOH abuse presenting following mechanical fall\n and traumatic T spine fracture, now s/p trach, PEG, placement being\n treated for HAP.\n# HAP vs Aspiration PNA: Cultures grew, Klebsiella Oxytoca, Klebsiella Pneumonia\ne, GNR, GP Cocci. Will continue to treat for potential HAP for 8 days.Pt continu\ning to have some fevers, last night 100.8, and new sputum on today w/ gram stain\n showing GPC p/c. New VAP/HAP w/ staph possible, but given no clear infiltrate o\nn CXR and good respiratory status, significant PNA is unlikely, colonization of\ntrach is possible, as is contamination of sputum. Given improving clinical \n, wait until CX data or change in clinical status or CXR to initiate HAP\n/VAP treatment.\n - Continue Ceftriaxone HAP (Day #6 of 8)\n - Continue to f/u cultures\n .\n # Respiratory failure: Improving status. Will continue to increase\n time on trach mask as tolerated.\n - PMV with suctioning.\n - Weaning FiO2 as tolerated\n # Tachycardia: Pt in ST 120\ns to 150s. Etiology remains unclear and\n etiologies include hypovolemia, pain, infection (pt with known\n klebsiella), . DDx also includes PE given hx of RUE DVT, mucus\n plugging given large amount of secretions, and spinal injury.\n - Treating underlying infection\n - Restarting patients Coumadin, last INR 1.2 yesterday, not\n therapeutic, will recheck this PM\n - TSH 2.4 on early , will check free T3, T4.\n - Continue Pain Control\n - Assess for PE w/ CTPA and UE u/s\n # Sedation: Pt has pain/delirium causing tachycardia and hypertension\n with intermittent hypotension. Had good response to morphine, minimal\n response to haldol bolus.\n - Haldol 5 PRN, Fentanyl 75 mcg TP, Diazapam 5 QID;\n - tolerating current regimen well, will continue to wean\n # Adrenal Insufficency: Followed up with endocrine that suggested if\n the patient under goes major stressors such as major surgery, sepsis,\n she may need stress dosed steroids.\n - Will consider MRI at later date for evaluation of pituitary\n # Fluid Status: Volume overloaded in prior setting of Hypernatremia\n Goal even today.\n - Monitoring urine output\n - increasse Free H20, for mild hypernatremia\n # RUE DVT: restarted Coumadin for INR 1.2, will follow INR carefully,\n given Abx.\n - Check INR this PM\n # Spine fracture: Stable\n - Brace for OOB, will discuss with Neurosurgery if current brace is\n optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n # Tracheomalacia?: Discussed with IP.\n - Outpatient f/u once off pressure support to assess for possible\n stenting\n #. Thyroid Nodule on CT\n - Outpatient follow up\n # Nutrition: TFs with goal of 60\n # Glycemic control: SSI, well controlled\n # Lines L PICC ().\n # Ppx: Restarting Coumadin, Ranitidine, Bowel Regimen\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n # Code: Full\n # Dispo: ICU, Screening for vent facilities\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 06:23 AM 60 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2167-10-14 00:00:00.000","description":"Physician Attending Progress Note","row_id":637565,"text":"Chief Complaint: resp failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n s/p t spine fx with resp failure\n 24 Hour Events:\n BLOOD CULTURED - At 02:18 AM\n SPUTUM CULTURE - At 02:18 AM\n URINE CULTURE - At 02:18 AM\n FEVER Pan cx\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Ceftriaxone - 12:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Atrovent/Albuterol, Miralax, Chlorhex, Ceftriaxone, Thiamine Folate\n Valium 5 mg QID COumadin 2.5\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fever\n Flowsheet Data as of 08:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.8\n Tcurrent: 37.2\nC (99\n HR: 137 (120 - 151) bpm\n BP: 125/55(73) {98/41(54) - 202/97(111)} mmHg\n RR: 23 (12 - 39) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,934 mL\n 497 mL\n PO:\n TF:\n 1,104 mL\n 447 mL\n IVF:\n 1,000 mL\n 50 mL\n Blood products:\n Total out:\n 530 mL\n 240 mL\n Urine:\n 530 mL\n 240 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,404 mL\n 257 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 318 (318 - 475) mL\n PS : 10 cmH2O\n RR (Spontaneous): 34\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 171\n SpO2: 98%\n ABG: ///32/\n Ve: 9 L/min\n Physical Examination\n Gen sitting up in , on trach mask, interactive\n CV tachy RRR\n Chest good air movement ANT\n Abd soft NT + NS\n Ext: no edema\n Neuro: alert follows simple commands\n Labs / Radiology\n 8.8 g/dL\n 306 K/uL\n 134 mg/dL\n 0.6 mg/dL\n 32 mEq/L\n 4.0 mEq/L\n 11 mg/dL\n 106 mEq/L\n 146 mEq/L\n 26.8 %\n 7.5 K/uL\n [image002.jpg]\n 03:10 AM\n 03:08 PM\n 03:00 AM\n 03:36 AM\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n 05:00 AM\n 02:06 AM\n WBC\n 11.3\n 7.3\n 6.1\n 7.2\n 5.2\n 5.9\n 7.5\n Hct\n 24.9\n 27.6\n 26.5\n 26.9\n 26.0\n 27.2\n 26.8\n Plt\n 227\n 189\n 209\n 238\n 240\n 296\n 306\n Cr\n 0.7\n 0.6\n 0.6\n 0.9\n 0.7\n 0.6\n 0.7\n 0.6\n TCO2\n 26\n Glucose\n 114\n 99\n 115\n 106\n 100\n 134\n 134\n Other labs: PT / PTT / INR:13.5/23.6/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:27/19, Alk Phos / T Bili:118/0.3,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:243 IU/L, Ca++:9.2 mg/dL, Mg++:2.1 mg/dL, PO4:4.0\n mg/dL\n - Sputum: 3+ GPC cocci in prs and chains\n yeast\n Assessment and Plan 55 yr old alcoholic s/p t spine fx s/p trcah and\n PEG with persistent resp failure\n 1. Resp Failure: currently on trach mask, can do a few hours per\n day, then needs for support. New pan Klebs in sputum, day\n . Re- try. Holding off on stent by IP until after pulm rehab.\n 2. Fevers: DDx - line infection VAP, check LFTs, check blood and\n urine cx, LUE ultrasounds -\n 3 Hemodynamics: persistant simus tachy\n check CTPA to look for\n emboli- has been off on anti coag - tachycardia with slightly decreased\n UOP\n bolus IVF and trend UOP. Watch to see if response with\n tachycardia.\n 4. Anti coag: for upper ext DVT but INR elevated on coumadin +\n quinolone\n repeat inr low- trend inr with po COumadin\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 06:23 AM 60 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n Communication: try to contact boyfriend\n status: Full code\n Disposition : call case management for screening options\n Total time spent:\n"},{"category":"Nursing","chartdate":"2167-10-15 00:00:00.000","description":"Nursing Progress Note","row_id":637622,"text":"Tachycardia, Other\n Assessment:\n Continues to be Tachycardia in 120-145 (anxiety). SBP has been 100-145\n without ectopy.\n Action:\n No medication given for tachycardia.Pt gets Valium 5 mg scheduled Q6H\n with little effect. CTA done to r/o pe as a source of tachycardia.\n Response:\n Results pending on CTA.\n Plan:\n Continue to evaluate HR and BP for need of treatment.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt has a known DVT to RUE. Today pt had a US of LUEand ruled out small\n non occlusive clot on her left axial vein.\n Action:\n Dr ,pt received ceftriaxone via PICC line.Coumadin dosage\n increased from 2.5 to 5 mg ( INR 1.4).\n Response:\n Repeat ultrasound orderd for right arm . Pt received 5 mg coumadin at\n 2200.\n Plan:\n Ultrasound today,cont coumadin and closely monitor INR.\n Altered mental status (not Delirium)\n Assessment:\n Pt has been restless most of the night. Pt nodded her head for pain and\n simple yes or no questions.\n Action:\n Pt given scheduled Valium with little effect.\n Response:\n Pt slept for a while,Hr dropped to 120s at the time of rest.\n Plan:\n Continue to eval MS,Valium and Prn Morphine and haldol?.\n"},{"category":"Physician ","chartdate":"2167-10-16 00:00:00.000","description":"Physician Attending Progress Note","row_id":637931,"text":"Chief Complaint: resp failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n ULTRASOUND - At 08:11 AM\n right arm\n PICC LINE - STOP 12:02 PM\n PEG INSERTION - At 05:33 PM\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Ceftriaxone - 10:00 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 12:00 PM\n Haloperidol (Haldol) - 02:00 PM\n Diazepam (Valium) - 03:52 PM\n Furosemide (Lasix) - 06:40 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.8\nC (98.3\n HR: 137 (97 - 146) bpm\n BP: 153/66(87) {93/43(55) - 183/129(134)} mmHg\n RR: 18 (13 - 33) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,220 mL\n 807 mL\n PO:\n TF:\n IVF:\n 500 mL\n 807 mL\n Blood products:\n Total out:\n 1,514 mL\n 150 mL\n Urine:\n 1,439 mL\n 150 mL\n NG:\n 75 mL\n Stool:\n Drains:\n Balance:\n -294 mL\n 657 mL\n Respiratory support\n O2 Delivery Device: Trach mask , Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 384 (311 - 675) mL\n PS : 10 cmH2O\n RR (Spontaneous): 12\n PEEP: 5 cmH2O\n FiO2: 70%\n RSBI: 52\n PIP: 15 cmH2O\n SpO2: 95%\n ABG: ///35/\n Ve: 4.6 L/min\n Physical Examination\n Labs / Radiology\n 9.0 g/dL\n 395 K/uL\n 126 mg/dL\n 0.7 mg/dL\n 35 mEq/L\n 4.0 mEq/L\n 7 mg/dL\n 102 mEq/L\n 144 mEq/L\n 29.7 %\n 7.0 K/uL\n [image002.jpg]\n 03:36 AM\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n 05:00 AM\n 02:06 AM\n 07:34 AM\n 03:50 AM\n 06:22 AM\n WBC\n 7.2\n 5.2\n 5.9\n 7.5\n 5.6\n 6.1\n 7.0\n Hct\n 26.9\n 26.0\n 27.2\n 26.8\n 27.0\n 27.0\n 29.7\n Plt\n 238\n 240\n 296\n \n 395\n Cr\n 0.6\n 0.9\n 0.7\n 0.6\n 0.7\n 0.6\n 0.5\n 0.7\n 0.7\n TCO2\n 26\n Glucose\n 115\n 106\n 100\n 134\n 134\n 121\n 619\n 126\n Other labs: PT / PTT / INR:24.2/27.7/2.4, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:9.5 mg/dL, Mg++:2.1 mg/dL, PO4:4.2\n mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:26 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n"},{"category":"Physician ","chartdate":"2167-10-16 00:00:00.000","description":"Physician Attending Progress Note","row_id":637932,"text":"Chief Complaint: resp failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n ULTRASOUND - At 08:11 AM\n right arm\n PICC LINE - STOP 12:02 PM\n PEG INSERTION - At 05:33 PM\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Ceftriaxone - 10:00 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 12:00 PM\n Haloperidol (Haldol) - 02:00 PM\n Diazepam (Valium) - 03:52 PM\n Furosemide (Lasix) - 06:40 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.8\nC (98.3\n HR: 137 (97 - 146) bpm\n BP: 153/66(87) {93/43(55) - 183/129(134)} mmHg\n RR: 18 (13 - 33) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,220 mL\n 807 mL\n PO:\n TF:\n IVF:\n 500 mL\n 807 mL\n Blood products:\n Total out:\n 1,514 mL\n 150 mL\n Urine:\n 1,439 mL\n 150 mL\n NG:\n 75 mL\n Stool:\n Drains:\n Balance:\n -294 mL\n 657 mL\n Respiratory support\n O2 Delivery Device: Trach mask , Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 384 (311 - 675) mL\n PS : 10 cmH2O\n RR (Spontaneous): 12\n PEEP: 5 cmH2O\n FiO2: 70%\n RSBI: 52\n PIP: 15 cmH2O\n SpO2: 95%\n ABG: ///35/\n Ve: 4.6 L/min\n Physical Examination\n Labs / Radiology\n 9.0 g/dL\n 395 K/uL\n 126 mg/dL\n 0.7 mg/dL\n 35 mEq/L\n 4.0 mEq/L\n 7 mg/dL\n 102 mEq/L\n 144 mEq/L\n 29.7 %\n 7.0 K/uL\n [image002.jpg]\n 03:36 AM\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n 05:00 AM\n 02:06 AM\n 07:34 AM\n 03:50 AM\n 06:22 AM\n WBC\n 7.2\n 5.2\n 5.9\n 7.5\n 5.6\n 6.1\n 7.0\n Hct\n 26.9\n 26.0\n 27.2\n 26.8\n 27.0\n 27.0\n 29.7\n Plt\n 238\n 240\n 296\n \n 395\n Cr\n 0.6\n 0.9\n 0.7\n 0.6\n 0.7\n 0.6\n 0.5\n 0.7\n 0.7\n TCO2\n 26\n Glucose\n 115\n 106\n 100\n 134\n 134\n 121\n 619\n 126\n Other labs: PT / PTT / INR:24.2/27.7/2.4, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:9.5 mg/dL, Mg++:2.1 mg/dL, PO4:4.2\n mg/dL\n Assessment and Plan 55 yr old alcoholic s/p t spine fx s/p trcah and\n PEG with persistent resp failure\n 1. Resp Failure: currently on trach mask, can do sevreal hours per\n day, then needs for support QHS. Completed Rx for\n pan Klebs PNA.\n 2. Hemodynamics: persistant simus tachy but also has runs of SVT-\n will add low dose bblocker today\n watch MAPs at night as\n she tends to run low\n 3. New L Ext DVT: PICC out, coumadin\n 4. Emesis: start Reglan, watch qt and restart low dose tf tonight-\n discuss with TSurg\n ICU Care\n Nutrition: restart TFs\n Glycemic Control:\n Lines:\n 20 Gauge - 12:26 PM\n Prophylaxis:\n DVT: couadin\n Stress ulcer: PPI\n Communication: try to reach boyfriend\n status: Full code\n Disposition :screening for rehab\n"},{"category":"Respiratory ","chartdate":"2167-10-18 00:00:00.000","description":"Respiratory Care Shift Note","row_id":638207,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 30\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Tracheostomy tube:\n Type: Standard, Cuffed\n Manufacturer: Portex\n Size: 7.0mm\n PMV: No\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Rhonchi\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Periodic SBT's for conditioning; Comments: Continue trach trials\n Rsbi: 150\n Mdis given as ordered.\n"},{"category":"Nursing","chartdate":"2167-10-14 00:00:00.000","description":"Nursing Progress Note","row_id":637452,"text":"Tachycardia, Other\n Assessment:\n Continues to be tachycardic 120-150\n Action:\n Given pain meds PRN\n Response:\n HR down to 120\ns when sleeping\n Plan:\n No current RX for tachycardia manage pain & fever\n Alteration in Nutrition\n Assessment:\n TF currently infusing at goal of 50 cc/hr with minimal residuals\n Action:\n Strict aspiration precautions HOB 30 degrees\n Response:\n Plan:\n Continue to monitor tolerance to TF\n Altered mental status (not Delirium)\n Assessment:\n Pt continues to be confused & up most of the night. PERRLA following\n commands consistently.\n Action:\n Continues on Valium QTC, given Morphine 4 mg Q 4 hours, Haldol PO x 2.\n Response:\n Pt able to rest in short naps, then awake and aggitated\n Plan:\n Continues on soft wrist restraints, needs titrated on of medications to\n prevent agitation\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Placed back on PS overnight. RR up to 40\ns when agitated. Sats\n 94-98% on 50%. Lungs rhonchorous throughout. Suctionned for moderate\n amounts of thick tan secretions Q 3-4 hours.\n Action:\n Tolerated PS when not agitated. Trialed on CMV became dysnchrous with\n the vent\n Response:\n Plan:\n Continue trach collar trials during the day.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Temp spike to 100.8\n Action:\n Pan cultured, Tylenol given\n Response:\n Lactate stable, WBC stable continues on ceftriaxone\n Plan:\n Follow temp curve, follow up on culture results\n"},{"category":"Respiratory ","chartdate":"2167-10-07 00:00:00.000","description":"Respiratory Care Shift Note","row_id":636228,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 19\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Not applicable\n Size: Not applicable\n Tracheostomy tube:\n Type: Cuffed, Extra Length\n Manufacturer: Portex\n Size: 7.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n ------ Protected Section------\n Original note did not copy!\n ------ Protected Section Error Entered By: , \n on: 16:51 ------\n"},{"category":"Respiratory ","chartdate":"2167-10-07 00:00:00.000","description":"Respiratory Care Shift Note","row_id":636229,"text":"Demographics\n Day of mechanical ventilation: 19\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Tracheostomy tube:\n Type: Standard, Cuffed, Inner Cannula\n Manufacturer: Portex\n Size: 7.0mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Pt placed on MMV due to periods of apnea after given\n sedatives. Then pt was weaned back to PS.\n Assessment of breathing comfort: No claim of dyspnea)\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts; Comments: Pt desating to 87% when PEEP weaned to 5\n from 8.\n"},{"category":"Nursing","chartdate":"2167-10-15 00:00:00.000","description":"Nursing Progress Note","row_id":637621,"text":"Tachycardia, Other\n Assessment:\n Continues to be Tachycardia in 120-145 (anxiety). SBP has been 100-145\n without ectopy.\n Action:\n No medication given for tachycardia.Pt gets Valium 5 mg scheduled Q6H\n with little effect. CTA done to r/o pe as a source of tachycardia.\n Response:\n Results pending on CTA.\n Plan:\n Continue to evaluate HR and BP for need of treatment.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt has a known DVT to RUE. Today pt had a US of LUE to R/O DVT as a\n source of tachycardia.\n Action:\n After DVT found, IVF stopped.\n Response:\n Pt found to have a clot to Lt ax vein and MD notified.\n Plan:\n Pt to cont coumadin tonight, awaiting dosage for inr 1.4 . ? Access now\n that Lt arm has a DVT.\n Altered mental status (not Delirium)\n Assessment:\n Pt has been restless most of the day. Pt only follow direct commands.\n When asked to keep her hand off the TC, she will for only 3sec, and\n then she will reach for it again.\n Action:\n Pt given valium, morphine and haldol prn.\n Response:\n Little effect noted from sedations.\n Plan:\n Continue to eval MS.\n"},{"category":"Nursing","chartdate":"2167-10-15 00:00:00.000","description":"Nursing Progress Note","row_id":637674,"text":"56 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\n with prolonged hospital course c/b by PNA, anxiety/altered mental\n status, RUE DVT .Pt found to have small non occlusive Clot on her right\n axial vein via Ultrasound.\n Tachycardia, Other\n Assessment:\n Continues to be Tachycardia in 120-145 (anxiety). SBP has been 100-145\n without ectopy.\n Action:\n No medication given for tachycardia.Pt gets Valium 5 mg scheduled Q6H\n with little effect. CTA done to r/o pe as a source of tachycardia.\n Response:\n Results pending on CTA.\n Plan:\n Continue to evaluate HR and BP for need of treatment.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt has a known DVT to RUE. Today pt had a US of LUEand ruled out small\n non occlusive clot on her left axial vein.\n Action:\n Dr ,pt received ceftriaxone via PICC line.Coumadin dosage\n increased from 2.5 to 5 mg ( INR 1.4).\n Response:\n Repeat ultrasound orderd for right arm to check old clot. Pt received 5\n mg coumadin at 2200.\n Plan:\n Ultrasound today,cont coumadin and closely monitor INR.\n Altered mental status (not Delirium)\n Assessment:\n Pt has been restless most of the night. Pt nodded her head for pain and\n simple yes or no questions.pt got disconnected byself from vent onetime\n Action:\n Pt given scheduled Valium with little effect.Pt received 2 mg morphine\n PRN at 0620 .\n Response:\n Pt slept for a while,Hr dropped to 120s at the time of rest.\n Plan:\n Continue to eval MS,Valium and PRN Morphine and haldol?.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt rested on CPAP+ PS 50%/,sats stayed upper 90\ns,Pt found to have\n TF coming around Tracheostomy. As well as from her mouth\n Action:\n Cont pulm toilet as needed,Held TF throughout the night .Pressure\n support dropped to 8 from10\n Response:\n Pt suctioned for small- moderate amount thick yellow secretions.No more\n leakage noted around the tracheostomy as well as Minimal residuals from\n PEG tube.Pt had to put back on 10 tachypnea and tachycardia\n Plan:\n Continue to wean pt off vent and place on TC once pt can tol it again\n and frequent pulmonary toileting. Restart TF?\n"},{"category":"Nursing","chartdate":"2167-10-15 00:00:00.000","description":"Nursing Progress Note","row_id":637844,"text":"Pt down to IR for replacement of PEG with J-tube d/t high risk of\n aspiration. Unable to place jtube at this time d/t type of peg in\n place. Will need surgery to remove PEG in IR and IR will place j tube\n at later date.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Left hand to elbow area with edema 2mm\nknown DVT to left axillary vein;\n US of right arm\n Action:\n DL PICC d/c\nd; left arm elevated on pillow; US results pnd for right\n arm\n Response:\n PIV placed for access issues to right arm; edema unchanged;\n Plan:\n Cont to monitor left arm status; no BP/blood draws left arm. NIBP cuff\n to right calf. F/U w/ team Re: right arm status\n Hypernatremia (high sodium)\n Assessment:\n hypernatremic\n Action:\n Free water boluses cont; bloused with D5W/500cc\n Response:\n Remains hypernatremic with min improvement\n Plan:\n Cont with free water boluses; check labs am\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Restless, anxious am\n Action:\n Trach collar placed 70% early am--\n Response:\n Brief episode of desaturation to mid 80\ns requiring increase of Fi02 to\n 100% briefly (approx 20min); placed on 70% remainder of shift with\n adequate o2 sats in low 90\ns;NOTE: pt vomited approx 50cc clear liquid\n prior to going to IR also had some clear lix come from trach\npossible\n aspiration\nteam notified. Placed on PSV at 1840 to rest\n Plan:\n Rest overnight; ?aspiration. Hold TF for now\nf/u team re: free water\n boluses. CXR am. Monitor resp status closely.\n Tachycardia, Other\n Assessment:\n Tachy to 130-140\ns continuous while awake; continuous tachy in 120\n while sound asleep\n Action:\n Standing valium decreased; cont with fent patch; morphine and haldol\n prn\n Response:\n No significant change in level of restlessness/anxiety; freq pulling at\n any objects/lines with short term memory issues; no significant\n response to IV morphine; was able to obtain some sleep after 2mg haldol\n ivp\n Plan:\n Cont to closely monitor mental status; maintain safety w/use of\n restraints, soft wrist restraints and bed alarm. Assess degree of\n change with titration of meds\n"},{"category":"Nursing","chartdate":"2167-10-16 00:00:00.000","description":"Nursing Progress Note","row_id":637909,"text":"56 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\n with prolonged hospital course c/b by PNA, anxiety/altered mental\n status, RUE DVT .Pt found to have small non occlusive Clot on her right\n axial vein via Ultrasound.Yesterday Pt went down to IR for Peg revision\n aspiration riskcouldn\nt do it,due the type of peg she has now.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt has known DVT to left axillary vein; US of right arm showed no\n clots.\n Action:\n DL PICC d/c\nd; from left arm and elevated on pillow and received\n Coumadin scheduled dose.\n Response:\n PIV placed for access issues to right arm; edema looks better;\n Plan:\n Cont to monitor left arm status; no BP/blood draws left arm PICC line\n to right arm?.\n Hypernatremia (high sodium)\n Assessment:\n Hypernatremic NA was 146 yesterday evening.\n Action:\n Started on D5 W at 100cc/hr for 1000cc,held free wqater bolus \n aspiration..\n Response:\n Awaiting for AM lab report.\n Plan:\n Cont with D5W,follow up with AM lab,resume Free water bolus via PEG\n tube?.\n Tachycardia, Other\n Assessment:\n Tachy to 130-140\ns continuous while awake; HR stayed 90- 120 sound\n asleep\n Action:\n Standing valium decreased; cont with fent patch; morphine and haldol\n prn.Bilateral restraints on\n Response:\n No significant change in level of restlessness/anxiety; freq pulling at\n any objects/lines with short term memory issues. She keeps\n disconnecting from vent,desat to low 80s within seconds.\n Plan:\n Cont to closely monitor mental status; maintain safety w/use of\n restraints, soft wrist restraints and bed alarm. PRN Haldol or\n Morphine.\n Altered mental status (not Delirium)\n Assessment:\n Pt has been slept most of the time,hard to wake up.responded to deep\n stimuli.\n Action:\n Held Scheduled dose of valium at 2200.Pt has Fentanyl 75 mcg patch on\n her lleft thigh.\n Response:\n Pt start waking up around 0300,got disconnected from vent by\n herself,given valium 2.5 mg at 0315.\n Plan:\n Continue to eval MS,Valium and PRN Morphine and haldol?,cont reorient\n and emotional support to pt .\n"},{"category":"Nursing","chartdate":"2167-10-16 00:00:00.000","description":"Nursing Progress Note","row_id":637910,"text":"56 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\n with prolonged hospital course c/b by PNA, anxiety/altered mental\n status, RUE DVT .Pt found to have small non occlusive Clot on her right\n axial vein via Ultrasound.Yesterday Pt went down to IR for Peg revision\n aspiration riskcouldn\nt do it,due the type of peg she has now.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt has known DVT to left axillary vein; US of right arm showed no\n clots.\n Action:\n DL PICC d/c\nd; from left arm and elevated on pillow and received\n Coumadin scheduled dose.\n Response:\n PIV placed for access issues to right arm; edema looks better;\n Plan:\n Cont to monitor left arm status; no BP/blood draws left arm PICC line\n to right arm?.\n Hypernatremia (high sodium)\n Assessment:\n Hypernatremic NA was 146 yesterday evening.\n Action:\n Started on D5 W at 100cc/hr for 1000cc,held free wqater bolus \n aspiration..\n Response:\n Awaiting for AM lab report.\n Plan:\n Cont with D5W,follow up with AM lab,resume Free water bolus via PEG\n tube?.\n Tachycardia, Other\n Assessment:\n Tachy to 130-140\ns continuous while awake; HR stayed 90- 120 sound\n asleep\n Action:\n Standing valium decreased; cont with fent patch; morphine and haldol\n prn.Bilateral restraints on\n Response:\n No significant change in level of restlessness/anxiety; freq pulling at\n any objects/lines with short term memory issues. She keeps\n disconnecting from vent,desat to low 80s within seconds.\n Plan:\n Cont to closely monitor mental status; maintain safety w/use of\n restraints, soft wrist restraints and bed alarm. PRN Haldol or\n Morphine.\n Altered mental status (not Delirium)\n Assessment:\n Pt has been slept most of the time,hard to wake up.responded to deep\n stimuli.\n Action:\n Held Scheduled dose of valium at 2200.Pt has Fentanyl 75 mcg patch on\n her lleft thigh.\n Response:\n Pt start waking up around 0300,got disconnected from vent by\n herself,given valium 2.5 mg at 0315.\n Plan:\n Continue to eval MS,Valium and PRN Morphine and haldol?,cont reorient\n and emotional support to pt .\n"},{"category":"Physician ","chartdate":"2167-10-16 00:00:00.000","description":"Physician Resident Progress Note","row_id":637915,"text":"Chief Complaint: Tracheomalacia\n 24 Hour Events:\n ULTRASOUND - At 08:11 AM\n right arm - negative for DVT\n PICC LINE - STOP 12:02 PM\n - IR unable to advance PEG\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Ceftriaxone - 10:00 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:12 AM\n Morphine Sulfate - 12:00 PM\n Haloperidol (Haldol) - 02:00 PM\n Diazepam (Valium) - 03:52 PM\n Furosemide (Lasix) - 06:40 AM\n Other medications:\n Changes to medical and family history:\n None\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.2\nC (97.1\n HR: 139 (97 - 146) bpm\n BP: 133/67(84) {93/43(55) - 183/129(134)} mmHg\n RR: 18 (13 - 33) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,220 mL\n 568 mL\n PO:\n TF:\n IVF:\n 500 mL\n 568 mL\n Blood products:\n Total out:\n 1,514 mL\n 150 mL\n Urine:\n 1,439 mL\n 150 mL\n NG:\n 75 mL\n Stool:\n Drains:\n Balance:\n -294 mL\n 418 mL\n Respiratory support\n O2 Delivery Device: Trach mask , Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 384 (311 - 675) mL\n PS : 10 cmH2O\n RR (Spontaneous): 12\n PEEP: 5 cmH2O\n FiO2: 70%\n RSBI: 52\n PIP: 15 cmH2O\n SpO2: 96%\n ABG: ///31/\n Ve: 4.6 L/min\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic,\n No(t) Diastolic), tachy\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 395 K/uL\n 9.0 g/dL\n 619 mg/dL\n 0.7 mg/dL\n 31 mEq/L\n 3.3 mEq/L\n 6 mg/dL\n 91 mEq/L\n 129 mEq/L\n 29.7 %\n 7.0 K/uL\n [image002.jpg]\n 03:36 AM\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n 05:00 AM\n 02:06 AM\n 07:34 AM\n 03:50 AM\n 06:22 AM\n WBC\n 7.2\n 5.2\n 5.9\n 7.5\n 5.6\n 6.1\n 7.0\n Hct\n 26.9\n 26.0\n 27.2\n 26.8\n 27.0\n 27.0\n 29.7\n Plt\n 238\n 240\n 296\n \n 395\n Cr\n 0.6\n 0.9\n 0.7\n 0.6\n 0.7\n 0.6\n 0.5\n 0.7\n TCO2\n 26\n Glucose\n 115\n 106\n 100\n 134\n 134\n 121\n 619\n Other labs: PT / PTT / INR:23.4/29.6/2.3, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:8.4 mg/dL, Mg++:1.9 mg/dL, PO4:3.9\n mg/dL\n Microbiology: 7:34 am STOOL CONSISTENCY: FORMED\n Source: Stool.\n **FINAL REPORT **\n CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final ):\n Feces negative for C.difficile toxin A & B by EIA.\n (Reference Range-Negative).\n .\n 7:33 am BLOOD CULTURE Source: Line-picc.\n **FINAL REPORT **\n Blood Culture, Routine (Final ): NO GROWTH\n Assessment and Plan\n Assessment and Plan\n 55yoF with history of EtOH abuse presenting following mechanical fall\n and traumatic T spine fracture, now s/p trach, PEG, placement being\n treated for HAP.\n # HAP vs Aspiration PNA: Cultures grew, Klebsiella Oxytoca, Klebsiella\n Pneumoniae, GNR, GP Cocci. Has completed 8 day course of Ceftriaxone.\n Has had occasional low grade fevers, but has continued to improve\n clinically. Had a sputum gram stain from w/ GPC p/c. a new VAP/HAP\n w/ staph possible, but given no clear infiltrate on CXR and good\n respiratory status, significant PNA is unlikely, colonization of\n tracheostomy tube is more likely, as is contamination of sputum. Given\n improving clinical picture, will wait until CX data or change in\n clinical status or CXR to initiate HAP/VAP treatment.\n - D/c Ceftriaxone\n - Continue to f/u cultures\n .\n # Respiratory failure: Improving status. Will continue to increase\n time on trach mask as tolerated.\n - PMV with suctioning.\n - Weaning FiO2 as tolerated\n .\n # Tachycardia: Pt in ST 120\ns to 150s. Etiology remains unclear and\n include hypovolemia, pain, infection (pt with known klebsiella), and\n incrased work of breathing from secretions and tracheomalacia, . DDx\n also includes PE given hx of RUE DVT, mucus plugging given large\n amount of secretions, and spinal injury. Tachycardia is unresponsive to\n IVF, Pt has had a negative CT-PA and has not had sig response to pain\n meds. Has completed treatment for her HAP. Thyroid function was checked\n and had normal TSH and T3 and free T4. Had been on albuterol q4 and\n atrovent , she has not been wheezing, and perhaps she is sensitive to\n the B-agonist.\n - Continue Pain Control\n - Change albuterol to PRN\n - Test if HR decreases when placed on higher pressure support\n for period of time.\n .\n # Sedation: Has had inconsistent response to sedation, unclear what is\n best regime. Will continue to wean overall\n - Change to haldol 2.5 PRN, Fentanyl 75 mcg TP, Morphine PRN,\n Benadryl, Valium 5mg PRN\n .\n # Adrenal Insufficency: Followed up with endocrine that suggested if\n the patient under goes major stressors such as major surgery, sepsis,\n she may need stress dosed steroids.\n - Will consider MRI at later date for evaluation of pituitary\n .\n # Fluid Status: Volume overloaded in prior setting of Hypernatremia\n - Monitoring urine output\n - increasse Free H20, for mild hypernatremia 200cc Free bolus PEG, and\n - 500cc D5W at 125.\n - PM lytes to assess hypernatremia\n .\n # UE DVT: right has resolved, new non occlusive in left axillary. INR\n 1.5\n -continue coumadin\n -follow INR\n - D/c Left PICC line, and place peripheral IVs. If unable, can place a\n R PICC.\n .\n # Spine fracture: Stable\n - Brace for OOB, will discuss with Neurosurgery if current brace is\n optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n .\n # Tracheomalacia?: Was initially addressed with IP and they wanted to\n follow up as outpatient.\n - Consult IP for stent placement given improved clinical status, will\n readdresses\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n # Nutrition: Pt had emesis and extrusion of gastric contents through\n tracheostomy site (not through tube).\n - TFs held\n - Consult IR for advancement of her PEG to jejunum.\n # Glycemic control: SSI, well controlled\n # PIV x 1\n # Ppx: Restarting Coumadin, Ranitidine, Bowel Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n # Code: Full\n # Dispo: ICU, Screening for vent facilities\n ICU Care\n Nutrition:\n Comments: Tube feeds\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 12:26 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition:ICU\n"},{"category":"Nursing","chartdate":"2167-10-16 00:00:00.000","description":"Nursing Progress Note","row_id":637994,"text":"Airway Clearance, Impaired\n Assessment:\n Action:\n Response:\n Plan:\n Tachycardia, Other\n Assessment:\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2167-10-16 00:00:00.000","description":"Nursing Progress Note","row_id":637997,"text":"56 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\n with prolonged hospital course c/b by PNA, anxiety/altered mental\n status, RUE DVT .Pt found to have small non occlusive Clot on her right\n axial vein via Ultrasound.Yesterday Pt went down to IR for Peg revision\n aspiration risk couldn\nt do it due the type of peg she has now.\n Airway Clearance, Impaired\n Assessment:\n Pt continues to have copious amount of secretions. She was placed on\n 50% trach mask at 6am and continues on it. She was on a passey muir\n valve for several hours during the afternoon but was only removed due\n to secretions.\n Action:\n Pt has been suctioned q1-2h for a large amount of creamy white\n secretions.\n Response:\n O2 sats have been between 95-98% with RR 24-32\n Plan:\n Suction PRN, continue to monitor\n Tachycardia, Other\n Assessment:\n Her HR continues to be tachy, 130-140. B/P 140-150/60-70.\n Action:\n She was started on lopressor this am. The first dose was 12.5 mg with\n no change in HR, she has received 25mg at 1600.\n Response:\n She continues to be tachy but her HR is 130\ns vs her normal 140\n Plan:\n Continue to monitor HR, ask MD\ns about increasing her dose.\n Alteration in Nutrition\n Assessment:\n She remains NPO while the MD\ns decide what to do to get a post pyloric\n feeding tube in place.\n Action:\n PEG in her stomach so free water and meds have been given into her PEG.\n Response:\n Remains NPO.\n Plan:\n Continue to give meds and free water into peg, await medical plan from\n MD\n Impaired Skin Integrity\n Assessment:\n The area around her trach is slightly reddened. The surgeons came by\n this am and removed the remaining stitches that held the trach tube on\n to her skin\n Action:\n Trach care done with some antibiotic ointment.\n Response:\n Area still reddened but no longer being pulled by the stitches\n Plan:\n Continue to monitor the redness, continue trach \n"},{"category":"Physician ","chartdate":"2167-10-19 00:00:00.000","description":"Physician Attending Progress Note","row_id":638436,"text":"Chief Complaint: resp failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Another episode of emesis\n Was on MMV\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Diazepam (Valium) - 12:00 AM\n Furosemide (Lasix) - 01:30 AM\n Morphine Sulfate - 02:00 AM\n Pantoprazole (Protonix) - 08:24 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:35 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.6\nC (97.8\n HR: 101 (74 - 137) bpm\n BP: 105/57(67) {75/42(50) - 130/73(108)} mmHg\n RR: 24 (12 - 28) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 3,165 mL\n 1,720 mL\n PO:\n TF:\n 691 mL\n IVF:\n 1,574 mL\n 1,665 mL\n Blood products:\n Total out:\n 1,670 mL\n 1,020 mL\n Urine:\n 1,470 mL\n 965 mL\n NG:\n 200 mL\n 55 mL\n Stool:\n Drains:\n Balance:\n 1,495 mL\n 700 mL\n Respiratory support\n O2 Delivery Device: Trach mask , Tracheostomy tube\n Ventilator mode: MMV/PSV/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 94 (94 - 450) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n RSBI Deferred: No Spon Resp\n PIP: 20 cmH2O\n SpO2: 97%\n ABG: ///38/\n Ve: 5.6 L/min\n Physical Examination\n Gen: sitting in bed, alert NAD\n CV: tachy RR\n Ches: bibasilar rhonchi no hweezest\n Abd; soft NT\n Ex: no edemat\n Neuro: alert, follows simple commands and mouth words grip and \n strength inlower ext\n Labs / Radiology\n 8.6 g/dL\n 467 K/uL\n 131 mg/dL\n 0.7 mg/dL\n 38 mEq/L\n 3.4 mEq/L\n 8 mg/dL\n 101 mEq/L\n 145 mEq/L\n 27.8 %\n 6.9 K/uL\n [image002.jpg]\n 03:00 AM\n 05:00 AM\n 02:06 AM\n 07:34 AM\n 03:50 AM\n 06:22 AM\n 02:58 AM\n 03:43 AM\n 05:02 PM\n 03:36 AM\n WBC\n 5.2\n 5.9\n 7.5\n 5.6\n 6.1\n 7.0\n 7.1\n 7.1\n 6.9\n Hct\n 26.0\n 27.2\n 26.8\n 27.0\n 27.0\n 29.7\n 28.9\n 29.2\n 27.8\n Plt\n 35\n 52\n 467\n Cr\n 0.6\n 0.7\n 0.6\n 0.5\n 0.7\n 0.7\n 0.6\n 0.7\n 0.8\n 0.7\n Glucose\n 100\n 134\n 134\n 121\n 04\n 108\n 131\n Other labs: PT / PTT / INR:38.8/34.5/4.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:9.4 mg/dL, Mg++:2.3 mg/dL, PO4:4.2\n mg/dL\n Assessment and Plan\n 1. Tachycardia: runs of atach versus AVNRT. On bblocker be not very\n effective- EP consult for ? is there an ablatable focus.\n 2. Resp Failure\n Trach mask trials as tolerating (needing QHS support at\n present)\n PMV trials\n S/P rx for pan Klebs PNA.\n Per IP not stent planned as technically not possible to\n place into her airway\n 3. DVT and coagulopathy On warfarin but high inr. Hold warfarin until\n inr 2-2.5 range or bridge with loveox if may get procedures\n 4. Feeding tube Getting reglan trial but still with emesis. Need to\n coordinate IR advance of G to J tube with Thoracics\n 5. Hypernatremia Replete free water.\n Please see today\ns ICU team note for other issues.\n ICU Care\n Nutrition: TFs\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n Prophylaxis:\n DVT: anti coag\n Stress ulcer: ppi\n Communication: trying to reach boyfriend\n status: Full code\n Disposition : ICU, start screening still need to fix tachycardia\n"},{"category":"Physician ","chartdate":"2167-10-19 00:00:00.000","description":"Physician Resident Progress Note","row_id":638444,"text":"Chief Complaint:\n 24 Hour Events:\n 8pm: Vomited tube feeds while receiving free water flushes. Suctioned\n by RT and no apparent aspiration, only blood tinged sputum. O2 sats\n 99-100%. No increased O2 requirement. Held TF, given free water via IV\n 100 cc/hr x 1L since Na 148. Will need to reassess in am, CXR ordered\n for am.\n Thoracics recs: place dophoff post pyloric or have GI place pedi GT\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Diazepam (Valium) - 12:00 AM\n Furosemide (Lasix) - 01:30 AM\n Morphine Sulfate - 02:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:21 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.3\n Tcurrent: 36.8\nC (98.3\n HR: 113 (81 - 137) bpm\n BP: 78/45(52) {78/39(50) - 130/73(108)} mmHg\n RR: 12 (12 - 32) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 3,165 mL\n 700 mL\n PO:\n TF:\n 691 mL\n IVF:\n 1,574 mL\n 700 mL\n Blood products:\n Total out:\n 1,670 mL\n 680 mL\n Urine:\n 1,470 mL\n 680 mL\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n 1,495 mL\n 20 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: MMV/PSV/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 94 (94 - 450) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 7\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 25 cmH2O\n SpO2: 97%\n ABG: ///38/\n Ve: 5.1 L/min\n Physical Examination\n Gen: Obtunded this am, not responsive to voice, minimally responsive to\n noxious stimuli, on MMV through trach tube\n HEENT: PERRL, MMM,\n Resp: Limited by patients mobility, but CTA anteriorly and laterally,\n no rales, rhonchi, or wheezing, some referred upper airway noises from\n secretions.\n Card: S1S2 tachicardic, no m/r/g\n Abd: Obese, soft, Non-distended, BS+\n Exte: No edema, DP 2+, RP2+ bil.\n NEURO: Toes downgoing bilaterally, patellar reflexs 2+ bil, biceps 2+\n bil,\n Labs / Radiology\n 467 K/uL\n 8.6 g/dL\n 131 mg/dL\n 0.7 mg/dL\n 38 mEq/L\n 3.4 mEq/L\n 8 mg/dL\n 101 mEq/L\n 145 mEq/L\n 27.8 %\n 6.9 K/uL\n [image002.jpg]\n COAGs: 38.8/34.5/4.2\n 03:00 AM\n 05:00 AM\n 02:06 AM\n 07:34 AM\n 03:50 AM\n 06:22 AM\n 02:58 AM\n 03:43 AM\n 05:02 PM\n 03:36 AM\n WBC\n 5.2\n 5.9\n 7.5\n 5.6\n 6.1\n 7.0\n 7.1\n 7.1\n 6.9\n Hct\n 26.0\n 27.2\n 26.8\n 27.0\n 27.0\n 29.7\n 28.9\n 29.2\n 27.8\n Plt\n 35\n 52\n 467\n Cr\n 0.6\n 0.7\n 0.6\n 0.5\n 0.7\n 0.7\n 0.6\n 0.7\n 0.8\n 0.7\n Glucose\n 100\n 134\n 134\n 121\n 04\n 108\n 131\n Other labs: PT / PTT / INR:66.1/32.7/8.0, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:9.4 mg/dL, Mg++:2.3 mg/dL, PO4:4.2\n mg/dL\n Assessment and Plan\n 55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach, PEG, placement no with respiratory failure secondary to\n tracheomalacia , resolving HAP.\n .\n # Respiratory failure: Slowly Improving. Now remaining on trach mask\n for most of the day and night, with periods of pressure support of \n over night. Last night required MMV and was not breathing well while\n asleep, likely oversedated with Benadryl, Morhpine, and Valium\n administered in the early morning. Pt awake and alert at rounds,\n interactive, and breathing comfortably on trach mask\n - Continue to increase time on trach mask as tolerated.\n - Decrease sedation and valium use see Sedation below\n - PMV with suctioning again today.\n .\n # HAP vs Aspiration PNA: Afebrile without leukocytosis\n - Completed course of ceftriaxone\n - good O2 saturation on trach mask\n - Continue to f/u cultures\n .\n # Tachycardia: Previously was assessed as sinus tach with occasional\n runs of SVT and sources such as hypovolemia, PE, infection, and pain\n were assessed as possibly etiologies. But, now appears to be SVT for\n much of time, rhythm/rate nonresponsive to carotid massage. HR\n occaisonaly decreases to 70s-80s w/ stable BPs at times that might be\n associated with administration of her BB and valium. Rhythm strip shows\n conversion from a narrow complex SVT to normal sinus rhythm and then\n back. Metroprolol was increased from 25mg TID to QID yesterday, without\n any affect on the SVT.\n - EP consulted for conversion of SVT, appreciate recs\n .\n # Sedation: Inconsistent response to sedation, unclear what is best\n regime. Will continue to wean overall.\n - Continue w Olanzapine QHS\n - D/d valium to 2.5 mg TID and leave just valium 2.5 mg PRN.\n # Nutrition: Pt has had several episodes of vomiting up her TFs,\n reglan started to increase GI motility, but pt had another episode of\n vomiting last night.\n - Hold TFs\n - Thoracic surgery recs: 1) oral/nasal tube in post-piloric position,\n or 2) IR to place a pediatric feeding tube through her PEG site to a\n post-piloric position.\n - Will attempt to coordinate thoracic surgery and IR for tube placement\n tomorrow.\n .\n # Adrenal Insufficency: Endocrine following. Pt does not appear to be\n adrenally insufficient at baseline. Suggesting if the patient under\n goes major stressors such as major surgery, sepsis, she may need stress\n dosed steroids.\n .\n # Fluid Status: Likely approaching euvolemia, though still has mild\n hypernatramia which may suggest is still intravascularly depleated.\n - Monitoring urine output\n - FW flushes w/ tube feeds held due to vomitting\n - will provide D5W IVF as need for hypernatremia and follow lytes\n .\n # UE DVT and elevated INR: DVT in right UE has resolved, new\n non-occlusive in left axillary vein. INR supratherapeutic today\n - COumadin held, will restart at low dose when INR approaches\n therapeutic range.\n - INR 4.2 today, will check PM coags and consider restarting at a low\n dose tonight or tomorrow morning.\n .\n # Spine fracture: Stable\n - Brace for OOB, will discuss with Neurosurgery if current brace is\n optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n .\n # Tracheomalacia. Was initially addressed with IP and they wanted to\n follow up as outpatient. IP reevaluated and does not believe that a\n stent would be feasible.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # PIV x 1\n # Ppx: Coumadin, Ranitidine, Bowel Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n - Will contact Social and Case management today\n # Code: Full\n # Dispo: ICU, Screening for vent facilities\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Respiratory ","chartdate":"2167-10-14 00:00:00.000","description":"Respiratory Care Shift Note","row_id":637448,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 26\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason:\n Tube Type\n Tracheostomy tube:\n Type: Standard, Cuffed, Inner Cannula\n Manufacturer: Portex\n Size: 7.0mm\n PMV: No\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: Yellow / Plug\n Sputum source/amount: Suctioned / Small\n Comments/Plan\n Pt agitated overnight, more sedation received with fairly good effect.\n Administering Albuterol and Atrovent MDI\ns as ordered, see flowsheet\n for rx times and data. RSBI=171 this am. Will follow, trache mask\n trials as tolerated.\n 05:38\n"},{"category":"Nutrition","chartdate":"2167-10-15 00:00:00.000","description":"Clinical Nutrition Note","row_id":637769,"text":"Objective\n Pertinent medications: noted\n Labs:\n Value\n Date\n Glucose\n 134 mg/dL\n 02:06 AM\n Glucose Finger Stick\n 139\n 10:00 AM\n BUN\n 11 mg/dL\n 02:06 AM\n Creatinine\n 0.6 mg/dL\n 02:06 AM\n Sodium\n 146 mEq/L\n 02:06 AM\n Potassium\n 4.0 mEq/L\n 02:06 AM\n Chloride\n 106 mEq/L\n 02:06 AM\n TCO2\n 32 mEq/L\n 02:06 AM\n Albumin\n 3.5 g/dL\n 03:00 AM\n Calcium non-ionized\n 9.2 mg/dL\n 02:06 AM\n Phosphorus\n 4.0 mg/dL\n 02:06 AM\n Ionized Calcium\n 1.24 mmol/L\n 02:51 AM\n Magnesium\n 2.1 mg/dL\n 02:06 AM\n Current diet order / nutrition support: Replete c. Fiber @60mL/hr (1440\n kcals/89 gr aa)\n GI: Abd: soft/dist/+bs\n Assessment of Nutritional Status\n Estimation of current intake: Adequate\n Specifics:\n Pt continues on TF\ns for full nutrition support via PEG, currently\n tolerating @ goal s/ problems. (Noted TF\ns were off over weekend / ?\n aspiration event) FWB down to 100mL q 4 hr c/ Na WNL. BG\ns well\n controlled.\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: via TF\n Tube feeding recommendations: Continue TF's @ goal\n Monitor fluid status and adjust FWB prn.\n BG and lyte management as you are\n Please check current wt\n"},{"category":"Physician ","chartdate":"2167-10-15 00:00:00.000","description":"Physician Attending Progress Note","row_id":637774,"text":"Chief Complaint: resp failuire\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n ULTRASOUND - At 03:48 PM\n US of Lt arm shows small 1 cm axillary clot non occlusive near PICC\n RUS US shows resolution of formal clot\n Vomiting tube feeds around trach\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Ceftriaxone - 10:00 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 06:20 AM\n Pantoprazole (Protonix) - 08:12 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Gastrointestinal: Emesis\n Flowsheet Data as of 10:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 36.2\nC (97.1\n HR: 146 (123 - 146) bpm\n BP: 153/129(134) {106/41(56) - 185/129(142)} mmHg\n RR: 26 (11 - 33) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,888 mL\n 520 mL\n PO:\n TF:\n 1,268 mL\n IVF:\n 100 mL\n Blood products:\n Total out:\n 1,530 mL\n 845 mL\n Urine:\n 1,510 mL\n 820 mL\n NG:\n 20 mL\n 25 mL\n Stool:\n Drains:\n Balance:\n 358 mL\n -325 mL\n Respiratory support\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 227 (227 - 397) mL\n PS : 8 cmH2O\n RR (Spontaneous): 20\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 194\n PIP: 16 cmH2O\n SpO2: 96%\n ABG: ///34/\n Ve: 6.5 L/min\n Physical Examination\n Labs / Radiology\n 8.5 g/dL\n 335 K/uL\n 121 mg/dL\n 0.5 mg/dL\n 34 mEq/L\n 3.8 mEq/L\n 7 mg/dL\n 107 mEq/L\n 147 mEq/L\n 27.0 %\n 5.6 K/uL\n [image002.jpg]\n 03:08 PM\n 03:00 AM\n 03:36 AM\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n 05:00 AM\n 02:06 AM\n 07:34 AM\n WBC\n 7.3\n 6.1\n 7.2\n 5.2\n 5.9\n 7.5\n 5.6\n Hct\n 27.6\n 26.5\n 26.9\n 26.0\n 27.2\n 26.8\n 27.0\n Plt\n 189\n 209\n 238\n \n 335\n Cr\n 0.6\n 0.6\n 0.9\n 0.7\n 0.6\n 0.7\n 0.6\n 0.5\n TCO2\n 26\n Glucose\n 99\n 115\n 106\n 100\n 134\n 134\n 121\n Other labs: PT / PTT / INR:16.6/25.0/1.5, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:9.3 mg/dL, Mg++:2.3 mg/dL, PO4:4.1\n mg/dL\n Assessment and Plan\n 55 yr old alcoholic s/p t spine fx s/p trcah and PEG with persistent\n resp failure\n 1. Resp Failure: currently on trach mask, can do a few hours per\n day, then needs for support. New pan Klebs in sputum, day\n . Try more vent support and see if it helps her.\n 2. Fevers: did not persist- cultures neg to date.\n 3 Hemodynamics: persistant simus tachy\n CTPA to look for emboli\n negative for proximal clot. IOs the of trach mask and her TB\n malacia too much for her. We will see what happens if we out her on\n 15-20 and 5.\n 4. New L Ext DVT\n 5. Emesis: call IR and get g pushed to a j tube\n ICU Care\n Nutrition: tfs held for vomiting\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Prophylaxis:\n DVT: coumadin\n Stress ulcer: ppi\n Communication: try to reach boyfriend\n status: Full code\n Disposition :ICU\n"},{"category":"Nursing","chartdate":"2167-10-14 00:00:00.000","description":"Nursing Progress Note","row_id":637612,"text":"Tachycardia, Other\n Assessment:\n Hr has been in sinus tachycardia all day at 130-140\ns, Hr noted to also\n stay elevated in the 130\ns while at rest also. SBP has been elevated\n throughout the day at 150-170\ns while awake and 120-130\ns while at\n rest. Pt also very restless.\n Action:\n No med to be given for tachycardia or BP MD. Pt given Morphine and\n haldol for restlessness w/o effect. Pt also on valium ATC w/little\n effect. CTA done to r/o pe as a source of tachycardia.\n Response:\n Results pending on CTA.\n Plan:\n Continue to evaluate HR and BP for need of treatment.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt has a known DVT to RUE. Today pt had a US of LUE to R/O DVT as a\n source of tachycardia.\n Action:\n After DVT found, IVF stopped.\n Response:\n Pt found to have a clot to Lt ax vein and MD notified.\n Plan:\n Pt to cont coumadin tonight, awaiting dosage for inr 1.4 . ? Access now\n that Lt arm has a DVT.\n Altered mental status (not Delirium)\n Assessment:\n Pt has been restless most of the day. Pt only follow direct commands.\n When asked to keep her hand off the TC, she will for only 3sec, and\n then she will reach for it again.\n Action:\n Pt given valium, morphine and haldol prn.\n Response:\n Little effect noted from sedations.\n Plan:\n Continue to eval MS.\n"},{"category":"Nursing","chartdate":"2167-10-15 00:00:00.000","description":"Nursing Progress Note","row_id":637618,"text":"Tachycardia, Other\n Assessment:\n Continues to be Tachycardia in 120-145 (anxiety). SBP has been 100-145\n without ectopy.\n Action:\n No medication given for tachycardia.Pt gets Valium 5 mg scheduled Q6H\n with little effect. CTA done to r/o pe as a source of tachycardia.\n Response:\n Results pending on CTA.\n Plan:\n Continue to evaluate HR and BP for need of treatment.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt has a known DVT to RUE. Today pt had a US of LUE to R/O DVT as a\n source of tachycardia.\n Action:\n After DVT found, IVF stopped.\n Response:\n Pt found to have a clot to Lt ax vein and MD notified.\n Plan:\n Pt to cont coumadin tonight, awaiting dosage for inr 1.4 . ? Access now\n that Lt arm has a DVT.\n Altered mental status (not Delirium)\n Assessment:\n Pt has been restless most of the day. Pt only follow direct commands.\n When asked to keep her hand off the TC, she will for only 3sec, and\n then she will reach for it again.\n Action:\n Pt given valium, morphine and haldol prn.\n Response:\n Little effect noted from sedations.\n Plan:\n Continue to eval MS.\n"},{"category":"Nursing","chartdate":"2167-10-17 00:00:00.000","description":"Nursing Progress Note","row_id":638072,"text":"Tachycardia, Other\n Assessment:\n HR continues to be 120-140\n Action:\n On Lopressor 25 mg TID\n Response:\n Needs further titration upwards\n Plan:\n Continue to titrate BB as BP allows\n Airway Clearance, Impaired\n Assessment:\n Pt with copious secretions Suctioned A 30-1 hour for thick white\n secretions Sats stable 92-96%\n Action:\n Placed back on vent overnight to allow for periods of rest, Lavaged by\n RT x 2\n Response:\n Secretions diminished as night when on\n Plan:\n Continue with aggressive pulmonary toliet\n Altered mental status (not Delirium)\n Assessment:\n Pt continues to be agitated, following commands inconsistently. MAE,\n PERRLA. Soft restraints remain in place to prevent dislodgement of\n trach\n Action:\n On valium TID given dose of Zyprexa at HS\n Response:\n Pt able to sleep in extended naps overnight, less agitated\n Plan:\n Continue to follow mental status, try to D/C restraints when able\n Impaired Skin Integrity\n Assessment:\n Area around track red & excoriated\n Action:\n Trach care provided, Antibiotic ointment placed\n Response:\n Plan:\n Continue to monitor\n Alteration in Nutrition\n Assessment:\n Pt remains NPO DT high aspiration risk, no residual overnight\n Action:\n Started on raglan QID, ? needs feeding tube changed to post pyloric\n Response:\n No evidence of aspiration overnight\n Plan:\n Awaiting surgery input re: Advancement of feeding tube\n"},{"category":"Respiratory ","chartdate":"2167-10-18 00:00:00.000","description":"Respiratory Care Shift Note","row_id":638279,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 30\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Tracheostomy tube:\n Type: Standard, Cuffed\n Manufacturer: Portex\n Size: 7.0mm\n PMV: Not wearing\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n :\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Plan\n Next 24-48 hours:\n : Continue T-collar as tolerated\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"},{"category":"Respiratory ","chartdate":"2167-10-19 00:00:00.000","description":"Respiratory Care Shift Note","row_id":638339,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 31\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Tracheostomy tube:\n Type: Standard, Cuffed\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Periodic SBT's for conditioning; Comments: Continue with trach trials\n"},{"category":"Nursing","chartdate":"2167-10-05 00:00:00.000","description":"Nursing Progress Note","row_id":635876,"text":"Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt cont on Heparin gtt @ 1500units/h. PTT in therapeutic range.\n Coumadin po HS.\n Action:\n No further action taken.\n Response:\n Plan:\n Daily PT/PTT levels,? Plan to transition off heparin and increase\n coumadin dose.\n Altered mental status (not Delirium)\n Assessment:\n PT alert and very agitated throughout shift- making several attempts to\n pull at trach\n.fell asleep briefly following afternoon valium dose-\n Systolic dropped into low 80s, HR in the 50s- SB. Following commands\n inconsistently.\n Action:\n Fentanyl/versed titrated throughout shift. Restarted on Haldol IV prn,\n and given addititional one time dose of valium. Soft wrist restraints\n in place for safety. EKG done of QTC interval\n Response:\n Cont to be anxious, attempting to pull at trach. QTI -442\n Plan:\n Cont daily QTC Intervals, titrate down Fent/versed Gtt as able.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Hypernatremia (high sodium)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2167-10-05 00:00:00.000","description":"Nursing Progress Note","row_id":635877,"text":"55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\n Now with prolonged hospital course c/b by PNA with high PEEP\n requirement, anxiety, RUE DVT on heparin qtt.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt cont on Heparin gtt @ 1500units/h. PTT in therapeutic range.\n Coumadin po HS.\n Action:\n No further action taken.\n Response:\n Plan:\n Daily PT/PTT levels-? Plan to transition off heparin and increase\n coumadin dose.\n Altered mental status (not Delirium)\n Assessment:\n PT alert and very agitated throughout shift- making several attempts to\n pull at trach\n.fell asleep briefly following afternoon valium dose-\n Systolic dropped into low 80s, HR in the 50s- SB. Following commands\n inconsistently.\n Action:\n Fentanyl/versed titrated throughout shift. Restarted on Haldol IV prn,\n and given addititional one time dose of valium. Soft wrist restraints\n in place for safety. EKG done of QTC interval\n Response:\n Cont to be anxious, attempting to pull at trach. QTI -442\n Plan:\n Cont daily QTC Intervals, titrate down Fent/versed Gtt as able, cont w/\n prn haldol and standing valium.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Cont to be trached/vented on AC. Pleural effusions on CXR worsening.\n Action:\n Tolerated PS briefly this am. ABG/VBG collected\n Response:\n Pt w/ periods of apnea on PS.\n Plan:\n Non-contrast CT today to check size of pleural effusions, ? tap\n effusions following CT, make vent changes as needed, wean fent/versed\n as able to tolerate vent changes. Recheck ABG/VBG this evening.\n Hypernatremia (high sodium)\n Assessment:\n NA level cont to be ^^\n Action:\n FWB increased to 300cc every 4 hrs.\n Response:\n Lytes to be rechecked this evening\n Plan:\n Check day and evening lytes, cont w/ q 4h boluses\n"},{"category":"Physician ","chartdate":"2167-10-05 00:00:00.000","description":"Physician Resident/Attending Progress Note - MICU","row_id":635878,"text":"Chief Complaint:\n 24 Hour Events:\n On lasix drip\n Attempted to wean FiO2\n No acute events\n No BM\n Agitated this am\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions :\n Midazolam (Versed)\n 1 mg/hour\n Furosemide (Lasix)\n 2 mg/hour\n Heparin Sodium\n 1,500 units/hour\n Fentanyl\n 75 mcg/hour\n Other ICU medications:\n Other medications:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.9\nC (98.5\n HR: 126 (49 - 131) bpm\n BP: 156/84(117) {78/38(52) - 164/95(125)} mmHg\n RR: 20 (9 - 21) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 4,160 mL\n 1,185 mL\n PO:\n TF:\n 1,267 mL\n 315 mL\n IVF:\n 1,018 mL\n 260 mL\n Blood products:\n Total out:\n 4,015 mL\n 2,090 mL\n Urine:\n 4,015 mL\n 2,090 mL\n NG:\n Stool:\n Drains:\n Balance:\n 145 mL\n -905 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 500) mL\n Vt (Spontaneous): 675 (675 - 675) mL\n PS : 8 cmH2O\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 19 cmH2O\n Plateau: 16 cmH2O\n SpO2: 96%\n ABG: 7.39/46/118/28/2\n Ve: 8.9 L/min\n PaO2 / FiO2: 236\n Physical Examination\n General Appearance: Intubated and sedated. Responsive, following\n commands, Overweight / Obese, mild agitation but NAD\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\n deviation\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Respiratory / Chest: (Expansion: Symmetric), CTA anteriorly, decreased\n BS\n Abdominal: Obese, Firm, Non-tender, no rebound, no guarding, + BS, PEG\n in place with dressing C/D/I\n Extremities: No clubbing or cyanosis, 1+ nonpitting edema of b/l hands,\n anasarca\n Skin: no rashes or jaundice\n Lines: r brachioceph ART and L PICC C/D/I\n Labs / Radiology\n 272 K/uL\n 8.6 g/dL\n 128 mg/dL\n 0.6 mg/dL\n 28 mEq/L\n 3.1 mEq/L\n 8 mg/dL\n 110 mEq/L\n 148 mEq/L\n 27.4 %\n 11.2 K/uL\n [image002.jpg]\n 05:17 PM\n 11:41 PM\n 03:06 AM\n 03:38 AM\n 04:05 PM\n 03:55 AM\n 07:19 AM\n 11:24 AM\n 03:18 PM\n 02:47 AM\n WBC\n 10.6\n 10.0\n 8.3\n 11.2\n Hct\n 27.3\n 25.8\n 24.6\n 27.4\n Plt\n 72\n Cr\n 0.5\n 0.6\n 0.6\n 0.5\n 0.6\n 0.6\n TCO2\n 32\n 31\n 29\n 29\n Glucose\n 110\n 94\n 111\n 106\n 121\n 123\n 137\n 128\n Other labs: Ca++:9.0 mg/dL, Mg++:2.6 mg/dL, PO4:4.3 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA and\n ARDS intubated since the end of now s/p trach and PEG placement.\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation. Stenting\n unlikely to help for trachiomalacia as airways have poor structure\n diffusely. S/P Trach and PEG on . Increased effusion on recent\n CXR.\n - wean FiO2 as tolerated\n - non-con head CT to further characterize pulmonary effusions,\n det potential for thoracentesis\n # Adrenal Insufficency: Hypotension that resolved with steroids,\n returned as they came off and is now improved again. Possible primary\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\n started on .\n - wean per endo recs, decrease to q8 today, likely q12 dosing\n tomorrow\n # Volume overloaded in setting of hypernatremia with TBW deficit.\n - Lasix gtt, continue with goal -1-2 L per day.\n - electrolytes\n - continue tube feeds with free water flushes increase from 250 to 300\n cc q4\n # Sedation: Sedation control remains somewhat poor although fentanyl\n patch and diazpem are likely therapeutic range today. On Versed 2.0,\n Fentanyl 100, Fentanyl patch, Diazepam standing and haldo 2.5-5 mg\n PRN. QTc increased to 480.\n - Wean versed/fentanyl as tolerated, continue diazepam in\n hopes for vent facility placement\n - Increase diazepam to 12mg q4\n - Check ekg for QTc\n if <480, restart haldol and/or increase\n fentanyl patch\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\n coumadin at least until s/p trach.\n - heparin gtt restarted\n - coumadin 5mg G-tube today\n hold coumadin today for possible \n # Constipation\n current regimen of colace and senna, stooled during\n rounds\n - dulcolax PO/PR\n - reassess and increase bowel regimen PRN\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n -f/u full trauma spine eval from OSH to determine need for further back\n imaging in-house (to be done )\n # Nutrition: Tube feeds with free water flushes, tolerating well,\n continue Replete (Full) - 11:20 AM 30 mL/hour\n # Glycemic control: SSI, well controlled\n # Lines L PICC () and R ART ()\n both working well, check\n ABG/VBG today\n if correlate well, d/c art line\n # Ppx: heparin, ranitidine, VAP prevention, colace and senna\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n Code: Full\n Dispo: ICU, being screening for vent facilities\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 55F T5-8 fractures with retropulsion and ARDS\n from klebsiella VAP; on heparin for UE DVT and lasix for volume\n overload. Tolerating slow vent wean but failed SBT. Was TBB negative\n yesterday with lasix drip; sedation remains challenging.\n Exam notable for Tm 99.4 BP 145/77 HR 120 RR 18-20 with sat 97% on VAC\n 400x18 PEEP 8 FiO2 0.5. TBB -2L/24h, +9L/MICU LOS. Eyes opens, will\n squeeze hands and wiggle toes but very drowsy. Bronchial BS bilaterally\n with RRR s1s2 SM at base. Abdomen is distended with decreased BS.\n 1+ edema in BLE, no cords. Labs notable for WBC 11K, HCT 27, K+ 3.1, Na\n 148, Cr 0.6. CXR with resolving B LL airspace disease and effusions.\n Agree with plan to continue supportive care and wean vent as we\n continue diuresis with attention to contraction alkalosis. Will check\n CT without contrast to assess lung parenchyma and effusions. Will\n increase fentanyl patch to 200 and valium to 15 TID po in addition to\n drips. Will check EKG prior to reinitiating haldol, which worked very\n well for her. Will wean hydrocortisone 25 q8 today and reduce to q12\n tomorrow, with long term goal for oral prednisone. Will continue IV\n heparin for UE DVT and continue transition to anticoagulation with\n coumadin. Will restart tube feeds and continue FW boluses for\n hypernatremia. Continue spinal stabilization with brace when OOB. Will\n eventually need MRI for surgical planning; remainder of plan as\n outlined above.\n Patient is critically ill\n Total time: 40 min\n ------ Protected Section Addendum Entered By: , MD\n on: 02:40 PM ------\n"},{"category":"Nursing","chartdate":"2167-09-28 00:00:00.000","description":"Nursing Progress Note","row_id":635021,"text":"Events: Wean from vent to 10 PEEP- tolerating w/ goal sat >90%. Lasix\n gtt started for volume overload. IP then consulted for ?\n trach/PEG . Plan NPO @ MS, Hep gtt off @ 0600 anticipation add on\n in or for open trach/PEG. MS n to acutely agitation-\n Versed and Fent gtt titrated- bolus PRN and starting PO Valium, Fent\n patch and IV Haldol for improved and longer acting pain control and ?\n delirium.\n Edema, peripheral\n Assessment:\n 3+ anasarca, pitting and dependent edema\n Action:\n Starting Lasix gtt @ 5cc/gr for goal >100cc/hr output\n Response:\n Initial reaction > 1L / 1 and\n hrs, titrated down to 2cc/hr with\n recent history of hypotensive w/ sedation\n Plan:\n monitor I+O, Resume Lasix gtt for goal UOP > 100cc/hr, BP\n monitoring, monitor edema\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Hep gtt infusing @ 1700 units/hr, no s/s bleeding\n Action:\n gtt\n Response:\n No change\n Plan:\n Hep gtt PT w/ AM Labs- off @ 0600 for anticipated trach/page \n Impaired Skin Integrity\n Assessment:\n Anasarca, excoriated/mild rash/reddened but blancking perianal area,\n mild shearing tear in perianal area, pannus folds w/o infection, left\n palp near ? friction skin impairment\n Action:\n Multipodus boots on, thin duoderm to bilat elbows, duoderm to left\n palm, barrier cream on perianal area-attempting to reposition,\n attempting IV/PO, pain patch and emotional support for decrease\n shearing movement in bed\n Response:\n No new breakdown in skin integrity noted\n Plan:\n comitor breakdown in skin integrity, minimize fracture and\n pressure- turning and pressure reduction as tolerated, duodern,\n emotional support and medications\n Altered mental status (not Delirium)\n Assessment:\n MS variable from sedated to acutely agitated attempting to hit while\n being turned,/oral care, intermittently alert, following commands\n nodding and mouthing words-pt unable to use white board, BP w/\n MS- when sedated SBP 88-90\ns, agitated 140-160\ns- art line positional\n Action:\n IV sedation as HD necessary, blousing PRN, inc dose on IV Haldol,\n attempting to wean IV sedation w/ additional of Fentanyl patch and PO\n valium, emotional support\n Response:\n MS , occ apears in pain and attempting to move in bed,\n others acutely agitated- pulling @ line and actively pointing and\n attempting to pull @ ETT\n Plan:\n IV medication, patch and PO medication for sedation/pain\n medication, emotional support, encourage nodding/use of white boad for\n expression as tolerated, repositioning\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS diminished throughout, scant suctioning clear white secretions, goal\n sat >90%\n Action:\n PEEP from 15-10, administering IV Lasix gtt,\n Response:\n LS unchanges, ABD w/I pt normal limits, - inc WOB w/ agitation,\n Plan:\n Monitor resp status, ABG as needed, wean as tolerated, monitor sat,\n emotional support- trach/PEG \n Hypernatremia (high sodium)\n Assessment:\n NA 146\n Action:\n Administering changed flush to 150cc free water Q 4hrs\n Response:\n minimal residuals\n Plan:\n free water flushes, monitor NA, s/s hypernatremia\n"},{"category":"Nursing","chartdate":"2167-09-28 00:00:00.000","description":"Nursing Progress Note","row_id":635022,"text":"Events: Wean from vent to 10 PEEP- tolerating w/ goal sat >90%. Lasix\n gtt started for volume overload. IP then consulted for ?\n trach/PEG . Plan NPO @ MS, Hep gtt off @ 0600 anticipation add on\n in or for open trach/PEG. MS n to acutely agitation-\n Versed and Fent gtt titrated- bolus PRN and starting PO Valium, Fent\n patch and IV Haldol for improved and longer acting pain control and ?\n delirium.\n Edema, peripheral\n Assessment:\n 3+ anasarca, pitting and dependent edema\n Action:\n Starting Lasix gtt @ 5cc/gr for goal >100cc/hr output\n Response:\n Initial reaction > 1L / 1 and\n hrs, titrated down to 2cc/hr with\n recent history of hypotensive w/ sedation\n Plan:\n monitor I+O, Resume Lasix gtt for goal UOP > 100cc/hr, BP\n monitoring, monitor edema\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Hep gtt infusing @ 1700 units/hr, no s/s bleeding\n Action:\n gtt\n Response:\n No change\n Plan:\n Hep gtt PT w/ AM Labs- off @ 0600 for anticipated trach/page \n Impaired Skin Integrity\n Assessment:\n Anasarca, excoriated/mild rash/reddened but blancking perianal area,\n mild shearing tear in perianal area, pannus folds w/o infection, left\n palp near ? friction skin impairment\n Action:\n Multipodus boots on, thin duoderm to bilat elbows, duoderm to left\n palm, barrier cream on perianal area-attempting to reposition,\n attempting IV/PO, pain patch and emotional support for decrease\n shearing movement in bed\n Response:\n No new breakdown in skin integrity noted\n Plan:\n comitor breakdown in skin integrity, minimize fracture and\n pressure- turning and pressure reduction as tolerated, duodern,\n emotional support and medications\n Altered mental status (not Delirium)\n Assessment:\n MS variable from sedated to acutely agitated attempting to hit while\n being turned,/oral care, intermittently alert, following commands\n nodding and mouthing words-pt unable to use white board, BP w/\n MS- when sedated SBP 88-90\ns, agitated 140-160\ns- art line positional\n Action:\n IV sedation as HD necessary, blousing PRN, inc dose on IV Haldol,\n attempting to wean IV sedation w/ additional of Fentanyl patch and PO\n valium, emotional support\n Response:\n MS , occ apears in pain and attempting to move in bed,\n others acutely agitated- pulling @ line and actively pointing and\n attempting to pull @ ETT\n Plan:\n IV medication, patch and PO medication for sedation/pain\n medication, emotional support, encourage nodding/use of white boad for\n expression as tolerated, repositioning\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS diminished throughout, scant suctioning clear white secretions, goal\n sat >90%\n Action:\n PEEP from 15-10, administering IV Lasix gtt,\n Response:\n LS unchanges, ABD w/I pt normal limits, - inc WOB w/ agitation,\n Plan:\n Monitor resp status, ABG as needed, wean as tolerated, monitor sat,\n emotional support- trach/PEG \n Hypernatremia (high sodium)\n Assessment:\n NA 146\n Action:\n Administering changed flush to 150cc free water Q 4hrs\n Response:\n minimal residuals\n Plan:\n free water flushes, monitor NA, s/s hypernatremia\n"},{"category":"Physician ","chartdate":"2167-09-20 00:00:00.000","description":"Physician Resident Admission Note","row_id":634095,"text":"TITLE: PGY3 MICU Admission Note\n Chief Complaint: persistent respiratory failure\n HPI:\n 55 year old woman with hx of obesity presented to Medical Center\n on after falling down stairs while at home. She suffered a\n traumatic T5-8 fracture with retropulsion of fragments. Per medical\n records and discussion with her brother, she was awake for the fall (no\n LOC) and the fall was triggered by unsteady gait, potentially\n influenced by alcohol. Her fracture was managed concervatively. She\n was placed in a torso brace but her course was complicated by\n respiratory failure requiring intubation. At that time a CT was\n negative for PE but showed bilateral bibasilar consolidations vs\n atelectasis. At that time an ABG was 7.20/89/57 (unknown FIO2 but\n likely >6L facemask). She was intubated on at 08:40. The\n respiratory failure was thought likely to be related to pain med\n induced hypoventilation, bronchospasm, or restricted breathing duet to\n the back brace. The hospital course was complicated by\n difficulty weaning form the ventilator. Her periodic agitation was\n managed with seroquel. Prior to transfer her vent settings were: SIMV\n 12x600 FIO2 0.45.\n The neurosurgery service evaluated her and recommended concervative\n management of her fracture including a back brace and outpatient\n neurosurgery followup. The CT chest showed notable narrowing of her\n central airways and the patient was referred for Interventional\n Pulmonary evaluation for airway stenting.\n Patient admitted from: Transfer from other hospital\n History obtained from Family / Medical records\n Patient unable to provide history: Sedated\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Other medications:\n Home Medications:\n ativan prn\n prilosec OTC\n Medications on transfer:\n dexmedetomidine\n senna 2 tabs qhs\n zofran 4 mg IV q6hr:prn\n tinzaparin 4500 units q24\n acetaminophen 650 mg q6prn\n famotidine 20 mg IV daily\n colace 100 mg \n albuterol/ipratropium INH q4\n seroquel 50 mg \n lactated ringer's @75cc/hr\n Past medical history:\n Family history:\n Social History:\n GERD\n s/p TAH\n s/p left total hip replacement\n s/p appendectomy\n remote benign breast mass\n nc\n Occupation: regional manager at insurance company\n Drugs: denies\n Tobacco: unknown\n Alcohol: heavy\n Other:\n Review of systems:\n Flowsheet Data as of 03:00 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36\nC (96.8\n Tcurrent: 36\nC (96.8\n HR: 75 (75 - 90) bpm\n BP: 106/43(59) {106/43(59) - 154/71(103)} mmHg\n RR: 12 (12 - 18) insp/min\n SpO2: 100%\n Total In:\n 10 mL\n 32 mL\n PO:\n TF:\n IVF:\n 10 mL\n 32 mL\n Blood products:\n Total out:\n 425 mL\n 225 mL\n Urine:\n 425 mL\n 225 mL\n NG:\n Stool:\n Drains:\n Balance:\n -416 mL\n -194 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 100%\n PIP: 34 cmH2O\n SpO2: 100%\n ABG: 7.42/47/61/30/4\n Ve: 6.1 L/min\n PaO2 / FiO2: 61\n Physical Examination\n General Appearance: Overweight / Obese\n Eyes / Conjunctiva: PERRL, Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Rhonchorous: bilaterally)\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended, Obese\n Extremities: Right: Trace, Left: Trace, Cyanosis\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Purposeful, Sedated, Tone: Not assessed\n Labs / Radiology\n 333 K/uL\n 9.7 g/dL\n 103 mg/dL\n 0.6 mg/dL\n 6 mg/dL\n 30 mEq/L\n 109 mEq/L\n 3.8 mEq/L\n 150 mEq/L\n 30.7 %\n 9.7 K/uL\n [image002.jpg]\n \n 2:33 A9/6/ 11:54 PM\n \n 10:20 P9/7/ 01:00 AM\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 9.7\n Hct\n 30.7\n Plt\n 333\n Cr\n 0.6\n TC02\n 32\n Glucose\n 103\n Other labs: PT / PTT / INR:13.8/22.4/1.2, ALT / AST:30/19, Alk Phos / T\n Bili:149/0.7, Differential-Neuts:76.9 %, Lymph:17.3 %, Mono:3.0 %,\n Eos:2.5 %, Albumin:3.0 g/dL, LDH:222 IU/L, Ca++:8.6 mg/dL, Mg++:2.1\n mg/dL, PO4:4.1 mg/dL\n ECG: sinus @ @86. low voltage. nl axis and intervals. no ischemic\n changes.\n Assessment and Plan\n A/P: 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture\n Respiratory failure: initially likely multifactorial including\n bronchspasm, hypoventilation from narcotics, and potential aspiration.\n prior evaluation negative for PE. still with significant A-a gradient.\n cxr appears under penetrated with small lung fields and potential\n effusion on right. potentially from additional pulmonary edema, however\n hypernatremia would limit ability to diurese.\n - daily chest xray\n - will hold on CT chest or airway pending IP consult\n - IP consult\n - vent settings: AC 500 x14 PEEP >8 (given body habitus), FIO2 as\n needed\n - sedation: fentanyl gtt/versed bolus\n - trial of diuresis when able\n Spine fracture: neurologically intact distal to the lesion. prior notes\n from MMC neurosurgeons indicated no surgical procedure needed and would\n continue with spine brace.\n - monitor distal neurologic function\n - cto brace x3 months unless supine in bed\n Anemia: admission to MMC was ~40 now down to 30% w/o sign of active GI\n bleed or other source of blood loss. likely related to crystalloid\n administration, anemia of inflammation, chronic phlebotomy. given bili\n and LDH normal would be unlikely for hemolysis.\n - trend Hct\n - guaiac stools\n Hypernatremia: most likely related to inadequate free water repletion.\n free water defecit ~3L.\n - replete via OGT primarily\n - D5W x1 L\n ICU Care\n Nutrition:\n Comments: tube feed with free water\n nutrition consult\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 10:30 PM\n 18 Gauge - 10:30 PM\n 20 Gauge - 01:36 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Family meeting held , ICU consent signed Comments: \n (brother) \n (boyfriend/POA) \n Code status: Full code\n Disposition: ICU\n"},{"category":"Respiratory ","chartdate":"2167-10-03 00:00:00.000","description":"Respiratory Care Shift Note","row_id":635640,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation:\n Ideal body weight:\n Ideal tidal volume:\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position:\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure:\n Cuff volume:\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds:\n RUL Lung Sounds:\n LUL Lung Sounds:\n LLL Lung Sounds:\n Comments:\n Secretions\n Sputum color / consistency:\n Sputum source/amount:\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Specialized Gas Therapy\n Nitric Oxide\n PPM used: ppm\n Indication:\n Effect of therapy: []\n Nitric Oxide trial:\n Comments:\n HeliOx:\n Additional O[2] by cannula: L/min\n Continuous nebulized bronchodilator:\n Comments:\n Recruitment Maneuvers Done\n CPAP pressure used: cm H2O\n Duration: sec\n Times per shift:\n Comments:\n"},{"category":"Nursing","chartdate":"2167-10-05 00:00:00.000","description":"Nursing Progress Note","row_id":635868,"text":"Impaired Skin Integrity\n Assessment:\n Skin warm to touch, yeast-like red rash under skin folds, coccyx\n red,\n skin intact.\n Action:\n Miconazole powder applied to skin folds/periarea. Miconazole skin\n cream barrier applied to coccyx. Frequent repositioning.\n Response:\n Cont w/ rash\n Plan:\n Cont w/ frequent repositioning and current skin care regimen\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt cont on Heparin gtt @ 1500units/h. PTT in therapeutic range.\n Coumadin po HS.\n Action:\n No further action taken.\n Response:\n Plan:\n Daily PT/PTT levels,? Plan to transition off heparin and increase\n coumadin dose.\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Hypernatremia (high sodium)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2167-10-05 00:00:00.000","description":"Nursing Progress Note","row_id":635874,"text":"Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt cont on Heparin gtt @ 1500units/h. PTT in therapeutic range.\n Coumadin po HS.\n Action:\n No further action taken.\n Response:\n Plan:\n Daily PT/PTT levels,? Plan to transition off heparin and increase\n coumadin dose.\n Altered mental status (not Delirium)\n Assessment:\n PT alert and very agitated throughout shift\n.fell asleep briefly\n following afternoon valium dose- Systolic dropped into low 80s, HR in\n the 50s- SB. Following commands inconsistently.\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Hypernatremia (high sodium)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Physician ","chartdate":"2167-09-28 00:00:00.000","description":"Physician Resident Progress Note","row_id":634940,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n PICC placed, Central line d/c'd\n Lasix 10 mg given with 400 cc UOP in afternoon, pH improved\n Lasix 20 mg given at ~ 4AM.\n Lots of thick sinus secreations\n Delerium/anxiety overnight with periods of hypertension.\n Could not draw of A-line.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Aztreonam - 06:00 AM\n Vancomycin - 09:00 AM\n Levofloxacin - 08:06 AM\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Fentanyl - 150 mcg/hour\n Heparin Sodium - 1,700 units/hour\n Other ICU medications:\n Furosemide (Lasix) - 03:01 AM\n Midazolam (Versed) - 04:36 AM\n Fentanyl - 04:36 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36.4\nC (97.6\n HR: 90 (47 - 92) bpm\n BP: 118/59(80) {80/40(53) - 137/105(111)} mmHg\n RR: 17 (15 - 24) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101 kg (admission): 94.2 kg\n Height: 67 Inch\n CVP: 19 (16 - 19)mmHg\n Total In:\n 2,560 mL\n 543 mL\n PO:\n TF:\n 1,441 mL\n 342 mL\n IVF:\n 1,020 mL\n 201 mL\n Blood products:\n Total out:\n 1,680 mL\n 860 mL\n Urine:\n 1,680 mL\n 860 mL\n NG:\n Stool:\n Drains:\n Balance:\n 880 mL\n -317 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 15 cmH2O\n FiO2: 50%\n PIP: 27 cmH2O\n Plateau: 23 cmH2O\n SpO2: 98%\n ABG: 7.41/45/77./28/2\n Ve: 6.5 L/min\n PaO2 / FiO2: 156\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese, opens eyes\n but no purposeful movement\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric)\n Abdominal: No(t) Soft, Non-tender, Bowel sounds present, Distended\n Extremities: No clubbing or cyanosis, 3+ nonpitting edema of b/l hands,\n LE without edema\n Skin: no rashes or jaundice\n Labs / Radiology\n 411 K/uL\n 8.3 g/dL\n 133 mg/dL\n 0.5 mg/dL\n 28 mEq/L\n 4.1 mEq/L\n 13 mg/dL\n 111 mEq/L\n 145 mEq/L\n 26.0 %\n 9.7 K/uL\n [image002.jpg]\n 04:05 PM\n 01:12 AM\n 04:00 AM\n 04:09 AM\n 10:18 AM\n 02:33 PM\n 02:46 PM\n 03:31 AM\n 02:26 PM\n 05:53 PM\n WBC\n 9.6\n 9.7\n Hct\n 27.8\n 26.0\n Plt\n 374\n 411\n Cr\n 0.5\n 0.5\n 0.5\n 0.5\n TCO2\n 26\n 27\n 28\n 29\n 26\n 27\n 30\n Glucose\n 194\n 195\n 195\n 163\n 133\n Other labs: PT / PTT / INR:15.3/69.9/1.3, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:86.1 %, Lymph:10.3 %,\n Mono:2.8 %, Eos:0.5 %, Lactic Acid:2.0 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:8.3 mg/dL, Mg++:2.2 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with respiratory failure\n and difficulty weaning from vent.\n # Respiratory failure: Intubated on for resp decompensation.\n Likely VAP. Unlikely to have tracheomalacia as initially\n transferred for.\n - wean PEEP\n - Given mild alkalosis, will decrease RR to 18, repeat ABG\n - discuss need for trach with patient and her family\n - Will continue gentle diuresis once alkalosis resolved\n # Pneumonia: Pansensitive Kleb oxytoca pneumonia and sputum with GPCs\n on gram stain. Afebrile overnight. On levofloxacin since .\n Vancomycin, aztreonam have been stopped. Resp status seems to be\n improving.\n - Follow cultures\n - d/c levofloxacin having completed 8 day course\n # Sedation: On versed and fentanyl\n # EKG changes: Sinus bradycardia, now somewhat improved. Likely\n related to increased vagal tone possibly related to steroid\n replacement. Atrial EKG shows p-waves and cardiac enzymes normal.\n - Continue to monitor\n # Hypotension: Improved, off levophed for 2-3 days now, with good urine\n output. CVP increasing with reduction in PEEP. Likely poor\n adrenal response in setting of acute illness and very high PEEP.\n -D/C fludricort and hydrocortisone now that the 5 day steroid course is\n complete\n -monitor, expect improvement with continual reduction in PEEP\n # RUE DVT: Started on heparin gtt on , now therapeutic. Follow\n PTTs. Would hold off on coumadin at least until s/p trach.\n - continue to monitor\n # Adrenal Insufficency: Random cortisol was approx 3 when it should\n have been maximally stimulated.\n - hydrocortisone and florinef for 5 days\n # Anemia: Stable.\n - Trend HCT\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n FEN/GI: Tube feeds @ goal\n DVT: Treatment dose heparin\n Ulcer: Ranitidine\n VAP: Prevention per routine\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 08:12 PM 60 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 04:00 PM\n PICC Line - 09:19 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2167-09-29 00:00:00.000","description":"Physician Resident / Attending Progress Note - MIC","row_id":635107,"text":"Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - STOP 09:00 PM - attempted to re-wire but\n patient was very agitated and re-wire was unsuccessful\n Patient alternated between tachycardia and normotension and hypotension\n in the high-80s/low 90s and HRs in the 50s\n Given haldol, valium, midaz and fentanyl for sedation\n ABG with low paO2 on PEEP 10, had to increase -- went back up to 15 and\n then attempted to re-wean down with goal 8 in anticipation of OR\n To OR for trach and PEG today (thoracics)\n Put on lasix drip and put out >1L in just over an hour\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 08:06 AM\n Infusions:\n Midazolam (Versed) - 1.5 mg/hour\n Fentanyl - 200 mcg/hour\n Other ICU medications:\n Fentanyl - 06:45 PM\n Ranitidine (Prophylaxis) - 08:00 PM\n Haloperidol (Haldol) - 10:00 PM\n Midazolam (Versed) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.7\nC (99.8\n HR: 109 (55 - 134) bpm\n BP: 120/56(70) {80/43(51) - 133/85(94)} mmHg\n RR: 20 (16 - 28) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 101 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 3,064 mL\n 404 mL\n PO:\n TF:\n 1,440 mL\n IVF:\n 1,014 mL\n 314 mL\n Blood products:\n Total out:\n 4,257 mL\n 1,195 mL\n Urine:\n 4,257 mL\n 1,195 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,193 mL\n -791 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 18\n RR (Spontaneous): 10\n PEEP: 15 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10\n PIP: 23 cmH2O\n Plateau: 24 cmH2O\n SpO2: 97%\n ABG: 7.46/48/65/31/8 @ 10:20 PM\n Ve: 7.8 L/min\n PaO2 / FiO2: 108\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 320 K/uL\n 8.0 g/dL\n 94 mg/dL\n 0.6 mg/dL\n 31 mEq/L\n 3.6 mEq/L\n 13 mg/dL\n 110 mEq/L\n 147 mEq/L\n 25.8 %\n 9.0 K/uL\n [image002.jpg]\n 10:18 AM\n 02:33 PM\n 02:46 PM\n 03:31 AM\n 02:26 PM\n 05:53 PM\n 05:01 AM\n 03:32 PM\n 10:19 PM\n 02:50 AM\n WBC\n 9.7\n 9.5\n 9.0\n Hct\n 26.0\n 27.6\n 25.8\n Plt\n \n Cr\n 0.5\n 0.5\n 0.5\n 0.6\n 0.6\n TCO2\n 29\n 26\n 27\n 30\n 30\n 35\n Glucose\n 195\n 195\n 163\n 133\n 102\n 94\n Other labs: PT / PTT / INR:14.1/59.6/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:71.2 %, Lymph:22.7 %,\n Mono:4.0 %, Eos:1.7 %, Lactic Acid:1.5 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:8.2 mg/dL, Mg++:2.1 mg/dL, PO4:4.6 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with respiratory failure\n and difficulty weaning from vent.\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation.\n Transferred here for tracheomalacia, but not sure this is a component.\n Will need bronch eval when improved\n - Thoracics will do trach and PEG once stable on PEEPs around 10. Had\n been planned for today but currently holding as PEEP is 15.\n - wean PEEP as tolerated\n - needs A-line\n # Volume overload\n Currently with hypernatremia, Cr increase, contract\n alk, but mild\n - continue gentle diuresis with goal -1L per day as tolerated by blood\n pressure. IV lasix drip at 1-5 mg/hr.\n - FW in TF at 150 cc q4hrs\n - PM lytes.\n # Sedation: Now well seadated on Versed 1.5, Fentanyl 175, Fentanyl\n patch, Diazepam standing and haldo 2.5-5 mg PRN. QTc stable at .44\n - Wean versed/fentanyl as tolerated\n # HCT\n Has had slow decline while in ICU.\n - Xfuse PRN Hct < 21\n - continue to follow, guiac stools\n # Hypotension: Related to sedation, but high PEEP, adrenial\n insufficiency, sepsis have previously been contributing.\n - needs A-line for monitoring\n - cortisol stim to rule out persistent adrenal insufficiency\n # RUE DVT: Started on heparin gtt on , now off for trach that was\n planned for today. Follow PTTs. Would hold off on coumadin at least\n until s/p trach.\n - restart heparin\n # Adrenal Insufficency: Random cortisol was approx 3 when it should\n have been maximally stimulated. S/P 5 days of hydrocortisone and\n florinef.\n - will recheck as above and start at 50 q8 if needed\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n FEN/GI: Tube feeds @ goal. No need to be NPO while awaiting stable\n PEEP\n DVT: Treatment dose heparin\n Ulcer: Ranitidine\n VAP: Prevention per routine\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 55F T5-8 fractures with retropulsion and ARDS\n from VAP; on heparin for UE DVT. PEEP as low as 10 yesterday but now up\n to 15; good response to lasix. Arterial line is out; sedation remains\n challenging despite multiple interventions.\n Exam notable for Tm 98.5 BP 90/45 HR 67 RR 16-28 with sat 97 on VAC\n 400x18 PEEP 15 FiO2 0.6 for 7.46/48/65. TBB -1.2/24, +14L/MICU LOS.\n Eyes opens, will squeeze hands and wiggle toes but very drowsy.\n Bronchial BS bilaterally with RRR s1s2 SM at base. Abdomen is\n distended with decreased BS. 3+ edema in BLE, no cords. Labs notable\n for WBC 9K, HCT 26, K+ 4.1, Na 147, Cr 0.5. CXR with resolving B LL\n airspace disease and effusions.\n Agree with plan to replace arterial line in R axillary artery today and\n try to wean PEEP. If BP remains low, will need stim and\n supplementation with hydrocortisone 50 q6-8h; will check bladder\n pressure, rule out auto-PEEP and continue to monitor for occult\n infection, but will hold off on antibiotics for now. Will continue\n fentanyl patch and po valium as we wean IV sedation. Will retry gentle\n IV lasix to affect a negative fluid balance and use haldol for\n breakthrough agitiation. Will restart IV heparin for UE DVT; consider\n transition to coumadin only after tracheostomy and feeding tube\n placement, which will require lower ventilator settings. Will restart\n tube feeds and add FW boluses for hypernatremia. Continue spinal\n stabilization with brace when OOB; will eventually need MRI for\n surgical planning; remainder of plan as outlined above.\n Patient is critically ill\n Total time: 40 min\n ------ Protected Section Addendum Entered By: , MD\n on: 02:46 PM ------\n"},{"category":"General","chartdate":"2167-10-03 00:00:00.000","description":"Generic Note","row_id":635631,"text":"TITLE: Addendum to Dr. \ns note\n MICU ATTENDING ADDENDUM \n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points:\n trauma thoracic spine fracture\n intubated\n VAP\n tracheomalacia\n trached yesterday\n desaturated and PEEP increased\n Exam notable for Tm 99.2 BP 127/63 HR 111 RR 18 with 95 sat on\n AC/18/400/10/.6\n anasarca\n awake, no purposeful movements\n decreased breath sounds ant and lat\n tachy, regular\n abd benign\n 7.45/43/82\n Labs notable for WBC 10 K, HCT 26 , K+ 4.1 , Cr .6 , HCO3 29\n CXR reviewed - bilat effusion, trach ok\n Problems:\n respiratory failure\n airway malacia\n anasarca, effusions\n spine fracture\n agitation\n adrenal insufficiency\n DVT\n Agree with plan to wean vent as tolerated, diurese, wean sedation\n though continue pain medications, continue steroids, continue heparin -\n eventual coumadin\n Remainder of plan as outlined above.\n Patient is critically ill.\n Total time: 37 min\n"},{"category":"Nursing","chartdate":"2167-10-04 00:00:00.000","description":"Nursing Progress Note","row_id":635680,"text":"55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\n Now with prolonged hospital course c/b by PNA with high PEEP\n requirement, anxiety, RUE DVT on heparin qtt.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt on Vent settings AC 55%/18 X 400/+10 with no overbreathing of\n set RR. O2 sat 92-98%. Lung snds clear, diminished in bases. Pt sxn\n for small-moderate amts thick white secretions. Trach site with small\n amt serosang drainage.\n Action:\n Cont same vent settings\n Response:\n Pt doesn\nt over breath on the vent and never desat.\n Plan:\n Wean from vent as she tolerates,monitor sats,ABG?.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt rec\nd with Heparin qtt off post trach/PEG yesterday.\n Action:\n Heparin restarted @ 1100 @ previous rate 1700units/hr.\n Response:\n PTT @ 1630 58.5. Heparin inc\nd to 1900units/hr per sliding scale @\n 1715.\n Plan:\n Repeat PTT @ 2300.\n Alteration in Nutrition\n Assessment:\n Received pt on TF 10cc/hr\n Action:\n Pt tolerated TF with minimal residuals as well as free water bolus Q4H\n Response:\n TF ^ as tolerated, currently at 30cc/hr.\n Plan:\n Cont to monitor TF residuals, hold if more than 100cc\n Altered mental status (not Delirium)\n Assessment:\n Pt w/ periods of agitation and sleeping at other times, while she\n aweake follow commands intermittently.\n Action:\n Cont on fent 100 mics ,Versed 2mg/hr and requires frequent boluses .\n Cont diazepam 10 mg PO Q6H. Fent ^ 125 mics/hr\n Response:\n HR ranging from SB in the 40\ns when asleep to the 120-140\ns when\n agitated, b/p ranging from 90\ns/40\ns when asleep to 140-170\ns/ 70\n when agitated. When pt awake appropriate and following commands HR\n 80\ns-100\ns and b/p 100\ns-120\ns/ 60-70\n Plan:\n Titrate sedation as needed\n"},{"category":"Nursing","chartdate":"2167-10-04 00:00:00.000","description":"Nursing Progress Note","row_id":635685,"text":"55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\n Now with prolonged hospital course c/b by PNA with high PEEP\n requirement, anxiety, RUE DVT on heparin qtt.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt on Vent settings AC 55%/18 X 400/+10 with no overbreathing of\n set RR. O2 sat 92-98%. Lung snds clear, diminished in bases. Pt sxn\n for small-moderate amts thick white secretions. Trach site with small\n amt serosang drainage.\n Action:\n Cont same vent settings\n Response:\n Pt doesn\nt over breath on the vent and never desat.Kept same Vent\n settings.\n Plan:\n Wean from vent as she tolerates,monitor sats,ABG?.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt rec\nd with Heparin qtt 1900units/hr.\n Action:\n PTT drawn at 2300.\n Response:\n PTT @ 2300 was 107,Decreased Heparin gtt 1700 u/hr as per sliding\n scale.Next PTT due at 0600. .\n Plan:\n Cont monitor PTT,titrate accordingly,next PTT due at 0600.\n Alteration in Nutrition\n Assessment:\n Received pt on TF 10cc/hr\n Action:\n Pt tolerated TF with minimal residuals as well as free water bolus Q4H\n Response:\n TF ^ as tolerated, currently at 30cc/hr.\n Plan:\n Cont to monitor TF residuals, hold if more than 100cc\n Altered mental status (not Delirium)\n Assessment:\n Pt w/ periods of agitation and sleeping at other times, while she\n aweake follow commands intermittently.\n Action:\n Cont on fent 100 mics ,Versed 2mg/hr and requires frequent boluses .\n Cont diazepam 10 mg PO Q6H. Fent ^ 125 mics/hr,Versed 3mg/hr.\n Response:\n HR ranging from SB in the 40\ns when asleep to the 120-140\ns when\n agitated, b/p ranging from 90\ns/40\ns when asleep to 140-170\ns/ 70\n when agitated. When pt awake appropriate and following commands HR\n 80\ns-100\ns and b/p 100\ns-120\ns/ 60-70\n Plan:\n Titrate sedation as needed\n"},{"category":"Physician ","chartdate":"2167-10-05 00:00:00.000","description":"Physician Resident Progress Note","row_id":635862,"text":"Chief Complaint:\n 24 Hour Events:\n On lasix drip\n Attempted to wean FiO2\n No acute events\n No BM\n Agitated this am\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions :\n Midazolam (Versed)\n 1 mg/hour\n Furosemide (Lasix)\n 2 mg/hour\n Heparin Sodium\n 1,500 units/hour\n Fentanyl\n 75 mcg/hour\n Other ICU medications:\n Other medications:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.9\nC (98.5\n HR: 126 (49 - 131) bpm\n BP: 156/84(117) {78/38(52) - 164/95(125)} mmHg\n RR: 20 (9 - 21) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 4,160 mL\n 1,185 mL\n PO:\n TF:\n 1,267 mL\n 315 mL\n IVF:\n 1,018 mL\n 260 mL\n Blood products:\n Total out:\n 4,015 mL\n 2,090 mL\n Urine:\n 4,015 mL\n 2,090 mL\n NG:\n Stool:\n Drains:\n Balance:\n 145 mL\n -905 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 500) mL\n Vt (Spontaneous): 675 (675 - 675) mL\n PS : 8 cmH2O\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 19 cmH2O\n Plateau: 16 cmH2O\n SpO2: 96%\n ABG: 7.39/46/118/28/2\n Ve: 8.9 L/min\n PaO2 / FiO2: 236\n Physical Examination\n Labs / Radiology\n 272 K/uL\n 8.6 g/dL\n 128 mg/dL\n 0.6 mg/dL\n 28 mEq/L\n 3.1 mEq/L\n 8 mg/dL\n 110 mEq/L\n 148 mEq/L\n 27.4 %\n 11.2 K/uL\n [image002.jpg]\n 05:17 PM\n 11:41 PM\n 03:06 AM\n 03:38 AM\n 04:05 PM\n 03:55 AM\n 07:19 AM\n 11:24 AM\n 03:18 PM\n 02:47 AM\n WBC\n 10.6\n 10.0\n 8.3\n 11.2\n Hct\n 27.3\n 25.8\n 24.6\n 27.4\n Plt\n 72\n Cr\n 0.5\n 0.6\n 0.6\n 0.5\n 0.6\n 0.6\n TCO2\n 32\n 31\n 29\n 29\n Glucose\n 110\n 94\n 111\n 106\n 121\n 123\n 137\n 128\n Other labs: PT / PTT / INR:15.2/62.2/1.3, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:13.1 %,\n Mono:2.7 %, Eos:0.6 %, Lactic Acid:0.9 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:9.0 mg/dL, Mg++:2.6 mg/dL, PO4:4.3 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA and\n ARDS intubated since the end of now s/p trach and PEG placement.\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation. Stenting\n unlikely to help for trachiomalacia as airways have poor structure\n diffusely. S/P Trach and PEG on .\n - wean FiO2 today\n # Adrenal Insufficency: Hypotension that resolved with steroids,\n returned as they came off and is now improved again. Possible primary\n adrenal insufficency. Appreciate endocrine recommendations. Halved\n dose today.\n - hydrocortt (day 1 = ), wean per endo recs\n # Volume overloaded in setting of hypernatremia with TBW deficit.\n - Lasix gtt, continue with goal -1-2 L per day.\n - electrolytes\n - continue tube feeds with free water flushes 250 cc q4\n # Sedation: Sedation control remains somewhat poor although fentanyl\n patch and diazpem are likely therapeutic range today. On Versed 2.0,\n Fentanyl 100, Fentanyl patch, Diazepam standing and haldo 2.5-5 mg\n PRN. QTc increased to 480.\n - Wean versed/fentanyl as tolerated, continue diazepam. Avoid haldol\n use if possible to avoid further prolongation of QTc\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\n coumadin at least until s/p trach.\n - heparin gtt restarted\n - coumadin 5mg G-tube today\n # Constipation\n current regimen of colace and senna, no BM over last\n 24 hours\n - dulcolax PO/PR today\n - reassess and increase bowel regimen PRN\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n -f/u full trauma spine eval from OSH to determine need for further back\n imaging in-house (to be done )\n # Nutrition: Tube feeds with free water flushes, tolerating well,\n continue Replete (Full) - 11:20 AM 30 mL/hour\n # Glycemic control: SSI, well controlled\n # Lines L PICC () and R ART ()\n both working well, mainitain\n # Ppx: heparin, ranitidine, VAP prevention, colace and senna\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n Code: Full\n Dispo: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Arterial Line - 02:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2167-10-05 00:00:00.000","description":"Physician Resident Progress Note","row_id":635863,"text":"Chief Complaint:\n 24 Hour Events:\n On lasix drip\n Attempted to wean FiO2\n No acute events\n No BM\n Agitated this am\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions :\n Midazolam (Versed)\n 1 mg/hour\n Furosemide (Lasix)\n 2 mg/hour\n Heparin Sodium\n 1,500 units/hour\n Fentanyl\n 75 mcg/hour\n Other ICU medications:\n Other medications:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.9\nC (98.5\n HR: 126 (49 - 131) bpm\n BP: 156/84(117) {78/38(52) - 164/95(125)} mmHg\n RR: 20 (9 - 21) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 4,160 mL\n 1,185 mL\n PO:\n TF:\n 1,267 mL\n 315 mL\n IVF:\n 1,018 mL\n 260 mL\n Blood products:\n Total out:\n 4,015 mL\n 2,090 mL\n Urine:\n 4,015 mL\n 2,090 mL\n NG:\n Stool:\n Drains:\n Balance:\n 145 mL\n -905 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 500) mL\n Vt (Spontaneous): 675 (675 - 675) mL\n PS : 8 cmH2O\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 19 cmH2O\n Plateau: 16 cmH2O\n SpO2: 96%\n ABG: 7.39/46/118/28/2\n Ve: 8.9 L/min\n PaO2 / FiO2: 236\n Physical Examination\n General Appearance: Intubated and sedated. Responsive, following\n commands, Overweight / Obese, mild agitation but NAD\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\n deviation\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Respiratory / Chest: (Expansion: Symmetric), CTA anteriorly, decreased\n BS\n Abdominal: Obese, Firm, Non-tender, no rebound, no guarding, + BS, PEG\n in place with dressing C/D/I\n Extremities: No clubbing or cyanosis, 1+ nonpitting edema of b/l hands,\n anasarca\n Skin: no rashes or jaundice\n Lines: r brachioceph ART and L PICC C/D/I\n Labs / Radiology\n 272 K/uL\n 8.6 g/dL\n 128 mg/dL\n 0.6 mg/dL\n 28 mEq/L\n 3.1 mEq/L\n 8 mg/dL\n 110 mEq/L\n 148 mEq/L\n 27.4 %\n 11.2 K/uL\n [image002.jpg]\n 05:17 PM\n 11:41 PM\n 03:06 AM\n 03:38 AM\n 04:05 PM\n 03:55 AM\n 07:19 AM\n 11:24 AM\n 03:18 PM\n 02:47 AM\n WBC\n 10.6\n 10.0\n 8.3\n 11.2\n Hct\n 27.3\n 25.8\n 24.6\n 27.4\n Plt\n 72\n Cr\n 0.5\n 0.6\n 0.6\n 0.5\n 0.6\n 0.6\n TCO2\n 32\n 31\n 29\n 29\n Glucose\n 110\n 94\n 111\n 106\n 121\n 123\n 137\n 128\n Other labs: Ca++:9.0 mg/dL, Mg++:2.6 mg/dL, PO4:4.3 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA and\n ARDS intubated since the end of now s/p trach and PEG placement.\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation. Stenting\n unlikely to help for trachiomalacia as airways have poor structure\n diffusely. S/P Trach and PEG on . Increased effusion on recent\n CXR.\n - wean FiO2 as tolerated\n - non-con head CT to further characterize pulmonary effusions,\n det potential for thoracentesis\n # Adrenal Insufficency: Hypotension that resolved with steroids,\n returned as they came off and is now improved again. Possible primary\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\n started on .\n - wean per endo recs, decrease to q8 today, likely q12 dosing\n tomorrow\n # Volume overloaded in setting of hypernatremia with TBW deficit.\n - Lasix gtt, continue with goal -1-2 L per day.\n - electrolytes\n - continue tube feeds with free water flushes increase from 250 to 300\n cc q4\n # Sedation: Sedation control remains somewhat poor although fentanyl\n patch and diazpem are likely therapeutic range today. On Versed 2.0,\n Fentanyl 100, Fentanyl patch, Diazepam standing and haldo 2.5-5 mg\n PRN. QTc increased to 480.\n - Wean versed/fentanyl as tolerated, continue diazepam in\n hopes for vent facility placement\n - Increase diazepam to 12mg q4\n - Check ekg for QTc\n if <480, restart haldol and/or increase\n fentanyl patch\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\n coumadin at least until s/p trach.\n - heparin gtt restarted\n - coumadin 5mg G-tube today\n hold coumadin today for possible \n # Constipation\n current regimen of colace and senna, stooled during\n rounds\n - dulcolax PO/PR\n - reassess and increase bowel regimen PRN\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n -f/u full trauma spine eval from OSH to determine need for further back\n imaging in-house (to be done )\n # Nutrition: Tube feeds with free water flushes, tolerating well,\n continue Replete (Full) - 11:20 AM 30 mL/hour\n # Glycemic control: SSI, well controlled\n # Lines L PICC () and R ART ()\n both working well, check\n ABG/VBG today\n if correlate well, d/c art line\n # Ppx: heparin, ranitidine, VAP prevention, colace and senna\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n Code: Full\n Dispo: ICU, being screening for vent facilities\n"},{"category":"Nursing","chartdate":"2167-10-05 00:00:00.000","description":"Nursing Progress Note","row_id":635866,"text":"Impaired Skin Integrity\n Assessment:\n Skin warm to touch, yeast-like red rash under skin folds, coccyx\n red,\n skin intact.\n Action:\n Miconazole powder applied to skin folds/periarea. Miconazole skin\n cream barrier applied to coccyx. Frequent repositioning.\n Response:\n Cont w/ rash\n Plan:\n Cont w/ frequent repositioning, apply miconazole powder to infected\n areas\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt cont on Heparin gtt @ 1500units/h. PTT in therapeutic range.\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Hypernatremia (high sodium)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Physician ","chartdate":"2167-10-06 00:00:00.000","description":"Physician Resident Progress Note","row_id":635981,"text":"Chief Complaint:\n 24 Hour Events:\n EKG - At 11:00 AM\n Started on Warfarin\n Extremely labile pressures over night\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 0.5 mg/hour\n Heparin Sodium - 1,500 units/hour\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:00 AM\n Haloperidol (Haldol) - 01:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:12 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.6\n Tcurrent: 37.1\nC (98.8\n HR: 100 (56 - 142) bpm\n BP: 98/47(65) {77/40(53) - 164/93(123)} mmHg\n RR: 18 (15 - 24) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 4,228 mL\n 1,123 mL\n PO:\n TF:\n 1,440 mL\n 360 mL\n IVF:\n 978 mL\n 343 mL\n Blood products:\n Total out:\n 6,725 mL\n 780 mL\n Urine:\n 6,725 mL\n 780 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,497 mL\n 343 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 450 (450 - 450) mL\n PS : 8 cmH2O\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 23 cmH2O\n Plateau: 19 cmH2O\n SpO2: 94%\n ABG: 7.50/41/81./29/7\n Ve: 7.2 L/min\n PaO2 / FiO2: 164\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 229 K/uL\n 7.9 g/dL\n 107 mg/dL\n 0.6 mg/dL\n 29 mEq/L\n 3.8 mEq/L\n 11 mg/dL\n 109 mEq/L\n 147 mEq/L\n 25.3 %\n 9.6 K/uL\n [image002.jpg]\n 03:55 AM\n 07:19 AM\n 11:24 AM\n 03:18 PM\n 02:47 AM\n 11:01 AM\n 04:40 PM\n 05:08 PM\n 03:44 AM\n 06:04 AM\n WBC\n 8.3\n 11.2\n 9.6\n Hct\n 24.6\n 27.4\n 25.3\n Plt\n 279\n 272\n 229\n Cr\n 0.5\n 0.6\n 0.6\n 0.6\n 0.6\n TCO2\n 29\n 29\n 31\n 34\n 33\n Glucose\n 123\n 137\n 128\n 138\n 107\n Other labs: PT / PTT / INR:16.5/78.5/1.5, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:13.1 %,\n Mono:2.7 %, Eos:0.6 %, Lactic Acid:1.1 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:8.7 mg/dL, Mg++:2.4 mg/dL, PO4:4.7 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Arterial Line - 02:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2167-10-06 00:00:00.000","description":"Physician Resident Progress Note","row_id":635982,"text":"Chief Complaint:\n 24 Hour Events:\n EKG - At 11:00 AM\n Started on Warfarin\n Extremely labile pressures over night\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 0.5 mg/hour\n Heparin Sodium - 1,500 units/hour\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:00 AM\n Haloperidol (Haldol) - 01:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:12 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.6\n Tcurrent: 37.1\nC (98.8\n HR: 100 (56 - 142) bpm\n BP: 98/47(65) {77/40(53) - 164/93(123)} mmHg\n RR: 18 (15 - 24) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 4,228 mL\n 1,123 mL\n PO:\n TF:\n 1,440 mL\n 360 mL\n IVF:\n 978 mL\n 343 mL\n Blood products:\n Total out:\n 6,725 mL\n 780 mL\n Urine:\n 6,725 mL\n 780 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,497 mL\n 343 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 450 (450 - 450) mL\n PS : 8 cmH2O\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 23 cmH2O\n Plateau: 19 cmH2O\n SpO2: 94%\n ABG: 7.50/41/81./29/7\n Ve: 7.2 L/min\n PaO2 / FiO2: 164\n Physical Examination\n General Appearance: Intubated and sedated. Responsive, following\n commands, Overweight / Obese, mild agitation but NAD\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\n deviation\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Respiratory / Chest: (Expansion: Symmetric), CTA anteriorly, decreased\n BS\n Abdominal: Obese, Firm, Non-tender, no rebound, no guarding, + BS, PEG\n in place with dressing C/D/I\n Extremities: No clubbing or cyanosis, 1+ nonpitting edema of b/l hands,\n anasarca\n Skin: no rashes or jaundice\n Lines: r brachioceph ART and L PICC C/D/I\n Labs / Radiology\n 229 K/uL\n 7.9 g/dL\n 107 mg/dL\n 0.6 mg/dL\n 29 mEq/L\n 3.8 mEq/L\n 11 mg/dL\n 109 mEq/L\n 147 mEq/L\n 25.3 %\n 9.6 K/uL\n [image002.jpg]\n 03:55 AM\n 07:19 AM\n 11:24 AM\n 03:18 PM\n 02:47 AM\n 11:01 AM\n 04:40 PM\n 05:08 PM\n 03:44 AM\n 06:04 AM\n WBC\n 8.3\n 11.2\n 9.6\n Hct\n 24.6\n 27.4\n 25.3\n Plt\n 279\n 272\n 229\n Cr\n 0.5\n 0.6\n 0.6\n 0.6\n 0.6\n TCO2\n 29\n 29\n 31\n 34\n 33\n Glucose\n 123\n 137\n 128\n 138\n 107\n Other labs: PT / PTT / INR:16.5/78.5/1.5, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:13.1 %,\n Mono:2.7 %, Eos:0.6 %, Lactic Acid:1.1 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:8.7 mg/dL, Mg++:2.4 mg/dL, PO4:4.7 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Arterial Line - 02:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2167-10-06 00:00:00.000","description":"Physician Resident Progress Note","row_id":635984,"text":"Chief Complaint:\n 24 Hour Events:\n EKG - At 11:00 AM\n Started on Warfarin\n Extremely labile pressures over night, trying to wean off Fentanyl and\n use more Haldol.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 0.5 mg/hour\n Heparin Sodium - 1,500 units/hour\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:00 AM\n Haloperidol (Haldol) - 01:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:12 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.6\n Tcurrent: 37.1\nC (98.8\n HR: 100 (56 - 142) bpm\n BP: 98/47(65) {77/40(53) - 164/93(123)} mmHg\n RR: 18 (15 - 24) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 4,228 mL\n 1,123 mL\n PO:\n TF:\n 1,440 mL\n 360 mL\n IVF:\n 978 mL\n 343 mL\n Blood products:\n Total out:\n 6,725 mL\n 780 mL\n Urine:\n 6,725 mL\n 780 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,497 mL\n 343 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 450 (450 - 450) mL\n PS : 8 cmH2O\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 23 cmH2O\n Plateau: 19 cmH2O\n SpO2: 94%\n ABG: 7.50/41/81./29/7\n Ve: 7.2 L/min\n PaO2 / FiO2: 164\n Physical Examination\n General Appearance: Intubated and sedated. Responsive, following\n commands, Overweight / Obese, mild agitation but NAD\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\n deviation\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Respiratory / Chest: (Expansion: Symmetric), CTA anteriorly, decreased\n BS\n Abdominal: Obese, Firm, Non-tender, no rebound, no guarding, + BS, PEG\n in place with dressing C/D/I\n Extremities: No clubbing or cyanosis, 1+ nonpitting edema of b/l hands,\n anasarca\n Skin: no rashes or jaundice\n Lines: r brachioceph ART and L PICC C/D/I\n Labs / Radiology\n 229 K/uL\n 7.9 g/dL\n 107 mg/dL\n 0.6 mg/dL\n 29 mEq/L\n 3.8 mEq/L\n 11 mg/dL\n 109 mEq/L\n 147 mEq/L\n 25.3 %\n 9.6 K/uL\n [image002.jpg]\n 03:55 AM\n 07:19 AM\n 11:24 AM\n 03:18 PM\n 02:47 AM\n 11:01 AM\n 04:40 PM\n 05:08 PM\n 03:44 AM\n 06:04 AM\n WBC\n 8.3\n 11.2\n 9.6\n Hct\n 24.6\n 27.4\n 25.3\n Plt\n 279\n 272\n 229\n Cr\n 0.5\n 0.6\n 0.6\n 0.6\n 0.6\n TCO2\n 29\n 29\n 31\n 34\n 33\n Glucose\n 123\n 137\n 128\n 138\n 107\n Other labs: PT / PTT / INR:16.5/78.5/1.5, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:13.1 %,\n Mono:2.7 %, Eos:0.6 %, Lactic Acid:1.1 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:8.7 mg/dL, Mg++:2.4 mg/dL, PO4:4.7 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA and\n ARDS intubated since the end of now s/p trach and PEG placement.\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation. Stenting\n unlikely to help for trachiomalacia as airways have poor structure\n diffusely. S/P Trach and PEG on . Increased effusion on recent\n CXR.\n - wean FiO2 as tolerated\n - non-con head CT to further characterize pulmonary effusions,\n det potential for thoracentesis\n # Adrenal Insufficency: Hypotension that resolved with steroids,\n returned as they came off and is now improved again. Possible primary\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\n started on .\n - wean per endo recs, decrease to q8 today, likely q12 dosing\n tomorrow\n # Volume overloaded in setting of hypernatremia with TBW deficit.\n - Lasix gtt, continue with goal -1-2 L per day.\n - electrolytes\n - continue tube feeds with free water flushes increase from 250 to 300\n cc q4\n # Sedation: Sedation control remains somewhat poor although fentanyl\n patch and diazpem are likely therapeutic range today. On Versed 2.0,\n Fentanyl 100, Fentanyl patch, Diazepam standing and haldo 2.5-5 mg\n PRN. QTc increased to 480.\n - Wean versed/fentanyl as tolerated, continue diazepam in\n hopes for vent facility placement\n - Increase diazepam to 12mg q4\n - Check ekg for QTc\n if <480, restart haldol and/or increase\n fentanyl patch\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\n coumadin at least until s/p trach.\n - heparin gtt restarted\n - coumadin 5mg G-tube today\n hold coumadin today for possible \n # Constipation\n current regimen of colace and senna, stooled during\n rounds\n - dulcolax PO/PR\n - reassess and increase bowel regimen PRN\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n -f/u full trauma spine eval from OSH to determine need for further back\n imaging in-house (to be done )\n # Nutrition: Tube feeds with free water flushes, tolerating well,\n continue Replete (Full) - 11:20 AM 30 mL/hour\n # Glycemic control: SSI, well controlled\n # Lines L PICC () and R ART ()\n both working well, check\n ABG/VBG today\n if correlate well, d/c art line\n # Ppx: heparin, ranitidine, VAP prevention, colace and senna\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n Code: Full\n Dispo: ICU, being screening for vent facilities\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Arterial Line - 02:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Respiratory ","chartdate":"2167-09-29 00:00:00.000","description":"Respiratory Care Shift Note","row_id":635110,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 11\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Patient remains on ventilatory support, all settings documented on flow\n sheet. Breath sounds diminished throughout, bronchodilators\n administered. A-line placed and ABG\ns drawn. Slow deliberate decrease\n in PEEP as ordered.\n"},{"category":"Nursing","chartdate":"2167-09-20 00:00:00.000","description":"Nursing Progress Note","row_id":634170,"text":"Obese woman s/p t spine injury tx from Med for failure to wean\n from mech ventilation and evaluation for stent for\n tracheobronchomalacia.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Pt cont w/ low grade fever.\n Action:\n Given tyelenol q6 h prn, pt pan cultured. PICC line and foley d/c\n (new foley placed). IV antibiotics started.\n Response:\n Fever slightly improved to 99.\n Plan:\n Cont w/ q 6 hr tyelenol prn, closely monitor temp and f/u w/ cultures.\n Fracture, other\n Assessment:\n Pt w/ T5-T8 compression fracture.\n Action:\n Pt on log-roll precautions, back brace at bedside- to be used when pt\n is OOB.\n Response:\n Pt denies pain when asked.\n Plan:\n Cont on log roll precautions, Neuro- consult ordered to clarify\n order for brace.\n Anemia, other\n Assessment:\n HCT 25 from 30.0. No active bleeding noted.\n Action:\n Cont to check HCT and s/s of bleeding.\n Response:\n No action taken.\n Plan:\n Type & Screen to be collected. Cont to monitor HCT, guiac all stools.\n Hypernatremia (high sodium)\n Assessment:\n NA level 150-> 147. No seizure activity.\n Action:\n Free H2O boluses q 4hrs were started, but currently on hold d/t high\n residuals. Pt on D5W for 1L .\n Response:\n NA level slightly improved.\n Plan:\n Cont w/ free-water boluses as tolerated, cont to monitor lytes, bolus\n w/ LR prn.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS rhonchorous throughout, diminished to bilateral bases, deep sxn\n thick tan/bloody secretions.\n Action:\n Given MDIs, cont to be orally intubated on A/C, mini-BAL performed by\n RT and sample sent to lab. Increased sedation for adequate\n ventilation.\n Response:\n Cont to be orally intubated and sedated.\n Plan:\n Consult w/ IP for eval for stent, wean vent as tolerated\n"},{"category":"Nursing","chartdate":"2167-10-04 00:00:00.000","description":"Nursing Progress Note","row_id":635677,"text":"55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\n Now with prolonged hospital course c/b by PNA with high PEEP\n requirement, anxiety, RUE DVT on heparin qtt.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt on Vent settings AC 55%/18 X 400/+10 with no overbreathing of\n set RR. O2 sat 92-98%. Lung snds clear, diminished in bases. Pt sxn\n for small-moderate amts thick white secretions. Trach site with small\n amt serosang drainage.\n Action:\n Cont same vent settings\n Response:\n Pt doesn\nt over breath on the vent and never desat.\n Plan:\n Wean from vent as she tolerates,monitor sats,ABG?.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt rec\nd with Heparin qtt off post trach/PEG yesterday.\n Action:\n Heparin restarted @ 1100 @ previous rate 1700units/hr.\n Response:\n PTT @ 1630 58.5. Heparin inc\nd to 1900units/hr per sliding scale @\n 1715.\n Plan:\n Repeat PTT @ 2300.\n Alteration in Nutrition\n Assessment:\n Rec\nd pt NPO post OR yesterday. Abd obese/distended with + BS. No BM\n today.\n Action:\n Restarted TF Replete with fiber @ 1000 per surgical team @ 10ml/hr, as\n well as FWB of 250ml Q4hrs for elevated Na.\n Response:\n Residual @ 1600 140ml of TF/water/yellow bilious. TF stopped and FWB\n held.\n Plan:\n Resume TF @ 1830. Cont to monitor residuals, holding TF if >100ml.\n"},{"category":"Respiratory ","chartdate":"2167-10-04 00:00:00.000","description":"Respiratory Care Shift Note","row_id":635682,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 16\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 7.0mm\n PMV: No\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Pt was trached yesterday with #7 Portex. Trach site appears clean,\n little oozing around site. Suctioned at beginning of shift for blood\n tinged thick tan sputum, less blood tinged later in shift. Plan is to\n continue with weaning attempts.\n"},{"category":"Respiratory ","chartdate":"2167-10-04 00:00:00.000","description":"Respiratory Care Shift Note","row_id":635771,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 16\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Standard, Cuffed, Inner Cannula\n Manufacturer: Portex\n Size: 7.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Copious\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern:\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"},{"category":"Respiratory ","chartdate":"2167-10-06 00:00:00.000","description":"Respiratory Care Shift Note","row_id":636070,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 18\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Standard, Extra Length\n Manufacturer: Portex\n Size: 7.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: pt weaned to PSV tolerated well for msot of the shift\n aroun d 1600 vt began to drop and rr increased so ips increased to 12\n with improved vt and rr\n Assessment of breathing comfort: No claim of dyspnea)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Reduce PEEP as tolerated\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"},{"category":"Nursing","chartdate":"2167-09-30 00:00:00.000","description":"Nursing Progress Note","row_id":635159,"text":" Problem - Description In Comments\n Assessment:\n Action:\n Response:\n Plan:\n Hypernatremia (high sodium)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Action:\n Response:\n Plan:\n Bradycardia\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2167-09-30 00:00:00.000","description":"Nursing Progress Note","row_id":635160,"text":" Problem - Description In Comments\n Assessment:\n Action:\n Response:\n Plan:\n Hypernatremia (high sodium)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Action:\n Response:\n Plan:\n Bradycardia\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Physician ","chartdate":"2167-10-01 00:00:00.000","description":"Physician Resident Progress Note","row_id":635302,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n Thorasics will take to OR if 24 hours stable on PEEP < 10, was on PEEP\n of 8 since AM\n Weaned off midazolam drip\n NPO past midnight for possible OR tomorrow (attendings are in clinic,\n however)\n Endocrine recs: Continue steroids until stable, then taper\n ABG for low O2 sat, looked good, held on FiO2 of 50\n Broncoscopy (11:30AM) : Diffuse stuctural instability c/w\n tracheomalacia\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Furosemide (Lasix) - 3 mg/hour\n Fentanyl - 100 mcg/hour\n Other ICU medications:\n Haloperidol (Haldol) - 11:47 PM\n Midazolam (Versed) - 02:45 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.2\nC (97.2\n HR: 104 (46 - 134) bpm\n BP: 134/69(98) {88/41(57) - 143/76(103)} mmHg\n RR: 18 (18 - 27) insp/min\n SpO2: 91%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 4,162 mL\n 139 mL\n PO:\n TF:\n 1,448 mL\n 1 mL\n IVF:\n 1,003 mL\n 138 mL\n Blood products:\n Total out:\n 1,615 mL\n 640 mL\n Urine:\n 1,615 mL\n 640 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,547 mL\n -501 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n PIP: 35 cmH2O\n Plateau: 25 cmH2O\n Compliance: 24.7 cmH2O/mL\n SpO2: 91%\n ABG: 7.42/47/86./29/4\n Ve: 6.8 L/min\n PaO2 / FiO2: 174\n Physical Examination\n General Appearance: Easily agitated, appears uncomfortable, Overweight\n / Obese, opens eyes but no purposeful movement\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\n deviation\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Respiratory / Chest: (Expansion: Symmetric), referred breath sounds\n from ETT\n Abdominal: No(t) Soft, Non-tender, Few Bowel sounds present, Distended\n Extremities: No clubbing or cyanosis, 3+ nonpitting edema of b/l hands,\n anasarca\n Skin: no rashes or jaundice\n Neuro: diffusely hyperreflexic with LE clonus\n Lines: r brachioceph ART and L PICC C/D/I\n Labs / Radiology\n 280 K/uL\n 8.0 g/dL\n 136 mg/dL\n 0.5 mg/dL\n 29 mEq/L\n 4.0 mEq/L\n 11 mg/dL\n 105 mEq/L\n 143 mEq/L\n 25.9 %\n 8.6 K/uL\n [image002.jpg]\n 02:44 PM\n 03:33 PM\n 07:26 PM\n 07:46 PM\n 02:04 AM\n 02:18 AM\n 01:27 PM\n 03:06 PM\n 10:04 PM\n 03:00 AM\n WBC\n 8.4\n 11.8\n 8.6\n Hct\n 23.0\n 28.1\n 29.9\n 25.9\n Plt\n \n Cr\n 0.5\n 0.6\n 0.5\n TCO2\n 33\n 31\n 33\n 32\n 32\n Glucose\n 168\n 176\n 136\n Other labs: PT / PTT / INR:13.2/26.6/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:89.7 %, Lymph:8.7 %, Mono:1.1\n %, Eos:0.4 %, Lactic Acid:0.9 mmol/L, Albumin:2.4 g/dL, LDH:204 IU/L,\n Ca++:8.4 mg/dL, Mg++:2.4 mg/dL, PO4:4.1 mg/dL\n Fluid analysis / Other labs: BAL fluid:\n WBC: 0\n RBC: 0\n Polys: 82\n Lymphs: 3\n Monos: 6\n Eos: 2\n Macro: 7\n Imaging: ECHOCARDIOGRAM: The left atrium is elongated. No atrial\n septal defect is seen by 2D or color Doppler. The right atrial pressure\n is indeterminate. Left ventricular wall thickness, cavity size and\n regional/global systolic function are normal (LVEF >55%). There is no\n ventricular septal defect. Right ventricular chamber size and free wall\n motion are normal. The aortic valve leaflets (3) are mildly thickened\n but aortic stenosis is not present. No aortic regurgitation is seen.\n The mitral valve appears structurally normal with trivial mitral\n regurgitation. There is no mitral valve prolapse. The tricuspid valve\n leaflets are mildly thickened. There is moderate pulmonary artery\n systolic hypertension. There is no pericardial effusion.\n Compared with the prior study (images reviewed) of , no\n change.\n Microbiology: BRONCHIAL LAVAGE:\n GRAM STAIN (Final ):\n 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.\n NO MICROORGANISMS SEEN.\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA and\n ARDS intubated since the end of .\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation.\n Transferred here for airway stenting. Will need bronch eval when\n improved.\n - Thoracics will do trach and PEG once stable on PEEPs around 10.\n Re-c/s today.\n - wean PEEP as tolerated\n # # Adrenal Insufficency: Minimal response to stim test again.\n - hydrocort and fludrocort (day 1 = )\n - endocrine c/s for further elucidation of etiology\n # Hypotension: Likely adrenal insufficiency. Goal map > 60.\n - hydrocortisol and fludrocortisone as above\n - restart levophed if necessary to maintain MAP > 60\n # Volume overloaded in setting of hypernatremia (? Relationship to\n adrenal insufficiency), TBW deficit 2.6L.\n - goal even to -500cc I/Os today\n - continue FW in TF at 250 cc q4hrs\n - lasix drip (1-5mg/hr) when MAP > 60\n # Hyperreflexia - ? meds vs central pathology. Unlikely to be \n intracranial hemorrhage as patient is diffusely hyperreflexic.\n Possible relationship to endocrine pathology?\n - consider head CT in setting of heparin gtt\n - monitor\n # Sedation: Sedation control remains somewhat poor although fentanyl\n patch and diazpem are likely starting increase to therapeutic range\n today. On Versed 1.5, Fentanyl 175, Fentanyl patch, Diazepam standing\n and haldo 2.5-5 mg PRN. QTc stable at .44.\n - Wean versed/fentanyl as tolerated, continue diazepam and prn\n haldol\n - Recheck EKG today\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\n coumadin at least until s/p trach.\n - hold heparin gtt when anticipate trach/peg\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n # FEN/GI: Tube feeds @ goal.\n DVT: Treatment dose heparin\n Ulcer: Ranitidine\n VAP: Prevention per routine\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Arterial Line - 02:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2167-09-20 00:00:00.000","description":"Physician Resident Progress Note","row_id":634155,"text":"Chief Complaint:\n 24 Hour Events:\n -cultured for fever to 102.7 at 4:00 am\n -Patient developed hypotension to 102.7 at 6:15 a.m. BP responded well\n to LR 500 cc. However, urine output remained low despite bolus and\n additional LR 500 cc bolus. Antibiotics initiated (levofloxacin,\n aztreonam, vancomycin, metronidazole).\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.3\nC (102.7\n Tcurrent: 39.3\nC (102.7\n HR: 89 (72 - 97) bpm\n BP: 96/41(55) {96/41(55) - 154/71(103)} mmHg\n RR: 12 (12 - 18) insp/min\n SpO2: 95%\n Total In:\n 10 mL\n 232 mL\n PO:\n TF:\n IVF:\n 10 mL\n 232 mL\n Blood products:\n Total out:\n 425 mL\n 570 mL\n Urine:\n 425 mL\n 570 mL\n NG:\n Stool:\n Drains:\n Balance:\n -416 mL\n -338 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 32 cmH2O\n SpO2: 95%\n ABG: 7.42/47/61/30/4\n Ve: 8 L/min\n PaO2 / FiO2: 102\n Physical Examination\n Gen: Appears uncomfortable on vent.\n HEENT: Anicteric. Pupils 3 mm non-reactive bilaterally.\n Resp: Symmetric expansion. Vesicular sounds throughout. Inspiratory\n and expiratory tracheal sounds (?related to ET tube).\n CV: Cannot see jugular veins due to neck size. RRR. Normal s1 and\n s2. No M/G/R.\n Abd: Quiet. Distended. Non-tender.\n Ext: Edema in RUE, especially right hand. Mildly increased warmth of\n RUE compared with LUE.\n Peripheral vascular: Radial pulses 2+ bilaterally.\n Neuro: Pupils as above. Moving all 4 extremities.\n Labs / Radiology\n 333 K/uL\n 9.7 g/dL\n 103 mg/dL\n 0.6 mg/dL\n 30 mEq/L\n 3.8 mEq/L\n 6 mg/dL\n 109 mEq/L\n 150 mEq/L\n 30.7 %\n 9.7 K/uL\n [image002.jpg]\n 11:54 PM\n 01:00 AM\n WBC\n 9.7\n Hct\n 30.7\n Plt\n 333\n Cr\n 0.6\n TCO2\n 32\n Glucose\n 103\n Other labs: PT / PTT / INR:13.8/22.4/1.2, ALT / AST:30/19, Alk Phos / T\n Bili:149/0.7, Differential-Neuts:76.9 %, Lymph:17.3 %, Mono:3.0 %,\n Eos:2.5 %, Albumin:3.0 g/dL, LDH:222 IU/L, Ca++:8.6 mg/dL, Mg++:2.1\n mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n A/P: 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture\n # Respiratory failure: initially likely multifactorial including\n bronchspasm, hypoventilation from narcotics, and potential aspiration.\n prior evaluation negative for PE. still with significant A-a gradient.\n cxr appears under penetrated with small lung fields and potential\n effusion on right. potentially from pneumonia given patient\ns fever.\n - daily CXR\n - will hold on CT chest or airway pending IP consult\n - IP consult\n - vent settings: AC 500 x 12 PEEP 10, FIO2 60%\n - sedation: fentanyl and midazolam infusions\n - trial of diuresis when able\n # Fever: Differential diagnosis includes infection cause (VAP, infected\n PICC line, UTI) or DVT. Cultures sent. Will treat with empiric\n antibiotics. Tylenol PRN for fever.\n - Flagyl, aztreonam, vancomycin, levofloxacin for coverage of gram\n positives, gram negatives, anaerobes, MRSA, and MDR pathogens.\n - f/u blood and urine cultures\n - Once further IV access is established, remove PICC and culture tip.\n # Hypotension: Differential diagnosis includes hypovolemia, sepsis, and\n cardiogenic. Sepsis likely given fever, although hypovolemia remains\n in differential given falling hematocrit. BP responded well to fluid\n boluses but urine output low.\n - Monitor BP and urine output.\n - Consider additional fluid boluses.\n - If patient\ns hypotension becomes refractory to fluid boluses, would\n place central line for CVP monitoring and initiate pressors.\n # Spine fracture: neurologically intact distal to the lesion. prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - monitor distal neurologic function\n - cto brace x3 months unless supine in bed\n # Anemia: admission to MMC was ~40 now down to 30% w/o sign of active\n GI bleed or other source of blood loss. likely related to crystalloid\n administration, anemia of inflammation, chronic phlebotomy. given bili\n and LDH normal would be unlikely for hemolysis.\n - trend Hct\n - guaiac stools\n Hypernatremia: most likely related to inadequate free water repletion.\n free water defecit ~3L.\n - replete via OGT primarily\n - D5W x1 L\n ICU Care\n Nutrition:\n Comments: tube feed with free water\n nutrition consult\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 10:30 PM\n 18 Gauge - 10:30 PM\n 20 Gauge - 01:36 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Family meeting held , ICU consent signed Comments: \n (brother) \n (boyfriend/POA) \n Code status: Full code\n Disposition: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 10:30 PM\n 20 Gauge - 01:36 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Physician ","chartdate":"2167-09-20 00:00:00.000","description":"Physician Resident Progress Note","row_id":634156,"text":"Chief Complaint:\n 24 Hour Events:\n -cultured for fever to 102.7 at 4:00 am\n -Patient developed hypotension to 102.7 at 6:15 a.m. BP responded well\n to LR 500 cc. However, urine output remained low despite bolus and\n additional LR 500 cc bolus. Antibiotics initiated (levofloxacin,\n aztreonam, vancomycin, metronidazole).\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.3\nC (102.7\n Tcurrent: 39.3\nC (102.7\n HR: 89 (72 - 97) bpm\n BP: 96/41(55) {96/41(55) - 154/71(103)} mmHg\n RR: 12 (12 - 18) insp/min\n SpO2: 95%\n Total In:\n 10 mL\n 232 mL\n PO:\n TF:\n IVF:\n 10 mL\n 232 mL\n Blood products:\n Total out:\n 425 mL\n 570 mL\n Urine:\n 425 mL\n 570 mL\n NG:\n Stool:\n Drains:\n Balance:\n -416 mL\n -338 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 32 cmH2O\n SpO2: 95%\n ABG: 7.42/47/61/30/4\n Ve: 8 L/min\n PaO2 / FiO2: 102\n Physical Examination\n Gen: Appears uncomfortable on vent.\n HEENT: Anicteric. Pupils 3 mm non-reactive bilaterally.\n Resp: Symmetric expansion. Vesicular sounds throughout. Inspiratory\n and expiratory tracheal sounds (?related to ET tube).\n CV: Cannot see jugular veins due to neck size. RRR. Normal s1 and\n s2. No M/G/R.\n Abd: Quiet. Distended. Non-tender.\n Ext: Edema in RUE, especially right hand. Mildly increased warmth of\n RUE compared with LUE.\n Peripheral vascular: Radial pulses 2+ bilaterally.\n Neuro: Pupils as above. Moving all 4 extremities.\n Labs / Radiology\n 333 K/uL\n 9.7 g/dL\n 103 mg/dL\n 0.6 mg/dL\n 30 mEq/L\n 3.8 mEq/L\n 6 mg/dL\n 109 mEq/L\n 150 mEq/L\n 30.7 %\n 9.7 K/uL\n [image002.jpg]\n 11:54 PM\n 01:00 AM\n WBC\n 9.7\n Hct\n 30.7\n Plt\n 333\n Cr\n 0.6\n TCO2\n 32\n Glucose\n 103\n Other labs: PT / PTT / INR:13.8/22.4/1.2, ALT / AST:30/19, Alk Phos / T\n Bili:149/0.7, Differential-Neuts:76.9 %, Lymph:17.3 %, Mono:3.0 %,\n Eos:2.5 %, Albumin:3.0 g/dL, LDH:222 IU/L, Ca++:8.6 mg/dL, Mg++:2.1\n mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n A/P: 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture\n # Respiratory failure: initially likely multifactorial including\n bronchspasm, hypoventilation from narcotics, and potential aspiration.\n prior evaluation negative for PE. still with significant A-a gradient.\n cxr appears under penetrated with small lung fields and potential\n effusion on right. potentially from pneumonia given patient\ns fever.\n - daily CXR\n - will hold on CT chest or airway pending IP consult\n - IP consult\n - vent settings: AC 500 x 12 PEEP 10, FIO2 60%\n - sedation: fentanyl and midazolam infusions\n - ipratropium and atrovent nebs\n # Fever: Differential diagnosis includes infection cause (VAP, infected\n PICC line, UTI) or DVT. Cultures sent. Will treat with empiric\n antibiotics. Tylenol PRN for fever.\n - Flagyl, aztreonam, vancomycin, levofloxacin for coverage of gram\n positives, gram negatives, anaerobes, MRSA, and MDR pathogens.\n - f/u blood, urine, and sputum cultures\n - BAL\n - Once further IV access is established, remove PICC and culture tip.\n # Hypotension: Differential diagnosis includes hypovolemia, sepsis, and\n cardiogenic. Sepsis likely given fever, although hypovolemia remains\n in differential given falling hematocrit. BP responded well to fluid\n boluses but urine output low.\n - Monitor BP and urine output.\n - Consider additional fluid boluses.\n - If patient\ns hypotension becomes refractory to fluid boluses, would\n place central line for CVP monitoring and initiate pressors.\n # Anemia: On admission to Medical Center, Hct was ~40, now down\n to 30 and then 25 w/o sign of active GI bleed or other source of blood\n loss. be related to fluid administration, phlebotomy, anemia of\n inflammation, active bleed still considered in differential.\n -Follow Hct\n -guaiac stools\n # Spine fracture: neurologically intact distal to the lesion. prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - monitor distal neurologic function\n - cto brace x3 months unless supine in bed\n - consult neurosurgery for further recs\n # Anemia: admission to MMC was ~40 now down to 30% w/o sign of active\n GI bleed or other source of blood loss. likely related to crystalloid\n administration, anemia of inflammation, chronic phlebotomy. given bili\n and LDH normal would be unlikely for hemolysis.\n - trend Hct\n - guaiac stools\n - insert additional PIV\n Hypernatremia: Na improved to 147 (from 150) today, most likely\n related to inadequate free water repletion. Free water defecit ~2 L.\n - replete via OGT primarily\n - D5W x1 L\n ICU Care\n Nutrition:\n Comments: tube feed with free water\n nutrition consult\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 10:30 PM\n 18 Gauge - 10:30 PM\n 20 Gauge - 01:36 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Family meeting held , ICU consent signed Comments: \n (brother) \n (boyfriend/POA) \n Code status: Full code\n Disposition: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 10:30 PM\n 20 Gauge - 01:36 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Physician ","chartdate":"2167-09-20 00:00:00.000","description":"Physician Resident Progress Note","row_id":634157,"text":"Chief Complaint:\n 24 Hour Events:\n -cultured for fever to 102.7 at 4:00 am\n -Patient developed hypotension to 102.7 at 6:15 a.m. BP responded well\n to LR 500 cc. However, urine output remained low despite bolus and\n additional LR 500 cc bolus. Antibiotics initiated (levofloxacin,\n aztreonam, vancomycin, metronidazole).\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.3\nC (102.7\n Tcurrent: 39.3\nC (102.7\n HR: 89 (72 - 97) bpm\n BP: 96/41(55) {96/41(55) - 154/71(103)} mmHg\n RR: 12 (12 - 18) insp/min\n SpO2: 95%\n Total In:\n 10 mL\n 232 mL\n PO:\n TF:\n IVF:\n 10 mL\n 232 mL\n Blood products:\n Total out:\n 425 mL\n 570 mL\n Urine:\n 425 mL\n 570 mL\n NG:\n Stool:\n Drains:\n Balance:\n -416 mL\n -338 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 32 cmH2O\n SpO2: 95%\n ABG: 7.42/47/61/30/4\n Ve: 8 L/min\n PaO2 / FiO2: 102\n Physical Examination\n Gen: Appears uncomfortable on vent.\n HEENT: Anicteric. Pupils 3 mm non-reactive bilaterally.\n Resp: Symmetric expansion. Vesicular sounds throughout. Inspiratory\n and expiratory tracheal sounds (?related to ET tube).\n CV: Cannot see jugular veins due to neck size. RRR. Normal s1 and\n s2. No M/G/R.\n Abd: Quiet. Distended. Non-tender.\n Ext: Edema in RUE, especially right hand. Mildly increased warmth of\n RUE compared with LUE.\n Peripheral vascular: Radial pulses 2+ bilaterally.\n Neuro: Pupils as above. Moving all 4 extremities.\n Labs / Radiology\n 333 K/uL\n 9.7 g/dL\n 103 mg/dL\n 0.6 mg/dL\n 30 mEq/L\n 3.8 mEq/L\n 6 mg/dL\n 109 mEq/L\n 150 mEq/L\n 30.7 %\n 9.7 K/uL\n [image002.jpg]\n 11:54 PM\n 01:00 AM\n WBC\n 9.7\n Hct\n 30.7\n Plt\n 333\n Cr\n 0.6\n TCO2\n 32\n Glucose\n 103\n Other labs: PT / PTT / INR:13.8/22.4/1.2, ALT / AST:30/19, Alk Phos / T\n Bili:149/0.7, Differential-Neuts:76.9 %, Lymph:17.3 %, Mono:3.0 %,\n Eos:2.5 %, Albumin:3.0 g/dL, LDH:222 IU/L, Ca++:8.6 mg/dL, Mg++:2.1\n mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n A/P: 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture\n # Respiratory failure: initially likely multifactorial including\n bronchspasm, hypoventilation from narcotics, and potential aspiration.\n prior evaluation negative for PE. still with significant A-a gradient.\n cxr appears under penetrated with small lung fields and potential\n effusion on right. potentially from pneumonia given patient\ns fever.\n - daily CXR\n - will hold on CT chest or airway pending IP consult\n - IP consult\n - vent settings: AC 500 x 12 PEEP 10, FIO2 60%\n - sedation: fentanyl and midazolam infusions\n - ipratropium and atrovent nebs\n # Fever: Differential diagnosis includes infection cause (VAP, infected\n PICC line, UTI) or DVT. Cultures sent. Will treat with empiric\n antibiotics. Tylenol PRN for fever.\n - Flagyl, aztreonam, vancomycin, levofloxacin for coverage of gram\n positives, gram negatives, anaerobes, MRSA, and MDR pathogens.\n - f/u blood, urine, and sputum cultures\n - BAL\n - Once further IV access is established, remove PICC and culture tip.\n # Hypotension: Differential diagnosis includes hypovolemia, sepsis, and\n cardiogenic. Sepsis likely given fever, although hypovolemia remains\n in differential given falling hematocrit. BP responded well to fluid\n boluses but urine output low.\n - Monitor BP and urine output.\n - Consider additional fluid boluses.\n - If patient\ns hypotension becomes refractory to fluid boluses, would\n place central line for CVP monitoring and initiate pressors.\n # Anemia: On admission to Medical Center, Hct was ~40, now down\n to 30 and then 25 w/o sign of active GI bleed or other source of blood\n loss. be related to fluid administration, phlebotomy, anemia of\n inflammation, active bleed still considered in differential. given\n bili and LDH normal would be unlikely for hemolysis.\n - trend Hct\n -Follow Hct\n -guaiac stools\n # Spine fracture: neurologically intact distal to the lesion. prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - monitor distal neurologic function\n - cto brace x3 months unless supine in bed\n - consult neurosurgery for further recs\n # Hypernatremia: Na improved to 147 (from 150) today, most likely\n related to inadequate free water repletion. Free water defecit ~2 L.\n - replete via OGT primarily\n - D5W x1 L\n # Right upper extremity edema: Could be caused by DVT related to PICC.\n - d/c PICC\n - RUE U/S\n ICU Care\n Nutrition:\n Comments: tube feed with free water\n nutrition consult\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 10:30 PM\n 18 Gauge - 10:30 PM\n 20 Gauge - 01:36 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Family meeting held , ICU consent signed Comments: \n (brother) \n (boyfriend/POA) \n Code status: Full code\n Disposition: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 10:30 PM\n 20 Gauge - 01:36 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Physician ","chartdate":"2167-09-20 00:00:00.000","description":"Physician Resident Progress Note","row_id":634158,"text":"Chief Complaint:\n 24 Hour Events:\n -cultured for fever to 102.7 at 4:00 am\n -Patient developed hypotension to 83/38 at 6:15 a.m. BP responded well\n to LR 500 cc. However, urine output remained low despite bolus and\n additional LR 500 cc bolus. Antibiotics initiated (levofloxacin,\n aztreonam, vancomycin, metronidazole).\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.3\nC (102.7\n Tcurrent: 39.3\nC (102.7\n HR: 89 (72 - 97) bpm\n BP: 96/41(55) {96/41(55) - 154/71(103)} mmHg\n RR: 12 (12 - 18) insp/min\n SpO2: 95%\n Total In:\n 10 mL\n 232 mL\n PO:\n TF:\n IVF:\n 10 mL\n 232 mL\n Blood products:\n Total out:\n 425 mL\n 570 mL\n Urine:\n 425 mL\n 570 mL\n NG:\n Stool:\n Drains:\n Balance:\n -416 mL\n -338 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 32 cmH2O\n SpO2: 95%\n ABG: 7.42/47/61/30/4\n Ve: 8 L/min\n PaO2 / FiO2: 102\n Physical Examination\n Gen: Appears uncomfortable on vent.\n HEENT: Anicteric. Pupils 3 mm non-reactive bilaterally.\n Resp: Symmetric expansion. Vesicular sounds throughout. Inspiratory\n and expiratory tracheal sounds (?related to ET tube).\n CV: Cannot see jugular veins due to neck size. RRR. Normal s1 and\n s2. No M/G/R.\n Abd: Quiet. Distended. Non-tender.\n Ext: Edema in RUE, especially right hand. Mildly increased warmth of\n RUE compared with LUE.\n Peripheral vascular: Radial pulses 2+ bilaterally.\n Neuro: Pupils as above. Moving all 4 extremities.\n Labs / Radiology\n 333 K/uL\n 9.7 g/dL\n 103 mg/dL\n 0.6 mg/dL\n 30 mEq/L\n 3.8 mEq/L\n 6 mg/dL\n 109 mEq/L\n 150 mEq/L\n 30.7 %\n 9.7 K/uL\n [image002.jpg]\n 11:54 PM\n 01:00 AM\n WBC\n 9.7\n Hct\n 30.7\n Plt\n 333\n Cr\n 0.6\n TCO2\n 32\n Glucose\n 103\n Other labs: PT / PTT / INR:13.8/22.4/1.2, ALT / AST:30/19, Alk Phos / T\n Bili:149/0.7, Differential-Neuts:76.9 %, Lymph:17.3 %, Mono:3.0 %,\n Eos:2.5 %, Albumin:3.0 g/dL, LDH:222 IU/L, Ca++:8.6 mg/dL, Mg++:2.1\n mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n A/P: 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture\n # Respiratory failure: initially likely multifactorial including\n bronchspasm, hypoventilation from narcotics, and potential aspiration.\n prior evaluation negative for PE. still with significant A-a gradient.\n cxr appears under penetrated with small lung fields and potential\n effusion on right. potentially from pneumonia given patient\ns fever.\n - daily CXR\n - will hold on CT chest or airway pending IP consult\n - IP consult\n - vent settings: AC 500 x 12 PEEP 10, FIO2 60%\n - sedation: fentanyl and midazolam infusions\n - ipratropium and atrovent nebs\n # Fever: Differential diagnosis includes infection cause (VAP, infected\n PICC line, UTI) or DVT. Cultures sent. Will treat with empiric\n antibiotics. Tylenol PRN for fever.\n - Flagyl, aztreonam, vancomycin, levofloxacin for coverage of gram\n positives, gram negatives, anaerobes, MRSA, and MDR pathogens.\n - f/u blood, urine, and sputum cultures\n - BAL\n - Once further IV access is established, remove PICC and culture tip.\n # Hypotension: Differential diagnosis includes hypovolemia, sepsis, and\n cardiogenic. Sepsis likely given fever, although hypovolemia remains\n in differential given falling hematocrit. BP responded well to fluid\n boluses but urine output low.\n - Monitor BP and urine output.\n - Consider additional fluid boluses.\n - If patient\ns hypotension becomes refractory to fluid boluses, would\n place central line for CVP monitoring and initiate pressors.\n # Anemia: On admission to Medical Center, Hct was ~40, now down\n to 30 and then 25 w/o sign of active GI bleed or other source of blood\n loss. be related to fluid administration, phlebotomy, anemia of\n inflammation, active bleed still considered in differential. given\n bili and LDH normal would be unlikely for hemolysis.\n - trend Hct\n -Follow Hct\n -guaiac stools\n # Spine fracture: neurologically intact distal to the lesion. prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - monitor distal neurologic function\n - cto brace x3 months unless supine in bed\n - consult neurosurgery for further recs\n # Hypernatremia: Na improved to 147 (from 150) today, most likely\n related to inadequate free water repletion. Free water defecit ~2 L.\n - replete via OGT primarily\n - D5W x1 L\n # Right upper extremity edema: Could be caused by DVT related to PICC.\n - d/c PICC\n - RUE U/S\n ICU Care\n Nutrition:\n Comments: tube feed with free water\n nutrition consult\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 10:30 PM\n 18 Gauge - 10:30 PM\n 20 Gauge - 01:36 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Family meeting held , ICU consent signed Comments: \n (brother) \n (boyfriend/POA) \n Code status: Full code\n Disposition: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 10:30 PM\n 20 Gauge - 01:36 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Physician ","chartdate":"2167-09-20 00:00:00.000","description":"Physician Resident Progress Note","row_id":634159,"text":"Chief Complaint:\n 24 Hour Events:\n -cultured for fever to 102.7 at 4:00 am\n -Patient developed hypotension to 83/38 at 6:15 a.m. BP responded well\n to LR 500 cc. However, urine output remained low despite bolus and\n additional LR 500 cc bolus. Antibiotics initiated (levofloxacin,\n aztreonam, vancomycin, metronidazole).\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.3\nC (102.7\n Tcurrent: 39.3\nC (102.7\n HR: 89 (72 - 97) bpm\n BP: 96/41(55) {96/41(55) - 154/71(103)} mmHg\n RR: 12 (12 - 18) insp/min\n SpO2: 95%\n Total In:\n 10 mL\n 232 mL\n PO:\n TF:\n IVF:\n 10 mL\n 232 mL\n Blood products:\n Total out:\n 425 mL\n 570 mL\n Urine:\n 425 mL\n 570 mL\n NG:\n Stool:\n Drains:\n Balance:\n -416 mL\n -338 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 32 cmH2O\n SpO2: 95%\n ABG: 7.42/47/61/30/4\n Ve: 8 L/min\n PaO2 / FiO2: 102\n Physical Examination\n Gen: Appears uncomfortable on vent.\n HEENT: Anicteric. Pupils 3 mm non-reactive bilaterally.\n Resp: Symmetric expansion. Vesicular sounds throughout. Inspiratory\n and expiratory tracheal sounds (?related to ET tube).\n CV: Cannot see jugular veins due to neck size. RRR. Normal s1 and\n s2. No M/G/R.\n Abd: Quiet. Distended. Non-tender.\n Ext: Edema in RUE, especially right hand. Mildly increased warmth of\n RUE compared with LUE.\n Peripheral vascular: Radial pulses 2+ bilaterally.\n Neuro: Pupils as above. Moving all 4 extremities.\n Labs / Radiology\n 333 K/uL\n 9.7 g/dL\n 103 mg/dL\n 0.6 mg/dL\n 30 mEq/L\n 3.8 mEq/L\n 6 mg/dL\n 109 mEq/L\n 150 mEq/L\n 30.7 %\n 9.7 K/uL\n [image002.jpg]\n 11:54 PM\n 01:00 AM\n WBC\n 9.7\n Hct\n 30.7\n Plt\n 333\n Cr\n 0.6\n TCO2\n 32\n Glucose\n 103\n Other labs: PT / PTT / INR:13.8/22.4/1.2, ALT / AST:30/19, Alk Phos / T\n Bili:149/0.7, Differential-Neuts:76.9 %, Lymph:17.3 %, Mono:3.0 %,\n Eos:2.5 %, Albumin:3.0 g/dL, LDH:222 IU/L, Ca++:8.6 mg/dL, Mg++:2.1\n mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n A/P: 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture\n # Respiratory failure: initially likely multifactorial including\n bronchspasm, hypoventilation from narcotics, and potential aspiration.\n prior evaluation negative for PE. still with significant A-a gradient.\n cxr appears under penetrated with small lung fields and potential\n effusion on right. potentially from pneumonia given patient\ns fever.\n - daily CXR\n - will hold on CT chest or airway pending IP consult\n - IP consult\n - vent settings: AC 500 x 12 PEEP 10, FIO2 60%\n - sedation: fentanyl and midazolam infusions\n - ipratropium and atrovent nebs\n # Fever: Differential diagnosis includes infection cause (VAP, infected\n PICC line, UTI) or DVT. Cultures sent. Will treat with empiric\n antibiotics. Tylenol PRN for fever.\n - Flagyl, aztreonam, vancomycin, levofloxacin for coverage of gram\n positives, gram negatives, anaerobes, MRSA, and MDR pathogens.\n - f/u blood, urine, and sputum cultures\n - mini-BAL\n - Once further IV access is established, remove PICC and culture tip.\n # Hypotension: Differential diagnosis includes hypovolemia, sepsis, and\n cardiogenic. Sepsis likely given fever, although hypovolemia remains\n in differential given falling hematocrit. BP responded well to fluid\n boluses but urine output low.\n - Monitor BP and urine output.\n - Consider additional fluid boluses.\n - If patient\ns hypotension becomes refractory to fluid boluses, would\n place central line for CVP monitoring and initiate pressors.\n # Anemia: On admission to Medical Center, Hct was ~40, now down\n to 30 and then 25 w/o sign of active GI bleed or other source of blood\n loss. be related to fluid administration, phlebotomy, anemia of\n inflammation, active bleed still considered in differential. given\n bili and LDH normal would be unlikely for hemolysis.\n - trend Hct\n -Follow Hct\n -guaiac stools\n # Spine fracture: neurologically intact distal to the lesion. prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - monitor distal neurologic function\n - cto brace x3 months unless supine in bed\n - consult neurosurgery for further recs\n # Hypernatremia: Na improved to 147 (from 150) today, most likely\n related to inadequate free water repletion. Free water defecit ~2 L.\n - replete via OGT primarily\n - D5W x1 L\n # Right upper extremity edema: Could be caused by DVT related to PICC.\n - d/c PICC\n - RUE U/S\n ICU Care\n Nutrition:\n Comments: tube feed with free water\n nutrition consult\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 10:30 PM\n 18 Gauge - 10:30 PM\n 20 Gauge - 01:36 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Family meeting held , ICU consent signed Comments: \n (brother) \n (boyfriend/POA) \n Code status: Full code\n Disposition: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 10:30 PM\n 20 Gauge - 01:36 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n This note was written by , HMS IV, to be cosigned by the\n on-call MICU resident. I had to have the on-call intern sign me in to\n MetaVision because I do not yet have access to edit.\n"},{"category":"Nursing","chartdate":"2167-09-20 00:00:00.000","description":"Nursing Progress Note","row_id":634169,"text":"Obese woman s/p t spine injury tx from Med for failure to wean\n from mech ventilation and evaluation for stent for\n tracheobronchomalacia.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Pt cont w/ low grade fever.\n Action:\n Given tyelenol q6 h prn, pt pan cultured. PICC line and foley d/c\n (new foley placed).\n Response:\n Fever slightly improved to 99.\n Plan:\n Cont w/ q 6 hr tyelenol prn, closely monitor temp and f/u w/ cultures.\n Fracture, other\n Assessment:\n Pt w/ T5-T8 compression fracture.\n Action:\n Pt on log-roll precautions, back brace at bedside- to be used when pt\n is OOB.\n Response:\n Pt denies pain when asked.\n Plan:\n Cont on log roll precautions, Neuro- consult ordered to clarify\n order for brace.\n Anemia, other\n Assessment:\n HCT 25 from 30.0. No active bleeding noted.\n Action:\n Cont to check HCT and s/s of bleeding.\n Response:\n No action taken.\n Plan:\n Type & Screen to be collected. Cont to monitor HCT, guiac all stools.\n Hypernatremia (high sodium)\n Assessment:\n NA level 150-> 147. No seizure activity.\n Action:\n Given free H2O boluses q 4hrs. Pt on D5W for 1L .\n Response:\n NA level slightly improved.\n Plan:\n Cont w/ free-water boluses as tolerated, cont to monitor lytes, bolus\n w/ LR prn.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS rhonchorous throughout, diminished to bilateral bases, deep sxn\n thick tan/bloody secretions.\n Action:\n Given MDIs, cont to be orally intubated on A/C, mini-BAL performed by\n RT and sample sent to lab.\n Response:\n Cont to be orally intubated and sedated.\n Plan:\n Consult w/ IP for eval for stent, wean vent as tolerated\n"},{"category":"Respiratory ","chartdate":"2167-09-21 00:00:00.000","description":"Respiratory Care Shift Note","row_id":634211,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Tube Type\n ETT:\n Position: 19 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Utilize ARDSnet protocol, Maintain PEEP at current\n level and reduce FiO2 as tolerated, Adjust Min. ventilation to control\n pH\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Intolerant of weaning attempts, Cannot protect airway, Underlying\n illness not resolved\n"},{"category":"Physician ","chartdate":"2167-09-21 00:00:00.000","description":"Physician Resident Progress Note","row_id":634217,"text":"Chief Complaint:\n 24 Hour Events:\n Removed PICC line because RUE was noted to be warm and erythematous;\n ultrasound revealed DVT. No definitive treatment was started given\n difficulty obtaining central venous access.\n Multiple attempts at central access; tried left and then right.\n Acute episode of oxygen desat during first central line attempt. Pt\n recovered, however, increased FiO2.\n Decreased UOP (10-30mL/hr) and hypotension overnight. However,\n lactate remains low.\n Placed art line x 2. NBP and ABP similar\n mini- BAL, sputum, urine, blood cultures pending. Yesterday, started\n on levofloxicin and aztreonam instead of cefepime. Switched due to\n question of PCN allergy\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 09:30 AM\n Metronidazole - 12:00 AM\n Vancomycin - 01:00 AM\n Aztreonam - 04:00 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 150 mcg/hour\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:00 AM\n Midazolam (Versed) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (100.9\n Tcurrent: 37.3\nC (99.2\n HR: 76 (71 - 116) bpm\n BP: 116/51(70) {60/46(54) - 146/71(91)} mmHg\n RR: 18 (12 - 24) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 94.2 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 5,600 mL\n 1,811 mL\n PO:\n TF:\n 120 mL\n IVF:\n 4,700 mL\n 1,511 mL\n Blood products:\n Total out:\n 798 mL\n 110 mL\n Urine:\n 798 mL\n 110 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,802 mL\n 1,701 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 80%\n RSBI Deferred: PEEP > 10\n PIP: 36 cmH2O\n Plateau: 25 cmH2O\n SpO2: 93%\n ABG: 7.45/42/95./28/4\n Ve: 9.5 L/min\n PaO2 / FiO2: 120\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 319 K/uL\n 7.6 g/dL\n 129 mg/dL\n 0.6 mg/dL\n 28 mEq/L\n 4.3 mEq/L\n 6 mg/dL\n 109 mEq/L\n 144 mEq/L\n 24.1 %\n 6.4 K/uL\n [image002.jpg]\n 11:54 PM\n 01:00 AM\n 06:14 AM\n 08:56 AM\n 08:57 AM\n 05:01 PM\n 08:03 PM\n 11:00 PM\n 03:01 AM\n 03:13 AM\n WBC\n 9.7\n 9.4\n 7.6\n 6.4\n Hct\n 30.7\n 25.1\n 24.1\n 24.1\n Plt\n 333\n 281\n 306\n 319\n Cr\n 0.6\n 0.6\n 0.7\n 0.6\n 0.6\n TCO2\n 32\n 33\n 35\n 33\n 30\n Glucose\n 103\n 126\n 126\n 127\n 129\n Other labs: PT / PTT / INR:16.9/26.3/1.5, ALT / AST:27/18, Alk Phos / T\n Bili:113/0.7, Differential-Neuts:76.9 %, Lymph:17.3 %, Mono:3.0 %,\n Eos:2.5 %, Lactic Acid:0.7 mmol/L, Albumin:2.3 g/dL, LDH:154 IU/L,\n Ca++:8.2 mg/dL, Mg++:2.6 mg/dL, PO4:3.1 mg/dL\n RUE ultrasound:\n - Non-occlusive right axillary deep vein thrombus\n - Non-occlusive right basilic superficial thrombosis.\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 01:16 AM\n 20 Gauge - 01:36 AM\n 22 Gauge - 02:00 PM\n Arterial Line - 03:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Physician ","chartdate":"2167-09-21 00:00:00.000","description":"Physician Attending Progress Note","row_id":634290,"text":"Chief Complaint: respiratory failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n URINE CULTURE - At 08:09 AM\n EKG - At 09:00 AM\n PICC LINE - STOP 10:30 AM\n BLOOD CULTURED - At 10:30 AM\n ULTRASOUND - At 01:00 PM\n U/S of RUE\n URINE CULTURE - At 03:00 PM\n UA/UC collected after new foley inserted.\n BAL FLUID CULTURE - At 03:00 PM\n mini-BAL\n ARTERIAL LINE - START 04:45 PM\n ARTERIAL LINE - STOP 02:03 AM\n ARTERIAL LINE - START 03:00 AM\n Multiple attempts at central access were unsuccessful due to\n malposition and difficulty threading wire.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 09:30 AM\n Vancomycin - 01:00 AM\n Aztreonam - 04:00 AM\n Metronidazole - 08:50 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 150 mcg/hour\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:00 AM\n Midazolam (Versed) - 09:32 AM\n Other medications:\n colace, CHG, SQI, H2B, SQH, MDIs, Flagyl, vanco, levo, aztreonam,\n versed, fentanyl\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (100.9\n Tcurrent: 37.9\nC (100.3\n HR: 72 (70 - 116) bpm\n BP: 100/48(60) {89/47(60) - 139/75(79)} mmHg\n RR: 18 (12 - 24) insp/min\n SpO2: 89%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 94.2 kg (admission): 94.2 kg\n Height: 67 Inch\n Bladder pressure: 18 (18 - 18) mmHg\n Total In:\n 5,600 mL\n 2,088 mL\n PO:\n TF:\n 120 mL\n IVF:\n 4,700 mL\n 1,728 mL\n Blood products:\n Total out:\n 798 mL\n 205 mL\n Urine:\n 798 mL\n 205 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,802 mL\n 1,883 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 80%\n RSBI Deferred: PEEP > 10\n PIP: 37 cmH2O\n Plateau: 25 cmH2O\n SpO2: 89%\n ABG: 7.45/42/95./28/4\n Ve: 9.1 L/min\n PaO2 / FiO2: 96\n Physical Examination\n Sedated. Breath sounds are coarse. Heart sounds are distant. Abdomen\n is protuberant with quiet breath sounds. Some peripheral edema. She\n is not able to cooperate with peripheral strength or sensory exam.\n Labs / Radiology\n 7.6 g/dL\n 319 K/uL\n 129 mg/dL\n 0.6 mg/dL\n 28 mEq/L\n 4.3 mEq/L\n 6 mg/dL\n 109 mEq/L\n 144 mEq/L\n 24.1 %\n 6.4 K/uL\n [image002.jpg]\n 11:54 PM\n 01:00 AM\n 06:14 AM\n 08:56 AM\n 08:57 AM\n 05:01 PM\n 08:03 PM\n 11:00 PM\n 03:01 AM\n 03:13 AM\n WBC\n 9.7\n 9.4\n 7.6\n 6.4\n Hct\n 30.7\n 25.1\n 24.1\n 24.1\n Plt\n 333\n 281\n 306\n 319\n Cr\n 0.6\n 0.6\n 0.7\n 0.6\n 0.6\n TCO2\n 32\n 33\n 35\n 33\n 30\n Glucose\n 103\n 126\n 126\n 127\n 129\n Other labs: PT / PTT / INR:16.9/26.3/1.5, ALT / AST:27/18, Alk Phos / T\n Bili:113/0.7, Differential-Neuts:76.9 %, Lymph:17.3 %, Mono:3.0 %,\n Eos:2.5 %, Lactic Acid:0.7 mmol/L, Albumin:2.3 g/dL, LDH:154 IU/L,\n Ca++:8.2 mg/dL, Mg++:2.6 mg/dL, PO4:3.1 mg/dL\n Imaging: CXR with bilateral opacities; ETT a little high. No PTX.\n Assessment and Plan\n 55-year-old woman with\n Respiratory failure\n Traumatic thoracic spinal fractures\n Probable VAP\n Upper extremity DVT\n Oliguria\n Anemia\n Possible tracheobronchomalacia (reason for transfer)\n I am uncertain about both the risks of anticoagulation and the risks of\n moving to radiology (e.g. CT or IR) in the context of her spinal\n fractures. Therefore we will consult spine surgery urgently for help\n with these questions.\n Her respiratory failure is likely multifactorial, including obesity,\n probable VAP, probable PE, and possible tracheobronchomalacia. She may\n also have weakness, but she is sedated and cannot cooperate with exam\n at present. We will check an echo to examine her RV. We will\n ventilate per ARDSnet; she may warrant esophageal-balloon-guided\n therapy if she does not improve in the next few hours.\n Oliguria is concerning, though BUN/Creatinine are reassuring. NG to\n suction to relieve abdominal distention. We will check urine lytes and\n assess stroke volume variation with the Vigileo. We will consider\n volume challenge based on this result.\n For central access, if we are able to safely move her we will ask I.R.\n to help with central access.\n We will continue broad antibiotics while awaiting cultures.\n ICU Care\n Nutrition: NPO for now\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 01:16 AM\n 20 Gauge - 01:36 AM\n 22 Gauge - 02:00 PM\n Arterial Line - 03:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 45 min\n Patient is critically ill\n ------ Protected Section ------\n Critical Care Staff Addendum\n 5:45p\n CVL successfully placed. CVP and SVV argue that she is adequately\n volume-replete. Hypoxemia has been a major issue, and we have taken\n her to CT this afternoon. We are awaiting final reads of the images.\n We will pursue esophageal balloon to help guide PEEP; first attempt was\n unsuccessful due to oropharyngeal coiling.\n Discussed in detail with patient\ns brother at bedside. Unable to reach\n her significant other.\n 35 minutes\n ------ Protected Section Addendum Entered By: , MD\n on: 17:55 ------\n Critical Care Staff\n 7:30p\n Stable on PEEP 15, FiO2 0.8, low-dose Levophed. RT was unable to place\n esophageal balloon. CT reviewed and shows basilar >> apical collapse\n but no PE. Echo was limited but reassuring, with normal RV function\n and no obvious shunt.\n We will continue to pursue 6cc/kg PBW ventilation. If unable to wean\n FiO2 further, will increase PEEP. If difficulties, will repeat\n attempts at esophageal balloon and consider proning.\n Since sputum is growing GNR, suspect that much of this may be related\n to VAP acquired at OSH. Since we do not know their resistance\n patterns, will continue extended-spectrum GNR coverage with aztreonam\n and levofloxacin.\n Await spine surgery\ns input on risks of anticoagulation. If OK, begin\n full-dose heparin tonight.\n Discussed with , RN, and RT.\n 30 minutes\n ------ Protected Section Addendum Entered By: , MD\n on: 07:49 PM ------\n"},{"category":"Physician ","chartdate":"2167-10-05 00:00:00.000","description":"Physician Resident Progress Note","row_id":635843,"text":"Chief Complaint:\n 24 Hour Events:\n On lasix drip\n Attempted to wean FiO2\n No acute events\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Furosemide (Lasix) - 2 mg/hour\n Heparin Sodium - 1,500 units/hour\n Fentanyl - 75 mcg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.9\nC (98.5\n HR: 126 (49 - 131) bpm\n BP: 156/84(117) {78/38(52) - 164/95(125)} mmHg\n RR: 20 (9 - 21) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 4,160 mL\n 1,185 mL\n PO:\n TF:\n 1,267 mL\n 315 mL\n IVF:\n 1,018 mL\n 260 mL\n Blood products:\n Total out:\n 4,015 mL\n 2,090 mL\n Urine:\n 4,015 mL\n 2,090 mL\n NG:\n Stool:\n Drains:\n Balance:\n 145 mL\n -905 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 500) mL\n Vt (Spontaneous): 675 (675 - 675) mL\n PS : 8 cmH2O\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 19 cmH2O\n Plateau: 16 cmH2O\n SpO2: 96%\n ABG: 7.39/46/118/28/2\n Ve: 8.9 L/min\n PaO2 / FiO2: 236\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 272 K/uL\n 8.6 g/dL\n 128 mg/dL\n 0.6 mg/dL\n 28 mEq/L\n 3.1 mEq/L\n 8 mg/dL\n 110 mEq/L\n 148 mEq/L\n 27.4 %\n 11.2 K/uL\n [image002.jpg]\n 05:17 PM\n 11:41 PM\n 03:06 AM\n 03:38 AM\n 04:05 PM\n 03:55 AM\n 07:19 AM\n 11:24 AM\n 03:18 PM\n 02:47 AM\n WBC\n 10.6\n 10.0\n 8.3\n 11.2\n Hct\n 27.3\n 25.8\n 24.6\n 27.4\n Plt\n 72\n Cr\n 0.5\n 0.6\n 0.6\n 0.5\n 0.6\n 0.6\n TCO2\n 32\n 31\n 29\n 29\n Glucose\n 110\n 94\n 111\n 106\n 121\n 123\n 137\n 128\n Other labs: PT / PTT / INR:15.2/62.2/1.3, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:13.1 %,\n Mono:2.7 %, Eos:0.6 %, Lactic Acid:0.9 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:9.0 mg/dL, Mg++:2.6 mg/dL, PO4:4.3 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA and\n ARDS intubated since the end of now s/p trach and PEG placement.\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation. Stenting\n unlikely to help for trachiomalacia as airways have poor structure\n diffusely. S/P Trach and PEG on .\n - wean FiO2 today\n # Adrenal Insufficency: Hypotension that resolved with steroids,\n returned as they came off and is now improved again. Possible primary\n adrenal insufficency. Appreciate endocrine recommendations. Halved\n dose today.\n - hydrocortt (day 1 = ), wean per endo recs\n # Volume overloaded in setting of hypernatremia with TBW deficit.\n - Lasix gtt, continue with goal -1-2 L per day.\n - electrolytes\n - continue tube feeds with free water flushes 250 cc q4\n # Sedation: Sedation control remains somewhat poor although fentanyl\n patch and diazpem are likely therapeutic range today. On Versed 2.0,\n Fentanyl 100, Fentanyl patch, Diazepam standing and haldo 2.5-5 mg\n PRN. QTc increased to 480.\n - Wean versed/fentanyl as tolerated, continue diazepam. Avoid haldol\n use if possible to avoid further prolongation of QTc\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\n coumadin at least until s/p trach.\n - heparin gtt restarted\n - coumadin 5mg G-tube today\n # Constipation\n current regimen of colace and senna, no BM over last\n 24 hours\n - dulcolax PO/PR today\n - reassess and increase bowel regimen PRN\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n -f/u full trauma spine eval from OSH to determine need for further back\n imaging in-house (to be done )\n # Nutrition: Tube feeds with free water flushes, tolerating well,\n continue Replete (Full) - 11:20 AM 30 mL/hour\n # Glycemic control: SSI, well controlled\n # Lines L PICC () and R ART ()\n both working well, mainitain\n # Ppx: heparin, ranitidine, VAP prevention, colace and senna\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n Code: Full\n Dispo: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Arterial Line - 02:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Nutrition","chartdate":"2167-10-05 00:00:00.000","description":"Clinical Nutrition Note","row_id":635848,"text":"Subjective\n Patient intubated\n Objective\n Pertinent medications: fentanyl, versed, lasix gtt\n Labs:\n Value\n Date\n Glucose\n 128 mg/dL\n 02:47 AM\n Glucose Finger Stick\n 134\n 04:00 AM\n BUN\n 8 mg/dL\n 02:47 AM\n Creatinine\n 0.6 mg/dL\n 02:47 AM\n Sodium\n 148 mEq/L\n 02:47 AM\n Potassium\n 3.1 mEq/L\n 02:47 AM\n Chloride\n 110 mEq/L\n 02:47 AM\n TCO2\n 28 mEq/L\n 02:47 AM\n Albumin\n 2.4 g/dL\n 03:59 AM\n Calcium non-ionized\n 9.0 mg/dL\n 02:47 AM\n Phosphorus\n 4.3 mg/dL\n 02:47 AM\n Ionized Calcium\n 1.17 mmol/L\n 03:32 PM\n Magnesium\n 2.6 mg/dL\n 02:47 AM\n Current diet order / nutrition support: Replete with Fiber at 60ml/hr x\n 24 hours - provides 1440kcal and 89g protein\n GI: Abdomen soft/distended with positive bowel sounds\n Assessment of Nutritional Status\n Specifics:\n 55 year old female s/p fall with t-spine fracture now with pneumonia\n and ARDS requiring intubation now s/p trach/PEG placement. Patient is\n tolerating tube feedings well with residuals of 10 and 35ml noted.\n Would continue with tube feedings as ordered.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. Continue to provide patient with Replete with Fiber at 60ml/hr\n x 24 hours\n 2. Monitor residuals q4H and hold tube feedings if >150ml\n 08:14\n"},{"category":"Physician ","chartdate":"2167-09-29 00:00:00.000","description":"Physician Resident Progress Note","row_id":635091,"text":"Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - STOP 09:00 PM - attempted to re-wire but\n patient was very agitated and re-wire was unsuccessful\n Patient alternated between tachycardia and normotension and hypotension\n in the high-80s/low 90s and HRs in the 50s\n Given haldol, valium, midaz and fentanyl for sedation\n ABG with low paO2 on PEEP 10, had to increase -- went back up to 15 and\n then attempted to re-wean down with goal 8 in anticipation of OR\n To OR for trach and PEG today (thoracics)\n Put on lasix drip and put out >1L in just over an hour\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 08:06 AM\n Infusions:\n Midazolam (Versed) - 1.5 mg/hour\n Fentanyl - 200 mcg/hour\n Other ICU medications:\n Fentanyl - 06:45 PM\n Ranitidine (Prophylaxis) - 08:00 PM\n Haloperidol (Haldol) - 10:00 PM\n Midazolam (Versed) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.7\nC (99.8\n HR: 109 (55 - 134) bpm\n BP: 120/56(70) {80/43(51) - 133/85(94)} mmHg\n RR: 20 (16 - 28) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 101 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 3,064 mL\n 404 mL\n PO:\n TF:\n 1,440 mL\n IVF:\n 1,014 mL\n 314 mL\n Blood products:\n Total out:\n 4,257 mL\n 1,195 mL\n Urine:\n 4,257 mL\n 1,195 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,193 mL\n -791 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 18\n RR (Spontaneous): 10\n PEEP: 15 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10\n PIP: 23 cmH2O\n Plateau: 24 cmH2O\n SpO2: 97%\n ABG: 7.46/48/65/31/8 @ 10:20 PM\n Ve: 7.8 L/min\n PaO2 / FiO2: 108\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 320 K/uL\n 8.0 g/dL\n 94 mg/dL\n 0.6 mg/dL\n 31 mEq/L\n 3.6 mEq/L\n 13 mg/dL\n 110 mEq/L\n 147 mEq/L\n 25.8 %\n 9.0 K/uL\n [image002.jpg]\n 10:18 AM\n 02:33 PM\n 02:46 PM\n 03:31 AM\n 02:26 PM\n 05:53 PM\n 05:01 AM\n 03:32 PM\n 10:19 PM\n 02:50 AM\n WBC\n 9.7\n 9.5\n 9.0\n Hct\n 26.0\n 27.6\n 25.8\n Plt\n \n Cr\n 0.5\n 0.5\n 0.5\n 0.6\n 0.6\n TCO2\n 29\n 26\n 27\n 30\n 30\n 35\n Glucose\n 195\n 195\n 163\n 133\n 102\n 94\n Other labs: PT / PTT / INR:14.1/59.6/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:71.2 %, Lymph:22.7 %,\n Mono:4.0 %, Eos:1.7 %, Lactic Acid:1.5 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:8.2 mg/dL, Mg++:2.1 mg/dL, PO4:4.6 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with respiratory failure\n and difficulty weaning from vent.\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation.\n Transferred here for tracheomalacia, but not sure this is a component.\n Will need bronch eval when improved\n - Thoracics will do trach and PEG once stable on PEEPs around 10. Had\n been planned for today but currently holding as PEEP is 15.\n - wean PEEP as tolerated\n - needs A-line\n # Volume overload\n Currently with hypernatremia, Cr increase, contract\n alk, but mild\n - continue gentle diuresis with goal -1L per day as tolerated by blood\n pressure. IV lasix drip at 1-5 mg/hr.\n - FW in TF at 150 cc q4hrs\n - PM lytes.\n # Sedation: Now well seadated on Versed 1.5, Fentanyl 175, Fentanyl\n patch, Diazepam standing and haldo 2.5-5 mg PRN. QTc stable at .44\n - Wean versed/fentanyl as tolerated\n # HCT\n Has had slow decline while in ICU.\n - Xfuse PRN Hct < 21\n - continue to follow, guiac stools\n # Hypotension: Related to sedation, but high PEEP, adrenial\n insufficiency, sepsis have previously been contributing.\n - needs A-line for monitoring\n - cortisol stim to rule out persistent adrenal insufficiency\n # RUE DVT: Started on heparin gtt on , now off for trach that was\n planned for today. Follow PTTs. Would hold off on coumadin at least\n until s/p trach.\n - restart heparin\n # Adrenal Insufficency: Random cortisol was approx 3 when it should\n have been maximally stimulated. S/P 5 days of hydrocortisone and\n florinef.\n - will recheck as above and start at 50 q8 if needed\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n FEN/GI: Tube feeds @ goal. No need to be NPO while awaiting stable\n PEEP\n DVT: Treatment dose heparin\n Ulcer: Ranitidine\n VAP: Prevention per routine\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Nutrition","chartdate":"2167-09-29 00:00:00.000","description":"Clinical Nutrition Note","row_id":635093,"text":"Objective\n Pertinent medications: noted\n Labs:\n Value\n Date\n Glucose\n 94 mg/dL\n 02:50 AM\n Glucose Finger Stick\n 98, 101\n \n BUN\n 13 mg/dL\n 02:50 AM\n Creatinine\n 0.6 mg/dL\n 02:50 AM\n Sodium\n 147 mEq/L\n 02:50 AM\n Potassium\n 3.6 mEq/L\n 02:50 AM\n Chloride\n 110 mEq/L\n 02:50 AM\n TCO2\n 31 mEq/L\n 02:50 AM\n Albumin\n 2.4 g/dL\n 03:59 AM\n Calcium non-ionized\n 8.2 mg/dL\n 02:50 AM\n Phosphorus\n 4.6 mg/dL\n 02:50 AM\n Ionized Calcium\n 1.17 mmol/L\n 03:32 PM\n Magnesium\n 2.1 mg/dL\n 02:50 AM\n Current diet order / nutrition support: Replte c/ Fiber @60mL/hr (1440\n kcals/89 gr aa)\n GI: Abd soft/+bs/+bm\n Assessment of Nutritional Status\n Estimation of current intake: Adequate\n Specifics:\n Pt continues on TF\ns for full nutrition support. TF\ns well tolerated @\n goal, meeting 100% estimated needs. They were opn hold last night as\n plan was for trach and PEG today, but not done 2/2 PEEP to high. PT on\n lasix gtt for diuresis. Na trending up daily, today is 147. need\n to increase FWB if level continues to increase.\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: via TF\n Tube feeding recommendations: Continue current TF's @ goal\n Adjust FWB prn c/ diuresis\n Will follow- page c/ ?\ns #\n"},{"category":"Physician ","chartdate":"2167-09-30 00:00:00.000","description":"Physician Resident Progress Note","row_id":635225,"text":"Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - START 02:00 PM - in right brachial atery\n Hypotensive- started on levophed, weaned off over night\n Low cortisol and failed stim test - started on steroids\n TTE ordered\n Free water flushes were increased for hypernatremia (250cc q4)\n Able to hear patient breathing at times during exam this am (poor am\n CXR, reordered)\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 08:06 AM\n Infusions:\n Heparin Sodium - 1,700 units/hour\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 150 mcg/hour\n Other ICU medications:\n Haloperidol (Haldol) - 12:15 AM\n Other medications:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 36.7\nC (98\n HR: 63 (48 - 138) bpm\n BP: 91/41(58) {68/30(49) - 143/78(105)} mmHg\n RR: 18 (13 - 23) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Mixed Venous O2% Sat: 59 - 59\n Total In:\n 3,898 mL\n 1,155 mL\n PO:\n TF:\n 802 mL\n 348 mL\n IVF:\n 2,126 mL\n 247 mL\n Blood products:\n Total out:\n 2,367 mL\n 800 mL\n Urine:\n 2,367 mL\n 800 mL\n NG:\n Stool:\n ?\n ?\n Drains:\n Balance:\n 1,531 mL\n 355 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 401) mL\n RR (Set): 18\n RR (Spontaneous): 1\n PEEP: 10 cmH2O\n FiO2: 40%\n PIP: 23 cmH2O\n Plateau: 19 cmH2O\n Compliance: 57.1 cmH2O/mL\n SpO2: 91%\n ABG: 7.42/49/93/33/5\n Ve: 8.1 L/min\n PaO2 / FiO2: 155\n Physical Examination\n General Appearance: Easily agitated, appears uncomfortable, Overweight\n / Obese, opens eyes but no purposeful movement\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\n deviation\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Respiratory / Chest: (Expansion: Symmetric), referred breath sounds\n from ETT\n Abdominal: No(t) Soft, Non-tender, Few Bowel sounds present, Distended\n Extremities: No clubbing or cyanosis, 3+ nonpitting edema of b/l hands,\n anasarca\n Skin: no rashes or jaundice\n Neuro: diffusely hyperreflexic with LE clonus\n Lines: r brachioceph ART and L PICC C/D/I\n Labs / Radiology\n 355 K/uL\n 9.1 g/dL\n 168 mg/dL\n 0.5 mg/dL\n 30 mEq/L\n 3.9 mEq/L\n 11 mg/dL\n 108 mEq/L\n 146 mEq/L\n 29.9 %\n 11.8 K/uL\n [image002.jpg]\n 03:32 PM\n 10:19 PM\n 02:50 AM\n 02:30 PM\n 02:44 PM\n 03:33 PM\n 07:26 PM\n 07:46 PM\n 02:04 AM\n 02:18 AM\n WBC\n 9.0\n 8.4\n 11.8\n Hct\n 25.8\n 23.0\n 28.1\n 29.9\n Plt\n \n Cr\n 0.6\n 0.7\n 0.5\n TCO2\n 30\n 35\n 33\n 31\n 33\n Glucose\n 94\n 97\n 168\n Other labs: PT / PTT / INR:13.8/70.4/1.2, Differential-Neuts:89.7 %,\n Lymph:8.7 %, Mono:1.1 %, Eos:0.4 %, Ca++:8.5 mg/dL, Mg++:2.2 mg/dL,\n PO4:5.4 mg/dL\n TSH 2.9; FT4 1.5; stim 3.1, 10.5, 10.6\n Culture Data: endotrach with K oxytoca; gram stain GPCs in\n pairs and clusters\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA and\n ARDS intubated since the end of .\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation.\n Transferred here for airway stenting. Will need bronch eval when\n improved.\n - Thoracics will do trach and PEG once stable on PEEPs around 10.\n Re-c/s today.\n - wean PEEP as tolerated\n # # Adrenal Insufficency: Minimal response to stim test again.\n - hydrocort and fludrocort (day 1 = )\n - endocrine c/s for further elucidation of etiology\n # Hypotension: Likely adrenal insufficiency. Goal map > 60.\n - hydrocortisol and fludrocortisone as above\n - restart levophed if necessary to maintain MAP > 60\n # Volume overloaded in setting of hypernatremia (? Relationship to\n adrenal insufficiency), TBW deficit 2.6L.\n - goal even to -500cc I/Os today\n - continue FW in TF at 250 cc q4hrs\n - lasix drip (1-5mg/hr) when MAP > 60\n # Hyperreflexia - ? meds vs central pathology. Unlikely to be \n intracranial hemorrhage as patient is diffusely hyperreflexic.\n Possible relationship to endocrine pathology?\n - consider head CT in setting of heparin gtt\n - monitor\n # Sedation: Sedation control remains somewhat poor although fentanyl\n patch and diazpem are likely starting increase to therapeutic range\n today. On Versed 1.5, Fentanyl 175, Fentanyl patch, Diazepam standing\n and haldo 2.5-5 mg PRN. QTc stable at .44.\n - Wean versed/fentanyl as tolerated, continue diazepam and prn\n haldol\n - Recheck EKG today\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\n coumadin at least until s/p trach.\n - hold heparin gtt when anticipate trach/peg\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n # FEN/GI: Tube feeds @ goal.\n DVT: Treatment dose heparin\n Ulcer: Ranitidine\n VAP: Prevention per routine\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 09:51 PM 60 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Arterial Line - 02:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"General","chartdate":"2167-10-01 00:00:00.000","description":"Generic Note","row_id":635300,"text":"55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP now with prolonged\n hospital course c/o by PNA anxiety,RUE DVD with high PEEP requirement\n .\n Events\n Heparin gtt and TF held since MN for ? trach and peg\n placement today.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on AC 400/18/8/50%. 02 sats mainly 88-92% but did fall to\n 86% when pt positioned on L side. Pt fluid overloaded with TFB for LOS\n ~ ccs.\n Action:\n ABG taken while sat 88%. Lasix gtt increased to 3mg/hr\n Response:\n ABG 7.42/47/87/4/32. Urine output initially 25 ccs/hr but pt began\n autodiuresing after MN with output improving to ~140ccs/hr\n Plan:\n Continue with current vent settings. Trach today. Titrate lasix gtt to\n maintain MAP > 60 and u/o 100-150ccs/hr.\n Altered mental status (not Delirium)\n Assessment:\n Pt restless at times, thrashing in bed with HR up to 140 ST . Denies\n pain or doesn\nt respond when questioned if she is having pain.\n Action:\n Fentanyl drip infusing at 100mcgs/hr. Fentanyl patch in place. Also\n treated with haldol and valium . Bolused with 2 mg versed when acutely\n agitated. Bilateral wrist restraints in place.\n Response:\n Pt falls back to sleep, HR decreases (occasionally as low as 45 SB)\n Plan:\n Continue to assess MS. as indicated. Reorientation. Restraints\n for safety.\n Hypernatremia (high sodium)\n Assessment:\n Na 146 on \n Action:\n Treated with free h20 boluses\n Response:\n Na 143 this am\n Plan:\n Continue to monitor f+e status.\n Impaired Skin Integrity\n Assessment:\n Pt with excoriated yeast infection on abd and in perineal area. +\n reddened perirectal area.\n Action:\n Barrier cream and miconazole powder applied\n Response:\n To be determined.\n Plan:\n Diligent skin care.\n"},{"category":"Respiratory ","chartdate":"2167-09-30 00:00:00.000","description":"Respiratory Care Shift Note","row_id":635162,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 12\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Pt remains stable on current support. When pt is placed on\n \"sides\" (pillows) of her back by RN, she tends to desaturate and is\n intolerant of weaning attempts\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Reduce PEEP as tolerated, Adjust Min. ventilation to\n control pH, Tracheostomy planned; Comments: Pt is stable on current\n vent settings, but SpO2 is too sensitive to weaning attempts of FiO2 or\n PEEP\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts; Comments: Although Work of breathing and RR are\n without fault, pt desaturates with weaning attempts.\n"},{"category":"Physician ","chartdate":"2167-09-20 00:00:00.000","description":"Physician Attending Progress Note","row_id":634163,"text":"Chief Complaint: respiratory failure\n HPI:\n 24 Hour Events:\n PICC LINE - START 10:30 PM\n INVASIVE VENTILATION - START 10:45 PM\n EKG - At 11:25 PM\n BLOOD CULTURED - At 05:30 AM\n TMax 102.7 BCX1 drawn\n FEVER - 102.7\nF - 04:00 AM\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Metronidazole - 08:00 AM\n Infusions:\n Fentanyl - 75 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.3\nC (102.7\n Tcurrent: 37.2\nC (99\n HR: 88 (72 - 97) bpm\n BP: 110/55(64) {83/38(48) - 154/71(103)} mmHg\n RR: 14 (12 - 18) insp/min\n SpO2: 100%\n Total In:\n 10 mL\n 1,043 mL\n PO:\n TF:\n 54 mL\n IVF:\n 10 mL\n 988 mL\n Blood products:\n Total out:\n 425 mL\n 585 mL\n Urine:\n 425 mL\n 585 mL\n NG:\n Stool:\n Drains:\n Balance:\n -416 mL\n 458 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 32 cmH2O\n SpO2: 100%\n ABG: 7.39/53/81./30/5\n Ve: 8 L/min\n PaO2 / FiO2: 135\n Physical Examination\n Labs / Radiology\n 9.7 g/dL\n 333 K/uL\n 103 mg/dL\n 0.6 mg/dL\n 30 mEq/L\n 3.8 mEq/L\n 6 mg/dL\n 109 mEq/L\n 150 mEq/L\n 30.7 %\n 9.7 K/uL\n [image002.jpg]\n 11:54 PM\n 01:00 AM\n 06:14 AM\n WBC\n 9.7\n Hct\n 30.7\n Plt\n 333\n Cr\n 0.6\n TCO2\n 32\n 33\n Glucose\n 103\n Other labs: PT / PTT / INR:13.8/22.4/1.2, ALT / AST:30/19, Alk Phos / T\n Bili:149/0.7, Differential-Neuts:76.9 %, Lymph:17.3 %, Mono:3.0 %,\n Eos:2.5 %, Albumin:3.0 g/dL, LDH:222 IU/L, Ca++:8.6 mg/dL, Mg++:2.1\n mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n Obese woman s/p t spine injury tx from Med for failure to wean\n from mech ventilation and evaluation for stent for\n tracheobronchomalacia\n 1. Resp Failure: initial etiology unclear\n but currently\n we need to assess what she can do here. Switch to PSV 10/5 and see what\n she can pull, check NIF. not act on this info. Let IP know she is\n here though not stable for intervention at this point.\n 2. New fevers and hypotension\n Is fluid responsive, watch\n UOP, goal 30 cc/hr. Check lactate.\n DDx VAP, asp PNA, lines. Has PCN and blactam allergy.\n For VAP- mini , change to Levoquin, Aztreonam, Vanco, and add\n Flagyl for asp.\n Lines: D/C PICC send cultures, try for 2nd PIV and if unable will\n place CVL. Check lactate.\n Belly: repeat LFTs, KUB OK, check residuals.\n 3. HyperNa: correcting with g tube free flush and D5W\n repeat lytes this evening and recalculate\n 4. Spine Fx: consult NSurg here re reccs for back bracing and\n activity\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 03:30 AM 10 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 10:30 PM\n 20 Gauge - 01:36 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition :\n Total time spent:\n Patient is critically ill\n"},{"category":"Physician ","chartdate":"2167-09-20 00:00:00.000","description":"Physician Attending Progress Note","row_id":634166,"text":"Chief Complaint: respiratory failure\n HPI: 55 yr old woman s/p t soine injury from Med with difficulty\n vent weaning ? tbmalacia requiring stent\n Hour Events:\n PICC LINE - START 10:30 PM\n INVASIVE VENTILATION - START 10:45 PM\n EKG - At 11:25 PM\n BLOOD CULTURED - At 05:30 AM\n TMax 102.7 BCX1 drawn\n FEVER - 102.7\nF - 04:00 AM\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Metronidazole - 08:00 AM\n Infusions:\n Fentanyl - 75 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.3\nC (102.7\n Tcurrent: 37.2\nC (99\n HR: 88 (72 - 97) bpm\n BP: 110/55(64) {83/38(48) - 154/71(103)} mmHg\n RR: 14 (12 - 18) insp/min\n SpO2: 100%\n Total In:\n 10 mL\n 1,043 mL\n PO:\n TF:\n 54 mL\n IVF:\n 10 mL\n 988 mL\n Blood products:\n Total out:\n 425 mL\n 585 mL\n Urine:\n 425 mL\n 585 mL\n NG:\n Stool:\n Drains:\n Balance:\n -416 mL\n 458 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 32 cmH2O\n SpO2: 100%\n ABG: 7.39/53/81./30/5\n Ve: 8 L/min\n PaO2 / FiO2: 135\n Physical Examination\n Gen: intubated and sedated\n CV: RR\n Chest: fair air movement\n Abd: obese soft NT+BS\n Ext RUEgreater than LUE edema\n Labs / Radiology\n 9.7 g/dL\n 333 K/uL\n 103 mg/dL\n 0.6 mg/dL\n 30 mEq/L\n 3.8 mEq/L\n 6 mg/dL\n 109 mEq/L\n 150 mEq/L\n 30.7 %\n 9.7 K/uL\n [image002.jpg]\n 11:54 PM\n 01:00 AM\n 06:14 AM\n WBC\n 9.7\n Hct\n 30.7\n Plt\n 333\n Cr\n 0.6\n TCO2\n 32\n 33\n Glucose\n 103\n Other labs: PT / PTT / INR:13.8/22.4/1.2, ALT / AST:30/19, Alk Phos / T\n Bili:149/0.7, Differential-Neuts:76.9 %, Lymph:17.3 %, Mono:3.0 %,\n Eos:2.5 %, Albumin:3.0 g/dL, LDH:222 IU/L, Ca++:8.6 mg/dL, Mg++:2.1\n mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n Obese woman s/p t spine injury tx from Med for failure to wean\n from mech ventilation and evaluation for stent for\n tracheobronchomalacia\n 1. Resp Failure: initial etiology unclear\n but we need to\n assess current mechanics and reserve. Switch to PSV 10/5 and see what\n she can pull, check NIF. not act on this info in light of issue\n sbelow but important for us to understand. Let IP know she is here\n though not stable for intervention at this point.\n 2. New fevers and transient hypotension\n Is fluid\n responsive, watch UOP, goal 30 cc/hr.\n DDx VAP, asp PNA, lines. Has PCN and blactam allergy.\n For VAP- mini , change to Levoquin, Aztreonam, Vanco, and add\n Flagyl for asp.\n Lines: D/C PICC send cultures, try for 2nd PIV and if unable will\n place CVL. Check lactate.\n Belly: repeat LFTs, KUB OK, check residuals.\n 3. HyperNa: correcting with g tube free flush and D5W\n repeat lytes this evening and recalculate\n 4. Spine Fx: consult NSurg here re reccs for back bracing and\n activity\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 03:30 AM 10 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 10:30 PM\n 20 Gauge - 01:36 AM\n Prophylaxis:\n DVT: SC hep\n Stress ulcer: Zantac\n VAP: chlorhex HOB daily wake ups\n Comments:\n Communication: boyfriend is proxy not the brother but need to clarify\n paperwork.\n Code status: FULL\n Disposition :ICU\n Total time spent: 45\n Patient is critically ill\n"},{"category":"Nursing","chartdate":"2167-09-21 00:00:00.000","description":"Nursing Progress Note","row_id":634282,"text":"55-year-old woman with\n Respiratory failure\n Traumatic thoracic spinal fractures\n Probable VAP\n Upper extremity DVT\n Oliguria\n Anemia\n * Possible tracheobronchomalacia (reason for transfer from OSH)\n Alteration in Nutrition\n Assessment:\n Pt NPO, Pt w/ high residuals yesterday. Abdomen distended/obese/soft.\n BS hypoactive. Low albumin.\n Action:\n OGT to low wall suction. TF off.\n Response:\n Small amount of gastric fluid suctioned- approx 30cc-50cc.\n Plan:\n Plan for CT of Abdomen, cont NPO at this time.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n RUE + DVT\n Action:\n Cont on sq heparin\n Response:\n No change\n Plan:\n Consult neuro-surgery regarding anti-coagulation w/ T-spine fx, elevate\n RUE, no blood draws or blood pressures to RUE.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Temp max 100\n Action:\n Antibiotics given and dosage changed to vanco and aztreonam.\n Response:\n No further temp spike.\n Plan:\n Cont w/ antibiotics, f/u on cultures, tyelenol prn, vanco trough to be\n drawn prior to evening dose.\n Fracture, other\n Assessment:\n T-spine compression fx, Back brace at bedside when OOB.\n Action:\n Ortho tech consulted for placement of back brace. Cont w/ log roll\n precautions.\n Response:\n Pt denies c/o pain when asked.\n Plan:\n Cont w/ log roll precautions, back brace for OOB, CT scan, consult w/\n neurosurg.\n Anemia, other\n Assessment:\n HCT 24.1 from 28\n Action:\n Given 1 unit of PRBCs\n Response:\n HCT to be drawn.\n Plan:\n Cont to follow HCTs, guiac stools, monitor of s/s of bleeding.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS- bronchial throughout, deep sxn\nd for thick/tan secretions, copious\n clear oral secretions suctioned, PO2 68% on 70% FIO2 and 12 peep. ?\n PE/? VAP.\n Action:\n Vent changes made throughout shift.\n Response:\n Plan:\n Esophageal balloon placement to be performed, monitor ABGs, vent\n changes as needed.\n Hypotension (not Shock)\n Assessment:\n Pt hypotensive into low-mid 80s systolic, HR 70s-90s. Low uop-\n BUN/Creat negative. Bladder pressure 18-20.\n Action:\n Vigeleo set up, given 1 unit of blood, bloused x 1, multi-lumen RIJ\n placed at bedside.\n Response:\n No response to blusing, SBP improved following blood transfusion, RIJ\n okay to use. CVP 18.\n Plan:\n Levophed to be started if needed, transfuse as needed.\n"},{"category":"Nursing","chartdate":"2167-09-21 00:00:00.000","description":"Nursing Progress Note","row_id":634283,"text":"55-year-old woman with\n Respiratory failure\n Traumatic thoracic spinal fractures\n Probable VAP\n Upper extremity DVT\n Oliguria\n Anemia\n * Possible tracheobronchomalacia (reason for transfer from OSH)\n Events:\n Alteration in Nutrition\n Assessment:\n Pt NPO, Pt w/ high residuals yesterday. Abdomen distended/obese/soft.\n BS hypoactive. Low albumin.\n Action:\n OGT to low wall suction. TF off.\n Response:\n Small amount of gastric fluid suctioned- approx 30cc-50cc.\n Plan:\n Plan for CT of Abdomen, cont NPO at this time.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n RUE + DVT\n Action:\n Cont on sq heparin\n Response:\n No change\n Plan:\n Consult neuro-surgery regarding anti-coagulation w/ T-spine fx, elevate\n RUE, no blood draws or blood pressures to RUE.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Temp max 100\n Action:\n Antibiotics given and dosage changed to vanco and aztreonam.\n Response:\n No further temp spike.\n Plan:\n Cont w/ antibiotics, f/u on cultures, tyelenol prn, vanco trough to be\n drawn prior to evening dose.\n Fracture, other\n Assessment:\n T-spine compression fx, Back brace at bedside when OOB.\n Action:\n Ortho tech consulted for placement of back brace. Cont w/ log roll\n precautions.\n Response:\n Pt denies c/o pain when asked.\n Plan:\n Cont w/ log roll precautions, back brace for OOB, CT scan, consult w/\n neurosurg.\n Anemia, other\n Assessment:\n HCT 24.1 from 28\n Action:\n Given 1 unit of PRBCs\n Response:\n HCT to be drawn.\n Plan:\n Cont to follow HCTs, guiac stools, monitor of s/s of bleeding.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS- bronchial throughout, deep sxn\nd for thick/tan secretions, copious\n clear oral secretions suctioned, PO2 68% on 70% FIO2 and 12 peep. ?\n PE/? VAP.\n Action:\n Vent changes made throughout shift.\n Response:\n Plan:\n Esophageal balloon placement to be performed, monitor ABGs, vent\n changes as needed.\n Hypotension (not Shock)\n Assessment:\n Pt hypotensive into low-mid 80s systolic, HR 70s-90s. Low uop-\n BUN/Creat negative. Bladder pressure 18-20.\n Action:\n Vigeleo set up, given 1 unit of blood, bloused x 1, multi-lumen RIJ\n placed at bedside.\n Response:\n No response to blusing, SBP improved following blood transfusion, RIJ\n okay to use. CVP 18.\n Plan:\n Levophed to be started if needed, transfuse as needed.\n"},{"category":"Nursing","chartdate":"2167-09-22 00:00:00.000","description":"Nursing Progress Note","row_id":634365,"text":"Alteration in Nutrition\n Assessment:\n TF d/c\nd d/t high residuals; abd soft, mod distended; hypoactive\n BSx4; abd CT without evidence of obstruction\n Action:\n Sedation weaned down; TF restarted; bowel regimen w/reglan\nsoap suds\n enema and fleet enema given; begun naloxone for Gi motility\n Response:\n Tol TF; sm amt stool w/enemas; stool for c-diff\n Plan:\n Monitor bowel status; do not advance TF beyond 10cc/hr. Cont with bowel\n meds; place rectal tube for decompression\n Hypotension (not Shock)\n Assessment:\n Bp improved with MAP >65 and SBP >90\n Action:\n Levophed weaned off\n Response:\n Adequate Bp off pressor\n Plan:\n Cont to monitor BP; restart levophed prn\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Bil effusions L>R, RLL consolidation. Tol ACV\n Action:\n Esophageal balloon placed; bladder pressure elevated; increased PEEP;\n freq suctioning\n Response:\n Tol elevated PEEP and freq position changes\n Plan:\n Cont to monitor resp status and titrate vent settings accordingly.\n Suction prn. Await further micro data.\n Fracture, other\n Assessment:\n Logrolling; reverse tredelenberg pnd clarification of spinal fx\n Action:\n Spine/ortho consult-off logrolling prec. HoB>30\n Response:\n Tol position changes\n Plan:\n Activity as tol; needs to wear TLSO brace when OOB or sitting up for T8\n compression fx\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n DVT RUE-3+ edema\n Action:\n Awaiting clearance for heparin gtt from /spine service\n Response:\n Cleared for heparin gtt\n Plan:\n Awaiting further orders from MICU team\n"},{"category":"Respiratory ","chartdate":"2167-09-22 00:00:00.000","description":"Respiratory Care Shift Note","row_id":634367,"text":"Demographics\n Day of intubation: \n Day of mechanical ventilation: 4\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location: Outside hospital\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Utilize ARDSnet protocol\n Reason for continuing current ventilatory support: Hemodynimic\n instability, Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Pleural pressure measurement (1330hrs)\n Comments: Approximate time\n, RRT 17:21\n"},{"category":"Nursing","chartdate":"2167-10-05 00:00:00.000","description":"Nursing Progress Note","row_id":635825,"text":"55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\n Now with prolonged hospital course c/b by PNA with high PEEP\n requirement, anxiety, RUE DVT on heparin qtt.\n Edema, peripheral\n Assessment:\n Fluid balance for previous 24hrs decreased by 3 liters D/T diuresis.\n Rec\nd pt off of Lasix qtt. Urine output decreased to 45ml/hr @1000.\n Action:\n Lasix qtt restarted @ 2mg/hr to maintain urine output 1-2liters/day.\n Response:\n Fluid balance approx -50ml/hr, with 24hr fluid balance -650ml @ 1500.\n However, SBP 78 when pt soundly sleeping/sedated. Lasix qtt stopped @\n 1530.\n Plan:\n Restart Lasix qtt when BP stabilized.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Rec\nd pt on Heparin qtt @ 1500units/hr.\n Action:\n PTT 62,2 @ 0230.\n Response:\n Heparin rate unchanged.pt had 2 therapeutic PTT,started on coumadin\n 5mg at 2200,.\n Plan:\n Cont heparin gtt as well as Coumadin until INR ^ 2.\n Altered mental status (not Delirium)\n Assessment:\n Rec\nd pt on Versed @ 2mg/hr, Fentanyl @ 75 mcg/hr, as well as Fentanyl\n patches totaling 150mcg in place. Pt also rec\ning Diazepam 10mg po\n Q6hrs, in hope of weaning pt from IV sedation. Agitated most time\n moving around intermittently following commands. Moving arms\n purposefully towards trach, so soft wrist restraints remain in place..\n Action:\n Pt required bolus sedation x2 with care and activity.\n Response:\n Pt restless/squirming in bed when she appears awake..\n Plan:\n Cont to attempt weaning from IV sedation. emotional support to pt and\n family,reorient pt .\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt on vent settings AC 50%/18 X 400/+10, no over-breathing of\n rate . O2 sats 94-96%. ABG done yesterday was 7.44/42/93. Lung sounds\n clear but diminished in lower lobes. Suctioned for small-moderate amts\n thick white secretions.\n Action:\n Cont same Vent settings.Getting breathing rx by respitory\n Response:\n Pts secretions got better\n Plan:\n Cont wean from vent with PS trials,Monitor mental status.\n"},{"category":"Nursing","chartdate":"2167-10-05 00:00:00.000","description":"Nursing Progress Note","row_id":635826,"text":"55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\n Now with prolonged hospital course c/b by PNA with high PEEP\n requirement, anxiety, RUE DVT on heparin qtt.\n Edema, peripheral\n Assessment:\n Rec\nd pt on 2mg/hr lasix gtt\n Action:\n Pt putting out 400-500cc/hr.\n Response:\n Fluid balance approx -50ml/hr, with 24hr fluid balance -650ml @ 1500.\n However, SBP 78 when pt soundly sleeping/sedated. Lasix qtt stopped @\n 1530.\n Plan:\n Cont Lasix gtt goal Negative 1-2L,monitor BPclosely\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Rec\nd pt on Heparin qtt @ 1500units/hr.\n Action:\n PTT 62,2 @ 0230.\n Response:\n Heparin rate unchanged.pt had 2 therapeutic PTT,started on coumadin\n 5mg at 2200,.\n Plan:\n Cont heparin gtt as well as Coumadin until INR ^ 2.\n Altered mental status (not Delirium)\n Assessment:\n Rec\nd pt on Versed @ 2mg/hr, Fentanyl @ 75 mcg/hr, as well as Fentanyl\n patches totaling 150mcg in place. Pt also rec\ning Diazepam 10mg po\n Q6hrs, in hope of weaning pt from IV sedation. Agitated most time\n moving around intermittently following commands. Moving arms\n purposefully towards trach, so soft wrist restraints remain in place..\n Action:\n Pt required bolus sedation x2 with care and activity.\n Response:\n Pt restless/squirming in bed when she appears awake..\n Plan:\n Cont to attempt weaning from IV sedation. emotional support to pt and\n family,reorient pt .\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt on vent settings AC 50%/18 X 400/+10, no over-breathing of\n rate . O2 sats 94-96%. ABG done yesterday was 7.44/42/93. Lung sounds\n clear but diminished in lower lobes. Suctioned for small-moderate amts\n thick white secretions.\n Action:\n Cont same Vent settings.Getting breathing rx by respitory\n Response:\n Pts secretions got better\n Plan:\n Cont wean from vent with PS trials,Monitor mental status.\n"},{"category":"Nursing","chartdate":"2167-10-05 00:00:00.000","description":"Nursing Progress Note","row_id":635834,"text":"55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\n Now with prolonged hospital course c/b by PNA with high PEEP\n requirement, anxiety, RUE DVT on heparin qtt.\n Edema, peripheral\n Assessment:\n Rec\nd pt on 2mg/hr lasix gtt\n Action:\n Pt putting out 400-500cc/hr.K was 3.1 this morning.\n Response:\n Pt still putting out 400-500cc.hr,BP stayed stable.K repleted w/total\n of 80 Meq\n Plan:\n Cont Lasix gtt goal Negative 1-2L,monitor BPclosely\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Rec\nd pt on Heparin qtt @ 1500units/hr.\n Action:\n PTT 62,2 @ 0230.\n Response:\n Heparin rate unchanged two therapeutic PTT level,started on\n coumadin 5mg yesterday at 2200,.\n Plan:\n Cont heparin gtt as well as Coumadin until INR ^ 2.\n Altered mental status (not Delirium)\n Assessment:\n Rec\nd pt on Versed @ 2mg/hr, Fentanyl @ 75 mcg/hr, as well as Fentanyl\n patches totaling 150mcg in place. Pt also rec\ning Diazepam 10mg po\n Q6hrs, in hope of weaning pt from IV sedation. Agitated most time\n moving around intermittently following commands. Moving arms\n purposefully towards trach, so soft wrist restraints remain in place..\n Action:\n Pt required bolus sedation x2 with care and activity.\n Response:\n Pt restless/squirming in bed when she appears awake..\n Plan:\n Cont to attempt weaning from IV sedation. emotional support to pt and\n family,reorient pt .\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt on vent settings AC 50%/18 X 400/+10, no over-breathing of\n rate . O2 sats 94-96%. ABG done yesterday was 7.44/42/93. Lung sounds\n clear but diminished in lower lobes. Suctioned for small-moderate amts\n thick white secretions.\n Action:\n Cont same Vent settings.Getting breathing rx by respitory\n Response:\n Pts secretions got better\n Plan:\n Cont wean from vent with PS trials,Monitor mental status.\n"},{"category":"Physician ","chartdate":"2167-09-29 00:00:00.000","description":"Physician Resident Progress Note","row_id":635063,"text":"Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - STOP 09:00 PM - attempted to re-wire but\n patient was very agitated and re-wire was unsuccessful\n Patient alternated between tachycardia and normotension and hypotension\n in the high-80s/low 90s and HRs in the 50s\n Given haldol, valium, midaz and fentanyl for sedation\n ABG with low paO2 on PEEP 10, had to increase -- went back up to 15 and\n then attempted to re-wean down with goal 8 in anticipation of OR\n To OR for trach and PEG today (thoracics)\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 08:06 AM\n Infusions:\n Midazolam (Versed) - 1.5 mg/hour\n Fentanyl - 200 mcg/hour\n Other ICU medications:\n Fentanyl - 06:45 PM\n Ranitidine (Prophylaxis) - 08:00 PM\n Haloperidol (Haldol) - 10:00 PM\n Midazolam (Versed) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.7\nC (99.8\n HR: 109 (55 - 134) bpm\n BP: 120/56(70) {80/43(51) - 133/85(94)} mmHg\n RR: 20 (16 - 28) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 101 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 3,064 mL\n 404 mL\n PO:\n TF:\n 1,440 mL\n IVF:\n 1,014 mL\n 314 mL\n Blood products:\n Total out:\n 4,257 mL\n 1,195 mL\n Urine:\n 4,257 mL\n 1,195 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,193 mL\n -791 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 18\n RR (Spontaneous): 10\n PEEP: 15 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10\n PIP: 23 cmH2O\n Plateau: 24 cmH2O\n SpO2: 97%\n ABG: 7.46/48/65/31/8\n Ve: 7.8 L/min\n PaO2 / FiO2: 108\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 320 K/uL\n 8.0 g/dL\n 94 mg/dL\n 0.6 mg/dL\n 31 mEq/L\n 3.6 mEq/L\n 13 mg/dL\n 110 mEq/L\n 147 mEq/L\n 25.8 %\n 9.0 K/uL\n [image002.jpg]\n 10:18 AM\n 02:33 PM\n 02:46 PM\n 03:31 AM\n 02:26 PM\n 05:53 PM\n 05:01 AM\n 03:32 PM\n 10:19 PM\n 02:50 AM\n WBC\n 9.7\n 9.5\n 9.0\n Hct\n 26.0\n 27.6\n 25.8\n Plt\n \n Cr\n 0.5\n 0.5\n 0.5\n 0.6\n 0.6\n TCO2\n 29\n 26\n 27\n 30\n 30\n 35\n Glucose\n 195\n 195\n 163\n 133\n 102\n 94\n Other labs: PT / PTT / INR:14.1/59.6/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:71.2 %, Lymph:22.7 %,\n Mono:4.0 %, Eos:1.7 %, Lactic Acid:1.5 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:8.2 mg/dL, Mg++:2.1 mg/dL, PO4:4.6 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with respiratory failure\n and difficulty weaning from vent.\n # Respiratory failure: Intubated on for resp decompensation.\n Likely VAP. Transferred here for tracheomalacia, but not sure this\n is a component. Will need bronch eval when improved\n - will discuss PEEP goal for trach placement with IP.\n - wean PEEP\n - repeat ABG this AM\n - discuss need for trach with patient and her family\n - Volume overload may be contributing.\n # Volume overload\n Currently with hypernatremia, Cr increase, contract\n alk, but mild\n - continue gentle diuresis\n - FW in TF at 150 cc q4hrs\n - PM lytes.\n # Sedation: On versed 3mg/hr + .5 q 1hr and fentanyl 150 mcg/hr + 50\n bolus q 1hr.\n - Start fentanyl patch and diazepam to provide long acting analgesia\n and wean from drips\n - Haldol 1 mg Q4h PRN agitation\n # Pneumonia: Pansensitive Kleb oxytoca pneumonia and sputum with GPCs\n on gram stain. Afebrile off abx.\n # EKG changes: Sinus bradycardia, responsive to stress. Related to\n sedation, increased vagal tone, possibly related to steroid\n replacement. Atrial EKG shows p-waves and cardiac enzymes normal.\n - Continue to monitor\n # Hypotension: Improved, off levophed for 2-3 days now, with good urine\n output. s/p 5 d course of steroids for adrenal insufficiency. High\n PEEP may have been contributing. Now likely related to sedation and\n decreased intravascular volume,\n -monitor, expect improvement with continual reduction in PEEP\n # RUE DVT: Started on heparin gtt on , now therapeutic. Follow\n PTTs. Would hold off on coumadin at least until s/p trach.\n - continue to monitor\n # Adrenal Insufficency: Random cortisol was approx 3 when it should\n have been maximally stimulated.\n - hydrocortisone and florinef for 5 days\n # Anemia: Stable.\n - Trend HCT\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n FEN/GI: Tube feeds @ goal\n DVT: Treatment dose heparin\n Ulcer: Ranitidine\n VAP: Prevention per routine\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2167-09-30 00:00:00.000","description":"Physician Resident Progress Note","row_id":635216,"text":"Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - START 02:00 PM - in right brachial atery\n Hypotensive- started on levophed, weaned off over night\n Low cortisol and failed stim test - started on steroids\n TTE ordered\n Free water flushes were increased for hypernatremia (250cc q4)\n Able to hear patient breathing at times during exam this am (poor am\n CXR, reordered)\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 08:06 AM\n Infusions:\n Heparin Sodium - 1,700 units/hour\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 150 mcg/hour\n Other ICU medications:\n Haloperidol (Haldol) - 12:15 AM\n Other medications:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 36.7\nC (98\n HR: 63 (48 - 138) bpm\n BP: 91/41(58) {68/30(49) - 143/78(105)} mmHg\n RR: 18 (13 - 23) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Mixed Venous O2% Sat: 59 - 59\n Total In:\n 3,898 mL\n 1,155 mL\n PO:\n TF:\n 802 mL\n 348 mL\n IVF:\n 2,126 mL\n 247 mL\n Blood products:\n Total out:\n 2,367 mL\n 800 mL\n Urine:\n 2,367 mL\n 800 mL\n NG:\n Stool:\n ?\n ?\n Drains:\n Balance:\n 1,531 mL\n 355 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 401) mL\n RR (Set): 18\n RR (Spontaneous): 1\n PEEP: 10 cmH2O\n FiO2: 40%\n PIP: 23 cmH2O\n Plateau: 19 cmH2O\n Compliance: 57.1 cmH2O/mL\n SpO2: 91%\n ABG: 7.42/49/93/33/5\n Ve: 8.1 L/min\n PaO2 / FiO2: 155\n Physical Examination\n General Appearance: Easily agitated, appears uncomfortable, Overweight\n / Obese, opens eyes but no purposeful movement\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\n deviation\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Respiratory / Chest: (Expansion: Symmetric), referred breath sounds\n from ETT\n Abdominal: No(t) Soft, Non-tender, Few Bowel sounds present, Distended\n Extremities: No clubbing or cyanosis, 3+ nonpitting edema of b/l hands,\n anasarca\n Skin: no rashes or jaundice\n Neuro: diffusely hyperreflexic with LE clonus\n Lines: r brachioceph ART and L PICC C/D/I\n Labs / Radiology\n 355 K/uL\n 9.1 g/dL\n 168 mg/dL\n 0.5 mg/dL\n 30 mEq/L\n 3.9 mEq/L\n 11 mg/dL\n 108 mEq/L\n 146 mEq/L\n 29.9 %\n 11.8 K/uL\n [image002.jpg]\n 03:32 PM\n 10:19 PM\n 02:50 AM\n 02:30 PM\n 02:44 PM\n 03:33 PM\n 07:26 PM\n 07:46 PM\n 02:04 AM\n 02:18 AM\n WBC\n 9.0\n 8.4\n 11.8\n Hct\n 25.8\n 23.0\n 28.1\n 29.9\n Plt\n \n Cr\n 0.6\n 0.7\n 0.5\n TCO2\n 30\n 35\n 33\n 31\n 33\n Glucose\n 94\n 97\n 168\n Other labs: PT / PTT / INR:13.8/70.4/1.2, Differential-Neuts:89.7 %,\n Lymph:8.7 %, Mono:1.1 %, Eos:0.4 %, Ca++:8.5 mg/dL, Mg++:2.2 mg/dL,\n PO4:5.4 mg/dL\n TSH 2.9; FT4 1.5; stim 3.1, 10.5, 10.6\n Culture Data: endotrach with K oxytoca; gram stain GPCs in\n pairs and clusters\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca, .\n # Respiratory failure: Related to ARDS, ? trachiomalacia, resolved\n VAP, volume overload. Intubated on for resp decompensation.\n Transferred here for tracheomalacia, but not sure this is a component.\n Will need bronch eval when improved\n - Thoracics will do trach and PEG once stable on PEEPs around 10.\n Re-c/s today.\n - wean PEEP as tolerated\n # Volume overload\n Hypernatremic (? Relationship to adrenal\n insufficiency), TBW deficit 2.6L.\n - goal even I/Os today\n - FW in TF at 250 cc q4hrs\n - PM lytes\n # Hyperreflexia - ? meds vs central pathology\n - consider head CT in context of heparin gtt to r/o intracranial\n hemmorhage\n # Sedation: Poor sedation control. On Versed 1.5, Fentanyl 175,\n Fentanyl patch, Diazepam standing and haldo 2.5-5 mg PRN. QTc stable\n at .44\n - Wean versed/fentanyl as tolerated\n - Recheck EKG today\n -\n # Hypotension: Related to sedation, but high PEEP, adrenial\n insufficiency, sepsis have previously been contributing. Monitor with\n A-line. Failed stim again.\n - hydrocortisol and fludrocortisone\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\n coumadin at least until s/p trach.\n - hold heparin gtt when anticipate trach/peg\n # Adrenal Insufficency: Minimal response to stim test again.\n - hydrocort and fludrocort\n - consider endocrine c/s for further elucidation of etiology\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n # FEN/GI: Tube feeds @ goal.\n DVT: Treatment dose heparin\n Ulcer: Ranitidine\n VAP: Prevention per routine\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 09:51 PM 60 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Arterial Line - 02:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2167-09-30 00:00:00.000","description":"Physician Resident/Attending Progress Note - MICU","row_id":635227,"text":"Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - START 02:00 PM - in right brachial atery\n Hypotensive- started on levophed, weaned off over night\n Low cortisol and failed stim test - started on steroids\n TTE ordered\n Free water flushes were increased for hypernatremia (250cc q4)\n Able to hear patient breathing at times during exam this am (poor am\n CXR, reordered)\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 08:06 AM\n Infusions:\n Heparin Sodium - 1,700 units/hour\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 150 mcg/hour\n Other ICU medications:\n Haloperidol (Haldol) - 12:15 AM\n Other medications:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 36.7\nC (98\n HR: 63 (48 - 138) bpm\n BP: 91/41(58) {68/30(49) - 143/78(105)} mmHg\n RR: 18 (13 - 23) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Mixed Venous O2% Sat: 59 - 59\n Total In:\n 3,898 mL\n 1,155 mL\n PO:\n TF:\n 802 mL\n 348 mL\n IVF:\n 2,126 mL\n 247 mL\n Blood products:\n Total out:\n 2,367 mL\n 800 mL\n Urine:\n 2,367 mL\n 800 mL\n NG:\n Stool:\n ?\n ?\n Drains:\n Balance:\n 1,531 mL\n 355 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 401) mL\n RR (Set): 18\n RR (Spontaneous): 1\n PEEP: 10 cmH2O\n FiO2: 40%\n PIP: 23 cmH2O\n Plateau: 19 cmH2O\n Compliance: 57.1 cmH2O/mL\n SpO2: 91%\n ABG: 7.42/49/93/33/5\n Ve: 8.1 L/min\n PaO2 / FiO2: 155\n Physical Examination\n General Appearance: Easily agitated, appears uncomfortable, Overweight\n / Obese, opens eyes but no purposeful movement\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\n deviation\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Respiratory / Chest: (Expansion: Symmetric), referred breath sounds\n from ETT\n Abdominal: No(t) Soft, Non-tender, Few Bowel sounds present, Distended\n Extremities: No clubbing or cyanosis, 3+ nonpitting edema of b/l hands,\n anasarca\n Skin: no rashes or jaundice\n Neuro: diffusely hyperreflexic with LE clonus\n Lines: r brachioceph ART and L PICC C/D/I\n Labs / Radiology\n 355 K/uL\n 9.1 g/dL\n 168 mg/dL\n 0.5 mg/dL\n 30 mEq/L\n 3.9 mEq/L\n 11 mg/dL\n 108 mEq/L\n 146 mEq/L\n 29.9 %\n 11.8 K/uL\n [image002.jpg]\n 03:32 PM\n 10:19 PM\n 02:50 AM\n 02:30 PM\n 02:44 PM\n 03:33 PM\n 07:26 PM\n 07:46 PM\n 02:04 AM\n 02:18 AM\n WBC\n 9.0\n 8.4\n 11.8\n Hct\n 25.8\n 23.0\n 28.1\n 29.9\n Plt\n \n Cr\n 0.6\n 0.7\n 0.5\n TCO2\n 30\n 35\n 33\n 31\n 33\n Glucose\n 94\n 97\n 168\n Other labs: PT / PTT / INR:13.8/70.4/1.2, Differential-Neuts:89.7 %,\n Lymph:8.7 %, Mono:1.1 %, Eos:0.4 %, Ca++:8.5 mg/dL, Mg++:2.2 mg/dL,\n PO4:5.4 mg/dL\n TSH 2.9; FT4 1.5; stim 3.1, 10.5, 10.6\n Culture Data: endotrach with K oxytoca; gram stain GPCs in\n pairs and clusters\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA and\n ARDS intubated since the end of .\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation.\n Transferred here for airway stenting. Will need bronch eval when\n improved.\n - Thoracics will do trach and PEG once stable on PEEPs around 10.\n Re-c/s today.\n - wean PEEP as tolerated\n # # Adrenal Insufficency: Minimal response to stim test again.\n - hydrocort and fludrocort (day 1 = )\n - endocrine c/s for further elucidation of etiology\n # Hypotension: Likely adrenal insufficiency. Goal map > 60.\n - hydrocortisol and fludrocortisone as above\n - restart levophed if necessary to maintain MAP > 60\n # Volume overloaded in setting of hypernatremia (? Relationship to\n adrenal insufficiency), TBW deficit 2.6L.\n - goal even to -500cc I/Os today\n - continue FW in TF at 250 cc q4hrs\n - lasix drip (1-5mg/hr) when MAP > 60\n # Hyperreflexia - ? meds vs central pathology. Unlikely to be \n intracranial hemorrhage as patient is diffusely hyperreflexic.\n Possible relationship to endocrine pathology?\n - consider head CT in setting of heparin gtt\n - monitor\n # Sedation: Sedation control remains somewhat poor although fentanyl\n patch and diazpem are likely starting increase to therapeutic range\n today. On Versed 1.5, Fentanyl 175, Fentanyl patch, Diazepam standing\n and haldo 2.5-5 mg PRN. QTc stable at .44.\n - Wean versed/fentanyl as tolerated, continue diazepam and prn\n haldol\n - Recheck EKG today\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\n coumadin at least until s/p trach.\n - hold heparin gtt when anticipate trach/peg\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n # FEN/GI: Tube feeds @ goal.\n DVT: Treatment dose heparin\n Ulcer: Ranitidine\n VAP: Prevention per routine\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 09:51 PM 60 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Arterial Line - 02:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 55F T5-8 fractures with retropulsion and ARDS\n from VAP; on heparin for UE DVT. Yesterday, hypotension confirmed by\n placement of R axillary arterial line, required levophed for several\n hours. Random cortisol 3, increased to 10 s/p ACTH; restarted on\n hydrocortisone 50IV q6h with improved BP, able to come off pressors.\n Has made progress on the vent, with PEEP back down to 10 and FiO2 0.5.\n On rounds, has audible ETT cuff leak, tube appears high on CXR.\n Exam notable for Tm 99.5 BP 105/45 HR 50-115 RR 18-20 with sat 93% on\n VAC 400x18 PEEP 10 FiO2 0.5 for 7.42/49/93. TBB +14L/MICU LOS. Eyes\n opens, will squeeze hands and wiggle toes but very drowsy. Positive\n cuff leak, bronchial BS bilaterally with RRR s1s2 SM at base.\n Abdomen is distended with decreased BS. 3+ edema in BLE, no cords. Labs\n notable for WBC 11K, HCT 30, K+ 3.9, Na 146, Cr 0.5. CXR with resolving\n B LL airspace disease and effusions.\n Agree with plan to continue supplementation with hydrocortisone 50\n q6-8h and discuss with endocrine as she seems to have adrenal\n insufficiency. Needs bronchoscopy now to confirm tube position, will\n continue vent weaning by dropping PEEP to 8 and discuss with T-\n regarding T+G in AM. Will continue fentanyl patch and po valium as we\n wean IV sedation. Consider head CT if neuro exam becomes more focal\n while on heparin, but will hold off for now. Will continue diuresis\n with IV lasix to affect a negative fluid balance and use haldol for\n breakthrough agitiation. Will continue IV heparin for UE DVT; consider\n transition to coumadin only after tracheostomy and feeding tube\n placement, which will require lower ventilator settings. Will restart\n tube feeds and add FW boluses for hypernatremia. Continue spinal\n stabilization with brace when OOB; will eventually need MRI for\n surgical planning; remainder of plan as outlined above.\n Patient is critically ill\n Total time: 40 min\n ------ Protected Section Addendum Entered By: , MD\n on: 12:55 PM ------\n"},{"category":"Respiratory ","chartdate":"2167-10-01 00:00:00.000","description":"Generic Note","row_id":635294,"text":"TITLE:\n Respiratory Care: Rec\nd pt on a/c 18/400/+8/50%. Ett 7.5, retaped,\n rotated and secured @ 20 lip. BS are coarse with diminished bases.\n Suctioned for small amounts of thick white secretions. MDI\n administered as ordered alb/atr with no adverse reactions AM ABG\n 7.42/47/87. No rsbi due to trach/peg procedure possibly in OR.\n"},{"category":"General","chartdate":"2167-10-01 00:00:00.000","description":"Generic Note","row_id":635295,"text":"55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP now with prolonged\n hospital course c/o by PNA anxiety,RUE DVD with high PEEP requirement\n .\n Events\n Heparin gtt and TF held since MN for ? trach and peg\n placement today.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on AC 400/18/8/50%. 02 sats mainly 88-92% but did fall to\n 86% when pt positioned on L side. Pt fluid overloaded with TFB for LOS\n ~ ccs.\n Action:\n ABG taken while sat 88%. Lasix gtt increased to 3mg/hr\n Response:\n ABG 7.42/47/87/4/32. Urine output initially 25 ccs/hr but pt began\n autodiuresing after MN with output improving to ~140ccs/hr\n Plan:\n Continue with current vent settings. Trach today. Titrate lasix gtt to\n maintain MAP > 60 and u/o 100-150ccs/hr.\n Altered mental status (not Delirium)\n Assessment:\n Pt restless at times, thrashing in bed with HR up to 140 ST . Denies\n pain or doesn\nt respond when questioned if she is having pain.\n Action:\n Fentanyl drip infusing at 100mcgs/hr. Fentanyl patch in place. Also\n treated with haldol and valium . Bolused with 2 mg versed when acutely\n agitated. Bilateral wrist restraints in place.\n Response:\n Pt falls back to sleep, HR decreases (occasionally as low as 45 SB)\n Plan:\n Continue to assess MS. as indicated. Reorientation. Restraints\n for safety.\n Hypernatremia (high sodium)\n Assessment:\n Na 146 on \n Action:\n Treated with free h20 boluses\n Response:\n Na 143 this am\n Plan:\n Continue to monitor f+e status.\n Impaired Skin Integrity\n Assessment:\n Pt with excoriated yeast infection on abd and in perineal area. +\n reddened perirectal area.\n Action:\n Barrier cream and miconazole powder applied\n Response:\n To be determined.\n Plan:\n Diligent skin care.\n"},{"category":"Respiratory ","chartdate":"2167-09-21 00:00:00.000","description":"Respiratory Care Shift Note","row_id":634284,"text":"Demographics\n Day of intubation: \n Day of mechanical ventilation: 3\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Crackles\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Crackles\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Pt went to CT this PM for CT of head and chest, attempted to place\n Esoph balloon but kept tangeling on the OET and\n tube\n Will try again later. Ventrac in room..\n, RRT 18:43\n"},{"category":"Nursing","chartdate":"2167-09-21 00:00:00.000","description":"Nursing Progress Note","row_id":634286,"text":"55-year-old woman with\n Respiratory failure\n Traumatic thoracic spinal fractures\n Probable VAP\n Upper extremity DVT\n Oliguria\n Anemia\n * Possible tracheobronchomalacia (reason for transfer from OSH)\n Events: Multi-lumen CVL placed at bedside. CXR cleared for use. Bedside\n Echo performed and Non-contrast CT of spine and Torso done.\n Alteration in Nutrition\n Assessment:\n NPO, Pt w/ high residuals yesterday. Abdomen increasingly distended and\n slightly firm. BS hypoactive. Low albumin. Bladder pressure performed\n d/t distended abdomen and low UOP: 18-20.\n Action:\n OGT to low wall suction to decompress abdomen. TF off. CT of abdomen\n done.\n Response:\n OGT putting out clear/pink drainage <100cc. CT scan results pending.\n Plan:\n Cont NPO at this time and OGT to low wall sxn. ? Restart TF.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n RUE + DVT\n Action:\n Cont on sq heparin\n Response:\n No change\n Plan:\n Consult neuro-surgery regarding anti-coagulation w/ T-spine fx, elevate\n RUE, no blood draws or blood pressures to RUE. ? Start heparin gtt once\n cleared from neurosurgery.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Temp max 100\n Action:\n Antibiotics given. Dosage changes made to vanco and aztreonam.\n Response:\n No further temp spike.\n Plan:\n Cont w/ antibiotics, f/u on cultures, Tylenol prn, vanco trough to be\n drawn prior to 8am dose on per pharmacy (if drawn earlier than\n results will be falsely elevated d/t dosage changes).\n Fracture, other\n Assessment:\n T-spine compression fx, Back brace at bedside when OOB.\n Action:\n Ortho tech consulted for placement of back brace. Cont w/ log roll\n precautions. CT scan done\n Response:\n Pt denies c/o pain when asked.\n Plan:\n Cont w/ log roll precautions, back brace for OOB, consult w/\n neurosurgery, pain mgmt.\n Anemia, other\n Assessment:\n HCT 24.1 from 28 yesterday (30 on admission)\n Action:\n Given 1 unit of PRBCs\n Response:\n Post HCT pending.\n Plan:\n Cont to follow HCTs, guiac stools, monitor of s/s of bleeding.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS- bronchial/rhonchorous throughout diminished to bilateral bases,\n deep sxn\nd for thick/tan secretions, copious clear oral secretions\n suctioned. ? PE/? VAP.\n Action:\n Vent changes made throughout shift. Esophageal balloon attempted-\n unable to place. CT scan of chest done.\n Response:\n Pt w/ high O2 requirements.\n Plan:\n Monitor ABGs, vent changes as needed.\n Hypotension (not Shock)\n Assessment:\n Pt hypotensive into low-mid 80s systolic, HR 70s-90, SR. Low uop-\n BUN/Creat negative.\n Action:\n Vigeleo set up, given 1 unit of blood, bloused x 1, multi-lumen RIJ\n placed at bedside. Levophed started.\n Response:\n No response to bolusing, RIJ okay to use. CVP 18. CO . Stroke\n volume 3.0.\n Plan:\n Cont to monitor VS closely, monitor I&O, levophed for MAPS >65\n"},{"category":"Nursing","chartdate":"2167-09-22 00:00:00.000","description":"Nursing Progress Note","row_id":634362,"text":"Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Fracture, other\n Assessment:\n Action:\n Response:\n Plan:\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2167-09-23 00:00:00.000","description":"Nursing Progress Note","row_id":634442,"text":"Events: Attempt to lighten sedation, stop Levophed gtt- MS \n stability labile from lethargic to restless in bed/crying w/\n intermittent BP 120\ns/ w/ and W/O stimulation. UOP cont 10-30cc/hr.\n Vigileo monitor on- SVV . Bladder pressure 14. TF restarted w/ goal\n slow inc as tolerated w/ recent high residuals.\n Alteration in Nutrition\n Assessment:\n Minimal residuals\n Action:\n Restarting TF replete w/ fiber @ 10cc/hr w/ Q6hr 20cc flush\n Response:\n Tolerating, goal advance Q6hr as tolerated\n Plan:\n Cont TF, monitor residuals, inc Q6hrs as tolerated\n Hypotension (not Shock)\n Assessment:\n BP labile- SBP 86-120, UOP down to 10cc/hr\n Action:\n Vigileo on- SVV , In AM attempt wean off Levo gtt\n Response:\n No fluid blousing, Levophed gtt started- titrated for MAP .65, UOP,\n Levo @ .02\n Plan:\n Cont Vigeligo monitoring,\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2167-10-06 00:00:00.000","description":"Nursing Progress Note","row_id":635959,"text":"55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\n Now with prolonged hospital course c/b by PNA with high PEEP\n requirement, anxiety, RUE DVT on heparin qtt.\n Bradycardia\n Assessment:\n Pt conts with HR 50-70\ns at rest, 100-140\ns during care, pt\n asymptomatic; easily arousable\n Action:\n Sedation decreased, Lasix off @0200\n Response:\n HR 60\n Plan:\n Cont to wean sedation, ?cardiac consult\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Action:\n Cont with IV Heparin @ 1500u/hr, Coumadin d\ncd for? thoracentesis\n Response:\n Pt therapeutic, cont with daily PTT\n Plan:\n Cont to labs, cont to wean off Heparin, Coumadin 5mg given x 1dose\n @ 2200, re-eval dosing this am\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt cont on AC 18/400/50%/10, LS clear bilat, occ scat rhonchi\n Action:\n Pt suct for sm thin tan secretions\n Response:\n Pt 02 Sats 94-97%,\n Plan:\n Cont to ABGs,\n Hypotension (not Shock)\n Assessment:\n SBP 140\ns when pt is agitated, SBP dropping to 70\ns-80\ns, UO 200/hr\n (total 2500 in 2hr)\n Action:\n Fent/Versed turned down @ 0000, Lasix gtt on hold, team informed\n Response:\n Pt SBP\ns in 80\n Plan:\n Cardiac consult to further eval SB/ST, re-evalu cont. Lasix gtt\n Hypernatremia (high sodium)\n Assessment:\n Na 146\n Action:\n Cont with 300cc free water flush Q4hrs\n Response:\n Plan:\n Cont to sodium levels, treat as ordered\n Altered mental status (not Delirium)\n Assessment:\n Pt alert and agitated throughout shift, pt following commands\n inconsistently; sleeping off and off throughout shift\n Action:\n Fent/Versed decreased low SBP\ns, pt recved prn dose of Haldol 1mg @\n 0100; cont with bilat. Wrist restraints for safety\n Response:\n pt sleeping off/on throughout shift, with periods of\n agitation/restlessness\n Plan:\n Cont to wean fent/versed gtt down, cont with scheduled Haldol/Valium;\n cont to QTC intervals daily\n"},{"category":"Nursing","chartdate":"2167-10-06 00:00:00.000","description":"Nursing Progress Note","row_id":635961,"text":"55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\n Now with prolonged hospital course c/b by PNA with high PEEP\n requirement, anxiety, RUE DVT on heparin qtt.\n Bradycardia\n Assessment:\n Pt conts with HR 50-70\ns at rest, 100-140\ns during care, pt\n asymptomatic; easily arousable\n Action:\n Sedation decreased, Lasix off @0200\n Response:\n HR 60\n Plan:\n Cont to wean sedation, ?cardiac consult\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Action:\n Cont with IV Heparin @ 1500u/hr, Coumadin d\ncd for? thoracentesis\n Response:\n Pt therapeutic, cont with daily PTT\n Plan:\n Cont to labs, cont to wean off Heparin, Coumadin 5mg given x 1dose\n @ 2200, re-eval dosing this am\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt cont on AC 18/400/50%/10, LS clear bilat, occ scat rhonchi\n Action:\n Pt suct for sm thin tan secretions\n Response:\n Pt 02 Sats 94-97%,\n Plan:\n Cont to ABGs,\n Hypotension (not Shock)\n Assessment:\n SBP 140\ns when pt is agitated, SBP dropping to 70\ns-80\ns, UO 200/hr\n (total 2500 in 2hr) K 3.3\n Action:\n Fent/Versed turned down @ 0000, Lasix gtt on hold, team informed ; pt\n recvd 1x dose of 40meg/Peg, 20meqK/250D5W x 1 dose\n Response:\n Pt SBP\ns in 80\n Plan:\n Cardiac consult to further eval SB/ST, re-evalu cont. Lasix gtt,\n recheck am labs\n Hypernatremia (high sodium)\n Assessment:\n Na 146\n Action:\n Cont with 300cc free water flush Q4hrs\n Response:\n Plan:\n Cont to sodium levels, treat as ordered\n Altered mental status (not Delirium)\n Assessment:\n Pt alert and agitated throughout shift, pt following commands\n inconsistently; sleeping off and off throughout shift\n Action:\n Fent/Versed decreased low SBP\ns, pt recved prn dose of Haldol 1mg @\n 0100; cont with bilat. Wrist restraints for safety\n Response:\n pt sleeping off/on throughout shift, with periods of\n agitation/restlessness\n Plan:\n Cont to wean fent/versed gtt down, cont with scheduled Haldol/Valium;\n cont to QTC intervals daily\n"},{"category":"Physician ","chartdate":"2167-09-30 00:00:00.000","description":"Physician Resident Progress Note","row_id":635219,"text":"Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - START 02:00 PM - in right brachial atery\n Hypotensive- started on levophed, weaned off over night\n Low cortisol and failed stim test - started on steroids\n TTE ordered\n Free water flushes were increased for hypernatremia (250cc q4)\n Able to hear patient breathing at times during exam this am (poor am\n CXR, reordered)\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 08:06 AM\n Infusions:\n Heparin Sodium - 1,700 units/hour\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 150 mcg/hour\n Other ICU medications:\n Haloperidol (Haldol) - 12:15 AM\n Other medications:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 36.7\nC (98\n HR: 63 (48 - 138) bpm\n BP: 91/41(58) {68/30(49) - 143/78(105)} mmHg\n RR: 18 (13 - 23) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Mixed Venous O2% Sat: 59 - 59\n Total In:\n 3,898 mL\n 1,155 mL\n PO:\n TF:\n 802 mL\n 348 mL\n IVF:\n 2,126 mL\n 247 mL\n Blood products:\n Total out:\n 2,367 mL\n 800 mL\n Urine:\n 2,367 mL\n 800 mL\n NG:\n Stool:\n ?\n ?\n Drains:\n Balance:\n 1,531 mL\n 355 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 401) mL\n RR (Set): 18\n RR (Spontaneous): 1\n PEEP: 10 cmH2O\n FiO2: 40%\n PIP: 23 cmH2O\n Plateau: 19 cmH2O\n Compliance: 57.1 cmH2O/mL\n SpO2: 91%\n ABG: 7.42/49/93/33/5\n Ve: 8.1 L/min\n PaO2 / FiO2: 155\n Physical Examination\n General Appearance: Easily agitated, appears uncomfortable, Overweight\n / Obese, opens eyes but no purposeful movement\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\n deviation\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Respiratory / Chest: (Expansion: Symmetric), referred breath sounds\n from ETT\n Abdominal: No(t) Soft, Non-tender, Few Bowel sounds present, Distended\n Extremities: No clubbing or cyanosis, 3+ nonpitting edema of b/l hands,\n anasarca\n Skin: no rashes or jaundice\n Neuro: diffusely hyperreflexic with LE clonus\n Lines: r brachioceph ART and L PICC C/D/I\n Labs / Radiology\n 355 K/uL\n 9.1 g/dL\n 168 mg/dL\n 0.5 mg/dL\n 30 mEq/L\n 3.9 mEq/L\n 11 mg/dL\n 108 mEq/L\n 146 mEq/L\n 29.9 %\n 11.8 K/uL\n [image002.jpg]\n 03:32 PM\n 10:19 PM\n 02:50 AM\n 02:30 PM\n 02:44 PM\n 03:33 PM\n 07:26 PM\n 07:46 PM\n 02:04 AM\n 02:18 AM\n WBC\n 9.0\n 8.4\n 11.8\n Hct\n 25.8\n 23.0\n 28.1\n 29.9\n Plt\n \n Cr\n 0.6\n 0.7\n 0.5\n TCO2\n 30\n 35\n 33\n 31\n 33\n Glucose\n 94\n 97\n 168\n Other labs: PT / PTT / INR:13.8/70.4/1.2, Differential-Neuts:89.7 %,\n Lymph:8.7 %, Mono:1.1 %, Eos:0.4 %, Ca++:8.5 mg/dL, Mg++:2.2 mg/dL,\n PO4:5.4 mg/dL\n TSH 2.9; FT4 1.5; stim 3.1, 10.5, 10.6\n Culture Data: endotrach with K oxytoca; gram stain GPCs in\n pairs and clusters\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA and\n ARDS intubated since the end of .\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation.\n Transferred here for airway stenting. Will need bronch eval when\n improved.\n - Thoracics will do trach and PEG once stable on PEEPs around 10.\n Re-c/s today.\n - wean PEEP as tolerated\n # Hypotension: Likely adrenal insufficiency.\n - hydrocortisol and fludrocortisone\n # Volume overload\n Hypernatremic (? Relationship to adrenal\n insufficiency), TBW deficit 2.6L.\n - goal even I/Os today\n - FW in TF at 250 cc q4hrs\n - PM lytes\n # Hyperreflexia - ? meds vs central pathology\n - consider head CT in context of heparin gtt to r/o intracranial\n hemmorhage\n # Sedation: Poor sedation control. On Versed 1.5, Fentanyl 175,\n Fentanyl patch, Diazepam standing and haldo 2.5-5 mg PRN. QTc stable\n at .44\n - Wean versed/fentanyl as tolerated\n - Recheck EKG today\n -\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\n coumadin at least until s/p trach.\n - hold heparin gtt when anticipate trach/peg\n # Adrenal Insufficency: Minimal response to stim test again.\n - hydrocort and fludrocort\n - consider endocrine c/s for further elucidation of etiology\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n # FEN/GI: Tube feeds @ goal.\n DVT: Treatment dose heparin\n Ulcer: Ranitidine\n VAP: Prevention per routine\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 09:51 PM 60 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Arterial Line - 02:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2167-10-02 00:00:00.000","description":"Physician Resident Progress Note","row_id":635440,"text":"Chief Complaint:\n 24 Hour Events:\n Patient agitated and combative overnight - restarted midazolam gtt and\n patient was becoming increasingly tachycardic and hypertensive\n Thoracics to take to OR this am for trach and PEG\n Discussion with patient's boyfriend yesterday - her should be here this\n weekend, wants to be involved, just hard for him to get here\n On lasix drip with excellent response (200 cc urine/hour)\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Fentanyl - 100 mcg/hour\n Furosemide (Lasix) - 1 mg/hour\n Heparin Sodium - 1,700 units/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:07 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.3\nC (99.2\n HR: 118 (45 - 138) bpm\n BP: 155/84(118) {91/38(56) - 177/106(139)} mmHg\n RR: 18 (17 - 27) insp/min\n SpO2: 90%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,604 mL\n 1,447 mL\n PO:\n TF:\n 675 mL\n 17 mL\n IVF:\n 1,089 mL\n 730 mL\n Blood products:\n Total out:\n 4,130 mL\n 2,430 mL\n Urine:\n 4,130 mL\n 2,430 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,526 mL\n -983 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n PS : 5 cmH2O\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n PIP: 22 cmH2O\n Plateau: 19 cmH2O\n Compliance: 48.2 cmH2O/mL\n SpO2: 90%\n ABG: 7.45/50/67/29/8\n Ve: 7.5 L/min\n PaO2 / FiO2: 134\n Physical Examination\n General Appearance: Responsive, following commands, Overweight / Obese,\n NAD\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\n deviation\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Respiratory / Chest: (Expansion: Symmetric), referred breath sounds\n from ETT\n Abdominal: No(t) Soft, Non-tender, Few Bowel sounds present, Distended\n Extremities: No clubbing or cyanosis, 3+ nonpitting edema of b/l hands,\n anasarca\n Skin: no rashes or jaundice\n Neuro: 3+ UE b/l, 4+ LE b/l\n Lines: r brachioceph ART and L PICC C/D/I\n Labs / Radiology\n 306 K/uL\n 8.5 g/dL\n 165 mg/dL\n 0.7 mg/dL\n 29 mEq/L\n 3.7 mEq/L\n 10 mg/dL\n 108 mEq/L\n 146 mEq/L\n 27.1 %\n 11.2 K/uL\n [image002.jpg]\n 02:18 AM\n 01:27 PM\n 03:06 PM\n 10:04 PM\n 03:00 AM\n 10:47 AM\n 04:10 PM\n 12:13 AM\n 05:08 AM\n 05:20 AM\n WBC\n 8.6\n 11.2\n Hct\n 25.9\n 27.1\n Plt\n 280\n 306\n Cr\n 0.6\n 0.5\n 0.7\n TCO2\n 33\n 32\n 32\n 34\n 36\n 36\n Glucose\n 176\n 136\n 165\n Other labs: PT / PTT / INR:13.2/68.7/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:89.7 %, Lymph:8.7 %, Mono:1.1\n %, Eos:0.4 %, Lactic Acid:0.9 mmol/L, Albumin:2.4 g/dL, LDH:204 IU/L,\n Ca++:10.6 mg/dL, Mg++:2.8 mg/dL, PO4:4.3 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA and\n ARDS intubated since the end of .\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation.\n Transferred here for airway stenting.\n - attempt SBT today\n - OR add on for trach and PEG with Dr. (tube feeds off\n after MN, heparin off after 6am)\n # # Adrenal Insufficency: Minimal response to stim test again.\n Appreciate endocrine recommendations.\n - hydrocort and fludrocort (day 1 = )\n - will continue at current dose until s/p trach and PEG and\n hemodynamically stable for 24 hours\n will then plan to taper\n hydrocortisone to 25mg IV q6 with a slow taper\n - will repreat ACTH stim test after tapered to <30mg\n hydrocortisone or off steroids\n - f/u daily endocrine recs\n # Hypotension: Likely adrenal insufficiency and sedation. Goal map\n > 60. Much improved since re-administration of steroids.\n - hydrocortisone and fludrocortisone as above\n - restart levophed if necessary to maintain MAP > 60\n # Volume overloaded in setting of hypernatremia with TBW deficit.\n - goal -1000cc I/Os today\n - continue FW in TF at 250 cc q4hrs\n - lasix drip (1-5mg/hr) when MAP >\n 60\n # Sedation: Sedation control remains somewhat poor although fentanyl\n patch and diazpem are likely therapeutic range today. On Versed 1.5,\n Fentanyl 175, Fentanyl patch, Diazepam standing and haldo 2.5-5 mg\n PRN. QTc increased to 480.\n - Wean versed/fentanyl as tolerated, continue diazepam. Avoid\n haldol use if possible to avoid further prolongation of QTc\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\n coumadin at least until s/p trach.\n - hold heparin gtt when anticipate trach/peg\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n # FEN/GI: Tube feeds with FWF @ goal.\n DVT: Treatment dose heparin\n Ulcer: Ranitidine\n VAP: Prevention per routine\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n - touch base with SW today\n Code: Full\n Dispo: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Arterial Line - 02:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Nursing","chartdate":"2167-10-02 00:00:00.000","description":"Nursing Progress Note","row_id":635441,"text":"55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP now with prolonged\n hospital course c/o by PNA anxiety,RUE DVD with high PEEP requirement\n .\n Events:\n Pt found at 19:30 to have loose restraints and was pulling on ETT. Pt\n found to have pulled out her esophageal tube and disconnected IV lines.\n CXR done and ETT and OGGT in right position.\n Plan: Plan for OR this am for trach and peg. Heparin gtt off at 6am.\n Edema, peripheral\n Assessment:\n Pt has gen edema with +2 pitting.\n Action:\n Pt is on lasix gtt, now at 1 mg/hr. Goal to remove 1-2 liters/24hrs. Pt\n is currently + 17.3 liters for LOS.\n Response:\n Pt is diuresing well to lasix .\n Plan:\n Continue to evaluate need for Lasix. Follow K level closely lasix\n gtt and need for freq replacements as nted.\n Hypernatremia (high sodium)\n Assessment:\n Hypernatremia.\n Action:\n D5W x 1 liter at 75 cc/hr in conjunction with H2O flushes.\n Response:\n Awaiting am Na level.\n Plan:\n Follow Na level.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains intubated on CMV settings at 50%/400x18/8. ABGs stable as\n noted. Goal PO2 > 60. LS coarse to upper resp areas with diminished\n bases. Pt has been deep sx\nd for scant amounts of yellow/tan\n secretions. Oral care q 4hrs. Pt noted to desat to 85% when turned onto\n her Rt side, but recovered within seconds. Ftom 5am, pt noted to desat\n to 85% with any restlessness and agitation. MD notified and sedation\n increased with good effect.\n Action:\n Response:\n Continue to eval need for sedation in order to support resp status.\n Plan:\n Plan for trach and Peg today this am.\n Altered mental status (not Delirium)\n Assessment:\n Pt has been awake and alert most of this shift. Pt follows immediate\n commands only. When told not to reach for ETT, she stopps, but within 2\n sec she will reach for ETT again. Pt continues to have freq episodes\n of being restless in bed and agitation, trying to sit up and reaching\n for ETT. Haldol DC\nd sl prolonged QT interval and versed prn\n boluses initiated as need with some effect. While resting (with\n sedation); Hr is in the 50\ns and SBP 99-105. While awake and agitated;\n HR now increases to 140-150\ns and SBP increases to high 170\ns, and pt\n noted to start to desat to 85% since 5am.\n Action:\n Emotional support given, but very short lived. Versed gtt initiated\n with good effect to protect resp status until trach placed.\n Response:\n Pt more relaxed.\n Plan:\n Continue to eval MS.\n Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt has a clot to her Rt arm. Rt arm with good radial pulses to palp and\n cap refill < 3 sec.\n Action:\n Pt on heparin gtt protocol. Gtt was DC\nd at 6am in preparation for OR.\n Response:\n PTT has been therapeutic at 1700 units/hr.\n Plan:\n ? need to restart heparin gtt post-op.\n"},{"category":"Nursing","chartdate":"2167-10-02 00:00:00.000","description":"Nursing Progress Note","row_id":635534,"text":"55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP now with prolonged\n hospital course c/o by PNA anxiety,RUE DVD with high PEEP requirement\n .\n EVENTS: trach PEG done, PEG OK for meds, restart TF in am. restart hep\n gtt tomorrow, diamox/ KCL added for alkalosis.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt rec\nd intubated, on AC 400x18 50% +PEEP 8\n Action:\n Trach placed in the OR, pt returned from OR and placed on previous vent\n settings, failed att at CPAP wean.\n Response:\n Plan:\n Att to wean vent/ sedation slowly in am. Cont to monitor\n Altered mental status (not Delirium)\n Assessment:\n Pt w/ periods of agitation and sleeping at other times, but overall\n more alert, following commands intermittently.\n Action:\n Midaz/ fentanyl changed to propofol in OR, changerd back to midazolam\n 2mg/hr and fentanyl 100mcg/hr upon return from OR r/t SB/ hypotension,\n cont on q6hr diazepam.\n Response:\n HR ranging from SB in the 40\ns when asleep to the 120\ns when agitated,\n b/p ranging from 90\ns/40\ns when asleep to 140-150\ns/ 70\ns when\n agitated. When pt awake appropriate and following commands HR\n 80\ns-100\ns and b/p 100\ns-120\ns/ 60-70\n Plan:\n Cont Fent/ versed gtt\ns titrate. As needed\n Alteration in Nutrition\n Assessment:\n Pt on lasix gtt at 1mg/hr, TF on hold for PEG placement\n Action:\n PEG placed in OR, lasix gtt restarted upon return from OR, diamox and\n KCL added to replete K+ and treat alkalosis\n Response:\n UOP 600mg after diamox, repeat K+ 4.1, PEG dsg D/I,\n Plan:\n PEG tube OK for meds restart TF in am, monitor and replete K+ as\n needed.\n"},{"category":"Physician ","chartdate":"2167-09-21 00:00:00.000","description":"Physician Attending Progress Note","row_id":634278,"text":"Chief Complaint: respiratory failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n URINE CULTURE - At 08:09 AM\n EKG - At 09:00 AM\n PICC LINE - STOP 10:30 AM\n BLOOD CULTURED - At 10:30 AM\n ULTRASOUND - At 01:00 PM\n U/S of RUE\n URINE CULTURE - At 03:00 PM\n UA/UC collected after new foley inserted.\n BAL FLUID CULTURE - At 03:00 PM\n mini-BAL\n ARTERIAL LINE - START 04:45 PM\n ARTERIAL LINE - STOP 02:03 AM\n ARTERIAL LINE - START 03:00 AM\n Multiple attempts at central access were unsuccessful due to\n malposition and difficulty threading wire.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 09:30 AM\n Vancomycin - 01:00 AM\n Aztreonam - 04:00 AM\n Metronidazole - 08:50 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 150 mcg/hour\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:00 AM\n Midazolam (Versed) - 09:32 AM\n Other medications:\n colace, CHG, SQI, H2B, SQH, MDIs, Flagyl, vanco, levo, aztreonam,\n versed, fentanyl\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (100.9\n Tcurrent: 37.9\nC (100.3\n HR: 72 (70 - 116) bpm\n BP: 100/48(60) {89/47(60) - 139/75(79)} mmHg\n RR: 18 (12 - 24) insp/min\n SpO2: 89%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 94.2 kg (admission): 94.2 kg\n Height: 67 Inch\n Bladder pressure: 18 (18 - 18) mmHg\n Total In:\n 5,600 mL\n 2,088 mL\n PO:\n TF:\n 120 mL\n IVF:\n 4,700 mL\n 1,728 mL\n Blood products:\n Total out:\n 798 mL\n 205 mL\n Urine:\n 798 mL\n 205 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,802 mL\n 1,883 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 80%\n RSBI Deferred: PEEP > 10\n PIP: 37 cmH2O\n Plateau: 25 cmH2O\n SpO2: 89%\n ABG: 7.45/42/95./28/4\n Ve: 9.1 L/min\n PaO2 / FiO2: 96\n Physical Examination\n Sedated. Breath sounds are coarse. Heart sounds are distant. Abdomen\n is protuberant with quiet breath sounds. Some peripheral edema. She\n is not able to cooperate with peripheral strength or sensory exam.\n Labs / Radiology\n 7.6 g/dL\n 319 K/uL\n 129 mg/dL\n 0.6 mg/dL\n 28 mEq/L\n 4.3 mEq/L\n 6 mg/dL\n 109 mEq/L\n 144 mEq/L\n 24.1 %\n 6.4 K/uL\n [image002.jpg]\n 11:54 PM\n 01:00 AM\n 06:14 AM\n 08:56 AM\n 08:57 AM\n 05:01 PM\n 08:03 PM\n 11:00 PM\n 03:01 AM\n 03:13 AM\n WBC\n 9.7\n 9.4\n 7.6\n 6.4\n Hct\n 30.7\n 25.1\n 24.1\n 24.1\n Plt\n 333\n 281\n 306\n 319\n Cr\n 0.6\n 0.6\n 0.7\n 0.6\n 0.6\n TCO2\n 32\n 33\n 35\n 33\n 30\n Glucose\n 103\n 126\n 126\n 127\n 129\n Other labs: PT / PTT / INR:16.9/26.3/1.5, ALT / AST:27/18, Alk Phos / T\n Bili:113/0.7, Differential-Neuts:76.9 %, Lymph:17.3 %, Mono:3.0 %,\n Eos:2.5 %, Lactic Acid:0.7 mmol/L, Albumin:2.3 g/dL, LDH:154 IU/L,\n Ca++:8.2 mg/dL, Mg++:2.6 mg/dL, PO4:3.1 mg/dL\n Imaging: CXR with bilateral opacities; ETT a little high. No PTX.\n Assessment and Plan\n 55-year-old woman with\n Respiratory failure\n Traumatic thoracic spinal fractures\n Probable VAP\n Upper extremity DVT\n Oliguria\n Anemia\n Possible tracheobronchomalacia (reason for transfer)\n I am uncertain about both the risks of anticoagulation and the risks of\n moving to radiology (e.g. CT or IR) in the context of her spinal\n fractures. Therefore we will consult spine surgery urgently for help\n with these questions.\n Her respiratory failure is likely multifactorial, including obesity,\n probable VAP, probable PE, and possible tracheobronchomalacia. She may\n also have weakness, but she is sedated and cannot cooperate with exam\n at present. We will check an echo to examine her RV. We will\n ventilate per ARDSnet; she may warrant esophageal-balloon-guided\n therapy if she does not improve in the next few hours.\n Oliguria is concerning, though BUN/Creatinine are reassuring. NG to\n suction to relieve abdominal distention. We will check urine lytes and\n assess stroke volume variation with the Vigileo. We will consider\n volume challenge based on this result.\n For central access, if we are able to safely move her we will ask I.R.\n to help with central access.\n We will continue broad antibiotics while awaiting cultures.\n ICU Care\n Nutrition: NPO for now\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 01:16 AM\n 20 Gauge - 01:36 AM\n 22 Gauge - 02:00 PM\n Arterial Line - 03:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 45 min\n Patient is critically ill\n ------ Protected Section ------\n Critical Care Staff Addendum\n 5:45p\n CVL successfully placed. CVP and SVV argue that she is adequately\n volume-replete. Hypoxemia has been a major issue, and we have taken\n her to CT this afternoon. We are awaiting final reads of the images.\n We will pursue esophageal balloon to help guide PEEP; first attempt was\n unsuccessful due to oropharyngeal coiling.\n Discussed in detail with patient\ns brother at bedside. Unable to reach\n her significant other.\n 35 minutes\n ------ Protected Section Addendum Entered By: , MD\n on: 17:55 ------\n"},{"category":"Physician ","chartdate":"2167-09-23 00:00:00.000","description":"Physician Resident Progress Note","row_id":634435,"text":"Chief Complaint:\n 24 Hour Events:\n ESOPHOGEAL BALLOON - At 01:46 PM - went well, were able to\n increase PEEP to improve oxygenation\n - started naloxone to encourage bowel motility, with some success,\n rectal tube in place with some stool\n -started heparin gtt for RUE DVT\n -borderline hypotensive at times (low 90s) with low urine output,\n received boluses and norepi back on at 0.04 (now down to 0.02)\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 09:45 AM\n Metronidazole - 03:32 PM\n Vancomycin - 08:00 PM\n Aztreonam - 10:00 PM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Heparin Sodium - 1,700 units/hour\n Fentanyl - 100 mcg/hour\n Norepinephrine - 0.04 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38\nC (100.4\n Tcurrent: 37.3\nC (99.2\n HR: 73 (60 - 102) bpm\n BP: 90/46(61) {76/38(56) - 160/71(97)} mmHg\n RR: 23 (16 - 25) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101 kg (admission): 94.2 kg\n Height: 67 Inch\n CVP: 8 (8 - 15)mmHg\n Bladder pressure: 18 (18 - 21) mmHg\n Esophageal Pressure:\n 26\n Total In:\n 3,524 mL\n 234 mL\n PO:\n TF:\n 48 mL\n IVF:\n 3,236 mL\n 234 mL\n Blood products:\n Total out:\n 935 mL\n 215 mL\n Urine:\n 650 mL\n 215 mL\n NG:\n 285 mL\n Stool:\n Drains:\n Balance:\n 2,589 mL\n 19 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: AC\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 0 (0 - 0) mL\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 23 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 42 cmH2O\n Plateau: 32 cmH2O\n Compliance: 44.4 cmH2O/mL\n SpO2: 100%\n ABG: 7.37/44/160 (6am)\n Ve: 9.5 L/min\n PaO2 / FiO2: 255\n Physical Examination\n Gen: Does not arouse to voice\n HEENT: Pupils 3 mm reactive bilaterally. Scleral edema bilat\n Resp: Symmetric expansion. Coarse breath sounds throughout. Cannot\n adeq listen to post bases\n CV: RRR.\n Abd: Hypoactive bowel sounds. Distended.\n Ext: Edema in bilat UE.\n Peripheral vascular: Radial pulses 2+ bilaterally.\n Neuro: Moving all 4 extremities.\n Labs / Radiology\n 358 K/uL\n 8.9 g/dL\n 126 mg/dL\n 0.7 mg/dL\n 25 mEq/L\n 3.5 mEq/L\n 4 mg/dL\n 108 mEq/L\n 143 mEq/L\n 28.0 %\n 8.1 K/uL\n [image002.jpg]\n 03:01 AM\n 03:13 AM\n 12:05 PM\n 06:08 PM\n 06:11 PM\n 07:53 PM\n 02:02 AM\n 03:59 AM\n 09:14 PM\n 01:04 AM\n WBC\n 6.4\n 8.4\n Hct\n 24.1\n 29.0\n 28.1\n Plt\n 319\n 376\n Cr\n 0.6\n 0.6\n TCO2\n 30\n 29\n 29\n 25\n 25\n 28\n 28\n Glucose\n 129\n 120\n PT 22.2 PTT 76.0 INR 2.1\n Differential-Neuts:74.7 %, Lymph:17.6 %, Mono:3.5 %, Eos:3.8 %\n Ca++:8.2 mg/dL, Mg++:2.0 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture\n # Respiratory failure: initial etiology unclear, likely multifactorial\n now with significant pneumonia. Had one sputum that showed GNR.\n - Concern for ARDS given clinical and radiographic picture. Will hold\n on bronch given high PEEP; can consider proning. Have some room to\n increase PEEP based on esoph balloon\n - Placed esophageal balloon and increased PEEP\n - Will allow her to stay on current vent settings today in order to let\n her lungs rest\n # VAP: Had been febrile, now resolved\n - be aspiration or be VAP. Sputum from grew rare GNR;\n awaiting speciation.\n - Has been Vanc, aztreonam, levofloxicin. Vanc trough today was 20\n - Will d/c vanc today () as no current evidence to suggest a gram\n positive infection\n - Will d/c flagyl because had one neg c. diff toxin and CT did not show\n evidence of colitis\n - Continue aztreonam and levofloxicin for gram neg pneumonia for 8 days\n pending speciation (at that time can increase to 15 days if necessary)\n # Hypotension, requiring Levophed:\n - Hypovolemia is possibly a factor- responded to a transfusion; HCT had\n been dropping\n - Sepsis also a factor- on broad spectrum abs\n - Central line in place.\n - Will check a SVV (with vigileo) today to determine volume status\n # Oliguria:\n -BUN and Cr reassuring.\n - Continue to monitor\n # RUE DVT: Started on heparin gtt on .\n -Therapeutic in one day; may be related to poor nutritional status.\n Will continue to closely monitor\n # Abd distention: be chronic condition not requiring immediate\n medical attention\n - CT abd only showed appendiceal mucocele without inflammation, not\n concerning, most likely chronic. No concern for intraabd disaster\n - Now having BMs; c. diff toxin neg\n - amylase and lipase wnl\n # Anemia:\n - Trend HCT\n - Gave 1 un pRBC with good results\n - INR rising, now 2.0, may be nutritional\n # Spine fracture: neurologically intact distal to the lesion. prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per verbal report.\n # Hypernatremia, resolved: correcting with g tube free flush and D5W\n -Holding on g tube feeds at present due to high residuals\n -Replete lytes as necessary\n # Communication:\n - Brother has been with pt, although, live in boyfriend of 10 is\n her HCP. Boyfriend will hopefully visit pt today\n ICU Care\n Nutrition: tube feed with free water when able\n Glycemic Control: Regular insulin sliding scale\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Communication: ICU consent signed, (brother) \n (boyfriend/POA) \n Code status: Full code\n Disposition: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 01:36 AM\n Arterial Line - 03:00 AM\n Multi Lumen - 11:30 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2167-09-23 00:00:00.000","description":"Physician Attending Progress Note","row_id":634436,"text":"Chief Complaint: respiratory failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n ESOPHOGEAL BALLOON - At 01:46 PM\n Restarted levophed overnight\n Patient unable to provide history: Sedated\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Aztreonam - 06:09 AM\n Metronidazole - 08:00 AM\n Levofloxacin - 08:39 AM\n Infusions:\n Midazolam (Versed) - 1.5 mg/hour\n Fentanyl - 75 mcg/hour\n Norepinephrine - 0.02 mcg/Kg/min\n Other ICU medications:\n Other medications:\n vanc, aztreonam, flagyl (day ), CHG, SQI, nebs, naloxone enteral,\n heparin infusion\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38\nC (100.4\n Tcurrent: 37.6\nC (99.6\n HR: 75 (64 - 102) bpm\n BP: 96/49(65) {76/38(56) - 160/71(97)} mmHg\n RR: 22 (16 - 25) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101 kg (admission): 94.2 kg\n Height: 67 Inch\n CVP: 20 (8 - 339)mmHg\n Bladder pressure: 18 (18 - 21) mmHg\n Total In:\n 3,524 mL\n 848 mL\n PO:\n TF:\n 48 mL\n IVF:\n 3,236 mL\n 698 mL\n Blood products:\n Total out:\n 935 mL\n 325 mL\n Urine:\n 650 mL\n 325 mL\n NG:\n 285 mL\n Stool:\n Drains:\n Balance:\n 2,589 mL\n 523 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 0 (0 - 0) mL\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 23 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 37 cmH2O\n Plateau: 33 cmH2O\n Compliance: 40 cmH2O/mL\n SpO2: 99%\n ABG: 7.37/44/160/25/0\n Ve: 8.9 L/min\n PaO2 / FiO2: 320\n Physical Examination\n General Appearance: Overweight / Obese\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: coarse breath sounds\n Abdominal: Soft, Obese\n Extremities: Right: 1+, Left: 1+\n Skin: Warm\n Neurologic: Responds to: Unresponsive, Movement: No spontaneous\n movement, Tone: Normal\n Labs / Radiology\n 8.9 g/dL\n 358 K/uL\n 126 mg/dL\n 0.7 mg/dL\n 25 mEq/L\n 3.5 mEq/L\n 4 mg/dL\n 108 mEq/L\n 143 mEq/L\n 28.0 %\n 8.1 K/uL\n [image002.jpg]\n 12:05 PM\n 06:08 PM\n 06:11 PM\n 07:53 PM\n 02:02 AM\n 03:59 AM\n 09:14 PM\n 01:04 AM\n 05:54 AM\n 06:11 AM\n WBC\n 8.4\n 8.1\n Hct\n 29.0\n 28.1\n 28.0\n Plt\n 376\n 358\n Cr\n 0.6\n 0.7\n TCO2\n 29\n 29\n 25\n 25\n 28\n 28\n 26\n Glucose\n 120\n 126\n Other labs: PT / PTT / INR:22.2/76.0/2.1, ALT / AST:24/16, Alk Phos / T\n Bili:117/0.7, Amylase / Lipase:, Differential-Neuts:74.7 %,\n Lymph:17.6 %, Mono:3.8 %, Eos:3.4 %, Lactic Acid:0.7 mmol/L,\n Albumin:2.4 g/dL, LDH:204 IU/L, Ca++:8.2 mg/dL, Mg++:2.0 mg/dL, PO4:3.2\n mg/dL\n Assessment and Plan\n 55-year-old woman with\n Respiratory failure\n End-exp transpulmonary pressure: -2\n End-insp transpulmonary pressure: +5\n Esophageal pressures suggest that she is at safe pressures.\n Traumatic thoracic spinal fracture\n Eventual MRI. Too high-risk at present. Brace when out of\n bed.\n Probable VAP\n Discuss GNRs with lab\n Complete 8\n 15d course of present ABX pending cultures\n D/C vancomycin since no identified GPCs\n D/C Flagyl since no CT or toxin evidence of C diff\n Shock\n now back on levophed\n CVP is 20 mm Hg but Pes is ~25 cm H20\n Re-assess SVV with Vigileo and consider volume challenge\n Upper extremity DVT\n Therapeutic heparin\n Anemia\n Follow\n Possible tracheobronchomalacia (reason for transfer)\n Incidental peri-appendiceal finding (will need eventual\n follow-up)\n Although differential remains open, the most compelling course of\n events is probably that she required intubation at the outside hospital\n (?sedation ?restriction from obesity/brace ?other) and subsequently\n developed a GNR-related VAP. Her pattern of acute lung injury,\n combined with obesity, is resulting in basilar and\n posterior-predominant atelectasis/consolidation with a high proportion\n of shunt. Given her very high PEEP, will try to avoid bronchoscopy if\n possible.\n Other issues as per ICU team note.\n ICU Care\n Nutrition: resume tube feeds\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 01:36 AM\n Arterial Line - 03:00 AM\n Multi Lumen - 11:30 AM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Heparin gtt)\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 60 minutes\n Patient is critically ill\n"},{"category":"Respiratory ","chartdate":"2167-10-06 00:00:00.000","description":"Generic Note","row_id":635962,"text":"TITLE:\n Respiratory: Rec\nd pt on a/c 18/400/10+/50%. Pt has #7 portex trach.\n BS are coarse to clear with diminished bases. Suctioning for small\n amounts of tan thick secretions. MDI\ns administered as ordered of\n alb/atr with no adverse reactions. Pt continues to move around a lot\n in the bed, and anxious at times. No RSBI done due to increased peep\n of 10. Plan is to wean to psv as tolerated and eventually t/c trials.\n No abg\ns noc.\n"},{"category":"Respiratory ","chartdate":"2167-09-29 00:00:00.000","description":"Respiratory Care Shift Note","row_id":635050,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 11\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: appears agitated and\n uncomfortable at times,overbreathing by 10-15 breaths\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt required increased peep back up to 15 overnight due to\n desaturation into low 80s at times. She appears much more comfortable\n and in synch with the vent now.\n"},{"category":"Nursing","chartdate":"2167-09-29 00:00:00.000","description":"Nursing Progress Note","row_id":635138,"text":"55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP now with prolonged\n hospital course c/o by PNA anxiety,RUE DVD with high PEEP requirement\n . had tolerated peep wean up until last night when pt dropped sats and\n po2 requring increase in peep and fio2. Sedated with fentanyl and\n versed gtts. Trach and peg scheduled for today was cancelled for\n increased peep requirements.\n Hypotension (not Shock)\n Assessment:\n Pt hypotensive throughout morning but because was having difficulty\n maintaining a consistent bp on extremities felt that it was poss\n inaccurate u/o decreasing over course of am, pt with variable hr from\n sb40 with bp 120-130\ns-to junctional tach 130 when awake and agitated ,\n with lower bp making it difficult to titrate gtts\n Both levophed and sedatives.\n Action:\n Axillary aline placed by md\n Response:\n Aline confirmed hypotension given 1000 ml FB with min effect. started\n on neo at .5 mcgs/kg/min but pt became bradycardic to 40 switched to\n levophed .04 mcg/kg/min with desired effect stim test performed\n 50mgs hydrocortisone given x1\n Increasing u/o to 50 mls /hr\n Plan:\n Goal to maintain maps greater than 65\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lungs with coarse rhonchii upper and diminished at bases with sats\n 92-93% on peep 15 fio 60% cyanotic when agitated.\n Action:\n Suctioned for mod to copious amounts thick tan secretions. increased\n sedation continued rtc diazepam\n Response:\n Improved control over agitation pt sedated but easily rouseable\n maintained o2 sats greater than 93% allowing a gradual slow wean of\n peep from 15-12\n Plan:\n To wean to peep of 10 and fio2of 50%. Accepting sats 88-92% and po2 in\n 60\n When bp maintained off levophed poss to start lasix gtt at low dose\n 1mg/hr pt 106 kgs up approx 12kgs from baseline.\n"},{"category":"General","chartdate":"2167-10-01 00:00:00.000","description":"Generic Note","row_id":635278,"text":"55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP now with prolonged\n hospital course c/o by PNA anxiety,RUE DVD with high PEEP requirement\n .\n Events\n Heparin gtt and TF held since MN for ? trach and peg\n placement today.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on AC 400/18/8/50%. 02 sats mainly 88-92% but did fall to\n 86% when pt positioned on L side. Pt fluid overloaded with TFB for LOS\n ~ ccs.\n Action:\n ABG taken while sat 88%. Lasix gtt increased to 3mg/hr\n Response:\n ABG 7.42/47/87/4/32. Urine output 25-45ccs/hr (not meeting goal of neg\n 100-150ccs/hr)\n Plan:\n Continue with current vent settings. Trach today. Titrate lasix gtt up\n if can maintain MAP > 60.\n Altered mental status (not Delirium)\n Assessment:\n Pt restless at times, thrashing in bed with HR up to 140 ST . Denies\n pain or doesn\nt respond when questioned if she is having pain.\n Action:\n Fentanyl drip infusing at 100mcgs/hr. Also treated with haldol and\n valium . Bolused with 2 mg versed when acutely agitated. Bilateral\n wrist restraints in place.\n Response:\n Pt falls back to sleep, HR decreases (occasionally as low as 45 SB)\n Plan:\n Continue to assess MS. as indicated. Reorientation. Restraints\n for safety.\n Hypernatremia (high sodium)\n Assessment:\n Na 146 this am\n Action:\n Treated with free h20 boluses\n Response:\n Plan:\n Continue to monitor f+e status.\n Impaired Skin Integrity\n Assessment:\n Pt with excoriated yeast infection on abd and in perineal area.\n Action:\n Barrier cream and miconazole powder applied\n Response:\n To be determined.\n Plan:\n Diligent skin care.\n"},{"category":"General","chartdate":"2167-10-01 00:00:00.000","description":"Generic Note","row_id":635280,"text":"55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP now with prolonged\n hospital course c/o by PNA anxiety,RUE DVD with high PEEP requirement\n .\n Events\n Heparin gtt and TF held since MN for ? trach and peg\n placement today.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on AC 400/18/8/50%. 02 sats mainly 88-92% but did fall to\n 86% when pt positioned on L side. Pt fluid overloaded with TFB for LOS\n ~ ccs.\n Action:\n ABG taken while sat 88%. Lasix gtt increased to 3mg/hr\n Response:\n ABG 7.42/47/87/4/32. Urine output initially 25 ccs/hr but pt began\n autodiuresing after MN with output improving to ~140ccs/hr\n Plan:\n Continue with current vent settings. Trach today. Titrate lasix gtt to\n maintain MAP > 60 and u/o 100-150ccs/hr.\n Altered mental status (not Delirium)\n Assessment:\n Pt restless at times, thrashing in bed with HR up to 140 ST . Denies\n pain or doesn\nt respond when questioned if she is having pain.\n Action:\n Fentanyl drip infusing at 100mcgs/hr. Also treated with haldol and\n valium . Bolused with 2 mg versed when acutely agitated. Bilateral\n wrist restraints in place.\n Response:\n Pt falls back to sleep, HR decreases (occasionally as low as 45 SB)\n Plan:\n Continue to assess MS. as indicated. Reorientation. Restraints\n for safety.\n Hypernatremia (high sodium)\n Assessment:\n Na 146 this am\n Action:\n Treated with free h20 boluses\n Response:\n Plan:\n Continue to monitor f+e status.\n Impaired Skin Integrity\n Assessment:\n Pt with excoriated yeast infection on abd and in perineal area.\n Action:\n Barrier cream and miconazole powder applied\n Response:\n To be determined.\n Plan:\n Diligent skin care.\n"},{"category":"Respiratory ","chartdate":"2167-10-02 00:00:00.000","description":"Generic Note","row_id":635432,"text":"TITLE:\n Respiratory Care: Rec\nd pt on a/c 15/400/+8/50%. Ett 7.5 taped @ 21\n lip. BS are coarse bilaterally with diminished bases. Suctioned for\n small to moderate amounts of thick yellow/tan secretions. MDI\n administered as ordered alb/atr with no adverse reactions. AM ABG\n 7.44/52/70. No rsbi due to Trach/peg procedure today. No further\n changes noted.\n"},{"category":"Physician ","chartdate":"2167-10-02 00:00:00.000","description":"Physician Resident Progress Note","row_id":635438,"text":"Chief Complaint:\n 24 Hour Events:\n Patient agitated and combative overnight - restarted midazolam gtt and\n patient was becoming increasingly tachycardic and hypertensive\n Thoracics to take to OR this am for trach and PEG\n Discussion with patient's boyfriend yesterday - her should be here this\n weekend, wants to be involved, just hard for him to get here\n On lasix drip with excellent response (200 cc urine/hour)\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Fentanyl - 100 mcg/hour\n Furosemide (Lasix) - 1 mg/hour\n Heparin Sodium - 1,700 units/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:07 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.3\nC (99.2\n HR: 118 (45 - 138) bpm\n BP: 155/84(118) {91/38(56) - 177/106(139)} mmHg\n RR: 18 (17 - 27) insp/min\n SpO2: 90%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,604 mL\n 1,447 mL\n PO:\n TF:\n 675 mL\n 17 mL\n IVF:\n 1,089 mL\n 730 mL\n Blood products:\n Total out:\n 4,130 mL\n 2,430 mL\n Urine:\n 4,130 mL\n 2,430 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,526 mL\n -983 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n PS : 5 cmH2O\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n PIP: 22 cmH2O\n Plateau: 19 cmH2O\n Compliance: 48.2 cmH2O/mL\n SpO2: 90%\n ABG: 7.45/50/67/29/8\n Ve: 7.5 L/min\n PaO2 / FiO2: 134\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 306 K/uL\n 8.5 g/dL\n 165 mg/dL\n 0.7 mg/dL\n 29 mEq/L\n 3.7 mEq/L\n 10 mg/dL\n 108 mEq/L\n 146 mEq/L\n 27.1 %\n 11.2 K/uL\n [image002.jpg]\n 02:18 AM\n 01:27 PM\n 03:06 PM\n 10:04 PM\n 03:00 AM\n 10:47 AM\n 04:10 PM\n 12:13 AM\n 05:08 AM\n 05:20 AM\n WBC\n 8.6\n 11.2\n Hct\n 25.9\n 27.1\n Plt\n 280\n 306\n Cr\n 0.6\n 0.5\n 0.7\n TCO2\n 33\n 32\n 32\n 34\n 36\n 36\n Glucose\n 176\n 136\n 165\n Other labs: PT / PTT / INR:13.2/68.7/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:89.7 %, Lymph:8.7 %, Mono:1.1\n %, Eos:0.4 %, Lactic Acid:0.9 mmol/L, Albumin:2.4 g/dL, LDH:204 IU/L,\n Ca++:10.6 mg/dL, Mg++:2.8 mg/dL, PO4:4.3 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA and\n ARDS intubated since the end of .\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation.\n Transferred here for airway stenting.\n - attempt SBT today\n - OR add on for trach and PEG with Dr. (tube feeds off\n after MN, heparin off after 6am)\n # # Adrenal Insufficency: Minimal response to stim test again.\n Appreciate endocrine recommendations.\n - hydrocort and fludrocort (day 1 = )\n - will continue at current dose until s/p trach and PEG and\n hemodynamically stable for 24 hours\n will then plan to taper\n hydrocortisone to 25mg IV q6 with a slow taper\n - will repreat ACTH stim test after tapered to <30mg\n hydrocortisone or off steroids\n - f/u daily endocrine recs\n # Hypotension: Likely adrenal insufficiency and sedation. Goal map\n > 60. Much improved since re-administration of steroids.\n - hydrocortisone and fludrocortisone as above\n - restart levophed if necessary to maintain MAP > 60\n # Volume overloaded in setting of hypernatremia with TBW deficit.\n - goal -1000cc I/Os today\n - continue FW in TF at 250 cc q4hrs\n - lasix drip (1-5mg/hr) when MAP >\n 60\n # Sedation: Sedation control remains somewhat poor although fentanyl\n patch and diazpem are likely therapeutic range today. On Versed 1.5,\n Fentanyl 175, Fentanyl patch, Diazepam standing and haldo 2.5-5 mg\n PRN. QTc increased to 480.\n - Wean versed/fentanyl as tolerated, continue diazepam. Avoid\n haldol use if possible to avoid further prolongation of QTc\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\n coumadin at least until s/p trach.\n - hold heparin gtt when anticipate trach/peg\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n # FEN/GI: Tube feeds with FWF @ goal.\n DVT: Treatment dose heparin\n Ulcer: Ranitidine\n VAP: Prevention per routine\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n - touch base with SW today\n Code: Full\n Dispo: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Arterial Line - 02:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2167-09-20 00:00:00.000","description":"Physician Attending Progress Note","row_id":634144,"text":"Chief Complaint:\n HPI:\n 24 Hour Events:\n PICC LINE - START 10:30 PM\n INVASIVE VENTILATION - START 10:45 PM\n EKG - At 11:25 PM\n BLOOD CULTURED - At 05:30 AM\n TMax 102.7 BCX1 drawn\n FEVER - 102.7\nF - 04:00 AM\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Metronidazole - 08:00 AM\n Infusions:\n Fentanyl - 75 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.3\nC (102.7\n Tcurrent: 37.2\nC (99\n HR: 88 (72 - 97) bpm\n BP: 110/55(64) {83/38(48) - 154/71(103)} mmHg\n RR: 14 (12 - 18) insp/min\n SpO2: 100%\n Total In:\n 10 mL\n 1,043 mL\n PO:\n TF:\n 54 mL\n IVF:\n 10 mL\n 988 mL\n Blood products:\n Total out:\n 425 mL\n 585 mL\n Urine:\n 425 mL\n 585 mL\n NG:\n Stool:\n Drains:\n Balance:\n -416 mL\n 458 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 32 cmH2O\n SpO2: 100%\n ABG: 7.39/53/81./30/5\n Ve: 8 L/min\n PaO2 / FiO2: 135\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 9.7 g/dL\n 333 K/uL\n 103 mg/dL\n 0.6 mg/dL\n 30 mEq/L\n 3.8 mEq/L\n 6 mg/dL\n 109 mEq/L\n 150 mEq/L\n 30.7 %\n 9.7 K/uL\n [image002.jpg]\n 11:54 PM\n 01:00 AM\n 06:14 AM\n WBC\n 9.7\n Hct\n 30.7\n Plt\n 333\n Cr\n 0.6\n TCO2\n 32\n 33\n Glucose\n 103\n Other labs: PT / PTT / INR:13.8/22.4/1.2, ALT / AST:30/19, Alk Phos / T\n Bili:149/0.7, Differential-Neuts:76.9 %, Lymph:17.3 %, Mono:3.0 %,\n Eos:2.5 %, Albumin:3.0 g/dL, LDH:222 IU/L, Ca++:8.6 mg/dL, Mg++:2.1\n mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n Obese woman s/p t spine injury tx from Med for failure to wean\n from mech ventilation and evaluation for stent for\n tracheobronchomalacia\n 1. Resp Failure: initial etiology unclear\n but currently\n we need to assess what she can do here. Switch to PSV 10/5 and see what\n she can pull, check NIF. not act on this info. Let IP know she is\n here though not stable for intervention at this point.\n 2. New fevers and hypotension\n Is fluid responsive, watch\n UOP, goal 30 cc/hr. Check lactate.\n DDx VAP, asp PNA, lines. Has PCN and blactam allergy.\n For VAP- mini , change to Levoquin, Aztreonam, Vanco, and add\n Flagyl for asp.\n Lines: D/C PICC send cultures, try for 2nd PIV and if unable will\n place CVL. Check lactate.\n Belly: repeat LFTs, KUB OK, check residuals.\n 3. HyperNa: correcting with g tube free flush and D5W\n repeat lytes this evening and recalculate\n 4. Spine Fx: consult NSurg here re reccs for back bracing and\n activity\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 03:30 AM 10 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 10:30 PM\n 20 Gauge - 01:36 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition :\n Total time spent:\n Patient is critically ill\n"},{"category":"Nutrition","chartdate":"2167-09-22 00:00:00.000","description":"Clinical Nutrition Note","row_id":634347,"text":"Subjective\n Pt intubated /sedated\n Objective\n Pertinent medications: noted\n Labs:\n Value\n Date\n Glucose\n 120 mg/dL\n 03:59 AM\n Glucose Finger Stick\n 124\n 10:00 AM\n FSBG\n 111, 111, 145, 123\n \n BUN\n 4 mg/dL\n 03:59 AM\n Creatinine\n 0.6 mg/dL\n 03:59 AM\n Sodium\n 141 mEq/L\n 03:59 AM\n Potassium\n 3.7 mEq/L\n 03:59 AM\n Chloride\n 108 mEq/L\n 03:59 AM\n Albumin\n 2.4 g/dL\n 03:59 AM\n Calcium non-ionized\n 8.2 mg/dL\n 03:59 AM\n Phosphorus\n 3.1 mg/dL\n 03:59 AM\n Ionized Calcium\n 1.16 mmol/L\n 12:05 PM\n Magnesium\n 2.2 mg/dL\n 03:59 AM\n Corrented Ca\n 9.48\n Current diet order / nutrition support: replete c/ Fiber @60mL/hr (1440\n kcals 89 gr aa)- currently on hold\n GI: Abd: softly dist/absent bs/no BM\n Assessment of Nutritional Status\n Specifics:\n TF\ns trialed. Held high residuals and OGT placed to suction. OGT\n is currently clamped. Pt has not had a BM since admission. Would\n consider increasing bowel regimen and adding a promotility . If\n unable to resume TFs in next 2-3 days, will need to TPN for nutrition\n support.\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: via nutrition support\n Consider reglan +/- increase bowel regimen\n Resume TF's as medically feasible, if unable in next 2-3 days, will\n need to consider PN to prevent nutritional decline\n BG/lyte management\n"},{"category":"Physician ","chartdate":"2167-09-22 00:00:00.000","description":"Physician Resident Progress Note","row_id":634352,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n -Neurosurg: ok to transport. Will decide on anticoagulation in AM\n -Central line placed\n -NGT to suction\n -Bowel regimen\n -Respiratory attempted to place esophageal ballon in order to measure\n intrathoracic pressure, unsuccessful\n -Desaturation around 23:00 to low 80s on 400/22/15/0.9 following turn.\n Recruitment maneuver (PEEP to 30) done x2 with good effect, Sat came up\n to 100%. PEEP left at 17\n -Transfused 1 un pRBC\n - Started levophed yesterday for hypotension\n - No BM\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 10:00 AM\n Aztreonam - 02:00 PM\n Vancomycin - 12:00 AM\n Metronidazole - 12:00 AM\n Infusions:\n Norepinephrine - 0.02 mcg/Kg/min\n Fentanyl - 200 mcg/hour\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:00 AM\n Midazolam (Versed) - 02:20 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 37.6\nC (99.6\n HR: 73 (64 - 96) bpm\n BP: 119/48(69) {85/39(55) - 142/67(91)} mmHg\n RR: 22 (11 - 22) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 94.2 kg (admission): 94.2 kg\n Height: 67 Inch\n CVP: 20 (11 - 21)mmHg\n Bladder pressure: 14 (14 - 18) mmHg\n Total In:\n 3,482 mL\n 465 mL\n PO:\n TF:\n IVF:\n 2,845 mL\n 465 mL\n Blood products:\n 277 mL\n Total out:\n 580 mL\n 65 mL\n Urine:\n 580 mL\n 65 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,902 mL\n 400 mL\n Respiratory support\n Ventilator mode: AC\n Vt (Set): 400 (400 - 500) mL\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 17 cmH2O\n FiO2: 80%\n PIP: 33 cmH2O\n Plateau: 30 cmH2O\n Compliance: 30.8 cmH2O/mL\n SpO2: 98%\n ABG: 7.38/41/86./24/0\n Ve: 9.1 L/min\n PaO2 / FiO2: 109\n Physical Examination\n Gen: Does not arouse to voice\n HEENT: Pupils 3 mm non-reactive bilaterally. Scleral edema bilat\n Resp: Symmetric expansion. Vesicular sounds throughout. Inspiratory\n and expiratory tracheal sounds (?related to ET tube).\n CV: RRR.\n Abd: Hypoactive bowel sounds. Distended.\n Ext: Edema in bilat UE.\n Peripheral vascular: Radial pulses 2+ bilaterally.\n Neuro: Moving all 4 extremities.\n Labs / Radiology\n 376 K/uL\n 9.0 g/dL\n 120 mg/dL\n 0.6 mg/dL\n 24 mEq/L\n 3.7 mEq/L\n 4 mg/dL\n 108 mEq/L\n 141 mEq/L\n 28.1 %\n 8.4 K/uL\n [image002.jpg]\n ALT 24 PT 18.7\n AST 16 PTT 25.4\n AP 117 INR 1.7\n Tbili 0.7\n Alb 2.4\n 08:03 PM\n 11:00 PM\n 03:01 AM\n 03:13 AM\n 12:05 PM\n 06:08 PM\n 06:11 PM\n 07:53 PM\n 02:02 AM\n 03:59 AM\n WBC\n 7.6\n 6.4\n 8.4\n Hct\n 24.1\n 24.1\n 29.0\n 28.1\n Plt\n \n Cr\n 0.6\n 0.6\n 0.6\n TCO2\n 33\n 30\n 29\n 29\n 25\n 25\n Glucose\n 127\n 129\n 120\n Differential-Neuts:80.8 %, Lymph:12.0 %, Mono:3.5 %, Eos:3.3 %\n Ca++:8.2 mg/dL, Mg++:2.2 mg/dL, PO4:3.1 mg/dL, ion Ca++ () 1.16\n Cortisol:\n : 2:15am 24.2 Midnight 2.7\n : 3am 4.5\n Micro: neg or NGTD if not mentioned\n : blood, \n : urine, sputum-OP flora\n : BAL, - coag neg staph, lactobacillus, cath tip, sputum- OP\n flora, rare GNR, blood\n U/a:\n Color\n Amber\n Appear\n Clear\n SpecGr\n 1.015\n pH\n 5.5\n Urobil\n 2\n Bili\n Mod\n Leuk\n Tr\n Bld\n Tr\n Nitr\n Pos\n Prot\n 100\n Glu\n Neg\n Ket\n 40\n RBC\n 0-2\n WBC\n 0-2\n Bact\n Few\n Yeast\n None\n Epi\n 0-2\n Imaging:\n Echo\n post recruitment CXR showed deep sulcus but no pnumothorax per rads.\n CT: Prelim Read\n Right lower lobe consolidation, and superimposed atelectasis/lower lobe\n collapse, and effusions. Acute T8 compression deformity, with no\n posterior\n retropulsion of fracture fragments. No associated hematoma.\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture\n # Respiratory failure: initial etiology unclear, likely multifactorial\n now with significant pneumonia. Had one sputum that showed GNR.\n - Had a desat event yesterday. Responded positively to recruitment\n maneuvers.\n - Will attempt placement of an esophageal balloon; with knowledge of\n intrathoracic pressures, can consider going up on PEEP\n # Infectious process: Had been febrile, now resolved\n - be aspiration or be VAP. Sputum from grew rare GNR;\n awaiting speciation.\n - Continues on Vanc, aztreonam, levofloxicin. Vanc trough pending today\n - Also on flagyl for empiric coverage of c. diff\n - Per CT, unlikely to be abdominal process\n # Hypotension, requiring Levophed:\n - Hypovolemia is possibly a factor- responded to a transfusion; HCT had\n been dropping\n - Sepsis also a factor- on broad spectrum abs\n - Central line in place.\n # Oliguria:\n -BUN and Cr reassuring.\n # RUE DVT: Have held on starting treatment in light of need for central\n access. Can start therapeutic heparin vs Lovenox with bridge to\n coumadin.\n - No PE noted on CT scan.\n # Abd distention:\n - CT abd only showed appendiceal mucocele without inflammation, not\n concerning, most likely chronic\n - No BM in several days, continue bowel regimen, add fleets enema\n - Can test for c.diff when pt stool\ns. Continue flagyl empirically\n - Check amylase and lipase\n # Anemia:\n - Trend HCT\n - Gave 1 un pRBC with good results\n - Will guiac stools when she has a BM\n - INR rising, now 1.7, may be nutritional\n # Spine fracture: neurologically intact distal to the lesion. prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - Will have spine see pt today for recs regarding pt movement and\n anticoagulation\n # Hypernatremia, resolved: correcting with g tube free flush and D5W\n -Holding on g tube feeds at present due to high residuals\n -Replete lytes as necessary\n # Communication:\n - Brother has been with pt, although, live in boyfriend of 10 is\n her HCP. Boyfriend will hopefully visit pt today\n ICU Care\n Nutrition: tube feed with free water when able\n Glycemic Control: Regular insulin sliding scale\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Communication: ICU consent signed, (brother) \n (boyfriend/POA) \n Code status: Full code\n Disposition: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 01:36 AM\n 22 Gauge - 02:00 PM\n Arterial Line - 03:00 AM\n Multi Lumen - 11:30 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Nursing","chartdate":"2167-09-23 00:00:00.000","description":"Nursing Progress Note","row_id":634404,"text":"55 yr old women admitted from outside hospital. Patient fell down\n stairs at home per boyfriend pt with fracture and placed in torso\n brace at OSH, pt became hypoxic and was intubated (family requested a\n second opinion and pt was trans to ) Pt admitted for Resp failure,\n failure to wean, and ? tracheal bronchial malacia. Full code,\n Allergies: PCN, Tetracycline, Sulfta.\n Per boyfriend tonight he reported that for the last two months pt has\n been drinking 2 bottles of wine almost every night.\n And that this is an increase from what she previously did which was a\n couple of beers per night.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n RLL consolidation, bilat effusions, R < L ; suct for thick yellowish\n secretions from ETT; copious thick secretions suct from mouth\n Action:\n Pt 2 down to 60%, Peep @ 23 0600 Fio2 decreased to 50% 2/2 Pao2 of\n 160\n Response:\n Pt tolerating turns and current vent settings well\n Plan:\n Cont to ABGS, VS;\n Hypotension (not Shock)\n Assessment:\n SBP down in 80\ns, MAP 60\n Action:\n Levophed restarted @0130, currently running @ 0.02mcg\n Response:\n BP improved 110-90\ns MAP 65\n Plan:\n Cont to BP, MAP goal >65 , Levo as needed\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt (+) DVT RUE\n Action:\n Pt started on IV Heparin @1700U/hr\n Response:\n Pt PTT@ 0030 62.7, no changes to infusion\n Plan:\n Cont to PTT, adjust heparin accordingly; cont with no BP/LAB draws\n to R arm\n Alteration in Nutrition\n Assessment:\n TF currently on hold high residuals, abd distended soft, hypoactive\n bowel sounds\n Action:\n Pt started on Naloxone x 3 doses, rectal tube in place for\n decompression; bowel regimen continued\n Response:\n Pt passing sm. Amt loose green stool with dose of Naxolone\n Plan:\n Re-evaluate for increase in Naloxone dose; ? restarting TF/advancing\n Fracture, other\n Assessment:\n Pt T5/T8 fracture s/p fall \n Action:\n Spine/ortho consult done\n Response:\n Pt off logroll precautions, tolerates position changes\n Plan:\n Activity as tolerated, needs to wear TorsoBrace when OOB or sitting up\n"},{"category":"Nursing","chartdate":"2167-09-23 00:00:00.000","description":"Nursing Progress Note","row_id":634440,"text":"Events: Attempt to lighten sedation, stop Levophed gtt- MS \n stability labile from lethargic to restless in bed/crying w/\n intermittent BP 120\ns/ w/ and W/O stimulation. UOP cont 10-30cc/hr.\n Vigileo monitor on- SVV . Bladder pressure 14.\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Physician ","chartdate":"2167-09-24 00:00:00.000","description":"Physician Resident Progress Note","row_id":634585,"text":"24 Hour Events:\n -Yesterday, stopped vanc and flagyl. Continued Aztreonam and\n Levofloxicin\n -Febrile to 101- pan cultured; cxr\n -Micro on sputum GNR due back today\n -Decreased FiO2 and PEEP to 21 (from 23 for ABG 7.42/39/116 at 11PM)\n -Early am, HR dropped to 40s-50s. EKG suggestive of junctional rhythm.\n Held pressures, making good UOP, good O2 sats\n -This am, art line is intermittently working. Drew ABG - pending\n -Yesterday, SVV was 7; held on giving more fluids\n -Random cortisol was very low; started hydrocortisone and florinef\n -UOP picked up this AM\n -Restarted tube feeds\n -K, Phos given this AM\n -New possible junctional rhythm (low voltage) at 5AM. Enzymes added on\n -Spine -> request CT C, L spine, MRI, TLSO, non-operative, d/c log roll\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Metronidazole - 08:00 AM\n Levofloxacin - 08:39 AM\n Aztreonam - 02:00 PM\n Infusions:\n Norepinephrine - 0.02 mcg/Kg/min\n Midazolam (Versed) - 4 mg/hour\n Other ICU medications:\n Midazolam (Versed) - 03:50 PM\n Fentanyl - 03:50 PM\n Ranitidine (Prophylaxis) - 08:31 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (101\n Tcurrent: 37.1\nC (98.8\n HR: 60 (60 - 86) bpm\n BP: 103/46(61) {103/46(61) - 121/50(66)} mmHg\n RR: 22 (17 - 23) insp/min\n SpO2: 99%\n Heart rhythm: JR (Junctional Rhythm)\n Wgt (current): 101 kg (admission): 94.2 kg\n Height: 67 Inch\n CVP: 12 (12 - 339)mmHg\n Total In:\n 1,675 mL\n 232 mL\n PO:\n TF:\n 182 mL\n 134 mL\n IVF:\n 1,233 mL\n 98 mL\n Blood products:\n Total out:\n 877 mL\n 565 mL\n Urine:\n 727 mL\n 535 mL\n NG:\n 30 mL\n Stool:\n Drains:\n Balance:\n 798 mL\n -333 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 22\n RR (Spontaneous): 2\n PEEP: 21 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 33 cmH2O\n Plateau: 30 cmH2O\n Compliance: 44.4 cmH2O/mL\n SpO2: 99%\n ABG: 7.46/28/129 at 6AM\n Repeated at 9AM 7.4/38/97\n Ve: 9.7 L/min\n PaO2 / FiO2: 290\n Physical Examination\n Gen: Does not arouse to voice\n HEENT: Pupils 3 mm reactive bilaterally. Scleral edema bilat\n Resp: Symmetric expansion. Coarse breath sounds throughout. Cannot\n adeq listen to post bases\n CV: RRR.\n Abd: Hypoactive bowel sounds. Distended.\n Ext: Edema in bilat UE.\n Peripheral vascular: Radial pulses 2+ bilaterally.\n Neuro: Moving all 4 extremities.\n Labs / Radiology\n 326 K/uL\n 8.9 g/dL\n 151 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 3.6 mEq/L\n 2 mg/dL\n 108 mEq/L\n 141 mEq/L\n 28.6 %\n 8.9 K/uL\n [image002.jpg]\n 06:11 PM\n 07:53 PM\n 02:02 AM\n 03:59 AM\n 09:14 PM\n 01:04 AM\n 05:54 AM\n 06:11 AM\n 11:07 PM\n 03:51 AM\n WBC\n 8.4\n 8.1\n 8.9\n Hct\n 28.1\n 28.0\n 28.6\n Plt\n 376\n 358\n 326\n Cr\n 0.6\n 0.7\n 0.7\n TCO2\n 29\n 25\n 25\n 28\n 28\n 26\n 26\n Glucose\n 120\n 126\n 151\n Other labs: PT / PTT / INR:24.3/68.6/2.4, ALT / AST:24/16, Alk Phos / T\n Bili:117/0.7, Amylase / Lipase:, Differential-Neuts:82.5 %,\n Lymph:11.6 %, Mono:3.3 %, Eos:2.2 %, Lactic Acid:0.7 mmol/L,\n Albumin:2.4 g/dL, LDH:204 IU/L, Ca++:8.5 mg/dL, Mg++:2.1 mg/dL, PO4:2.5\n mg/dL\nMicro: 2:38 am SPUTUM Site: ENDOTRACHEAL\n GRAM STAIN (Final ):\n >25 PMNs and <10 epithelial cells/100X field.\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.\n IN PAIRS AND CLUSTERS.\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).\n RESPIRATORY CULTURE (Pending)\n GRAM STAIN (Final ) SPUTUM Site: ENDOTRACHEAL:\n <10 PMNs and <10 epithelial cells/100X field.\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.\n IN PAIRS.\n 1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).\n CULTURE: GRAM NEGATIVE ROD(S). RARE GROWTH. WORK-UP PER DR ().\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with respiratory failure\n and difficulty weaning from vent.\n # Respiratory failure: Over the evening yesterday, were able to\n decrease FiO2 and PEEP. Clinical and imaging suggestive of ARDS.\n Initial preceptiationg factors: sedation, hypovent obesity,\n orthotic brace. Now thought to have VAP.\n - Placed esophageal balloon on which will help guide PEEP settings.\n # VAP: Re-spiked fever overnight. Stopped vanc yesterday, , as\n treating for GNR infection. Current GS shows GPC\n - Follow cultures\n - Restart Vanc.\n - Continue aztreonam, levofloxicin for 8 days pending speciation (at\n that time can increase to 15 days if necessary)\n - Also, stopped flagyl because had one neg c. diff toxin and CT did not\n show evidence of colitis\n # EKG changes: very low voltages and no change in QRS morphology.\n P-waves may be buried.\n -repeat\n -f/u enzymes\n # Hypotension, requiring Levophed: Increased urine output c/w\n autodiuresing\n - Attempt to wean from levophed with MAP goal 65 and UOP goal >30 cc/hr\n - Hypovolemia is possibly a factor- responded to a transfusion; HCT had\n been dropping. However, SVV with Vigileo was 13, making her CO less\n likely to respond to fluids. Held on giving any boluses overnight.\n - Sepsis also a factor- on broad spectrum abs\n - Central line in place.\n # Oliguria: Improved recently. BUN and Cr reassuring.\n -Continue to monitor\n # RUE DVT: Started on heparin gtt on .\n -Therapeutic in one day; may be related to poor nutritional status.\n Will continue to closely monitor\n # Abd distention: be chronic condition not requiring immediate\n medical attention\n - CT abd only showed appendiceal mucocele without inflammation, not\n concerning, most likely chronic. No concern for intraabd disaster\n - Now having BMs; c. diff toxin neg\n - amylase and lipase wnl\n # Adrenal Insufficency:\n -Random cortisol was approx 3 when it should have been maximally\n stimulated.\n -Started hydrocortisone and florinef. ? switch to methylpred\n # Anemia:\n - Trend HCT\n - Gave 1 un pRBC with good results\n - INR rising, now 2.0, may be nutritional\n # Spine fracture: neurologically intact distal to the lesion. prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - Repeat CT C, L spine.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n # Hypernatremia, resolved: correcting with g tube free flush and D5W\n -Holding on g tube feeds at present due to high residuals\n -Replete lytes as necessary\n # Communication:\n - Brother has been with pt, although, live in boyfriend of 10 is\n her HCP. Boyfriend will hopefully visit pt today\n ICU Care\n Nutrition: tube feed with free water when able\n Glycemic Control: Regular insulin sliding scale\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Communication: ICU consent signed, (brother) \n (boyfriend/POA) \n Code status: Full code\n Disposition: ICU\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 10:55 PM 30 mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 01:36 AM\n Arterial Line - 03:00 AM\n Multi Lumen - 11:30 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2167-09-30 00:00:00.000","description":"Physician Resident Progress Note","row_id":635194,"text":"Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - START 02:00 PM - in right brachial atery\n Hypotensive- started on levophed, weaned off over night\n Low cortisol and failed stim test - started on steroids\n TTE ordered\n Free water flushes were increased for hypernatremia (250cc q4)\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 08:06 AM\n Infusions:\n Heparin Sodium - 1,700 units/hour\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 150 mcg/hour\n Other ICU medications:\n Haloperidol (Haldol) - 12:15 AM\n Other medications:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 36.7\nC (98\n HR: 63 (48 - 138) bpm\n BP: 91/41(58) {68/30(49) - 143/78(105)} mmHg\n RR: 18 (13 - 23) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Mixed Venous O2% Sat: 59 - 59\n Total In:\n 3,898 mL\n 1,155 mL\n PO:\n TF:\n 802 mL\n 348 mL\n IVF:\n 2,126 mL\n 247 mL\n Blood products:\n Total out:\n 2,367 mL\n 800 mL\n Urine:\n 2,367 mL\n 800 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,531 mL\n 355 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 401) mL\n RR (Set): 18\n RR (Spontaneous): 1\n PEEP: 10 cmH2O\n FiO2: 40%\n PIP: 23 cmH2O\n Plateau: 19 cmH2O\n Compliance: 57.1 cmH2O/mL\n SpO2: 91%\n ABG: 7.42/49/93/33/5\n Ve: 8.1 L/min\n PaO2 / FiO2: 155\n Physical Examination\n Labs / Radiology\n 355 K/uL\n 9.1 g/dL\n 168 mg/dL\n 0.5 mg/dL\n 30 mEq/L\n 3.9 mEq/L\n 11 mg/dL\n 108 mEq/L\n 146 mEq/L\n 29.9 %\n 11.8 K/uL\n [image002.jpg]\n 03:32 PM\n 10:19 PM\n 02:50 AM\n 02:30 PM\n 02:44 PM\n 03:33 PM\n 07:26 PM\n 07:46 PM\n 02:04 AM\n 02:18 AM\n WBC\n 9.0\n 8.4\n 11.8\n Hct\n 25.8\n 23.0\n 28.1\n 29.9\n Plt\n \n Cr\n 0.6\n 0.7\n 0.5\n TCO2\n 30\n 35\n 33\n 31\n 33\n Glucose\n 94\n 97\n 168\n Other labs: PT / PTT / INR:13.8/70.4/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:89.7 %, Lymph:8.7 %, Mono:1.1\n %, Eos:0.4 %, Lactic Acid:0.9 mmol/L, Albumin:2.4 g/dL, LDH:204 IU/L,\n Ca++:8.5 mg/dL, Mg++:2.2 mg/dL, PO4:5.4 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with respiratory failure\n and difficulty weaning from vent.\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation.\n Transferred here for tracheomalacia, but not sure this is a component.\n Will need bronch eval when improved\n - Thoracics will do trach and PEG once stable on PEEPs around 10. Had\n been planned for today but currently holding as PEEP is 15.\n - wean PEEP as tolerated\n - needs A-line\n # Volume overload\n Currently with hypernatremia, Cr increase, contract\n alk, but mild\n - continue gentle diuresis with goal -1L per day as tolerated by blood\n pressure. IV lasix drip at 1-5 mg/hr.\n - FW in TF at 150 cc q4hrs\n - PM lytes.\n # Sedation: Now well seadated on Versed 1.5, Fentanyl 175, Fentanyl\n patch, Diazepam standing and haldo 2.5-5 mg PRN. QTc stable at .44\n - Wean versed/fentanyl as tolerated\n # HCT\n Has had slow decline while in ICU.\n - Xfuse PRN Hct < 21\n - continue to follow, guiac stools\n # Hypotension: Related to sedation, but high PEEP, adrenial\n insufficiency, sepsis have previously been contributing.\n - needs A-line for monitoring\n - cortisol stim to rule out persistent adrenal insufficiency\n # RUE DVT: Started on heparin gtt on , now off for trach that was\n planned for today. Follow PTTs. Would hold off on coumadin at least\n until s/p trach.\n - restart heparin\n # Adrenal Insufficency: Random cortisol was approx 3 when it should\n have been maximally stimulated. S/P 5 days of hydrocortisone and\n florinef.\n - will recheck as above and start at 50 q8 if needed\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n # FEN/GI: Tube feeds @ goal. No need to be NPO while awaiting stable\n PEEP\n DVT: Treatment dose heparin\n Ulcer: Ranitidine\n VAP: Prevention per routine\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 09:51 PM 60 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Arterial Line - 02:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2167-09-30 00:00:00.000","description":"Physician Resident Progress Note","row_id":635196,"text":"Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - START 02:00 PM - in right brachial atery\n Hypotensive- started on levophed, weaned off over night\n Low cortisol and failed stim test - started on steroids\n TTE ordered\n Free water flushes were increased for hypernatremia (250cc q4)\n Able to hear patient breathing at times during exam this am (poor am\n CXR, reordered)\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 08:06 AM\n Infusions:\n Heparin Sodium - 1,700 units/hour\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 150 mcg/hour\n Other ICU medications:\n Haloperidol (Haldol) - 12:15 AM\n Other medications:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 36.7\nC (98\n HR: 63 (48 - 138) bpm\n BP: 91/41(58) {68/30(49) - 143/78(105)} mmHg\n RR: 18 (13 - 23) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Mixed Venous O2% Sat: 59 - 59\n Total In:\n 3,898 mL\n 1,155 mL\n PO:\n TF:\n 802 mL\n 348 mL\n IVF:\n 2,126 mL\n 247 mL\n Blood products:\n Total out:\n 2,367 mL\n 800 mL\n Urine:\n 2,367 mL\n 800 mL\n NG:\n Stool:\n ?\n ?\n Drains:\n Balance:\n 1,531 mL\n 355 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 401) mL\n RR (Set): 18\n RR (Spontaneous): 1\n PEEP: 10 cmH2O\n FiO2: 40%\n PIP: 23 cmH2O\n Plateau: 19 cmH2O\n Compliance: 57.1 cmH2O/mL\n SpO2: 91%\n ABG: 7.42/49/93/33/5\n Ve: 8.1 L/min\n PaO2 / FiO2: 155\n Physical Examination\n General Appearance: Easily agitated, appears uncomfortable, Overweight\n / Obese, opens eyes but no purposeful movement\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\n deviation\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Respiratory / Chest: (Expansion: Symmetric), referred breath sounds\n from ETT\n Abdominal: No(t) Soft, Non-tender, Few Bowel sounds present, Distended\n Extremities: No clubbing or cyanosis, 3+ nonpitting edema of b/l hands,\n anasarca\n Skin: no rashes or jaundice\n Neuro: diffusely hyperreflexic with LE clonus\n Lines: r brachioceph ART and L PICC C/D/I\n Labs / Radiology\n 355 K/uL\n 9.1 g/dL\n 168 mg/dL\n 0.5 mg/dL\n 30 mEq/L\n 3.9 mEq/L\n 11 mg/dL\n 108 mEq/L\n 146 mEq/L\n 29.9 %\n 11.8 K/uL\n [image002.jpg]\n 03:32 PM\n 10:19 PM\n 02:50 AM\n 02:30 PM\n 02:44 PM\n 03:33 PM\n 07:26 PM\n 07:46 PM\n 02:04 AM\n 02:18 AM\n WBC\n 9.0\n 8.4\n 11.8\n Hct\n 25.8\n 23.0\n 28.1\n 29.9\n Plt\n \n Cr\n 0.6\n 0.7\n 0.5\n TCO2\n 30\n 35\n 33\n 31\n 33\n Glucose\n 94\n 97\n 168\n Other labs: PT / PTT / INR:13.8/70.4/1.2, Differential-Neuts:89.7 %,\n Lymph:8.7 %, Mono:1.1 %, Eos:0.4 %, Ca++:8.5 mg/dL, Mg++:2.2 mg/dL,\n PO4:5.4 mg/dL\n Culture Data: endotrach with K oxytoca; gram stain GPCs in\n pairs and clusters\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with respiratory failure\n and difficulty weaning from vent.\n # Respiratory failure: Related to ARDS, ? trachiomalacia, resolved\n VAP, volume overload. Intubated on for resp decompensation.\n Transferred here for tracheomalacia, but not sure this is a component.\n Will need bronch eval when improved\n - Thoracics will do trach and PEG once stable on PEEPs around 10.\n Re-c/s today.\n - wean PEEP as tolerated\n # Volume overload\n Hypernatremic (? Relationship to adrenal\n insufficiency), TBW deficit 2.6L.\n - goal even I/Os today\n - FW in TF at 250 cc q4hrs\n - PM lytes\n # Hyperreflexia - ? meds vs central pathology\n - consider head CT in context of heparin gtt to r/o intracranial\n hemmorhage\n # Sedation: Poor sedation control. On Versed 1.5, Fentanyl 175,\n Fentanyl patch, Diazepam standing and haldo 2.5-5 mg PRN. QTc stable\n at .44\n - Wean versed/fentanyl as tolerated\n - Recheck EKG today\n -\n # Hypotension: Related to sedation, but high PEEP, adrenial\n insufficiency, sepsis have previously been contributing. Monitor with\n A-line. Failed stim again.\n - hydrocortisol and fludrocortisone\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\n coumadin at least until s/p trach.\n - hold heparin gtt when anticipate trach/peg\n # Adrenal Insufficency: Minimal response to stim test again.\n - hydrocort and fludrocort\n - consider endocrine c/s for further elucidation of etiology\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n # FEN/GI: Tube feeds @ goal.\n DVT: Treatment dose heparin\n Ulcer: Ranitidine\n VAP: Prevention per routine\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 09:51 PM 60 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Arterial Line - 02:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Nursing","chartdate":"2167-10-01 00:00:00.000","description":"Nursing Progress Note","row_id":635377,"text":"55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP now with prolonged\n hospital course c/o by PNA anxiety,RUE DVD with high PEEP requirement\n .\n Events: pt to go to OR on for trach/PEG. Failed spont. Breathing\n trial.\n"},{"category":"Nursing","chartdate":"2167-10-02 00:00:00.000","description":"Nursing Progress Note","row_id":635434,"text":"55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP now with prolonged\n hospital course c/o by PNA anxiety,RUE DVD with high PEEP requirement\n .\n Events:\n Pt found at 19:30 to have loose restraints and was pulling on ETT. Pt\n found to have pulled out her esophageal tube and disconnected IV lines.\n CXR done and ETT and OGGT in right position.\n Plan: Plan for OR this am for trach and peg. Heparin gtt off at 6am.\n Edema, peripheral\n Assessment:\n Pt has gen edema with +2 pitting.\n Action:\n Pt is on lasix gtt, now at 1 mg/hr. Goal to remove 1-2 liters/24hrs. Pt\n is currently + 17.3 liters for LOS.\n Response:\n Pt is diuresing well to lasix .\n Plan:\n Continue to evaluate need for lasix and follow K level closely. K level\n replaced x 1 with 80m meq of Kcl 3.0 ,\n Hypernatremia (high sodium)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2167-10-02 00:00:00.000","description":"Nursing Progress Note","row_id":635531,"text":"55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP now with prolonged\n hospital course c/o by PNA anxiety,RUE DVD with high PEEP requirement\n .\n EVENTS: trach PEG done, PEG OK for meds, restart TF in am. restart hep\n gtt tomorrow, diamox/ KCL added for alkalosis.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt rec\nd intubated, on AC 400x18 50% +PEEP 8\n Action:\n Trach placed in the OR, pt returned from OR and placed on previous vent\n settings, failed att at CPAP wean.\n Response:\n Plan:\n Att to wean vent/ sedation slowly in am. Cont to monitor\n Altered mental status (not Delirium)\n Assessment:\n Pt rec\nd on fent/ versed gtt\ns at 100mcg/hr/ 2mg/hr respectively,\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2167-10-02 00:00:00.000","description":"Nursing Progress Note","row_id":635532,"text":"55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP now with prolonged\n hospital course c/o by PNA anxiety,RUE DVD with high PEEP requirement\n .\n EVENTS: trach PEG done, PEG OK for meds, restart TF in am. restart hep\n gtt tomorrow, diamox/ KCL added for alkalosis.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt rec\nd intubated, on AC 400x18 50% +PEEP 8\n Action:\n Trach placed in the OR, pt returned from OR and placed on previous vent\n settings, failed att at CPAP wean.\n Response:\n Plan:\n Att to wean vent/ sedation slowly in am. Cont to monitor\n Altered mental status (not Delirium)\n Assessment:\n Pt rec\nd on fent/ versed gtt\ns at 100mcg/hr/ 2mg/hr respectively,\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Respiratory ","chartdate":"2167-09-23 00:00:00.000","description":"Respiratory Care Shift Note","row_id":634402,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Comments: Pt continues to be intubated on full vent support. This\n shift , peep was increased to 23 cmh20 while the fio2 was wean down to\n 50%, and is tolerated well. Pt was suctioned for small thick tan\n secretions. No other vent changes were made.\n"},{"category":"Physician ","chartdate":"2167-09-23 00:00:00.000","description":"Physician Resident Progress Note","row_id":634412,"text":"Chief Complaint:\n 24 Hour Events:\n ESOPHOGEAL BALLOON - At 01:46 PM - went well, were able to\n increase PEEP to improve oxygenation\n - started naloxone to encourage bowel motility, with some success,\n rectal tube in place\n -started heparin gtt for RUE DVT\n -borderline hypotensive at times (low 90s) with low urine output,\n received boluses and norepi back on at 0.04\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 09:45 AM\n Metronidazole - 03:32 PM\n Vancomycin - 08:00 PM\n Aztreonam - 10:00 PM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Heparin Sodium - 1,700 units/hour\n Fentanyl - 100 mcg/hour\n Norepinephrine - 0.04 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38\nC (100.4\n Tcurrent: 37.3\nC (99.2\n HR: 73 (60 - 102) bpm\n BP: 90/46(61) {76/38(56) - 160/71(97)} mmHg\n RR: 23 (16 - 25) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101 kg (admission): 94.2 kg\n Height: 67 Inch\n CVP: 8 (8 - 15)mmHg\n Bladder pressure: 18 (18 - 21) mmHg\n Total In:\n 3,524 mL\n 234 mL\n PO:\n TF:\n 48 mL\n IVF:\n 3,236 mL\n 234 mL\n Blood products:\n Total out:\n 935 mL\n 215 mL\n Urine:\n 650 mL\n 215 mL\n NG:\n 285 mL\n Stool:\n Drains:\n Balance:\n 2,589 mL\n 19 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 0 (0 - 0) mL\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 23 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 42 cmH2O\n Plateau: 32 cmH2O\n Compliance: 44.4 cmH2O/mL\n SpO2: 100%\n ABG: 7.36/47/153//0\n Ve: 9.5 L/min\n PaO2 / FiO2: 255\n Physical Examination\n Gen: Does not arouse to voice\n HEENT: Pupils 3 mm non-reactive bilaterally. Scleral edema bilat\n Resp: Symmetric expansion. Vesicular sounds throughout. Inspiratory\n and expiratory tracheal sounds (?related to ET tube).\n CV: RRR.\n Abd: Hypoactive bowel sounds. Distended.\n Ext: Edema in bilat UE.\n Peripheral vascular: Radial pulses 2+ bilaterally.\n Neuro: Moving all 4 extremities.\n Labs / Radiology\n 376 K/uL\n 9.0 g/dL\n 120 mg/dL\n 0.6 mg/dL\n 24 mEq/L\n 3.7 mEq/L\n 4 mg/dL\n 108 mEq/L\n 141 mEq/L\n 28.1 %\n 8.4 K/uL\n [image002.jpg]\n 03:01 AM\n 03:13 AM\n 12:05 PM\n 06:08 PM\n 06:11 PM\n 07:53 PM\n 02:02 AM\n 03:59 AM\n 09:14 PM\n 01:04 AM\n WBC\n 6.4\n 8.4\n Hct\n 24.1\n 29.0\n 28.1\n Plt\n 319\n 376\n Cr\n 0.6\n 0.6\n TCO2\n 30\n 29\n 29\n 25\n 25\n 28\n 28\n Glucose\n 129\n 120\n Other labs: PT / PTT / INR:18.7/62.7/1.7, ALT / AST:24/16, Alk Phos / T\n Bili:117/0.7, Amylase / Lipase:, Differential-Neuts:80.8 %,\n Lymph:12.0 %, Mono:3.5 %, Eos:3.3 %, Lactic Acid:0.7 mmol/L,\n Albumin:2.4 g/dL, LDH:204 IU/L, Ca++:8.2 mg/dL, Mg++:2.2 mg/dL, PO4:3.1\n mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture\n # Respiratory failure: initial etiology unclear, likely multifactorial\n now with significant pneumonia. Had one sputum that showed GNR.\n - Had a desat event yesterday. Responded positively to recruitment\n maneuvers.\n - Will attempt placement of an esophageal balloon; with knowledge of\n intrathoracic pressures, can consider going up on PEEP\n # Infectious process: Had been febrile, now resolved\n - be aspiration or be VAP. Sputum from grew rare GNR;\n awaiting speciation.\n - Continues on Vanc, aztreonam, levofloxicin. Vanc trough pending today\n - Also on flagyl for empiric coverage of c. diff\n - Per CT, unlikely to be abdominal process\n # Hypotension, requiring Levophed:\n - Hypovolemia is possibly a factor- responded to a transfusion; HCT had\n been dropping\n - Sepsis also a factor- on broad spectrum abs\n - Central line in place.\n # Oliguria:\n -BUN and Cr reassuring.\n # RUE DVT: Have held on starting treatment in light of need for central\n access. Can start therapeutic heparin vs Lovenox with bridge to\n coumadin.\n - No PE noted on CT scan.\n # Abd distention:\n - CT abd only showed appendiceal mucocele without inflammation, not\n concerning, most likely chronic\n - No BM in several days, continue bowel regimen, add fleets enema\n - Can test for c.diff when pt stool\ns. Continue flagyl empirically\n - Check amylase and lipase\n # Anemia:\n - Trend HCT\n - Gave 1 un pRBC with good results\n - Will guiac stools when she has a BM\n - INR rising, now 1.7, may be nutritional\n # Spine fracture: neurologically intact distal to the lesion. prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per verbal report.\n # Hypernatremia, resolved: correcting with g tube free flush and D5W\n -Holding on g tube feeds at present due to high residuals\n -Replete lytes as necessary\n # Communication:\n - Brother has been with pt, although, live in boyfriend of 10 is\n her HCP. Boyfriend will hopefully visit pt today\n ICU Care\n Nutrition: tube feed with free water when able\n Glycemic Control: Regular insulin sliding scale\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Communication: ICU consent signed, (brother) \n (boyfriend/POA) \n Code status: Full code\n Disposition: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 01:36 AM\n Arterial Line - 03:00 AM\n Multi Lumen - 11:30 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2167-09-23 00:00:00.000","description":"Physician Resident Progress Note","row_id":634413,"text":"Chief Complaint:\n 24 Hour Events:\n ESOPHOGEAL BALLOON - At 01:46 PM - went well, were able to\n increase PEEP to improve oxygenation\n - started naloxone to encourage bowel motility, with some success,\n rectal tube in place with some stool\n -started heparin gtt for RUE DVT\n -borderline hypotensive at times (low 90s) with low urine output,\n received boluses and norepi back on at 0.04 (now down to 0.02)\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 09:45 AM\n Metronidazole - 03:32 PM\n Vancomycin - 08:00 PM\n Aztreonam - 10:00 PM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Heparin Sodium - 1,700 units/hour\n Fentanyl - 100 mcg/hour\n Norepinephrine - 0.04 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38\nC (100.4\n Tcurrent: 37.3\nC (99.2\n HR: 73 (60 - 102) bpm\n BP: 90/46(61) {76/38(56) - 160/71(97)} mmHg\n RR: 23 (16 - 25) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101 kg (admission): 94.2 kg\n Height: 67 Inch\n CVP: 8 (8 - 15)mmHg\n Bladder pressure: 18 (18 - 21) mmHg\n Total In:\n 3,524 mL\n 234 mL\n PO:\n TF:\n 48 mL\n IVF:\n 3,236 mL\n 234 mL\n Blood products:\n Total out:\n 935 mL\n 215 mL\n Urine:\n 650 mL\n 215 mL\n NG:\n 285 mL\n Stool:\n Drains:\n Balance:\n 2,589 mL\n 19 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: AC\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 0 (0 - 0) mL\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 23 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 42 cmH2O\n Plateau: 32 cmH2O\n Compliance: 44.4 cmH2O/mL\n SpO2: 100%\n ABG: 7.37/44/160 (6am)\n Ve: 9.5 L/min\n PaO2 / FiO2: 255\n Physical Examination\n Gen: Does not arouse to voice\n HEENT: Pupils 3 mm non-reactive bilaterally. Scleral edema bilat\n Resp: Symmetric expansion. Vesicular sounds throughout. Inspiratory\n and expiratory tracheal sounds (?related to ET tube).\n CV: RRR.\n Abd: Hypoactive bowel sounds. Distended.\n Ext: Edema in bilat UE.\n Peripheral vascular: Radial pulses 2+ bilaterally.\n Neuro: Moving all 4 extremities.\n Labs / Radiology\n 358 K/uL\n 8.9 g/dL\n 126 mg/dL\n 0.7 mg/dL\n 25 mEq/L\n 3.5 mEq/L\n 4 mg/dL\n 108 mEq/L\n 143 mEq/L\n 28.0 %\n 8.1 K/uL\n [image002.jpg]\n 03:01 AM\n 03:13 AM\n 12:05 PM\n 06:08 PM\n 06:11 PM\n 07:53 PM\n 02:02 AM\n 03:59 AM\n 09:14 PM\n 01:04 AM\n WBC\n 6.4\n 8.4\n Hct\n 24.1\n 29.0\n 28.1\n Plt\n 319\n 376\n Cr\n 0.6\n 0.6\n TCO2\n 30\n 29\n 29\n 25\n 25\n 28\n 28\n Glucose\n 129\n 120\n PT 22.2 PTT 76.0 INR 2.1\n Differential-Neuts:74.7 %, Lymph:17.6 %, Mono:3.5 %, Eos:3.8 %\n Ca++:8.2 mg/dL, Mg++:2.0 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture\n # Respiratory failure: initial etiology unclear, likely multifactorial\n now with significant pneumonia. Had one sputum that showed GNR.\n - Had a desat event yesterday. Responded positively to recruitment\n maneuvers.\n - Will attempt placement of an esophageal balloon; with knowledge of\n intrathoracic pressures, can consider going up on PEEP\n # Infectious process: Had been febrile, now resolved\n - be aspiration or be VAP. Sputum from grew rare GNR;\n awaiting speciation.\n - Continues on Vanc, aztreonam, levofloxicin. Vanc trough pending today\n - Also on flagyl for empiric coverage of c. diff\n - Per CT, unlikely to be abdominal process\n # Hypotension, requiring Levophed:\n - Hypovolemia is possibly a factor- responded to a transfusion; HCT had\n been dropping\n - Sepsis also a factor- on broad spectrum abs\n - Central line in place.\n # Oliguria:\n -BUN and Cr reassuring.\n # RUE DVT: Have held on starting treatment in light of need for central\n access. Can start therapeutic heparin vs Lovenox with bridge to\n coumadin.\n - No PE noted on CT scan.\n # Abd distention:\n - CT abd only showed appendiceal mucocele without inflammation, not\n concerning, most likely chronic\n - No BM in several days, continue bowel regimen, add fleets enema\n - Can test for c.diff when pt stool\ns. Continue flagyl empirically\n - Check amylase and lipase\n # Anemia:\n - Trend HCT\n - Gave 1 un pRBC with good results\n - Will guiac stools when she has a BM\n - INR rising, now 1.7, may be nutritional\n # Spine fracture: neurologically intact distal to the lesion. prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per verbal report.\n # Hypernatremia, resolved: correcting with g tube free flush and D5W\n -Holding on g tube feeds at present due to high residuals\n -Replete lytes as necessary\n # Communication:\n - Brother has been with pt, although, live in boyfriend of 10 is\n her HCP. Boyfriend will hopefully visit pt today\n ICU Care\n Nutrition: tube feed with free water when able\n Glycemic Control: Regular insulin sliding scale\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Communication: ICU consent signed, (brother) \n (boyfriend/POA) \n Code status: Full code\n Disposition: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 01:36 AM\n Arterial Line - 03:00 AM\n Multi Lumen - 11:30 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2167-09-23 00:00:00.000","description":"Physician Attending Progress Note","row_id":634419,"text":"Chief Complaint: respiratory failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n ESOPHOGEAL BALLOON - At 01:46 PM\n Restarted levophed overnight\n Patient unable to provide history: Sedated\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Aztreonam - 06:09 AM\n Metronidazole - 08:00 AM\n Levofloxacin - 08:39 AM\n Infusions:\n Midazolam (Versed) - 1.5 mg/hour\n Fentanyl - 75 mcg/hour\n Norepinephrine - 0.02 mcg/Kg/min\n Other ICU medications:\n Other medications:\n vanc, aztreonam, flagyl (day ), CHG, SQI, nebs, naloxone enteral,\n heparin infusion\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38\nC (100.4\n Tcurrent: 37.6\nC (99.6\n HR: 75 (64 - 102) bpm\n BP: 96/49(65) {76/38(56) - 160/71(97)} mmHg\n RR: 22 (16 - 25) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101 kg (admission): 94.2 kg\n Height: 67 Inch\n CVP: 20 (8 - 339)mmHg\n Bladder pressure: 18 (18 - 21) mmHg\n Total In:\n 3,524 mL\n 848 mL\n PO:\n TF:\n 48 mL\n IVF:\n 3,236 mL\n 698 mL\n Blood products:\n Total out:\n 935 mL\n 325 mL\n Urine:\n 650 mL\n 325 mL\n NG:\n 285 mL\n Stool:\n Drains:\n Balance:\n 2,589 mL\n 523 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 0 (0 - 0) mL\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 23 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 37 cmH2O\n Plateau: 33 cmH2O\n Compliance: 40 cmH2O/mL\n SpO2: 99%\n ABG: 7.37/44/160/25/0\n Ve: 8.9 L/min\n PaO2 / FiO2: 320\n Physical Examination\n General Appearance: Overweight / Obese\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: coarse breath sounds\n Abdominal: Soft, Obese\n Extremities: Right: 1+, Left: 1+\n Skin: Warm\n Neurologic: Responds to: Unresponsive, Movement: No spontaneous\n movement, Tone: Normal\n Labs / Radiology\n 8.9 g/dL\n 358 K/uL\n 126 mg/dL\n 0.7 mg/dL\n 25 mEq/L\n 3.5 mEq/L\n 4 mg/dL\n 108 mEq/L\n 143 mEq/L\n 28.0 %\n 8.1 K/uL\n [image002.jpg]\n 12:05 PM\n 06:08 PM\n 06:11 PM\n 07:53 PM\n 02:02 AM\n 03:59 AM\n 09:14 PM\n 01:04 AM\n 05:54 AM\n 06:11 AM\n WBC\n 8.4\n 8.1\n Hct\n 29.0\n 28.1\n 28.0\n Plt\n 376\n 358\n Cr\n 0.6\n 0.7\n TCO2\n 29\n 29\n 25\n 25\n 28\n 28\n 26\n Glucose\n 120\n 126\n Other labs: PT / PTT / INR:22.2/76.0/2.1, ALT / AST:24/16, Alk Phos / T\n Bili:117/0.7, Amylase / Lipase:, Differential-Neuts:74.7 %,\n Lymph:17.6 %, Mono:3.8 %, Eos:3.4 %, Lactic Acid:0.7 mmol/L,\n Albumin:2.4 g/dL, LDH:204 IU/L, Ca++:8.2 mg/dL, Mg++:2.0 mg/dL, PO4:3.2\n mg/dL\n Assessment and Plan\n End-exp transpulmonary pressure: -2\n End-insp transpulmonary pressure: +5\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 01:36 AM\n Arterial Line - 03:00 AM\n Multi Lumen - 11:30 AM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Heparin gtt)\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent:\n Patient is critically ill\n"},{"category":"Physician ","chartdate":"2167-09-23 00:00:00.000","description":"Physician Attending Progress Note","row_id":634421,"text":"Chief Complaint: respiratory failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n ESOPHOGEAL BALLOON - At 01:46 PM\n Restarted levophed overnight\n Patient unable to provide history: Sedated\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Aztreonam - 06:09 AM\n Metronidazole - 08:00 AM\n Levofloxacin - 08:39 AM\n Infusions:\n Midazolam (Versed) - 1.5 mg/hour\n Fentanyl - 75 mcg/hour\n Norepinephrine - 0.02 mcg/Kg/min\n Other ICU medications:\n Other medications:\n vanc, aztreonam, flagyl (day ), CHG, SQI, nebs, naloxone enteral,\n heparin infusion\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38\nC (100.4\n Tcurrent: 37.6\nC (99.6\n HR: 75 (64 - 102) bpm\n BP: 96/49(65) {76/38(56) - 160/71(97)} mmHg\n RR: 22 (16 - 25) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101 kg (admission): 94.2 kg\n Height: 67 Inch\n CVP: 20 (8 - 339)mmHg\n Bladder pressure: 18 (18 - 21) mmHg\n Total In:\n 3,524 mL\n 848 mL\n PO:\n TF:\n 48 mL\n IVF:\n 3,236 mL\n 698 mL\n Blood products:\n Total out:\n 935 mL\n 325 mL\n Urine:\n 650 mL\n 325 mL\n NG:\n 285 mL\n Stool:\n Drains:\n Balance:\n 2,589 mL\n 523 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 0 (0 - 0) mL\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 23 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 37 cmH2O\n Plateau: 33 cmH2O\n Compliance: 40 cmH2O/mL\n SpO2: 99%\n ABG: 7.37/44/160/25/0\n Ve: 8.9 L/min\n PaO2 / FiO2: 320\n Physical Examination\n General Appearance: Overweight / Obese\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: coarse breath sounds\n Abdominal: Soft, Obese\n Extremities: Right: 1+, Left: 1+\n Skin: Warm\n Neurologic: Responds to: Unresponsive, Movement: No spontaneous\n movement, Tone: Normal\n Labs / Radiology\n 8.9 g/dL\n 358 K/uL\n 126 mg/dL\n 0.7 mg/dL\n 25 mEq/L\n 3.5 mEq/L\n 4 mg/dL\n 108 mEq/L\n 143 mEq/L\n 28.0 %\n 8.1 K/uL\n [image002.jpg]\n 12:05 PM\n 06:08 PM\n 06:11 PM\n 07:53 PM\n 02:02 AM\n 03:59 AM\n 09:14 PM\n 01:04 AM\n 05:54 AM\n 06:11 AM\n WBC\n 8.4\n 8.1\n Hct\n 29.0\n 28.1\n 28.0\n Plt\n 376\n 358\n Cr\n 0.6\n 0.7\n TCO2\n 29\n 29\n 25\n 25\n 28\n 28\n 26\n Glucose\n 120\n 126\n Other labs: PT / PTT / INR:22.2/76.0/2.1, ALT / AST:24/16, Alk Phos / T\n Bili:117/0.7, Amylase / Lipase:, Differential-Neuts:74.7 %,\n Lymph:17.6 %, Mono:3.8 %, Eos:3.4 %, Lactic Acid:0.7 mmol/L,\n Albumin:2.4 g/dL, LDH:204 IU/L, Ca++:8.2 mg/dL, Mg++:2.0 mg/dL, PO4:3.2\n mg/dL\n Assessment and Plan\n Assessment and Plan\n 55-year-old woman with\n Respiratory failure\n End-exp transpulmonary pressure: -2\n End-insp transpulmonary pressure: +5\n Esophageal pressures suggest that she is at safe pressures.\n Traumatic thoracic spinal fracture\n Eventual MRI. Too high-risk at present. Brace when out of\n bed.\n Probable VAP\n Discuss GNRs with lab\n Complete 8\n 15d course of present ABX pending cultures\n D/C vancomycin since no identified GPCs\n D/C Flagyl since no CT or toxin evidence of C diff\n Shock\n now back on levophed\n CVP is 20 mm Hg but Pes is ~25 cm H20\n Re-assess SVV with Vigileo and consider volume challenge\n Upper extremity DVT\n Therapeutic heparin\n Anemia\n Follow\n Possible tracheobronchomalacia (reason for transfer)\n Incidental peri-appendiceal finding (will need eventual\n follow-up)\n Although differential remains open, the most compelling course of\n events is probably that she required intubation at the outside hospital\n (?sedation ?restriction from obesity/brace ?other) and subsequently\n developed a GNR-related VAP. Her pattern of acute lung injury,\n combined with obesity, is resulting in basilar and\n posterior-predominant atelectasis/consolidation with a high proportion\n of shunt. Given her very high PEEP, will try to avoid bronchoscopy if\n possible.\n Other issues as per ICU team note.\n ICU Care\n Nutrition: resume tube feeds\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 01:36 AM\n Arterial Line - 03:00 AM\n Multi Lumen - 11:30 AM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Heparin gtt)\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent:\n Patient is critically ill\n"},{"category":"Nursing","chartdate":"2167-09-24 00:00:00.000","description":"Nursing Progress Note","row_id":634499,"text":"55 yr old woman admitted from OSH after she fell down the stairs and\n had traumatic T-spine fracture. Pt came to us with PNA from unknown\n etiology? VAP. Full code, Allergies: PCN, tetracycline, Sulfa. PMH:\n ETOH, smoker, Gerd, Hip replacement.\n Alteration in Nutrition\n Assessment:\n Tube feeds at 20ml/hr. Tube feed residual 20ml.\n Action:\n Kept TF at 20ml/hr and will cont to check residuals and try to increase\n rate\n Response:\n No change\n Plan:\n Try to increase Tube feeds to goal rate.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n RUE DVT, pt on heparin gtt at 1700units/hr.\n Action:\n Ptt was therapeutic x2, AM PTT\n Response:\n Plan:\n Cont heparin gtt, check PTT adjust heparin gtt per scale.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Moderate thick white in-line secretions, copious clear oral secretions,\n clear/diminished lung sounds. Esophageal balloon in place. Previous\n Sputum culture shows GNR, speciation PND.\n Action:\n Lots of suctioning through the night, decreased FiO2 from 50% to 40%,\n decreased Peep from 23 to 21, HOB >30, oral care.\n Response:\n ABG WNL\n Plan:\n Cont to try to wean vent settings as tolerated, cont monitoring ABG\n Hypotension (not Shock)\n Assessment:\n SBP 90-110\ns MAP 62-66 Goal MAP >65 Levophed gtt @ 0.020 mcg/kg/min.\n Action:\n Trying to wean levophed gtt off\n Response:\n Plan:\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n T-max 101.0\n Action:\n Sent blood, urine, and sputum cultures, treated with tylenol\n Response:\n Temp decreased\n Plan:\n Follow up on cultures\n CT scan from earlier in the week confirms fracture but did not detect\n retropulsion. Neuro want pt in back brace when she is out of bed.\n Log rolling pt has been d/c.\n"},{"category":"Physician ","chartdate":"2167-09-24 00:00:00.000","description":"Physician Resident Progress Note","row_id":634552,"text":"24 Hour Events:\n -Yesterday, stopped vanc and flagyl. Continued Aztreonam and\n Levofloxicin\n -Febrile to 101- pan cultured; cxr\n -Micro on sputum GNR due back today\n -Decreased FiO2 and PEEP to 21 (from 23 for ABG 7.42/39/116 at 11PM)\n -Early am, HR dropped to 40s-50s. EKG suggestive of junctional rhythm.\n Held pressures, making good UOP, good O2 sats\n -This am, art line is intermittently working. Drew ABG - pending\n -Yesterday, SVV was 7; held on giving more fluids\n -Random cortisol was very low; started hydrocortisone and florinef\n -UOP picked up this AM\n -Restarted tube feeds\n -K, Phos given this AM\n -New possible junctional rhythm (low voltage) at 5AM. Enzymes added on\n -Spine -> request CT C, L spine, MRI, TLSO, non-operative, d/c log roll\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Metronidazole - 08:00 AM\n Levofloxacin - 08:39 AM\n Aztreonam - 02:00 PM\n Infusions:\n Norepinephrine - 0.02 mcg/Kg/min\n Midazolam (Versed) - 4 mg/hour\n Other ICU medications:\n Midazolam (Versed) - 03:50 PM\n Fentanyl - 03:50 PM\n Ranitidine (Prophylaxis) - 08:31 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (101\n Tcurrent: 37.1\nC (98.8\n HR: 60 (60 - 86) bpm\n BP: 103/46(61) {103/46(61) - 121/50(66)} mmHg\n RR: 22 (17 - 23) insp/min\n SpO2: 99%\n Heart rhythm: JR (Junctional Rhythm)\n Wgt (current): 101 kg (admission): 94.2 kg\n Height: 67 Inch\n CVP: 12 (12 - 339)mmHg\n Total In:\n 1,675 mL\n 232 mL\n PO:\n TF:\n 182 mL\n 134 mL\n IVF:\n 1,233 mL\n 98 mL\n Blood products:\n Total out:\n 877 mL\n 565 mL\n Urine:\n 727 mL\n 535 mL\n NG:\n 30 mL\n Stool:\n Drains:\n Balance:\n 798 mL\n -333 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 22\n RR (Spontaneous): 2\n PEEP: 21 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 33 cmH2O\n Plateau: 30 cmH2O\n Compliance: 44.4 cmH2O/mL\n SpO2: 99%\n ABG: 7.46/28/129\n Ve: 9.7 L/min\n PaO2 / FiO2: 290\n Physical Examination\n Gen: Does not arouse to voice\n HEENT: Pupils 3 mm reactive bilaterally. Scleral edema bilat\n Resp: Symmetric expansion. Coarse breath sounds throughout. Cannot\n adeq listen to post bases\n CV: RRR.\n Abd: Hypoactive bowel sounds. Distended.\n Ext: Edema in bilat UE.\n Peripheral vascular: Radial pulses 2+ bilaterally.\n Neuro: Moving all 4 extremities.\n Labs / Radiology\n 326 K/uL\n 8.9 g/dL\n 151 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 3.6 mEq/L\n 2 mg/dL\n 108 mEq/L\n 141 mEq/L\n 28.6 %\n 8.9 K/uL\n [image002.jpg]\n 06:11 PM\n 07:53 PM\n 02:02 AM\n 03:59 AM\n 09:14 PM\n 01:04 AM\n 05:54 AM\n 06:11 AM\n 11:07 PM\n 03:51 AM\n WBC\n 8.4\n 8.1\n 8.9\n Hct\n 28.1\n 28.0\n 28.6\n Plt\n 376\n 358\n 326\n Cr\n 0.6\n 0.7\n 0.7\n TCO2\n 29\n 25\n 25\n 28\n 28\n 26\n 26\n Glucose\n 120\n 126\n 151\n Other labs: PT / PTT / INR:24.3/68.6/2.4, ALT / AST:24/16, Alk Phos / T\n Bili:117/0.7, Amylase / Lipase:, Differential-Neuts:82.5 %,\n Lymph:11.6 %, Mono:3.3 %, Eos:2.2 %, Lactic Acid:0.7 mmol/L,\n Albumin:2.4 g/dL, LDH:204 IU/L, Ca++:8.5 mg/dL, Mg++:2.1 mg/dL, PO4:2.5\n mg/dL\nMicro: 2:38 am SPUTUM Site: ENDOTRACHEAL\n GRAM STAIN (Final ):\n >25 PMNs and <10 epithelial cells/100X field.\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.\n IN PAIRS AND CLUSTERS.\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).\n RESPIRATORY CULTURE (Pending)\n GRAM STAIN (Final ) SPUTUM Site: ENDOTRACHEAL:\n <10 PMNs and <10 epithelial cells/100X field.\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.\n IN PAIRS.\n 1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).\n CULTURE: GRAM NEGATIVE ROD(S). RARE GROWTH. WORK-UP PER DR ().\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with respiratory failure\n and difficulty weaning from vent.\n # Respiratory failure: Over the evening yesterday, were able to\n decrease FiO2 and PEEP. Clinical and imaging suggestive of ARDS.\n Initial preceptiationg factors: sedation, hypovent obesity,\n orthotic brace. Now thought to have VAP.\n - Placed esophageal balloon on which will help guide PEEP settings.\n # VAP: Re-spiked fever overnight. Stopped vanc yesterday, , as\n treating for GNR infection. Current GS shows GPC\n - Follow cultures\n - Restart Vanc.\n - Continue aztreonam, levofloxicin for 8 days pending speciation (at\n that time can increase to 15 days if necessary)\n - Also, stopped flagyl because had one neg c. diff toxin and CT did not\n show evidence of colitis\n # EKG changes: very low voltages and no change in QRS morphology.\n P-waves may be buried.\n -repeat\n -f/u enzymes\n # Hypotension, requiring Levophed: Increased urine output c/w\n autodiuresing\n - Attempt to wean from levophed with MAP goal 65 and UOP goal >30 cc/hr\n - Hypovolemia is possibly a factor- responded to a transfusion; HCT had\n been dropping. However, SVV with Vigileo was 13, making her CO less\n likely to respond to fluids. Held on giving any boluses overnight.\n - Sepsis also a factor- on broad spectrum abs\n - Central line in place.\n # Oliguria: Improved recently. BUN and Cr reassuring.\n -Continue to monitor\n # RUE DVT: Started on heparin gtt on .\n -Therapeutic in one day; may be related to poor nutritional status.\n Will continue to closely monitor\n # Abd distention: be chronic condition not requiring immediate\n medical attention\n - CT abd only showed appendiceal mucocele without inflammation, not\n concerning, most likely chronic. No concern for intraabd disaster\n - Now having BMs; c. diff toxin neg\n - amylase and lipase wnl\n # Adrenal Insufficency:\n -Random cortisol was approx 3 when it should have been maximally\n stimulated.\n -Started hydrocortisone and florinef. ? switch to methylpred\n # Anemia:\n - Trend HCT\n - Gave 1 un pRBC with good results\n - INR rising, now 2.0, may be nutritional\n # Spine fracture: neurologically intact distal to the lesion. prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - Repeat CT C, L spine.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n # Hypernatremia, resolved: correcting with g tube free flush and D5W\n -Holding on g tube feeds at present due to high residuals\n -Replete lytes as necessary\n # Communication:\n - Brother has been with pt, although, live in boyfriend of 10 is\n her HCP. Boyfriend will hopefully visit pt today\n ICU Care\n Nutrition: tube feed with free water when able\n Glycemic Control: Regular insulin sliding scale\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Communication: ICU consent signed, (brother) \n (boyfriend/POA) \n Code status: Full code\n Disposition: ICU\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 10:55 PM 30 mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 01:36 AM\n Arterial Line - 03:00 AM\n Multi Lumen - 11:30 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2167-09-24 00:00:00.000","description":"Physician Attending Progress Note","row_id":634564,"text":"Chief Complaint: respiratory failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n BLOOD CULTURED - At 12:24 AM\n URINE CULTURE - At 12:24 AM\n SPUTUM CULTURE - At 03:30 AM\n EKG - At 05:20 AM\n pt in junctional rhythem, holding stable BP, intern aware and came to\n assess pt. HR 47-50.\n Fever spike to 101\n Steroids started\n Antibiotics tailored\n PEEP decreased\n History obtained from Medical records, ICU team\n Patient unable to provide history: Sedated\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Metronidazole - 08:00 AM\n Levofloxacin - 08:39 AM\n Aztreonam - 06:00 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 100 mcg/hour\n Other ICU medications:\n Midazolam (Versed) - 03:50 PM\n Fentanyl - 03:50 PM\n Ranitidine (Prophylaxis) - 08:31 PM\n Other medications:\n versed, fentanyl, colace, H2B, CHG, SQI, MDIs, heparin infusion,\n levoflox, aztreonam, hydrocortisone 50 q6, fludrocort\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (101\n Tcurrent: 37.1\nC (98.8\n HR: 57 (48 - 86) bpm\n BP: 102/48(61) {102/46(61) - 121/52(66)} mmHg\n RR: 22 (17 - 23) insp/min\n SpO2: 99%\n Heart rhythm: JR (Junctional Rhythm)\n Wgt (current): 101 kg (admission): 94.2 kg\n Height: 67 Inch\n CVP: 11 (11 - 20)mmHg\n Bladder pressure: 12 (12 - 12) mmHg\n Total In:\n 1,708 mL\n 460 mL\n PO:\n TF:\n 182 mL\n 138 mL\n IVF:\n 1,267 mL\n 321 mL\n Blood products:\n Total out:\n 877 mL\n 1,305 mL\n Urine:\n 727 mL\n 1,275 mL\n NG:\n 30 mL\n Stool:\n Drains:\n Balance:\n 831 mL\n -845 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 21 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 36 cmH2O\n Plateau: 29 cmH2O\n Compliance: 50 cmH2O/mL\n SpO2: 99%\n ABG: 7.46/38/96./26/2\n Ve: 8.6 L/min\n PaO2 / FiO2: 242\n Physical Examination\n General Appearance: Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear :\n anteriorly)\n Abdominal: Soft, Non-tender, Obese\n Extremities: Right: 1+, Left: 1+\n Musculoskeletal: Unable to stand\n Skin: Warm\n Neurologic: Responds to: Unresponsive, Movement: No spontaneous\n movement, Sedated, Tone: Normal\n Labs / Radiology\n 8.9 g/dL\n 326 K/uL\n 151 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 3.6 mEq/L\n 2 mg/dL\n 108 mEq/L\n 141 mEq/L\n 28.6 %\n 8.9 K/uL\n [image002.jpg]\n 02:02 AM\n 03:59 AM\n 09:14 PM\n 01:04 AM\n 05:54 AM\n 06:11 AM\n 11:07 PM\n 03:51 AM\n 06:17 AM\n 08:18 AM\n WBC\n 8.4\n 8.1\n 8.9\n Hct\n 28.1\n 28.0\n 28.6\n Plt\n 376\n 358\n 326\n Cr\n 0.6\n 0.7\n 0.7\n TCO2\n 25\n 28\n 28\n 26\n 26\n 21\n 28\n Glucose\n 120\n 126\n 151\n Other labs: PT / PTT / INR:24.3/68.6/2.4, CK / CKMB / Troponin-T:24//,\n ALT / AST:24/16, Alk Phos / T Bili:117/0.7, Amylase / Lipase:,\n Differential-Neuts:82.5 %, Lymph:11.6 %, Mono:3.3 %, Eos:2.2 %, Lactic\n Acid:0.7 mmol/L, Albumin:2.4 g/dL, LDH:204 IU/L, Ca++:8.5 mg/dL,\n Mg++:2.1 mg/dL, PO4:2.5 mg/dL\n Imaging: CXR: increased right base opacity\n Microbiology: Sputum from overnight: GPCs with 2+ GPCs in\n pairs/clusters and 2+ GPRs\n Prior sputum growing GNRs\n Assessment and Plan\n 55-year-old woman with\n Respiratory failure\n Recheck esophageal pressures today.\n Wean PEEP as tolerated and guided by Pes\n On our ultrasound exam, effusion would be high risk to tap\n Adrenal insufficiency\n Based on very low random cortisol while in shock and\n respiratory failure\n On steroids\n Bradycardia\n Rhythm appear sinus.\n Will try to check an atrial EKG via her CVL to confirm\n Heart rate increases with stimulation, suggesting that this\n is mostly vagal in etiology\n Sedation and high ventilatory pressures may contribute to\n high vagal tone\n Continues to have signs of good perfusion\n This may be reflex bradycardia from increased perfusion\n relating to steroid dosing\n Probable VAP\n Discuss GNRs with lab\n Complete 8\n 15d course of present ABX pending cultures\n D/C vancomycin since no identified GPCs\n D/C Flagyl since no CT or toxin evidence of C diff\n Shock\n now off of levophed (again)\n SVV is low, suggesting adequate volume repletion\n Treating adrenal insufficiency\n Polyuria\n be response to increased perfusion (comes at right time\n course to be an effect of treating adrenal insufficiency)\n Upper extremity DVT\n Therapeutic heparin\n Anemia\n Follow\n Possible tracheobronchomalacia (reason for transfer)\n Incidental peri-appendiceal finding (will need eventual\n follow-up)\n Traumatic thoracic spinal fracture\n Eventual MRI. Too high-risk at present. Brace when out of\n bed.\n Fever\n Restart vanco (GPCs on G/S of sputum)\n Follow cultures\n Resite art line (dysfunctional).\n CVL is within 3 days; will follow\n Although differential remains open, the most compelling course of\n events is probably that she required intubation at the outside hospital\n (?sedation ?restriction from obesity/brace ?other) and subsequently\n developed a GNR-related VAP. Her pattern of acute lung injury,\n combined with obesity, is resulting in basilar and\n posterior-predominant atelectasis/consolidation with a high proportion\n of shunt. Will consider bronchoscopy based on course today, given\n apparent increased atelectasis on CXR.\n Other issues as per ICU team note.\n ICU Care\n Nutrition: tube feeds\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 01:36 AM\n Arterial Line - 03:00 AM\n Multi Lumen - 11:30 AM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Heparin gtt)\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 40 min\n Patient is critically ill\n"},{"category":"Physician ","chartdate":"2167-09-24 00:00:00.000","description":"Physician Resident Progress Note","row_id":634591,"text":"24 Hour Events:\n -Yesterday, stopped vanc and flagyl. Continued Aztreonam and\n Levofloxicin\n -Febrile to 101- pan cultured; cxr\n -Micro on sputum GNR due back today\n -Decreased FiO2 and PEEP to 21 (from 23 for ABG 7.42/39/116 at 11PM)\n -Early am, HR dropped to 40s-50s. EKG suggestive of junctional rhythm.\n Held pressures, making good UOP, good O2 sats\n -This am, art line is intermittently working. Drew ABG - pending\n -Yesterday, SVV was 7; held on giving more fluids\n -Random cortisol was very low; started hydrocortisone and florinef\n -UOP picked up this AM\n -Restarted tube feeds\n -K, Phos given this AM\n -New possible junctional rhythm (low voltage) at 5AM. Enzymes added on\n -Spine -> request CT C, L spine, MRI, TLSO, non-operative, d/c log roll\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Metronidazole - 08:00 AM\n Levofloxacin - 08:39 AM\n Aztreonam - 02:00 PM\n Infusions:\n Norepinephrine - 0.02 mcg/Kg/min\n Midazolam (Versed) - 4 mg/hour\n Other ICU medications:\n Midazolam (Versed) - 03:50 PM\n Fentanyl - 03:50 PM\n Ranitidine (Prophylaxis) - 08:31 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (101\n Tcurrent: 37.1\nC (98.8\n HR: 60 (60 - 86) bpm\n BP: 103/46(61) {103/46(61) - 121/50(66)} mmHg\n RR: 22 (17 - 23) insp/min\n SpO2: 99%\n Heart rhythm: JR (Junctional Rhythm)\n Wgt (current): 101 kg (admission): 94.2 kg\n Height: 67 Inch\n CVP: 12 (12 - 339)mmHg\n Total In:\n 1,675 mL\n 232 mL\n PO:\n TF:\n 182 mL\n 134 mL\n IVF:\n 1,233 mL\n 98 mL\n Blood products:\n Total out:\n 877 mL\n 565 mL\n Urine:\n 727 mL\n 535 mL\n NG:\n 30 mL\n Stool:\n Drains:\n Balance:\n 798 mL\n -333 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 22\n RR (Spontaneous): 2\n PEEP: 21 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 33 cmH2O\n Plateau: 30 cmH2O\n Compliance: 44.4 cmH2O/mL\n SpO2: 99%\n ABG: 7.46/28/129 at 6AM\n Repeated at 9AM 7.4/38/97\n Ve: 9.7 L/min\n PaO2 / FiO2: 290\n Physical Examination\n Gen: Does not arouse to voice\n HEENT: Pupils 3 mm reactive bilaterally. Scleral edema bilat\n Resp: Symmetric expansion. Coarse breath sounds throughout. Cannot\n adeq listen to post bases\n CV: RRR.\n Abd: Hypoactive bowel sounds. Distended.\n Ext: Edema in bilat UE.\n Peripheral vascular: Radial pulses 2+ bilaterally.\n Neuro: Moving all 4 extremities.\n Labs / Radiology\n 326 K/uL\n 8.9 g/dL\n 151 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 3.6 mEq/L\n 2 mg/dL\n 108 mEq/L\n 141 mEq/L\n 28.6 %\n 8.9 K/uL\n [image002.jpg]\n 06:11 PM\n 07:53 PM\n 02:02 AM\n 03:59 AM\n 09:14 PM\n 01:04 AM\n 05:54 AM\n 06:11 AM\n 11:07 PM\n 03:51 AM\n WBC\n 8.4\n 8.1\n 8.9\n Hct\n 28.1\n 28.0\n 28.6\n Plt\n 376\n 358\n 326\n Cr\n 0.6\n 0.7\n 0.7\n TCO2\n 29\n 25\n 25\n 28\n 28\n 26\n 26\n Glucose\n 120\n 126\n 151\n Other labs: PT / PTT / INR:24.3/68.6/2.4, ALT / AST:24/16, Alk Phos / T\n Bili:117/0.7, Amylase / Lipase:, Differential-Neuts:82.5 %,\n Lymph:11.6 %, Mono:3.3 %, Eos:2.2 %, Lactic Acid:0.7 mmol/L,\n Albumin:2.4 g/dL, LDH:204 IU/L, Ca++:8.5 mg/dL, Mg++:2.1 mg/dL, PO4:2.5\n mg/dL\nMicro: 2:38 am SPUTUM Site: ENDOTRACHEAL\n GRAM STAIN (Final ):\n >25 PMNs and <10 epithelial cells/100X field.\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.\n IN PAIRS AND CLUSTERS.\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).\n RESPIRATORY CULTURE (Pending)\n GRAM STAIN (Final ) SPUTUM Site: ENDOTRACHEAL:\n <10 PMNs and <10 epithelial cells/100X field.\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.\n IN PAIRS.\n 1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).\n CULTURE: GRAM NEGATIVE ROD(S). RARE GROWTH. WORK-UP PER DR ().\n US of effusion (by MICU staff): small effusion, accessible but\n difficult to tap\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with respiratory failure\n and difficulty weaning from vent.\n # Respiratory failure: Over the evening yesterday, were able to\n decrease FiO2 and PEEP. Clinical and imaging suggestive of ARDS.\n Initial precipitating factors were thought to be: sedation, hypovent\n obesity, orthotic brace. Now thought to have VAP.\n - Placed esophageal balloon on which will help guide PEEP settings.\n - Given small size of effusion and high PEEP (risk of pneumothorax),\n will not attempt to tap\n - Appreciate IP recs. Will consider tracheomalacia workup when more\n stable.\n # VAP/ID: Re-spiked fever overnight. Stopped vanc yesterday, , as\n treating for GNR infection. Current GS shows GPC\n - Follow cultures\n - Restart Vanc.\n - Continue aztreonam, levofloxicin for 8 days pending speciation (at\n that time can increase to 15 days if necessary)\n - Also, stopped flagyl because had one neg c. diff toxin and CT did not\n show evidence of colitis\n - Will replace A-line today.\n # EKG changes: Sinus bradycardia. Very low voltages and no change in\n QRS morphology. P-waves are visible and prolonged PR interval is old.\n CK and troponins flat. Likely related to increased vagal tone possibly\n related to steroid replacement.\n - Will avoid excessive alpha-agonism\n - Continue to monitor\n - could consider atrial EKG\n .\n # Hypotension: now off levophed, with good urine output. Hypovolemia\n is possibly a factor- responded to a transfusion; HCT had been\n dropping. However, SVV with Vigileo was 7, making her CO less likely\n to respond to fluids. Held on giving any boluses overnight. Today CVP\n is low given PEEP. Sepsis also a consideration\n - continue on broad spectrum abs\n - replete fluids.\n - Restart pressors as needed. Consider dopamine over levophed given\n bradycardia.\n - Central line in place.\n # Urine output: Previously oliguric, now with high urine output.\n Concern for autodiuresis but BUN and Cr reassuring.\n -Continue to monitor\n # RUE DVT: Started on heparin gtt on .\n -Therapeutic in one day; may be related to poor nutritional status.\n Will continue to closely monitor\n # Adrenal Insufficency:\n -Random cortisol was approx 3 when it should have been maximally\n stimulated.\n -Started hydrocortisone and florinef. ? switch to methylpred\n # Anemia:\n - Trend HCT\n - Gave 1 un pRBC with good results\n - INR rising, now 2.0, may be nutritional\n # Spine fracture: neurologically intact distal to the lesion. prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n # Hypernatremia, resolved: correcting with g tube free flush and D5W\n -Continue to follow\n # Communication:\n - Brother has been with pt, although, live in boyfriend of 10 is\n her HCP. Boyfriend will hopefully visit pt today\n ICU Care\n Nutrition: tube feed with free water when able\n Glycemic Control: Regular insulin sliding scale\n DVT: Theraputic Heparin gtt\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Communication: ICU consent signed, (brother) \n (boyfriend/POA) \n Code status: Full code\n Disposition: ICU\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 10:55 PM 30 mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 01:36 AM\n Arterial Line - 03:00 AM\n Multi Lumen - 11:30 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Respiratory ","chartdate":"2167-09-30 00:00:00.000","description":"Respiratory Care Shift Note","row_id":635270,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 12\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location: Medical Center\n Reason: Emergent (1st time); Comments: Mechanical fall\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments: Bronchoscopic procedure done today,BAL collected.\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments: 55 yr old female transfered from Medical Center to\n intubated post mechanical fall. Patient now @ for\n evaluation of tracheomalacia.It has been very difficult to wean her off\n mechanical ventilation.Easily desaturated and agitated with the lesser\n interaction.Very PEEP sensitive , but was able to decrease level of\n PEEP down to 8 cmH20 today.Plan to trach and PEG in AM if PEEP level\n remains bellow 10cmH20.Last ABG acceptable with hypoxemia;hypernatremic\n ? renal insufficiency free water given. Bronchoscopic procedure\n performed by MD today,sample collected,sent to lab for culture.\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"},{"category":"Nursing","chartdate":"2167-10-04 00:00:00.000","description":"Nursing Progress Note","row_id":635714,"text":"55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\n Now with prolonged hospital course c/b by PNA with high PEEP\n requirement, anxiety, RUE DVT on heparin qtt.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt on Vent settings AC 55%/18 X 400/+10 with no overbreathing of\n set RR. O2 sat 92-98%. Lung snds clear, diminished in bases. Pt sxn\n for small-moderate amts thick white secretions. Trach site with small\n amt serosang drainage.\n Action:\n Cont same vent settings\n Response:\n Pt doesn\nt over breath on the vent and never desat.Kept same Vent\n settings overnight.\n Plan:\n Monitor sats,resp and titrate Vent as she tolerats.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt rec\nd with Heparin qtt 1900units/hr.\n Action:\n PTT drawn at 2300.RUE elevated with pillow and no BP or blood drawn\n from that arm.\n Response:\n PTT @ 2300 was 107, Decreased Heparin gtt 1700 u/hr as per sliding\n scale. Next PTT due at 0600. .\n Plan:\n Cont monitor PTT,titrate accordingly, next PTT due at 0600.\n Alteration in Nutrition\n Assessment:\n Received pt on TF 10cc/hr.Abd soft w/+ BS.\n Action:\n Pt tolerated TF with minimal residuals as well as free water bolus\n Q4H.Received scheduled Colace\n Response:\n TF ^ as tolerated, currently at 30cc/hr.No BM noted this shift.HCt 24.6\n (25.8)\n Plan:\n Cont to monitor TF residuals, hold if more than 100cc\n Altered mental status (not Delirium)\n Assessment:\n Pt w/ periods of agitation and sleeping at other times, while she\n aweake follow commands intermittently.\n Action:\n Cont on fent 100 mics ,Versed 2mg/hr and requires frequent boluses .\n Cont diazepam 10 mg PO Q6H. Fent ^ 125 mics/hr,Versed 3mg/hr.\n Response:\n HR ranging from SB in the 40\ns when asleep to the 120-140\ns when\n agitated, b/p ranging from 90\ns/40\ns when asleep to 140-170\ns/ 70\n when agitated. When pt awake appropriate and following commands HR\n 80\ns-100\ns and b/p 100\ns-120\ns/ 60-70\n Plan:\n Titrate sedation as needed\n"},{"category":"Social Work","chartdate":"2167-09-21 00:00:00.000","description":"Social Work Progress Note","row_id":634274,"text":"Social Work:\n Received referral re pt/family coping and questions re HCP for this 55\n y.o. pt admitted with dx of tracheobroncheal malacia. Reviewed\n chart and discussed with RN. Spoke with pt\ns brother, (c:\n ), by phone. He asks questions re who pt\ns legal NOK would\n be and who should be involved in decision making re healthcare issues\n given that pt also has a live-in boyfriend of 10 years in . He\n mentions his understanding of a Companion Law in ME where a domestic\n partner might have automatic rights to decision-making responsibilities\n in the event that pt cannot make decisions for herself. SW discussed\n with attorney on call who will do some research into this question. In\n the meantime, assured brother that both he and pt\ns bf will be\n consulted re any healthcare decisions while pt is intubated and\n sedated. Brother is satisfied with this and states he does not\n anticipate any conflicts. He is visiting from and bf is\n reportedly on his way in from ME.\n SW will continue to follow for pt/family support as needed. Brother\n seems to be coping well at this time. Please page PRN.\n , LCSW, #\n"},{"category":"Physician ","chartdate":"2167-09-22 00:00:00.000","description":"Physician Resident Progress Note","row_id":634330,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n -Neurosurg: ok to transport. Will decide on anticoagulation in AM\n -Central line placed\n -NGT to suction\n -Bowel regimen\n -Respiratory attempted to place esophageal ballon in order to measure\n intrathoracic pressure, unsuccessful\n -Desaturation around 23:00 to low 80s on 400/22/15/0.9 following turn.\n Recruitment maneuver (PEEP to 30) done x2 with good effect, Sat came up\n to 100%. PEEP left at 17\n -Transfused 1 un pRBC\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 10:00 AM\n Aztreonam - 02:00 PM\n Vancomycin - 12:00 AM\n Metronidazole - 12:00 AM\n Infusions:\n Norepinephrine - 0.02 mcg/Kg/min\n Fentanyl - 200 mcg/hour\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:00 AM\n Midazolam (Versed) - 02:20 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 37.6\nC (99.6\n HR: 73 (64 - 96) bpm\n BP: 119/48(69) {85/39(55) - 142/67(91)} mmHg\n RR: 22 (11 - 22) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 94.2 kg (admission): 94.2 kg\n Height: 67 Inch\n CVP: 20 (11 - 21)mmHg\n Bladder pressure: 14 (14 - 18) mmHg\n Total In:\n 3,482 mL\n 465 mL\n PO:\n TF:\n IVF:\n 2,845 mL\n 465 mL\n Blood products:\n 277 mL\n Total out:\n 580 mL\n 65 mL\n Urine:\n 580 mL\n 65 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,902 mL\n 400 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 500) mL\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 17 cmH2O\n FiO2: 80%\n PIP: 33 cmH2O\n Plateau: 30 cmH2O\n Compliance: 30.8 cmH2O/mL\n SpO2: 98%\n ABG: 7.38/41/86./24/0\n Ve: 9.1 L/min\n PaO2 / FiO2: 109\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 376 K/uL\n 9.0 g/dL\n 120 mg/dL\n 0.6 mg/dL\n 24 mEq/L\n 3.7 mEq/L\n 4 mg/dL\n 108 mEq/L\n 141 mEq/L\n 28.1 %\n 8.4 K/uL\n [image002.jpg]\n ALT 24 PT 18.7\n AST 16 PTT 25.4\n AP 117 INR 1.7\n Tbili 0.7\n Alb 2.4\n 08:03 PM\n 11:00 PM\n 03:01 AM\n 03:13 AM\n 12:05 PM\n 06:08 PM\n 06:11 PM\n 07:53 PM\n 02:02 AM\n 03:59 AM\n WBC\n 7.6\n 6.4\n 8.4\n Hct\n 24.1\n 24.1\n 29.0\n 28.1\n Plt\n \n Cr\n 0.6\n 0.6\n 0.6\n TCO2\n 33\n 30\n 29\n 29\n 25\n 25\n Glucose\n 127\n 129\n 120\n Differential-Neuts:80.8 %, Lymph:12.0 %, Mono:3.5 %, Eos:3.3 %\n Ca++:8.2 mg/dL, Mg++:2.2 mg/dL, PO4:3.1 mg/dL, ion Ca++ () 1.16\n Cortisol:\n : 2:15am 24.2 Midnight 2.7\n : 3am 4.5\n Micro: neg or NGTD if not mentioned\n : blood, \n : urine, sputum-OP flora\n : BAL, - coag neg staph, lactobacillus, cath tip, sputum- OP\n flora, rare GNR, blood\n U/a:\n Color\n Amber\n Appear\n Clear\n SpecGr\n 1.015\n pH\n 5.5\n Urobil\n 2\n Bili\n Mod\n Leuk\n Tr\n Bld\n Tr\n Nitr\n Pos\n Prot\n 100\n Glu\n Neg\n Ket\n 40\n RBC\n 0-2\n WBC\n 0-2\n Bact\n Few\n Yeast\n None\n Epi\n 0-2\n Imaging:\n Echo\n post recruitment CXR showed deep sulcus but no pnumothorax per rads.\n CT: Prelim Read\n Right lower lobe consolidation, and superimposed atelectasis/lower lobe\n collapse, and effusions. Acute T8 compression deformity, with no\n posterior\n retropulsion of fracture fragments. No associated hematoma.\n Assessment and Plan\n comm with fam, vanc dosing\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture\n # Respiratory failure: initial etiology unclear, likely multifactorial\n including bronchspasm, hypoventilation from narcotics, potential\n aspiration, infection. By report, had a neg evaluation for PE at OSH,\n however, unable to open disc to confirm. Concern for VAP.\n - Failed yesterday\ns NIF; score was -15\n - Increased FiO2 overnight. Had increased pCO2 which resolved with\n increasing RR\n - IP stopped by but will complete official consult today; suggested\n repeating CT scan\n - Need to contact Medical re previous CT scan. Can attempt to\n resend disc. Otherwise, will most likely benefit from repeat CT to\n look for acute pulm process such as PE or PNA.\n # Fever: Likely due to combination of infection and DVT. Cultures\n sent. Will treat with empiric antibiotics. Tylenol PRN for fever.\n - Known RUE DVT\n - Infectious etiologies include VAP, asp PNA, line infections. Removed\n PICC yesterday and cultured tip. Mini-BAL- gram stain neg. Sputum\n grew GPC in pairs and GPR. Flagyl, aztreonam, vancomycin, levofloxacin\n for coverage of gram positives, gram negatives, anaerobes, MRSA. Urine\n and blood cultures NGTD\n - f/u blood, urine, and sputum cultures.\n - Concern for abd cause; KUB unrevealing. High residuals. require\n further imaging\n # Transient hypotension: Has been somewhat fluid responsive; UOP \n ccs/hr. Diff dx includes hypovolemia, sepsis, cardiogenic.\n - Sepsis most likely given fever.\n - HCT decreasing; ? stable at 24-25\n - Unable to place central line despite multiple attempts. First tired\n left IJ RUE DVT. 2^nd attempt in left IJ. Can place femoral if pt\n requires more active repletion\n - Consider another attempt at a line.\n # Oliguria:\n -BUN and Cr as well as lactate reassuring.\n -Increased bladder pressures this am- 20. Further imaging may be\n helpful\n # RUE DVT: Have held on starting treatment in light of need for central\n access. Can start therapeutic heparin vs Lovenox with bridge to\n coumadin.\n -Can consider rescanning for PE. High risk for PE given UE DVT.\n # Abd distention:\n -KUB unrevealing\n -High residuals\n - benefit from further imaging; if unstable consider ultrasound,\n however, if pt can tolerate it, a CT scan might be more helpful. Can\n also scan chest and pelvis.\n # Anemia: On admission to Medical Center, Hct was ~40, now down\n to 30 and then 25 w/o sign of active GI bleed or other source of blood\n loss. be related to fluid administration, phlebotomy, anemia of\n inflammation, active bleed still considered in differential.\n - trend Hct\n - guaiac stools\n - S/p failed attempts at line placement; watch for neck hematomas\n - INR elev at 1.5. ? may be related to poor nutrition as albumin is\n 2.3\n # Spine fracture: neurologically intact distal to the lesion. prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - Need to talk to neurosurg to see if pt can tolerate a CT scan as well\n as the risks of anticoag for DVT\n - monitor distal neurologic function\n - cto brace x3 months unless supine in bed\n - consult neurosurgery for further recs\n # Hypernatremia: correcting with g tube free flush and D5W\n -Holding on g tube feeds at present due to high residuals\n -Replete lytes as necessary\n # Communication:\n SW discussed with attorney on call who will do some research into this\n question. In the meantime, assured brother that both he and pt\ns bf\n will be consulted re any healthcare decisions while pt is intubated and\n sedated. Brother is satisfied with this and states he does not\n anticipate any conflicts. He is visiting from and bf is\n reportedly on his way in from ME.\n ICU Care\n Nutrition: tube feed with free water\n Glycemic Control: Regular insulin sliding scale\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Communication: ICU consent signed, (brother) \n (boyfriend/POA) \n Code status: Full code\n Disposition: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 01:36 AM\n 22 Gauge - 02:00 PM\n Arterial Line - 03:00 AM\n Multi Lumen - 11:30 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Nursing","chartdate":"2167-09-24 00:00:00.000","description":"Nursing Progress Note","row_id":634493,"text":"55 yr old woman admitted from OSH after she fell down the stairs. Pt\n came to us with ? PNA from VAP. Full code, Allergies: PCN,\n tetracycline, Sulfa. PMH: ETOH, smoker, Gerd, Hip replacement.\n Alteration in Nutrition\n Assessment:\n Tube feeds at 20ml/hr. Tube feed residual 20ml.\n Action:\n Kept TF at 20ml/hr and will cont to check residuals and try to increase\n rate\n Response:\n No change\n Plan:\n Try to increase Tube feeds to goal rate.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n RUE DVT, pt on heparin gtt at 1700units/hr.\n Action:\n Ptt was therapeutic x2, AM PTT\n Response:\n Plan:\n Cont heparin gtt, check PTT adjust heparin gtt per scale.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Moderate thick white in-line secretions, copious clear oral secretions,\n clear/diminished lung sounds. Esophageal balloon in place.\n Action:\n Lots of suctioning through the night, decreased FiO2 from 50% to 40%,\n decreased Peep from 23 to 21\n Response:\n ABG WNL\n Plan:\n Cont to try to wean vent settings as tolerated, cont monitoring ABG\n Hypotension (not Shock)\n Assessment:\n SBP 90-110\ns MAP 64-66 Goal MAP >65 Levophed gtt @ 0.020 mcg/kg/min.\n Action:\n Trying to wean levophed gtt off\n Response:\n Plan:\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n T-max 101.0\n Action:\n Sent blood, urine, and sputum cultures, treated with tylenol\n Response:\n Temp decreased\n Plan:\n Follow up on cultures\n"},{"category":"Nursing","chartdate":"2167-09-24 00:00:00.000","description":"Nursing Progress Note","row_id":634494,"text":"55 yr old woman admitted from OSH after she fell down the stairs. Pt\n came to us with ? PNA from VAP. Full code, Allergies: PCN,\n tetracycline, Sulfa. PMH: ETOH, smoker, Gerd, Hip replacement.\n Alteration in Nutrition\n Assessment:\n Tube feeds at 20ml/hr. Tube feed residual 20ml.\n Action:\n Kept TF at 20ml/hr and will cont to check residuals and try to increase\n rate\n Response:\n No change\n Plan:\n Try to increase Tube feeds to goal rate.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n RUE DVT, pt on heparin gtt at 1700units/hr.\n Action:\n Ptt was therapeutic x2, AM PTT\n Response:\n Plan:\n Cont heparin gtt, check PTT adjust heparin gtt per scale.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Moderate thick white in-line secretions, copious clear oral secretions,\n clear/diminished lung sounds. Esophageal balloon in place.\n Action:\n Lots of suctioning through the night, decreased FiO2 from 50% to 40%,\n decreased Peep from 23 to 21\n Response:\n ABG WNL\n Plan:\n Cont to try to wean vent settings as tolerated, cont monitoring ABG\n Hypotension (not Shock)\n Assessment:\n SBP 90-110\ns MAP 62-66 Goal MAP >65 Levophed gtt @ 0.020 mcg/kg/min.\n Action:\n Trying to wean levophed gtt off\n Response:\n Plan:\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n T-max 101.0\n Action:\n Sent blood, urine, and sputum cultures, treated with tylenol\n Response:\n Temp decreased\n Plan:\n Follow up on cultures\n"},{"category":"Nursing","chartdate":"2167-09-25 00:00:00.000","description":"Nursing Progress Note","row_id":634718,"text":"Events: PT found on CXR ETT 5cm too high- bronched and repositioning,\n sample sent- tolerated w/ w/ mod amt sedation. Sadation weaned w/\n boluses for agitation. No IVF bolus, cont off Levo gtt. Resting post\n bronch w/ plan to wean PEEP as tolerated.\n Bradycardia\n Assessment:\n When sedated pt sinus bradycardic 49-50\ns, BP remaining stable.\n Action:\n Sedation monitored weaned w/ blousing PRN\n Response:\n Cont bradycardia when sedated\n Plan:\n Cont monitoring HS stability, sedation as tolerated- MS labile from\n awake and pulling at tube/lines/moving in bed to sedation w/ able to\n wake up to voice\n Alteration in Nutrition\n Assessment:\n TF residuals 5-70cc, cont hypoactive BS\n Action:\n Inc to goal TF- replete w/ fiber @ 60cc/hr\n Response:\n Tolerating @ this time\n Plan:\n Monitor residuals, bowel sounds, cont @ goal 60cc/hr, monitor stool\n output\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Hep gtt infusing @ 1700 units/hr, no s/s bleeding\n Action:\n Cont Hep gtt, check PTT w/ AM labs\n Response:\n Plan:\n Cont Hep gtt per order, check PTT w/ AM labs and adjust per scale,\n monitor s/s bleeding\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS diminished/rhonchi, minimal thin clear secretions, desat to 92%\n while on R side,\n Action:\n Cont pulm toilet as tolerated, turning side-middle side Q2hrs, bronch,\n Response:\n Sat > 95% post repositioning,\n Plan:\n Cont pulm toilet, wean from vent as tolerated\n Hypotension (not Shock)\n Assessment:\n A line positional, intermittently correlating W/ NBP w/ intermittent\n dampened waveform and over dampened, able to draw ABG, BP labile w/\n sedation Map >65 throughout day, CVP 15-19\n Action:\n A Line not re-sited, positioning art line, correlating NBP and ABP\n Response:\n MAP >65 throughout shift\n Plan:\n Cont monitor, cont IV steroids, CVP monitoring w/ UOP for additional\n fluid bolus\n"},{"category":"Respiratory ","chartdate":"2167-09-28 00:00:00.000","description":"Respiratory Care Shift Note","row_id":634998,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 10\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Decreasing PEEP as talerated with intent to possible\n preform tracheostomy within the next day or two.\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: patient remains on ventilatory support with all settings and\n changes documented on flow sheet. PEEP decreased to 10cm with plan to\n perform tracheostomy within the next day or two. Patient appears to be\n agitated but talerating PEEP change. MDI\ns administered as ordered.\n"},{"category":"Nursing","chartdate":"2167-09-29 00:00:00.000","description":"Nursing Progress Note","row_id":635133,"text":"55yrold lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n consertively with pain meds and back brace. Developed resp distress\n requiring intubation on ct neg for PE cxr showed pna pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia /\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2167-10-03 00:00:00.000","description":"Nursing Progress Note","row_id":635658,"text":"55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\n Now with prolonged hospital course c/b by PNA with high PEEP\n requirement, anxiety, RUE DVT on heparin qtt.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt on Vent settings AC 60%/18 X 400/+10 with no overbreathing of\n set RR. O2 sat 92-98%. Lung snds clear, diminished in bases. Pt sxn\n for small amts thick white secretions. Trach site with small amt\n serosang drainage.\n Action:\n FiO2 \nd to 55%.\n Response:\n ABG to follow.\n Plan:\n Cont to gently wean from vent.\n Edema, peripheral\n Assessment:\n Pt with general edema. LOS fluid balance +approx 13 liters. Lasix\n stopped as PICC line clogged.\n Action:\n TPA used to clear PICC line. Lasix restarted @ 2mg/hr.\n Response:\n By 1330 24hr fluid balance\n 2liters. Lasix qtt stopped @ 1330, but pt\n cont to autodiurese. Pt presently\n 3 liters since MN. Lytes sent @\n 1630.\n Plan:\n Cont to monitor urine output, restarting Lasix if necessary to maintain\n goal -1-2liters/day. Monitor lytes.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt rec\nd with Heparin qtt off post trach/PEG yesterday.\n Action:\n Heparin restarted @ 1100 @ previous rate 1700units/hr.\n Response:\n PTT @ 1630 58.5. Heparin inc\nd to 1900units/hr per sliding scale @\n 1715.\n Plan:\n Repeat PTT @ 2300.\n Alteration in Nutrition\n Assessment:\n Rec\nd pt NPO post OR yesterday. Abd obese/distended with + BS. No BM\n today.\n Action:\n Restarted TF Replete with fiber @ 1000 per surgical team @ 10ml/hr, as\n well as FWB of 250ml Q4hrs for elevated Na.\n Response:\n Residual @ 1600 140ml of TF/water/yellow bilious. TF stopped and FWB\n held.\n Plan:\n Resume TF @ 1830. Cont to monitor residuals, holding TF if >100ml.\n"},{"category":"Nutrition","chartdate":"2167-09-22 00:00:00.000","description":"Clinical Nutrition Note","row_id":634346,"text":"Subjective\n Pt intubated /sedated\n Objective\n Pertinent medications: noted\n Labs:\n Value\n Date\n Glucose\n 120 mg/dL\n 03:59 AM\n Glucose Finger Stick\n 124\n 10:00 AM\n FSBG\n 111, 111, 145, 123\n \n BUN\n 4 mg/dL\n 03:59 AM\n Creatinine\n 0.6 mg/dL\n 03:59 AM\n Sodium\n 141 mEq/L\n 03:59 AM\n Potassium\n 3.7 mEq/L\n 03:59 AM\n Chloride\n 108 mEq/L\n 03:59 AM\n Albumin\n 2.4 g/dL\n 03:59 AM\n Calcium non-ionized\n 8.2 mg/dL\n 03:59 AM\n Phosphorus\n 3.1 mg/dL\n 03:59 AM\n Ionized Calcium\n 1.16 mmol/L\n 12:05 PM\n Magnesium\n 2.2 mg/dL\n 03:59 AM\n Corrented Ca\n 9.48\n Current diet order / nutrition support: replete c/ Fiber @60mL/hr (1440\n kcals 89 gr aa)- currently on hold\n GI: Abd: softly dist/absent bs/no BM\n Assessment of Nutritional Status\n Specifics:\n TF\ns trialed. Held high residuals and OGT placed to suction. OGT\n is currently clamped.\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: via nutrition support\n Consider reglan +/- increase bowel regimen\n Resume TF's as medically feasible, if unable in next 2-3 days, will\n need to consider PN to prevent nutritional decline\n BG/lyte management\n"},{"category":"Respiratory ","chartdate":"2167-09-25 00:00:00.000","description":"Respiratory Care Shift Note","row_id":634642,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 7\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Tube Type\n ETT:\n Position: 18 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Comments: Pt. remains on A/C overnoc, no vent changes this shift.\n Maintain current vent settings.\n"},{"category":"Physician ","chartdate":"2167-09-25 00:00:00.000","description":"Physician Resident Progress Note","row_id":634722,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n New A-line placed (left), good tracing but positional\n Vanco restarted\n Atrial EKG->p-waves\n Multiple IVF boluses for MAPs < 65. Did not restart pressors\n Brother came, confirmed history\n Eye drops\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Metronidazole - 08:00 AM\n Levofloxacin - 10:00 AM\n Vancomycin - 08:09 PM\n Aztreonam - 10:00 PM\n Infusions:\n Midazolam (Versed) - 4 mg/hour\n Heparin Sodium - 1,700 units/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 04:29 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.7\nC (98.1\n HR: 56 (45 - 63) bpm\n BP: 103/54(72) {83/44(59) - 142/105(109)} mmHg\n RR: 22 (0 - 22) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101 kg (admission): 94.2 kg\n Height: 67 Inch\n CVP: 12 (11 - 14)mmHg\n Total In:\n 4,750 mL\n 868 mL\n PO:\n TF:\n 773 mL\n 223 mL\n IVF:\n 3,827 mL\n 645 mL\n Blood products:\n Total out:\n 2,365 mL\n 60 mL\n Urine:\n 2,325 mL\n 60 mL\n NG:\n 40 mL\n Stool:\n Drains:\n Balance:\n 2,385 mL\n 808 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 21 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 34 cmH2O\n Plateau: 29 cmH2O\n Compliance: 50 cmH2O/mL\n SpO2: 99%\n ABG: 7.46/38/96./23/2\n Ve: 8.6 L/min\n PaO2 / FiO2: 242\n Physical Examination\n General Appearance: Obese\n Eyes / Conjunctiva: PERRL, subconjunctival hematoma on left\n Cardiovascular: brady, regular, no MRG, nL S1, S2\n Respiratory / Chest: CTA b/l\n Abdominal: Soft, Non-tender, Obese, +BS\n Extremities: Right: 1+, Left: 1+\n Skin: Warm\n Neurologic: Responds to: Verbal stimuli, Movement: Purposeful, Tone:\n Normal\n Labs / Radiology\n 326 K/uL\n 8.9 g/dL\n 153 mg/dL\n 0.6 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n 6 mg/dL\n 113 mEq/L\n 141 mEq/L\n 28.6 %\n 8.9 K/uL\n [image002.jpg]\n 09:14 PM\n 01:04 AM\n 05:54 AM\n 06:11 AM\n 11:07 PM\n 03:51 AM\n 06:17 AM\n 07:00 AM\n 08:18 AM\n 04:18 PM\n WBC\n 8.1\n 8.9\n Hct\n 28.0\n 28.6\n Plt\n 358\n 326\n Cr\n 0.7\n 0.7\n 0.6\n TropT\n <0.01\n <0.01\n TCO2\n 28\n 28\n 26\n 26\n 21\n 28\n Glucose\n 126\n 151\n 153\n Other labs: PT / PTT / INR:24.3/68.6/2.4, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:82.5 %, Lymph:11.6 %,\n Mono:3.3 %, Eos:2.2 %, Lactic Acid:0.7 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:7.8 mg/dL, Mg++:2.1 mg/dL, PO4:2.6 mg/dL\n Culture data: Sputum with Klebsiella Oxytoca\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with respiratory failure\n and difficulty weaning from vent.\n # Respiratory failure: Over the evening yesterday, were able to\n decrease FiO2 and PEEP. Clinical and imaging suggestive of ARDS.\n Initial precipitating factors were thought to be: sedation, hypovent\n obesity, orthotic brace. Now thought to have VAP.\n - Placed esophageal balloon on which will help guide PEEP settings.\n - Given small size of effusion and high PEEP (risk of pneumothorax),\n will not attempt to tap\n - Appreciate IP recs. Will consider tracheomalacia workup when more\n stable.\n - Approaching 2-week intubation point (intubated ); Trach?\n # VAP/ID: Re-spiked fever overnight. Stopped vanc yesterday, , as\n treating for GNR infection. Current GS shows GPC\n - Follow cultures\n - Restart Vanc.\n - Continue aztreonam, levofloxicin for 8 days pending speciation (at\n that time can increase to 15 days if necessary)\n - Also, stopped flagyl because had one neg c. diff toxin and CT did not\n show evidence of colitis\n - Will replace A-line today.\n # EKG changes: Sinus bradycardia. Very low voltages and no change in\n QRS morphology. P-waves are visible and prolonged PR interval is old.\n CK and troponins flat. Likely related to increased vagal tone possibly\n related to steroid replacement.\n - Will avoid excessive alpha-agonism\n - Continue to monitor\n - could consider atrial EKG\n .\n # Hypotension: now off levophed, with good urine output. Hypovolemia\n is possibly a factor- responded to a transfusion; HCT had been\n dropping. However, SVV with Vigileo was 7, making her CO less likely\n to respond to fluids. Held on giving any boluses overnight. Today CVP\n is low given PEEP. Sepsis also a consideration\n - continue on broad spectrum abs\n - replete fluids.\n - Restart pressors as needed. Consider dopamine over levophed given\n bradycardia.\n - Central line in place.\n # Urine output: Previously oliguric, now with high urine output.\n Concern for autodiuresis but BUN and Cr reassuring.\n -Continue to monitor\n # RUE DVT: Started on heparin gtt on .\n -Therapeutic in one day; may be related to poor nutritional status.\n Will continue to closely monitor\n # Adrenal Insufficency:\n -Random cortisol was approx 3 when it should have been maximally\n stimulated.\n -Started hydrocortisone and florinef. ? switch to methylpred\n # Anemia:\n - Trend HCT\n - Gave 1 un pRBC with good results\n - INR rising, now 2.0, may be nutritional\n # Spine fracture: neurologically intact distal to the lesion. prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n # Hypernatremia, resolved: correcting with g tube free flush and D5W\n -Continue to follow\n # Communication:\n - Brother has been with pt, although, live in boyfriend of 10 is\n her HCP. Boyfriend will hopefully visit pt today\n ICU Care\n Nutrition: tube feed with free water when able\n Glycemic Control: Regular insulin sliding scale\n DVT: Theraputic Heparin gtt\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Communication: ICU consent signed, (brother) \n (boyfriend/POA) \n Code status: Full code\n Disposition: ICU\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 07:00 AM 50 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 11:30 AM\n Arterial Line - 04:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2167-09-25 00:00:00.000","description":"Physician Resident Progress Note","row_id":634723,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n New A-line placed (left), good tracing but positional\n Vanco restarted\n Atrial EKG->p-waves\n Multiple IVF boluses for MAPs < 65. Did not restart pressors\n Brother came, confirmed history\n Eye drops\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Metronidazole - 08:00 AM\n Levofloxacin - 10:00 AM\n Vancomycin - 08:09 PM\n Aztreonam - 10:00 PM\n Infusions:\n Midazolam (Versed) - 4 mg/hour\n Heparin Sodium - 1,700 units/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 04:29 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.7\nC (98.1\n HR: 56 (45 - 63) bpm\n BP: 103/54(72) {83/44(59) - 142/105(109)} mmHg\n RR: 22 (0 - 22) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101 kg (admission): 94.2 kg\n Height: 67 Inch\n CVP: 12 (11 - 14)mmHg\n Total In:\n 4,750 mL\n 868 mL\n PO:\n TF:\n 773 mL\n 223 mL\n IVF:\n 3,827 mL\n 645 mL\n Blood products:\n Total out:\n 2,365 mL\n 60 mL\n Urine:\n 2,325 mL\n 60 mL\n NG:\n 40 mL\n Stool:\n Drains:\n Balance:\n 2,385 mL\n 808 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 21 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 34 cmH2O\n Plateau: 29 cmH2O\n Compliance: 50 cmH2O/mL\n SpO2: 99%\n ABG: 7.46/38/96./23/2\n Ve: 8.6 L/min\n PaO2 / FiO2: 242\n Physical Examination\n General Appearance: Obese\n Eyes / Conjunctiva: PERRL, subconjunctival hematoma on left\n Cardiovascular: brady, regular, no MRG, nL S1, S2\n Respiratory / Chest: CTA b/l\n Abdominal: Soft, Non-tender, Obese, +BS\n Extremities: Right: 1+, Left: 1+\n Skin: Warm\n Neurologic: Responds to: Verbal stimuli, Movement: Purposeful, Tone:\n Normal\n Labs / Radiology\n 326 K/uL\n 8.9 g/dL\n 153 mg/dL\n 0.6 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n 6 mg/dL\n 113 mEq/L\n 141 mEq/L\n 28.6 %\n 8.9 K/uL\n [image002.jpg]\n 09:14 PM\n 01:04 AM\n 05:54 AM\n 06:11 AM\n 11:07 PM\n 03:51 AM\n 06:17 AM\n 07:00 AM\n 08:18 AM\n 04:18 PM\n WBC\n 8.1\n 8.9\n Hct\n 28.0\n 28.6\n Plt\n 358\n 326\n Cr\n 0.7\n 0.7\n 0.6\n TropT\n <0.01\n <0.01\n TCO2\n 28\n 28\n 26\n 26\n 21\n 28\n Glucose\n 126\n 151\n 153\n Other labs: PT / PTT / INR:24.3/68.6/2.4, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:82.5 %, Lymph:11.6 %,\n Mono:3.3 %, Eos:2.2 %, Lactic Acid:0.7 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:7.8 mg/dL, Mg++:2.1 mg/dL, PO4:2.6 mg/dL\n Culture data: Sputum with Klebsiella Oxytoca\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with respiratory failure\n and difficulty weaning from vent.\n 55-year-old woman with\n Unclear location of ETT\n Since only 18cm in holder, we will bronch to confirm correct\n position since an inadvertent extubation might be fatal.\n Respiratory failure\n Oxygenation is improving\n Wean PEEP as tolerated by hypoxemia\n eventually need investigation for TBM\n At present, her PEEP is too high to consider tracheostomy\n but if we are able to wean it (and not able to extubate her) would\n consider tracheostomy soon\n Adrenal insufficiency\n Based on very low random cortisol while in shock and\n respiratory failure\n On steroids, has come off and stayed off of pressors.\n Eventually wean, but still getting fluid boluses\n Bradycardia\n Rhythm is sinus, confirmed by CVL-directed\natrial\n lead\n Heart rate increases with stimulation, suggesting that this\n is mostly vagal in etiology\n Klebsiella VAP\n Complete 8d course of levofloxacin\n Discontinue aztreonam\n If sputum culture remains negative (GPCs on G/S),\n discontinue vancomycin tomorrow\n Shock\n now off of levophed\n Intermittent fluid boluses\n Treating adrenal insufficiency\n Upper extremity DVT\n Therapeutic heparin\n Anemia\n Follow\n Possible tracheobronchomalacia (reason for transfer)\n Incidental peri-appendiceal finding (will need eventual\n follow-up)\n Traumatic thoracic spinal fracture\n Eventual MRI. Too high-risk at present. Brace when out of\n bed.\n # Respiratory failure currently with unclear ETT location: Intubated\n on for resp decompensation. Likely VAP. Unlikely to have\n tracheomalacia as initially transferred for.\n - bronch for ETT location\n - wean PEEP\n # Pneumonia: Kleb oxytoca pneumonia and sputum with GPCs on gram stain.\n Afebrile overnight. On levofloxacin, vancomycin, aztreonam. Resp\n status seems to be improving.\n - Follow cultures\n - d/c aztreonam\n - Continue levofloxacin for 8 days\n # EKG changes: Sinus bradycardia. Very low voltages and no change in\n QRS morphology. P-waves are visible and prolonged PR interval is old.\n CK and troponins flat. Likely related to increased vagal tone possibly\n related to steroid replacement. Atrial EKG with p-waves c/w sinus\n bradycardia.\n - Will avoid excessive alpha-agonism\n - Continue to monitor\n .\n # Hypotension: now off levophed, with good urine output. Hypovolemia\n is possibly a factor- responded to a transfusion; HCT had been\n dropping. However, SVV with Vigileo was 7, making her CO less likely\n to respond to fluids. Held on giving any boluses overnight. Today CVP\n is low given PEEP. Sepsis also a consideration.\n - continue abx as above (vanc and levofloxacin)\n - replete fluids.\n - Restart pressors as needed. Consider dopamine given bradycardia.\n # RUE DVT: Started on heparin gtt on .\n - closely monitor\n # Adrenal Insufficency: Random cortisol was approx 3 when it should\n have been maximally stimulated.\n - hydrocortisone and florinef for 5 days\n # Anemia: Stable.\n - Trend HCT\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n # Communication:\n - Brother has been with pt, although, live in boyfriend of 10 is\n her HCP.\n ICU \n Nutrition: tube feed with free water when able, INR rising likely \n nutritional deficiencies\n Glycemic Control: Regular insulin sliding scale\n DVT: Theraputic Heparin gtt\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Communication: ICU consent signed, (brother) \n (boyfriend/POA) \n Code status: Full code\n Disposition: ICU\n"},{"category":"Social Work","chartdate":"2167-10-01 00:00:00.000","description":"Social Work Progress Note","row_id":635364,"text":"Social Work:\n Spoke by phone with pt\ns boyfriend, (), to\n offer support re pt\ns hospitalization and to facilitate communication\n with MICU team. He and pt have been living together in ME for the past\n 12 years. He speaks of how it is difficult to come to to visit\n pt because of the distance and the financial cost of taking the train.\n SW offered a cab voucher between train and hospital, if this would\n defray the cost and feel more manageable for him. He states he\nll let\n SW know if this would be helpful in the future. However, he also\n speaks of his own health problems which have limited his ability to\n travel this summer, and he describes feeling as if he is doing the best\n he can to come in.\n Mr. that even though he may not be able to come into\n the hospital as much as he\nd like, he still very much wants to stay\n involved in pt\ns care by communicating with team by phone. Discussed\n how pt\ns brother, as , has also been involved in communicating with\n team and, per Intern, has been giving consent for certain procedures\n when pt has been unable to speak for herself. Mr. confirms that\n he is not aware of pt having signed a HCP form and he understands and\n accepts that pt\ns brother as been involved re questions of consent.\n Discussed how it is important to Mr. that he, too, be consulted by\n phone re any major decisions re direction of care.\n SW discussed above with Intern and recommended she call Mr. today\n to discuss direction of care issues.\n Encouraged Mr. to contact SW as needed for further support and\n provided contact info. continue to follow for ongoing support.\n Please page PRN.\n , LCSW, #\n"},{"category":"Respiratory ","chartdate":"2167-10-02 00:00:00.000","description":"Respiratory Care Shift Note","row_id":635521,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation:\n Ideal body weight:\n Ideal tidal volume:\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position:\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure:\n Cuff volume:\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds:\n RUL Lung Sounds:\n LUL Lung Sounds:\n LLL Lung Sounds:\n Comments:\n Secretions\n Sputum color / consistency:\n Sputum source/amount:\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Specialized Gas Therapy\n Nitric Oxide\n PPM used: ppm\n Indication:\n Effect of therapy: []\n Nitric Oxide trial:\n Comments:\n HeliOx:\n Additional O[2] by cannula: L/min\n Continuous nebulized bronchodilator:\n Comments:\n Recruitment Maneuvers Done\n CPAP pressure used: cm H2O\n Duration: sec\n Times per shift:\n Comments:\n"},{"category":"Nursing","chartdate":"2167-10-03 00:00:00.000","description":"Nursing Progress Note","row_id":635576,"text":"55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP now with prolonged\n hospital course c/o by PNA anxiety,RUE DVD with high PEEP requirement\n .\n Pt has had an uneventful night. Plan to start heparin and TF this am.\n Awaiting time. Wean sedation today as tol by pt.\n Edema, peripheral\n Assessment:\n Pt has gen edema with gen pitting. Gen swelling has improved over the\n last 24hrs after lasix gtt initiated.\n Action:\n Lasix gtt infusing with goal of negative 1-2 liters over 24hrs. Lasix\n stopped at 5am access issues.\n Response:\n Pt is very sensitive to lasix, and is diuresing well while it is\n infusing with stable BP. K level has been stable and no replaements\n needed.\n Plan:\n Restart lasix once access available.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt has a clot to Rt arm and has been on heparin gtt per protocol.\n Heparin stopped yesterday trach and PEG placed.\n Action:\n Response:\n Plan:\n Heparin to be started today and ? time.\n Altered mental status (not Delirium)\n Assessment:\n Pt has been sedated throughout the night with plans to wean sedation\n today. Pt has a HR in the 40-50\ns while asleep with SBP 99-110. Pt has\n a HR in the 70\ns with a SBP 110-140\ns while awake. Pt will open eyes to\n voice and will follow most commands. While awake, pt is restless and\n will try to sit up and pull on trach.\n Action:\n Emotional support given with short lived effect. Pt continues on\n fentanyl and versed gtt for sedation and diazepam ATC.\n Response:\n Plan:\n Plan to wean pt off sedation gtts today.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt was trached yesterday failure to wean of vent ? tracheal\n malacia. Pt noted to be desatting while awake and while sedated to 85%.\n LS clear to coarse to upper resp areas with diminished bases. Pt has\n been sx\nd for sml amounts of rusty blood tinged secretions.\n Action:\n CMV settings changed to 60% FiO2 and peep increased to 10 after episode\n of low O2sat.\n Response:\n After vent changes, O2sat d and ABGs improved.\n Plan:\n Wean vent settings as pt tol.\n"},{"category":"Nursing","chartdate":"2167-10-04 00:00:00.000","description":"Nursing Progress Note","row_id":635706,"text":"55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\n Now with prolonged hospital course c/b by PNA with high PEEP\n requirement, anxiety, RUE DVT on heparin qtt.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt on Vent settings AC 55%/18 X 400/+10 with no overbreathing of\n set RR. O2 sat 92-98%. Lung snds clear, diminished in bases. Pt sxn\n for small-moderate amts thick white secretions. Trach site with small\n amt serosang drainage.\n Action:\n Cont same vent settings\n Response:\n Pt doesn\nt over breath on the vent and never desat.Kept same Vent\n settings overnight.\n Plan:\n Monitor sats,resp and titrate Vent as she tolerats.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt rec\nd with Heparin qtt 1900units/hr.\n Action:\n PTT drawn at 2300.RUE elevated with pillow and no BP or blood drawn\n from that arm.\n Response:\n PTT @ 2300 was 107, Decreased Heparin gtt 1700 u/hr as per sliding\n scale. Next PTT due at 0600. .\n Plan:\n Cont monitor PTT,titrate accordingly, next PTT due at 0600.\n Alteration in Nutrition\n Assessment:\n Received pt on TF 10cc/hr.Abd soft w/+ BS.\n Action:\n Pt tolerated TF with minimal residuals as well as free water bolus\n Q4H.Received scheduled Colace\n Response:\n TF ^ as tolerated, currently at 30cc/hr.No BM noted this shift.HCt 24.6\n (25.8)\n Plan:\n Cont to monitor TF residuals, hold if more than 100cc\n Altered mental status (not Delirium)\n Assessment:\n Pt w/ periods of agitation and sleeping at other times, while she\n aweake follow commands intermittently.\n Action:\n Cont on fent 100 mics ,Versed 2mg/hr and requires frequent boluses .\n Cont diazepam 10 mg PO Q6H. Fent ^ 125 mics/hr,Versed 3mg/hr.\n Response:\n HR ranging from SB in the 40\ns when asleep to the 120-140\ns when\n agitated, b/p ranging from 90\ns/40\ns when asleep to 140-170\ns/ 70\n when agitated. When pt awake appropriate and following commands HR\n 80\ns-100\ns and b/p 100\ns-120\ns/ 60-70\n Plan:\n Titrate sedation as needed\n"},{"category":"Nursing","chartdate":"2167-09-30 00:00:00.000","description":"Nursing Progress Note","row_id":635177,"text":"55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP now with prolonged\n hospital course c/o by PNA anxiety,RUE DVD with high PEEP requirement\n .\n Plan : Plan for trach and peg today or the next few days, if pt tol\n peep of 10.\n Hypernatremia (high sodium)\n Assessment:\n Na level elevated\n Action:\n H2O flushes increased to 250 cc q 4hrs.\n Response:\n Na level remains elevated this am at 146 (sl improved).\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains intubated on CMV settings, now at 60%/400x18/10. LS coarse\n to upper resp area with diminished bases. Pt has been deep sx\nd for\n scant amounts of yellow secretions q 2hrs. Pt cont to have copious\n amounts of clear oral secretions and in need of freq oral care. Pt\n noted to have a decrease in O2sat, while she is on her Lt side, but it\n has improved throughout the night.\n Action:\n Peep weaned to 10, and tol well by pt with good ABGs. Fio2 weaned to 50\n %, but pt\ns O2sat decreased to 88% right away.\n Response:\n LS clear to upper resp area after sx.\n Plan:\n Plan for trach and Peg today if p[t cont to tol peep of 10.\n Altered mental status (not Delirium)\n Assessment:\n Pt found at 8pm to 10pm to be awake, alert and following commands. Pt\n was slight restless, but appropriate. 10pm, pt became very restless in\n bed, trying to sit up and was reaching for ETT. Once reposition and\n back rubs did not work, MD notified and haldol given and diazepam given\n with only effect for one hr. When pt is awake and restless, her HR will\n increase to 120-130\ns (ST) and BP will increase to 120-130\ns. When pt\n was sleeping (after sedation), Hr will deacrease to 50\ns with a SBP in\n the 80\ns. Fentanyl patch increased and diazepam changed to q6hrs, with\n no effect.\n Action:\n 2:30am, versed gtt was initiated again with good effect. Pt more\n relaxed and fell back to sleep with stable HR and BP.\n Response:\n Plan:\n Continue to evaluate restlessness.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt on heparin gtt protocol for DVT to Rt arm. No signs of bleeding\n noted. Hct stable.\n Action:\n Response:\n PTT drawn q 6hrs; and it has been therapeutic.\n Plan:\n Plan to check PTT now daily.\n"},{"category":"Nursing","chartdate":"2167-10-05 00:00:00.000","description":"Nursing Progress Note","row_id":635805,"text":"55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\n Now with prolonged hospital course c/b by PNA with high PEEP\n requirement, anxiety, RUE DVT on heparin qtt.\n Edema, peripheral\n Assessment:\n Fluid balance for previous 24hrs decreased by 3 liters D/T diuresis.\n Rec\nd pt off of Lasix qtt. Urine output decreased to 45ml/hr @1000.\n Action:\n Lasix qtt restarted @ 2mg/hr to maintain urine output 1-2liters/day.\n Response:\n Fluid balance approx -50ml/hr, with 24hr fluid balance -650ml @ 1500.\n However, SBP 78 when pt soundly sleeping/sedated. Lasix qtt stopped @\n 1530.\n Plan:\n Restart Lasix qtt when BP stabilized.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Rec\nd pt on Heparin qtt @ 1500units/hr.\n Action:\n PTT 92.1 @ 1230.\n Response:\n Per goal PTT 60-100, Heparin rate unchanged.\n Plan:\n Repeat PTT @ 1830. Start po Coumadin tonight.\n Altered mental status (not Delirium)\n Assessment:\n Rec\nd pt on Versed @ 2mg/hr, Fentanyl @ 100mcg/hr, as well as Fentanyl\n patches totaling 150mcg in place. Pt also rec\ning Diazepam 10mg po\n Q6hrs, in hope of weaning pt from IV sedation. Pt alternately appears\n very sedated and very restless. When she appears alert, she intermit\n responds to commands approp but not attempting to mouth words or nod to\n communicate. Moving arms purposefully towards trach, so soft wrist\n restraints remain in place. When very sedated @ 1530, SBP to 78 per\n below.\n Action:\n Versed \nd to 1mg/hr, Fentanyl \nd to 75mcg/hr.\n Response:\n Pt restless/squirming in bed when she appears awake. Not responding to\n verbal reassurance.\n Plan:\n Cont to attempt weaning from IV sedation. Cont to freq reorient pt,\n emotional support.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt on vent settings AC 55%/18 X 400/+10, with no over-breathing\n of rate by pt. O2 sat 95-99%. ABG 7.44/42/93. Lung snds clear but\n diminished in lower lobes. Suctionned for mod-lg amts thick white\n secretions.\n Action:\n Vent changed to CMV with PS 8/+10 on 55%.\n Response:\n Pt tolerated PS approx 3hrs, but after rec\ning scheduled dose Diazepam\n @ 1200 began having extended pauses apnea. She was then returned to AC\n 55%/9 X 500/+10.\n Plan:\n Cont wean from vent with PS trials, as well as \ning FiO2.\n"},{"category":"Nursing","chartdate":"2167-09-26 00:00:00.000","description":"Nursing Progress Note","row_id":634795,"text":"Events:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2167-09-30 00:00:00.000","description":"Nursing Progress Note","row_id":635254,"text":"55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP now with prolonged\n hospital course c/o by PNA anxiety,RUE DVD with high PEEP requirement\n .\n Events: PEEP weaned to 8, tol well, restarted on lasix gtt, midazolam\n weaned off, fentanyl decreased. ? trach and PEG in AM.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt on AC 400x18 50% +PEEP 10, 02 sat mid 90%\ns, ABG this AM\n 7.42/49/93\n Action:\n PEEP weaned to 8, thoracic surgery reconsulted r/t trach placement.\n Response:\n 02 sat dropped to 89-92% ABG on current settings 7.44/45/66 team is\n aware.\n Plan:\n Cont on current vent settings as tol. Plan for trach placement in am.\n Hypotension (not Shock)\n Assessment:\n Pt b/p when asleep 90\ns-100\ns/ 40\ns-50\ns. increases when pt is awake/\n agitated. Pt rec\nd on fentanyl gtt at 150mcg/hr and Midazolam 2mg/hr.\n stim test from shows adrenal insuff.\n Action:\n Midazolam weaned off, fentanyl decreased, pt restarted on florinef and\n hydrocortisone. Started on lasix gtt. Currently at 2mg/hr.\n Response:\n b/p stable in the 90\ns-110\ns/ 40\ns-60\ns. UOP 35-50ml/hr.\n Plan:\n Titrate lasix gtt and sedation as tol by b/p restart levophed if b/p\n drops and remains low.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt on heparin gtt at 1700 units/hr, PTT therapeutic x 2\n Action:\n Monitor heparin gtt\n Response:\n n/a\n Plan:\n Cont heparin gtt at current rate, recheck PTT in the am.\n Alteration in Nutrition\n Assessment:\n TF currently at goal rate 60ml/hr tol well, serum Na 146 (down from\n 147). Last BM \n Action:\n Cont free H20 boluses to decrease Na,\n Response:\n Plan:\n Cont TF/ free H20 as tol, cont bowel regime.\n"},{"category":"Nursing","chartdate":"2167-10-05 00:00:00.000","description":"Nursing Progress Note","row_id":635890,"text":"55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\n Now with prolonged hospital course c/b by PNA with high PEEP\n requirement, anxiety, RUE DVT on heparin qtt.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt cont on Heparin gtt @ 1500units/h. PTT in therapeutic range.\n Coumadin po HS.\n Action:\n No further action taken.\n Response:\n Plan:\n Daily PT/PTT levels-? Plan to transition off heparin and increase\n coumadin dose.\n Altered mental status (not Delirium)\n Assessment:\n PT alert and very agitated throughout shift- making several attempts to\n pull at trach\n.fell asleep briefly following afternoon valium dose-\n Systolic dropped into low 80s, HR in the 50s- SB. Following commands\n inconsistently.\n Action:\n Fentanyl/versed titrated throughout shift. Restarted on Haldol IV prn,\n and given addititional one time dose of valium. Soft wrist restraints\n in place for safety. EKG done of QTC interval\n Response:\n Cont to be anxious, attempting to pull at trach. QTI -442\n Plan:\n Cont daily QTC Intervals, titrate down Fent/versed Gtt as able, cont w/\n prn haldol and standing valium.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Cont to be trached/vented on AC. Pleural effusions on CXR worsening.\n Action:\n Tolerated PS briefly this am. ABG/VBG collected\n Response:\n Pt w/ periods of apnea on PS.\n Plan:\n Non-contrast CT today to further characterize effusions, ? possible\n thoracentesis following CT, make vent changes as needed, wean\n fent/versed as able to tolerate vent changes. Recheck ABG/VBG this\n evening.\n Hypernatremia (high sodium)\n Assessment:\n NA level cont to be ^^, pt cont on lasix gtt\n Action:\n FWB increased to 300cc every 4 hrs.\n Response:\n Lytes to be rechecked this evening\n Plan:\n Check day and evening lytes, cont w/ q 4h boluses\n"},{"category":"Nursing","chartdate":"2167-10-06 00:00:00.000","description":"Nursing Progress Note","row_id":635948,"text":"Bradycardia\n Assessment:\n Pt conts with HR 50-70\ns at rest, 100-140\ns during care, pt\n asymptomatic; easily arousable\n Action:\n Sedation decreased, Lasix off @0200\n Response:\n HR 60\n Plan:\n Cont to wean sedation, ?cardiac consult\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Action:\n Cont with IV Heparin @ 1500u/hr\n Response:\n Pt therapeutic, cont with daily PTT\n Plan:\n Cont to labs, adjust per Heparin protocol\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt cont on AC 18/400/50%/10, LS clear bilat, occ scat rhonchi\n Action:\n Pt suct for sm thin tan secretions\n Response:\n Plan:\n Cont to ABGs,\n Hypotension (not Shock)\n Assessment:\n SBP 140\ns when pt is agitated, SBP dropping to 70\ns-80\ns, UO 200/hr\n (total 2500 in 2hr)\n Action:\n Fent/Versed turned down @ 0000, Lasix gtt on hold, team informed\n Response:\n Pt SBP\ns in 80\n Plan:\n Cardiac consult to further eval SB/ST, re-evalu cont. Lasix gtt\n Hypernatremia (high sodium)\n Assessment:\n Na 143\n Action:\n Cont with 300cc free water flush\n Response:\n Plan:\n Cont to sodium levels, treat as ordered\n"},{"category":"Respiratory ","chartdate":"2167-09-27 00:00:00.000","description":"Respiratory Care Shift Note","row_id":634888,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 9\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Patient remains on mechanical ventilation with all changes documented\n on flow sheet. MDI\ns given as ordered. Breath sounds diminished with\n scattered.\n"},{"category":"Physician ","chartdate":"2167-10-01 00:00:00.000","description":"Physician Attending Progress Note","row_id":635334,"text":"Chief Complaint: respiratory failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n BRONCHOSCOPY - At 11:30 AM\n Midaz weaned.\n Heparin held due to potential OR today, but now on schedule for\n tomorrow for trach.\n History obtained from Medical records, ICU team\n Patient unable to provide history: Sedated\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Furosemide (Lasix) - 3 mg/hour\n Fentanyl - 100 mcg/hour\n Other ICU medications:\n Haloperidol (Haldol) - 11:47 PM\n Midazolam (Versed) - 02:45 AM\n Other medications:\n SQI, H2B, MDIs, CHG, colace, tears, florinef, hydrocort 50q6,\n duragesic, valium 10mg q6, Lasix @ 3\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:21 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.2\nC (97.2\n HR: 107 (46 - 121) bpm\n BP: 147/79(111) {88/41(57) - 148/85(113)} mmHg\n RR: 18 (18 - 20) insp/min\n SpO2: 89%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 4,162 mL\n 266 mL\n PO:\n TF:\n 1,448 mL\n 1 mL\n IVF:\n 1,003 mL\n 235 mL\n Blood products:\n Total out:\n 1,615 mL\n 1,500 mL\n Urine:\n 1,615 mL\n 1,500 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,547 mL\n -1,234 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n PIP: 27 cmH2O\n Plateau: 22 cmH2O\n Compliance: 44.4 cmH2O/mL\n SpO2: 89%\n ABG: 7.42/47/86./29/4\n Ve: 7.3 L/min\n PaO2 / FiO2: 174\n Physical Examination\n General Appearance: Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : anterior exam)\n Abdominal: Soft, No(t) Tender: , Obese\n Extremities: Right: 1+, Left: 1+\n Skin: Warm\n Neurologic: Responds to: Verbal stimuli, Movement: Non -purposeful,\n Tone: Normal\n Labs / Radiology\n 8.0 g/dL\n 280 K/uL\n 136 mg/dL\n 0.5 mg/dL\n 29 mEq/L\n 4.0 mEq/L\n 11 mg/dL\n 105 mEq/L\n 143 mEq/L\n 25.9 %\n 8.6 K/uL\n [image002.jpg]\n 02:44 PM\n 03:33 PM\n 07:26 PM\n 07:46 PM\n 02:04 AM\n 02:18 AM\n 01:27 PM\n 03:06 PM\n 10:04 PM\n 03:00 AM\n WBC\n 8.4\n 11.8\n 8.6\n Hct\n 23.0\n 28.1\n 29.9\n 25.9\n Plt\n \n Cr\n 0.5\n 0.6\n 0.5\n TCO2\n 33\n 31\n 33\n 32\n 32\n Glucose\n 168\n 176\n 136\n Other labs: PT / PTT / INR:13.2/26.6/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:89.7 %, Lymph:8.7 %, Mono:1.1\n %, Eos:0.4 %, Lactic Acid:0.9 mmol/L, Albumin:2.4 g/dL, LDH:204 IU/L,\n Ca++:8.4 mg/dL, Mg++:2.4 mg/dL, PO4:4.1 mg/dL\n CXR with slightly increased right base opacity, but lower lung\n volumes. Retrocardiac opacity.\n Assessment and Plan\n 55 y/o woman with thoracic spinal fracture (mechanical after fall)\n complicated by ARDS from VAP, UE DVT, and adrenal insufficiency.\n Respiratory failure\n Try RSBI/SBT today. If not extubatable, plan trach/G tomorrow\n Diurese with Lasix gtt\n eventually need rx of tracheobronchomalacia\n s/p treatment for Klebsiella VAP acquired at OSH\n Shock / adrenal insufficiency\n She has essentially proven adrenal insufficiency, with a baseline\n cortisol that was very low on pressors and a vent, followed by\n resolution of shock with steroids, followed by recrudescence of shock\n when steroids stopped, followed by resolution of shock with steroids (a\n second time).\n Continue steroids at current dose until after tracheostomy/PEG.\n Appreciate endocrine\ns help.\n DVT (UE)\n Resume heparin until several hours before O.R.\n Nutrition / Lytes\n Will restart tube feeds and free water boluses for hypernatremia.\n Spine fractures\n Continue spinal stabilization with brace when OOB; will eventually need\n MRI for further evaluation. Would wait until she has a surgical airway\n if she does not pass SBT today.\n ICU Care\n Nutrition: resume TF\n Comments: Held for possible OR\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 09:19 PM\n Arterial Line - 02:00 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Restart Heparin gtt)\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments: with brother and boyfriend \n Code status: Full code\n Disposition :ICU\n Total time spent: 45 min\n Patient is critically ill\n"},{"category":"Physician ","chartdate":"2167-10-01 00:00:00.000","description":"Physician Resident Progress Note","row_id":635347,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n Thoracics will take to OR if stable on PEEP < 10 for 24 hours, was on\n PEEP of 8 since AM\n due to scheduling, will not be able to go to OR\n today, but rather tomorrow with Dr. ()\n Weaned off midazolam drip\n Endocrine saw patient for adrenal insufficiency: Continue steroids\n until stable, then taper; assoc between Precedex and adrenal\n insufficiency in animal studies\n ABG for low O2 sat, looked good, held on FiO2 of 50\n Broncoscopy (11:30AM) : Diffuse stuctural instability c/w\n tracheomalacia\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Furosemide (Lasix) - 3 mg/hour\n Fentanyl - 100 mcg/hour\n Other ICU medications:\n Haloperidol (Haldol) - 11:47 PM\n Midazolam (Versed) - 02:45 AM\n Other medications:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.2\nC (97.2\n HR: 104 (46 - 134) bpm\n BP: 134/69(98) {88/41(57) - 143/76(103)} mmHg\n RR: 18 (18 - 27) insp/min\n SpO2: 91%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 4,162 mL\n 139 mL\n PO:\n TF:\n 1,448 mL\n 1 mL\n IVF:\n 1,003 mL\n 138 mL\n Blood products:\n Total out:\n 1,615 mL\n 640 mL\n Urine:\n 1,615 mL\n 640 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,547 mL\n -501 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n PIP: 35 cmH2O\n Plateau: 25 cmH2O\n Compliance: 24.7 cmH2O/mL\n SpO2: 91%\n ABG: 7.42/47/87/33/4\n Ve: 6.8 L/min\n PaO2 / FiO2: 174\n Physical Examination\n General Appearance: Responsive, following commands, Overweight / Obese,\n NAD\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\n deviation\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Respiratory / Chest: (Expansion: Symmetric), referred breath sounds\n from ETT\n Abdominal: No(t) Soft, Non-tender, Few Bowel sounds present, Distended\n Extremities: No clubbing or cyanosis, 3+ nonpitting edema of b/l hands,\n anasarca\n Skin: no rashes or jaundice\n Neuro: 3+ UE b/l, 4+ LE b/l\n Lines: r brachioceph ART and L PICC C/D/I\n Labs / Radiology\n 280 K/uL\n 8.0 g/dL\n 136 mg/dL\n 0.5 mg/dL\n 29 mEq/L\n 4.0 mEq/L\n 11 mg/dL\n 105 mEq/L\n 143 mEq/L\n 25.9 %\n 8.6 K/uL\n [image002.jpg]\n 02:44 PM\n 03:33 PM\n 07:26 PM\n 07:46 PM\n 02:04 AM\n 02:18 AM\n 01:27 PM\n 03:06 PM\n 10:04 PM\n 03:00 AM\n WBC\n 8.4\n 11.8\n 8.6\n Hct\n 23.0\n 28.1\n 29.9\n 25.9\n Plt\n \n Cr\n 0.5\n 0.6\n 0.5\n TCO2\n 33\n 31\n 33\n 32\n 32\n Glucose\n 168\n 176\n 136\n Other labs: PT / PTT / INR:13.2/26.6/1.1, Ca++:8.4 mg/dL, Mg++:2.4\n mg/dL, PO4:4.1 mg/dL, FSH 4.1, prolactin 48\n Fluid analysis / Other labs: BAL fluid:\n WBC: 0\n RBC: 0\n Polys: 82\n Lymphs: 3\n Monos: 6\n Eos: 2\n Macro: 7\n G.S\n PMNs\n Sputum culture - + GPCs in pairs and clusters, gram + rods\n Imaging: ECHOCARDIOGRAM: The left atrium is elongated. No atrial\n septal defect is seen by 2D or color Doppler. The right atrial pressure\n is indeterminate. Left ventricular wall thickness, cavity size and\n regional/global systolic function are normal (LVEF >55%). There is no\n ventricular septal defect. Right ventricular chamber size and free wall\n motion are normal. The aortic valve leaflets (3) are mildly thickened\n but aortic stenosis is not present. No aortic regurgitation is seen.\n The mitral valve appears structurally normal with trivial mitral\n regurgitation. There is no mitral valve prolapse. The tricuspid valve\n leaflets are mildly thickened. There is moderate pulmonary artery\n systolic hypertension. There is no pericardial effusion.\n Compared with the prior study (images reviewed) of , no\n change.\n EKG = sinus bradycardia\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA and\n ARDS intubated since the end of .\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation.\n Transferred here for airway stenting.\n - attempt SBT today\n - OR add on for trach and PEG with Dr. (tube feeds off\n after MN, heparin off after 6am)\n # # Adrenal Insufficency: Minimal response to stim test again.\n Appreciate endocrine recommendations.\n - hydrocort and fludrocort (day 1 = )\n - will continue at current dose until s/p trach and PEG and\n hemodynamically stable for 24 hours\n will then plan to taper\n hydrocortisone to 25mg IV q6 with a slow taper\n - will repreat ACTH stim test after tapered to <30mg\n hydrocortisone or off steroids\n - f/u daily endocrine recs\n # Hypotension: Likely adrenal insufficiency and sedation. Goal map\n > 60. Much improved since re-administration of steroids.\n - hydrocortisone and fludrocortisone as above\n - restart levophed if necessary to maintain MAP > 60\n # Volume overloaded in setting of hypernatremia with TBW deficit.\n - goal -1000cc I/Os today\n - continue FW in TF at 250 cc q4hrs\n - lasix drip (1-5mg/hr) when MAP > 60\n # Sedation: Sedation control remains somewhat poor although fentanyl\n patch and diazpem are likely therapeutic range today. On Versed 1.5,\n Fentanyl 175, Fentanyl patch, Diazepam standing and haldo 2.5-5 mg\n PRN. QTc increased to 480.\n - Wean versed/fentanyl as tolerated, continue diazepam. Avoid\n haldol use if possible to avoid further prolongation of QTc\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\n coumadin at least until s/p trach.\n - hold heparin gtt when anticipate trach/peg\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n # FEN/GI: Tube feeds with FWF @ goal.\n DVT: Treatment dose heparin\n Ulcer: Ranitidine\n VAP: Prevention per routine\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n - touch base with SW today\n Code: Full\n Dispo: ICU\n"},{"category":"Nursing","chartdate":"2167-10-03 00:00:00.000","description":"Nursing Progress Note","row_id":635567,"text":"55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP now with prolonged\n hospital course c/o by PNA anxiety,RUE DVD with high PEEP requirement\n .\n Edema, peripheral\n Assessment:\n Action:\n Response:\n Plan:\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Hypernatremia (high sodium)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Respiratory ","chartdate":"2167-10-03 00:00:00.000","description":"Respiratory Care Shift Note","row_id":635569,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 15\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Tracheostomy tube:\n Type: Standard, Cuffed, Inner Cannula\n Manufacturer: Portex\n Size: 7.0mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: mL /\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Visual assessment of breathing pattern: Normal quiet breathing\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Comments: Patient desaturated during the shift, requiring an increase\n to 10 cm PEEP and 60% FIO2. Latest abg results determined a metabolic\n alkalemia with adequate oxygenation on the current settings. No RSBI\n measured due to the level of PEEP and the high FIO2 currently required.\n"},{"category":"Physician ","chartdate":"2167-10-04 00:00:00.000","description":"Physician Resident Progress Note","row_id":635696,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n Hydrocortisone dose to 25 Q6 per renal recs.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Heparin Sodium - 1,700 units/hour\n Fentanyl - 125 mcg/hour\n Other ICU medications:\n Ranitidine (Prophylaxis) - 09:00 AM\n Midazolam (Versed) - 07:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36.8\nC (98.3\n HR: 66 (50 - 131) bpm\n BP: 103/46(65) {100/46(65) - 157/102(127)} mmHg\n RR: 18 (15 - 21) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,984 mL\n 948 mL\n PO:\n TF:\n 103 mL\n 121 mL\n IVF:\n 747 mL\n 277 mL\n Blood products:\n Total out:\n 5,270 mL\n 1,420 mL\n Urine:\n 5,270 mL\n 1,420 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,286 mL\n -472 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 55%\n RSBI Deferred: PEEP > 10\n PIP: 25 cmH2O\n Plateau: 14 cmH2O\n Compliance: 100 cmH2O/mL\n SpO2: 93%\n ABG: ///32/\n Ve: 6.8 L/min\n Physical Examination\n General Appearance: Responsive, following commands, Overweight / Obese,\n NAD\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\n deviation\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Respiratory / Chest: (Expansion: Symmetric), referred breath sounds\n from ETT, mild rhonchi diffusely\n Abdominal: Obese, Soft, Non-tender, no rebound, no guarding\n Extremities: No clubbing or cyanosis, + nonpitting edema of b/l\n hands, anasarca\n Skin: no rashes or jaundice\n Neuro: alert. Strength 4/5 upper and lower extremeties, light touch\n sensation intact bil.\n Lines: r brachioceph ART and L PICC C/D/I\n Labs / Radiology\n 279 K/uL\n 8.0 g/dL\n 121 mg/dL\n 0.5 mg/dL\n 32 mEq/L\n 3.6 mEq/L\n 8 mg/dL\n 109 mEq/L\n 143 mEq/L\n 24.6 %\n 8.3 K/uL\n [image002.jpg]\n 04:10 PM\n 12:13 AM\n 05:08 AM\n 05:20 AM\n 05:17 PM\n 11:41 PM\n 03:06 AM\n 03:38 AM\n 04:05 PM\n 03:55 AM\n WBC\n 11.2\n 10.6\n 10.0\n 8.3\n Hct\n 27.1\n 27.3\n 25.8\n 24.6\n Plt\n 79\n Cr\n 0.7\n 0.5\n 0.5\n 0.6\n 0.6\n 0.5\n TCO2\n 36\n 36\n 32\n 31\n Glucose\n 165\n 143\n 110\n 94\n 111\n 106\n 121\n Other labs: PT / PTT / INR:15.9/107.7/1.4, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:13.1 %,\n Mono:2.7 %, Eos:0.6 %, Lactic Acid:0.9 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:8.8 mg/dL, Mg++:3.1 mg/dL, PO4:4.2 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA and\n ARDS intubated since the end of .\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation. Stenting\n unlikely to help for trachiomalacia as airways have poor structure\n diffusely. S/P Trach yesterday\n - Continue to wean O2 as tolerated\n # Adrenal Insufficency: Hypotension that resolved with steroids,\n returned as they came off and is now improved again. Possible primary\n adrenal insufficency. Appreciate endocrine recommendations.\n - hydrocortt (day 1 = ), wean per endo recs\n # Hypotension: Likely adrenal insufficiency and sedation. Goal map\n > 60. Much improved since re-administration of steroids.\n - hydrocortisone as above\n - restart levophed if necessary to maintain MAP > 60\n # Volume overloaded in setting of hypernatremia with TBW deficit.\n - Lasix gtt, continue with goal -1L per day.\n - electrolytes\n - may have some contraction alkalosis, w/ rising pH and bicarb. Start\n Diamox 500mg TID to decrease bicarb and pH and may improve respiratory\n drive.\n # Sedation: Sedation control remains somewhat poor although fentanyl\n patch and diazpem are likely therapeutic range today. On Versed 2.0,\n Fentanyl 100, Fentanyl patch, Diazepam standing and haldo 2.5-5 mg\n PRN. QTc increased to 480.\n - Wean versed/fentanyl as tolerated, continue diazepam. Avoid haldol\n use if possible to avoid further prolongation of QTc\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\n coumadin at least until s/p trach.\n - heparin gtt restarted\n - plan to start coumadin night of if stable\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n # FEN/GI: Tube feeds\n DVT: Treatment dose heparin\n Ulcer: Ranitidine\n VAP: Prevention per routine\n # Access: L PICC line, and R brachial a-line\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n - touch base with SW today\n Code: Full\n Dispo: ICU\n ICU Care\n Nutrition:\n Replete (Full) - 11:20 AM 30 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Arterial Line - 02:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Nursing","chartdate":"2167-09-26 00:00:00.000","description":"Nursing Progress Note","row_id":634788,"text":"Events:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Respiratory ","chartdate":"2167-10-03 00:00:00.000","description":"Respiratory Care Shift Note","row_id":635642,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation:\n Ideal body weight:\n Ideal tidal volume:\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position:\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure:\n Cuff volume:\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds:\n RUL Lung Sounds:\n LUL Lung Sounds:\n LLL Lung Sounds:\n Comments:\n Secretions\n Sputum color / consistency:\n Sputum source/amount:\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Specialized Gas Therapy\n Nitric Oxide\n PPM used: ppm\n Indication:\n Effect of therapy: []\n Nitric Oxide trial:\n Comments:\n HeliOx:\n Additional O[2] by cannula: L/min\n Continuous nebulized bronchodilator:\n Comments:\n Recruitment Maneuvers Done\n CPAP pressure used: cm H2O\n Duration: sec\n Times per shift:\n Comments:\n"},{"category":"Respiratory ","chartdate":"2167-10-03 00:00:00.000","description":"Respiratory Care Shift Note","row_id":635643,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 15\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 7.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Brown / Thick\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Maintain PEEP at current level and reduce FiO2 as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"},{"category":"Nursing","chartdate":"2167-10-04 00:00:00.000","description":"Nursing Progress Note","row_id":635781,"text":"55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\n Now with prolonged hospital course c/b by PNA with high PEEP\n requirement, anxiety, RUE DVT on heparin qtt.\n Edema, peripheral\n Assessment:\n Fluid balance for previous 24hrs decreased by 3 liters D/T diuresis.\n Rec\nd pt off of Lasix qtt. Urine output decreased to 45ml/hr @1000.\n Action:\n Lasix qtt restarted @ 2mg/hr to maintain urine output 1-2liters/day.\n Response:\n Fluid balance approx -50ml/hr, with 24hr fluid balance -650ml @ 1500.\n However, SBP 78 when pt soundly sleeping/sedated. Lasix qtt stopped @\n 1530.\n Plan:\n Restart Lasix qtt when BP stabilized.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Rec\nd pt on Heparin qtt @ 1500units/hr.\n Action:\n PTT 92.1 @ 1230.\n Response:\n Per goal PTT 60-100, Heparin rate unchanged.\n Plan:\n Repeat PTT @ 1830. Start po Coumadin tonight.\n Altered mental status (not Delirium)\n Assessment:\n Rec\nd pt on Versed @ 2mg/hr, Fentanyl @ 100mcg/hr, as well as Fentanyl\n patches totaling 150mcg in place. Pt also rec\ning Diazepam 10mg po\n Q6hrs, in hope of weaning pt from IV sedation. Pt alternately appears\n very sedated and very restless. When she appears alert, she intermit\n responds to commands approp but not attempting to mouth words or nod to\n communicate. Moving arms purposefully towards trach, so soft wrist\n restraints remain in place. When very sedated @ 1530, SBP to 78 per\n below.\n Action:\n Versed \nd to 1mg/hr, Fentanyl \nd to 75mcg/hr.\n Response:\n Pt restless/squirming in bed when she appears awake. Not responding to\n verbal reassurance.\n Plan:\n Cont to attempt weaning from IV sedation. Cont to freq reorient pt,\n emotional support.\n Hypotension (not Shock)\n Assessment:\n VS generally stable with HR 68-123SR with occas PVC\ns, BP\n 122/65-144/76. However, when pt sleeping/sedated soundly @ 1530 SBP\n remained in high 70\n Action:\n Sedation decreased per above, Lasix qtt stopped. Pt woken and turned\n STS in bed.\n Response:\n VS returned to baseline, with BP presently 133/76.\n Plan:\n Restart Lasix qtt when BP stabilized WNL.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt on vent settings AC 55%/18 X 400/+10, with no over-breathing\n of rate by pt. O2 sat 95-99%. ABG 7.44/42/93. Lung snds clear but\n diminished in lower lobes. Suctionned for mod-lg amts thick white\n secretions.\n Action:\n Vent changed to CMV with PS 8/+10 on 55%.\n Response:\n Pt tolerated PS approx 3hrs, but after rec\ning scheduled dose Diazepam\n @ 1200 began having extended pauses apnea. She was then returned to AC\n 55%/9 X 500/+10.\n Plan:\n Cont wean from vent with PS trials, as well as \ning FiO2.\n"},{"category":"Nursing","chartdate":"2167-09-28 00:00:00.000","description":"Nursing Progress Note","row_id":634951,"text":"TITLE: This is a 55 yr old female admitted from an OSH to on\n with resp failure, +PNA s/p fall down stairs with fracture of\n T5-T8 and possible tracheobronchomalacia for IP consult and possible Y\n stenting. Pt now s/p IP consult with no tracheobronchomalacia found on\n exam. Pt has been diff to wean with high PEEP requirements. The pt\n has finished a course of IV Levofloxacin, Vanco, and Aztreonam antibx\n for Klebsiella PNA/VAP. Pt found to have RUE DVT and maintained on an\n IV Heparin gtt (no NBP or blood draw in this appendage please). The pt\n is net input more than fifteen liters for LOS @ this time. The pt has\n documented allergies to Tetracycline, PCN & Hydrazaline. The pt is a\n Full Code. The pt has a boyfriend and a brother, the brother is the\n designated HCP.\n Events: Optimal sedation continues to be a challenge for this pt with\n pt either oversedated with resulting borderline hypotension and\n bradycardia and acute agitation with HTN, tachycardia, dysphoria,\n agitation. TLC d/c\ned by team overnight, now utilizing RUE AC PICC for\n IV therapy. RUE radial a-line remains positional, unable to send and\n ABG this AM\n team aware. 20mg IVP Lasix provided overnight for\n hypervolemia with approx one liter output.\n Altered mental status (not Delirium)\n Assessment:\n Pt MS noted to wax/wane overnight. Pt intermittently able to follow\n simple commands (wiggle toes) and mouthed her name correctly. However,\n pt also has periods of acute delirious agitation with thrashing and\n pulling on soft wrist restraints.\n Action:\n Pt received/maintained on IV Fentanyl & Midazolam gtt\ns with multiple\n IVP boluses of these agents for acute agitation. Pt also freq\n re-oriented to person/place/time/care rationale to assist with nl\n cogntion. Soft wrist restraints maintained in place for pt safety.\n Pts episodes of agitation/delirium discussed with team, PRN Seroquil\n med therapy discussed.\n Response:\n Pt responds transiently to IV Fentanyl/Midazolam boluses.\n Plan:\n Cont to provide both gtt & IVP sedation for pt comfort. Reviewing the\n use of additional agents 2^nd current limitations with present regime.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt received/maintained on AC-18-50-400-15 with nl sats, RR and resp\n effort. Unable to send AM ABG 2^nd declining a-line function\n issue\n discussed with team.\n Action:\n Pt seems to be doing well with current MV support. 20mg IVP Lasix\n admin @ 02:30 for hypervolemia to optimize resp fxn. Pt sat upright 30\n to 45 degrees. Small amounts of thick tan sec per ETT. The pt is\n currently off all antibx cov @ this time. Of note, pt noted to have\n large yellowish oral sec, ?sinusitis\n issue discussed with team.\n Response:\n Pt seems to be doing well with current MV support despite inability to\n send an AM ABG.\n Plan:\n Cont to follow pts MS, resp fxn closely to ensure optimal resp fxn.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt with documented RUE DVT. No NBP nor blood sticks/FS in this\n appendage please.\n Action:\n Pt received/maintained on IV Heparin gtt infusing @ 1,700 units/hr.\n Response:\n Serial therapeutic PTT values noted with an AM PTT today of 59.6.\n Plan:\n Edema, peripheral\n Assessment:\n Pt remains +2 generalized anasarcoid and positive 16 liters for LOS.\n Action:\n Pt med with 20mg IVP Lasix @ 02:30 this AM.\n Response:\n Pt with approx one liter output to 20mg IV Lasix.\n Plan:\n Pt remains + 16 liters for LOS despite IV Lasix therapy (pt receives\n high hourly input esp with tube feeds @ 60ml/hr). Of note, pts AM\n sodium value is 146 and pt has a free water deficit.\n"},{"category":"Nursing","chartdate":"2167-09-26 00:00:00.000","description":"Nursing Progress Note","row_id":634794,"text":"Events:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2167-10-04 00:00:00.000","description":"Nursing Progress Note","row_id":635691,"text":"55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\n Now with prolonged hospital course c/b by PNA with high PEEP\n requirement, anxiety, RUE DVT on heparin qtt.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt on Vent settings AC 55%/18 X 400/+10 with no overbreathing of\n set RR. O2 sat 92-98%. Lung snds clear, diminished in bases. Pt sxn\n for small-moderate amts thick white secretions. Trach site with small\n amt serosang drainage.\n Action:\n Cont same vent settings\n Response:\n Pt doesn\nt over breath on the vent and never desat.Kept same Vent\n settings overnight.\n Plan:\n Monitor sats,resp and titrate Vent as she tolerats.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt rec\nd with Heparin qtt 1900units/hr.\n Action:\n PTT drawn at 2300.RUE elevated with pillow and no BP or blood drawn\n from that arm.\n Response:\n PTT @ 2300 was 107,Decreased Heparin gtt 1700 u/hr as per sliding\n scale.Next PTT due at 0600. .\n Plan:\n Cont monitor PTT,titrate accordingly,next PTT due at 0600.\n Alteration in Nutrition\n Assessment:\n Received pt on TF 10cc/hr.\n Action:\n Pt tolerated TF with minimal residuals as well as free water bolus Q4H\n Response:\n TF ^ as tolerated, currently at 30cc/hr.\n Plan:\n Cont to monitor TF residuals, hold if more than 100cc\n Altered mental status (not Delirium)\n Assessment:\n Pt w/ periods of agitation and sleeping at other times, while she\n aweake follow commands intermittently.\n Action:\n Cont on fent 100 mics ,Versed 2mg/hr and requires frequent boluses .\n Cont diazepam 10 mg PO Q6H. Fent ^ 125 mics/hr,Versed 3mg/hr.\n Response:\n HR ranging from SB in the 40\ns when asleep to the 120-140\ns when\n agitated, b/p ranging from 90\ns/40\ns when asleep to 140-170\ns/ 70\n when agitated. When pt awake appropriate and following commands HR\n 80\ns-100\ns and b/p 100\ns-120\ns/ 60-70\n Plan:\n Titrate sedation as needed\n"},{"category":"Physician ","chartdate":"2167-09-24 00:00:00.000","description":"Physician Resident Progress Note","row_id":634520,"text":"24 Hour Events:\n -Yesterday, stopped vanc and flagyl. Continued Aztreonam and\n Levofloxicin\n -Micro on sputum GNR due back today\n -Febrile to 101- pan cultured; cxr\n -Decreased FiO2 and PEEP to 21\n -Early am, HR dropped to 40s-50s. EKG suggestive of junctional rhythm.\n Held pressures, making good UOP, good O2 sats\n -Yesterday, SVV was 13; held on giving more fluids\n -Random cortisol was very low; started hydrocortisone and florinef\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Metronidazole - 08:00 AM\n Levofloxacin - 08:39 AM\n Aztreonam - 02:00 PM\n Infusions:\n Norepinephrine - 0.02 mcg/Kg/min\n Midazolam (Versed) - 4 mg/hour\n Other ICU medications:\n Midazolam (Versed) - 03:50 PM\n Fentanyl - 03:50 PM\n Ranitidine (Prophylaxis) - 08:31 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (101\n Tcurrent: 37.1\nC (98.8\n HR: 60 (60 - 86) bpm\n BP: 103/46(61) {103/46(61) - 121/50(66)} mmHg\n RR: 22 (17 - 23) insp/min\n SpO2: 99%\n Heart rhythm: JR (Junctional Rhythm)\n Wgt (current): 101 kg (admission): 94.2 kg\n Height: 67 Inch\n CVP: 12 (12 - 339)mmHg\n Total In:\n 1,675 mL\n 232 mL\n PO:\n TF:\n 182 mL\n 134 mL\n IVF:\n 1,233 mL\n 98 mL\n Blood products:\n Total out:\n 877 mL\n 565 mL\n Urine:\n 727 mL\n 535 mL\n NG:\n 30 mL\n Stool:\n Drains:\n Balance:\n 798 mL\n -333 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 22\n RR (Spontaneous): 2\n PEEP: 21 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 33 cmH2O\n Plateau: 30 cmH2O\n Compliance: 44.4 cmH2O/mL\n SpO2: 99%\n ABG: 7.42/39/116/26/0\n Ve: 9.7 L/min\n PaO2 / FiO2: 290\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 326 K/uL\n 8.9 g/dL\n 151 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 3.6 mEq/L\n 2 mg/dL\n 108 mEq/L\n 141 mEq/L\n 28.6 %\n 8.9 K/uL\n [image002.jpg]\n 06:11 PM\n 07:53 PM\n 02:02 AM\n 03:59 AM\n 09:14 PM\n 01:04 AM\n 05:54 AM\n 06:11 AM\n 11:07 PM\n 03:51 AM\n WBC\n 8.4\n 8.1\n 8.9\n Hct\n 28.1\n 28.0\n 28.6\n Plt\n 376\n 358\n 326\n Cr\n 0.6\n 0.7\n 0.7\n TCO2\n 29\n 25\n 25\n 28\n 28\n 26\n 26\n Glucose\n 120\n 126\n 151\n Other labs: PT / PTT / INR:24.3/68.6/2.4, ALT / AST:24/16, Alk Phos / T\n Bili:117/0.7, Amylase / Lipase:, Differential-Neuts:82.5 %,\n Lymph:11.6 %, Mono:3.3 %, Eos:2.2 %, Lactic Acid:0.7 mmol/L,\n Albumin:2.4 g/dL, LDH:204 IU/L, Ca++:8.5 mg/dL, Mg++:2.1 mg/dL, PO4:2.5\n mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with respiratory failure\n and difficulty weaning from vent.\n # Respiratory failure: initial etiology unclear, likely multifactorial\n (sedation vs hypovent obesity/orthotic brace vs ?) which lead to\n VAP most likely with GNR (by one sputum).\n - Concern for ARDS given clinical and radiographic picture.\n - Placed esophageal balloon on which will help guide PEEP\n settings.\n - Over the evening yesterday, were able to decrease FiO2 and PEEP.\n # VAP: Re-spiked fever overnight.\n - Sputum from grew rare GNR; awaiting speciation.\n - Has been Vanc, aztreonam, levofloxicin. Vanc trough today was 20\n - Stopped vanc yesterday, , as there was no current evidence to\n suggest a gram positive infection\n - Also, stopped flagyl because had one neg c. diff toxin and CT did not\n show evidence of colitis\n - Continued aztreonam and levofloxicin for gram neg pneumonia for 8\n days pending speciation (at that time can increase to 15 days if\n necessary)\n - need to reconsider restarting d/c'd meds if she continues to\n spike a fever\n # Hypotension, requiring Levophed:\n - Hypovolemia is possibly a factor- responded to a transfusion; HCT had\n been dropping. However, SVV with Vigileo was 13, making her CO less\n likely to respond to fluids. Held on giving any boluses overnight.\n - Sepsis also a factor- on broad spectrum abs\n - Central line in place.\n # Oliguria:\n -BUN and Cr reassuring.\n -Continues to be low. Hopefully, by decreasing PEEP and using levophed\n to keep MAPs high, UOP will increase.\n # RUE DVT: Started on heparin gtt on .\n -Therapeutic in one day; may be related to poor nutritional status.\n Will continue to closely monitor\n # Abd distention: be chronic condition not requiring immediate\n medical attention\n - CT abd only showed appendiceal mucocele without inflammation, not\n concerning, most likely chronic. No concern for intraabd disaster\n - Now having BMs; c. diff toxin neg\n - amylase and lipase wnl\n # Adrenal Insufficency:\n -Random cortisol was approx 3 when it should have been maximally\n stimulated.\n -Started hydrocortisone and florinef. ? switch to methylpred\n # Anemia:\n - Trend HCT\n - Gave 1 un pRBC with good results\n - INR rising, now 2.0, may be nutritional\n # Spine fracture: neurologically intact distal to the lesion. prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per verbal report.\n # Hypernatremia, resolved: correcting with g tube free flush and D5W\n -Holding on g tube feeds at present due to high residuals\n -Replete lytes as necessary\n # Communication:\n - Brother has been with pt, although, live in boyfriend of 10 is\n her HCP. Boyfriend will hopefully visit pt today\n ICU Care\n Nutrition: tube feed with free water when able\n Glycemic Control: Regular insulin sliding scale\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Communication: ICU consent signed, (brother) \n (boyfriend/POA) \n Code status: Full code\n Disposition: ICU\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 10:55 PM 30 mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 01:36 AM\n Arterial Line - 03:00 AM\n Multi Lumen - 11:30 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Nursing","chartdate":"2167-09-24 00:00:00.000","description":"Nursing Progress Note","row_id":634525,"text":"55 yr old woman admitted from OSH after she fell down the stairs and\n had traumatic T-spine fracture. Pt came to us with PNA from unknown\n etiology? VAP. Full code, Allergies: PCN, tetracycline, Sulfa. PMH:\n ETOH, smoker, Gerd, Hip replacement.\n Alteration in Nutrition\n Assessment:\n Tube feeds increased to 30ml/hr. Tube feed residual 10-20ml.\n Action:\n cont to check residuals and try to increase rate\n Response:\n Residual staying 10ml/hr, kept rate at 30ml\n Plan:\n Try to increase Tube feeds to goal rate.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n RUE DVT, pt on heparin gtt at 1700units/hr.\n Action:\n Ptt was therapeutic x2, AM PTT 68.6 WNL\n Response:\n No change to drip made, therapeutic dose.\n Plan:\n Cont heparin gtt, check PTT adjust heparin gtt per scale.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Moderate thick white in-line secretions, copious clear oral secretions,\n clear/diminished lung sounds. Esophageal balloon in place. Previous\n Sputum culture shows GNR, speciation PND.\n Action:\n Lots of suctioning through the night, decreased FiO2 from 50% to 40%,\n decreased Peep from 23 to 21, HOB >30, oral care.\n Response:\n ABG WNL, could not draw a AM ABG because A-line no longer drawing,\n intern aware.\n Plan:\n Cont to try to wean vent settings as tolerated, cont monitoring ABG\n Hypotension (not Shock)\n Assessment:\n SBP 90-110\ns MAP 62-66 Goal MAP >65 Levophed gtt @ 0.018 mcg/kg/min.\n Action:\n Trying to wean levophed gtt off\n Response:\n MAP tend to drop below 65 when weaned all the way off levophed.\n Plan:\n Cont to try to wean gtt off\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n T-max 101.0\n Action:\n Sent blood, urine, and sputum cultures, treated with Tylenol\n Response:\n Temp decreased\n Plan:\n Follow up on cultures\n CT scan from earlier in the week confirms fracture but did not detect\n retropulsion. Neuro want pt in back brace when she is out of bed.\n Log rolling pt has been d/c.\n Bradycardia\n Assessment:\n At 0515 Patient HR dropped from 60-70\ns to 45-50.\n Action:\n EKG done, showed pt was in junctional rhythm, intern came to assess pt.\n Electrolytes WNL.\n Response:\n No intervention done yet because pt BP cont to be stable and all other\n vital signs stable.\n Plan:\n Cont to monitor pt HR.\n Fracture, other\n Assessment:\n Log roll precautions removed from day shift. Back brace needs to be\n applied if pt is out of bed. Please read CT scan results from above\n portion of note.\n Action:\n Still taking precautions to carefully turn pt but no longer long\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2167-09-24 00:00:00.000","description":"Nursing Progress Note","row_id":634527,"text":"55 yr old woman admitted from OSH after she fell down the stairs and\n had traumatic T-spine fracture. Pt came to us with PNA from unknown\n etiology? VAP. Full code, Allergies: PCN, tetracycline, Sulfa. PMH:\n ETOH, smoker, Gerd, Hip replacement.\n Alteration in Nutrition\n Assessment:\n Tube feeds increased to 30ml/hr. Tube feed residual 10-20ml.\n Action:\n cont to check residuals and try to increase rate\n Response:\n Residual staying 10ml/hr, kept rate at 30ml\n Plan:\n Try to increase Tube feeds to goal rate.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n RUE DVT, pt on heparin gtt at 1700units/hr.\n Action:\n Ptt was therapeutic x2, AM PTT 68.6 WNL\n Response:\n No change to drip made, therapeutic dose.\n Plan:\n Cont heparin gtt, check PTT adjust heparin gtt per scale.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Moderate thick white in-line secretions, copious clear oral secretions,\n clear/diminished lung sounds. Esophageal balloon in place. Previous\n Sputum culture shows GNR, speciation PND.\n Action:\n Lots of suctioning through the night, decreased FiO2 from 50% to 40%,\n decreased Peep from 23 to 21, HOB >30, oral care.\n Response:\n ABG WNL, could not draw an AM ABG because A-line no longer drawing,\n intern aware. Intern and resp therapy to get ABG for AM.\n Plan:\n Cont to try to wean vent settings as tolerated, cont monitoring ABG\n Hypotension (not Shock)\n Assessment:\n SBP 90-110\ns MAP 62-66 Goal MAP >65 Levophed gtt @ 0.018 mcg/kg/min.\n Action:\n Trying to wean levophed gtt off\n Response:\n MAP tends to drop below 65 when weaned all the way off levophed.\n Plan:\n Cont to try to wean gtt off\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n T-max 101.0\n Action:\n Sent blood, urine, and sputum cultures, treated with Tylenol\n Response:\n Temp decreased\n Plan:\n Follow up on cultures\n CT scan from earlier in the week confirms fracture but did not detect\n retropulsion. Neuro want pt in back brace when she is out of bed.\n Log rolling pt has been d/c.\n Bradycardia\n Assessment:\n At 0515 Patient HR dropped from 60-70\ns to 45-50.\n Action:\n EKG done, showed pt was in junctional rhythm, intern came to assess pt.\n Electrolytes WNL.\n Response:\n No intervention done yet because pt BP cont to be stable and all other\n vital signs stable.\n Plan:\n Cont to monitor pt HR.\n Fracture, other\n Assessment:\n Log roll precautions removed from day shift. Back brace needs to be\n applied if pt is out of bed. Please read CT scan results from above\n portion of note.\n Action:\n Still taking precautions to carefully turn pt but no longer on log roll\n precautions\n Response:\n Pt tolerating turning fine.\n Plan:\n Use back brace if pt get out of bed. Back brace in room\n"},{"category":"Physician ","chartdate":"2167-09-24 00:00:00.000","description":"Physician Resident Progress Note","row_id":634528,"text":"24 Hour Events:\n -Yesterday, stopped vanc and flagyl. Continued Aztreonam and\n Levofloxicin\n -Micro on sputum GNR due back today\n -Febrile to 101- pan cultured; cxr\n -Decreased FiO2 and PEEP to 21\n -Early am, HR dropped to 40s-50s. EKG suggestive of junctional rhythm.\n Held pressures, making good UOP, good O2 sats\n -This am, art line is intermittently working. Drew ABG - pending\n -Yesterday, SVV was 13; held on giving more fluids\n -Random cortisol was very low; started hydrocortisone and florinef\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Metronidazole - 08:00 AM\n Levofloxacin - 08:39 AM\n Aztreonam - 02:00 PM\n Infusions:\n Norepinephrine - 0.02 mcg/Kg/min\n Midazolam (Versed) - 4 mg/hour\n Other ICU medications:\n Midazolam (Versed) - 03:50 PM\n Fentanyl - 03:50 PM\n Ranitidine (Prophylaxis) - 08:31 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (101\n Tcurrent: 37.1\nC (98.8\n HR: 60 (60 - 86) bpm\n BP: 103/46(61) {103/46(61) - 121/50(66)} mmHg\n RR: 22 (17 - 23) insp/min\n SpO2: 99%\n Heart rhythm: JR (Junctional Rhythm)\n Wgt (current): 101 kg (admission): 94.2 kg\n Height: 67 Inch\n CVP: 12 (12 - 339)mmHg\n Total In:\n 1,675 mL\n 232 mL\n PO:\n TF:\n 182 mL\n 134 mL\n IVF:\n 1,233 mL\n 98 mL\n Blood products:\n Total out:\n 877 mL\n 565 mL\n Urine:\n 727 mL\n 535 mL\n NG:\n 30 mL\n Stool:\n Drains:\n Balance:\n 798 mL\n -333 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 22\n RR (Spontaneous): 2\n PEEP: 21 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 33 cmH2O\n Plateau: 30 cmH2O\n Compliance: 44.4 cmH2O/mL\n SpO2: 99%\n ABG: 7.42/39/116/26/0\n Ve: 9.7 L/min\n PaO2 / FiO2: 290\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 326 K/uL\n 8.9 g/dL\n 151 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 3.6 mEq/L\n 2 mg/dL\n 108 mEq/L\n 141 mEq/L\n 28.6 %\n 8.9 K/uL\n [image002.jpg]\n 06:11 PM\n 07:53 PM\n 02:02 AM\n 03:59 AM\n 09:14 PM\n 01:04 AM\n 05:54 AM\n 06:11 AM\n 11:07 PM\n 03:51 AM\n WBC\n 8.4\n 8.1\n 8.9\n Hct\n 28.1\n 28.0\n 28.6\n Plt\n 376\n 358\n 326\n Cr\n 0.6\n 0.7\n 0.7\n TCO2\n 29\n 25\n 25\n 28\n 28\n 26\n 26\n Glucose\n 120\n 126\n 151\n Other labs: PT / PTT / INR:24.3/68.6/2.4, ALT / AST:24/16, Alk Phos / T\n Bili:117/0.7, Amylase / Lipase:, Differential-Neuts:82.5 %,\n Lymph:11.6 %, Mono:3.3 %, Eos:2.2 %, Lactic Acid:0.7 mmol/L,\n Albumin:2.4 g/dL, LDH:204 IU/L, Ca++:8.5 mg/dL, Mg++:2.1 mg/dL, PO4:2.5\n mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with respiratory failure\n and difficulty weaning from vent.\n # Respiratory failure: initial etiology unclear, likely multifactorial\n (sedation vs hypovent obesity/orthotic brace vs ?) which lead to\n VAP most likely with GNR (by one sputum).\n - Concern for ARDS given clinical and radiographic picture.\n - Placed esophageal balloon on which will help guide PEEP\n settings.\n - Over the evening yesterday, were able to decrease FiO2 and PEEP.\n # VAP: Re-spiked fever overnight.\n - Sputum from grew rare GNR; awaiting speciation.\n - Has been Vanc, aztreonam, levofloxicin. Vanc trough today was 20\n - Stopped vanc yesterday, , as there was no current evidence to\n suggest a gram positive infection\n - Also, stopped flagyl because had one neg c. diff toxin and CT did not\n show evidence of colitis\n - Continued aztreonam and levofloxicin for gram neg pneumonia for 8\n days pending speciation (at that time can increase to 15 days if\n necessary)\n - need to reconsider restarting d/c'd meds if she continues to\n spike a fever\n # Hypotension, requiring Levophed:\n - Hypovolemia is possibly a factor- responded to a transfusion; HCT had\n been dropping. However, SVV with Vigileo was 13, making her CO less\n likely to respond to fluids. Held on giving any boluses overnight.\n - Sepsis also a factor- on broad spectrum abs\n - Central line in place.\n # Oliguria:\n -BUN and Cr reassuring.\n -Continues to be low. Hopefully, by decreasing PEEP and using levophed\n to keep MAPs high, UOP will increase.\n # RUE DVT: Started on heparin gtt on .\n -Therapeutic in one day; may be related to poor nutritional status.\n Will continue to closely monitor\n # Abd distention: be chronic condition not requiring immediate\n medical attention\n - CT abd only showed appendiceal mucocele without inflammation, not\n concerning, most likely chronic. No concern for intraabd disaster\n - Now having BMs; c. diff toxin neg\n - amylase and lipase wnl\n # Adrenal Insufficency:\n -Random cortisol was approx 3 when it should have been maximally\n stimulated.\n -Started hydrocortisone and florinef. ? switch to methylpred\n # Anemia:\n - Trend HCT\n - Gave 1 un pRBC with good results\n - INR rising, now 2.0, may be nutritional\n # Spine fracture: neurologically intact distal to the lesion. prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per verbal report.\n # Hypernatremia, resolved: correcting with g tube free flush and D5W\n -Holding on g tube feeds at present due to high residuals\n -Replete lytes as necessary\n # Communication:\n - Brother has been with pt, although, live in boyfriend of 10 is\n her HCP. Boyfriend will hopefully visit pt today\n ICU Care\n Nutrition: tube feed with free water when able\n Glycemic Control: Regular insulin sliding scale\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Communication: ICU consent signed, (brother) \n (boyfriend/POA) \n Code status: Full code\n Disposition: ICU\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 10:55 PM 30 mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 01:36 AM\n Arterial Line - 03:00 AM\n Multi Lumen - 11:30 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2167-09-27 00:00:00.000","description":"Physician Resident Progress Note","row_id":634882,"text":"Chief Complaint:\n 24 Hour Events:\n - Anxiety yesterday afternoon and poor sleep overnight per nursing\n - Per ABG, increased FiO2 (40->50%), holding PEEP (15)\n - Gave Lasix 10 mg x 3, with small urine output response.\n - Today is last day of steroids as well as last day of abx\n (levofloxicin)\n - Tightened sliding scale insulin yesterday\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Aztreonam - 06:00 AM\n Vancomycin - 09:00 AM\n Levofloxacin - 08:00 AM\n Infusions:\n Midazolam (Versed) - 4 mg/hour\n Heparin Sodium - 1,700 units/hour\n Fentanyl - 150 mcg/hour\n Other ICU medications:\n Haloperidol (Haldol) - 04:26 PM\n Furosemide (Lasix) - 04:30 PM\n Midazolam (Versed) - 06:16 AM\n Fentanyl - 06:16 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 35.7\nC (96.2\n HR: 66 (53 - 93) bpm\n BP: 111/56(74) {103/52(69) - 135/78(93)} mmHg\n RR: 20 (16 - 28) insp/min\n SpO2: 95% on 400/20/15/.5\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101 kg (admission): 94.2 kg\n Height: 67 Inch\n CVP: 18 (6 - 21)mmHg\n Total In:\n 2,681 mL\n 687 mL\n PO:\n TF:\n 1,443 mL\n 432 mL\n IVF:\n 888 mL\n 255 mL\n Blood products:\n Total out:\n 3,135 mL\n 185 mL\n Urine:\n 3,035 mL\n 185 mL\n NG:\n Stool:\n 100 mL\n Drains:\n Balance:\n -454 mL\n 502 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 20\n RR (Spontaneous): 23\n PEEP: 15 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 31 cmH2O\n Plateau: 25 cmH2O\n SpO2: 95%\n ABG: 7.46/39/68/27/3\n Ve: 7.7 L/min\n PaO2 / FiO2: 136\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese, opens eyes\n but no purposeful movement\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric)\n Abdominal: No(t) Soft, Non-tender, Bowel sounds present, Distended\n Extremities: No clubbing or cyanosis, 3+ nonpitting edema of b/l hands,\n LE without edema\n Skin: no rashes or jaundice\n Labs / Radiology\n 411 K/uL\n 8.3 g/dL\n 163 mg/dL\n 0.5 mg/dL\n 27 mEq/L\n 3.8 mEq/L\n 12 mg/dL\n 111 mEq/L\n 144 mEq/L\n 26.0 %\n 9.7 K/uL\n [image002.jpg]\n 03:47 AM\n 02:14 PM\n 04:05 PM\n 01:12 AM\n 04:00 AM\n 04:09 AM\n 10:18 AM\n 02:33 PM\n 02:46 PM\n 03:31 AM\n WBC\n 10.5\n 9.6\n 9.7\n Hct\n 27.5\n 27.8\n 26.0\n Plt\n 374\n 374\n 411\n Cr\n 0.6\n 0.5\n 0.5\n 0.5\n TCO2\n 27\n 26\n 27\n 28\n 29\n 26\n 27\n Glucose\n 187\n 194\n 195\n 195\n 163\n Other labs: PT / PTT / INR:15.3/69.9/1.3, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:86.1 %, Lymph:10.3 %,\n Mono:2.8 %, Eos:0.5 %, Lactic Acid:2.0 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:8.3 mg/dL, Mg++:2.1 mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with respiratory failure\n and difficulty weaning from vent.\n # Respiratory failure: Intubated on for resp decompensation.\n Likely VAP. Unlikely to have tracheomalacia as initially\n transferred for.\n - wean PEEP\n - Given mild alkalosis, will decrease RR to 18, repeat ABG\n - discuss need for trach with patient and her family\n - Will continue gentle diuresis once alkalosis resolved\n # Pneumonia: Pansensitive Kleb oxytoca pneumonia and sputum with GPCs\n on gram stain. Afebrile overnight. On levofloxacin since .\n Vancomycin, aztreonam have been stopped. Resp status seems to be\n improving.\n - Follow cultures\n - d/c levofloxacin having completed 8 day course\n # Sedation: On versed and fentanyl\n # EKG changes: Sinus bradycardia, now somewhat improved. Likely\n related to increased vagal tone possibly related to steroid\n replacement. Atrial EKG shows p-waves and cardiac enzymes normal.\n - Continue to monitor\n # Hypotension: Improved, off levophed for 2-3 days now, with good urine\n output. CVP increasing with reduction in PEEP. Likely poor\n adrenal response in setting of acute illness and very high PEEP.\n -D/C fludricort and hydrocortisone now that the 5 day steroid course is\n complete\n -monitor, expect improvement with continual reduction in PEEP\n # RUE DVT: Started on heparin gtt on , now therapeutic. Follow\n PTTs. Would hold off on coumadin at least until s/p trach.\n - continue to monitor\n # Adrenal Insufficency: Random cortisol was approx 3 when it should\n have been maximally stimulated.\n - hydrocortisone and florinef for 5 days\n # Anemia: Stable.\n - Trend HCT\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n FEN/GI: Tube feeds @ goal\n DVT: Treatment dose heparin\n Ulcer: Ranitidine\n VAP: Prevention per routine\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 08:13 PM 60 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 11:30 AM\n Arterial Line - 04:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2167-09-27 00:00:00.000","description":"Physician Resident Progress Note","row_id":634883,"text":"Chief Complaint:\n 24 Hour Events:\n - Anxiety yesterday afternoon and poor sleep overnight per nursing\n - Per ABG, increased FiO2 (40->50%), holding PEEP (15)\n - Gave Lasix 10 mg x 3, with small urine output response.\n - Today is last day of steroids as well as last day of abx\n (levofloxicin)\n - Tightened sliding scale insulin yesterday\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Aztreonam - 06:00 AM\n Vancomycin - 09:00 AM\n Levofloxacin - 08:00 AM\n Infusions:\n Midazolam (Versed) - 4 mg/hour\n Heparin Sodium - 1,700 units/hour\n Fentanyl - 150 mcg/hour\n Other ICU medications:\n Haloperidol (Haldol) - 04:26 PM\n Furosemide (Lasix) - 04:30 PM\n Midazolam (Versed) - 06:16 AM\n Fentanyl - 06:16 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 35.7\nC (96.2\n HR: 66 (53 - 93) bpm\n BP: 111/56(74) {103/52(69) - 135/78(93)} mmHg\n RR: 20 (16 - 28) insp/min\n SpO2: 95% on 400/20/15/.5\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101 kg (admission): 94.2 kg\n Height: 67 Inch\n CVP: 18 (6 - 21)mmHg\n Total In:\n 2,681 mL\n 687 mL\n PO:\n TF:\n 1,443 mL\n 432 mL\n IVF:\n 888 mL\n 255 mL\n Blood products:\n Total out:\n 3,135 mL\n 185 mL\n Urine:\n 3,035 mL\n 185 mL\n NG:\n Stool:\n 100 mL\n Drains:\n Balance:\n -454 mL\n 502 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 20\n RR (Spontaneous): 23\n PEEP: 15 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 31 cmH2O\n Plateau: 25 cmH2O\n SpO2: 95%\n ABG: 7.46/39/68/27/3\n Ve: 7.7 L/min\n PaO2 / FiO2: 136\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese, opens eyes\n but no purposeful movement\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric)\n Abdominal: No(t) Soft, Non-tender, Bowel sounds present, Distended\n Extremities: No clubbing or cyanosis, 3+ nonpitting edema of b/l hands,\n LE without edema\n Skin: no rashes or jaundice\n Labs / Radiology\n 411 K/uL\n 8.3 g/dL\n 163 mg/dL\n 0.5 mg/dL\n 27 mEq/L\n 3.8 mEq/L\n 12 mg/dL\n 111 mEq/L\n 144 mEq/L\n 26.0 %\n 9.7 K/uL\n [image002.jpg]\n 03:47 AM\n 02:14 PM\n 04:05 PM\n 01:12 AM\n 04:00 AM\n 04:09 AM\n 10:18 AM\n 02:33 PM\n 02:46 PM\n 03:31 AM\n WBC\n 10.5\n 9.6\n 9.7\n Hct\n 27.5\n 27.8\n 26.0\n Plt\n 374\n 374\n 411\n Cr\n 0.6\n 0.5\n 0.5\n 0.5\n TCO2\n 27\n 26\n 27\n 28\n 29\n 26\n 27\n Glucose\n 187\n 194\n 195\n 195\n 163\n Other labs: PT / PTT / INR:15.3/69.9/1.3, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:86.1 %, Lymph:10.3 %,\n Mono:2.8 %, Eos:0.5 %, Lactic Acid:2.0 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:8.3 mg/dL, Mg++:2.1 mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with respiratory failure\n and difficulty weaning from vent.\n # Respiratory failure: Intubated on for resp decompensation.\n Likely VAP. Unlikely to have tracheomalacia as initially\n transferred for.\n - wean PEEP\n - Given mild alkalosis, will decrease RR to 18, repeat ABG\n - discuss need for trach with patient and her family\n - Will continue gentle diuresis once alkalosis resolved\n # Pneumonia: Pansensitive Kleb oxytoca pneumonia and sputum with GPCs\n on gram stain. Afebrile overnight. On levofloxacin since .\n Vancomycin, aztreonam have been stopped. Resp status seems to be\n improving.\n - Follow cultures\n - d/c levofloxacin having completed 8 day course\n # Sedation: On versed and fentanyl\n # EKG changes: Sinus bradycardia, now somewhat improved. Likely\n related to increased vagal tone possibly related to steroid\n replacement. Atrial EKG shows p-waves and cardiac enzymes normal.\n - Continue to monitor\n # Hypotension: Improved, off levophed for 2-3 days now, with good urine\n output. CVP increasing with reduction in PEEP. Likely poor\n adrenal response in setting of acute illness and very high PEEP.\n -D/C fludricort and hydrocortisone now that the 5 day steroid course is\n complete\n -monitor, expect improvement with continual reduction in PEEP\n # RUE DVT: Started on heparin gtt on , now therapeutic. Follow\n PTTs. Would hold off on coumadin at least until s/p trach.\n - continue to monitor\n # Adrenal Insufficency: Random cortisol was approx 3 when it should\n have been maximally stimulated.\n - hydrocortisone and florinef for 5 days\n # Anemia: Stable.\n - Trend HCT\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n FEN/GI: Tube feeds @ goal\n DVT: Treatment dose heparin\n Ulcer: Ranitidine\n VAP: Prevention per routine\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 08:13 PM 60 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 11:30 AM\n Arterial Line - 04:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"},{"category":"Nursing","chartdate":"2167-09-23 00:00:00.000","description":"Nursing Progress Note","row_id":634459,"text":"Events: Attempt to lighten sedation, stop Levophed gtt- MS \n stability labile from lethargic to restless in bed/crying w/\n intermittent BP 120\ns/ w/ and W/O stimulation. UOP cont 10-30cc/hr.\n Vigileo monitor on- SVV . Bladder pressure 14. TF restarted w/ goal\n slow inc as tolerated w/ recent high residuals.\n Alteration in Nutrition\n Assessment:\n Minimal residuals\n Action:\n Restarting TF replete w/ fiber @ 10cc/hr w/ Q6hr 20cc flush\n Response:\n Tolerating, goal advance Q6hr as tolerated\n Plan:\n Cont TF, monitor residuals, inc Q6hrs as tolerated\n Hypotension (not Shock)\n Assessment:\n BP labile- SBP 86-120, UOP down to 10cc/hr\n Action:\n Vigileo on- SVV , In AM attempt wean off Levo gtt\n Response:\n No fluid blousing, Levophed gtt started- titrated for MAP >65, UOP,\n Levo gtt @ .020mcg/kg/min\n Plan:\n Cont Vigeligo monitoring, CVP monitoring, UOP, Levophed gtt, fluid\n bolus if inc in SVV, in CVP\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Heparin gtt @ 1700units/hr, PTT 76\n Action:\n Heparin gtt therapeutic x2, cont @ 1700units/hr\n Response:\n No s/s bleeding, guiac neg gastric secretions, stool\n Plan:\n Cont Hep gtt as ordered w/I scale parameters, check PTT w/ AM labs,\n monitor s/s bleeding\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS clear bilat upper lobes, diminished bilat lower lobes, turning w/o\n desating, suctioning minimally for thin clear secretions, Sat 96-100%,\n w/ decres in sedation waking in afternoon and overbreathing vent 1-3\n bpm\n Action:\n No vent changes, suctioned post coughing x1, turning as tolerated,\n sedation titrated- currently @ 100mcg/hr Fentanyl gtt, 2 mg/hr Versed\n gtt. 1x blousing w/ .5mg Versed and 50mcg Fentanyl for sig inc in\n agitation/breathing over vent/pulling @ lines, resp tesing w/\n esophageal balloon\n Response:\n Synchronous w/ vent, RN care/turning/mouth care w/ decreased agitation,\n Sat >96%,\n Plan:\n Cont IV ABX, pulm toilet, esophageal balloon readins, monitor sat\n"},{"category":"Nursing","chartdate":"2167-09-23 00:00:00.000","description":"Nursing Progress Note","row_id":634460,"text":"Events: Attempt to lighten sedation, stop Levophed gtt- MS \n stability labile from lethargic to restless in bed/crying w/\n intermittent BP 120\ns/ w/ and W/O stimulation. UOP cont 10-30cc/hr.\n Vigileo monitor on- SVV . Bladder pressure 14. TF restarted w/ goal\n slow inc as tolerated w/ recent high residuals.\n Alteration in Nutrition\n Assessment:\n Minimal residuals\n Action:\n Restarting TF replete w/ fiber @ 10cc/hr w/ Q6hr 20cc flush\n Response:\n Tolerating, goal advance Q6hr as tolerated\n Plan:\n Cont TF, monitor residuals, inc Q6hrs as tolerated\n Hypotension (not Shock)\n Assessment:\n BP labile- SBP 86-120, UOP down to 10cc/hr\n Action:\n Vigileo on- SVV , In AM attempt wean off Levo gtt\n Response:\n No fluid blousing, Levophed gtt started- titrated for MAP >65, UOP,\n Levo gtt @ .020mcg/kg/min\n Plan:\n Cont Vigeligo monitoring, CVP monitoring, UOP, Levophed gtt, fluid\n bolus if inc in SVV, in CVP\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Heparin gtt @ 1700units/hr, PTT 76\n Action:\n Heparin gtt therapeutic x2, cont @ 1700units/hr\n Response:\n No s/s bleeding, guiac neg gastric secretions, stool\n Plan:\n Cont Hep gtt as ordered w/I scale parameters, check PTT w/ AM labs,\n monitor s/s bleeding\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS clear bilat upper lobes, diminished bilat lower lobes, turning w/o\n desating, suctioning minimally for thin clear secretions, Sat 96-100%,\n w/ decres in sedation waking in afternoon and overbreathing vent 1-3\n bpm, afebrile\n Action:\n No vent changes, suctioned post coughing x1, turning as tolerated,\n sedation titrated- currently @ 100mcg/hr Fentanyl gtt, 2 mg/hr Versed\n gtt. 1x blousing w/ .5mg Versed and 50mcg Fentanyl for sig inc in\n agitation/breathing over vent/pulling @ lines, resp tesing w/\n esophageal balloon\n Response:\n Synchronous w/ vent, RN care/turning/mouth care w/ decreased agitation,\n Sat >96%,\n Plan:\n Cont IV ABX, pulm toilet, esophageal balloon readins, monitor sat\n"},{"category":"Nursing","chartdate":"2167-09-24 00:00:00.000","description":"Nursing Progress Note","row_id":634608,"text":"Synopsis per prior nursing note:\n 55 yr old woman admitted from OSH after she fell down the stairs and\n had traumatic T-spine fracture. Pt came to us with PNA from unknown\n etiology? VAP. Full code, Allergies: PCN, tetracycline, Sulfa. PMH:\n ETOH, smoker, Gerd, Hip replacement.\n Alteration in Nutrition\n Assessment:\n Tube feeds increased to 40ml/hr. Residuals ~10ml. Hypoactive BS.\n Continues to have brown, liquid stool.\n Action:\n Residuals and BS checked. Rate increased to 40ml/hr.\n Response:\n Residual continued at 10ml/hr, continued rate of 40cc/hr.\n Plan:\n Advance TF to goal as tolerated. Monitor BS.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n RUE DVT, pt on heparin gtt at 1700units/hr.\n Action:\n Ptt was therapeutic x3. Heparin gtt continued.\n Response:\n No change to drip made, therapeutic dose.\n Plan:\n Cont heparin gtt, check PTT w/ am labs and adjust heparin gtt per\n scale.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Suctioned moderate, thick white ET tube secretions and copious clear,\n oral secretions. LS rhonchi w/ dim bases. Esophageal balloon in\n place.\n Action:\n Continued to suction frequently, HOB >30, oral care. Continued\n steroids.\n Response:\n ABG WNL. Continued to need suctioning. O2 sats >98%.\n Plan:\n Monitor LS. Suction as needed. Wean vent as tolerated.\n Hypotension (not Shock)\n Assessment:\n BP 89-106/43-53. MAP 56-67. Goal MAP >60. Urine output>40cc/hr.\n Action:\n Levophed gtt weaned off. Given 2.5 L NS total in bolus\n for low BP. New\n A-line placed-positional.\n Response:\n MAPs continued to be ~60-65.\n Plan:\n Monitor BP. ?fluid bolus vs levophed gtt. ?need for new a-line.\n Bradycardia\n Assessment:\n SB, HR 45-63. HR increased w/ activity.\n Action:\n HR monitored.\n Response:\n No intervention done because BP cont to be stable and all other vital\n signs stable.\n Plan:\n Monitor HR. EKG if indicated.\n"},{"category":"Respiratory ","chartdate":"2167-09-24 00:00:00.000","description":"Respiratory Care Shift Note","row_id":634611,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 6\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Utilize ARDSnet protocol, Reduce PEEP as tolerated;\n Comments: Pt remains on 21 of\n PEEP. Ballon measurements taken, which showed that pt was -3cm of peep.\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Intolerant of weaning attempts\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Pleural pressure measurement (930)\n Comments:\n"},{"category":"Respiratory ","chartdate":"2167-09-25 00:00:00.000","description":"Respiratory Care Shift Note","row_id":634686,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 7\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Reason: re-positioned 21cm this shift - confirmed correct placement via\n bronchoscopy at bedside\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Continues on A/C ventilation w/ PIP/Pplat = 34/28, not\n overbreathing set vent rate. PEEP remains at +21cm. Bronch at bedside\n to confirm ETT placement after ETT was not clearly visible on CXR.\n Sputum spec sent.\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Plan\n Next 24-48 hours: Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved; Comments: esophogeal balloon remains in place w/ PEEP at\n +21. no measurements made this shift.\n Respiratory Care Shift Procedures\n Bedside Procedures:\n Bronchoscopy (1100)\n Comments: bronchoscopy at bedside w/out complication.\n"},{"category":"Respiratory ","chartdate":"2167-09-26 00:00:00.000","description":"Respiratory Care Shift Note","row_id":634783,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 8\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Patient remains on mechanical ventilation, with oxygenation issues\n persisting. Decrease in PEEP followed by increase in Fi02 as noted on\n flow sheet. Bilateral breath sounds diminished with few scattered\n rhonchi. MDI\ns given as ordered.\n"},{"category":"Physician ","chartdate":"2167-09-27 00:00:00.000","description":"Physician Attending Progress Note","row_id":634870,"text":"Chief Complaint: respiratory failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 55 yo F w/ prolonged hospital course, etoh abuse with fall and thoracic\n compression fxs who was tranferred from OSH for evaluation of Y stent\n for BTM, course has been c/b R UE DVT and sepsis with hypotension,\n pressor needs, and resp failure likely VAP,TBM now with failure to\n wean, still with high PEEP requirements.\n 24 Hour Events:\n EKG - At 12:00 PM\n low voltage, pre Haldol administration QRS .46\n lasix X 3 doses with good urine output\n peep held at 15, fio2 increased to 50%\n History obtained from ho\n Patient unable to provide history: Sedated, intubated\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Aztreonam - 06:00 AM\n Vancomycin - 09:00 AM\n Levofloxacin - 08:06 AM\n Infusions:\n Midazolam (Versed) - 4 mg/hour\n Fentanyl - 150 mcg/hour\n Heparin Sodium - 1,700 units/hour\n Other ICU medications:\n Haloperidol (Haldol) - 04:26 PM\n Furosemide (Lasix) - 04:30 PM\n Midazolam (Versed) - 06:16 AM\n Fentanyl - 06:16 AM\n Other medications:\n per (reviewed)\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.8\nC (98.2\n HR: 61 (53 - 93) bpm\n BP: 137/70(95) {103/52(69) - 137/70(95)} mmHg\n RR: 20 (16 - 28) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101 kg (admission): 94.2 kg\n Height: 67 Inch\n CVP: 19 (6 - 21)mmHg\n Total In:\n 2,679 mL\n 1,165 mL\n PO:\n TF:\n 1,443 mL\n 639 mL\n IVF:\n 886 mL\n 526 mL\n Blood products:\n Total out:\n 3,135 mL\n 305 mL\n Urine:\n 3,035 mL\n 305 mL\n NG:\n Stool:\n 100 mL\n Drains:\n Balance:\n -456 mL\n 860 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 15 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 29 cmH2O\n Plateau: 26 cmH2O\n SpO2: 96%\n ABG: 7.46/39/68/27/3\n Ve: 7.8 L/min\n PaO2 / FiO2: 136\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Endotracheal tube\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Diminished), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n )\n Extremities: Right: 1+, Left: 1+, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: No(t) Muscle wasting\n Skin: Warm\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Not assessed, Movement: Non -purposeful, Sedated, No(t) Paralyzed,\n Tone: Not assessed\n Labs / Radiology\n 8.3 g/dL\n 411 K/uL\n 163 mg/dL\n 0.5 mg/dL\n 27 mEq/L\n 3.8 mEq/L\n 12 mg/dL\n 111 mEq/L\n 144 mEq/L\n 26.0 %\n 9.7 K/uL\n [image002.jpg]\n 03:47 AM\n 02:14 PM\n 04:05 PM\n 01:12 AM\n 04:00 AM\n 04:09 AM\n 10:18 AM\n 02:33 PM\n 02:46 PM\n 03:31 AM\n WBC\n 10.5`\n 1q\n 9.6\n 9.7\n Hct\n 27.5\n 27.8\n 26.0\n Plt\n 374\n 374\n 411\n Cr\n 0.6\n 0.5\n 0.5\n 0.5\n TCO2\n 27\n 26\n 27\n 28\n 29\n 26\n 27\n Glucose\n 187\n 194\n 195\n 195\n 163\n Other labs: PT / PTT / INR:15.3/69.9/1.3, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:86.1 %, Lymph:10.3 %,\n Mono:2.8 %, Eos:0.5 %, Lactic Acid:2.0 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:8.3 mg/dL, Mg++:2.1 mg/dL, PO4:3.3 mg/dL\n Imaging: cxr--et, og,r IJ in good position, slightly improved aeration\n at r and l base, still with b/l effusions, opacaities\n Microbiology: no new data\n Assessment and Plan\n 55 yo F w/ prolonged hospital course, etoh abuse with fall and thoracic\n compression fxs who was tranferred from OSH for evaluation of Y stent\n for BTM, course has been c/b R UE DVT and sepsis with hypotension,\n pressor needs, and resp failure likely VAP,TBM now with failure to\n wean, still with high PEEP requirements.\n Main issues remain--\n # Respiratory failure\n Continue to wean PEEP as tolerated following abg/sats\n Once PEEP lower, heading toward trach, given prolonged course,\n poor MS, vol overload\n Vol overload with effusions likely also contributing to poor\n wean\noff pressors and no longer needing boluses to maintain BP, keep\n I/O goal even to neg 500 cc neg, trend I/os and continue IV lasix today\n ultimately benefit form investigation for TBM\n Decrease RR on vent to optimize pH\n # Adrenal insufficiency\n Had very low random cortisol while in shock and respiratory\n failure\n On steroids, has come off and stayed off of pressors.\n cpmplete 5 day course of stress dose steroids--will discontinue\n after today.\n # Bradycardia\n Rhythm is sinus, confirmed by CVL-directed\natrial\n lead\n Heart rate increases with stimulation, suggesting mostly vagal\n in etiology\n # Klebsiella VAP\n complete course of levofloxacin today (day ), received vanco\n and which where d/c\nd given neg cx data.\n # Shock\nresolved, remains hemdynamically stable off pressors\n Treating adrenal insufficiency as above\n # R Upper extremity DVT\n Therapeutic heparin gtt (continue for now as heading toward trach)\n # Traumatic thoracic spinal fracture\n Eventual MRI. Too high-risk at present. Brace when out of bed.\n Ortho trauma following.\n # Glycemic control--imporved control with tightened SSI while on\n steroids\n Other issues as per ICU team note. Put in for picc placement.\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 08:13 PM 60 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 11:30 AM\n Arterial Line - 04:00 PM\n Comments: put in for picc line\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer:\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 45 minutes\n Patient is critically ill\n"},{"category":"Physician ","chartdate":"2167-09-26 00:00:00.000","description":"Physician Resident Progress Note","row_id":634753,"text":"Chief Complaint:\n 24 Hour Events:\n BRONCHOSCOPY - At 10:45 AM\n bronchoscopy for reposition of ETT not seen on CHX. Sedated on total\n 250mcg IVP FEntanyl, 2 MG IVP Midaz and cont on IV sedation for\n precedure. Provedure completed w/o incedence bacn on previous AC vent\n settings\n Able to wean PEEP throughout the day after bronch\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Metronidazole - 08:00 AM\n Aztreonam - 06:00 AM\n Vancomycin - 09:00 AM\n Levofloxacin - 09:30 AM\n Infusions:\n Midazolam (Versed) - 4 mg/hour\n Fentanyl - 125 mcg/hour\n Heparin Sodium - 1,700 units/hour\n Other ICU medications:\n Ranitidine (Prophylaxis) - 09:28 AM\n Fentanyl - 01:36 AM\n Midazolam (Versed) - 01:37 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.1\nC (97\n HR: 64 (47 - 79) bpm\n BP: 105/55(348) {89/45(61) - 125/84(348)} mmHg\n RR: 20 (20 - 30) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101 kg (admission): 94.2 kg\n Height: 67 Inch\n CVP: 19 (13 - 19)mmHg\n Total In:\n 4,142 mL\n 640 mL\n PO:\n TF:\n 2,219 mL\n 411 mL\n IVF:\n 1,833 mL\n 229 mL\n Blood products:\n Total out:\n 1,000 mL\n 660 mL\n Urine:\n 800 mL\n 660 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,142 mL\n -20 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 15 cmH2O\n FiO2: 40%\n PIP: 28 cmH2O\n Plateau: 23 cmH2O\n Compliance: 50 cmH2O/mL\n SpO2: 95%\n ABG: 7.43/41/80/24/2\n Ve: 7.4 L/min\n PaO2 / FiO2: 200\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric)\n Abdominal: No(t) Soft, Non-tender, Bowel sounds present, Distended\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Sedated, Tone: Not assessed\n Labs / Radiology\n 374 K/uL\n 8.7 g/dL\n 194 mg/dL\n 0.5 mg/dL\n 24 mEq/L\n 4.9 mEq/L\n 8 mg/dL\n 111 mEq/L\n 142 mEq/L\n 27.8 %\n 9.6 K/uL\n [image002.jpg]\n 06:17 AM\n 07:00 AM\n 08:18 AM\n 04:18 PM\n 03:47 AM\n 02:14 PM\n 04:05 PM\n 01:12 AM\n 04:00 AM\n 04:09 AM\n WBC\n 10.5\n 9.6\n Hct\n 27.5\n 27.8\n Plt\n 374\n 374\n Cr\n 0.6\n 0.6\n 0.5\n TropT\n <0.01\n <0.01\n TCO2\n 21\n 28\n 27\n 26\n 27\n 28\n Glucose\n 153\n 187\n 194\n Other labs: PT / PTT / INR:17.0/84.8/1.5, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:86.1 %, Lymph:10.3 %,\n Mono:2.8 %, Eos:0.5 %, Lactic Acid:2.0 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:8.4 mg/dL, Mg++:2.1 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with respiratory failure\n and difficulty weaning from vent.\n # Respiratory failure currently with unclear ETT location: Intubated\n on for resp decompensation. Likely VAP. Unlikely to have\n tracheomalacia as initially transferred for.\n - bronch for ETT location\n - wean PEEP\n # Pneumonia: Kleb oxytoca pneumonia and sputum with GPCs on gram\n stain. Afebrile overnight. On levofloxacin, vancomycin, aztreonam.\n Resp status seems to be improving.\n - Follow cultures\n - d/c aztreonam\n - Continue levofloxacin for 8 days\n # EKG changes: Sinus bradycardia. Very low voltages and no change in\n QRS morphology. P-waves are visible and prolonged PR interval is old.\n CK and troponins flat. Likely related to increased vagal tone possibly\n related to steroid replacement. Atrial EKG with p-waves c/w sinus\n bradycardia.\n - Will avoid excessive alpha-agonism\n - Continue to monitor\n # Hypotension: now off levophed, with good urine output. Hypovolemia\n is possibly a factor- responded to a transfusion; HCT had been\n dropping. However, SVV with Vigileo was 7, making her CO less likely\n to respond to fluids. Held on giving any boluses overnight. Today CVP\n is low given PEEP. Sepsis also a consideration.\n - continue abx as above (vanc and levofloxacin)\n - replete fluids.\n - Restart pressors as needed. Consider dopamine given bradycardia.\n # RUE DVT: Started on heparin gtt on .\n - closely monitor\n # Adrenal Insufficency: Random cortisol was approx 3 when it should\n have been maximally stimulated.\n - hydrocortisone and florinef for 5 days\n # Anemia: Stable.\n - Trend HCT\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n # Communication:\n - Brother has been with pt, although, live in boyfriend of 10 is\n her HCP.\n ICU \n Nutrition:\n Replete with Fiber (Full) - 08:13 PM 60 mL/hour, INR rising\n (? Nutritional deficiencies)\n Glycemic Control: ISS\n Lines:\n Multi Lumen - 11:30 AM\n Arterial Line - 04:00 PM\n Prophylaxis:\n DVT: heparin gtt\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: ICU consent signed, (brother) \n (boyfriend/POA) \n Code status: Full code\n Disposition: ICU\n"},{"category":"Physician ","chartdate":"2167-09-26 00:00:00.000","description":"Physician Resident Progress Note","row_id":634761,"text":"Chief Complaint:\n 24 Hour Events:\n BRONCHOSCOPY - At 10:45 AM\n bronchoscopy for reposition of ETT not seen on CHX. Sedated on total\n 250mcg IVP FEntanyl, 2 MG IVP Midaz and cont on IV sedation for\n precedure. Provedure completed w/o incedence bacn on previous AC vent\n settings\n Able to wean PEEP throughout the day after bronch\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Metronidazole - 08:00 AM\n Aztreonam - 06:00 AM\n Vancomycin - 09:00 AM\n Levofloxacin - 09:30 AM\n Infusions:\n Midazolam (Versed) - 4 mg/hour\n Fentanyl - 125 mcg/hour\n Heparin Sodium - 1,700 units/hour\n Other ICU medications:\n Ranitidine (Prophylaxis) - 09:28 AM\n Fentanyl - 01:36 AM\n Midazolam (Versed) - 01:37 AM\n Other medications:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.1\nC (97\n HR: 64 (47 - 79) bpm\n BP: 105/55(348) {89/45(61) - 125/84(348)} mmHg\n RR: 20 (20 - 30) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101 kg (admission): 94.2 kg\n Height: 67 Inch\n CVP: 19 (13 - 19)mmHg\n Total In:\n 4,142 mL\n 640 mL\n PO:\n TF:\n 2,219 mL\n 411 mL\n IVF:\n 1,833 mL\n 229 mL\n Blood products:\n Total out:\n 1,000 mL\n 660 mL\n Urine:\n 800 mL\n 660 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,142 mL\n -20 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 15 cmH2O\n FiO2: 40%\n PIP: 28 cmH2O\n Plateau: 23 cmH2O\n Compliance: 50 cmH2O/mL\n SpO2: 95%\n ABG: 7.43/41/80/24/2\n Ve: 7.4 L/min\n PaO2 / FiO2: 200\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese, opens eyes\n but no purposeful movement\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric)\n Abdominal: No(t) Soft, Non-tender, Bowel sounds present, Distended\n Extremities: No clubbing or cyanosis, 3+ nonpitting edema of b/l hands,\n LE without edema\n Skin: no rashes or jaundice\n Labs / Radiology\n 374 K/uL\n 8.7 g/dL\n 194 mg/dL\n 0.5 mg/dL\n 24 mEq/L\n 4.9 mEq/L\n 8 mg/dL\n 111 mEq/L\n 142 mEq/L\n 27.8 %\n 9.6 K/uL\n [image002.jpg]\n 06:17 AM\n 07:00 AM\n 08:18 AM\n 04:18 PM\n 03:47 AM\n 02:14 PM\n 04:05 PM\n 01:12 AM\n 04:00 AM\n 04:09 AM\n WBC\n 10.5\n 9.6\n Hct\n 27.5\n 27.8\n Plt\n 374\n 374\n Cr\n 0.6\n 0.6\n 0.5\n TropT\n <0.01\n <0.01\n TCO2\n 21\n 28\n 27\n 26\n 27\n 28\n Glucose\n 153\n 187\n 194\n Other labs: PT / PTT / INR:17.0/84.8/1.5, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:86.1 %, Lymph:10.3 %,\n Mono:2.8 %, Eos:0.5 %, Lactic Acid:2.0 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:8.4 mg/dL, Mg++:2.1 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with respiratory failure\n and difficulty weaning from vent.\n # Respiratory failure: Intubated on for resp decompensation.\n Likely VAP. Unlikely to have tracheomalacia as initially\n transferred for.\n - wean PEEP\n - discuss need for trach with patient and her family\n # Pneumonia: Pansensitive Kleb oxytoca pneumonia and sputum with GPCs\n on gram stain. Afebrile overnight. On levofloxacin since .\n Vancomycin, aztreonam have been stopped. Resp status seems to be\n improving.\n - Follow cultures\n - d/c aztreonam\n - Continue levofloxacin for 8 days (today = day )\n # EKG changes: Sinus bradycardia. Very low voltages and no change in\n QRS morphology. P-waves are visible and prolonged PR interval is old.\n CK and troponins flat. Likely related to increased vagal tone possibly\n related to steroid replacement. Atrial EKG with p-waves c/w sinus\n bradycardia.\n - Will avoid excessive alpha-agonism\n - Continue to monitor\n # Hypotension: Improved, off levophed for 2 days, with good urine\n output. SVV with Vigileo was 7, making her CO less likely to respond\n to fluids. CVP increasing with reduction in PEEP. Unlikely\n hypovolemic or septic. Likely poor adrenal response in setting of\n acute illness and very high PEEP.\n -continue fludricort and hydrocortisone for total 5 days (begun )\n -monitor, expect improvement with continual reduction in PEEP\n # RUE DVT: Started on heparin gtt on .\n - closely monitor\n # Adrenal Insufficency: Random cortisol was approx 3 when it should\n have been maximally stimulated.\n - hydrocortisone and florinef for 5 days\n # Anemia: Stable.\n - Trend HCT\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n # Communication:\n - Brother has been with pt, although, live in boyfriend of 10 is\n her HCP.\n ICU \n Nutrition:\n Replete with Fiber (Full) - 08:13 PM 60 mL/hour, INR rising\n (? Nutritional deficiencies)\n Glycemic Control: ISS\n titrate sliding scale up if persistent\n hyperglycemia\n Lines:\n Multi Lumen - 11:30 AM\n Arterial Line - 04:00 PM\n Prophylaxis:\n DVT: heparin gtt\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: ICU consent signed, (brother) \n (boyfriend/POA) \n Code status: Full code\n Disposition: ICU\n"},{"category":"Physician ","chartdate":"2167-09-26 00:00:00.000","description":"Physician Attending Progress Note","row_id":634764,"text":"Chief Complaint: resp failure, VAP, compression fx,\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n bronch for reposiitoning of ET tube, peep weaned down to 15 post-bronch\n 24 Hour Events:\n BRONCHOSCOPY - At 10:45 AM\n bronchoscopy for reposition of ETT not seen on CHX, samile. Sedated on\n total 250mcg IVP FEntanyl, 2 MG IVP Midaz and cont on IV sedation for\n precedure. Provedure completed w/o incedence bacn on previous AC vent\n settings\n BRONCHOSCOPY - At 11:03 AM\n History obtained from Medical records, HO\n Patient unable to provide history: Sedated\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Aztreonam - 06:00 AM\n Vancomycin - 09:00 AM\n Levofloxacin - 08:00 AM\n Infusions:\n Fentanyl - 125 mcg/hour\n Heparin Sodium - 1,700 units/hour\n Other ICU medications:\n Ranitidine (Prophylaxis) - 09:28 AM\n Midazolam (Versed) - 08:25 AM\n Fentanyl - 08:25 AM\n Other medications:\n per (reviewed)\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36\nC (96.8\n HR: 55 (47 - 88) bpm\n BP: 116/60(80) {89/45(61) - 135/78(348)} mmHg\n RR: 20 (20 - 25) insp/min\n SpO2: 93%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 101 kg (admission): 94.2 kg\n Height: 67 Inch\n CVP: 20 (13 - 20)mmHg\n Total In:\n 4,142 mL\n 1,082 mL\n PO:\n TF:\n 2,219 mL\n 564 mL\n IVF:\n 1,833 mL\n 408 mL\n Blood products:\n Total out:\n 1,000 mL\n 775 mL\n Urine:\n 800 mL\n 775 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,142 mL\n 307 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 15 cmH2O\n FiO2: 40%\n PIP: 28 cmH2O\n Plateau: 24 cmH2O\n Compliance: 44.4 cmH2O/mL\n SpO2: 93%\n ABG: 7.43/41/80./24/2\n Ve: 7.6 L/min\n PaO2 / FiO2: 200\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear :\n ant, Crackles : , Diminished: at bases, No(t) Absent : )\n Abdominal: Bowel sounds present, Distended, No(t) Tender: , Obese, BS\n hypoactive\n Extremities: Right: Absent, Left: Absent, 3+ UE/hand edema\n Skin: Warm, Rash:\n Neurologic: Attentive, No(t) Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 8.7 g/dL\n 374 K/uL\n 194 mg/dL\n 0.5 mg/dL\n 24 mEq/L\n 4.9 mEq/L\n 8 mg/dL\n 111 mEq/L\n 142 mEq/L\n 27.8 %\n 9.6 K/uL\n [image002.jpg]\n 06:17 AM\n 07:00 AM\n 08:18 AM\n 04:18 PM\n 03:47 AM\n 02:14 PM\n 04:05 PM\n 01:12 AM\n 04:00 AM\n 04:09 AM\n WBC\n 10.5\n 9.6\n Hct\n 27.5\n 27.8\n Plt\n 374\n 374\n Cr\n 0.6\n 0.6\n 0.5\n TropT\n <0.01\n <0.01\n TCO2\n 21\n 28\n 27\n 26\n 27\n 28\n Glucose\n 153\n 187\n 194\n Other labs: PT / PTT / INR:17.0/84.8/1.5, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:86.1 %, Lymph:10.3 %,\n Mono:2.8 %, Eos:0.5 %, Lactic Acid:2.0 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:8.4 mg/dL, Mg++:2.1 mg/dL, PO4:3.1 mg/dL\n Imaging: cxr--et ok, r ij, b/l effusions layering, increased haziness R\n base\n Microbiology: Kleb pan \n Assessment and Plan\n Assessment and Plan\n 55-year-old woman with prolonged hospital course, etoh abuse tranferred\n from OSH with fall and compression fx course c/b sepsis and resp\n failure likely VAP,TBM, failure to wean, with high PEEP\n requirements, R UE DVT\n Respiratory failure\n Oxygenation is improving\n continue to wean PEEP as tolerated\n eventually need investigation for TBM\n Once PEEP lower, would consider trach\n vol overload and effusions liekly also contrinuting to poor wean--goal\n 500 cc neg, trend I/os and consider gently IV lasix\n Adrenal insufficiency\n Based on very low random cortisol while in shock and\n respiratory failure\n On steroids, has come off and stayed off of pressors.\n Eventually wean, but still getting fluid boluses\n Bradycardia\n Rhythm is sinus, confirmed by CVL-directed\natrial\n lead\n Heart rate increases with stimulation, suggesting that this\n is mostly vagal in etiology\n Klebsiella VAP\n Complete 8d course of levofloxacin (day )\n If sputum culture remains negative (GPCs on G/S),\n discontinue vancomycin tomorrow\n Shock\n remains hemdynamically stable off pressors\n Intermittent fluid boluses\n Treating adrenal insufficiency\n R Upper extremity DVT\n Therapeutic heparin gtt (heading toward trach)\n Anemia\n Follow\n Possible tracheobronchomalacia (reason for transfer)\n Traumatic thoracic spinal fracture\n Eventual MRI. Too high-risk at present. Brace when out of\n bed. Ortho trauma following.\n glycemic control--tighten SSI\n Other issues as per ICU team note.\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 08:13 PM 60 mL/hour\n Comments: increase bowel reg\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 11:30 AM\n Arterial Line - 04:00 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer:\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 45 minutes\n Patient is critically ill\n"},{"category":"Physician ","chartdate":"2167-09-26 00:00:00.000","description":"Physician Attending Progress Note","row_id":634778,"text":"Chief Complaint: shock (resolved), adrenal insuff, resp failure, VAP,\n compression fx,\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI: 55 yo F w/ prolonged hospital course, etoh abuse with fall and\n thoracic compression fxs who was tranferred from OSH for evaluation of\n Y stent for BTM, course has been c/b R UE DVT and sepsis with\n hypotension, pressor needs, and resp failure likely VAP,TBM now\n with failure to wean, still with high PEEP requirements.\n 24 Hour Events:\n BRONCHOSCOPY - At 10:45 AM\n bronchoscopy for reposition of ETT not seen on CHX, samile. Sedated on\n total 250mcg IVP FEntanyl, 2 MG IVP Midaz and cont on IV sedation for\n precedure. Provedure completed w/o incedence bacn on previous AC vent\n settings\n BRONCHOSCOPY - At 11:03 AM\n Peep decreased to 15\n History obtained from Medical records, HO\n Patient unable to provide history: Sedated\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Aztreonam - 06:00 AM\n Vancomycin - 09:00 AM\n Levofloxacin - 08:00 AM\n Infusions:\n Fentanyl - 125 mcg/hour\n Heparin Sodium - 1,700 units/hour\n Other ICU medications:\n Ranitidine (Prophylaxis) - 09:28 AM\n Midazolam (Versed) - 08:25 AM\n Fentanyl - 08:25 AM\n Other medications:\n per (reviewed)\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36\nC (96.8\n HR: 55 (47 - 88) bpm\n BP: 116/60(80) {89/45(61) - 135/78(348)} mmHg\n RR: 20 (20 - 25) insp/min\n SpO2: 93%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 101 kg (admission): 94.2 kg\n Height: 67 Inch\n CVP: 20 (13 - 20)mmHg\n Total In:\n 4,142 mL\n 1,082 mL\n PO:\n TF:\n 2,219 mL\n 564 mL\n IVF:\n 1,833 mL\n 408 mL\n Blood products:\n Total out:\n 1,000 mL\n 775 mL\n Urine:\n 800 mL\n 775 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,142 mL\n 307 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 15 cmH2O\n FiO2: 40%\n PIP: 28 cmH2O\n Plateau: 24 cmH2O\n Compliance: 44.4 cmH2O/mL\n SpO2: 93%\n ABG: 7.43/41/80./24/2\n Ve: 7.6 L/min\n PaO2 / FiO2: 200\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n Eyes / Conjunctiva: PERRL, MMM\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear :\n ant, Crackles : , Diminished: at bases, No(t) Absent : )\n Abdominal: Bowel sounds present but decreased, Distended, No(t)\n Tender:, Obese,\n Extremities: Right: trace, Left:trace, + depedent, 2+ UE/hand edema\n Skin: Warm, Rash:\n Neurologic: Attentive, No(t) Follows simple commands,:, Movement:non\n purposeful, Tone: wnl\n Labs / Radiology\n 8.7 g/dL\n 374 K/uL\n 194 mg/dL\n 0.5 mg/dL\n 24 mEq/L\n 4.9 mEq/L\n 8 mg/dL\n 111 mEq/L\n 142 mEq/L\n 27.8 %\n 9.6 K/uL\n [image002.jpg]\n 06:17 AM\n 07:00 AM\n 08:18 AM\n 04:18 PM\n 03:47 AM\n 02:14 PM\n 04:05 PM\n 01:12 AM\n 04:00 AM\n 04:09 AM\n WBC\n 10.5\n 9.6\n Hct\n 27.5\n 27.8\n Plt\n 374\n 374\n Cr\n 0.6\n 0.6\n 0.5\n TropT\n <0.01\n <0.01\n TCO2\n 21\n 28\n 27\n 26\n 27\n 28\n Glucose\n 153\n 187\n 194\n Other labs: PT / PTT / INR:17.0/84.8/1.5, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:86.1 %, Lymph:10.3 %,\n Mono:2.8 %, Eos:0.5 %, Lactic Acid:2.0 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:8.4 mg/dL, Mg++:2.1 mg/dL, PO4:3.1 mg/dL\n Imaging: cxr--et ok, r ij, b/l effusions layering, increased haziness R\n base\n Microbiology: Kleb--pan \n Assessment and Plan\n 55 yo F w/ prolonged hospital course, etoh abuse with fall and thoracic\n compression fxs who was tranferred from OSH for evaluation of Y stent\n for BTM, course has been c/b R UE DVT and sepsis with hypotension,\n pressor needs, and resp failure likely VAP,TBM now with failure to\n wean, still with high PEEP requirements.\n Main issues remain--\n # Respiratory failure\n Oxygenation is improving\n Continue to wean PEEP as tolerated following abg/sats\n Once PEEP lower, would consider trach, given prolonged course,\n poor MS, vol overload\n Vol overload with effusions likely also contributing to poor\n wean\noff pressors and no longer needing boluses to maintain BP, keep\n I/O goal even to neg 500 cc neg, trend I/os and consider gently IV\n lasix later today\n ultimately benefit form investigation for TBM\n # Adrenal insufficiency\n Had very low random cortisol while in shock and respiratory\n failure\n On steroids, has come off and stayed off of pressors.\n Continue current doses, consider starting wean tomorrow as no\n longer needing fluid boluses and off pressors\n # Bradycardia\n Rhythm is sinus, confirmed by CVL-directed\natrial\n lead\n Heart rate increases with stimulation, suggesting mostly vagal\n in etiology\n # Klebsiella VAP\n Complete 8d course of levofloxacin (day ), received vanco and\n which where d/c\nd given neg cx data.\n # Shock\nresolved, remains hemdynamically stable off pressors\n Treating adrenal insufficiency\n # R Upper extremity DVT\n Therapeutic heparin gtt (continue for now as heading toward trach)\n # Traumatic thoracic spinal fracture\n Eventual MRI. Too high-risk at present. Brace when out of bed.\n Ortho trauma following.\n # Glycemic control--tighten SSI for improved control, on steroids\n Other issues as per ICU team note.\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 08:13 PM 60 mL/hour\n Comments: increase bowel reg\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 11:30 AM\n Arterial Line - 04:00 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer:\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 45 minutes\n Patient is critically ill\n"},{"category":"Physician ","chartdate":"2167-09-27 00:00:00.000","description":"Physician Attending Progress Note","row_id":634875,"text":"Chief Complaint: respiratory failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 55 yo F w/ prolonged hospital course, etoh abuse with fall and thoracic\n compression fxs who was tranferred from OSH for evaluation of Y stent\n for BTM, course has been c/b R UE DVT and sepsis with hypotension,\n pressor needs, and resp failure likely VAP,TBM now with failure to\n wean, still with high PEEP requirements.\n 24 Hour Events:\n EKG - At 12:00 PM\n low voltage, pre Haldol administration QRS .46\n lasix X 3 doses with good urine output\n peep held at 15, fio2 increased to 50%\n History obtained from ho\n Patient unable to provide history: Sedated, intubated\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Aztreonam - 06:00 AM\n Vancomycin - 09:00 AM\n Levofloxacin - 08:06 AM\n Infusions:\n Midazolam (Versed) - 4 mg/hour\n Fentanyl - 150 mcg/hour\n Heparin Sodium - 1,700 units/hour\n Other ICU medications:\n Haloperidol (Haldol) - 04:26 PM\n Furosemide (Lasix) - 04:30 PM\n Midazolam (Versed) - 06:16 AM\n Fentanyl - 06:16 AM\n Other medications:\n per (reviewed)\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.8\nC (98.2\n HR: 61 (53 - 93) bpm\n BP: 137/70(95) {103/52(69) - 137/70(95)} mmHg\n RR: 20 (16 - 28) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101 kg (admission): 94.2 kg\n Height: 67 Inch\n CVP: 19 (6 - 21)mmHg\n Total In:\n 2,679 mL\n 1,165 mL\n PO:\n TF:\n 1,443 mL\n 639 mL\n IVF:\n 886 mL\n 526 mL\n Blood products:\n Total out:\n 3,135 mL\n 305 mL\n Urine:\n 3,035 mL\n 305 mL\n NG:\n Stool:\n 100 mL\n Drains:\n Balance:\n -456 mL\n 860 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 15 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 29 cmH2O\n Plateau: 26 cmH2O\n SpO2: 96%\n ABG: 7.46/39/68/27/3\n Ve: 7.8 L/min\n PaO2 / FiO2: 136\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Endotracheal tube\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Diminished), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n ) bases b/l, coarse\n Extremities: Right: 1+, Left: 1+, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: No(t) Muscle wasting\n Skin: Warm\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Not assessed, Movement: Non -purposeful, Sedated, No(t) Paralyzed,\n Tone: Not assessed\n Labs / Radiology\n 8.3 g/dL\n 411 K/uL\n 163 mg/dL\n 0.5 mg/dL\n 27 mEq/L\n 3.8 mEq/L\n 12 mg/dL\n 111 mEq/L\n 144 mEq/L\n 26.0 %\n 9.7 K/uL\n [image002.jpg]\n 03:47 AM\n 02:14 PM\n 04:05 PM\n 01:12 AM\n 04:00 AM\n 04:09 AM\n 10:18 AM\n 02:33 PM\n 02:46 PM\n 03:31 AM\n WBC\n 10.5`\n 1q\n 9.6\n 9.7\n Hct\n 27.5\n 27.8\n 26.0\n Plt\n 374\n 374\n 411\n Cr\n 0.6\n 0.5\n 0.5\n 0.5\n TCO2\n 27\n 26\n 27\n 28\n 29\n 26\n 27\n Glucose\n 187\n 194\n 195\n 195\n 163\n Other labs: PT / PTT / INR:15.3/69.9/1.3, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:86.1 %, Lymph:10.3 %,\n Mono:2.8 %, Eos:0.5 %, Lactic Acid:2.0 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:8.3 mg/dL, Mg++:2.1 mg/dL, PO4:3.3 mg/dL\n Imaging: cxr--et, og,r IJ in good position, slightly improved aeration\n at r and l base, still with b/l effusions, opacaities\n Microbiology: no new data\n Assessment and Plan\n 55 yo F w/ prolonged hospital course, etoh abuse with fall and thoracic\n compression fxs who was tranferred from OSH for evaluation of Y stent\n for BTM, course has been c/b R UE DVT and sepsis with hypotension,\n pressor needs, and resp failure likely VAP,TBM now with failure to\n wean, still with high PEEP requirements.\n Main issues remain--\n # Respiratory failure\n Continue to wean PEEP as tolerated following abg/sats\n Once PEEP lower, heading toward trach, given prolonged course,\n poor MS, vol overload\n IV lasix for goal neg 500 cc i/o\n ultimately benefit form investigation for TBM\n Decrease RR on vent to optimize pH given alkalosis (mixed,\n mainly resp)\n # Adrenal insufficiency\n Had very low random cortisol while in shock and respiratory\n failure\n On steroids, has come off and stayed off of pressors\n Today completes 5 day course of stress dose steroids--will\n discontinue tomorrow\n # Klebsiella VAP\n complete course of levofloxacin today (day ), received vanco\n and which where d/c\nd given neg cx data.\n # R Upper extremity DVT\n Therapeutic heparin gtt (continue for now as heading toward trach)\n # Traumatic thoracic spinal fracture\n Eventual MRI. Too high-risk at present. Brace when out of bed.\n Ortho trauma following.\n # Glycemic control--improved with tightened SSI while on steroids\n Other issues as per ICU team note.\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 08:13 PM 60 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 11:30 AM\n Arterial Line - 04:00 PM\n Comments: put in for picc line\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer:\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 45 minutes\n Patient is critically ill\n"},{"category":"Nursing","chartdate":"2167-09-24 00:00:00.000","description":"Nursing Progress Note","row_id":634596,"text":"55 yr old woman admitted from OSH after she fell down the stairs and\n had traumatic T-spine fracture. Pt came to us with PNA from unknown\n etiology? VAP. Full code, Allergies: PCN, tetracycline, Sulfa. PMH:\n ETOH, smoker, Gerd, Hip replacement.\n Alteration in Nutrition\n Assessment:\n Tube feeds increased to 40ml/hr. Tube feed residual 10ml. Hypoactive\n BS.\n Action:\n cont to check residuals and try to increase rate\n Response:\n Residual staying 10ml/hr, continued rate of 40cc/hr.\n Plan:\n Try to increase Tube feeds to goal rate.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n RUE DVT, pt on heparin gtt at 1700units/hr.\n Action:\n Ptt was therapeutic x2, AM PTT 68.6 WNL\n Response:\n No change to drip made, therapeutic dose.\n Plan:\n Cont heparin gtt, check PTT adjust heparin gtt per scale.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Moderate thick white in-line secretions, copious clear oral secretions,\n clear/diminished lung sounds. Esophageal balloon in place. Previous\n Sputum culture shows GNR, speciation PND.\n Action:\n Lots of suctioning through the night, decreased FiO2 from 50% to 40%,\n decreased Peep from 23 to 21, HOB >30, oral care.\n Response:\n ABG WNL, could not draw an AM ABG because A-line no longer drawing,\n intern aware. Intern and resp therapy to get ABG for AM.\n Plan:\n Cont to try to wean vent settings as tolerated, cont monitoring ABG\n Hypotension (not Shock)\n Assessment:\n SBP 90-110\ns MAP 62-66 Goal MAP >65 Levophed gtt @ 0.018 mcg/kg/min.\n Action:\n Trying to wean levophed gtt off\n Response:\n MAP tends to drop below 65 when weaned all the way off levophed.\n Plan:\n Cont to try to wean gtt off\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n T-max 101.0\n Action:\n Sent blood, urine, and sputum cultures, treated with Tylenol\n Response:\n Temp decreased\n Plan:\n Follow up on cultures\n CT scan from earlier in the week confirms fracture but did not detect\n retropulsion. Neuro want pt in back brace when she is out of bed.\n Log rolling pt has been d/c.\n Bradycardia\n Assessment:\n At 0515 Patient HR dropped from 60-70\ns to 45-50.\n Action:\n EKG done, showed pt was in junctional rhythm, intern came to assess pt.\n Electrolytes WNL.\n Response:\n No intervention done yet because pt BP cont to be stable and all other\n vital signs stable.\n Plan:\n Cont to monitor pt HR.\n Fracture, other\n Assessment:\n Log roll precautions removed from day shift. Back brace needs to be\n applied if pt is out of bed. Please read CT scan results from above\n portion of note.\n Action:\n Still taking precautions to carefully turn pt but no longer on log roll\n precautions\n Response:\n Pt tolerating turning fine.\n Plan:\n Use back brace if pt get out of bed. Back brace in room\n"},{"category":"Nursing","chartdate":"2167-09-24 00:00:00.000","description":"Nursing Progress Note","row_id":634599,"text":"55 yr old woman admitted from OSH after she fell down the stairs and\n had traumatic T-spine fracture. Pt came to us with PNA from unknown\n etiology? VAP. Full code, Allergies: PCN, tetracycline, Sulfa. PMH:\n ETOH, smoker, Gerd, Hip replacement.\n Alteration in Nutrition\n Assessment:\n Tube feeds increased to 40ml/hr. Residuals ~10ml. Hypoactive BS.\n Action:\n Residuals and BS checked. Rate increased to 40ml/hr.\n Response:\n Residual continued at 10ml/hr, continued rate of 40cc/hr.\n Plan:\n Advance TF to goal as tolerated. Monitor BS.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n RUE DVT, pt on heparin gtt at 1700units/hr.\n Action:\n Ptt was therapeutic x2, AM PTT 68.6 WNL\n Response:\n No change to drip made, therapeutic dose.\n Plan:\n Cont heparin gtt, check PTT adjust heparin gtt per scale.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Moderate thick white in-line secretions, copious clear oral secretions,\n clear/diminished lung sounds. Esophageal balloon in place. Previous\n Sputum culture shows GNR, speciation PND.\n Action:\n Lots of suctioning through the night, decreased FiO2 from 50% to 40%,\n decreased Peep from 23 to 21, HOB >30, oral care.\n Response:\n ABG WNL, could not draw an AM ABG because A-line no longer drawing,\n intern aware. Intern and resp therapy to get ABG for AM.\n Plan:\n Cont to try to wean vent settings as tolerated, cont monitoring ABG\n Hypotension (not Shock)\n Assessment:\n SBP 90-110\ns MAP 62-66 Goal MAP >65 Levophed gtt @ 0.018 mcg/kg/min.\n Action:\n Trying to wean levophed gtt off\n Response:\n MAP tends to drop below 65 when weaned all the way off levophed.\n Plan:\n Cont to try to wean gtt off\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n T-max 101.0\n Action:\n Sent blood, urine, and sputum cultures, treated with Tylenol\n Response:\n Temp decreased\n Plan:\n Follow up on cultures\n CT scan from earlier in the week confirms fracture but did not detect\n retropulsion. Neuro want pt in back brace when she is out of bed.\n Log rolling pt has been d/c.\n Bradycardia\n Assessment:\n At 0515 Patient HR dropped from 60-70\ns to 45-50.\n Action:\n EKG done, showed pt was in junctional rhythm, intern came to assess pt.\n Electrolytes WNL.\n Response:\n No intervention done yet because pt BP cont to be stable and all other\n vital signs stable.\n Plan:\n Cont to monitor pt HR.\n Fracture, other\n Assessment:\n Log roll precautions removed from day shift. Back brace needs to be\n applied if pt is out of bed. Please read CT scan results from above\n portion of note.\n Action:\n Still taking precautions to carefully turn pt but no longer on log roll\n precautions\n Response:\n Pt tolerating turning fine.\n Plan:\n Use back brace if pt get out of bed. Back brace in room\n"},{"category":"Respiratory ","chartdate":"2167-09-23 00:00:00.000","description":"Respiratory Care Shift Note","row_id":634451,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Utilize ARDSnet protocol, Maintain PEEP at current\n level and reduce FiO2 as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"},{"category":"Nursing","chartdate":"2167-09-24 00:00:00.000","description":"Nursing Progress Note","row_id":634513,"text":"55 yr old woman admitted from OSH after she fell down the stairs and\n had traumatic T-spine fracture. Pt came to us with PNA from unknown\n etiology? VAP. Full code, Allergies: PCN, tetracycline, Sulfa. PMH:\n ETOH, smoker, Gerd, Hip replacement.\n Alteration in Nutrition\n Assessment:\n Tube feeds at 20ml/hr. Tube feed residual 20ml.\n Action:\n Kept TF at 20ml/hr and will cont to check residuals and try to increase\n rate\n Response:\n No change\n Plan:\n Try to increase Tube feeds to goal rate.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n RUE DVT, pt on heparin gtt at 1700units/hr.\n Action:\n Ptt was therapeutic x2, AM PTT\n Response:\n Plan:\n Cont heparin gtt, check PTT adjust heparin gtt per scale.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Moderate thick white in-line secretions, copious clear oral secretions,\n clear/diminished lung sounds. Esophageal balloon in place. Previous\n Sputum culture shows GNR, speciation PND.\n Action:\n Lots of suctioning through the night, decreased FiO2 from 50% to 40%,\n decreased Peep from 23 to 21, HOB >30, oral care.\n Response:\n ABG WNL\n Plan:\n Cont to try to wean vent settings as tolerated, cont monitoring ABG\n Hypotension (not Shock)\n Assessment:\n SBP 90-110\ns MAP 62-66 Goal MAP >65 Levophed gtt @ 0.020 mcg/kg/min.\n Action:\n Trying to wean levophed gtt off\n Response:\n Plan:\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n T-max 101.0\n Action:\n Sent blood, urine, and sputum cultures, treated with tylenol\n Response:\n Temp decreased\n Plan:\n Follow up on cultures\n CT scan from earlier in the week confirms fracture but did not detect\n retropulsion. Neuro want pt in back brace when she is out of bed.\n Log rolling pt has been d/c.\n"},{"category":"Nursing","chartdate":"2167-09-24 00:00:00.000","description":"Nursing Progress Note","row_id":634514,"text":"55 yr old woman admitted from OSH after she fell down the stairs and\n had traumatic T-spine fracture. Pt came to us with PNA from unknown\n etiology? VAP. Full code, Allergies: PCN, tetracycline, Sulfa. PMH:\n ETOH, smoker, Gerd, Hip replacement.\n Alteration in Nutrition\n Assessment:\n Tube feeds at 20ml/hr. Tube feed residual 20ml.\n Action:\n Kept TF at 20ml/hr and will cont to check residuals and try to increase\n rate\n Response:\n No change\n Plan:\n Try to increase Tube feeds to goal rate.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n RUE DVT, pt on heparin gtt at 1700units/hr.\n Action:\n Ptt was therapeutic x2, AM PTT\n Response:\n Plan:\n Cont heparin gtt, check PTT adjust heparin gtt per scale.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Moderate thick white in-line secretions, copious clear oral secretions,\n clear/diminished lung sounds. Esophageal balloon in place. Previous\n Sputum culture shows GNR, speciation PND.\n Action:\n Lots of suctioning through the night, decreased FiO2 from 50% to 40%,\n decreased Peep from 23 to 21, HOB >30, oral care.\n Response:\n ABG WNL\n Plan:\n Cont to try to wean vent settings as tolerated, cont monitoring ABG\n Hypotension (not Shock)\n Assessment:\n SBP 90-110\ns MAP 62-66 Goal MAP >65 Levophed gtt @ 0.020 mcg/kg/min.\n Action:\n Trying to wean levophed gtt off\n Response:\n Plan:\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n T-max 101.0\n Action:\n Sent blood, urine, and sputum cultures, treated with tylenol\n Response:\n Temp decreased\n Plan:\n Follow up on cultures\n CT scan from earlier in the week confirms fracture but did not detect\n retropulsion. Neuro want pt in back brace when she is out of bed.\n Log rolling pt has been d/c.\n Bradycardia\n Assessment:\n Action:\n Response:\n Plan:\n Fracture, other\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Physician ","chartdate":"2167-09-27 00:00:00.000","description":"Physician Resident Progress Note","row_id":634853,"text":"Chief Complaint:\n 24 Hour Events:\n - Rec\nd one dose of Haldol yesterday afternoon\n - Poor sleep overnight per nursing\n - Per ABG, holding steady on FiO2 (50%) and PEEP (15)\n - Gave Lasix, net neg ~ 500 yesterday\n - Today is last day of steroids as well as last day of abx\n (levofloxicin)\n - Tightened sliding scale insulin yesterday\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Aztreonam - 06:00 AM\n Vancomycin - 09:00 AM\n Levofloxacin - 08:00 AM\n Infusions:\n Midazolam (Versed) - 4 mg/hour\n Heparin Sodium - 1,700 units/hour\n Fentanyl - 150 mcg/hour\n Other ICU medications:\n Haloperidol (Haldol) - 04:26 PM\n Furosemide (Lasix) - 04:30 PM\n Midazolam (Versed) - 06:16 AM\n Fentanyl - 06:16 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 35.7\nC (96.2\n HR: 66 (53 - 93) bpm\n BP: 111/56(74) {103/52(69) - 135/78(93)} mmHg\n RR: 20 (16 - 28) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101 kg (admission): 94.2 kg\n Height: 67 Inch\n CVP: 18 (6 - 21)mmHg\n Total In:\n 2,681 mL\n 687 mL\n PO:\n TF:\n 1,443 mL\n 432 mL\n IVF:\n 888 mL\n 255 mL\n Blood products:\n Total out:\n 3,135 mL\n 185 mL\n Urine:\n 3,035 mL\n 185 mL\n NG:\n Stool:\n 100 mL\n Drains:\n Balance:\n -454 mL\n 502 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 20\n RR (Spontaneous): 23\n PEEP: 15 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 31 cmH2O\n Plateau: 25 cmH2O\n SpO2: 95%\n ABG: 7.46/39/68/27/3\n Ve: 7.7 L/min\n PaO2 / FiO2: 136\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 411 K/uL\n 8.3 g/dL\n 163 mg/dL\n 0.5 mg/dL\n 27 mEq/L\n 3.8 mEq/L\n 12 mg/dL\n 111 mEq/L\n 144 mEq/L\n 26.0 %\n 9.7 K/uL\n [image002.jpg]\n 03:47 AM\n 02:14 PM\n 04:05 PM\n 01:12 AM\n 04:00 AM\n 04:09 AM\n 10:18 AM\n 02:33 PM\n 02:46 PM\n 03:31 AM\n WBC\n 10.5\n 9.6\n 9.7\n Hct\n 27.5\n 27.8\n 26.0\n Plt\n 374\n 374\n 411\n Cr\n 0.6\n 0.5\n 0.5\n 0.5\n TCO2\n 27\n 26\n 27\n 28\n 29\n 26\n 27\n Glucose\n 187\n 194\n 195\n 195\n 163\n Other labs: PT / PTT / INR:15.3/69.9/1.3, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:86.1 %, Lymph:10.3 %,\n Mono:2.8 %, Eos:0.5 %, Lactic Acid:2.0 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:8.3 mg/dL, Mg++:2.1 mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 08:13 PM 60 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 11:30 AM\n Arterial Line - 04:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2167-09-27 00:00:00.000","description":"Physician Resident Progress Note","row_id":634854,"text":"Chief Complaint:\n 24 Hour Events:\n - Rec\nd one dose of Haldol yesterday afternoon\n - Poor sleep overnight per nursing\n - Per ABG, holding steady on FiO2 (50%) and PEEP (15)\n - Gave Lasix, net neg ~ 500 yesterday\n - Today is last day of steroids as well as last day of abx\n (levofloxicin)\n - Tightened sliding scale insulin yesterday\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Aztreonam - 06:00 AM\n Vancomycin - 09:00 AM\n Levofloxacin - 08:00 AM\n Infusions:\n Midazolam (Versed) - 4 mg/hour\n Heparin Sodium - 1,700 units/hour\n Fentanyl - 150 mcg/hour\n Other ICU medications:\n Haloperidol (Haldol) - 04:26 PM\n Furosemide (Lasix) - 04:30 PM\n Midazolam (Versed) - 06:16 AM\n Fentanyl - 06:16 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 35.7\nC (96.2\n HR: 66 (53 - 93) bpm\n BP: 111/56(74) {103/52(69) - 135/78(93)} mmHg\n RR: 20 (16 - 28) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101 kg (admission): 94.2 kg\n Height: 67 Inch\n CVP: 18 (6 - 21)mmHg\n Total In:\n 2,681 mL\n 687 mL\n PO:\n TF:\n 1,443 mL\n 432 mL\n IVF:\n 888 mL\n 255 mL\n Blood products:\n Total out:\n 3,135 mL\n 185 mL\n Urine:\n 3,035 mL\n 185 mL\n NG:\n Stool:\n 100 mL\n Drains:\n Balance:\n -454 mL\n 502 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 20\n RR (Spontaneous): 23\n PEEP: 15 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 31 cmH2O\n Plateau: 25 cmH2O\n SpO2: 95%\n ABG: 7.46/39/68/27/3\n Ve: 7.7 L/min\n PaO2 / FiO2: 136\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese, opens eyes\n but no purposeful movement\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric)\n Abdominal: No(t) Soft, Non-tender, Bowel sounds present, Distended\n Extremities: No clubbing or cyanosis, 3+ nonpitting edema of b/l hands,\n LE without edema\n Skin: no rashes or jaundice\n Labs / Radiology\n 411 K/uL\n 8.3 g/dL\n 163 mg/dL\n 0.5 mg/dL\n 27 mEq/L\n 3.8 mEq/L\n 12 mg/dL\n 111 mEq/L\n 144 mEq/L\n 26.0 %\n 9.7 K/uL\n [image002.jpg]\n 03:47 AM\n 02:14 PM\n 04:05 PM\n 01:12 AM\n 04:00 AM\n 04:09 AM\n 10:18 AM\n 02:33 PM\n 02:46 PM\n 03:31 AM\n WBC\n 10.5\n 9.6\n 9.7\n Hct\n 27.5\n 27.8\n 26.0\n Plt\n 374\n 374\n 411\n Cr\n 0.6\n 0.5\n 0.5\n 0.5\n TCO2\n 27\n 26\n 27\n 28\n 29\n 26\n 27\n Glucose\n 187\n 194\n 195\n 195\n 163\n Other labs: PT / PTT / INR:15.3/69.9/1.3, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:86.1 %, Lymph:10.3 %,\n Mono:2.8 %, Eos:0.5 %, Lactic Acid:2.0 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:8.3 mg/dL, Mg++:2.1 mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with respiratory failure\n and difficulty weaning from vent.\n # Respiratory failure: Intubated on for resp decompensation.\n Likely VAP. Unlikely to have tracheomalacia as initially\n transferred for.\n - wean PEEP\n - discuss need for trach with patient and her family\n # Pneumonia: Pansensitive Kleb oxytoca pneumonia and sputum with GPCs\n on gram stain. Afebrile overnight. On levofloxacin since .\n Vancomycin, aztreonam have been stopped. Resp status seems to be\n improving.\n - Follow cultures\n - d/c aztreonam\n - Continue levofloxacin for 8 days (today = day )\n # EKG changes: Sinus bradycardia. Very low voltages and no change in\n QRS morphology. P-waves are visible and prolonged PR interval is old.\n CK and troponins flat. Likely related to increased vagal tone possibly\n related to steroid replacement. Atrial EKG with p-waves c/w sinus\n bradycardia.\n - Will avoid excessive alpha-agonism\n - Continue to monitor\n # Hypotension: Improved, off levophed for 2 days, with good urine\n output. SVV with Vigileo was 7, making her CO less likely to respond\n to fluids. CVP increasing with reduction in PEEP. Unlikely\n hypovolemic or septic. Likely poor adrenal response in setting of\n acute illness and very high PEEP.\n -continue fludricort and hydrocortisone for total 5 days (begun )\n -monitor, expect improvement with continual reduction in PEEP\n # RUE DVT: Started on heparin gtt on .\n - closely monitor\n # Adrenal Insufficency: Random cortisol was approx 3 when it should\n have been maximally stimulated.\n - hydrocortisone and florinef for 5 days\n # Anemia: Stable.\n - Trend HCT\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n # Communication:\n - Brother has been with pt, although, live in boyfriend of 10 is\n her HCP.\n ICU \n Nutrition:\n Replete with Fiber (Full) - 08:13 PM 60 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 11:30 AM\n Arterial Line - 04:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Nursing","chartdate":"2167-09-25 00:00:00.000","description":"Nursing Progress Note","row_id":634654,"text":"Pt is a 55 yr old women admitted from OSH after she fell down the\n stairs (did not have LOC per boyfriend) and had a traumatic T-spine\n Fracture. Pt came to us with PNA from unknown etiology? VAP. Full\n code, Allergies: PCN, tetracycline, sulfa. PMH: ETOH, smoker, Gerd, Hip\n replacement. Pt afebrile during the night, was Pan cultured\n yesterday. Pt brother is her spokesperson. Pt boyfriend was in last\n night to see her, it is a 2 hr train ride from for him to get\n here. Pt boyfriend reported on night that for the last 2 months\n pt has been drinking 2 large bottles of wine almost every night and\n that this is an increase from what she used to drink.\n Bradycardia\n Assessment:\n HR 46-60\ns, HR decreases when pt is asleep. Stays in the 45-50 range\n when she is asleep. BP stable with low HR.\n Action:\n Monitor HR, monitor SBP with low HR\n Response:\n No action taken because vital sign have been stable.\n Plan:\n Cont to monitor\n Alteration in Nutrition\n Assessment:\n Replete with fiber Goal rate 60ml/hr. distended firm belly but pt is\n stooling now. Hypoactive bowel sounds.\n Action:\n Increased rate to 50ml/hr. cont to watch TF residuals. Pt did have past\n problems with high residuals.\n Response:\n Residuals 10ml.\n Plan:\n Cont to advance TF as tolerated. Cont stool softners/monitor for high\n residuals.\n Deep Venous Thrombosis (DVT), Upper extremity,\n Assessment:\n RUE DVT, Pt on heparin gtt at 1700 units/hr. No blood draws or BP on\n RUE.\n Action:\n PTT has been at therapeutic dose.\n Response:\n Repeat PTT in AM\n Plan:\n If PTT cont to be therapeutic cont to check PTT Q 24 hr., if not make\n changes per protocol.\n Fracture, other\n Assessment:\n Ortho reported that pt has T8 fracture. Pt does move all extremities,\n needs to wear back brace when out of bed. Brace is in the room, pt no\n longer on log roll precautions. Hard to tell if pt is in pain from\n fracture but she is on fentanyl and versed gtts.\n Action:\n Per ortho pt will need MRI of the spine and CT scan of the C and L\n portions of the spine to check for any other spinal injury. Ortho\n states we can do this when pt is more stable.\n Response:\n Plan:\n Will do MRI and CT at a later date.\n Hypotension (not Shock)\n Assessment:\n SBP ranges 80-100\ns with MAPs 55-70 Goal MAP >60. levophed off for\n almost 24hr. pt did get total of 3 liters in fluid boluses over the\n last 24 hr. CVP 12-14 but pt on 21 of peep. A-line very positional\n and was just re-sited yesterday. Pt was on vigileo monitor but D/C\n during the day because A-line tracing is so positional that the\n accuracy of this monitoring is questionable.\n Action:\n Gave 500ml fluid bolus for MAP of 55. and low urine output 10-20ml/hr.\n Response:\n Urine output increased, and MAP/BP increased\n Plan:\n Cont to monitor BP and MAPs and urine output.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Suctioning clear/white thick secretions in-line, copious amounts of\n clear secretions suctioned orally. Cough intact. Lung sounds clear\n diminished, no vent setting changes, Vent mode CMV: 40%/400/22/21,\n esophageal balloon in place.\n Action:\n VAP protocol: HOB 30 degrees, oral care. Suctioning, cont steroids.\n Chest x-ray done in AM. Cont antibiotics.\n Response:\n Cont to needs lots of suctioning.\n Plan:\n Wean vent as ordered by the Micu team. Cont to check ABG\ns when\n indicated.\n"},{"category":"Nutrition","chartdate":"2167-09-25 00:00:00.000","description":"Clinical Nutrition Note","row_id":634666,"text":"Objective\n Pertinent medications: noted\n Labs:\n Value\n Date\n Glucose\n 187 mg/dL\n 03:47 AM\n Glucose Finger Stick\n 207, 190\n \n BUN\n 6 mg/dL\n 03:47 AM\n Creatinine\n 0.6 mg/dL\n 03:47 AM\n Sodium\n 144 mEq/L\n 03:47 AM\n Potassium\n 4.3 mEq/L\n 03:47 AM\n Chloride\n 113 mEq/L\n 03:47 AM\n TCO2\n 26 mEq/L\n 03:47 AM\n Albumin\n 2.4 g/dL\n 03:59 AM\n Calcium non-ionized\n 9.0 mg/dL\n 03:47 AM\n Phosphorus\n 2.7 mg/dL\n 03:47 AM\n Ionized Calcium\n 1.20 mmol/L\n 08:18 AM\n Magnesium\n 2.0 mg/dL\n 03:47 AM\n Current diet order / nutrition support: Replte c/ Fiber @60mL/hr (1440\n kcals/89 gr aa)\n GI: Abd: firm/dist/+bs/+bm\n Assessment of Nutritional Status\n Specifics:\n Pt remains intubated. TF\ns retrialed . Currently infusing @50mL/\n hr c/ minimal residuals, advancing slowly to goal of 60mL/hr. Pt\ns abd\n remains firm, but pt now stooling. BG\ns elevated on steroids.\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: via TF\n Advance TF's to goal rate of 60mL/hr, as ordered\n Residual checks q 4 hr, hold if >200mL\n Consider tighter SS insulin\n"},{"category":"Physician ","chartdate":"2167-09-25 00:00:00.000","description":"Physician Attending Progress Note","row_id":634672,"text":"Chief Complaint:\n HPI:\n 24 Hour Events:\n ARTERIAL LINE - STOP 04:00 PM\n ARTERIAL LINE - START 04:00 PM\n Patient unable to provide history: Sedated\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Metronidazole - 08:00 AM\n Levofloxacin - 10:00 AM\n Aztreonam - 06:00 AM\n Vancomycin - 09:00 AM\n Infusions:\n Heparin Sodium - 1,700 units/hour\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 4 mg/hour\n Other ICU medications:\n Midazolam (Versed) - 09:17 AM\n Ranitidine (Prophylaxis) - 09:28 AM\n Other medications:\n midaz, fent, colace, H2B, CHG, SQI, MDIs, IV heparin, levoflox,\n aztreonam, vanco, hydrocort, fludrocort,\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.9\nC (98.4\n HR: 61 (45 - 79) bpm\n BP: 125/65(87) {83/44(59) - 125/84(134)} mmHg\n RR: 22 (0 - 30) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101 kg (admission): 94.2 kg\n Height: 67 Inch\n CVP: 16 (12 - 17)mmHg\n Total In:\n 4,751 mL\n 1,813 mL\n PO:\n TF:\n 773 mL\n 523 mL\n IVF:\n 3,828 mL\n 1,200 mL\n Blood products:\n Total out:\n 2,365 mL\n 465 mL\n Urine:\n 2,325 mL\n 265 mL\n NG:\n 40 mL\n Stool:\n Drains:\n Balance:\n 2,386 mL\n 1,348 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 22\n RR (Spontaneous): 5\n PEEP: 21 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 33 cmH2O\n Plateau: 28 cmH2O\n Compliance: 57.2 cmH2O/mL\n SpO2: 99%\n ABG: ///26/\n Ve: 10.4 L/min\n Physical Examination\n General Appearance: Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Percussion: Resonant : ), (Breath Sounds: Clear :\n anterior exam)\n Abdominal: Soft, Non-tender, Obese\n Extremities: Right: 1+, Left: 1+\n Musculoskeletal: Unable to stand\n Skin: Warm\n Neurologic: Responds to: Verbal stimuli, Movement: Purposeful, Tone:\n Normal\n Labs / Radiology\n 8.3 g/dL\n 374 K/uL\n 187 mg/dL\n 0.6 mg/dL\n 26 mEq/L\n 4.3 mEq/L\n 6 mg/dL\n 113 mEq/L\n 144 mEq/L\n 27.5 %\n 10.5 K/uL\n [image002.jpg]\n 01:04 AM\n 05:54 AM\n 06:11 AM\n 11:07 PM\n 03:51 AM\n 06:17 AM\n 07:00 AM\n 08:18 AM\n 04:18 PM\n 03:47 AM\n WBC\n 8.1\n 8.9\n 10.5\n Hct\n 28.0\n 28.6\n 27.5\n Plt\n 358\n 326\n 374\n Cr\n 0.7\n 0.7\n 0.6\n 0.6\n TropT\n <0.01\n <0.01\n TCO2\n 28\n 26\n 26\n 21\n 28\n Glucose\n 126\n 151\n 153\n 187\n Other labs: PT / PTT / INR:20.3/89.3/1.9, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:84.8 %, Lymph:12.5 %,\n Mono:2.4 %, Eos:0.1 %, Lactic Acid:0.7 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:9.0 mg/dL, Mg++:2.0 mg/dL, PO4:2.7 mg/dL\n Imaging: CXR: right base opacity; difficult to identify endotracheal\n tube\n Microbiology: Sputum: pan-sensitive Klebs\n Assessment and Plan\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 07:00 AM 60 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 11:30 AM\n Arterial Line - 04:00 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Heparin gtt)\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent:\n Patient is critically ill\n"},{"category":"Physician ","chartdate":"2167-09-25 00:00:00.000","description":"Physician Attending Progress Note","row_id":634673,"text":"Chief Complaint:\n HPI:\n 24 Hour Events:\n ARTERIAL LINE - STOP 04:00 PM\n ARTERIAL LINE - START 04:00 PM\n Patient unable to provide history: Sedated\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Metronidazole - 08:00 AM\n Levofloxacin - 10:00 AM\n Aztreonam - 06:00 AM\n Vancomycin - 09:00 AM\n Infusions:\n Heparin Sodium - 1,700 units/hour\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 4 mg/hour\n Other ICU medications:\n Midazolam (Versed) - 09:17 AM\n Ranitidine (Prophylaxis) - 09:28 AM\n Other medications:\n midaz, fent, colace, H2B, CHG, SQI, MDIs, IV heparin, levoflox,\n aztreonam, vanco, hydrocort, fludrocort,\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.9\nC (98.4\n HR: 61 (45 - 79) bpm\n BP: 125/65(87) {83/44(59) - 125/84(134)} mmHg\n RR: 22 (0 - 30) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101 kg (admission): 94.2 kg\n Height: 67 Inch\n CVP: 16 (12 - 17)mmHg\n Total In:\n 4,751 mL\n 1,813 mL\n PO:\n TF:\n 773 mL\n 523 mL\n IVF:\n 3,828 mL\n 1,200 mL\n Blood products:\n Total out:\n 2,365 mL\n 465 mL\n Urine:\n 2,325 mL\n 265 mL\n NG:\n 40 mL\n Stool:\n Drains:\n Balance:\n 2,386 mL\n 1,348 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 22\n RR (Spontaneous): 5\n PEEP: 21 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 33 cmH2O\n Plateau: 28 cmH2O\n Compliance: 57.2 cmH2O/mL\n SpO2: 99%\n ABG: ///26/\n Ve: 10.4 L/min\n Physical Examination\n General Appearance: Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Percussion: Resonant : ), (Breath Sounds: Clear :\n anterior exam)\n Abdominal: Soft, Non-tender, Obese\n Extremities: Right: 1+, Left: 1+\n Musculoskeletal: Unable to stand\n Skin: Warm\n Neurologic: Responds to: Verbal stimuli, Movement: Purposeful, Tone:\n Normal\n Labs / Radiology\n 8.3 g/dL\n 374 K/uL\n 187 mg/dL\n 0.6 mg/dL\n 26 mEq/L\n 4.3 mEq/L\n 6 mg/dL\n 113 mEq/L\n 144 mEq/L\n 27.5 %\n 10.5 K/uL\n [image002.jpg]\n 01:04 AM\n 05:54 AM\n 06:11 AM\n 11:07 PM\n 03:51 AM\n 06:17 AM\n 07:00 AM\n 08:18 AM\n 04:18 PM\n 03:47 AM\n WBC\n 8.1\n 8.9\n 10.5\n Hct\n 28.0\n 28.6\n 27.5\n Plt\n 358\n 326\n 374\n Cr\n 0.7\n 0.7\n 0.6\n 0.6\n TropT\n <0.01\n <0.01\n TCO2\n 28\n 26\n 26\n 21\n 28\n Glucose\n 126\n 151\n 153\n 187\n Other labs: PT / PTT / INR:20.3/89.3/1.9, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:84.8 %, Lymph:12.5 %,\n Mono:2.4 %, Eos:0.1 %, Lactic Acid:0.7 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:9.0 mg/dL, Mg++:2.0 mg/dL, PO4:2.7 mg/dL\n Imaging: CXR: right base opacity; difficult to identify endotracheal\n tube\n Microbiology: Sputum: pan-sensitive Klebs\n Assessment and Plan\n 55-year-old woman with\n Unclear location of ETT\n Since only 18cm in holder, we will bronch to confirm correct\n position since an inadvertent extubation might be fatal.\n Respiratory failure\n Oxygenation is improving\n Wean PEEP as tolerated by hypoxemia\n eventually need investigation for TBM\n At present, her PEEP is too high to consider tracheostomy\n but if we are able to wean it (and not able to extubate her) would\n consider tracheostomy soon\n Adrenal insufficiency\n Based on very low random cortisol while in shock and\n respiratory failure\n On steroids, has come off and stayed off of pressors.\n Eventually wean, but still getting fluid boluses\n Bradycardia\n Rhythm is sinus, confirmed by CVL-directed\natrial\n lead\n Heart rate increases with stimulation, suggesting that this\n is mostly vagal in etiology\n Klebsiella VAP\n Complete 8d course of levofloxacin\n Discontinue aztreonam\n If sputum culture remains negative (GPCs on G/S),\n discontinue vancomycin tomorrow\n Shock\n now off of levophed\n Intermittent fluid boluses\n Treating adrenal insufficiency\n Upper extremity DVT\n Therapeutic heparin\n Anemia\n Follow\n Possible tracheobronchomalacia (reason for transfer)\n Incidental peri-appendiceal finding (will need eventual\n follow-up)\n Traumatic thoracic spinal fracture\n Eventual MRI. Too high-risk at present. Brace when out of\n bed.\n Other issues as per ICU team note.\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 07:00 AM 60 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 11:30 AM\n Arterial Line - 04:00 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Heparin gtt)\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 50 min\n Patient is critically ill\n"},{"category":"Respiratory ","chartdate":"2167-09-27 00:00:00.000","description":"Respiratory Care Shift Note","row_id":634836,"text":"TITLE:\n Demographics\n :\n Day of mechanical ventilation: 9\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:MOV\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: A/C400x20/+15 peep/.5\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n :\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Dysynchrony assessment: none noted\n Plan\n Next 24-48 hours: Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Underlying illness not resolved\n"},{"category":"Nursing","chartdate":"2167-09-26 00:00:00.000","description":"Nursing Progress Note","row_id":634729,"text":"TITLE: This is a 55 yr old female admitted from an OSH to on\n with resp failure, +PNA s/p fall down stairs with fracture of\n T5-T8 and possible tracheobronchomalacia for IP consult and possible Y\n stenting. Pt now s/p IP consult with no tracheobronchomalacia found on\n exam. Pt has been diff to wean with high PEEP requirements. The pt\n has finished a course of IV Levofloxacin, Vanco, and Aztreonam antibx\n for Klebsiella PNA/VAP. Pt found to have RUE DVT and maintained on an\n IV Heparin gtt (no NBP or blood draw in this appendage please). The pt\n is net input more than fifteen liters for LOS @ this time. The pt has\n documented allergies to Tetracycline, PCN & Hydrazaline. The pt is a\n Full Code. The pt has a boyfriend and a brother, the brother is the\n designated HCP.\n Bradycardia\n Assessment:\n NSR/Sinus bradycardia all shift. Pt maintains good cardiac output\n whether in NSR or SB with good hourly urine output and MAP\ns > 65 as\n desired by team.\n Action:\n No specific action required.\n Response:\n Pt remains hemodynamically stable on current pt care regime.\n Plan:\n Cont to follow pts hemodynamic status closely.\n Alteration in Nutrition\n Assessment:\n Pt received/maintained on full strength Replete with Fiber @ target\n rate of 60ml/hr via OGT with low residuals noted all shift.\n Action:\n Pt maintained on Replete with Fiber tube feeds @ target rate of\n 60ml/hr. Rectal tube d/c\ned 2^nd low output.\n Response:\n Pt appears to be tolerating current tube feeds.\n Plan:\n Cont to provide tube feeds @ stated target goal per Nutrition recs.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt has a documented RUE DVT and received on IV Heparin gtt infusing @\n 1,700 units/hr with serial therapeutic PTT noted.\n Action:\n Pt maintained on a 1,700 unit/hr Heparin gtt infusion rate.\n Response:\n Therapeutic AM PTT value of 84.8 noted.\n Plan:\n Cont with current IV Heparin gtt, hope to transistion to PO anti-coag\n when medically suited.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt received on CMV:22-40%-400-21 with normal sats, RR @ set rate and no\n evidence of SOB/dyspnea. Of note, the pts O2 sat perfectly correlates\n with ABG sat.\n Action:\n Rate dropped to 20, PEEP slowly/cautiously reduced down to 16. Pt\n sxn\ned for small amounts of thick tan sec per ETT overnight. AM CXR\n obtained this AM, results pending.\n Response:\n Pt cont to do well on reduced levels of MV support with last ABG\n values; 7.43-41-80.\n Plan:\n Cont to wean PEEP down as tol. Hope to avoid trach placement if\n possible.\n Hypotension (not Shock)\n Assessment:\n Pt has remained hemodynamically stable and afebrile all shift. CVP\n values in the low/mid teens, real value likely < 10 in setting of high\n PEEP (16).\n Action:\n Reduced PEEP overnight may be helping to improve cardiac output with\n increased venous return.\n Response:\n Pt has been maintained off pressors.\n Plan:\n Cont to follow hemodynamic status closely.\n"},{"category":"Respiratory ","chartdate":"2167-09-26 00:00:00.000","description":"Respiratory Care Shift Note","row_id":634731,"text":"TITLE:\n Demographics\n Day of intubation: 13\n Day of mechanical ventilation: 13\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: mL /\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: A/C 400x20/+16 peep/.4\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Dysynchrony assessment: none noted\n Comments: tolerated decrease in rate/Ve and decrease in peep from +21\n to +16 overnoc\n Plan\n Next 24-48 hours: Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n"},{"category":"Nursing","chartdate":"2167-09-26 00:00:00.000","description":"Nursing Progress Note","row_id":634807,"text":"Events: MS labile from resting to agitated/ ? in pain in bed.\n Titrating sedation and adding IV Haldol for agitation. Tolerating TF\n and tightened RISS w/ recent high blood sugars. TF w/ minimal\n residual- firm abd and given Ducolax supp w/ good effect. Unable to\n wean from vent\n sat 90-93%, desat to 88-90% w/ cleaning and turning.\n Starting IV diuresis for edema/vent weaning.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS clear bilat upper lobes, diminished bilat lower lobes, pt w/ strong\n cough but minimal amts or thin clear secretions, large amt oral\n secretions, sat 90-95%\n Action:\n Turning as tolerated, suctioned PRN, up FiO2 w/ repete ABG O2 72,\n starting diuresis 10mg IVP Lasix x2\n Response:\n Sat 95-96%, 50%/400/x20/+15, post each dose Lasix mod response\n 500-700cc out/2hrs then tapering, BP w/o change post Lasix,\n Plan:\n Cont IV duiresis for goal envolemic to neg 500cc for decrease in angio\n and pulm edema to wean from vent, possibly Lasix gtt if not negative\n and BP tolerates\n Impaired Skin Integrity\n Assessment:\n Post supp- inc soft, semi formed brown guiac neg BM- while cleaning\n noted peri anal rash and sm area R glut/peri anal area\n? Skin tear\n from excoriation and resistance w/ turning and agitation/moving self in\n bed, skin tear site pink, clear w/ no odor, peri wound tissue mild\n excoriated/reddened\n Action:\n Pressure reduction as tolerated, barrier cream and criticaid cream,\n heals and elbows elevated, multipudus boots\n Response:\n No additional breakdown noted\n Plan:\n Cont monitor skin integrity, pressure reduction and shearing\n protection, cont support nutrition\n Altered mental status (not Delirium)\n Assessment:\n Pt will track follow, when released from restraints will reach in air\n and intermittently attempt pull @ ETT, ? nodding to questioning x 1,\n unable to write to make needs known, pt frequently attempting to turn\n in bed\n Action:\n Repositionged in afternoon for ? back pain, x1 sig inc in agitation\n administering 1mg IVP Haldol w/ good effect\n Response:\n Resting comfortable, VSS for several hours- able to mild titrate down\n Versed gtt,\n Plan:\n Cont monitor MS, emotional support, frequent reorientation, cont\n sedation as tolerated ? dilerium w/ PRN Haldol for aggitation\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n afebrile\n Action:\n Cont IV ABD Levoflox day \n Response:\n Plan:\n Cont monitor for temp spike, VAP prevention, skin care, IV ABX\n team\n to D/C Levoflox \n Edema, peripheral\n Assessment:\n 2+ generalized/dependent edema, CVP 15-21\n Action:\n Arms, hands, and legs elevated as tolerated, administering 10mg IVP\n Lasix x 2\n Response:\n Mod output w/ >500cc/2hrs and tapering post both doses\n Plan:\n Goal envolemic to neg 500 cc\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Heparin gtt @ 1700 units/hr, no S/S bleeding\n Action:\n Cont Hep gtt\n Response:\n Plan:\n Cont Hep gtt check PTT w/ Am labs, cont IV anticoagulation likely\n slow wean from vent and possible trach placement\n"},{"category":"Nursing","chartdate":"2167-09-26 00:00:00.000","description":"Nursing Progress Note","row_id":634809,"text":"Events: MS labile from resting to agitated/ ? in pain in bed.\n Titrating sedation and adding IV Haldol for agitation. Tolerating TF\n and tightened RISS w/ recent high blood sugars. TF w/ minimal\n residual- firm abd and given Ducolax supp w/ good effect. Unable to\n wean from vent\n sat 90-93%, desat to 88-90% w/ cleaning and turning.\n Starting IV diuresis for edema/vent weaning.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS clear bilat upper lobes, diminished bilat lower lobes, pt w/ strong\n cough but minimal amts or thin clear secretions, large amt oral\n secretions, sat 90-95%\n Action:\n Turning as tolerated, suctioned PRN, up FiO2 w/ repete ABG O2 72,\n starting diuresis 10mg IVP Lasix x2\n Response:\n Sat 95-96%, 50%/400/x20/+15, post each dose Lasix mod response\n 500-700cc out/2hrs then tapering, BP w/o change post Lasix,\n Plan:\n Cont IV duiresis for goal envolemic to neg 500cc for decrease in angio\n and pulm edema to wean from vent, possibly Lasix gtt if not negative\n and BP tolerates\n Impaired Skin Integrity\n Assessment:\n Post supp- inc soft, semi formed brown guiac neg BM- while cleaning\n noted peri anal rash and sm area R glut/peri anal area\n? Skin tear\n from excoriation and resistance w/ turning and agitation/moving self in\n bed, skin tear site pink, clear w/ no odor, peri wound tissue mild\n excoriated/reddened\n Action:\n Pressure reduction as tolerated, barrier cream and criticaid cream,\n heals and elbows elevated, multipudus boots\n Response:\n No additional breakdown noted\n Plan:\n Cont monitor skin integrity, pressure reduction and shearing\n protection, cont support nutrition\n Altered mental status (not Delirium)\n Assessment:\n Pt will track follow, when released from restraints will reach in air\n and intermittently attempt pull @ ETT, ? nodding to questioning x 1,\n unable to write to make needs known, pt frequently attempting to turn\n in bed\n Action:\n Repositioned in afternoon for ? back pain, x1 sig inc in agitation\n administering 1mg IVP Haldol w/ good effect\n Response:\n Resting comfortable, in afternoon VSS for several hours- able to mild\n titrate down Versed gtt,\n Plan:\n Cont monitor MS, emotional support, frequent reorientation, cont\n sedation as tolerated ? dilerium w/ PRN Haldol for aggitation\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n afebrile\n Action:\n Cont IV ABD Levoflox day \n Response:\n Plan:\n Cont monitor for temp spike, VAP prevention, skin care, IV ABX\n team\n to D/C Levoflox \n Edema, peripheral\n Assessment:\n 2+ generalized/dependent edema, CVP 15-21\n Action:\n Arms, hands, and legs elevated as tolerated, administering 10mg IVP\n Lasix x 2\n Response:\n Mod output w/ >500cc/2hrs and tapering post both doses\n Plan:\n Goal envolemic to neg 500 cc\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Heparin gtt @ 1700 units/hr, no S/S bleeding\n Action:\n Cont Hep gtt\n Response:\n No change\n Plan:\n Cont Hep gtt check PTT w/ Am labs, cont IV anticoagulation likely\n slow wean from vent and possible trach placement\n"},{"category":"Respiratory ","chartdate":"2167-09-27 00:00:00.000","description":"Respiratory Care Shift Note","row_id":634816,"text":"TITLE:\n Demographics\n Day of intubation:\n Day of mechanical ventilation: 9\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: A/C400x20/+15 peep/.5\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"},{"category":"Nursing","chartdate":"2167-09-27 00:00:00.000","description":"Nursing Progress Note","row_id":634817,"text":"TITLE:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n Edema, peripheral\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2167-09-27 00:00:00.000","description":"Nursing Progress Note","row_id":634818,"text":"TITLE: This is a 55 yr old female admitted from an OSH to on\n with resp failure, +PNA s/p fall down stairs with fracture of\n T5-T8 and possible tracheobronchomalacia for IP consult and possible Y\n stenting. Pt now s/p IP consult with no tracheobronchomalacia found on\n exam. Pt has been diff to wean with high PEEP requirements. The pt\n has finished a course of IV Levofloxacin, Vanco, and Aztreonam antibx\n for Klebsiella PNA/VAP. Pt found to have RUE DVT and maintained on an\n IV Heparin gtt (no NBP or blood draw in this appendage please). The pt\n is net input more than fifteen liters for LOS @ this time. The pt has\n documented allergies to Tetracycline, PCN & Hydrazaline. The pt is a\n Full Code. The pt has a boyfriend and a brother, the brother is the\n designated HCP.\n Overnight Events: No significant events overnight. Unable to wean MV\n support. Pt sedation needs appear to be increasing with increased\n levels of agitation requiring increased Midazolam & Fentanyl gtt rates\n and more freq IVP bolus dosing.\n Altered mental status (not Delirium)\n Assessment:\n Pt received/maintained on IV Fentanyl & Midazolam gtt\ns infusing @\n 125mcg/hr & 3mg/hr respectively. Unfortunately, pt easily becomes\n agitated with the slightest stimulation and does not respond to verbal\n re- assurance. Pt intermittently follows commands. At one point the\n pt nodded her head negatively when asked if she was in pain.\n Action:\n IV Fentanyl & IV Midazolam gtts titrated up, freq sedation boluses also\n provided. Soft wrist restraints maintained for pt safety. Pt freq\n re-oriented to person/place/time/care rationale to assist with nl\n cognition.\n Response:\n Pt seems to do well when left alone with lights out. Pt does not seem\n to get agitated to verbal stimuli, but does is not appeased by verbal &\n non-verbal reassurance.\n Plan:\n Pt responded well to IV Haldol on , may need to repeat?\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt received/maintained on AC-20-50%-400-15 with adequate ABG values\n (7.46-39-68) and subsequently no MV setting changes.\n Actioin:\n HOB kept @ 30 to 45 degrees. Sxn\ning provided to ETT Q 2-3 hr for sm\n amounts of thick tan sec. No RSBI 2^nd PEEP >/= 10.\n Response:\n Current AM ABG is acceptable.\n Plan:\n Pt appears to be moving in the direction of tracheostomy placement when\n PEEP reduced to more tolerable levels.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt has a documented DVT in RUE. No blood draws nor NBP measurements in\n this extremity please.\n Action:\n Pt received/maintained on IV Heparin gtt infusing @ 1,700 units/hr.\n Response:\n Pt has had serial therapeutic PTT values on current IV Heparin gtt rate\n of 1,700 units/hr.\n Plan:\n Currently awaiting AM PTT value to ensure optimal anti-coagulation\n status.\n Alteration in Nutrition\n Assessment:\n Pt received/maintained on full strength Replete with Fiber.\n Action:\n Pt continues to tol Replete with Fiber @ target rate of 60ml/hr.\n Response:\n Pt appears to be tol enteral nutrition @ this time with minimal\n residual per OGT.\n Plan:\n Cont to maintain pt on current tube feeds.\n Edema, peripheral\n Assessment:\n The pt is net input 16 liters for LOS and is +3 generalized\n anasarcoid. CVP values in the low teens in setting of high PEEP\n needs(15).\n Action:\n 10mg IVP Lasix provided @ 20:00.\n Response:\n Pt voided approximately 750ml dilute clear urine s/p 10mg IVP Lasix\n dose.\n Plan:\n Pt remains approx 16 liters input for LOS.\n"},{"category":"Respiratory ","chartdate":"2167-09-28 00:00:00.000","description":"Respiratory Care Shift Note","row_id":634929,"text":"TITLE:\n Demographics\n Day of intubation:\n Day of mechanical ventilation: 10\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management: MOV\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: A/C 400x18/+15 peep/.5\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: occ periods of agitation\n Assessment of breathing comfort: comf\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved; rsbi held d/t peep level\n"},{"category":"Nursing","chartdate":"2167-09-27 00:00:00.000","description":"Nursing Progress Note","row_id":634911,"text":"TITLE: This is a 55 yr old female admitted from an OSH to on\n with resp failure, +PNA s/p fall down stairs with fracture of\n T5-T8 and possible tracheobronchomalacia for IP consult and possible Y\n stenting. Pt now s/p IP consult with no tracheobronchomalacia found on\n exam. Pt has been diff to wean with high PEEP requirements. The pt\n has finished a course of IV Levofloxacin, Vanco, and Aztreonam antibx\n for Klebsiella PNA/VAP. Pt found to have RUE DVT and maintained on an\n IV Heparin gtt (no NBP or blood draw in this appendage please). The pt\n is net input more than fifteen liters for LOS @ this time. The pt has\n documented allergies to Tetracycline, PCN & Hydrazaline. The pt is a\n Full Code. The pt has a boyfriend and a brother, the brother is the\n designated HCP.\n Events: PICC line placed at bedside, RR decreased from 20 to 18,\n levaquin d/c\nd. cont to diurese w/ lasix.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt on AC 20x400 50% PEEP 15. ABG n these settings 7.46/ 39/68\n Action:\n RR decreased to 18 to correct pH\n Response:\n Repeat ABG\ns 7.41/ 45/78\n Plan:\n Wean vent as tol, ? trach if unable to extubate\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n PTT 69.9 on heparin at 1700 units/hr\n Action:\n Response:\n Plan:\n Cont to monitor PTT, titrate heparin per protocol\n Edema, peripheral\n Assessment:\n Generalized edema r/t +FB of ~16.5L for LOS\n Action:\n Lasix 10mg IV given a/o\n Response:\n Pt diuresed 700ml over 2hrs.\n Plan:\n Monitor lytes, cont diuresis as tol.\n"},{"category":"Nursing","chartdate":"2167-09-20 00:00:00.000","description":"Nursing Progress Note","row_id":634115,"text":"55 year old woman with hx of obesity presented to Medical Center\n on after falling down stairs while at home. She suffered a\n traumatic T5-8 fracture with retropulsion of fragments. Per medical\n records and discussion with her brother, she was awake for the fall (no\n LOC) and the fall was triggered by unsteady gait, potentially\n influenced by alcohol. Her fracture was managed concervatively. She\n was placed in a torso brace but her course was complicated by\n respiratory failure requiring intubation. At that time a CT was\n negative for PE but showed bilateral bibasilar consolidations vs\n atelectasis. At that time an ABG was 7.20/89/57 (unknown FIO2 but\n likely >6L facemask). She was intubated on at 08:40. The\n respiratory failure was thought likely to be related to pain med\n induced hypoventilation, bronchospasm, or restricted breathing due\n to the back brace. The hospital course was complicated by\n difficulty weaning form the ventilator. Her periodic agitation was\n managed with seroquel. Prior to transfer her vent settings were: SIMV\n 12x600 FIO2 0.45.\n The neurosurgery service evaluated her and recommended concervative\n management of her fracture including a back brace and outpatient\n neurosurgery followup. The CT chest showed notable narrowing of her\n central airways and the patient was referred for Interventional\n Pulmonary evaluation for airway stenting.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt O2Sats down 80-90\ns upon arrival, ABG\ns showed PaO2 61%, pt up to\n 100%Fio2, bilat rhonchi, Dim bases, suct for mod thick tan secretions;\n copious oral secretions; pt RR with care, breathing against vent\n Action:\n FIO2 increased 100%, weaning down as tolerated; sedation increased for\n ventilation\n Response:\n Pt O2Sats 98-100%\n Plan:\n ABG\ns, VS; Wean Fio2 as tolerated; CXRAY; cont with sedation\n for improved ventilation\n Fracture, other\n Assessment:\n pt s/p fall---T7 fracture/no surgical intervention\n Action:\n pt on log roll precautions, reverse t @30 degrees\n Response:\n pt tolerating turns well, no s/sx pain with care\n Plan:\n f/u with PT consult, cont log roll precautions\n Hypernatremia (high sodium)\n Assessment:\n Na 150\n Action:\n pt to receive D5W @50 X1L, TF started with 150 free water flushes every\n 4hrs\n Response:\n TF @ 10, no residual noted repeat labs in am\n Plan:\n labs, cont with free water flushes\n Anemia, other\n Assessment:\n HCT 30, down from 40 upon admission to OSH\n Action:\n No s/sx of bleeding noted,\n Response:\n Plan:\n hct, quiac stools\n"},{"category":"Nursing","chartdate":"2167-09-20 00:00:00.000","description":"Nursing Progress Note","row_id":634116,"text":"55 year old woman with hx of obesity presented to Medical Center\n on after falling down stairs while at home. She suffered a\n traumatic T5-8 fracture with retropulsion of fragments. Per medical\n records and discussion with her brother, she was awake for the fall (no\n LOC) and the fall was triggered by unsteady gait, potentially\n influenced by alcohol. Her fracture was managed concervatively. She\n was placed in a torso brace but her course was complicated by\n respiratory failure requiring intubation. At that time a CT was\n negative for PE but showed bilateral bibasilar consolidations vs\n atelectasis. At that time an ABG was 7.20/89/57 (unknown FIO2 but\n likely >6L facemask). She was intubated on at 08:40. The\n respiratory failure was thought likely to be related to pain med\n induced hypoventilation, bronchospasm, or restricted breathing due\n to the back brace. The hospital course was complicated by\n difficulty weaning form the ventilator. Her periodic agitation was\n managed with seroquel. Prior to transfer her vent settings were: SIMV\n 12x600 FIO2 0.45.\n The neurosurgery service evaluated her and recommended concervative\n management of her fracture including a back brace and outpatient\n neurosurgery followup. The CT chest showed notable narrowing of her\n central airways and the patient was referred for Interventional\n Pulmonary evaluation for airway stenting.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt O2Sats down 80-90\ns upon arrival, ABG\ns showed PaO2 61%, pt up to\n 100%Fio2, bilat rhonchi, Dim bases, suct for mod thick tan secretions;\n copious oral secretions; pt RR with care, breathing against vent\n Action:\n FIO2 increased 100%, weaning down as tolerated; sedation increased for\n ventilation\n Response:\n Pt O2Sats 98-100%\n Plan:\n ABG\ns, VS; Wean Fio2 as tolerated; CXRAY; cont with sedation\n for improved ventilation\n Fracture, other\n Assessment:\n pt s/p fall---T7 fracture/no surgical intervention\n Action:\n pt on log roll precautions, reverse t @30 degrees\n Response:\n pt tolerating turns well, no s/sx pain with care\n Plan:\n f/u with PT consult, cont log roll precautions:\n Hypernatremia (high sodium)\n Assessment:\n Na 150\n Action:\n pt to receive D5W @50 X1L, TF started with 150 free water flushes every\n 4hrs\n Response:\n TF @ 10, no residual noted repeat labs in am\n Plan:\n labs, cont with free water flushes\n Anemia, other\n Assessment:\n HCT 30, down from 40 upon admission to OSH\n Action:\n No s/sx of bleeding noted,\n Response:\n Plan:\n hct, quiac stools\n"},{"category":"Physician ","chartdate":"2167-09-20 00:00:00.000","description":"Physician Resident Progress Note","row_id":634117,"text":"Chief Complaint:\n 24 Hour Events:\n -cultured for fever to 102.7 at 4:00 am\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.3\nC (102.7\n Tcurrent: 39.3\nC (102.7\n HR: 89 (72 - 97) bpm\n BP: 96/41(55) {96/41(55) - 154/71(103)} mmHg\n RR: 12 (12 - 18) insp/min\n SpO2: 95%\n Total In:\n 10 mL\n 232 mL\n PO:\n TF:\n IVF:\n 10 mL\n 232 mL\n Blood products:\n Total out:\n 425 mL\n 570 mL\n Urine:\n 425 mL\n 570 mL\n NG:\n Stool:\n Drains:\n Balance:\n -416 mL\n -338 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 32 cmH2O\n SpO2: 95%\n ABG: 7.42/47/61/30/4\n Ve: 8 L/min\n PaO2 / FiO2: 102\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 333 K/uL\n 9.7 g/dL\n 103 mg/dL\n 0.6 mg/dL\n 30 mEq/L\n 3.8 mEq/L\n 6 mg/dL\n 109 mEq/L\n 150 mEq/L\n 30.7 %\n 9.7 K/uL\n [image002.jpg]\n 11:54 PM\n 01:00 AM\n WBC\n 9.7\n Hct\n 30.7\n Plt\n 333\n Cr\n 0.6\n TCO2\n 32\n Glucose\n 103\n Other labs: PT / PTT / INR:13.8/22.4/1.2, ALT / AST:30/19, Alk Phos / T\n Bili:149/0.7, Differential-Neuts:76.9 %, Lymph:17.3 %, Mono:3.0 %,\n Eos:2.5 %, Albumin:3.0 g/dL, LDH:222 IU/L, Ca++:8.6 mg/dL, Mg++:2.1\n mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n A/P: 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture\n # Respiratory failure: initially likely multifactorial including\n bronchspasm, hypoventilation from narcotics, and potential aspiration.\n prior evaluation negative for PE. still with significant A-a gradient.\n cxr appears under penetrated with small lung fields and potential\n effusion on right. potentially from additional pulmonary edema, however\n hypernatremia would limit ability to diurese.\n - daily chest xray\n - will hold on CT chest or airway pending IP consult\n - IP consult\n - vent settings: AC 500 x14 PEEP >8 (given body habitus), FIO2 as\n needed\n - sedation: fentanyl gtt/versed bolus\n - trial of diuresis when able\n # Spine fracture: neurologically intact distal to the lesion. prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - monitor distal neurologic function\n - cto brace x3 months unless supine in bed\n # Anemia: admission to MMC was ~40 now down to 30% w/o sign of active\n GI bleed or other source of blood loss. likely related to crystalloid\n administration, anemia of inflammation, chronic phlebotomy. given bili\n and LDH normal would be unlikely for hemolysis.\n - trend Hct\n - guaiac stools\n Hypernatremia: most likely related to inadequate free water repletion.\n free water defecit ~3L.\n - replete via OGT primarily\n - D5W x1 L\n ICU Care\n Nutrition:\n Comments: tube feed with free water\n nutrition consult\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 10:30 PM\n 18 Gauge - 10:30 PM\n 20 Gauge - 01:36 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Family meeting held , ICU consent signed Comments: \n (brother) \n (boyfriend/POA) \n Code status: Full code\n Disposition: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 10:30 PM\n 20 Gauge - 01:36 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Nursing","chartdate":"2167-09-20 00:00:00.000","description":"Nursing Progress Note","row_id":634136,"text":"55 year old woman with hx of obesity presented to Medical Center\n on after falling down stairs while at home. She suffered a\n traumatic T5-8 fracture with retropulsion of fragments. Per medical\n records and discussion with her brother, she was awake for the fall (no\n LOC) and the fall was triggered by unsteady gait, potentially\n influenced by alcohol. Her fracture was managed concervatively. She\n was placed in a torso brace but her course was complicated by\n respiratory failure requiring intubation. At that time a CT was\n negative for PE but showed bilateral bibasilar consolidations vs\n atelectasis. At that time an ABG was 7.20/89/57 (unknown FIO2 but\n likely >6L facemask). She was intubated on at 08:40. The\n respiratory failure was thought likely to be related to pain med\n induced hypoventilation, bronchospasm, or restricted breathing due\n to the back brace. The hospital course was complicated by\n difficulty weaning form the ventilator. Her periodic agitation was\n managed with seroquel. Prior to transfer her vent settings were: SIMV\n 12x600 FIO2 0.45.\n The neurosurgery service evaluated her and recommended concervative\n management of her fracture including a back brace and outpatient\n neurosurgery followup. The CT chest showed notable narrowing of her\n central airways and the patient was referred for Interventional\n Pulmonary evaluation for airway stenting.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt O2Sats down 80-90\ns upon arrival, ABG\ns showed PaO2 61%, pt up to\n 100%Fio2, bilat rhonchi, Dim bases, suct for mod thick tan secretions;\n copious oral secretions; pt RR with care, breathing against vent\n Action:\n FIO2 increased 100%, weaning down as tolerated; sedation increased for\n ventilation\n Response:\n Pt O2Sats 98-100%\n Plan:\n ABG\ns, VS; Wean Fio2 as tolerated; CXRAY; cont with sedation\n for improved ventilation\n Fracture, other\n Assessment:\n pt s/p fall---T7 fracture/no surgical intervention\n Action:\n pt on log roll precautions, reverse t @30 degrees\n Response:\n pt tolerating turns well, no s/sx pain with care\n Plan:\n f/u with PT consult, cont log roll precautions:\n Hypernatremia (high sodium)\n Assessment:\n Na 150\n Action:\n pt to receive D5W @50 X1L, TF started with 150 free water flushes every\n 4hrs\n Response:\n TF @ 10, no residual noted repeat labs in am\n Plan:\n labs, cont with free water flushes\n Anemia, other\n Assessment:\n HCT 30, down from 40 upon admission to OSH\n Action:\n No s/sx of bleeding noted,\n Response:\n Plan:\n hct, quiac stools\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Pt TMax 102.6 orally @ 0400\n Action:\n BC X1 obtained, sputum cx, pt recvd APAP 650mg\n Response:\n Pt down 99.8 orally\n Plan:\n Obtain second set cultures, urine cultures; start IV Abx as ordered,\n administer APAP as ordered\n"},{"category":"Nursing","chartdate":"2167-09-22 00:00:00.000","description":"Nursing Progress Note","row_id":634325,"text":"55 yr old women admitted from outside hospital. Patient fell down\n stairs at home per boyfriend pt with fracture and placed in torso\n brace at OSH, pt became hypoxic and was intubated (family requested a\n second opinion and pt was trans to ) Pt admitted for Resp failure,\n failure to wean, and ? tracheal bronchial malacia. Full code,\n Allergies: PCN, Tetracycline, Sulfta. Pt on log roll precautions for\n spine.\n Per boyfriend tonight he reported that for the last two months pt has\n been drinking 2 bottles of wine almost every night.\n And that this is an increase from what she previously did which was a\n couple of beers per night.\n Alteration in Nutrition\n Assessment:\n Increase in residuals out of OG tube. Tube feeds have not been\n restarted. Bowel sounds hypoactive, per family abdomen is about 30%\n larger than normal, no BM since admission.\n Action:\n Senna and colace given. OG tube to low int. suction, was able to clamp\n tube for 2hr but residuals returned.\n Response:\n 100 ml yellow-pinkish fluid out OG tube\n Plan:\n Cont to check residuals, restart tube feeds as tolerated, ? if raglan\n would help. Increase bowel regimen if needed.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n DVT in RUE\n Action:\n No BP or blood draws in RUE. Neuro to see pt in AM to see if we\n can start heparin gtt (neuro to okay because of the spine\n fracture)\n Response:\n Plan:\n Wait for decision by Neuro and anticoagulate with heparin if\n possible.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n T-max for this shift 100.5\n Action:\n Pt on Vanco, Aztreonam, Levoflaxacin, Flagyl., pt blood from\n central/A-line/peripheral drawn, urine also sent\n Response:\n Pt went down to 99.2 without any Tylenol\n Plan:\n Cont to monitor Temp, cont antibiotics, follow up cultures, re-culture\n if pt does spike temp again.\n Fracture, other\n Assessment:\n Reported that pt has a T5-T8 spinal fracture, Wet read from yesterdays\n CT may show just a T-9 compression, still waiting for the true results\n of this CT.\n Action:\n Log roll pt, pt increased with reverse trandelenburg positionsing,\n back brace in room if pt OOB.\n Response:\n Pt not tolerating turning\n Plan:\n Consult with neuro /wait for true CT scan results to know if spine\n is actually fractured or not and if not ? removing spine precautions.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lung sounds clear/diminished, ? VAP and possibly ARDS on top of that.\n small amounts thick yellow secretions, vent setting changed during the\n night. Pt desats to 80% with turning and takes a long time to\n recover. Face becomes blue/purple. On ARDS type vent settings\n Action:\n Did not turn pt during the night, Vent setting changed during night\n currently CMV 80%/400/22/17. cont suctioning/oral care/ subglottal\n suctioning. Resp tried to place esophageal balloon again tonight\n Response:\n Small secretions out of in-line suction. Last ABG better at 7.38/41/87,\n esophageal balloon placement unsuccessful\n Plan:\n ? if team will have respiratory try to place esophageal balloon again,\n wean vent as tolerated. Cont ABG\ns with vent changes.\n Hypotension (not Shock)\n Assessment:\n Pt received on 0.04 mcg/kg/min of norepi gtt.\n Action:\n Weaned gtt off in early evening but MAPs dropped <65\n Response:\n Turned norepi gtt back on at 0.02 mg/kg/min\n Plan:\n Cont to wean norepi gtt as tolerated.\n Goals: switch pt to air mattress bed if okayed by neuro that pt\n can be moved, start heparin gtt for RUE DVT if neuro okays. Wean\n norepi gtt. Restart Tube feeds when tolerates, ? if team will try to\n float esophageal balloon again.\n"},{"category":"Respiratory ","chartdate":"2167-09-22 00:00:00.000","description":"Respiratory Care Shift Note","row_id":634326,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 4\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7mm\n Manufacturer:\n Size:\n PMV:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Comments: Pt was received on AC settings 400x 22 peep 17 and 70%. Pt\n peep and fio2 was increased by MD d/t significant oxygen desaturation.\n Recruitment maneuver was done with good results. Abgs post maneuver\n 7.38/41/87. Pt spo2 remained stable through the night. Attempt to\n insert Esophageal balloon without success. Will await sedation order\n from MD.\n"},{"category":"Physician ","chartdate":"2167-09-21 00:00:00.000","description":"Physician Resident Progress Note","row_id":634250,"text":"Chief Complaint:\n 24 Hour Events:\n Removed PICC line because RUE was noted to be warm and erythematous;\n ultrasound revealed DVT. No definitive treatment was started given\n difficulty obtaining central venous access.\n Multiple attempts at central access; tried left and then right.\n Acute episode of oxygen desat during first central line attempt. Pt\n recovered, however, increased FiO2.\n Decreased UOP (10-30mL/hr) and hypotension overnight. However,\n lactate remains low. Originally, hypotension resolved with fluid\n boluses however by early am, oliguria was persistent despite bolus.\n Placed art line x 2. NBP and ABP similar\n mini- BAL, sputum, urine, blood cultures pending. Yesterday, started\n on levofloxicin and aztreonam instead of cefepime. Switched due to\n question of PCN allergy\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 09:30 AM\n Metronidazole - 12:00 AM\n Vancomycin - 01:00 AM\n Aztreonam - 04:00 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 150 mcg/hour\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:00 AM\n Midazolam (Versed) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (100.9\nF at 10am on )\n Tcurrent: 37.3\nC (99.2\n HR: 76 (71 - 116) bpm\n BP: 116/51(70) {60/46(54) - 146/71(91)} mmHg\n RR: 18 (12 - 24) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 94.2 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 5,600 mL\n 1,811 mL\n PO:\n TF:\n 120 mL\n IVF:\n 4,700 mL\n 1,511 mL\n Blood products:\n Total out:\n 798 mL\n 110 mL\n Urine:\n 798 mL\n 110 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,802 mL\n 1,701 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 80%\n RSBI Deferred: PEEP > 10\n PIP: 36 cmH2O\n Plateau: 25 cmH2O\n SpO2: 93%\n ABG: 7.45/42/95./28/4\n Ve: 9.5 L/min\n PaO2 / FiO2: 120\n Physical Examination\n Gen: Appears uncomfortable on vent.\n HEENT: Pupils 3 mm non-reactive bilaterally. Scleral edema bilat\n Resp: Symmetric expansion. Vesicular sounds throughout. Inspiratory\n and expiratory tracheal sounds (?related to ET tube).\n CV: RRR.\n Abd: Hypoactive bowel sounds. Distended. Non-tender.\n Ext: Edema in bilat UE, especially right hand.\n Peripheral vascular: Radial pulses 2+ bilaterally.\n Neuro: Moving all 4 extremities.\n Labs / Radiology\n 319 K/uL\n 7.6 g/dL\n 129 mg/dL\n 0.6 mg/dL\n 28 mEq/L\n 4.3 mEq/L\n 6 mg/dL\n 109 mEq/L\n 144 mEq/L\n 24.1 %\n 6.4 K/uL\n [image002.jpg]\n 11:54 PM\n 01:00 AM\n 06:14 AM\n 08:56 AM\n 08:57 AM\n 05:01 PM\n 08:03 PM\n 11:00 PM\n 03:01 AM\n 03:13 AM\n WBC\n 9.7\n 9.4\n 7.6\n 6.4\n Hct\n 30.7\n 25.1\n 24.1\n 24.1\n Plt\n 333\n 281\n 306\n 319\n Cr\n 0.6\n 0.6\n 0.7\n 0.6\n 0.6\n TCO2\n 32\n 33\n 35\n 33\n 30\n Glucose\n 103\n 126\n 126\n 127\n 129\n Other labs: PT / PTT / INR:16.9/26.3/1.5, ALT / AST:27/18, Alk Phos / T\n Bili:113/0.7, Differential-Neuts:76.9 %, Lymph:17.3 %, Mono:3.0 %,\n Eos:2.5 %, Lactic Acid:0.7 mmol/L, Albumin:2.3 g/dL, LDH:154 IU/L,\n Ca++:8.2 mg/dL, Mg++:2.6 mg/dL, PO4:3.1 mg/dL\n RUE ultrasound:\n - Non-occlusive right axillary deep vein thrombus\n - Non-occlusive right basilic superficial thrombosis.\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture\n # Respiratory failure: initial etiology unclear, likely multifactorial\n including bronchspasm, hypoventilation from narcotics, potential\n aspiration, infection. By report, had a neg evaluation for PE at OSH,\n however, unable to open disc to confirm. Concern for VAP.\n - Failed yesterday\ns NIF; score was -15\n - Increased FiO2 overnight. Had increased pCO2 which resolved with\n increasing RR\n - IP stopped by but will complete official consult today; suggested\n repeating CT scan\n - Need to contact Medical re previous CT scan. Can attempt to\n resend disc. Otherwise, will most likely benefit from repeat CT to\n look for acute pulm process such as PE or PNA.\n # Fever: Likely due to combination of infection and DVT. Cultures\n sent. Will treat with empiric antibiotics. Tylenol PRN for fever.\n - Known RUE DVT\n - Infectious etiologies include VAP, asp PNA, line infections. Removed\n PICC yesterday and cultured tip. Mini-BAL- gram stain neg. Sputum\n grew GPC in pairs and GPR. Flagyl, aztreonam, vancomycin, levofloxacin\n for coverage of gram positives, gram negatives, anaerobes, MRSA. Urine\n and blood cultures NGTD\n - f/u blood, urine, and sputum cultures.\n - Concern for abd cause; KUB unrevealing. High residuals. require\n further imaging\n # Transient hypotension: Has been somewhat fluid responsive; UOP \n ccs/hr. Diff dx includes hypovolemia, sepsis, cardiogenic.\n - Sepsis most likely given fever.\n - HCT decreasing; ? stable at 24-25\n - Unable to place central line despite multiple attempts. First tired\n left IJ RUE DVT. 2^nd attempt in left IJ. Can place femoral if pt\n requires more active repletion\n - Consider another attempt at a line.\n # Oliguria:\n -BUN and Cr as well as lactate reassuring.\n -Increased bladder pressures this am- 20. Further imaging may be\n helpful\n # RUE DVT: Have held on starting treatment in light of need for central\n access. Can start therapeutic heparin vs Lovenox with bridge to\n coumadin.\n -Can consider rescanning for PE. High risk for PE given UE DVT.\n # Abd distention:\n -KUB unrevealing\n -High residuals\n - benefit from further imaging; if unstable consider ultrasound,\n however, if pt can tolerate it, a CT scan might be more helpful. Can\n also scan chest and pelvis.\n # Anemia: On admission to Medical Center, Hct was ~40, now down\n to 30 and then 25 w/o sign of active GI bleed or other source of blood\n loss. be related to fluid administration, phlebotomy, anemia of\n inflammation, active bleed still considered in differential.\n - trend Hct\n - guaiac stools\n - S/p failed attempts at line placement; watch for neck hematomas\n - INR elev at 1.5. ? may be related to poor nutrition as albumin is\n 2.3\n # Spine fracture: neurologically intact distal to the lesion. prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - Need to talk to neurosurg to see if pt can tolerate a CT scan as well\n as the risks of anticoag for DVT\n - monitor distal neurologic function\n - cto brace x3 months unless supine in bed\n - consult neurosurgery for further recs\n # Hypernatremia: correcting with g tube free flush and D5W\n -Holding on g tube feeds at present due to high residuals\n -Replete lytes as necessary\n ICU Care\n Nutrition: tube feed with free water\n Glycemic Control: Regular insulin sliding scale\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Communication: Family meeting held , ICU consent signed, \n (brother) (boyfriend/POA) \n Code status: Full code\n Disposition: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 01:16 AM\n 20 Gauge - 01:36 AM\n 22 Gauge - 02:00 PM\n Arterial Line - 03:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Nursing","chartdate":"2167-09-21 00:00:00.000","description":"Nursing Progress Note","row_id":634263,"text":"Alteration in Nutrition\n Assessment:\n Pt NPO, Pt w/ high residuals yesterday. Abdomen distended/obese/soft.\n BS hypoactive. Low albumin.\n Action:\n OGT to low wall suction. TF off.\n Response:\n Small amount of gastric fluid suctioned- approx 30cc-50cc.\n Plan:\n Plan for CT of Abdomen, cont NPO at this time.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n RUE + DVT\n Action:\n Cont on sq heparin\n Response:\n No change\n Plan:\n Consult neuro-surgery regarding anti-coagulation w/ T-spine fx, elevate\n RUE, no blood draws or blood pressures to RUE.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Temp max 100\n Action:\n Antibiotics given and dosage changed to vanco and aztreonam.\n Response:\n No further temp spike.\n Plan:\n Cont w/ antibiotics, f/u on cultures, tyelenol prn, vanco trough to be\n drawn prior to evening dose.\n Fracture, other\n Assessment:\n T-spine compression fx, Back brace at bedside when OOB.\n Action:\n Ortho tech consulted for placement of back brace. Cont w/ log roll\n precautions.\n Response:\n Pt denies c/o pain when asked.\n Plan:\n Cont w/ log roll precautions, back brace for OOB, CT scan, consult w/\n neurosurg.\n Anemia, other\n Assessment:\n HCT 24.1 from 28\n Action:\n Given 1 unit of PRBCs\n Response:\n HCT to be drawn.\n Plan:\n Cont to follow HCTs, guiac stools, monitor of s/s of bleeding.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS bronchial, deep sxn\nd for thick/tan secretions, copious clear\n secretions suctioned from mouth, PO2 68% on 70% FIO2 and 12 peep.\n Action:\n Vent changes made throughout shift.\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Pt hypotensive into low-mid 80s systolic, HR 70s-90s. Low uop- bladder\n pressure 18-20.\n Action:\n Vigeleo set up, given 1 unit of blood, bloused x 1, multi-lumen RIJ\n placed at bedside.\n Response:\n No response to blusing, SBP improved following blood transfusion, RIJ\n okay to use. CVP 18.\n Plan:\n Levophed to be started if needed, transfuse as needed.\n"},{"category":"Nursing","chartdate":"2167-09-21 00:00:00.000","description":"Nursing Progress Note","row_id":634264,"text":"55-year-old woman with\n Respiratory failure\n Traumatic thoracic spinal fractures\n Probable VAP\n Upper extremity DVT\n Oliguria\n Anemia\n * Possible tracheobronchomalacia (reason for transfer\n Alteration in Nutrition\n Assessment:\n Pt NPO, Pt w/ high residuals yesterday. Abdomen distended/obese/soft.\n BS hypoactive. Low albumin.\n Action:\n OGT to low wall suction. TF off.\n Response:\n Small amount of gastric fluid suctioned- approx 30cc-50cc.\n Plan:\n Plan for CT of Abdomen, cont NPO at this time.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n RUE + DVT\n Action:\n Cont on sq heparin\n Response:\n No change\n Plan:\n Consult neuro-surgery regarding anti-coagulation w/ T-spine fx, elevate\n RUE, no blood draws or blood pressures to RUE.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Temp max 100\n Action:\n Antibiotics given and dosage changed to vanco and aztreonam.\n Response:\n No further temp spike.\n Plan:\n Cont w/ antibiotics, f/u on cultures, tyelenol prn, vanco trough to be\n drawn prior to evening dose.\n Fracture, other\n Assessment:\n T-spine compression fx, Back brace at bedside when OOB.\n Action:\n Ortho tech consulted for placement of back brace. Cont w/ log roll\n precautions.\n Response:\n Pt denies c/o pain when asked.\n Plan:\n Cont w/ log roll precautions, back brace for OOB, CT scan, consult w/\n neurosurg.\n Anemia, other\n Assessment:\n HCT 24.1 from 28\n Action:\n Given 1 unit of PRBCs\n Response:\n HCT to be drawn.\n Plan:\n Cont to follow HCTs, guiac stools, monitor of s/s of bleeding.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS bronchial, deep sxn\nd for thick/tan secretions, copious clear\n secretions suctioned from mouth, PO2 68% on 70% FIO2 and 12 peep.\n Action:\n Vent changes made throughout shift.\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Pt hypotensive into low-mid 80s systolic, HR 70s-90s. Low uop- bladder\n pressure 18-20.\n Action:\n Vigeleo set up, given 1 unit of blood, bloused x 1, multi-lumen RIJ\n placed at bedside.\n Response:\n No response to blusing, SBP improved following blood transfusion, RIJ\n okay to use. CVP 18.\n Plan:\n Levophed to be started if needed, transfuse as needed.\n"},{"category":"Nursing","chartdate":"2167-09-21 00:00:00.000","description":"Nursing Progress Note","row_id":634265,"text":"55-year-old woman with\n Respiratory failure\n Traumatic thoracic spinal fractures\n Probable VAP\n Upper extremity DVT\n Oliguria\n Anemia\n * Possible tracheobronchomalacia (reason for transfer\n Alteration in Nutrition\n Assessment:\n Pt NPO, Pt w/ high residuals yesterday. Abdomen distended/obese/soft.\n BS hypoactive. Low albumin.\n Action:\n OGT to low wall suction. TF off.\n Response:\n Small amount of gastric fluid suctioned- approx 30cc-50cc.\n Plan:\n Plan for CT of Abdomen, cont NPO at this time.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n RUE + DVT\n Action:\n Cont on sq heparin\n Response:\n No change\n Plan:\n Consult neuro-surgery regarding anti-coagulation w/ T-spine fx, elevate\n RUE, no blood draws or blood pressures to RUE.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Temp max 100\n Action:\n Antibiotics given and dosage changed to vanco and aztreonam.\n Response:\n No further temp spike.\n Plan:\n Cont w/ antibiotics, f/u on cultures, tyelenol prn, vanco trough to be\n drawn prior to evening dose.\n Fracture, other\n Assessment:\n T-spine compression fx, Back brace at bedside when OOB.\n Action:\n Ortho tech consulted for placement of back brace. Cont w/ log roll\n precautions.\n Response:\n Pt denies c/o pain when asked.\n Plan:\n Cont w/ log roll precautions, back brace for OOB, CT scan, consult w/\n neurosurg.\n Anemia, other\n Assessment:\n HCT 24.1 from 28\n Action:\n Given 1 unit of PRBCs\n Response:\n HCT to be drawn.\n Plan:\n Cont to follow HCTs, guiac stools, monitor of s/s of bleeding.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS- bronchial throughout, deep sxn\nd for thick/tan secretions, copious\n clear oral secretions suctioned, PO2 68% on 70% FIO2 and 12 peep. ?\n PE/? VAP.\n Action:\n Vent changes made throughout shift.\n Response:\n Plan:\n Esophageal balloon placement to be performed, monitor ABGs, vent\n changes as needed.\n Hypotension (not Shock)\n Assessment:\n Pt hypotensive into low-mid 80s systolic, HR 70s-90s. Low uop-\n BUN/Creat negative. Bladder pressure 18-20.\n Action:\n Vigeleo set up, given 1 unit of blood, bloused x 1, multi-lumen RIJ\n placed at bedside.\n Response:\n No response to blusing, SBP improved following blood transfusion, RIJ\n okay to use. CVP 18.\n Plan:\n Levophed to be started if needed, transfuse as needed.\n"},{"category":"Nursing","chartdate":"2167-09-23 00:00:00.000","description":"Nursing Progress Note","row_id":634388,"text":"Respiratory failure, acute (not ARDS/)\n Assessment:\n RLL consolidation, bilat effusions, R < L ; suct for thick yellowish\n secretions from ETT; copious thick secretions suct from mouth\n Action:\n Pt 2 down to 60%, Peep @ 23\n Response:\n Pt tolerating turns and current vent settings well\n Plan:\n Cont to ABGS, VS;\n Hypotension (not Shock)\n Assessment:\n SBP down in 80\ns, MAP 60\n Action:\n Levophed restarted @0130\n Response:\n BP improved 110-90\ns MAP 65\n Plan:\n Cont to BP, MAP goal >65 , Levo as needed\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt (+) DVT RUE\n Action:\n Pt started on IV Heparin @1700U/hr\n Response:\n Pt PTT@ 0030 62.7, no changes to infusion\n Plan:\n Cont to PTT, adjust heparin accordingly; cont with no BP/LAB draws\n to R arm\n Alteration in Nutrition\n Assessment:\n TF currently on hold high residuals, abd distended soft, hypoactive\n bowel sounds\n Action:\n Pt started on Naloxone x 3 doses, rectal tube in place for\n decompression; bowel regimen continued\n Response:\n Pt passing sm. Amt loose green stool with dose of Naxolone\n Plan:\n Re-evaluate for increase in Naloxone dose; ? restarting TF/advancing\n Fracture, other\n Assessment:\n Pt T5/T8 fracture s/p fall \n Action:\n Spine/ortho consult done\n Response:\n Pt off logroll precautions, tolerates position changes\n Plan:\n Activity as tolerated, needs to wear TorsoBrace when OOB or sitting up\n"},{"category":"Nursing","chartdate":"2167-09-23 00:00:00.000","description":"Nursing Progress Note","row_id":634389,"text":"55 yr old women admitted from outside hospital. Patient fell down\n stairs at home per boyfriend pt with fracture and placed in torso\n brace at OSH, pt became hypoxic and was intubated (family requested a\n second opinion and pt was trans to ) Pt admitted for Resp failure,\n failure to wean, and ? tracheal bronchial malacia. Full code,\n Allergies: PCN, Tetracycline, Sulfta.\n Per boyfriend tonight he reported that for the last two months pt has\n been drinking 2 bottles of wine almost every night.\n And that this is an increase from what she previously did which was a\n couple of beers per night.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n RLL consolidation, bilat effusions, R < L ; suct for thick yellowish\n secretions from ETT; copious thick secretions suct from mouth\n Action:\n Pt 2 down to 60%, Peep @ 23\n Response:\n Pt tolerating turns and current vent settings well\n Plan:\n Cont to ABGS, VS;\n Hypotension (not Shock)\n Assessment:\n SBP down in 80\ns, MAP 60\n Action:\n Levophed restarted @0130\n Response:\n BP improved 110-90\ns MAP 65\n Plan:\n Cont to BP, MAP goal >65 , Levo as needed\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt (+) DVT RUE\n Action:\n Pt started on IV Heparin @1700U/hr\n Response:\n Pt PTT@ 0030 62.7, no changes to infusion\n Plan:\n Cont to PTT, adjust heparin accordingly; cont with no BP/LAB draws\n to R arm\n Alteration in Nutrition\n Assessment:\n TF currently on hold high residuals, abd distended soft, hypoactive\n bowel sounds\n Action:\n Pt started on Naloxone x 3 doses, rectal tube in place for\n decompression; bowel regimen continued\n Response:\n Pt passing sm. Amt loose green stool with dose of Naxolone\n Plan:\n Re-evaluate for increase in Naloxone dose; ? restarting TF/advancing\n Fracture, other\n Assessment:\n Pt T5/T8 fracture s/p fall \n Action:\n Spine/ortho consult done\n Response:\n Pt off logroll precautions, tolerates position changes\n Plan:\n Activity as tolerated, needs to wear TorsoBrace when OOB or sitting up\n"},{"category":"Physician ","chartdate":"2167-09-23 00:00:00.000","description":"Physician Resident Progress Note","row_id":634393,"text":"Chief Complaint:\n 24 Hour Events:\n ESOPHOGEAL BALLOON - At 01:46 PM - went well, were able to\n increase PEEP to improve oxygenation\n - started naloxone to encourage bowel motility, with some success,\n rectal tube in place\n -started heparin gtt for RUE DVT\n -borderline hypotensive at times (low 90s), received boluses and norepi\n back on at 0.04\n -did well with 0/7 yesterday and overnight with prn fentanyl for\n pain and prn haldol for agitation (did not require haldol), back on 0/7\n this am\n -gave extra dose metoprolol 25 via OG\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 09:45 AM\n Metronidazole - 03:32 PM\n Vancomycin - 08:00 PM\n Aztreonam - 10:00 PM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Heparin Sodium - 1,700 units/hour\n Fentanyl - 100 mcg/hour\n Norepinephrine - 0.04 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38\nC (100.4\n Tcurrent: 37.3\nC (99.2\n HR: 73 (60 - 102) bpm\n BP: 90/46(61) {76/38(56) - 160/71(97)} mmHg\n RR: 23 (16 - 25) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101 kg (admission): 94.2 kg\n Height: 67 Inch\n CVP: 8 (8 - 15)mmHg\n Bladder pressure: 18 (18 - 21) mmHg\n Total In:\n 3,524 mL\n 234 mL\n PO:\n TF:\n 48 mL\n IVF:\n 3,236 mL\n 234 mL\n Blood products:\n Total out:\n 935 mL\n 215 mL\n Urine:\n 650 mL\n 215 mL\n NG:\n 285 mL\n Stool:\n Drains:\n Balance:\n 2,589 mL\n 19 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 0 (0 - 0) mL\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 23 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 42 cmH2O\n Plateau: 32 cmH2O\n Compliance: 44.4 cmH2O/mL\n SpO2: 100%\n ABG: 7.36/47/153//0\n Ve: 9.5 L/min\n PaO2 / FiO2: 255\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 376 K/uL\n 9.0 g/dL\n 120 mg/dL\n 0.6 mg/dL\n 24 mEq/L\n 3.7 mEq/L\n 4 mg/dL\n 108 mEq/L\n 141 mEq/L\n 28.1 %\n 8.4 K/uL\n [image002.jpg]\n 03:01 AM\n 03:13 AM\n 12:05 PM\n 06:08 PM\n 06:11 PM\n 07:53 PM\n 02:02 AM\n 03:59 AM\n 09:14 PM\n 01:04 AM\n WBC\n 6.4\n 8.4\n Hct\n 24.1\n 29.0\n 28.1\n Plt\n 319\n 376\n Cr\n 0.6\n 0.6\n TCO2\n 30\n 29\n 29\n 25\n 25\n 28\n 28\n Glucose\n 129\n 120\n Other labs: PT / PTT / INR:18.7/62.7/1.7, ALT / AST:24/16, Alk Phos / T\n Bili:117/0.7, Amylase / Lipase:, Differential-Neuts:80.8 %,\n Lymph:12.0 %, Mono:3.5 %, Eos:3.3 %, Lactic Acid:0.7 mmol/L,\n Albumin:2.4 g/dL, LDH:204 IU/L, Ca++:8.2 mg/dL, Mg++:2.2 mg/dL, PO4:3.1\n mg/dL\n Assessment and Plan\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture\n # Respiratory failure: initial etiology unclear, likely multifactorial\n now with significant pneumonia. Had one sputum that showed GNR.\n - Had a desat event yesterday. Responded positively to recruitment\n maneuvers.\n - Will attempt placement of an esophageal balloon; with knowledge of\n intrathoracic pressures, can consider going up on PEEP\n # Infectious process: Had been febrile, now resolved\n - be aspiration or be VAP. Sputum from grew rare GNR;\n awaiting speciation.\n - Continues on Vanc, aztreonam, levofloxicin. Vanc trough pending today\n - Also on flagyl for empiric coverage of c. diff\n - Per CT, unlikely to be abdominal process\n # Hypotension, requiring Levophed:\n - Hypovolemia is possibly a factor- responded to a transfusion; HCT had\n been dropping\n - Sepsis also a factor- on broad spectrum abs\n - Central line in place.\n # Oliguria:\n -BUN and Cr reassuring.\n # RUE DVT: Have held on starting treatment in light of need for central\n access. Can start therapeutic heparin vs Lovenox with bridge to\n coumadin.\n - No PE noted on CT scan.\n # Abd distention:\n - CT abd only showed appendiceal mucocele without inflammation, not\n concerning, most likely chronic\n - No BM in several days, continue bowel regimen, add fleets enema\n - Can test for c.diff when pt stool\ns. Continue flagyl empirically\n - Check amylase and lipase\n # Anemia:\n - Trend HCT\n - Gave 1 un pRBC with good results\n - Will guiac stools when she has a BM\n - INR rising, now 1.7, may be nutritional\n # Spine fracture: neurologically intact distal to the lesion. prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - Will have spine see pt today for recs regarding pt movement and\n anticoagulation\n # Hypernatremia, resolved: correcting with g tube free flush and D5W\n -Holding on g tube feeds at present due to high residuals\n -Replete lytes as necessary\n # Communication:\n - Brother has been with pt, although, live in boyfriend of 10 is\n her HCP. Boyfriend will hopefully visit pt today\n ICU Care\n Nutrition: tube feed with free water when able\n Glycemic Control: Regular insulin sliding scale\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Communication: ICU consent signed, (brother) \n (boyfriend/POA) \n Code status: Full code\n Disposition: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 01:36 AM\n Arterial Line - 03:00 AM\n Multi Lumen - 11:30 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2167-09-23 00:00:00.000","description":"Physician Resident Progress Note","row_id":634394,"text":"Chief Complaint:\n 24 Hour Events:\n ESOPHOGEAL BALLOON - At 01:46 PM - went well, were able to\n increase PEEP to improve oxygenation\n - started naloxone to encourage bowel motility, with some success,\n rectal tube in place\n -started heparin gtt for RUE DVT\n -borderline hypotensive at times (low 90s) with low urine output,\n received boluses and norepi back on at 0.04\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 09:45 AM\n Metronidazole - 03:32 PM\n Vancomycin - 08:00 PM\n Aztreonam - 10:00 PM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Heparin Sodium - 1,700 units/hour\n Fentanyl - 100 mcg/hour\n Norepinephrine - 0.04 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38\nC (100.4\n Tcurrent: 37.3\nC (99.2\n HR: 73 (60 - 102) bpm\n BP: 90/46(61) {76/38(56) - 160/71(97)} mmHg\n RR: 23 (16 - 25) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101 kg (admission): 94.2 kg\n Height: 67 Inch\n CVP: 8 (8 - 15)mmHg\n Bladder pressure: 18 (18 - 21) mmHg\n Total In:\n 3,524 mL\n 234 mL\n PO:\n TF:\n 48 mL\n IVF:\n 3,236 mL\n 234 mL\n Blood products:\n Total out:\n 935 mL\n 215 mL\n Urine:\n 650 mL\n 215 mL\n NG:\n 285 mL\n Stool:\n Drains:\n Balance:\n 2,589 mL\n 19 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 0 (0 - 0) mL\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 23 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 42 cmH2O\n Plateau: 32 cmH2O\n Compliance: 44.4 cmH2O/mL\n SpO2: 100%\n ABG: 7.36/47/153//0\n Ve: 9.5 L/min\n PaO2 / FiO2: 255\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 376 K/uL\n 9.0 g/dL\n 120 mg/dL\n 0.6 mg/dL\n 24 mEq/L\n 3.7 mEq/L\n 4 mg/dL\n 108 mEq/L\n 141 mEq/L\n 28.1 %\n 8.4 K/uL\n [image002.jpg]\n 03:01 AM\n 03:13 AM\n 12:05 PM\n 06:08 PM\n 06:11 PM\n 07:53 PM\n 02:02 AM\n 03:59 AM\n 09:14 PM\n 01:04 AM\n WBC\n 6.4\n 8.4\n Hct\n 24.1\n 29.0\n 28.1\n Plt\n 319\n 376\n Cr\n 0.6\n 0.6\n TCO2\n 30\n 29\n 29\n 25\n 25\n 28\n 28\n Glucose\n 129\n 120\n Other labs: PT / PTT / INR:18.7/62.7/1.7, ALT / AST:24/16, Alk Phos / T\n Bili:117/0.7, Amylase / Lipase:, Differential-Neuts:80.8 %,\n Lymph:12.0 %, Mono:3.5 %, Eos:3.3 %, Lactic Acid:0.7 mmol/L,\n Albumin:2.4 g/dL, LDH:204 IU/L, Ca++:8.2 mg/dL, Mg++:2.2 mg/dL, PO4:3.1\n mg/dL\n Assessment and Plan\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture\n # Respiratory failure: initial etiology unclear, likely multifactorial\n now with significant pneumonia. Had one sputum that showed GNR.\n - Had a desat event yesterday. Responded positively to recruitment\n maneuvers.\n - Will attempt placement of an esophageal balloon; with knowledge of\n intrathoracic pressures, can consider going up on PEEP\n # Infectious process: Had been febrile, now resolved\n - be aspiration or be VAP. Sputum from grew rare GNR;\n awaiting speciation.\n - Continues on Vanc, aztreonam, levofloxicin. Vanc trough pending today\n - Also on flagyl for empiric coverage of c. diff\n - Per CT, unlikely to be abdominal process\n # Hypotension, requiring Levophed:\n - Hypovolemia is possibly a factor- responded to a transfusion; HCT had\n been dropping\n - Sepsis also a factor- on broad spectrum abs\n - Central line in place.\n # Oliguria:\n -BUN and Cr reassuring.\n # RUE DVT: Have held on starting treatment in light of need for central\n access. Can start therapeutic heparin vs Lovenox with bridge to\n coumadin.\n - No PE noted on CT scan.\n # Abd distention:\n - CT abd only showed appendiceal mucocele without inflammation, not\n concerning, most likely chronic\n - No BM in several days, continue bowel regimen, add fleets enema\n - Can test for c.diff when pt stool\ns. Continue flagyl empirically\n - Check amylase and lipase\n # Anemia:\n - Trend HCT\n - Gave 1 un pRBC with good results\n - Will guiac stools when she has a BM\n - INR rising, now 1.7, may be nutritional\n # Spine fracture: neurologically intact distal to the lesion. prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - Will have spine see pt today for recs regarding pt movement and\n anticoagulation\n # Hypernatremia, resolved: correcting with g tube free flush and D5W\n -Holding on g tube feeds at present due to high residuals\n -Replete lytes as necessary\n # Communication:\n - Brother has been with pt, although, live in boyfriend of 10 is\n her HCP. Boyfriend will hopefully visit pt today\n ICU Care\n Nutrition: tube feed with free water when able\n Glycemic Control: Regular insulin sliding scale\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Communication: ICU consent signed, (brother) \n (boyfriend/POA) \n Code status: Full code\n Disposition: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 01:36 AM\n Arterial Line - 03:00 AM\n Multi Lumen - 11:30 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Nutrition","chartdate":"2167-09-20 00:00:00.000","description":"Clinical Nutrition Note","row_id":634175,"text":"Subjective\n Intubated & versed.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 170 cm\n 94.2 kg\n 32.4\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 61.2 kg\n 126% based on EDW of 77.2kg\n 65.2kg\n 77.2kg ( adm WT at OSH)\n ?122\n Diagnosis: Tracheobroncheal malacia\n PMH : obesity, GERD, s/p TAH, s/p L THR, s/p appy, ETOH abuse.\n Food allergies and intolerances: none noted in record.\n Pertinent medications: fentanyl, midazolam, colace, heparin, zantac,\n RISS, flagyl.\n Labs:\n Value\n Date\n Glucose\n 126 mg/dL\n 08:57 AM\n Glucose Finger Stick\n 137\n 04:00 PM\n BUN\n 6 mg/dL\n 08:57 AM\n Creatinine\n 0.7 mg/dL\n 08:57 AM\n Sodium\n 147 mEq/L\n 08:57 AM\n Potassium\n 3.5 mEq/L\n 08:57 AM\n Chloride\n 108 mEq/L\n 08:57 AM\n TCO2\n 28 mEq/L\n 08:57 AM\n PO2 (arterial)\n 81. mm Hg\n 06:14 AM\n PCO2 (arterial)\n 53 mm Hg\n 06:14 AM\n pH (arterial)\n 7.39 units\n 06:14 AM\n pH (urine)\n 5.0 units\n 02:46 PM\n CO2 (Calc) arterial\n 33 mEq/L\n 06:14 AM\n Albumin\n 3.0 g/dL\n 01:00 AM\n Calcium non-ionized\n 8.6 mg/dL\n 01:00 AM\n Phosphorus\n 3.8 mg/dL\n 08:57 AM\n Magnesium\n 1.8 mg/dL\n 08:57 AM\n ALT\n 30 IU/L\n 01:00 AM\n Alkaline Phosphate\n 149 IU/L\n 01:00 AM\n AST\n 19 IU/L\n 01:00 AM\n Total Bilirubin\n 0.7 mg/dL\n 08:57 AM\n WBC\n 9.4 K/uL\n 08:57 AM\n Hgb\n 8.2 g/dL\n 08:57 AM\n Hematocrit\n 25.1 %\n 08:57 AM\n Current diet order / nutrition support: NPO. TF: FS Replete w/ Fiber at\n 60mL/hr with 150mL Q 4hrs via OGT.\n GI:\n Assessment of Nutritional Status\n Obese, At risk for malnutrition\n Pt at risk due to: Low protein stores\n Estimated Nutritional Needs based on Est Dry WT of 77.2kg\n Calories: 1300 - 1625 (BEE x or / 20 - 25 cal/kg)\n Protein: 78 - 98 (1.2 - 1.5 g/kg)\n Fluid: per team.\n Specifics:\n 55 YO Female hospitalized at OSH after a fall resulting in traumatic\n T5-8 fracture w/ retropulsion of fragments. Was intubated & was c/b\n difficulty weaning from vent, referred here for interventional pulm\n evaluation for airway stenting. Consulted for TF recs. Currently\n tolerating TF at 10mL/hr. Would recommend decrease current TF goal rate\n to 55mL/hr to feed at 20kcal/kg while intubated otherwise higher\n calories would make it difficult to wean or extubated. Noted documented\n as -3L water deficit upon admission & is being hydrated with IFV\ns but\n is still slightly hypernatremic. Suggest increasing free water boluses\n via OGT.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. Decrease TF goal rate to 55mL/hr of Replete with Fiber\n 2. Continue to advance by 10mL Q 4-6hrs to goal\n 3. check residuals Q 4hrs, hold x 1hr if >150mL\n 4. Adjust free water flushes per hydration\n 5. Monitor & replete lytes PRN\n"},{"category":"Physician ","chartdate":"2167-09-22 00:00:00.000","description":"Physician Resident Progress Note","row_id":634311,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n Neurosurg: ok to transport. Will decide on anticoagulation in AM\n Central line placed\n NGT to suction\n Bowel regimen\n Resperatory attempted to place esophageal ballon, unsuccessful\n Desaturation around 23:00 to low 80s on 400/22/15/0.9 following turn.\n Recruitment maneuver (PEEP to 30) done x2 with good effect, Sat came up\n to 100%. PEEP left at 17\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 10:00 AM\n Aztreonam - 02:00 PM\n Vancomycin - 12:00 AM\n Metronidazole - 12:00 AM\n Infusions:\n Norepinephrine - 0.02 mcg/Kg/min\n Fentanyl - 200 mcg/hour\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:00 AM\n Midazolam (Versed) - 02:20 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 37.6\nC (99.6\n HR: 73 (64 - 96) bpm\n BP: 119/48(69) {85/39(55) - 142/67(91)} mmHg\n RR: 22 (11 - 22) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 94.2 kg (admission): 94.2 kg\n Height: 67 Inch\n CVP: 20 (11 - 21)mmHg\n Bladder pressure: 14 (14 - 18) mmHg\n Total In:\n 3,482 mL\n 465 mL\n PO:\n TF:\n IVF:\n 2,845 mL\n 465 mL\n Blood products:\n 277 mL\n Total out:\n 580 mL\n 65 mL\n Urine:\n 580 mL\n 65 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,902 mL\n 400 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 500) mL\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 17 cmH2O\n FiO2: 80%\n PIP: 33 cmH2O\n Plateau: 30 cmH2O\n Compliance: 30.8 cmH2O/mL\n SpO2: 98%\n ABG: 7.38/41/86./24/0\n Ve: 9.1 L/min\n PaO2 / FiO2: 109\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 376 K/uL\n 9.0 g/dL\n 120 mg/dL\n 0.6 mg/dL\n 24 mEq/L\n 3.7 mEq/L\n 4 mg/dL\n 108 mEq/L\n 141 mEq/L\n 28.1 %\n 8.4 K/uL\n [image002.jpg]\n 08:03 PM\n 11:00 PM\n 03:01 AM\n 03:13 AM\n 12:05 PM\n 06:08 PM\n 06:11 PM\n 07:53 PM\n 02:02 AM\n 03:59 AM\n WBC\n 7.6\n 6.4\n 8.4\n Hct\n 24.1\n 24.1\n 29.0\n 28.1\n Plt\n \n Cr\n 0.6\n 0.6\n 0.6\n TCO2\n 33\n 30\n 29\n 29\n 25\n 25\n Glucose\n 127\n 129\n 120\n Other labs: PT / PTT / INR:18.7/25.4/1.7, ALT / AST:24/16, Alk Phos / T\n Bili:117/0.7, Differential-Neuts:80.8 %, Lymph:12.0 %, Mono:3.5 %,\n Eos:3.3 %, Lactic Acid:0.7 mmol/L, Albumin:2.4 g/dL, LDH:204 IU/L,\n Ca++:8.2 mg/dL, Mg++:2.2 mg/dL, PO4:3.1 mg/dL\n Fluid analysis / Other labs: sputum, stimm\n Imaging:\n Echo\n post recruitment CXR showed deep sulcus but no pnumothorax per rads.\n Assessment and Plan\n comm with fam, vanc dosing\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture\n # Respiratory failure: initial etiology unclear, likely multifactorial\n including bronchspasm, hypoventilation from narcotics, potential\n aspiration, infection. By report, had a neg evaluation for PE at OSH,\n however, unable to open disc to confirm. Concern for VAP.\n - Failed yesterday\ns NIF; score was -15\n - Increased FiO2 overnight. Had increased pCO2 which resolved with\n increasing RR\n - IP stopped by but will complete official consult today; suggested\n repeating CT scan\n - Need to contact Medical re previous CT scan. Can attempt to\n resend disc. Otherwise, will most likely benefit from repeat CT to\n look for acute pulm process such as PE or PNA.\n # Fever: Likely due to combination of infection and DVT. Cultures\n sent. Will treat with empiric antibiotics. Tylenol PRN for fever.\n - Known RUE DVT\n - Infectious etiologies include VAP, asp PNA, line infections. Removed\n PICC yesterday and cultured tip. Mini-BAL- gram stain neg. Sputum\n grew GPC in pairs and GPR. Flagyl, aztreonam, vancomycin, levofloxacin\n for coverage of gram positives, gram negatives, anaerobes, MRSA. Urine\n and blood cultures NGTD\n - f/u blood, urine, and sputum cultures.\n - Concern for abd cause; KUB unrevealing. High residuals. require\n further imaging\n # Transient hypotension: Has been somewhat fluid responsive; UOP \n ccs/hr. Diff dx includes hypovolemia, sepsis, cardiogenic.\n - Sepsis most likely given fever.\n - HCT decreasing; ? stable at 24-25\n - Unable to place central line despite multiple attempts. First tired\n left IJ RUE DVT. 2^nd attempt in left IJ. Can place femoral if pt\n requires more active repletion\n - Consider another attempt at a line.\n # Oliguria:\n -BUN and Cr as well as lactate reassuring.\n -Increased bladder pressures this am- 20. Further imaging may be\n helpful\n # RUE DVT: Have held on starting treatment in light of need for central\n access. Can start therapeutic heparin vs Lovenox with bridge to\n coumadin.\n -Can consider rescanning for PE. High risk for PE given UE DVT.\n # Abd distention:\n -KUB unrevealing\n -High residuals\n - benefit from further imaging; if unstable consider ultrasound,\n however, if pt can tolerate it, a CT scan might be more helpful. Can\n also scan chest and pelvis.\n # Anemia: On admission to Medical Center, Hct was ~40, now down\n to 30 and then 25 w/o sign of active GI bleed or other source of blood\n loss. be related to fluid administration, phlebotomy, anemia of\n inflammation, active bleed still considered in differential.\n - trend Hct\n - guaiac stools\n - S/p failed attempts at line placement; watch for neck hematomas\n - INR elev at 1.5. ? may be related to poor nutrition as albumin is\n 2.3\n # Spine fracture: neurologically intact distal to the lesion. prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - Need to talk to neurosurg to see if pt can tolerate a CT scan as well\n as the risks of anticoag for DVT\n - monitor distal neurologic function\n - cto brace x3 months unless supine in bed\n - consult neurosurgery for further recs\n # Hypernatremia: correcting with g tube free flush and D5W\n -Holding on g tube feeds at present due to high residuals\n -Replete lytes as necessary\n ICU Care\n Nutrition: tube feed with free water\n Glycemic Control: Regular insulin sliding scale\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Communication: Family meeting held , ICU consent signed, \n (brother) (boyfriend/POA) \n Code status: Full code\n Disposition: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 01:36 AM\n 22 Gauge - 02:00 PM\n Arterial Line - 03:00 AM\n Multi Lumen - 11:30 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Nursing","chartdate":"2167-09-23 00:00:00.000","description":"Nursing Progress Note","row_id":634477,"text":"Events: Attempt to lighten sedation, stop Levophed gtt- MS \n stability labile from lethargic to restless in bed/crying w/\n intermittent BP 120\ns/ w/ and W/O stimulation. UOP cont 10-30cc/hr.\n Vigileo monitor on- SVV . Bladder pressure 14. TF restarted w/ goal\n slow inc as tolerated w/ recent high residuals. Sm amt bowel\n movement.\n Alteration in Nutrition\n Assessment:\n Minimal residuals\n Action:\n Restarting TF replete w/ fiber @ 10cc/hr w/ Q6hr 20cc flush\n Response:\n Tolerating, goal advance Q6hr as tolerated\n Plan:\n Cont TF, monitor residuals, inc Q6hrs as tolerated, monitor stool\n output for improving GI motility w/ PO Narcan\n Hypotension (not Shock)\n Assessment:\n BP labile- SBP 86-120, UOP down to 10cc/hr\n Action:\n Vigileo on- SVV , In AM attempt wean off Levo gtt\n Response:\n No fluid blousing, Levophed gtt started- titrated for MAP >65, UOP,\n Levo gtt @ .020mcg/kg/min\n Plan:\n Cont Vigilieo monitoring, CVP monitoring, UOP, Levophed gtt, fluid\n bolus if inc in SVV, in CVP\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Heparin gtt @ 1700units/hr, PTT 76\n Action:\n Heparin gtt therapeutic x2, cont @ 1700units/hr\n Response:\n No s/s bleeding, guiac neg gastric secretions, stool\n Plan:\n Cont Hep gtt as ordered w/I scale parameters, check PTT w/ AM labs,\n monitor s/s bleeding\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS clear bilat upper lobes, diminished bilat lower lobes, turning w/o\n desating, suctioning minimally for thin clear secretions, Sat 96-100%,\n w/ decres in sedation waking in afternoon and overbreathing vent 1-3\n bpm, afebrile\n Action:\n No vent changes, suctioned post coughing x1, turning as tolerated,\n sedation titrated- currently @ 100mcg/hr Fentanyl gtt, 2 mg/hr Versed\n gtt. 1x blousing w/ .5mg Versed and 50mcg Fentanyl for sig inc in\n agitation/breathing over vent/pulling @ lines, resp tesing w/\n esophageal balloon\n Response:\n Synchronous w/ vent, RN care/turning/mouth care w/ decreased agitation,\n Sat >96%, pt on appropriate PEEP\n Plan:\n Cont IV ABX, pulm toilet, esophageal balloon readings, monitor sat\n"},{"category":"Physician ","chartdate":"2167-09-23 00:00:00.000","description":"Physician Attending Progress Note","row_id":634478,"text":"Chief Complaint: respiratory failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n ESOPHOGEAL BALLOON - At 01:46 PM\n Restarted levophed overnight\n Patient unable to provide history: Sedated\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Aztreonam - 06:09 AM\n Metronidazole - 08:00 AM\n Levofloxacin - 08:39 AM\n Infusions:\n Midazolam (Versed) - 1.5 mg/hour\n Fentanyl - 75 mcg/hour\n Norepinephrine - 0.02 mcg/Kg/min\n Other ICU medications:\n Other medications:\n vanc, aztreonam, flagyl (day ), CHG, SQI, nebs, naloxone enteral,\n heparin infusion\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38\nC (100.4\n Tcurrent: 37.6\nC (99.6\n HR: 75 (64 - 102) bpm\n BP: 96/49(65) {76/38(56) - 160/71(97)} mmHg\n RR: 22 (16 - 25) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101 kg (admission): 94.2 kg\n Height: 67 Inch\n CVP: 20 (8 - 339)mmHg\n Bladder pressure: 18 (18 - 21) mmHg\n Total In:\n 3,524 mL\n 848 mL\n PO:\n TF:\n 48 mL\n IVF:\n 3,236 mL\n 698 mL\n Blood products:\n Total out:\n 935 mL\n 325 mL\n Urine:\n 650 mL\n 325 mL\n NG:\n 285 mL\n Stool:\n Drains:\n Balance:\n 2,589 mL\n 523 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 0 (0 - 0) mL\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 23 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 37 cmH2O\n Plateau: 33 cmH2O\n Compliance: 40 cmH2O/mL\n SpO2: 99%\n ABG: 7.37/44/160/25/0\n Ve: 8.9 L/min\n PaO2 / FiO2: 320\n Physical Examination\n General Appearance: Overweight / Obese\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: coarse breath sounds\n Abdominal: Soft, Obese\n Extremities: Right: 1+, Left: 1+\n Skin: Warm\n Neurologic: Responds to: Unresponsive, Movement: No spontaneous\n movement, Tone: Normal\n Labs / Radiology\n 8.9 g/dL\n 358 K/uL\n 126 mg/dL\n 0.7 mg/dL\n 25 mEq/L\n 3.5 mEq/L\n 4 mg/dL\n 108 mEq/L\n 143 mEq/L\n 28.0 %\n 8.1 K/uL\n [image002.jpg]\n 12:05 PM\n 06:08 PM\n 06:11 PM\n 07:53 PM\n 02:02 AM\n 03:59 AM\n 09:14 PM\n 01:04 AM\n 05:54 AM\n 06:11 AM\n WBC\n 8.4\n 8.1\n Hct\n 29.0\n 28.1\n 28.0\n Plt\n 376\n 358\n Cr\n 0.6\n 0.7\n TCO2\n 29\n 29\n 25\n 25\n 28\n 28\n 26\n Glucose\n 120\n 126\n Other labs: PT / PTT / INR:22.2/76.0/2.1, ALT / AST:24/16, Alk Phos / T\n Bili:117/0.7, Amylase / Lipase:, Differential-Neuts:74.7 %,\n Lymph:17.6 %, Mono:3.8 %, Eos:3.4 %, Lactic Acid:0.7 mmol/L,\n Albumin:2.4 g/dL, LDH:204 IU/L, Ca++:8.2 mg/dL, Mg++:2.0 mg/dL, PO4:3.2\n mg/dL\n Assessment and Plan\n 55-year-old woman with\n Respiratory failure\n End-exp transpulmonary pressure: -2\n End-insp transpulmonary pressure: +5\n Esophageal pressures suggest that she is at safe pressures.\n Traumatic thoracic spinal fracture\n Eventual MRI. Too high-risk at present. Brace when out of\n bed.\n Probable VAP\n Discuss GNRs with lab\n Complete 8\n 15d course of present ABX pending cultures\n D/C vancomycin since no identified GPCs\n D/C Flagyl since no CT or toxin evidence of C diff\n Shock\n now back on levophed\n CVP is 20 mm Hg but Pes is ~25 cm H20\n Re-assess SVV with Vigileo and consider volume challenge\n Upper extremity DVT\n Therapeutic heparin\n Anemia\n Follow\n Possible tracheobronchomalacia (reason for transfer)\n Incidental peri-appendiceal finding (will need eventual\n follow-up)\n Although differential remains open, the most compelling course of\n events is probably that she required intubation at the outside hospital\n (?sedation ?restriction from obesity/brace ?other) and subsequently\n developed a GNR-related VAP. Her pattern of acute lung injury,\n combined with obesity, is resulting in basilar and\n posterior-predominant atelectasis/consolidation with a high proportion\n of shunt. Given her very high PEEP, will try to avoid bronchoscopy if\n possible.\n Other issues as per ICU team note.\n ICU Care\n Nutrition: resume tube feeds\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 01:36 AM\n Arterial Line - 03:00 AM\n Multi Lumen - 11:30 AM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Heparin gtt)\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 60 minutes\n Patient is critically ill\n ------ Protected Section ------\n CRITICAL CARE STAFF\n 7p\n Oxygenation has continued to improved throughout the day.\n Remains on levophed.\n Repeat baseline cortisol < 5.\n Had relative oliguria for several hours.\n Her baseline cortisol should be substantially higher than it is; she\n should be maximally stimulated given her degree of illness. I\n therefore think this represents meaningful cortisol deficiency. Since\n she is vasopressor-requiring, we will treat for adrenal insufficiency.\n We will wean FiO2 to 0.4. If tolerates, then wean PEEP.\n These maneuvers are likely to help with urine output, as well. If they\n do not, will increase levophed and see if higher blood pressures result\n in higher UOP.\n Critical Care Time: 30 minutes\n ------ Protected Section Addendum Entered By: , MD\n on: 19:13 ------\n"},{"category":"Respiratory ","chartdate":"2167-09-20 00:00:00.000","description":"Respiratory Care Shift Note","row_id":634099,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: Outside hospital\n Tube Type\n ETT:\n Position: 19 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous non-invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Episodes of coughing with high pips, Bs clear, mdis and\n sedation given, subsides.\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Utilize ARDSnet protocol, Maintain PEEP at current level and reduce\n FiO2 as tolerated, Reduce PEEP as tolerated, Adjust Min. ventilation to\n control pH; Comments: Further workup of Tracheal malacia status.\n possible bronch\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Pending procedure / OR, Underlying illness not\n resolved\n"},{"category":"Respiratory ","chartdate":"2167-09-20 00:00:00.000","description":"Respiratory Care Shift Note","row_id":634177,"text":"Demographics\n Day of intubation: \n Day of mechanical ventilation: 2\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments: Pt had a MINI BAL @ 1500hrs \n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Bronchoscopy (1500hrs)\n Comments: MINI BAL spec sent to micro\n, RRT 16:44\n"},{"category":"Nursing","chartdate":"2167-09-20 00:00:00.000","description":"Nursing Progress Note","row_id":634180,"text":"Obese woman s/p t spine injury tx from Med for failure to wean\n from mech ventilation and evaluation for stent for\n tracheobronchomalacia.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Pt cont w/ low grade fever.\n Action:\n Given tyelenol q6 h prn, pt pan cultured. PICC line and foley d/c\n (new foley placed). IV antibiotics started.\n Response:\n Fever slightly improved to 99.\n Plan:\n Cont w/ q 6 hr tyelenol prn, closely monitor temp and f/u w/ cultures.\n Fracture, other\n Assessment:\n Pt w/ T5-T8 compression fracture.\n Action:\n Pt on log-roll precautions, back brace at bedside- to be used when pt\n is OOB.\n Response:\n Pt denies pain when asked.\n Plan:\n Cont on log roll precautions, Neuro- consult ordered to clarify\n order for brace.\n Anemia, other\n Assessment:\n HCT 25 from 30.0. No active bleeding noted.\n Action:\n Cont to check HCT and s/s of bleeding.\n Response:\n No action taken.\n Plan:\n Type & Screen to be collected. Cont to monitor HCT, guiac all stools.\n Hypernatremia (high sodium)\n Assessment:\n NA level 150-> 147. No seizure activity.\n Action:\n Free H2O boluses q 4hrs were started, but currently on hold d/t high\n residuals. Pt on D5W for 1L .\n Response:\n NA level slightly improved.\n Plan:\n Cont w/ free-water boluses as tolerated, cont to monitor lytes, bolus\n w/ LR prn.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS rhonchorous throughout, diminished to bilateral bases, deep sxn\n thick tan/bloody secretions.\n Action:\n Given MDIs, cont to be orally intubated on A/C, mini-BAL performed by\n RT and sample sent to lab. Increased sedation for adequate\n ventilation. Arterial line placed to Lt wrist.\n Response:\n Cont to be orally intubated and sedated.\n Plan:\n Consult w/ IP for eval for stent, wean vent as tolerated\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n RUE edematous\n Action:\n U/S done, RUE elevated, Pt cont on sq heparin\n Response:\n US + for DVT to RUE\n Plan:\n No blood draws or NBP to RUE, elevate RUE, cont w/ heparin sq\n"},{"category":"Nursing","chartdate":"2167-09-20 00:00:00.000","description":"Nursing Progress Note","row_id":634181,"text":"Obese woman s/p t spine injury tx from Med for failure to wean\n from mechanical ventilation and evaluation for stent for\n tracheobronchomalacia.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Pt cont w/ low grade fever.\n Action:\n Given tyelenol q6 h prn, pt pan cultured. PICC line and foley d/c\n (new foley placed). IV antibiotics started.\n Response:\n Fever slightly improved to 99.\n Plan:\n Cont w/ q 6 hr tyelenol prn, closely monitor temp and f/u w/ cultures.\n Fracture, other\n Assessment:\n Pt w/ T5-T8 compression fracture.\n Action:\n Pt on log-roll precautions, back brace at bedside- to be used when pt\n is OOB.\n Response:\n Pt denies pain when asked.\n Plan:\n Cont on log roll precautions, Neuro- consult ordered to clarify\n order for brace.\n Anemia, other\n Assessment:\n HCT 25 from 30.0. No active bleeding noted.\n Action:\n Cont to check HCT and s/s of bleeding.\n Response:\n No action taken.\n Plan:\n Type & Screen to be collected. Cont to monitor HCT, guiac all stools.\n Hypernatremia (high sodium)\n Assessment:\n NA level 150-> 147. No seizure activity.\n Action:\n Free H2O boluses q 4hrs were started, but currently on hold d/t high\n residuals. Pt on D5W for 1L .\n Response:\n NA level slightly improved.\n Plan:\n Cont w/ free-water boluses as tolerated, cont to monitor lytes, bolus\n w/ LR prn.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS rhonchorous throughout, diminished to bilateral bases, deep sxn\n thick tan/bloody secretions.\n Action:\n Given MDIs, cont to be orally intubated on A/C, mini-BAL performed by\n RT and sample sent to lab. Increased sedation for adequate\n ventilation. Arterial line placed to Lt wrist.\n Response:\n Cont to be orally intubated and sedated.\n Plan:\n Consult w/ IP for eval for stent, wean vent as tolerated\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n RUE edematous\n Action:\n U/S done, RUE elevated, Pt cont on sq heparin\n Response:\n US + for DVT to RUE\n Plan:\n No blood draws or NBP to RUE, elevate RUE, cont w/ heparin sq\n Hypotension (not Shock)\n Assessment:\n Pt hypotensive into mid 80s systolic, SR/ST, HR 80s-120s. Low UOP\n /h.\n Action:\n Given 500cc LR boluses x 3. Arterial line placed. EKG done-no change.\n Response:\n Minimal response to UOP. BP improved\n> 100s-130s systolic.\n Plan:\n Central line to be placed, cont to bolus as needed.\n"},{"category":"Respiratory ","chartdate":"2167-09-24 00:00:00.000","description":"Respiratory Care Shift Note","row_id":634535,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 6\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt received intubated and vented on AC . 400x22 23 peep and\n 40%. peep was decreased 21 cmh20 and tolerated well.pt sp02 remains\n 98-99. BS reveals rhonchi to auscultation,but clears with suctioning.\n Sputum sample sent to lab d/t ^ temp. will continue to wean peep as\n tolerated. Close monitoring will continue\n"},{"category":"Nursing","chartdate":"2167-09-25 00:00:00.000","description":"Nursing Progress Note","row_id":634628,"text":"Pt is a 55 yr old women admitted from OSH after she fell down the\n stairs (did not have LOC per boyfriend) and had a traumatic T-spine\n Fracture. Pt came to us with PNA from unknown etiology? VAP. Full\n code, Allergies: PCN, tetracycline, sulfa. PMH: ETOH, smoker, Gerd, Hip\n replacement. Pt afebrile during the night, was Pan cultured\n yesterday. Pt brother is her spokesperson. Pt boyfriend was in last\n night to see her, it is a 2 hr train ride from for him to get\n here. Pt boyfriend reported on night that for the last 2 months\n pt has been drinking 2 large bottles of wine almost every night and\n that this is an increase from what she used to drink.\n Bradycardia\n Assessment:\n HR 46-60\ns, HR decreases when pt is asleep. Stays in the 45-50 range\n when she is asleep. BP stable with low HR.\n Action:\n Monitor HR, monitor SBP with low HR\n Response:\n No action taken because vital sign have been stable.\n Plan:\n Cont to monitor\n Alteration in Nutrition\n Assessment:\n Replete with fiber Goal rate 60ml/hr. distended firm belly but pt is\n stooling now. Hypoactive bowel sounds.\n Action:\n Increased rate to 50ml/hr. cont to watch TF residuals. Pt did have past\n problems with high residuals.\n Response:\n Residuals 10ml.\n Plan:\n Cont to advance TF as tolerated. Cont stool softners/monitor for high\n residuals.\n Deep Venous Thrombosis (DVT), Upper extremity,\n Assessment:\n RUE DVT, Pt on heparin gtt at 1700 units/hr. No blood draws or BP on\n RUE.\n Action:\n PTT has been at therapeutic dose.\n Response:\n Repeat PTT in AM\n Plan:\n If PTT cont to be therapeutic cont to check PTT Q 24 hr., if not make\n changes per protocol.\n Fracture, other\n Assessment:\n Ortho reported that pt has T8 fracture. Pt does move all extremities,\n needs to wear back brace when out of bed. Brace is in the room, pt no\n longer on log roll precautions. Hard to tell if pt is in pain from\n fracture but she is on fentanyl and versed gtts.\n Action:\n Per ortho pt will need MRI of the spine and CT scan of the C and L\n portions of the spine to check for any other spinal injury. Ortho\n states we can do this when pt is more stable.\n Response:\n Plan:\n Will do MRI and CT at a later date.\n Hypotension (not Shock)\n Assessment:\n SBP ranges 80-100\ns with MAPs 55-70 Goal MAP >60. levophed off for\n almost 24hr. pt did get total of 3 liters in fluid boluses over the\n last 24 hr. CVP 12-14 but pt on 21 of peep. A-line very positional\n and was just re-sited yesterday. Pt was on vigileo monitor but D/C\n during the day because A-line tracing is so positional that the\n accuracy of this monitoring is questionable.\n Action:\n Gave 500ml fluid bolus for MAP of 55. and low urine output 10-20ml/hr.\n Response:\n Urine output increased, and MAP/BP increased\n Plan:\n Cont to monitor BP and MAPs and urine output.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Suctioning clear/white thick secretions in-line, copious amounts of\n clear secretions suctioned orally. Cough intact. Lung sounds clear\n diminished, no vent setting changes, Vent mode CMV: 40%/400/22/21,\n esophageal balloon in place.\n Action:\n VAP protocol: HOB 30 degrees, oral care. Suctioning, cont steroids.\n Chest x-ray done in AM. Cont antibiotics.\n Response:\n Cont to needs lots of suctioning.\n Plan:\n Wean vent as ordered by the Micu team. Cont to check ABG\ns when\n indicated.\n"},{"category":"Physician ","chartdate":"2167-09-25 00:00:00.000","description":"Physician Resident Progress Note","row_id":634629,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n New A-line placed (left), good tracing but positional\n Vanco restarted\n Atrial EKG->p-waves\n Multiple IVF boluses for MAPs < 65. Did not restart pressors\n Brother came, confirmed history\n Eye drops\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Metronidazole - 08:00 AM\n Levofloxacin - 10:00 AM\n Vancomycin - 08:09 PM\n Aztreonam - 10:00 PM\n Infusions:\n Midazolam (Versed) - 4 mg/hour\n Heparin Sodium - 1,700 units/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 04:29 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.7\nC (98.1\n HR: 56 (45 - 63) bpm\n BP: 103/54(72) {83/44(59) - 142/105(109)} mmHg\n RR: 22 (0 - 22) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101 kg (admission): 94.2 kg\n Height: 67 Inch\n CVP: 12 (11 - 14)mmHg\n Total In:\n 4,750 mL\n 868 mL\n PO:\n TF:\n 773 mL\n 223 mL\n IVF:\n 3,827 mL\n 645 mL\n Blood products:\n Total out:\n 2,365 mL\n 60 mL\n Urine:\n 2,325 mL\n 60 mL\n NG:\n 40 mL\n Stool:\n Drains:\n Balance:\n 2,385 mL\n 808 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 21 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 34 cmH2O\n Plateau: 29 cmH2O\n Compliance: 50 cmH2O/mL\n SpO2: 99%\n ABG: 7.46/38/96./23/2\n Ve: 8.6 L/min\n PaO2 / FiO2: 242\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 326 K/uL\n 8.9 g/dL\n 153 mg/dL\n 0.6 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n 6 mg/dL\n 113 mEq/L\n 141 mEq/L\n 28.6 %\n 8.9 K/uL\n [image002.jpg]\n 09:14 PM\n 01:04 AM\n 05:54 AM\n 06:11 AM\n 11:07 PM\n 03:51 AM\n 06:17 AM\n 07:00 AM\n 08:18 AM\n 04:18 PM\n WBC\n 8.1\n 8.9\n Hct\n 28.0\n 28.6\n Plt\n 358\n 326\n Cr\n 0.7\n 0.7\n 0.6\n TropT\n <0.01\n <0.01\n TCO2\n 28\n 28\n 26\n 26\n 21\n 28\n Glucose\n 126\n 151\n 153\n Other labs: PT / PTT / INR:24.3/68.6/2.4, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:82.5 %, Lymph:11.6 %,\n Mono:3.3 %, Eos:2.2 %, Lactic Acid:0.7 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:7.8 mg/dL, Mg++:2.1 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with respiratory failure\n and difficulty weaning from vent.\n # Respiratory failure: Over the evening yesterday, were able to\n decrease FiO2 and PEEP. Clinical and imaging suggestive of ARDS.\n Initial precipitating factors were thought to be: sedation, hypovent\n obesity, orthotic brace. Now thought to have VAP.\n - Placed esophageal balloon on which will help guide PEEP settings.\n - Given small size of effusion and high PEEP (risk of pneumothorax),\n will not attempt to tap\n - Appreciate IP recs. Will consider tracheomalacia workup when more\n stable.\n - Approaching 2-week intubation point (intubated ); Trach?\n # VAP/ID: Re-spiked fever overnight. Stopped vanc yesterday, , as\n treating for GNR infection. Current GS shows GPC\n - Follow cultures\n - Restart Vanc.\n - Continue aztreonam, levofloxicin for 8 days pending speciation (at\n that time can increase to 15 days if necessary)\n - Also, stopped flagyl because had one neg c. diff toxin and CT did not\n show evidence of colitis\n - Will replace A-line today.\n # EKG changes: Sinus bradycardia. Very low voltages and no change in\n QRS morphology. P-waves are visible and prolonged PR interval is old.\n CK and troponins flat. Likely related to increased vagal tone possibly\n related to steroid replacement.\n - Will avoid excessive alpha-agonism\n - Continue to monitor\n - could consider atrial EKG\n .\n # Hypotension: now off levophed, with good urine output. Hypovolemia\n is possibly a factor- responded to a transfusion; HCT had been\n dropping. However, SVV with Vigileo was 7, making her CO less likely\n to respond to fluids. Held on giving any boluses overnight. Today CVP\n is low given PEEP. Sepsis also a consideration\n - continue on broad spectrum abs\n - replete fluids.\n - Restart pressors as needed. Consider dopamine over levophed given\n bradycardia.\n - Central line in place.\n # Urine output: Previously oliguric, now with high urine output.\n Concern for autodiuresis but BUN and Cr reassuring.\n -Continue to monitor\n # RUE DVT: Started on heparin gtt on .\n -Therapeutic in one day; may be related to poor nutritional status.\n Will continue to closely monitor\n # Adrenal Insufficency:\n -Random cortisol was approx 3 when it should have been maximally\n stimulated.\n -Started hydrocortisone and florinef. ? switch to methylpred\n # Anemia:\n - Trend HCT\n - Gave 1 un pRBC with good results\n - INR rising, now 2.0, may be nutritional\n # Spine fracture: neurologically intact distal to the lesion. prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n # Hypernatremia, resolved: correcting with g tube free flush and D5W\n -Continue to follow\n # Communication:\n - Brother has been with pt, although, live in boyfriend of 10 is\n her HCP. Boyfriend will hopefully visit pt today\n ICU Care\n Nutrition: tube feed with free water when able\n Glycemic Control: Regular insulin sliding scale\n DVT: Theraputic Heparin gtt\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Communication: ICU consent signed, (brother) \n (boyfriend/POA) \n Code status: Full code\n Disposition: ICU\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 07:00 AM 50 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 11:30 AM\n Arterial Line - 04:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Nursing","chartdate":"2167-09-21 00:00:00.000","description":"Nursing Progress Note","row_id":634224,"text":"Respiratory failure, acute (not ARDS/)\n Assessment:\n LS cont rhonchi throughout, dim bilat in base, occ. bronchospasms with\n care; abg showed resp. acidosis\n Action:\n Cont to suct for smll thick tan secretions, copious oral secretions\n suctioned, vent settings changed to 18/500/80/10\n Response:\n ABG improved, O2 Sats 97-98%\n Plan:\n f/f with IP ? tracheabronchial malacia, abgs, neb tx as needed\n Hypotension (not Shock)\n Assessment:\n Sbp down in high 90\ns, Aline damped\n Action:\n pt bolused x 1L LR, 500mg NS for low urinary output, L-aline d/cd\n Response:\n R-wrist Aline placed, SBP 110-120\n Plan:\n Cont . VS, I &O; treat as ordered\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n +DVT\n Action:\n Cont SC heparin\n Response:\n Plan:\n Cont SC heparin,\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n TMax 99.2\n Action:\n Cont with IV ABX, second UA sent\n Response:\n Remains low grade temp\n Plan:\n f/u with pending cultures; attempt repeat sputum culture, treat temp as\n ordered\n Fracture, other\n Assessment:\n T7 fracture to fall on \n Action:\n Cont in Reverse Trend., log roll precautions HOB 30\n Response:\n Remains stable\n Plan:\n Cont log roll precautions, f/u with PT, ? specialty mattress??\n Anemia, other\n Assessment:\n H/H 24.1/7.6, no active bleeding noted\n Action:\n Stool guiac negative\n Response:\n Plan:\n Cont to Hct, guiac stools\n"},{"category":"Physician ","chartdate":"2167-09-21 00:00:00.000","description":"Physician Resident Progress Note","row_id":634225,"text":"Chief Complaint:\n 24 Hour Events:\n Removed PICC line because RUE was noted to be warm and erythematous;\n ultrasound revealed DVT. No definitive treatment was started given\n difficulty obtaining central venous access.\n Multiple attempts at central access; tried left and then right.\n Acute episode of oxygen desat during first central line attempt. Pt\n recovered, however, increased FiO2.\n Decreased UOP (10-30mL/hr) and hypotension overnight. However,\n lactate remains low.\n Placed art line x 2. NBP and ABP similar\n mini- BAL, sputum, urine, blood cultures pending. Yesterday, started\n on levofloxicin and aztreonam instead of cefepime. Switched due to\n question of PCN allergy\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 09:30 AM\n Metronidazole - 12:00 AM\n Vancomycin - 01:00 AM\n Aztreonam - 04:00 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 150 mcg/hour\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:00 AM\n Midazolam (Versed) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (100.9\nF at 10am on )\n Tcurrent: 37.3\nC (99.2\n HR: 76 (71 - 116) bpm\n BP: 116/51(70) {60/46(54) - 146/71(91)} mmHg\n RR: 18 (12 - 24) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 94.2 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 5,600 mL\n 1,811 mL\n PO:\n TF:\n 120 mL\n IVF:\n 4,700 mL\n 1,511 mL\n Blood products:\n Total out:\n 798 mL\n 110 mL\n Urine:\n 798 mL\n 110 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,802 mL\n 1,701 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 80%\n RSBI Deferred: PEEP > 10\n PIP: 36 cmH2O\n Plateau: 25 cmH2O\n SpO2: 93%\n ABG: 7.45/42/95./28/4\n Ve: 9.5 L/min\n PaO2 / FiO2: 120\n Physical Examination\n Gen: Appears uncomfortable on vent.\n HEENT: Anicteric. Pupils 3 mm non-reactive bilaterally.\n Resp: Symmetric expansion. Vesicular sounds throughout. Inspiratory\n and expiratory tracheal sounds (?related to ET tube).\n CV: Cannot see jugular veins due to neck size. RRR. Normal s1 and\n s2. No M/G/R.\n Abd: Quiet. Distended. Non-tender.\n Ext: Edema in RUE, especially right hand. Mildly increased warmth of\n RUE compared with LUE.\n Peripheral vascular: Radial pulses 2+ bilaterally.\n Neuro: Pupils as above. Moving all 4 extremities.\n Labs / Radiology\n 319 K/uL\n 7.6 g/dL\n 129 mg/dL\n 0.6 mg/dL\n 28 mEq/L\n 4.3 mEq/L\n 6 mg/dL\n 109 mEq/L\n 144 mEq/L\n 24.1 %\n 6.4 K/uL\n [image002.jpg]\n 11:54 PM\n 01:00 AM\n 06:14 AM\n 08:56 AM\n 08:57 AM\n 05:01 PM\n 08:03 PM\n 11:00 PM\n 03:01 AM\n 03:13 AM\n WBC\n 9.7\n 9.4\n 7.6\n 6.4\n Hct\n 30.7\n 25.1\n 24.1\n 24.1\n Plt\n 333\n 281\n 306\n 319\n Cr\n 0.6\n 0.6\n 0.7\n 0.6\n 0.6\n TCO2\n 32\n 33\n 35\n 33\n 30\n Glucose\n 103\n 126\n 126\n 127\n 129\n Other labs: PT / PTT / INR:16.9/26.3/1.5, ALT / AST:27/18, Alk Phos / T\n Bili:113/0.7, Differential-Neuts:76.9 %, Lymph:17.3 %, Mono:3.0 %,\n Eos:2.5 %, Lactic Acid:0.7 mmol/L, Albumin:2.3 g/dL, LDH:154 IU/L,\n Ca++:8.2 mg/dL, Mg++:2.6 mg/dL, PO4:3.1 mg/dL\n RUE ultrasound:\n - Non-occlusive right axillary deep vein thrombus\n - Non-occlusive right basilic superficial thrombosis.\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture\n # Respiratory failure: initial etiology unclear, likely multifactorial\n including bronchspasm, hypoventilation from narcotics, potential\n aspiration, infection. By report, had a neg evaluation for PE at OSH,\n however, unable to open disc to confirm. Concern for VAP.\n - Failed yesterday\ns NIF; score was -15\n - Increased FiO2 overnight. Had increased pCO2 which resolved with\n increasing RR\n - IP stopped by but will complete official consult today; suggested\n repeating CT scan\n - Need to contact Medical re previous CT scan. Can attempt to\n resend disc. Otherwise, will most likely benefit from repeat CT to\n look for acute pulm process such as PE or PNA.\n # Fever: Likely due to combination of infection and DVT. Cultures\n sent. Will treat with empiric antibiotics. Tylenol PRN for fever.\n - Known RUE DVT\n - Infectious etiologies include VAP, asp PNA, line infections. Removed\n PICC yesterday and cultured tip. Mini-BAL- gram stain neg. Sputum\n grew GPC in pairs and GPR. Flagyl, aztreonam, vancomycin, levofloxacin\n for coverage of gram positives, gram negatives, anaerobes, MRSA. Urine\n and blood cultures NGTD\n - f/u blood, urine, and sputum cultures.\n - Concern for abd cause; KUB unrevealing. High residuals. require\n further imaging\n # Transient hypotension: Has been somewhat fluid responsive; UOP \n ccs/hr. Diff dx includes hypovolemia, sepsis, cardiogenic.\n - Sepsis most likely given fever.\n - HCT decreasing; ? stable at 24-25\n - Unable to place central line despite multiple attempts. First tired\n left IJ RUE DVT. 2^nd attempt in left IJ. Can place femoral if pt\n requires more active repletion\n # RUE DVT: Have held on starting treatment in light of need for central\n access. Can start therapeutic heparin vs Lovenox with bridge to\n coumadin.\n # Abd distention:\n -KUB unrevealing\n -High residuals\n - benefit from further imaging; if unstable consider ultrasound,\n however, if pt can tolerate it, a CT scan might be more helpful. Can\n also scan chest and pelvis.\n # Anemia: On admission to Medical Center, Hct was ~40, now down\n to 30 and then 25 w/o sign of active GI bleed or other source of blood\n loss. be related to fluid administration, phlebotomy, anemia of\n inflammation, active bleed still considered in differential.\n - trend Hct\n - guaiac stools\n - S/p failed attempts at line placement; watch for neck hematomas\n # Spine fracture: neurologically intact distal to the lesion. prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - monitor distal neurologic function\n - cto brace x3 months unless supine in bed\n - consult neurosurgery for further recs\n # Hypernatremia: correcting with g tube free flush and D5W\n -Holding on g tube feeds at present due to high residuals\n -Replete lytes as necessary\n ICU Care\n Nutrition: tube feed with free water\n Glycemic Control: Regular insulin sliding scale\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Communication: Family meeting held , ICU consent signed, \n (brother) (boyfriend/POA) \n Code status: Full code\n Disposition: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 01:16 AM\n 20 Gauge - 01:36 AM\n 22 Gauge - 02:00 PM\n Arterial Line - 03:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Physician ","chartdate":"2167-09-21 00:00:00.000","description":"Physician Resident Progress Note","row_id":634226,"text":"Chief Complaint:\n 24 Hour Events:\n Removed PICC line because RUE was noted to be warm and erythematous;\n ultrasound revealed DVT. No definitive treatment was started given\n difficulty obtaining central venous access.\n Multiple attempts at central access; tried left and then right.\n Acute episode of oxygen desat during first central line attempt. Pt\n recovered, however, increased FiO2.\n Decreased UOP (10-30mL/hr) and hypotension overnight. However,\n lactate remains low.\n Placed art line x 2. NBP and ABP similar\n mini- BAL, sputum, urine, blood cultures pending. Yesterday, started\n on levofloxicin and aztreonam instead of cefepime. Switched due to\n question of PCN allergy\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 09:30 AM\n Metronidazole - 12:00 AM\n Vancomycin - 01:00 AM\n Aztreonam - 04:00 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 150 mcg/hour\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:00 AM\n Midazolam (Versed) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (100.9\nF at 10am on )\n Tcurrent: 37.3\nC (99.2\n HR: 76 (71 - 116) bpm\n BP: 116/51(70) {60/46(54) - 146/71(91)} mmHg\n RR: 18 (12 - 24) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 94.2 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 5,600 mL\n 1,811 mL\n PO:\n TF:\n 120 mL\n IVF:\n 4,700 mL\n 1,511 mL\n Blood products:\n Total out:\n 798 mL\n 110 mL\n Urine:\n 798 mL\n 110 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,802 mL\n 1,701 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 80%\n RSBI Deferred: PEEP > 10\n PIP: 36 cmH2O\n Plateau: 25 cmH2O\n SpO2: 93%\n ABG: 7.45/42/95./28/4\n Ve: 9.5 L/min\n PaO2 / FiO2: 120\n Physical Examination\n Gen: Appears uncomfortable on vent.\n HEENT: Anicteric. Pupils 3 mm non-reactive bilaterally.\n Resp: Symmetric expansion. Vesicular sounds throughout. Inspiratory\n and expiratory tracheal sounds (?related to ET tube).\n CV: Cannot see jugular veins due to neck size. RRR. Normal s1 and\n s2. No M/G/R.\n Abd: Quiet. Distended. Non-tender.\n Ext: Edema in RUE, especially right hand. Mildly increased warmth of\n RUE compared with LUE.\n Peripheral vascular: Radial pulses 2+ bilaterally.\n Neuro: Pupils as above. Moving all 4 extremities.\n Labs / Radiology\n 319 K/uL\n 7.6 g/dL\n 129 mg/dL\n 0.6 mg/dL\n 28 mEq/L\n 4.3 mEq/L\n 6 mg/dL\n 109 mEq/L\n 144 mEq/L\n 24.1 %\n 6.4 K/uL\n [image002.jpg]\n 11:54 PM\n 01:00 AM\n 06:14 AM\n 08:56 AM\n 08:57 AM\n 05:01 PM\n 08:03 PM\n 11:00 PM\n 03:01 AM\n 03:13 AM\n WBC\n 9.7\n 9.4\n 7.6\n 6.4\n Hct\n 30.7\n 25.1\n 24.1\n 24.1\n Plt\n 333\n 281\n 306\n 319\n Cr\n 0.6\n 0.6\n 0.7\n 0.6\n 0.6\n TCO2\n 32\n 33\n 35\n 33\n 30\n Glucose\n 103\n 126\n 126\n 127\n 129\n Other labs: PT / PTT / INR:16.9/26.3/1.5, ALT / AST:27/18, Alk Phos / T\n Bili:113/0.7, Differential-Neuts:76.9 %, Lymph:17.3 %, Mono:3.0 %,\n Eos:2.5 %, Lactic Acid:0.7 mmol/L, Albumin:2.3 g/dL, LDH:154 IU/L,\n Ca++:8.2 mg/dL, Mg++:2.6 mg/dL, PO4:3.1 mg/dL\n RUE ultrasound:\n - Non-occlusive right axillary deep vein thrombus\n - Non-occlusive right basilic superficial thrombosis.\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture\n # Respiratory failure: initial etiology unclear, likely multifactorial\n including bronchspasm, hypoventilation from narcotics, potential\n aspiration, infection. By report, had a neg evaluation for PE at OSH,\n however, unable to open disc to confirm. Concern for VAP.\n - Failed yesterday\ns NIF; score was -15\n - Increased FiO2 overnight. Had increased pCO2 which resolved with\n increasing RR\n - IP stopped by but will complete official consult today; suggested\n repeating CT scan\n - Need to contact Medical re previous CT scan. Can attempt to\n resend disc. Otherwise, will most likely benefit from repeat CT to\n look for acute pulm process such as PE or PNA.\n # Fever: Likely due to combination of infection and DVT. Cultures\n sent. Will treat with empiric antibiotics. Tylenol PRN for fever.\n - Known RUE DVT\n - Infectious etiologies include VAP, asp PNA, line infections. Removed\n PICC yesterday and cultured tip. Mini-BAL- gram stain neg. Sputum\n grew GPC in pairs and GPR. Flagyl, aztreonam, vancomycin, levofloxacin\n for coverage of gram positives, gram negatives, anaerobes, MRSA. Urine\n and blood cultures NGTD\n - f/u blood, urine, and sputum cultures.\n - Concern for abd cause; KUB unrevealing. High residuals. require\n further imaging\n # Transient hypotension: Has been somewhat fluid responsive; UOP \n ccs/hr. Diff dx includes hypovolemia, sepsis, cardiogenic.\n - Sepsis most likely given fever.\n - HCT decreasing; ? stable at 24-25\n - Unable to place central line despite multiple attempts. First tired\n left IJ RUE DVT. 2^nd attempt in left IJ. Can place femoral if pt\n requires more active repletion\n # RUE DVT: Have held on starting treatment in light of need for central\n access. Can start therapeutic heparin vs Lovenox with bridge to\n coumadin.\n # Abd distention:\n -KUB unrevealing\n -High residuals\n - benefit from further imaging; if unstable consider ultrasound,\n however, if pt can tolerate it, a CT scan might be more helpful. Can\n also scan chest and pelvis.\n # Anemia: On admission to Medical Center, Hct was ~40, now down\n to 30 and then 25 w/o sign of active GI bleed or other source of blood\n loss. be related to fluid administration, phlebotomy, anemia of\n inflammation, active bleed still considered in differential.\n - trend Hct\n - guaiac stools\n - S/p failed attempts at line placement; watch for neck hematomas\n # Spine fracture: neurologically intact distal to the lesion. prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - monitor distal neurologic function\n - cto brace x3 months unless supine in bed\n - consult neurosurgery for further recs\n # Hypernatremia: correcting with g tube free flush and D5W\n -Holding on g tube feeds at present due to high residuals\n -Replete lytes as necessary\n ICU Care\n Nutrition: tube feed with free water\n Glycemic Control: Regular insulin sliding scale\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Communication: Family meeting held , ICU consent signed, \n (brother) (boyfriend/POA) \n Code status: Full code\n Disposition: ICU\n 55 year old woman with hx of obesity presented to Medical Center\n on after falling down stairs while at home. She suffered a\n traumatic T5-8 fracture with retropulsion of fragments. Per medical\n records and discussion with her brother, she was awake for the fall (no\n LOC) and the fall was triggered by unsteady gait, potentially\n influenced by alcohol. Her fracture was managed concervatively. She\n was placed in a torso brace but her course was complicated by\n respiratory failure requiring intubation. At that time a CT was\n negative for PE but showed bilateral bibasilar consolidations vs\n atelectasis. At that time an ABG was 7.20/89/57 (unknown FIO2 but\n likely >6L facemask). She was intubated on at 08:40. The\n respiratory failure was thought likely to be related to pain med\n induced hypoventilation, bronchospasm, or restricted breathing duet to\n the back brace. The hospital course was complicated by\n difficulty weaning form the ventilator. Her periodic agitation was\n managed with seroquel. Prior to transfer her vent settings were: SIMV\n 12x600 FIO2 0.45.\n The neurosurgery service evaluated her and recommended concervative\n management of her fracture including a back brace and outpatient\n neurosurgery followup. The CT chest showed notable narrowing of her\n central airways and the patient was referred for Interventional\n Pulmonary evaluation for airway stenting.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 01:16 AM\n 20 Gauge - 01:36 AM\n 22 Gauge - 02:00 PM\n Arterial Line - 03:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Nursing","chartdate":"2167-09-21 00:00:00.000","description":"Nursing Progress Note","row_id":634231,"text":"55yo admitted from OSH. Pt s/p fall , sustained T5-T8\n fracture. Pt transf to failure to wean from vent. ? stent for\n tracheobronchialmalacia.\n Events: Pt had 2 attempts at Central line placement; unsuccessful at\n this point; team will attempt for femoral line placement this am.\n R-wrist Aline placed this am. Pt had KUB abdomen appears more\n distended and firm, ? possible ABD CT today.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS cont rhonchi throughout, dim bilat in base, occ. bronchospasms with\n care; abg showed resp. acidosis\n Action:\n Cont to suct for smll thick tan secretions, copious oral secretions\n suctioned, vent settings changed to 18/500/80/10\n Response:\n ABG improved, PC02 42 ; O2 Sats 95-97%\n Plan:\n f/u with IP ? tracheabronchial malacia, abgs, neb tx as needed\n Hypotension (not Shock)\n Assessment:\n Sbp down in high 90\ns, Aline damped, cont wit low UO 15-30cc/hr\n Action:\n pt bolused x 1L LR, 500mg NS for low urinary output, L-aline d/cd\n Response:\n R-radial Aline placed, SBP 110-120\n Plan:\n Cont . VS, I &O; treat as ordered\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n +DVT\n Action:\n Cont SC heparin, no BP\ns or Lab draws to R arm\n Response:\n Cont to elevate RUE\n Plan:\n Cont SC heparin,\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n TMax 99.2\n Action:\n Cont with IV ABX, second UA sent\n Response:\n Remains low grade temp\n Plan:\n f/u with pending cultures; attempt repeat sputum culture, treat temp as\n ordered\n Fracture, other\n Assessment:\n T5-T8 fracture to fall on \n Action:\n Cont in Reverse Trend., log roll precautions HOB 30\n Response:\n No s/sx pain noted\n Plan:\n Cont log roll precautions, f/u with PT, ? specialty mattress??\n Anemia, other\n Assessment:\n H/H 24.1/7.6, no active bleeding noted\n Action:\n Stool guiac negative\n Response:\n No action taken\n Plan:\n Cont to Hct, guiac stools\n"},{"category":"Physician ","chartdate":"2167-09-21 00:00:00.000","description":"Physician Attending Progress Note","row_id":634244,"text":"Chief Complaint: respiratory failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n URINE CULTURE - At 08:09 AM\n EKG - At 09:00 AM\n PICC LINE - STOP 10:30 AM\n BLOOD CULTURED - At 10:30 AM\n ULTRASOUND - At 01:00 PM\n U/S of RUE\n URINE CULTURE - At 03:00 PM\n UA/UC collected after new foley inserted.\n BAL FLUID CULTURE - At 03:00 PM\n mini-BAL\n ARTERIAL LINE - START 04:45 PM\n ARTERIAL LINE - STOP 02:03 AM\n ARTERIAL LINE - START 03:00 AM\n Multiple attempts at central access were unsuccessful due to\n malposition and difficulty threading wire.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 09:30 AM\n Vancomycin - 01:00 AM\n Aztreonam - 04:00 AM\n Metronidazole - 08:50 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 150 mcg/hour\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:00 AM\n Midazolam (Versed) - 09:32 AM\n Other medications:\n colace, CHG, SQI, H2B, SQH, MDIs, Flagyl, vanco, levo, aztreonam,\n versed, fentanyl\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (100.9\n Tcurrent: 37.9\nC (100.3\n HR: 72 (70 - 116) bpm\n BP: 100/48(60) {89/47(60) - 139/75(79)} mmHg\n RR: 18 (12 - 24) insp/min\n SpO2: 89%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 94.2 kg (admission): 94.2 kg\n Height: 67 Inch\n Bladder pressure: 18 (18 - 18) mmHg\n Total In:\n 5,600 mL\n 2,088 mL\n PO:\n TF:\n 120 mL\n IVF:\n 4,700 mL\n 1,728 mL\n Blood products:\n Total out:\n 798 mL\n 205 mL\n Urine:\n 798 mL\n 205 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,802 mL\n 1,883 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 80%\n RSBI Deferred: PEEP > 10\n PIP: 37 cmH2O\n Plateau: 25 cmH2O\n SpO2: 89%\n ABG: 7.45/42/95./28/4\n Ve: 9.1 L/min\n PaO2 / FiO2: 96\n Physical Examination\n Sedated. Breath sounds are coarse. Heart sounds are distant. Abdomen\n is protuberant with quiet breath sounds. Some peripheral edema. She\n is not able to cooperate with peripheral strength or sensory exam.\n Labs / Radiology\n 7.6 g/dL\n 319 K/uL\n 129 mg/dL\n 0.6 mg/dL\n 28 mEq/L\n 4.3 mEq/L\n 6 mg/dL\n 109 mEq/L\n 144 mEq/L\n 24.1 %\n 6.4 K/uL\n [image002.jpg]\n 11:54 PM\n 01:00 AM\n 06:14 AM\n 08:56 AM\n 08:57 AM\n 05:01 PM\n 08:03 PM\n 11:00 PM\n 03:01 AM\n 03:13 AM\n WBC\n 9.7\n 9.4\n 7.6\n 6.4\n Hct\n 30.7\n 25.1\n 24.1\n 24.1\n Plt\n 333\n 281\n 306\n 319\n Cr\n 0.6\n 0.6\n 0.7\n 0.6\n 0.6\n TCO2\n 32\n 33\n 35\n 33\n 30\n Glucose\n 103\n 126\n 126\n 127\n 129\n Other labs: PT / PTT / INR:16.9/26.3/1.5, ALT / AST:27/18, Alk Phos / T\n Bili:113/0.7, Differential-Neuts:76.9 %, Lymph:17.3 %, Mono:3.0 %,\n Eos:2.5 %, Lactic Acid:0.7 mmol/L, Albumin:2.3 g/dL, LDH:154 IU/L,\n Ca++:8.2 mg/dL, Mg++:2.6 mg/dL, PO4:3.1 mg/dL\n Imaging: CXR with bilateral opacities; ETT a little high. No PTX.\n Assessment and Plan\n 55-year-old woman with\n Respiratory failure\n Traumatic thoracic spinal fractures\n Probable VAP\n Upper extremity DVT\n Oliguria\n Anemia\n Possible tracheobronchomalacia (reason for transfer)\n I am uncertain about both the risks of anticoagulation and the risks of\n moving to radiology (e.g. CT or IR) in the context of her spinal\n fractures. Therefore we will consult spine surgery urgently for help\n with these questions.\n Her respiratory failure is likely multifactorial, including obesity,\n probable VAP, probable PE, and possible tracheobronchomalacia. She may\n also have weakness, but she is sedated and cannot cooperate with exam\n at present. We will check an echo to examine her RV. We will\n ventilate per ARDSnet; she may warrant esophageal-balloon-guided\n therapy if she does not improve in the next few hours.\n Oliguria is concerning, though BUN/Creatinine are reassuring. NG to\n suction to relieve abdominal distention. We will check urine lytes and\n assess stroke volume variation with the Vigileo. We will consider\n volume challenge based on this result.\n For central access, if we are able to safely move her we will ask I.R.\n to help with central access.\n We will continue broad antibiotics while awaiting cultures.\n ICU Care\n Nutrition: NPO for now\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 01:16 AM\n 20 Gauge - 01:36 AM\n 22 Gauge - 02:00 PM\n Arterial Line - 03:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 45 min\n Patient is critically ill\n"},{"category":"Physician ","chartdate":"2167-09-22 00:00:00.000","description":"Resident / Attending Notes","row_id":634383,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n -Neurosurg: ok to transport. Will decide on anticoagulation in AM\n -Central line placed\n -NGT to suction\n -Bowel regimen\n -Respiratory attempted to place esophageal ballon in order to measure\n intrathoracic pressure, unsuccessful\n -Desaturation around 23:00 to low 80s on 400/22/15/0.9 following turn.\n Recruitment maneuver (PEEP to 30) done x2 with good effect, Sat came up\n to 100%. PEEP left at 17\n -Transfused 1 un pRBC\n - Started levophed yesterday for hypotension\n - No BM\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 10:00 AM\n Aztreonam - 02:00 PM\n Vancomycin - 12:00 AM\n Metronidazole - 12:00 AM\n Infusions:\n Norepinephrine - 0.02 mcg/Kg/min\n Fentanyl - 200 mcg/hour\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:00 AM\n Midazolam (Versed) - 02:20 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 37.6\nC (99.6\n HR: 73 (64 - 96) bpm\n BP: 119/48(69) {85/39(55) - 142/67(91)} mmHg\n RR: 22 (11 - 22) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 94.2 kg (admission): 94.2 kg\n Height: 67 Inch\n CVP: 20 (11 - 21)mmHg\n Bladder pressure: 14 (14 - 18) mmHg\n Total In:\n 3,482 mL\n 465 mL\n PO:\n TF:\n IVF:\n 2,845 mL\n 465 mL\n Blood products:\n 277 mL\n Total out:\n 580 mL\n 65 mL\n Urine:\n 580 mL\n 65 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,902 mL\n 400 mL\n Respiratory support\n Ventilator mode: AC\n Vt (Set): 400 (400 - 500) mL\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 17 cmH2O\n FiO2: 80%\n PIP: 33 cmH2O\n Plateau: 30 cmH2O\n Compliance: 30.8 cmH2O/mL\n SpO2: 98%\n ABG: 7.38/41/86./24/0\n Ve: 9.1 L/min\n PaO2 / FiO2: 109\n Physical Examination\n Gen: Does not arouse to voice\n HEENT: Pupils 3 mm non-reactive bilaterally. Scleral edema bilat\n Resp: Symmetric expansion. Vesicular sounds throughout. Inspiratory\n and expiratory tracheal sounds (?related to ET tube).\n CV: RRR.\n Abd: Hypoactive bowel sounds. Distended.\n Ext: Edema in bilat UE.\n Peripheral vascular: Radial pulses 2+ bilaterally.\n Neuro: Moving all 4 extremities.\n Labs / Radiology\n 376 K/uL\n 9.0 g/dL\n 120 mg/dL\n 0.6 mg/dL\n 24 mEq/L\n 3.7 mEq/L\n 4 mg/dL\n 108 mEq/L\n 141 mEq/L\n 28.1 %\n 8.4 K/uL\n [image002.jpg]\n ALT 24 PT 18.7\n AST 16 PTT 25.4\n AP 117 INR 1.7\n Tbili 0.7\n Alb 2.4\n 08:03 PM\n 11:00 PM\n 03:01 AM\n 03:13 AM\n 12:05 PM\n 06:08 PM\n 06:11 PM\n 07:53 PM\n 02:02 AM\n 03:59 AM\n WBC\n 7.6\n 6.4\n 8.4\n Hct\n 24.1\n 24.1\n 29.0\n 28.1\n Plt\n \n Cr\n 0.6\n 0.6\n 0.6\n TCO2\n 33\n 30\n 29\n 29\n 25\n 25\n Glucose\n 127\n 129\n 120\n Differential-Neuts:80.8 %, Lymph:12.0 %, Mono:3.5 %, Eos:3.3 %\n Ca++:8.2 mg/dL, Mg++:2.2 mg/dL, PO4:3.1 mg/dL, ion Ca++ () 1.16\n Cortisol:\n : 2:15am 24.2 Midnight 2.7\n : 3am 4.5\n Micro: neg or NGTD if not mentioned\n : blood, \n : urine, sputum-OP flora\n : BAL, - coag neg staph, lactobacillus, cath tip, sputum- OP\n flora, rare GNR, blood\n U/a:\n Color\n Amber\n Appear\n Clear\n SpecGr\n 1.015\n pH\n 5.5\n Urobil\n 2\n Bili\n Mod\n Leuk\n Tr\n Bld\n Tr\n Nitr\n Pos\n Prot\n 100\n Glu\n Neg\n Ket\n 40\n RBC\n 0-2\n WBC\n 0-2\n Bact\n Few\n Yeast\n None\n Epi\n 0-2\n Imaging:\n Echo\n post recruitment CXR showed deep sulcus but no pnumothorax per rads.\n CT: Prelim Read\n Right lower lobe consolidation, and superimposed atelectasis/lower lobe\n collapse, and effusions. Acute T8 compression deformity, with no\n posterior\n retropulsion of fracture fragments. No associated hematoma.\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture\n # Respiratory failure: initial etiology unclear, likely multifactorial\n now with significant pneumonia. Had one sputum that showed GNR.\n - Had a desat event yesterday. Responded positively to recruitment\n maneuvers.\n - Will attempt placement of an esophageal balloon; with knowledge of\n intrathoracic pressures, can consider going up on PEEP\n # Infectious process: Had been febrile, now resolved\n - be aspiration or be VAP. Sputum from grew rare GNR;\n awaiting speciation.\n - Continues on Vanc, aztreonam, levofloxicin. Vanc trough pending today\n - Also on flagyl for empiric coverage of c. diff\n - Per CT, unlikely to be abdominal process\n # Hypotension, requiring Levophed:\n - Hypovolemia is possibly a factor- responded to a transfusion; HCT had\n been dropping\n - Sepsis also a factor- on broad spectrum abs\n - Central line in place.\n # Oliguria:\n -BUN and Cr reassuring.\n # RUE DVT: Have held on starting treatment in light of need for central\n access. Can start therapeutic heparin vs Lovenox with bridge to\n coumadin.\n - No PE noted on CT scan.\n # Abd distention:\n - CT abd only showed appendiceal mucocele without inflammation, not\n concerning, most likely chronic\n - No BM in several days, continue bowel regimen, add fleets enema\n - Can test for c.diff when pt stool\ns. Continue flagyl empirically\n - Check amylase and lipase\n # Anemia:\n - Trend HCT\n - Gave 1 un pRBC with good results\n - Will guiac stools when she has a BM\n - INR rising, now 1.7, may be nutritional\n # Spine fracture: neurologically intact distal to the lesion. prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - Will have spine see pt today for recs regarding pt movement and\n anticoagulation\n # Hypernatremia, resolved: correcting with g tube free flush and D5W\n -Holding on g tube feeds at present due to high residuals\n -Replete lytes as necessary\n # Communication:\n - Brother has been with pt, although, live in boyfriend of 10 is\n her HCP. Boyfriend will hopefully visit pt today\n ICU Care\n Nutrition: tube feed with free water when able\n Glycemic Control: Regular insulin sliding scale\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Communication: ICU consent signed, (brother) \n (boyfriend/POA) \n Code status: Full code\n Disposition: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 01:36 AM\n 22 Gauge - 02:00 PM\n Arterial Line - 03:00 AM\n Multi Lumen - 11:30 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n Critical Care Staff Addendum\n 6:15pm\n I saw and examined Ms. with the ICU team this morning and have\n seen Ms. several times throughout the day; Dr. \ns note\n reflects my input. I would add/emphasize that she continues to have\n severe hypoxemic respiratory failure. She has come off of her\n vasopressor.\n CT imaging did not show PE or an intrabdominal catastrophe. Spine\n imaging confirms a compression fracture but did not detect\n retropulsion. Her lungs shows basilar and posterior atelectasis that\n is consistent with one of the CT patterns of ARDS [see Intensive Care\n Med. ;26(7):857-69], probably exacerbated by\n obesity/extra-pulmonary chest wall issues. In addition, there are\n patchy, more-apical consolidations suggestive of pneumonia. There is\n also a peri-appendiceal finding that will eventually need follow-up to\n exclude malignancy.\n CVP and stroke-volume variation suggest she is adequately\n volume-replete.\n Esophageal manometry confirmed the clinical impression that she has\n substantial extrapulmonary contribution to her plateau pressures: at\n PEEP 20, her end-expiratory transpulmonary pressure is -3 cm H2O. Her\n end-inspiratory transpulmonary pressures are minimal on current Vt of\n 400.\n Sputum is growing GNR; speciation is pending.\n Assessment and Plan\n 55-year-old woman with\n Respiratory failure\n Traumatic thoracic spinal fracture\n Probable VAP\n Shock -- improved\n Upper extremity DVT\n Anemia\n Possible tracheobronchomalacia (reason for transfer)\n Incidental peri-appendiceal finding (will need eventual\n follow-up)\n Although differential remains open, the most compelling course of\n events is probably that she required intubation at the outside hospital\n (?sedation ?restriction from obesity/brace ?other) and subsequently\n developed a GNR-related VAP. Her pattern of acute lung injury,\n combined with obesity, is resulting in basilar and\n posterior-predominant atelectasis/consolidation with a high proportion\n of shunt.\n We will\n Continue broad antibiotics pending speciation of organisms\n Ventilate with approximately 6 cc/kg predicted body weight\n Use esophageal-manometry guideded PEEP, with goal of weaning\n FiO2 to below 60% in next 12-24 hours. If unable to do so, will\n increase PEEP to end-expiratory transpulmonary pressure of 0-+3 as long\n as hemodynamics and intra-abdominal pressures allow\n If OK with spine surgery, begin anticoagulation for her\n PICC-related DVT\n Prophylaxis: full-dose heparin, H2-blocker, HOB elevation,\n oral care, CHG, etc.\n Other issues as per ICU team note.\n I discussed Ms. \ns status with her brother at bedside, including\n review of images and discussion of her critical status. All questions\n answered.\n CC Time: 75 minutes\n ------ Protected Section Addendum Entered By: , MD\n on: 18:35 ------\n"},{"category":"Nursing","chartdate":"2167-09-24 00:00:00.000","description":"Nursing Progress Note","row_id":634617,"text":"Synopsis per prior nursing note:\n 55 yr old woman admitted from OSH after she fell down the stairs and\n had traumatic T-spine fracture. Pt came to us with PNA from unknown\n etiology? VAP. Full code, Allergies: PCN, tetracycline, Sulfa. PMH:\n ETOH, smoker, Gerd, Hip replacement.\n Alteration in Nutrition\n Assessment:\n Tube feeds increased to 40ml/hr. Residuals ~10ml. Hypoactive BS.\n Continues to have brown, liquid stool.\n Action:\n Residuals and BS checked. Rate increased to 40ml/hr.\n Response:\n Residual continued at 10ml/hr, continued rate of 40cc/hr.\n Plan:\n Advance TF to goal as tolerated. Monitor BS.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n RUE DVT, pt on heparin gtt at 1700units/hr.\n Action:\n Ptt was therapeutic x3. Heparin gtt continued.\n Response:\n No change to drip made, therapeutic dose.\n Plan:\n Cont heparin gtt, check PTT w/ am labs and adjust heparin gtt per\n scale.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Suctioned moderate, thick white ET tube secretions and copious clear,\n oral secretions. LS rhonchi w/ dim bases. Esophageal balloon in\n place.\n Action:\n Continued to suction frequently, HOB >30, oral care. Continued\n steroids.\n Response:\n ABG WNL. Continued to need suctioning. O2 sats >98%.\n Plan:\n Monitor LS. Suction as needed. Wean vent as tolerated.\n Hypotension (not Shock)\n Assessment:\n BP 89-106/43-53. MAP 56-67. Goal MAP >60. Urine output>40cc/hr.\n Action:\n Levophed gtt weaned off. Given 2.5 L NS total in bolus\n for low BP. New\n A-line placed-positional.\n Response:\n MAPs continued to be ~60-65.\n Plan:\n Monitor BP. ?fluid bolus vs levophed gtt. ?need for new a-line.\n Bradycardia\n Assessment:\n SB, HR 45-63. HR increased w/ activity.\n Action:\n HR monitored.\n Response:\n No intervention done because BP cont to be stable and all other vital\n signs stable.\n Plan:\n Monitor HR. EKG if indicated.\n"},{"category":"Nursing","chartdate":"2167-09-21 00:00:00.000","description":"Nursing Progress Note","row_id":634229,"text":"55yo admitted from OSH. Pt s/p fall , sustained T5-T8\n fracture. Pt transf to failure to wean from vent. ? stent for\n tracheobronchialmalacia.\n Events: Pt had 2 attempts at Central line placement; unsuccessful at\n this point; team will attempt for femoral line placement this am.\n R-wrist Aline placed this am. Pt had KUB abdomen appears more\n distended and firm, ? possible ABD CT today.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS cont rhonchi throughout, dim bilat in base, occ. bronchospasms with\n care; abg showed resp. acidosis\n Action:\n Cont to suct for smll thick tan secretions, copious oral secretions\n suctioned, vent settings changed to 18/500/80/10\n Response:\n ABG improved, PC02 42 ; O2 Sats 95-97%\n Plan:\n f/u with IP ? tracheabronchial malacia, abgs, neb tx as needed\n Hypotension (not Shock)\n Assessment:\n Sbp down in high 90\ns, Aline damped, cont wit low UO 15-30cc/hr\n Action:\n pt bolused x 1L LR, 500mg NS for low urinary output, L-aline d/cd\n Response:\n R-radial Aline placed, SBP 110-120\n Plan:\n Cont . VS, I &O; treat as ordered\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n +DVT\n Action:\n Cont SC heparin, no BP\ns or Lab draws to R arm\n Response:\n Cont to elevate RUE\n Plan:\n Cont SC heparin,\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n TMax 99.2\n Action:\n Cont with IV ABX, second UA sent\n Response:\n Remains low grade temp\n Plan:\n f/u with pending cultures; attempt repeat sputum culture, treat temp as\n ordered\n Fracture, other\n Assessment:\n T5-T8 fracture to fall on \n Action:\n Cont in Reverse Trend., log roll precautions HOB 30\n Response:\n No s/sx pain noted\n Plan:\n Cont log roll precautions, f/u with PT, ? specialty mattress??\n Anemia, other\n Assessment:\n H/H 24.1/7.6, no active bleeding noted\n Action:\n Stool guiac negative\n Response:\n No action taken\n Plan:\n Cont to Hct, guiac stools\n"},{"category":"Nursing","chartdate":"2167-09-22 00:00:00.000","description":"Nursing Progress Note","row_id":634295,"text":"55 yr old women admitted from outside hospital. Patient fell down\n stairs at home per boyfriend pt with fracture and placed in torso\n brace at OSH, pt became hypoxic and was intubated (family requested a\n second opinion and pt was trans to ) Pt admitted for Resp failure,\n failure to wean, and ? trachial bronchial malacia. Full code,\n Allergies: PCN, Tetracycline, Sulfta.\n Per boyfriend tonight he reported that for the last two months pt has\n been drinking 2 bottles of wine almost every night.\n And that this is an increase from what she previously did which was a\n couple of beers per night.\n Alteration in Nutrition\n Assessment:\n Increase in residuals out of OG tube. Tube feeds have not been\n restarted. Bowel sounds hypoactive, per family abdomen is about 30%\n larger than normal, no BM since admission.\n Action:\n Senna and colace given. OG tube to low int. suction, was able to clamp\n tube for 2hr but residuals returned.\n Response:\n 100 ml yellow-pinkish fluid out OG tube\n Plan:\n Cont to check residuals, restart tube feeds as tolerated, ? if raglan\n would help. Increase bowel regimen if needed.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n DVT in RUE\n Action:\n No BP or blood draws in RUE. Neuro to see pt in AM to see if we\n can start heparin gtt (neuro to okay because of the spine\n fracture)\n Response:\n Plan:\n Wait for decision by Neuro and anticoagulate with heparin if\n possible.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Action:\n Response:\n Plan:\n Fracture, other\n Assessment:\n Action:\n Response:\n Plan:\n Anemia, other\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2167-09-22 00:00:00.000","description":"Nursing Progress Note","row_id":634297,"text":"55 yr old women admitted from outside hospital. Patient fell down\n stairs at home per boyfriend pt with fracture and placed in torso\n brace at OSH, pt became hypoxic and was intubated (family requested a\n second opinion and pt was trans to ) Pt admitted for Resp failure,\n failure to wean, and ? trachial bronchial malacia. Full code,\n Allergies: PCN, Tetracycline, Sulfta. Pt on log roll precautions for\n spine.\n Per boyfriend tonight he reported that for the last two months pt has\n been drinking 2 bottles of wine almost every night.\n And that this is an increase from what she previously did which was a\n couple of beers per night.\n Alteration in Nutrition\n Assessment:\n Increase in residuals out of OG tube. Tube feeds have not been\n restarted. Bowel sounds hypoactive, per family abdomen is about 30%\n larger than normal, no BM since admission.\n Action:\n Senna and colace given. OG tube to low int. suction, was able to clamp\n tube for 2hr but residuals returned.\n Response:\n 100 ml yellow-pinkish fluid out OG tube\n Plan:\n Cont to check residuals, restart tube feeds as tolerated, ? if raglan\n would help. Increase bowel regimen if needed.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n DVT in RUE\n Action:\n No BP or blood draws in RUE. Neuro to see pt in AM to see if we\n can start heparin gtt (neuro to okay because of the spine\n fracture)\n Response:\n Plan:\n Wait for decision by Neuro and anticoagulate with heparin if\n possible.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n T-max for this shift 99.6\n Action:\n Pt on Vanco, Aztreonam, Levoflaxacin, Flagyl.\n Response:\n Pt not spiking over 100\n Plan:\n Cont to monitor Temp, cont antibiotics, follow up cultures, re-culture\n if pt does spike temp again.\n Fracture, other\n Assessment:\n Reported that pt has a T5-T8 spinal fracture, Wet read from yesterdays\n CT may show just a T-9 compression, still waiting for the true results\n of this CT.\n Action:\n Log roll pt, pt increased with reverse trandelenburg positionsing,\n back brace in room if pt OOB.\n Response:\n Pt not tolerating turning\n Plan:\n Consult with neuro /wait for true CT scan results to know if spine\n is actually fractured or not and if not ? removing spine precautions.\n Anemia, other\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lung sounds clear/diminished, ? VAP and possibly ARDS on top of that.\n small amounts thick yellow secretions, vent setting changed during the\n night. Pt desats to 80% with turning and takes a long time to\n recover. Face becomes blue/purple.\n Action:\n Did not turn pt during the night, Vent setting changed during night\n currently CMV 80%/400/22/17. cont suctioning/oral care/ subglottal\n suctioning. Resp tried to place esophageal balloon again tonight\n Response:\n Small secretions out of in-line suction. Last ABG better at 7.38/41/87,\n esophageal balloon placement unsuccessful\n Plan:\n ? if team will have respiratory try to place esophageal balloon again,\n wean vent as tolerated. Cont ABG\ns with vent changes.\n Hypotension (not Shock)\n Assessment:\n Pt received on 0.04 mcg/kg/min of norepi gtt.\n Action:\n Weaned gtt off in early evening but MAPs dropped <65\n Response:\n Turned norepi gtt back on at 0.02 mg/kg/min\n Plan:\n Cont to wean norepi gtt as tolerated.\n Goals: switch pt to air mattress bed if okayed by neuro that pt\n can be moved, start heparin gtt for RUE DVT if neuro okays. Wean\n norepi gtt. Restart Tube feeds when tolerates, ? if team will try to\n float esophageal balloon again.\n"},{"category":"Physician ","chartdate":"2167-10-30 00:00:00.000","description":"Physician Resident Progress Note","row_id":640202,"text":"Chief Complaint:\n 24 Hour Events:\n - ENT team believes that vocal cord adductor dysfunction is NOT a risk\n for aspiration, rather her increased secretions put her at risk for\n aspiration. They will follow-up in clinic in two weeks with Dr.\n , call in am to schedule appt.\n - Psych recs: consider head CT if patient does not improve off\n scopolamine and metoclopramide; address anemia and\nerratic BP\n consider increasing am dose of risperdal; monitor \n - Pt continued to be agitated O/N (eg: pulled rectal tubex2 and\n foleyx1, disoriented). To receive head CT this AM\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.9\n HR: 77 (66 - 114) bpm\n BP: 128/40(60) {90/37(31) - 164/75(87)} mmHg\n RR: 23 (16 - 29) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,726 mL\n 595 mL\n PO:\n TF:\n 1,388 mL\n 301 mL\n IVF:\n 249 mL\n 105 mL\n Blood products:\n Total out:\n 1,666 mL\n 222 mL\n Urine:\n 836 mL\n 222 mL\n NG:\n Stool:\n Drains:\n Balance:\n 60 mL\n 373 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 100%\n ABG: ///34/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 183 K/uL\n 7.1 g/dL\n 115 mg/dL\n 0.5 mg/dL\n 34 mEq/L\n 3.6 mEq/L\n 13 mg/dL\n 106 mEq/L\n 145 mEq/L\n 22.8 %\n 5.4 K/uL\n [image002.jpg]\n 04:00 AM\n 05:45 AM\n 03:51 AM\n 04:45 PM\n 04:00 AM\n 07:37 PM\n 04:05 AM\n 06:05 PM\n 03:23 AM\n 02:54 AM\n WBC\n 8.0\n 8.7\n 5.5\n 5.7\n 5.8\n 5.1\n 5.4\n Hct\n 27.0\n 28.7\n 24.7\n 25.2\n 25.3\n 23.7\n 24.7\n 23.7\n 22.8\n Plt\n \n 183\n Cr\n 0.7\n 0.7\n 0.5\n 0.4\n 0.5\n 0.5\n 0.5\n 0.5\n Glucose\n 114\n 112\n 122\n 145\n 137\n 149\n 105\n 115\n Other labs: PT / PTT / INR:13.3/32.4/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.4 mg/dL, Mg++:1.9 mg/dL, PO4:3.6\n mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2167-10-30 00:00:00.000","description":"Physician Resident Progress Note","row_id":640203,"text":"Chief Complaint:\n 24 Hour Events:\n Tube Feed goals increased from 30cc to 60cc/hr. No issues O/N with\n regard to vomiting.\n Calm overnight. Risperdal decreased from 0.5mg to 0.25mg qam.\n runs of asymptomatic SVT peaking in 110-120\ns, metoprolol 37.5mg\n changed from TID\nQID and first daily dose given early after runs;\n decrease of HR to 80\n Loose, brown, malodorous stools O/N, afebrile, C.dif cx sent.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Enoxaparin (Lovenox) - 06:33 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.5\nC (97.7\n HR: 114 (61 - 122) bpm\n BP: 119/54(75) {91/36(50) - 167/84(101)} mmHg\n RR: 19 (10 - 30) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,952 mL\n 429 mL\n PO:\n TF:\n 646 mL\n 376 mL\n IVF:\n 950 mL\n 54 mL\n Blood products:\n Total out:\n 2,430 mL\n 470 mL\n Urine:\n 2,430 mL\n 240 mL\n NG:\n Stool:\n Drains:\n Balance:\n 522 mL\n -41 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 100%\n ABG: ///35/\n Physical Examination\n Gen: Alert, NAD, lying in bed, comfortable, mouthing words, less\n sedated than yest.\n HEENT: No pallor in conjunctiva, MMM, TM in place\n Resp: Transmitted upper airway sounds/coarse breath sounds.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, decreased bowel sounds, G-Tube in\n place with no erythema/induration\n Exte: No edema, DP 2+ bil\n NEURO: Alert, difficult to assess orientation due to poor voice\n although pt oriented to year not place. MAE\n Labs / Radiology\n 187 K/uL\n 7.2 g/dL\n 105 mg/dL\n 0.5 mg/dL\n 35 mEq/L\n 3.8 mEq/L\n 17 mg/dL\n 108 mEq/L\n 147 mEq/L\n 23.7 %\n 5.1 K/uL\n [image002.jpg]\n 03:00 AM\n 04:00 AM\n 05:45 AM\n 03:51 AM\n 04:45 PM\n 04:00 AM\n 07:37 PM\n 04:05 AM\n 06:05 PM\n 03:23 AM\n WBC\n 7.3\n 8.0\n 8.7\n 5.5\n 5.7\n 5.8\n 5.1\n Hct\n 27.3\n 27.0\n 28.7\n 24.7\n 25.2\n 25.3\n 23.7\n 24.7\n 23.7\n Plt\n 346\n 316\n 271\n 249\n 231\n 203\n 187\n Cr\n 0.7\n 0.7\n 0.7\n 0.5\n 0.4\n 0.5\n 0.5\n 0.5\n Glucose\n 123\n 114\n 112\n 122\n 145\n 137\n 149\n 105\n Other labs: PT / PTT / INR:13.3/32.4/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.8 mg/dL, Mg++:2.1 mg/dL, PO4:3.5\n mg/dL\n Assessment and Plan\n 56yoF s/p mechanical fall and traumatic T spine fracture transferred\n from OSH to for TBM eval with hospitalization complicated by\n respiratory failure and HAP, s/p trach/PEG, atrial tachycardia, ileus,\n and delirium/agitation.\n .\n # Respiratory: s/p intubation/extubation, now on trach mask, FiO2 50%.\n Tolerating well with good O2 sat in mid-high 90\ns. Pt continues to be\n at risk for aspiration given recent history of vomiting with tube feed\n trials and increased secretions. ENT believes that the posterior gap is\n not a risk factor for aspiration as this is a common finding in females\n and that her increased secretions and edema pose a greater aspiration\n threat; no intervention was recommended.\n - Appreciate ENT and S&S input.\n - ENT recs to f/u in 2wks with Dr. () for an\n outpatient/clinic re-evaluation.\n - ppi for aspiration prophylaxis, PMV precautions: \nt use w/o\n supervision, frequent suctioning\n - TM as tolerated.\n - d/c scopolamine as it was a cause for delirium.\n - Holding sedation with exception of Risperidal 0.25mg qam PRN\n # Delirium: Pt continues to be slightly agitated with paranoia and\n disorientation. Delirium and agitation most likely secondary to long\n hospital course and multiple psychotropic medications as well as hx of\n EtOH abuse.\n - Risperdal 0.25mg PO qam.\n - continue to hold all benzos. opiates, and antihistamines. Will\n decrease or d/c raglan and scopolamine.\n - Appreciate psych. Will call and f/u psych recs.\n -Follow EKG to assess for prolongation (last EKG ; 457).\n #Loose Stools: Multiple, loose stools O/N; afebrile, tachycardia,\n without abdominal pain\n -F/u stool c.dif cultures\n -f/u WBC and vital signs daily\n -Hold bowel regimen\n # Atrial Tachycardia: Compared to recent b/l, HR increased to max of\n 120\ns. Pt now on PO Amiodarone 200 TID and PO increased metoprolol\n 37.5mg QID.\n - Will continue amiodarone 200 TID for three weeks and then switch to\n qday for 1week and then d/c amiodarone.\n - Will need to schedule f/u in 4wks with Dr. upon d/c/transfer.\n #Anemia: HCT low compared to b/l. No known etiology of blood loss.\n -Will continue to follow HCT daily.\n - Guaiac stools.\n # Hypernatremia/Fluid Status: Mild hypernatramia resolving with free\n water administration. On TPN/TF. Good UOP. Free water deficit of 2.8L\n - increase D5W IVFx 1L from 10cc/hr to 150cc/hr, free water flushes\n with TF\n -Will f/u lytes in afternoon (5pm)\n # UE DVT and h/o labile INR: Decision made to d/c Coumadin given her\n labile INR, and start Lovenox . INR at 1.1\n - Will flush L PICC with TPA if does not flush\n - Daily coags\n .\n # Spine fracture: Stable. T5-T8.\n - Brace for OOB.\n - Pt to follow up with Dr. in .\n .\n # Tracheomalacia. Reevaluation bronchoscopy by IP as written above;\n patient not a candidate for stent; pt to follow up as outpatient. No\n new issues.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # FEN: Currently receiving TF at 50cc/hr, w/o issue.\n - Appreciate GI input and S&S eval\n -D/c Reglan for emesis precaution as pt is tolerating TF without\n vomiting and Reglan increases agitation/delirium risk.\n -meds via G-J tube,\n .\n # ACCESS: PIV x 1, L PICC\n # Ppx: Lovenox, PPi , Bowel Regimen PRN\n # Communication:\n - (brother) is primary contact\n - Boyfriend of 10 , but minimal contact has been maintained at\n this point\n - Social Work and Case management involved; have discussed situation\n w/ brother and boyfriend.\n # Code: Full\n # Dispo: ICU, Will d/w case management re rehab facilities, likely d/c\n today/tomorrow if insurance/bed confirmed\n MSIV\n PGY1 addendum: \n Agree with assessment and plan in excellent MSIV note as detailed\n above. Briefly, 56 F s/p fall with T spine fracture (T5-T8),\n respiratory failure now s/p trach/PEG. Now on trach mask. Nutrition\n issues continue; will follow up with psychiatry recs. Etiology of\n delirium/agitation still unclear but likely prolonged hospital\n course, illness and multiple medications. Currently discussing with CM\n about potential placement to rehab.\n"},{"category":"Physician ","chartdate":"2167-10-30 00:00:00.000","description":"Physician Resident Progress Note","row_id":640204,"text":"Chief Complaint:\n 24 Hour Events:\n - ENT team believes that vocal cord adductor dysfunction is NOT a risk\n for aspiration, rather her increased secretions put her at risk for\n aspiration. They will follow-up in clinic in two weeks with Dr.\n , call in am to schedule appt.\n - Psych recs: consider head CT if patient does not improve off\n scopolamine and metoclopramide; address anemia and\nerratic BP\n consider increasing am dose of risperdal; monitor \n - Pt continued to be agitated O/N (eg: pulled rectal tubex2 and\n foleyx1, disoriented). To receive head CT this AM\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.9\n HR: 77 (66 - 114) bpm\n BP: 128/40(60) {90/37(31) - 164/75(87)} mmHg\n RR: 23 (16 - 29) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,726 mL\n 595 mL\n PO:\n TF:\n 1,388 mL\n 301 mL\n IVF:\n 249 mL\n 105 mL\n Blood products:\n Total out:\n 1,666 mL\n 222 mL\n Urine:\n 836 mL\n 222 mL\n NG:\n Stool:\n Drains:\n Balance:\n 60 mL\n 373 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 100%\n ABG: ///34/\n Physical Examination\n Gen: Alert, NAD, lying in bed, comfortable, mouthing words, less\n sedated than yest.\n HEENT: No pallor in conjunctiva, MMM, TM in place\n Resp: Transmitted upper airway sounds/coarse breath sounds.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, decreased bowel sounds, G-Tube in\n place with no erythema/induration\n Exte: No edema, DP 2+ bil\n NEURO: Alert, difficult to assess orientation due to poor voice\n although pt oriented to year not place. MAE\n Labs / Radiology\n 183 K/uL\n 7.1 g/dL\n 115 mg/dL\n 0.5 mg/dL\n 34 mEq/L\n 3.6 mEq/L\n 13 mg/dL\n 106 mEq/L\n 145 mEq/L\n 22.8 %\n 5.4 K/uL\n [image002.jpg]\n 04:00 AM\n 05:45 AM\n 03:51 AM\n 04:45 PM\n 04:00 AM\n 07:37 PM\n 04:05 AM\n 06:05 PM\n 03:23 AM\n 02:54 AM\n WBC\n 8.0\n 8.7\n 5.5\n 5.7\n 5.8\n 5.1\n 5.4\n Hct\n 27.0\n 28.7\n 24.7\n 25.2\n 25.3\n 23.7\n 24.7\n 23.7\n 22.8\n Plt\n \n 183\n Cr\n 0.7\n 0.7\n 0.5\n 0.4\n 0.5\n 0.5\n 0.5\n 0.5\n Glucose\n 114\n 112\n 122\n 145\n 137\n 149\n 105\n 115\n Other labs: PT / PTT / INR:13.3/32.4/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.4 mg/dL, Mg++:1.9 mg/dL, PO4:3.6\n mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2167-10-30 00:00:00.000","description":"Physician Resident Progress Note","row_id":640206,"text":"Chief Complaint:\n 24 Hour Events:\n - ENT team believes that vocal cord adductor dysfunction is NOT a risk\n for aspiration, rather her increased secretions put her at risk for\n aspiration. They will follow-up in clinic in two weeks with Dr.\n , call in am to schedule appt.\n - Psych recs: consider head CT if patient does not improve off\n scopolamine and metoclopramide; address anemia and\nerratic BP\n consider increasing am dose of risperdal; monitor \n - Pt continued to be agitated O/N (eg: pulled rectal tubex2 and\n foleyx1, disoriented). To receive head CT this AM\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.9\n HR: 77 (66 - 114) bpm\n BP: 128/40(60) {90/37(31) - 164/75(87)} mmHg\n RR: 23 (16 - 29) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,726 mL\n 595 mL\n PO:\n TF:\n 1,388 mL\n 301 mL\n IVF:\n 249 mL\n 105 mL\n Blood products:\n Total out:\n 1,666 mL\n 222 mL\n Urine:\n 836 mL\n 222 mL\n NG:\n Stool:\n Drains:\n Balance:\n 60 mL\n 373 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 100%\n ABG: ///34/\n Physical Examination\n Gen: Alert, NAD, lying in bed, comfortable, mouthing words, less\n sedated than yest.\n HEENT: No pallor in conjunctiva, MMM, TM in place\n Resp: Transmitted upper airway sounds/coarse breath sounds.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, decreased bowel sounds, G-Tube in\n place with no erythema/induration\n Exte: No edema, DP 2+ bil\n NEURO: Alert, difficult to assess orientation due to poor voice\n although pt oriented to year not place. MAE\n Labs / Radiology\n 183 K/uL\n 7.1 g/dL\n 115 mg/dL\n 0.5 mg/dL\n 34 mEq/L\n 3.6 mEq/L\n 13 mg/dL\n 106 mEq/L\n 145 mEq/L\n 22.8 %\n 5.4 K/uL\n [image002.jpg]\n 04:00 AM\n 05:45 AM\n 03:51 AM\n 04:45 PM\n 04:00 AM\n 07:37 PM\n 04:05 AM\n 06:05 PM\n 03:23 AM\n 02:54 AM\n WBC\n 8.0\n 8.7\n 5.5\n 5.7\n 5.8\n 5.1\n 5.4\n Hct\n 27.0\n 28.7\n 24.7\n 25.2\n 25.3\n 23.7\n 24.7\n 23.7\n 22.8\n Plt\n \n 183\n Cr\n 0.7\n 0.7\n 0.5\n 0.4\n 0.5\n 0.5\n 0.5\n 0.5\n Glucose\n 114\n 112\n 122\n 145\n 137\n 149\n 105\n 115\n Other labs: PT / PTT / INR:13.3/32.4/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.4 mg/dL, Mg++:1.9 mg/dL, PO4:3.6\n mg/dL\n Assessment and Plan\n 56yoF s/p mechanical fall and traumatic T spine fracture transferred\n from OSH to for TBM eval with hospitalization complicated by\n respiratory failure and HAP, s/p trach/PEG, atrial tachycardia, ileus,\n and delirium/agitation.\n .\n # Respiratory: s/p intubation/extubation, now on trach mask, FiO2 50%.\n Tolerating well with good O2 sat in mid-high 90\ns. Pt continues to be\n at risk for aspiration given recent history of vomiting with tube feed\n trials and increased secretions. ENT believes that the posterior gap is\n not a risk factor for aspiration as this is a common finding in females\n and that her increased secretions and edema pose a greater aspiration\n threat; no intervention was recommended.\n - Appreciate ENT and S&S input.\n - ENT recs to f/u in 2wks with Dr. () for an\n outpatient/clinic re-evaluation.\n - ppi for aspiration prophylaxis, PMV precautions: \nt use w/o\n supervision, frequent suctioning\n - TM as tolerated.\n - d/c scopolamine as it was a cause for delirium.\n - Holding sedation with exception of Risperidal 0.25mg qam PRN\n # Delirium: Pt continues to be slightly agitated with paranoia and\n disorientation. Delirium and agitation most likely secondary to long\n hospital course and multiple psychotropic medications as well as hx of\n EtOH abuse.\n - Risperdal 0.25mg PO qam.\n - continue to hold all benzos. opiates, and antihistamines. Will\n decrease or d/c raglan and scopolamine.\n - Appreciate psych. Will call and f/u psych recs.\n -Follow EKG to assess for prolongation (last EKG ; 457).\n #Loose Stools: Multiple, loose stools O/N; afebrile, tachycardia,\n without abdominal pain\n -F/u stool c.dif cultures\n -f/u WBC and vital signs daily\n -Hold bowel regimen\n # Atrial Tachycardia: Compared to recent b/l, HR increased to max of\n 120\ns. Pt now on PO Amiodarone 200 TID and PO increased metoprolol\n 37.5mg QID.\n - Will continue amiodarone 200 TID for three weeks and then switch to\n qday for 1week and then d/c amiodarone.\n - Will need to schedule f/u in 4wks with Dr. upon d/c/transfer.\n #Anemia: HCT low compared to b/l. No known etiology of blood loss.\n -Will continue to follow HCT daily.\n - Guaiac stools.\n # Hypernatremia/Fluid Status: Mild hypernatramia resolving with free\n water administration. On TPN/TF. Good UOP. Free water deficit of 2.8L\n - increase D5W IVFx 1L from 10cc/hr to 150cc/hr, free water flushes\n with TF\n -Will f/u lytes in afternoon (5pm)\n # UE DVT and h/o labile INR: Decision made to d/c Coumadin given her\n labile INR, and start Lovenox . INR at 1.1\n - Will flush L PICC with TPA if does not flush\n - Daily coags\n .\n # Spine fracture: Stable. T5-T8.\n - Brace for OOB.\n - Pt to follow up with Dr. in .\n .\n # Tracheomalacia. Reevaluation bronchoscopy by IP as written above;\n patient not a candidate for stent; pt to follow up as outpatient. No\n new issues.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # FEN: Currently receiving TF at 50cc/hr, w/o issue.\n - Appreciate GI input and S&S eval\n -D/c Reglan for emesis precaution as pt is tolerating TF without\n vomiting and Reglan increases agitation/delirium risk.\n -meds via G-J tube,\n .\n # ACCESS: PIV x 1, L PICC\n # Ppx: Lovenox, PPi , Bowel Regimen PRN\n # Communication:\n - (brother) is primary contact\n - Boyfriend of 10 , but minimal contact has been maintained at\n this point\n - Social Work and Case management involved; have discussed situation\n w/ brother and boyfriend.\n # Code: Full\n # Dispo: ICU, Will d/w case management re rehab facilities, likely d/c\n today/tomorrow if insurance/bed confirmed\n MSIV\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Respiratory ","chartdate":"2167-10-29 00:00:00.000","description":"Respiratory Care Shift Note","row_id":640135,"text":"Demographics\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Tube Type\n Tracheostomy tube:\n Type: Cuffed\n Manufacturer: Portex\n Size: 7.0mm\n PMV: Yes\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Copious\n Comments: Pt continues to require frequent suctioning. Did wear PMV\n for 15 mins today.\n"},{"category":"Physician ","chartdate":"2167-10-28 00:00:00.000","description":"Physician Resident Progress Note","row_id":639845,"text":"Chief Complaint:\n 24 Hour Events:\n BRONCHOSCOPY by IP- At 09:43 AM. Tracheomalacia, lack of\n posterior complete closure above cords resulting in possible etiology\n of recurrent aspiration\n Per nursing had increased secretions requiring deep suctioning\n overnight\n Restarted TF\n Changed PPI to per IP recs\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:05 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.1\nC (97\n HR: 86 (62 - 122) bpm\n BP: 146/61(82) {87/42(53) - 152/87(98)} mmHg\n RR: 23 (19 - 36) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 3,692 mL\n 1,252 mL\n PO:\n TF:\n 116 mL\n 116 mL\n IVF:\n 2,175 mL\n 775 mL\n Blood products:\n Total out:\n 3,790 mL\n 400 mL\n Urine:\n 3,790 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n -98 mL\n 854 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 95%\n ABG: ///32/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 203 K/uL\n 7.5 g/dL\n 137 mg/dL\n 0.5 mg/dL\n 32 mEq/L\n 3.8 mEq/L\n 13 mg/dL\n 110 mEq/L\n 148 mEq/L\n 23.7 %\n 5.8 K/uL\n [image002.jpg]\n 03:20 PM\n 03:23 AM\n 03:00 AM\n 04:00 AM\n 05:45 AM\n 03:51 AM\n 04:45 PM\n 04:00 AM\n 07:37 PM\n 04:05 AM\n WBC\n 5.7\n 7.3\n 8.0\n 8.7\n 5.5\n 5.7\n 5.8\n Hct\n 30.0\n 26.9\n 27.3\n 27.0\n 28.7\n 24.7\n 25.2\n 25.3\n 23.7\n Plt\n 356\n 346\n 316\n 271\n 249\n 231\n 203\n Cr\n 0.7\n 0.7\n 0.7\n 0.7\n 0.5\n 0.4\n 0.5\n Glucose\n 129\n 123\n 114\n 112\n 122\n 145\n 137\n Other labs: PT / PTT / INR:13.3/32.4/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.9 mg/dL, Mg++:2.1 mg/dL, PO4:3.6\n mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Replete with Fiber () - 06:00 PM 20 mL/hour\n TPN w/ Lipids - 06:02 PM 62.5 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2167-10-28 00:00:00.000","description":"Physician Resident Progress Note","row_id":639846,"text":"Chief Complaint:\n 24 Hour Events:\n BRONCHOSCOPY by IP- At 09:43 AM. Severe diffuse\n Tracheobronchomalacia, large gap posterior commisure above cords\n resulting in possible etiology of recurrent aspiration\n Seen by ENT, no attg note. Consider posterior augmentation\n Per nursing had increased secretions requiring deep suctioning\n overnight\n Restarted TF\n Changed PPI to per IP recs\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:05 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.1\nC (97\n HR: 86 (62 - 122) bpm\n BP: 146/61(82) {87/42(53) - 152/87(98)} mmHg\n RR: 23 (19 - 36) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 3,692 mL\n 1,252 mL\n PO:\n TF:\n 116 mL\n 116 mL\n IVF:\n 2,175 mL\n 775 mL\n Blood products:\n Total out:\n 3,790 mL\n 400 mL\n Urine:\n 3,790 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n -98 mL\n 854 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 95%\n ABG: ///32/\n Physical Examination\n Gen: Sedating post-bronchoscopy; Sleeping; pt would not wake for exam.\n HEENT: No pallor in conjunctiva, MMM\n Resp: Course breath sounds anteriorly, mild exp wheeze.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, decreased bowel sounds, G-Tube in\n place with no erythema/induration\n Exte: No edema, DP 2+ bil\n NEURO: Sedated\n Labs / Radiology\n 203 K/uL\n 7.5 g/dL\n 137 mg/dL\n 0.5 mg/dL\n 32 mEq/L\n 3.8 mEq/L\n 13 mg/dL\n 110 mEq/L\n 148 mEq/L\n 23.7 %\n 5.8 K/uL\n [image002.jpg]\n 03:20 PM\n 03:23 AM\n 03:00 AM\n 04:00 AM\n 05:45 AM\n 03:51 AM\n 04:45 PM\n 04:00 AM\n 07:37 PM\n 04:05 AM\n WBC\n 5.7\n 7.3\n 8.0\n 8.7\n 5.5\n 5.7\n 5.8\n Hct\n 30.0\n 26.9\n 27.3\n 27.0\n 28.7\n 24.7\n 25.2\n 25.3\n 23.7\n Plt\n 356\n 346\n 316\n 271\n 249\n 231\n 203\n Cr\n 0.7\n 0.7\n 0.7\n 0.7\n 0.5\n 0.4\n 0.5\n Glucose\n 129\n 123\n 114\n 112\n 122\n 145\n 137\n Other labs: PT / PTT / INR:13.3/32.4/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.9 mg/dL, Mg++:2.1 mg/dL, PO4:3.6\n mg/dL\n Assessment and Plan\n 56yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach/PEG with resolving respiratory failure and HAP.\n .\n # Respiratory failure/Aspiration Risk: s/p intubation/extubation, now\n on trach mask, FiO2 50%. Tolerating well with good O2 sat. No further\n self-decanulations overnight. Pt continues to be at risk for aspiration\n given new IP finding of opening defect in posterior vocal cord space\n and given recent history of vomiting with tube feed trials.\n - ENT consulted for evaluation of larynx and possible intervention;\n will follow ENT recs\n - increase ppi from qday to for aspiration prophylaxis\n - Trach mask as tolerated.\n - scopolamine patch q72hrs for secretions\n - Holding sedation with exception of Risperidal 0.5mg PRN\n - F/u CXR tomorrow\n .\n # Nutrition/Vomiting: Currently receiving TPN; BMx2 in past 24 hrs to\n indicate possible improvement in ileus. TF tolerated during trial O/N\n without emesis.\n - Cont Reglan 20mg IV Q 8 hours; meds via G-J tube,\n - Will obtain recommendations from Nutrition re TPN today and will\n provide TF as tolerated\n - Speech and Swallow eval today for Passy Muir valve eval;\n - GI consult, will f/u recs\n .\n # Tachycardia: Improved HR max of 120\ns versus 160s previously. Pt now\n on PO Amiodarone 200 TID and PO metoprolol 37.5mg TID\n - Continue current med regimen. Will continue amiodarone 200 TID for\n three weeks and then switch to qday for 1week and then d/c amiodarone.\n - Will need to schedule f/u in 4wks with Dr. upon d/c/transfer.\n - f/u Cards recs\n # Sedation/Anxiolysis/AlteredMS: Resolved O/N with risperdal. Previous\n delirium and agitation most likely secondary to long hospital course\n and multiple psychotropic medications as well as hx of EtOH abuse.\n - started Risperdal 0.5mg PO BID PRN.\n - continue to hold all benzos. opiates, and antihistamines\n - Appreciate psych. Will call and f/u psych recs.\n -Obtain EKG to assess for QTc prolongation.\n #Anemia: HCT stable at 25. No known etiology of blood loss.\n -Will repeat HCT in am .\n # Hypernatremia/Fluid Status: Mild hypernatramia resolving with free\n water administration. On TPN/TF. Good UOP.\n - providing D5W IVFx 1L at 125cc/hr, free water flushes with TF\n -Will f/u lytes in afternoon (5pm)\n # UE DVT and elevated INR: Decision made to d/c Coumadin given her\n labile INR, and start Lovenox .\n - Will flush L PICC with TPA if does not flush\n - Add coags to am labs\n .\n # Spine fracture: Stable\n - Brace for OOB, need to discuss with Neurosurgery before d/c if\n current brace is optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n .\n # Tracheomalacia. Reevaluation bronchoscopy by IP as written above;\n patient not a candidate for stent; pt to follow up as outpatient. No\n new issues.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # ACCESS: PIV x 1, L PICC\n # Ppx: Lovenox, PPi-to increase to , Bowel Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n - Social Work and Case management involved; have discussed situation\n w/ brother and boyfriend.\n # Code: Full\n # Dispo: ICU, Will d/w case management re rehab facilities.\n MSIV\n PGY2 addendum:\n Agree with assessment and plan in MSIV note as detailed above.\n Briefly, 56 F s/p fall with T spine fracture, respiratory failure now\n s/p trach/PEG. Now on trach mask. Patient s/p bronch with IP today;\n ENT to see and follow for ?intervention. Nutrition issues continue;\n will receive TPN today plus possible restart of tube feeds as tolerated\n (later today), continue reglan. Appreciate psych recs; continuing\n risperidone for agitation. Etiology of delirium/agitation still\n unclear. Likely eventual dispo to rehab facility directly from ICU\n given high nursing requirements.\n ICU Care\n Nutrition:\n Replete with Fiber () - 06:00 PM 20 mL/hour\n TPN w/ Lipids - 06:02 PM 62.5 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Respiratory ","chartdate":"2167-10-28 00:00:00.000","description":"Respiratory Care Shift Note","row_id":639853,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 40\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason:\n Tube Type\n Tracheostomy tube:\n Type: Cuffed\n Manufacturer: Portex\n Size: 7.0mm\n PMV: No\n Cuff Management:\n Vol/Press:\n Cuff pressure: 23 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thin\n Sputum source/amount: Suctioned / Copious\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Unassisted spontaneous breathing\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n"},{"category":"Physician ","chartdate":"2167-10-29 00:00:00.000","description":"Physician Resident Progress Note","row_id":640120,"text":"Chief Complaint:\n 24 Hour Events:\n Tube Feed goals increased from 30cc to 60cc/hr. No issues O/N with\n regard to vomiting.\n Calm overnight. Risperdal decreased from 0.5mg to 0.25mg qam.\n runs of asymptomatic SVT peaking in 110-120\ns, metoprolol 37.5mg\n changed from TID\nQID and first daily dose given early after runs;\n decrease of HR to 80\n Loose, brown, malodorous stools O/N, afebrile, C.dif cx sent.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Enoxaparin (Lovenox) - 06:33 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.5\nC (97.7\n HR: 114 (61 - 122) bpm\n BP: 119/54(75) {91/36(50) - 167/84(101)} mmHg\n RR: 19 (10 - 30) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,952 mL\n 429 mL\n PO:\n TF:\n 646 mL\n 376 mL\n IVF:\n 950 mL\n 54 mL\n Blood products:\n Total out:\n 2,430 mL\n 470 mL\n Urine:\n 2,430 mL\n 240 mL\n NG:\n Stool:\n Drains:\n Balance:\n 522 mL\n -41 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 100%\n ABG: ///35/\n Physical Examination\n Gen: Alert, NAD, lying in bed, comfortable, mouthing words, less\n sedated than yest.\n HEENT: No pallor in conjunctiva, MMM, TM in place\n Resp: Transmitted upper airway sounds/coarse breath sounds.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, decreased bowel sounds, G-Tube in\n place with no erythema/induration\n Exte: No edema, DP 2+ bil\n NEURO: Alert, difficult to assess orientation due to poor voice\n although pt oriented to year not place. MAE\n Labs / Radiology\n 187 K/uL\n 7.2 g/dL\n 105 mg/dL\n 0.5 mg/dL\n 35 mEq/L\n 3.8 mEq/L\n 17 mg/dL\n 108 mEq/L\n 147 mEq/L\n 23.7 %\n 5.1 K/uL\n [image002.jpg]\n 03:00 AM\n 04:00 AM\n 05:45 AM\n 03:51 AM\n 04:45 PM\n 04:00 AM\n 07:37 PM\n 04:05 AM\n 06:05 PM\n 03:23 AM\n WBC\n 7.3\n 8.0\n 8.7\n 5.5\n 5.7\n 5.8\n 5.1\n Hct\n 27.3\n 27.0\n 28.7\n 24.7\n 25.2\n 25.3\n 23.7\n 24.7\n 23.7\n Plt\n 346\n 316\n 271\n 249\n 231\n 203\n 187\n Cr\n 0.7\n 0.7\n 0.7\n 0.5\n 0.4\n 0.5\n 0.5\n 0.5\n Glucose\n 123\n 114\n 112\n 122\n 145\n 137\n 149\n 105\n Other labs: PT / PTT / INR:13.3/32.4/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.8 mg/dL, Mg++:2.1 mg/dL, PO4:3.5\n mg/dL\n Assessment and Plan\n 56yoF s/p mechanical fall and traumatic T spine fracture transferred\n from OSH to for TBM eval with hospitalization complicated by\n respiratory failure and HAP, s/p trach/PEG, atrial tachycardia, ileus,\n and delirium/agitation.\n .\n # Respiratory: s/p intubation/extubation, now on trach mask, FiO2 50%.\n Tolerating well with good O2 sat in mid-high 90\ns. Pt continues to be\n at risk for aspiration given recent history of vomiting with tube feed\n trials and increased secretions. ENT believes that the posterior gap is\n not a risk factor for aspiration as this is a common finding in females\n and that her increased secretions and edema pose a greater aspiration\n threat; no intervention was recommended.\n - Appreciate ENT and S&S input.\n - ENT recs to f/u in 2wks with Dr. () for an\n outpatient/clinic re-evaluation.\n - ppi for aspiration prophylaxis, PMV precautions: \nt use w/o\n supervision, frequent suctioning\n - TM as tolerated.\n - d/c scopolamine as it was a cause for delirium.\n - Holding sedation with exception of Risperidal 0.25mg qam PRN\n # Delirium: Pt continues to be slightly agitated with paranoia and\n disorientation. Delirium and agitation most likely secondary to long\n hospital course and multiple psychotropic medications as well as hx of\n EtOH abuse.\n - Risperdal 0.25mg PO qam.\n - continue to hold all benzos. opiates, and antihistamines. Will\n decrease or d/c raglan and scopolamine.\n - Appreciate psych. Will call and f/u psych recs.\n -Follow EKG to assess for QTc prolongation (last EKG ; QTc 457).\n #Loose Stools: Multiple, loose stools O/N; afebrile, tachycardia,\n without abdominal pain\n -F/u stool c.dif cultures\n -f/u WBC and vital signs daily\n -Hold bowel regimen\n # Atrial Tachycardia: Compared to recent b/l, HR increased to max of\n 120\ns. Pt now on PO Amiodarone 200 TID and PO increased metoprolol\n 37.5mg QID.\n - Will continue amiodarone 200 TID for three weeks and then switch to\n qday for 1week and then d/c amiodarone.\n - Will need to schedule f/u in 4wks with Dr. upon d/c/transfer.\n #Anemia: HCT low compared to b/l. No known etiology of blood loss.\n -Will continue to follow HCT daily.\n - Guaiac stools.\n # Hypernatremia/Fluid Status: Mild hypernatramia resolving with free\n water administration. On TPN/TF. Good UOP. Free water deficit of 2.8L\n - increase D5W IVFx 1L from 10cc/hr to 150cc/hr, free water flushes\n with TF\n -Will f/u lytes in afternoon (5pm)\n # UE DVT and h/o labile INR: Decision made to d/c Coumadin given her\n labile INR, and start Lovenox . INR at 1.1\n - Will flush L PICC with TPA if does not flush\n - Daily coags\n .\n # Spine fracture: Stable. T5-T8.\n - Brace for OOB.\n - Pt to follow up with Dr. in .\n .\n # Tracheomalacia. Reevaluation bronchoscopy by IP as written above;\n patient not a candidate for stent; pt to follow up as outpatient. No\n new issues.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # FEN: Currently receiving TF at 50cc/hr, w/o issue.\n - Appreciate GI input and S&S eval\n -D/c Reglan for emesis precaution as pt is tolerating TF without\n vomiting and Reglan increases agitation/delirium risk.\n -meds via G-J tube,\n .\n # ACCESS: PIV x 1, L PICC\n # Ppx: Lovenox, PPi , Bowel Regimen PRN\n # Communication:\n - (brother) is primary contact\n - Boyfriend of 10 , but minimal contact has been maintained at\n this point\n - Social Work and Case management involved; have discussed situation\n w/ brother and boyfriend.\n # Code: Full\n # Dispo: ICU, Will d/w case management re rehab facilities, likely d/c\n today/tomorrow if insurance/bed confirmed\n MSIV\n PGY2 addendum: , \n Agree with assessment and plan in excellent MSIV note as detailed\n above. Briefly, 56 F s/p fall with T spine fracture (T5-T8),\n respiratory failure now s/p trach/PEG. Now on trach mask. Patient s/p\n bronch with IP yesterday. Nutrition issues continue; have discontinued\n TPN today and will continue tubefeeding to goal of 60cc/hr per\n Nutrition. Will continue reglan until at goal feedings, and decrease\n and d/c as able given potential for delirium. Appreciate psych recs;\n continuing risperidone for agitation. Etiology of delirium/agitation\n still unclear but likely prolonged hospital course, illness and\n multiple medications. Currently discussing with CM about potential\n placement to rehab tomorrow.\n"},{"category":"Nursing","chartdate":"2167-10-29 00:00:00.000","description":"Nursing Progress Note","row_id":640121,"text":"Synopsis per prior nursing note:\n 56 yr old woman, who was transferred from osh for evaluation of\n tracheal bronchial malacia on .Pt presented to Medical\n Center on s/p fall down a flight of stairs fracturing, t5-t8 with\n propulsion treated conservatively with pain meds and back brace. She\n developed resp distress requiring intubation on . Trach/PEG done\n . Now with prolonged hospital course c/b by PNA, anxiety/altered\n mental status, R&LUE DVT .Pt found to have small non occlusive clot on\n her right axial vein via Ultrasound, now rec\ning Lovenox. She has had\n problems with vomiting tube feedings, so feeding tube passed through\n g-tube to her jejunenum. However, she continued to intermit raise\n gastric contents assoc with bronchospasm. Has not required ventilation\n since , on humidified TM @ 50%. Presently on TPN and restarted on\n TF\nings at low rate via J-tube.\n BRONCHOSCOPY by IP- At 09:43 AM. Severe diffuse\n Tracheobronchomalacia, large gap posterior commisure above true vocal\n cords resulting in possible etiology of recurrent aspiration\n Airway Clearance, Impaired\n Assessment:\n LS-bilat rhonchi. O2 sat >95% on 50% trach collar. Suctioned large amts\n of thick, white secretions. Passy-muir valve in only while being\n evaluated by Psych d/t large amt of secretions.\n Action:\n Suctioned every one hour. Scolpolamine patch d/c\nd d/t mental status.\n Response:\n Needed suctioning every 1hour.\n Plan:\n to monitor and clear airway as needed.\n Alteration in Nutrition\n Assessment:\n Continues on replete w/fiber full strength.. Advance by 10ml q6 hours.\n Flush w/ 100 ml hour every 4 hours. Denies nausea. No vomiting.\n Mushroom cath in place.\n Action:\n J tube in place, unable to check resuduals. Increased TF as tolerated.\n Reglan d/c\nd d/t to mental status. Colace/senna/polyethylene glycol\n held.\n Response:\n Continues to have liquid stool. Currently tolerating TF.\n Plan:\n Advance TF to goal as tolerated.\n Fracture, other\n Assessment:\n Patient has a fracture of t5-t8. Denied pain. Brace on while OOB in\n chair.\n Action:\n Changed position. Brace on while OOB.\n Response:\n Continued to deny pain.\n Plan:\n Assess/treat pain. Brace on while OOB.\n Altered mental status (not Delirium)\n Assessment:\n When passy-muir valve on, patient had +VH and +AH. She was paranoid\n about her brother in hallway (brother was not at hospital). Stated that\n she will be driving her car home tomorrow. Stated that she is scared.\n Follows commands. Continues to try to pull out lines/tubes. Continues\n to throw her legs over the side of the bed.\n Action:\n w/ soft wrist restraints. Reoriented frequently. Assured patient\n that she is safe in hospital.\n Response:\n Patient remains safe. Able to be calmed when told she is safe in\n hospital.\n Plan:\n current safety plan. Reorient frequently. Psych will continue to\n follow.\n"},{"category":"Rehab Services","chartdate":"2167-10-30 00:00:00.000","description":"Physical Therapy Progress Note","row_id":640295,"text":"Subjective:\n I thought I could stand but then I couldn't when I tried!\n Objective:\n Follow up PT visit to address goals of: . Patient seen today\n for balance training, patient education\n Updated medical status: improving mental status\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Rolling:\n\n\n\n\n\n Supine/\n Sidelying to Sit:\n\n\n\n\n\n Transfer:\n\n\n\n T\n\n Sit to Stand:\n\n\n\n T\n\n Ambulation:\n\n\n\n T\n\n Stairs:\n\n\n\n\n\n Aerobic Activity Response:\n Position\n HR\n BP\n RR\n O[2] sat\n RPE\n Rest\n Sit\n 84\n 100/44\n Activity\n Sit\n 84\n 186/64\n Recovery\n /\n Total distance walked: 3 steps\n Minutes:\n Gait: able to bear wt B. took three steps bed-chair, chair-bed,\n bed-chair. transfer performed x 3.\n Balance: falling forward in standing with mod a to recover\n Education / Communication: pt ed: role of PT\n case discussed with rn\n Other: strong congested cough productive for mod amounts of thick\n sputum.\n tlso attempted to fit brace but brace is too large excessive weight\n loss\n ms: oriented to self. following commands.\n Assessment: 56 f s/p fall with T8fx presents with improved ability to\n participate in PT today. She continues to require extensive rehab but\n given improvements in mental status her potential is good to return to\n ambulation. She may be limited by confusion. She needs to be fit for a\n new brace as her most recent CT showed worsening vertebral body height.\n Anticipated Discharge: Rehab\n Plan: F/u if pt not d/c to rehab for new brace and continued mobility\n and gait traininig.\n"},{"category":"Physician ","chartdate":"2167-10-30 00:00:00.000","description":"Physician Attending Progress Note","row_id":640278,"text":"Chief Complaint: Delerium, respiratory failure (chronic)\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n STOOL CULTURE - At 06:33 AM\n Remains delerious, confused. Remains somewhat paranoid.\n Up in chair.\n History obtained from Medical records\n Patient unable to provide history: Encephalopathy\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 PM\n Enoxaparin (Lovenox) - 06:00 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, Tube feeds, No(t) Parenteral nutrition\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation, PEG\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, No(t) Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: No(t) Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 12:02 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.1\nC (96.9\n HR: 70 (66 - 112) bpm\n BP: 96/52(61) {90/37(31) - 164/75(87)} mmHg\n RR: 22 (16 - 29) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,726 mL\n 901 mL\n PO:\n TF:\n 1,388 mL\n 301 mL\n IVF:\n 249 mL\n 330 mL\n Blood products:\n Total out:\n 1,666 mL\n 282 mL\n Urine:\n 836 mL\n 282 mL\n NG:\n Stool:\n Drains:\n Balance:\n 60 mL\n 619 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 100%\n ABG: ///34/\n Physical Examination\n General Appearance: No(t) Well nourished, No acute distress, Overweight\n / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic,\n No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: No(t) Clear : , No(t) Crackles : , No(t) Bronchial: ,\n No(t) Wheezes : , No(t) Diminished: , No(t) Absent : , Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): , Movement: Purposeful, No(t) Sedated, No(t)\n Paralyzed, Tone: Normal\n Labs / Radiology\n 7.1 g/dL\n 183 K/uL\n 115 mg/dL\n 0.5 mg/dL\n 34 mEq/L\n 3.6 mEq/L\n 13 mg/dL\n 106 mEq/L\n 145 mEq/L\n 22.8 %\n 5.4 K/uL\n [image002.jpg]\n 04:00 AM\n 05:45 AM\n 03:51 AM\n 04:45 PM\n 04:00 AM\n 07:37 PM\n 04:05 AM\n 06:05 PM\n 03:23 AM\n 02:54 AM\n WBC\n 8.0\n 8.7\n 5.5\n 5.7\n 5.8\n 5.1\n 5.4\n Hct\n 27.0\n 28.7\n 24.7\n 25.2\n 25.3\n 23.7\n 24.7\n 23.7\n 22.8\n Plt\n \n 183\n Cr\n 0.7\n 0.7\n 0.5\n 0.4\n 0.5\n 0.5\n 0.5\n 0.5\n Glucose\n 114\n 112\n 122\n 145\n 137\n 149\n 105\n 115\n Other labs: PT / PTT / INR:13.3/32.4/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.4 mg/dL, Mg++:1.9 mg/dL, PO4:3.6\n mg/dL\n Assessment and Plan\n Delerium.\n DELERIUM -- likely multifactorial. EtOH withdrawl-related,\n medications, ICU psychosis.\n RESPIRATORY FUNCTION -- stable with trach. Remains on trach collar.\n TRACHEOBRONCHOMALACIA --\n VOCAL CORD DYSFUNCTION -- adduction problem. need ENT f/u in\n future.\n NUTRITIONAL SUPPORT -- TF via PEG\n FLUIDS -- euvolemic. Monitor I/O.\n REHABILITATION placement in progress.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 55 minutes\n Patient is critically ill\n"},{"category":"Nutrition","chartdate":"2167-10-30 00:00:00.000","description":"Clinical Nutrition Note","row_id":640283,"text":"Objective\n Pertinent medications: noted\n Labs:\n Value\n Date\n Glucose\n 115 mg/dL\n 02:54 AM\n Glucose Finger Stick\n 111\n 10:00 AM\n BUN\n 13 mg/dL\n 02:54 AM\n Creatinine\n 0.5 mg/dL\n 02:54 AM\n Sodium\n 145 mEq/L\n 02:54 AM\n Potassium\n 3.6 mEq/L\n 02:54 AM\n Chloride\n 106 mEq/L\n 02:54 AM\n TCO2\n 34 mEq/L\n 02:54 AM\n PO2 (arterial)\n 120 mm Hg\n 03:36 AM\n PO2 (venous)\n 62 mm Hg\n 02:35 AM\n PCO2 (arterial)\n 44 mm Hg\n 03:36 AM\n PCO2 (venous)\n 58 mm Hg\n 02:35 AM\n pH (arterial)\n 7.37 units\n 03:36 AM\n pH (venous)\n 7.37 units\n 02:35 AM\n pH (urine)\n 5.0 units\n 03:05 AM\n CO2 (Calc) arterial\n 26 mEq/L\n 03:36 AM\n CO2 (Calc) venous\n 35 mEq/L\n 02:35 AM\n Albumin\n 3.1 g/dL\n 03:23 AM\n Calcium non-ionized\n 8.4 mg/dL\n 02:54 AM\n Phosphorus\n 3.6 mg/dL\n 02:54 AM\n Ionized Calcium\n 1.24 mmol/L\n 02:51 AM\n Magnesium\n 1.9 mg/dL\n 02:54 AM\n Current diet order / nutrition support: Replte c/ Fiber @60mL/hr (1440\n kcals/89 graa)\n GI: abd soft/+bs.+BM\n Assessment of Nutritional Status\n Specifics:\n TF\ns advanced over past 2 days, were infusing @ goal, until held p/\n suctioned for thick mucous and ? possible aspiration. Per rounds plan\n to resume TF\ns this afternoon and advance back to goal slowly. IF pt\n c/ continuous need to held TF\ns will need to resume TPN to prevent\n nutritional decline.\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: via TF\n Resume TF's as able c/ low threshold for resumption of TPN to avoid\n nutritional decline\n Aspiration precautions keep HOB .45 degrees when feeding\n BG and lyte management as you are\n Will follow- please call c/ ?\ns #\n"},{"category":"Physician ","chartdate":"2167-10-30 00:00:00.000","description":"Physician Resident Progress Note","row_id":640284,"text":"Chief Complaint:\n 24 Hour Events:\n - ENT team believes that vocal cord adductor dysfunction is NOT a risk\n for aspiration, rather her increased secretions put her at risk for\n aspiration. They will follow-up in clinic in two weeks with Dr.\n , call in am to schedule appt.\n - Psych recs: consider head CT if patient does not improve off\n scopolamine and metoclopramide; address anemia and\nerratic BP\n consider increasing am dose of risperdal; monitor \n - Pt continued to be agitated O/N (eg: pulled rectal tubex2 and\n foleyx1, disoriented). To receive head CT this AM\n -HCT at 22.8 down 1pt with b/l in high 20\n -Suctioned thick green mucus from mouth (not trach) this am, TF held.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.9\n HR: 77 (66 - 114) bpm\n BP: 128/40(60) {90/37(31) - 164/75(87)} mmHg\n RR: 23 (16 - 29) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,726 mL\n 595 mL\n PO:\n TF:\n 1,388 mL\n 301 mL\n IVF:\n 249 mL\n 105 mL\n Blood products:\n Total out:\n 1,666 mL\n 222 mL\n Urine:\n 836 mL\n 222 mL\n NG:\n Stool:\n Drains:\n Balance:\n 60 mL\n 373 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 100%\n ABG: ///34/\n Physical Examination\n Gen: NAD, lying in bed, comfortable, PMV on, able to vocalize. HEENT:\n No pallor in conjunctiva, MMM, TM in place\n Resp: Transmitted upper airway sounds/coarse breath sounds, improved\n compared to yesterday.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, decreased bowel sounds, G-Tube in\n place with no s/s of infection\n Exte: No edema, DP 2+ bil\n NEURO: AxO to year (not to place or day-thinks it is\nthe day before\n \n), MAE\n Labs / Radiology\n 183 K/uL\n 7.1 g/dL\n 115 mg/dL\n 0.5 mg/dL\n 34 mEq/L\n 3.6 mEq/L\n 13 mg/dL\n 106 mEq/L\n 145 mEq/L\n 22.8 %\n 5.4 K/uL\n [image002.jpg]\n C.dif negative x1; Cdif#2 pending. BCx and Urine Cx No Growth.\n 04:00 AM\n 05:45 AM\n 03:51 AM\n 04:45 PM\n 04:00 AM\n 07:37 PM\n 04:05 AM\n 06:05 PM\n 03:23 AM\n 02:54 AM\n WBC\n 8.0\n 8.7\n 5.5\n 5.7\n 5.8\n 5.1\n 5.4\n Hct\n 27.0\n 28.7\n 24.7\n 25.2\n 25.3\n 23.7\n 24.7\n 23.7\n 22.8\n Plt\n \n 183\n Cr\n 0.7\n 0.7\n 0.5\n 0.4\n 0.5\n 0.5\n 0.5\n 0.5\n Glucose\n 114\n 112\n 122\n 145\n 137\n 149\n 105\n 115\n Other labs: PT / PTT / INR:13.3/32.4/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.4 mg/dL, Mg++:1.9 mg/dL, PO4:3.6\n mg/dL\n Assessment and Plan\n 56yoF s/p mechanical fall and traumatic T spine fracture transferred\n from OSH to for TBM eval with hospitalization complicated by\n respiratory failure and HAP, s/p trach/PEG, atrial tachycardia, ileus,\n and delirium/agitation.\n .\n # Delirium: Pt continues to be agitated with paranoia, disorientation\n and hallucinations. Most likely secondary to long hospital course and\n recent multiple psychotropic medications. Other lab values (lytes, past\n LFTs within normal limits), infections processes negative on culture.\n CT of head at OSH negative. d/c\ned Reglan and scopolamine.\n - Appreciate psych. Will call and f/u psych recs.\n -Consider CT of head with contrast if mental status does not improve\n this am.\n - Risperdal 0.25mg PO qam. Consider increasing per psych recs to 0.5mg\n if continues to be agitated. Will d/w psych re any additional meds we\n could use for night time agitation.\n - continue to hold all benzos. opiates, and antihistamines.\n -Follow EKG to assess for prolongation (last EKG ; 457).\n #Anemia: HCT continues to decrease, currently at 22.8 from 23.7 with\n b/l in high 20\ns. No known etiology of blood loss.\n -Will continue to follow HCT\n - Guaiac stools.\n # Respiratory: s/p trach on trach mask, FiO2 50%. Tolerating well with\n good O2 sat in mid-high 90\ns. Pt continues to be at risk for aspiration\n given recent history of vomiting with tube feed trials and increased\n secretions. ENT believes that the posterior gap is not a risk factor\n for aspiration as this is a common finding in females and that her\n increased secretions and edema pose a greater aspiration threat; no\n intervention was recommended.\n - Appreciate ENT and S&S input.\n - Pt to f/u on ^th at 3:30pm with Dr. \n () for an outpatient/clinic re-evaluation.\n - ppi for aspiration prophylaxis, PMV precautions: \nt use w/o\n supervision, frequent suctioning\n - TM as tolerated.\n - Holding sedation with exception of Risperidal 0.25mg PO qam\n #Loose Stools: rectal tube pulled out x2; afebrile, HD stable, without\n abdominal pain. Stool cdif cx negativex1.\n -F/u stool c.dif cultures\n -f/u WBC and vital signs daily\n -Hold bowel regimen\n # Atrial Tachycardia: Stable without issue O/N. Pt now on PO Amiodarone\n 200 TID and PO metoprolol 50mg TID\n - Will continue amiodarone 200 TID for three weeks (start ) and\n then switch to qday for 1week and then d/c amiodarone.\n - Will need to schedule f/u in 4wks with Dr. upon d/c/transfer.\n # Hypernatremia/Fluid Status: resolving after free water\n administration. On TPN/TF. Free water deficit of 1.6L\n - increase NS at 10cc/hr, water flushes with TF\n -Will f/u lytes \n # UE DVT and h/o labile INR: Decision made to d/c Coumadin given her\n labile INR, and start Lovenox . INR at 1.1\n - Will flush L PICC with TPA if does not flush\n - Daily coags\n .\n # Spine fracture: Stable. T5-T8.\n - Brace for OOB.\n - Pt to follow up with Dr. in .\n .\n # Tracheomalacia. Reevaluation bronchoscopy by IP as written above;\n patient not a candidate for stent; pt to follow up as outpatient. No\n new issues.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # FEN: Currently TF held secondary to possible risk of aspiration O/N;\n will increase TF back slowly to max goal.\n - Appreciate GI input and S&S eval\n -D/c\ned Reglan for emesis precaution as pt is tolerating TF without\n vomiting and Reglan increases agitation/delirium risk.\n -meds via G-J tube\n .\n # ACCESS: L PICC\n # Ppx: Lovenox, PPi , Bowel Regimen PRN currently held\n # Communication:\n - (brother) is primary contact; visiting\n patient today and aware of status and disposition\n - Boyfriend of 10 , but minimal contact has been maintained at\n this point\n - Social Work and Case management involved\n # Code: Full\n # Dispo: ICU, Will currently has bed at Rehab and waiting\n insurance approval before transfer of care.\n MSIV\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Nursing","chartdate":"2167-10-31 00:00:00.000","description":"Nursing Progress Note","row_id":640438,"text":"56yoF s/p mechanical fall and traumatic T spine fracture transferred\n from OSH to for TBM eval with hospitalization complicated by\n respiratory failure and HAP, s/p trach/PEG, atrial tachycardia, ileus,\n and delirium/agitation.\n Airway Clearance, Impaired\n Assessment:\n Cont on TM 50% O2 sats 96-94%, suct for copious amts of thin white\n secretions, bilat rhonchi, dim bases.\n Action:\n Frequent suctioning, pt able to cough up some secretions on her own\n Response:\n Pt able to cough up secretions on her own at times\n Plan:\n Cont to resp status, encourage CDB\n Altered mental status (not Delirium)\n Assessment:\n Alert/oriented with some confusion, follows commands consistently, but\n requires frequent re-direction\n Action:\n Pt oriented to place/time\n Response:\n Pt still makes attempts to remove TM despite re-direction, pt remains\n with bilat wrist restraints for safety\n Plan:\n Cont to orient pt, frequent monitor for safety\n Alteration in Nutrition\n Assessment:\n TF restarted @ 0000, BS present x 4Quads, soft, NT\n Action:\n HOB 45 when TF on, TF off prior to turning, TF currently running at\n goal\n Response:\n No n/v reported or witness, TTFW\n Plan:\n Cont to nutritional status\n"},{"category":"Physician ","chartdate":"2167-10-29 00:00:00.000","description":"Physician Resident Progress Note","row_id":640018,"text":"Chief Complaint:\n 24 Hour Events:\n Tube Feed goals increased\n Calm overnight\n 3 runs of SVT peaking in 110s.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Enoxaparin (Lovenox) - 06:33 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.5\nC (97.7\n HR: 114 (61 - 122) bpm\n BP: 119/54(75) {91/36(50) - 167/84(101)} mmHg\n RR: 19 (10 - 30) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,952 mL\n 429 mL\n PO:\n TF:\n 646 mL\n 376 mL\n IVF:\n 950 mL\n 54 mL\n Blood products:\n Total out:\n 2,430 mL\n 470 mL\n Urine:\n 2,430 mL\n 240 mL\n NG:\n Stool:\n Drains:\n Balance:\n 522 mL\n -41 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 100%\n ABG: ///35/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 187 K/uL\n 7.2 g/dL\n 105 mg/dL\n 0.5 mg/dL\n 35 mEq/L\n 3.8 mEq/L\n 17 mg/dL\n 108 mEq/L\n 147 mEq/L\n 23.7 %\n 5.1 K/uL\n [image002.jpg]\n 03:00 AM\n 04:00 AM\n 05:45 AM\n 03:51 AM\n 04:45 PM\n 04:00 AM\n 07:37 PM\n 04:05 AM\n 06:05 PM\n 03:23 AM\n WBC\n 7.3\n 8.0\n 8.7\n 5.5\n 5.7\n 5.8\n 5.1\n Hct\n 27.3\n 27.0\n 28.7\n 24.7\n 25.2\n 25.3\n 23.7\n 24.7\n 23.7\n Plt\n 346\n 316\n 271\n 249\n 231\n 203\n 187\n Cr\n 0.7\n 0.7\n 0.7\n 0.5\n 0.4\n 0.5\n 0.5\n 0.5\n Glucose\n 123\n 114\n 112\n 122\n 145\n 137\n 149\n 105\n Other labs: PT / PTT / INR:13.3/32.4/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.8 mg/dL, Mg++:2.1 mg/dL, PO4:3.5\n mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Replete with Fiber () - 09:45 PM 40 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2167-10-29 00:00:00.000","description":"Physician Resident Progress Note","row_id":640020,"text":"Chief Complaint:\n 24 Hour Events:\n Tube Feed goals increased\n Calm overnight\n 3 runs of SVT peaking in 110s.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Enoxaparin (Lovenox) - 06:33 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.5\nC (97.7\n HR: 114 (61 - 122) bpm\n BP: 119/54(75) {91/36(50) - 167/84(101)} mmHg\n RR: 19 (10 - 30) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,952 mL\n 429 mL\n PO:\n TF:\n 646 mL\n 376 mL\n IVF:\n 950 mL\n 54 mL\n Blood products:\n Total out:\n 2,430 mL\n 470 mL\n Urine:\n 2,430 mL\n 240 mL\n NG:\n Stool:\n Drains:\n Balance:\n 522 mL\n -41 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 100%\n ABG: ///35/\n Physical Examination\n Gen: Alert, NAD, lying in bed, comfortable, mouthing words, less\n sedated than yest.\n HEENT: No pallor in conjunctiva, MMM, TM in place\n Resp: Transmitted upper airway sounds/coarse breath sounds.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, decreased bowel sounds, G-Tube in\n place with no erythema/induration\n Exte: No edema, DP 2+ bil\n NEURO: Alert, difficult to assess orientation due to poor voice. MAE\n Labs / Radiology\n 187 K/uL\n 7.2 g/dL\n 105 mg/dL\n 0.5 mg/dL\n 35 mEq/L\n 3.8 mEq/L\n 17 mg/dL\n 108 mEq/L\n 147 mEq/L\n 23.7 %\n 5.1 K/uL\n [image002.jpg]\n 03:00 AM\n 04:00 AM\n 05:45 AM\n 03:51 AM\n 04:45 PM\n 04:00 AM\n 07:37 PM\n 04:05 AM\n 06:05 PM\n 03:23 AM\n WBC\n 7.3\n 8.0\n 8.7\n 5.5\n 5.7\n 5.8\n 5.1\n Hct\n 27.3\n 27.0\n 28.7\n 24.7\n 25.2\n 25.3\n 23.7\n 24.7\n 23.7\n Plt\n 346\n 316\n 271\n 249\n 231\n 203\n 187\n Cr\n 0.7\n 0.7\n 0.7\n 0.5\n 0.4\n 0.5\n 0.5\n 0.5\n Glucose\n 123\n 114\n 112\n 122\n 145\n 137\n 149\n 105\n Other labs: PT / PTT / INR:13.3/32.4/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.8 mg/dL, Mg++:2.1 mg/dL, PO4:3.5\n mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Replete with Fiber () - 09:45 PM 40 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2167-10-29 00:00:00.000","description":"Physician Resident Progress Note","row_id":640021,"text":"Chief Complaint:\n 24 Hour Events:\n Tube Feed goals increased\n Calm overnight\n 3 runs of SVT peaking in 110s.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Enoxaparin (Lovenox) - 06:33 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.5\nC (97.7\n HR: 114 (61 - 122) bpm\n BP: 119/54(75) {91/36(50) - 167/84(101)} mmHg\n RR: 19 (10 - 30) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,952 mL\n 429 mL\n PO:\n TF:\n 646 mL\n 376 mL\n IVF:\n 950 mL\n 54 mL\n Blood products:\n Total out:\n 2,430 mL\n 470 mL\n Urine:\n 2,430 mL\n 240 mL\n NG:\n Stool:\n Drains:\n Balance:\n 522 mL\n -41 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 100%\n ABG: ///35/\n Physical Examination\n Gen: Alert, NAD, lying in bed, comfortable, mouthing words, less\n sedated than yest.\n HEENT: No pallor in conjunctiva, MMM, TM in place\n Resp: Transmitted upper airway sounds/coarse breath sounds.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, decreased bowel sounds, G-Tube in\n place with no erythema/induration\n Exte: No edema, DP 2+ bil\n NEURO: Alert, difficult to assess orientation due to poor voice. MAE\n Labs / Radiology\n 187 K/uL\n 7.2 g/dL\n 105 mg/dL\n 0.5 mg/dL\n 35 mEq/L\n 3.8 mEq/L\n 17 mg/dL\n 108 mEq/L\n 147 mEq/L\n 23.7 %\n 5.1 K/uL\n [image002.jpg]\n 03:00 AM\n 04:00 AM\n 05:45 AM\n 03:51 AM\n 04:45 PM\n 04:00 AM\n 07:37 PM\n 04:05 AM\n 06:05 PM\n 03:23 AM\n WBC\n 7.3\n 8.0\n 8.7\n 5.5\n 5.7\n 5.8\n 5.1\n Hct\n 27.3\n 27.0\n 28.7\n 24.7\n 25.2\n 25.3\n 23.7\n 24.7\n 23.7\n Plt\n 346\n 316\n 271\n 249\n 231\n 203\n 187\n Cr\n 0.7\n 0.7\n 0.7\n 0.5\n 0.4\n 0.5\n 0.5\n 0.5\n Glucose\n 123\n 114\n 112\n 122\n 145\n 137\n 149\n 105\n Other labs: PT / PTT / INR:13.3/32.4/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.8 mg/dL, Mg++:2.1 mg/dL, PO4:3.5\n mg/dL\n Assessment and Plan\n 56yoF s/p mechanical fall and traumatic T spine fracture with resolving\n respiratory failure and HAP s/p trach with complicating TBM and s/p\n PEG.\n .\n # Respiratory: s/p intubation/extubation, now on trach mask, FiO2 50%.\n Tolerating well with good O2 sat in mid-high 90\ns. Pt continues to be\n at risk for aspiration given new IP finding of opening defect in\n posterior vocal cord space and given recent history of vomiting with\n tube feed trials.\n - Appreciate ENT and S&S input.\n - will follow ENT recs; awaiting input for possible intervention.\n - ppi for aspiration prophylaxis, PMV precautions: \nt use w/o\n supervision, frequent suctioning\n - TM as tolerated.\n - continue scopolamine patch q72hrs for secretions\n - Holding sedation with exception of Risperidal 0.5mg PRN\n - F/u CXR tomorrow\n # Sedation/Anxiolysis/AlteredMS: Resolved O/N with risperdal. Previous\n delirium and agitation most likely secondary to long hospital course\n and multiple psychotropic medications as well as hx of EtOH abuse.\n - started Risperdal 0.5mg PO BID PRN.\n - continue to hold all benzos. opiates, and antihistamines\n - Appreciate psych. Will call and f/u psych recs.\n -Obtain EKG to assess for QTc prolongation.\n #Anemia: HCT low compared to b/l at 23.7. No known etiology of blood\n loss.\n -Will continue to follow HCT daily.\n - Guaiac stools.\n -f/u HCT this afternoon\n -T&S\n # Atrial Tachycardia: Improved HR max of 120\ns versus 160s previously.\n Pt now on PO Amiodarone 200 TID and PO metoprolol 37.5mg TID\n - Will continue amiodarone 200 TID for three weeks and then switch to\n qday for 1week and then d/c amiodarone.\n - Will need to schedule f/u in 4wks with Dr. upon d/c/transfer.\n # Hypernatremia/Fluid Status: Mild hypernatramia resolving with free\n water administration. On TPN/TF. Good UOP.\n - providing D5W IVFx 1L at 150cc/hr, free water flushes with TF\n -Will f/u lytes in afternoon (5pm)\n # UE DVT and h/o labile INR: Decision made to d/c Coumadin given her\n labile INR, and start Lovenox . INR at 1.9\n - Will flush L PICC with TPA if does not flush\n - Daily coags\n .\n # Spine fracture: Stable. T5-T8.\n - Brace for OOB, need to discuss with Neurosurgery before d/c if\n current brace is optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in .\n .\n # Tracheomalacia. Reevaluation bronchoscopy by IP as written above;\n patient not a candidate for stent; pt to follow up as outpatient. No\n new issues.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # FEN: Currently receiving TPN, restarted TF yest, currently at\n 20cc/hr, w/o issue.\n - Appreciate GI input and S&S eval\n -Cont Reglan 20mg IV Q 8 hours for emesis precaution; meds via G-J\n tube,\n -D/w GI; rec: continue bowel regimen if no BM\n .\n # ACCESS: PIV x 1, L PICC\n # Ppx: Lovenox, PPi , Bowel Regimen PRN\n # Communication:\n - (brother) is primary contact\n - Boyfriend of 10 , but minimal contact has been maintained at\n this point\n - Social Work and Case management involved; have discussed situation\n w/ brother and boyfriend.\n # Code: Full\n # Dispo: ICU, Will d/w case management re rehab facilities, likely d/c\n tomorrow if insurance/bed confirmed\n MSIV\n PGY2 addendum: , \n Agree with assessment and plan in excellent MSIV note as detailed\n above. Briefly, 56 F s/p fall with T spine fracture (T5-T8),\n respiratory failure now s/p trach/PEG. Now on trach mask. Patient s/p\n bronch with IP yesterday. Nutrition issues continue; have discontinued\n TPN today and will continue tubefeeding to goal of 60cc/hr per\n Nutrition. Will continue reglan until at goal feedings, and decrease\n and d/c as able given potential for delirium. Appreciate psych recs;\n continuing risperidone for agitation. Etiology of delirium/agitation\n still unclear but likely prolonged hospital course, illness and\n multiple medications. Currently discussing with CM about potential\n placement to rehab tomorrow.\n ICU Care\n Nutrition:\n Replete with Fiber () - 09:45 PM 40 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Nursing","chartdate":"2167-10-30 00:00:00.000","description":"Nursing Progress Note","row_id":640182,"text":"Synopsis per prior nursing note:\n 56 yr old woman, who was transferred from osh for evaluation of\n tracheal bronchial malacia on .Pt presented to Medical\n Center on s/p fall down a flight of stairs fracturing, t5-t8 with\n propulsion treated conservatively with pain meds and back brace. She\n developed resp distress requiring intubation on . Trach/PEG done\n . Now with prolonged hospital course c/b by PNA, anxiety/altered\n mental status, R&LUE DVT .Pt found to have small non occlusive clot on\n her right axial vein via Ultrasound, now rec\ning Lovenox. She has had\n problems with vomiting tube feedings, so feeding tube passed through\n g-tube to her jejunenum. However, she continued to intermit raise\n gastric contents assoc with bronchospasm. Has not required ventilation\n since , on humidified TM @ 50%. Presently on TPN and restarted on\n TF\nings at low rate via J-tube.\n Airway Clearance, Impaired\n Assessment:\n LS-bilat rhonchi. O2 sat >95% on 50% trach collar. Suctioned small to\n moderate amts of thick, white secretions and pt clearing secretions\n independently with strong cough. Passy-muir valve in only while being\n evaluated by Psych d/t large amt of secretions.\n Action:\n Suctioned every one hour. Scolpolamine patch d/c\nd d/t mental status.\n Response:\n Needed suctioning every 1hour.\n Plan:\n to monitor and clear airway as needed.\n Alteration in Nutrition\n Assessment:\n Continues on replete w/fiber full strength.. Advance by 10ml q6 hours.\n Flush w/ 100 ml hour every 4 hours. Denies nausea. No vomiting.\n Mushroom cath in place.\n Action:\n J tube in place, unable to check resuduals. Increased TF as tolerated.\n Reglan d/c\nd d/t to mental status. Colace/senna/polyethylene glycol\n held.\n Response:\n Continues to have liquid stool. Currently tolerating TF.\n Plan:\n Advance TF to goal as tolerated.\n Fracture, other\n Assessment:\n Patient has a fracture of t5-t8. Denied pain. Brace on while OOB in\n chair.\n Action:\n Changed position. Brace on while OOB.\n Response:\n Continued to deny pain.\n Plan:\n Assess/treat pain. Brace on while OOB.\n Altered mental status (not Delirium)\n Assessment:\n When passy-muir valve on, patient had +VH and +AH. She was paranoid\n about her brother in hallway (brother was not at hospital). Stated that\n she will be driving her car home tomorrow. Stated that she is scared.\n Follows commands. Continues to try to pull out lines/tubes. Continues\n to throw her legs over the side of the bed.\n Action:\n w/ soft wrist restraints. Reoriented frequently. Assured patient\n that she is safe in hospital.\n Response:\n Patient remains safe. Able to be calmed when told she is safe in\n hospital.\n Plan:\n current safety plan. Reorient frequently. Psych will continue to\n follow.\n"},{"category":"Nursing","chartdate":"2167-10-30 00:00:00.000","description":"Nursing Progress Note","row_id":640183,"text":"Synopsis per prior nursing note:\n 56 yr old woman, who was transferred from osh for evaluation of\n tracheal bronchial malacia on .Pt presented to Medical\n Center on s/p fall down a flight of stairs fracturing, t5-t8 with\n propulsion treated conservatively with pain meds and back brace. She\n developed resp distress requiring intubation on . Trach/PEG done\n . Now with prolonged hospital course c/b by PNA, anxiety/altered\n mental status, R&LUE DVT .Pt found to have small non occlusive clot on\n her right axial vein via Ultrasound, now rec\ning Lovenox. She has had\n problems with vomiting tube feedings, so feeding tube passed through\n g-tube to her jejunenum. However, she continued to intermit raise\n gastric contents assoc with bronchospasm. Has not required ventilation\n since , on humidified TM @ 50%. Presently on TPN and restarted on\n TF\nings at low rate via J-tube.\n Airway Clearance, Impaired\n Assessment:\n LS-bilat rhonchi. O2 sat >95% on 50% humidified trach collar. Suctioned\n small to moderate amts of frothy and thin, white secretions and pt\n clearing secretions independently with strong cough.\n Action:\n Repositioned frequently and CPT. Suctioned q2-3hours.\n Response:\n n/a\n Plan:\n to monitor resp status and clear airway as needed.\n Alteration in Nutrition\n Assessment:\n Continues on replete w/fiber full strength.. Advance by 10ml q6 hours.\n Flush w/ 100 ml hour every 4 hours. Denies nausea. No vomiting.\n Mushroom cath in place.\n Action:\n J tube in place, unable to check resuduals. Increased TF as tolerated.\n Reglan d/c\nd d/t to mental status. Colace/senna/polyethylene glycol\n held.\n Response:\n Continues to have liquid stool. Currently tolerating TF.\n Plan:\n Advance TF to goal as tolerated.\n Fracture, other\n Assessment:\n Patient has a fracture of t5-t8. Denied pain. Brace on while OOB in\n chair.\n Action:\n Changed position. Brace on while OOB.\n Response:\n Continued to deny pain.\n Plan:\n Assess/treat pain. Brace on while OOB.\n Altered mental status (not Delirium)\n Assessment:\n When passy-muir valve on, patient had +VH and +AH. She was paranoid\n about her brother in hallway (brother was not at hospital). Stated that\n she will be driving her car home tomorrow. Stated that she is scared.\n Follows commands. Continues to try to pull out lines/tubes. Continues\n to throw her legs over the side of the bed.\n Action:\n w/ soft wrist restraints. Reoriented frequently. Assured patient\n that she is safe in hospital.\n Response:\n Patient remains safe. Able to be calmed when told she is safe in\n hospital.\n Plan:\n current safety plan. Reorient frequently. Psych will continue to\n follow.\n"},{"category":"Physician ","chartdate":"2167-10-29 00:00:00.000","description":"Physician Resident Progress Note","row_id":640111,"text":"Chief Complaint:\n 24 Hour Events:\n Tube Feed goals increased from 30cc to 60cc/hr. No issues O/N with\n regard to vomiting.\n Calm overnight. Risperdal decreased from 0.5mg to 0.25mg qam.\n runs of asymptomatic SVT peaking in 110-120\ns, metoprolol 37.5mg\n changed from TID\nQID and first daily dose given early after runs;\n decrease of HR to 80\n Loose, brown, malodorous stools O/N, afebrile, C.dif cx sent.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Enoxaparin (Lovenox) - 06:33 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.5\nC (97.7\n HR: 114 (61 - 122) bpm\n BP: 119/54(75) {91/36(50) - 167/84(101)} mmHg\n RR: 19 (10 - 30) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,952 mL\n 429 mL\n PO:\n TF:\n 646 mL\n 376 mL\n IVF:\n 950 mL\n 54 mL\n Blood products:\n Total out:\n 2,430 mL\n 470 mL\n Urine:\n 2,430 mL\n 240 mL\n NG:\n Stool:\n Drains:\n Balance:\n 522 mL\n -41 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 100%\n ABG: ///35/\n Physical Examination\n Gen: Alert, NAD, lying in bed, comfortable, mouthing words, less\n sedated than yest.\n HEENT: No pallor in conjunctiva, MMM, TM in place\n Resp: Transmitted upper airway sounds/coarse breath sounds.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, decreased bowel sounds, G-Tube in\n place with no erythema/induration\n Exte: No edema, DP 2+ bil\n NEURO: Alert, difficult to assess orientation due to poor voice\n although pt oriented to year not place. MAE\n Labs / Radiology\n 187 K/uL\n 7.2 g/dL\n 105 mg/dL\n 0.5 mg/dL\n 35 mEq/L\n 3.8 mEq/L\n 17 mg/dL\n 108 mEq/L\n 147 mEq/L\n 23.7 %\n 5.1 K/uL\n [image002.jpg]\n 03:00 AM\n 04:00 AM\n 05:45 AM\n 03:51 AM\n 04:45 PM\n 04:00 AM\n 07:37 PM\n 04:05 AM\n 06:05 PM\n 03:23 AM\n WBC\n 7.3\n 8.0\n 8.7\n 5.5\n 5.7\n 5.8\n 5.1\n Hct\n 27.3\n 27.0\n 28.7\n 24.7\n 25.2\n 25.3\n 23.7\n 24.7\n 23.7\n Plt\n 346\n 316\n 271\n 249\n 231\n 203\n 187\n Cr\n 0.7\n 0.7\n 0.7\n 0.5\n 0.4\n 0.5\n 0.5\n 0.5\n Glucose\n 123\n 114\n 112\n 122\n 145\n 137\n 149\n 105\n Other labs: PT / PTT / INR:13.3/32.4/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.8 mg/dL, Mg++:2.1 mg/dL, PO4:3.5\n mg/dL\n Assessment and Plan\n 56yoF s/p mechanical fall and traumatic T spine fracture transferred\n from OSH to for TBM eval with hospitalization complicated by\n respiratory failure and HAP, s/p trach/PEG, atrial tachycardia, ileus,\n and delirium/agitation.\n .\n # Respiratory: s/p intubation/extubation, now on trach mask, FiO2 50%.\n Tolerating well with good O2 sat in mid-high 90\ns. Pt continues to be\n at risk for aspiration given recent history of vomiting with tube feed\n trials and increased secretions. ENT believes that the posterior gap is\n not a risk factor for aspiration as this is a common finding in females\n and that her increased secretions and edema pose a greater aspiration\n threat; no intervention was recommended.\n - Appreciate ENT and S&S input.\n - ENT recs to f/u in 2wks with Dr. () for an\n outpatient/clinic re-evaluation.\n - ppi for aspiration prophylaxis, PMV precautions: \nt use w/o\n supervision, frequent suctioning\n - TM as tolerated.\n - d/c\ned scopolamine as it was a cause for delirium.\n - Holding sedation with exception of Risperidal 0.25mg qam PRN\n # Delirium/Anxiolysis/AlteredMS: Resolving although pt continues to be\n slightly agitated. Previous delirium and agitation most likely\n secondary to long hospital course and multiple psychotropic medications\n as well as hx of EtOH abuse.\n - Risperdal 0.25mg PO qam.\n - continue to hold all benzos. opiates, and antihistamines. Will\n decrease or d/c raglan and scopolamine.\n - Appreciate psych. Will call and f/u psych recs.\n -Follow EKG to assess for QTc prolongation (last EKG ; QTc 457).\n #Loose Stools: Multiple, loose stools O/N; afebrile, tachycardia,\n without abdominal pain\n -F/u stool c.dif cultures\n -f/u WBC and vital signs daily\n -Hold bowel regimen\n # Atrial Tachycardia: Compared to recent b/l, HR increased to max of\n 120\ns. Pt now on PO Amiodarone 200 TID and PO increased metoprolol\n 37.5mg QID.\n - Will continue amiodarone 200 TID for three weeks and then switch to\n qday for 1week and then d/c amiodarone.\n - Will need to schedule f/u in 4wks with Dr. upon d/c/transfer.\n #Anemia: HCT low compared to b/l. No known etiology of blood loss.\n -Will continue to follow HCT daily.\n - Guaiac stools.\n # Hypernatremia/Fluid Status: Mild hypernatramia resolving with free\n water administration. On TPN/TF. Good UOP. Free water deficit of 2.8L\n - increase D5W IVFx 1L from 10cc/hr to 150cc/hr, free water flushes\n with TF\n -Will f/u lytes in afternoon (5pm)\n # UE DVT and h/o labile INR: Decision made to d/c Coumadin given her\n labile INR, and start Lovenox . INR at 1.1\n - Will flush L PICC with TPA if does not flush\n - Daily coags\n .\n # Spine fracture: Stable. T5-T8.\n - Brace for OOB.\n - Pt to follow up with Dr. in .\n .\n # Tracheomalacia. Reevaluation bronchoscopy by IP as written above;\n patient not a candidate for stent; pt to follow up as outpatient. No\n new issues.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # FEN: Currently receiving TF at 50cc/hr, w/o issue.\n - Appreciate GI input and S&S eval\n -D/c Reglan for emesis precaution as pt is tolerating TF without\n vomiting and Reglan increases agitation/delirium risk.\n -meds via G-J tube,\n .\n # ACCESS: PIV x 1, L PICC\n # Ppx: Lovenox, PPi , Bowel Regimen PRN\n # Communication:\n - (brother) is primary contact\n - Boyfriend of 10 , but minimal contact has been maintained at\n this point\n - Social Work and Case management involved; have discussed situation\n w/ brother and boyfriend.\n # Code: Full\n # Dispo: ICU, Will d/w case management re rehab facilities, likely d/c\n today/tomorrow if insurance/bed confirmed\n MSIV\n PGY2 addendum: , \n Agree with assessment and plan in excellent MSIV note as detailed\n above. Briefly, 56 F s/p fall with T spine fracture (T5-T8),\n respiratory failure now s/p trach/PEG. Now on trach mask. Patient s/p\n bronch with IP yesterday. Nutrition issues continue; have discontinued\n TPN today and will continue tubefeeding to goal of 60cc/hr per\n Nutrition. Will continue reglan until at goal feedings, and decrease\n and d/c as able given potential for delirium. Appreciate psych recs;\n continuing risperidone for agitation. Etiology of delirium/agitation\n still unclear but likely prolonged hospital course, illness and\n multiple medications. Currently discussing with CM about potential\n placement to rehab tomorrow.\n"},{"category":"Nursing","chartdate":"2167-10-30 00:00:00.000","description":"Nursing Progress Note","row_id":640235,"text":"Synopsis per prior nursing note:\n 56 yr old woman, who was transferred from osh for evaluation of\n tracheal bronchial malacia on .Pt presented to Medical\n Center on s/p fall down a flight of stairs fracturing, t5-t8 with\n propulsion treated conservatively with pain meds and back brace. She\n developed resp distress requiring intubation on . Trach/PEG done\n . Now with prolonged hospital course c/b by PNA, anxiety/altered\n mental status, R&LUE DVT .Pt found to have small non occlusive clot on\n her right axial vein via Ultrasound, now rec\ning Lovenox. She has had\n problems with vomiting tube feedings, so feeding tube passed through\n g-tube to her jejunenum. However, she continued to intermit raise\n gastric contents assoc with bronchospasm. Has not required ventilation\n since , on humidified TM @ 50%. Presently on TPN and restarted on\n TF\nings at low rate via J-tube.\n Airway Clearance, Impaired\n Assessment:\n LS-bilat rhonchi. O2 sat >95% on 50% humidified trach collar. Suctioned\n small to moderate amts of frothy and thin, white secretions and pt\n clearing secretions independently with strong cough.\n Action:\n Repositioned frequently and CPT. Suctioned q2-3hours.\n Response:\n n/a\n Plan:\n Continue to monitor resp status, reposition, CPT as needed.\n Alteration in Nutrition\n Assessment:\n Pt received with tube feeds at goal 60cc/hr and 50cc free water flush\n q4hour via J-tube. Denies nausea, stomach pain or cramping. No\n vomiting. K 3.6.\n Action:\n Unable to check residuals. Tube feeds stopped at 5AM after ?tube feeds\n were suctioned from back of throat. Unlikely aspirated sats 100%.\n Colace/senna/polyethylene glycol held for loose stool. Mushroom\n catheter pulled out x2 this shift and not replaced after 2^nd time.\n Stool #2 sent for c.diff. Repleted with 40 mEq KCl.\n Response:\n Currently TF stopped, team aware.\n Plan:\n Restart TF. Monitor labs and replete lytes as needed.\n Altered mental status (not Delirium)\n Assessment:\n Alert and oriented x2. Continues to think she is in a hotel. Pt\n restless and agitated many times throughout night. Pulled out rectal\n tube x2 and foley x1 this shift. Follows commands. PERL brisk.\n Action:\n Soft wrist restraints for pt safetly to pulling at lines and hx to\n decanulating herself. Bed locked in low position and bed alarm on.\n Reoriented frequently. All meds and interventions explained.\n Response:\n Patient remains safe. Continues to throw her legs over the side of the\n bed and pull at lines.\n Plan:\n Continue current safety plan. Reorient frequently. Psych consulting.\n"},{"category":"Physician ","chartdate":"2167-10-30 00:00:00.000","description":"Physician Resident Progress Note","row_id":640247,"text":"Chief Complaint:\n 24 Hour Events:\n - ENT team believes that vocal cord adductor dysfunction is NOT a risk\n for aspiration, rather her increased secretions put her at risk for\n aspiration. They will follow-up in clinic in two weeks with Dr.\n , call in am to schedule appt.\n - Psych recs: consider head CT if patient does not improve off\n scopolamine and metoclopramide; address anemia and\nerratic BP\n consider increasing am dose of risperdal; monitor \n - Pt continued to be agitated O/N (eg: pulled rectal tubex2 and\n foleyx1, disoriented). To receive head CT this AM\n -HCT at 22.8 down 1pt with b/l in high 20\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.9\n HR: 77 (66 - 114) bpm\n BP: 128/40(60) {90/37(31) - 164/75(87)} mmHg\n RR: 23 (16 - 29) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,726 mL\n 595 mL\n PO:\n TF:\n 1,388 mL\n 301 mL\n IVF:\n 249 mL\n 105 mL\n Blood products:\n Total out:\n 1,666 mL\n 222 mL\n Urine:\n 836 mL\n 222 mL\n NG:\n Stool:\n Drains:\n Balance:\n 60 mL\n 373 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 100%\n ABG: ///34/\n Physical Examination\n Gen: Alert, NAD, lying in bed, comfortable, mouthing words, less\n sedated than yest.\n HEENT: No pallor in conjunctiva, MMM, TM in place\n Resp: Transmitted upper airway sounds/coarse breath sounds.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, decreased bowel sounds, G-Tube in\n place with no erythema/induration\n Exte: No edema, DP 2+ bil\n NEURO: Alert, difficult to assess orientation due to poor voice\n although pt oriented to year not place. MAE\n Labs / Radiology\n 183 K/uL\n 7.1 g/dL\n 115 mg/dL\n 0.5 mg/dL\n 34 mEq/L\n 3.6 mEq/L\n 13 mg/dL\n 106 mEq/L\n 145 mEq/L\n 22.8 %\n 5.4 K/uL\n [image002.jpg]\n 04:00 AM\n 05:45 AM\n 03:51 AM\n 04:45 PM\n 04:00 AM\n 07:37 PM\n 04:05 AM\n 06:05 PM\n 03:23 AM\n 02:54 AM\n WBC\n 8.0\n 8.7\n 5.5\n 5.7\n 5.8\n 5.1\n 5.4\n Hct\n 27.0\n 28.7\n 24.7\n 25.2\n 25.3\n 23.7\n 24.7\n 23.7\n 22.8\n Plt\n \n 183\n Cr\n 0.7\n 0.7\n 0.5\n 0.4\n 0.5\n 0.5\n 0.5\n 0.5\n Glucose\n 114\n 112\n 122\n 145\n 137\n 149\n 105\n 115\n Other labs: PT / PTT / INR:13.3/32.4/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.4 mg/dL, Mg++:1.9 mg/dL, PO4:3.6\n mg/dL\n Assessment and Plan\n 56yoF s/p mechanical fall and traumatic T spine fracture transferred\n from OSH to for TBM eval with hospitalization complicated by\n respiratory failure and HAP, s/p trach/PEG, atrial tachycardia, ileus,\n and delirium/agitation.\n .\n # Delirium: Pt continues to be agitated with paranoia and\n disorientation with paranoia and hallucinations. Delirium and agitation\n most likely secondary to long hospital course and multiple psychotropic\n medications as well as hx of EtOH abuse; yet could also be due to\n anemia. Other lab values (lytes, past LFTs within normal limits). CT of\n head at OSH negative. d/c\ned Reglan and scopolamine.\n - Consider CT of head with contrast if mental status does not improve\n this am.\n - U/A\n - Risperdal 0.25mg PO qam. Consider increasing per psych recs to 0.5mg\n if continues to be agitated.\n - continue to hold all benzos. opiates, and antihistamines. Will\n decrease or d/c raglan and scopolamine.\n - Appreciate psych. Will call and f/u psych recs.\n -Follow EKG to assess for prolongation (last EKG ; 457).\n #Anemia: HCT continues to decrease, currently at 22.8 from 23.7 with\n b/l in high 20\ns. No known etiology of blood loss.\n -Will continue to follow HCT with 1pm HCT.\n - Guaiac stools.\n -T&S. Transfuse 1unit\n # Respiratory: s/p trach on trach mask, FiO2 50%. Tolerating well with\n good O2 sat in mid-high 90\ns. Pt continues to be at risk for aspiration\n given recent history of vomiting with tube feed trials and increased\n secretions. ENT believes that the posterior gap is not a risk factor\n for aspiration as this is a common finding in females and that her\n increased secretions and edema pose a greater aspiration threat; no\n intervention was recommended.\n - Appreciate ENT and S&S input.\n - ENT recs to f/u in 2wks with Dr. () for an\n outpatient/clinic re-evaluation. Will schedule appt today.\n - ppi for aspiration prophylaxis, PMV precautions: \nt use w/o\n supervision, frequent suctioning\n - TM as tolerated.\n - Holding sedation with exception of Risperidal 0.25mg PO qam\n #Loose Stools: rectal tube pulled out x2; afebrile, HD stable, without\n abdominal pain\n -F/u stool c.dif cultures\n -f/u WBC and vital signs daily\n -Hold bowel regimen\n # Atrial Tachycardia: Stable without issue O/N. Pt now on PO Amiodarone\n 200 TID and PO metoprolol 50mg TID\n - Will continue amiodarone 200 TID for three weeks (start ?) and\n then switch to qday for 1week and then d/c amiodarone.\n - Will need to schedule f/u in 4wks with Dr. upon d/c/transfer.\n # Hypernatremia/Fluid Status: Mild hypernatramia resolving with free\n water administration. On TPN/TF. Good UOP. Free water deficit of 2.8L\n - increase D5W IVFx 1L from 10cc/hr to 150cc/hr, free water flushes\n with TF\n -Will f/u lytes in afternoon (5pm)\n # UE DVT and h/o labile INR: Decision made to d/c Coumadin given her\n labile INR, and start Lovenox . INR at 1.1\n - Will flush L PICC with TPA if does not flush\n - Daily coags\n .\n # Spine fracture: Stable. T5-T8.\n - Brace for OOB.\n - Pt to follow up with Dr. in .\n .\n # Tracheomalacia. Reevaluation bronchoscopy by IP as written above;\n patient not a candidate for stent; pt to follow up as outpatient. No\n new issues.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # FEN: Currently receiving TF at 50cc/hr, w/o issue.\n - Appreciate GI input and S&S eval\n -D/c Reglan for emesis precaution as pt is tolerating TF without\n vomiting and Reglan increases agitation/delirium risk.\n -meds via G-J tube,\n .\n # ACCESS: PIV x 1, L PICC\n # Ppx: Lovenox, PPi , Bowel Regimen PRN\n # Communication:\n - (brother) is primary contact\n - Boyfriend of 10 , but minimal contact has been maintained at\n this point\n - Social Work and Case management involved; have discussed situation\n w/ brother and boyfriend.\n # Code: Full\n # Dispo: ICU, Will d/w case management re rehab facilities, likely d/c\n today/tomorrow if insurance/bed confirmed\n MSIV\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2167-10-29 00:00:00.000","description":"Physician Resident Progress Note","row_id":640108,"text":"Chief Complaint:\n 24 Hour Events:\n Tube Feed goals increased from 30cc to 60cc/hr. No issues O/N with\n regard to vomiting.\n Calm overnight. Risperdal decreased from 0.5mg to 0.25mg qam.\n runs of asymptomatic SVT peaking in 110-120\ns, metoprolol 37.5mg\n changed from TID\nQID and first daily dose given early after runs;\n decrease of HR to 80\n Loose, brown, malodorous stools O/N, afebrile, C.dif cx sent.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Enoxaparin (Lovenox) - 06:33 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.5\nC (97.7\n HR: 114 (61 - 122) bpm\n BP: 119/54(75) {91/36(50) - 167/84(101)} mmHg\n RR: 19 (10 - 30) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,952 mL\n 429 mL\n PO:\n TF:\n 646 mL\n 376 mL\n IVF:\n 950 mL\n 54 mL\n Blood products:\n Total out:\n 2,430 mL\n 470 mL\n Urine:\n 2,430 mL\n 240 mL\n NG:\n Stool:\n Drains:\n Balance:\n 522 mL\n -41 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 100%\n ABG: ///35/\n Physical Examination\n Gen: Alert, NAD, lying in bed, comfortable, mouthing words, less\n sedated than yest.\n HEENT: No pallor in conjunctiva, MMM, TM in place\n Resp: Transmitted upper airway sounds/coarse breath sounds.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, decreased bowel sounds, G-Tube in\n place with no erythema/induration\n Exte: No edema, DP 2+ bil\n NEURO: Alert, difficult to assess orientation due to poor voice\n although pt oriented to year not place. MAE\n Labs / Radiology\n 187 K/uL\n 7.2 g/dL\n 105 mg/dL\n 0.5 mg/dL\n 35 mEq/L\n 3.8 mEq/L\n 17 mg/dL\n 108 mEq/L\n 147 mEq/L\n 23.7 %\n 5.1 K/uL\n [image002.jpg]\n 03:00 AM\n 04:00 AM\n 05:45 AM\n 03:51 AM\n 04:45 PM\n 04:00 AM\n 07:37 PM\n 04:05 AM\n 06:05 PM\n 03:23 AM\n WBC\n 7.3\n 8.0\n 8.7\n 5.5\n 5.7\n 5.8\n 5.1\n Hct\n 27.3\n 27.0\n 28.7\n 24.7\n 25.2\n 25.3\n 23.7\n 24.7\n 23.7\n Plt\n 346\n 316\n 271\n 249\n 231\n 203\n 187\n Cr\n 0.7\n 0.7\n 0.7\n 0.5\n 0.4\n 0.5\n 0.5\n 0.5\n Glucose\n 123\n 114\n 112\n 122\n 145\n 137\n 149\n 105\n Other labs: PT / PTT / INR:13.3/32.4/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.8 mg/dL, Mg++:2.1 mg/dL, PO4:3.5\n mg/dL\n Assessment and Plan\n 56yoF s/p mechanical fall and traumatic T spine fracture transferred\n from OSH to for TBM eval with hospitalization complicated by\n respiratory failure and HAP, s/p trach/PEG, atrial tachycardia, ileus,\n and delirium/agitation.\n .\n # Respiratory: s/p intubation/extubation, now on trach mask, FiO2 50%.\n Tolerating well with good O2 sat in mid-high 90\ns. Pt continues to be\n at risk for aspiration given recent history of vomiting with tube feed\n trials and increased secretions. ENT believes that the posterior gap is\n not a risk factor for aspiration as this is a common finding in females\n and that her increased secretions and edema pose a greater aspiration\n threat; no intervention was recommended.\n - Appreciate ENT and S&S input.\n - ENT recs to f/u in 2wks with Dr. () for an\n outpatient/clinic re-evaluation.\n - ppi for aspiration prophylaxis, PMV precautions: \nt use w/o\n supervision, frequent suctioning\n - TM as tolerated.\n - d/c\ned scopolamine as it was a cause for delirium.\n - Holding sedation with exception of Risperidal 0.25mg qam PRN\n #Loose Stools: Multiple, loose stools O/N; afebrile, tachycardia,\n without abdominal pain\n -F/u stool c.dif cultures\n -f/u WBC and vital signs daily\n -Hold bowel regimen\n # Atrial Tachycardia: Compared to recent b/l, HR increased to max of\n 120\ns. Pt now on PO Amiodarone 200 TID and PO increased metoprolol\n 37.5mg QID.\n - Will continue amiodarone 200 TID for three weeks and then switch to\n qday for 1week and then d/c amiodarone.\n - Will need to schedule f/u in 4wks with Dr. upon d/c/transfer.\n # Delirium/Anxiolysis/AlteredMS: Resolving although pt continues to be\n slightly agitated. Previous delirium and agitation most likely\n secondary to long hospital course and multiple psychotropic medications\n as well as hx of EtOH abuse.\n - Risperdal 0.25mg PO qam.\n - continue to hold all benzos. opiates, and antihistamines\n - Appreciate psych. Will call and f/u psych recs.\n -Follow EKG to assess for QTc prolongation (last EKG ; QTc 457).\n #Anemia: HCT low compared to b/l. No known etiology of blood loss.\n -Will continue to follow HCT daily.\n - Guaiac stools.\n # Hypernatremia/Fluid Status: Mild hypernatramia resolving with free\n water administration. On TPN/TF. Good UOP. Free water deficit of 2.8L\n - increase D5W IVFx 1L from 10cc/hr to 150cc/hr, free water flushes\n with TF\n -Will f/u lytes in afternoon (5pm)\n # UE DVT and h/o labile INR: Decision made to d/c Coumadin given her\n labile INR, and start Lovenox . INR at 1.1\n - Will flush L PICC with TPA if does not flush\n - Daily coags\n .\n # Spine fracture: Stable. T5-T8.\n - Brace for OOB.\n - Pt to follow up with Dr. in .\n .\n # Tracheomalacia. Reevaluation bronchoscopy by IP as written above;\n patient not a candidate for stent; pt to follow up as outpatient. No\n new issues.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # FEN: Currently receiving TF at 50cc/hr, w/o issue.\n - Appreciate GI input and S&S eval\n -D/c Reglan for emesis precaution as pt is tolerating TF without\n vomiting and Reglan increases agitation/delirium risk.\n -meds via G-J tube,\n .\n # ACCESS: PIV x 1, L PICC\n # Ppx: Lovenox, PPi , Bowel Regimen PRN\n # Communication:\n - (brother) is primary contact\n - Boyfriend of 10 , but minimal contact has been maintained at\n this point\n - Social Work and Case management involved; have discussed situation\n w/ brother and boyfriend.\n # Code: Full\n # Dispo: ICU, Will d/w case management re rehab facilities, likely d/c\n today/tomorrow if insurance/bed confirmed\n MSIV\n PGY2 addendum: , \n Agree with assessment and plan in excellent MSIV note as detailed\n above. Briefly, 56 F s/p fall with T spine fracture (T5-T8),\n respiratory failure now s/p trach/PEG. Now on trach mask. Patient s/p\n bronch with IP yesterday. Nutrition issues continue; have discontinued\n TPN today and will continue tubefeeding to goal of 60cc/hr per\n Nutrition. Will continue reglan until at goal feedings, and decrease\n and d/c as able given potential for delirium. Appreciate psych recs;\n continuing risperidone for agitation. Etiology of delirium/agitation\n still unclear but likely prolonged hospital course, illness and\n multiple medications. Currently discussing with CM about potential\n placement to rehab tomorrow.\n"},{"category":"Physician ","chartdate":"2167-10-29 00:00:00.000","description":"Physician Resident Progress Note","row_id":640112,"text":"Chief Complaint:\n 24 Hour Events:\n Tube Feed goals increased from 30cc to 60cc/hr. No issues O/N with\n regard to vomiting.\n Calm overnight. Risperdal decreased from 0.5mg to 0.25mg qam.\n runs of asymptomatic SVT peaking in 110-120\ns, metoprolol 37.5mg\n changed from TID\nQID and first daily dose given early after runs;\n decrease of HR to 80\n Loose, brown, malodorous stools O/N, afebrile, C.dif cx sent.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Enoxaparin (Lovenox) - 06:33 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.5\nC (97.7\n HR: 114 (61 - 122) bpm\n BP: 119/54(75) {91/36(50) - 167/84(101)} mmHg\n RR: 19 (10 - 30) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,952 mL\n 429 mL\n PO:\n TF:\n 646 mL\n 376 mL\n IVF:\n 950 mL\n 54 mL\n Blood products:\n Total out:\n 2,430 mL\n 470 mL\n Urine:\n 2,430 mL\n 240 mL\n NG:\n Stool:\n Drains:\n Balance:\n 522 mL\n -41 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 100%\n ABG: ///35/\n Physical Examination\n Gen: Alert, NAD, lying in bed, comfortable, mouthing words, less\n sedated than yest.\n HEENT: No pallor in conjunctiva, MMM, TM in place\n Resp: Transmitted upper airway sounds/coarse breath sounds.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, decreased bowel sounds, G-Tube in\n place with no erythema/induration\n Exte: No edema, DP 2+ bil\n NEURO: Alert, difficult to assess orientation due to poor voice\n although pt oriented to year not place. MAE\n Labs / Radiology\n 187 K/uL\n 7.2 g/dL\n 105 mg/dL\n 0.5 mg/dL\n 35 mEq/L\n 3.8 mEq/L\n 17 mg/dL\n 108 mEq/L\n 147 mEq/L\n 23.7 %\n 5.1 K/uL\n [image002.jpg]\n 03:00 AM\n 04:00 AM\n 05:45 AM\n 03:51 AM\n 04:45 PM\n 04:00 AM\n 07:37 PM\n 04:05 AM\n 06:05 PM\n 03:23 AM\n WBC\n 7.3\n 8.0\n 8.7\n 5.5\n 5.7\n 5.8\n 5.1\n Hct\n 27.3\n 27.0\n 28.7\n 24.7\n 25.2\n 25.3\n 23.7\n 24.7\n 23.7\n Plt\n 346\n 316\n 271\n 249\n 231\n 203\n 187\n Cr\n 0.7\n 0.7\n 0.7\n 0.5\n 0.4\n 0.5\n 0.5\n 0.5\n Glucose\n 123\n 114\n 112\n 122\n 145\n 137\n 149\n 105\n Other labs: PT / PTT / INR:13.3/32.4/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.8 mg/dL, Mg++:2.1 mg/dL, PO4:3.5\n mg/dL\n Assessment and Plan\n 56yoF s/p mechanical fall and traumatic T spine fracture transferred\n from OSH to for TBM eval with hospitalization complicated by\n respiratory failure and HAP, s/p trach/PEG, atrial tachycardia, ileus,\n and delirium/agitation.\n .\n # Respiratory: s/p intubation/extubation, now on trach mask, FiO2 50%.\n Tolerating well with good O2 sat in mid-high 90\ns. Pt continues to be\n at risk for aspiration given recent history of vomiting with tube feed\n trials and increased secretions. ENT believes that the posterior gap is\n not a risk factor for aspiration as this is a common finding in females\n and that her increased secretions and edema pose a greater aspiration\n threat; no intervention was recommended.\n - Appreciate ENT and S&S input.\n - ENT recs to f/u in 2wks with Dr. () for an\n outpatient/clinic re-evaluation.\n - ppi for aspiration prophylaxis, PMV precautions: \nt use w/o\n supervision, frequent suctioning\n - TM as tolerated.\n - d/c scopolamine as it was a cause for delirium.\n - Holding sedation with exception of Risperidal 0.25mg qam PRN\n # Delirium/Anxiolysis/AlteredMS: Resolving although pt continues to be\n slightly agitated. Previous delirium and agitation most likely\n secondary to long hospital course and multiple psychotropic medications\n as well as hx of EtOH abuse.\n - Risperdal 0.25mg PO qam.\n - continue to hold all benzos. opiates, and antihistamines. Will\n decrease or d/c raglan and scopolamine.\n - Appreciate psych. Will call and f/u psych recs.\n -Follow EKG to assess for QTc prolongation (last EKG ; QTc 457).\n #Loose Stools: Multiple, loose stools O/N; afebrile, tachycardia,\n without abdominal pain\n -F/u stool c.dif cultures\n -f/u WBC and vital signs daily\n -Hold bowel regimen\n # Atrial Tachycardia: Compared to recent b/l, HR increased to max of\n 120\ns. Pt now on PO Amiodarone 200 TID and PO increased metoprolol\n 37.5mg QID.\n - Will continue amiodarone 200 TID for three weeks and then switch to\n qday for 1week and then d/c amiodarone.\n - Will need to schedule f/u in 4wks with Dr. upon d/c/transfer.\n #Anemia: HCT low compared to b/l. No known etiology of blood loss.\n -Will continue to follow HCT daily.\n - Guaiac stools.\n # Hypernatremia/Fluid Status: Mild hypernatramia resolving with free\n water administration. On TPN/TF. Good UOP. Free water deficit of 2.8L\n - increase D5W IVFx 1L from 10cc/hr to 150cc/hr, free water flushes\n with TF\n -Will f/u lytes in afternoon (5pm)\n # UE DVT and h/o labile INR: Decision made to d/c Coumadin given her\n labile INR, and start Lovenox . INR at 1.1\n - Will flush L PICC with TPA if does not flush\n - Daily coags\n .\n # Spine fracture: Stable. T5-T8.\n - Brace for OOB.\n - Pt to follow up with Dr. in .\n .\n # Tracheomalacia. Reevaluation bronchoscopy by IP as written above;\n patient not a candidate for stent; pt to follow up as outpatient. No\n new issues.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # FEN: Currently receiving TF at 50cc/hr, w/o issue.\n - Appreciate GI input and S&S eval\n -D/c Reglan for emesis precaution as pt is tolerating TF without\n vomiting and Reglan increases agitation/delirium risk.\n -meds via G-J tube,\n .\n # ACCESS: PIV x 1, L PICC\n # Ppx: Lovenox, PPi , Bowel Regimen PRN\n # Communication:\n - (brother) is primary contact\n - Boyfriend of 10 , but minimal contact has been maintained at\n this point\n - Social Work and Case management involved; have discussed situation\n w/ brother and boyfriend.\n # Code: Full\n # Dispo: ICU, Will d/w case management re rehab facilities, likely d/c\n today/tomorrow if insurance/bed confirmed\n MSIV\n PGY2 addendum: , \n Agree with assessment and plan in excellent MSIV note as detailed\n above. Briefly, 56 F s/p fall with T spine fracture (T5-T8),\n respiratory failure now s/p trach/PEG. Now on trach mask. Patient s/p\n bronch with IP yesterday. Nutrition issues continue; have discontinued\n TPN today and will continue tubefeeding to goal of 60cc/hr per\n Nutrition. Will continue reglan until at goal feedings, and decrease\n and d/c as able given potential for delirium. Appreciate psych recs;\n continuing risperidone for agitation. Etiology of delirium/agitation\n still unclear but likely prolonged hospital course, illness and\n multiple medications. Currently discussing with CM about potential\n placement to rehab tomorrow.\n"},{"category":"Physician ","chartdate":"2167-10-31 00:00:00.000","description":"Physician Resident Progress Note","row_id":640424,"text":"Chief Complaint:\n 24 Hour Events:\n Going to rehab 10am on Saturday\n DC summary up to date\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Enoxaparin (Lovenox) - 06:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 04:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.2\nC (97.2\n HR: 72 (66 - 88) bpm\n BP: 104/63(70) {78/34(48) - 186/71(98)} mmHg\n RR: 25 (15 - 33) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,197 mL\n 380 mL\n PO:\n TF:\n 301 mL\n 285 mL\n IVF:\n 577 mL\n 95 mL\n Blood products:\n Total out:\n 867 mL\n 245 mL\n Urine:\n 867 mL\n 245 mL\n NG:\n Stool:\n Drains:\n Balance:\n 330 mL\n 135 mL\n Respiratory support\n SpO2: 98%\n ABG: ///36/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 197 K/uL\n 7.1 g/dL\n 117\n 0.6 mg/dL\n 36 mEq/L\n 4.0 mEq/L\n 11 mg/dL\n 106 mEq/L\n 146 mEq/L\n 22.7 %\n 4.9 K/uL\n [image002.jpg]\n 04:45 PM\n 04:00 AM\n 07:37 PM\n 04:05 AM\n 06:05 PM\n 03:23 AM\n 02:54 AM\n 04:14 PM\n 10:00 PM\n 03:46 AM\n WBC\n 5.7\n 5.8\n 5.1\n 5.4\n 5.2\n 4.9\n Hct\n 25.2\n 25.3\n 23.7\n 24.7\n 23.7\n 22.8\n 24.0\n 22.7\n Plt\n 83\n 185\n 197\n Cr\n 0.4\n 0.5\n 0.5\n 0.5\n 0.5\n 0.6\n Glucose\n 145\n 137\n 149\n 105\n 115\n 95\n 117\n Other labs: PT / PTT / INR:13.2/23.9/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.9 mg/dL, Mg++:1.9 mg/dL, PO4:3.6\n mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 12:00 AM 60 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2167-10-31 00:00:00.000","description":"Physician Resident Progress Note","row_id":640425,"text":"Chief Complaint:\n 24 Hour Events:\n Going to rehab 10am on Saturday\n DC summary up to date\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Enoxaparin (Lovenox) - 06:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 04:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.2\nC (97.2\n HR: 72 (66 - 88) bpm\n BP: 104/63(70) {78/34(48) - 186/71(98)} mmHg\n RR: 25 (15 - 33) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,197 mL\n 380 mL\n PO:\n TF:\n 301 mL\n 285 mL\n IVF:\n 577 mL\n 95 mL\n Blood products:\n Total out:\n 867 mL\n 245 mL\n Urine:\n 867 mL\n 245 mL\n NG:\n Stool:\n Drains:\n Balance:\n 330 mL\n 135 mL\n Respiratory support\n SpO2: 98%\n ABG: ///36/\n Physical Examination\n Gen: NAD, lying in bed, comfortable, PMV on, able to vocalize. HEENT:\n No pallor in conjunctiva, MMM, TM in place\n Resp: Transmitted upper airway sounds/coarse breath sounds, improved\n compared to yesterday.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, decreased bowel sounds, G-Tube in\n place with no s/s of infection\n Exte: No edema, DP 2+ bil\n NEURO: AxO to year (not to place or day-thinks it is\nthe day before\n \n), MAE\n Labs / Radiology\n 197 K/uL\n 7.1 g/dL\n 117\n 0.6 mg/dL\n 36 mEq/L\n 4.0 mEq/L\n 11 mg/dL\n 106 mEq/L\n 146 mEq/L\n 22.7 %\n 4.9 K/uL\n [image002.jpg]\n 04:45 PM\n 04:00 AM\n 07:37 PM\n 04:05 AM\n 06:05 PM\n 03:23 AM\n 02:54 AM\n 04:14 PM\n 10:00 PM\n 03:46 AM\n WBC\n 5.7\n 5.8\n 5.1\n 5.4\n 5.2\n 4.9\n Hct\n 25.2\n 25.3\n 23.7\n 24.7\n 23.7\n 22.8\n 24.0\n 22.7\n Plt\n 83\n 185\n 197\n Cr\n 0.4\n 0.5\n 0.5\n 0.5\n 0.5\n 0.6\n Glucose\n 145\n 137\n 149\n 105\n 115\n 95\n 117\n Other labs: PT / PTT / INR:13.2/23.9/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.9 mg/dL, Mg++:1.9 mg/dL, PO4:3.6\n mg/dL\n Assessment and Plan\n 56yoF s/p mechanical fall and traumatic T spine fracture transferred\n from OSH to for TBM eval with hospitalization complicated by\n respiratory failure and HAP, s/p trach/PEG, atrial tachycardia, ileus,\n and delirium/agitation.\n .\n # Delirium: Pt continues to be agitated with paranoia, disorientation\n and hallucinations. Most likely secondary to long hospital course and\n recent multiple psychotropic medications. Other lab values (lytes, past\n LFTs within normal limits), infections processes negative on culture.\n CT of head at OSH negative. d/c\ned Reglan and scopolamine.\n - Appreciate psych. Will call and f/u psych recs.\n -Consider CT of head with contrast if mental status does not improve\n this am.\n - Risperdal 0.25mg PO qam. Consider increasing per psych recs to 0.5mg\n if continues to be agitated. Will d/w psych re any additional meds we\n could use for night time agitation.\n - continue to hold all benzos. opiates, and antihistamines.\n -Follow EKG to assess for QTc prolongation (last EKG ; QTc 457).\n #Anemia: HCT continues to decrease, currently at 22.8 from 23.7 with\n b/l in high 20\ns. No known etiology of blood loss.\n -Will continue to follow HCT\n - Guaiac stools.\n # Respiratory: s/p trach on trach mask, FiO2 50%. Tolerating well with\n good O2 sat in mid-high 90\ns. Pt continues to be at risk for aspiration\n given recent history of vomiting with tube feed trials and increased\n secretions. ENT believes that the posterior gap is not a risk factor\n for aspiration as this is a common finding in females and that her\n increased secretions and edema pose a greater aspiration threat; no\n intervention was recommended.\n - Appreciate ENT and S&S input.\n - Pt to f/u on ^th at 3:30pm with Dr. \n () for an outpatient/clinic re-evaluation.\n - ppi for aspiration prophylaxis, PMV precautions: \nt use w/o\n supervision, frequent suctioning\n - TM as tolerated.\n - Holding sedation with exception of Risperidal 0.25mg PO qam\n #Loose Stools: rectal tube pulled out x2; afebrile, HD stable, without\n abdominal pain. Stool cdif cx negativex1.\n -F/u stool c.dif cultures\n -f/u WBC and vital signs daily\n -Hold bowel regimen\n # Atrial Tachycardia: Stable without issue O/N. Pt now on PO Amiodarone\n 200 TID and PO metoprolol 50mg TID\n - Will continue amiodarone 200 TID for three weeks (start ) and\n then switch to qday for 1week and then d/c amiodarone.\n - Will need to schedule f/u in 4wks with Dr. upon d/c/transfer.\n # Hypernatremia/Fluid Status: resolving after free water\n administration. On TPN/TF. Free water deficit of 1.6L\n - increase NS at 10cc/hr, water flushes with TF\n -Will f/u lytes \n # UE DVT and h/o labile INR: Decision made to d/c Coumadin given her\n labile INR, and start Lovenox . INR at 1.1\n - Will flush L PICC with TPA if does not flush\n - Daily coags\n .\n # Spine fracture: Stable. T5-T8.\n - Brace for OOB.\n - Pt to follow up with Dr. in .\n .\n # Tracheomalacia. Reevaluation bronchoscopy by IP as written above;\n patient not a candidate for stent; pt to follow up as outpatient. No\n new issues.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # FEN: Currently TF held secondary to possible risk of aspiration O/N;\n will increase TF back slowly to max goal.\n - Appreciate GI input and S&S eval\n -D/c\ned Reglan for emesis precaution as pt is tolerating TF without\n vomiting and Reglan increases agitation/delirium risk.\n -meds via G-J tube\n .\n # ACCESS: L PICC\n # Ppx: Lovenox, PPi , Bowel Regimen PRN currently held\n # Communication:\n - (brother) is primary contact; visiting\n patient today and aware of status and disposition\n - Boyfriend of 10 , but minimal contact has been maintained at\n this point\n - Social Work and Case management involved\n # Code: Full\n # Dispo: ICU, Will currently has bed at Rehab and waiting\n insurance approval before transfer of care.\n MSIV\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 12:00 AM 60 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Nursing","chartdate":"2167-10-28 00:00:00.000","description":"Nursing Progress Note","row_id":639938,"text":"56 yr old woman, who was transferred from osh for evaluation of\n tracheal bronchial malacia on .Pt presented to Medical\n Center on s/p fall down a flight of stairs fracturing, t5-t8 with\n propulsion treated conservatively with pain meds and back brace. She\n developed resp distress requiring intubation on . Trach/PEG done\n . Now with prolonged hospital course c/b by PNA, anxiety/altered\n mental status, R&LUE DVT .Pt found to have small non occlusive clot on\n her right axial vein via Ultrasound, now rec\ning Lovenox. She has had\n problems with vomiting tube feedings, so feeding tube passed through\n g-tube to her jejunenum. However, she continued to intermit raise\n gastric contents assoc with bronchospasm. Has not required ventilation\n since , on humidified TM @ 50%. Presently on TPN and restarted on\n TF\nings at low rate via J-tube.\n Airway Clearance, Impaired\n Assessment:\n Pt conts to have a large amount of secreations, she has been requiring\n q1 hr suctioning from her trache\n light yellow in color. Her 02 SATs\n have been in the upper 90s on 50% trache mask.\n Action:\n Scopolamine patch added, freaquent suctioning\n Response:\n Large amounts of secreations through the day\n Plan:\n Cont to watch, cont with the scopolamine patch\n Altered mental status (not Delirium)\n Assessment:\n Pt was somulent this morning but was awake enough this afternoon to\n help us get her out of bed with 2 strong assists. She is able to\n follow commands but continues to require wrist restraints to keep her\n trache in place and her in bed.\n Action:\n Reperidol conts\n Response:\n Not as agitated as she has been, able to cooperate with some care\n Plan:\n Cont with the resperidol, cont to follow\n"},{"category":"Respiratory ","chartdate":"2167-10-30 00:00:00.000","description":"Respiratory Care Shift Note","row_id":640225,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 42\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Tracheostomy tube:\n Type: Standard, Cuffed, Inner Cannula\n Manufacturer: Portex\n Size: 7.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 22 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: White / Thin\n Sputum source/amount: Suctioned / Small\n Comments:\n Pt has not required ventiatory assistance over past several days.\n Remains on 50% humidified trach collar.\n"},{"category":"Respiratory ","chartdate":"2167-10-28 00:00:00.000","description":"Respiratory Care Shift Note","row_id":639939,"text":"Demographics\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Tube Type\n Tracheostomy tube:\n Type: Standard, Cuffed\n Manufacturer: Portex\n Size: 7.0mm\n PMV: as tolerated\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Copious\n Visual assessment of breathing pattern: Pt off ventilatory support.\n FiO2 = 50% via trach collar.\n"},{"category":"Respiratory ","chartdate":"2167-10-29 00:00:00.000","description":"Respiratory Care Shift Note","row_id":640003,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 41\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Tracheostomy tube:\n Type: Cuffed\n Manufacturer: Portex\n Size: 7.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 22 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Patient required frequent suctioning overnight for thick yellow/white\n sputum.\n"},{"category":"Nursing","chartdate":"2167-10-30 00:00:00.000","description":"Nursing Progress Note","row_id":640343,"text":"Synopsis per prior nursing note:\n 56 yr old woman, who was transferred from osh for evaluation of\n tracheal bronchial malacia on .Pt presented to Medical\n Center on s/p fall down a flight of stairs fracturing, t5-t8 with\n propulsion treated conservatively with pain meds and back brace. She\n developed resp distress requiring intubation on . Trach/PEG done\n . Now with prolonged hospital course c/b by PNA, anxiety/altered\n mental status, R&LUE DVT .Pt found to have small non occlusive clot on\n her right axial vein via Ultrasound, now rec\ning Lovenox. She has had\n problems with vomiting tube feedings, so feeding tube passed through\n g-tube to her jejunenum. However, she continued to intermit raise\n gastric contents assoc with bronchospasm. Has not required ventilation\n since , on humidified TM @ 50%. Presently on TPN and restarted on\n TF\nings at low rate via J-tube.\n BRONCHOSCOPY by IP- At 09:43 AM. Severe diffuse\n Tracheobronchomalacia, large gap posterior commisure above true vocal\n cords resulting in possible etiology of recurrent aspiration\n Airway Clearance, Impaired\n Assessment:\n LS-bilat rhonchi. O2 sat >95% on 50% trach collar. Suctioned small to\n moderate amts of thick, white/dark yellow secretions. Passy-muir valve\n on during day/while in chair. Able to cough secretions into tissue\n when passy-muir valve on.\n Action:\n Suctioned every 2 hour. Encouraged to CDB.\n Response:\n Able to cough secretions into tissue. Need for suctioning decreased\n throughout shift.\n Plan:\n to monitor and clear airway as needed. Encourage CDB.\n Alteration in Nutrition\n Assessment:\n Continues on replete w/fiber full strength. Restarted @30cc/hr. Flush\n w/ 100 ml hour every 4 hours. Denies nausea. No vomiting. Small loose\n stool in am.\n Action:\n J tube in place, unable to check residuals. Colace/senna/polyethylene\n glycol held.\n Response:\n Continues to have loose stool. Currently tolerating TF.\n Plan:\n Advance TF to goal as tolerated.\n Fracture, other\n Assessment:\n Patient has a fracture of t5-t8. Denied pain. Brace on while OOB in\n chair.\n Action:\n Changed position. Brace on while OOB.\n Response:\n Continued to deny pain.\n Plan:\n Assess/treat pain. Brace on while OOB. ? transfer to \n @ Medical Center tomorrow @ 10am.\n Altered mental status (not Delirium)\n Assessment:\n When passy-muir valve on, patient had +VH and +AH. Stated paranoid\n thoughts. Stated that she is scared. She is starting to acknowledge\n that hallucinations may not be real. Acknowledges that even though she\n her friend die, she knows that her friend is alive. Follows\n commands. Not pulling at lines/tubes very often.\n Action:\n w/ soft wrist restraints. Reoriented frequently. Assured patient\n that she is safe in hospital. Feels more calm when told that she is\n safe.\n Response:\n Patient remains safe. Able to be calmed when told she is safe in\n hospital.\n Plan:\n current safety plan. Reorient frequently. Psych will continue to\n follow.\n"},{"category":"Respiratory ","chartdate":"2167-10-27 00:00:00.000","description":"Respiratory Care Shift Note","row_id":639761,"text":"Demographics\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Tracheostomy tube:\n Type: Standard, Cuffed\n Manufacturer: Portex\n Size: 7.0mm\n PMV:Yes\n Cuff Management:\n Vol/Press:\n Cuff pressure: 23 cmH2O\n Cuff volume: mL /\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: White / Thin\n Sputum source/amount: Suctioned / Moderate\n Plan\n Next 24-48 hours: Continue to monitor patients respiratory status; sxn\n & tx as indicated.\n"},{"category":"Nursing","chartdate":"2167-10-22 00:00:00.000","description":"Nursing Progress Note","row_id":638886,"text":"Nausea / vomiting\n Assessment:\n Tube feeds started Promote\n @ 10cc/hr. via new jtube. Pt vomited ~ 1\n hr after TF started ->>coffee grounds, TF, H2O(flush). Also\n expectorating same from trach.\n Action:\n Tube feeds stopped. Zofran 4 mg.\n Response:\n No further vomiting, although pt coughing with copious thick tan\n secretions after vomiting episode.\n Plan:\n NPO. Meds given IV for now. Pt to have tube study today.\n Altered mental status (not Delirium)\n Assessment:\n Pt very agitated attempting to get OOB, legs through side rails.\n Mouthing words but difficlt to understand.\n Action:\n Frequent re-orientation. Zyprexa 5 mg x 2. MSO4 2 mg. Valium 2.5 mg.\n Response:\n 1^st dose Zyprexa seemed to have transient calming effect but then pt\n agitated again, 2^nd dose with no effect. Valium with very good effect,\n pt is sleeping but arouseable to voice.\n Plan:\n Zyprexa @ hs (usually effective). Valium 2.5 IV prn, please use\n sparingly d/t ongoing delerium. Re-orientation, emotional support.\n Hypernatremia (high sodium)\n Assessment:\n Na 148 last evening.\n Action:\n D5W c 40 KCL @ 100/hr x 1 liter. Repeat labs sent this AM.\n Response:\n Plan:\n Continue to monitor lytes.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Coughing frequently with copious thick tan secretions after vomiting.\n Asking to be suctioned, also coughing secretions to end of trach.\n Action:\n Frequent suctioning. Placed on CPAP 5/5 this AM to rest.\n Response:\n RR 22 on vent when sedated. Sats 100%\n Plan:\n Wean from vent as tolerated. Pulmonary hygiene.\n"},{"category":"Nursing","chartdate":"2167-10-31 00:00:00.000","description":"Nursing Progress Note","row_id":640414,"text":"Airway Clearance, Impaired\n Assessment:\n Cont on TM 50% O2 sats 96-94%, suct for copious amts of thin white\n secretions, bilat rhonchi, dim bases.\n Action:\n Frequent suctioning, pt able to cough up some secretions on her own\n Response:\n Pt able to cough up secretions on her own at times\n Plan:\n Cont to resp status, encourage CDB\n Altered mental status (not Delirium)\n Assessment:\n Alert/oriented with some confusion, follows commands consistently, but\n requires frequent re-direction\n Action:\n Pt oriented to place/time\n Response:\n Pt still makes attempts to remove TM despite re-direction, pt remains\n with bilat wrist restraints for safety\n Plan:\n Cont to orient pt, frequent monitor for safety\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2167-10-28 00:00:00.000","description":"Nursing Progress Note","row_id":639825,"text":"56 yr old woman, who was transferred from osh for evaluation of\n tracheal bronchial malacia on .Pt presented to Medical\n Center on s/p fall down a flight of stairs fracturing, t5-t8 with\n propulsion treated conservatively with pain meds and back brace. She\n developed resp distress requiring intubation on . Trach/PEG done\n . Now with prolonged hospital course c/b by PNA, anxiety/altered\n mental status, R&LUE DVT .Pt found to have small non occlusive clot on\n her right axial vein via Ultrasound, now rec\ning Lovenox. She has had\n problems with vomiting tube feedings, so feeding tube passed through\n g-tube to her jejunenum. However, she continued to intermit raise\n gastric contents assoc with bronchospasm. Has not required ventilation\n since , on humidified TM @ 50%. Presently on TPN and restarted on\n TF\nings at low rate via J-tube.\n Airway Clearance, Impaired\n Assessment:\n On 50% trach collar overnight, 02 sats 92-100%\n LS rhonchi upper, diminished bases.\n Increased sputum production overnight, strong cough.\n Episode of mucus plugging overnight with desat to <80%, quickly\n recovered with 100% 02 and suctioning.\n Action:\n Suctioned q1-2 hrs for mod/copious amt thick tan secretions.\n Trach care performed.\n AM CXR done.\n Response:\n 02 sats remain 92-100%\n Hemodynamically stable.\n Plan:\n Cont to monitor oxygenation and need for suctioning.\n Altered mental status (not Delirium)\n Assessment:\n Opens eyes, follows commands (squeezes hands), swings legs over side of\n bed, unable to assess orientation (did not use PM valve overnight r/t\n increased secretions/plugging episode.)\n Does move hands near airway and attempted to pull at J-tube/foley cath.\n Action:\n Remains in bilateral soft wrist restraints MD order.\n Response:\n Pt continues altered MS.\n :\n Cont to re-orient pt, monitor pt safety (bed low and locked, bed\n alarm).\n Evaluate need for restraints and obtain MD order.\n"},{"category":"Physician ","chartdate":"2167-10-29 00:00:00.000","description":"Physician Attending Progress Note","row_id":640099,"text":"Chief Complaint: Delerium\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Remains with delerium.\n Experienced episode of SVT --> responded to extra iv dose metoprolol.\n History obtained from Medical records\n Patient unable to provide history: Encephalopathy\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, Tube feeds, No(t) Parenteral nutrition\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, No(t) Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: No(t) Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 11:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.2\nC (97.2\n HR: 78 (61 - 115) bpm\n BP: 108/48(60) {91/36(50) - 156/79(101)} mmHg\n RR: 24 (17 - 30) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,952 mL\n 760 mL\n PO:\n TF:\n 646 mL\n 685 mL\n IVF:\n 950 mL\n 75 mL\n Blood products:\n Total out:\n 2,430 mL\n 610 mL\n Urine:\n 2,430 mL\n 380 mL\n NG:\n Stool:\n Drains:\n Balance:\n 522 mL\n 150 mL\n Respiratory support\n SpO2: 100%\n ABG: ///35/\n Physical Examination\n General Appearance: No(t) Well nourished, No acute distress, No(t)\n Overweight / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic,\n No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, Paradoxical), (Percussion:\n Resonant : , No(t) Hyperresonant: , No(t) Dullness : ), (Breath Sounds:\n Clear : , No(t) Crackles : , No(t) Bronchial: , No(t) Wheezes : , No(t)\n Diminished: , No(t) Absent : , No(t) Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\n Extremities: No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, No(t) Oriented (to): , Movement: Purposeful, No(t) Sedated,\n No(t) Paralyzed, Tone: Normal\n Labs / Radiology\n 7.2 g/dL\n 187 K/uL\n 105 mg/dL\n 0.5 mg/dL\n 35 mEq/L\n 3.8 mEq/L\n 17 mg/dL\n 108 mEq/L\n 147 mEq/L\n 23.7 %\n 5.1 K/uL\n [image002.jpg]\n 03:00 AM\n 04:00 AM\n 05:45 AM\n 03:51 AM\n 04:45 PM\n 04:00 AM\n 07:37 PM\n 04:05 AM\n 06:05 PM\n 03:23 AM\n WBC\n 7.3\n 8.0\n 8.7\n 5.5\n 5.7\n 5.8\n 5.1\n Hct\n 27.3\n 27.0\n 28.7\n 24.7\n 25.2\n 25.3\n 23.7\n 24.7\n 23.7\n Plt\n 346\n 316\n 271\n 249\n 231\n 203\n 187\n Cr\n 0.7\n 0.7\n 0.7\n 0.5\n 0.4\n 0.5\n 0.5\n 0.5\n Glucose\n 123\n 114\n 112\n 122\n 145\n 137\n 149\n 105\n Other labs: PT / PTT / INR:13.3/32.4/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.8 mg/dL, Mg++:2.1 mg/dL, PO4:3.5\n mg/dL\n Assessment and Plan\n T-spine fracture, delerium.\n DELERIUM -- persistent. Etiology may be related to prior EtOH use,\n contribution of medications. Intermittently oriented. Continue\n respiradol. Avoid medications that have psych complications or side\n effects.\n RESPIRATORY FAILURE -- s/p trach. Maintain trach for pulmonary\n toilet/frequent suctioning.\n TACHYCARDIA -- SVT. Continue amiodarone loading schedule. Continue\n beta-blocker, with extra doses prn if needed.\n NUTRITIONAL SUPPORT -- TF via PEJ approaching goal.\n T-SPINE FRACTURE -- s/p fall. Tolerating back brace as per ortho\n service. Activity as tolerated (up in chair).\n ASPIRATION RISK -- poor adduction of vocal cords (post. portion).\n Eventually may require intervention.\n TRANCHEOBRONCHOMALACIA -- no interventions planned at present.\n ICU Care\n Nutrition:\n Replete with Fiber () - 09:45 PM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 55 minutes\n Patient is critically ill\n"},{"category":"Nursing","chartdate":"2167-10-30 00:00:00.000","description":"Nursing Progress Note","row_id":640220,"text":"Synopsis per prior nursing note:\n 56 yr old woman, who was transferred from osh for evaluation of\n tracheal bronchial malacia on .Pt presented to Medical\n Center on s/p fall down a flight of stairs fracturing, t5-t8 with\n propulsion treated conservatively with pain meds and back brace. She\n developed resp distress requiring intubation on . Trach/PEG done\n . Now with prolonged hospital course c/b by PNA, anxiety/altered\n mental status, R&LUE DVT .Pt found to have small non occlusive clot on\n her right axial vein via Ultrasound, now rec\ning Lovenox. She has had\n problems with vomiting tube feedings, so feeding tube passed through\n g-tube to her jejunenum. However, she continued to intermit raise\n gastric contents assoc with bronchospasm. Has not required ventilation\n since , on humidified TM @ 50%. Presently on TPN and restarted on\n TF\nings at low rate via J-tube.\n Airway Clearance, Impaired\n Assessment:\n LS-bilat rhonchi. O2 sat >95% on 50% humidified trach collar. Suctioned\n small to moderate amts of frothy and thin, white secretions and pt\n clearing secretions independently with strong cough.\n Action:\n Repositioned frequently and CPT. Suctioned q2-3hours.\n Response:\n n/a\n Plan:\n Continue to monitor resp status, reposition, CPT as needed.\n Alteration in Nutrition\n Assessment:\n Pt received with tube feeds at goal 60cc/hr and 50cc free water flush\n q4hour via J-tube. Denies nausea, stomach pain or cramping. No\n vomiting. K 3.6.\n Action:\n Unable to check residuals. Tube feeds stopped at 5AM after ?tube feeds\n were suctioned from back of throat. Unlikely aspirated sats 100%.\n Colace/senna/polyethylene glycol held for loose stool. Mushroom\n catheter pulled out x2 this shift and not replaced after 2^nd time.\n Stool #2 sent for c.diff. Repleted with 40 mEq KCl.\n Response:\n Currently TF stopped, team aware.\n Plan:\n Restart TF. Monitor labs and replete lytes as needed.\n Altered mental status (not Delirium)\n Assessment:\n Alert and oriented x2. Continues to think she is in a hotel. Pt\n restless and agitated many times throughout night. Pulled out rectal\n tube x2 and foley x1 this shift. Follows commands. PERL brisk.\n Action:\n Soft wrist restraints for pt safetly to pulling at lines and hx to\n decanulating herself. Bed locked in low position and bed alarm on.\n Reoriented frequently. All meds and interventions explained.\n Response:\n Patient remains safe. Continues to throw her legs over the side of the\n bed and pull at lines.\n Plan:\n Continue current safety plan. Reorient frequently. Psych consulting.\n"},{"category":"Physician ","chartdate":"2167-10-28 00:00:00.000","description":"Physician Resident Progress Note","row_id":639937,"text":"Chief Complaint:\n 24 Hour Events:\n BRONCHOSCOPY by IP- At 09:43 AM. Severe diffuse\n Tracheobronchomalacia, large gap posterior commisure above true vocal\n cords resulting in possible etiology of recurrent aspiration\n Seen by ENT, no note from attg (Dr. re possible posterior\n augmentation.\nWill require better exam in clinic with stroboscopic\n video\n S&S PMV Eval: Pt not to have PMV without supervision and only for short\n periods of time aspiration risk and vocal cord edema with freq\n suctioning when PMV in place. Per nursing had increased secretions\n requiring deep suctioning overnight, otherwise pt is able to clear with\n productive cough.\n Restarted TF yest: 10\n20cc/hr, no issues.\n Changed PPI to per IP recs\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:05 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.1\nC (97\n HR: 86 (62 - 122) bpm\n BP: 146/61(82) {87/42(53) - 152/87(98)} mmHg\n RR: 23 (19 - 36) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 3,692 mL\n 1,252 mL\n PO:\n TF:\n 116 mL\n 116 mL\n IVF:\n 2,175 mL\n 775 mL\n Blood products:\n Total out:\n 3,790 mL\n 400 mL\n Urine:\n 3,790 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n -98 mL\n 854 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 95%\n ABG: ///32/\n Physical Examination\n Gen: Alert, NAD, lying in bed, comfortable, mouthing words, less\n sedated than yest.\n HEENT: No pallor in conjunctiva, MMM, TM in place\n Resp: Transmitted upper airway sounds/coarse breath sounds.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, decreased bowel sounds, G-Tube in\n place with no erythema/induration\n Exte: No edema, DP 2+ bil\n NEURO: Alert, difficult to assess orientation due to poor voice. MAE\n Labs / Radiology\n 203 K/uL\n 7.5 g/dL\n 149 mg/dL\n 0.5 mg/dL\n 27 mEq/L\n 4.1 mEq/L\n 14 mg/dL\n 108 mEq/L\n 143 mEq/L\n 23.7 %\n 5.8 K/uL\n [image002.jpg] Ca 8.6, Mg 2.0, P 3.7; PT/PTT/INR: 13.3/32.4/1.1\n 03:20 PM\n 03:23 AM\n 03:00 AM\n 04:00 AM\n 05:45 AM\n 03:51 AM\n 04:45 PM\n 04:00 AM\n 07:37 PM\n 04:05 AM\n WBC\n 5.7\n 7.3\n 8.0\n 8.7\n 5.5\n 5.7\n 5.8\n Hct\n 30.0\n 26.9\n 27.3\n 27.0\n 28.7\n 24.7\n 25.2\n 25.3\n 23.7\n Plt\n 356\n 346\n 316\n 271\n 249\n 231\n 203\n Cr\n 0.7\n 0.7\n 0.7\n 0.7\n 0.5\n 0.4\n 0.5\n Glucose\n 129\n 123\n 114\n 112\n 122\n 145\n 137\n Other labs: PT / PTT / INR:13.3/32.4/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.9 mg/dL, Mg++:2.1 mg/dL, PO4:3.6\n mg/dL\n Assessment and Plan\n 56yoF s/p mechanical fall and traumatic T spine fracture with resolving\n respiratory failure and HAP s/p trach with complicating TBM and s/p\n PEG.\n .\n # Respiratory: s/p intubation/extubation, now on trach mask, FiO2 50%.\n Tolerating well with good O2 sat in mid-high 90\ns. Pt continues to be\n at risk for aspiration given new IP finding of opening defect in\n posterior vocal cord space and given recent history of vomiting with\n tube feed trials.\n - Appreciate ENT and S&S input.\n - will follow ENT recs; awaiting input for possible intervention.\n - ppi for aspiration prophylaxis, PMV precautions: \nt use w/o\n supervision, frequent suctioning\n - TM as tolerated.\n - continue scopolamine patch q72hrs for secretions\n - Holding sedation with exception of Risperidal 0.5mg PRN\n - F/u CXR tomorrow\n # Sedation/Anxiolysis/AlteredMS: Resolved O/N with risperdal. Previous\n delirium and agitation most likely secondary to long hospital course\n and multiple psychotropic medications as well as hx of EtOH abuse.\n - started Risperdal 0.5mg PO BID PRN.\n - continue to hold all benzos. opiates, and antihistamines\n - Appreciate psych. Will call and f/u psych recs.\n -Obtain EKG to assess for QTc prolongation.\n #Anemia: HCT low compared to b/l at 23.7. No known etiology of blood\n loss.\n -Will continue to follow HCT daily.\n - Guaiac stools.\n -f/u HCT this afternoon\n -T&S\n # Atrial Tachycardia: Improved HR max of 120\ns versus 160s previously.\n Pt now on PO Amiodarone 200 TID and PO metoprolol 37.5mg TID\n - Will continue amiodarone 200 TID for three weeks and then switch to\n qday for 1week and then d/c amiodarone.\n - Will need to schedule f/u in 4wks with Dr. upon d/c/transfer.\n # Hypernatremia/Fluid Status: Mild hypernatramia resolving with free\n water administration. On TPN/TF. Good UOP.\n - providing D5W IVFx 1L at 150cc/hr, free water flushes with TF\n -Will f/u lytes in afternoon (5pm)\n # UE DVT and h/o labile INR: Decision made to d/c Coumadin given her\n labile INR, and start Lovenox . INR at 1.9\n - Will flush L PICC with TPA if does not flush\n - Daily coags\n .\n # Spine fracture: Stable. T5-T8.\n - Brace for OOB, need to discuss with Neurosurgery before d/c if\n current brace is optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in .\n .\n # Tracheomalacia. Reevaluation bronchoscopy by IP as written above;\n patient not a candidate for stent; pt to follow up as outpatient. No\n new issues.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # FEN: Currently receiving TPN, restarted TF yest, currently at\n 20cc/hr, w/o issue.\n - Appreciate GI input and S&S eval\n -Cont Reglan 20mg IV Q 8 hours for emesis precaution; meds via G-J\n tube,\n -D/w GI; rec: continue bowel regimen if no BM\n .\n # ACCESS: PIV x 1, L PICC\n # Ppx: Lovenox, PPi , Bowel Regimen PRN\n # Communication:\n - (brother) is primary contact\n - Boyfriend of 10 , but minimal contact has been maintained at\n this point\n - Social Work and Case management involved; have discussed situation\n w/ brother and boyfriend.\n # Code: Full\n # Dispo: ICU, Will d/w case management re rehab facilities, likely d/c\n tomorrow if insurance/bed confirmed\n MSIV\n PGY2 addendum: , \n Agree with assessment and plan in excellent MSIV note as detailed\n above. Briefly, 56 F s/p fall with T spine fracture (T5-T8),\n respiratory failure now s/p trach/PEG. Now on trach mask. Patient s/p\n bronch with IP yesterday. Nutrition issues continue; have discontinued\n TPN today and will continue tubefeeding to goal of 60cc/hr per\n Nutrition. Will continue reglan until at goal feedings, and decrease\n and d/c as able given potential for delirium. Appreciate psych recs;\n continuing risperidone for agitation. Etiology of delirium/agitation\n still unclear but likely prolonged hospital course, illness and\n multiple medications. Currently discussing with CM about potential\n placement to rehab tomorrow.\n"},{"category":"Physician ","chartdate":"2167-10-30 00:00:00.000","description":"Physician Attending Progress Note","row_id":640328,"text":"Chief Complaint: Delerium, respiratory failure (chronic)\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n STOOL CULTURE - At 06:33 AM\n Remains delerious, confused. Remains somewhat paranoid, but able to\n reorient. Much less agitated.\n Up in chair with brace.\n History obtained from Medical records\n Patient unable to provide history: Encephalopathy\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 PM\n Enoxaparin (Lovenox) - 06:00 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, Tube feeds, No(t) Parenteral nutrition\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation, PEG\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, No(t) Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: No(t) Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 12:02 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.1\nC (96.9\n HR: 70 (66 - 112) bpm\n BP: 96/52(61) {90/37(31) - 164/75(87)} mmHg\n RR: 22 (16 - 29) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,726 mL\n 901 mL\n PO:\n TF:\n 1,388 mL\n 301 mL\n IVF:\n 249 mL\n 330 mL\n Blood products:\n Total out:\n 1,666 mL\n 282 mL\n Urine:\n 836 mL\n 282 mL\n NG:\n Stool:\n Drains:\n Balance:\n 60 mL\n 619 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 100%\n ABG: ///34/\n Physical Examination\n General Appearance: No(t) Well nourished, No acute distress, Overweight\n / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic,\n No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: No(t) Clear : , No(t) Crackles : , No(t) Bronchial: ,\n No(t) Wheezes : , No(t) Diminished: , No(t) Absent : , Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): , Movement: Purposeful, No(t) Sedated, No(t)\n Paralyzed, Tone: Normal\n Labs / Radiology\n 7.1 g/dL\n 183 K/uL\n 115 mg/dL\n 0.5 mg/dL\n 34 mEq/L\n 3.6 mEq/L\n 13 mg/dL\n 106 mEq/L\n 145 mEq/L\n 22.8 %\n 5.4 K/uL\n [image002.jpg]\n 04:00 AM\n 05:45 AM\n 03:51 AM\n 04:45 PM\n 04:00 AM\n 07:37 PM\n 04:05 AM\n 06:05 PM\n 03:23 AM\n 02:54 AM\n WBC\n 8.0\n 8.7\n 5.5\n 5.7\n 5.8\n 5.1\n 5.4\n Hct\n 27.0\n 28.7\n 24.7\n 25.2\n 25.3\n 23.7\n 24.7\n 23.7\n 22.8\n Plt\n \n 183\n Cr\n 0.7\n 0.7\n 0.5\n 0.4\n 0.5\n 0.5\n 0.5\n 0.5\n Glucose\n 114\n 112\n 122\n 145\n 137\n 149\n 105\n 115\n Other labs: PT / PTT / INR:13.3/32.4/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.4 mg/dL, Mg++:1.9 mg/dL, PO4:3.6\n mg/dL\n Assessment and Plan\n Delerium.\n DELERIUM -- likely multifactorial. EtOH withdrawl-related,\n medications, ICU psychosis.\n RESPIRATORY FUNCTION -- stable with trach. Remains on trach collar.\n T-SPINE Fx\n will likely need new fitted brace (as pt. experienced much\n weight loss since admission). Continue PT rehab.\n TRACHEOBRONCHOMALACIA\n no further immediate plans. Will need F/U with\n IP service in future.\n VOCAL CORD DYSFUNCTION -- adduction problem. need ENT f/u in\n future.\n NUTRITIONAL SUPPORT -- TF via PEG\n FLUIDS -- euvolemic. Monitor I/O.\n REHABILITATION placement in progress.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 55 minutes\n Patient is critically ill\n"},{"category":"Nursing","chartdate":"2167-10-22 00:00:00.000","description":"Nursing Progress Note","row_id":639073,"text":"56 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\n with prolonged hospital course c/b by PNA, anxiety/altered mental\n status, R&LUE DVT .Pt found to have small non occlusive Clot on her\n right axial vein via Ultrasound.Yesterday. She has had problems with\n vomiting tube feedings, feeding tube passed through g-tube (g-tube in\n place with mushroom on inside so cannot pull out) to her jejunenum but\n continues vomit.\n Tachycardia, Other\n Assessment:\n HR better but still 110-130. Receiving 7.5mg lopressor IV Q4h\n Action:\n Heart rate better on lopressor. Lopressor increased to 10mg IV Q4h.\n Response:\n HR still up but is due to her agitation .\n Plan:\n Continue to monitor B/P and HR, do not hold lopressor but decrease the\n dose (ask HO)\n Assessment:\n Pt had tube studies today, contrast injected into feeding tube, it\n went into her jejuneum and went no furtere. Pt has had 2 xrayes to\n see if it has advanced at all.\n Action:\n Pt has been restarted on raglan, narcotics and other meds that slow GI\n motility have been D/C\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Hypernatremia (high sodium)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Physician ","chartdate":"2167-10-27 00:00:00.000","description":"Physician Attending Progress Note","row_id":639745,"text":"Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Aggitation, remains delerious.\n Bedside bronchoscopy by IP service revealed inability of posterior\n portion of vocal cords to adduct. Unclear etiology.\n Sedated for bronchoscopy.\n 24 Hour Events:\n More awake this afternoon, less agitated, but remains confused.\n Tolerating Passe-Muir valve -> speaking but not coherent.\n History obtained from Medical records\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Enoxaparin (Lovenox) - 06:48 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG\n tube, Tracheotomy tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, Tube feeds, No(t) Parenteral nutrition\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, No(t) Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: No(t) Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 11:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.1\nC (96.9\n HR: 62 (62 - 123) bpm\n BP: 87/42(53) {87/42(53) - 179/121(130)} mmHg\n RR: 20 (18 - 31) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 4,004 mL\n 2,070 mL\n PO:\n TF:\n 137 mL\n 51 mL\n IVF:\n 2,544 mL\n 1,423 mL\n Blood products:\n Total out:\n 3,813 mL\n 1,380 mL\n Urine:\n 3,813 mL\n 1,380 mL\n NG:\n Stool:\n Drains:\n Balance:\n 191 mL\n 690 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 98%\n ABG: ///33/\n Physical Examination\n General Appearance: No(t) Well nourished, No(t) No acute distress,\n No(t) Overweight / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic,\n Sedated\n Eyes / Conjunctiva: No(t) PERRL, No(t) Pupils dilated, No(t)\n Conjunctiva pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: No(t) Normocephalic, No(t) Poor dentition,\n No(t) Endotracheal tube, No(t) NG tube, No(t) OG tube, Tracheotomy tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic,\n No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: No(t) Resonant : , No(t) Hyperresonant: , No(t) Dullness :\n ), (Breath Sounds: Clear : , No(t) Crackles : , Bronchial: Right base,\n No(t) Wheezes : , No(t) Diminished: , No(t) Absent : , No(t)\n Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended, No(t)\n Tender: , No(t) Obese, PEG\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Verbal stimuli, No(t) Oriented (to): , Movement: Purposeful, No(t)\n Sedated, No(t) Paralyzed, Tone: Normal\n Labs / Radiology\n 7.7 g/dL\n 231 K/uL\n 145 mg/dL\n 0.4 mg/dL\n 33 mEq/L\n 3.5 mEq/L\n 11 mg/dL\n 109 mEq/L\n 146 mEq/L\n 25.3 %\n 5.7 K/uL\n [image002.jpg]\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n 03:00 AM\n 04:00 AM\n 05:45 AM\n 03:51 AM\n 04:45 PM\n 04:00 AM\n WBC\n 9.5\n 5.7\n 7.3\n 8.0\n 8.7\n 5.5\n 5.7\n Hct\n 28.6\n 28.9\n 30.0\n 26.9\n 27.3\n 27.0\n 28.7\n 24.7\n 25.2\n 25.3\n Plt\n 528\n 356\n 346\n \n 231\n Cr\n 1.0\n 0.7\n 0.7\n 0.7\n 0.7\n 0.5\n 0.4\n Glucose\n 121\n 129\n 123\n 114\n 112\n 122\n 145\n Other labs: PT / PTT / INR:13.6/31.1/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.6 mg/dL, Mg++:2.0 mg/dL, PO4:3.6\n mg/dL\n Assessment and Plan\n Respiratory failure, delerium.\n RESPIRATORY FAILURE -- chronic, s/p trach. Underlying\n tracheobronchomalacia. Possible elevated right hemidiaphragm.\n Continue current care, including aspiration precautions. Maintain\n trach, monitor SaO2 --> maintain >90%.\n TRACHEOBRONCOMALACIA -- no immediate plans for IP intervention.\n VOCAL CORD dysfunction -- ENT to evaluate limited ability of posterior\n portion of cords to adduct. consult ENT service.\n RUE DVT -- anticoagulation with lovenox.\n HYPERNATREMIA -- improved with free H2O repletion. Monitor.\n A-FIB -- rate controlled on amioderone. Monitor HR.\n DELERIUM -- currently sedated from procedure. Unclear etiology.\n Concerns include medications and ICU psychosis. Psychiatry consulted.\n Respiradol dose being adjusted.\n NUTRITIONAL SUPPORT -- hope to transition TPN to TF via PEG.\n T4-T8 VETEBRAL Fx -- suportive care. Will require rehabilitation.\n ICU Care\n Nutrition:\n TPN without Lipids - 05:44 PM 43. mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n 18 Gauge - 10:14 AM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 55 minutes\n Patient is critically ill\n"},{"category":"Rehab Services","chartdate":"2167-10-28 00:00:00.000","description":"Physical Therapy Evaluation Note","row_id":639900,"text":"Attending Physician:\n date: \n Medical Diagnosis / ICD 9: /\n Reason of :\n History of Present Illness / Subjective Complaint: 55 yo F originally\n admitted for questionable\n alcohol-related fall from stairs sustaining T4-8 fracture. She\n developed respiratory failure, aspiration, sepsis, ARDS, RUE DVT,\n intubated then trached on . She has been in the MICU over a\n month requiring ventilation, and has now been generally weaned to\n trach mask. She has had recurrent aspiration and emesis even with\n J-tube feeding, now requiring TPN\n Past Medical / Surgical History:\n Medications:\n Radiology:\n Labs:\n 23.7\n 7.5\n 203\n 5.8\n [image002.jpg]\n Other labs:\n Activity Orders:\n Social / Occupational History:\n Living Environment:\n Prior Functional Status / Activity Level:\n Objective Test\n Arousal / Attention / Cognition / Communication:\n Hemodynamic Response\n Aerobic Capacity\n HR\n BP\n RR\n O[2 ]sat\n HR\n BP\n RR\n O[2] sat\n RPE\n Supine\n /\n Rest\n /\n Sit\n /\n Activity\n /\n Stand\n /\n Recovery\n /\n Total distance walked:\n Minutes:\n Pulmonary Status:\n Integumentary / Vascular:\n Sensory Integrity:\n Pain / Limiting Symptoms:\n Posture:\n Range of Motion\n Muscle Performance\n Motor Function:\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion:\n Rolling:\n\n\n\n\n\n\n Supine /\n Sidelying to Sit:\n\n\n\n\n\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n\n\n\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Balance:\n Education / Communication:\n Intervention:\n Other:\n Diagnosis:\n 1.\n Airway Clearance, Impaired\n 2.\n Arousal, Attention, and Cognition, Impaired\n 3.\n Balance, Impaired\n 4.\n Knowledge, Impaired\n 5.\n Respiration / Gas Exchange, Impaired\n Clinical impression / Prognosis:\n Goals\n Time frame:\n 1.\n 2.\n 3.\n 4.\n 5.\n 6.\n Anticipated Discharge: Rehab\n Treatment Plan:\n Frequency / Duration:\n Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n"},{"category":"Rehab Services","chartdate":"2167-10-28 00:00:00.000","description":"Physical Therapy Evaluation Note","row_id":639905,"text":"Attending Physician:\n date: \n Medical Diagnosis / ICD 9: /\n Reason of :\n History of Present Illness / Subjective Complaint: 55 yo F originally\n admitted from OSH c fall from stairs sustaining T8 compression fx. She\n developed respiratory failure, aspiration, sepsis, ARDS, RUE DVT,\n required prolonged intubatation and then was trached on . She has\n been in the MICU over a month requiring ventilation, and has weaned to\n trach mask. She has had recurrent aspiration and emesis with J-tube\n feeding, now requiring TPN. Pts mental status has waxed and waned since\n sedation was lifted. Pt had recent broncoscopy which revealed TBM\n Past Medical / Surgical History: See initial eval\n Medications: Risperidone, TPN, midazolam, metoprolol\n Radiology: Extensive basal atelectasis\n Labs:\n 23.7\n 7.5\n 203\n 5.8\n [image002.jpg]\n Other labs:\n Activity Orders: TLSO for OOB\n Social / Occupational History: Has boyfriend\n Environment: Lives in private home\n Prior Functional Status / Activity Level: I PTA\n Objective Test\n Arousal / Attention / Cognition / Communication: Pt very lethargic,\n eyes closed t/o 80% of evaluation. Pt following approx 50% of commands.\n Hemodynamic Response\n Aerobic Capacity\n HR\n BP\n RR\n O[2 ]sat\n HR\n BP\n RR\n O[2] sat\n RPE\n Supine\n 68\n 122/72\n 24\n 98% 50% TM\n Rest\n /\n Sit\n /\n Activity\n 78\n /\n 38\n 87-98% 50% TM\n Stand\n /\n Recovery\n /\n Total distance walked:\n Minutes:\n Pulmonary Status: Coarse upper airways, strong cough. Pt was suctioned\n via trach with moderate amounts of thin white sputum.\n Integumentary / Vascular: Trach, peg, foley, PICC\n Sensory Integrity: withdraws to pain t/o\n Pain / Limiting Symptoms: Pts mental status limited extent of\n evaluation\n Posture:\n Range of Motion\n Muscle Performance\n B UE and LE \n Pt actively moving B UE and LE in bed against gravity\n Motor Function:\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion:\n Rolling:\n\n\n\n\n X 2\n\n Supine /\n Sidelying to Sit:\n NA\n\n\n\n\n\n\n Transfer:\n NA\n\n\n\n\n\n\n Sit to Stand:\n NA\n\n\n\n\n\n\n Ambulation:\n NA\n\n\n\n\n\n\n Stairs:\n NA\n\n\n\n\n\n\n Balance: Unable to assess 2/2 pts mental status\n Education / Communication: Pt status discussed with RN\n Intervention:\n Other:\n Diagnosis:\n 55 yo f s/p fall with resultant T8 fx, with hospital course significant\n for respiratory failure and prolonged ICU stay requiring trach and peg.\n Pt presents with above impairments c/w impaired gas exchange and\n deconditioning. In comparison to prior treatment on pt shows a\n decline in function and mental status, likely related to initiation of\n new medications to treat delirium, however in this instance they have\n sedated her to the point where she is unable to participate with PT.\n Feel pt has good potential based on prior treatments to participate and\n make gains with continued PT in rehab setting, as long as sedation from\n current medications improves.\n 1.\n Airway Clearance, Impaired\n 2.\n Arousal, Attention, and Cognition, Impaired\n 3.\n Balance, Impaired\n 4.\n Knowledge, Impaired\n 5.\n Respiration / Gas Exchange, Impaired\n Clinical impression / Prognosis:\n Goals\n Time frame:\n 1.\n Follow 100% of commands\n 2.\n Maintain eyes open t/o treatment\n 3.\n Sit at EOB c CG\n 4.\n CG for bed mobility\n 5.\n 6.\n Anticipated Discharge: Rehab\n Treatment Plan: f/u mobility, balance, cognitive training, pulm\n hygiene.\n Frequency / Duration:\n 3-5xw/k\n Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n"},{"category":"Physician ","chartdate":"2167-10-28 00:00:00.000","description":"Physician Attending Progress Note","row_id":639928,"text":"Chief Complaint: Respriatory failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n BRONCHOSCOPY - At 09:43 AM\n More wake.\n Less aggitated today.\n Up in chair with back brace this afternoon.\n Requiring more frequent suctioning, now every 1-2 hrs. Sputum thin,\n slight yellow color.\n History obtained from Medical records\n Patient unable to provide history: Encephalopathy\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:05 PM\n Enoxaparin (Lovenox) - 06:33 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, No(t) Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: No(t) Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 12:33 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.9\nC (98.5\n HR: 71 (70 - 122) bpm\n BP: 122/84(94) {115/48(66) - 167/87(98)} mmHg\n RR: 10 (10 - 36) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 3,692 mL\n 1,980 mL\n PO:\n TF:\n 116 mL\n 244 mL\n IVF:\n 2,175 mL\n 832 mL\n Blood products:\n Total out:\n 3,790 mL\n 1,180 mL\n Urine:\n 3,790 mL\n 1,180 mL\n NG:\n Stool:\n Drains:\n Balance:\n -98 mL\n 800 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 98%\n ABG: ///27/\n Physical Examination\n General Appearance: No(t) Well nourished, No acute distress, No(t)\n Overweight / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic,\n No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: Clear : , No(t) Crackles : , No(t) Bronchial: , No(t)\n Wheezes : , No(t) Diminished: , No(t) Absent : , No(t) Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese, PEG\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, No(t) Oriented (to): , Movement: Purposeful, No(t) Sedated,\n No(t) Paralyzed, Tone: Normal\n Labs / Radiology\n 7.5 g/dL\n 203 K/uL\n 149 mg/dL\n 0.5 mg/dL\n 27 mEq/L\n 4.1 mEq/L\n 14 mg/dL\n 108 mEq/L\n 143 mEq/L\n 23.7 %\n 5.8 K/uL\n [image002.jpg]\n 03:20 PM\n 03:23 AM\n 03:00 AM\n 04:00 AM\n 05:45 AM\n 03:51 AM\n 04:45 PM\n 04:00 AM\n 07:37 PM\n 04:05 AM\n WBC\n 5.7\n 7.3\n 8.0\n 8.7\n 5.5\n 5.7\n 5.8\n Hct\n 30.0\n 26.9\n 27.3\n 27.0\n 28.7\n 24.7\n 25.2\n 25.3\n 23.7\n Plt\n 356\n 346\n 316\n 271\n 249\n 231\n 203\n Cr\n 0.7\n 0.7\n 0.7\n 0.7\n 0.5\n 0.4\n 0.5\n 0.5\n Glucose\n 129\n 123\n 114\n 112\n 122\n 145\n 137\n 149\n Other labs: PT / PTT / INR:13.3/32.4/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.6 mg/dL, Mg++:2.0 mg/dL, PO4:3.7\n mg/dL\n Assessment and Plan\n Delerium.\n RESPIRATORY FAILURE -- chronic, persistent. Tracheotomy tube in place,\n with tach collar/mask. Use Passe-Muir valve as tolerated.\n INCREASED SPUTUM production -- concern for evolving LLL pneumonia.\n Monitor closely. COntinue frequent suctioning.\n T-SPINE Fx -- Back brace. Up in chair as tolerated. Ortho to F/U.\n TRACHEOBRONCHOMALAcIA -- no immediate plans for intervention at this\n time.\n VOCAL CORD DYSFUNCTION -- poor adduction of posterior portions of vocal\n cords --> ENT to further assess.\n NUTRITIONAL SUPPORT -- TF via PEG at low rate. ALso receiving TPN.\n DELERIUM -- likely due to medications and ICU. Possible contribution\n of EtOH withdraw/DT. Improved on Respiradol.\n DVT\n continue lovenox\n REHABILITATION evaluation for transfer.\n ICU Care\n Nutrition:\n Replete with Fiber () - 06:00 PM 20 mL/hour\n TPN w/ Lipids - 06:02 PM 62.5 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer:\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 55 minutes\n Patient is critically ill\n"},{"category":"Physician ","chartdate":"2167-10-28 00:00:00.000","description":"Physician Resident Progress Note","row_id":639934,"text":"Chief Complaint:\n 24 Hour Events:\n BRONCHOSCOPY by IP- At 09:43 AM. Severe diffuse\n Tracheobronchomalacia, large gap posterior commisure above true vocal\n cords resulting in possible etiology of recurrent aspiration\n Seen by ENT, no note from attg (Dr. re possible posterior\n augmentation.\nWill require better exam in clinic with stroboscopic\n video\n S&S PMV Eval: Pt not to have PMV without supervision and only for short\n periods of time aspiration risk and vocal cord edema with freq\n suctioning when PMV in place. Per nursing had increased secretions\n requiring deep suctioning overnight, otherwise pt is able to clear with\n productive cough.\n Restarted TF yest: 10\n20cc/hr, no issues.\n Changed PPI to per IP recs\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:05 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.1\nC (97\n HR: 86 (62 - 122) bpm\n BP: 146/61(82) {87/42(53) - 152/87(98)} mmHg\n RR: 23 (19 - 36) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 3,692 mL\n 1,252 mL\n PO:\n TF:\n 116 mL\n 116 mL\n IVF:\n 2,175 mL\n 775 mL\n Blood products:\n Total out:\n 3,790 mL\n 400 mL\n Urine:\n 3,790 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n -98 mL\n 854 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 95%\n ABG: ///32/\n Physical Examination\n Gen: Alert, NAD, lying in bed, comfortable, mouthing words, less\n sedated than yest.\n HEENT: No pallor in conjunctiva, MMM, TM in place\n Resp: Transmitted upper airway sounds/coarse breath sounds.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, decreased bowel sounds, G-Tube in\n place with no erythema/induration\n Exte: No edema, DP 2+ bil\n NEURO: Alert, difficult to assess orientation due to poor voice. MAE\n Labs / Radiology\n 203 K/uL\n 7.5 g/dL\n 149 mg/dL\n 0.5 mg/dL\n 27 mEq/L\n 4.1 mEq/L\n 14 mg/dL\n 108 mEq/L\n 143 mEq/L\n 23.7 %\n 5.8 K/uL\n [image002.jpg] Ca 8.6, Mg 2.0, P 3.7; PT/PTT/INR: 13.3/32.4/1.1\n 03:20 PM\n 03:23 AM\n 03:00 AM\n 04:00 AM\n 05:45 AM\n 03:51 AM\n 04:45 PM\n 04:00 AM\n 07:37 PM\n 04:05 AM\n WBC\n 5.7\n 7.3\n 8.0\n 8.7\n 5.5\n 5.7\n 5.8\n Hct\n 30.0\n 26.9\n 27.3\n 27.0\n 28.7\n 24.7\n 25.2\n 25.3\n 23.7\n Plt\n 356\n 346\n 316\n 271\n 249\n 231\n 203\n Cr\n 0.7\n 0.7\n 0.7\n 0.7\n 0.5\n 0.4\n 0.5\n Glucose\n 129\n 123\n 114\n 112\n 122\n 145\n 137\n Other labs: PT / PTT / INR:13.3/32.4/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.9 mg/dL, Mg++:2.1 mg/dL, PO4:3.6\n mg/dL\n Assessment and Plan\n 56yoF s/p mechanical fall and traumatic T spine fracture with resolving\n respiratory failure and HAP s/p trach with complicating TBM and s/p\n PEG.\n .\n # Respiratory: s/p intubation/extubation, now on trach mask, FiO2 50%.\n Tolerating well with good O2 sat in mid-high 90\ns. Pt continues to be\n at risk for aspiration given new IP finding of opening defect in\n posterior vocal cord space and given recent history of vomiting with\n tube feed trials.\n - Appreciate ENT and S&S input.\n - will follow ENT recs; awaiting input for possible intervention.\n - ppi for aspiration prophylaxis, PMV precautions: \nt use w/o\n supervision, frequent suctioning\n - TM as tolerated.\n - continue scopolamine patch q72hrs for secretions\n - Holding sedation with exception of Risperidal 0.5mg PRN\n - F/u CXR tomorrow\n .\n # FEN: Currently receiving TPN, restarted TF yest, currently at\n 20cc/hr, w/o issue.\n - Appreciate GI input and S&S eval\n -Cont Reglan 20mg IV Q 8 hours for emesis precaution; meds via G-J\n tube,\n -D/w GI; rec: continue bowel regimen if no BM\n # Sedation/Anxiolysis/AlteredMS: Resolved O/N with risperdal. Previous\n delirium and agitation most likely secondary to long hospital course\n and multiple psychotropic medications as well as hx of EtOH abuse.\n - started Risperdal 0.5mg PO BID PRN.\n - continue to hold all benzos. opiates, and antihistamines\n - Appreciate psych. Will call and f/u psych recs.\n -Obtain EKG to assess for QTc prolongation.\n #Anemia: HCT low compared to b/l at 23.7. No known etiology of blood\n loss.\n -Will continue to follow HCT daily.\n - Guaiac stools.\n -f/u HCT this afternoon\n -T&S\n # Tachycardia: Improved HR max of 120\ns versus 160s previously. Pt now\n on PO Amiodarone 200 TID and PO metoprolol 37.5mg TID\n - Will continue amiodarone 200 TID for three weeks and then switch to\n qday for 1week and then d/c amiodarone.\n - Will need to schedule f/u in 4wks with Dr. upon d/c/transfer.\n # Hypernatremia/Fluid Status: Mild hypernatramia resolving with free\n water administration. On TPN/TF. Good UOP.\n - providing D5W IVFx 1L at 150cc/hr, free water flushes with TF\n -Will f/u lytes in afternoon (5pm)\n # UE DVT and h/o labile INR: Decision made to d/c Coumadin given her\n labile INR, and start Lovenox . INR at 1.9\n - Will flush L PICC with TPA if does not flush\n - Daily coags\n .\n # Spine fracture: Stable\n - Brace for OOB, need to discuss with Neurosurgery before d/c if\n current brace is optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in .\n .\n # Tracheomalacia. Reevaluation bronchoscopy by IP as written above;\n patient not a candidate for stent; pt to follow up as outpatient. No\n new issues.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # ACCESS: PIV x 1, L PICC\n # Ppx: Lovenox, PPi , Bowel Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n - Social Work and Case management involved; have discussed situation\n w/ brother and boyfriend.\n # Code: Full\n # Dispo: ICU, Will d/w case management re rehab facilities. Need to\n complete d/c summary.\n MSIV\n PGY2 addendum:\n Agree with assessment and plan in MSIV note as detailed above.\n Briefly, 56 F s/p fall with T spine fracture, respiratory failure now\n s/p trach/PEG. Now on trach mask. Patient s/p bronch with IP today;\n ENT to see and follow for ?intervention. Nutrition issues continue;\n will receive TPN today plus possible restart of tube feeds as tolerated\n (later today), continue reglan. Appreciate psych recs; continuing\n risperidone for agitation. Etiology of delirium/agitation still\n unclear. Likely eventual dispo to rehab facility directly from ICU\n given high nursing requirements.\n"},{"category":"Physician ","chartdate":"2167-10-29 00:00:00.000","description":"Physician Resident Progress Note","row_id":640059,"text":"Chief Complaint:\n 24 Hour Events:\n Tube Feed goals increased from 30cc to 60cc/hr. No issues O/N with\n regard to vomiting.\n Calm overnight. Risperdal decreased from 0.5mg to 0.25mg qam.\n 3 runs of SVT peaking in 110-120\ns, metoprolol 37.5mg changed from\n TID\nQID; given with decrease of HR to 80\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Enoxaparin (Lovenox) - 06:33 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.5\nC (97.7\n HR: 114 (61 - 122) bpm\n BP: 119/54(75) {91/36(50) - 167/84(101)} mmHg\n RR: 19 (10 - 30) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,952 mL\n 429 mL\n PO:\n TF:\n 646 mL\n 376 mL\n IVF:\n 950 mL\n 54 mL\n Blood products:\n Total out:\n 2,430 mL\n 470 mL\n Urine:\n 2,430 mL\n 240 mL\n NG:\n Stool:\n Drains:\n Balance:\n 522 mL\n -41 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 100%\n ABG: ///35/\n Physical Examination\n Gen: Alert, NAD, lying in bed, comfortable, mouthing words, less\n sedated than yest.\n HEENT: No pallor in conjunctiva, MMM, TM in place\n Resp: Transmitted upper airway sounds/coarse breath sounds.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, decreased bowel sounds, G-Tube in\n place with no erythema/induration\n Exte: No edema, DP 2+ bil\n NEURO: Alert, difficult to assess orientation due to poor voice. MAE\n Labs / Radiology\n 187 K/uL\n 7.2 g/dL\n 105 mg/dL\n 0.5 mg/dL\n 35 mEq/L\n 3.8 mEq/L\n 17 mg/dL\n 108 mEq/L\n 147 mEq/L\n 23.7 %\n 5.1 K/uL\n [image002.jpg]\n 03:00 AM\n 04:00 AM\n 05:45 AM\n 03:51 AM\n 04:45 PM\n 04:00 AM\n 07:37 PM\n 04:05 AM\n 06:05 PM\n 03:23 AM\n WBC\n 7.3\n 8.0\n 8.7\n 5.5\n 5.7\n 5.8\n 5.1\n Hct\n 27.3\n 27.0\n 28.7\n 24.7\n 25.2\n 25.3\n 23.7\n 24.7\n 23.7\n Plt\n 346\n 316\n 271\n 249\n 231\n 203\n 187\n Cr\n 0.7\n 0.7\n 0.7\n 0.5\n 0.4\n 0.5\n 0.5\n 0.5\n Glucose\n 123\n 114\n 112\n 122\n 145\n 137\n 149\n 105\n Other labs: PT / PTT / INR:13.3/32.4/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.8 mg/dL, Mg++:2.1 mg/dL, PO4:3.5\n mg/dL\n Assessment and Plan\n 56yoF s/p mechanical fall and traumatic T spine fracture with resolving\n respiratory failure and HAP s/p trach with complicating TBM and s/p\n PEG.\n .\n # Respiratory: s/p intubation/extubation, now on trach mask, FiO2 50%.\n Tolerating well with good O2 sat in mid-high 90\ns. Pt continues to be\n at risk for aspiration given new IP finding of opening defect in\n posterior vocal cord space and given recent history of vomiting with\n tube feed trials.\n - Appreciate ENT and S&S input.\n - will follow ENT recs; awaiting input for possible intervention.\n - ppi for aspiration prophylaxis, PMV precautions: \nt use w/o\n supervision, frequent suctioning\n - TM as tolerated.\n - continue scopolamine patch q72hrs for secretions\n - Holding sedation with exception of Risperidal 0.25mg qam PRN\n # Atrial Tachycardia: Compared to recent b/l, HR increased to max of\n 120\ns. Pt now on PO Amiodarone 200 TID and PO increased metoprolol\n 37.5mg QID.\n - Will continue amiodarone 200 TID for three weeks and then switch to\n qday for 1week and then d/c amiodarone.\n - Will need to schedule f/u in 4wks with Dr. upon d/c/transfer.\n # Sedation/Anxiolysis/AlteredMS: Resolving. Previous delirium and\n agitation most likely secondary to long hospital course and multiple\n psychotropic medications as well as hx of EtOH abuse.\n - Risperdal 0.25mg PO qam PRN.\n - continue to hold all benzos. opiates, and antihistamines\n - Appreciate psych. Will call and f/u psych recs.\n -Follow EKG to assess for QTc prolongation (last EKG ; QTc 457).\n #Anemia: HCT low compared to b/l at 23.7. No known etiology of blood\n loss.\n -Will continue to follow HCT daily.\n - Guaiac stools.\n -f/u HCT this afternoon\n -T&S\n # Hypernatremia/Fluid Status: Mild hypernatramia resolving with free\n water administration. On TPN/TF. Good UOP.\n - increase D5W IVFx 1L from 10cc/hr to 150cc/hr, free water flushes\n with TF\n -Will f/u lytes in afternoon (5pm)\n # UE DVT and h/o labile INR: Decision made to d/c Coumadin given her\n labile INR, and start Lovenox . INR at 1.1\n - Will flush L PICC with TPA if does not flush\n - Daily coags\n .\n # Spine fracture: Stable. T5-T8.\n - Brace for OOB, need to discuss with Neurosurgery before d/c if\n current brace is optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in .\n .\n # Tracheomalacia. Reevaluation bronchoscopy by IP as written above;\n patient not a candidate for stent; pt to follow up as outpatient. No\n new issues.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # FEN: Currently receiving TPN, restarted TF yest, currently at\n 20cc/hr, w/o issue.\n - Appreciate GI input and S&S eval\n -Cont Reglan 20mg IV Q 8 hours for emesis precaution; meds via G-J\n tube,\n -D/w GI; rec: continue bowel regimen if no BM\n .\n # ACCESS: PIV x 1, L PICC\n # Ppx: Lovenox, PPi , Bowel Regimen PRN\n # Communication:\n - (brother) is primary contact\n - Boyfriend of 10 , but minimal contact has been maintained at\n this point\n - Social Work and Case management involved; have discussed situation\n w/ brother and boyfriend.\n # Code: Full\n # Dispo: ICU, Will d/w case management re rehab facilities, likely d/c\n tomorrow if insurance/bed confirmed\n MSIV\n PGY2 addendum: , \n Agree with assessment and plan in excellent MSIV note as detailed\n above. Briefly, 56 F s/p fall with T spine fracture (T5-T8),\n respiratory failure now s/p trach/PEG. Now on trach mask. Patient s/p\n bronch with IP yesterday. Nutrition issues continue; have discontinued\n TPN today and will continue tubefeeding to goal of 60cc/hr per\n Nutrition. Will continue reglan until at goal feedings, and decrease\n and d/c as able given potential for delirium. Appreciate psych recs;\n continuing risperidone for agitation. Etiology of delirium/agitation\n still unclear but likely prolonged hospital course, illness and\n multiple medications. Currently discussing with CM about potential\n placement to rehab tomorrow.\n ICU Care\n Nutrition:\n Replete with Fiber () - 09:45 PM 40 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2167-10-28 00:00:00.000","description":"Physician Resident Progress Note","row_id":639874,"text":"Chief Complaint:\n 24 Hour Events:\n BRONCHOSCOPY by IP- At 09:43 AM. Severe diffuse\n Tracheobronchomalacia, large gap posterior commisure above true vocal\n cords resulting in possible etiology of recurrent aspiration\n Seen by ENT, no note from attg (Dr. re possible posterior\n augmentation.\nWill require better exam in clinic with stroboscopic\n video\n S&S PMV Eval: Pt not to have PMV without supervision and only for short\n periods of time aspiration risk and vocal cord edema with freq\n suctioning when PMV in place. Per nursing had increased secretions\n requiring deep suctioning overnight, otherwise pt is able to clear with\n productive cough.\n Restarted TF yest: 10\n20cc/hr, no issues.\n Changed PPI to per IP recs\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:05 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.1\nC (97\n HR: 86 (62 - 122) bpm\n BP: 146/61(82) {87/42(53) - 152/87(98)} mmHg\n RR: 23 (19 - 36) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 3,692 mL\n 1,252 mL\n PO:\n TF:\n 116 mL\n 116 mL\n IVF:\n 2,175 mL\n 775 mL\n Blood products:\n Total out:\n 3,790 mL\n 400 mL\n Urine:\n 3,790 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n -98 mL\n 854 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 95%\n ABG: ///32/\n Physical Examination\n Gen: Alert, NAD, lying in bed, comfortable, mouthing words, less\n sedated than yest.\n HEENT: No pallor in conjunctiva, MMM, TM in place\n Resp: Transmitted upper airway sounds/coarse breath sounds.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, decreased bowel sounds, G-Tube in\n place with no erythema/induration\n Exte: No edema, DP 2+ bil\n NEURO: Alert, difficult to assess orientation due to poor voice.\n Labs / Radiology\n 203 K/uL\n 7.5 g/dL\n 149 mg/dL\n 0.5 mg/dL\n 27 mEq/L\n 4.1 mEq/L\n 14 mg/dL\n 108 mEq/L\n 143 mEq/L\n 23.7 %\n 5.8 K/uL\n [image002.jpg] Ca 8.6, Mg 2.0, P 3.7; PT/PTT/INR: 13.3/32.4/1.1\n 03:20 PM\n 03:23 AM\n 03:00 AM\n 04:00 AM\n 05:45 AM\n 03:51 AM\n 04:45 PM\n 04:00 AM\n 07:37 PM\n 04:05 AM\n WBC\n 5.7\n 7.3\n 8.0\n 8.7\n 5.5\n 5.7\n 5.8\n Hct\n 30.0\n 26.9\n 27.3\n 27.0\n 28.7\n 24.7\n 25.2\n 25.3\n 23.7\n Plt\n 356\n 346\n 316\n 271\n 249\n 231\n 203\n Cr\n 0.7\n 0.7\n 0.7\n 0.7\n 0.5\n 0.4\n 0.5\n Glucose\n 129\n 123\n 114\n 112\n 122\n 145\n 137\n Other labs: PT / PTT / INR:13.3/32.4/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.9 mg/dL, Mg++:2.1 mg/dL, PO4:3.6\n mg/dL\n Assessment and Plan\n 56yoF s/p mechanical fall and traumatic T spine fracture with resolving\n respiratory failure and HAP s/p trach with complicating TBM and s/p\n PEG.\n .\n # Respiratory: s/p intubation/extubation, now on trach mask, FiO2 50%.\n Tolerating well with good O2 sat in mid-high 90\ns. Pt continues to be\n at risk for aspiration given new IP finding of opening defect in\n posterior vocal cord space and given recent history of vomiting with\n tube feed trials.\n - Appreciate ENT and S&S input.\n - will follow ENT recs; awaiting input for possible intervention.\n - ppi for aspiration prophylaxis\n - Trach mask as tolerated.\n - scopolamine patch q72hrs for secretions\n - Holding sedation with exception of Risperidal 0.5mg PRN\n - F/u CXR tomorrow\n - PMV precautions: \nt use w/o supervision, frequent suctioning\n .\n # FEN: Currently receiving TPN, restarted TF yest, currently at\n 20cc/hr, w/o issue.\n - Appreciate S&S eval\n - Cont Reglan 20mg IV Q 8 hours for emesis precaution; meds via G-J\n tube,\n - Will f/u GI recs\n .\n # Tachycardia: Improved HR max of 120\ns versus 160s previously. Pt now\n on PO Amiodarone 200 TID and PO metoprolol 37.5mg TID\n - Will continue amiodarone 200 TID for three weeks and then switch to\n qday for 1week and then d/c amiodarone.\n - Will need to schedule f/u in 4wks with Dr. upon d/c/transfer.\n # Sedation/Anxiolysis/AlteredMS: Resolved O/N with risperdal. Previous\n delirium and agitation most likely secondary to long hospital course\n and multiple psychotropic medications as well as hx of EtOH abuse.\n - started Risperdal 0.5mg PO BID PRN.\n - continue to hold all benzos. opiates, and antihistamines\n - Appreciate psych. Will call and f/u psych recs.\n -Obtain EKG to assess for QTc prolongation.\n #Anemia: HCT low compared to b/l at 23.7. No known etiology of blood\n loss.\n -Will continue to follow HCT daily.\n # Hypernatremia/Fluid Status: Mild hypernatramia resolving with free\n water administration. On TPN/TF. Good UOP.\n - providing D5W IVFx 1L at 150cc/hr, free water flushes with TF\n -Will f/u lytes in afternoon (5pm)\n # UE DVT and h/o labile INR: Decision made to d/c Coumadin given her\n labile INR, and start Lovenox . INR at 1.9\n - Will flush L PICC with TPA if does not flush\n - Daily coags\n .\n # Spine fracture: Stable\n - Brace for OOB, need to discuss with Neurosurgery before d/c if\n current brace is optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in .\n .\n # Tracheomalacia. Reevaluation bronchoscopy by IP as written above;\n patient not a candidate for stent; pt to follow up as outpatient. No\n new issues.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # ACCESS: PIV x 1, L PICC\n # Ppx: Lovenox, PPi , Bowel Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n - Social Work and Case management involved; have discussed situation\n w/ brother and boyfriend.\n # Code: Full\n # Dispo: ICU, Will d/w case management re rehab facilities.\n MSIV\n PGY2 addendum:\n Agree with assessment and plan in MSIV note as detailed above.\n Briefly, 56 F s/p fall with T spine fracture, respiratory failure now\n s/p trach/PEG. Now on trach mask. Patient s/p bronch with IP today;\n ENT to see and follow for ?intervention. Nutrition issues continue;\n will receive TPN today plus possible restart of tube feeds as tolerated\n (later today), continue reglan. Appreciate psych recs; continuing\n risperidone for agitation. Etiology of delirium/agitation still\n unclear. Likely eventual dispo to rehab facility directly from ICU\n given high nursing requirements.\n"},{"category":"Physician ","chartdate":"2167-10-28 00:00:00.000","description":"Physician Attending Progress Note","row_id":639909,"text":"Chief Complaint: Respriatory failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n BRONCHOSCOPY - At 09:43 AM\n More wake.\n Less aggitated today.\n Up in chair with back brace this afternoon.\n Requiring more frequent suctioning, now every 1-2 hrs. Sputum thin,\n slight yellow color.\n History obtained from Medical records\n Patient unable to provide history: Encephalopathy\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:05 PM\n Enoxaparin (Lovenox) - 06:33 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, No(t) Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: No(t) Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 12:33 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.9\nC (98.5\n HR: 71 (70 - 122) bpm\n BP: 122/84(94) {115/48(66) - 167/87(98)} mmHg\n RR: 10 (10 - 36) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 3,692 mL\n 1,980 mL\n PO:\n TF:\n 116 mL\n 244 mL\n IVF:\n 2,175 mL\n 832 mL\n Blood products:\n Total out:\n 3,790 mL\n 1,180 mL\n Urine:\n 3,790 mL\n 1,180 mL\n NG:\n Stool:\n Drains:\n Balance:\n -98 mL\n 800 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 98%\n ABG: ///27/\n Physical Examination\n General Appearance: No(t) Well nourished, No acute distress, No(t)\n Overweight / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic,\n No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: Clear : , No(t) Crackles : , No(t) Bronchial: , No(t)\n Wheezes : , No(t) Diminished: , No(t) Absent : , No(t) Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese, PEG\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, No(t) Oriented (to): , Movement: Purposeful, No(t) Sedated,\n No(t) Paralyzed, Tone: Normal\n Labs / Radiology\n 7.5 g/dL\n 203 K/uL\n 149 mg/dL\n 0.5 mg/dL\n 27 mEq/L\n 4.1 mEq/L\n 14 mg/dL\n 108 mEq/L\n 143 mEq/L\n 23.7 %\n 5.8 K/uL\n [image002.jpg]\n 03:20 PM\n 03:23 AM\n 03:00 AM\n 04:00 AM\n 05:45 AM\n 03:51 AM\n 04:45 PM\n 04:00 AM\n 07:37 PM\n 04:05 AM\n WBC\n 5.7\n 7.3\n 8.0\n 8.7\n 5.5\n 5.7\n 5.8\n Hct\n 30.0\n 26.9\n 27.3\n 27.0\n 28.7\n 24.7\n 25.2\n 25.3\n 23.7\n Plt\n 356\n 346\n 316\n 271\n 249\n 231\n 203\n Cr\n 0.7\n 0.7\n 0.7\n 0.7\n 0.5\n 0.4\n 0.5\n 0.5\n Glucose\n 129\n 123\n 114\n 112\n 122\n 145\n 137\n 149\n Other labs: PT / PTT / INR:13.3/32.4/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.6 mg/dL, Mg++:2.0 mg/dL, PO4:3.7\n mg/dL\n Assessment and Plan\n Delerium.\n RESPIRATORY FAILURE -- chronic, persistent. Tracheotomy tube in place,\n with tach collar/mask. Use Passe-Muir valve as tolerated.\n INCREASED SPUTUM production -- concern for evolving LLL pneumonia.\n Monitor closely. COntinue frequent suctioning.\n T-SPINE Fx -- Back brace. Up in chair as tolerated. Ortho to F/U.\n TRACHEOBRONCHOMALAcIA -- no immediate plans for intervention at this\n time.\n VOCAL CORD DYSFUNCTION -- poor adduction of posterior portions of vocal\n cords --> ENT to further assess.\n NUTRITIONAL SUPPORT -- TF via PEG at low rate. ALso receiving TPN.\n DELERIUM -- likely due to medications and ICU. Possible contribution\n Improved on Respiradol.\n DVT -- lovenox\n REHABILITATION evaluation for transfer.\n ICU Care\n Nutrition:\n Replete with Fiber () - 06:00 PM 20 mL/hour\n TPN w/ Lipids - 06:02 PM 62.5 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer:\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 55 minutes\n Patient is critically ill\n"},{"category":"Nutrition","chartdate":"2167-10-28 00:00:00.000","description":"Clinical Nutrition Note","row_id":639931,"text":"Subjective\n Pt sitting in chair, appears comfortable\n Objective\n Pertinent medications: noted\n Labs:\n Value\n Date\n Glucose\n 149 mg/dL\n 04:05 AM\n Glucose Finger Stick\n 134\n 10:00 AM\n BUN\n 14 mg/dL\n 04:05 AM\n Creatinine\n 0.5 mg/dL\n 04:05 AM\n Sodium\n 143 mEq/L\n 04:05 AM\n Potassium\n 4.1 mEq/L\n 04:05 AM\n Chloride\n 108 mEq/L\n 04:05 AM\n Albumin\n 3.1 g/dL\n 03:23 AM\n Calcium non-ionized\n 8.6 mg/dL\n 04:05 AM\n Phosphorus\n 3.7 mg/dL\n 04:05 AM\n Ionized Calcium\n 1.24 mmol/L\n 02:51 AM\n Magnesium\n 2.0 mg/dL\n 04:05 AM\n ALT\n 25 IU/L\n 07:34 AM\n Alkaline Phosphate\n 106 IU/L\n 07:34 AM\n AST\n 19 IU/L\n 07:34 AM\n Amylase\n 10 IU/L\n 03:59 AM\n Total Bilirubin\n 0.2 mg/dL\n 07:34 AM\n Triglyceride\n 109 mg/dL\n 03:51 AM\n WBC\n 5.8 K/uL\n 04:05 AM\n Hgb\n 7.5 g/dL\n 04:05 AM\n Hematocrit\n 23.7 %\n 04:05 AM\n Current diet order / nutrition support: i/2 strength Replte c/ Fiber\n @30mL/hr\n GI: Abd obese/hypo bs\n Assessment of Nutritional Status\n Estimation of current intake: Adequate until TPN off at 6 pm\n Specifics:\n TF\ns retrialed, were tolerated up to 20mL/hr-now off cannot infuse\n c/ apparatus needed around torso while in chair. TPN rec were paged\n this am as pt c/ long h/o intolerance to TF\ns, to continue until TF\n tolerance established. TPN ordered then d/c\nd. Will need to change TF\n goal rate to better meet needs and have low threshold for resuming TPN\n if intolerance to TF occurs.\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: TF\n Tube feeding recommendations: Change TF to Replete c/ Fiber @60mL/hr\n (1440 kcals/89 gr aa)\n MOnitor tolerance via abd exam/pt complaints/BM's\n BG management as you are\n If pt does not tolerateTF's will need to resume TPN\n Will follow- please call c/ ?\ns #\n"},{"category":"Physician ","chartdate":"2167-10-28 00:00:00.000","description":"Physician Resident Progress Note","row_id":639932,"text":"Chief Complaint:\n 24 Hour Events:\n BRONCHOSCOPY by IP- At 09:43 AM. Severe diffuse\n Tracheobronchomalacia, large gap posterior commisure above true vocal\n cords resulting in possible etiology of recurrent aspiration\n Seen by ENT, no note from attg (Dr. re possible posterior\n augmentation.\nWill require better exam in clinic with stroboscopic\n video\n S&S PMV Eval: Pt not to have PMV without supervision and only for short\n periods of time aspiration risk and vocal cord edema with freq\n suctioning when PMV in place. Per nursing had increased secretions\n requiring deep suctioning overnight, otherwise pt is able to clear with\n productive cough.\n Restarted TF yest: 10\n20cc/hr, no issues.\n Changed PPI to per IP recs\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:05 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.1\nC (97\n HR: 86 (62 - 122) bpm\n BP: 146/61(82) {87/42(53) - 152/87(98)} mmHg\n RR: 23 (19 - 36) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 3,692 mL\n 1,252 mL\n PO:\n TF:\n 116 mL\n 116 mL\n IVF:\n 2,175 mL\n 775 mL\n Blood products:\n Total out:\n 3,790 mL\n 400 mL\n Urine:\n 3,790 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n -98 mL\n 854 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 95%\n ABG: ///32/\n Physical Examination\n Gen: Alert, NAD, lying in bed, comfortable, mouthing words, less\n sedated than yest.\n HEENT: No pallor in conjunctiva, MMM, TM in place\n Resp: Transmitted upper airway sounds/coarse breath sounds.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, decreased bowel sounds, G-Tube in\n place with no erythema/induration\n Exte: No edema, DP 2+ bil\n NEURO: Alert, difficult to assess orientation due to poor voice. MAE\n Labs / Radiology\n 203 K/uL\n 7.5 g/dL\n 149 mg/dL\n 0.5 mg/dL\n 27 mEq/L\n 4.1 mEq/L\n 14 mg/dL\n 108 mEq/L\n 143 mEq/L\n 23.7 %\n 5.8 K/uL\n [image002.jpg] Ca 8.6, Mg 2.0, P 3.7; PT/PTT/INR: 13.3/32.4/1.1\n 03:20 PM\n 03:23 AM\n 03:00 AM\n 04:00 AM\n 05:45 AM\n 03:51 AM\n 04:45 PM\n 04:00 AM\n 07:37 PM\n 04:05 AM\n WBC\n 5.7\n 7.3\n 8.0\n 8.7\n 5.5\n 5.7\n 5.8\n Hct\n 30.0\n 26.9\n 27.3\n 27.0\n 28.7\n 24.7\n 25.2\n 25.3\n 23.7\n Plt\n 356\n 346\n 316\n 271\n 249\n 231\n 203\n Cr\n 0.7\n 0.7\n 0.7\n 0.7\n 0.5\n 0.4\n 0.5\n Glucose\n 129\n 123\n 114\n 112\n 122\n 145\n 137\n Other labs: PT / PTT / INR:13.3/32.4/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.9 mg/dL, Mg++:2.1 mg/dL, PO4:3.6\n mg/dL\n Assessment and Plan\n 56yoF s/p mechanical fall and traumatic T spine fracture with resolving\n respiratory failure and HAP s/p trach with complicating TBM and s/p\n PEG.\n .\n # Respiratory: s/p intubation/extubation, now on trach mask, FiO2 50%.\n Tolerating well with good O2 sat in mid-high 90\ns. Pt continues to be\n at risk for aspiration given new IP finding of opening defect in\n posterior vocal cord space and given recent history of vomiting with\n tube feed trials.\n - Appreciate ENT and S&S input.\n - will follow ENT recs; awaiting input for possible intervention.\n - ppi for aspiration prophylaxis\n - Trach mask as tolerated.\n - scopolamine patch q72hrs for secretions\n - Holding sedation with exception of Risperidal 0.5mg PRN\n - F/u CXR tomorrow\n - PMV precautions: \nt use w/o supervision, frequent suctioning\n .\n # FEN: Currently receiving TPN, restarted TF yest, currently at\n 20cc/hr, w/o issue.\n - Appreciate S&S eval\n - Cont Reglan 20mg IV Q 8 hours for emesis precaution; meds via G-J\n tube,\n - Will f/u GI recs\n -D/w GI 00\n .\n # Tachycardia: Improved HR max of 120\ns versus 160s previously. Pt now\n on PO Amiodarone 200 TID and PO metoprolol 37.5mg TID\n - Will continue amiodarone 200 TID for three weeks and then switch to\n qday for 1week and then d/c amiodarone.\n - Will need to schedule f/u in 4wks with Dr. upon d/c/transfer.\n # Sedation/Anxiolysis/AlteredMS: Resolved O/N with risperdal. Previous\n delirium and agitation most likely secondary to long hospital course\n and multiple psychotropic medications as well as hx of EtOH abuse.\n - started Risperdal 0.5mg PO BID PRN.\n - continue to hold all benzos. opiates, and antihistamines\n - Appreciate psych. Will call and f/u psych recs.\n -Obtain EKG to assess for QTc prolongation.\n #Anemia: HCT low compared to b/l at 23.7. No known etiology of blood\n loss.\n -Will continue to follow HCT daily.\n # Hypernatremia/Fluid Status: Mild hypernatramia resolving with free\n water administration. On TPN/TF. Good UOP.\n - providing D5W IVFx 1L at 150cc/hr, free water flushes with TF\n -Will f/u lytes in afternoon (5pm)\n # UE DVT and h/o labile INR: Decision made to d/c Coumadin given her\n labile INR, and start Lovenox . INR at 1.9\n - Will flush L PICC with TPA if does not flush\n - Daily coags\n .\n # Spine fracture: Stable\n - Brace for OOB, need to discuss with Neurosurgery before d/c if\n current brace is optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in .\n .\n # Tracheomalacia. Reevaluation bronchoscopy by IP as written above;\n patient not a candidate for stent; pt to follow up as outpatient. No\n new issues.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # ACCESS: PIV x 1, L PICC\n # Ppx: Lovenox, PPi , Bowel Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n - Social Work and Case management involved; have discussed situation\n w/ brother and boyfriend.\n # Code: Full\n # Dispo: ICU, Will d/w case management re rehab facilities.\n MSIV\n PGY2 addendum:\n Agree with assessment and plan in MSIV note as detailed above.\n Briefly, 56 F s/p fall with T spine fracture, respiratory failure now\n s/p trach/PEG. Now on trach mask. Patient s/p bronch with IP today;\n ENT to see and follow for ?intervention. Nutrition issues continue;\n will receive TPN today plus possible restart of tube feeds as tolerated\n (later today), continue reglan. Appreciate psych recs; continuing\n risperidone for agitation. Etiology of delirium/agitation still\n unclear. Likely eventual dispo to rehab facility directly from ICU\n given high nursing requirements.\n"},{"category":"Nursing","chartdate":"2167-10-29 00:00:00.000","description":"Nursing Progress Note","row_id":639980,"text":"56 yr old woman, who was transferred from osh for evaluation of\n tracheal bronchial malacia on .Pt presented to Medical\n Center on s/p fall down a flight of stairs fracturing, t5-t8 with\n propulsion treated conservatively with pain meds and back brace. She\n developed resp distress requiring intubation on . Trach/PEG done\n . Now with prolonged hospital course c/b by PNA, anxiety/altered\n mental status, R&LUE DVT .Pt found to have small non occlusive clot on\n her right axial vein via Ultrasound, now rec\ning Lovenox. She has had\n problems with vomiting tube feedings, so feeding tube passed through\n g-tube to her jejunenum. However, she continued to intermit raise\n gastric contents assoc with bronchospasm. Has not required ventilation\n since , on humidified TM @ 50%. Presently on TPN and restarted on\n TF\nings at low rate via J-tube.\n BRONCHOSCOPY by IP- At 09:43 AM. Severe diffuse\n Tracheobronchomalacia, large gap posterior commisure above true vocal\n cords resulting in possible etiology of recurrent aspiration\n Airway Clearance, Impaired\n Assessment:\n Patients lung sounds are course bilat. O2 sat 95-100 on 50% trach\n collar. She has a productive cough. Yellow , clear white sputum in\n small to mod amounts.\n Action:\n Suctioned every one hour, in increase in secretion. She also has\n scolpolamine patch on.\n Response:\n Sx every 1- 11/2 hours.\n Plan:\n to monitor and clear airway as needed.\n Alteration in Nutrition\n Assessment:\n She did start promote 1/2 strength w/ fiber. Advance by 10ml q6 hours.\n Flush w/ 50 ml hour every 4 hurs.\n Action:\n She has a J tube in place, so we are unable to check resuduals. Patient\n had liquid brown stool over night.\n Response:\n colace and senna held. Mushroom cath placed.\n Plan:\n to advance to goal rate.\n Fracture, other\n Assessment:\n Patient has a fracture of t5-t8. she c/o of pain. She was not able to\n tell me where the pain was located.\n Action:\n Changed the position.\n Response:\n She did fall asleep for a few hours.\n Plan:\n Given Tylenol if she to c/o pain.\n Altered mental status (not Delirium)\n Assessment:\n He is trached and appears confused at times. She will follow commands.\n But she makes attempt to pull out her mushroom tube and iv line. In the\n past she has pulled out her trach x2. she is also throwing her legs\n over the side of the bed.\n Action:\n w/ soft wrist restraints.\n Response:\n Patient remains safe.\n Plan:\n current safety plan.\n 02:34\n"},{"category":"Nursing","chartdate":"2167-10-25 00:00:00.000","description":"Nursing Progress Note","row_id":639400,"text":"Airway Clearance, Impaired\n Assessment:\n Action:\n Response:\n Plan:\n Tachycardia, Other\n Assessment:\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n Hypernatremia (high sodium)\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2167-10-25 00:00:00.000","description":"Nursing Progress Note","row_id":639401,"text":"56 yr old woman, who was transferred from osh for evaluation of\n tracheal bronchial malacia on .Pt presented to Medical\n Center on s/p fall down a flight of stairs fracturing, t5-t8 with\n propulsion treated conservatively with pain meds and back brace. She\n developed resp distress requiring intubation on . Trach/PEG done\n . Now with prolonged hospital course c/b by PNA, anxiety/altered\n mental status, R&LUE DVT .Pt found to have small non occlusive Clot on\n her right axial vein via Ultrasound. She has had problems with\n vomiting tube feedings, feeding tube passed through g-tube to her\n jejunenum but she continues to vomit. Trach mask, has not required\n ventilation since . Has also required 1:1 sitters since\n decanulating herself twice, despite restraints.\n Airway Clearance, Impaired\n Assessment:\n Action:\n Response:\n Plan:\n Tachycardia, Other\n Assessment:\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n Hypernatremia (high sodium)\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2167-10-29 00:00:00.000","description":"Nursing Progress Note","row_id":639975,"text":"56 yr old woman, who was transferred from osh for evaluation of\n tracheal bronchial malacia on .Pt presented to Medical\n Center on s/p fall down a flight of stairs fracturing, t5-t8 with\n propulsion treated conservatively with pain meds and back brace. She\n developed resp distress requiring intubation on . Trach/PEG done\n . Now with prolonged hospital course c/b by PNA, anxiety/altered\n mental status, R&LUE DVT .Pt found to have small non occlusive clot on\n her right axial vein via Ultrasound, now rec\ning Lovenox. She has had\n problems with vomiting tube feedings, so feeding tube passed through\n g-tube to her jejunenum. However, she continued to intermit raise\n gastric contents assoc with bronchospasm. Has not required ventilation\n since , on humidified TM @ 50%. Presently on TPN and restarted on\n TF\nings at low rate via J-tube.\n"},{"category":"Nursing","chartdate":"2167-10-29 00:00:00.000","description":"Nursing Progress Note","row_id":640038,"text":"56 yr old woman, who was transferred from osh for evaluation of\n tracheal bronchial malacia on .Pt presented to Medical\n Center on s/p fall down a flight of stairs fracturing, t5-t8 with\n propulsion treated conservatively with pain meds and back brace. She\n developed resp distress requiring intubation on . Trach/PEG done\n . Now with prolonged hospital course c/b by PNA, anxiety/altered\n mental status, R&LUE DVT .Pt found to have small non occlusive clot on\n her right axial vein via Ultrasound, now rec\ning Lovenox. She has had\n problems with vomiting tube feedings, so feeding tube passed through\n g-tube to her jejunenum. However, she continued to intermit raise\n gastric contents assoc with bronchospasm. Has not required ventilation\n since , on humidified TM @ 50%. Presently on TPN and restarted on\n TF\nings at low rate via J-tube.\n BRONCHOSCOPY by IP- At 09:43 AM. Severe diffuse\n Tracheobronchomalacia, large gap posterior commisure above true vocal\n cords resulting in possible etiology of recurrent aspiration\n Airway Clearance, Impaired\n Assessment:\n Patients lung sounds are course bilat. O2 sat 95-100 on 50% trach\n collar. She has a productive cough. Yellow , clear white sputum in\n small to mod amounts.\n Action:\n Suctioned every one hour, in increase in secretion. She also has\n scolpolamine patch on.\n Response:\n Sx every 1- 11/2 hours.\n Plan:\n to monitor and clear airway as needed.\n Alteration in Nutrition\n Assessment:\n She did start promote 1/2 strength w/ fiber. Advance by 10ml q6 hours.\n Flush w/ 50 ml hour every 4 hurs.\n Action:\n She has a J tube in place, so we are unable to check resuduals. Patient\n had liquid brown stool over night.\n Response:\n colace and senna held. Mushroom cath placed.\n Plan:\n to advance to goal rate.\n Fracture, other\n Assessment:\n Patient has a fracture of t5-t8. she c/o of pain. She was not able to\n tell me where the pain was located.\n Action:\n Changed the position.\n Response:\n She did fall asleep for a few hours.\n Plan:\n Given Tylenol if she to c/o pain.\n Altered mental status (not Delirium)\n Assessment:\n He is trached and appears confused at times. She will follow commands.\n But she makes attempt to pull out her mushroom tube and iv line. In the\n past she has pulled out her trach x2. she is also throwing her legs\n over the side of the bed.\n Action:\n w/ soft wrist restraints.\n Response:\n Patient remains safe.\n Plan:\n current safety plan.\n 02:34\n ------ Protected Section ------\n Patient put out 230ml of brown/gold colored liquid foul smelling\n stool. The stool was sent for c diff. All Bowel meds held.\n ------ Protected Section Addendum Entered By: ,\n RN on: 06:13 ------\n 06:13\n"},{"category":"Nursing","chartdate":"2167-10-29 00:00:00.000","description":"Nursing Progress Note","row_id":640142,"text":"Synopsis per prior nursing note:\n 56 yr old woman, who was transferred from osh for evaluation of\n tracheal bronchial malacia on .Pt presented to Medical\n Center on s/p fall down a flight of stairs fracturing, t5-t8 with\n propulsion treated conservatively with pain meds and back brace. She\n developed resp distress requiring intubation on . Trach/PEG done\n . Now with prolonged hospital course c/b by PNA, anxiety/altered\n mental status, R&LUE DVT .Pt found to have small non occlusive clot on\n her right axial vein via Ultrasound, now rec\ning Lovenox. She has had\n problems with vomiting tube feedings, so feeding tube passed through\n g-tube to her jejunenum. However, she continued to intermit raise\n gastric contents assoc with bronchospasm. Has not required ventilation\n since , on humidified TM @ 50%. Presently on TPN and restarted on\n TF\nings at low rate via J-tube.\n BRONCHOSCOPY by IP- At 09:43 AM. Severe diffuse\n Tracheobronchomalacia, large gap posterior commisure above true vocal\n cords resulting in possible etiology of recurrent aspiration\n Airway Clearance, Impaired\n Assessment:\n LS-bilat rhonchi. O2 sat >95% on 50% trach collar. Suctioned large amts\n of thick, white secretions. Passy-muir valve in only while being\n evaluated by Psych d/t large amt of secretions.\n Action:\n Suctioned every one hour. Scolpolamine patch d/c\nd d/t mental status.\n Response:\n Needed suctioning every 1hour.\n Plan:\n to monitor and clear airway as needed.\n Alteration in Nutrition\n Assessment:\n Continues on replete w/fiber full strength.. Advance by 10ml q6 hours.\n Flush w/ 100 ml hour every 4 hours. Denies nausea. No vomiting.\n Mushroom cath in place.\n Action:\n J tube in place, unable to check resuduals. Increased TF as tolerated.\n Reglan d/c\nd d/t to mental status. Colace/senna/polyethylene glycol\n held.\n Response:\n Continues to have liquid stool. Currently tolerating TF.\n Plan:\n Advance TF to goal as tolerated.\n Fracture, other\n Assessment:\n Patient has a fracture of t5-t8. Denied pain. Brace on while OOB in\n chair.\n Action:\n Changed position. Brace on while OOB.\n Response:\n Continued to deny pain.\n Plan:\n Assess/treat pain. Brace on while OOB.\n Altered mental status (not Delirium)\n Assessment:\n When passy-muir valve on, patient had +VH and +AH. She was paranoid\n about her brother in hallway (brother was not at hospital). Stated that\n she will be driving her car home tomorrow. Stated that she is scared.\n Follows commands. Continues to try to pull out lines/tubes. Continues\n to throw her legs over the side of the bed.\n Action:\n w/ soft wrist restraints. Reoriented frequently. Assured patient\n that she is safe in hospital.\n Response:\n Patient remains safe. Able to be calmed when told she is safe in\n hospital.\n Plan:\n current safety plan. Reorient frequently. Psych will continue to\n follow.\n"},{"category":"Nursing","chartdate":"2167-10-30 00:00:00.000","description":"Nursing Progress Note","row_id":640378,"text":"Synopsis per prior nursing note:\n 56 yr old woman, who was transferred from osh for evaluation of\n tracheal bronchial malacia on .Pt presented to Medical\n Center on s/p fall down a flight of stairs fracturing, t5-t8 with\n propulsion treated conservatively with pain meds and back brace. She\n developed resp distress requiring intubation on . Trach/PEG done\n . Now with prolonged hospital course c/b by PNA, anxiety/altered\n mental status, R&LUE DVT .Pt found to have small non occlusive clot on\n her right axial vein via Ultrasound, now rec\ning Lovenox. She has had\n problems with vomiting tube feedings, so feeding tube passed through\n g-tube to her jejunenum. However, she continued to intermit raise\n gastric contents assoc with bronchospasm. Has not required ventilation\n since , on humidified TM @ 50%. Presently on TPN and restarted on\n TF\nings at low rate via J-tube.\n BRONCHOSCOPY by IP- At 09:43 AM. Severe diffuse\n Tracheobronchomalacia, large gap posterior commisure above true vocal\n cords resulting in possible etiology of recurrent aspiration\n Airway Clearance, Impaired\n Assessment:\n LS-bilat rhonchi. O2 sat >95% on 50% trach collar. Suctioned small to\n moderate amts of thick, white/dark yellow secretions. Passy-muir valve\n on during day/while in chair. Able to cough secretions into tissue\n when passy-muir valve on.\n Action:\n Suctioned every 2 hour. Encouraged to CDB.\n Response:\n Able to cough secretions into tissue. Need for suctioning decreased\n throughout shift.\n Plan:\n to monitor and clear airway as needed. Encourage CDB.\n Alteration in Nutrition\n Assessment:\n Continues on replete w/fiber full strength. Restarted @30cc/hr. Flush\n w/ 100 ml hour every 4 hours. Denies nausea. No vomiting. Small loose\n stool in am.\n Action:\n J tube in place, unable to check residuals. Colace/senna/polyethylene\n glycol held.\n Response:\n Continues to have loose stool. Currently tolerating TF.\n Plan:\n Advance TF to goal as tolerated.\n Fracture, other\n Assessment:\n Patient has a fracture of t5-t8. Denied pain. Brace on while OOB in\n chair.\n Action:\n Changed position. Brace on while OOB.\n Response:\n Continued to deny pain.\n Plan:\n Assess/treat pain. Brace on while OOB. ? transfer to \n @ Medical Center tomorrow @ 10am.\n Altered mental status (not Delirium)\n Assessment:\n When passy-muir valve on, patient had +VH and +AH. Stated paranoid\n thoughts. Stated that she is scared. She is starting to acknowledge\n that hallucinations may not be real. Acknowledges that even though she\n her friend die, she knows that her friend is alive. Follows\n commands. Not pulling at lines/tubes very often.\n Action:\n w/ soft wrist restraints. Reoriented frequently. Assured patient\n that she is safe in hospital. Feels more calm when told that she is\n safe.\n Response:\n Patient remains safe. Able to be calmed when told she is safe in\n hospital.\n Plan:\n current safety plan. Reorient frequently. Psych will continue to\n follow.\n"},{"category":"Respiratory ","chartdate":"2167-10-24 00:00:00.000","description":"Generic Note","row_id":639299,"text":"TITLE:\n Respiratory Care:\n Pt has #7 portex perc trach on 40% trach collar for the night and\n tolerated well. Cuff is deflated. PMV removed. BS are coarse\n bilaterally which clear when suctioned. Pt is being suctioned\n frequently. MDI\ns ald/atr being administered with no adverse\n reactions. Sitter in room. Pt continues to be agitated. PMV worn\n during the day. Pt not requiring the vent this night. Vent pulled.\n"},{"category":"Physician ","chartdate":"2167-10-24 00:00:00.000","description":"Physician Resident Progress Note","row_id":639302,"text":"Chief Complaint:\n 24 Hour Events:\n Pt decannulated herself x2 yesterday, the 1st episode she desatted to\n the 80s, the second episode she desated and her heart rate decreased to\n 39-40, before the trach could be replaced.\n PICC line placed by IR, called to notify that there was clot in both\n arms, placed in L arm more proximally than small Bacillis vein clot.\n Coumadin restarted after PICC placement with 2mg\n Per GI Recs: Reglan restarted at 20mg IV q 8 hours, and meds were\n restarted via tube. No vomitting.\n Per PSYCH recs: d/c'd all benzoes, (also requested d/c reglan if GI\n ok), added Risperdal 0.5mg (and can add 0.5mg PRN, and titrate up\n to total daily dose of 2-3mg if helping)\n Per Cards recs: after 18hr of amiodaron drip. Start PO amiodarone 200mg\n TID, which was done at 1am.\n Brother visited\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 37.4\nC (99.4\n HR: 90 (73 - 121) bpm\n BP: 155/49(75) {103/47(66) - 175/98(111)} mmHg\n RR: 32 (14 - 32) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,151 mL\n 293 mL\n PO:\n TF:\n IVF:\n 1,852 mL\n 13 mL\n Blood products:\n Total out:\n 2,460 mL\n 820 mL\n Urine:\n 2,460 mL\n 820 mL\n NG:\n Stool:\n Drains:\n Balance:\n -309 mL\n -527 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Set): 0 (0 - 0) mL\n Vt (Spontaneous): 360 (360 - 360) mL\n PS : 10 cmH2O\n RR (Set): 0\n RR (Spontaneous): 21\n FiO2: 40%\n SpO2: 98%\n ABG: ///33/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 316 K/uL\n 8.3 g/dL\n 114 mg/dL\n 0.7 mg/dL\n 33 mEq/L\n 4.0 mEq/L\n 7 mg/dL\n 111 mEq/L\n 149 mEq/L\n 27.0 %\n 8.0 K/uL\n [image002.jpg]\n 03:43 AM\n 05:02 PM\n 03:36 AM\n 02:30 AM\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n 03:00 AM\n 04:00 AM\n WBC\n 7.1\n 6.9\n 7.6\n 9.5\n 5.7\n 7.3\n 8.0\n Hct\n 29.2\n 27.8\n 32.7\n 28.6\n 28.9\n 30.0\n 26.9\n 27.3\n 27.0\n Plt\n 452\n 467\n 548\n 528\n 356\n 346\n 316\n Cr\n 0.7\n 0.8\n 0.7\n 0.8\n 1.0\n 0.7\n 0.7\n 0.7\n Glucose\n 104\n 108\n 131\n 128\n 121\n 129\n 123\n 114\n Other labs: PT / PTT / INR:13.2/22.4/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:9.0 mg/dL, Mg++:2.3 mg/dL, PO4:4.1\n mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n TPN without Lipids - 06:00 PM 41. mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n PICC Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2167-10-24 00:00:00.000","description":"Physician Resident Progress Note","row_id":639304,"text":"Chief Complaint:\n 24 Hour Events:\n Pt decannulated herself x2 yesterday, the 1st episode she desatted to\n the 80s, the second episode she desated and her heart rate decreased to\n 39-40, before the trach could be replaced.\n PICC line placed by IR, called to notify that there was clot in both\n arms, placed in L arm more proximally than small Bacillis vein clot.\n Coumadin restarted after PICC placement with 2mg\n Per GI Recs: Reglan restarted at 20mg IV q 8 hours, and meds were\n restarted via tube. No vomitting.\n Per PSYCH recs: d/c'd all benzoes, (also requested d/c reglan if GI\n ok), added Risperdal 0.5mg (and can add 0.5mg PRN, and titrate up\n to total daily dose of 2-3mg if helping)\n Per Cards recs: after 18hr of amiodaron drip. Start PO amiodarone 200mg\n TID, which was done at 1am.\n Brother visited\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 37.4\nC (99.4\n HR: 90 (73 - 121) bpm\n BP: 155/49(75) {103/47(66) - 175/98(111)} mmHg\n RR: 32 (14 - 32) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,151 mL\n 293 mL\n PO:\n TF:\n IVF:\n 1,852 mL\n 13 mL\n Blood products:\n Total out:\n 2,460 mL\n 820 mL\n Urine:\n 2,460 mL\n 820 mL\n NG:\n Stool:\n Drains:\n Balance:\n -309 mL\n -527 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Set): 0 (0 - 0) mL\n Vt (Spontaneous): 360 (360 - 360) mL\n PS : 10 cmH2O\n RR (Set): 0\n RR (Spontaneous): 21\n FiO2: 40%\n SpO2: 98%\n ABG: ///33/\n Physical Examination\n Gen: Awake and alert this am, following commands, mildly agitated,\n stated that she\n wanted to get out of here\n HEENT: PERRL, MMM\n Resp: Diffuse rhonchi and transmitted airway sounds.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, BS+\n Exte: No edema, DP 2+ bil\n NEURO: CNII\nXII intact, reflexes 2+ bilaterally.\n Labs / Radiology\n 316 K/uL\n 8.3 g/dL\n 114 mg/dL\n 0.7 mg/dL\n 33 mEq/L\n 4.0 mEq/L\n 7 mg/dL\n 111 mEq/L\n 149 mEq/L\n 27.0 %\n 8.0 K/uL\n [image002.jpg]\n 03:43 AM\n 05:02 PM\n 03:36 AM\n 02:30 AM\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n 03:00 AM\n 04:00 AM\n WBC\n 7.1\n 6.9\n 7.6\n 9.5\n 5.7\n 7.3\n 8.0\n Hct\n 29.2\n 27.8\n 32.7\n 28.6\n 28.9\n 30.0\n 26.9\n 27.3\n 27.0\n Plt\n 452\n 467\n 548\n 528\n 356\n 346\n 316\n Cr\n 0.7\n 0.8\n 0.7\n 0.8\n 1.0\n 0.7\n 0.7\n 0.7\n Glucose\n 104\n 108\n 131\n 128\n 121\n 129\n 123\n 114\n Other labs: PT / PTT / INR:13.2/22.4/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:9.0 mg/dL, Mg++:2.3 mg/dL, PO4:4.1\n mg/dL\n Assessment and Plan\n 55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach, PEG placement now with respiratory failure secondary to\n tracheomalacia , resolved HAP.\n .\n # Respiratory failure: Slowly improving, spending most of the day on\n trach mask with short periods of rest on PSV at night and setbacks\n from increased secretions to vomiting/aspiration events and her\n self-decanulations.\n - Continue to increase time on trach mask as tolerated.\n - Discontinue all orders for sedation except for Zyprexa QHS.\n - PMV with suctioning as tolerated\n # Nutrition/Vomiting: Normal CT-abdomen, had FT placed via peg into\n jejunum, but continued to vomit. Tube study yesterday showed\n dysmotility in small bowel, but no obstruction, no retrograde flow.\n Awaiting GI recs.\n - Hold TFs\n - GI consult, appreciate recs\n - PICC line placement for parenteral nutrition this am\n - Nutrition recs to start TPN today\n # HAP vs Aspiration PNA: Had been afebrile for last several days, now\n with new fever last night after having decanulated herself. Likely had\n some aspiration. Chemical pneumonitis versus new aspiration PNA.\n - CXR today\n - F/u cx data\n - If remains febrile, send sputum cx.\n .\n # Tachycardia: Pt in and out of SVT and sinus, increased BB seems to\n help, but pt does not stay in sinus. Cards rec to start Amiodarone IV\n drip, and then convert to PO, 200mg TID. Would consider EPS if\n amiodarone not successful, though would wait until pt more stable for\n GA.\n - Changed to IV metoprolol to 10mg IV q4hr during the day and 7.5mg q4\n hours at night.\n - Amiodarone 0.5mg/min IV drip x 18 hours.\n - Cards c/s, appreciate recs\n # Sedation/Anxiolysis/AlteredMS: unclear etiology of her confusion and\n agitation. Has had long hospital course and multiple psychotropic\n medications as well as hx of EtOH abuse.\n - Continue w Olanzapine QHS\n - d/c all benzos, d/c all opiates given GI dysmotlitiy\n - Psychiatry consulted, appreciate recs\n # Adrenal Insufficency: Endocrine following. Pt does not appear to be\n adrenally insufficient at baseline. Suggesting if the patient under\n goes major stressors such as major surgery, sepsis, she may need stress\n dosed steroids.\n .\n # Fluid Status: Likely approaching euvolemia, though still has mild\n hypernatramia which may suggest is still intravascularly depleated.\n - Monitoring urine output\n - will provide D5W IVF as need for hypernatremia and follow lytes\n # UE DVT and elevated INR: DVT in right UE has resolved, new\n non-occlusive in left axillary vein. INR had risen quickly on coumadin,\n likely to poor nutrition, resonded quickly to Vitamin K IV, but now\n subtherapeutic again. Kept subtherapeutic today for PICC line placement\n (for TPN), will restart w/ 2mg Coumadin after line placement.\n - Restart coumadin after PICC line placement today\n - Continue to follow INR closely to reach therapeutic INR.\n .\n #Hematemesis: Pt had small amt Hematemesis, after vomiting, 2 days ago.\n None today. HCT stable.\n -Will follow HCT.\n - Guaiac stools\n # Spine fracture: Stable\n - Brace for OOB, will discuss with Neurosurgery if current brace is\n optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n .\n # Tracheomalacia. Was initially addressed with IP and they wanted to\n follow up as outpatient. IP reevaluated and does not believe that a\n stent would be feasible.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # ACCESS: PIV x 1, PICC placement\n today.\n # Ppx: subtherapeutic INR restarting coumadin today, Ranitidine, Bowel\n Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n - Social Work and Case management involved, have discussed situation\n w/ brother and boyfriend.\n # Code: Full\n # Dispo: ICU, Screening for vent facilities\n ICU Care\n Nutrition:\n TPN without Lipids - 06:00 PM 41. mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n PICC Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Nursing","chartdate":"2167-10-24 00:00:00.000","description":"Nursing Progress Note","row_id":639305,"text":"Airway Clearance, Impaired\n Assessment:\n Secretions thick, white. LS coarse, diminished at bases.\n Action:\n Requiring frequent suctioning, at times q 30 minutes, clearing\n initially and within minutes, pt rattling with secretions once again.\n Response:\n Secretions con\nt to accumulate despite frequent suctioning.\n Plan:\n Con\nt to pulmonary toilet , clear secretions as appropriate. Maintain\n O2 Sat of greater than 94%.\n Tachycardia, Other\n Assessment:\n HR maintained in the 80\ns and 90\ns for the most part. Up to110\n immediately prior to receiving the lopressor.\n Action:\n Receiving lopressor 10 mg IV a4hr.\n Response:\n Maintaining HR below 100 successfully.\n Plan:\n Attempt to keep HR at 100 or lower.\n Alteration in Nutrition\n Assessment:\n Hypoactive BS, TF\ns on hold. J-tube intact, 2 small liquid stools.\n Action:\n TF\ns on hold due to vomiting, Reglan increased to 20mg TID\n Response:\n No vomiting this shift.\n Plan:\n Monitor GI status,\n Altered mental status (not Delirium)\n Assessment:\n Alert but confused, asking for boyfriend. Seems to be concerned about\n some insurance. Encouraged to rest and get some sleep. 1:1 sitter in\n at bedside all night. Pt very active, attempting to swing legs over\n side rails at times. At one point, pt attempted to kick this RN.\n Begun on resperidone 0.5 mg \n Action:\n Frequent re-orientation\n Response:\n Remains confused, poor STM\n Plan:\n Con\nt with 1:1 sitters to maintain safety of pt, she will attempt to\n grab tubes if unrestrained, Monitor effect to meds.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Tmax 99.4 po\n Action:\n Receiving Tylenol 650 PR TID\n Response:\n Stable no change\n Plan:\n Pt to become normalize temp\n"},{"category":"Respiratory ","chartdate":"2167-10-17 00:00:00.000","description":"Respiratory Care Shift Note","row_id":638039,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 29\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Tracheostomy tube:\n Type: Standard, Cuffed\n Manufacturer: Portex\n Size: 7.0mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Copious\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support:\n Note: On trach collar for most of shift, then placed on vent to rest.\n"},{"category":"Nursing","chartdate":"2167-10-20 00:00:00.000","description":"Nursing Progress Note","row_id":638536,"text":"55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach, PEG, placement no with respiratory failure secondary to\n tracheomalacia , resolving HAP.\n Arousal, Attention, and Cognition, Impaired\n Assessment:\n Alert, mouthing words but very difficult to understand. Follows\n commands. MAE on bed, attempting to get up. Restless last evening, did\n eventually fall off to sleep this AM.\n Action:\n Zyprexa x 1 . Frequent re-orientation to place, situation. Soft wrist\n restraints for patient safety.\n Response:\n Pt did eventually fall asleep. Re-orientation does have calming effect\n however it is short term.\n Plan:\n No valium or benadryl per psych as this exacerbates delirium. Zyprexa\n for agitation. pt prn.\n Hypernatremia (high sodium)\n Assessment:\n Na 145 last night, 148 this AM.\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Trach collar @ 50% O2 overnight until 4AM, Sats 90-97%. RR 17-20s.\n Around 4AM RR in low 30s, sats low 90s while sleeping--? Fatiguing.\n Strong cough, able to cough thick white ->tan secretions out of trach.\n Occ suctioned for same. Lungs are rhonchorous throughout. Impaired gag.\n Action:\n Suctioned prn for copious secretions. MDIs. Placed back on vent @ 4AM\n d/t fatigue.\n Response:\n Tolerated trach collar most of night, back on vent this AM d/t fatigue\n with RR in teens, Sats 98%.\n Plan:\n Wean from vent as tolerated. MDIs, suction as needed.\n Alteration in Nutrition\n Assessment:\n Tube feeds off overnight d/t constant vomiting. No vomiting overnight.\n Action:\n NPO. Reglan q 6 hrs.\n Response:\n No vomiting. Small brown stool x 1.\n Plan:\n NPO. ? may go to IR today to change Gtube to Jtube. Reglan. Meds via\n Gtube.\n"},{"category":"Physician ","chartdate":"2167-10-22 00:00:00.000","description":"Physician Resident Progress Note","row_id":639041,"text":"Chief Complaint:\n 24 Hour Events:\n Increased Metoprolol to 7.5 IV q 4\n Getting tube study in am\n had J tube placed by IR via PEG, then had tube feeds at 10/hr which she\n proceeded to vomit, TF held\n Agitated so given Haldol, put back on pressure support\n Na 148 but had not received D5W yet.\n INR 2.3 after 10 IV Vit K\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:30 AM\n Diazepam (Valium) - 02:24 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:35 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 35.7\nC (96.2\n HR: 107 (93 - 140) bpm\n BP: 85/45(55) {83/40(51) - 148/101(105)} mmHg\n RR: 23 (11 - 37) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 3,808 mL\n 557 mL\n PO:\n TF:\n 4 mL\n IVF:\n 3,804 mL\n 557 mL\n Blood products:\n Total out:\n 1,650 mL\n 385 mL\n Urine:\n 1,590 mL\n 385 mL\n NG:\n 60 mL\n Stool:\n Drains:\n Balance:\n 2,158 mL\n 172 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 169 (169 - 438) mL\n PS : 5 cmH2O\n RR (Spontaneous): 23\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 67\n PIP: 10 cmH2O\n SpO2: 100%\n ABG: ///33/\n Ve: 3.7 L/min\n Physical Examination\n Gen: Mildly obtunded in am, responsive to noxious stimuli, on MMV\n through trach tube, but later in alert, responding normally.\n HEENT: PERRL, MMM\n Resp: Coarse BS anteriorly, no focal rales, rhonchi, or wheezing with\n some referred upper airway noises from secretions.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, BS+\n Exte: No edema, DP 2+ bil.\n NEURO: Toes downgoing bilaterally,\n Labs / Radiology\n 356 K/uL\n 8.2 g/dL\n 129 mg/dL\n 0.7 mg/dL\n 33 mEq/L\n 3.6 mEq/L\n 4 mg/dL\n 110 mEq/L\n 148 mEq/L\n 26.9 %\n 5.7 K/uL\n [image002.jpg]\n 06:22 AM\n 02:58 AM\n 03:43 AM\n 05:02 PM\n 03:36 AM\n 02:30 AM\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n WBC\n 7.0\n 7.1\n 7.1\n 6.9\n 7.6\n 9.5\n 5.7\n Hct\n 29.7\n 28.9\n 29.2\n 27.8\n 32.7\n 28.6\n 28.9\n 30.0\n 26.9\n Plt\n 395\n 462\n 452\n 467\n 548\n 528\n 356\n Cr\n 0.7\n 0.6\n 0.7\n 0.8\n 0.7\n 0.8\n 1.0\n 0.7\n Glucose\n 126\n 137\n 104\n 108\n 131\n 128\n 121\n 129\n Other labs: PT / PTT / INR:15.2/24.6/1.3, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:8.7 mg/dL, Mg++:2.1 mg/dL, PO4:4.1\n mg/dL\n CXR: no sig change from previous. R hemidiaphragm remains elevated, L\n hemidiaphragm remains obscured, some patchy opacities in L lobe,\n ?atelectasis\n Assessment and Plan\n 55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach, PEG placement now with respiratory failure secondary to\n tracheomalacia , resolved HAP.\n .\n # Respiratory failure: Slowly Improving. Intermittently on trach mask\n for most of the day, with periods of pressure support of over night.\n This am on MMV. Previously likely oversedated but Benadryl, Morhpine,\n and Valium held now. Pt awake and alert at rounds, interactive, and\n breathing comfortably on trach mask\n - Continue to increase time on trach mask as tolerated.\n - Decrease sedation and valium use\n - PMV with suctioning\n # Nutrition/Vomiting: Has had several days of vomiting up TFs but had\n a normal CT abdoment. Yesterday she had a pediatric feeding tube placed\n by GI through her PEG tube into her jejunum, and was given TFs last\n night, which she vomited. Pt had a tube study this am that showed\n dysmotility of her jejunum. GI continuing to follow study during the\n day with KUBs. Unclear etiology of her ileus; pt has hx of GI problems\n and chronic N/V and this may be her chronic baseline. Alternatively pt\n has had long course of opiates during MICU stay, however, her opiates\n have been decreased steady for the past week and she has had periods\n where she tolerated TFs. Will need to provide parenteral nutrition at\n this point.\n - Hold TFs\n - GI consulted\n - F/u results of Tube study\n - PICC line placement for parenteral nutrition\n -.\n # HAP vs Aspiration PNA: Afebrile without leukocytosis\n - Completed course of ceftriaxone\n - good O2 saturation on trach mask\n .\n # Tachycardia: Previously was assessed as sinus tach with occasional\n runs of SVT and sources such as hypovolemia, PE, infection, and pain\n were assessed as possibly etiologies. Per Cardiology, most likely AT\n given transient response to Adenosine. HR occasionally decreases to\n 70s-80s w/ stable BPs at times that might be associated with\n administration of her BB and valium. Cards recommended titrating up her\n beta blocker as tolerated. Dose increased to 50 yesterday and\n intermittently responded but then had to hold PO meds given need to\n hold PO. Changed PO to IV lopressor.\n - EP consulted for SVT, appreciate recs, will change metoprololt o IV\n and hopefully will be able to restart PO meds soon once able to\n tolerate\n - Changed to IV metoprolol 10mg q4hr during the day and 7.5mg q4 hours\n at night.\n - Per EP, after good trial on PO BB and recovery from current\n hospitalization, would consider EP study or short course of\n amiodarone..\n .\n # Sedation: Inconsistent response to sedation, unclear what is best\n regime. Will continue to wean overall.\n - Continue w Olanzapine QHS\n - d/c all opiates given GI dysmotlitiy\n .\n # Adrenal Insufficency: Endocrine following. Pt does not appear to be\n adrenally insufficient at baseline. Suggesting if the patient under\n goes major stressors such as major surgery, sepsis, she may need stress\n dosed steroids.\n .\n # Fluid Status: Likely approaching euvolemia, though still has mild\n hypernatramia which may suggest is still intravascularly depleated.\n - Monitoring urine output\n - will provide D5W IVF as need for hypernatremia and follow lytes\n .\n # UE DVT and elevated INR: DVT in right UE has resolved, new\n non-occlusive in left axillary vein. INR supratherapeutic yesterday at\n 10.5 despite having stopped coumadin the day before. INR increase is\n most likely continuing to rise nutritional deficiencies given\n continued lack of PO intake. Pt was given Vitamin K IV yesterday, and\n today INR is 1.3.\n - Restart coumadin after PICC line placement today\n - Continue to follow INR closely to reach therapeutic INR.\n .\n #Hematemesis: Pt had small amt Hematemesis, after vomiting, yesterday.\n None today.\n -Will follow HCT.\n - Guaiac stools\n # Spine fracture: Stable\n - Brace for OOB, will discuss with Neurosurgery if current brace is\n optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n .\n # Tracheomalacia. Was initially addressed with IP and they wanted to\n follow up as outpatient. IP reevaluated and does not believe that a\n stent would be feasible.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # ACCESS: PIV x 1, PICC placement\n today.\n # Ppx: supratherapeutic INR, Ranitidine, Bowel Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n - Social Work and Case management involved, have discussed situation\n w/ brother and boyfriend.\n # Code: Full\n # Dispo: ICU, Screening for vent facilities\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 04:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Nursing","chartdate":"2167-10-23 00:00:00.000","description":"Nursing Progress Note","row_id":639131,"text":"56 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\n with prolonged hospital course c/b by PNA, anxiety/altered mental\n status, R&LUE DVT .Pt found to have small non occlusive Clot on her\n right axial vein via Ultrasound.Yesterday. She has had problems with\n vomiting tube feedings, feeding tube passed through g-tube (g-tube in\n place with mushroom on inside so cannot pull out) to her jejunenum but\n continues vomit.\n Tachycardia, Other\n Assessment:\n HR continued to be 110-140, ST w/ rare PVC\n Action:\n Amiordarone 75mg bolus given, and drip started at 1mg/min\n Response:\n HR at rest now 100-120\n Plan:\n Will continue drip for 18 hr then titrate down to 0.5mg/min\n Altered mental status (not Delirium)\n Assessment:\n Pt very restless and agitated throughout night\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2167-10-24 00:00:00.000","description":"Nursing Progress Note","row_id":639387,"text":"56 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\n with prolonged hospital course c/b by PNA, anxiety/altered mental\n status, R&LUE DVT .Pt found to have small non occlusive Clot on her\n right axial vein via Ultrasound . She has had problems with\n vomiting tube feedings, feeding tube passed through g-tube (g-tube in\n place with mushroom on inside so cannot pull out) to her jejunenum but\n continued vomit.\n At 7:30 pt pulled out her trach tube with staff 6feet away. Her\n HR initially was 120\ns, before an airway could be re-established her HR\n had blocked down to 38 and she had lost consciousness. She returned as\n soon as her airway was re-established. Sitter now @ bedside RTC.\n Altered mental status (not Delirium)\n Assessment:\n Pt very somulent most of shift, awake only from 1500-1700 when she\n opened eyes spont and mouthed words as @ baseline. MAEE with good\n strength. Gag and cough impaired while sleeping.\n Action:\n Pt stimulated with painful stimuli, and sitting upright in\n bed-as-chair. AM Risperidone held. PRN Olanzipine D/C\n Response:\n Pt cont to be difficult to waken.\n Plan:\n Cont Risperidine when pt awake. Sitter and bilat wrist restraints\n remain as pt mental status labile.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt has remained on humidified TM @ 50% all shift. RR 23-31 and regular\n but occas shallow. Lung snds rhonchorous in upper lobes but clearing\n after sxn\ning. LL snds diminished. Trach site clean, well healed.\n Action:\n Pt suctioned freq for mod-copious amts thick white tenacious sputum.\n Response:\n O2 sat bouncing up to 100% after sxn\ning.\n Plan:\n Cont aggressive pulm toilet.\n Alteration in Nutrition\n Assessment:\n Rec\nd pt on TPN via PICC line. J tube site clean/dry, tube clamped\n except for meds. BS present, abd soft/obese.\n Action:\n Shortly after pt rec\nd scheduled dose Reglan she was incont of lg amt\n golden loose stool.\n Response:\n TF of\n strength Promote with fiber restarted @ 10ml/hr, with goal\n 40ml/hr. Water flush of 50ml Q4hrs.\n Plan:\n Cont to increase TF to goal as tolerated. Pt to receive TF only when\n she is in sitting position with strict aspiration precautions.\n"},{"category":"Physician ","chartdate":"2167-10-26 00:00:00.000","description":"Physician Resident Progress Note","row_id":639533,"text":"Chief Complaint:\n 24 Hour Events:\n Pt agitated overnight given extra Risperidone 0.5 mg x 2 overnight.\n (1.5mg total)\n 1000 mL D5W for Hypernatremia\n Changed B-Blocker from IV to PO, Metoprolol Tartrate 25 mg PO TID\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:17 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.7\nC (98\n HR: 120 (67 - 120) bpm\n BP: 110/64(76) {109/47(60) - 141/115(118)} mmHg\n RR: 26 (18 - 30) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 3,820 mL\n 856 mL\n PO:\n TF:\n 117 mL\n 20 mL\n IVF:\n 2,612 mL\n 572 mL\n Blood products:\n Total out:\n 2,460 mL\n 1,180 mL\n Urine:\n 2,460 mL\n 1,180 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,360 mL\n -324 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 100%\n ABG: ///33/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 249 K/uL\n 8.0 g/dL\n 122 mg/dL\n 0.5 mg/dL\n 33 mEq/L\n 3.7 mEq/L\n 13 mg/dL\n 108 mEq/L\n 146 mEq/L\n 24.7 %\n 5.5 K/uL\n [image002.jpg]\n 03:36 AM\n 02:30 AM\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n 03:00 AM\n 04:00 AM\n 05:45 AM\n 03:51 AM\n WBC\n 6.9\n 7.6\n 9.5\n 5.7\n 7.3\n 8.0\n 8.7\n 5.5\n Hct\n 27.8\n 32.7\n 28.6\n 28.9\n 30.0\n 26.9\n 27.3\n 27.0\n 28.7\n 24.7\n Plt\n 467\n 548\n 528\n 356\n 346\n 316\n 271\n 249\n Cr\n 0.7\n 0.8\n 1.0\n 0.7\n 0.7\n 0.7\n 0.7\n 0.5\n Glucose\n 131\n 128\n 121\n 129\n 123\n 114\n 112\n 122\n Other labs: PT / PTT / INR:13.6/31.1/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:9.0 mg/dL, Mg++:2.2 mg/dL, PO4:3.1\n mg/dL\n Assessment and Plan\n 55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach, PEG with resolving respiratory failure and HAP.\n .\n # Respiratory failure: 36hrs off vent, now on trach mask. No further\n self-decanulations overnight.\n - Tach mask as tolerated.\n - Holding sedation with exception of Risperidal 0.5mg .\n - PMV with suctioning as tolerated\n .\n # Nutrition/Vomiting: TFs restarted yesterday while patient was not in\n optimal positioning. One large BM in past 24 hrs to indicate potential\n improvement in ileus.\n - Cont Reglan 20mg IV Q 8 hours and restart meds via G-J tube,\n - Slowly restarting TFs and will increase as tolerated.\n - PICC line in place with TPN given when pt not tolerating.\n - GI consult, appreciate recs\n .\n # Tachycardia: One episode of SVT overnight with improved HR max of\n 100\ns versus 160s previously. Pt now on PO Amiodarone 200 TID, and IV\n metoprolol\n - Will change IV metoprolol to metoprolol 25mg PO TID\n - f/u Cards recs\n # Sedation/Anxiolysis/AlteredMS: Improved alertness. Long hospital\n course and multiple psychotropic medications as well as hx of EtOH\n abuse.\n - - started Risperdal 0.5mg PO BID\n - continue to hold all benzos. opiates, and antihistamines\n - f/u psych recs.\n .\n # Fluid Status: Mild hypernatramia with good UOP.\n - providing D5W IVF PRN and follow lytes\n # UE DVT and elevated INR: Decision made to d/c Coumadin given her\n labile INR, and start Lovenox . L Picc difficult to flush this AM.\n - Will flush L PICC with TPA\n .\n # Spine fracture: Stable\n - Brace for OOB, will discuss with Neurosurgery if current brace is\n optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n .\n # Tracheomalacia. Was initially addressed with IP and they wanted to\n follow up as outpatient. IP reevaluated and does not believe that a\n stent would be feasible.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # ACCESS: PIV x 1, L PICC\n # Ppx: Lovenox, PPi, Bowel Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n - Social Work and Case management involved, have discussed situation\n w/ brother and boyfriend.\n # Code: Full\n # Dispo: ICU, Screening for vent facilities\n ICU Care\n Nutrition:\n TPN without Lipids - 07:10 PM 43. mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n PICC Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2167-10-26 00:00:00.000","description":"Physician Resident Progress Note","row_id":639546,"text":"Chief Complaint:\n 24 Hour Events:\n Pt agitated overnight given extra Risperidone 0.5 mg x 2 overnight.\n (1.5mg total)\n 1000 mL D5W for Hypernatremia\n Changed B-Blocker from IV to PO, Metoprolol Tartrate 25 mg PO TID\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:17 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.7\nC (98\n HR: 120 (67 - 120) bpm\n BP: 110/64(76) {109/47(60) - 141/115(118)} mmHg\n RR: 26 (18 - 30) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 3,820 mL\n 856 mL\n PO:\n TF:\n 117 mL\n 20 mL\n IVF:\n 2,612 mL\n 572 mL\n Blood products:\n Total out:\n 2,460 mL\n 1,180 mL\n Urine:\n 2,460 mL\n 1,180 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,360 mL\n -324 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 100%\n ABG: ///33/\n Physical Examination\n Gen: Awake, Mouthing words, More agitated compared to previous\n mornings.\n HEENT: EOMI, No pallor in conjunctiva, MMM\n Resp: CTA bilaterally, no rales, rhonchi, or wheezing, good airway\n movement.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, decreased bowel sounds,, G-Tube in\n place with no erythema/induration\n Exte: No edema, DP 2+ bil\n NEURO: Gross Motor and Sensation in 4 extremities\n Labs / Radiology\n 249 K/uL\n 8.0 g/dL\n 122 mg/dL\n 0.5 mg/dL\n 33 mEq/L\n 3.7 mEq/L\n 13 mg/dL\n 108 mEq/L\n 146 mEq/L\n 24.7 %\n 5.5 K/uL\n [image002.jpg]\n 03:36 AM\n 02:30 AM\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n 03:00 AM\n 04:00 AM\n 05:45 AM\n 03:51 AM\n WBC\n 6.9\n 7.6\n 9.5\n 5.7\n 7.3\n 8.0\n 8.7\n 5.5\n Hct\n 27.8\n 32.7\n 28.6\n 28.9\n 30.0\n 26.9\n 27.3\n 27.0\n 28.7\n 24.7\n Plt\n 467\n 548\n 528\n 356\n 346\n 316\n 271\n 249\n Cr\n 0.7\n 0.8\n 1.0\n 0.7\n 0.7\n 0.7\n 0.7\n 0.5\n Glucose\n 131\n 128\n 121\n 129\n 123\n 114\n 112\n 122\n Other labs: PT / PTT / INR:13.6/31.1/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:9.0 mg/dL, Mg++:2.2 mg/dL, PO4:3.1\n mg/dL\n Assessment and Plan\n 55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach, PEG with resolving respiratory failure and HAP.\n .\n # Respiratory failure: 36hrs off vent, now on trach mask, FiO2 70%. No\n further self-decanulations overnight.\n - Tach mask as tolerated.\n - Holding sedation with exception of Risperidal 0.5mg .\n - PMV with suctioning as tolerated\n .\n # Nutrition/Vomiting: TFs restarted yesterday while patient was not in\n optimal positioning. One large BM in past 24 hrs to indicate potential\n improvement in ileus.\n - Cont Reglan 20mg IV Q 8 hours and restart meds via G-J tube,\n - Increase TF as tolerated\n - PICC line in place with TPN given when pt not tolerating TF\n - GI consult, appreciate recs\n .\n # Tachycardia: One episode of SVT overnight with improved HR max of\n 100\ns versus 160s previously. Pt now on PO Amiodarone 200 TID, and IV\n metoprolol\n - Will change IV metoprolol to metoprolol 25mg PO TID\n - f/u Cards recs\n # Sedation/Anxiolysis/AlteredMS: Improved alertness. Long hospital\n course and multiple psychotropic medications as well as hx of EtOH\n abuse.\n - - started Risperdal 0.5mg PO BID\n - continue to hold all benzos. opiates, and antihistamines\n - f/u psych recs.\n .\n # Fluid Status: Mild hypernatramia with good UOP.\n - providing D5W IVF PRN and follow lytes\n # UE DVT and elevated INR: Decision made to d/c Coumadin given her\n labile INR, and start Lovenox . L Picc difficult to flush this AM.\n - Will flush L PICC with TPA\n .\n # Spine fracture: Stable\n - Brace for OOB, will discuss with Neurosurgery if current brace is\n optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n .\n # Tracheomalacia. Was initially addressed with IP and they wanted to\n follow up as outpatient. IP reevaluated and does not believe that a\n stent would be feasible.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # ACCESS: PIV x 1, L PICC\n # Ppx: Lovenox, PPi, Bowel Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n - Social Work and Case management involved, have discussed situation\n w/ brother and boyfriend.\n # Code: Full\n # Dispo: ICU, Screening for vent facilities\n"},{"category":"Nursing","chartdate":"2167-10-26 00:00:00.000","description":"Nursing Progress Note","row_id":639547,"text":"TITLE:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt on TM @ 70% with O2 sat mid 90\ns-100%. Requiring tracheal\n sxn\ning approx Q1hr for mod-copious amts thick white tenacious\n secretions. Pt with strong cough, but freq unable to clear secretions\n herself. Lung snds rhonchorous in upper lobes, diminished in bases.\n Action:\n Freq sxn\ning per above. Pt encouraged to C&DB. Pt in\nchair\n position\n in bed with head @ 45-90degree angle.\n Response:\n Pt cont to have lg amt secretions requiring assist to clear.\n Plan:\n Cont aggressive pulm toilet.\n Arousal, Attention, and Cognition, Impaired\n Assessment:\n Pt has been awake and alert . Pt chatty, but difficult to read her lips\n and she has trouble writing clearly. Slept for ~ 2 hrs .Pt very\n agitated since ~ 2am. Tryming to climb out of bed\n Action:\n BUE & lt LE restrained with soft restraints. Emotional support\n provided, Risperidone 0.5 x 2 extra doses given.\n Response:\n Little effect with Med. Team aware.\n Plan:\n Speech/swallow consult needed re valve, ? if it is damaged. Cont\n Risperidone. Cont soft wrist restraints and sitter @ bedside for pt\n safety.\n Alteration in Nutrition\n Assessment:\n Abd soft/obese with + BS. On J-tube feeds in upright position.\n Action:\n Pt on colace and senna, held the evening dose as pt had 2 BM\ns during\n the day.\n Response:\n Pt with lg loose yellow BM in am. TF started in afternoon @ 10ml/hr as\n well as 50ml water Q4hrs, with HOB @ 45-90degree angle. Tolerated well.\n Feeds stopped as she became agitated & had to be repositioned multiple\n times to help her maintain a comfortable position, tried bed as chair,\n tolerated for few minutes.\n Plan:\n Currently feed held. Cont to gently advance TF per order. Strict\n aspiration orders, with pt rec\ning TF ONLY when in sitting position.\n Hypernatremia (high sodium)\n Assessment:\n Na 146 , K+ 3.7in am labs\n Action:\n Continued on D5 W@ 100 mls/hr for 1000 mls.\n Response:\n Awaiting order from team for K+ repletion.\n Plan:\n Replete As per orders & Monitor Lytes.\n"},{"category":"Nursing","chartdate":"2167-10-27 00:00:00.000","description":"Nursing Progress Note","row_id":639644,"text":"56 yr old woman, who was transferred from osh for evaluation of\n tracheal bronchial malacia on .Pt presented to Medical\n Center on s/p fall down a flight of stairs fracturing, t5-t8 with\n propulsion treated conservatively with pain meds and back brace. She\n developed resp distress requiring intubation on . Trach/PEG done\n . Now with prolonged hospital course c/b by PNA, anxiety/altered\n mental status, R&LUE DVT .Pt found to have small non occlusive clot on\n her right axial vein via Ultrasound, now rec\ning Lovenox. She has had\n problems with vomiting tube feedings, so feeding tube passed through\n g-tube to her jejunenum. However, she continues to intermit raise\n gastric contents assoc with bronchospasm. Has not required ventilation\n since , on humidified TM @ 50%. Has required 1:1 sitters since\n decanulating herself, twice, despite restraints.\n Airway Clearance, Impaired\n Assessment:\n Pt cont on TM 50%, bilat rhonchi, diminished in bases. 02 SATS 94-95%\n Action:\n Pt requiring frequent suction, copious loose white secretions noted,\n scolopamine patch applied to help with secretions\n Response:\n Cont to suction for copious secretions\n Plan:\n Cont to resp. status, suction as needed, s/swallow to re-evaluate\n for bigger PMV in am\n Alteration in Nutrition\n Assessment:\n Pt cont with restlessness, TF off 00 due to pts restlessness, BS\n positive bilat, loose BM\ns x 2\n Action:\n Pt placed on chair positin in bed, pt recvd scheduled Reglan, colace\n Response:\n Pt had two loose bm\ns x 2,\n Plan:\n Re-start TF when pt more relaxed, cont with TPN 43.6 as ordered, cont\n strict asp precautions :holding TF when pt not in upright position and\n turning TF off for 15 mins before turning\n Arousal, Attention, and Cognition, Impaired\n Assessment:\n Pt cont to be very restless in bed, cont with bilat wrist restraints\n and 1:1 sitter @ bedside\n Action:\n Pt seen by psych @, Risperadol dosing increased\n Response:\n Pt cont to be restless despite increase in HS risperadol and prn dose\n Plan:\n Psych to re-evaluate in am, EKG to be taken in am\n"},{"category":"Nutrition","chartdate":"2167-10-20 00:00:00.000","description":"Clinical Nutrition Note","row_id":638616,"text":"Subjective\n Objective\n Pertinent medications: noted\n Labs:\n Value\n Date\n Glucose\n 128 mg/dL\n 02:30 AM\n Glucose Finger Stick\n 142\n 10:00 AM\n BUN\n 6 mg/dL\n 02:30 AM\n Creatinine\n 0.8 mg/dL\n 02:30 AM\n Sodium\n 148 mEq/L\n 02:30 AM\n Potassium\n 4.1 mEq/L\n 02:30 AM\n Chloride\n 105 mEq/L\n 02:30 AM\n TCO2\n 36 mEq/L\n 02:30 AM\n Albumin\n 3.5 g/dL\n 03:00 AM\n Calcium non-ionized\n 10.0 mg/dL\n 02:30 AM\n Phosphorus\n 4.3 mg/dL\n 02:30 AM\n Ionized Calcium\n 1.24 mmol/L\n 02:51 AM\n Magnesium\n 2.5 mg/dL\n 02:30 AM\n ALT\n 25 IU/L\n 07:34 AM\n Alkaline Phosphate\n 106 IU/L\n 07:34 AM\n AST\n 19 IU/L\n 07:34 AM\n WBC\n 7.6 K/uL\n 02:30 AM\n Hgb\n 10.0 g/dL\n 02:30 AM\n Hematocrit\n 32.7 %\n 02:30 AM\n Current diet order / nutrition support: NPO\n GI: Abd soft/obese/hypo bs\n Assessment of Nutritional Status\n Estimation of previous intake: Adequate\n Estimation of current intake: Inadequate\n Specifics:\n 55 y/o female c/ long hospital course,\n Medical Nutrition Therapy Plan - Recommend the Following\n Other: Will follow POC- access for resuming feeds, If unable to resume\n enteral feeds in next 2-3 days, will need to consider PPN/TPN to avoid\n nutritional decline\n"},{"category":"Physician ","chartdate":"2167-10-23 00:00:00.000","description":"Physician Resident Progress Note","row_id":639120,"text":"Chief Complaint:\n 24 Hour Events:\n Pt pulled out her trach tube, tube replaced\n PICC Line Placed\n Seen By EP and started on Amiodarone Drip\n Fever - 101.4\nF Cultures sent\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Amiodarone - 1 mg/min\n Other ICU medications:\n Metoprolol - 01:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.4\n Tcurrent: 36.9\nC (98.5\n HR: 107 (107 - 142) bpm\n BP: 86/44(54) {82/39(49) - 181/113(122)} mmHg\n RR: 22 (13 - 25) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,127 mL\n 537 mL\n PO:\n TF:\n IVF:\n 2,127 mL\n 537 mL\n Blood products:\n Total out:\n 995 mL\n 400 mL\n Urine:\n 995 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,132 mL\n 137 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Spontaneous): 208 (208 - 243) mL\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 0 cmH2O\n SpO2: 97%\n ABG: ///31/\n Ve: 4.1 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 346 K/uL\n 8.4 g/dL\n 123 mg/dL\n 0.7 mg/dL\n 31 mEq/L\n 3.8 mEq/L\n 4 mg/dL\n 107 mEq/L\n 144 mEq/L\n 27.3 %\n 7.3 K/uL\n [image002.jpg]\n 02:58 AM\n 03:43 AM\n 05:02 PM\n 03:36 AM\n 02:30 AM\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n 03:00 AM\n WBC\n 7.1\n 7.1\n 6.9\n 7.6\n 9.5\n 5.7\n 7.3\n Hct\n 28.9\n 29.2\n 27.8\n 32.7\n 28.6\n 28.9\n 30.0\n 26.9\n 27.3\n Plt\n 462\n 452\n 467\n 548\n 528\n 356\n 346\n Cr\n 0.6\n 0.7\n 0.8\n 0.7\n 0.8\n 1.0\n 0.7\n 0.7\n Glucose\n 137\n 104\n 108\n 131\n 128\n 121\n 129\n 123\n Other labs: PT / PTT / INR:14.1/23.7/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.8 mg/dL, Mg++:1.9 mg/dL, PO4:3.7\n mg/dL\n Assessment and Plan\n 55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach, PEG placement now with respiratory failure secondary to\n tracheomalacia , resolved HAP.\n .\n # Respiratory failure: Slowly Improving. Intermittently on trach mask\n for most of the day, with periods of pressure support of over night.\n This am on MMV. Previously likely oversedated but Benadryl, Morhpine,\n and Valium held now. Pt awake and alert at rounds, interactive, and\n breathing comfortably on trach mask\n - Continue to increase time on trach mask as tolerated.\n - Decrease sedation and valium use\n - PMV with suctioning\n # Nutrition/Vomiting: Has had several days of vomiting up TFs but had\n a normal CT abdoment. Yesterday she had a pediatric feeding tube placed\n by GI through her PEG tube into her jejunum, and was given TFs last\n night, which she vomited. Pt had a tube study this am that showed\n dysmotility of her jejunum. GI continuing to follow study during the\n day with KUBs. Unclear etiology of her ileus; pt has hx of GI problems\n and chronic N/V and this may be her chronic baseline. Alternatively pt\n has had long course of opiates during MICU stay, however, her opiates\n have been decreased steady for the past week and she has had periods\n where she tolerated TFs. Will need to provide parenteral nutrition at\n this point.\n - Hold TFs\n - GI consulted\n - F/u results of Tube study\n - PICC line placement for parenteral nutrition\n -.\n # HAP vs Aspiration PNA: Afebrile without leukocytosis\n - Completed course of ceftriaxone\n - good O2 saturation on trach mask\n .\n # Tachycardia: Previously was assessed as sinus tach with occasional\n runs of SVT and sources such as hypovolemia, PE, infection, and pain\n were assessed as possibly etiologies. Per Cardiology, most likely AT\n given transient response to Adenosine. HR occasionally decreases to\n 70s-80s w/ stable BPs at times that might be associated with\n administration of her BB and valium. Cards recommended titrating up her\n beta blocker as tolerated. Dose increased to 50 yesterday and\n intermittently responded but then had to hold PO meds given need to\n hold PO. Changed PO to IV lopressor.\n - EP consulted for SVT, appreciate recs, will change metoprololt o IV\n and hopefully will be able to restart PO meds soon once able to\n tolerate\n - Changed to IV metoprolol 10mg q4hr during the day and 7.5mg q4 hours\n at night.\n - Per EP, after good trial on PO BB and recovery from current\n hospitalization, would consider EP study or short course of\n amiodarone..\n # Sedation: Inconsistent response to sedation, unclear what is best\n regime. Will continue to wean overall.\n - Continue w Olanzapine QHS\n - d/c all opiates given GI dysmotlitiy\n # Adrenal Insufficency: Endocrine following. Pt does not appear to be\n adrenally insufficient at baseline. Suggesting if the patient under\n goes major stressors such as major surgery, sepsis, she may need stress\n dosed steroids.\n .\n # Fluid Status: Likely approaching euvolemia, though still has mild\n hypernatramia which may suggest is still intravascularly depleated.\n - Monitoring urine output\n - will provide D5W IVF as need for hypernatremia and follow lytes\n # UE DVT and elevated INR: DVT in right UE has resolved, new\n non-occlusive in left axillary vein. INR supratherapeutic yesterday at\n 10.5 despite having stopped coumadin the day before. INR increase is\n most likely continuing to rise nutritional deficiencies given\n continued lack of PO intake. Pt was given Vitamin K IV yesterday, and\n today INR is 1.3.\n - Restart coumadin after PICC line placement today\n - Continue to follow INR closely to reach therapeutic INR.\n .\n #Hematemesis: Pt had small amt Hematemesis, after vomiting, yesterday.\n None today.\n -Will follow HCT.\n - Guaiac stools\n # Spine fracture: Stable\n - Brace for OOB, will discuss with Neurosurgery if current brace is\n optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n .\n # Tracheomalacia. Was initially addressed with IP and they wanted to\n follow up as outpatient. IP reevaluated and does not believe that a\n stent would be feasible.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # ACCESS: PIV x 1, PICC placement today.\n # Ppx: supratherapeutic INR, Ranitidine, Bowel Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n - Social Work and Case management involved, have discussed situation\n w/ brother and boyfriend.\n # Code: Full\n # Dispo: ICU, Screening for vent facilities\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 04:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Nursing","chartdate":"2167-10-17 00:00:00.000","description":"Nursing Progress Note","row_id":638175,"text":"Airway Clearance, Impaired\n Assessment:\n Pt placed on trach mask this am (on vent o/n). She continues to have\n moderate amts of thick secretions, requiring frequent sxn. Pt does have\n a strong/productive cough.\n Action:\n Sxn prn; chest pt; pt repositioned frequently (including OOB to chair)\n to help mobilize secretions.\n Response:\n Unchanged at this time.\n Plan:\n Continue to sxn prn; chest pt prn; OOB as tolerated.\n Altered mental status (not Delirium)\n Assessment:\n Pt extremely restless/agitated today. Attempting to get OOB/chair. Very\n difficult to redirect.\n Action:\n Pt reoriented frequently; Valium given prn; Morphine given per presumed\n pain.\n Response:\n Pt had no improvement after Valium; however, she appeared more\n calm/comfortable after Morphine administration.\n Plan:\n Medicate for agitation prn; continue to follow exam.\n Alteration in Nutrition\n Assessment:\n Pt NPO for past few days ( recurrent aspiration/risk for). Pt with\n one episode of emesis today (mod amt) after coughing episode.\n Action:\n Reglan given per orders; TFs restarted this am.\n Response:\n No residuals noted. No further emesis.\n Plan:\n Increase TFs to goal as tolerated; continue with Reglan.\n Tachycardia, Other\n Assessment:\n HR 120\ns-140\ns today (baseline for ~ 1 week).\n Action:\n Lopressor given per orders.\n Response:\n HR in low 120\ns after Morphine, but otherwise unchanged.\n Plan:\n Continue Lopressor; ? need to increase dose.\n"},{"category":"Nursing","chartdate":"2167-10-21 00:00:00.000","description":"Nursing Progress Note","row_id":638715,"text":"Nausea / vomiting\n Assessment:\n NPO. Vomitted meds ~10\n after given via gtube. Coughing same emesis\n from tracheostomy. Later found to have vomited coffee ground emesis,\n guiac +. Denies nausea every time although continues to dry heave,\n vomit small amts clear emesis. BRB suctioned from back of throat also,\n d/t irritation from frequent vomiting. Abd soft, hypoactive BS.\n Action:\n Tube feeds on hold. No residual aspirated from gtube, gtube\n placed->>gravity. Stat Hct, coags T&S sent. Zofran x 1. HOB^^ 30. 2^nd\n PIV placed.\n Response:\n On/off vomiting, coffee grounds x 1, with no c/o nausea. Hct 28.6,\n baseline. INR 10.5 .\n Plan:\n Recheck Hct, FDP @ 7AM. Zofran. NPO. IV meds only. Needs gtube changed\n to jtube.\n Tachycardia, Other\n Assessment:\n ST 109-114, NSR 70s briefly. No lopressor given d/t BP<100 most of\n night when pt sleeping.\n Action:\n Lopressor changed from PO->>IV prn d/t vomiting after meds.\n Response:\n ST 110s most of night.\n Plan:\n IV lopressor prn for HR>130.\n Alteration in Nutrition\n Assessment:\n NPO. Na 146 x 2. D5W per orders. UOP decreased 10-20cc/hr with lower\n BP.\n Action:\n D5W now @ 150cc/hr x 1 liter.\n Response:\n Na 146.\n Plan:\n Recheck Na @ 7AM. D5W x 1 liter.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n On 50% trach mask all day. RR ^^40 after first episode of vomiting last\n night. Copious thick tan, dark brown secretions.\n Action:\n Placed on Vent MMV mode when tachypneic. Frequent suctioning.\n Response:\n Comfortable on vent, RR 12 (set), no spontaneous btreaths when asleep.\n Apneic for a full minute during RSBI. Sats 100%.\n Plan:\n Wean from vent as tolerated. Suction as needed, MDIs.\n Altered mental status (not Delirium)\n Assessment:\n Occaisionally restless, less so than night before. Slept most of night,\n sometimes difficult to arouse. No zyprexa given. Opens eyes to voice,\n follows commands. Mouthing words although difficult to understand.\n Action:\n Reorient pt prn. Emotional support.\n Response:\n Slept most of night, calmer than previous nights.\n Plan:\n No valium or benadryl per psych recommendations. Zyprexa HS prn for\n agitation. Reorient prn. Emotional support.\n"},{"category":"Physician ","chartdate":"2167-10-22 00:00:00.000","description":"Physician Resident Progress Note","row_id":638903,"text":"Chief Complaint:\n 24 Hour Events:\n Increased Metoprolol to 7.5 IV q 4\n Getting tube study in am\n had J tube placed by IR via PEG, then had tube feeds at 10/hr which she\n proceeded to vomit, TF held\n Agitated so given Haldol, put back on pressure support\n Na 148 but had not received D5W yet.\n INR 2.3 after 10 IV Vit K\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:30 AM\n Diazepam (Valium) - 02:24 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:35 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 35.7\nC (96.2\n HR: 107 (93 - 140) bpm\n BP: 85/45(55) {83/40(51) - 148/101(105)} mmHg\n RR: 23 (11 - 37) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 3,808 mL\n 557 mL\n PO:\n TF:\n 4 mL\n IVF:\n 3,804 mL\n 557 mL\n Blood products:\n Total out:\n 1,650 mL\n 385 mL\n Urine:\n 1,590 mL\n 385 mL\n NG:\n 60 mL\n Stool:\n Drains:\n Balance:\n 2,158 mL\n 172 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 169 (169 - 438) mL\n PS : 5 cmH2O\n RR (Spontaneous): 23\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 67\n PIP: 10 cmH2O\n SpO2: 100%\n ABG: ///33/\n Ve: 3.7 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 356 K/uL\n 8.2 g/dL\n 129 mg/dL\n 0.7 mg/dL\n 33 mEq/L\n 3.6 mEq/L\n 4 mg/dL\n 110 mEq/L\n 148 mEq/L\n 26.9 %\n 5.7 K/uL\n [image002.jpg]\n 06:22 AM\n 02:58 AM\n 03:43 AM\n 05:02 PM\n 03:36 AM\n 02:30 AM\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n WBC\n 7.0\n 7.1\n 7.1\n 6.9\n 7.6\n 9.5\n 5.7\n Hct\n 29.7\n 28.9\n 29.2\n 27.8\n 32.7\n 28.6\n 28.9\n 30.0\n 26.9\n Plt\n 395\n 462\n 452\n 467\n 548\n 528\n 356\n Cr\n 0.7\n 0.6\n 0.7\n 0.8\n 0.7\n 0.8\n 1.0\n 0.7\n Glucose\n 126\n 137\n 104\n 108\n 131\n 128\n 121\n 129\n Other labs: PT / PTT / INR:15.2/24.6/1.3, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:8.7 mg/dL, Mg++:2.1 mg/dL, PO4:4.1\n mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 04:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2167-10-22 00:00:00.000","description":"Physician Resident Progress Note","row_id":638904,"text":"Chief Complaint:\n 24 Hour Events:\n Increased Metoprolol to 7.5 IV q 4\n Getting tube study in am\n had J tube placed by IR via PEG, then had tube feeds at 10/hr which she\n proceeded to vomit, TF held\n Agitated so given Haldol, put back on pressure support\n Na 148 but had not received D5W yet.\n INR 2.3 after 10 IV Vit K\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:30 AM\n Diazepam (Valium) - 02:24 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:35 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 35.7\nC (96.2\n HR: 107 (93 - 140) bpm\n BP: 85/45(55) {83/40(51) - 148/101(105)} mmHg\n RR: 23 (11 - 37) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 3,808 mL\n 557 mL\n PO:\n TF:\n 4 mL\n IVF:\n 3,804 mL\n 557 mL\n Blood products:\n Total out:\n 1,650 mL\n 385 mL\n Urine:\n 1,590 mL\n 385 mL\n NG:\n 60 mL\n Stool:\n Drains:\n Balance:\n 2,158 mL\n 172 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 169 (169 - 438) mL\n PS : 5 cmH2O\n RR (Spontaneous): 23\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 67\n PIP: 10 cmH2O\n SpO2: 100%\n ABG: ///33/\n Ve: 3.7 L/min\n Physical Examination\n Gen: Mildly obtunded in am, responsive to noxious stimuli, on MMV\n through trach tube, but later in am responsive to voice, appropriate,\n asking questions,\n HEENT: PERRL, MMM\n Resp: Coarse BS anteriorly, no focal rales, rhonchi, or wheezing with\n some referred upper airway noises from secretions.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, hypoactive BS\n Exte: No edema, DP 2+ bil.\n NEURO: Toes downgoing bilaterally,\n Labs / Radiology\n 356 K/uL\n 8.2 g/dL\n 129 mg/dL\n 0.7 mg/dL\n 33 mEq/L\n 3.6 mEq/L\n 4 mg/dL\n 110 mEq/L\n 148 mEq/L\n 26.9 %\n 5.7 K/uL\n [image002.jpg]\n 06:22 AM\n 02:58 AM\n 03:43 AM\n 05:02 PM\n 03:36 AM\n 02:30 AM\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n WBC\n 7.0\n 7.1\n 7.1\n 6.9\n 7.6\n 9.5\n 5.7\n Hct\n 29.7\n 28.9\n 29.2\n 27.8\n 32.7\n 28.6\n 28.9\n 30.0\n 26.9\n Plt\n 395\n 462\n 452\n 467\n 548\n 528\n 356\n Cr\n 0.7\n 0.6\n 0.7\n 0.8\n 0.7\n 0.8\n 1.0\n 0.7\n Glucose\n 126\n 137\n 104\n 108\n 131\n 128\n 121\n 129\n Other labs: PT / PTT / INR:15.2/24.6/1.3, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:8.7 mg/dL, Mg++:2.1 mg/dL, PO4:4.1\n mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 04:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2167-10-22 00:00:00.000","description":"Physician Resident Progress Note","row_id":638905,"text":"Chief Complaint:\n 24 Hour Events:\n Increased Metoprolol to 7.5 IV q 4\n Getting tube study in am\n had J tube placed by IR via PEG, then had tube feeds at 10/hr which she\n proceeded to vomit, TF held\n Agitated so given Haldol, put back on pressure support\n Na 148 but had not received D5W yet.\n INR 2.3 after 10 IV Vit K\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:30 AM\n Diazepam (Valium) - 02:24 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:35 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 35.7\nC (96.2\n HR: 107 (93 - 140) bpm\n BP: 85/45(55) {83/40(51) - 148/101(105)} mmHg\n RR: 23 (11 - 37) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 3,808 mL\n 557 mL\n PO:\n TF:\n 4 mL\n IVF:\n 3,804 mL\n 557 mL\n Blood products:\n Total out:\n 1,650 mL\n 385 mL\n Urine:\n 1,590 mL\n 385 mL\n NG:\n 60 mL\n Stool:\n Drains:\n Balance:\n 2,158 mL\n 172 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 169 (169 - 438) mL\n PS : 5 cmH2O\n RR (Spontaneous): 23\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 67\n PIP: 10 cmH2O\n SpO2: 100%\n ABG: ///33/\n Ve: 3.7 L/min\n Physical Examination\n Gen: Mildly obtunded in am, responsive to noxious stimuli, on MMV\n through trach tube, but later in am responsive to voice, appropriate,\n asking questions,\n HEENT: PERRL, MMM\n Resp: Coarse BS anteriorly, no focal rales, rhonchi, or wheezing with\n some referred upper airway noises from secretions.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, hypoactive BS\n Exte: No edema, DP 2+ bil.\n NEURO: Toes downgoing bilaterally,\n Labs / Radiology\n 356 K/uL\n 8.2 g/dL\n 129 mg/dL\n 0.7 mg/dL\n 33 mEq/L\n 3.6 mEq/L\n 4 mg/dL\n 110 mEq/L\n 148 mEq/L\n 26.9 %\n 5.7 K/uL\n [image002.jpg]\n 06:22 AM\n 02:58 AM\n 03:43 AM\n 05:02 PM\n 03:36 AM\n 02:30 AM\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n WBC\n 7.0\n 7.1\n 7.1\n 6.9\n 7.6\n 9.5\n 5.7\n Hct\n 29.7\n 28.9\n 29.2\n 27.8\n 32.7\n 28.6\n 28.9\n 30.0\n 26.9\n Plt\n 395\n 462\n 452\n 467\n 548\n 528\n 356\n Cr\n 0.7\n 0.6\n 0.7\n 0.8\n 0.7\n 0.8\n 1.0\n 0.7\n Glucose\n 126\n 137\n 104\n 108\n 131\n 128\n 121\n 129\n Other labs: PT / PTT / INR:15.2/24.6/1.3, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:8.7 mg/dL, Mg++:2.1 mg/dL, PO4:4.1\n mg/dL\n Assessment and Plan\n 55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach, PEG placement now with respiratory failure secondary to\n tracheomalacia , resolved HAP.\n .\n # Respiratory failure: Slowly Improving. Intermittently on trach mask\n for most of the day, with periods of pressure support of over\n night. This am on MMV. Previously likely oversedated but Benadryl,\n Morhpine, and Valium held now. Pt awake and alert at rounds,\n interactive, and breathing comfortably on trach mask\n - Continue to increase time on trach mask as tolerated.\n - Decrease sedation and valium use\n - PMV with suctioning\n .\n # HAP vs Aspiration PNA: Afebrile without leukocytosis\n - Completed course of ceftriaxone\n - good O2 saturation on trach mask\n .\n # Tachycardia: Previously was assessed as sinus tach with occasional\n runs of SVT and sources such as hypovolemia, PE, infection, and pain\n were assessed as possibly etiologies. Per Cardiology, most likely AT\n given transient response to Adenosine. HR occasionally decreases to\n 70s-80s w/ stable BPs at times that might be associated with\n administration of her BB and valium. Cards recommended titrating up her\n beta blocker as tolerated. Dose increased to 50 yesterday and\n intermittently responded but then had to hold PO meds given need to\n hold PO. Changed PO to IV lopressor.\n - EP consulted for SVT, appreciate recs, will change metoprololt o IV\n and hopefully will be able to restart PO meds soon once able to\n tolerate\n - IV metoprolol 5 mg IV q 4\n .\n # Sedation: Inconsistent response to sedation, unclear what is best\n regime. Will continue to wean overall.\n - Continue w Olanzapine QHS\n - Just valium 2.5 mg PRN.\n # Nutrition/Vomiting: Pt has had several episodes of vomiting up her\n TFs, reglan started to increase GI motility, but pt had another episode\n of vomiting this am, not improved with zofran or reglan. Patient also\n had hypoactive BS on exam, concern for obstruction given persistent\n vomiting, inability to tolerate tube feeds.\n - Hold TFs\n - Thoracic surgery recs: 1) oral/nasal tube in post-piloric position,\n or 2) IR to place a pediatric feeding tube through her PEG site to a\n post-piloric position.\n - Will attempt to coordinate thoracic surgery and IR for tube placement\n ; will d/w thoracics\n - CT scan did not reveal evidence of obstruction. Attempted to\n coordinate tube study or UGI btu per Radiology would not be useful\n studies since no obstruction or dysmotility evident on CT\n - Reglan DCd since not helping\n - Will decrease narcotics for possible cause of decreased motility\n .\n # Adrenal Insufficency: Endocrine following. Pt does not appear to be\n adrenally insufficient at baseline. Suggesting if the patient under\n goes major stressors such as major surgery, sepsis, she may need stress\n dosed steroids.\n .\n # Fluid Status: Likely approaching euvolemia, though still has mild\n hypernatramia which may suggest is still intravascularly depleated.\n - Monitoring urine output\n - will provide D5W IVF as need for hypernatremia and follow lytes\n .\n # UE DVT and elevated INR: DVT in right UE has resolved, new\n non-occlusive in left axillary vein. INR supratherapeutic today and\n trending upward. INR most likely continuing to rise nutritional\n deficiencies given continued lack of PO intake\n - Cumadin stopped.\n - INR 10.5 today, up from 5.5, will give Vitamin K IV and reassess will\n check PM coags and follow\n - vitamin K IV x 1. Will likely need to continue with SC, follow coags\n .\n #Hematemesis: Pt had small amt Hematemesis this am. Concerning in\n setting of elevated INR. Will give IV Vitamin K and may need continued\n dosing\n - Vit K IV x 1\n -\n # Spine fracture: Stable\n - Brace for OOB, will discuss with Neurosurgery if current brace is\n optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n .\n # Tracheomalacia. Was initially addressed with IP and they wanted to\n follow up as outpatient. IP reevaluated and does not believe that a\n stent would be feasible.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # PIV x 1\n # Ppx: supratherapeutic INR, Ranitidine, Bowel Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n - Will contact Social and Case management today\n # Code: Full\n # Dispo: ICU, Screening for vent facilities\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 04:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Social Work","chartdate":"2167-10-22 00:00:00.000","description":"Social Work Progress Note","row_id":639036,"text":"Social Work:\n Discussed with legal department brother\ns questions re whether the\n hospital should pursue guardianship for pt. Also discussed with MICU\n attending, resident, and RNCM. Per discussion with all of the above,\n shared with pt\ns brother that it does not appear necessary for the\n hospital to pursue guardianship at this time given that, as pt\ns legal\n , brother has been available, communicating regularly with team, and\n making decisions re her healthcare on her behalf\n decisions that also\n appear to be aligned with what pt\ns boyfriend understands pt would\n want. Per RNCM, there is also no indication at this time that, with\n pt\ns legal acting on pt\ns behalf, guardianship would be necessary\n for her for disposition/placement purposes. Reminded brother that he\n can address any further questions or concerns about disposition-related\n issues with RNCM. Brother states he agrees that communication re pt\n medical care is going smoothly. He reiterates from our phone\n conversation yesterday that his questions about guardianship \n largely from his concern about how pt\ns finances are being managed or\n will be managed should she remain unable to attend to them herself.\n Encouraged him to discuss this with pt\ns boyfriend, as it seems\n boyfriend has been trying to manage these matters in recent weeks.\n Brother states he plans to fly in from tomorrow and will come\n to the hospital in the afternoon to visit pt and meet with MICU team.\n Arranged family meeting with MICU team for 3:30 Friday. ,\n , be available to attend along with team. Discussed with\n RN. Please page as needed.\n , LCSW, #\n"},{"category":"Physician ","chartdate":"2167-10-27 00:00:00.000","description":"Physician Resident Progress Note","row_id":639727,"text":"Chief Complaint:\n 24 Hour Events:\n -hypernatremia: Repeat Na 148-->146 (this am), continuing D5W at\n 125cc/hr\n -TF up to 30cc/hr; tolerated O/N; stopped at 12am\n -Psych recs: Gave risperidone m-tab 1mg PO x1 HS last night and will\n continue risperdone 0.5mg qam and 0.5 PRN; f/u EKG in am;\n -Changed Metoprolol 25 to 37.5mg TID given tach to 110-120\ns; gave 5mg\n x1\n -GI recs: pending\n -IP: seen by IP this am for eval of possible stent placement, pt not a\n candidate as she is at risk of aspiration given opening defect\n posterior to vocal cords; recommended d/w ENT and increase ppi to .\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:30 AM\n Enoxaparin (Lovenox) - 06:48 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.7\nC (98.1\n HR: 79 (68 - 124) bpm\n BP: 134/57(75) {124/52(70) - 179/121(130)} mmHg\n RR: 27 (18 - 31) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 4,004 mL\n 1,084 mL\n PO:\n TF:\n 137 mL\n 51 mL\n IVF:\n 2,544 mL\n 729 mL\n Blood products:\n Total out:\n 3,813 mL\n 1,000 mL\n Urine:\n 3,813 mL\n 1,000 mL\n NG:\n Stool:\n Drains:\n Balance:\n 191 mL\n 84 mL\n Respiratory support\n O2 Delivery Device: Trach mask 40-50%\n SpO2: 99%\n ABG: ///33/\n Physical Examination\n Gen: Sedating post-bronchoscopy; Sleeping; pt would not wake for exam.\n HEENT: No pallor in conjunctiva, MMM\n Resp: Course breath sounds anteriorly, mild exp wheeze.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, decreased bowel sounds, G-Tube in\n place with no erythema/induration\n Exte: No edema, DP 2+ bil\n NEURO: Sedated\n Labs / Radiology\n 231 K/uL\n 7.7 g/dL\n 145 mg/dL\n 0.4 mg/dL\n 33 mEq/L\n 3.5 mEq/L\n 11 mg/dL\n 109 mEq/L\n 146 mEq/L\n 25.3 %\n 5.7 K/uL\n [image002.jpg]\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n 03:00 AM\n 04:00 AM\n 05:45 AM\n 03:51 AM\n 04:45 PM\n 04:00 AM\n WBC\n 9.5\n 5.7\n 7.3\n 8.0\n 8.7\n 5.5\n 5.7\n Hct\n 28.6\n 28.9\n 30.0\n 26.9\n 27.3\n 27.0\n 28.7\n 24.7\n 25.2\n 25.3\n Plt\n 528\n 356\n 346\n \n 231\n Cr\n 1.0\n 0.7\n 0.7\n 0.7\n 0.7\n 0.5\n 0.4\n Glucose\n 121\n 129\n 123\n 114\n 112\n 122\n 145\n Other labs: PT / PTT / INR:13.6/31.1/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.6 mg/dL, Mg++:2.0 mg/dL, PO4:3.6\n mg/dL\n Assessment and Plan\n 56yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach/PEG with resolving respiratory failure and HAP.\n .\n # Respiratory failure/Aspiration Risk: s/p intubation/extubation, now\n on trach mask, FiO2 50%. Tolerating well with good O2 sat. No further\n self-decanulations overnight. Pt continues to be at risk for aspiration\n given new IP finding of opening defect in posterior vocal cord space\n and given recent history of vomiting with tube feed trials.\n - ENT consulted for evaluation of larynx and possible intervention;\n will follow ENT recs\n - increase ppi from qday to for aspiration prophylaxis\n - Trach mask as tolerated.\n - scopolamine patch q72hrs for secretions\n - Holding sedation with exception of Risperidal 0.5mg PRN\n - F/u CXR tomorrow\n .\n # Nutrition/Vomiting: Currently receiving TPN; BMx2 in past 24 hrs to\n indicate possible improvement in ileus. TF tolerated during trial O/N\n without emesis.\n - Cont Reglan 20mg IV Q 8 hours; meds via G-J tube,\n - Will obtain recommendations from Nutrition re TPN today and will\n provide TF as tolerated\n - Speech and Swallow eval today for Passy Muir valve eval;\n - GI consult, will f/u recs\n .\n # Tachycardia: Improved HR max of 120\ns versus 160s previously. Pt now\n on PO Amiodarone 200 TID and PO metoprolol 37.5mg TID\n - Continue current med regimen. Will continue amiodarone 200 TID for\n three weeks and then switch to qday for 1week and then d/c amiodarone.\n - Will need to schedule f/u in 4wks with Dr. upon d/c/transfer.\n - f/u Cards recs\n # Sedation/Anxiolysis/AlteredMS: Resolved O/N with risperdal. Previous\n delirium and agitation most likely secondary to long hospital course\n and multiple psychotropic medications as well as hx of EtOH abuse.\n - started Risperdal 0.5mg PO BID PRN.\n - continue to hold all benzos. opiates, and antihistamines\n - Appreciate psych. Will call and f/u psych recs.\n -Obtain EKG to assess for QTc prolongation.\n #Anemia: HCT stable at 25. No known etiology of blood loss.\n -Will repeat HCT in am .\n # Hypernatremia/Fluid Status: Mild hypernatramia resolving with free\n water administration. On TPN/TF. Good UOP.\n - providing D5W IVFx 1L at 125cc/hr, free water flushes with TF\n -Will f/u lytes in afternoon (5pm)\n # UE DVT and elevated INR: Decision made to d/c Coumadin given her\n labile INR, and start Lovenox .\n - Will flush L PICC with TPA if does not flush\n - Add coags to am labs\n .\n # Spine fracture: Stable\n - Brace for OOB, need to discuss with Neurosurgery before d/c if\n current brace is optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n .\n # Tracheomalacia. Reevaluation bronchoscopy by IP as written above;\n patient not a candidate for stent; pt to follow up as outpatient. No\n new issues.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # ACCESS: PIV x 1, L PICC\n # Ppx: Lovenox, PPi-to increase to , Bowel Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n - Social Work and Case management involved; have discussed situation\n w/ brother and boyfriend.\n # Code: Full\n # Dispo: ICU, Will d/w case management re rehab facilities.\n MSIV\n PGY2 addendum:\n Agree with assessment and plan in MSIV note as detailed above.\n Briefly, 56 F s/p fall with T spine fracture, respiratory failure now\n s/p trach/PEG. Now on trach mask. Patient s/p bronch with IP today;\n ENT to see and follow for ?intervention. Nutrition issues continue;\n will receive TPN today plus possible restart of tube feeds as tolerated\n (later today), continue reglan. Appreciate psych recs; continuing\n risperidone for agitation. Etiology of delirium/agitation still\n unclear. Likely eventual dispo to rehab facility directly from ICU\n given high nursing requirements.\n"},{"category":"Physician ","chartdate":"2167-10-20 00:00:00.000","description":"Physician Attending Progress Note","row_id":638599,"text":"Chief Complaint: resp failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n CARDIOVERSION/DEFIBRILLATION - At 11:50 AM\n aqdenosine 6mg given X 1 by cardiologist to assess pt's rhythm. Pt\n tolerated well.\n Held Valium ansd Benedryl and has done well without\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.5\nC (97.7\n HR: 118 (76 - 144) bpm\n BP: 131/72(85) {93/43(0) - 154/134(138)} mmHg\n RR: 26 (12 - 36) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,945 mL\n 680 mL\n PO:\n TF:\n IVF:\n 1,800 mL\n 560 mL\n Blood products:\n Total out:\n 2,300 mL\n 680 mL\n Urine:\n 2,245 mL\n 680 mL\n NG:\n 55 mL\n Stool:\n Drains:\n Balance:\n -355 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: High flow neb, Tracheostomy tube\n Ventilator mode: MMV/PSV/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 319 (319 - 319) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 15\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 15 cmH2O\n SpO2: 94%\n ABG: ///36/\n Ve: 5.5 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 10.0 g/dL\n 548 K/uL\n 128 mg/dL\n 0.8 mg/dL\n 36 mEq/L\n 4.1 mEq/L\n 6 mg/dL\n 105 mEq/L\n 148 mEq/L\n 32.7 %\n 7.6 K/uL\n [image002.jpg]\n 05:00 AM\n 02:06 AM\n 07:34 AM\n 03:50 AM\n 06:22 AM\n 02:58 AM\n 03:43 AM\n 05:02 PM\n 03:36 AM\n 02:30 AM\n WBC\n 5.9\n 7.5\n 5.6\n 6.1\n 7.0\n 7.1\n 7.1\n 6.9\n 7.6\n Hct\n 27.2\n 26.8\n 27.0\n 27.0\n 29.7\n 28.9\n 29.2\n 27.8\n 32.7\n Plt\n 296\n 306\n 335\n \n 452\n 467\n 548\n Cr\n 0.7\n 0.6\n 0.5\n 0.7\n 0.7\n 0.6\n 0.7\n 0.8\n 0.7\n 0.8\n Glucose\n 134\n 134\n 121\n \n 104\n 108\n 131\n 128\n Other labs: PT / PTT / INR:48.3/33.3/5.5, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:10.0 mg/dL, Mg++:2.5 mg/dL,\n PO4:4.3 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent:\n"},{"category":"Physician ","chartdate":"2167-10-20 00:00:00.000","description":"Physician Attending Progress Note","row_id":638600,"text":"Chief Complaint: resp failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n CARDIOVERSION/DEFIBRILLATION - At 11:50 AM\n aqdenosine 6mg given X 1 by cardiologist to assess pt's rhythm. Pt\n tolerated well.\n Held Valium ansd Benedryl and has done well without\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.5\nC (97.7\n HR: 118 (76 - 144) bpm\n BP: 131/72(85) {93/43(0) - 154/134(138)} mmHg\n RR: 26 (12 - 36) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,945 mL\n 680 mL\n PO:\n TF:\n IVF:\n 1,800 mL\n 560 mL\n Blood products:\n Total out:\n 2,300 mL\n 680 mL\n Urine:\n 2,245 mL\n 680 mL\n NG:\n 55 mL\n Stool:\n Drains:\n Balance:\n -355 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: High flow neb, Tracheostomy tube\n Ventilator mode: MMV/PSV/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 319 (319 - 319) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 15\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 15 cmH2O\n SpO2: 94%\n ABG: ///36/\n Ve: 5.5 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 10.0 g/dL\n 548 K/uL\n 128 mg/dL\n 0.8 mg/dL\n 36 mEq/L\n 4.1 mEq/L\n 6 mg/dL\n 105 mEq/L\n 148 mEq/L\n 32.7 %\n 7.6 K/uL\n [image002.jpg]\n 05:00 AM\n 02:06 AM\n 07:34 AM\n 03:50 AM\n 06:22 AM\n 02:58 AM\n 03:43 AM\n 05:02 PM\n 03:36 AM\n 02:30 AM\n WBC\n 5.9\n 7.5\n 5.6\n 6.1\n 7.0\n 7.1\n 7.1\n 6.9\n 7.6\n Hct\n 27.2\n 26.8\n 27.0\n 27.0\n 29.7\n 28.9\n 29.2\n 27.8\n 32.7\n Plt\n 296\n 306\n 335\n \n 452\n 467\n 548\n Cr\n 0.7\n 0.6\n 0.5\n 0.7\n 0.7\n 0.6\n 0.7\n 0.8\n 0.7\n 0.8\n Glucose\n 134\n 134\n 121\n \n 104\n 108\n 131\n 128\n Other labs: PT / PTT / INR:48.3/33.3/5.5, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:10.0 mg/dL, Mg++:2.5 mg/dL,\n PO4:4.3 mg/dL\n Assessment and Plan\n 1. Tachycardia: runs of atach versus AVNRT. On bblocker be not very\n effective- EP consult for ? is there an ablatable focus.\n 2. Resp Failure\n Trach mask trials as tolerating (needing QHS support at\n present)\n PMV trials\n S/P rx for pan Klebs PNA.\n Per IP not stent planned as technically not possible to\n place into her airway\n 3. DVT and coagulopathy On warfarin but high inr. Hold warfarin until\n inr 2-2.5 range or bridge with loveox if may get procedures\n 4. Feeding tube Getting reglan trial but still with emesis. Need to\n coordinate IR advance of G to J tube with Thoracics\n 5. Hypernatremia Replete free water.\n Please see today\ns ICU team note for other issues.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent:\n"},{"category":"Physician ","chartdate":"2167-10-20 00:00:00.000","description":"Physician Attending Progress Note","row_id":638602,"text":"Chief Complaint: resp failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n CARDIOVERSION/DEFIBRILLATION - At 11:50 AM\n aqdenosine 6mg given X 1 by cardiologist to assess pt's rhythm. Pt\n tolerated well.\n Held Valium ansd Benedryl and has done well without\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.5\nC (97.7\n HR: 118 (76 - 144) bpm\n BP: 131/72(85) {93/43(0) - 154/134(138)} mmHg\n RR: 26 (12 - 36) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,945 mL\n 680 mL\n PO:\n TF:\n IVF:\n 1,800 mL\n 560 mL\n Blood products:\n Total out:\n 2,300 mL\n 680 mL\n Urine:\n 2,245 mL\n 680 mL\n NG:\n 55 mL\n Stool:\n Drains:\n Balance:\n -355 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: High flow neb, Tracheostomy tube\n Ventilator mode: MMV/PSV/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 319 (319 - 319) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 15\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 15 cmH2O\n SpO2: 94%\n ABG: ///36/\n Ve: 5.5 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 10.0 g/dL\n 548 K/uL\n 128 mg/dL\n 0.8 mg/dL\n 36 mEq/L\n 4.1 mEq/L\n 6 mg/dL\n 105 mEq/L\n 148 mEq/L\n 32.7 %\n 7.6 K/uL\n [image002.jpg]\n 05:00 AM\n 02:06 AM\n 07:34 AM\n 03:50 AM\n 06:22 AM\n 02:58 AM\n 03:43 AM\n 05:02 PM\n 03:36 AM\n 02:30 AM\n WBC\n 5.9\n 7.5\n 5.6\n 6.1\n 7.0\n 7.1\n 7.1\n 6.9\n 7.6\n Hct\n 27.2\n 26.8\n 27.0\n 27.0\n 29.7\n 28.9\n 29.2\n 27.8\n 32.7\n Plt\n 296\n 306\n 335\n \n 452\n 467\n 548\n Cr\n 0.7\n 0.6\n 0.5\n 0.7\n 0.7\n 0.6\n 0.7\n 0.8\n 0.7\n 0.8\n Glucose\n 134\n 134\n 121\n \n 104\n 108\n 131\n 128\n Other labs: PT / PTT / INR:48.3/33.3/5.5, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:10.0 mg/dL, Mg++:2.5 mg/dL,\n PO4:4.3 mg/dL\n Assessment and Plan\n 1. Tachycardia: runs of attach Appreciate EP consult\n will increase\n bblocker. If fails may need EP study for further study and ? ablatable\n focus.\n 2. Persistent Nausea/Vomiting: very poor bowel sounds, get ABD ct to\n look for SBO, talk with GI about EGD or tube study to look for more\n proximal gastric outlet obstruction.\n 2. Resp Failure\n Trach mask trials all day, PSV\n PMV trials\n S/P rx for pan Klebs PNA.\n Per IP not stent planned as technically not possible to\n place into her airway\n 3. DVT and coagulopathy: On warfarin but high inr. Hold warfarin until\n inr 2-2.5 range or bridge with loveox if may get procedures\n 4. Feeding tube Getting reglan trial but still with emesis. Need to\n coordinate IR advance of G to J tube with Thoracics\n 5. Hypernatremia Replete free water.\n Please see today\ns ICU team note for other issues.\n ICU Care\n Nutrition: NPPO while sorting out gi obstruction issues\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n Prophylaxis:\n DVT: coumadin\n Stress ulcer: PPI\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent:\n"},{"category":"Rehab Services","chartdate":"2167-10-22 00:00:00.000","description":"Physical Therapy Progress Note","row_id":639038,"text":"Subjective:\n \"I think they are trying to kill me here\"\n Objective:\n Follow up PT visit to address goals of: .\n Updated medical status: PMV\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Rolling:\n T\n\n\n\n\n\n Supine/\n Sidelying to Sit:\n\n\n T\n\n\n Transfer:\n\n\n\n T\n\n Sit to Stand:\n\n\n\n T\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Aerobic Activity Response:\n Position\n HR\n BP\n RR\n O[2] sat\n RPE\n Rest\n Supine\n 110-125\n 142/80\n 99% 50% TM\n Activity\n /\n Recovery\n Sit\n 110-130s\n 138/80\n 96-99% TM\n Total distance walked:\n Minutes:\n Gait: Attempted ambulation, pt unable to advance LEs, was mod x 2 to\n take 2 small steps forward, and Max A to take 2 steps back. Mod A x 1\n to stand pivot to chair.\n Balance: Pt has fair sitting balance. Retropulsive in standing.\n Education / Communication: Pt status discussed with RN\n Other: Pt making nonsensical statements t/o treatment. A and O x 2,\n person and year not month, date or place.\n Pulm: Pt with strong productive cough, thick yellow sputum. Tolerated\n PMV t/o treatment.\n Pt performed sit to stand x 3 with mod A x 2\n Assessment: 56 yo f s/p fall with T8 fx and complicated hospital course\n due to resp distress. Pt continues to be functioning below baseline,\n from both cognitive and mobility stand points. Pt would benefit from OT\n consult and continue PT in rehab setting upon d/c to optimize function\n and independence\n Anticipated Discharge: Rehab\n Plan: f/u progress mobility, advance ambulation.\n"},{"category":"Nursing","chartdate":"2167-10-23 00:00:00.000","description":"Nursing Progress Note","row_id":639111,"text":"Tachycardia, Other\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2167-10-23 00:00:00.000","description":"Nursing Progress Note","row_id":639114,"text":"56 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\n with prolonged hospital course c/b by PNA, anxiety/altered mental\n status, R&LUE DVT .Pt found to have small non occlusive Clot on her\n right axial vein via Ultrasound.Yesterday. She has had problems with\n vomiting tube feedings, feeding tube passed through g-tube (g-tube in\n place with mushroom on inside so cannot pull out) to her jejunenum but\n continues vomit.\n Tachycardia, Other\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2167-10-27 00:00:00.000","description":"Nursing Progress Note","row_id":639639,"text":"Airway Clearance, Impaired\n Assessment:\n Pt cont on TM 50%, bilat rhonchi, diminished in bases. 02 SATS 94-95%\n Action:\n Pt requiring frequent suction, copious loose white secretions noted,\n scolopamine patch applied to help with secretions\n Response:\n Cont to suction for copious secretions\n Plan:\n Cont to resp. status, suction as needed, s/swallow to re-evaluate\n for bigger PMV in am\n Alteration in Nutrition\n Assessment:\n Pt cont with restlessness, TF off 00 due to pts restlessness, BS\n positive bilat, loose BM\ns x 2\n Action:\n Pt placed on chair positin in bed, pt recvd scheduled Reglan, colace\n Response:\n Pt had two loose bm\ns x 2,\n Plan:\n Re-start TF when pt more relaxed, cont with TPN 43.6 as ordered, cont\n strict asp precautions :holding TF when pt not in upright position and\n turning TF off for 15 mins before turning\n Arousal, Attention, and Cognition, Impaired\n Assessment:\n Pt cont to be very restless in bed, cont with bilat wrist restraints\n and 1:1 sitter @ bedside\n Action:\n Pt seen by psych @, Risperadol dosing increased\n Response:\n Pt cont to be restless despite increase in HS risperadol and prn dose\n Plan:\n Psych to re-evaluate in am, EKG to be taken in am\n"},{"category":"Physician ","chartdate":"2167-10-27 00:00:00.000","description":"Physician Attending Progress Note","row_id":639709,"text":"Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Aggitation, remains delerious.\n Bedside bronchoscopy by IP service revealed inability of posterior\n portion of vocal cords to adduct. Unclear etiology.\n Sedated for bronchoscopy.\n 24 Hour Events:\n History obtained from Medical records\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Enoxaparin (Lovenox) - 06:48 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG\n tube, Tracheotomy tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, Tube feeds, No(t) Parenteral nutrition\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, No(t) Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: No(t) Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 11:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.1\nC (96.9\n HR: 62 (62 - 123) bpm\n BP: 87/42(53) {87/42(53) - 179/121(130)} mmHg\n RR: 20 (18 - 31) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 4,004 mL\n 2,070 mL\n PO:\n TF:\n 137 mL\n 51 mL\n IVF:\n 2,544 mL\n 1,423 mL\n Blood products:\n Total out:\n 3,813 mL\n 1,380 mL\n Urine:\n 3,813 mL\n 1,380 mL\n NG:\n Stool:\n Drains:\n Balance:\n 191 mL\n 690 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 98%\n ABG: ///33/\n Physical Examination\n General Appearance: No(t) Well nourished, No(t) No acute distress,\n No(t) Overweight / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic,\n Sedated\n Eyes / Conjunctiva: No(t) PERRL, No(t) Pupils dilated, No(t)\n Conjunctiva pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: No(t) Normocephalic, No(t) Poor dentition,\n No(t) Endotracheal tube, No(t) NG tube, No(t) OG tube, Tracheotomy tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic,\n No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: No(t) Resonant : , No(t) Hyperresonant: , No(t) Dullness :\n ), (Breath Sounds: Clear : , No(t) Crackles : , Bronchial: Right base,\n No(t) Wheezes : , No(t) Diminished: , No(t) Absent : , No(t)\n Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended, No(t)\n Tender: , No(t) Obese, PEG\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Verbal stimuli, No(t) Oriented (to): , Movement: Purposeful, No(t)\n Sedated, No(t) Paralyzed, Tone: Normal\n Labs / Radiology\n 7.7 g/dL\n 231 K/uL\n 145 mg/dL\n 0.4 mg/dL\n 33 mEq/L\n 3.5 mEq/L\n 11 mg/dL\n 109 mEq/L\n 146 mEq/L\n 25.3 %\n 5.7 K/uL\n [image002.jpg]\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n 03:00 AM\n 04:00 AM\n 05:45 AM\n 03:51 AM\n 04:45 PM\n 04:00 AM\n WBC\n 9.5\n 5.7\n 7.3\n 8.0\n 8.7\n 5.5\n 5.7\n Hct\n 28.6\n 28.9\n 30.0\n 26.9\n 27.3\n 27.0\n 28.7\n 24.7\n 25.2\n 25.3\n Plt\n 528\n 356\n 346\n \n 231\n Cr\n 1.0\n 0.7\n 0.7\n 0.7\n 0.7\n 0.5\n 0.4\n Glucose\n 121\n 129\n 123\n 114\n 112\n 122\n 145\n Other labs: PT / PTT / INR:13.6/31.1/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.6 mg/dL, Mg++:2.0 mg/dL, PO4:3.6\n mg/dL\n Assessment and Plan\n Respiratory failure, delerium.\n RESPIRATORY FAILURE -- chronic, s/p trach. Underlying\n tracheobronchomalacia. Possible elevated right hemidiaphragm.\n Continue current care, including aspiration precautions. Maintain\n trach, monitor SaO2 --> maintain >90%.\n TRACHEOBRONCOMALACIA -- no immediate plans for IP intervention.\n VOCAL CORD dysfunction -- ENT to evaluate limited ability of posterior\n portion of cords to adduct. consult ENT service.\n RUE DVT -- anticoagulation with lovenox.\n HYPERNATREMIA -- improved with free H2O repletion. Monitor.\n A-FIB -- rate controlled on amioderone.\n DELERIUM -- currently sedated from procedure. Unclear etiology.\n Concerns include medications and ICU psychosis. Psychiatry consulted.\n Respiradol dose being adjusted.\n NUTRITIONAL SUPPORT -- hope to transition TPN to TF via PEG.\n T4-T8 VETEBRAL Fx -- suportive care. Will require rehabilitation.\n ICU Care\n Nutrition:\n TPN without Lipids - 05:44 PM 43. mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n 18 Gauge - 10:14 AM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 55 minutes\n Patient is critically ill\n"},{"category":"Physician ","chartdate":"2167-10-27 00:00:00.000","description":"Physician Resident Progress Note","row_id":639711,"text":"Chief Complaint:\n 24 Hour Events:\n -hypernatremia: Repeat Na 148-->146 (this am), continuing D5W at\n 125cc/hr\n -TF up to 30cc/hr; tolerated O/N; stopped at 12am\n -Psych recs: Gave risperidone m-tab 1mg PO x1 HS last night and will\n continue risperdone 0.5mg qam and 0.5 PRN; f/u EKG in am;\n -Changed Metoprolol 25 to 37.5mg TID given tach to 110-120\ns; gave 5mg\n x1\n -GI recs: pending\n -IP: seen by IP this am for eval of possible stent placement, pt not a\n candidate as she is at risk of aspiration given opening defect\n posterior to vocal cords; recommended d/w ENT and increase ppi to .\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:30 AM\n Enoxaparin (Lovenox) - 06:48 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.7\nC (98.1\n HR: 79 (68 - 124) bpm\n BP: 134/57(75) {124/52(70) - 179/121(130)} mmHg\n RR: 27 (18 - 31) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 4,004 mL\n 1,084 mL\n PO:\n TF:\n 137 mL\n 51 mL\n IVF:\n 2,544 mL\n 729 mL\n Blood products:\n Total out:\n 3,813 mL\n 1,000 mL\n Urine:\n 3,813 mL\n 1,000 mL\n NG:\n Stool:\n Drains:\n Balance:\n 191 mL\n 84 mL\n Respiratory support\n O2 Delivery Device: Trach mask 40-50%\n SpO2: 99%\n ABG: ///33/\n Physical Examination\n Gen: Sedating post-bronchoscopy; Sleeping; pt would not wake for exam.\n HEENT: No pallor in conjunctiva, MMM\n Resp: Course breath sounds anteriorly, mild exp wheeze.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, decreased bowel sounds, G-Tube in\n place with no erythema/induration\n Exte: No edema, DP 2+ bil\n NEURO: Sedated\n Labs / Radiology\n 231 K/uL\n 7.7 g/dL\n 145 mg/dL\n 0.4 mg/dL\n 33 mEq/L\n 3.5 mEq/L\n 11 mg/dL\n 109 mEq/L\n 146 mEq/L\n 25.3 %\n 5.7 K/uL\n [image002.jpg]\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n 03:00 AM\n 04:00 AM\n 05:45 AM\n 03:51 AM\n 04:45 PM\n 04:00 AM\n WBC\n 9.5\n 5.7\n 7.3\n 8.0\n 8.7\n 5.5\n 5.7\n Hct\n 28.6\n 28.9\n 30.0\n 26.9\n 27.3\n 27.0\n 28.7\n 24.7\n 25.2\n 25.3\n Plt\n 528\n 356\n 346\n \n 231\n Cr\n 1.0\n 0.7\n 0.7\n 0.7\n 0.7\n 0.5\n 0.4\n Glucose\n 121\n 129\n 123\n 114\n 112\n 122\n 145\n Other labs: PT / PTT / INR:13.6/31.1/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.6 mg/dL, Mg++:2.0 mg/dL, PO4:3.6\n mg/dL\n Assessment and Plan\n 56yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach/PEG with resolving respiratory failure and HAP.\n .\n # Respiratory failure/Aspiration Risk: s/p intubation/extubation, now\n on trach mask, FiO2 50%. Tolerating well with good O2 sat. No further\n self-decanulations overnight. Pt continues to be at risk for aspiration\n given new IP finding of opening defect in posterior vocal cord space\n and given recent history of vomiting with tube feed trials.\n - ENT consulted for evaluation of larynx and possible intervention;\n will follow ENT recs\n - increase ppi from qday to for aspiration prophylaxis\n - Trach mask as tolerated.\n - scopolamine patch q72hrs for secretions\n - Holding sedation with exception of Risperidal 0.5mg PRN\n - F/u CXR tomorrow\n .\n # Nutrition/Vomiting: Currently receiving TPN; BMx2 in past 24 hrs to\n indicate possible improvement in ileus. TF tolerated during trial O/N\n without emesis.\n - Cont Reglan 20mg IV Q 8 hours; meds via G-J tube,\n - Will obtain recommendations from Nutrition re TPN today and will\n provide TF as tolerated\n - Speech and Swallow eval today for Passy Muir valve eval;\n - GI consult, will f/u recs\n .\n # Tachycardia: Improved HR max of 120\ns versus 160s previously. Pt now\n on PO Amiodarone 200 TID and PO metoprolol 25mg TID\n - Continue current med regimen. Will continue amiodarone 200 TID for\n three weeks and then switch to qday.\n - Will need to schedule f/u in 4wks with Dr. upon d/c/transfer.\n - f/u Cards recs\n # Sedation/Anxiolysis/AlteredMS: Resolved O/N. Previous delirium and\n agitation most likely secondary to long hospital course and multiple\n psychotropic medications as well as hx of EtOH abuse. Risperdal given\n O/N per Psych recs.\n - started Risperdal 0.5mg PO BID PRN.\n - continue to hold all benzos. opiates, and antihistamines\n - Appreciate psych. Will call and f/u psych recs.\n #Anemia: HCT stable at 25. No known etiology of blood loss.\n -Will repeat HCT in am .\n # Hypernatremia/Fluid Status: Mild hypernatramia resolving with free\n water administration. On TPN/TF. Good UOP.\n - providing D5W IVF, free water flushes with TF\n -Will f/u lytes in afternoon (5pm)\n # UE DVT and elevated INR: Decision made to d/c Coumadin given her\n labile INR, and start Lovenox .\n - Will flush L PICC with TPA if does not flush\n - Add coags to am labs\n .\n # Spine fracture: Stable\n - Brace for OOB, need to discuss with Neurosurgery before d/c if\n current brace is optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n .\n # Tracheomalacia. Was initially addressed with IP and they wanted to\n follow up as outpatient. IP reevaluated and does not believe that a\n stent would be feasible. No new issues.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # ACCESS: PIV x 1, L PICC\n # Ppx: Lovenox, PPi, Bowel Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n - Social Work and Case management involved, have discussed situation\n w/ brother and boyfriend.\n # Code: Full\n # Dispo: ICU, Will d/w case management re rehab facilities.\n ICU Care\n Nutrition:\n TPN without Lipids - 05:44 PM 43. mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n PICC Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2167-10-27 00:00:00.000","description":"Physician Resident Progress Note","row_id":639715,"text":"Chief Complaint:\n 24 Hour Events:\n -hypernatremia: Repeat Na 148-->146 (this am), continuing D5W at\n 125cc/hr\n -TF up to 30cc/hr; tolerated O/N; stopped at 12am\n -Psych recs: Gave risperidone m-tab 1mg PO x1 HS last night and will\n continue risperdone 0.5mg qam and 0.5 PRN; f/u EKG in am;\n -Changed Metoprolol 25 to 37.5mg TID given tach to 110-120\ns; gave 5mg\n x1\n -GI recs: pending\n -IP: seen by IP this am for eval of possible stent placement, pt not a\n candidate as she is at risk of aspiration given opening defect\n posterior to vocal cords; recommended d/w ENT and increase ppi to .\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:30 AM\n Enoxaparin (Lovenox) - 06:48 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.7\nC (98.1\n HR: 79 (68 - 124) bpm\n BP: 134/57(75) {124/52(70) - 179/121(130)} mmHg\n RR: 27 (18 - 31) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 4,004 mL\n 1,084 mL\n PO:\n TF:\n 137 mL\n 51 mL\n IVF:\n 2,544 mL\n 729 mL\n Blood products:\n Total out:\n 3,813 mL\n 1,000 mL\n Urine:\n 3,813 mL\n 1,000 mL\n NG:\n Stool:\n Drains:\n Balance:\n 191 mL\n 84 mL\n Respiratory support\n O2 Delivery Device: Trach mask 40-50%\n SpO2: 99%\n ABG: ///33/\n Physical Examination\n Gen: Sedating post-bronchoscopy; Sleeping; pt would not wake for exam.\n HEENT: No pallor in conjunctiva, MMM\n Resp: Course breath sounds anteriorly, mild exp wheeze.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, decreased bowel sounds, G-Tube in\n place with no erythema/induration\n Exte: No edema, DP 2+ bil\n NEURO: Sedated\n Labs / Radiology\n 231 K/uL\n 7.7 g/dL\n 145 mg/dL\n 0.4 mg/dL\n 33 mEq/L\n 3.5 mEq/L\n 11 mg/dL\n 109 mEq/L\n 146 mEq/L\n 25.3 %\n 5.7 K/uL\n [image002.jpg]\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n 03:00 AM\n 04:00 AM\n 05:45 AM\n 03:51 AM\n 04:45 PM\n 04:00 AM\n WBC\n 9.5\n 5.7\n 7.3\n 8.0\n 8.7\n 5.5\n 5.7\n Hct\n 28.6\n 28.9\n 30.0\n 26.9\n 27.3\n 27.0\n 28.7\n 24.7\n 25.2\n 25.3\n Plt\n 528\n 356\n 346\n \n 231\n Cr\n 1.0\n 0.7\n 0.7\n 0.7\n 0.7\n 0.5\n 0.4\n Glucose\n 121\n 129\n 123\n 114\n 112\n 122\n 145\n Other labs: PT / PTT / INR:13.6/31.1/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.6 mg/dL, Mg++:2.0 mg/dL, PO4:3.6\n mg/dL\n Assessment and Plan\n 56yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach/PEG with resolving respiratory failure and HAP.\n .\n # Respiratory failure/Aspiration Risk: s/p intubation/extubation, now\n on trach mask, FiO2 50%. Tolerating well with good O2 sat. No further\n self-decanulations overnight. Pt continues to be at risk for aspiration\n given new IP finding of opening defect in posterior vocal cord space\n and given recent history of vomiting with tube feed trials.\n - ENT consulted for evaluation of larynx and possible intervention;\n will follow ENT recs\n - increase ppi from qday to for aspiration prophylaxis\n - Trach mask as tolerated.\n - scopolamine patch q72hrs for secretions\n - Holding sedation with exception of Risperidal 0.5mg PRN\n - F/u CXR tomorrow\n .\n # Nutrition/Vomiting: Currently receiving TPN; BMx2 in past 24 hrs to\n indicate possible improvement in ileus. TF tolerated during trial O/N\n without emesis.\n - Cont Reglan 20mg IV Q 8 hours; meds via G-J tube,\n - Will obtain recommendations from Nutrition re TPN today and will\n provide TF as tolerated\n - Speech and Swallow eval today for Passy Muir valve eval;\n - GI consult, will f/u recs\n .\n # Tachycardia: Improved HR max of 120\ns versus 160s previously. Pt now\n on PO Amiodarone 200 TID and PO metoprolol 37.5mg TID\n - Continue current med regimen. Will continue amiodarone 200 TID for\n three weeks and then switch to qday for 1week and then d/c amiodarone.\n - Will need to schedule f/u in 4wks with Dr. upon d/c/transfer.\n - f/u Cards recs\n # Sedation/Anxiolysis/AlteredMS: Resolved O/N with risperdal. Previous\n delirium and agitation most likely secondary to long hospital course\n and multiple psychotropic medications as well as hx of EtOH abuse.\n - started Risperdal 0.5mg PO BID PRN.\n - continue to hold all benzos. opiates, and antihistamines\n - Appreciate psych. Will call and f/u psych recs.\n -Obtain EKG to assess for QTc prolongation.\n #Anemia: HCT stable at 25. No known etiology of blood loss.\n -Will repeat HCT in am .\n # Hypernatremia/Fluid Status: Mild hypernatramia resolving with free\n water administration. On TPN/TF. Good UOP.\n - providing D5W IVFx 1L at 125cc/hr, free water flushes with TF\n -Will f/u lytes in afternoon (5pm)\n # UE DVT and elevated INR: Decision made to d/c Coumadin given her\n labile INR, and start Lovenox .\n - Will flush L PICC with TPA if does not flush\n - Add coags to am labs\n .\n # Spine fracture: Stable\n - Brace for OOB, need to discuss with Neurosurgery before d/c if\n current brace is optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n .\n # Tracheomalacia. Reevaluation bronchoscopy by IP as written above;\n patient not a candidate for stent; pt to follow up as outpatient. No\n new issues.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # ACCESS: PIV x 1, L PICC\n # Ppx: Lovenox, PPi-to increase to , Bowel Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n - Social Work and Case management involved; have discussed situation\n w/ brother and boyfriend.\n # Code: Full\n # Dispo: ICU, Will d/w case management re rehab facilities.\n MSIV\n"},{"category":"Nursing","chartdate":"2167-10-20 00:00:00.000","description":"Nursing Progress Note","row_id":638525,"text":"55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach, PEG, placement no with respiratory failure secondary to\n tracheomalacia , resolving HAP.\n Arousal, Attention, and Cognition, Impaired\n Assessment:\n Alert, mouthing words but very difficult to understand. Follows\n commands. MAE on bed, attempting to get up. Restless last evening, did\n eventually fall off to sleep this AM.\n Action:\n Zyprexa x 1 . Frequent re-orientation to place, situation. Soft wrist\n restraints for patient safety.\n Response:\n Pt did eventually fall asleep. Re-orientation does have calming effect\n however it is short term.\n Plan:\n No valium or benadryl per psych as this exacerbates delirium. Zyprexa\n for agitation. pt prn.\n Hypernatremia (high sodium)\n Assessment:\n Na 145 last night, 148 this AM.\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Trach collar @ 50% O2 overnight. Sats 90-97%. RR 17-20s. Strong cough,\n able to cough thick white ->tan secretions out of trach. Occ suctioned\n for same. Lungs are rhonchorous throughout. Impaired gag.\n Action:\n Suctioned prn for copious secretions. MDIs.\n Response:\n Trach collar overnight.\n Plan:\n Wean from vent as tolerated. MDIs, suction as needed.\n Alteration in Nutrition\n Assessment:\n NPO overnight d/t constant vomiting. No vomiting overnight.\n Action:\n NPO. Reglan q 6 hrs.\n Response:\n No vomiting. Small brown stool x 1.\n Plan:\n NPO. ? may go to IR today to change Gtube to Jtube.\n"},{"category":"Nursing","chartdate":"2167-10-20 00:00:00.000","description":"Nursing Progress Note","row_id":638657,"text":"Tachycardia, Other\n Assessment:\n Pt has remained in ST , with HR 90-140. B/P has remained 110-140/\n 50-70\n Action:\n Lopressor increased to 50mg 4x/day\n Response:\n Pt has been vomiting throughout day, ? amt of lopressor absorbed.\n Lopressor 5mg IV given\n Plan:\n Alteration in Nutrition\n Assessment:\n ABD soft, not distended, very hypoactive bowel sounds, TF on hold.\n NA 148\n Action:\n D5W infusing at 125cc/hr then decreased to 75cc/hr. Abd CT done,\n poorly prepped , vomited Bari-kat. reconsulted, ? placement of\n Jtube\nif CT negative for SBO/illeus.\n Response:\n NA level at 1600 =>146, CT scan results pending\n Plan:\n Continue to monitor lytes, continue D5W\n Altered mental status (not Delirium)\n Assessment:\n Pt has been very restless thru the day despite frequent reorientation.\n Pt attempting to mouth words but difficult to interpret. Unable to PMV\n secondary to increased secretions. Pt follows commands, but unable to\n use call light appropriately\n.needs verbal cueing.\n Action:\n Pt OOB to chair , but remained restless.\n Response:\n Pt remains confused and restless\n Plan:\n Continue to reorient\n Nausea / vomiting\n Assessment:\n During am assessment pt was found to be gagging and vomited about\n 50-75cc/hr. Pt pre-medicated w/ Zofran 8mg IV prior to am meds. Pt\n given 60cc fluids w/ am via PEG. Pt vomited about 15 minutes after\n meds. Abd as noted above is soft, NO BM >24hr and BS very distant and\n hypoactive.\n Action:\n Team into assess, CT of abd ordered. Pt was unable to tolerate prep\n and vomited prep. Zofran 4mg given.\n Response:\n Awaiting CT results\n Plan:\n Airway Clearance, Impaired\n Assessment:\n Pt has a very congested cough, w/ bronchial and rhonchi noted in upper\n airway. Sat\ns on trach collar 95-100%\n Action:\n Trach care done and suctioned Q\n-1hr for sm-moderate amts of thin\n yellow sectretions\n Response:\n Sat\ns have remained stable on 50% trach mask 95-100%\n Plan:\n Continue to monitor\n"},{"category":"Respiratory ","chartdate":"2167-10-23 00:00:00.000","description":"Respiratory Care Shift Note","row_id":639217,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 35\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 7.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 23 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Unassisted spontaneous breathing\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Patient decannulated herself at approximately 0730. New tracheostomy\n tube placed in a timley manner. Placed on mechanical ventilation for\n several hours during recover period. Then placed on trach collar.\n"},{"category":"Respiratory ","chartdate":"2167-10-21 00:00:00.000","description":"Respiratory Care Shift Note","row_id":638708,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 33\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Tube Type\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 8.0mm\n PMV: No\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Back to MMV last eve for ?aspiration & increased WOB.\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: No spont resp this morning/ Back to Tc as tolerated.\n Reason for continuing current ventilatory support:\n"},{"category":"Nursing","chartdate":"2167-10-24 00:00:00.000","description":"Nursing Progress Note","row_id":639281,"text":"Airway Clearance, Impaired\n Assessment:\n Secretions thick, white. LS coarse, diminished at bases.\n Action:\n Requiring frequent suctioning, at times q 30 minutes, clearing\n initially and within minutes, pt rattling with secretions once again.\n Response:\n Secretions con\nt to accumulate despite frequent suctioning.\n Plan:\n Con\nt to pulmonary toilet , clear secretions as appropriate. Maintain\n O2 Sat of greater than 94%.\n Tachycardia, Other\n Assessment:\n HR maintained in the 80\ns and 90\ns for the most part. Up to110\n immediately prior to receiving the lopressor.\n Action:\n Rec\n Response:\n Maintaining HR below 100 successfully.\n Plan:\n Alteration in Nutrition\n Assessment:\n Hypoactive BS, TF\ns on hold. J-tube ind\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Alert but confused, re\n Action:\n Frequent re-orientation\n Response:\n Plan:\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Tmax 99.4 po\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2167-10-25 00:00:00.000","description":"Nursing Progress Note","row_id":639434,"text":"56 yr old woman, who was transferred from osh for evaluation of\n tracheal bronchial malacia on .Pt presented to Medical\n Center on s/p fall down a flight of stairs fracturing, t5-t8 with\n propulsion treated conservatively with pain meds and back brace. She\n developed resp distress requiring intubation on . Trach/PEG done\n . Now with prolonged hospital course c/b by PNA, anxiety/altered\n mental status, R&LUE DVT .Pt found to have small non occlusive Clot on\n her right axial vein via Ultrasound. She has had problems with\n vomiting tube feedings, feeding tube passed through g-tube to her\n jejunenum but she continues to vomit. Trach mask, has not required\n ventilation since . Has also required 1:1 sitters since\n decanulating herself twice, despite restraints. Events of the last\n 12hrs include, restarted TF\ns, however, infused for ~7 hrs, then began\n suctioning bile-like fluid from trach after pt experienced a prolonged\n coughing jag. TF\ns placed on hold.\n Airway Clearance, Impaired\n Assessment:\n Requiring frequent suctioning ~q15 minutes to 1hr. Secretions\n initially white, changing to greenish and back to whitish yellow. LS\n coarse, diminished at bases\n Action:\n CPT, frequent suctioning,\n Response:\n CXR, maintain patent airway\n Plan:\n F/U with CXR results, CPT\n Tachycardia, Other\n Assessment:\n Becoming tachy in the 110\ns approx 30 minutes prior receiving standard\n lopressor dose. HR basically in the 70\ns the entire shift.\n Action:\n Lopressor 10 mg IV q4hr, amiodarone\n Response:\n Tolerating meds\n Plan:\n Monitor VS,\n Alteration in Nutrition\n Assessment:\n TF\ns infusing at rate of 10cc/hr. ~2240, pt began coughing. Required\n suctioning. Pt noted to have thin greenish secretions from trach tube.\n Action:\n TF\ns placed on hold.\n Response:\n Not tolerating feedings\n Plan:\n Con\nt to administer bowel meds as ordered, reglan as ordered.\n Hypernatremia (high sodium)\n Assessment:\n Na+ elevated at 148\n Action:\n Receiving an additional 1L of D5W at 150cc/hr\n Response:\n F/U with am lab levels\n Plan:\n Con\nt to monitor Na+ levels, Attempt free H2O bolus\n this am.\n Altered mental status (not Delirium)\n Assessment:\n Some agitation noted in the beginning of the shift. Settling down by\n ~2100. At times attempting to mouth full conversations, but since pt\n has so many secretions, PMV was not placed. She is confused, asking\n for the phone, requiring frequent re-orientation, 1:1 sitter at\n bedside, soft wrist restraints intact.\n Action:\n Re-orient as appropriate\n Response:\n Remains confused, requiring sitters for safety.\n Plan:\n Assess MS\n"},{"category":"Physician ","chartdate":"2167-10-20 00:00:00.000","description":"Physician Resident Progress Note","row_id":638568,"text":"Chief Complaint:\n 24 Hour Events:\n CARDIOVERSION/DEFIBRILLATION - At 11:50 AM\n aqdenosine 6mg given X 1 by cardiologist to assess pt's rhythm. Pt\n tolerated well.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:24 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36\nC (96.8\n HR: 114 (85 - 144) bpm\n BP: 111/59(69) {84/42(0) - 154/134(138)} mmHg\n RR: 12 (12 - 36) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,945 mL\n 274 mL\n PO:\n TF:\n IVF:\n 1,800 mL\n 154 mL\n Blood products:\n Total out:\n 2,300 mL\n 500 mL\n Urine:\n 2,245 mL\n 500 mL\n NG:\n 55 mL\n Stool:\n Drains:\n Balance:\n -355 mL\n -226 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: MMV/PSV/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 319 (319 - 319) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 15\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 15 cmH2O\n SpO2: 100%\n ABG: ///36/\n Ve: 5.5 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 548 K/uL\n 10.0 g/dL\n 128 mg/dL\n 0.8 mg/dL\n 36 mEq/L\n 4.1 mEq/L\n 6 mg/dL\n 105 mEq/L\n 148 mEq/L\n 32.7 %\n 7.6 K/uL\n [image002.jpg]\n 05:00 AM\n 02:06 AM\n 07:34 AM\n 03:50 AM\n 06:22 AM\n 02:58 AM\n 03:43 AM\n 05:02 PM\n 03:36 AM\n 02:30 AM\n WBC\n 5.9\n 7.5\n 5.6\n 6.1\n 7.0\n 7.1\n 7.1\n 6.9\n 7.6\n Hct\n 27.2\n 26.8\n 27.0\n 27.0\n 29.7\n 28.9\n 29.2\n 27.8\n 32.7\n Plt\n 296\n 306\n 335\n \n 452\n 467\n 548\n Cr\n 0.7\n 0.6\n 0.5\n 0.7\n 0.7\n 0.6\n 0.7\n 0.8\n 0.7\n 0.8\n Glucose\n 134\n 134\n 121\n \n 104\n 108\n 131\n 128\n Other labs: PT / PTT / INR:48.3/33.3/5.5, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:10.0 mg/dL, Mg++:2.5 mg/dL,\n PO4:4.3 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2167-10-20 00:00:00.000","description":"Physician Resident Progress Note","row_id":638569,"text":"Chief Complaint:\n 24 Hour Events:\n CARDIOVERSION/DEFIBRILLATION - At 11:50 AM\n aqdenosine 6mg given X 1 by cardiologist to assess pt's rhythm. Pt\n tolerated well.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:24 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36\nC (96.8\n HR: 114 (85 - 144) bpm\n BP: 111/59(69) {84/42(0) - 154/134(138)} mmHg\n RR: 12 (12 - 36) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,945 mL\n 274 mL\n PO:\n TF:\n IVF:\n 1,800 mL\n 154 mL\n Blood products:\n Total out:\n 2,300 mL\n 500 mL\n Urine:\n 2,245 mL\n 500 mL\n NG:\n 55 mL\n Stool:\n Drains:\n Balance:\n -355 mL\n -226 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: MMV/PSV/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 319 (319 - 319) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 15\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 15 cmH2O\n SpO2: 100%\n ABG: ///36/\n Ve: 5.5 L/min\n Physical Examination\n Gen: Obtunded this am, not responsive to voice, minimally responsive to\n noxious stimuli, on MMV through trach tube\n HEENT: PERRL, MMM,\n Resp: Limited by patients mobility, but CTA anteriorly and laterally,\n no rales, rhonchi, or wheezing, some referred upper airway noises from\n secretions.\n Card: S1S2 tachicardic, no m/r/g\n Abd: Obese, soft, Non-distended, BS+\n Exte: No edema, DP 2+, RP2+ bil.\n NEURO: Toes downgoing bilaterally, patellar reflexs 2+ bil, biceps 2+\n bil,\n Labs / Radiology\n 548 K/uL\n 10.0 g/dL\n 128 mg/dL\n 0.8 mg/dL\n 36 mEq/L\n 4.1 mEq/L\n 6 mg/dL\n 105 mEq/L\n 148 mEq/L\n 32.7 %\n 7.6 K/uL\n [image002.jpg]\n 05:00 AM\n 02:06 AM\n 07:34 AM\n 03:50 AM\n 06:22 AM\n 02:58 AM\n 03:43 AM\n 05:02 PM\n 03:36 AM\n 02:30 AM\n WBC\n 5.9\n 7.5\n 5.6\n 6.1\n 7.0\n 7.1\n 7.1\n 6.9\n 7.6\n Hct\n 27.2\n 26.8\n 27.0\n 27.0\n 29.7\n 28.9\n 29.2\n 27.8\n 32.7\n Plt\n 296\n 306\n 335\n \n 452\n 467\n 548\n Cr\n 0.7\n 0.6\n 0.5\n 0.7\n 0.7\n 0.6\n 0.7\n 0.8\n 0.7\n 0.8\n Glucose\n 134\n 134\n 121\n \n 104\n 108\n 131\n 128\n Other labs: PT / PTT / INR:48.3/33.3/5.5, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:10.0 mg/dL, Mg++:2.5 mg/dL,\n PO4:4.3 mg/dL\n Assessment and Plan\n 55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach, PEG, placement no with respiratory failure secondary to\n tracheomalacia , resolving HAP.\n .\n # Respiratory failure: Slowly Improving. Now remaining on trach mask\n for most of the day and night, with periods of pressure support of \n over night. Last night required MMV and was not breathing well while\n asleep, likely oversedated with Benadryl, Morhpine, and Valium\n administered in the early morning. Pt awake and alert at rounds,\n interactive, and breathing comfortably on trach mask\n - Continue to increase time on trach mask as tolerated.\n - Decrease sedation and valium use see Sedation below\n - PMV with suctioning again today.\n .\n # HAP vs Aspiration PNA: Afebrile without leukocytosis\n - Completed course of ceftriaxone\n - good O2 saturation on trach mask\n - Continue to f/u cultures\n .\n # Tachycardia: Previously was assessed as sinus tach with occasional\n runs of SVT and sources such as hypovolemia, PE, infection, and pain\n were assessed as possibly etiologies. But, now appears to be SVT for\n much of time, rhythm/rate nonresponsive to carotid massage. HR\n occaisonaly decreases to 70s-80s w/ stable BPs at times that might be\n associated with administration of her BB and valium. Rhythm strip shows\n conversion from a narrow complex SVT to normal sinus rhythm and then\n back. Metroprolol was increased from 25mg TID to QID yesterday, without\n any affect on the SVT.\n - EP consulted for conversion of SVT, appreciate recs\n .\n # Sedation: Inconsistent response to sedation, unclear what is best\n regime. Will continue to wean overall.\n - Continue w Olanzapine QHS\n - D/d valium to 2.5 mg TID and leave just valium 2.5 mg PRN.\n # Nutrition: Pt has had several episodes of vomiting up her TFs,\n reglan started to increase GI motility, but pt had another episode of\n vomiting last night.\n - Hold TFs\n - Thoracic surgery recs: 1) oral/nasal tube in post-piloric position,\n or 2) IR to place a pediatric feeding tube through her PEG site to a\n post-piloric position.\n - Will attempt to coordinate thoracic surgery and IR for tube placement\n tomorrow.\n .\n # Adrenal Insufficency: Endocrine following. Pt does not appear to be\n adrenally insufficient at baseline. Suggesting if the patient under\n goes major stressors such as major surgery, sepsis, she may need stress\n dosed steroids.\n .\n # Fluid Status: Likely approaching euvolemia, though still has mild\n hypernatramia which may suggest is still intravascularly depleated.\n - Monitoring urine output\n - FW flushes w/ tube feeds held due to vomitting\n - will provide D5W IVF as need for hypernatremia and follow lytes\n .\n # UE DVT and elevated INR: DVT in right UE has resolved, new\n non-occlusive in left axillary vein. INR supratherapeutic today\n - COumadin held, will restart at low dose when INR approaches\n therapeutic range.\n - INR 4.2 today, will check PM coags and consider restarting at a low\n dose tonight or tomorrow morning.\n .\n # Spine fracture: Stable\n - Brace for OOB, will discuss with Neurosurgery if current brace is\n optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n .\n # Tracheomalacia. Was initially addressed with IP and they wanted to\n follow up as outpatient. IP reevaluated and does not believe that a\n stent would be feasible.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # PIV x 1\n # Ppx: Coumadin, Ranitidine, Bowel Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n - Will contact Social and Case management today\n # Code: Full\n # Dispo: ICU, Screening for vent facilities\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Respiratory ","chartdate":"2167-10-22 00:00:00.000","description":"Respiratory Care Shift Note","row_id":638899,"text":"Demographics\n Day of mechanical ventilation: 34\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 7.0mm\n Cuff Management:\n Cuff pressure: 23 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Brown / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Pt tolerated t/c all day and then placed on psv 5/5/50% to\n rest noc. RSBI=67. Will continue with t/c trials in am\n Assessment of breathing comfort: comfortable\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment: none\n :\n Plan\n Next 24-48 hours: continue with t/c trials\n"},{"category":"Nursing","chartdate":"2167-10-26 00:00:00.000","description":"Nursing Progress Note","row_id":639504,"text":"TITLE:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt on TM @ 70% with O2 sat mid 90\ns-100%. Requiring tracheal\n sxn\ning approx Q1hr for mod-copious amts thick white tenacious\n secretions. Pt with strong cough, but freq unable to clear secretions\n herself. Lung snds rhonchorous in upper lobes, diminished in bases.\n Action:\n Freq sxn\ning per above. Pt encouraged to C&DB. Pt in\nchair\n position\n in bed with head @ 45-90degree angle.\n Response:\n Pt cont to have lg amt secretions requiring assist to clear.\n Plan:\n Cont aggressive pulm toilet.\n Arousal, Attention, and Cognition, Impaired\n Assessment:\n Pt has been awake and alert . Pt chatty, but difficult to read her lips\n and she has trouble writing clearly.\n Action:\n Emotional support provided, Pt was able to yes as to feeling cold\n & nodded yes for warm blanket & was comfortable after she had the warm\n blanket.\n Response:\n Pt slept for couple of hours , until awakened for care & assessment.\n Plan:\n Speech/swallow consult needed re valve, ? if it is damaged. Cont\n Risperidone. Cont soft wrist restraints and sitter @ bedside for pt\n safety.\n Alteration in Nutrition\n Assessment:\n Abd soft/obese with + BS. On J-tube feeds in upright position.\n Action:\n Pt on colace and senna, held the night dose as pt had 2 BM\ns during the\n day.\n Response:\n Pt with lg loose yellow BM in am. TF started in afternoon @ 10ml/hr as\n well as 50ml water Q4hrs, with HOB @ 45-90degree angle. Tolerated well.\n Plan:\n Cont to gently advance TF per order. Strict aspiration orders, with pt\n rec\ning TF ONLY when in sitting position.\n Hypernatremia (high sodium)\n Assessment:\n Na 147 in pm labs.\n Action:\n Continued on D5 W@ 100 mls/hr for 1000 mls.\n Response:\n AM labs pending.\n Plan:\n Follow up on am labs.\n"},{"category":"Nursing","chartdate":"2167-10-26 00:00:00.000","description":"Nursing Progress Note","row_id":639615,"text":"56 yr old woman, who was transferred from osh for evaluation of\n tracheal bronchial malacia on .Pt presented to Medical\n Center on s/p fall down a flight of stairs fracturing, t5-t8 with\n propulsion treated conservatively with pain meds and back brace. She\n developed resp distress requiring intubation on . Trach/PEG done\n . Now with prolonged hospital course c/b by PNA, anxiety/altered\n mental status, R&LUE DVT .Pt found to have small non occlusive clot on\n her right axial vein via Ultrasound, now rec\ning Lovenox. She has had\n problems with vomiting tube feedings, so feeding tube passed through\n g-tube to her jejunenum. However, she continues to intermit raise\n gastric contents assoc with bronchospasm. Has not required ventilation\n since , on humidified TM @ 50%. Has required 1:1 sitters since\n decanulating herself, twice, despite restraints.\n Airway Clearance, Impaired\n Assessment:\n Rec\nd pt on humidified TM @ 70% with O2 sat 97-100%. RR 22-31 and\n regular. Lung snds rhonchorous in upper lobes, clearing with sxn\ning.\n Lower lobe snds diminished bilat.\n Action:\n FiO2 \nd to 50%. Pt requiring tracheal sxn\ning Q30-60mins, producing\n mod-copious amts thick white tenacious secretions. Pt generally unable\n to fully raise and expectorate secretions.\n Response:\n O2 sat has remained 99-100%, but drops to high 80\ns when requires\n sxn\ning.\n Plan:\n Cont to encourage pt to deep breathe and cough. Cont aggressive pulm\n toilet.\n Alteration in Nutrition\n Assessment:\n Per noc shift nurse, TF off overnight as pt too restless to maintain in\n upright position per strict aspiration precautions. BS +, abd\n soft/obese.\n Action:\n Pt placed on chair position in bed and TF restarted @ 0830 @\n 10ml/hr+50ml free water Q4hrs. She rec\nd her scheduled doses Reglan\n 20mg and colace, senna.\n Response:\n Pt tolerated TF well (but unable to check residuals), so TF inc\nd to\n 20ml/hr @ 1230. Small loose yellow BM today X1.\n Plan:\n Cont strict aspiration prec, holding TF when pt not in upright position\n and turning TF off for 15mins before turning.\n Arousal, Attention, and Cognition, Impaired\n Assessment:\n Pt rec\nd very restless in bed, attempting to exit despite bilat soft\n wrist restraints and sitter @ bedside. When PMV in place pt\n disoriented X 2, and reported she had been in a hotel and could pay\n $3000 cash to leave. When told she was in a hospital bed, she asked,\nWhere\ns the bed\n, unconvinced that she was lying in bed.\n Action:\n Pt rec\nd scheduled 0800 dose Resperadine. EKG taken.\n Response:\n Pt slept for 90mins until woken by team for am rounds. She has appeared\n sleepy since but resistant to falling asleep. Intermit attempting to\n exit bed. QT interval WNL.\n Plan:\n Psych to consult and eval pt/meds.\n"},{"category":"Physician ","chartdate":"2167-10-27 00:00:00.000","description":"Physician Resident Progress Note","row_id":639684,"text":"Chief Complaint:\n 24 Hour Events:\n -hypernatremia: Repeat Na 148-->146 (this am), continuing D5W at\n 125cc/hr\n -TF up to 30cc/hr; tolerated O/N\n -Per psych recs: Gave risperidone m-tab 1mg PO x1 HS and will continue\n risperdone 0.5mg qam and 0.5 PRN; gave scopolamine patch q72hrs;\n f/u EKG in am\n -Changed Metoprolol 25 to 37.5mg TID; gave 5mg x1\n -GI recs: pending\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:30 AM\n Enoxaparin (Lovenox) - 06:48 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.7\nC (98.1\n HR: 79 (68 - 124) bpm\n BP: 134/57(75) {124/52(70) - 179/121(130)} mmHg\n RR: 27 (18 - 31) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 4,004 mL\n 1,084 mL\n PO:\n TF:\n 137 mL\n 51 mL\n IVF:\n 2,544 mL\n 729 mL\n Blood products:\n Total out:\n 3,813 mL\n 1,000 mL\n Urine:\n 3,813 mL\n 1,000 mL\n NG:\n Stool:\n Drains:\n Balance:\n 191 mL\n 84 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 99%\n ABG: ///33/\n Physical Examination\n Gen: Awake, Mouthing words, More agitated compared to previous\n mornings.\n HEENT: EOMI, No pallor in conjunctiva, MMM\n Resp: CTAB, no rales, rhonchi, or wheezing, good airway movement.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, decreased bowel sounds,, G-Tube in\n place with no erythema/induration\n Exte: No edema, DP 2+ bil\n NEURO: Gross Motor and Sensation in 4 extremities\n Labs / Radiology\n 231 K/uL\n 7.7 g/dL\n 145 mg/dL\n 0.4 mg/dL\n 33 mEq/L\n 3.5 mEq/L\n 11 mg/dL\n 109 mEq/L\n 146 mEq/L\n 25.3 %\n 5.7 K/uL\n [image002.jpg]\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n 03:00 AM\n 04:00 AM\n 05:45 AM\n 03:51 AM\n 04:45 PM\n 04:00 AM\n WBC\n 9.5\n 5.7\n 7.3\n 8.0\n 8.7\n 5.5\n 5.7\n Hct\n 28.6\n 28.9\n 30.0\n 26.9\n 27.3\n 27.0\n 28.7\n 24.7\n 25.2\n 25.3\n Plt\n 528\n 356\n 346\n \n 231\n Cr\n 1.0\n 0.7\n 0.7\n 0.7\n 0.7\n 0.5\n 0.4\n Glucose\n 121\n 129\n 123\n 114\n 112\n 122\n 145\n Other labs: PT / PTT / INR:13.6/31.1/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.6 mg/dL, Mg++:2.0 mg/dL, PO4:3.6\n mg/dL\n Assessment and Plan\n 56yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach/PEG with resolving respiratory failure and HAP.\n .\n # Respiratory failure: s/p intubation/extubation, now on trach mask,\n FiO2 50%. Tolerating well with good O2 sat. No further\n self-decanulations overnight.\n - Trach mask as tolerated.\n - Holding sedation with exception of Risperidal 0.5mg PRN\n - F/u CXR tomorrow\n .\n # Nutrition/Vomiting: Currently receiving TPN;. One large BM in past\n 24 hrs to indicate potential improvement in ileus.\n - Cont Reglan 20mg IV Q 8 hours; meds via G-J tube,\n - Will obtain recommendations from Nutrition re TPN today\n - TF as tolerated\n - Speech and Swallow eval today for Passy Muir valve eval;\n - PICC line in place with TPN given when pt not tolerating TF\n - GI consult, will f/u recs\n .\n # Tachycardia: Improved HR max of 120\ns versus 160s previously. Pt now\n on PO Amiodarone 200 TID and PO metoprolol 25mg TID\n - Continue current med regimen. Will continue amiodarone 200 TID for\n three weeks and then switch to qday.\n - Will need to schedule f/u in 4wks with Dr. upon d/c/transfer.\n - f/u Cards recs\n # Sedation/Anxiolysis/AlteredMS: Resolved O/N. Previous delirium and\n agitation most likely secondary to long hospital course and multiple\n psychotropic medications as well as hx of EtOH abuse. Risperdal given\n O/N per Psych recs.\n - started Risperdal 0.5mg PO BID PRN.\n - continue to hold all benzos. opiates, and antihistamines\n - Appreciate psych. Will call and f/u psych recs.\n #Anemia: HCT stable at 25. No known etiology of blood loss.\n -Will repeat HCT in am .\n # Hypernatremia/Fluid Status: Mild hypernatramia resolving with free\n water administration. On TPN/TF. Good UOP.\n - providing D5W IVF, free water flushes with TF\n -Will f/u lytes in afternoon (5pm)\n # UE DVT and elevated INR: Decision made to d/c Coumadin given her\n labile INR, and start Lovenox .\n - Will flush L PICC with TPA if does not flush\n - Add coags to am labs\n .\n # Spine fracture: Stable\n - Brace for OOB, need to discuss with Neurosurgery before d/c if\n current brace is optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n .\n # Tracheomalacia. Was initially addressed with IP and they wanted to\n follow up as outpatient. IP reevaluated and does not believe that a\n stent would be feasible. No new issues.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # ACCESS: PIV x 1, L PICC\n # Ppx: Lovenox, PPi, Bowel Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n - Social Work and Case management involved, have discussed situation\n w/ brother and boyfriend.\n # Code: Full\n # Dispo: ICU, Will d/w case management re rehab facilities.\n ICU Care\n Nutrition:\n TPN without Lipids - 05:44 PM 43. mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n PICC Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2167-10-27 00:00:00.000","description":"Physician Resident Progress Note","row_id":639686,"text":"Chief Complaint:\n 24 Hour Events:\n -hypernatremia: Repeat Na 148-->146 (this am), continuing D5W at\n 125cc/hr\n -TF up to 30cc/hr; tolerated O/N\n -Per psych recs: Gave risperidone m-tab 1mg PO x1 HS and will continue\n risperdone 0.5mg qam and 0.5 PRN; f/u EKG in am\n -Changed Metoprolol 25 to 37.5mg TID; gave 5mg x1\n -GI recs: pending\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:30 AM\n Enoxaparin (Lovenox) - 06:48 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.7\nC (98.1\n HR: 79 (68 - 124) bpm\n BP: 134/57(75) {124/52(70) - 179/121(130)} mmHg\n RR: 27 (18 - 31) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 4,004 mL\n 1,084 mL\n PO:\n TF:\n 137 mL\n 51 mL\n IVF:\n 2,544 mL\n 729 mL\n Blood products:\n Total out:\n 3,813 mL\n 1,000 mL\n Urine:\n 3,813 mL\n 1,000 mL\n NG:\n Stool:\n Drains:\n Balance:\n 191 mL\n 84 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 99%\n ABG: ///33/\n Physical Examination\n Gen: Awake, Mouthing words, More agitated compared to previous\n mornings.\n HEENT: EOMI, No pallor in conjunctiva, MMM\n Resp: CTAB, no rales, rhonchi, or wheezing, good airway movement.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, decreased bowel sounds,, G-Tube in\n place with no erythema/induration\n Exte: No edema, DP 2+ bil\n NEURO: Gross Motor and Sensation in 4 extremities\n Labs / Radiology\n 231 K/uL\n 7.7 g/dL\n 145 mg/dL\n 0.4 mg/dL\n 33 mEq/L\n 3.5 mEq/L\n 11 mg/dL\n 109 mEq/L\n 146 mEq/L\n 25.3 %\n 5.7 K/uL\n [image002.jpg]\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n 03:00 AM\n 04:00 AM\n 05:45 AM\n 03:51 AM\n 04:45 PM\n 04:00 AM\n WBC\n 9.5\n 5.7\n 7.3\n 8.0\n 8.7\n 5.5\n 5.7\n Hct\n 28.6\n 28.9\n 30.0\n 26.9\n 27.3\n 27.0\n 28.7\n 24.7\n 25.2\n 25.3\n Plt\n 528\n 356\n 346\n \n 231\n Cr\n 1.0\n 0.7\n 0.7\n 0.7\n 0.7\n 0.5\n 0.4\n Glucose\n 121\n 129\n 123\n 114\n 112\n 122\n 145\n Other labs: PT / PTT / INR:13.6/31.1/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.6 mg/dL, Mg++:2.0 mg/dL, PO4:3.6\n mg/dL\n Assessment and Plan\n 56yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach/PEG with resolving respiratory failure and HAP.\n .\n # Respiratory failure: s/p intubation/extubation, now on trach mask,\n FiO2 50%. Tolerating well with good O2 sat. No further\n self-decanulations overnight.\n - Trach mask as tolerated.\n - gave scopolamine patch q72hrs for secretions\n - Holding sedation with exception of Risperidal 0.5mg PRN\n - F/u CXR tomorrow\n .\n # Nutrition/Vomiting: Currently receiving TPN;. One large BM in past\n 24 hrs to indicate potential improvement in ileus.\n - Cont Reglan 20mg IV Q 8 hours; meds via G-J tube,\n - Will obtain recommendations from Nutrition re TPN today\n - TF as tolerated\n - Speech and Swallow eval today for Passy Muir valve eval;\n - PICC line in place with TPN given when pt not tolerating TF\n - GI consult, will f/u recs\n .\n # Tachycardia: Improved HR max of 120\ns versus 160s previously. Pt now\n on PO Amiodarone 200 TID and PO metoprolol 25mg TID\n - Continue current med regimen. Will continue amiodarone 200 TID for\n three weeks and then switch to qday.\n - Will need to schedule f/u in 4wks with Dr. upon d/c/transfer.\n - f/u Cards recs\n # Sedation/Anxiolysis/AlteredMS: Resolved O/N. Previous delirium and\n agitation most likely secondary to long hospital course and multiple\n psychotropic medications as well as hx of EtOH abuse. Risperdal given\n O/N per Psych recs.\n - started Risperdal 0.5mg PO BID PRN.\n - continue to hold all benzos. opiates, and antihistamines\n - Appreciate psych. Will call and f/u psych recs.\n #Anemia: HCT stable at 25. No known etiology of blood loss.\n -Will repeat HCT in am .\n # Hypernatremia/Fluid Status: Mild hypernatramia resolving with free\n water administration. On TPN/TF. Good UOP.\n - providing D5W IVF, free water flushes with TF\n -Will f/u lytes in afternoon (5pm)\n # UE DVT and elevated INR: Decision made to d/c Coumadin given her\n labile INR, and start Lovenox .\n - Will flush L PICC with TPA if does not flush\n - Add coags to am labs\n .\n # Spine fracture: Stable\n - Brace for OOB, need to discuss with Neurosurgery before d/c if\n current brace is optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n .\n # Tracheomalacia. Was initially addressed with IP and they wanted to\n follow up as outpatient. IP reevaluated and does not believe that a\n stent would be feasible. No new issues.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # ACCESS: PIV x 1, L PICC\n # Ppx: Lovenox, PPi, Bowel Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n - Social Work and Case management involved, have discussed situation\n w/ brother and boyfriend.\n # Code: Full\n # Dispo: ICU, Will d/w case management re rehab facilities.\n ICU Care\n Nutrition:\n TPN without Lipids - 05:44 PM 43. mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n PICC Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Nursing","chartdate":"2167-10-20 00:00:00.000","description":"Nursing Progress Note","row_id":638556,"text":"55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach, PEG, placement no with respiratory failure secondary to\n tracheomalacia , resolving HAP.\n Arousal, Attention, and Cognition, Impaired\n Assessment:\n Alert, mouthing words but very difficult to understand. Follows\n commands. MAE on bed, attempting to get up. Restless last evening, did\n eventually fall off to sleep this AM.\n Action:\n Zyprexa x 1 . Frequent re-orientation to place, situation. Soft wrist\n restraints for patient safety.\n Response:\n Pt did eventually fall asleep. Re-orientation does have calming effect\n however it is short term.\n Plan:\n No valium or benadryl per psych as this exacerbates delirium. Zyprexa\n for agitation. pt prn.\n Hypernatremia (high sodium)\n Assessment:\n Na 145 last night, 148 this AM.\n Action:\n D5W x 500cc @ 125/hr\n Response:\n Not known yet, will need to recheck Na later today.\n Plan:\n Follow lytes.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Trach collar @ 50% O2 overnight until 4AM, Sats 90-97%. RR 17-20s.\n Around 4AM RR in low 30s, sats low 90s while sleeping--? Fatiguing.\n Strong cough, able to cough thick white ->tan secretions out of trach.\n Occ suctioned for same. Lungs are rhonchorous throughout. Impaired gag.\n Action:\n Suctioned prn for copious secretions. MDIs. Placed back on vent @ 4AM\n d/t fatigue.\n Response:\n Tolerated trach collar most of night, back on vent this AM d/t fatigue\n with RR in teens, Sats 98-100%.\n Plan:\n Wean from vent as tolerated. MDIs, suction as needed.\n Alteration in Nutrition\n Assessment:\n Tube feeds off overnight d/t constant vomiting. No vomiting overnight.\n Action:\n NPO. Reglan q 6 hrs.\n Response:\n No vomiting. Small brown stool x 1.\n Plan:\n NPO. ? may go to IR today to change Gtube to Jtube. Reglan. Meds via\n Gtube.\n"},{"category":"Nursing","chartdate":"2167-10-20 00:00:00.000","description":"Nursing Progress Note","row_id":638648,"text":"Tachycardia, Other\n Assessment:\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2167-10-22 00:00:00.000","description":"Nursing Progress Note","row_id":638896,"text":"Nausea / vomiting\n Assessment:\n Tube feeds started Promote\n @ 10cc/hr. via new jtube. Pt vomited ~ 1\n hr after TF started ->>coffee grounds, TF, H2O(flush). Also\n expectorating same from trach.\n Action:\n Tube feeds stopped. Zofran 4 mg.\n Response:\n No further vomiting, although pt coughing with copious thick tan\n secretions after vomiting episode.\n Plan:\n NPO. Meds given IV for now. Pt to have tube study today.\n Altered mental status (not Delirium)\n Assessment:\n Pt very agitated attempting to get OOB, legs through side rails.\n Mouthing words but difficlt to understand.\n Action:\n Frequent re-orientation. Zyprexa 5 mg x 2. MSO4 2 mg. Valium 2.5 mg.\n Response:\n 1^st dose Zyprexa seemed to have transient calming effect but then pt\n agitated again, 2^nd dose with no effect. Valium with very good effect,\n pt is sleeping but arouseable to voice.\n Plan:\n Zyprexa @ hs (usually effective). Valium 2.5 IV prn, please use\n sparingly d/t ongoing delerium. Re-orientation, emotional support.\n Hypernatremia (high sodium)\n Assessment:\n Na 148 last evening.\n Action:\n D5W c 40 KCL @ 100/hr x 1 liter. Repeat labs sent this AM.\n Response:\n AM Na 148\n Plan:\n Continue to monitor lytes. Free H2O.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Coughing frequently with copious thick tan/brown secretions after\n vomiting. Asking to be suctioned, also coughing secretions to end of\n trach.\n Action:\n Frequent suctioning. Placed on CPAP 5/5 this AM to rest.\n Response:\n RR 22 on vent when sedated. Sats 100%\n Plan:\n Wean from vent as tolerated. Pulmonary hygiene.\n"},{"category":"Nursing","chartdate":"2167-10-19 00:00:00.000","description":"Nursing Progress Note","row_id":638502,"text":"56yo woman admitted 1 month ago with unstentable tracheal malacia,\n failure to wean.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt on MMV settings, no spont resp. Pt unarousable per below until\n 0830 when she woke and was placed on TM with high flow neb@ 50%. RR\n 16-25 and regular, with O2 sat 96-99%. Afebrile.Very bronchospastic\n upon awakening, vomiting mod amt clear/thick X 1 after cuff let down to\n try PMV. Lung snds rhonchorous in upper lobes, diminished in bases. Pt\n with congested/productive cough of mod-copious amts thick white\n secretions.\n Action:\n Pt encouraged to freq C&DB. Suctionned PRN for mod-copious amts thick\n white secretions which pt was unable to fully raise.\n Response:\n Pt cont to intermit require ET sxn\ning. She remains on TM @ this time,\n denies SOB.\n Plan:\n Cont TM, but may return to vent support overnight if again becomes\n somulent with apneic periods.\n Tachycardia, Other\n Assessment:\n Rec\nd pt unresponsive to pain in am with HR 80\ns SR. However, when\n woken HR returned to 130\ns without VEA. BP 92/46-151/78.\n Action:\n At 1140 cardiologists used Adenosine 6mg to eval her heart rhythm,\n which appeared to be AT per attending.\n Response:\n Pt\ns rate slowed to 80\ns but without extended pause, and pt responsive\n throughout administration of Adenosine.\n Plan:\n Lopressor inc\nd to 37.5mg Q6hrs.\n Arousal, Attention, and Cognition, Impaired\n Assessment:\n Rec\nd pt very difficult to rouse after rec\ning Benadryl, Morphine,\n Zyprexa, and Valium overnight. Pt woke @ 0830 and instantly alert and\n restless. Pt has required presence of nurse most of shift to keep her\n safe, despite bilat soft wrist restraints and waist restraint. Pt\n putting legs over/between siderail. Pt not cooperative with\n redirecting. However, she is mouthing words more approp: requesting\n bedpan for BM, that she is afraid she is dying, and wants to go home.\n She did appear to have visual hallucinations, asking who the man\n outside the window was, and smiling @ blank wall.\n Action:\n Restraints and bedside sitter when available from MICU staff. Pt\n constantly reoriented. Psych nurse consulted and eval done.\n Response:\n Psych nurse recommended D/C\ning Valium and Benadryl as they may\n aggravate her delirium.\n Plan:\n Sitter may be available if pt cont to put self @ risk. Zyprexa @ HS.\n"},{"category":"Physician ","chartdate":"2167-10-22 00:00:00.000","description":"Physician Attending Progress Note","row_id":638998,"text":"Chief Complaint: resp failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n increased bblocker\n J tube placed by IR through PEG- restarted TF and vomiting\n Went for tube study - dysmotility - contrast sat in stomach\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Diazepam (Valium) - 02:24 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 12:17 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 35.6\nC (96.1\n HR: 118 (93 - 140) bpm\n BP: 153/58(79) {82/39(49) - 153/101(105)} mmHg\n RR: 23 (14 - 37) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 3,808 mL\n 1,119 mL\n PO:\n TF:\n 4 mL\n IVF:\n 3,804 mL\n 1,119 mL\n Blood products:\n Total out:\n 1,650 mL\n 520 mL\n Urine:\n 1,590 mL\n 520 mL\n NG:\n 60 mL\n Stool:\n Drains:\n Balance:\n 2,158 mL\n 599 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 243 (169 - 281) mL\n PS : 5 cmH2O\n RR (Spontaneous): 17\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 67\n PIP: 11 cmH2O\n SpO2: 99%\n ABG: ///33/\n Ve: 4.1 L/min\n Physical Examination\n Labs / Radiology\n 8.2 g/dL\n 356 K/uL\n 129 mg/dL\n 0.7 mg/dL\n 33 mEq/L\n 3.6 mEq/L\n 4 mg/dL\n 110 mEq/L\n 148 mEq/L\n 26.9 %\n 5.7 K/uL\n [image002.jpg]\n 06:22 AM\n 02:58 AM\n 03:43 AM\n 05:02 PM\n 03:36 AM\n 02:30 AM\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n WBC\n 7.0\n 7.1\n 7.1\n 6.9\n 7.6\n 9.5\n 5.7\n Hct\n 29.7\n 28.9\n 29.2\n 27.8\n 32.7\n 28.6\n 28.9\n 30.0\n 26.9\n Plt\n 395\n 462\n 452\n 467\n 548\n 528\n 356\n Cr\n 0.7\n 0.6\n 0.7\n 0.8\n 0.7\n 0.8\n 1.0\n 0.7\n Glucose\n 126\n 137\n 104\n 108\n 131\n 128\n 121\n 129\n Other labs: PT / PTT / INR:15.2/24.6/1.3, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.7 mg/dL, Mg++:2.1 mg/dL, PO4:4.1\n mg/dL\n Assessment and Plan\n 1. Tachycardia: runs of attach Appreciate EP consult\n will increase\n bblocker. Have to convert to metoprolol 7.5mg IV Q4 because unable to\n take pos.\n 2. Persistent Nausea/Vomiting: we have ruled out\n pSBO/SBO, very poor\n bowel sounds, tube study this AM shows contrast not moving out of the\n jejunum. get emptying study and if unrevealing consult GI to discuss\n EGD. Place PICC for TPN as she has not had nurtrition.\n 2. Resp Failure\n Trach mask trials all day, PSV\n PMV trials\n Per IP not stent planned as technically not possible to\n place into her airway\n 3. DVT and coagulopathy: reversed with IV Vit k\n hold coumadin today\n 4. Hypernatremia Replete free water.\n Please see today\ns ICU team note for other issues.\n ICU Care\n Nutrition: plan for TPN\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 04:00 AM\n Prophylaxis:\n DVT: plan for coumadin\n Stress ulcer: ppi\n Communication: spoke with son and\n status: Full code\n Disposition : ICU\n"},{"category":"Physician ","chartdate":"2167-10-24 00:00:00.000","description":"Physician Resident Progress Note","row_id":639361,"text":"Chief Complaint:\n 24 Hour Events:\n Pt decannulated herself x2 yesterday, the 1st episode she desatted to\n the 80s, the second episode she desated and her heart rate decreased to\n 39-40, before the trach could be replaced.\n PICC line placed by IR, called to notify that there was clot in both\n arms, placed in L arm more proximally than small Bacillis vein clot.\n Coumadin restarted after PICC placement with 2mg\n Per GI Recs: Reglan restarted at 20mg IV q 8 hours, and meds were\n restarted via tube. No vomitting.\n Per PSYCH recs: d/c'd all benzoes, (also requested d/c reglan if GI\n ok), added Risperdal 0.5mg (and can add 0.5mg PRN, and titrate up\n to total daily dose of 2-3mg if helping)\n Per Cards recs: after 18hr of amiodaron drip. Start PO amiodarone 200mg\n TID, which was done at 1am.\n Brother visited\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 37.4\nC (99.4\n HR: 90 (73 - 121) bpm\n BP: 155/49(75) {103/47(66) - 175/98(111)} mmHg\n RR: 32 (14 - 32) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,151 mL\n 293 mL\n PO:\n TF:\n IVF:\n 1,852 mL\n 13 mL\n Blood products:\n Total out:\n 2,460 mL\n 820 mL\n Urine:\n 2,460 mL\n 820 mL\n NG:\n Stool:\n Drains:\n Balance:\n -309 mL\n -527 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Set): 0 (0 - 0) mL\n Vt (Spontaneous): 360 (360 - 360) mL\n PS : 10 cmH2O\n RR (Set): 0\n RR (Spontaneous): 21\n FiO2: 40%\n SpO2: 98%\n ABG: ///33/\n Physical Examination\n Gen: Asleep, unarousable, responds minimally to noxious stimuli\n HEENT: PERRL, MMM\n Resp: CTA bilaterally, no rales, rhonchi, or wheezing, small\n inspirations.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, BS+\n Exte: No edema, DP 2+ bil\n NEURO: reflexes 2+ bilaterally.\n Labs / Radiology\n 316 K/uL\n 8.3 g/dL\n 114 mg/dL\n 0.7 mg/dL\n 33 mEq/L\n 4.0 mEq/L\n 7 mg/dL\n 111 mEq/L\n 149 mEq/L\n 27.0 %\n 8.0 K/uL\n [image002.jpg]\n 03:43 AM\n 05:02 PM\n 03:36 AM\n 02:30 AM\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n 03:00 AM\n 04:00 AM\n WBC\n 7.1\n 6.9\n 7.6\n 9.5\n 5.7\n 7.3\n 8.0\n Hct\n 29.2\n 27.8\n 32.7\n 28.6\n 28.9\n 30.0\n 26.9\n 27.3\n 27.0\n Plt\n 452\n 467\n 548\n 528\n 356\n 346\n 316\n Cr\n 0.7\n 0.8\n 0.7\n 0.8\n 1.0\n 0.7\n 0.7\n 0.7\n Glucose\n 104\n 108\n 131\n 128\n 121\n 129\n 123\n 114\n Other labs: PT / PTT / INR:13.2/22.4/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:9.0 mg/dL, Mg++:2.3 mg/dL, PO4:4.1\n mg/dL\n Assessment and Plan\n 55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach, PEG placement now with respiratory failure secondary to\n tracheomalacia , resolved HAP.\n .\n # Respiratory failure: Slowly improving, spending most of the day on\n trach mask with short periods of rest on PSV at night and setbacks\n from increased secretions to vomiting/aspiration events and her\n self-decanulations.\n - Continue to increase time on trach mask as tolerated.\n - Discontinue all orders for sedation except for Risperdal QHS.\n - PMV with suctioning as tolerated\n # Nutrition/Vomiting: Normal CT-abdomen, had FT placed via peg into\n jejunum, but continued to vomit. Tube study showed dysmotility in small\n bowel, but no obstruction, no retrograde flow. GI recs Reglan 20mg IV Q\n 8 hours and restart meds via G-J tube, if tolerated slowly restart TFs.\n PICC line placed yesterday and TPN started.\n - GI consult, appreciate recs\n - Small volume TFs start today\n - Continue TPN today\n # HAP vs Aspiration PNA: Had been afebrile for last several days, now\n with new fever two nights ago after having decanulated herself. Likely\n had some aspiration. Chemical pneumonitis versus new aspiration PNA.\n Now Afebrile for past 24 hours.\n - f/u daily CXR\n - F/u cx data\n - If remains febrile, send sputum cx, otherwise hold on abx.\n .\n # Tachycardia: Pt in and out of SVT and sinus, increased BB seems to\n help, but pt does not stay in sinus. Cards rec to start Amiodarone IV\n drip, and then convert to PO, 200mg TID. Would consider EPS if\n amiodarone not successful, though would wait until pt more stable for\n general anesthesia.\n - Changed to IV metoprolol to 10mg IV q4hr.\n - Completed amiodarone 0.5mg/min IV drip x 18 hours, and converted to\n 200mg PO TID..\n - Cards c/s, appreciate recs\n # Sedation/Anxiolysis/AlteredMS: unclear etiology of her confusion and\n agitation. Has had long hospital course and multiple psychotropic\n medications as well as hx of EtOH abuse.\n - d/c all benzos. opiates, and antihistamines\n - Psychiatry consulted, appreciate recs\n - started Risperdal 0.5mg PO BID, d/c zyprexa.\n # Adrenal Insufficency: Endocrine following. Pt does not appear to be\n adrenally insufficient at baseline. Suggesting if the patient under\n goes major stressors such as major surgery, sepsis, she may need stress\n dosed steroids.\n .\n # Fluid Status: Likely approaching euvolemia, though still has mild\n hypernatramia which may suggest is still intravascularly depleated.\n - Monitoring urine output\n - will provide D5W IVF as need for hypernatremia and follow lytes\n # UE DVT and elevated INR: DVT in right UE has resolved, new\n non-occlusive in left axillary vein. INR has been volatile, likely from\n drug interactions and poor nutritional status. Have been unable to keep\n her appropariately therapeutic.\n - d/c coumadin\n - start Lovenox, maintain until GI issues resolved and can restart\n coumadin\n .\n #Hematemesis: Pt had small amt Hematemesis, after vomiting, last week.\n None today. HCT stable.\n -Will follow HCT.\n - Guaiac stools\n # Spine fracture: Stable\n - Brace for OOB, will discuss with Neurosurgery if current brace is\n optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n .\n # Tracheomalacia. Was initially addressed with IP and they wanted to\n follow up as outpatient. IP reevaluated and does not believe that a\n stent would be feasible.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # ACCESS: PIV x 1, PICC placement\n yesterday.\n # Ppx: subtherapeutic INR restarting coumadin today, Ranitidine, Bowel\n Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n - Social Work and Case management involved, have discussed situation\n w/ brother and boyfriend.\n # Code: Full\n # Dispo: ICU, Screening for vent facilities\n ICU Care\n Nutrition:\n TPN without Lipids - 06:00 PM 41. mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n PICC Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n MICU Attending Addendum:\n On this day I examined the patient and was present for the key portions\n of the services provided. I have reviewed Dr \ns note above and I\n agree with the findings and plan of care. I would only add/emphasize\n the following: Ms has done well of late on a trache collar,\n able to go all night without the vent. The active issues now are\n chiefly GI, cardiac, and pychiatric. Her hypomotility may be a bit\n better now that she is on high dose Reglan, and we will gingerly start\n feedings via her J in G tube, while continuing TPN for the present. Her\n SVT has for now converted to NSR on Amiodarone and Metoprolol. Her\n delirium is being addressed with the help of psychiatry, and we\n started Risperdal at their suggestion. Once these issues are stable\n she should be able to move to a resp rehab facility.\n , MD\n 30 min spent in the care of this critically ill patient\n ------ Protected Section Addendum Entered By: , MD\n on: 16:43 ------\n"},{"category":"Nursing","chartdate":"2167-10-25 00:00:00.000","description":"Nursing Progress Note","row_id":639502,"text":"56 yr old woman, who was transferred from osh for evaluation of\n tracheal bronchial malacia on .Pt presented to Medical\n Center on s/p fall down a flight of stairs fracturing, t5-t8 with\n propulsion treated conservatively with pain meds and back brace. She\n developed resp distress requiring intubation on . Trach/PEG done\n . Now with prolonged hospital course c/b by PNA, anxiety/altered\n mental status, R&LUE DVT .Pt found to have small non occlusive Clot on\n her right axial vein via Ultrasound. She has had problems with\n vomiting tube feedings, so feeding tube passed through g-tube to her\n jejunenum but she continues to vomit. Trach mask, has not required\n ventilation since . Has also required 1:1 sitters since\n decanulating herself twice, despite restraints. Overnight ,\n restarted TF\ns, however, infused for ~7 hrs, then began suctioning\n bile-like fluid from trach after pt experienced a prolonged coughing\n jag. TF\ns placed on hold.\n Tachycardia, Other\n Assessment:\n HR 67-118ST without VEA. BP 110/59-140/58. Pt rec\ning lopressor 10mg IV\n Q4hrs, as well as Amio via GT.\n Action:\n Lopressor changes to po TiD.\n Response:\n VSS.\n Plan:\n Cont present course of cardiac meds.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt on TM @ 70% with O2 sat 99-100%. Rare desat to 80\ns related to\n inc\nd secretions. Requiring tracheal sxn\ning approx Q1hr for\n mod-copious amts thick white tenacious secretions. Pt with strong\n cough, but freq unable to clear secretions herself. Lung snds\n rhonchorous in upper lobes, diminished in bases.\n Action:\n Freq sxn\ning per above. Pt encouraged to C&DB. Pt in\nchair\n position\n in bed with head @ 45-90degree angle.\n Response:\n Pt cont to have lg amt secretions requiring assist to clear.\n Plan:\n Cont aggressive pulm toilet.\n Arousal, Attention, and Cognition, Impaired\n Assessment:\n Pt very somulent in am, but has been awake and alert since approx 1100.\n Pt chatty, but difficult to read her lips and she has trouble writing\n clearly. Pt intermit very angry, with ? confusion re nurse\ns identity.\n Friend from visited () and pt recognized her.\n Action:\n Passy Muir Valve tried several times.\n Response:\n Pt not able to speak clearly with valve on. Also, D/T lg amt secretions\n could not leave valve on for more than a few minutes.\n Plan:\n Speech/swallow consult needed re valve, ? if it is damaged. Cont\n Risperidone. Cont soft wrist restraints and sitter @ bedside for pt\n safety.\n Alteration in Nutrition\n Assessment:\n Abd soft/obese with + BS. J tube clamped except for meds.\n Action:\n Pt rec\ning reglan, as well as colace and senna. Miralx held in am.\n Response:\n Pt with lg loose yellow BM in am. TF started in afternoon @ 10ml/hr as\n well as 50ml water Q4hrs, with HOB @ 45-90degree angle. Tolerated well.\n Plan:\n Cont to gently advance TF per order. Strict aspiration orders, with pt\n rec\ning TF ONLY when in sitting position.\n"},{"category":"Nursing","chartdate":"2167-10-20 00:00:00.000","description":"Nursing Progress Note","row_id":638549,"text":"55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach, PEG, placement no with respiratory failure secondary to\n tracheomalacia , resolving HAP.\n Arousal, Attention, and Cognition, Impaired\n Assessment:\n Alert, mouthing words but very difficult to understand. Follows\n commands. MAE on bed, attempting to get up. Restless last evening, did\n eventually fall off to sleep this AM.\n Action:\n Zyprexa x 1 . Frequent re-orientation to place, situation. Soft wrist\n restraints for patient safety.\n Response:\n Pt did eventually fall asleep. Re-orientation does have calming effect\n however it is short term.\n Plan:\n No valium or benadryl per psych as this exacerbates delirium. Zyprexa\n for agitation. pt prn.\n Hypernatremia (high sodium)\n Assessment:\n Na 145 last night, 148 this AM.\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Trach collar @ 50% O2 overnight until 4AM, Sats 90-97%. RR 17-20s.\n Around 4AM RR in low 30s, sats low 90s while sleeping--? Fatiguing.\n Strong cough, able to cough thick white ->tan secretions out of trach.\n Occ suctioned for same. Lungs are rhonchorous throughout. Impaired gag.\n Action:\n Suctioned prn for copious secretions. MDIs. Placed back on vent @ 4AM\n d/t fatigue.\n Response:\n Tolerated trach collar most of night, back on vent this AM d/t fatigue\n with RR in teens, Sats 98%.\n Plan:\n Wean from vent as tolerated. MDIs, suction as needed.\n Alteration in Nutrition\n Assessment:\n Tube feeds off overnight d/t constant vomiting. No vomiting overnight.\n Action:\n NPO. Reglan q 6 hrs.\n Response:\n No vomiting. Small brown stool x 1.\n Plan:\n NPO. ? may go to IR today to change Gtube to Jtube. Reglan. Meds via\n Gtube.\n"},{"category":"Physician ","chartdate":"2167-10-20 00:00:00.000","description":"Physician Attending Progress Note","row_id":638643,"text":"Chief Complaint: resp failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n CARDIOVERSION/DEFIBRILLATION - At 11:50 AM\n aqdenosine 6mg given X 1 by cardiologist to assess pt's rhythm. Pt\n tolerated well.\n Held Valium ansd Benedryl and has done well without\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.5\nC (97.7\n HR: 118 (76 - 144) bpm\n BP: 131/72(85) {93/43(0) - 154/134(138)} mmHg\n RR: 26 (12 - 36) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,945 mL\n 680 mL\n PO:\n TF:\n IVF:\n 1,800 mL\n 560 mL\n Blood products:\n Total out:\n 2,300 mL\n 680 mL\n Urine:\n 2,245 mL\n 680 mL\n NG:\n 55 mL\n Stool:\n Drains:\n Balance:\n -355 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: High flow neb, Tracheostomy tube\n Ventilator mode: MMV/PSV/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 319 (319 - 319) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 15\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 15 cmH2O\n SpO2: 94%\n ABG: ///36/\n Ve: 5.5 L/min\n Physical Examination\n Gen: lying in bed, alert, responding to questions\n CV; tachy RR\n Chest: bibasilar decreased BS, faint exo wheeze\n Abd: soft NT\n Ext: no edema:\n Labs / Radiology\n 10.0 g/dL\n 548 K/uL\n 128 mg/dL\n 0.8 mg/dL\n 36 mEq/L\n 4.1 mEq/L\n 6 mg/dL\n 105 mEq/L\n 148 mEq/L\n 32.7 %\n 7.6 K/uL\n [image002.jpg]\n 05:00 AM\n 02:06 AM\n 07:34 AM\n 03:50 AM\n 06:22 AM\n 02:58 AM\n 03:43 AM\n 05:02 PM\n 03:36 AM\n 02:30 AM\n WBC\n 5.9\n 7.5\n 5.6\n 6.1\n 7.0\n 7.1\n 7.1\n 6.9\n 7.6\n Hct\n 27.2\n 26.8\n 27.0\n 27.0\n 29.7\n 28.9\n 29.2\n 27.8\n 32.7\n Plt\n 296\n 306\n 335\n \n 452\n 467\n 548\n Cr\n 0.7\n 0.6\n 0.5\n 0.7\n 0.7\n 0.6\n 0.7\n 0.8\n 0.7\n 0.8\n Glucose\n 134\n 134\n 121\n \n 104\n 108\n 131\n 128\n Other labs: PT / PTT / INR:48.3/33.3/5.5, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:10.0 mg/dL, Mg++:2.5 mg/dL,\n PO4:4.3 mg/dL\n Assessment and Plan\n 1. Tachycardia: runs of attach Appreciate EP consult\n will increase\n bblocker. If fails may need EP study for further study and ? ablatable\n focus.\n 2. Persistent Nausea/Vomiting: very poor bowel sounds, get ABD ct to\n look for SBO, talk with GI about EGD or tube study to look for more\n proximal gastric outlet obstruction.\n 2. Resp Failure\n Trach mask trials all day, PSV\n PMV trials\n S/P rx for pan Klebs PNA.\n Per IP not stent planned as technically not possible to\n place into her airway\n 3. DVT and coagulopathy: On warfarin but high inr. Hold warfarin until\n inr 2-2.5 range or bridge with loveonx if may get procedures\n 4. Hypernatremia Replete free water.\n Please see today\ns ICU team note for other issues.\n ICU Care\n Nutrition: NPO while sorting out gi obstruction issues\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n Prophylaxis:\n DVT: coumadin\n Stress ulcer: PPI\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n"},{"category":"Nursing","chartdate":"2167-10-14 00:00:00.000","description":"Nursing Progress Note","row_id":637600,"text":"Tachycardia, Other\n Assessment:\n Hr has been in sinus tachycardia all day at 130-140\ns, Hr noted to also\n stay elevated in the 130\ns while at rest also. SBP has been elevated\n throughout the day at 150-170\ns while awake and 120-130\ns while at\n rest. Pt also very restless.\n Action:\n No med to be given for tachycardia or BP MD. Pt given Morphine and\n haldol for restlessness w/o effect. Pt also on valium ATC w/little\n effect. CTA done to r/o pe as a source of tachycardia.\n Response:\n Results pending on CTA.\n Plan:\n Continue to evaluate HR and BP for need of treatment.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt has a known DVT to RUE. Today pt had a US of LUE to R/O DVT as a\n source of tachycardia.\n Action:\n After DVT found, IVF stopped.\n Response:\n Pt found to have a clot to Lt ax vein and MD notified.\n Plan:\n Pt to cont coumadin tonight, awaiting dosage for inr 1.4 . ? Access now\n that Lt arm has a DVT.\n Altered mental status (not Delirium)\n Assessment:\n Pt has been restless most of the day. Pt only follow direct commands.\n When asked to keep her hand off the TC, she will for only 3sec, and\n then she will reach for it again.\n Action:\n Pt given valium, morphine and haldol prn.\n Response:\n Little effect noted from sedations.\n Plan:\n Continue to eval MS.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt placed on TC this am at 8am and was placed back on CPAP at 3pm after\n pt became tachypnic and tachycardic (150\ns). Pt has had a strong prod\n cough with mod amounts of thick yellow secretions. LS coarse before sx\n and CTA after sx. Pt found several times disconnecting herself from the\n vent (even though she is in restraints), and she will desat to 80%\n within seconds.\n Action:\n Cont pulm toilet as needed. Pt in need of freq oral care.\n Response:\n Plan:\n Continue to wean pt off vent and place on TC once pt can tol it again.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Temp 99.1 this am and now 99.5 .\n Action:\n Pt continues on IV ABx.\n Response:\n Awaiting effect from IV ABXs.\n Plan:\n Follow up cultures.\n"},{"category":"Respiratory ","chartdate":"2167-10-21 00:00:00.000","description":"Respiratory Care Shift Note","row_id":638813,"text":"Demographics\n Day of mechanical ventilation: 33\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Tracheostomy tube:\n Type: Standard, Cuffed, Inner Cannula\n Manufacturer: Portex\n Size: 8.0mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Scant\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Pt weaned to trach collar,\n tolerating well.\n Assessment of breathing comfort: No claim of dyspnea\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: stay on trach collar as tolerated.\n Reason for continuing current ventilatory support:\n"},{"category":"Physician ","chartdate":"2167-10-21 00:00:00.000","description":"Physician Attending Progress Note","row_id":638816,"text":"Chief Complaint: resp failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n rising INR to 10.5\n small volume hemetemesis\n abd CT\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:30 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.9\nC (98.4\n HR: 114 (88 - 136) bpm\n BP: 120/65(80) {80/40(49) - 149/88(92)} mmHg\n RR: 11 (11 - 33) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,241 mL\n 1,802 mL\n PO:\n TF:\n IVF:\n 1,941 mL\n 1,802 mL\n Blood products:\n Total out:\n 1,860 mL\n 260 mL\n Urine:\n 1,830 mL\n 210 mL\n NG:\n 30 mL\n 50 mL\n Stool:\n Drains:\n Balance:\n 381 mL\n 1,542 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 438 (300 - 1,054) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 13\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 16 cmH2O\n Plateau: 15 cmH2O\n SpO2: 100%\n ABG: ///35/\n Ve: 5.4 L/min\n Physical Examination\n Gen: lying in bed, alert, responding to questions\n CV; tachy RR\n Chest: bibasilar decreased BS, faint exp wheeze\n Abd: soft NT+BS\n Ext: no edema\n Labs / Radiology\n 9.2 g/dL\n 528 K/uL\n 121 mg/dL\n 1.0 mg/dL\n 35 mEq/L\n 3.4 mEq/L\n 6 mg/dL\n 103 mEq/L\n 144 mEq/L\n 28.9 %\n 9.5 K/uL\n [image002.jpg]\n 07:34 AM\n 03:50 AM\n 06:22 AM\n 02:58 AM\n 03:43 AM\n 05:02 PM\n 03:36 AM\n 02:30 AM\n 01:30 AM\n 06:41 AM\n WBC\n 5.6\n 6.1\n 7.0\n 7.1\n 7.1\n 6.9\n 7.6\n 9.5\n Hct\n 27.0\n 27.0\n 29.7\n 28.9\n 29.2\n 27.8\n 32.7\n 28.6\n 28.9\n Plt\n 335\n 321\n 395\n 462\n 452\n 467\n 548\n 528\n Cr\n 0.5\n 0.7\n 0.7\n 0.6\n 0.7\n 0.8\n 0.7\n 0.8\n 1.0\n Glucose\n 121\n 619\n 126\n 137\n 104\n 108\n 131\n 128\n 121\n Other labs: PT / PTT / INR:82.1/35.9/10.5, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:9.7 mg/dL, Mg++:2.4 mg/dL, PO4:2.9\n mg/dL\n Assessment and Plan\n 1. Tachycardia: runs of attach Appreciate EP consult\n will increase\n bblocker. Have to convert to metoprolol 5mg IV Q4 because unable to\n take pos\n 2. Persistent Nausea/Vomiting: we have ruled out\n pSBO/SBO, very poor\n bowel sounds, get emptying study and if unrevealing consult GI to\n discuss EGD. We will need to pursue NG dophoff by IR if cannot snake\n pedi tube into existing g tube. Was guiac + but in setting of high INR\n HCT stable. Will will reverse inr.\n 2. Resp Failure\n Trach mask trials all day, PSV\n PMV trials\n Per IP not stent planned as technically not possible to\n place into her airway\n 3. DVT and coagulopathy: reverre with IV VIt K today, then maintain\n daily SC Vit K until Inr less than 2\n 4. Hypernatremia Replete free water.\n Please see today\ns ICU team note for other issues.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 04:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n Communication: with pt and spoke at length with brother who would like\n to possibily become her guardian or power of atty to facilitate her\n care and finances. Her partner is alos interested in guardianship.\n We may need ot refer to legal for clarification.\n Code status: Full code\n Disposition : ICU\n"},{"category":"Physician ","chartdate":"2167-10-26 00:00:00.000","description":"Physician Resident Progress Note","row_id":639604,"text":"Chief Complaint:\n 24 Hour Events:\n Pt agitated overnight given extra Risperidone 0.5 mg x 2 overnight.\n (1.5mg total)\n 1000 mL D5W for Hypernatremia\n Changed B-Blocker from IV to PO, Metoprolol Tartrate 25 mg PO TID\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:17 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.7\nC (98\n HR: 120 (67 - 120) bpm\n BP: 110/64(76) {109/47(60) - 141/115(118)} mmHg\n RR: 26 (18 - 30) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 3,820 mL\n 856 mL\n PO:\n TF:\n 117 mL\n 20 mL\n IVF:\n 2,612 mL\n 572 mL\n Blood products:\n Total out:\n 2,460 mL\n 1,180 mL\n Urine:\n 2,460 mL\n 1,180 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,360 mL\n -324 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 100%\n ABG: ///33/\n Physical Examination\n Gen: Awake, Mouthing words, More agitated compared to previous\n mornings.\n HEENT: EOMI, No pallor in conjunctiva, MMM\n Resp: CTAB, no rales, rhonchi, or wheezing, good airway movement.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, decreased bowel sounds,, G-Tube in\n place with no erythema/induration\n Exte: No edema, DP 2+ bil\n NEURO: Gross Motor and Sensation in 4 extremities\n Labs / Radiology\n 249 K/uL\n 8.0 g/dL\n 122 mg/dL\n 0.5 mg/dL\n 33 mEq/L\n 3.7 mEq/L\n 13 mg/dL\n 108 mEq/L\n 146 mEq/L\n 24.7 %\n 5.5 K/uL\n [image002.jpg] CXR: L Picc, trach tip at midline, bibasilar\n opacities, low lung volumes, Bil pleural effusions.\n 03:36 AM\n 02:30 AM\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n 03:00 AM\n 04:00 AM\n 05:45 AM\n 03:51 AM\n WBC\n 6.9\n 7.6\n 9.5\n 5.7\n 7.3\n 8.0\n 8.7\n 5.5\n Hct\n 27.8\n 32.7\n 28.6\n 28.9\n 30.0\n 26.9\n 27.3\n 27.0\n 28.7\n 24.7\n Plt\n 467\n 548\n 528\n 356\n 346\n 316\n 271\n 249\n Cr\n 0.7\n 0.8\n 1.0\n 0.7\n 0.7\n 0.7\n 0.7\n 0.5\n Glucose\n 131\n 128\n 121\n 129\n 123\n 114\n 112\n 122\n Other labs: PT / PTT / INR:13.6/31.1/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:9.0 mg/dL, Mg++:2.2 mg/dL, PO4:3.1\n mg/dL\n Assessment and Plan\n 56yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach/PEG with resolving respiratory failure and HAP.\n .\n # Respiratory failure: s/p intubation/extubation, now on trach mask,\n FiO2 70%. Tolerating well with good O2 sat. No further\n self-decanulations overnight.\n - Tach mask as tolerated.\n - Holding sedation with exception of Risperidal 0.5mg .\n - F/u CXR tomorrow\n .\n # Nutrition/Vomiting: Currently receiving TPN;. One large BM in past\n 24 hrs to indicate potential improvement in ileus.\n - Cont Reglan 20mg IV Q 8 hours; meds via G-J tube,\n - Will obtain recommendations from Nutrition re TPN before starting TPN\n tomorrow\n - TF as tolerated\n - Speech and Swallow eval\n - PICC line in place with TPN given when pt not tolerating TF\n - GI consult, appreciate recs\n .\n # Tachycardia: Improved HR max of 120\ns versus 160s previously;\n elevated this am secondary to agitation. Pt now on PO Amiodarone 200\n TID and PO metoprolol 25mg TID\n - Continue current med regimen. Will continue amiodarone 200 TID for\n three weeks and then switch to qday.\n - Will schedule f/u in 4wks with Dr. upon d/c/transfer.\n - f/u Cards recs\n # Sedation/Anxiolysis/AlteredMS: Agitation O/N, continues to be\n agitated most likely secondary to long hospital course and multiple\n psychotropic medications as well as hx of EtOH abuse. Risperdal given\n O/N.\n - started Risperdal 0.5mg PO BID\n - continue to hold all benzos. opiates, and antihistamines\n - Appreciate psych. Will call and f/u psych recs.\n #Anemia: Decrease in HCT from 28\n24; tachycardia. No known etiology of\n blood loss, most likely related to variaton\n -Will repeat HCT check this afternoon.\n # Hypernatremia/Fluid Status: Mild hypernatramia with good UOP\n (hypervolemic hypernatremia). On TPN/TF.\n - providing D5W IVF, free water flushes with TF\n -Will f/u lytes (Na) this afternoon at 5pm.\n # UE DVT and elevated INR: Decision made to d/c Coumadin given her\n labile INR, and start Lovenox . Current INR 1.2.\n - Will flush L PICC with TPA if does not flush\n .\n # Spine fracture: Stable\n - Brace for OOB, need to discuss with Neurosurgery before d/c if\n current brace is optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n .\n # Tracheomalacia. Was initially addressed with IP and they wanted to\n follow up as outpatient. IP reevaluated and does not believe that a\n stent would be feasible. No new issues.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # ACCESS: PIV x 1, L PICC\n # Ppx: Lovenox, PPi, Bowel Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n - Social Work and Case management involved, have discussed situation\n w/ brother and boyfriend.\n # Code: Full\n # Dispo: ICU, Will d/w case management re rehab facilities.\n PGY2 Addendum\n Agree with excellent MS4 PN. Will touch base with psychiatry re:\n sedating meds and EP re: atrial tachycardia. Will obtain EKG to\n reassess QTc. Ordered for TPN. Giving d5W for hypernatremia. Re-consult\n S/S for PMV re-fitting. transfer to LTAC.\n \n PGY2\n ------ Protected Section ------\n MICU Attending Addendum:\n ------ Protected Section Addendum Entered By: , MD\n on: 16:21 ------\n MICU ATTENDING ADDENDUM:\n On this day I examined the patient and was present for the key portions\n of the services provided. I have reviewed the note above and agree with\n the findings and plan of care. I would add the following:\n Ms remains stable, on her trache mask, off the vent for 3 days.\n Secretions improved and she is using the PMV to talk in short spells.\n Her ileus seems better, with a good BM and good bowel sounds and no\n clear cut emesis. So TFs will be restarted and advanced. She remains\n on high dose raglan.\n We will rediscuss her case with psychiatry as her mentation varies from\n very alert to more somnolent and she is still confused.\n All in all, however, she is close to being able to go to resp rehab\n facility and we\nll talk to case manager tomorrow.\n , MD\n ------ Protected Section Addendum Entered By: , MD\n on: 17:10 ------\n"},{"category":"Respiratory ","chartdate":"2167-10-26 00:00:00.000","description":"Respiratory Care Shift Note","row_id":639607,"text":"Demographics\n Day of mechanical ventilation: 38\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Tube Type\n Tracheostomy tube:\n Type: Cuffed, Perc Trach\n Manufacturer: Portex\n Size: 7.0mm\n PMV: Yes\n Cuff Management:\n Vol/Press:\n Cuff pressure: 23 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Moderate\n Pt on 50% cool aerosol, SpO2 97-99%.\n"},{"category":"Social Work","chartdate":"2167-10-21 00:00:00.000","description":"Social Work Progress Note","row_id":638808,"text":"Social Work:\n Received phone message from pt\ns brother, (c: ),\n and called back to discuss his questions and concerns re pt\ns prolonged\n hospitalization. He is in on business at this time, but has\n been calling regularly to speak with MICU team for updates. He\ndefinitely\n plans on coming into the hospital next Thursday and Friday\n ( and ) and is also trying to come earlier on his way back\n from , perhaps this weekend. He will call to inform MICU team\n of whether this will be possible, and if it is, he hopes to be able to\n meet with pt\ns doctors at that time to discuss prognosis and plan of\n care. He also raises questions re whether it makes sense to pursue\n temporary guardianship for pt. SW discussed with MICU Attending, and\n further assessment of pt\ns medical condition and mental status is\n needed before a clear recommendation can be made. Of note, brother\n expresses his wish to become temporary guardian for pt, if necessary,\n and he expresses some concern about the possibility of pt\ns boyfriend\n taking this role.\n At this time, pt is unable to communicate clearly. SW met with her in\n MICU, and she presents as sitting up in a chair, awake and alert.\n While she is mouthing words, it is very difficult to discern what she\n is trying to say. SW provided her with paper and pen, and she tried to\n write with a loose grip, but her words are mostly incomprehensible in\n writing as well. She appears frustrated and agitated. SW attempted\n to offer emotional support, though it is unclear how much she\n understands.\n SW also called pt\ns boyfriend, (), to assess\n and support coping. He states he is doing well,\nin better spirits\n than when we last talked,\n as he reports he has been able to\nmake ends\n meat\n more easily than he had anticipated. He states he has gotten a\n 90 day reprieve on pt\ns car loan, has gotten an extension on her car\n insurance payments, and has managed to pay her other bills. He also\n raises the question of pursuing temporary guardianship, stating he has\n looked into this online and talked about it with friends and\n . states that he is\nnot in a rush\n to do this now, as he\n has been able to attend to pt\ns financial affairs as needed, but he\n wonders if it might be useful in the future if pt remains unable to\n communicate for herself. SW informed him that pt\ns brother has also\n raised this question and that team will be continuing to assess pt\n condition with this in mind. Of note, boyfriend states he still has\n not been able to visit pt in the hospital due to his own health\n problems (PVD, having surgery in a week and a half). He states he has\n been calling periodically to get updates from RN\ns re pt\ns care. SW\n put him in touch with MICU resident today for update.\n Plan:\n - SW will plan to discuss with legal department the question\n of pursuing temporary guardianship for pt.\n - Will remain available to both brother and boyfriend for\n continued emotional support and facilitation re team communication.\n Please page with any questions or concerns.\n , LCSW, #\n"},{"category":"Physician ","chartdate":"2167-10-22 00:00:00.000","description":"Physician Attending Progress Note","row_id":638991,"text":"Chief Complaint: resp failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n increased bblocker\n J tube placed by IR through PEG- restarted TF and vomiting\n Went for tube study - dysmotility - contrast sat in stomach\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Diazepam (Valium) - 02:24 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 12:17 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 35.6\nC (96.1\n HR: 118 (93 - 140) bpm\n BP: 153/58(79) {82/39(49) - 153/101(105)} mmHg\n RR: 23 (14 - 37) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 3,808 mL\n 1,119 mL\n PO:\n TF:\n 4 mL\n IVF:\n 3,804 mL\n 1,119 mL\n Blood products:\n Total out:\n 1,650 mL\n 520 mL\n Urine:\n 1,590 mL\n 520 mL\n NG:\n 60 mL\n Stool:\n Drains:\n Balance:\n 2,158 mL\n 599 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 243 (169 - 281) mL\n PS : 5 cmH2O\n RR (Spontaneous): 17\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 67\n PIP: 11 cmH2O\n SpO2: 99%\n ABG: ///33/\n Ve: 4.1 L/min\n Physical Examination\n Labs / Radiology\n 8.2 g/dL\n 356 K/uL\n 129 mg/dL\n 0.7 mg/dL\n 33 mEq/L\n 3.6 mEq/L\n 4 mg/dL\n 110 mEq/L\n 148 mEq/L\n 26.9 %\n 5.7 K/uL\n [image002.jpg]\n 06:22 AM\n 02:58 AM\n 03:43 AM\n 05:02 PM\n 03:36 AM\n 02:30 AM\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n WBC\n 7.0\n 7.1\n 7.1\n 6.9\n 7.6\n 9.5\n 5.7\n Hct\n 29.7\n 28.9\n 29.2\n 27.8\n 32.7\n 28.6\n 28.9\n 30.0\n 26.9\n Plt\n 395\n 462\n 452\n 467\n 548\n 528\n 356\n Cr\n 0.7\n 0.6\n 0.7\n 0.8\n 0.7\n 0.8\n 1.0\n 0.7\n Glucose\n 126\n 137\n 104\n 108\n 131\n 128\n 121\n 129\n Other labs: PT / PTT / INR:15.2/24.6/1.3, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.7 mg/dL, Mg++:2.1 mg/dL, PO4:4.1\n mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 04:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent:\n"},{"category":"Physician ","chartdate":"2167-10-23 00:00:00.000","description":"Physician Resident Progress Note","row_id":639210,"text":"Chief Complaint:\n 24 Hour Events:\n Pt pulled out her trach tube, tube replaced\n Seen By EP and started on Amiodarone Drip\n Fever - 101.4\nF Cultures sent\n Self-decanulated again this am during rounds, bradycardia down to\n 39-40, desated, tube was replaced and vitals normalized. Pt placed in\n 8-point restraints.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Amiodarone - 1 mg/min\n Other ICU medications:\n Metoprolol - 01:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.4\n Tcurrent: 36.9\nC (98.5\n HR: 107 (107 - 142) bpm\n BP: 86/44(54) {82/39(49) - 181/113(122)} mmHg\n RR: 22 (13 - 25) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,127 mL\n 537 mL\n PO:\n TF:\n IVF:\n 2,127 mL\n 537 mL\n Blood products:\n Total out:\n 995 mL\n 400 mL\n Urine:\n 995 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,132 mL\n 137 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Spontaneous): 208 (208 - 243) mL\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 0 cmH2O\n SpO2: 97%\n ABG: ///31/\n Ve: 4.1 L/min\n Physical Examination\n Gen: Awake and alert this am, following commands, mildly agitated,\n stated that she\n wanted to get out of here\n HEENT: PERRL, MMM\n Resp: Diffuse rhonchi and transmitted airway sounds.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, BS+\n Exte: No edema, DP 2+ bil\n NEURO: CNII\nXII intact, reflexes 2+ bilaterally.\n Labs / Radiology\n 346 K/uL\n 8.4 g/dL\n 123 mg/dL\n 0.7 mg/dL\n 31 mEq/L\n 3.8 mEq/L\n 4 mg/dL\n 107 mEq/L\n 144 mEq/L\n 27.3 %\n 7.3 K/uL\n [image002.jpg]\n 02:58 AM\n 03:43 AM\n 05:02 PM\n 03:36 AM\n 02:30 AM\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n 03:00 AM\n WBC\n 7.1\n 7.1\n 6.9\n 7.6\n 9.5\n 5.7\n 7.3\n Hct\n 28.9\n 29.2\n 27.8\n 32.7\n 28.6\n 28.9\n 30.0\n 26.9\n 27.3\n Plt\n 462\n 452\n 467\n 548\n 528\n 356\n 346\n Cr\n 0.6\n 0.7\n 0.8\n 0.7\n 0.8\n 1.0\n 0.7\n 0.7\n Glucose\n 137\n 104\n 108\n 131\n 128\n 121\n 129\n 123\n Other labs: PT / PTT / INR:14.1/23.7/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.8 mg/dL, Mg++:1.9 mg/dL, PO4:3.7\n mg/dL\n Assessment and Plan\n 55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach, PEG placement now with respiratory failure secondary to\n tracheomalacia , resolved HAP.\n .\n # Respiratory failure: Slowly improving, spending most of the day on\n trach mask with short periods of rest on PSV at night and setbacks\n from increased secretions to vomiting/aspiration events and her\n self-decanulations.\n - Continue to increase time on trach mask as tolerated.\n - Discontinue all orders for sedation except for Zyprexa QHS.\n - PMV with suctioning as tolerated\n # Nutrition/Vomiting: Normal CT-abdomen, had FT placed via peg into\n jejunum, but continued to vomit. Tube study yesterday showed\n dysmotility in small bowel, but no obstruction, no retrograde flow.\n Awaiting GI recs.\n - Hold TFs\n - GI consult, appreciate recs\n - PICC line placement for parenteral nutrition this am\n - Nutrition recs to start TPN today\n # HAP vs Aspiration PNA: Had been afebrile for last several days, now\n with new fever last night after having decanulated herself. Likely had\n some aspiration. Chemical pneumonitis versus new aspiration PNA.\n - CXR today\n - F/u cx data\n - If remains febrile, send sputum cx.\n .\n # Tachycardia: Pt in and out of SVT and sinus, increased BB seems to\n help, but pt does not stay in sinus. Cards rec to start Amiodarone IV\n drip, and then convert to PO, 200mg TID. Would consider EPS if\n amiodarone not successful, though would wait until pt more stable for\n GA.\n - Changed to IV metoprolol to 10mg IV q4hr during the day and 7.5mg q4\n hours at night.\n - Amiodarone 0.5mg/min IV drip x 18 hours.\n - Cards c/s, appreciate recs\n # Sedation/Anxiolysis/AlteredMS: unclear etiology of her confusion and\n agitation. Has had long hospital course and multiple psychotropic\n medications as well as hx of EtOH abuse.\n - Continue w Olanzapine QHS\n - d/c all benzos, d/c all opiates given GI dysmotlitiy\n - Psychiatry consulted, appreciate recs\n # Adrenal Insufficency: Endocrine following. Pt does not appear to be\n adrenally insufficient at baseline. Suggesting if the patient under\n goes major stressors such as major surgery, sepsis, she may need stress\n dosed steroids.\n .\n # Fluid Status: Likely approaching euvolemia, though still has mild\n hypernatramia which may suggest is still intravascularly depleated.\n - Monitoring urine output\n - will provide D5W IVF as need for hypernatremia and follow lytes\n # UE DVT and elevated INR: DVT in right UE has resolved, new\n non-occlusive in left axillary vein. INR had risen quickly on coumadin,\n likely to poor nutrition, resonded quickly to Vitamin K IV, but now\n subtherapeutic again. Kept subtherapeutic today for PICC line placement\n (for TPN), will restart w/ 2mg Coumadin after line placement.\n - Restart coumadin after PICC line placement today\n - Continue to follow INR closely to reach therapeutic INR.\n .\n #Hematemesis: Pt had small amt Hematemesis, after vomiting, 2 days ago.\n None today. HCT stable.\n -Will follow HCT.\n - Guaiac stools\n # Spine fracture: Stable\n - Brace for OOB, will discuss with Neurosurgery if current brace is\n optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n .\n # Tracheomalacia. Was initially addressed with IP and they wanted to\n follow up as outpatient. IP reevaluated and does not believe that a\n stent would be feasible.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # ACCESS: PIV x 1, PICC placement\n today.\n # Ppx: subtherapeutic INR restarting coumadin today, Ranitidine, Bowel\n Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n - Social Work and Case management involved, have discussed situation\n w/ brother and boyfriend.\n # Code: Full\n # Dispo: ICU, Screening for vent facilities\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 04:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2167-10-27 00:00:00.000","description":"Physician Resident Progress Note","row_id":639661,"text":"Chief Complaint:\n 24 Hour Events:\n -hypernatremia: Repeat Na 148-->146 (this am), continuing D5W at\n 125cc/hr\n -TF up to 30cc/hr; tolerated O/N\n -Per psych recs: Gave risperidone m-tab 1mg PO x1 HS and will continue\n risperdone 0.5mg qam and 0.5 PRN; gave scopolamine patch q72hrs;\n f/u EKG in am\n -Changed Metoprolol 25 to 37.5mg TID; gave 5mg x1\n -GI recs: pending\n -S&S re-eval: for Passy Muir valve eval;\n -Call case management \n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:30 AM\n Enoxaparin (Lovenox) - 06:48 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.7\nC (98.1\n HR: 79 (68 - 124) bpm\n BP: 134/57(75) {124/52(70) - 179/121(130)} mmHg\n RR: 27 (18 - 31) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 4,004 mL\n 1,084 mL\n PO:\n TF:\n 137 mL\n 51 mL\n IVF:\n 2,544 mL\n 729 mL\n Blood products:\n Total out:\n 3,813 mL\n 1,000 mL\n Urine:\n 3,813 mL\n 1,000 mL\n NG:\n Stool:\n Drains:\n Balance:\n 191 mL\n 84 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 99%\n ABG: ///33/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 231 K/uL\n 7.7 g/dL\n 145 mg/dL\n 0.4 mg/dL\n 33 mEq/L\n 3.5 mEq/L\n 11 mg/dL\n 109 mEq/L\n 146 mEq/L\n 25.3 %\n 5.7 K/uL\n [image002.jpg]\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n 03:00 AM\n 04:00 AM\n 05:45 AM\n 03:51 AM\n 04:45 PM\n 04:00 AM\n WBC\n 9.5\n 5.7\n 7.3\n 8.0\n 8.7\n 5.5\n 5.7\n Hct\n 28.6\n 28.9\n 30.0\n 26.9\n 27.3\n 27.0\n 28.7\n 24.7\n 25.2\n 25.3\n Plt\n 528\n 356\n 346\n \n 231\n Cr\n 1.0\n 0.7\n 0.7\n 0.7\n 0.7\n 0.5\n 0.4\n Glucose\n 121\n 129\n 123\n 114\n 112\n 122\n 145\n Other labs: PT / PTT / INR:13.6/31.1/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.6 mg/dL, Mg++:2.0 mg/dL, PO4:3.6\n mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n TPN without Lipids - 05:44 PM 43. mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n PICC Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2167-10-27 00:00:00.000","description":"Physician Resident Progress Note","row_id":639662,"text":"Chief Complaint:\n 24 Hour Events:\n -hypernatremia: Repeat Na 148-->146 (this am), continuing D5W at\n 125cc/hr\n -TF up to 30cc/hr; tolerated O/N\n -Per psych recs: Gave risperidone m-tab 1mg PO x1 HS and will continue\n risperdone 0.5mg qam and 0.5 PRN; gave scopolamine patch q72hrs;\n f/u EKG in am\n -Changed Metoprolol 25 to 37.5mg TID; gave 5mg x1\n -GI recs: pending\n -S&S re-eval: for Passy Muir valve eval;\n -Call case management \n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:30 AM\n Enoxaparin (Lovenox) - 06:48 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.7\nC (98.1\n HR: 79 (68 - 124) bpm\n BP: 134/57(75) {124/52(70) - 179/121(130)} mmHg\n RR: 27 (18 - 31) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 4,004 mL\n 1,084 mL\n PO:\n TF:\n 137 mL\n 51 mL\n IVF:\n 2,544 mL\n 729 mL\n Blood products:\n Total out:\n 3,813 mL\n 1,000 mL\n Urine:\n 3,813 mL\n 1,000 mL\n NG:\n Stool:\n Drains:\n Balance:\n 191 mL\n 84 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 99%\n ABG: ///33/\n Physical Examination\n Gen: Awake, Mouthing words, More agitated compared to previous\n mornings.\n HEENT: EOMI, No pallor in conjunctiva, MMM\n Resp: CTAB, no rales, rhonchi, or wheezing, good airway movement.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, decreased bowel sounds,, G-Tube in\n place with no erythema/induration\n Exte: No edema, DP 2+ bil\n NEURO: Gross Motor and Sensation in 4 extremities\n Labs / Radiology\n 231 K/uL\n 7.7 g/dL\n 145 mg/dL\n 0.4 mg/dL\n 33 mEq/L\n 3.5 mEq/L\n 11 mg/dL\n 109 mEq/L\n 146 mEq/L\n 25.3 %\n 5.7 K/uL\n [image002.jpg]\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n 03:00 AM\n 04:00 AM\n 05:45 AM\n 03:51 AM\n 04:45 PM\n 04:00 AM\n WBC\n 9.5\n 5.7\n 7.3\n 8.0\n 8.7\n 5.5\n 5.7\n Hct\n 28.6\n 28.9\n 30.0\n 26.9\n 27.3\n 27.0\n 28.7\n 24.7\n 25.2\n 25.3\n Plt\n 528\n 356\n 346\n \n 231\n Cr\n 1.0\n 0.7\n 0.7\n 0.7\n 0.7\n 0.5\n 0.4\n Glucose\n 121\n 129\n 123\n 114\n 112\n 122\n 145\n Other labs: PT / PTT / INR:13.6/31.1/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.6 mg/dL, Mg++:2.0 mg/dL, PO4:3.6\n mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n TPN without Lipids - 05:44 PM 43. mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n PICC Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2167-10-27 00:00:00.000","description":"Physician Resident Progress Note","row_id":639663,"text":"Chief Complaint:\n 24 Hour Events:\n -hypernatremia: Repeat Na 148-->146 (this am), continuing D5W at\n 125cc/hr\n -TF up to 30cc/hr; tolerated O/N\n -Per psych recs: Gave risperidone m-tab 1mg PO x1 HS and will continue\n risperdone 0.5mg qam and 0.5 PRN; gave scopolamine patch q72hrs;\n f/u EKG in am\n -Changed Metoprolol 25 to 37.5mg TID; gave 5mg x1\n -GI recs: pending\n -S&S re-eval: for Passy Muir valve eval;\n -Call case management \n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:30 AM\n Enoxaparin (Lovenox) - 06:48 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.7\nC (98.1\n HR: 79 (68 - 124) bpm\n BP: 134/57(75) {124/52(70) - 179/121(130)} mmHg\n RR: 27 (18 - 31) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 4,004 mL\n 1,084 mL\n PO:\n TF:\n 137 mL\n 51 mL\n IVF:\n 2,544 mL\n 729 mL\n Blood products:\n Total out:\n 3,813 mL\n 1,000 mL\n Urine:\n 3,813 mL\n 1,000 mL\n NG:\n Stool:\n Drains:\n Balance:\n 191 mL\n 84 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 99%\n ABG: ///33/\n Physical Examination\n Gen: Awake, Mouthing words, More agitated compared to previous\n mornings.\n HEENT: EOMI, No pallor in conjunctiva, MMM\n Resp: CTAB, no rales, rhonchi, or wheezing, good airway movement.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, decreased bowel sounds,, G-Tube in\n place with no erythema/induration\n Exte: No edema, DP 2+ bil\n NEURO: Gross Motor and Sensation in 4 extremities\n Labs / Radiology\n 231 K/uL\n 7.7 g/dL\n 145 mg/dL\n 0.4 mg/dL\n 33 mEq/L\n 3.5 mEq/L\n 11 mg/dL\n 109 mEq/L\n 146 mEq/L\n 25.3 %\n 5.7 K/uL\n [image002.jpg]\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n 03:00 AM\n 04:00 AM\n 05:45 AM\n 03:51 AM\n 04:45 PM\n 04:00 AM\n WBC\n 9.5\n 5.7\n 7.3\n 8.0\n 8.7\n 5.5\n 5.7\n Hct\n 28.6\n 28.9\n 30.0\n 26.9\n 27.3\n 27.0\n 28.7\n 24.7\n 25.2\n 25.3\n Plt\n 528\n 356\n 346\n \n 231\n Cr\n 1.0\n 0.7\n 0.7\n 0.7\n 0.7\n 0.5\n 0.4\n Glucose\n 121\n 129\n 123\n 114\n 112\n 122\n 145\n Other labs: PT / PTT / INR:13.6/31.1/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.6 mg/dL, Mg++:2.0 mg/dL, PO4:3.6\n mg/dL\n Assessment and Plan\n 56yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach/PEG with resolving respiratory failure and HAP.\n .\n # Respiratory failure: s/p intubation/extubation, now on trach mask,\n FiO2 70%. Tolerating well with good O2 sat. No further\n self-decanulations overnight.\n - Tach mask as tolerated.\n - Holding sedation with exception of Risperidal 0.5mg .\n - F/u CXR tomorrow\n .\n # Nutrition/Vomiting: Currently receiving TPN;. One large BM in past\n 24 hrs to indicate potential improvement in ileus.\n - Cont Reglan 20mg IV Q 8 hours; meds via G-J tube,\n - Will obtain recommendations from Nutrition re TPN before starting TPN\n tomorrow\n - TF as tolerated\n - Speech and Swallow eval\n - PICC line in place with TPN given when pt not tolerating TF\n - GI consult, appreciate recs\n .\n # Tachycardia: Improved HR max of 120\ns versus 160s previously;\n elevated this am secondary to agitation. Pt now on PO Amiodarone 200\n TID and PO metoprolol 25mg TID\n - Continue current med regimen. Will continue amiodarone 200 TID for\n three weeks and then switch to qday.\n - Will schedule f/u in 4wks with Dr. upon d/c/transfer.\n - f/u Cards recs\n # Sedation/Anxiolysis/AlteredMS: Agitation O/N, continues to be\n agitated most likely secondary to long hospital course and multiple\n psychotropic medications as well as hx of EtOH abuse. Risperdal given\n O/N.\n - started Risperdal 0.5mg PO BID\n - continue to hold all benzos. opiates, and antihistamines\n - Appreciate psych. Will call and f/u psych recs.\n #Anemia: Decrease in HCT from 28\n24; tachycardia. No known etiology of\n blood loss, most likely related to variaton\n -Will repeat HCT check this afternoon.\n # Hypernatremia/Fluid Status: Mild hypernatramia with good UOP\n (hypervolemic hypernatremia). On TPN/TF.\n - providing D5W IVF, free water flushes with TF\n -Will f/u lytes (Na) this afternoon at 5pm.\n # UE DVT and elevated INR: Decision made to d/c Coumadin given her\n labile INR, and start Lovenox . Current INR 1.2.\n - Will flush L PICC with TPA if does not flush\n .\n # Spine fracture: Stable\n - Brace for OOB, need to discuss with Neurosurgery before d/c if\n current brace is optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n .\n # Tracheomalacia. Was initially addressed with IP and they wanted to\n follow up as outpatient. IP reevaluated and does not believe that a\n stent would be feasible. No new issues.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # ACCESS: PIV x 1, L PICC\n # Ppx: Lovenox, PPi, Bowel Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n - Social Work and Case management involved, have discussed situation\n w/ brother and boyfriend.\n # Code: Full\n # Dispo: ICU, Will d/w case management re rehab facilities.\n ICU Care\n Nutrition:\n TPN without Lipids - 05:44 PM 43. mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n PICC Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2167-10-20 00:00:00.000","description":"Physician Resident Progress Note","row_id":638634,"text":"Chief Complaint:\n 24 Hour Events:\n CARDIOVERSION/DEFIBRILLATION - At 11:50 AM\n aqdenosine 6mg given X 1 by cardiologist to assess pt's rhythm. Pt\n tolerated well, transiently converted.\n Valium, Benadryl held overnight which pt tolerated.\n Emesis again this am so TF held.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:24 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36\nC (96.8\n HR: 114 (85 - 144) bpm\n BP: 111/59(69) {84/42(0) - 154/134(138)} mmHg\n RR: 12 (12 - 36) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,945 mL\n 274 mL\n PO:\n TF:\n IVF:\n 1,800 mL\n 154 mL\n Blood products:\n Total out:\n 2,300 mL\n 500 mL\n Urine:\n 2,245 mL\n 500 mL\n NG:\n 55 mL\n Stool:\n Drains:\n Balance:\n -355 mL\n -226 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: MMV/PSV/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 319 (319 - 319) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 15\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 15 cmH2O\n SpO2: 100%\n ABG: ///36/\n Ve: 5.5 L/min\n Physical Examination\n Gen: Obtunded this am, not responsive to voice, minimally responsive to\n noxious stimuli, on MMV through trach tube, but later responsive to\n voice, appropriate, asking questions, mouthing responses\n HEENT: PERRL, MMM,\n Resp: Coarse BS anteriorly, no focal rales, rhonchi, or wheezing with\n some referred upper airway noises from secretions.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, hypoactive BS\n Exte: No edema, DP 2+ bil.\n NEURO: Toes downgoing bilaterally,\n Labs / Radiology\n 548 K/uL\n 10.0 g/dL\n 128 mg/dL\n 0.8 mg/dL\n 36 mEq/L\n 4.1 mEq/L\n 6 mg/dL\n 105 mEq/L\n 148 mEq/L\n 32.7 %\n 7.6 K/uL\n [image002.jpg]\n , 10/2 blood cx NGTD\n 05:00 AM\n 02:06 AM\n 07:34 AM\n 03:50 AM\n 06:22 AM\n 02:58 AM\n 03:43 AM\n 05:02 PM\n 03:36 AM\n 02:30 AM\n WBC\n 5.9\n 7.5\n 5.6\n 6.1\n 7.0\n 7.1\n 7.1\n 6.9\n 7.6\n Hct\n 27.2\n 26.8\n 27.0\n 27.0\n 29.7\n 28.9\n 29.2\n 27.8\n 32.7\n Plt\n 296\n 306\n 335\n \n 452\n 467\n 548\n Cr\n 0.7\n 0.6\n 0.5\n 0.7\n 0.7\n 0.6\n 0.7\n 0.8\n 0.7\n 0.8\n Glucose\n 134\n 134\n 121\n \n 104\n 108\n 131\n 128\n Other labs: PT / PTT / INR:48.3/33.3/5.5, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:10.0 mg/dL, Mg++:2.5 mg/dL,\n PO4:4.3 mg/dL\n Assessment and Plan\n 55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach, PEG placement now with respiratory failure secondary to\n tracheomalacia , resolved HAP.\n .\n # Respiratory failure: Slowly Improving. Now remaining on trach mask\n for most of the day, with periods of pressure support of over\n night. This am on MMV. Previously likely oversedated with Benadryl,\n Morhpine, and Valium which were held overnight. Pt awake and alert at\n rounds, interactive, and breathing comfortably on trach mask\n - Continue to increase time on trach mask as tolerated.\n - Decrease sedation and valium use\n - PMV with suctioning\n .\n # HAP vs Aspiration PNA: Afebrile without leukocytosis\n - Completed course of ceftriaxone\n - good O2 saturation on trach mask\n - Continue to f/u cultures\n .\n # Tachycardia: Previously was assessed as sinus tach with occasional\n runs of SVT and sources such as hypovolemia, PE, infection, and pain\n were assessed as possibly etiologies. Per Cardiology, most likely AT\n given transient response to Adenosine. HR occasionally decreases to\n 70s-80s w/ stable BPs at times that might be associated with\n administration of her BB and valium. Cards recommended titating up her\n beta blocker as tolerated. Dose increased to 37.5 yesterday but still\n tachycardic.\n - EP consulted for conversion of SVT, appreciate recs\n - Increase metoprolol to 50 PO QID with holding parameters\n .\n # Sedation: Inconsistent response to sedation, unclear what is best\n regime. Will continue to wean overall.\n - Continue w Olanzapine QHS\n - Just valium 2.5 mg PRN.\n # Nutrition/Vomiting: Pt has had several episodes of vomiting up her\n TFs, reglan started to increase GI motility, but pt had another episode\n of vomiting this am, not improved with zofran or reglan. Pateint also\n had hypoactive BS on exam, concern for obstruction given persistent\n vomiting, inability to tolerate tube feeds.\n - Hold TFs\n - Thoracic surgery recs: 1) oral/nasal tube in post-piloric position,\n or 2) IR to place a pediatric feeding tube through her PEG site to a\n post-piloric position.\n - Will attempt to coordinate thoracic surgery and IR for tube placement\n ; will d/w thoracics. IR will not do further intervention due to disk\n on G tube\n - CT scan to evaluate for obstruction, etiology of persistent emesis,\n consider tube study as well\n .\n # Adrenal Insufficency: Endocrine following. Pt does not appear to be\n adrenally insufficient at baseline. Suggesting if the patient under\n goes major stressors such as major surgery, sepsis, she may need stress\n dosed steroids.\n .\n # Fluid Status: Likely approaching euvolemia, though still has mild\n hypernatramia which may suggest is still intravascularly depleated.\n - Monitoring urine output\n - FW flushes w/ tube feeds held due to vomitting\n - will provide D5W IVF as need for hypernatremia and follow lytes\n .\n # UE DVT and elevated INR: DVT in right UE has resolved, new\n non-occlusive in left axillary vein. INR supratherapeutic today and\n trending upward. INR most likely continuing to rise nutritional\n deficiencies given lack of PO intake\n - Cumadin held, will restart at low dose when INR approaches\n therapeutic range.\n - INR 5.5 today, will check PM coags and follow\n .\n # Spine fracture: Stable\n - Brace for OOB, will discuss with Neurosurgery if current brace is\n optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n .\n # Tracheomalacia. Was initially addressed with IP and they wanted to\n follow up as outpatient. IP reevaluated and does not believe that a\n stent would be feasible.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # PIV x 1\n # Ppx: supratherapeutic INR, Ranitidine, Bowel Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n - Will contact Social and Case management today\n # Code: Full\n # Dispo: ICU, Screening for vent facilities\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2167-10-21 00:00:00.000","description":"Physician Attending Progress Note","row_id":638760,"text":"Chief Complaint: resp failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n rising INR to 10.5\n small volume hemetemesis\n abd CT\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:30 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.9\nC (98.4\n HR: 114 (88 - 136) bpm\n BP: 120/65(80) {80/40(49) - 149/88(92)} mmHg\n RR: 11 (11 - 33) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,241 mL\n 1,802 mL\n PO:\n TF:\n IVF:\n 1,941 mL\n 1,802 mL\n Blood products:\n Total out:\n 1,860 mL\n 260 mL\n Urine:\n 1,830 mL\n 210 mL\n NG:\n 30 mL\n 50 mL\n Stool:\n Drains:\n Balance:\n 381 mL\n 1,542 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 438 (300 - 1,054) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 13\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 16 cmH2O\n Plateau: 15 cmH2O\n SpO2: 100%\n ABG: ///35/\n Ve: 5.4 L/min\n Physical Examination\n Gen\n HEENt\n CV\n Chest\n Abd\n Ext\n Labs / Radiology\n 9.2 g/dL\n 528 K/uL\n 121 mg/dL\n 1.0 mg/dL\n 35 mEq/L\n 3.4 mEq/L\n 6 mg/dL\n 103 mEq/L\n 144 mEq/L\n 28.9 %\n 9.5 K/uL\n [image002.jpg]\n 07:34 AM\n 03:50 AM\n 06:22 AM\n 02:58 AM\n 03:43 AM\n 05:02 PM\n 03:36 AM\n 02:30 AM\n 01:30 AM\n 06:41 AM\n WBC\n 5.6\n 6.1\n 7.0\n 7.1\n 7.1\n 6.9\n 7.6\n 9.5\n Hct\n 27.0\n 27.0\n 29.7\n 28.9\n 29.2\n 27.8\n 32.7\n 28.6\n 28.9\n Plt\n 335\n 321\n 395\n 462\n 452\n 467\n 548\n 528\n Cr\n 0.5\n 0.7\n 0.7\n 0.6\n 0.7\n 0.8\n 0.7\n 0.8\n 1.0\n Glucose\n 121\n 619\n 126\n 137\n 104\n 108\n 131\n 128\n 121\n Other labs: PT / PTT / INR:82.1/35.9/10.5, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:9.7 mg/dL, Mg++:2.4 mg/dL, PO4:2.9\n mg/dL\n Assessment and Plan\n 1. Tachycardia: runs of attach Appreciate EP consult\n will increase\n bblocker. Have to convert to metoprolol 5mg IV Q4.\n 2. Persistent Nausea/Vomiting: we have ruled out\n pSBO/SBO, very poor\n bowel sounds, get emptying study and if unrevealing consult GI to\n discuss EGD. We will need to pursue NG dophoff by IR\n 2. Resp Failure\n Trach mask trials all day, PSV\n PMV trials\n S/P rx for pan Klebs PNA.\n Per IP not stent planned as technically not possible to\n place into her airway\n 3. DVT and coagulopathy: revsre with IV VIt K today, then maintain\n daily SC Vit K until Inr less than 2\n 4. Hypernatremia Replete free water.\n Please see today\ns ICU team note for other issues.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 04:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n Communication: with pt and spoke at length with brother who would like\n to possibily become her guardian or power of atty to facilitate her\n care and finances\n Code status: Full code\n Disposition : ICU\n"},{"category":"Physician ","chartdate":"2167-10-21 00:00:00.000","description":"Physician Resident Progress Note","row_id":638800,"text":"Chief Complaint:\n 24 Hour Events:\n Multiple vomitting episodes, not improved much w/ zofran.\n Unable to tolerate anything through her PEG\n Had an Abdominal CT w/contrast, but vomitted up most of the constrast.\n limited study. Prelim read: no obstruction, PEG in place\n Nurse positive coffe-grounds emesis and w/ a later\n episode, clear emesis with some small blood when she suctioned the\n posterior pharynx. HCT stable\n TFs were held\n Dr. had a conversation with the pt\ns brother.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.7\nC (98\n HR: 110 (76 - 136) bpm\n BP: 98/63(60) {80/40(49) - 149/88(92)} mmHg\n RR: 12 (12 - 33) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,241 mL\n 1,335 mL\n PO:\n TF:\n IVF:\n 1,941 mL\n 1,335 mL\n Blood products:\n Total out:\n 1,860 mL\n 140 mL\n Urine:\n 1,830 mL\n 90 mL\n NG:\n 30 mL\n 50 mL\n Stool:\n Drains:\n Balance:\n 381 mL\n 1,195 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: MMV/PSV/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 809 (300 - 1,054) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 21 cmH2O\n Plateau: 15 cmH2O\n SpO2: 100%\n ABG: ///35/\n Ve: 5.8 L/min\n Physical Examination\n Gen: Mildly obtunded in am, responsive to noxious stimuli, on MMV\n through trach tube, but later in am responsive to voice, appropriate,\n asking questions,\n HEENT: PERRL, MMM\n Resp: Coarse BS anteriorly, no focal rales, rhonchi, or wheezing with\n some referred upper airway noises from secretions.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, hypoactive BS\n Exte: No edema, DP 2+ bil.\n NEURO: Toes downgoing bilaterally,\n Labs / Radiology\n 528 K/uL\n 9.2 g/dL\n 121 mg/dL\n 1.0 mg/dL\n 35 mEq/L\n 3.4 mEq/L\n 6 mg/dL\n 103 mEq/L\n 146 mEq/L\n 28.6 %\n 9.5 K/uL\n [image002.jpg]\n CT: No evidence of obstruction or acute intraabdominal process\n 02:06 AM\n 07:34 AM\n 03:50 AM\n 06:22 AM\n 02:58 AM\n 03:43 AM\n 05:02 PM\n 03:36 AM\n 02:30 AM\n 01:30 AM\n WBC\n 7.5\n 5.6\n 6.1\n 7.0\n 7.1\n 7.1\n 6.9\n 7.6\n 9.5\n Hct\n 26.8\n 27.0\n 27.0\n 29.7\n 28.9\n 29.2\n 27.8\n 32.7\n 28.6\n Plt\n 95\n 462\n 452\n 467\n 548\n 528\n Cr\n 0.6\n 0.5\n 0.7\n 0.7\n 0.6\n 0.7\n 0.8\n 0.7\n 0.8\n 1.0\n Glucose\n 134\n 121\n 619\n 126\n 137\n 104\n 108\n 131\n 128\n 121\n Other labs: PT / PTT / INR:82.1/35.9/10.5, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:9.7 mg/dL, Mg++:2.4 mg/dL, PO4:2.9\n mg/dL\n Assessment and Plan\n 55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach, PEG placement now with respiratory failure secondary to\n tracheomalacia , resolved HAP.\n .\n # Respiratory failure: Slowly Improving. Intermittently on trach mask\n for most of the day, with periods of pressure support of over\n night. This am on MMV. Previously likely oversedated but Benadryl,\n Morhpine, and Valium held now. Pt awake and alert at rounds,\n interactive, and breathing comfortably on trach mask\n - Continue to increase time on trach mask as tolerated.\n - Decrease sedation and valium use\n - PMV with suctioning\n .\n # HAP vs Aspiration PNA: Afebrile without leukocytosis\n - Completed course of ceftriaxone\n - good O2 saturation on trach mask\n .\n # Tachycardia: Previously was assessed as sinus tach with occasional\n runs of SVT and sources such as hypovolemia, PE, infection, and pain\n were assessed as possibly etiologies. Per Cardiology, most likely AT\n given transient response to Adenosine. HR occasionally decreases to\n 70s-80s w/ stable BPs at times that might be associated with\n administration of her BB and valium. Cards recommended titrating up her\n beta blocker as tolerated. Dose increased to 50 yesterday and\n intermittently responded but then had to hold PO meds given need to\n hold PO. Changed PO to IV lopressor.\n - EP consulted for SVT, appreciate recs, will change metoprololt o IV\n and hopefully will be able to restart PO meds soon once able to\n tolerate\n - IV metoprolol 5 mg IV q 4\n .\n # Sedation: Inconsistent response to sedation, unclear what is best\n regime. Will continue to wean overall.\n - Continue w Olanzapine QHS\n - Just valium 2.5 mg PRN.\n # Nutrition/Vomiting: Pt has had several episodes of vomiting up her\n TFs, reglan started to increase GI motility, but pt had another episode\n of vomiting this am, not improved with zofran or reglan. Patient also\n had hypoactive BS on exam, concern for obstruction given persistent\n vomiting, inability to tolerate tube feeds.\n - Hold TFs\n - Thoracic surgery recs: 1) oral/nasal tube in post-piloric position,\n or 2) IR to place a pediatric feeding tube through her PEG site to a\n post-piloric position.\n - Will attempt to coordinate thoracic surgery and IR for tube placement\n ; will d/w thoracics\n - CT scan did not reveal evidence of obstruction. Attempted to\n coordinate tube study or UGI btu per Radiology would not be useful\n studies since no obstruction or dysmotility evident on CT\n - Reglan DCd since not helping\n - Will decrease narcotics for possible cause of decreased motility\n .\n # Adrenal Insufficency: Endocrine following. Pt does not appear to be\n adrenally insufficient at baseline. Suggesting if the patient under\n goes major stressors such as major surgery, sepsis, she may need stress\n dosed steroids.\n .\n # Fluid Status: Likely approaching euvolemia, though still has mild\n hypernatramia which may suggest is still intravascularly depleated.\n - Monitoring urine output\n - will provide D5W IVF as need for hypernatremia and follow lytes\n .\n # UE DVT and elevated INR: DVT in right UE has resolved, new\n non-occlusive in left axillary vein. INR supratherapeutic today and\n trending upward. INR most likely continuing to rise nutritional\n deficiencies given continued lack of PO intake\n - Cumadin stopped.\n - INR 10.5 today, up from 5.5, will give Vitamin K IV and reassess will\n check PM coags and follow\n - vitamin K IV x 1. Will likely need to continue with SC, follow coags\n .\n #Hematemesis: Pt had small amt Hematemesis this am. Concerning in\n setting of elevated INR. Will give IV Vitamin K and may need continued\n dosing\n - Vit K IV x 1\n -\n # Spine fracture: Stable\n - Brace for OOB, will discuss with Neurosurgery if current brace is\n optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n .\n # Tracheomalacia. Was initially addressed with IP and they wanted to\n follow up as outpatient. IP reevaluated and does not believe that a\n stent would be feasible.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # PIV x 1\n # Ppx: supratherapeutic INR, Ranitidine, Bowel Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n - Will contact Social and Case management today\n # Code: Full\n # Dispo: ICU, Screening for vent facilities\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 04:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Nursing","chartdate":"2167-10-22 00:00:00.000","description":"Nursing Progress Note","row_id":638870,"text":"Nausea / vomiting\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Hypernatremia (high sodium)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2167-10-22 00:00:00.000","description":"Nursing Progress Note","row_id":639078,"text":"56 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\n with prolonged hospital course c/b by PNA, anxiety/altered mental\n status, R&LUE DVT .Pt found to have small non occlusive Clot on her\n right axial vein via Ultrasound.Yesterday. She has had problems with\n vomiting tube feedings, feeding tube passed through g-tube (g-tube in\n place with mushroom on inside so cannot pull out) to her jejunenum but\n continues vomit.\n Tachycardia, Other\n Assessment:\n HR better but still 110-130. Receiving 7.5mg lopressor IV Q4h\n Action:\n Heart rate better on lopressor. Lopressor increased to 10mg IV Q4h.\n Response:\n HR still up but is due to her agitation .\n Plan:\n Continue to monitor B/P and HR, do not hold lopressor but decrease the\n dose (ask HO)\n Assessment:\n Pt had tube studies today, contrast injected into feeding tube, it\n went into her jejuneum and went no furtere. Pt has had 2 xrayes to\n see if it has advanced at all.\n Action:\n Pt has been restarted on raglan, narcotics and other meds that slow GI\n motility have been D/C\n Response:\n Pt has not had a stool .\n Plan:\n Continue to monitor for movement of of monelity\n Altered mental status (not Delirium)\n Assessment:\n Pt was OOB to the chair most of the day and has been on the trach mask\n since 9am. She had the passey-muir valve place. She was pleasantly\n confused and stated that she is not in any pain. She stated that she\n was in Boson and in , and was not making any sense most of the\n time. She has no short term memory so needs constant reinforcement to\n stay safe. At 1550 she was found to have pulled out her trach tube and\n pulled apart her trach .\n Action:\n A new trach tube was placed, she is restrained so that she cannot pull\n anything.\n Response:\n She is able to move and all tubes, wires and catheters are out of her\n reach, under sheets and out of sight. She remains restraint so she\n cannot harm herself.\n Plan:\n Hypernatremia (high sodium)\n Assessment:\n Na down to 146, K+ 4.3.\n Action:\n IV D5w with 20meq Kcl at 100cc/hr stopped and D5W started at 75cc/hr\n Response:\n Na down, K+ better\n Plan:\n Continue to monitor.\n"},{"category":"Nursing","chartdate":"2167-10-22 00:00:00.000","description":"Nursing Progress Note","row_id":639079,"text":"56 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\n with prolonged hospital course c/b by PNA, anxiety/altered mental\n status, R&LUE DVT .Pt found to have small non occlusive Clot on her\n right axial vein via Ultrasound.Yesterday. She has had problems with\n vomiting tube feedings, feeding tube passed through g-tube (g-tube in\n place with mushroom on inside so cannot pull out) to her jejunenum but\n continues vomit.\n Tachycardia, Other\n Assessment:\n HR better but still 110-130. Receiving 7.5mg lopressor IV Q4h\n Action:\n Heart rate better on lopressor. Lopressor increased to 10mg IV Q4h.\n Response:\n HR still up but is due to her agitation .\n Plan:\n Continue to monitor B/P and HR, do not hold lopressor but decrease the\n dose (ask HO)\n Assessment:\n Pt had tube studies today, contrast injected into feeding tube, it\n went into her jejuneum and went no furtere. Pt has had 2 xrayes to\n see if it has advanced at all.\n Action:\n Pt has been restarted on raglan, narcotics and other meds that slow GI\n motility have been D/C\n Response:\n Pt has not had a stool .\n Plan:\n Continue to monitor for movement of of monelity\n Altered mental status (not Delirium)\n Assessment:\n Pt was OOB to the chair most of the day and has been on the trach mask\n since 9am. She had the passey-muir valve place. She was pleasantly\n confused and stated that she is not in any pain. She stated that she\n was in Boson and in , and was not making any sense most of the\n time. She has no short term memory so needs constant reinforcement to\n stay safe. At 1550 she was found to have pulled out her trach tube and\n pulled apart her trach .\n Action:\n A new trach tube was placed, she is restrained so that she cannot pull\n anything.\n Response:\n She is able to move and all tubes, wires and catheters are out of her\n reach, under sheets and out of sight. She remains restraint so she\n cannot harm herself.\n Plan:\n Hypernatremia (high sodium)\n Assessment:\n Na down to 146, K+ 4.3.\n Action:\n IV D5w with 20meq Kcl at 100cc/hr stopped and D5W started at 75cc/hr\n Response:\n Na down, K+ better\n Plan:\n Continue to monitor.\n"},{"category":"Physician ","chartdate":"2167-10-23 00:00:00.000","description":"Physician Attending Progress Note","row_id":639168,"text":"Chief Complaint: resp failure\n HPI:\n 24 Hour Events:\n UNPLANNED EXTUBATION (PATIENT-INITIATED) - At 03:50 PM\n Pt pulled out her trach tube, tube replaced\n FEVER - 101.4\nF - 12:00 AM\n 7 AM pulled out trach again , bradycardia, replaced.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Amiodarone - 0.5 mg/min\n Other ICU medications:\n Metoprolol - 01:00 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fever\n Flowsheet Data as of 10:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.4\n Tcurrent: 36.8\nC (98.2\n HR: 116 (84 - 142) bpm\n BP: 147/84(96) {86/39(53) - 181/113(137)} mmHg\n RR: 23 (13 - 27) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,127 mL\n 988 mL\n PO:\n TF:\n IVF:\n 2,127 mL\n 988 mL\n Blood products:\n Total out:\n 995 mL\n 900 mL\n Urine:\n 995 mL\n 900 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,132 mL\n 88 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: CPAP/PPS\n Vt (Set): 0 (0 - 0) mL\n Vt (Spontaneous): 360 (208 - 360) mL\n PS : 10 cmH2O\n RR (Set): 0\n RR (Spontaneous): 21\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 0 cmH2O\n SpO2: 99%\n ABG: ///31/\n Physical Examination\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, g tube\n Skin: warm\n Neurologic: Responds to voice\n Labs / Radiology\n 8.4 g/dL\n 346 K/uL\n 123 mg/dL\n 0.7 mg/dL\n 31 mEq/L\n 3.8 mEq/L\n 4 mg/dL\n 107 mEq/L\n 144 mEq/L\n 27.3 %\n 7.3 K/uL\n [image002.jpg]\n 02:58 AM\n 03:43 AM\n 05:02 PM\n 03:36 AM\n 02:30 AM\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n 03:00 AM\n WBC\n 7.1\n 7.1\n 6.9\n 7.6\n 9.5\n 5.7\n 7.3\n Hct\n 28.9\n 29.2\n 27.8\n 32.7\n 28.6\n 28.9\n 30.0\n 26.9\n 27.3\n Plt\n 462\n 452\n 467\n 548\n 528\n 356\n 346\n Cr\n 0.6\n 0.7\n 0.8\n 0.7\n 0.8\n 1.0\n 0.7\n 0.7\n Glucose\n 137\n 104\n 108\n 131\n 128\n 121\n 129\n 123\n Other labs: PT / PTT / INR:14.1/23.7/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.8 mg/dL, Mg++:1.9 mg/dL, PO4:3.7\n mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 06:31 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 40 minutes\n"},{"category":"Physician ","chartdate":"2167-10-23 00:00:00.000","description":"Physician Attending Progress Note","row_id":639170,"text":"Chief Complaint: resp failure\n HPI:\n 24 Hour Events:\n UNPLANNED EXTUBATION (PATIENT-INITIATED) - At 03:50 PM\n Pt pulled out her trach tube, tube replaced\n FEVER - 101.4\nF - 12:00 AM\n 7 AM pulled out trach again , bradycardia, replaced.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Amiodarone - 0.5 mg/min\n Other ICU medications:\n Metoprolol - 01:00 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fever\n Flowsheet Data as of 10:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.4\n Tcurrent: 36.8\nC (98.2\n HR: 116 (84 - 142) bpm\n BP: 147/84(96) {86/39(53) - 181/113(137)} mmHg\n RR: 23 (13 - 27) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,127 mL\n 988 mL\n PO:\n TF:\n IVF:\n 2,127 mL\n 988 mL\n Blood products:\n Total out:\n 995 mL\n 900 mL\n Urine:\n 995 mL\n 900 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,132 mL\n 88 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: CPAP/PPS\n Vt (Set): 0 (0 - 0) mL\n Vt (Spontaneous): 360 (208 - 360) mL\n PS : 10 cmH2O\n RR (Set): 0\n RR (Spontaneous): 21\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 0 cmH2O\n SpO2: 99%\n ABG: ///31/\n Physical Examination\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, g tube\n Skin: warm\n Neurologic: Responds to voice\n Labs / Radiology\n 8.4 g/dL\n 346 K/uL\n 123 mg/dL\n 0.7 mg/dL\n 31 mEq/L\n 3.8 mEq/L\n 4 mg/dL\n 107 mEq/L\n 144 mEq/L\n 27.3 %\n 7.3 K/uL\n [image002.jpg]\n 02:58 AM\n 03:43 AM\n 05:02 PM\n 03:36 AM\n 02:30 AM\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n 03:00 AM\n WBC\n 7.1\n 7.1\n 6.9\n 7.6\n 9.5\n 5.7\n 7.3\n Hct\n 28.9\n 29.2\n 27.8\n 32.7\n 28.6\n 28.9\n 30.0\n 26.9\n 27.3\n Plt\n 462\n 452\n 467\n 548\n 528\n 356\n 346\n Cr\n 0.6\n 0.7\n 0.8\n 0.7\n 0.8\n 1.0\n 0.7\n 0.7\n Glucose\n 137\n 104\n 108\n 131\n 128\n 121\n 129\n 123\n Other labs: PT / PTT / INR:14.1/23.7/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.8 mg/dL, Mg++:1.9 mg/dL, PO4:3.7\n mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 06:31 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 40 minutes\n ------ Protected Section------\n ------ Protected Section Error Entered By: , MD\n on: 10:46 ------\n"},{"category":"Nursing","chartdate":"2167-10-23 00:00:00.000","description":"Nursing Progress Note","row_id":639260,"text":"56 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\n with prolonged hospital course c/b by PNA, anxiety/altered mental\n status, R&LUE DVT .Pt found to have small non occlusive Clot on her\n right axial vein via Ultrasound.Yesterday. She has had problems with\n vomiting tube feedings, feeding tube passed through g-tube (g-tube in\n place with mushroom on inside so cannot pull out) to her jejunenum but\n continues vomit.\n At 7:30 this am pt pulled out her trach tube with staff 6feet away.\n Her HR initially was 120\ns, before an airway could be re-established\n her HR had blocked down to 38 and she had lost consciousness. She\n returned as soon as her airway was re-established.\n Tachycardia, Other\n Assessment:\n Pt amiodarone gtt decreased to .5mg/min as ordered at 8am. Following\n incident described above her HR returned to 80\ns SR. She remains\n hemodynamically stable.\n Action:\n Continued the amiodarone at .5mg.min for the next 18h\n Response:\n Her HR has been 80-94, B/P 138-154/70\n Plan:\n Transition her to PO amiodarone at midnight.\n Alteration in Nutrition\n Assessment:\n Pt still has hypoactive bowel sounds. She did have a small loose\n golden stool at 8am. She remains NPO except for meds\n Action:\n Pt on raglan, dose increased to 20mg q6h.\n Response:\n Pt still has hypoactive bowel sounds.\n Plan:\n Give raglan 20mg as ordered, give dose of lactulose.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt has DVT\ns in both upper extremities.\n Action:\n PICC place in left upper arm, for TPN.\n Response:\n Pt restarted on coumadin 2mg as ordered\n Plan:\n Monitor INR, given coumadin as ordered\n Altered mental status (not Delirium)\n Assessment:\n Pt continues to be very delirious pulling at everything. She has no\n memory and will continue to pull at tubes even when standing right next\n to her.\n Action:\n Pt in restraints, with bilateral soft wrist, mitts, and sheet to\n protect her brace when up in chair.\n Response:\n Pt started on 1:1 sitters for her safety, Psych consult done and\n risperidone ordered.\n Plan:\n Given risperidone as ordered with use of zyprexia and safety\n restraints.\n"},{"category":"Physician ","chartdate":"2167-10-25 00:00:00.000","description":"Physician Resident Progress Note","row_id":639412,"text":"Chief Complaint:\n 24 Hour Events:\n TF held for vomiting\n Given D5W x 2 liters for hypernatremia\n Lovenox 100mg SC BID for DVTs started rather than trying to titrate\n coumadin, follow INR\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:17 AM\n Enoxaparin (Lovenox) - 06:00 PM\n Metoprolol - 06:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.3\nC (97.4\n HR: 68 (64 - 104) bpm\n BP: 116/51(66) {105/45(44) - 151/74(89)} mmHg\n RR: 24 (21 - 38) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,676 mL\n 776 mL\n PO:\n TF:\n 61 mL\n IVF:\n 1,418 mL\n 540 mL\n Blood products:\n Total out:\n 1,910 mL\n 195 mL\n Urine:\n 1,910 mL\n 195 mL\n NG:\n Stool:\n Drains:\n Balance:\n 766 mL\n 581 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 96%\n ABG: ////\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 316 K/uL\n 8.3 g/dL\n 114 mg/dL\n 0.7 mg/dL\n 33 mEq/L\n 4.0 mEq/L\n 7 mg/dL\n 110 mEq/L\n 148 mEq/L\n 27.0 %\n 8.0 K/uL\n [image002.jpg]\n 03:43 AM\n 05:02 PM\n 03:36 AM\n 02:30 AM\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n 03:00 AM\n 04:00 AM\n WBC\n 7.1\n 6.9\n 7.6\n 9.5\n 5.7\n 7.3\n 8.0\n Hct\n 29.2\n 27.8\n 32.7\n 28.6\n 28.9\n 30.0\n 26.9\n 27.3\n 27.0\n Plt\n 452\n 467\n 548\n 528\n 356\n 346\n 316\n Cr\n 0.7\n 0.8\n 0.7\n 0.8\n 1.0\n 0.7\n 0.7\n 0.7\n Glucose\n 104\n 108\n 131\n 128\n 121\n 129\n 123\n 114\n Other labs: PT / PTT / INR:13.2/22.4/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:9.0 mg/dL, Mg++:2.3 mg/dL, PO4:4.1\n mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n TPN without Lipids - 06:10 PM 43. mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n PICC Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2167-10-26 00:00:00.000","description":"Physician Resident Progress Note","row_id":639599,"text":"Chief Complaint:\n 24 Hour Events:\n Pt agitated overnight given extra Risperidone 0.5 mg x 2 overnight.\n (1.5mg total)\n 1000 mL D5W for Hypernatremia\n Changed B-Blocker from IV to PO, Metoprolol Tartrate 25 mg PO TID\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:17 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.7\nC (98\n HR: 120 (67 - 120) bpm\n BP: 110/64(76) {109/47(60) - 141/115(118)} mmHg\n RR: 26 (18 - 30) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 3,820 mL\n 856 mL\n PO:\n TF:\n 117 mL\n 20 mL\n IVF:\n 2,612 mL\n 572 mL\n Blood products:\n Total out:\n 2,460 mL\n 1,180 mL\n Urine:\n 2,460 mL\n 1,180 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,360 mL\n -324 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 100%\n ABG: ///33/\n Physical Examination\n Gen: Awake, Mouthing words, More agitated compared to previous\n mornings.\n HEENT: EOMI, No pallor in conjunctiva, MMM\n Resp: CTAB, no rales, rhonchi, or wheezing, good airway movement.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, decreased bowel sounds,, G-Tube in\n place with no erythema/induration\n Exte: No edema, DP 2+ bil\n NEURO: Gross Motor and Sensation in 4 extremities\n Labs / Radiology\n 249 K/uL\n 8.0 g/dL\n 122 mg/dL\n 0.5 mg/dL\n 33 mEq/L\n 3.7 mEq/L\n 13 mg/dL\n 108 mEq/L\n 146 mEq/L\n 24.7 %\n 5.5 K/uL\n [image002.jpg] CXR: L Picc, trach tip at midline, bibasilar\n opacities, low lung volumes, Bil pleural effusions.\n 03:36 AM\n 02:30 AM\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n 03:00 AM\n 04:00 AM\n 05:45 AM\n 03:51 AM\n WBC\n 6.9\n 7.6\n 9.5\n 5.7\n 7.3\n 8.0\n 8.7\n 5.5\n Hct\n 27.8\n 32.7\n 28.6\n 28.9\n 30.0\n 26.9\n 27.3\n 27.0\n 28.7\n 24.7\n Plt\n 467\n 548\n 528\n 356\n 346\n 316\n 271\n 249\n Cr\n 0.7\n 0.8\n 1.0\n 0.7\n 0.7\n 0.7\n 0.7\n 0.5\n Glucose\n 131\n 128\n 121\n 129\n 123\n 114\n 112\n 122\n Other labs: PT / PTT / INR:13.6/31.1/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:9.0 mg/dL, Mg++:2.2 mg/dL, PO4:3.1\n mg/dL\n Assessment and Plan\n 56yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach/PEG with resolving respiratory failure and HAP.\n .\n # Respiratory failure: s/p intubation/extubation, now on trach mask,\n FiO2 70%. Tolerating well with good O2 sat. No further\n self-decanulations overnight.\n - Tach mask as tolerated.\n - Holding sedation with exception of Risperidal 0.5mg .\n - F/u CXR tomorrow\n .\n # Nutrition/Vomiting: Currently receiving TPN;. One large BM in past\n 24 hrs to indicate potential improvement in ileus.\n - Cont Reglan 20mg IV Q 8 hours; meds via G-J tube,\n - Will obtain recommendations from Nutrition re TPN before starting TPN\n tomorrow\n - TF as tolerated\n - Speech and Swallow eval\n - PICC line in place with TPN given when pt not tolerating TF\n - GI consult, appreciate recs\n .\n # Tachycardia: Improved HR max of 120\ns versus 160s previously;\n elevated this am secondary to agitation. Pt now on PO Amiodarone 200\n TID and PO metoprolol 25mg TID\n - Continue current med regimen. Will continue amiodarone 200 TID for\n three weeks and then switch to qday.\n - Will schedule f/u in 4wks with Dr. upon d/c/transfer.\n - f/u Cards recs\n # Sedation/Anxiolysis/AlteredMS: Agitation O/N, continues to be\n agitated most likely secondary to long hospital course and multiple\n psychotropic medications as well as hx of EtOH abuse. Risperdal given\n O/N.\n - started Risperdal 0.5mg PO BID\n - continue to hold all benzos. opiates, and antihistamines\n - Appreciate psych. Will call and f/u psych recs.\n #Anemia: Decrease in HCT from 28\n24; tachycardia. No known etiology of\n blood loss, most likely related to variaton\n -Will repeat HCT check this afternoon.\n # Hypernatremia/Fluid Status: Mild hypernatramia with good UOP\n (hypervolemic hypernatremia). On TPN/TF.\n - providing D5W IVF, free water flushes with TF\n -Will f/u lytes (Na) this afternoon at 5pm.\n # UE DVT and elevated INR: Decision made to d/c Coumadin given her\n labile INR, and start Lovenox . Current INR 1.2.\n - Will flush L PICC with TPA if does not flush\n .\n # Spine fracture: Stable\n - Brace for OOB, need to discuss with Neurosurgery before d/c if\n current brace is optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n .\n # Tracheomalacia. Was initially addressed with IP and they wanted to\n follow up as outpatient. IP reevaluated and does not believe that a\n stent would be feasible. No new issues.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # ACCESS: PIV x 1, L PICC\n # Ppx: Lovenox, PPi, Bowel Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n - Social Work and Case management involved, have discussed situation\n w/ brother and boyfriend.\n # Code: Full\n # Dispo: ICU, Will d/w case management re rehab facilities.\n PGY2 Addendum\n Agree with excellent MS4 PN. Will touch base with psychiatry re:\n sedating meds and EP re: atrial tachycardia. Will obtain EKG to\n reassess QTc. Ordered for TPN. Giving d5W for hypernatremia. Re-consult\n S/S for PMV re-fitting. transfer to LTAC.\n \n PGY2\n ------ Protected Section ------\n MICU Attending Addendum:\n ------ Protected Section Addendum Entered By: , MD\n on: 16:21 ------\n"},{"category":"Nursing","chartdate":"2167-10-19 00:00:00.000","description":"Nursing Progress Note","row_id":638487,"text":"56yo woman admitted 1 month ago with unstentable tracheal malacia,\n failure to wean.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt on MMV settings, no spont resp. Pt unarousable per below until\n 0830 when she woke and was placed on TM with high flow neb@ 50%.\n Action:\n Response:\n Plan:\n Tachycardia, Other\n Assessment:\n Action:\n Response:\n Plan:\n Arousal, Attention, and Cognition, Impaired\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2167-10-21 00:00:00.000","description":"Nursing Progress Note","row_id":638680,"text":"Nausea / vomiting\n Assessment:\n NPO. Vomitted meds ~10\n after given via gtube. Coughing same emesis\n from tracheostomy. Later found to have vomited coffee ground emesis,\n guiac +. Denies nausea every time although continues to dry heave,\n vomit small amts clear emesis. BRB suctioned from back of throat also,\n d/t irritation from frequent vomiting. Abd soft, hypoactive BS.\n Action:\n Tube feeds on hold. No residual aspirated from gtube, gtube\n placed->>gravity. Stat Hct, coags T&S sent. Zofran x 1. HOB^^ 30. 2^nd\n PIV placed.\n Response:\n On/off vomiting, coffee grounds x 1, with no c/o nausea. Hct 28.6,\n baseline. INR 10.5 .\n Plan:\n Recheck Hct, FDP @ 7AM. Zofran. NPO. IV meds only. Needs gtube changed\n to jtube.\n Tachycardia, Other\n Assessment:\n ST 109-114, NSR 70s briefly. No lopressor given d/t BP<100 most of\n night when pt sleeping.\n Action:\n Lopressor changed from PO->>IV prn d/t vomiting after meds.\n Response:\n ST 110s most of night.\n Plan:\n IV lopressor prn for HR>130.\n Alteration in Nutrition\n Assessment:\n NPO. Na 146 x 2. D5W per orders. UOP decreased 10-20cc/hr with lower\n BP.\n Action:\n D5W now @ 150cc/hr x 1 liter.\n Response:\n Na 146.\n Plan:\n Recheck Na @ 7AM. D5W x 1 liter.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n On 50% trach mask all day. RR ^^40 after first episode of vomiting last\n night. Copious thick tan, dark brown secretions.\n Action:\n Placed on Vent MMV mode when tachypneic. Frequent suctioning.\n Response:\n Comfortable on vent, RR 12 (set), Sats 100%.\n Plan:\n Wean from vent as tolerated. Suction as needed, MDIs.\n Altered mental status (not Delirium)\n Assessment:\n Occaisionally restless, less so than night before. Slept most of night,\n sometimes difficult to arouse. No zyprexa given. Opens eyes to voice,\n follows commands. Mouthing words although difficult to understand.\n Action:\n Reorient pt prn. Emotional support.\n Response:\n Slept most of night, calmer than previous nights.\n Plan:\n No valium or benadryl per psych recommendations. Zyprexa HS prn for\n agitation. Reorient prn. Emotional support.\n"},{"category":"Nursing","chartdate":"2167-10-21 00:00:00.000","description":"Nursing Progress Note","row_id":638681,"text":"Nausea / vomiting\n Assessment:\n NPO. Vomitted meds ~10\n after given via gtube. Coughing same emesis\n from tracheostomy. Later found to have vomited coffee ground emesis,\n guiac +. Denies nausea every time although continues to dry heave,\n vomit small amts clear emesis. BRB suctioned from back of throat also,\n d/t irritation from frequent vomiting. Abd soft, hypoactive BS.\n Action:\n Tube feeds on hold. No residual aspirated from gtube, gtube\n placed->>gravity. Stat Hct, coags T&S sent. Zofran x 1. HOB^^ 30. 2^nd\n PIV placed.\n Response:\n On/off vomiting, coffee grounds x 1, with no c/o nausea. Hct 28.6,\n baseline. INR 10.5 .\n Plan:\n Recheck Hct, FDP @ 7AM. Zofran. NPO. IV meds only. Needs gtube changed\n to jtube.\n Tachycardia, Other\n Assessment:\n ST 109-114, NSR 70s briefly. No lopressor given d/t BP<100 most of\n night when pt sleeping.\n Action:\n Lopressor changed from PO->>IV prn d/t vomiting after meds.\n Response:\n ST 110s most of night.\n Plan:\n IV lopressor prn for HR>130.\n Alteration in Nutrition\n Assessment:\n NPO. Na 146 x 2. D5W per orders. UOP decreased 10-20cc/hr with lower\n BP.\n Action:\n D5W now @ 150cc/hr x 1 liter.\n Response:\n Na 146.\n Plan:\n Recheck Na @ 7AM. D5W x 1 liter.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n On 50% trach mask all day. RR ^^40 after first episode of vomiting last\n night. Copious thick tan, dark brown secretions.\n Action:\n Placed on Vent MMV mode when tachypneic. Frequent suctioning.\n Response:\n Comfortable on vent, RR 12 (set), Sats 100%.\n Plan:\n Wean from vent as tolerated. Suction as needed, MDIs.\n Altered mental status (not Delirium)\n Assessment:\n Occaisionally restless, less so than night before. Slept most of night,\n sometimes difficult to arouse. No zyprexa given. Opens eyes to voice,\n follows commands. Mouthing words although difficult to understand.\n Action:\n Reorient pt prn. Emotional support.\n Response:\n Slept most of night, calmer than previous nights.\n Plan:\n No valium or benadryl per psych recommendations. Zyprexa HS prn for\n agitation. Reorient prn. Emotional support.\n"},{"category":"Nutrition","chartdate":"2167-10-23 00:00:00.000","description":"Clinical Nutrition Note","row_id":639158,"text":"Objective\n Pertinent medications: thiamine, folic acid, hep, protonix, colace,\n senna, reglan, D5w at 75ml/hr, others noted\n Labs:\n Value\n Date\n Glucose\n 123 mg/dL\n 03:00 AM\n Glucose Finger Stick\n 121\n 04:00 AM\n BUN\n 4 mg/dL\n 03:00 AM\n Creatinine\n 0.7 mg/dL\n 03:00 AM\n Sodium\n 144 mEq/L\n 03:00 AM\n Potassium\n 3.8 mEq/L\n 03:00 AM\n Chloride\n 107 mEq/L\n 03:00 AM\n TCO2\n 31 mEq/L\n 03:00 AM\n PO2 (arterial)\n 120 mm Hg\n 03:36 AM\n PO2 (venous)\n 62 mm Hg\n 02:35 AM\n PCO2 (arterial)\n 44 mm Hg\n 03:36 AM\n PCO2 (venous)\n 58 mm Hg\n 02:35 AM\n pH (arterial)\n 7.37 units\n 03:36 AM\n pH (venous)\n 7.37 units\n 02:35 AM\n pH (urine)\n 5.0 units\n 03:05 AM\n CO2 (Calc) arterial\n 26 mEq/L\n 03:36 AM\n CO2 (Calc) venous\n 35 mEq/L\n 02:35 AM\n Albumin\n 3.1 g/dL\n 03:23 AM\n Calcium non-ionized\n 8.8 mg/dL\n 03:00 AM\n Phosphorus\n 3.7 mg/dL\n 03:00 AM\n Ionized Calcium\n 1.24 mmol/L\n 02:51 AM\n Magnesium\n 1.9 mg/dL\n 03:00 AM\n ALT\n 25 IU/L\n 07:34 AM\n Alkaline Phosphate\n 106 IU/L\n 07:34 AM\n AST\n 19 IU/L\n 07:34 AM\n Amylase\n 10 IU/L\n 03:59 AM\n Total Bilirubin\n 0.2 mg/dL\n 07:34 AM\n WBC\n 7.3 K/uL\n 03:00 AM\n Hgb\n 8.4 g/dL\n 03:00 AM\n Hematocrit\n 27.3 %\n 03:00 AM\n Current diet order / nutrition support: NPO\n GI:\n Assessment of Nutritional Status\n Estimation of previous intake: Inadequate\n Estimation of current intake: Inadequate\n Specifics:\n 55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach, PEG placement now with respiratory failure secondary to\n tracheomalacia. Pt has not been tol TF since last wk, pt s/p\n pediatric feeding tube placed by GI through her PEG tube into her\n jejunum, and was given TFs last night, which pt vomited. Pt also s/p\n tube study this am that showed dysmotility of her jejunum, etiology of\n ileus unclear and ? pt' s chronic baseline or d/t long course of\n opiates during MICU stay. PICC line ordered to place and will need to\n start TPN today.\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: in NS, d/c outside folic acid and\n thiamine\n TPN recommendations: start day 1 (150dex/70aa), 70NaCl, 10KCl, 30KPhos,\n 10Mg, 10Ca, thiamine and folic acid in tpn\n Check chemistry 10 panel daily, replete prn\n Check triglycerides\n Start regular insulin sliding scale if serum glucose >150 mg/dL\n Change to non-dextrose IV fluids once TPN starts\n Provided BG < 150 and Trig < 400, can cont to adv TPN to goal of 60kg\n 3-in-1 to provide 1500kcal/day in the next few days\n Retrial TF with Vivonex ( low fat, elemental formula) at 10ml/hr if\n medically allowed\n Please page if has ?\n"},{"category":"Nutrition","chartdate":"2167-10-23 00:00:00.000","description":"Clinical Nutrition Note","row_id":639159,"text":"Objective\n Pertinent medications: thiamine, folic acid, hep, protonix, colace,\n senna, reglan, D5w at 75ml/hr, others noted\n Labs:\n Value\n Date\n Glucose\n 123 mg/dL\n 03:00 AM\n Glucose Finger Stick\n 121\n 04:00 AM\n BUN\n 4 mg/dL\n 03:00 AM\n Creatinine\n 0.7 mg/dL\n 03:00 AM\n Sodium\n 144 mEq/L\n 03:00 AM\n Potassium\n 3.8 mEq/L\n 03:00 AM\n Chloride\n 107 mEq/L\n 03:00 AM\n TCO2\n 31 mEq/L\n 03:00 AM\n PO2 (arterial)\n 120 mm Hg\n 03:36 AM\n PO2 (venous)\n 62 mm Hg\n 02:35 AM\n PCO2 (arterial)\n 44 mm Hg\n 03:36 AM\n PCO2 (venous)\n 58 mm Hg\n 02:35 AM\n pH (arterial)\n 7.37 units\n 03:36 AM\n pH (venous)\n 7.37 units\n 02:35 AM\n pH (urine)\n 5.0 units\n 03:05 AM\n CO2 (Calc) arterial\n 26 mEq/L\n 03:36 AM\n CO2 (Calc) venous\n 35 mEq/L\n 02:35 AM\n Albumin\n 3.1 g/dL\n 03:23 AM\n Calcium non-ionized\n 8.8 mg/dL\n 03:00 AM\n Phosphorus\n 3.7 mg/dL\n 03:00 AM\n Ionized Calcium\n 1.24 mmol/L\n 02:51 AM\n Magnesium\n 1.9 mg/dL\n 03:00 AM\n ALT\n 25 IU/L\n 07:34 AM\n Alkaline Phosphate\n 106 IU/L\n 07:34 AM\n AST\n 19 IU/L\n 07:34 AM\n Amylase\n 10 IU/L\n 03:59 AM\n Total Bilirubin\n 0.2 mg/dL\n 07:34 AM\n WBC\n 7.3 K/uL\n 03:00 AM\n Hgb\n 8.4 g/dL\n 03:00 AM\n Hematocrit\n 27.3 %\n 03:00 AM\n Current diet order / nutrition support: NPO\n Assessment of Nutritional Status\n Estimation of previous intake: Inadequate\n Estimation of current intake: Inadequate\n Specifics:\n 55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach, PEG placement now with respiratory failure secondary to\n tracheomalacia. Pt has not been tol TF since last wk, pt s/p\n pediatric feeding tube placed by GI through her PEG tube into her\n jejunum, and was given TFs last night, which pt vomited. Pt also s/p\n tube study this am that showed dysmotility of her jejunum, etiology of\n ileus unclear and ? pt' s chronic baseline or d/t long course of\n opiates during MICU stay. PICC line ordered to place and will need to\n start TPN today. Noted pt with elevated Na, currently on D5w, need to\n monitor BG closely.\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: in NS, d/c outside folic acid and\n thiamine\n TPN recommendations: start day 1 (150dex/70aa), 50NaCl, 10KCl, 30KPhos,\n 10Mg, 10Ca, thiamine and folic acid in tpn\n Check chemistry 10 panel daily, replete prn\n Check triglycerides\n Cont bg management\n Change to non-dextrose IV fluids once TPN starts if Na comes down,\n Provided BG < 150 and Trig < 400, can cont to adv TPN to goal of 60kg\n 3-in-1 to provide 1500kcal/day in the next few days\n Retrial TF with Vivonex ( low fat, elemental formula) at 10ml/hr if\n medically allowed\n Please page if has ?\n"},{"category":"Physician ","chartdate":"2167-10-25 00:00:00.000","description":"Physician Resident Progress Note","row_id":639414,"text":"Chief Complaint:\n 24 Hour Events:\n TF held for vomiting\n Given D5W x 2 liters for hypernatremia\n Lovenox 100mg SC BID for DVTs started rather than trying to titrate\n coumadin, follow INR\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:17 AM\n Enoxaparin (Lovenox) - 06:00 PM\n Metoprolol - 06:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.3\nC (97.4\n HR: 68 (64 - 104) bpm\n BP: 116/51(66) {105/45(44) - 151/74(89)} mmHg\n RR: 24 (21 - 38) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,676 mL\n 776 mL\n PO:\n TF:\n 61 mL\n IVF:\n 1,418 mL\n 540 mL\n Blood products:\n Total out:\n 1,910 mL\n 195 mL\n Urine:\n 1,910 mL\n 195 mL\n NG:\n Stool:\n Drains:\n Balance:\n 766 mL\n 581 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 96%\n ABG: ////\n Physical Examination\n Gen: Asleep, unarousable, responds minimally to noxious stimuli\n HEENT: PERRL, MMM\n Resp: CTA bilaterally, no rales, rhonchi, or wheezing, small\n inspirations.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, BS+\n Exte: No edema, DP 2+ bil\n NEURO: reflexes 2+ bilaterally.\n Labs / Radiology\n 316 K/uL\n 8.3 g/dL\n 114 mg/dL\n 0.7 mg/dL\n 33 mEq/L\n 4.0 mEq/L\n 7 mg/dL\n 110 mEq/L\n 148 mEq/L\n 27.0 %\n 8.0 K/uL\n [image002.jpg]\n 03:43 AM\n 05:02 PM\n 03:36 AM\n 02:30 AM\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n 03:00 AM\n 04:00 AM\n WBC\n 7.1\n 6.9\n 7.6\n 9.5\n 5.7\n 7.3\n 8.0\n Hct\n 29.2\n 27.8\n 32.7\n 28.6\n 28.9\n 30.0\n 26.9\n 27.3\n 27.0\n Plt\n 452\n 467\n 548\n 528\n 356\n 346\n 316\n Cr\n 0.7\n 0.8\n 0.7\n 0.8\n 1.0\n 0.7\n 0.7\n 0.7\n Glucose\n 104\n 108\n 131\n 128\n 121\n 129\n 123\n 114\n Other labs: PT / PTT / INR:13.2/22.4/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:9.0 mg/dL, Mg++:2.3 mg/dL, PO4:4.1\n mg/dL\n Assessment and Plan\n 55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach, PEG placement now with respiratory failure secondary to\n tracheomalacia , resolved HAP.\n .\n # Respiratory failure: Slowly improving, spending most of the day on\n trach mask with short periods of rest on PSV at night and setbacks\n from increased secretions to vomiting/aspiration events and her\n self-decanulations.\n - Continue to increase time on trach mask as tolerated.\n - Discontinue all orders for sedation except for Risperdal QHS.\n - PMV with suctioning as tolerated\n # Nutrition/Vomiting: Normal CT-abdomen, had FT placed via peg into\n jejunum, but continued to vomit. Tube study showed dysmotility in small\n bowel, but no obstruction, no retrograde flow. GI recs Reglan 20mg IV Q\n 8 hours and restart meds via G-J tube, if tolerated slowly restart TFs.\n PICC line placed yesterday and TPN started.\n - GI consult, appreciate recs\n - Small volume TFs start today\n - Continue TPN today\n # HAP vs Aspiration PNA: Had been afebrile for last several days, now\n with new fever two nights ago after having decanulated herself. Likely\n had some aspiration. Chemical pneumonitis versus new aspiration PNA.\n Now Afebrile for past 24 hours.\n - f/u daily CXR\n - F/u cx data\n - If remains febrile, send sputum cx, otherwise hold on abx.\n .\n # Tachycardia: Pt in and out of SVT and sinus, increased BB seems to\n help, but pt does not stay in sinus. Cards rec to start Amiodarone IV\n drip, and then convert to PO, 200mg TID. Would consider EPS if\n amiodarone not successful, though would wait until pt more stable for\n general anesthesia.\n - Changed to IV metoprolol to 10mg IV q4hr.\n - Completed amiodarone 0.5mg/min IV drip x 18 hours, and converted to\n 200mg PO TID..\n - Cards c/s, appreciate recs\n # Sedation/Anxiolysis/AlteredMS: unclear etiology of her confusion and\n agitation. Has had long hospital course and multiple psychotropic\n medications as well as hx of EtOH abuse.\n - d/c all benzos. opiates, and antihistamines\n - Psychiatry consulted, appreciate recs\n - started Risperdal 0.5mg PO BID, d/c zyprexa.\n # Adrenal Insufficency: Endocrine following. Pt does not appear to be\n adrenally insufficient at baseline. Suggesting if the patient under\n goes major stressors such as major surgery, sepsis, she may need stress\n dosed steroids.\n .\n # Fluid Status: Likely approaching euvolemia, though still has mild\n hypernatramia which may suggest is still intravascularly depleated.\n - Monitoring urine output\n - will provide D5W IVF as need for hypernatremia and follow lytes\n # UE DVT and elevated INR: DVT in right UE has resolved, new\n non-occlusive in left axillary vein. INR has been volatile, likely from\n drug interactions and poor nutritional status. Have been unable to keep\n her appropariately therapeutic.\n - d/c coumadin\n - start Lovenox, maintain until GI issues resolved and can restart\n coumadin\n .\n #Hematemesis: Pt had small amt Hematemesis, after vomiting, last week.\n None today. HCT stable.\n -Will follow HCT.\n - Guaiac stools\n # Spine fracture: Stable\n - Brace for OOB, will discuss with Neurosurgery if current brace is\n optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n .\n # Tracheomalacia. Was initially addressed with IP and they wanted to\n follow up as outpatient. IP reevaluated and does not believe that a\n stent would be feasible.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # ACCESS: PIV x 1, PICC placement yesterday.\n # Ppx: subtherapeutic INR restarting coumadin today, Ranitidine, Bowel\n Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n - Social Work and Case management involved, have discussed situation\n w/ brother and boyfriend.\n # Code: Full\n # Dispo: ICU, Screening for vent facilities\n ICU Care\n Nutrition:\n TPN without Lipids - 06:10 PM 43. mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n PICC Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Respiratory ","chartdate":"2167-10-20 00:00:00.000","description":"Respiratory Care Shift Note","row_id":638539,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 32\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Tracheostomy tube:\n Type: Standard, Cuffed, Inner Cannula\n Manufacturer: Portex\n Size: 8.0mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea); Comments: Pt on\n trach collar for most of the night. Dipping sats and high RR, pt then\n placed on vent to \"rest\"\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Periodic SBT's for conditioning; Comments: Continue with trach trials\n"},{"category":"Physician ","chartdate":"2167-10-21 00:00:00.000","description":"Physician Resident Progress Note","row_id":638738,"text":"Chief Complaint:\n 24 Hour Events:\n Multiple vomitting episodes, not improved much w/ zofran.\n Unable to tolerate anything through her PEG\n Had an Abdominal CT w/contrast, but vomitted up most of the constrast.\n limited study. Prelim read: no obstruction, PEG in place\n Nurse positive coffe-grounds emesis and w/ a later\n episode, clear emesis with some small blood when she suctioned the\n posterior pharynx.\n TFs were held\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.7\nC (98\n HR: 110 (76 - 136) bpm\n BP: 98/63(60) {80/40(49) - 149/88(92)} mmHg\n RR: 12 (12 - 33) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,241 mL\n 1,335 mL\n PO:\n TF:\n IVF:\n 1,941 mL\n 1,335 mL\n Blood products:\n Total out:\n 1,860 mL\n 140 mL\n Urine:\n 1,830 mL\n 90 mL\n NG:\n 30 mL\n 50 mL\n Stool:\n Drains:\n Balance:\n 381 mL\n 1,195 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: MMV/PSV/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 809 (300 - 1,054) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 21 cmH2O\n Plateau: 15 cmH2O\n SpO2: 100%\n ABG: ///35/\n Ve: 5.8 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 528 K/uL\n 9.2 g/dL\n 121 mg/dL\n 1.0 mg/dL\n 35 mEq/L\n 3.4 mEq/L\n 6 mg/dL\n 103 mEq/L\n 146 mEq/L\n 28.6 %\n 9.5 K/uL\n [image002.jpg]\n 02:06 AM\n 07:34 AM\n 03:50 AM\n 06:22 AM\n 02:58 AM\n 03:43 AM\n 05:02 PM\n 03:36 AM\n 02:30 AM\n 01:30 AM\n WBC\n 7.5\n 5.6\n 6.1\n 7.0\n 7.1\n 7.1\n 6.9\n 7.6\n 9.5\n Hct\n 26.8\n 27.0\n 27.0\n 29.7\n 28.9\n 29.2\n 27.8\n 32.7\n 28.6\n Plt\n 95\n 462\n 452\n 467\n 548\n 528\n Cr\n 0.6\n 0.5\n 0.7\n 0.7\n 0.6\n 0.7\n 0.8\n 0.7\n 0.8\n 1.0\n Glucose\n 134\n 121\n 619\n 126\n 137\n 104\n 108\n 131\n 128\n 121\n Other labs: PT / PTT / INR:82.1/35.9/10.5, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:9.7 mg/dL, Mg++:2.4 mg/dL, PO4:2.9\n mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 04:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2167-10-21 00:00:00.000","description":"Physician Resident Progress Note","row_id":638740,"text":"Chief Complaint:\n 24 Hour Events:\n Multiple vomitting episodes, not improved much w/ zofran.\n Unable to tolerate anything through her PEG\n Had an Abdominal CT w/contrast, but vomitted up most of the constrast.\n limited study. Prelim read: no obstruction, PEG in place\n Nurse positive coffe-grounds emesis and w/ a later\n episode, clear emesis with some small blood when she suctioned the\n posterior pharynx.\n TFs were held\n Dr. had a conversation with the pt\ns brother.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.7\nC (98\n HR: 110 (76 - 136) bpm\n BP: 98/63(60) {80/40(49) - 149/88(92)} mmHg\n RR: 12 (12 - 33) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,241 mL\n 1,335 mL\n PO:\n TF:\n IVF:\n 1,941 mL\n 1,335 mL\n Blood products:\n Total out:\n 1,860 mL\n 140 mL\n Urine:\n 1,830 mL\n 90 mL\n NG:\n 30 mL\n 50 mL\n Stool:\n Drains:\n Balance:\n 381 mL\n 1,195 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: MMV/PSV/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 809 (300 - 1,054) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 21 cmH2O\n Plateau: 15 cmH2O\n SpO2: 100%\n ABG: ///35/\n Ve: 5.8 L/min\n Physical Examination\n Gen: Obtunded this am, not responsive to voice, minimally responsive to\n noxious stimuli, on MMV through trach tube, but later responsive to\n voice, appropriate, asking questions, mouthing responses\n HEENT: PERRL, MMM,\n Resp: Coarse BS anteriorly, no focal rales, rhonchi, or wheezing with\n some referred upper airway noises from secretions.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, hypoactive BS\n Exte: No edema, DP 2+ bil.\n NEURO: Toes downgoing bilaterally,\n Labs / Radiology\n 528 K/uL\n 9.2 g/dL\n 121 mg/dL\n 1.0 mg/dL\n 35 mEq/L\n 3.4 mEq/L\n 6 mg/dL\n 103 mEq/L\n 146 mEq/L\n 28.6 %\n 9.5 K/uL\n [image002.jpg]\n 02:06 AM\n 07:34 AM\n 03:50 AM\n 06:22 AM\n 02:58 AM\n 03:43 AM\n 05:02 PM\n 03:36 AM\n 02:30 AM\n 01:30 AM\n WBC\n 7.5\n 5.6\n 6.1\n 7.0\n 7.1\n 7.1\n 6.9\n 7.6\n 9.5\n Hct\n 26.8\n 27.0\n 27.0\n 29.7\n 28.9\n 29.2\n 27.8\n 32.7\n 28.6\n Plt\n 95\n 462\n 452\n 467\n 548\n 528\n Cr\n 0.6\n 0.5\n 0.7\n 0.7\n 0.6\n 0.7\n 0.8\n 0.7\n 0.8\n 1.0\n Glucose\n 134\n 121\n 619\n 126\n 137\n 104\n 108\n 131\n 128\n 121\n Other labs: PT / PTT / INR:82.1/35.9/10.5, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:9.7 mg/dL, Mg++:2.4 mg/dL, PO4:2.9\n mg/dL\n Assessment and Plan\n 55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach, PEG placement now with respiratory failure secondary to\n tracheomalacia , resolved HAP.\n .\n # Respiratory failure: Slowly Improving. Now remaining on trach mask\n for most of the day, with periods of pressure support of over\n night. This am on MMV. Previously likely oversedated with Benadryl,\n Morhpine, and Valium which were held overnight. Pt awake and alert at\n rounds, interactive, and breathing comfortably on trach mask\n - Continue to increase time on trach mask as tolerated.\n - Decrease sedation and valium use\n - PMV with suctioning\n .\n # HAP vs Aspiration PNA: Afebrile without leukocytosis\n - Completed course of ceftriaxone\n - good O2 saturation on trach mask\n - Continue to f/u cultures\n .\n # Tachycardia: Previously was assessed as sinus tach with occasional\n runs of SVT and sources such as hypovolemia, PE, infection, and pain\n were assessed as possibly etiologies. Per Cardiology, most likely AT\n given transient response to Adenosine. HR occasionally decreases to\n 70s-80s w/ stable BPs at times that might be associated with\n administration of her BB and valium. Cards recommended titating up her\n beta blocker as tolerated. Dose increased to 37.5 yesterday but still\n tachycardic.\n - EP consulted for conversion of SVT, appreciate recs\n - Increase metoprolol to 50 PO QID with holding parameters\n .\n # Sedation: Inconsistent response to sedation, unclear what is best\n regime. Will continue to wean overall.\n - Continue w Olanzapine QHS\n - Just valium 2.5 mg PRN.\n # Nutrition/Vomiting: Pt has had several episodes of vomiting up her\n TFs, reglan started to increase GI motility, but pt had another episode\n of vomiting this am, not improved with zofran or reglan. Pateint also\n had hypoactive BS on exam, concern for obstruction given persistent\n vomiting, inability to tolerate tube feeds.\n - Hold TFs\n - Thoracic surgery recs: 1) oral/nasal tube in post-piloric position,\n or 2) IR to place a pediatric feeding tube through her PEG site to a\n post-piloric position.\n - Will attempt to coordinate thoracic surgery and IR for tube placement\n ; will d/w thoracics. IR will not do further intervention due to disk\n on G tube\n - CT scan to evaluate for obstruction, etiology of persistent emesis,\n consider tube study as well\n .\n # Adrenal Insufficency: Endocrine following. Pt does not appear to be\n adrenally insufficient at baseline. Suggesting if the patient under\n goes major stressors such as major surgery, sepsis, she may need stress\n dosed steroids.\n .\n # Fluid Status: Likely approaching euvolemia, though still has mild\n hypernatramia which may suggest is still intravascularly depleated.\n - Monitoring urine output\n - FW flushes w/ tube feeds held due to vomitting\n - will provide D5W IVF as need for hypernatremia and follow lytes\n .\n # UE DVT and elevated INR: DVT in right UE has resolved, new\n non-occlusive in left axillary vein. INR supratherapeutic today and\n trending upward. INR most likely continuing to rise nutritional\n deficiencies given lack of PO intake\n - Cumadin held, will restart at low dose when INR approaches\n therapeutic range.\n - INR 5.5 today, will check PM coags and follow\n .\n # Spine fracture: Stable\n - Brace for OOB, will discuss with Neurosurgery if current brace is\n optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n .\n # Tracheomalacia. Was initially addressed with IP and they wanted to\n follow up as outpatient. IP reevaluated and does not believe that a\n stent would be feasible.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # PIV x 1\n # Ppx: supratherapeutic INR, Ranitidine, Bowel Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n - Will contact Social and Case management today\n # Code: Full\n # Dispo: ICU, Screening for vent facilities\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 04:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2167-10-21 00:00:00.000","description":"Physician Attending Progress Note","row_id":638755,"text":"Chief Complaint: resp failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n rising INR to 10.5\n small volume hemetemesis\n abd CT\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:30 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.9\nC (98.4\n HR: 114 (88 - 136) bpm\n BP: 120/65(80) {80/40(49) - 149/88(92)} mmHg\n RR: 11 (11 - 33) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,241 mL\n 1,802 mL\n PO:\n TF:\n IVF:\n 1,941 mL\n 1,802 mL\n Blood products:\n Total out:\n 1,860 mL\n 260 mL\n Urine:\n 1,830 mL\n 210 mL\n NG:\n 30 mL\n 50 mL\n Stool:\n Drains:\n Balance:\n 381 mL\n 1,542 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 438 (300 - 1,054) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 13\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 16 cmH2O\n Plateau: 15 cmH2O\n SpO2: 100%\n ABG: ///35/\n Ve: 5.4 L/min\n Physical Examination\n Gen\n HEENt\n CV\n Chest\n Abd\n Ext\n Labs / Radiology\n 9.2 g/dL\n 528 K/uL\n 121 mg/dL\n 1.0 mg/dL\n 35 mEq/L\n 3.4 mEq/L\n 6 mg/dL\n 103 mEq/L\n 144 mEq/L\n 28.9 %\n 9.5 K/uL\n [image002.jpg]\n 07:34 AM\n 03:50 AM\n 06:22 AM\n 02:58 AM\n 03:43 AM\n 05:02 PM\n 03:36 AM\n 02:30 AM\n 01:30 AM\n 06:41 AM\n WBC\n 5.6\n 6.1\n 7.0\n 7.1\n 7.1\n 6.9\n 7.6\n 9.5\n Hct\n 27.0\n 27.0\n 29.7\n 28.9\n 29.2\n 27.8\n 32.7\n 28.6\n 28.9\n Plt\n 335\n 321\n 395\n 462\n 452\n 467\n 548\n 528\n Cr\n 0.5\n 0.7\n 0.7\n 0.6\n 0.7\n 0.8\n 0.7\n 0.8\n 1.0\n Glucose\n 121\n 619\n 126\n 137\n 104\n 108\n 131\n 128\n 121\n Other labs: PT / PTT / INR:82.1/35.9/10.5, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:9.7 mg/dL, Mg++:2.4 mg/dL, PO4:2.9\n mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 04:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n"},{"category":"Nursing","chartdate":"2167-10-21 00:00:00.000","description":"Nursing Progress Note","row_id":638862,"text":"Tachycardia, Other\n Assessment:\n ST120-140 with anxiety, BP stayed in 120- 140 systoli8caly.No Ectopy\n noted\n Action:\n Lopressor changed from PO->>IV prn d/t vomiting after meds.\n Response:\n Given lopressor 5mg IV evening, cont ST most of the time.\n Plan:\n IV lopressor 7.5 mg Q4H for Tachycardia.\n Alteration in Nutrition\n Assessment:\n Pt was until went for procedure . Na 144 this morning,^ this evening\n 148. K was low this morning 3.4,Pt also started autodiuresing this\n morning.\n Action:\n D5 with 40 K at 50cc/hr . x1000cc.Pt went down and had New feeding tube\n inside Peg tube,sutured securely with 150 fentanyl and 4mg Versed.\n Response:\n Will follow up with Labs,TF?.HCt stayed stable\n Plan:\n Recheck K and NA later tonight. Start TF and titrate as tol,erate\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Put On 50% trach mask most of the day.. Copious thick tan, dark brown\n secretions.\n Action:\n Placed on Vent onetime MMV mode when tachypneic. Frequent suctioning.\n Response:\n Cont be same, got breathing rx.\n Plan:\n Cont monitor resp status. Suction as needed, MDIs.\n Altered mental status (not Delirium)\n Assessment:\n Restless all day,follow commands intermittently,Mouthing words although\n difficult to understand.\n Action:\n Gave her Haldol and vaslium IV as per order , Reorient pt prn.\n Emotional support.Soft restraints still on.Her brother called this\n evening,will here Friday .\n Response:\n Cont same.\n Plan:\n Valium and Haldol PRN?. Zyprexa HS prn for agitation. Reorient prn.\n Emotional support to pt and family.\n"},{"category":"Respiratory ","chartdate":"2167-10-22 00:00:00.000","description":"Respiratory Care Shift Note","row_id":639062,"text":"Demographics\n Day of mechanical ventilation: 34\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Tracheostomy tube:\n Type: Standard, Cuffed\n Manufacturer: Portex\n Size: 7.0mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 23 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Pt on Trach collar this am,\n after 2 hrs pt desating to 87%, suctioned for copious thick brownish\n secretions, did not recover on 100% O2, needed to go back on Vent.\n Currently pt on Trach collar.\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: Trach collar as tolerated.\n Reason for continuing current ventilatory support: Cannot protect\n airway, Cannot manage secretions, pt desaturates and does not recover\n with O2 only.\n Respiratory Care Shift Procedures\n Bedside Procedures:\n 1550\n Comments: Pt decannulated herself, desated to 87%, Trach tube portex #\n 7 re-inserted by this RRT, no complication, Easy cap good color change\n to yellow, Good bilateral lung sounds, no bleeding from trach.\n"},{"category":"Nursing","chartdate":"2167-10-23 00:00:00.000","description":"Nursing Progress Note","row_id":639138,"text":"56 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\n with prolonged hospital course c/b by PNA, anxiety/altered mental\n status, R&LUE DVT .Pt found to have small non occlusive Clot on her\n right axial vein via Ultrasound.Yesterday. She has had problems with\n vomiting tube feedings, feeding tube passed through g-tube (g-tube in\n place with mushroom on inside so cannot pull out) to her jejunenum but\n continues vomit.\n Tachycardia, Other\n Assessment:\n HR continued to be 110-140, ST w/ rare PVC\n Action:\n Amiordarone 75mg bolus given, and drip started at 1mg/min\n Response:\n HR at rest now 100-120\n Plan:\n Will continue drip for 18 hr then titrate down to 0.5mg/min\n Altered mental status (not Delirium)\n Assessment:\n Pt very restless and agitated throughout night, pt has slept less than\n 2 hours. Zyprexa given w/ minimal effect. Pt seems very disoriented\n despite frequent reorientation. Pt has short term menmory deficits.\n Pt continues to grab at lines if hand are not restrained.\n Action:\n Zyprexa given and frequent reorientation and 1:1 time\n Response:\n Pt continues to be agitated\n Plan:\n Alteration in Nutrition\n Assessment:\n Remains NPO, IVF at 75cc/hr. Abd soft, distant hYPOactive BS. No\n vomiting noted\n Action:\n Continue to monitor for nausea\n Response:\n Plan:\n ? start PPN today if KUB + illeus\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Tmax this shift 101.4 rectally\n Action:\n BC x2 sent and U/A C+S sent . Tylenol supp given\n Response:\n Temp down to 98.5\n Plan:\n Await BC results and urine culture results\n"},{"category":"Nursing","chartdate":"2167-10-22 00:00:00.000","description":"Nursing Progress Note","row_id":639065,"text":"Tachycardia, Other\n Assessment:\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Hypernatremia (high sodium)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2167-10-16 00:00:00.000","description":"Nursing Progress Note","row_id":637887,"text":"Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Left hand to elbow area with edema 2mm\nknown DVT to left axillary vein;\n US of right arm\n Action:\n DL PICC d/c\nd; left arm elevated on pillow; US results pnd for right\n arm\n Response:\n PIV placed for access issues to right arm; edema unchanged;\n Plan:\n Cont to monitor left arm status; no BP/blood draws left arm. NIBP cuff\n to right calf. F/U w/ team Re: right arm status\n Hypernatremia (high sodium)\n Assessment:\n hypernatremic\n Action:\n Free water boluses cont; bloused with D5W/500cc\n Response:\n Remains hypernatremic with min improvement\n Plan:\n Cont with free water boluses; check labs am\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Restless, anxious am\n Action:\n Trach collar placed 70% early am--\n Response:\n Brief episode of desaturation to mid 80\ns requiring increase of Fi02 to\n 100% briefly (approx 20min); placed on 70% remainder of shift with\n adequate o2 sats in low 90\ns;NOTE: pt vomited approx 50cc clear liquid\n prior to going to IR also had some clear lix come from trach\npossible\n aspiration\nteam notified. Placed on PSV at 1840 to rest\n Plan:\n Rest overnight; ?aspiration. Hold TF for now\nf/u team re: free water\n boluses. CXR am. Monitor resp status closely.\n Tachycardia, Other\n Assessment:\n Tachy to 130-140\ns continuous while awake; Hr stayed 90- 120 sound\n asleep\n Action:\n Standing valium decreased; cont with fent patch; morphine and haldol\n prn.Bilateral restraints on\n Response:\n No significant change in level of restlessness/anxiety; freq pulling at\n any objects/lines with short term memory issues. She keeps\n disconnecting from vent,desat to low 80s within seconds.\n Plan:\n Cont to closely monitor mental status; maintain safety w/use of\n restraints, soft wrist restraints and bed alarm. PRN Haldol or\n Morphine.\n"},{"category":"Physician ","chartdate":"2167-10-26 00:00:00.000","description":"Physician Resident Progress Note","row_id":639594,"text":"Chief Complaint:\n 24 Hour Events:\n Pt agitated overnight given extra Risperidone 0.5 mg x 2 overnight.\n (1.5mg total)\n 1000 mL D5W for Hypernatremia\n Changed B-Blocker from IV to PO, Metoprolol Tartrate 25 mg PO TID\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:17 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.7\nC (98\n HR: 120 (67 - 120) bpm\n BP: 110/64(76) {109/47(60) - 141/115(118)} mmHg\n RR: 26 (18 - 30) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 3,820 mL\n 856 mL\n PO:\n TF:\n 117 mL\n 20 mL\n IVF:\n 2,612 mL\n 572 mL\n Blood products:\n Total out:\n 2,460 mL\n 1,180 mL\n Urine:\n 2,460 mL\n 1,180 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,360 mL\n -324 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 100%\n ABG: ///33/\n Physical Examination\n Gen: Awake, Mouthing words, More agitated compared to previous\n mornings.\n HEENT: EOMI, No pallor in conjunctiva, MMM\n Resp: CTAB, no rales, rhonchi, or wheezing, good airway movement.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, decreased bowel sounds,, G-Tube in\n place with no erythema/induration\n Exte: No edema, DP 2+ bil\n NEURO: Gross Motor and Sensation in 4 extremities\n Labs / Radiology\n 249 K/uL\n 8.0 g/dL\n 122 mg/dL\n 0.5 mg/dL\n 33 mEq/L\n 3.7 mEq/L\n 13 mg/dL\n 108 mEq/L\n 146 mEq/L\n 24.7 %\n 5.5 K/uL\n [image002.jpg] CXR: L Picc, trach tip at midline, bibasilar\n opacities, low lung volumes, Bil pleural effusions.\n 03:36 AM\n 02:30 AM\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n 03:00 AM\n 04:00 AM\n 05:45 AM\n 03:51 AM\n WBC\n 6.9\n 7.6\n 9.5\n 5.7\n 7.3\n 8.0\n 8.7\n 5.5\n Hct\n 27.8\n 32.7\n 28.6\n 28.9\n 30.0\n 26.9\n 27.3\n 27.0\n 28.7\n 24.7\n Plt\n 467\n 548\n 528\n 356\n 346\n 316\n 271\n 249\n Cr\n 0.7\n 0.8\n 1.0\n 0.7\n 0.7\n 0.7\n 0.7\n 0.5\n Glucose\n 131\n 128\n 121\n 129\n 123\n 114\n 112\n 122\n Other labs: PT / PTT / INR:13.6/31.1/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:9.0 mg/dL, Mg++:2.2 mg/dL, PO4:3.1\n mg/dL\n Assessment and Plan\n 56yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach/PEG with resolving respiratory failure and HAP.\n .\n # Respiratory failure: s/p intubation/extubation, now on trach mask,\n FiO2 70%. Tolerating well with good O2 sat. No further\n self-decanulations overnight.\n - Tach mask as tolerated.\n - Holding sedation with exception of Risperidal 0.5mg .\n - F/u CXR tomorrow\n .\n # Nutrition/Vomiting: Currently receiving TPN;. One large BM in past\n 24 hrs to indicate potential improvement in ileus.\n - Cont Reglan 20mg IV Q 8 hours; meds via G-J tube,\n - Will obtain recommendations from Nutrition re TPN before starting TPN\n tomorrow\n - TF as tolerated\n - Speech and Swallow eval\n - PICC line in place with TPN given when pt not tolerating TF\n - GI consult, appreciate recs\n .\n # Tachycardia: Improved HR max of 120\ns versus 160s previously;\n elevated this am secondary to agitation. Pt now on PO Amiodarone 200\n TID and PO metoprolol 25mg TID\n - Continue current med regimen. Will continue amiodarone 200 TID for\n three weeks and then switch to qday.\n - Will schedule f/u in 4wks with Dr. upon d/c/transfer.\n - f/u Cards recs\n # Sedation/Anxiolysis/AlteredMS: Agitation O/N, continues to be\n agitated most likely secondary to long hospital course and multiple\n psychotropic medications as well as hx of EtOH abuse. Risperdal given\n O/N.\n - started Risperdal 0.5mg PO BID\n - continue to hold all benzos. opiates, and antihistamines\n - Appreciate psych. Will call and f/u psych recs.\n #Anemia: Decrease in HCT from 28\n24; tachycardia. No known etiology of\n blood loss, most likely related to variaton\n -Will repeat HCT check this afternoon.\n # Hypernatremia/Fluid Status: Mild hypernatramia with good UOP\n (hypervolemic hypernatremia). On TPN/TF.\n - providing D5W IVF, free water flushes with TF\n -Will f/u lytes (Na) this afternoon at 5pm.\n # UE DVT and elevated INR: Decision made to d/c Coumadin given her\n labile INR, and start Lovenox . Current INR 1.2.\n - Will flush L PICC with TPA if does not flush\n .\n # Spine fracture: Stable\n - Brace for OOB, need to discuss with Neurosurgery before d/c if\n current brace is optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n .\n # Tracheomalacia. Was initially addressed with IP and they wanted to\n follow up as outpatient. IP reevaluated and does not believe that a\n stent would be feasible. No new issues.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # ACCESS: PIV x 1, L PICC\n # Ppx: Lovenox, PPi, Bowel Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n - Social Work and Case management involved, have discussed situation\n w/ brother and boyfriend.\n # Code: Full\n # Dispo: ICU, Will d/w case management re rehab facilities.\n PGY2 Addendum\n Agree with excellent MS4 PN. Will touch base with psychiatry re:\n sedating meds and EP re: atrial tachycardia. Will obtain EKG to\n reassess QTc. Ordered for TPN. Giving d5W for hypernatremia. Re-consult\n S/S for PMV re-fitting. transfer to LTAC.\n \n PGY2\n"},{"category":"Nursing","chartdate":"2167-10-26 00:00:00.000","description":"Nursing Progress Note","row_id":639597,"text":"56 yr old woman, who was transferred from osh for evaluation of\n tracheal bronchial malacia on .Pt presented to Medical\n Center on s/p fall down a flight of stairs fracturing, t5-t8 with\n propulsion treated conservatively with pain meds and back brace. She\n developed resp distress requiring intubation on . Trach/PEG done\n . Now with prolonged hospital course c/b by PNA, anxiety/altered\n mental status, R&LUE DVT .Pt found to have small non occlusive clot on\n her right axial vein via Ultrasound, now rec\ning Lovenox. She has had\n problems with vomiting tube feedings, so feeding tube passed through\n g-tube to her jejunenum. However, she continues to intermit raise\n gastric contents assoc with bronchospasm. Has not required ventilation\n since , on humidified TM @ 50%. Has required 1:1 sitters since\n decanulating herself, twice, despite restraints.\n Airway Clearance, Impaired\n Assessment:\n Rec\nd pt on humidified TM @ 70% with O2 sat 97-100%. RR 22-31 and\n regular. Lung snds rhonchorous in upper lobes, clearing with sxn\ning.\n Lower lobe snds diminished bilat.\n Action:\n FiO2 \nd to 50%. Pt requiring tracheal sxn\ning Q30-60mins, producing\n mod-copious amts thick white tenacious secretions. Pt generally unable\n to fully raise and expectorate secretions.\n Response:\n O2 sat has remained 99-100%, but drops to high 80\ns when requires\n sxn\ning.\n Plan:\n Cont to encourage pt to deep breathe and cough. Cont aggressive pulm\n toilet.\n Alteration in Nutrition\n Assessment:\n Per noc shift nurse, TF off overnight as pt too restless to maintain in\n upright position per strict aspiration precautions. BS +, abd\n soft/obese.\n Action:\n Pt placed on chair position in bed and TF restarted @ 0830 @\n 10ml/hr+50ml free water Q4hrs. She rec\nd her scheduled doses Reglan\n 20mg and colace, senna.\n Response:\n Pt tolerated TF well with no residuals, so TF inc\nd to 20ml/hr @ 1230.\n No BM yet today, but pt having flatus.\n Plan:\n Cont strict aspiration prec, holding TF when pt not in upright position\n and turning TF off for 15mins before turning.\n Arousal, Attention, and Cognition, Impaired\n Assessment:\n Pt rec\nd very restless in bed, attempting to exit despite bilat soft\n wrist restraints and sitter @ bedside. When PMV in place pt\n disoriented X 2, and reported she had been in a hotel and could pay\n $3000 cash to leave. When told she was in a hospital bed, she asked,\nWhere\ns the bed\n, unconvinced that she was lying in bed.\n Action:\n Pt rec\nd scheduled 0800 dose Resperadine. EKG taken.\n Response:\n Pt slept for 90mins until woken by team for am rounds. She has appeared\n sleepy since but resistant to falling asleep. QT interval WNL.\n Plan:\n Psych to consult and eval meds.\n"},{"category":"Physician ","chartdate":"2167-10-22 00:00:00.000","description":"Physician Attending Progress Note","row_id":639058,"text":"Chief Complaint: resp failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n increased bblocker\n J tube placed by IR through PEG- restarted TF and vomiting\n Went for tube study - dysmotility - contrast sat in stomach\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Diazepam (Valium) - 02:24 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 12:17 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 35.6\nC (96.1\n HR: 118 (93 - 140) bpm\n BP: 153/58(79) {82/39(49) - 153/101(105)} mmHg\n RR: 23 (14 - 37) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 3,808 mL\n 1,119 mL\n PO:\n TF:\n 4 mL\n IVF:\n 3,804 mL\n 1,119 mL\n Blood products:\n Total out:\n 1,650 mL\n 520 mL\n Urine:\n 1,590 mL\n 520 mL\n NG:\n 60 mL\n Stool:\n Drains:\n Balance:\n 2,158 mL\n 599 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 243 (169 - 281) mL\n PS : 5 cmH2O\n RR (Spontaneous): 17\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 67\n PIP: 11 cmH2O\n SpO2: 99%\n ABG: ///33/\n Ve: 4.1 L/min\n Physical Examination\n Gen: lying in bed, alert, responding to questions\n CV; tachy RR\n Chest: bibasilar decreased BS, faint exp wheeze\n Abd: soft NT+BS\n Ext: no edema\n Labs / Radiology\n 8.2 g/dL\n 356 K/uL\n 129 mg/dL\n 0.7 mg/dL\n 33 mEq/L\n 3.6 mEq/L\n 4 mg/dL\n 110 mEq/L\n 148 mEq/L\n 26.9 %\n 5.7 K/uL\n [image002.jpg]\n 06:22 AM\n 02:58 AM\n 03:43 AM\n 05:02 PM\n 03:36 AM\n 02:30 AM\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n WBC\n 7.0\n 7.1\n 7.1\n 6.9\n 7.6\n 9.5\n 5.7\n Hct\n 29.7\n 28.9\n 29.2\n 27.8\n 32.7\n 28.6\n 28.9\n 30.0\n 26.9\n Plt\n 395\n 462\n 452\n 467\n 548\n 528\n 356\n Cr\n 0.7\n 0.6\n 0.7\n 0.8\n 0.7\n 0.8\n 1.0\n 0.7\n Glucose\n 126\n 137\n 104\n 108\n 131\n 128\n 121\n 129\n Other labs: PT / PTT / INR:15.2/24.6/1.3, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.7 mg/dL, Mg++:2.1 mg/dL, PO4:4.1\n mg/dL\n Assessment and Plan\n 1. Tachycardia: runs of attach Appreciate EP consult\n will increase\n bblocker. Have to convert to metoprolol 7.5mg IV Q4 because unable to\n take pos.\n 2. Persistent Nausea/Vomiting: we have ruled out\n pSBO/SBO, very poor\n bowel sounds, tube study this AM shows contrast not moving out of the\n jejunum. GI consult to discuss any role for EGD. Place PICC for TPN as\n she has not had nutrition.\n 2. Resp Failure\n Trach mask trials all day, PSV\n PMV trials\n Per IP not stent planned as technically not possible to\n place into her airway\n 3. DVT and coagulopathy: reversed with IV Vit k\n hold coumadin today\n 4. Hypernatremia Replete free water.\n Please see today\ns ICU team note for other issues.\n ICU Care\n Nutrition: plan for TPN\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 04:00 AM\n Prophylaxis:\n DVT: plan for coumadin\n Stress ulcer: ppi\n Communication: spoke with son and\n status: Full code\n Disposition : ICU\n"},{"category":"Physician ","chartdate":"2167-10-24 00:00:00.000","description":"Physician Resident Progress Note","row_id":639334,"text":"Chief Complaint:\n 24 Hour Events:\n Pt decannulated herself x2 yesterday, the 1st episode she desatted to\n the 80s, the second episode she desated and her heart rate decreased to\n 39-40, before the trach could be replaced.\n PICC line placed by IR, called to notify that there was clot in both\n arms, placed in L arm more proximally than small Bacillis vein clot.\n Coumadin restarted after PICC placement with 2mg\n Per GI Recs: Reglan restarted at 20mg IV q 8 hours, and meds were\n restarted via tube. No vomitting.\n Per PSYCH recs: d/c'd all benzoes, (also requested d/c reglan if GI\n ok), added Risperdal 0.5mg (and can add 0.5mg PRN, and titrate up\n to total daily dose of 2-3mg if helping)\n Per Cards recs: after 18hr of amiodaron drip. Start PO amiodarone 200mg\n TID, which was done at 1am.\n Brother visited\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 37.4\nC (99.4\n HR: 90 (73 - 121) bpm\n BP: 155/49(75) {103/47(66) - 175/98(111)} mmHg\n RR: 32 (14 - 32) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,151 mL\n 293 mL\n PO:\n TF:\n IVF:\n 1,852 mL\n 13 mL\n Blood products:\n Total out:\n 2,460 mL\n 820 mL\n Urine:\n 2,460 mL\n 820 mL\n NG:\n Stool:\n Drains:\n Balance:\n -309 mL\n -527 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Set): 0 (0 - 0) mL\n Vt (Spontaneous): 360 (360 - 360) mL\n PS : 10 cmH2O\n RR (Set): 0\n RR (Spontaneous): 21\n FiO2: 40%\n SpO2: 98%\n ABG: ///33/\n Physical Examination\n Gen: Asleep, unarousable, responds minimally to noxious stimuli\n HEENT: PERRL, MMM\n Resp: CTA bilaterally, no rales, rhonchi, or wheezing, small\n inspirations.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, BS+\n Exte: No edema, DP 2+ bil\n NEURO: reflexes 2+ bilaterally.\n Labs / Radiology\n 316 K/uL\n 8.3 g/dL\n 114 mg/dL\n 0.7 mg/dL\n 33 mEq/L\n 4.0 mEq/L\n 7 mg/dL\n 111 mEq/L\n 149 mEq/L\n 27.0 %\n 8.0 K/uL\n [image002.jpg]\n 03:43 AM\n 05:02 PM\n 03:36 AM\n 02:30 AM\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n 03:00 AM\n 04:00 AM\n WBC\n 7.1\n 6.9\n 7.6\n 9.5\n 5.7\n 7.3\n 8.0\n Hct\n 29.2\n 27.8\n 32.7\n 28.6\n 28.9\n 30.0\n 26.9\n 27.3\n 27.0\n Plt\n 452\n 467\n 548\n 528\n 356\n 346\n 316\n Cr\n 0.7\n 0.8\n 0.7\n 0.8\n 1.0\n 0.7\n 0.7\n 0.7\n Glucose\n 104\n 108\n 131\n 128\n 121\n 129\n 123\n 114\n Other labs: PT / PTT / INR:13.2/22.4/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:9.0 mg/dL, Mg++:2.3 mg/dL, PO4:4.1\n mg/dL\n Assessment and Plan\n 55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach, PEG placement now with respiratory failure secondary to\n tracheomalacia , resolved HAP.\n .\n # Respiratory failure: Slowly improving, spending most of the day on\n trach mask with short periods of rest on PSV at night and setbacks\n from increased secretions to vomiting/aspiration events and her\n self-decanulations.\n - Continue to increase time on trach mask as tolerated.\n - Discontinue all orders for sedation except for Risperdal QHS.\n - PMV with suctioning as tolerated\n # Nutrition/Vomiting: Normal CT-abdomen, had FT placed via peg into\n jejunum, but continued to vomit. Tube study showed dysmotility in small\n bowel, but no obstruction, no retrograde flow. GI recs Reglan 20mg IV Q\n 8 hours and restart meds via G-J tube, if tolerated slowly restart TFs.\n PICC line placed yesterday and TPN started.\n - GI consult, appreciate recs\n - Small volume TFs start today\n - Continue TPN today\n # HAP vs Aspiration PNA: Had been afebrile for last several days, now\n with new fever two nights ago after having decanulated herself. Likely\n had some aspiration. Chemical pneumonitis versus new aspiration PNA.\n Now Afebrile for past 24 hours.\n - f/u daily CXR\n - F/u cx data\n - If remains febrile, send sputum cx, otherwise hold on abx.\n .\n # Tachycardia: Pt in and out of SVT and sinus, increased BB seems to\n help, but pt does not stay in sinus. Cards rec to start Amiodarone IV\n drip, and then convert to PO, 200mg TID. Would consider EPS if\n amiodarone not successful, though would wait until pt more stable for\n general anesthesia.\n - Changed to IV metoprolol to 10mg IV q4hr.\n - Completed amiodarone 0.5mg/min IV drip x 18 hours, and converted to\n 200mg PO TID..\n - Cards c/s, appreciate recs\n # Sedation/Anxiolysis/AlteredMS: unclear etiology of her confusion and\n agitation. Has had long hospital course and multiple psychotropic\n medications as well as hx of EtOH abuse.\n - d/c all benzos. opiates, and antihistamines\n - Psychiatry consulted, appreciate recs\n - started Risperdal 0.5mg PO BID, d/c zyprexa.\n # Adrenal Insufficency: Endocrine following. Pt does not appear to be\n adrenally insufficient at baseline. Suggesting if the patient under\n goes major stressors such as major surgery, sepsis, she may need stress\n dosed steroids.\n .\n # Fluid Status: Likely approaching euvolemia, though still has mild\n hypernatramia which may suggest is still intravascularly depleated.\n - Monitoring urine output\n - will provide D5W IVF as need for hypernatremia and follow lytes\n # UE DVT and elevated INR: DVT in right UE has resolved, new\n non-occlusive in left axillary vein. INR has been volatile, likely from\n drug interactions and poor nutritional status. Have been unable to keep\n her appropariately therapeutic.\n - d/c coumadin\n - start Lovenox, maintain until GI issues resolved and can restart\n coumadin\n .\n #Hematemesis: Pt had small amt Hematemesis, after vomiting, last week.\n None today. HCT stable.\n -Will follow HCT.\n - Guaiac stools\n # Spine fracture: Stable\n - Brace for OOB, will discuss with Neurosurgery if current brace is\n optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n .\n # Tracheomalacia. Was initially addressed with IP and they wanted to\n follow up as outpatient. IP reevaluated and does not believe that a\n stent would be feasible.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # ACCESS: PIV x 1, PICC placement\n yesterday.\n # Ppx: subtherapeutic INR restarting coumadin today, Ranitidine, Bowel\n Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n - Social Work and Case management involved, have discussed situation\n w/ brother and boyfriend.\n # Code: Full\n # Dispo: ICU, Screening for vent facilities\n ICU Care\n Nutrition:\n TPN without Lipids - 06:00 PM 41. mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n PICC Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Nursing","chartdate":"2167-10-20 00:00:00.000","description":"Nursing Progress Note","row_id":638537,"text":"55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach, PEG, placement no with respiratory failure secondary to\n tracheomalacia , resolving HAP.\n Arousal, Attention, and Cognition, Impaired\n Assessment:\n Alert, mouthing words but very difficult to understand. Follows\n commands. MAE on bed, attempting to get up. Restless last evening, did\n eventually fall off to sleep this AM.\n Action:\n Zyprexa x 1 . Frequent re-orientation to place, situation. Soft wrist\n restraints for patient safety.\n Response:\n Pt did eventually fall asleep. Re-orientation does have calming effect\n however it is short term.\n Plan:\n No valium or benadryl per psych as this exacerbates delirium. Zyprexa\n for agitation. pt prn.\n Hypernatremia (high sodium)\n Assessment:\n Na 145 last night, 148 this AM.\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Trach collar @ 50% O2 overnight until 4AM, Sats 90-97%. RR 17-20s.\n Around 4AM RR in low 30s, sats low 90s while sleeping--? Fatiguing.\n Strong cough, able to cough thick white ->tan secretions out of trach.\n Occ suctioned for same. Lungs are rhonchorous throughout. Impaired gag.\n Action:\n Suctioned prn for copious secretions. MDIs. Placed back on vent @ 4AM\n d/t fatigue.\n Response:\n Tolerated trach collar most of night, back on vent this AM d/t fatigue\n with RR in teens, Sats 98%.\n Plan:\n Wean from vent as tolerated. MDIs, suction as needed.\n Alteration in Nutrition\n Assessment:\n Tube feeds off overnight d/t constant vomiting. No vomiting overnight.\n Action:\n NPO. Reglan q 6 hrs.\n Response:\n No vomiting. Small brown stool x 1.\n Plan:\n NPO. ? may go to IR today to change Gtube to Jtube. Reglan. Meds via\n Gtube.\n"},{"category":"Respiratory ","chartdate":"2167-10-23 00:00:00.000","description":"Respiratory Care Shift Note","row_id":639134,"text":"Demographics\n Day of mechanical ventilation: 35\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Tube Type\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 7.0mm\n PMV:\n Cuff Management:\n Cuff pressure: 23 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments: pt has spc can expectorate secretions as well\n Ventilation Assessment\n Level of breathing assistance: Unassisted spontaneous breathing\n Visual assessment of breathing pattern: pt remained on t/c noc as\n tolerated.\n Plan\n Next 24-48 hours: continue with t/c as tolerates, has periods of ^ wob\n then return to vent. Remain on t/c noc.\n"},{"category":"Physician ","chartdate":"2167-10-23 00:00:00.000","description":"Physician Attending Progress Note","row_id":639232,"text":"Chief Complaint: resp distress\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n UNPLANNED EXTUBATION (PATIENT-INITIATED) - At 03:50 PM\n Pt pulled out her trach tube, tube replaced\n POulled out trach again at 7:15 AM complicated by bradycardia and\n profound desaturation\n FEVER - 101.4\nF - 12:00 AM\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Amiodarone - 0.5 mg/min\n Other ICU medications:\n Metoprolol - 01:00 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.4\n Tcurrent: 36.8\nC (98.2\n HR: 116 (84 - 142) bpm\n BP: 147/84(96) {86/39(53) - 181/113(137)} mmHg\n RR: 23 (13 - 27) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,127 mL\n 994 mL\n PO:\n TF:\n IVF:\n 2,127 mL\n 994 mL\n Blood products:\n Total out:\n 995 mL\n 900 mL\n Urine:\n 995 mL\n 900 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,132 mL\n 94 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: CPAP/PPS\n Vt (Set): 0 (0 - 0) mL\n Vt (Spontaneous): 360 (208 - 360) mL\n PS : 10 cmH2O\n RR (Set): 0\n RR (Spontaneous): 21\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 0 cmH2O\n SpO2: 99%\n ABG: ///31/\n Physical Examination\n Gen: lying in bed, alert, responding to questions, PMV placed\n CV; tachy RR\n Chest: bibasilar decreased BS, faint exp wheeze\n Abd: soft NT+BS\n Ext: no edema\n Skin: warm\n Neurologic: confused, stating that p[eople are trying to kill her\n Labs / Radiology\n 8.4 g/dL\n 346 K/uL\n 123 mg/dL\n 0.7 mg/dL\n 31 mEq/L\n 3.8 mEq/L\n 4 mg/dL\n 107 mEq/L\n 144 mEq/L\n 27.3 %\n 7.3 K/uL\n [image002.jpg]\n 02:58 AM\n 03:43 AM\n 05:02 PM\n 03:36 AM\n 02:30 AM\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n 03:00 AM\n WBC\n 7.1\n 7.1\n 6.9\n 7.6\n 9.5\n 5.7\n 7.3\n Hct\n 28.9\n 29.2\n 27.8\n 32.7\n 28.6\n 28.9\n 30.0\n 26.9\n 27.3\n Plt\n 462\n 452\n 467\n 548\n 528\n 356\n 346\n Cr\n 0.6\n 0.7\n 0.8\n 0.7\n 0.8\n 1.0\n 0.7\n 0.7\n Glucose\n 137\n 104\n 108\n 131\n 128\n 121\n 129\n 123\n Other labs: PT / PTT / INR:14.1/23.7/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.8 mg/dL, Mg++:1.9 mg/dL, PO4:3.7\n mg/dL\n Assessment and Plan\n 1. Tachycardia: runs of attach Appreciate EP consult\n trying IV Amio.\n will increase bblocker. Have to convert to metoprolol 10 mg IV Q4\n because unable to take pos.\n 2. Persistent Nausea/Vomiting: we have ruled out\n pSBO/SBO, very poor\n bowel sounds, tube study this AM shows contrast not moving out of the\n jejunum. GI consult to discuss any role for EGD. Place PICC for TPN as\n she has not had nutrition.\n 3. Agitation: delirium- trying to wean off narcotics- Will call psych\n as she is no harmful to self with pulling out trach x 2 and very\n paranoid. 1:1 sitter for safety\n 2. Resp Failure\n Trach mask trials all day, PSV\n PMV trials\n Per IP not stent planned as technically not possible to\n place into her airway\n 3. DVT and coagulopathy: reversed with IV Vit k\n hold coumadin today\n 4. Hypernatremia Replete free water.\n Please see today\ns ICU team note for other issues.\n ICU Care\n Nutrition: start TPN after PICC\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 06:31 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n Communication: met with brother for 30 minutes this afternoon and\n reviewed medical and social issues\n Code status: Full code\n Disposition :ICU\n Total time spent: 45\n"},{"category":"Nursing","chartdate":"2167-10-23 00:00:00.000","description":"Nursing Progress Note","row_id":639244,"text":"Tachycardia, Other\n Assessment:\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Physician ","chartdate":"2167-10-25 00:00:00.000","description":"Physician Resident Progress Note","row_id":639475,"text":"Chief Complaint:\n 24 Hour Events:\n TF were restarted in afternoon and held after one episode of a coughing\n fit in the evening. Pt was suctioned, CXR unchanged. AVSS.\n One episode of SVT to the low 100\ns overnight from 2:30 to 3:15am.\n Given D5W x 2 liters for hypernatremia\n Lovenox 100mg SC BID for prior UE DVT\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:17 AM\n Enoxaparin (Lovenox) - 06:00 PM\n Metoprolol - 06:00 PM\n Other medications:\n Changes to medical and family history: No additional\n Review of systems is unchanged from admission except as noted below\n Review of systems: Pt mouthing words but team unable to understand.\n Flowsheet Data as of 05:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.3\nC (97.4\n HR: 68 (64 - 104) bpm\n BP: 116/51(66) {105/45(44) - 151/74(89)} mmHg\n RR: 24 (21 - 38) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,676 mL\n 776 mL\n PO:\n TF:\n 61 mL\n IVF:\n 1,418 mL\n 540 mL\n Blood products:\n Total out:\n 1,910 mL\n 195 mL\n Urine:\n 1,910 mL\n 195 mL\n NG:\n Stool:\n Drains:\n Balance:\n 766 mL\n 581 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 96%\n ABG: ////\n Physical Examination\n Gen: Awake, Mouthing words\n HEENT: PERRL, MMM\n Resp: CTA bilaterally, no rales, rhonchi, or wheezing, small\n inspirations.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, BS+\n Exte: No edema, DP 2+ bil\n NEURO: Gross Motor and Sensation in 4 extremities\n Labs / Radiology\n 316 K/uL\n 8.3 g/dL\n 114 mg/dL\n 0.7 mg/dL\n 33 mEq/L\n 4.0 mEq/L\n 7 mg/dL\n 110 mEq/L\n 148 mEq/L\n 27.0 %\n 8.0 K/uL\n [image002.jpg]\n 03:43 AM\n 05:02 PM\n 03:36 AM\n 02:30 AM\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n 03:00 AM\n 04:00 AM\n WBC\n 7.1\n 6.9\n 7.6\n 9.5\n 5.7\n 7.3\n 8.0\n Hct\n 29.2\n 27.8\n 32.7\n 28.6\n 28.9\n 30.0\n 26.9\n 27.3\n 27.0\n Plt\n 452\n 467\n 548\n 528\n 356\n 346\n 316\n Cr\n 0.7\n 0.8\n 0.7\n 0.8\n 1.0\n 0.7\n 0.7\n 0.7\n Glucose\n 104\n 108\n 131\n 128\n 121\n 129\n 123\n 114\n Other labs: PT / PTT / INR:13.2/22.4/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:9.0 mg/dL, Mg++:2.3 mg/dL, PO4:4.1\n mg/dL\n Assessment and Plan\n 55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach, PEG with resolving respiratory failure and HAP.\n .\n # Respiratory failure: 36hrs off vent, now on trach mask. No further\n self-decanulations overnight.\n - Tach mask as tolerated.\n - Holding sedation with exception of Risperidal 0.5mg .\n - PMV with suctioning as tolerated\n .\n # Nutrition/Vomiting: TFs restarted yesterday while patient was not in\n optimal positioning. One large BM in past 24 hrs to indicate potential\n improvement in ileus.\n - Cont Reglan 20mg IV Q 8 hours and restart meds via G-J tube,\n - Slowly restarting TFs and will increase as tolerated.\n - PICC line in place with TPN given when pt not tolerating.\n - GI consult, appreciate recs\n .\n # Tachycardia: One episode of SVT overnight with improved HR max of\n 100\ns versus 160s previously. Pt now on PO Amiodarone 200 TID, and IV\n metoprolol\n - Will change IV metoprolol to metoprolol 25mg PO TID\n - f/u Cards recs\n # Sedation/Anxiolysis/AlteredMS: Improved alertness. Long hospital\n course and multiple psychotropic medications as well as hx of EtOH\n abuse.\n - - started Risperdal 0.5mg PO BID\n - continue to hold all benzos. opiates, and antihistamines\n - f/u psych recs.\n .\n # Fluid Status: Mild hypernatramia with good UOP.\n - providing D5W IVF PRN and follow lytes\n # UE DVT and elevated INR: Decision made to d/c Coumadin given her\n labile INR, and start Lovenox . L Picc difficult to flush this AM.\n - Will flush L PICC with TPA\n .\n # Spine fracture: Stable\n - Brace for OOB, will discuss with Neurosurgery if current brace is\n optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n .\n # Tracheomalacia. Was initially addressed with IP and they wanted to\n follow up as outpatient. IP reevaluated and does not believe that a\n stent would be feasible.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # ACCESS: PIV x 1, L PICC\n # Ppx: Lovenox, PPi, Bowel Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n - Social Work and Case management involved, have discussed situation\n w/ brother and boyfriend.\n # Code: Full\n # Dispo: ICU, Screening for vent facilities\n ICU Care\n Nutrition:\n TPN without Lipids - 06:10 PM 43. mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n PICC Line - 01:30 PM\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2167-10-25 00:00:00.000","description":"Physician Resident Progress Note","row_id":639476,"text":"Chief Complaint:\n 24 Hour Events:\n TF were restarted in afternoon and held after one episode of a coughing\n fit in the evening. Pt was suctioned, CXR unchanged. AVSS.\n One episode of SVT to the low 100\ns overnight from 2:30 to 3:15am.\n Given D5W x 2 liters for hypernatremia\n Lovenox 100mg SC BID for prior UE DVT\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:17 AM\n Enoxaparin (Lovenox) - 06:00 PM\n Metoprolol - 06:00 PM\n Other medications:\n Changes to medical and family history: No additional\n Review of systems is unchanged from admission except as noted below\n Review of systems: Pt mouthing words but team unable to understand.\n Flowsheet Data as of 05:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.3\nC (97.4\n HR: 68 (64 - 104) bpm\n BP: 116/51(66) {105/45(44) - 151/74(89)} mmHg\n RR: 24 (21 - 38) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,676 mL\n 776 mL\n PO:\n TF:\n 61 mL\n IVF:\n 1,418 mL\n 540 mL\n Blood products:\n Total out:\n 1,910 mL\n 195 mL\n Urine:\n 1,910 mL\n 195 mL\n NG:\n Stool:\n Drains:\n Balance:\n 766 mL\n 581 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 96%\n ABG: ////\n Physical Examination\n Gen: Awake, Mouthing words\n HEENT: PERRL, MMM\n Resp: CTA bilaterally, no rales, rhonchi, or wheezing, small\n inspirations.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, BS+\n Exte: No edema, DP 2+ bil\n NEURO: Gross Motor and Sensation in 4 extremities\n Labs / Radiology\n 316 K/uL\n 8.3 g/dL\n 114 mg/dL\n 0.7 mg/dL\n 33 mEq/L\n 4.0 mEq/L\n 7 mg/dL\n 110 mEq/L\n 148 mEq/L\n 27.0 %\n 8.0 K/uL\n [image002.jpg]\n 03:43 AM\n 05:02 PM\n 03:36 AM\n 02:30 AM\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n 03:00 AM\n 04:00 AM\n WBC\n 7.1\n 6.9\n 7.6\n 9.5\n 5.7\n 7.3\n 8.0\n Hct\n 29.2\n 27.8\n 32.7\n 28.6\n 28.9\n 30.0\n 26.9\n 27.3\n 27.0\n Plt\n 452\n 467\n 548\n 528\n 356\n 346\n 316\n Cr\n 0.7\n 0.8\n 0.7\n 0.8\n 1.0\n 0.7\n 0.7\n 0.7\n Glucose\n 104\n 108\n 131\n 128\n 121\n 129\n 123\n 114\n Other labs: PT / PTT / INR:13.2/22.4/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:9.0 mg/dL, Mg++:2.3 mg/dL, PO4:4.1\n mg/dL\n Assessment and Plan\n 55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach, PEG with resolving respiratory failure and HAP.\n .\n # Respiratory failure: 36hrs off vent, now on trach mask. No further\n self-decanulations overnight.\n - Tach mask as tolerated.\n - Holding sedation with exception of Risperidal 0.5mg .\n - PMV with suctioning as tolerated\n .\n # Nutrition/Vomiting: TFs restarted yesterday while patient was not in\n optimal positioning. One large BM in past 24 hrs to indicate potential\n improvement in ileus.\n - Cont Reglan 20mg IV Q 8 hours and restart meds via G-J tube,\n - Slowly restarting TFs and will increase as tolerated.\n - PICC line in place with TPN given when pt not tolerating.\n - GI consult, appreciate recs\n .\n # Tachycardia: One episode of SVT overnight with improved HR max of\n 100\ns versus 160s previously. Pt now on PO Amiodarone 200 TID, and IV\n metoprolol\n - Will change IV metoprolol to metoprolol 25mg PO TID\n - f/u Cards recs\n # Sedation/Anxiolysis/AlteredMS: Improved alertness. Long hospital\n course and multiple psychotropic medications as well as hx of EtOH\n abuse.\n - - started Risperdal 0.5mg PO BID\n - continue to hold all benzos. opiates, and antihistamines\n - f/u psych recs.\n .\n # Fluid Status: Mild hypernatramia with good UOP.\n - providing D5W IVF PRN and follow lytes\n # UE DVT and elevated INR: Decision made to d/c Coumadin given her\n labile INR, and start Lovenox . L Picc difficult to flush this AM.\n - Will flush L PICC with TPA\n .\n # Spine fracture: Stable\n - Brace for OOB, will discuss with Neurosurgery if current brace is\n optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n .\n # Tracheomalacia. Was initially addressed with IP and they wanted to\n follow up as outpatient. IP reevaluated and does not believe that a\n stent would be feasible.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # ACCESS: PIV x 1, L PICC\n # Ppx: Lovenox, PPi, Bowel Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n - Social Work and Case management involved, have discussed situation\n w/ brother and boyfriend.\n # Code: Full\n # Dispo: ICU, Screening for vent facilities\n ICU Care\n Nutrition:\n TPN without Lipids - 06:10 PM 43. mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n PICC Line - 01:30 PM\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM:\n On this day I examined the patient and was present for the key portions\n of the services provided. I have reviewed Dr \ns note above and\n agree with the findings and plan of care. I would emphasize that Ms\n has done well, and is off the ventilator now for over 36\n straight hours. Today she is awake, animated, but unable to talk as\n PMV is not in place due to secretions. Tube feeds had been held due to\n possible aspiration, but without clear cut evidence of such. So with\n the need for enteral nutrition and good bowel sounds, we will restart\n TFs today. For her emotional benefit, we will keep her well suctioned\n and allow her short periods on the PMV so that she can communicate and\n be less frustrated. The goal will be to have her remain stable so\n that transfer to pulm rehab can occur early this work week.\n , MD\n ------ Protected Section Addendum Entered By: , MD\n on: 14:29 ------\n"},{"category":"Physician ","chartdate":"2167-10-26 00:00:00.000","description":"Physician Resident Progress Note","row_id":639550,"text":"Chief Complaint:\n 24 Hour Events:\n Pt agitated overnight given extra Risperidone 0.5 mg x 2 overnight.\n (1.5mg total)\n 1000 mL D5W for Hypernatremia\n Changed B-Blocker from IV to PO, Metoprolol Tartrate 25 mg PO TID\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:17 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.7\nC (98\n HR: 120 (67 - 120) bpm\n BP: 110/64(76) {109/47(60) - 141/115(118)} mmHg\n RR: 26 (18 - 30) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 3,820 mL\n 856 mL\n PO:\n TF:\n 117 mL\n 20 mL\n IVF:\n 2,612 mL\n 572 mL\n Blood products:\n Total out:\n 2,460 mL\n 1,180 mL\n Urine:\n 2,460 mL\n 1,180 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,360 mL\n -324 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 100%\n ABG: ///33/\n Physical Examination\n Gen: Awake, Mouthing words, More agitated compared to previous\n mornings.\n HEENT: EOMI, No pallor in conjunctiva, MMM\n Resp: CTA bilaterally, no rales, rhonchi, or wheezing, good airway\n movement.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, decreased bowel sounds,, G-Tube in\n place with no erythema/induration\n Exte: No edema, DP 2+ bil\n NEURO: Gross Motor and Sensation in 4 extremities\n Labs / Radiology\n 249 K/uL\n 8.0 g/dL\n 122 mg/dL\n 0.5 mg/dL\n 33 mEq/L\n 3.7 mEq/L\n 13 mg/dL\n 108 mEq/L\n 146 mEq/L\n 24.7 %\n 5.5 K/uL\n [image002.jpg] CXR: L Picc, trach tip at midline, bibasilar\n opacities, low lung volumes, Bil pleural effusions.\n 03:36 AM\n 02:30 AM\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n 03:00 AM\n 04:00 AM\n 05:45 AM\n 03:51 AM\n WBC\n 6.9\n 7.6\n 9.5\n 5.7\n 7.3\n 8.0\n 8.7\n 5.5\n Hct\n 27.8\n 32.7\n 28.6\n 28.9\n 30.0\n 26.9\n 27.3\n 27.0\n 28.7\n 24.7\n Plt\n 467\n 548\n 528\n 356\n 346\n 316\n 271\n 249\n Cr\n 0.7\n 0.8\n 1.0\n 0.7\n 0.7\n 0.7\n 0.7\n 0.5\n Glucose\n 131\n 128\n 121\n 129\n 123\n 114\n 112\n 122\n Other labs: PT / PTT / INR:13.6/31.1/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:9.0 mg/dL, Mg++:2.2 mg/dL, PO4:3.1\n mg/dL\n Assessment and Plan\n 55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach, PEG with resolving respiratory failure and HAP.\n .\n # Respiratory failure: 36hrs off vent, now on trach mask, FiO2 70%. No\n further self-decanulations overnight.\n - Tach mask as tolerated.\n - Holding sedation with exception of Risperidal 0.5mg .\n - PMV with suctioning as tolerated\n - F/u CXR tomorrow\n .\n # Nutrition/Vomiting: TFs restarted yesterday while patient was not in\n optimal positioning. One large BM in past 24 hrs to indicate potential\n improvement in ileus.\n - Cont Reglan 20mg IV Q 8 hours and restart meds via G-J tube,\n - Increase TF as tolerated\n - PICC line in place with TPN given when pt not tolerating TF\n - GI consult, appreciate recs\n .\n # Tachycardia: Improved HR max of 120\ns versus 160s previously;\n elevated this am secondary to agitation. Pt now on PO Amiodarone 200\n TID and PO metoprolol 25mg TID\n - Continue current med regimen. Will continue amiodarone 200 TID for\n three weeks and then switch to qday.\n - Will schedule f/u in 4wks with Dr. upon d/c.\n - f/u Cards recs\n # Sedation/Anxiolysis/AlteredMS: Agitation O/N, continues to be\n agitated most likely secondary to long hospital course and multiple\n psychotropic medications as well as hx of EtOH abuse. Risperdal given\n O/N.\n - started Risperdal 0.5mg PO BID\n - continue to hold all benzos. opiates, and antihistamines\n - Appreciate psych. Will f/u psych recs.\n .\n # Hypernatremia/Fluid Status: Mild hypernatramia with good UOP\n (hypervolemic hypernatremia). On TPN/TF.\n - providing D5W IVF PRN and follow lytes (check Na this afternoon).\n # UE DVT and elevated INR: Decision made to d/c Coumadin given her\n labile INR, and start Lovenox . Current INR 1.2.\n - Will flush L PICC with TPA\n .\n # Spine fracture: Stable\n - Brace for OOB, will discuss with Neurosurgery if current brace is\n optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n .\n # Tracheomalacia. Was initially addressed with IP and they wanted to\n follow up as outpatient. IP reevaluated and does not believe that a\n stent would be feasible.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # ACCESS: PIV x 1, L PICC\n # Ppx: Lovenox, PPi, Bowel Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n - Social Work and Case management involved, have discussed situation\n w/ brother and boyfriend.\n # Code: Full\n # Dispo: ICU, Screening for vent facilities\n"},{"category":"Physician ","chartdate":"2167-10-26 00:00:00.000","description":"Physician Resident Progress Note","row_id":639588,"text":"Chief Complaint:\n 24 Hour Events:\n Pt agitated overnight given extra Risperidone 0.5 mg x 2 overnight.\n (1.5mg total)\n 1000 mL D5W for Hypernatremia\n Changed B-Blocker from IV to PO, Metoprolol Tartrate 25 mg PO TID\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:17 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.7\nC (98\n HR: 120 (67 - 120) bpm\n BP: 110/64(76) {109/47(60) - 141/115(118)} mmHg\n RR: 26 (18 - 30) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 3,820 mL\n 856 mL\n PO:\n TF:\n 117 mL\n 20 mL\n IVF:\n 2,612 mL\n 572 mL\n Blood products:\n Total out:\n 2,460 mL\n 1,180 mL\n Urine:\n 2,460 mL\n 1,180 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,360 mL\n -324 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 100%\n ABG: ///33/\n Physical Examination\n Gen: Awake, Mouthing words, More agitated compared to previous\n mornings.\n HEENT: EOMI, No pallor in conjunctiva, MMM\n Resp: CTAB, no rales, rhonchi, or wheezing, good airway movement.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, decreased bowel sounds,, G-Tube in\n place with no erythema/induration\n Exte: No edema, DP 2+ bil\n NEURO: Gross Motor and Sensation in 4 extremities\n Labs / Radiology\n 249 K/uL\n 8.0 g/dL\n 122 mg/dL\n 0.5 mg/dL\n 33 mEq/L\n 3.7 mEq/L\n 13 mg/dL\n 108 mEq/L\n 146 mEq/L\n 24.7 %\n 5.5 K/uL\n [image002.jpg] CXR: L Picc, trach tip at midline, bibasilar\n opacities, low lung volumes, Bil pleural effusions.\n 03:36 AM\n 02:30 AM\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n 03:00 AM\n 04:00 AM\n 05:45 AM\n 03:51 AM\n WBC\n 6.9\n 7.6\n 9.5\n 5.7\n 7.3\n 8.0\n 8.7\n 5.5\n Hct\n 27.8\n 32.7\n 28.6\n 28.9\n 30.0\n 26.9\n 27.3\n 27.0\n 28.7\n 24.7\n Plt\n 467\n 548\n 528\n 356\n 346\n 316\n 271\n 249\n Cr\n 0.7\n 0.8\n 1.0\n 0.7\n 0.7\n 0.7\n 0.7\n 0.5\n Glucose\n 131\n 128\n 121\n 129\n 123\n 114\n 112\n 122\n Other labs: PT / PTT / INR:13.6/31.1/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:9.0 mg/dL, Mg++:2.2 mg/dL, PO4:3.1\n mg/dL\n Assessment and Plan\n 56yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach/PEG with resolving respiratory failure and HAP.\n .\n # Respiratory failure: s/p intubation/extubation, now on trach mask,\n FiO2 70%. Tolerating well with good O2 sat. No further\n self-decanulations overnight.\n - Tach mask as tolerated.\n - Holding sedation with exception of Risperidal 0.5mg .\n - F/u CXR tomorrow\n .\n # Nutrition/Vomiting: Currently receiving TPN;. One large BM in past\n 24 hrs to indicate potential improvement in ileus.\n - Cont Reglan 20mg IV Q 8 hours; meds via G-J tube,\n - Will obtain recommendations from Nutrition re TPN before starting TPN\n tomorrow\n - TF as tolerated\n - Speech and Swallow eval\n - PICC line in place with TPN given when pt not tolerating TF\n - GI consult, appreciate recs\n .\n # Tachycardia: Improved HR max of 120\ns versus 160s previously;\n elevated this am secondary to agitation. Pt now on PO Amiodarone 200\n TID and PO metoprolol 25mg TID\n - Continue current med regimen. Will continue amiodarone 200 TID for\n three weeks and then switch to qday.\n - Will schedule f/u in 4wks with Dr. upon d/c/transfer.\n - f/u Cards recs\n # Sedation/Anxiolysis/AlteredMS: Agitation O/N, continues to be\n agitated most likely secondary to long hospital course and multiple\n psychotropic medications as well as hx of EtOH abuse. Risperdal given\n O/N.\n - started Risperdal 0.5mg PO BID\n - continue to hold all benzos. opiates, and antihistamines\n - Appreciate psych. Will call and f/u psych recs.\n #Anemia: Decrease in HCT from 28\n24; tachycardia. No known etiology of\n blood loss, most likely related to variaton\n -Will repeat HCT check this afternoon.\n # Hypernatremia/Fluid Status: Mild hypernatramia with good UOP\n (hypervolemic hypernatremia). On TPN/TF.\n - providing D5W IVF, free water flushes with TF\n -Will f/u lytes (Na) this afternoon at 5pm.\n # UE DVT and elevated INR: Decision made to d/c Coumadin given her\n labile INR, and start Lovenox . Current INR 1.2.\n - Will flush L PICC with TPA if does not flush\n .\n # Spine fracture: Stable\n - Brace for OOB, need to discuss with Neurosurgery before d/c if\n current brace is optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n .\n # Tracheomalacia. Was initially addressed with IP and they wanted to\n follow up as outpatient. IP reevaluated and does not believe that a\n stent would be feasible. No new issues.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # ACCESS: PIV x 1, L PICC\n # Ppx: Lovenox, PPi, Bowel Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n - Social Work and Case management involved, have discussed situation\n w/ brother and boyfriend.\n # Code: Full\n # Dispo: ICU, Will d/w case management re rehab facilities.\n"},{"category":"Nutrition","chartdate":"2167-10-20 00:00:00.000","description":"Clinical Nutrition Note","row_id":638618,"text":"Objective\n Pertinent medications: noted\n Labs:\n Value\n Date\n Glucose\n 128 mg/dL\n 02:30 AM\n Glucose Finger Stick\n 142\n 10:00 AM\n BUN\n 6 mg/dL\n 02:30 AM\n Creatinine\n 0.8 mg/dL\n 02:30 AM\n Sodium\n 148 mEq/L\n 02:30 AM\n Potassium\n 4.1 mEq/L\n 02:30 AM\n Chloride\n 105 mEq/L\n 02:30 AM\n TCO2\n 36 mEq/L\n 02:30 AM\n Albumin\n 3.5 g/dL\n 03:00 AM\n Calcium non-ionized\n 10.0 mg/dL\n 02:30 AM\n Phosphorus\n 4.3 mg/dL\n 02:30 AM\n Ionized Calcium\n 1.24 mmol/L\n 02:51 AM\n Magnesium\n 2.5 mg/dL\n 02:30 AM\n ALT\n 25 IU/L\n 07:34 AM\n Alkaline Phosphate\n 106 IU/L\n 07:34 AM\n AST\n 19 IU/L\n 07:34 AM\n WBC\n 7.6 K/uL\n 02:30 AM\n Hgb\n 10.0 g/dL\n 02:30 AM\n Hematocrit\n 32.7 %\n 02:30 AM\n Current diet order / nutrition support: NPO\n GI: Abd soft/obese/hypo bs\n Assessment of Nutritional Status\n Estimation of previous intake: Adequate\n Estimation of current intake: Inadequate\n Specifics:\n 55 y/o female s/p mechanical fall c/ T5-T8 fx c/ long hospital course,\n now s/p trach and PEG. Pt currently not receiving TF\ns development\n of N/V while TF\ns were infusing, despite addition of reglan. Ongoing\n discussion re changing FT to post-pyloric/JT, and the best way to do\n this. Hypernatremia since feeds/flushes held. Noted 500mL D5W\n given.\n Medical Nutrition Therapy Plan - Recommend the Following\n Will follow POC- ability to obtain access for resuming feeds, If unable\n to resume enteral feeds in next 2-3 days, will need to consider PPN/TPN\n to avoid nutritional decline\n Continue to monitor hydration status and give fluid prn\n Please page c/ ?\ns #\n"}],"string":"[\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-14 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 637511,\n \"text\": \"Chief Complaint: resp failure\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n s/p t spine fx with resp failure\\n 24 Hour Events:\\n BLOOD CULTURED - At 02:18 AM\\n SPUTUM CULTURE - At 02:18 AM\\n URINE CULTURE - At 02:18 AM\\n FEVER Pan cx\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Ceftriaxone - 12:00 AM\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Atrovent/Albuterol, Miralax, Chlorhex, Ceftriaxone, Thiamine Folate\\n Valium 5 mg QID COumadin 2.5\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Constitutional: Fever\\n Flowsheet Data as of 08:32 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.2\\nC (100.8\\n Tcurrent: 37.2\\nC (99\\n HR: 137 (120 - 151) bpm\\n BP: 125/55(73) {98/41(54) - 202/97(111)} mmHg\\n RR: 23 (12 - 39) insp/min\\n SpO2: 98%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 2,934 mL\\n 497 mL\\n PO:\\n TF:\\n 1,104 mL\\n 447 mL\\n IVF:\\n 1,000 mL\\n 50 mL\\n Blood products:\\n Total out:\\n 530 mL\\n 240 mL\\n Urine:\\n 530 mL\\n 240 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 2,404 mL\\n 257 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 318 (318 - 475) mL\\n PS : 10 cmH2O\\n RR (Spontaneous): 34\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n RSBI: 171\\n SpO2: 98%\\n ABG: ///32/\\n Ve: 9 L/min\\n Physical Examination\\n Gen sitting up in , on trach mask, interactive\\n CV tachy RRR\\n Chest good air movement ANT\\n Abd soft NT + NS\\n Ext: no edema\\n Neuro: alert follows simple commands\\n Labs / Radiology\\n 8.8 g/dL\\n 306 K/uL\\n 134 mg/dL\\n 0.6 mg/dL\\n 32 mEq/L\\n 4.0 mEq/L\\n 11 mg/dL\\n 106 mEq/L\\n 146 mEq/L\\n 26.8 %\\n 7.5 K/uL\\n [image002.jpg]\\n 03:10 AM\\n 03:08 PM\\n 03:00 AM\\n 03:36 AM\\n 04:40 PM\\n 03:00 AM\\n 07:05 PM\\n 03:00 AM\\n 05:00 AM\\n 02:06 AM\\n WBC\\n 11.3\\n 7.3\\n 6.1\\n 7.2\\n 5.2\\n 5.9\\n 7.5\\n Hct\\n 24.9\\n 27.6\\n 26.5\\n 26.9\\n 26.0\\n 27.2\\n 26.8\\n Plt\\n 227\\n 189\\n 209\\n 238\\n 240\\n 296\\n 306\\n Cr\\n 0.7\\n 0.6\\n 0.6\\n 0.9\\n 0.7\\n 0.6\\n 0.7\\n 0.6\\n TCO2\\n 26\\n Glucose\\n 114\\n 99\\n 115\\n 106\\n 100\\n 134\\n 134\\n Other labs: PT / PTT / INR:13.5/23.6/1.2, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:27/19, Alk Phos / T Bili:118/0.3,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.5 g/dL, LDH:243 IU/L, Ca++:9.2 mg/dL, Mg++:2.1 mg/dL, PO4:4.0\\n mg/dL\\n - Sputum: 3+ GPC cocci in prs and chains\\n yeast\\n Assessment and Plan 55 yr old alcoholic s/p t spine fx s/p trcah and\\n PEG with persistent resp failure\\n 1. Resp Failure: currently on trach mask, can do a few hours per\\n day, then needs for support. New pan Klebs in sputum, day\\n . Re- try. Holding off on stent by IP until after pulm rehab.\\n 2. Fevers: DDx - line infection VAP, check LFTs, check blood and\\n urine cx, LUE ultrasounds -\\n 3 Hemodynamics: persistant simus tachy\\n check CTPA to look for\\n emboli- has been off on anti coag - tachycardia with slightly decreased\\n UOP\\n bolus IVF and trend UOP. Watch to see if response with\\n tachycardia.\\n 4. Anti coag: for upper ext DVT but INR elevated on coumadin +\\n quinolone\\n repeat inr low- trend with po COumadin\\n 5. Adrenal Insufficiency: proper stim this AM, off steroids\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 06:23 AM 60 mL/hour\\n Glycemic Control:\\n Lines:\\n PICC Line - 09:19 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-23 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 639169,\n \"text\": \"Chief Complaint: resp distress\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 24 Hour Events:\\n UNPLANNED EXTUBATION (PATIENT-INITIATED) - At 03:50 PM\\n Pt pulled out her trach tube, tube replaced\\n FEVER - 101.4\\nF - 12:00 AM\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Amiodarone - 0.5 mg/min\\n Other ICU medications:\\n Metoprolol - 01:00 AM\\n Other medications:\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 10:40 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.6\\nC (101.4\\n Tcurrent: 36.8\\nC (98.2\\n HR: 116 (84 - 142) bpm\\n BP: 147/84(96) {86/39(53) - 181/113(137)} mmHg\\n RR: 23 (13 - 27) insp/min\\n SpO2: 99%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 2,127 mL\\n 994 mL\\n PO:\\n TF:\\n IVF:\\n 2,127 mL\\n 994 mL\\n Blood products:\\n Total out:\\n 995 mL\\n 900 mL\\n Urine:\\n 995 mL\\n 900 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,132 mL\\n 94 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask\\n Ventilator mode: CPAP/PPS\\n Vt (Set): 0 (0 - 0) mL\\n Vt (Spontaneous): 360 (208 - 360) mL\\n PS : 10 cmH2O\\n RR (Set): 0\\n RR (Spontaneous): 21\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n PIP: 0 cmH2O\\n SpO2: 99%\\n ABG: ///31/\\n Physical Examination\\n Gen: lying in bed, alert, responding to questions, PMV placed\\n CV; tachy RR\\n Chest: bibasilar decreased BS, faint exp wheeze\\n Abd: soft NT+BS\\n Ext: no edema\\n Skin: warm\\n Neurologic: confused, stating that p[eople are trying to kill kill,\\n that a owmna named is coming into her room\\n Labs / Radiology\\n 8.4 g/dL\\n 346 K/uL\\n 123 mg/dL\\n 0.7 mg/dL\\n 31 mEq/L\\n 3.8 mEq/L\\n 4 mg/dL\\n 107 mEq/L\\n 144 mEq/L\\n 27.3 %\\n 7.3 K/uL\\n [image002.jpg]\\n 02:58 AM\\n 03:43 AM\\n 05:02 PM\\n 03:36 AM\\n 02:30 AM\\n 01:30 AM\\n 06:41 AM\\n 03:20 PM\\n 03:23 AM\\n 03:00 AM\\n WBC\\n 7.1\\n 7.1\\n 6.9\\n 7.6\\n 9.5\\n 5.7\\n 7.3\\n Hct\\n 28.9\\n 29.2\\n 27.8\\n 32.7\\n 28.6\\n 28.9\\n 30.0\\n 26.9\\n 27.3\\n Plt\\n 462\\n 452\\n 467\\n 548\\n 528\\n 356\\n 346\\n Cr\\n 0.6\\n 0.7\\n 0.8\\n 0.7\\n 0.8\\n 1.0\\n 0.7\\n 0.7\\n Glucose\\n 137\\n 104\\n 108\\n 131\\n 128\\n 121\\n 129\\n 123\\n Other labs: PT / PTT / INR:14.1/23.7/1.2, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.8 mg/dL, Mg++:1.9 mg/dL, PO4:3.7\\n mg/dL\\n Assessment and Plan\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n 18 Gauge - 06:31 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :ICU\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-23 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 639171,\n \"text\": \"Chief Complaint: resp distress\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 24 Hour Events:\\n UNPLANNED EXTUBATION (PATIENT-INITIATED) - At 03:50 PM\\n Pt pulled out her trach tube, tube replaced\\n FEVER - 101.4\\nF - 12:00 AM\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Amiodarone - 0.5 mg/min\\n Other ICU medications:\\n Metoprolol - 01:00 AM\\n Other medications:\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 10:40 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.6\\nC (101.4\\n Tcurrent: 36.8\\nC (98.2\\n HR: 116 (84 - 142) bpm\\n BP: 147/84(96) {86/39(53) - 181/113(137)} mmHg\\n RR: 23 (13 - 27) insp/min\\n SpO2: 99%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 2,127 mL\\n 994 mL\\n PO:\\n TF:\\n IVF:\\n 2,127 mL\\n 994 mL\\n Blood products:\\n Total out:\\n 995 mL\\n 900 mL\\n Urine:\\n 995 mL\\n 900 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,132 mL\\n 94 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask\\n Ventilator mode: CPAP/PPS\\n Vt (Set): 0 (0 - 0) mL\\n Vt (Spontaneous): 360 (208 - 360) mL\\n PS : 10 cmH2O\\n RR (Set): 0\\n RR (Spontaneous): 21\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n PIP: 0 cmH2O\\n SpO2: 99%\\n ABG: ///31/\\n Physical Examination\\n Gen: lying in bed, alert, responding to questions, PMV placed\\n CV; tachy RR\\n Chest: bibasilar decreased BS, faint exp wheeze\\n Abd: soft NT+BS\\n Ext: no edema\\n Skin: warm\\n Neurologic: confused, stating that p[eople are trying to kill kill,\\n that a owmna named is coming into her room\\n Labs / Radiology\\n 8.4 g/dL\\n 346 K/uL\\n 123 mg/dL\\n 0.7 mg/dL\\n 31 mEq/L\\n 3.8 mEq/L\\n 4 mg/dL\\n 107 mEq/L\\n 144 mEq/L\\n 27.3 %\\n 7.3 K/uL\\n [image002.jpg]\\n 02:58 AM\\n 03:43 AM\\n 05:02 PM\\n 03:36 AM\\n 02:30 AM\\n 01:30 AM\\n 06:41 AM\\n 03:20 PM\\n 03:23 AM\\n 03:00 AM\\n WBC\\n 7.1\\n 7.1\\n 6.9\\n 7.6\\n 9.5\\n 5.7\\n 7.3\\n Hct\\n 28.9\\n 29.2\\n 27.8\\n 32.7\\n 28.6\\n 28.9\\n 30.0\\n 26.9\\n 27.3\\n Plt\\n 462\\n 452\\n 467\\n 548\\n 528\\n 356\\n 346\\n Cr\\n 0.6\\n 0.7\\n 0.8\\n 0.7\\n 0.8\\n 1.0\\n 0.7\\n 0.7\\n Glucose\\n 137\\n 104\\n 108\\n 131\\n 128\\n 121\\n 129\\n 123\\n Other labs: PT / PTT / INR:14.1/23.7/1.2, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.8 mg/dL, Mg++:1.9 mg/dL, PO4:3.7\\n mg/dL\\n Assessment and Plan\\n 1. Tachycardia: runs of attach Appreciate EP consult\\n trying IV Amio.\\n will increase bblocker. Have to convert to metoprolol 7.5mg IV Q4\\n because unable to take pos.\\n 2. Persistent Nausea/Vomiting: we have ruled out\\n pSBO/SBO, very poor\\n bowel sounds, tube study this AM shows contrast not moving out of the\\n jejunum. GI consult to discuss any role for EGD. Place PICC for TPN as\\n she has not had nutrition.\\n 2. Resp Failure\\n Trach mask trials all day, PSV\\n PMV trials\\n Per IP not stent planned as technically not possible to\\n place into her airway\\n 3. DVT and coagulopathy: reversed with IV Vit k\\n hold coumadin today\\n 4. Hypernatremia Replete free water.\\n Please see today\\ns ICU team note for other issues.\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n 18 Gauge - 06:31 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :ICU\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-29 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 640089,\n \"text\": \"Chief Complaint: Delerium\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 24 Hour Events:\\n Remains with delerium.\\n Experienced episode of SVT --> responded to extra iv dose metoprolol.\\n History obtained from Medical records\\n Patient unable to provide history: Encephalopathy\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Constitutional: No(t) Fatigue, No(t) Fever, No(t) Weight loss\\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, OG / NG tube\\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\\n Tachycardia, No(t) Orthopnea\\n Nutritional Support: No(t) NPO, Tube feeds, No(t) Parenteral nutrition\\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\\n No(t) Diarrhea, No(t) Constipation\\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\\n Integumentary (skin): No(t) Jaundice, No(t) Rash\\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\\n Heme / Lymph: No(t) Lymphadenopathy, No(t) Anemia, No(t) Coagulopathy\\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\\n No(t) Daytime somnolence\\n Allergy / Immunology: No(t) Immunocompromised, No(t) Influenza vaccine\\n Signs or concerns for abuse : No\\n Pain: No pain / appears comfortable\\n Flowsheet Data as of 11:42 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37\\nC (98.6\\n Tcurrent: 36.2\\nC (97.2\\n HR: 78 (61 - 115) bpm\\n BP: 108/48(60) {91/36(50) - 156/79(101)} mmHg\\n RR: 24 (17 - 30) insp/min\\n SpO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 2,952 mL\\n 760 mL\\n PO:\\n TF:\\n 646 mL\\n 685 mL\\n IVF:\\n 950 mL\\n 75 mL\\n Blood products:\\n Total out:\\n 2,430 mL\\n 610 mL\\n Urine:\\n 2,430 mL\\n 380 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 522 mL\\n 150 mL\\n Respiratory support\\n SpO2: 100%\\n ABG: ///35/\\n Physical Examination\\n General Appearance: No(t) Well nourished, No acute distress, No(t)\\n Overweight / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic\\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\\n pale, No(t) Sclera edema\\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\\n Endotracheal tube, No(t) NG tube, No(t) OG tube\\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\\n Cervical adenopathy\\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic,\\n No(t) Diastolic)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric, Paradoxical), (Percussion:\\n Resonant : , No(t) Hyperresonant: , No(t) Dullness : ), (Breath Sounds:\\n Clear : , No(t) Crackles : , No(t) Bronchial: , No(t) Wheezes : , No(t)\\n Diminished: , No(t) Absent : , No(t) Rhonchorous: )\\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\\n No(t) Tender: , No(t) Obese\\n Extremities: No(t) Cyanosis, No(t) Clubbing\\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\\n Skin: Warm, No(t) Rash: , No(t) Jaundice\\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\\n stimuli, No(t) Oriented (to): , Movement: Purposeful, No(t) Sedated,\\n No(t) Paralyzed, Tone: Normal\\n Labs / Radiology\\n 7.2 g/dL\\n 187 K/uL\\n 105 mg/dL\\n 0.5 mg/dL\\n 35 mEq/L\\n 3.8 mEq/L\\n 17 mg/dL\\n 108 mEq/L\\n 147 mEq/L\\n 23.7 %\\n 5.1 K/uL\\n [image002.jpg]\\n 03:00 AM\\n 04:00 AM\\n 05:45 AM\\n 03:51 AM\\n 04:45 PM\\n 04:00 AM\\n 07:37 PM\\n 04:05 AM\\n 06:05 PM\\n 03:23 AM\\n WBC\\n 7.3\\n 8.0\\n 8.7\\n 5.5\\n 5.7\\n 5.8\\n 5.1\\n Hct\\n 27.3\\n 27.0\\n 28.7\\n 24.7\\n 25.2\\n 25.3\\n 23.7\\n 24.7\\n 23.7\\n Plt\\n 346\\n 316\\n 271\\n 249\\n 231\\n 203\\n 187\\n Cr\\n 0.7\\n 0.7\\n 0.7\\n 0.5\\n 0.4\\n 0.5\\n 0.5\\n 0.5\\n Glucose\\n 123\\n 114\\n 112\\n 122\\n 145\\n 137\\n 149\\n 105\\n Other labs: PT / PTT / INR:13.3/32.4/1.1, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.8 mg/dL, Mg++:2.1 mg/dL, PO4:3.5\\n mg/dL\\n Assessment and Plan\\n T-spine fracture, delerium.\\n DELERIUM -- persistent. Etiology may be related to prior EtOH use,\\n contribution of medications. Intermittently oriented. Continue\\n respiradol. Avoid medications that have psych complications or side\\n effects.\\n RESPIRATORY FAILURE -- s/p trach. Maintain trach for pulmonary\\n toilet/frequent suctioning.\\n TACHYCARDIA -- SVT. Continue amiodarone. Continue beta-blocker, with\\n extra doses prn if needed.\\n NUTRITIONAL SUPPORT -- TF via PEJ approaching goal.\\n T-SPINE FRACTURE -- s/p fall. Tolerating back brace as per ortho\\n service. Activity as tolerated (up in chair).\\n ASPIRATION RISK -- poor adduction of vocal cords (post. portion).\\n Eventually may require intervention.\\n TRANCHEOBRONCHOMALACIA -- no interventions planned at present.\\n ICU Care\\n Nutrition:\\n Replete with Fiber () - 09:45 PM 50 mL/hour\\n Glycemic Control:\\n Lines:\\n PICC Line - 01:30 PM\\n Prophylaxis:\\n DVT: Boots(Systemic anticoagulation: None)\\n Stress ulcer: PPI\\n VAP: HOB elevation, Mouth care\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :ICU\\n Total time spent: 55 minutes\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-09-24 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 634562,\n \"text\": \"Chief Complaint: respiratory failure\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 24 Hour Events:\\n BLOOD CULTURED - At 12:24 AM\\n URINE CULTURE - At 12:24 AM\\n SPUTUM CULTURE - At 03:30 AM\\n EKG - At 05:20 AM\\n pt in junctional rhythem, holding stable BP, intern aware and came to\\n assess pt. HR 47-50.\\n Fever spike to 101\\n Steroids started\\n Antibiotics tailored\\n PEEP decreased\\n History obtained from Medical records, ICU team\\n Patient unable to provide history: Sedated\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Vancomycin - 08:00 PM\\n Metronidazole - 08:00 AM\\n Levofloxacin - 08:39 AM\\n Aztreonam - 06:00 AM\\n Infusions:\\n Midazolam (Versed) - 2 mg/hour\\n Fentanyl - 100 mcg/hour\\n Other ICU medications:\\n Midazolam (Versed) - 03:50 PM\\n Fentanyl - 03:50 PM\\n Ranitidine (Prophylaxis) - 08:31 PM\\n Other medications:\\n versed, fentanyl, colace, H2B, CHG, SQI, MDIs, heparin infusion,\\n levoflox, aztreonam, hydrocortisone 50 q6, fludrocort\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 08:57 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.3\\nC (101\\n Tcurrent: 37.1\\nC (98.8\\n HR: 57 (48 - 86) bpm\\n BP: 102/48(61) {102/46(61) - 121/52(66)} mmHg\\n RR: 22 (17 - 23) insp/min\\n SpO2: 99%\\n Heart rhythm: JR (Junctional Rhythm)\\n Wgt (current): 101 kg (admission): 94.2 kg\\n Height: 67 Inch\\n CVP: 11 (11 - 20)mmHg\\n Bladder pressure: 12 (12 - 12) mmHg\\n Total In:\\n 1,708 mL\\n 460 mL\\n PO:\\n TF:\\n 182 mL\\n 138 mL\\n IVF:\\n 1,267 mL\\n 321 mL\\n Blood products:\\n Total out:\\n 877 mL\\n 1,305 mL\\n Urine:\\n 727 mL\\n 1,275 mL\\n NG:\\n 30 mL\\n Stool:\\n Drains:\\n Balance:\\n 831 mL\\n -845 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 400 (400 - 400) mL\\n RR (Set): 22\\n RR (Spontaneous): 0\\n PEEP: 21 cmH2O\\n FiO2: 40%\\n RSBI Deferred: PEEP > 10\\n PIP: 36 cmH2O\\n Plateau: 29 cmH2O\\n Compliance: 50 cmH2O/mL\\n SpO2: 99%\\n ABG: 7.46/38/96./26/2\\n Ve: 8.6 L/min\\n PaO2 / FiO2: 242\\n Physical Examination\\n General Appearance: Overweight / Obese\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: Normocephalic\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear :\\n anteriorly)\\n Abdominal: Soft, Non-tender, Obese\\n Extremities: Right: 1+, Left: 1+\\n Musculoskeletal: Unable to stand\\n Skin: Warm\\n Neurologic: Responds to: Unresponsive, Movement: No spontaneous\\n movement, Sedated, Tone: Normal\\n Labs / Radiology\\n 8.9 g/dL\\n 326 K/uL\\n 151 mg/dL\\n 0.7 mg/dL\\n 26 mEq/L\\n 3.6 mEq/L\\n 2 mg/dL\\n 108 mEq/L\\n 141 mEq/L\\n 28.6 %\\n 8.9 K/uL\\n [image002.jpg]\\n 02:02 AM\\n 03:59 AM\\n 09:14 PM\\n 01:04 AM\\n 05:54 AM\\n 06:11 AM\\n 11:07 PM\\n 03:51 AM\\n 06:17 AM\\n 08:18 AM\\n WBC\\n 8.4\\n 8.1\\n 8.9\\n Hct\\n 28.1\\n 28.0\\n 28.6\\n Plt\\n 376\\n 358\\n 326\\n Cr\\n 0.6\\n 0.7\\n 0.7\\n TCO2\\n 25\\n 28\\n 28\\n 26\\n 26\\n 21\\n 28\\n Glucose\\n 120\\n 126\\n 151\\n Other labs: PT / PTT / INR:24.3/68.6/2.4, CK / CKMB / Troponin-T:24//,\\n ALT / AST:24/16, Alk Phos / T Bili:117/0.7, Amylase / Lipase:,\\n Differential-Neuts:82.5 %, Lymph:11.6 %, Mono:3.3 %, Eos:2.2 %, Lactic\\n Acid:0.7 mmol/L, Albumin:2.4 g/dL, LDH:204 IU/L, Ca++:8.5 mg/dL,\\n Mg++:2.1 mg/dL, PO4:2.5 mg/dL\\n Imaging: CXR: increased right base opacity\\n Microbiology: Sputum from overnight: GPCs with 2+ GPCs in\\n pairs/clusters and 2+ GPRs\\n Prior sputum growing GNRs\\n Assessment and Plan\\n Fever\\n ICU Care\\n Nutrition:\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n 20 Gauge - 01:36 AM\\n Arterial Line - 03:00 AM\\n Multi Lumen - 11:30 AM\\n Prophylaxis:\\n DVT: Boots(Systemic anticoagulation: Heparin gtt)\\n Stress ulcer: H2 blocker\\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :ICU\\n Total time spent:\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-14 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 637507,\n \"text\": \"Chief Complaint: resp failure\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n s/p t spine fx with resp failure\\n 24 Hour Events:\\n BLOOD CULTURED - At 02:18 AM\\n SPUTUM CULTURE - At 02:18 AM\\n URINE CULTURE - At 02:18 AM\\n FEVER Pan cx\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Ceftriaxone - 12:00 AM\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Constitutional: Fever\\n Flowsheet Data as of 08:32 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.2\\nC (100.8\\n Tcurrent: 37.2\\nC (99\\n HR: 137 (120 - 151) bpm\\n BP: 125/55(73) {98/41(54) - 202/97(111)} mmHg\\n RR: 23 (12 - 39) insp/min\\n SpO2: 98%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 2,934 mL\\n 497 mL\\n PO:\\n TF:\\n 1,104 mL\\n 447 mL\\n IVF:\\n 1,000 mL\\n 50 mL\\n Blood products:\\n Total out:\\n 530 mL\\n 240 mL\\n Urine:\\n 530 mL\\n 240 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 2,404 mL\\n 257 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 318 (318 - 475) mL\\n PS : 10 cmH2O\\n RR (Spontaneous): 34\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n RSBI: 171\\n SpO2: 98%\\n ABG: ///32/\\n Ve: 9 L/min\\n Physical Examination\\n Labs / Radiology\\n 8.8 g/dL\\n 306 K/uL\\n 134 mg/dL\\n 0.6 mg/dL\\n 32 mEq/L\\n 4.0 mEq/L\\n 11 mg/dL\\n 106 mEq/L\\n 146 mEq/L\\n 26.8 %\\n 7.5 K/uL\\n [image002.jpg]\\n 03:10 AM\\n 03:08 PM\\n 03:00 AM\\n 03:36 AM\\n 04:40 PM\\n 03:00 AM\\n 07:05 PM\\n 03:00 AM\\n 05:00 AM\\n 02:06 AM\\n WBC\\n 11.3\\n 7.3\\n 6.1\\n 7.2\\n 5.2\\n 5.9\\n 7.5\\n Hct\\n 24.9\\n 27.6\\n 26.5\\n 26.9\\n 26.0\\n 27.2\\n 26.8\\n Plt\\n 227\\n 189\\n 209\\n 238\\n 240\\n 296\\n 306\\n Cr\\n 0.7\\n 0.6\\n 0.6\\n 0.9\\n 0.7\\n 0.6\\n 0.7\\n 0.6\\n TCO2\\n 26\\n Glucose\\n 114\\n 99\\n 115\\n 106\\n 100\\n 134\\n 134\\n Other labs: PT / PTT / INR:13.5/23.6/1.2, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:27/19, Alk Phos / T Bili:118/0.3,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.5 g/dL, LDH:243 IU/L, Ca++:9.2 mg/dL, Mg++:2.1 mg/dL, PO4:4.0\\n mg/dL\\n Assessment and Plan 55 yr old alcoholic s/p t spine fx s/p trcah and\\n PEG with persistent resp failure\\n 1. Resp Failure: currently on trach mask, can do a few hours per\\n day, then needs for support. New pan Klebs in sputum, day\\n . Re- try. Holding off on stent by IP until after pulm rehab.\\n 2. Hemodynamics: tachycardia with slightly decreased UOP\\n bolus\\n IVF and trend UOP. Watch to see if response with tachycardia.\\n 3. Anti coag: for upper ext DVT but INR elevated on coumadin +\\n quinolone\\n repeat inr low- trend with po COumadin\\n 4. Adrenal Insufficiency: proper stim this AM, off steroids\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 06:23 AM 60 mL/hour\\n Glycemic Control:\\n Lines:\\n PICC Line - 09:19 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-09-29 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 635064,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n ARTERIAL LINE - STOP 09:00 PM - attempted to re-wire but\\n patient was very agitated and re-wire was unsuccessful\\n Patient alternated between tachycardia and normotension and hypotension\\n in the high-80s/low 90s and HRs in the 50s\\n Given haldol, valium, midaz and fentanyl for sedation\\n ABG with low paO2 on PEEP 10, had to increase -- went back up to 15 and\\n then attempted to re-wean down with goal 8 in anticipation of OR\\n To OR for trach and PEG today (thoracics)\\n Put on lasix drip and put out >1L in just over an hour\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Levofloxacin - 08:06 AM\\n Infusions:\\n Midazolam (Versed) - 1.5 mg/hour\\n Fentanyl - 200 mcg/hour\\n Other ICU medications:\\n Fentanyl - 06:45 PM\\n Ranitidine (Prophylaxis) - 08:00 PM\\n Haloperidol (Haldol) - 10:00 PM\\n Midazolam (Versed) - 10:00 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:03 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.7\\nC (99.8\\n Tcurrent: 37.7\\nC (99.8\\n HR: 109 (55 - 134) bpm\\n BP: 120/56(70) {80/43(51) - 133/85(94)} mmHg\\n RR: 20 (16 - 28) insp/min\\n SpO2: 97%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 101 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 3,064 mL\\n 404 mL\\n PO:\\n TF:\\n 1,440 mL\\n IVF:\\n 1,014 mL\\n 314 mL\\n Blood products:\\n Total out:\\n 4,257 mL\\n 1,195 mL\\n Urine:\\n 4,257 mL\\n 1,195 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,193 mL\\n -791 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 400 (400 - 400) mL\\n RR (Set): 18\\n RR (Spontaneous): 10\\n PEEP: 15 cmH2O\\n FiO2: 60%\\n RSBI Deferred: PEEP > 10\\n PIP: 23 cmH2O\\n Plateau: 24 cmH2O\\n SpO2: 97%\\n ABG: 7.46/48/65/31/8\\n Ve: 7.8 L/min\\n PaO2 / FiO2: 108\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 320 K/uL\\n 8.0 g/dL\\n 94 mg/dL\\n 0.6 mg/dL\\n 31 mEq/L\\n 3.6 mEq/L\\n 13 mg/dL\\n 110 mEq/L\\n 147 mEq/L\\n 25.8 %\\n 9.0 K/uL\\n [image002.jpg]\\n 10:18 AM\\n 02:33 PM\\n 02:46 PM\\n 03:31 AM\\n 02:26 PM\\n 05:53 PM\\n 05:01 AM\\n 03:32 PM\\n 10:19 PM\\n 02:50 AM\\n WBC\\n 9.7\\n 9.5\\n 9.0\\n Hct\\n 26.0\\n 27.6\\n 25.8\\n Plt\\n \\n Cr\\n 0.5\\n 0.5\\n 0.5\\n 0.6\\n 0.6\\n TCO2\\n 29\\n 26\\n 27\\n 30\\n 30\\n 35\\n Glucose\\n 195\\n 195\\n 163\\n 133\\n 102\\n 94\\n Other labs: PT / PTT / INR:14.1/59.6/1.2, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\\n Amylase / Lipase:, Differential-Neuts:71.2 %, Lymph:22.7 %,\\n Mono:4.0 %, Eos:1.7 %, Lactic Acid:1.5 mmol/L, Albumin:2.4 g/dL,\\n LDH:204 IU/L, Ca++:8.2 mg/dL, Mg++:2.1 mg/dL, PO4:4.6 mg/dL\\n Assessment and Plan\\n 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture with respiratory failure\\n and difficulty weaning from vent.\\n # Respiratory failure: Intubated on for resp decompensation.\\n Likely VAP. Transferred here for tracheomalacia, but not sure this\\n is a component. Will need bronch eval when improved\\n - will discuss PEEP goal for trach placement with IP.\\n - wean PEEP\\n - repeat ABG this AM\\n - discuss need for trach with patient and her family\\n - Volume overload may be contributing.\\n # Volume overload\\n Currently with hypernatremia, Cr increase, contract\\n alk, but mild\\n - continue gentle diuresis\\n - FW in TF at 150 cc q4hrs\\n - PM lytes.\\n # Sedation: On versed 3mg/hr + .5 q 1hr and fentanyl 150 mcg/hr + 50\\n bolus q 1hr.\\n - Start fentanyl patch and diazepam to provide long acting analgesia\\n and wean from drips\\n - Haldol 1 mg Q4h PRN agitation\\n # Pneumonia: Pansensitive Kleb oxytoca pneumonia and sputum with GPCs\\n on gram stain. Afebrile off abx.\\n # EKG changes: Sinus bradycardia, responsive to stress. Related to\\n sedation, increased vagal tone, possibly related to steroid\\n replacement. Atrial EKG shows p-waves and cardiac enzymes normal.\\n - Continue to monitor\\n # Hypotension: Improved, off levophed for 2-3 days now, with good urine\\n output. s/p 5 d course of steroids for adrenal insufficiency. High\\n PEEP may have been contributing. Now likely related to sedation and\\n decreased intravascular volume,\\n -monitor, expect improvement with continual reduction in\\n PEEP\\n # RUE DVT: Started on heparin gtt on , now therapeutic. Follow\\n PTTs. Would hold off on coumadin at least until s/p trach.\\n - continue to monitor\\n # Adrenal Insufficency: Random cortisol was approx 3 when it should\\n have been maximally stimulated.\\n - hydrocortisone and florinef for 5 days\\n # Anemia: Stable.\\n - Trend HCT\\n # Spine fracture: Neurologically intact distal to the lesion. Prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - CT of C, L spine when stable. Currently, unlikely to change\\n management and high risk for complications with transport.\\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\\n is low. Brace for OOB. Ok for anticoag per note.\\n # Communication:\\n - Boyfriend of 10 is her HCP. Also brother is involved\\n FEN/GI: Tube feeds @ goal\\n DVT: Treatment dose heparin\\n Ulcer: Ranitidine\\n VAP: Prevention per routine\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n PICC Line - 09:19 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-26 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 639585,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Pt agitated overnight given extra Risperidone 0.5 mg x 2 overnight.\\n (1.5mg total)\\n 1000 mL D5W for Hypernatremia\\n Changed B-Blocker from IV to PO, Metoprolol Tartrate 25 mg PO TID\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:17 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:47 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.8\\nC (98.2\\n Tcurrent: 36.7\\nC (98\\n HR: 120 (67 - 120) bpm\\n BP: 110/64(76) {109/47(60) - 141/115(118)} mmHg\\n RR: 26 (18 - 30) insp/min\\n SpO2: 100%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 3,820 mL\\n 856 mL\\n PO:\\n TF:\\n 117 mL\\n 20 mL\\n IVF:\\n 2,612 mL\\n 572 mL\\n Blood products:\\n Total out:\\n 2,460 mL\\n 1,180 mL\\n Urine:\\n 2,460 mL\\n 1,180 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,360 mL\\n -324 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask\\n SpO2: 100%\\n ABG: ///33/\\n Physical Examination\\n Gen: Awake, Mouthing words, More agitated compared to previous\\n mornings.\\n HEENT: EOMI, No pallor in conjunctiva, MMM\\n Resp: CTAB, no rales, rhonchi, or wheezing, good airway movement.\\n Card: S1S2 tachycardic, no m/r/g\\n Abd: Obese, soft, mildly distended, decreased bowel sounds,, G-Tube in\\n place with no erythema/induration\\n Exte: No edema, DP 2+ bil\\n NEURO: Gross Motor and Sensation in 4 extremities\\n Labs / Radiology\\n 249 K/uL\\n 8.0 g/dL\\n 122 mg/dL\\n 0.5 mg/dL\\n 33 mEq/L\\n 3.7 mEq/L\\n 13 mg/dL\\n 108 mEq/L\\n 146 mEq/L\\n 24.7 %\\n 5.5 K/uL\\n [image002.jpg] CXR: L Picc, trach tip at midline, bibasilar\\n opacities, low lung volumes, Bil pleural effusions.\\n 03:36 AM\\n 02:30 AM\\n 01:30 AM\\n 06:41 AM\\n 03:20 PM\\n 03:23 AM\\n 03:00 AM\\n 04:00 AM\\n 05:45 AM\\n 03:51 AM\\n WBC\\n 6.9\\n 7.6\\n 9.5\\n 5.7\\n 7.3\\n 8.0\\n 8.7\\n 5.5\\n Hct\\n 27.8\\n 32.7\\n 28.6\\n 28.9\\n 30.0\\n 26.9\\n 27.3\\n 27.0\\n 28.7\\n 24.7\\n Plt\\n 467\\n 548\\n 528\\n 356\\n 346\\n 316\\n 271\\n 249\\n Cr\\n 0.7\\n 0.8\\n 1.0\\n 0.7\\n 0.7\\n 0.7\\n 0.7\\n 0.5\\n Glucose\\n 131\\n 128\\n 121\\n 129\\n 123\\n 114\\n 112\\n 122\\n Other labs: PT / PTT / INR:13.6/31.1/1.2, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:9.0 mg/dL, Mg++:2.2 mg/dL, PO4:3.1\\n mg/dL\\n Assessment and Plan\\n 56yoF s/p mechanical fall and traumatic T spine fracture, now s/p\\n trach/PEG with resolving respiratory failure and HAP.\\n .\\n # Respiratory failure: s/p intubation/extubation, now on trach mask,\\n FiO2 70%. Tolerating well with good O2 sat. No further\\n self-decanulations overnight.\\n - Tach mask as tolerated.\\n - Holding sedation with exception of Risperidal 0.5mg .\\n - F/u CXR tomorrow\\n .\\n # Nutrition/Vomiting: Currently receiving TPN;. One large BM in past\\n 24 hrs to indicate potential improvement in ileus.\\n - Cont Reglan 20mg IV Q 8 hours; meds via G-J tube,\\n - Will obtain recommendations from Nutrition re TPN before starting TPN\\n tomorrow\\n - Increase TF as tolerated\\n - Speech and Swallow eval\\n - PICC line in place with TPN given when pt not tolerating TF\\n - GI consult, appreciate recs\\n .\\n # Tachycardia: Improved HR max of 120\\ns versus 160s previously;\\n elevated this am secondary to agitation. Pt now on PO Amiodarone 200\\n TID and PO metoprolol 25mg TID\\n - Continue current med regimen. Will continue amiodarone 200 TID for\\n three weeks and then switch to qday.\\n - Will schedule f/u in 4wks with Dr. upon d/c.\\n - f/u Cards recs\\n # Sedation/Anxiolysis/AlteredMS: Agitation O/N, continues to be\\n agitated most likely secondary to long hospital course and multiple\\n psychotropic medications as well as hx of EtOH abuse. Risperdal given\\n O/N.\\n - started Risperdal 0.5mg PO BID\\n - continue to hold all benzos. opiates, and antihistamines\\n - Appreciate psych. Will f/u psych recs.\\n .\\n # Hypernatremia/Fluid Status: Mild hypernatramia with good UOP\\n (hypervolemic hypernatremia). On TPN/TF.\\n - providing D5W IVF PRN and follow lytes (check Na this afternoon).\\n # UE DVT and elevated INR: Decision made to d/c Coumadin given her\\n labile INR, and start Lovenox . Current INR 1.2.\\n - Will flush L PICC with TPA\\n .\\n # Spine fracture: Stable\\n - Brace for OOB, will discuss with Neurosurgery if current brace is\\n optimal for stabilization given her mobility.\\n - Pt to follow up with Dr. in weeks\\n .\\n # Tracheomalacia. Was initially addressed with IP and they wanted to\\n follow up as outpatient. IP reevaluated and does not believe that a\\n stent would be feasible.\\n .\\n #. Thyroid Nodule on CT\\n - Outpatient follow up\\n .\\n # Glycemic control: SSI, well controlled\\n # ACCESS: PIV x 1, L PICC\\n # Ppx: Lovenox, PPi, Bowel Regimen PRN\\n # Communication:\\n - Boyfriend of 10 \\n - Brother also involved\\n - Social Work and Case management involved, have discussed situation\\n w/ brother and boyfriend.\\n # Code: Full\\n # Dispo: ICU, Screening for vent facilities\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-10-02 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1034896,\n \"text\": \" 3:25 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ? interval change, ? RLL process\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 55 year old woman with respiratory failure\\n REASON FOR THIS EXAMINATION:\\n ? interval change, ? RLL process\\n ______________________________________________________________________________\\n FINAL REPORT\\n AP CHEST, 3:31 A.M. ON \\n\\n HISTORY: Respiratory failure, question interval change in right lower lobe\\n process.\\n\\n IMPRESSION: AP chest compared to , 7:58 p.m.\\n\\n Pulmonary vascular congestion and mild edema have developed. Consolidation in\\n the right lower lung has progressed, probably worsening atelectasis. The\\n examination is positioned though as to underestimate the distance of the ET\\n tube from the carina. It ends above the level of the clavicles, and with the\\n chin down, and is at least 5 cm too high.\\n\\n Dr. was paged to report these at the time of dictation.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-09-30 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1034491,\n \"text\": \", F. MED MICU 7:28 AM\\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \\n Reason: please eval ET tube placement\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 55 year old woman with respiratory failure, unable to see ET tube and carina on\\n film from this AM.\\n REASON FOR THIS EXAMINATION:\\n please eval ET tube placement\\n ______________________________________________________________________________\\n PFI REPORT\\n ET tube tip 5.5 cm above the carina. Impingement of the left tracheal wall by\\n the ET tube that should be re-positioned.\\n\\n Interval improvement of pulmonary edema.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-09-27 00:00:00.000\",\n \"description\": \"BY SAME PHYSICIAN\",\n \"row_id\": 1033999,\n \"text\": \" 2:21 PM\\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \\n Reason: Pt had a left sided picc line placed,51cm and needs tip conf\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 55 year old woman with Respiratory Failure who needs picc line for IV access.\\n REASON FOR THIS EXAMINATION:\\n Pt had a left sided picc line placed,51cm and needs tip confirmation please\\n page at with wet read,thanks.\\n ______________________________________________________________________________\\n FINAL REPORT\\n PORTABLE CHEST \\n\\n CLINICAL INFORMATION: PICC line placement.\\n\\n FINDINGS:\\n\\n COMPARISON STUDY: at 04:22 hours.\\n\\n Left PICC has been placed. The tip terminates at the right atrium. The\\n endotracheal tube terminates at the carina and should be pulled back. The\\n nasogastric tube terminates in the stomach. Right IJ catheter terminates in\\n the superior vena cava. The heart is enlarged. Mediastinum is within normal\\n limits. There is a small left pleural effusion with a very small right\\n pleural effusion. There is elevation of the right hemidiaphragm. There is\\n bibasilar atelectasis.\\n\\n IMPRESSION:\\n\\n 1. Left PICC terminates in the right atrium.\\n\\n 2. Small bilateral pleural effusions with bibasilar atelectasis.\\n Cardiomegaly.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-10-01 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1034678,\n \"text\": \" 3:43 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval lines/tubes/infiltrates\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 55 year old woman with VAP and ARDS\\n REASON FOR THIS EXAMINATION:\\n eval lines/tubes/infiltrates\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Ventilator-associated pneumonia and ARDS.\\n\\n FINDINGS: A semi-upright frontal bedside chest radiograph compared to\\n and demonstrates no significant change. The lung volumes\\n are low. There are moderate bilateral layering effusions. There is a large\\n left retrocardiac atelectasis. There is mild pulmonary overload. The ETT is\\n 3 cm above the carina. NG tube is in the stomach. A left central venous\\n catheter tip terminates in the SVC.\\n\\n IMPRESSION: No marked interval change in mild pulmonary edema, bilateral\\n effusions, and large left retrocardiac atelectasis.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-09-27 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1033919,\n \"text\": \" 1:28 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval lines/tubes/infiltrates\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 55 year old woman with respiratory failure with VAP\\n REASON FOR THIS EXAMINATION:\\n eval lines/tubes/infiltrates\\n ______________________________________________________________________________\\n FINAL REPORT\\n PORTABLE CHEST \\n\\n CLINICAL INFORMATION: Respiratory failure.\\n\\n FINDINGS:\\n\\n Endotracheal tube terminates just above the thoracic inlet in appropriate\\n position. Nasogastric tube courses below the diaphragm. Right IJ catheter\\n terminates in the superior vena cava.\\n\\n There are moderate bilateral pleural effusions and bibasilar atelectasis.\\n There is essentially no change in the appearance of the chest since the prior\\n study.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-09-20 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 1032610,\n \"text\": \" 7:01 PM\\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \\n Reason: position of Left IJ\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 55 year old woman with resp failure s/p left IJ placement.\\n REASON FOR THIS EXAMINATION:\\n position of Left IJ\\n ______________________________________________________________________________\\n FINAL REPORT\\n\\n\\n HISTORY: Left IJ placement.\\n\\n FINDINGS: Left IJ central line is malpositioned, coursing towards the left\\n axilla. New left apical pleural capping could reflect the re-distribution of\\n effusion since the patient was in the Trendelenburg position for the\\n procedure, though the possibility of a hematoma complicating the line\\n placement must be considered. This information was discussed by the radiology\\n resident with Dr. .\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-09-22 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1032921,\n \"text\": \" 9:19 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Assess tube position\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 55 year old woman with respiratory distress, intubated. S/P repositioning of\\n ET tube.\\n REASON FOR THIS EXAMINATION:\\n Assess tube position\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Respiratory distress status post re-positioning of endotracheal\\n tube.\\n\\n FINDINGS: In comparison with the study of , the endotracheal tube tip now\\n lies approximately 7.4 cm above the carina. There is little overall change in\\n the appearance of heart and lungs. Elevation of the right hemidiaphragm\\n persists with bibasilar effusions and atelectatic change.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-09-24 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1033342,\n \"text\": \" 2:53 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Assess ET tube placement\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 55 year old woman with repiratory failure, intubated\\n REASON FOR THIS EXAMINATION:\\n Assess ET tube placement\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): 9:52 AM\\n No change.\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST RADIOGRAPH\\n\\n INDICATION: Assessment of endotracheal tube placement.\\n\\n COMPARISON: .\\n\\n FINDINGS: As compared to the previous radiograph, there is no relevant\\n change. The monitoring and support devices are in unchanged position. The\\n tip of the endotracheal tube projects 5.7 cm above the carina.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-09-24 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1033343,\n \"text\": \", D. MED MICU 2:53 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Assess ET tube placement\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 55 year old woman with repiratory failure, intubated\\n REASON FOR THIS EXAMINATION:\\n Assess ET tube placement\\n ______________________________________________________________________________\\n PFI REPORT\\n No change.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-09-29 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1034241,\n \"text\": \" 2:57 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ? Interval change\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 55 year old woman with recent ARDS\\n REASON FOR THIS EXAMINATION:\\n ? Interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Desaturation.\\n\\n FINDINGS: In comparison with study of , there is little overall change.\\n Again, there is enlargement of the cardiac silhouette with basilar atelectasis\\n and bilateral effusions. Elevation of the right hemidiaphragmatic contour\\n persists. Again, it is difficult to evaluate the area behind the heart in the\\n absence of a lateral view. Tubes remain in place.\\n\\n IMPRESSION: Little change.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-09-28 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1034222,\n \"text\": \" 10:24 PM\\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \\n Reason: atelectasis vs edema\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 55 year old woman intubated with recent desats.\\n REASON FOR THIS EXAMINATION:\\n atelectasis vs edema\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Intubated with the recent desaturation.\\n\\n FINDINGS: In comparison with study earlier in this date, there is again\\n enlargement of the cardiac silhouette with bilateral pleural effusion and\\n bibasilar atelectasis. Elevation of the right hemidiaphragmatic contour\\n persists. The area behind the heart is difficult to evaluate in the absence\\n of a lateral view. Tubes remain in place.\\n\\n IMPRESSION: Little change.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-09-30 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1034454,\n \"text\": \", F. MED MICU 3:16 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ?Interval change\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 55 year old woman with respiratory failure\\n REASON FOR THIS EXAMINATION:\\n ?Interval change\\n ______________________________________________________________________________\\n PFI REPORT\\n Increase in bilateral pleural effusions.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-09-23 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1033096,\n \"text\": \" 2:45 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ? tube/line position, infiltrates\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 55 year old woman with respiratory failure, T8 fracture.\\n REASON FOR THIS EXAMINATION:\\n ? tube/line position, infiltrates\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): PSS WED 10:36 AM\\n ET tube, right jugular line, NG tube okay. Left lower lobe atelectasis\\n improved. Mild pulmonary edema improved.\\n ______________________________________________________________________________\\n FINAL REPORT\\n AP CHEST 3 A.M. \\n\\n HISTORY: Respiratory failure. T8 fracture. Check lines and tubes.\\n\\n IMPRESSION: AP chest compared to :\\n\\n ET tube, right jugular line, in standard placements. Nasogastric tube passes\\n below the diaphragm and out of view. Mild pulmonary edema has improved,\\n previously severe left lower lobe atelectasis and milder right basal\\n atelectasis have also improved. No pneumothorax. Small pleural effusion is\\n presumed. Heart size normal.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-09-20 00:00:00.000\",\n \"description\": \"PORTABLE ABDOMEN\",\n \"row_id\": 1032618,\n \"text\": \" 8:20 PM\\n PORTABLE ABDOMEN Clip # \\n Reason: ? ileus v obstruction\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 55 year old woman with respiratory failure, distended abdomen.\\n REASON FOR THIS EXAMINATION:\\n ? ileus v obstruction\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 55-year-old woman with respiratory failure and distended abdomen.\\n Concern for ileus versus obstruction.\\n\\n COMPARISON: Portable abdominal radiograph .\\n\\n FINDINGS: A single AP supine portable radiograph of the abdomen was obtained\\n demonstrating a nasogastric tube with termination in the stomach. There are\\n no air-fluid levels or dilated loops of large or small bowel. There is no\\n evidence of pneumatosis or pneumoperitoneum. A few surgical clips are noted\\n to project over the right sacroiliac joint. Patient is status post left hip\\n arthroplasty. Mild convex left thoracolumbar scoliosis may be explained by\\n positioning.\\n\\n IMPRESSION: No obstruction.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-09-21 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1032860,\n \"text\": \" 11:12 PM\\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \\n Reason: Assess ET tube possition\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 55 year old woman with acute respiraotry distress. Acute desaturation.\\n REASON FOR THIS EXAMINATION:\\n Assess ET tube possition\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: To assess for endotracheal tube position.\\n\\n FINDINGS: In comparison with earlier study of this date, there are continued\\n bilateral pleural effusions with atelectatic changes especially in the\\n retrocardiac region. The endotracheal tube tip lies approximately 6.7 cm\\n above the carina. Nasogastric tube and right IJ catheter remain in place.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-09-23 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1033097,\n \"text\": \", D. MED MICU 2:45 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ? tube/line position, infiltrates\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 55 year old woman with respiratory failure, T8 fracture.\\n REASON FOR THIS EXAMINATION:\\n ? tube/line position, infiltrates\\n ______________________________________________________________________________\\n PFI REPORT\\n ET tube, right jugular line, NG tube okay. Left lower lobe atelectasis\\n improved. Mild pulmonary edema improved.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-09-20 00:00:00.000\",\n \"description\": \"RP UNILAT UP EXT VEINS US RIGHT PORT\",\n \"row_id\": 1032570,\n \"text\": \" 11:50 AM\\n UNILAT UP EXT VEINS US RIGHT PORT Clip # \\n Reason: EVAL FOR UPPER EXT DVT, SWELLING\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 55 year old woman with PICC with arm swelling\\n REASON FOR THIS EXAMINATION:\\n eval upper extremity DVT\\n ______________________________________________________________________________\\n WET READ: DXAe SUN 1:21 PM\\n 1. 2 cm Nonocclusive DVT in the right axillary vein\\n\\n 2. 1 cm superficial nonocclusive thrombus in the basillic vein).\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 55-year-old woman with PICC line and arm swelling, evaluate for\\n upper extremity DVT.\\n\\n COMPARISON: None.\\n\\n FINDINGS: Grayscale and Doppler imaging of the right superficial and deep\\n veins was performed. There is a non-occlusive thrombus in the right axillary\\n vein spanning 2 cm. There is also a non-occlusive thrombus in the right\\n basilic vein. The other veins including the internal jugular, brachial veins\\n demonstrate normal compressibility, augmentation, and waveforms.\\n\\n IMPRESSION:\\n\\n 1. Non-occlusive right axillary deep vein thrombus.\\n\\n 2. Non-occlusive right basilic superficial thrombosis.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-09-30 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1034490,\n \"text\": \" 7:28 AM\\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \\n Reason: please eval ET tube placement\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 55 year old woman with respiratory failure, unable to see ET tube and carina on\\n film from this AM.\\n REASON FOR THIS EXAMINATION:\\n please eval ET tube placement\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLnc WED 11:20 AM\\n ET tube tip 5.5 cm above the carina. Impingement of the left tracheal wall by\\n the ET tube that should be re-positioned.\\n\\n Interval improvement of pulmonary edema.\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAMINATION: Evaluation of ET tube tip.\\n\\n Portable AP chest radiograph was compared to .\\n\\n The ET tube tip is impinging the left tracheal wall and should be\\n re-positioned. Its tip is approximately 5.5 cm above the carina.\\n\\n The NG tube tip is in the stomach. The interval improvement in pulmonary\\n edema and slight decrease in pleural effusions is demonstrated. There is no\\n change in left retrocardiac opacity consistent with atelectasis. There is no\\n pneumothorax.\\n\\n IMPRESSION: ET tube tip 5.5 cm above the carina impinging the left tracheal\\n wall and should be re-positioned.\\n\\n Interval improvement of pulmonary edema and slight decrease in pleural\\n effusions.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-09-26 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1033806,\n \"text\": \" 3:31 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: please evaluate tubes/lines, infiltrates\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 55 year old woman with respiratory failure, ARDS, VAP.\\n REASON FOR THIS EXAMINATION:\\n please evaluate tubes/lines, infiltrates\\n ______________________________________________________________________________\\n FINAL REPORT\\n PORTABLE CHEST \\n\\n CLINICAL INFORMATION: Respiratory failure, ARDS.\\n\\n FINDINGS:\\n\\n Since the prior study from , there has been increased bilateral pleural\\n effusions, moderate on the right, small to moderate on the left, with\\n bilateral lower lobe consolidation. There is cardiomegaly.\\n\\n Endotracheal tube terminates in the thoracic inlet. Right IJ catheter\\n terminates in the superior vena cava. Endotracheal tube courses below the\\n diaphragm and the tip is not seen. Multiple lines project over the chest.\\n\\n IMPRESSION:\\n\\n Interval worsening, with increased bilateral pleural effusions and bibasilar\\n consolidation.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-09-20 00:00:00.000\",\n \"description\": \"BY SAME PHYSICIAN\",\n \"row_id\": 1032632,\n \"text\": \" 10:37 PM\\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \\n Reason: ? pneumothorax\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 55 year old woman with respiratory failure, s/p attempted right sided CVL.\\n REASON FOR THIS EXAMINATION:\\n ? pneumothorax\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Respiratory failure status post attempted right central venous\\n pressure insertion.\\n\\n FINDINGS: In comparison with study of , there is little change in the\\n appearance of the heart and lungs. Specifically, no evidence of pneumothorax\\n after the attempted central line placement.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-09-21 00:00:00.000\",\n \"description\": \"CTA CHEST W&W/O C&RECONS, NON-CORONARY\",\n \"row_id\": 1032824,\n \"text\": \" 4:59 PM\\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/CONTRAST Clip # \\n CT PELVIS W/CONTRAST\\n Reason: eval structures, bleeding, spinal cord impingement\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n Field of view: 42 Contrast: OPTIRAY Amt: 130\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 55 year old woman with respiratory failure, T5-T8 fracture, hypotension\\n REASON FOR THIS EXAMINATION:\\n eval structures, bleeding, spinal cord impingement\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): AHPb MON 9:28 PM\\n Right lower lobe consolidation, and superimposed atelectasis/lower lobe\\n collapse, and effusions. Acute T8 compression deformity, with no posterior\\n retropulsion of fracture fragments. No associated hematoma.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Respiratory failure, T5 through T8 fracture, hypotension,\\n evaluate structures, bleeding, spinal cord impingement.\\n\\n COMPARISON: None.\\n\\n TECHNIQUE: MDCT of the chest, abdomen, and pelvis performed before and after\\n the uneventful administration of 130 cc Optiray contrast. Multiplanar\\n reformatted images were also obtained and reviewed.\\n\\n CTA CHEST: The pulmonary arteries opacify normally without evidence for\\n filling defects. Evaluation of the subsegmental pulmonary arteries is limited\\n lower lobe collapse and body habitus. The main pulmonary artery is top normal\\n in size which could be secondary to mild pulmonary hypertension. The heart\\n and great vessels of the mediastinum are otherwise unremarkable. There are\\n coronary artery calcifications. NG tube terminates in the stomach.\\n Endotracheal tube terminates in the mid thoracic trachea. The airways are\\n patent to the segmental level but collapsed more distally in the right middle\\n and lower lobes.\\n\\n There is total collapse of the right middle and lower lobes. There is\\n atelectasis of the right upper lobe and superimposed patchy opacities and most\\n prominent in the basal portions of the right upper lobe, consistent with\\n aspiration or infection. There is also partial collapse of the left lower lobe\\n and left upper lobe. There are small bilateral pleural effusions. There is\\n presternal fluid and soft tissue stranding (3:15).\\n\\n CT ABDOMEN WITH CONTRAST: The liver, gallbladder, pancreas, spleen, stomach,\\n adrenal glands, kidneys, and small bowel loops are unremarkable aside from\\n small gallstones and right upper pole renal cyst. There is no free air, free\\n fluid, or pathologic adenopathy. Incidental note of a small duodenal\\n diverticulum.\\n\\n CT PELVIS WITH CONTRAST: The rectum, sigmoid, and large bowel are remarkable\\n for sigmoid diverticulosis. There is a 7.5 cm x 3.0 cm tubular fluid density\\n (Over)\\n\\n 4:59 PM\\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/CONTRAST Clip # \\n CT PELVIS W/CONTRAST\\n Reason: eval structures, bleeding, spinal cord impingement\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n Field of view: 42 Contrast: OPTIRAY Amt: 130\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n structure in continuation with the cecum in the anticipated location of the\\n appendix without adjacent inflammatory stranding. Surgical sutures are\\n present at the tip of this lesion. Foley is present within a collapsed\\n bladder. There is mild diffuse anasarca.\\n\\n OSSEOUS STRUCTURES: There is an acute compression deformity of the T8\\n vertebral body with approximately 25% loss of height, and no retropulsion of\\n fracture fragments, and no associated hematoma. Evaluation of the contents of\\n the spinal canal is limited by CT, but there is no evidence for gross cord\\n compression. Please see CT T-spine from today for further details.\\n\\n IMPRESSION:\\n 1. Collapse of the right middle and lower lobes with atelectasis of the right\\n upper lobe.\\n 2. Superimposed patchy opacities in right upper lobe consistent with\\n aspiration, infection, or combination.\\n 3. Partial collapse of left lower lobe and upper lobe.\\n 4. Acute T8 compression deformity without retropulsion of fracture fragments.\\n 5. Incidental appendiceal mucocele versus mucinous cystadenoma. Correlation\\n of abdominal surgery recommended given adjacent sutures. Recurrence of\\n previously excised lesion is a possibility.\\n\\n These findings were communicated with Dr. at 6:30 p.m., .\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-09-21 00:00:00.000\",\n \"description\": \"CT PELVIS W/CONTRAST\",\n \"row_id\": 1032825,\n \"text\": \", D. MED MICU 4:59 PM\\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/CONTRAST Clip # \\n CT PELVIS W/CONTRAST\\n Reason: eval structures, bleeding, spinal cord impingement\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n Field of view: 42 Contrast: OPTIRAY Amt: 130\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 55 year old woman with respiratory failure, T5-T8 fracture, hypotension\\n REASON FOR THIS EXAMINATION:\\n eval structures, bleeding, spinal cord impingement\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n PFI REPORT\\n Right lower lobe consolidation, and superimposed atelectasis/lower lobe\\n collapse, and effusions. Acute T8 compression deformity, with no posterior\\n retropulsion of fracture fragments. No associated hematoma.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-09-21 00:00:00.000\",\n \"description\": \"CT T-SPINE W/ CONTRAST\",\n \"row_id\": 1032826,\n \"text\": \" 5:00 PM\\n CT T-SPINE W/ CONTRAST Clip # \\n Reason: eval structures, bleeding, spinal cord impingement\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 55 year old woman with respiratory failure, T5-T8 fracture, hypotension\\n REASON FOR THIS EXAMINATION:\\n eval structures, bleeding, spinal cord impingement\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Respiratory failure, T5 through 8 fracture, hypotension. Please\\n evaluate for spinal cord impingement.\\n\\n TECHNIQUE: MDCT of the thoracic spine without contrast displayed in 3.75 mm\\n axial collimation. Coronal and sagittal reformatted images were also obtained\\n and reviewed.\\n\\n COMPARISON: CT chest, abdomen and pelvis from same day.\\n\\n CT THORACIC SPINE WITHOUT CONTRAST: There is an acute compression deformity\\n of the T8 vertebral body with approximately 25% loss of height. There is no\\n retropulsion of fracture fragments. Fracture lines do not extend into the\\n posterior elements. Although evaluation of the spinal cord is limited by CT,\\n there is no evidence for gross cord compression. There is also mild loss of\\n height at T5. The remaining thoracic and visualized lumbar vertebrae are\\n normal.\\n\\n Evaluation of the lung fields demonstrates complete collapse of the right\\n lower and middle lobes with partial collapse/atelectasis of the right upper\\n and left upper lobes. Superimposed patchy opacities in the right upper lobe\\n suggest aspiration, infection, or combination. Note is also made of a 1-cm\\n calcified granuloma in the left lung. NG tube courses into the stomach. ETT\\n terminates in the mid thoracic trachea.\\n\\n IMPRESSION:\\n 1. T8 compression deformity with 25% loss of height and no retropulsion of\\n fracture fragments. Mild loss of height at T5.\\n 2. Multifocal pumonary collapse and consolidation. Please see the\\n accompanying CT chest, abdomen and pelvis for further details.\\n\\n These findings were communicated with Dr. at the time of this study.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-10-01 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1034868,\n \"text\": \" 7:45 PM\\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \\n Reason: confirm ETT placement\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 55 year old woman intubated with difficult sedation, pulling at ETT.\\n REASON FOR THIS EXAMINATION:\\n confirm ETT placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n AP CHEST 7:58 P.M., \\n\\n HISTORY: Difficult intubation. Confirmed tube placement.\\n\\n IMPRESSION: AP chest compared to and at 4:13 a.m.:\\n\\n Tip of the ET tube, at the upper margin of the clavicles with the chin down is\\n 3 cm above optimal placement. Severe bibasilar atelectasis unchanged. Upper\\n lungs clear. Heart is top normal size, remains shifted to the left.\\n Nasogastric tube ends in the region of the pylorus.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-09-19 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1032505,\n \"text\": \" 11:37 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval lines/ tubes/infiltrates\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 55 year old woman with respiratory failure transfer to for vent wean\\n REASON FOR THIS EXAMINATION:\\n eval lines/ tubes/infiltrates\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Transfer to for vent wean. Check lines and tubes.\\n\\n FINDINGS: There is no old film available for comparison. The endotracheal\\n tube tip is 4.5 cm above the carina. The NG tube tip is in the stomach. The\\n right hemidiaphragm is mildly elevated. The heart is upper limits normal in\\n size. There is pulmonary vascular redistribution with volume loss/infiltrate\\n in the right mid lung. The left lateral lung is off the film.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-09-25 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1033584,\n \"text\": \" 2:54 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ETT and line loactions\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 55 year old woman with respiratory failure of unclear etiology.\\n REASON FOR THIS EXAMINATION:\\n ETT and line loactions\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Respiratory failure for ET tube and line locations.\\n\\n FINDINGS: In comparison with the study of , there is little overall\\n change. The endotracheal tube lies approximately 5 cm above the carina and\\n the right IJ catheter extends to the lower portion of the SVC. Little overall\\n change in the appearance of the heart and lungs.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-09-28 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1034039,\n \"text\": \", D. MED MICU 3:00 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: please eval infiltrates, lines\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 55 year old woman with respiratory failure, VAP, intubated.\\n REASON FOR THIS EXAMINATION:\\n please eval infiltrates, lines\\n ______________________________________________________________________________\\n PFI REPORT\\n PFI: No interval change.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-09-21 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 1032743,\n \"text\": \" 11:39 AM\\n CHEST PORT. LINE PLACEMENT Clip # \\n Reason: placement of right IJ\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 55 year old woman with resp failure, hypotension, oliguria. s/p placement of\\n right IJ\\n REASON FOR THIS EXAMINATION:\\n placement of right IJ\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Respiratory failure, for placement of a right IJ catheter.\\n\\n FINDINGS: In comparison with the study of , there has been placement of a\\n right IJ catheter that extends to the lower portion of the SVC. Endotracheal\\n and nasogastric tubes remain in place. Overlying artifacts make it very\\n difficult to properly evaluate the lungs.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-09-20 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1032518,\n \"text\": \" 3:16 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ETT tube placement\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 55 year old woman with resp distress s/p intubation transferred from OSH for\\n management of weaning.\\n REASON FOR THIS EXAMINATION:\\n ETT tube placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST SINGLE VIEW ON .\\n\\n HISTORY: Check endotracheal tube.\\n\\n FINDINGS: The endotracheal tube tip is 5 cm above the carina. There is a\\n right subclavian line with tip at the SVC/RA junction. The NG tube tip is in\\n the stomach. There is a small right effusion. There continues to be\\n right-sided volume loss/infiltrate. There is perihilar haze and pulmonary\\n vascular redistribution but slightly worse compared to the prior study\\n suggesting worsening fluid overload.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-09-22 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1032944,\n \"text\": \" 10:31 AM\\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \\n Reason: please re-eval tube positioning\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 55 year old woman with respiratory failure, s/p tube repositioning.\\n REASON FOR THIS EXAMINATION:\\n please re-eval tube positioning\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Respiratory failure status post tube repositioning.\\n\\n FINDINGS: In comparison with the earlier study of this date, the tip of the\\n endotracheal tube is approximately 5.2 cm above the carina. Nasogastric tube\\n and right IJ line remain in place. The opacification in the retrocardiac\\n region persists. There is some increasing opacification at the right base.\\n Although some of this could reflect atelectasis, the possibility of\\n supervening atelectasis or pneumonia should be considered.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-09-30 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1034453,\n \"text\": \" 3:16 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ?Interval change\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 55 year old woman with respiratory failure\\n REASON FOR THIS EXAMINATION:\\n ?Interval change\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLnc WED 10:33 AM\\n Increase in bilateral pleural effusions.\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAMINATION: Interval change in a patient with respiratory\\n failure.\\n\\n Portable AP chest radiograph was compared to obtained at\\n 02:59 a.m.\\n\\n The ET tube tip is 3.8 cm above the carina. The NG tube is in the stomach.\\n The cardiomediastinal silhouette is unchanged. Interval increase in bilateral\\n pleural effusions is present but no change in bibasal consolidations\\n consistent with atelectasis.\\n\\n IMPRESSION: No significant interval change except for increase in bilateral\\n pleural effusions.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-09-19 00:00:00.000\",\n \"description\": \"PORTABLE ABDOMEN\",\n \"row_id\": 1032503,\n \"text\": \" 11:22 PM\\n PORTABLE ABDOMEN Clip # \\n Reason: eval gas pattern for obstruction\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 55 year old woman with respiratory failure and abdominal distension\\n REASON FOR THIS EXAMINATION:\\n eval gas pattern for obstruction\\n ______________________________________________________________________________\\n FINAL REPORT\\n ABDOMEN FILM ON \\n\\n HISTORY: Respiratory failure and abdominal distention.\\n\\n FINDINGS: Patient is status post left total hip replacement. Gas is seen in\\n the stomach and a small amount of gas is seen in the colon and in the rectum\\n but otherwise there is a paucity of bowel gas. An NG tube is noted in the\\n stomach.\\n\\n IMPRESSION: Nonspecific bowel gas pattern.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-09-20 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 1032623,\n \"text\": \" 8:47 PM\\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \\n Reason: ? pneumothorax\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 55 year old woman with respiratory failure, s/p CVL placement. ? pneumo.\\n REASON FOR THIS EXAMINATION:\\n ? pneumothorax\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Respiratory failure with central line placement.\\n\\n FINDINGS: In comparison with the earlier study, the malpositioned left\\n subclavian line has been removed.\\n\\n Little change in the left apical opacification.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-09-28 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1034038,\n \"text\": \" 3:00 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: please eval infiltrates, lines\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 55 year old woman with respiratory failure, VAP, intubated.\\n REASON FOR THIS EXAMINATION:\\n please eval infiltrates, lines\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): AHPb MON 10:51 AM\\n PFI: No interval change.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Respiratory failure, ventilator-associated pneumonia.\\n\\n FINDINGS: Portable semi-upright chest radiograph is compared to at 14:33 and demonstrates no marked interval change in bilateral pleural\\n effusions, large bibasilar atelectases (left greater than right),\\n cardiomegaly. Lines and tubes are in standard fashion with left PICC\\n terminates at the cavoatrial junction.\\n\\n IMPRESSION: No interval changed in bibasilar pleural effusions and\\n atelectasis.\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2167-09-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 87285,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Left ventricular function. Braddycardia. Hypotension.\\nWeight (lb): 235\\nBP (mm Hg): 108/56\\nHR (bpm): 49\\nStatus: Inpatient\\nDate/Time: at 15:40\\nTest: Portable TTE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Suboptimal\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nThis study was compared to the prior study of .\\n\\n\\nLEFT ATRIUM: Elongated LA.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal interatrial septum.\\nNo ASD by 2D or color Doppler. Normal IVC diameter (<2.1cm) with <35% decrease\\nduring respiration (estimated RA pressure indeterminate).\\n\\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\\nsystolic function (LVEF >55%). No resting LVOT gradient. No VSD.\\n\\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\\n\\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\\ndiameter.\\n\\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\\n\\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. No MS.\\n\\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR.\\nModerate PA systolic hypertension.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: No PS.\\n\\nPERICARDIUM: No pericardial effusion.\\n\\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\\n\\nConclusions:\\nThe left atrium is elongated. No atrial septal defect is seen by 2D or color\\nDoppler. The right atrial pressure is indeterminate. Left ventricular wall\\nthickness, cavity size and regional/global systolic function are normal (LVEF\\n>55%). There is no ventricular septal defect. Right ventricular chamber size\\nand free wall motion are normal. The aortic valve leaflets (3) are mildly\\nthickened but aortic stenosis is not present. No aortic regurgitation is seen.\\nThe mitral valve appears structurally normal with trivial mitral\\nregurgitation. There is no mitral valve prolapse. The tricuspid valve leaflets\\nare mildly thickened. There is moderate pulmonary artery systolic\\nhypertension. There is no pericardial effusion.\\n\\nCompared with the prior study (images reviewed) of , no change.\\n\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2167-09-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 87286,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Right ventricular function. Shortness of breath. Hypotension. Bubble study.\\nHeight: (in) 68\\nWeight (lb): 230\\nBSA (m2): 2.17 m2\\nBP (mm Hg): 101/67\\nHR (bpm): 72\\nStatus: Inpatient\\nDate/Time: at 15:37\\nTest: Portable TTE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: Saline\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT ATRIUM: Normal LA and RA cavity sizes.\\n\\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolic\\nfunction (LVEF>55%). Suboptimal technical quality, a focal LV wall motion\\nabnormality cannot be fully excluded. No resting LVOT gradient.\\n\\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\\n\\nAORTIC VALVE: Normal aortic valve leaflets. No AR.\\n\\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\\n\\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Mild PA\\nsystolic hypertension.\\n\\nPERICARDIUM: There is an anterior space which most likely represents a fat\\npad, though a loculated anterior pericardial effusion cannot be excluded.\\n\\nGENERAL COMMENTS: Contrast study was performed with 3 iv injections of 8 ccs\\nof agitated normal saline, at rest, with cough and post-Valsalva maneuver.\\n\\nConclusions:\\nThe left atrium and right atrium are normal in cavity size. Suboptimal saline\\ncontrast study does not suggest an intracardiac shunt. Left ventricular wall\\nthickness, cavity size, and global systolic function are normal (LVEF>55%).\\nDue to suboptimal technical quality, a focal wall motion abnormality cannot be\\nfully excluded. Right ventricular chamber size and free wall motion are\\nnormal. The aortic valve leaflets appear structurally normal with good leaflet\\nexcursion. No aortic regurgitation is seen. .The mitral valve appears\\nstructurally normal with trivial mitral regurgitation. There is mild-moderate\\npulmonary artery systolic hypertension. There is an anterior space which most\\nlikely represents a fat pad.\\n\\nIMPRESSION: Suboptimal image quality. Preserved global biventricular systolic\\nfunction. Mild-moderate pulmonary artery systolic hypertension.\\n\\nCLINICAL IMPLICATIONS:\\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\\nindicate prophylaxis is NOT recommended. Clinical decisions regarding the need\\nfor prophylaxis should be based on clinical and echocardiographic data.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-10-28 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1040102,\n \"text\": \" 3:21 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ? interval change\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old woman with TBM, s/p trach\\n REASON FOR THIS EXAMINATION:\\n ? interval change\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLnc WED 11:40 AM\\n No significant change compared to the prior studies. Extensive basal\\n atelectasis.\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAMINATION: Followup of a patient with tracheobronchomalacia\\n after tracheostomy.\\n\\n COMPARISON: Chest radiographs from and .\\n\\n The study is limited due to motion artifact, but overall, there is no change\\n in bilateral significant atelectasis involving lower lobes and right middle\\n lobe. The upper lungs are ventilated. The tracheostomy is low with its tip\\n projecting less than 2 cm above the carina. Pleural effusion cannot be\\n excluded.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-10-28 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1040103,\n \"text\": \", MED MICU 3:21 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ? interval change\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old woman with TBM, s/p trach\\n REASON FOR THIS EXAMINATION:\\n ? interval change\\n ______________________________________________________________________________\\n PFI REPORT\\n No significant change compared to the prior studies. Extensive basal\\n atelectasis.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-10-23 00:00:00.000\",\n \"description\": \"PICC W/O PORT\",\n \"row_id\": 1039213,\n \"text\": \" 11:27 AM\\n PICC LINE PLACMENT SCH Clip # \\n Reason: Needs double lumen PICC; has Hx of DVT in upper extremities.\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ********************************* CPT Codes ********************************\\n * PICC W/O FLUORO GUID PLCT/REPLCT/REMOVE *\\n * US GUID FOR VAS. ACCESS *\\n ****************************************************************************\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old woman with ilius needs TPN\\n REASON FOR THIS EXAMINATION:\\n Needs double lumen PICC; has Hx of DVT in upper extremities.\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): JRCi 3:58 PM\\n PICC line ready for use. Non-occlusive thrombus bilateral upper extremity.\\n ______________________________________________________________________________\\n FINAL REPORT\\n STUDY: PICC line placement.\\n\\n INDICATION: Inability to perform bedside PICC line with patient needing TPN.\\n\\n The procedure was explained to the patient's proxy. A timeout was performed.\\n\\n RADIOLOGISTS: Dr. performed the procedure. Dr. , the Attending\\n Radiologist, was present and supervised the entire procedure.\\n\\n TECHNIQUE: Using sterile technique and local anesthesia, the left basilic\\n vein was punctured under direct ultrasound guidance using a micropuncture set.\\n A small focal non-occlusive thrombus was detected within the vein more\\n distally. Hard copy of ultrasound images were obtained before and immediately\\n after establishing intravenous access. A peel-away sheath was then placed\\n over a guidewire and a double-lumen PICC line measuring 41 cm in length was\\n then placed through the peel-away sheath with its tip positioned in the SVC\\n under fluoroscopic guidance. Position of the catheter was confirmed by a\\n fluoroscopic spot film of the chest.\\n\\n The peel-away sheath and guidewire were then removed. The catheter was\\n secured to the skin, flushed, and a sterile dressing applied.\\n\\n The patient was uncooperative during the procedure. There were no immediate\\n post- procedural complications.\\n\\n IMPRESSION:\\n 1. Uncomplicated ultrasound and fluoroscopically guided double-lumen PICC line\\n via the left basilic venous approach. Final internal length is 41 cm, with\\n the tip positioned in the SVC. The line is ready to use.\\n\\n 2. Small amount of non-occlusive thrombus was detected within bilateral\\n basilic veins.\\n\\n Findings discussed with Dr. at 4:44 pm the day of examination.\\n (Over)\\n\\n 11:27 AM\\n PICC LINE PLACMENT SCH Clip # \\n Reason: Needs double lumen PICC; has Hx of DVT in upper extremities.\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-10-23 00:00:00.000\",\n \"description\": \"FLUORO GUID PLCT/REPLCT/REMOVE CENTRAL LINE\",\n \"row_id\": 1039214,\n \"text\": \", C. MED MICU 11:27 AM\\n PICC LINE PLACMENT SCH Clip # \\n Reason: Needs double lumen PICC; has Hx of DVT in upper extremities.\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old woman with ilius needs TPN\\n REASON FOR THIS EXAMINATION:\\n Needs double lumen PICC; has Hx of DVT in upper extremities.\\n ______________________________________________________________________________\\n PFI REPORT\\n PICC line ready for use. Non-occlusive thrombus bilateral upper extremity.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-10-19 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1038109,\n \"text\": \" 3:18 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Please eval for change from prior\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old woman with tracheostomy\\n REASON FOR THIS EXAMINATION:\\n Please eval for change from prior\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Tracheostomy.\\n\\n COMPARISON: .\\n\\n PORTABLE CHEST RADIOGRAPH: Tracheostomy tube appears in unchanged position.\\n Gastric tube is seen overlying the abdomen. Cardiac and mediastinal contours\\n are unchanged. Bibasilar atelectasis and likely small pleural effusions are\\n also unchanged. Unusual opacity is seen overlying the left mid lung, possibly\\n atelectasis, although attention on followup is recommended.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-10-23 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1039135,\n \"text\": \" 7:23 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ? aspiration, ? PNA\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 yo F, w/ trach and peg, s/p self-extubation, now w/ fever, ? aspiration\\n REASON FOR THIS EXAMINATION:\\n ? aspiration, ? PNA\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Tracheostomy and PEG status post self-extubation, now with fever and\\n possible aspiration.\\n\\n FINDINGS: In comparison with the study of , there is opacification at the\\n left base that again could reflect atelectasis or aspiration. Right lower\\n lobe collapse is long-standing. Enlargement of the cardiac silhouette\\n persists. No definite vascular congestion, raising the possibility of\\n underlying cardiomyopathy.\\n\\n Tracheostomy tube remains in place.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-10-22 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1038849,\n \"text\": \" 2:54 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ? Interval change\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old woman with spinal injury, PEG tube in place but vomiting all tube\\n feeds and no bowel sounds on exam.\\n REASON FOR THIS EXAMINATION:\\n ? Interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n AP CHEST, 2:54 A.M. ON .\\n\\n HISTORY: Spinal injury, PEG tube in place. Vomiting.\\n\\n IMPRESSION: AP chest compared to and 8.\\n\\n Developing opacification in left lower lobe could represent atelectasis or\\n aspiration. Right lower lobe collapse is longstanding. Mild cardiomegaly is\\n worsened. Tracheostomy tube is turned and has a very short intratracheal\\n excursion. Clinical evaluation is advised. No pneumothorax.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-10-18 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1037930,\n \"text\": \", C. MED MICU 2:53 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for infiltrate, effusion\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old woman with long MICU admission, s/p trach, intermittently\\n mechanically ventilated.\\n REASON FOR THIS EXAMINATION:\\n eval for infiltrate, effusion\\n ______________________________________________________________________________\\n PFI REPORT\\n Unchanged right middle lobe and right lower lobe collapse and left lower lobe\\n atelectasis. No enlarging pleural effusions.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-10-22 00:00:00.000\",\n \"description\": \"UGI SGL CONTRAST W/ KUB\",\n \"row_id\": 1038939,\n \"text\": \" 10:29 AM\\n UGI SGL CONTRAST W/ KUB Clip # \\n Reason: evaluate for dysmotility\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old woman s/p t-spine fx, repeated emesis with TFs.\\n REASON FOR THIS EXAMINATION:\\n evaluate for dysmotility\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): 12:25 PM\\n PFI: Findings are suggestive of underlying dysmotility with minimal antegrade\\n or retrograde movement.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Status post thoracic spine fracture with repeated emesis, recently\\n placed GJ tube with port in jejunum and still not tolerating tube feeds with\\n episodes of tube feed vomiting.\\n\\n Comparison is made to CT examination dated and images from\\n recent J-tube placement.\\n\\n Initial scout radiograph demonstrates appropriately positioned GJ tube with\\n inflated balloon. Approximately 30 cc of Optiray contrast was injected\\n through the port and was noted to predominantly pool within the loop of\\n jejunum at the tube exit site with minimal retro and forward pulsion of\\n contents. Intermittent fluoroscopy was performed for approximately 5 minutes\\n to evaluate for motility pattern. Subsequently, an additional 10 mL of thin\\n barium was instilled and displayed a similar pattern with only mild motility\\n noted. No contrast is noted to reflux into the duodenum/stomach. Oral\\n contrast is noted within the large bowel from prior CT examination.\\n\\n IMPRESSION:\\n\\n Findings are suggestive of underlying intestinal dysmotility with limited\\n movement of injected contrast through the J-tube in either antegrade or\\n retrograde direction. A repeat KUB is recommended centered over the upper\\n abdomen in 15 minutes to evaluate for contrast progression.\\n\\n Findings discussed with Dr. shortly after exam acquisition.\\n\\n\\n *\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-10-22 00:00:00.000\",\n \"description\": \"UGI SGL CONTRAST W/ KUB\",\n \"row_id\": 1038940,\n \"text\": \", C. MED MICU 10:29 AM\\n UGI SGL CONTRAST W/ KUB Clip # \\n Reason: evaluate for dysmotility\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old woman s/p t-spine fx, repeated emesis with TFs.\\n REASON FOR THIS EXAMINATION:\\n evaluate for dysmotility\\n ______________________________________________________________________________\\n PFI REPORT\\n PFI: Findings are suggestive of underlying dysmotility with minimal antegrade\\n or retrograde movement.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-10-24 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1039350,\n \"text\": \" 3:26 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Please eval for change from prior\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old woman with trach, fever, recurrent vomiting, desaturation\\n REASON FOR THIS EXAMINATION:\\n Please eval for change from prior\\n ______________________________________________________________________________\\n FINAL REPORT\\n PORTABLE CHEST \\n\\n COMPARISON: .\\n\\n INDICATION: Fever.\\n\\n PICC terminates within the mid superior vena cava. There is otherwise no\\n substantial change since the recent radiograph allowing for marked leftward\\n patient rotation on the current study.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-10-25 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1039489,\n \"text\": \", C. MED MICU 2:55 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: please eval for change from prior\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old woman with respiratory failure, trach\\n REASON FOR THIS EXAMINATION:\\n please eval for change from prior\\n ______________________________________________________________________________\\n PFI REPORT\\n The left PICC line tip is at the junction of brachiocephalic vein and SVC,\\n more proximal than on the prior study, otherwise worsening of atelectasis in\\n the left lower lung.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-10-26 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1039687,\n \"text\": \" 3:41 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: please eval for change from prior\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old woman with trach ?aspiration\\n REASON FOR THIS EXAMINATION:\\n please eval for change from prior\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLnc MON 9:18 AM\\n PFI: No appreciable change.\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAMINATION: Suspected aspiration.\\n\\n Portable AP chest radiograph was compared to prior study obtained on , , at 03:38 a.m.\\n\\n No appreciable change is demonstrated in this approximately 24 hours interval.\\n Bibasilar atelectasis is unchanged, left more than right. The tracheostomy is\\n in unchanged position. The upper lungs are aerated. The patient's head\\n overlies the apices.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-10-18 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1037929,\n \"text\": \" 2:53 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for infiltrate, effusion\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old woman with long MICU admission, s/p trach, intermittently\\n mechanically ventilated.\\n REASON FOR THIS EXAMINATION:\\n eval for infiltrate, effusion\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): JRld SUN 2:35 PM\\n Unchanged right middle lobe and right lower lobe collapse and left lower lobe\\n atelectasis. No enlarging pleural effusions.\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAM: Intermittently mechanically ventilated, long MICU admission.\\n\\n Comparison is made with prior studies including most recent one on .\\n\\n Right middle lobe and right lower lobe collapse are unchanged as are left\\n lower lobe atelectasis. If any, there is a small left pleural effusion.\\n No PTX. Tracheostomy tube in standard position. Low lung volumes.\\n Cardiomediastinal silhouette is unchanged.\\n\\n DR. \\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-10-26 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1039688,\n \"text\": \", C. MED MICU 3:41 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: please eval for change from prior\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old woman with trach ?aspiration\\n REASON FOR THIS EXAMINATION:\\n please eval for change from prior\\n ______________________________________________________________________________\\n PFI REPORT\\n PFI: No appreciable change.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-10-22 00:00:00.000\",\n \"description\": \"PORTABLE ABDOMEN\",\n \"row_id\": 1039027,\n \"text\": \" 3:31 PM\\n PORTABLE ABDOMEN; -76 BY SAME PHYSICIAN # \\n Reason: eval for movement of contrast\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old woman with GI dysmotility, s/p UGI series this AM\\n REASON FOR THIS EXAMINATION:\\n eval for movement of contrast\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): 4:23 PM\\n Continued progression of oral contrast into the distal small bowel/proximal\\n large bowel. Findings are again suggestive of underlying intestinal\\n dysmotility without evidence of obstruction. No further radiographic followup\\n is deemed necessary.\\n ______________________________________________________________________________\\n FINAL REPORT\\n Evaluate for interval movement of contrast in patient with probable underlying\\n intestinal dysmotility.\\n\\n Comparison is made to prior portable abdominal radiograph and upper GI series\\n from same date.\\n\\n There continues to be progression of the oral contrast instilled during the\\n fluoroscopy examination from the morning, now in the distal small\\n bowel/proximal large bowel. No definite contrast is noted within the\\n duodenum/stomach.\\n\\n IMPRESSION:\\n\\n Findings again consistent with mild-to-moderate underlying intestinal\\n dysmotility but no evidence of retrograde contrast movement into the\\n duodenum/stomach was noted on real-time fluoroscopy or initial followup\\n radiograph. No further films are deemed necessary.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-10-22 00:00:00.000\",\n \"description\": \"PORTABLE ABDOMEN\",\n \"row_id\": 1039028,\n \"text\": \", C. MED MICU 3:31 PM\\n PORTABLE ABDOMEN; -76 BY SAME PHYSICIAN # \\n Reason: eval for movement of contrast\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old woman with GI dysmotility, s/p UGI series this AM\\n REASON FOR THIS EXAMINATION:\\n eval for movement of contrast\\n ______________________________________________________________________________\\n PFI REPORT\\n Continued progression of oral contrast into the distal small bowel/proximal\\n large bowel. Findings are again suggestive of underlying intestinal\\n dysmotility without evidence of obstruction. No further radiographic followup\\n is deemed necessary.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-10-20 00:00:00.000\",\n \"description\": \"CT ABDOMEN W/CONTRAST\",\n \"row_id\": 1038473,\n \"text\": \" 3:39 PM\\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \\n Reason: eval for transition point or evidence of obstruction\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n Contrast: OPTIRAY Amt: 130\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old woman with spinal injury, PEG tube in place but vomiting all tube\\n feeds and no bowel sounds on exam.\\n REASON FOR THIS EXAMINATION:\\n eval for transition point or evidence of obstruction\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): JXKc TUE 7:51 PM\\n No evidence of obstruction. No acute intra-abdominal process.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 56-year-old female with spinal injury, PEG tube in place, but\\n vomiting all tube feeds and no bowel sounds on examination. Evaluate for\\n evidence of obstruction.\\n\\n COMPARISON: .\\n\\n TECHNIQUE: MDCT axial images were obtained from the lung bases symphysis\\n pubis with administration of IV and oral contrast. Coronal and sagittal\\n reformations were obtained.\\n\\n CT OF THE ABDOMEN WITH IV CONTRAST: The visualized heart and pericardium are\\n unremarkable. There is atelectasis within both lung bases, with the\\n visualized airways suggestive of tracheobronchomalacia. A 1- cm rounded\\n calcific density within the left atelectatic left lower lobe is of unclear\\n etiology, could represent a calcified granuloma, or sequela from prior trauma.\\n There is no pleural effusion.\\n\\n The liver, spleen, adrenal glands, left kidney, and pancreas are unremarkable.\\n Gallstones are present, without secondary findings for cholecystitis. There\\n is a 3.5-cm cyst within the upper pole of the right kidney. Otherwise, the\\n right kidney is unremarkable.\\n\\n There is a gastrostomy tube in place. The stomach, small bowel, and colon are\\n collapsed, without evidence of bowel obstruction. There are scattered\\n diverticula throughout the colon, without evidence of diverticulitis. A 2.5 cm\\n rounded structure adjacent to the second/third portion of duodenum, likely\\n reflects a duodenal diverticulum. There is no free fluid, free air, or\\n pathologic adenopathy. Surgical clips are present within the right lower\\n quadrant of the abdomen.\\n\\n CT OF THE PELVIS WITH IV CONTRAST: Foley catheter courses into the bladder.\\n Rectum is unremarkable. There is no pelvic free fluid or adenopathy.\\n\\n OSSEOUS STRUCTURES: Patient is status post left hip replacement. There is a\\n compression fracture of the T8 vertebral body as well as likely the T6\\n vertebral body, as seen on , with a slightly increased loss\\n (Over)\\n\\n 3:39 PM\\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \\n Reason: eval for transition point or evidence of obstruction\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n Contrast: OPTIRAY Amt: 130\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n of vertebral body height.\\n\\n IMPRESSION:\\n\\n 1. No acute intra-abdominal process, without evidence of obstruction.\\n\\n 2. Atelectasis of both lung bases, with suggestion of tracheobronchomalacia,\\n which may be related to chronic tracheostomy. This can be further evaluated\\n with a CT trachea.\\n\\n 3. Cholelithiasis.\\n\\n 4. Diverticulosis without diverticulitis.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-10-20 00:00:00.000\",\n \"description\": \"CT ABDOMEN W/CONTRAST\",\n \"row_id\": 1038474,\n \"text\": \", C. MED MICU 3:39 PM\\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \\n Reason: eval for transition point or evidence of obstruction\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n Contrast: OPTIRAY Amt: 130\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old woman with spinal injury, tube in place but vomiting all tube\\n feeds and no bowel sounds on exam.\\n REASON FOR THIS EXAMINATION:\\n eval for transition point or evidence of obstruction\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n PFI REPORT\\n No evidence of obstruction. No acute intra-abdominal process.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-10-25 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1039488,\n \"text\": \" 2:55 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: please eval for change from prior\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old woman with respiratory failure, trach\\n REASON FOR THIS EXAMINATION:\\n please eval for change from prior\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLnc SUN 9:26 AM\\n The left PICC line tip is at the junction of brachiocephalic vein and SVC,\\n more proximal than on the prior study, otherwise worsening of atelectasis in\\n the left lower lung.\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAMINATION: Interval change in intubated patient with respiratory\\n failure and tracheostomy.\\n\\n Portable AP chest radiograph was compared to and .\\n\\n The left PICC line tip is at the junction of brachiocephalic vein and SVC,\\n slightly more proximal than on the prior study. The tracheostomy tip is at\\n the midline. The bibasilar opacities have increased, obscuring the right and\\n left heart border. The lung volumes remain low. Bilateral pleural effusion\\n is most likely present.\\n\\n The radiodense opacity projecting over the left lower lobe corresponds to\\n known calcified granuloma.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-10-21 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1038566,\n \"text\": \", C. MED MICU 3:09 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for infiltrate or effusion\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old woman with trach, concern for aspiration\\n REASON FOR THIS EXAMINATION:\\n eval for infiltrate or effusion\\n ______________________________________________________________________________\\n PFI REPORT\\n Tracheostomy tube oriented horizontally should be evaluated clinically. Right\\n basal atelectasis and small bilateral pleural effusions unchanged. Heart size\\n normal. No pneumothorax.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-10-22 00:00:00.000\",\n \"description\": \"PORTABLE ABDOMEN\",\n \"row_id\": 1038965,\n \"text\": \" 11:46 AM\\n PORTABLE ABDOMEN; -59 DISTINCT PROCEDURAL SERVICE Clip # \\n Reason: Need f/u study s/p tube study; requested by radiology\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old woman with PEG/TRACH s/p t-spine frx, resp failure, and PNA, w/\\n vomitting and now new Jtube via G-tube\\n REASON FOR THIS EXAMINATION:\\n Need f/u study s/p tube study; requested by radiology\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): 2:30 PM\\n PFI: Appropriate antegrade movement of injected contrast into the mid and\\n distal jejunum. No reflux of contrast noted within the duodenum or stomach.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Evaluate progression of contrast from prior J-tube study.\\n\\n Comparison is made to J-tube study performed on same date.\\n\\n PORTABLE SUPINE ABDOMINAL RADIOGRAPH\\n\\n FINDINGS: Positioning of the J-tube is unchanged with contrast noted to have\\n advanced antegrade into the mid to distal jejunum. No contrast is noted\\n within the duodenum or stomach. Oral contrast from prior CT examination is\\n again noted within the colon.\\n\\n IMPRESSION:\\n\\n No reflux contrast noted within the duodenum/stomach. Appropriate antegrade\\n movement of the stomach into the loops of mid and distal jejunum.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-10-22 00:00:00.000\",\n \"description\": \"PORTABLE ABDOMEN\",\n \"row_id\": 1038966,\n \"text\": \", C. MED MICU 11:46 AM\\n PORTABLE ABDOMEN; -59 DISTINCT PROCEDURAL SERVICE Clip # \\n Reason: Need f/u study s/p tube study; requested by radiology\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old woman with PEG/TRACH s/p t-spine frx, resp failure, and PNA, w/\\n vomitting and now new Jtube via G-tube\\n REASON FOR THIS EXAMINATION:\\n Need f/u study s/p tube study; requested by radiology\\n ______________________________________________________________________________\\n PFI REPORT\\n PFI: Appropriate antegrade movement of injected contrast into the mid and\\n distal jejunum. No reflux of contrast noted within the duodenum or stomach.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-10-21 00:00:00.000\",\n \"description\": \"CONVERT G TO GJ, ALL INCL.\",\n \"row_id\": 1038769,\n \"text\": \" 3:49 PM\\n PERC G/G-J TUBE PLMT Clip # \\n Reason: Please place J tube\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n Contrast: OPTIRAY Amt: 20\\n ********************************* CPT Codes ********************************\\n * CONVERT G TO GJ, ALL INCL. *\\n ****************************************************************************\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old woman with PEG tube. Please place smaller G-J tube through G tube.\\n REASON FOR THIS EXAMINATION:\\n Please place J tube\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 56-year-old female with PEG tube. Please convert to J-tube.\\n\\n RADIOLOGISTS: Dr. , , and attending radiologist, Dr. ,\\n who was present and supervised the entire procedure.\\n\\n PROCEDURE AND FINDINGS: The risks and benefits of the procedure were\\n explained to the healthcare proxy and informed consent was obtained.\\n A pre-procedure timeout was performed to confirm the identity of the patient\\n by name, medical record number, date of birth, and the nature of the procedure\\n to be performed. The patient was placed supine on the angiography table and\\n the patient's mid abdomen and indwelling G-tube were prepped and draped in\\n standard sterile fashion.\\n\\n Initial fluoroscopic image demonstrates gastrostomy tube located within the\\n stomach. Injection of contrast through the indwelling G-tube demonstrates\\n passage of contrast. After local anesthesia administration to the existing\\n site with 1% lidocaine, a 0.035 wire was passed through the pre-\\n existing G-tube and with the aid of a 5 French catheter was advanced\\n under fluoroscopic guidance past the pylorus into the jejunum. The \\n wire was replaced with a 0.035 Amplatz wire. After removal of the 5 French\\n catheter, a 10 French -Alvatecoons gastrojejunostomy catheter was\\n advanced over the wire through the indwelling gastrostomy tube with tip\\n positioned in the jejunum. Appropriate position of the catheter was confirmed\\n by injection of contrast. The wire was removed and the GJ tube secured to the\\n skin with 0 silk sutures and a Flexi-Trak device. The patient tolerated the\\n procedure well and there were no immediate complications.\\n\\n MODERATE SEDATION was provided by administering 180 mcg of Fentanyl and 3 mg\\n of Versed via divided doses throughout the 43 minute intraservice time with\\n continuous hemodynamic monitoring.\\n\\n IMPRESSION: Successful placement of a GJ tube through existing G-tube with\\n tip positioned in the jejunum.\\n (Over)\\n\\n 3:49 PM\\n PERC G/G-J TUBE PLMT Clip # \\n Reason: Please place J tube\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n Contrast: OPTIRAY Amt: 20\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-10-27 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1039854,\n \"text\": \" 2:53 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: interval change\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old woman with TBM, s/p trach\\n REASON FOR THIS EXAMINATION:\\n interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST RADIOGRAPH\\n\\n INDICATION: Follow up.\\n\\n COMPARISON: , 4:18 a.m.\\n\\n FINDINGS: The current radiograph is markedly impaired by severe motion\\n artifacts. On this limited basis, there is no obvious radiological change.\\n The tracheostomy tube is in unchanged position. The retrocardiac lung areas\\n could be minimally better ventilated.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-10-21 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1038565,\n \"text\": \" 3:09 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for infiltrate or effusion\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old woman with trach, concern for aspiration\\n REASON FOR THIS EXAMINATION:\\n eval for infiltrate or effusion\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): PSS WED 2:00 PM\\n Tracheostomy tube oriented horizontally should be evaluated clinically. Right\\n basal atelectasis and small bilateral pleural effusions unchanged. Heart size\\n normal. No pneumothorax.\\n ______________________________________________________________________________\\n FINAL REPORT\\n AP CHEST 3:14 A.M. \\n\\n HISTORY: Tracheostomy. Concern for aspiration.\\n\\n IMPRESSION: AP chest compared to and 6:\\n\\n Tracheostomy tube is oriented horizontally and should be evaluated clinically.\\n Heart size normal. Right lower lobe atelectasis persists. Pleural effusion\\n is bilateral and small. No pneumothorax.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-10-04 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1035231,\n \"text\": \" 3:24 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: lung fields\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old woman with resp failure\\n REASON FOR THIS EXAMINATION:\\n lung fields\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): DJRX SUN 10:25 AM\\n No significant change.\\n ______________________________________________________________________________\\n FINAL REPORT\\n SUPINE PORTABLE CHEST\\n\\n HISTORY: Respiratory failure, check lungs.\\n\\n One view. Comparison with . Lung volumes are somewhat low. There is\\n continued evidence of pulmonary vascular congestion and bilateral pleural\\n effusions unchanged. There is increased density in the retrocardiac area as\\n before. Mediastinal structures are stable. A tracheostomy tube remains in\\n place.\\n\\n IMPRESSION: No definite interval change.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-10-04 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1035232,\n \"text\": \", F. MED MICU 3:24 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: lung fields\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old woman with resp failure\\n REASON FOR THIS EXAMINATION:\\n lung fields\\n ______________________________________________________________________________\\n PFI REPORT\\n No significant change.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-10-09 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1036271,\n \"text\": \" 3:26 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ?interval change\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old woman with t-spine frx and respiratory failure, s/p VAP, and\\n PEG/trach\\n REASON FOR THIS EXAMINATION:\\n ?interval change\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLnc FRI 12:08 PM\\n No appreciable change during the short-time interval.\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAMINATION: Followup of a patient with T-spine fractures and\\n respiratory failure.\\n\\n Portable AP chest radiograph was compared to obtained at\\n 8:30 p.m.\\n\\n The current study demonstrates no significant change in the degree of left\\n retrocardiac consolidation, consistent with atelectasis/aspiration. The right\\n hemidiaphragm remains high. The upper lungs are grossly unremarkable. The\\n position of the tracheostomy is unchanged. The PICC line tip can be followed\\n till the cavoatrial junction.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-10-14 00:00:00.000\",\n \"description\": \"L UNILAT UP EXT VEINS US LEFT\",\n \"row_id\": 1037258,\n \"text\": \", C. MED MICU 3:29 PM\\n UNILAT UP EXT VEINS US LEFT Clip # \\n Reason: Pleas eeval for DVT\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old woman with fever, h/o UE DVT with PICC line\\n REASON FOR THIS EXAMINATION:\\n Pleas eeval for DVT\\n ______________________________________________________________________________\\n PFI REPORT\\n PFI: Very small segment (1-cm in length) of nonocclusive thrombus in the left\\n axillary vein. A PICC catheter is present on the left.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-10-12 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1036725,\n \"text\": \" 2:50 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ? interval change\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old woman with traumatic T-spine frx, HAP/VAP and respiratory ditress,\\n now extubated, but spiking fevers and slowly improving MS\\n REASON FOR THIS EXAMINATION:\\n ? interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST RADIOGRAPH\\n\\n INDICATION: Status post respiratory distress.\\n\\n COMPARISON: , 12:44 a.m.\\n\\n FINDINGS: As compared to the previous radiograph, there is little overall\\n change. Small newly occurred left-sided atelectasis that project over the\\n costophrenic sinus. The right lung base has slightly increased in\\n transparency. Unchanged is a small right-sided pleural effusion. The size of\\n the cardiac silhouette is unchanged and at the upper range of normal. No\\n obvious overhydration. No newly occurred focal parenchymal opacities\\n suggestive of pneumonia.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-10-09 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1036272,\n \"text\": \", F. MED MICU 3:26 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ?interval change\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old woman with t-spine frx and respiratory failure, s/p VAP, and\\n PEG/trach\\n REASON FOR THIS EXAMINATION:\\n ?interval change\\n ______________________________________________________________________________\\n PFI REPORT\\n No appreciable change during the short-time interval.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-10-15 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1037316,\n \"text\": \" 3:31 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Please eval for change\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old woman with elevated diaphragm, ? effusion\\n REASON FOR THIS EXAMINATION:\\n Please eval for change\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 56-year-old woman with question of effusion and interval change.\\n\\n COMPARISON: Comparison is made to chest radiograph from .\\n\\n FINDINGS: A tracheostomy tube and left PICC are in good position, unchanged\\n from previous study.\\n\\n Small right pleural effusion is unchanged. There is no left pleural effusion.\\n Right middle and lower lobe collapse is unchanged. There is interval increase\\n in left lung base opacity, likely progressive atelectasis. Lungs are\\n otherwise clear. Cardiac contours are obscured by adjacent atelectasis and\\n effusion. Mediastinal contours are normal. Visualized soft tissue structures\\n and bony thorax are unremarkable.\\n\\n IMPRESSION:\\n 1. Persistent right middle/lower lobe collapse and progressive left basilar\\n atelectasis.\\n 2. Unchanged small right pleural effusion.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-10-11 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1036618,\n \"text\": \" 12:13 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: r/o aspiration/infection\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old woman with recent aspiration and fever.\\n REASON FOR THIS EXAMINATION:\\n r/o aspiration/infection\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST RADIOGRAPH\\n\\n INDICATION: Followup.\\n\\n COMPARISON: , 4:24 a.m.\\n\\n FINDINGS: As compared to the previous radiograph, the tracheostomy tube is in\\n unchanged position. The size of the cardiac silhouette is also unchanged.\\n The retrocardiac lung areas are slightly better ventilated than before, the\\n right basal opacities are unchanged. There is no evidence of newly occurred\\n focal parenchymal opacities. Unchanged moderate cardiomegaly without signs of\\n obvious overhydration. No pneumothorax.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-10-14 00:00:00.000\",\n \"description\": \"L UNILAT UP EXT VEINS US LEFT\",\n \"row_id\": 1037257,\n \"text\": \" 3:29 PM\\n UNILAT UP EXT VEINS US LEFT Clip # \\n Reason: Pleas eeval for DVT\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old woman with fever, h/o UE DVT with PICC line\\n REASON FOR THIS EXAMINATION:\\n Pleas eeval for DVT\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): AHPb WED 7:35 PM\\n PFI: Very small segment (1-cm in length) of nonocclusive thrombus in the left\\n axillary vein. A PICC catheter is present on the left.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Fever, history of upper extremity DVT with PICC line.\\n\\n FINDINGS: -scale and color Doppler son of the left upper extremity\\n including the subclavian, internal jugular, axillary, basilic, and cephalic\\n veins demonstrate very small segment of nonocclusive thrombus in the left\\n axillary (1-cm in length). Otherwise, there is normal flow, compressibility,\\n and waveforms. A PICC catheter is present entering the left basilic.\\n\\n IMPRESSION: Very small nonocclusive DVT in the left axillary vein.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-10-05 00:00:00.000\",\n \"description\": \"CT CHEST W/O CONTRAST\",\n \"row_id\": 1035524,\n \"text\": \" 5:23 PM\\n CT CHEST W/O CONTRAST Clip # \\n Reason: ? loculated effusion,\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n Field of view: 40\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old woman with resp failure s/p fall and T-spine frx, now w/ worsening\\n bilateral effusions, s/p treated VAP, considering Tap of effusion\\n REASON FOR THIS EXAMINATION:\\n ? loculated effusion,\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): KCLd TUE 5:10 PM\\n 1. Improving bilateral consolidations, atelectasis, and effusions. No\\n loculated effusion identified. Persistent smaller bilateral pleural effusions\\n and atelectasis/consolidation could be secondary to aspiration.\\n 2. Evidence of tracheobronchomalacia.\\n 3. Evidence of overinflation of the tracheostomy cuff.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Respiratory failure, status post fall with T-spine fracture,\\n worsening bilateral effusions. Evaluate for loculated effusion.\\n\\n COMPARISON: .\\n\\n TECHNIQUE: MDCT-acquired axial images of the chest were obtained without\\n contrast. 5- and 1.25-mm thin section images were displayed. Coronal and\\n sagittal reformatted images were also displayed.\\n\\n FINDINGS: Patient is status post tracheostomy. Small amount of hematoma is\\n seen surrounding the tracheostomy tube. The tracheal cuff appears slightly\\n overinflated. Right hypoattenuating thyroid nodule is noted.\\n\\n Compared to prior study, there is improved aeration of the lungs bilaterally.\\n There has been interval decrease in the pleural effusions not atelectasis\\n bilaterally. Persistent lower lobe atelectasis is seen bilaterally, with\\n small pleural effusions. There is no loculated effusion. There has been\\n interval improvement of the patchy nodular densities as well, suggesting\\n improving infection. Persistent large calcified granuloma measuring upwards\\n of 13 mm again seen in the left lower lobe.\\n\\n There is a severe collapse of the tracheal and bronchial airways, consistent\\n with tracheobronchomalacia. Pulmonary artery appears enlarged measuring\\n upwards of 3.5 cm, raising concern for possible pulmonary arterial\\n hypertension. Coronary artery calcifications are seen. Heart size appears\\n upper limits of normal. No pathologically enlarged mediastinal or hilar\\n lymphadenopathy identified. Gastric tube is seen in the stomach. Calcified\\n stones seen within the gallbladder. A cystic lesion in the right kidney again\\n identified. Otherwise, limited views of the upper abdomen are grossly\\n unremarkable.\\n\\n IMPRESSION:\\n (Over)\\n\\n 5:23 PM\\n CT CHEST W/O CONTRAST Clip # \\n Reason: ? loculated effusion,\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n Field of view: 40\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n 1. Improving bilateral consolidations and effusions. No loculated effusion\\n identified. Persistent atelectasis/consolidation at the lower lobes\\n bilaterally with small effusions, possibly secondary to aspiration.\\n 2. Evidence of tracheobronchomalacia.\\n 3. Evidence of slight overinflation of the tracheostomy cuff.\\n 4. Cholelithiasis.\\n 5. Right thyroid nodule. Ultrasound for further evaluation as clinically\\n indicated would be recommended when patient is stable.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-10-05 00:00:00.000\",\n \"description\": \"CT CHEST W/O CONTRAST\",\n \"row_id\": 1035525,\n \"text\": \", F. MED MICU 5:23 PM\\n CT CHEST W/O CONTRAST Clip # \\n Reason: ? loculated effusion,\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n Field of view: 40\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old woman with resp failure s/p fall and T-spine frx, now w/ worsening\\n bilateral effusions, s/p treated VAP, considering Tap of effusion\\n REASON FOR THIS EXAMINATION:\\n ? loculated effusion,\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n PFI REPORT\\n 1. Improving bilateral consolidations, atelectasis, and effusions. No\\n loculated effusion identified. Persistent smaller bilateral pleural effusions\\n and atelectasis/consolidation could be secondary to aspiration.\\n 2. Evidence of tracheobronchomalacia.\\n 3. Evidence of overinflation of the tracheostomy cuff.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-10-15 00:00:00.000\",\n \"description\": \"CONVERT G TO GJ, ALL INCL.\",\n \"row_id\": 1037472,\n \"text\": \" 5:01 PM\\n PERC G/J TUBE CHECK Clip # \\n Reason: Please reposition gastric tube into duodenum or jejunum.\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n Contrast: OPTIRAY Amt: 15\\n ********************************* CPT Codes ********************************\\n * CONVERT G TO GJ, ALL INCL. -52 REDUCED SERVICES *\\n ****************************************************************************\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old woman with PEG and Trach, s/p traumatic T-spine frx and respiratory\\n failure, HAP/VAP,now w/ multiple episodes of emesis into oropharynx.\\n REASON FOR THIS EXAMINATION:\\n Please reposition gastric tube into duodenum or jejunum.\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): JXXb FRI 10:08 AM\\n Exchange of existing G tube for a GJ tube without success.\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL INFORMATION: The patient is a 56-year-old woman with a PEG and\\n tracheostomy, status post traumatic thoracic spinal fracture and respiratory\\n failure. A G tube was placed surgically, and multiple episodes reflux. A\\n request was made for conversion of G to a gasrto-jejunal feeding tube.\\n\\n OPERATORS: Dr. and Dr. , the attending radiologist\\n who was present and supervised during the whole procedure.\\n\\n PROCEDURE: G tube injection.\\n\\n SEDATION: Lidocaine was used for local anesthesia.\\n\\n PROCEDURE AND FINDINGS: After the risks and benefits of the procedure as well\\n as the conscious sedation were explained, informed consent was obtained. The\\n patient was brought to the angiographic suite and placed supine on the imaging\\n table. The catheter area was prepared and draped in the usual sterile\\n fashion.\\n\\n A scout image and contrast injection verified the existing gastric tube with\\n its tip in the gastric lumen. A guide wire from a MIC GJ feeding tube kit was\\n advanced into the gastric lumen through the existing G tube. The external\\n skin sutures were removed, but the existing G tube could not be removed due to\\n the existence of an internal securing disc which could not be removed. A\\n portion of the external gastric tube was cut and a connector was placed. Tube\\n exchange can be performed only after surgical removal of the existing tube.\\n\\n The existing gastric tube was sutured to the skin and a sterile dressing was\\n applied.\\n\\n There were no immediate complications.\\n\\n IMPRESSION:\\n 1. Unsuccessful exchange of the existing gastric tube for a jejunal feeding\\n tube due to the existence of internal securing disc of the gastric tube that\\n (Over)\\n\\n 5:01 PM\\n PERC G/J TUBE CHECK Clip # \\n Reason: Please reposition gastric tube into duodenum or jejunum.\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n Contrast: OPTIRAY Amt: 15\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n requires surgical removal.\\n 2. Existing tube has it's tip within the gastric lumen.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-10-08 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1035989,\n \"text\": \" 2:52 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ? Interval change\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old woman with tramatic T-spine frx, and respiratory failure\\n REASON FOR THIS EXAMINATION:\\n ? Interval change\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): 9:24 AM\\n No relevant change.\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST RADIOGRAPH\\n\\n INDICATION: Respiratory failure, interval change.\\n\\n COMPARISON: .\\n\\n FINDINGS: As compared to the previous radiograph, there are extensive motion\\n artifacts that clearly limits the interpretation. Unchanged moderate\\n retrocardiac opacity and elevation of the hemidiaphragm. There could be a\\n minimal right-sided pleural effusion. The size of the cardiac silhouette is\\n unchanged. No newly occurred focal parenchymal opacity suggestive of\\n pneumonia.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-10-08 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1035990,\n \"text\": \", F. MED MICU 2:52 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ? Interval change\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old woman with tramatic T-spine frx, and respiratory failure\\n REASON FOR THIS EXAMINATION:\\n ? Interval change\\n ______________________________________________________________________________\\n PFI REPORT\\n No relevant change.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-10-11 00:00:00.000\",\n \"description\": \"P ABDOMEN (SUPINE ONLY) PORT\",\n \"row_id\": 1036673,\n \"text\": \" 11:35 AM\\n ABDOMEN (SUPINE ONLY) PORT Clip # \\n Reason: Eval for signs of obstruction,\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old woman s/p T-spine frx, HAP/, and trach w/ episodes of\\n vomiting and ?aspiration. Long course of narcotics. ?ileus/obstruction\\n REASON FOR THIS EXAMINATION:\\n Eval for signs of obstruction,\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Episodes of vomiting, signs of obstruction.\\n\\n FINDINGS: Normal borders of the psoas muscle. Total hip replacement, left.\\n Air in the rectum. tube in situ. No secure evidence of free air. No\\n evidence of pathologic air-fluid levels.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-10-15 00:00:00.000\",\n \"description\": \"CONVERT G TO GJ, ALL INCL.\",\n \"row_id\": 1037473,\n \"text\": \", C. MED MICU 5:01 PM\\n PERC G/J TUBE CHECK Clip # \\n Reason: Please reposition gastric tube into duodenum or jejunum.\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n Contrast: OPTIRAY Amt: 15\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old woman with PEG and Trach, s/p traumatic T-spine frx and respiratory\\n failure, HAP/VAP,now w/ multiple episodes of emesis into oropharynx.\\n REASON FOR THIS EXAMINATION:\\n Please reposition gastric tube into duodenum or jejunum.\\n ______________________________________________________________________________\\n PFI REPORT\\n Exchange of existing G tube for a GJ tube without success.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-10-16 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1037530,\n \"text\": \", C. MED MICU 3:49 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ? interval change\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old woman with respiratory failure, s/p traumatic t-spine frx, s/pHAP\\n REASON FOR THIS EXAMINATION:\\n ? interval change\\n ______________________________________________________________________________\\n PFI REPORT\\n No change since at least in right middle and lower lobe collapse,\\n left lower lobe atelectasis, and small bilateral pleural effusions.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-10-14 00:00:00.000\",\n \"description\": \"CTA CHEST W&W/O C&RECONS, NON-CORONARY\",\n \"row_id\": 1037218,\n \"text\": \" 12:55 PM\\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \\n Reason: Pleas eevaluate for PE\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n Contrast: OPTIRAY Amt: 100\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old woman with persistent sinus tachycardia, h/o UE DVT, fever,\\n abnormal CXR\\n REASON FOR THIS EXAMINATION:\\n Pleas eevaluate for PE\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): MLKb WED 3:12 PM\\n No PE centrally.\\n Study limited due to motion.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 56-year-old female with persistent sinus tachycardia, history of\\n upper extremity DVT, fever, abnormal chest x-ray. Please evaluate for PE.\\n\\n TECHNIQUE: MDCT of the chest was performed before and after administration of\\n intravenous contrast. Images were reformatted in the axial, sagittal, coronal\\n and oblique planes.\\n\\n COMPARISON: CT performed .\\n\\n FINDINGS: No filling defect can be identified in the central pulmonary\\n arteries, that could suggest pulmonary embolism. Study is limited due to\\n motion and poor contrast enhancement of pulmonary arteries.\\n A central line is seen with the tip in the cavoatrial junction. The patient is\\n status post tracheostomy. Minimal soft tissue edema is seen surrounding the\\n tracheostomy tube at its insertion. Above the level of the tracheal cuff,\\n pulling secretions are noted. Stable calcified granuloma in the left lower\\n lobe, (measuring 12 mm). Increased in number of borderline size lymph nodes in\\n the mediastinum, measuring up to 10 mm in the APW . Air- trapping is noted.\\n There is resolution of pleural effusions bilaterally. There is complete\\n collapse of the right middle lobe and partial collapse of the right lower\\n lobe. Dependent atelectases are seen in the lingula and left lower lobe. A\\n wedge-shaped consolidation is seen in the right upper lobe could correspond to\\n an area of infarction. There is severe collapsability of the tracheal and\\n bronchial airways, as previously described, consistent with\\n tracheobronchomalacia. Coronary artery calcifications are seen. Heart size\\n appears in the normal limits. Minimal pericardial effusion. Enlarged pulmonary\\n arteries measuring up to 30 mm suggest presence of pulmonary hypertension.\\n Limited evaluation of abdominal organs represents of calcified stones within\\n the gallbladder.\\n\\n BONE WINDOWS: Multiple collapsed fractures are seen in the thoracic spine.\\n\\n IMPRESSION:\\n\\n 1. No evidence of the central pulmonary embolism. The study is limited due\\n (Over)\\n\\n 12:55 PM\\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \\n Reason: Pleas eevaluate for PE\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n Contrast: OPTIRAY Amt: 100\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n to motion and poor enhancement of pulmonary artery branches.\\n 2. Persistent collapse of the right middle lobe and right lower lobe.\\n 3. Evidence of tracheobronchomalacia.\\n 4. Cholelithiasis.\\n 5. A wedge-shaped opacity in the right upper lobe on today's study but not\\n seen in the prior study on , is nonspecific but could\\n potentially represent infarction.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-10-08 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1036239,\n \"text\": \" 8:04 PM\\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \\n Reason: eval for infiltrate\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old woman with respiratory failure, recent pneumonia, on mechanical\\n vent, now with new fever.\\n REASON FOR THIS EXAMINATION:\\n eval for infiltrate\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLnc FRI 10:15 AM\\n Newly developed left lower lobe retrocardiac opacity most likely consistent\\n with atelectasis. Infectious process cannot be excluded.\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAMINATION: Respiratory failure in a patient on mechanical\\n ventilation.\\n\\n Portable AP chest radiograph was compared to prior study obtained the same day\\n earlier at 03:23 a.m. and .\\n\\n The tracheostomy is at the midline with the tip terminating 3 cm above the\\n carina. The left PICC line tip terminates approximately at the level of\\n cavoatrial junction.\\n\\n The cardiomediastinal silhouette is unchanged. Interval worsening in left\\n retrocardiac opacity is demonstrated consistent with a newly developed\\n atelectasis. Aspiration is another possibility. Left pleural effusion is\\n noted, small, grossly unchanged. The rest of the findings are unchanged.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-10-08 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1036240,\n \"text\": \", F. MED MICU 8:04 PM\\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \\n Reason: eval for infiltrate\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old woman with respiratory failure, recent pneumonia, on mechanical\\n vent, now with new fever.\\n REASON FOR THIS EXAMINATION:\\n eval for infiltrate\\n ______________________________________________________________________________\\n PFI REPORT\\n Newly developed left lower lobe retrocardiac opacity most likely consistent\\n with atelectasis. Infectious process cannot be excluded.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-10-14 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1037126,\n \"text\": \" 1:21 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: interval change. evaluate for new infiltrate\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old woman with traumatic T-spine frx, HAP/VAP and respiratory ditress,\\n now extubated, fevers, agitation and tachypnic\\n REASON FOR THIS EXAMINATION:\\n interval change. evaluate for new infiltrate\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): JRld WED 1:03 PM\\n Unchanged appearance of the chest with small atelectasis in the left lower\\n lobe, small right pleural effusion and right lower lobe atelectasis.\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAM: T-spine fracture, respiratory distress with fever.\\n\\n Comparison is made with prior study of .\\n\\n Mildly improved left lower lobe opacities. Likely improving atelectasis.\\n There is a small left pleural effusion. Tracheostomy tube is in place.\\n Cardiomediastinal contours are unchanged. Small right pleural effusion and\\n right lower lobe atelectasis are unchanged.\\n\\n jr\\n\\n DR. \\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-10-14 00:00:00.000\",\n \"description\": \"CTA CHEST W&W/O C&RECONS, NON-CORONARY\",\n \"row_id\": 1037219,\n \"text\": \", C. MED MICU 12:55 PM\\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \\n Reason: Pleas eevaluate for PE\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n Contrast: OPTIRAY Amt: 100\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old woman with persistent sinus tachycardia, h/o UE DVT, fever,\\n abnormal CXR\\n REASON FOR THIS EXAMINATION:\\n Pleas eevaluate for PE\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n PFI REPORT\\n No PE centrally.\\n Study limited due to motion.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-10-07 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1035784,\n \"text\": \" 3:38 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: interval change\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old woman with asp PNA, intubated\\n REASON FOR THIS EXAMINATION:\\n interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n STUDY: Bedside supine AP chest radiograph.\\n\\n HISTORY: 56-year-old woman with aspiration pneumonia. Question interval\\n change.\\n\\n COMPARISON: Comparison is made to chest radiograph from .\\n\\n FINDINGS: There has been interval improvement in the retrocardiac\\n consolidation with minimal areas of residual consolidations seen at the left\\n lung base and right lung base. Small right and tiny left pleural effusions\\n are also improved from the most recent radiograph. The lungs are otherwise\\n clear. The right hemidiaphragm is elevated. Cardiomediastinal contours is\\n normal. Visualized soft tissue structures and bony thorax are normal. A\\n tracheostomy tube and left PICC line are again seen in good position.\\n\\n IMPRESSION:\\n 1. Interval improvement in retrocardiac consolidation with minimal residual\\n consolidation.\\n 2. Interval improvement in bilateral pleural effusions.\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-10-14 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1037127,\n \"text\": \", C. MED MICU 1:21 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: interval change. evaluate for new infiltrate\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old woman with traumatic T-spine frx, HAP/ and respiratory ditress,\\n now extubated, fevers, agitation and tachypnic\\n REASON FOR THIS EXAMINATION:\\n interval change. evaluate for new infiltrate\\n ______________________________________________________________________________\\n PFI REPORT\\n Unchanged appearance of the chest with small atelectasis in the left lower\\n lobe, small right pleural effusion and right lower lobe atelectasis.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-10-10 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1036501,\n \"text\": \" 3:27 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ? interval change\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old woman with traumatic T-spine frx, respiratory distress follwed by\\n HAP/VAP, resolving, now w/ ? new aspiration vs brewing LLL process.\\n REASON FOR THIS EXAMINATION:\\n ? interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Traumatic T spine fracture, concern for aspiration or left lower\\n lobe pneumonia.\\n\\n FINDINGS: A single frontal chest radiograph was compared to . No new\\n opacities seen. There is improved aeration within the retrocardiac\\n space. There is stable elevation of the right hemidiaphragm. There is a\\n stable appearance of the cardiac and mediastinal contours. Tracheostomy\\n remains in place. The osseous structures are stable.\\n\\n IMPRESSION: No new opacities identified, as questioned. Improved\\n aeration within the retrocardiac space. Stable elevation of the right\\n hemidiaphragm.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-10-03 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1035114,\n \"text\": \" 2:50 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Volume status, interval change\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old woman with respiratory distress, s/p trach placement.\\n REASON FOR THIS EXAMINATION:\\n Volume status, interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n AP CHEST 4:02 A.M., \\n\\n HISTORY: 56-year-old woman with respiratory distress. Trach placement.\\n\\n IMPRESSION: AP chest compared to , through 19.\\n\\n Large right pleural effusion and moderate pulmonary edema have worsened since\\n . Heart size top normal. Tracheostomy tube midline. No\\n pneumothorax. Left pleural effusion is small-to-moderate, but more difficult\\n to assess.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-10-16 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1037529,\n \"text\": \" 3:49 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ? interval change\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old woman with respiratory failure, s/p traumatic t-spine frx, s/pHAP\\n REASON FOR THIS EXAMINATION:\\n ? interval change\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): PSS 3:34 PM\\n No change since at least in right middle and lower lobe collapse,\\n left lower lobe atelectasis, and small bilateral pleural effusions.\\n ______________________________________________________________________________\\n FINAL REPORT\\n AP CHEST, 4:18 AM \\n\\n HISTORY: Respiratory failure, spine fracture.\\n\\n IMPRESSION: AP chest compared to :\\n\\n Right middle and lower lobe collapse, less severe left lower lobe atelectasis\\n and small bilateral pleural effusions unchanged since . Tracheostomy\\n tube in standard placement.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-10-15 00:00:00.000\",\n \"description\": \"PR UNILAT UP EXT VEINS US PORT RIGHT\",\n \"row_id\": 1037340,\n \"text\": \" 7:34 AM\\n UNILAT UP EXT VEINS US PORT RIGHT Clip # \\n Reason: please eval for DVT\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old woman with h/o UE DVT and tachycardia, please eval for clot.\\n REASON FOR THIS EXAMINATION:\\n please eval for DVT\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): 10:09 AM\\n No evidence of DVT in the right upper extremity. Resolution of nonocclusive\\n thrombus in the right axillary and basilic veins.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: History of upper extremity DVT and tachycardia. Assess for clot.\\n\\n COMPARISON: Upper extremity ultrasound of .\\n\\n RIGHT UPPER EXTREMITY ULTRASOUND: -scale and Doppler son of the\\n right internal jugular, subclavian, axillary, basilic, cephalic, and brachial\\n veins was performed. Normal flow, compressibility and waveforms were\\n demonstrated. No thrombus was identified today, particularly in the axillary\\n and basilic veins where nonocclusive thrombus was seen previously. The wall of\\n the axillary vein appeared diffusely thickened, possibly an inflammatory\\n change related to prior non- occlusive thrombus. Augmentation was not\\n performed on this examination due to the concern for clot that was previously\\n present.\\n\\n IMPRESSION: No evidence of DVT in the right upper extremity.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-10-15 00:00:00.000\",\n \"description\": \"PR UNILAT UP EXT VEINS US PORT RIGHT\",\n \"row_id\": 1037341,\n \"text\": \", C. MED MICU 7:34 AM\\n UNILAT UP EXT VEINS US PORT RIGHT Clip # \\n Reason: please eval for DVT\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old woman with h/o UE DVT and tachycardia, please eval for clot.\\n REASON FOR THIS EXAMINATION:\\n please eval for DVT\\n ______________________________________________________________________________\\n PFI REPORT\\n No evidence of DVT in the right upper extremity. Resolution of nonocclusive\\n thrombus in the right axillary and basilic veins.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2167-10-02 00:00:00.000\",\n \"description\": \"BY DIFFERENT PHYSICIAN\",\n \"row_id\": 1035051,\n \"text\": \" 3:11 PM\\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \\n Reason: interval change\\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old woman S/P trach/PEG\\n REASON FOR THIS EXAMINATION:\\n interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n PORTABLE CHEST, \\n\\n INDICATION: Status post tracheostomy.\\n\\n Tracheostomy tube is in standard position with tip terminating about 5 cm\\n above the carina. Left PICC terminates in superior vena cava, and nasogastric\\n tube has been removed. Cardiomediastinal contour appears slightly less\\n widened, and pulmonary edema has slightly improved. Moderate right and small-\\n to-moderate left pleural effusion have also slightly decreased. No\\n pneumothorax or pneumomediastinum. Incidental left lower lobe granuloma.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2167-09-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 222651,\n \"text\": \"Narrow complex tachycardia at rate 123. Atrial mechanism is uncertain.\\nThe differential is between sinus tachycardia, supraventricular\\ntachy-arrhythmia and accelerated junctional rhythm. Compared to the previous\\ntracing of sinus tachycardia with first degree A-V block has given\\nway to the current rhythm. Both tracings show borderline low voltage with\\ngeneralized non-specific repolarization abnormality.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2167-10-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 222642,\n \"text\": \"Normal sinus rhythm with A-V conduction delay. Borderline voltage criteria for\\nleft ventricular hypertrophy. Compared to tracing #1 the A-V conduction delay\\nis new.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2167-10-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 222643,\n \"text\": \"Normal sinus rhythm. Voltage criteria for left ventricular hypertrophy with\\nsecondary ST-T wave abnormalities. Compared to the previous tracing of \\nthe A-V nodal re-entrant tachycardia is no longer present.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2167-10-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 222644,\n \"text\": \"Supraventricular tachycardia, probable A-V nodal re-entrant tachycardia.\\nCompared to the previous tracing of the supraventricular tachycardia\\nis as previously described. There is also delayed R wave transition.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2167-10-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 222645,\n \"text\": \"There is a run of supraventricular tachycardia followed by a premature atrial\\ncontraction and then sinus rhythm with probable left atrial abnormality.\\nCompared to tracing #3 the premature atrial contraction and sinus rhythm are\\nboth new.\\nTRACING #4\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2167-10-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 222646,\n \"text\": \"Supraventricular tachycardia or sinus tachycardia. Compared to tracing #2\\nearlier the same date supraventricular tachycardia is present in the entire\\nstrip.\\nTRACING #3\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2167-10-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 222647,\n \"text\": \"There appears to be a run of supraventricular tachycardia followed by a\\npremature atrial contraction and then sinus rhythm with probable left\\natrial abnormality and borderline first degree A-V block. Compared to the\\nprevious tracing of no significant change.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2167-10-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 222648,\n \"text\": \"There is a run of supraventricular tachycardia followed by a premature atrial\\ncontraction and then sinus rhythm. Consider left atrial abnormality. Compared\\nto the previous tracing of supraventricular tachycardia is present.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2167-10-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 222649,\n \"text\": \"Narrow complex rhythm with probable low amplitude P waves. A wider complex\\nbeat may be supraventricular with aberration or ventricular premature beat.\\nThere are probable atrial premature beats of multifocal origin. Borderline\\nlow voltage throughout. Since the previous tracing of the rate is\\nfaster.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2167-10-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 222650,\n \"text\": \"Compared with the prior tracing undisclosed narrow complex tachycardia has\\ngiven way once again to sinus bradycardia with first degree A-V block and\\noccasional interpolated ventricular premature beat. Non-specific\\nrepolarization change and low voltage. Pericardial disease should be included\\nin the differential.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2167-09-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 222871,\n \"text\": \"Regular supraventricular rhythm. Some semblance of P waves is discerned in\\nlead V3 but this is not definite. Borderline low voltage in the limb leads.\\nDiffuse non-specific ST-T wave changes. Compared to the previous tracing\\nof the findings are similar.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2167-09-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 222872,\n \"text\": \"Sinus rhythm. Non-specific ST-T wave changes. Compared to the previous\\ntracing of no significant change.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2167-09-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 222873,\n \"text\": \"Sinus rhythm. Non-specific ST-T wave changes. No previous tracing available\\nfor comparison.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2167-09-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 222869,\n \"text\": \"Sinus rhythm. First degree A-V block. Low QRS voltage in the precordial leads\\nwith a delayed R wave progression, probably a normal variant. Diffuse\\nnon-specific T wave flattening. Compared to the previous tracing of \\nno significant change.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2167-09-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 222870,\n \"text\": \"Atrial mechanism is unclear but probable sinus bradycardia with first\\ndegree A-V blcok. Generalized low voltage. Generalized non-specific\\nrepolarization abnormalities. Consider electrolyte abnormality, consider\\npericardial effusion, consider drug effect. A junctional mechanism at\\nrate 48 cannot be excluded but is somewhat less likely. Compared to the\\nprevious tracing of normal sinus rhythm at rate 80 has given way to\\nsinus bradycardia with first degree A-V block.\\n\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-12 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 637207,\n \"text\": \"Tachycardia, Other\\n Assessment:\\n Pt restless and awake with tachycardia at 140-150. Md notified and in\\n to assess. Pt also denies any pain every time asked.\\n Action:\\n Pt given haldol po and IV, valium po/IV and morphine IVP. Emotional\\n support also given w/o effect.\\n Response:\\n Sedation given with NO effect. MD aware. No more interventions for now.\\n HR decreased to 120 once pt back in bed and sleeping.\\n Plan:\\n Continue to eval tachycardia.\\n Hypernatremia (high sodium)\\n Assessment:\\n NA elevated this am .\\n Action:\\n H2O flushes increased to 100 cc q 4hrs.\\n Response:\\n Na level to be drawn in am.\\n Plan:\\n Continue current plan.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n LS coarse throughout and slight improved after deep sx.\\n Action:\\n Pt placed on TC this am at 9am x 8hrs and tol well by pt with O2sat\\n 93-96%. Pt was able to have prod cough of now green-yellow secretions.\\n Pt placed on CPAP +PS once back in bed in order to rest pt overnight.\\n Response:\\n Pt tol being on TC very well. Pt was placed on pass\\n muir valve, but\\n was only able to tol it for 15 min inability to clear secretions.\\n Plan:\\n Needs sputum sample for culture.\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt awake almost the whole day and has been restless. MD aware.\\n Action:\\n Pt given haldol, valium and Morphine.\\n Response:\\n No effect from sedation.\\n Plan:\\n Continue to eval MS.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-06 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 636097,\n \"text\": \"55 yr old transferred from OSH on ^th. Pt with PNA/ARDS and\\n T-spine fracture. Pt now with trach and PEG.\\n Altered mental status (not Delirium)\\n Assessment:\\n Versed and fentanyl gtt stopped and pt had PO doses of valium and\\n haldol given\\n Action:\\n Pt lethargic throughout the day, did wake more during the day.\\n Response:\\n Follows all commands but intermittently, does get very aggited with\\n stimulation but PO meds did help\\n Plan:\\n Try to keep pt off IV sedation meds. And give PO haldol and valium.\\n Hypotension (not Shock)\\n Assessment:\\n Pt lethargic and hypotensive throughout entire day, team aware and\\n feels its d/t her being over sedated. Pt SBP will go into the 70\\n when asleep and not being stimulated.\\n Action:\\n Fentanyl and versed gtt turned off, and pt did not have any sedation\\n meds until 1400 when she became more alert and her HR went into 130\\n and SBP 120-130\\n Response:\\n As the day went on pt became more awake and her SBP stayed in the 90\\n but she will still drop into SBP of low 80\\ns when she is asleep.\\n Plan:\\n Keep pt off IV sedation meds\\n Hypernatremia (high sodium)\\n Assessment:\\n NA level of 147\\n Action:\\n Free water flushed given 300 Q 4 hr.\\n Response:\\n NA level 141\\n Plan:\\n Free water flush decreased to 150 Q4 hr.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Vent settings weaned to Pressure support 12 and Peep 10.\\n Action:\\n ABG on these settings acceptable to team, O2 sats in 92-94 range and\\n team accepting that.\\n Response:\\n Pt cont to be on this vent setting and doing fine.\\n Plan:\\n Cont to monitor resp status, wean as tolerated.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-07 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 636204,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n EKG - At 11:53 PM for qrs (<500)\\n Continued to have alternating tachy and bradycadia with associated\\n pressure swings on adjusted pain regimen. Unable to diurese given\\n intermittant hypotension. Finally got one dose lasix when BP in an\\n acceptable range.\\n Much more anxious than previous nights. Increased Valium back to 10 mg\\n QID.\\n CT showed cuff distention. Per respiratory, still has a leak, likely\\n needs a larger cuff.\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Heparin Sodium - 1,500 units/hour\\n Other ICU medications:\\n Diazepam (Valium) - 02:00 AM\\n Furosemide (Lasix) - 03:56 AM\\n Haloperidol (Haldol) - 03:57 AM\\n Midazolam (Versed) - 05:11 AM\\n Other medications:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:03 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.6\\nC (99.6\\n Tcurrent: 37.1\\nC (98.7\\n HR: 124 (66 - 135) bpm\\n BP: 137/67(92) {74/35(48) - 150/81(106)} mmHg\\n RR: 15 (7 - 28) insp/min\\n SpO2: 94%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 3,707 mL\\n 723 mL\\n PO:\\n TF:\\n 1,457 mL\\n 364 mL\\n IVF:\\n 810 mL\\n 150 mL\\n Blood products:\\n Total out:\\n 2,535 mL\\n 2,760 mL\\n Urine:\\n 2,535 mL\\n 2,760 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,172 mL\\n -2,037 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: CPAP/PSV\\n Vt (Set): 400 (400 - 400) mL\\n Vt (Spontaneous): 964 (260 - 964) mL\\n PS : 12 cmH2O\\n RR (Set): 10\\n RR (Spontaneous): 8\\n PEEP: 8 cmH2O\\n FiO2: 50%\\n RSBI Deferred: Agitated\\n PIP: 21 cmH2O\\n SpO2: 94%\\n ABG: 7.41/53/86/35/6\\n Ve: 7.8 L/min\\n PaO2 / FiO2: 172\\n Physical Examination\\n General Appearance: Trached and sedated. Responsive, following\\n commands, Overweight / Obese, mild agitation but NAD\\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\\n deviation\\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\\n Cardiovascular: (S1: Normal), (S2: Normal), distant\\n Respiratory / Chest: (Expansion: Symmetric), CTA anteriorly, decreased\\n BS\\n Abdominal: Obese, soft, Non-tender, no rebound, no guarding, + BS, PEG\\n in place with dressing C/D/I\\n Extremities: no CCE\\n Skin: no rashes or jaundice\\n Lines: r brachioceph ART with large amount of bloody drainage and L\\n PICC C/D/I\\n Labs / Radiology\\n 213 K/uL\\n 8.3 g/dL\\n 118 mg/dL\\n 0.6 mg/dL\\n 32 mEq/L\\n 3.5 mEq/L\\n 11 mg/dL\\n 108 mEq/L\\n 146 mEq/L\\n 27.4 %\\n 8.2 K/uL\\n [image002.jpg]\\n 02:47 AM\\n 11:01 AM\\n 04:40 PM\\n 05:08 PM\\n 03:44 AM\\n 06:04 AM\\n 09:09 AM\\n 05:07 PM\\n 03:31 AM\\n 03:46 AM\\n WBC\\n 11.2\\n 9.6\\n 8.2\\n Hct\\n 27.4\\n 25.3\\n 27.4\\n Plt\\n 272\\n 229\\n 213\\n Cr\\n 0.6\\n 0.6\\n 0.6\\n 0.8\\n 0.6\\n TCO2\\n 31\\n 34\\n 33\\n 32\\n 35\\n Glucose\\n 128\\n 138\\n 107\\n 121\\n 118\\n Other labs: PT / PTT / INR:18.4/68.9/1.7, Ca++:9.0 mg/dL, Mg++:2.5\\n mg/dL, PO4:4.8 mg/dL\\n Assessment and Plan\\n 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA and\\n ARDS intubated since the end of now s/p trach and PEG placement.\\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\\n volume overload. Intubated on for resp decompensation. Stenting\\n unlikely to help for trachiomalacia as airways have poor structure\\n diffusely. S/P Trach and PEG on .\\n - wean FiO2 as tolerated\\n - attempt wean PS today and hopeful for trach mask trial\\n # Adrenal Insufficency: Hypotension that resolved with steroids,\\n returned as they came off and is now improved again. Possible primary\\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\\n started on .\\n - wean per endo recs, decrease to 20q am and 10 q pm today\\n - ok to go to 10 q am and 5 q pm tomorrow ()\\n # Volume overloaded in setting of hypernatremia with TBW deficit and\\n metabolic alkalosis\\n - Lasix boluses with diamox today\\n - electrolytes\\n - continue tube feeds with free water flushes 300 cc q4\\n # Sedation: Sedation control remains somewhat poor although fentanyl\\n patch and diazpem are likely therapeutic range today. On Versed 2.0,\\n Fentanyl 100, Fentanyl patch, Diazepam standing and haldo 2.5-5 mg\\n PRN. QTc increased to 480.\\n - Wean versed/fentanyl as tolerated, continue diazepam in\\n hopes for vent facility placement\\n - Continue diazepam 10 mg q8 with haldol 5 mg q8 with 2.5-5\\n prn haldol\\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\\n coumadin at least until s/p trach. INR 1.7 today.\\n - heparin gtt restarted\\n - coumadin 5mg G-tube today, INR in am\\n # Spine fracture: Neurologically intact distal to the lesion. Prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - CT of C, L spine when stable. Currently, unlikely to change\\n management and high risk for complications with transport.\\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\\n is low. Brace for OOB. Ok for anticoag per note.\\n -f/u full trauma spine eval from OSH to determine need for further back\\n imaging in-house (to be done )\\n #. Thyroid Nodule on CT\\n -outpatient follow up\\n # Nutrition: Tube feeds with free water flushes, tolerating well,\\n continue Replete (Full) - 11:20 AM 30 mL/hour\\n # Glycemic control: SSI, well controlled\\n # Lines L PICC () and R ART ()\\n d/c art and re-site today\\n # Ppx: heparin drip until INR therapeutic for 2 days, ranitidine, VAP\\n prevention, colace and senna\\n # Communication:\\n - Boyfriend of 10 is her HCP. Also brother is involved\\n Code: Full\\n Dispo: ICU, being screening for vent facilities\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-09-30 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 635164,\n \"text\": \"55 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP now with prolonged\\n hospital course c/o by PNA anxiety,RUE DVD with high PEEP requirement\\n .\\n Plan : Plan for trach and peg today or the next few days, if pt tol\\n peep of 10.\\n Hypernatremia (high sodium)\\n Assessment:\\n Na level elevated\\n Action:\\n H2O flushes increased to 250 cc q 4hrs.\\n Response:\\n Na level remains elevated this am at 146 (sl improved).\\n Plan:\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt remains intubated on CMV settings, now at 60%/400x18/10. LS coarse\\n to upper resp area with diminished bases. Pt has been deep sx\\nd for\\n scant amounts of yellow secretions q 2hrs. Pt cont to have copious\\n amounts of clear oral secretions and in need of freq oral care. Pt\\n noted to have a decrease in O2sat, while she is on her Lt side, but it\\n has improved throughout the night.\\n Action:\\n Peep weaned to 10, and tol well by pt with good ABGs. Fio2 weaned to 50\\n %, but pt\\ns O2sat decreased to 88% right away.\\n Response:\\n LS clear to upper resp area after sx.\\n Plan:\\n Plan for trach and Peg today if p[t cont to tol peep of 10.\\n Altered mental status (not Delirium)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Pt on heparin gtt protocol for DVT to Rt arm. No signs of bleeding\\n noted. Hct stable.\\n Action:\\n Response:\\n PTT drawn q 6hrs; and it has been therapeutic.\\n Plan:\\n Plan to check PTT now daily.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-09-30 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 635166,\n \"text\": \"55 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP now with prolonged\\n hospital course c/o by PNA anxiety,RUE DVD with high PEEP requirement\\n .\\n Plan : Plan for trach and peg today or the next few days, if pt tol\\n peep of 10.\\n Hypernatremia (high sodium)\\n Assessment:\\n Na level elevated\\n Action:\\n H2O flushes increased to 250 cc q 4hrs.\\n Response:\\n Na level remains elevated this am at 146 (sl improved).\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt remains intubated on CMV settings, now at 60%/400x18/10. LS coarse\\n to upper resp area with diminished bases. Pt has been deep sx\\nd for\\n scant amounts of yellow secretions q 2hrs. Pt cont to have copious\\n amounts of clear oral secretions and in need of freq oral care. Pt\\n noted to have a decrease in O2sat, while she is on her Lt side, but it\\n has improved throughout the night.\\n Action:\\n Peep weaned to 10, and tol well by pt with good ABGs. Fio2 weaned to 50\\n %, but pt\\ns O2sat decreased to 88% right away.\\n Response:\\n LS clear to upper resp area after sx.\\n Plan:\\n Plan for trach and Peg today if p[t cont to tol peep of 10.\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt found at 8pm to 10pm to be awake, alert and following commands. Pt\\n was slight restless, but appropriate. 10pm, pt became very restless in\\n bed, trying to sit up and was reaching for ETT. Once reposition and\\n back rubs did not work, MD notified and haldol given and diazepam given\\n with only effect for one hr. When pt is awake and restless, her HR will\\n increase to 120-130\\ns (ST) and BP will increase to 120-130\\ns. When pt\\n was sleeping (after sedation), Hr will deacrease to 50\\ns with a SBP in\\n the 80\\ns. Fentanyl patch increased and diazepam changed to q6hrs, with\\n no effect.\\n Action:\\n 2:30am, versed gtt was initiated again with good effect. Pt more\\n relaxed and fell back to sleep with stable HR and BP.\\n Response:\\n Plan:\\n Continue to evaluate restlessness.\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Pt on heparin gtt protocol for DVT to Rt arm. No signs of bleeding\\n noted. Hct stable.\\n Action:\\n Response:\\n PTT drawn q 6hrs; and it has been therapeutic.\\n Plan:\\n Plan to check PTT now daily.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-12 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 637018,\n \"text\": \"56 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\\n with prolonged hospital course c/b by PNA, anxiety/altered mental\\n status, RUE DVT .\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Received pt on PSV 10/5/50%. RR 20-30. )2 sat > 97%\\n Action:\\n Pt remained on PSV rather than AC overnight. Suctioned ~q 3-4 hrs for\\n sm amt yellow bld-tinged secretions. Continues to have copious oral\\n secretions\\n removed with yankeur.\\n Response:\\n Tolerated PSV well, no tachypnea or desaturation.\\n Plan:\\n Attempt trach collar trial again in am. On-going pulm hygiene\\n Hypotension (not Shock)\\n Assessment:\\n BP 90/40 with urine output falling to 10-15ccs/hr via foley. HR remains\\n tachycardic (110-140ST) even when pt is not agitated or febrile.\\n Action:\\n Given 1 500cc d5\\n ns fluid bolus\\n Response:\\n SBP > 90, Urine output improving to >30ccs/hr\\n Plan:\\n Continue to monitor hemodynamic status and f+e balance.\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt lethargic after receiving benedryl for several hrs but then awoke\\n agitated, attempting to climb OOB and pull at trach despite restraints.\\n Denies pain ( fentanyl patch in place) or need to go to the bathroom.\\n c/o itchiness on back secondary to rash.\\n Action:\\n Medicated with iv benedryl.\\n Response:\\n Less agitated. Slept again\\n Plan:\\n Continue to reorient pt, benedryl for pruritis, safety precautions.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-12 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 637208,\n \"text\": \"Tachycardia, Other\\n Assessment:\\n Pt restless and awake with tachycardia at 140-150. Md notified and in\\n to assess. Pt also denies any pain every time asked. ? if pt is\\n dehydrated with U/O 15-30cc/hr, but no IVF for now MD. Pt remains\\n afebrile.\\n Action:\\n Pt given haldol po and IV, valium po/IV and morphine IVP. Emotional\\n support also given w/o effect.\\n Response:\\n Sedation given with NO effect. MD aware. No more interventions for now.\\n HR decreased to 120 once pt back in bed and sleeping.\\n Plan:\\n Continue to eval tachycardia.\\n Hypernatremia (high sodium)\\n Assessment:\\n NA elevated this am .\\n Action:\\n H2O flushes increased to 100 cc q 4hrs.\\n Response:\\n Na level to be drawn in am.\\n Plan:\\n Continue current plan.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n LS coarse throughout and slight improved after deep sx. RR 18-24.\\n Action:\\n Pt placed on TC this am at 9am x 8hrs and tol well by pt with O2sat\\n 93-96%. Pt was able to have prod cough of now green-yellow secretions.\\n Pt placed on CPAP +PS once back in bed in order to rest pt overnight.\\n Response:\\n Pt tol being on TC very well. Pt was placed on pass\\n muir valve, but\\n was only able to tol it for 15 min inability to clear secretions.\\n Plan:\\n Needs sputum sample for culture.\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt awake almost the whole day and has been restless. MD aware.\\n Action:\\n Pt given haldol, valium and Morphine.\\n Response:\\n No effect from sedation.\\n Plan:\\n Continue to eval MS.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-07 00:00:00.000\",\n \"description\": \"Physician Resident/Attending Progress Note - MICU\",\n \"row_id\": 636214,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n EKG - At 11:53 PM for qrs (<500)\\n Continued to have alternating tachy and bradycadia with associated\\n pressure swings on adjusted pain regimen. Unable to diurese given\\n intermittant hypotension. Finally got one dose lasix when BP in an\\n acceptable range.\\n Much more anxious than previous nights. Increased Valium back to 10 mg\\n QID.\\n CT showed cuff distention. Per respiratory, still has a leak, likely\\n needs a larger cuff.\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Heparin Sodium - 1,500 units/hour\\n Other ICU medications:\\n Diazepam (Valium) - 02:00 AM\\n Furosemide (Lasix) - 03:56 AM\\n Haloperidol (Haldol) - 03:57 AM\\n Midazolam (Versed) - 05:11 AM\\n Other medications:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:03 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.6\\nC (99.6\\n Tcurrent: 37.1\\nC (98.7\\n HR: 124 (66 - 135) bpm\\n BP: 137/67(92) {74/35(48) - 150/81(106)} mmHg\\n RR: 15 (7 - 28) insp/min\\n SpO2: 94%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 3,707 mL\\n 723 mL\\n PO:\\n TF:\\n 1,457 mL\\n 364 mL\\n IVF:\\n 810 mL\\n 150 mL\\n Blood products:\\n Total out:\\n 2,535 mL\\n 2,760 mL\\n Urine:\\n 2,535 mL\\n 2,760 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,172 mL\\n -2,037 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: CPAP/PSV\\n Vt (Set): 400 (400 - 400) mL\\n Vt (Spontaneous): 964 (260 - 964) mL\\n PS : 12 cmH2O\\n RR (Set): 10\\n RR (Spontaneous): 8\\n PEEP: 8 cmH2O\\n FiO2: 50%\\n RSBI Deferred: Agitated\\n PIP: 21 cmH2O\\n SpO2: 94%\\n ABG: 7.41/53/86/35/6\\n Ve: 7.8 L/min\\n PaO2 / FiO2: 172\\n Physical Examination\\n General Appearance: Trached and sedated. Responsive, following\\n commands, Overweight / Obese, mild agitation but NAD\\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\\n deviation\\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\\n Cardiovascular: (S1: Normal), (S2: Normal), distant\\n Respiratory / Chest: (Expansion: Symmetric), CTA anteriorly, decreased\\n BS\\n Abdominal: Obese, soft, Non-tender, no rebound, no guarding, + BS, PEG\\n in place with dressing C/D/I\\n Extremities: no CCE\\n Skin: no rashes or jaundice\\n Lines: r brachioceph ART with large amount of bloody drainage and L\\n PICC C/D/I\\n Labs / Radiology\\n 213 K/uL\\n 8.3 g/dL\\n 118 mg/dL\\n 0.6 mg/dL\\n 32 mEq/L\\n 3.5 mEq/L\\n 11 mg/dL\\n 108 mEq/L\\n 146 mEq/L\\n 27.4 %\\n 8.2 K/uL\\n [image002.jpg]\\n 02:47 AM\\n 11:01 AM\\n 04:40 PM\\n 05:08 PM\\n 03:44 AM\\n 06:04 AM\\n 09:09 AM\\n 05:07 PM\\n 03:31 AM\\n 03:46 AM\\n WBC\\n 11.2\\n 9.6\\n 8.2\\n Hct\\n 27.4\\n 25.3\\n 27.4\\n Plt\\n 272\\n 229\\n 213\\n Cr\\n 0.6\\n 0.6\\n 0.6\\n 0.8\\n 0.6\\n TCO2\\n 31\\n 34\\n 33\\n 32\\n 35\\n Glucose\\n 128\\n 138\\n 107\\n 121\\n 118\\n Other labs: PT / PTT / INR:18.4/68.9/1.7, Ca++:9.0 mg/dL, Mg++:2.5\\n mg/dL, PO4:4.8 mg/dL\\n Assessment and Plan\\n 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA and\\n ARDS intubated since the end of now s/p trach and PEG placement.\\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\\n volume overload. Intubated on for resp decompensation. Stenting\\n unlikely to help for trachiomalacia as airways have poor structure\\n diffusely. S/P Trach and PEG on .\\n - wean FiO2 as tolerated\\n - attempt wean PS today and hopeful for trach mask trial\\n # Adrenal Insufficency: Hypotension that resolved with steroids,\\n returned as they came off and is now improved again. Possible primary\\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\\n started on .\\n - wean per endo recs, decrease to 20q am and 10 q pm today\\n - ok to go to 10 q am and 5 q pm tomorrow ()\\n # Volume overloaded in setting of hypernatremia with TBW deficit and\\n metabolic alkalosis\\n - Lasix boluses with diamox today\\n - electrolytes\\n - continue tube feeds with free water flushes 300 cc q4\\n # Sedation: Sedation control remains somewhat poor although fentanyl\\n patch and diazpem are likely therapeutic range today. On Versed 2.0,\\n Fentanyl 100, Fentanyl patch, Diazepam standing and haldo 2.5-5 mg\\n PRN. QTc increased to 480.\\n - Wean versed/fentanyl as tolerated, continue diazepam in\\n hopes for vent facility placement\\n - Continue diazepam 10 mg q8 with haldol 5 mg q8 with 2.5-5\\n prn haldol\\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\\n coumadin at least until s/p trach. INR 1.7 today.\\n - heparin gtt restarted\\n - coumadin 5mg G-tube today, INR in am\\n # Spine fracture: Neurologically intact distal to the lesion. Prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - CT of C, L spine when stable. Currently, unlikely to change\\n management and high risk for complications with transport.\\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\\n is low. Brace for OOB. Ok for anticoag per note.\\n -f/u full trauma spine eval from OSH to determine need for further back\\n imaging in-house (to be done )\\n #. Thyroid Nodule on CT\\n -outpatient follow up\\n # Nutrition: Tube feeds with free water flushes, tolerating well,\\n continue Replete (Full) - 11:20 AM 30 mL/hour\\n # Glycemic control: SSI, well controlled\\n # Lines L PICC () and R ART ()\\n d/c art and re-site today\\n # Ppx: heparin drip until INR therapeutic for 2 days, ranitidine, VAP\\n prevention, colace and senna\\n # Communication:\\n - Boyfriend of 10 is her HCP. Also brother is involved\\n Code: Full\\n Dispo: ICU, being screening for vent facilities\\n ------ Protected Section ------\\n MICU ATTENDING ADDENDUM\\n I saw and examined the patient, and was physically present with the ICU\\n team for the key portions of the services provided. I agree with the\\n note above, including the assessment and plan. I would emphasize and\\n add the following points: 55F T5-8 fractures with retropulsion and ARDS\\n from klebsiella VAP; on heparin for UE DVT and lasix for volume\\n overload.\\n Exam notable for Tm 99.6 BP 110/50 HR 110 RR 18-20 with sat 97%\\n on PSV 12/8 FiO2 0.5, ABG 7.41/53/86. TBB -3L/8h, +6L/MICU LOS. Eyes\\n opens, will squeeze hands and wiggle toes but very drowsy. Clearer BS\\n bilaterally with RRR s1s2 SM at base. Abdomen is distended with\\n decreased BS. Trace edema in BLE, no cords. Labs notable for WBC 8K,\\n HCT 27, K+ 3.5, Na 146, Cr 0.6, INR 1.7. CXR with resolving B LL\\n airspace disease and RLL collapse.\\n Agree with plan to continue supportive care, wean PSV to , and\\n continue diuresis with lasix / diamox as BP allows. Will continue\\n fentanyl patch at 150mcg, haldol 5q8h alternating with valium 10q6h at\\n lower dose, now off drips. Will use haldol for breakthrough agitation.\\n Will wean hydrocortisone 20/10q12 PGT today and will discuss more\\n aggressive wean with endocrine as I think she has a component of\\n steroid psychosis. Will continue IV heparin for UE DVT and transition\\n to anticoagulation with coumadin. Will continue tube feeds and continue\\n FW boluses for hypernatremia. Arterial line to be resited today.\\n Continue spinal stabilization with brace when OOB and discuss follow-up\\n plan with spine surgery. Will eventually need MRI for surgical\\n planning; remainder of plan as outlined above.\\n Patient is critically ill\\n Total time: 50 min\\n ------ Protected Section Addendum Entered By: , MD\\n on: 03:06 PM ------\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2167-10-01 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 635396,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 13\\n Ideal body weight: 61.2 None\\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: Unknown\\n Procedure location:\\n Reason:\\n Tube Type\\n ETT:\\n Position: cm at teeth\\n Route:\\n Type: Standard\\n Size: 7.5mm\\n Tracheostomy tube:\\n Type:\\n Manufacturer:\\n Size:\\n PMV:\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: cmH2O\\n Cuff volume: mL /\\n Airway problems:\\n Comments:\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Diminished\\n Comments:\\n Secretions\\n Sputum color / consistency: Clear / Thick\\n Sputum source/amount: Suctioned / Small\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance:\\n Visual assessment of breathing pattern:\\n Assessment of breathing comfort:\\n Non-invasive ventilation assessment:\\n Invasive ventilation assessment:\\n Trigger work assessment:\\n Dysynchrony assessment:\\n Comments: Patient remains on mechanical ventilation with hypoxemic ABG\\n on A/C 400*18-.50-8p.Patient more alert today,BS clear,suctioned for\\n minimal to moderate amount of thick tan secretion.Plan to go to OR in\\n AM for tracheostomy and PEG procedure.Trial of SBT failed as patient\\n quickly desaturated with increase in HR.\\n Plan\\n Next 24-48 hours:\\n Reason for continuing current ventilatory support:\\n Respiratory Care Shift Procedures\\n Transports:\\n Destination (R/T)\\n Time\\n Complications\\n Comments\\n Bedside Procedures:\\n Comments:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-02 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 635495,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Patient agitated and combative overnight - restarted midazolam gtt and\\n patient was becoming increasingly tachycardic and hypertensive\\n Thoracics to take to OR this am for trach and PEG\\n Discussion with patient's boyfriend yesterday - her should be here this\\n weekend, wants to be involved, just hard for him to get here\\n On lasix drip with excellent response (200 cc urine/hour)\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Fentanyl - 100 mcg/hour\\n Furosemide (Lasix) - 1 mg/hour\\n Heparin Sodium - 1,700 units/hour\\n Midazolam (Versed) - 2 mg/hour\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:07 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.3\\nC (99.2\\n Tcurrent: 37.3\\nC (99.2\\n HR: 118 (45 - 138) bpm\\n BP: 155/84(118) {91/38(56) - 177/106(139)} mmHg\\n RR: 18 (17 - 27) insp/min\\n SpO2: 90%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 2,604 mL\\n 1,447 mL\\n PO:\\n TF:\\n 675 mL\\n 17 mL\\n IVF:\\n 1,089 mL\\n 730 mL\\n Blood products:\\n Total out:\\n 4,130 mL\\n 2,430 mL\\n Urine:\\n 4,130 mL\\n 2,430 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,526 mL\\n -983 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 400 (400 - 400) mL\\n PS : 5 cmH2O\\n RR (Set): 18\\n RR (Spontaneous): 0\\n PEEP: 8 cmH2O\\n FiO2: 50%\\n PIP: 22 cmH2O\\n Plateau: 19 cmH2O\\n Compliance: 48.2 cmH2O/mL\\n SpO2: 90%\\n ABG: 7.45/50/67/36/8\\n Ve: 7.5 L/min\\n PaO2 / FiO2: 134\\n Physical Examination\\n General Appearance: Responsive, following commands, Overweight / Obese,\\n NAD\\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\\n deviation\\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\\n Cardiovascular: (S1: Normal), (S2: Normal), distant\\n Respiratory / Chest: (Expansion: Symmetric), referred breath sounds\\n from ETT, mild rhonchi diffusely\\n Abdominal: Obese, Soft, Non-tender, no rebound, no guarding\\n Extremities: No clubbing or cyanosis, + nonpitting edema of b/l\\n hands, anasarca\\n Skin: no rashes or jaundice\\n Neuro: alert. Strength 4/5 upper and lower extremeties, light touch\\n sensation intact bil.\\n Lines: r brachioceph ART and L PICC C/D/I\\n Labs / Radiology\\n 306 K/uL\\n 8.5 g/dL\\n 165 mg/dL\\n 0.7 mg/dL\\n 29 mEq/L\\n 3.7 mEq/L\\n 10 mg/dL\\n 108 mEq/L\\n 146 mEq/L\\n 27.1 %\\n 11.2 K/uL\\n [image002.jpg]\\n WBC 11.2 up from 8.6\\n HCT 27.1 up from 25.9\\n HCO2 32 up from 29\\n 02:18 AM\\n 01:27 PM\\n 03:06 PM\\n 10:04 PM\\n 03:00 AM\\n 10:47 AM\\n 04:10 PM\\n 12:13 AM\\n 05:08 AM\\n 05:20 AM\\n WBC\\n 8.6\\n 11.2\\n Hct\\n 25.9\\n 27.1\\n Plt\\n 280\\n 306\\n Cr\\n 0.6\\n 0.5\\n 0.7\\n TCO2\\n 33\\n 32\\n 32\\n 34\\n 36\\n 36\\n Glucose\\n 176\\n 136\\n 165\\n Other labs: PT / PTT / INR:13.2/68.7/1.1, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\\n Amylase / Lipase:, Differential-Neuts:89.7 %, Lymph:8.7 %, Mono:1.1\\n %, Eos:0.4 %, Lactic Acid:0.9 mmol/L, Albumin:2.4 g/dL, LDH:204 IU/L,\\n Ca++:10.6 mg/dL, Mg++:2.8 mg/dL, PO4:4.3 mg/dL\\n MICRO: sputum Gram stain: 2+ GPC in P/C, 2+ GPR. Cx: sparse\\n flora, sparse yeast\\n MICRO: MiniBAL: Gram stain: 2+PMNs, Cx: GNR #1, GNR#2, yeast.\\n CXR: Poor penetration, hazy opacification of both lung fields R>L,\\n patchy opacities in LLL, new. Focal atelectasis vs. PNA\\n Assessment and Plan\\n 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA and\\n ARDS intubated since the end of .\\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\\n volume overload. Intubated on for resp decompensation.\\n Transferred here for airway stenting.\\n - attempt SBT yesterday. Failed.\\n -To OR today , add-on for trach and PEG with Dr. (tube feeds\\n off after MN, heparin off after 6am)\\n - Repeat CXR in PM post trach.\\n ## Adrenal Insufficency: Minimal response to stim test again.\\n Appreciate endocrine recommendations.\\n - hydrocort and fludrocort (day 1 = )\\n - will continue at current dose until s/p trach and PEG and\\n hemodynamically stable for 24 hours\\n will then plan to taper\\n hydrocortisone to 25mg IV q6 with a slow taper\\n - f/u daily endocrine recs\\n - Endocrine recs: d/c Fludrocort. Continue Hydrocort for now.\\n # Hypotension: Likely adrenal insufficiency and sedation. Goal map\\n > 60. Much improved since re-administration of steroids.\\n - hydrocortisone as above\\n - restart levophed if necessary to maintain MAP > 60\\n # Volume overloaded in setting of hypernatremia with TBW deficit.\\n - goal -1000cc I/Os yesterday, was -1500cc for last 24 hours.\\n - continue FW in TF at 250 cc q4hrs\\n - lasix drip (1-5mg/hr) held before surgery, will restart when returns\\n to MICU.\\n - may have some contraction alkalosis, w/ rising pH and bicarb. Start\\n Diamox 500mg TID to decrease bicarb and pH and may improve respiratory\\n drive.\\n # Sedation: Sedation control remains somewhat poor although fentanyl\\n patch and diazpem are likely therapeutic range today. On Versed 2.0,\\n Fentanyl 100, Fentanyl patch, Diazepam standing and haldo 2.5-5 mg\\n PRN. QTc increased to 480.\\n - Wean versed/fentanyl as tolerated, continue diazepam. Avoid haldol\\n use if possible to avoid further prolongation of QTc\\n - Will reassess sedation/agitation after PEG/Trach.\\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\\n coumadin at least until s/p trach.\\n - hold heparin gtt when anticipate trach/peg\\n - will restart heparin gtt per recs from surgery post-op\\n # Spine fracture: Neurologically intact distal to the lesion. Prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - CT of C, L spine when stable. Currently, unlikely to change\\n management and high risk for complications with transport.\\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\\n is low. Brace for OOB. Ok for anticoag per note.\\n # FEN/GI: Tube feeds with FWF @ goal.\\n -held for surgery. Will restart based on post-op recs after PEG\\n placement.\\n DVT: Treatment dose heparin, holding until post-op recs from PEG/Trach\\n Ulcer: Ranitidine\\n VAP: Prevention per routine\\n # Access: L PICC line, and R brachial a-line\\n # Communication:\\n - Boyfriend of 10 is her HCP. Also brother is involved\\n - touch base with SW today\\n Code: Full\\n Dispo: ICU\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n PICC Line - 09:19 PM\\n Arterial Line - 02:00 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-02 00:00:00.000\",\n \"description\": \"Physician Resident/Attending Progress Note - MICU\",\n \"row_id\": 635496,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Patient agitated and combative overnight - restarted midazolam gtt and\\n patient was becoming increasingly tachycardic and hypertensive\\n Thoracics to take to OR this am for trach and PEG\\n Discussion with patient's boyfriend yesterday - her should be here this\\n weekend, wants to be involved, just hard for him to get here\\n On lasix drip with excellent response (200 cc urine/hour)\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Fentanyl - 100 mcg/hour\\n Furosemide (Lasix) - 1 mg/hour\\n Heparin Sodium - 1,700 units/hour\\n Midazolam (Versed) - 2 mg/hour\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:07 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.3\\nC (99.2\\n Tcurrent: 37.3\\nC (99.2\\n HR: 118 (45 - 138) bpm\\n BP: 155/84(118) {91/38(56) - 177/106(139)} mmHg\\n RR: 18 (17 - 27) insp/min\\n SpO2: 90%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 2,604 mL\\n 1,447 mL\\n PO:\\n TF:\\n 675 mL\\n 17 mL\\n IVF:\\n 1,089 mL\\n 730 mL\\n Blood products:\\n Total out:\\n 4,130 mL\\n 2,430 mL\\n Urine:\\n 4,130 mL\\n 2,430 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,526 mL\\n -983 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 400 (400 - 400) mL\\n PS : 5 cmH2O\\n RR (Set): 18\\n RR (Spontaneous): 0\\n PEEP: 8 cmH2O\\n FiO2: 50%\\n PIP: 22 cmH2O\\n Plateau: 19 cmH2O\\n Compliance: 48.2 cmH2O/mL\\n SpO2: 90%\\n ABG: 7.45/50/67/36/8\\n Ve: 7.5 L/min\\n PaO2 / FiO2: 134\\n Physical Examination\\n General Appearance: Responsive, following commands, Overweight / Obese,\\n NAD\\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\\n deviation\\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\\n Cardiovascular: (S1: Normal), (S2: Normal), distant\\n Respiratory / Chest: (Expansion: Symmetric), referred breath sounds\\n from ETT, mild rhonchi diffusely\\n Abdominal: Obese, Soft, Non-tender, no rebound, no guarding\\n Extremities: No clubbing or cyanosis, + nonpitting edema of b/l\\n hands, anasarca\\n Skin: no rashes or jaundice\\n Neuro: alert. Strength 4/5 upper and lower extremeties, light touch\\n sensation intact bil.\\n Lines: r brachioceph ART and L PICC C/D/I\\n Labs / Radiology\\n 306 K/uL\\n 8.5 g/dL\\n 165 mg/dL\\n 0.7 mg/dL\\n 29 mEq/L\\n 3.7 mEq/L\\n 10 mg/dL\\n 108 mEq/L\\n 146 mEq/L\\n 27.1 %\\n 11.2 K/uL\\n [image002.jpg]\\n WBC 11.2 up from 8.6\\n HCT 27.1 up from 25.9\\n HCO2 32 up from 29\\n 02:18 AM\\n 01:27 PM\\n 03:06 PM\\n 10:04 PM\\n 03:00 AM\\n 10:47 AM\\n 04:10 PM\\n 12:13 AM\\n 05:08 AM\\n 05:20 AM\\n WBC\\n 8.6\\n 11.2\\n Hct\\n 25.9\\n 27.1\\n Plt\\n 280\\n 306\\n Cr\\n 0.6\\n 0.5\\n 0.7\\n TCO2\\n 33\\n 32\\n 32\\n 34\\n 36\\n 36\\n Glucose\\n 176\\n 136\\n 165\\n Other labs: PT / PTT / INR:13.2/68.7/1.1, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\\n Amylase / Lipase:, Differential-Neuts:89.7 %, Lymph:8.7 %, Mono:1.1\\n %, Eos:0.4 %, Lactic Acid:0.9 mmol/L, Albumin:2.4 g/dL, LDH:204 IU/L,\\n Ca++:10.6 mg/dL, Mg++:2.8 mg/dL, PO4:4.3 mg/dL\\n MICRO: sputum Gram stain: 2+ GPC in P/C, 2+ GPR. Cx: sparse\\n flora, sparse yeast\\n MICRO: MiniBAL: Gram stain: 2+PMNs, Cx: GNR #1, GNR#2, yeast.\\n CXR: Poor penetration, hazy opacification of both lung fields R>L,\\n patchy opacities in LLL, new. Focal atelectasis vs. PNA\\n Assessment and Plan\\n 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA and\\n ARDS intubated since the end of .\\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\\n volume overload. Intubated on for resp decompensation.\\n Transferred here for airway stenting.\\n - attempt SBT yesterday. Failed.\\n -To OR today , add-on for trach and PEG with Dr. (tube feeds\\n off after MN, heparin off after 6am)\\n - Repeat CXR in PM post trach.\\n ## Adrenal Insufficency: Minimal response to stim test again.\\n Appreciate endocrine recommendations.\\n - hydrocort and fludrocort (day 1 = )\\n - will continue at current dose until s/p trach and PEG and\\n hemodynamically stable for 24 hours\\n will then plan to taper\\n hydrocortisone to 25mg IV q6 with a slow taper\\n - f/u daily endocrine recs\\n - Endocrine recs: d/c Fludrocort. Continue Hydrocort for now.\\n # Hypotension: Likely adrenal insufficiency and sedation. Goal map\\n > 60. Much improved since re-administration of steroids.\\n - hydrocortisone as above\\n - restart levophed if necessary to maintain MAP > 60\\n # Volume overloaded in setting of hypernatremia with TBW deficit.\\n - goal -1000cc I/Os yesterday, was -1500cc for last 24 hours.\\n - continue FW in TF at 250 cc q4hrs\\n - lasix drip (1-5mg/hr) held before surgery, will restart when returns\\n to MICU.\\n - may have some contraction alkalosis, w/ rising pH and bicarb. Start\\n Diamox 500mg TID to decrease bicarb and pH and may improve respiratory\\n drive.\\n # Sedation: Sedation control remains somewhat poor although fentanyl\\n patch and diazpem are likely therapeutic range today. On Versed 2.0,\\n Fentanyl 100, Fentanyl patch, Diazepam standing and haldo 2.5-5 mg\\n PRN. QTc increased to 480.\\n - Wean versed/fentanyl as tolerated, continue diazepam. Avoid haldol\\n use if possible to avoid further prolongation of QTc\\n - Will reassess sedation/agitation after PEG/Trach.\\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\\n coumadin at least until s/p trach.\\n - hold heparin gtt when anticipate trach/peg\\n - will restart heparin gtt per recs from surgery post-op\\n # Spine fracture: Neurologically intact distal to the lesion. Prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - CT of C, L spine when stable. Currently, unlikely to change\\n management and high risk for complications with transport.\\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\\n is low. Brace for OOB. Ok for anticoag per note.\\n # FEN/GI: Tube feeds with FWF @ goal.\\n -held for surgery. Will restart based on post-op recs after PEG\\n placement.\\n DVT: Treatment dose heparin, holding until post-op recs from PEG/Trach\\n Ulcer: Ranitidine\\n VAP: Prevention per routine\\n # Access: L PICC line, and R brachial a-line\\n # Communication:\\n - Boyfriend of 10 is her HCP. Also brother is involved\\n - touch base with SW today\\n Code: Full\\n Dispo: ICU\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n PICC Line - 09:19 PM\\n Arterial Line - 02:00 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n ------ Protected Section ------\\n MICU ATTENDING ADDENDUM\\n I saw and examined the patient, and was physically present with the ICU\\n team for the key portions of the services provided. I agree with the\\n note above, including the assessment and plan. I would emphasize and\\n add the following points: 55F T5-8 fractures with retropulsion and ARDS\\n from VAP; on heparin for UE DVT. Tolerating slow vent wean but failed\\n SBT. Was TBB negative yesterday with lasix drip; sedation remains\\n challenging. Plan for T+G today.\\n Exam notable for Tm 99.2 BP 105/45 HR 45-120 RR 18-20 with sat 93-96%\\n on VAC 400x18 PEEP 8 FiO2 0.5 for 7.45/50/67. TBB -2.6L/24h, +15L/MICU\\n LOS. Eyes opens, will squeeze hands and wiggle toes but very\\n drowsyBronchial BS bilaterally with RRR s1s2 SM at base. Abdomen is\\n distended with decreased BS. 3+ edema in BLE, no cords. Labs notable\\n for WBC 11K, HCT 27, K+ 3.8, Na 146, Cr 0.5. CXR with resolving B LL\\n airspace disease and effusions.\\n Agree with plan to continue supportive care and wean vent after\\n procedures today. Needs diamox and aggressive KCl repletion in addition\\n to lasix given progressive alkalosis and rising pCO2. Once sedation\\n requirements are clarified following T+G, will try PSV. For now,\\n continue fentanyl patch and valium 10 TID po in addition to drips. Will\\n continue hydrocortisone 50 q6 today and reduce to q8 tomorrow, with\\n long term goal for oral prednisone. Will d/c fludrocortisone. Will\\n resume IV heparin for UE DVT when cleared from a surgical perspective\\n with plan for eventual transition to coumadin. Will restart tube feeds\\n and continue FW boluses for hypernatremia once PEG cleared by surgery.\\n Continue spinal stabilization with brace when OOB; will eventually need\\n MRI for surgical planning; remainder of plan as outlined above.\\n Patient is critically ill\\n Total time: 40 min\\n ------ Protected Section Addendum Entered By: , MD\\n on: 02:53 PM ------\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2167-10-10 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 636796,\n \"text\": \"TITLE:\\n Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 22\\n Ideal body weight: 61.2 None\\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: Yes\\n Procedure location:\\n Reason:\\n Tube Type\\n ETT:\\n Position: cm at teeth\\n Route:\\n Type:\\n Size:\\n Tracheostomy tube:\\n Type: Cuffed\\n Manufacturer: Portex\\n Size: 7.0mm\\n PMV:\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 28 cmH2O\\n Cuff volume: mL /\\n Airway problems:\\n Comments:\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Rhonchi\\n LUL Lung Sounds: Rhonchi\\n LLL Lung Sounds: Diminished\\n Comments:\\n Secretions\\n Sputum color / consistency: White / Thick\\n Sputum source/amount: Suctioned / Moderate\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance: Intermittent invasive ventilation\\n Visual assessment of breathing pattern: Normal quiet breathing\\n Assessment of breathing comfort: No claim of dyspnea)\\n Non-invasive ventilation assessment:\\n Invasive ventilation assessment:\\n Trigger work assessment: Triggering synchronously\\n Dysynchrony assessment:\\n Comments:\\n Plan\\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\\n Reduce PEEP as tolerated\\n Reason for continuing current ventilatory support: Cannot protect\\n airway; Comments: some weaning to trach collar tolerated today\\n Respiratory Care Shift Procedures\\n Transports:\\n Destination (R/T)\\n Time\\n Complications\\n Comments\\n Bedside Procedures:\\n Comments:\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2167-10-11 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 636848,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 23\\n Ideal body weight: 61.2 None\\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: Yes\\n Procedure location:\\n Reason:\\n Tube Type\\n Tracheostomy tube:\\n Type: Cuffed\\n Manufacturer: Portex\\n Size: 7.0mm\\n PMV:\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 28 cmH2O\\n Cuff volume: mL /\\n Airway problems:\\n Comments:\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Rhonchi\\n LUL Lung Sounds: Rhonchi\\n LLL Lung Sounds: Diminished\\n Comments:\\n Secretions\\n Sputum color / consistency: White / Thin\\n Sputum source/amount: Suctioned / Moderate\\n Comments: Pt had excessive coughing all shift\\n Ventilation Assessment\\n Level of breathing assistance: Continuous invasive ventilation\\n Visual assessment of breathing pattern: Normal quiet breathing\\n Assessment of breathing comfort:\\n Non-invasive ventilation assessment:\\n Invasive ventilation assessment:\\n Trigger work assessment: Triggering synchronously\\n Dysynchrony assessment: Frequent alarms (High pressure, High rate)\\n Comments: Pt coughing all shift, very agitated by thrashing in bed\\n Plan\\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\\n Adjust Min. ventilation to control pH, Increase ventilatory support at\\n night; Comments: Pt needed to be suctioned many times this shift.\\n Sputum culture sent. Pt thrashes in bed, causing tracheostomy to shift\\n and causing her cough.\\n Reason for continuing current ventilatory support: Intolerant of\\n weaning attempts, Cannot protect airway, Cannot manage secretions,\\n Underlying illness not resolved\\n Bedside RSBI- deferred due to agitation\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2167-10-12 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 637200,\n \"text\": \"TITLE:\\n Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 24\\n Ideal body weight: 61.2 None\\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: Yes\\n Procedure location:\\n Reason:\\n Tube Type\\n ETT:\\n Position: cm at teeth\\n Route:\\n Type: Not applicable\\n Size: Not applicable\\n Tracheostomy tube:\\n Type: Cuffed\\n Manufacturer: Portex\\n Size: 7.0mm\\n PMV: No\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 28 cmH2O\\n Cuff volume: mL /\\n Airway problems:\\n Comments: PMV eval done today... only partially\\n successful\\n Lung sounds\\n RLL Lung Sounds: Clear\\n RUL Lung Sounds: Rhonchi\\n LUL Lung Sounds: Rhonchi\\n LLL Lung Sounds: Clear\\n Comments:\\n Secretions\\n Sputum color / consistency: Yellow / Thick\\n Sputum source/amount: Suctioned / Small\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance: Intermittent invasive ventilation\\n Visual assessment of breathing pattern: Normal quiet breathing\\n Assessment of breathing comfort: No claim of dyspnea)\\n Non-invasive ventilation assessment:\\n Invasive ventilation assessment:\\n Trigger work assessment: Triggering synchronously\\n Dysynchrony assessment:\\n Comments:\\n Plan\\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\\n Reason for continuing current ventilatory support: Cannot protect\\n airway, Cannot manage secretions, Underlying illness not resolved;\\n Comments: weaning to trach collar as tolerated each day\\n Respiratory Care Shift Procedures\\n Transports:\\n Destination (R/T)\\n Time\\n Complications\\n Comments\\n Bedside Procedures:\\n Comments:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-07 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 636189,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n EKG - At 11:53 PM for qrs (<500)\\n Continued to have alternating tachy and bradycadia with associated\\n pressure swings on adjusted pain regimen. Unable to diurese given\\n intermittant hypotension. Finally got one dose lasix when BP in an\\n acceptable range.\\n Much more anxious than previous nights. Increased Valium back to 10 mg\\n QID.\\n CT showed cuff distention. Per respiratory, still has a leak, likely\\n needs a larger cuff.\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Heparin Sodium - 1,500 units/hour\\n Other ICU medications:\\n Diazepam (Valium) - 02:00 AM\\n Furosemide (Lasix) - 03:56 AM\\n Haloperidol (Haldol) - 03:57 AM\\n Midazolam (Versed) - 05:11 AM\\n Other medications:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:03 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.6\\nC (99.6\\n Tcurrent: 37.1\\nC (98.7\\n HR: 124 (66 - 135) bpm\\n BP: 137/67(92) {74/35(48) - 150/81(106)} mmHg\\n RR: 15 (7 - 28) insp/min\\n SpO2: 94%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 3,707 mL\\n 723 mL\\n PO:\\n TF:\\n 1,457 mL\\n 364 mL\\n IVF:\\n 810 mL\\n 150 mL\\n Blood products:\\n Total out:\\n 2,535 mL\\n 2,760 mL\\n Urine:\\n 2,535 mL\\n 2,760 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,172 mL\\n -2,037 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: CPAP/PSV\\n Vt (Set): 400 (400 - 400) mL\\n Vt (Spontaneous): 964 (260 - 964) mL\\n PS : 12 cmH2O\\n RR (Set): 10\\n RR (Spontaneous): 8\\n PEEP: 8 cmH2O\\n FiO2: 50%\\n RSBI Deferred: Agitated\\n PIP: 21 cmH2O\\n SpO2: 94%\\n ABG: 7.41/53/86/35/6\\n Ve: 7.8 L/min\\n PaO2 / FiO2: 172\\n Physical Examination\\n General Appearance: Trached and sedated. Responsive, following\\n commands, Overweight / Obese, mild agitation but NAD\\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\\n deviation\\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\\n Cardiovascular: (S1: Normal), (S2: Normal), distant\\n Respiratory / Chest: (Expansion: Symmetric), CTA anteriorly, decreased\\n BS\\n Abdominal: Obese, Firm, Non-tender, no rebound, no guarding, + BS, PEG\\n in place with dressing C/D/I\\n Extremities: no CCE\\n Skin: no rashes or jaundice\\n Lines: r brachioceph ART with large amount of bloody drainage and L\\n PICC C/D/I\\n Labs / Radiology\\n 213 K/uL\\n 8.3 g/dL\\n 118 mg/dL\\n 0.6 mg/dL\\n 32 mEq/L\\n 3.5 mEq/L\\n 11 mg/dL\\n 108 mEq/L\\n 146 mEq/L\\n 27.4 %\\n 8.2 K/uL\\n [image002.jpg]\\n 02:47 AM\\n 11:01 AM\\n 04:40 PM\\n 05:08 PM\\n 03:44 AM\\n 06:04 AM\\n 09:09 AM\\n 05:07 PM\\n 03:31 AM\\n 03:46 AM\\n WBC\\n 11.2\\n 9.6\\n 8.2\\n Hct\\n 27.4\\n 25.3\\n 27.4\\n Plt\\n 272\\n 229\\n 213\\n Cr\\n 0.6\\n 0.6\\n 0.6\\n 0.8\\n 0.6\\n TCO2\\n 31\\n 34\\n 33\\n 32\\n 35\\n Glucose\\n 128\\n 138\\n 107\\n 121\\n 118\\n Other labs: PT / PTT / INR:18.4/68.9/1.7, Ca++:9.0 mg/dL, Mg++:2.5\\n mg/dL, PO4:4.8 mg/dL\\n Assessment and Plan\\n 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA and\\n ARDS intubated since the end of now s/p trach and PEG placement.\\n Thyroid nodule on CT\\n Watch phos product\\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\\n volume overload. Intubated on for resp decompensation. Stenting\\n unlikely to help for trachiomalacia as airways have poor structure\\n diffusely. S/P Trach and PEG on . Increased effusion on recent\\n CXR.\\n - wean FiO2 as tolerated\\n # Adrenal Insufficency: Hypotension that resolved with steroids,\\n returned as they came off and is now improved again. Possible primary\\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\\n started on .\\n - wean per endo recs, decrease to 20q am and 10 q pm starting\\n tonight\\n will maintain this maintenance dose and check am cortisol\\n level one week later\\n # Volume overloaded in setting of hypernatremia with TBW deficit.\\n - Lasix gtt, continue with goal -1-2 L per day\\n currently off as\\n patient is somewhat hypotensive\\n will restart once/if BP increases and\\n remains stable for several hours\\n - electrolytes\\n - continue tube feeds with free water flushes 300 cc q4\\n # Sedation: Sedation control remains somewhat poor although fentanyl\\n patch and diazpem are likely therapeutic range today. On Versed 2.0,\\n Fentanyl 100, Fentanyl patch, Diazepam standing and haldo 2.5-5 mg\\n PRN. QTc increased to 480.\\n - Wean versed/fentanyl as tolerated, continue diazepam in\\n hopes for vent facility placement\\n - Change diazepam to 5mg q8 with haldol 5 mg q8\\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\\n coumadin at least until s/p trach.\\n - heparin gtt restarted\\n - coumadin 5mg G-tube today, INR in am\\n # Spine fracture: Neurologically intact distal to the lesion. Prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - CT of C, L spine when stable. Currently, unlikely to change\\n management and high risk for complications with transport.\\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\\n is low. Brace for OOB. Ok for anticoag per note.\\n -f/u full trauma spine eval from OSH to determine need for further back\\n imaging in-house (to be done )\\n #. Thyroid Nodule\\n # Nutrition: Tube feeds with free water flushes, tolerating well,\\n continue Replete (Full) - 11:20 AM 30 mL/hour\\n # Glycemic control: SSI, well controlled\\n # Lines L PICC () and R ART ()\\n similarly but will\\n keep in setting of hypotension\\n # Ppx: heparin drip until INR therapeutic for 2 days, ranitidine, VAP\\n prevention, colace and senna\\n # Communication:\\n - Boyfriend of 10 is her HCP. Also brother is involved\\n Code: Full\\n Dispo: ICU, being screening for vent facilities\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 01:39 AM 60 mL/hour\\n Glycemic Control:\\n Lines:\\n PICC Line - 09:19 PM\\n Arterial Line - 02:00 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nutrition\",\n \"chartdate\": \"2167-10-07 00:00:00.000\",\n \"description\": \"Clinical Nutrition Note\",\n \"row_id\": 636190,\n \"text\": \"Objective\\n Pertinent medications: nted\\n Labs:\\n Value\\n Date\\n Glucose\\n 155 mg/dL\\n 10:20 AM\\n Glucose Finger Stick\\n 115\\n 04:00 AM\\n BUN\\n 12 mg/dL\\n 10:20 AM\\n Creatinine\\n 0.8 mg/dL\\n 10:20 AM\\n Sodium\\n 150 mEq/L\\n 10:20 AM\\n Potassium\\n 4.8 mEq/L\\n 10:20 AM\\n Chloride\\n 109 mEq/L\\n 10:20 AM\\n TCO2\\n 32 mEq/L\\n 10:20 AM\\n Albumin\\n 2.4 g/dL\\n 03:59 AM\\n Calcium non-ionized\\n 10.0 mg/dL\\n 10:20 AM\\n Phosphorus\\n 4.8 mg/dL\\n 10:20 AM\\n Ionized Calcium\\n 1.17 mmol/L\\n 03:32 PM\\n Magnesium\\n 2.8 mg/dL\\n 10:20 AM\\n Current diet order / nutrition support: Replete c/ Fiber @ 60mL/hr\\n (1440 kcals/89 graa) Flush c/ 150mL q4hr per medbook\\n GI: Abd: soft/+bs\\n Assessment of Nutritional Status\\n Estimation of current intake: Adequate\\n Specifics:\\n Pt continues on TF\\ns for full nutrition support via PEG. TF\\ns meeting\\n 100% estimated nutrition needs. Asked by RN to evaluate TF in relation\\n to high Na and PO4. Pt is receiving TF\\ns c/ the most free H2O able in\\n a standard formula, therefore will need to increase FWB to increase\\n free H2O in. A low PO4 formula would also have low K, which is not\\n appropriate in this pt given need for frequent K repletions. Would\\n consider PO4 binder instead.\\n Medical Nutrition Therapy Plan - Recommend the Following\\n Increase FWB to 250mL q 4 hr\\n Consider CaCO3 500mg daily for high Po4\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-08 00:00:00.000\",\n \"description\": \"Generic Note\",\n \"row_id\": 636274,\n \"text\": \"TITLE:\\n 55 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\\n Now with prolonged hospital course c/b by PNA with high PEEP\\n requirement, anxiety, RUE DVT ,continued on heparin qtt.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Lungs clear bilat upper lobes and diminished bilat bases with\\n occasional scattered rhonchi, prod cough thick yellow/tan sputum, trach\\n sx for mod.amt. Placed on MMV for the night with good effect.\\n Action:\\n Vent changed from CPAP+PS to MMV overnight, Peep @ to 8cm. Freq.\\n pulmonary toileting.\\n Response:\\n Tolerating slow vent wean, requiring pulmonary toileting, good\\n diuresis in attempt to wean vent further\\n Plan:\\n Attempt to wean PS and FI02 down further today as tolerated, Continue\\n aggressive pulmonary toileting, Diurese as tolerated.\\n Altered mental status (not Delirium)\\n Assessment:\\n Increased agitation throughout night with pt wriggling in bed and\\n attempting to get OOB and attempting to pull at all lines and tubes,\\n makes eye contact and follows commands but doesn\\nt stay calm for long,\\n HR up to 130- with agitation and BP up to 130-150\\ns/60-70\\n received valium and Haldol as ordered. Prn Midazolam given as per\\n orders. dosing in between scheduled doses with poor effect. appears\\n generally uncomfortable but denies pain when asked.\\n Action:\\n Freq. attempts to reorient and calm pt with no effect, Is on Haldol po\\n q 8 & also on prn dosing. On po diazepam 10 mgs q 6 & iv versed 0.5 mg\\n to 2 mgs q 1 hr. stimulation decreased, bilat soft wrist restraints to\\n prevent pt from pulling at lines and tubes\\n Response:\\n Increased agitation off of continuous IV sedation, poor effect from\\n current medical regime, MICU team aware.\\n Plan:\\n Continue meds to control agitation.\\n Hypernatremia (high sodium)\\n Assessment:\\n No seizure activity noted, Na= 150 yesterday during the day\\n Action:\\n Free water flushes 300ml Q 4hr\\n Response:\\n Na --MICU team aware\\n Plan:\\n Continue free water flushes, address tube feedings with nutrition and\\n possible change to a lower sodium tube feeding. monitor Na levels. Will\\n follow up on am labs.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-08 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 636396,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n ARTERIAL LINE - STOP 12:23 PM\\n ARTERIAL LINE - START 02:00 PM\\n A-line resited, not working again\\n tube feed machine not working\\n failed SBT - low MV with PSV - switched to MMV overnight\\n tachycardic to 140-142\\n Ortho spine ok with documented final read of CT trauma from attending\\n at OSH and week f/u - faxed request and spoke with med recs at\\n Medical re: sending report which was agreed upon.\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Heparin Sodium - 1,500 units/hour\\n Other ICU medications:\\n Morphine Sulfate - 12:15 PM\\n Midazolam (Versed) - 03:50 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:13 AM\\n Vital signs\\n Cardiac monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.5\\nC (99.5\\n Tcurrent: 37.1\\nC (98.8\\n HR: 105 (70 - 148) bpm\\n BP: 85/55(66) {85/41(57) - 158/110(323)} mmHg\\n RR: 23 (10 - 31) insp/min\\n SpO2: 95%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n QTc: 411\\n Total In:\\n 3,562 mL\\n 965 mL\\n PO:\\n TF:\\n 1,685 mL\\n 150 mL\\n IVF:\\n 548 mL\\n 215 mL\\n Blood products:\\n Total out:\\n 5,695 mL\\n 1,740 mL\\n Urine:\\n 5,695 mL\\n 1,740 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -2,133 mL\\n -775 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: CPAP/PSV\\n Vt (Set): 400 (400 - 400) mL\\n Vt (Spontaneous): 359 (137 - 695) mL\\n PS : 8 cmH2O\\n RR (Set): 10\\n RR (Spontaneous): 26\\n PEEP: 8 cmH2O\\n FiO2: 50%\\n RSBI: 58\\n PIP: 16 cmH2O\\n SpO2: 95%\\n ABG: 7.40/49/114/32/3\\n Ve: 7.2 L/min\\n PaO2 / FiO2: 228\\n Physical Examination\\n General Appearance: Trached and sedated. Responsive, following\\n commands, Overweight / Obese, mild agitation but NAD\\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\\n deviation\\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\\n Cardiovascular: (S1: Normal), (S2: Normal), distant\\n Respiratory / Chest: (Expansion: Symmetric), CTA anteriorly, decreased\\n BS\\n Abdominal: Obese, soft, Non-tender, no rebound, no guarding, + BS, PEG\\n in place with dressing C/D/I\\n Extremities: no CCE\\n Skin: no rashes or jaundice\\n Lines: r brachioceph ART with large amount of bloody drainage and L\\n PICC C/D/I\\n Labs / Radiology\\n 213 K/uL\\n 8.8 g/dL\\n 123 mg/dL\\n 0.6 mg/dL\\n 32 mEq/L\\n 3.6 mEq/L\\n 13 mg/dL\\n 107 mEq/L\\n 145 mEq/L\\n 29.4 %\\n 11.1 K/uL\\n [image002.jpg]\\n 03:44 AM\\n 06:04 AM\\n 09:09 AM\\n 05:07 PM\\n 03:31 AM\\n 03:46 AM\\n 10:20 AM\\n 03:46 PM\\n 01:37 AM\\n 05:32 AM\\n WBC\\n 9.6\\n 8.2\\n 11.1\\n Hct\\n 25.3\\n 27.4\\n 29.4\\n Plt\\n \\n Cr\\n 0.6\\n 0.8\\n 0.6\\n 0.8\\n 0.6\\n TCO2\\n 33\\n 32\\n 35\\n 37\\n 31\\n Glucose\\n 107\\n 121\\n 118\\n 155\\n 123\\n Other labs: PT / PTT / INR:22.3/69.7/2.1, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:13.1 %,\\n Mono:2.7 %, Eos:0.6 %, Lactic Acid:1.1 mmol/L, Albumin:2.4 g/dL,\\n LDH:204 IU/L, Ca++:9.2 mg/dL, Mg++:2.5 mg/dL, PO4:4.1 mg/dL\\n Assessment and Plan\\n 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA, and\\n ARDS, intubated since the end of now s/p trach and PEG\\n placement.\\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\\n volume overload. Intubated on for resp decompensation. S/P Trach\\n and PEG on .\\n - wean FiO2 as tolerated\\n - attempt wean PS today and hopeful for trach mask trial\\n # Sedation: Continue to have issues with pain/delirium causing\\n tachycardia and hypertension with intermittent hypotension. On Haldol\\n 5 TID, Fentanyl 100-150 mcg TP, Diazapam 10 QID; Haldol, midazolam and\\n morphine PRN. Had good response to morphine, minimal response to\\n haldol bolus.\\n - Will d/c midazolam and haldol PRN and use morphine for now.\\n - If stable, would d/c standing Haldol tonight or tomorrow\\n # Adrenal Insufficency: Hypotension that resolved with steroids,\\n returned as they came off and is now improved again. Possible primary\\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\\n started on .\\n - ok to go to 10 q am and 5 q pm prednisone, will wean to\\n maintenance dose as tolerated, in consultation with endo.\\n # Volume overloaded in setting of hypernatremia with TBW deficit and\\n metabolic alkalosis\\n - Lasix boluses, goal -1L today\\n - Diamox until HCO3 < 30\\n - electrolytes\\n - continue tube feeds with free water flushes 300 cc q4\\n # RUE DVT: INR now therapeutic on coumadin. Goal \\n - stop heparin gtt\\n - coumadin 5mg QHS\\n # Spine fracture: Neurologically intact distal to the lesion. Prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - Brace for OOB\\n - will f/u full trauma spine eval from OSH to determine need for\\n further back imaging in-house.\\n # Tracheomalacia: Discussed with IP. Stenting unlikely to help for\\n trachiomalacia as airways have poor structure diffusely.\\n - Outpatient f/u once off pressure support to assess for possible\\n stenting\\n #. Thyroid Nodule on CT\\n -outpatient follow up\\n # Nutrition: Tube feeds with free water flushes, tolerating well,\\n continue Replete (Full) - 11:20 AM 30 mL/hour\\n # Glycemic control: SSI, well controlled\\n # Lines L PICC () and R ART ()\\n d/c art today. Correlate ABG\\n and VBG.\\n # Ppx: INR therapeutic, ranitidine, colace and senna\\n # Communication:\\n - Boyfriend of 10 is her HCP. Also brother is involved\\n Code: Full\\n Dispo: ICU, being screening for vent facilities\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n PICC Line - 09:19 PM\\n Arterial Line - 02:00 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-11 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 636943,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Spiked to 102.2 after aspiration of tube feeds (only at 10 cc/hr) - pan\\n cultured and given tylenol\\n INR rising\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Aztreonam - 03:42 AM\\n Vancomycin - 09:40 AM\\n Levofloxacin - 11:15 PM\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 07:47 AM\\n Morphine Sulfate - 05:16 AM\\n Other medications:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:08 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 39\\nC (102.2\\n Tcurrent: 37.1\\nC (98.7\\n HR: 129 (86 - 137) bpm\\n BP: 102/52(64) {78/26(42) - 155/89(100)} mmHg\\n RR: 15 (12 - 65) insp/min\\n SpO2: 99%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 1,299 mL\\n 500 mL\\n PO:\\n TF:\\n 55 mL\\n IVF:\\n 699 mL\\n 500 mL\\n Blood products:\\n Total out:\\n 2,990 mL\\n 485 mL\\n Urine:\\n 2,990 mL\\n 485 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,691 mL\\n 15 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 500 (500 - 500) mL\\n Vt (Spontaneous): 513 (328 - 561) mL\\n PS : 0 cmH2O\\n RR (Set): 12\\n RR (Spontaneous): 0\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n RSBI Deferred: Agitated\\n PIP: 22 cmH2O\\n SpO2: 99%\\n ABG: ///26/\\n Ve: 6.6 L/min\\n Physical Examination\\n General Appearance: Trached. Interactive. Responsive, following\\n commands, Overweight / Obese, mild agitation but NAD\\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\\n deviation\\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\\n Cardiovascular: (S1: Normal), (S2: Normal), distant\\n Respiratory / Chest: (Expansion: Symmetric), b/l rhonchi R>L, decreased\\n BS\\n Abdominal: Obese, soft, Non-tender, no rebound, no guarding, + BS, PEG\\n in place with dressing C/D/I\\n Extremities: no CCE\\n Skin: no rashes or jaundice\\n Lines: L PICC C/D/I\\n Labs / Radiology\\n 238 K/uL\\n 8.4 g/dL\\n 106 mg/dL\\n 0.9 mg/dL\\n 26 mEq/L\\n 3.9 mEq/L\\n 11 mg/dL\\n 108 mEq/L\\n 143 mEq/L\\n 26.9 %\\n 7.2 K/uL\\n [image002.jpg]\\n 02:43 PM\\n 03:03 PM\\n 08:11 PM\\n 02:51 AM\\n 03:10 AM\\n 03:08 PM\\n 03:00 AM\\n 03:36 AM\\n 04:40 PM\\n 03:00 AM\\n WBC\\n 9.4\\n 11.3\\n 7.3\\n 6.1\\n 7.2\\n Hct\\n 26.6\\n 24.9\\n 27.6\\n 26.5\\n 26.9\\n Plt\\n 09\\n 238\\n Cr\\n 0.9\\n 0.7\\n 0.6\\n 0.6\\n 0.9\\n TCO2\\n 31\\n 30\\n 29\\n 26\\n Glucose\\n 128\\n 114\\n 114\\n 99\\n 115\\n 106\\n Other labs: PT / PTT / INR:72.4/42.1/9.0, Ca++:9.3 mg/dL, Mg++:2.5\\n mg/dL, PO4:3.6 mg/dL\\n Assessment and Plan\\n 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA, and\\n ARDS, intubated since the end of now s/p trach and PEG\\n placement.\\n # Recent Aspiration of tube feeds. Given prolonged hospitalization and\\n tenuous respiratory status will treat with antibiotics while cultures\\n pending\\n - Levoflox for 48 hours while waiting for sputum results.\\n - hold tube feeds\\n - Follow cultures\\n - check tube placement\\n .\\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\\n volume overload. Intubated on for resp decompensation. S/P Trach\\n and PEG on .\\n - wean FiO2 as tolerated\\n - attempt wean PS today and hopeful for trach mask trial\\n # Sedation: Continue to have issues with pain/delirium causing\\n tachycardia and hypertension with intermittent hypotension. On Haldol\\n 5 TID, Fentanyl 75 mcg TP, Diazapam 10 QID; Haldol, midazolam and\\n morphine PRN. Had good response to morphine, minimal response to\\n haldol bolus.\\n - tolerating current regimen well, no changes today\\n # Adrenal Insufficency: Hypotension that resolved with steroids,\\n returned as they came off and is now improved again. Possible primary\\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\\n started on .\\n - stopped steroids as per endocrine today\\n # Volume overloaded in setting of hypernatremia\\n Goal even today.\\n - monitor urine output\\n # RUE DVT: INR super-therapeutic on coumadin. Goal . Hasn\\n received coumadin in days yet INR continues to rise. Likely\\n contributors are nutritional and antibiotics.\\n - will start coumadin 2.5 mg QHS once INR < 3\\n # Spine fracture: Neurologically intact distal to the lesion. Prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - Brace for OOB\\n - report from full trauma series from OSH is in chart. No evidence of\\n other fracture and no need for further spinal imaging based on this\\n report and ortho note.\\n # Tracheomalacia: Discussed with IP. Stenting unlikely to help for\\n trachiomalacia as airways have poor structure diffusely.\\n - Outpatient f/u once off pressure support to assess for possible\\n stenting\\n #. Thyroid Nodule on CT\\n -outpatient follow up\\n # Nutrition: Replete (Full)\\n hold\\n # Glycemic control: SSI, well controlled\\n # Lines L PICC\\n ().\\n # Ppx: INR therapeutic, ranitidine, colace and senna, miralax,\\n bisacodyl.\\n # Communication:\\n - Boyfriend of 10 \\n - Brother also involved\\n Code: Full\\n Dispo: ICU, being screening for vent facilities\\n ------ Protected Section ------\\n I saw and examined the patient, and was physically present with the ICU\\n team for the key portions of the services provided. I agree with the\\n note above, including the assessment and plan. I would emphasize and\\n add the following points: 55F T5-8 fractures with retropulsion and ARDS\\n from klebsiella VAP; on heparin for UE DVT and lasix for volume\\n overload. Overnight spiked to 102.2 after apparent aspiration of TF\\n despite low rate (suctioned whitish material from trache).\\n On exam:\\n Tmax: 39\\nC (102.2\\n Tcurrent: 37.1\\nC (98.7\\n HR: 129 (86 - 137) bpm\\n BP: 102/52(64) {78/26(42) - 155/89(100)} mmHg\\n RR: 15 (12 - 65) insp/min\\n SpO2: 99%\\n Trached, lightly sedated, following commands.\\n CV RRR, distant\\n Lungs\\n distant bs, otherwise clear\\n abd: soft NTND BS+, +PEG site\\n Ext- no c/c/e\\n 55F h/o EtOH abuse presenting following mech fall -> traumatic T spine\\n fracture with K. oxytoca PNA, and ARDS, intubated since the end of\\n now s/p trach and PEG placement.\\n Cont efforts to wean mech vent including spont breathing trials w/\\n monitoring given RR. Resp failure related to ARDS, tracheomalacia,\\n VAP (resolved) and component of fluid overload. Now w/ apparent\\n aspiration of TF. Check position of FT to ensure intragastric. Hold\\n TF until confirmed. SCx/GS. Sedation continues to be challenge given\\n delirium, agitation and tolerance for medications. Ortho following re:\\n fx. Cont brace. Agree with recs as outlined above.\\n Code: FULL\\n ------ Protected Section Addendum Entered By: , MD\\n on: 04:14 PM ------\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-08 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 636389,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n ARTERIAL LINE - STOP 12:23 PM\\n ARTERIAL LINE - START 02:00 PM\\n A-line resited, not working again\\n tube feed machine not working\\n failed SBT - low MV with PSV - switched to MMV overnight\\n tachycardic to 140-142\\n Ortho spine ok with documented final read of CT trauma from attending\\n at OSH and week f/u - faxed request and spoke with med recs at\\n Medical re: sending report which was agreed upon.\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Heparin Sodium - 1,500 units/hour\\n Other ICU medications:\\n Morphine Sulfate - 12:15 PM\\n Midazolam (Versed) - 03:50 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:13 AM\\n Vital signs\\n Cardiac monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.5\\nC (99.5\\n Tcurrent: 37.1\\nC (98.8\\n HR: 105 (70 - 148) bpm\\n BP: 85/55(66) {85/41(57) - 158/110(323)} mmHg\\n RR: 23 (10 - 31) insp/min\\n SpO2: 95%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n QTc: 411\\n Total In:\\n 3,562 mL\\n 965 mL\\n PO:\\n TF:\\n 1,685 mL\\n 150 mL\\n IVF:\\n 548 mL\\n 215 mL\\n Blood products:\\n Total out:\\n 5,695 mL\\n 1,740 mL\\n Urine:\\n 5,695 mL\\n 1,740 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -2,133 mL\\n -775 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: CPAP/PSV\\n Vt (Set): 400 (400 - 400) mL\\n Vt (Spontaneous): 359 (137 - 695) mL\\n PS : 8 cmH2O\\n RR (Set): 10\\n RR (Spontaneous): 26\\n PEEP: 8 cmH2O\\n FiO2: 50%\\n RSBI: 58\\n PIP: 16 cmH2O\\n SpO2: 95%\\n ABG: 7.40/49/114/32/3\\n Ve: 7.2 L/min\\n PaO2 / FiO2: 228\\n Physical Examination\\n General Appearance: Trached and sedated. Responsive, following\\n commands, Overweight / Obese, mild agitation but NAD\\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\\n deviation\\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\\n Cardiovascular: (S1: Normal), (S2: Normal), distant\\n Respiratory / Chest: (Expansion: Symmetric), CTA anteriorly, decreased\\n BS\\n Abdominal: Obese, soft, Non-tender, no rebound, no guarding, + BS, PEG\\n in place with dressing C/D/I\\n Extremities: no CCE\\n Skin: no rashes or jaundice\\n Lines: r brachioceph ART with large amount of bloody drainage and L\\n PICC C/D/I\\n Labs / Radiology\\n 213 K/uL\\n 8.8 g/dL\\n 123 mg/dL\\n 0.6 mg/dL\\n 32 mEq/L\\n 3.6 mEq/L\\n 13 mg/dL\\n 107 mEq/L\\n 145 mEq/L\\n 29.4 %\\n 11.1 K/uL\\n [image002.jpg]\\n 03:44 AM\\n 06:04 AM\\n 09:09 AM\\n 05:07 PM\\n 03:31 AM\\n 03:46 AM\\n 10:20 AM\\n 03:46 PM\\n 01:37 AM\\n 05:32 AM\\n WBC\\n 9.6\\n 8.2\\n 11.1\\n Hct\\n 25.3\\n 27.4\\n 29.4\\n Plt\\n \\n Cr\\n 0.6\\n 0.8\\n 0.6\\n 0.8\\n 0.6\\n TCO2\\n 33\\n 32\\n 35\\n 37\\n 31\\n Glucose\\n 107\\n 121\\n 118\\n 155\\n 123\\n Other labs: PT / PTT / INR:22.3/69.7/2.1, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:13.1 %,\\n Mono:2.7 %, Eos:0.6 %, Lactic Acid:1.1 mmol/L, Albumin:2.4 g/dL,\\n LDH:204 IU/L, Ca++:9.2 mg/dL, Mg++:2.5 mg/dL, PO4:4.1 mg/dL\\n Assessment and Plan\\n 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA, and\\n ARDS, intubated since the end of now s/p trach and PEG\\n placement.\\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\\n volume overload. Intubated on for resp decompensation. Stenting\\n unlikely to help for trachiomalacia as airways have poor structure\\n diffusely. S/P Trach and PEG on .\\n - wean FiO2 as tolerated\\n - attempt wean PS today and hopeful for trach mask trial\\n # Sedation: Sedation control remains somewhat poor although fentanyl\\n patch and diazpem are likely therapeutic range today. On Versed 2.0,\\n Fentanyl 100, Fentanyl patch, Diazepam standing and haldo 2.5-5 mg\\n PRN. QTc increased to 480.\\n - Wean versed/fentanyl as tolerated, continue diazepam in\\n hopes for vent facility placement\\n - Continue diazepam 10 mg q8 with haldol 5 mg q8 with 2.5-5\\n prn haldol\\n # Adrenal Insufficency: Hypotension that resolved with steroids,\\n returned as they came off and is now improved again. Possible primary\\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\\n started on .\\n - wean per endo recs, decrease to 20q am and 10 q pm today\\n - ok to go to 10 q am and 5 q pm tomorrow ()\\n # Volume overloaded in setting of hypernatremia with TBW deficit and\\n metabolic alkalosis\\n - Lasix boluses with diamox today, goal -1L\\n - electrolytes\\n - continue tube feeds with free water flushes 300 cc q4\\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\\n coumadin at least until s/p trach. INR 1.7 today.\\n - heparin gtt restarted\\n - coumadin 5mg G-tube today, INR in am\\n # Spine fracture: Neurologically intact distal to the lesion. Prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - CT of C, L spine when stable. Currently, unlikely to change\\n management and high risk for complications with transport.\\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\\n is low. Brace for OOB. Ok for anticoag per note.\\n -f/u full trauma spine eval from OSH to determine need for further back\\n imaging in-house (to be done )\\n # Tracheomalacia: Discussed with IP.\\n - Outpatient f/u once off pressure support to assess for possible\\n stenting\\n #. Thyroid Nodule on CT\\n -outpatient follow up\\n # Nutrition: Tube feeds with free water flushes, tolerating well,\\n continue Replete (Full) - 11:20 AM 30 mL/hour\\n # Glycemic control: SSI, well controlled\\n # Lines L PICC () and R ART ()\\n d/c art and re-site today\\n # Ppx: heparin drip until INR therapeutic for 2 days, ranitidine, VAP\\n prevention, colace and senna\\n # Communication:\\n - Boyfriend of 10 is her HCP. Also brother is involved\\n Code: Full\\n Dispo: ICU, being screening for vent facilities\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n PICC Line - 09:19 PM\\n Arterial Line - 02:00 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-04 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 635675,\n \"text\": \"55 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\\n Now with prolonged hospital course c/b by PNA with high PEEP\\n requirement, anxiety, RUE DVT on heparin qtt.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Rec\\nd pt on Vent settings AC 55%/18 X 400/+10 with no overbreathing of\\n set RR. O2 sat 92-98%. Lung snds clear, diminished in bases. Pt sxn\\n for small-moderate amts thick white secretions. Trach site with small\\n amt serosang drainage.\\n Action:\\n Cont same vent settings\\n Response:\\n Pt doesn\\nt over breath on the vent and never desat.\\n Plan:\\n Wean from vent as she tolerates,monitor sats,ABG?.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-13 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 637258,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Vancomycin - 09:40 AM\\n Levofloxacin - 11:15 PM\\n Ceftriaxone - 07:50 PM\\n Infusions:\\n Other ICU medications:\\n Haloperidol (Haldol) - 10:26 AM\\n Diazepam (Valium) - 11:33 AM\\n Morphine Sulfate - 02:30 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:34 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.4\\nC (99.4\\n Tcurrent: 36.7\\nC (98.1\\n HR: 118 (118 - 148) bpm\\n BP: 90/37(48) {90/37(48) - 171/111(115)} mmHg\\n RR: 14 (12 - 36) insp/min\\n SpO2: 95%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 1,614 mL\\n 439 mL\\n PO:\\n TF:\\n 884 mL\\n 279 mL\\n IVF:\\n 100 mL\\n Blood products:\\n Total out:\\n 834 mL\\n 20 mL\\n Urine:\\n 834 mL\\n 20 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 780 mL\\n 419 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 354 (244 - 376) mL\\n PS : 10 cmH2O\\n RR (Spontaneous): 12\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n RSBI: 56\\n PIP: 15 cmH2O\\n SpO2: 95%\\n ABG: ////\\n Ve: 4.1 L/min\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 240 K/uL\\n 7.9 g/dL\\n 100 mg/dL\\n 0.6 mg/dL\\n 30 mEq/L\\n 3.4 mEq/L\\n 12 mg/dL\\n 108 mEq/L\\n 146 mEq/L\\n 26.0 %\\n 5.2 K/uL\\n [image002.jpg]\\n 08:11 PM\\n 02:51 AM\\n 03:10 AM\\n 03:08 PM\\n 03:00 AM\\n 03:36 AM\\n 04:40 PM\\n 03:00 AM\\n 07:05 PM\\n 03:00 AM\\n WBC\\n 9.4\\n 11.3\\n 7.3\\n 6.1\\n 7.2\\n 5.2\\n Hct\\n 26.6\\n 24.9\\n 27.6\\n 26.5\\n 26.9\\n 26.0\\n Plt\\n \\n Cr\\n 0.9\\n 0.7\\n 0.6\\n 0.6\\n 0.9\\n 0.7\\n 0.6\\n TCO2\\n 29\\n 26\\n Glucose\\n 128\\n 114\\n 114\\n 99\\n 115\\n 106\\n 100\\n Other labs: PT / PTT / INR:17.6/27.4/1.6, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:33/22, Alk Phos / T Bili:143/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:0.5 mmol/L,\\n Albumin:3.5 g/dL, LDH:199 IU/L, Ca++:8.9 mg/dL, Mg++:2.4 mg/dL, PO4:4.1\\n mg/dL\\n Assessment and Plan\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 10:31 PM 50 mL/hour\\n Glycemic Control:\\n Lines:\\n PICC Line - 09:19 PM\\n 20 Gauge - 04:59 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-13 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 637259,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Vancomycin - 09:40 AM\\n Levofloxacin - 11:15 PM\\n Ceftriaxone - 07:50 PM\\n Infusions:\\n Other ICU medications:\\n Haloperidol (Haldol) - 10:26 AM\\n Diazepam (Valium) - 11:33 AM\\n Morphine Sulfate - 02:30 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:34 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.4\\nC (99.4\\n Tcurrent: 36.7\\nC (98.1\\n HR: 118 (118 - 148) bpm\\n BP: 90/37(48) {90/37(48) - 171/111(115)} mmHg\\n RR: 14 (12 - 36) insp/min\\n SpO2: 95%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 1,614 mL\\n 439 mL\\n PO:\\n TF:\\n 884 mL\\n 279 mL\\n IVF:\\n 100 mL\\n Blood products:\\n Total out:\\n 834 mL\\n 20 mL\\n Urine:\\n 834 mL\\n 20 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 780 mL\\n 419 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 354 (244 - 376) mL\\n PS : 10 cmH2O\\n RR (Spontaneous): 12\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n RSBI: 56\\n PIP: 15 cmH2O\\n SpO2: 95%\\n ABG: ////\\n Ve: 4.1 L/min\\n Physical Examination\\n General Appearance: No acute distress, Overweight / Obese\\n Eyes / Conjunctiva: PERRL, Pupils dilated\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\\n Present)\\n Respiratory / Chest: (Breath Sounds: Clear : )\\n Abdominal: Soft, Bowel sounds present, Obese, Patient with thoracic\\n brace on\\n Skin: Not assessed, No(t) Rash: , Per Nursing: Pt with vesicular rash\\n on inferior back.\\n Neurologic: Follows simple commands, Responds to: Not assessed,\\n Movement: Not assessed, Tone: Not assessed\\n Labs / Radiology\\n 240 K/uL\\n 7.9 g/dL\\n 100 mg/dL\\n 0.6 mg/dL\\n 30 mEq/L\\n 3.4 mEq/L\\n 12 mg/dL\\n 108 mEq/L\\n 146 mEq/L\\n 26.0 %\\n 5.2 K/uL\\n [image002.jpg]\\n 08:11 PM\\n 02:51 AM\\n 03:10 AM\\n 03:08 PM\\n 03:00 AM\\n 03:36 AM\\n 04:40 PM\\n 03:00 AM\\n 07:05 PM\\n 03:00 AM\\n WBC\\n 9.4\\n 11.3\\n 7.3\\n 6.1\\n 7.2\\n 5.2\\n Hct\\n 26.6\\n 24.9\\n 27.6\\n 26.5\\n 26.9\\n 26.0\\n Plt\\n \\n Cr\\n 0.9\\n 0.7\\n 0.6\\n 0.6\\n 0.9\\n 0.7\\n 0.6\\n TCO2\\n 29\\n 26\\n Glucose\\n 128\\n 114\\n 114\\n 99\\n 115\\n 106\\n 100\\n Other labs: PT / PTT / INR:17.6/27.4/1.6, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:33/22, Alk Phos / T Bili:143/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:0.5 mmol/L,\\n Albumin:3.5 g/dL, LDH:199 IU/L, Ca++:8.9 mg/dL, Mg++:2.4 mg/dL, PO4:4.1\\n mg/dL\\n Assessment and Plan\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 10:31 PM 50 mL/hour\\n Glycemic Control:\\n Lines:\\n PICC Line - 09:19 PM\\n 20 Gauge - 04:59 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-13 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 637260,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Vancomycin - 09:40 AM\\n Levofloxacin - 11:15 PM\\n Ceftriaxone - 07:50 PM\\n Infusions:\\n Other ICU medications:\\n Haloperidol (Haldol) - 10:26 AM\\n Diazepam (Valium) - 11:33 AM\\n Morphine Sulfate - 02:30 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:34 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.4\\nC (99.4\\n Tcurrent: 36.7\\nC (98.1\\n HR: 118 (118 - 148) bpm\\n BP: 90/37(48) {90/37(48) - 171/111(115)} mmHg\\n RR: 14 (12 - 36) insp/min\\n SpO2: 95%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 1,614 mL\\n 439 mL\\n PO:\\n TF:\\n 884 mL\\n 279 mL\\n IVF:\\n 100 mL\\n Blood products:\\n Total out:\\n 834 mL\\n 20 mL\\n Urine:\\n 834 mL\\n 20 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 780 mL\\n 419 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 354 (244 - 376) mL\\n PS : 10 cmH2O\\n RR (Spontaneous): 12\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n RSBI: 56\\n PIP: 15 cmH2O\\n SpO2: 95%\\n ABG: ////\\n Ve: 4.1 L/min\\n Physical Examination\\n General Appearance: No acute distress, Overweight / Obese\\n Eyes / Conjunctiva: PERRL, Pupils dilated\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\\n Present)\\n Respiratory / Chest: (Breath Sounds: Clear : )\\n Abdominal: Soft, Bowel sounds present, Obese, Patient with thoracic\\n brace on\\n Skin: Not assessed, No(t) Rash: , Per Nursing: Pt with vesicular rash\\n on inferior back.\\n Neurologic: Follows simple commands, Responds to: Not assessed,\\n Movement: Not assessed, Tone: Not assessed\\n Labs / Radiology\\n 240 K/uL\\n 7.9 g/dL\\n 100 mg/dL\\n 0.6 mg/dL\\n 30 mEq/L\\n 3.4 mEq/L\\n 12 mg/dL\\n 108 mEq/L\\n 146 mEq/L\\n 26.0 %\\n 5.2 K/uL\\n [image002.jpg]\\n 08:11 PM\\n 02:51 AM\\n 03:10 AM\\n 03:08 PM\\n 03:00 AM\\n 03:36 AM\\n 04:40 PM\\n 03:00 AM\\n 07:05 PM\\n 03:00 AM\\n WBC\\n 9.4\\n 11.3\\n 7.3\\n 6.1\\n 7.2\\n 5.2\\n Hct\\n 26.6\\n 24.9\\n 27.6\\n 26.5\\n 26.9\\n 26.0\\n Plt\\n \\n Cr\\n 0.9\\n 0.7\\n 0.6\\n 0.6\\n 0.9\\n 0.7\\n 0.6\\n TCO2\\n 29\\n 26\\n Glucose\\n 128\\n 114\\n 114\\n 99\\n 115\\n 106\\n 100\\n Other labs: PT / PTT / INR:17.6/27.4/1.6, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:33/22, Alk Phos / T Bili:143/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:0.5 mmol/L,\\n Albumin:3.5 g/dL, LDH:199 IU/L, Ca++:8.9 mg/dL, Mg++:2.4 mg/dL, PO4:4.1\\n mg/dL\\n Assessment and Plan\\n 55yoF with history of EtOH abuse presenting following mechanical fall\\n and traumatic T spine fracture with K. oxytoca PNA, and ARDS, intubated\\n since the end of now s/p trach and PEG placement.\\n# Recent Aspiration on Tube Feeds. Cultures growing Klebsiella Oxytoca and Klebs\\niella Pneumoniae. Pt received developed rash on Levofloxacin, switched to Ceftri\\naxone overnight. Will treat for potential HAP for 8 days.\\n - Continue Ceftriaxone day #1.\\n - Tube Feeds restarted with goal of 60/hr\\n - Follow cultures\\n - check tube placement\\n .\\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\\n volume overload. Intubated on for resp decompensation. S/P Trach\\n and PEG on .\\n - Weaning FiO2 as tolerated\\n - Will attempt trach collar today\\n # Tachycardia: Pt in ST for most of the day 120\\ns to 140s. Etiology\\n remains unclear although she has been tachy since admission. Etiologies\\n include pain (especially when sitting upright with thoracic brace on),\\n infection (pt with known klebsiella, possibly acquired HAP). DDx also\\n includes PE, hyperthyroidism.\\n - Will keep pt\\ns INR therapeutic\\n - TSH 2.4 on early , will check free T3, T4.\\n - Continue Pain Control\\n - Treat underlying infection\\n # Sedation: Pt has pain/delirium causing tachycardia and hypertension\\n with intermittent hypotension. On Haldol 5 TID, Fentanyl 75 mcg TP,\\n Diazapam 10 QID; Haldol, midazolam and morphine PRN. Had good response\\n to morphine, minimal response to haldol bolus.\\n - tolerating current regimen well, no changes today\\n # Adrenal Insufficency: Hypotension that resolved with steroids,\\n returned as they came off and is now improved again. Possible primary\\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\\n started on .\\n - stopped steroids as per endocrine today\\n # Volume overloaded in prior setting of hypernatremia\\n Goal even\\n today.\\n - Monitoring urine output\\n # RUE DVT: INR was super-therapeutic on coumadin. Goal . Hasn\\n received coumadin in days yet INR continues to rise. Likely\\n contributors are nutritional and antibiotics.\\n - will start coumadin 2.5 mg QHS once INR < 3\\n # Spine fracture: Neurologically intact distal to the lesion. Prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - Brace for OOB\\n - Report from full trauma series from OSH is in chart.\\n - Pt to follow up with Dr. in weeks\\n # Tracheomalacia: Discussed with IP. Stenting unlikely to help for\\n trachiomalacia as airways have poor structure diffusely.\\n - Outpatient f/u once off pressure support to assess for possible\\n stenting\\n #. Thyroid Nodule on CT\\n - Outpatient follow up\\n # Nutrition: Replete (Full)\\n hold\\n # Glycemic control: SSI, well controlled\\n # Lines L PICC ().\\n # Ppx: INR remains therapeutic, ranitidine, colace and senna, miralax,\\n bisacodyl.\\n # Communication:\\n - Boyfriend of 10 \\n - Brother also involved\\n Code: Full\\n Dispo: ICU, being screening for vent facilities\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 11:38 AM 50 mL/hour\\n Glycemic Control:\\n Lines:\\n PICC Line - 09:19 PM\\n 20 Gauge - 04:59 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 10:31 PM 50 mL/hour\\n Glycemic Control:\\n Lines:\\n PICC Line - 09:19 PM\\n 20 Gauge - 04:59 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-07 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 636150,\n \"text\": \"55 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\\n Now with prolonged hospital course c/b by PNA with high PEEP\\n requirement, anxiety, RUE DVT on heparin qtt.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Lungs clear bilat upper lobes and diminished bilat bases with\\n occasional scattered rhonchi, prod cough thick yellow/tan sputum, trach\\n sx for mod. Amt of same, tolerated CPAP+PS until fell asleep and then\\n RR down to 4-5 breaths with MV down to 1-5. Placed on MMV for\\n remainder of night with good effect.\\n Action:\\n Vent changed from CPAP+PS to MMV overnight and weaned back to CPAP+PS\\n this am, Peep decreased to 8cm. Freq. pulmonary toileting, diuresing\\n with 40mg. IV Lasix dose\\n Response:\\n Tolerating slow vent wean, ABG: 7.41-53-86, requiring pulmonary\\n toileting, good diuresis in attempt to wean vent further\\n Plan:\\n Attempt to wean PS and FI02 down further today as tolerated, may need\\n MMV mode at night or when sedated, Continue aggressive pulmonary\\n toileting, Diurese as tolerated.\\n Altered mental status (not Delirium)\\n Assessment:\\n Increased agitation throughout night with pt writhing in bed and\\n attempting to get OOB and attempting to pull at all lines and tubes,\\n makes eye contact and follows commands but doesn\\nt stay calm for long,\\n HR up to 130- with agitation and BP up to 130-150\\ns/60-70\\n received valium and Haldol as ordered with prn dosing in between\\n scheduled doses with poor effect, received 4 mg. Iv versed with poor\\n effect, appears generally uncomfortable but denies pain when asked.\\n Action:\\n Freq. attempts to reorient and calm pt, Valium 5mg x 2 with no effect,\\n Haldol 5mg po and additional 1 mg. IV with no effect, Versed 4 mg. with\\n no effect, stimulation decreased, bilat soft wrist restraints to\\n prevent pt from pulling at lines and tubes\\n Response:\\n Increased agitation off of continuous IV sedation, poor effect from\\n current medical regime, MICU team aware and addressing\\n Plan:\\n Valium dose to be increased, Potential head CT today, obtain psych and\\n neuro consults if pt\\ns mental status doesn\\nt improve\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-07 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 636153,\n \"text\": \"55 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\\n Now with prolonged hospital course c/b by PNA with high PEEP\\n requirement, anxiety, RUE DVT on heparin qtt.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Lungs clear bilat upper lobes and diminished bilat bases with\\n occasional scattered rhonchi, prod cough thick yellow/tan sputum, trach\\n sx for mod. Amt of same, tolerated CPAP+PS until fell asleep and then\\n RR down to 4-5 breaths with MV down to 1-5. Placed on MMV for\\n remainder of night with good effect.\\n Action:\\n Vent changed from CPAP+PS to MMV overnight and weaned back to CPAP+PS\\n this am, Peep decreased to 8cm. Freq. pulmonary toileting, diuresing\\n with 40mg. IV Lasix dose\\n Response:\\n Tolerating slow vent wean, ABG: 7.41-53-86, requiring pulmonary\\n toileting, good diuresis in attempt to wean vent further\\n Plan:\\n Attempt to wean PS and FI02 down further today as tolerated, may need\\n MMV mode at night or when sedated, Continue aggressive pulmonary\\n toileting, Diurese as tolerated.\\n Altered mental status (not Delirium)\\n Assessment:\\n Increased agitation throughout night with pt writhing in bed and\\n attempting to get OOB and attempting to pull at all lines and tubes,\\n makes eye contact and follows commands but doesn\\nt stay calm for long,\\n HR up to 130- with agitation and BP up to 130-150\\ns/60-70\\n received valium and Haldol as ordered with prn dosing in between\\n scheduled doses with poor effect, received 4 mg. Iv versed with poor\\n effect, appears generally uncomfortable but denies pain when asked.\\n Action:\\n Freq. attempts to reorient and calm pt, Valium 5mg x 2 with no effect,\\n Haldol 5mg po and additional 1 mg. IV with no effect, Versed 4 mg. with\\n no effect, stimulation decreased, bilat soft wrist restraints to\\n prevent pt from pulling at lines and tubes\\n Response:\\n Increased agitation off of continuous IV sedation, poor effect from\\n current medical regime, MICU team aware and addressing\\n Plan:\\n Valium dose to be increased, Potential head CT today, obtain psych and\\n neuro consults if pt\\ns mental status doesn\\nt improve\\n Hypernatremia (high sodium)\\n Assessment:\\n No seizure activity noted, Na= 141 last evening\\n Action:\\n Free water flushes decreased to 150 ml Q4hr from 300ml Q 4hr\\n Response:\\n Na back up to 146---MICU team aware\\n Plan:\\n Continue free water flushes, address tube feedings with nutrition and\\n possible change to a lower sodium tube feeding, potential need to\\n increase free water amts back to 300ml, monitor Na levels\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2167-10-08 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 636432,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 20\\n Ideal body weight: 61.2 None\\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: Yes\\n Procedure location:\\n Reason:\\n Tube Type\\n ETT:\\n Position: cm at teeth\\n Route:\\n Type:\\n Size:\\n Tracheostomy tube:\\n Type: Cuffed\\n Manufacturer: Portex\\n Size: 8.0mm\\n PMV:\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 28 cmH2O\\n Cuff volume: mL /\\n Airway problems:\\n Comments:\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Diminished\\n Comments:\\n Secretions\\n Sputum color / consistency: Yellow / Thick\\n Sputum source/amount: Suctioned / Moderate\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance:\\n Visual assessment of breathing pattern:\\n Assessment of breathing comfort:\\n Non-invasive ventilation assessment:\\n Invasive ventilation assessment:\\n Trigger work assessment:\\n Dysynchrony assessment:\\n Comments: Patient ewaned to then back on due to increase RR and\\n HR.Was oob/chair today for many hours with neck brace on.ABG on \\n shows hypoxemia with pao2 66 mmhg and compensated resp acidosis,has # 8\\n Portex,suctioned for small thick sputum.\\n Plan\\n Next 24-48 hours:\\n Reason for continuing current ventilatory support:\\n Respiratory Care Shift Procedures\\n Transports:\\n Destination (R/T)\\n Time\\n Complications\\n Comments\\n Bedside Procedures:\\n Comments:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-01 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 635388,\n \"text\": \"55 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP now with prolonged\\n hospital course c/o by PNA anxiety,RUE DVD with high PEEP requirement\\n .\\n Events:. Failed spont. Breathing trial. pt to go to OR on for\\n trach/PEG\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Rec\\nd on AC 400x18 50% +PEEP 8, 02 sat 88-93% ABG last night 7.42/47/87\\n Action:\\n Pt changed to PSV 5/0 for spontaneous breathing trial,\\n Response:\\n Pt immediately deatted to the low 80%\\ns, sbp increased to the\\n 150\\ns-160\\ns and HR increased to the 120\\ns-130\\ns. pt placed back on\\n above vent settings and VS returned to baseline.\\n Plan:\\n Pt to have trach placed in the OR in the am.\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt w/ periods of agitation and sleeping at other times, but overall\\n more alert, following commands intermittently.\\n Action:\\n Midazolam remains off, Fentanyl at 100mcg/hr. pt rec\\nd Haldol x1 and\\n cont on q6hr diazepam.\\n Response:\\n HR ranging from SB in the 40\\ns when asleep to the 120\\ns when agitated,\\n b/p ranging from 90\\ns/40\\ns when asleep to 140-150\\ns/ 70\\ns when\\n agitated. When pt awake appropriate and following commands HR\\n 80\\ns-100\\ns and b/p 100\\ns-120\\ns/ 60-70\\n Plan:\\n Cont scheduled valium for anxiety w/ haldol for breakthrough, titrate\\n Fentanyl for pain control.\\n Alteration in Nutrition\\n Assessment:\\n TF on hold this am for possible procedure in OR, FS 123 this am. Pt\\n total body fluid balance remains +~16L for LOS. UOP improving since\\n midnight\\n Action:\\n TF restarted at goal rate 60ml/hr w/ H20 boluses 250ml Q4hrs. when OR\\n procedure moved until tomorrow. Lasix gtt continues at 3mg/hr\\n Response:\\n Pt tol TF well stools x2 this shift, serum Na 146 at 1600. K= 4.1UOP\\n 140-540ml/hr on lasix gtt at 3mg/hr\\n Plan:\\n Cont lasix gtt as b/p tol w/ goal 24 FB neg 1-2L. cont TF and free H20\\n boluses until midnight. Pt NPO after midnight for trach/PEG placement\\n in am.\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Heparin gtt off this am for possible trip to OR. Ptt 26.6 INR 1.1\\n Action:\\n Heparin gtt restarted at 1700units/hr this am when OR time changed\\n until tomorrow.\\n Response:\\n Repeat PTT pending at the time of this note\\n Plan:\\n Cont to monitor PTT and titrate heparin gtt per protocol, heparin to be\\n shut off at 6am for procedure in OR.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-13 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 637263,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Low UOP. UOP 10-20cc/hr, tachy to 130s\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Vancomycin - 09:40 AM\\n Levofloxacin - 11:15 PM\\n Ceftriaxone - 07:50 PM\\n Infusions:\\n Other ICU medications:\\n Haloperidol (Haldol) - 10:26 AM\\n Diazepam (Valium) - 11:33 AM\\n Morphine Sulfate - 02:30 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:34 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.4\\nC (99.4\\n Tcurrent: 36.7\\nC (98.1\\n HR: 118 (118 - 148) bpm\\n BP: 90/37(48) {90/37(48) - 171/111(115)} mmHg\\n RR: 14 (12 - 36) insp/min\\n SpO2: 95%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 1,614 mL\\n 439 mL\\n PO:\\n TF:\\n 884 mL\\n 279 mL\\n IVF:\\n 100 mL\\n Blood products:\\n Total out:\\n 834 mL\\n 20 mL\\n Urine:\\n 834 mL\\n 20 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 780 mL\\n 419 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 354 (244 - 376) mL\\n PS : 10 cmH2O\\n RR (Spontaneous): 12\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n RSBI: 56\\n PIP: 15 cmH2O\\n SpO2: 95%\\n ABG: ////\\n Ve: 4.1 L/min\\n Physical Examination\\n General Appearance: No acute distress, Overweight / Obese\\n Eyes / Conjunctiva: PERRL, Pupils dilated\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\\n Present)\\n Respiratory / Chest: (Breath Sounds: Clear : )\\n Abdominal: Soft, Bowel sounds present, Obese, Patient with thoracic\\n brace on\\n Skin: Not assessed, No(t) Rash: , Per Nursing: Pt with vesicular rash\\n on inferior back.\\n Neurologic: Follows simple commands, Responds to: Not assessed,\\n Movement: Not assessed, Tone: Not assessed\\n Labs / Radiology\\n 240 K/uL\\n 7.9 g/dL\\n 100 mg/dL\\n 0.6 mg/dL\\n 30 mEq/L\\n 3.4 mEq/L\\n 12 mg/dL\\n 108 mEq/L\\n 146 mEq/L\\n 26.0 %\\n 5.2 K/uL\\n [image002.jpg]\\n 08:11 PM\\n 02:51 AM\\n 03:10 AM\\n 03:08 PM\\n 03:00 AM\\n 03:36 AM\\n 04:40 PM\\n 03:00 AM\\n 07:05 PM\\n 03:00 AM\\n WBC\\n 9.4\\n 11.3\\n 7.3\\n 6.1\\n 7.2\\n 5.2\\n Hct\\n 26.6\\n 24.9\\n 27.6\\n 26.5\\n 26.9\\n 26.0\\n Plt\\n \\n Cr\\n 0.9\\n 0.7\\n 0.6\\n 0.6\\n 0.9\\n 0.7\\n 0.6\\n TCO2\\n 29\\n 26\\n Glucose\\n 128\\n 114\\n 114\\n 99\\n 115\\n 106\\n 100\\n Other labs: PT / PTT / INR:17.6/27.4/1.6, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:33/22, Alk Phos / T Bili:143/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:0.5 mmol/L,\\n Albumin:3.5 g/dL, LDH:199 IU/L, Ca++:8.9 mg/dL, Mg++:2.4 mg/dL, PO4:4.1\\n mg/dL\\n Assessment and Plan\\n 55yoF with history of EtOH abuse presenting following mechanical fall\\n and traumatic T spine fracture with K. oxytoca PNA, and ARDS, intubated\\n since the end of now s/p trach and PEG placement.\\n# Recent Aspiration on Tube Feeds. Cultures growing Klebsiella Oxytoca and Klebs\\niella Pneumoniae. Pt received developed rash on Levofloxacin, switched to Ceftri\\naxone overnight. Will treat for potential HAP for 8 days.\\n - Continue Ceftriaxone day #1.\\n - Tube Feeds restarted with goal of 60/hr\\n - Follow cultures\\n - check tube placement\\n .\\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\\n volume overload. Intubated on for resp decompensation. S/P Trach\\n and PEG on .\\n - Weaning FiO2 as tolerated\\n - Will attempt trach collar today\\n # Tachycardia: Pt in ST for most of the day 120\\ns to 140s. Etiology\\n remains unclear although she has been tachy since admission. Etiologies\\n include pain (especially when sitting upright with thoracic brace on),\\n infection (pt with known klebsiella, possibly acquired HAP). DDx also\\n includes PE, hyperthyroidism.\\n - Will keep pt\\ns INR therapeutic\\n - TSH 2.4 on early , will check free T3, T4.\\n - Continue Pain Control\\n - Treat underlying infection\\n # Sedation: Pt has pain/delirium causing tachycardia and hypertension\\n with intermittent hypotension. On Haldol 5 TID, Fentanyl 75 mcg TP,\\n Diazapam 10 QID; Haldol, midazolam and morphine PRN. Had good response\\n to morphine, minimal response to haldol bolus.\\n - tolerating current regimen well, no changes today\\n # Adrenal Insufficency: Hypotension that resolved with steroids,\\n returned as they came off and is now improved again. Possible primary\\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\\n started on .\\n - stopped steroids as per endocrine today\\n # Volume overloaded in prior setting of hypernatremia\\n Goal even\\n today.\\n - Monitoring urine output\\n # RUE DVT: INR was super-therapeutic on coumadin. Goal . Hasn\\n received coumadin in days yet INR continues to rise. Likely\\n contributors are nutritional and antibiotics.\\n - will start coumadin 2.5 mg QHS once INR < 3\\n # Spine fracture: Neurologically intact distal to the lesion. Prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - Brace for OOB\\n - Report from full trauma series from OSH is in chart.\\n - Pt to follow up with Dr. in weeks\\n # Tracheomalacia: Discussed with IP. Stenting unlikely to help for\\n trachiomalacia as airways have poor structure diffusely.\\n - Outpatient f/u once off pressure support to assess for possible\\n stenting\\n #. Thyroid Nodule on CT\\n - Outpatient follow up\\n # Nutrition: Replete (Full)\\n hold\\n # Glycemic control: SSI, well controlled\\n # Lines L PICC\\n ().\\n # Ppx: INR remains therapeutic, ranitidine, colace and senna, miralax,\\n bisacodyl.\\n # Communication:\\n - Boyfriend of 10 \\n - Brother also involved\\n Code: Full\\n Dispo: ICU, being screening for vent facilities\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 11:38 AM 50 mL/hour\\n Glycemic Control:\\n Lines:\\n PICC Line - 09:19 PM\\n 20 Gauge - 04:59 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 10:31 PM 50 mL/hour\\n Glycemic Control:\\n Lines:\\n PICC Line - 09:19 PM\\n 20 Gauge - 04:59 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-07 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 636133,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n EKG - At 11:53 PM for qrs\\n Continued to have alternating tachy and bradycadia with associated\\n pressure swings on adjusted pain regimen. Unable to diurese given\\n intermittant hypotension. Finally got one dose lasix.\\n Much more anxious than previous nights. Increased Valium back to 10 mg\\n QID.\\n CT showed cuff distention. Per respiratory, still has a leak, likely\\n needs a larger cuff.\\n Hypernatremia resolved, cut back on FWB\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Heparin Sodium - 1,500 units/hour\\n Other ICU medications:\\n Diazepam (Valium) - 02:00 AM\\n Furosemide (Lasix) - 03:56 AM\\n Haloperidol (Haldol) - 03:57 AM\\n Midazolam (Versed) - 05:11 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:03 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.6\\nC (99.6\\n Tcurrent: 37.1\\nC (98.7\\n HR: 124 (66 - 135) bpm\\n BP: 137/67(92) {74/35(48) - 150/81(106)} mmHg\\n RR: 15 (7 - 28) insp/min\\n SpO2: 94%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 3,707 mL\\n 723 mL\\n PO:\\n TF:\\n 1,457 mL\\n 364 mL\\n IVF:\\n 810 mL\\n 150 mL\\n Blood products:\\n Total out:\\n 2,535 mL\\n 2,760 mL\\n Urine:\\n 2,535 mL\\n 2,760 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,172 mL\\n -2,037 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: CPAP/PSV\\n Vt (Set): 400 (400 - 400) mL\\n Vt (Spontaneous): 964 (260 - 964) mL\\n PS : 12 cmH2O\\n RR (Set): 10\\n RR (Spontaneous): 8\\n PEEP: 8 cmH2O\\n FiO2: 50%\\n RSBI Deferred: Agitated\\n PIP: 21 cmH2O\\n SpO2: 94%\\n ABG: 7.41/53/86/32/6\\n Ve: 7.8 L/min\\n PaO2 / FiO2: 172\\n Physical Examination\\n General Appearance: Trached and sedated. Responsive, following\\n commands, Overweight / Obese, mild agitation but NAD\\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\\n deviation\\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\\n Cardiovascular: (S1: Normal), (S2: Normal), distant\\n Respiratory / Chest: (Expansion: Symmetric), CTA anteriorly, decreased\\n BS\\n Abdominal: Obese, Firm, Non-tender, no rebound, no guarding, + BS, PEG\\n in place with dressing C/D/I\\n Extremities: No clubbing or cyanosis, trace edema of b/l hands,\\n anasarca\\n Skin: no rashes or jaundice\\n Lines: r brachioceph ART with small amount of bloody drainage and L\\n PICC C/D/I\\n Labs / Radiology\\n 213 K/uL\\n 8.3 g/dL\\n 118 mg/dL\\n 0.6 mg/dL\\n 32 mEq/L\\n 3.5 mEq/L\\n 11 mg/dL\\n 108 mEq/L\\n 146 mEq/L\\n 27.4 %\\n 8.2 K/uL\\n [image002.jpg]\\n 02:47 AM\\n 11:01 AM\\n 04:40 PM\\n 05:08 PM\\n 03:44 AM\\n 06:04 AM\\n 09:09 AM\\n 05:07 PM\\n 03:31 AM\\n 03:46 AM\\n WBC\\n 11.2\\n 9.6\\n 8.2\\n Hct\\n 27.4\\n 25.3\\n 27.4\\n Plt\\n 272\\n 229\\n 213\\n Cr\\n 0.6\\n 0.6\\n 0.6\\n 0.8\\n 0.6\\n TCO2\\n 31\\n 34\\n 33\\n 32\\n 35\\n Glucose\\n 128\\n 138\\n 107\\n 121\\n 118\\n Other labs: PT / PTT / INR:18.4/68.9/1.7, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:13.1 %,\\n Mono:2.7 %, Eos:0.6 %, Lactic Acid:1.1 mmol/L, Albumin:2.4 g/dL,\\n LDH:204 IU/L, Ca++:9.0 mg/dL, Mg++:2.5 mg/dL, PO4:4.8 mg/dL\\n Assessment and Plan\\n 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA and\\n ARDS intubated since the end of now s/p trach and PEG placement.\\n Thyroid nodule on CT\\n Watch phos product\\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\\n volume overload. Intubated on for resp decompensation. Stenting\\n unlikely to help for trachiomalacia as airways have poor structure\\n diffusely. S/P Trach and PEG on . Increased effusion on recent\\n CXR.\\n - wean FiO2 as tolerated\\n # Adrenal Insufficency: Hypotension that resolved with steroids,\\n returned as they came off and is now improved again. Possible primary\\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\\n started on .\\n - wean per endo recs, decrease to 20q am and 10 q pm starting\\n tonight\\n will maintain this maintenance dose and check am cortisol\\n level one week later\\n # Volume overloaded in setting of hypernatremia with TBW deficit.\\n - Lasix gtt, continue with goal -1-2 L per day\\n currently off as\\n patient is somewhat hypotensive\\n will restart once/if BP increases and\\n remains stable for several hours\\n - electrolytes\\n - continue tube feeds with free water flushes 300 cc q4\\n # Sedation: Sedation control remains somewhat poor although fentanyl\\n patch and diazpem are likely therapeutic range today. On Versed 2.0,\\n Fentanyl 100, Fentanyl patch, Diazepam standing and haldo 2.5-5 mg\\n PRN. QTc increased to 480.\\n - Wean versed/fentanyl as tolerated, continue diazepam in\\n hopes for vent facility placement\\n - Change diazepam to 5mg q8 with haldol 5 mg q8\\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\\n coumadin at least until s/p trach.\\n - heparin gtt restarted\\n - coumadin 5mg G-tube today, INR in am\\n # Spine fracture: Neurologically intact distal to the lesion. Prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - CT of C, L spine when stable. Currently, unlikely to change\\n management and high risk for complications with transport.\\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\\n is low. Brace for OOB. Ok for anticoag per note.\\n -f/u full trauma spine eval from OSH to determine need for further back\\n imaging in-house (to be done )\\n # Nutrition: Tube feeds with free water flushes, tolerating well,\\n continue Replete (Full) - 11:20 AM 30 mL/hour\\n # Glycemic control: SSI, well controlled\\n # Lines L PICC () and R ART ()\\n similarly but will\\n keep in setting of hypotension\\n # Ppx: heparin drip until INR therapeutic for 2 days, ranitidine, VAP\\n prevention, colace and senna\\n # Communication:\\n - Boyfriend of 10 is her HCP. Also brother is involved\\n Code: Full\\n Dispo: ICU, being screening for vent facilities\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 01:39 AM 60 mL/hour\\n Glycemic Control:\\n Lines:\\n PICC Line - 09:19 PM\\n Arterial Line - 02:00 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-07 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 636259,\n \"text\": \"Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Altered mental status (not Delirium)\\n Assessment:\\n Following commands, but pt with flat affect most of the day. Does at\\n times nod to questions of pain. But does not see to understand what I\\n am telling her.\\n Action:\\n Tried to give pain meds for agitation today instead of the valium and\\n haldol which see to sedate her. Gave her 2 mg morphine\\n Response:\\n To 2 mg morhphine pt settles down just as well as when haldol and\\n valium are used, but it still seem to sedate her.\\n Plan:\\n Possibly cont to try pain med for agitation but give lower doses.\\n Hypernatremia (high sodium)\\n Assessment:\\n NA level 150\\n Action:\\n 300 ml flushes Q 4hr. free water.\\n Response:\\n Plan:\\n Draw AM labs and either increase or decrease flushes depending on NA\\n level\\n Hypotension (not Shock)\\n Assessment:\\n Hypotensive SBP in 80/40 when she is sleeping and or given\\n pain/sedation meds For her aggitaiton\\n Action:\\n Tried to give pt pain meds instead of the haldol and valium\\n Response:\\n 2mg of morphine sedates pt just as much but her BP doesn\\nt seem to drop\\n as low.\\n Plan:\\n Cont to try pain meds for agitation but give lower doses.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-07 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 636260,\n \"text\": \"Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Lung sounds clear, thick yellow secretions out of ET tube, O2 sats\\n 92-94 team aware.\\n Action:\\n Pt on MMV mode overnight, changed to CPAP this AM pt with metabolic\\n alkolosis ABG and diomox given, pt then weaned to CPAP .\\n Response:\\n Pt started desaturating into 87-89%, ABG 7.33/68/78, put pt back to\\n CPAP \\n Plan:\\n Possibly put pt back on MMV mode to rest for the night like last night\\n and wean again in the AM.\\n Altered mental status (not Delirium)\\n Assessment:\\n Following commands, but pt with flat affect most of the day. Does at\\n times nod to questions of pain. But does not see to understand what I\\n am telling her.\\n Action:\\n Tried to give pain meds for agitation today instead of the valium and\\n haldol which see to sedate her. Gave her 2 mg morphine\\n Response:\\n To 2 mg morhphine pt settles down just as well as when haldol and\\n valium are used, but it still seem to sedate her.\\n Plan:\\n Possibly cont to try pain med for agitation but give lower doses.\\n Hypernatremia (high sodium)\\n Assessment:\\n NA level 150\\n Action:\\n 300 ml flushes Q 4hr. free water.\\n Response:\\n Plan:\\n Draw AM labs and either increase or decrease flushes depending on NA\\n level\\n Hypotension (not Shock)\\n Assessment:\\n Hypotensive SBP in 80/40 when she is sleeping and or given\\n pain/sedation meds For her aggitaiton\\n Action:\\n Tried to give pt pain meds instead of the haldol and valium\\n Response:\\n 2mg of morphine sedates pt just as much but her BP doesn\\nt seem to drop\\n as low.\\n Plan:\\n Cont to try pain meds for agitation but give lower doses.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-04 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 635763,\n \"text\": \"55 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\\n Now with prolonged hospital course c/b by PNA with high PEEP\\n requirement, anxiety, RUE DVT on heparin qtt.\\n Edema, peripheral\\n Assessment:\\n Fluid balance for previous 24hrs decreased by 3 liters D/T diuresis.\\n Rec\\nd pt off of Lasix qtt. Urine output decreased to 45ml/hr @1000.\\n Action:\\n Lasix qtt restarted @ 2mg/hr to maintain urine output 1-2liters/day.\\n Response:\\n Fluid balance approx -50ml/hr, with 24hr fluid balance -650ml @ 1500.\\n However, SBP 78 when pt soundly sleeping/sedated. Lasix qtt stopped @\\n 1530.\\n Plan:\\n Restart Lasix qtt when BP stabilized.\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Rec\\nd pt on Heparin qtt @ 1500units/hr.\\n Action:\\n PTT 92.1 @ 1230.\\n Response:\\n Per goal PTT 60-100, Heparin rate unchanged.\\n Plan:\\n Repeat PTT @ 1830. Start po Coumadin tonight.\\n Altered mental status (not Delirium)\\n Assessment:\\n Rec\\nd pt on Versed @ 2mg/hr, Fentanyl @ 100mcg/hr, as well as Fentanyl\\n patches totaling 150mcg in place. Pt also rec\\ning Diazepam 10mg po\\n Q6hrs, in hope of weaning pt from IV sedation. Pt alternately appears\\n very sedated and very restless. When she appears alert, she intermit\\n responds to commands approp but not attempting to mouth words or nod to\\n communicate. Moving arms purposefully towards trach, so soft wrist\\n restraints remain in place. When very sedated @ 1530, SBP to 78 per\\n below.\\n Action:\\n Versed \\nd to 1mg/hr, Fentanyl \\nd to 75mcg/hr.\\n Response:\\n Pt restless/squirming in bed when she appears awake. Not responding to\\n verbal reassurance.\\n Plan:\\n Cont to attempt weaning from IV sedation. Cont to freq reorient pt,\\n emotional support.\\n Hypotension (not Shock)\\n Assessment:\\n VS generally stable with HR 68-123SR with occas PVC\\ns, BP\\n 122/65-144/76. However, when pt sleeping/sedated soundly @ 1530 SBP\\n remained in high 70\\n Action:\\n Sedation decreased per above, Lasix qtt stopped. Pt woken and turned\\n STS in bed.\\n Response:\\n VS returned to baseline, with BP presently 133/76.\\n Plan:\\n Restart Lasix qtt when BP stabilized WNL.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Rec\\nd pt on vent settings AC 55%/18 X 400/+10, with no over-breathing\\n of rate by pt. O2 sat 95-99%. ABG 7.44/42/93. Lung snds clear but\\n diminished in lower lobes. Suctionned for mod-lg amts thick white\\n secretions.\\n Action:\\n Vent changed to CMV with PS 8/+10 on 55%.\\n Response:\\n Pt tolerated PS approx 3hrs, but after rec\\ning scheduled dose Diazepam\\n @ 1200 began having extended pauses apnea. She was then returned to AC\\n 55%/9 X 500/+10.\\n Plan:\\n Cont wean from vent with PS trials, as well as \\ning FiO2.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-04 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 635764,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n Hydrocortisone decreased from 50 to 25 mg Q6 per endocrine recs.\\n Lasix drip turned off yesterday after 3L negative.\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Midazolam (Versed) - 3 mg/hour\\n Heparin Sodium - 1,700 units/hour\\n Fentanyl - 125 mcg/hour\\n Other ICU medications:\\n Ranitidine (Prophylaxis) - 09:00 AM\\n Midazolam (Versed) - 07:30 PM\\n Other medications:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:30 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.9\\nC (98.5\\n Tcurrent: 36.8\\nC (98.3\\n HR: 66 (50 - 131) bpm\\n BP: 103/46(65) {100/46(65) - 157/102(127)} mmHg\\n RR: 18 (15 - 21) insp/min\\n SpO2: 93%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 1,984 mL\\n 948 mL\\n PO:\\n TF:\\n 103 mL\\n 121 mL\\n IVF:\\n 747 mL\\n 277 mL\\n Blood products:\\n Total out:\\n 5,270 mL\\n 1,420 mL\\n Urine:\\n 5,270 mL\\n 1,420 mL\\n NG:\\n Stool:\\n 0\\n Drains:\\n Balance:\\n -3,286 mL\\n LOS + 10.5 L\\n -472 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 400 (400 - 400) mL\\n RR (Set): 18\\n RR (Spontaneous): 0\\n PEEP: 10 cmH2O\\n FiO2: 55%\\n RSBI Deferred: PEEP > 10\\n PIP: 25 cmH2O\\n Plateau: 14 cmH2O\\n Compliance: 100 cmH2O/mL\\n SpO2: 93%\\n ABG: 7.44/42/93/29\\n Ve: 6.8 L/min\\n Physical Examination\\n General Appearance: Intubated and sedated. Responsive, following some\\n commands, Overweight / Obese, mild agitation but NAD\\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\\n deviation\\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\\n Cardiovascular: (S1: Normal), (S2: Normal), distant\\n Respiratory / Chest: (Expansion: Symmetric), CTA anteriorly, decreased\\n BS\\n Abdominal: Obese, Firm, Non-tender, no rebound, no guarding, + BS, PEG\\n in place with dressing C/D/I\\n Extremities: No clubbing or cyanosis, 1+ nonpitting edema of b/l hands,\\n anasarca\\n Skin: no rashes or jaundice\\n Lines: r brachioceph ART and L PICC C/D/I\\n Labs / Radiology\\n 279 K/uL\\n 8.0 g/dL\\n 123 mg/dL\\n 0.5 mg/dL\\n 27 mEq/L\\n 3.6 mEq/L\\n 6 mg/dL\\n 109 mEq/L\\n 143 mEq/L\\n 24.6 %\\n 8.3 K/uL\\n [image002.jpg]\\n 04:10 PM\\n 12:13 AM\\n 05:08 AM\\n 05:20 AM\\n 05:17 PM\\n 11:41 PM\\n 03:06 AM\\n 03:38 AM\\n 04:05 PM\\n 03:55 AM\\n WBC\\n 11.2\\n 10.6\\n 10.0\\n 8.3\\n Hct\\n 27.1\\n 27.3\\n 25.8\\n 24.6\\n Plt\\n 79\\n Cr\\n 0.7\\n 0.5\\n 0.5\\n 0.6\\n 0.6\\n 0.5\\n TCO2\\n 36\\n 36\\n 32\\n 31\\n Glucose\\n 165\\n 143\\n 110\\n 94\\n 111\\n 106\\n 121\\n Other labs: PT / PTT / INR:15.9/107.7/1.4, Ca++:8.8 mg/dL, Mg++:3.1\\n mg/dL, PO4:4.2 mg/dL\\n No new culture data\\n Assessment and Plan\\n 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA and\\n ARDS intubated since the end of now s/p trach and PEG placement.\\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\\n volume overload. Intubated on for resp decompensation. Stenting\\n unlikely to help for trachiomalacia as airways have poor structure\\n diffusely. S/P Trach and PEG on .\\n - wean FiO2 today\\n # Adrenal Insufficency: Hypotension that resolved with steroids,\\n returned as they came off and is now improved again. Possible primary\\n adrenal insufficency. Appreciate endocrine recommendations. Halved\\n dose today.\\n - hydrocortt (day 1 = ), wean per endo recs\\n # Volume overloaded in setting of hypernatremia with TBW deficit.\\n - Lasix gtt, continue with goal -1-2 L per day.\\n - electrolytes\\n - continue tube feeds with free water flushes 250 cc q4\\n # Sedation: Sedation control remains somewhat poor although fentanyl\\n patch and diazpem are likely therapeutic range today. On Versed 2.0,\\n Fentanyl 100, Fentanyl patch, Diazepam standing and haldo 2.5-5 mg\\n PRN. QTc increased to 480.\\n - Wean versed/fentanyl as tolerated, continue diazepam. Avoid haldol\\n use if possible to avoid further prolongation of QTc\\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\\n coumadin at least until s/p trach.\\n - heparin gtt restarted\\n - coumadin 5mg G-tube today\\n # Constipation\\n current regimen of colace and senna, no BM over last\\n 24 hours\\n - dulcolax PO/PR today\\n - reassess and increase bowel regimen PRN\\n # Spine fracture: Neurologically intact distal to the lesion. Prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - CT of C, L spine when stable. Currently, unlikely to change\\n management and high risk for complications with transport.\\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\\n is low. Brace for OOB. Ok for anticoag per note.\\n -f/u full trauma spine eval from OSH to determine need for further back\\n imaging in-house (to be done )\\n # Nutrition: Tube feeds with free water flushes, tolerating well,\\n continue Replete (Full) - 11:20 AM 30 mL/hour\\n # Glycemic control: SSI, well controlled\\n # Lines L PICC () and R ART ()\\n both working well, mainitain\\n # Ppx: heparin, ranitidine, VAP prevention, colace and senna\\n # Communication:\\n - Boyfriend of 10 is her HCP. Also brother is involved\\n Code: Full\\n Dispo: ICU\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2167-10-05 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 635822,\n \"text\": \"TITLE:\\n Demographics\\n Day of mechanical ventilation: 17\\n Ideal body weight: 61.2 None\\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: Yes\\n Tracheostomy tube:\\n Type: Cuffed\\n Manufacturer: Portex\\n Size: 7.0mm\\n PMV:\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 28 cmH2O\\n Cuff volume: mL /\\n Airway problems:\\n Comments:\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Diminished\\n Comments:\\n Secretions\\n Sputum color / consistency: Yellow / Thick\\n Sputum source/amount: Suctioned / Scant\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance: A/C400x18/+10 peep/.5\\n Visual assessment of breathing pattern: Normal quiet breathing;\\n Comments: occ periods of agitation with increased rr\\n Assessment of breathing comfort: comf\\n Invasive ventilation assessment:\\n Trigger work assessment: Triggering synchronously\\n Dysynchrony assessment: none noted\\n Plan\\n Next 24-48 hours: Reduce PEEP as tolerated; Comments: periodic psv\\n trials for conditioning\\n Reason for continuing current ventilatory support: Intolerant of\\n weaning attempts\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-08 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 636337,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n ARTERIAL LINE - STOP 12:23 PM\\n ARTERIAL LINE - START 02:00 PM\\n A-line resited, not working again\\n tube feed machine not working\\n failed SBT - low MV with PSV - switched to MMV overnight\\n tachycardic to 140-142\\n Ortho spine ok with documented final read of CT trauma from attending\\n at OSH and week f/u - faxed request and spoke with med recs at\\n Medical re: sending report which was agreed upon.\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Heparin Sodium - 1,500 units/hour\\n Other ICU medications:\\n Morphine Sulfate - 12:15 PM\\n Midazolam (Versed) - 03:50 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:13 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.5\\nC (99.5\\n Tcurrent: 37.1\\nC (98.8\\n HR: 105 (70 - 148) bpm\\n BP: 85/55(66) {85/41(57) - 158/110(323)} mmHg\\n RR: 23 (10 - 31) insp/min\\n SpO2: 95%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 3,562 mL\\n 965 mL\\n PO:\\n TF:\\n 1,685 mL\\n 150 mL\\n IVF:\\n 548 mL\\n 215 mL\\n Blood products:\\n Total out:\\n 5,695 mL\\n 1,740 mL\\n Urine:\\n 5,695 mL\\n 1,740 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -2,133 mL\\n -775 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: CPAP/PSV\\n Vt (Set): 400 (400 - 400) mL\\n Vt (Spontaneous): 359 (137 - 695) mL\\n PS : 8 cmH2O\\n RR (Set): 10\\n RR (Spontaneous): 26\\n PEEP: 8 cmH2O\\n FiO2: 50%\\n RSBI: 58\\n PIP: 16 cmH2O\\n SpO2: 95%\\n ABG: 7.40/49/114/32/3\\n Ve: 7.2 L/min\\n PaO2 / FiO2: 228\\n Physical Examination\\n General Appearance: Trached and sedated. Responsive, following\\n commands, Overweight / Obese, mild agitation but NAD\\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\\n deviation\\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\\n Cardiovascular: (S1: Normal), (S2: Normal), distant\\n Respiratory / Chest: (Expansion: Symmetric), CTA anteriorly, decreased\\n BS\\n Abdominal: Obese, soft, Non-tender, no rebound, no guarding, + BS, PEG\\n in place with dressing C/D/I\\n Extremities: no CCE\\n Skin: no rashes or jaundice\\n Lines: r brachioceph ART with large amount of bloody drainage and L\\n PICC C/D/I\\n Labs / Radiology\\n 213 K/uL\\n 8.8 g/dL\\n 123 mg/dL\\n 0.6 mg/dL\\n 32 mEq/L\\n 3.6 mEq/L\\n 13 mg/dL\\n 107 mEq/L\\n 145 mEq/L\\n 29.4 %\\n 11.1 K/uL\\n [image002.jpg]\\n 03:44 AM\\n 06:04 AM\\n 09:09 AM\\n 05:07 PM\\n 03:31 AM\\n 03:46 AM\\n 10:20 AM\\n 03:46 PM\\n 01:37 AM\\n 05:32 AM\\n WBC\\n 9.6\\n 8.2\\n 11.1\\n Hct\\n 25.3\\n 27.4\\n 29.4\\n Plt\\n \\n Cr\\n 0.6\\n 0.8\\n 0.6\\n 0.8\\n 0.6\\n TCO2\\n 33\\n 32\\n 35\\n 37\\n 31\\n Glucose\\n 107\\n 121\\n 118\\n 155\\n 123\\n Other labs: PT / PTT / INR:22.3/69.7/2.1, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:13.1 %,\\n Mono:2.7 %, Eos:0.6 %, Lactic Acid:1.1 mmol/L, Albumin:2.4 g/dL,\\n LDH:204 IU/L, Ca++:9.2 mg/dL, Mg++:2.5 mg/dL, PO4:4.1 mg/dL\\n Assessment and Plan\\n 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA and\\n ARDS intubated since the end of now s/p trach and PEG placement.\\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\\n volume overload. Intubated on for resp decompensation. Stenting\\n unlikely to help for trachiomalacia as airways have poor structure\\n diffusely. S/P Trach and PEG on .\\n - wean FiO2 as tolerated\\n - attempt wean PS today and hopeful for trach mask trial\\n # Adrenal Insufficency: Hypotension that resolved with steroids,\\n returned as they came off and is now improved again. Possible primary\\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\\n started on .\\n - wean per endo recs, decrease to 20q am and 10 q pm today\\n - ok to go to 10 q am and 5 q pm tomorrow ()\\n # Volume overloaded in setting of hypernatremia with TBW deficit and\\n metabolic alkalosis\\n - Lasix boluses with diamox today\\n - electrolytes\\n - continue tube feeds with free water flushes 300 cc q4\\n # Sedation: Sedation control remains somewhat poor although fentanyl\\n patch and diazpem are likely therapeutic range today. On Versed 2.0,\\n Fentanyl 100, Fentanyl patch, Diazepam standing and haldo 2.5-5 mg\\n PRN. QTc increased to 480.\\n - Wean versed/fentanyl as tolerated, continue diazepam in\\n hopes for vent facility placement\\n - Continue diazepam 10 mg q8 with haldol 5 mg q8 with 2.5-5\\n prn haldol\\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\\n coumadin at least until s/p trach. INR 1.7 today.\\n - heparin gtt restarted\\n - coumadin 5mg G-tube today, INR in am\\n # Spine fracture: Neurologically intact distal to the lesion. Prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - CT of C, L spine when stable. Currently, unlikely to change\\n management and high risk for complications with transport.\\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\\n is low. Brace for OOB. Ok for anticoag per note.\\n -f/u full trauma spine eval from OSH to determine need for further back\\n imaging in-house (to be done )\\n #. Thyroid Nodule on CT\\n -outpatient follow up\\n # Nutrition: Tube feeds with free water flushes, tolerating well,\\n continue Replete (Full) - 11:20 AM 30 mL/hour\\n # Glycemic control: SSI, well controlled\\n # Lines L PICC () and R ART ()\\n d/c art and re-site today\\n # Ppx: heparin drip until INR therapeutic for 2 days, ranitidine, VAP\\n prevention, colace and senna\\n # Communication:\\n - Boyfriend of 10 is her HCP. Also brother is involved\\n Code: Full\\n Dispo: ICU, being screening for vent facilities\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n PICC Line - 09:19 PM\\n Arterial Line - 02:00 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-09 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 636607,\n \"text\": \"Event: Pt had a stable day and was OOB for 4 hrs. VSS throughout the\\n day.\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Pt has a clot to RUE and was taken off heparin gtt . inr this am\\n 4.4. No signs of bleeding noted.\\n Action:\\n No interventions done at this time.\\n Response:\\n Plan:\\n F/U coags.\\n Hypernatremia (high sodium)\\n Assessment:\\n Na level increased this am from 140 to 145.\\n Action:\\n H2O flushes DC\\nd NPO and started on D5 IVF at 100 cc/hr x 1 lliter.\\n Response:\\n Plan:\\n Follow up Na level in am.\\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\\n Assessment:\\n Pt has been Afebrile throughout the day. IV ABXs to continue for 48hrs\\n until cultures back.\\n Action:\\n No actions done. WBC now WNLs.\\n Response:\\n Plan:\\n Follow up cultures.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n LA this am very coarse and was sx\\nd for copious amounts of thick tan\\n secretions. Aggressive pulm toilet done and resp status improved\\n throughout the day. LS now CTA and pt is being deep sx\\nd for scant\\n amounts of yellow secretions. Pt placed on CPAP this am and weaned down\\n to 50/5/5 and was placed on TC. Pt tol it for 2 hrs and was then placed\\n back on CPAP. Pt in need of freq oral care for copious amounts of\\n clear-white secretions.\\n Action:\\n As noted above.\\n Response:\\n Resp status has improved.\\n Plan:\\n Continue aggressive oral care and pulm toilet and wean vent as tol.\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt found this am to be very awake and follows commands. Pt able to have\\n eye contact and tracking people. = strength. Pt noted to have some\\n restlessness at times, but no prn meds needed.\\n Action:\\n Pt given MSo4 for pain while she was OOB in brace with good effect.\\n Response:\\n Plan:\\n Continue to eval MS.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-10 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 636689,\n \"text\": \"55 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\\n Now with prolonged hospital course c/b by PNA with high PEEP\\n requirement, anxiety, RUE DVT .\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt more alert, following commands intermittently. Periods of agitation\\n with HR rising to 130\\n Action:\\n Fentanyl patch in place. Valium RTC. MSO4 given x 2 for discomfort.\\n Response:\\n Pt with less episodes of agitation previously. ? steroid psychosis.\\n Plan:\\n Check cortisol level in am and wean hydrocortisone MD. Continue to\\n reorient pt. MSO4 prn for discomfort.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Received pt on PSV 8/5/50%.RR 19-24. Tidal volumes 200-250. 02 sats\\n variable 90-100%. LS rhoncherous to clear, diminished at bases.\\n Action:\\n Pt maintained at current settings given reduced tv\\ns and sats. Orally\\n suctioned q 2 hrs for copious secretions. Deep suctioned q 3-4 hrs for\\n sm amt thick white secretions.\\n Response:\\n ABG 7.37/40/120/0/26 on PSV. At 0530 pt hypoventilating with RR 4-6,\\n changed to AC mode of ventilation (500x 12 x 5 50%)\\n Plan:\\n Attempt PSV again this am. Pulm hygiene.\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Pt with RUE DVT. Heparin dcd on .\\n Action:\\n Coags being monitored. INR 4.4 yest. Hct was falling.\\n Response:\\n Hct 26.5 today, previously 27.6. INR pend.\\n Plan:\\n Coumadin to be started when INR < 3\\n Hypernatremia (high sodium)\\n Assessment:\\n Na 140. Pt volume overloaded. LOS + ~10,000ccs.\\n Action:\\n Treated with 1 liter d5w iv.\\n Response:\\n Urine output 120-400ccs/hr via foley. TFB neg 100cc. Na 145. Goal ~\\n even fluid balance.\\n Plan:\\n Continue to monitor f+e status.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-03 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 635586,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n # To OR for Peg and Trach placement\\n # Desatted in the evening to 84%, increased PEEP and FiO2\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Furosemide (Lasix) - 2 mg/hour\\n Fentanyl - 100 mcg/hour\\n Midazolam (Versed) - 2 mg/hour\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:10 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.3\\nC (99.2\\n Tcurrent: 36.4\\nC (97.6\\n HR: 111 (44 - 133) bpm\\n BP: 127/63(90) {90/46(63) - 165/89(123)} mmHg\\n RR: 18 (15 - 24) insp/min\\n SpO2: 93%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 2,751 mL\\n 534 mL\\n PO:\\n TF:\\n 17 mL\\n IVF:\\n 1,834 mL\\n 84 mL\\n Blood products:\\n Total out:\\n 6,600 mL\\n 950 mL\\n Urine:\\n 6,600 mL\\n 950 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -3,849 mL\\n -416 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 400 (400 - 400) mL\\n RR (Set): 18\\n RR (Spontaneous): 0\\n PEEP: 10 cmH2O\\n FiO2: 60%\\n RSBI Deferred: PEEP > 10, FiO2 > 60%\\n PIP: 23 cmH2O\\n Plateau: 25 cmH2O\\n SpO2: 93%\\n ABG: 7.45/43/81./29/4\\n Ve: 7.6 L/min\\n PaO2 / FiO2: 137\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 256 K/uL\\n 7.8 g/dL\\n 106 mg/dL\\n 0.6 mg/dL\\n 29 mEq/L\\n 4.1 mEq/L\\n 7 mg/dL\\n 110 mEq/L\\n 144 mEq/L\\n 25.8 %\\n 10.0 K/uL\\n [image002.jpg]\\n 03:00 AM\\n 10:47 AM\\n 04:10 PM\\n 12:13 AM\\n 05:08 AM\\n 05:20 AM\\n 05:17 PM\\n 11:41 PM\\n 03:06 AM\\n 03:38 AM\\n WBC\\n 8.6\\n 11.2\\n 10.6\\n 10.0\\n Hct\\n 25.9\\n 27.1\\n 27.3\\n 25.8\\n Plt\\n 280\\n 306\\n 321\\n 256\\n Cr\\n 0.5\\n 0.7\\n 0.5\\n 0.5\\n 0.6\\n TCO2\\n 34\\n 36\\n 36\\n 32\\n 31\\n Glucose\\n 136\\n 165\\n 143\\n 110\\n 94\\n 111\\n 106\\n Other labs: PT / PTT / INR:13.6/24.4/1.2, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:13.1 %,\\n Mono:2.7 %, Eos:0.6 %, Lactic Acid:0.9 mmol/L, Albumin:2.4 g/dL,\\n LDH:204 IU/L, Ca++:8.4 mg/dL, Mg++:2.5 mg/dL, PO4:3.8 mg/dL\\n Assessment and Plan\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n PICC Line - 09:19 PM\\n Arterial Line - 02:00 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-03 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 635587,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n # To OR for Peg and Trach placement\\n # Desatted in the evening to 84%, increased PEEP and FiO2\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Furosemide (Lasix) - 2 mg/hour\\n Fentanyl - 100 mcg/hour\\n Midazolam (Versed) - 2 mg/hour\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:10 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.3\\nC (99.2\\n Tcurrent: 36.4\\nC (97.6\\n HR: 111 (44 - 133) bpm\\n BP: 127/63(90) {90/46(63) - 165/89(123)} mmHg\\n RR: 18 (15 - 24) insp/min\\n SpO2: 93%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 2,751 mL\\n 534 mL\\n PO:\\n TF:\\n 17 mL\\n IVF:\\n 1,834 mL\\n 84 mL\\n Blood products:\\n Total out:\\n 6,600 mL\\n 950 mL\\n Urine:\\n 6,600 mL\\n 950 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -3,849 mL\\n -416 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 400 (400 - 400) mL\\n RR (Set): 18\\n RR (Spontaneous): 0\\n PEEP: 10 cmH2O\\n FiO2: 60%\\n RSBI Deferred: PEEP > 10, FiO2 > 60%\\n PIP: 23 cmH2O\\n Plateau: 25 cmH2O\\n SpO2: 93%\\n ABG: 7.45/43/81./29/4\\n Ve: 7.6 L/min\\n PaO2 / FiO2: 137\\n Physical Examination\\n General Appearance: Responsive, following commands, Overweight / Obese,\\n NAD\\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\\n deviation\\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\\n Cardiovascular: (S1: Normal), (S2: Normal), distant\\n Respiratory / Chest: (Expansion: Symmetric), referred breath sounds\\n from ETT, mild rhonchi diffusely\\n Abdominal: Obese, Soft, Non-tender, no rebound, no guarding\\n Extremities: No clubbing or cyanosis, + nonpitting edema of b/l\\n hands, anasarca\\n Skin: no rashes or jaundice\\n Neuro: alert. Strength 4/5 upper and lower extremeties, light touch\\n sensation intact bil.\\n Lines: r brachioceph ART and L PICC C/D/I\\n Labs / Radiology\\n 256 K/uL\\n 7.8 g/dL\\n 106 mg/dL\\n 0.6 mg/dL\\n 29 mEq/L\\n 4.1 mEq/L\\n 7 mg/dL\\n 110 mEq/L\\n 144 mEq/L\\n 25.8 %\\n 10.0 K/uL\\n [image002.jpg]\\n 03:00 AM\\n 10:47 AM\\n 04:10 PM\\n 12:13 AM\\n 05:08 AM\\n 05:20 AM\\n 05:17 PM\\n 11:41 PM\\n 03:06 AM\\n 03:38 AM\\n WBC\\n 8.6\\n 11.2\\n 10.6\\n 10.0\\n Hct\\n 25.9\\n 27.1\\n 27.3\\n 25.8\\n Plt\\n 280\\n 306\\n 321\\n 256\\n Cr\\n 0.5\\n 0.7\\n 0.5\\n 0.5\\n 0.6\\n TCO2\\n 34\\n 36\\n 36\\n 32\\n 31\\n Glucose\\n 136\\n 165\\n 143\\n 110\\n 94\\n 111\\n 106\\n Other labs: PT / PTT / INR:13.6/24.4/1.2, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:13.1 %,\\n Mono:2.7 %, Eos:0.6 %, Lactic Acid:0.9 mmol/L, Albumin:2.4 g/dL,\\n LDH:204 IU/L, Ca++:8.4 mg/dL, Mg++:2.5 mg/dL, PO4:3.8 mg/dL\\n Assessment and Plan\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n PICC Line - 09:19 PM\\n Arterial Line - 02:00 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-03 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 635588,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n # To OR for Peg and Trach placement\\n # Desatted in the evening to 84%, increased PEEP and FiO2\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Furosemide (Lasix) - 2 mg/hour\\n Fentanyl - 100 mcg/hour\\n Midazolam (Versed) - 2 mg/hour\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:10 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.3\\nC (99.2\\n Tcurrent: 36.4\\nC (97.6\\n HR: 111 (44 - 133) bpm\\n BP: 127/63(90) {90/46(63) - 165/89(123)} mmHg\\n RR: 18 (15 - 24) insp/min\\n SpO2: 93%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 2,751 mL\\n 534 mL\\n PO:\\n TF:\\n 17 mL\\n IVF:\\n 1,834 mL\\n 84 mL\\n Blood products:\\n Total out:\\n 6,600 mL\\n 950 mL\\n Urine:\\n 6,600 mL\\n 950 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -3,849 mL\\n -416 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 400 (400 - 400) mL\\n RR (Set): 18\\n RR (Spontaneous): 0\\n PEEP: 10 cmH2O\\n FiO2: 60%\\n RSBI Deferred: PEEP > 10, FiO2 > 60%\\n PIP: 23 cmH2O\\n Plateau: 25 cmH2O\\n SpO2: 93%\\n ABG: 7.45/43/81./29/4\\n Ve: 7.6 L/min\\n PaO2 / FiO2: 137\\n Physical Examination\\n General Appearance: Responsive, following commands, Overweight / Obese,\\n NAD\\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\\n deviation\\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\\n Cardiovascular: (S1: Normal), (S2: Normal), distant\\n Respiratory / Chest: (Expansion: Symmetric), referred breath sounds\\n from ETT, mild rhonchi diffusely\\n Abdominal: Obese, Soft, Non-tender, no rebound, no guarding\\n Extremities: No clubbing or cyanosis, + nonpitting edema of b/l\\n hands, anasarca\\n Skin: no rashes or jaundice\\n Neuro: alert. Strength 4/5 upper and lower extremeties, light touch\\n sensation intact bil.\\n Lines: r brachioceph ART and L PICC C/D/I\\n Labs / Radiology\\n 256 K/uL\\n 7.8 g/dL\\n 106 mg/dL\\n 0.6 mg/dL\\n 29 mEq/L\\n 4.1 mEq/L\\n 7 mg/dL\\n 110 mEq/L\\n 144 mEq/L\\n 25.8 %\\n 10.0 K/uL\\n [image002.jpg]\\n 03:00 AM\\n 10:47 AM\\n 04:10 PM\\n 12:13 AM\\n 05:08 AM\\n 05:20 AM\\n 05:17 PM\\n 11:41 PM\\n 03:06 AM\\n 03:38 AM\\n WBC\\n 8.6\\n 11.2\\n 10.6\\n 10.0\\n Hct\\n 25.9\\n 27.1\\n 27.3\\n 25.8\\n Plt\\n 280\\n 306\\n 321\\n 256\\n Cr\\n 0.5\\n 0.7\\n 0.5\\n 0.5\\n 0.6\\n TCO2\\n 34\\n 36\\n 36\\n 32\\n 31\\n Glucose\\n 136\\n 165\\n 143\\n 110\\n 94\\n 111\\n 106\\n Other labs: PT / PTT / INR:13.6/24.4/1.2, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:13.1 %,\\n Mono:2.7 %, Eos:0.6 %, Lactic Acid:0.9 mmol/L, Albumin:2.4 g/dL,\\n LDH:204 IU/L, Ca++:8.4 mg/dL, Mg++:2.5 mg/dL, PO4:3.8 mg/dL\\n Assessment and Plan\\n Assessment and Plan\\n 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA and\\n ARDS intubated since the end of .\\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\\n volume overload. Intubated on for resp decompensation.\\n Transferred here for airway stenting.\\n - attempt SBT yesterday. Failed.\\n -To OR today , add-on for trach and PEG with Dr. (tube feeds\\n off after MN, heparin off after 6am)\\n - Repeat CXR in PM post trach.\\n ## Adrenal Insufficency: Minimal response to stim test again.\\n Appreciate endocrine recommendations.\\n - hydrocort and fludrocort (day 1 = )\\n - will continue at current dose until s/p trach and PEG and\\n hemodynamically stable for 24 hours\\n will then plan to taper\\n hydrocortisone to 25mg IV q6 with a slow taper\\n - f/u daily endocrine recs\\n - Endocrine recs: d/c Fludrocort. Continue Hydrocort for now.\\n # Hypotension: Likely adrenal insufficiency and sedation. Goal map\\n > 60. Much improved since re-administration of steroids.\\n - hydrocortisone as above\\n - restart levophed if necessary to maintain MAP > 60\\n # Volume overloaded in setting of hypernatremia with TBW deficit.\\n - goal -1000cc I/Os yesterday, was -1500cc for last 24 hours.\\n - continue FW in TF at 250 cc q4hrs\\n - lasix drip (1-5mg/hr) held before surgery, will restart when returns\\n to MICU.\\n - may have some contraction alkalosis, w/ rising pH and bicarb. Start\\n Diamox 500mg TID to decrease bicarb and pH and may improve respiratory\\n drive.\\n # Sedation: Sedation control remains somewhat poor although fentanyl\\n patch and diazpem are likely therapeutic range today. On Versed 2.0,\\n Fentanyl 100, Fentanyl patch, Diazepam standing and haldo 2.5-5 mg\\n PRN. QTc increased to 480.\\n - Wean versed/fentanyl as tolerated, continue diazepam. Avoid haldol\\n use if possible to avoid further prolongation of QTc\\n - Will reassess sedation/agitation after PEG/Trach.\\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\\n coumadin at least until s/p trach.\\n - hold heparin gtt when anticipate trach/peg\\n - will restart heparin gtt per recs from surgery post-op\\n # Spine fracture: Neurologically intact distal to the lesion. Prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - CT of C, L spine when stable. Currently, unlikely to change\\n management and high risk for complications with transport.\\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\\n is low. Brace for OOB. Ok for anticoag per note.\\n # FEN/GI: Tube feeds with FWF @ goal.\\n -held for surgery. Will restart based on post-op recs after PEG\\n placement.\\n DVT: Treatment dose heparin, holding until post-op recs from PEG/Trach\\n Ulcer: Ranitidine\\n VAP: Prevention per routine\\n # Access: L PICC line, and R brachial a-line\\n # Communication:\\n - Boyfriend of 10 is her HCP. Also brother is involved\\n - touch base with SW today\\n Code: Full\\n Dispo: ICU\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n PICC Line - 09:19 PM\\n Arterial Line - 02:00 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-04 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 635759,\n \"text\": \"55 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\\n Now with prolonged hospital course c/b by PNA with high PEEP\\n requirement, anxiety, RUE DVT on heparin qtt.\\n Edema, peripheral\\n Assessment:\\n Fluid balance for previous 24hrs decreased by 3 liters D/T diuresis.\\n Rec\\nd pt off of Lasix qtt. Urine output decreased to 45ml/hr @1000.\\n Action:\\n Lasix qtt restarted @ 2mg/hr to maintain urine output 1-2liters/day.\\n Response:\\n Fluid balance approx -50ml/hr, with 24hr fluid balance -650ml @ 1500.\\n However, SBP 78 when pt soundly sleeping/sedated. Lasix qtt stopped @\\n 1530.\\n Plan:\\n Restart Lasix qtt when BP stabilized.\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Rec\\nd pt on Heparin qtt @ 1500units/hr.\\n Action:\\n PTT 92.1 @ 1230.\\n Response:\\n Per goal PTT 60-100, Heparin rate unchanged.\\n Plan:\\n Repeat PTT @ 1830. Start po Coumadin tonight.\\n Altered mental status (not Delirium)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Hypotension (not Shock)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2167-10-07 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 636126,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 19\\n Ideal body weight: 61.2 None\\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: Yes\\n Tube Type\\n Tracheostomy tube:\\n Type: Cuffed, Extra Length\\n Manufacturer: Portex\\n Size: 7.0mm\\n PMV: No\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 28 cmH2O\\n Lung sounds\\n RLL Lung Sounds: Rhonchi\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Rhonchi\\n Secretions\\n Sputum color / consistency: White / Thick\\n Sputum source/amount: Suctioned / Small\\n Ventilation Assessment\\n Level of breathing assistance: Continuous invasive ventilation\\n Visual assessment of breathing pattern: Placed on MMV for constant LMV\\n alarms/apnea. Weaned PEEp to ~8cmH20.\\n Invasive ventilation assessment:\\n Trigger work assessment: Frequent failed trigger efforts\\n Dysynchrony assessment: Frequent alarms (Low min. ventilation)\\n Comments:\\n Plan\\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\\n Comments: rsbi deffered for agitation, req sedation\\n Reason for continuing current ventilatory support: Sedated / Paralyzed\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-07 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 636127,\n \"text\": \"55 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\\n Now with prolonged hospital course c/b by PNA with high PEEP\\n requirement, anxiety, RUE DVT on heparin qtt.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Lungs clear bilat upper lobes and diminished bilat bases with\\n occasional scattered rhonchi, prod cough thick yellow/tan sputum, trach\\n sx for mod. Amt of same, tolerated CPAP+PS until fell asleep and then\\n RR down to 4-5 breaths with MV down to 1-5. Placed on MMV for\\n remainder of night with good effect.\\n Action:\\n Vent changed from CPAP+PS to MMV overnight and weaned back to CPAP+PS\\n this am, Peep decreased to 8cm. Freq. pulmonary toileting, diuresing\\n with 40mg. IV Lasix dose\\n Response:\\n Tolerating slow vent wean, requiring pulmonary toileting, good diuresis\\n in attempt to wean vent further\\n Plan:\\n Attempt to wean PS and FI02 down further today as tolerated, may need\\n MMV mode at night or when sedated, Continue aggressive pulmonary\\n toileting, Diurese as tolerated.\\n Altered mental status (not Delirium)\\n Assessment:\\n Increased agitation throughout night with pt writhing in bed and\\n attempting to get OOB and attempting to pull at all lines and tubes,\\n makes eye contact and follows commands but doesn\\nt stay calm for long,\\n HR up to 130- with agitation and BP up to 130-150\\ns/60-70\\n received valium and Haldol as ordered with prn dosing in between\\n scheduled doses with poor effect, received 4 mg. Iv versed with poor\\n effect, appears generally uncomfortable but denies pain when asked.\\n Action:\\n Freq. attempts to reorient and calm pt, Valium 5mg x 2 with no effect,\\n Haldol 5mg po and additional 1 mg. IV with no effect, Versed 4 mg. with\\n no effect, stimulation decreased, bilat soft wrist restraints to\\n prevent pt from pulling at lines and tubes\\n Response:\\n Increased agitation off of continuous IV sedation, poor effect from\\n current medical regime, MICU team aware and addressing\\n Plan:\\n Valium dose to be increased, Potential head CT today, obtain psych and\\n neuro consults if pt\\ns mental status doesn\\nt improve\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-07 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 636128,\n \"text\": \"55 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\\n Now with prolonged hospital course c/b by PNA with high PEEP\\n requirement, anxiety, RUE DVT on heparin qtt.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Lungs clear bilat upper lobes and diminished bilat bases with\\n occasional scattered rhonchi, prod cough thick yellow/tan sputum, trach\\n sx for mod. Amt of same, tolerated CPAP+PS until fell asleep and then\\n RR down to 4-5 breaths with MV down to 1-5. Placed on MMV for\\n remainder of night with good effect.\\n Action:\\n Vent changed from CPAP+PS to MMV overnight and weaned back to CPAP+PS\\n this am, Peep decreased to 8cm. Freq. pulmonary toileting, diuresing\\n with 40mg. IV Lasix dose\\n Response:\\n Tolerating slow vent wean, ABG: 7.41-53-86, requiring pulmonary\\n toileting, good diuresis in attempt to wean vent further\\n Plan:\\n Attempt to wean PS and FI02 down further today as tolerated, may need\\n MMV mode at night or when sedated, Continue aggressive pulmonary\\n toileting, Diurese as tolerated.\\n Altered mental status (not Delirium)\\n Assessment:\\n Increased agitation throughout night with pt writhing in bed and\\n attempting to get OOB and attempting to pull at all lines and tubes,\\n makes eye contact and follows commands but doesn\\nt stay calm for long,\\n HR up to 130- with agitation and BP up to 130-150\\ns/60-70\\n received valium and Haldol as ordered with prn dosing in between\\n scheduled doses with poor effect, received 4 mg. Iv versed with poor\\n effect, appears generally uncomfortable but denies pain when asked.\\n Action:\\n Freq. attempts to reorient and calm pt, Valium 5mg x 2 with no effect,\\n Haldol 5mg po and additional 1 mg. IV with no effect, Versed 4 mg. with\\n no effect, stimulation decreased, bilat soft wrist restraints to\\n prevent pt from pulling at lines and tubes\\n Response:\\n Increased agitation off of continuous IV sedation, poor effect from\\n current medical regime, MICU team aware and addressing\\n Plan:\\n Valium dose to be increased, Potential head CT today, obtain psych and\\n neuro consults if pt\\ns mental status doesn\\nt improve\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-08 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 636428,\n \"text\": \"Alteration in Nutrition\\n Assessment:\\n Abd dist, soft with hypoactive BS. No BM on this shift.\\n Action:\\n TF restarted at goal at 60 cc/hr with minimal residuals.\\n Response:\\n Plan:\\n Follow FSBS. ? adding more laxatives until BM.\\n Fracture, other\\n Assessment:\\n Pt out of bed in stretcher chair with brace in place most of day. Pt\\n did very well.\\n Action:\\n Pt tol being OOb well in regards to resp status and MS.\\n Response:\\n Plan:\\n Plan to take pt OOB to cahir tomorrow also.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt remains on vent via trach in CPAP+PS at 50 %/. LS CTA with\\n diminished bases. Pt has been deep sx\\nd for sml amounts of tan to thick\\n yellow secretions.\\n Action:\\n Vent changed to 5/5, but was only tolerated for 1 hr.\\n Response:\\n After 1 hr pt became tachycardic and tachypnic. O2sat decreased to 95%.\\n Plan:\\n Continue to wean vent settings as tolerated. Plan to IP to follow up\\n regarding ? need for stent tomorrow.\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt opens eyes to voice, but will only follow simple commands very\\n inconsistently. Pt is very lethargic. Pt found this am to be very\\n restless and given versed with no effect.\\n Action:\\n After pt placed in a chair, and pt more relaxed. Pt was calm, but her\\n HR was in the 120-130\\ns (while awake). Pt given Morphine with good\\n effect. Fentanyl patches weaned down to 100 mcg.\\n Response:\\n Plan:\\n Continue to eval restlessness.\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Pt was on heparin gtt for clot to Rt upper arm. Inr 2.1 . No signs of\\n any bleeding.\\n Action:\\n Heparin was dc\\nd this am.\\n Response:\\n Plan:\\n ? coumadin tonight. Continue to eval for bleeding.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-08 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 636430,\n \"text\": \"Alteration in Nutrition\\n Assessment:\\n Abd dist, soft with hypoactive BS. No BM on this shift.\\n Action:\\n TF restarted at goal at 60 cc/hr with minimal residuals.\\n Response:\\n Plan:\\n Follow FSBS. ? adding more laxatives until BM.\\n Fracture, other\\n Assessment:\\n Pt out of bed in stretcher chair with brace in place most of day. Pt\\n did very well.\\n Action:\\n Pt tol being OOb well in regards to resp status and MS.\\n Response:\\n Plan:\\n Plan to take pt OOB to cahir tomorrow also.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt remains on vent via trach in CPAP+PS at 50 %/. LS CTA with\\n diminished bases. Pt has been deep sx\\nd for sml amounts of tan to thick\\n yellow secretions.\\n Action:\\n Vent changed to 5/5, but was only tolerated for 1 hr.\\n Response:\\n After 1 hr pt became tachycardic and tachypnic. O2sat decreased to 95%.\\n Plan:\\n Continue to wean vent settings as tolerated. Plan to IP to follow up\\n regarding ? need for stent tomorrow.\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt opens eyes to voice, but will only follow simple commands very\\n inconsistently. Pt is very lethargic. Pt found this am to be very\\n restless and given versed with no effect.\\n Action:\\n After pt placed in a chair, and pt more relaxed. Pt was calm, but her\\n HR was in the 120-130\\ns (while awake). Pt given Morphine with good\\n effect. Fentanyl patches weaned down to 100 mcg.\\n Response:\\n Plan:\\n Continue to eval restlessness.\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Pt was on heparin gtt for clot to Rt upper arm. Inr 2.1 . No signs of\\n any bleeding.\\n Action:\\n Heparin was dc\\nd this am.\\n Response:\\n Plan:\\n ? coumadin tonight. Continue to eval for bleeding.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-09 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 636500,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Arterial line d/c'd\\n Spiked a fever of 101.4, blood and urine cultures sent, CXR. Started\\n Vanc, Levo, Aztreonam\\n Persistently hypotensive to 70s SBP overnight with low urine output and\\n poor O2 sats.\\n Started on Levophed, and given 1.75L NS. BPs improved to 90-120s SBP,\\n and urine output increased significantly.\\n Large amount of oral secretions, ?gastric in origin\\n Tube feeds held for ? of aspiration.\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Vancomycin - 11:00 PM\\n Levofloxacin - 11:43 PM\\n Aztreonam - 04:07 AM\\n Infusions:\\n Norepinephrine - 0.03 mcg/Kg/min\\n Other ICU medications:\\n Midazolam (Versed) - 09:30 AM\\n Morphine Sulfate - 03:17 PM\\n Furosemide (Lasix) - 06:36 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:36 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.6\\nC (101.4\\n Tcurrent: 36.7\\nC (98.1\\n HR: 131 (73 - 142) bpm\\n BP: 127/43(60) {71/29(42) - 137/97(101)} mmHg\\n RR: 21 (12 - 36) insp/min\\n SpO2: 97%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 4,627 mL\\n 1,084 mL\\n PO:\\n TF:\\n 839 mL\\n IVF:\\n 2,288 mL\\n 1,084 mL\\n Blood products:\\n Total out:\\n 2,407 mL\\n 2,220 mL\\n Urine:\\n 2,407 mL\\n 2,220 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 2,220 mL\\n -1,136 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 400 (400 - 400) mL\\n Vt (Spontaneous): 412 (236 - 480) mL\\n PS : 8 cmH2O\\n RR (Set): 12\\n RR (Spontaneous): 0\\n PEEP: 8 cmH2O\\n FiO2: 50%\\n RSBI: 126\\n PIP: 21 cmH2O\\n Plateau: 17 cmH2O\\n Compliance: 44.4 cmH2O/mL\\n SpO2: 97%\\n ABG: 7.35/50/81./26/0\\n Ve: 7 L/min\\n PaO2 / FiO2: 162\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 227 K/uL\\n 7.7 g/dL\\n 114 mg/dL\\n 0.7 mg/dL\\n 26 mEq/L\\n 4.0 mEq/L\\n 16 mg/dL\\n 112 mEq/L\\n 145 mEq/L\\n 24.9 %\\n 11.3 K/uL\\n [image002.jpg]\\n 03:46 AM\\n 10:20 AM\\n 03:46 PM\\n 01:37 AM\\n 05:32 AM\\n 02:43 PM\\n 03:03 PM\\n 08:11 PM\\n 02:51 AM\\n 03:10 AM\\n WBC\\n 11.1\\n 9.4\\n 11.3\\n Hct\\n 29.4\\n 26.6\\n 24.9\\n Plt\\n \\n Cr\\n 0.8\\n 0.6\\n 0.9\\n 0.7\\n TCO2\\n 35\\n 37\\n 31\\n 31\\n 30\\n 29\\n Glucose\\n 155\\n 123\\n 128\\n 114\\n 114\\n Other labs: PT / PTT / INR:37.2/37.9/4.0, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Lactic Acid:0.5 mmol/L, Albumin:2.4 g/dL,\\n LDH:204 IU/L, Ca++:8.7 mg/dL, Mg++:2.6 mg/dL, PO4:4.2 mg/dL\\n Assessment and Plan\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n PICC Line - 09:19 PM\\n 18 Gauge - 08:15 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-09 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 636501,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Arterial line d/c'd\\n Spiked a fever of 101.4, blood and urine cultures sent, CXR. Started\\n Vanc, Levo, Aztreonam\\n Persistently hypotensive to 70s SBP overnight with low urine output and\\n poor O2 sats.\\n Started on Levophed, and given 1.75L NS. BPs improved to 90-120s SBP,\\n and urine output increased significantly.\\n Large amount of oral secretions, ?gastric in origin\\n Tube feeds held for ? of aspiration.\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Vancomycin - 11:00 PM\\n Levofloxacin - 11:43 PM\\n Aztreonam - 04:07 AM\\n Infusions:\\n Norepinephrine - 0.03 mcg/Kg/min\\n Other ICU medications:\\n Midazolam (Versed) - 09:30 AM\\n Morphine Sulfate - 03:17 PM\\n Furosemide (Lasix) - 06:36 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:36 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.6\\nC (101.4\\n Tcurrent: 36.7\\nC (98.1\\n HR: 131 (73 - 142) bpm\\n BP: 127/43(60) {71/29(42) - 137/97(101)} mmHg\\n RR: 21 (12 - 36) insp/min\\n SpO2: 97%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 4,627 mL\\n 1,084 mL\\n PO:\\n TF:\\n 839 mL\\n IVF:\\n 2,288 mL\\n 1,084 mL\\n Blood products:\\n Total out:\\n 2,407 mL\\n 2,220 mL\\n Urine:\\n 2,407 mL\\n 2,220 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 2,220 mL\\n -1,136 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 400 (400 - 400) mL\\n Vt (Spontaneous): 412 (236 - 480) mL\\n PS : 8 cmH2O\\n RR (Set): 12\\n RR (Spontaneous): 0\\n PEEP: 8 cmH2O\\n FiO2: 50%\\n RSBI: 126\\n PIP: 21 cmH2O\\n Plateau: 17 cmH2O\\n Compliance: 44.4 cmH2O/mL\\n SpO2: 97%\\n ABG: 7.35/50/81./26/0\\n Ve: 7 L/min\\n PaO2 / FiO2: 162\\n Physical Examination\\n General Appearance: Trached and sedated. Responsive, following\\n commands, Overweight / Obese, mild agitation but NAD\\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\\n deviation\\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\\n Cardiovascular: (S1: Normal), (S2: Normal), distant\\n Respiratory / Chest: (Expansion: Symmetric), CTA anteriorly, decreased\\n BS\\n Abdominal: Obese, soft, Non-tender, no rebound, no guarding, + BS, PEG\\n in place with dressing C/D/I\\n Extremities: no CCE\\n Skin: no rashes or jaundice\\n Lines: r brachioceph ART with large amount of bloody drainage and L\\n PICC C/D/I\\n Labs / Radiology\\n 227 K/uL\\n 7.7 g/dL\\n 114 mg/dL\\n 0.7 mg/dL\\n 26 mEq/L\\n 4.0 mEq/L\\n 16 mg/dL\\n 112 mEq/L\\n 145 mEq/L\\n 24.9 %\\n 11.3 K/uL\\n [image002.jpg]\\n 03:46 AM\\n 10:20 AM\\n 03:46 PM\\n 01:37 AM\\n 05:32 AM\\n 02:43 PM\\n 03:03 PM\\n 08:11 PM\\n 02:51 AM\\n 03:10 AM\\n WBC\\n 11.1\\n 9.4\\n 11.3\\n Hct\\n 29.4\\n 26.6\\n 24.9\\n Plt\\n \\n Cr\\n 0.8\\n 0.6\\n 0.9\\n 0.7\\n TCO2\\n 35\\n 37\\n 31\\n 31\\n 30\\n 29\\n Glucose\\n 155\\n 123\\n 128\\n 114\\n 114\\n Other labs: PT / PTT / INR:37.2/37.9/4.0, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Lactic Acid:0.5 mmol/L, Albumin:2.4 g/dL,\\n LDH:204 IU/L, Ca++:8.7 mg/dL, Mg++:2.6 mg/dL, PO4:4.2 mg/dL\\n Assessment and Plan\\n 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA, and\\n ARDS, intubated since the end of now s/p trach and PEG\\n placement.\\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\\n volume overload. Intubated on for resp decompensation. S/P Trach\\n and PEG on .\\n - wean FiO2 as tolerated\\n - attempt wean PS today and hopeful for trach mask trial\\n # Sedation: Continue to have issues with pain/delirium causing\\n tachycardia and hypertension with intermittent hypotension. On Haldol\\n 5 TID, Fentanyl 100-150 mcg TP, Diazapam 10 QID; Haldol, midazolam and\\n morphine PRN. Had good response to morphine, minimal response to\\n haldol bolus.\\n - Will d/c midazolam and haldol PRN and use morphine for now.\\n - If stable, would d/c standing Haldol tonight or tomorrow\\n # Adrenal Insufficency: Hypotension that resolved with steroids,\\n returned as they came off and is now improved again. Possible primary\\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\\n started on .\\n - ok to go to 10 q am and 5 q pm prednisone, will wean to\\n maintenance dose as tolerated, in consultation with endo.\\n # Volume overloaded in setting of hypernatremia with TBW deficit and\\n metabolic alkalosis\\n - Lasix boluses, goal -1L today\\n - Diamox until HCO3 < 30\\n - electrolytes\\n - continue tube feeds with free water flushes 300 cc q4\\n # RUE DVT: INR now therapeutic on coumadin. Goal \\n - stop heparin gtt\\n - coumadin 5mg QHS\\n # Spine fracture: Neurologically intact distal to the lesion. Prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - Brace for OOB\\n - will f/u full trauma spine eval from OSH to determine need for\\n further back imaging in-house.\\n # Tracheomalacia: Discussed with IP. Stenting unlikely to help for\\n trachiomalacia as airways have poor structure diffusely.\\n - Outpatient f/u once off pressure support to assess for possible\\n stenting\\n #. Thyroid Nodule on CT\\n -outpatient follow up\\n # Nutrition: Tube feeds with free water flushes, tolerating well,\\n continue Replete (Full) - 11:20 AM 30 mL/hour\\n # Glycemic control: SSI, well controlled\\n # Lines L PICC () and R ART ()\\n d/c art today. Correlate ABG\\n and VBG.\\n # Ppx: INR therapeutic, ranitidine, colace and senna\\n # Communication:\\n - Boyfriend of 10 is her HCP. Also brother is involved\\n Code: Full\\n Dispo: ICU, being screening for vent facilities\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n PICC Line - 09:19 PM\\n 18 Gauge - 08:15 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-09 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 636605,\n \"text\": \"Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Pt has a clot to RUE and was taken off heparin gtt . inr this am\\n 4.4. No signs of bleeding noted.\\n Action:\\n No interventions done at this time.\\n Response:\\n Plan:\\n F/U coags.\\n Hypernatremia (high sodium)\\n Assessment:\\n Na level increased this am from 140 to 145.\\n Action:\\n H2O flushes DC\\nd NPO and started on D5 IVF at 100 cc/hr x 1 lliter.\\n Response:\\n Plan:\\n Follow up Na level in am.\\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\\n Assessment:\\n Pt has been Afebrile throughout the day. IV ABXs to continue for 48hrs\\n until cultures back.\\n Action:\\n No actions done.\\n Response:\\n Plan:\\n Follow up cultures.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n LS this am very coarse and sx\\nd for copious amounts amount secretions.\\n Pt was given aggressive pulm toilet, and respm status improved\\n throughout the day\\n Action:\\n Response:\\n Plan:\\n Altered mental status (not Delirium)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-04 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 635668,\n \"text\": \"55 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\\n Now with prolonged hospital course c/b by PNA with high PEEP\\n requirement, anxiety, RUE DVT on heparin qtt.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Rec\\nd pt on Vent settings AC 60%/18 X 400/+10 with no overbreathing of\\n set RR. O2 sat 92-98%. Lung snds clear, diminished in bases. Pt sxn\\n for small amts thick white secretions. Trach site with small amt\\n serosang drainage.\\n Action:\\n FiO2 \\nd to 55%.\\n Response:\\n ABG to follow.\\n Plan:\\n Cont to gently wean from vent.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-04 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 635669,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n # To OR for Peg and Trach placement\\n # Desatted in the evening to 84%, increased PEEP and FiO2\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Furosemide (Lasix) - 2 mg/hour\\n Fentanyl - 100 mcg/hour\\n Midazolam (Versed) - 2 mg/hour\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:10 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.3\\nC (99.2\\n Tcurrent: 36.4\\nC (97.6\\n HR: 111 (44 - 133) bpm\\n BP: 127/63(90) {90/46(63) - 165/89(123)} mmHg\\n RR: 18 (15 - 24) insp/min\\n SpO2: 93%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 2,751 mL\\n 534 mL\\n PO:\\n TF:\\n 17 mL\\n IVF:\\n 1,834 mL\\n 84 mL\\n Blood products:\\n Total out:\\n 6,600 mL\\n 950 mL\\n Urine:\\n 6,600 mL\\n 950 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -3,849 mL\\n -416 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 400 (400 - 400) mL\\n RR (Set): 18\\n RR (Spontaneous): 0\\n PEEP: 10 cmH2O\\n FiO2: 60%\\n RSBI Deferred: PEEP > 10, FiO2 > 60%\\n PIP: 23 cmH2O\\n Plateau: 25 cmH2O\\n SpO2: 93%\\n ABG: 7.45/43/81./29/4\\n Ve: 7.6 L/min\\n PaO2 / FiO2: 137\\n Physical Examination\\n General Appearance: Responsive, following commands, Overweight / Obese,\\n NAD\\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\\n deviation\\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\\n Cardiovascular: (S1: Normal), (S2: Normal), distant\\n Respiratory / Chest: (Expansion: Symmetric), referred breath sounds\\n from ETT, mild rhonchi diffusely\\n Abdominal: Obese, Soft, Non-tender, no rebound, no guarding\\n Extremities: No clubbing or cyanosis, + nonpitting edema of b/l\\n hands, anasarca\\n Skin: no rashes or jaundice\\n Neuro: alert. Strength 4/5 upper and lower extremeties, light touch\\n sensation intact bil.\\n Lines: r brachioceph ART and L PICC C/D/I\\n Labs / Radiology\\n 256 K/uL\\n 7.8 g/dL\\n 106 mg/dL\\n 0.6 mg/dL\\n 29 mEq/L\\n 4.1 mEq/L\\n 7 mg/dL\\n 110 mEq/L\\n 144 mEq/L\\n 25.8 %\\n 10.0 K/uL\\n [image002.jpg]\\n 03:00 AM\\n 10:47 AM\\n 04:10 PM\\n 12:13 AM\\n 05:08 AM\\n 05:20 AM\\n 05:17 PM\\n 11:41 PM\\n 03:06 AM\\n 03:38 AM\\n WBC\\n 8.6\\n 11.2\\n 10.6\\n 10.0\\n Hct\\n 25.9\\n 27.1\\n 27.3\\n 25.8\\n Plt\\n 280\\n 306\\n 321\\n 256\\n Cr\\n 0.5\\n 0.7\\n 0.5\\n 0.5\\n 0.6\\n TCO2\\n 34\\n 36\\n 36\\n 32\\n 31\\n Glucose\\n 136\\n 165\\n 143\\n 110\\n 94\\n 111\\n 106\\n Other labs: PT / PTT / INR:13.6/24.4/1.2, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:13.1 %,\\n Mono:2.7 %, Eos:0.6 %, Lactic Acid:0.9 mmol/L, Albumin:2.4 g/dL,\\n LDH:204 IU/L, Ca++:8.4 mg/dL, Mg++:2.5 mg/dL, PO4:3.8 mg/dL\\n Assessment and Plan\\n 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA and\\n ARDS intubated since the end of .\\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\\n volume overload. Intubated on for resp decompensation. Stenting\\n unlikely to help for trachiomalacia as airways have poor structure\\n diffusely. S/P Trach yesterday\\n - Continue to wean O2 as tolerated\\n # Adrenal Insufficency: Hypotension that resolved with steroids,\\n returned as they came off and is now improved again. Possible primary\\n adrenal insufficency. Appreciate endocrine recommendations.\\n - hydrocortt (day 1 = ), wean per endo recs\\n # Hypotension: Likely adrenal insufficiency and sedation. Goal map\\n > 60. Much improved since re-administration of steroids.\\n - hydrocortisone as above\\n - restart levophed if necessary to maintain MAP > 60\\n # Volume overloaded in setting of hypernatremia with TBW deficit.\\n - Lasix gtt, continue with goal -1L per day.\\n - electrolytes\\n - may have some contraction alkalosis, w/ rising pH and bicarb. Start\\n Diamox 500mg TID to decrease bicarb and pH and may improve respiratory\\n drive.\\n # Sedation: Sedation control remains somewhat poor although fentanyl\\n patch and diazpem are likely therapeutic range today. On Versed 2.0,\\n Fentanyl 100, Fentanyl patch, Diazepam standing and haldo 2.5-5 mg\\n PRN. QTc increased to 480.\\n - Wean versed/fentanyl as tolerated, continue diazepam. Avoid haldol\\n use if possible to avoid further prolongation of QTc\\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\\n coumadin at least until s/p trach.\\n - heparin gtt restarted\\n - plan to start coumadin night of if stable\\n # Spine fracture: Neurologically intact distal to the lesion. Prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - CT of C, L spine when stable. Currently, unlikely to change\\n management and high risk for complications with transport.\\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\\n is low. Brace for OOB. Ok for anticoag per note.\\n # FEN/GI: Tube feeds\\n DVT: Treatment dose heparin\\n Ulcer: Ranitidine\\n VAP: Prevention per routine\\n # Access: L PICC line, and R brachial a-line\\n # Communication:\\n - Boyfriend of 10 is her HCP. Also brother is involved\\n - touch base with SW today\\n Code: Full\\n Dispo: ICU\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n PICC Line - 09:19 PM\\n Arterial Line - 02:00 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-08 00:00:00.000\",\n \"description\": \"Generic Note\",\n \"row_id\": 636314,\n \"text\": \"TITLE:\\n 55 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\\n Now with prolonged hospital course c/b by PNA with high PEEP\\n requirement, anxiety, RUE DVT ,continued on heparin qtt.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Lungs clear bilat upper lobes and diminished bilat bases with\\n occasional scattered rhonchi, prod cough thick yellow/tan sputum, trach\\n sx for mod.amt. Placed on MMV for the night with good effect.\\n Action:\\n Vent changed from CPAP+PS to MMV overnight, Peep @ to 8cm. Freq.\\n pulmonary toileting.\\n Response:\\n Tolerating slow vent wean, requiring pulmonary toileting, Mode\\n changed to Cpap+ PS Peep 8, PS 8.\\n Plan:\\n Attempt to wean PS and FI02 down further today as tolerated, Continue\\n aggressive pulmonary toileting.\\n Altered mental status (not Delirium)\\n Assessment:\\n Increased agitation throughout night with pt wriggling in bed and\\n attempting to get OOB and attempting to pull at all lines and tubes,\\n makes eye contact and follows commands but doesn\\nt stay calm for long,\\n HR up to 130- with agitation and BP up to 130-150\\ns/60-70\\n received valium and Haldol as ordered. Prn Midazolam given as per\\n orders. dosing in between scheduled doses with poor effect. appears\\n generally uncomfortable but denies pain when asked.\\n Action:\\n Freq. attempts to reorient and calm pt with no effect, Is on Haldol po\\n q 8 & also on prn dosing. On po diazepam 10 mgs q 6 & iv versed 0.5 mg\\n to 2 mgs q 1 hr. stimulation decreased, bilat soft wrist restraints to\\n prevent pt from pulling at lines and tubes\\n Response:\\n Increased agitation off of continuous IV sedation, poor effect from\\n current medical regime, MICU team aware.\\n Plan:\\n Continue meds to control agitation.\\n Hypernatremia (high sodium)\\n Assessment:\\n NA+ 145 in am labs.\\n Action:\\n Orders to continue Free water flushes 300ml Q 4hr\\n Response:\\n Na level has comparatively reduced since yesterday.\\n Plan:\\n Continue free water flushes. monitor Na levels.\\n Arterial line has no return, Team aware. A-line Dressing\\n changed. Labs obtained from Picc. ABG done by Intern. Reassess A-line\\n ? change A-line .\\n Alteration in Nutrition\\n Assessment:\\n Tube feeds held as per orders . Had problems with priming the new\\n tubing. Changed 3 pumps & 2 new tubing set. Tried by 3 RN\\ns. Unable to\\n prime the tubing in the auto or the manual mode. Orders by team not to\\n continue feeds for now, Only to continue the water flushes manually.\\n Action:\\n Peg Feeds held as of now.\\n Response:\\n Peg tube flushed & clamped.\\n Plan:\\n Follow up with the Problem. Monitor Glucose.\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2167-10-08 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 636320,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 20\\n Ideal body weight: 61.2 None\\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: Yes\\n Tube Type\\n Tracheostomy tube:\\n Type: Cuffed\\n Manufacturer: Portex\\n Size: 8.0mm\\n PMV: No\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 28 cmH2O\\n Cuff volume: mL /\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Rhonchi\\n LUL Lung Sounds: Rhonchi\\n LLL Lung Sounds: Diminished\\n Secretions\\n Sputum color / consistency: Tan / Thick\\n Sputum source/amount: Suctioned / Moderate\\n Ventilation Assessment\\n Level of breathing assistance: Continuous invasive ventilation\\n Visual assessment of breathing pattern: Accessory muscle use; Comments:\\n Switch to MMV @ beginning of shift till this morning/\\n Back to CPAP.\\n Assessment of breathing comfort: No response (sleeping / sedated)\\n Invasive ventilation assessment:\\n Trigger work assessment:\\n Dysynchrony assessment: Frequent alarms (Low min. ventilation)\\n Plan\\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\\n Comments: Rsbi done ~56.------\\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\\n Intolerant of weaning attempts\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-10 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 636671,\n \"text\": \"55 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\\n Now with prolonged hospital course c/b by PNA with high PEEP\\n requirement, anxiety, RUE DVT .\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt more alert, following commands intermittently. Periods of agitation\\n with HR rising to 130\\n Action:\\n Fentanyl patch in place. Valium RTC. MSO4 given x 1 for discomfort.\\n Response:\\n Pt with less episodes of agitation previously. ? steroid psychosis.\\n Plan:\\n Check cortisol level in am and wean hydrocortisone MD. Continue to\\n reorient pt. MSO4 prn for discomfort.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Received pt on PSV 8/5/50%.RR 19-24. Tidal volumes 200-250. 02 sats\\n variable 90-100%. LS rhoncherous to clear, diminished at bases.\\n Action:\\n Pt maintained at current settings given reduced tv\\ns and sats. Orally\\n suctioned q 2 hrs for copious secretions. Deep suctioned q 3-4 hrs for\\n sm amt thick white secretions.\\n Response:\\n ABG 7.37/40/120/0/26 on PSV. At 0530 pt hypoventilating with RR 4-6,\\n changed to AC mode of ventilation (500x 12 x 5 50%)\\n Plan:\\n Attempt PSV again this am. Pulm hygiene.\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Pt with RUE DVT. Heparin dcd on .\\n Action:\\n Coags being monitored. INR 4.4 yest. Hct was falling.\\n Response:\\n Hct 26.5 today, previously 27.6. INR pend.\\n Plan:\\n Coumadin to be started when INR < 3\\n Hypernatremia (high sodium)\\n Assessment:\\n Na 140. Pt volume overloaded. LOS + ~10,000ccs.\\n Action:\\n Treated with 1 liter d5w iv.\\n Response:\\n Urine output 120-400ccs/hr via foley. TFB neg 100cc. Na 145. Goal ~\\n even fluid balance.\\n Plan:\\n Continue to monitor f+e status.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-11 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 636837,\n \"text\": \"Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Received pt on trach collar 50%. Sats fell to 78%. Pt ambu\\nd and\\n lavaged with no plugs detected. RR 30-40 . Pt diaphoretic.\\n Action:\\n Placed on PSV 10/5/50%\\n Response:\\n Apneic with RR 3-5\\n Plan:\\n Rested on AC 500/12/5/50%. No further episodes of desating or\\n tachypnea.\\n Hypotension (not Shock)\\n Assessment:\\n BP falling to 78/37. Urine output 5-30ccs/hr via foley\\n Action:\\n Given 500ccs\\n NS fluid bolus\\n Response:\\n Pt normotensive, improved urine output\\n Plan:\\n Continue to monitor.\\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\\n Assessment:\\n Temp spike to 102.2 po\\n Action:\\n Blood, urine and sputum cxs sent. Sputum white, not yellow or\\n consistant with TF. Chest x-ray taken. Tylenol pr given. Cool cloths\\n applied.\\n Response:\\n Pt normothermic\\n Plan:\\n Monitor fever curve, cooling measures. Follow-up on cx results.\\n Alteration in Nutrition\\n Assessment:\\n Pt vomiting yellow fluid with coughing and when turned\\n Action:\\n TF held. Peg to gravity. Medicated with 4 mg zofran iv.\\n Response:\\n No further episodes of vomiting.\\n Plan:\\n Continue to monitor. Aspiration precautions. ? need for alternative\\n form of nutrition.\\n Altered mental status (not Delirium)\\n Assessment:\\n Onset of shift, pt lethargic, not following commands but MAE. ~ 12 mn\\n pt agitated, attempting to climb oob, disconnecting self from vent\\n despite restraints\\n Action:\\n 5 mg valium given q 8hrs\\n Response:\\n Pt still agitated\\n Plan:\\n Needs better sedation at bedtime - ? zyprexa or alternative med\\n\"\n },\n {\n \"category\": \"General\",\n \"chartdate\": \"2167-10-04 00:00:00.000\",\n \"description\": \"Generic Note\",\n \"row_id\": 635747,\n \"text\": \"TITLE: Addendum to Dr. \\ns note\\n MICU ATTENDING ADDENDUM \\n I saw and examined the patient, and was physically present with the ICU\\n team for the key portions of the services provided. I agree with the\\n note above, including the assessment and plan. I would emphasize and\\n add the following points:\\n trauma thoracic spine fracture\\n intubated\\n VAP\\n tracheomalacia\\n trached\\n desaturated and PEEP increased\\n Exam notable for Tm 98.5 BP 86/42 HR 91 RR 14 with 94 sat on PS\\n /.55\\n anasarca\\n awake, occasional purposeful movements\\n decreased breath sounds ant and lat\\n tachy, regular\\n abd benign\\n 7.39/46/118\\n Labs notable for WBC 8 K, HCT 25 , K+ 3.6 , Cr .5 , HCO3 27\\n CXR reviewed - bilat effusion, trach ok\\n Problems:\\n respiratory failure\\n airway malacia\\n anasarca, effusions\\n spine fracture\\n agitation\\n adrenal insufficiency\\n UE DVT\\n hypernatremia\\n Agree with plan to wean O2 as tolerated, diurese, wean sedation though\\n continue pain medications, wean steroids, continue heparin - start\\n coumadin, continue H2O\\n Remainder of plan as outlined above.\\n Patient is critically ill.\\n Total time: 36 min\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-04 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 635755,\n \"text\": \"55 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\\n Now with prolonged hospital course c/b by PNA with high PEEP\\n requirement, anxiety, RUE DVT on heparin qtt.\\n Edema, peripheral\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Altered mental status (not Delirium)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Hypotension (not Shock)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2167-10-05 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 635906,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 17\\n Ideal body weight: 61.2 None\\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: Yes\\n Procedure location:\\n Reason:\\n Tube Type\\n ETT:\\n Position: cm at teeth\\n Route:\\n Type:\\n Size:\\n Tracheostomy tube:\\n Type: Standard\\n Manufacturer: Portex\\n Size: 7.0mm\\n PMV:\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 28 cmH2O\\n Cuff volume: mL /\\n Airway problems:\\n Comments:\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Exp Wheeze\\n LUL Lung Sounds: Exp Wheeze\\n LLL Lung Sounds: Diminished\\n Comments:\\n Secretions\\n Sputum color / consistency: Green / Thick\\n Sputum source/amount: Suctioned / Small\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance: Continuous invasive ventilation\\n Visual assessment of breathing pattern:\\n Assessment of breathing comfort: No claim of dyspnea)\\n Non-invasive ventilation assessment:\\n Invasive ventilation assessment:\\n Trigger work assessment:\\n Dysynchrony assessment: Erratic exhaled Tidal Volumes\\n Comments: pt dysynchrones at times though PSV attempted and pt had\\n periods of apnea >30 seconds\\n Plan\\n Next 24-48 hours: Reduce PEEP as tolerated\\n Reason for continuing current ventilatory support:\\n Respiratory Care Shift Procedures\\n Transports:\\n Destination (R/T)\\n Time\\n Complications\\n Comments\\n CT\\n 1730\\n Bedside Procedures:\\n Comments:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-06 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 636054,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n CT showed small effusions, not amenable for tap and so given warfarin\\n (2^nd night)\\n Extremely labile pressures over night, trying to wean off Fentanyl and\\n use more Haldol.\\n Tapering hydrocortisone\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Fentanyl - 50 mcg/hour\\n Midazolam (Versed) - 0.5 mg/hour\\n Heparin Sodium - 1,500 units/hour\\n Other ICU medications:\\n Ranitidine (Prophylaxis) - 08:00 AM\\n Haloperidol (Haldol) - 01:00 AM\\n Other medications:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:12 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.1\\nC (100.6\\n Tcurrent: 37.1\\nC (98.8\\n HR: 100 (56 - 142) bpm\\n BP: 98/47(65) {77/40(53) - 164/93(123)} mmHg\\n RR: 18 (15 - 24) insp/min\\n SpO2: 94%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 4,228 mL\\n 1,123 mL\\n PO:\\n TF:\\n 1,440 mL\\n 360 mL\\n IVF:\\n 978 mL\\n 343 mL\\n Blood products:\\n Total out:\\n 6,725 mL\\n 780 mL\\n Urine:\\n 6,725 mL\\n 780 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -2,497 mL\\n 343 mL\\n Respiratory support\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 400 (400 - 400) mL\\n Vt (Spontaneous): 450 (450 - 450) mL\\n PS : 8 cmH2O\\n RR (Set): 18\\n RR (Spontaneous): 0\\n PEEP: 10 cmH2O\\n FiO2: 50%\\n RSBI Deferred: PEEP > 10\\n PIP: 23 cmH2O\\n Plateau: 19 cmH2O\\n SpO2: 94%\\n ABG: 7.50/41/81./29/7\\n Ve: 7.2 L/min\\n PaO2 / FiO2: 164\\n Physical Examination\\n General Appearance: Trached and sedated. Responsive, following\\n commands, Overweight / Obese, mild agitation but NAD\\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\\n deviation\\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\\n Cardiovascular: (S1: Normal), (S2: Normal), distant\\n Respiratory / Chest: (Expansion: Symmetric), CTA anteriorly, decreased\\n BS\\n Abdominal: Obese, Firm, Non-tender, no rebound, no guarding, + BS, PEG\\n in place with dressing C/D/I\\n Extremities: No clubbing or cyanosis, trace edema of b/l hands,\\n anasarca\\n Skin: no rashes or jaundice\\n Lines: r brachioceph ART with small amount of bloody drainage and L\\n PICC C/D/I\\n Labs / Radiology\\n 229 K/uL\\n 7.9 g/dL\\n 107 mg/dL\\n 0.6 mg/dL\\n 29 mEq/L\\n 3.8 mEq/L\\n 11 mg/dL\\n 109 mEq/L\\n 147 mEq/L\\n 25.3 %\\n 9.6 K/uL\\n [image002.jpg]\\n 03:55 AM\\n 07:19 AM\\n 11:24 AM\\n 03:18 PM\\n 02:47 AM\\n 11:01 AM\\n 04:40 PM\\n 05:08 PM\\n 03:44 AM\\n 06:04 AM\\n WBC\\n 8.3\\n 11.2\\n 9.6\\n Hct\\n 24.6\\n 27.4\\n 25.3\\n Plt\\n 279\\n 272\\n 229\\n Cr\\n 0.5\\n 0.6\\n 0.6\\n 0.6\\n 0.6\\n TCO2\\n 29\\n 29\\n 31\\n 34\\n 33\\n Glucose\\n 123\\n 137\\n 128\\n 138\\n 107\\n Other labs: PT / PTT / INR:16.5/78.5/1.5, Ca++:8.7 mg/dL, Mg++:2.4\\n mg/dL, PO4:4.7 mg/dL\\n Assessment and Plan\\n 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA and\\n ARDS intubated since the end of now s/p trach and PEG placement.\\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\\n volume overload. Intubated on for resp decompensation. Stenting\\n unlikely to help for trachiomalacia as airways have poor structure\\n diffusely. S/P Trach and PEG on . Increased effusion on recent\\n CXR.\\n - wean FiO2 as tolerated\\n # Adrenal Insufficency: Hypotension that resolved with steroids,\\n returned as they came off and is now improved again. Possible primary\\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\\n started on .\\n - wean per endo recs, decrease to 20q am and 10 q pm starting\\n tonight\\n will maintain this maintenance dose and check am cortisol\\n level one week later\\n # Volume overloaded in setting of hypernatremia with TBW deficit.\\n - Lasix gtt, continue with goal -1-2 L per day\\n currently off as\\n patient is somewhat hypotensive\\n will restart once/if BP increases and\\n remains stable for several hours\\n - electrolytes\\n - continue tube feeds with free water flushes 300 cc q4\\n # Sedation: Sedation control remains somewhat poor although fentanyl\\n patch and diazpem are likely therapeutic range today. On Versed 2.0,\\n Fentanyl 100, Fentanyl patch, Diazepam standing and haldo 2.5-5 mg\\n PRN. QTc increased to 480.\\n - Wean versed/fentanyl as tolerated, continue diazepam in\\n hopes for vent facility placement\\n - Change diazepam to 5mg q8 with haldol 5 mg q8\\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\\n coumadin at least until s/p trach.\\n - heparin gtt restarted\\n - coumadin 5mg G-tube today, INR in am\\n # Spine fracture: Neurologically intact distal to the lesion. Prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - CT of C, L spine when stable. Currently, unlikely to change\\n management and high risk for complications with transport.\\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\\n is low. Brace for OOB. Ok for anticoag per note.\\n -f/u full trauma spine eval from OSH to determine need for further back\\n imaging in-house (to be done )\\n # Nutrition: Tube feeds with free water flushes, tolerating well,\\n continue Replete (Full) - 11:20 AM 30 mL/hour\\n # Glycemic control: SSI, well controlled\\n # Lines L PICC () and R ART ()\\n similarly but will\\n keep in setting of hypotension\\n # Ppx: heparin drip until INR therapeutic for 2 days, ranitidine, VAP\\n prevention, colace and senna\\n # Communication:\\n - Boyfriend of 10 is her HCP. Also brother is involved\\n Code: Full\\n Dispo: ICU, being screening for vent facilities\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n PICC Line - 09:19 PM\\n Arterial Line - 02:00 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-06 00:00:00.000\",\n \"description\": \"Physician Resident/Attending Progress Note - MICU\",\n \"row_id\": 636058,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n CT showed small effusions, not amenable for tap and so given warfarin\\n (2^nd night)\\n Extremely labile pressures over night, trying to wean off Fentanyl and\\n use more Haldol.\\n Tapering hydrocortisone\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Fentanyl - 50 mcg/hour\\n Midazolam (Versed) - 0.5 mg/hour\\n Heparin Sodium - 1,500 units/hour\\n Other ICU medications:\\n Ranitidine (Prophylaxis) - 08:00 AM\\n Haloperidol (Haldol) - 01:00 AM\\n Other medications:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:12 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.1\\nC (100.6\\n Tcurrent: 37.1\\nC (98.8\\n HR: 100 (56 - 142) bpm\\n BP: 98/47(65) {77/40(53) - 164/93(123)} mmHg\\n RR: 18 (15 - 24) insp/min\\n SpO2: 94%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 4,228 mL\\n 1,123 mL\\n PO:\\n TF:\\n 1,440 mL\\n 360 mL\\n IVF:\\n 978 mL\\n 343 mL\\n Blood products:\\n Total out:\\n 6,725 mL\\n 780 mL\\n Urine:\\n 6,725 mL\\n 780 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -2,497 mL\\n 343 mL\\n Respiratory support\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 400 (400 - 400) mL\\n Vt (Spontaneous): 450 (450 - 450) mL\\n PS : 8 cmH2O\\n RR (Set): 18\\n RR (Spontaneous): 0\\n PEEP: 10 cmH2O\\n FiO2: 50%\\n RSBI Deferred: PEEP > 10\\n PIP: 23 cmH2O\\n Plateau: 19 cmH2O\\n SpO2: 94%\\n ABG: 7.50/41/81./29/7\\n Ve: 7.2 L/min\\n PaO2 / FiO2: 164\\n Physical Examination\\n General Appearance: Trached and sedated. Responsive, following\\n commands, Overweight / Obese, mild agitation but NAD\\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\\n deviation\\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\\n Cardiovascular: (S1: Normal), (S2: Normal), distant\\n Respiratory / Chest: (Expansion: Symmetric), CTA anteriorly, decreased\\n BS\\n Abdominal: Obese, Firm, Non-tender, no rebound, no guarding, + BS, PEG\\n in place with dressing C/D/I\\n Extremities: No clubbing or cyanosis, trace edema of b/l hands,\\n anasarca\\n Skin: no rashes or jaundice\\n Lines: r brachioceph ART with small amount of bloody drainage and L\\n PICC C/D/I\\n Labs / Radiology\\n 229 K/uL\\n 7.9 g/dL\\n 107 mg/dL\\n 0.6 mg/dL\\n 29 mEq/L\\n 3.8 mEq/L\\n 11 mg/dL\\n 109 mEq/L\\n 147 mEq/L\\n 25.3 %\\n 9.6 K/uL\\n [image002.jpg]\\n 03:55 AM\\n 07:19 AM\\n 11:24 AM\\n 03:18 PM\\n 02:47 AM\\n 11:01 AM\\n 04:40 PM\\n 05:08 PM\\n 03:44 AM\\n 06:04 AM\\n WBC\\n 8.3\\n 11.2\\n 9.6\\n Hct\\n 24.6\\n 27.4\\n 25.3\\n Plt\\n 279\\n 272\\n 229\\n Cr\\n 0.5\\n 0.6\\n 0.6\\n 0.6\\n 0.6\\n TCO2\\n 29\\n 29\\n 31\\n 34\\n 33\\n Glucose\\n 123\\n 137\\n 128\\n 138\\n 107\\n Other labs: PT / PTT / INR:16.5/78.5/1.5, Ca++:8.7 mg/dL, Mg++:2.4\\n mg/dL, PO4:4.7 mg/dL\\n Assessment and Plan\\n 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA and\\n ARDS intubated since the end of now s/p trach and PEG placement.\\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\\n volume overload. Intubated on for resp decompensation. Stenting\\n unlikely to help for trachiomalacia as airways have poor structure\\n diffusely. S/P Trach and PEG on . Increased effusion on recent\\n CXR.\\n - wean FiO2 as tolerated\\n # Adrenal Insufficency: Hypotension that resolved with steroids,\\n returned as they came off and is now improved again. Possible primary\\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\\n started on .\\n - wean per endo recs, decrease to 20q am and 10 q pm starting\\n tonight\\n will maintain this maintenance dose and check am cortisol\\n level one week later\\n # Volume overloaded in setting of hypernatremia with TBW deficit.\\n - Lasix gtt, continue with goal -1-2 L per day\\n currently off as\\n patient is somewhat hypotensive\\n will restart once/if BP increases and\\n remains stable for several hours\\n - electrolytes\\n - continue tube feeds with free water flushes 300 cc q4\\n # Sedation: Sedation control remains somewhat poor although fentanyl\\n patch and diazpem are likely therapeutic range today. On Versed 2.0,\\n Fentanyl 100, Fentanyl patch, Diazepam standing and haldo 2.5-5 mg\\n PRN. QTc increased to 480.\\n - Wean versed/fentanyl as tolerated, continue diazepam in\\n hopes for vent facility placement\\n - Change diazepam to 5mg q8 with haldol 5 mg q8\\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\\n coumadin at least until s/p trach.\\n - heparin gtt restarted\\n - coumadin 5mg G-tube today, INR in am\\n # Spine fracture: Neurologically intact distal to the lesion. Prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - CT of C, L spine when stable. Currently, unlikely to change\\n management and high risk for complications with transport.\\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\\n is low. Brace for OOB. Ok for anticoag per note.\\n -f/u full trauma spine eval from OSH to determine need for further back\\n imaging in-house (to be done )\\n # Nutrition: Tube feeds with free water flushes, tolerating well,\\n continue Replete (Full) - 11:20 AM 30 mL/hour\\n # Glycemic control: SSI, well controlled\\n # Lines L PICC () and R ART ()\\n similarly but will\\n keep in setting of hypotension\\n # Ppx: heparin drip until INR therapeutic for 2 days, ranitidine, VAP\\n prevention, colace and senna\\n # Communication:\\n - Boyfriend of 10 is her HCP. Also brother is involved\\n Code: Full\\n Dispo: ICU, being screening for vent facilities\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n PICC Line - 09:19 PM\\n Arterial Line - 02:00 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n ------ Protected Section ------\\n MICU ATTENDING ADDENDUM\\n I saw and examined the patient, and was physically present with the ICU\\n team for the key portions of the services provided. I agree with the\\n note above, including the assessment and plan. I would emphasize and\\n add the following points: 55F T5-8 fractures with retropulsion and ARDS\\n from klebsiella VAP; on heparin for UE DVT and lasix for volume\\n overload. Tolerating slow vent wean but failed SBT. Was TBB positive\\n yesterday despite lasix drip; sedation remains challenging. CT without\\n tappable effusions and resolving airspace disease.\\n Exam notable for Tm 100.6 BP 100/50 HR 62 RR 18-20 with sat 97% on VAC\\n 400x18 PEEP 8 FiO2 0.5, ABG 7.50/41/82. TBB -2L/24h, +9L/MICU LOS. Eyes\\n opens, will squeeze hands and wiggle toes but very drowsy. Bronchial BS\\n bilaterally with RRR s1s2 SM at base. Abdomen is distended with\\n decreased BS. 1+ edema in BLE, no cords. Labs notable for WBC 9K, HCT\\n 25, K+ 3.8, Na 147, Cr 0.6. CXR with resolving B LL airspace disease\\n and effusions.\\n Agree with plan to continue supportive care, wean vent to PSV, and\\n continue diuresis as BP allows. CT without drainable effusions. Will\\n continue fentanyl patch at 100mcg, haldol 5q8h alternating with\\n valium 5q8h at lower dose, now off drips. Will wean hydrocortisone\\n 20/10q12 PGT today. Will continue IV heparin for UE DVT and transition\\n to anticoagulation with coumadin. Will continue tube feeds and continue\\n FW boluses for hypernatremia. Continue spinal stabilization with brace\\n when OOB and discuss followup plan with spine surgery. Will eventually\\n need MRI for surgical planning; remainder of plan as outlined above.\\n Patient is critically ill\\n Total time: 40 min\\n ------ Protected Section Addendum Entered By: , MD\\n on: 03:04 PM ------\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-07 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 636122,\n \"text\": \"55 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\\n Now with prolonged hospital course c/b by PNA with high PEEP\\n requirement, anxiety, RUE DVT on heparin qtt.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Altered mental status (not Delirium)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-09 00:00:00.000\",\n \"description\": \"Generic Note\",\n \"row_id\": 636488,\n \"text\": \"TITLE:\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Received Pt on vent via trach in CPAP+PS at 50 %/. LS finely\\n coarse with diminished bases.. RR 28 to 30/min sats intermittently down\\n to 91 %.\\n Action:\\n Suctioned fro small amts of tan thick mildly blood tinged sputum. Vent\\n Mode changed to AC TV 400, RR 10, peep 8 for the night as per\\n discussion By Resident & MD to rest for the night.\\n Response:\\n Sats maintained in Mid 90\\ns to high 90\\ns. ABG done in am PH\\n 7.35/50/81/29/ Sats 96. Set RR ^ to 12 post abg\\n Plan:\\n Wean vent settings as tolerated. Plan to IP to follow up regarding ?\\n need for stent tomorrow.\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt lethargic, arousable to stimuli, Po diazepam dose was held at 1800\\n hrs,.haldol po dose was given at hrs to keep the patient calm\\n Action:\\n HR was in the 120-130\\ns (while awake) Fentanyl patch weaned down to 75\\n micgs. off fentanyl patch From Midnight till 530am.\\n Response:\\n Patient wide awake at 4am, Calm & still after being restless for few\\n minutes. responds to name & follows commands inconsistently,Tracks\\n well. Continues to be lethargic.\\n Plan:\\n Continue to eval restlessness & treat as needed.\\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\\n Assessment:\\n Temp up to 101.4. axillary at hrs .\\n Action:\\n Tylenol 650 mgs given, Pan cultured, started on vanco, aztreonam &\\n Levofloxacin.\\n Response:\\n Temp down to 98.1 orally at 4 am.\\n Plan:\\n Continue monitoring temp, continue anbx, follow up on cultures.\\n Anemia, other\\n Assessment:\\n Blood tinged sputum obtained when suctioned via trach. INR 4.0 ( Goal\\n INR 2 to 3.0), HCT down to 24.9, HgB 7.7 in am labs, (Total of 2lits NS\\n was given at this time)\\n Action:\\n Coumadin not given on the night of \\n Response:\\n No other bleeding seen.\\n Plan:\\n Monitor Labs, S/S bleeding\\n Hypotension (not Shock)\\n Assessment:\\n Received with NIBP systolic in mid 90\\ns, maps of mid 50\\ns. At \\n hrs Sbp\\ns 70\\ns to 80\\ns, Maps in low to high 40\\n Action:\\n Total 2.25 litres of fluid given, started on Levophed gtt at 0040 hrs.\\n Response:\\n Sbp\\ns in 100\\ns to 120\\ns, maps in 60\\ns to 70\\n Plan:\\n Continue monitoring BP, I/O\\n Alteration in Nutrition\\n Assessment:\\n Obtained large feed like secretions orally. ? aspiration Abd\\n dist, soft with hypoactive BS. No BM on this shift. Pt\\ns head needs to\\n be lowered down as BP is Low.\\n Action:\\n TF held . Peg tube flushed & clamped.\\n Response:\\n Towards morning changed to thick secretions like the color of the\\n feeds mixed with saliva. By MD . At 4am obtained tannish\\n loose copious amts of oral secretions.\\n Plan:\\n Hold feeds till am rounds as MD . Intern Discussed about a\\n dye test. No plans at present to do the dye study to determine\\n aspiration.\\n Hypernatremia (high sodium)\\n Assessment:\\n Na 140 in pm labs. As feeds were held water boluses held too.\\n Action:\\n Orders to give NS Fluid bolus( discussed about the chances of ^ Na\\n levels) . Team would like to go ahead with NS fluid boluses. Total of\\n 2250 mls given overnight. Patient diuresed a total of mls.\\n Response:\\n Na 145 in am labs\\n Plan:\\n Continue to monitor I/O, Lytes.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-09 00:00:00.000\",\n \"description\": \"Generic Note\",\n \"row_id\": 636494,\n \"text\": \"TITLE:\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Received Pt on vent via trach in CPAP+PS at 50 %/. LS coarse\\n with diminished bases.. RR 28 to 30/min sats intermittently down to 91\\n %.\\n Action:\\n Suctioned fro small amts of tan thick mildly blood tinged sputum. Vent\\n Mode changed to AC TV 400, RR 10, peep 8 for the night as per\\n discussion By Resident & MD to rest for the night.\\n Response:\\n Sats maintained in Mid 90\\ns to high 90\\ns. ABG done in am PH\\n 7.35/50/81/29/ Sats 96. Set RR ^ to 12 post abg\\n Plan:\\n Wean vent settings as tolerated. Plan to IP to follow up regarding ?\\n need for stent tomorrow.\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt lethargic, arousable to stimuli, Po diazepam dose was held at 1800\\n hrs, Haldol po dose was given at hrs to continue to rest the\\n patient & keep her calm .\\n Action:\\n Fentanyl patch weaned down to 75 micgs. off fentanyl patch From\\n Midnight till 530am.\\n Response:\\n Patient wide awake at 0345 am, Calm & still after being restless for\\n few minutes. responds to name & follows commands inconsistently, Tracks\\n well. Continues to be lethargic. Further haldol & diazepam doses held .\\n Plan:\\n Continue to eval restlessness & treat as needed.\\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\\n Assessment:\\n Temp up to 101.4. axillary at hrs . WBC Upto 11.3 in am labs. Was\\n 9.4 in pm labs.\\n Action:\\n Tylenol 650 mgs given, Pan cultured, started on vanco, aztreonam &\\n Levofloxacin.\\n Response:\\n Temp down to 98.1 orally at 4 am.\\n Plan:\\n Continue monitoring temp, continue anbx, follow up on cultures.\\n Anemia, other\\n Assessment:\\n Blood tinged sputum obtained when suctioned via trach. INR 4.0 ( Goal\\n INR 2 to 3.0as MD ), HCT down to 24.9, HgB 7.7 in am labs, (Total\\n of 2lits NS was given at this time)\\n Action:\\n Coumadin not given on the night of \\n Response:\\n No other bleeding seen.\\n Plan:\\n Monitor Labs, S/S bleeding\\n Hypotension (not Shock)\\n Assessment:\\n Received with NIBP systolic in mid 90\\ns, maps of mid 50\\ns. At \\n hrs Sbp\\ns 70\\ns to 80\\ns, Maps in low to high 40\\n Action:\\n Total 2.25 litres of fluid given, started on Levophed gtt at 0040 hrs.\\n Response:\\n Sbp\\ns in 100\\ns to 130\\ns, maps in 60\\ns to 70\\ns.Patient diuresing copious\\n amts when she is awake & bp is higher Weaned Levophed titrated to\\n maintain BP. Currently @ 0.03 mics/kg/min, BP is 119/55(68).\\n Plan:\\n Continue monitoring BP, I/O.\\n Alteration in Nutrition\\n Assessment:\\n Obtained large feed like secretions orally. ? aspiration Abd\\n dist, soft with hypoactive BS. No BM on this shift. Pt\\ns head needs to\\n be lowered down as BP is Low.\\n Action:\\n TF held . Peg tube flushed & clamped.\\n Response:\\n Towards morning changed to thick secretions like the color of the\\n feeds mixed with saliva. By MD . At 4am obtained tannish\\n loose copious amts of oral secretions.\\n Plan:\\n Hold feeds till am rounds as MD . Intern Discussed about a\\n dye test. No plans at present to do the dye study to determine\\n aspiration.\\n Hypernatremia (high sodium)\\n Assessment:\\n Na 140 in pm labs. As feeds were held water boluses held too.\\n Action:\\n Orders to give NS Fluid bolus( discussed about the chances of ^ Na\\n levels) . Team would like to go ahead with NS fluid boluses. Total of\\n 2250 mls of Fluid bolus given overnight. Patient diuresed a total of\\n 2220 mls from 7pm to 6am.\\n Response:\\n Na 145 in am labs\\n Plan:\\n Continue to monitor I/O, Lytes.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-10 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 636772,\n \"text\": \"Altered mental status (not Delirium)\\n Assessment:\\n Rec\\nd pt restless, intermit following commands. MAEE with good\\n strength. Pt shaking head\\n when asked if has pain or SOB.\\n Action:\\n Torso brace applied\\nwith difficulty\\nand pt OOB to stretcher/chair with\\n transfer via board.\\n Response:\\n Pt increasingly restless with HR 130-140ST, grimacing. Pt attempting to\\n stand and/or exit chair. Pt rec\\nd scheduled Valium 5mg po early, as\\n well as Morphine Sulfate 2mg IVP without relief of discomfort. Pt\\n returned to bed after 45mins. When brace removed, chin noted to be\\n abraided from chin rest. Pt cont to be restless all afternoon, freq\\n attempting to sit up in bed. Soft wrist restraints in place for pt\\n safety.\\n Plan:\\n Duoderm to chin or chin-rest when brace applied. Attempt OOB to chair\\n again tomorrow.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Rec\\nd pt on vent settings AC 50%/ 12 X 500/+5 with rare over-breathing\\n of rate. O2 sat 100%. Lung snds with rhonchi in RUL, clear in LUL, and\\n diminished bilat in bases. Pt requiring sxn\\ning Q2-4hrs for mod amts\\n yellow/white thick secretions. Pt also intermit with copious thick,\\n clear oral secretions.\\n Action:\\n Vent changed to CPAP/PS 8/+5/50% with SRR 14-25 and regular, O2 sat\\n remaining 98-100%. Pt then placed on trach mask @ 80%.\\n Response:\\n Pt has tolerated TM for several hrs, with RR remaining regular @\\n 14-25/min, O2 sat 100%.\\n Plan:\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2167-10-11 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 636930,\n \"text\": \"TITLE:\\n Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 23\\n Ideal body weight: 61.2 None\\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: Yes\\n Procedure location:\\n Reason:\\n Tube Type\\n ETT:\\n Position: cm at teeth\\n Route:\\n Type:\\n Size:\\n Tracheostomy tube:\\n Type: Cuffed\\n Manufacturer: Portex\\n Size: 7.0mm\\n PMV:\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 28 cmH2O\\n Cuff volume: mL /\\n Airway problems:\\n Comments: probable for PMV eval tomorrow by speech\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Rhonchi\\n LUL Lung Sounds: Rhonchi\\n LLL Lung Sounds: Diminished\\n Comments:\\n Secretions\\n Sputum color / consistency: White / Thick\\n Sputum source/amount: Suctioned / Moderate\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance: Intermittent invasive ventilation\\n Visual assessment of breathing pattern: Normal quiet breathing;\\n Comments: pt tolerating trach collar through majority of shift thus\\n far, will contiue to eval periodically\\n Assessment of breathing comfort: No claim of dyspnea)\\n Non-invasive ventilation assessment:\\n Invasive ventilation assessment:\\n Trigger work assessment: Triggering synchronously\\n Dysynchrony assessment:\\n Comments:\\n Plan\\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\\n Reason for continuing current ventilatory support: weaning as tolerated\\n Respiratory Care Shift Procedures\\n Transports:\\n Destination (R/T)\\n Time\\n Complications\\n Comments\\n Bedside Procedures:\\n Comments:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-05 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 635811,\n \"text\": \"55 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\\n Now with prolonged hospital course c/b by PNA with high PEEP\\n requirement, anxiety, RUE DVT on heparin qtt.\\n Edema, peripheral\\n Assessment:\\n Fluid balance for previous 24hrs decreased by 3 liters D/T diuresis.\\n Rec\\nd pt off of Lasix qtt. Urine output decreased to 45ml/hr @1000.\\n Action:\\n Lasix qtt restarted @ 2mg/hr to maintain urine output 1-2liters/day.\\n Response:\\n Fluid balance approx -50ml/hr, with 24hr fluid balance -650ml @ 1500.\\n However, SBP 78 when pt soundly sleeping/sedated. Lasix qtt stopped @\\n 1530.\\n Plan:\\n Restart Lasix qtt when BP stabilized.\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Rec\\nd pt on Heparin qtt @ 1500units/hr.\\n Action:\\n PTT 92.1 @ 1230.\\n Response:\\n Per goal PTT 60-100, Heparin rate unchanged.\\n Plan:\\n Repeat PTT @ 1830. Start po Coumadin tonight.\\n Altered mental status (not Delirium)\\n Assessment:\\n Rec\\nd pt on Versed @ 2mg/hr, Fentanyl @ 75 mcg/hr, as well as Fentanyl\\n patches totaling 150mcg in place. Pt also rec\\ning Diazepam 10mg po\\n Q6hrs, in hope of weaning pt from IV sedation. Agitated most time\\n moving around intermittently following commands. Moving arms\\n purposefully towards trach, so soft wrist restraints remain in place..\\n Action:\\n Pt required bolus sedation x2 with care and activity.\\n Response:\\n Pt restless/squirming in bed when she appears awake..\\n Plan:\\n Cont to attempt weaning from IV sedation. emotional support to pt and\\n family,reorient pt .\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Rec\\nd pt on vent settings AC 50%/18 X 400/+10, with no over-breathing\\n of rate by pt. O2 sa\\\\94-96%. ABG done yesterday was 7.44/42/93. Lung\\n snds clear but diminished in lower lobes. Suctionned for small-moderate\\n amts thick white secretions.\\n Action:\\n .Cont same Vent settings.\\n Response:\\n Pts secretions got better\\n Plan:\\n Cont wean from vent with PS trials,Monitor mental status.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-05 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 635814,\n \"text\": \"55 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\\n Now with prolonged hospital course c/b by PNA with high PEEP\\n requirement, anxiety, RUE DVT on heparin qtt.\\n Edema, peripheral\\n Assessment:\\n Fluid balance for previous 24hrs decreased by 3 liters D/T diuresis.\\n Rec\\nd pt off of Lasix qtt. Urine output decreased to 45ml/hr @1000.\\n Action:\\n Lasix qtt restarted @ 2mg/hr to maintain urine output 1-2liters/day.\\n Response:\\n Fluid balance approx -50ml/hr, with 24hr fluid balance -650ml @ 1500.\\n However, SBP 78 when pt soundly sleeping/sedated. Lasix qtt stopped @\\n 1530.\\n Plan:\\n Restart Lasix qtt when BP stabilized.\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Rec\\nd pt on Heparin qtt @ 1500units/hr.\\n Action:\\n PTT 62,2 @ 0230.\\n Response:\\n Heparin rate unchanged.pt had 2 therapeutic PTT,started on coumadin\\n 5mg at 2200,.\\n Plan:\\n Cont heparin gtt as well as Coumadin until INR ^ 2.\\n Altered mental status (not Delirium)\\n Assessment:\\n Rec\\nd pt on Versed @ 2mg/hr, Fentanyl @ 75 mcg/hr, as well as Fentanyl\\n patches totaling 150mcg in place. Pt also rec\\ning Diazepam 10mg po\\n Q6hrs, in hope of weaning pt from IV sedation. Agitated most time\\n moving around intermittently following commands. Moving arms\\n purposefully towards trach, so soft wrist restraints remain in place..\\n Action:\\n Pt required bolus sedation x2 with care and activity.\\n Response:\\n Pt restless/squirming in bed when she appears awake..\\n Plan:\\n Cont to attempt weaning from IV sedation. emotional support to pt and\\n family,reorient pt .\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Rec\\nd pt on vent settings AC 50%/18 X 400/+10, with no over-breathing\\n of rate by pt. O2 sa\\\\94-96%. ABG done yesterday was 7.44/42/93. Lung\\n snds clear but diminished in lower lobes. Suctionned for small-moderate\\n amts thick white secretions.\\n Action:\\n .Cont same Vent settings.\\n Response:\\n Pts secretions got better\\n Plan:\\n Cont wean from vent with PS trials,Monitor mental status.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-06 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 635952,\n \"text\": \"Bradycardia\\n Assessment:\\n Pt conts with HR 50-70\\ns at rest, 100-140\\ns during care, pt\\n asymptomatic; easily arousable\\n Action:\\n Sedation decreased, Lasix off @0200\\n Response:\\n HR 60\\n Plan:\\n Cont to wean sedation, ?cardiac consult\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Action:\\n Cont with IV Heparin @ 1500u/hr, Coumadin d\\ncd for? thoracentesis\\n Response:\\n Pt therapeutic, cont with daily PTT\\n Plan:\\n Cont to labs, cont to wean off Heparin, Coumadin 5mg given x 1dose\\n @ 2200, re-eval dosing this am\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt cont on AC 18/400/50%/10, LS clear bilat, occ scat rhonchi\\n Action:\\n Pt suct for sm thin tan secretions\\n Response:\\n Plan:\\n Cont to ABGs,\\n Hypotension (not Shock)\\n Assessment:\\n SBP 140\\ns when pt is agitated, SBP dropping to 70\\ns-80\\ns, UO 200/hr\\n (total 2500 in 2hr)\\n Action:\\n Fent/Versed turned down @ 0000, Lasix gtt on hold, team informed\\n Response:\\n Pt SBP\\ns in 80\\n Plan:\\n Cardiac consult to further eval SB/ST, re-evalu cont. Lasix gtt\\n Hypernatremia (high sodium)\\n Assessment:\\n Na 146\\n Action:\\n Cont with 300cc free water flush Q4hrs\\n Response:\\n Plan:\\n Cont to sodium levels, treat as ordered\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt alert and agitated throughout shift, pt following commands\\n inconsistently; sleeping off and off throughout shift\\n Action:\\n Fent/Versed decreased low SBP\\ns, pt recved prn dose of Haldol 1mg @\\n 0100; cont with bilat. Wrist restraints for safety\\n Response:\\n pt sleeping off/on throughout shift, with periods of\\n agitation/restlessness\\n Plan:\\n Cont to wean fent/versed gtt down, cont with scheduled Haldol/Valium;\\n cont to QTC intervals daily\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-06 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 635953,\n \"text\": \"55 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\\n Now with prolonged hospital course c/b by PNA with high PEEP\\n requirement, anxiety, RUE DVT on heparin qtt.\\n Bradycardia\\n Assessment:\\n Pt conts with HR 50-70\\ns at rest, 100-140\\ns during care, pt\\n asymptomatic; easily arousable\\n Action:\\n Sedation decreased, Lasix off @0200\\n Response:\\n HR 60\\n Plan:\\n Cont to wean sedation, ?cardiac consult\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Action:\\n Cont with IV Heparin @ 1500u/hr, Coumadin d\\ncd for? thoracentesis\\n Response:\\n Pt therapeutic, cont with daily PTT\\n Plan:\\n Cont to labs, cont to wean off Heparin, Coumadin 5mg given x 1dose\\n @ 2200, re-eval dosing this am\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt cont on AC 18/400/50%/10, LS clear bilat, occ scat rhonchi\\n Action:\\n Pt suct for sm thin tan secretions\\n Response:\\n Plan:\\n Cont to ABGs,\\n Hypotension (not Shock)\\n Assessment:\\n SBP 140\\ns when pt is agitated, SBP dropping to 70\\ns-80\\ns, UO 200/hr\\n (total 2500 in 2hr)\\n Action:\\n Fent/Versed turned down @ 0000, Lasix gtt on hold, team informed\\n Response:\\n Pt SBP\\ns in 80\\n Plan:\\n Cardiac consult to further eval SB/ST, re-evalu cont. Lasix gtt\\n Hypernatremia (high sodium)\\n Assessment:\\n Na 146\\n Action:\\n Cont with 300cc free water flush Q4hrs\\n Response:\\n Plan:\\n Cont to sodium levels, treat as ordered\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt alert and agitated throughout shift, pt following commands\\n inconsistently; sleeping off and off throughout shift\\n Action:\\n Fent/Versed decreased low SBP\\ns, pt recved prn dose of Haldol 1mg @\\n 0100; cont with bilat. Wrist restraints for safety\\n Response:\\n pt sleeping off/on throughout shift, with periods of\\n agitation/restlessness\\n Plan:\\n Cont to wean fent/versed gtt down, cont with scheduled Haldol/Valium;\\n cont to QTC intervals daily\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-08 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 636425,\n \"text\": \"Alteration in Nutrition\\n Assessment:\\n Abd dist, soft with hypoactive BS. No BM on this shift.\\n Action:\\n TF restarted at goal at 60 cc/hr with minimal residuals.\\n Response:\\n Plan:\\n Follow FSBS. ? adding more laxatives until BM.\\n Fracture, other\\n Assessment:\\n Pt out of bed in stretcher chair with brace in place most of day. Pt\\n did very well.\\n Action:\\n Pt tol being OOb well in regards to resp status and MS.\\n Response:\\n Plan:\\n Plan to take pt OOB to cahir tomorrow also.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt remains on vent via trach in CPAP+PS at 50 %/. LS CTA with\\n diminished bases. Pt has been deep sx\\nd for sml amounts of tan to thick\\n yellow secretions.\\n Action:\\n Vent changed to 5/5, but was only tolerated for 1 hr.\\n Response:\\n After 1 hr pt became tachycardic and tachypnic. O2sat decreased to 95%.\\n Plan:\\n Continue to wean vent settings as tolerated. Plan to IP to follow up\\n regarding ? need for stent tomorrow.\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt opens eyes to voice, but will only follow simple commands very\\n inconsistently. Pt is very lethargic. Pt found this am to be very\\n restless and given versed with no effect.\\n Action:\\n After pt placed in a chair, and pt more relaxed. Pt was calm, but her\\n HR was in the 120-130\\ns (while awake). Pt given Morphine with good\\n effect. Fentanyl patches weaned down to 100 mcg.\\n Response:\\n Plan:\\n Continue to eval restlessness.\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2167-10-09 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 636480,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 21\\n Ideal body weight: 61.2 None\\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: Yes\\n Procedure location:\\n Reason:\\n Tube Type\\n Tracheostomy tube:\\n Type: Cuffed\\n Manufacturer: Portex\\n Size: 7.0mm\\n PMV: No\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 28 cmH2O\\n Cuff volume: mL /\\n Airway problems:\\n Comments: Large cuff volume needed for air tight seal\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Rhonchi\\n LUL Lung Sounds: Rhonchi\\n LLL Lung Sounds: Diminished\\n Comments:\\n Secretions\\n Sputum color / consistency: Tan / Thick\\n Sputum source/amount: Suctioned / Copious\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance: Continuous invasive ventilation\\n Visual assessment of breathing pattern: Normal quiet breathing,\\n Frequent desaturation episodes; Comments: Pt had some episodes of\\n desaturations after turning and suctioning. Pt was switched to AC as\\n MD orders due to lowing SpO2 and increased WOB\\n Assessment of breathing comfort:\\n Non-invasive ventilation assessment:\\n Invasive ventilation assessment:\\n Trigger work assessment: Triggering synchronously\\n Dysynchrony assessment:\\n Comments: Pt is stable on vent (AC settings)as per Expiratory Tv, RR\\n and SpO2\\n Plan\\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\\n Periodic SBT's for conditioning, Adjust Min. ventilation to control pH;\\n Comments: Pt to con't current support. Pt showed poor RSBI trial, due\\n to low Tidal volumes.\\n Reason for continuing current ventilatory support: Cannot protect\\n airway, Cannot manage secretions, Underlying illness not resolved\\n BEDSIDE RSBI- 126\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-09 00:00:00.000\",\n \"description\": \"Generic Note\",\n \"row_id\": 636485,\n \"text\": \"TITLE:\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Received Pt on vent via trach in CPAP+PS at 50 %/. LS finely\\n coarse with diminished bases.. RR 28 to 30/min sats intermittently down\\n to 91 %.\\n Action:\\n Suctioned fro small amts of tan thick mildly blood tinged sputum. Vent\\n Mode changed to AC TV 400, RR 10, peep 8 for the night as per\\n discussion By Resident & MD to rest for the night.\\n Response:\\n Sats maintained in Mid 90\\ns to high 90\\ns. ABG done in am PH\\n 7.35/50/81/29/ Sats 96. Set RR ^ to 12 post abg\\n Plan:\\n Wean vent settings as tolerated. Plan to IP to follow up regarding ?\\n need for stent tomorrow.\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt lethargic, arousable to stimuli, Po diazepam dose was held at 1800\\n hrs,.haldol po dose was given at hrs\\n Action:\\n HR was in the 120-130\\ns (while awake) Fentanyl patches weaned down to\\n 75 micgs. Currently off fentanyl patch.\\n Response:\\n Patient wide awake at 4am, Calm & still after being restless for few\\n minutes. responds to name & follows commands inconsistently, continues\\n to be lethargic.\\n Plan:\\n Continue to eval restlessness.\\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\\n Assessment:\\n Temp up to 101.4. axillary at hrs .\\n Action:\\n Tylenol 650 mgs given, Pan cultured, started on vanco, aztreonam &\\n Levofloxacin.\\n Response:\\n Temp down to 98.1 orally at 4 am.\\n Plan:\\n Continue monitoring temp, continue anbx, follow up on cultures.\\n Anemia, other\\n Assessment:\\n Blood tinged sputum obtained when suctioned via trach. INR 4.0 ,HCT\\n down to 24.9, HgB 7.7 in am labs, (Total of 2lits NS was given at this\\n time)\\n Action:\\n Coumadin not given on the night of \\n Response:\\n No other bleeding seen.\\n Plan:\\n Monitor Labs, S/S bleeding\\n Hypotension (not Shock)\\n Assessment:\\n Received with NIBP systolic in mid 90\\ns, maps of mid 50\\ns. At \\n hrs Sbp\\ns 70\\ns to 80\\ns, Maps in low to high 40\\n Action:\\n Total 2.25 litres of fluid given, started on Levophed gtt at 0040 hrs.\\n Response:\\n Sbp\\ns in 100\\ns to 120\\ns, maps in 60\\ns to 70\\n Plan:\\n Continue monitoring BP, I/O\\n Alteration in Nutrition\\n Assessment:\\n Obtained large feed like secretions orally. ? aspiration Abd\\n dist, soft with hypoactive BS. No BM on this shift. Pt\\ns head needs to\\n be lowered down as BP is Low.\\n Action:\\n TF held . Peg tube flushed & clamped.\\n Response:\\n Towards morning changed to thick secretions like the color of the\\n feeds mixed with saliva. By MD . At 4am obtained tannish\\n loose copious amts of oral secretions.\\n Plan:\\n Hold feeds till am rounds as MD . Intern Discussed about a\\n dye test. No plans at present to do the dye study to determine\\n aspiration.\\n Hypernatremia (high sodium)\\n Assessment:\\n Na 140 in pm labs. As feeds were held water boluses held too.\\n Action:\\n Orders to give NS Fluid bolus( discussed about the chances of ^ Na\\n levels) . Team would like to go ahead with NS fluid boluses. Total of\\n 2250 mls given overnight. Patient diuresed a total of mls.\\n Response:\\n Na 145 in am labs\\n Plan:\\n Continue to monitor I/O, Lytes.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-09 00:00:00.000\",\n \"description\": \"Physician Resident/Attending Progress Note - MICU\",\n \"row_id\": 636590,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Arterial line d/c'd\\n Spiked a fever of 101.4, blood and urine cultures sent, CXR. Started\\n Vanc, Levo, Aztreonam\\n Persistently hypotensive to 70s SBP overnight with low urine output and\\n poor O2 sats.\\n Started on Levophed, and given 1.75L NS. BPs improved to 90-120s SBP,\\n and urine output increased significantly.\\n Large amount of oral secretions, ?gastric in origin\\n Tube feeds held for ? of aspiration.\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Vancomycin - 11:00 PM\\n Levofloxacin - 11:43 PM\\n Aztreonam - 04:07 AM\\n Infusions:\\n Norepinephrine\\n Off at 7:30 AM\\n Other ICU medications:\\n Midazolam (Versed) - 09:30 AM\\n Morphine Sulfate - 03:17 PM\\n Furosemide (Lasix) - 06:36 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:36 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.6\\nC (101.4\\n Tcurrent: 36.7\\nC (98.1\\n HR: 131 (73 - 142) bpm\\n BP: 127/43(60) {71/29(42) - 137/97(101)} mmHg\\n RR: 21 (12 - 36) insp/min\\n SpO2: 97%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 4,627 mL\\n 1,084 mL\\n PO:\\n TF:\\n 839 mL\\n IVF:\\n 2,288 mL\\n 1,084 mL\\n Blood products:\\n Total out:\\n 2,407 mL\\n 2,220 mL\\n Urine:\\n 2,407 mL\\n 2,220 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 2,220 mL\\n -1,136 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 400 (400 - 400) mL\\n Vt (Spontaneous): 412 (236 - 480) mL\\n PS : 8 cmH2O\\n RR (Set): 12\\n RR (Spontaneous): 0\\n PEEP: 8 cmH2O\\n FiO2: 50%\\n RSBI: 126\\n PIP: 21 cmH2O\\n Plateau: 17 cmH2O\\n Compliance: 44.4 cmH2O/mL\\n SpO2: 97%\\n ABG: 7.35/50/81./26/0\\n Ve: 7 L/min\\n PaO2 / FiO2: 162\\n Physical Examination\\n General Appearance: Trached and sedated. Responsive, following\\n commands, Overweight / Obese, mild agitation but NAD\\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\\n deviation\\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\\n Cardiovascular: (S1: Normal), (S2: Normal), distant\\n Respiratory / Chest: (Expansion: Symmetric), CTA anteriorly, decreased\\n BS\\n Abdominal: Obese, soft, Non-tender, no rebound, no guarding, + BS, PEG\\n in place with dressing C/D/I\\n Extremities: no CCE\\n Skin: no rashes or jaundice\\n Lines: r brachioceph ART with large amount of bloody drainage and L\\n PICC C/D/I\\n Labs / Radiology\\n 227 K/uL\\n 7.7 g/dL\\n 114 mg/dL\\n 0.7 mg/dL\\n 26 mEq/L\\n 4.0 mEq/L\\n 16 mg/dL\\n 112 mEq/L\\n 145 mEq/L\\n 24.9 %\\n 11.3 K/uL\\n [image002.jpg]\\n 03:46 AM\\n 10:20 AM\\n 03:46 PM\\n 01:37 AM\\n 05:32 AM\\n 02:43 PM\\n 03:03 PM\\n 08:11 PM\\n 02:51 AM\\n 03:10 AM\\n WBC\\n 11.1\\n 9.4\\n 11.3\\n Hct\\n 29.4\\n 26.6\\n 24.9\\n Plt\\n \\n Cr\\n 0.8\\n 0.6\\n 0.9\\n 0.7\\n TCO2\\n 35\\n 37\\n 31\\n 31\\n 30\\n 29\\n Glucose\\n 155\\n 123\\n 128\\n 114\\n 114\\n Other labs: PT / PTT / INR:37.2/37.9/4.0, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Lactic Acid:0.5 mmol/L, Albumin:2.4 g/dL,\\n LDH:204 IU/L, Ca++:8.7 mg/dL, Mg++:2.6 mg/dL, PO4:4.2 mg/dL\\n Blood/Urine/Sputum culture pending\\n Assessment and Plan\\n 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA, and\\n ARDS, intubated since the end of now s/p trach and PEG\\n placement.\\n # Fever: Likely secondary to aspiration pneumonitis. Given prolonged\\n hospitalization and tenuous respiratory status will treat with\\n antibiotics while cultures pending\\n - Vanc/Cef/Azithro for 48 hours while waiting for sputum results.\\n - Hold tube feeds for 24 hours\\n - Follow cultures\\n - Off levophed\\n .\\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\\n volume overload. Intubated on for resp decompensation. S/P Trach\\n and PEG on .\\n - wean FiO2 as tolerated\\n - attempt wean PS today and hopeful for trach mask trial\\n # Sedation: Continue to have issues with pain/delirium causing\\n tachycardia and hypertension with intermittent hypotension. On Haldol\\n 5 TID, Fentanyl 75 mcg TP, Diazapam 10 QID; Haldol, midazolam and\\n morphine PRN. Had good response to morphine, minimal response to\\n haldol bolus.\\n - Reduce diazepam to 5 q 8hrs.\\n - d/c standing Haldol\\n # Adrenal Insufficency: Hypotension that resolved with steroids,\\n returned as they came off and is now improved again. Possible primary\\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\\n started on .\\n - 10 q am and 5 q pm prednisone day 2 of 3, will wean to\\n maintenance dose as tolerated, in consultation with endo.\\n # Volume overloaded in setting of hypernatremia with TBW deficit and\\n metabolic alkalosis\\n - Goal of even in the setting of recent hypotension.\\n - Off diamox\\n - electrolytes\\n - Will give IV free water rather than flushes. D5W 1L@100 cc/hr\\n # Falling Hct: Likely dilutional. Concern given elevated INR\\n - Recheck in PM\\n - Type and screen\\n # RUE DVT: INR now therapeutic on coumadin. Goal \\n - stop heparin gtt\\n - will start coumadin 2.5 mg QHS once INR < 3\\n # Spine fracture: Neurologically intact distal to the lesion. Prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - Brace for OOB\\n - report from full trauma series from OSH is in chart. No evidence of\\n other fracture and no need for further spinal imaging based on this\\n report and ortho note.\\n # Tracheomalacia: Discussed with IP. Stenting unlikely to help for\\n trachiomalacia as airways have poor structure diffusely.\\n - Outpatient f/u once off pressure support to assess for possible\\n stenting\\n #. Thyroid Nodule on CT\\n -outpatient follow up\\n # Nutrition: Hold tube feeds x 24 hours, continue Replete (Full)\\n will reintroduce slowly\\n - advance bowel regimen\\n # Glycemic control: SSI, well controlled\\n # Lines L PICC (). ABG and VBG correlate well.\\n # Ppx: INR therapeutic, ranitidine, colace and senna, miralax,\\n bisacodyl.\\n # Communication:\\n - Boyfriend of 10 \\n - Brother is her HCP, also involved\\n Code: Full\\n Dispo: ICU, being screening for vent facilities\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n PICC Line - 09:19 PM\\n 18 Gauge - 08:15 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n ------ Protected Section ------\\n MICU ATTENDING ADDENDUM\\n I saw and examined the patient, and was physically present with the ICU\\n team for the key portions of the services provided. I agree with the\\n note above, including the assessment and plan. I would emphasize and\\n add the following points: 55F T5-8 fractures with retropulsion and ARDS\\n from klebsiella VAP; on heparin for UE DVT and lasix for volume\\n overload. Febrile overnight with ? aspiration, now back on antibiotics\\n with HCT drop, hypotensive requiring levophed.\\n Exam notable for Tm 101.4 BP 120/43 HR 100-130 RR 18-20 with sat 97% on\\n VAC 400x12 PEEP 8, FiO2 0.4, ABG 7.35/50/81. Eyes opens, more alert.\\n Clearer BS bilaterally with RRR s1s2 SM at base. Abdomen is\\n distended with decreased BS. Trace edema in BLE, no cords. Labs notable\\n for WBC 11K, HCT 25, K+ 4.0, Na 145, Cr 0.7, INR 4.0. CXR without\\n significant change.\\n Agree with plan to transition back from VAC to PSV and to continue\\n antibiotics x48 while awaiting cultures. Abdomen is distended; will\\n hold tube feeds and increase bowel regimen including possible PO\\n narcan. INR is high and HCT is down; will hold coumadin and guiac\\n stool, confirm BBS and check PM HCT. Will continue fentanyl patch at\\n 150mcg and valium 5q8h. Will change haldol to PRN, and wean\\n hydrocortisone per endocrine. Will continue FW boluses for\\n hypernatremia. Continue spinal stabilization with brace when OOB; will\\n review outside images with spine surgery but no plan for acute\\n intervention. Remainder of plan as outlined above.\\n Patient is critically ill\\n Total time: 45 min\\n ------ Protected Section Addendum Entered By: , MD\\n on: 05:19 PM ------\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-11 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 636829,\n \"text\": \"Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Received pt on trach collar 50%. Sats fell to 78%. Pt ambu\\nd and\\n lavaged with no plugs detected. RR 30-40 . Pt diaphoretic.\\n Action:\\n Placed on PSV 10/5/50%\\n Response:\\n Apneic with RR 3-5\\n Plan:\\n Rested on AC 500/12/5/50%. No further episodes of desating or\\n tachypnea.\\n Hypotension (not Shock)\\n Assessment:\\n BP falling to 78/37. Urine output 5-30ccs/hr via foley\\n Action:\\n Given 500ccs\\n NS fluid bolus\\n Response:\\n Plan:\\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\\n Assessment:\\n Temp spike to 102.2 po\\n Action:\\n Blood, urine and sputum cxs sent. Chest x-ray taken. Tylenol pr given.\\n Cool cloths applied.\\n Response:\\n Temp down to 100.4\\n Plan:\\n Alteration in Nutrition\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-11 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 636830,\n \"text\": \"Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Received pt on trach collar 50%. Sats fell to 78%. Pt ambu\\nd and\\n lavaged with no plugs detected. RR 30-40 . Pt diaphoretic.\\n Action:\\n Placed on PSV 10/5/50%\\n Response:\\n Apneic with RR 3-5\\n Plan:\\n Rested on AC 500/12/5/50%. No further episodes of desating or\\n tachypnea.\\n Hypotension (not Shock)\\n Assessment:\\n BP falling to 78/37. Urine output 5-30ccs/hr via foley\\n Action:\\n Given 500ccs\\n NS fluid bolus\\n Response:\\n Pt normotensive, improved urine output\\n Plan:\\n Continue to monitor.\\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\\n Assessment:\\n Temp spike to 102.2 po\\n Action:\\n Blood, urine and sputum cxs sent. Sputum white, not yellow or\\n consistant with TF. Chest x-ray taken. Tylenol pr given. Cool cloths\\n applied.\\n Response:\\n Temp down to 100.4\\n Plan:\\n Monitor fever curve, cooling measures. Follow-up on cx results.\\n Alteration in Nutrition\\n Assessment:\\n Pt vomiting yellow fluid with coughing and when turned\\n Action:\\n TF held. Peg to gravity. Medicated with 4 mg zofran iv.\\n Response:\\n No further episodes of vomiting.\\n Plan:\\n Continue to monitor. Aspiration precautions.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-11 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 636833,\n \"text\": \"Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Received pt on trach collar 50%. Sats fell to 78%. Pt ambu\\nd and\\n lavaged with no plugs detected. RR 30-40 . Pt diaphoretic.\\n Action:\\n Placed on PSV 10/5/50%\\n Response:\\n Apneic with RR 3-5\\n Plan:\\n Rested on AC 500/12/5/50%. No further episodes of desating or\\n tachypnea.\\n Hypotension (not Shock)\\n Assessment:\\n BP falling to 78/37. Urine output 5-30ccs/hr via foley\\n Action:\\n Given 500ccs\\n NS fluid bolus\\n Response:\\n Pt normotensive, improved urine output\\n Plan:\\n Continue to monitor.\\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\\n Assessment:\\n Temp spike to 102.2 po\\n Action:\\n Blood, urine and sputum cxs sent. Sputum white, not yellow or\\n consistant with TF. Chest x-ray taken. Tylenol pr given. Cool cloths\\n applied.\\n Response:\\n Temp down to 100.4\\n Plan:\\n Monitor fever curve, cooling measures. Follow-up on cx results.\\n Alteration in Nutrition\\n Assessment:\\n Pt vomiting yellow fluid with coughing and when turned\\n Action:\\n TF held. Peg to gravity. Medicated with 4 mg zofran iv.\\n Response:\\n No further episodes of vomiting.\\n Plan:\\n Continue to monitor. Aspiration precautions.\\n Altered mental status (not Delirium)\\n Assessment:\\n Onset of shift, pt lethargic, not following commands but MAE. ~ 12 mn\\n pt agitated, attempting to climb oob, disconnecting self from vent\\n despite restraints\\n Action:\\n 5 mg valium given q 8hrs\\n Response:\\n Pt still agitated\\n Plan:\\n Needs better sedation at bedtime - ? zyprexa or alternative med\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-11 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 636905,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Spiked to 102.2 after aspiration of tube feeds (only at 10 cc/hr) - pan\\n cultured and given tylenol\\n INR rising\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Aztreonam - 03:42 AM\\n Vancomycin - 09:40 AM\\n Levofloxacin - 11:15 PM\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 07:47 AM\\n Morphine Sulfate - 05:16 AM\\n Other medications:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:08 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 39\\nC (102.2\\n Tcurrent: 37.1\\nC (98.7\\n HR: 129 (86 - 137) bpm\\n BP: 102/52(64) {78/26(42) - 155/89(100)} mmHg\\n RR: 15 (12 - 65) insp/min\\n SpO2: 99%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 1,299 mL\\n 500 mL\\n PO:\\n TF:\\n 55 mL\\n IVF:\\n 699 mL\\n 500 mL\\n Blood products:\\n Total out:\\n 2,990 mL\\n 485 mL\\n Urine:\\n 2,990 mL\\n 485 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,691 mL\\n 15 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 500 (500 - 500) mL\\n Vt (Spontaneous): 513 (328 - 561) mL\\n PS : 0 cmH2O\\n RR (Set): 12\\n RR (Spontaneous): 0\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n RSBI Deferred: Agitated\\n PIP: 22 cmH2O\\n SpO2: 99%\\n ABG: ///26/\\n Ve: 6.6 L/min\\n Physical Examination\\n Labs / Radiology\\n 238 K/uL\\n 8.4 g/dL\\n 106 mg/dL\\n 0.9 mg/dL\\n 26 mEq/L\\n 3.9 mEq/L\\n 11 mg/dL\\n 108 mEq/L\\n 143 mEq/L\\n 26.9 %\\n 7.2 K/uL\\n [image002.jpg]\\n 02:43 PM\\n 03:03 PM\\n 08:11 PM\\n 02:51 AM\\n 03:10 AM\\n 03:08 PM\\n 03:00 AM\\n 03:36 AM\\n 04:40 PM\\n 03:00 AM\\n WBC\\n 9.4\\n 11.3\\n 7.3\\n 6.1\\n 7.2\\n Hct\\n 26.6\\n 24.9\\n 27.6\\n 26.5\\n 26.9\\n Plt\\n 09\\n 238\\n Cr\\n 0.9\\n 0.7\\n 0.6\\n 0.6\\n 0.9\\n TCO2\\n 31\\n 30\\n 29\\n 26\\n Glucose\\n 128\\n 114\\n 114\\n 99\\n 115\\n 106\\n Other labs: PT / PTT / INR:72.4/42.1/9.0, Ca++:9.3 mg/dL, Mg++:2.5\\n mg/dL, PO4:3.6 mg/dL\\n Assessment and Plan\\n 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA, and\\n ARDS, intubated since the end of now s/p trach and PEG\\n placement.\\n # Recent Aspiration of tube feeds. Given prolonged hospitalization and\\n tenuous respiratory status will treat with antibiotics while cultures\\n pending\\n - Levoflox for 48 hours while waiting for sputum results.\\n - restart tube feeds slowly\\n - Follow cultures\\n .\\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\\n volume overload. Intubated on for resp decompensation. S/P Trach\\n and PEG on .\\n - wean FiO2 as tolerated\\n - attempt wean PS today and hopeful for trach mask trial\\n # Sedation: Continue to have issues with pain/delirium causing\\n tachycardia and hypertension with intermittent hypotension. On Haldol\\n 5 TID, Fentanyl 75 mcg TP, Diazapam 10 QID; Haldol, midazolam and\\n morphine PRN. Had good response to morphine, minimal response to\\n haldol bolus.\\n - Reduce diazepam to 5 q 8hrs.\\n - d/c standing Haldol\\n # Adrenal Insufficency: Hypotension that resolved with steroids,\\n returned as they came off and is now improved again. Possible primary\\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\\n started on .\\n - 10 q am and 5 q pm prednisone day 2 of 3, will wean to\\n maintenance dose as tolerated, in consultation with endo.\\n # Volume overloaded in setting of hypernatremia\\n Goal even today.\\n - Off diamox\\n - electrolytes\\n - Free water flushes with tube feeds.\\n # Falling Hct: Likely dilutional. Concern given elevated INR. Stable\\n today.\\n - monitor\\n - maintain active type and screen\\n # RUE DVT: INR now therapeutic on coumadin. Goal \\n - will start coumadin 2.5 mg QHS once INR < 3\\n # Spine fracture: Neurologically intact distal to the lesion. Prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - Brace for OOB\\n - report from full trauma series from OSH is in chart. No evidence of\\n other fracture and no need for further spinal imaging based on this\\n report and ortho note.\\n # Tracheomalacia: Discussed with IP. Stenting unlikely to help for\\n trachiomalacia as airways have poor structure diffusely.\\n - Outpatient f/u once off pressure support to assess for possible\\n stenting\\n #. Thyroid Nodule on CT\\n -outpatient follow up\\n # Nutrition: Replete (Full)\\n will reintroduce slowly\\n - advance bowel regimen\\n # Glycemic control: SSI, well controlled\\n # Lines L PICC\\n ().\\n # Ppx: INR therapeutic, ranitidine, colace and senna, miralax,\\n bisacodyl.\\n # Communication:\\n - Boyfriend of 10 \\n - Brother also involved\\n Code: Full\\n Dispo: ICU, being screening for vent facilities\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-11 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 636906,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Spiked to 102.2 after aspiration of tube feeds (only at 10 cc/hr) - pan\\n cultured and given tylenol\\n INR rising\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Aztreonam - 03:42 AM\\n Vancomycin - 09:40 AM\\n Levofloxacin - 11:15 PM\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 07:47 AM\\n Morphine Sulfate - 05:16 AM\\n Other medications:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:08 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 39\\nC (102.2\\n Tcurrent: 37.1\\nC (98.7\\n HR: 129 (86 - 137) bpm\\n BP: 102/52(64) {78/26(42) - 155/89(100)} mmHg\\n RR: 15 (12 - 65) insp/min\\n SpO2: 99%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 1,299 mL\\n 500 mL\\n PO:\\n TF:\\n 55 mL\\n IVF:\\n 699 mL\\n 500 mL\\n Blood products:\\n Total out:\\n 2,990 mL\\n 485 mL\\n Urine:\\n 2,990 mL\\n 485 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,691 mL\\n 15 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 500 (500 - 500) mL\\n Vt (Spontaneous): 513 (328 - 561) mL\\n PS : 0 cmH2O\\n RR (Set): 12\\n RR (Spontaneous): 0\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n RSBI Deferred: Agitated\\n PIP: 22 cmH2O\\n SpO2: 99%\\n ABG: ///26/\\n Ve: 6.6 L/min\\n Physical Examination\\n General Appearance: Trached. Interactive. Responsive, following\\n commands, Overweight / Obese, mild agitation but NAD\\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\\n deviation\\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\\n Cardiovascular: (S1: Normal), (S2: Normal), distant\\n Respiratory / Chest: (Expansion: Symmetric), b/l rhonchi R>L, decreased\\n BS\\n Abdominal: Obese, soft, Non-tender, no rebound, no guarding, + BS, PEG\\n in place with dressing C/D/I\\n Extremities: no CCE\\n Skin: no rashes or jaundice\\n Lines: L PICC C/D/I\\n Labs / Radiology\\n 238 K/uL\\n 8.4 g/dL\\n 106 mg/dL\\n 0.9 mg/dL\\n 26 mEq/L\\n 3.9 mEq/L\\n 11 mg/dL\\n 108 mEq/L\\n 143 mEq/L\\n 26.9 %\\n 7.2 K/uL\\n [image002.jpg]\\n 02:43 PM\\n 03:03 PM\\n 08:11 PM\\n 02:51 AM\\n 03:10 AM\\n 03:08 PM\\n 03:00 AM\\n 03:36 AM\\n 04:40 PM\\n 03:00 AM\\n WBC\\n 9.4\\n 11.3\\n 7.3\\n 6.1\\n 7.2\\n Hct\\n 26.6\\n 24.9\\n 27.6\\n 26.5\\n 26.9\\n Plt\\n 09\\n 238\\n Cr\\n 0.9\\n 0.7\\n 0.6\\n 0.6\\n 0.9\\n TCO2\\n 31\\n 30\\n 29\\n 26\\n Glucose\\n 128\\n 114\\n 114\\n 99\\n 115\\n 106\\n Other labs: PT / PTT / INR:72.4/42.1/9.0, Ca++:9.3 mg/dL, Mg++:2.5\\n mg/dL, PO4:3.6 mg/dL\\n Assessment and Plan\\n 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA, and\\n ARDS, intubated since the end of now s/p trach and PEG\\n placement.\\n # Recent Aspiration of tube feeds. Given prolonged hospitalization and\\n tenuous respiratory status will treat with antibiotics while cultures\\n pending\\n - Levoflox for 48 hours while waiting for sputum results.\\n - hold tube feeds\\n - Follow cultures\\n - check tube placement\\n .\\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\\n volume overload. Intubated on for resp decompensation. S/P Trach\\n and PEG on .\\n - wean FiO2 as tolerated\\n - attempt wean PS today and hopeful for trach mask trial\\n # Sedation: Continue to have issues with pain/delirium causing\\n tachycardia and hypertension with intermittent hypotension. On Haldol\\n 5 TID, Fentanyl 75 mcg TP, Diazapam 10 QID; Haldol, midazolam and\\n morphine PRN. Had good response to morphine, minimal response to\\n haldol bolus.\\n - tolerating current regimen well, no changes today\\n # Adrenal Insufficency: Hypotension that resolved with steroids,\\n returned as they came off and is now improved again. Possible primary\\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\\n started on .\\n - stopped steroids as per endocrine today\\n # Volume overloaded in setting of hypernatremia\\n Goal even today.\\n - monitor urine output\\n # RUE DVT: INR super-therapeutic on coumadin. Goal . Hasn\\n received coumadin in days yet INR continues to rise. Likely\\n contributors are nutritional and antibiotics.\\n - will start coumadin 2.5 mg QHS once INR < 3\\n # Spine fracture: Neurologically intact distal to the lesion. Prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - Brace for OOB\\n - report from full trauma series from OSH is in chart. No evidence of\\n other fracture and no need for further spinal imaging based on this\\n report and ortho note.\\n # Tracheomalacia: Discussed with IP. Stenting unlikely to help for\\n trachiomalacia as airways have poor structure diffusely.\\n - Outpatient f/u once off pressure support to assess for possible\\n stenting\\n #. Thyroid Nodule on CT\\n -outpatient follow up\\n # Nutrition: Replete (Full)\\n hold\\n # Glycemic control: SSI, well controlled\\n # Lines L PICC\\n ().\\n # Ppx: INR therapeutic, ranitidine, colace and senna, miralax,\\n bisacodyl.\\n # Communication:\\n - Boyfriend of 10 \\n - Brother also involved\\n Code: Full\\n Dispo: ICU, being screening for vent facilities\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-09 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 636576,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Arterial line d/c'd\\n Spiked a fever of 101.4, blood and urine cultures sent, CXR. Started\\n Vanc, Levo, Aztreonam\\n Persistently hypotensive to 70s SBP overnight with low urine output and\\n poor O2 sats.\\n Started on Levophed, and given 1.75L NS. BPs improved to 90-120s SBP,\\n and urine output increased significantly.\\n Large amount of oral secretions, ?gastric in origin\\n Tube feeds held for ? of aspiration.\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Vancomycin - 11:00 PM\\n Levofloxacin - 11:43 PM\\n Aztreonam - 04:07 AM\\n Infusions:\\n Norepinephrine\\n Off at 7:30 AM\\n Other ICU medications:\\n Midazolam (Versed) - 09:30 AM\\n Morphine Sulfate - 03:17 PM\\n Furosemide (Lasix) - 06:36 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:36 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.6\\nC (101.4\\n Tcurrent: 36.7\\nC (98.1\\n HR: 131 (73 - 142) bpm\\n BP: 127/43(60) {71/29(42) - 137/97(101)} mmHg\\n RR: 21 (12 - 36) insp/min\\n SpO2: 97%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 4,627 mL\\n 1,084 mL\\n PO:\\n TF:\\n 839 mL\\n IVF:\\n 2,288 mL\\n 1,084 mL\\n Blood products:\\n Total out:\\n 2,407 mL\\n 2,220 mL\\n Urine:\\n 2,407 mL\\n 2,220 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 2,220 mL\\n -1,136 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 400 (400 - 400) mL\\n Vt (Spontaneous): 412 (236 - 480) mL\\n PS : 8 cmH2O\\n RR (Set): 12\\n RR (Spontaneous): 0\\n PEEP: 8 cmH2O\\n FiO2: 50%\\n RSBI: 126\\n PIP: 21 cmH2O\\n Plateau: 17 cmH2O\\n Compliance: 44.4 cmH2O/mL\\n SpO2: 97%\\n ABG: 7.35/50/81./26/0\\n Ve: 7 L/min\\n PaO2 / FiO2: 162\\n Physical Examination\\n General Appearance: Trached and sedated. Responsive, following\\n commands, Overweight / Obese, mild agitation but NAD\\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\\n deviation\\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\\n Cardiovascular: (S1: Normal), (S2: Normal), distant\\n Respiratory / Chest: (Expansion: Symmetric), CTA anteriorly, decreased\\n BS\\n Abdominal: Obese, soft, Non-tender, no rebound, no guarding, + BS, PEG\\n in place with dressing C/D/I\\n Extremities: no CCE\\n Skin: no rashes or jaundice\\n Lines: r brachioceph ART with large amount of bloody drainage and L\\n PICC C/D/I\\n Labs / Radiology\\n 227 K/uL\\n 7.7 g/dL\\n 114 mg/dL\\n 0.7 mg/dL\\n 26 mEq/L\\n 4.0 mEq/L\\n 16 mg/dL\\n 112 mEq/L\\n 145 mEq/L\\n 24.9 %\\n 11.3 K/uL\\n [image002.jpg]\\n 03:46 AM\\n 10:20 AM\\n 03:46 PM\\n 01:37 AM\\n 05:32 AM\\n 02:43 PM\\n 03:03 PM\\n 08:11 PM\\n 02:51 AM\\n 03:10 AM\\n WBC\\n 11.1\\n 9.4\\n 11.3\\n Hct\\n 29.4\\n 26.6\\n 24.9\\n Plt\\n \\n Cr\\n 0.8\\n 0.6\\n 0.9\\n 0.7\\n TCO2\\n 35\\n 37\\n 31\\n 31\\n 30\\n 29\\n Glucose\\n 155\\n 123\\n 128\\n 114\\n 114\\n Other labs: PT / PTT / INR:37.2/37.9/4.0, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Lactic Acid:0.5 mmol/L, Albumin:2.4 g/dL,\\n LDH:204 IU/L, Ca++:8.7 mg/dL, Mg++:2.6 mg/dL, PO4:4.2 mg/dL\\n Blood/Urine/Sputum culture pending\\n Assessment and Plan\\n 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA, and\\n ARDS, intubated since the end of now s/p trach and PEG\\n placement.\\n # Fever: Likely secondary to aspiration pneumonitis. Given prolonged\\n hospitalization and tenuous respiratory status will treat with\\n antibiotics while cultures pending\\n - Vanc/Cef/Azithro for 48 hours while waiting for sputum results.\\n - Hold tube feeds for 24 hours\\n - Follow cultures\\n - Off levophed\\n .\\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\\n volume overload. Intubated on for resp decompensation. S/P Trach\\n and PEG on .\\n - wean FiO2 as tolerated\\n - attempt wean PS today and hopeful for trach mask trial\\n # Sedation: Continue to have issues with pain/delirium causing\\n tachycardia and hypertension with intermittent hypotension. On Haldol\\n 5 TID, Fentanyl 75 mcg TP, Diazapam 10 QID; Haldol, midazolam and\\n morphine PRN. Had good response to morphine, minimal response to\\n haldol bolus.\\n - Reduce diazepam to 5 q 8hrs.\\n - d/c standing Haldol\\n # Adrenal Insufficency: Hypotension that resolved with steroids,\\n returned as they came off and is now improved again. Possible primary\\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\\n started on .\\n - 10 q am and 5 q pm prednisone day 2 of 3, will wean to\\n maintenance dose as tolerated, in consultation with endo.\\n # Volume overloaded in setting of hypernatremia with TBW deficit and\\n metabolic alkalosis\\n - Goal of even in the setting of recent hypotension.\\n - Off diamox\\n - electrolytes\\n - Will give IV free water rather than flushes. D5W 1L@100 cc/hr\\n # Falling Hct: Likely dilutional. Concern given elevated INR\\n - Recheck in PM\\n - Type and screen\\n # RUE DVT: INR now therapeutic on coumadin. Goal \\n - stop heparin gtt\\n - will start coumadin 2.5 mg QHS once INR < 3\\n # Spine fracture: Neurologically intact distal to the lesion. Prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - Brace for OOB\\n - report from full trauma series from OSH is in chart. No evidence of\\n other fracture and no need for further spinal imaging based on this\\n report and ortho note.\\n # Tracheomalacia: Discussed with IP. Stenting unlikely to help for\\n trachiomalacia as airways have poor structure diffusely.\\n - Outpatient f/u once off pressure support to assess for possible\\n stenting\\n #. Thyroid Nodule on CT\\n -outpatient follow up\\n # Nutrition: Hold tube feeds x 24 hours, continue Replete (Full)\\n will reintroduce slowly\\n - advance bowel regimen\\n # Glycemic control: SSI, well controlled\\n # Lines L PICC (). ABG and VBG correlate well.\\n # Ppx: INR therapeutic, ranitidine, colace and senna, miralax,\\n bisacodyl.\\n # Communication:\\n - Boyfriend of 10 \\n - Brother is her HCP, also involved\\n Code: Full\\n Dispo: ICU, being screening for vent facilities\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n PICC Line - 09:19 PM\\n 18 Gauge - 08:15 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-11 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 636884,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Spiked to 102.2 after aspiration of tube feeds (only at 10 cc/hr) - pan\\n cultured and given tylenol\\n INR rising\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Aztreonam - 03:42 AM\\n Vancomycin - 09:40 AM\\n Levofloxacin - 11:15 PM\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 07:47 AM\\n Morphine Sulfate - 05:16 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:08 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 39\\nC (102.2\\n Tcurrent: 37.1\\nC (98.7\\n HR: 129 (86 - 137) bpm\\n BP: 102/52(64) {78/26(42) - 155/89(100)} mmHg\\n RR: 15 (12 - 65) insp/min\\n SpO2: 99%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 1,299 mL\\n 500 mL\\n PO:\\n TF:\\n 55 mL\\n IVF:\\n 699 mL\\n 500 mL\\n Blood products:\\n Total out:\\n 2,990 mL\\n 485 mL\\n Urine:\\n 2,990 mL\\n 485 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,691 mL\\n 15 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 500 (500 - 500) mL\\n Vt (Spontaneous): 513 (328 - 561) mL\\n PS : 0 cmH2O\\n RR (Set): 12\\n RR (Spontaneous): 0\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n RSBI Deferred: Agitated\\n PIP: 22 cmH2O\\n SpO2: 99%\\n ABG: ///26/\\n Ve: 6.6 L/min\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 238 K/uL\\n 8.4 g/dL\\n 106 mg/dL\\n 0.9 mg/dL\\n 26 mEq/L\\n 3.9 mEq/L\\n 11 mg/dL\\n 108 mEq/L\\n 143 mEq/L\\n 26.9 %\\n 7.2 K/uL\\n [image002.jpg]\\n 02:43 PM\\n 03:03 PM\\n 08:11 PM\\n 02:51 AM\\n 03:10 AM\\n 03:08 PM\\n 03:00 AM\\n 03:36 AM\\n 04:40 PM\\n 03:00 AM\\n WBC\\n 9.4\\n 11.3\\n 7.3\\n 6.1\\n 7.2\\n Hct\\n 26.6\\n 24.9\\n 27.6\\n 26.5\\n 26.9\\n Plt\\n 09\\n 238\\n Cr\\n 0.9\\n 0.7\\n 0.6\\n 0.6\\n 0.9\\n TCO2\\n 31\\n 30\\n 29\\n 26\\n Glucose\\n 128\\n 114\\n 114\\n 99\\n 115\\n 106\\n Other labs: PT / PTT / INR:72.4/42.1/9.0, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Lactic Acid:0.5 mmol/L, Albumin:2.4 g/dL,\\n LDH:204 IU/L, Ca++:9.3 mg/dL, Mg++:2.5 mg/dL, PO4:3.6 mg/dL\\n Assessment and Plan\\n 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA, and\\n ARDS, intubated since the end of now s/p trach and PEG\\n placement.\\n # Recent Aspiration of tube feeds. Given prolonged hospitalization and\\n tenuous respiratory status will treat with antibiotics while cultures\\n pending\\n - Levoflox for 48 hours while waiting for sputum results.\\n - restart tube feeds slowly\\n - Follow cultures\\n .\\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\\n volume overload. Intubated on for resp decompensation. S/P Trach\\n and PEG on .\\n - wean FiO2 as tolerated\\n - attempt wean PS today and hopeful for trach mask trial\\n # Sedation: Continue to have issues with pain/delirium causing\\n tachycardia and hypertension with intermittent hypotension. On Haldol\\n 5 TID, Fentanyl 75 mcg TP, Diazapam 10 QID; Haldol, midazolam and\\n morphine PRN. Had good response to morphine, minimal response to\\n haldol bolus.\\n - Reduce diazepam to 5 q 8hrs.\\n - d/c standing Haldol\\n # Adrenal Insufficency: Hypotension that resolved with steroids,\\n returned as they came off and is now improved again. Possible primary\\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\\n started on .\\n - 10 q am and 5 q pm prednisone day 2 of 3, will wean to\\n maintenance dose as tolerated, in consultation with endo.\\n # Volume overloaded in setting of hypernatremia\\n Goal even today.\\n - Off diamox\\n - electrolytes\\n - Free water flushes with tube feeds.\\n # Falling Hct: Likely dilutional. Concern given elevated INR. Stable\\n today.\\n - monitor\\n - maintain active type and screen\\n # RUE DVT: INR now therapeutic on coumadin. Goal \\n - will start coumadin 2.5 mg QHS once INR < 3\\n # Spine fracture: Neurologically intact distal to the lesion. Prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - Brace for OOB\\n - report from full trauma series from OSH is in chart. No evidence of\\n other fracture and no need for further spinal imaging based on this\\n report and ortho note.\\n # Tracheomalacia: Discussed with IP. Stenting unlikely to help for\\n trachiomalacia as airways have poor structure diffusely.\\n - Outpatient f/u once off pressure support to assess for possible\\n stenting\\n #. Thyroid Nodule on CT\\n -outpatient follow up\\n # Nutrition: Replete (Full)\\n will reintroduce slowly\\n - advance bowel regimen\\n # Glycemic control: SSI, well controlled\\n # Lines L PICC\\n ().\\n # Ppx: INR therapeutic, ranitidine, colace and senna, miralax,\\n bisacodyl.\\n # Communication:\\n - Boyfriend of 10 \\n - Brother also involved\\n Code: Full\\n Dispo: ICU, being screening for vent facilities\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-12 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 637037,\n \"text\": \"56 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\\n with prolonged hospital course c/b by PNA, anxiety/altered mental\\n status, RUE DVT .\\n Events\\n stim test performed. TF restarted. INR down to 1.6 from 9\\n ( pt given vit K yesterday)\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Received pt on PSV 10/5/50%. RR 20-30. )2 sat > 97%\\n Action:\\n Pt remained on PSV rather than AC overnight. Suctioned ~q 3-4 hrs for\\n sm amt yellow bld-tinged secretions. Continues to have copious oral\\n secretions\\n removed with yankeur.\\n Response:\\n Tolerated PSV well, no tachypnea or desaturation.\\n Plan:\\n Attempt trach collar trial again in am. On-going pulm hygiene\\n Hypotension (not Shock)\\n Assessment:\\n BP 90/40 with urine output falling to 10-15ccs/hr via foley. HR remains\\n tachycardic (110-140ST) even when pt is not agitated or febrile.\\n Action:\\n Given 1 500cc d5\\n ns fluid bolus\\n Response:\\n SBP > 90, Urine output improving to >30ccs/hr\\n Plan:\\n Continue to monitor hemodynamic status and f+e balance.\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt lethargic after receiving benedryl for several hrs but then awoke\\n agitated, attempting to climb OOB and pull at trach despite restraints.\\n Denies pain ( fentanyl patch in place) or need to go to the bathroom.\\n c/o itchiness on back secondary to rash.\\n Action:\\n Medicated with iv benedryl.\\n Response:\\n Less agitated. Slept again for a few hours.\\n Plan:\\n Continue to reorient pt, benedryl for pruritis, safety precautions.\\n Alteration in Nutrition\\n Assessment:\\n Pt with previous episodes of vomiting last eve. Kub showed no evidence\\n of obstruction. Na 146\\n Action:\\n TF initiated with 50ccs free h20 boluses q 4hrs\\n Response:\\n No nausea or vomiting. No residuals.\\n Plan:\\n Advance TF as tolerated. ? increase free h20 boluses for hypernatremia.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-09-28 00:00:00.000\",\n \"description\": \"Physician Resident / Attending Progress Note - MIC\",\n \"row_id\": 634984,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n PICC placed, Central line d/c'd\\n Lasix 10 mg given with 400 cc UOP in afternoon, pH improved\\n Lasix 20 mg given at ~ 4AM.\\n Lots of thick sinus secreations\\n Delerium/anxiety overnight with periods of hypertension.\\n Could not draw of A-line.\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Aztreonam - 06:00 AM\\n Vancomycin - 09:00 AM\\n Levofloxacin - 08:06 AM\\n Infusions:\\n Midazolam (Versed) - 3 mg/hour\\n Fentanyl - 150 mcg/hour\\n Heparin Sodium - 1,700 units/hour\\n Other ICU medications:\\n Furosemide (Lasix) - 03:01 AM\\n Midazolam (Versed) - 04:36 AM\\n Fentanyl - 04:36 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:44 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.9\\nC (98.5\\n Tcurrent: 36.4\\nC (97.6\\n HR: 90 (47 - 92) bpm\\n BP: 118/59(80) {80/40(53) - 137/105(111)} mmHg\\n RR: 17 (15 - 24) insp/min\\n SpO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 101 kg (admission): 94.2 kg\\n Height: 67 Inch\\n CVP: 19 (16 - 19)mmHg\\n Total In:\\n 2,560 mL\\n 543 mL\\n PO:\\n TF:\\n 1,441 mL\\n 342 mL\\n IVF:\\n 1,020 mL\\n 201 mL\\n Blood products:\\n Total out:\\n 1,680 mL\\n 860 mL\\n Urine:\\n 1,680 mL\\n 860 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 880 mL\\n -317 mL\\n Respiratory support\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 400 (400 - 400) mL\\n RR (Set): 18\\n RR (Spontaneous): 0\\n PEEP: 15 cmH2O\\n FiO2: 50%\\n PIP: 27 cmH2O\\n Plateau: 23 cmH2O\\n SpO2: 98%\\n ABG: 7.41/45/77./28/2\\n Ve: 6.5 L/min\\n PaO2 / FiO2: 156\\n Physical Examination\\n General Appearance: No acute distress, Overweight / Obese, opens eyes\\n but no purposeful movement\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric)\\n Abdominal: No(t) Soft, Non-tender, Bowel sounds present, Distended\\n Extremities: No clubbing or cyanosis, 3+ nonpitting edema of b/l hands,\\n LE without edema\\n Skin: no rashes or jaundice\\n Labs / Radiology\\n 411 K/uL\\n 8.3 g/dL\\n 133 mg/dL\\n 0.5 mg/dL\\n 28 mEq/L\\n 4.1 mEq/L\\n 13 mg/dL\\n 111 mEq/L\\n 145 mEq/L\\n 26.0 %\\n 9.7 K/uL\\n [image002.jpg]\\n 04:05 PM\\n 01:12 AM\\n 04:00 AM\\n 04:09 AM\\n 10:18 AM\\n 02:33 PM\\n 02:46 PM\\n 03:31 AM\\n 02:26 PM\\n 05:53 PM\\n WBC\\n 9.6\\n 9.7\\n Hct\\n 27.8\\n 26.0\\n Plt\\n 374\\n 411\\n Cr\\n 0.5\\n 0.5\\n 0.5\\n 0.5\\n TCO2\\n 26\\n 27\\n 28\\n 29\\n 26\\n 27\\n 30\\n Glucose\\n 194\\n 195\\n 195\\n 163\\n 133\\n Other labs: PT / PTT / INR:15.3/69.9/1.3, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\\n Amylase / Lipase:, Differential-Neuts:86.1 %, Lymph:10.3 %,\\n Mono:2.8 %, Eos:0.5 %, Lactic Acid:2.0 mmol/L, Albumin:2.4 g/dL,\\n LDH:204 IU/L, Ca++:8.3 mg/dL, Mg++:2.2 mg/dL, PO4:3.5 mg/dL\\n Assessment and Plan\\n 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture with respiratory failure\\n and difficulty weaning from vent.\\n # Respiratory failure: Intubated on for resp decompensation.\\n Likely VAP. Transferred here for tracheomalacia, but not sure this\\n is a component. Will need bronch eval when improved\\n - will discuss PEEP goal for trach placement with IP.\\n - wean PEEP\\n - repeat ABG this AM\\n - discuss need for trach with patient and her family\\n - Volume overload may be contributing.\\n # Volume overload\\n Currently with hypernatremia, Cr increase, contract\\n alk, but mild\\n - continue gentle diuresis\\n - FW in TF at 150 cc q4hrs\\n - PM lytes.\\n # Sedation: On versed 3mg/hr + .5 q 1hr and fentanyl 150 mcg/hr + 50\\n bolus q 1hr.\\n - Start fentanyl patch and diazepam to provide long acting analgesia\\n and wean from drips\\n - Haldol 1 mg Q4h PRN agitation\\n # Pneumonia: Pansensitive Kleb oxytoca pneumonia and sputum with GPCs\\n on gram stain. Afebrile off abx.\\n # EKG changes: Sinus bradycardia, responsive to stress. Related to\\n sedation, increased vagal tone, possibly related to steroid\\n replacement. Atrial EKG shows p-waves and cardiac enzymes normal.\\n - Continue to monitor\\n # Hypotension: Improved, off levophed for 2-3 days now, with good urine\\n output. s/p 5 d course of steroids for adrenal insufficiency. High\\n PEEP may have been contributing. Now likely related to sedation and\\n decreased intravascular volume,\\n -monitor, expect improvement with continual reduction in\\n PEEP\\n # RUE DVT: Started on heparin gtt on , now therapeutic. Follow\\n PTTs. Would hold off on coumadin at least until s/p trach.\\n - continue to monitor\\n # Adrenal Insufficency: Random cortisol was approx 3 when it should\\n have been maximally stimulated.\\n - hydrocortisone and florinef for 5 days\\n # Anemia: Stable.\\n - Trend HCT\\n # Spine fracture: Neurologically intact distal to the lesion. Prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - CT of C, L spine when stable. Currently, unlikely to change\\n management and high risk for complications with transport.\\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\\n is low. Brace for OOB. Ok for anticoag per note.\\n # Communication:\\n - Boyfriend of 10 is her HCP. Also brother is involved\\n FEN/GI: Tube feeds @ goal\\n DVT: Treatment dose heparin\\n Ulcer: Ranitidine\\n VAP: Prevention per routine\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 08:12 PM 60 mL/hour\\n Glycemic Control:\\n Lines:\\n Arterial Line - 04:00 PM\\n PICC Line - 09:19 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n ------ Protected Section ------\\n MICU ATTENDING ADDENDUM\\n I saw and examined the patient, and was physically present with the ICU\\n team for the key portions of the services provided. I agree with the\\n note above, including the assessment and plan. I would emphasize and\\n add the following points: 55F T5-8 fractures with retropulsion and ARDS\\n from VAP; on heparin for UE DVT.\\n Exam notable for Tm 97.5 BP 90/45 HR 67 RR with sat 95 on VAC 400x18\\n PEEP 15 FiO2 0.5 for 7.41/45/78. Eyes opens, will squeeze hands and\\n wiggle toes but very drowsy. Bronchial BS bilaterally with RRR s1s2 \\n SM at base. Abdomen is mildly distended with decreased BS. 3+ edema in\\n BLE, no cords. Labs notable for WBC 9K, HCT 26, K+ 4.1, Cr 0.5. CXR\\n with resolving B LL airspace disease and effusions.\\n Agree with plan to start fentanyl patch and po valium and wean IV\\n sedation while slowly coming down on PEEP. Will start gentle IV lasix\\n (drip or bolus) to affect a negative fluid balance and use haldol for\\n breakthrough agitiation. In addition, we will continue IV heparin for\\n UE DVT; consider transition to coumadin only after tracheostomy and\\n feeding tube placement, which will require lower ventilator settings.\\n Will ask IP to reevaluate today, given need for tracheostomy and\\n possible tracheobronchomalacia. Continue spinal stabilization with\\n brace when OOB; will eventually need MRI for surgical planning.\\n Continue TF; remainder of plan as outlined above.\\n Patient is critically ill\\n Total time: 40 min\\n ------ Protected Section Addendum Entered By: , MD\\n on: 01:45 PM ------\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-09-29 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 635035,\n \"text\": \"Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n RUE edematous, warm, red\\n Action:\\n Heparin gtt WNL\\n Response:\\n No change\\n Plan:\\n Heparin off at 0600 for procedure\\n Altered mental status (not Delirium)\\n Assessment:\\n Periods of agitation\\n Action:\\n Fentanyl and Versed Gtt, haldol and valium started. Fentanyl patch\\n Response:\\n Calm with increased sedation needed\\n Plan:\\n Monitor, continue with sedation as tolerates.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt desatted to 87%\\n Action:\\n Peep increased\\n Response:\\n O2 sat improved\\n Plan:\\n Team to attempt to replace aline or will draw am abg. AM RSBI\\n Hypotension (not Shock)\\n Assessment:\\n Sbp 70\\n Action:\\n Sedation weaned, but pt agitated\\n Response:\\n Sbp > 90\\n Plan:\\n Maintain sbp > 90 with adequate sedation\\n Bradycardia\\n Assessment:\\n HR 50\\ns with increased sedation\\n Action:\\n Sedation weaned, but pt agitated\\n Response:\\n HR 70-130\\ns, with decreased sedation\\n Plan:\\n Maintain sedation, monitor hr\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-10 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 636651,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n Discussed imaging with ortho. They do not need further imaging. She\\n should wear TLSO for 2 months and f/u with at 2 months\\n prior to removal of TLSO.\\n Changed to PSV, was stable on trach mask for 1-2 hrs\\n Tube feeds held\\n Endo recs: check AM cortisol prior to dose\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Vancomycin - 10:04 PM\\n Levofloxacin - 10:49 PM\\n Aztreonam - 03:42 AM\\n Infusions:\\n Other ICU medications:\\n Morphine Sulfate - 10:49 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:01 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.4\\nC (99.4\\n Tcurrent: 36.7\\nC (98\\n HR: 125 (74 - 151) bpm\\n BP: 121/64(77) {89/32(45) - 179/99(120)} mmHg\\n RR: 20 (13 - 30) insp/min\\n SpO2: 100%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 5,817 mL\\n 457 mL\\n PO:\\n TF:\\n IVF:\\n 5,277 mL\\n 327 mL\\n Blood products:\\n Total out:\\n 5,205 mL\\n 1,460 mL\\n Urine:\\n 5,205 mL\\n 1,460 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 612 mL\\n -1,003 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: CPAP/PSV\\n Vt (Set): 400 (400 - 400) mL\\n Vt (Spontaneous): 429 (340 - 480) mL\\n PS : 8 cmH2O\\n RR (Set): 0\\n RR (Spontaneous): 25\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n PIP: 13 cmH2O\\n SpO2: 100%\\n ABG: 7.37/44/120/25/0\\n Ve: 6.3 L/min\\n PaO2 / FiO2: 240\\n Physical Examination\\n General Appearance: Trached and sedated. Responsive, following\\n commands, Overweight / Obese, mild agitation but NAD\\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\\n deviation\\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\\n Cardiovascular: (S1: Normal), (S2: Normal), distant\\n Respiratory / Chest: (Expansion: Symmetric), CTA anteriorly, decreased\\n BS\\n Abdominal: Obese, soft, Non-tender, no rebound, no guarding, + BS, PEG\\n in place with dressing C/D/I\\n Extremities: no CCE\\n Skin: no rashes or jaundice\\n Lines: r brachioceph ART with large amount of bloody drainage and L\\n PICC C/D/I\\n Labs / Radiology\\n 209 K/uL\\n 8.3 g/dL\\n 99 mg/dL\\n 0.6 mg/dL\\n 25 mEq/L\\n 4.3 mEq/L\\n 9 mg/dL\\n 111 mEq/L\\n 145 mEq/L\\n 26.5 %\\n 6.1 K/uL\\n [image002.jpg]\\n 01:37 AM\\n 05:32 AM\\n 02:43 PM\\n 03:03 PM\\n 08:11 PM\\n 02:51 AM\\n 03:10 AM\\n 03:08 PM\\n 03:00 AM\\n 03:36 AM\\n WBC\\n 11.1\\n 9.4\\n 11.3\\n 7.3\\n 6.1\\n Hct\\n 29.4\\n 26.6\\n 24.9\\n 27.6\\n 26.5\\n Plt\\n 89\\n 209\\n Cr\\n 0.6\\n 0.9\\n 0.7\\n 0.6\\n TCO2\\n 31\\n 31\\n 30\\n 29\\n 26\\n Glucose\\n 123\\n 128\\n 114\\n 114\\n 99\\n Other labs: PT / PTT / INR:40.1/40.7/4.4, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Lactic Acid:0.5 mmol/L, Albumin:2.4 g/dL,\\n LDH:204 IU/L, Ca++:8.9 mg/dL, Mg++:2.6 mg/dL, PO4:4.1 mg/dL\\n Assessment and Plan\\n 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA, and\\n ARDS, intubated since the end of now s/p trach and PEG\\n placement.\\n # Fever: Likely secondary to aspiration pneumonitis. Given prolonged\\n hospitalization and tenuous respiratory status will treat with\\n antibiotics while cultures pending\\n - Vanc/Cef/Azithro for 48 hours while waiting for sputum results.\\n - Hold tube feeds for 24 hours\\n - Follow cultures\\n - Off levophed\\n .\\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\\n volume overload. Intubated on for resp decompensation. S/P Trach\\n and PEG on .\\n - wean FiO2 as tolerated\\n - attempt wean PS today and hopeful for trach mask trial\\n # Sedation: Continue to have issues with pain/delirium causing\\n tachycardia and hypertension with intermittent hypotension. On Haldol\\n 5 TID, Fentanyl 75 mcg TP, Diazapam 10 QID; Haldol, midazolam and\\n morphine PRN. Had good response to morphine, minimal response to\\n haldol bolus.\\n - Reduce diazepam to 5 q 8hrs.\\n - d/c standing Haldol\\n # Adrenal Insufficency: Hypotension that resolved with steroids,\\n returned as they came off and is now improved again. Possible primary\\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\\n started on .\\n - 10 q am and 5 q pm prednisone day 2 of 3, will wean to\\n maintenance dose as tolerated, in consultation with endo.\\n # Volume overloaded in setting of hypernatremia with TBW deficit and\\n metabolic alkalosis\\n - Goal of even in the setting of recent hypotension.\\n - Off diamox\\n - electrolytes\\n - Will give IV free water rather than flushes. D5W 1L@100 cc/hr\\n # Falling Hct: Likely dilutional. Concern given elevated INR\\n - Recheck in PM\\n - Type and screen\\n # RUE DVT: INR now therapeutic on coumadin. Goal \\n - stop heparin gtt\\n - will start coumadin 2.5 mg QHS once INR < 3\\n # Spine fracture: Neurologically intact distal to the lesion. Prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - Brace for OOB\\n - report from full trauma series from OSH is in chart. No evidence of\\n other fracture and no need for further spinal imaging based on this\\n report and ortho note.\\n # Tracheomalacia: Discussed with IP. Stenting unlikely to help for\\n trachiomalacia as airways have poor structure diffusely.\\n - Outpatient f/u once off pressure support to assess for possible\\n stenting\\n #. Thyroid Nodule on CT\\n -outpatient follow up\\n # Nutrition: Hold tube feeds x 24 hours, continue Replete (Full)\\n will reintroduce slowly\\n - advance bowel regimen\\n # Glycemic control: SSI, well controlled\\n # Lines L PICC (). ABG and VBG correlate well.\\n # Ppx: INR therapeutic, ranitidine, colace and senna, miralax,\\n bisacodyl.\\n # Communication:\\n - Boyfriend of 10 \\n - Brother is her HCP, also involved\\n Code: Full\\n Dispo: ICU, being screening for vent facilities\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n PICC Line - 09:19 PM\\n 18 Gauge - 08:15 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2167-10-10 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 636655,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 22\\n Ideal body weight: 61.2 None\\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: Yes\\n Procedure location:\\n Reason:\\n Tube Type\\n Tracheostomy tube:\\n Type: Cuffed\\n Manufacturer: Portex\\n Size: 7.0mm\\n PMV: No\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 28 cmH2O\\n Cuff volume: mL /\\n Airway problems:\\n Comments:\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Diminished\\n Comments:\\n Secretions\\n Sputum color / consistency: White / Thick\\n Sputum source/amount: Suctioned / Small\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance: Continuous invasive ventilation\\n Visual assessment of breathing pattern: Normal quiet breathing\\n Assessment of breathing comfort:\\n Non-invasive ventilation assessment:\\n Invasive ventilation assessment:\\n Trigger work assessment: Triggering synchronously\\n Dysynchrony assessment:\\n Comments:\\n Plan\\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\\n Periodic SBT's for conditioning, Adjust Min. ventilation to control pH,\\n Increase ventilatory support at night; Comments: During RSBI trial,\\n ptwould not breathe in normal pattern, very deep but slow breaths\\n Reason for continuing current ventilatory support: Intolerant of\\n weaning attempts, Cannot protect airway, Underlying illness not\\n resolved\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-10 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 636749,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n Discussed imaging with ortho. They do not need further imaging. She\\n should wear TLSO for 2 months and f/u with at 2 months\\n prior to removal of TLSO.\\n Changed to PSV, was stable on trach mask for 1-2 hrs\\n Tube feeds held\\n Endo recs: check AM cortisol prior to dose\\n At 5:45 am --- RR 4, switched from CPAP/PSV to AC\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Vancomycin - 10:04 PM\\n Levofloxacin - 10:49 PM\\n Aztreonam - 03:42 AM\\n Infusions:\\n Other ICU medications:\\n Morphine Sulfate - 10:49 PM\\n Other medications:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:01 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.4\\nC (99.4\\n Tcurrent: 36.7\\nC (98\\n HR: 125 (74 - 151) bpm\\n BP: 121/64(77) {89/32(45) - 179/99(120)} mmHg\\n RR: 20 (13 - 30) insp/min\\n SpO2: 100%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 5,817 mL\\n 457 mL\\n PO:\\n TF:\\n IVF:\\n 5,277 mL\\n 327 mL\\n Blood products:\\n Total out:\\n 5,205 mL\\n 1,460 mL\\n Urine:\\n 5,205 mL\\n 1,460 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 612 mL\\n -1,003 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: CPAP/PSV\\n Vt (Set): 400 (400 - 400) mL\\n Vt (Spontaneous): 429 (340 - 480) mL\\n PS : 8 cmH2O\\n RR (Set): 0\\n RR (Spontaneous): 25\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n PIP: 13 cmH2O\\n SpO2: 100%\\n ABG: 7.37/44/120/25/0\\n Ve: 6.3 L/min\\n PaO2 / FiO2: 240\\n Physical Examination\\n On CMV\\n Peep 5, FiO2 40%, Vt 500, R 14\\n General Appearance: Trached and sedated. Responsive, following\\n commands, Overweight / Obese, mild agitation but NAD\\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\\n deviation\\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\\n Cardiovascular: (S1: Normal), (S2: Normal), distant\\n Respiratory / Chest: (Expansion: Symmetric), CTA anteriorly, decreased\\n BS\\n Abdominal: Obese, soft, Non-tender, no rebound, no guarding, + BS, PEG\\n in place with dressing C/D/I\\n Extremities: no CCE\\n Skin: no rashes or jaundice\\n Lines: L PICC C/D/I\\n Labs / Radiology\\n 209 K/uL\\n 8.3 g/dL\\n 99 mg/dL\\n 0.6 mg/dL\\n 25 mEq/L\\n 4.3 mEq/L\\n 9 mg/dL\\n 111 mEq/L\\n 145 mEq/L\\n 26.5 %\\n 6.1 K/uL\\n [image002.jpg]\\n 01:37 AM\\n 05:32 AM\\n 02:43 PM\\n 03:03 PM\\n 08:11 PM\\n 02:51 AM\\n 03:10 AM\\n 03:08 PM\\n 03:00 AM\\n 03:36 AM\\n WBC\\n 11.1\\n 9.4\\n 11.3\\n 7.3\\n 6.1\\n Hct\\n 29.4\\n 26.6\\n 24.9\\n 27.6\\n 26.5\\n Plt\\n 89\\n 209\\n Cr\\n 0.6\\n 0.9\\n 0.7\\n 0.6\\n TCO2\\n 31\\n 31\\n 30\\n 29\\n 26\\n Glucose\\n 123\\n 128\\n 114\\n 114\\n 99\\n Other labs: PT / PTT / INR:36.4/38.8/3.9, Ca++:8.9 mg/dL, Mg++:2.6\\n mg/dL, PO4:4.1 mg/dL\\n Cx: endotrach \\n GN diplococci, budding yeast\\n Assessment and Plan\\n 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA, and\\n ARDS, intubated since the end of now s/p trach and PEG\\n placement.\\n # Recent Aspiration of tube feeds. Given prolonged hospitalization and\\n tenuous respiratory status will treat with antibiotics while cultures\\n pending\\n - Levoflox for 48 hours while waiting for sputum results.\\n - restart tube feeds slowly\\n - Follow cultures\\n .\\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\\n volume overload. Intubated on for resp decompensation. S/P Trach\\n and PEG on .\\n - wean FiO2 as tolerated\\n - attempt wean PS today and hopeful for trach mask trial\\n # Sedation: Continue to have issues with pain/delirium causing\\n tachycardia and hypertension with intermittent hypotension. On Haldol\\n 5 TID, Fentanyl 75 mcg TP, Diazapam 10 QID; Haldol, midazolam and\\n morphine PRN. Had good response to morphine, minimal response to\\n haldol bolus.\\n - Reduce diazepam to 5 q 8hrs.\\n - d/c standing Haldol\\n # Adrenal Insufficency: Hypotension that resolved with steroids,\\n returned as they came off and is now improved again. Possible primary\\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\\n started on .\\n - 10 q am and 5 q pm prednisone day 2 of 3, will wean to\\n maintenance dose as tolerated, in consultation with endo.\\n # Volume overloaded in setting of hypernatremia\\n Goal even today.\\n - Off diamox\\n - electrolytes\\n - Free water flushes with tube feeds.\\n # Falling Hct: Likely dilutional. Concern given elevated INR. Stable\\n today.\\n - monitor\\n - maintain active type and screen\\n # RUE DVT: INR now therapeutic on coumadin. Goal \\n - will start coumadin 2.5 mg QHS once INR < 3\\n # Spine fracture: Neurologically intact distal to the lesion. Prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - Brace for OOB\\n - report from full trauma series from OSH is in chart. No evidence of\\n other fracture and no need for further spinal imaging based on this\\n report and ortho note.\\n # Tracheomalacia: Discussed with IP. Stenting unlikely to help for\\n trachiomalacia as airways have poor structure diffusely.\\n - Outpatient f/u once off pressure support to assess for possible\\n stenting\\n #. Thyroid Nodule on CT\\n -outpatient follow up\\n # Nutrition: Replete (Full)\\n will reintroduce slowly\\n - advance bowel regimen\\n # Glycemic control: SSI, well controlled\\n # Lines L PICC ().\\n # Ppx: INR therapeutic, ranitidine, colace and senna, miralax,\\n bisacodyl.\\n # Communication:\\n - Boyfriend of 10 \\n - Brother is her HCP, also involved\\n Code: Full\\n Dispo: ICU, being screening for vent facilities\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-11 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 636873,\n \"text\": \"Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Received pt on trach collar 50%. Sats fell to 78%. Pt ambu\\nd and\\n lavaged with no plugs detected. RR 30-40 . Pt diaphoretic.\\n Action:\\n Placed on PSV 10/5/50%\\n Response:\\n Apneic with RR 3-5\\n Plan:\\n Rested on AC 500/12/5/50%. No further episodes of desating or\\n tachypnea.\\n Hypotension (not Shock)\\n Assessment:\\n BP falling to 78/37. Urine output 5-30ccs/hr via foley\\n Action:\\n Given 500ccs\\n NS fluid bolus\\n Response:\\n Pt normotensive, improved urine output\\n Plan:\\n Continue to monitor.\\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\\n Assessment:\\n Temp spike to 102.2 po\\n Action:\\n Blood, urine and sputum cxs sent. Sputum white, not yellow or\\n consistant with TF. Chest x-ray taken. Tylenol pr given. Cool cloths\\n applied.\\n Response:\\n Pt normothermic. WBC 7.2\\n Plan:\\n Monitor fever curve, cooling measures. Follow-up on cx results.\\n Alteration in Nutrition\\n Assessment:\\n Pt vomiting yellow fluid with coughing and when turned\\n Action:\\n TF held. Peg to gravity. Medicated with 4 mg zofran iv.\\n Response:\\n No further episodes of vomiting.\\n Plan:\\n Continue to monitor. Aspiration precautions. ? need for alternative\\n form of nutrition.\\n Altered mental status (not Delirium)\\n Assessment:\\n Onset of shift, pt lethargic, not following commands but MAE. ~ 12 mn\\n pt agitated, attempting to climb oob, disconnecting self from vent\\n despite restraints\\n Action:\\n 5 mg valium given q 8hrs. Haldol 2.5 mg given.\\n Response:\\n Pt still agitated\\n Plan:\\n Needs better sedation at bedtime - ? zyprexa or alternative med\\n Addendum\\n PT and INR rising to 72.4 and 9.0 ( venipuncture, not drawn\\n from PIC ). MD notified. No intervention at this time.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-12 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 637162,\n \"text\": \"Chief Complaint: resp failure\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 24 Hour Events:\\n rash- vesicular and d/c l;evoquin and started Ceftriaxone\\n More tachycardic this AM - autonomic dysregulation\\n Trach Mask for several hours\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Aztreonam - 03:42 AM\\n Vancomycin - 09:40 AM\\n Levofloxacin - 11:15 PM\\n Ceftriaxone - 07:50 PM\\n Infusions:\\n Other ICU medications:\\n Morphine Sulfate - 09:45 AM\\n Haloperidol (Haldol) - 10:26 AM\\n Other medications:\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 10:57 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.2\\nC (98.9\\n Tcurrent: 36.9\\nC (98.5\\n HR: 143 (113 - 145) bpm\\n BP: 153/89(102) {85/40(50) - 153/89(102)} mmHg\\n RR: 24 (9 - 30) insp/min\\n SpO2: 98%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 1,362 mL\\n 537 mL\\n PO:\\n TF:\\n 47 mL\\n 287 mL\\n IVF:\\n 1,061 mL\\n 100 mL\\n Blood products:\\n Total out:\\n 1,203 mL\\n 615 mL\\n Urine:\\n 1,203 mL\\n 615 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 159 mL\\n -78 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask\\n Ventilator mode: Standby\\n Vt (Set): 0 (0 - 0) mL\\n Vt (Spontaneous): 244 (110 - 504) mL\\n PS : 10 cmH2O\\n RR (Set): 0\\n RR (Spontaneous): 19\\n PEEP: 5 cmH2O\\n FiO2: 70%\\n RSBI: 245\\n PIP: 16 cmH2O\\n SpO2: 98%\\n ABG: ///30/\\n Ve: 10 L/min\\n Physical Examination\\n Gen sitting up in , on trach mask, interactive\\n CV tachy RRR\\n Chest good movement ANT\\n Abd soft NT + NS\\n Ext: no edema\\n Neuroalert follows simple commands\\n Labs / Radiology\\n 7.9 g/dL\\n 240 K/uL\\n 100 mg/dL\\n 0.6 mg/dL\\n 30 mEq/L\\n 3.4 mEq/L\\n 12 mg/dL\\n 108 mEq/L\\n 146 mEq/L\\n 26.0 %\\n 5.2 K/uL\\n [image002.jpg]\\n 08:11 PM\\n 02:51 AM\\n 03:10 AM\\n 03:08 PM\\n 03:00 AM\\n 03:36 AM\\n 04:40 PM\\n 03:00 AM\\n 07:05 PM\\n 03:00 AM\\n WBC\\n 9.4\\n 11.3\\n 7.3\\n 6.1\\n 7.2\\n 5.2\\n Hct\\n 26.6\\n 24.9\\n 27.6\\n 26.5\\n 26.9\\n 26.0\\n Plt\\n \\n Cr\\n 0.9\\n 0.7\\n 0.6\\n 0.6\\n 0.9\\n 0.7\\n 0.6\\n TCO2\\n 29\\n 26\\n Glucose\\n 128\\n 114\\n 114\\n 99\\n 115\\n 106\\n 100\\n Other labs: PT / PTT / INR:17.6/27.4/1.6, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:33/22, Alk Phos / T Bili:143/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:0.5 mmol/L,\\n Albumin:3.5 g/dL, LDH:199 IU/L, Ca++:8.9 mg/dL, Mg++:2.4 mg/dL, PO4:4.1\\n mg/dL\\n Assessment and Plan 55 yr old alcoholic s/p t spine fx s/p trcah and\\n PEG with persistent resp failure\\n 1. Resp Failure: currently on trach mask, can do a few hours per\\n day, then needs for support. New pan Klebs in sputum, day\\n . Get Speech consult for PMV evaluation. Holding off on stent by IP\\n until after pulm rehab.\\n 2. Hemodynamics: tachycardia seems most likely due to agitation\\n at present, did taper Valium aggressively, may be need to increase\\n benzo slightly and see f it helps (haldol and morphione have not helped\\n yet this AM)\\n 3. Anti coag: for upper ext DVT but INR elevated on coumadin +\\n quinolone\\n repeat\\n 4. Adrenal Insufficny: proper stim this AM, off steroids\\n ICU Care\\n Nutrition: Replete with Fiber (Full) - 07:46 AM 30 mL/hour\\n Glycemic Control:\\n Lines: PICC Line - 09:19 PM\\n Prophylaxis:\\n DVT: inr levetaed recheck, and start coumadin when at 2.0\\n Stress ulcer: ppi\\n Communication:\\n Code status: Full code\\n Disposition :ICU\\n Total time spent: 35 minutes\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-13 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 637226,\n \"text\": \"56 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\\n with prolonged hospital course c/b by PNA, anxiety/altered mental\\n status, RUE DVT .\\n Tachycardia, Other\\n Assessment:\\n HR\\n Action:\\n Response:\\n Plan:\\n Altered mental status (not Delirium)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Alteration in Nutrition\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Impaired Skin Integrity\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-06 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 636001,\n \"text\": \"55 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\\n Now with prolonged hospital course c/b by PNA with high PEEP\\n requirement, anxiety, RUE DVT on heparin qtt.\\n Bradycardia\\n Assessment:\\n Pt conts with HR 50-70\\ns at rest, 100-140\\ns during care, pt\\n asymptomatic; easily arousable\\n Action:\\n Sedation decreased, Lasix off @0200\\n Response:\\n HR 60\\n Plan:\\n Cont to wean sedation, ?cardiac consult\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Action:\\n Cont with IV Heparin @ 1500u/hr, Coumadin d\\ncd for? thoracentesis\\n Response:\\n Pt therapeutic, cont with daily PTT\\n Plan:\\n Cont to labs, cont to wean off Heparin, Coumadin 5mg given x 1dose\\n @ 2200, re-eval dosing this am\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt cont on AC 18/400/50%/10, LS clear bilat, occ scat rhonchi\\n Action:\\n Pt suct for sm thin tan secretions\\n Response:\\n Pt 02 Sats 94-97%,\\n Plan:\\n Cont to ABGs, Rate decreased to 16 this am to PC02 elevated\\n Hypotension (not Shock)\\n Assessment:\\n SBP 140\\ns when pt is agitated, SBP dropping to 70\\ns-80\\ns, UO 200/hr\\n (total 2500 in 2hr) K 3.3\\n Action:\\n Fent/Versed turned down @ 0000, Lasix gtt on hold, team informed ; pt\\n recvd 1x dose of 40meg/Peg, 20meqK/250D5W x 1 dose\\n Response:\\n Pt SBP\\ns in 80\\n Plan:\\n Cardiac consult to further eval SB/ST, re-evalu cont. Lasix gtt,\\n recheck am labs\\n Hypernatremia (high sodium)\\n Assessment:\\n Na 146\\n Action:\\n Cont with 300cc free water flush Q4hrs\\n Response:\\n Plan:\\n Cont to sodium levels, treat as ordered\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt alert and agitated throughout shift, pt following commands\\n inconsistently; sleeping off and off throughout shift\\n Action:\\n Fent/Versed decreased low SBP\\ns, pt recved prn dose of Haldol 1mg @\\n 0100; cont with bilat. Wrist restraints for safety\\n Response:\\n pt sleeping off/on throughout shift, with periods of\\n agitation/restlessness\\n Plan:\\n Cont to wean fent/versed gtt down, cont with scheduled Haldol/Valium;\\n cont to QTC intervals daily\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-09-28 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 634960,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n PICC placed, Central line d/c'd\\n Lasix 10 mg given with 400 cc UOP in afternoon, pH improved\\n Lasix 20 mg given at ~ 4AM.\\n Lots of thick sinus secreations\\n Delerium/anxiety overnight with periods of hypertension.\\n Could not draw of A-line.\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Aztreonam - 06:00 AM\\n Vancomycin - 09:00 AM\\n Levofloxacin - 08:06 AM\\n Infusions:\\n Midazolam (Versed) - 3 mg/hour\\n Fentanyl - 150 mcg/hour\\n Heparin Sodium - 1,700 units/hour\\n Other ICU medications:\\n Furosemide (Lasix) - 03:01 AM\\n Midazolam (Versed) - 04:36 AM\\n Fentanyl - 04:36 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:44 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.9\\nC (98.5\\n Tcurrent: 36.4\\nC (97.6\\n HR: 90 (47 - 92) bpm\\n BP: 118/59(80) {80/40(53) - 137/105(111)} mmHg\\n RR: 17 (15 - 24) insp/min\\n SpO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 101 kg (admission): 94.2 kg\\n Height: 67 Inch\\n CVP: 19 (16 - 19)mmHg\\n Total In:\\n 2,560 mL\\n 543 mL\\n PO:\\n TF:\\n 1,441 mL\\n 342 mL\\n IVF:\\n 1,020 mL\\n 201 mL\\n Blood products:\\n Total out:\\n 1,680 mL\\n 860 mL\\n Urine:\\n 1,680 mL\\n 860 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 880 mL\\n -317 mL\\n Respiratory support\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 400 (400 - 400) mL\\n RR (Set): 18\\n RR (Spontaneous): 0\\n PEEP: 15 cmH2O\\n FiO2: 50%\\n PIP: 27 cmH2O\\n Plateau: 23 cmH2O\\n SpO2: 98%\\n ABG: 7.41/45/77./28/2\\n Ve: 6.5 L/min\\n PaO2 / FiO2: 156\\n Physical Examination\\n General Appearance: No acute distress, Overweight / Obese, opens eyes\\n but no purposeful movement\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric)\\n Abdominal: No(t) Soft, Non-tender, Bowel sounds present, Distended\\n Extremities: No clubbing or cyanosis, 3+ nonpitting edema of b/l hands,\\n LE without edema\\n Skin: no rashes or jaundice\\n Labs / Radiology\\n 411 K/uL\\n 8.3 g/dL\\n 133 mg/dL\\n 0.5 mg/dL\\n 28 mEq/L\\n 4.1 mEq/L\\n 13 mg/dL\\n 111 mEq/L\\n 145 mEq/L\\n 26.0 %\\n 9.7 K/uL\\n [image002.jpg]\\n 04:05 PM\\n 01:12 AM\\n 04:00 AM\\n 04:09 AM\\n 10:18 AM\\n 02:33 PM\\n 02:46 PM\\n 03:31 AM\\n 02:26 PM\\n 05:53 PM\\n WBC\\n 9.6\\n 9.7\\n Hct\\n 27.8\\n 26.0\\n Plt\\n 374\\n 411\\n Cr\\n 0.5\\n 0.5\\n 0.5\\n 0.5\\n TCO2\\n 26\\n 27\\n 28\\n 29\\n 26\\n 27\\n 30\\n Glucose\\n 194\\n 195\\n 195\\n 163\\n 133\\n Other labs: PT / PTT / INR:15.3/69.9/1.3, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\\n Amylase / Lipase:, Differential-Neuts:86.1 %, Lymph:10.3 %,\\n Mono:2.8 %, Eos:0.5 %, Lactic Acid:2.0 mmol/L, Albumin:2.4 g/dL,\\n LDH:204 IU/L, Ca++:8.3 mg/dL, Mg++:2.2 mg/dL, PO4:3.5 mg/dL\\n Assessment and Plan\\n 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture with respiratory failure\\n and difficulty weaning from vent.\\n # Respiratory failure: Intubated on for resp decompensation.\\n Likely VAP. Transferred here for tracheomalacia, but not sure this\\n is a component. Will need bronch eval when improved\\n - wean PEEP\\n - repeat ABG this AM\\n - discuss need for trach with patient and her family\\n - Will continue gentle diuresis once alkalosis resolved\\n # Diuresis\\n Currently with hypernatremia, Cr increase, contract alk\\n suggestive of overdiuresis\\n - FW in TF at 150 cc q4hrs\\n - PM lytes. Can restart lasix if resolved\\n # Pneumonia: Pansensitive Kleb oxytoca pneumonia and sputum with GPCs\\n on gram stain. Afebrile off abx.\\n # Sedation: On versed 3mg/hr + .5 q 1hr and fentanyl 150 mcg/hr + 50\\n bolus q 1hr.\\n - seroquil 25 \\n # EKG changes: Sinus bradycardia, responsive to stress. Related to\\n sedation, increased vagal tone, possibly related to steroid\\n replacement. Atrial EKG shows p-waves and cardiac enzymes normal.\\n - Continue to monitor\\n # Hypotension: Improved, off levophed for 2-3 days now, with good urine\\n output. s/p 5 d courserof steroids and getting high PEEP. Now likely\\n related to sedation and decreased intravascual volume,\\n -monitor, expect improvement with continual reduction in PEEP\\n # RUE DVT: Started on heparin gtt on , now therapeutic. Follow\\n PTTs. Would hold off on coumadin at least until s/p trach.\\n - continue to monitor\\n # Adrenal Insufficency: Random cortisol was approx 3 when it should\\n have been maximally stimulated.\\n - hydrocortisone and florinef for 5 days\\n # Anemia: Stable.\\n - Trend HCT\\n # Spine fracture: Neurologically intact distal to the lesion. Prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - CT of C, L spine when stable. Currently, unlikely to change\\n management and high risk for complications with transport.\\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\\n is low. Brace for OOB. Ok for anticoag per note.\\n # Communication:\\n - Boyfriend of 10 is her HCP. Also brother is involved\\n FEN/GI: Tube feeds @ goal\\n DVT: Treatment dose heparin\\n Ulcer: Ranitidine\\n VAP: Prevention per routine\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 08:12 PM 60 mL/hour\\n Glycemic Control:\\n Lines:\\n Arterial Line - 04:00 PM\\n PICC Line - 09:19 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-09-28 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 634969,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n PICC placed, Central line d/c'd\\n Lasix 10 mg given with 400 cc UOP in afternoon, pH improved\\n Lasix 20 mg given at ~ 4AM.\\n Lots of thick sinus secreations\\n Delerium/anxiety overnight with periods of hypertension.\\n Could not draw of A-line.\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Aztreonam - 06:00 AM\\n Vancomycin - 09:00 AM\\n Levofloxacin - 08:06 AM\\n Infusions:\\n Midazolam (Versed) - 3 mg/hour\\n Fentanyl - 150 mcg/hour\\n Heparin Sodium - 1,700 units/hour\\n Other ICU medications:\\n Furosemide (Lasix) - 03:01 AM\\n Midazolam (Versed) - 04:36 AM\\n Fentanyl - 04:36 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:44 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.9\\nC (98.5\\n Tcurrent: 36.4\\nC (97.6\\n HR: 90 (47 - 92) bpm\\n BP: 118/59(80) {80/40(53) - 137/105(111)} mmHg\\n RR: 17 (15 - 24) insp/min\\n SpO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 101 kg (admission): 94.2 kg\\n Height: 67 Inch\\n CVP: 19 (16 - 19)mmHg\\n Total In:\\n 2,560 mL\\n 543 mL\\n PO:\\n TF:\\n 1,441 mL\\n 342 mL\\n IVF:\\n 1,020 mL\\n 201 mL\\n Blood products:\\n Total out:\\n 1,680 mL\\n 860 mL\\n Urine:\\n 1,680 mL\\n 860 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 880 mL\\n -317 mL\\n Respiratory support\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 400 (400 - 400) mL\\n RR (Set): 18\\n RR (Spontaneous): 0\\n PEEP: 15 cmH2O\\n FiO2: 50%\\n PIP: 27 cmH2O\\n Plateau: 23 cmH2O\\n SpO2: 98%\\n ABG: 7.41/45/77./28/2\\n Ve: 6.5 L/min\\n PaO2 / FiO2: 156\\n Physical Examination\\n General Appearance: No acute distress, Overweight / Obese, opens eyes\\n but no purposeful movement\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric)\\n Abdominal: No(t) Soft, Non-tender, Bowel sounds present, Distended\\n Extremities: No clubbing or cyanosis, 3+ nonpitting edema of b/l hands,\\n LE without edema\\n Skin: no rashes or jaundice\\n Labs / Radiology\\n 411 K/uL\\n 8.3 g/dL\\n 133 mg/dL\\n 0.5 mg/dL\\n 28 mEq/L\\n 4.1 mEq/L\\n 13 mg/dL\\n 111 mEq/L\\n 145 mEq/L\\n 26.0 %\\n 9.7 K/uL\\n [image002.jpg]\\n 04:05 PM\\n 01:12 AM\\n 04:00 AM\\n 04:09 AM\\n 10:18 AM\\n 02:33 PM\\n 02:46 PM\\n 03:31 AM\\n 02:26 PM\\n 05:53 PM\\n WBC\\n 9.6\\n 9.7\\n Hct\\n 27.8\\n 26.0\\n Plt\\n 374\\n 411\\n Cr\\n 0.5\\n 0.5\\n 0.5\\n 0.5\\n TCO2\\n 26\\n 27\\n 28\\n 29\\n 26\\n 27\\n 30\\n Glucose\\n 194\\n 195\\n 195\\n 163\\n 133\\n Other labs: PT / PTT / INR:15.3/69.9/1.3, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\\n Amylase / Lipase:, Differential-Neuts:86.1 %, Lymph:10.3 %,\\n Mono:2.8 %, Eos:0.5 %, Lactic Acid:2.0 mmol/L, Albumin:2.4 g/dL,\\n LDH:204 IU/L, Ca++:8.3 mg/dL, Mg++:2.2 mg/dL, PO4:3.5 mg/dL\\n Assessment and Plan\\n 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture with respiratory failure\\n and difficulty weaning from vent.\\n # Respiratory failure: Intubated on for resp decompensation.\\n Likely VAP. Transferred here for tracheomalacia, but not sure this\\n is a component. Will need bronch eval when improved\\n - will discuss PEEP goal for trach placement with IP.\\n - wean PEEP\\n - repeat ABG this AM\\n - discuss need for trach with patient and her family\\n - Volume overload may be contributing.\\n # Volume overload\\n Currently with hypernatremia, Cr increase, contract\\n alk, but mild\\n - continue gentle diuresis\\n - FW in TF at 150 cc q4hrs\\n - PM lytes.\\n # Sedation: On versed 3mg/hr + .5 q 1hr and fentanyl 150 mcg/hr + 50\\n bolus q 1hr.\\n - Start fentanyl patch and diazepam to provide long acting analgesia\\n and wean from drips\\n - Haldol 1 mg Q4h PRN agitation\\n # Pneumonia: Pansensitive Kleb oxytoca pneumonia and sputum with GPCs\\n on gram stain. Afebrile off abx.\\n # EKG changes: Sinus bradycardia, responsive to stress. Related to\\n sedation, increased vagal tone, possibly related to steroid\\n replacement. Atrial EKG shows p-waves and cardiac enzymes normal.\\n - Continue to monitor\\n # Hypotension: Improved, off levophed for 2-3 days now, with good urine\\n output. s/p 5 d course of steroids for adrenal insufficiency. High\\n PEEP may have been contributing. Now likely related to sedation and\\n decreased intravascular volume,\\n -monitor, expect improvement with continual reduction in\\n PEEP\\n # RUE DVT: Started on heparin gtt on , now therapeutic. Follow\\n PTTs. Would hold off on coumadin at least until s/p trach.\\n - continue to monitor\\n # Adrenal Insufficency: Random cortisol was approx 3 when it should\\n have been maximally stimulated.\\n - hydrocortisone and florinef for 5 days\\n # Anemia: Stable.\\n - Trend HCT\\n # Spine fracture: Neurologically intact distal to the lesion. Prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - CT of C, L spine when stable. Currently, unlikely to change\\n management and high risk for complications with transport.\\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\\n is low. Brace for OOB. Ok for anticoag per note.\\n # Communication:\\n - Boyfriend of 10 is her HCP. Also brother is involved\\n FEN/GI: Tube feeds @ goal\\n DVT: Treatment dose heparin\\n Ulcer: Ranitidine\\n VAP: Prevention per routine\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 08:12 PM 60 mL/hour\\n Glycemic Control:\\n Lines:\\n Arterial Line - 04:00 PM\\n PICC Line - 09:19 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-10 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 636755,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n Discussed imaging with ortho. They do not need further imaging. She\\n should wear TLSO for 2 months and f/u with at 2 months\\n prior to removal of TLSO.\\n Changed to PSV, was stable on trach mask for 1-2 hrs\\n Tube feeds held\\n Endo recs: check AM cortisol prior to dose\\n At 5:45 am --- RR 4, switched from CPAP/PSV to AC\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Vancomycin - 10:04 PM\\n Levofloxacin - 10:49 PM\\n Aztreonam - 03:42 AM\\n Infusions:\\n Other ICU medications:\\n Morphine Sulfate - 10:49 PM\\n Other medications:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:01 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.4\\nC (99.4\\n Tcurrent: 36.7\\nC (98\\n HR: 125 (74 - 151) bpm\\n BP: 121/64(77) {89/32(45) - 179/99(120)} mmHg\\n RR: 20 (13 - 30) insp/min\\n SpO2: 100%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 5,817 mL\\n 457 mL\\n PO:\\n TF:\\n IVF:\\n 5,277 mL\\n 327 mL\\n Blood products:\\n Total out:\\n 5,205 mL\\n 1,460 mL\\n Urine:\\n 5,205 mL\\n 1,460 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 612 mL\\n -1,003 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: CPAP/PSV\\n Vt (Set): 400 (400 - 400) mL\\n Vt (Spontaneous): 429 (340 - 480) mL\\n PS : 8 cmH2O\\n RR (Set): 0\\n RR (Spontaneous): 25\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n PIP: 13 cmH2O\\n SpO2: 100%\\n ABG: 7.37/44/120/25/0\\n Ve: 6.3 L/min\\n PaO2 / FiO2: 240\\n Physical Examination\\n On CMV\\n Peep 5, FiO2 40%, Vt 500, R 14\\n General Appearance: Trached and sedated. Responsive, following\\n commands, Overweight / Obese, mild agitation but NAD\\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\\n deviation\\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\\n Cardiovascular: (S1: Normal), (S2: Normal), distant\\n Respiratory / Chest: (Expansion: Symmetric), CTA anteriorly, decreased\\n BS\\n Abdominal: Obese, soft, Non-tender, no rebound, no guarding, + BS, PEG\\n in place with dressing C/D/I\\n Extremities: no CCE\\n Skin: no rashes or jaundice\\n Lines: L PICC C/D/I\\n Labs / Radiology\\n 209 K/uL\\n 8.3 g/dL\\n 99 mg/dL\\n 0.6 mg/dL\\n 25 mEq/L\\n 4.3 mEq/L\\n 9 mg/dL\\n 111 mEq/L\\n 145 mEq/L\\n 26.5 %\\n 6.1 K/uL\\n [image002.jpg]\\n 01:37 AM\\n 05:32 AM\\n 02:43 PM\\n 03:03 PM\\n 08:11 PM\\n 02:51 AM\\n 03:10 AM\\n 03:08 PM\\n 03:00 AM\\n 03:36 AM\\n WBC\\n 11.1\\n 9.4\\n 11.3\\n 7.3\\n 6.1\\n Hct\\n 29.4\\n 26.6\\n 24.9\\n 27.6\\n 26.5\\n Plt\\n 89\\n 209\\n Cr\\n 0.6\\n 0.9\\n 0.7\\n 0.6\\n TCO2\\n 31\\n 31\\n 30\\n 29\\n 26\\n Glucose\\n 123\\n 128\\n 114\\n 114\\n 99\\n Other labs: PT / PTT / INR:36.4/38.8/3.9, Ca++:8.9 mg/dL, Mg++:2.6\\n mg/dL, PO4:4.1 mg/dL\\n Cx: endotrach \\n GN diplococci, budding yeast\\n Assessment and Plan\\n 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA, and\\n ARDS, intubated since the end of now s/p trach and PEG\\n placement.\\n # Recent Aspiration of tube feeds. Given prolonged hospitalization and\\n tenuous respiratory status will treat with antibiotics while cultures\\n pending\\n - Levoflox for 48 hours while waiting for sputum results.\\n - restart tube feeds slowly\\n - Follow cultures\\n .\\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\\n volume overload. Intubated on for resp decompensation. S/P Trach\\n and PEG on .\\n - wean FiO2 as tolerated\\n - attempt wean PS today and hopeful for trach mask trial\\n # Sedation: Continue to have issues with pain/delirium causing\\n tachycardia and hypertension with intermittent hypotension. On Haldol\\n 5 TID, Fentanyl 75 mcg TP, Diazapam 10 QID; Haldol, midazolam and\\n morphine PRN. Had good response to morphine, minimal response to\\n haldol bolus.\\n - Reduce diazepam to 5 q 8hrs.\\n - d/c standing Haldol\\n # Adrenal Insufficency: Hypotension that resolved with steroids,\\n returned as they came off and is now improved again. Possible primary\\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\\n started on .\\n - 10 q am and 5 q pm prednisone day 2 of 3, will wean to\\n maintenance dose as tolerated, in consultation with endo.\\n # Volume overloaded in setting of hypernatremia\\n Goal even today.\\n - Off diamox\\n - electrolytes\\n - Free water flushes with tube feeds.\\n # Falling Hct: Likely dilutional. Concern given elevated INR. Stable\\n today.\\n - monitor\\n - maintain active type and screen\\n # RUE DVT: INR now therapeutic on coumadin. Goal \\n - will start coumadin 2.5 mg QHS once INR < 3\\n # Spine fracture: Neurologically intact distal to the lesion. Prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - Brace for OOB\\n - report from full trauma series from OSH is in chart. No evidence of\\n other fracture and no need for further spinal imaging based on this\\n report and ortho note.\\n # Tracheomalacia: Discussed with IP. Stenting unlikely to help for\\n trachiomalacia as airways have poor structure diffusely.\\n - Outpatient f/u once off pressure support to assess for possible\\n stenting\\n #. Thyroid Nodule on CT\\n -outpatient follow up\\n # Nutrition: Replete (Full)\\n will reintroduce slowly\\n - advance bowel regimen\\n # Glycemic control: SSI, well controlled\\n # Lines L PICC ().\\n # Ppx: INR therapeutic, ranitidine, colace and senna, miralax,\\n bisacodyl.\\n # Communication:\\n - Boyfriend of 10 \\n - Brother is her HCP, also involved\\n Code: Full\\n Dispo: ICU, being screening for vent facilities\\n ------ Protected Section ------\\n I saw and examined the patient, and was physically present with the ICU\\n team for the key portions of the services provided. I agree with the\\n note above, including the assessment and plan. I would emphasize and\\n add the following points: 55F T5-8 fractures with retropulsion and ARDS\\n from klebsiella VAP; on heparin for UE DVT and lasix for volume\\n overload. Overnight transitioned to PSV and trial spont breathing\\n performed. RR down to 4 terminated trial\\n mode changed back to AC.\\n On exam:\\n Tmax: 37.4\\nC (99.4\\n Tcurrent: 36.7\\nC (98\\n HR: 125 (74 - 151) bpm\\n BP: 121/64(77) {89/32(45) - 179/99(120)} mmHg\\n RR: 20 (13 - 30) insp/min\\n SpO2: 100%\\n Trached, lightly sedated, following commands.\\n CV RRR, distantstant\\n Lungs\\n distant bs, otherwise clear\\n abd: soft NTND BS+, +PEG site\\n Ext- no c/c/e\\n Data: WBC 6.1 hct 26.5 creat 0.6\\n 55F h/o EtOH abuse presenting following mech fall -> traumatic T spine\\n fracture with K. oxytoca PNA, and ARDS, intubated since the end of\\n now s/p trach and PEG placement. Cont efforts to wean mech vent\\n including spont breathing trials w/ monitoring given RR. Check ABG\\n prior to d/c to assess adequacy of vent. Tracheomalacia\\n indication for intervention per IP. Ortho following re: fx. Cont\\n brace. Agree with recs as outlined above.\\n ------ Protected Section Addendum Entered By: , MD\\n on: 02:09 PM ------\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-10 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 636806,\n \"text\": \"55 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\\n with prolonged hospital course c/b by PNA with high PEEP requirement,\\n anxiety, RUE DVT .\\n Altered mental status (not Delirium)\\n Assessment:\\n Rec\\nd pt restless, intermit following commands. MAEE with good\\n strength. Pt shaking head\\n when asked if has pain or SOB.\\n Action:\\n Torso brace applied\\nwith difficulty\\nand pt OOB to stretcher/chair with\\n transfer via board.\\n Response:\\n Pt increasingly restless with HR 130-140ST, grimacing. Pt attempting to\\n stand and/or exit chair. She dislodged her periph IV. Pt rec\\n scheduled Valium 5mg po early, as well as Morphine Sulfate 2mg IVP\\n without relief of discomfort. Pt returned to bed after 45mins. When\\n brace removed, chin noted to be abraided from chin rest. Pt cont to be\\n restless until approx 1600, freq attempting to sit up in bed. Soft\\n wrist restraints in place for pt safety.\\n Plan:\\n Duoderm to chin or chin-rest when brace applied. Attempt OOB to chair\\n again tomorrow, but meanwhile bed as chair intermit.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Rec\\nd pt on vent settings AC 50%/ 12 X 500/+5 with rare over-breathing\\n of rate. O2 sat 100%. Lung snds with rhonchi in RUL, clear in LUL, and\\n diminished bilat in bases. Pt requiring sxn\\ning Q2-4hrs for mod amts\\n yellow/white thick secretions. Pt also intermit with copious thick,\\n clear oral secretions.\\n Action:\\n Vent changed to CPAP/PS 8/+5/50% with SRR 14-25 and regular, O2 sat\\n remaining 98-100%. Pt then placed on trach mask @ 80% at 1230.\\n Response:\\n Pt has tolerated TM for several hrs, with RR remaining regular @\\n 14-25/min, O2 sat generally 100%. However, desated to 70\\ns X 2,\\n returning to baseline after suctioning and ambu.\\n Plan:\\n Cont pt on TM as tol, monitoring for ? plugs requiring ambu/suctioning.\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2167-10-12 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 637021,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 24\\n Ideal body weight: 61.2 None\\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: Yes\\n Procedure location:\\n Reason:\\n Tube Type\\n Tracheostomy tube:\\n Type: Cuffed\\n Manufacturer: Portex\\n Size: 7.0mm\\n PMV: No\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 28 cmH2O\\n Cuff volume: mL /\\n Airway problems:\\n Comments:\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Rhonchi\\n LUL Lung Sounds: Rhonchi\\n LLL Lung Sounds: Diminished\\n Comments: Lung sounds are rhonchi, but clear up after suction. Pt has\\n consistent cough, but minimal secretions are sucitoned\\n Secretions\\n Sputum color / consistency: Blood Tinged / Thick\\n Sputum source/amount: Suctioned / Small\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance: Continuous invasive ventilation\\n Visual assessment of breathing pattern: Normal quiet breathing;\\n Comments: Pt has strong, consistent productive cough\\n Assessment of breathing comfort:\\n Non-invasive ventilation assessment:\\n Invasive ventilation assessment:\\n Trigger work assessment: Triggering synchronously\\n Dysynchrony assessment: Frequent alarms (High pressure)\\n Comments: Pt is always coughing, although minimal is suctioned out\\n Plan\\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\\n Periodic SBT's for conditioning, Increase ventilatory support at night\\n Reason for continuing current ventilatory support: Intolerant of\\n weaning attempts, Cannot protect airway, Cannot manage secretions;\\n Comments: Pt is stable on current vent settings, switch to trachmask\\n during the day, vent usage at night.\\n BEDSIDE RSBI FAILED due to small tidal volumes\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-13 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 637228,\n \"text\": \"56 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\\n with prolonged hospital course c/b by PNA, anxiety/altered mental\\n status, RUE DVT .\\n Tachycardia, Other\\n Assessment:\\n HR at rest and sleeping 120-130 , when awake pt is very restless and at\\n times seems agitated also. When restless HR is 140-155 w/o ectopy.\\n Pt shakes head no when asked if in pain. Attempted to reposition pt,\\n but wiggles back to her back.\\n Action:\\n MD notified and valium PO continues. Morphine 2 mg IV given\\n Response:\\n No effect noted on HR after valium or morphine\\n Plan:\\n Will discuss in am rounds\\n Altered mental status (not Delirium)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Alteration in Nutrition\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Impaired Skin Integrity\\n Assessment:\\n Pt has fungal rash noted under bil breasts\\n Action:\\n Nystatin powder to affected areas\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-09-29 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 635033,\n \"text\": \"Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n RUE edematous, warm, red\\n Action:\\n Heparin gtt WNL\\n Response:\\n No change\\n Plan:\\n Heparin off at 0600 for procedure\\n Altered mental status (not Delirium)\\n Assessment:\\n Periods of agitation\\n Action:\\n Fentanyl and Versed Gtt, haldol and valium started. Fentanyl patch\\n Response:\\n Calm with increased sedation needed\\n Plan:\\n Monitor, continue with sedation as tolerates.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt desatted to 87%\\n Action:\\n Peep increased\\n Response:\\n O2 sat improved\\n Plan:\\n Team to attempt to replace aline or will draw am abg. AM RSBI\\n Hypotension (not Shock)\\n Assessment:\\n Sbp 70\\n Action:\\n Sedation weaned, but pt agitated\\n Response:\\n Sbp > 90\\n Plan:\\n Maintain sbp > 90 with adequate sedation\\n Bradycardia\\n Assessment:\\n HR 50\\ns with increased sedation\\n Action:\\n Sedation weaned, but pt agitated\\n Response:\\n HR 70-130\\ns, with increased sedation noted\\n Plan:\\n Maintain sedation, monitor hr\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-10 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 636645,\n \"text\": \"55 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\\n Now with prolonged hospital course c/b by PNA with high PEEP\\n requirement, anxiety, RUE DVT .\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt more alert, following commands intermittently. Periods of agitation\\n with HR rising to 130\\n Action:\\n Fentanyl patch in place. Valium RTC. MSO4 given x 1 for discomfort.\\n Response:\\n Pt with less episodes of agitation previously. ? steroid psychosis.\\n Plan:\\n Check cortisol level in am and wean hydrocortisone MD. Continue to\\n reorient pt. MSO4 prn for discomfort.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Received pt on PSV 8/5/50%.RR 19-24. Tidal volumes 200-250. 02 sats\\n variable 90-100%. LS rhoncherous to clear, diminished at bases.\\n Action:\\n Pt maintained at current settings given reduced tv\\ns and sats. Orally\\n suctioned q 2 hrs for copious secretions. Deep suctioned q 3-4 hrs for\\n sm amt thick white secretions.\\n Response:\\n Resp status continues to improve. ABG 7.37/40/120/0/26\\n Plan:\\n Wean fio2 and peep as tolerated. Vigorous pulm hygiene.\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Pt with RUE DVT. Heparin dcd on .\\n Action:\\n Coags being monitored. INR 4.4 yest. Hct waws falling.\\n Response:\\n Hct 26.5 today, previously 27.6.\\n Plan:\\n Coumadin to be started when INR < 3\\n Hypernatremia (high sodium)\\n Assessment:\\n Na 140. Pt volume overloaded. LOS + ~10,000ccs.\\n Action:\\n Treated with 1 liter d5w iv.\\n Response:\\n Urine output 120-400ccs/hr via foley. TFB neg 100cc. Na 145. Goal ~\\n even fluid balance.\\n Plan:\\n Continue to monitor f+e status.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-10 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 636804,\n \"text\": \"Altered mental status (not Delirium)\\n Assessment:\\n Rec\\nd pt restless, intermit following commands. MAEE with good\\n strength. Pt shaking head\\n when asked if has pain or SOB.\\n Action:\\n Torso brace applied\\nwith difficulty\\nand pt OOB to stretcher/chair with\\n transfer via board.\\n Response:\\n Pt increasingly restless with HR 130-140ST, grimacing. Pt attempting to\\n stand and/or exit chair. Pt rec\\nd scheduled Valium 5mg po early, as\\n well as Morphine Sulfate 2mg IVP without relief of discomfort. Pt\\n returned to bed after 45mins. When brace removed, chin noted to be\\n abraided from chin rest. Pt cont to be restless until approx 1600, freq\\n attempting to sit up in bed. Soft wrist restraints in place for pt\\n safety.\\n Plan:\\n Duoderm to chin or chin-rest when brace applied. Attempt OOB to chair\\n again tomorrow, but meanwhile bed as chair intermit.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Rec\\nd pt on vent settings AC 50%/ 12 X 500/+5 with rare over-breathing\\n of rate. O2 sat 100%. Lung snds with rhonchi in RUL, clear in LUL, and\\n diminished bilat in bases. Pt requiring sxn\\ning Q2-4hrs for mod amts\\n yellow/white thick secretions. Pt also intermit with copious thick,\\n clear oral secretions.\\n Action:\\n Vent changed to CPAP/PS 8/+5/50% with SRR 14-25 and regular, O2 sat\\n remaining 98-100%. Pt then placed on trach mask @ 80% at 1230.\\n Response:\\n Pt has tolerated TM for several hrs, with RR remaining regular @\\n 14-25/min, O2 sat generally 100%. However, desated to 70\\ns X 2,\\n returning to baseline after suctioning and ambu.\\n Plan:\\n Cont pt on TM as tol, monitoring for ? plugs requiring ambu/suctioning.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-12 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 637026,\n \"text\": \"56 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\\n with prolonged hospital course c/b by PNA, anxiety/altered mental\\n status, RUE DVT .\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Received pt on PSV 10/5/50%. RR 20-30. )2 sat > 97%\\n Action:\\n Pt remained on PSV rather than AC overnight. Suctioned ~q 3-4 hrs for\\n sm amt yellow bld-tinged secretions. Continues to have copious oral\\n secretions\\n removed with yankeur.\\n Response:\\n Tolerated PSV well, no tachypnea or desaturation.\\n Plan:\\n Attempt trach collar trial again in am. On-going pulm hygiene\\n Hypotension (not Shock)\\n Assessment:\\n BP 90/40 with urine output falling to 10-15ccs/hr via foley. HR remains\\n tachycardic (110-140ST) even when pt is not agitated or febrile.\\n Action:\\n Given 1 500cc d5\\n ns fluid bolus\\n Response:\\n SBP > 90, Urine output improving to >30ccs/hr\\n Plan:\\n Continue to monitor hemodynamic status and f+e balance.\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt lethargic after receiving benedryl for several hrs but then awoke\\n agitated, attempting to climb OOB and pull at trach despite restraints.\\n Denies pain ( fentanyl patch in place) or need to go to the bathroom.\\n c/o itchiness on back secondary to rash.\\n Action:\\n Medicated with iv benedryl.\\n Response:\\n Less agitated. Slept again\\n Plan:\\n Continue to reorient pt, benedryl for pruritis, safety precautions.\\n Alteration in Nutrition\\n Assessment:\\n Pt with previous episodes of vomiting last eve. Kub showed no evidence\\n of obstruction. Na 146\\n Action:\\n TF initiated with 50ccs free h20 boluses q 4hrs\\n Response:\\n No nausea or vomiting. No residuals.\\n Plan:\\n Advance TF as tolerated. ? increase free h20 boluses for hypernatremia.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-13 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 637220,\n \"text\": \"Tachycardia, Other\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Altered mental status (not Delirium)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Alteration in Nutrition\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Impaired Skin Integrity\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-13 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 637221,\n \"text\": \"Tachycardia, Other\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Altered mental status (not Delirium)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Alteration in Nutrition\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Impaired Skin Integrity\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-13 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 637223,\n \"text\": \"56 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\\n with prolonged hospital course c/b by PNA, anxiety/altered mental\\n status, RUE DVT .\\n Tachycardia, Other\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Altered mental status (not Delirium)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Alteration in Nutrition\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Impaired Skin Integrity\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-13 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 637284,\n \"text\": \"56 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\\n with prolonged hospital course c/b by PNA, anxiety/altered mental\\n status, RUE DVT .\\n Tachycardia, Other\\n Assessment:\\n HR at rest and sleeping 120-130 , when awake pt is very restless and at\\n times seems agitated also. When restless HR is 140-155 w/o ectopy.\\n Pt shakes head no when asked if in pain. Attempted to reposition pt,\\n but wiggles back to her back.\\n Action:\\n MD notified and valium PO continues. Morphine 2 mg IV given\\n Response:\\n No effect noted on HR after valium or morphine\\n Plan:\\n Will discuss in am rounds\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt very restless at times and seems not to follow verbal commands at\\n times. Pt will nod head appropriately when asked simple questions. Ie\\n if she has pain\\n Action:\\n Pt continues to be reoriented to surrounding\\n Response:\\n Pt not following commands consistently and not able to use call light\\n Plan:\\n Continue to reorient\\n Alteration in Nutrition\\n Assessment:\\n Abd distended , TF residuals >50cc and TF held at 6am. BS present, no\\n BM\\n Action:\\n Will continue to assess\\n Response:\\n Plan:\\n Impaired Skin Integrity\\n Assessment:\\n Pt has fungal rash noted under bil breasts\\n Action:\\n Nystatin powder to affected areas\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-09-30 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 635174,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n ARTERIAL LINE - START 02:00 PM - in right brachial atery\\n Hypotensive- started on levophed, weaned off over night\\n Low cortisol and failed stim test - started on steroids\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Levofloxacin - 08:06 AM\\n Infusions:\\n Heparin Sodium - 1,700 units/hour\\n Midazolam (Versed) - 2 mg/hour\\n Fentanyl - 150 mcg/hour\\n Other ICU medications:\\n Haloperidol (Haldol) - 12:15 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:50 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.5\\nC (99.5\\n Tcurrent: 36.7\\nC (98\\n HR: 63 (48 - 138) bpm\\n BP: 91/41(58) {68/30(49) - 143/78(105)} mmHg\\n RR: 18 (13 - 23) insp/min\\n SpO2: 91%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Mixed Venous O2% Sat: 59 - 59\\n Total In:\\n 3,898 mL\\n 1,155 mL\\n PO:\\n TF:\\n 802 mL\\n 348 mL\\n IVF:\\n 2,126 mL\\n 247 mL\\n Blood products:\\n Total out:\\n 2,367 mL\\n 800 mL\\n Urine:\\n 2,367 mL\\n 800 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,531 mL\\n 355 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 400 (400 - 401) mL\\n RR (Set): 18\\n RR (Spontaneous): 1\\n PEEP: 10 cmH2O\\n FiO2: 60%\\n PIP: 23 cmH2O\\n Plateau: 19 cmH2O\\n Compliance: 57.1 cmH2O/mL\\n SpO2: 91%\\n ABG: 7.42/49/92./30/5\\n Ve: 8.1 L/min\\n PaO2 / FiO2: 155\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 355 K/uL\\n 9.1 g/dL\\n 168 mg/dL\\n 0.5 mg/dL\\n 30 mEq/L\\n 3.9 mEq/L\\n 11 mg/dL\\n 108 mEq/L\\n 146 mEq/L\\n 29.9 %\\n 11.8 K/uL\\n [image002.jpg]\\n 03:32 PM\\n 10:19 PM\\n 02:50 AM\\n 02:30 PM\\n 02:44 PM\\n 03:33 PM\\n 07:26 PM\\n 07:46 PM\\n 02:04 AM\\n 02:18 AM\\n WBC\\n 9.0\\n 8.4\\n 11.8\\n Hct\\n 25.8\\n 23.0\\n 28.1\\n 29.9\\n Plt\\n \\n Cr\\n 0.6\\n 0.7\\n 0.5\\n TCO2\\n 30\\n 35\\n 33\\n 31\\n 33\\n Glucose\\n 94\\n 97\\n 168\\n Other labs: PT / PTT / INR:13.8/70.4/1.2, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\\n Amylase / Lipase:, Differential-Neuts:89.7 %, Lymph:8.7 %, Mono:1.1\\n %, Eos:0.4 %, Lactic Acid:0.9 mmol/L, Albumin:2.4 g/dL, LDH:204 IU/L,\\n Ca++:8.5 mg/dL, Mg++:2.2 mg/dL, PO4:5.4 mg/dL\\n Assessment and Plan\\n 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture with respiratory failure\\n and difficulty weaning from vent.\\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\\n volume overload. Intubated on for resp decompensation.\\n Transferred here for tracheomalacia, but not sure this is a component.\\n Will need bronch eval when improved\\n - Thoracics will do trach and PEG once stable on PEEPs around 10. Had\\n been planned for today but currently holding as PEEP is 15.\\n - wean PEEP as tolerated\\n - needs A-line\\n # Volume overload\\n Currently with hypernatremia, Cr increase, contract\\n alk, but mild\\n - continue gentle diuresis with goal -1L per day as tolerated by blood\\n pressure. IV lasix drip at 1-5 mg/hr.\\n - FW in TF at 150 cc q4hrs\\n - PM lytes.\\n # Sedation: Now well seadated on Versed 1.5, Fentanyl 175, Fentanyl\\n patch, Diazepam standing and haldo 2.5-5 mg PRN. QTc stable at .44\\n - Wean versed/fentanyl as tolerated\\n # HCT\\n Has had slow decline while in ICU.\\n - Xfuse PRN Hct < 21\\n - continue to follow, guiac stools\\n # Hypotension: Related to sedation, but high PEEP, adrenial\\n insufficiency, sepsis have previously been contributing.\\n - needs A-line for monitoring\\n - cortisol stim to rule out persistent adrenal insufficiency\\n # RUE DVT: Started on heparin gtt on , now off for trach that was\\n planned for today. Follow PTTs. Would hold off on coumadin at least\\n until s/p trach.\\n - restart heparin\\n # Adrenal Insufficency: Random cortisol was approx 3 when it should\\n have been maximally stimulated. S/P 5 days of hydrocortisone and\\n florinef.\\n - will recheck as above and start at 50 q8 if needed\\n # Spine fracture: Neurologically intact distal to the lesion. Prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - CT of C, L spine when stable. Currently, unlikely to change\\n management and high risk for complications with transport.\\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\\n is low. Brace for OOB. Ok for anticoag per note.\\n # Communication:\\n - Boyfriend of 10 is her HCP. Also brother is involved\\n # FEN/GI: Tube feeds @ goal. No need to be NPO while awaiting stable\\n PEEP\\n DVT: Treatment dose heparin\\n Ulcer: Ranitidine\\n VAP: Prevention per routine\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 09:51 PM 60 mL/hour\\n Glycemic Control:\\n Lines:\\n PICC Line - 09:19 PM\\n Arterial Line - 02:00 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2167-10-07 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 636226,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 19\\n Ideal body weight: 61.2 None\\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: Yes\\n Procedure location:\\n Reason:\\n Tube Type\\n ETT:\\n Position: cm at teeth\\n Route:\\n Type: Not applicable\\n Size: Not applicable\\n Tracheostomy tube:\\n Type: Cuffed, Extra Length\\n Manufacturer: Portex\\n Size: 7.0mm\\n PMV:\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 28 cmH2O\\n Cuff volume: mL /\\n Airway problems:\\n Comments:\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Diminished\\n Comments:\\n Secretions\\n Sputum color / consistency: Yellow / Thick\\n Sputum source/amount: Suctioned / Moderate\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance:\\n Visual assessment of breathing pattern:\\n Assessment of breathing comfort:\\n Non-invasive ventilation assessment:\\n Invasive ventilation assessment:\\n Trigger work assessment:\\n Dysynchrony assessment:\\n Comments:\\n Plan\\n Next 24-48 hours:\\n Reason for continuing current ventilatory support:\\n Respiratory Care Shift Procedures\\n Transports:\\n Destination (R/T)\\n Time\\n Complications\\n Comments\\n Bedside Procedures:\\n Comments:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-09 00:00:00.000\",\n \"description\": \"Generic Note\",\n \"row_id\": 636471,\n \"text\": \"TITLE:\\n Alteration in Nutrition\\n Assessment:\\n Obtained large feed like secretions orally. ? aspiration Abd\\n dist, soft with hypoactive BS. No BM on this shift. Pt\\ns head needs to\\n be lowered down as BP is Low.\\n Action:\\n TF held .\\n Response:\\n Continues to have thick secretions like the color of the feeds mixed\\n with saliva. By MD .\\n Plan:\\n Hold feeds till am rounds. Intern Discussed about a dye test. No plans\\n at present to do the dye study to determine aspiration.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Received Pt on vent via trach in CPAP+PS at 50 %/. LS finely\\n coarse with diminished bases.. RR 28 to 30/min sats intermittently down\\n to 91 %.\\n Action:\\n Suctioned fro small amts of tan thick mildly blood tinged sputum. Vent\\n Mode changed to AC TV 400, RR 10, peep 8 for the night as per\\n discussion By Resident & MD to rest for the night.\\n Response:\\n Sats maintained in Mid 90\\ns to high 90\\ns. ABG done in am PH\\n 7.35/50/81/29/ Sats 96. Set RR ^ to 12 post abg\\n Plan:\\n Wean vent settings as tolerated. Plan to IP to follow up regarding ?\\n need for stent tomorrow.\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt opens eyes to voice, but will only follow simple commands very\\n inconsistently. Pt is very lethargic. Pt found this am to be very\\n restless and given versed with no effect.\\n Action:\\n After pt placed in a chair, and pt more relaxed. Pt was calm, but her\\n HR was in the 120-130\\ns (while awake). Pt given Morphine with good\\n effect. Fentanyl patches weaned down to 100 mcg.\\n Response:\\n Plan:\\n Continue to eval restlessness.\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Pt was on heparin gtt for clot to Rt upper arm. Inr 2.1 . No signs of\\n any bleeding.\\n Action:\\n Heparin was dc\\nd this am,\\n Response:\\n Plan:\\n ? coumadin tonight. Continue to eval for bleeding.\\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\\n Assessment:\\n Temp up to 101.4. Axillary at hrs\\n Action:\\n Tylenol 650 mgs given, Pan cultured, started on vanco, aztreonam &\\n Levofloxacin.\\n Response:\\n Temp down to 97.5 axillary.\\n Plan:\\n Continue monitoring temp, continue anbx, follow up on cultures.\\n Alteration in Nutrition\\n Assessment:\\n Oral secretions large feedlike. Pt\\ns head needs to be lowered down as\\n BP was Low.\\n Action:\\n Feeds held . by MD. as BP improved.\\n Response:\\n Continues to have small amts of the same color mixed with saliva .\\n Plan:\\n Anemia, other\\n Assessment:\\n HCT down to\\n Action:\\n Response:\\n Plan:\\n Hypotension (not Shock)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-15 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 637663,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n ULTRASOUND - At 03:48 PM\\n US of Lt arm to R/O DVT. Shows small , nonobstructing clot in axillary\\n vein of LEFT arm\\n CTA- neg for PE, though study limited by movement artifact\\n Coumadin increased to 5mg last night\\n Episode of emesis w/ tube gastric contents/ TFs extruding from\\n tracheostomy site, around tube. TFs held.\\n L PICC line left in place until AM.\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Ceftriaxone - 10:00 PM\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:20 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.5\\nC (99.5\\n Tcurrent: 36.3\\nC (97.3\\n HR: 135 (123 - 146) bpm\\n BP: 141/65(82) {106/41(56) - 185/128(142)} mmHg\\n RR: 19 (11 - 32) insp/min\\n SpO2: 96%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 1,888 mL\\n 360 mL\\n PO:\\n TF:\\n 1,268 mL\\n IVF:\\n 100 mL\\n Blood products:\\n Total out:\\n 1,530 mL\\n 240 mL\\n Urine:\\n 1,510 mL\\n 240 mL\\n NG:\\n 20 mL\\n Stool:\\n Drains:\\n Balance:\\n 358 mL\\n 120 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 227 (227 - 397) mL\\n PS : 8 cmH2O\\n RR (Spontaneous): 20\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n RSBI: 194\\n PIP: 16 cmH2O\\n SpO2: 96%\\n ABG: ////\\n Ve: 6.5 L/min\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 306 K/uL\\n 8.8 g/dL\\n 134 mg/dL\\n 0.6 mg/dL\\n 32 mEq/L\\n 4.0 mEq/L\\n 11 mg/dL\\n 106 mEq/L\\n 146 mEq/L\\n 26.8 %\\n 7.5 K/uL\\n [image002.jpg]\\n 03:10 AM\\n 03:08 PM\\n 03:00 AM\\n 03:36 AM\\n 04:40 PM\\n 03:00 AM\\n 07:05 PM\\n 03:00 AM\\n 05:00 AM\\n 02:06 AM\\n WBC\\n 11.3\\n 7.3\\n 6.1\\n 7.2\\n 5.2\\n 5.9\\n 7.5\\n Hct\\n 24.9\\n 27.6\\n 26.5\\n 26.9\\n 26.0\\n 27.2\\n 26.8\\n Plt\\n 227\\n 189\\n 209\\n 238\\n 240\\n 296\\n 306\\n Cr\\n 0.7\\n 0.6\\n 0.6\\n 0.9\\n 0.7\\n 0.6\\n 0.7\\n 0.6\\n TCO2\\n 26\\n Glucose\\n 114\\n 99\\n 115\\n 106\\n 100\\n 134\\n 134\\n Other labs: PT / PTT / INR:15.5/24.8/1.4, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:27/19, Alk Phos / T Bili:118/0.3,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.5 g/dL, LDH:243 IU/L, Ca++:9.2 mg/dL, Mg++:2.1 mg/dL, PO4:4.0\\n mg/dL\\n Assessment and Plan\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n PICC Line - 09:19 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-15 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 637665,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n ULTRASOUND - At 03:48 PM\\n US of Lt arm to R/O DVT. Shows small , nonobstructing clot in axillary\\n vein of LEFT arm\\n CTA- neg for PE, though study limited by movement artifact\\n Coumadin increased to 5mg last night\\n Episode of emesis w/ tube gastric contents/ TFs extruding from\\n tracheostomy site, around tube. TFs held.\\n L PICC line left in place until AM.\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Ceftriaxone - 10:00 PM\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:20 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.5\\nC (99.5\\n Tcurrent: 36.3\\nC (97.3\\n HR: 135 (123 - 146) bpm\\n BP: 141/65(82) {106/41(56) - 185/128(142)} mmHg\\n RR: 19 (11 - 32) insp/min\\n SpO2: 96%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 1,888 mL\\n 360 mL\\n PO:\\n TF:\\n 1,268 mL\\n IVF:\\n 100 mL\\n Blood products:\\n Total out:\\n 1,530 mL\\n 240 mL\\n Urine:\\n 1,510 mL\\n 240 mL\\n NG:\\n 20 mL\\n Stool:\\n Drains:\\n Balance:\\n 358 mL\\n 120 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 227 (227 - 397) mL\\n PS : 8 cmH2O\\n RR (Spontaneous): 20\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n RSBI: 194\\n PIP: 16 cmH2O\\n SpO2: 96%\\n ABG: ////\\n Ve: 6.5 L/min\\n Physical Examination\\n GEN: Awake, alert, responsive. Sitting in chair, in back brace.\\n Following commands.\\n HEENT: PERRL\\n PULM: CTA anteriorly, no r/r/w\\n CARD: tachycardic, regular, ,s1, s2,\\n ABD: abdomen, inferior to brace, soft, nontender\\n EXT: DP 2+\\n NEURO: able to move all extremeties, strength 5/5 upper and lower, R\\n hip < L hip.\\n Labs / Radiology\\n 306 K/uL\\n 8.8 g/dL\\n 134 mg/dL\\n 0.6 mg/dL\\n 32 mEq/L\\n 4.0 mEq/L\\n 11 mg/dL\\n 106 mEq/L\\n 146 mEq/L\\n 26.8 %\\n 7.5 K/uL\\n [image002.jpg]\\n 03:10 AM\\n 03:08 PM\\n 03:00 AM\\n 03:36 AM\\n 04:40 PM\\n 03:00 AM\\n 07:05 PM\\n 03:00 AM\\n 05:00 AM\\n 02:06 AM\\n WBC\\n 11.3\\n 7.3\\n 6.1\\n 7.2\\n 5.2\\n 5.9\\n 7.5\\n Hct\\n 24.9\\n 27.6\\n 26.5\\n 26.9\\n 26.0\\n 27.2\\n 26.8\\n Plt\\n 227\\n 189\\n 209\\n 238\\n 240\\n 296\\n 306\\n Cr\\n 0.7\\n 0.6\\n 0.6\\n 0.9\\n 0.7\\n 0.6\\n 0.7\\n 0.6\\n TCO2\\n 26\\n Glucose\\n 114\\n 99\\n 115\\n 106\\n 100\\n 134\\n 134\\n Other labs: PT / PTT / INR:15.5/24.8/1.4, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:27/19, Alk Phos / T Bili:118/0.3,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.5 g/dL, LDH:243 IU/L, Ca++:9.2 mg/dL, Mg++:2.1 mg/dL, PO4:4.0\\n mg/dL\\n Assessment and Plan\\n 55yoF with history of EtOH abuse presenting following mechanical fall\\n and traumatic T spine fracture, now s/p trach, PEG, placement being\\n treated for HAP.\\n# HAP vs Aspiration PNA: Cultures grew, Klebsiella Oxytoca, Klebsiella Pneumonia\\ne, GNR, GP Cocci. Will continue to treat for potential HAP for 8 days.Pt continu\\ning to have some fevers, last night 100.8, and new sputum on today w/ gram stain\\n showing GPC p/c. New VAP/HAP w/ staph possible, but given no clear infiltrate o\\nn CXR and good respiratory status, significant PNA is unlikely, colonization of\\ntrach is possible, as is contamination of sputum. Given improving clinical \\n, wait until CX data or change in clinical status or CXR to initiate HAP\\n/VAP treatment.\\n - Continue Ceftriaxone HAP (Day #6 of 8)\\n - Continue to f/u cultures\\n .\\n # Respiratory failure: Improving status. Will continue to increase\\n time on trach mask as tolerated.\\n - PMV with suctioning.\\n - Weaning FiO2 as tolerated\\n # Tachycardia: Pt in ST 120\\ns to 150s. Etiology remains unclear and\\n etiologies include hypovolemia, pain, infection (pt with known\\n klebsiella), . DDx also includes PE given hx of RUE DVT, mucus\\n plugging given large amount of secretions, and spinal injury.\\n - Treating underlying infection\\n - Restarting patients Coumadin, last INR 1.2 yesterday, not\\n therapeutic, will recheck this PM\\n - TSH 2.4 on early , will check free T3, T4.\\n - Continue Pain Control\\n - Assess for PE w/ CTPA and UE u/s\\n # Sedation: Pt has pain/delirium causing tachycardia and hypertension\\n with intermittent hypotension. Had good response to morphine, minimal\\n response to haldol bolus.\\n - Haldol 5 PRN, Fentanyl 75 mcg TP, Diazapam 5 QID;\\n - tolerating current regimen well, will continue to wean\\n # Adrenal Insufficency: Followed up with endocrine that suggested if\\n the patient under goes major stressors such as major surgery, sepsis,\\n she may need stress dosed steroids.\\n - Will consider MRI at later date for evaluation of pituitary\\n # Fluid Status: Volume overloaded in prior setting of Hypernatremia\\n Goal even today.\\n - Monitoring urine output\\n - increasse Free H20, for mild hypernatremia\\n # RUE DVT: restarted Coumadin for INR 1.2, will follow INR carefully,\\n given Abx.\\n - Check INR this PM\\n # Spine fracture: Stable\\n - Brace for OOB, will discuss with Neurosurgery if current brace is\\n optimal for stabilization given her mobility.\\n - Pt to follow up with Dr. in weeks\\n # Tracheomalacia?: Discussed with IP.\\n - Outpatient f/u once off pressure support to assess for possible\\n stenting\\n #. Thyroid Nodule on CT\\n - Outpatient follow up\\n # Nutrition: TFs with goal of 60\\n # Glycemic control: SSI, well controlled\\n # Lines L PICC\\n ().\\n # Ppx: Restarting Coumadin, Ranitidine, Bowel Regimen\\n # Communication:\\n - Boyfriend of 10 \\n - Brother also involved\\n # Code: Full\\n # Dispo: ICU, Screening for vent facilities\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n PICC Line - 09:19 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-15 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 637796,\n \"text\": \"Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Left hand to elbow area with edema 2mm\\nknown DVT to left axillary vein;\\n US of right arm\\n Action:\\n DL PICC d/c\\nd; left arm elevated on pillow; US results pnd for right\\n arm\\n Response:\\n PIV placed for access issues to right arm; edema unchanged;\\n Plan:\\n Cont to monitor left arm status; no BP/blood draws left arm. NIBP cuff\\n to right calf. F/U w/ team Re: right arm status\\n Hypernatremia (high sodium)\\n Assessment:\\n hypernatremic\\n Action:\\n Free water boluses cont; bloused with D5W/500cc\\n Response:\\n Remains hypernatremic with min improvement\\n Plan:\\n Cont with free water boluses; check labs am\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Restless, anxious am\\n Action:\\n Trach collar placed 70% early am--\\n Response:\\n Brief episode of desaturation to mid 80\\ns requiring increase of Fi02 to\\n 100% briefly (approx 20min); placed on 70% remainder of shift with\\n adequate o2 sats in low 90\\n Plan:\\n Passer muir valve for brief periods of time with direct supervision by\\n nsg or resp as tolerated by patient; keep on trach collar thru night\\n and try to avoid PSV; nebs changed to prn status for ?partial cause for\\n tachycardia\\n Tachycardia, Other\\n Assessment:\\n Tachy to 130-140\\ns continuous while awake; continuous tachy in 120\\n while sound asleep\\n Action:\\n Standing valium decreased; cont with fent patch; morphine and haldol\\n prn\\n Response:\\n No significant change in level of restlessness/anxiety; freq pulling at\\n any objects/lines with short term memory issues; no significant\\n response to IV morphine; was able to obtain some sleep after 2mg haldol\\n ivp\\n Plan:\\n Cont to closely monitor mental status; maintain safety w/use of\\n restraints, soft wrist restraints and bed alarm. Assess degree of\\n change with titration of meds\\n\"\n },\n {\n \"category\": \"Social Work\",\n \"chartdate\": \"2167-10-07 00:00:00.000\",\n \"description\": \"Social Work Progress Note\",\n \"row_id\": 636222,\n \"text\": \"Social Work:\\n Received phone call from pt\\ns brother, (c: ).\\n He is back at his home in but reports he has been in touch by\\n phone with MICU daily for updates and any issues re consent for\\n procedures. As previously mentioned, brother is pt\\ns legal and\\n therefore the primary person to give consent when pt is unable to speak\\n for herself re her healthcare wishes. Per brother and pt\\ns long-time\\n boyfriend, (h: ), pt has not completed a HCP\\n form. However, per pt\\ns wishes (verbally expressed to MICU team at\\n beginning of her admission), boyfriend should also be consulted, if\\n possible, re plan of care. In prior discussion with brother and\\n boyfriend, both are in agreement with this and seem to have been\\n communicating well with each other and with MICU team. Confirmed this\\n with brother again today.\\n Brother states he is planning on flying in from this Saturday\\n () to visit pt in hospital and meet with MICU team. He plans to be\\n here from about noon\\n 3:00 p.m. before flying back home.\\n Brother asks about pt\\ns long-term prognosis with regards to how long\\n she might not be able to speak for herself or attend to her financial\\n matters. Brother is concerned about how pt will pay her bills (i.e.\\n new car payments and car insurance, etc.). Discussed with him that\\n physicians at hospital can write letter as needed to state that pt is\\n unable to attend to her financial matters at this time and that this\\n often suffices for a temporary period. Brother understands that\\n boyfriend is already assisting with this and has been in touch with a\\n lawyer for help around this issue as well. Brother also states he is\\n able to pay pt\\ns bills temporarily. However, his main concern seems to\\n be how long pt might be in this\\nlimbo\\n place and what her longer-term\\n prognosis is. He is wondering if it makes sense to pursue\\n conservatorship or guardianship for pt at this time. SW discussed with\\n MICU team who report more information re pt\\ns prognosis may be\\n available in the next few days, and this can be shared with pt\\n brother during his meeting with MICU team on Saturday.\\n SW discussed with RNCM who will begin to screen pt for rehab facilities\\n as appropriate. While brother will remain primary point of contact\\n during this process, encouraged him to remain in good communication\\n with pt\\ns boyfriend around dispo planning issues as well. He clearly\\n states his intention to do so. Attempted to call pt\\ns boyfriend to\\n discuss as well, but was unable to reach him by phone.\\n SW will remain available to pt/family for continued emotional support\\n and for facilitation re communication with team as needed. Please page\\n with any questions or concerns.\\n , LCSW, #\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-15 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 637793,\n \"text\": \"Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Left hand to elbow area with edema 2mm\\nknown DVT to left axillary vein;\\n US of right arm\\n Action:\\n DL PICC d/c\\nd; left arm elevated on pillow; US results pnd for right\\n arm\\n Response:\\n PIV placed for access issues to right arm; edema unchanged;\\n Plan:\\n Cont to monitor left arm status; no BP/blood draws left arm. NIBP cuff\\n to right calf. F/U w/ team Re: right arm status\\n Hypernatremia (high sodium)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Restless, anxious am\\n Action:\\n Trach collar placed 70% early am--\\n Response:\\n Brief episode of desaturation to mid 80\\ns requiring increase of Fi02 to\\n 100% briefly (approx 20min); placed on 70% remainder of shift with\\n adequate o2 sats in low 90\\n Plan:\\n Passer muir valve for brief periods of time with direct supervision by\\n nsg or resp as tolerated by patient; keep on trach collar thru night\\n and try to avoid PSV; nebs changed to prn status for ?partial cause for\\n tachycardia\\n Tachycardia, Other\\n Assessment:\\n Tachy to 130-140\\ns continuous while awake; continuous tachy in 120\\n while sound asleep\\n Action:\\n Standing valium decreased; cont with fent patch; morphine and haldol\\n prn\\n Response:\\n No significant change in level of restlessness/anxiety; freq pulling at\\n any objects/lines with short term memory issues; no significant\\n response to IV morphine; was able to obtain some sleep after 2mg haldol\\n ivp\\n Plan:\\n Cont to closely monitor mental status; maintain safety w/use of\\n restraints, soft wrist restraints and bed alarm. Assess degree of\\n change with titration of meds\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-16 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 637897,\n \"text\": \"56 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\\n with prolonged hospital course c/b by PNA, anxiety/altered mental\\n status, RUE DVT .Pt found to have small non occlusive Clot on her right\\n axial vein via Ultrasound.Yesterday Pt went down to IR for Peg revision\\n aspiration riskcouldn\\nt do it,due the type of peg she has now.\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Pt has known DVT to left axillary vein; US of right arm showed no\\n clots.\\n Action:\\n DL PICC d/c\\nd; from left arm and elevated on pillow and received\\n Coumadin scheduled dose.\\n Response:\\n PIV placed for access issues to right arm; edema looks better;\\n Plan:\\n Cont to monitor left arm status; no BP/blood draws left arm PICC line\\n to right arm?.\\n Hypernatremia (high sodium)\\n Assessment:\\n Hypernatremic NA was 146 yesterday evening.\\n Action:\\n Started on D5 W at 100cc/hr for 1000cc,held free wqater bolus \\n aspiration..\\n Response:\\n Awaiting for AM lab report.\\n Plan:\\n Cont with D5W,follow up with AM lab,resume Free water bolus via PEG\\n tube?.\\n Tachycardia, Other\\n Assessment:\\n Tachy to 130-140\\ns continuous while awake; HR stayed 90- 120 sound\\n asleep\\n Action:\\n Standing valium decreased; cont with fent patch; morphine and haldol\\n prn.Bilateral restraints on\\n Response:\\n No significant change in level of restlessness/anxiety; freq pulling at\\n any objects/lines with short term memory issues. She keeps\\n disconnecting from vent,desat to low 80s within seconds.\\n Plan:\\n Cont to closely monitor mental status; maintain safety w/use of\\n restraints, soft wrist restraints and bed alarm. PRN Haldol or\\n Morphine.\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt has been slept most of the time,hard to wake up.responded to deep\\n stimuli.\\n Action:\\n Held Scheduled dose of valium at 2200.Pt has Fentanyl 75 mcg patch on\\n her lleft thigh.\\n Response:\\n Pt start waking up around 0300,got disconnected from vent by\\n herself,given valium 2.5 mg at 0315.\\n Plan:\\n Continue to eval MS,Valium and PRN Morphine and haldol?,cont reorient\\n and emotional support to pt .\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2167-10-17 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 638138,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 29\\n Ideal body weight: 61.2 None\\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: Yes\\n Procedure location:\\n Reason:\\n Tube Type\\n ETT:\\n Position: cm at teeth\\n Route:\\n Type:\\n Size:\\n Tracheostomy tube:\\n Type:\\n Manufacturer: Portex\\n Size:\\n PMV:\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 25 cmH2O\\n Cuff volume: mL /\\n Airway problems:\\n Comments:\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Rhonchi\\n LUL Lung Sounds: Rhonchi\\n LLL Lung Sounds: Diminished\\n Comments:\\n Secretions\\n Sputum color / consistency: Yellow / Thick\\n Sputum source/amount: Suctioned / Small\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance: Unassisted spontaneous breathing\\n Visual assessment of breathing pattern: Normal quiet breathing\\n Assessment of breathing comfort: No response (sleeping / sedated)\\n Non-invasive ventilation assessment:\\n Invasive ventilation assessment:\\n Trigger work assessment:\\n Dysynchrony assessment:\\n Comments:\\n Plan\\n Next 24-48 hours: Increase ventilatory support at night\\n Reason for continuing current ventilatory support: Underlying illness\\n not resolved\\n Respiratory Care Shift Procedures\\n Transports:\\n Destination (R/T)\\n Time\\n Complications\\n Comments\\n Bedside Procedures:\\n Comments:\\n Maintained on Trach Collar all day, plan to stay on TC as tolerated\\n overnoc\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-17 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 638116,\n \"text\": \"Chief Complaint: respiratory distress\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 24 Hour Events:\\n episode of SVT -- beta blocker begun\\n valium decreased, haldol d/c'd, zyprexa started\\n c collar removed\\n History obtained from Medical records, ICU team\\n Patient unable to provide history: Encephalopathy\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Ceftriaxone - 10:00 PM\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:11 AM\\n Other medications:\\n , , docusate, senna, SQI, thiamine, folate, warfarin,\\n lopressor, valium, reglan\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 10:37 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.6\\nC (99.6\\n Tcurrent: 36.4\\nC (97.5\\n HR: 131 (119 - 149) bpm\\n BP: 118/95(99) {99/28(50) - 185/99(144)} mmHg\\n RR: 28 (11 - 31) insp/min\\n SpO2: 99%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 2,408 mL\\n 370 mL\\n PO:\\n 50 mL\\n TF:\\n IVF:\\n 2,358 mL\\n 210 mL\\n Blood products:\\n Total out:\\n 1,795 mL\\n 1,445 mL\\n Urine:\\n 1,795 mL\\n 1,445 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 613 mL\\n -1,075 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask\\n Ventilator mode: Standby\\n Vt (Set): 500 (500 - 500) mL\\n Vt (Spontaneous): 415 (244 - 415) mL\\n PS : 10 cmH2O\\n RR (Set): 12\\n RR (Spontaneous): 0\\n PEEP: 5 cmH2O\\n FiO2: 70%\\n RSBI Deferred: No Spon Resp\\n PIP: 22 cmH2O\\n Plateau: 17 cmH2O\\n SpO2: 99%\\n ABG: ///38/\\n Ve: 5.5 L/min\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 9.0 g/dL\\n 462 K/uL\\n 137 mg/dL\\n 0.6 mg/dL\\n 38 mEq/L\\n 3.9 mEq/L\\n 5 mg/dL\\n 101 mEq/L\\n 146 mEq/L\\n 28.9 %\\n 7.1 K/uL\\n [image002.jpg]\\n 04:40 PM\\n 03:00 AM\\n 07:05 PM\\n 03:00 AM\\n 05:00 AM\\n 02:06 AM\\n 07:34 AM\\n 03:50 AM\\n 06:22 AM\\n 02:58 AM\\n WBC\\n 7.2\\n 5.2\\n 5.9\\n 7.5\\n 5.6\\n 6.1\\n 7.0\\n 7.1\\n Hct\\n 26.9\\n 26.0\\n 27.2\\n 26.8\\n 27.0\\n 27.0\\n 29.7\\n 28.9\\n Plt\\n 238\\n 240\\n 296\\n \\n 395\\n 462\\n Cr\\n 0.6\\n 0.9\\n 0.7\\n 0.6\\n 0.7\\n 0.6\\n 0.5\\n 0.7\\n 0.7\\n 0.6\\n Glucose\\n 115\\n 106\\n 100\\n 134\\n 134\\n 121\\n \\n Other labs: PT / PTT / INR:36.6/30.0/3.9, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:9.8 mg/dL, Mg++:2.2 mg/dL, PO4:3.3\\n mg/dL\\n Assessment and Plan\\n 1. Resp Failure: currently on trach mask, can do sevreal hours per\\n day and increasing each day, then needs for support QHS. Completed\\n Rx for pan Klebs PNA. Per IP not stent planned as technically\\n not possible to place into her airway\\n 2. Hemodynamics: persistant simus tachy but also has runs of SVT-\\n will add low dose bblocker today\\n watch MAPs at night as\\n she tends to run low. Anticoagulated.\\n 3. New L Ext DVT: PICC out, on coumadin\\n 4. Emesis: start Reglan, watch qt and restart low dose tf tonight-\\n discuss with TSurg role of J prior to hospital d/c\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 08:39 AM\\n Prophylaxis:\\n DVT: Boots(Systemic anticoagulation: Coumadin)\\n Stress ulcer: Not indicated\\n VAP:\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds Comments:\\n Code status: Full code\\n Disposition :ICU\\n Total time spent:\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-17 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 638119,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Pt continued on B-Blocker for prior runs of SVT, HR peaked in 135\\n Olanzapine 5mg QHS, Haldol d/c\\nd, diazepam decreased\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Ceftriaxone - 10:00 PM\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history: None\\n Review of systems is unchanged from admission except as noted below\\n Review of systems: Pt denies pain in chest, abdomen. Pt unable to\\n further communicate,\\n Flowsheet Data as of 08:14 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.6\\nC (99.6\\n Tcurrent: 36.4\\nC (97.5\\n HR: 131 (119 - 149) bpm\\n BP: 111/53(67) {99/28(50) - 185/99(144)} mmHg\\n RR: 11 (11 - 30) insp/min\\n SpO2: 98%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 2,408 mL\\n 200 mL\\n PO:\\n 50 mL\\n TF:\\n IVF:\\n 2,358 mL\\n 200 mL\\n Blood products:\\n Total out:\\n 1,795 mL\\n 1,320 mL\\n Urine:\\n 1,795 mL\\n 1,320 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 613 mL\\n -1,120 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask\\n Ventilator mode: MMV/PSV/AutoFlow\\n Vt (Set): 500 (500 - 500) mL\\n Vt (Spontaneous): 415 (244 - 415) mL\\n PS : 10 cmH2O\\n RR (Set): 12\\n RR (Spontaneous): 0\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n RSBI Deferred: No Spon Resp\\n PIP: 22 cmH2O\\n Plateau: 17 cmH2O\\n SpO2: 98%\\n ABG: ///38/\\n Ve: 5.5 L/min\\n Physical Examination\\n Gen: NAD, A0X3\\n HEENT: PERRLA, EOMI\\n Resp: Limited by patients mobility, but CTA anteriorly\\n Card: S1S2 tachy\\n Abd: Soft, Non-tender, Non-distended, BS+\\n Exte: No edema\\n Labs / Radiology\\n 462 K/uL\\n 9.0 g/dL\\n 137 mg/dL\\n 0.6 mg/dL\\n 38 mEq/L\\n 3.9 mEq/L\\n 5 mg/dL\\n 101 mEq/L\\n 146 mEq/L\\n 28.9 %\\n 7.1 K/uL\\n [image002.jpg]\\n 04:40 PM\\n 03:00 AM\\n 07:05 PM\\n 03:00 AM\\n 05:00 AM\\n 02:06 AM\\n 07:34 AM\\n 03:50 AM\\n 06:22 AM\\n 02:58 AM\\n WBC\\n 7.2\\n 5.2\\n 5.9\\n 7.5\\n 5.6\\n 6.1\\n 7.0\\n 7.1\\n Hct\\n 26.9\\n 26.0\\n 27.2\\n 26.8\\n 27.0\\n 27.0\\n 29.7\\n 28.9\\n Plt\\n 238\\n 240\\n 296\\n \\n 395\\n 462\\n Cr\\n 0.6\\n 0.9\\n 0.7\\n 0.6\\n 0.7\\n 0.6\\n 0.5\\n 0.7\\n 0.7\\n 0.6\\n Glucose\\n 115\\n 106\\n 100\\n 134\\n 134\\n 121\\n \\n Other labs: PT / PTT / INR:36.6/30.0/3.9, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:9.8 mg/dL, Mg++:2.2 mg/dL, PO4:3.3\\n mg/dL\\n Assessment and Plan\\n 55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\\n trach, PEG, placement no with respiratory failure secondary to\\n tracheomalacia , resolving HAP.\\n .\\n # Respiratory failure: Slowly Improving. Pressure support of at\\n night.\\n - Continue to increase time on trach mask as tolerated.\\n - PMV with suctioning.\\n .\\n # HAP vs Aspiration PNA: Afebrile without leukocytosis\\n - Completed course of ceftriaxone\\n - Continue to f/u cultures\\n - Continue trach mask as tolerated\\n .\\n # Tachycardia: Sinus Tach with occasional runs of SVT, now on low dose\\n b-blocker. . HR decreased overnight with ranges of 115-135. From\\n yesterday when pt found had runs of SVT as well as ST 120\\ns to 150s.\\n SBPs approx 65.\\n Had Negative CTA, thyroid fxn WNL,\\n - HR became tachy on , will further investigate events surrounding\\n the event for further data\\n - cont metoprolol 12.5mg TID and up titrate as tolerated\\n - monitor on telemetry\\n - Continue Pain Control\\n .\\n # Sedation: Inconsistent response to sedation, unclear what is best\\n regime. Will continue to wean overall\\n - Started on Olanzapine QHS\\n - DC\\nd haldol and taper valium to 2.5 mg PRN TID, taper off\\n # Nutrition: Pt had emesis overnight. TFs currently held. Given\\n Reglan.\\n - Restart Nutrition as tolerated\\n .\\n # Adrenal Insufficency: Endocrine following. Followed Suggesting if\\n the patient under goes major stressors such as major surgery, sepsis,\\n she may need stress dosed steroids.\\n - Endocrine s/o\\n no need for steroids currently\\n .\\n # Fluid Status: Volume overloaded in prior setting of Hypernatremia\\n - Monitoring urine output\\n - increase Free H20, for mild hypernatremia 200cc Free bolus PEG, and\\n - 500cc D5W at 125.\\n - PM lytes to assess hypernatremia\\n .\\n # UE DVT: right has resolved, new non occlusive in left axillary. INR\\n supratherapeutic today\\n - decrease coumadin to home dose of 2.5mg\\n - follow INR\\n .\\n # Spine fracture: Stable\\n - Brace for OOB, will discuss with Neurosurgery if current brace is\\n optimal for stabilization given her mobility.\\n - Pt to follow up with Dr. in weeks\\n .\\n # Tracheomalacia. Was initially addressed with IP and they wanted to\\n follow up as outpatient.\\n - Consult IP for stent placement given improved clinical status, will\\n readdresses\\n .\\n #. Thyroid Nodule on CT\\n - Outpatient follow up\\n .\\n # Glycemic control: SSI, well controlled\\n # PIV x 1\\n # Ppx: Coumadin, Ranitidine, Bowel Regimen PRN\\n # Communication:\\n - Boyfriend of 10 \\n - Brother also involved\\n # Code: Full\\n # Dispo: ICU, Screening for vent facilities\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:10 AM\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-17 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 638123,\n \"text\": \"Chief Complaint: respiratory distress\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 24 Hour Events:\\n episode of SVT -- beta blocker begun\\n valium decreased, haldol d/c'd, zyprexa started\\n c collar removed\\n History obtained from Medical records, ICU team\\n Patient unable to provide history: Encephalopathy\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Ceftriaxone - 10:00 PM\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:11 AM\\n Other medications:\\n , , docusate, senna, SQI, thiamine, folate, warfarin,\\n lopressor, valium, reglan\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 10:37 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.6\\nC (99.6\\n Tcurrent: 36.4\\nC (97.5\\n HR: 131 (119 - 149) bpm\\n BP: 118/95(99) {99/28(50) - 185/99(144)} mmHg\\n RR: 28 (11 - 31) insp/min\\n SpO2: 99%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 2,408 mL\\n 370 mL\\n PO:\\n 50 mL\\n TF:\\n IVF:\\n 2,358 mL\\n 210 mL\\n Blood products:\\n Total out:\\n 1,795 mL\\n 1,445 mL\\n Urine:\\n 1,795 mL\\n 1,445 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 613 mL\\n -1,075 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask\\n Ventilator mode: Standby\\n Vt (Set): 500 (500 - 500) mL\\n Vt (Spontaneous): 415 (244 - 415) mL\\n PS : 10 cmH2O\\n RR (Set): 12\\n RR (Spontaneous): 0\\n PEEP: 5 cmH2O\\n FiO2: 70%\\n RSBI Deferred: No Spon Resp\\n PIP: 22 cmH2O\\n Plateau: 17 cmH2O\\n SpO2: 99%\\n ABG: ///38/\\n Ve: 5.5 L/min\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 9.0 g/dL\\n 462 K/uL\\n 137 mg/dL\\n 0.6 mg/dL\\n 38 mEq/L\\n 3.9 mEq/L\\n 5 mg/dL\\n 101 mEq/L\\n 146 mEq/L\\n 28.9 %\\n 7.1 K/uL\\n [image002.jpg]\\n 04:40 PM\\n 03:00 AM\\n 07:05 PM\\n 03:00 AM\\n 05:00 AM\\n 02:06 AM\\n 07:34 AM\\n 03:50 AM\\n 06:22 AM\\n 02:58 AM\\n WBC\\n 7.2\\n 5.2\\n 5.9\\n 7.5\\n 5.6\\n 6.1\\n 7.0\\n 7.1\\n Hct\\n 26.9\\n 26.0\\n 27.2\\n 26.8\\n 27.0\\n 27.0\\n 29.7\\n 28.9\\n Plt\\n 238\\n 240\\n 296\\n \\n 395\\n 462\\n Cr\\n 0.6\\n 0.9\\n 0.7\\n 0.6\\n 0.7\\n 0.6\\n 0.5\\n 0.7\\n 0.7\\n 0.6\\n Glucose\\n 115\\n 106\\n 100\\n 134\\n 134\\n 121\\n \\n Other labs: PT / PTT / INR:36.6/30.0/3.9, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:9.8 mg/dL, Mg++:2.2 mg/dL, PO4:3.3\\n mg/dL\\n Assessment and Plan\\n Resp Failure\\n Trach mask trials as tolerating (needing QHS support at\\n present)\\n S/P rx for pan Klebs PNA.\\n Per IP not stent planned as technically not possible to\\n place into her airway\\n Tachycardia\\n Extensive evaluation. Will test whether BZD or opiate withdrawal might\\n be playing a role. Review hx of medication additions that might\\n contribute. Otherwise, will continue beta blocker.\\n DVT\\n On warfarin\\n Emesis\\n Getting raglan trial. Restart TF\\n Hypernatremia\\n Replete free water.\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 08:39 AM\\n Prophylaxis:\\n DVT: Boots(Systemic anticoagulation: Coumadin)\\n Stress ulcer: Not indicated\\n VAP:\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds Comments:\\n Code status: Full code\\n Disposition :ICU. Screen for rehab.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-09 00:00:00.000\",\n \"description\": \"Generic Note\",\n \"row_id\": 636465,\n \"text\": \"TITLE:\\n Alteration in Nutrition\\n Assessment:\\n Abd dist, soft with hypoactive BS. No BM on this shift.\\n Action:\\n TF restarted at goal at 60 cc/hr with minimal residuals.\\n Response:\\n Plan:\\n Follow FSBS. ? adding more laxatives until BM.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt remains on vent via trach in CPAP+PS at 50 %/. LS CTA with\\n diminished bases. Pt has been deep sx\\nd for sml amounts of tan to thick\\n yellow secretions.\\n Action:\\n Vent changed to 5/5, but was only tolerated for 1 hr.\\n Response:\\n After 1 hr pt became tachycardic and tachypnic. O2sat decreased to 95%.\\n Plan:\\n Continue to wean vent settings as tolerated. Plan to IP to follow up\\n regarding ? need for stent tomorrow.\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt opens eyes to voice, but will only follow simple commands very\\n inconsistently. Pt is very lethargic. Pt found this am to be very\\n restless and given versed with no effect.\\n Action:\\n After pt placed in a chair, and pt more relaxed. Pt was calm, but her\\n HR was in the 120-130\\ns (while awake). Pt given Morphine with good\\n effect. Fentanyl patches weaned down to 100 mcg.\\n Response:\\n Plan:\\n Continue to eval restlessness.\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Pt was on heparin gtt for clot to Rt upper arm. Inr 2.1 . No signs of\\n any bleeding.\\n Action:\\n Heparin was dc\\nd this am.\\n Response:\\n Plan:\\n ? coumadin tonight. Continue to eval for bleeding.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-16 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 637889,\n \"text\": \"Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Left hand to elbow area with edema 2mm\\nknown DVT to left axillary vein;\\n US of right arm\\n Action:\\n DL PICC d/c\\nd; left arm elevated on pillow; US results pnd for right\\n arm\\n Response:\\n PIV placed for access issues to right arm; edema unchanged;\\n Plan:\\n Cont to monitor left arm status; no BP/blood draws left arm. NIBP cuff\\n to right calf. F/U w/ team Re: right arm status\\n Hypernatremia (high sodium)\\n Assessment:\\n Hypernatremic NA was 146 yesterday evening.\\n Action:\\n Started on D5 W at 100cc/hr for 1000cc.\\n Response:\\n Awaiting for AM lab report.\\n Plan:\\n Cont with D5W,follow up with AM lab,resume Free water bolus via PEG\\n tube\\n Tachycardia, Other\\n Assessment:\\n Tachy to 130-140\\ns continuous while awake; Hr stayed 90- 120 sound\\n asleep\\n Action:\\n Standing valium decreased; cont with fent patch; morphine and haldol\\n prn.Bilateral restraints on\\n Response:\\n No significant change in level of restlessness/anxiety; freq pulling at\\n any objects/lines with short term memory issues. She keeps\\n disconnecting from vent,desat to low 80s within seconds.\\n Plan:\\n Cont to closely monitor mental status; maintain safety w/use of\\n restraints, soft wrist restraints and bed alarm. PRN Haldol or\\n Morphine.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-16 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 637893,\n \"text\": \"Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Pt has known DVT to left axillary vein; US of right arm showed no\\n clots.\\n Action:\\n DL PICC d/c\\nd; from left arm and elevated on pillow and received\\n Coumadin scheduled dose.\\n Response:\\n PIV placed for access issues to right arm; edema looks better;\\n Plan:\\n Cont to monitor left arm status; no BP/blood draws left arm PICC line\\n to right arm?.\\n Hypernatremia (high sodium)\\n Assessment:\\n Hypernatremic NA was 146 yesterday evening.\\n Action:\\n Started on D5 W at 100cc/hr for 1000cc.\\n Response:\\n Awaiting for AM lab report.\\n Plan:\\n Cont with D5W,follow up with AM lab,resume Free water bolus via PEG\\n tube?.\\n Tachycardia, Other\\n Assessment:\\n Tachy to 130-140\\ns continuous while awake; HR stayed 90- 120 sound\\n asleep\\n Action:\\n Standing valium decreased; cont with fent patch; morphine and haldol\\n prn.Bilateral restraints on\\n Response:\\n No significant change in level of restlessness/anxiety; freq pulling at\\n any objects/lines with short term memory issues. She keeps\\n disconnecting from vent,desat to low 80s within seconds.\\n Plan:\\n Cont to closely monitor mental status; maintain safety w/use of\\n restraints, soft wrist restraints and bed alarm. PRN Haldol or\\n Morphine.\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt has been slept most of the time,hard to wake up.responded to deep\\n stimuli.\\n Action:\\n Held Scheduled dose of valium at 2200.Pt has Fentanyl 75 mcg patch on\\n her lleft thigh.\\n Response:\\n Pt start waking up around 0300,got disconnected from vent by\\n herself,given valium 2.5 mg at 0315.\\n Plan:\\n Continue to eval MS,Valium and PRN Morphine and haldol?,cont reorient\\n and emotional support to pt .\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-16 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 637894,\n \"text\": \"56 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\\n with prolonged hospital course c/b by PNA, anxiety/altered mental\\n status, RUE DVT .Pt found to have small non occlusive Clot on her right\\n axial vein via Ultrasound.\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Pt has known DVT to left axillary vein; US of right arm showed no\\n clots.\\n Action:\\n DL PICC d/c\\nd; from left arm and elevated on pillow and received\\n Coumadin scheduled dose.\\n Response:\\n PIV placed for access issues to right arm; edema looks better;\\n Plan:\\n Cont to monitor left arm status; no BP/blood draws left arm PICC line\\n to right arm?.\\n Hypernatremia (high sodium)\\n Assessment:\\n Hypernatremic NA was 146 yesterday evening.\\n Action:\\n Started on D5 W at 100cc/hr for 1000cc.\\n Response:\\n Awaiting for AM lab report.\\n Plan:\\n Cont with D5W,follow up with AM lab,resume Free water bolus via PEG\\n tube?.\\n Tachycardia, Other\\n Assessment:\\n Tachy to 130-140\\ns continuous while awake; HR stayed 90- 120 sound\\n asleep\\n Action:\\n Standing valium decreased; cont with fent patch; morphine and haldol\\n prn.Bilateral restraints on\\n Response:\\n No significant change in level of restlessness/anxiety; freq pulling at\\n any objects/lines with short term memory issues. She keeps\\n disconnecting from vent,desat to low 80s within seconds.\\n Plan:\\n Cont to closely monitor mental status; maintain safety w/use of\\n restraints, soft wrist restraints and bed alarm. PRN Haldol or\\n Morphine.\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt has been slept most of the time,hard to wake up.responded to deep\\n stimuli.\\n Action:\\n Held Scheduled dose of valium at 2200.Pt has Fentanyl 75 mcg patch on\\n her lleft thigh.\\n Response:\\n Pt start waking up around 0300,got disconnected from vent by\\n herself,given valium 2.5 mg at 0315.\\n Plan:\\n Continue to eval MS,Valium and PRN Morphine and haldol?,cont reorient\\n and emotional support to pt .\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-18 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 638197,\n \"text\": \"Altered mental status (not Delirium)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Hypernatremia (high sodium)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-18 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 638198,\n \"text\": \"56 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\\n with prolonged hospital course c/b by PNA, anxiety/altered mental\\n status, RUE DVT .Pt found to have small non occlusive Clot on her right\\n axial vein via Ultrasound.Yesterday Pt went down to IR for Peg revision\\n aspiration risk couldn\\nt do it due the type of peg she has now.\\n Altered mental status (not Delirium)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Hypernatremia (high sodium)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nutrition\",\n \"chartdate\": \"2167-10-14 00:00:00.000\",\n \"description\": \"Clinical Nutrition Note\",\n \"row_id\": 637523,\n \"text\": \"Objective\\n Pertinent medications: noted\\n Labs:\\n Value\\n Date\\n Glucose\\n 134 mg/dL\\n 02:06 AM\\n Glucose Finger Stick\\n 139\\n 10:00 AM\\n BUN\\n 11 mg/dL\\n 02:06 AM\\n Creatinine\\n 0.6 mg/dL\\n 02:06 AM\\n Sodium\\n 146 mEq/L\\n 02:06 AM\\n Potassium\\n 4.0 mEq/L\\n 02:06 AM\\n Chloride\\n 106 mEq/L\\n 02:06 AM\\n TCO2\\n 32 mEq/L\\n 02:06 AM\\n Albumin\\n 3.5 g/dL\\n 03:00 AM\\n Calcium non-ionized\\n 9.2 mg/dL\\n 02:06 AM\\n Phosphorus\\n 4.0 mg/dL\\n 02:06 AM\\n Ionized Calcium\\n 1.24 mmol/L\\n 02:51 AM\\n Magnesium\\n 2.1 mg/dL\\n 02:06 AM\\n Current diet order / nutrition support: Replete c. Fiber @60mL/hr (1440\\n kcals/89 gr aa)\\n GI: Abd: soft/dist/+bs\\n Assessment of Nutritional Status\\n Estimation of current intake: Adequate\\n Specifics:\\n Pt continues on TF\\ns for full nutrition support via PEG, currently\\n tolerating @ goal s/ problems. (Noted TF\\ns were off over weekend / ?\\n aspiration event) FWB down to 100mL q 4 hr c/ Na WNL. BG\\ns well\\n controlled.\\n Medical Nutrition Therapy Plan - Recommend the Following\\n Multivitamin / Mineral supplement: via TF\\n Tube feeding recommendations: Continue TF's @ goal\\n Monitor fluid status and adjust FWB prn.\\n BG and lyte management as you are\\n Please check current wt\\n\"\n },\n {\n \"category\": \"Nutrition\",\n \"chartdate\": \"2167-10-14 00:00:00.000\",\n \"description\": \"Clinical Nutrition Note\",\n \"row_id\": 637524,\n \"text\": \"Objective\\n Pertinent medications: noted\\n Labs:\\n Value\\n Date\\n Glucose\\n 134 mg/dL\\n 02:06 AM\\n Glucose Finger Stick\\n 139\\n 10:00 AM\\n BUN\\n 11 mg/dL\\n 02:06 AM\\n Creatinine\\n 0.6 mg/dL\\n 02:06 AM\\n Sodium\\n 146 mEq/L\\n 02:06 AM\\n Potassium\\n 4.0 mEq/L\\n 02:06 AM\\n Chloride\\n 106 mEq/L\\n 02:06 AM\\n TCO2\\n 32 mEq/L\\n 02:06 AM\\n Albumin\\n 3.5 g/dL\\n 03:00 AM\\n Calcium non-ionized\\n 9.2 mg/dL\\n 02:06 AM\\n Phosphorus\\n 4.0 mg/dL\\n 02:06 AM\\n Ionized Calcium\\n 1.24 mmol/L\\n 02:51 AM\\n Magnesium\\n 2.1 mg/dL\\n 02:06 AM\\n Current diet order / nutrition support: Replete c. Fiber @60mL/hr (1440\\n kcals/89 gr aa)\\n GI: Abd: soft/dist/+bs\\n Assessment of Nutritional Status\\n Estimation of current intake: Adequate\\n Specifics:\\n Pt continues on TF\\ns for full nutrition support via PEG, currently\\n tolerating @ goal s/ problems. (Noted TF\\ns were off over weekend / ?\\n aspiration event) FWB down to 100mL q 4 hr c/ Na WNL. BG\\ns well\\n controlled.\\n Medical Nutrition Therapy Plan - Recommend the Following\\n Multivitamin / Mineral supplement: via TF\\n Tube feeding recommendations: Continue TF's @ goal\\n Monitor fluid status and adjust FWB prn.\\n BG and lyte management as you are\\n Please check current wt\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-17 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 638171,\n \"text\": \"Airway Clearance, Impaired\\n Assessment:\\n Pt placed on trach mask this am (on vent o/n). She continues to have\\n moderate amts of thick secretions, requiring frequent sxn. Pt does have\\n a strong/productive cough.\\n Action:\\n Sxn prn; chest pt; pt repositioned frequently (including OOB to chair)\\n to help mobilize secretions.\\n Response:\\n Unchanged at this time.\\n Plan:\\n Continue to sxn prn; chest pt prn; OOB as tolerated.\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt extremely restless/agitated today. Attempting to get OOB/chair. Very\\n difficult to redirect.\\n Action:\\n Pt reoriented frequently; Valium given prn; Morphine given per presumed\\n pain.\\n Response:\\n Pt had no improvement after Valium; however, she appeared more\\n calm/comfortable after Morphine administration.\\n Plan:\\n Medicate for agitation prn; continue to follow exam.\\n Alteration in Nutrition\\n Assessment:\\n Pt NPO for past few days ( recurrent aspiration/risk for of TFs)\\n Action:\\n Response:\\n Plan:\\n Tachycardia, Other\\n Assessment:\\n HR 120\\ns-140\\ns today (baseline for ~ 1 week).\\n Action:\\n Lopressor given per orders.\\n Response:\\n HR in low 120\\ns after Morphine, but otherwise unchanged.\\n Plan:\\n Continue Lopressor; ? need to increase dose.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-08 00:00:00.000\",\n \"description\": \"Physician Resident/Attending Progress Note - MICU\",\n \"row_id\": 636409,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n ARTERIAL LINE - STOP 12:23 PM\\n ARTERIAL LINE - START 02:00 PM\\n A-line resited, not working again\\n tube feed machine not working\\n failed SBT - low MV with PSV - switched to MMV overnight\\n tachycardic to 140-142\\n Ortho spine ok with documented final read of CT trauma from attending\\n at OSH and week f/u - faxed request and spoke with med recs at\\n Medical re: sending report which was agreed upon.\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Heparin Sodium - 1,500 units/hour\\n Other ICU medications:\\n Morphine Sulfate - 12:15 PM\\n Midazolam (Versed) - 03:50 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:13 AM\\n Vital signs\\n Cardiac monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.5\\nC (99.5\\n Tcurrent: 37.1\\nC (98.8\\n HR: 105 (70 - 148) bpm\\n BP: 85/55(66) {85/41(57) - 158/110(323)} mmHg\\n RR: 23 (10 - 31) insp/min\\n SpO2: 95%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n QTc: 411\\n Total In:\\n 3,562 mL\\n 965 mL\\n PO:\\n TF:\\n 1,685 mL\\n 150 mL\\n IVF:\\n 548 mL\\n 215 mL\\n Blood products:\\n Total out:\\n 5,695 mL\\n 1,740 mL\\n Urine:\\n 5,695 mL\\n 1,740 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -2,133 mL\\n -775 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: CPAP/PSV\\n Vt (Set): 400 (400 - 400) mL\\n Vt (Spontaneous): 359 (137 - 695) mL\\n PS : 8 cmH2O\\n RR (Set): 10\\n RR (Spontaneous): 26\\n PEEP: 8 cmH2O\\n FiO2: 50%\\n RSBI: 58\\n PIP: 16 cmH2O\\n SpO2: 95%\\n ABG: 7.40/49/114/32/3\\n Ve: 7.2 L/min\\n PaO2 / FiO2: 228\\n Physical Examination\\n General Appearance: Trached and sedated. Responsive, following\\n commands, Overweight / Obese, mild agitation but NAD\\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\\n deviation\\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\\n Cardiovascular: (S1: Normal), (S2: Normal), distant\\n Respiratory / Chest: (Expansion: Symmetric), CTA anteriorly, decreased\\n BS\\n Abdominal: Obese, soft, Non-tender, no rebound, no guarding, + BS, PEG\\n in place with dressing C/D/I\\n Extremities: no CCE\\n Skin: no rashes or jaundice\\n Lines: r brachioceph ART with large amount of bloody drainage and L\\n PICC C/D/I\\n Labs / Radiology\\n 213 K/uL\\n 8.8 g/dL\\n 123 mg/dL\\n 0.6 mg/dL\\n 32 mEq/L\\n 3.6 mEq/L\\n 13 mg/dL\\n 107 mEq/L\\n 145 mEq/L\\n 29.4 %\\n 11.1 K/uL\\n [image002.jpg]\\n 03:44 AM\\n 06:04 AM\\n 09:09 AM\\n 05:07 PM\\n 03:31 AM\\n 03:46 AM\\n 10:20 AM\\n 03:46 PM\\n 01:37 AM\\n 05:32 AM\\n WBC\\n 9.6\\n 8.2\\n 11.1\\n Hct\\n 25.3\\n 27.4\\n 29.4\\n Plt\\n \\n Cr\\n 0.6\\n 0.8\\n 0.6\\n 0.8\\n 0.6\\n TCO2\\n 33\\n 32\\n 35\\n 37\\n 31\\n Glucose\\n 107\\n 121\\n 118\\n 155\\n 123\\n Other labs: PT / PTT / INR:22.3/69.7/2.1, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:13.1 %,\\n Mono:2.7 %, Eos:0.6 %, Lactic Acid:1.1 mmol/L, Albumin:2.4 g/dL,\\n LDH:204 IU/L, Ca++:9.2 mg/dL, Mg++:2.5 mg/dL, PO4:4.1 mg/dL\\n Assessment and Plan\\n 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA, and\\n ARDS, intubated since the end of now s/p trach and PEG\\n placement.\\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\\n volume overload. Intubated on for resp decompensation. S/P Trach\\n and PEG on .\\n - wean FiO2 as tolerated\\n - attempt wean PS today and hopeful for trach mask trial\\n # Sedation: Continue to have issues with pain/delirium causing\\n tachycardia and hypertension with intermittent hypotension. On Haldol\\n 5 TID, Fentanyl 100-150 mcg TP, Diazapam 10 QID; Haldol, midazolam and\\n morphine PRN. Had good response to morphine, minimal response to\\n haldol bolus.\\n - Will d/c midazolam and haldol PRN and use morphine for now.\\n - If stable, would d/c standing Haldol tonight or tomorrow\\n # Adrenal Insufficency: Hypotension that resolved with steroids,\\n returned as they came off and is now improved again. Possible primary\\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\\n started on .\\n - ok to go to 10 q am and 5 q pm prednisone, will wean to\\n maintenance dose as tolerated, in consultation with endo.\\n # Volume overloaded in setting of hypernatremia with TBW deficit and\\n metabolic alkalosis\\n - Lasix boluses, goal -1L today\\n - Diamox until HCO3 < 30\\n - electrolytes\\n - continue tube feeds with free water flushes 300 cc q4\\n # RUE DVT: INR now therapeutic on coumadin. Goal \\n - stop heparin gtt\\n - coumadin 5mg QHS\\n # Spine fracture: Neurologically intact distal to the lesion. Prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - Brace for OOB\\n - will f/u full trauma spine eval from OSH to determine need for\\n further back imaging in-house.\\n # Tracheomalacia: Discussed with IP. Stenting unlikely to help for\\n trachiomalacia as airways have poor structure diffusely.\\n - Outpatient f/u once off pressure support to assess for possible\\n stenting\\n #. Thyroid Nodule on CT\\n -outpatient follow up\\n # Nutrition: Tube feeds with free water flushes, tolerating well,\\n continue Replete (Full) - 11:20 AM 30 mL/hour\\n # Glycemic control: SSI, well controlled\\n # Lines L PICC () and R ART ()\\n d/c art today. Correlate ABG\\n and VBG.\\n # Ppx: INR therapeutic, ranitidine, colace and senna\\n # Communication:\\n - Boyfriend of 10 is her HCP. Also brother is involved\\n Code: Full\\n Dispo: ICU, being screening for vent facilities\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n PICC Line - 09:19 PM\\n Arterial Line - 02:00 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n ------ Protected Section ------\\n MICU ATTENDING ADDENDUM\\n I saw and examined the patient, and was physically present with the ICU\\n team for the key portions of the services provided. I agree with the\\n note above, including the assessment and plan. I would emphasize and\\n add the following points: 55F T5-8 fractures with retropulsion and ARDS\\n from klebsiella VAP; on heparin for UE DVT and lasix for volume\\n overload. Failed SBT but mental status slowly stabilizing off drip\\n sedation. Awaiting OSH spine films.\\n Exam notable for Tm 99.5 BP 110/50 HR 70-120 RR 18-20 with sat 97%\\n on PSV 8/8 FiO2 0.5, 350x 20, ABG 7.41/53/86. TBB -2L/8h, +7L/MICU LOS.\\n Eyes opens, will squeeze hands and wiggle toes but very drowsy. Clearer\\n BS bilaterally with RRR s1s2 SM at base. Abdomen is distended with\\n decreased BS. Trace edema in BLE, no cords. Labs notable for WBC 11K,\\n HCT 29, K+ 3.6, Na 145, Cr 0.6, INR 2.1. CXR without significant\\n change.\\n Agree with plan to continue supportive care, continue PSV at 8/8, and\\n continue diuresis with lasix / diamox as BP allows. Will discuss\\n management of TBM with IP but would favor supportive care and slow wean\\n until she has recovered from her severe pneumonia / ARDS. Will continue\\n fentanyl patch at 150mcg, haldol 5q8h alternating with valium 10q6h\\n with morphine PRN pain. Will wean hydrocortisone 20/10q12 PGT today and\\n will discuss more aggressive wean with endocrine, as I think she has a\\n component of steroid psychosis. Will stop IV heparin for UE DVT and\\n continue coumadin now that her INR is >2. Will continue tube feeds and\\n continue FW boluses for hypernatremia. Continue spinal stabilization\\n with brace when OOB; will review outside images with spine surgery but\\n no plan for acute intervention. Remainder of plan as outlined above.\\n Total time 50 minutes\\n Patient is critically ill\\n ------ Protected Section Addendum Entered By: , MD\\n on: 03:32 PM ------\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-09 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 636566,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Arterial line d/c'd\\n Spiked a fever of 101.4, blood and urine cultures sent, CXR. Started\\n Vanc, Levo, Aztreonam\\n Persistently hypotensive to 70s SBP overnight with low urine output and\\n poor O2 sats.\\n Started on Levophed, and given 1.75L NS. BPs improved to 90-120s SBP,\\n and urine output increased significantly.\\n Large amount of oral secretions, ?gastric in origin\\n Tube feeds held for ? of aspiration.\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Vancomycin - 11:00 PM\\n Levofloxacin - 11:43 PM\\n Aztreonam - 04:07 AM\\n Infusions:\\n Norepinephrine - 0.03 mcg/Kg/min\\n Other ICU medications:\\n Midazolam (Versed) - 09:30 AM\\n Morphine Sulfate - 03:17 PM\\n Furosemide (Lasix) - 06:36 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:36 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.6\\nC (101.4\\n Tcurrent: 36.7\\nC (98.1\\n HR: 131 (73 - 142) bpm\\n BP: 127/43(60) {71/29(42) - 137/97(101)} mmHg\\n RR: 21 (12 - 36) insp/min\\n SpO2: 97%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 4,627 mL\\n 1,084 mL\\n PO:\\n TF:\\n 839 mL\\n IVF:\\n 2,288 mL\\n 1,084 mL\\n Blood products:\\n Total out:\\n 2,407 mL\\n 2,220 mL\\n Urine:\\n 2,407 mL\\n 2,220 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 2,220 mL\\n -1,136 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 400 (400 - 400) mL\\n Vt (Spontaneous): 412 (236 - 480) mL\\n PS : 8 cmH2O\\n RR (Set): 12\\n RR (Spontaneous): 0\\n PEEP: 8 cmH2O\\n FiO2: 50%\\n RSBI: 126\\n PIP: 21 cmH2O\\n Plateau: 17 cmH2O\\n Compliance: 44.4 cmH2O/mL\\n SpO2: 97%\\n ABG: 7.35/50/81./26/0\\n Ve: 7 L/min\\n PaO2 / FiO2: 162\\n Physical Examination\\n General Appearance: Trached and sedated. Responsive, following\\n commands, Overweight / Obese, mild agitation but NAD\\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\\n deviation\\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\\n Cardiovascular: (S1: Normal), (S2: Normal), distant\\n Respiratory / Chest: (Expansion: Symmetric), CTA anteriorly, decreased\\n BS\\n Abdominal: Obese, soft, Non-tender, no rebound, no guarding, + BS, PEG\\n in place with dressing C/D/I\\n Extremities: no CCE\\n Skin: no rashes or jaundice\\n Lines: r brachioceph ART with large amount of bloody drainage and L\\n PICC C/D/I\\n Labs / Radiology\\n 227 K/uL\\n 7.7 g/dL\\n 114 mg/dL\\n 0.7 mg/dL\\n 26 mEq/L\\n 4.0 mEq/L\\n 16 mg/dL\\n 112 mEq/L\\n 145 mEq/L\\n 24.9 %\\n 11.3 K/uL\\n [image002.jpg]\\n 03:46 AM\\n 10:20 AM\\n 03:46 PM\\n 01:37 AM\\n 05:32 AM\\n 02:43 PM\\n 03:03 PM\\n 08:11 PM\\n 02:51 AM\\n 03:10 AM\\n WBC\\n 11.1\\n 9.4\\n 11.3\\n Hct\\n 29.4\\n 26.6\\n 24.9\\n Plt\\n \\n Cr\\n 0.8\\n 0.6\\n 0.9\\n 0.7\\n TCO2\\n 35\\n 37\\n 31\\n 31\\n 30\\n 29\\n Glucose\\n 155\\n 123\\n 128\\n 114\\n 114\\n Other labs: PT / PTT / INR:37.2/37.9/4.0, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Lactic Acid:0.5 mmol/L, Albumin:2.4 g/dL,\\n LDH:204 IU/L, Ca++:8.7 mg/dL, Mg++:2.6 mg/dL, PO4:4.2 mg/dL\\n Blood/Urine/Sputum culture pending\\n Assessment and Plan\\n 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA, and\\n ARDS, intubated since the end of now s/p trach and PEG\\n placement.\\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\\n volume overload. Intubated on for resp decompensation. S/P Trach\\n and PEG on .\\n - wean FiO2 as tolerated\\n - attempt wean PS today and hopeful for trach mask trial\\n # Sedation: Continue to have issues with pain/delirium causing\\n tachycardia and hypertension with intermittent hypotension. On Haldol\\n 5 TID, Fentanyl 100-150 mcg TP, Diazapam 10 QID; Haldol, midazolam and\\n morphine PRN. Had good response to morphine, minimal response to\\n haldol bolus.\\n - Will d/c midazolam and haldol PRN and use morphine for now.\\n - If stable, would d/c standing Haldol tonight or tomorrow\\n # Adrenal Insufficency: Hypotension that resolved with steroids,\\n returned as they came off and is now improved again. Possible primary\\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\\n started on .\\n - ok to go to 10 q am and 5 q pm prednisone, will wean to\\n maintenance dose as tolerated, in consultation with endo.\\n # Volume overloaded in setting of hypernatremia with TBW deficit and\\n metabolic alkalosis\\n - Lasix boluses, goal -1L today\\n - Diamox until HCO3 < 30\\n - electrolytes\\n - continue tube feeds with free water flushes 300 cc q4\\n # RUE DVT: INR now therapeutic on coumadin. Goal \\n - stop heparin gtt\\n - coumadin 5mg QHS\\n # Spine fracture: Neurologically intact distal to the lesion. Prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - Brace for OOB\\n - will f/u full trauma spine eval from OSH to determine need for\\n further back imaging in-house.\\n # Tracheomalacia: Discussed with IP. Stenting unlikely to help for\\n trachiomalacia as airways have poor structure diffusely.\\n - Outpatient f/u once off pressure support to assess for possible\\n stenting\\n #. Thyroid Nodule on CT\\n -outpatient follow up\\n # Nutrition: Tube feeds with free water flushes, tolerating well,\\n continue Replete (Full) - 11:20 AM 30 mL/hour\\n # Glycemic control: SSI, well controlled\\n # Lines L PICC () and R ART ()\\n d/c art today. Correlate ABG\\n and VBG.\\n # Ppx: INR therapeutic, ranitidine, colace and senna\\n # Communication:\\n - Boyfriend of 10 is her HCP. Also brother is involved\\n Code: Full\\n Dispo: ICU, being screening for vent facilities\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n PICC Line - 09:19 PM\\n 18 Gauge - 08:15 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-18 00:00:00.000\",\n \"description\": \"ICU Attending Addendum\",\n \"row_id\": 638264,\n \"text\": \"CRITICAL CARE STAFF ADDENDUM\\n 10A\\n I saw and physically examined with the ICU team, whose note today\\n reflects my input. I would add/emphasize that she had an episode of\\n normal heart rate today that allowed further elucidation of her\\n rhythm. Her INR is also quite elevated today.\\n Tachycardia\\n * My examination of telemetry suggests that this was a brisk\\n conversion into sinus. Her fast rate is a narrow complex\\n tachycardia without obvious p waves. DDx for this is AVNRT, atrial\\n tach, AVRT, Aflutter. Suspect AVNRT and atrial tach.\\n * Check 12 lead.\\n * No response to carotid massage.\\n * Will try to increase beta blockade for now. If cannot maintain\\n sinus, will consult cardiology. We are already anticoagulating\\n her.\\n Resp Failure\\n Trach mask trials as tolerating (needing QHS support at\\n present)\\n PMV trials\\n S/P rx for pan Klebs PNA.\\n Per IP not stent planned as technically not possible to\\n place into her airway\\n DVT and coagulopathy\\n On warfarin. Hold warfarin\\n Feeding tube\\n Getting reglan trial. See thoracic surgery note for plans if this\\n does not succeed.\\n Hypernatremia\\n Replete free water.\\n After feeding tube and tachycardia more settled, will be appropriate\\n for rehab.\\n Please see today\\ns ICU team note for other issues.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-18 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 638270,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Pt was agitated during the day with no response to PRN zyprexa.\\n Her sodium was increased to 150 yesterday, and she was given 500cc D5W\\n bolus and her FW flushes for her tube feeds were increases from 100 to\\n 150.\\n Overnight, pt received zyprexa, valium, and was placed back on the\\n ventilator, after which she was more sedated and her SBP dropped to the\\n 70s and HR remained 120-130s. Her BP came back up to 110s-120s when she\\n was woken up.\\n She was agitated again until approx 5am when she was given her\\n Metoprolol and 2.5 mg valium, after which her HR dropped to the 80s and\\n stayed there for 2+ hours.\\n Careful examination of telemetry revealed that she has likely been in\\n an SVT and that after getting her BB, converted back to a sinus rhythm.\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:11 AM\\n Morphine Sulfate - 04:00 AM\\n Diazepam (Valium) - 05:24 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:03 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.5\\nC (97.7\\n Tcurrent: 36.4\\nC (97.5\\n HR: 126 (118 - 140) bpm\\n BP: 98/62(70) {74/38(47) - 145/105(114)} mmHg\\n RR: 29 (11 - 35) insp/min\\n SpO2: 95%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 959 mL\\n 1,250 mL\\n PO:\\n TF:\\n 176 mL\\n 140 mL\\n IVF:\\n 463 mL\\n 810 mL\\n Blood products:\\n Total out:\\n 1,980 mL\\n 130 mL\\n Urine:\\n 1,980 mL\\n 130 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,021 mL\\n 1,120 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: MMV/PSV/AutoFlow\\n Vt (Set): 500 (500 - 500) mL\\n Vt (Spontaneous): 408 (408 - 499) mL\\n PS : 10 cmH2O\\n RR (Set): 12\\n RR (Spontaneous): 26\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n RSBI: 149\\n PIP: 16 cmH2O\\n Plateau: 21 cmH2O\\n SpO2: 95%\\n ABG: ///36/\\n Ve: 6.4 L/min\\n Physical Examination\\n Gen: NAD, difficult to assess orientation as patient is nonverbal on\\n trach mask, but she appeared alert, and resonded appropriately to\\n questions and followed commands.\\n HEENT: PERRLA, EOMI, OP w/o erythema.\\n Resp: Limited by patients mobility, but CTA anteriorly and laterally\\n Card: S1S2 tachicardic, no m/r/g\\n Abd: Soft, Non-tender, Non-distended, BS+\\n Exte: No edema, DP 2+, RP2+ bil.\\n NEURO: CN II\\nXII grossly intact. Strength 4/5 upper and lower\\n bilaterally. Reflexes 2+ bilaterally, 3+ at L patellar tendon, with\\n mild adductor crossover\\n Labs / Radiology\\n 452 K/uL\\n 8.9 g/dL\\n 104 mg/dL\\n 0.7 mg/dL\\n 36 mEq/L\\n 3.5 mEq/L\\n 6 mg/dL\\n 103 mEq/L\\n 145 mEq/L\\n 29.2 %\\n 7.1 K/uL\\n [image002.jpg]\\n 03:00 AM\\n 07:05 PM\\n 03:00 AM\\n 05:00 AM\\n 02:06 AM\\n 07:34 AM\\n 03:50 AM\\n 06:22 AM\\n 02:58 AM\\n 03:43 AM\\n WBC\\n 7.2\\n 5.2\\n 5.9\\n 7.5\\n 5.6\\n 6.1\\n 7.0\\n 7.1\\n 7.1\\n Hct\\n 26.9\\n 26.0\\n 27.2\\n 26.8\\n 27.0\\n 27.0\\n 29.7\\n 28.9\\n 29.2\\n Plt\\n 238\\n 240\\n 296\\n \\n 395\\n 462\\n 452\\n Cr\\n 0.9\\n 0.7\\n 0.6\\n 0.7\\n 0.6\\n 0.5\\n 0.7\\n 0.7\\n 0.6\\n 0.7\\n Glucose\\n 106\\n 100\\n 134\\n 134\\n 121\\n 619\\n 126\\n 137\\n 104\\n Other labs: PT / PTT / INR:66.1/32.7/8.0, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:9.3 mg/dL, Mg++:2.2 mg/dL, PO4:3.8\\n mg/dL\\n Assessment and Plan\\n 55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\\n trach, PEG, placement no with respiratory failure secondary to\\n tracheomalacia , resolving HAP.\\n .\\n # Respiratory failure: Slowly Improving. Now remaining on trach mask\\n for most of the day and night, with periods of pressure support of \\n over night.\\n - Continue to increase time on trach mask as tolerated.\\n - PMV with suctioning again today.\\n .\\n # HAP vs Aspiration PNA: Afebrile without leukocytosis\\n - Completed course of ceftriaxone\\n - Continue to f/u cultures\\n - Continue trach mask as tolerated\\n .\\n # Tachycardia: Previously was assessed as sinus tach with occasional\\n runs of SVT and sources such as hypovolemia, PE, infection, and pain\\n were assessed as possibly etiologies. But, now appears to be SVT for\\n much of time, rhythm,/rate nonresponsive to carotid massage. HR\\n decreased to 80s w/ stable BPs for approx 2 hour period overnight that\\n seems to be associated with administration of her BB and valium. Rhythm\\n strip shows conversion from a narrow complex non-sinus tachycardia to\\n normal sinus rhythm.\\n - Increase Metroprolol from 25mg TID to 25mg QID\\n - Consider further adjustment of BB as tolerated by BP.\\n - If not sufficient for rhythm conversion, consult cardiology for\\n management.\\n .\\n # Sedation: Inconsistent response to sedation, unclear what is best\\n regime. Will continue to wean overall. Possibly improved level of\\n agitation when rhytm returned to sinus.\\n - Continue w Olanzapine QHS\\n - DC\\nd haldol and taper valium to 2.5 mg PRN TID w/ 2.5 mg PRNs.\\n # Nutrition: Tube feeds have been restarted and pt started on raglan.\\n Has been tolerating feeds well so far.\\n - Continue TFs, w/ FW flushes\\n - Nutrition recs appreciated.\\n .\\n # Adrenal Insufficency: Endocrine following. Pt does not appear to be\\n adrenally insufficient at baseline. Suggesting if the patient under\\n goes major stressors such as major surgery, sepsis, she may need stress\\n dosed steroids.\\n .\\n # Fluid Status: Likely approaching euvolemia, though still has\\n hypernatramia which may suggest is still intravascularly depleated.\\n - Monitoring urine output\\n - FW flushes at 100/hr w/ tube feeds\\n - PM lytes to trend Na\\n .\\n # UE DVT and elevated INR: DVT in right UE has resolved, new\\n non-occlusive in left axillary vein. INR supratherapeutic today\\n - COumadin held, will restart at low dose when INR approaches\\n therapeutic range.\\n - follow INR\\n .\\n # Spine fracture: Stable\\n - Brace for OOB, will discuss with Neurosurgery if current brace is\\n optimal for stabilization given her mobility.\\n - Pt to follow up with Dr. in weeks\\n .\\n # Tracheomalacia. Was initially addressed with IP and they wanted to\\n follow up as outpatient.\\n - Consult IP for stent placement given improved clinical status, will\\n readdress\\n .\\n #. Thyroid Nodule on CT\\n - Outpatient follow up\\n .\\n # Glycemic control: SSI, well controlled\\n # PIV x 1\\n # Ppx: Coumadin, Ranitidine, Bowel Regimen PRN\\n # Communication:\\n - Boyfriend of 10 \\n - Brother also involved\\n # Code: Full\\n # Dispo: ICU, Screening for vent facilities\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 12:38 PM 30 mL/hour\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:35 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2167-10-15 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 637824,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 27\\n Ideal body weight: 61.2 None\\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\\n Airway\\n Known difficult intubation: Yes\\n Reason:\\n Tracheostomy tube:\\n Type: Standard\\n Manufacturer: Portex\\n Size: 7.0mm\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 25 cmH2O\\n Lung sounds\\n RLL Lung Sounds: Clear\\n RUL Lung Sounds: Rhonchi\\n LUL Lung Sounds: Rhonchi\\n LLL Lung Sounds: Clear\\n Secretions\\n Sputum color / consistency: White / Thick\\n Sputum source/amount: Expectorated / Small\\n Ventilation Assessment\\n Level of breathing assistance: Unassisted spontaneous breathing\\n Visual assessment of breathing pattern: Supra-sternal retractions,\\n Accessory muscle use\\n Assessment of breathing comfort: No claim of dyspnea)\\n Plan to keep pt on trach collar over night. Vent is on stand-by.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-10 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 636630,\n \"text\": \"55 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\\n Now with prolonged hospital course c/b by PNA with high PEEP\\n requirement, anxiety, RUE DVT .\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt more alert, following commands intermittently. Periods of agitation\\n with HR rising to 130\\n Action:\\n Fentanyl patch in place. Valium RTC. MSO4 given x 1 for discomfort.\\n Response:\\n Pt with less episodes of agitation previously. ? steroid psychosis.\\n Plan:\\n Check cortisol level in am and wean hydrocortisone MD. Continue to\\n reorient pt. MSO4 prn for discomfort.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Received pt on PSV 8/5/50%.RR 19-24. Tidal volumes 200-250. 02 sats\\n variable 90-100%. LS rhoncherous to clear, diminished at bases.\\n Action:\\n Pt maintained at current settings given reduced tv\\ns and sats. Orally\\n suctioned q 2 hrs for copious secretions. Deep suctioned q 3-4 hrs for\\n sm amt thick white secretions.\\n Response:\\n Resp status continues to improve\\n Plan:\\n Wean fio2 and peep as tolerated. Vigorous pulm hygiene.\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Pt with RUE DVT. Heparin dcd on .\\n Action:\\n Coags being monitored.\\n Response:\\n Plan:\\n Coumadin to be started when INR < 3\\n Hypernatremia (high sodium)\\n Assessment:\\n Na 140. Pt volume overloaded.\\n Action:\\n Treated with 1 liter d5w iv.\\n Response:\\n TFB Na Goal ~ even fluid balance.\\n Plan:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-15 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 637734,\n \"text\": \"Chief Complaint: resp failuire\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 24 Hour Events:\\n ULTRASOUND - At 03:48 PM\\n US of Lt arm shows small 1 cm axillary clot non occlusive near PICC\\n RUS US shows resolutyion of formal clot\\n Vomting tube feeds around trach\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Ceftriaxone - 10:00 PM\\n Infusions:\\n Other ICU medications:\\n Morphine Sulfate - 06:20 AM\\n Pantoprazole (Protonix) - 08:12 AM\\n Other medications:\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Gastrointestinal: Emesis\\n Flowsheet Data as of 10:59 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.5\\nC (99.5\\n Tcurrent: 36.2\\nC (97.1\\n HR: 146 (123 - 146) bpm\\n BP: 153/129(134) {106/41(56) - 185/129(142)} mmHg\\n RR: 26 (11 - 33) insp/min\\n SpO2: 96%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 1,888 mL\\n 520 mL\\n PO:\\n TF:\\n 1,268 mL\\n IVF:\\n 100 mL\\n Blood products:\\n Total out:\\n 1,530 mL\\n 845 mL\\n Urine:\\n 1,510 mL\\n 820 mL\\n NG:\\n 20 mL\\n 25 mL\\n Stool:\\n Drains:\\n Balance:\\n 358 mL\\n -325 mL\\n Respiratory support\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 227 (227 - 397) mL\\n PS : 8 cmH2O\\n RR (Spontaneous): 20\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n RSBI: 194\\n PIP: 16 cmH2O\\n SpO2: 96%\\n ABG: ///34/\\n Ve: 6.5 L/min\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 8.5 g/dL\\n 335 K/uL\\n 121 mg/dL\\n 0.5 mg/dL\\n 34 mEq/L\\n 3.8 mEq/L\\n 7 mg/dL\\n 107 mEq/L\\n 147 mEq/L\\n 27.0 %\\n 5.6 K/uL\\n [image002.jpg]\\n 03:08 PM\\n 03:00 AM\\n 03:36 AM\\n 04:40 PM\\n 03:00 AM\\n 07:05 PM\\n 03:00 AM\\n 05:00 AM\\n 02:06 AM\\n 07:34 AM\\n WBC\\n 7.3\\n 6.1\\n 7.2\\n 5.2\\n 5.9\\n 7.5\\n 5.6\\n Hct\\n 27.6\\n 26.5\\n 26.9\\n 26.0\\n 27.2\\n 26.8\\n 27.0\\n Plt\\n 189\\n 209\\n 238\\n \\n 335\\n Cr\\n 0.6\\n 0.6\\n 0.9\\n 0.7\\n 0.6\\n 0.7\\n 0.6\\n 0.5\\n TCO2\\n 26\\n Glucose\\n 99\\n 115\\n 106\\n 100\\n 134\\n 134\\n 121\\n Other labs: PT / PTT / INR:16.6/25.0/1.5, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:9.3 mg/dL, Mg++:2.3 mg/dL, PO4:4.1\\n mg/dL\\n Assessment and Plan\\n 55 yr old alcoholic s/p t spine fx s/p trcah and PEG with persistent\\n resp failure\\n 1. Resp Failure: currently on trach mask, can do a few hours per\\n day, then needs for support. New pan Klebs in sputum, day\\n . Try more vent support and see if it helps her.\\n 2. Fevers: did not persist- cultures neg to date.\\n 3 Hemodynamics: persistant simus tachy\\n CTPA to look for emboli\\n negative for proximal clot. IOs the of trach mask and her TB\\n malacia too much for her. We will see what happens if we out her on\\n 15-20 and 5.\\n 4. New L Ext DVT\\n 5. Emesis: call IR and get g pushed to a j tube\\n ICU Care\\n Nutrition: tfs held for vomiting\\n Glycemic Control:\\n Lines:\\n PICC Line - 09:19 PM\\n Prophylaxis:\\n DVT: coumadin\\n Stress ulcer: ppi\\n Communication: try to reach boyfriend\\n status: Full code\\n Disposition :ICU\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-11 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 636941,\n \"text\": \"56 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\\n with prolonged hospital course c/b by PNA, anxiety/altered mental\\n status, RUE DVT .\\n Altered mental status (not Delirium)\\n Assessment:\\n Rec\\nd pt very restless/agitated, repeatedly attempting to sit up in bed\\n and pulling at soft wrist restraints. When arms freed, she immediately\\n disconnected trach from vent. Agitation did not subside with verbal\\n reassurance or scheduled dose valium. Pt follows commands\\n inconsistently, has difficulty initiating cough on command. MAEE with\\n good strength. Not grimacing and denied pain by mouthing words.\\n Action:\\n Pt noted to have rash per below, nodded\\n to\\nDoes you back itch?\\n and rec\\nd Benadryl 25mg IV @ 1345.\\n Response:\\n Pt finally sleeping after having been awake most of night and very\\n restless all morning.\\n Plan:\\n Benadryl Q6hrs PRN. Cont freq mental/neuro eval.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Rec\\nd pt on AC vent settings 50%/12 X 500/+5 with SRR 17-20\\ns and\\n regular. O2 sat 96-100%. Lungs snds rhonchorous bilat, diminished in\\n bases. Pt with weak cough, raising mod amts thick white sputum but not\\n fully expectorating it from trach.\\n Action:\\n Pt placed on TM @ 70% @ 0900. Suctionned PRN for mod amts sputum.\\n Response:\\n O2 sat stable until pt soundly sleeping and de-sated to 80\\ns. TM inc\\n to 100% with return of O2 sat to high 90\\n Plan:\\n Cont to wean from vent as tolerated. Cont to encourage C&DB.\\n Tachycardia, Other\\n Assessment:\\n HR 130\\ns @ rest throughout shift, and still > 125 when pt soundly\\n sleeping. Pt Afebrile.\\n Action:\\n Response:\\n Plan:\\n Rash\\n Assessment:\\n Pt noted to have raised red rash evenly distributed over mid/lower\\n back. Pt has been very restless, and nodded\\n to\\nDoes your back\\n itch?\\n. No new meds recently.\\n Action:\\n Team made aware, and they examined rash. Pt rec\\nd Benadryl 25mg IV X 1.\\n Response:\\n Pt finally able to sleep after very restless night and morning. HR\\n 130\\ns->125ST. O2 sat \\nd to 80\\ns with RR inc\\nd to high 20\\ns and\\n shallow.\\n Plan:\\n Benadryl PRN Q6hrs. ? Sarna lotion. Cont to monitor rash. FiO2 inc\\nd to\\n 100% on TM while pt sleeping with good response per O2 sat.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-19 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 638411,\n \"text\": \"Chief Complaint: resp failure\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 24 Hour Events:\\n Another episode of emesis\\n Was on MMV\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Diazepam (Valium) - 12:00 AM\\n Furosemide (Lasix) - 01:30 AM\\n Morphine Sulfate - 02:00 AM\\n Pantoprazole (Protonix) - 08:24 AM\\n Other medications:\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 10:35 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.1\\nC (98.8\\n Tcurrent: 36.6\\nC (97.8\\n HR: 101 (74 - 137) bpm\\n BP: 105/57(67) {75/42(50) - 130/73(108)} mmHg\\n RR: 24 (12 - 28) insp/min\\n SpO2: 97%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 3,165 mL\\n 1,720 mL\\n PO:\\n TF:\\n 691 mL\\n IVF:\\n 1,574 mL\\n 1,665 mL\\n Blood products:\\n Total out:\\n 1,670 mL\\n 1,020 mL\\n Urine:\\n 1,470 mL\\n 965 mL\\n NG:\\n 200 mL\\n 55 mL\\n Stool:\\n Drains:\\n Balance:\\n 1,495 mL\\n 700 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask , Tracheostomy tube\\n Ventilator mode: MMV/PSV/AutoFlow\\n Vt (Set): 500 (500 - 500) mL\\n Vt (Spontaneous): 94 (94 - 450) mL\\n PS : 10 cmH2O\\n RR (Set): 12\\n RR (Spontaneous): 0\\n PEEP: 5 cmH2O\\n FiO2: 60%\\n RSBI Deferred: No Spon Resp\\n PIP: 20 cmH2O\\n SpO2: 97%\\n ABG: ///38/\\n Ve: 5.6 L/min\\n Physical Examination\\n Labs / Radiology\\n 8.6 g/dL\\n 467 K/uL\\n 131 mg/dL\\n 0.7 mg/dL\\n 38 mEq/L\\n 3.4 mEq/L\\n 8 mg/dL\\n 101 mEq/L\\n 145 mEq/L\\n 27.8 %\\n 6.9 K/uL\\n [image002.jpg]\\n 03:00 AM\\n 05:00 AM\\n 02:06 AM\\n 07:34 AM\\n 03:50 AM\\n 06:22 AM\\n 02:58 AM\\n 03:43 AM\\n 05:02 PM\\n 03:36 AM\\n WBC\\n 5.2\\n 5.9\\n 7.5\\n 5.6\\n 6.1\\n 7.0\\n 7.1\\n 7.1\\n 6.9\\n Hct\\n 26.0\\n 27.2\\n 26.8\\n 27.0\\n 27.0\\n 29.7\\n 28.9\\n 29.2\\n 27.8\\n Plt\\n 35\\n 52\\n 467\\n Cr\\n 0.6\\n 0.7\\n 0.6\\n 0.5\\n 0.7\\n 0.7\\n 0.6\\n 0.7\\n 0.8\\n 0.7\\n Glucose\\n 100\\n 134\\n 134\\n 121\\n 04\\n 108\\n 131\\n Other labs: PT / PTT / INR:38.8/34.5/4.2, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:9.4 mg/dL, Mg++:2.3 mg/dL, PO4:4.2\\n mg/dL\\n Assessment and Plan\\n 1. Tachycardia: runs of atach versus AVNRT. On bblocker be not very\\n effective- EP cinsult for ? is there an ablatable focus.\\n 2. Resp Failure\\n Trach mask trials as tolerating (needing QHS support at\\n present)\\n PMV trials\\n S/P rx for pan Klebs PNA.\\n Per IP not stent planned as technically not possible to\\n place into her airway\\n 3. DVT and coagulopathy On warfarin. Hold warfarin\\n 4. Feeding tube Getting reglan trial but still with emesis.\\n 5. Hypernatremia Replete free water.\\n Please see today\\ns ICU team note for other issues.\\n ICU Care\\n Nutrition: TFs\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n Prophylaxis:\\n DVT: anti coag\\n Stress ulcer: ppi\\n Communication: trying to reach boyfriend\\n status: Full code\\n Disposition : ICU, start screening still need to fix tachycardia\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-15 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 637745,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n ULTRASOUND - At 03:48 PM\\n US of Lt arm to R/O DVT. Shows small , nonobstructing clot in axillary\\n vein of LEFT arm\\n CTA- wet read neg for PE, though study limited by movement artifact\\n Coumadin increased to 5mg last night\\n Episode of emesis w/ tube gastric contents/ TFs extruding from\\n tracheostomy site, around tube. TFs held.\\n L PICC line left in place until AM.\\n RUE U/S in am showed no DVT in right arm, resolved old clot.\\n Endocrine consult left impressions/recs\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Ceftriaxone - 10:00 PM\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:20 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.5\\nC (99.5\\n Tcurrent: 36.3\\nC (97.3\\n HR: 135 (123 - 146) bpm\\n BP: 141/65(82) {106/41(56) - 185/128(142)} mmHg\\n RR: 19 (11 - 32) insp/min\\n SpO2: 96%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 1,888 mL\\n 360 mL\\n PO:\\n TF:\\n 1,268 mL\\n IVF:\\n 100 mL\\n Blood products:\\n Total out:\\n 1,530 mL\\n 240 mL\\n Urine:\\n 1,510 mL\\n 240 mL\\n NG:\\n 20 mL\\n Stool:\\n Drains:\\n Balance:\\n 358 mL\\n 120 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 227 (227 - 397) mL\\n PS : 8 cmH2O\\n RR (Spontaneous): 20\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n RSBI: 194\\n PIP: 16 cmH2O\\n SpO2: 96%\\n ABG: ////\\n Ve: 6.5 L/min\\n Physical Examination\\n GEN: Awake, alert, responsive. Sitting in bed. Indicated that she\\n wanted to get out of the hospital. Cooperative.\\n HEENT: PERRL, EOMI, no scleral icterus or injections.\\n PULM: Large secretions, diffuse loud wet upperairway sounds/rhonchi, no\\n wheezes, no rales, but difficult exam w/ poor inspiration.\\n CARD: tachycardic, regular, ,s1, s2,\\n ABD: abdomen obese, mildly distended, nontender, no rebound, no\\n guarding.\\n EXT: DP 2+\\n NEURO: able to move all extremeties, strength 5/5 upper and 4-5/5\\n lower, R hip < L hip.\\n Labs / Radiology\\n 306 K/uL\\n 8.8 g/dL\\n 134 mg/dL\\n 0.6 mg/dL\\n 32 mEq/L\\n 4.0 mEq/L\\n 11 mg/dL\\n 106 mEq/L\\n 146 mEq/L\\n 26.8 %\\n 7.5 K/uL\\n [image002.jpg]\\n 03:10 AM\\n 03:08 PM\\n 03:00 AM\\n 03:36 AM\\n 04:40 PM\\n 03:00 AM\\n 07:05 PM\\n 03:00 AM\\n 05:00 AM\\n 02:06 AM\\n WBC\\n 11.3\\n 7.3\\n 6.1\\n 7.2\\n 5.2\\n 5.9\\n 7.5\\n Hct\\n 24.9\\n 27.6\\n 26.5\\n 26.9\\n 26.0\\n 27.2\\n 26.8\\n Plt\\n 227\\n 189\\n 209\\n 238\\n 240\\n 296\\n 306\\n Cr\\n 0.7\\n 0.6\\n 0.6\\n 0.9\\n 0.7\\n 0.6\\n 0.7\\n 0.6\\n TCO2\\n 26\\n Glucose\\n 114\\n 99\\n 115\\n 106\\n 100\\n 134\\n 134\\n Other labs: PT / PTT / INR:15.5/24.8/1.4, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:27/19, Alk Phos / T Bili:118/0.3,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.5 g/dL, LDH:243 IU/L, Ca++:9.2 mg/dL, Mg++:2.1 mg/dL, PO4:4.0\\n mg/dL\\n CXR: no sig change from previous, some R sided infiltrate vs effusion,\\n redistrubted from previous\\n RUE U/S: (PRELIM) No evidence of DVT in the right upper extremity.\\n Resolution of nonocclusive thrombus in the right axillary and basilic\\n veins.\\n LUE U/S: (PRELIM) Very small segment (1-cm in length) of nonocclusive\\n thrombus in the left axillary vein. A PICC catheter is present on the\\n left.\\n Assessment and Plan\\n 55yoF with history of EtOH abuse presenting following mechanical fall\\n and traumatic T spine fracture, now s/p trach, PEG, placement being\\n treated for HAP.\\n# HAP vs Aspiration PNA: Cultures grew, Klebsiella Oxytoca, Klebsiella Pneumonia\\ne, GNR, GP Cocci. Has completed 8 day course of Ceftriaxone. Has had occasional\\nlow grade fevers, but has continued to improve clinically. Had a sputum gram sta\\nin from w/ GPC p/c. a new VAP/HAP w/ staph possible, but given no clear inf\\niltrate on CXR and good respiratory status, significant PNA is unlikely, coloniz\\nation of tracheostomy tube is more likely, as is contamination of sputum. Given\\n improving clinical picture, will wait until CX data or change in clinical statu\\ns or CXR to initiate HAP/VAP treatment.\\n - D/c Ceftriaxone\\n - Continue to f/u cultures\\n .\\n # Respiratory failure: Improving status. Will continue to increase\\n time on trach mask as tolerated.\\n - PMV with suctioning.\\n - Weaning FiO2 as tolerated\\n # Tachycardia: Pt in ST 120\\ns to 150s. Etiology remains unclear and\\n include hypovolemia, pain, infection (pt with known klebsiella), and\\n incrased work of breathing from secretions and tracheomalacia, . DDx\\n also includes PE given hx of RUE DVT, mucus plugging given large\\n amount of secretions, and spinal injury. Tachycardia is unresponsive to\\n IVF, Pt has had a negative CT-PA and has not had sig response to pain\\n meds. Has completed treatment for her HAP. Thyroid function was checked\\n and had normal TSH and T3 and free T4. Had been on albuterol q4 and\\n atrovent , she has not been wheezing, and perhaps she is sensitive to\\n the B-agonist.\\n - Continue Pain Control\\n - Change albuterol to PRN\\n - Test if HR decreases when placed on higher pressure support\\n for period of time.\\n # Sedation: Has had inconsistent response to sedation, unclear what is\\n best regime. Will continue to wean overall\\n - Change to haldol 2.5 PRN, Fentanyl 75 mcg TP, Morphine PRN,\\n Benadryl, Valium 5mg PRN\\n # Adrenal Insufficency: Followed up with endocrine that suggested if\\n the patient under goes major stressors such as major surgery, sepsis,\\n she may need stress dosed steroids.\\n - Will consider MRI at later date for evaluation of pituitary\\n # Fluid Status: Volume overloaded in prior setting of Hypernatremia\\n - Monitoring urine output\\n - increasse Free H20, for mild hypernatremia 200cc Free bolus PEG, and\\n - 500cc D5W at 125.\\n - PM lytes to assess hypernatremia\\n # UE DVT: right has resolved, new non occlusive in left axillary. INR\\n 1.5\\n -continue coumadin\\n -follow INR\\n - D/c Left PICC line, and place peripheral IVs. If unable, can place a\\n R PICC.\\n # Spine fracture: Stable\\n - Brace for OOB, will discuss with Neurosurgery if current brace is\\n optimal for stabilization given her mobility.\\n - Pt to follow up with Dr. in weeks\\n # Tracheomalacia?: Was initially addressed with IP and they wanted to\\n follow up as outpatient.\\n - Consult IP for stent placement given improved clinical status, will\\n readdresses\\n #. Thyroid Nodule on CT\\n - Outpatient follow up\\n # Nutrition: Pt had emesis and extrusion of gastric contents through\\n tracheostomy site (not through tube).\\n - TFs held\\n - Consult IR for advancement of her PEG to jejunum.\\n # Glycemic control: SSI, well controlled\\n # PIV x 1\\n # Ppx: Restarting Coumadin, Ranitidine, Bowel Regimen PRN\\n # Communication:\\n - Boyfriend of 10 \\n - Brother also involved\\n # Code: Full\\n # Dispo: ICU, Screening for vent facilities\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n PICC Line - 09:19 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nutrition\",\n \"chartdate\": \"2167-10-14 00:00:00.000\",\n \"description\": \"Clinical Nutrition Note\",\n \"row_id\": 637522,\n \"text\": \"Objective\\n Pertinent medications: noted\\n Labs:\\n Value\\n Date\\n Glucose\\n 134 mg/dL\\n 02:06 AM\\n Glucose Finger Stick\\n 139\\n 10:00 AM\\n BUN\\n 11 mg/dL\\n 02:06 AM\\n Creatinine\\n 0.6 mg/dL\\n 02:06 AM\\n Sodium\\n 146 mEq/L\\n 02:06 AM\\n Potassium\\n 4.0 mEq/L\\n 02:06 AM\\n Chloride\\n 106 mEq/L\\n 02:06 AM\\n TCO2\\n 32 mEq/L\\n 02:06 AM\\n Albumin\\n 3.5 g/dL\\n 03:00 AM\\n Calcium non-ionized\\n 9.2 mg/dL\\n 02:06 AM\\n Phosphorus\\n 4.0 mg/dL\\n 02:06 AM\\n Ionized Calcium\\n 1.24 mmol/L\\n 02:51 AM\\n Magnesium\\n 2.1 mg/dL\\n 02:06 AM\\n Current diet order / nutrition support: Replete c. Fiber @60mL/hr (1440\\n kcals/89 gr aa)\\n GI: Abd: soft/dist/+bs\\n Assessment of Nutritional Status\\n Estimation of current intake: Adequate\\n Specifics:\\n Pt continues on TF\\ns for full nutrition support via PEG, currently\\n tolerating @ goal s/ problems. (Noted TF\\ns were off over weekend / ?\\n aspiration event) FWB down to 100mL q 4 hr c/ Na WNL. BG\\ns well\\n controlled.\\n Medical Nutrition Therapy Plan - Recommend the Following\\n Multivitamin / Mineral supplement: via TF\\n Tube feeding recommendations: Continue TF's @ goal\\n Monitor fluid status and adjust FWB prn.\\n BG and lyte management as you are\\n Please check current wt\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2167-10-16 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 637872,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 28\\n Ideal body weight: 61.2 None\\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: Yes\\n Tracheostomy tube:\\n Type: Standard\\n Manufacturer: Portex\\n Size: 7.0mm\\n PMV: No\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Rhonchi\\n LUL Lung Sounds: Rhonchi\\n LLL Lung Sounds: Diminished\\n Secretions\\n Sputum color / consistency: White / Thick\\n Sputum source/amount: Suctioned / Moderate\\n Ventilation Assessment\\n Level of breathing assistance: Continuous invasive ventilation\\n Visual assessment of breathing pattern: Normal quiet breathing\\n Assessment of breathing comfort: No claim of dyspnea)\\n Invasive ventilation assessment:\\n Trigger work assessment: Triggering synchronously\\n Plan\\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\\n Increase ventilatory support at night; Comments: Trach Trials as\\n tolerated.\\n Reason for continuing current ventilatory support:\\n Note: rsbi 52\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-17 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 638106,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Pt continued on B-Blocker for prior runs of SVT, HR peaked in 135\\n Olanzapine 5mg QHS\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Ceftriaxone - 10:00 PM\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 08:14 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.6\\nC (99.6\\n Tcurrent: 36.4\\nC (97.5\\n HR: 131 (119 - 149) bpm\\n BP: 111/53(67) {99/28(50) - 185/99(144)} mmHg\\n RR: 11 (11 - 30) insp/min\\n SpO2: 98%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 2,408 mL\\n 200 mL\\n PO:\\n 50 mL\\n TF:\\n IVF:\\n 2,358 mL\\n 200 mL\\n Blood products:\\n Total out:\\n 1,795 mL\\n 1,320 mL\\n Urine:\\n 1,795 mL\\n 1,320 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 613 mL\\n -1,120 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask\\n Ventilator mode: MMV/PSV/AutoFlow\\n Vt (Set): 500 (500 - 500) mL\\n Vt (Spontaneous): 415 (244 - 415) mL\\n PS : 10 cmH2O\\n RR (Set): 12\\n RR (Spontaneous): 0\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n RSBI Deferred: No Spon Resp\\n PIP: 22 cmH2O\\n Plateau: 17 cmH2O\\n SpO2: 98%\\n ABG: ///38/\\n Ve: 5.5 L/min\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 462 K/uL\\n 9.0 g/dL\\n 137 mg/dL\\n 0.6 mg/dL\\n 38 mEq/L\\n 3.9 mEq/L\\n 5 mg/dL\\n 101 mEq/L\\n 146 mEq/L\\n 28.9 %\\n 7.1 K/uL\\n [image002.jpg]\\n 04:40 PM\\n 03:00 AM\\n 07:05 PM\\n 03:00 AM\\n 05:00 AM\\n 02:06 AM\\n 07:34 AM\\n 03:50 AM\\n 06:22 AM\\n 02:58 AM\\n WBC\\n 7.2\\n 5.2\\n 5.9\\n 7.5\\n 5.6\\n 6.1\\n 7.0\\n 7.1\\n Hct\\n 26.9\\n 26.0\\n 27.2\\n 26.8\\n 27.0\\n 27.0\\n 29.7\\n 28.9\\n Plt\\n 238\\n 240\\n 296\\n \\n 395\\n 462\\n Cr\\n 0.6\\n 0.9\\n 0.7\\n 0.6\\n 0.7\\n 0.6\\n 0.5\\n 0.7\\n 0.7\\n 0.6\\n Glucose\\n 115\\n 106\\n 100\\n 134\\n 134\\n 121\\n \\n Other labs: PT / PTT / INR:36.6/30.0/3.9, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:9.8 mg/dL, Mg++:2.2 mg/dL, PO4:3.3\\n mg/dL\\n Assessment and Plan\\n 55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\\n trach, PEG, placement being with respiratory failure secondary to\\n tracheomalacia and HAP.\\n .\\n # Respiratory failure: Improving status. Will continue to increase\\n time on trach mask as tolerated.\\n - PMV with suctioning.\\n - Continue to increase time on trach mask as tolerated.\\n .\\n # HAP vs Aspiration PNA: Cultures Positive for, Klebsiella Oxytoca,\\n Klebsiella Pneumoniae, GNR, GP Cocci. 8 day course of Ceftriaxone\\n completed. Occasional low grade fevers, clinically improved. Sputum\\n gram stain from w/ GPC p/c. new VAP/HAP w/ staph possible, no\\n clear infiltrate on CXR and good respiratory status. Potential\\n colonization of tracheostomy and contamination of sputum. Given\\n improving clinical picture, will wait until CX data or change in\\n clinical status or CXR to initiate HAP/VAP treatment.\\n - Completed course of ceftriaxone\\n - Continue to f/u cultures\\n - Continue trach mask as tolerated\\n .\\n # Tachycardia: Sinus Tach. HR decreases overnight with ranges of\\n 115-135. From yesterday when pt found had runs of SVT as well as ST\\n 120\\ns to 150s. SBPs approx 65.\\n Negative CT to evaluate for DVT, resp failure likely contributing\\n - cont metoprolol 12.5mg TID and uptitrate as tolerated\\n - monitor on telemetry\\n - Continue Pain Control\\n - Change albuterol to PRN\\n .\\n # Mental Status / Sedation: Has had inconsistent response to sedation,\\n unclear what is best regime. Will continue to wean overall\\n - DC haldol and taper valium to 2.5 mg PRN TID, taper off\\n # Adrenal Insufficency: Followed up with endocrine that suggested if\\n the patient under goes major stressors such as major surgery, sepsis,\\n she may need stress dosed steroids.\\n - Endocrine s/o\\n no need for steroids currently\\n .\\n # Fluid Status: Volume overloaded in prior setting of Hypernatremia\\n - Monitoring urine output\\n - increasse Free H20, for mild hypernatremia 200cc Free bolus PEG, and\\n - 500cc D5W at 125.\\n - PM lytes to assess hypernatremia\\n .\\n # UE DVT: right has resolved, new non occlusive in left axillary. INR\\n 1.5\\n - continue coumadin\\n - follow INR\\n - PICC lines DC\\n .\\n # Spine fracture: Stable\\n - Brace for OOB, will discuss with Neurosurgery if current brace is\\n optimal for stabilization given her mobility.\\n - Pt to follow up with Dr. in weeks\\n .\\n # Tracheomalacia?: Was initially addressed with IP and they wanted to\\n follow up as outpatient.\\n - Consult IP for stent placement given improved clinical status, will\\n readdresses\\n .\\n #. Thyroid Nodule on CT\\n - Outpatient follow up\\n .\\n # Nutrition: Pt had emesis and extrusion of gastric contents through\\n tracheostomy site (not through tube).\\n - TFs held\\n - Appreciate thoracic\\ns recs\\n will add reglan 10mg Q6\\n .\\n # Glycemic control: SSI, well controlled\\n # PIV x 1\\n # Ppx: Restarting Coumadin, Ranitidine, Bowel Regimen PRN\\n # Communication:\\n - Boyfriend of 10 \\n - Brother also involved\\n # Code: Full\\n # Dispo: ICU, Screening for vent facilities\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:10 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-17 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 638167,\n \"text\": \"Airway Clearance, Impaired\\n Assessment:\\n Pt placed on trach mask this am (on vent o/n). She continues to have\\n moderate amts of thick secretions, requiring frequent sxn. Pt does have\\n a strong/productive cough.\\n Action:\\n Response:\\n Plan:\\n Altered mental status (not Delirium)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Alteration in Nutrition\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Tachycardia, Other\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-19 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 638356,\n \"text\": \"Hypernatremia (high sodium)\\n Assessment:\\n Na 148, pt vomited and tube feeds on hold as well as fluid boluses on\\n hold.\\n Action:\\n Iv fluids of D5w at 125 cc/hr\\n Response:\\n Na decreased to 145 at 0330 lab check\\n Plan:\\n Continue with D5w at 125 cc/hr. check with ho in am regarding further\\n iv orders and next na level check.\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt restless and moving all over bed.. There are also times when pt\\n sleeps. pt nodded yes to generalized pain times once and at another\\n time she nodded yes when asked if she was itichy.\\n Action:\\n Medicated with valium 2.5 mg gtube atc dose. Pt also received one dose\\n of 2.5 mg iv for increased restlessness. Medicated with benadryl 25 mg\\n iv for the c/o itch. Pt also received a dose of morphine 2 mg iv for\\n c/o generalized discomfort.\\n Response:\\n Pt behaviour continues with episodic agitation followed by a period of\\n sleep\\n Plan:\\n Continue atc valium. Evaluate pt for c/o itch/ pain and medicate\\n accordingly\\n Alteration in Nutrition\\n Assessment:\\n Pt vomited large amounts of tube feed. Copious amounts gushing from her\\n mouth times three. Tube feeds stopped and hydration with iv fluids\\n initiated. Pt continues to gag and have small amounts of brownish\\n emesis when she coughs.\\n Action:\\n Regaln iv ATC, zofran 4 mg iv times 2, gtube to drainage.\\n Response:\\n Gtube drained 50 cc brownish/bilious.\\n Plan:\\n Airway Clearance, Impaired\\n Assessment:\\n Pt vomiting and tube feed gushing from mouth. Later when pt resting o2\\n sats decreased to 90 %.\\n Action:\\n Pt turned to side to prevent aspiration. Suctioned trach for sm/mod\\n white and blood tinged time 2 , pt placed on vent for decreased o2\\n saturation.\\n Response: sats improved to 97-99 % on 50 % mmv\\n Plan: monitor sats, follow temp, chest xray done am rounds.. check\\n results\\n Response:\\n [image002.jpg]\\n Plan:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-12 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 637102,\n \"text\": \"Chief Complaint: resp failure\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 24 Hour Events:\\n rash- vesicular and d/c l;evoquin and started Ceftriaxone\\n More tachycardic this AM - autonomic dysregulation\\n Trach Mask for several hours\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Aztreonam - 03:42 AM\\n Vancomycin - 09:40 AM\\n Levofloxacin - 11:15 PM\\n Ceftriaxone - 07:50 PM\\n Infusions:\\n Other ICU medications:\\n Morphine Sulfate - 09:45 AM\\n Haloperidol (Haldol) - 10:26 AM\\n Other medications:\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 10:57 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.2\\nC (98.9\\n Tcurrent: 36.9\\nC (98.5\\n HR: 143 (113 - 145) bpm\\n BP: 153/89(102) {85/40(50) - 153/89(102)} mmHg\\n RR: 24 (9 - 30) insp/min\\n SpO2: 98%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 1,362 mL\\n 537 mL\\n PO:\\n TF:\\n 47 mL\\n 287 mL\\n IVF:\\n 1,061 mL\\n 100 mL\\n Blood products:\\n Total out:\\n 1,203 mL\\n 615 mL\\n Urine:\\n 1,203 mL\\n 615 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 159 mL\\n -78 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask\\n Ventilator mode: Standby\\n Vt (Set): 0 (0 - 0) mL\\n Vt (Spontaneous): 244 (110 - 504) mL\\n PS : 10 cmH2O\\n RR (Set): 0\\n RR (Spontaneous): 19\\n PEEP: 5 cmH2O\\n FiO2: 70%\\n RSBI: 245\\n PIP: 16 cmH2O\\n SpO2: 98%\\n ABG: ///30/\\n Ve: 10 L/min\\n Physical Examination\\n Gen\\n Heent\\n CV\\n Chest\\n Abd\\n Ext\\n Neuro\\n Labs / Radiology\\n 7.9 g/dL\\n 240 K/uL\\n 100 mg/dL\\n 0.6 mg/dL\\n 30 mEq/L\\n 3.4 mEq/L\\n 12 mg/dL\\n 108 mEq/L\\n 146 mEq/L\\n 26.0 %\\n 5.2 K/uL\\n [image002.jpg]\\n 08:11 PM\\n 02:51 AM\\n 03:10 AM\\n 03:08 PM\\n 03:00 AM\\n 03:36 AM\\n 04:40 PM\\n 03:00 AM\\n 07:05 PM\\n 03:00 AM\\n WBC\\n 9.4\\n 11.3\\n 7.3\\n 6.1\\n 7.2\\n 5.2\\n Hct\\n 26.6\\n 24.9\\n 27.6\\n 26.5\\n 26.9\\n 26.0\\n Plt\\n \\n Cr\\n 0.9\\n 0.7\\n 0.6\\n 0.6\\n 0.9\\n 0.7\\n 0.6\\n TCO2\\n 29\\n 26\\n Glucose\\n 128\\n 114\\n 114\\n 99\\n 115\\n 106\\n 100\\n Other labs: PT / PTT / INR:17.6/27.4/1.6, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:33/22, Alk Phos / T Bili:143/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:0.5 mmol/L,\\n Albumin:3.5 g/dL, LDH:199 IU/L, Ca++:8.9 mg/dL, Mg++:2.4 mg/dL, PO4:4.1\\n mg/dL\\n Assessment and Plan 55 yr old alcoholic s/p t spine fx s/p trcah and\\n PEG with persistent resp failure\\n 1. Resp Failure: currently on trach mask, can do a few hours per\\n day, then needs for support. New pan Klebs in sputum, day\\n . Get Speech consult for PMV evaluation. Holding off on stent by IP\\n until after pulm rehab.\\n 2. Hemodynamics: tachycardia seems most likely due to agitation\\n at present, did taper Valium aggressively, may be need to increase\\n benzo slightly and see f it helps (haldol and morphione have not helped\\n yet this AM)\\n 3.\\n ICU Care\\n Nutrition: Replete with Fiber (Full) - 07:46 AM 30 mL/hour\\n Glycemic Control:\\n Lines: PICC Line - 09:19 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n Communication:\\n Code status: Full code\\n Disposition :ICU\\n Total time spent: 35 minutes\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-12 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 637104,\n \"text\": \"Chief Complaint: resp failure\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 24 Hour Events:\\n rash- vesicular and d/c l;evoquin and started Ceftriaxone\\n More tachycardic this AM - autonomic dysregulation\\n Trach Mask for several hours\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Aztreonam - 03:42 AM\\n Vancomycin - 09:40 AM\\n Levofloxacin - 11:15 PM\\n Ceftriaxone - 07:50 PM\\n Infusions:\\n Other ICU medications:\\n Morphine Sulfate - 09:45 AM\\n Haloperidol (Haldol) - 10:26 AM\\n Other medications:\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 10:57 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.2\\nC (98.9\\n Tcurrent: 36.9\\nC (98.5\\n HR: 143 (113 - 145) bpm\\n BP: 153/89(102) {85/40(50) - 153/89(102)} mmHg\\n RR: 24 (9 - 30) insp/min\\n SpO2: 98%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 1,362 mL\\n 537 mL\\n PO:\\n TF:\\n 47 mL\\n 287 mL\\n IVF:\\n 1,061 mL\\n 100 mL\\n Blood products:\\n Total out:\\n 1,203 mL\\n 615 mL\\n Urine:\\n 1,203 mL\\n 615 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 159 mL\\n -78 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask\\n Ventilator mode: Standby\\n Vt (Set): 0 (0 - 0) mL\\n Vt (Spontaneous): 244 (110 - 504) mL\\n PS : 10 cmH2O\\n RR (Set): 0\\n RR (Spontaneous): 19\\n PEEP: 5 cmH2O\\n FiO2: 70%\\n RSBI: 245\\n PIP: 16 cmH2O\\n SpO2: 98%\\n ABG: ///30/\\n Ve: 10 L/min\\n Physical Examination\\n Gen\\n Heent\\n CV\\n Chest\\n Abd\\n Ext\\n Neuro\\n Labs / Radiology\\n 7.9 g/dL\\n 240 K/uL\\n 100 mg/dL\\n 0.6 mg/dL\\n 30 mEq/L\\n 3.4 mEq/L\\n 12 mg/dL\\n 108 mEq/L\\n 146 mEq/L\\n 26.0 %\\n 5.2 K/uL\\n [image002.jpg]\\n 08:11 PM\\n 02:51 AM\\n 03:10 AM\\n 03:08 PM\\n 03:00 AM\\n 03:36 AM\\n 04:40 PM\\n 03:00 AM\\n 07:05 PM\\n 03:00 AM\\n WBC\\n 9.4\\n 11.3\\n 7.3\\n 6.1\\n 7.2\\n 5.2\\n Hct\\n 26.6\\n 24.9\\n 27.6\\n 26.5\\n 26.9\\n 26.0\\n Plt\\n \\n Cr\\n 0.9\\n 0.7\\n 0.6\\n 0.6\\n 0.9\\n 0.7\\n 0.6\\n TCO2\\n 29\\n 26\\n Glucose\\n 128\\n 114\\n 114\\n 99\\n 115\\n 106\\n 100\\n Other labs: PT / PTT / INR:17.6/27.4/1.6, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:33/22, Alk Phos / T Bili:143/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:0.5 mmol/L,\\n Albumin:3.5 g/dL, LDH:199 IU/L, Ca++:8.9 mg/dL, Mg++:2.4 mg/dL, PO4:4.1\\n mg/dL\\n Assessment and Plan 55 yr old alcoholic s/p t spine fx s/p trcah and\\n PEG with persistent resp failure\\n 1. Resp Failure: currently on trach mask, can do a few hours per\\n day, then needs for support. New pan Klebs in sputum, day\\n . Get Speech consult for PMV evaluation. Holding off on stent by IP\\n until after pulm rehab.\\n 2. Hemodynamics: tachycardia seems most likely due to agitation\\n at present, did taper Valium aggressively, may be need to increase\\n benzo slightly and see f it helps (haldol and morphione have not helped\\n yet this AM)\\n 3. Anti coag: for upper ext DVT but INR elevated on coumadin +\\n quinolone\\n repeat\\n 4. Adrenal Insufficny: proper stim this AM\\n ICU Care\\n Nutrition: Replete with Fiber (Full) - 07:46 AM 30 mL/hour\\n Glycemic Control:\\n Lines: PICC Line - 09:19 PM\\n Prophylaxis:\\n DVT: inr levetaed recheck, and start coumadin when at 2.0\\n Stress ulcer: ppi\\n Communication:\\n Code status: Full code\\n Disposition :ICU\\n Total time spent: 35 minutes\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-14 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 637493,\n \"text\": \"Chief Complaint: resp failure\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n s/p t spine fx with resp failure\\n 24 Hour Events:\\n BLOOD CULTURED - At 02:18 AM\\n SPUTUM CULTURE - At 02:18 AM\\n URINE CULTURE - At 02:18 AM\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Ceftriaxone - 12:00 AM\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Constitutional: Fever\\n Flowsheet Data as of 08:32 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.2\\nC (100.8\\n Tcurrent: 37.2\\nC (99\\n HR: 137 (120 - 151) bpm\\n BP: 125/55(73) {98/41(54) - 202/97(111)} mmHg\\n RR: 23 (12 - 39) insp/min\\n SpO2: 98%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 2,934 mL\\n 497 mL\\n PO:\\n TF:\\n 1,104 mL\\n 447 mL\\n IVF:\\n 1,000 mL\\n 50 mL\\n Blood products:\\n Total out:\\n 530 mL\\n 240 mL\\n Urine:\\n 530 mL\\n 240 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 2,404 mL\\n 257 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 318 (318 - 475) mL\\n PS : 10 cmH2O\\n RR (Spontaneous): 34\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n RSBI: 171\\n SpO2: 98%\\n ABG: ///32/\\n Ve: 9 L/min\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 8.8 g/dL\\n 306 K/uL\\n 134 mg/dL\\n 0.6 mg/dL\\n 32 mEq/L\\n 4.0 mEq/L\\n 11 mg/dL\\n 106 mEq/L\\n 146 mEq/L\\n 26.8 %\\n 7.5 K/uL\\n [image002.jpg]\\n 03:10 AM\\n 03:08 PM\\n 03:00 AM\\n 03:36 AM\\n 04:40 PM\\n 03:00 AM\\n 07:05 PM\\n 03:00 AM\\n 05:00 AM\\n 02:06 AM\\n WBC\\n 11.3\\n 7.3\\n 6.1\\n 7.2\\n 5.2\\n 5.9\\n 7.5\\n Hct\\n 24.9\\n 27.6\\n 26.5\\n 26.9\\n 26.0\\n 27.2\\n 26.8\\n Plt\\n 227\\n 189\\n 209\\n 238\\n 240\\n 296\\n 306\\n Cr\\n 0.7\\n 0.6\\n 0.6\\n 0.9\\n 0.7\\n 0.6\\n 0.7\\n 0.6\\n TCO2\\n 26\\n Glucose\\n 114\\n 99\\n 115\\n 106\\n 100\\n 134\\n 134\\n Other labs: PT / PTT / INR:13.5/23.6/1.2, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:27/19, Alk Phos / T Bili:118/0.3,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.5 g/dL, LDH:243 IU/L, Ca++:9.2 mg/dL, Mg++:2.1 mg/dL, PO4:4.0\\n mg/dL\\n Assessment and Plan\\n Assessment and Plan 55 yr old alcoholic s/p t spine fx s/p trcah and\\n PEG with persistent resp failure\\n 1. Resp Failure: currently on trach mask, can do a few hours per\\n day, then needs for support. New pan Klebs in sputum, day\\n . Re- try. Holding off on stent by IP until after pulm rehab.\\n 2. Hemodynamics: tachycardia with slightly decreased UOP\\n bolus\\n IVF and trend UOP. Watch to see if response with tachycardia.\\n 3. Anti coag: for upper ext DVT but INR elevated on coumadin +\\n quinolone\\n repeat inr low- trend with po COumadin\\n 4. Adrenal Insufficiency: proper stim this AM, off steroids\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 06:23 AM 60 mL/hour\\n Glycemic Control:\\n Lines:\\n PICC Line - 09:19 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-15 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 637630,\n \"text\": \"Tachycardia, Other\\n Assessment:\\n Continues to be Tachycardia in 120-145 (anxiety). SBP has been 100-145\\n without ectopy.\\n Action:\\n No medication given for tachycardia.Pt gets Valium 5 mg scheduled Q6H\\n with little effect. CTA done to r/o pe as a source of tachycardia.\\n Response:\\n Results pending on CTA.\\n Plan:\\n Continue to evaluate HR and BP for need of treatment.\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Pt has a known DVT to RUE. Today pt had a US of LUEand ruled out small\\n non occlusive clot on her left axial vein.\\n Action:\\n Dr ,pt received ceftriaxone via PICC line.Coumadin dosage\\n increased from 2.5 to 5 mg ( INR 1.4).\\n Response:\\n Repeat ultrasound orderd for right arm to check old clot. Pt received 5\\n mg coumadin at 2200.\\n Plan:\\n Ultrasound today,cont coumadin and closely monitor INR.\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt has been restless most of the night. Pt nodded her head for pain and\\n simple yes or no questions.\\n Action:\\n Pt given scheduled Valium with little effect.\\n Response:\\n Pt slept for a while,Hr dropped to 120s at the time of rest.\\n Plan:\\n Continue to eval MS,Valium and PRN Morphine and haldol?.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt rested on CPAP+ PS 50%/,sats stayed upper 90\\ns,Pt found to have\\n TF coming around Tracheostomy. As well as from her mouth\\n Action:\\n Cont pulm toilet as needed,Held TF throughout the night .\\n Response:\\n Pt suctioned for small- moderate amount thick yellow secretions.No more\\n leakage noted around the tracheostomy as well as Minimal residuals from\\n PEG tube\\n Plan:\\n Continue to wean pt off vent and place on TC once pt can tol it again\\n and frequent pulmonary toileting. Restart TF?\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-15 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 637633,\n \"text\": \"56 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\\n with prolonged hospital course c/b by PNA, anxiety/altered mental\\n status, RUE DVT .Pt found to have small non occlusive Clot on her right\\n axial vein via Ultrasound.\\n Tachycardia, Other\\n Assessment:\\n Continues to be Tachycardia in 120-145 (anxiety). SBP has been 100-145\\n without ectopy.\\n Action:\\n No medication given for tachycardia.Pt gets Valium 5 mg scheduled Q6H\\n with little effect. CTA done to r/o pe as a source of tachycardia.\\n Response:\\n Results pending on CTA.\\n Plan:\\n Continue to evaluate HR and BP for need of treatment.\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Pt has a known DVT to RUE. Today pt had a US of LUEand ruled out small\\n non occlusive clot on her left axial vein.\\n Action:\\n Dr ,pt received ceftriaxone via PICC line.Coumadin dosage\\n increased from 2.5 to 5 mg ( INR 1.4).\\n Response:\\n Repeat ultrasound orderd for right arm to check old clot. Pt received 5\\n mg coumadin at 2200.\\n Plan:\\n Ultrasound today,cont coumadin and closely monitor INR.\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt has been restless most of the night. Pt nodded her head for pain and\\n simple yes or no questions.\\n Action:\\n Pt given scheduled Valium with little effect.\\n Response:\\n Pt slept for a while,Hr dropped to 120s at the time of rest.\\n Plan:\\n Continue to eval MS,Valium and PRN Morphine and haldol?.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt rested on CPAP+ PS 50%/,sats stayed upper 90\\ns,Pt found to have\\n TF coming around Tracheostomy. As well as from her mouth\\n Action:\\n Cont pulm toilet as needed,Held TF throughout the night .\\n Response:\\n Pt suctioned for small- moderate amount thick yellow secretions.No more\\n leakage noted around the tracheostomy as well as Minimal residuals from\\n PEG tube\\n Plan:\\n Continue to wean pt off vent and place on TC once pt can tol it again\\n and frequent pulmonary toileting. Restart TF?\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-16 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 638014,\n \"text\": \"Chief Complaint: Tracheomalacia\\n 24 Hour Events:\\n ULTRASOUND - At 08:11 AM\\n right arm - negative for DVT\\n PICC LINE - STOP 12:02 PM\\n - IR unable to advance PEG\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Ceftriaxone - 10:00 PM\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:12 AM\\n Morphine Sulfate - 12:00 PM\\n Haloperidol (Haldol) - 02:00 PM\\n Diazepam (Valium) - 03:52 PM\\n Furosemide (Lasix) - 06:40 AM\\n Other medications:\\n Changes to medical and family history:\\n None\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:50 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.9\\nC (98.4\\n Tcurrent: 36.2\\nC (97.1\\n HR: 139 (97 - 146) bpm\\n BP: 133/67(84) {93/43(55) - 183/129(134)} mmHg\\n RR: 18 (13 - 33) insp/min\\n SpO2: 96%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 1,220 mL\\n 568 mL\\n PO:\\n TF:\\n IVF:\\n 500 mL\\n 568 mL\\n Blood products:\\n Total out:\\n 1,514 mL\\n 150 mL\\n Urine:\\n 1,439 mL\\n 150 mL\\n NG:\\n 75 mL\\n Stool:\\n Drains:\\n Balance:\\n -294 mL\\n 418 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask , Tracheostomy tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 384 (311 - 675) mL\\n PS : 10 cmH2O\\n RR (Spontaneous): 12\\n PEEP: 5 cmH2O\\n FiO2: 70%\\n RSBI: 52\\n PIP: 15 cmH2O\\n SpO2: 96%\\n ABG: ///31/\\n Ve: 4.6 L/min\\n Physical Examination\\n General Appearance: No acute distress\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: Normocephalic\\n Lymphatic: Cervical WNL\\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic,\\n No(t) Diastolic), tachy, regular\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : )\\n Abdominal: Soft, Non-tender, Bowel sounds present\\n Extremities: Right: Absent, Left: Absent\\n Skin: Warm\\n Neurologic: Attentive,\\n Labs / Radiology\\n 395 K/uL\\n 9.0 g/dL\\n 619 mg/dL\\n 0.7 mg/dL\\n 31 mEq/L\\n 3.3 mEq/L\\n 6 mg/dL\\n 91 mEq/L\\n 129 mEq/L\\n 29.7 %\\n 7.0 K/uL\\n [image002.jpg]\\n 03:36 AM\\n 04:40 PM\\n 03:00 AM\\n 07:05 PM\\n 03:00 AM\\n 05:00 AM\\n 02:06 AM\\n 07:34 AM\\n 03:50 AM\\n 06:22 AM\\n WBC\\n 7.2\\n 5.2\\n 5.9\\n 7.5\\n 5.6\\n 6.1\\n 7.0\\n Hct\\n 26.9\\n 26.0\\n 27.2\\n 26.8\\n 27.0\\n 27.0\\n 29.7\\n Plt\\n 238\\n 240\\n 296\\n \\n 395\\n Cr\\n 0.6\\n 0.9\\n 0.7\\n 0.6\\n 0.7\\n 0.6\\n 0.5\\n 0.7\\n TCO2\\n 26\\n Glucose\\n 115\\n 106\\n 100\\n 134\\n 134\\n 121\\n 619\\n Other labs: PT / PTT / INR:23.4/29.6/2.3, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:8.4 mg/dL, Mg++:1.9 mg/dL, PO4:3.9\\n mg/dL\\n Microbiology: 7:34 am STOOL CONSISTENCY: FORMED\\n Source: Stool.\\n **FINAL REPORT **\\n CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final ):\\n Feces negative for C.difficile toxin A & B by EIA.\\n (Reference Range-Negative).\\n .\\n 7:33 am BLOOD CULTURE Source: Line-picc.\\n **FINAL REPORT **\\n Blood Culture, Routine (Final ): NO GROWTH\\n Assessment and Plan\\n Assessment and Plan\\n 55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\\n trach, PEG, placement being with respiratory failure secondary to\\n tracheomalacia and HAP.\\n .\\n # HAP vs Aspiration PNA: Cultures grew, Klebsiella Oxytoca, Klebsiella\\n Pneumoniae, GNR, GP Cocci. Has completed 8 day course of Ceftriaxone.\\n Has had occasional low grade fevers, but has continued to improve\\n clinically. Had a sputum gram stain from w/ GPC p/c. a new VAP/HAP\\n w/ staph possible, but given no clear infiltrate on CXR and good\\n respiratory status, significant PNA is unlikely, colonization of\\n tracheostomy tube is more likely, as is contamination of sputum. Given\\n improving clinical picture, will wait until CX data or change in\\n clinical status or CXR to initiate HAP/VAP treatment.\\n - Completed course of ceftriaxone\\n - Continue to f/u cultures\\n - Continue trach mask as tolerated\\n .\\n # Respiratory failure: Improving status. Will continue to increase\\n time on trach mask as tolerated.\\n - PMV with suctioning.\\n - Tolerating trach mask\\n .\\n # Tachycardia: Pt found to have runs of SVT as well as ST 120\\ns to\\n 150s. She had a negative CT to evaluate for DVT, resp failure likely\\n contributing\\n - start metoprolol 12.5mg TID and uptitrate as tolerated\\n - monitor on telemetry\\n - Continue Pain Control\\n - Change albuterol to PRN\\n .\\n # Sedation: Has had inconsistent response to sedation, unclear what is\\n best regime. Will continue to wean overall\\n - DC haldol and taper valium to 2.5 mg PRN TID, taper off\\n - .\\n # Adrenal Insufficency: Followed up with endocrine that suggested if\\n the patient under goes major stressors such as major surgery, sepsis,\\n she may need stress dosed steroids.\\n - Endocrine s/o\\n no need for steroids currently\\n .\\n # Fluid Status: Volume overloaded in prior setting of Hypernatremia\\n - Monitoring urine output\\n - increasse Free H20, for mild hypernatremia 200cc Free bolus PEG, and\\n - 500cc D5W at 125.\\n - PM lytes to assess hypernatremia\\n .\\n # UE DVT: right has resolved, new non occlusive in left axillary. INR\\n 1.5\\n -continue coumadin\\n -follow INR\\n - PICC lines DC\\n .\\n # Spine fracture: Stable\\n - Brace for OOB, will discuss with Neurosurgery if current brace is\\n optimal for stabilization given her mobility.\\n - Pt to follow up with Dr. in weeks\\n .\\n # Tracheomalacia?: Was initially addressed with IP and they wanted to\\n follow up as outpatient.\\n - Consult IP for stent placement given improved clinical status, will\\n readdresses\\n .\\n #. Thyroid Nodule on CT\\n - Outpatient follow up\\n .\\n # Nutrition: Pt had emesis and extrusion of gastric contents through\\n tracheostomy site (not through tube).\\n - TFs held\\n - Appreciate thoracic\\ns recs\\n will add reglan 10mg Q6\\n .\\n # Glycemic control: SSI, well controlled\\n .\\n # PIV x 1\\n .\\n # Ppx: Restarting Coumadin, Ranitidine, Bowel Regimen PRN\\n # Communication:\\n - Boyfriend of 10 \\n - Brother also involved\\n # Code: Full\\n # Dispo: ICU, Screening for vent facilities\\n ICU Care\\n Nutrition:\\n Comments: Tube feeds\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n 20 Gauge - 12:26 PM\\n Prophylaxis:\\n DVT: (Systemic anticoagulation: Coumadin)\\n Stress ulcer: PPI\\n VAP:\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds Comments:\\n Code status: Full code\\n Disposition:ICU\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-18 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 638227,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Pt was agitated during the day with no response to PRN zyprexa.\\n Her sodium was increased to 150 yesterday, and she was given 500cc D5W\\n bolus and her FW flushes for her tube feeds was increases from 100 to\\n 150.\\n Overnight, pt received zyprexa, valium, and was placed back on the\\n ventilator, after which she was more sedated and her SBP dropped to the\\n 70s and HR remained 120-130s. Her BP came back up to 110s-120s when she\\n was woken up.\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:11 AM\\n Morphine Sulfate - 04:00 AM\\n Diazepam (Valium) - 05:24 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:03 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.5\\nC (97.7\\n Tcurrent: 36.4\\nC (97.5\\n HR: 126 (118 - 140) bpm\\n BP: 98/62(70) {74/38(47) - 145/105(114)} mmHg\\n RR: 29 (11 - 35) insp/min\\n SpO2: 95%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 959 mL\\n 1,250 mL\\n PO:\\n TF:\\n 176 mL\\n 140 mL\\n IVF:\\n 463 mL\\n 810 mL\\n Blood products:\\n Total out:\\n 1,980 mL\\n 130 mL\\n Urine:\\n 1,980 mL\\n 130 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,021 mL\\n 1,120 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: MMV/PSV/AutoFlow\\n Vt (Set): 500 (500 - 500) mL\\n Vt (Spontaneous): 408 (408 - 499) mL\\n PS : 10 cmH2O\\n RR (Set): 12\\n RR (Spontaneous): 26\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n RSBI: 149\\n PIP: 16 cmH2O\\n Plateau: 21 cmH2O\\n SpO2: 95%\\n ABG: ///36/\\n Ve: 6.4 L/min\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 452 K/uL\\n 8.9 g/dL\\n 104 mg/dL\\n 0.7 mg/dL\\n 36 mEq/L\\n 3.5 mEq/L\\n 6 mg/dL\\n 103 mEq/L\\n 145 mEq/L\\n 29.2 %\\n 7.1 K/uL\\n [image002.jpg]\\n 03:00 AM\\n 07:05 PM\\n 03:00 AM\\n 05:00 AM\\n 02:06 AM\\n 07:34 AM\\n 03:50 AM\\n 06:22 AM\\n 02:58 AM\\n 03:43 AM\\n WBC\\n 7.2\\n 5.2\\n 5.9\\n 7.5\\n 5.6\\n 6.1\\n 7.0\\n 7.1\\n 7.1\\n Hct\\n 26.9\\n 26.0\\n 27.2\\n 26.8\\n 27.0\\n 27.0\\n 29.7\\n 28.9\\n 29.2\\n Plt\\n 238\\n 240\\n 296\\n \\n 395\\n 462\\n 452\\n Cr\\n 0.9\\n 0.7\\n 0.6\\n 0.7\\n 0.6\\n 0.5\\n 0.7\\n 0.7\\n 0.6\\n 0.7\\n Glucose\\n 106\\n 100\\n 134\\n 134\\n 121\\n 619\\n 126\\n 137\\n 104\\n Other labs: PT / PTT / INR:66.1/32.7/8.0, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:9.3 mg/dL, Mg++:2.2 mg/dL, PO4:3.8\\n mg/dL\\n Assessment and Plan\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 12:38 PM 30 mL/hour\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:35 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-18 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 638228,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Pt was agitated during the day with no response to PRN zyprexa.\\n Her sodium was increased to 150 yesterday, and she was given 500cc D5W\\n bolus and her FW flushes for her tube feeds was increases from 100 to\\n 150.\\n Overnight, pt received zyprexa, valium, and was placed back on the\\n ventilator, after which she was more sedated and her SBP dropped to the\\n 70s and HR remained 120-130s. Her BP came back up to 110s-120s when she\\n was woken up.\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:11 AM\\n Morphine Sulfate - 04:00 AM\\n Diazepam (Valium) - 05:24 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:03 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.5\\nC (97.7\\n Tcurrent: 36.4\\nC (97.5\\n HR: 126 (118 - 140) bpm\\n BP: 98/62(70) {74/38(47) - 145/105(114)} mmHg\\n RR: 29 (11 - 35) insp/min\\n SpO2: 95%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 959 mL\\n 1,250 mL\\n PO:\\n TF:\\n 176 mL\\n 140 mL\\n IVF:\\n 463 mL\\n 810 mL\\n Blood products:\\n Total out:\\n 1,980 mL\\n 130 mL\\n Urine:\\n 1,980 mL\\n 130 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,021 mL\\n 1,120 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: MMV/PSV/AutoFlow\\n Vt (Set): 500 (500 - 500) mL\\n Vt (Spontaneous): 408 (408 - 499) mL\\n PS : 10 cmH2O\\n RR (Set): 12\\n RR (Spontaneous): 26\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n RSBI: 149\\n PIP: 16 cmH2O\\n Plateau: 21 cmH2O\\n SpO2: 95%\\n ABG: ///36/\\n Ve: 6.4 L/min\\n Physical Examination\\n Gen: NAD, A0X3\\n HEENT: PERRLA, EOMI\\n Resp: Limited by patients mobility, but CTA anteriorly\\n Card: S1S2 tachy\\n Abd: Soft, Non-tender, Non-distended, BS+\\n Exte: No edema\\n Labs / Radiology\\n 452 K/uL\\n 8.9 g/dL\\n 104 mg/dL\\n 0.7 mg/dL\\n 36 mEq/L\\n 3.5 mEq/L\\n 6 mg/dL\\n 103 mEq/L\\n 145 mEq/L\\n 29.2 %\\n 7.1 K/uL\\n [image002.jpg]\\n 03:00 AM\\n 07:05 PM\\n 03:00 AM\\n 05:00 AM\\n 02:06 AM\\n 07:34 AM\\n 03:50 AM\\n 06:22 AM\\n 02:58 AM\\n 03:43 AM\\n WBC\\n 7.2\\n 5.2\\n 5.9\\n 7.5\\n 5.6\\n 6.1\\n 7.0\\n 7.1\\n 7.1\\n Hct\\n 26.9\\n 26.0\\n 27.2\\n 26.8\\n 27.0\\n 27.0\\n 29.7\\n 28.9\\n 29.2\\n Plt\\n 238\\n 240\\n 296\\n \\n 395\\n 462\\n 452\\n Cr\\n 0.9\\n 0.7\\n 0.6\\n 0.7\\n 0.6\\n 0.5\\n 0.7\\n 0.7\\n 0.6\\n 0.7\\n Glucose\\n 106\\n 100\\n 134\\n 134\\n 121\\n 619\\n 126\\n 137\\n 104\\n Other labs: PT / PTT / INR:66.1/32.7/8.0, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:9.3 mg/dL, Mg++:2.2 mg/dL, PO4:3.8\\n mg/dL\\n Assessment and Plan\\n 55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\\n trach, PEG, placement no with respiratory failure secondary to\\n tracheomalacia , resolving HAP.\\n .\\n # Respiratory failure: Slowly Improving. Pressure support of at\\n night.\\n - Continue to increase time on trach mask as tolerated.\\n - PMV with suctioning.\\n .\\n # HAP vs Aspiration PNA: Afebrile without leukocytosis\\n - Completed course of ceftriaxone\\n - Continue to f/u cultures\\n - Continue trach mask as tolerated\\n .\\n # Tachycardia: Sinus Tach with occasional runs of SVT, now on low dose\\n b-blocker. . HR decreased overnight with ranges of 115-135. From\\n yesterday when pt found had runs of SVT as well as ST 120\\ns to 150s.\\n SBPs approx 65.\\n Had Negative CTA, thyroid fxn WNL,\\n - HR became tachy on , will further investigate events surrounding\\n the event for further data\\n - cont metoprolol 12.5mg TID and up titrate as tolerated\\n - monitor on telemetry\\n - Continue Pain Control\\n .\\n # Sedation: Inconsistent response to sedation, unclear what is best\\n regime. Will continue to wean overall\\n - Started on Olanzapine QHS\\n - DC\\nd haldol and taper valium to 2.5 mg PRN TID, taper off\\n # Nutrition: Pt had emesis overnight. TFs currently held. Given\\n Reglan.\\n - Restart Nutrition as tolerated\\n .\\n # Adrenal Insufficency: Endocrine following. Followed Suggesting if\\n the patient under goes major stressors such as major surgery, sepsis,\\n she may need stress dosed steroids.\\n - Endocrine s/o\\n no need for steroids currently\\n .\\n # Fluid Status: Volume overloaded in prior setting of Hypernatremia\\n - Monitoring urine output\\n - increase Free H20, for mild hypernatremia 200cc Free bolus PEG, and\\n - 500cc D5W at 125.\\n - PM lytes to assess hypernatremia\\n .\\n # UE DVT: right has resolved, new non occlusive in left axillary. INR\\n supratherapeutic today\\n - decrease coumadin to home dose of 2.5mg\\n - follow INR\\n .\\n # Spine fracture: Stable\\n - Brace for OOB, will discuss with Neurosurgery if current brace is\\n optimal for stabilization given her mobility.\\n - Pt to follow up with Dr. in weeks\\n .\\n # Tracheomalacia. Was initially addressed with IP and they wanted to\\n follow up as outpatient.\\n - Consult IP for stent placement given improved clinical status, will\\n readdresses\\n .\\n #. Thyroid Nodule on CT\\n - Outpatient follow up\\n .\\n # Glycemic control: SSI, well controlled\\n # PIV x 1\\n # Ppx: Coumadin, Ranitidine, Bowel Regimen PRN\\n # Communication:\\n - Boyfriend of 10 \\n - Brother also involved\\n # Code: Full\\n # Dispo: ICU, Screening for vent facilities\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 12:38 PM 30 mL/hour\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:35 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-11 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 636842,\n \"text\": \"Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Received pt on trach collar 50%. Sats fell to 78%. Pt ambu\\nd and\\n lavaged with no plugs detected. RR 30-40 . Pt diaphoretic.\\n Action:\\n Placed on PSV 10/5/50%\\n Response:\\n Apneic with RR 3-5\\n Plan:\\n Rested on AC 500/12/5/50%. No further episodes of desating or\\n tachypnea.\\n Hypotension (not Shock)\\n Assessment:\\n BP falling to 78/37. Urine output 5-30ccs/hr via foley\\n Action:\\n Given 500ccs\\n NS fluid bolus\\n Response:\\n Pt normotensive, improved urine output\\n Plan:\\n Continue to monitor.\\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\\n Assessment:\\n Temp spike to 102.2 po\\n Action:\\n Blood, urine and sputum cxs sent. Sputum white, not yellow or\\n consistant with TF. Chest x-ray taken. Tylenol pr given. Cool cloths\\n applied.\\n Response:\\n Pt normothermic. WBC 7.2\\n Plan:\\n Monitor fever curve, cooling measures. Follow-up on cx results.\\n Alteration in Nutrition\\n Assessment:\\n Pt vomiting yellow fluid with coughing and when turned\\n Action:\\n TF held. Peg to gravity. Medicated with 4 mg zofran iv.\\n Response:\\n No further episodes of vomiting.\\n Plan:\\n Continue to monitor. Aspiration precautions. ? need for alternative\\n form of nutrition.\\n Altered mental status (not Delirium)\\n Assessment:\\n Onset of shift, pt lethargic, not following commands but MAE. ~ 12 mn\\n pt agitated, attempting to climb oob, disconnecting self from vent\\n despite restraints\\n Action:\\n 5 mg valium given q 8hrs. Haldol 2.5 mg given.\\n Response:\\n Pt still agitated\\n Plan:\\n Needs better sedation at bedtime - ? zyprexa or alternative med\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-11 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 636935,\n \"text\": \"56 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\\n with prolonged hospital course c/b by PNA, anxiety/altered mental\\n status, RUE DVT .\\n Altered mental status (not Delirium)\\n Assessment:\\n Rec\\nd pt very restless/agitated, repeatedly attempting to sit up in bed\\n and pulling at soft wrist restraints. When arms freed, she immediately\\n disconnected trach from vent. Agitation did not subside with verbal\\n reassurance or scheduled dose valium. Pt follows commands\\n inconsistently, has difficulty initiating cough on command. MAEE with\\n good strength. Not grimacing and denied pain by mouthing words.\\n Action:\\n Pt noted to have rash per below, nodded\\n to\\nDoes you back itch?\\n and rec\\nd Benadryl 25mg IV @ 1345.\\n Response:\\n Pt finally sleeping after having been awake most of night and very\\n restless all morning.\\n Plan:\\n Benadryl Q6hrs PRN. Cont freq mental/neuro eval.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Rec\\nd pt on AC vent settings 50%/12 X 500/+5.\\n Action:\\n Response:\\n Plan:\\n Tachycardia, Other\\n Assessment:\\n HR 130\\ns @ rest throughout shift, and still > 125 when pt soundly\\n sleeping. Pt Afebrile.\\n Action:\\n Response:\\n Plan:\\n Rash\\n Assessment:\\n Pt noted to have raised red rash evenly distributed over mid/lower\\n back. Pt has been very restless, and nodded\\n to\\nDoes your back\\n itch?\\n. No new meds recently.\\n Action:\\n Team made aware, and they examined rash. Pt rec\\nd Benadryl 25mg IV X 1.\\n Response:\\n Pt finally able to sleep after very restless night and morning.\\n Plan:\\n Benadryl PRN Q6hrs. ? Sarna lotion. Cont to monitor rash.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-19 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 638376,\n \"text\": \"Addendum:\\n Decreased urine ouput:\\n Urine ouput decreased to 20 -10 cc/hr. foley catheter flushed easily\\n and return clear. D 5 w increased to 125 cc/hr. urine ouput did not\\n pick up until after pt given lasix dose of 10 mg iv. Diuresed. 0600\\n urine ouput again decreased to 15 cc/hr\\n Plan: monitor urine ouput.. notify ho if uo continues < 30 cc/hr.\\n Altered rhythm: pt in a sinus tachycardia throughout the night, about\\n 6:05 this morning pt converted to a first degree avb. O0600 lopressor\\n dose held for sbp 86/\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-14 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 637419,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n UOP 10-20cc/hr, tachy to 150s while sitting upright, 120s at rest.\\n Pt on PMV but had heavy secretions. Trach collar for 5 hours.\\n Repeat Sputum Cx + for GNR, fungal, 1+ Gram + Cocci in Pairs.\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Vancomycin - 09:40 AM\\n Levofloxacin - 11:15 PM\\n Ceftriaxone - 07:50 PM\\n Infusions:\\n Other ICU medications:\\n Haloperidol (Haldol) - 10:26 AM\\n Diazepam (Valium) - 11:33 AM\\n Morphine Sulfate - 02:30 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:34 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.4\\nC (99.4\\n Tcurrent: 36.7\\nC (98.1\\n HR: 118 (118 - 148) bpm\\n BP: 90/37(48) {90/37(48) - 171/111(115)} mmHg\\n RR: 14 (12 - 36) insp/min\\n SpO2: 95%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 1,614 mL\\n 439 mL\\n PO:\\n TF:\\n 884 mL\\n 279 mL\\n IVF:\\n 100 mL\\n Blood products:\\n Total out:\\n 834 mL\\n 20 mL\\n Urine:\\n 834 mL\\n 20 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 780 mL\\n 419 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 354 (244 - 376) mL\\n PS : 10 cmH2O\\n RR (Spontaneous): 12\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n RSBI: 56\\n PIP: 15 cmH2O\\n SpO2: 95%\\n ABG: ////\\n Ve: 4.1 L/min\\n Physical Examination\\n General Appearance: No acute distress, Overweight / Obese\\n Eyes / Conjunctiva: PERRL, Pupils dilated\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\\n Present)\\n Respiratory / Chest: (Breath Sounds: Clear : )\\n Abdominal: Soft, Bowel sounds present, Obese, Patient with thoracic\\n brace on\\n Skin: Not assessed, No(t) Rash: , Per Nursing: Pt with vesicular rash\\n on inferior back.\\n Neurologic: Follows simple commands, Responds to: Not assessed,\\n Movement: Not assessed, Tone: Not assessed\\n Labs / Radiology\\n 240 K/uL\\n 7.9 g/dL\\n 100 mg/dL\\n 0.6 mg/dL\\n 30 mEq/L\\n 3.4 mEq/L\\n 12 mg/dL\\n 108 mEq/L\\n 146 mEq/L\\n 26.0 %\\n 5.2 K/uL\\n [image002.jpg]\\n 08:11 PM\\n 02:51 AM\\n 03:10 AM\\n 03:08 PM\\n 03:00 AM\\n 03:36 AM\\n 04:40 PM\\n 03:00 AM\\n 07:05 PM\\n 03:00 AM\\n WBC\\n 9.4\\n 11.3\\n 7.3\\n 6.1\\n 7.2\\n 5.2\\n Hct\\n 26.6\\n 24.9\\n 27.6\\n 26.5\\n 26.9\\n 26.0\\n Plt\\n \\n Cr\\n 0.9\\n 0.7\\n 0.6\\n 0.6\\n 0.9\\n 0.7\\n 0.6\\n TCO2\\n 29\\n 26\\n Glucose\\n 128\\n 114\\n 114\\n 99\\n 115\\n 106\\n 100\\n Other labs: PT / PTT / INR:17.6/27.4/1.6, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:33/22, Alk Phos / T Bili:143/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:0.5 mmol/L,\\n Albumin:3.5 g/dL, LDH:199 IU/L, Ca++:8.9 mg/dL, Mg++:2.4 mg/dL, PO4:4.1\\n mg/dL\\n Assessment and Plan\\n 55yoF with history of EtOH abuse presenting following mechanical fall\\n and traumatic T spine fracture, now s/p trach, PEG, placement being\\n treated for HAP.\\n# HAP vs Aspiration PNA: Cultures growing Klebsiella Oxytoca, Klebsiella Pneumon\\niae, GNR, GP Cocci. Pt received developed rash on Levofloxacin, switched to Ceft\\nriaxone overnight. Will treat for potential HAP for 8 days.\\n - Continue Ceftriaxone HAP (Day #6 of 8)\\n - Tube Feeds now at 50 with goal of 60/hr\\n - Following Cultures\\n .\\n # Respiratory failure: 5 hours on Trach mask yesterday, will assess\\n length of tolerance today.\\n - PMV with suctioning.\\n - Weaning FiO2 as tolerated\\n # Tachycardia: Pt in ST 120\\ns to 150s. Etiology remains unclear and\\n etiologies include hypovolemia, pain, infection (pt with known\\n klebsiella), . DDx also includes PE\\n - Treating underlying infection\\n - Bolus NS 500cc x 2 today and assess HR\\n - Restarting patients Coumadin\\n - TSH 2.4 on early , will check free T3, T4.\\n - Continue Pain Control\\n # Sedation: Pt has pain/delirium causing tachycardia and hypertension\\n with intermittent hypotension. Had good response to morphine, minimal\\n response to haldol bolus.\\n - Haldol 5 TID, Fentanyl 75 mcg TP, Diazapam 10 QID;\\n - Haldol, midazolam and morphine PRN.\\n - tolerating current regimen well\\n # Adrenal Insufficency: Followed up with endocrine that suggested if\\n the patient under goes major stressors such as major surgery, sepsis,\\n she may need stress dosed steroids.\\n - Will consider MRI at later date for evaluation of pituitary\\n # Fluid Status: Volume overloaded in prior setting of Hypernatremia\\n Goal even today.\\n - Monitoring urine output\\n # RUE DVT: INR was super-therapeutic on coumadin. Goal . Received 5\\n of coumadin overnight.\\n - Restarting Coumadin 2.5 mg QHS once INR < 3\\n # Spine fracture: Stable\\n - Brace for OOB, will discuss with Neurosurgery if current brace is\\n optimal for stabilization given her mobility.\\n - Pt to follow up with Dr. in weeks\\n # Tracheomalacia?: Discussed with IP.\\n - Outpatient f/u once off pressure support to assess for possible\\n stenting\\n #. Thyroid Nodule on CT\\n - Outpatient follow up\\n # Nutrition: TFs with goal of 60\\n # Glycemic control: SSI, well controlled\\n # Lines L PICC\\n ().\\n # Ppx: Restarting Coumadin, Ranitidine, Bowel Regimen\\n # Communication:\\n - Boyfriend of 10 \\n - Brother also involved\\n # Code: Full\\n # Dispo: ICU, Screening for vent facilities\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 11:38 AM 50 mL/hour\\n Glycemic Control:\\n Lines:\\n PICC Line - 09:19 PM\\n 20 Gauge - 04:59 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-15 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 637728,\n \"text\": \"Chief Complaint: resp failuire\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 24 Hour Events:\\n ULTRASOUND - At 03:48 PM\\n US of Lt arm shows small 1 cm axillary clot non occlusive near PICC\\n RUS US shows resolutyion of formal clot\\n Vomting tube feeds around trach\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Ceftriaxone - 10:00 PM\\n Infusions:\\n Other ICU medications:\\n Morphine Sulfate - 06:20 AM\\n Pantoprazole (Protonix) - 08:12 AM\\n Other medications:\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Gastrointestinal: Emesis\\n Flowsheet Data as of 10:59 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.5\\nC (99.5\\n Tcurrent: 36.2\\nC (97.1\\n HR: 146 (123 - 146) bpm\\n BP: 153/129(134) {106/41(56) - 185/129(142)} mmHg\\n RR: 26 (11 - 33) insp/min\\n SpO2: 96%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 1,888 mL\\n 520 mL\\n PO:\\n TF:\\n 1,268 mL\\n IVF:\\n 100 mL\\n Blood products:\\n Total out:\\n 1,530 mL\\n 845 mL\\n Urine:\\n 1,510 mL\\n 820 mL\\n NG:\\n 20 mL\\n 25 mL\\n Stool:\\n Drains:\\n Balance:\\n 358 mL\\n -325 mL\\n Respiratory support\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 227 (227 - 397) mL\\n PS : 8 cmH2O\\n RR (Spontaneous): 20\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n RSBI: 194\\n PIP: 16 cmH2O\\n SpO2: 96%\\n ABG: ///34/\\n Ve: 6.5 L/min\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 8.5 g/dL\\n 335 K/uL\\n 121 mg/dL\\n 0.5 mg/dL\\n 34 mEq/L\\n 3.8 mEq/L\\n 7 mg/dL\\n 107 mEq/L\\n 147 mEq/L\\n 27.0 %\\n 5.6 K/uL\\n [image002.jpg]\\n 03:08 PM\\n 03:00 AM\\n 03:36 AM\\n 04:40 PM\\n 03:00 AM\\n 07:05 PM\\n 03:00 AM\\n 05:00 AM\\n 02:06 AM\\n 07:34 AM\\n WBC\\n 7.3\\n 6.1\\n 7.2\\n 5.2\\n 5.9\\n 7.5\\n 5.6\\n Hct\\n 27.6\\n 26.5\\n 26.9\\n 26.0\\n 27.2\\n 26.8\\n 27.0\\n Plt\\n 189\\n 209\\n 238\\n \\n 335\\n Cr\\n 0.6\\n 0.6\\n 0.9\\n 0.7\\n 0.6\\n 0.7\\n 0.6\\n 0.5\\n TCO2\\n 26\\n Glucose\\n 99\\n 115\\n 106\\n 100\\n 134\\n 134\\n 121\\n Other labs: PT / PTT / INR:16.6/25.0/1.5, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:9.3 mg/dL, Mg++:2.3 mg/dL, PO4:4.1\\n mg/dL\\n Assessment and Plan\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n PICC Line - 09:19 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :ICU\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-18 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 638220,\n \"text\": \"56 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\\n with prolonged hospital course c/b by PNA, anxiety/altered mental\\n status, RUE DVT .Pt found to have small non occlusive Clot on her right\\n axial vein via Ultrasound.Yesterday Pt went down to IR for Peg revision\\n aspiration risk couldn\\nt do it due the type of peg she has now.\\n Altered mental status (not Delirium)\\n Assessment:\\n Restless, attempting to get OOB, kicking and hitting siderails,\\n attempting to sit up, attempting to grab at all lines and tubes, bilat\\n wrist restraints and waist belt on for pt\\ns safety, mouthing words and\\n following simple commands, slept soundly for 3-4 hours following\\n zyprexa and valium\\n Action:\\n Morphine 2 mg. IV x 2 with no effect, Zyprexa and valium at bedtime\\n with pt asleep for 3-4 hours, Valium 2.5 mg again this am with no\\n effect, When pt asleep s BP dips to 70-80\\ns---MICU team assessed and pt\\n received LR 500ml fluid bolus x 1, scheduled 2am valium dose held d/t\\n low BP, freq. reorientation and freq. safety checks\\n Response:\\n Good response with combination of zyprexa and valium, otherwise no sig.\\n improvement with other interventions\\n Plan:\\n Continue freq. safety checks and reorientation, INR level is 8 this am\\n and with pt a high fall risk pt will need to be a 1:1 if gets OOB to\\n chair today, continue valium and zyprexa, obtain psych consult to\\n assist with management of anxiety issues and for advice on other\\n medicines available that may help pt\\ns agitation.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Tachypneic but with good Sats on trach mask during eves, Tolerating\\n trach mask until received zyprexa and valium and then pt RR drive down\\n with apneic periods requiring rest on vent overnight, mod. Amts thick\\n secretions continue\\n Action:\\n Placed on MMV mode overnight, suctioned Q2-3 hours for thick\\n tan/bloodtinged sputum, CPT, trach care\\n Response:\\n Sats >95 % on vent overnight\\n Plan:\\n Wean back to trach mask this am, continue to rest on vent overnight as\\n needed, continue aggressive pulmonary toileting.\\n Hypernatremia (high sodium)\\n Assessment:\\n Na up to 150 during eves, low urine output, low BP when asleep\\n Action:\\n 500 ml of D5W over 4hours followed by 500 ml LR over 4 hours for both\\n high sodium and low urine output, Free water fluid boluses via PEG\\n increased to 150ml q 4hrs.\\n Response:\\n Sodium down to 145 this am, urine output increased from 10-15ml/hr to\\n 20-30ml/hr\\n Plan:\\n Continue free water via PEG, continue to monitor lytes QD.\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Good peripheral pulses bilat, no BP on upper extremities, on coumadin\\n Action:\\n Assessed for evidence of bleeding\\n Response:\\n No signs of bleeding noted, INR reported as 8.0 this am---MICU team\\n aware, Hct stable at 29.2 and platelets WNL\\n Plan:\\n Hold coumadin dose today and resend coags this evening, send clot to BB\\n at next blood draw, monitor for signs of bleeding\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-12 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 637005,\n \"text\": \"56 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\\n with prolonged hospital course c/b by PNA, anxiety/altered mental\\n status, RUE DVT .\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Received pt on PSV 10/5/50%. RR 20-30. )2 sat > 97%\\n Action:\\n Pt remained on PSV rather than AC overnight. Suctioned ~q 3-4 hrs for\\n sm amt yellow bld-tinged secretions. Continues to have copious oral\\n secretions\\n removed with yankeur.\\n Response:\\n Tolerated PSV well, no tachypnea or desaturation.\\n Plan:\\n Attempt trach collar trial again in am. On-going pulm hygiene\\n Hypotension (not Shock)\\n Assessment:\\n BP 90/40 with urine output falling to 10-15ccs/hr via foley. HR remains\\n tachycardic (110-140ST) even when pt is not agitated or febrile.\\n Action:\\n Given 1 500cc d5\\n ns fluid bolus\\n Response:\\n SBP > 90, Urine output improving to >30ccs/hr\\n Plan:\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt lethargic after receiving benedryl for several hrs but then awoke\\n agitated, attempting to climb OOB and pull at trach despite restraints.\\n Denies pain ( fentanyl patch in place) or need to go to the bathroom.\\n c/o itchiness on back\\n Action:\\n Medicated with iv benedryl.\\n Response:\\n Less agitated. Slept again\\n Plan:\\n Continue to reorient pt, benedryl for pruritis, safety precautions.\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2167-10-13 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 637241,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 25\\n Ideal body weight: 61.2 None\\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: Yes\\n Procedure location:\\n Reason:\\n Tube Type\\n ETT:\\n Position: cm at teeth\\n Route:\\n Type:\\n Size:\\n Tracheostomy tube:\\n Type: Cuffed\\n Manufacturer: Portex\\n Size: 7.0mm\\n PMV:\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 25 cmH2O\\n Cuff volume: mL /\\n Airway problems:\\n Comments:\\n Lung sounds\\n RLL Lung Sounds: Clear\\n RUL Lung Sounds: Bronchial\\n LUL Lung Sounds: Rhonchi\\n LLL Lung Sounds: Clear\\n Comments:\\n Secretions\\n Sputum color / consistency: Tan / Thick\\n Sputum source/amount: Suctioned / Moderate\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance: Continuous invasive ventilation\\n Visual assessment of breathing pattern: Normal quiet breathing\\n Assessment of breathing comfort: No response (sleeping / sedated)\\n Non-invasive ventilation assessment:\\n Invasive ventilation assessment:\\n Trigger work assessment: Triggering synchronously\\n Dysynchrony assessment:\\n Comments:\\n Plan\\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\\n Reason for continuing current ventilatory support: Underlying illness\\n not resolved\\n Respiratory Care Shift Procedures\\n Transports:\\n Destination (R/T)\\n Time\\n Complications\\n Comments\\n Bedside Procedures:\\n Comments:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-18 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 638221,\n \"text\": \"56 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\\n with prolonged hospital course c/b by PNA, anxiety/altered mental\\n status, RUE DVT .Pt found to have small non occlusive Clot on her right\\n axial vein via Ultrasound.Yesterday Pt went down to IR for Peg revision\\n aspiration risk couldn\\nt do it due the type of peg she has now.\\n Altered mental status (not Delirium)\\n Assessment:\\n Restless, attempting to get OOB, kicking and hitting siderails,\\n attempting to sit up, attempting to grab at all lines and tubes, bilat\\n wrist restraints and waist belt on for pt\\ns safety, mouthing words and\\n following simple commands, slept soundly for 3-4 hours following\\n zyprexa and valium\\n Action:\\n Morphine 2 mg. IV x 2 with no effect, Zyprexa and valium at bedtime\\n with pt asleep for 3-4 hours, Valium 2.5 mg again this am with no\\n effect, When pt asleep s BP dips to 70-80\\ns---MICU team assessed and pt\\n received LR 500ml fluid bolus x 1, scheduled 2am valium dose held d/t\\n low BP, freq. reorientation and freq. safety checks\\n Response:\\n Good response with combination of zyprexa and valium, otherwise no sig.\\n improvement with other interventions\\n Plan:\\n Continue freq. safety checks and reorientation, INR level is 8 this am\\n and with pt a high fall risk pt will need to be a 1:1 if gets OOB to\\n chair today, continue valium and zyprexa, obtain psych consult to\\n assist with management of anxiety issues and for advice on other\\n medicines available that may help pt\\ns agitation.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Tachypneic but with good Sats on trach mask during eves, Tolerating\\n trach mask until received zyprexa and valium and then pt RR drive down\\n with apneic periods requiring rest on vent overnight, mod. Amts thick\\n secretions continue\\n Action:\\n Placed on MMV mode overnight, suctioned Q2-3 hours for thick\\n tan/bloodtinged sputum, CPT, trach care\\n Response:\\n Sats >95 % on vent overnight\\n Plan:\\n Wean back to trach mask this am, continue to rest on vent overnight as\\n needed, continue aggressive pulmonary toileting.\\n Hypernatremia (high sodium)\\n Assessment:\\n Na up to 150 during eves, low urine output, low BP when asleep\\n Action:\\n 500 ml of D5W over 4hours followed by 500 ml LR over 4 hours for both\\n high sodium and low urine output, Free water fluid boluses via PEG\\n increased to 150ml q 4hrs.\\n Response:\\n Sodium down to 145 this am, urine output increased from 10-15ml/hr to\\n 20-30ml/hr\\n Plan:\\n Continue free water via PEG, continue to monitor lytes QD.\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Good peripheral pulses bilat, no BP on upper extremities, on coumadin\\n Action:\\n Assessed for evidence of bleeding\\n Response:\\n No signs of bleeding noted, INR reported as 8.0 this am---MICU team\\n aware, Hct stable at 29.2 and platelets WNL\\n Plan:\\n Hold coumadin dose today and resend coags this evening, send clot to BB\\n at next blood draw, monitor for signs of bleeding\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-18 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 638222,\n \"text\": \"56 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\\n with prolonged hospital course c/b by PNA, anxiety/altered mental\\n status, RUE DVT .Pt found to have small non occlusive Clot on her right\\n axial vein via Ultrasound.Yesterday Pt went down to IR for Peg revision\\n aspiration risk couldn\\nt do it due the type of peg she has now.\\n Altered mental status (not Delirium)\\n Assessment:\\n Restless, attempting to get OOB, kicking and hitting siderails,\\n attempting to sit up, attempting to grab at all lines and tubes, bilat\\n wrist restraints and waist belt on for pt\\ns safety, mouthing words and\\n following simple commands, slept soundly for 3-4 hours following\\n zyprexa and valium\\n Action:\\n Morphine 2 mg. IV x 2 with no effect, Zyprexa and valium at bedtime\\n with pt asleep for 3-4 hours, Valium 2.5 mg again this am with no\\n effect, When pt asleep s BP dips to 70-80\\ns---MICU team assessed and pt\\n received LR 500ml fluid bolus x 1, scheduled 2am valium dose held d/t\\n low BP, freq. reorientation and freq. safety checks\\n Response:\\n Good response with combination of zyprexa and valium, otherwise no sig.\\n improvement with other interventions\\n Plan:\\n Continue freq. safety checks and reorientation, INR level is 8 this am\\n and with pt a high fall risk pt will need to be a 1:1 if gets OOB to\\n chair today, continue valium and zyprexa, obtain psych consult to\\n assist with management of anxiety issues and for advice on other\\n medicines available that may help pt\\ns agitation.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Tachypneic but with good Sats on trach mask during eves, Tolerating\\n trach mask until received zyprexa and valium and then pt RR drive down\\n with apneic periods requiring rest on vent overnight, mod. Amts thick\\n secretions continue\\n Action:\\n Placed on MMV mode overnight, suctioned Q2-3 hours for thick\\n tan/bloodtinged sputum, CPT, trach care\\n Response:\\n Sats >95 % on vent overnight\\n Plan:\\n Wean back to trach mask this am, continue to rest on vent overnight as\\n needed, continue aggressive pulmonary toileting.\\n Hypernatremia (high sodium)\\n Assessment:\\n Na up to 150 during eves, low urine output, low BP when asleep\\n Action:\\n 500 ml of D5W over 4hours followed by 500 ml LR over 4 hours for both\\n high sodium and low urine output, Free water fluid boluses via PEG\\n increased to 150ml q 4hrs.\\n Response:\\n Sodium down to 145 this am, urine output increased from 10-15ml/hr to\\n 20-30ml/hr\\n Plan:\\n Continue free water via PEG, continue to monitor lytes QD.\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Good peripheral pulses bilat, no BP on upper extremities, on coumadin\\n Action:\\n Assessed for evidence of bleeding\\n Response:\\n No signs of bleeding noted, INR reported as 8.0 this am---MICU team\\n aware, Hct stable at 29.2 and platelets WNL\\n Plan:\\n Hold coumadin dose today and resend coags this evening, send clot to BB\\n at next blood draw, monitor for signs of bleeding\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-11 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 636932,\n \"text\": \"56 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\\n with prolonged hospital course c/b by PNA, anxiety/altered mental\\n status, RUE DVT .\\n Altered mental status (not Delirium)\\n Assessment:\\n Rec\\nd pt very restless/agitated, repeatedly attempting to sit up in bed\\n and pulling at soft wrist restraints. When arms freed, she immediately\\n disconnected trach from vent. Agitation did not subside with verbal\\n reassurance or scheduled dose valium. Pt follows commands\\n inconsistently, has difficulty initiating cough on command. MAEE with\\n good strength. Not grimacing and denied pain by mouthing words.\\n Action:\\n Pt noted to have rash per below, nodded\\n to\\nDoes you back itch?\\n and rec\\nd Benadryl 25mg IV @ 1345.\\n Response:\\n Pt finally sleeping after having been awake most of night and very\\n restless all morning.\\n Plan:\\n Benadryl Q6hrs PRN. Cont freq mental/neuro eval.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-11 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 636986,\n \"text\": \"56 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\\n with prolonged hospital course c/b by PNA, anxiety/altered mental\\n status, RUE DVT .\\n Altered mental status (not Delirium)\\n Assessment:\\n Rec\\nd pt very restless/agitated, repeatedly attempting to sit up in bed\\n and pulling at soft wrist restraints. When arms freed, she immediately\\n disconnected trach from vent. Agitation did not subside with verbal\\n reassurance or scheduled dose valium. Pt follows commands\\n inconsistently, has difficulty initiating cough on command. MAEE with\\n good strength. Not grimacing and denied pain by mouthing words.\\n Action:\\n Pt noted to have rash per below, nodded\\n to\\nDoes you back itch?\\n and rec\\nd Benadryl 25mg IV @ 1345.\\n Response:\\n Pt finally slept for 2hrs after having been awake most of night and\\n very restless all morning.\\n Plan:\\n Benadryl Q6hrs PRN. Cont freq mental/neuro eval.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Rec\\nd pt on AC vent settings 50%/12 X 500/+5 with SRR 17-20\\ns and\\n regular. O2 sat 96-100%. Lungs snds rhonchorous bilat, diminished in\\n bases. Pt with weak cough, raising mod amts thick white sputum but not\\n fully expectorating it from trach.\\n Action:\\n Pt placed on TM @ 70% @ 0900. Suctionned PRN for mod amts sputum.\\n Response:\\n O2 sat stable until pt soundly sleeping and de-sated to 80\\ns. TM inc\\n to 100% with return of O2 sat to high 90\\ns. However, when she woke @\\n 1600 RR inc\\nd and HR 140\\ns with pt becoming diaphoretic. Pt returned to\\n CPAP/PS 8/+5/50% @ 1800. HR presently in 120\\ns with pt appearing\\n comfortable.\\n Plan:\\n Cont to wean from vent as tolerated. Cont to encourage C&DB.\\n Tachycardia, Other\\n Assessment:\\n HR 130- without VEA @ rest throughout shift, and still > 125\\n when pt soundly sleeping. Pt Afebrile.\\n Action:\\n MD aware. After being on TM all day, pt returned to CPAP/PS @ 1800.\\n Response:\\n HR presently in 120\\ns with pt looking comfortable.\\n Plan:\\n ? pt dry->monitor I/O\\ns. Cont emotional support.\\n Rash\\n Assessment:\\n Pt noted to have raised red rash evenly distributed over mid/lower\\n back. Pt has been very restless, and nodded\\n to\\nDoes your back\\n itch?\\n. No new meds recently.\\n Action:\\n Team made aware, and they examined rash. Pt rec\\nd Benadryl 25mg IV X 1.\\n Levofloxacin D/C\\n Response:\\n Pt finally able to sleep after very restless night and morning. HR\\n 130\\ns->125ST. O2 sat \\nd to 80\\ns with RR inc\\nd to high 20\\ns and\\n shallow.\\n Plan:\\n Benadryl PRN Q6hrs. ? Sarna lotion. Cont to monitor rash.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-12 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 637175,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Developed papular rash over entire back, bilaterally in multidermatomal\\n distributions, opaque vesicles on erythematous base, non-painful,\\n possibly pruritic\\n Levofloxacin d/c'd\\n Ceftriaxone Initiated for pan-sensitive\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Aztreonam - 03:42 AM\\n Vancomycin - 09:40 AM\\n Levofloxacin - 11:15 PM\\n Ceftriaxone - 07:50 PM\\n Infusions:\\n Other ICU medications:\\n Haloperidol (Haldol) - 10:26 AM\\n Diazepam (Valium) - 11:33 AM\\n Morphine Sulfate - 02:30 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Ear, Nose, Throat: Dry mouth\\n Cardiovascular: No(t) Chest pain\\n Respiratory: No(t) Tachypnea\\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea\\n Flowsheet Data as of 05:15 PM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.4\\nC (99.4\\n Tcurrent: 37.1\\nC (98.7\\n HR: 129 (113 - 148) bpm\\n BP: 100/45(57) {85/40(50) - 171/111(115)} mmHg\\n RR: 21 (9 - 36) insp/min\\n SpO2: 93%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 1,362 mL\\n 1,102 mL\\n PO:\\n TF:\\n 47 mL\\n 532 mL\\n IVF:\\n 1,061 mL\\n 100 mL\\n Blood products:\\n Total out:\\n 1,203 mL\\n 755 mL\\n Urine:\\n 1,203 mL\\n 755 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 159 mL\\n 347 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask\\n Ventilator mode: Standby\\n Vt (Set): 0 (0 - 0) mL\\n Vt (Spontaneous): 244 (110 - 504) mL\\n PS : 10 cmH2O\\n RR (Set): 0\\n RR (Spontaneous): 19\\n PEEP: 5 cmH2O\\n FiO2: 70%\\n RSBI: 245\\n PIP: 16 cmH2O\\n SpO2: 93%\\n ABG: ///30/\\n Ve: 10 L/min\\n Physical Examination\\n General Appearance: No acute distress, Overweight / Obese\\n Eyes / Conjunctiva: PERRL, Pupils dilated\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\\n Present)\\n Respiratory / Chest: (Breath Sounds: Clear : )\\n Abdominal: Soft, Bowel sounds present, Obese, Patient with thoracic\\n brace on\\n Skin: Not assessed, No(t) Rash: , Per Nursing: Pt with vesicular rash\\n on inferior back.\\n Neurologic: Follows simple commands, Responds to: Not assessed,\\n Movement: Not assessed, Tone: Not assessed\\n Labs / Radiology\\n 240 K/uL\\n 7.9 g/dL\\n 100 mg/dL\\n 0.6 mg/dL\\n 30 mEq/L\\n 3.4 mEq/L\\n 12 mg/dL\\n 108 mEq/L\\n 146 mEq/L\\n 26.0 %\\n 5.2 K/uL\\n [image002.jpg]\\n 08:11 PM\\n 02:51 AM\\n 03:10 AM\\n 03:08 PM\\n 03:00 AM\\n 03:36 AM\\n 04:40 PM\\n 03:00 AM\\n 07:05 PM\\n 03:00 AM\\n WBC\\n 9.4\\n 11.3\\n 7.3\\n 6.1\\n 7.2\\n 5.2\\n Hct\\n 26.6\\n 24.9\\n 27.6\\n 26.5\\n 26.9\\n 26.0\\n Plt\\n \\n Cr\\n 0.9\\n 0.7\\n 0.6\\n 0.6\\n 0.9\\n 0.7\\n 0.6\\n TCO2\\n 29\\n 26\\n Glucose\\n 128\\n 114\\n 114\\n 99\\n 115\\n 106\\n 100\\n Other labs: PT / PTT / INR:17.6/27.4/1.6, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:33/22, Alk Phos / T Bili:143/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:0.5 mmol/L,\\n Albumin:3.5 g/dL, LDH:199 IU/L, Ca++:8.9 mg/dL, Mg++:2.4 mg/dL, PO4:4.1\\n mg/dL\\n Assessment and Plan\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 11:38 AM 50 mL/hour\\n Glycemic Control:\\n Lines:\\n PICC Line - 09:19 PM\\n 20 Gauge - 04:59 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-12 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 637177,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Developed papular rash over entire back, bilaterally in multidermatomal\\n distributions, opaque vesicles on erythematous base, non-painful,\\n possibly pruritic\\n Levofloxacin d/c'd\\n Ceftriaxone Initiated for pan-sensitive\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Aztreonam - 03:42 AM\\n Vancomycin - 09:40 AM\\n Levofloxacin - 11:15 PM\\n Ceftriaxone - 07:50 PM\\n Infusions:\\n Other ICU medications:\\n Haloperidol (Haldol) - 10:26 AM\\n Diazepam (Valium) - 11:33 AM\\n Morphine Sulfate - 02:30 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Ear, Nose, Throat: Dry mouth\\n Cardiovascular: No(t) Chest pain\\n Respiratory: No(t) Tachypnea\\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea\\n Flowsheet Data as of 05:15 PM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.4\\nC (99.4\\n Tcurrent: 37.1\\nC (98.7\\n HR: 129 (113 - 148) bpm\\n BP: 100/45(57) {85/40(50) - 171/111(115)} mmHg\\n RR: 21 (9 - 36) insp/min\\n SpO2: 93%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 1,362 mL\\n 1,102 mL\\n PO:\\n TF:\\n 47 mL\\n 532 mL\\n IVF:\\n 1,061 mL\\n 100 mL\\n Blood products:\\n Total out:\\n 1,203 mL\\n 755 mL\\n Urine:\\n 1,203 mL\\n 755 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 159 mL\\n 347 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask\\n Ventilator mode: Standby\\n Vt (Set): 0 (0 - 0) mL\\n Vt (Spontaneous): 244 (110 - 504) mL\\n PS : 10 cmH2O\\n RR (Set): 0\\n RR (Spontaneous): 19\\n PEEP: 5 cmH2O\\n FiO2: 70%\\n RSBI: 245\\n PIP: 16 cmH2O\\n SpO2: 93%\\n ABG: ///30/\\n Ve: 10 L/min\\n Physical Examination\\n General Appearance: No acute distress, Overweight / Obese\\n Eyes / Conjunctiva: PERRL, Pupils dilated\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\\n Present)\\n Respiratory / Chest: (Breath Sounds: Clear : )\\n Abdominal: Soft, Bowel sounds present, Obese, Patient with thoracic\\n brace on\\n Skin: Not assessed, No(t) Rash: , Per Nursing: Pt with vesicular rash\\n on inferior back.\\n Neurologic: Follows simple commands, Responds to: Not assessed,\\n Movement: Not assessed, Tone: Not assessed\\n Labs / Radiology\\n 240 K/uL\\n 7.9 g/dL\\n 100 mg/dL\\n 0.6 mg/dL\\n 30 mEq/L\\n 3.4 mEq/L\\n 12 mg/dL\\n 108 mEq/L\\n 146 mEq/L\\n 26.0 %\\n 5.2 K/uL\\n [image002.jpg]\\n 08:11 PM\\n 02:51 AM\\n 03:10 AM\\n 03:08 PM\\n 03:00 AM\\n 03:36 AM\\n 04:40 PM\\n 03:00 AM\\n 07:05 PM\\n 03:00 AM\\n WBC\\n 9.4\\n 11.3\\n 7.3\\n 6.1\\n 7.2\\n 5.2\\n Hct\\n 26.6\\n 24.9\\n 27.6\\n 26.5\\n 26.9\\n 26.0\\n Plt\\n \\n Cr\\n 0.9\\n 0.7\\n 0.6\\n 0.6\\n 0.9\\n 0.7\\n 0.6\\n TCO2\\n 29\\n 26\\n Glucose\\n 128\\n 114\\n 114\\n 99\\n 115\\n 106\\n 100\\n Other labs: PT / PTT / INR:17.6/27.4/1.6, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:33/22, Alk Phos / T Bili:143/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:0.5 mmol/L,\\n Albumin:3.5 g/dL, LDH:199 IU/L, Ca++:8.9 mg/dL, Mg++:2.4 mg/dL, PO4:4.1\\n mg/dL\\n Assessment and Plan\\n 55yoF with history of EtOH abuse presenting following mechanical fall\\n and traumatic T spine fracture with K. oxytoca PNA, and ARDS, intubated\\n since the end of now s/p trach and PEG placement.\\n# Recent Aspiration on Tube Feeds. Cultures growing Klebsiella Oxytoca and Klebs\\niella Pneumoniae. Pt received developed rash on Levofloxacin, switched to Ceftri\\naxone overnight. Will treat for potential HAP for 8 days.\\n - Continue Ceftriaxone day #1.\\n - Tube Feeds restarted with goal of 60/hr\\n - Follow cultures\\n - check tube placement\\n .\\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\\n volume overload. Intubated on for resp decompensation. S/P Trach\\n and PEG on .\\n - Weaning FiO2 as tolerated\\n - Will attempt trach collar today\\n # Sedation: Pt has pain/delirium causing tachycardia and hypertension\\n with intermittent hypotension. On Haldol 5 TID, Fentanyl 75 mcg TP,\\n Diazapam 10 QID; Haldol, midazolam and morphine PRN. Had good response\\n to morphine, minimal response to haldol bolus.\\n - tolerating current regimen well, no changes today\\n # Adrenal Insufficency: Hypotension that resolved with steroids,\\n returned as they came off and is now improved again. Possible primary\\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\\n started on .\\n - stopped steroids as per endocrine today\\n # Volume overloaded in prior setting of hypernatremia\\n Goal even\\n today.\\n - monitor urine output\\n # RUE DVT: INR was super-therapeutic on coumadin. Goal . Hasn\\n received coumadin in days yet INR continues to rise. Likely\\n contributors are nutritional and antibiotics.\\n - will start coumadin 2.5 mg QHS once INR < 3\\n # Spine fracture: Neurologically intact distal to the lesion. Prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - Brace for OOB\\n - Report from full trauma series from OSH is in chart.\\n - No evidence of other fracture and no need for further spinal imaging\\n based on this report and ortho note.\\n # Tracheomalacia: Discussed with IP. Stenting unlikely to help for\\n trachiomalacia as airways have poor structure diffusely.\\n - Outpatient f/u once off pressure support to assess for possible\\n stenting\\n #. Thyroid Nodule on CT\\n - Outpatient follow up\\n # Nutrition: Replete (Full)\\n hold\\n # Glycemic control: SSI, well controlled\\n # Lines L PICC\\n ().\\n # Ppx: INR remains therapeutic, ranitidine, colace and senna, miralax,\\n bisacodyl.\\n # Communication:\\n - Boyfriend of 10 \\n - Brother also involved\\n Code: Full\\n Dispo: ICU, being screening for vent facilities\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 11:38 AM 50 mL/hour\\n Glycemic Control:\\n Lines:\\n PICC Line - 09:19 PM\\n 20 Gauge - 04:59 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-12 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 637179,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Developed papular rash over entire back, bilaterally in multidermatomal\\n distributions, opaque vesicles on erythematous base, non-painful,\\n possibly pruritic\\n Levofloxacin d/c'd\\n Ceftriaxone Initiated for pan-sensitive\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Aztreonam - 03:42 AM\\n Vancomycin - 09:40 AM\\n Levofloxacin - 11:15 PM\\n Ceftriaxone - 07:50 PM\\n Infusions:\\n Other ICU medications:\\n Haloperidol (Haldol) - 10:26 AM\\n Diazepam (Valium) - 11:33 AM\\n Morphine Sulfate - 02:30 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Ear, Nose, Throat: Dry mouth\\n Cardiovascular: No(t) Chest pain\\n Respiratory: No(t) Tachypnea\\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea\\n Flowsheet Data as of 05:15 PM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.4\\nC (99.4\\n Tcurrent: 37.1\\nC (98.7\\n HR: 129 (113 - 148) bpm\\n BP: 100/45(57) {85/40(50) - 171/111(115)} mmHg\\n RR: 21 (9 - 36) insp/min\\n SpO2: 93%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 1,362 mL\\n 1,102 mL\\n PO:\\n TF:\\n 47 mL\\n 532 mL\\n IVF:\\n 1,061 mL\\n 100 mL\\n Blood products:\\n Total out:\\n 1,203 mL\\n 755 mL\\n Urine:\\n 1,203 mL\\n 755 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 159 mL\\n 347 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask\\n Ventilator mode: Standby\\n Vt (Set): 0 (0 - 0) mL\\n Vt (Spontaneous): 244 (110 - 504) mL\\n PS : 10 cmH2O\\n RR (Set): 0\\n RR (Spontaneous): 19\\n PEEP: 5 cmH2O\\n FiO2: 70%\\n RSBI: 245\\n PIP: 16 cmH2O\\n SpO2: 93%\\n ABG: ///30/\\n Ve: 10 L/min\\n Physical Examination\\n General Appearance: No acute distress, Overweight / Obese\\n Eyes / Conjunctiva: PERRL, Pupils dilated\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\\n Present)\\n Respiratory / Chest: (Breath Sounds: Clear : )\\n Abdominal: Soft, Bowel sounds present, Obese, Patient with thoracic\\n brace on\\n Skin: Not assessed, No(t) Rash: , Per Nursing: Pt with vesicular rash\\n on inferior back.\\n Neurologic: Follows simple commands, Responds to: Not assessed,\\n Movement: Not assessed, Tone: Not assessed\\n Labs / Radiology\\n 240 K/uL\\n 7.9 g/dL\\n 100 mg/dL\\n 0.6 mg/dL\\n 30 mEq/L\\n 3.4 mEq/L\\n 12 mg/dL\\n 108 mEq/L\\n 146 mEq/L\\n 26.0 %\\n 5.2 K/uL\\n [image002.jpg]\\n 08:11 PM\\n 02:51 AM\\n 03:10 AM\\n 03:08 PM\\n 03:00 AM\\n 03:36 AM\\n 04:40 PM\\n 03:00 AM\\n 07:05 PM\\n 03:00 AM\\n WBC\\n 9.4\\n 11.3\\n 7.3\\n 6.1\\n 7.2\\n 5.2\\n Hct\\n 26.6\\n 24.9\\n 27.6\\n 26.5\\n 26.9\\n 26.0\\n Plt\\n \\n Cr\\n 0.9\\n 0.7\\n 0.6\\n 0.6\\n 0.9\\n 0.7\\n 0.6\\n TCO2\\n 29\\n 26\\n Glucose\\n 128\\n 114\\n 114\\n 99\\n 115\\n 106\\n 100\\n Other labs: PT / PTT / INR:17.6/27.4/1.6, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:33/22, Alk Phos / T Bili:143/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:0.5 mmol/L,\\n Albumin:3.5 g/dL, LDH:199 IU/L, Ca++:8.9 mg/dL, Mg++:2.4 mg/dL, PO4:4.1\\n mg/dL\\n Assessment and Plan\\n 55yoF with history of EtOH abuse presenting following mechanical fall\\n and traumatic T spine fracture with K. oxytoca PNA, and ARDS, intubated\\n since the end of now s/p trach and PEG placement.\\n# Recent Aspiration on Tube Feeds. Cultures growing Klebsiella Oxytoca and Klebs\\niella Pneumoniae. Pt received developed rash on Levofloxacin, switched to Ceftri\\naxone overnight. Will treat for potential HAP for 8 days.\\n - Continue Ceftriaxone day #1.\\n - Tube Feeds restarted with goal of 60/hr\\n - Follow cultures\\n - check tube placement\\n .\\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\\n volume overload. Intubated on for resp decompensation. S/P Trach\\n and PEG on .\\n - Weaning FiO2 as tolerated\\n - Will attempt trach collar today\\n # Tachycardia: Pt in ST for most of the day 120\\ns to 140s. Etiology\\n remains unclear although she has been tachy since admission. Etiologies\\n include pain (especially when sitting upright with thoracic brace on),\\n infection (pt with known klebsiella, possibly acquired HAP). DDx also\\n includes PE, hyperthyroidism.\\n - Will keep pt\\ns INR therapeutic\\n - TSH 2.4 on early , will check free T3, T4.\\n - Continue Pain Control\\n - Treat underlying infection\\n # Sedation: Pt has pain/delirium causing tachycardia and hypertension\\n with intermittent hypotension. On Haldol 5 TID, Fentanyl 75 mcg TP,\\n Diazapam 10 QID; Haldol, midazolam and morphine PRN. Had good response\\n to morphine, minimal response to haldol bolus.\\n - tolerating current regimen well, no changes today\\n # Adrenal Insufficency: Hypotension that resolved with steroids,\\n returned as they came off and is now improved again. Possible primary\\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\\n started on .\\n - stopped steroids as per endocrine today\\n # Volume overloaded in prior setting of hypernatremia\\n Goal even\\n today.\\n - Monitoring urine output\\n # RUE DVT: INR was super-therapeutic on coumadin. Goal . Hasn\\n received coumadin in days yet INR continues to rise. Likely\\n contributors are nutritional and antibiotics.\\n - will start coumadin 2.5 mg QHS once INR < 3\\n # Spine fracture: Neurologically intact distal to the lesion. Prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - Brace for OOB\\n - Report from full trauma series from OSH is in chart.\\n - Pt to follow up with Dr. in weeks\\n # Tracheomalacia: Discussed with IP. Stenting unlikely to help for\\n trachiomalacia as airways have poor structure diffusely.\\n - Outpatient f/u once off pressure support to assess for possible\\n stenting\\n #. Thyroid Nodule on CT\\n - Outpatient follow up\\n # Nutrition: Replete (Full)\\n hold\\n # Glycemic control: SSI, well controlled\\n # Lines L PICC\\n ().\\n # Ppx: INR remains therapeutic, ranitidine, colace and senna, miralax,\\n bisacodyl.\\n # Communication:\\n - Boyfriend of 10 \\n - Brother also involved\\n Code: Full\\n Dispo: ICU, being screening for vent facilities\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 11:38 AM 50 mL/hour\\n Glycemic Control:\\n Lines:\\n PICC Line - 09:19 PM\\n 20 Gauge - 04:59 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2167-10-14 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 637595,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 26\\n Ideal body weight: 61.2 None\\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: Yes\\n Procedure location:\\n Reason:\\n Tube Type\\n ETT:\\n Position: cm at teeth\\n Route:\\n Type:\\n Size:\\n Tracheostomy tube:\\n Type: Standard\\n Manufacturer: Portex\\n Size: 7.0mm\\n PMV:\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 25 cmH2O\\n Cuff volume: mL /\\n Airway problems:\\n Comments:\\n Lung sounds\\n RLL Lung Sounds: Clear\\n RUL Lung Sounds: Rhonchi\\n LUL Lung Sounds: Rhonchi\\n LLL Lung Sounds: Clear\\n Comments:\\n Secretions\\n Sputum color / consistency: Yellow / Thick\\n Sputum source/amount: Suctioned / Small\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance: Continuous invasive ventilation\\n Visual assessment of breathing pattern: Normal quiet breathing\\n Assessment of breathing comfort: No claim of dyspnea)\\n Non-invasive ventilation assessment:\\n Invasive ventilation assessment:\\n Trigger work assessment: Triggering synchronously\\n Dysynchrony assessment:\\n Comments:\\n Plan\\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\\n Periodic SBT's for conditioning\\n Reason for continuing current ventilatory support: Intolerant of\\n weaning attempts, Cannot manage secretions\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-12 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 637047,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Developed papular rash over entire back, bilateraly, in multiple\\n dermatomal distributions, opaque vesicles on erythematous base,\\n nonpainful, possibly pruritic.\\n Levofloxaxin was d/c'd.\\n Ceftriaxone started.\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Aztreonam - 03:42 AM\\n Vancomycin - 09:40 AM\\n Levofloxacin - 11:15 PM\\n Ceftriaxone - 07:50 PM\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:14 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:28 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.2\\nC (98.9\\n Tcurrent: 37.2\\nC (98.9\\n HR: 139 (113 - 145) bpm\\n BP: 97/61(68) {85/28(50) - 127/86(90)} mmHg\\n RR: 12 (9 - 30) insp/min\\n SpO2: 100%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 1,362 mL\\n 302 mL\\n PO:\\n TF:\\n 47 mL\\n 152 mL\\n IVF:\\n 1,061 mL\\n 100 mL\\n Blood products:\\n Total out:\\n 1,203 mL\\n 460 mL\\n Urine:\\n 1,203 mL\\n 460 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 159 mL\\n -158 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: CPAP/PSV\\n Vt (Set): 0 (0 - 0) mL\\n Vt (Spontaneous): 504 (110 - 504) mL\\n PS : 10 cmH2O\\n RR (Set): 0\\n RR (Spontaneous): 14\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n RSBI: 245\\n PIP: 16 cmH2O\\n SpO2: 100%\\n ABG: ///30/\\n Ve: 5.9 L/min\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 240 K/uL\\n 7.9 g/dL\\n 100 mg/dL\\n 0.6 mg/dL\\n 30 mEq/L\\n 3.4 mEq/L\\n 12 mg/dL\\n 108 mEq/L\\n 146 mEq/L\\n 26.0 %\\n 5.2 K/uL\\n [image002.jpg]\\n 08:11 PM\\n 02:51 AM\\n 03:10 AM\\n 03:08 PM\\n 03:00 AM\\n 03:36 AM\\n 04:40 PM\\n 03:00 AM\\n 07:05 PM\\n 03:00 AM\\n WBC\\n 9.4\\n 11.3\\n 7.3\\n 6.1\\n 7.2\\n 5.2\\n Hct\\n 26.6\\n 24.9\\n 27.6\\n 26.5\\n 26.9\\n 26.0\\n Plt\\n \\n Cr\\n 0.9\\n 0.7\\n 0.6\\n 0.6\\n 0.9\\n 0.7\\n 0.6\\n TCO2\\n 29\\n 26\\n Glucose\\n 128\\n 114\\n 114\\n 99\\n 115\\n 106\\n 100\\n Other labs: PT / PTT / INR:17.6/27.4/1.6, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:33/22, Alk Phos / T Bili:143/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:0.5 mmol/L,\\n Albumin:3.5 g/dL, LDH:199 IU/L, Ca++:8.9 mg/dL, Mg++:2.4 mg/dL, PO4:4.1\\n mg/dL\\n Assessment and Plan\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 03:36 AM 30 mL/hour\\n Glycemic Control:\\n Lines:\\n PICC Line - 09:19 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2167-10-13 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 637399,\n \"text\": \"TITLE:\\n Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 25\\n Ideal body weight: 61.2 None\\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: Yes\\n Procedure location:\\n Reason:\\n Tube Type\\n ETT:\\n Position: cm at teeth\\n Route:\\n Type: Not applicable\\n Size: Not applicable\\n Tracheostomy tube:\\n Type: Cuffed\\n Manufacturer: Portex\\n Size: 7.0mm\\n PMV:\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 25 cmH2O\\n Cuff volume: mL /\\n Airway problems:\\n Comments:\\n Lung sounds\\n RLL Lung Sounds: Clear\\n RUL Lung Sounds: Rhonchi\\n LUL Lung Sounds: Rhonchi\\n LLL Lung Sounds: Clear\\n Comments:\\n Secretions\\n Sputum color / consistency: Tan / Thick\\n Sputum source/amount: Suctioned / Small\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance: Intermittent invasive ventilation\\n Visual assessment of breathing pattern: Normal quiet breathing\\n Assessment of breathing comfort: No claim of dyspnea)\\n Non-invasive ventilation assessment:\\n Invasive ventilation assessment:\\n Trigger work assessment: Triggering synchronously\\n Dysynchrony assessment:\\n Comments:\\n Plan\\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\\n Reason for continuing current ventilatory support: weaning daily to\\n trach collar as tolerated\\n Respiratory Care Shift Procedures\\n Transports:\\n Destination (R/T)\\n Time\\n Complications\\n Comments\\n Bedside Procedures:\\n Comments:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-13 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 637402,\n \"text\": \"Tachycardia, Other\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Alteration in Nutrition\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-13 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 637407,\n \"text\": \"56 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\\n with prolonged hospital course c/b by PNA, anxiety/altered mental\\n status, RUE DVT .\\n Tachycardia, Other\\n Assessment:\\n Pt\\ns HR was 120\\ns this am when asleep. When she woke up her HR went to\\n 140\\ns. When she was placed in the chair her HR increased to 150\\n Her U/O was marginal at 5-10cc/hr. Her B/P 110/70\\ns when in bed to\\n 160-180/80 when in the chair.\\n Action:\\n She was given 2 boluses of 500cc NS.\\n Response:\\n The fluid boluses had no effect on her HR at all. Her U/O increased to\\n 35-40cc/hr\\n Plan:\\n Continue to monitor her HR, B/P and U/O.\\n Alteration in Nutrition\\n Assessment:\\n Tube feeding had been stopped for high residuals.\\n Action:\\n She was restarted at 8am back at 50cc/hr.\\n Response:\\n She tolerated the tube feeding with 10 cc residuals, and she had a very\\n large stool.\\n Plan:\\n Continue to monitor TF residuals.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt\\ns resp status stable, with RR 18-24 and O2 sats 95-97%.\\n Action:\\n She was placed in a chair at 10am and then put on the trach collar at\\n 10:30.\\n Response:\\n She tolerated being up in the chair for 8hours and she is still on the\\n trach collar\\n Plan:\\n Place back on PSV 8/5 for the night.\\n Pt has been accepted at rehab. They were awaiting insurance\\n approval and could have gone today but will probably go tomorrow.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-13 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 637412,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n UOP 10-20cc/hr, tachy to 150s while sitting upright, 120s at rest.\\n Pt on PMV but had heavy secretions. Trach collar for 5 hours.\\n Repeat Sputum Cx + for GNR, fungal, 1+ Gram + Cocci in Pairs.\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Vancomycin - 09:40 AM\\n Levofloxacin - 11:15 PM\\n Ceftriaxone - 07:50 PM\\n Infusions:\\n Other ICU medications:\\n Haloperidol (Haldol) - 10:26 AM\\n Diazepam (Valium) - 11:33 AM\\n Morphine Sulfate - 02:30 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:34 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.4\\nC (99.4\\n Tcurrent: 36.7\\nC (98.1\\n HR: 118 (118 - 148) bpm\\n BP: 90/37(48) {90/37(48) - 171/111(115)} mmHg\\n RR: 14 (12 - 36) insp/min\\n SpO2: 95%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 1,614 mL\\n 439 mL\\n PO:\\n TF:\\n 884 mL\\n 279 mL\\n IVF:\\n 100 mL\\n Blood products:\\n Total out:\\n 834 mL\\n 20 mL\\n Urine:\\n 834 mL\\n 20 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 780 mL\\n 419 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 354 (244 - 376) mL\\n PS : 10 cmH2O\\n RR (Spontaneous): 12\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n RSBI: 56\\n PIP: 15 cmH2O\\n SpO2: 95%\\n ABG: ////\\n Ve: 4.1 L/min\\n Physical Examination\\n General Appearance: No acute distress, Overweight / Obese\\n Eyes / Conjunctiva: PERRL, Pupils dilated\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\\n Present)\\n Respiratory / Chest: (Breath Sounds: Clear : )\\n Abdominal: Soft, Bowel sounds present, Obese, Patient with thoracic\\n brace on\\n Skin: Not assessed, No(t) Rash: , Per Nursing: Pt with vesicular rash\\n on inferior back.\\n Neurologic: Follows simple commands, Responds to: Not assessed,\\n Movement: Not assessed, Tone: Not assessed\\n Labs / Radiology\\n 240 K/uL\\n 7.9 g/dL\\n 100 mg/dL\\n 0.6 mg/dL\\n 30 mEq/L\\n 3.4 mEq/L\\n 12 mg/dL\\n 108 mEq/L\\n 146 mEq/L\\n 26.0 %\\n 5.2 K/uL\\n [image002.jpg]\\n 08:11 PM\\n 02:51 AM\\n 03:10 AM\\n 03:08 PM\\n 03:00 AM\\n 03:36 AM\\n 04:40 PM\\n 03:00 AM\\n 07:05 PM\\n 03:00 AM\\n WBC\\n 9.4\\n 11.3\\n 7.3\\n 6.1\\n 7.2\\n 5.2\\n Hct\\n 26.6\\n 24.9\\n 27.6\\n 26.5\\n 26.9\\n 26.0\\n Plt\\n \\n Cr\\n 0.9\\n 0.7\\n 0.6\\n 0.6\\n 0.9\\n 0.7\\n 0.6\\n TCO2\\n 29\\n 26\\n Glucose\\n 128\\n 114\\n 114\\n 99\\n 115\\n 106\\n 100\\n Other labs: PT / PTT / INR:17.6/27.4/1.6, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:33/22, Alk Phos / T Bili:143/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:0.5 mmol/L,\\n Albumin:3.5 g/dL, LDH:199 IU/L, Ca++:8.9 mg/dL, Mg++:2.4 mg/dL, PO4:4.1\\n mg/dL\\n Assessment and Plan\\n 55yoF with history of EtOH abuse presenting following mechanical fall\\n and traumatic T spine fracture with K. oxytoca PNA, and ARDS, intubated\\n since the end of now s/p trach and PEG placement.\\n# Recent Aspiration on Tube Feeds. Cultures growing Klebsiella Oxytoca and Klebs\\niella Pneumoniae. Pt received developed rash on Levofloxacin, switched to Ceftri\\naxone overnight. Will treat for potential HAP for 8 days.\\n - Continue Ceftriaxone day #1.\\n - Tube Feeds restarted with goal of 60/hr\\n - Follow cultures\\n - check tube placement\\n .\\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\\n volume overload. Intubated on for resp decompensation. S/P Trach\\n and PEG on .\\n - Weaning FiO2 as tolerated\\n - Will attempt trach collar today\\n # Tachycardia: Pt in ST for most of the day 120\\ns to 140s. Etiology\\n remains unclear although she has been tachy since admission. Etiologies\\n include pain (especially when sitting upright with thoracic brace on),\\n infection (pt with known klebsiella, possibly acquired HAP). DDx also\\n includes PE, hyperthyroidism.\\n - Will keep pt\\ns INR therapeutic\\n - TSH 2.4 on early , will check free T3, T4.\\n - Continue Pain Control\\n - Treat underlying infection\\n # Sedation: Pt has pain/delirium causing tachycardia and hypertension\\n with intermittent hypotension. On Haldol 5 TID, Fentanyl 75 mcg TP,\\n Diazapam 10 QID; Haldol, midazolam and morphine PRN. Had good response\\n to morphine, minimal response to haldol bolus.\\n - tolerating current regimen well, no changes today\\n # Adrenal Insufficency: Hypotension that resolved with steroids,\\n returned as they came off and is now improved again. Possible primary\\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\\n started on .\\n - stopped steroids as per endocrine today\\n # Volume overloaded in prior setting of hypernatremia\\n Goal even\\n today.\\n - Monitoring urine output\\n # RUE DVT: INR was super-therapeutic on coumadin. Goal . Hasn\\n received coumadin in days yet INR continues to rise. Likely\\n contributors are nutritional and antibiotics.\\n - will start coumadin 2.5 mg QHS once INR < 3\\n # Spine fracture: Neurologically intact distal to the lesion. Prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - Brace for OOB\\n - Report from full trauma series from OSH is in chart.\\n - Pt to follow up with Dr. in weeks\\n # Tracheomalacia: Discussed with IP. Stenting unlikely to help for\\n trachiomalacia as airways have poor structure diffusely.\\n - Outpatient f/u once off pressure support to assess for possible\\n stenting\\n #. Thyroid Nodule on CT\\n - Outpatient follow up\\n # Nutrition: Replete (Full)\\n hold\\n # Glycemic control: SSI, well controlled\\n # Lines L PICC\\n ().\\n # Ppx: INR remains therapeutic, ranitidine, colace and senna, miralax,\\n bisacodyl.\\n # Communication:\\n - Boyfriend of 10 \\n - Brother also involved\\n Code: Full\\n Dispo: ICU, being screening for vent facilities\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 11:38 AM 50 mL/hour\\n Glycemic Control:\\n Lines:\\n PICC Line - 09:19 PM\\n 20 Gauge - 04:59 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 10:31 PM 50 mL/hour\\n Glycemic Control:\\n Lines:\\n PICC Line - 09:19 PM\\n 20 Gauge - 04:59 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-13 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 637413,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n UOP 10-20cc/hr, tachy to 150s while sitting upright, 120s at rest.\\n Pt on PMV but had heavy secretions. Trach collar for 5 hours.\\n Repeat Sputum Cx + for GNR, fungal, 1+ Gram + Cocci in Pairs.\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Vancomycin - 09:40 AM\\n Levofloxacin - 11:15 PM\\n Ceftriaxone - 07:50 PM\\n Infusions:\\n Other ICU medications:\\n Haloperidol (Haldol) - 10:26 AM\\n Diazepam (Valium) - 11:33 AM\\n Morphine Sulfate - 02:30 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:34 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.4\\nC (99.4\\n Tcurrent: 36.7\\nC (98.1\\n HR: 118 (118 - 148) bpm\\n BP: 90/37(48) {90/37(48) - 171/111(115)} mmHg\\n RR: 14 (12 - 36) insp/min\\n SpO2: 95%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 1,614 mL\\n 439 mL\\n PO:\\n TF:\\n 884 mL\\n 279 mL\\n IVF:\\n 100 mL\\n Blood products:\\n Total out:\\n 834 mL\\n 20 mL\\n Urine:\\n 834 mL\\n 20 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 780 mL\\n 419 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 354 (244 - 376) mL\\n PS : 10 cmH2O\\n RR (Spontaneous): 12\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n RSBI: 56\\n PIP: 15 cmH2O\\n SpO2: 95%\\n ABG: ////\\n Ve: 4.1 L/min\\n Physical Examination\\n General Appearance: No acute distress, Overweight / Obese\\n Eyes / Conjunctiva: PERRL, Pupils dilated\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\\n Present)\\n Respiratory / Chest: (Breath Sounds: Clear : )\\n Abdominal: Soft, Bowel sounds present, Obese, Patient with thoracic\\n brace on\\n Skin: Not assessed, No(t) Rash: , Per Nursing: Pt with vesicular rash\\n on inferior back.\\n Neurologic: Follows simple commands, Responds to: Not assessed,\\n Movement: Not assessed, Tone: Not assessed\\n Labs / Radiology\\n 240 K/uL\\n 7.9 g/dL\\n 100 mg/dL\\n 0.6 mg/dL\\n 30 mEq/L\\n 3.4 mEq/L\\n 12 mg/dL\\n 108 mEq/L\\n 146 mEq/L\\n 26.0 %\\n 5.2 K/uL\\n [image002.jpg]\\n 08:11 PM\\n 02:51 AM\\n 03:10 AM\\n 03:08 PM\\n 03:00 AM\\n 03:36 AM\\n 04:40 PM\\n 03:00 AM\\n 07:05 PM\\n 03:00 AM\\n WBC\\n 9.4\\n 11.3\\n 7.3\\n 6.1\\n 7.2\\n 5.2\\n Hct\\n 26.6\\n 24.9\\n 27.6\\n 26.5\\n 26.9\\n 26.0\\n Plt\\n \\n Cr\\n 0.9\\n 0.7\\n 0.6\\n 0.6\\n 0.9\\n 0.7\\n 0.6\\n TCO2\\n 29\\n 26\\n Glucose\\n 128\\n 114\\n 114\\n 99\\n 115\\n 106\\n 100\\n Other labs: PT / PTT / INR:17.6/27.4/1.6, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:33/22, Alk Phos / T Bili:143/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:0.5 mmol/L,\\n Albumin:3.5 g/dL, LDH:199 IU/L, Ca++:8.9 mg/dL, Mg++:2.4 mg/dL, PO4:4.1\\n mg/dL\\n Assessment and Plan\\n 55yoF with history of EtOH abuse presenting following mechanical fall\\n and traumatic T spine fracture, now s/p trach, PEG, placement being\\n treated for HAP.\\n# HAP vs Aspiration PNA: Cultures growing Klebsiella Oxytoca, Klebsiella Pneumon\\niae, GNR, GP Cocci. Pt received developed rash on Levofloxacin, switched to Ceft\\nriaxone overnight. Will treat for potential HAP for 8 days.\\n - Continue Ceftriaxone HAP (Day #6 of 8)\\n - Tube Feeds now at 50 with goal of 60/hr\\n - Following Cultures\\n .\\n # Respiratory failure: 5 hours on Trach mask yesterday, will assess\\n length of tolerance today.\\n - PMV with suctioning.\\n - Weaning FiO2 as tolerated\\n # Tachycardia: Pt in ST 120\\ns to 150s. Etiology remains unclear and\\n etiologies include hypovolemia, pain, infection (pt with known\\n klebsiella), . DDx also includes PE\\n - Treating underlying infection\\n - Bolus NS 500cc x 2 today and assess HR\\n - Restarting patients Coumadin\\n - TSH 2.4 on early , will check free T3, T4.\\n - Continue Pain Control\\n # Sedation: Pt has pain/delirium causing tachycardia and hypertension\\n with intermittent hypotension. Had good response to morphine, minimal\\n response to haldol bolus.\\n - Haldol 5 TID, Fentanyl 75 mcg TP, Diazapam 10 QID;\\n - Haldol, midazolam and morphine PRN.\\n - tolerating current regimen well\\n # Adrenal Insufficency: Followed up with endocrine that suggested if\\n the patient under goes major stressors such as major surgery, sepsis,\\n she may need stress dosed steroids.\\n - Will consider MRI at later date for evaluation of pituitary\\n # Fluid Status: Volume overloaded in prior setting of Hypernatremia\\n Goal even today.\\n - Monitoring urine output\\n # RUE DVT: INR was super-therapeutic on coumadin. Goal . Received 5\\n of coumadin overnight.\\n - Restarting Coumadin 2.5 mg QHS once INR < 3\\n # Spine fracture: Stable\\n - Brace for OOB, will discuss with Neurosurgery if current brace is\\n optimal for stabilization given her mobility.\\n - Pt to follow up with Dr. in weeks\\n # Tracheomalacia?: Discussed with IP.\\n - Outpatient f/u once off pressure support to assess for possible\\n stenting\\n #. Thyroid Nodule on CT\\n - Outpatient follow up\\n # Nutrition: TFs with goal of 60\\n # Glycemic control: SSI, well controlled\\n # Lines L PICC\\n ().\\n # Ppx: Restarting Coumadin, Ranitidine, Bowel Regimen\\n # Communication:\\n - Boyfriend of 10 \\n - Brother also involved\\n # Code: Full\\n # Dispo: ICU, Screening for vent facilities\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 11:38 AM 50 mL/hour\\n Glycemic Control:\\n Lines:\\n PICC Line - 09:19 PM\\n 20 Gauge - 04:59 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-15 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 637626,\n \"text\": \"Tachycardia, Other\\n Assessment:\\n Continues to be Tachycardia in 120-145 (anxiety). SBP has been 100-145\\n without ectopy.\\n Action:\\n No medication given for tachycardia.Pt gets Valium 5 mg scheduled Q6H\\n with little effect. CTA done to r/o pe as a source of tachycardia.\\n Response:\\n Results pending on CTA.\\n Plan:\\n Continue to evaluate HR and BP for need of treatment.\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Pt has a known DVT to RUE. Today pt had a US of LUEand ruled out small\\n non occlusive clot on her left axial vein.\\n Action:\\n Dr ,pt received ceftriaxone via PICC line.Coumadin dosage\\n increased from 2.5 to 5 mg ( INR 1.4).\\n Response:\\n Repeat ultrasound orderd for right arm . Pt received 5 mg coumadin at\\n 2200.\\n Plan:\\n Ultrasound today,cont coumadin and closely monitor INR.\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt has been restless most of the night. Pt nodded her head for pain and\\n simple yes or no questions.\\n Action:\\n Pt given scheduled Valium with little effect.\\n Response:\\n Pt slept for a while,Hr dropped to 120s at the time of rest.\\n Plan:\\n Continue to eval MS,Valium and Prn Morphine and haldol?.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt rested on CPAP+ PS 50%/,sats stayed upper 90\\ns,Pt found to have\\n TF coming aroundTracheostomy\\n Action:\\n Cont pulm toilet as needed. Pt in need of freq oral care.\\n Response:\\n Plan:\\n Continue to wean pt off vent and place on TC once pt can tol it again.\\n\"\n },\n {\n \"category\": \"Rehab Services\",\n \"chartdate\": \"2167-10-16 00:00:00.000\",\n \"description\": \"Physical Therapy Evaluation Note\",\n \"row_id\": 637950,\n \"text\": \"Attending Physician:\\n date: \\n Medical Diagnosis / ICD 9: / e888.9\\n Reason of : eval and tx\\n History of Present Illness / Subjective Complaint: 55 y/o female with\\n h/o obesity admitted to OSH in on after falling down\\n stairs at home. She suffered traumatic T8 fx, course was complicated by\\n respiratory failure requiring intubation. Respiratory failure was felt\\n to be hypoventilation from pain meds. She was transferred to \\n on for further intervention after CT chest showed narrowing of\\n her central airways. She was evaluated for airway stenting. Course was\\n complicated by VAP and became septic. Pt is s/p trach/PEG on . Pt\\n has had continues tachycardia and developed B UE DVTs.\\n Past Medical / Surgical History: GERD, s/p TAH, s/p appendectomy,\\n remote benign breast mass , L THA\\n Medications:\\n Radiology: Mildly improved left lower lobe opacities. Likely improving\\n atelectasis. There is a small left pleural effusion. Small right\\n pleural effusion and right lower lobe atelectasis are unchanged.\\n Labs:\\n 29.7\\n 9.0\\n 395\\n 7.0\\n [image002.jpg]\\n Other labs:\\n Activity Orders:\\n Social / Occupational History: Unable to obtain history from pt due to\\n mental status per chart pt lives with boyfriend\\n Environment:\\n Prior Functional Status / Activity Level: Assume pt was I PTA\\n Objective Test\\n Arousal / Attention / Cognition / Communication: Pt alert, poor\\n attention, pt agitated pulling at brace and trach. Pt was able to\\n follow 90% of 1 step commands with frequent cues and re-direction. Pt\\n nodding \\\"yes no\\\" inappropriately to questions. Pt impulsive, trying to\\n crawl over bedrails.\\n Hemodynamic Response\\n Aerobic Capacity\\n HR\\n BP\\n RR\\n O[2 ]sat\\n HR\\n BP\\n RR\\n O[2] sat\\n RPE\\n Supine\\n 140-150\\n 117/85\\n 98% TM\\n Rest\\n /\\n Sit\\n 130-155\\n 110/80\\n 98%TM\\n Activity\\n /\\n Stand\\n /\\n Recovery\\n /\\n Total distance walked:\\n Minutes:\\n Pulmonary Status: Strong cough productive of thick yellow sputum\\n Integumentary / Vascular: Trach, Peg, foley, , pt has breakdown on\\n her chin\\n Sensory Integrity: withdraws to pain x 4\\n Pain / Limiting Symptoms: Pt appears uncomfortable in bracing, pulling\\n at cervical extension\\n Posture: unremarkable\\n Range of Motion\\n Muscle Performance\\n B UE and LE \\n Pt moving all extremities against gravity\\n Motor Function: Purposeful movement patterns\\n Functional Status:\\n Activity\\n Clarification\\n I\\n S\\n CG\\n Min\\n Mod\\n Max\\n Gait, Locomotion: Transfer: Pt was able to scoot from bed to stretcher\\n chair with Min A\\n Rolling:\\n\\n\\n\\n T\\n\\n\\n Supine /\\n Sidelying to Sit:\\n\\n\\n T\\n\\n\\n Transfer:\\n\\n\\n\\n\\n\\n Sit to Stand:\\n\\n\\n\\n\\n\\n Ambulation:\\n\\n\\n\\n\\n\\n Stairs:\\n\\n\\n\\n\\n\\n Balance: Fair sitting balance at EOB. Deferred standing due to pts MS\\n Education / Communication: Pt status discussed with RN, MDs. Talked to\\n Dr. regarding pts current brace. She agrees that a cervical\\n extension is not needed. Neops was called and are planning to come\\n assess brace today and either remove cervical extension or make a new\\n TLSO.\\n Intervention:\\n Other:\\n Diagnosis:\\n 1.\\n Airway Clearance, Impaired\\n 2.\\n Arousal, Attention, and Cognition, Impaired\\n 3.\\n Balance, Impaired\\n 4.\\n Knowledge, Impaired\\n 5.\\n Respiration / Gas Exchange, Impaired\\n Clinical impression / Prognosis: 55 yo f s/p fall with resultant T8 fx\\n and hospital course c/b prolonged intubation, resp failure, and\\n tachycardia. Pt is functioning well below baseline, most significantly\\n limited by mental status. Feel with new brace, increased time OOB, pts\\n pulmonary status should improve. Pts mental status maybe related to\\n prolonged ICU stay or medications, if it does not improve may also\\n benefit from further w/u given h/o trauma. Pts mobility is good and\\n anticipates she will rapidly progress with continued PT in rehab\\n setting.\\n Goals\\n Time frame: 1 wk\\n 1.\\n follow all 1 step commands\\n 2.\\n sit at EOB I'ly > 10 mins\\n 3.\\n tolerate PMV during treatment and maintain SaO2> 95% on 35% TM\\n 4.\\n transfer goals to follow\\n 5.\\n 6.\\n Anticipated Discharge: Rehab\\n Treatment Plan:\\n Frequency / Duration: 3-5x/wk\\n f/u balance, cognitive training. Progress to transfer training and\\n ambulation as appropriate.\\n T Patient agrees with the above goals and is willing to participate in\\n the rehabilitation program.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-16 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 637951,\n \"text\": \"Chief Complaint: resp failuire\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 24 Hour Events:\\n ULTRASOUND - At 03:48 PM\\n US of Lt arm shows small 1 cm axillary clot non occlusive near PICC\\n RUS US shows resolution of formal clot\\n Vomiting tube feeds around trach\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Ceftriaxone - 10:00 PM\\n Infusions:\\n Other ICU medications:\\n Morphine Sulfate - 06:20 AM\\n Pantoprazole (Protonix) - 08:12 AM\\n Other medications:\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Gastrointestinal: Emesis\\n Flowsheet Data as of 10:59 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.5\\nC (99.5\\n Tcurrent: 36.2\\nC (97.1\\n HR: 146 (123 - 146) bpm\\n BP: 153/129(134) {106/41(56) - 185/129(142)} mmHg\\n RR: 26 (11 - 33) insp/min\\n SpO2: 96%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 1,888 mL\\n 520 mL\\n PO:\\n TF:\\n 1,268 mL\\n IVF:\\n 100 mL\\n Blood products:\\n Total out:\\n 1,530 mL\\n 845 mL\\n Urine:\\n 1,510 mL\\n 820 mL\\n NG:\\n 20 mL\\n 25 mL\\n Stool:\\n Drains:\\n Balance:\\n 358 mL\\n -325 mL\\n Respiratory support\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 227 (227 - 397) mL\\n PS : 8 cmH2O\\n RR (Spontaneous): 20\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n RSBI: 194\\n PIP: 16 cmH2O\\n SpO2: 96%\\n ABG: ///34/\\n Ve: 6.5 L/min\\n Physical Examination\\n Gen: up in bed, alert, follows simples commands\\n Tachy regular\\n Fair air movement ant\\n No edema\\n Labs / Radiology\\n 8.5 g/dL\\n 335 K/uL\\n 121 mg/dL\\n 0.5 mg/dL\\n 34 mEq/L\\n 3.8 mEq/L\\n 7 mg/dL\\n 107 mEq/L\\n 147 mEq/L\\n 27.0 %\\n 5.6 K/uL\\n [image002.jpg]\\n 03:08 PM\\n 03:00 AM\\n 03:36 AM\\n 04:40 PM\\n 03:00 AM\\n 07:05 PM\\n 03:00 AM\\n 05:00 AM\\n 02:06 AM\\n 07:34 AM\\n WBC\\n 7.3\\n 6.1\\n 7.2\\n 5.2\\n 5.9\\n 7.5\\n 5.6\\n Hct\\n 27.6\\n 26.5\\n 26.9\\n 26.0\\n 27.2\\n 26.8\\n 27.0\\n Plt\\n 189\\n 209\\n 238\\n \\n 335\\n Cr\\n 0.6\\n 0.6\\n 0.9\\n 0.7\\n 0.6\\n 0.7\\n 0.6\\n 0.5\\n TCO2\\n 26\\n Glucose\\n 99\\n 115\\n 106\\n 100\\n 134\\n 134\\n 121\\n Other labs: PT / PTT / INR:16.6/25.0/1.5, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:9.3 mg/dL, Mg++:2.3 mg/dL, PO4:4.1\\n mg/dL\\n Assessment and Plan\\n 55 yr old alcoholic s/p t spine fx s/p trcah and PEG with persistent\\n resp failure\\n 1. Resp Failure: currently on trach mask, can do a few hours per\\n day, then needs for support. New pan Klebs in sputum, day\\n . Try more vent support and see if it helps her.\\n 2. Fevers: did not persist- cultures neg to date.\\n 3 Hemodynamics: persistant simus tachy\\n CTPA to look for emboli\\n negative for proximal clot. IOs the of trach mask and her TB\\n malacia too much for her. We will see what happens if we out her on\\n 15-20 and 5.\\n 4. New L Ext DVT\\n 5. Emesis: call IR and get g pushed to a j tube\\n ICU Care\\n Nutrition: tfs held for vomiting\\n Glycemic Control:\\n Lines:\\n PICC Line - 09:19 PM\\n Prophylaxis:\\n DVT: coumadin\\n Stress ulcer: ppi\\n Communication: try to reach boyfriend\\n status: Full code\\n Disposition :ICU\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-16 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 637952,\n \"text\": \"Chief Complaint: resp failure\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 24 Hour Events:\\n ULTRASOUND - At 08:11 AM\\n right arm\\n PICC LINE - STOP 12:02 PM\\n PEG INSERTION - At 05:33 PM\\n placed PEG which\\n cannot be advanced by IR. TSurg by and felt needs to fail Reglan first\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Ceftriaxone - 10:00 PM\\n Infusions:\\n Other ICU medications:\\n Morphine Sulfate - 12:00 PM\\n Haloperidol (Haldol) - 02:00 PM\\n Diazepam (Valium) - 03:52 PM\\n Furosemide (Lasix) - 06:40 AM\\n Other medications:\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 09:09 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.9\\nC (98.4\\n Tcurrent: 36.8\\nC (98.3\\n HR: 137 (97 - 146) bpm\\n BP: 153/66(87) {93/43(55) - 183/129(134)} mmHg\\n RR: 18 (13 - 33) insp/min\\n SpO2: 95%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 1,220 mL\\n 807 mL\\n PO:\\n TF:\\n IVF:\\n 500 mL\\n 807 mL\\n Blood products:\\n Total out:\\n 1,514 mL\\n 150 mL\\n Urine:\\n 1,439 mL\\n 150 mL\\n NG:\\n 75 mL\\n Stool:\\n Drains:\\n Balance:\\n -294 mL\\n 657 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask , Tracheostomy tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 384 (311 - 675) mL\\n PS : 10 cmH2O\\n RR (Spontaneous): 12\\n PEEP: 5 cmH2O\\n FiO2: 70%\\n RSBI: 52\\n PIP: 15 cmH2O\\n SpO2: 95%\\n ABG: ///35/\\n Ve: 4.6 L/min\\n Physical Examination\\n Gen: sitting up in bed, answers simples questions\\n CV: tachy RR\\n Chest: good air moevemtn but long exp time and bibasilar rales\\n Abd: soft NT + BS PEG CDI\\n Ext: no edema\\n Neuro: attentive, mouths answers to words, moving all ext\\n Labs / Radiology\\n 9.0 g/dL\\n 395 K/uL\\n 126 mg/dL\\n 0.7 mg/dL\\n 35 mEq/L\\n 4.0 mEq/L\\n 7 mg/dL\\n 102 mEq/L\\n 144 mEq/L\\n 29.7 %\\n 7.0 K/uL\\n [image002.jpg]\\n 03:36 AM\\n 04:40 PM\\n 03:00 AM\\n 07:05 PM\\n 03:00 AM\\n 05:00 AM\\n 02:06 AM\\n 07:34 AM\\n 03:50 AM\\n 06:22 AM\\n WBC\\n 7.2\\n 5.2\\n 5.9\\n 7.5\\n 5.6\\n 6.1\\n 7.0\\n Hct\\n 26.9\\n 26.0\\n 27.2\\n 26.8\\n 27.0\\n 27.0\\n 29.7\\n Plt\\n 238\\n 240\\n 296\\n \\n 395\\n Cr\\n 0.6\\n 0.9\\n 0.7\\n 0.6\\n 0.7\\n 0.6\\n 0.5\\n 0.7\\n 0.7\\n TCO2\\n 26\\n Glucose\\n 115\\n 106\\n 100\\n 134\\n 134\\n 121\\n 619\\n 126\\n Other labs: PT / PTT / INR:24.2/27.7/2.4, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:9.5 mg/dL, Mg++:2.1 mg/dL, PO4:4.2\\n mg/dL\\n Assessment and Plan 55 yr old alcoholic s/p t spine fx s/p trcah and\\n PEG with persistent resp failure\\n 1. Resp Failure: currently on trach mask, can do sevreal hours per\\n day and increasing each day, then needs for support QHS. Completed\\n Rx for pan Klebs PNA. Per IP not stent planned as technically\\n not possible to place into her airway\\n 2. Hemodynamics: persistant simus tachy but also has runs of SVT-\\n will add low dose bblocker today\\n watch MAPs at night as\\n she tends to run low. Anticoagulated.\\n 3. New L Ext DVT: PICC out, on coumadin\\n 4. Emesis: start Reglan, watch qt and restart low dose tf tonight-\\n discuss with TSurg role of J prior to hospital d/c\\n ICU Care\\n Nutrition: restart TFs\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:26 PM\\n Prophylaxis:\\n DVT: couadin\\n Stress ulcer: PPI\\n Communication: trying to reach boyfriend\\n status: Full code\\n Disposition :screening for rehab\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2167-10-16 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 638002,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 28\\n Ideal body weight: 61.2 None\\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: Yes\\n Procedure location:\\n Reason:\\n Tube Type\\n ETT:\\n Position: cm at teeth\\n Route:\\n Type:\\n Size:\\n Tracheostomy tube:\\n Type:\\n Manufacturer: Portex\\n Size:\\n PMV:\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 25 cmH2O\\n Cuff volume: mL /\\n Airway problems:\\n Comments:\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Rhonchi\\n LUL Lung Sounds: Rhonchi\\n LLL Lung Sounds: Diminished\\n Comments:\\n Secretions\\n Sputum color / consistency: White / Thick\\n Sputum source/amount: Suctioned / Copious\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance: Unassisted spontaneous breathing\\n Visual assessment of breathing pattern: Normal quiet breathing\\n Assessment of breathing comfort: No response (sleeping / sedated)\\n Non-invasive ventilation assessment:\\n Invasive ventilation assessment:\\n Trigger work assessment:\\n Dysynchrony assessment:\\n Comments:\\n Plan\\n Next 24-48 hours: Increase ventilatory support at night\\n Reason for continuing current ventilatory support: Underlying illness\\n not resolved\\n Respiratory Care Shift Procedures\\n Transports:\\n Destination (R/T)\\n Time\\n Complications\\n Comments\\n Bedside Procedures:\\n Comments:\\n Maintained on Trach Collar all day. Plan to stay as tolerated\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-19 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 638347,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n 8pm: Vomited tube feeds while receiving free water flushes. Suctioned\\n by RT and no apparent aspiration, only blood tinged sputum. O2 sats\\n 99-100%. No increased O2 requirement. Held TF, given free water via IV\\n 100 cc/hr x 1L since Na 148. Will need to reassess in am, CXR ordered\\n for am.\\n Thoracics recs: place dophoff post pyloric or have GI place pedi GT\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Diazepam (Valium) - 12:00 AM\\n Furosemide (Lasix) - 01:30 AM\\n Morphine Sulfate - 02:00 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:21 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.4\\nC (99.3\\n Tcurrent: 36.8\\nC (98.3\\n HR: 113 (81 - 137) bpm\\n BP: 78/45(52) {78/39(50) - 130/73(108)} mmHg\\n RR: 12 (12 - 32) insp/min\\n SpO2: 97%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 3,165 mL\\n 700 mL\\n PO:\\n TF:\\n 691 mL\\n IVF:\\n 1,574 mL\\n 700 mL\\n Blood products:\\n Total out:\\n 1,670 mL\\n 680 mL\\n Urine:\\n 1,470 mL\\n 680 mL\\n NG:\\n 200 mL\\n Stool:\\n Drains:\\n Balance:\\n 1,495 mL\\n 20 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: MMV/PSV/AutoFlow\\n Vt (Set): 500 (500 - 500) mL\\n Vt (Spontaneous): 94 (94 - 450) mL\\n PS : 10 cmH2O\\n RR (Set): 12\\n RR (Spontaneous): 7\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n RSBI Deferred: No Spon Resp\\n PIP: 25 cmH2O\\n SpO2: 97%\\n ABG: ///38/\\n Ve: 5.1 L/min\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 467 K/uL\\n 8.6 g/dL\\n 131 mg/dL\\n 0.7 mg/dL\\n 38 mEq/L\\n 3.4 mEq/L\\n 8 mg/dL\\n 101 mEq/L\\n 145 mEq/L\\n 27.8 %\\n 6.9 K/uL\\n [image002.jpg]\\n 03:00 AM\\n 05:00 AM\\n 02:06 AM\\n 07:34 AM\\n 03:50 AM\\n 06:22 AM\\n 02:58 AM\\n 03:43 AM\\n 05:02 PM\\n 03:36 AM\\n WBC\\n 5.2\\n 5.9\\n 7.5\\n 5.6\\n 6.1\\n 7.0\\n 7.1\\n 7.1\\n 6.9\\n Hct\\n 26.0\\n 27.2\\n 26.8\\n 27.0\\n 27.0\\n 29.7\\n 28.9\\n 29.2\\n 27.8\\n Plt\\n 35\\n 52\\n 467\\n Cr\\n 0.6\\n 0.7\\n 0.6\\n 0.5\\n 0.7\\n 0.7\\n 0.6\\n 0.7\\n 0.8\\n 0.7\\n Glucose\\n 100\\n 134\\n 134\\n 121\\n 04\\n 108\\n 131\\n Other labs: PT / PTT / INR:66.1/32.7/8.0, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:9.4 mg/dL, Mg++:2.3 mg/dL, PO4:4.2\\n mg/dL\\n Assessment and Plan\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-19 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 638348,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n 8pm: Vomited tube feeds while receiving free water flushes. Suctioned\\n by RT and no apparent aspiration, only blood tinged sputum. O2 sats\\n 99-100%. No increased O2 requirement. Held TF, given free water via IV\\n 100 cc/hr x 1L since Na 148. Will need to reassess in am, CXR ordered\\n for am.\\n Thoracics recs: place dophoff post pyloric or have GI place pedi GT\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Diazepam (Valium) - 12:00 AM\\n Furosemide (Lasix) - 01:30 AM\\n Morphine Sulfate - 02:00 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:21 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.4\\nC (99.3\\n Tcurrent: 36.8\\nC (98.3\\n HR: 113 (81 - 137) bpm\\n BP: 78/45(52) {78/39(50) - 130/73(108)} mmHg\\n RR: 12 (12 - 32) insp/min\\n SpO2: 97%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 3,165 mL\\n 700 mL\\n PO:\\n TF:\\n 691 mL\\n IVF:\\n 1,574 mL\\n 700 mL\\n Blood products:\\n Total out:\\n 1,670 mL\\n 680 mL\\n Urine:\\n 1,470 mL\\n 680 mL\\n NG:\\n 200 mL\\n Stool:\\n Drains:\\n Balance:\\n 1,495 mL\\n 20 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: MMV/PSV/AutoFlow\\n Vt (Set): 500 (500 - 500) mL\\n Vt (Spontaneous): 94 (94 - 450) mL\\n PS : 10 cmH2O\\n RR (Set): 12\\n RR (Spontaneous): 7\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n RSBI Deferred: No Spon Resp\\n PIP: 25 cmH2O\\n SpO2: 97%\\n ABG: ///38/\\n Ve: 5.1 L/min\\n Physical Examination\\n Gen: NAD, difficult to assess orientation as patient is nonverbal on\\n trach mask, but she appeared alert, and resonded appropriately to\\n questions and followed commands.\\n HEENT: PERRLA, EOMI, OP w/o erythema.\\n Resp: Limited by patients mobility, but CTA anteriorly and laterally\\n Card: S1S2 tachicardic, no m/r/g\\n Abd: Soft, Non-tender, Non-distended, BS+\\n Exte: No edema, DP 2+, RP2+ bil.\\n NEURO: CN II\\nXII grossly intact. Strength 4/5 upper and lower\\n bilaterally. Reflexes 2+ bilaterally, 3+ at L patellar tendon, with\\n mild adductor crossover\\n Labs / Radiology\\n 467 K/uL\\n 8.6 g/dL\\n 131 mg/dL\\n 0.7 mg/dL\\n 38 mEq/L\\n 3.4 mEq/L\\n 8 mg/dL\\n 101 mEq/L\\n 145 mEq/L\\n 27.8 %\\n 6.9 K/uL\\n [image002.jpg]\\n 03:00 AM\\n 05:00 AM\\n 02:06 AM\\n 07:34 AM\\n 03:50 AM\\n 06:22 AM\\n 02:58 AM\\n 03:43 AM\\n 05:02 PM\\n 03:36 AM\\n WBC\\n 5.2\\n 5.9\\n 7.5\\n 5.6\\n 6.1\\n 7.0\\n 7.1\\n 7.1\\n 6.9\\n Hct\\n 26.0\\n 27.2\\n 26.8\\n 27.0\\n 27.0\\n 29.7\\n 28.9\\n 29.2\\n 27.8\\n Plt\\n 35\\n 52\\n 467\\n Cr\\n 0.6\\n 0.7\\n 0.6\\n 0.5\\n 0.7\\n 0.7\\n 0.6\\n 0.7\\n 0.8\\n 0.7\\n Glucose\\n 100\\n 134\\n 134\\n 121\\n 04\\n 108\\n 131\\n Other labs: PT / PTT / INR:66.1/32.7/8.0, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:9.4 mg/dL, Mg++:2.3 mg/dL, PO4:4.2\\n mg/dL\\n Assessment and Plan\\n 55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\\n trach, PEG, placement no with respiratory failure secondary to\\n tracheomalacia , resolving HAP.\\n .\\n # Respiratory failure: Slowly Improving. Now remaining on trach mask\\n for most of the day and night, with periods of pressure support of \\n over night.\\n - Continue to increase time on trach mask as tolerated.\\n - PMV with suctioning again today.\\n .\\n # HAP vs Aspiration PNA: Afebrile without leukocytosis\\n - Completed course of ceftriaxone\\n - Continue to f/u cultures\\n - Continue trach mask as tolerated\\n .\\n # Tachycardia: Previously was assessed as sinus tach with occasional\\n runs of SVT and sources such as hypovolemia, PE, infection, and pain\\n were assessed as possibly etiologies. But, now appears to be SVT for\\n much of time, rhythm,/rate nonresponsive to carotid massage. HR\\n decreased to 80s w/ stable BPs for approx 2 hour period overnight that\\n seems to be associated with administration of her BB and valium. Rhythm\\n strip shows conversion from a narrow complex non-sinus tachycardia to\\n normal sinus rhythm.\\n - Increase Metroprolol from 25mg TID to 25mg QID\\n - Consider further adjustment of BB as tolerated by BP.\\n - If not sufficient for rhythm conversion, consult cardiology for\\n management.\\n .\\n # Sedation: Inconsistent response to sedation, unclear what is best\\n regime. Will continue to wean overall. Possibly improved level of\\n agitation when rhytm returned to sinus.\\n - Continue w Olanzapine QHS\\n - DC\\nd haldol and taper valium to 2.5 mg PRN TID w/ 2.5 mg PRNs.\\n # Nutrition: Tube feeds have been restarted and pt started on raglan.\\n Has been tolerating feeds well so far.\\n - Continue TFs, w/ FW flushes\\n - Nutrition recs appreciated.\\n .\\n # Adrenal Insufficency: Endocrine following. Pt does not appear to be\\n adrenally insufficient at baseline. Suggesting if the patient under\\n goes major stressors such as major surgery, sepsis, she may need stress\\n dosed steroids.\\n .\\n # Fluid Status: Likely approaching euvolemia, though still has\\n hypernatramia which may suggest is still intravascularly depleated.\\n - Monitoring urine output\\n - FW flushes at 100/hr w/ tube feeds\\n - PM lytes to trend Na\\n .\\n # UE DVT and elevated INR: DVT in right UE has resolved, new\\n non-occlusive in left axillary vein. INR supratherapeutic today\\n - COumadin held, will restart at low dose when INR approaches\\n therapeutic range.\\n - follow INR\\n .\\n # Spine fracture: Stable\\n - Brace for OOB, will discuss with Neurosurgery if current brace is\\n optimal for stabilization given her mobility.\\n - Pt to follow up with Dr. in weeks\\n .\\n # Tracheomalacia. Was initially addressed with IP and they wanted to\\n follow up as outpatient.\\n - Consult IP for stent placement given improved clinical status, will\\n readdress\\n .\\n #. Thyroid Nodule on CT\\n - Outpatient follow up\\n .\\n # Glycemic control: SSI, well controlled\\n # PIV x 1\\n # Ppx: Coumadin, Ranitidine, Bowel Regimen PRN\\n # Communication:\\n - Boyfriend of 10 \\n - Brother also involved\\n # Code: Full\\n # Dispo: ICU, Screening for vent facilities\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2167-10-15 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 637649,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 27\\n Ideal body weight: 61.2 None\\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: Yes\\n Tube Type\\n Tracheostomy tube:\\n Type: Standard, Cuffed\\n Manufacturer: Portex\\n Size: 7.0mm\\n PMV: No\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 25 cmH2O\\n Cuff volume: mL /\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Rhonchi\\n LUL Lung Sounds: Rhonchi\\n LLL Lung Sounds: Diminished\\n Secretions\\n Sputum color / consistency: Yellow / Thick\\n Sputum source/amount: Suctioned / Small\\n Ventilation Assessment\\n Level of breathing assistance: Continuous invasive ventilation\\n Visual assessment of breathing pattern: Normal quiet breathing\\n Invasive ventilation assessment:\\n Dysynchrony assessment: Frequent alarms (Low min. ventilation)\\n Comments: with PSV at 10 pt demonstrating frequent periods of decreased\\n RR and low minute ventilation, PVS decreased to 8 resulting in more\\n consistent RR and minute ventilation. Attempted to further decrease PSV\\n to 5 but pt RR increased to 35-40 with very small Vt less then 200ml,\\n PS returned to 8, eventually required return to PS 10 due to increasing\\n tachypnea.\\n Plan\\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated.\\n Comments:\\n Tol decrease in PS to 8 from 10 for 2 hours eventually becoming\\n tachypneac with smaller Vt, PS returned to 10.\\n Continue with trach collar trials as tol, return to PSV for rest.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-12 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 637049,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Developed papular rash over entire back, bilateraly, in multiple\\n dermatomal distributions, opaque vesicles on erythematous base,\\n nonpainful, possibly pruritic.\\n Levofloxaxin was d/c'd.\\n Ceftriaxone started.\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Aztreonam - 03:42 AM\\n Vancomycin - 09:40 AM\\n Levofloxacin - 11:15 PM\\n Ceftriaxone - 07:50 PM\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:14 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:28 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.2\\nC (98.9\\n Tcurrent: 37.2\\nC (98.9\\n HR: 139 (113 - 145) bpm\\n BP: 97/61(68) {85/28(50) - 127/86(90)} mmHg\\n RR: 12 (9 - 30) insp/min\\n SpO2: 100%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 1,362 mL\\n 302 mL\\n PO:\\n TF:\\n 47 mL\\n 152 mL\\n IVF:\\n 1,061 mL\\n 100 mL\\n Blood products:\\n Total out:\\n 1,203 mL\\n 460 mL\\n Urine:\\n 1,203 mL\\n 460 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 159 mL\\n -158 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: CPAP/PSV\\n Vt (Set): 0 (0 - 0) mL\\n Vt (Spontaneous): 504 (110 - 504) mL\\n PS : 10 cmH2O\\n RR (Set): 0\\n RR (Spontaneous): 14\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n RSBI: 245\\n PIP: 16 cmH2O\\n SpO2: 100%\\n ABG: ///30/\\n Ve: 5.9 L/min\\n Physical Examination\\n General Appearance: Trached. Interactive. Responsive, following\\n commands, Overweight / Obese, mild agitation but NAD\\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\\n deviation\\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\\n Cardiovascular: (S1: Normal), (S2: Normal), distant\\n Respiratory / Chest: (Expansion: Symmetric), b/l rhonchi R>L, decreased\\n BS\\n Abdominal: Obese, soft, Non-tender, no rebound, no guarding, + BS, PEG\\n in place with dressing C/D/I\\n Extremities: no CCE\\n Skin: no rashes or jaundice\\n Lines: L PICC C/D/I\\n Labs / Radiology\\n 240 K/uL\\n 7.9 g/dL\\n 100 mg/dL\\n 0.6 mg/dL\\n 30 mEq/L\\n 3.4 mEq/L\\n 12 mg/dL\\n 108 mEq/L\\n 146 mEq/L\\n 26.0 %\\n 5.2 K/uL\\n [image002.jpg]\\n 08:11 PM\\n 02:51 AM\\n 03:10 AM\\n 03:08 PM\\n 03:00 AM\\n 03:36 AM\\n 04:40 PM\\n 03:00 AM\\n 07:05 PM\\n 03:00 AM\\n WBC\\n 9.4\\n 11.3\\n 7.3\\n 6.1\\n 7.2\\n 5.2\\n Hct\\n 26.6\\n 24.9\\n 27.6\\n 26.5\\n 26.9\\n 26.0\\n Plt\\n \\n Cr\\n 0.9\\n 0.7\\n 0.6\\n 0.6\\n 0.9\\n 0.7\\n 0.6\\n TCO2\\n 29\\n 26\\n Glucose\\n 128\\n 114\\n 114\\n 99\\n 115\\n 106\\n 100\\n Other labs: PT / PTT / INR:17.6/27.4/1.6, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:33/22, Alk Phos / T Bili:143/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:0.5 mmol/L,\\n Albumin:3.5 g/dL, LDH:199 IU/L, Ca++:8.9 mg/dL, Mg++:2.4 mg/dL, PO4:4.1\\n mg/dL\\n Assessment and Plan\\n 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA, and\\n ARDS, intubated since the end of now s/p trach and PEG\\n placement.\\n # Recent Aspiration of tube feeds. Given prolonged hospitalization and\\n tenuous respiratory status will treat with antibiotics while cultures\\n pending\\n - Levoflox for 48 hours while waiting for sputum results.\\n - hold tube feeds\\n - Follow cultures\\n - check tube placement\\n .\\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\\n volume overload. Intubated on for resp decompensation. S/P Trach\\n and PEG on .\\n - wean FiO2 as tolerated\\n - attempt wean PS today and hopeful for trach mask trial\\n # Sedation: Continue to have issues with pain/delirium causing\\n tachycardia and hypertension with intermittent hypotension. On Haldol\\n 5 TID, Fentanyl 75 mcg TP, Diazapam 10 QID; Haldol, midazolam and\\n morphine PRN. Had good response to morphine, minimal response to\\n haldol bolus.\\n - tolerating current regimen well, no changes today\\n # Adrenal Insufficency: Hypotension that resolved with steroids,\\n returned as they came off and is now improved again. Possible primary\\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\\n started on .\\n - stopped steroids as per endocrine today\\n # Volume overloaded in setting of hypernatremia\\n Goal even today.\\n - monitor urine output\\n # RUE DVT: INR super-therapeutic on coumadin. Goal . Hasn\\n received coumadin in days yet INR continues to rise. Likely\\n contributors are nutritional and antibiotics.\\n - will start coumadin 2.5 mg QHS once INR < 3\\n # Spine fracture: Neurologically intact distal to the lesion. Prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - Brace for OOB\\n - report from full trauma series from OSH is in chart. No evidence of\\n other fracture and no need for further spinal imaging based on this\\n report and ortho note.\\n # Tracheomalacia: Discussed with IP. Stenting unlikely to help for\\n trachiomalacia as airways have poor structure diffusely.\\n - Outpatient f/u once off pressure support to assess for possible\\n stenting\\n #. Thyroid Nodule on CT\\n -outpatient follow up\\n # Nutrition: Replete (Full)\\n hold\\n # Glycemic control: SSI, well controlled\\n # Lines L PICC ().\\n # Ppx: INR therapeutic, ranitidine, colace and senna, miralax,\\n bisacodyl.\\n # Communication:\\n - Boyfriend of 10 \\n - Brother also involved\\n Code: Full\\n Dispo: ICU, being screening for vent facilities\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 03:36 AM 30 mL/hour\\n Glycemic Control:\\n Lines:\\n PICC Line - 09:19 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-14 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 637472,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n BLOOD CULTURED - At 02:18 AM\\n SPUTUM CULTURE - At 02:18 AM\\n URINE CULTURE - At 02:18 AM\\n Pt tachy to mid 150's yesterday.\\n Restarted on Warfarin 2.5mg\\n Bolused 500cc x2 without change in HR\\n Overnight Tm 100.8, BCx, UCx, CXR\\n Tachypnic to high 30's.\\n Given Valium 5mg IV x 1, Tylenol\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Ceftriaxone - 12:00 AM\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:44 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.2\\nC (100.8\\n Tcurrent: 37.2\\nC (99\\n HR: 137 (120 - 151) bpm\\n BP: 125/55(73) {91/41(54) - 202/97(111)} mmHg\\n RR: 21 (12 - 39) insp/min\\n SpO2: 97%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 2,934 mL\\n 390 mL\\n PO:\\n TF:\\n 1,104 mL\\n 340 mL\\n IVF:\\n 1,000 mL\\n 50 mL\\n Blood products:\\n Total out:\\n 530 mL\\n 240 mL\\n Urine:\\n 530 mL\\n 240 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 2,404 mL\\n 150 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 318 (318 - 475) mL\\n PS : 10 cmH2O\\n RR (Spontaneous): 34\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n RSBI: 171\\n SpO2: 97%\\n ABG: ///32/\\n Ve: 9 L/min\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 306 K/uL\\n 8.8 g/dL\\n 134 mg/dL\\n 0.6 mg/dL\\n 32 mEq/L\\n 4.0 mEq/L\\n 11 mg/dL\\n 106 mEq/L\\n 146 mEq/L\\n 26.8 %\\n 7.5 K/uL\\n [image002.jpg]\\n 03:10 AM\\n 03:08 PM\\n 03:00 AM\\n 03:36 AM\\n 04:40 PM\\n 03:00 AM\\n 07:05 PM\\n 03:00 AM\\n 05:00 AM\\n 02:06 AM\\n WBC\\n 11.3\\n 7.3\\n 6.1\\n 7.2\\n 5.2\\n 5.9\\n 7.5\\n Hct\\n 24.9\\n 27.6\\n 26.5\\n 26.9\\n 26.0\\n 27.2\\n 26.8\\n Plt\\n 227\\n 189\\n 209\\n 238\\n 240\\n 296\\n 306\\n Cr\\n 0.7\\n 0.6\\n 0.6\\n 0.9\\n 0.7\\n 0.6\\n 0.7\\n 0.6\\n TCO2\\n 26\\n Glucose\\n 114\\n 99\\n 115\\n 106\\n 100\\n 134\\n 134\\n Other labs: PT / PTT / INR:13.5/23.6/1.2, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:27/19, Alk Phos / T Bili:118/0.3,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.5 g/dL, LDH:243 IU/L, Ca++:9.2 mg/dL, Mg++:2.1 mg/dL, PO4:4.0\\n mg/dL\\n Assessment and Plan\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 06:23 AM 60 mL/hour\\n Glycemic Control:\\n Lines:\\n PICC Line - 09:19 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-14 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 637473,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n BLOOD CULTURED - At 02:18 AM\\n SPUTUM CULTURE - At 02:18 AM\\n URINE CULTURE - At 02:18 AM\\n Pt tachy to mid 150's yesterday.\\n Restarted on Warfarin 2.5mg\\n Bolused 500cc x2 without change in HR\\n Overnight Tm 100.8, BCx, UCx, CXR\\n Tachypnic to high 30's.\\n Given Valium 5mg IV x 1, Tylenol\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Ceftriaxone - 12:00 AM\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:44 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.2\\nC (100.8\\n Tcurrent: 37.2\\nC (99\\n HR: 137 (120 - 151) bpm\\n BP: 125/55(73) {91/41(54) - 202/97(111)} mmHg\\n RR: 21 (12 - 39) insp/min\\n SpO2: 97%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 2,934 mL\\n 390 mL\\n PO:\\n TF:\\n 1,104 mL\\n 340 mL\\n IVF:\\n 1,000 mL\\n 50 mL\\n Blood products:\\n Total out:\\n 530 mL\\n 240 mL\\n Urine:\\n 530 mL\\n 240 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 2,404 mL\\n 150 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 318 (318 - 475) mL\\n PS : 10 cmH2O\\n RR (Spontaneous): 34\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n RSBI: 171\\n SpO2: 97%\\n ABG: ///32/\\n Ve: 9 L/min\\n Physical Examination\\n GEN:\\n HEENT:\\n PULM\\n CARD:\\n ABD:\\n EXT:\\n NEURO:\\n Labs / Radiology\\n 306 K/uL\\n 8.8 g/dL\\n 134 mg/dL\\n 0.6 mg/dL\\n 32 mEq/L\\n 4.0 mEq/L\\n 11 mg/dL\\n 106 mEq/L\\n 146 mEq/L\\n 26.8 %\\n 7.5 K/uL\\n [image002.jpg]\\n 03:10 AM\\n 03:08 PM\\n 03:00 AM\\n 03:36 AM\\n 04:40 PM\\n 03:00 AM\\n 07:05 PM\\n 03:00 AM\\n 05:00 AM\\n 02:06 AM\\n WBC\\n 11.3\\n 7.3\\n 6.1\\n 7.2\\n 5.2\\n 5.9\\n 7.5\\n Hct\\n 24.9\\n 27.6\\n 26.5\\n 26.9\\n 26.0\\n 27.2\\n 26.8\\n Plt\\n 227\\n 189\\n 209\\n 238\\n 240\\n 296\\n 306\\n Cr\\n 0.7\\n 0.6\\n 0.6\\n 0.9\\n 0.7\\n 0.6\\n 0.7\\n 0.6\\n TCO2\\n 26\\n Glucose\\n 114\\n 99\\n 115\\n 106\\n 100\\n 134\\n 134\\n Other labs: PT / PTT / INR:13.5/23.6/1.2, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:27/19, Alk Phos / T Bili:118/0.3,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.5 g/dL, LDH:243 IU/L, Ca++:9.2 mg/dL, Mg++:2.1 mg/dL, PO4:4.0\\n mg/dL\\n Assessment and Plan\\n 55yoF with history of EtOH abuse presenting following mechanical fall\\n and traumatic T spine fracture, now s/p trach, PEG, placement being\\n treated for HAP.\\n# HAP vs Aspiration PNA: Cultures growing Klebsiella Oxytoca, Klebsiella Pneumon\\niae, GNR, GP Cocci. Pt received developed rash on Levofloxacin, switched to Ceft\\nriaxone overnight. Will treat for potential HAP for 8 days.\\n - Continue Ceftriaxone HAP (Day #6 of 8)\\n - Tube Feeds now at 50 with goal of 60/hr\\n - Following Cultures\\n .\\n # Respiratory failure: 5 hours on Trach mask yesterday, will assess\\n length of tolerance today.\\n - PMV with suctioning.\\n - Weaning FiO2 as tolerated\\n # Tachycardia: Pt in ST 120\\ns to 150s. Etiology remains unclear and\\n etiologies include hypovolemia, pain, infection (pt with known\\n klebsiella), . DDx also includes PE\\n - Treating underlying infection\\n - Bolus NS 500cc x 2 today and assess HR\\n - Restarting patients Coumadin\\n - TSH 2.4 on early , will check free T3, T4.\\n - Continue Pain Control\\n # Sedation: Pt has pain/delirium causing tachycardia and hypertension\\n with intermittent hypotension. Had good response to morphine, minimal\\n response to haldol bolus.\\n - Haldol 5 TID, Fentanyl 75 mcg TP, Diazapam 10 QID;\\n - Haldol, midazolam and morphine PRN.\\n - tolerating current regimen well\\n # Adrenal Insufficency: Followed up with endocrine that suggested if\\n the patient under goes major stressors such as major surgery, sepsis,\\n she may need stress dosed steroids.\\n - Will consider MRI at later date for evaluation of pituitary\\n # Fluid Status: Volume overloaded in prior setting of Hypernatremia\\n Goal even today.\\n - Monitoring urine output\\n # RUE DVT: INR was super-therapeutic on coumadin. Goal . Received 5\\n of coumadin overnight.\\n - Restarting Coumadin 2.5 mg QHS once INR < 3\\n # Spine fracture: Stable\\n - Brace for OOB, will discuss with Neurosurgery if current brace is\\n optimal for stabilization given her mobility.\\n - Pt to follow up with Dr. in weeks\\n # Tracheomalacia?: Discussed with IP.\\n - Outpatient f/u once off pressure support to assess for possible\\n stenting\\n #. Thyroid Nodule on CT\\n - Outpatient follow up\\n # Nutrition: TFs with goal of 60\\n # Glycemic control: SSI, well controlled\\n # Lines L PICC\\n ().\\n # Ppx: Restarting Coumadin, Ranitidine, Bowel Regimen\\n # Communication:\\n - Boyfriend of 10 \\n - Brother also involved\\n # Code: Full\\n # Dispo: ICU, Screening for vent facilities\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 06:23 AM 60 mL/hour\\n Glycemic Control:\\n Lines:\\n PICC Line - 09:19 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-18 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 638287,\n \"text\": \"Airway Clearance, Impaired\\n Assessment:\\n Pt placed TM50% this am, changed to high flow TM 60% @ for low\\n O2Sats, cont with mod thick tan secretions.\\n Action:\\n Suctioned prn, pt repositioned frequently\\n Response:\\n No s/sx resp distress; pt tolerating trach mask\\n Plan:\\n Cont prn suctioning; repositioning; monitor CXry as ordered\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt cont with extreme restlessness and periods of agitation, requiring\\n frequent redirection\\n Action:\\n Cont with scheduled valium, prn meds offered, pt oriented to , pt\\n given IV morphine for presumed pain\\n Response:\\n Pt cont with periods of restlessness, minimal effect with valium; pt\\n responded well to IV Morphine\\n Plan:\\n Medicate as needed for agitation; attempt to try PMV when pt secretions\\n lessen to initiate communication\\n Tachycardia, Other\\n Assessment:\\n HR 110-140\\ns today\\n Action:\\n Cont with Lopressor as ordered\\n Response:\\n HR in 110\\ns, otherwise unchanged\\n Plan:\\n Cont. Lopressor, ? cardiology consult\\n Alteration in Nutrition\\n Assessment:\\n Pt cont on Promote w/ Fiber, currently at 50ml/hr goal 60ml, no\\n episodes of emesis today\\n Action:\\n Advanced TF as tolerated for goal 60ml, IV Reglan given per order\\n Response:\\n No residuals noted, no further emesis\\n Plan:\\n Advance TF\\ns as tolerated, cont IV reglan\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-13 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 637378,\n \"text\": \"Chief Complaint: resp failure\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 24 Hour Events:\\n Trach Mask x 5 hours\\n Tried PMV but had secretions\\n History obtained from Patient\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Levofloxacin - 11:15 PM\\n Ceftriaxone - 07:50 PM\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:13 PM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.6\\nC (99.6\\n Tcurrent: 37\\nC (98.6\\n HR: 135 (118 - 151) bpm\\n BP: 137/78(91) {90/37(48) - 202/96(111)} mmHg\\n RR: 37 (13 - 39) insp/min\\n SpO2: 92%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 1,614 mL\\n 2,451 mL\\n PO:\\n TF:\\n 884 mL\\n 761 mL\\n IVF:\\n 100 mL\\n 1,000 mL\\n Blood products:\\n Total out:\\n 834 mL\\n 320 mL\\n Urine:\\n 834 mL\\n 320 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 780 mL\\n 2,131 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask\\n Ventilator mode: Standby\\n Vt (Spontaneous): 354 (316 - 376) mL\\n PS : 10 cmH2O\\n RR (Spontaneous): 12\\n PEEP: 5 cmH2O\\n FiO2: 70%\\n RSBI: 56\\n PIP: 15 cmH2O\\n SpO2: 92%\\n ABG: ///32/\\n Ve: 4.1 L/min\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 8.7 g/dL\\n 296 K/uL\\n 134 mg/dL\\n 0.7 mg/dL\\n 32 mEq/L\\n 3.8 mEq/L\\n 14 mg/dL\\n 107 mEq/L\\n 147 mEq/L\\n 27.2 %\\n 5.9 K/uL\\n [image002.jpg]\\n 02:51 AM\\n 03:10 AM\\n 03:08 PM\\n 03:00 AM\\n 03:36 AM\\n 04:40 PM\\n 03:00 AM\\n 07:05 PM\\n 03:00 AM\\n 05:00 AM\\n WBC\\n 11.3\\n 7.3\\n 6.1\\n 7.2\\n 5.2\\n 5.9\\n Hct\\n 24.9\\n 27.6\\n 26.5\\n 26.9\\n 26.0\\n 27.2\\n Plt\\n 227\\n 189\\n 209\\n 238\\n 240\\n 296\\n Cr\\n 0.7\\n 0.6\\n 0.6\\n 0.9\\n 0.7\\n 0.6\\n 0.7\\n TCO2\\n 29\\n 26\\n Glucose\\n 114\\n 114\\n 99\\n 115\\n 106\\n 100\\n 134\\n Other labs: PT / PTT / INR:13.5/23.6/1.2, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:27/19, Alk Phos / T Bili:118/0.3,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:0.5 mmol/L,\\n Albumin:3.5 g/dL, LDH:178 IU/L, Ca++:9.2 mg/dL, Mg++:2.3 mg/dL, PO4:4.6\\n mg/dL\\n Assessment and Plan\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 10:29 AM 50 mL/hour\\n Glycemic Control:\\n Lines:\\n PICC Line - 09:19 PM\\n 20 Gauge - 04:59 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :ICU\\n Total time spent: 35 minutes\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-13 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 637379,\n \"text\": \"Chief Complaint: resp failure\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 24 Hour Events:\\n Trach Mask x 5 hours\\n Tried PMV but had secretions\\n History obtained from Patient\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Levofloxacin - 11:15 PM\\n Ceftriaxone - 07:50 PM\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:13 PM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.6\\nC (99.6\\n Tcurrent: 37\\nC (98.6\\n HR: 135 (118 - 151) bpm\\n BP: 137/78(91) {90/37(48) - 202/96(111)} mmHg\\n RR: 37 (13 - 39) insp/min\\n SpO2: 92%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 1,614 mL\\n 2,451 mL\\n PO:\\n TF:\\n 884 mL\\n 761 mL\\n IVF:\\n 100 mL\\n 1,000 mL\\n Blood products:\\n Total out:\\n 834 mL\\n 320 mL\\n Urine:\\n 834 mL\\n 320 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 780 mL\\n 2,131 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask\\n Ventilator mode: Standby\\n Vt (Spontaneous): 354 (316 - 376) mL\\n PS : 10 cmH2O\\n RR (Spontaneous): 12\\n PEEP: 5 cmH2O\\n FiO2: 70%\\n RSBI: 56\\n PIP: 15 cmH2O\\n SpO2: 92%\\n ABG: ///32/\\n Ve: 4.1 L/min\\n Physical Examination\\n Gen sitting up in , on trach mask, interactive\\n CV tachy RRR\\n Chest good movement ANT\\n Abd soft NT + NS\\n Ext: no edema\\n Neuroalert follows simple commands\\n Labs / Radiology\\n 8.7 g/dL\\n 296 K/uL\\n 134 mg/dL\\n 0.7 mg/dL\\n 32 mEq/L\\n 3.8 mEq/L\\n 14 mg/dL\\n 107 mEq/L\\n 147 mEq/L\\n 27.2 %\\n 5.9 K/uL\\n [image002.jpg]\\n 02:51 AM\\n 03:10 AM\\n 03:08 PM\\n 03:00 AM\\n 03:36 AM\\n 04:40 PM\\n 03:00 AM\\n 07:05 PM\\n 03:00 AM\\n 05:00 AM\\n WBC\\n 11.3\\n 7.3\\n 6.1\\n 7.2\\n 5.2\\n 5.9\\n Hct\\n 24.9\\n 27.6\\n 26.5\\n 26.9\\n 26.0\\n 27.2\\n Plt\\n 227\\n 189\\n 209\\n 238\\n 240\\n 296\\n Cr\\n 0.7\\n 0.6\\n 0.6\\n 0.9\\n 0.7\\n 0.6\\n 0.7\\n TCO2\\n 29\\n 26\\n Glucose\\n 114\\n 114\\n 99\\n 115\\n 106\\n 100\\n 134\\n Other labs: PT / PTT / INR:13.5/23.6/1.2, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:27/19, Alk Phos / T Bili:118/0.3,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:0.5 mmol/L,\\n Albumin:3.5 g/dL, LDH:178 IU/L, Ca++:9.2 mg/dL, Mg++:2.3 mg/dL, PO4:4.6\\n mg/dL\\n Assessment and Plan\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 10:29 AM 50 mL/hour\\n Glycemic Control:\\n Lines:\\n PICC Line - 09:19 PM\\n 20 Gauge - 04:59 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :ICU\\n Total time spent: 35 minutes\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-13 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 637380,\n \"text\": \"Chief Complaint: resp failure\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI: 56 yr old with t spine fx, resp failure\\n 24 Hour Events:\\n Trach Mask x 5 hours\\n Tried PMV but had secretions\\n History obtained from Patient\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Levofloxacin - 11:15 PM\\n Ceftriaxone - 07:50 PM\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:13 PM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.6\\nC (99.6\\n Tcurrent: 37\\nC (98.6\\n HR: 135 (118 - 151) bpm\\n BP: 137/78(91) {90/37(48) - 202/96(111)} mmHg\\n RR: 37 (13 - 39) insp/min\\n SpO2: 92%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 1,614 mL\\n 2,451 mL\\n PO:\\n TF:\\n 884 mL\\n 761 mL\\n IVF:\\n 100 mL\\n 1,000 mL\\n Blood products:\\n Total out:\\n 834 mL\\n 320 mL\\n Urine:\\n 834 mL\\n 320 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 780 mL\\n 2,131 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask\\n Ventilator mode: Standby\\n Vt (Spontaneous): 354 (316 - 376) mL\\n PS : 10 cmH2O\\n RR (Spontaneous): 12\\n PEEP: 5 cmH2O\\n FiO2: 70%\\n RSBI: 56\\n PIP: 15 cmH2O\\n SpO2: 92%\\n ABG: ///32/\\n Ve: 4.1 L/min\\n Physical Examination\\n Gen sitting up in , on trach mask, interactive\\n CV tachy RRR\\n Chest good air movement ANT\\n Abd soft NT + NS\\n Ext: no edema\\n Neuro: alert follows simple commands\\n Labs / Radiology\\n 8.7 g/dL\\n 296 K/uL\\n 134 mg/dL\\n 0.7 mg/dL\\n 32 mEq/L\\n 3.8 mEq/L\\n 14 mg/dL\\n 107 mEq/L\\n 147 mEq/L\\n 27.2 %\\n 5.9 K/uL\\n [image002.jpg]\\n 02:51 AM\\n 03:10 AM\\n 03:08 PM\\n 03:00 AM\\n 03:36 AM\\n 04:40 PM\\n 03:00 AM\\n 07:05 PM\\n 03:00 AM\\n 05:00 AM\\n WBC\\n 11.3\\n 7.3\\n 6.1\\n 7.2\\n 5.2\\n 5.9\\n Hct\\n 24.9\\n 27.6\\n 26.5\\n 26.9\\n 26.0\\n 27.2\\n Plt\\n 227\\n 189\\n 209\\n 238\\n 240\\n 296\\n Cr\\n 0.7\\n 0.6\\n 0.6\\n 0.9\\n 0.7\\n 0.6\\n 0.7\\n TCO2\\n 29\\n 26\\n Glucose\\n 114\\n 114\\n 99\\n 115\\n 106\\n 100\\n 134\\n Other labs: PT / PTT / INR:13.5/23.6/1.2, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:27/19, Alk Phos / T Bili:118/0.3,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:0.5 mmol/L,\\n Albumin:3.5 g/dL, LDH:178 IU/L, Ca++:9.2 mg/dL, Mg++:2.3 mg/dL, PO4:4.6\\n mg/dL\\n Assessment and Plan 55 yr old alcoholic s/p t spine fx s/p trcah and\\n PEG with persistent resp failure\\n 1. Resp Failure: currently on trach mask, can do a few hours per\\n day, then needs for support. New pan Klebs in sputum, day\\n . Re- try. Holding off on stent by IP until after pulm rehab.\\n 2. Hemodynamics: tachycardia with slightly decreased UOP\\n bolus\\n IVF and trend UOP. Watch to see if response with tachycardia.\\n 3. Anti coag: for upper ext DVT but INR elevated on coumadin +\\n quinolone\\n repeat inr low- trend with po COumadin\\n 4. Adrenal Insufficiency: proper stim this AM, off steroids\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 10:29 AM 50 mL/hour\\n Glycemic Control:\\n Lines:\\n PICC Line - 09:19 PM\\n 20 Gauge - 04:59 PM\\n Prophylaxis:\\n DVT: coumadin\\n Stress ulcer: ppi\\n Code status: Full code\\n Disposition :ICU\\n Total time spent: 35 minutes\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-14 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 637594,\n \"text\": \"Tachycardia, Other\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Altered mental status (not Delirium)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-14 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 637564,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n BLOOD CULTURED - At 02:18 AM\\n SPUTUM CULTURE - At 02:18 AM\\n URINE CULTURE - At 02:18 AM\\n Pt tachy to mid 150's yesterday.\\n Restarted on Warfarin 2.5mg\\n Bolused 500cc x2 without change in HR\\n Overnight Tm 100.8, BCx, UCx, CXR\\n Tachypnic to high 30's.\\n Given Valium 5mg IV x 1, Tylenol\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Ceftriaxone - 12:00 AM\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:44 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.2\\nC (100.8\\n Tcurrent: 37.2\\nC (99\\n HR: 137 (120 - 151) bpm\\n BP: 125/55(73) {91/41(54) - 202/97(111)} mmHg\\n RR: 21 (12 - 39) insp/min\\n SpO2: 97%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 2,934 mL\\n 390 mL\\n PO:\\n TF:\\n 1,104 mL\\n 340 mL\\n IVF:\\n 1,000 mL\\n 50 mL\\n Blood products:\\n Total out:\\n 530 mL\\n 240 mL\\n Urine:\\n 530 mL\\n 240 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 2,404 mL\\n 150 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 318 (318 - 475) mL\\n PS : 10 cmH2O\\n RR (Spontaneous): 34\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n RSBI: 171\\n SpO2: 97%\\n ABG: ///32/\\n Ve: 9 L/min\\n Physical Examination\\n GEN: Awake, alert, responsive. Sitting in chair, in back brace.\\n Following commands.\\n HEENT: PERRL\\n PULM: CTA anteriorly, no r/r/w\\n CARD: tachycardic, regular, ,s1, s2,\\n ABD: abdomen, inferior to brace, soft, nontender\\n EXT: DP 2+\\n NEURO: able to move all extremeties, strength 5/5 upper and lower, R\\n hip < L hip.\\n Labs / Radiology\\n 306 K/uL\\n 8.8 g/dL\\n 134 mg/dL\\n 0.6 mg/dL\\n 32 mEq/L\\n 4.0 mEq/L\\n 11 mg/dL\\n 106 mEq/L\\n 146 mEq/L\\n 26.8 %\\n 7.5 K/uL\\n [image002.jpg]\\n LACTATE 1.1\\n 03:10 AM\\n 03:08 PM\\n 03:00 AM\\n 03:36 AM\\n 04:40 PM\\n 03:00 AM\\n 07:05 PM\\n 03:00 AM\\n 05:00 AM\\n 02:06 AM\\n WBC\\n 11.3\\n 7.3\\n 6.1\\n 7.2\\n 5.2\\n 5.9\\n 7.5\\n Hct\\n 24.9\\n 27.6\\n 26.5\\n 26.9\\n 26.0\\n 27.2\\n 26.8\\n Plt\\n 227\\n 189\\n 209\\n 238\\n 240\\n 296\\n 306\\n Cr\\n 0.7\\n 0.6\\n 0.6\\n 0.9\\n 0.7\\n 0.6\\n 0.7\\n 0.6\\n TCO2\\n 26\\n Glucose\\n 114\\n 99\\n 115\\n 106\\n 100\\n 134\\n 134\\n Other labs: PT / PTT / INR:13.5/23.6/1.2, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:27/19, Alk Phos / T Bili:118/0.3,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.5 g/dL, LDH:243 IU/L, Ca++:9.2 mg/dL, Mg++:2.1 mg/dL, PO4:4.0\\n mg/dL\\n UA: WBC, RBC, EPI, trace bld, trace leuk, few bacter\\n CXR: not sig changed from prev, R diaphragm elevated, possibly improved\\n L costophrenic angle effusion, PICC line terminus difficult to\\n visualize.\\n Assessment and Plan\\n 55yoF with history of EtOH abuse presenting following mechanical fall\\n and traumatic T spine fracture, now s/p trach, PEG, placement being\\n treated for HAP.\\n# HAP vs Aspiration PNA: Cultures grew, Klebsiella Oxytoca, Klebsiella Pneumonia\\ne, GNR, GP Cocci. Will continue to treat for potential HAP for 8 days.Pt continu\\ning to have some fevers, last night 100.8, and new sputum on today w/ gram stain\\n showing GPC p/c. New VAP/HAP w/ staph possible, but given no clear infiltrate o\\nn CXR and good respiratory status, significant PNA is unlikely, colonization of\\ntrach is possible, as is contamination of sputum. Given improving clinical \\n, wait until CX data or change in clinical status or CXR to initiate HAP\\n/VAP treatment.\\n - Continue Ceftriaxone HAP (Day #6 of 8)\\n - Continue to f/u cultures\\n .\\n # Respiratory failure: Improving status. Will continue to increase\\n time on trach mask as tolerated.\\n - PMV with suctioning.\\n - Weaning FiO2 as tolerated\\n # Tachycardia: Pt in ST 120\\ns to 150s. Etiology remains unclear and\\n etiologies include hypovolemia, pain, infection (pt with known\\n klebsiella), . DDx also includes PE given hx of RUE DVT, mucus\\n plugging given large amount of secretions, and spinal injury.\\n - Treating underlying infection\\n - Restarting patients Coumadin, last INR 1.2 yesterday, not\\n therapeutic, will recheck this PM\\n - TSH 2.4 on early , will check free T3, T4.\\n - Continue Pain Control\\n - Assess for PE w/ CTPA and UE u/s\\n # Sedation: Pt has pain/delirium causing tachycardia and hypertension\\n with intermittent hypotension. Had good response to morphine, minimal\\n response to haldol bolus.\\n - Haldol 5 PRN, Fentanyl 75 mcg TP, Diazapam 5 QID;\\n - tolerating current regimen well, will continue to wean\\n # Adrenal Insufficency: Followed up with endocrine that suggested if\\n the patient under goes major stressors such as major surgery, sepsis,\\n she may need stress dosed steroids.\\n - Will consider MRI at later date for evaluation of pituitary\\n # Fluid Status: Volume overloaded in prior setting of Hypernatremia\\n Goal even today.\\n - Monitoring urine output\\n - increasse Free H20, for mild hypernatremia\\n # RUE DVT: restarted Coumadin for INR 1.2, will follow INR carefully,\\n given Abx.\\n - Check INR this PM\\n # Spine fracture: Stable\\n - Brace for OOB, will discuss with Neurosurgery if current brace is\\n optimal for stabilization given her mobility.\\n - Pt to follow up with Dr. in weeks\\n # Tracheomalacia?: Discussed with IP.\\n - Outpatient f/u once off pressure support to assess for possible\\n stenting\\n #. Thyroid Nodule on CT\\n - Outpatient follow up\\n # Nutrition: TFs with goal of 60\\n # Glycemic control: SSI, well controlled\\n # Lines L PICC ().\\n # Ppx: Restarting Coumadin, Ranitidine, Bowel Regimen\\n # Communication:\\n - Boyfriend of 10 \\n - Brother also involved\\n # Code: Full\\n # Dispo: ICU, Screening for vent facilities\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 06:23 AM 60 mL/hour\\n Glycemic Control:\\n Lines:\\n PICC Line - 09:19 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-14 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 637565,\n \"text\": \"Chief Complaint: resp failure\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n s/p t spine fx with resp failure\\n 24 Hour Events:\\n BLOOD CULTURED - At 02:18 AM\\n SPUTUM CULTURE - At 02:18 AM\\n URINE CULTURE - At 02:18 AM\\n FEVER Pan cx\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Ceftriaxone - 12:00 AM\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Atrovent/Albuterol, Miralax, Chlorhex, Ceftriaxone, Thiamine Folate\\n Valium 5 mg QID COumadin 2.5\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Constitutional: Fever\\n Flowsheet Data as of 08:32 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.2\\nC (100.8\\n Tcurrent: 37.2\\nC (99\\n HR: 137 (120 - 151) bpm\\n BP: 125/55(73) {98/41(54) - 202/97(111)} mmHg\\n RR: 23 (12 - 39) insp/min\\n SpO2: 98%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 2,934 mL\\n 497 mL\\n PO:\\n TF:\\n 1,104 mL\\n 447 mL\\n IVF:\\n 1,000 mL\\n 50 mL\\n Blood products:\\n Total out:\\n 530 mL\\n 240 mL\\n Urine:\\n 530 mL\\n 240 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 2,404 mL\\n 257 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 318 (318 - 475) mL\\n PS : 10 cmH2O\\n RR (Spontaneous): 34\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n RSBI: 171\\n SpO2: 98%\\n ABG: ///32/\\n Ve: 9 L/min\\n Physical Examination\\n Gen sitting up in , on trach mask, interactive\\n CV tachy RRR\\n Chest good air movement ANT\\n Abd soft NT + NS\\n Ext: no edema\\n Neuro: alert follows simple commands\\n Labs / Radiology\\n 8.8 g/dL\\n 306 K/uL\\n 134 mg/dL\\n 0.6 mg/dL\\n 32 mEq/L\\n 4.0 mEq/L\\n 11 mg/dL\\n 106 mEq/L\\n 146 mEq/L\\n 26.8 %\\n 7.5 K/uL\\n [image002.jpg]\\n 03:10 AM\\n 03:08 PM\\n 03:00 AM\\n 03:36 AM\\n 04:40 PM\\n 03:00 AM\\n 07:05 PM\\n 03:00 AM\\n 05:00 AM\\n 02:06 AM\\n WBC\\n 11.3\\n 7.3\\n 6.1\\n 7.2\\n 5.2\\n 5.9\\n 7.5\\n Hct\\n 24.9\\n 27.6\\n 26.5\\n 26.9\\n 26.0\\n 27.2\\n 26.8\\n Plt\\n 227\\n 189\\n 209\\n 238\\n 240\\n 296\\n 306\\n Cr\\n 0.7\\n 0.6\\n 0.6\\n 0.9\\n 0.7\\n 0.6\\n 0.7\\n 0.6\\n TCO2\\n 26\\n Glucose\\n 114\\n 99\\n 115\\n 106\\n 100\\n 134\\n 134\\n Other labs: PT / PTT / INR:13.5/23.6/1.2, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:27/19, Alk Phos / T Bili:118/0.3,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.5 g/dL, LDH:243 IU/L, Ca++:9.2 mg/dL, Mg++:2.1 mg/dL, PO4:4.0\\n mg/dL\\n - Sputum: 3+ GPC cocci in prs and chains\\n yeast\\n Assessment and Plan 55 yr old alcoholic s/p t spine fx s/p trcah and\\n PEG with persistent resp failure\\n 1. Resp Failure: currently on trach mask, can do a few hours per\\n day, then needs for support. New pan Klebs in sputum, day\\n . Re- try. Holding off on stent by IP until after pulm rehab.\\n 2. Fevers: DDx - line infection VAP, check LFTs, check blood and\\n urine cx, LUE ultrasounds -\\n 3 Hemodynamics: persistant simus tachy\\n check CTPA to look for\\n emboli- has been off on anti coag - tachycardia with slightly decreased\\n UOP\\n bolus IVF and trend UOP. Watch to see if response with\\n tachycardia.\\n 4. Anti coag: for upper ext DVT but INR elevated on coumadin +\\n quinolone\\n repeat inr low- trend inr with po COumadin\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 06:23 AM 60 mL/hour\\n Glycemic Control:\\n Lines:\\n PICC Line - 09:19 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n Communication: try to contact boyfriend\\n status: Full code\\n Disposition : call case management for screening options\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-15 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 637622,\n \"text\": \"Tachycardia, Other\\n Assessment:\\n Continues to be Tachycardia in 120-145 (anxiety). SBP has been 100-145\\n without ectopy.\\n Action:\\n No medication given for tachycardia.Pt gets Valium 5 mg scheduled Q6H\\n with little effect. CTA done to r/o pe as a source of tachycardia.\\n Response:\\n Results pending on CTA.\\n Plan:\\n Continue to evaluate HR and BP for need of treatment.\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Pt has a known DVT to RUE. Today pt had a US of LUEand ruled out small\\n non occlusive clot on her left axial vein.\\n Action:\\n Dr ,pt received ceftriaxone via PICC line.Coumadin dosage\\n increased from 2.5 to 5 mg ( INR 1.4).\\n Response:\\n Repeat ultrasound orderd for right arm . Pt received 5 mg coumadin at\\n 2200.\\n Plan:\\n Ultrasound today,cont coumadin and closely monitor INR.\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt has been restless most of the night. Pt nodded her head for pain and\\n simple yes or no questions.\\n Action:\\n Pt given scheduled Valium with little effect.\\n Response:\\n Pt slept for a while,Hr dropped to 120s at the time of rest.\\n Plan:\\n Continue to eval MS,Valium and Prn Morphine and haldol?.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-16 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 637931,\n \"text\": \"Chief Complaint: resp failure\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 24 Hour Events:\\n ULTRASOUND - At 08:11 AM\\n right arm\\n PICC LINE - STOP 12:02 PM\\n PEG INSERTION - At 05:33 PM\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Ceftriaxone - 10:00 PM\\n Infusions:\\n Other ICU medications:\\n Morphine Sulfate - 12:00 PM\\n Haloperidol (Haldol) - 02:00 PM\\n Diazepam (Valium) - 03:52 PM\\n Furosemide (Lasix) - 06:40 AM\\n Other medications:\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 09:09 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.9\\nC (98.4\\n Tcurrent: 36.8\\nC (98.3\\n HR: 137 (97 - 146) bpm\\n BP: 153/66(87) {93/43(55) - 183/129(134)} mmHg\\n RR: 18 (13 - 33) insp/min\\n SpO2: 95%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 1,220 mL\\n 807 mL\\n PO:\\n TF:\\n IVF:\\n 500 mL\\n 807 mL\\n Blood products:\\n Total out:\\n 1,514 mL\\n 150 mL\\n Urine:\\n 1,439 mL\\n 150 mL\\n NG:\\n 75 mL\\n Stool:\\n Drains:\\n Balance:\\n -294 mL\\n 657 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask , Tracheostomy tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 384 (311 - 675) mL\\n PS : 10 cmH2O\\n RR (Spontaneous): 12\\n PEEP: 5 cmH2O\\n FiO2: 70%\\n RSBI: 52\\n PIP: 15 cmH2O\\n SpO2: 95%\\n ABG: ///35/\\n Ve: 4.6 L/min\\n Physical Examination\\n Labs / Radiology\\n 9.0 g/dL\\n 395 K/uL\\n 126 mg/dL\\n 0.7 mg/dL\\n 35 mEq/L\\n 4.0 mEq/L\\n 7 mg/dL\\n 102 mEq/L\\n 144 mEq/L\\n 29.7 %\\n 7.0 K/uL\\n [image002.jpg]\\n 03:36 AM\\n 04:40 PM\\n 03:00 AM\\n 07:05 PM\\n 03:00 AM\\n 05:00 AM\\n 02:06 AM\\n 07:34 AM\\n 03:50 AM\\n 06:22 AM\\n WBC\\n 7.2\\n 5.2\\n 5.9\\n 7.5\\n 5.6\\n 6.1\\n 7.0\\n Hct\\n 26.9\\n 26.0\\n 27.2\\n 26.8\\n 27.0\\n 27.0\\n 29.7\\n Plt\\n 238\\n 240\\n 296\\n \\n 395\\n Cr\\n 0.6\\n 0.9\\n 0.7\\n 0.6\\n 0.7\\n 0.6\\n 0.5\\n 0.7\\n 0.7\\n TCO2\\n 26\\n Glucose\\n 115\\n 106\\n 100\\n 134\\n 134\\n 121\\n 619\\n 126\\n Other labs: PT / PTT / INR:24.2/27.7/2.4, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:9.5 mg/dL, Mg++:2.1 mg/dL, PO4:4.2\\n mg/dL\\n Assessment and Plan\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:26 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-16 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 637932,\n \"text\": \"Chief Complaint: resp failure\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 24 Hour Events:\\n ULTRASOUND - At 08:11 AM\\n right arm\\n PICC LINE - STOP 12:02 PM\\n PEG INSERTION - At 05:33 PM\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Ceftriaxone - 10:00 PM\\n Infusions:\\n Other ICU medications:\\n Morphine Sulfate - 12:00 PM\\n Haloperidol (Haldol) - 02:00 PM\\n Diazepam (Valium) - 03:52 PM\\n Furosemide (Lasix) - 06:40 AM\\n Other medications:\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 09:09 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.9\\nC (98.4\\n Tcurrent: 36.8\\nC (98.3\\n HR: 137 (97 - 146) bpm\\n BP: 153/66(87) {93/43(55) - 183/129(134)} mmHg\\n RR: 18 (13 - 33) insp/min\\n SpO2: 95%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 1,220 mL\\n 807 mL\\n PO:\\n TF:\\n IVF:\\n 500 mL\\n 807 mL\\n Blood products:\\n Total out:\\n 1,514 mL\\n 150 mL\\n Urine:\\n 1,439 mL\\n 150 mL\\n NG:\\n 75 mL\\n Stool:\\n Drains:\\n Balance:\\n -294 mL\\n 657 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask , Tracheostomy tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 384 (311 - 675) mL\\n PS : 10 cmH2O\\n RR (Spontaneous): 12\\n PEEP: 5 cmH2O\\n FiO2: 70%\\n RSBI: 52\\n PIP: 15 cmH2O\\n SpO2: 95%\\n ABG: ///35/\\n Ve: 4.6 L/min\\n Physical Examination\\n Labs / Radiology\\n 9.0 g/dL\\n 395 K/uL\\n 126 mg/dL\\n 0.7 mg/dL\\n 35 mEq/L\\n 4.0 mEq/L\\n 7 mg/dL\\n 102 mEq/L\\n 144 mEq/L\\n 29.7 %\\n 7.0 K/uL\\n [image002.jpg]\\n 03:36 AM\\n 04:40 PM\\n 03:00 AM\\n 07:05 PM\\n 03:00 AM\\n 05:00 AM\\n 02:06 AM\\n 07:34 AM\\n 03:50 AM\\n 06:22 AM\\n WBC\\n 7.2\\n 5.2\\n 5.9\\n 7.5\\n 5.6\\n 6.1\\n 7.0\\n Hct\\n 26.9\\n 26.0\\n 27.2\\n 26.8\\n 27.0\\n 27.0\\n 29.7\\n Plt\\n 238\\n 240\\n 296\\n \\n 395\\n Cr\\n 0.6\\n 0.9\\n 0.7\\n 0.6\\n 0.7\\n 0.6\\n 0.5\\n 0.7\\n 0.7\\n TCO2\\n 26\\n Glucose\\n 115\\n 106\\n 100\\n 134\\n 134\\n 121\\n 619\\n 126\\n Other labs: PT / PTT / INR:24.2/27.7/2.4, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:9.5 mg/dL, Mg++:2.1 mg/dL, PO4:4.2\\n mg/dL\\n Assessment and Plan 55 yr old alcoholic s/p t spine fx s/p trcah and\\n PEG with persistent resp failure\\n 1. Resp Failure: currently on trach mask, can do sevreal hours per\\n day, then needs for support QHS. Completed Rx for\\n pan Klebs PNA.\\n 2. Hemodynamics: persistant simus tachy but also has runs of SVT-\\n will add low dose bblocker today\\n watch MAPs at night as\\n she tends to run low\\n 3. New L Ext DVT: PICC out, coumadin\\n 4. Emesis: start Reglan, watch qt and restart low dose tf tonight-\\n discuss with TSurg\\n ICU Care\\n Nutrition: restart TFs\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:26 PM\\n Prophylaxis:\\n DVT: couadin\\n Stress ulcer: PPI\\n Communication: try to reach boyfriend\\n status: Full code\\n Disposition :screening for rehab\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2167-10-18 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 638207,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 30\\n Ideal body weight: 61.2 None\\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: Yes\\n Tracheostomy tube:\\n Type: Standard, Cuffed\\n Manufacturer: Portex\\n Size: 7.0mm\\n PMV: No\\n Lung sounds\\n RLL Lung Sounds: Rhonchi\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Rhonchi\\n Secretions\\n Sputum color / consistency: White / Thick\\n Sputum source/amount: Suctioned / Moderate\\n Ventilation Assessment\\n Level of breathing assistance: Continuous invasive ventilation\\n Visual assessment of breathing pattern: Normal quiet breathing\\n Assessment of breathing comfort: No claim of dyspnea)\\n Invasive ventilation assessment:\\n Trigger work assessment: Triggering synchronously:\\n Plan\\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\\n Periodic SBT's for conditioning; Comments: Continue trach trials\\n Rsbi: 150\\n Mdis given as ordered.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-14 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 637452,\n \"text\": \"Tachycardia, Other\\n Assessment:\\n Continues to be tachycardic 120-150\\n Action:\\n Given pain meds PRN\\n Response:\\n HR down to 120\\ns when sleeping\\n Plan:\\n No current RX for tachycardia manage pain & fever\\n Alteration in Nutrition\\n Assessment:\\n TF currently infusing at goal of 50 cc/hr with minimal residuals\\n Action:\\n Strict aspiration precautions HOB 30 degrees\\n Response:\\n Plan:\\n Continue to monitor tolerance to TF\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt continues to be confused & up most of the night. PERRLA following\\n commands consistently.\\n Action:\\n Continues on Valium QTC, given Morphine 4 mg Q 4 hours, Haldol PO x 2.\\n Response:\\n Pt able to rest in short naps, then awake and aggitated\\n Plan:\\n Continues on soft wrist restraints, needs titrated on of medications to\\n prevent agitation\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Placed back on PS overnight. RR up to 40\\ns when agitated. Sats\\n 94-98% on 50%. Lungs rhonchorous throughout. Suctionned for moderate\\n amounts of thick tan secretions Q 3-4 hours.\\n Action:\\n Tolerated PS when not agitated. Trialed on CMV became dysnchrous with\\n the vent\\n Response:\\n Plan:\\n Continue trach collar trials during the day.\\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\\n Assessment:\\n Temp spike to 100.8\\n Action:\\n Pan cultured, Tylenol given\\n Response:\\n Lactate stable, WBC stable continues on ceftriaxone\\n Plan:\\n Follow temp curve, follow up on culture results\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2167-10-07 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 636228,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 19\\n Ideal body weight: 61.2 None\\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: Yes\\n Procedure location:\\n Reason:\\n Tube Type\\n ETT:\\n Position: cm at teeth\\n Route:\\n Type: Not applicable\\n Size: Not applicable\\n Tracheostomy tube:\\n Type: Cuffed, Extra Length\\n Manufacturer: Portex\\n Size: 7.0mm\\n PMV:\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 28 cmH2O\\n Cuff volume: mL /\\n Airway problems:\\n Comments:\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Diminished\\n Comments:\\n Secretions\\n Sputum color / consistency: Yellow / Thick\\n Sputum source/amount: Suctioned / Moderate\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance:\\n Visual assessment of breathing pattern:\\n Assessment of breathing comfort:\\n Non-invasive ventilation assessment:\\n Invasive ventilation assessment:\\n Trigger work assessment:\\n Dysynchrony assessment:\\n Comments:\\n Plan\\n Next 24-48 hours:\\n Reason for continuing current ventilatory support:\\n Respiratory Care Shift Procedures\\n Transports:\\n Destination (R/T)\\n Time\\n Complications\\n Comments\\n Bedside Procedures:\\n Comments:\\n ------ Protected Section------\\n Original note did not copy!\\n ------ Protected Section Error Entered By: , \\n on: 16:51 ------\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2167-10-07 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 636229,\n \"text\": \"Demographics\\n Day of mechanical ventilation: 19\\n Ideal body weight: 61.2 None\\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: Yes\\n Tracheostomy tube:\\n Type: Standard, Cuffed, Inner Cannula\\n Manufacturer: Portex\\n Size: 7.0mm\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 28 cmH2O\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Diminished\\n Secretions\\n Sputum color / consistency: Yellow / Thick\\n Sputum source/amount: Suctioned / Moderate\\n Ventilation Assessment\\n Level of breathing assistance: Continuous invasive ventilation\\n Visual assessment of breathing pattern: Normal quiet breathing;\\n Comments: Pt placed on MMV due to periods of apnea after given\\n sedatives. Then pt was weaned back to PS.\\n Assessment of breathing comfort: No claim of dyspnea)\\n Plan\\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\\n Reduce PEEP as tolerated\\n Reason for continuing current ventilatory support: Intolerant of\\n weaning attempts; Comments: Pt desating to 87% when PEEP weaned to 5\\n from 8.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-15 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 637621,\n \"text\": \"Tachycardia, Other\\n Assessment:\\n Continues to be Tachycardia in 120-145 (anxiety). SBP has been 100-145\\n without ectopy.\\n Action:\\n No medication given for tachycardia.Pt gets Valium 5 mg scheduled Q6H\\n with little effect. CTA done to r/o pe as a source of tachycardia.\\n Response:\\n Results pending on CTA.\\n Plan:\\n Continue to evaluate HR and BP for need of treatment.\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Pt has a known DVT to RUE. Today pt had a US of LUE to R/O DVT as a\\n source of tachycardia.\\n Action:\\n After DVT found, IVF stopped.\\n Response:\\n Pt found to have a clot to Lt ax vein and MD notified.\\n Plan:\\n Pt to cont coumadin tonight, awaiting dosage for inr 1.4 . ? Access now\\n that Lt arm has a DVT.\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt has been restless most of the day. Pt only follow direct commands.\\n When asked to keep her hand off the TC, she will for only 3sec, and\\n then she will reach for it again.\\n Action:\\n Pt given valium, morphine and haldol prn.\\n Response:\\n Little effect noted from sedations.\\n Plan:\\n Continue to eval MS.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-15 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 637674,\n \"text\": \"56 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\\n with prolonged hospital course c/b by PNA, anxiety/altered mental\\n status, RUE DVT .Pt found to have small non occlusive Clot on her right\\n axial vein via Ultrasound.\\n Tachycardia, Other\\n Assessment:\\n Continues to be Tachycardia in 120-145 (anxiety). SBP has been 100-145\\n without ectopy.\\n Action:\\n No medication given for tachycardia.Pt gets Valium 5 mg scheduled Q6H\\n with little effect. CTA done to r/o pe as a source of tachycardia.\\n Response:\\n Results pending on CTA.\\n Plan:\\n Continue to evaluate HR and BP for need of treatment.\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Pt has a known DVT to RUE. Today pt had a US of LUEand ruled out small\\n non occlusive clot on her left axial vein.\\n Action:\\n Dr ,pt received ceftriaxone via PICC line.Coumadin dosage\\n increased from 2.5 to 5 mg ( INR 1.4).\\n Response:\\n Repeat ultrasound orderd for right arm to check old clot. Pt received 5\\n mg coumadin at 2200.\\n Plan:\\n Ultrasound today,cont coumadin and closely monitor INR.\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt has been restless most of the night. Pt nodded her head for pain and\\n simple yes or no questions.pt got disconnected byself from vent onetime\\n Action:\\n Pt given scheduled Valium with little effect.Pt received 2 mg morphine\\n PRN at 0620 .\\n Response:\\n Pt slept for a while,Hr dropped to 120s at the time of rest.\\n Plan:\\n Continue to eval MS,Valium and PRN Morphine and haldol?.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt rested on CPAP+ PS 50%/,sats stayed upper 90\\ns,Pt found to have\\n TF coming around Tracheostomy. As well as from her mouth\\n Action:\\n Cont pulm toilet as needed,Held TF throughout the night .Pressure\\n support dropped to 8 from10\\n Response:\\n Pt suctioned for small- moderate amount thick yellow secretions.No more\\n leakage noted around the tracheostomy as well as Minimal residuals from\\n PEG tube.Pt had to put back on 10 tachypnea and tachycardia\\n Plan:\\n Continue to wean pt off vent and place on TC once pt can tol it again\\n and frequent pulmonary toileting. Restart TF?\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-15 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 637844,\n \"text\": \"Pt down to IR for replacement of PEG with J-tube d/t high risk of\\n aspiration. Unable to place jtube at this time d/t type of peg in\\n place. Will need surgery to remove PEG in IR and IR will place j tube\\n at later date.\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Left hand to elbow area with edema 2mm\\nknown DVT to left axillary vein;\\n US of right arm\\n Action:\\n DL PICC d/c\\nd; left arm elevated on pillow; US results pnd for right\\n arm\\n Response:\\n PIV placed for access issues to right arm; edema unchanged;\\n Plan:\\n Cont to monitor left arm status; no BP/blood draws left arm. NIBP cuff\\n to right calf. F/U w/ team Re: right arm status\\n Hypernatremia (high sodium)\\n Assessment:\\n hypernatremic\\n Action:\\n Free water boluses cont; bloused with D5W/500cc\\n Response:\\n Remains hypernatremic with min improvement\\n Plan:\\n Cont with free water boluses; check labs am\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Restless, anxious am\\n Action:\\n Trach collar placed 70% early am--\\n Response:\\n Brief episode of desaturation to mid 80\\ns requiring increase of Fi02 to\\n 100% briefly (approx 20min); placed on 70% remainder of shift with\\n adequate o2 sats in low 90\\ns;NOTE: pt vomited approx 50cc clear liquid\\n prior to going to IR also had some clear lix come from trach\\npossible\\n aspiration\\nteam notified. Placed on PSV at 1840 to rest\\n Plan:\\n Rest overnight; ?aspiration. Hold TF for now\\nf/u team re: free water\\n boluses. CXR am. Monitor resp status closely.\\n Tachycardia, Other\\n Assessment:\\n Tachy to 130-140\\ns continuous while awake; continuous tachy in 120\\n while sound asleep\\n Action:\\n Standing valium decreased; cont with fent patch; morphine and haldol\\n prn\\n Response:\\n No significant change in level of restlessness/anxiety; freq pulling at\\n any objects/lines with short term memory issues; no significant\\n response to IV morphine; was able to obtain some sleep after 2mg haldol\\n ivp\\n Plan:\\n Cont to closely monitor mental status; maintain safety w/use of\\n restraints, soft wrist restraints and bed alarm. Assess degree of\\n change with titration of meds\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-16 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 637909,\n \"text\": \"56 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\\n with prolonged hospital course c/b by PNA, anxiety/altered mental\\n status, RUE DVT .Pt found to have small non occlusive Clot on her right\\n axial vein via Ultrasound.Yesterday Pt went down to IR for Peg revision\\n aspiration riskcouldn\\nt do it,due the type of peg she has now.\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Pt has known DVT to left axillary vein; US of right arm showed no\\n clots.\\n Action:\\n DL PICC d/c\\nd; from left arm and elevated on pillow and received\\n Coumadin scheduled dose.\\n Response:\\n PIV placed for access issues to right arm; edema looks better;\\n Plan:\\n Cont to monitor left arm status; no BP/blood draws left arm PICC line\\n to right arm?.\\n Hypernatremia (high sodium)\\n Assessment:\\n Hypernatremic NA was 146 yesterday evening.\\n Action:\\n Started on D5 W at 100cc/hr for 1000cc,held free wqater bolus \\n aspiration..\\n Response:\\n Awaiting for AM lab report.\\n Plan:\\n Cont with D5W,follow up with AM lab,resume Free water bolus via PEG\\n tube?.\\n Tachycardia, Other\\n Assessment:\\n Tachy to 130-140\\ns continuous while awake; HR stayed 90- 120 sound\\n asleep\\n Action:\\n Standing valium decreased; cont with fent patch; morphine and haldol\\n prn.Bilateral restraints on\\n Response:\\n No significant change in level of restlessness/anxiety; freq pulling at\\n any objects/lines with short term memory issues. She keeps\\n disconnecting from vent,desat to low 80s within seconds.\\n Plan:\\n Cont to closely monitor mental status; maintain safety w/use of\\n restraints, soft wrist restraints and bed alarm. PRN Haldol or\\n Morphine.\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt has been slept most of the time,hard to wake up.responded to deep\\n stimuli.\\n Action:\\n Held Scheduled dose of valium at 2200.Pt has Fentanyl 75 mcg patch on\\n her lleft thigh.\\n Response:\\n Pt start waking up around 0300,got disconnected from vent by\\n herself,given valium 2.5 mg at 0315.\\n Plan:\\n Continue to eval MS,Valium and PRN Morphine and haldol?,cont reorient\\n and emotional support to pt .\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-16 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 637910,\n \"text\": \"56 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\\n with prolonged hospital course c/b by PNA, anxiety/altered mental\\n status, RUE DVT .Pt found to have small non occlusive Clot on her right\\n axial vein via Ultrasound.Yesterday Pt went down to IR for Peg revision\\n aspiration riskcouldn\\nt do it,due the type of peg she has now.\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Pt has known DVT to left axillary vein; US of right arm showed no\\n clots.\\n Action:\\n DL PICC d/c\\nd; from left arm and elevated on pillow and received\\n Coumadin scheduled dose.\\n Response:\\n PIV placed for access issues to right arm; edema looks better;\\n Plan:\\n Cont to monitor left arm status; no BP/blood draws left arm PICC line\\n to right arm?.\\n Hypernatremia (high sodium)\\n Assessment:\\n Hypernatremic NA was 146 yesterday evening.\\n Action:\\n Started on D5 W at 100cc/hr for 1000cc,held free wqater bolus \\n aspiration..\\n Response:\\n Awaiting for AM lab report.\\n Plan:\\n Cont with D5W,follow up with AM lab,resume Free water bolus via PEG\\n tube?.\\n Tachycardia, Other\\n Assessment:\\n Tachy to 130-140\\ns continuous while awake; HR stayed 90- 120 sound\\n asleep\\n Action:\\n Standing valium decreased; cont with fent patch; morphine and haldol\\n prn.Bilateral restraints on\\n Response:\\n No significant change in level of restlessness/anxiety; freq pulling at\\n any objects/lines with short term memory issues. She keeps\\n disconnecting from vent,desat to low 80s within seconds.\\n Plan:\\n Cont to closely monitor mental status; maintain safety w/use of\\n restraints, soft wrist restraints and bed alarm. PRN Haldol or\\n Morphine.\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt has been slept most of the time,hard to wake up.responded to deep\\n stimuli.\\n Action:\\n Held Scheduled dose of valium at 2200.Pt has Fentanyl 75 mcg patch on\\n her lleft thigh.\\n Response:\\n Pt start waking up around 0300,got disconnected from vent by\\n herself,given valium 2.5 mg at 0315.\\n Plan:\\n Continue to eval MS,Valium and PRN Morphine and haldol?,cont reorient\\n and emotional support to pt .\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-16 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 637915,\n \"text\": \"Chief Complaint: Tracheomalacia\\n 24 Hour Events:\\n ULTRASOUND - At 08:11 AM\\n right arm - negative for DVT\\n PICC LINE - STOP 12:02 PM\\n - IR unable to advance PEG\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Ceftriaxone - 10:00 PM\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:12 AM\\n Morphine Sulfate - 12:00 PM\\n Haloperidol (Haldol) - 02:00 PM\\n Diazepam (Valium) - 03:52 PM\\n Furosemide (Lasix) - 06:40 AM\\n Other medications:\\n Changes to medical and family history:\\n None\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:50 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.9\\nC (98.4\\n Tcurrent: 36.2\\nC (97.1\\n HR: 139 (97 - 146) bpm\\n BP: 133/67(84) {93/43(55) - 183/129(134)} mmHg\\n RR: 18 (13 - 33) insp/min\\n SpO2: 96%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 1,220 mL\\n 568 mL\\n PO:\\n TF:\\n IVF:\\n 500 mL\\n 568 mL\\n Blood products:\\n Total out:\\n 1,514 mL\\n 150 mL\\n Urine:\\n 1,439 mL\\n 150 mL\\n NG:\\n 75 mL\\n Stool:\\n Drains:\\n Balance:\\n -294 mL\\n 418 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask , Tracheostomy tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 384 (311 - 675) mL\\n PS : 10 cmH2O\\n RR (Spontaneous): 12\\n PEEP: 5 cmH2O\\n FiO2: 70%\\n RSBI: 52\\n PIP: 15 cmH2O\\n SpO2: 96%\\n ABG: ///31/\\n Ve: 4.6 L/min\\n Physical Examination\\n General Appearance: No acute distress\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: Normocephalic\\n Lymphatic: Cervical WNL\\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic,\\n No(t) Diastolic), tachy\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : )\\n Abdominal: Soft, Non-tender, Bowel sounds present\\n Extremities: Right: Absent, Left: Absent\\n Skin: Warm\\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\\n assessed, Tone: Not assessed\\n Labs / Radiology\\n 395 K/uL\\n 9.0 g/dL\\n 619 mg/dL\\n 0.7 mg/dL\\n 31 mEq/L\\n 3.3 mEq/L\\n 6 mg/dL\\n 91 mEq/L\\n 129 mEq/L\\n 29.7 %\\n 7.0 K/uL\\n [image002.jpg]\\n 03:36 AM\\n 04:40 PM\\n 03:00 AM\\n 07:05 PM\\n 03:00 AM\\n 05:00 AM\\n 02:06 AM\\n 07:34 AM\\n 03:50 AM\\n 06:22 AM\\n WBC\\n 7.2\\n 5.2\\n 5.9\\n 7.5\\n 5.6\\n 6.1\\n 7.0\\n Hct\\n 26.9\\n 26.0\\n 27.2\\n 26.8\\n 27.0\\n 27.0\\n 29.7\\n Plt\\n 238\\n 240\\n 296\\n \\n 395\\n Cr\\n 0.6\\n 0.9\\n 0.7\\n 0.6\\n 0.7\\n 0.6\\n 0.5\\n 0.7\\n TCO2\\n 26\\n Glucose\\n 115\\n 106\\n 100\\n 134\\n 134\\n 121\\n 619\\n Other labs: PT / PTT / INR:23.4/29.6/2.3, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:8.4 mg/dL, Mg++:1.9 mg/dL, PO4:3.9\\n mg/dL\\n Microbiology: 7:34 am STOOL CONSISTENCY: FORMED\\n Source: Stool.\\n **FINAL REPORT **\\n CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final ):\\n Feces negative for C.difficile toxin A & B by EIA.\\n (Reference Range-Negative).\\n .\\n 7:33 am BLOOD CULTURE Source: Line-picc.\\n **FINAL REPORT **\\n Blood Culture, Routine (Final ): NO GROWTH\\n Assessment and Plan\\n Assessment and Plan\\n 55yoF with history of EtOH abuse presenting following mechanical fall\\n and traumatic T spine fracture, now s/p trach, PEG, placement being\\n treated for HAP.\\n # HAP vs Aspiration PNA: Cultures grew, Klebsiella Oxytoca, Klebsiella\\n Pneumoniae, GNR, GP Cocci. Has completed 8 day course of Ceftriaxone.\\n Has had occasional low grade fevers, but has continued to improve\\n clinically. Had a sputum gram stain from w/ GPC p/c. a new VAP/HAP\\n w/ staph possible, but given no clear infiltrate on CXR and good\\n respiratory status, significant PNA is unlikely, colonization of\\n tracheostomy tube is more likely, as is contamination of sputum. Given\\n improving clinical picture, will wait until CX data or change in\\n clinical status or CXR to initiate HAP/VAP treatment.\\n - D/c Ceftriaxone\\n - Continue to f/u cultures\\n .\\n # Respiratory failure: Improving status. Will continue to increase\\n time on trach mask as tolerated.\\n - PMV with suctioning.\\n - Weaning FiO2 as tolerated\\n .\\n # Tachycardia: Pt in ST 120\\ns to 150s. Etiology remains unclear and\\n include hypovolemia, pain, infection (pt with known klebsiella), and\\n incrased work of breathing from secretions and tracheomalacia, . DDx\\n also includes PE given hx of RUE DVT, mucus plugging given large\\n amount of secretions, and spinal injury. Tachycardia is unresponsive to\\n IVF, Pt has had a negative CT-PA and has not had sig response to pain\\n meds. Has completed treatment for her HAP. Thyroid function was checked\\n and had normal TSH and T3 and free T4. Had been on albuterol q4 and\\n atrovent , she has not been wheezing, and perhaps she is sensitive to\\n the B-agonist.\\n - Continue Pain Control\\n - Change albuterol to PRN\\n - Test if HR decreases when placed on higher pressure support\\n for period of time.\\n .\\n # Sedation: Has had inconsistent response to sedation, unclear what is\\n best regime. Will continue to wean overall\\n - Change to haldol 2.5 PRN, Fentanyl 75 mcg TP, Morphine PRN,\\n Benadryl, Valium 5mg PRN\\n .\\n # Adrenal Insufficency: Followed up with endocrine that suggested if\\n the patient under goes major stressors such as major surgery, sepsis,\\n she may need stress dosed steroids.\\n - Will consider MRI at later date for evaluation of pituitary\\n .\\n # Fluid Status: Volume overloaded in prior setting of Hypernatremia\\n - Monitoring urine output\\n - increasse Free H20, for mild hypernatremia 200cc Free bolus PEG, and\\n - 500cc D5W at 125.\\n - PM lytes to assess hypernatremia\\n .\\n # UE DVT: right has resolved, new non occlusive in left axillary. INR\\n 1.5\\n -continue coumadin\\n -follow INR\\n - D/c Left PICC line, and place peripheral IVs. If unable, can place a\\n R PICC.\\n .\\n # Spine fracture: Stable\\n - Brace for OOB, will discuss with Neurosurgery if current brace is\\n optimal for stabilization given her mobility.\\n - Pt to follow up with Dr. in weeks\\n .\\n # Tracheomalacia?: Was initially addressed with IP and they wanted to\\n follow up as outpatient.\\n - Consult IP for stent placement given improved clinical status, will\\n readdresses\\n .\\n #. Thyroid Nodule on CT\\n - Outpatient follow up\\n # Nutrition: Pt had emesis and extrusion of gastric contents through\\n tracheostomy site (not through tube).\\n - TFs held\\n - Consult IR for advancement of her PEG to jejunum.\\n # Glycemic control: SSI, well controlled\\n # PIV x 1\\n # Ppx: Restarting Coumadin, Ranitidine, Bowel Regimen PRN\\n # Communication:\\n - Boyfriend of 10 \\n - Brother also involved\\n # Code: Full\\n # Dispo: ICU, Screening for vent facilities\\n ICU Care\\n Nutrition:\\n Comments: Tube feeds\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n 20 Gauge - 12:26 PM\\n Prophylaxis:\\n DVT: (Systemic anticoagulation: Coumadin)\\n Stress ulcer: PPI\\n VAP:\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds Comments:\\n Code status: Full code\\n Disposition:ICU\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-16 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 637994,\n \"text\": \"Airway Clearance, Impaired\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Tachycardia, Other\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Alteration in Nutrition\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Impaired Skin Integrity\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-16 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 637997,\n \"text\": \"56 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\\n with prolonged hospital course c/b by PNA, anxiety/altered mental\\n status, RUE DVT .Pt found to have small non occlusive Clot on her right\\n axial vein via Ultrasound.Yesterday Pt went down to IR for Peg revision\\n aspiration risk couldn\\nt do it due the type of peg she has now.\\n Airway Clearance, Impaired\\n Assessment:\\n Pt continues to have copious amount of secretions. She was placed on\\n 50% trach mask at 6am and continues on it. She was on a passey muir\\n valve for several hours during the afternoon but was only removed due\\n to secretions.\\n Action:\\n Pt has been suctioned q1-2h for a large amount of creamy white\\n secretions.\\n Response:\\n O2 sats have been between 95-98% with RR 24-32\\n Plan:\\n Suction PRN, continue to monitor\\n Tachycardia, Other\\n Assessment:\\n Her HR continues to be tachy, 130-140. B/P 140-150/60-70.\\n Action:\\n She was started on lopressor this am. The first dose was 12.5 mg with\\n no change in HR, she has received 25mg at 1600.\\n Response:\\n She continues to be tachy but her HR is 130\\ns vs her normal 140\\n Plan:\\n Continue to monitor HR, ask MD\\ns about increasing her dose.\\n Alteration in Nutrition\\n Assessment:\\n She remains NPO while the MD\\ns decide what to do to get a post pyloric\\n feeding tube in place.\\n Action:\\n PEG in her stomach so free water and meds have been given into her PEG.\\n Response:\\n Remains NPO.\\n Plan:\\n Continue to give meds and free water into peg, await medical plan from\\n MD\\n Impaired Skin Integrity\\n Assessment:\\n The area around her trach is slightly reddened. The surgeons came by\\n this am and removed the remaining stitches that held the trach tube on\\n to her skin\\n Action:\\n Trach care done with some antibiotic ointment.\\n Response:\\n Area still reddened but no longer being pulled by the stitches\\n Plan:\\n Continue to monitor the redness, continue trach \\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-19 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 638436,\n \"text\": \"Chief Complaint: resp failure\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 24 Hour Events:\\n Another episode of emesis\\n Was on MMV\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Diazepam (Valium) - 12:00 AM\\n Furosemide (Lasix) - 01:30 AM\\n Morphine Sulfate - 02:00 AM\\n Pantoprazole (Protonix) - 08:24 AM\\n Other medications:\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 10:35 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.1\\nC (98.8\\n Tcurrent: 36.6\\nC (97.8\\n HR: 101 (74 - 137) bpm\\n BP: 105/57(67) {75/42(50) - 130/73(108)} mmHg\\n RR: 24 (12 - 28) insp/min\\n SpO2: 97%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 3,165 mL\\n 1,720 mL\\n PO:\\n TF:\\n 691 mL\\n IVF:\\n 1,574 mL\\n 1,665 mL\\n Blood products:\\n Total out:\\n 1,670 mL\\n 1,020 mL\\n Urine:\\n 1,470 mL\\n 965 mL\\n NG:\\n 200 mL\\n 55 mL\\n Stool:\\n Drains:\\n Balance:\\n 1,495 mL\\n 700 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask , Tracheostomy tube\\n Ventilator mode: MMV/PSV/AutoFlow\\n Vt (Set): 500 (500 - 500) mL\\n Vt (Spontaneous): 94 (94 - 450) mL\\n PS : 10 cmH2O\\n RR (Set): 12\\n RR (Spontaneous): 0\\n PEEP: 5 cmH2O\\n FiO2: 60%\\n RSBI Deferred: No Spon Resp\\n PIP: 20 cmH2O\\n SpO2: 97%\\n ABG: ///38/\\n Ve: 5.6 L/min\\n Physical Examination\\n Gen: sitting in bed, alert NAD\\n CV: tachy RR\\n Ches: bibasilar rhonchi no hweezest\\n Abd; soft NT\\n Ex: no edemat\\n Neuro: alert, follows simple commands and mouth words grip and \\n strength inlower ext\\n Labs / Radiology\\n 8.6 g/dL\\n 467 K/uL\\n 131 mg/dL\\n 0.7 mg/dL\\n 38 mEq/L\\n 3.4 mEq/L\\n 8 mg/dL\\n 101 mEq/L\\n 145 mEq/L\\n 27.8 %\\n 6.9 K/uL\\n [image002.jpg]\\n 03:00 AM\\n 05:00 AM\\n 02:06 AM\\n 07:34 AM\\n 03:50 AM\\n 06:22 AM\\n 02:58 AM\\n 03:43 AM\\n 05:02 PM\\n 03:36 AM\\n WBC\\n 5.2\\n 5.9\\n 7.5\\n 5.6\\n 6.1\\n 7.0\\n 7.1\\n 7.1\\n 6.9\\n Hct\\n 26.0\\n 27.2\\n 26.8\\n 27.0\\n 27.0\\n 29.7\\n 28.9\\n 29.2\\n 27.8\\n Plt\\n 35\\n 52\\n 467\\n Cr\\n 0.6\\n 0.7\\n 0.6\\n 0.5\\n 0.7\\n 0.7\\n 0.6\\n 0.7\\n 0.8\\n 0.7\\n Glucose\\n 100\\n 134\\n 134\\n 121\\n 04\\n 108\\n 131\\n Other labs: PT / PTT / INR:38.8/34.5/4.2, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:9.4 mg/dL, Mg++:2.3 mg/dL, PO4:4.2\\n mg/dL\\n Assessment and Plan\\n 1. Tachycardia: runs of atach versus AVNRT. On bblocker be not very\\n effective- EP consult for ? is there an ablatable focus.\\n 2. Resp Failure\\n Trach mask trials as tolerating (needing QHS support at\\n present)\\n PMV trials\\n S/P rx for pan Klebs PNA.\\n Per IP not stent planned as technically not possible to\\n place into her airway\\n 3. DVT and coagulopathy On warfarin but high inr. Hold warfarin until\\n inr 2-2.5 range or bridge with loveox if may get procedures\\n 4. Feeding tube Getting reglan trial but still with emesis. Need to\\n coordinate IR advance of G to J tube with Thoracics\\n 5. Hypernatremia Replete free water.\\n Please see today\\ns ICU team note for other issues.\\n ICU Care\\n Nutrition: TFs\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n Prophylaxis:\\n DVT: anti coag\\n Stress ulcer: ppi\\n Communication: trying to reach boyfriend\\n status: Full code\\n Disposition : ICU, start screening still need to fix tachycardia\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-19 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 638444,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n 8pm: Vomited tube feeds while receiving free water flushes. Suctioned\\n by RT and no apparent aspiration, only blood tinged sputum. O2 sats\\n 99-100%. No increased O2 requirement. Held TF, given free water via IV\\n 100 cc/hr x 1L since Na 148. Will need to reassess in am, CXR ordered\\n for am.\\n Thoracics recs: place dophoff post pyloric or have GI place pedi GT\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Diazepam (Valium) - 12:00 AM\\n Furosemide (Lasix) - 01:30 AM\\n Morphine Sulfate - 02:00 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:21 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.4\\nC (99.3\\n Tcurrent: 36.8\\nC (98.3\\n HR: 113 (81 - 137) bpm\\n BP: 78/45(52) {78/39(50) - 130/73(108)} mmHg\\n RR: 12 (12 - 32) insp/min\\n SpO2: 97%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 3,165 mL\\n 700 mL\\n PO:\\n TF:\\n 691 mL\\n IVF:\\n 1,574 mL\\n 700 mL\\n Blood products:\\n Total out:\\n 1,670 mL\\n 680 mL\\n Urine:\\n 1,470 mL\\n 680 mL\\n NG:\\n 200 mL\\n Stool:\\n Drains:\\n Balance:\\n 1,495 mL\\n 20 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: MMV/PSV/AutoFlow\\n Vt (Set): 500 (500 - 500) mL\\n Vt (Spontaneous): 94 (94 - 450) mL\\n PS : 10 cmH2O\\n RR (Set): 12\\n RR (Spontaneous): 7\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n RSBI Deferred: No Spon Resp\\n PIP: 25 cmH2O\\n SpO2: 97%\\n ABG: ///38/\\n Ve: 5.1 L/min\\n Physical Examination\\n Gen: Obtunded this am, not responsive to voice, minimally responsive to\\n noxious stimuli, on MMV through trach tube\\n HEENT: PERRL, MMM,\\n Resp: Limited by patients mobility, but CTA anteriorly and laterally,\\n no rales, rhonchi, or wheezing, some referred upper airway noises from\\n secretions.\\n Card: S1S2 tachicardic, no m/r/g\\n Abd: Obese, soft, Non-distended, BS+\\n Exte: No edema, DP 2+, RP2+ bil.\\n NEURO: Toes downgoing bilaterally, patellar reflexs 2+ bil, biceps 2+\\n bil,\\n Labs / Radiology\\n 467 K/uL\\n 8.6 g/dL\\n 131 mg/dL\\n 0.7 mg/dL\\n 38 mEq/L\\n 3.4 mEq/L\\n 8 mg/dL\\n 101 mEq/L\\n 145 mEq/L\\n 27.8 %\\n 6.9 K/uL\\n [image002.jpg]\\n COAGs: 38.8/34.5/4.2\\n 03:00 AM\\n 05:00 AM\\n 02:06 AM\\n 07:34 AM\\n 03:50 AM\\n 06:22 AM\\n 02:58 AM\\n 03:43 AM\\n 05:02 PM\\n 03:36 AM\\n WBC\\n 5.2\\n 5.9\\n 7.5\\n 5.6\\n 6.1\\n 7.0\\n 7.1\\n 7.1\\n 6.9\\n Hct\\n 26.0\\n 27.2\\n 26.8\\n 27.0\\n 27.0\\n 29.7\\n 28.9\\n 29.2\\n 27.8\\n Plt\\n 35\\n 52\\n 467\\n Cr\\n 0.6\\n 0.7\\n 0.6\\n 0.5\\n 0.7\\n 0.7\\n 0.6\\n 0.7\\n 0.8\\n 0.7\\n Glucose\\n 100\\n 134\\n 134\\n 121\\n 04\\n 108\\n 131\\n Other labs: PT / PTT / INR:66.1/32.7/8.0, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:9.4 mg/dL, Mg++:2.3 mg/dL, PO4:4.2\\n mg/dL\\n Assessment and Plan\\n 55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\\n trach, PEG, placement no with respiratory failure secondary to\\n tracheomalacia , resolving HAP.\\n .\\n # Respiratory failure: Slowly Improving. Now remaining on trach mask\\n for most of the day and night, with periods of pressure support of \\n over night. Last night required MMV and was not breathing well while\\n asleep, likely oversedated with Benadryl, Morhpine, and Valium\\n administered in the early morning. Pt awake and alert at rounds,\\n interactive, and breathing comfortably on trach mask\\n - Continue to increase time on trach mask as tolerated.\\n - Decrease sedation and valium use see Sedation below\\n - PMV with suctioning again today.\\n .\\n # HAP vs Aspiration PNA: Afebrile without leukocytosis\\n - Completed course of ceftriaxone\\n - good O2 saturation on trach mask\\n - Continue to f/u cultures\\n .\\n # Tachycardia: Previously was assessed as sinus tach with occasional\\n runs of SVT and sources such as hypovolemia, PE, infection, and pain\\n were assessed as possibly etiologies. But, now appears to be SVT for\\n much of time, rhythm/rate nonresponsive to carotid massage. HR\\n occaisonaly decreases to 70s-80s w/ stable BPs at times that might be\\n associated with administration of her BB and valium. Rhythm strip shows\\n conversion from a narrow complex SVT to normal sinus rhythm and then\\n back. Metroprolol was increased from 25mg TID to QID yesterday, without\\n any affect on the SVT.\\n - EP consulted for conversion of SVT, appreciate recs\\n .\\n # Sedation: Inconsistent response to sedation, unclear what is best\\n regime. Will continue to wean overall.\\n - Continue w Olanzapine QHS\\n - D/d valium to 2.5 mg TID and leave just valium 2.5 mg PRN.\\n # Nutrition: Pt has had several episodes of vomiting up her TFs,\\n reglan started to increase GI motility, but pt had another episode of\\n vomiting last night.\\n - Hold TFs\\n - Thoracic surgery recs: 1) oral/nasal tube in post-piloric position,\\n or 2) IR to place a pediatric feeding tube through her PEG site to a\\n post-piloric position.\\n - Will attempt to coordinate thoracic surgery and IR for tube placement\\n tomorrow.\\n .\\n # Adrenal Insufficency: Endocrine following. Pt does not appear to be\\n adrenally insufficient at baseline. Suggesting if the patient under\\n goes major stressors such as major surgery, sepsis, she may need stress\\n dosed steroids.\\n .\\n # Fluid Status: Likely approaching euvolemia, though still has mild\\n hypernatramia which may suggest is still intravascularly depleated.\\n - Monitoring urine output\\n - FW flushes w/ tube feeds held due to vomitting\\n - will provide D5W IVF as need for hypernatremia and follow lytes\\n .\\n # UE DVT and elevated INR: DVT in right UE has resolved, new\\n non-occlusive in left axillary vein. INR supratherapeutic today\\n - COumadin held, will restart at low dose when INR approaches\\n therapeutic range.\\n - INR 4.2 today, will check PM coags and consider restarting at a low\\n dose tonight or tomorrow morning.\\n .\\n # Spine fracture: Stable\\n - Brace for OOB, will discuss with Neurosurgery if current brace is\\n optimal for stabilization given her mobility.\\n - Pt to follow up with Dr. in weeks\\n .\\n # Tracheomalacia. Was initially addressed with IP and they wanted to\\n follow up as outpatient. IP reevaluated and does not believe that a\\n stent would be feasible.\\n .\\n #. Thyroid Nodule on CT\\n - Outpatient follow up\\n .\\n # Glycemic control: SSI, well controlled\\n # PIV x 1\\n # Ppx: Coumadin, Ranitidine, Bowel Regimen PRN\\n # Communication:\\n - Boyfriend of 10 \\n - Brother also involved\\n - Will contact Social and Case management today\\n # Code: Full\\n # Dispo: ICU, Screening for vent facilities\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2167-10-14 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 637448,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 26\\n Ideal body weight: 61.2 None\\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: Yes\\n Procedure location:\\n Reason:\\n Tube Type\\n Tracheostomy tube:\\n Type: Standard, Cuffed, Inner Cannula\\n Manufacturer: Portex\\n Size: 7.0mm\\n PMV: No\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 25 cmH2O\\n Cuff volume: mL /\\n Lung sounds\\n RLL Lung Sounds: Clear\\n RUL Lung Sounds: Rhonchi\\n LUL Lung Sounds: Rhonchi\\n LLL Lung Sounds: Clear\\n Secretions\\n Sputum color / consistency: Yellow / Plug\\n Sputum source/amount: Suctioned / Small\\n Comments/Plan\\n Pt agitated overnight, more sedation received with fairly good effect.\\n Administering Albuterol and Atrovent MDI\\ns as ordered, see flowsheet\\n for rx times and data. RSBI=171 this am. Will follow, trache mask\\n trials as tolerated.\\n 05:38\\n\"\n },\n {\n \"category\": \"Nutrition\",\n \"chartdate\": \"2167-10-15 00:00:00.000\",\n \"description\": \"Clinical Nutrition Note\",\n \"row_id\": 637769,\n \"text\": \"Objective\\n Pertinent medications: noted\\n Labs:\\n Value\\n Date\\n Glucose\\n 134 mg/dL\\n 02:06 AM\\n Glucose Finger Stick\\n 139\\n 10:00 AM\\n BUN\\n 11 mg/dL\\n 02:06 AM\\n Creatinine\\n 0.6 mg/dL\\n 02:06 AM\\n Sodium\\n 146 mEq/L\\n 02:06 AM\\n Potassium\\n 4.0 mEq/L\\n 02:06 AM\\n Chloride\\n 106 mEq/L\\n 02:06 AM\\n TCO2\\n 32 mEq/L\\n 02:06 AM\\n Albumin\\n 3.5 g/dL\\n 03:00 AM\\n Calcium non-ionized\\n 9.2 mg/dL\\n 02:06 AM\\n Phosphorus\\n 4.0 mg/dL\\n 02:06 AM\\n Ionized Calcium\\n 1.24 mmol/L\\n 02:51 AM\\n Magnesium\\n 2.1 mg/dL\\n 02:06 AM\\n Current diet order / nutrition support: Replete c. Fiber @60mL/hr (1440\\n kcals/89 gr aa)\\n GI: Abd: soft/dist/+bs\\n Assessment of Nutritional Status\\n Estimation of current intake: Adequate\\n Specifics:\\n Pt continues on TF\\ns for full nutrition support via PEG, currently\\n tolerating @ goal s/ problems. (Noted TF\\ns were off over weekend / ?\\n aspiration event) FWB down to 100mL q 4 hr c/ Na WNL. BG\\ns well\\n controlled.\\n Medical Nutrition Therapy Plan - Recommend the Following\\n Multivitamin / Mineral supplement: via TF\\n Tube feeding recommendations: Continue TF's @ goal\\n Monitor fluid status and adjust FWB prn.\\n BG and lyte management as you are\\n Please check current wt\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-15 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 637774,\n \"text\": \"Chief Complaint: resp failuire\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 24 Hour Events:\\n ULTRASOUND - At 03:48 PM\\n US of Lt arm shows small 1 cm axillary clot non occlusive near PICC\\n RUS US shows resolution of formal clot\\n Vomiting tube feeds around trach\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Ceftriaxone - 10:00 PM\\n Infusions:\\n Other ICU medications:\\n Morphine Sulfate - 06:20 AM\\n Pantoprazole (Protonix) - 08:12 AM\\n Other medications:\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Gastrointestinal: Emesis\\n Flowsheet Data as of 10:59 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.5\\nC (99.5\\n Tcurrent: 36.2\\nC (97.1\\n HR: 146 (123 - 146) bpm\\n BP: 153/129(134) {106/41(56) - 185/129(142)} mmHg\\n RR: 26 (11 - 33) insp/min\\n SpO2: 96%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 1,888 mL\\n 520 mL\\n PO:\\n TF:\\n 1,268 mL\\n IVF:\\n 100 mL\\n Blood products:\\n Total out:\\n 1,530 mL\\n 845 mL\\n Urine:\\n 1,510 mL\\n 820 mL\\n NG:\\n 20 mL\\n 25 mL\\n Stool:\\n Drains:\\n Balance:\\n 358 mL\\n -325 mL\\n Respiratory support\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 227 (227 - 397) mL\\n PS : 8 cmH2O\\n RR (Spontaneous): 20\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n RSBI: 194\\n PIP: 16 cmH2O\\n SpO2: 96%\\n ABG: ///34/\\n Ve: 6.5 L/min\\n Physical Examination\\n Labs / Radiology\\n 8.5 g/dL\\n 335 K/uL\\n 121 mg/dL\\n 0.5 mg/dL\\n 34 mEq/L\\n 3.8 mEq/L\\n 7 mg/dL\\n 107 mEq/L\\n 147 mEq/L\\n 27.0 %\\n 5.6 K/uL\\n [image002.jpg]\\n 03:08 PM\\n 03:00 AM\\n 03:36 AM\\n 04:40 PM\\n 03:00 AM\\n 07:05 PM\\n 03:00 AM\\n 05:00 AM\\n 02:06 AM\\n 07:34 AM\\n WBC\\n 7.3\\n 6.1\\n 7.2\\n 5.2\\n 5.9\\n 7.5\\n 5.6\\n Hct\\n 27.6\\n 26.5\\n 26.9\\n 26.0\\n 27.2\\n 26.8\\n 27.0\\n Plt\\n 189\\n 209\\n 238\\n \\n 335\\n Cr\\n 0.6\\n 0.6\\n 0.9\\n 0.7\\n 0.6\\n 0.7\\n 0.6\\n 0.5\\n TCO2\\n 26\\n Glucose\\n 99\\n 115\\n 106\\n 100\\n 134\\n 134\\n 121\\n Other labs: PT / PTT / INR:16.6/25.0/1.5, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:9.3 mg/dL, Mg++:2.3 mg/dL, PO4:4.1\\n mg/dL\\n Assessment and Plan\\n 55 yr old alcoholic s/p t spine fx s/p trcah and PEG with persistent\\n resp failure\\n 1. Resp Failure: currently on trach mask, can do a few hours per\\n day, then needs for support. New pan Klebs in sputum, day\\n . Try more vent support and see if it helps her.\\n 2. Fevers: did not persist- cultures neg to date.\\n 3 Hemodynamics: persistant simus tachy\\n CTPA to look for emboli\\n negative for proximal clot. IOs the of trach mask and her TB\\n malacia too much for her. We will see what happens if we out her on\\n 15-20 and 5.\\n 4. New L Ext DVT\\n 5. Emesis: call IR and get g pushed to a j tube\\n ICU Care\\n Nutrition: tfs held for vomiting\\n Glycemic Control:\\n Lines:\\n PICC Line - 09:19 PM\\n Prophylaxis:\\n DVT: coumadin\\n Stress ulcer: ppi\\n Communication: try to reach boyfriend\\n status: Full code\\n Disposition :ICU\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-14 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 637612,\n \"text\": \"Tachycardia, Other\\n Assessment:\\n Hr has been in sinus tachycardia all day at 130-140\\ns, Hr noted to also\\n stay elevated in the 130\\ns while at rest also. SBP has been elevated\\n throughout the day at 150-170\\ns while awake and 120-130\\ns while at\\n rest. Pt also very restless.\\n Action:\\n No med to be given for tachycardia or BP MD. Pt given Morphine and\\n haldol for restlessness w/o effect. Pt also on valium ATC w/little\\n effect. CTA done to r/o pe as a source of tachycardia.\\n Response:\\n Results pending on CTA.\\n Plan:\\n Continue to evaluate HR and BP for need of treatment.\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Pt has a known DVT to RUE. Today pt had a US of LUE to R/O DVT as a\\n source of tachycardia.\\n Action:\\n After DVT found, IVF stopped.\\n Response:\\n Pt found to have a clot to Lt ax vein and MD notified.\\n Plan:\\n Pt to cont coumadin tonight, awaiting dosage for inr 1.4 . ? Access now\\n that Lt arm has a DVT.\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt has been restless most of the day. Pt only follow direct commands.\\n When asked to keep her hand off the TC, she will for only 3sec, and\\n then she will reach for it again.\\n Action:\\n Pt given valium, morphine and haldol prn.\\n Response:\\n Little effect noted from sedations.\\n Plan:\\n Continue to eval MS.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-15 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 637618,\n \"text\": \"Tachycardia, Other\\n Assessment:\\n Continues to be Tachycardia in 120-145 (anxiety). SBP has been 100-145\\n without ectopy.\\n Action:\\n No medication given for tachycardia.Pt gets Valium 5 mg scheduled Q6H\\n with little effect. CTA done to r/o pe as a source of tachycardia.\\n Response:\\n Results pending on CTA.\\n Plan:\\n Continue to evaluate HR and BP for need of treatment.\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Pt has a known DVT to RUE. Today pt had a US of LUE to R/O DVT as a\\n source of tachycardia.\\n Action:\\n After DVT found, IVF stopped.\\n Response:\\n Pt found to have a clot to Lt ax vein and MD notified.\\n Plan:\\n Pt to cont coumadin tonight, awaiting dosage for inr 1.4 . ? Access now\\n that Lt arm has a DVT.\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt has been restless most of the day. Pt only follow direct commands.\\n When asked to keep her hand off the TC, she will for only 3sec, and\\n then she will reach for it again.\\n Action:\\n Pt given valium, morphine and haldol prn.\\n Response:\\n Little effect noted from sedations.\\n Plan:\\n Continue to eval MS.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-17 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 638072,\n \"text\": \"Tachycardia, Other\\n Assessment:\\n HR continues to be 120-140\\n Action:\\n On Lopressor 25 mg TID\\n Response:\\n Needs further titration upwards\\n Plan:\\n Continue to titrate BB as BP allows\\n Airway Clearance, Impaired\\n Assessment:\\n Pt with copious secretions Suctioned A 30-1 hour for thick white\\n secretions Sats stable 92-96%\\n Action:\\n Placed back on vent overnight to allow for periods of rest, Lavaged by\\n RT x 2\\n Response:\\n Secretions diminished as night when on\\n Plan:\\n Continue with aggressive pulmonary toliet\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt continues to be agitated, following commands inconsistently. MAE,\\n PERRLA. Soft restraints remain in place to prevent dislodgement of\\n trach\\n Action:\\n On valium TID given dose of Zyprexa at HS\\n Response:\\n Pt able to sleep in extended naps overnight, less agitated\\n Plan:\\n Continue to follow mental status, try to D/C restraints when able\\n Impaired Skin Integrity\\n Assessment:\\n Area around track red & excoriated\\n Action:\\n Trach care provided, Antibiotic ointment placed\\n Response:\\n Plan:\\n Continue to monitor\\n Alteration in Nutrition\\n Assessment:\\n Pt remains NPO DT high aspiration risk, no residual overnight\\n Action:\\n Started on raglan QID, ? needs feeding tube changed to post pyloric\\n Response:\\n No evidence of aspiration overnight\\n Plan:\\n Awaiting surgery input re: Advancement of feeding tube\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2167-10-18 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 638279,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 30\\n Ideal body weight: 61.2 None\\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: Yes\\n Tracheostomy tube:\\n Type: Standard, Cuffed\\n Manufacturer: Portex\\n Size: 7.0mm\\n PMV: Not wearing\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 25 cmH2O\\n Cuff volume: mL /\\n :\\n Lung sounds\\n RLL Lung Sounds: Clear\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Clear\\n Comments:\\n Secretions\\n Sputum color / consistency: Yellow / Thick\\n Sputum source/amount: Suctioned / Small\\n Comments:\\n Plan\\n Next 24-48 hours:\\n : Continue T-collar as tolerated\\n Respiratory Care Shift Procedures\\n Transports:\\n Destination (R/T)\\n Time\\n Complications\\n Comments\\n Bedside Procedures:\\n Comments:\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2167-10-19 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 638339,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 31\\n Ideal body weight: 61.2 None\\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: Yes\\n Tracheostomy tube:\\n Type: Standard, Cuffed\\n Manufacturer: Portex\\n Size: 8.0mm\\n PMV:\\n Lung sounds\\n RLL Lung Sounds: Clear\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Clear\\n Secretions\\n Sputum color / consistency: White / Thick\\n Sputum source/amount: Suctioned / Moderate\\n Ventilation Assessment\\n Level of breathing assistance: Continuous invasive ventilation\\n Visual assessment of breathing pattern: Normal quiet breathing\\n Assessment of breathing comfort: No claim of dyspnea)\\n Invasive ventilation assessment:\\n Trigger work assessment: Triggering synchronously\\n Plan\\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\\n Periodic SBT's for conditioning; Comments: Continue with trach trials\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-05 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 635876,\n \"text\": \"Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Pt cont on Heparin gtt @ 1500units/h. PTT in therapeutic range.\\n Coumadin po HS.\\n Action:\\n No further action taken.\\n Response:\\n Plan:\\n Daily PT/PTT levels,? Plan to transition off heparin and increase\\n coumadin dose.\\n Altered mental status (not Delirium)\\n Assessment:\\n PT alert and very agitated throughout shift- making several attempts to\\n pull at trach\\n.fell asleep briefly following afternoon valium dose-\\n Systolic dropped into low 80s, HR in the 50s- SB. Following commands\\n inconsistently.\\n Action:\\n Fentanyl/versed titrated throughout shift. Restarted on Haldol IV prn,\\n and given addititional one time dose of valium. Soft wrist restraints\\n in place for safety. EKG done of QTC interval\\n Response:\\n Cont to be anxious, attempting to pull at trach. QTI -442\\n Plan:\\n Cont daily QTC Intervals, titrate down Fent/versed Gtt as able.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Hypernatremia (high sodium)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-05 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 635877,\n \"text\": \"55 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\\n Now with prolonged hospital course c/b by PNA with high PEEP\\n requirement, anxiety, RUE DVT on heparin qtt.\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Pt cont on Heparin gtt @ 1500units/h. PTT in therapeutic range.\\n Coumadin po HS.\\n Action:\\n No further action taken.\\n Response:\\n Plan:\\n Daily PT/PTT levels-? Plan to transition off heparin and increase\\n coumadin dose.\\n Altered mental status (not Delirium)\\n Assessment:\\n PT alert and very agitated throughout shift- making several attempts to\\n pull at trach\\n.fell asleep briefly following afternoon valium dose-\\n Systolic dropped into low 80s, HR in the 50s- SB. Following commands\\n inconsistently.\\n Action:\\n Fentanyl/versed titrated throughout shift. Restarted on Haldol IV prn,\\n and given addititional one time dose of valium. Soft wrist restraints\\n in place for safety. EKG done of QTC interval\\n Response:\\n Cont to be anxious, attempting to pull at trach. QTI -442\\n Plan:\\n Cont daily QTC Intervals, titrate down Fent/versed Gtt as able, cont w/\\n prn haldol and standing valium.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Cont to be trached/vented on AC. Pleural effusions on CXR worsening.\\n Action:\\n Tolerated PS briefly this am. ABG/VBG collected\\n Response:\\n Pt w/ periods of apnea on PS.\\n Plan:\\n Non-contrast CT today to check size of pleural effusions, ? tap\\n effusions following CT, make vent changes as needed, wean fent/versed\\n as able to tolerate vent changes. Recheck ABG/VBG this evening.\\n Hypernatremia (high sodium)\\n Assessment:\\n NA level cont to be ^^\\n Action:\\n FWB increased to 300cc every 4 hrs.\\n Response:\\n Lytes to be rechecked this evening\\n Plan:\\n Check day and evening lytes, cont w/ q 4h boluses\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-05 00:00:00.000\",\n \"description\": \"Physician Resident/Attending Progress Note - MICU\",\n \"row_id\": 635878,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n On lasix drip\\n Attempted to wean FiO2\\n No acute events\\n No BM\\n Agitated this am\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions :\\n Midazolam (Versed)\\n 1 mg/hour\\n Furosemide (Lasix)\\n 2 mg/hour\\n Heparin Sodium\\n 1,500 units/hour\\n Fentanyl\\n 75 mcg/hour\\n Other ICU medications:\\n Other medications:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:23 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.3\\nC (99.2\\n Tcurrent: 36.9\\nC (98.5\\n HR: 126 (49 - 131) bpm\\n BP: 156/84(117) {78/38(52) - 164/95(125)} mmHg\\n RR: 20 (9 - 21) insp/min\\n SpO2: 96%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 4,160 mL\\n 1,185 mL\\n PO:\\n TF:\\n 1,267 mL\\n 315 mL\\n IVF:\\n 1,018 mL\\n 260 mL\\n Blood products:\\n Total out:\\n 4,015 mL\\n 2,090 mL\\n Urine:\\n 4,015 mL\\n 2,090 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 145 mL\\n -905 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 400 (400 - 500) mL\\n Vt (Spontaneous): 675 (675 - 675) mL\\n PS : 8 cmH2O\\n RR (Set): 18\\n RR (Spontaneous): 0\\n PEEP: 10 cmH2O\\n FiO2: 50%\\n RSBI Deferred: PEEP > 10\\n PIP: 19 cmH2O\\n Plateau: 16 cmH2O\\n SpO2: 96%\\n ABG: 7.39/46/118/28/2\\n Ve: 8.9 L/min\\n PaO2 / FiO2: 236\\n Physical Examination\\n General Appearance: Intubated and sedated. Responsive, following\\n commands, Overweight / Obese, mild agitation but NAD\\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\\n deviation\\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\\n Cardiovascular: (S1: Normal), (S2: Normal), distant\\n Respiratory / Chest: (Expansion: Symmetric), CTA anteriorly, decreased\\n BS\\n Abdominal: Obese, Firm, Non-tender, no rebound, no guarding, + BS, PEG\\n in place with dressing C/D/I\\n Extremities: No clubbing or cyanosis, 1+ nonpitting edema of b/l hands,\\n anasarca\\n Skin: no rashes or jaundice\\n Lines: r brachioceph ART and L PICC C/D/I\\n Labs / Radiology\\n 272 K/uL\\n 8.6 g/dL\\n 128 mg/dL\\n 0.6 mg/dL\\n 28 mEq/L\\n 3.1 mEq/L\\n 8 mg/dL\\n 110 mEq/L\\n 148 mEq/L\\n 27.4 %\\n 11.2 K/uL\\n [image002.jpg]\\n 05:17 PM\\n 11:41 PM\\n 03:06 AM\\n 03:38 AM\\n 04:05 PM\\n 03:55 AM\\n 07:19 AM\\n 11:24 AM\\n 03:18 PM\\n 02:47 AM\\n WBC\\n 10.6\\n 10.0\\n 8.3\\n 11.2\\n Hct\\n 27.3\\n 25.8\\n 24.6\\n 27.4\\n Plt\\n 72\\n Cr\\n 0.5\\n 0.6\\n 0.6\\n 0.5\\n 0.6\\n 0.6\\n TCO2\\n 32\\n 31\\n 29\\n 29\\n Glucose\\n 110\\n 94\\n 111\\n 106\\n 121\\n 123\\n 137\\n 128\\n Other labs: Ca++:9.0 mg/dL, Mg++:2.6 mg/dL, PO4:4.3 mg/dL\\n Assessment and Plan\\n 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA and\\n ARDS intubated since the end of now s/p trach and PEG placement.\\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\\n volume overload. Intubated on for resp decompensation. Stenting\\n unlikely to help for trachiomalacia as airways have poor structure\\n diffusely. S/P Trach and PEG on . Increased effusion on recent\\n CXR.\\n - wean FiO2 as tolerated\\n - non-con head CT to further characterize pulmonary effusions,\\n det potential for thoracentesis\\n # Adrenal Insufficency: Hypotension that resolved with steroids,\\n returned as they came off and is now improved again. Possible primary\\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\\n started on .\\n - wean per endo recs, decrease to q8 today, likely q12 dosing\\n tomorrow\\n # Volume overloaded in setting of hypernatremia with TBW deficit.\\n - Lasix gtt, continue with goal -1-2 L per day.\\n - electrolytes\\n - continue tube feeds with free water flushes increase from 250 to 300\\n cc q4\\n # Sedation: Sedation control remains somewhat poor although fentanyl\\n patch and diazpem are likely therapeutic range today. On Versed 2.0,\\n Fentanyl 100, Fentanyl patch, Diazepam standing and haldo 2.5-5 mg\\n PRN. QTc increased to 480.\\n - Wean versed/fentanyl as tolerated, continue diazepam in\\n hopes for vent facility placement\\n - Increase diazepam to 12mg q4\\n - Check ekg for QTc\\n if <480, restart haldol and/or increase\\n fentanyl patch\\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\\n coumadin at least until s/p trach.\\n - heparin gtt restarted\\n - coumadin 5mg G-tube today\\n hold coumadin today for possible \\n # Constipation\\n current regimen of colace and senna, stooled during\\n rounds\\n - dulcolax PO/PR\\n - reassess and increase bowel regimen PRN\\n # Spine fracture: Neurologically intact distal to the lesion. Prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - CT of C, L spine when stable. Currently, unlikely to change\\n management and high risk for complications with transport.\\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\\n is low. Brace for OOB. Ok for anticoag per note.\\n -f/u full trauma spine eval from OSH to determine need for further back\\n imaging in-house (to be done )\\n # Nutrition: Tube feeds with free water flushes, tolerating well,\\n continue Replete (Full) - 11:20 AM 30 mL/hour\\n # Glycemic control: SSI, well controlled\\n # Lines L PICC () and R ART ()\\n both working well, check\\n ABG/VBG today\\n if correlate well, d/c art line\\n # Ppx: heparin, ranitidine, VAP prevention, colace and senna\\n # Communication:\\n - Boyfriend of 10 is her HCP. Also brother is involved\\n Code: Full\\n Dispo: ICU, being screening for vent facilities\\n ------ Protected Section ------\\n MICU ATTENDING ADDENDUM\\n I saw and examined the patient, and was physically present with the ICU\\n team for the key portions of the services provided. I agree with the\\n note above, including the assessment and plan. I would emphasize and\\n add the following points: 55F T5-8 fractures with retropulsion and ARDS\\n from klebsiella VAP; on heparin for UE DVT and lasix for volume\\n overload. Tolerating slow vent wean but failed SBT. Was TBB negative\\n yesterday with lasix drip; sedation remains challenging.\\n Exam notable for Tm 99.4 BP 145/77 HR 120 RR 18-20 with sat 97% on VAC\\n 400x18 PEEP 8 FiO2 0.5. TBB -2L/24h, +9L/MICU LOS. Eyes opens, will\\n squeeze hands and wiggle toes but very drowsy. Bronchial BS bilaterally\\n with RRR s1s2 SM at base. Abdomen is distended with decreased BS.\\n 1+ edema in BLE, no cords. Labs notable for WBC 11K, HCT 27, K+ 3.1, Na\\n 148, Cr 0.6. CXR with resolving B LL airspace disease and effusions.\\n Agree with plan to continue supportive care and wean vent as we\\n continue diuresis with attention to contraction alkalosis. Will check\\n CT without contrast to assess lung parenchyma and effusions. Will\\n increase fentanyl patch to 200 and valium to 15 TID po in addition to\\n drips. Will check EKG prior to reinitiating haldol, which worked very\\n well for her. Will wean hydrocortisone 25 q8 today and reduce to q12\\n tomorrow, with long term goal for oral prednisone. Will continue IV\\n heparin for UE DVT and continue transition to anticoagulation with\\n coumadin. Will restart tube feeds and continue FW boluses for\\n hypernatremia. Continue spinal stabilization with brace when OOB. Will\\n eventually need MRI for surgical planning; remainder of plan as\\n outlined above.\\n Patient is critically ill\\n Total time: 40 min\\n ------ Protected Section Addendum Entered By: , MD\\n on: 02:40 PM ------\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-09-28 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 635021,\n \"text\": \"Events: Wean from vent to 10 PEEP- tolerating w/ goal sat >90%. Lasix\\n gtt started for volume overload. IP then consulted for ?\\n trach/PEG . Plan NPO @ MS, Hep gtt off @ 0600 anticipation add on\\n in or for open trach/PEG. MS n to acutely agitation-\\n Versed and Fent gtt titrated- bolus PRN and starting PO Valium, Fent\\n patch and IV Haldol for improved and longer acting pain control and ?\\n delirium.\\n Edema, peripheral\\n Assessment:\\n 3+ anasarca, pitting and dependent edema\\n Action:\\n Starting Lasix gtt @ 5cc/gr for goal >100cc/hr output\\n Response:\\n Initial reaction > 1L / 1 and\\n hrs, titrated down to 2cc/hr with\\n recent history of hypotensive w/ sedation\\n Plan:\\n monitor I+O, Resume Lasix gtt for goal UOP > 100cc/hr, BP\\n monitoring, monitor edema\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Hep gtt infusing @ 1700 units/hr, no s/s bleeding\\n Action:\\n gtt\\n Response:\\n No change\\n Plan:\\n Hep gtt PT w/ AM Labs- off @ 0600 for anticipated trach/page \\n Impaired Skin Integrity\\n Assessment:\\n Anasarca, excoriated/mild rash/reddened but blancking perianal area,\\n mild shearing tear in perianal area, pannus folds w/o infection, left\\n palp near ? friction skin impairment\\n Action:\\n Multipodus boots on, thin duoderm to bilat elbows, duoderm to left\\n palm, barrier cream on perianal area-attempting to reposition,\\n attempting IV/PO, pain patch and emotional support for decrease\\n shearing movement in bed\\n Response:\\n No new breakdown in skin integrity noted\\n Plan:\\n comitor breakdown in skin integrity, minimize fracture and\\n pressure- turning and pressure reduction as tolerated, duodern,\\n emotional support and medications\\n Altered mental status (not Delirium)\\n Assessment:\\n MS variable from sedated to acutely agitated attempting to hit while\\n being turned,/oral care, intermittently alert, following commands\\n nodding and mouthing words-pt unable to use white board, BP w/\\n MS- when sedated SBP 88-90\\ns, agitated 140-160\\ns- art line positional\\n Action:\\n IV sedation as HD necessary, blousing PRN, inc dose on IV Haldol,\\n attempting to wean IV sedation w/ additional of Fentanyl patch and PO\\n valium, emotional support\\n Response:\\n MS , occ apears in pain and attempting to move in bed,\\n others acutely agitated- pulling @ line and actively pointing and\\n attempting to pull @ ETT\\n Plan:\\n IV medication, patch and PO medication for sedation/pain\\n medication, emotional support, encourage nodding/use of white boad for\\n expression as tolerated, repositioning\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n LS diminished throughout, scant suctioning clear white secretions, goal\\n sat >90%\\n Action:\\n PEEP from 15-10, administering IV Lasix gtt,\\n Response:\\n LS unchanges, ABD w/I pt normal limits, - inc WOB w/ agitation,\\n Plan:\\n Monitor resp status, ABG as needed, wean as tolerated, monitor sat,\\n emotional support- trach/PEG \\n Hypernatremia (high sodium)\\n Assessment:\\n NA 146\\n Action:\\n Administering changed flush to 150cc free water Q 4hrs\\n Response:\\n minimal residuals\\n Plan:\\n free water flushes, monitor NA, s/s hypernatremia\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-09-28 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 635022,\n \"text\": \"Events: Wean from vent to 10 PEEP- tolerating w/ goal sat >90%. Lasix\\n gtt started for volume overload. IP then consulted for ?\\n trach/PEG . Plan NPO @ MS, Hep gtt off @ 0600 anticipation add on\\n in or for open trach/PEG. MS n to acutely agitation-\\n Versed and Fent gtt titrated- bolus PRN and starting PO Valium, Fent\\n patch and IV Haldol for improved and longer acting pain control and ?\\n delirium.\\n Edema, peripheral\\n Assessment:\\n 3+ anasarca, pitting and dependent edema\\n Action:\\n Starting Lasix gtt @ 5cc/gr for goal >100cc/hr output\\n Response:\\n Initial reaction > 1L / 1 and\\n hrs, titrated down to 2cc/hr with\\n recent history of hypotensive w/ sedation\\n Plan:\\n monitor I+O, Resume Lasix gtt for goal UOP > 100cc/hr, BP\\n monitoring, monitor edema\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Hep gtt infusing @ 1700 units/hr, no s/s bleeding\\n Action:\\n gtt\\n Response:\\n No change\\n Plan:\\n Hep gtt PT w/ AM Labs- off @ 0600 for anticipated trach/page \\n Impaired Skin Integrity\\n Assessment:\\n Anasarca, excoriated/mild rash/reddened but blancking perianal area,\\n mild shearing tear in perianal area, pannus folds w/o infection, left\\n palp near ? friction skin impairment\\n Action:\\n Multipodus boots on, thin duoderm to bilat elbows, duoderm to left\\n palm, barrier cream on perianal area-attempting to reposition,\\n attempting IV/PO, pain patch and emotional support for decrease\\n shearing movement in bed\\n Response:\\n No new breakdown in skin integrity noted\\n Plan:\\n comitor breakdown in skin integrity, minimize fracture and\\n pressure- turning and pressure reduction as tolerated, duodern,\\n emotional support and medications\\n Altered mental status (not Delirium)\\n Assessment:\\n MS variable from sedated to acutely agitated attempting to hit while\\n being turned,/oral care, intermittently alert, following commands\\n nodding and mouthing words-pt unable to use white board, BP w/\\n MS- when sedated SBP 88-90\\ns, agitated 140-160\\ns- art line positional\\n Action:\\n IV sedation as HD necessary, blousing PRN, inc dose on IV Haldol,\\n attempting to wean IV sedation w/ additional of Fentanyl patch and PO\\n valium, emotional support\\n Response:\\n MS , occ apears in pain and attempting to move in bed,\\n others acutely agitated- pulling @ line and actively pointing and\\n attempting to pull @ ETT\\n Plan:\\n IV medication, patch and PO medication for sedation/pain\\n medication, emotional support, encourage nodding/use of white boad for\\n expression as tolerated, repositioning\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n LS diminished throughout, scant suctioning clear white secretions, goal\\n sat >90%\\n Action:\\n PEEP from 15-10, administering IV Lasix gtt,\\n Response:\\n LS unchanges, ABD w/I pt normal limits, - inc WOB w/ agitation,\\n Plan:\\n Monitor resp status, ABG as needed, wean as tolerated, monitor sat,\\n emotional support- trach/PEG \\n Hypernatremia (high sodium)\\n Assessment:\\n NA 146\\n Action:\\n Administering changed flush to 150cc free water Q 4hrs\\n Response:\\n minimal residuals\\n Plan:\\n free water flushes, monitor NA, s/s hypernatremia\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-09-20 00:00:00.000\",\n \"description\": \"Physician Resident Admission Note\",\n \"row_id\": 634095,\n \"text\": \"TITLE: PGY3 MICU Admission Note\\n Chief Complaint: persistent respiratory failure\\n HPI:\\n 55 year old woman with hx of obesity presented to Medical Center\\n on after falling down stairs while at home. She suffered a\\n traumatic T5-8 fracture with retropulsion of fragments. Per medical\\n records and discussion with her brother, she was awake for the fall (no\\n LOC) and the fall was triggered by unsteady gait, potentially\\n influenced by alcohol. Her fracture was managed concervatively. She\\n was placed in a torso brace but her course was complicated by\\n respiratory failure requiring intubation. At that time a CT was\\n negative for PE but showed bilateral bibasilar consolidations vs\\n atelectasis. At that time an ABG was 7.20/89/57 (unknown FIO2 but\\n likely >6L facemask). She was intubated on at 08:40. The\\n respiratory failure was thought likely to be related to pain med\\n induced hypoventilation, bronchospasm, or restricted breathing duet to\\n the back brace. The hospital course was complicated by\\n difficulty weaning form the ventilator. Her periodic agitation was\\n managed with seroquel. Prior to transfer her vent settings were: SIMV\\n 12x600 FIO2 0.45.\\n The neurosurgery service evaluated her and recommended concervative\\n management of her fracture including a back brace and outpatient\\n neurosurgery followup. The CT chest showed notable narrowing of her\\n central airways and the patient was referred for Interventional\\n Pulmonary evaluation for airway stenting.\\n Patient admitted from: Transfer from other hospital\\n History obtained from Family / Medical records\\n Patient unable to provide history: Sedated\\n Allergies:\\n Last dose of Antibiotics:\\n Infusions:\\n Fentanyl - 100 mcg/hour\\n Midazolam (Versed) - 2 mg/hour\\n Other ICU medications:\\n Other medications:\\n Home Medications:\\n ativan prn\\n prilosec OTC\\n Medications on transfer:\\n dexmedetomidine\\n senna 2 tabs qhs\\n zofran 4 mg IV q6hr:prn\\n tinzaparin 4500 units q24\\n acetaminophen 650 mg q6prn\\n famotidine 20 mg IV daily\\n colace 100 mg \\n albuterol/ipratropium INH q4\\n seroquel 50 mg \\n lactated ringer's @75cc/hr\\n Past medical history:\\n Family history:\\n Social History:\\n GERD\\n s/p TAH\\n s/p left total hip replacement\\n s/p appendectomy\\n remote benign breast mass\\n nc\\n Occupation: regional manager at insurance company\\n Drugs: denies\\n Tobacco: unknown\\n Alcohol: heavy\\n Other:\\n Review of systems:\\n Flowsheet Data as of 03:00 AM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36\\nC (96.8\\n Tcurrent: 36\\nC (96.8\\n HR: 75 (75 - 90) bpm\\n BP: 106/43(59) {106/43(59) - 154/71(103)} mmHg\\n RR: 12 (12 - 18) insp/min\\n SpO2: 100%\\n Total In:\\n 10 mL\\n 32 mL\\n PO:\\n TF:\\n IVF:\\n 10 mL\\n 32 mL\\n Blood products:\\n Total out:\\n 425 mL\\n 225 mL\\n Urine:\\n 425 mL\\n 225 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -416 mL\\n -194 mL\\n Respiratory\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 500 (500 - 500) mL\\n RR (Set): 12\\n RR (Spontaneous): 0\\n PEEP: 12 cmH2O\\n FiO2: 100%\\n PIP: 34 cmH2O\\n SpO2: 100%\\n ABG: 7.42/47/61/30/4\\n Ve: 6.1 L/min\\n PaO2 / FiO2: 61\\n Physical Examination\\n General Appearance: Overweight / Obese\\n Eyes / Conjunctiva: PERRL, Sclera edema\\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\\n (Breath Sounds: Rhonchorous: bilaterally)\\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended, Obese\\n Extremities: Right: Trace, Left: Trace, Cyanosis\\n Skin: Warm\\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\\n stimuli, Movement: Purposeful, Sedated, Tone: Not assessed\\n Labs / Radiology\\n 333 K/uL\\n 9.7 g/dL\\n 103 mg/dL\\n 0.6 mg/dL\\n 6 mg/dL\\n 30 mEq/L\\n 109 mEq/L\\n 3.8 mEq/L\\n 150 mEq/L\\n 30.7 %\\n 9.7 K/uL\\n [image002.jpg]\\n \\n 2:33 A9/6/ 11:54 PM\\n \\n 10:20 P9/7/ 01:00 AM\\n \\n 1:20 P\\n \\n 11:50 P\\n \\n 1:20 A\\n \\n 7:20 P\\n 1//11/006\\n 1:23 P\\n \\n 1:20 P\\n \\n 11:20 P\\n \\n 4:20 P\\n WBC\\n 9.7\\n Hct\\n 30.7\\n Plt\\n 333\\n Cr\\n 0.6\\n TC02\\n 32\\n Glucose\\n 103\\n Other labs: PT / PTT / INR:13.8/22.4/1.2, ALT / AST:30/19, Alk Phos / T\\n Bili:149/0.7, Differential-Neuts:76.9 %, Lymph:17.3 %, Mono:3.0 %,\\n Eos:2.5 %, Albumin:3.0 g/dL, LDH:222 IU/L, Ca++:8.6 mg/dL, Mg++:2.1\\n mg/dL, PO4:4.1 mg/dL\\n ECG: sinus @ @86. low voltage. nl axis and intervals. no ischemic\\n changes.\\n Assessment and Plan\\n A/P: 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture\\n Respiratory failure: initially likely multifactorial including\\n bronchspasm, hypoventilation from narcotics, and potential aspiration.\\n prior evaluation negative for PE. still with significant A-a gradient.\\n cxr appears under penetrated with small lung fields and potential\\n effusion on right. potentially from additional pulmonary edema, however\\n hypernatremia would limit ability to diurese.\\n - daily chest xray\\n - will hold on CT chest or airway pending IP consult\\n - IP consult\\n - vent settings: AC 500 x14 PEEP >8 (given body habitus), FIO2 as\\n needed\\n - sedation: fentanyl gtt/versed bolus\\n - trial of diuresis when able\\n Spine fracture: neurologically intact distal to the lesion. prior notes\\n from MMC neurosurgeons indicated no surgical procedure needed and would\\n continue with spine brace.\\n - monitor distal neurologic function\\n - cto brace x3 months unless supine in bed\\n Anemia: admission to MMC was ~40 now down to 30% w/o sign of active GI\\n bleed or other source of blood loss. likely related to crystalloid\\n administration, anemia of inflammation, chronic phlebotomy. given bili\\n and LDH normal would be unlikely for hemolysis.\\n - trend Hct\\n - guaiac stools\\n Hypernatremia: most likely related to inadequate free water repletion.\\n free water defecit ~3L.\\n - replete via OGT primarily\\n - D5W x1 L\\n ICU Care\\n Nutrition:\\n Comments: tube feed with free water\\n nutrition consult\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n PICC Line - 10:30 PM\\n 18 Gauge - 10:30 PM\\n 20 Gauge - 01:36 AM\\n Prophylaxis:\\n DVT: SQ UF Heparin\\n Stress ulcer: H2 blocker\\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\\n Need for restraints reviewed\\n Comments:\\n Communication: Family meeting held , ICU consent signed Comments: \\n (brother) \\n (boyfriend/POA) \\n Code status: Full code\\n Disposition: ICU\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2167-10-03 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 635640,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation:\\n Ideal body weight:\\n Ideal tidal volume:\\n Airway\\n Airway Placement Data\\n Known difficult intubation:\\n Procedure location:\\n Reason:\\n Tube Type\\n ETT:\\n Position:\\n Route:\\n Type:\\n Size:\\n Tracheostomy tube:\\n Type:\\n Manufacturer:\\n Size:\\n PMV:\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure:\\n Cuff volume:\\n Airway problems:\\n Comments:\\n Lung sounds\\n RLL Lung Sounds:\\n RUL Lung Sounds:\\n LUL Lung Sounds:\\n LLL Lung Sounds:\\n Comments:\\n Secretions\\n Sputum color / consistency:\\n Sputum source/amount:\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance:\\n Visual assessment of breathing pattern:\\n Assessment of breathing comfort:\\n Non-invasive ventilation assessment:\\n Invasive ventilation assessment:\\n Trigger work assessment:\\n Dysynchrony assessment:\\n Comments:\\n Plan\\n Next 24-48 hours:\\n Reason for continuing current ventilatory support:\\n Respiratory Care Shift Procedures\\n Transports:\\n Destination (R/T)\\n Time\\n Complications\\n Comments\\n Bedside Procedures:\\n Comments:\\n Specialized Gas Therapy\\n Nitric Oxide\\n PPM used: ppm\\n Indication:\\n Effect of therapy: []\\n Nitric Oxide trial:\\n Comments:\\n HeliOx:\\n Additional O[2] by cannula: L/min\\n Continuous nebulized bronchodilator:\\n Comments:\\n Recruitment Maneuvers Done\\n CPAP pressure used: cm H2O\\n Duration: sec\\n Times per shift:\\n Comments:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-05 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 635868,\n \"text\": \"Impaired Skin Integrity\\n Assessment:\\n Skin warm to touch, yeast-like red rash under skin folds, coccyx\\n red,\\n skin intact.\\n Action:\\n Miconazole powder applied to skin folds/periarea. Miconazole skin\\n cream barrier applied to coccyx. Frequent repositioning.\\n Response:\\n Cont w/ rash\\n Plan:\\n Cont w/ frequent repositioning and current skin care regimen\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Pt cont on Heparin gtt @ 1500units/h. PTT in therapeutic range.\\n Coumadin po HS.\\n Action:\\n No further action taken.\\n Response:\\n Plan:\\n Daily PT/PTT levels,? Plan to transition off heparin and increase\\n coumadin dose.\\n Altered mental status (not Delirium)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Hypernatremia (high sodium)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-05 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 635874,\n \"text\": \"Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Pt cont on Heparin gtt @ 1500units/h. PTT in therapeutic range.\\n Coumadin po HS.\\n Action:\\n No further action taken.\\n Response:\\n Plan:\\n Daily PT/PTT levels,? Plan to transition off heparin and increase\\n coumadin dose.\\n Altered mental status (not Delirium)\\n Assessment:\\n PT alert and very agitated throughout shift\\n.fell asleep briefly\\n following afternoon valium dose- Systolic dropped into low 80s, HR in\\n the 50s- SB. Following commands inconsistently.\\n Action:\\n Response:\\n Plan:\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Hypernatremia (high sodium)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-09-28 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 634940,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n PICC placed, Central line d/c'd\\n Lasix 10 mg given with 400 cc UOP in afternoon, pH improved\\n Lasix 20 mg given at ~ 4AM.\\n Lots of thick sinus secreations\\n Delerium/anxiety overnight with periods of hypertension.\\n Could not draw of A-line.\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Aztreonam - 06:00 AM\\n Vancomycin - 09:00 AM\\n Levofloxacin - 08:06 AM\\n Infusions:\\n Midazolam (Versed) - 3 mg/hour\\n Fentanyl - 150 mcg/hour\\n Heparin Sodium - 1,700 units/hour\\n Other ICU medications:\\n Furosemide (Lasix) - 03:01 AM\\n Midazolam (Versed) - 04:36 AM\\n Fentanyl - 04:36 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:44 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.9\\nC (98.5\\n Tcurrent: 36.4\\nC (97.6\\n HR: 90 (47 - 92) bpm\\n BP: 118/59(80) {80/40(53) - 137/105(111)} mmHg\\n RR: 17 (15 - 24) insp/min\\n SpO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 101 kg (admission): 94.2 kg\\n Height: 67 Inch\\n CVP: 19 (16 - 19)mmHg\\n Total In:\\n 2,560 mL\\n 543 mL\\n PO:\\n TF:\\n 1,441 mL\\n 342 mL\\n IVF:\\n 1,020 mL\\n 201 mL\\n Blood products:\\n Total out:\\n 1,680 mL\\n 860 mL\\n Urine:\\n 1,680 mL\\n 860 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 880 mL\\n -317 mL\\n Respiratory support\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 400 (400 - 400) mL\\n RR (Set): 18\\n RR (Spontaneous): 0\\n PEEP: 15 cmH2O\\n FiO2: 50%\\n PIP: 27 cmH2O\\n Plateau: 23 cmH2O\\n SpO2: 98%\\n ABG: 7.41/45/77./28/2\\n Ve: 6.5 L/min\\n PaO2 / FiO2: 156\\n Physical Examination\\n General Appearance: No acute distress, Overweight / Obese, opens eyes\\n but no purposeful movement\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric)\\n Abdominal: No(t) Soft, Non-tender, Bowel sounds present, Distended\\n Extremities: No clubbing or cyanosis, 3+ nonpitting edema of b/l hands,\\n LE without edema\\n Skin: no rashes or jaundice\\n Labs / Radiology\\n 411 K/uL\\n 8.3 g/dL\\n 133 mg/dL\\n 0.5 mg/dL\\n 28 mEq/L\\n 4.1 mEq/L\\n 13 mg/dL\\n 111 mEq/L\\n 145 mEq/L\\n 26.0 %\\n 9.7 K/uL\\n [image002.jpg]\\n 04:05 PM\\n 01:12 AM\\n 04:00 AM\\n 04:09 AM\\n 10:18 AM\\n 02:33 PM\\n 02:46 PM\\n 03:31 AM\\n 02:26 PM\\n 05:53 PM\\n WBC\\n 9.6\\n 9.7\\n Hct\\n 27.8\\n 26.0\\n Plt\\n 374\\n 411\\n Cr\\n 0.5\\n 0.5\\n 0.5\\n 0.5\\n TCO2\\n 26\\n 27\\n 28\\n 29\\n 26\\n 27\\n 30\\n Glucose\\n 194\\n 195\\n 195\\n 163\\n 133\\n Other labs: PT / PTT / INR:15.3/69.9/1.3, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\\n Amylase / Lipase:, Differential-Neuts:86.1 %, Lymph:10.3 %,\\n Mono:2.8 %, Eos:0.5 %, Lactic Acid:2.0 mmol/L, Albumin:2.4 g/dL,\\n LDH:204 IU/L, Ca++:8.3 mg/dL, Mg++:2.2 mg/dL, PO4:3.5 mg/dL\\n Assessment and Plan\\n 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture with respiratory failure\\n and difficulty weaning from vent.\\n # Respiratory failure: Intubated on for resp decompensation.\\n Likely VAP. Unlikely to have tracheomalacia as initially\\n transferred for.\\n - wean PEEP\\n - Given mild alkalosis, will decrease RR to 18, repeat ABG\\n - discuss need for trach with patient and her family\\n - Will continue gentle diuresis once alkalosis resolved\\n # Pneumonia: Pansensitive Kleb oxytoca pneumonia and sputum with GPCs\\n on gram stain. Afebrile overnight. On levofloxacin since .\\n Vancomycin, aztreonam have been stopped. Resp status seems to be\\n improving.\\n - Follow cultures\\n - d/c levofloxacin having completed 8 day course\\n # Sedation: On versed and fentanyl\\n # EKG changes: Sinus bradycardia, now somewhat improved. Likely\\n related to increased vagal tone possibly related to steroid\\n replacement. Atrial EKG shows p-waves and cardiac enzymes normal.\\n - Continue to monitor\\n # Hypotension: Improved, off levophed for 2-3 days now, with good urine\\n output. CVP increasing with reduction in PEEP. Likely poor\\n adrenal response in setting of acute illness and very high PEEP.\\n -D/C fludricort and hydrocortisone now that the 5 day steroid course is\\n complete\\n -monitor, expect improvement with continual reduction in PEEP\\n # RUE DVT: Started on heparin gtt on , now therapeutic. Follow\\n PTTs. Would hold off on coumadin at least until s/p trach.\\n - continue to monitor\\n # Adrenal Insufficency: Random cortisol was approx 3 when it should\\n have been maximally stimulated.\\n - hydrocortisone and florinef for 5 days\\n # Anemia: Stable.\\n - Trend HCT\\n # Spine fracture: Neurologically intact distal to the lesion. Prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - CT of C, L spine when stable. Currently, unlikely to change\\n management and high risk for complications with transport.\\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\\n is low. Brace for OOB. Ok for anticoag per note.\\n # Communication:\\n - Boyfriend of 10 is her HCP. Also brother is involved\\n FEN/GI: Tube feeds @ goal\\n DVT: Treatment dose heparin\\n Ulcer: Ranitidine\\n VAP: Prevention per routine\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 08:12 PM 60 mL/hour\\n Glycemic Control:\\n Lines:\\n Arterial Line - 04:00 PM\\n PICC Line - 09:19 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-09-29 00:00:00.000\",\n \"description\": \"Physician Resident / Attending Progress Note - MIC\",\n \"row_id\": 635107,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n ARTERIAL LINE - STOP 09:00 PM - attempted to re-wire but\\n patient was very agitated and re-wire was unsuccessful\\n Patient alternated between tachycardia and normotension and hypotension\\n in the high-80s/low 90s and HRs in the 50s\\n Given haldol, valium, midaz and fentanyl for sedation\\n ABG with low paO2 on PEEP 10, had to increase -- went back up to 15 and\\n then attempted to re-wean down with goal 8 in anticipation of OR\\n To OR for trach and PEG today (thoracics)\\n Put on lasix drip and put out >1L in just over an hour\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Levofloxacin - 08:06 AM\\n Infusions:\\n Midazolam (Versed) - 1.5 mg/hour\\n Fentanyl - 200 mcg/hour\\n Other ICU medications:\\n Fentanyl - 06:45 PM\\n Ranitidine (Prophylaxis) - 08:00 PM\\n Haloperidol (Haldol) - 10:00 PM\\n Midazolam (Versed) - 10:00 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:03 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.7\\nC (99.8\\n Tcurrent: 37.7\\nC (99.8\\n HR: 109 (55 - 134) bpm\\n BP: 120/56(70) {80/43(51) - 133/85(94)} mmHg\\n RR: 20 (16 - 28) insp/min\\n SpO2: 97%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 101 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 3,064 mL\\n 404 mL\\n PO:\\n TF:\\n 1,440 mL\\n IVF:\\n 1,014 mL\\n 314 mL\\n Blood products:\\n Total out:\\n 4,257 mL\\n 1,195 mL\\n Urine:\\n 4,257 mL\\n 1,195 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,193 mL\\n -791 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 400 (400 - 400) mL\\n RR (Set): 18\\n RR (Spontaneous): 10\\n PEEP: 15 cmH2O\\n FiO2: 60%\\n RSBI Deferred: PEEP > 10\\n PIP: 23 cmH2O\\n Plateau: 24 cmH2O\\n SpO2: 97%\\n ABG: 7.46/48/65/31/8 @ 10:20 PM\\n Ve: 7.8 L/min\\n PaO2 / FiO2: 108\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 320 K/uL\\n 8.0 g/dL\\n 94 mg/dL\\n 0.6 mg/dL\\n 31 mEq/L\\n 3.6 mEq/L\\n 13 mg/dL\\n 110 mEq/L\\n 147 mEq/L\\n 25.8 %\\n 9.0 K/uL\\n [image002.jpg]\\n 10:18 AM\\n 02:33 PM\\n 02:46 PM\\n 03:31 AM\\n 02:26 PM\\n 05:53 PM\\n 05:01 AM\\n 03:32 PM\\n 10:19 PM\\n 02:50 AM\\n WBC\\n 9.7\\n 9.5\\n 9.0\\n Hct\\n 26.0\\n 27.6\\n 25.8\\n Plt\\n \\n Cr\\n 0.5\\n 0.5\\n 0.5\\n 0.6\\n 0.6\\n TCO2\\n 29\\n 26\\n 27\\n 30\\n 30\\n 35\\n Glucose\\n 195\\n 195\\n 163\\n 133\\n 102\\n 94\\n Other labs: PT / PTT / INR:14.1/59.6/1.2, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\\n Amylase / Lipase:, Differential-Neuts:71.2 %, Lymph:22.7 %,\\n Mono:4.0 %, Eos:1.7 %, Lactic Acid:1.5 mmol/L, Albumin:2.4 g/dL,\\n LDH:204 IU/L, Ca++:8.2 mg/dL, Mg++:2.1 mg/dL, PO4:4.6 mg/dL\\n Assessment and Plan\\n 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture with respiratory failure\\n and difficulty weaning from vent.\\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\\n volume overload. Intubated on for resp decompensation.\\n Transferred here for tracheomalacia, but not sure this is a component.\\n Will need bronch eval when improved\\n - Thoracics will do trach and PEG once stable on PEEPs around 10. Had\\n been planned for today but currently holding as PEEP is 15.\\n - wean PEEP as tolerated\\n - needs A-line\\n # Volume overload\\n Currently with hypernatremia, Cr increase, contract\\n alk, but mild\\n - continue gentle diuresis with goal -1L per day as tolerated by blood\\n pressure. IV lasix drip at 1-5 mg/hr.\\n - FW in TF at 150 cc q4hrs\\n - PM lytes.\\n # Sedation: Now well seadated on Versed 1.5, Fentanyl 175, Fentanyl\\n patch, Diazepam standing and haldo 2.5-5 mg PRN. QTc stable at .44\\n - Wean versed/fentanyl as tolerated\\n # HCT\\n Has had slow decline while in ICU.\\n - Xfuse PRN Hct < 21\\n - continue to follow, guiac stools\\n # Hypotension: Related to sedation, but high PEEP, adrenial\\n insufficiency, sepsis have previously been contributing.\\n - needs A-line for monitoring\\n - cortisol stim to rule out persistent adrenal insufficiency\\n # RUE DVT: Started on heparin gtt on , now off for trach that was\\n planned for today. Follow PTTs. Would hold off on coumadin at least\\n until s/p trach.\\n - restart heparin\\n # Adrenal Insufficency: Random cortisol was approx 3 when it should\\n have been maximally stimulated. S/P 5 days of hydrocortisone and\\n florinef.\\n - will recheck as above and start at 50 q8 if needed\\n # Spine fracture: Neurologically intact distal to the lesion. Prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - CT of C, L spine when stable. Currently, unlikely to change\\n management and high risk for complications with transport.\\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\\n is low. Brace for OOB. Ok for anticoag per note.\\n # Communication:\\n - Boyfriend of 10 is her HCP. Also brother is involved\\n FEN/GI: Tube feeds @ goal. No need to be NPO while awaiting stable\\n PEEP\\n DVT: Treatment dose heparin\\n Ulcer: Ranitidine\\n VAP: Prevention per routine\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n PICC Line - 09:19 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n ------ Protected Section ------\\n MICU ATTENDING ADDENDUM\\n I saw and examined the patient, and was physically present with the ICU\\n team for the key portions of the services provided. I agree with the\\n note above, including the assessment and plan. I would emphasize and\\n add the following points: 55F T5-8 fractures with retropulsion and ARDS\\n from VAP; on heparin for UE DVT. PEEP as low as 10 yesterday but now up\\n to 15; good response to lasix. Arterial line is out; sedation remains\\n challenging despite multiple interventions.\\n Exam notable for Tm 98.5 BP 90/45 HR 67 RR 16-28 with sat 97 on VAC\\n 400x18 PEEP 15 FiO2 0.6 for 7.46/48/65. TBB -1.2/24, +14L/MICU LOS.\\n Eyes opens, will squeeze hands and wiggle toes but very drowsy.\\n Bronchial BS bilaterally with RRR s1s2 SM at base. Abdomen is\\n distended with decreased BS. 3+ edema in BLE, no cords. Labs notable\\n for WBC 9K, HCT 26, K+ 4.1, Na 147, Cr 0.5. CXR with resolving B LL\\n airspace disease and effusions.\\n Agree with plan to replace arterial line in R axillary artery today and\\n try to wean PEEP. If BP remains low, will need stim and\\n supplementation with hydrocortisone 50 q6-8h; will check bladder\\n pressure, rule out auto-PEEP and continue to monitor for occult\\n infection, but will hold off on antibiotics for now. Will continue\\n fentanyl patch and po valium as we wean IV sedation. Will retry gentle\\n IV lasix to affect a negative fluid balance and use haldol for\\n breakthrough agitiation. Will restart IV heparin for UE DVT; consider\\n transition to coumadin only after tracheostomy and feeding tube\\n placement, which will require lower ventilator settings. Will restart\\n tube feeds and add FW boluses for hypernatremia. Continue spinal\\n stabilization with brace when OOB; will eventually need MRI for\\n surgical planning; remainder of plan as outlined above.\\n Patient is critically ill\\n Total time: 40 min\\n ------ Protected Section Addendum Entered By: , MD\\n on: 02:46 PM ------\\n\"\n },\n {\n \"category\": \"General\",\n \"chartdate\": \"2167-10-03 00:00:00.000\",\n \"description\": \"Generic Note\",\n \"row_id\": 635631,\n \"text\": \"TITLE: Addendum to Dr. \\ns note\\n MICU ATTENDING ADDENDUM \\n I saw and examined the patient, and was physically present with the ICU\\n team for the key portions of the services provided. I agree with the\\n note above, including the assessment and plan. I would emphasize and\\n add the following points:\\n trauma thoracic spine fracture\\n intubated\\n VAP\\n tracheomalacia\\n trached yesterday\\n desaturated and PEEP increased\\n Exam notable for Tm 99.2 BP 127/63 HR 111 RR 18 with 95 sat on\\n AC/18/400/10/.6\\n anasarca\\n awake, no purposeful movements\\n decreased breath sounds ant and lat\\n tachy, regular\\n abd benign\\n 7.45/43/82\\n Labs notable for WBC 10 K, HCT 26 , K+ 4.1 , Cr .6 , HCO3 29\\n CXR reviewed - bilat effusion, trach ok\\n Problems:\\n respiratory failure\\n airway malacia\\n anasarca, effusions\\n spine fracture\\n agitation\\n adrenal insufficiency\\n DVT\\n Agree with plan to wean vent as tolerated, diurese, wean sedation\\n though continue pain medications, continue steroids, continue heparin -\\n eventual coumadin\\n Remainder of plan as outlined above.\\n Patient is critically ill.\\n Total time: 37 min\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-04 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 635680,\n \"text\": \"55 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\\n Now with prolonged hospital course c/b by PNA with high PEEP\\n requirement, anxiety, RUE DVT on heparin qtt.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Rec\\nd pt on Vent settings AC 55%/18 X 400/+10 with no overbreathing of\\n set RR. O2 sat 92-98%. Lung snds clear, diminished in bases. Pt sxn\\n for small-moderate amts thick white secretions. Trach site with small\\n amt serosang drainage.\\n Action:\\n Cont same vent settings\\n Response:\\n Pt doesn\\nt over breath on the vent and never desat.\\n Plan:\\n Wean from vent as she tolerates,monitor sats,ABG?.\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Pt rec\\nd with Heparin qtt off post trach/PEG yesterday.\\n Action:\\n Heparin restarted @ 1100 @ previous rate 1700units/hr.\\n Response:\\n PTT @ 1630 58.5. Heparin inc\\nd to 1900units/hr per sliding scale @\\n 1715.\\n Plan:\\n Repeat PTT @ 2300.\\n Alteration in Nutrition\\n Assessment:\\n Received pt on TF 10cc/hr\\n Action:\\n Pt tolerated TF with minimal residuals as well as free water bolus Q4H\\n Response:\\n TF ^ as tolerated, currently at 30cc/hr.\\n Plan:\\n Cont to monitor TF residuals, hold if more than 100cc\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt w/ periods of agitation and sleeping at other times, while she\\n aweake follow commands intermittently.\\n Action:\\n Cont on fent 100 mics ,Versed 2mg/hr and requires frequent boluses .\\n Cont diazepam 10 mg PO Q6H. Fent ^ 125 mics/hr\\n Response:\\n HR ranging from SB in the 40\\ns when asleep to the 120-140\\ns when\\n agitated, b/p ranging from 90\\ns/40\\ns when asleep to 140-170\\ns/ 70\\n when agitated. When pt awake appropriate and following commands HR\\n 80\\ns-100\\ns and b/p 100\\ns-120\\ns/ 60-70\\n Plan:\\n Titrate sedation as needed\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-04 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 635685,\n \"text\": \"55 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\\n Now with prolonged hospital course c/b by PNA with high PEEP\\n requirement, anxiety, RUE DVT on heparin qtt.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Rec\\nd pt on Vent settings AC 55%/18 X 400/+10 with no overbreathing of\\n set RR. O2 sat 92-98%. Lung snds clear, diminished in bases. Pt sxn\\n for small-moderate amts thick white secretions. Trach site with small\\n amt serosang drainage.\\n Action:\\n Cont same vent settings\\n Response:\\n Pt doesn\\nt over breath on the vent and never desat.Kept same Vent\\n settings.\\n Plan:\\n Wean from vent as she tolerates,monitor sats,ABG?.\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Pt rec\\nd with Heparin qtt 1900units/hr.\\n Action:\\n PTT drawn at 2300.\\n Response:\\n PTT @ 2300 was 107,Decreased Heparin gtt 1700 u/hr as per sliding\\n scale.Next PTT due at 0600. .\\n Plan:\\n Cont monitor PTT,titrate accordingly,next PTT due at 0600.\\n Alteration in Nutrition\\n Assessment:\\n Received pt on TF 10cc/hr\\n Action:\\n Pt tolerated TF with minimal residuals as well as free water bolus Q4H\\n Response:\\n TF ^ as tolerated, currently at 30cc/hr.\\n Plan:\\n Cont to monitor TF residuals, hold if more than 100cc\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt w/ periods of agitation and sleeping at other times, while she\\n aweake follow commands intermittently.\\n Action:\\n Cont on fent 100 mics ,Versed 2mg/hr and requires frequent boluses .\\n Cont diazepam 10 mg PO Q6H. Fent ^ 125 mics/hr,Versed 3mg/hr.\\n Response:\\n HR ranging from SB in the 40\\ns when asleep to the 120-140\\ns when\\n agitated, b/p ranging from 90\\ns/40\\ns when asleep to 140-170\\ns/ 70\\n when agitated. When pt awake appropriate and following commands HR\\n 80\\ns-100\\ns and b/p 100\\ns-120\\ns/ 60-70\\n Plan:\\n Titrate sedation as needed\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-05 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 635862,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n On lasix drip\\n Attempted to wean FiO2\\n No acute events\\n No BM\\n Agitated this am\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions :\\n Midazolam (Versed)\\n 1 mg/hour\\n Furosemide (Lasix)\\n 2 mg/hour\\n Heparin Sodium\\n 1,500 units/hour\\n Fentanyl\\n 75 mcg/hour\\n Other ICU medications:\\n Other medications:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:23 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.3\\nC (99.2\\n Tcurrent: 36.9\\nC (98.5\\n HR: 126 (49 - 131) bpm\\n BP: 156/84(117) {78/38(52) - 164/95(125)} mmHg\\n RR: 20 (9 - 21) insp/min\\n SpO2: 96%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 4,160 mL\\n 1,185 mL\\n PO:\\n TF:\\n 1,267 mL\\n 315 mL\\n IVF:\\n 1,018 mL\\n 260 mL\\n Blood products:\\n Total out:\\n 4,015 mL\\n 2,090 mL\\n Urine:\\n 4,015 mL\\n 2,090 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 145 mL\\n -905 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 400 (400 - 500) mL\\n Vt (Spontaneous): 675 (675 - 675) mL\\n PS : 8 cmH2O\\n RR (Set): 18\\n RR (Spontaneous): 0\\n PEEP: 10 cmH2O\\n FiO2: 50%\\n RSBI Deferred: PEEP > 10\\n PIP: 19 cmH2O\\n Plateau: 16 cmH2O\\n SpO2: 96%\\n ABG: 7.39/46/118/28/2\\n Ve: 8.9 L/min\\n PaO2 / FiO2: 236\\n Physical Examination\\n Labs / Radiology\\n 272 K/uL\\n 8.6 g/dL\\n 128 mg/dL\\n 0.6 mg/dL\\n 28 mEq/L\\n 3.1 mEq/L\\n 8 mg/dL\\n 110 mEq/L\\n 148 mEq/L\\n 27.4 %\\n 11.2 K/uL\\n [image002.jpg]\\n 05:17 PM\\n 11:41 PM\\n 03:06 AM\\n 03:38 AM\\n 04:05 PM\\n 03:55 AM\\n 07:19 AM\\n 11:24 AM\\n 03:18 PM\\n 02:47 AM\\n WBC\\n 10.6\\n 10.0\\n 8.3\\n 11.2\\n Hct\\n 27.3\\n 25.8\\n 24.6\\n 27.4\\n Plt\\n 72\\n Cr\\n 0.5\\n 0.6\\n 0.6\\n 0.5\\n 0.6\\n 0.6\\n TCO2\\n 32\\n 31\\n 29\\n 29\\n Glucose\\n 110\\n 94\\n 111\\n 106\\n 121\\n 123\\n 137\\n 128\\n Other labs: PT / PTT / INR:15.2/62.2/1.3, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:13.1 %,\\n Mono:2.7 %, Eos:0.6 %, Lactic Acid:0.9 mmol/L, Albumin:2.4 g/dL,\\n LDH:204 IU/L, Ca++:9.0 mg/dL, Mg++:2.6 mg/dL, PO4:4.3 mg/dL\\n Assessment and Plan\\n 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA and\\n ARDS intubated since the end of now s/p trach and PEG placement.\\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\\n volume overload. Intubated on for resp decompensation. Stenting\\n unlikely to help for trachiomalacia as airways have poor structure\\n diffusely. S/P Trach and PEG on .\\n - wean FiO2 today\\n # Adrenal Insufficency: Hypotension that resolved with steroids,\\n returned as they came off and is now improved again. Possible primary\\n adrenal insufficency. Appreciate endocrine recommendations. Halved\\n dose today.\\n - hydrocortt (day 1 = ), wean per endo recs\\n # Volume overloaded in setting of hypernatremia with TBW deficit.\\n - Lasix gtt, continue with goal -1-2 L per day.\\n - electrolytes\\n - continue tube feeds with free water flushes 250 cc q4\\n # Sedation: Sedation control remains somewhat poor although fentanyl\\n patch and diazpem are likely therapeutic range today. On Versed 2.0,\\n Fentanyl 100, Fentanyl patch, Diazepam standing and haldo 2.5-5 mg\\n PRN. QTc increased to 480.\\n - Wean versed/fentanyl as tolerated, continue diazepam. Avoid haldol\\n use if possible to avoid further prolongation of QTc\\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\\n coumadin at least until s/p trach.\\n - heparin gtt restarted\\n - coumadin 5mg G-tube today\\n # Constipation\\n current regimen of colace and senna, no BM over last\\n 24 hours\\n - dulcolax PO/PR today\\n - reassess and increase bowel regimen PRN\\n # Spine fracture: Neurologically intact distal to the lesion. Prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - CT of C, L spine when stable. Currently, unlikely to change\\n management and high risk for complications with transport.\\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\\n is low. Brace for OOB. Ok for anticoag per note.\\n -f/u full trauma spine eval from OSH to determine need for further back\\n imaging in-house (to be done )\\n # Nutrition: Tube feeds with free water flushes, tolerating well,\\n continue Replete (Full) - 11:20 AM 30 mL/hour\\n # Glycemic control: SSI, well controlled\\n # Lines L PICC () and R ART ()\\n both working well, mainitain\\n # Ppx: heparin, ranitidine, VAP prevention, colace and senna\\n # Communication:\\n - Boyfriend of 10 is her HCP. Also brother is involved\\n Code: Full\\n Dispo: ICU\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n PICC Line - 09:19 PM\\n Arterial Line - 02:00 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-05 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 635863,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n On lasix drip\\n Attempted to wean FiO2\\n No acute events\\n No BM\\n Agitated this am\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions :\\n Midazolam (Versed)\\n 1 mg/hour\\n Furosemide (Lasix)\\n 2 mg/hour\\n Heparin Sodium\\n 1,500 units/hour\\n Fentanyl\\n 75 mcg/hour\\n Other ICU medications:\\n Other medications:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:23 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.3\\nC (99.2\\n Tcurrent: 36.9\\nC (98.5\\n HR: 126 (49 - 131) bpm\\n BP: 156/84(117) {78/38(52) - 164/95(125)} mmHg\\n RR: 20 (9 - 21) insp/min\\n SpO2: 96%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 4,160 mL\\n 1,185 mL\\n PO:\\n TF:\\n 1,267 mL\\n 315 mL\\n IVF:\\n 1,018 mL\\n 260 mL\\n Blood products:\\n Total out:\\n 4,015 mL\\n 2,090 mL\\n Urine:\\n 4,015 mL\\n 2,090 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 145 mL\\n -905 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 400 (400 - 500) mL\\n Vt (Spontaneous): 675 (675 - 675) mL\\n PS : 8 cmH2O\\n RR (Set): 18\\n RR (Spontaneous): 0\\n PEEP: 10 cmH2O\\n FiO2: 50%\\n RSBI Deferred: PEEP > 10\\n PIP: 19 cmH2O\\n Plateau: 16 cmH2O\\n SpO2: 96%\\n ABG: 7.39/46/118/28/2\\n Ve: 8.9 L/min\\n PaO2 / FiO2: 236\\n Physical Examination\\n General Appearance: Intubated and sedated. Responsive, following\\n commands, Overweight / Obese, mild agitation but NAD\\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\\n deviation\\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\\n Cardiovascular: (S1: Normal), (S2: Normal), distant\\n Respiratory / Chest: (Expansion: Symmetric), CTA anteriorly, decreased\\n BS\\n Abdominal: Obese, Firm, Non-tender, no rebound, no guarding, + BS, PEG\\n in place with dressing C/D/I\\n Extremities: No clubbing or cyanosis, 1+ nonpitting edema of b/l hands,\\n anasarca\\n Skin: no rashes or jaundice\\n Lines: r brachioceph ART and L PICC C/D/I\\n Labs / Radiology\\n 272 K/uL\\n 8.6 g/dL\\n 128 mg/dL\\n 0.6 mg/dL\\n 28 mEq/L\\n 3.1 mEq/L\\n 8 mg/dL\\n 110 mEq/L\\n 148 mEq/L\\n 27.4 %\\n 11.2 K/uL\\n [image002.jpg]\\n 05:17 PM\\n 11:41 PM\\n 03:06 AM\\n 03:38 AM\\n 04:05 PM\\n 03:55 AM\\n 07:19 AM\\n 11:24 AM\\n 03:18 PM\\n 02:47 AM\\n WBC\\n 10.6\\n 10.0\\n 8.3\\n 11.2\\n Hct\\n 27.3\\n 25.8\\n 24.6\\n 27.4\\n Plt\\n 72\\n Cr\\n 0.5\\n 0.6\\n 0.6\\n 0.5\\n 0.6\\n 0.6\\n TCO2\\n 32\\n 31\\n 29\\n 29\\n Glucose\\n 110\\n 94\\n 111\\n 106\\n 121\\n 123\\n 137\\n 128\\n Other labs: Ca++:9.0 mg/dL, Mg++:2.6 mg/dL, PO4:4.3 mg/dL\\n Assessment and Plan\\n 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA and\\n ARDS intubated since the end of now s/p trach and PEG placement.\\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\\n volume overload. Intubated on for resp decompensation. Stenting\\n unlikely to help for trachiomalacia as airways have poor structure\\n diffusely. S/P Trach and PEG on . Increased effusion on recent\\n CXR.\\n - wean FiO2 as tolerated\\n - non-con head CT to further characterize pulmonary effusions,\\n det potential for thoracentesis\\n # Adrenal Insufficency: Hypotension that resolved with steroids,\\n returned as they came off and is now improved again. Possible primary\\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\\n started on .\\n - wean per endo recs, decrease to q8 today, likely q12 dosing\\n tomorrow\\n # Volume overloaded in setting of hypernatremia with TBW deficit.\\n - Lasix gtt, continue with goal -1-2 L per day.\\n - electrolytes\\n - continue tube feeds with free water flushes increase from 250 to 300\\n cc q4\\n # Sedation: Sedation control remains somewhat poor although fentanyl\\n patch and diazpem are likely therapeutic range today. On Versed 2.0,\\n Fentanyl 100, Fentanyl patch, Diazepam standing and haldo 2.5-5 mg\\n PRN. QTc increased to 480.\\n - Wean versed/fentanyl as tolerated, continue diazepam in\\n hopes for vent facility placement\\n - Increase diazepam to 12mg q4\\n - Check ekg for QTc\\n if <480, restart haldol and/or increase\\n fentanyl patch\\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\\n coumadin at least until s/p trach.\\n - heparin gtt restarted\\n - coumadin 5mg G-tube today\\n hold coumadin today for possible \\n # Constipation\\n current regimen of colace and senna, stooled during\\n rounds\\n - dulcolax PO/PR\\n - reassess and increase bowel regimen PRN\\n # Spine fracture: Neurologically intact distal to the lesion. Prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - CT of C, L spine when stable. Currently, unlikely to change\\n management and high risk for complications with transport.\\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\\n is low. Brace for OOB. Ok for anticoag per note.\\n -f/u full trauma spine eval from OSH to determine need for further back\\n imaging in-house (to be done )\\n # Nutrition: Tube feeds with free water flushes, tolerating well,\\n continue Replete (Full) - 11:20 AM 30 mL/hour\\n # Glycemic control: SSI, well controlled\\n # Lines L PICC () and R ART ()\\n both working well, check\\n ABG/VBG today\\n if correlate well, d/c art line\\n # Ppx: heparin, ranitidine, VAP prevention, colace and senna\\n # Communication:\\n - Boyfriend of 10 is her HCP. Also brother is involved\\n Code: Full\\n Dispo: ICU, being screening for vent facilities\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-05 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 635866,\n \"text\": \"Impaired Skin Integrity\\n Assessment:\\n Skin warm to touch, yeast-like red rash under skin folds, coccyx\\n red,\\n skin intact.\\n Action:\\n Miconazole powder applied to skin folds/periarea. Miconazole skin\\n cream barrier applied to coccyx. Frequent repositioning.\\n Response:\\n Cont w/ rash\\n Plan:\\n Cont w/ frequent repositioning, apply miconazole powder to infected\\n areas\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Pt cont on Heparin gtt @ 1500units/h. PTT in therapeutic range.\\n Action:\\n Response:\\n Plan:\\n Altered mental status (not Delirium)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Hypernatremia (high sodium)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-06 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 635981,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n EKG - At 11:00 AM\\n Started on Warfarin\\n Extremely labile pressures over night\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Fentanyl - 50 mcg/hour\\n Midazolam (Versed) - 0.5 mg/hour\\n Heparin Sodium - 1,500 units/hour\\n Other ICU medications:\\n Ranitidine (Prophylaxis) - 08:00 AM\\n Haloperidol (Haldol) - 01:00 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:12 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.1\\nC (100.6\\n Tcurrent: 37.1\\nC (98.8\\n HR: 100 (56 - 142) bpm\\n BP: 98/47(65) {77/40(53) - 164/93(123)} mmHg\\n RR: 18 (15 - 24) insp/min\\n SpO2: 94%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 4,228 mL\\n 1,123 mL\\n PO:\\n TF:\\n 1,440 mL\\n 360 mL\\n IVF:\\n 978 mL\\n 343 mL\\n Blood products:\\n Total out:\\n 6,725 mL\\n 780 mL\\n Urine:\\n 6,725 mL\\n 780 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -2,497 mL\\n 343 mL\\n Respiratory support\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 400 (400 - 400) mL\\n Vt (Spontaneous): 450 (450 - 450) mL\\n PS : 8 cmH2O\\n RR (Set): 18\\n RR (Spontaneous): 0\\n PEEP: 10 cmH2O\\n FiO2: 50%\\n RSBI Deferred: PEEP > 10\\n PIP: 23 cmH2O\\n Plateau: 19 cmH2O\\n SpO2: 94%\\n ABG: 7.50/41/81./29/7\\n Ve: 7.2 L/min\\n PaO2 / FiO2: 164\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 229 K/uL\\n 7.9 g/dL\\n 107 mg/dL\\n 0.6 mg/dL\\n 29 mEq/L\\n 3.8 mEq/L\\n 11 mg/dL\\n 109 mEq/L\\n 147 mEq/L\\n 25.3 %\\n 9.6 K/uL\\n [image002.jpg]\\n 03:55 AM\\n 07:19 AM\\n 11:24 AM\\n 03:18 PM\\n 02:47 AM\\n 11:01 AM\\n 04:40 PM\\n 05:08 PM\\n 03:44 AM\\n 06:04 AM\\n WBC\\n 8.3\\n 11.2\\n 9.6\\n Hct\\n 24.6\\n 27.4\\n 25.3\\n Plt\\n 279\\n 272\\n 229\\n Cr\\n 0.5\\n 0.6\\n 0.6\\n 0.6\\n 0.6\\n TCO2\\n 29\\n 29\\n 31\\n 34\\n 33\\n Glucose\\n 123\\n 137\\n 128\\n 138\\n 107\\n Other labs: PT / PTT / INR:16.5/78.5/1.5, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:13.1 %,\\n Mono:2.7 %, Eos:0.6 %, Lactic Acid:1.1 mmol/L, Albumin:2.4 g/dL,\\n LDH:204 IU/L, Ca++:8.7 mg/dL, Mg++:2.4 mg/dL, PO4:4.7 mg/dL\\n Assessment and Plan\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n PICC Line - 09:19 PM\\n Arterial Line - 02:00 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-06 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 635982,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n EKG - At 11:00 AM\\n Started on Warfarin\\n Extremely labile pressures over night\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Fentanyl - 50 mcg/hour\\n Midazolam (Versed) - 0.5 mg/hour\\n Heparin Sodium - 1,500 units/hour\\n Other ICU medications:\\n Ranitidine (Prophylaxis) - 08:00 AM\\n Haloperidol (Haldol) - 01:00 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:12 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.1\\nC (100.6\\n Tcurrent: 37.1\\nC (98.8\\n HR: 100 (56 - 142) bpm\\n BP: 98/47(65) {77/40(53) - 164/93(123)} mmHg\\n RR: 18 (15 - 24) insp/min\\n SpO2: 94%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 4,228 mL\\n 1,123 mL\\n PO:\\n TF:\\n 1,440 mL\\n 360 mL\\n IVF:\\n 978 mL\\n 343 mL\\n Blood products:\\n Total out:\\n 6,725 mL\\n 780 mL\\n Urine:\\n 6,725 mL\\n 780 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -2,497 mL\\n 343 mL\\n Respiratory support\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 400 (400 - 400) mL\\n Vt (Spontaneous): 450 (450 - 450) mL\\n PS : 8 cmH2O\\n RR (Set): 18\\n RR (Spontaneous): 0\\n PEEP: 10 cmH2O\\n FiO2: 50%\\n RSBI Deferred: PEEP > 10\\n PIP: 23 cmH2O\\n Plateau: 19 cmH2O\\n SpO2: 94%\\n ABG: 7.50/41/81./29/7\\n Ve: 7.2 L/min\\n PaO2 / FiO2: 164\\n Physical Examination\\n General Appearance: Intubated and sedated. Responsive, following\\n commands, Overweight / Obese, mild agitation but NAD\\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\\n deviation\\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\\n Cardiovascular: (S1: Normal), (S2: Normal), distant\\n Respiratory / Chest: (Expansion: Symmetric), CTA anteriorly, decreased\\n BS\\n Abdominal: Obese, Firm, Non-tender, no rebound, no guarding, + BS, PEG\\n in place with dressing C/D/I\\n Extremities: No clubbing or cyanosis, 1+ nonpitting edema of b/l hands,\\n anasarca\\n Skin: no rashes or jaundice\\n Lines: r brachioceph ART and L PICC C/D/I\\n Labs / Radiology\\n 229 K/uL\\n 7.9 g/dL\\n 107 mg/dL\\n 0.6 mg/dL\\n 29 mEq/L\\n 3.8 mEq/L\\n 11 mg/dL\\n 109 mEq/L\\n 147 mEq/L\\n 25.3 %\\n 9.6 K/uL\\n [image002.jpg]\\n 03:55 AM\\n 07:19 AM\\n 11:24 AM\\n 03:18 PM\\n 02:47 AM\\n 11:01 AM\\n 04:40 PM\\n 05:08 PM\\n 03:44 AM\\n 06:04 AM\\n WBC\\n 8.3\\n 11.2\\n 9.6\\n Hct\\n 24.6\\n 27.4\\n 25.3\\n Plt\\n 279\\n 272\\n 229\\n Cr\\n 0.5\\n 0.6\\n 0.6\\n 0.6\\n 0.6\\n TCO2\\n 29\\n 29\\n 31\\n 34\\n 33\\n Glucose\\n 123\\n 137\\n 128\\n 138\\n 107\\n Other labs: PT / PTT / INR:16.5/78.5/1.5, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:13.1 %,\\n Mono:2.7 %, Eos:0.6 %, Lactic Acid:1.1 mmol/L, Albumin:2.4 g/dL,\\n LDH:204 IU/L, Ca++:8.7 mg/dL, Mg++:2.4 mg/dL, PO4:4.7 mg/dL\\n Assessment and Plan\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n PICC Line - 09:19 PM\\n Arterial Line - 02:00 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-06 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 635984,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n EKG - At 11:00 AM\\n Started on Warfarin\\n Extremely labile pressures over night, trying to wean off Fentanyl and\\n use more Haldol.\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Fentanyl - 50 mcg/hour\\n Midazolam (Versed) - 0.5 mg/hour\\n Heparin Sodium - 1,500 units/hour\\n Other ICU medications:\\n Ranitidine (Prophylaxis) - 08:00 AM\\n Haloperidol (Haldol) - 01:00 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:12 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.1\\nC (100.6\\n Tcurrent: 37.1\\nC (98.8\\n HR: 100 (56 - 142) bpm\\n BP: 98/47(65) {77/40(53) - 164/93(123)} mmHg\\n RR: 18 (15 - 24) insp/min\\n SpO2: 94%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 4,228 mL\\n 1,123 mL\\n PO:\\n TF:\\n 1,440 mL\\n 360 mL\\n IVF:\\n 978 mL\\n 343 mL\\n Blood products:\\n Total out:\\n 6,725 mL\\n 780 mL\\n Urine:\\n 6,725 mL\\n 780 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -2,497 mL\\n 343 mL\\n Respiratory support\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 400 (400 - 400) mL\\n Vt (Spontaneous): 450 (450 - 450) mL\\n PS : 8 cmH2O\\n RR (Set): 18\\n RR (Spontaneous): 0\\n PEEP: 10 cmH2O\\n FiO2: 50%\\n RSBI Deferred: PEEP > 10\\n PIP: 23 cmH2O\\n Plateau: 19 cmH2O\\n SpO2: 94%\\n ABG: 7.50/41/81./29/7\\n Ve: 7.2 L/min\\n PaO2 / FiO2: 164\\n Physical Examination\\n General Appearance: Intubated and sedated. Responsive, following\\n commands, Overweight / Obese, mild agitation but NAD\\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\\n deviation\\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\\n Cardiovascular: (S1: Normal), (S2: Normal), distant\\n Respiratory / Chest: (Expansion: Symmetric), CTA anteriorly, decreased\\n BS\\n Abdominal: Obese, Firm, Non-tender, no rebound, no guarding, + BS, PEG\\n in place with dressing C/D/I\\n Extremities: No clubbing or cyanosis, 1+ nonpitting edema of b/l hands,\\n anasarca\\n Skin: no rashes or jaundice\\n Lines: r brachioceph ART and L PICC C/D/I\\n Labs / Radiology\\n 229 K/uL\\n 7.9 g/dL\\n 107 mg/dL\\n 0.6 mg/dL\\n 29 mEq/L\\n 3.8 mEq/L\\n 11 mg/dL\\n 109 mEq/L\\n 147 mEq/L\\n 25.3 %\\n 9.6 K/uL\\n [image002.jpg]\\n 03:55 AM\\n 07:19 AM\\n 11:24 AM\\n 03:18 PM\\n 02:47 AM\\n 11:01 AM\\n 04:40 PM\\n 05:08 PM\\n 03:44 AM\\n 06:04 AM\\n WBC\\n 8.3\\n 11.2\\n 9.6\\n Hct\\n 24.6\\n 27.4\\n 25.3\\n Plt\\n 279\\n 272\\n 229\\n Cr\\n 0.5\\n 0.6\\n 0.6\\n 0.6\\n 0.6\\n TCO2\\n 29\\n 29\\n 31\\n 34\\n 33\\n Glucose\\n 123\\n 137\\n 128\\n 138\\n 107\\n Other labs: PT / PTT / INR:16.5/78.5/1.5, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:13.1 %,\\n Mono:2.7 %, Eos:0.6 %, Lactic Acid:1.1 mmol/L, Albumin:2.4 g/dL,\\n LDH:204 IU/L, Ca++:8.7 mg/dL, Mg++:2.4 mg/dL, PO4:4.7 mg/dL\\n Assessment and Plan\\n 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA and\\n ARDS intubated since the end of now s/p trach and PEG placement.\\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\\n volume overload. Intubated on for resp decompensation. Stenting\\n unlikely to help for trachiomalacia as airways have poor structure\\n diffusely. S/P Trach and PEG on . Increased effusion on recent\\n CXR.\\n - wean FiO2 as tolerated\\n - non-con head CT to further characterize pulmonary effusions,\\n det potential for thoracentesis\\n # Adrenal Insufficency: Hypotension that resolved with steroids,\\n returned as they came off and is now improved again. Possible primary\\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\\n started on .\\n - wean per endo recs, decrease to q8 today, likely q12 dosing\\n tomorrow\\n # Volume overloaded in setting of hypernatremia with TBW deficit.\\n - Lasix gtt, continue with goal -1-2 L per day.\\n - electrolytes\\n - continue tube feeds with free water flushes increase from 250 to 300\\n cc q4\\n # Sedation: Sedation control remains somewhat poor although fentanyl\\n patch and diazpem are likely therapeutic range today. On Versed 2.0,\\n Fentanyl 100, Fentanyl patch, Diazepam standing and haldo 2.5-5 mg\\n PRN. QTc increased to 480.\\n - Wean versed/fentanyl as tolerated, continue diazepam in\\n hopes for vent facility placement\\n - Increase diazepam to 12mg q4\\n - Check ekg for QTc\\n if <480, restart haldol and/or increase\\n fentanyl patch\\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\\n coumadin at least until s/p trach.\\n - heparin gtt restarted\\n - coumadin 5mg G-tube today\\n hold coumadin today for possible \\n # Constipation\\n current regimen of colace and senna, stooled during\\n rounds\\n - dulcolax PO/PR\\n - reassess and increase bowel regimen PRN\\n # Spine fracture: Neurologically intact distal to the lesion. Prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - CT of C, L spine when stable. Currently, unlikely to change\\n management and high risk for complications with transport.\\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\\n is low. Brace for OOB. Ok for anticoag per note.\\n -f/u full trauma spine eval from OSH to determine need for further back\\n imaging in-house (to be done )\\n # Nutrition: Tube feeds with free water flushes, tolerating well,\\n continue Replete (Full) - 11:20 AM 30 mL/hour\\n # Glycemic control: SSI, well controlled\\n # Lines L PICC () and R ART ()\\n both working well, check\\n ABG/VBG today\\n if correlate well, d/c art line\\n # Ppx: heparin, ranitidine, VAP prevention, colace and senna\\n # Communication:\\n - Boyfriend of 10 is her HCP. Also brother is involved\\n Code: Full\\n Dispo: ICU, being screening for vent facilities\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n PICC Line - 09:19 PM\\n Arterial Line - 02:00 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2167-09-29 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 635110,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 11\\n Ideal body weight: 61.2 None\\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: Unknown\\n Procedure location:\\n Reason:\\n Tube Type\\n ETT:\\n Position: cm at teeth\\n Route:\\n Type: Standard\\n Size: 7.5mm\\n Tracheostomy tube:\\n Type:\\n Manufacturer:\\n Size:\\n PMV:\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: cmH2O\\n Cuff volume: mL /\\n Airway problems:\\n Comments:\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Diminished\\n Comments:\\n Secretions\\n Sputum color / consistency: Yellow / Thick\\n Sputum source/amount: Suctioned / Moderate\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance:\\n Visual assessment of breathing pattern:\\n Assessment of breathing comfort:\\n Non-invasive ventilation assessment:\\n Invasive ventilation assessment:\\n Trigger work assessment:\\n Dysynchrony assessment:\\n Comments:\\n Plan\\n Next 24-48 hours:\\n Reason for continuing current ventilatory support:\\n Respiratory Care Shift Procedures\\n Transports:\\n Destination (R/T)\\n Time\\n Complications\\n Comments\\n Bedside Procedures:\\n Comments:\\n Patient remains on ventilatory support, all settings documented on flow\\n sheet. Breath sounds diminished throughout, bronchodilators\\n administered. A-line placed and ABG\\ns drawn. Slow deliberate decrease\\n in PEEP as ordered.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-09-20 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 634170,\n \"text\": \"Obese woman s/p t spine injury tx from Med for failure to wean\\n from mech ventilation and evaluation for stent for\\n tracheobronchomalacia.\\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\\n Assessment:\\n Pt cont w/ low grade fever.\\n Action:\\n Given tyelenol q6 h prn, pt pan cultured. PICC line and foley d/c\\n (new foley placed). IV antibiotics started.\\n Response:\\n Fever slightly improved to 99.\\n Plan:\\n Cont w/ q 6 hr tyelenol prn, closely monitor temp and f/u w/ cultures.\\n Fracture, other\\n Assessment:\\n Pt w/ T5-T8 compression fracture.\\n Action:\\n Pt on log-roll precautions, back brace at bedside- to be used when pt\\n is OOB.\\n Response:\\n Pt denies pain when asked.\\n Plan:\\n Cont on log roll precautions, Neuro- consult ordered to clarify\\n order for brace.\\n Anemia, other\\n Assessment:\\n HCT 25 from 30.0. No active bleeding noted.\\n Action:\\n Cont to check HCT and s/s of bleeding.\\n Response:\\n No action taken.\\n Plan:\\n Type & Screen to be collected. Cont to monitor HCT, guiac all stools.\\n Hypernatremia (high sodium)\\n Assessment:\\n NA level 150-> 147. No seizure activity.\\n Action:\\n Free H2O boluses q 4hrs were started, but currently on hold d/t high\\n residuals. Pt on D5W for 1L .\\n Response:\\n NA level slightly improved.\\n Plan:\\n Cont w/ free-water boluses as tolerated, cont to monitor lytes, bolus\\n w/ LR prn.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n LS rhonchorous throughout, diminished to bilateral bases, deep sxn\\n thick tan/bloody secretions.\\n Action:\\n Given MDIs, cont to be orally intubated on A/C, mini-BAL performed by\\n RT and sample sent to lab. Increased sedation for adequate\\n ventilation.\\n Response:\\n Cont to be orally intubated and sedated.\\n Plan:\\n Consult w/ IP for eval for stent, wean vent as tolerated\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-04 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 635677,\n \"text\": \"55 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\\n Now with prolonged hospital course c/b by PNA with high PEEP\\n requirement, anxiety, RUE DVT on heparin qtt.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Rec\\nd pt on Vent settings AC 55%/18 X 400/+10 with no overbreathing of\\n set RR. O2 sat 92-98%. Lung snds clear, diminished in bases. Pt sxn\\n for small-moderate amts thick white secretions. Trach site with small\\n amt serosang drainage.\\n Action:\\n Cont same vent settings\\n Response:\\n Pt doesn\\nt over breath on the vent and never desat.\\n Plan:\\n Wean from vent as she tolerates,monitor sats,ABG?.\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Pt rec\\nd with Heparin qtt off post trach/PEG yesterday.\\n Action:\\n Heparin restarted @ 1100 @ previous rate 1700units/hr.\\n Response:\\n PTT @ 1630 58.5. Heparin inc\\nd to 1900units/hr per sliding scale @\\n 1715.\\n Plan:\\n Repeat PTT @ 2300.\\n Alteration in Nutrition\\n Assessment:\\n Rec\\nd pt NPO post OR yesterday. Abd obese/distended with + BS. No BM\\n today.\\n Action:\\n Restarted TF Replete with fiber @ 1000 per surgical team @ 10ml/hr, as\\n well as FWB of 250ml Q4hrs for elevated Na.\\n Response:\\n Residual @ 1600 140ml of TF/water/yellow bilious. TF stopped and FWB\\n held.\\n Plan:\\n Resume TF @ 1830. Cont to monitor residuals, holding TF if >100ml.\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2167-10-04 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 635682,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 16\\n Ideal body weight: 61.2 None\\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: Yes\\n Procedure location:\\n Reason:\\n Tube Type\\n ETT:\\n Position: cm at teeth\\n Route:\\n Type:\\n Size:\\n Tracheostomy tube:\\n Type: Standard\\n Manufacturer: Portex\\n Size: 7.0mm\\n PMV: No\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 28 cmH2O\\n Cuff volume: mL /\\n Airway problems:\\n Comments:\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Diminished\\n Comments:\\n Secretions\\n Sputum color / consistency: Tan / Thick\\n Sputum source/amount: Suctioned / Moderate\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance:\\n Visual assessment of breathing pattern: Normal quiet breathing\\n Assessment of breathing comfort: No response (sleeping / sedated)\\n Non-invasive ventilation assessment:\\n Invasive ventilation assessment:\\n Trigger work assessment:\\n Dysynchrony assessment:\\n Comments:\\n Plan\\n Next 24-48 hours: Reduce PEEP as tolerated\\n Reason for continuing current ventilatory support: Underlying illness\\n not resolved\\n Respiratory Care Shift Procedures\\n Transports:\\n Destination (R/T)\\n Time\\n Complications\\n Comments\\n Bedside Procedures:\\n Comments:\\n Pt was trached yesterday with #7 Portex. Trach site appears clean,\\n little oozing around site. Suctioned at beginning of shift for blood\\n tinged thick tan sputum, less blood tinged later in shift. Plan is to\\n continue with weaning attempts.\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2167-10-04 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 635771,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 16\\n Ideal body weight: 61.2 None\\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: Yes\\n Procedure location:\\n Reason:\\n Tube Type\\n ETT:\\n Position: cm at teeth\\n Route:\\n Type:\\n Size:\\n Tracheostomy tube:\\n Type: Standard, Cuffed, Inner Cannula\\n Manufacturer: Portex\\n Size: 7.0mm\\n PMV:\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 28 cmH2O\\n Cuff volume: mL /\\n Airway problems:\\n Comments:\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Diminished\\n Comments:\\n Secretions\\n Sputum color / consistency: White / Thick\\n Sputum source/amount: Suctioned / Copious\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance: Continuous invasive ventilation\\n Visual assessment of breathing pattern:\\n Assessment of breathing comfort: No response (sleeping / sedated)\\n Non-invasive ventilation assessment:\\n Invasive ventilation assessment:\\n Trigger work assessment: Triggering synchronously\\n Dysynchrony assessment:\\n Comments:\\n Plan\\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\\n Reason for continuing current ventilatory support: Intolerant of\\n weaning attempts\\n Respiratory Care Shift Procedures\\n Transports:\\n Destination (R/T)\\n Time\\n Complications\\n Comments\\n Bedside Procedures:\\n Comments:\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2167-10-06 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 636070,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 18\\n Ideal body weight: 61.2 None\\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: Yes\\n Procedure location:\\n Reason:\\n Tube Type\\n ETT:\\n Position: cm at teeth\\n Route:\\n Type:\\n Size:\\n Tracheostomy tube:\\n Type: Standard, Extra Length\\n Manufacturer: Portex\\n Size: 7.0mm\\n PMV:\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 28 cmH2O\\n Cuff volume: mL /\\n Airway problems:\\n Comments:\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Diminished\\n Comments:\\n Secretions\\n Sputum color / consistency: Tan / Thick\\n Sputum source/amount: Suctioned / Small\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance: Continuous invasive ventilation\\n Visual assessment of breathing pattern: Normal quiet breathing;\\n Comments: pt weaned to PSV tolerated well for msot of the shift\\n aroun d 1600 vt began to drop and rr increased so ips increased to 12\\n with improved vt and rr\\n Assessment of breathing comfort: No claim of dyspnea)\\n Non-invasive ventilation assessment:\\n Invasive ventilation assessment:\\n Trigger work assessment:\\n Dysynchrony assessment:\\n Comments:\\n Plan\\n Next 24-48 hours: Reduce PEEP as tolerated\\n Reason for continuing current ventilatory support:\\n Respiratory Care Shift Procedures\\n Transports:\\n Destination (R/T)\\n Time\\n Complications\\n Comments\\n Bedside Procedures:\\n Comments:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-09-30 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 635159,\n \"text\": \" Problem - Description In Comments\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Hypernatremia (high sodium)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Altered mental status (not Delirium)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Bradycardia\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-09-30 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 635160,\n \"text\": \" Problem - Description In Comments\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Hypernatremia (high sodium)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Altered mental status (not Delirium)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Bradycardia\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-01 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 635302,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n Thorasics will take to OR if 24 hours stable on PEEP < 10, was on PEEP\\n of 8 since AM\\n Weaned off midazolam drip\\n NPO past midnight for possible OR tomorrow (attendings are in clinic,\\n however)\\n Endocrine recs: Continue steroids until stable, then taper\\n ABG for low O2 sat, looked good, held on FiO2 of 50\\n Broncoscopy (11:30AM) : Diffuse stuctural instability c/w\\n tracheomalacia\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Furosemide (Lasix) - 3 mg/hour\\n Fentanyl - 100 mcg/hour\\n Other ICU medications:\\n Haloperidol (Haldol) - 11:47 PM\\n Midazolam (Versed) - 02:45 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:06 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.1\\nC (98.8\\n Tcurrent: 36.2\\nC (97.2\\n HR: 104 (46 - 134) bpm\\n BP: 134/69(98) {88/41(57) - 143/76(103)} mmHg\\n RR: 18 (18 - 27) insp/min\\n SpO2: 91%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 4,162 mL\\n 139 mL\\n PO:\\n TF:\\n 1,448 mL\\n 1 mL\\n IVF:\\n 1,003 mL\\n 138 mL\\n Blood products:\\n Total out:\\n 1,615 mL\\n 640 mL\\n Urine:\\n 1,615 mL\\n 640 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 2,547 mL\\n -501 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 400 (400 - 400) mL\\n RR (Set): 18\\n RR (Spontaneous): 0\\n PEEP: 8 cmH2O\\n FiO2: 50%\\n PIP: 35 cmH2O\\n Plateau: 25 cmH2O\\n Compliance: 24.7 cmH2O/mL\\n SpO2: 91%\\n ABG: 7.42/47/86./29/4\\n Ve: 6.8 L/min\\n PaO2 / FiO2: 174\\n Physical Examination\\n General Appearance: Easily agitated, appears uncomfortable, Overweight\\n / Obese, opens eyes but no purposeful movement\\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\\n deviation\\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\\n Cardiovascular: (S1: Normal), (S2: Normal), distant\\n Respiratory / Chest: (Expansion: Symmetric), referred breath sounds\\n from ETT\\n Abdominal: No(t) Soft, Non-tender, Few Bowel sounds present, Distended\\n Extremities: No clubbing or cyanosis, 3+ nonpitting edema of b/l hands,\\n anasarca\\n Skin: no rashes or jaundice\\n Neuro: diffusely hyperreflexic with LE clonus\\n Lines: r brachioceph ART and L PICC C/D/I\\n Labs / Radiology\\n 280 K/uL\\n 8.0 g/dL\\n 136 mg/dL\\n 0.5 mg/dL\\n 29 mEq/L\\n 4.0 mEq/L\\n 11 mg/dL\\n 105 mEq/L\\n 143 mEq/L\\n 25.9 %\\n 8.6 K/uL\\n [image002.jpg]\\n 02:44 PM\\n 03:33 PM\\n 07:26 PM\\n 07:46 PM\\n 02:04 AM\\n 02:18 AM\\n 01:27 PM\\n 03:06 PM\\n 10:04 PM\\n 03:00 AM\\n WBC\\n 8.4\\n 11.8\\n 8.6\\n Hct\\n 23.0\\n 28.1\\n 29.9\\n 25.9\\n Plt\\n \\n Cr\\n 0.5\\n 0.6\\n 0.5\\n TCO2\\n 33\\n 31\\n 33\\n 32\\n 32\\n Glucose\\n 168\\n 176\\n 136\\n Other labs: PT / PTT / INR:13.2/26.6/1.1, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\\n Amylase / Lipase:, Differential-Neuts:89.7 %, Lymph:8.7 %, Mono:1.1\\n %, Eos:0.4 %, Lactic Acid:0.9 mmol/L, Albumin:2.4 g/dL, LDH:204 IU/L,\\n Ca++:8.4 mg/dL, Mg++:2.4 mg/dL, PO4:4.1 mg/dL\\n Fluid analysis / Other labs: BAL fluid:\\n WBC: 0\\n RBC: 0\\n Polys: 82\\n Lymphs: 3\\n Monos: 6\\n Eos: 2\\n Macro: 7\\n Imaging: ECHOCARDIOGRAM: The left atrium is elongated. No atrial\\n septal defect is seen by 2D or color Doppler. The right atrial pressure\\n is indeterminate. Left ventricular wall thickness, cavity size and\\n regional/global systolic function are normal (LVEF >55%). There is no\\n ventricular septal defect. Right ventricular chamber size and free wall\\n motion are normal. The aortic valve leaflets (3) are mildly thickened\\n but aortic stenosis is not present. No aortic regurgitation is seen.\\n The mitral valve appears structurally normal with trivial mitral\\n regurgitation. There is no mitral valve prolapse. The tricuspid valve\\n leaflets are mildly thickened. There is moderate pulmonary artery\\n systolic hypertension. There is no pericardial effusion.\\n Compared with the prior study (images reviewed) of , no\\n change.\\n Microbiology: BRONCHIAL LAVAGE:\\n GRAM STAIN (Final ):\\n 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.\\n NO MICROORGANISMS SEEN.\\n Assessment and Plan\\n 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA and\\n ARDS intubated since the end of .\\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\\n volume overload. Intubated on for resp decompensation.\\n Transferred here for airway stenting. Will need bronch eval when\\n improved.\\n - Thoracics will do trach and PEG once stable on PEEPs around 10.\\n Re-c/s today.\\n - wean PEEP as tolerated\\n # # Adrenal Insufficency: Minimal response to stim test again.\\n - hydrocort and fludrocort (day 1 = )\\n - endocrine c/s for further elucidation of etiology\\n # Hypotension: Likely adrenal insufficiency. Goal map > 60.\\n - hydrocortisol and fludrocortisone as above\\n - restart levophed if necessary to maintain MAP > 60\\n # Volume overloaded in setting of hypernatremia (? Relationship to\\n adrenal insufficiency), TBW deficit 2.6L.\\n - goal even to -500cc I/Os today\\n - continue FW in TF at 250 cc q4hrs\\n - lasix drip (1-5mg/hr) when MAP > 60\\n # Hyperreflexia - ? meds vs central pathology. Unlikely to be \\n intracranial hemorrhage as patient is diffusely hyperreflexic.\\n Possible relationship to endocrine pathology?\\n - consider head CT in setting of heparin gtt\\n - monitor\\n # Sedation: Sedation control remains somewhat poor although fentanyl\\n patch and diazpem are likely starting increase to therapeutic range\\n today. On Versed 1.5, Fentanyl 175, Fentanyl patch, Diazepam standing\\n and haldo 2.5-5 mg PRN. QTc stable at .44.\\n - Wean versed/fentanyl as tolerated, continue diazepam and prn\\n haldol\\n - Recheck EKG today\\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\\n coumadin at least until s/p trach.\\n - hold heparin gtt when anticipate trach/peg\\n # Spine fracture: Neurologically intact distal to the lesion. Prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - CT of C, L spine when stable. Currently, unlikely to change\\n management and high risk for complications with transport.\\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\\n is low. Brace for OOB. Ok for anticoag per note.\\n # Communication:\\n - Boyfriend of 10 is her HCP. Also brother is involved\\n # FEN/GI: Tube feeds @ goal.\\n DVT: Treatment dose heparin\\n Ulcer: Ranitidine\\n VAP: Prevention per routine\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n PICC Line - 09:19 PM\\n Arterial Line - 02:00 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-09-20 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 634155,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n -cultured for fever to 102.7 at 4:00 am\\n -Patient developed hypotension to 102.7 at 6:15 a.m. BP responded well\\n to LR 500 cc. However, urine output remained low despite bolus and\\n additional LR 500 cc bolus. Antibiotics initiated (levofloxacin,\\n aztreonam, vancomycin, metronidazole).\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Fentanyl - 100 mcg/hour\\n Midazolam (Versed) - 2 mg/hour\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:13 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 39.3\\nC (102.7\\n Tcurrent: 39.3\\nC (102.7\\n HR: 89 (72 - 97) bpm\\n BP: 96/41(55) {96/41(55) - 154/71(103)} mmHg\\n RR: 12 (12 - 18) insp/min\\n SpO2: 95%\\n Total In:\\n 10 mL\\n 232 mL\\n PO:\\n TF:\\n IVF:\\n 10 mL\\n 232 mL\\n Blood products:\\n Total out:\\n 425 mL\\n 570 mL\\n Urine:\\n 425 mL\\n 570 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -416 mL\\n -338 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 500 (500 - 500) mL\\n RR (Set): 12\\n RR (Spontaneous): 0\\n PEEP: 10 cmH2O\\n FiO2: 60%\\n RSBI Deferred: PEEP > 10, FiO2 > 60%\\n PIP: 32 cmH2O\\n SpO2: 95%\\n ABG: 7.42/47/61/30/4\\n Ve: 8 L/min\\n PaO2 / FiO2: 102\\n Physical Examination\\n Gen: Appears uncomfortable on vent.\\n HEENT: Anicteric. Pupils 3 mm non-reactive bilaterally.\\n Resp: Symmetric expansion. Vesicular sounds throughout. Inspiratory\\n and expiratory tracheal sounds (?related to ET tube).\\n CV: Cannot see jugular veins due to neck size. RRR. Normal s1 and\\n s2. No M/G/R.\\n Abd: Quiet. Distended. Non-tender.\\n Ext: Edema in RUE, especially right hand. Mildly increased warmth of\\n RUE compared with LUE.\\n Peripheral vascular: Radial pulses 2+ bilaterally.\\n Neuro: Pupils as above. Moving all 4 extremities.\\n Labs / Radiology\\n 333 K/uL\\n 9.7 g/dL\\n 103 mg/dL\\n 0.6 mg/dL\\n 30 mEq/L\\n 3.8 mEq/L\\n 6 mg/dL\\n 109 mEq/L\\n 150 mEq/L\\n 30.7 %\\n 9.7 K/uL\\n [image002.jpg]\\n 11:54 PM\\n 01:00 AM\\n WBC\\n 9.7\\n Hct\\n 30.7\\n Plt\\n 333\\n Cr\\n 0.6\\n TCO2\\n 32\\n Glucose\\n 103\\n Other labs: PT / PTT / INR:13.8/22.4/1.2, ALT / AST:30/19, Alk Phos / T\\n Bili:149/0.7, Differential-Neuts:76.9 %, Lymph:17.3 %, Mono:3.0 %,\\n Eos:2.5 %, Albumin:3.0 g/dL, LDH:222 IU/L, Ca++:8.6 mg/dL, Mg++:2.1\\n mg/dL, PO4:4.1 mg/dL\\n Assessment and Plan\\n A/P: 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture\\n # Respiratory failure: initially likely multifactorial including\\n bronchspasm, hypoventilation from narcotics, and potential aspiration.\\n prior evaluation negative for PE. still with significant A-a gradient.\\n cxr appears under penetrated with small lung fields and potential\\n effusion on right. potentially from pneumonia given patient\\ns fever.\\n - daily CXR\\n - will hold on CT chest or airway pending IP consult\\n - IP consult\\n - vent settings: AC 500 x 12 PEEP 10, FIO2 60%\\n - sedation: fentanyl and midazolam infusions\\n - trial of diuresis when able\\n # Fever: Differential diagnosis includes infection cause (VAP, infected\\n PICC line, UTI) or DVT. Cultures sent. Will treat with empiric\\n antibiotics. Tylenol PRN for fever.\\n - Flagyl, aztreonam, vancomycin, levofloxacin for coverage of gram\\n positives, gram negatives, anaerobes, MRSA, and MDR pathogens.\\n - f/u blood and urine cultures\\n - Once further IV access is established, remove PICC and culture tip.\\n # Hypotension: Differential diagnosis includes hypovolemia, sepsis, and\\n cardiogenic. Sepsis likely given fever, although hypovolemia remains\\n in differential given falling hematocrit. BP responded well to fluid\\n boluses but urine output low.\\n - Monitor BP and urine output.\\n - Consider additional fluid boluses.\\n - If patient\\ns hypotension becomes refractory to fluid boluses, would\\n place central line for CVP monitoring and initiate pressors.\\n # Spine fracture: neurologically intact distal to the lesion. prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - monitor distal neurologic function\\n - cto brace x3 months unless supine in bed\\n # Anemia: admission to MMC was ~40 now down to 30% w/o sign of active\\n GI bleed or other source of blood loss. likely related to crystalloid\\n administration, anemia of inflammation, chronic phlebotomy. given bili\\n and LDH normal would be unlikely for hemolysis.\\n - trend Hct\\n - guaiac stools\\n Hypernatremia: most likely related to inadequate free water repletion.\\n free water defecit ~3L.\\n - replete via OGT primarily\\n - D5W x1 L\\n ICU Care\\n Nutrition:\\n Comments: tube feed with free water\\n nutrition consult\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n PICC Line - 10:30 PM\\n 18 Gauge - 10:30 PM\\n 20 Gauge - 01:36 AM\\n Prophylaxis:\\n DVT: SQ UF Heparin\\n Stress ulcer: H2 blocker\\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\\n Need for restraints reviewed\\n Comments:\\n Communication: Family meeting held , ICU consent signed Comments: \\n (brother) \\n (boyfriend/POA) \\n Code status: Full code\\n Disposition: ICU\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n PICC Line - 10:30 PM\\n 20 Gauge - 01:36 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-09-20 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 634156,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n -cultured for fever to 102.7 at 4:00 am\\n -Patient developed hypotension to 102.7 at 6:15 a.m. BP responded well\\n to LR 500 cc. However, urine output remained low despite bolus and\\n additional LR 500 cc bolus. Antibiotics initiated (levofloxacin,\\n aztreonam, vancomycin, metronidazole).\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Fentanyl - 100 mcg/hour\\n Midazolam (Versed) - 2 mg/hour\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:13 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 39.3\\nC (102.7\\n Tcurrent: 39.3\\nC (102.7\\n HR: 89 (72 - 97) bpm\\n BP: 96/41(55) {96/41(55) - 154/71(103)} mmHg\\n RR: 12 (12 - 18) insp/min\\n SpO2: 95%\\n Total In:\\n 10 mL\\n 232 mL\\n PO:\\n TF:\\n IVF:\\n 10 mL\\n 232 mL\\n Blood products:\\n Total out:\\n 425 mL\\n 570 mL\\n Urine:\\n 425 mL\\n 570 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -416 mL\\n -338 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 500 (500 - 500) mL\\n RR (Set): 12\\n RR (Spontaneous): 0\\n PEEP: 10 cmH2O\\n FiO2: 60%\\n RSBI Deferred: PEEP > 10, FiO2 > 60%\\n PIP: 32 cmH2O\\n SpO2: 95%\\n ABG: 7.42/47/61/30/4\\n Ve: 8 L/min\\n PaO2 / FiO2: 102\\n Physical Examination\\n Gen: Appears uncomfortable on vent.\\n HEENT: Anicteric. Pupils 3 mm non-reactive bilaterally.\\n Resp: Symmetric expansion. Vesicular sounds throughout. Inspiratory\\n and expiratory tracheal sounds (?related to ET tube).\\n CV: Cannot see jugular veins due to neck size. RRR. Normal s1 and\\n s2. No M/G/R.\\n Abd: Quiet. Distended. Non-tender.\\n Ext: Edema in RUE, especially right hand. Mildly increased warmth of\\n RUE compared with LUE.\\n Peripheral vascular: Radial pulses 2+ bilaterally.\\n Neuro: Pupils as above. Moving all 4 extremities.\\n Labs / Radiology\\n 333 K/uL\\n 9.7 g/dL\\n 103 mg/dL\\n 0.6 mg/dL\\n 30 mEq/L\\n 3.8 mEq/L\\n 6 mg/dL\\n 109 mEq/L\\n 150 mEq/L\\n 30.7 %\\n 9.7 K/uL\\n [image002.jpg]\\n 11:54 PM\\n 01:00 AM\\n WBC\\n 9.7\\n Hct\\n 30.7\\n Plt\\n 333\\n Cr\\n 0.6\\n TCO2\\n 32\\n Glucose\\n 103\\n Other labs: PT / PTT / INR:13.8/22.4/1.2, ALT / AST:30/19, Alk Phos / T\\n Bili:149/0.7, Differential-Neuts:76.9 %, Lymph:17.3 %, Mono:3.0 %,\\n Eos:2.5 %, Albumin:3.0 g/dL, LDH:222 IU/L, Ca++:8.6 mg/dL, Mg++:2.1\\n mg/dL, PO4:4.1 mg/dL\\n Assessment and Plan\\n A/P: 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture\\n # Respiratory failure: initially likely multifactorial including\\n bronchspasm, hypoventilation from narcotics, and potential aspiration.\\n prior evaluation negative for PE. still with significant A-a gradient.\\n cxr appears under penetrated with small lung fields and potential\\n effusion on right. potentially from pneumonia given patient\\ns fever.\\n - daily CXR\\n - will hold on CT chest or airway pending IP consult\\n - IP consult\\n - vent settings: AC 500 x 12 PEEP 10, FIO2 60%\\n - sedation: fentanyl and midazolam infusions\\n - ipratropium and atrovent nebs\\n # Fever: Differential diagnosis includes infection cause (VAP, infected\\n PICC line, UTI) or DVT. Cultures sent. Will treat with empiric\\n antibiotics. Tylenol PRN for fever.\\n - Flagyl, aztreonam, vancomycin, levofloxacin for coverage of gram\\n positives, gram negatives, anaerobes, MRSA, and MDR pathogens.\\n - f/u blood, urine, and sputum cultures\\n - BAL\\n - Once further IV access is established, remove PICC and culture tip.\\n # Hypotension: Differential diagnosis includes hypovolemia, sepsis, and\\n cardiogenic. Sepsis likely given fever, although hypovolemia remains\\n in differential given falling hematocrit. BP responded well to fluid\\n boluses but urine output low.\\n - Monitor BP and urine output.\\n - Consider additional fluid boluses.\\n - If patient\\ns hypotension becomes refractory to fluid boluses, would\\n place central line for CVP monitoring and initiate pressors.\\n # Anemia: On admission to Medical Center, Hct was ~40, now down\\n to 30 and then 25 w/o sign of active GI bleed or other source of blood\\n loss. be related to fluid administration, phlebotomy, anemia of\\n inflammation, active bleed still considered in differential.\\n -Follow Hct\\n -guaiac stools\\n # Spine fracture: neurologically intact distal to the lesion. prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - monitor distal neurologic function\\n - cto brace x3 months unless supine in bed\\n - consult neurosurgery for further recs\\n # Anemia: admission to MMC was ~40 now down to 30% w/o sign of active\\n GI bleed or other source of blood loss. likely related to crystalloid\\n administration, anemia of inflammation, chronic phlebotomy. given bili\\n and LDH normal would be unlikely for hemolysis.\\n - trend Hct\\n - guaiac stools\\n - insert additional PIV\\n Hypernatremia: Na improved to 147 (from 150) today, most likely\\n related to inadequate free water repletion. Free water defecit ~2 L.\\n - replete via OGT primarily\\n - D5W x1 L\\n ICU Care\\n Nutrition:\\n Comments: tube feed with free water\\n nutrition consult\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n PICC Line - 10:30 PM\\n 18 Gauge - 10:30 PM\\n 20 Gauge - 01:36 AM\\n Prophylaxis:\\n DVT: SQ UF Heparin\\n Stress ulcer: H2 blocker\\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\\n Need for restraints reviewed\\n Comments:\\n Communication: Family meeting held , ICU consent signed Comments: \\n (brother) \\n (boyfriend/POA) \\n Code status: Full code\\n Disposition: ICU\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n PICC Line - 10:30 PM\\n 20 Gauge - 01:36 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-09-20 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 634157,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n -cultured for fever to 102.7 at 4:00 am\\n -Patient developed hypotension to 102.7 at 6:15 a.m. BP responded well\\n to LR 500 cc. However, urine output remained low despite bolus and\\n additional LR 500 cc bolus. Antibiotics initiated (levofloxacin,\\n aztreonam, vancomycin, metronidazole).\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Fentanyl - 100 mcg/hour\\n Midazolam (Versed) - 2 mg/hour\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:13 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 39.3\\nC (102.7\\n Tcurrent: 39.3\\nC (102.7\\n HR: 89 (72 - 97) bpm\\n BP: 96/41(55) {96/41(55) - 154/71(103)} mmHg\\n RR: 12 (12 - 18) insp/min\\n SpO2: 95%\\n Total In:\\n 10 mL\\n 232 mL\\n PO:\\n TF:\\n IVF:\\n 10 mL\\n 232 mL\\n Blood products:\\n Total out:\\n 425 mL\\n 570 mL\\n Urine:\\n 425 mL\\n 570 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -416 mL\\n -338 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 500 (500 - 500) mL\\n RR (Set): 12\\n RR (Spontaneous): 0\\n PEEP: 10 cmH2O\\n FiO2: 60%\\n RSBI Deferred: PEEP > 10, FiO2 > 60%\\n PIP: 32 cmH2O\\n SpO2: 95%\\n ABG: 7.42/47/61/30/4\\n Ve: 8 L/min\\n PaO2 / FiO2: 102\\n Physical Examination\\n Gen: Appears uncomfortable on vent.\\n HEENT: Anicteric. Pupils 3 mm non-reactive bilaterally.\\n Resp: Symmetric expansion. Vesicular sounds throughout. Inspiratory\\n and expiratory tracheal sounds (?related to ET tube).\\n CV: Cannot see jugular veins due to neck size. RRR. Normal s1 and\\n s2. No M/G/R.\\n Abd: Quiet. Distended. Non-tender.\\n Ext: Edema in RUE, especially right hand. Mildly increased warmth of\\n RUE compared with LUE.\\n Peripheral vascular: Radial pulses 2+ bilaterally.\\n Neuro: Pupils as above. Moving all 4 extremities.\\n Labs / Radiology\\n 333 K/uL\\n 9.7 g/dL\\n 103 mg/dL\\n 0.6 mg/dL\\n 30 mEq/L\\n 3.8 mEq/L\\n 6 mg/dL\\n 109 mEq/L\\n 150 mEq/L\\n 30.7 %\\n 9.7 K/uL\\n [image002.jpg]\\n 11:54 PM\\n 01:00 AM\\n WBC\\n 9.7\\n Hct\\n 30.7\\n Plt\\n 333\\n Cr\\n 0.6\\n TCO2\\n 32\\n Glucose\\n 103\\n Other labs: PT / PTT / INR:13.8/22.4/1.2, ALT / AST:30/19, Alk Phos / T\\n Bili:149/0.7, Differential-Neuts:76.9 %, Lymph:17.3 %, Mono:3.0 %,\\n Eos:2.5 %, Albumin:3.0 g/dL, LDH:222 IU/L, Ca++:8.6 mg/dL, Mg++:2.1\\n mg/dL, PO4:4.1 mg/dL\\n Assessment and Plan\\n A/P: 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture\\n # Respiratory failure: initially likely multifactorial including\\n bronchspasm, hypoventilation from narcotics, and potential aspiration.\\n prior evaluation negative for PE. still with significant A-a gradient.\\n cxr appears under penetrated with small lung fields and potential\\n effusion on right. potentially from pneumonia given patient\\ns fever.\\n - daily CXR\\n - will hold on CT chest or airway pending IP consult\\n - IP consult\\n - vent settings: AC 500 x 12 PEEP 10, FIO2 60%\\n - sedation: fentanyl and midazolam infusions\\n - ipratropium and atrovent nebs\\n # Fever: Differential diagnosis includes infection cause (VAP, infected\\n PICC line, UTI) or DVT. Cultures sent. Will treat with empiric\\n antibiotics. Tylenol PRN for fever.\\n - Flagyl, aztreonam, vancomycin, levofloxacin for coverage of gram\\n positives, gram negatives, anaerobes, MRSA, and MDR pathogens.\\n - f/u blood, urine, and sputum cultures\\n - BAL\\n - Once further IV access is established, remove PICC and culture tip.\\n # Hypotension: Differential diagnosis includes hypovolemia, sepsis, and\\n cardiogenic. Sepsis likely given fever, although hypovolemia remains\\n in differential given falling hematocrit. BP responded well to fluid\\n boluses but urine output low.\\n - Monitor BP and urine output.\\n - Consider additional fluid boluses.\\n - If patient\\ns hypotension becomes refractory to fluid boluses, would\\n place central line for CVP monitoring and initiate pressors.\\n # Anemia: On admission to Medical Center, Hct was ~40, now down\\n to 30 and then 25 w/o sign of active GI bleed or other source of blood\\n loss. be related to fluid administration, phlebotomy, anemia of\\n inflammation, active bleed still considered in differential. given\\n bili and LDH normal would be unlikely for hemolysis.\\n - trend Hct\\n -Follow Hct\\n -guaiac stools\\n # Spine fracture: neurologically intact distal to the lesion. prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - monitor distal neurologic function\\n - cto brace x3 months unless supine in bed\\n - consult neurosurgery for further recs\\n # Hypernatremia: Na improved to 147 (from 150) today, most likely\\n related to inadequate free water repletion. Free water defecit ~2 L.\\n - replete via OGT primarily\\n - D5W x1 L\\n # Right upper extremity edema: Could be caused by DVT related to PICC.\\n - d/c PICC\\n - RUE U/S\\n ICU Care\\n Nutrition:\\n Comments: tube feed with free water\\n nutrition consult\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n PICC Line - 10:30 PM\\n 18 Gauge - 10:30 PM\\n 20 Gauge - 01:36 AM\\n Prophylaxis:\\n DVT: SQ UF Heparin\\n Stress ulcer: H2 blocker\\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\\n Need for restraints reviewed\\n Comments:\\n Communication: Family meeting held , ICU consent signed Comments: \\n (brother) \\n (boyfriend/POA) \\n Code status: Full code\\n Disposition: ICU\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n PICC Line - 10:30 PM\\n 20 Gauge - 01:36 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-09-20 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 634158,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n -cultured for fever to 102.7 at 4:00 am\\n -Patient developed hypotension to 83/38 at 6:15 a.m. BP responded well\\n to LR 500 cc. However, urine output remained low despite bolus and\\n additional LR 500 cc bolus. Antibiotics initiated (levofloxacin,\\n aztreonam, vancomycin, metronidazole).\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Fentanyl - 100 mcg/hour\\n Midazolam (Versed) - 2 mg/hour\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:13 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 39.3\\nC (102.7\\n Tcurrent: 39.3\\nC (102.7\\n HR: 89 (72 - 97) bpm\\n BP: 96/41(55) {96/41(55) - 154/71(103)} mmHg\\n RR: 12 (12 - 18) insp/min\\n SpO2: 95%\\n Total In:\\n 10 mL\\n 232 mL\\n PO:\\n TF:\\n IVF:\\n 10 mL\\n 232 mL\\n Blood products:\\n Total out:\\n 425 mL\\n 570 mL\\n Urine:\\n 425 mL\\n 570 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -416 mL\\n -338 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 500 (500 - 500) mL\\n RR (Set): 12\\n RR (Spontaneous): 0\\n PEEP: 10 cmH2O\\n FiO2: 60%\\n RSBI Deferred: PEEP > 10, FiO2 > 60%\\n PIP: 32 cmH2O\\n SpO2: 95%\\n ABG: 7.42/47/61/30/4\\n Ve: 8 L/min\\n PaO2 / FiO2: 102\\n Physical Examination\\n Gen: Appears uncomfortable on vent.\\n HEENT: Anicteric. Pupils 3 mm non-reactive bilaterally.\\n Resp: Symmetric expansion. Vesicular sounds throughout. Inspiratory\\n and expiratory tracheal sounds (?related to ET tube).\\n CV: Cannot see jugular veins due to neck size. RRR. Normal s1 and\\n s2. No M/G/R.\\n Abd: Quiet. Distended. Non-tender.\\n Ext: Edema in RUE, especially right hand. Mildly increased warmth of\\n RUE compared with LUE.\\n Peripheral vascular: Radial pulses 2+ bilaterally.\\n Neuro: Pupils as above. Moving all 4 extremities.\\n Labs / Radiology\\n 333 K/uL\\n 9.7 g/dL\\n 103 mg/dL\\n 0.6 mg/dL\\n 30 mEq/L\\n 3.8 mEq/L\\n 6 mg/dL\\n 109 mEq/L\\n 150 mEq/L\\n 30.7 %\\n 9.7 K/uL\\n [image002.jpg]\\n 11:54 PM\\n 01:00 AM\\n WBC\\n 9.7\\n Hct\\n 30.7\\n Plt\\n 333\\n Cr\\n 0.6\\n TCO2\\n 32\\n Glucose\\n 103\\n Other labs: PT / PTT / INR:13.8/22.4/1.2, ALT / AST:30/19, Alk Phos / T\\n Bili:149/0.7, Differential-Neuts:76.9 %, Lymph:17.3 %, Mono:3.0 %,\\n Eos:2.5 %, Albumin:3.0 g/dL, LDH:222 IU/L, Ca++:8.6 mg/dL, Mg++:2.1\\n mg/dL, PO4:4.1 mg/dL\\n Assessment and Plan\\n A/P: 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture\\n # Respiratory failure: initially likely multifactorial including\\n bronchspasm, hypoventilation from narcotics, and potential aspiration.\\n prior evaluation negative for PE. still with significant A-a gradient.\\n cxr appears under penetrated with small lung fields and potential\\n effusion on right. potentially from pneumonia given patient\\ns fever.\\n - daily CXR\\n - will hold on CT chest or airway pending IP consult\\n - IP consult\\n - vent settings: AC 500 x 12 PEEP 10, FIO2 60%\\n - sedation: fentanyl and midazolam infusions\\n - ipratropium and atrovent nebs\\n # Fever: Differential diagnosis includes infection cause (VAP, infected\\n PICC line, UTI) or DVT. Cultures sent. Will treat with empiric\\n antibiotics. Tylenol PRN for fever.\\n - Flagyl, aztreonam, vancomycin, levofloxacin for coverage of gram\\n positives, gram negatives, anaerobes, MRSA, and MDR pathogens.\\n - f/u blood, urine, and sputum cultures\\n - BAL\\n - Once further IV access is established, remove PICC and culture tip.\\n # Hypotension: Differential diagnosis includes hypovolemia, sepsis, and\\n cardiogenic. Sepsis likely given fever, although hypovolemia remains\\n in differential given falling hematocrit. BP responded well to fluid\\n boluses but urine output low.\\n - Monitor BP and urine output.\\n - Consider additional fluid boluses.\\n - If patient\\ns hypotension becomes refractory to fluid boluses, would\\n place central line for CVP monitoring and initiate pressors.\\n # Anemia: On admission to Medical Center, Hct was ~40, now down\\n to 30 and then 25 w/o sign of active GI bleed or other source of blood\\n loss. be related to fluid administration, phlebotomy, anemia of\\n inflammation, active bleed still considered in differential. given\\n bili and LDH normal would be unlikely for hemolysis.\\n - trend Hct\\n -Follow Hct\\n -guaiac stools\\n # Spine fracture: neurologically intact distal to the lesion. prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - monitor distal neurologic function\\n - cto brace x3 months unless supine in bed\\n - consult neurosurgery for further recs\\n # Hypernatremia: Na improved to 147 (from 150) today, most likely\\n related to inadequate free water repletion. Free water defecit ~2 L.\\n - replete via OGT primarily\\n - D5W x1 L\\n # Right upper extremity edema: Could be caused by DVT related to PICC.\\n - d/c PICC\\n - RUE U/S\\n ICU Care\\n Nutrition:\\n Comments: tube feed with free water\\n nutrition consult\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n PICC Line - 10:30 PM\\n 18 Gauge - 10:30 PM\\n 20 Gauge - 01:36 AM\\n Prophylaxis:\\n DVT: SQ UF Heparin\\n Stress ulcer: H2 blocker\\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\\n Need for restraints reviewed\\n Comments:\\n Communication: Family meeting held , ICU consent signed Comments: \\n (brother) \\n (boyfriend/POA) \\n Code status: Full code\\n Disposition: ICU\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n PICC Line - 10:30 PM\\n 20 Gauge - 01:36 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-09-20 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 634159,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n -cultured for fever to 102.7 at 4:00 am\\n -Patient developed hypotension to 83/38 at 6:15 a.m. BP responded well\\n to LR 500 cc. However, urine output remained low despite bolus and\\n additional LR 500 cc bolus. Antibiotics initiated (levofloxacin,\\n aztreonam, vancomycin, metronidazole).\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Fentanyl - 100 mcg/hour\\n Midazolam (Versed) - 2 mg/hour\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:13 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 39.3\\nC (102.7\\n Tcurrent: 39.3\\nC (102.7\\n HR: 89 (72 - 97) bpm\\n BP: 96/41(55) {96/41(55) - 154/71(103)} mmHg\\n RR: 12 (12 - 18) insp/min\\n SpO2: 95%\\n Total In:\\n 10 mL\\n 232 mL\\n PO:\\n TF:\\n IVF:\\n 10 mL\\n 232 mL\\n Blood products:\\n Total out:\\n 425 mL\\n 570 mL\\n Urine:\\n 425 mL\\n 570 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -416 mL\\n -338 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 500 (500 - 500) mL\\n RR (Set): 12\\n RR (Spontaneous): 0\\n PEEP: 10 cmH2O\\n FiO2: 60%\\n RSBI Deferred: PEEP > 10, FiO2 > 60%\\n PIP: 32 cmH2O\\n SpO2: 95%\\n ABG: 7.42/47/61/30/4\\n Ve: 8 L/min\\n PaO2 / FiO2: 102\\n Physical Examination\\n Gen: Appears uncomfortable on vent.\\n HEENT: Anicteric. Pupils 3 mm non-reactive bilaterally.\\n Resp: Symmetric expansion. Vesicular sounds throughout. Inspiratory\\n and expiratory tracheal sounds (?related to ET tube).\\n CV: Cannot see jugular veins due to neck size. RRR. Normal s1 and\\n s2. No M/G/R.\\n Abd: Quiet. Distended. Non-tender.\\n Ext: Edema in RUE, especially right hand. Mildly increased warmth of\\n RUE compared with LUE.\\n Peripheral vascular: Radial pulses 2+ bilaterally.\\n Neuro: Pupils as above. Moving all 4 extremities.\\n Labs / Radiology\\n 333 K/uL\\n 9.7 g/dL\\n 103 mg/dL\\n 0.6 mg/dL\\n 30 mEq/L\\n 3.8 mEq/L\\n 6 mg/dL\\n 109 mEq/L\\n 150 mEq/L\\n 30.7 %\\n 9.7 K/uL\\n [image002.jpg]\\n 11:54 PM\\n 01:00 AM\\n WBC\\n 9.7\\n Hct\\n 30.7\\n Plt\\n 333\\n Cr\\n 0.6\\n TCO2\\n 32\\n Glucose\\n 103\\n Other labs: PT / PTT / INR:13.8/22.4/1.2, ALT / AST:30/19, Alk Phos / T\\n Bili:149/0.7, Differential-Neuts:76.9 %, Lymph:17.3 %, Mono:3.0 %,\\n Eos:2.5 %, Albumin:3.0 g/dL, LDH:222 IU/L, Ca++:8.6 mg/dL, Mg++:2.1\\n mg/dL, PO4:4.1 mg/dL\\n Assessment and Plan\\n A/P: 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture\\n # Respiratory failure: initially likely multifactorial including\\n bronchspasm, hypoventilation from narcotics, and potential aspiration.\\n prior evaluation negative for PE. still with significant A-a gradient.\\n cxr appears under penetrated with small lung fields and potential\\n effusion on right. potentially from pneumonia given patient\\ns fever.\\n - daily CXR\\n - will hold on CT chest or airway pending IP consult\\n - IP consult\\n - vent settings: AC 500 x 12 PEEP 10, FIO2 60%\\n - sedation: fentanyl and midazolam infusions\\n - ipratropium and atrovent nebs\\n # Fever: Differential diagnosis includes infection cause (VAP, infected\\n PICC line, UTI) or DVT. Cultures sent. Will treat with empiric\\n antibiotics. Tylenol PRN for fever.\\n - Flagyl, aztreonam, vancomycin, levofloxacin for coverage of gram\\n positives, gram negatives, anaerobes, MRSA, and MDR pathogens.\\n - f/u blood, urine, and sputum cultures\\n - mini-BAL\\n - Once further IV access is established, remove PICC and culture tip.\\n # Hypotension: Differential diagnosis includes hypovolemia, sepsis, and\\n cardiogenic. Sepsis likely given fever, although hypovolemia remains\\n in differential given falling hematocrit. BP responded well to fluid\\n boluses but urine output low.\\n - Monitor BP and urine output.\\n - Consider additional fluid boluses.\\n - If patient\\ns hypotension becomes refractory to fluid boluses, would\\n place central line for CVP monitoring and initiate pressors.\\n # Anemia: On admission to Medical Center, Hct was ~40, now down\\n to 30 and then 25 w/o sign of active GI bleed or other source of blood\\n loss. be related to fluid administration, phlebotomy, anemia of\\n inflammation, active bleed still considered in differential. given\\n bili and LDH normal would be unlikely for hemolysis.\\n - trend Hct\\n -Follow Hct\\n -guaiac stools\\n # Spine fracture: neurologically intact distal to the lesion. prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - monitor distal neurologic function\\n - cto brace x3 months unless supine in bed\\n - consult neurosurgery for further recs\\n # Hypernatremia: Na improved to 147 (from 150) today, most likely\\n related to inadequate free water repletion. Free water defecit ~2 L.\\n - replete via OGT primarily\\n - D5W x1 L\\n # Right upper extremity edema: Could be caused by DVT related to PICC.\\n - d/c PICC\\n - RUE U/S\\n ICU Care\\n Nutrition:\\n Comments: tube feed with free water\\n nutrition consult\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n PICC Line - 10:30 PM\\n 18 Gauge - 10:30 PM\\n 20 Gauge - 01:36 AM\\n Prophylaxis:\\n DVT: SQ UF Heparin\\n Stress ulcer: H2 blocker\\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\\n Need for restraints reviewed\\n Comments:\\n Communication: Family meeting held , ICU consent signed Comments: \\n (brother) \\n (boyfriend/POA) \\n Code status: Full code\\n Disposition: ICU\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n PICC Line - 10:30 PM\\n 20 Gauge - 01:36 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n This note was written by , HMS IV, to be cosigned by the\\n on-call MICU resident. I had to have the on-call intern sign me in to\\n MetaVision because I do not yet have access to edit.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-09-20 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 634169,\n \"text\": \"Obese woman s/p t spine injury tx from Med for failure to wean\\n from mech ventilation and evaluation for stent for\\n tracheobronchomalacia.\\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\\n Assessment:\\n Pt cont w/ low grade fever.\\n Action:\\n Given tyelenol q6 h prn, pt pan cultured. PICC line and foley d/c\\n (new foley placed).\\n Response:\\n Fever slightly improved to 99.\\n Plan:\\n Cont w/ q 6 hr tyelenol prn, closely monitor temp and f/u w/ cultures.\\n Fracture, other\\n Assessment:\\n Pt w/ T5-T8 compression fracture.\\n Action:\\n Pt on log-roll precautions, back brace at bedside- to be used when pt\\n is OOB.\\n Response:\\n Pt denies pain when asked.\\n Plan:\\n Cont on log roll precautions, Neuro- consult ordered to clarify\\n order for brace.\\n Anemia, other\\n Assessment:\\n HCT 25 from 30.0. No active bleeding noted.\\n Action:\\n Cont to check HCT and s/s of bleeding.\\n Response:\\n No action taken.\\n Plan:\\n Type & Screen to be collected. Cont to monitor HCT, guiac all stools.\\n Hypernatremia (high sodium)\\n Assessment:\\n NA level 150-> 147. No seizure activity.\\n Action:\\n Given free H2O boluses q 4hrs. Pt on D5W for 1L .\\n Response:\\n NA level slightly improved.\\n Plan:\\n Cont w/ free-water boluses as tolerated, cont to monitor lytes, bolus\\n w/ LR prn.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n LS rhonchorous throughout, diminished to bilateral bases, deep sxn\\n thick tan/bloody secretions.\\n Action:\\n Given MDIs, cont to be orally intubated on A/C, mini-BAL performed by\\n RT and sample sent to lab.\\n Response:\\n Cont to be orally intubated and sedated.\\n Plan:\\n Consult w/ IP for eval for stent, wean vent as tolerated\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2167-09-21 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 634211,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 3\\n Ideal body weight: 61.2 None\\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\\n Airway\\n Tube Type\\n ETT:\\n Position: 19 cm at teeth\\n Route: Oral\\n Type: Standard\\n Size: 7mm\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Diminished\\n Secretions\\n Sputum color / consistency: Yellow / Thick\\n Sputum source/amount: Suctioned / Moderate\\n Ventilation Assessment\\n Level of breathing assistance: Continuous invasive ventilation\\n Visual assessment of breathing pattern: Normal quiet breathing\\n Assessment of breathing comfort: No response (sleeping / sedated)\\n Invasive ventilation assessment:\\n Trigger work assessment: Triggering synchronously\\n Plan\\n Next 24-48 hours: Utilize ARDSnet protocol, Maintain PEEP at current\\n level and reduce FiO2 as tolerated, Adjust Min. ventilation to control\\n pH\\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\\n Intolerant of weaning attempts, Cannot protect airway, Underlying\\n illness not resolved\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-09-21 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 634217,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Removed PICC line because RUE was noted to be warm and erythematous;\\n ultrasound revealed DVT. No definitive treatment was started given\\n difficulty obtaining central venous access.\\n Multiple attempts at central access; tried left and then right.\\n Acute episode of oxygen desat during first central line attempt. Pt\\n recovered, however, increased FiO2.\\n Decreased UOP (10-30mL/hr) and hypotension overnight. However,\\n lactate remains low.\\n Placed art line x 2. NBP and ABP similar\\n mini- BAL, sputum, urine, blood cultures pending. Yesterday, started\\n on levofloxicin and aztreonam instead of cefepime. Switched due to\\n question of PCN allergy\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Levofloxacin - 09:30 AM\\n Metronidazole - 12:00 AM\\n Vancomycin - 01:00 AM\\n Aztreonam - 04:00 AM\\n Infusions:\\n Midazolam (Versed) - 2 mg/hour\\n Fentanyl - 150 mcg/hour\\n Other ICU medications:\\n Ranitidine (Prophylaxis) - 08:00 AM\\n Midazolam (Versed) - 10:00 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:31 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.3\\nC (100.9\\n Tcurrent: 37.3\\nC (99.2\\n HR: 76 (71 - 116) bpm\\n BP: 116/51(70) {60/46(54) - 146/71(91)} mmHg\\n RR: 18 (12 - 24) insp/min\\n SpO2: 93%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 94.2 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 5,600 mL\\n 1,811 mL\\n PO:\\n TF:\\n 120 mL\\n IVF:\\n 4,700 mL\\n 1,511 mL\\n Blood products:\\n Total out:\\n 798 mL\\n 110 mL\\n Urine:\\n 798 mL\\n 110 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 4,802 mL\\n 1,701 mL\\n Respiratory support\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 500 (500 - 500) mL\\n RR (Set): 18\\n RR (Spontaneous): 0\\n PEEP: 10 cmH2O\\n FiO2: 80%\\n RSBI Deferred: PEEP > 10\\n PIP: 36 cmH2O\\n Plateau: 25 cmH2O\\n SpO2: 93%\\n ABG: 7.45/42/95./28/4\\n Ve: 9.5 L/min\\n PaO2 / FiO2: 120\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 319 K/uL\\n 7.6 g/dL\\n 129 mg/dL\\n 0.6 mg/dL\\n 28 mEq/L\\n 4.3 mEq/L\\n 6 mg/dL\\n 109 mEq/L\\n 144 mEq/L\\n 24.1 %\\n 6.4 K/uL\\n [image002.jpg]\\n 11:54 PM\\n 01:00 AM\\n 06:14 AM\\n 08:56 AM\\n 08:57 AM\\n 05:01 PM\\n 08:03 PM\\n 11:00 PM\\n 03:01 AM\\n 03:13 AM\\n WBC\\n 9.7\\n 9.4\\n 7.6\\n 6.4\\n Hct\\n 30.7\\n 25.1\\n 24.1\\n 24.1\\n Plt\\n 333\\n 281\\n 306\\n 319\\n Cr\\n 0.6\\n 0.6\\n 0.7\\n 0.6\\n 0.6\\n TCO2\\n 32\\n 33\\n 35\\n 33\\n 30\\n Glucose\\n 103\\n 126\\n 126\\n 127\\n 129\\n Other labs: PT / PTT / INR:16.9/26.3/1.5, ALT / AST:27/18, Alk Phos / T\\n Bili:113/0.7, Differential-Neuts:76.9 %, Lymph:17.3 %, Mono:3.0 %,\\n Eos:2.5 %, Lactic Acid:0.7 mmol/L, Albumin:2.3 g/dL, LDH:154 IU/L,\\n Ca++:8.2 mg/dL, Mg++:2.6 mg/dL, PO4:3.1 mg/dL\\n RUE ultrasound:\\n - Non-occlusive right axillary deep vein thrombus\\n - Non-occlusive right basilic superficial thrombosis.\\n Assessment and Plan\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 01:16 AM\\n 20 Gauge - 01:36 AM\\n 22 Gauge - 02:00 PM\\n Arterial Line - 03:00 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-09-21 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 634290,\n \"text\": \"Chief Complaint: respiratory failure\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 24 Hour Events:\\n URINE CULTURE - At 08:09 AM\\n EKG - At 09:00 AM\\n PICC LINE - STOP 10:30 AM\\n BLOOD CULTURED - At 10:30 AM\\n ULTRASOUND - At 01:00 PM\\n U/S of RUE\\n URINE CULTURE - At 03:00 PM\\n UA/UC collected after new foley inserted.\\n BAL FLUID CULTURE - At 03:00 PM\\n mini-BAL\\n ARTERIAL LINE - START 04:45 PM\\n ARTERIAL LINE - STOP 02:03 AM\\n ARTERIAL LINE - START 03:00 AM\\n Multiple attempts at central access were unsuccessful due to\\n malposition and difficulty threading wire.\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Levofloxacin - 09:30 AM\\n Vancomycin - 01:00 AM\\n Aztreonam - 04:00 AM\\n Metronidazole - 08:50 AM\\n Infusions:\\n Midazolam (Versed) - 2 mg/hour\\n Fentanyl - 150 mcg/hour\\n Other ICU medications:\\n Ranitidine (Prophylaxis) - 08:00 AM\\n Midazolam (Versed) - 09:32 AM\\n Other medications:\\n colace, CHG, SQI, H2B, SQH, MDIs, Flagyl, vanco, levo, aztreonam,\\n versed, fentanyl\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 09:51 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.3\\nC (100.9\\n Tcurrent: 37.9\\nC (100.3\\n HR: 72 (70 - 116) bpm\\n BP: 100/48(60) {89/47(60) - 139/75(79)} mmHg\\n RR: 18 (12 - 24) insp/min\\n SpO2: 89%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 94.2 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Bladder pressure: 18 (18 - 18) mmHg\\n Total In:\\n 5,600 mL\\n 2,088 mL\\n PO:\\n TF:\\n 120 mL\\n IVF:\\n 4,700 mL\\n 1,728 mL\\n Blood products:\\n Total out:\\n 798 mL\\n 205 mL\\n Urine:\\n 798 mL\\n 205 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 4,802 mL\\n 1,883 mL\\n Respiratory support\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 500 (500 - 500) mL\\n RR (Set): 18\\n RR (Spontaneous): 0\\n PEEP: 10 cmH2O\\n FiO2: 80%\\n RSBI Deferred: PEEP > 10\\n PIP: 37 cmH2O\\n Plateau: 25 cmH2O\\n SpO2: 89%\\n ABG: 7.45/42/95./28/4\\n Ve: 9.1 L/min\\n PaO2 / FiO2: 96\\n Physical Examination\\n Sedated. Breath sounds are coarse. Heart sounds are distant. Abdomen\\n is protuberant with quiet breath sounds. Some peripheral edema. She\\n is not able to cooperate with peripheral strength or sensory exam.\\n Labs / Radiology\\n 7.6 g/dL\\n 319 K/uL\\n 129 mg/dL\\n 0.6 mg/dL\\n 28 mEq/L\\n 4.3 mEq/L\\n 6 mg/dL\\n 109 mEq/L\\n 144 mEq/L\\n 24.1 %\\n 6.4 K/uL\\n [image002.jpg]\\n 11:54 PM\\n 01:00 AM\\n 06:14 AM\\n 08:56 AM\\n 08:57 AM\\n 05:01 PM\\n 08:03 PM\\n 11:00 PM\\n 03:01 AM\\n 03:13 AM\\n WBC\\n 9.7\\n 9.4\\n 7.6\\n 6.4\\n Hct\\n 30.7\\n 25.1\\n 24.1\\n 24.1\\n Plt\\n 333\\n 281\\n 306\\n 319\\n Cr\\n 0.6\\n 0.6\\n 0.7\\n 0.6\\n 0.6\\n TCO2\\n 32\\n 33\\n 35\\n 33\\n 30\\n Glucose\\n 103\\n 126\\n 126\\n 127\\n 129\\n Other labs: PT / PTT / INR:16.9/26.3/1.5, ALT / AST:27/18, Alk Phos / T\\n Bili:113/0.7, Differential-Neuts:76.9 %, Lymph:17.3 %, Mono:3.0 %,\\n Eos:2.5 %, Lactic Acid:0.7 mmol/L, Albumin:2.3 g/dL, LDH:154 IU/L,\\n Ca++:8.2 mg/dL, Mg++:2.6 mg/dL, PO4:3.1 mg/dL\\n Imaging: CXR with bilateral opacities; ETT a little high. No PTX.\\n Assessment and Plan\\n 55-year-old woman with\\n Respiratory failure\\n Traumatic thoracic spinal fractures\\n Probable VAP\\n Upper extremity DVT\\n Oliguria\\n Anemia\\n Possible tracheobronchomalacia (reason for transfer)\\n I am uncertain about both the risks of anticoagulation and the risks of\\n moving to radiology (e.g. CT or IR) in the context of her spinal\\n fractures. Therefore we will consult spine surgery urgently for help\\n with these questions.\\n Her respiratory failure is likely multifactorial, including obesity,\\n probable VAP, probable PE, and possible tracheobronchomalacia. She may\\n also have weakness, but she is sedated and cannot cooperate with exam\\n at present. We will check an echo to examine her RV. We will\\n ventilate per ARDSnet; she may warrant esophageal-balloon-guided\\n therapy if she does not improve in the next few hours.\\n Oliguria is concerning, though BUN/Creatinine are reassuring. NG to\\n suction to relieve abdominal distention. We will check urine lytes and\\n assess stroke volume variation with the Vigileo. We will consider\\n volume challenge based on this result.\\n For central access, if we are able to safely move her we will ask I.R.\\n to help with central access.\\n We will continue broad antibiotics while awaiting cultures.\\n ICU Care\\n Nutrition: NPO for now\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n 18 Gauge - 01:16 AM\\n 20 Gauge - 01:36 AM\\n 22 Gauge - 02:00 PM\\n Arterial Line - 03:00 AM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin\\n Stress ulcer: H2 blocker\\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds Comments:\\n Code status: Full code\\n Disposition :ICU\\n Total time spent: 45 min\\n Patient is critically ill\\n ------ Protected Section ------\\n Critical Care Staff Addendum\\n 5:45p\\n CVL successfully placed. CVP and SVV argue that she is adequately\\n volume-replete. Hypoxemia has been a major issue, and we have taken\\n her to CT this afternoon. We are awaiting final reads of the images.\\n We will pursue esophageal balloon to help guide PEEP; first attempt was\\n unsuccessful due to oropharyngeal coiling.\\n Discussed in detail with patient\\ns brother at bedside. Unable to reach\\n her significant other.\\n 35 minutes\\n ------ Protected Section Addendum Entered By: , MD\\n on: 17:55 ------\\n Critical Care Staff\\n 7:30p\\n Stable on PEEP 15, FiO2 0.8, low-dose Levophed. RT was unable to place\\n esophageal balloon. CT reviewed and shows basilar >> apical collapse\\n but no PE. Echo was limited but reassuring, with normal RV function\\n and no obvious shunt.\\n We will continue to pursue 6cc/kg PBW ventilation. If unable to wean\\n FiO2 further, will increase PEEP. If difficulties, will repeat\\n attempts at esophageal balloon and consider proning.\\n Since sputum is growing GNR, suspect that much of this may be related\\n to VAP acquired at OSH. Since we do not know their resistance\\n patterns, will continue extended-spectrum GNR coverage with aztreonam\\n and levofloxacin.\\n Await spine surgery\\ns input on risks of anticoagulation. If OK, begin\\n full-dose heparin tonight.\\n Discussed with , RN, and RT.\\n 30 minutes\\n ------ Protected Section Addendum Entered By: , MD\\n on: 07:49 PM ------\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-05 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 635843,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n On lasix drip\\n Attempted to wean FiO2\\n No acute events\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Midazolam (Versed) - 1 mg/hour\\n Furosemide (Lasix) - 2 mg/hour\\n Heparin Sodium - 1,500 units/hour\\n Fentanyl - 75 mcg/hour\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:23 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.3\\nC (99.2\\n Tcurrent: 36.9\\nC (98.5\\n HR: 126 (49 - 131) bpm\\n BP: 156/84(117) {78/38(52) - 164/95(125)} mmHg\\n RR: 20 (9 - 21) insp/min\\n SpO2: 96%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 4,160 mL\\n 1,185 mL\\n PO:\\n TF:\\n 1,267 mL\\n 315 mL\\n IVF:\\n 1,018 mL\\n 260 mL\\n Blood products:\\n Total out:\\n 4,015 mL\\n 2,090 mL\\n Urine:\\n 4,015 mL\\n 2,090 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 145 mL\\n -905 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 400 (400 - 500) mL\\n Vt (Spontaneous): 675 (675 - 675) mL\\n PS : 8 cmH2O\\n RR (Set): 18\\n RR (Spontaneous): 0\\n PEEP: 10 cmH2O\\n FiO2: 50%\\n RSBI Deferred: PEEP > 10\\n PIP: 19 cmH2O\\n Plateau: 16 cmH2O\\n SpO2: 96%\\n ABG: 7.39/46/118/28/2\\n Ve: 8.9 L/min\\n PaO2 / FiO2: 236\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 272 K/uL\\n 8.6 g/dL\\n 128 mg/dL\\n 0.6 mg/dL\\n 28 mEq/L\\n 3.1 mEq/L\\n 8 mg/dL\\n 110 mEq/L\\n 148 mEq/L\\n 27.4 %\\n 11.2 K/uL\\n [image002.jpg]\\n 05:17 PM\\n 11:41 PM\\n 03:06 AM\\n 03:38 AM\\n 04:05 PM\\n 03:55 AM\\n 07:19 AM\\n 11:24 AM\\n 03:18 PM\\n 02:47 AM\\n WBC\\n 10.6\\n 10.0\\n 8.3\\n 11.2\\n Hct\\n 27.3\\n 25.8\\n 24.6\\n 27.4\\n Plt\\n 72\\n Cr\\n 0.5\\n 0.6\\n 0.6\\n 0.5\\n 0.6\\n 0.6\\n TCO2\\n 32\\n 31\\n 29\\n 29\\n Glucose\\n 110\\n 94\\n 111\\n 106\\n 121\\n 123\\n 137\\n 128\\n Other labs: PT / PTT / INR:15.2/62.2/1.3, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:13.1 %,\\n Mono:2.7 %, Eos:0.6 %, Lactic Acid:0.9 mmol/L, Albumin:2.4 g/dL,\\n LDH:204 IU/L, Ca++:9.0 mg/dL, Mg++:2.6 mg/dL, PO4:4.3 mg/dL\\n Assessment and Plan\\n 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA and\\n ARDS intubated since the end of now s/p trach and PEG placement.\\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\\n volume overload. Intubated on for resp decompensation. Stenting\\n unlikely to help for trachiomalacia as airways have poor structure\\n diffusely. S/P Trach and PEG on .\\n - wean FiO2 today\\n # Adrenal Insufficency: Hypotension that resolved with steroids,\\n returned as they came off and is now improved again. Possible primary\\n adrenal insufficency. Appreciate endocrine recommendations. Halved\\n dose today.\\n - hydrocortt (day 1 = ), wean per endo recs\\n # Volume overloaded in setting of hypernatremia with TBW deficit.\\n - Lasix gtt, continue with goal -1-2 L per day.\\n - electrolytes\\n - continue tube feeds with free water flushes 250 cc q4\\n # Sedation: Sedation control remains somewhat poor although fentanyl\\n patch and diazpem are likely therapeutic range today. On Versed 2.0,\\n Fentanyl 100, Fentanyl patch, Diazepam standing and haldo 2.5-5 mg\\n PRN. QTc increased to 480.\\n - Wean versed/fentanyl as tolerated, continue diazepam. Avoid haldol\\n use if possible to avoid further prolongation of QTc\\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\\n coumadin at least until s/p trach.\\n - heparin gtt restarted\\n - coumadin 5mg G-tube today\\n # Constipation\\n current regimen of colace and senna, no BM over last\\n 24 hours\\n - dulcolax PO/PR today\\n - reassess and increase bowel regimen PRN\\n # Spine fracture: Neurologically intact distal to the lesion. Prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - CT of C, L spine when stable. Currently, unlikely to change\\n management and high risk for complications with transport.\\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\\n is low. Brace for OOB. Ok for anticoag per note.\\n -f/u full trauma spine eval from OSH to determine need for further back\\n imaging in-house (to be done )\\n # Nutrition: Tube feeds with free water flushes, tolerating well,\\n continue Replete (Full) - 11:20 AM 30 mL/hour\\n # Glycemic control: SSI, well controlled\\n # Lines L PICC () and R ART ()\\n both working well, mainitain\\n # Ppx: heparin, ranitidine, VAP prevention, colace and senna\\n # Communication:\\n - Boyfriend of 10 is her HCP. Also brother is involved\\n Code: Full\\n Dispo: ICU\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n PICC Line - 09:19 PM\\n Arterial Line - 02:00 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nutrition\",\n \"chartdate\": \"2167-10-05 00:00:00.000\",\n \"description\": \"Clinical Nutrition Note\",\n \"row_id\": 635848,\n \"text\": \"Subjective\\n Patient intubated\\n Objective\\n Pertinent medications: fentanyl, versed, lasix gtt\\n Labs:\\n Value\\n Date\\n Glucose\\n 128 mg/dL\\n 02:47 AM\\n Glucose Finger Stick\\n 134\\n 04:00 AM\\n BUN\\n 8 mg/dL\\n 02:47 AM\\n Creatinine\\n 0.6 mg/dL\\n 02:47 AM\\n Sodium\\n 148 mEq/L\\n 02:47 AM\\n Potassium\\n 3.1 mEq/L\\n 02:47 AM\\n Chloride\\n 110 mEq/L\\n 02:47 AM\\n TCO2\\n 28 mEq/L\\n 02:47 AM\\n Albumin\\n 2.4 g/dL\\n 03:59 AM\\n Calcium non-ionized\\n 9.0 mg/dL\\n 02:47 AM\\n Phosphorus\\n 4.3 mg/dL\\n 02:47 AM\\n Ionized Calcium\\n 1.17 mmol/L\\n 03:32 PM\\n Magnesium\\n 2.6 mg/dL\\n 02:47 AM\\n Current diet order / nutrition support: Replete with Fiber at 60ml/hr x\\n 24 hours - provides 1440kcal and 89g protein\\n GI: Abdomen soft/distended with positive bowel sounds\\n Assessment of Nutritional Status\\n Specifics:\\n 55 year old female s/p fall with t-spine fracture now with pneumonia\\n and ARDS requiring intubation now s/p trach/PEG placement. Patient is\\n tolerating tube feedings well with residuals of 10 and 35ml noted.\\n Would continue with tube feedings as ordered.\\n Medical Nutrition Therapy Plan - Recommend the Following\\n 1. Continue to provide patient with Replete with Fiber at 60ml/hr\\n x 24 hours\\n 2. Monitor residuals q4H and hold tube feedings if >150ml\\n 08:14\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-09-29 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 635091,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n ARTERIAL LINE - STOP 09:00 PM - attempted to re-wire but\\n patient was very agitated and re-wire was unsuccessful\\n Patient alternated between tachycardia and normotension and hypotension\\n in the high-80s/low 90s and HRs in the 50s\\n Given haldol, valium, midaz and fentanyl for sedation\\n ABG with low paO2 on PEEP 10, had to increase -- went back up to 15 and\\n then attempted to re-wean down with goal 8 in anticipation of OR\\n To OR for trach and PEG today (thoracics)\\n Put on lasix drip and put out >1L in just over an hour\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Levofloxacin - 08:06 AM\\n Infusions:\\n Midazolam (Versed) - 1.5 mg/hour\\n Fentanyl - 200 mcg/hour\\n Other ICU medications:\\n Fentanyl - 06:45 PM\\n Ranitidine (Prophylaxis) - 08:00 PM\\n Haloperidol (Haldol) - 10:00 PM\\n Midazolam (Versed) - 10:00 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:03 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.7\\nC (99.8\\n Tcurrent: 37.7\\nC (99.8\\n HR: 109 (55 - 134) bpm\\n BP: 120/56(70) {80/43(51) - 133/85(94)} mmHg\\n RR: 20 (16 - 28) insp/min\\n SpO2: 97%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 101 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 3,064 mL\\n 404 mL\\n PO:\\n TF:\\n 1,440 mL\\n IVF:\\n 1,014 mL\\n 314 mL\\n Blood products:\\n Total out:\\n 4,257 mL\\n 1,195 mL\\n Urine:\\n 4,257 mL\\n 1,195 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,193 mL\\n -791 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 400 (400 - 400) mL\\n RR (Set): 18\\n RR (Spontaneous): 10\\n PEEP: 15 cmH2O\\n FiO2: 60%\\n RSBI Deferred: PEEP > 10\\n PIP: 23 cmH2O\\n Plateau: 24 cmH2O\\n SpO2: 97%\\n ABG: 7.46/48/65/31/8 @ 10:20 PM\\n Ve: 7.8 L/min\\n PaO2 / FiO2: 108\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 320 K/uL\\n 8.0 g/dL\\n 94 mg/dL\\n 0.6 mg/dL\\n 31 mEq/L\\n 3.6 mEq/L\\n 13 mg/dL\\n 110 mEq/L\\n 147 mEq/L\\n 25.8 %\\n 9.0 K/uL\\n [image002.jpg]\\n 10:18 AM\\n 02:33 PM\\n 02:46 PM\\n 03:31 AM\\n 02:26 PM\\n 05:53 PM\\n 05:01 AM\\n 03:32 PM\\n 10:19 PM\\n 02:50 AM\\n WBC\\n 9.7\\n 9.5\\n 9.0\\n Hct\\n 26.0\\n 27.6\\n 25.8\\n Plt\\n \\n Cr\\n 0.5\\n 0.5\\n 0.5\\n 0.6\\n 0.6\\n TCO2\\n 29\\n 26\\n 27\\n 30\\n 30\\n 35\\n Glucose\\n 195\\n 195\\n 163\\n 133\\n 102\\n 94\\n Other labs: PT / PTT / INR:14.1/59.6/1.2, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\\n Amylase / Lipase:, Differential-Neuts:71.2 %, Lymph:22.7 %,\\n Mono:4.0 %, Eos:1.7 %, Lactic Acid:1.5 mmol/L, Albumin:2.4 g/dL,\\n LDH:204 IU/L, Ca++:8.2 mg/dL, Mg++:2.1 mg/dL, PO4:4.6 mg/dL\\n Assessment and Plan\\n 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture with respiratory failure\\n and difficulty weaning from vent.\\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\\n volume overload. Intubated on for resp decompensation.\\n Transferred here for tracheomalacia, but not sure this is a component.\\n Will need bronch eval when improved\\n - Thoracics will do trach and PEG once stable on PEEPs around 10. Had\\n been planned for today but currently holding as PEEP is 15.\\n - wean PEEP as tolerated\\n - needs A-line\\n # Volume overload\\n Currently with hypernatremia, Cr increase, contract\\n alk, but mild\\n - continue gentle diuresis with goal -1L per day as tolerated by blood\\n pressure. IV lasix drip at 1-5 mg/hr.\\n - FW in TF at 150 cc q4hrs\\n - PM lytes.\\n # Sedation: Now well seadated on Versed 1.5, Fentanyl 175, Fentanyl\\n patch, Diazepam standing and haldo 2.5-5 mg PRN. QTc stable at .44\\n - Wean versed/fentanyl as tolerated\\n # HCT\\n Has had slow decline while in ICU.\\n - Xfuse PRN Hct < 21\\n - continue to follow, guiac stools\\n # Hypotension: Related to sedation, but high PEEP, adrenial\\n insufficiency, sepsis have previously been contributing.\\n - needs A-line for monitoring\\n - cortisol stim to rule out persistent adrenal insufficiency\\n # RUE DVT: Started on heparin gtt on , now off for trach that was\\n planned for today. Follow PTTs. Would hold off on coumadin at least\\n until s/p trach.\\n - restart heparin\\n # Adrenal Insufficency: Random cortisol was approx 3 when it should\\n have been maximally stimulated. S/P 5 days of hydrocortisone and\\n florinef.\\n - will recheck as above and start at 50 q8 if needed\\n # Spine fracture: Neurologically intact distal to the lesion. Prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - CT of C, L spine when stable. Currently, unlikely to change\\n management and high risk for complications with transport.\\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\\n is low. Brace for OOB. Ok for anticoag per note.\\n # Communication:\\n - Boyfriend of 10 is her HCP. Also brother is involved\\n FEN/GI: Tube feeds @ goal. No need to be NPO while awaiting stable\\n PEEP\\n DVT: Treatment dose heparin\\n Ulcer: Ranitidine\\n VAP: Prevention per routine\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n PICC Line - 09:19 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nutrition\",\n \"chartdate\": \"2167-09-29 00:00:00.000\",\n \"description\": \"Clinical Nutrition Note\",\n \"row_id\": 635093,\n \"text\": \"Objective\\n Pertinent medications: noted\\n Labs:\\n Value\\n Date\\n Glucose\\n 94 mg/dL\\n 02:50 AM\\n Glucose Finger Stick\\n 98, 101\\n \\n BUN\\n 13 mg/dL\\n 02:50 AM\\n Creatinine\\n 0.6 mg/dL\\n 02:50 AM\\n Sodium\\n 147 mEq/L\\n 02:50 AM\\n Potassium\\n 3.6 mEq/L\\n 02:50 AM\\n Chloride\\n 110 mEq/L\\n 02:50 AM\\n TCO2\\n 31 mEq/L\\n 02:50 AM\\n Albumin\\n 2.4 g/dL\\n 03:59 AM\\n Calcium non-ionized\\n 8.2 mg/dL\\n 02:50 AM\\n Phosphorus\\n 4.6 mg/dL\\n 02:50 AM\\n Ionized Calcium\\n 1.17 mmol/L\\n 03:32 PM\\n Magnesium\\n 2.1 mg/dL\\n 02:50 AM\\n Current diet order / nutrition support: Replte c/ Fiber @60mL/hr (1440\\n kcals/89 gr aa)\\n GI: Abd soft/+bs/+bm\\n Assessment of Nutritional Status\\n Estimation of current intake: Adequate\\n Specifics:\\n Pt continues on TF\\ns for full nutrition support. TF\\ns well tolerated @\\n goal, meeting 100% estimated needs. They were opn hold last night as\\n plan was for trach and PEG today, but not done 2/2 PEEP to high. PT on\\n lasix gtt for diuresis. Na trending up daily, today is 147. need\\n to increase FWB if level continues to increase.\\n Medical Nutrition Therapy Plan - Recommend the Following\\n Multivitamin / Mineral supplement: via TF\\n Tube feeding recommendations: Continue current TF's @ goal\\n Adjust FWB prn c/ diuresis\\n Will follow- page c/ ?\\ns #\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-09-30 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 635225,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n ARTERIAL LINE - START 02:00 PM - in right brachial atery\\n Hypotensive- started on levophed, weaned off over night\\n Low cortisol and failed stim test - started on steroids\\n TTE ordered\\n Free water flushes were increased for hypernatremia (250cc q4)\\n Able to hear patient breathing at times during exam this am (poor am\\n CXR, reordered)\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Levofloxacin - 08:06 AM\\n Infusions:\\n Heparin Sodium - 1,700 units/hour\\n Midazolam (Versed) - 2 mg/hour\\n Fentanyl - 150 mcg/hour\\n Other ICU medications:\\n Haloperidol (Haldol) - 12:15 AM\\n Other medications:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:50 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.5\\nC (99.5\\n Tcurrent: 36.7\\nC (98\\n HR: 63 (48 - 138) bpm\\n BP: 91/41(58) {68/30(49) - 143/78(105)} mmHg\\n RR: 18 (13 - 23) insp/min\\n SpO2: 91%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Mixed Venous O2% Sat: 59 - 59\\n Total In:\\n 3,898 mL\\n 1,155 mL\\n PO:\\n TF:\\n 802 mL\\n 348 mL\\n IVF:\\n 2,126 mL\\n 247 mL\\n Blood products:\\n Total out:\\n 2,367 mL\\n 800 mL\\n Urine:\\n 2,367 mL\\n 800 mL\\n NG:\\n Stool:\\n ?\\n ?\\n Drains:\\n Balance:\\n 1,531 mL\\n 355 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 400 (400 - 401) mL\\n RR (Set): 18\\n RR (Spontaneous): 1\\n PEEP: 10 cmH2O\\n FiO2: 40%\\n PIP: 23 cmH2O\\n Plateau: 19 cmH2O\\n Compliance: 57.1 cmH2O/mL\\n SpO2: 91%\\n ABG: 7.42/49/93/33/5\\n Ve: 8.1 L/min\\n PaO2 / FiO2: 155\\n Physical Examination\\n General Appearance: Easily agitated, appears uncomfortable, Overweight\\n / Obese, opens eyes but no purposeful movement\\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\\n deviation\\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\\n Cardiovascular: (S1: Normal), (S2: Normal), distant\\n Respiratory / Chest: (Expansion: Symmetric), referred breath sounds\\n from ETT\\n Abdominal: No(t) Soft, Non-tender, Few Bowel sounds present, Distended\\n Extremities: No clubbing or cyanosis, 3+ nonpitting edema of b/l hands,\\n anasarca\\n Skin: no rashes or jaundice\\n Neuro: diffusely hyperreflexic with LE clonus\\n Lines: r brachioceph ART and L PICC C/D/I\\n Labs / Radiology\\n 355 K/uL\\n 9.1 g/dL\\n 168 mg/dL\\n 0.5 mg/dL\\n 30 mEq/L\\n 3.9 mEq/L\\n 11 mg/dL\\n 108 mEq/L\\n 146 mEq/L\\n 29.9 %\\n 11.8 K/uL\\n [image002.jpg]\\n 03:32 PM\\n 10:19 PM\\n 02:50 AM\\n 02:30 PM\\n 02:44 PM\\n 03:33 PM\\n 07:26 PM\\n 07:46 PM\\n 02:04 AM\\n 02:18 AM\\n WBC\\n 9.0\\n 8.4\\n 11.8\\n Hct\\n 25.8\\n 23.0\\n 28.1\\n 29.9\\n Plt\\n \\n Cr\\n 0.6\\n 0.7\\n 0.5\\n TCO2\\n 30\\n 35\\n 33\\n 31\\n 33\\n Glucose\\n 94\\n 97\\n 168\\n Other labs: PT / PTT / INR:13.8/70.4/1.2, Differential-Neuts:89.7 %,\\n Lymph:8.7 %, Mono:1.1 %, Eos:0.4 %, Ca++:8.5 mg/dL, Mg++:2.2 mg/dL,\\n PO4:5.4 mg/dL\\n TSH 2.9; FT4 1.5; stim 3.1, 10.5, 10.6\\n Culture Data: endotrach with K oxytoca; gram stain GPCs in\\n pairs and clusters\\n Assessment and Plan\\n 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA and\\n ARDS intubated since the end of .\\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\\n volume overload. Intubated on for resp decompensation.\\n Transferred here for airway stenting. Will need bronch eval when\\n improved.\\n - Thoracics will do trach and PEG once stable on PEEPs around 10.\\n Re-c/s today.\\n - wean PEEP as tolerated\\n # # Adrenal Insufficency: Minimal response to stim test again.\\n - hydrocort and fludrocort (day 1 = )\\n - endocrine c/s for further elucidation of etiology\\n # Hypotension: Likely adrenal insufficiency. Goal map > 60.\\n - hydrocortisol and fludrocortisone as above\\n - restart levophed if necessary to maintain MAP > 60\\n # Volume overloaded in setting of hypernatremia (? Relationship to\\n adrenal insufficiency), TBW deficit 2.6L.\\n - goal even to -500cc I/Os today\\n - continue FW in TF at 250 cc q4hrs\\n - lasix drip (1-5mg/hr) when MAP > 60\\n # Hyperreflexia - ? meds vs central pathology. Unlikely to be \\n intracranial hemorrhage as patient is diffusely hyperreflexic.\\n Possible relationship to endocrine pathology?\\n - consider head CT in setting of heparin gtt\\n - monitor\\n # Sedation: Sedation control remains somewhat poor although fentanyl\\n patch and diazpem are likely starting increase to therapeutic range\\n today. On Versed 1.5, Fentanyl 175, Fentanyl patch, Diazepam standing\\n and haldo 2.5-5 mg PRN. QTc stable at .44.\\n - Wean versed/fentanyl as tolerated, continue diazepam and prn\\n haldol\\n - Recheck EKG today\\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\\n coumadin at least until s/p trach.\\n - hold heparin gtt when anticipate trach/peg\\n # Spine fracture: Neurologically intact distal to the lesion. Prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - CT of C, L spine when stable. Currently, unlikely to change\\n management and high risk for complications with transport.\\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\\n is low. Brace for OOB. Ok for anticoag per note.\\n # Communication:\\n - Boyfriend of 10 is her HCP. Also brother is involved\\n # FEN/GI: Tube feeds @ goal.\\n DVT: Treatment dose heparin\\n Ulcer: Ranitidine\\n VAP: Prevention per routine\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 09:51 PM 60 mL/hour\\n Glycemic Control:\\n Lines:\\n PICC Line - 09:19 PM\\n Arterial Line - 02:00 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"General\",\n \"chartdate\": \"2167-10-01 00:00:00.000\",\n \"description\": \"Generic Note\",\n \"row_id\": 635300,\n \"text\": \"55 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP now with prolonged\\n hospital course c/o by PNA anxiety,RUE DVD with high PEEP requirement\\n .\\n Events\\n Heparin gtt and TF held since MN for ? trach and peg\\n placement today.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Received pt on AC 400/18/8/50%. 02 sats mainly 88-92% but did fall to\\n 86% when pt positioned on L side. Pt fluid overloaded with TFB for LOS\\n ~ ccs.\\n Action:\\n ABG taken while sat 88%. Lasix gtt increased to 3mg/hr\\n Response:\\n ABG 7.42/47/87/4/32. Urine output initially 25 ccs/hr but pt began\\n autodiuresing after MN with output improving to ~140ccs/hr\\n Plan:\\n Continue with current vent settings. Trach today. Titrate lasix gtt to\\n maintain MAP > 60 and u/o 100-150ccs/hr.\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt restless at times, thrashing in bed with HR up to 140 ST . Denies\\n pain or doesn\\nt respond when questioned if she is having pain.\\n Action:\\n Fentanyl drip infusing at 100mcgs/hr. Fentanyl patch in place. Also\\n treated with haldol and valium . Bolused with 2 mg versed when acutely\\n agitated. Bilateral wrist restraints in place.\\n Response:\\n Pt falls back to sleep, HR decreases (occasionally as low as 45 SB)\\n Plan:\\n Continue to assess MS. as indicated. Reorientation. Restraints\\n for safety.\\n Hypernatremia (high sodium)\\n Assessment:\\n Na 146 on \\n Action:\\n Treated with free h20 boluses\\n Response:\\n Na 143 this am\\n Plan:\\n Continue to monitor f+e status.\\n Impaired Skin Integrity\\n Assessment:\\n Pt with excoriated yeast infection on abd and in perineal area. +\\n reddened perirectal area.\\n Action:\\n Barrier cream and miconazole powder applied\\n Response:\\n To be determined.\\n Plan:\\n Diligent skin care.\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2167-09-30 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 635162,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 12\\n Ideal body weight: 61.2 None\\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\\n Airway\\n Tube Type\\n ETT:\\n Position: 21 cm at teeth\\n Route: Oral\\n Type: Standard\\n Size: 7.5mm\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: cmH2O\\n Cuff volume: mL /\\n Airway problems:\\n Comments:\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Rhonchi\\n LUL Lung Sounds: Rhonchi\\n LLL Lung Sounds: Diminished\\n Comments:\\n Secretions\\n Sputum color / consistency: Yellow / Thick\\n Sputum source/amount: Suctioned / Scant\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance: Continuous invasive ventilation\\n Visual assessment of breathing pattern: Normal quiet breathing;\\n Comments: Pt remains stable on current support. When pt is placed on\\n \\\"sides\\\" (pillows) of her back by RN, she tends to desaturate and is\\n intolerant of weaning attempts\\n Assessment of breathing comfort:\\n Non-invasive ventilation assessment:\\n Invasive ventilation assessment:\\n Trigger work assessment: Triggering synchronously\\n Dysynchrony assessment:\\n Comments:\\n Plan\\n Next 24-48 hours: Reduce PEEP as tolerated, Adjust Min. ventilation to\\n control pH, Tracheostomy planned; Comments: Pt is stable on current\\n vent settings, but SpO2 is too sensitive to weaning attempts of FiO2 or\\n PEEP\\n Reason for continuing current ventilatory support: Intolerant of\\n weaning attempts; Comments: Although Work of breathing and RR are\\n without fault, pt desaturates with weaning attempts.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-09-20 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 634163,\n \"text\": \"Chief Complaint: respiratory failure\\n HPI:\\n 24 Hour Events:\\n PICC LINE - START 10:30 PM\\n INVASIVE VENTILATION - START 10:45 PM\\n EKG - At 11:25 PM\\n BLOOD CULTURED - At 05:30 AM\\n TMax 102.7 BCX1 drawn\\n FEVER - 102.7\\nF - 04:00 AM\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Metronidazole - 08:00 AM\\n Infusions:\\n Fentanyl - 75 mcg/hour\\n Midazolam (Versed) - 2 mg/hour\\n Other ICU medications:\\n Ranitidine (Prophylaxis) - 08:00 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 08:56 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 39.3\\nC (102.7\\n Tcurrent: 37.2\\nC (99\\n HR: 88 (72 - 97) bpm\\n BP: 110/55(64) {83/38(48) - 154/71(103)} mmHg\\n RR: 14 (12 - 18) insp/min\\n SpO2: 100%\\n Total In:\\n 10 mL\\n 1,043 mL\\n PO:\\n TF:\\n 54 mL\\n IVF:\\n 10 mL\\n 988 mL\\n Blood products:\\n Total out:\\n 425 mL\\n 585 mL\\n Urine:\\n 425 mL\\n 585 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -416 mL\\n 458 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 500 (500 - 500) mL\\n RR (Set): 12\\n RR (Spontaneous): 0\\n PEEP: 10 cmH2O\\n FiO2: 60%\\n RSBI Deferred: PEEP > 10, FiO2 > 60%\\n PIP: 32 cmH2O\\n SpO2: 100%\\n ABG: 7.39/53/81./30/5\\n Ve: 8 L/min\\n PaO2 / FiO2: 135\\n Physical Examination\\n Labs / Radiology\\n 9.7 g/dL\\n 333 K/uL\\n 103 mg/dL\\n 0.6 mg/dL\\n 30 mEq/L\\n 3.8 mEq/L\\n 6 mg/dL\\n 109 mEq/L\\n 150 mEq/L\\n 30.7 %\\n 9.7 K/uL\\n [image002.jpg]\\n 11:54 PM\\n 01:00 AM\\n 06:14 AM\\n WBC\\n 9.7\\n Hct\\n 30.7\\n Plt\\n 333\\n Cr\\n 0.6\\n TCO2\\n 32\\n 33\\n Glucose\\n 103\\n Other labs: PT / PTT / INR:13.8/22.4/1.2, ALT / AST:30/19, Alk Phos / T\\n Bili:149/0.7, Differential-Neuts:76.9 %, Lymph:17.3 %, Mono:3.0 %,\\n Eos:2.5 %, Albumin:3.0 g/dL, LDH:222 IU/L, Ca++:8.6 mg/dL, Mg++:2.1\\n mg/dL, PO4:4.1 mg/dL\\n Assessment and Plan\\n Obese woman s/p t spine injury tx from Med for failure to wean\\n from mech ventilation and evaluation for stent for\\n tracheobronchomalacia\\n 1. Resp Failure: initial etiology unclear\\n but currently\\n we need to assess what she can do here. Switch to PSV 10/5 and see what\\n she can pull, check NIF. not act on this info. Let IP know she is\\n here though not stable for intervention at this point.\\n 2. New fevers and hypotension\\n Is fluid responsive, watch\\n UOP, goal 30 cc/hr. Check lactate.\\n DDx VAP, asp PNA, lines. Has PCN and blactam allergy.\\n For VAP- mini , change to Levoquin, Aztreonam, Vanco, and add\\n Flagyl for asp.\\n Lines: D/C PICC send cultures, try for 2nd PIV and if unable will\\n place CVL. Check lactate.\\n Belly: repeat LFTs, KUB OK, check residuals.\\n 3. HyperNa: correcting with g tube free flush and D5W\\n repeat lytes this evening and recalculate\\n 4. Spine Fx: consult NSurg here re reccs for back bracing and\\n activity\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 03:30 AM 10 mL/hour\\n Glycemic Control:\\n Lines:\\n PICC Line - 10:30 PM\\n 20 Gauge - 01:36 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition :\\n Total time spent:\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-09-20 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 634166,\n \"text\": \"Chief Complaint: respiratory failure\\n HPI: 55 yr old woman s/p t soine injury from Med with difficulty\\n vent weaning ? tbmalacia requiring stent\\n Hour Events:\\n PICC LINE - START 10:30 PM\\n INVASIVE VENTILATION - START 10:45 PM\\n EKG - At 11:25 PM\\n BLOOD CULTURED - At 05:30 AM\\n TMax 102.7 BCX1 drawn\\n FEVER - 102.7\\nF - 04:00 AM\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Metronidazole - 08:00 AM\\n Infusions:\\n Fentanyl - 75 mcg/hour\\n Midazolam (Versed) - 2 mg/hour\\n Other ICU medications:\\n Ranitidine (Prophylaxis) - 08:00 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 08:56 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 39.3\\nC (102.7\\n Tcurrent: 37.2\\nC (99\\n HR: 88 (72 - 97) bpm\\n BP: 110/55(64) {83/38(48) - 154/71(103)} mmHg\\n RR: 14 (12 - 18) insp/min\\n SpO2: 100%\\n Total In:\\n 10 mL\\n 1,043 mL\\n PO:\\n TF:\\n 54 mL\\n IVF:\\n 10 mL\\n 988 mL\\n Blood products:\\n Total out:\\n 425 mL\\n 585 mL\\n Urine:\\n 425 mL\\n 585 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -416 mL\\n 458 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 500 (500 - 500) mL\\n RR (Set): 12\\n RR (Spontaneous): 0\\n PEEP: 10 cmH2O\\n FiO2: 60%\\n RSBI Deferred: PEEP > 10, FiO2 > 60%\\n PIP: 32 cmH2O\\n SpO2: 100%\\n ABG: 7.39/53/81./30/5\\n Ve: 8 L/min\\n PaO2 / FiO2: 135\\n Physical Examination\\n Gen: intubated and sedated\\n CV: RR\\n Chest: fair air movement\\n Abd: obese soft NT+BS\\n Ext RUEgreater than LUE edema\\n Labs / Radiology\\n 9.7 g/dL\\n 333 K/uL\\n 103 mg/dL\\n 0.6 mg/dL\\n 30 mEq/L\\n 3.8 mEq/L\\n 6 mg/dL\\n 109 mEq/L\\n 150 mEq/L\\n 30.7 %\\n 9.7 K/uL\\n [image002.jpg]\\n 11:54 PM\\n 01:00 AM\\n 06:14 AM\\n WBC\\n 9.7\\n Hct\\n 30.7\\n Plt\\n 333\\n Cr\\n 0.6\\n TCO2\\n 32\\n 33\\n Glucose\\n 103\\n Other labs: PT / PTT / INR:13.8/22.4/1.2, ALT / AST:30/19, Alk Phos / T\\n Bili:149/0.7, Differential-Neuts:76.9 %, Lymph:17.3 %, Mono:3.0 %,\\n Eos:2.5 %, Albumin:3.0 g/dL, LDH:222 IU/L, Ca++:8.6 mg/dL, Mg++:2.1\\n mg/dL, PO4:4.1 mg/dL\\n Assessment and Plan\\n Obese woman s/p t spine injury tx from Med for failure to wean\\n from mech ventilation and evaluation for stent for\\n tracheobronchomalacia\\n 1. Resp Failure: initial etiology unclear\\n but we need to\\n assess current mechanics and reserve. Switch to PSV 10/5 and see what\\n she can pull, check NIF. not act on this info in light of issue\\n sbelow but important for us to understand. Let IP know she is here\\n though not stable for intervention at this point.\\n 2. New fevers and transient hypotension\\n Is fluid\\n responsive, watch UOP, goal 30 cc/hr.\\n DDx VAP, asp PNA, lines. Has PCN and blactam allergy.\\n For VAP- mini , change to Levoquin, Aztreonam, Vanco, and add\\n Flagyl for asp.\\n Lines: D/C PICC send cultures, try for 2nd PIV and if unable will\\n place CVL. Check lactate.\\n Belly: repeat LFTs, KUB OK, check residuals.\\n 3. HyperNa: correcting with g tube free flush and D5W\\n repeat lytes this evening and recalculate\\n 4. Spine Fx: consult NSurg here re reccs for back bracing and\\n activity\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 03:30 AM 10 mL/hour\\n Glycemic Control:\\n Lines:\\n PICC Line - 10:30 PM\\n 20 Gauge - 01:36 AM\\n Prophylaxis:\\n DVT: SC hep\\n Stress ulcer: Zantac\\n VAP: chlorhex HOB daily wake ups\\n Comments:\\n Communication: boyfriend is proxy not the brother but need to clarify\\n paperwork.\\n Code status: FULL\\n Disposition :ICU\\n Total time spent: 45\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-09-21 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 634282,\n \"text\": \"55-year-old woman with\\n Respiratory failure\\n Traumatic thoracic spinal fractures\\n Probable VAP\\n Upper extremity DVT\\n Oliguria\\n Anemia\\n * Possible tracheobronchomalacia (reason for transfer from OSH)\\n Alteration in Nutrition\\n Assessment:\\n Pt NPO, Pt w/ high residuals yesterday. Abdomen distended/obese/soft.\\n BS hypoactive. Low albumin.\\n Action:\\n OGT to low wall suction. TF off.\\n Response:\\n Small amount of gastric fluid suctioned- approx 30cc-50cc.\\n Plan:\\n Plan for CT of Abdomen, cont NPO at this time.\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n RUE + DVT\\n Action:\\n Cont on sq heparin\\n Response:\\n No change\\n Plan:\\n Consult neuro-surgery regarding anti-coagulation w/ T-spine fx, elevate\\n RUE, no blood draws or blood pressures to RUE.\\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\\n Assessment:\\n Temp max 100\\n Action:\\n Antibiotics given and dosage changed to vanco and aztreonam.\\n Response:\\n No further temp spike.\\n Plan:\\n Cont w/ antibiotics, f/u on cultures, tyelenol prn, vanco trough to be\\n drawn prior to evening dose.\\n Fracture, other\\n Assessment:\\n T-spine compression fx, Back brace at bedside when OOB.\\n Action:\\n Ortho tech consulted for placement of back brace. Cont w/ log roll\\n precautions.\\n Response:\\n Pt denies c/o pain when asked.\\n Plan:\\n Cont w/ log roll precautions, back brace for OOB, CT scan, consult w/\\n neurosurg.\\n Anemia, other\\n Assessment:\\n HCT 24.1 from 28\\n Action:\\n Given 1 unit of PRBCs\\n Response:\\n HCT to be drawn.\\n Plan:\\n Cont to follow HCTs, guiac stools, monitor of s/s of bleeding.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n LS- bronchial throughout, deep sxn\\nd for thick/tan secretions, copious\\n clear oral secretions suctioned, PO2 68% on 70% FIO2 and 12 peep. ?\\n PE/? VAP.\\n Action:\\n Vent changes made throughout shift.\\n Response:\\n Plan:\\n Esophageal balloon placement to be performed, monitor ABGs, vent\\n changes as needed.\\n Hypotension (not Shock)\\n Assessment:\\n Pt hypotensive into low-mid 80s systolic, HR 70s-90s. Low uop-\\n BUN/Creat negative. Bladder pressure 18-20.\\n Action:\\n Vigeleo set up, given 1 unit of blood, bloused x 1, multi-lumen RIJ\\n placed at bedside.\\n Response:\\n No response to blusing, SBP improved following blood transfusion, RIJ\\n okay to use. CVP 18.\\n Plan:\\n Levophed to be started if needed, transfuse as needed.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-09-21 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 634283,\n \"text\": \"55-year-old woman with\\n Respiratory failure\\n Traumatic thoracic spinal fractures\\n Probable VAP\\n Upper extremity DVT\\n Oliguria\\n Anemia\\n * Possible tracheobronchomalacia (reason for transfer from OSH)\\n Events:\\n Alteration in Nutrition\\n Assessment:\\n Pt NPO, Pt w/ high residuals yesterday. Abdomen distended/obese/soft.\\n BS hypoactive. Low albumin.\\n Action:\\n OGT to low wall suction. TF off.\\n Response:\\n Small amount of gastric fluid suctioned- approx 30cc-50cc.\\n Plan:\\n Plan for CT of Abdomen, cont NPO at this time.\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n RUE + DVT\\n Action:\\n Cont on sq heparin\\n Response:\\n No change\\n Plan:\\n Consult neuro-surgery regarding anti-coagulation w/ T-spine fx, elevate\\n RUE, no blood draws or blood pressures to RUE.\\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\\n Assessment:\\n Temp max 100\\n Action:\\n Antibiotics given and dosage changed to vanco and aztreonam.\\n Response:\\n No further temp spike.\\n Plan:\\n Cont w/ antibiotics, f/u on cultures, tyelenol prn, vanco trough to be\\n drawn prior to evening dose.\\n Fracture, other\\n Assessment:\\n T-spine compression fx, Back brace at bedside when OOB.\\n Action:\\n Ortho tech consulted for placement of back brace. Cont w/ log roll\\n precautions.\\n Response:\\n Pt denies c/o pain when asked.\\n Plan:\\n Cont w/ log roll precautions, back brace for OOB, CT scan, consult w/\\n neurosurg.\\n Anemia, other\\n Assessment:\\n HCT 24.1 from 28\\n Action:\\n Given 1 unit of PRBCs\\n Response:\\n HCT to be drawn.\\n Plan:\\n Cont to follow HCTs, guiac stools, monitor of s/s of bleeding.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n LS- bronchial throughout, deep sxn\\nd for thick/tan secretions, copious\\n clear oral secretions suctioned, PO2 68% on 70% FIO2 and 12 peep. ?\\n PE/? VAP.\\n Action:\\n Vent changes made throughout shift.\\n Response:\\n Plan:\\n Esophageal balloon placement to be performed, monitor ABGs, vent\\n changes as needed.\\n Hypotension (not Shock)\\n Assessment:\\n Pt hypotensive into low-mid 80s systolic, HR 70s-90s. Low uop-\\n BUN/Creat negative. Bladder pressure 18-20.\\n Action:\\n Vigeleo set up, given 1 unit of blood, bloused x 1, multi-lumen RIJ\\n placed at bedside.\\n Response:\\n No response to blusing, SBP improved following blood transfusion, RIJ\\n okay to use. CVP 18.\\n Plan:\\n Levophed to be started if needed, transfuse as needed.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-09-22 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 634365,\n \"text\": \"Alteration in Nutrition\\n Assessment:\\n TF d/c\\nd d/t high residuals; abd soft, mod distended; hypoactive\\n BSx4; abd CT without evidence of obstruction\\n Action:\\n Sedation weaned down; TF restarted; bowel regimen w/reglan\\nsoap suds\\n enema and fleet enema given; begun naloxone for Gi motility\\n Response:\\n Tol TF; sm amt stool w/enemas; stool for c-diff\\n Plan:\\n Monitor bowel status; do not advance TF beyond 10cc/hr. Cont with bowel\\n meds; place rectal tube for decompression\\n Hypotension (not Shock)\\n Assessment:\\n Bp improved with MAP >65 and SBP >90\\n Action:\\n Levophed weaned off\\n Response:\\n Adequate Bp off pressor\\n Plan:\\n Cont to monitor BP; restart levophed prn\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Bil effusions L>R, RLL consolidation. Tol ACV\\n Action:\\n Esophageal balloon placed; bladder pressure elevated; increased PEEP;\\n freq suctioning\\n Response:\\n Tol elevated PEEP and freq position changes\\n Plan:\\n Cont to monitor resp status and titrate vent settings accordingly.\\n Suction prn. Await further micro data.\\n Fracture, other\\n Assessment:\\n Logrolling; reverse tredelenberg pnd clarification of spinal fx\\n Action:\\n Spine/ortho consult-off logrolling prec. HoB>30\\n Response:\\n Tol position changes\\n Plan:\\n Activity as tol; needs to wear TLSO brace when OOB or sitting up for T8\\n compression fx\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n DVT RUE-3+ edema\\n Action:\\n Awaiting clearance for heparin gtt from /spine service\\n Response:\\n Cleared for heparin gtt\\n Plan:\\n Awaiting further orders from MICU team\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2167-09-22 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 634367,\n \"text\": \"Demographics\\n Day of intubation: \\n Day of mechanical ventilation: 4\\n Ideal body weight: 61.2 None\\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: Unknown\\n Procedure location: Outside hospital\\n Reason: Emergent (1st time)\\n Tube Type\\n ETT:\\n Position: cm at teeth\\n Route:\\n Type: Standard\\n Size: 7.5mm\\n Tracheostomy tube:\\n Type:\\n Manufacturer:\\n Size:\\n PMV:\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: cmH2O\\n Cuff volume: mL /\\n Airway problems:\\n Comments:\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Rhonchi\\n LUL Lung Sounds: Rhonchi\\n LLL Lung Sounds: Diminished\\n Comments:\\n Secretions\\n Sputum color / consistency: Yellow / Thick\\n Sputum source/amount: Suctioned / Small\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance:\\n Visual assessment of breathing pattern: Normal quiet breathing\\n Assessment of breathing comfort:\\n Non-invasive ventilation assessment:\\n Invasive ventilation assessment:\\n Trigger work assessment: Not triggering\\n Dysynchrony assessment:\\n Comments:\\n Plan\\n Next 24-48 hours: Utilize ARDSnet protocol\\n Reason for continuing current ventilatory support: Hemodynimic\\n instability, Underlying illness not resolved\\n Respiratory Care Shift Procedures\\n Transports:\\n Destination (R/T)\\n Time\\n Complications\\n Comments\\n Bedside Procedures:\\n Pleural pressure measurement (1330hrs)\\n Comments: Approximate time\\n, RRT 17:21\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-05 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 635825,\n \"text\": \"55 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\\n Now with prolonged hospital course c/b by PNA with high PEEP\\n requirement, anxiety, RUE DVT on heparin qtt.\\n Edema, peripheral\\n Assessment:\\n Fluid balance for previous 24hrs decreased by 3 liters D/T diuresis.\\n Rec\\nd pt off of Lasix qtt. Urine output decreased to 45ml/hr @1000.\\n Action:\\n Lasix qtt restarted @ 2mg/hr to maintain urine output 1-2liters/day.\\n Response:\\n Fluid balance approx -50ml/hr, with 24hr fluid balance -650ml @ 1500.\\n However, SBP 78 when pt soundly sleeping/sedated. Lasix qtt stopped @\\n 1530.\\n Plan:\\n Restart Lasix qtt when BP stabilized.\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Rec\\nd pt on Heparin qtt @ 1500units/hr.\\n Action:\\n PTT 62,2 @ 0230.\\n Response:\\n Heparin rate unchanged.pt had 2 therapeutic PTT,started on coumadin\\n 5mg at 2200,.\\n Plan:\\n Cont heparin gtt as well as Coumadin until INR ^ 2.\\n Altered mental status (not Delirium)\\n Assessment:\\n Rec\\nd pt on Versed @ 2mg/hr, Fentanyl @ 75 mcg/hr, as well as Fentanyl\\n patches totaling 150mcg in place. Pt also rec\\ning Diazepam 10mg po\\n Q6hrs, in hope of weaning pt from IV sedation. Agitated most time\\n moving around intermittently following commands. Moving arms\\n purposefully towards trach, so soft wrist restraints remain in place..\\n Action:\\n Pt required bolus sedation x2 with care and activity.\\n Response:\\n Pt restless/squirming in bed when she appears awake..\\n Plan:\\n Cont to attempt weaning from IV sedation. emotional support to pt and\\n family,reorient pt .\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Rec\\nd pt on vent settings AC 50%/18 X 400/+10, no over-breathing of\\n rate . O2 sats 94-96%. ABG done yesterday was 7.44/42/93. Lung sounds\\n clear but diminished in lower lobes. Suctioned for small-moderate amts\\n thick white secretions.\\n Action:\\n Cont same Vent settings.Getting breathing rx by respitory\\n Response:\\n Pts secretions got better\\n Plan:\\n Cont wean from vent with PS trials,Monitor mental status.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-05 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 635826,\n \"text\": \"55 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\\n Now with prolonged hospital course c/b by PNA with high PEEP\\n requirement, anxiety, RUE DVT on heparin qtt.\\n Edema, peripheral\\n Assessment:\\n Rec\\nd pt on 2mg/hr lasix gtt\\n Action:\\n Pt putting out 400-500cc/hr.\\n Response:\\n Fluid balance approx -50ml/hr, with 24hr fluid balance -650ml @ 1500.\\n However, SBP 78 when pt soundly sleeping/sedated. Lasix qtt stopped @\\n 1530.\\n Plan:\\n Cont Lasix gtt goal Negative 1-2L,monitor BPclosely\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Rec\\nd pt on Heparin qtt @ 1500units/hr.\\n Action:\\n PTT 62,2 @ 0230.\\n Response:\\n Heparin rate unchanged.pt had 2 therapeutic PTT,started on coumadin\\n 5mg at 2200,.\\n Plan:\\n Cont heparin gtt as well as Coumadin until INR ^ 2.\\n Altered mental status (not Delirium)\\n Assessment:\\n Rec\\nd pt on Versed @ 2mg/hr, Fentanyl @ 75 mcg/hr, as well as Fentanyl\\n patches totaling 150mcg in place. Pt also rec\\ning Diazepam 10mg po\\n Q6hrs, in hope of weaning pt from IV sedation. Agitated most time\\n moving around intermittently following commands. Moving arms\\n purposefully towards trach, so soft wrist restraints remain in place..\\n Action:\\n Pt required bolus sedation x2 with care and activity.\\n Response:\\n Pt restless/squirming in bed when she appears awake..\\n Plan:\\n Cont to attempt weaning from IV sedation. emotional support to pt and\\n family,reorient pt .\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Rec\\nd pt on vent settings AC 50%/18 X 400/+10, no over-breathing of\\n rate . O2 sats 94-96%. ABG done yesterday was 7.44/42/93. Lung sounds\\n clear but diminished in lower lobes. Suctioned for small-moderate amts\\n thick white secretions.\\n Action:\\n Cont same Vent settings.Getting breathing rx by respitory\\n Response:\\n Pts secretions got better\\n Plan:\\n Cont wean from vent with PS trials,Monitor mental status.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-05 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 635834,\n \"text\": \"55 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\\n Now with prolonged hospital course c/b by PNA with high PEEP\\n requirement, anxiety, RUE DVT on heparin qtt.\\n Edema, peripheral\\n Assessment:\\n Rec\\nd pt on 2mg/hr lasix gtt\\n Action:\\n Pt putting out 400-500cc/hr.K was 3.1 this morning.\\n Response:\\n Pt still putting out 400-500cc.hr,BP stayed stable.K repleted w/total\\n of 80 Meq\\n Plan:\\n Cont Lasix gtt goal Negative 1-2L,monitor BPclosely\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Rec\\nd pt on Heparin qtt @ 1500units/hr.\\n Action:\\n PTT 62,2 @ 0230.\\n Response:\\n Heparin rate unchanged two therapeutic PTT level,started on\\n coumadin 5mg yesterday at 2200,.\\n Plan:\\n Cont heparin gtt as well as Coumadin until INR ^ 2.\\n Altered mental status (not Delirium)\\n Assessment:\\n Rec\\nd pt on Versed @ 2mg/hr, Fentanyl @ 75 mcg/hr, as well as Fentanyl\\n patches totaling 150mcg in place. Pt also rec\\ning Diazepam 10mg po\\n Q6hrs, in hope of weaning pt from IV sedation. Agitated most time\\n moving around intermittently following commands. Moving arms\\n purposefully towards trach, so soft wrist restraints remain in place..\\n Action:\\n Pt required bolus sedation x2 with care and activity.\\n Response:\\n Pt restless/squirming in bed when she appears awake..\\n Plan:\\n Cont to attempt weaning from IV sedation. emotional support to pt and\\n family,reorient pt .\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Rec\\nd pt on vent settings AC 50%/18 X 400/+10, no over-breathing of\\n rate . O2 sats 94-96%. ABG done yesterday was 7.44/42/93. Lung sounds\\n clear but diminished in lower lobes. Suctioned for small-moderate amts\\n thick white secretions.\\n Action:\\n Cont same Vent settings.Getting breathing rx by respitory\\n Response:\\n Pts secretions got better\\n Plan:\\n Cont wean from vent with PS trials,Monitor mental status.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-09-29 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 635063,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n ARTERIAL LINE - STOP 09:00 PM - attempted to re-wire but\\n patient was very agitated and re-wire was unsuccessful\\n Patient alternated between tachycardia and normotension and hypotension\\n in the high-80s/low 90s and HRs in the 50s\\n Given haldol, valium, midaz and fentanyl for sedation\\n ABG with low paO2 on PEEP 10, had to increase -- went back up to 15 and\\n then attempted to re-wean down with goal 8 in anticipation of OR\\n To OR for trach and PEG today (thoracics)\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Levofloxacin - 08:06 AM\\n Infusions:\\n Midazolam (Versed) - 1.5 mg/hour\\n Fentanyl - 200 mcg/hour\\n Other ICU medications:\\n Fentanyl - 06:45 PM\\n Ranitidine (Prophylaxis) - 08:00 PM\\n Haloperidol (Haldol) - 10:00 PM\\n Midazolam (Versed) - 10:00 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:03 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.7\\nC (99.8\\n Tcurrent: 37.7\\nC (99.8\\n HR: 109 (55 - 134) bpm\\n BP: 120/56(70) {80/43(51) - 133/85(94)} mmHg\\n RR: 20 (16 - 28) insp/min\\n SpO2: 97%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 101 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 3,064 mL\\n 404 mL\\n PO:\\n TF:\\n 1,440 mL\\n IVF:\\n 1,014 mL\\n 314 mL\\n Blood products:\\n Total out:\\n 4,257 mL\\n 1,195 mL\\n Urine:\\n 4,257 mL\\n 1,195 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,193 mL\\n -791 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 400 (400 - 400) mL\\n RR (Set): 18\\n RR (Spontaneous): 10\\n PEEP: 15 cmH2O\\n FiO2: 60%\\n RSBI Deferred: PEEP > 10\\n PIP: 23 cmH2O\\n Plateau: 24 cmH2O\\n SpO2: 97%\\n ABG: 7.46/48/65/31/8\\n Ve: 7.8 L/min\\n PaO2 / FiO2: 108\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 320 K/uL\\n 8.0 g/dL\\n 94 mg/dL\\n 0.6 mg/dL\\n 31 mEq/L\\n 3.6 mEq/L\\n 13 mg/dL\\n 110 mEq/L\\n 147 mEq/L\\n 25.8 %\\n 9.0 K/uL\\n [image002.jpg]\\n 10:18 AM\\n 02:33 PM\\n 02:46 PM\\n 03:31 AM\\n 02:26 PM\\n 05:53 PM\\n 05:01 AM\\n 03:32 PM\\n 10:19 PM\\n 02:50 AM\\n WBC\\n 9.7\\n 9.5\\n 9.0\\n Hct\\n 26.0\\n 27.6\\n 25.8\\n Plt\\n \\n Cr\\n 0.5\\n 0.5\\n 0.5\\n 0.6\\n 0.6\\n TCO2\\n 29\\n 26\\n 27\\n 30\\n 30\\n 35\\n Glucose\\n 195\\n 195\\n 163\\n 133\\n 102\\n 94\\n Other labs: PT / PTT / INR:14.1/59.6/1.2, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\\n Amylase / Lipase:, Differential-Neuts:71.2 %, Lymph:22.7 %,\\n Mono:4.0 %, Eos:1.7 %, Lactic Acid:1.5 mmol/L, Albumin:2.4 g/dL,\\n LDH:204 IU/L, Ca++:8.2 mg/dL, Mg++:2.1 mg/dL, PO4:4.6 mg/dL\\n Assessment and Plan\\n 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture with respiratory failure\\n and difficulty weaning from vent.\\n # Respiratory failure: Intubated on for resp decompensation.\\n Likely VAP. Transferred here for tracheomalacia, but not sure this\\n is a component. Will need bronch eval when improved\\n - will discuss PEEP goal for trach placement with IP.\\n - wean PEEP\\n - repeat ABG this AM\\n - discuss need for trach with patient and her family\\n - Volume overload may be contributing.\\n # Volume overload\\n Currently with hypernatremia, Cr increase, contract\\n alk, but mild\\n - continue gentle diuresis\\n - FW in TF at 150 cc q4hrs\\n - PM lytes.\\n # Sedation: On versed 3mg/hr + .5 q 1hr and fentanyl 150 mcg/hr + 50\\n bolus q 1hr.\\n - Start fentanyl patch and diazepam to provide long acting analgesia\\n and wean from drips\\n - Haldol 1 mg Q4h PRN agitation\\n # Pneumonia: Pansensitive Kleb oxytoca pneumonia and sputum with GPCs\\n on gram stain. Afebrile off abx.\\n # EKG changes: Sinus bradycardia, responsive to stress. Related to\\n sedation, increased vagal tone, possibly related to steroid\\n replacement. Atrial EKG shows p-waves and cardiac enzymes normal.\\n - Continue to monitor\\n # Hypotension: Improved, off levophed for 2-3 days now, with good urine\\n output. s/p 5 d course of steroids for adrenal insufficiency. High\\n PEEP may have been contributing. Now likely related to sedation and\\n decreased intravascular volume,\\n -monitor, expect improvement with continual reduction in PEEP\\n # RUE DVT: Started on heparin gtt on , now therapeutic. Follow\\n PTTs. Would hold off on coumadin at least until s/p trach.\\n - continue to monitor\\n # Adrenal Insufficency: Random cortisol was approx 3 when it should\\n have been maximally stimulated.\\n - hydrocortisone and florinef for 5 days\\n # Anemia: Stable.\\n - Trend HCT\\n # Spine fracture: Neurologically intact distal to the lesion. Prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - CT of C, L spine when stable. Currently, unlikely to change\\n management and high risk for complications with transport.\\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\\n is low. Brace for OOB. Ok for anticoag per note.\\n # Communication:\\n - Boyfriend of 10 is her HCP. Also brother is involved\\n FEN/GI: Tube feeds @ goal\\n DVT: Treatment dose heparin\\n Ulcer: Ranitidine\\n VAP: Prevention per routine\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n PICC Line - 09:19 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-09-30 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 635216,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n ARTERIAL LINE - START 02:00 PM - in right brachial atery\\n Hypotensive- started on levophed, weaned off over night\\n Low cortisol and failed stim test - started on steroids\\n TTE ordered\\n Free water flushes were increased for hypernatremia (250cc q4)\\n Able to hear patient breathing at times during exam this am (poor am\\n CXR, reordered)\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Levofloxacin - 08:06 AM\\n Infusions:\\n Heparin Sodium - 1,700 units/hour\\n Midazolam (Versed) - 2 mg/hour\\n Fentanyl - 150 mcg/hour\\n Other ICU medications:\\n Haloperidol (Haldol) - 12:15 AM\\n Other medications:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:50 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.5\\nC (99.5\\n Tcurrent: 36.7\\nC (98\\n HR: 63 (48 - 138) bpm\\n BP: 91/41(58) {68/30(49) - 143/78(105)} mmHg\\n RR: 18 (13 - 23) insp/min\\n SpO2: 91%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Mixed Venous O2% Sat: 59 - 59\\n Total In:\\n 3,898 mL\\n 1,155 mL\\n PO:\\n TF:\\n 802 mL\\n 348 mL\\n IVF:\\n 2,126 mL\\n 247 mL\\n Blood products:\\n Total out:\\n 2,367 mL\\n 800 mL\\n Urine:\\n 2,367 mL\\n 800 mL\\n NG:\\n Stool:\\n ?\\n ?\\n Drains:\\n Balance:\\n 1,531 mL\\n 355 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 400 (400 - 401) mL\\n RR (Set): 18\\n RR (Spontaneous): 1\\n PEEP: 10 cmH2O\\n FiO2: 40%\\n PIP: 23 cmH2O\\n Plateau: 19 cmH2O\\n Compliance: 57.1 cmH2O/mL\\n SpO2: 91%\\n ABG: 7.42/49/93/33/5\\n Ve: 8.1 L/min\\n PaO2 / FiO2: 155\\n Physical Examination\\n General Appearance: Easily agitated, appears uncomfortable, Overweight\\n / Obese, opens eyes but no purposeful movement\\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\\n deviation\\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\\n Cardiovascular: (S1: Normal), (S2: Normal), distant\\n Respiratory / Chest: (Expansion: Symmetric), referred breath sounds\\n from ETT\\n Abdominal: No(t) Soft, Non-tender, Few Bowel sounds present, Distended\\n Extremities: No clubbing or cyanosis, 3+ nonpitting edema of b/l hands,\\n anasarca\\n Skin: no rashes or jaundice\\n Neuro: diffusely hyperreflexic with LE clonus\\n Lines: r brachioceph ART and L PICC C/D/I\\n Labs / Radiology\\n 355 K/uL\\n 9.1 g/dL\\n 168 mg/dL\\n 0.5 mg/dL\\n 30 mEq/L\\n 3.9 mEq/L\\n 11 mg/dL\\n 108 mEq/L\\n 146 mEq/L\\n 29.9 %\\n 11.8 K/uL\\n [image002.jpg]\\n 03:32 PM\\n 10:19 PM\\n 02:50 AM\\n 02:30 PM\\n 02:44 PM\\n 03:33 PM\\n 07:26 PM\\n 07:46 PM\\n 02:04 AM\\n 02:18 AM\\n WBC\\n 9.0\\n 8.4\\n 11.8\\n Hct\\n 25.8\\n 23.0\\n 28.1\\n 29.9\\n Plt\\n \\n Cr\\n 0.6\\n 0.7\\n 0.5\\n TCO2\\n 30\\n 35\\n 33\\n 31\\n 33\\n Glucose\\n 94\\n 97\\n 168\\n Other labs: PT / PTT / INR:13.8/70.4/1.2, Differential-Neuts:89.7 %,\\n Lymph:8.7 %, Mono:1.1 %, Eos:0.4 %, Ca++:8.5 mg/dL, Mg++:2.2 mg/dL,\\n PO4:5.4 mg/dL\\n TSH 2.9; FT4 1.5; stim 3.1, 10.5, 10.6\\n Culture Data: endotrach with K oxytoca; gram stain GPCs in\\n pairs and clusters\\n Assessment and Plan\\n 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture with K. oxytoca, .\\n # Respiratory failure: Related to ARDS, ? trachiomalacia, resolved\\n VAP, volume overload. Intubated on for resp decompensation.\\n Transferred here for tracheomalacia, but not sure this is a component.\\n Will need bronch eval when improved\\n - Thoracics will do trach and PEG once stable on PEEPs around 10.\\n Re-c/s today.\\n - wean PEEP as tolerated\\n # Volume overload\\n Hypernatremic (? Relationship to adrenal\\n insufficiency), TBW deficit 2.6L.\\n - goal even I/Os today\\n - FW in TF at 250 cc q4hrs\\n - PM lytes\\n # Hyperreflexia - ? meds vs central pathology\\n - consider head CT in context of heparin gtt to r/o intracranial\\n hemmorhage\\n # Sedation: Poor sedation control. On Versed 1.5, Fentanyl 175,\\n Fentanyl patch, Diazepam standing and haldo 2.5-5 mg PRN. QTc stable\\n at .44\\n - Wean versed/fentanyl as tolerated\\n - Recheck EKG today\\n -\\n # Hypotension: Related to sedation, but high PEEP, adrenial\\n insufficiency, sepsis have previously been contributing. Monitor with\\n A-line. Failed stim again.\\n - hydrocortisol and fludrocortisone\\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\\n coumadin at least until s/p trach.\\n - hold heparin gtt when anticipate trach/peg\\n # Adrenal Insufficency: Minimal response to stim test again.\\n - hydrocort and fludrocort\\n - consider endocrine c/s for further elucidation of etiology\\n # Spine fracture: Neurologically intact distal to the lesion. Prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - CT of C, L spine when stable. Currently, unlikely to change\\n management and high risk for complications with transport.\\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\\n is low. Brace for OOB. Ok for anticoag per note.\\n # Communication:\\n - Boyfriend of 10 is her HCP. Also brother is involved\\n # FEN/GI: Tube feeds @ goal.\\n DVT: Treatment dose heparin\\n Ulcer: Ranitidine\\n VAP: Prevention per routine\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 09:51 PM 60 mL/hour\\n Glycemic Control:\\n Lines:\\n PICC Line - 09:19 PM\\n Arterial Line - 02:00 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-09-30 00:00:00.000\",\n \"description\": \"Physician Resident/Attending Progress Note - MICU\",\n \"row_id\": 635227,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n ARTERIAL LINE - START 02:00 PM - in right brachial atery\\n Hypotensive- started on levophed, weaned off over night\\n Low cortisol and failed stim test - started on steroids\\n TTE ordered\\n Free water flushes were increased for hypernatremia (250cc q4)\\n Able to hear patient breathing at times during exam this am (poor am\\n CXR, reordered)\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Levofloxacin - 08:06 AM\\n Infusions:\\n Heparin Sodium - 1,700 units/hour\\n Midazolam (Versed) - 2 mg/hour\\n Fentanyl - 150 mcg/hour\\n Other ICU medications:\\n Haloperidol (Haldol) - 12:15 AM\\n Other medications:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:50 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.5\\nC (99.5\\n Tcurrent: 36.7\\nC (98\\n HR: 63 (48 - 138) bpm\\n BP: 91/41(58) {68/30(49) - 143/78(105)} mmHg\\n RR: 18 (13 - 23) insp/min\\n SpO2: 91%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Mixed Venous O2% Sat: 59 - 59\\n Total In:\\n 3,898 mL\\n 1,155 mL\\n PO:\\n TF:\\n 802 mL\\n 348 mL\\n IVF:\\n 2,126 mL\\n 247 mL\\n Blood products:\\n Total out:\\n 2,367 mL\\n 800 mL\\n Urine:\\n 2,367 mL\\n 800 mL\\n NG:\\n Stool:\\n ?\\n ?\\n Drains:\\n Balance:\\n 1,531 mL\\n 355 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 400 (400 - 401) mL\\n RR (Set): 18\\n RR (Spontaneous): 1\\n PEEP: 10 cmH2O\\n FiO2: 40%\\n PIP: 23 cmH2O\\n Plateau: 19 cmH2O\\n Compliance: 57.1 cmH2O/mL\\n SpO2: 91%\\n ABG: 7.42/49/93/33/5\\n Ve: 8.1 L/min\\n PaO2 / FiO2: 155\\n Physical Examination\\n General Appearance: Easily agitated, appears uncomfortable, Overweight\\n / Obese, opens eyes but no purposeful movement\\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\\n deviation\\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\\n Cardiovascular: (S1: Normal), (S2: Normal), distant\\n Respiratory / Chest: (Expansion: Symmetric), referred breath sounds\\n from ETT\\n Abdominal: No(t) Soft, Non-tender, Few Bowel sounds present, Distended\\n Extremities: No clubbing or cyanosis, 3+ nonpitting edema of b/l hands,\\n anasarca\\n Skin: no rashes or jaundice\\n Neuro: diffusely hyperreflexic with LE clonus\\n Lines: r brachioceph ART and L PICC C/D/I\\n Labs / Radiology\\n 355 K/uL\\n 9.1 g/dL\\n 168 mg/dL\\n 0.5 mg/dL\\n 30 mEq/L\\n 3.9 mEq/L\\n 11 mg/dL\\n 108 mEq/L\\n 146 mEq/L\\n 29.9 %\\n 11.8 K/uL\\n [image002.jpg]\\n 03:32 PM\\n 10:19 PM\\n 02:50 AM\\n 02:30 PM\\n 02:44 PM\\n 03:33 PM\\n 07:26 PM\\n 07:46 PM\\n 02:04 AM\\n 02:18 AM\\n WBC\\n 9.0\\n 8.4\\n 11.8\\n Hct\\n 25.8\\n 23.0\\n 28.1\\n 29.9\\n Plt\\n \\n Cr\\n 0.6\\n 0.7\\n 0.5\\n TCO2\\n 30\\n 35\\n 33\\n 31\\n 33\\n Glucose\\n 94\\n 97\\n 168\\n Other labs: PT / PTT / INR:13.8/70.4/1.2, Differential-Neuts:89.7 %,\\n Lymph:8.7 %, Mono:1.1 %, Eos:0.4 %, Ca++:8.5 mg/dL, Mg++:2.2 mg/dL,\\n PO4:5.4 mg/dL\\n TSH 2.9; FT4 1.5; stim 3.1, 10.5, 10.6\\n Culture Data: endotrach with K oxytoca; gram stain GPCs in\\n pairs and clusters\\n Assessment and Plan\\n 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA and\\n ARDS intubated since the end of .\\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\\n volume overload. Intubated on for resp decompensation.\\n Transferred here for airway stenting. Will need bronch eval when\\n improved.\\n - Thoracics will do trach and PEG once stable on PEEPs around 10.\\n Re-c/s today.\\n - wean PEEP as tolerated\\n # # Adrenal Insufficency: Minimal response to stim test again.\\n - hydrocort and fludrocort (day 1 = )\\n - endocrine c/s for further elucidation of etiology\\n # Hypotension: Likely adrenal insufficiency. Goal map > 60.\\n - hydrocortisol and fludrocortisone as above\\n - restart levophed if necessary to maintain MAP > 60\\n # Volume overloaded in setting of hypernatremia (? Relationship to\\n adrenal insufficiency), TBW deficit 2.6L.\\n - goal even to -500cc I/Os today\\n - continue FW in TF at 250 cc q4hrs\\n - lasix drip (1-5mg/hr) when MAP > 60\\n # Hyperreflexia - ? meds vs central pathology. Unlikely to be \\n intracranial hemorrhage as patient is diffusely hyperreflexic.\\n Possible relationship to endocrine pathology?\\n - consider head CT in setting of heparin gtt\\n - monitor\\n # Sedation: Sedation control remains somewhat poor although fentanyl\\n patch and diazpem are likely starting increase to therapeutic range\\n today. On Versed 1.5, Fentanyl 175, Fentanyl patch, Diazepam standing\\n and haldo 2.5-5 mg PRN. QTc stable at .44.\\n - Wean versed/fentanyl as tolerated, continue diazepam and prn\\n haldol\\n - Recheck EKG today\\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\\n coumadin at least until s/p trach.\\n - hold heparin gtt when anticipate trach/peg\\n # Spine fracture: Neurologically intact distal to the lesion. Prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - CT of C, L spine when stable. Currently, unlikely to change\\n management and high risk for complications with transport.\\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\\n is low. Brace for OOB. Ok for anticoag per note.\\n # Communication:\\n - Boyfriend of 10 is her HCP. Also brother is involved\\n # FEN/GI: Tube feeds @ goal.\\n DVT: Treatment dose heparin\\n Ulcer: Ranitidine\\n VAP: Prevention per routine\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 09:51 PM 60 mL/hour\\n Glycemic Control:\\n Lines:\\n PICC Line - 09:19 PM\\n Arterial Line - 02:00 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n ------ Protected Section ------\\n MICU ATTENDING ADDENDUM\\n I saw and examined the patient, and was physically present with the ICU\\n team for the key portions of the services provided. I agree with the\\n note above, including the assessment and plan. I would emphasize and\\n add the following points: 55F T5-8 fractures with retropulsion and ARDS\\n from VAP; on heparin for UE DVT. Yesterday, hypotension confirmed by\\n placement of R axillary arterial line, required levophed for several\\n hours. Random cortisol 3, increased to 10 s/p ACTH; restarted on\\n hydrocortisone 50IV q6h with improved BP, able to come off pressors.\\n Has made progress on the vent, with PEEP back down to 10 and FiO2 0.5.\\n On rounds, has audible ETT cuff leak, tube appears high on CXR.\\n Exam notable for Tm 99.5 BP 105/45 HR 50-115 RR 18-20 with sat 93% on\\n VAC 400x18 PEEP 10 FiO2 0.5 for 7.42/49/93. TBB +14L/MICU LOS. Eyes\\n opens, will squeeze hands and wiggle toes but very drowsy. Positive\\n cuff leak, bronchial BS bilaterally with RRR s1s2 SM at base.\\n Abdomen is distended with decreased BS. 3+ edema in BLE, no cords. Labs\\n notable for WBC 11K, HCT 30, K+ 3.9, Na 146, Cr 0.5. CXR with resolving\\n B LL airspace disease and effusions.\\n Agree with plan to continue supplementation with hydrocortisone 50\\n q6-8h and discuss with endocrine as she seems to have adrenal\\n insufficiency. Needs bronchoscopy now to confirm tube position, will\\n continue vent weaning by dropping PEEP to 8 and discuss with T-\\n regarding T+G in AM. Will continue fentanyl patch and po valium as we\\n wean IV sedation. Consider head CT if neuro exam becomes more focal\\n while on heparin, but will hold off for now. Will continue diuresis\\n with IV lasix to affect a negative fluid balance and use haldol for\\n breakthrough agitiation. Will continue IV heparin for UE DVT; consider\\n transition to coumadin only after tracheostomy and feeding tube\\n placement, which will require lower ventilator settings. Will restart\\n tube feeds and add FW boluses for hypernatremia. Continue spinal\\n stabilization with brace when OOB; will eventually need MRI for\\n surgical planning; remainder of plan as outlined above.\\n Patient is critically ill\\n Total time: 40 min\\n ------ Protected Section Addendum Entered By: , MD\\n on: 12:55 PM ------\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2167-10-01 00:00:00.000\",\n \"description\": \"Generic Note\",\n \"row_id\": 635294,\n \"text\": \"TITLE:\\n Respiratory Care: Rec\\nd pt on a/c 18/400/+8/50%. Ett 7.5, retaped,\\n rotated and secured @ 20 lip. BS are coarse with diminished bases.\\n Suctioned for small amounts of thick white secretions. MDI\\n administered as ordered alb/atr with no adverse reactions AM ABG\\n 7.42/47/87. No rsbi due to trach/peg procedure possibly in OR.\\n\"\n },\n {\n \"category\": \"General\",\n \"chartdate\": \"2167-10-01 00:00:00.000\",\n \"description\": \"Generic Note\",\n \"row_id\": 635295,\n \"text\": \"55 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP now with prolonged\\n hospital course c/o by PNA anxiety,RUE DVD with high PEEP requirement\\n .\\n Events\\n Heparin gtt and TF held since MN for ? trach and peg\\n placement today.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Received pt on AC 400/18/8/50%. 02 sats mainly 88-92% but did fall to\\n 86% when pt positioned on L side. Pt fluid overloaded with TFB for LOS\\n ~ ccs.\\n Action:\\n ABG taken while sat 88%. Lasix gtt increased to 3mg/hr\\n Response:\\n ABG 7.42/47/87/4/32. Urine output initially 25 ccs/hr but pt began\\n autodiuresing after MN with output improving to ~140ccs/hr\\n Plan:\\n Continue with current vent settings. Trach today. Titrate lasix gtt to\\n maintain MAP > 60 and u/o 100-150ccs/hr.\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt restless at times, thrashing in bed with HR up to 140 ST . Denies\\n pain or doesn\\nt respond when questioned if she is having pain.\\n Action:\\n Fentanyl drip infusing at 100mcgs/hr. Fentanyl patch in place. Also\\n treated with haldol and valium . Bolused with 2 mg versed when acutely\\n agitated. Bilateral wrist restraints in place.\\n Response:\\n Pt falls back to sleep, HR decreases (occasionally as low as 45 SB)\\n Plan:\\n Continue to assess MS. as indicated. Reorientation. Restraints\\n for safety.\\n Hypernatremia (high sodium)\\n Assessment:\\n Na 146 on \\n Action:\\n Treated with free h20 boluses\\n Response:\\n Na 143 this am\\n Plan:\\n Continue to monitor f+e status.\\n Impaired Skin Integrity\\n Assessment:\\n Pt with excoriated yeast infection on abd and in perineal area. +\\n reddened perirectal area.\\n Action:\\n Barrier cream and miconazole powder applied\\n Response:\\n To be determined.\\n Plan:\\n Diligent skin care.\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2167-09-21 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 634284,\n \"text\": \"Demographics\\n Day of intubation: \\n Day of mechanical ventilation: 3\\n Ideal body weight: 61.2 None\\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation:\\n Procedure location:\\n Reason:\\n Tube Type\\n ETT:\\n Position: cm at teeth\\n Route: Oral\\n Type: Standard\\n Size: 7mm\\n Tracheostomy tube:\\n Type:\\n Manufacturer:\\n Size:\\n PMV:\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: cmH2O\\n Cuff volume: mL /\\n Airway problems:\\n Comments:\\n Lung sounds\\n RLL Lung Sounds: Crackles\\n RUL Lung Sounds: Rhonchi\\n LUL Lung Sounds: Rhonchi\\n LLL Lung Sounds: Crackles\\n Comments:\\n Secretions\\n Sputum color / consistency: Yellow / Thick\\n Sputum source/amount: Suctioned / Small\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance:\\n Visual assessment of breathing pattern: Normal quiet breathing\\n Assessment of breathing comfort:\\n Non-invasive ventilation assessment:\\n Invasive ventilation assessment:\\n Trigger work assessment: Not triggering\\n Dysynchrony assessment:\\n Comments:\\n Plan\\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\\n Reason for continuing current ventilatory support: Underlying illness\\n not resolved\\n Respiratory Care Shift Procedures\\n Transports:\\n Destination (R/T)\\n Time\\n Complications\\n Comments\\n Bedside Procedures:\\n Comments:\\n Pt went to CT this PM for CT of head and chest, attempted to place\\n Esoph balloon but kept tangeling on the OET and\\n tube\\n Will try again later. Ventrac in room..\\n, RRT 18:43\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-09-21 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 634286,\n \"text\": \"55-year-old woman with\\n Respiratory failure\\n Traumatic thoracic spinal fractures\\n Probable VAP\\n Upper extremity DVT\\n Oliguria\\n Anemia\\n * Possible tracheobronchomalacia (reason for transfer from OSH)\\n Events: Multi-lumen CVL placed at bedside. CXR cleared for use. Bedside\\n Echo performed and Non-contrast CT of spine and Torso done.\\n Alteration in Nutrition\\n Assessment:\\n NPO, Pt w/ high residuals yesterday. Abdomen increasingly distended and\\n slightly firm. BS hypoactive. Low albumin. Bladder pressure performed\\n d/t distended abdomen and low UOP: 18-20.\\n Action:\\n OGT to low wall suction to decompress abdomen. TF off. CT of abdomen\\n done.\\n Response:\\n OGT putting out clear/pink drainage <100cc. CT scan results pending.\\n Plan:\\n Cont NPO at this time and OGT to low wall sxn. ? Restart TF.\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n RUE + DVT\\n Action:\\n Cont on sq heparin\\n Response:\\n No change\\n Plan:\\n Consult neuro-surgery regarding anti-coagulation w/ T-spine fx, elevate\\n RUE, no blood draws or blood pressures to RUE. ? Start heparin gtt once\\n cleared from neurosurgery.\\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\\n Assessment:\\n Temp max 100\\n Action:\\n Antibiotics given. Dosage changes made to vanco and aztreonam.\\n Response:\\n No further temp spike.\\n Plan:\\n Cont w/ antibiotics, f/u on cultures, Tylenol prn, vanco trough to be\\n drawn prior to 8am dose on per pharmacy (if drawn earlier than\\n results will be falsely elevated d/t dosage changes).\\n Fracture, other\\n Assessment:\\n T-spine compression fx, Back brace at bedside when OOB.\\n Action:\\n Ortho tech consulted for placement of back brace. Cont w/ log roll\\n precautions. CT scan done\\n Response:\\n Pt denies c/o pain when asked.\\n Plan:\\n Cont w/ log roll precautions, back brace for OOB, consult w/\\n neurosurgery, pain mgmt.\\n Anemia, other\\n Assessment:\\n HCT 24.1 from 28 yesterday (30 on admission)\\n Action:\\n Given 1 unit of PRBCs\\n Response:\\n Post HCT pending.\\n Plan:\\n Cont to follow HCTs, guiac stools, monitor of s/s of bleeding.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n LS- bronchial/rhonchorous throughout diminished to bilateral bases,\\n deep sxn\\nd for thick/tan secretions, copious clear oral secretions\\n suctioned. ? PE/? VAP.\\n Action:\\n Vent changes made throughout shift. Esophageal balloon attempted-\\n unable to place. CT scan of chest done.\\n Response:\\n Pt w/ high O2 requirements.\\n Plan:\\n Monitor ABGs, vent changes as needed.\\n Hypotension (not Shock)\\n Assessment:\\n Pt hypotensive into low-mid 80s systolic, HR 70s-90, SR. Low uop-\\n BUN/Creat negative.\\n Action:\\n Vigeleo set up, given 1 unit of blood, bloused x 1, multi-lumen RIJ\\n placed at bedside. Levophed started.\\n Response:\\n No response to bolusing, RIJ okay to use. CVP 18. CO . Stroke\\n volume 3.0.\\n Plan:\\n Cont to monitor VS closely, monitor I&O, levophed for MAPS >65\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-09-22 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 634362,\n \"text\": \"Alteration in Nutrition\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Hypotension (not Shock)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Fracture, other\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-09-23 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 634442,\n \"text\": \"Events: Attempt to lighten sedation, stop Levophed gtt- MS \\n stability labile from lethargic to restless in bed/crying w/\\n intermittent BP 120\\ns/ w/ and W/O stimulation. UOP cont 10-30cc/hr.\\n Vigileo monitor on- SVV . Bladder pressure 14. TF restarted w/ goal\\n slow inc as tolerated w/ recent high residuals.\\n Alteration in Nutrition\\n Assessment:\\n Minimal residuals\\n Action:\\n Restarting TF replete w/ fiber @ 10cc/hr w/ Q6hr 20cc flush\\n Response:\\n Tolerating, goal advance Q6hr as tolerated\\n Plan:\\n Cont TF, monitor residuals, inc Q6hrs as tolerated\\n Hypotension (not Shock)\\n Assessment:\\n BP labile- SBP 86-120, UOP down to 10cc/hr\\n Action:\\n Vigileo on- SVV , In AM attempt wean off Levo gtt\\n Response:\\n No fluid blousing, Levophed gtt started- titrated for MAP .65, UOP,\\n Levo @ .02\\n Plan:\\n Cont Vigeligo monitoring,\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-06 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 635959,\n \"text\": \"55 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\\n Now with prolonged hospital course c/b by PNA with high PEEP\\n requirement, anxiety, RUE DVT on heparin qtt.\\n Bradycardia\\n Assessment:\\n Pt conts with HR 50-70\\ns at rest, 100-140\\ns during care, pt\\n asymptomatic; easily arousable\\n Action:\\n Sedation decreased, Lasix off @0200\\n Response:\\n HR 60\\n Plan:\\n Cont to wean sedation, ?cardiac consult\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Action:\\n Cont with IV Heparin @ 1500u/hr, Coumadin d\\ncd for? thoracentesis\\n Response:\\n Pt therapeutic, cont with daily PTT\\n Plan:\\n Cont to labs, cont to wean off Heparin, Coumadin 5mg given x 1dose\\n @ 2200, re-eval dosing this am\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt cont on AC 18/400/50%/10, LS clear bilat, occ scat rhonchi\\n Action:\\n Pt suct for sm thin tan secretions\\n Response:\\n Pt 02 Sats 94-97%,\\n Plan:\\n Cont to ABGs,\\n Hypotension (not Shock)\\n Assessment:\\n SBP 140\\ns when pt is agitated, SBP dropping to 70\\ns-80\\ns, UO 200/hr\\n (total 2500 in 2hr)\\n Action:\\n Fent/Versed turned down @ 0000, Lasix gtt on hold, team informed\\n Response:\\n Pt SBP\\ns in 80\\n Plan:\\n Cardiac consult to further eval SB/ST, re-evalu cont. Lasix gtt\\n Hypernatremia (high sodium)\\n Assessment:\\n Na 146\\n Action:\\n Cont with 300cc free water flush Q4hrs\\n Response:\\n Plan:\\n Cont to sodium levels, treat as ordered\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt alert and agitated throughout shift, pt following commands\\n inconsistently; sleeping off and off throughout shift\\n Action:\\n Fent/Versed decreased low SBP\\ns, pt recved prn dose of Haldol 1mg @\\n 0100; cont with bilat. Wrist restraints for safety\\n Response:\\n pt sleeping off/on throughout shift, with periods of\\n agitation/restlessness\\n Plan:\\n Cont to wean fent/versed gtt down, cont with scheduled Haldol/Valium;\\n cont to QTC intervals daily\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-06 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 635961,\n \"text\": \"55 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\\n Now with prolonged hospital course c/b by PNA with high PEEP\\n requirement, anxiety, RUE DVT on heparin qtt.\\n Bradycardia\\n Assessment:\\n Pt conts with HR 50-70\\ns at rest, 100-140\\ns during care, pt\\n asymptomatic; easily arousable\\n Action:\\n Sedation decreased, Lasix off @0200\\n Response:\\n HR 60\\n Plan:\\n Cont to wean sedation, ?cardiac consult\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Action:\\n Cont with IV Heparin @ 1500u/hr, Coumadin d\\ncd for? thoracentesis\\n Response:\\n Pt therapeutic, cont with daily PTT\\n Plan:\\n Cont to labs, cont to wean off Heparin, Coumadin 5mg given x 1dose\\n @ 2200, re-eval dosing this am\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt cont on AC 18/400/50%/10, LS clear bilat, occ scat rhonchi\\n Action:\\n Pt suct for sm thin tan secretions\\n Response:\\n Pt 02 Sats 94-97%,\\n Plan:\\n Cont to ABGs,\\n Hypotension (not Shock)\\n Assessment:\\n SBP 140\\ns when pt is agitated, SBP dropping to 70\\ns-80\\ns, UO 200/hr\\n (total 2500 in 2hr) K 3.3\\n Action:\\n Fent/Versed turned down @ 0000, Lasix gtt on hold, team informed ; pt\\n recvd 1x dose of 40meg/Peg, 20meqK/250D5W x 1 dose\\n Response:\\n Pt SBP\\ns in 80\\n Plan:\\n Cardiac consult to further eval SB/ST, re-evalu cont. Lasix gtt,\\n recheck am labs\\n Hypernatremia (high sodium)\\n Assessment:\\n Na 146\\n Action:\\n Cont with 300cc free water flush Q4hrs\\n Response:\\n Plan:\\n Cont to sodium levels, treat as ordered\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt alert and agitated throughout shift, pt following commands\\n inconsistently; sleeping off and off throughout shift\\n Action:\\n Fent/Versed decreased low SBP\\ns, pt recved prn dose of Haldol 1mg @\\n 0100; cont with bilat. Wrist restraints for safety\\n Response:\\n pt sleeping off/on throughout shift, with periods of\\n agitation/restlessness\\n Plan:\\n Cont to wean fent/versed gtt down, cont with scheduled Haldol/Valium;\\n cont to QTC intervals daily\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-09-30 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 635219,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n ARTERIAL LINE - START 02:00 PM - in right brachial atery\\n Hypotensive- started on levophed, weaned off over night\\n Low cortisol and failed stim test - started on steroids\\n TTE ordered\\n Free water flushes were increased for hypernatremia (250cc q4)\\n Able to hear patient breathing at times during exam this am (poor am\\n CXR, reordered)\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Levofloxacin - 08:06 AM\\n Infusions:\\n Heparin Sodium - 1,700 units/hour\\n Midazolam (Versed) - 2 mg/hour\\n Fentanyl - 150 mcg/hour\\n Other ICU medications:\\n Haloperidol (Haldol) - 12:15 AM\\n Other medications:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:50 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.5\\nC (99.5\\n Tcurrent: 36.7\\nC (98\\n HR: 63 (48 - 138) bpm\\n BP: 91/41(58) {68/30(49) - 143/78(105)} mmHg\\n RR: 18 (13 - 23) insp/min\\n SpO2: 91%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Mixed Venous O2% Sat: 59 - 59\\n Total In:\\n 3,898 mL\\n 1,155 mL\\n PO:\\n TF:\\n 802 mL\\n 348 mL\\n IVF:\\n 2,126 mL\\n 247 mL\\n Blood products:\\n Total out:\\n 2,367 mL\\n 800 mL\\n Urine:\\n 2,367 mL\\n 800 mL\\n NG:\\n Stool:\\n ?\\n ?\\n Drains:\\n Balance:\\n 1,531 mL\\n 355 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 400 (400 - 401) mL\\n RR (Set): 18\\n RR (Spontaneous): 1\\n PEEP: 10 cmH2O\\n FiO2: 40%\\n PIP: 23 cmH2O\\n Plateau: 19 cmH2O\\n Compliance: 57.1 cmH2O/mL\\n SpO2: 91%\\n ABG: 7.42/49/93/33/5\\n Ve: 8.1 L/min\\n PaO2 / FiO2: 155\\n Physical Examination\\n General Appearance: Easily agitated, appears uncomfortable, Overweight\\n / Obese, opens eyes but no purposeful movement\\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\\n deviation\\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\\n Cardiovascular: (S1: Normal), (S2: Normal), distant\\n Respiratory / Chest: (Expansion: Symmetric), referred breath sounds\\n from ETT\\n Abdominal: No(t) Soft, Non-tender, Few Bowel sounds present, Distended\\n Extremities: No clubbing or cyanosis, 3+ nonpitting edema of b/l hands,\\n anasarca\\n Skin: no rashes or jaundice\\n Neuro: diffusely hyperreflexic with LE clonus\\n Lines: r brachioceph ART and L PICC C/D/I\\n Labs / Radiology\\n 355 K/uL\\n 9.1 g/dL\\n 168 mg/dL\\n 0.5 mg/dL\\n 30 mEq/L\\n 3.9 mEq/L\\n 11 mg/dL\\n 108 mEq/L\\n 146 mEq/L\\n 29.9 %\\n 11.8 K/uL\\n [image002.jpg]\\n 03:32 PM\\n 10:19 PM\\n 02:50 AM\\n 02:30 PM\\n 02:44 PM\\n 03:33 PM\\n 07:26 PM\\n 07:46 PM\\n 02:04 AM\\n 02:18 AM\\n WBC\\n 9.0\\n 8.4\\n 11.8\\n Hct\\n 25.8\\n 23.0\\n 28.1\\n 29.9\\n Plt\\n \\n Cr\\n 0.6\\n 0.7\\n 0.5\\n TCO2\\n 30\\n 35\\n 33\\n 31\\n 33\\n Glucose\\n 94\\n 97\\n 168\\n Other labs: PT / PTT / INR:13.8/70.4/1.2, Differential-Neuts:89.7 %,\\n Lymph:8.7 %, Mono:1.1 %, Eos:0.4 %, Ca++:8.5 mg/dL, Mg++:2.2 mg/dL,\\n PO4:5.4 mg/dL\\n TSH 2.9; FT4 1.5; stim 3.1, 10.5, 10.6\\n Culture Data: endotrach with K oxytoca; gram stain GPCs in\\n pairs and clusters\\n Assessment and Plan\\n 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA and\\n ARDS intubated since the end of .\\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\\n volume overload. Intubated on for resp decompensation.\\n Transferred here for airway stenting. Will need bronch eval when\\n improved.\\n - Thoracics will do trach and PEG once stable on PEEPs around 10.\\n Re-c/s today.\\n - wean PEEP as tolerated\\n # Hypotension: Likely adrenal insufficiency.\\n - hydrocortisol and fludrocortisone\\n # Volume overload\\n Hypernatremic (? Relationship to adrenal\\n insufficiency), TBW deficit 2.6L.\\n - goal even I/Os today\\n - FW in TF at 250 cc q4hrs\\n - PM lytes\\n # Hyperreflexia - ? meds vs central pathology\\n - consider head CT in context of heparin gtt to r/o intracranial\\n hemmorhage\\n # Sedation: Poor sedation control. On Versed 1.5, Fentanyl 175,\\n Fentanyl patch, Diazepam standing and haldo 2.5-5 mg PRN. QTc stable\\n at .44\\n - Wean versed/fentanyl as tolerated\\n - Recheck EKG today\\n -\\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\\n coumadin at least until s/p trach.\\n - hold heparin gtt when anticipate trach/peg\\n # Adrenal Insufficency: Minimal response to stim test again.\\n - hydrocort and fludrocort\\n - consider endocrine c/s for further elucidation of etiology\\n # Spine fracture: Neurologically intact distal to the lesion. Prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - CT of C, L spine when stable. Currently, unlikely to change\\n management and high risk for complications with transport.\\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\\n is low. Brace for OOB. Ok for anticoag per note.\\n # Communication:\\n - Boyfriend of 10 is her HCP. Also brother is involved\\n # FEN/GI: Tube feeds @ goal.\\n DVT: Treatment dose heparin\\n Ulcer: Ranitidine\\n VAP: Prevention per routine\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 09:51 PM 60 mL/hour\\n Glycemic Control:\\n Lines:\\n PICC Line - 09:19 PM\\n Arterial Line - 02:00 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-02 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 635440,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Patient agitated and combative overnight - restarted midazolam gtt and\\n patient was becoming increasingly tachycardic and hypertensive\\n Thoracics to take to OR this am for trach and PEG\\n Discussion with patient's boyfriend yesterday - her should be here this\\n weekend, wants to be involved, just hard for him to get here\\n On lasix drip with excellent response (200 cc urine/hour)\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Fentanyl - 100 mcg/hour\\n Furosemide (Lasix) - 1 mg/hour\\n Heparin Sodium - 1,700 units/hour\\n Midazolam (Versed) - 2 mg/hour\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:07 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.3\\nC (99.2\\n Tcurrent: 37.3\\nC (99.2\\n HR: 118 (45 - 138) bpm\\n BP: 155/84(118) {91/38(56) - 177/106(139)} mmHg\\n RR: 18 (17 - 27) insp/min\\n SpO2: 90%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 2,604 mL\\n 1,447 mL\\n PO:\\n TF:\\n 675 mL\\n 17 mL\\n IVF:\\n 1,089 mL\\n 730 mL\\n Blood products:\\n Total out:\\n 4,130 mL\\n 2,430 mL\\n Urine:\\n 4,130 mL\\n 2,430 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,526 mL\\n -983 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 400 (400 - 400) mL\\n PS : 5 cmH2O\\n RR (Set): 18\\n RR (Spontaneous): 0\\n PEEP: 8 cmH2O\\n FiO2: 50%\\n PIP: 22 cmH2O\\n Plateau: 19 cmH2O\\n Compliance: 48.2 cmH2O/mL\\n SpO2: 90%\\n ABG: 7.45/50/67/29/8\\n Ve: 7.5 L/min\\n PaO2 / FiO2: 134\\n Physical Examination\\n General Appearance: Responsive, following commands, Overweight / Obese,\\n NAD\\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\\n deviation\\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\\n Cardiovascular: (S1: Normal), (S2: Normal), distant\\n Respiratory / Chest: (Expansion: Symmetric), referred breath sounds\\n from ETT\\n Abdominal: No(t) Soft, Non-tender, Few Bowel sounds present, Distended\\n Extremities: No clubbing or cyanosis, 3+ nonpitting edema of b/l hands,\\n anasarca\\n Skin: no rashes or jaundice\\n Neuro: 3+ UE b/l, 4+ LE b/l\\n Lines: r brachioceph ART and L PICC C/D/I\\n Labs / Radiology\\n 306 K/uL\\n 8.5 g/dL\\n 165 mg/dL\\n 0.7 mg/dL\\n 29 mEq/L\\n 3.7 mEq/L\\n 10 mg/dL\\n 108 mEq/L\\n 146 mEq/L\\n 27.1 %\\n 11.2 K/uL\\n [image002.jpg]\\n 02:18 AM\\n 01:27 PM\\n 03:06 PM\\n 10:04 PM\\n 03:00 AM\\n 10:47 AM\\n 04:10 PM\\n 12:13 AM\\n 05:08 AM\\n 05:20 AM\\n WBC\\n 8.6\\n 11.2\\n Hct\\n 25.9\\n 27.1\\n Plt\\n 280\\n 306\\n Cr\\n 0.6\\n 0.5\\n 0.7\\n TCO2\\n 33\\n 32\\n 32\\n 34\\n 36\\n 36\\n Glucose\\n 176\\n 136\\n 165\\n Other labs: PT / PTT / INR:13.2/68.7/1.1, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\\n Amylase / Lipase:, Differential-Neuts:89.7 %, Lymph:8.7 %, Mono:1.1\\n %, Eos:0.4 %, Lactic Acid:0.9 mmol/L, Albumin:2.4 g/dL, LDH:204 IU/L,\\n Ca++:10.6 mg/dL, Mg++:2.8 mg/dL, PO4:4.3 mg/dL\\n Assessment and Plan\\n 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA and\\n ARDS intubated since the end of .\\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\\n volume overload. Intubated on for resp decompensation.\\n Transferred here for airway stenting.\\n - attempt SBT today\\n - OR add on for trach and PEG with Dr. (tube feeds off\\n after MN, heparin off after 6am)\\n # # Adrenal Insufficency: Minimal response to stim test again.\\n Appreciate endocrine recommendations.\\n - hydrocort and fludrocort (day 1 = )\\n - will continue at current dose until s/p trach and PEG and\\n hemodynamically stable for 24 hours\\n will then plan to taper\\n hydrocortisone to 25mg IV q6 with a slow taper\\n - will repreat ACTH stim test after tapered to <30mg\\n hydrocortisone or off steroids\\n - f/u daily endocrine recs\\n # Hypotension: Likely adrenal insufficiency and sedation. Goal map\\n > 60. Much improved since re-administration of steroids.\\n - hydrocortisone and fludrocortisone as above\\n - restart levophed if necessary to maintain MAP > 60\\n # Volume overloaded in setting of hypernatremia with TBW deficit.\\n - goal -1000cc I/Os today\\n - continue FW in TF at 250 cc q4hrs\\n - lasix drip (1-5mg/hr) when MAP >\\n 60\\n # Sedation: Sedation control remains somewhat poor although fentanyl\\n patch and diazpem are likely therapeutic range today. On Versed 1.5,\\n Fentanyl 175, Fentanyl patch, Diazepam standing and haldo 2.5-5 mg\\n PRN. QTc increased to 480.\\n - Wean versed/fentanyl as tolerated, continue diazepam. Avoid\\n haldol use if possible to avoid further prolongation of QTc\\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\\n coumadin at least until s/p trach.\\n - hold heparin gtt when anticipate trach/peg\\n # Spine fracture: Neurologically intact distal to the lesion. Prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - CT of C, L spine when stable. Currently, unlikely to change\\n management and high risk for complications with transport.\\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\\n is low. Brace for OOB. Ok for anticoag per note.\\n # FEN/GI: Tube feeds with FWF @ goal.\\n DVT: Treatment dose heparin\\n Ulcer: Ranitidine\\n VAP: Prevention per routine\\n # Communication:\\n - Boyfriend of 10 is her HCP. Also brother is involved\\n - touch base with SW today\\n Code: Full\\n Dispo: ICU\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n PICC Line - 09:19 PM\\n Arterial Line - 02:00 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-02 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 635441,\n \"text\": \"55 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP now with prolonged\\n hospital course c/o by PNA anxiety,RUE DVD with high PEEP requirement\\n .\\n Events:\\n Pt found at 19:30 to have loose restraints and was pulling on ETT. Pt\\n found to have pulled out her esophageal tube and disconnected IV lines.\\n CXR done and ETT and OGGT in right position.\\n Plan: Plan for OR this am for trach and peg. Heparin gtt off at 6am.\\n Edema, peripheral\\n Assessment:\\n Pt has gen edema with +2 pitting.\\n Action:\\n Pt is on lasix gtt, now at 1 mg/hr. Goal to remove 1-2 liters/24hrs. Pt\\n is currently + 17.3 liters for LOS.\\n Response:\\n Pt is diuresing well to lasix .\\n Plan:\\n Continue to evaluate need for Lasix. Follow K level closely lasix\\n gtt and need for freq replacements as nted.\\n Hypernatremia (high sodium)\\n Assessment:\\n Hypernatremia.\\n Action:\\n D5W x 1 liter at 75 cc/hr in conjunction with H2O flushes.\\n Response:\\n Awaiting am Na level.\\n Plan:\\n Follow Na level.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt remains intubated on CMV settings at 50%/400x18/8. ABGs stable as\\n noted. Goal PO2 > 60. LS coarse to upper resp areas with diminished\\n bases. Pt has been deep sx\\nd for scant amounts of yellow/tan\\n secretions. Oral care q 4hrs. Pt noted to desat to 85% when turned onto\\n her Rt side, but recovered within seconds. Ftom 5am, pt noted to desat\\n to 85% with any restlessness and agitation. MD notified and sedation\\n increased with good effect.\\n Action:\\n Response:\\n Continue to eval need for sedation in order to support resp status.\\n Plan:\\n Plan for trach and Peg today this am.\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt has been awake and alert most of this shift. Pt follows immediate\\n commands only. When told not to reach for ETT, she stopps, but within 2\\n sec she will reach for ETT again. Pt continues to have freq episodes\\n of being restless in bed and agitation, trying to sit up and reaching\\n for ETT. Haldol DC\\nd sl prolonged QT interval and versed prn\\n boluses initiated as need with some effect. While resting (with\\n sedation); Hr is in the 50\\ns and SBP 99-105. While awake and agitated;\\n HR now increases to 140-150\\ns and SBP increases to high 170\\ns, and pt\\n noted to start to desat to 85% since 5am.\\n Action:\\n Emotional support given, but very short lived. Versed gtt initiated\\n with good effect to protect resp status until trach placed.\\n Response:\\n Pt more relaxed.\\n Plan:\\n Continue to eval MS.\\n Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Pt has a clot to her Rt arm. Rt arm with good radial pulses to palp and\\n cap refill < 3 sec.\\n Action:\\n Pt on heparin gtt protocol. Gtt was DC\\nd at 6am in preparation for OR.\\n Response:\\n PTT has been therapeutic at 1700 units/hr.\\n Plan:\\n ? need to restart heparin gtt post-op.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-02 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 635534,\n \"text\": \"55 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP now with prolonged\\n hospital course c/o by PNA anxiety,RUE DVD with high PEEP requirement\\n .\\n EVENTS: trach PEG done, PEG OK for meds, restart TF in am. restart hep\\n gtt tomorrow, diamox/ KCL added for alkalosis.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt rec\\nd intubated, on AC 400x18 50% +PEEP 8\\n Action:\\n Trach placed in the OR, pt returned from OR and placed on previous vent\\n settings, failed att at CPAP wean.\\n Response:\\n Plan:\\n Att to wean vent/ sedation slowly in am. Cont to monitor\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt w/ periods of agitation and sleeping at other times, but overall\\n more alert, following commands intermittently.\\n Action:\\n Midaz/ fentanyl changed to propofol in OR, changerd back to midazolam\\n 2mg/hr and fentanyl 100mcg/hr upon return from OR r/t SB/ hypotension,\\n cont on q6hr diazepam.\\n Response:\\n HR ranging from SB in the 40\\ns when asleep to the 120\\ns when agitated,\\n b/p ranging from 90\\ns/40\\ns when asleep to 140-150\\ns/ 70\\ns when\\n agitated. When pt awake appropriate and following commands HR\\n 80\\ns-100\\ns and b/p 100\\ns-120\\ns/ 60-70\\n Plan:\\n Cont Fent/ versed gtt\\ns titrate. As needed\\n Alteration in Nutrition\\n Assessment:\\n Pt on lasix gtt at 1mg/hr, TF on hold for PEG placement\\n Action:\\n PEG placed in OR, lasix gtt restarted upon return from OR, diamox and\\n KCL added to replete K+ and treat alkalosis\\n Response:\\n UOP 600mg after diamox, repeat K+ 4.1, PEG dsg D/I,\\n Plan:\\n PEG tube OK for meds restart TF in am, monitor and replete K+ as\\n needed.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-09-21 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 634278,\n \"text\": \"Chief Complaint: respiratory failure\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 24 Hour Events:\\n URINE CULTURE - At 08:09 AM\\n EKG - At 09:00 AM\\n PICC LINE - STOP 10:30 AM\\n BLOOD CULTURED - At 10:30 AM\\n ULTRASOUND - At 01:00 PM\\n U/S of RUE\\n URINE CULTURE - At 03:00 PM\\n UA/UC collected after new foley inserted.\\n BAL FLUID CULTURE - At 03:00 PM\\n mini-BAL\\n ARTERIAL LINE - START 04:45 PM\\n ARTERIAL LINE - STOP 02:03 AM\\n ARTERIAL LINE - START 03:00 AM\\n Multiple attempts at central access were unsuccessful due to\\n malposition and difficulty threading wire.\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Levofloxacin - 09:30 AM\\n Vancomycin - 01:00 AM\\n Aztreonam - 04:00 AM\\n Metronidazole - 08:50 AM\\n Infusions:\\n Midazolam (Versed) - 2 mg/hour\\n Fentanyl - 150 mcg/hour\\n Other ICU medications:\\n Ranitidine (Prophylaxis) - 08:00 AM\\n Midazolam (Versed) - 09:32 AM\\n Other medications:\\n colace, CHG, SQI, H2B, SQH, MDIs, Flagyl, vanco, levo, aztreonam,\\n versed, fentanyl\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 09:51 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.3\\nC (100.9\\n Tcurrent: 37.9\\nC (100.3\\n HR: 72 (70 - 116) bpm\\n BP: 100/48(60) {89/47(60) - 139/75(79)} mmHg\\n RR: 18 (12 - 24) insp/min\\n SpO2: 89%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 94.2 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Bladder pressure: 18 (18 - 18) mmHg\\n Total In:\\n 5,600 mL\\n 2,088 mL\\n PO:\\n TF:\\n 120 mL\\n IVF:\\n 4,700 mL\\n 1,728 mL\\n Blood products:\\n Total out:\\n 798 mL\\n 205 mL\\n Urine:\\n 798 mL\\n 205 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 4,802 mL\\n 1,883 mL\\n Respiratory support\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 500 (500 - 500) mL\\n RR (Set): 18\\n RR (Spontaneous): 0\\n PEEP: 10 cmH2O\\n FiO2: 80%\\n RSBI Deferred: PEEP > 10\\n PIP: 37 cmH2O\\n Plateau: 25 cmH2O\\n SpO2: 89%\\n ABG: 7.45/42/95./28/4\\n Ve: 9.1 L/min\\n PaO2 / FiO2: 96\\n Physical Examination\\n Sedated. Breath sounds are coarse. Heart sounds are distant. Abdomen\\n is protuberant with quiet breath sounds. Some peripheral edema. She\\n is not able to cooperate with peripheral strength or sensory exam.\\n Labs / Radiology\\n 7.6 g/dL\\n 319 K/uL\\n 129 mg/dL\\n 0.6 mg/dL\\n 28 mEq/L\\n 4.3 mEq/L\\n 6 mg/dL\\n 109 mEq/L\\n 144 mEq/L\\n 24.1 %\\n 6.4 K/uL\\n [image002.jpg]\\n 11:54 PM\\n 01:00 AM\\n 06:14 AM\\n 08:56 AM\\n 08:57 AM\\n 05:01 PM\\n 08:03 PM\\n 11:00 PM\\n 03:01 AM\\n 03:13 AM\\n WBC\\n 9.7\\n 9.4\\n 7.6\\n 6.4\\n Hct\\n 30.7\\n 25.1\\n 24.1\\n 24.1\\n Plt\\n 333\\n 281\\n 306\\n 319\\n Cr\\n 0.6\\n 0.6\\n 0.7\\n 0.6\\n 0.6\\n TCO2\\n 32\\n 33\\n 35\\n 33\\n 30\\n Glucose\\n 103\\n 126\\n 126\\n 127\\n 129\\n Other labs: PT / PTT / INR:16.9/26.3/1.5, ALT / AST:27/18, Alk Phos / T\\n Bili:113/0.7, Differential-Neuts:76.9 %, Lymph:17.3 %, Mono:3.0 %,\\n Eos:2.5 %, Lactic Acid:0.7 mmol/L, Albumin:2.3 g/dL, LDH:154 IU/L,\\n Ca++:8.2 mg/dL, Mg++:2.6 mg/dL, PO4:3.1 mg/dL\\n Imaging: CXR with bilateral opacities; ETT a little high. No PTX.\\n Assessment and Plan\\n 55-year-old woman with\\n Respiratory failure\\n Traumatic thoracic spinal fractures\\n Probable VAP\\n Upper extremity DVT\\n Oliguria\\n Anemia\\n Possible tracheobronchomalacia (reason for transfer)\\n I am uncertain about both the risks of anticoagulation and the risks of\\n moving to radiology (e.g. CT or IR) in the context of her spinal\\n fractures. Therefore we will consult spine surgery urgently for help\\n with these questions.\\n Her respiratory failure is likely multifactorial, including obesity,\\n probable VAP, probable PE, and possible tracheobronchomalacia. She may\\n also have weakness, but she is sedated and cannot cooperate with exam\\n at present. We will check an echo to examine her RV. We will\\n ventilate per ARDSnet; she may warrant esophageal-balloon-guided\\n therapy if she does not improve in the next few hours.\\n Oliguria is concerning, though BUN/Creatinine are reassuring. NG to\\n suction to relieve abdominal distention. We will check urine lytes and\\n assess stroke volume variation with the Vigileo. We will consider\\n volume challenge based on this result.\\n For central access, if we are able to safely move her we will ask I.R.\\n to help with central access.\\n We will continue broad antibiotics while awaiting cultures.\\n ICU Care\\n Nutrition: NPO for now\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n 18 Gauge - 01:16 AM\\n 20 Gauge - 01:36 AM\\n 22 Gauge - 02:00 PM\\n Arterial Line - 03:00 AM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin\\n Stress ulcer: H2 blocker\\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds Comments:\\n Code status: Full code\\n Disposition :ICU\\n Total time spent: 45 min\\n Patient is critically ill\\n ------ Protected Section ------\\n Critical Care Staff Addendum\\n 5:45p\\n CVL successfully placed. CVP and SVV argue that she is adequately\\n volume-replete. Hypoxemia has been a major issue, and we have taken\\n her to CT this afternoon. We are awaiting final reads of the images.\\n We will pursue esophageal balloon to help guide PEEP; first attempt was\\n unsuccessful due to oropharyngeal coiling.\\n Discussed in detail with patient\\ns brother at bedside. Unable to reach\\n her significant other.\\n 35 minutes\\n ------ Protected Section Addendum Entered By: , MD\\n on: 17:55 ------\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-09-23 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 634435,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n ESOPHOGEAL BALLOON - At 01:46 PM - went well, were able to\\n increase PEEP to improve oxygenation\\n - started naloxone to encourage bowel motility, with some success,\\n rectal tube in place with some stool\\n -started heparin gtt for RUE DVT\\n -borderline hypotensive at times (low 90s) with low urine output,\\n received boluses and norepi back on at 0.04 (now down to 0.02)\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Levofloxacin - 09:45 AM\\n Metronidazole - 03:32 PM\\n Vancomycin - 08:00 PM\\n Aztreonam - 10:00 PM\\n Infusions:\\n Midazolam (Versed) - 2 mg/hour\\n Heparin Sodium - 1,700 units/hour\\n Fentanyl - 100 mcg/hour\\n Norepinephrine - 0.04 mcg/Kg/min\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:34 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38\\nC (100.4\\n Tcurrent: 37.3\\nC (99.2\\n HR: 73 (60 - 102) bpm\\n BP: 90/46(61) {76/38(56) - 160/71(97)} mmHg\\n RR: 23 (16 - 25) insp/min\\n SpO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 101 kg (admission): 94.2 kg\\n Height: 67 Inch\\n CVP: 8 (8 - 15)mmHg\\n Bladder pressure: 18 (18 - 21) mmHg\\n Esophageal Pressure:\\n 26\\n Total In:\\n 3,524 mL\\n 234 mL\\n PO:\\n TF:\\n 48 mL\\n IVF:\\n 3,236 mL\\n 234 mL\\n Blood products:\\n Total out:\\n 935 mL\\n 215 mL\\n Urine:\\n 650 mL\\n 215 mL\\n NG:\\n 285 mL\\n Stool:\\n Drains:\\n Balance:\\n 2,589 mL\\n 19 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: AC\\n Vt (Set): 400 (400 - 400) mL\\n Vt (Spontaneous): 0 (0 - 0) mL\\n RR (Set): 22\\n RR (Spontaneous): 0\\n PEEP: 23 cmH2O\\n FiO2: 60%\\n RSBI Deferred: PEEP > 10, FiO2 > 60%\\n PIP: 42 cmH2O\\n Plateau: 32 cmH2O\\n Compliance: 44.4 cmH2O/mL\\n SpO2: 100%\\n ABG: 7.37/44/160 (6am)\\n Ve: 9.5 L/min\\n PaO2 / FiO2: 255\\n Physical Examination\\n Gen: Does not arouse to voice\\n HEENT: Pupils 3 mm reactive bilaterally. Scleral edema bilat\\n Resp: Symmetric expansion. Coarse breath sounds throughout. Cannot\\n adeq listen to post bases\\n CV: RRR.\\n Abd: Hypoactive bowel sounds. Distended.\\n Ext: Edema in bilat UE.\\n Peripheral vascular: Radial pulses 2+ bilaterally.\\n Neuro: Moving all 4 extremities.\\n Labs / Radiology\\n 358 K/uL\\n 8.9 g/dL\\n 126 mg/dL\\n 0.7 mg/dL\\n 25 mEq/L\\n 3.5 mEq/L\\n 4 mg/dL\\n 108 mEq/L\\n 143 mEq/L\\n 28.0 %\\n 8.1 K/uL\\n [image002.jpg]\\n 03:01 AM\\n 03:13 AM\\n 12:05 PM\\n 06:08 PM\\n 06:11 PM\\n 07:53 PM\\n 02:02 AM\\n 03:59 AM\\n 09:14 PM\\n 01:04 AM\\n WBC\\n 6.4\\n 8.4\\n Hct\\n 24.1\\n 29.0\\n 28.1\\n Plt\\n 319\\n 376\\n Cr\\n 0.6\\n 0.6\\n TCO2\\n 30\\n 29\\n 29\\n 25\\n 25\\n 28\\n 28\\n Glucose\\n 129\\n 120\\n PT 22.2 PTT 76.0 INR 2.1\\n Differential-Neuts:74.7 %, Lymph:17.6 %, Mono:3.5 %, Eos:3.8 %\\n Ca++:8.2 mg/dL, Mg++:2.0 mg/dL, PO4:3.2 mg/dL\\n Assessment and Plan\\n 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture\\n # Respiratory failure: initial etiology unclear, likely multifactorial\\n now with significant pneumonia. Had one sputum that showed GNR.\\n - Concern for ARDS given clinical and radiographic picture. Will hold\\n on bronch given high PEEP; can consider proning. Have some room to\\n increase PEEP based on esoph balloon\\n - Placed esophageal balloon and increased PEEP\\n - Will allow her to stay on current vent settings today in order to let\\n her lungs rest\\n # VAP: Had been febrile, now resolved\\n - be aspiration or be VAP. Sputum from grew rare GNR;\\n awaiting speciation.\\n - Has been Vanc, aztreonam, levofloxicin. Vanc trough today was 20\\n - Will d/c vanc today () as no current evidence to suggest a gram\\n positive infection\\n - Will d/c flagyl because had one neg c. diff toxin and CT did not show\\n evidence of colitis\\n - Continue aztreonam and levofloxicin for gram neg pneumonia for 8 days\\n pending speciation (at that time can increase to 15 days if necessary)\\n # Hypotension, requiring Levophed:\\n - Hypovolemia is possibly a factor- responded to a transfusion; HCT had\\n been dropping\\n - Sepsis also a factor- on broad spectrum abs\\n - Central line in place.\\n - Will check a SVV (with vigileo) today to determine volume status\\n # Oliguria:\\n -BUN and Cr reassuring.\\n - Continue to monitor\\n # RUE DVT: Started on heparin gtt on .\\n -Therapeutic in one day; may be related to poor nutritional status.\\n Will continue to closely monitor\\n # Abd distention: be chronic condition not requiring immediate\\n medical attention\\n - CT abd only showed appendiceal mucocele without inflammation, not\\n concerning, most likely chronic. No concern for intraabd disaster\\n - Now having BMs; c. diff toxin neg\\n - amylase and lipase wnl\\n # Anemia:\\n - Trend HCT\\n - Gave 1 un pRBC with good results\\n - INR rising, now 2.0, may be nutritional\\n # Spine fracture: neurologically intact distal to the lesion. prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\\n is low. Brace for OOB. Ok for anticoag per verbal report.\\n # Hypernatremia, resolved: correcting with g tube free flush and D5W\\n -Holding on g tube feeds at present due to high residuals\\n -Replete lytes as necessary\\n # Communication:\\n - Brother has been with pt, although, live in boyfriend of 10 is\\n her HCP. Boyfriend will hopefully visit pt today\\n ICU Care\\n Nutrition: tube feed with free water when able\\n Glycemic Control: Regular insulin sliding scale\\n DVT: SQ UF Heparin\\n Stress ulcer: H2 blocker\\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\\n Communication: ICU consent signed, (brother) \\n (boyfriend/POA) \\n Code status: Full code\\n Disposition: ICU\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 01:36 AM\\n Arterial Line - 03:00 AM\\n Multi Lumen - 11:30 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-09-23 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 634436,\n \"text\": \"Chief Complaint: respiratory failure\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 24 Hour Events:\\n ESOPHOGEAL BALLOON - At 01:46 PM\\n Restarted levophed overnight\\n Patient unable to provide history: Sedated\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Vancomycin - 08:00 PM\\n Aztreonam - 06:09 AM\\n Metronidazole - 08:00 AM\\n Levofloxacin - 08:39 AM\\n Infusions:\\n Midazolam (Versed) - 1.5 mg/hour\\n Fentanyl - 75 mcg/hour\\n Norepinephrine - 0.02 mcg/Kg/min\\n Other ICU medications:\\n Other medications:\\n vanc, aztreonam, flagyl (day ), CHG, SQI, nebs, naloxone enteral,\\n heparin infusion\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 09:55 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38\\nC (100.4\\n Tcurrent: 37.6\\nC (99.6\\n HR: 75 (64 - 102) bpm\\n BP: 96/49(65) {76/38(56) - 160/71(97)} mmHg\\n RR: 22 (16 - 25) insp/min\\n SpO2: 99%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 101 kg (admission): 94.2 kg\\n Height: 67 Inch\\n CVP: 20 (8 - 339)mmHg\\n Bladder pressure: 18 (18 - 21) mmHg\\n Total In:\\n 3,524 mL\\n 848 mL\\n PO:\\n TF:\\n 48 mL\\n IVF:\\n 3,236 mL\\n 698 mL\\n Blood products:\\n Total out:\\n 935 mL\\n 325 mL\\n Urine:\\n 650 mL\\n 325 mL\\n NG:\\n 285 mL\\n Stool:\\n Drains:\\n Balance:\\n 2,589 mL\\n 523 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 400 (400 - 400) mL\\n Vt (Spontaneous): 0 (0 - 0) mL\\n RR (Set): 22\\n RR (Spontaneous): 0\\n PEEP: 23 cmH2O\\n FiO2: 50%\\n RSBI Deferred: PEEP > 10, FiO2 > 60%\\n PIP: 37 cmH2O\\n Plateau: 33 cmH2O\\n Compliance: 40 cmH2O/mL\\n SpO2: 99%\\n ABG: 7.37/44/160/25/0\\n Ve: 8.9 L/min\\n PaO2 / FiO2: 320\\n Physical Examination\\n General Appearance: Overweight / Obese\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\\n Respiratory / Chest: coarse breath sounds\\n Abdominal: Soft, Obese\\n Extremities: Right: 1+, Left: 1+\\n Skin: Warm\\n Neurologic: Responds to: Unresponsive, Movement: No spontaneous\\n movement, Tone: Normal\\n Labs / Radiology\\n 8.9 g/dL\\n 358 K/uL\\n 126 mg/dL\\n 0.7 mg/dL\\n 25 mEq/L\\n 3.5 mEq/L\\n 4 mg/dL\\n 108 mEq/L\\n 143 mEq/L\\n 28.0 %\\n 8.1 K/uL\\n [image002.jpg]\\n 12:05 PM\\n 06:08 PM\\n 06:11 PM\\n 07:53 PM\\n 02:02 AM\\n 03:59 AM\\n 09:14 PM\\n 01:04 AM\\n 05:54 AM\\n 06:11 AM\\n WBC\\n 8.4\\n 8.1\\n Hct\\n 29.0\\n 28.1\\n 28.0\\n Plt\\n 376\\n 358\\n Cr\\n 0.6\\n 0.7\\n TCO2\\n 29\\n 29\\n 25\\n 25\\n 28\\n 28\\n 26\\n Glucose\\n 120\\n 126\\n Other labs: PT / PTT / INR:22.2/76.0/2.1, ALT / AST:24/16, Alk Phos / T\\n Bili:117/0.7, Amylase / Lipase:, Differential-Neuts:74.7 %,\\n Lymph:17.6 %, Mono:3.8 %, Eos:3.4 %, Lactic Acid:0.7 mmol/L,\\n Albumin:2.4 g/dL, LDH:204 IU/L, Ca++:8.2 mg/dL, Mg++:2.0 mg/dL, PO4:3.2\\n mg/dL\\n Assessment and Plan\\n 55-year-old woman with\\n Respiratory failure\\n End-exp transpulmonary pressure: -2\\n End-insp transpulmonary pressure: +5\\n Esophageal pressures suggest that she is at safe pressures.\\n Traumatic thoracic spinal fracture\\n Eventual MRI. Too high-risk at present. Brace when out of\\n bed.\\n Probable VAP\\n Discuss GNRs with lab\\n Complete 8\\n 15d course of present ABX pending cultures\\n D/C vancomycin since no identified GPCs\\n D/C Flagyl since no CT or toxin evidence of C diff\\n Shock\\n now back on levophed\\n CVP is 20 mm Hg but Pes is ~25 cm H20\\n Re-assess SVV with Vigileo and consider volume challenge\\n Upper extremity DVT\\n Therapeutic heparin\\n Anemia\\n Follow\\n Possible tracheobronchomalacia (reason for transfer)\\n Incidental peri-appendiceal finding (will need eventual\\n follow-up)\\n Although differential remains open, the most compelling course of\\n events is probably that she required intubation at the outside hospital\\n (?sedation ?restriction from obesity/brace ?other) and subsequently\\n developed a GNR-related VAP. Her pattern of acute lung injury,\\n combined with obesity, is resulting in basilar and\\n posterior-predominant atelectasis/consolidation with a high proportion\\n of shunt. Given her very high PEEP, will try to avoid bronchoscopy if\\n possible.\\n Other issues as per ICU team note.\\n ICU Care\\n Nutrition: resume tube feeds\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n 20 Gauge - 01:36 AM\\n Arterial Line - 03:00 AM\\n Multi Lumen - 11:30 AM\\n Prophylaxis:\\n DVT: Boots(Systemic anticoagulation: Heparin gtt)\\n Stress ulcer: H2 blocker\\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds Comments:\\n Code status: Full code\\n Disposition :ICU\\n Total time spent: 60 minutes\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2167-10-06 00:00:00.000\",\n \"description\": \"Generic Note\",\n \"row_id\": 635962,\n \"text\": \"TITLE:\\n Respiratory: Rec\\nd pt on a/c 18/400/10+/50%. Pt has #7 portex trach.\\n BS are coarse to clear with diminished bases. Suctioning for small\\n amounts of tan thick secretions. MDI\\ns administered as ordered of\\n alb/atr with no adverse reactions. Pt continues to move around a lot\\n in the bed, and anxious at times. No RSBI done due to increased peep\\n of 10. Plan is to wean to psv as tolerated and eventually t/c trials.\\n No abg\\ns noc.\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2167-09-29 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 635050,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 11\\n Ideal body weight: 61.2 None\\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: Unknown\\n Procedure location:\\n Reason:\\n Tube Type\\n ETT:\\n Position: cm at teeth\\n Route:\\n Type: Standard\\n Size: 7.5mm\\n Comments:\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Diminished\\n Comments:\\n Secretions\\n Sputum color / consistency: Tan / Thick\\n Sputum source/amount: Suctioned / Moderate\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance:\\n Visual assessment of breathing pattern: appears agitated and\\n uncomfortable at times,overbreathing by 10-15 breaths\\n Respiratory Care Shift Procedures\\n Transports:\\n Destination (R/T)\\n Time\\n Complications\\n Comments\\n Bedside Procedures:\\n Comments: Pt required increased peep back up to 15 overnight due to\\n desaturation into low 80s at times. She appears much more comfortable\\n and in synch with the vent now.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-09-29 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 635138,\n \"text\": \"55 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP now with prolonged\\n hospital course c/o by PNA anxiety,RUE DVD with high PEEP requirement\\n . had tolerated peep wean up until last night when pt dropped sats and\\n po2 requring increase in peep and fio2. Sedated with fentanyl and\\n versed gtts. Trach and peg scheduled for today was cancelled for\\n increased peep requirements.\\n Hypotension (not Shock)\\n Assessment:\\n Pt hypotensive throughout morning but because was having difficulty\\n maintaining a consistent bp on extremities felt that it was poss\\n inaccurate u/o decreasing over course of am, pt with variable hr from\\n sb40 with bp 120-130\\ns-to junctional tach 130 when awake and agitated ,\\n with lower bp making it difficult to titrate gtts\\n Both levophed and sedatives.\\n Action:\\n Axillary aline placed by md\\n Response:\\n Aline confirmed hypotension given 1000 ml FB with min effect. started\\n on neo at .5 mcgs/kg/min but pt became bradycardic to 40 switched to\\n levophed .04 mcg/kg/min with desired effect stim test performed\\n 50mgs hydrocortisone given x1\\n Increasing u/o to 50 mls /hr\\n Plan:\\n Goal to maintain maps greater than 65\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Lungs with coarse rhonchii upper and diminished at bases with sats\\n 92-93% on peep 15 fio 60% cyanotic when agitated.\\n Action:\\n Suctioned for mod to copious amounts thick tan secretions. increased\\n sedation continued rtc diazepam\\n Response:\\n Improved control over agitation pt sedated but easily rouseable\\n maintained o2 sats greater than 93% allowing a gradual slow wean of\\n peep from 15-12\\n Plan:\\n To wean to peep of 10 and fio2of 50%. Accepting sats 88-92% and po2 in\\n 60\\n When bp maintained off levophed poss to start lasix gtt at low dose\\n 1mg/hr pt 106 kgs up approx 12kgs from baseline.\\n\"\n },\n {\n \"category\": \"General\",\n \"chartdate\": \"2167-10-01 00:00:00.000\",\n \"description\": \"Generic Note\",\n \"row_id\": 635278,\n \"text\": \"55 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP now with prolonged\\n hospital course c/o by PNA anxiety,RUE DVD with high PEEP requirement\\n .\\n Events\\n Heparin gtt and TF held since MN for ? trach and peg\\n placement today.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Received pt on AC 400/18/8/50%. 02 sats mainly 88-92% but did fall to\\n 86% when pt positioned on L side. Pt fluid overloaded with TFB for LOS\\n ~ ccs.\\n Action:\\n ABG taken while sat 88%. Lasix gtt increased to 3mg/hr\\n Response:\\n ABG 7.42/47/87/4/32. Urine output 25-45ccs/hr (not meeting goal of neg\\n 100-150ccs/hr)\\n Plan:\\n Continue with current vent settings. Trach today. Titrate lasix gtt up\\n if can maintain MAP > 60.\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt restless at times, thrashing in bed with HR up to 140 ST . Denies\\n pain or doesn\\nt respond when questioned if she is having pain.\\n Action:\\n Fentanyl drip infusing at 100mcgs/hr. Also treated with haldol and\\n valium . Bolused with 2 mg versed when acutely agitated. Bilateral\\n wrist restraints in place.\\n Response:\\n Pt falls back to sleep, HR decreases (occasionally as low as 45 SB)\\n Plan:\\n Continue to assess MS. as indicated. Reorientation. Restraints\\n for safety.\\n Hypernatremia (high sodium)\\n Assessment:\\n Na 146 this am\\n Action:\\n Treated with free h20 boluses\\n Response:\\n Plan:\\n Continue to monitor f+e status.\\n Impaired Skin Integrity\\n Assessment:\\n Pt with excoriated yeast infection on abd and in perineal area.\\n Action:\\n Barrier cream and miconazole powder applied\\n Response:\\n To be determined.\\n Plan:\\n Diligent skin care.\\n\"\n },\n {\n \"category\": \"General\",\n \"chartdate\": \"2167-10-01 00:00:00.000\",\n \"description\": \"Generic Note\",\n \"row_id\": 635280,\n \"text\": \"55 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP now with prolonged\\n hospital course c/o by PNA anxiety,RUE DVD with high PEEP requirement\\n .\\n Events\\n Heparin gtt and TF held since MN for ? trach and peg\\n placement today.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Received pt on AC 400/18/8/50%. 02 sats mainly 88-92% but did fall to\\n 86% when pt positioned on L side. Pt fluid overloaded with TFB for LOS\\n ~ ccs.\\n Action:\\n ABG taken while sat 88%. Lasix gtt increased to 3mg/hr\\n Response:\\n ABG 7.42/47/87/4/32. Urine output initially 25 ccs/hr but pt began\\n autodiuresing after MN with output improving to ~140ccs/hr\\n Plan:\\n Continue with current vent settings. Trach today. Titrate lasix gtt to\\n maintain MAP > 60 and u/o 100-150ccs/hr.\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt restless at times, thrashing in bed with HR up to 140 ST . Denies\\n pain or doesn\\nt respond when questioned if she is having pain.\\n Action:\\n Fentanyl drip infusing at 100mcgs/hr. Also treated with haldol and\\n valium . Bolused with 2 mg versed when acutely agitated. Bilateral\\n wrist restraints in place.\\n Response:\\n Pt falls back to sleep, HR decreases (occasionally as low as 45 SB)\\n Plan:\\n Continue to assess MS. as indicated. Reorientation. Restraints\\n for safety.\\n Hypernatremia (high sodium)\\n Assessment:\\n Na 146 this am\\n Action:\\n Treated with free h20 boluses\\n Response:\\n Plan:\\n Continue to monitor f+e status.\\n Impaired Skin Integrity\\n Assessment:\\n Pt with excoriated yeast infection on abd and in perineal area.\\n Action:\\n Barrier cream and miconazole powder applied\\n Response:\\n To be determined.\\n Plan:\\n Diligent skin care.\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2167-10-02 00:00:00.000\",\n \"description\": \"Generic Note\",\n \"row_id\": 635432,\n \"text\": \"TITLE:\\n Respiratory Care: Rec\\nd pt on a/c 15/400/+8/50%. Ett 7.5 taped @ 21\\n lip. BS are coarse bilaterally with diminished bases. Suctioned for\\n small to moderate amounts of thick yellow/tan secretions. MDI\\n administered as ordered alb/atr with no adverse reactions. AM ABG\\n 7.44/52/70. No rsbi due to Trach/peg procedure today. No further\\n changes noted.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-02 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 635438,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Patient agitated and combative overnight - restarted midazolam gtt and\\n patient was becoming increasingly tachycardic and hypertensive\\n Thoracics to take to OR this am for trach and PEG\\n Discussion with patient's boyfriend yesterday - her should be here this\\n weekend, wants to be involved, just hard for him to get here\\n On lasix drip with excellent response (200 cc urine/hour)\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Fentanyl - 100 mcg/hour\\n Furosemide (Lasix) - 1 mg/hour\\n Heparin Sodium - 1,700 units/hour\\n Midazolam (Versed) - 2 mg/hour\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:07 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.3\\nC (99.2\\n Tcurrent: 37.3\\nC (99.2\\n HR: 118 (45 - 138) bpm\\n BP: 155/84(118) {91/38(56) - 177/106(139)} mmHg\\n RR: 18 (17 - 27) insp/min\\n SpO2: 90%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 2,604 mL\\n 1,447 mL\\n PO:\\n TF:\\n 675 mL\\n 17 mL\\n IVF:\\n 1,089 mL\\n 730 mL\\n Blood products:\\n Total out:\\n 4,130 mL\\n 2,430 mL\\n Urine:\\n 4,130 mL\\n 2,430 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,526 mL\\n -983 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 400 (400 - 400) mL\\n PS : 5 cmH2O\\n RR (Set): 18\\n RR (Spontaneous): 0\\n PEEP: 8 cmH2O\\n FiO2: 50%\\n PIP: 22 cmH2O\\n Plateau: 19 cmH2O\\n Compliance: 48.2 cmH2O/mL\\n SpO2: 90%\\n ABG: 7.45/50/67/29/8\\n Ve: 7.5 L/min\\n PaO2 / FiO2: 134\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 306 K/uL\\n 8.5 g/dL\\n 165 mg/dL\\n 0.7 mg/dL\\n 29 mEq/L\\n 3.7 mEq/L\\n 10 mg/dL\\n 108 mEq/L\\n 146 mEq/L\\n 27.1 %\\n 11.2 K/uL\\n [image002.jpg]\\n 02:18 AM\\n 01:27 PM\\n 03:06 PM\\n 10:04 PM\\n 03:00 AM\\n 10:47 AM\\n 04:10 PM\\n 12:13 AM\\n 05:08 AM\\n 05:20 AM\\n WBC\\n 8.6\\n 11.2\\n Hct\\n 25.9\\n 27.1\\n Plt\\n 280\\n 306\\n Cr\\n 0.6\\n 0.5\\n 0.7\\n TCO2\\n 33\\n 32\\n 32\\n 34\\n 36\\n 36\\n Glucose\\n 176\\n 136\\n 165\\n Other labs: PT / PTT / INR:13.2/68.7/1.1, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\\n Amylase / Lipase:, Differential-Neuts:89.7 %, Lymph:8.7 %, Mono:1.1\\n %, Eos:0.4 %, Lactic Acid:0.9 mmol/L, Albumin:2.4 g/dL, LDH:204 IU/L,\\n Ca++:10.6 mg/dL, Mg++:2.8 mg/dL, PO4:4.3 mg/dL\\n Assessment and Plan\\n 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA and\\n ARDS intubated since the end of .\\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\\n volume overload. Intubated on for resp decompensation.\\n Transferred here for airway stenting.\\n - attempt SBT today\\n - OR add on for trach and PEG with Dr. (tube feeds off\\n after MN, heparin off after 6am)\\n # # Adrenal Insufficency: Minimal response to stim test again.\\n Appreciate endocrine recommendations.\\n - hydrocort and fludrocort (day 1 = )\\n - will continue at current dose until s/p trach and PEG and\\n hemodynamically stable for 24 hours\\n will then plan to taper\\n hydrocortisone to 25mg IV q6 with a slow taper\\n - will repreat ACTH stim test after tapered to <30mg\\n hydrocortisone or off steroids\\n - f/u daily endocrine recs\\n # Hypotension: Likely adrenal insufficiency and sedation. Goal map\\n > 60. Much improved since re-administration of steroids.\\n - hydrocortisone and fludrocortisone as above\\n - restart levophed if necessary to maintain MAP > 60\\n # Volume overloaded in setting of hypernatremia with TBW deficit.\\n - goal -1000cc I/Os today\\n - continue FW in TF at 250 cc q4hrs\\n - lasix drip (1-5mg/hr) when MAP >\\n 60\\n # Sedation: Sedation control remains somewhat poor although fentanyl\\n patch and diazpem are likely therapeutic range today. On Versed 1.5,\\n Fentanyl 175, Fentanyl patch, Diazepam standing and haldo 2.5-5 mg\\n PRN. QTc increased to 480.\\n - Wean versed/fentanyl as tolerated, continue diazepam. Avoid\\n haldol use if possible to avoid further prolongation of QTc\\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\\n coumadin at least until s/p trach.\\n - hold heparin gtt when anticipate trach/peg\\n # Spine fracture: Neurologically intact distal to the lesion. Prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - CT of C, L spine when stable. Currently, unlikely to change\\n management and high risk for complications with transport.\\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\\n is low. Brace for OOB. Ok for anticoag per note.\\n # FEN/GI: Tube feeds with FWF @ goal.\\n DVT: Treatment dose heparin\\n Ulcer: Ranitidine\\n VAP: Prevention per routine\\n # Communication:\\n - Boyfriend of 10 is her HCP. Also brother is involved\\n - touch base with SW today\\n Code: Full\\n Dispo: ICU\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n PICC Line - 09:19 PM\\n Arterial Line - 02:00 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-09-20 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 634144,\n \"text\": \"Chief Complaint:\\n HPI:\\n 24 Hour Events:\\n PICC LINE - START 10:30 PM\\n INVASIVE VENTILATION - START 10:45 PM\\n EKG - At 11:25 PM\\n BLOOD CULTURED - At 05:30 AM\\n TMax 102.7 BCX1 drawn\\n FEVER - 102.7\\nF - 04:00 AM\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Metronidazole - 08:00 AM\\n Infusions:\\n Fentanyl - 75 mcg/hour\\n Midazolam (Versed) - 2 mg/hour\\n Other ICU medications:\\n Ranitidine (Prophylaxis) - 08:00 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 08:56 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 39.3\\nC (102.7\\n Tcurrent: 37.2\\nC (99\\n HR: 88 (72 - 97) bpm\\n BP: 110/55(64) {83/38(48) - 154/71(103)} mmHg\\n RR: 14 (12 - 18) insp/min\\n SpO2: 100%\\n Total In:\\n 10 mL\\n 1,043 mL\\n PO:\\n TF:\\n 54 mL\\n IVF:\\n 10 mL\\n 988 mL\\n Blood products:\\n Total out:\\n 425 mL\\n 585 mL\\n Urine:\\n 425 mL\\n 585 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -416 mL\\n 458 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 500 (500 - 500) mL\\n RR (Set): 12\\n RR (Spontaneous): 0\\n PEEP: 10 cmH2O\\n FiO2: 60%\\n RSBI Deferred: PEEP > 10, FiO2 > 60%\\n PIP: 32 cmH2O\\n SpO2: 100%\\n ABG: 7.39/53/81./30/5\\n Ve: 8 L/min\\n PaO2 / FiO2: 135\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 9.7 g/dL\\n 333 K/uL\\n 103 mg/dL\\n 0.6 mg/dL\\n 30 mEq/L\\n 3.8 mEq/L\\n 6 mg/dL\\n 109 mEq/L\\n 150 mEq/L\\n 30.7 %\\n 9.7 K/uL\\n [image002.jpg]\\n 11:54 PM\\n 01:00 AM\\n 06:14 AM\\n WBC\\n 9.7\\n Hct\\n 30.7\\n Plt\\n 333\\n Cr\\n 0.6\\n TCO2\\n 32\\n 33\\n Glucose\\n 103\\n Other labs: PT / PTT / INR:13.8/22.4/1.2, ALT / AST:30/19, Alk Phos / T\\n Bili:149/0.7, Differential-Neuts:76.9 %, Lymph:17.3 %, Mono:3.0 %,\\n Eos:2.5 %, Albumin:3.0 g/dL, LDH:222 IU/L, Ca++:8.6 mg/dL, Mg++:2.1\\n mg/dL, PO4:4.1 mg/dL\\n Assessment and Plan\\n Obese woman s/p t spine injury tx from Med for failure to wean\\n from mech ventilation and evaluation for stent for\\n tracheobronchomalacia\\n 1. Resp Failure: initial etiology unclear\\n but currently\\n we need to assess what she can do here. Switch to PSV 10/5 and see what\\n she can pull, check NIF. not act on this info. Let IP know she is\\n here though not stable for intervention at this point.\\n 2. New fevers and hypotension\\n Is fluid responsive, watch\\n UOP, goal 30 cc/hr. Check lactate.\\n DDx VAP, asp PNA, lines. Has PCN and blactam allergy.\\n For VAP- mini , change to Levoquin, Aztreonam, Vanco, and add\\n Flagyl for asp.\\n Lines: D/C PICC send cultures, try for 2nd PIV and if unable will\\n place CVL. Check lactate.\\n Belly: repeat LFTs, KUB OK, check residuals.\\n 3. HyperNa: correcting with g tube free flush and D5W\\n repeat lytes this evening and recalculate\\n 4. Spine Fx: consult NSurg here re reccs for back bracing and\\n activity\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 03:30 AM 10 mL/hour\\n Glycemic Control:\\n Lines:\\n PICC Line - 10:30 PM\\n 20 Gauge - 01:36 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition :\\n Total time spent:\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Nutrition\",\n \"chartdate\": \"2167-09-22 00:00:00.000\",\n \"description\": \"Clinical Nutrition Note\",\n \"row_id\": 634347,\n \"text\": \"Subjective\\n Pt intubated /sedated\\n Objective\\n Pertinent medications: noted\\n Labs:\\n Value\\n Date\\n Glucose\\n 120 mg/dL\\n 03:59 AM\\n Glucose Finger Stick\\n 124\\n 10:00 AM\\n FSBG\\n 111, 111, 145, 123\\n \\n BUN\\n 4 mg/dL\\n 03:59 AM\\n Creatinine\\n 0.6 mg/dL\\n 03:59 AM\\n Sodium\\n 141 mEq/L\\n 03:59 AM\\n Potassium\\n 3.7 mEq/L\\n 03:59 AM\\n Chloride\\n 108 mEq/L\\n 03:59 AM\\n Albumin\\n 2.4 g/dL\\n 03:59 AM\\n Calcium non-ionized\\n 8.2 mg/dL\\n 03:59 AM\\n Phosphorus\\n 3.1 mg/dL\\n 03:59 AM\\n Ionized Calcium\\n 1.16 mmol/L\\n 12:05 PM\\n Magnesium\\n 2.2 mg/dL\\n 03:59 AM\\n Corrented Ca\\n 9.48\\n Current diet order / nutrition support: replete c/ Fiber @60mL/hr (1440\\n kcals 89 gr aa)- currently on hold\\n GI: Abd: softly dist/absent bs/no BM\\n Assessment of Nutritional Status\\n Specifics:\\n TF\\ns trialed. Held high residuals and OGT placed to suction. OGT\\n is currently clamped. Pt has not had a BM since admission. Would\\n consider increasing bowel regimen and adding a promotility . If\\n unable to resume TFs in next 2-3 days, will need to TPN for nutrition\\n support.\\n Medical Nutrition Therapy Plan - Recommend the Following\\n Multivitamin / Mineral supplement: via nutrition support\\n Consider reglan +/- increase bowel regimen\\n Resume TF's as medically feasible, if unable in next 2-3 days, will\\n need to consider PN to prevent nutritional decline\\n BG/lyte management\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-09-22 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 634352,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n -Neurosurg: ok to transport. Will decide on anticoagulation in AM\\n -Central line placed\\n -NGT to suction\\n -Bowel regimen\\n -Respiratory attempted to place esophageal ballon in order to measure\\n intrathoracic pressure, unsuccessful\\n -Desaturation around 23:00 to low 80s on 400/22/15/0.9 following turn.\\n Recruitment maneuver (PEEP to 30) done x2 with good effect, Sat came up\\n to 100%. PEEP left at 17\\n -Transfused 1 un pRBC\\n - Started levophed yesterday for hypotension\\n - No BM\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Levofloxacin - 10:00 AM\\n Aztreonam - 02:00 PM\\n Vancomycin - 12:00 AM\\n Metronidazole - 12:00 AM\\n Infusions:\\n Norepinephrine - 0.02 mcg/Kg/min\\n Fentanyl - 200 mcg/hour\\n Other ICU medications:\\n Ranitidine (Prophylaxis) - 08:00 AM\\n Midazolam (Versed) - 02:20 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:27 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.9\\nC (100.3\\n Tcurrent: 37.6\\nC (99.6\\n HR: 73 (64 - 96) bpm\\n BP: 119/48(69) {85/39(55) - 142/67(91)} mmHg\\n RR: 22 (11 - 22) insp/min\\n SpO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 94.2 kg (admission): 94.2 kg\\n Height: 67 Inch\\n CVP: 20 (11 - 21)mmHg\\n Bladder pressure: 14 (14 - 18) mmHg\\n Total In:\\n 3,482 mL\\n 465 mL\\n PO:\\n TF:\\n IVF:\\n 2,845 mL\\n 465 mL\\n Blood products:\\n 277 mL\\n Total out:\\n 580 mL\\n 65 mL\\n Urine:\\n 580 mL\\n 65 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 2,902 mL\\n 400 mL\\n Respiratory support\\n Ventilator mode: AC\\n Vt (Set): 400 (400 - 500) mL\\n RR (Set): 22\\n RR (Spontaneous): 0\\n PEEP: 17 cmH2O\\n FiO2: 80%\\n PIP: 33 cmH2O\\n Plateau: 30 cmH2O\\n Compliance: 30.8 cmH2O/mL\\n SpO2: 98%\\n ABG: 7.38/41/86./24/0\\n Ve: 9.1 L/min\\n PaO2 / FiO2: 109\\n Physical Examination\\n Gen: Does not arouse to voice\\n HEENT: Pupils 3 mm non-reactive bilaterally. Scleral edema bilat\\n Resp: Symmetric expansion. Vesicular sounds throughout. Inspiratory\\n and expiratory tracheal sounds (?related to ET tube).\\n CV: RRR.\\n Abd: Hypoactive bowel sounds. Distended.\\n Ext: Edema in bilat UE.\\n Peripheral vascular: Radial pulses 2+ bilaterally.\\n Neuro: Moving all 4 extremities.\\n Labs / Radiology\\n 376 K/uL\\n 9.0 g/dL\\n 120 mg/dL\\n 0.6 mg/dL\\n 24 mEq/L\\n 3.7 mEq/L\\n 4 mg/dL\\n 108 mEq/L\\n 141 mEq/L\\n 28.1 %\\n 8.4 K/uL\\n [image002.jpg]\\n ALT 24 PT 18.7\\n AST 16 PTT 25.4\\n AP 117 INR 1.7\\n Tbili 0.7\\n Alb 2.4\\n 08:03 PM\\n 11:00 PM\\n 03:01 AM\\n 03:13 AM\\n 12:05 PM\\n 06:08 PM\\n 06:11 PM\\n 07:53 PM\\n 02:02 AM\\n 03:59 AM\\n WBC\\n 7.6\\n 6.4\\n 8.4\\n Hct\\n 24.1\\n 24.1\\n 29.0\\n 28.1\\n Plt\\n \\n Cr\\n 0.6\\n 0.6\\n 0.6\\n TCO2\\n 33\\n 30\\n 29\\n 29\\n 25\\n 25\\n Glucose\\n 127\\n 129\\n 120\\n Differential-Neuts:80.8 %, Lymph:12.0 %, Mono:3.5 %, Eos:3.3 %\\n Ca++:8.2 mg/dL, Mg++:2.2 mg/dL, PO4:3.1 mg/dL, ion Ca++ () 1.16\\n Cortisol:\\n : 2:15am 24.2 Midnight 2.7\\n : 3am 4.5\\n Micro: neg or NGTD if not mentioned\\n : blood, \\n : urine, sputum-OP flora\\n : BAL, - coag neg staph, lactobacillus, cath tip, sputum- OP\\n flora, rare GNR, blood\\n U/a:\\n Color\\n Amber\\n Appear\\n Clear\\n SpecGr\\n 1.015\\n pH\\n 5.5\\n Urobil\\n 2\\n Bili\\n Mod\\n Leuk\\n Tr\\n Bld\\n Tr\\n Nitr\\n Pos\\n Prot\\n 100\\n Glu\\n Neg\\n Ket\\n 40\\n RBC\\n 0-2\\n WBC\\n 0-2\\n Bact\\n Few\\n Yeast\\n None\\n Epi\\n 0-2\\n Imaging:\\n Echo\\n post recruitment CXR showed deep sulcus but no pnumothorax per rads.\\n CT: Prelim Read\\n Right lower lobe consolidation, and superimposed atelectasis/lower lobe\\n collapse, and effusions. Acute T8 compression deformity, with no\\n posterior\\n retropulsion of fracture fragments. No associated hematoma.\\n Assessment and Plan\\n 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture\\n # Respiratory failure: initial etiology unclear, likely multifactorial\\n now with significant pneumonia. Had one sputum that showed GNR.\\n - Had a desat event yesterday. Responded positively to recruitment\\n maneuvers.\\n - Will attempt placement of an esophageal balloon; with knowledge of\\n intrathoracic pressures, can consider going up on PEEP\\n # Infectious process: Had been febrile, now resolved\\n - be aspiration or be VAP. Sputum from grew rare GNR;\\n awaiting speciation.\\n - Continues on Vanc, aztreonam, levofloxicin. Vanc trough pending today\\n - Also on flagyl for empiric coverage of c. diff\\n - Per CT, unlikely to be abdominal process\\n # Hypotension, requiring Levophed:\\n - Hypovolemia is possibly a factor- responded to a transfusion; HCT had\\n been dropping\\n - Sepsis also a factor- on broad spectrum abs\\n - Central line in place.\\n # Oliguria:\\n -BUN and Cr reassuring.\\n # RUE DVT: Have held on starting treatment in light of need for central\\n access. Can start therapeutic heparin vs Lovenox with bridge to\\n coumadin.\\n - No PE noted on CT scan.\\n # Abd distention:\\n - CT abd only showed appendiceal mucocele without inflammation, not\\n concerning, most likely chronic\\n - No BM in several days, continue bowel regimen, add fleets enema\\n - Can test for c.diff when pt stool\\ns. Continue flagyl empirically\\n - Check amylase and lipase\\n # Anemia:\\n - Trend HCT\\n - Gave 1 un pRBC with good results\\n - Will guiac stools when she has a BM\\n - INR rising, now 1.7, may be nutritional\\n # Spine fracture: neurologically intact distal to the lesion. prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - Will have spine see pt today for recs regarding pt movement and\\n anticoagulation\\n # Hypernatremia, resolved: correcting with g tube free flush and D5W\\n -Holding on g tube feeds at present due to high residuals\\n -Replete lytes as necessary\\n # Communication:\\n - Brother has been with pt, although, live in boyfriend of 10 is\\n her HCP. Boyfriend will hopefully visit pt today\\n ICU Care\\n Nutrition: tube feed with free water when able\\n Glycemic Control: Regular insulin sliding scale\\n DVT: SQ UF Heparin\\n Stress ulcer: H2 blocker\\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\\n Communication: ICU consent signed, (brother) \\n (boyfriend/POA) \\n Code status: Full code\\n Disposition: ICU\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 01:36 AM\\n 22 Gauge - 02:00 PM\\n Arterial Line - 03:00 AM\\n Multi Lumen - 11:30 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-09-23 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 634404,\n \"text\": \"55 yr old women admitted from outside hospital. Patient fell down\\n stairs at home per boyfriend pt with fracture and placed in torso\\n brace at OSH, pt became hypoxic and was intubated (family requested a\\n second opinion and pt was trans to ) Pt admitted for Resp failure,\\n failure to wean, and ? tracheal bronchial malacia. Full code,\\n Allergies: PCN, Tetracycline, Sulfta.\\n Per boyfriend tonight he reported that for the last two months pt has\\n been drinking 2 bottles of wine almost every night.\\n And that this is an increase from what she previously did which was a\\n couple of beers per night.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n RLL consolidation, bilat effusions, R < L ; suct for thick yellowish\\n secretions from ETT; copious thick secretions suct from mouth\\n Action:\\n Pt 2 down to 60%, Peep @ 23 0600 Fio2 decreased to 50% 2/2 Pao2 of\\n 160\\n Response:\\n Pt tolerating turns and current vent settings well\\n Plan:\\n Cont to ABGS, VS;\\n Hypotension (not Shock)\\n Assessment:\\n SBP down in 80\\ns, MAP 60\\n Action:\\n Levophed restarted @0130, currently running @ 0.02mcg\\n Response:\\n BP improved 110-90\\ns MAP 65\\n Plan:\\n Cont to BP, MAP goal >65 , Levo as needed\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Pt (+) DVT RUE\\n Action:\\n Pt started on IV Heparin @1700U/hr\\n Response:\\n Pt PTT@ 0030 62.7, no changes to infusion\\n Plan:\\n Cont to PTT, adjust heparin accordingly; cont with no BP/LAB draws\\n to R arm\\n Alteration in Nutrition\\n Assessment:\\n TF currently on hold high residuals, abd distended soft, hypoactive\\n bowel sounds\\n Action:\\n Pt started on Naloxone x 3 doses, rectal tube in place for\\n decompression; bowel regimen continued\\n Response:\\n Pt passing sm. Amt loose green stool with dose of Naxolone\\n Plan:\\n Re-evaluate for increase in Naloxone dose; ? restarting TF/advancing\\n Fracture, other\\n Assessment:\\n Pt T5/T8 fracture s/p fall \\n Action:\\n Spine/ortho consult done\\n Response:\\n Pt off logroll precautions, tolerates position changes\\n Plan:\\n Activity as tolerated, needs to wear TorsoBrace when OOB or sitting up\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-09-23 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 634440,\n \"text\": \"Events: Attempt to lighten sedation, stop Levophed gtt- MS \\n stability labile from lethargic to restless in bed/crying w/\\n intermittent BP 120\\ns/ w/ and W/O stimulation. UOP cont 10-30cc/hr.\\n Vigileo monitor on- SVV . Bladder pressure 14.\\n Alteration in Nutrition\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Hypotension (not Shock)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-09-24 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 634585,\n \"text\": \"24 Hour Events:\\n -Yesterday, stopped vanc and flagyl. Continued Aztreonam and\\n Levofloxicin\\n -Febrile to 101- pan cultured; cxr\\n -Micro on sputum GNR due back today\\n -Decreased FiO2 and PEEP to 21 (from 23 for ABG 7.42/39/116 at 11PM)\\n -Early am, HR dropped to 40s-50s. EKG suggestive of junctional rhythm.\\n Held pressures, making good UOP, good O2 sats\\n -This am, art line is intermittently working. Drew ABG - pending\\n -Yesterday, SVV was 7; held on giving more fluids\\n -Random cortisol was very low; started hydrocortisone and florinef\\n -UOP picked up this AM\\n -Restarted tube feeds\\n -K, Phos given this AM\\n -New possible junctional rhythm (low voltage) at 5AM. Enzymes added on\\n -Spine -> request CT C, L spine, MRI, TLSO, non-operative, d/c log roll\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Vancomycin - 08:00 PM\\n Metronidazole - 08:00 AM\\n Levofloxacin - 08:39 AM\\n Aztreonam - 02:00 PM\\n Infusions:\\n Norepinephrine - 0.02 mcg/Kg/min\\n Midazolam (Versed) - 4 mg/hour\\n Other ICU medications:\\n Midazolam (Versed) - 03:50 PM\\n Fentanyl - 03:50 PM\\n Ranitidine (Prophylaxis) - 08:31 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:39 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.3\\nC (101\\n Tcurrent: 37.1\\nC (98.8\\n HR: 60 (60 - 86) bpm\\n BP: 103/46(61) {103/46(61) - 121/50(66)} mmHg\\n RR: 22 (17 - 23) insp/min\\n SpO2: 99%\\n Heart rhythm: JR (Junctional Rhythm)\\n Wgt (current): 101 kg (admission): 94.2 kg\\n Height: 67 Inch\\n CVP: 12 (12 - 339)mmHg\\n Total In:\\n 1,675 mL\\n 232 mL\\n PO:\\n TF:\\n 182 mL\\n 134 mL\\n IVF:\\n 1,233 mL\\n 98 mL\\n Blood products:\\n Total out:\\n 877 mL\\n 565 mL\\n Urine:\\n 727 mL\\n 535 mL\\n NG:\\n 30 mL\\n Stool:\\n Drains:\\n Balance:\\n 798 mL\\n -333 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 400 (400 - 400) mL\\n RR (Set): 22\\n RR (Spontaneous): 2\\n PEEP: 21 cmH2O\\n FiO2: 40%\\n RSBI Deferred: PEEP > 10\\n PIP: 33 cmH2O\\n Plateau: 30 cmH2O\\n Compliance: 44.4 cmH2O/mL\\n SpO2: 99%\\n ABG: 7.46/28/129 at 6AM\\n Repeated at 9AM 7.4/38/97\\n Ve: 9.7 L/min\\n PaO2 / FiO2: 290\\n Physical Examination\\n Gen: Does not arouse to voice\\n HEENT: Pupils 3 mm reactive bilaterally. Scleral edema bilat\\n Resp: Symmetric expansion. Coarse breath sounds throughout. Cannot\\n adeq listen to post bases\\n CV: RRR.\\n Abd: Hypoactive bowel sounds. Distended.\\n Ext: Edema in bilat UE.\\n Peripheral vascular: Radial pulses 2+ bilaterally.\\n Neuro: Moving all 4 extremities.\\n Labs / Radiology\\n 326 K/uL\\n 8.9 g/dL\\n 151 mg/dL\\n 0.7 mg/dL\\n 26 mEq/L\\n 3.6 mEq/L\\n 2 mg/dL\\n 108 mEq/L\\n 141 mEq/L\\n 28.6 %\\n 8.9 K/uL\\n [image002.jpg]\\n 06:11 PM\\n 07:53 PM\\n 02:02 AM\\n 03:59 AM\\n 09:14 PM\\n 01:04 AM\\n 05:54 AM\\n 06:11 AM\\n 11:07 PM\\n 03:51 AM\\n WBC\\n 8.4\\n 8.1\\n 8.9\\n Hct\\n 28.1\\n 28.0\\n 28.6\\n Plt\\n 376\\n 358\\n 326\\n Cr\\n 0.6\\n 0.7\\n 0.7\\n TCO2\\n 29\\n 25\\n 25\\n 28\\n 28\\n 26\\n 26\\n Glucose\\n 120\\n 126\\n 151\\n Other labs: PT / PTT / INR:24.3/68.6/2.4, ALT / AST:24/16, Alk Phos / T\\n Bili:117/0.7, Amylase / Lipase:, Differential-Neuts:82.5 %,\\n Lymph:11.6 %, Mono:3.3 %, Eos:2.2 %, Lactic Acid:0.7 mmol/L,\\n Albumin:2.4 g/dL, LDH:204 IU/L, Ca++:8.5 mg/dL, Mg++:2.1 mg/dL, PO4:2.5\\n mg/dL\\nMicro: 2:38 am SPUTUM Site: ENDOTRACHEAL\\n GRAM STAIN (Final ):\\n >25 PMNs and <10 epithelial cells/100X field.\\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.\\n IN PAIRS AND CLUSTERS.\\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).\\n RESPIRATORY CULTURE (Pending)\\n GRAM STAIN (Final ) SPUTUM Site: ENDOTRACHEAL:\\n <10 PMNs and <10 epithelial cells/100X field.\\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.\\n IN PAIRS.\\n 1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).\\n CULTURE: GRAM NEGATIVE ROD(S). RARE GROWTH. WORK-UP PER DR ().\\n Assessment and Plan\\n 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture with respiratory failure\\n and difficulty weaning from vent.\\n # Respiratory failure: Over the evening yesterday, were able to\\n decrease FiO2 and PEEP. Clinical and imaging suggestive of ARDS.\\n Initial preceptiationg factors: sedation, hypovent obesity,\\n orthotic brace. Now thought to have VAP.\\n - Placed esophageal balloon on which will help guide PEEP settings.\\n # VAP: Re-spiked fever overnight. Stopped vanc yesterday, , as\\n treating for GNR infection. Current GS shows GPC\\n - Follow cultures\\n - Restart Vanc.\\n - Continue aztreonam, levofloxicin for 8 days pending speciation (at\\n that time can increase to 15 days if necessary)\\n - Also, stopped flagyl because had one neg c. diff toxin and CT did not\\n show evidence of colitis\\n # EKG changes: very low voltages and no change in QRS morphology.\\n P-waves may be buried.\\n -repeat\\n -f/u enzymes\\n # Hypotension, requiring Levophed: Increased urine output c/w\\n autodiuresing\\n - Attempt to wean from levophed with MAP goal 65 and UOP goal >30 cc/hr\\n - Hypovolemia is possibly a factor- responded to a transfusion; HCT had\\n been dropping. However, SVV with Vigileo was 13, making her CO less\\n likely to respond to fluids. Held on giving any boluses overnight.\\n - Sepsis also a factor- on broad spectrum abs\\n - Central line in place.\\n # Oliguria: Improved recently. BUN and Cr reassuring.\\n -Continue to monitor\\n # RUE DVT: Started on heparin gtt on .\\n -Therapeutic in one day; may be related to poor nutritional status.\\n Will continue to closely monitor\\n # Abd distention: be chronic condition not requiring immediate\\n medical attention\\n - CT abd only showed appendiceal mucocele without inflammation, not\\n concerning, most likely chronic. No concern for intraabd disaster\\n - Now having BMs; c. diff toxin neg\\n - amylase and lipase wnl\\n # Adrenal Insufficency:\\n -Random cortisol was approx 3 when it should have been maximally\\n stimulated.\\n -Started hydrocortisone and florinef. ? switch to methylpred\\n # Anemia:\\n - Trend HCT\\n - Gave 1 un pRBC with good results\\n - INR rising, now 2.0, may be nutritional\\n # Spine fracture: neurologically intact distal to the lesion. prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - Repeat CT C, L spine.\\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\\n is low. Brace for OOB. Ok for anticoag per note.\\n # Hypernatremia, resolved: correcting with g tube free flush and D5W\\n -Holding on g tube feeds at present due to high residuals\\n -Replete lytes as necessary\\n # Communication:\\n - Brother has been with pt, although, live in boyfriend of 10 is\\n her HCP. Boyfriend will hopefully visit pt today\\n ICU Care\\n Nutrition: tube feed with free water when able\\n Glycemic Control: Regular insulin sliding scale\\n DVT: SQ UF Heparin\\n Stress ulcer: H2 blocker\\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\\n Communication: ICU consent signed, (brother) \\n (boyfriend/POA) \\n Code status: Full code\\n Disposition: ICU\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 10:55 PM 30 mL/hour\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 01:36 AM\\n Arterial Line - 03:00 AM\\n Multi Lumen - 11:30 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-09-30 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 635194,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n ARTERIAL LINE - START 02:00 PM - in right brachial atery\\n Hypotensive- started on levophed, weaned off over night\\n Low cortisol and failed stim test - started on steroids\\n TTE ordered\\n Free water flushes were increased for hypernatremia (250cc q4)\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Levofloxacin - 08:06 AM\\n Infusions:\\n Heparin Sodium - 1,700 units/hour\\n Midazolam (Versed) - 2 mg/hour\\n Fentanyl - 150 mcg/hour\\n Other ICU medications:\\n Haloperidol (Haldol) - 12:15 AM\\n Other medications:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:50 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.5\\nC (99.5\\n Tcurrent: 36.7\\nC (98\\n HR: 63 (48 - 138) bpm\\n BP: 91/41(58) {68/30(49) - 143/78(105)} mmHg\\n RR: 18 (13 - 23) insp/min\\n SpO2: 91%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Mixed Venous O2% Sat: 59 - 59\\n Total In:\\n 3,898 mL\\n 1,155 mL\\n PO:\\n TF:\\n 802 mL\\n 348 mL\\n IVF:\\n 2,126 mL\\n 247 mL\\n Blood products:\\n Total out:\\n 2,367 mL\\n 800 mL\\n Urine:\\n 2,367 mL\\n 800 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,531 mL\\n 355 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 400 (400 - 401) mL\\n RR (Set): 18\\n RR (Spontaneous): 1\\n PEEP: 10 cmH2O\\n FiO2: 40%\\n PIP: 23 cmH2O\\n Plateau: 19 cmH2O\\n Compliance: 57.1 cmH2O/mL\\n SpO2: 91%\\n ABG: 7.42/49/93/33/5\\n Ve: 8.1 L/min\\n PaO2 / FiO2: 155\\n Physical Examination\\n Labs / Radiology\\n 355 K/uL\\n 9.1 g/dL\\n 168 mg/dL\\n 0.5 mg/dL\\n 30 mEq/L\\n 3.9 mEq/L\\n 11 mg/dL\\n 108 mEq/L\\n 146 mEq/L\\n 29.9 %\\n 11.8 K/uL\\n [image002.jpg]\\n 03:32 PM\\n 10:19 PM\\n 02:50 AM\\n 02:30 PM\\n 02:44 PM\\n 03:33 PM\\n 07:26 PM\\n 07:46 PM\\n 02:04 AM\\n 02:18 AM\\n WBC\\n 9.0\\n 8.4\\n 11.8\\n Hct\\n 25.8\\n 23.0\\n 28.1\\n 29.9\\n Plt\\n \\n Cr\\n 0.6\\n 0.7\\n 0.5\\n TCO2\\n 30\\n 35\\n 33\\n 31\\n 33\\n Glucose\\n 94\\n 97\\n 168\\n Other labs: PT / PTT / INR:13.8/70.4/1.2, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\\n Amylase / Lipase:, Differential-Neuts:89.7 %, Lymph:8.7 %, Mono:1.1\\n %, Eos:0.4 %, Lactic Acid:0.9 mmol/L, Albumin:2.4 g/dL, LDH:204 IU/L,\\n Ca++:8.5 mg/dL, Mg++:2.2 mg/dL, PO4:5.4 mg/dL\\n Assessment and Plan\\n 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture with respiratory failure\\n and difficulty weaning from vent.\\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\\n volume overload. Intubated on for resp decompensation.\\n Transferred here for tracheomalacia, but not sure this is a component.\\n Will need bronch eval when improved\\n - Thoracics will do trach and PEG once stable on PEEPs around 10. Had\\n been planned for today but currently holding as PEEP is 15.\\n - wean PEEP as tolerated\\n - needs A-line\\n # Volume overload\\n Currently with hypernatremia, Cr increase, contract\\n alk, but mild\\n - continue gentle diuresis with goal -1L per day as tolerated by blood\\n pressure. IV lasix drip at 1-5 mg/hr.\\n - FW in TF at 150 cc q4hrs\\n - PM lytes.\\n # Sedation: Now well seadated on Versed 1.5, Fentanyl 175, Fentanyl\\n patch, Diazepam standing and haldo 2.5-5 mg PRN. QTc stable at .44\\n - Wean versed/fentanyl as tolerated\\n # HCT\\n Has had slow decline while in ICU.\\n - Xfuse PRN Hct < 21\\n - continue to follow, guiac stools\\n # Hypotension: Related to sedation, but high PEEP, adrenial\\n insufficiency, sepsis have previously been contributing.\\n - needs A-line for monitoring\\n - cortisol stim to rule out persistent adrenal insufficiency\\n # RUE DVT: Started on heparin gtt on , now off for trach that was\\n planned for today. Follow PTTs. Would hold off on coumadin at least\\n until s/p trach.\\n - restart heparin\\n # Adrenal Insufficency: Random cortisol was approx 3 when it should\\n have been maximally stimulated. S/P 5 days of hydrocortisone and\\n florinef.\\n - will recheck as above and start at 50 q8 if needed\\n # Spine fracture: Neurologically intact distal to the lesion. Prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - CT of C, L spine when stable. Currently, unlikely to change\\n management and high risk for complications with transport.\\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\\n is low. Brace for OOB. Ok for anticoag per note.\\n # Communication:\\n - Boyfriend of 10 is her HCP. Also brother is involved\\n # FEN/GI: Tube feeds @ goal. No need to be NPO while awaiting stable\\n PEEP\\n DVT: Treatment dose heparin\\n Ulcer: Ranitidine\\n VAP: Prevention per routine\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 09:51 PM 60 mL/hour\\n Glycemic Control:\\n Lines:\\n PICC Line - 09:19 PM\\n Arterial Line - 02:00 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-09-30 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 635196,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n ARTERIAL LINE - START 02:00 PM - in right brachial atery\\n Hypotensive- started on levophed, weaned off over night\\n Low cortisol and failed stim test - started on steroids\\n TTE ordered\\n Free water flushes were increased for hypernatremia (250cc q4)\\n Able to hear patient breathing at times during exam this am (poor am\\n CXR, reordered)\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Levofloxacin - 08:06 AM\\n Infusions:\\n Heparin Sodium - 1,700 units/hour\\n Midazolam (Versed) - 2 mg/hour\\n Fentanyl - 150 mcg/hour\\n Other ICU medications:\\n Haloperidol (Haldol) - 12:15 AM\\n Other medications:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:50 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.5\\nC (99.5\\n Tcurrent: 36.7\\nC (98\\n HR: 63 (48 - 138) bpm\\n BP: 91/41(58) {68/30(49) - 143/78(105)} mmHg\\n RR: 18 (13 - 23) insp/min\\n SpO2: 91%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Mixed Venous O2% Sat: 59 - 59\\n Total In:\\n 3,898 mL\\n 1,155 mL\\n PO:\\n TF:\\n 802 mL\\n 348 mL\\n IVF:\\n 2,126 mL\\n 247 mL\\n Blood products:\\n Total out:\\n 2,367 mL\\n 800 mL\\n Urine:\\n 2,367 mL\\n 800 mL\\n NG:\\n Stool:\\n ?\\n ?\\n Drains:\\n Balance:\\n 1,531 mL\\n 355 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 400 (400 - 401) mL\\n RR (Set): 18\\n RR (Spontaneous): 1\\n PEEP: 10 cmH2O\\n FiO2: 40%\\n PIP: 23 cmH2O\\n Plateau: 19 cmH2O\\n Compliance: 57.1 cmH2O/mL\\n SpO2: 91%\\n ABG: 7.42/49/93/33/5\\n Ve: 8.1 L/min\\n PaO2 / FiO2: 155\\n Physical Examination\\n General Appearance: Easily agitated, appears uncomfortable, Overweight\\n / Obese, opens eyes but no purposeful movement\\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\\n deviation\\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\\n Cardiovascular: (S1: Normal), (S2: Normal), distant\\n Respiratory / Chest: (Expansion: Symmetric), referred breath sounds\\n from ETT\\n Abdominal: No(t) Soft, Non-tender, Few Bowel sounds present, Distended\\n Extremities: No clubbing or cyanosis, 3+ nonpitting edema of b/l hands,\\n anasarca\\n Skin: no rashes or jaundice\\n Neuro: diffusely hyperreflexic with LE clonus\\n Lines: r brachioceph ART and L PICC C/D/I\\n Labs / Radiology\\n 355 K/uL\\n 9.1 g/dL\\n 168 mg/dL\\n 0.5 mg/dL\\n 30 mEq/L\\n 3.9 mEq/L\\n 11 mg/dL\\n 108 mEq/L\\n 146 mEq/L\\n 29.9 %\\n 11.8 K/uL\\n [image002.jpg]\\n 03:32 PM\\n 10:19 PM\\n 02:50 AM\\n 02:30 PM\\n 02:44 PM\\n 03:33 PM\\n 07:26 PM\\n 07:46 PM\\n 02:04 AM\\n 02:18 AM\\n WBC\\n 9.0\\n 8.4\\n 11.8\\n Hct\\n 25.8\\n 23.0\\n 28.1\\n 29.9\\n Plt\\n \\n Cr\\n 0.6\\n 0.7\\n 0.5\\n TCO2\\n 30\\n 35\\n 33\\n 31\\n 33\\n Glucose\\n 94\\n 97\\n 168\\n Other labs: PT / PTT / INR:13.8/70.4/1.2, Differential-Neuts:89.7 %,\\n Lymph:8.7 %, Mono:1.1 %, Eos:0.4 %, Ca++:8.5 mg/dL, Mg++:2.2 mg/dL,\\n PO4:5.4 mg/dL\\n Culture Data: endotrach with K oxytoca; gram stain GPCs in\\n pairs and clusters\\n Assessment and Plan\\n 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture with respiratory failure\\n and difficulty weaning from vent.\\n # Respiratory failure: Related to ARDS, ? trachiomalacia, resolved\\n VAP, volume overload. Intubated on for resp decompensation.\\n Transferred here for tracheomalacia, but not sure this is a component.\\n Will need bronch eval when improved\\n - Thoracics will do trach and PEG once stable on PEEPs around 10.\\n Re-c/s today.\\n - wean PEEP as tolerated\\n # Volume overload\\n Hypernatremic (? Relationship to adrenal\\n insufficiency), TBW deficit 2.6L.\\n - goal even I/Os today\\n - FW in TF at 250 cc q4hrs\\n - PM lytes\\n # Hyperreflexia - ? meds vs central pathology\\n - consider head CT in context of heparin gtt to r/o intracranial\\n hemmorhage\\n # Sedation: Poor sedation control. On Versed 1.5, Fentanyl 175,\\n Fentanyl patch, Diazepam standing and haldo 2.5-5 mg PRN. QTc stable\\n at .44\\n - Wean versed/fentanyl as tolerated\\n - Recheck EKG today\\n -\\n # Hypotension: Related to sedation, but high PEEP, adrenial\\n insufficiency, sepsis have previously been contributing. Monitor with\\n A-line. Failed stim again.\\n - hydrocortisol and fludrocortisone\\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\\n coumadin at least until s/p trach.\\n - hold heparin gtt when anticipate trach/peg\\n # Adrenal Insufficency: Minimal response to stim test again.\\n - hydrocort and fludrocort\\n - consider endocrine c/s for further elucidation of etiology\\n # Spine fracture: Neurologically intact distal to the lesion. Prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - CT of C, L spine when stable. Currently, unlikely to change\\n management and high risk for complications with transport.\\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\\n is low. Brace for OOB. Ok for anticoag per note.\\n # Communication:\\n - Boyfriend of 10 is her HCP. Also brother is involved\\n # FEN/GI: Tube feeds @ goal.\\n DVT: Treatment dose heparin\\n Ulcer: Ranitidine\\n VAP: Prevention per routine\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 09:51 PM 60 mL/hour\\n Glycemic Control:\\n Lines:\\n PICC Line - 09:19 PM\\n Arterial Line - 02:00 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-01 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 635377,\n \"text\": \"55 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP now with prolonged\\n hospital course c/o by PNA anxiety,RUE DVD with high PEEP requirement\\n .\\n Events: pt to go to OR on for trach/PEG. Failed spont. Breathing\\n trial.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-02 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 635434,\n \"text\": \"55 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP now with prolonged\\n hospital course c/o by PNA anxiety,RUE DVD with high PEEP requirement\\n .\\n Events:\\n Pt found at 19:30 to have loose restraints and was pulling on ETT. Pt\\n found to have pulled out her esophageal tube and disconnected IV lines.\\n CXR done and ETT and OGGT in right position.\\n Plan: Plan for OR this am for trach and peg. Heparin gtt off at 6am.\\n Edema, peripheral\\n Assessment:\\n Pt has gen edema with +2 pitting.\\n Action:\\n Pt is on lasix gtt, now at 1 mg/hr. Goal to remove 1-2 liters/24hrs. Pt\\n is currently + 17.3 liters for LOS.\\n Response:\\n Pt is diuresing well to lasix .\\n Plan:\\n Continue to evaluate need for lasix and follow K level closely. K level\\n replaced x 1 with 80m meq of Kcl 3.0 ,\\n Hypernatremia (high sodium)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Altered mental status (not Delirium)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Impaired Skin Integrity\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Alteration in Nutrition\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-02 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 635531,\n \"text\": \"55 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP now with prolonged\\n hospital course c/o by PNA anxiety,RUE DVD with high PEEP requirement\\n .\\n EVENTS: trach PEG done, PEG OK for meds, restart TF in am. restart hep\\n gtt tomorrow, diamox/ KCL added for alkalosis.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt rec\\nd intubated, on AC 400x18 50% +PEEP 8\\n Action:\\n Trach placed in the OR, pt returned from OR and placed on previous vent\\n settings, failed att at CPAP wean.\\n Response:\\n Plan:\\n Att to wean vent/ sedation slowly in am. Cont to monitor\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt rec\\nd on fent/ versed gtt\\ns at 100mcg/hr/ 2mg/hr respectively,\\n Action:\\n Response:\\n Plan:\\n Alteration in Nutrition\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-02 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 635532,\n \"text\": \"55 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP now with prolonged\\n hospital course c/o by PNA anxiety,RUE DVD with high PEEP requirement\\n .\\n EVENTS: trach PEG done, PEG OK for meds, restart TF in am. restart hep\\n gtt tomorrow, diamox/ KCL added for alkalosis.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt rec\\nd intubated, on AC 400x18 50% +PEEP 8\\n Action:\\n Trach placed in the OR, pt returned from OR and placed on previous vent\\n settings, failed att at CPAP wean.\\n Response:\\n Plan:\\n Att to wean vent/ sedation slowly in am. Cont to monitor\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt rec\\nd on fent/ versed gtt\\ns at 100mcg/hr/ 2mg/hr respectively,\\n Action:\\n Response:\\n Plan:\\n Alteration in Nutrition\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2167-09-23 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 634402,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 5\\n Ideal body weight: 61.2 None\\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: Unknown\\n Procedure location:\\n Reason:\\n Tube Type\\n ETT:\\n Position: cm at teeth\\n Route:\\n Type: Standard\\n Size: 7.5mm\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Diminished\\n Comments:\\n Secretions\\n Sputum color / consistency: Yellow / Thick\\n Sputum source/amount: Suctioned / Scant\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance:\\n Visual assessment of breathing pattern:\\n Assessment of breathing comfort:\\n Non-invasive ventilation assessment:\\n Invasive ventilation assessment:\\n Trigger work assessment:\\n Dysynchrony assessment:\\n Comments:\\n Plan\\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\\n tolerated\\n Reason for continuing current ventilatory support:\\n Respiratory Care Shift Procedures\\n Transports:\\n Destination (R/T)\\n Time\\n Complications\\n Comments\\n Comments: Pt continues to be intubated on full vent support. This\\n shift , peep was increased to 23 cmh20 while the fio2 was wean down to\\n 50%, and is tolerated well. Pt was suctioned for small thick tan\\n secretions. No other vent changes were made.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-09-23 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 634412,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n ESOPHOGEAL BALLOON - At 01:46 PM - went well, were able to\\n increase PEEP to improve oxygenation\\n - started naloxone to encourage bowel motility, with some success,\\n rectal tube in place\\n -started heparin gtt for RUE DVT\\n -borderline hypotensive at times (low 90s) with low urine output,\\n received boluses and norepi back on at 0.04\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Levofloxacin - 09:45 AM\\n Metronidazole - 03:32 PM\\n Vancomycin - 08:00 PM\\n Aztreonam - 10:00 PM\\n Infusions:\\n Midazolam (Versed) - 2 mg/hour\\n Heparin Sodium - 1,700 units/hour\\n Fentanyl - 100 mcg/hour\\n Norepinephrine - 0.04 mcg/Kg/min\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:34 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38\\nC (100.4\\n Tcurrent: 37.3\\nC (99.2\\n HR: 73 (60 - 102) bpm\\n BP: 90/46(61) {76/38(56) - 160/71(97)} mmHg\\n RR: 23 (16 - 25) insp/min\\n SpO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 101 kg (admission): 94.2 kg\\n Height: 67 Inch\\n CVP: 8 (8 - 15)mmHg\\n Bladder pressure: 18 (18 - 21) mmHg\\n Total In:\\n 3,524 mL\\n 234 mL\\n PO:\\n TF:\\n 48 mL\\n IVF:\\n 3,236 mL\\n 234 mL\\n Blood products:\\n Total out:\\n 935 mL\\n 215 mL\\n Urine:\\n 650 mL\\n 215 mL\\n NG:\\n 285 mL\\n Stool:\\n Drains:\\n Balance:\\n 2,589 mL\\n 19 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 400 (400 - 400) mL\\n Vt (Spontaneous): 0 (0 - 0) mL\\n RR (Set): 22\\n RR (Spontaneous): 0\\n PEEP: 23 cmH2O\\n FiO2: 60%\\n RSBI Deferred: PEEP > 10, FiO2 > 60%\\n PIP: 42 cmH2O\\n Plateau: 32 cmH2O\\n Compliance: 44.4 cmH2O/mL\\n SpO2: 100%\\n ABG: 7.36/47/153//0\\n Ve: 9.5 L/min\\n PaO2 / FiO2: 255\\n Physical Examination\\n Gen: Does not arouse to voice\\n HEENT: Pupils 3 mm non-reactive bilaterally. Scleral edema bilat\\n Resp: Symmetric expansion. Vesicular sounds throughout. Inspiratory\\n and expiratory tracheal sounds (?related to ET tube).\\n CV: RRR.\\n Abd: Hypoactive bowel sounds. Distended.\\n Ext: Edema in bilat UE.\\n Peripheral vascular: Radial pulses 2+ bilaterally.\\n Neuro: Moving all 4 extremities.\\n Labs / Radiology\\n 376 K/uL\\n 9.0 g/dL\\n 120 mg/dL\\n 0.6 mg/dL\\n 24 mEq/L\\n 3.7 mEq/L\\n 4 mg/dL\\n 108 mEq/L\\n 141 mEq/L\\n 28.1 %\\n 8.4 K/uL\\n [image002.jpg]\\n 03:01 AM\\n 03:13 AM\\n 12:05 PM\\n 06:08 PM\\n 06:11 PM\\n 07:53 PM\\n 02:02 AM\\n 03:59 AM\\n 09:14 PM\\n 01:04 AM\\n WBC\\n 6.4\\n 8.4\\n Hct\\n 24.1\\n 29.0\\n 28.1\\n Plt\\n 319\\n 376\\n Cr\\n 0.6\\n 0.6\\n TCO2\\n 30\\n 29\\n 29\\n 25\\n 25\\n 28\\n 28\\n Glucose\\n 129\\n 120\\n Other labs: PT / PTT / INR:18.7/62.7/1.7, ALT / AST:24/16, Alk Phos / T\\n Bili:117/0.7, Amylase / Lipase:, Differential-Neuts:80.8 %,\\n Lymph:12.0 %, Mono:3.5 %, Eos:3.3 %, Lactic Acid:0.7 mmol/L,\\n Albumin:2.4 g/dL, LDH:204 IU/L, Ca++:8.2 mg/dL, Mg++:2.2 mg/dL, PO4:3.1\\n mg/dL\\n Assessment and Plan\\n 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture\\n # Respiratory failure: initial etiology unclear, likely multifactorial\\n now with significant pneumonia. Had one sputum that showed GNR.\\n - Had a desat event yesterday. Responded positively to recruitment\\n maneuvers.\\n - Will attempt placement of an esophageal balloon; with knowledge of\\n intrathoracic pressures, can consider going up on PEEP\\n # Infectious process: Had been febrile, now resolved\\n - be aspiration or be VAP. Sputum from grew rare GNR;\\n awaiting speciation.\\n - Continues on Vanc, aztreonam, levofloxicin. Vanc trough pending today\\n - Also on flagyl for empiric coverage of c. diff\\n - Per CT, unlikely to be abdominal process\\n # Hypotension, requiring Levophed:\\n - Hypovolemia is possibly a factor- responded to a transfusion; HCT had\\n been dropping\\n - Sepsis also a factor- on broad spectrum abs\\n - Central line in place.\\n # Oliguria:\\n -BUN and Cr reassuring.\\n # RUE DVT: Have held on starting treatment in light of need for central\\n access. Can start therapeutic heparin vs Lovenox with bridge to\\n coumadin.\\n - No PE noted on CT scan.\\n # Abd distention:\\n - CT abd only showed appendiceal mucocele without inflammation, not\\n concerning, most likely chronic\\n - No BM in several days, continue bowel regimen, add fleets enema\\n - Can test for c.diff when pt stool\\ns. Continue flagyl empirically\\n - Check amylase and lipase\\n # Anemia:\\n - Trend HCT\\n - Gave 1 un pRBC with good results\\n - Will guiac stools when she has a BM\\n - INR rising, now 1.7, may be nutritional\\n # Spine fracture: neurologically intact distal to the lesion. prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\\n is low. Brace for OOB. Ok for anticoag per verbal report.\\n # Hypernatremia, resolved: correcting with g tube free flush and D5W\\n -Holding on g tube feeds at present due to high residuals\\n -Replete lytes as necessary\\n # Communication:\\n - Brother has been with pt, although, live in boyfriend of 10 is\\n her HCP. Boyfriend will hopefully visit pt today\\n ICU Care\\n Nutrition: tube feed with free water when able\\n Glycemic Control: Regular insulin sliding scale\\n DVT: SQ UF Heparin\\n Stress ulcer: H2 blocker\\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\\n Communication: ICU consent signed, (brother) \\n (boyfriend/POA) \\n Code status: Full code\\n Disposition: ICU\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 01:36 AM\\n Arterial Line - 03:00 AM\\n Multi Lumen - 11:30 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-09-23 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 634413,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n ESOPHOGEAL BALLOON - At 01:46 PM - went well, were able to\\n increase PEEP to improve oxygenation\\n - started naloxone to encourage bowel motility, with some success,\\n rectal tube in place with some stool\\n -started heparin gtt for RUE DVT\\n -borderline hypotensive at times (low 90s) with low urine output,\\n received boluses and norepi back on at 0.04 (now down to 0.02)\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Levofloxacin - 09:45 AM\\n Metronidazole - 03:32 PM\\n Vancomycin - 08:00 PM\\n Aztreonam - 10:00 PM\\n Infusions:\\n Midazolam (Versed) - 2 mg/hour\\n Heparin Sodium - 1,700 units/hour\\n Fentanyl - 100 mcg/hour\\n Norepinephrine - 0.04 mcg/Kg/min\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:34 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38\\nC (100.4\\n Tcurrent: 37.3\\nC (99.2\\n HR: 73 (60 - 102) bpm\\n BP: 90/46(61) {76/38(56) - 160/71(97)} mmHg\\n RR: 23 (16 - 25) insp/min\\n SpO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 101 kg (admission): 94.2 kg\\n Height: 67 Inch\\n CVP: 8 (8 - 15)mmHg\\n Bladder pressure: 18 (18 - 21) mmHg\\n Total In:\\n 3,524 mL\\n 234 mL\\n PO:\\n TF:\\n 48 mL\\n IVF:\\n 3,236 mL\\n 234 mL\\n Blood products:\\n Total out:\\n 935 mL\\n 215 mL\\n Urine:\\n 650 mL\\n 215 mL\\n NG:\\n 285 mL\\n Stool:\\n Drains:\\n Balance:\\n 2,589 mL\\n 19 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: AC\\n Vt (Set): 400 (400 - 400) mL\\n Vt (Spontaneous): 0 (0 - 0) mL\\n RR (Set): 22\\n RR (Spontaneous): 0\\n PEEP: 23 cmH2O\\n FiO2: 60%\\n RSBI Deferred: PEEP > 10, FiO2 > 60%\\n PIP: 42 cmH2O\\n Plateau: 32 cmH2O\\n Compliance: 44.4 cmH2O/mL\\n SpO2: 100%\\n ABG: 7.37/44/160 (6am)\\n Ve: 9.5 L/min\\n PaO2 / FiO2: 255\\n Physical Examination\\n Gen: Does not arouse to voice\\n HEENT: Pupils 3 mm non-reactive bilaterally. Scleral edema bilat\\n Resp: Symmetric expansion. Vesicular sounds throughout. Inspiratory\\n and expiratory tracheal sounds (?related to ET tube).\\n CV: RRR.\\n Abd: Hypoactive bowel sounds. Distended.\\n Ext: Edema in bilat UE.\\n Peripheral vascular: Radial pulses 2+ bilaterally.\\n Neuro: Moving all 4 extremities.\\n Labs / Radiology\\n 358 K/uL\\n 8.9 g/dL\\n 126 mg/dL\\n 0.7 mg/dL\\n 25 mEq/L\\n 3.5 mEq/L\\n 4 mg/dL\\n 108 mEq/L\\n 143 mEq/L\\n 28.0 %\\n 8.1 K/uL\\n [image002.jpg]\\n 03:01 AM\\n 03:13 AM\\n 12:05 PM\\n 06:08 PM\\n 06:11 PM\\n 07:53 PM\\n 02:02 AM\\n 03:59 AM\\n 09:14 PM\\n 01:04 AM\\n WBC\\n 6.4\\n 8.4\\n Hct\\n 24.1\\n 29.0\\n 28.1\\n Plt\\n 319\\n 376\\n Cr\\n 0.6\\n 0.6\\n TCO2\\n 30\\n 29\\n 29\\n 25\\n 25\\n 28\\n 28\\n Glucose\\n 129\\n 120\\n PT 22.2 PTT 76.0 INR 2.1\\n Differential-Neuts:74.7 %, Lymph:17.6 %, Mono:3.5 %, Eos:3.8 %\\n Ca++:8.2 mg/dL, Mg++:2.0 mg/dL, PO4:3.2 mg/dL\\n Assessment and Plan\\n 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture\\n # Respiratory failure: initial etiology unclear, likely multifactorial\\n now with significant pneumonia. Had one sputum that showed GNR.\\n - Had a desat event yesterday. Responded positively to recruitment\\n maneuvers.\\n - Will attempt placement of an esophageal balloon; with knowledge of\\n intrathoracic pressures, can consider going up on PEEP\\n # Infectious process: Had been febrile, now resolved\\n - be aspiration or be VAP. Sputum from grew rare GNR;\\n awaiting speciation.\\n - Continues on Vanc, aztreonam, levofloxicin. Vanc trough pending today\\n - Also on flagyl for empiric coverage of c. diff\\n - Per CT, unlikely to be abdominal process\\n # Hypotension, requiring Levophed:\\n - Hypovolemia is possibly a factor- responded to a transfusion; HCT had\\n been dropping\\n - Sepsis also a factor- on broad spectrum abs\\n - Central line in place.\\n # Oliguria:\\n -BUN and Cr reassuring.\\n # RUE DVT: Have held on starting treatment in light of need for central\\n access. Can start therapeutic heparin vs Lovenox with bridge to\\n coumadin.\\n - No PE noted on CT scan.\\n # Abd distention:\\n - CT abd only showed appendiceal mucocele without inflammation, not\\n concerning, most likely chronic\\n - No BM in several days, continue bowel regimen, add fleets enema\\n - Can test for c.diff when pt stool\\ns. Continue flagyl empirically\\n - Check amylase and lipase\\n # Anemia:\\n - Trend HCT\\n - Gave 1 un pRBC with good results\\n - Will guiac stools when she has a BM\\n - INR rising, now 1.7, may be nutritional\\n # Spine fracture: neurologically intact distal to the lesion. prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\\n is low. Brace for OOB. Ok for anticoag per verbal report.\\n # Hypernatremia, resolved: correcting with g tube free flush and D5W\\n -Holding on g tube feeds at present due to high residuals\\n -Replete lytes as necessary\\n # Communication:\\n - Brother has been with pt, although, live in boyfriend of 10 is\\n her HCP. Boyfriend will hopefully visit pt today\\n ICU Care\\n Nutrition: tube feed with free water when able\\n Glycemic Control: Regular insulin sliding scale\\n DVT: SQ UF Heparin\\n Stress ulcer: H2 blocker\\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\\n Communication: ICU consent signed, (brother) \\n (boyfriend/POA) \\n Code status: Full code\\n Disposition: ICU\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 01:36 AM\\n Arterial Line - 03:00 AM\\n Multi Lumen - 11:30 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-09-23 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 634419,\n \"text\": \"Chief Complaint: respiratory failure\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 24 Hour Events:\\n ESOPHOGEAL BALLOON - At 01:46 PM\\n Restarted levophed overnight\\n Patient unable to provide history: Sedated\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Vancomycin - 08:00 PM\\n Aztreonam - 06:09 AM\\n Metronidazole - 08:00 AM\\n Levofloxacin - 08:39 AM\\n Infusions:\\n Midazolam (Versed) - 1.5 mg/hour\\n Fentanyl - 75 mcg/hour\\n Norepinephrine - 0.02 mcg/Kg/min\\n Other ICU medications:\\n Other medications:\\n vanc, aztreonam, flagyl (day ), CHG, SQI, nebs, naloxone enteral,\\n heparin infusion\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 09:55 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38\\nC (100.4\\n Tcurrent: 37.6\\nC (99.6\\n HR: 75 (64 - 102) bpm\\n BP: 96/49(65) {76/38(56) - 160/71(97)} mmHg\\n RR: 22 (16 - 25) insp/min\\n SpO2: 99%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 101 kg (admission): 94.2 kg\\n Height: 67 Inch\\n CVP: 20 (8 - 339)mmHg\\n Bladder pressure: 18 (18 - 21) mmHg\\n Total In:\\n 3,524 mL\\n 848 mL\\n PO:\\n TF:\\n 48 mL\\n IVF:\\n 3,236 mL\\n 698 mL\\n Blood products:\\n Total out:\\n 935 mL\\n 325 mL\\n Urine:\\n 650 mL\\n 325 mL\\n NG:\\n 285 mL\\n Stool:\\n Drains:\\n Balance:\\n 2,589 mL\\n 523 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 400 (400 - 400) mL\\n Vt (Spontaneous): 0 (0 - 0) mL\\n RR (Set): 22\\n RR (Spontaneous): 0\\n PEEP: 23 cmH2O\\n FiO2: 50%\\n RSBI Deferred: PEEP > 10, FiO2 > 60%\\n PIP: 37 cmH2O\\n Plateau: 33 cmH2O\\n Compliance: 40 cmH2O/mL\\n SpO2: 99%\\n ABG: 7.37/44/160/25/0\\n Ve: 8.9 L/min\\n PaO2 / FiO2: 320\\n Physical Examination\\n General Appearance: Overweight / Obese\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\\n Respiratory / Chest: coarse breath sounds\\n Abdominal: Soft, Obese\\n Extremities: Right: 1+, Left: 1+\\n Skin: Warm\\n Neurologic: Responds to: Unresponsive, Movement: No spontaneous\\n movement, Tone: Normal\\n Labs / Radiology\\n 8.9 g/dL\\n 358 K/uL\\n 126 mg/dL\\n 0.7 mg/dL\\n 25 mEq/L\\n 3.5 mEq/L\\n 4 mg/dL\\n 108 mEq/L\\n 143 mEq/L\\n 28.0 %\\n 8.1 K/uL\\n [image002.jpg]\\n 12:05 PM\\n 06:08 PM\\n 06:11 PM\\n 07:53 PM\\n 02:02 AM\\n 03:59 AM\\n 09:14 PM\\n 01:04 AM\\n 05:54 AM\\n 06:11 AM\\n WBC\\n 8.4\\n 8.1\\n Hct\\n 29.0\\n 28.1\\n 28.0\\n Plt\\n 376\\n 358\\n Cr\\n 0.6\\n 0.7\\n TCO2\\n 29\\n 29\\n 25\\n 25\\n 28\\n 28\\n 26\\n Glucose\\n 120\\n 126\\n Other labs: PT / PTT / INR:22.2/76.0/2.1, ALT / AST:24/16, Alk Phos / T\\n Bili:117/0.7, Amylase / Lipase:, Differential-Neuts:74.7 %,\\n Lymph:17.6 %, Mono:3.8 %, Eos:3.4 %, Lactic Acid:0.7 mmol/L,\\n Albumin:2.4 g/dL, LDH:204 IU/L, Ca++:8.2 mg/dL, Mg++:2.0 mg/dL, PO4:3.2\\n mg/dL\\n Assessment and Plan\\n End-exp transpulmonary pressure: -2\\n End-insp transpulmonary pressure: +5\\n ICU Care\\n Nutrition:\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n 20 Gauge - 01:36 AM\\n Arterial Line - 03:00 AM\\n Multi Lumen - 11:30 AM\\n Prophylaxis:\\n DVT: Boots(Systemic anticoagulation: Heparin gtt)\\n Stress ulcer: H2 blocker\\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds Comments:\\n Code status: Full code\\n Disposition :ICU\\n Total time spent:\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-09-23 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 634421,\n \"text\": \"Chief Complaint: respiratory failure\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 24 Hour Events:\\n ESOPHOGEAL BALLOON - At 01:46 PM\\n Restarted levophed overnight\\n Patient unable to provide history: Sedated\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Vancomycin - 08:00 PM\\n Aztreonam - 06:09 AM\\n Metronidazole - 08:00 AM\\n Levofloxacin - 08:39 AM\\n Infusions:\\n Midazolam (Versed) - 1.5 mg/hour\\n Fentanyl - 75 mcg/hour\\n Norepinephrine - 0.02 mcg/Kg/min\\n Other ICU medications:\\n Other medications:\\n vanc, aztreonam, flagyl (day ), CHG, SQI, nebs, naloxone enteral,\\n heparin infusion\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 09:55 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38\\nC (100.4\\n Tcurrent: 37.6\\nC (99.6\\n HR: 75 (64 - 102) bpm\\n BP: 96/49(65) {76/38(56) - 160/71(97)} mmHg\\n RR: 22 (16 - 25) insp/min\\n SpO2: 99%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 101 kg (admission): 94.2 kg\\n Height: 67 Inch\\n CVP: 20 (8 - 339)mmHg\\n Bladder pressure: 18 (18 - 21) mmHg\\n Total In:\\n 3,524 mL\\n 848 mL\\n PO:\\n TF:\\n 48 mL\\n IVF:\\n 3,236 mL\\n 698 mL\\n Blood products:\\n Total out:\\n 935 mL\\n 325 mL\\n Urine:\\n 650 mL\\n 325 mL\\n NG:\\n 285 mL\\n Stool:\\n Drains:\\n Balance:\\n 2,589 mL\\n 523 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 400 (400 - 400) mL\\n Vt (Spontaneous): 0 (0 - 0) mL\\n RR (Set): 22\\n RR (Spontaneous): 0\\n PEEP: 23 cmH2O\\n FiO2: 50%\\n RSBI Deferred: PEEP > 10, FiO2 > 60%\\n PIP: 37 cmH2O\\n Plateau: 33 cmH2O\\n Compliance: 40 cmH2O/mL\\n SpO2: 99%\\n ABG: 7.37/44/160/25/0\\n Ve: 8.9 L/min\\n PaO2 / FiO2: 320\\n Physical Examination\\n General Appearance: Overweight / Obese\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\\n Respiratory / Chest: coarse breath sounds\\n Abdominal: Soft, Obese\\n Extremities: Right: 1+, Left: 1+\\n Skin: Warm\\n Neurologic: Responds to: Unresponsive, Movement: No spontaneous\\n movement, Tone: Normal\\n Labs / Radiology\\n 8.9 g/dL\\n 358 K/uL\\n 126 mg/dL\\n 0.7 mg/dL\\n 25 mEq/L\\n 3.5 mEq/L\\n 4 mg/dL\\n 108 mEq/L\\n 143 mEq/L\\n 28.0 %\\n 8.1 K/uL\\n [image002.jpg]\\n 12:05 PM\\n 06:08 PM\\n 06:11 PM\\n 07:53 PM\\n 02:02 AM\\n 03:59 AM\\n 09:14 PM\\n 01:04 AM\\n 05:54 AM\\n 06:11 AM\\n WBC\\n 8.4\\n 8.1\\n Hct\\n 29.0\\n 28.1\\n 28.0\\n Plt\\n 376\\n 358\\n Cr\\n 0.6\\n 0.7\\n TCO2\\n 29\\n 29\\n 25\\n 25\\n 28\\n 28\\n 26\\n Glucose\\n 120\\n 126\\n Other labs: PT / PTT / INR:22.2/76.0/2.1, ALT / AST:24/16, Alk Phos / T\\n Bili:117/0.7, Amylase / Lipase:, Differential-Neuts:74.7 %,\\n Lymph:17.6 %, Mono:3.8 %, Eos:3.4 %, Lactic Acid:0.7 mmol/L,\\n Albumin:2.4 g/dL, LDH:204 IU/L, Ca++:8.2 mg/dL, Mg++:2.0 mg/dL, PO4:3.2\\n mg/dL\\n Assessment and Plan\\n Assessment and Plan\\n 55-year-old woman with\\n Respiratory failure\\n End-exp transpulmonary pressure: -2\\n End-insp transpulmonary pressure: +5\\n Esophageal pressures suggest that she is at safe pressures.\\n Traumatic thoracic spinal fracture\\n Eventual MRI. Too high-risk at present. Brace when out of\\n bed.\\n Probable VAP\\n Discuss GNRs with lab\\n Complete 8\\n 15d course of present ABX pending cultures\\n D/C vancomycin since no identified GPCs\\n D/C Flagyl since no CT or toxin evidence of C diff\\n Shock\\n now back on levophed\\n CVP is 20 mm Hg but Pes is ~25 cm H20\\n Re-assess SVV with Vigileo and consider volume challenge\\n Upper extremity DVT\\n Therapeutic heparin\\n Anemia\\n Follow\\n Possible tracheobronchomalacia (reason for transfer)\\n Incidental peri-appendiceal finding (will need eventual\\n follow-up)\\n Although differential remains open, the most compelling course of\\n events is probably that she required intubation at the outside hospital\\n (?sedation ?restriction from obesity/brace ?other) and subsequently\\n developed a GNR-related VAP. Her pattern of acute lung injury,\\n combined with obesity, is resulting in basilar and\\n posterior-predominant atelectasis/consolidation with a high proportion\\n of shunt. Given her very high PEEP, will try to avoid bronchoscopy if\\n possible.\\n Other issues as per ICU team note.\\n ICU Care\\n Nutrition: resume tube feeds\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n 20 Gauge - 01:36 AM\\n Arterial Line - 03:00 AM\\n Multi Lumen - 11:30 AM\\n Prophylaxis:\\n DVT: Boots(Systemic anticoagulation: Heparin gtt)\\n Stress ulcer: H2 blocker\\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds Comments:\\n Code status: Full code\\n Disposition :ICU\\n Total time spent:\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-09-24 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 634499,\n \"text\": \"55 yr old woman admitted from OSH after she fell down the stairs and\\n had traumatic T-spine fracture. Pt came to us with PNA from unknown\\n etiology? VAP. Full code, Allergies: PCN, tetracycline, Sulfa. PMH:\\n ETOH, smoker, Gerd, Hip replacement.\\n Alteration in Nutrition\\n Assessment:\\n Tube feeds at 20ml/hr. Tube feed residual 20ml.\\n Action:\\n Kept TF at 20ml/hr and will cont to check residuals and try to increase\\n rate\\n Response:\\n No change\\n Plan:\\n Try to increase Tube feeds to goal rate.\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n RUE DVT, pt on heparin gtt at 1700units/hr.\\n Action:\\n Ptt was therapeutic x2, AM PTT\\n Response:\\n Plan:\\n Cont heparin gtt, check PTT adjust heparin gtt per scale.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Moderate thick white in-line secretions, copious clear oral secretions,\\n clear/diminished lung sounds. Esophageal balloon in place. Previous\\n Sputum culture shows GNR, speciation PND.\\n Action:\\n Lots of suctioning through the night, decreased FiO2 from 50% to 40%,\\n decreased Peep from 23 to 21, HOB >30, oral care.\\n Response:\\n ABG WNL\\n Plan:\\n Cont to try to wean vent settings as tolerated, cont monitoring ABG\\n Hypotension (not Shock)\\n Assessment:\\n SBP 90-110\\ns MAP 62-66 Goal MAP >65 Levophed gtt @ 0.020 mcg/kg/min.\\n Action:\\n Trying to wean levophed gtt off\\n Response:\\n Plan:\\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\\n Assessment:\\n T-max 101.0\\n Action:\\n Sent blood, urine, and sputum cultures, treated with tylenol\\n Response:\\n Temp decreased\\n Plan:\\n Follow up on cultures\\n CT scan from earlier in the week confirms fracture but did not detect\\n retropulsion. Neuro want pt in back brace when she is out of bed.\\n Log rolling pt has been d/c.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-09-24 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 634552,\n \"text\": \"24 Hour Events:\\n -Yesterday, stopped vanc and flagyl. Continued Aztreonam and\\n Levofloxicin\\n -Febrile to 101- pan cultured; cxr\\n -Micro on sputum GNR due back today\\n -Decreased FiO2 and PEEP to 21 (from 23 for ABG 7.42/39/116 at 11PM)\\n -Early am, HR dropped to 40s-50s. EKG suggestive of junctional rhythm.\\n Held pressures, making good UOP, good O2 sats\\n -This am, art line is intermittently working. Drew ABG - pending\\n -Yesterday, SVV was 7; held on giving more fluids\\n -Random cortisol was very low; started hydrocortisone and florinef\\n -UOP picked up this AM\\n -Restarted tube feeds\\n -K, Phos given this AM\\n -New possible junctional rhythm (low voltage) at 5AM. Enzymes added on\\n -Spine -> request CT C, L spine, MRI, TLSO, non-operative, d/c log roll\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Vancomycin - 08:00 PM\\n Metronidazole - 08:00 AM\\n Levofloxacin - 08:39 AM\\n Aztreonam - 02:00 PM\\n Infusions:\\n Norepinephrine - 0.02 mcg/Kg/min\\n Midazolam (Versed) - 4 mg/hour\\n Other ICU medications:\\n Midazolam (Versed) - 03:50 PM\\n Fentanyl - 03:50 PM\\n Ranitidine (Prophylaxis) - 08:31 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:39 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.3\\nC (101\\n Tcurrent: 37.1\\nC (98.8\\n HR: 60 (60 - 86) bpm\\n BP: 103/46(61) {103/46(61) - 121/50(66)} mmHg\\n RR: 22 (17 - 23) insp/min\\n SpO2: 99%\\n Heart rhythm: JR (Junctional Rhythm)\\n Wgt (current): 101 kg (admission): 94.2 kg\\n Height: 67 Inch\\n CVP: 12 (12 - 339)mmHg\\n Total In:\\n 1,675 mL\\n 232 mL\\n PO:\\n TF:\\n 182 mL\\n 134 mL\\n IVF:\\n 1,233 mL\\n 98 mL\\n Blood products:\\n Total out:\\n 877 mL\\n 565 mL\\n Urine:\\n 727 mL\\n 535 mL\\n NG:\\n 30 mL\\n Stool:\\n Drains:\\n Balance:\\n 798 mL\\n -333 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 400 (400 - 400) mL\\n RR (Set): 22\\n RR (Spontaneous): 2\\n PEEP: 21 cmH2O\\n FiO2: 40%\\n RSBI Deferred: PEEP > 10\\n PIP: 33 cmH2O\\n Plateau: 30 cmH2O\\n Compliance: 44.4 cmH2O/mL\\n SpO2: 99%\\n ABG: 7.46/28/129\\n Ve: 9.7 L/min\\n PaO2 / FiO2: 290\\n Physical Examination\\n Gen: Does not arouse to voice\\n HEENT: Pupils 3 mm reactive bilaterally. Scleral edema bilat\\n Resp: Symmetric expansion. Coarse breath sounds throughout. Cannot\\n adeq listen to post bases\\n CV: RRR.\\n Abd: Hypoactive bowel sounds. Distended.\\n Ext: Edema in bilat UE.\\n Peripheral vascular: Radial pulses 2+ bilaterally.\\n Neuro: Moving all 4 extremities.\\n Labs / Radiology\\n 326 K/uL\\n 8.9 g/dL\\n 151 mg/dL\\n 0.7 mg/dL\\n 26 mEq/L\\n 3.6 mEq/L\\n 2 mg/dL\\n 108 mEq/L\\n 141 mEq/L\\n 28.6 %\\n 8.9 K/uL\\n [image002.jpg]\\n 06:11 PM\\n 07:53 PM\\n 02:02 AM\\n 03:59 AM\\n 09:14 PM\\n 01:04 AM\\n 05:54 AM\\n 06:11 AM\\n 11:07 PM\\n 03:51 AM\\n WBC\\n 8.4\\n 8.1\\n 8.9\\n Hct\\n 28.1\\n 28.0\\n 28.6\\n Plt\\n 376\\n 358\\n 326\\n Cr\\n 0.6\\n 0.7\\n 0.7\\n TCO2\\n 29\\n 25\\n 25\\n 28\\n 28\\n 26\\n 26\\n Glucose\\n 120\\n 126\\n 151\\n Other labs: PT / PTT / INR:24.3/68.6/2.4, ALT / AST:24/16, Alk Phos / T\\n Bili:117/0.7, Amylase / Lipase:, Differential-Neuts:82.5 %,\\n Lymph:11.6 %, Mono:3.3 %, Eos:2.2 %, Lactic Acid:0.7 mmol/L,\\n Albumin:2.4 g/dL, LDH:204 IU/L, Ca++:8.5 mg/dL, Mg++:2.1 mg/dL, PO4:2.5\\n mg/dL\\nMicro: 2:38 am SPUTUM Site: ENDOTRACHEAL\\n GRAM STAIN (Final ):\\n >25 PMNs and <10 epithelial cells/100X field.\\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.\\n IN PAIRS AND CLUSTERS.\\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).\\n RESPIRATORY CULTURE (Pending)\\n GRAM STAIN (Final ) SPUTUM Site: ENDOTRACHEAL:\\n <10 PMNs and <10 epithelial cells/100X field.\\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.\\n IN PAIRS.\\n 1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).\\n CULTURE: GRAM NEGATIVE ROD(S). RARE GROWTH. WORK-UP PER DR ().\\n Assessment and Plan\\n 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture with respiratory failure\\n and difficulty weaning from vent.\\n # Respiratory failure: Over the evening yesterday, were able to\\n decrease FiO2 and PEEP. Clinical and imaging suggestive of ARDS.\\n Initial preceptiationg factors: sedation, hypovent obesity,\\n orthotic brace. Now thought to have VAP.\\n - Placed esophageal balloon on which will help guide PEEP settings.\\n # VAP: Re-spiked fever overnight. Stopped vanc yesterday, , as\\n treating for GNR infection. Current GS shows GPC\\n - Follow cultures\\n - Restart Vanc.\\n - Continue aztreonam, levofloxicin for 8 days pending speciation (at\\n that time can increase to 15 days if necessary)\\n - Also, stopped flagyl because had one neg c. diff toxin and CT did not\\n show evidence of colitis\\n # EKG changes: very low voltages and no change in QRS morphology.\\n P-waves may be buried.\\n -repeat\\n -f/u enzymes\\n # Hypotension, requiring Levophed: Increased urine output c/w\\n autodiuresing\\n - Attempt to wean from levophed with MAP goal 65 and UOP goal >30 cc/hr\\n - Hypovolemia is possibly a factor- responded to a transfusion; HCT had\\n been dropping. However, SVV with Vigileo was 13, making her CO less\\n likely to respond to fluids. Held on giving any boluses overnight.\\n - Sepsis also a factor- on broad spectrum abs\\n - Central line in place.\\n # Oliguria: Improved recently. BUN and Cr reassuring.\\n -Continue to monitor\\n # RUE DVT: Started on heparin gtt on .\\n -Therapeutic in one day; may be related to poor nutritional status.\\n Will continue to closely monitor\\n # Abd distention: be chronic condition not requiring immediate\\n medical attention\\n - CT abd only showed appendiceal mucocele without inflammation, not\\n concerning, most likely chronic. No concern for intraabd disaster\\n - Now having BMs; c. diff toxin neg\\n - amylase and lipase wnl\\n # Adrenal Insufficency:\\n -Random cortisol was approx 3 when it should have been maximally\\n stimulated.\\n -Started hydrocortisone and florinef. ? switch to methylpred\\n # Anemia:\\n - Trend HCT\\n - Gave 1 un pRBC with good results\\n - INR rising, now 2.0, may be nutritional\\n # Spine fracture: neurologically intact distal to the lesion. prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - Repeat CT C, L spine.\\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\\n is low. Brace for OOB. Ok for anticoag per note.\\n # Hypernatremia, resolved: correcting with g tube free flush and D5W\\n -Holding on g tube feeds at present due to high residuals\\n -Replete lytes as necessary\\n # Communication:\\n - Brother has been with pt, although, live in boyfriend of 10 is\\n her HCP. Boyfriend will hopefully visit pt today\\n ICU Care\\n Nutrition: tube feed with free water when able\\n Glycemic Control: Regular insulin sliding scale\\n DVT: SQ UF Heparin\\n Stress ulcer: H2 blocker\\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\\n Communication: ICU consent signed, (brother) \\n (boyfriend/POA) \\n Code status: Full code\\n Disposition: ICU\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 10:55 PM 30 mL/hour\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 01:36 AM\\n Arterial Line - 03:00 AM\\n Multi Lumen - 11:30 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-09-24 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 634564,\n \"text\": \"Chief Complaint: respiratory failure\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 24 Hour Events:\\n BLOOD CULTURED - At 12:24 AM\\n URINE CULTURE - At 12:24 AM\\n SPUTUM CULTURE - At 03:30 AM\\n EKG - At 05:20 AM\\n pt in junctional rhythem, holding stable BP, intern aware and came to\\n assess pt. HR 47-50.\\n Fever spike to 101\\n Steroids started\\n Antibiotics tailored\\n PEEP decreased\\n History obtained from Medical records, ICU team\\n Patient unable to provide history: Sedated\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Vancomycin - 08:00 PM\\n Metronidazole - 08:00 AM\\n Levofloxacin - 08:39 AM\\n Aztreonam - 06:00 AM\\n Infusions:\\n Midazolam (Versed) - 2 mg/hour\\n Fentanyl - 100 mcg/hour\\n Other ICU medications:\\n Midazolam (Versed) - 03:50 PM\\n Fentanyl - 03:50 PM\\n Ranitidine (Prophylaxis) - 08:31 PM\\n Other medications:\\n versed, fentanyl, colace, H2B, CHG, SQI, MDIs, heparin infusion,\\n levoflox, aztreonam, hydrocortisone 50 q6, fludrocort\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 08:57 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.3\\nC (101\\n Tcurrent: 37.1\\nC (98.8\\n HR: 57 (48 - 86) bpm\\n BP: 102/48(61) {102/46(61) - 121/52(66)} mmHg\\n RR: 22 (17 - 23) insp/min\\n SpO2: 99%\\n Heart rhythm: JR (Junctional Rhythm)\\n Wgt (current): 101 kg (admission): 94.2 kg\\n Height: 67 Inch\\n CVP: 11 (11 - 20)mmHg\\n Bladder pressure: 12 (12 - 12) mmHg\\n Total In:\\n 1,708 mL\\n 460 mL\\n PO:\\n TF:\\n 182 mL\\n 138 mL\\n IVF:\\n 1,267 mL\\n 321 mL\\n Blood products:\\n Total out:\\n 877 mL\\n 1,305 mL\\n Urine:\\n 727 mL\\n 1,275 mL\\n NG:\\n 30 mL\\n Stool:\\n Drains:\\n Balance:\\n 831 mL\\n -845 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 400 (400 - 400) mL\\n RR (Set): 22\\n RR (Spontaneous): 0\\n PEEP: 21 cmH2O\\n FiO2: 40%\\n RSBI Deferred: PEEP > 10\\n PIP: 36 cmH2O\\n Plateau: 29 cmH2O\\n Compliance: 50 cmH2O/mL\\n SpO2: 99%\\n ABG: 7.46/38/96./26/2\\n Ve: 8.6 L/min\\n PaO2 / FiO2: 242\\n Physical Examination\\n General Appearance: Overweight / Obese\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: Normocephalic\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear :\\n anteriorly)\\n Abdominal: Soft, Non-tender, Obese\\n Extremities: Right: 1+, Left: 1+\\n Musculoskeletal: Unable to stand\\n Skin: Warm\\n Neurologic: Responds to: Unresponsive, Movement: No spontaneous\\n movement, Sedated, Tone: Normal\\n Labs / Radiology\\n 8.9 g/dL\\n 326 K/uL\\n 151 mg/dL\\n 0.7 mg/dL\\n 26 mEq/L\\n 3.6 mEq/L\\n 2 mg/dL\\n 108 mEq/L\\n 141 mEq/L\\n 28.6 %\\n 8.9 K/uL\\n [image002.jpg]\\n 02:02 AM\\n 03:59 AM\\n 09:14 PM\\n 01:04 AM\\n 05:54 AM\\n 06:11 AM\\n 11:07 PM\\n 03:51 AM\\n 06:17 AM\\n 08:18 AM\\n WBC\\n 8.4\\n 8.1\\n 8.9\\n Hct\\n 28.1\\n 28.0\\n 28.6\\n Plt\\n 376\\n 358\\n 326\\n Cr\\n 0.6\\n 0.7\\n 0.7\\n TCO2\\n 25\\n 28\\n 28\\n 26\\n 26\\n 21\\n 28\\n Glucose\\n 120\\n 126\\n 151\\n Other labs: PT / PTT / INR:24.3/68.6/2.4, CK / CKMB / Troponin-T:24//,\\n ALT / AST:24/16, Alk Phos / T Bili:117/0.7, Amylase / Lipase:,\\n Differential-Neuts:82.5 %, Lymph:11.6 %, Mono:3.3 %, Eos:2.2 %, Lactic\\n Acid:0.7 mmol/L, Albumin:2.4 g/dL, LDH:204 IU/L, Ca++:8.5 mg/dL,\\n Mg++:2.1 mg/dL, PO4:2.5 mg/dL\\n Imaging: CXR: increased right base opacity\\n Microbiology: Sputum from overnight: GPCs with 2+ GPCs in\\n pairs/clusters and 2+ GPRs\\n Prior sputum growing GNRs\\n Assessment and Plan\\n 55-year-old woman with\\n Respiratory failure\\n Recheck esophageal pressures today.\\n Wean PEEP as tolerated and guided by Pes\\n On our ultrasound exam, effusion would be high risk to tap\\n Adrenal insufficiency\\n Based on very low random cortisol while in shock and\\n respiratory failure\\n On steroids\\n Bradycardia\\n Rhythm appear sinus.\\n Will try to check an atrial EKG via her CVL to confirm\\n Heart rate increases with stimulation, suggesting that this\\n is mostly vagal in etiology\\n Sedation and high ventilatory pressures may contribute to\\n high vagal tone\\n Continues to have signs of good perfusion\\n This may be reflex bradycardia from increased perfusion\\n relating to steroid dosing\\n Probable VAP\\n Discuss GNRs with lab\\n Complete 8\\n 15d course of present ABX pending cultures\\n D/C vancomycin since no identified GPCs\\n D/C Flagyl since no CT or toxin evidence of C diff\\n Shock\\n now off of levophed (again)\\n SVV is low, suggesting adequate volume repletion\\n Treating adrenal insufficiency\\n Polyuria\\n be response to increased perfusion (comes at right time\\n course to be an effect of treating adrenal insufficiency)\\n Upper extremity DVT\\n Therapeutic heparin\\n Anemia\\n Follow\\n Possible tracheobronchomalacia (reason for transfer)\\n Incidental peri-appendiceal finding (will need eventual\\n follow-up)\\n Traumatic thoracic spinal fracture\\n Eventual MRI. Too high-risk at present. Brace when out of\\n bed.\\n Fever\\n Restart vanco (GPCs on G/S of sputum)\\n Follow cultures\\n Resite art line (dysfunctional).\\n CVL is within 3 days; will follow\\n Although differential remains open, the most compelling course of\\n events is probably that she required intubation at the outside hospital\\n (?sedation ?restriction from obesity/brace ?other) and subsequently\\n developed a GNR-related VAP. Her pattern of acute lung injury,\\n combined with obesity, is resulting in basilar and\\n posterior-predominant atelectasis/consolidation with a high proportion\\n of shunt. Will consider bronchoscopy based on course today, given\\n apparent increased atelectasis on CXR.\\n Other issues as per ICU team note.\\n ICU Care\\n Nutrition: tube feeds\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n 20 Gauge - 01:36 AM\\n Arterial Line - 03:00 AM\\n Multi Lumen - 11:30 AM\\n Prophylaxis:\\n DVT: Boots(Systemic anticoagulation: Heparin gtt)\\n Stress ulcer: H2 blocker\\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :ICU\\n Total time spent: 40 min\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-09-24 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 634591,\n \"text\": \"24 Hour Events:\\n -Yesterday, stopped vanc and flagyl. Continued Aztreonam and\\n Levofloxicin\\n -Febrile to 101- pan cultured; cxr\\n -Micro on sputum GNR due back today\\n -Decreased FiO2 and PEEP to 21 (from 23 for ABG 7.42/39/116 at 11PM)\\n -Early am, HR dropped to 40s-50s. EKG suggestive of junctional rhythm.\\n Held pressures, making good UOP, good O2 sats\\n -This am, art line is intermittently working. Drew ABG - pending\\n -Yesterday, SVV was 7; held on giving more fluids\\n -Random cortisol was very low; started hydrocortisone and florinef\\n -UOP picked up this AM\\n -Restarted tube feeds\\n -K, Phos given this AM\\n -New possible junctional rhythm (low voltage) at 5AM. Enzymes added on\\n -Spine -> request CT C, L spine, MRI, TLSO, non-operative, d/c log roll\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Vancomycin - 08:00 PM\\n Metronidazole - 08:00 AM\\n Levofloxacin - 08:39 AM\\n Aztreonam - 02:00 PM\\n Infusions:\\n Norepinephrine - 0.02 mcg/Kg/min\\n Midazolam (Versed) - 4 mg/hour\\n Other ICU medications:\\n Midazolam (Versed) - 03:50 PM\\n Fentanyl - 03:50 PM\\n Ranitidine (Prophylaxis) - 08:31 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:39 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.3\\nC (101\\n Tcurrent: 37.1\\nC (98.8\\n HR: 60 (60 - 86) bpm\\n BP: 103/46(61) {103/46(61) - 121/50(66)} mmHg\\n RR: 22 (17 - 23) insp/min\\n SpO2: 99%\\n Heart rhythm: JR (Junctional Rhythm)\\n Wgt (current): 101 kg (admission): 94.2 kg\\n Height: 67 Inch\\n CVP: 12 (12 - 339)mmHg\\n Total In:\\n 1,675 mL\\n 232 mL\\n PO:\\n TF:\\n 182 mL\\n 134 mL\\n IVF:\\n 1,233 mL\\n 98 mL\\n Blood products:\\n Total out:\\n 877 mL\\n 565 mL\\n Urine:\\n 727 mL\\n 535 mL\\n NG:\\n 30 mL\\n Stool:\\n Drains:\\n Balance:\\n 798 mL\\n -333 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 400 (400 - 400) mL\\n RR (Set): 22\\n RR (Spontaneous): 2\\n PEEP: 21 cmH2O\\n FiO2: 40%\\n RSBI Deferred: PEEP > 10\\n PIP: 33 cmH2O\\n Plateau: 30 cmH2O\\n Compliance: 44.4 cmH2O/mL\\n SpO2: 99%\\n ABG: 7.46/28/129 at 6AM\\n Repeated at 9AM 7.4/38/97\\n Ve: 9.7 L/min\\n PaO2 / FiO2: 290\\n Physical Examination\\n Gen: Does not arouse to voice\\n HEENT: Pupils 3 mm reactive bilaterally. Scleral edema bilat\\n Resp: Symmetric expansion. Coarse breath sounds throughout. Cannot\\n adeq listen to post bases\\n CV: RRR.\\n Abd: Hypoactive bowel sounds. Distended.\\n Ext: Edema in bilat UE.\\n Peripheral vascular: Radial pulses 2+ bilaterally.\\n Neuro: Moving all 4 extremities.\\n Labs / Radiology\\n 326 K/uL\\n 8.9 g/dL\\n 151 mg/dL\\n 0.7 mg/dL\\n 26 mEq/L\\n 3.6 mEq/L\\n 2 mg/dL\\n 108 mEq/L\\n 141 mEq/L\\n 28.6 %\\n 8.9 K/uL\\n [image002.jpg]\\n 06:11 PM\\n 07:53 PM\\n 02:02 AM\\n 03:59 AM\\n 09:14 PM\\n 01:04 AM\\n 05:54 AM\\n 06:11 AM\\n 11:07 PM\\n 03:51 AM\\n WBC\\n 8.4\\n 8.1\\n 8.9\\n Hct\\n 28.1\\n 28.0\\n 28.6\\n Plt\\n 376\\n 358\\n 326\\n Cr\\n 0.6\\n 0.7\\n 0.7\\n TCO2\\n 29\\n 25\\n 25\\n 28\\n 28\\n 26\\n 26\\n Glucose\\n 120\\n 126\\n 151\\n Other labs: PT / PTT / INR:24.3/68.6/2.4, ALT / AST:24/16, Alk Phos / T\\n Bili:117/0.7, Amylase / Lipase:, Differential-Neuts:82.5 %,\\n Lymph:11.6 %, Mono:3.3 %, Eos:2.2 %, Lactic Acid:0.7 mmol/L,\\n Albumin:2.4 g/dL, LDH:204 IU/L, Ca++:8.5 mg/dL, Mg++:2.1 mg/dL, PO4:2.5\\n mg/dL\\nMicro: 2:38 am SPUTUM Site: ENDOTRACHEAL\\n GRAM STAIN (Final ):\\n >25 PMNs and <10 epithelial cells/100X field.\\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.\\n IN PAIRS AND CLUSTERS.\\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).\\n RESPIRATORY CULTURE (Pending)\\n GRAM STAIN (Final ) SPUTUM Site: ENDOTRACHEAL:\\n <10 PMNs and <10 epithelial cells/100X field.\\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.\\n IN PAIRS.\\n 1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).\\n CULTURE: GRAM NEGATIVE ROD(S). RARE GROWTH. WORK-UP PER DR ().\\n US of effusion (by MICU staff): small effusion, accessible but\\n difficult to tap\\n Assessment and Plan\\n 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture with respiratory failure\\n and difficulty weaning from vent.\\n # Respiratory failure: Over the evening yesterday, were able to\\n decrease FiO2 and PEEP. Clinical and imaging suggestive of ARDS.\\n Initial precipitating factors were thought to be: sedation, hypovent\\n obesity, orthotic brace. Now thought to have VAP.\\n - Placed esophageal balloon on which will help guide PEEP settings.\\n - Given small size of effusion and high PEEP (risk of pneumothorax),\\n will not attempt to tap\\n - Appreciate IP recs. Will consider tracheomalacia workup when more\\n stable.\\n # VAP/ID: Re-spiked fever overnight. Stopped vanc yesterday, , as\\n treating for GNR infection. Current GS shows GPC\\n - Follow cultures\\n - Restart Vanc.\\n - Continue aztreonam, levofloxicin for 8 days pending speciation (at\\n that time can increase to 15 days if necessary)\\n - Also, stopped flagyl because had one neg c. diff toxin and CT did not\\n show evidence of colitis\\n - Will replace A-line today.\\n # EKG changes: Sinus bradycardia. Very low voltages and no change in\\n QRS morphology. P-waves are visible and prolonged PR interval is old.\\n CK and troponins flat. Likely related to increased vagal tone possibly\\n related to steroid replacement.\\n - Will avoid excessive alpha-agonism\\n - Continue to monitor\\n - could consider atrial EKG\\n .\\n # Hypotension: now off levophed, with good urine output. Hypovolemia\\n is possibly a factor- responded to a transfusion; HCT had been\\n dropping. However, SVV with Vigileo was 7, making her CO less likely\\n to respond to fluids. Held on giving any boluses overnight. Today CVP\\n is low given PEEP. Sepsis also a consideration\\n - continue on broad spectrum abs\\n - replete fluids.\\n - Restart pressors as needed. Consider dopamine over levophed given\\n bradycardia.\\n - Central line in place.\\n # Urine output: Previously oliguric, now with high urine output.\\n Concern for autodiuresis but BUN and Cr reassuring.\\n -Continue to monitor\\n # RUE DVT: Started on heparin gtt on .\\n -Therapeutic in one day; may be related to poor nutritional status.\\n Will continue to closely monitor\\n # Adrenal Insufficency:\\n -Random cortisol was approx 3 when it should have been maximally\\n stimulated.\\n -Started hydrocortisone and florinef. ? switch to methylpred\\n # Anemia:\\n - Trend HCT\\n - Gave 1 un pRBC with good results\\n - INR rising, now 2.0, may be nutritional\\n # Spine fracture: neurologically intact distal to the lesion. prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - CT of C, L spine when stable. Currently, unlikely to change\\n management and high risk for complications with transport.\\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\\n is low. Brace for OOB. Ok for anticoag per note.\\n # Hypernatremia, resolved: correcting with g tube free flush and D5W\\n -Continue to follow\\n # Communication:\\n - Brother has been with pt, although, live in boyfriend of 10 is\\n her HCP. Boyfriend will hopefully visit pt today\\n ICU Care\\n Nutrition: tube feed with free water when able\\n Glycemic Control: Regular insulin sliding scale\\n DVT: Theraputic Heparin gtt\\n Stress ulcer: H2 blocker\\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\\n Communication: ICU consent signed, (brother) \\n (boyfriend/POA) \\n Code status: Full code\\n Disposition: ICU\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 10:55 PM 30 mL/hour\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 01:36 AM\\n Arterial Line - 03:00 AM\\n Multi Lumen - 11:30 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2167-09-30 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 635270,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 12\\n Ideal body weight: 61.2 None\\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: Unknown\\n Procedure location: Medical Center\\n Reason: Emergent (1st time); Comments: Mechanical fall\\n Tube Type\\n ETT:\\n Position: 21 cm at teeth\\n Route: Oral\\n Type: Standard\\n Size: 7.5mm\\n Tracheostomy tube:\\n Type:\\n Manufacturer:\\n Size:\\n PMV:\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: cmH2O\\n Cuff volume: mL /\\n Airway problems:\\n Comments:\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Diminished\\n Comments:\\n Secretions\\n Sputum color / consistency: Yellow / Thick\\n Sputum source/amount: Suctioned / Moderate\\n Comments: Bronchoscopic procedure done today,BAL collected.\\n Ventilation Assessment\\n Level of breathing assistance:\\n Visual assessment of breathing pattern:\\n Assessment of breathing comfort:\\n Non-invasive ventilation assessment:\\n Invasive ventilation assessment:\\n Trigger work assessment:\\n Dysynchrony assessment:\\n Comments: 55 yr old female transfered from Medical Center to\\n intubated post mechanical fall. Patient now @ for\\n evaluation of tracheomalacia.It has been very difficult to wean her off\\n mechanical ventilation.Easily desaturated and agitated with the lesser\\n interaction.Very PEEP sensitive , but was able to decrease level of\\n PEEP down to 8 cmH20 today.Plan to trach and PEG in AM if PEEP level\\n remains bellow 10cmH20.Last ABG acceptable with hypoxemia;hypernatremic\\n ? renal insufficiency free water given. Bronchoscopic procedure\\n performed by MD today,sample collected,sent to lab for culture.\\n Plan\\n Next 24-48 hours:\\n Reason for continuing current ventilatory support:\\n Respiratory Care Shift Procedures\\n Transports:\\n Destination (R/T)\\n Time\\n Complications\\n Comments\\n Bedside Procedures:\\n Comments:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-04 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 635714,\n \"text\": \"55 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\\n Now with prolonged hospital course c/b by PNA with high PEEP\\n requirement, anxiety, RUE DVT on heparin qtt.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Rec\\nd pt on Vent settings AC 55%/18 X 400/+10 with no overbreathing of\\n set RR. O2 sat 92-98%. Lung snds clear, diminished in bases. Pt sxn\\n for small-moderate amts thick white secretions. Trach site with small\\n amt serosang drainage.\\n Action:\\n Cont same vent settings\\n Response:\\n Pt doesn\\nt over breath on the vent and never desat.Kept same Vent\\n settings overnight.\\n Plan:\\n Monitor sats,resp and titrate Vent as she tolerats.\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Pt rec\\nd with Heparin qtt 1900units/hr.\\n Action:\\n PTT drawn at 2300.RUE elevated with pillow and no BP or blood drawn\\n from that arm.\\n Response:\\n PTT @ 2300 was 107, Decreased Heparin gtt 1700 u/hr as per sliding\\n scale. Next PTT due at 0600. .\\n Plan:\\n Cont monitor PTT,titrate accordingly, next PTT due at 0600.\\n Alteration in Nutrition\\n Assessment:\\n Received pt on TF 10cc/hr.Abd soft w/+ BS.\\n Action:\\n Pt tolerated TF with minimal residuals as well as free water bolus\\n Q4H.Received scheduled Colace\\n Response:\\n TF ^ as tolerated, currently at 30cc/hr.No BM noted this shift.HCt 24.6\\n (25.8)\\n Plan:\\n Cont to monitor TF residuals, hold if more than 100cc\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt w/ periods of agitation and sleeping at other times, while she\\n aweake follow commands intermittently.\\n Action:\\n Cont on fent 100 mics ,Versed 2mg/hr and requires frequent boluses .\\n Cont diazepam 10 mg PO Q6H. Fent ^ 125 mics/hr,Versed 3mg/hr.\\n Response:\\n HR ranging from SB in the 40\\ns when asleep to the 120-140\\ns when\\n agitated, b/p ranging from 90\\ns/40\\ns when asleep to 140-170\\ns/ 70\\n when agitated. When pt awake appropriate and following commands HR\\n 80\\ns-100\\ns and b/p 100\\ns-120\\ns/ 60-70\\n Plan:\\n Titrate sedation as needed\\n\"\n },\n {\n \"category\": \"Social Work\",\n \"chartdate\": \"2167-09-21 00:00:00.000\",\n \"description\": \"Social Work Progress Note\",\n \"row_id\": 634274,\n \"text\": \"Social Work:\\n Received referral re pt/family coping and questions re HCP for this 55\\n y.o. pt admitted with dx of tracheobroncheal malacia. Reviewed\\n chart and discussed with RN. Spoke with pt\\ns brother, (c:\\n ), by phone. He asks questions re who pt\\ns legal NOK would\\n be and who should be involved in decision making re healthcare issues\\n given that pt also has a live-in boyfriend of 10 years in . He\\n mentions his understanding of a Companion Law in ME where a domestic\\n partner might have automatic rights to decision-making responsibilities\\n in the event that pt cannot make decisions for herself. SW discussed\\n with attorney on call who will do some research into this question. In\\n the meantime, assured brother that both he and pt\\ns bf will be\\n consulted re any healthcare decisions while pt is intubated and\\n sedated. Brother is satisfied with this and states he does not\\n anticipate any conflicts. He is visiting from and bf is\\n reportedly on his way in from ME.\\n SW will continue to follow for pt/family support as needed. Brother\\n seems to be coping well at this time. Please page PRN.\\n , LCSW, #\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-09-22 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 634330,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n -Neurosurg: ok to transport. Will decide on anticoagulation in AM\\n -Central line placed\\n -NGT to suction\\n -Bowel regimen\\n -Respiratory attempted to place esophageal ballon in order to measure\\n intrathoracic pressure, unsuccessful\\n -Desaturation around 23:00 to low 80s on 400/22/15/0.9 following turn.\\n Recruitment maneuver (PEEP to 30) done x2 with good effect, Sat came up\\n to 100%. PEEP left at 17\\n -Transfused 1 un pRBC\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Levofloxacin - 10:00 AM\\n Aztreonam - 02:00 PM\\n Vancomycin - 12:00 AM\\n Metronidazole - 12:00 AM\\n Infusions:\\n Norepinephrine - 0.02 mcg/Kg/min\\n Fentanyl - 200 mcg/hour\\n Other ICU medications:\\n Ranitidine (Prophylaxis) - 08:00 AM\\n Midazolam (Versed) - 02:20 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:27 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.9\\nC (100.3\\n Tcurrent: 37.6\\nC (99.6\\n HR: 73 (64 - 96) bpm\\n BP: 119/48(69) {85/39(55) - 142/67(91)} mmHg\\n RR: 22 (11 - 22) insp/min\\n SpO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 94.2 kg (admission): 94.2 kg\\n Height: 67 Inch\\n CVP: 20 (11 - 21)mmHg\\n Bladder pressure: 14 (14 - 18) mmHg\\n Total In:\\n 3,482 mL\\n 465 mL\\n PO:\\n TF:\\n IVF:\\n 2,845 mL\\n 465 mL\\n Blood products:\\n 277 mL\\n Total out:\\n 580 mL\\n 65 mL\\n Urine:\\n 580 mL\\n 65 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 2,902 mL\\n 400 mL\\n Respiratory support\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 400 (400 - 500) mL\\n RR (Set): 22\\n RR (Spontaneous): 0\\n PEEP: 17 cmH2O\\n FiO2: 80%\\n PIP: 33 cmH2O\\n Plateau: 30 cmH2O\\n Compliance: 30.8 cmH2O/mL\\n SpO2: 98%\\n ABG: 7.38/41/86./24/0\\n Ve: 9.1 L/min\\n PaO2 / FiO2: 109\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 376 K/uL\\n 9.0 g/dL\\n 120 mg/dL\\n 0.6 mg/dL\\n 24 mEq/L\\n 3.7 mEq/L\\n 4 mg/dL\\n 108 mEq/L\\n 141 mEq/L\\n 28.1 %\\n 8.4 K/uL\\n [image002.jpg]\\n ALT 24 PT 18.7\\n AST 16 PTT 25.4\\n AP 117 INR 1.7\\n Tbili 0.7\\n Alb 2.4\\n 08:03 PM\\n 11:00 PM\\n 03:01 AM\\n 03:13 AM\\n 12:05 PM\\n 06:08 PM\\n 06:11 PM\\n 07:53 PM\\n 02:02 AM\\n 03:59 AM\\n WBC\\n 7.6\\n 6.4\\n 8.4\\n Hct\\n 24.1\\n 24.1\\n 29.0\\n 28.1\\n Plt\\n \\n Cr\\n 0.6\\n 0.6\\n 0.6\\n TCO2\\n 33\\n 30\\n 29\\n 29\\n 25\\n 25\\n Glucose\\n 127\\n 129\\n 120\\n Differential-Neuts:80.8 %, Lymph:12.0 %, Mono:3.5 %, Eos:3.3 %\\n Ca++:8.2 mg/dL, Mg++:2.2 mg/dL, PO4:3.1 mg/dL, ion Ca++ () 1.16\\n Cortisol:\\n : 2:15am 24.2 Midnight 2.7\\n : 3am 4.5\\n Micro: neg or NGTD if not mentioned\\n : blood, \\n : urine, sputum-OP flora\\n : BAL, - coag neg staph, lactobacillus, cath tip, sputum- OP\\n flora, rare GNR, blood\\n U/a:\\n Color\\n Amber\\n Appear\\n Clear\\n SpecGr\\n 1.015\\n pH\\n 5.5\\n Urobil\\n 2\\n Bili\\n Mod\\n Leuk\\n Tr\\n Bld\\n Tr\\n Nitr\\n Pos\\n Prot\\n 100\\n Glu\\n Neg\\n Ket\\n 40\\n RBC\\n 0-2\\n WBC\\n 0-2\\n Bact\\n Few\\n Yeast\\n None\\n Epi\\n 0-2\\n Imaging:\\n Echo\\n post recruitment CXR showed deep sulcus but no pnumothorax per rads.\\n CT: Prelim Read\\n Right lower lobe consolidation, and superimposed atelectasis/lower lobe\\n collapse, and effusions. Acute T8 compression deformity, with no\\n posterior\\n retropulsion of fracture fragments. No associated hematoma.\\n Assessment and Plan\\n comm with fam, vanc dosing\\n 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture\\n # Respiratory failure: initial etiology unclear, likely multifactorial\\n including bronchspasm, hypoventilation from narcotics, potential\\n aspiration, infection. By report, had a neg evaluation for PE at OSH,\\n however, unable to open disc to confirm. Concern for VAP.\\n - Failed yesterday\\ns NIF; score was -15\\n - Increased FiO2 overnight. Had increased pCO2 which resolved with\\n increasing RR\\n - IP stopped by but will complete official consult today; suggested\\n repeating CT scan\\n - Need to contact Medical re previous CT scan. Can attempt to\\n resend disc. Otherwise, will most likely benefit from repeat CT to\\n look for acute pulm process such as PE or PNA.\\n # Fever: Likely due to combination of infection and DVT. Cultures\\n sent. Will treat with empiric antibiotics. Tylenol PRN for fever.\\n - Known RUE DVT\\n - Infectious etiologies include VAP, asp PNA, line infections. Removed\\n PICC yesterday and cultured tip. Mini-BAL- gram stain neg. Sputum\\n grew GPC in pairs and GPR. Flagyl, aztreonam, vancomycin, levofloxacin\\n for coverage of gram positives, gram negatives, anaerobes, MRSA. Urine\\n and blood cultures NGTD\\n - f/u blood, urine, and sputum cultures.\\n - Concern for abd cause; KUB unrevealing. High residuals. require\\n further imaging\\n # Transient hypotension: Has been somewhat fluid responsive; UOP \\n ccs/hr. Diff dx includes hypovolemia, sepsis, cardiogenic.\\n - Sepsis most likely given fever.\\n - HCT decreasing; ? stable at 24-25\\n - Unable to place central line despite multiple attempts. First tired\\n left IJ RUE DVT. 2^nd attempt in left IJ. Can place femoral if pt\\n requires more active repletion\\n - Consider another attempt at a line.\\n # Oliguria:\\n -BUN and Cr as well as lactate reassuring.\\n -Increased bladder pressures this am- 20. Further imaging may be\\n helpful\\n # RUE DVT: Have held on starting treatment in light of need for central\\n access. Can start therapeutic heparin vs Lovenox with bridge to\\n coumadin.\\n -Can consider rescanning for PE. High risk for PE given UE DVT.\\n # Abd distention:\\n -KUB unrevealing\\n -High residuals\\n - benefit from further imaging; if unstable consider ultrasound,\\n however, if pt can tolerate it, a CT scan might be more helpful. Can\\n also scan chest and pelvis.\\n # Anemia: On admission to Medical Center, Hct was ~40, now down\\n to 30 and then 25 w/o sign of active GI bleed or other source of blood\\n loss. be related to fluid administration, phlebotomy, anemia of\\n inflammation, active bleed still considered in differential.\\n - trend Hct\\n - guaiac stools\\n - S/p failed attempts at line placement; watch for neck hematomas\\n - INR elev at 1.5. ? may be related to poor nutrition as albumin is\\n 2.3\\n # Spine fracture: neurologically intact distal to the lesion. prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - Need to talk to neurosurg to see if pt can tolerate a CT scan as well\\n as the risks of anticoag for DVT\\n - monitor distal neurologic function\\n - cto brace x3 months unless supine in bed\\n - consult neurosurgery for further recs\\n # Hypernatremia: correcting with g tube free flush and D5W\\n -Holding on g tube feeds at present due to high residuals\\n -Replete lytes as necessary\\n # Communication:\\n SW discussed with attorney on call who will do some research into this\\n question. In the meantime, assured brother that both he and pt\\ns bf\\n will be consulted re any healthcare decisions while pt is intubated and\\n sedated. Brother is satisfied with this and states he does not\\n anticipate any conflicts. He is visiting from and bf is\\n reportedly on his way in from ME.\\n ICU Care\\n Nutrition: tube feed with free water\\n Glycemic Control: Regular insulin sliding scale\\n DVT: SQ UF Heparin\\n Stress ulcer: H2 blocker\\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\\n Communication: ICU consent signed, (brother) \\n (boyfriend/POA) \\n Code status: Full code\\n Disposition: ICU\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 01:36 AM\\n 22 Gauge - 02:00 PM\\n Arterial Line - 03:00 AM\\n Multi Lumen - 11:30 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-09-24 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 634493,\n \"text\": \"55 yr old woman admitted from OSH after she fell down the stairs. Pt\\n came to us with ? PNA from VAP. Full code, Allergies: PCN,\\n tetracycline, Sulfa. PMH: ETOH, smoker, Gerd, Hip replacement.\\n Alteration in Nutrition\\n Assessment:\\n Tube feeds at 20ml/hr. Tube feed residual 20ml.\\n Action:\\n Kept TF at 20ml/hr and will cont to check residuals and try to increase\\n rate\\n Response:\\n No change\\n Plan:\\n Try to increase Tube feeds to goal rate.\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n RUE DVT, pt on heparin gtt at 1700units/hr.\\n Action:\\n Ptt was therapeutic x2, AM PTT\\n Response:\\n Plan:\\n Cont heparin gtt, check PTT adjust heparin gtt per scale.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Moderate thick white in-line secretions, copious clear oral secretions,\\n clear/diminished lung sounds. Esophageal balloon in place.\\n Action:\\n Lots of suctioning through the night, decreased FiO2 from 50% to 40%,\\n decreased Peep from 23 to 21\\n Response:\\n ABG WNL\\n Plan:\\n Cont to try to wean vent settings as tolerated, cont monitoring ABG\\n Hypotension (not Shock)\\n Assessment:\\n SBP 90-110\\ns MAP 64-66 Goal MAP >65 Levophed gtt @ 0.020 mcg/kg/min.\\n Action:\\n Trying to wean levophed gtt off\\n Response:\\n Plan:\\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\\n Assessment:\\n T-max 101.0\\n Action:\\n Sent blood, urine, and sputum cultures, treated with tylenol\\n Response:\\n Temp decreased\\n Plan:\\n Follow up on cultures\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-09-24 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 634494,\n \"text\": \"55 yr old woman admitted from OSH after she fell down the stairs. Pt\\n came to us with ? PNA from VAP. Full code, Allergies: PCN,\\n tetracycline, Sulfa. PMH: ETOH, smoker, Gerd, Hip replacement.\\n Alteration in Nutrition\\n Assessment:\\n Tube feeds at 20ml/hr. Tube feed residual 20ml.\\n Action:\\n Kept TF at 20ml/hr and will cont to check residuals and try to increase\\n rate\\n Response:\\n No change\\n Plan:\\n Try to increase Tube feeds to goal rate.\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n RUE DVT, pt on heparin gtt at 1700units/hr.\\n Action:\\n Ptt was therapeutic x2, AM PTT\\n Response:\\n Plan:\\n Cont heparin gtt, check PTT adjust heparin gtt per scale.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Moderate thick white in-line secretions, copious clear oral secretions,\\n clear/diminished lung sounds. Esophageal balloon in place.\\n Action:\\n Lots of suctioning through the night, decreased FiO2 from 50% to 40%,\\n decreased Peep from 23 to 21\\n Response:\\n ABG WNL\\n Plan:\\n Cont to try to wean vent settings as tolerated, cont monitoring ABG\\n Hypotension (not Shock)\\n Assessment:\\n SBP 90-110\\ns MAP 62-66 Goal MAP >65 Levophed gtt @ 0.020 mcg/kg/min.\\n Action:\\n Trying to wean levophed gtt off\\n Response:\\n Plan:\\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\\n Assessment:\\n T-max 101.0\\n Action:\\n Sent blood, urine, and sputum cultures, treated with tylenol\\n Response:\\n Temp decreased\\n Plan:\\n Follow up on cultures\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-09-25 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 634718,\n \"text\": \"Events: PT found on CXR ETT 5cm too high- bronched and repositioning,\\n sample sent- tolerated w/ w/ mod amt sedation. Sadation weaned w/\\n boluses for agitation. No IVF bolus, cont off Levo gtt. Resting post\\n bronch w/ plan to wean PEEP as tolerated.\\n Bradycardia\\n Assessment:\\n When sedated pt sinus bradycardic 49-50\\ns, BP remaining stable.\\n Action:\\n Sedation monitored weaned w/ blousing PRN\\n Response:\\n Cont bradycardia when sedated\\n Plan:\\n Cont monitoring HS stability, sedation as tolerated- MS labile from\\n awake and pulling at tube/lines/moving in bed to sedation w/ able to\\n wake up to voice\\n Alteration in Nutrition\\n Assessment:\\n TF residuals 5-70cc, cont hypoactive BS\\n Action:\\n Inc to goal TF- replete w/ fiber @ 60cc/hr\\n Response:\\n Tolerating @ this time\\n Plan:\\n Monitor residuals, bowel sounds, cont @ goal 60cc/hr, monitor stool\\n output\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Hep gtt infusing @ 1700 units/hr, no s/s bleeding\\n Action:\\n Cont Hep gtt, check PTT w/ AM labs\\n Response:\\n Plan:\\n Cont Hep gtt per order, check PTT w/ AM labs and adjust per scale,\\n monitor s/s bleeding\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n LS diminished/rhonchi, minimal thin clear secretions, desat to 92%\\n while on R side,\\n Action:\\n Cont pulm toilet as tolerated, turning side-middle side Q2hrs, bronch,\\n Response:\\n Sat > 95% post repositioning,\\n Plan:\\n Cont pulm toilet, wean from vent as tolerated\\n Hypotension (not Shock)\\n Assessment:\\n A line positional, intermittently correlating W/ NBP w/ intermittent\\n dampened waveform and over dampened, able to draw ABG, BP labile w/\\n sedation Map >65 throughout day, CVP 15-19\\n Action:\\n A Line not re-sited, positioning art line, correlating NBP and ABP\\n Response:\\n MAP >65 throughout shift\\n Plan:\\n Cont monitor, cont IV steroids, CVP monitoring w/ UOP for additional\\n fluid bolus\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2167-09-28 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 634998,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 10\\n Ideal body weight: 61.2 None\\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: Unknown\\n Procedure location:\\n Reason:\\n Tube Type\\n ETT:\\n Position: cm at teeth\\n Route:\\n Type: Standard\\n Size: 7.5mm\\n Tracheostomy tube:\\n Type:\\n Manufacturer:\\n Size:\\n PMV:\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: cmH2O\\n Cuff volume: mL /\\n Airway problems:\\n Comments:\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Rhonchi\\n LUL Lung Sounds: Rhonchi\\n LLL Lung Sounds: Diminished\\n Comments:\\n Secretions\\n Sputum color / consistency: Tan / Thick\\n Sputum source/amount: Suctioned / Small\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance:\\n Visual assessment of breathing pattern:\\n Assessment of breathing comfort:\\n Non-invasive ventilation assessment:\\n Invasive ventilation assessment:\\n Trigger work assessment:\\n Dysynchrony assessment:\\n Comments:\\n Plan\\n Next 24-48 hours: Decreasing PEEP as talerated with intent to possible\\n preform tracheostomy within the next day or two.\\n Reason for continuing current ventilatory support:\\n Respiratory Care Shift Procedures\\n Transports:\\n Destination (R/T)\\n Time\\n Complications\\n Comments\\n Bedside Procedures:\\n Comments: patient remains on ventilatory support with all settings and\\n changes documented on flow sheet. PEEP decreased to 10cm with plan to\\n perform tracheostomy within the next day or two. Patient appears to be\\n agitated but talerating PEEP change. MDI\\ns administered as ordered.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-09-29 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 635133,\n \"text\": \"55yrold lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n consertively with pain meds and back brace. Developed resp distress\\n requiring intubation on ct neg for PE cxr showed pna pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia /\\n Hypotension (not Shock)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-03 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 635658,\n \"text\": \"55 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\\n Now with prolonged hospital course c/b by PNA with high PEEP\\n requirement, anxiety, RUE DVT on heparin qtt.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Rec\\nd pt on Vent settings AC 60%/18 X 400/+10 with no overbreathing of\\n set RR. O2 sat 92-98%. Lung snds clear, diminished in bases. Pt sxn\\n for small amts thick white secretions. Trach site with small amt\\n serosang drainage.\\n Action:\\n FiO2 \\nd to 55%.\\n Response:\\n ABG to follow.\\n Plan:\\n Cont to gently wean from vent.\\n Edema, peripheral\\n Assessment:\\n Pt with general edema. LOS fluid balance +approx 13 liters. Lasix\\n stopped as PICC line clogged.\\n Action:\\n TPA used to clear PICC line. Lasix restarted @ 2mg/hr.\\n Response:\\n By 1330 24hr fluid balance\\n 2liters. Lasix qtt stopped @ 1330, but pt\\n cont to autodiurese. Pt presently\\n 3 liters since MN. Lytes sent @\\n 1630.\\n Plan:\\n Cont to monitor urine output, restarting Lasix if necessary to maintain\\n goal -1-2liters/day. Monitor lytes.\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Pt rec\\nd with Heparin qtt off post trach/PEG yesterday.\\n Action:\\n Heparin restarted @ 1100 @ previous rate 1700units/hr.\\n Response:\\n PTT @ 1630 58.5. Heparin inc\\nd to 1900units/hr per sliding scale @\\n 1715.\\n Plan:\\n Repeat PTT @ 2300.\\n Alteration in Nutrition\\n Assessment:\\n Rec\\nd pt NPO post OR yesterday. Abd obese/distended with + BS. No BM\\n today.\\n Action:\\n Restarted TF Replete with fiber @ 1000 per surgical team @ 10ml/hr, as\\n well as FWB of 250ml Q4hrs for elevated Na.\\n Response:\\n Residual @ 1600 140ml of TF/water/yellow bilious. TF stopped and FWB\\n held.\\n Plan:\\n Resume TF @ 1830. Cont to monitor residuals, holding TF if >100ml.\\n\"\n },\n {\n \"category\": \"Nutrition\",\n \"chartdate\": \"2167-09-22 00:00:00.000\",\n \"description\": \"Clinical Nutrition Note\",\n \"row_id\": 634346,\n \"text\": \"Subjective\\n Pt intubated /sedated\\n Objective\\n Pertinent medications: noted\\n Labs:\\n Value\\n Date\\n Glucose\\n 120 mg/dL\\n 03:59 AM\\n Glucose Finger Stick\\n 124\\n 10:00 AM\\n FSBG\\n 111, 111, 145, 123\\n \\n BUN\\n 4 mg/dL\\n 03:59 AM\\n Creatinine\\n 0.6 mg/dL\\n 03:59 AM\\n Sodium\\n 141 mEq/L\\n 03:59 AM\\n Potassium\\n 3.7 mEq/L\\n 03:59 AM\\n Chloride\\n 108 mEq/L\\n 03:59 AM\\n Albumin\\n 2.4 g/dL\\n 03:59 AM\\n Calcium non-ionized\\n 8.2 mg/dL\\n 03:59 AM\\n Phosphorus\\n 3.1 mg/dL\\n 03:59 AM\\n Ionized Calcium\\n 1.16 mmol/L\\n 12:05 PM\\n Magnesium\\n 2.2 mg/dL\\n 03:59 AM\\n Corrented Ca\\n 9.48\\n Current diet order / nutrition support: replete c/ Fiber @60mL/hr (1440\\n kcals 89 gr aa)- currently on hold\\n GI: Abd: softly dist/absent bs/no BM\\n Assessment of Nutritional Status\\n Specifics:\\n TF\\ns trialed. Held high residuals and OGT placed to suction. OGT\\n is currently clamped.\\n Medical Nutrition Therapy Plan - Recommend the Following\\n Multivitamin / Mineral supplement: via nutrition support\\n Consider reglan +/- increase bowel regimen\\n Resume TF's as medically feasible, if unable in next 2-3 days, will\\n need to consider PN to prevent nutritional decline\\n BG/lyte management\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2167-09-25 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 634642,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 7\\n Ideal body weight: 61.2 None\\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: Unknown\\n Tube Type\\n ETT:\\n Position: 18 cm at teeth\\n Route: Oral\\n Type: Standard\\n Size: 7.5mm\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Diminished\\n Comments:\\n Secretions\\n Sputum color / consistency: White / Thick\\n Sputum source/amount: Suctioned / Small\\n Comments:\\n Ventilation Assessment\\n Invasive ventilation assessment:\\n Trigger work assessment: Triggering synchronously\\n Plan\\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\\n tolerated\\n Reason for continuing current ventilatory support: Underlying illness\\n not resolved\\n Comments: Pt. remains on A/C overnoc, no vent changes this shift.\\n Maintain current vent settings.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-09-25 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 634722,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n New A-line placed (left), good tracing but positional\\n Vanco restarted\\n Atrial EKG->p-waves\\n Multiple IVF boluses for MAPs < 65. Did not restart pressors\\n Brother came, confirmed history\\n Eye drops\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Metronidazole - 08:00 AM\\n Levofloxacin - 10:00 AM\\n Vancomycin - 08:09 PM\\n Aztreonam - 10:00 PM\\n Infusions:\\n Midazolam (Versed) - 4 mg/hour\\n Heparin Sodium - 1,700 units/hour\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 04:29 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.7\\nC (98.1\\n Tcurrent: 36.7\\nC (98.1\\n HR: 56 (45 - 63) bpm\\n BP: 103/54(72) {83/44(59) - 142/105(109)} mmHg\\n RR: 22 (0 - 22) insp/min\\n SpO2: 99%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 101 kg (admission): 94.2 kg\\n Height: 67 Inch\\n CVP: 12 (11 - 14)mmHg\\n Total In:\\n 4,750 mL\\n 868 mL\\n PO:\\n TF:\\n 773 mL\\n 223 mL\\n IVF:\\n 3,827 mL\\n 645 mL\\n Blood products:\\n Total out:\\n 2,365 mL\\n 60 mL\\n Urine:\\n 2,325 mL\\n 60 mL\\n NG:\\n 40 mL\\n Stool:\\n Drains:\\n Balance:\\n 2,385 mL\\n 808 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 400 (400 - 400) mL\\n RR (Set): 22\\n RR (Spontaneous): 0\\n PEEP: 21 cmH2O\\n FiO2: 40%\\n RSBI Deferred: PEEP > 10\\n PIP: 34 cmH2O\\n Plateau: 29 cmH2O\\n Compliance: 50 cmH2O/mL\\n SpO2: 99%\\n ABG: 7.46/38/96./23/2\\n Ve: 8.6 L/min\\n PaO2 / FiO2: 242\\n Physical Examination\\n General Appearance: Obese\\n Eyes / Conjunctiva: PERRL, subconjunctival hematoma on left\\n Cardiovascular: brady, regular, no MRG, nL S1, S2\\n Respiratory / Chest: CTA b/l\\n Abdominal: Soft, Non-tender, Obese, +BS\\n Extremities: Right: 1+, Left: 1+\\n Skin: Warm\\n Neurologic: Responds to: Verbal stimuli, Movement: Purposeful, Tone:\\n Normal\\n Labs / Radiology\\n 326 K/uL\\n 8.9 g/dL\\n 153 mg/dL\\n 0.6 mg/dL\\n 23 mEq/L\\n 4.2 mEq/L\\n 6 mg/dL\\n 113 mEq/L\\n 141 mEq/L\\n 28.6 %\\n 8.9 K/uL\\n [image002.jpg]\\n 09:14 PM\\n 01:04 AM\\n 05:54 AM\\n 06:11 AM\\n 11:07 PM\\n 03:51 AM\\n 06:17 AM\\n 07:00 AM\\n 08:18 AM\\n 04:18 PM\\n WBC\\n 8.1\\n 8.9\\n Hct\\n 28.0\\n 28.6\\n Plt\\n 358\\n 326\\n Cr\\n 0.7\\n 0.7\\n 0.6\\n TropT\\n <0.01\\n <0.01\\n TCO2\\n 28\\n 28\\n 26\\n 26\\n 21\\n 28\\n Glucose\\n 126\\n 151\\n 153\\n Other labs: PT / PTT / INR:24.3/68.6/2.4, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\\n Amylase / Lipase:, Differential-Neuts:82.5 %, Lymph:11.6 %,\\n Mono:3.3 %, Eos:2.2 %, Lactic Acid:0.7 mmol/L, Albumin:2.4 g/dL,\\n LDH:204 IU/L, Ca++:7.8 mg/dL, Mg++:2.1 mg/dL, PO4:2.6 mg/dL\\n Culture data: Sputum with Klebsiella Oxytoca\\n Assessment and Plan\\n 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture with respiratory failure\\n and difficulty weaning from vent.\\n # Respiratory failure: Over the evening yesterday, were able to\\n decrease FiO2 and PEEP. Clinical and imaging suggestive of ARDS.\\n Initial precipitating factors were thought to be: sedation, hypovent\\n obesity, orthotic brace. Now thought to have VAP.\\n - Placed esophageal balloon on which will help guide PEEP settings.\\n - Given small size of effusion and high PEEP (risk of pneumothorax),\\n will not attempt to tap\\n - Appreciate IP recs. Will consider tracheomalacia workup when more\\n stable.\\n - Approaching 2-week intubation point (intubated ); Trach?\\n # VAP/ID: Re-spiked fever overnight. Stopped vanc yesterday, , as\\n treating for GNR infection. Current GS shows GPC\\n - Follow cultures\\n - Restart Vanc.\\n - Continue aztreonam, levofloxicin for 8 days pending speciation (at\\n that time can increase to 15 days if necessary)\\n - Also, stopped flagyl because had one neg c. diff toxin and CT did not\\n show evidence of colitis\\n - Will replace A-line today.\\n # EKG changes: Sinus bradycardia. Very low voltages and no change in\\n QRS morphology. P-waves are visible and prolonged PR interval is old.\\n CK and troponins flat. Likely related to increased vagal tone possibly\\n related to steroid replacement.\\n - Will avoid excessive alpha-agonism\\n - Continue to monitor\\n - could consider atrial EKG\\n .\\n # Hypotension: now off levophed, with good urine output. Hypovolemia\\n is possibly a factor- responded to a transfusion; HCT had been\\n dropping. However, SVV with Vigileo was 7, making her CO less likely\\n to respond to fluids. Held on giving any boluses overnight. Today CVP\\n is low given PEEP. Sepsis also a consideration\\n - continue on broad spectrum abs\\n - replete fluids.\\n - Restart pressors as needed. Consider dopamine over levophed given\\n bradycardia.\\n - Central line in place.\\n # Urine output: Previously oliguric, now with high urine output.\\n Concern for autodiuresis but BUN and Cr reassuring.\\n -Continue to monitor\\n # RUE DVT: Started on heparin gtt on .\\n -Therapeutic in one day; may be related to poor nutritional status.\\n Will continue to closely monitor\\n # Adrenal Insufficency:\\n -Random cortisol was approx 3 when it should have been maximally\\n stimulated.\\n -Started hydrocortisone and florinef. ? switch to methylpred\\n # Anemia:\\n - Trend HCT\\n - Gave 1 un pRBC with good results\\n - INR rising, now 2.0, may be nutritional\\n # Spine fracture: neurologically intact distal to the lesion. prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - CT of C, L spine when stable. Currently, unlikely to change\\n management and high risk for complications with transport.\\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\\n is low. Brace for OOB. Ok for anticoag per note.\\n # Hypernatremia, resolved: correcting with g tube free flush and D5W\\n -Continue to follow\\n # Communication:\\n - Brother has been with pt, although, live in boyfriend of 10 is\\n her HCP. Boyfriend will hopefully visit pt today\\n ICU Care\\n Nutrition: tube feed with free water when able\\n Glycemic Control: Regular insulin sliding scale\\n DVT: Theraputic Heparin gtt\\n Stress ulcer: H2 blocker\\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\\n Communication: ICU consent signed, (brother) \\n (boyfriend/POA) \\n Code status: Full code\\n Disposition: ICU\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 07:00 AM 50 mL/hour\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 11:30 AM\\n Arterial Line - 04:00 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-09-25 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 634723,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n New A-line placed (left), good tracing but positional\\n Vanco restarted\\n Atrial EKG->p-waves\\n Multiple IVF boluses for MAPs < 65. Did not restart pressors\\n Brother came, confirmed history\\n Eye drops\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Metronidazole - 08:00 AM\\n Levofloxacin - 10:00 AM\\n Vancomycin - 08:09 PM\\n Aztreonam - 10:00 PM\\n Infusions:\\n Midazolam (Versed) - 4 mg/hour\\n Heparin Sodium - 1,700 units/hour\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 04:29 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.7\\nC (98.1\\n Tcurrent: 36.7\\nC (98.1\\n HR: 56 (45 - 63) bpm\\n BP: 103/54(72) {83/44(59) - 142/105(109)} mmHg\\n RR: 22 (0 - 22) insp/min\\n SpO2: 99%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 101 kg (admission): 94.2 kg\\n Height: 67 Inch\\n CVP: 12 (11 - 14)mmHg\\n Total In:\\n 4,750 mL\\n 868 mL\\n PO:\\n TF:\\n 773 mL\\n 223 mL\\n IVF:\\n 3,827 mL\\n 645 mL\\n Blood products:\\n Total out:\\n 2,365 mL\\n 60 mL\\n Urine:\\n 2,325 mL\\n 60 mL\\n NG:\\n 40 mL\\n Stool:\\n Drains:\\n Balance:\\n 2,385 mL\\n 808 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 400 (400 - 400) mL\\n RR (Set): 22\\n RR (Spontaneous): 0\\n PEEP: 21 cmH2O\\n FiO2: 40%\\n RSBI Deferred: PEEP > 10\\n PIP: 34 cmH2O\\n Plateau: 29 cmH2O\\n Compliance: 50 cmH2O/mL\\n SpO2: 99%\\n ABG: 7.46/38/96./23/2\\n Ve: 8.6 L/min\\n PaO2 / FiO2: 242\\n Physical Examination\\n General Appearance: Obese\\n Eyes / Conjunctiva: PERRL, subconjunctival hematoma on left\\n Cardiovascular: brady, regular, no MRG, nL S1, S2\\n Respiratory / Chest: CTA b/l\\n Abdominal: Soft, Non-tender, Obese, +BS\\n Extremities: Right: 1+, Left: 1+\\n Skin: Warm\\n Neurologic: Responds to: Verbal stimuli, Movement: Purposeful, Tone:\\n Normal\\n Labs / Radiology\\n 326 K/uL\\n 8.9 g/dL\\n 153 mg/dL\\n 0.6 mg/dL\\n 23 mEq/L\\n 4.2 mEq/L\\n 6 mg/dL\\n 113 mEq/L\\n 141 mEq/L\\n 28.6 %\\n 8.9 K/uL\\n [image002.jpg]\\n 09:14 PM\\n 01:04 AM\\n 05:54 AM\\n 06:11 AM\\n 11:07 PM\\n 03:51 AM\\n 06:17 AM\\n 07:00 AM\\n 08:18 AM\\n 04:18 PM\\n WBC\\n 8.1\\n 8.9\\n Hct\\n 28.0\\n 28.6\\n Plt\\n 358\\n 326\\n Cr\\n 0.7\\n 0.7\\n 0.6\\n TropT\\n <0.01\\n <0.01\\n TCO2\\n 28\\n 28\\n 26\\n 26\\n 21\\n 28\\n Glucose\\n 126\\n 151\\n 153\\n Other labs: PT / PTT / INR:24.3/68.6/2.4, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\\n Amylase / Lipase:, Differential-Neuts:82.5 %, Lymph:11.6 %,\\n Mono:3.3 %, Eos:2.2 %, Lactic Acid:0.7 mmol/L, Albumin:2.4 g/dL,\\n LDH:204 IU/L, Ca++:7.8 mg/dL, Mg++:2.1 mg/dL, PO4:2.6 mg/dL\\n Culture data: Sputum with Klebsiella Oxytoca\\n Assessment and Plan\\n 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture with respiratory failure\\n and difficulty weaning from vent.\\n 55-year-old woman with\\n Unclear location of ETT\\n Since only 18cm in holder, we will bronch to confirm correct\\n position since an inadvertent extubation might be fatal.\\n Respiratory failure\\n Oxygenation is improving\\n Wean PEEP as tolerated by hypoxemia\\n eventually need investigation for TBM\\n At present, her PEEP is too high to consider tracheostomy\\n but if we are able to wean it (and not able to extubate her) would\\n consider tracheostomy soon\\n Adrenal insufficiency\\n Based on very low random cortisol while in shock and\\n respiratory failure\\n On steroids, has come off and stayed off of pressors.\\n Eventually wean, but still getting fluid boluses\\n Bradycardia\\n Rhythm is sinus, confirmed by CVL-directed\\natrial\\n lead\\n Heart rate increases with stimulation, suggesting that this\\n is mostly vagal in etiology\\n Klebsiella VAP\\n Complete 8d course of levofloxacin\\n Discontinue aztreonam\\n If sputum culture remains negative (GPCs on G/S),\\n discontinue vancomycin tomorrow\\n Shock\\n now off of levophed\\n Intermittent fluid boluses\\n Treating adrenal insufficiency\\n Upper extremity DVT\\n Therapeutic heparin\\n Anemia\\n Follow\\n Possible tracheobronchomalacia (reason for transfer)\\n Incidental peri-appendiceal finding (will need eventual\\n follow-up)\\n Traumatic thoracic spinal fracture\\n Eventual MRI. Too high-risk at present. Brace when out of\\n bed.\\n # Respiratory failure currently with unclear ETT location: Intubated\\n on for resp decompensation. Likely VAP. Unlikely to have\\n tracheomalacia as initially transferred for.\\n - bronch for ETT location\\n - wean PEEP\\n # Pneumonia: Kleb oxytoca pneumonia and sputum with GPCs on gram stain.\\n Afebrile overnight. On levofloxacin, vancomycin, aztreonam. Resp\\n status seems to be improving.\\n - Follow cultures\\n - d/c aztreonam\\n - Continue levofloxacin for 8 days\\n # EKG changes: Sinus bradycardia. Very low voltages and no change in\\n QRS morphology. P-waves are visible and prolonged PR interval is old.\\n CK and troponins flat. Likely related to increased vagal tone possibly\\n related to steroid replacement. Atrial EKG with p-waves c/w sinus\\n bradycardia.\\n - Will avoid excessive alpha-agonism\\n - Continue to monitor\\n .\\n # Hypotension: now off levophed, with good urine output. Hypovolemia\\n is possibly a factor- responded to a transfusion; HCT had been\\n dropping. However, SVV with Vigileo was 7, making her CO less likely\\n to respond to fluids. Held on giving any boluses overnight. Today CVP\\n is low given PEEP. Sepsis also a consideration.\\n - continue abx as above (vanc and levofloxacin)\\n - replete fluids.\\n - Restart pressors as needed. Consider dopamine given bradycardia.\\n # RUE DVT: Started on heparin gtt on .\\n - closely monitor\\n # Adrenal Insufficency: Random cortisol was approx 3 when it should\\n have been maximally stimulated.\\n - hydrocortisone and florinef for 5 days\\n # Anemia: Stable.\\n - Trend HCT\\n # Spine fracture: Neurologically intact distal to the lesion. Prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - CT of C, L spine when stable. Currently, unlikely to change\\n management and high risk for complications with transport.\\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\\n is low. Brace for OOB. Ok for anticoag per note.\\n # Communication:\\n - Brother has been with pt, although, live in boyfriend of 10 is\\n her HCP.\\n ICU \\n Nutrition: tube feed with free water when able, INR rising likely \\n nutritional deficiencies\\n Glycemic Control: Regular insulin sliding scale\\n DVT: Theraputic Heparin gtt\\n Stress ulcer: H2 blocker\\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\\n Communication: ICU consent signed, (brother) \\n (boyfriend/POA) \\n Code status: Full code\\n Disposition: ICU\\n\"\n },\n {\n \"category\": \"Social Work\",\n \"chartdate\": \"2167-10-01 00:00:00.000\",\n \"description\": \"Social Work Progress Note\",\n \"row_id\": 635364,\n \"text\": \"Social Work:\\n Spoke by phone with pt\\ns boyfriend, (), to\\n offer support re pt\\ns hospitalization and to facilitate communication\\n with MICU team. He and pt have been living together in ME for the past\\n 12 years. He speaks of how it is difficult to come to to visit\\n pt because of the distance and the financial cost of taking the train.\\n SW offered a cab voucher between train and hospital, if this would\\n defray the cost and feel more manageable for him. He states he\\nll let\\n SW know if this would be helpful in the future. However, he also\\n speaks of his own health problems which have limited his ability to\\n travel this summer, and he describes feeling as if he is doing the best\\n he can to come in.\\n Mr. that even though he may not be able to come into\\n the hospital as much as he\\nd like, he still very much wants to stay\\n involved in pt\\ns care by communicating with team by phone. Discussed\\n how pt\\ns brother, as , has also been involved in communicating with\\n team and, per Intern, has been giving consent for certain procedures\\n when pt has been unable to speak for herself. Mr. confirms that\\n he is not aware of pt having signed a HCP form and he understands and\\n accepts that pt\\ns brother as been involved re questions of consent.\\n Discussed how it is important to Mr. that he, too, be consulted by\\n phone re any major decisions re direction of care.\\n SW discussed above with Intern and recommended she call Mr. today\\n to discuss direction of care issues.\\n Encouraged Mr. to contact SW as needed for further support and\\n provided contact info. continue to follow for ongoing support.\\n Please page PRN.\\n , LCSW, #\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2167-10-02 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 635521,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation:\\n Ideal body weight:\\n Ideal tidal volume:\\n Airway\\n Airway Placement Data\\n Known difficult intubation:\\n Procedure location:\\n Reason:\\n Tube Type\\n ETT:\\n Position:\\n Route:\\n Type:\\n Size:\\n Tracheostomy tube:\\n Type:\\n Manufacturer:\\n Size:\\n PMV:\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure:\\n Cuff volume:\\n Airway problems:\\n Comments:\\n Lung sounds\\n RLL Lung Sounds:\\n RUL Lung Sounds:\\n LUL Lung Sounds:\\n LLL Lung Sounds:\\n Comments:\\n Secretions\\n Sputum color / consistency:\\n Sputum source/amount:\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance:\\n Visual assessment of breathing pattern:\\n Assessment of breathing comfort:\\n Non-invasive ventilation assessment:\\n Invasive ventilation assessment:\\n Trigger work assessment:\\n Dysynchrony assessment:\\n Comments:\\n Plan\\n Next 24-48 hours:\\n Reason for continuing current ventilatory support:\\n Respiratory Care Shift Procedures\\n Transports:\\n Destination (R/T)\\n Time\\n Complications\\n Comments\\n Bedside Procedures:\\n Comments:\\n Specialized Gas Therapy\\n Nitric Oxide\\n PPM used: ppm\\n Indication:\\n Effect of therapy: []\\n Nitric Oxide trial:\\n Comments:\\n HeliOx:\\n Additional O[2] by cannula: L/min\\n Continuous nebulized bronchodilator:\\n Comments:\\n Recruitment Maneuvers Done\\n CPAP pressure used: cm H2O\\n Duration: sec\\n Times per shift:\\n Comments:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-03 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 635576,\n \"text\": \"55 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP now with prolonged\\n hospital course c/o by PNA anxiety,RUE DVD with high PEEP requirement\\n .\\n Pt has had an uneventful night. Plan to start heparin and TF this am.\\n Awaiting time. Wean sedation today as tol by pt.\\n Edema, peripheral\\n Assessment:\\n Pt has gen edema with gen pitting. Gen swelling has improved over the\\n last 24hrs after lasix gtt initiated.\\n Action:\\n Lasix gtt infusing with goal of negative 1-2 liters over 24hrs. Lasix\\n stopped at 5am access issues.\\n Response:\\n Pt is very sensitive to lasix, and is diuresing well while it is\\n infusing with stable BP. K level has been stable and no replaements\\n needed.\\n Plan:\\n Restart lasix once access available.\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Pt has a clot to Rt arm and has been on heparin gtt per protocol.\\n Heparin stopped yesterday trach and PEG placed.\\n Action:\\n Response:\\n Plan:\\n Heparin to be started today and ? time.\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt has been sedated throughout the night with plans to wean sedation\\n today. Pt has a HR in the 40-50\\ns while asleep with SBP 99-110. Pt has\\n a HR in the 70\\ns with a SBP 110-140\\ns while awake. Pt will open eyes to\\n voice and will follow most commands. While awake, pt is restless and\\n will try to sit up and pull on trach.\\n Action:\\n Emotional support given with short lived effect. Pt continues on\\n fentanyl and versed gtt for sedation and diazepam ATC.\\n Response:\\n Plan:\\n Plan to wean pt off sedation gtts today.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt was trached yesterday failure to wean of vent ? tracheal\\n malacia. Pt noted to be desatting while awake and while sedated to 85%.\\n LS clear to coarse to upper resp areas with diminished bases. Pt has\\n been sx\\nd for sml amounts of rusty blood tinged secretions.\\n Action:\\n CMV settings changed to 60% FiO2 and peep increased to 10 after episode\\n of low O2sat.\\n Response:\\n After vent changes, O2sat d and ABGs improved.\\n Plan:\\n Wean vent settings as pt tol.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-04 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 635706,\n \"text\": \"55 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\\n Now with prolonged hospital course c/b by PNA with high PEEP\\n requirement, anxiety, RUE DVT on heparin qtt.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Rec\\nd pt on Vent settings AC 55%/18 X 400/+10 with no overbreathing of\\n set RR. O2 sat 92-98%. Lung snds clear, diminished in bases. Pt sxn\\n for small-moderate amts thick white secretions. Trach site with small\\n amt serosang drainage.\\n Action:\\n Cont same vent settings\\n Response:\\n Pt doesn\\nt over breath on the vent and never desat.Kept same Vent\\n settings overnight.\\n Plan:\\n Monitor sats,resp and titrate Vent as she tolerats.\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Pt rec\\nd with Heparin qtt 1900units/hr.\\n Action:\\n PTT drawn at 2300.RUE elevated with pillow and no BP or blood drawn\\n from that arm.\\n Response:\\n PTT @ 2300 was 107, Decreased Heparin gtt 1700 u/hr as per sliding\\n scale. Next PTT due at 0600. .\\n Plan:\\n Cont monitor PTT,titrate accordingly, next PTT due at 0600.\\n Alteration in Nutrition\\n Assessment:\\n Received pt on TF 10cc/hr.Abd soft w/+ BS.\\n Action:\\n Pt tolerated TF with minimal residuals as well as free water bolus\\n Q4H.Received scheduled Colace\\n Response:\\n TF ^ as tolerated, currently at 30cc/hr.No BM noted this shift.HCt 24.6\\n (25.8)\\n Plan:\\n Cont to monitor TF residuals, hold if more than 100cc\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt w/ periods of agitation and sleeping at other times, while she\\n aweake follow commands intermittently.\\n Action:\\n Cont on fent 100 mics ,Versed 2mg/hr and requires frequent boluses .\\n Cont diazepam 10 mg PO Q6H. Fent ^ 125 mics/hr,Versed 3mg/hr.\\n Response:\\n HR ranging from SB in the 40\\ns when asleep to the 120-140\\ns when\\n agitated, b/p ranging from 90\\ns/40\\ns when asleep to 140-170\\ns/ 70\\n when agitated. When pt awake appropriate and following commands HR\\n 80\\ns-100\\ns and b/p 100\\ns-120\\ns/ 60-70\\n Plan:\\n Titrate sedation as needed\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-09-30 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 635177,\n \"text\": \"55 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP now with prolonged\\n hospital course c/o by PNA anxiety,RUE DVD with high PEEP requirement\\n .\\n Plan : Plan for trach and peg today or the next few days, if pt tol\\n peep of 10.\\n Hypernatremia (high sodium)\\n Assessment:\\n Na level elevated\\n Action:\\n H2O flushes increased to 250 cc q 4hrs.\\n Response:\\n Na level remains elevated this am at 146 (sl improved).\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt remains intubated on CMV settings, now at 60%/400x18/10. LS coarse\\n to upper resp area with diminished bases. Pt has been deep sx\\nd for\\n scant amounts of yellow secretions q 2hrs. Pt cont to have copious\\n amounts of clear oral secretions and in need of freq oral care. Pt\\n noted to have a decrease in O2sat, while she is on her Lt side, but it\\n has improved throughout the night.\\n Action:\\n Peep weaned to 10, and tol well by pt with good ABGs. Fio2 weaned to 50\\n %, but pt\\ns O2sat decreased to 88% right away.\\n Response:\\n LS clear to upper resp area after sx.\\n Plan:\\n Plan for trach and Peg today if p[t cont to tol peep of 10.\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt found at 8pm to 10pm to be awake, alert and following commands. Pt\\n was slight restless, but appropriate. 10pm, pt became very restless in\\n bed, trying to sit up and was reaching for ETT. Once reposition and\\n back rubs did not work, MD notified and haldol given and diazepam given\\n with only effect for one hr. When pt is awake and restless, her HR will\\n increase to 120-130\\ns (ST) and BP will increase to 120-130\\ns. When pt\\n was sleeping (after sedation), Hr will deacrease to 50\\ns with a SBP in\\n the 80\\ns. Fentanyl patch increased and diazepam changed to q6hrs, with\\n no effect.\\n Action:\\n 2:30am, versed gtt was initiated again with good effect. Pt more\\n relaxed and fell back to sleep with stable HR and BP.\\n Response:\\n Plan:\\n Continue to evaluate restlessness.\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Pt on heparin gtt protocol for DVT to Rt arm. No signs of bleeding\\n noted. Hct stable.\\n Action:\\n Response:\\n PTT drawn q 6hrs; and it has been therapeutic.\\n Plan:\\n Plan to check PTT now daily.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-05 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 635805,\n \"text\": \"55 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\\n Now with prolonged hospital course c/b by PNA with high PEEP\\n requirement, anxiety, RUE DVT on heparin qtt.\\n Edema, peripheral\\n Assessment:\\n Fluid balance for previous 24hrs decreased by 3 liters D/T diuresis.\\n Rec\\nd pt off of Lasix qtt. Urine output decreased to 45ml/hr @1000.\\n Action:\\n Lasix qtt restarted @ 2mg/hr to maintain urine output 1-2liters/day.\\n Response:\\n Fluid balance approx -50ml/hr, with 24hr fluid balance -650ml @ 1500.\\n However, SBP 78 when pt soundly sleeping/sedated. Lasix qtt stopped @\\n 1530.\\n Plan:\\n Restart Lasix qtt when BP stabilized.\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Rec\\nd pt on Heparin qtt @ 1500units/hr.\\n Action:\\n PTT 92.1 @ 1230.\\n Response:\\n Per goal PTT 60-100, Heparin rate unchanged.\\n Plan:\\n Repeat PTT @ 1830. Start po Coumadin tonight.\\n Altered mental status (not Delirium)\\n Assessment:\\n Rec\\nd pt on Versed @ 2mg/hr, Fentanyl @ 100mcg/hr, as well as Fentanyl\\n patches totaling 150mcg in place. Pt also rec\\ning Diazepam 10mg po\\n Q6hrs, in hope of weaning pt from IV sedation. Pt alternately appears\\n very sedated and very restless. When she appears alert, she intermit\\n responds to commands approp but not attempting to mouth words or nod to\\n communicate. Moving arms purposefully towards trach, so soft wrist\\n restraints remain in place. When very sedated @ 1530, SBP to 78 per\\n below.\\n Action:\\n Versed \\nd to 1mg/hr, Fentanyl \\nd to 75mcg/hr.\\n Response:\\n Pt restless/squirming in bed when she appears awake. Not responding to\\n verbal reassurance.\\n Plan:\\n Cont to attempt weaning from IV sedation. Cont to freq reorient pt,\\n emotional support.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Rec\\nd pt on vent settings AC 55%/18 X 400/+10, with no over-breathing\\n of rate by pt. O2 sat 95-99%. ABG 7.44/42/93. Lung snds clear but\\n diminished in lower lobes. Suctionned for mod-lg amts thick white\\n secretions.\\n Action:\\n Vent changed to CMV with PS 8/+10 on 55%.\\n Response:\\n Pt tolerated PS approx 3hrs, but after rec\\ning scheduled dose Diazepam\\n @ 1200 began having extended pauses apnea. She was then returned to AC\\n 55%/9 X 500/+10.\\n Plan:\\n Cont wean from vent with PS trials, as well as \\ning FiO2.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-09-26 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 634795,\n \"text\": \"Events:\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Impaired Skin Integrity\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Altered mental status (not Delirium)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-09-30 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 635254,\n \"text\": \"55 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP now with prolonged\\n hospital course c/o by PNA anxiety,RUE DVD with high PEEP requirement\\n .\\n Events: PEEP weaned to 8, tol well, restarted on lasix gtt, midazolam\\n weaned off, fentanyl decreased. ? trach and PEG in AM.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Rec\\nd pt on AC 400x18 50% +PEEP 10, 02 sat mid 90%\\ns, ABG this AM\\n 7.42/49/93\\n Action:\\n PEEP weaned to 8, thoracic surgery reconsulted r/t trach placement.\\n Response:\\n 02 sat dropped to 89-92% ABG on current settings 7.44/45/66 team is\\n aware.\\n Plan:\\n Cont on current vent settings as tol. Plan for trach placement in am.\\n Hypotension (not Shock)\\n Assessment:\\n Pt b/p when asleep 90\\ns-100\\ns/ 40\\ns-50\\ns. increases when pt is awake/\\n agitated. Pt rec\\nd on fentanyl gtt at 150mcg/hr and Midazolam 2mg/hr.\\n stim test from shows adrenal insuff.\\n Action:\\n Midazolam weaned off, fentanyl decreased, pt restarted on florinef and\\n hydrocortisone. Started on lasix gtt. Currently at 2mg/hr.\\n Response:\\n b/p stable in the 90\\ns-110\\ns/ 40\\ns-60\\ns. UOP 35-50ml/hr.\\n Plan:\\n Titrate lasix gtt and sedation as tol by b/p restart levophed if b/p\\n drops and remains low.\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Pt on heparin gtt at 1700 units/hr, PTT therapeutic x 2\\n Action:\\n Monitor heparin gtt\\n Response:\\n n/a\\n Plan:\\n Cont heparin gtt at current rate, recheck PTT in the am.\\n Alteration in Nutrition\\n Assessment:\\n TF currently at goal rate 60ml/hr tol well, serum Na 146 (down from\\n 147). Last BM \\n Action:\\n Cont free H20 boluses to decrease Na,\\n Response:\\n Plan:\\n Cont TF/ free H20 as tol, cont bowel regime.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-05 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 635890,\n \"text\": \"55 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\\n Now with prolonged hospital course c/b by PNA with high PEEP\\n requirement, anxiety, RUE DVT on heparin qtt.\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Pt cont on Heparin gtt @ 1500units/h. PTT in therapeutic range.\\n Coumadin po HS.\\n Action:\\n No further action taken.\\n Response:\\n Plan:\\n Daily PT/PTT levels-? Plan to transition off heparin and increase\\n coumadin dose.\\n Altered mental status (not Delirium)\\n Assessment:\\n PT alert and very agitated throughout shift- making several attempts to\\n pull at trach\\n.fell asleep briefly following afternoon valium dose-\\n Systolic dropped into low 80s, HR in the 50s- SB. Following commands\\n inconsistently.\\n Action:\\n Fentanyl/versed titrated throughout shift. Restarted on Haldol IV prn,\\n and given addititional one time dose of valium. Soft wrist restraints\\n in place for safety. EKG done of QTC interval\\n Response:\\n Cont to be anxious, attempting to pull at trach. QTI -442\\n Plan:\\n Cont daily QTC Intervals, titrate down Fent/versed Gtt as able, cont w/\\n prn haldol and standing valium.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Cont to be trached/vented on AC. Pleural effusions on CXR worsening.\\n Action:\\n Tolerated PS briefly this am. ABG/VBG collected\\n Response:\\n Pt w/ periods of apnea on PS.\\n Plan:\\n Non-contrast CT today to further characterize effusions, ? possible\\n thoracentesis following CT, make vent changes as needed, wean\\n fent/versed as able to tolerate vent changes. Recheck ABG/VBG this\\n evening.\\n Hypernatremia (high sodium)\\n Assessment:\\n NA level cont to be ^^, pt cont on lasix gtt\\n Action:\\n FWB increased to 300cc every 4 hrs.\\n Response:\\n Lytes to be rechecked this evening\\n Plan:\\n Check day and evening lytes, cont w/ q 4h boluses\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-06 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 635948,\n \"text\": \"Bradycardia\\n Assessment:\\n Pt conts with HR 50-70\\ns at rest, 100-140\\ns during care, pt\\n asymptomatic; easily arousable\\n Action:\\n Sedation decreased, Lasix off @0200\\n Response:\\n HR 60\\n Plan:\\n Cont to wean sedation, ?cardiac consult\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Action:\\n Cont with IV Heparin @ 1500u/hr\\n Response:\\n Pt therapeutic, cont with daily PTT\\n Plan:\\n Cont to labs, adjust per Heparin protocol\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt cont on AC 18/400/50%/10, LS clear bilat, occ scat rhonchi\\n Action:\\n Pt suct for sm thin tan secretions\\n Response:\\n Plan:\\n Cont to ABGs,\\n Hypotension (not Shock)\\n Assessment:\\n SBP 140\\ns when pt is agitated, SBP dropping to 70\\ns-80\\ns, UO 200/hr\\n (total 2500 in 2hr)\\n Action:\\n Fent/Versed turned down @ 0000, Lasix gtt on hold, team informed\\n Response:\\n Pt SBP\\ns in 80\\n Plan:\\n Cardiac consult to further eval SB/ST, re-evalu cont. Lasix gtt\\n Hypernatremia (high sodium)\\n Assessment:\\n Na 143\\n Action:\\n Cont with 300cc free water flush\\n Response:\\n Plan:\\n Cont to sodium levels, treat as ordered\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2167-09-27 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 634888,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 9\\n Ideal body weight: 61.2 None\\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: Unknown\\n Procedure location:\\n Reason:\\n Tube Type\\n ETT:\\n Position: cm at teeth\\n Route:\\n Type: Standard\\n Size: 7.5mm\\n Tracheostomy tube:\\n Type:\\n Manufacturer:\\n Size:\\n PMV:\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: cmH2O\\n Cuff volume: mL /\\n Airway problems:\\n Comments:\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Rhonchi\\n LUL Lung Sounds: Rhonchi\\n LLL Lung Sounds: Diminished\\n Comments:\\n Secretions\\n Sputum color / consistency: Yellow / Thick\\n Sputum source/amount: Suctioned / Small\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance:\\n Visual assessment of breathing pattern:\\n Assessment of breathing comfort:\\n Non-invasive ventilation assessment:\\n Invasive ventilation assessment:\\n Trigger work assessment:\\n Dysynchrony assessment:\\n Comments:\\n Plan\\n Next 24-48 hours:\\n Reason for continuing current ventilatory support:\\n Respiratory Care Shift Procedures\\n Transports:\\n Destination (R/T)\\n Time\\n Complications\\n Comments\\n Bedside Procedures:\\n Comments:\\n Patient remains on mechanical ventilation with all changes documented\\n on flow sheet. MDI\\ns given as ordered. Breath sounds diminished with\\n scattered.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-01 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 635334,\n \"text\": \"Chief Complaint: respiratory failure\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 24 Hour Events:\\n BRONCHOSCOPY - At 11:30 AM\\n Midaz weaned.\\n Heparin held due to potential OR today, but now on schedule for\\n tomorrow for trach.\\n History obtained from Medical records, ICU team\\n Patient unable to provide history: Sedated\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Furosemide (Lasix) - 3 mg/hour\\n Fentanyl - 100 mcg/hour\\n Other ICU medications:\\n Haloperidol (Haldol) - 11:47 PM\\n Midazolam (Versed) - 02:45 AM\\n Other medications:\\n SQI, H2B, MDIs, CHG, colace, tears, florinef, hydrocort 50q6,\\n duragesic, valium 10mg q6, Lasix @ 3\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 10:21 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.1\\nC (98.8\\n Tcurrent: 36.2\\nC (97.2\\n HR: 107 (46 - 121) bpm\\n BP: 147/79(111) {88/41(57) - 148/85(113)} mmHg\\n RR: 18 (18 - 20) insp/min\\n SpO2: 89%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 4,162 mL\\n 266 mL\\n PO:\\n TF:\\n 1,448 mL\\n 1 mL\\n IVF:\\n 1,003 mL\\n 235 mL\\n Blood products:\\n Total out:\\n 1,615 mL\\n 1,500 mL\\n Urine:\\n 1,615 mL\\n 1,500 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 2,547 mL\\n -1,234 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST\\n Vt (Set): 400 (400 - 400) mL\\n RR (Set): 18\\n RR (Spontaneous): 0\\n PEEP: 8 cmH2O\\n FiO2: 50%\\n PIP: 27 cmH2O\\n Plateau: 22 cmH2O\\n Compliance: 44.4 cmH2O/mL\\n SpO2: 89%\\n ABG: 7.42/47/86./29/4\\n Ve: 7.3 L/min\\n PaO2 / FiO2: 174\\n Physical Examination\\n General Appearance: Overweight / Obese\\n Head, Ears, Nose, Throat: Normocephalic\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\\n Respiratory / Chest: (Breath Sounds: Clear : anterior exam)\\n Abdominal: Soft, No(t) Tender: , Obese\\n Extremities: Right: 1+, Left: 1+\\n Skin: Warm\\n Neurologic: Responds to: Verbal stimuli, Movement: Non -purposeful,\\n Tone: Normal\\n Labs / Radiology\\n 8.0 g/dL\\n 280 K/uL\\n 136 mg/dL\\n 0.5 mg/dL\\n 29 mEq/L\\n 4.0 mEq/L\\n 11 mg/dL\\n 105 mEq/L\\n 143 mEq/L\\n 25.9 %\\n 8.6 K/uL\\n [image002.jpg]\\n 02:44 PM\\n 03:33 PM\\n 07:26 PM\\n 07:46 PM\\n 02:04 AM\\n 02:18 AM\\n 01:27 PM\\n 03:06 PM\\n 10:04 PM\\n 03:00 AM\\n WBC\\n 8.4\\n 11.8\\n 8.6\\n Hct\\n 23.0\\n 28.1\\n 29.9\\n 25.9\\n Plt\\n \\n Cr\\n 0.5\\n 0.6\\n 0.5\\n TCO2\\n 33\\n 31\\n 33\\n 32\\n 32\\n Glucose\\n 168\\n 176\\n 136\\n Other labs: PT / PTT / INR:13.2/26.6/1.1, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\\n Amylase / Lipase:, Differential-Neuts:89.7 %, Lymph:8.7 %, Mono:1.1\\n %, Eos:0.4 %, Lactic Acid:0.9 mmol/L, Albumin:2.4 g/dL, LDH:204 IU/L,\\n Ca++:8.4 mg/dL, Mg++:2.4 mg/dL, PO4:4.1 mg/dL\\n CXR with slightly increased right base opacity, but lower lung\\n volumes. Retrocardiac opacity.\\n Assessment and Plan\\n 55 y/o woman with thoracic spinal fracture (mechanical after fall)\\n complicated by ARDS from VAP, UE DVT, and adrenal insufficiency.\\n Respiratory failure\\n Try RSBI/SBT today. If not extubatable, plan trach/G tomorrow\\n Diurese with Lasix gtt\\n eventually need rx of tracheobronchomalacia\\n s/p treatment for Klebsiella VAP acquired at OSH\\n Shock / adrenal insufficiency\\n She has essentially proven adrenal insufficiency, with a baseline\\n cortisol that was very low on pressors and a vent, followed by\\n resolution of shock with steroids, followed by recrudescence of shock\\n when steroids stopped, followed by resolution of shock with steroids (a\\n second time).\\n Continue steroids at current dose until after tracheostomy/PEG.\\n Appreciate endocrine\\ns help.\\n DVT (UE)\\n Resume heparin until several hours before O.R.\\n Nutrition / Lytes\\n Will restart tube feeds and free water boluses for hypernatremia.\\n Spine fractures\\n Continue spinal stabilization with brace when OOB; will eventually need\\n MRI for further evaluation. Would wait until she has a surgical airway\\n if she does not pass SBT today.\\n ICU Care\\n Nutrition: resume TF\\n Comments: Held for possible OR\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n PICC Line - 09:19 PM\\n Arterial Line - 02:00 PM\\n Prophylaxis:\\n DVT: Boots(Systemic anticoagulation: Restart Heparin gtt)\\n Stress ulcer: H2 blocker\\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\\n Comments:\\n Communication: Comments: with brother and boyfriend \\n Code status: Full code\\n Disposition :ICU\\n Total time spent: 45 min\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-01 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 635347,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n Thoracics will take to OR if stable on PEEP < 10 for 24 hours, was on\\n PEEP of 8 since AM\\n due to scheduling, will not be able to go to OR\\n today, but rather tomorrow with Dr. ()\\n Weaned off midazolam drip\\n Endocrine saw patient for adrenal insufficiency: Continue steroids\\n until stable, then taper; assoc between Precedex and adrenal\\n insufficiency in animal studies\\n ABG for low O2 sat, looked good, held on FiO2 of 50\\n Broncoscopy (11:30AM) : Diffuse stuctural instability c/w\\n tracheomalacia\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Furosemide (Lasix) - 3 mg/hour\\n Fentanyl - 100 mcg/hour\\n Other ICU medications:\\n Haloperidol (Haldol) - 11:47 PM\\n Midazolam (Versed) - 02:45 AM\\n Other medications:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:06 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.1\\nC (98.8\\n Tcurrent: 36.2\\nC (97.2\\n HR: 104 (46 - 134) bpm\\n BP: 134/69(98) {88/41(57) - 143/76(103)} mmHg\\n RR: 18 (18 - 27) insp/min\\n SpO2: 91%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 4,162 mL\\n 139 mL\\n PO:\\n TF:\\n 1,448 mL\\n 1 mL\\n IVF:\\n 1,003 mL\\n 138 mL\\n Blood products:\\n Total out:\\n 1,615 mL\\n 640 mL\\n Urine:\\n 1,615 mL\\n 640 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 2,547 mL\\n -501 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 400 (400 - 400) mL\\n RR (Set): 18\\n RR (Spontaneous): 0\\n PEEP: 8 cmH2O\\n FiO2: 50%\\n PIP: 35 cmH2O\\n Plateau: 25 cmH2O\\n Compliance: 24.7 cmH2O/mL\\n SpO2: 91%\\n ABG: 7.42/47/87/33/4\\n Ve: 6.8 L/min\\n PaO2 / FiO2: 174\\n Physical Examination\\n General Appearance: Responsive, following commands, Overweight / Obese,\\n NAD\\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\\n deviation\\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\\n Cardiovascular: (S1: Normal), (S2: Normal), distant\\n Respiratory / Chest: (Expansion: Symmetric), referred breath sounds\\n from ETT\\n Abdominal: No(t) Soft, Non-tender, Few Bowel sounds present, Distended\\n Extremities: No clubbing or cyanosis, 3+ nonpitting edema of b/l hands,\\n anasarca\\n Skin: no rashes or jaundice\\n Neuro: 3+ UE b/l, 4+ LE b/l\\n Lines: r brachioceph ART and L PICC C/D/I\\n Labs / Radiology\\n 280 K/uL\\n 8.0 g/dL\\n 136 mg/dL\\n 0.5 mg/dL\\n 29 mEq/L\\n 4.0 mEq/L\\n 11 mg/dL\\n 105 mEq/L\\n 143 mEq/L\\n 25.9 %\\n 8.6 K/uL\\n [image002.jpg]\\n 02:44 PM\\n 03:33 PM\\n 07:26 PM\\n 07:46 PM\\n 02:04 AM\\n 02:18 AM\\n 01:27 PM\\n 03:06 PM\\n 10:04 PM\\n 03:00 AM\\n WBC\\n 8.4\\n 11.8\\n 8.6\\n Hct\\n 23.0\\n 28.1\\n 29.9\\n 25.9\\n Plt\\n \\n Cr\\n 0.5\\n 0.6\\n 0.5\\n TCO2\\n 33\\n 31\\n 33\\n 32\\n 32\\n Glucose\\n 168\\n 176\\n 136\\n Other labs: PT / PTT / INR:13.2/26.6/1.1, Ca++:8.4 mg/dL, Mg++:2.4\\n mg/dL, PO4:4.1 mg/dL, FSH 4.1, prolactin 48\\n Fluid analysis / Other labs: BAL fluid:\\n WBC: 0\\n RBC: 0\\n Polys: 82\\n Lymphs: 3\\n Monos: 6\\n Eos: 2\\n Macro: 7\\n G.S\\n PMNs\\n Sputum culture - + GPCs in pairs and clusters, gram + rods\\n Imaging: ECHOCARDIOGRAM: The left atrium is elongated. No atrial\\n septal defect is seen by 2D or color Doppler. The right atrial pressure\\n is indeterminate. Left ventricular wall thickness, cavity size and\\n regional/global systolic function are normal (LVEF >55%). There is no\\n ventricular septal defect. Right ventricular chamber size and free wall\\n motion are normal. The aortic valve leaflets (3) are mildly thickened\\n but aortic stenosis is not present. No aortic regurgitation is seen.\\n The mitral valve appears structurally normal with trivial mitral\\n regurgitation. There is no mitral valve prolapse. The tricuspid valve\\n leaflets are mildly thickened. There is moderate pulmonary artery\\n systolic hypertension. There is no pericardial effusion.\\n Compared with the prior study (images reviewed) of , no\\n change.\\n EKG = sinus bradycardia\\n Assessment and Plan\\n 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA and\\n ARDS intubated since the end of .\\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\\n volume overload. Intubated on for resp decompensation.\\n Transferred here for airway stenting.\\n - attempt SBT today\\n - OR add on for trach and PEG with Dr. (tube feeds off\\n after MN, heparin off after 6am)\\n # # Adrenal Insufficency: Minimal response to stim test again.\\n Appreciate endocrine recommendations.\\n - hydrocort and fludrocort (day 1 = )\\n - will continue at current dose until s/p trach and PEG and\\n hemodynamically stable for 24 hours\\n will then plan to taper\\n hydrocortisone to 25mg IV q6 with a slow taper\\n - will repreat ACTH stim test after tapered to <30mg\\n hydrocortisone or off steroids\\n - f/u daily endocrine recs\\n # Hypotension: Likely adrenal insufficiency and sedation. Goal map\\n > 60. Much improved since re-administration of steroids.\\n - hydrocortisone and fludrocortisone as above\\n - restart levophed if necessary to maintain MAP > 60\\n # Volume overloaded in setting of hypernatremia with TBW deficit.\\n - goal -1000cc I/Os today\\n - continue FW in TF at 250 cc q4hrs\\n - lasix drip (1-5mg/hr) when MAP > 60\\n # Sedation: Sedation control remains somewhat poor although fentanyl\\n patch and diazpem are likely therapeutic range today. On Versed 1.5,\\n Fentanyl 175, Fentanyl patch, Diazepam standing and haldo 2.5-5 mg\\n PRN. QTc increased to 480.\\n - Wean versed/fentanyl as tolerated, continue diazepam. Avoid\\n haldol use if possible to avoid further prolongation of QTc\\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\\n coumadin at least until s/p trach.\\n - hold heparin gtt when anticipate trach/peg\\n # Spine fracture: Neurologically intact distal to the lesion. Prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - CT of C, L spine when stable. Currently, unlikely to change\\n management and high risk for complications with transport.\\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\\n is low. Brace for OOB. Ok for anticoag per note.\\n # FEN/GI: Tube feeds with FWF @ goal.\\n DVT: Treatment dose heparin\\n Ulcer: Ranitidine\\n VAP: Prevention per routine\\n # Communication:\\n - Boyfriend of 10 is her HCP. Also brother is involved\\n - touch base with SW today\\n Code: Full\\n Dispo: ICU\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-03 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 635567,\n \"text\": \"55 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP now with prolonged\\n hospital course c/o by PNA anxiety,RUE DVD with high PEEP requirement\\n .\\n Edema, peripheral\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Altered mental status (not Delirium)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Hypernatremia (high sodium)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2167-10-03 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 635569,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 15\\n Ideal body weight: 61.2 None\\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: Yes\\n Tracheostomy tube:\\n Type: Standard, Cuffed, Inner Cannula\\n Manufacturer: Portex\\n Size: 7.0mm\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 28 cmH2O\\n Cuff volume: mL /\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Rhonchi\\n LUL Lung Sounds: Rhonchi\\n LLL Lung Sounds: Diminished\\n Secretions\\n Sputum color / consistency: Blood Tinged / Thick\\n Sputum source/amount: Suctioned / Small\\n Ventilation Assessment\\n Visual assessment of breathing pattern: Normal quiet breathing\\n Plan\\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\\n tolerated\\n Reason for continuing current ventilatory support:\\n Respiratory Care Shift Procedures\\n Comments: Patient desaturated during the shift, requiring an increase\\n to 10 cm PEEP and 60% FIO2. Latest abg results determined a metabolic\\n alkalemia with adequate oxygenation on the current settings. No RSBI\\n measured due to the level of PEEP and the high FIO2 currently required.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-04 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 635696,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n Hydrocortisone dose to 25 Q6 per renal recs.\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Midazolam (Versed) - 3 mg/hour\\n Heparin Sodium - 1,700 units/hour\\n Fentanyl - 125 mcg/hour\\n Other ICU medications:\\n Ranitidine (Prophylaxis) - 09:00 AM\\n Midazolam (Versed) - 07:30 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:30 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.9\\nC (98.5\\n Tcurrent: 36.8\\nC (98.3\\n HR: 66 (50 - 131) bpm\\n BP: 103/46(65) {100/46(65) - 157/102(127)} mmHg\\n RR: 18 (15 - 21) insp/min\\n SpO2: 93%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 1,984 mL\\n 948 mL\\n PO:\\n TF:\\n 103 mL\\n 121 mL\\n IVF:\\n 747 mL\\n 277 mL\\n Blood products:\\n Total out:\\n 5,270 mL\\n 1,420 mL\\n Urine:\\n 5,270 mL\\n 1,420 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -3,286 mL\\n -472 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 400 (400 - 400) mL\\n RR (Set): 18\\n RR (Spontaneous): 0\\n PEEP: 10 cmH2O\\n FiO2: 55%\\n RSBI Deferred: PEEP > 10\\n PIP: 25 cmH2O\\n Plateau: 14 cmH2O\\n Compliance: 100 cmH2O/mL\\n SpO2: 93%\\n ABG: ///32/\\n Ve: 6.8 L/min\\n Physical Examination\\n General Appearance: Responsive, following commands, Overweight / Obese,\\n NAD\\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\\n deviation\\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\\n Cardiovascular: (S1: Normal), (S2: Normal), distant\\n Respiratory / Chest: (Expansion: Symmetric), referred breath sounds\\n from ETT, mild rhonchi diffusely\\n Abdominal: Obese, Soft, Non-tender, no rebound, no guarding\\n Extremities: No clubbing or cyanosis, + nonpitting edema of b/l\\n hands, anasarca\\n Skin: no rashes or jaundice\\n Neuro: alert. Strength 4/5 upper and lower extremeties, light touch\\n sensation intact bil.\\n Lines: r brachioceph ART and L PICC C/D/I\\n Labs / Radiology\\n 279 K/uL\\n 8.0 g/dL\\n 121 mg/dL\\n 0.5 mg/dL\\n 32 mEq/L\\n 3.6 mEq/L\\n 8 mg/dL\\n 109 mEq/L\\n 143 mEq/L\\n 24.6 %\\n 8.3 K/uL\\n [image002.jpg]\\n 04:10 PM\\n 12:13 AM\\n 05:08 AM\\n 05:20 AM\\n 05:17 PM\\n 11:41 PM\\n 03:06 AM\\n 03:38 AM\\n 04:05 PM\\n 03:55 AM\\n WBC\\n 11.2\\n 10.6\\n 10.0\\n 8.3\\n Hct\\n 27.1\\n 27.3\\n 25.8\\n 24.6\\n Plt\\n 79\\n Cr\\n 0.7\\n 0.5\\n 0.5\\n 0.6\\n 0.6\\n 0.5\\n TCO2\\n 36\\n 36\\n 32\\n 31\\n Glucose\\n 165\\n 143\\n 110\\n 94\\n 111\\n 106\\n 121\\n Other labs: PT / PTT / INR:15.9/107.7/1.4, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:13.1 %,\\n Mono:2.7 %, Eos:0.6 %, Lactic Acid:0.9 mmol/L, Albumin:2.4 g/dL,\\n LDH:204 IU/L, Ca++:8.8 mg/dL, Mg++:3.1 mg/dL, PO4:4.2 mg/dL\\n Assessment and Plan\\n 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA and\\n ARDS intubated since the end of .\\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\\n volume overload. Intubated on for resp decompensation. Stenting\\n unlikely to help for trachiomalacia as airways have poor structure\\n diffusely. S/P Trach yesterday\\n - Continue to wean O2 as tolerated\\n # Adrenal Insufficency: Hypotension that resolved with steroids,\\n returned as they came off and is now improved again. Possible primary\\n adrenal insufficency. Appreciate endocrine recommendations.\\n - hydrocortt (day 1 = ), wean per endo recs\\n # Hypotension: Likely adrenal insufficiency and sedation. Goal map\\n > 60. Much improved since re-administration of steroids.\\n - hydrocortisone as above\\n - restart levophed if necessary to maintain MAP > 60\\n # Volume overloaded in setting of hypernatremia with TBW deficit.\\n - Lasix gtt, continue with goal -1L per day.\\n - electrolytes\\n - may have some contraction alkalosis, w/ rising pH and bicarb. Start\\n Diamox 500mg TID to decrease bicarb and pH and may improve respiratory\\n drive.\\n # Sedation: Sedation control remains somewhat poor although fentanyl\\n patch and diazpem are likely therapeutic range today. On Versed 2.0,\\n Fentanyl 100, Fentanyl patch, Diazepam standing and haldo 2.5-5 mg\\n PRN. QTc increased to 480.\\n - Wean versed/fentanyl as tolerated, continue diazepam. Avoid haldol\\n use if possible to avoid further prolongation of QTc\\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\\n coumadin at least until s/p trach.\\n - heparin gtt restarted\\n - plan to start coumadin night of if stable\\n # Spine fracture: Neurologically intact distal to the lesion. Prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - CT of C, L spine when stable. Currently, unlikely to change\\n management and high risk for complications with transport.\\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\\n is low. Brace for OOB. Ok for anticoag per note.\\n # FEN/GI: Tube feeds\\n DVT: Treatment dose heparin\\n Ulcer: Ranitidine\\n VAP: Prevention per routine\\n # Access: L PICC line, and R brachial a-line\\n # Communication:\\n - Boyfriend of 10 is her HCP. Also brother is involved\\n - touch base with SW today\\n Code: Full\\n Dispo: ICU\\n ICU Care\\n Nutrition:\\n Replete (Full) - 11:20 AM 30 mL/hour\\n Glycemic Control:\\n Lines:\\n PICC Line - 09:19 PM\\n Arterial Line - 02:00 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-09-26 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 634788,\n \"text\": \"Events:\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2167-10-03 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 635642,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation:\\n Ideal body weight:\\n Ideal tidal volume:\\n Airway\\n Airway Placement Data\\n Known difficult intubation:\\n Procedure location:\\n Reason:\\n Tube Type\\n ETT:\\n Position:\\n Route:\\n Type:\\n Size:\\n Tracheostomy tube:\\n Type:\\n Manufacturer:\\n Size:\\n PMV:\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure:\\n Cuff volume:\\n Airway problems:\\n Comments:\\n Lung sounds\\n RLL Lung Sounds:\\n RUL Lung Sounds:\\n LUL Lung Sounds:\\n LLL Lung Sounds:\\n Comments:\\n Secretions\\n Sputum color / consistency:\\n Sputum source/amount:\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance:\\n Visual assessment of breathing pattern:\\n Assessment of breathing comfort:\\n Non-invasive ventilation assessment:\\n Invasive ventilation assessment:\\n Trigger work assessment:\\n Dysynchrony assessment:\\n Comments:\\n Plan\\n Next 24-48 hours:\\n Reason for continuing current ventilatory support:\\n Respiratory Care Shift Procedures\\n Transports:\\n Destination (R/T)\\n Time\\n Complications\\n Comments\\n Bedside Procedures:\\n Comments:\\n Specialized Gas Therapy\\n Nitric Oxide\\n PPM used: ppm\\n Indication:\\n Effect of therapy: []\\n Nitric Oxide trial:\\n Comments:\\n HeliOx:\\n Additional O[2] by cannula: L/min\\n Continuous nebulized bronchodilator:\\n Comments:\\n Recruitment Maneuvers Done\\n CPAP pressure used: cm H2O\\n Duration: sec\\n Times per shift:\\n Comments:\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2167-10-03 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 635643,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 15\\n Ideal body weight: 61.2 None\\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: Yes\\n Procedure location:\\n Reason:\\n Tube Type\\n ETT:\\n Position: cm at teeth\\n Route:\\n Type:\\n Size:\\n Tracheostomy tube:\\n Type: Standard\\n Manufacturer: Portex\\n Size: 7.0mm\\n PMV:\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 28 cmH2O\\n Cuff volume: mL /\\n Airway problems:\\n Comments:\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Diminished\\n Comments:\\n Secretions\\n Sputum color / consistency: Brown / Thick\\n Sputum source/amount: Suctioned / Scant\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance:\\n Visual assessment of breathing pattern: Normal quiet breathing\\n Assessment of breathing comfort: No response (sleeping / sedated)\\n Non-invasive ventilation assessment:\\n Invasive ventilation assessment:\\n Trigger work assessment: Not triggering\\n Dysynchrony assessment:\\n Comments:\\n Plan\\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\\n Maintain PEEP at current level and reduce FiO2 as tolerated\\n Reason for continuing current ventilatory support: Underlying illness\\n not resolved\\n Respiratory Care Shift Procedures\\n Transports:\\n Destination (R/T)\\n Time\\n Complications\\n Comments\\n Bedside Procedures:\\n Comments:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-04 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 635781,\n \"text\": \"55 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\\n Now with prolonged hospital course c/b by PNA with high PEEP\\n requirement, anxiety, RUE DVT on heparin qtt.\\n Edema, peripheral\\n Assessment:\\n Fluid balance for previous 24hrs decreased by 3 liters D/T diuresis.\\n Rec\\nd pt off of Lasix qtt. Urine output decreased to 45ml/hr @1000.\\n Action:\\n Lasix qtt restarted @ 2mg/hr to maintain urine output 1-2liters/day.\\n Response:\\n Fluid balance approx -50ml/hr, with 24hr fluid balance -650ml @ 1500.\\n However, SBP 78 when pt soundly sleeping/sedated. Lasix qtt stopped @\\n 1530.\\n Plan:\\n Restart Lasix qtt when BP stabilized.\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Rec\\nd pt on Heparin qtt @ 1500units/hr.\\n Action:\\n PTT 92.1 @ 1230.\\n Response:\\n Per goal PTT 60-100, Heparin rate unchanged.\\n Plan:\\n Repeat PTT @ 1830. Start po Coumadin tonight.\\n Altered mental status (not Delirium)\\n Assessment:\\n Rec\\nd pt on Versed @ 2mg/hr, Fentanyl @ 100mcg/hr, as well as Fentanyl\\n patches totaling 150mcg in place. Pt also rec\\ning Diazepam 10mg po\\n Q6hrs, in hope of weaning pt from IV sedation. Pt alternately appears\\n very sedated and very restless. When she appears alert, she intermit\\n responds to commands approp but not attempting to mouth words or nod to\\n communicate. Moving arms purposefully towards trach, so soft wrist\\n restraints remain in place. When very sedated @ 1530, SBP to 78 per\\n below.\\n Action:\\n Versed \\nd to 1mg/hr, Fentanyl \\nd to 75mcg/hr.\\n Response:\\n Pt restless/squirming in bed when she appears awake. Not responding to\\n verbal reassurance.\\n Plan:\\n Cont to attempt weaning from IV sedation. Cont to freq reorient pt,\\n emotional support.\\n Hypotension (not Shock)\\n Assessment:\\n VS generally stable with HR 68-123SR with occas PVC\\ns, BP\\n 122/65-144/76. However, when pt sleeping/sedated soundly @ 1530 SBP\\n remained in high 70\\n Action:\\n Sedation decreased per above, Lasix qtt stopped. Pt woken and turned\\n STS in bed.\\n Response:\\n VS returned to baseline, with BP presently 133/76.\\n Plan:\\n Restart Lasix qtt when BP stabilized WNL.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Rec\\nd pt on vent settings AC 55%/18 X 400/+10, with no over-breathing\\n of rate by pt. O2 sat 95-99%. ABG 7.44/42/93. Lung snds clear but\\n diminished in lower lobes. Suctionned for mod-lg amts thick white\\n secretions.\\n Action:\\n Vent changed to CMV with PS 8/+10 on 55%.\\n Response:\\n Pt tolerated PS approx 3hrs, but after rec\\ning scheduled dose Diazepam\\n @ 1200 began having extended pauses apnea. She was then returned to AC\\n 55%/9 X 500/+10.\\n Plan:\\n Cont wean from vent with PS trials, as well as \\ning FiO2.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-09-28 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 634951,\n \"text\": \"TITLE: This is a 55 yr old female admitted from an OSH to on\\n with resp failure, +PNA s/p fall down stairs with fracture of\\n T5-T8 and possible tracheobronchomalacia for IP consult and possible Y\\n stenting. Pt now s/p IP consult with no tracheobronchomalacia found on\\n exam. Pt has been diff to wean with high PEEP requirements. The pt\\n has finished a course of IV Levofloxacin, Vanco, and Aztreonam antibx\\n for Klebsiella PNA/VAP. Pt found to have RUE DVT and maintained on an\\n IV Heparin gtt (no NBP or blood draw in this appendage please). The pt\\n is net input more than fifteen liters for LOS @ this time. The pt has\\n documented allergies to Tetracycline, PCN & Hydrazaline. The pt is a\\n Full Code. The pt has a boyfriend and a brother, the brother is the\\n designated HCP.\\n Events: Optimal sedation continues to be a challenge for this pt with\\n pt either oversedated with resulting borderline hypotension and\\n bradycardia and acute agitation with HTN, tachycardia, dysphoria,\\n agitation. TLC d/c\\ned by team overnight, now utilizing RUE AC PICC for\\n IV therapy. RUE radial a-line remains positional, unable to send and\\n ABG this AM\\n team aware. 20mg IVP Lasix provided overnight for\\n hypervolemia with approx one liter output.\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt MS noted to wax/wane overnight. Pt intermittently able to follow\\n simple commands (wiggle toes) and mouthed her name correctly. However,\\n pt also has periods of acute delirious agitation with thrashing and\\n pulling on soft wrist restraints.\\n Action:\\n Pt received/maintained on IV Fentanyl & Midazolam gtt\\ns with multiple\\n IVP boluses of these agents for acute agitation. Pt also freq\\n re-oriented to person/place/time/care rationale to assist with nl\\n cogntion. Soft wrist restraints maintained in place for pt safety.\\n Pts episodes of agitation/delirium discussed with team, PRN Seroquil\\n med therapy discussed.\\n Response:\\n Pt responds transiently to IV Fentanyl/Midazolam boluses.\\n Plan:\\n Cont to provide both gtt & IVP sedation for pt comfort. Reviewing the\\n use of additional agents 2^nd current limitations with present regime.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt received/maintained on AC-18-50-400-15 with nl sats, RR and resp\\n effort. Unable to send AM ABG 2^nd declining a-line function\\n issue\\n discussed with team.\\n Action:\\n Pt seems to be doing well with current MV support. 20mg IVP Lasix\\n admin @ 02:30 for hypervolemia to optimize resp fxn. Pt sat upright 30\\n to 45 degrees. Small amounts of thick tan sec per ETT. The pt is\\n currently off all antibx cov @ this time. Of note, pt noted to have\\n large yellowish oral sec, ?sinusitis\\n issue discussed with team.\\n Response:\\n Pt seems to be doing well with current MV support despite inability to\\n send an AM ABG.\\n Plan:\\n Cont to follow pts MS, resp fxn closely to ensure optimal resp fxn.\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Pt with documented RUE DVT. No NBP nor blood sticks/FS in this\\n appendage please.\\n Action:\\n Pt received/maintained on IV Heparin gtt infusing @ 1,700 units/hr.\\n Response:\\n Serial therapeutic PTT values noted with an AM PTT today of 59.6.\\n Plan:\\n Edema, peripheral\\n Assessment:\\n Pt remains +2 generalized anasarcoid and positive 16 liters for LOS.\\n Action:\\n Pt med with 20mg IVP Lasix @ 02:30 this AM.\\n Response:\\n Pt with approx one liter output to 20mg IV Lasix.\\n Plan:\\n Pt remains + 16 liters for LOS despite IV Lasix therapy (pt receives\\n high hourly input esp with tube feeds @ 60ml/hr). Of note, pts AM\\n sodium value is 146 and pt has a free water deficit.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-09-26 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 634794,\n \"text\": \"Events:\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-04 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 635691,\n \"text\": \"55 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\\n Now with prolonged hospital course c/b by PNA with high PEEP\\n requirement, anxiety, RUE DVT on heparin qtt.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Rec\\nd pt on Vent settings AC 55%/18 X 400/+10 with no overbreathing of\\n set RR. O2 sat 92-98%. Lung snds clear, diminished in bases. Pt sxn\\n for small-moderate amts thick white secretions. Trach site with small\\n amt serosang drainage.\\n Action:\\n Cont same vent settings\\n Response:\\n Pt doesn\\nt over breath on the vent and never desat.Kept same Vent\\n settings overnight.\\n Plan:\\n Monitor sats,resp and titrate Vent as she tolerats.\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Pt rec\\nd with Heparin qtt 1900units/hr.\\n Action:\\n PTT drawn at 2300.RUE elevated with pillow and no BP or blood drawn\\n from that arm.\\n Response:\\n PTT @ 2300 was 107,Decreased Heparin gtt 1700 u/hr as per sliding\\n scale.Next PTT due at 0600. .\\n Plan:\\n Cont monitor PTT,titrate accordingly,next PTT due at 0600.\\n Alteration in Nutrition\\n Assessment:\\n Received pt on TF 10cc/hr.\\n Action:\\n Pt tolerated TF with minimal residuals as well as free water bolus Q4H\\n Response:\\n TF ^ as tolerated, currently at 30cc/hr.\\n Plan:\\n Cont to monitor TF residuals, hold if more than 100cc\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt w/ periods of agitation and sleeping at other times, while she\\n aweake follow commands intermittently.\\n Action:\\n Cont on fent 100 mics ,Versed 2mg/hr and requires frequent boluses .\\n Cont diazepam 10 mg PO Q6H. Fent ^ 125 mics/hr,Versed 3mg/hr.\\n Response:\\n HR ranging from SB in the 40\\ns when asleep to the 120-140\\ns when\\n agitated, b/p ranging from 90\\ns/40\\ns when asleep to 140-170\\ns/ 70\\n when agitated. When pt awake appropriate and following commands HR\\n 80\\ns-100\\ns and b/p 100\\ns-120\\ns/ 60-70\\n Plan:\\n Titrate sedation as needed\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-09-24 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 634520,\n \"text\": \"24 Hour Events:\\n -Yesterday, stopped vanc and flagyl. Continued Aztreonam and\\n Levofloxicin\\n -Micro on sputum GNR due back today\\n -Febrile to 101- pan cultured; cxr\\n -Decreased FiO2 and PEEP to 21\\n -Early am, HR dropped to 40s-50s. EKG suggestive of junctional rhythm.\\n Held pressures, making good UOP, good O2 sats\\n -Yesterday, SVV was 13; held on giving more fluids\\n -Random cortisol was very low; started hydrocortisone and florinef\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Vancomycin - 08:00 PM\\n Metronidazole - 08:00 AM\\n Levofloxacin - 08:39 AM\\n Aztreonam - 02:00 PM\\n Infusions:\\n Norepinephrine - 0.02 mcg/Kg/min\\n Midazolam (Versed) - 4 mg/hour\\n Other ICU medications:\\n Midazolam (Versed) - 03:50 PM\\n Fentanyl - 03:50 PM\\n Ranitidine (Prophylaxis) - 08:31 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:39 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.3\\nC (101\\n Tcurrent: 37.1\\nC (98.8\\n HR: 60 (60 - 86) bpm\\n BP: 103/46(61) {103/46(61) - 121/50(66)} mmHg\\n RR: 22 (17 - 23) insp/min\\n SpO2: 99%\\n Heart rhythm: JR (Junctional Rhythm)\\n Wgt (current): 101 kg (admission): 94.2 kg\\n Height: 67 Inch\\n CVP: 12 (12 - 339)mmHg\\n Total In:\\n 1,675 mL\\n 232 mL\\n PO:\\n TF:\\n 182 mL\\n 134 mL\\n IVF:\\n 1,233 mL\\n 98 mL\\n Blood products:\\n Total out:\\n 877 mL\\n 565 mL\\n Urine:\\n 727 mL\\n 535 mL\\n NG:\\n 30 mL\\n Stool:\\n Drains:\\n Balance:\\n 798 mL\\n -333 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 400 (400 - 400) mL\\n RR (Set): 22\\n RR (Spontaneous): 2\\n PEEP: 21 cmH2O\\n FiO2: 40%\\n RSBI Deferred: PEEP > 10\\n PIP: 33 cmH2O\\n Plateau: 30 cmH2O\\n Compliance: 44.4 cmH2O/mL\\n SpO2: 99%\\n ABG: 7.42/39/116/26/0\\n Ve: 9.7 L/min\\n PaO2 / FiO2: 290\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 326 K/uL\\n 8.9 g/dL\\n 151 mg/dL\\n 0.7 mg/dL\\n 26 mEq/L\\n 3.6 mEq/L\\n 2 mg/dL\\n 108 mEq/L\\n 141 mEq/L\\n 28.6 %\\n 8.9 K/uL\\n [image002.jpg]\\n 06:11 PM\\n 07:53 PM\\n 02:02 AM\\n 03:59 AM\\n 09:14 PM\\n 01:04 AM\\n 05:54 AM\\n 06:11 AM\\n 11:07 PM\\n 03:51 AM\\n WBC\\n 8.4\\n 8.1\\n 8.9\\n Hct\\n 28.1\\n 28.0\\n 28.6\\n Plt\\n 376\\n 358\\n 326\\n Cr\\n 0.6\\n 0.7\\n 0.7\\n TCO2\\n 29\\n 25\\n 25\\n 28\\n 28\\n 26\\n 26\\n Glucose\\n 120\\n 126\\n 151\\n Other labs: PT / PTT / INR:24.3/68.6/2.4, ALT / AST:24/16, Alk Phos / T\\n Bili:117/0.7, Amylase / Lipase:, Differential-Neuts:82.5 %,\\n Lymph:11.6 %, Mono:3.3 %, Eos:2.2 %, Lactic Acid:0.7 mmol/L,\\n Albumin:2.4 g/dL, LDH:204 IU/L, Ca++:8.5 mg/dL, Mg++:2.1 mg/dL, PO4:2.5\\n mg/dL\\n Assessment and Plan\\n 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture with respiratory failure\\n and difficulty weaning from vent.\\n # Respiratory failure: initial etiology unclear, likely multifactorial\\n (sedation vs hypovent obesity/orthotic brace vs ?) which lead to\\n VAP most likely with GNR (by one sputum).\\n - Concern for ARDS given clinical and radiographic picture.\\n - Placed esophageal balloon on which will help guide PEEP\\n settings.\\n - Over the evening yesterday, were able to decrease FiO2 and PEEP.\\n # VAP: Re-spiked fever overnight.\\n - Sputum from grew rare GNR; awaiting speciation.\\n - Has been Vanc, aztreonam, levofloxicin. Vanc trough today was 20\\n - Stopped vanc yesterday, , as there was no current evidence to\\n suggest a gram positive infection\\n - Also, stopped flagyl because had one neg c. diff toxin and CT did not\\n show evidence of colitis\\n - Continued aztreonam and levofloxicin for gram neg pneumonia for 8\\n days pending speciation (at that time can increase to 15 days if\\n necessary)\\n - need to reconsider restarting d/c'd meds if she continues to\\n spike a fever\\n # Hypotension, requiring Levophed:\\n - Hypovolemia is possibly a factor- responded to a transfusion; HCT had\\n been dropping. However, SVV with Vigileo was 13, making her CO less\\n likely to respond to fluids. Held on giving any boluses overnight.\\n - Sepsis also a factor- on broad spectrum abs\\n - Central line in place.\\n # Oliguria:\\n -BUN and Cr reassuring.\\n -Continues to be low. Hopefully, by decreasing PEEP and using levophed\\n to keep MAPs high, UOP will increase.\\n # RUE DVT: Started on heparin gtt on .\\n -Therapeutic in one day; may be related to poor nutritional status.\\n Will continue to closely monitor\\n # Abd distention: be chronic condition not requiring immediate\\n medical attention\\n - CT abd only showed appendiceal mucocele without inflammation, not\\n concerning, most likely chronic. No concern for intraabd disaster\\n - Now having BMs; c. diff toxin neg\\n - amylase and lipase wnl\\n # Adrenal Insufficency:\\n -Random cortisol was approx 3 when it should have been maximally\\n stimulated.\\n -Started hydrocortisone and florinef. ? switch to methylpred\\n # Anemia:\\n - Trend HCT\\n - Gave 1 un pRBC with good results\\n - INR rising, now 2.0, may be nutritional\\n # Spine fracture: neurologically intact distal to the lesion. prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\\n is low. Brace for OOB. Ok for anticoag per verbal report.\\n # Hypernatremia, resolved: correcting with g tube free flush and D5W\\n -Holding on g tube feeds at present due to high residuals\\n -Replete lytes as necessary\\n # Communication:\\n - Brother has been with pt, although, live in boyfriend of 10 is\\n her HCP. Boyfriend will hopefully visit pt today\\n ICU Care\\n Nutrition: tube feed with free water when able\\n Glycemic Control: Regular insulin sliding scale\\n DVT: SQ UF Heparin\\n Stress ulcer: H2 blocker\\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\\n Communication: ICU consent signed, (brother) \\n (boyfriend/POA) \\n Code status: Full code\\n Disposition: ICU\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 10:55 PM 30 mL/hour\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 01:36 AM\\n Arterial Line - 03:00 AM\\n Multi Lumen - 11:30 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-09-24 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 634525,\n \"text\": \"55 yr old woman admitted from OSH after she fell down the stairs and\\n had traumatic T-spine fracture. Pt came to us with PNA from unknown\\n etiology? VAP. Full code, Allergies: PCN, tetracycline, Sulfa. PMH:\\n ETOH, smoker, Gerd, Hip replacement.\\n Alteration in Nutrition\\n Assessment:\\n Tube feeds increased to 30ml/hr. Tube feed residual 10-20ml.\\n Action:\\n cont to check residuals and try to increase rate\\n Response:\\n Residual staying 10ml/hr, kept rate at 30ml\\n Plan:\\n Try to increase Tube feeds to goal rate.\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n RUE DVT, pt on heparin gtt at 1700units/hr.\\n Action:\\n Ptt was therapeutic x2, AM PTT 68.6 WNL\\n Response:\\n No change to drip made, therapeutic dose.\\n Plan:\\n Cont heparin gtt, check PTT adjust heparin gtt per scale.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Moderate thick white in-line secretions, copious clear oral secretions,\\n clear/diminished lung sounds. Esophageal balloon in place. Previous\\n Sputum culture shows GNR, speciation PND.\\n Action:\\n Lots of suctioning through the night, decreased FiO2 from 50% to 40%,\\n decreased Peep from 23 to 21, HOB >30, oral care.\\n Response:\\n ABG WNL, could not draw a AM ABG because A-line no longer drawing,\\n intern aware.\\n Plan:\\n Cont to try to wean vent settings as tolerated, cont monitoring ABG\\n Hypotension (not Shock)\\n Assessment:\\n SBP 90-110\\ns MAP 62-66 Goal MAP >65 Levophed gtt @ 0.018 mcg/kg/min.\\n Action:\\n Trying to wean levophed gtt off\\n Response:\\n MAP tend to drop below 65 when weaned all the way off levophed.\\n Plan:\\n Cont to try to wean gtt off\\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\\n Assessment:\\n T-max 101.0\\n Action:\\n Sent blood, urine, and sputum cultures, treated with Tylenol\\n Response:\\n Temp decreased\\n Plan:\\n Follow up on cultures\\n CT scan from earlier in the week confirms fracture but did not detect\\n retropulsion. Neuro want pt in back brace when she is out of bed.\\n Log rolling pt has been d/c.\\n Bradycardia\\n Assessment:\\n At 0515 Patient HR dropped from 60-70\\ns to 45-50.\\n Action:\\n EKG done, showed pt was in junctional rhythm, intern came to assess pt.\\n Electrolytes WNL.\\n Response:\\n No intervention done yet because pt BP cont to be stable and all other\\n vital signs stable.\\n Plan:\\n Cont to monitor pt HR.\\n Fracture, other\\n Assessment:\\n Log roll precautions removed from day shift. Back brace needs to be\\n applied if pt is out of bed. Please read CT scan results from above\\n portion of note.\\n Action:\\n Still taking precautions to carefully turn pt but no longer long\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-09-24 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 634527,\n \"text\": \"55 yr old woman admitted from OSH after she fell down the stairs and\\n had traumatic T-spine fracture. Pt came to us with PNA from unknown\\n etiology? VAP. Full code, Allergies: PCN, tetracycline, Sulfa. PMH:\\n ETOH, smoker, Gerd, Hip replacement.\\n Alteration in Nutrition\\n Assessment:\\n Tube feeds increased to 30ml/hr. Tube feed residual 10-20ml.\\n Action:\\n cont to check residuals and try to increase rate\\n Response:\\n Residual staying 10ml/hr, kept rate at 30ml\\n Plan:\\n Try to increase Tube feeds to goal rate.\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n RUE DVT, pt on heparin gtt at 1700units/hr.\\n Action:\\n Ptt was therapeutic x2, AM PTT 68.6 WNL\\n Response:\\n No change to drip made, therapeutic dose.\\n Plan:\\n Cont heparin gtt, check PTT adjust heparin gtt per scale.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Moderate thick white in-line secretions, copious clear oral secretions,\\n clear/diminished lung sounds. Esophageal balloon in place. Previous\\n Sputum culture shows GNR, speciation PND.\\n Action:\\n Lots of suctioning through the night, decreased FiO2 from 50% to 40%,\\n decreased Peep from 23 to 21, HOB >30, oral care.\\n Response:\\n ABG WNL, could not draw an AM ABG because A-line no longer drawing,\\n intern aware. Intern and resp therapy to get ABG for AM.\\n Plan:\\n Cont to try to wean vent settings as tolerated, cont monitoring ABG\\n Hypotension (not Shock)\\n Assessment:\\n SBP 90-110\\ns MAP 62-66 Goal MAP >65 Levophed gtt @ 0.018 mcg/kg/min.\\n Action:\\n Trying to wean levophed gtt off\\n Response:\\n MAP tends to drop below 65 when weaned all the way off levophed.\\n Plan:\\n Cont to try to wean gtt off\\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\\n Assessment:\\n T-max 101.0\\n Action:\\n Sent blood, urine, and sputum cultures, treated with Tylenol\\n Response:\\n Temp decreased\\n Plan:\\n Follow up on cultures\\n CT scan from earlier in the week confirms fracture but did not detect\\n retropulsion. Neuro want pt in back brace when she is out of bed.\\n Log rolling pt has been d/c.\\n Bradycardia\\n Assessment:\\n At 0515 Patient HR dropped from 60-70\\ns to 45-50.\\n Action:\\n EKG done, showed pt was in junctional rhythm, intern came to assess pt.\\n Electrolytes WNL.\\n Response:\\n No intervention done yet because pt BP cont to be stable and all other\\n vital signs stable.\\n Plan:\\n Cont to monitor pt HR.\\n Fracture, other\\n Assessment:\\n Log roll precautions removed from day shift. Back brace needs to be\\n applied if pt is out of bed. Please read CT scan results from above\\n portion of note.\\n Action:\\n Still taking precautions to carefully turn pt but no longer on log roll\\n precautions\\n Response:\\n Pt tolerating turning fine.\\n Plan:\\n Use back brace if pt get out of bed. Back brace in room\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-09-24 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 634528,\n \"text\": \"24 Hour Events:\\n -Yesterday, stopped vanc and flagyl. Continued Aztreonam and\\n Levofloxicin\\n -Micro on sputum GNR due back today\\n -Febrile to 101- pan cultured; cxr\\n -Decreased FiO2 and PEEP to 21\\n -Early am, HR dropped to 40s-50s. EKG suggestive of junctional rhythm.\\n Held pressures, making good UOP, good O2 sats\\n -This am, art line is intermittently working. Drew ABG - pending\\n -Yesterday, SVV was 13; held on giving more fluids\\n -Random cortisol was very low; started hydrocortisone and florinef\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Vancomycin - 08:00 PM\\n Metronidazole - 08:00 AM\\n Levofloxacin - 08:39 AM\\n Aztreonam - 02:00 PM\\n Infusions:\\n Norepinephrine - 0.02 mcg/Kg/min\\n Midazolam (Versed) - 4 mg/hour\\n Other ICU medications:\\n Midazolam (Versed) - 03:50 PM\\n Fentanyl - 03:50 PM\\n Ranitidine (Prophylaxis) - 08:31 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:39 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.3\\nC (101\\n Tcurrent: 37.1\\nC (98.8\\n HR: 60 (60 - 86) bpm\\n BP: 103/46(61) {103/46(61) - 121/50(66)} mmHg\\n RR: 22 (17 - 23) insp/min\\n SpO2: 99%\\n Heart rhythm: JR (Junctional Rhythm)\\n Wgt (current): 101 kg (admission): 94.2 kg\\n Height: 67 Inch\\n CVP: 12 (12 - 339)mmHg\\n Total In:\\n 1,675 mL\\n 232 mL\\n PO:\\n TF:\\n 182 mL\\n 134 mL\\n IVF:\\n 1,233 mL\\n 98 mL\\n Blood products:\\n Total out:\\n 877 mL\\n 565 mL\\n Urine:\\n 727 mL\\n 535 mL\\n NG:\\n 30 mL\\n Stool:\\n Drains:\\n Balance:\\n 798 mL\\n -333 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 400 (400 - 400) mL\\n RR (Set): 22\\n RR (Spontaneous): 2\\n PEEP: 21 cmH2O\\n FiO2: 40%\\n RSBI Deferred: PEEP > 10\\n PIP: 33 cmH2O\\n Plateau: 30 cmH2O\\n Compliance: 44.4 cmH2O/mL\\n SpO2: 99%\\n ABG: 7.42/39/116/26/0\\n Ve: 9.7 L/min\\n PaO2 / FiO2: 290\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 326 K/uL\\n 8.9 g/dL\\n 151 mg/dL\\n 0.7 mg/dL\\n 26 mEq/L\\n 3.6 mEq/L\\n 2 mg/dL\\n 108 mEq/L\\n 141 mEq/L\\n 28.6 %\\n 8.9 K/uL\\n [image002.jpg]\\n 06:11 PM\\n 07:53 PM\\n 02:02 AM\\n 03:59 AM\\n 09:14 PM\\n 01:04 AM\\n 05:54 AM\\n 06:11 AM\\n 11:07 PM\\n 03:51 AM\\n WBC\\n 8.4\\n 8.1\\n 8.9\\n Hct\\n 28.1\\n 28.0\\n 28.6\\n Plt\\n 376\\n 358\\n 326\\n Cr\\n 0.6\\n 0.7\\n 0.7\\n TCO2\\n 29\\n 25\\n 25\\n 28\\n 28\\n 26\\n 26\\n Glucose\\n 120\\n 126\\n 151\\n Other labs: PT / PTT / INR:24.3/68.6/2.4, ALT / AST:24/16, Alk Phos / T\\n Bili:117/0.7, Amylase / Lipase:, Differential-Neuts:82.5 %,\\n Lymph:11.6 %, Mono:3.3 %, Eos:2.2 %, Lactic Acid:0.7 mmol/L,\\n Albumin:2.4 g/dL, LDH:204 IU/L, Ca++:8.5 mg/dL, Mg++:2.1 mg/dL, PO4:2.5\\n mg/dL\\n Assessment and Plan\\n 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture with respiratory failure\\n and difficulty weaning from vent.\\n # Respiratory failure: initial etiology unclear, likely multifactorial\\n (sedation vs hypovent obesity/orthotic brace vs ?) which lead to\\n VAP most likely with GNR (by one sputum).\\n - Concern for ARDS given clinical and radiographic picture.\\n - Placed esophageal balloon on which will help guide PEEP\\n settings.\\n - Over the evening yesterday, were able to decrease FiO2 and PEEP.\\n # VAP: Re-spiked fever overnight.\\n - Sputum from grew rare GNR; awaiting speciation.\\n - Has been Vanc, aztreonam, levofloxicin. Vanc trough today was 20\\n - Stopped vanc yesterday, , as there was no current evidence to\\n suggest a gram positive infection\\n - Also, stopped flagyl because had one neg c. diff toxin and CT did not\\n show evidence of colitis\\n - Continued aztreonam and levofloxicin for gram neg pneumonia for 8\\n days pending speciation (at that time can increase to 15 days if\\n necessary)\\n - need to reconsider restarting d/c'd meds if she continues to\\n spike a fever\\n # Hypotension, requiring Levophed:\\n - Hypovolemia is possibly a factor- responded to a transfusion; HCT had\\n been dropping. However, SVV with Vigileo was 13, making her CO less\\n likely to respond to fluids. Held on giving any boluses overnight.\\n - Sepsis also a factor- on broad spectrum abs\\n - Central line in place.\\n # Oliguria:\\n -BUN and Cr reassuring.\\n -Continues to be low. Hopefully, by decreasing PEEP and using levophed\\n to keep MAPs high, UOP will increase.\\n # RUE DVT: Started on heparin gtt on .\\n -Therapeutic in one day; may be related to poor nutritional status.\\n Will continue to closely monitor\\n # Abd distention: be chronic condition not requiring immediate\\n medical attention\\n - CT abd only showed appendiceal mucocele without inflammation, not\\n concerning, most likely chronic. No concern for intraabd disaster\\n - Now having BMs; c. diff toxin neg\\n - amylase and lipase wnl\\n # Adrenal Insufficency:\\n -Random cortisol was approx 3 when it should have been maximally\\n stimulated.\\n -Started hydrocortisone and florinef. ? switch to methylpred\\n # Anemia:\\n - Trend HCT\\n - Gave 1 un pRBC with good results\\n - INR rising, now 2.0, may be nutritional\\n # Spine fracture: neurologically intact distal to the lesion. prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\\n is low. Brace for OOB. Ok for anticoag per verbal report.\\n # Hypernatremia, resolved: correcting with g tube free flush and D5W\\n -Holding on g tube feeds at present due to high residuals\\n -Replete lytes as necessary\\n # Communication:\\n - Brother has been with pt, although, live in boyfriend of 10 is\\n her HCP. Boyfriend will hopefully visit pt today\\n ICU Care\\n Nutrition: tube feed with free water when able\\n Glycemic Control: Regular insulin sliding scale\\n DVT: SQ UF Heparin\\n Stress ulcer: H2 blocker\\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\\n Communication: ICU consent signed, (brother) \\n (boyfriend/POA) \\n Code status: Full code\\n Disposition: ICU\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 10:55 PM 30 mL/hour\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 01:36 AM\\n Arterial Line - 03:00 AM\\n Multi Lumen - 11:30 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-09-27 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 634882,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n - Anxiety yesterday afternoon and poor sleep overnight per nursing\\n - Per ABG, increased FiO2 (40->50%), holding PEEP (15)\\n - Gave Lasix 10 mg x 3, with small urine output response.\\n - Today is last day of steroids as well as last day of abx\\n (levofloxicin)\\n - Tightened sliding scale insulin yesterday\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Aztreonam - 06:00 AM\\n Vancomycin - 09:00 AM\\n Levofloxacin - 08:00 AM\\n Infusions:\\n Midazolam (Versed) - 4 mg/hour\\n Heparin Sodium - 1,700 units/hour\\n Fentanyl - 150 mcg/hour\\n Other ICU medications:\\n Haloperidol (Haldol) - 04:26 PM\\n Furosemide (Lasix) - 04:30 PM\\n Midazolam (Versed) - 06:16 AM\\n Fentanyl - 06:16 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:14 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37\\nC (98.6\\n Tcurrent: 35.7\\nC (96.2\\n HR: 66 (53 - 93) bpm\\n BP: 111/56(74) {103/52(69) - 135/78(93)} mmHg\\n RR: 20 (16 - 28) insp/min\\n SpO2: 95% on 400/20/15/.5\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 101 kg (admission): 94.2 kg\\n Height: 67 Inch\\n CVP: 18 (6 - 21)mmHg\\n Total In:\\n 2,681 mL\\n 687 mL\\n PO:\\n TF:\\n 1,443 mL\\n 432 mL\\n IVF:\\n 888 mL\\n 255 mL\\n Blood products:\\n Total out:\\n 3,135 mL\\n 185 mL\\n Urine:\\n 3,035 mL\\n 185 mL\\n NG:\\n Stool:\\n 100 mL\\n Drains:\\n Balance:\\n -454 mL\\n 502 mL\\n Respiratory support\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 400 (400 - 400) mL\\n RR (Set): 20\\n RR (Spontaneous): 23\\n PEEP: 15 cmH2O\\n FiO2: 50%\\n RSBI Deferred: PEEP > 10\\n PIP: 31 cmH2O\\n Plateau: 25 cmH2O\\n SpO2: 95%\\n ABG: 7.46/39/68/27/3\\n Ve: 7.7 L/min\\n PaO2 / FiO2: 136\\n Physical Examination\\n General Appearance: No acute distress, Overweight / Obese, opens eyes\\n but no purposeful movement\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric)\\n Abdominal: No(t) Soft, Non-tender, Bowel sounds present, Distended\\n Extremities: No clubbing or cyanosis, 3+ nonpitting edema of b/l hands,\\n LE without edema\\n Skin: no rashes or jaundice\\n Labs / Radiology\\n 411 K/uL\\n 8.3 g/dL\\n 163 mg/dL\\n 0.5 mg/dL\\n 27 mEq/L\\n 3.8 mEq/L\\n 12 mg/dL\\n 111 mEq/L\\n 144 mEq/L\\n 26.0 %\\n 9.7 K/uL\\n [image002.jpg]\\n 03:47 AM\\n 02:14 PM\\n 04:05 PM\\n 01:12 AM\\n 04:00 AM\\n 04:09 AM\\n 10:18 AM\\n 02:33 PM\\n 02:46 PM\\n 03:31 AM\\n WBC\\n 10.5\\n 9.6\\n 9.7\\n Hct\\n 27.5\\n 27.8\\n 26.0\\n Plt\\n 374\\n 374\\n 411\\n Cr\\n 0.6\\n 0.5\\n 0.5\\n 0.5\\n TCO2\\n 27\\n 26\\n 27\\n 28\\n 29\\n 26\\n 27\\n Glucose\\n 187\\n 194\\n 195\\n 195\\n 163\\n Other labs: PT / PTT / INR:15.3/69.9/1.3, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\\n Amylase / Lipase:, Differential-Neuts:86.1 %, Lymph:10.3 %,\\n Mono:2.8 %, Eos:0.5 %, Lactic Acid:2.0 mmol/L, Albumin:2.4 g/dL,\\n LDH:204 IU/L, Ca++:8.3 mg/dL, Mg++:2.1 mg/dL, PO4:3.3 mg/dL\\n Assessment and Plan\\n 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture with respiratory failure\\n and difficulty weaning from vent.\\n # Respiratory failure: Intubated on for resp decompensation.\\n Likely VAP. Unlikely to have tracheomalacia as initially\\n transferred for.\\n - wean PEEP\\n - Given mild alkalosis, will decrease RR to 18, repeat ABG\\n - discuss need for trach with patient and her family\\n - Will continue gentle diuresis once alkalosis resolved\\n # Pneumonia: Pansensitive Kleb oxytoca pneumonia and sputum with GPCs\\n on gram stain. Afebrile overnight. On levofloxacin since .\\n Vancomycin, aztreonam have been stopped. Resp status seems to be\\n improving.\\n - Follow cultures\\n - d/c levofloxacin having completed 8 day course\\n # Sedation: On versed and fentanyl\\n # EKG changes: Sinus bradycardia, now somewhat improved. Likely\\n related to increased vagal tone possibly related to steroid\\n replacement. Atrial EKG shows p-waves and cardiac enzymes normal.\\n - Continue to monitor\\n # Hypotension: Improved, off levophed for 2-3 days now, with good urine\\n output. CVP increasing with reduction in PEEP. Likely poor\\n adrenal response in setting of acute illness and very high PEEP.\\n -D/C fludricort and hydrocortisone now that the 5 day steroid course is\\n complete\\n -monitor, expect improvement with continual reduction in PEEP\\n # RUE DVT: Started on heparin gtt on , now therapeutic. Follow\\n PTTs. Would hold off on coumadin at least until s/p trach.\\n - continue to monitor\\n # Adrenal Insufficency: Random cortisol was approx 3 when it should\\n have been maximally stimulated.\\n - hydrocortisone and florinef for 5 days\\n # Anemia: Stable.\\n - Trend HCT\\n # Spine fracture: Neurologically intact distal to the lesion. Prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - CT of C, L spine when stable. Currently, unlikely to change\\n management and high risk for complications with transport.\\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\\n is low. Brace for OOB. Ok for anticoag per note.\\n # Communication:\\n - Boyfriend of 10 is her HCP. Also brother is involved\\n FEN/GI: Tube feeds @ goal\\n DVT: Treatment dose heparin\\n Ulcer: Ranitidine\\n VAP: Prevention per routine\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 08:13 PM 60 mL/hour\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 11:30 AM\\n Arterial Line - 04:00 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-09-27 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 634883,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n - Anxiety yesterday afternoon and poor sleep overnight per nursing\\n - Per ABG, increased FiO2 (40->50%), holding PEEP (15)\\n - Gave Lasix 10 mg x 3, with small urine output response.\\n - Today is last day of steroids as well as last day of abx\\n (levofloxicin)\\n - Tightened sliding scale insulin yesterday\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Aztreonam - 06:00 AM\\n Vancomycin - 09:00 AM\\n Levofloxacin - 08:00 AM\\n Infusions:\\n Midazolam (Versed) - 4 mg/hour\\n Heparin Sodium - 1,700 units/hour\\n Fentanyl - 150 mcg/hour\\n Other ICU medications:\\n Haloperidol (Haldol) - 04:26 PM\\n Furosemide (Lasix) - 04:30 PM\\n Midazolam (Versed) - 06:16 AM\\n Fentanyl - 06:16 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:14 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37\\nC (98.6\\n Tcurrent: 35.7\\nC (96.2\\n HR: 66 (53 - 93) bpm\\n BP: 111/56(74) {103/52(69) - 135/78(93)} mmHg\\n RR: 20 (16 - 28) insp/min\\n SpO2: 95% on 400/20/15/.5\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 101 kg (admission): 94.2 kg\\n Height: 67 Inch\\n CVP: 18 (6 - 21)mmHg\\n Total In:\\n 2,681 mL\\n 687 mL\\n PO:\\n TF:\\n 1,443 mL\\n 432 mL\\n IVF:\\n 888 mL\\n 255 mL\\n Blood products:\\n Total out:\\n 3,135 mL\\n 185 mL\\n Urine:\\n 3,035 mL\\n 185 mL\\n NG:\\n Stool:\\n 100 mL\\n Drains:\\n Balance:\\n -454 mL\\n 502 mL\\n Respiratory support\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 400 (400 - 400) mL\\n RR (Set): 20\\n RR (Spontaneous): 23\\n PEEP: 15 cmH2O\\n FiO2: 50%\\n RSBI Deferred: PEEP > 10\\n PIP: 31 cmH2O\\n Plateau: 25 cmH2O\\n SpO2: 95%\\n ABG: 7.46/39/68/27/3\\n Ve: 7.7 L/min\\n PaO2 / FiO2: 136\\n Physical Examination\\n General Appearance: No acute distress, Overweight / Obese, opens eyes\\n but no purposeful movement\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric)\\n Abdominal: No(t) Soft, Non-tender, Bowel sounds present, Distended\\n Extremities: No clubbing or cyanosis, 3+ nonpitting edema of b/l hands,\\n LE without edema\\n Skin: no rashes or jaundice\\n Labs / Radiology\\n 411 K/uL\\n 8.3 g/dL\\n 163 mg/dL\\n 0.5 mg/dL\\n 27 mEq/L\\n 3.8 mEq/L\\n 12 mg/dL\\n 111 mEq/L\\n 144 mEq/L\\n 26.0 %\\n 9.7 K/uL\\n [image002.jpg]\\n 03:47 AM\\n 02:14 PM\\n 04:05 PM\\n 01:12 AM\\n 04:00 AM\\n 04:09 AM\\n 10:18 AM\\n 02:33 PM\\n 02:46 PM\\n 03:31 AM\\n WBC\\n 10.5\\n 9.6\\n 9.7\\n Hct\\n 27.5\\n 27.8\\n 26.0\\n Plt\\n 374\\n 374\\n 411\\n Cr\\n 0.6\\n 0.5\\n 0.5\\n 0.5\\n TCO2\\n 27\\n 26\\n 27\\n 28\\n 29\\n 26\\n 27\\n Glucose\\n 187\\n 194\\n 195\\n 195\\n 163\\n Other labs: PT / PTT / INR:15.3/69.9/1.3, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\\n Amylase / Lipase:, Differential-Neuts:86.1 %, Lymph:10.3 %,\\n Mono:2.8 %, Eos:0.5 %, Lactic Acid:2.0 mmol/L, Albumin:2.4 g/dL,\\n LDH:204 IU/L, Ca++:8.3 mg/dL, Mg++:2.1 mg/dL, PO4:3.3 mg/dL\\n Assessment and Plan\\n 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture with respiratory failure\\n and difficulty weaning from vent.\\n # Respiratory failure: Intubated on for resp decompensation.\\n Likely VAP. Unlikely to have tracheomalacia as initially\\n transferred for.\\n - wean PEEP\\n - Given mild alkalosis, will decrease RR to 18, repeat ABG\\n - discuss need for trach with patient and her family\\n - Will continue gentle diuresis once alkalosis resolved\\n # Pneumonia: Pansensitive Kleb oxytoca pneumonia and sputum with GPCs\\n on gram stain. Afebrile overnight. On levofloxacin since .\\n Vancomycin, aztreonam have been stopped. Resp status seems to be\\n improving.\\n - Follow cultures\\n - d/c levofloxacin having completed 8 day course\\n # Sedation: On versed and fentanyl\\n # EKG changes: Sinus bradycardia, now somewhat improved. Likely\\n related to increased vagal tone possibly related to steroid\\n replacement. Atrial EKG shows p-waves and cardiac enzymes normal.\\n - Continue to monitor\\n # Hypotension: Improved, off levophed for 2-3 days now, with good urine\\n output. CVP increasing with reduction in PEEP. Likely poor\\n adrenal response in setting of acute illness and very high PEEP.\\n -D/C fludricort and hydrocortisone now that the 5 day steroid course is\\n complete\\n -monitor, expect improvement with continual reduction in PEEP\\n # RUE DVT: Started on heparin gtt on , now therapeutic. Follow\\n PTTs. Would hold off on coumadin at least until s/p trach.\\n - continue to monitor\\n # Adrenal Insufficency: Random cortisol was approx 3 when it should\\n have been maximally stimulated.\\n - hydrocortisone and florinef for 5 days\\n # Anemia: Stable.\\n - Trend HCT\\n # Spine fracture: Neurologically intact distal to the lesion. Prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - CT of C, L spine when stable. Currently, unlikely to change\\n management and high risk for complications with transport.\\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\\n is low. Brace for OOB. Ok for anticoag per note.\\n # Communication:\\n - Boyfriend of 10 is her HCP. Also brother is involved\\n FEN/GI: Tube feeds @ goal\\n DVT: Treatment dose heparin\\n Ulcer: Ranitidine\\n VAP: Prevention per routine\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 08:13 PM 60 mL/hour\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 11:30 AM\\n Arterial Line - 04:00 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition: ICU\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-09-23 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 634459,\n \"text\": \"Events: Attempt to lighten sedation, stop Levophed gtt- MS \\n stability labile from lethargic to restless in bed/crying w/\\n intermittent BP 120\\ns/ w/ and W/O stimulation. UOP cont 10-30cc/hr.\\n Vigileo monitor on- SVV . Bladder pressure 14. TF restarted w/ goal\\n slow inc as tolerated w/ recent high residuals.\\n Alteration in Nutrition\\n Assessment:\\n Minimal residuals\\n Action:\\n Restarting TF replete w/ fiber @ 10cc/hr w/ Q6hr 20cc flush\\n Response:\\n Tolerating, goal advance Q6hr as tolerated\\n Plan:\\n Cont TF, monitor residuals, inc Q6hrs as tolerated\\n Hypotension (not Shock)\\n Assessment:\\n BP labile- SBP 86-120, UOP down to 10cc/hr\\n Action:\\n Vigileo on- SVV , In AM attempt wean off Levo gtt\\n Response:\\n No fluid blousing, Levophed gtt started- titrated for MAP >65, UOP,\\n Levo gtt @ .020mcg/kg/min\\n Plan:\\n Cont Vigeligo monitoring, CVP monitoring, UOP, Levophed gtt, fluid\\n bolus if inc in SVV, in CVP\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Heparin gtt @ 1700units/hr, PTT 76\\n Action:\\n Heparin gtt therapeutic x2, cont @ 1700units/hr\\n Response:\\n No s/s bleeding, guiac neg gastric secretions, stool\\n Plan:\\n Cont Hep gtt as ordered w/I scale parameters, check PTT w/ AM labs,\\n monitor s/s bleeding\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n LS clear bilat upper lobes, diminished bilat lower lobes, turning w/o\\n desating, suctioning minimally for thin clear secretions, Sat 96-100%,\\n w/ decres in sedation waking in afternoon and overbreathing vent 1-3\\n bpm\\n Action:\\n No vent changes, suctioned post coughing x1, turning as tolerated,\\n sedation titrated- currently @ 100mcg/hr Fentanyl gtt, 2 mg/hr Versed\\n gtt. 1x blousing w/ .5mg Versed and 50mcg Fentanyl for sig inc in\\n agitation/breathing over vent/pulling @ lines, resp tesing w/\\n esophageal balloon\\n Response:\\n Synchronous w/ vent, RN care/turning/mouth care w/ decreased agitation,\\n Sat >96%,\\n Plan:\\n Cont IV ABX, pulm toilet, esophageal balloon readins, monitor sat\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-09-23 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 634460,\n \"text\": \"Events: Attempt to lighten sedation, stop Levophed gtt- MS \\n stability labile from lethargic to restless in bed/crying w/\\n intermittent BP 120\\ns/ w/ and W/O stimulation. UOP cont 10-30cc/hr.\\n Vigileo monitor on- SVV . Bladder pressure 14. TF restarted w/ goal\\n slow inc as tolerated w/ recent high residuals.\\n Alteration in Nutrition\\n Assessment:\\n Minimal residuals\\n Action:\\n Restarting TF replete w/ fiber @ 10cc/hr w/ Q6hr 20cc flush\\n Response:\\n Tolerating, goal advance Q6hr as tolerated\\n Plan:\\n Cont TF, monitor residuals, inc Q6hrs as tolerated\\n Hypotension (not Shock)\\n Assessment:\\n BP labile- SBP 86-120, UOP down to 10cc/hr\\n Action:\\n Vigileo on- SVV , In AM attempt wean off Levo gtt\\n Response:\\n No fluid blousing, Levophed gtt started- titrated for MAP >65, UOP,\\n Levo gtt @ .020mcg/kg/min\\n Plan:\\n Cont Vigeligo monitoring, CVP monitoring, UOP, Levophed gtt, fluid\\n bolus if inc in SVV, in CVP\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Heparin gtt @ 1700units/hr, PTT 76\\n Action:\\n Heparin gtt therapeutic x2, cont @ 1700units/hr\\n Response:\\n No s/s bleeding, guiac neg gastric secretions, stool\\n Plan:\\n Cont Hep gtt as ordered w/I scale parameters, check PTT w/ AM labs,\\n monitor s/s bleeding\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n LS clear bilat upper lobes, diminished bilat lower lobes, turning w/o\\n desating, suctioning minimally for thin clear secretions, Sat 96-100%,\\n w/ decres in sedation waking in afternoon and overbreathing vent 1-3\\n bpm, afebrile\\n Action:\\n No vent changes, suctioned post coughing x1, turning as tolerated,\\n sedation titrated- currently @ 100mcg/hr Fentanyl gtt, 2 mg/hr Versed\\n gtt. 1x blousing w/ .5mg Versed and 50mcg Fentanyl for sig inc in\\n agitation/breathing over vent/pulling @ lines, resp tesing w/\\n esophageal balloon\\n Response:\\n Synchronous w/ vent, RN care/turning/mouth care w/ decreased agitation,\\n Sat >96%,\\n Plan:\\n Cont IV ABX, pulm toilet, esophageal balloon readins, monitor sat\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-09-24 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 634608,\n \"text\": \"Synopsis per prior nursing note:\\n 55 yr old woman admitted from OSH after she fell down the stairs and\\n had traumatic T-spine fracture. Pt came to us with PNA from unknown\\n etiology? VAP. Full code, Allergies: PCN, tetracycline, Sulfa. PMH:\\n ETOH, smoker, Gerd, Hip replacement.\\n Alteration in Nutrition\\n Assessment:\\n Tube feeds increased to 40ml/hr. Residuals ~10ml. Hypoactive BS.\\n Continues to have brown, liquid stool.\\n Action:\\n Residuals and BS checked. Rate increased to 40ml/hr.\\n Response:\\n Residual continued at 10ml/hr, continued rate of 40cc/hr.\\n Plan:\\n Advance TF to goal as tolerated. Monitor BS.\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n RUE DVT, pt on heparin gtt at 1700units/hr.\\n Action:\\n Ptt was therapeutic x3. Heparin gtt continued.\\n Response:\\n No change to drip made, therapeutic dose.\\n Plan:\\n Cont heparin gtt, check PTT w/ am labs and adjust heparin gtt per\\n scale.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Suctioned moderate, thick white ET tube secretions and copious clear,\\n oral secretions. LS rhonchi w/ dim bases. Esophageal balloon in\\n place.\\n Action:\\n Continued to suction frequently, HOB >30, oral care. Continued\\n steroids.\\n Response:\\n ABG WNL. Continued to need suctioning. O2 sats >98%.\\n Plan:\\n Monitor LS. Suction as needed. Wean vent as tolerated.\\n Hypotension (not Shock)\\n Assessment:\\n BP 89-106/43-53. MAP 56-67. Goal MAP >60. Urine output>40cc/hr.\\n Action:\\n Levophed gtt weaned off. Given 2.5 L NS total in bolus\\n for low BP. New\\n A-line placed-positional.\\n Response:\\n MAPs continued to be ~60-65.\\n Plan:\\n Monitor BP. ?fluid bolus vs levophed gtt. ?need for new a-line.\\n Bradycardia\\n Assessment:\\n SB, HR 45-63. HR increased w/ activity.\\n Action:\\n HR monitored.\\n Response:\\n No intervention done because BP cont to be stable and all other vital\\n signs stable.\\n Plan:\\n Monitor HR. EKG if indicated.\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2167-09-24 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 634611,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 6\\n Ideal body weight: 61.2 None\\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: Unknown\\n Procedure location:\\n Reason:\\n Tube Type\\n ETT:\\n Position: cm at teeth\\n Route:\\n Type: Standard\\n Size: 7.5mm\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Diminished\\n Comments:\\n Secretions\\n Sputum color / consistency: White / Thick\\n Sputum source/amount: Suctioned / Small\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance: Continuous invasive ventilation\\n Visual assessment of breathing pattern: Normal quiet breathing\\n Assessment of breathing comfort: No response (sleeping / sedated)\\n Non-invasive ventilation assessment:\\n Invasive ventilation assessment:\\n Trigger work assessment:\\n Dysynchrony assessment:\\n Comments:\\n Plan\\n Next 24-48 hours: Utilize ARDSnet protocol, Reduce PEEP as tolerated;\\n Comments: Pt remains on 21 of\\n PEEP. Ballon measurements taken, which showed that pt was -3cm of peep.\\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\\n Intolerant of weaning attempts\\n Respiratory Care Shift Procedures\\n Transports:\\n Destination (R/T)\\n Time\\n Complications\\n Comments\\n Bedside Procedures:\\n Pleural pressure measurement (930)\\n Comments:\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2167-09-25 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 634686,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 7\\n Ideal body weight: 61.2 None\\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: Unknown\\n Reason: re-positioned 21cm this shift - confirmed correct placement via\\n bronchoscopy at bedside\\n Tube Type\\n ETT:\\n Position: 21 cm at teeth\\n Route: Oral\\n Type: Standard\\n Size: 7.5mm\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Rhonchi\\n LUL Lung Sounds: Rhonchi\\n LLL Lung Sounds: Diminished\\n Secretions\\n Sputum color / consistency: White / Thick\\n Sputum source/amount: Suctioned / Small\\n Ventilation Assessment\\n Level of breathing assistance: Continuous invasive ventilation\\n Visual assessment of breathing pattern: Normal quiet breathing;\\n Comments: Continues on A/C ventilation w/ PIP/Pplat = 34/28, not\\n overbreathing set vent rate. PEEP remains at +21cm. Bronch at bedside\\n to confirm ETT placement after ETT was not clearly visible on CXR.\\n Sputum spec sent.\\n Assessment of breathing comfort: No response (sleeping / sedated)\\n Non-invasive ventilation assessment:\\n Invasive ventilation assessment:\\n Trigger work assessment: Not triggering\\n Plan\\n Next 24-48 hours: Reduce PEEP as tolerated\\n Reason for continuing current ventilatory support: Underlying illness\\n not resolved; Comments: esophogeal balloon remains in place w/ PEEP at\\n +21. no measurements made this shift.\\n Respiratory Care Shift Procedures\\n Bedside Procedures:\\n Bronchoscopy (1100)\\n Comments: bronchoscopy at bedside w/out complication.\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2167-09-26 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 634783,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 8\\n Ideal body weight: 61.2 None\\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: Unknown\\n Procedure location:\\n Reason:\\n Tube Type\\n ETT:\\n Position: cm at teeth\\n Route:\\n Type: Standard\\n Size: 7.5mm\\n Tracheostomy tube:\\n Type:\\n Manufacturer:\\n Size:\\n PMV:\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: cmH2O\\n Cuff volume: mL /\\n Airway problems:\\n Comments:\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Diminished\\n Comments:\\n Secretions\\n Sputum color / consistency: Tan / Thick\\n Sputum source/amount: Suctioned / Small\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance:\\n Visual assessment of breathing pattern:\\n Assessment of breathing comfort:\\n Non-invasive ventilation assessment:\\n Invasive ventilation assessment:\\n Trigger work assessment:\\n Dysynchrony assessment:\\n Comments:\\n Plan\\n Next 24-48 hours:\\n Reason for continuing current ventilatory support:\\n Respiratory Care Shift Procedures\\n Transports:\\n Destination (R/T)\\n Time\\n Complications\\n Comments\\n Bedside Procedures:\\n Comments:\\n Patient remains on mechanical ventilation, with oxygenation issues\\n persisting. Decrease in PEEP followed by increase in Fi02 as noted on\\n flow sheet. Bilateral breath sounds diminished with few scattered\\n rhonchi. MDI\\ns given as ordered.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-09-27 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 634870,\n \"text\": \"Chief Complaint: respiratory failure\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 55 yo F w/ prolonged hospital course, etoh abuse with fall and thoracic\\n compression fxs who was tranferred from OSH for evaluation of Y stent\\n for BTM, course has been c/b R UE DVT and sepsis with hypotension,\\n pressor needs, and resp failure likely VAP,TBM now with failure to\\n wean, still with high PEEP requirements.\\n 24 Hour Events:\\n EKG - At 12:00 PM\\n low voltage, pre Haldol administration QRS .46\\n lasix X 3 doses with good urine output\\n peep held at 15, fio2 increased to 50%\\n History obtained from ho\\n Patient unable to provide history: Sedated, intubated\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Aztreonam - 06:00 AM\\n Vancomycin - 09:00 AM\\n Levofloxacin - 08:06 AM\\n Infusions:\\n Midazolam (Versed) - 4 mg/hour\\n Fentanyl - 150 mcg/hour\\n Heparin Sodium - 1,700 units/hour\\n Other ICU medications:\\n Haloperidol (Haldol) - 04:26 PM\\n Furosemide (Lasix) - 04:30 PM\\n Midazolam (Versed) - 06:16 AM\\n Fentanyl - 06:16 AM\\n Other medications:\\n per (reviewed)\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 10:59 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37\\nC (98.6\\n Tcurrent: 36.8\\nC (98.2\\n HR: 61 (53 - 93) bpm\\n BP: 137/70(95) {103/52(69) - 137/70(95)} mmHg\\n RR: 20 (16 - 28) insp/min\\n SpO2: 96%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 101 kg (admission): 94.2 kg\\n Height: 67 Inch\\n CVP: 19 (6 - 21)mmHg\\n Total In:\\n 2,679 mL\\n 1,165 mL\\n PO:\\n TF:\\n 1,443 mL\\n 639 mL\\n IVF:\\n 886 mL\\n 526 mL\\n Blood products:\\n Total out:\\n 3,135 mL\\n 305 mL\\n Urine:\\n 3,035 mL\\n 305 mL\\n NG:\\n Stool:\\n 100 mL\\n Drains:\\n Balance:\\n -456 mL\\n 860 mL\\n Respiratory support\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 400 (400 - 400) mL\\n RR (Set): 20\\n RR (Spontaneous): 0\\n PEEP: 15 cmH2O\\n FiO2: 50%\\n RSBI Deferred: PEEP > 10\\n PIP: 29 cmH2O\\n Plateau: 26 cmH2O\\n SpO2: 96%\\n ABG: 7.46/39/68/27/3\\n Ve: 7.8 L/min\\n PaO2 / FiO2: 136\\n Physical Examination\\n General Appearance: No acute distress, Overweight / Obese\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: Endotracheal tube\\n Lymphatic: Cervical WNL\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Diminished), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\\n )\\n Extremities: Right: 1+, Left: 1+, No(t) Cyanosis, No(t) Clubbing\\n Musculoskeletal: No(t) Muscle wasting\\n Skin: Warm\\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\\n to: Not assessed, Movement: Non -purposeful, Sedated, No(t) Paralyzed,\\n Tone: Not assessed\\n Labs / Radiology\\n 8.3 g/dL\\n 411 K/uL\\n 163 mg/dL\\n 0.5 mg/dL\\n 27 mEq/L\\n 3.8 mEq/L\\n 12 mg/dL\\n 111 mEq/L\\n 144 mEq/L\\n 26.0 %\\n 9.7 K/uL\\n [image002.jpg]\\n 03:47 AM\\n 02:14 PM\\n 04:05 PM\\n 01:12 AM\\n 04:00 AM\\n 04:09 AM\\n 10:18 AM\\n 02:33 PM\\n 02:46 PM\\n 03:31 AM\\n WBC\\n 10.5`\\n 1q\\n 9.6\\n 9.7\\n Hct\\n 27.5\\n 27.8\\n 26.0\\n Plt\\n 374\\n 374\\n 411\\n Cr\\n 0.6\\n 0.5\\n 0.5\\n 0.5\\n TCO2\\n 27\\n 26\\n 27\\n 28\\n 29\\n 26\\n 27\\n Glucose\\n 187\\n 194\\n 195\\n 195\\n 163\\n Other labs: PT / PTT / INR:15.3/69.9/1.3, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\\n Amylase / Lipase:, Differential-Neuts:86.1 %, Lymph:10.3 %,\\n Mono:2.8 %, Eos:0.5 %, Lactic Acid:2.0 mmol/L, Albumin:2.4 g/dL,\\n LDH:204 IU/L, Ca++:8.3 mg/dL, Mg++:2.1 mg/dL, PO4:3.3 mg/dL\\n Imaging: cxr--et, og,r IJ in good position, slightly improved aeration\\n at r and l base, still with b/l effusions, opacaities\\n Microbiology: no new data\\n Assessment and Plan\\n 55 yo F w/ prolonged hospital course, etoh abuse with fall and thoracic\\n compression fxs who was tranferred from OSH for evaluation of Y stent\\n for BTM, course has been c/b R UE DVT and sepsis with hypotension,\\n pressor needs, and resp failure likely VAP,TBM now with failure to\\n wean, still with high PEEP requirements.\\n Main issues remain--\\n # Respiratory failure\\n Continue to wean PEEP as tolerated following abg/sats\\n Once PEEP lower, heading toward trach, given prolonged course,\\n poor MS, vol overload\\n Vol overload with effusions likely also contributing to poor\\n wean\\noff pressors and no longer needing boluses to maintain BP, keep\\n I/O goal even to neg 500 cc neg, trend I/os and continue IV lasix today\\n ultimately benefit form investigation for TBM\\n Decrease RR on vent to optimize pH\\n # Adrenal insufficiency\\n Had very low random cortisol while in shock and respiratory\\n failure\\n On steroids, has come off and stayed off of pressors.\\n cpmplete 5 day course of stress dose steroids--will discontinue\\n after today.\\n # Bradycardia\\n Rhythm is sinus, confirmed by CVL-directed\\natrial\\n lead\\n Heart rate increases with stimulation, suggesting mostly vagal\\n in etiology\\n # Klebsiella VAP\\n complete course of levofloxacin today (day ), received vanco\\n and which where d/c\\nd given neg cx data.\\n # Shock\\nresolved, remains hemdynamically stable off pressors\\n Treating adrenal insufficiency as above\\n # R Upper extremity DVT\\n Therapeutic heparin gtt (continue for now as heading toward trach)\\n # Traumatic thoracic spinal fracture\\n Eventual MRI. Too high-risk at present. Brace when out of bed.\\n Ortho trauma following.\\n # Glycemic control--imporved control with tightened SSI while on\\n steroids\\n Other issues as per ICU team note. Put in for picc placement.\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 08:13 PM 60 mL/hour\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n Multi Lumen - 11:30 AM\\n Arterial Line - 04:00 PM\\n Comments: put in for picc line\\n Prophylaxis:\\n DVT: (Systemic anticoagulation: Heparin gtt)\\n Stress ulcer:\\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :ICU\\n Total time spent: 45 minutes\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-09-26 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 634753,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n BRONCHOSCOPY - At 10:45 AM\\n bronchoscopy for reposition of ETT not seen on CHX. Sedated on total\\n 250mcg IVP FEntanyl, 2 MG IVP Midaz and cont on IV sedation for\\n precedure. Provedure completed w/o incedence bacn on previous AC vent\\n settings\\n Able to wean PEEP throughout the day after bronch\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Metronidazole - 08:00 AM\\n Aztreonam - 06:00 AM\\n Vancomycin - 09:00 AM\\n Levofloxacin - 09:30 AM\\n Infusions:\\n Midazolam (Versed) - 4 mg/hour\\n Fentanyl - 125 mcg/hour\\n Heparin Sodium - 1,700 units/hour\\n Other ICU medications:\\n Ranitidine (Prophylaxis) - 09:28 AM\\n Fentanyl - 01:36 AM\\n Midazolam (Versed) - 01:37 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:54 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.9\\nC (98.4\\n Tcurrent: 36.1\\nC (97\\n HR: 64 (47 - 79) bpm\\n BP: 105/55(348) {89/45(61) - 125/84(348)} mmHg\\n RR: 20 (20 - 30) insp/min\\n SpO2: 95%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 101 kg (admission): 94.2 kg\\n Height: 67 Inch\\n CVP: 19 (13 - 19)mmHg\\n Total In:\\n 4,142 mL\\n 640 mL\\n PO:\\n TF:\\n 2,219 mL\\n 411 mL\\n IVF:\\n 1,833 mL\\n 229 mL\\n Blood products:\\n Total out:\\n 1,000 mL\\n 660 mL\\n Urine:\\n 800 mL\\n 660 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 3,142 mL\\n -20 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 400 (400 - 400) mL\\n RR (Set): 20\\n RR (Spontaneous): 0\\n PEEP: 15 cmH2O\\n FiO2: 40%\\n PIP: 28 cmH2O\\n Plateau: 23 cmH2O\\n Compliance: 50 cmH2O/mL\\n SpO2: 95%\\n ABG: 7.43/41/80/24/2\\n Ve: 7.4 L/min\\n PaO2 / FiO2: 200\\n Physical Examination\\n General Appearance: No acute distress, Overweight / Obese\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric)\\n Abdominal: No(t) Soft, Non-tender, Bowel sounds present, Distended\\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\\n Clubbing\\n Skin: Not assessed\\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\\n assessed, Sedated, Tone: Not assessed\\n Labs / Radiology\\n 374 K/uL\\n 8.7 g/dL\\n 194 mg/dL\\n 0.5 mg/dL\\n 24 mEq/L\\n 4.9 mEq/L\\n 8 mg/dL\\n 111 mEq/L\\n 142 mEq/L\\n 27.8 %\\n 9.6 K/uL\\n [image002.jpg]\\n 06:17 AM\\n 07:00 AM\\n 08:18 AM\\n 04:18 PM\\n 03:47 AM\\n 02:14 PM\\n 04:05 PM\\n 01:12 AM\\n 04:00 AM\\n 04:09 AM\\n WBC\\n 10.5\\n 9.6\\n Hct\\n 27.5\\n 27.8\\n Plt\\n 374\\n 374\\n Cr\\n 0.6\\n 0.6\\n 0.5\\n TropT\\n <0.01\\n <0.01\\n TCO2\\n 21\\n 28\\n 27\\n 26\\n 27\\n 28\\n Glucose\\n 153\\n 187\\n 194\\n Other labs: PT / PTT / INR:17.0/84.8/1.5, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\\n Amylase / Lipase:, Differential-Neuts:86.1 %, Lymph:10.3 %,\\n Mono:2.8 %, Eos:0.5 %, Lactic Acid:2.0 mmol/L, Albumin:2.4 g/dL,\\n LDH:204 IU/L, Ca++:8.4 mg/dL, Mg++:2.1 mg/dL, PO4:3.1 mg/dL\\n Assessment and Plan\\n 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture with respiratory failure\\n and difficulty weaning from vent.\\n # Respiratory failure currently with unclear ETT location: Intubated\\n on for resp decompensation. Likely VAP. Unlikely to have\\n tracheomalacia as initially transferred for.\\n - bronch for ETT location\\n - wean PEEP\\n # Pneumonia: Kleb oxytoca pneumonia and sputum with GPCs on gram\\n stain. Afebrile overnight. On levofloxacin, vancomycin, aztreonam.\\n Resp status seems to be improving.\\n - Follow cultures\\n - d/c aztreonam\\n - Continue levofloxacin for 8 days\\n # EKG changes: Sinus bradycardia. Very low voltages and no change in\\n QRS morphology. P-waves are visible and prolonged PR interval is old.\\n CK and troponins flat. Likely related to increased vagal tone possibly\\n related to steroid replacement. Atrial EKG with p-waves c/w sinus\\n bradycardia.\\n - Will avoid excessive alpha-agonism\\n - Continue to monitor\\n # Hypotension: now off levophed, with good urine output. Hypovolemia\\n is possibly a factor- responded to a transfusion; HCT had been\\n dropping. However, SVV with Vigileo was 7, making her CO less likely\\n to respond to fluids. Held on giving any boluses overnight. Today CVP\\n is low given PEEP. Sepsis also a consideration.\\n - continue abx as above (vanc and levofloxacin)\\n - replete fluids.\\n - Restart pressors as needed. Consider dopamine given bradycardia.\\n # RUE DVT: Started on heparin gtt on .\\n - closely monitor\\n # Adrenal Insufficency: Random cortisol was approx 3 when it should\\n have been maximally stimulated.\\n - hydrocortisone and florinef for 5 days\\n # Anemia: Stable.\\n - Trend HCT\\n # Spine fracture: Neurologically intact distal to the lesion. Prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - CT of C, L spine when stable. Currently, unlikely to change\\n management and high risk for complications with transport.\\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\\n is low. Brace for OOB. Ok for anticoag per note.\\n # Communication:\\n - Brother has been with pt, although, live in boyfriend of 10 is\\n her HCP.\\n ICU \\n Nutrition:\\n Replete with Fiber (Full) - 08:13 PM 60 mL/hour, INR rising\\n (? Nutritional deficiencies)\\n Glycemic Control: ISS\\n Lines:\\n Multi Lumen - 11:30 AM\\n Arterial Line - 04:00 PM\\n Prophylaxis:\\n DVT: heparin gtt\\n Stress ulcer: H2 blocker\\n VAP:\\n Comments:\\n Communication: ICU consent signed, (brother) \\n (boyfriend/POA) \\n Code status: Full code\\n Disposition: ICU\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-09-26 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 634761,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n BRONCHOSCOPY - At 10:45 AM\\n bronchoscopy for reposition of ETT not seen on CHX. Sedated on total\\n 250mcg IVP FEntanyl, 2 MG IVP Midaz and cont on IV sedation for\\n precedure. Provedure completed w/o incedence bacn on previous AC vent\\n settings\\n Able to wean PEEP throughout the day after bronch\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Metronidazole - 08:00 AM\\n Aztreonam - 06:00 AM\\n Vancomycin - 09:00 AM\\n Levofloxacin - 09:30 AM\\n Infusions:\\n Midazolam (Versed) - 4 mg/hour\\n Fentanyl - 125 mcg/hour\\n Heparin Sodium - 1,700 units/hour\\n Other ICU medications:\\n Ranitidine (Prophylaxis) - 09:28 AM\\n Fentanyl - 01:36 AM\\n Midazolam (Versed) - 01:37 AM\\n Other medications:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:54 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.9\\nC (98.4\\n Tcurrent: 36.1\\nC (97\\n HR: 64 (47 - 79) bpm\\n BP: 105/55(348) {89/45(61) - 125/84(348)} mmHg\\n RR: 20 (20 - 30) insp/min\\n SpO2: 95%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 101 kg (admission): 94.2 kg\\n Height: 67 Inch\\n CVP: 19 (13 - 19)mmHg\\n Total In:\\n 4,142 mL\\n 640 mL\\n PO:\\n TF:\\n 2,219 mL\\n 411 mL\\n IVF:\\n 1,833 mL\\n 229 mL\\n Blood products:\\n Total out:\\n 1,000 mL\\n 660 mL\\n Urine:\\n 800 mL\\n 660 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 3,142 mL\\n -20 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 400 (400 - 400) mL\\n RR (Set): 20\\n RR (Spontaneous): 0\\n PEEP: 15 cmH2O\\n FiO2: 40%\\n PIP: 28 cmH2O\\n Plateau: 23 cmH2O\\n Compliance: 50 cmH2O/mL\\n SpO2: 95%\\n ABG: 7.43/41/80/24/2\\n Ve: 7.4 L/min\\n PaO2 / FiO2: 200\\n Physical Examination\\n General Appearance: No acute distress, Overweight / Obese, opens eyes\\n but no purposeful movement\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric)\\n Abdominal: No(t) Soft, Non-tender, Bowel sounds present, Distended\\n Extremities: No clubbing or cyanosis, 3+ nonpitting edema of b/l hands,\\n LE without edema\\n Skin: no rashes or jaundice\\n Labs / Radiology\\n 374 K/uL\\n 8.7 g/dL\\n 194 mg/dL\\n 0.5 mg/dL\\n 24 mEq/L\\n 4.9 mEq/L\\n 8 mg/dL\\n 111 mEq/L\\n 142 mEq/L\\n 27.8 %\\n 9.6 K/uL\\n [image002.jpg]\\n 06:17 AM\\n 07:00 AM\\n 08:18 AM\\n 04:18 PM\\n 03:47 AM\\n 02:14 PM\\n 04:05 PM\\n 01:12 AM\\n 04:00 AM\\n 04:09 AM\\n WBC\\n 10.5\\n 9.6\\n Hct\\n 27.5\\n 27.8\\n Plt\\n 374\\n 374\\n Cr\\n 0.6\\n 0.6\\n 0.5\\n TropT\\n <0.01\\n <0.01\\n TCO2\\n 21\\n 28\\n 27\\n 26\\n 27\\n 28\\n Glucose\\n 153\\n 187\\n 194\\n Other labs: PT / PTT / INR:17.0/84.8/1.5, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\\n Amylase / Lipase:, Differential-Neuts:86.1 %, Lymph:10.3 %,\\n Mono:2.8 %, Eos:0.5 %, Lactic Acid:2.0 mmol/L, Albumin:2.4 g/dL,\\n LDH:204 IU/L, Ca++:8.4 mg/dL, Mg++:2.1 mg/dL, PO4:3.1 mg/dL\\n Assessment and Plan\\n 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture with respiratory failure\\n and difficulty weaning from vent.\\n # Respiratory failure: Intubated on for resp decompensation.\\n Likely VAP. Unlikely to have tracheomalacia as initially\\n transferred for.\\n - wean PEEP\\n - discuss need for trach with patient and her family\\n # Pneumonia: Pansensitive Kleb oxytoca pneumonia and sputum with GPCs\\n on gram stain. Afebrile overnight. On levofloxacin since .\\n Vancomycin, aztreonam have been stopped. Resp status seems to be\\n improving.\\n - Follow cultures\\n - d/c aztreonam\\n - Continue levofloxacin for 8 days (today = day )\\n # EKG changes: Sinus bradycardia. Very low voltages and no change in\\n QRS morphology. P-waves are visible and prolonged PR interval is old.\\n CK and troponins flat. Likely related to increased vagal tone possibly\\n related to steroid replacement. Atrial EKG with p-waves c/w sinus\\n bradycardia.\\n - Will avoid excessive alpha-agonism\\n - Continue to monitor\\n # Hypotension: Improved, off levophed for 2 days, with good urine\\n output. SVV with Vigileo was 7, making her CO less likely to respond\\n to fluids. CVP increasing with reduction in PEEP. Unlikely\\n hypovolemic or septic. Likely poor adrenal response in setting of\\n acute illness and very high PEEP.\\n -continue fludricort and hydrocortisone for total 5 days (begun )\\n -monitor, expect improvement with continual reduction in PEEP\\n # RUE DVT: Started on heparin gtt on .\\n - closely monitor\\n # Adrenal Insufficency: Random cortisol was approx 3 when it should\\n have been maximally stimulated.\\n - hydrocortisone and florinef for 5 days\\n # Anemia: Stable.\\n - Trend HCT\\n # Spine fracture: Neurologically intact distal to the lesion. Prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - CT of C, L spine when stable. Currently, unlikely to change\\n management and high risk for complications with transport.\\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\\n is low. Brace for OOB. Ok for anticoag per note.\\n # Communication:\\n - Brother has been with pt, although, live in boyfriend of 10 is\\n her HCP.\\n ICU \\n Nutrition:\\n Replete with Fiber (Full) - 08:13 PM 60 mL/hour, INR rising\\n (? Nutritional deficiencies)\\n Glycemic Control: ISS\\n titrate sliding scale up if persistent\\n hyperglycemia\\n Lines:\\n Multi Lumen - 11:30 AM\\n Arterial Line - 04:00 PM\\n Prophylaxis:\\n DVT: heparin gtt\\n Stress ulcer: H2 blocker\\n VAP:\\n Comments:\\n Communication: ICU consent signed, (brother) \\n (boyfriend/POA) \\n Code status: Full code\\n Disposition: ICU\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-09-26 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 634764,\n \"text\": \"Chief Complaint: resp failure, VAP, compression fx,\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n bronch for reposiitoning of ET tube, peep weaned down to 15 post-bronch\\n 24 Hour Events:\\n BRONCHOSCOPY - At 10:45 AM\\n bronchoscopy for reposition of ETT not seen on CHX, samile. Sedated on\\n total 250mcg IVP FEntanyl, 2 MG IVP Midaz and cont on IV sedation for\\n precedure. Provedure completed w/o incedence bacn on previous AC vent\\n settings\\n BRONCHOSCOPY - At 11:03 AM\\n History obtained from Medical records, HO\\n Patient unable to provide history: Sedated\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Aztreonam - 06:00 AM\\n Vancomycin - 09:00 AM\\n Levofloxacin - 08:00 AM\\n Infusions:\\n Fentanyl - 125 mcg/hour\\n Heparin Sodium - 1,700 units/hour\\n Other ICU medications:\\n Ranitidine (Prophylaxis) - 09:28 AM\\n Midazolam (Versed) - 08:25 AM\\n Fentanyl - 08:25 AM\\n Other medications:\\n per (reviewed)\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 09:49 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.7\\nC (98\\n Tcurrent: 36\\nC (96.8\\n HR: 55 (47 - 88) bpm\\n BP: 116/60(80) {89/45(61) - 135/78(348)} mmHg\\n RR: 20 (20 - 25) insp/min\\n SpO2: 93%\\n Heart rhythm: SB (Sinus Bradycardia)\\n Wgt (current): 101 kg (admission): 94.2 kg\\n Height: 67 Inch\\n CVP: 20 (13 - 20)mmHg\\n Total In:\\n 4,142 mL\\n 1,082 mL\\n PO:\\n TF:\\n 2,219 mL\\n 564 mL\\n IVF:\\n 1,833 mL\\n 408 mL\\n Blood products:\\n Total out:\\n 1,000 mL\\n 775 mL\\n Urine:\\n 800 mL\\n 775 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 3,142 mL\\n 307 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 400 (400 - 400) mL\\n RR (Set): 20\\n RR (Spontaneous): 0\\n PEEP: 15 cmH2O\\n FiO2: 40%\\n PIP: 28 cmH2O\\n Plateau: 24 cmH2O\\n Compliance: 44.4 cmH2O/mL\\n SpO2: 93%\\n ABG: 7.43/41/80./24/2\\n Ve: 7.6 L/min\\n PaO2 / FiO2: 200\\n Physical Examination\\n General Appearance: Well nourished, No acute distress, Overweight /\\n Obese\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear :\\n ant, Crackles : , Diminished: at bases, No(t) Absent : )\\n Abdominal: Bowel sounds present, Distended, No(t) Tender: , Obese, BS\\n hypoactive\\n Extremities: Right: Absent, Left: Absent, 3+ UE/hand edema\\n Skin: Warm, Rash:\\n Neurologic: Attentive, No(t) Follows simple commands, Responds to: Not\\n assessed, Movement: Not assessed, Tone: Not assessed\\n Labs / Radiology\\n 8.7 g/dL\\n 374 K/uL\\n 194 mg/dL\\n 0.5 mg/dL\\n 24 mEq/L\\n 4.9 mEq/L\\n 8 mg/dL\\n 111 mEq/L\\n 142 mEq/L\\n 27.8 %\\n 9.6 K/uL\\n [image002.jpg]\\n 06:17 AM\\n 07:00 AM\\n 08:18 AM\\n 04:18 PM\\n 03:47 AM\\n 02:14 PM\\n 04:05 PM\\n 01:12 AM\\n 04:00 AM\\n 04:09 AM\\n WBC\\n 10.5\\n 9.6\\n Hct\\n 27.5\\n 27.8\\n Plt\\n 374\\n 374\\n Cr\\n 0.6\\n 0.6\\n 0.5\\n TropT\\n <0.01\\n <0.01\\n TCO2\\n 21\\n 28\\n 27\\n 26\\n 27\\n 28\\n Glucose\\n 153\\n 187\\n 194\\n Other labs: PT / PTT / INR:17.0/84.8/1.5, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\\n Amylase / Lipase:, Differential-Neuts:86.1 %, Lymph:10.3 %,\\n Mono:2.8 %, Eos:0.5 %, Lactic Acid:2.0 mmol/L, Albumin:2.4 g/dL,\\n LDH:204 IU/L, Ca++:8.4 mg/dL, Mg++:2.1 mg/dL, PO4:3.1 mg/dL\\n Imaging: cxr--et ok, r ij, b/l effusions layering, increased haziness R\\n base\\n Microbiology: Kleb pan \\n Assessment and Plan\\n Assessment and Plan\\n 55-year-old woman with prolonged hospital course, etoh abuse tranferred\\n from OSH with fall and compression fx course c/b sepsis and resp\\n failure likely VAP,TBM, failure to wean, with high PEEP\\n requirements, R UE DVT\\n Respiratory failure\\n Oxygenation is improving\\n continue to wean PEEP as tolerated\\n eventually need investigation for TBM\\n Once PEEP lower, would consider trach\\n vol overload and effusions liekly also contrinuting to poor wean--goal\\n 500 cc neg, trend I/os and consider gently IV lasix\\n Adrenal insufficiency\\n Based on very low random cortisol while in shock and\\n respiratory failure\\n On steroids, has come off and stayed off of pressors.\\n Eventually wean, but still getting fluid boluses\\n Bradycardia\\n Rhythm is sinus, confirmed by CVL-directed\\natrial\\n lead\\n Heart rate increases with stimulation, suggesting that this\\n is mostly vagal in etiology\\n Klebsiella VAP\\n Complete 8d course of levofloxacin (day )\\n If sputum culture remains negative (GPCs on G/S),\\n discontinue vancomycin tomorrow\\n Shock\\n remains hemdynamically stable off pressors\\n Intermittent fluid boluses\\n Treating adrenal insufficiency\\n R Upper extremity DVT\\n Therapeutic heparin gtt (heading toward trach)\\n Anemia\\n Follow\\n Possible tracheobronchomalacia (reason for transfer)\\n Traumatic thoracic spinal fracture\\n Eventual MRI. Too high-risk at present. Brace when out of\\n bed. Ortho trauma following.\\n glycemic control--tighten SSI\\n Other issues as per ICU team note.\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 08:13 PM 60 mL/hour\\n Comments: increase bowel reg\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n Multi Lumen - 11:30 AM\\n Arterial Line - 04:00 PM\\n Prophylaxis:\\n DVT: (Systemic anticoagulation: Heparin gtt)\\n Stress ulcer:\\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\\n Comments:\\n Communication: ICU consent signed Comments:\\n Code status: Full code\\n Disposition :ICU\\n Total time spent: 45 minutes\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-09-26 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 634778,\n \"text\": \"Chief Complaint: shock (resolved), adrenal insuff, resp failure, VAP,\\n compression fx,\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI: 55 yo F w/ prolonged hospital course, etoh abuse with fall and\\n thoracic compression fxs who was tranferred from OSH for evaluation of\\n Y stent for BTM, course has been c/b R UE DVT and sepsis with\\n hypotension, pressor needs, and resp failure likely VAP,TBM now\\n with failure to wean, still with high PEEP requirements.\\n 24 Hour Events:\\n BRONCHOSCOPY - At 10:45 AM\\n bronchoscopy for reposition of ETT not seen on CHX, samile. Sedated on\\n total 250mcg IVP FEntanyl, 2 MG IVP Midaz and cont on IV sedation for\\n precedure. Provedure completed w/o incedence bacn on previous AC vent\\n settings\\n BRONCHOSCOPY - At 11:03 AM\\n Peep decreased to 15\\n History obtained from Medical records, HO\\n Patient unable to provide history: Sedated\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Aztreonam - 06:00 AM\\n Vancomycin - 09:00 AM\\n Levofloxacin - 08:00 AM\\n Infusions:\\n Fentanyl - 125 mcg/hour\\n Heparin Sodium - 1,700 units/hour\\n Other ICU medications:\\n Ranitidine (Prophylaxis) - 09:28 AM\\n Midazolam (Versed) - 08:25 AM\\n Fentanyl - 08:25 AM\\n Other medications:\\n per (reviewed)\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 09:49 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.7\\nC (98\\n Tcurrent: 36\\nC (96.8\\n HR: 55 (47 - 88) bpm\\n BP: 116/60(80) {89/45(61) - 135/78(348)} mmHg\\n RR: 20 (20 - 25) insp/min\\n SpO2: 93%\\n Heart rhythm: SB (Sinus Bradycardia)\\n Wgt (current): 101 kg (admission): 94.2 kg\\n Height: 67 Inch\\n CVP: 20 (13 - 20)mmHg\\n Total In:\\n 4,142 mL\\n 1,082 mL\\n PO:\\n TF:\\n 2,219 mL\\n 564 mL\\n IVF:\\n 1,833 mL\\n 408 mL\\n Blood products:\\n Total out:\\n 1,000 mL\\n 775 mL\\n Urine:\\n 800 mL\\n 775 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 3,142 mL\\n 307 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 400 (400 - 400) mL\\n RR (Set): 20\\n RR (Spontaneous): 0\\n PEEP: 15 cmH2O\\n FiO2: 40%\\n PIP: 28 cmH2O\\n Plateau: 24 cmH2O\\n Compliance: 44.4 cmH2O/mL\\n SpO2: 93%\\n ABG: 7.43/41/80./24/2\\n Ve: 7.6 L/min\\n PaO2 / FiO2: 200\\n Physical Examination\\n General Appearance: No acute distress, Overweight / Obese\\n Eyes / Conjunctiva: PERRL, MMM\\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear :\\n ant, Crackles : , Diminished: at bases, No(t) Absent : )\\n Abdominal: Bowel sounds present but decreased, Distended, No(t)\\n Tender:, Obese,\\n Extremities: Right: trace, Left:trace, + depedent, 2+ UE/hand edema\\n Skin: Warm, Rash:\\n Neurologic: Attentive, No(t) Follows simple commands,:, Movement:non\\n purposeful, Tone: wnl\\n Labs / Radiology\\n 8.7 g/dL\\n 374 K/uL\\n 194 mg/dL\\n 0.5 mg/dL\\n 24 mEq/L\\n 4.9 mEq/L\\n 8 mg/dL\\n 111 mEq/L\\n 142 mEq/L\\n 27.8 %\\n 9.6 K/uL\\n [image002.jpg]\\n 06:17 AM\\n 07:00 AM\\n 08:18 AM\\n 04:18 PM\\n 03:47 AM\\n 02:14 PM\\n 04:05 PM\\n 01:12 AM\\n 04:00 AM\\n 04:09 AM\\n WBC\\n 10.5\\n 9.6\\n Hct\\n 27.5\\n 27.8\\n Plt\\n 374\\n 374\\n Cr\\n 0.6\\n 0.6\\n 0.5\\n TropT\\n <0.01\\n <0.01\\n TCO2\\n 21\\n 28\\n 27\\n 26\\n 27\\n 28\\n Glucose\\n 153\\n 187\\n 194\\n Other labs: PT / PTT / INR:17.0/84.8/1.5, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\\n Amylase / Lipase:, Differential-Neuts:86.1 %, Lymph:10.3 %,\\n Mono:2.8 %, Eos:0.5 %, Lactic Acid:2.0 mmol/L, Albumin:2.4 g/dL,\\n LDH:204 IU/L, Ca++:8.4 mg/dL, Mg++:2.1 mg/dL, PO4:3.1 mg/dL\\n Imaging: cxr--et ok, r ij, b/l effusions layering, increased haziness R\\n base\\n Microbiology: Kleb--pan \\n Assessment and Plan\\n 55 yo F w/ prolonged hospital course, etoh abuse with fall and thoracic\\n compression fxs who was tranferred from OSH for evaluation of Y stent\\n for BTM, course has been c/b R UE DVT and sepsis with hypotension,\\n pressor needs, and resp failure likely VAP,TBM now with failure to\\n wean, still with high PEEP requirements.\\n Main issues remain--\\n # Respiratory failure\\n Oxygenation is improving\\n Continue to wean PEEP as tolerated following abg/sats\\n Once PEEP lower, would consider trach, given prolonged course,\\n poor MS, vol overload\\n Vol overload with effusions likely also contributing to poor\\n wean\\noff pressors and no longer needing boluses to maintain BP, keep\\n I/O goal even to neg 500 cc neg, trend I/os and consider gently IV\\n lasix later today\\n ultimately benefit form investigation for TBM\\n # Adrenal insufficiency\\n Had very low random cortisol while in shock and respiratory\\n failure\\n On steroids, has come off and stayed off of pressors.\\n Continue current doses, consider starting wean tomorrow as no\\n longer needing fluid boluses and off pressors\\n # Bradycardia\\n Rhythm is sinus, confirmed by CVL-directed\\natrial\\n lead\\n Heart rate increases with stimulation, suggesting mostly vagal\\n in etiology\\n # Klebsiella VAP\\n Complete 8d course of levofloxacin (day ), received vanco and\\n which where d/c\\nd given neg cx data.\\n # Shock\\nresolved, remains hemdynamically stable off pressors\\n Treating adrenal insufficiency\\n # R Upper extremity DVT\\n Therapeutic heparin gtt (continue for now as heading toward trach)\\n # Traumatic thoracic spinal fracture\\n Eventual MRI. Too high-risk at present. Brace when out of bed.\\n Ortho trauma following.\\n # Glycemic control--tighten SSI for improved control, on steroids\\n Other issues as per ICU team note.\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 08:13 PM 60 mL/hour\\n Comments: increase bowel reg\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n Multi Lumen - 11:30 AM\\n Arterial Line - 04:00 PM\\n Prophylaxis:\\n DVT: (Systemic anticoagulation: Heparin gtt)\\n Stress ulcer:\\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\\n Comments:\\n Communication: ICU consent signed Comments:\\n Code status: Full code\\n Disposition :ICU\\n Total time spent: 45 minutes\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-09-27 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 634875,\n \"text\": \"Chief Complaint: respiratory failure\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 55 yo F w/ prolonged hospital course, etoh abuse with fall and thoracic\\n compression fxs who was tranferred from OSH for evaluation of Y stent\\n for BTM, course has been c/b R UE DVT and sepsis with hypotension,\\n pressor needs, and resp failure likely VAP,TBM now with failure to\\n wean, still with high PEEP requirements.\\n 24 Hour Events:\\n EKG - At 12:00 PM\\n low voltage, pre Haldol administration QRS .46\\n lasix X 3 doses with good urine output\\n peep held at 15, fio2 increased to 50%\\n History obtained from ho\\n Patient unable to provide history: Sedated, intubated\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Aztreonam - 06:00 AM\\n Vancomycin - 09:00 AM\\n Levofloxacin - 08:06 AM\\n Infusions:\\n Midazolam (Versed) - 4 mg/hour\\n Fentanyl - 150 mcg/hour\\n Heparin Sodium - 1,700 units/hour\\n Other ICU medications:\\n Haloperidol (Haldol) - 04:26 PM\\n Furosemide (Lasix) - 04:30 PM\\n Midazolam (Versed) - 06:16 AM\\n Fentanyl - 06:16 AM\\n Other medications:\\n per (reviewed)\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 10:59 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37\\nC (98.6\\n Tcurrent: 36.8\\nC (98.2\\n HR: 61 (53 - 93) bpm\\n BP: 137/70(95) {103/52(69) - 137/70(95)} mmHg\\n RR: 20 (16 - 28) insp/min\\n SpO2: 96%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 101 kg (admission): 94.2 kg\\n Height: 67 Inch\\n CVP: 19 (6 - 21)mmHg\\n Total In:\\n 2,679 mL\\n 1,165 mL\\n PO:\\n TF:\\n 1,443 mL\\n 639 mL\\n IVF:\\n 886 mL\\n 526 mL\\n Blood products:\\n Total out:\\n 3,135 mL\\n 305 mL\\n Urine:\\n 3,035 mL\\n 305 mL\\n NG:\\n Stool:\\n 100 mL\\n Drains:\\n Balance:\\n -456 mL\\n 860 mL\\n Respiratory support\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 400 (400 - 400) mL\\n RR (Set): 20\\n RR (Spontaneous): 0\\n PEEP: 15 cmH2O\\n FiO2: 50%\\n RSBI Deferred: PEEP > 10\\n PIP: 29 cmH2O\\n Plateau: 26 cmH2O\\n SpO2: 96%\\n ABG: 7.46/39/68/27/3\\n Ve: 7.8 L/min\\n PaO2 / FiO2: 136\\n Physical Examination\\n General Appearance: No acute distress, Overweight / Obese\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: Endotracheal tube\\n Lymphatic: Cervical WNL\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Diminished), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\\n ) bases b/l, coarse\\n Extremities: Right: 1+, Left: 1+, No(t) Cyanosis, No(t) Clubbing\\n Musculoskeletal: No(t) Muscle wasting\\n Skin: Warm\\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\\n to: Not assessed, Movement: Non -purposeful, Sedated, No(t) Paralyzed,\\n Tone: Not assessed\\n Labs / Radiology\\n 8.3 g/dL\\n 411 K/uL\\n 163 mg/dL\\n 0.5 mg/dL\\n 27 mEq/L\\n 3.8 mEq/L\\n 12 mg/dL\\n 111 mEq/L\\n 144 mEq/L\\n 26.0 %\\n 9.7 K/uL\\n [image002.jpg]\\n 03:47 AM\\n 02:14 PM\\n 04:05 PM\\n 01:12 AM\\n 04:00 AM\\n 04:09 AM\\n 10:18 AM\\n 02:33 PM\\n 02:46 PM\\n 03:31 AM\\n WBC\\n 10.5`\\n 1q\\n 9.6\\n 9.7\\n Hct\\n 27.5\\n 27.8\\n 26.0\\n Plt\\n 374\\n 374\\n 411\\n Cr\\n 0.6\\n 0.5\\n 0.5\\n 0.5\\n TCO2\\n 27\\n 26\\n 27\\n 28\\n 29\\n 26\\n 27\\n Glucose\\n 187\\n 194\\n 195\\n 195\\n 163\\n Other labs: PT / PTT / INR:15.3/69.9/1.3, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\\n Amylase / Lipase:, Differential-Neuts:86.1 %, Lymph:10.3 %,\\n Mono:2.8 %, Eos:0.5 %, Lactic Acid:2.0 mmol/L, Albumin:2.4 g/dL,\\n LDH:204 IU/L, Ca++:8.3 mg/dL, Mg++:2.1 mg/dL, PO4:3.3 mg/dL\\n Imaging: cxr--et, og,r IJ in good position, slightly improved aeration\\n at r and l base, still with b/l effusions, opacaities\\n Microbiology: no new data\\n Assessment and Plan\\n 55 yo F w/ prolonged hospital course, etoh abuse with fall and thoracic\\n compression fxs who was tranferred from OSH for evaluation of Y stent\\n for BTM, course has been c/b R UE DVT and sepsis with hypotension,\\n pressor needs, and resp failure likely VAP,TBM now with failure to\\n wean, still with high PEEP requirements.\\n Main issues remain--\\n # Respiratory failure\\n Continue to wean PEEP as tolerated following abg/sats\\n Once PEEP lower, heading toward trach, given prolonged course,\\n poor MS, vol overload\\n IV lasix for goal neg 500 cc i/o\\n ultimately benefit form investigation for TBM\\n Decrease RR on vent to optimize pH given alkalosis (mixed,\\n mainly resp)\\n # Adrenal insufficiency\\n Had very low random cortisol while in shock and respiratory\\n failure\\n On steroids, has come off and stayed off of pressors\\n Today completes 5 day course of stress dose steroids--will\\n discontinue tomorrow\\n # Klebsiella VAP\\n complete course of levofloxacin today (day ), received vanco\\n and which where d/c\\nd given neg cx data.\\n # R Upper extremity DVT\\n Therapeutic heparin gtt (continue for now as heading toward trach)\\n # Traumatic thoracic spinal fracture\\n Eventual MRI. Too high-risk at present. Brace when out of bed.\\n Ortho trauma following.\\n # Glycemic control--improved with tightened SSI while on steroids\\n Other issues as per ICU team note.\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 08:13 PM 60 mL/hour\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n Multi Lumen - 11:30 AM\\n Arterial Line - 04:00 PM\\n Comments: put in for picc line\\n Prophylaxis:\\n DVT: (Systemic anticoagulation: Heparin gtt)\\n Stress ulcer:\\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :ICU\\n Total time spent: 45 minutes\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-09-24 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 634596,\n \"text\": \"55 yr old woman admitted from OSH after she fell down the stairs and\\n had traumatic T-spine fracture. Pt came to us with PNA from unknown\\n etiology? VAP. Full code, Allergies: PCN, tetracycline, Sulfa. PMH:\\n ETOH, smoker, Gerd, Hip replacement.\\n Alteration in Nutrition\\n Assessment:\\n Tube feeds increased to 40ml/hr. Tube feed residual 10ml. Hypoactive\\n BS.\\n Action:\\n cont to check residuals and try to increase rate\\n Response:\\n Residual staying 10ml/hr, continued rate of 40cc/hr.\\n Plan:\\n Try to increase Tube feeds to goal rate.\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n RUE DVT, pt on heparin gtt at 1700units/hr.\\n Action:\\n Ptt was therapeutic x2, AM PTT 68.6 WNL\\n Response:\\n No change to drip made, therapeutic dose.\\n Plan:\\n Cont heparin gtt, check PTT adjust heparin gtt per scale.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Moderate thick white in-line secretions, copious clear oral secretions,\\n clear/diminished lung sounds. Esophageal balloon in place. Previous\\n Sputum culture shows GNR, speciation PND.\\n Action:\\n Lots of suctioning through the night, decreased FiO2 from 50% to 40%,\\n decreased Peep from 23 to 21, HOB >30, oral care.\\n Response:\\n ABG WNL, could not draw an AM ABG because A-line no longer drawing,\\n intern aware. Intern and resp therapy to get ABG for AM.\\n Plan:\\n Cont to try to wean vent settings as tolerated, cont monitoring ABG\\n Hypotension (not Shock)\\n Assessment:\\n SBP 90-110\\ns MAP 62-66 Goal MAP >65 Levophed gtt @ 0.018 mcg/kg/min.\\n Action:\\n Trying to wean levophed gtt off\\n Response:\\n MAP tends to drop below 65 when weaned all the way off levophed.\\n Plan:\\n Cont to try to wean gtt off\\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\\n Assessment:\\n T-max 101.0\\n Action:\\n Sent blood, urine, and sputum cultures, treated with Tylenol\\n Response:\\n Temp decreased\\n Plan:\\n Follow up on cultures\\n CT scan from earlier in the week confirms fracture but did not detect\\n retropulsion. Neuro want pt in back brace when she is out of bed.\\n Log rolling pt has been d/c.\\n Bradycardia\\n Assessment:\\n At 0515 Patient HR dropped from 60-70\\ns to 45-50.\\n Action:\\n EKG done, showed pt was in junctional rhythm, intern came to assess pt.\\n Electrolytes WNL.\\n Response:\\n No intervention done yet because pt BP cont to be stable and all other\\n vital signs stable.\\n Plan:\\n Cont to monitor pt HR.\\n Fracture, other\\n Assessment:\\n Log roll precautions removed from day shift. Back brace needs to be\\n applied if pt is out of bed. Please read CT scan results from above\\n portion of note.\\n Action:\\n Still taking precautions to carefully turn pt but no longer on log roll\\n precautions\\n Response:\\n Pt tolerating turning fine.\\n Plan:\\n Use back brace if pt get out of bed. Back brace in room\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-09-24 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 634599,\n \"text\": \"55 yr old woman admitted from OSH after she fell down the stairs and\\n had traumatic T-spine fracture. Pt came to us with PNA from unknown\\n etiology? VAP. Full code, Allergies: PCN, tetracycline, Sulfa. PMH:\\n ETOH, smoker, Gerd, Hip replacement.\\n Alteration in Nutrition\\n Assessment:\\n Tube feeds increased to 40ml/hr. Residuals ~10ml. Hypoactive BS.\\n Action:\\n Residuals and BS checked. Rate increased to 40ml/hr.\\n Response:\\n Residual continued at 10ml/hr, continued rate of 40cc/hr.\\n Plan:\\n Advance TF to goal as tolerated. Monitor BS.\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n RUE DVT, pt on heparin gtt at 1700units/hr.\\n Action:\\n Ptt was therapeutic x2, AM PTT 68.6 WNL\\n Response:\\n No change to drip made, therapeutic dose.\\n Plan:\\n Cont heparin gtt, check PTT adjust heparin gtt per scale.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Moderate thick white in-line secretions, copious clear oral secretions,\\n clear/diminished lung sounds. Esophageal balloon in place. Previous\\n Sputum culture shows GNR, speciation PND.\\n Action:\\n Lots of suctioning through the night, decreased FiO2 from 50% to 40%,\\n decreased Peep from 23 to 21, HOB >30, oral care.\\n Response:\\n ABG WNL, could not draw an AM ABG because A-line no longer drawing,\\n intern aware. Intern and resp therapy to get ABG for AM.\\n Plan:\\n Cont to try to wean vent settings as tolerated, cont monitoring ABG\\n Hypotension (not Shock)\\n Assessment:\\n SBP 90-110\\ns MAP 62-66 Goal MAP >65 Levophed gtt @ 0.018 mcg/kg/min.\\n Action:\\n Trying to wean levophed gtt off\\n Response:\\n MAP tends to drop below 65 when weaned all the way off levophed.\\n Plan:\\n Cont to try to wean gtt off\\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\\n Assessment:\\n T-max 101.0\\n Action:\\n Sent blood, urine, and sputum cultures, treated with Tylenol\\n Response:\\n Temp decreased\\n Plan:\\n Follow up on cultures\\n CT scan from earlier in the week confirms fracture but did not detect\\n retropulsion. Neuro want pt in back brace when she is out of bed.\\n Log rolling pt has been d/c.\\n Bradycardia\\n Assessment:\\n At 0515 Patient HR dropped from 60-70\\ns to 45-50.\\n Action:\\n EKG done, showed pt was in junctional rhythm, intern came to assess pt.\\n Electrolytes WNL.\\n Response:\\n No intervention done yet because pt BP cont to be stable and all other\\n vital signs stable.\\n Plan:\\n Cont to monitor pt HR.\\n Fracture, other\\n Assessment:\\n Log roll precautions removed from day shift. Back brace needs to be\\n applied if pt is out of bed. Please read CT scan results from above\\n portion of note.\\n Action:\\n Still taking precautions to carefully turn pt but no longer on log roll\\n precautions\\n Response:\\n Pt tolerating turning fine.\\n Plan:\\n Use back brace if pt get out of bed. Back brace in room\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2167-09-23 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 634451,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 5\\n Ideal body weight: 61.2 None\\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: Unknown\\n Procedure location:\\n Reason:\\n Tube Type\\n ETT:\\n Position: cm at teeth\\n Route:\\n Type: Standard\\n Size: 7.5mm\\n Tracheostomy tube:\\n Type:\\n Manufacturer:\\n Size:\\n PMV:\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: cmH2O\\n Cuff volume: mL /\\n Airway problems:\\n Comments:\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Diminished\\n Comments:\\n Secretions\\n Sputum color / consistency: /\\n Sputum source/amount: /\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance: Continuous invasive ventilation\\n Visual assessment of breathing pattern: Normal quiet breathing\\n Assessment of breathing comfort: No response (sleeping / sedated)\\n Non-invasive ventilation assessment:\\n Invasive ventilation assessment:\\n Trigger work assessment: Triggering synchronously\\n Dysynchrony assessment:\\n Comments:\\n Plan\\n Next 24-48 hours: Utilize ARDSnet protocol, Maintain PEEP at current\\n level and reduce FiO2 as tolerated\\n Reason for continuing current ventilatory support: Sedated / Paralyzed\\n Respiratory Care Shift Procedures\\n Transports:\\n Destination (R/T)\\n Time\\n Complications\\n Comments\\n Bedside Procedures:\\n Comments:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-09-24 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 634513,\n \"text\": \"55 yr old woman admitted from OSH after she fell down the stairs and\\n had traumatic T-spine fracture. Pt came to us with PNA from unknown\\n etiology? VAP. Full code, Allergies: PCN, tetracycline, Sulfa. PMH:\\n ETOH, smoker, Gerd, Hip replacement.\\n Alteration in Nutrition\\n Assessment:\\n Tube feeds at 20ml/hr. Tube feed residual 20ml.\\n Action:\\n Kept TF at 20ml/hr and will cont to check residuals and try to increase\\n rate\\n Response:\\n No change\\n Plan:\\n Try to increase Tube feeds to goal rate.\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n RUE DVT, pt on heparin gtt at 1700units/hr.\\n Action:\\n Ptt was therapeutic x2, AM PTT\\n Response:\\n Plan:\\n Cont heparin gtt, check PTT adjust heparin gtt per scale.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Moderate thick white in-line secretions, copious clear oral secretions,\\n clear/diminished lung sounds. Esophageal balloon in place. Previous\\n Sputum culture shows GNR, speciation PND.\\n Action:\\n Lots of suctioning through the night, decreased FiO2 from 50% to 40%,\\n decreased Peep from 23 to 21, HOB >30, oral care.\\n Response:\\n ABG WNL\\n Plan:\\n Cont to try to wean vent settings as tolerated, cont monitoring ABG\\n Hypotension (not Shock)\\n Assessment:\\n SBP 90-110\\ns MAP 62-66 Goal MAP >65 Levophed gtt @ 0.020 mcg/kg/min.\\n Action:\\n Trying to wean levophed gtt off\\n Response:\\n Plan:\\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\\n Assessment:\\n T-max 101.0\\n Action:\\n Sent blood, urine, and sputum cultures, treated with tylenol\\n Response:\\n Temp decreased\\n Plan:\\n Follow up on cultures\\n CT scan from earlier in the week confirms fracture but did not detect\\n retropulsion. Neuro want pt in back brace when she is out of bed.\\n Log rolling pt has been d/c.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-09-24 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 634514,\n \"text\": \"55 yr old woman admitted from OSH after she fell down the stairs and\\n had traumatic T-spine fracture. Pt came to us with PNA from unknown\\n etiology? VAP. Full code, Allergies: PCN, tetracycline, Sulfa. PMH:\\n ETOH, smoker, Gerd, Hip replacement.\\n Alteration in Nutrition\\n Assessment:\\n Tube feeds at 20ml/hr. Tube feed residual 20ml.\\n Action:\\n Kept TF at 20ml/hr and will cont to check residuals and try to increase\\n rate\\n Response:\\n No change\\n Plan:\\n Try to increase Tube feeds to goal rate.\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n RUE DVT, pt on heparin gtt at 1700units/hr.\\n Action:\\n Ptt was therapeutic x2, AM PTT\\n Response:\\n Plan:\\n Cont heparin gtt, check PTT adjust heparin gtt per scale.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Moderate thick white in-line secretions, copious clear oral secretions,\\n clear/diminished lung sounds. Esophageal balloon in place. Previous\\n Sputum culture shows GNR, speciation PND.\\n Action:\\n Lots of suctioning through the night, decreased FiO2 from 50% to 40%,\\n decreased Peep from 23 to 21, HOB >30, oral care.\\n Response:\\n ABG WNL\\n Plan:\\n Cont to try to wean vent settings as tolerated, cont monitoring ABG\\n Hypotension (not Shock)\\n Assessment:\\n SBP 90-110\\ns MAP 62-66 Goal MAP >65 Levophed gtt @ 0.020 mcg/kg/min.\\n Action:\\n Trying to wean levophed gtt off\\n Response:\\n Plan:\\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\\n Assessment:\\n T-max 101.0\\n Action:\\n Sent blood, urine, and sputum cultures, treated with tylenol\\n Response:\\n Temp decreased\\n Plan:\\n Follow up on cultures\\n CT scan from earlier in the week confirms fracture but did not detect\\n retropulsion. Neuro want pt in back brace when she is out of bed.\\n Log rolling pt has been d/c.\\n Bradycardia\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Fracture, other\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-09-27 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 634853,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n - Rec\\nd one dose of Haldol yesterday afternoon\\n - Poor sleep overnight per nursing\\n - Per ABG, holding steady on FiO2 (50%) and PEEP (15)\\n - Gave Lasix, net neg ~ 500 yesterday\\n - Today is last day of steroids as well as last day of abx\\n (levofloxicin)\\n - Tightened sliding scale insulin yesterday\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Aztreonam - 06:00 AM\\n Vancomycin - 09:00 AM\\n Levofloxacin - 08:00 AM\\n Infusions:\\n Midazolam (Versed) - 4 mg/hour\\n Heparin Sodium - 1,700 units/hour\\n Fentanyl - 150 mcg/hour\\n Other ICU medications:\\n Haloperidol (Haldol) - 04:26 PM\\n Furosemide (Lasix) - 04:30 PM\\n Midazolam (Versed) - 06:16 AM\\n Fentanyl - 06:16 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:14 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37\\nC (98.6\\n Tcurrent: 35.7\\nC (96.2\\n HR: 66 (53 - 93) bpm\\n BP: 111/56(74) {103/52(69) - 135/78(93)} mmHg\\n RR: 20 (16 - 28) insp/min\\n SpO2: 95%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 101 kg (admission): 94.2 kg\\n Height: 67 Inch\\n CVP: 18 (6 - 21)mmHg\\n Total In:\\n 2,681 mL\\n 687 mL\\n PO:\\n TF:\\n 1,443 mL\\n 432 mL\\n IVF:\\n 888 mL\\n 255 mL\\n Blood products:\\n Total out:\\n 3,135 mL\\n 185 mL\\n Urine:\\n 3,035 mL\\n 185 mL\\n NG:\\n Stool:\\n 100 mL\\n Drains:\\n Balance:\\n -454 mL\\n 502 mL\\n Respiratory support\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 400 (400 - 400) mL\\n RR (Set): 20\\n RR (Spontaneous): 23\\n PEEP: 15 cmH2O\\n FiO2: 50%\\n RSBI Deferred: PEEP > 10\\n PIP: 31 cmH2O\\n Plateau: 25 cmH2O\\n SpO2: 95%\\n ABG: 7.46/39/68/27/3\\n Ve: 7.7 L/min\\n PaO2 / FiO2: 136\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 411 K/uL\\n 8.3 g/dL\\n 163 mg/dL\\n 0.5 mg/dL\\n 27 mEq/L\\n 3.8 mEq/L\\n 12 mg/dL\\n 111 mEq/L\\n 144 mEq/L\\n 26.0 %\\n 9.7 K/uL\\n [image002.jpg]\\n 03:47 AM\\n 02:14 PM\\n 04:05 PM\\n 01:12 AM\\n 04:00 AM\\n 04:09 AM\\n 10:18 AM\\n 02:33 PM\\n 02:46 PM\\n 03:31 AM\\n WBC\\n 10.5\\n 9.6\\n 9.7\\n Hct\\n 27.5\\n 27.8\\n 26.0\\n Plt\\n 374\\n 374\\n 411\\n Cr\\n 0.6\\n 0.5\\n 0.5\\n 0.5\\n TCO2\\n 27\\n 26\\n 27\\n 28\\n 29\\n 26\\n 27\\n Glucose\\n 187\\n 194\\n 195\\n 195\\n 163\\n Other labs: PT / PTT / INR:15.3/69.9/1.3, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\\n Amylase / Lipase:, Differential-Neuts:86.1 %, Lymph:10.3 %,\\n Mono:2.8 %, Eos:0.5 %, Lactic Acid:2.0 mmol/L, Albumin:2.4 g/dL,\\n LDH:204 IU/L, Ca++:8.3 mg/dL, Mg++:2.1 mg/dL, PO4:3.3 mg/dL\\n Assessment and Plan\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 08:13 PM 60 mL/hour\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 11:30 AM\\n Arterial Line - 04:00 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-09-27 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 634854,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n - Rec\\nd one dose of Haldol yesterday afternoon\\n - Poor sleep overnight per nursing\\n - Per ABG, holding steady on FiO2 (50%) and PEEP (15)\\n - Gave Lasix, net neg ~ 500 yesterday\\n - Today is last day of steroids as well as last day of abx\\n (levofloxicin)\\n - Tightened sliding scale insulin yesterday\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Aztreonam - 06:00 AM\\n Vancomycin - 09:00 AM\\n Levofloxacin - 08:00 AM\\n Infusions:\\n Midazolam (Versed) - 4 mg/hour\\n Heparin Sodium - 1,700 units/hour\\n Fentanyl - 150 mcg/hour\\n Other ICU medications:\\n Haloperidol (Haldol) - 04:26 PM\\n Furosemide (Lasix) - 04:30 PM\\n Midazolam (Versed) - 06:16 AM\\n Fentanyl - 06:16 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:14 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37\\nC (98.6\\n Tcurrent: 35.7\\nC (96.2\\n HR: 66 (53 - 93) bpm\\n BP: 111/56(74) {103/52(69) - 135/78(93)} mmHg\\n RR: 20 (16 - 28) insp/min\\n SpO2: 95%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 101 kg (admission): 94.2 kg\\n Height: 67 Inch\\n CVP: 18 (6 - 21)mmHg\\n Total In:\\n 2,681 mL\\n 687 mL\\n PO:\\n TF:\\n 1,443 mL\\n 432 mL\\n IVF:\\n 888 mL\\n 255 mL\\n Blood products:\\n Total out:\\n 3,135 mL\\n 185 mL\\n Urine:\\n 3,035 mL\\n 185 mL\\n NG:\\n Stool:\\n 100 mL\\n Drains:\\n Balance:\\n -454 mL\\n 502 mL\\n Respiratory support\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 400 (400 - 400) mL\\n RR (Set): 20\\n RR (Spontaneous): 23\\n PEEP: 15 cmH2O\\n FiO2: 50%\\n RSBI Deferred: PEEP > 10\\n PIP: 31 cmH2O\\n Plateau: 25 cmH2O\\n SpO2: 95%\\n ABG: 7.46/39/68/27/3\\n Ve: 7.7 L/min\\n PaO2 / FiO2: 136\\n Physical Examination\\n General Appearance: No acute distress, Overweight / Obese, opens eyes\\n but no purposeful movement\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric)\\n Abdominal: No(t) Soft, Non-tender, Bowel sounds present, Distended\\n Extremities: No clubbing or cyanosis, 3+ nonpitting edema of b/l hands,\\n LE without edema\\n Skin: no rashes or jaundice\\n Labs / Radiology\\n 411 K/uL\\n 8.3 g/dL\\n 163 mg/dL\\n 0.5 mg/dL\\n 27 mEq/L\\n 3.8 mEq/L\\n 12 mg/dL\\n 111 mEq/L\\n 144 mEq/L\\n 26.0 %\\n 9.7 K/uL\\n [image002.jpg]\\n 03:47 AM\\n 02:14 PM\\n 04:05 PM\\n 01:12 AM\\n 04:00 AM\\n 04:09 AM\\n 10:18 AM\\n 02:33 PM\\n 02:46 PM\\n 03:31 AM\\n WBC\\n 10.5\\n 9.6\\n 9.7\\n Hct\\n 27.5\\n 27.8\\n 26.0\\n Plt\\n 374\\n 374\\n 411\\n Cr\\n 0.6\\n 0.5\\n 0.5\\n 0.5\\n TCO2\\n 27\\n 26\\n 27\\n 28\\n 29\\n 26\\n 27\\n Glucose\\n 187\\n 194\\n 195\\n 195\\n 163\\n Other labs: PT / PTT / INR:15.3/69.9/1.3, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\\n Amylase / Lipase:, Differential-Neuts:86.1 %, Lymph:10.3 %,\\n Mono:2.8 %, Eos:0.5 %, Lactic Acid:2.0 mmol/L, Albumin:2.4 g/dL,\\n LDH:204 IU/L, Ca++:8.3 mg/dL, Mg++:2.1 mg/dL, PO4:3.3 mg/dL\\n Assessment and Plan\\n 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture with respiratory failure\\n and difficulty weaning from vent.\\n # Respiratory failure: Intubated on for resp decompensation.\\n Likely VAP. Unlikely to have tracheomalacia as initially\\n transferred for.\\n - wean PEEP\\n - discuss need for trach with patient and her family\\n # Pneumonia: Pansensitive Kleb oxytoca pneumonia and sputum with GPCs\\n on gram stain. Afebrile overnight. On levofloxacin since .\\n Vancomycin, aztreonam have been stopped. Resp status seems to be\\n improving.\\n - Follow cultures\\n - d/c aztreonam\\n - Continue levofloxacin for 8 days (today = day )\\n # EKG changes: Sinus bradycardia. Very low voltages and no change in\\n QRS morphology. P-waves are visible and prolonged PR interval is old.\\n CK and troponins flat. Likely related to increased vagal tone possibly\\n related to steroid replacement. Atrial EKG with p-waves c/w sinus\\n bradycardia.\\n - Will avoid excessive alpha-agonism\\n - Continue to monitor\\n # Hypotension: Improved, off levophed for 2 days, with good urine\\n output. SVV with Vigileo was 7, making her CO less likely to respond\\n to fluids. CVP increasing with reduction in PEEP. Unlikely\\n hypovolemic or septic. Likely poor adrenal response in setting of\\n acute illness and very high PEEP.\\n -continue fludricort and hydrocortisone for total 5 days (begun )\\n -monitor, expect improvement with continual reduction in PEEP\\n # RUE DVT: Started on heparin gtt on .\\n - closely monitor\\n # Adrenal Insufficency: Random cortisol was approx 3 when it should\\n have been maximally stimulated.\\n - hydrocortisone and florinef for 5 days\\n # Anemia: Stable.\\n - Trend HCT\\n # Spine fracture: Neurologically intact distal to the lesion. Prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - CT of C, L spine when stable. Currently, unlikely to change\\n management and high risk for complications with transport.\\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\\n is low. Brace for OOB. Ok for anticoag per note.\\n # Communication:\\n - Brother has been with pt, although, live in boyfriend of 10 is\\n her HCP.\\n ICU \\n Nutrition:\\n Replete with Fiber (Full) - 08:13 PM 60 mL/hour\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 11:30 AM\\n Arterial Line - 04:00 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-09-25 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 634654,\n \"text\": \"Pt is a 55 yr old women admitted from OSH after she fell down the\\n stairs (did not have LOC per boyfriend) and had a traumatic T-spine\\n Fracture. Pt came to us with PNA from unknown etiology? VAP. Full\\n code, Allergies: PCN, tetracycline, sulfa. PMH: ETOH, smoker, Gerd, Hip\\n replacement. Pt afebrile during the night, was Pan cultured\\n yesterday. Pt brother is her spokesperson. Pt boyfriend was in last\\n night to see her, it is a 2 hr train ride from for him to get\\n here. Pt boyfriend reported on night that for the last 2 months\\n pt has been drinking 2 large bottles of wine almost every night and\\n that this is an increase from what she used to drink.\\n Bradycardia\\n Assessment:\\n HR 46-60\\ns, HR decreases when pt is asleep. Stays in the 45-50 range\\n when she is asleep. BP stable with low HR.\\n Action:\\n Monitor HR, monitor SBP with low HR\\n Response:\\n No action taken because vital sign have been stable.\\n Plan:\\n Cont to monitor\\n Alteration in Nutrition\\n Assessment:\\n Replete with fiber Goal rate 60ml/hr. distended firm belly but pt is\\n stooling now. Hypoactive bowel sounds.\\n Action:\\n Increased rate to 50ml/hr. cont to watch TF residuals. Pt did have past\\n problems with high residuals.\\n Response:\\n Residuals 10ml.\\n Plan:\\n Cont to advance TF as tolerated. Cont stool softners/monitor for high\\n residuals.\\n Deep Venous Thrombosis (DVT), Upper extremity,\\n Assessment:\\n RUE DVT, Pt on heparin gtt at 1700 units/hr. No blood draws or BP on\\n RUE.\\n Action:\\n PTT has been at therapeutic dose.\\n Response:\\n Repeat PTT in AM\\n Plan:\\n If PTT cont to be therapeutic cont to check PTT Q 24 hr., if not make\\n changes per protocol.\\n Fracture, other\\n Assessment:\\n Ortho reported that pt has T8 fracture. Pt does move all extremities,\\n needs to wear back brace when out of bed. Brace is in the room, pt no\\n longer on log roll precautions. Hard to tell if pt is in pain from\\n fracture but she is on fentanyl and versed gtts.\\n Action:\\n Per ortho pt will need MRI of the spine and CT scan of the C and L\\n portions of the spine to check for any other spinal injury. Ortho\\n states we can do this when pt is more stable.\\n Response:\\n Plan:\\n Will do MRI and CT at a later date.\\n Hypotension (not Shock)\\n Assessment:\\n SBP ranges 80-100\\ns with MAPs 55-70 Goal MAP >60. levophed off for\\n almost 24hr. pt did get total of 3 liters in fluid boluses over the\\n last 24 hr. CVP 12-14 but pt on 21 of peep. A-line very positional\\n and was just re-sited yesterday. Pt was on vigileo monitor but D/C\\n during the day because A-line tracing is so positional that the\\n accuracy of this monitoring is questionable.\\n Action:\\n Gave 500ml fluid bolus for MAP of 55. and low urine output 10-20ml/hr.\\n Response:\\n Urine output increased, and MAP/BP increased\\n Plan:\\n Cont to monitor BP and MAPs and urine output.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Suctioning clear/white thick secretions in-line, copious amounts of\\n clear secretions suctioned orally. Cough intact. Lung sounds clear\\n diminished, no vent setting changes, Vent mode CMV: 40%/400/22/21,\\n esophageal balloon in place.\\n Action:\\n VAP protocol: HOB 30 degrees, oral care. Suctioning, cont steroids.\\n Chest x-ray done in AM. Cont antibiotics.\\n Response:\\n Cont to needs lots of suctioning.\\n Plan:\\n Wean vent as ordered by the Micu team. Cont to check ABG\\ns when\\n indicated.\\n\"\n },\n {\n \"category\": \"Nutrition\",\n \"chartdate\": \"2167-09-25 00:00:00.000\",\n \"description\": \"Clinical Nutrition Note\",\n \"row_id\": 634666,\n \"text\": \"Objective\\n Pertinent medications: noted\\n Labs:\\n Value\\n Date\\n Glucose\\n 187 mg/dL\\n 03:47 AM\\n Glucose Finger Stick\\n 207, 190\\n \\n BUN\\n 6 mg/dL\\n 03:47 AM\\n Creatinine\\n 0.6 mg/dL\\n 03:47 AM\\n Sodium\\n 144 mEq/L\\n 03:47 AM\\n Potassium\\n 4.3 mEq/L\\n 03:47 AM\\n Chloride\\n 113 mEq/L\\n 03:47 AM\\n TCO2\\n 26 mEq/L\\n 03:47 AM\\n Albumin\\n 2.4 g/dL\\n 03:59 AM\\n Calcium non-ionized\\n 9.0 mg/dL\\n 03:47 AM\\n Phosphorus\\n 2.7 mg/dL\\n 03:47 AM\\n Ionized Calcium\\n 1.20 mmol/L\\n 08:18 AM\\n Magnesium\\n 2.0 mg/dL\\n 03:47 AM\\n Current diet order / nutrition support: Replte c/ Fiber @60mL/hr (1440\\n kcals/89 gr aa)\\n GI: Abd: firm/dist/+bs/+bm\\n Assessment of Nutritional Status\\n Specifics:\\n Pt remains intubated. TF\\ns retrialed . Currently infusing @50mL/\\n hr c/ minimal residuals, advancing slowly to goal of 60mL/hr. Pt\\ns abd\\n remains firm, but pt now stooling. BG\\ns elevated on steroids.\\n Medical Nutrition Therapy Plan - Recommend the Following\\n Multivitamin / Mineral supplement: via TF\\n Advance TF's to goal rate of 60mL/hr, as ordered\\n Residual checks q 4 hr, hold if >200mL\\n Consider tighter SS insulin\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-09-25 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 634672,\n \"text\": \"Chief Complaint:\\n HPI:\\n 24 Hour Events:\\n ARTERIAL LINE - STOP 04:00 PM\\n ARTERIAL LINE - START 04:00 PM\\n Patient unable to provide history: Sedated\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Metronidazole - 08:00 AM\\n Levofloxacin - 10:00 AM\\n Aztreonam - 06:00 AM\\n Vancomycin - 09:00 AM\\n Infusions:\\n Heparin Sodium - 1,700 units/hour\\n Fentanyl - 100 mcg/hour\\n Midazolam (Versed) - 4 mg/hour\\n Other ICU medications:\\n Midazolam (Versed) - 09:17 AM\\n Ranitidine (Prophylaxis) - 09:28 AM\\n Other medications:\\n midaz, fent, colace, H2B, CHG, SQI, MDIs, IV heparin, levoflox,\\n aztreonam, vanco, hydrocort, fludrocort,\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 10:26 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.9\\nC (98.4\\n Tcurrent: 36.9\\nC (98.4\\n HR: 61 (45 - 79) bpm\\n BP: 125/65(87) {83/44(59) - 125/84(134)} mmHg\\n RR: 22 (0 - 30) insp/min\\n SpO2: 99%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 101 kg (admission): 94.2 kg\\n Height: 67 Inch\\n CVP: 16 (12 - 17)mmHg\\n Total In:\\n 4,751 mL\\n 1,813 mL\\n PO:\\n TF:\\n 773 mL\\n 523 mL\\n IVF:\\n 3,828 mL\\n 1,200 mL\\n Blood products:\\n Total out:\\n 2,365 mL\\n 465 mL\\n Urine:\\n 2,325 mL\\n 265 mL\\n NG:\\n 40 mL\\n Stool:\\n Drains:\\n Balance:\\n 2,386 mL\\n 1,348 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 400 (400 - 400) mL\\n RR (Set): 22\\n RR (Spontaneous): 5\\n PEEP: 21 cmH2O\\n FiO2: 40%\\n RSBI Deferred: PEEP > 10\\n PIP: 33 cmH2O\\n Plateau: 28 cmH2O\\n Compliance: 57.2 cmH2O/mL\\n SpO2: 99%\\n ABG: ///26/\\n Ve: 10.4 L/min\\n Physical Examination\\n General Appearance: Overweight / Obese\\n Eyes / Conjunctiva: PERRL\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\\n Respiratory / Chest: (Percussion: Resonant : ), (Breath Sounds: Clear :\\n anterior exam)\\n Abdominal: Soft, Non-tender, Obese\\n Extremities: Right: 1+, Left: 1+\\n Musculoskeletal: Unable to stand\\n Skin: Warm\\n Neurologic: Responds to: Verbal stimuli, Movement: Purposeful, Tone:\\n Normal\\n Labs / Radiology\\n 8.3 g/dL\\n 374 K/uL\\n 187 mg/dL\\n 0.6 mg/dL\\n 26 mEq/L\\n 4.3 mEq/L\\n 6 mg/dL\\n 113 mEq/L\\n 144 mEq/L\\n 27.5 %\\n 10.5 K/uL\\n [image002.jpg]\\n 01:04 AM\\n 05:54 AM\\n 06:11 AM\\n 11:07 PM\\n 03:51 AM\\n 06:17 AM\\n 07:00 AM\\n 08:18 AM\\n 04:18 PM\\n 03:47 AM\\n WBC\\n 8.1\\n 8.9\\n 10.5\\n Hct\\n 28.0\\n 28.6\\n 27.5\\n Plt\\n 358\\n 326\\n 374\\n Cr\\n 0.7\\n 0.7\\n 0.6\\n 0.6\\n TropT\\n <0.01\\n <0.01\\n TCO2\\n 28\\n 26\\n 26\\n 21\\n 28\\n Glucose\\n 126\\n 151\\n 153\\n 187\\n Other labs: PT / PTT / INR:20.3/89.3/1.9, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\\n Amylase / Lipase:, Differential-Neuts:84.8 %, Lymph:12.5 %,\\n Mono:2.4 %, Eos:0.1 %, Lactic Acid:0.7 mmol/L, Albumin:2.4 g/dL,\\n LDH:204 IU/L, Ca++:9.0 mg/dL, Mg++:2.0 mg/dL, PO4:2.7 mg/dL\\n Imaging: CXR: right base opacity; difficult to identify endotracheal\\n tube\\n Microbiology: Sputum: pan-sensitive Klebs\\n Assessment and Plan\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 07:00 AM 60 mL/hour\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n Multi Lumen - 11:30 AM\\n Arterial Line - 04:00 PM\\n Prophylaxis:\\n DVT: Boots(Systemic anticoagulation: Heparin gtt)\\n Stress ulcer: H2 blocker\\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :ICU\\n Total time spent:\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-09-25 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 634673,\n \"text\": \"Chief Complaint:\\n HPI:\\n 24 Hour Events:\\n ARTERIAL LINE - STOP 04:00 PM\\n ARTERIAL LINE - START 04:00 PM\\n Patient unable to provide history: Sedated\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Metronidazole - 08:00 AM\\n Levofloxacin - 10:00 AM\\n Aztreonam - 06:00 AM\\n Vancomycin - 09:00 AM\\n Infusions:\\n Heparin Sodium - 1,700 units/hour\\n Fentanyl - 100 mcg/hour\\n Midazolam (Versed) - 4 mg/hour\\n Other ICU medications:\\n Midazolam (Versed) - 09:17 AM\\n Ranitidine (Prophylaxis) - 09:28 AM\\n Other medications:\\n midaz, fent, colace, H2B, CHG, SQI, MDIs, IV heparin, levoflox,\\n aztreonam, vanco, hydrocort, fludrocort,\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 10:26 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.9\\nC (98.4\\n Tcurrent: 36.9\\nC (98.4\\n HR: 61 (45 - 79) bpm\\n BP: 125/65(87) {83/44(59) - 125/84(134)} mmHg\\n RR: 22 (0 - 30) insp/min\\n SpO2: 99%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 101 kg (admission): 94.2 kg\\n Height: 67 Inch\\n CVP: 16 (12 - 17)mmHg\\n Total In:\\n 4,751 mL\\n 1,813 mL\\n PO:\\n TF:\\n 773 mL\\n 523 mL\\n IVF:\\n 3,828 mL\\n 1,200 mL\\n Blood products:\\n Total out:\\n 2,365 mL\\n 465 mL\\n Urine:\\n 2,325 mL\\n 265 mL\\n NG:\\n 40 mL\\n Stool:\\n Drains:\\n Balance:\\n 2,386 mL\\n 1,348 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 400 (400 - 400) mL\\n RR (Set): 22\\n RR (Spontaneous): 5\\n PEEP: 21 cmH2O\\n FiO2: 40%\\n RSBI Deferred: PEEP > 10\\n PIP: 33 cmH2O\\n Plateau: 28 cmH2O\\n Compliance: 57.2 cmH2O/mL\\n SpO2: 99%\\n ABG: ///26/\\n Ve: 10.4 L/min\\n Physical Examination\\n General Appearance: Overweight / Obese\\n Eyes / Conjunctiva: PERRL\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\\n Respiratory / Chest: (Percussion: Resonant : ), (Breath Sounds: Clear :\\n anterior exam)\\n Abdominal: Soft, Non-tender, Obese\\n Extremities: Right: 1+, Left: 1+\\n Musculoskeletal: Unable to stand\\n Skin: Warm\\n Neurologic: Responds to: Verbal stimuli, Movement: Purposeful, Tone:\\n Normal\\n Labs / Radiology\\n 8.3 g/dL\\n 374 K/uL\\n 187 mg/dL\\n 0.6 mg/dL\\n 26 mEq/L\\n 4.3 mEq/L\\n 6 mg/dL\\n 113 mEq/L\\n 144 mEq/L\\n 27.5 %\\n 10.5 K/uL\\n [image002.jpg]\\n 01:04 AM\\n 05:54 AM\\n 06:11 AM\\n 11:07 PM\\n 03:51 AM\\n 06:17 AM\\n 07:00 AM\\n 08:18 AM\\n 04:18 PM\\n 03:47 AM\\n WBC\\n 8.1\\n 8.9\\n 10.5\\n Hct\\n 28.0\\n 28.6\\n 27.5\\n Plt\\n 358\\n 326\\n 374\\n Cr\\n 0.7\\n 0.7\\n 0.6\\n 0.6\\n TropT\\n <0.01\\n <0.01\\n TCO2\\n 28\\n 26\\n 26\\n 21\\n 28\\n Glucose\\n 126\\n 151\\n 153\\n 187\\n Other labs: PT / PTT / INR:20.3/89.3/1.9, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\\n Amylase / Lipase:, Differential-Neuts:84.8 %, Lymph:12.5 %,\\n Mono:2.4 %, Eos:0.1 %, Lactic Acid:0.7 mmol/L, Albumin:2.4 g/dL,\\n LDH:204 IU/L, Ca++:9.0 mg/dL, Mg++:2.0 mg/dL, PO4:2.7 mg/dL\\n Imaging: CXR: right base opacity; difficult to identify endotracheal\\n tube\\n Microbiology: Sputum: pan-sensitive Klebs\\n Assessment and Plan\\n 55-year-old woman with\\n Unclear location of ETT\\n Since only 18cm in holder, we will bronch to confirm correct\\n position since an inadvertent extubation might be fatal.\\n Respiratory failure\\n Oxygenation is improving\\n Wean PEEP as tolerated by hypoxemia\\n eventually need investigation for TBM\\n At present, her PEEP is too high to consider tracheostomy\\n but if we are able to wean it (and not able to extubate her) would\\n consider tracheostomy soon\\n Adrenal insufficiency\\n Based on very low random cortisol while in shock and\\n respiratory failure\\n On steroids, has come off and stayed off of pressors.\\n Eventually wean, but still getting fluid boluses\\n Bradycardia\\n Rhythm is sinus, confirmed by CVL-directed\\natrial\\n lead\\n Heart rate increases with stimulation, suggesting that this\\n is mostly vagal in etiology\\n Klebsiella VAP\\n Complete 8d course of levofloxacin\\n Discontinue aztreonam\\n If sputum culture remains negative (GPCs on G/S),\\n discontinue vancomycin tomorrow\\n Shock\\n now off of levophed\\n Intermittent fluid boluses\\n Treating adrenal insufficiency\\n Upper extremity DVT\\n Therapeutic heparin\\n Anemia\\n Follow\\n Possible tracheobronchomalacia (reason for transfer)\\n Incidental peri-appendiceal finding (will need eventual\\n follow-up)\\n Traumatic thoracic spinal fracture\\n Eventual MRI. Too high-risk at present. Brace when out of\\n bed.\\n Other issues as per ICU team note.\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 07:00 AM 60 mL/hour\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n Multi Lumen - 11:30 AM\\n Arterial Line - 04:00 PM\\n Prophylaxis:\\n DVT: Boots(Systemic anticoagulation: Heparin gtt)\\n Stress ulcer: H2 blocker\\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :ICU\\n Total time spent: 50 min\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2167-09-27 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 634836,\n \"text\": \"TITLE:\\n Demographics\\n :\\n Day of mechanical ventilation: 9\\n Ideal body weight: 61.2 None\\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: Unknown\\n Tube Type\\n ETT:\\n Position: 21 cm at teeth\\n Route: Oral\\n Type: Standard\\n Size: 7.5mm\\n Cuff Management:MOV\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Diminished\\n Comments:\\n Secretions\\n Sputum color / consistency: Tan / Thick\\n Sputum source/amount: Suctioned / Small\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance: A/C400x20/+15 peep/.5\\n Visual assessment of breathing pattern: Normal quiet breathing\\n Assessment of breathing comfort: No response (sleeping / sedated)\\n :\\n Invasive ventilation assessment:\\n Trigger work assessment: Not triggering\\n Dysynchrony assessment: none noted\\n Plan\\n Next 24-48 hours: Reduce PEEP as tolerated\\n Reason for continuing current ventilatory support: Intolerant of\\n weaning attempts, Underlying illness not resolved\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-09-26 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 634729,\n \"text\": \"TITLE: This is a 55 yr old female admitted from an OSH to on\\n with resp failure, +PNA s/p fall down stairs with fracture of\\n T5-T8 and possible tracheobronchomalacia for IP consult and possible Y\\n stenting. Pt now s/p IP consult with no tracheobronchomalacia found on\\n exam. Pt has been diff to wean with high PEEP requirements. The pt\\n has finished a course of IV Levofloxacin, Vanco, and Aztreonam antibx\\n for Klebsiella PNA/VAP. Pt found to have RUE DVT and maintained on an\\n IV Heparin gtt (no NBP or blood draw in this appendage please). The pt\\n is net input more than fifteen liters for LOS @ this time. The pt has\\n documented allergies to Tetracycline, PCN & Hydrazaline. The pt is a\\n Full Code. The pt has a boyfriend and a brother, the brother is the\\n designated HCP.\\n Bradycardia\\n Assessment:\\n NSR/Sinus bradycardia all shift. Pt maintains good cardiac output\\n whether in NSR or SB with good hourly urine output and MAP\\ns > 65 as\\n desired by team.\\n Action:\\n No specific action required.\\n Response:\\n Pt remains hemodynamically stable on current pt care regime.\\n Plan:\\n Cont to follow pts hemodynamic status closely.\\n Alteration in Nutrition\\n Assessment:\\n Pt received/maintained on full strength Replete with Fiber @ target\\n rate of 60ml/hr via OGT with low residuals noted all shift.\\n Action:\\n Pt maintained on Replete with Fiber tube feeds @ target rate of\\n 60ml/hr. Rectal tube d/c\\ned 2^nd low output.\\n Response:\\n Pt appears to be tolerating current tube feeds.\\n Plan:\\n Cont to provide tube feeds @ stated target goal per Nutrition recs.\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Pt has a documented RUE DVT and received on IV Heparin gtt infusing @\\n 1,700 units/hr with serial therapeutic PTT noted.\\n Action:\\n Pt maintained on a 1,700 unit/hr Heparin gtt infusion rate.\\n Response:\\n Therapeutic AM PTT value of 84.8 noted.\\n Plan:\\n Cont with current IV Heparin gtt, hope to transistion to PO anti-coag\\n when medically suited.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt received on CMV:22-40%-400-21 with normal sats, RR @ set rate and no\\n evidence of SOB/dyspnea. Of note, the pts O2 sat perfectly correlates\\n with ABG sat.\\n Action:\\n Rate dropped to 20, PEEP slowly/cautiously reduced down to 16. Pt\\n sxn\\ned for small amounts of thick tan sec per ETT overnight. AM CXR\\n obtained this AM, results pending.\\n Response:\\n Pt cont to do well on reduced levels of MV support with last ABG\\n values; 7.43-41-80.\\n Plan:\\n Cont to wean PEEP down as tol. Hope to avoid trach placement if\\n possible.\\n Hypotension (not Shock)\\n Assessment:\\n Pt has remained hemodynamically stable and afebrile all shift. CVP\\n values in the low/mid teens, real value likely < 10 in setting of high\\n PEEP (16).\\n Action:\\n Reduced PEEP overnight may be helping to improve cardiac output with\\n increased venous return.\\n Response:\\n Pt has been maintained off pressors.\\n Plan:\\n Cont to follow hemodynamic status closely.\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2167-09-26 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 634731,\n \"text\": \"TITLE:\\n Demographics\\n Day of intubation: 13\\n Day of mechanical ventilation: 13\\n Ideal body weight: 61.2 None\\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: Unknown\\n Tube Type\\n ETT:\\n Position: 21 cm at teeth\\n Route: Oral\\n Type: Standard\\n Size: 7.5mm\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 28 cmH2O\\n Cuff volume: mL /\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Clear\\n Comments:\\n Secretions\\n Sputum color / consistency: Tan / Thick\\n Sputum source/amount: Suctioned / Small\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance: A/C 400x20/+16 peep/.4\\n Visual assessment of breathing pattern: Normal quiet breathing\\n Assessment of breathing comfort: No response (sleeping / sedated)\\n Invasive ventilation assessment:\\n Trigger work assessment: Not triggering\\n Dysynchrony assessment: none noted\\n Comments: tolerated decrease in rate/Ve and decrease in peep from +21\\n to +16 overnoc\\n Plan\\n Next 24-48 hours: Reduce PEEP as tolerated\\n Reason for continuing current ventilatory support: Underlying illness\\n not resolved\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-09-26 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 634807,\n \"text\": \"Events: MS labile from resting to agitated/ ? in pain in bed.\\n Titrating sedation and adding IV Haldol for agitation. Tolerating TF\\n and tightened RISS w/ recent high blood sugars. TF w/ minimal\\n residual- firm abd and given Ducolax supp w/ good effect. Unable to\\n wean from vent\\n sat 90-93%, desat to 88-90% w/ cleaning and turning.\\n Starting IV diuresis for edema/vent weaning.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n LS clear bilat upper lobes, diminished bilat lower lobes, pt w/ strong\\n cough but minimal amts or thin clear secretions, large amt oral\\n secretions, sat 90-95%\\n Action:\\n Turning as tolerated, suctioned PRN, up FiO2 w/ repete ABG O2 72,\\n starting diuresis 10mg IVP Lasix x2\\n Response:\\n Sat 95-96%, 50%/400/x20/+15, post each dose Lasix mod response\\n 500-700cc out/2hrs then tapering, BP w/o change post Lasix,\\n Plan:\\n Cont IV duiresis for goal envolemic to neg 500cc for decrease in angio\\n and pulm edema to wean from vent, possibly Lasix gtt if not negative\\n and BP tolerates\\n Impaired Skin Integrity\\n Assessment:\\n Post supp- inc soft, semi formed brown guiac neg BM- while cleaning\\n noted peri anal rash and sm area R glut/peri anal area\\n? Skin tear\\n from excoriation and resistance w/ turning and agitation/moving self in\\n bed, skin tear site pink, clear w/ no odor, peri wound tissue mild\\n excoriated/reddened\\n Action:\\n Pressure reduction as tolerated, barrier cream and criticaid cream,\\n heals and elbows elevated, multipudus boots\\n Response:\\n No additional breakdown noted\\n Plan:\\n Cont monitor skin integrity, pressure reduction and shearing\\n protection, cont support nutrition\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt will track follow, when released from restraints will reach in air\\n and intermittently attempt pull @ ETT, ? nodding to questioning x 1,\\n unable to write to make needs known, pt frequently attempting to turn\\n in bed\\n Action:\\n Repositionged in afternoon for ? back pain, x1 sig inc in agitation\\n administering 1mg IVP Haldol w/ good effect\\n Response:\\n Resting comfortable, VSS for several hours- able to mild titrate down\\n Versed gtt,\\n Plan:\\n Cont monitor MS, emotional support, frequent reorientation, cont\\n sedation as tolerated ? dilerium w/ PRN Haldol for aggitation\\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\\n Assessment:\\n afebrile\\n Action:\\n Cont IV ABD Levoflox day \\n Response:\\n Plan:\\n Cont monitor for temp spike, VAP prevention, skin care, IV ABX\\n team\\n to D/C Levoflox \\n Edema, peripheral\\n Assessment:\\n 2+ generalized/dependent edema, CVP 15-21\\n Action:\\n Arms, hands, and legs elevated as tolerated, administering 10mg IVP\\n Lasix x 2\\n Response:\\n Mod output w/ >500cc/2hrs and tapering post both doses\\n Plan:\\n Goal envolemic to neg 500 cc\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Heparin gtt @ 1700 units/hr, no S/S bleeding\\n Action:\\n Cont Hep gtt\\n Response:\\n Plan:\\n Cont Hep gtt check PTT w/ Am labs, cont IV anticoagulation likely\\n slow wean from vent and possible trach placement\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-09-26 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 634809,\n \"text\": \"Events: MS labile from resting to agitated/ ? in pain in bed.\\n Titrating sedation and adding IV Haldol for agitation. Tolerating TF\\n and tightened RISS w/ recent high blood sugars. TF w/ minimal\\n residual- firm abd and given Ducolax supp w/ good effect. Unable to\\n wean from vent\\n sat 90-93%, desat to 88-90% w/ cleaning and turning.\\n Starting IV diuresis for edema/vent weaning.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n LS clear bilat upper lobes, diminished bilat lower lobes, pt w/ strong\\n cough but minimal amts or thin clear secretions, large amt oral\\n secretions, sat 90-95%\\n Action:\\n Turning as tolerated, suctioned PRN, up FiO2 w/ repete ABG O2 72,\\n starting diuresis 10mg IVP Lasix x2\\n Response:\\n Sat 95-96%, 50%/400/x20/+15, post each dose Lasix mod response\\n 500-700cc out/2hrs then tapering, BP w/o change post Lasix,\\n Plan:\\n Cont IV duiresis for goal envolemic to neg 500cc for decrease in angio\\n and pulm edema to wean from vent, possibly Lasix gtt if not negative\\n and BP tolerates\\n Impaired Skin Integrity\\n Assessment:\\n Post supp- inc soft, semi formed brown guiac neg BM- while cleaning\\n noted peri anal rash and sm area R glut/peri anal area\\n? Skin tear\\n from excoriation and resistance w/ turning and agitation/moving self in\\n bed, skin tear site pink, clear w/ no odor, peri wound tissue mild\\n excoriated/reddened\\n Action:\\n Pressure reduction as tolerated, barrier cream and criticaid cream,\\n heals and elbows elevated, multipudus boots\\n Response:\\n No additional breakdown noted\\n Plan:\\n Cont monitor skin integrity, pressure reduction and shearing\\n protection, cont support nutrition\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt will track follow, when released from restraints will reach in air\\n and intermittently attempt pull @ ETT, ? nodding to questioning x 1,\\n unable to write to make needs known, pt frequently attempting to turn\\n in bed\\n Action:\\n Repositioned in afternoon for ? back pain, x1 sig inc in agitation\\n administering 1mg IVP Haldol w/ good effect\\n Response:\\n Resting comfortable, in afternoon VSS for several hours- able to mild\\n titrate down Versed gtt,\\n Plan:\\n Cont monitor MS, emotional support, frequent reorientation, cont\\n sedation as tolerated ? dilerium w/ PRN Haldol for aggitation\\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\\n Assessment:\\n afebrile\\n Action:\\n Cont IV ABD Levoflox day \\n Response:\\n Plan:\\n Cont monitor for temp spike, VAP prevention, skin care, IV ABX\\n team\\n to D/C Levoflox \\n Edema, peripheral\\n Assessment:\\n 2+ generalized/dependent edema, CVP 15-21\\n Action:\\n Arms, hands, and legs elevated as tolerated, administering 10mg IVP\\n Lasix x 2\\n Response:\\n Mod output w/ >500cc/2hrs and tapering post both doses\\n Plan:\\n Goal envolemic to neg 500 cc\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Heparin gtt @ 1700 units/hr, no S/S bleeding\\n Action:\\n Cont Hep gtt\\n Response:\\n No change\\n Plan:\\n Cont Hep gtt check PTT w/ Am labs, cont IV anticoagulation likely\\n slow wean from vent and possible trach placement\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2167-09-27 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 634816,\n \"text\": \"TITLE:\\n Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 9\\n Ideal body weight: 61.2 None\\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: Unknown\\n Tube Type\\n ETT:\\n Position: 21 cm at teeth\\n Route: Oral\\n Type: Standard\\n Size: 7.5mm\\n Tracheostomy tube:\\n Type:\\n Manufacturer:\\n Size:\\n PMV:\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 28 cmH2O\\n Cuff volume: mL /\\n Airway problems:\\n Comments:\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Diminished\\n Comments:\\n Secretions\\n Sputum color / consistency: Tan / Thick\\n Sputum source/amount: Suctioned / Small\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance: A/C400x20/+15 peep/.5\\n Visual assessment of breathing pattern: Normal quiet breathing\\n Assessment of breathing comfort: No response (sleeping / sedated)\\n Non-invasive ventilation assessment:\\n Invasive ventilation assessment:\\n Trigger work assessment: Not triggering\\n Dysynchrony assessment:\\n Comments:\\n Plan\\n Next 24-48 hours: Reduce PEEP as tolerated\\n Reason for continuing current ventilatory support: Intolerant of\\n weaning attempts, Underlying illness not resolved\\n Respiratory Care Shift Procedures\\n Transports:\\n Destination (R/T)\\n Time\\n Complications\\n Comments\\n Bedside Procedures:\\n Comments:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-09-27 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 634817,\n \"text\": \"TITLE:\\n Altered mental status (not Delirium)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Alteration in Nutrition\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Edema, peripheral\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-09-27 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 634818,\n \"text\": \"TITLE: This is a 55 yr old female admitted from an OSH to on\\n with resp failure, +PNA s/p fall down stairs with fracture of\\n T5-T8 and possible tracheobronchomalacia for IP consult and possible Y\\n stenting. Pt now s/p IP consult with no tracheobronchomalacia found on\\n exam. Pt has been diff to wean with high PEEP requirements. The pt\\n has finished a course of IV Levofloxacin, Vanco, and Aztreonam antibx\\n for Klebsiella PNA/VAP. Pt found to have RUE DVT and maintained on an\\n IV Heparin gtt (no NBP or blood draw in this appendage please). The pt\\n is net input more than fifteen liters for LOS @ this time. The pt has\\n documented allergies to Tetracycline, PCN & Hydrazaline. The pt is a\\n Full Code. The pt has a boyfriend and a brother, the brother is the\\n designated HCP.\\n Overnight Events: No significant events overnight. Unable to wean MV\\n support. Pt sedation needs appear to be increasing with increased\\n levels of agitation requiring increased Midazolam & Fentanyl gtt rates\\n and more freq IVP bolus dosing.\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt received/maintained on IV Fentanyl & Midazolam gtt\\ns infusing @\\n 125mcg/hr & 3mg/hr respectively. Unfortunately, pt easily becomes\\n agitated with the slightest stimulation and does not respond to verbal\\n re- assurance. Pt intermittently follows commands. At one point the\\n pt nodded her head negatively when asked if she was in pain.\\n Action:\\n IV Fentanyl & IV Midazolam gtts titrated up, freq sedation boluses also\\n provided. Soft wrist restraints maintained for pt safety. Pt freq\\n re-oriented to person/place/time/care rationale to assist with nl\\n cognition.\\n Response:\\n Pt seems to do well when left alone with lights out. Pt does not seem\\n to get agitated to verbal stimuli, but does is not appeased by verbal &\\n non-verbal reassurance.\\n Plan:\\n Pt responded well to IV Haldol on , may need to repeat?\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt received/maintained on AC-20-50%-400-15 with adequate ABG values\\n (7.46-39-68) and subsequently no MV setting changes.\\n Actioin:\\n HOB kept @ 30 to 45 degrees. Sxn\\ning provided to ETT Q 2-3 hr for sm\\n amounts of thick tan sec. No RSBI 2^nd PEEP >/= 10.\\n Response:\\n Current AM ABG is acceptable.\\n Plan:\\n Pt appears to be moving in the direction of tracheostomy placement when\\n PEEP reduced to more tolerable levels.\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Pt has a documented DVT in RUE. No blood draws nor NBP measurements in\\n this extremity please.\\n Action:\\n Pt received/maintained on IV Heparin gtt infusing @ 1,700 units/hr.\\n Response:\\n Pt has had serial therapeutic PTT values on current IV Heparin gtt rate\\n of 1,700 units/hr.\\n Plan:\\n Currently awaiting AM PTT value to ensure optimal anti-coagulation\\n status.\\n Alteration in Nutrition\\n Assessment:\\n Pt received/maintained on full strength Replete with Fiber.\\n Action:\\n Pt continues to tol Replete with Fiber @ target rate of 60ml/hr.\\n Response:\\n Pt appears to be tol enteral nutrition @ this time with minimal\\n residual per OGT.\\n Plan:\\n Cont to maintain pt on current tube feeds.\\n Edema, peripheral\\n Assessment:\\n The pt is net input 16 liters for LOS and is +3 generalized\\n anasarcoid. CVP values in the low teens in setting of high PEEP\\n needs(15).\\n Action:\\n 10mg IVP Lasix provided @ 20:00.\\n Response:\\n Pt voided approximately 750ml dilute clear urine s/p 10mg IVP Lasix\\n dose.\\n Plan:\\n Pt remains approx 16 liters input for LOS.\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2167-09-28 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 634929,\n \"text\": \"TITLE:\\n Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 10\\n Ideal body weight: 61.2 None\\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: Unknown\\n Tube Type\\n ETT:\\n Position: 21 cm at teeth\\n Route: Oral\\n Type: Standard\\n Size: 7.5mm\\n Cuff Management: MOV\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Diminished\\n Comments:\\n Secretions\\n Sputum color / consistency: Tan / Thick\\n Sputum source/amount: Suctioned / Small\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance: A/C 400x18/+15 peep/.5\\n Visual assessment of breathing pattern: Normal quiet breathing;\\n Comments: occ periods of agitation\\n Assessment of breathing comfort: comf\\n Invasive ventilation assessment:\\n Trigger work assessment: Triggering synchronously\\n Plan\\n Next 24-48 hours: Reduce PEEP as tolerated\\n Reason for continuing current ventilatory support: Underlying illness\\n not resolved; rsbi held d/t peep level\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-09-27 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 634911,\n \"text\": \"TITLE: This is a 55 yr old female admitted from an OSH to on\\n with resp failure, +PNA s/p fall down stairs with fracture of\\n T5-T8 and possible tracheobronchomalacia for IP consult and possible Y\\n stenting. Pt now s/p IP consult with no tracheobronchomalacia found on\\n exam. Pt has been diff to wean with high PEEP requirements. The pt\\n has finished a course of IV Levofloxacin, Vanco, and Aztreonam antibx\\n for Klebsiella PNA/VAP. Pt found to have RUE DVT and maintained on an\\n IV Heparin gtt (no NBP or blood draw in this appendage please). The pt\\n is net input more than fifteen liters for LOS @ this time. The pt has\\n documented allergies to Tetracycline, PCN & Hydrazaline. The pt is a\\n Full Code. The pt has a boyfriend and a brother, the brother is the\\n designated HCP.\\n Events: PICC line placed at bedside, RR decreased from 20 to 18,\\n levaquin d/c\\nd. cont to diurese w/ lasix.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Rec\\nd pt on AC 20x400 50% PEEP 15. ABG n these settings 7.46/ 39/68\\n Action:\\n RR decreased to 18 to correct pH\\n Response:\\n Repeat ABG\\ns 7.41/ 45/78\\n Plan:\\n Wean vent as tol, ? trach if unable to extubate\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n PTT 69.9 on heparin at 1700 units/hr\\n Action:\\n Response:\\n Plan:\\n Cont to monitor PTT, titrate heparin per protocol\\n Edema, peripheral\\n Assessment:\\n Generalized edema r/t +FB of ~16.5L for LOS\\n Action:\\n Lasix 10mg IV given a/o\\n Response:\\n Pt diuresed 700ml over 2hrs.\\n Plan:\\n Monitor lytes, cont diuresis as tol.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-09-20 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 634115,\n \"text\": \"55 year old woman with hx of obesity presented to Medical Center\\n on after falling down stairs while at home. She suffered a\\n traumatic T5-8 fracture with retropulsion of fragments. Per medical\\n records and discussion with her brother, she was awake for the fall (no\\n LOC) and the fall was triggered by unsteady gait, potentially\\n influenced by alcohol. Her fracture was managed concervatively. She\\n was placed in a torso brace but her course was complicated by\\n respiratory failure requiring intubation. At that time a CT was\\n negative for PE but showed bilateral bibasilar consolidations vs\\n atelectasis. At that time an ABG was 7.20/89/57 (unknown FIO2 but\\n likely >6L facemask). She was intubated on at 08:40. The\\n respiratory failure was thought likely to be related to pain med\\n induced hypoventilation, bronchospasm, or restricted breathing due\\n to the back brace. The hospital course was complicated by\\n difficulty weaning form the ventilator. Her periodic agitation was\\n managed with seroquel. Prior to transfer her vent settings were: SIMV\\n 12x600 FIO2 0.45.\\n The neurosurgery service evaluated her and recommended concervative\\n management of her fracture including a back brace and outpatient\\n neurosurgery followup. The CT chest showed notable narrowing of her\\n central airways and the patient was referred for Interventional\\n Pulmonary evaluation for airway stenting.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt O2Sats down 80-90\\ns upon arrival, ABG\\ns showed PaO2 61%, pt up to\\n 100%Fio2, bilat rhonchi, Dim bases, suct for mod thick tan secretions;\\n copious oral secretions; pt RR with care, breathing against vent\\n Action:\\n FIO2 increased 100%, weaning down as tolerated; sedation increased for\\n ventilation\\n Response:\\n Pt O2Sats 98-100%\\n Plan:\\n ABG\\ns, VS; Wean Fio2 as tolerated; CXRAY; cont with sedation\\n for improved ventilation\\n Fracture, other\\n Assessment:\\n pt s/p fall---T7 fracture/no surgical intervention\\n Action:\\n pt on log roll precautions, reverse t @30 degrees\\n Response:\\n pt tolerating turns well, no s/sx pain with care\\n Plan:\\n f/u with PT consult, cont log roll precautions\\n Hypernatremia (high sodium)\\n Assessment:\\n Na 150\\n Action:\\n pt to receive D5W @50 X1L, TF started with 150 free water flushes every\\n 4hrs\\n Response:\\n TF @ 10, no residual noted repeat labs in am\\n Plan:\\n labs, cont with free water flushes\\n Anemia, other\\n Assessment:\\n HCT 30, down from 40 upon admission to OSH\\n Action:\\n No s/sx of bleeding noted,\\n Response:\\n Plan:\\n hct, quiac stools\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-09-20 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 634116,\n \"text\": \"55 year old woman with hx of obesity presented to Medical Center\\n on after falling down stairs while at home. She suffered a\\n traumatic T5-8 fracture with retropulsion of fragments. Per medical\\n records and discussion with her brother, she was awake for the fall (no\\n LOC) and the fall was triggered by unsteady gait, potentially\\n influenced by alcohol. Her fracture was managed concervatively. She\\n was placed in a torso brace but her course was complicated by\\n respiratory failure requiring intubation. At that time a CT was\\n negative for PE but showed bilateral bibasilar consolidations vs\\n atelectasis. At that time an ABG was 7.20/89/57 (unknown FIO2 but\\n likely >6L facemask). She was intubated on at 08:40. The\\n respiratory failure was thought likely to be related to pain med\\n induced hypoventilation, bronchospasm, or restricted breathing due\\n to the back brace. The hospital course was complicated by\\n difficulty weaning form the ventilator. Her periodic agitation was\\n managed with seroquel. Prior to transfer her vent settings were: SIMV\\n 12x600 FIO2 0.45.\\n The neurosurgery service evaluated her and recommended concervative\\n management of her fracture including a back brace and outpatient\\n neurosurgery followup. The CT chest showed notable narrowing of her\\n central airways and the patient was referred for Interventional\\n Pulmonary evaluation for airway stenting.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt O2Sats down 80-90\\ns upon arrival, ABG\\ns showed PaO2 61%, pt up to\\n 100%Fio2, bilat rhonchi, Dim bases, suct for mod thick tan secretions;\\n copious oral secretions; pt RR with care, breathing against vent\\n Action:\\n FIO2 increased 100%, weaning down as tolerated; sedation increased for\\n ventilation\\n Response:\\n Pt O2Sats 98-100%\\n Plan:\\n ABG\\ns, VS; Wean Fio2 as tolerated; CXRAY; cont with sedation\\n for improved ventilation\\n Fracture, other\\n Assessment:\\n pt s/p fall---T7 fracture/no surgical intervention\\n Action:\\n pt on log roll precautions, reverse t @30 degrees\\n Response:\\n pt tolerating turns well, no s/sx pain with care\\n Plan:\\n f/u with PT consult, cont log roll precautions:\\n Hypernatremia (high sodium)\\n Assessment:\\n Na 150\\n Action:\\n pt to receive D5W @50 X1L, TF started with 150 free water flushes every\\n 4hrs\\n Response:\\n TF @ 10, no residual noted repeat labs in am\\n Plan:\\n labs, cont with free water flushes\\n Anemia, other\\n Assessment:\\n HCT 30, down from 40 upon admission to OSH\\n Action:\\n No s/sx of bleeding noted,\\n Response:\\n Plan:\\n hct, quiac stools\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-09-20 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 634117,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n -cultured for fever to 102.7 at 4:00 am\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Fentanyl - 100 mcg/hour\\n Midazolam (Versed) - 2 mg/hour\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:13 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 39.3\\nC (102.7\\n Tcurrent: 39.3\\nC (102.7\\n HR: 89 (72 - 97) bpm\\n BP: 96/41(55) {96/41(55) - 154/71(103)} mmHg\\n RR: 12 (12 - 18) insp/min\\n SpO2: 95%\\n Total In:\\n 10 mL\\n 232 mL\\n PO:\\n TF:\\n IVF:\\n 10 mL\\n 232 mL\\n Blood products:\\n Total out:\\n 425 mL\\n 570 mL\\n Urine:\\n 425 mL\\n 570 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -416 mL\\n -338 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 500 (500 - 500) mL\\n RR (Set): 12\\n RR (Spontaneous): 0\\n PEEP: 10 cmH2O\\n FiO2: 60%\\n RSBI Deferred: PEEP > 10, FiO2 > 60%\\n PIP: 32 cmH2O\\n SpO2: 95%\\n ABG: 7.42/47/61/30/4\\n Ve: 8 L/min\\n PaO2 / FiO2: 102\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 333 K/uL\\n 9.7 g/dL\\n 103 mg/dL\\n 0.6 mg/dL\\n 30 mEq/L\\n 3.8 mEq/L\\n 6 mg/dL\\n 109 mEq/L\\n 150 mEq/L\\n 30.7 %\\n 9.7 K/uL\\n [image002.jpg]\\n 11:54 PM\\n 01:00 AM\\n WBC\\n 9.7\\n Hct\\n 30.7\\n Plt\\n 333\\n Cr\\n 0.6\\n TCO2\\n 32\\n Glucose\\n 103\\n Other labs: PT / PTT / INR:13.8/22.4/1.2, ALT / AST:30/19, Alk Phos / T\\n Bili:149/0.7, Differential-Neuts:76.9 %, Lymph:17.3 %, Mono:3.0 %,\\n Eos:2.5 %, Albumin:3.0 g/dL, LDH:222 IU/L, Ca++:8.6 mg/dL, Mg++:2.1\\n mg/dL, PO4:4.1 mg/dL\\n Assessment and Plan\\n A/P: 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture\\n # Respiratory failure: initially likely multifactorial including\\n bronchspasm, hypoventilation from narcotics, and potential aspiration.\\n prior evaluation negative for PE. still with significant A-a gradient.\\n cxr appears under penetrated with small lung fields and potential\\n effusion on right. potentially from additional pulmonary edema, however\\n hypernatremia would limit ability to diurese.\\n - daily chest xray\\n - will hold on CT chest or airway pending IP consult\\n - IP consult\\n - vent settings: AC 500 x14 PEEP >8 (given body habitus), FIO2 as\\n needed\\n - sedation: fentanyl gtt/versed bolus\\n - trial of diuresis when able\\n # Spine fracture: neurologically intact distal to the lesion. prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - monitor distal neurologic function\\n - cto brace x3 months unless supine in bed\\n # Anemia: admission to MMC was ~40 now down to 30% w/o sign of active\\n GI bleed or other source of blood loss. likely related to crystalloid\\n administration, anemia of inflammation, chronic phlebotomy. given bili\\n and LDH normal would be unlikely for hemolysis.\\n - trend Hct\\n - guaiac stools\\n Hypernatremia: most likely related to inadequate free water repletion.\\n free water defecit ~3L.\\n - replete via OGT primarily\\n - D5W x1 L\\n ICU Care\\n Nutrition:\\n Comments: tube feed with free water\\n nutrition consult\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n PICC Line - 10:30 PM\\n 18 Gauge - 10:30 PM\\n 20 Gauge - 01:36 AM\\n Prophylaxis:\\n DVT: SQ UF Heparin\\n Stress ulcer: H2 blocker\\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\\n Need for restraints reviewed\\n Comments:\\n Communication: Family meeting held , ICU consent signed Comments: \\n (brother) \\n (boyfriend/POA) \\n Code status: Full code\\n Disposition: ICU\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n PICC Line - 10:30 PM\\n 20 Gauge - 01:36 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-09-20 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 634136,\n \"text\": \"55 year old woman with hx of obesity presented to Medical Center\\n on after falling down stairs while at home. She suffered a\\n traumatic T5-8 fracture with retropulsion of fragments. Per medical\\n records and discussion with her brother, she was awake for the fall (no\\n LOC) and the fall was triggered by unsteady gait, potentially\\n influenced by alcohol. Her fracture was managed concervatively. She\\n was placed in a torso brace but her course was complicated by\\n respiratory failure requiring intubation. At that time a CT was\\n negative for PE but showed bilateral bibasilar consolidations vs\\n atelectasis. At that time an ABG was 7.20/89/57 (unknown FIO2 but\\n likely >6L facemask). She was intubated on at 08:40. The\\n respiratory failure was thought likely to be related to pain med\\n induced hypoventilation, bronchospasm, or restricted breathing due\\n to the back brace. The hospital course was complicated by\\n difficulty weaning form the ventilator. Her periodic agitation was\\n managed with seroquel. Prior to transfer her vent settings were: SIMV\\n 12x600 FIO2 0.45.\\n The neurosurgery service evaluated her and recommended concervative\\n management of her fracture including a back brace and outpatient\\n neurosurgery followup. The CT chest showed notable narrowing of her\\n central airways and the patient was referred for Interventional\\n Pulmonary evaluation for airway stenting.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt O2Sats down 80-90\\ns upon arrival, ABG\\ns showed PaO2 61%, pt up to\\n 100%Fio2, bilat rhonchi, Dim bases, suct for mod thick tan secretions;\\n copious oral secretions; pt RR with care, breathing against vent\\n Action:\\n FIO2 increased 100%, weaning down as tolerated; sedation increased for\\n ventilation\\n Response:\\n Pt O2Sats 98-100%\\n Plan:\\n ABG\\ns, VS; Wean Fio2 as tolerated; CXRAY; cont with sedation\\n for improved ventilation\\n Fracture, other\\n Assessment:\\n pt s/p fall---T7 fracture/no surgical intervention\\n Action:\\n pt on log roll precautions, reverse t @30 degrees\\n Response:\\n pt tolerating turns well, no s/sx pain with care\\n Plan:\\n f/u with PT consult, cont log roll precautions:\\n Hypernatremia (high sodium)\\n Assessment:\\n Na 150\\n Action:\\n pt to receive D5W @50 X1L, TF started with 150 free water flushes every\\n 4hrs\\n Response:\\n TF @ 10, no residual noted repeat labs in am\\n Plan:\\n labs, cont with free water flushes\\n Anemia, other\\n Assessment:\\n HCT 30, down from 40 upon admission to OSH\\n Action:\\n No s/sx of bleeding noted,\\n Response:\\n Plan:\\n hct, quiac stools\\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\\n Assessment:\\n Pt TMax 102.6 orally @ 0400\\n Action:\\n BC X1 obtained, sputum cx, pt recvd APAP 650mg\\n Response:\\n Pt down 99.8 orally\\n Plan:\\n Obtain second set cultures, urine cultures; start IV Abx as ordered,\\n administer APAP as ordered\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-09-22 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 634325,\n \"text\": \"55 yr old women admitted from outside hospital. Patient fell down\\n stairs at home per boyfriend pt with fracture and placed in torso\\n brace at OSH, pt became hypoxic and was intubated (family requested a\\n second opinion and pt was trans to ) Pt admitted for Resp failure,\\n failure to wean, and ? tracheal bronchial malacia. Full code,\\n Allergies: PCN, Tetracycline, Sulfta. Pt on log roll precautions for\\n spine.\\n Per boyfriend tonight he reported that for the last two months pt has\\n been drinking 2 bottles of wine almost every night.\\n And that this is an increase from what she previously did which was a\\n couple of beers per night.\\n Alteration in Nutrition\\n Assessment:\\n Increase in residuals out of OG tube. Tube feeds have not been\\n restarted. Bowel sounds hypoactive, per family abdomen is about 30%\\n larger than normal, no BM since admission.\\n Action:\\n Senna and colace given. OG tube to low int. suction, was able to clamp\\n tube for 2hr but residuals returned.\\n Response:\\n 100 ml yellow-pinkish fluid out OG tube\\n Plan:\\n Cont to check residuals, restart tube feeds as tolerated, ? if raglan\\n would help. Increase bowel regimen if needed.\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n DVT in RUE\\n Action:\\n No BP or blood draws in RUE. Neuro to see pt in AM to see if we\\n can start heparin gtt (neuro to okay because of the spine\\n fracture)\\n Response:\\n Plan:\\n Wait for decision by Neuro and anticoagulate with heparin if\\n possible.\\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\\n Assessment:\\n T-max for this shift 100.5\\n Action:\\n Pt on Vanco, Aztreonam, Levoflaxacin, Flagyl., pt blood from\\n central/A-line/peripheral drawn, urine also sent\\n Response:\\n Pt went down to 99.2 without any Tylenol\\n Plan:\\n Cont to monitor Temp, cont antibiotics, follow up cultures, re-culture\\n if pt does spike temp again.\\n Fracture, other\\n Assessment:\\n Reported that pt has a T5-T8 spinal fracture, Wet read from yesterdays\\n CT may show just a T-9 compression, still waiting for the true results\\n of this CT.\\n Action:\\n Log roll pt, pt increased with reverse trandelenburg positionsing,\\n back brace in room if pt OOB.\\n Response:\\n Pt not tolerating turning\\n Plan:\\n Consult with neuro /wait for true CT scan results to know if spine\\n is actually fractured or not and if not ? removing spine precautions.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Lung sounds clear/diminished, ? VAP and possibly ARDS on top of that.\\n small amounts thick yellow secretions, vent setting changed during the\\n night. Pt desats to 80% with turning and takes a long time to\\n recover. Face becomes blue/purple. On ARDS type vent settings\\n Action:\\n Did not turn pt during the night, Vent setting changed during night\\n currently CMV 80%/400/22/17. cont suctioning/oral care/ subglottal\\n suctioning. Resp tried to place esophageal balloon again tonight\\n Response:\\n Small secretions out of in-line suction. Last ABG better at 7.38/41/87,\\n esophageal balloon placement unsuccessful\\n Plan:\\n ? if team will have respiratory try to place esophageal balloon again,\\n wean vent as tolerated. Cont ABG\\ns with vent changes.\\n Hypotension (not Shock)\\n Assessment:\\n Pt received on 0.04 mcg/kg/min of norepi gtt.\\n Action:\\n Weaned gtt off in early evening but MAPs dropped <65\\n Response:\\n Turned norepi gtt back on at 0.02 mg/kg/min\\n Plan:\\n Cont to wean norepi gtt as tolerated.\\n Goals: switch pt to air mattress bed if okayed by neuro that pt\\n can be moved, start heparin gtt for RUE DVT if neuro okays. Wean\\n norepi gtt. Restart Tube feeds when tolerates, ? if team will try to\\n float esophageal balloon again.\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2167-09-22 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 634326,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 4\\n Ideal body weight: 61.2 None\\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation:\\n Procedure location:\\n Reason:\\n Tube Type\\n ETT:\\n Position: cm at teeth\\n Route:\\n Type: Standard\\n Size: 7mm\\n Manufacturer:\\n Size:\\n PMV:\\n Cuff pressure: cmH2O\\n Cuff volume: mL /\\n Airway problems:\\n Comments:\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Diminished\\n Comments:\\n Secretions\\n Sputum color / consistency: Yellow / Thick\\n Sputum source/amount: Suctioned / Small\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance:\\n Visual assessment of breathing pattern:\\n Assessment of breathing comfort:\\n Non-invasive ventilation assessment:\\n Invasive ventilation assessment:\\n Trigger work assessment:\\n Dysynchrony assessment:\\n Comments:\\n Plan\\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\\n tolerated\\n Reason for continuing current ventilatory support:\\n Respiratory Care Shift Procedures\\n Transports:\\n Destination (R/T)\\n Time\\n Complications\\n Comments\\n Comments: Pt was received on AC settings 400x 22 peep 17 and 70%. Pt\\n peep and fio2 was increased by MD d/t significant oxygen desaturation.\\n Recruitment maneuver was done with good results. Abgs post maneuver\\n 7.38/41/87. Pt spo2 remained stable through the night. Attempt to\\n insert Esophageal balloon without success. Will await sedation order\\n from MD.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-09-21 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 634250,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Removed PICC line because RUE was noted to be warm and erythematous;\\n ultrasound revealed DVT. No definitive treatment was started given\\n difficulty obtaining central venous access.\\n Multiple attempts at central access; tried left and then right.\\n Acute episode of oxygen desat during first central line attempt. Pt\\n recovered, however, increased FiO2.\\n Decreased UOP (10-30mL/hr) and hypotension overnight. However,\\n lactate remains low. Originally, hypotension resolved with fluid\\n boluses however by early am, oliguria was persistent despite bolus.\\n Placed art line x 2. NBP and ABP similar\\n mini- BAL, sputum, urine, blood cultures pending. Yesterday, started\\n on levofloxicin and aztreonam instead of cefepime. Switched due to\\n question of PCN allergy\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Levofloxacin - 09:30 AM\\n Metronidazole - 12:00 AM\\n Vancomycin - 01:00 AM\\n Aztreonam - 04:00 AM\\n Infusions:\\n Midazolam (Versed) - 2 mg/hour\\n Fentanyl - 150 mcg/hour\\n Other ICU medications:\\n Ranitidine (Prophylaxis) - 08:00 AM\\n Midazolam (Versed) - 10:00 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:31 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.3\\nC (100.9\\nF at 10am on )\\n Tcurrent: 37.3\\nC (99.2\\n HR: 76 (71 - 116) bpm\\n BP: 116/51(70) {60/46(54) - 146/71(91)} mmHg\\n RR: 18 (12 - 24) insp/min\\n SpO2: 93%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 94.2 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 5,600 mL\\n 1,811 mL\\n PO:\\n TF:\\n 120 mL\\n IVF:\\n 4,700 mL\\n 1,511 mL\\n Blood products:\\n Total out:\\n 798 mL\\n 110 mL\\n Urine:\\n 798 mL\\n 110 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 4,802 mL\\n 1,701 mL\\n Respiratory support\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 500 (500 - 500) mL\\n RR (Set): 18\\n RR (Spontaneous): 0\\n PEEP: 10 cmH2O\\n FiO2: 80%\\n RSBI Deferred: PEEP > 10\\n PIP: 36 cmH2O\\n Plateau: 25 cmH2O\\n SpO2: 93%\\n ABG: 7.45/42/95./28/4\\n Ve: 9.5 L/min\\n PaO2 / FiO2: 120\\n Physical Examination\\n Gen: Appears uncomfortable on vent.\\n HEENT: Pupils 3 mm non-reactive bilaterally. Scleral edema bilat\\n Resp: Symmetric expansion. Vesicular sounds throughout. Inspiratory\\n and expiratory tracheal sounds (?related to ET tube).\\n CV: RRR.\\n Abd: Hypoactive bowel sounds. Distended. Non-tender.\\n Ext: Edema in bilat UE, especially right hand.\\n Peripheral vascular: Radial pulses 2+ bilaterally.\\n Neuro: Moving all 4 extremities.\\n Labs / Radiology\\n 319 K/uL\\n 7.6 g/dL\\n 129 mg/dL\\n 0.6 mg/dL\\n 28 mEq/L\\n 4.3 mEq/L\\n 6 mg/dL\\n 109 mEq/L\\n 144 mEq/L\\n 24.1 %\\n 6.4 K/uL\\n [image002.jpg]\\n 11:54 PM\\n 01:00 AM\\n 06:14 AM\\n 08:56 AM\\n 08:57 AM\\n 05:01 PM\\n 08:03 PM\\n 11:00 PM\\n 03:01 AM\\n 03:13 AM\\n WBC\\n 9.7\\n 9.4\\n 7.6\\n 6.4\\n Hct\\n 30.7\\n 25.1\\n 24.1\\n 24.1\\n Plt\\n 333\\n 281\\n 306\\n 319\\n Cr\\n 0.6\\n 0.6\\n 0.7\\n 0.6\\n 0.6\\n TCO2\\n 32\\n 33\\n 35\\n 33\\n 30\\n Glucose\\n 103\\n 126\\n 126\\n 127\\n 129\\n Other labs: PT / PTT / INR:16.9/26.3/1.5, ALT / AST:27/18, Alk Phos / T\\n Bili:113/0.7, Differential-Neuts:76.9 %, Lymph:17.3 %, Mono:3.0 %,\\n Eos:2.5 %, Lactic Acid:0.7 mmol/L, Albumin:2.3 g/dL, LDH:154 IU/L,\\n Ca++:8.2 mg/dL, Mg++:2.6 mg/dL, PO4:3.1 mg/dL\\n RUE ultrasound:\\n - Non-occlusive right axillary deep vein thrombus\\n - Non-occlusive right basilic superficial thrombosis.\\n Assessment and Plan\\n 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture\\n # Respiratory failure: initial etiology unclear, likely multifactorial\\n including bronchspasm, hypoventilation from narcotics, potential\\n aspiration, infection. By report, had a neg evaluation for PE at OSH,\\n however, unable to open disc to confirm. Concern for VAP.\\n - Failed yesterday\\ns NIF; score was -15\\n - Increased FiO2 overnight. Had increased pCO2 which resolved with\\n increasing RR\\n - IP stopped by but will complete official consult today; suggested\\n repeating CT scan\\n - Need to contact Medical re previous CT scan. Can attempt to\\n resend disc. Otherwise, will most likely benefit from repeat CT to\\n look for acute pulm process such as PE or PNA.\\n # Fever: Likely due to combination of infection and DVT. Cultures\\n sent. Will treat with empiric antibiotics. Tylenol PRN for fever.\\n - Known RUE DVT\\n - Infectious etiologies include VAP, asp PNA, line infections. Removed\\n PICC yesterday and cultured tip. Mini-BAL- gram stain neg. Sputum\\n grew GPC in pairs and GPR. Flagyl, aztreonam, vancomycin, levofloxacin\\n for coverage of gram positives, gram negatives, anaerobes, MRSA. Urine\\n and blood cultures NGTD\\n - f/u blood, urine, and sputum cultures.\\n - Concern for abd cause; KUB unrevealing. High residuals. require\\n further imaging\\n # Transient hypotension: Has been somewhat fluid responsive; UOP \\n ccs/hr. Diff dx includes hypovolemia, sepsis, cardiogenic.\\n - Sepsis most likely given fever.\\n - HCT decreasing; ? stable at 24-25\\n - Unable to place central line despite multiple attempts. First tired\\n left IJ RUE DVT. 2^nd attempt in left IJ. Can place femoral if pt\\n requires more active repletion\\n - Consider another attempt at a line.\\n # Oliguria:\\n -BUN and Cr as well as lactate reassuring.\\n -Increased bladder pressures this am- 20. Further imaging may be\\n helpful\\n # RUE DVT: Have held on starting treatment in light of need for central\\n access. Can start therapeutic heparin vs Lovenox with bridge to\\n coumadin.\\n -Can consider rescanning for PE. High risk for PE given UE DVT.\\n # Abd distention:\\n -KUB unrevealing\\n -High residuals\\n - benefit from further imaging; if unstable consider ultrasound,\\n however, if pt can tolerate it, a CT scan might be more helpful. Can\\n also scan chest and pelvis.\\n # Anemia: On admission to Medical Center, Hct was ~40, now down\\n to 30 and then 25 w/o sign of active GI bleed or other source of blood\\n loss. be related to fluid administration, phlebotomy, anemia of\\n inflammation, active bleed still considered in differential.\\n - trend Hct\\n - guaiac stools\\n - S/p failed attempts at line placement; watch for neck hematomas\\n - INR elev at 1.5. ? may be related to poor nutrition as albumin is\\n 2.3\\n # Spine fracture: neurologically intact distal to the lesion. prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - Need to talk to neurosurg to see if pt can tolerate a CT scan as well\\n as the risks of anticoag for DVT\\n - monitor distal neurologic function\\n - cto brace x3 months unless supine in bed\\n - consult neurosurgery for further recs\\n # Hypernatremia: correcting with g tube free flush and D5W\\n -Holding on g tube feeds at present due to high residuals\\n -Replete lytes as necessary\\n ICU Care\\n Nutrition: tube feed with free water\\n Glycemic Control: Regular insulin sliding scale\\n DVT: SQ UF Heparin\\n Stress ulcer: H2 blocker\\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\\n Communication: Family meeting held , ICU consent signed, \\n (brother) (boyfriend/POA) \\n Code status: Full code\\n Disposition: ICU\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 01:16 AM\\n 20 Gauge - 01:36 AM\\n 22 Gauge - 02:00 PM\\n Arterial Line - 03:00 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-09-21 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 634263,\n \"text\": \"Alteration in Nutrition\\n Assessment:\\n Pt NPO, Pt w/ high residuals yesterday. Abdomen distended/obese/soft.\\n BS hypoactive. Low albumin.\\n Action:\\n OGT to low wall suction. TF off.\\n Response:\\n Small amount of gastric fluid suctioned- approx 30cc-50cc.\\n Plan:\\n Plan for CT of Abdomen, cont NPO at this time.\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n RUE + DVT\\n Action:\\n Cont on sq heparin\\n Response:\\n No change\\n Plan:\\n Consult neuro-surgery regarding anti-coagulation w/ T-spine fx, elevate\\n RUE, no blood draws or blood pressures to RUE.\\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\\n Assessment:\\n Temp max 100\\n Action:\\n Antibiotics given and dosage changed to vanco and aztreonam.\\n Response:\\n No further temp spike.\\n Plan:\\n Cont w/ antibiotics, f/u on cultures, tyelenol prn, vanco trough to be\\n drawn prior to evening dose.\\n Fracture, other\\n Assessment:\\n T-spine compression fx, Back brace at bedside when OOB.\\n Action:\\n Ortho tech consulted for placement of back brace. Cont w/ log roll\\n precautions.\\n Response:\\n Pt denies c/o pain when asked.\\n Plan:\\n Cont w/ log roll precautions, back brace for OOB, CT scan, consult w/\\n neurosurg.\\n Anemia, other\\n Assessment:\\n HCT 24.1 from 28\\n Action:\\n Given 1 unit of PRBCs\\n Response:\\n HCT to be drawn.\\n Plan:\\n Cont to follow HCTs, guiac stools, monitor of s/s of bleeding.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n LS bronchial, deep sxn\\nd for thick/tan secretions, copious clear\\n secretions suctioned from mouth, PO2 68% on 70% FIO2 and 12 peep.\\n Action:\\n Vent changes made throughout shift.\\n Response:\\n Plan:\\n Hypotension (not Shock)\\n Assessment:\\n Pt hypotensive into low-mid 80s systolic, HR 70s-90s. Low uop- bladder\\n pressure 18-20.\\n Action:\\n Vigeleo set up, given 1 unit of blood, bloused x 1, multi-lumen RIJ\\n placed at bedside.\\n Response:\\n No response to blusing, SBP improved following blood transfusion, RIJ\\n okay to use. CVP 18.\\n Plan:\\n Levophed to be started if needed, transfuse as needed.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-09-21 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 634264,\n \"text\": \"55-year-old woman with\\n Respiratory failure\\n Traumatic thoracic spinal fractures\\n Probable VAP\\n Upper extremity DVT\\n Oliguria\\n Anemia\\n * Possible tracheobronchomalacia (reason for transfer\\n Alteration in Nutrition\\n Assessment:\\n Pt NPO, Pt w/ high residuals yesterday. Abdomen distended/obese/soft.\\n BS hypoactive. Low albumin.\\n Action:\\n OGT to low wall suction. TF off.\\n Response:\\n Small amount of gastric fluid suctioned- approx 30cc-50cc.\\n Plan:\\n Plan for CT of Abdomen, cont NPO at this time.\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n RUE + DVT\\n Action:\\n Cont on sq heparin\\n Response:\\n No change\\n Plan:\\n Consult neuro-surgery regarding anti-coagulation w/ T-spine fx, elevate\\n RUE, no blood draws or blood pressures to RUE.\\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\\n Assessment:\\n Temp max 100\\n Action:\\n Antibiotics given and dosage changed to vanco and aztreonam.\\n Response:\\n No further temp spike.\\n Plan:\\n Cont w/ antibiotics, f/u on cultures, tyelenol prn, vanco trough to be\\n drawn prior to evening dose.\\n Fracture, other\\n Assessment:\\n T-spine compression fx, Back brace at bedside when OOB.\\n Action:\\n Ortho tech consulted for placement of back brace. Cont w/ log roll\\n precautions.\\n Response:\\n Pt denies c/o pain when asked.\\n Plan:\\n Cont w/ log roll precautions, back brace for OOB, CT scan, consult w/\\n neurosurg.\\n Anemia, other\\n Assessment:\\n HCT 24.1 from 28\\n Action:\\n Given 1 unit of PRBCs\\n Response:\\n HCT to be drawn.\\n Plan:\\n Cont to follow HCTs, guiac stools, monitor of s/s of bleeding.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n LS bronchial, deep sxn\\nd for thick/tan secretions, copious clear\\n secretions suctioned from mouth, PO2 68% on 70% FIO2 and 12 peep.\\n Action:\\n Vent changes made throughout shift.\\n Response:\\n Plan:\\n Hypotension (not Shock)\\n Assessment:\\n Pt hypotensive into low-mid 80s systolic, HR 70s-90s. Low uop- bladder\\n pressure 18-20.\\n Action:\\n Vigeleo set up, given 1 unit of blood, bloused x 1, multi-lumen RIJ\\n placed at bedside.\\n Response:\\n No response to blusing, SBP improved following blood transfusion, RIJ\\n okay to use. CVP 18.\\n Plan:\\n Levophed to be started if needed, transfuse as needed.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-09-21 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 634265,\n \"text\": \"55-year-old woman with\\n Respiratory failure\\n Traumatic thoracic spinal fractures\\n Probable VAP\\n Upper extremity DVT\\n Oliguria\\n Anemia\\n * Possible tracheobronchomalacia (reason for transfer\\n Alteration in Nutrition\\n Assessment:\\n Pt NPO, Pt w/ high residuals yesterday. Abdomen distended/obese/soft.\\n BS hypoactive. Low albumin.\\n Action:\\n OGT to low wall suction. TF off.\\n Response:\\n Small amount of gastric fluid suctioned- approx 30cc-50cc.\\n Plan:\\n Plan for CT of Abdomen, cont NPO at this time.\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n RUE + DVT\\n Action:\\n Cont on sq heparin\\n Response:\\n No change\\n Plan:\\n Consult neuro-surgery regarding anti-coagulation w/ T-spine fx, elevate\\n RUE, no blood draws or blood pressures to RUE.\\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\\n Assessment:\\n Temp max 100\\n Action:\\n Antibiotics given and dosage changed to vanco and aztreonam.\\n Response:\\n No further temp spike.\\n Plan:\\n Cont w/ antibiotics, f/u on cultures, tyelenol prn, vanco trough to be\\n drawn prior to evening dose.\\n Fracture, other\\n Assessment:\\n T-spine compression fx, Back brace at bedside when OOB.\\n Action:\\n Ortho tech consulted for placement of back brace. Cont w/ log roll\\n precautions.\\n Response:\\n Pt denies c/o pain when asked.\\n Plan:\\n Cont w/ log roll precautions, back brace for OOB, CT scan, consult w/\\n neurosurg.\\n Anemia, other\\n Assessment:\\n HCT 24.1 from 28\\n Action:\\n Given 1 unit of PRBCs\\n Response:\\n HCT to be drawn.\\n Plan:\\n Cont to follow HCTs, guiac stools, monitor of s/s of bleeding.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n LS- bronchial throughout, deep sxn\\nd for thick/tan secretions, copious\\n clear oral secretions suctioned, PO2 68% on 70% FIO2 and 12 peep. ?\\n PE/? VAP.\\n Action:\\n Vent changes made throughout shift.\\n Response:\\n Plan:\\n Esophageal balloon placement to be performed, monitor ABGs, vent\\n changes as needed.\\n Hypotension (not Shock)\\n Assessment:\\n Pt hypotensive into low-mid 80s systolic, HR 70s-90s. Low uop-\\n BUN/Creat negative. Bladder pressure 18-20.\\n Action:\\n Vigeleo set up, given 1 unit of blood, bloused x 1, multi-lumen RIJ\\n placed at bedside.\\n Response:\\n No response to blusing, SBP improved following blood transfusion, RIJ\\n okay to use. CVP 18.\\n Plan:\\n Levophed to be started if needed, transfuse as needed.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-09-23 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 634388,\n \"text\": \"Respiratory failure, acute (not ARDS/)\\n Assessment:\\n RLL consolidation, bilat effusions, R < L ; suct for thick yellowish\\n secretions from ETT; copious thick secretions suct from mouth\\n Action:\\n Pt 2 down to 60%, Peep @ 23\\n Response:\\n Pt tolerating turns and current vent settings well\\n Plan:\\n Cont to ABGS, VS;\\n Hypotension (not Shock)\\n Assessment:\\n SBP down in 80\\ns, MAP 60\\n Action:\\n Levophed restarted @0130\\n Response:\\n BP improved 110-90\\ns MAP 65\\n Plan:\\n Cont to BP, MAP goal >65 , Levo as needed\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Pt (+) DVT RUE\\n Action:\\n Pt started on IV Heparin @1700U/hr\\n Response:\\n Pt PTT@ 0030 62.7, no changes to infusion\\n Plan:\\n Cont to PTT, adjust heparin accordingly; cont with no BP/LAB draws\\n to R arm\\n Alteration in Nutrition\\n Assessment:\\n TF currently on hold high residuals, abd distended soft, hypoactive\\n bowel sounds\\n Action:\\n Pt started on Naloxone x 3 doses, rectal tube in place for\\n decompression; bowel regimen continued\\n Response:\\n Pt passing sm. Amt loose green stool with dose of Naxolone\\n Plan:\\n Re-evaluate for increase in Naloxone dose; ? restarting TF/advancing\\n Fracture, other\\n Assessment:\\n Pt T5/T8 fracture s/p fall \\n Action:\\n Spine/ortho consult done\\n Response:\\n Pt off logroll precautions, tolerates position changes\\n Plan:\\n Activity as tolerated, needs to wear TorsoBrace when OOB or sitting up\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-09-23 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 634389,\n \"text\": \"55 yr old women admitted from outside hospital. Patient fell down\\n stairs at home per boyfriend pt with fracture and placed in torso\\n brace at OSH, pt became hypoxic and was intubated (family requested a\\n second opinion and pt was trans to ) Pt admitted for Resp failure,\\n failure to wean, and ? tracheal bronchial malacia. Full code,\\n Allergies: PCN, Tetracycline, Sulfta.\\n Per boyfriend tonight he reported that for the last two months pt has\\n been drinking 2 bottles of wine almost every night.\\n And that this is an increase from what she previously did which was a\\n couple of beers per night.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n RLL consolidation, bilat effusions, R < L ; suct for thick yellowish\\n secretions from ETT; copious thick secretions suct from mouth\\n Action:\\n Pt 2 down to 60%, Peep @ 23\\n Response:\\n Pt tolerating turns and current vent settings well\\n Plan:\\n Cont to ABGS, VS;\\n Hypotension (not Shock)\\n Assessment:\\n SBP down in 80\\ns, MAP 60\\n Action:\\n Levophed restarted @0130\\n Response:\\n BP improved 110-90\\ns MAP 65\\n Plan:\\n Cont to BP, MAP goal >65 , Levo as needed\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Pt (+) DVT RUE\\n Action:\\n Pt started on IV Heparin @1700U/hr\\n Response:\\n Pt PTT@ 0030 62.7, no changes to infusion\\n Plan:\\n Cont to PTT, adjust heparin accordingly; cont with no BP/LAB draws\\n to R arm\\n Alteration in Nutrition\\n Assessment:\\n TF currently on hold high residuals, abd distended soft, hypoactive\\n bowel sounds\\n Action:\\n Pt started on Naloxone x 3 doses, rectal tube in place for\\n decompression; bowel regimen continued\\n Response:\\n Pt passing sm. Amt loose green stool with dose of Naxolone\\n Plan:\\n Re-evaluate for increase in Naloxone dose; ? restarting TF/advancing\\n Fracture, other\\n Assessment:\\n Pt T5/T8 fracture s/p fall \\n Action:\\n Spine/ortho consult done\\n Response:\\n Pt off logroll precautions, tolerates position changes\\n Plan:\\n Activity as tolerated, needs to wear TorsoBrace when OOB or sitting up\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-09-23 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 634393,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n ESOPHOGEAL BALLOON - At 01:46 PM - went well, were able to\\n increase PEEP to improve oxygenation\\n - started naloxone to encourage bowel motility, with some success,\\n rectal tube in place\\n -started heparin gtt for RUE DVT\\n -borderline hypotensive at times (low 90s), received boluses and norepi\\n back on at 0.04\\n -did well with 0/7 yesterday and overnight with prn fentanyl for\\n pain and prn haldol for agitation (did not require haldol), back on 0/7\\n this am\\n -gave extra dose metoprolol 25 via OG\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Levofloxacin - 09:45 AM\\n Metronidazole - 03:32 PM\\n Vancomycin - 08:00 PM\\n Aztreonam - 10:00 PM\\n Infusions:\\n Midazolam (Versed) - 2 mg/hour\\n Heparin Sodium - 1,700 units/hour\\n Fentanyl - 100 mcg/hour\\n Norepinephrine - 0.04 mcg/Kg/min\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:34 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38\\nC (100.4\\n Tcurrent: 37.3\\nC (99.2\\n HR: 73 (60 - 102) bpm\\n BP: 90/46(61) {76/38(56) - 160/71(97)} mmHg\\n RR: 23 (16 - 25) insp/min\\n SpO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 101 kg (admission): 94.2 kg\\n Height: 67 Inch\\n CVP: 8 (8 - 15)mmHg\\n Bladder pressure: 18 (18 - 21) mmHg\\n Total In:\\n 3,524 mL\\n 234 mL\\n PO:\\n TF:\\n 48 mL\\n IVF:\\n 3,236 mL\\n 234 mL\\n Blood products:\\n Total out:\\n 935 mL\\n 215 mL\\n Urine:\\n 650 mL\\n 215 mL\\n NG:\\n 285 mL\\n Stool:\\n Drains:\\n Balance:\\n 2,589 mL\\n 19 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 400 (400 - 400) mL\\n Vt (Spontaneous): 0 (0 - 0) mL\\n RR (Set): 22\\n RR (Spontaneous): 0\\n PEEP: 23 cmH2O\\n FiO2: 60%\\n RSBI Deferred: PEEP > 10, FiO2 > 60%\\n PIP: 42 cmH2O\\n Plateau: 32 cmH2O\\n Compliance: 44.4 cmH2O/mL\\n SpO2: 100%\\n ABG: 7.36/47/153//0\\n Ve: 9.5 L/min\\n PaO2 / FiO2: 255\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 376 K/uL\\n 9.0 g/dL\\n 120 mg/dL\\n 0.6 mg/dL\\n 24 mEq/L\\n 3.7 mEq/L\\n 4 mg/dL\\n 108 mEq/L\\n 141 mEq/L\\n 28.1 %\\n 8.4 K/uL\\n [image002.jpg]\\n 03:01 AM\\n 03:13 AM\\n 12:05 PM\\n 06:08 PM\\n 06:11 PM\\n 07:53 PM\\n 02:02 AM\\n 03:59 AM\\n 09:14 PM\\n 01:04 AM\\n WBC\\n 6.4\\n 8.4\\n Hct\\n 24.1\\n 29.0\\n 28.1\\n Plt\\n 319\\n 376\\n Cr\\n 0.6\\n 0.6\\n TCO2\\n 30\\n 29\\n 29\\n 25\\n 25\\n 28\\n 28\\n Glucose\\n 129\\n 120\\n Other labs: PT / PTT / INR:18.7/62.7/1.7, ALT / AST:24/16, Alk Phos / T\\n Bili:117/0.7, Amylase / Lipase:, Differential-Neuts:80.8 %,\\n Lymph:12.0 %, Mono:3.5 %, Eos:3.3 %, Lactic Acid:0.7 mmol/L,\\n Albumin:2.4 g/dL, LDH:204 IU/L, Ca++:8.2 mg/dL, Mg++:2.2 mg/dL, PO4:3.1\\n mg/dL\\n Assessment and Plan\\n Assessment and Plan\\n 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture\\n # Respiratory failure: initial etiology unclear, likely multifactorial\\n now with significant pneumonia. Had one sputum that showed GNR.\\n - Had a desat event yesterday. Responded positively to recruitment\\n maneuvers.\\n - Will attempt placement of an esophageal balloon; with knowledge of\\n intrathoracic pressures, can consider going up on PEEP\\n # Infectious process: Had been febrile, now resolved\\n - be aspiration or be VAP. Sputum from grew rare GNR;\\n awaiting speciation.\\n - Continues on Vanc, aztreonam, levofloxicin. Vanc trough pending today\\n - Also on flagyl for empiric coverage of c. diff\\n - Per CT, unlikely to be abdominal process\\n # Hypotension, requiring Levophed:\\n - Hypovolemia is possibly a factor- responded to a transfusion; HCT had\\n been dropping\\n - Sepsis also a factor- on broad spectrum abs\\n - Central line in place.\\n # Oliguria:\\n -BUN and Cr reassuring.\\n # RUE DVT: Have held on starting treatment in light of need for central\\n access. Can start therapeutic heparin vs Lovenox with bridge to\\n coumadin.\\n - No PE noted on CT scan.\\n # Abd distention:\\n - CT abd only showed appendiceal mucocele without inflammation, not\\n concerning, most likely chronic\\n - No BM in several days, continue bowel regimen, add fleets enema\\n - Can test for c.diff when pt stool\\ns. Continue flagyl empirically\\n - Check amylase and lipase\\n # Anemia:\\n - Trend HCT\\n - Gave 1 un pRBC with good results\\n - Will guiac stools when she has a BM\\n - INR rising, now 1.7, may be nutritional\\n # Spine fracture: neurologically intact distal to the lesion. prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - Will have spine see pt today for recs regarding pt movement and\\n anticoagulation\\n # Hypernatremia, resolved: correcting with g tube free flush and D5W\\n -Holding on g tube feeds at present due to high residuals\\n -Replete lytes as necessary\\n # Communication:\\n - Brother has been with pt, although, live in boyfriend of 10 is\\n her HCP. Boyfriend will hopefully visit pt today\\n ICU Care\\n Nutrition: tube feed with free water when able\\n Glycemic Control: Regular insulin sliding scale\\n DVT: SQ UF Heparin\\n Stress ulcer: H2 blocker\\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\\n Communication: ICU consent signed, (brother) \\n (boyfriend/POA) \\n Code status: Full code\\n Disposition: ICU\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 01:36 AM\\n Arterial Line - 03:00 AM\\n Multi Lumen - 11:30 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-09-23 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 634394,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n ESOPHOGEAL BALLOON - At 01:46 PM - went well, were able to\\n increase PEEP to improve oxygenation\\n - started naloxone to encourage bowel motility, with some success,\\n rectal tube in place\\n -started heparin gtt for RUE DVT\\n -borderline hypotensive at times (low 90s) with low urine output,\\n received boluses and norepi back on at 0.04\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Levofloxacin - 09:45 AM\\n Metronidazole - 03:32 PM\\n Vancomycin - 08:00 PM\\n Aztreonam - 10:00 PM\\n Infusions:\\n Midazolam (Versed) - 2 mg/hour\\n Heparin Sodium - 1,700 units/hour\\n Fentanyl - 100 mcg/hour\\n Norepinephrine - 0.04 mcg/Kg/min\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:34 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38\\nC (100.4\\n Tcurrent: 37.3\\nC (99.2\\n HR: 73 (60 - 102) bpm\\n BP: 90/46(61) {76/38(56) - 160/71(97)} mmHg\\n RR: 23 (16 - 25) insp/min\\n SpO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 101 kg (admission): 94.2 kg\\n Height: 67 Inch\\n CVP: 8 (8 - 15)mmHg\\n Bladder pressure: 18 (18 - 21) mmHg\\n Total In:\\n 3,524 mL\\n 234 mL\\n PO:\\n TF:\\n 48 mL\\n IVF:\\n 3,236 mL\\n 234 mL\\n Blood products:\\n Total out:\\n 935 mL\\n 215 mL\\n Urine:\\n 650 mL\\n 215 mL\\n NG:\\n 285 mL\\n Stool:\\n Drains:\\n Balance:\\n 2,589 mL\\n 19 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 400 (400 - 400) mL\\n Vt (Spontaneous): 0 (0 - 0) mL\\n RR (Set): 22\\n RR (Spontaneous): 0\\n PEEP: 23 cmH2O\\n FiO2: 60%\\n RSBI Deferred: PEEP > 10, FiO2 > 60%\\n PIP: 42 cmH2O\\n Plateau: 32 cmH2O\\n Compliance: 44.4 cmH2O/mL\\n SpO2: 100%\\n ABG: 7.36/47/153//0\\n Ve: 9.5 L/min\\n PaO2 / FiO2: 255\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 376 K/uL\\n 9.0 g/dL\\n 120 mg/dL\\n 0.6 mg/dL\\n 24 mEq/L\\n 3.7 mEq/L\\n 4 mg/dL\\n 108 mEq/L\\n 141 mEq/L\\n 28.1 %\\n 8.4 K/uL\\n [image002.jpg]\\n 03:01 AM\\n 03:13 AM\\n 12:05 PM\\n 06:08 PM\\n 06:11 PM\\n 07:53 PM\\n 02:02 AM\\n 03:59 AM\\n 09:14 PM\\n 01:04 AM\\n WBC\\n 6.4\\n 8.4\\n Hct\\n 24.1\\n 29.0\\n 28.1\\n Plt\\n 319\\n 376\\n Cr\\n 0.6\\n 0.6\\n TCO2\\n 30\\n 29\\n 29\\n 25\\n 25\\n 28\\n 28\\n Glucose\\n 129\\n 120\\n Other labs: PT / PTT / INR:18.7/62.7/1.7, ALT / AST:24/16, Alk Phos / T\\n Bili:117/0.7, Amylase / Lipase:, Differential-Neuts:80.8 %,\\n Lymph:12.0 %, Mono:3.5 %, Eos:3.3 %, Lactic Acid:0.7 mmol/L,\\n Albumin:2.4 g/dL, LDH:204 IU/L, Ca++:8.2 mg/dL, Mg++:2.2 mg/dL, PO4:3.1\\n mg/dL\\n Assessment and Plan\\n Assessment and Plan\\n 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture\\n # Respiratory failure: initial etiology unclear, likely multifactorial\\n now with significant pneumonia. Had one sputum that showed GNR.\\n - Had a desat event yesterday. Responded positively to recruitment\\n maneuvers.\\n - Will attempt placement of an esophageal balloon; with knowledge of\\n intrathoracic pressures, can consider going up on PEEP\\n # Infectious process: Had been febrile, now resolved\\n - be aspiration or be VAP. Sputum from grew rare GNR;\\n awaiting speciation.\\n - Continues on Vanc, aztreonam, levofloxicin. Vanc trough pending today\\n - Also on flagyl for empiric coverage of c. diff\\n - Per CT, unlikely to be abdominal process\\n # Hypotension, requiring Levophed:\\n - Hypovolemia is possibly a factor- responded to a transfusion; HCT had\\n been dropping\\n - Sepsis also a factor- on broad spectrum abs\\n - Central line in place.\\n # Oliguria:\\n -BUN and Cr reassuring.\\n # RUE DVT: Have held on starting treatment in light of need for central\\n access. Can start therapeutic heparin vs Lovenox with bridge to\\n coumadin.\\n - No PE noted on CT scan.\\n # Abd distention:\\n - CT abd only showed appendiceal mucocele without inflammation, not\\n concerning, most likely chronic\\n - No BM in several days, continue bowel regimen, add fleets enema\\n - Can test for c.diff when pt stool\\ns. Continue flagyl empirically\\n - Check amylase and lipase\\n # Anemia:\\n - Trend HCT\\n - Gave 1 un pRBC with good results\\n - Will guiac stools when she has a BM\\n - INR rising, now 1.7, may be nutritional\\n # Spine fracture: neurologically intact distal to the lesion. prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - Will have spine see pt today for recs regarding pt movement and\\n anticoagulation\\n # Hypernatremia, resolved: correcting with g tube free flush and D5W\\n -Holding on g tube feeds at present due to high residuals\\n -Replete lytes as necessary\\n # Communication:\\n - Brother has been with pt, although, live in boyfriend of 10 is\\n her HCP. Boyfriend will hopefully visit pt today\\n ICU Care\\n Nutrition: tube feed with free water when able\\n Glycemic Control: Regular insulin sliding scale\\n DVT: SQ UF Heparin\\n Stress ulcer: H2 blocker\\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\\n Communication: ICU consent signed, (brother) \\n (boyfriend/POA) \\n Code status: Full code\\n Disposition: ICU\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 01:36 AM\\n Arterial Line - 03:00 AM\\n Multi Lumen - 11:30 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nutrition\",\n \"chartdate\": \"2167-09-20 00:00:00.000\",\n \"description\": \"Clinical Nutrition Note\",\n \"row_id\": 634175,\n \"text\": \"Subjective\\n Intubated & versed.\\n Objective\\n Height\\n Admit weight\\n Daily weight\\n Weight change\\n BMI\\n 170 cm\\n 94.2 kg\\n 32.4\\n Ideal body weight\\n % Ideal body weight\\n Adjusted weight\\n Usual body weight\\n % Usual body weight\\n 61.2 kg\\n 126% based on EDW of 77.2kg\\n 65.2kg\\n 77.2kg ( adm WT at OSH)\\n ?122\\n Diagnosis: Tracheobroncheal malacia\\n PMH : obesity, GERD, s/p TAH, s/p L THR, s/p appy, ETOH abuse.\\n Food allergies and intolerances: none noted in record.\\n Pertinent medications: fentanyl, midazolam, colace, heparin, zantac,\\n RISS, flagyl.\\n Labs:\\n Value\\n Date\\n Glucose\\n 126 mg/dL\\n 08:57 AM\\n Glucose Finger Stick\\n 137\\n 04:00 PM\\n BUN\\n 6 mg/dL\\n 08:57 AM\\n Creatinine\\n 0.7 mg/dL\\n 08:57 AM\\n Sodium\\n 147 mEq/L\\n 08:57 AM\\n Potassium\\n 3.5 mEq/L\\n 08:57 AM\\n Chloride\\n 108 mEq/L\\n 08:57 AM\\n TCO2\\n 28 mEq/L\\n 08:57 AM\\n PO2 (arterial)\\n 81. mm Hg\\n 06:14 AM\\n PCO2 (arterial)\\n 53 mm Hg\\n 06:14 AM\\n pH (arterial)\\n 7.39 units\\n 06:14 AM\\n pH (urine)\\n 5.0 units\\n 02:46 PM\\n CO2 (Calc) arterial\\n 33 mEq/L\\n 06:14 AM\\n Albumin\\n 3.0 g/dL\\n 01:00 AM\\n Calcium non-ionized\\n 8.6 mg/dL\\n 01:00 AM\\n Phosphorus\\n 3.8 mg/dL\\n 08:57 AM\\n Magnesium\\n 1.8 mg/dL\\n 08:57 AM\\n ALT\\n 30 IU/L\\n 01:00 AM\\n Alkaline Phosphate\\n 149 IU/L\\n 01:00 AM\\n AST\\n 19 IU/L\\n 01:00 AM\\n Total Bilirubin\\n 0.7 mg/dL\\n 08:57 AM\\n WBC\\n 9.4 K/uL\\n 08:57 AM\\n Hgb\\n 8.2 g/dL\\n 08:57 AM\\n Hematocrit\\n 25.1 %\\n 08:57 AM\\n Current diet order / nutrition support: NPO. TF: FS Replete w/ Fiber at\\n 60mL/hr with 150mL Q 4hrs via OGT.\\n GI:\\n Assessment of Nutritional Status\\n Obese, At risk for malnutrition\\n Pt at risk due to: Low protein stores\\n Estimated Nutritional Needs based on Est Dry WT of 77.2kg\\n Calories: 1300 - 1625 (BEE x or / 20 - 25 cal/kg)\\n Protein: 78 - 98 (1.2 - 1.5 g/kg)\\n Fluid: per team.\\n Specifics:\\n 55 YO Female hospitalized at OSH after a fall resulting in traumatic\\n T5-8 fracture w/ retropulsion of fragments. Was intubated & was c/b\\n difficulty weaning from vent, referred here for interventional pulm\\n evaluation for airway stenting. Consulted for TF recs. Currently\\n tolerating TF at 10mL/hr. Would recommend decrease current TF goal rate\\n to 55mL/hr to feed at 20kcal/kg while intubated otherwise higher\\n calories would make it difficult to wean or extubated. Noted documented\\n as -3L water deficit upon admission & is being hydrated with IFV\\ns but\\n is still slightly hypernatremic. Suggest increasing free water boluses\\n via OGT.\\n Medical Nutrition Therapy Plan - Recommend the Following\\n 1. Decrease TF goal rate to 55mL/hr of Replete with Fiber\\n 2. Continue to advance by 10mL Q 4-6hrs to goal\\n 3. check residuals Q 4hrs, hold x 1hr if >150mL\\n 4. Adjust free water flushes per hydration\\n 5. Monitor & replete lytes PRN\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-09-22 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 634311,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n Neurosurg: ok to transport. Will decide on anticoagulation in AM\\n Central line placed\\n NGT to suction\\n Bowel regimen\\n Resperatory attempted to place esophageal ballon, unsuccessful\\n Desaturation around 23:00 to low 80s on 400/22/15/0.9 following turn.\\n Recruitment maneuver (PEEP to 30) done x2 with good effect, Sat came up\\n to 100%. PEEP left at 17\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Levofloxacin - 10:00 AM\\n Aztreonam - 02:00 PM\\n Vancomycin - 12:00 AM\\n Metronidazole - 12:00 AM\\n Infusions:\\n Norepinephrine - 0.02 mcg/Kg/min\\n Fentanyl - 200 mcg/hour\\n Other ICU medications:\\n Ranitidine (Prophylaxis) - 08:00 AM\\n Midazolam (Versed) - 02:20 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:27 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.9\\nC (100.3\\n Tcurrent: 37.6\\nC (99.6\\n HR: 73 (64 - 96) bpm\\n BP: 119/48(69) {85/39(55) - 142/67(91)} mmHg\\n RR: 22 (11 - 22) insp/min\\n SpO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 94.2 kg (admission): 94.2 kg\\n Height: 67 Inch\\n CVP: 20 (11 - 21)mmHg\\n Bladder pressure: 14 (14 - 18) mmHg\\n Total In:\\n 3,482 mL\\n 465 mL\\n PO:\\n TF:\\n IVF:\\n 2,845 mL\\n 465 mL\\n Blood products:\\n 277 mL\\n Total out:\\n 580 mL\\n 65 mL\\n Urine:\\n 580 mL\\n 65 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 2,902 mL\\n 400 mL\\n Respiratory support\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 400 (400 - 500) mL\\n RR (Set): 22\\n RR (Spontaneous): 0\\n PEEP: 17 cmH2O\\n FiO2: 80%\\n PIP: 33 cmH2O\\n Plateau: 30 cmH2O\\n Compliance: 30.8 cmH2O/mL\\n SpO2: 98%\\n ABG: 7.38/41/86./24/0\\n Ve: 9.1 L/min\\n PaO2 / FiO2: 109\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 376 K/uL\\n 9.0 g/dL\\n 120 mg/dL\\n 0.6 mg/dL\\n 24 mEq/L\\n 3.7 mEq/L\\n 4 mg/dL\\n 108 mEq/L\\n 141 mEq/L\\n 28.1 %\\n 8.4 K/uL\\n [image002.jpg]\\n 08:03 PM\\n 11:00 PM\\n 03:01 AM\\n 03:13 AM\\n 12:05 PM\\n 06:08 PM\\n 06:11 PM\\n 07:53 PM\\n 02:02 AM\\n 03:59 AM\\n WBC\\n 7.6\\n 6.4\\n 8.4\\n Hct\\n 24.1\\n 24.1\\n 29.0\\n 28.1\\n Plt\\n \\n Cr\\n 0.6\\n 0.6\\n 0.6\\n TCO2\\n 33\\n 30\\n 29\\n 29\\n 25\\n 25\\n Glucose\\n 127\\n 129\\n 120\\n Other labs: PT / PTT / INR:18.7/25.4/1.7, ALT / AST:24/16, Alk Phos / T\\n Bili:117/0.7, Differential-Neuts:80.8 %, Lymph:12.0 %, Mono:3.5 %,\\n Eos:3.3 %, Lactic Acid:0.7 mmol/L, Albumin:2.4 g/dL, LDH:204 IU/L,\\n Ca++:8.2 mg/dL, Mg++:2.2 mg/dL, PO4:3.1 mg/dL\\n Fluid analysis / Other labs: sputum, stimm\\n Imaging:\\n Echo\\n post recruitment CXR showed deep sulcus but no pnumothorax per rads.\\n Assessment and Plan\\n comm with fam, vanc dosing\\n 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture\\n # Respiratory failure: initial etiology unclear, likely multifactorial\\n including bronchspasm, hypoventilation from narcotics, potential\\n aspiration, infection. By report, had a neg evaluation for PE at OSH,\\n however, unable to open disc to confirm. Concern for VAP.\\n - Failed yesterday\\ns NIF; score was -15\\n - Increased FiO2 overnight. Had increased pCO2 which resolved with\\n increasing RR\\n - IP stopped by but will complete official consult today; suggested\\n repeating CT scan\\n - Need to contact Medical re previous CT scan. Can attempt to\\n resend disc. Otherwise, will most likely benefit from repeat CT to\\n look for acute pulm process such as PE or PNA.\\n # Fever: Likely due to combination of infection and DVT. Cultures\\n sent. Will treat with empiric antibiotics. Tylenol PRN for fever.\\n - Known RUE DVT\\n - Infectious etiologies include VAP, asp PNA, line infections. Removed\\n PICC yesterday and cultured tip. Mini-BAL- gram stain neg. Sputum\\n grew GPC in pairs and GPR. Flagyl, aztreonam, vancomycin, levofloxacin\\n for coverage of gram positives, gram negatives, anaerobes, MRSA. Urine\\n and blood cultures NGTD\\n - f/u blood, urine, and sputum cultures.\\n - Concern for abd cause; KUB unrevealing. High residuals. require\\n further imaging\\n # Transient hypotension: Has been somewhat fluid responsive; UOP \\n ccs/hr. Diff dx includes hypovolemia, sepsis, cardiogenic.\\n - Sepsis most likely given fever.\\n - HCT decreasing; ? stable at 24-25\\n - Unable to place central line despite multiple attempts. First tired\\n left IJ RUE DVT. 2^nd attempt in left IJ. Can place femoral if pt\\n requires more active repletion\\n - Consider another attempt at a line.\\n # Oliguria:\\n -BUN and Cr as well as lactate reassuring.\\n -Increased bladder pressures this am- 20. Further imaging may be\\n helpful\\n # RUE DVT: Have held on starting treatment in light of need for central\\n access. Can start therapeutic heparin vs Lovenox with bridge to\\n coumadin.\\n -Can consider rescanning for PE. High risk for PE given UE DVT.\\n # Abd distention:\\n -KUB unrevealing\\n -High residuals\\n - benefit from further imaging; if unstable consider ultrasound,\\n however, if pt can tolerate it, a CT scan might be more helpful. Can\\n also scan chest and pelvis.\\n # Anemia: On admission to Medical Center, Hct was ~40, now down\\n to 30 and then 25 w/o sign of active GI bleed or other source of blood\\n loss. be related to fluid administration, phlebotomy, anemia of\\n inflammation, active bleed still considered in differential.\\n - trend Hct\\n - guaiac stools\\n - S/p failed attempts at line placement; watch for neck hematomas\\n - INR elev at 1.5. ? may be related to poor nutrition as albumin is\\n 2.3\\n # Spine fracture: neurologically intact distal to the lesion. prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - Need to talk to neurosurg to see if pt can tolerate a CT scan as well\\n as the risks of anticoag for DVT\\n - monitor distal neurologic function\\n - cto brace x3 months unless supine in bed\\n - consult neurosurgery for further recs\\n # Hypernatremia: correcting with g tube free flush and D5W\\n -Holding on g tube feeds at present due to high residuals\\n -Replete lytes as necessary\\n ICU Care\\n Nutrition: tube feed with free water\\n Glycemic Control: Regular insulin sliding scale\\n DVT: SQ UF Heparin\\n Stress ulcer: H2 blocker\\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\\n Communication: Family meeting held , ICU consent signed, \\n (brother) (boyfriend/POA) \\n Code status: Full code\\n Disposition: ICU\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 01:36 AM\\n 22 Gauge - 02:00 PM\\n Arterial Line - 03:00 AM\\n Multi Lumen - 11:30 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-09-23 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 634477,\n \"text\": \"Events: Attempt to lighten sedation, stop Levophed gtt- MS \\n stability labile from lethargic to restless in bed/crying w/\\n intermittent BP 120\\ns/ w/ and W/O stimulation. UOP cont 10-30cc/hr.\\n Vigileo monitor on- SVV . Bladder pressure 14. TF restarted w/ goal\\n slow inc as tolerated w/ recent high residuals. Sm amt bowel\\n movement.\\n Alteration in Nutrition\\n Assessment:\\n Minimal residuals\\n Action:\\n Restarting TF replete w/ fiber @ 10cc/hr w/ Q6hr 20cc flush\\n Response:\\n Tolerating, goal advance Q6hr as tolerated\\n Plan:\\n Cont TF, monitor residuals, inc Q6hrs as tolerated, monitor stool\\n output for improving GI motility w/ PO Narcan\\n Hypotension (not Shock)\\n Assessment:\\n BP labile- SBP 86-120, UOP down to 10cc/hr\\n Action:\\n Vigileo on- SVV , In AM attempt wean off Levo gtt\\n Response:\\n No fluid blousing, Levophed gtt started- titrated for MAP >65, UOP,\\n Levo gtt @ .020mcg/kg/min\\n Plan:\\n Cont Vigilieo monitoring, CVP monitoring, UOP, Levophed gtt, fluid\\n bolus if inc in SVV, in CVP\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Heparin gtt @ 1700units/hr, PTT 76\\n Action:\\n Heparin gtt therapeutic x2, cont @ 1700units/hr\\n Response:\\n No s/s bleeding, guiac neg gastric secretions, stool\\n Plan:\\n Cont Hep gtt as ordered w/I scale parameters, check PTT w/ AM labs,\\n monitor s/s bleeding\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n LS clear bilat upper lobes, diminished bilat lower lobes, turning w/o\\n desating, suctioning minimally for thin clear secretions, Sat 96-100%,\\n w/ decres in sedation waking in afternoon and overbreathing vent 1-3\\n bpm, afebrile\\n Action:\\n No vent changes, suctioned post coughing x1, turning as tolerated,\\n sedation titrated- currently @ 100mcg/hr Fentanyl gtt, 2 mg/hr Versed\\n gtt. 1x blousing w/ .5mg Versed and 50mcg Fentanyl for sig inc in\\n agitation/breathing over vent/pulling @ lines, resp tesing w/\\n esophageal balloon\\n Response:\\n Synchronous w/ vent, RN care/turning/mouth care w/ decreased agitation,\\n Sat >96%, pt on appropriate PEEP\\n Plan:\\n Cont IV ABX, pulm toilet, esophageal balloon readings, monitor sat\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-09-23 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 634478,\n \"text\": \"Chief Complaint: respiratory failure\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 24 Hour Events:\\n ESOPHOGEAL BALLOON - At 01:46 PM\\n Restarted levophed overnight\\n Patient unable to provide history: Sedated\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Vancomycin - 08:00 PM\\n Aztreonam - 06:09 AM\\n Metronidazole - 08:00 AM\\n Levofloxacin - 08:39 AM\\n Infusions:\\n Midazolam (Versed) - 1.5 mg/hour\\n Fentanyl - 75 mcg/hour\\n Norepinephrine - 0.02 mcg/Kg/min\\n Other ICU medications:\\n Other medications:\\n vanc, aztreonam, flagyl (day ), CHG, SQI, nebs, naloxone enteral,\\n heparin infusion\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 09:55 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38\\nC (100.4\\n Tcurrent: 37.6\\nC (99.6\\n HR: 75 (64 - 102) bpm\\n BP: 96/49(65) {76/38(56) - 160/71(97)} mmHg\\n RR: 22 (16 - 25) insp/min\\n SpO2: 99%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 101 kg (admission): 94.2 kg\\n Height: 67 Inch\\n CVP: 20 (8 - 339)mmHg\\n Bladder pressure: 18 (18 - 21) mmHg\\n Total In:\\n 3,524 mL\\n 848 mL\\n PO:\\n TF:\\n 48 mL\\n IVF:\\n 3,236 mL\\n 698 mL\\n Blood products:\\n Total out:\\n 935 mL\\n 325 mL\\n Urine:\\n 650 mL\\n 325 mL\\n NG:\\n 285 mL\\n Stool:\\n Drains:\\n Balance:\\n 2,589 mL\\n 523 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 400 (400 - 400) mL\\n Vt (Spontaneous): 0 (0 - 0) mL\\n RR (Set): 22\\n RR (Spontaneous): 0\\n PEEP: 23 cmH2O\\n FiO2: 50%\\n RSBI Deferred: PEEP > 10, FiO2 > 60%\\n PIP: 37 cmH2O\\n Plateau: 33 cmH2O\\n Compliance: 40 cmH2O/mL\\n SpO2: 99%\\n ABG: 7.37/44/160/25/0\\n Ve: 8.9 L/min\\n PaO2 / FiO2: 320\\n Physical Examination\\n General Appearance: Overweight / Obese\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\\n Respiratory / Chest: coarse breath sounds\\n Abdominal: Soft, Obese\\n Extremities: Right: 1+, Left: 1+\\n Skin: Warm\\n Neurologic: Responds to: Unresponsive, Movement: No spontaneous\\n movement, Tone: Normal\\n Labs / Radiology\\n 8.9 g/dL\\n 358 K/uL\\n 126 mg/dL\\n 0.7 mg/dL\\n 25 mEq/L\\n 3.5 mEq/L\\n 4 mg/dL\\n 108 mEq/L\\n 143 mEq/L\\n 28.0 %\\n 8.1 K/uL\\n [image002.jpg]\\n 12:05 PM\\n 06:08 PM\\n 06:11 PM\\n 07:53 PM\\n 02:02 AM\\n 03:59 AM\\n 09:14 PM\\n 01:04 AM\\n 05:54 AM\\n 06:11 AM\\n WBC\\n 8.4\\n 8.1\\n Hct\\n 29.0\\n 28.1\\n 28.0\\n Plt\\n 376\\n 358\\n Cr\\n 0.6\\n 0.7\\n TCO2\\n 29\\n 29\\n 25\\n 25\\n 28\\n 28\\n 26\\n Glucose\\n 120\\n 126\\n Other labs: PT / PTT / INR:22.2/76.0/2.1, ALT / AST:24/16, Alk Phos / T\\n Bili:117/0.7, Amylase / Lipase:, Differential-Neuts:74.7 %,\\n Lymph:17.6 %, Mono:3.8 %, Eos:3.4 %, Lactic Acid:0.7 mmol/L,\\n Albumin:2.4 g/dL, LDH:204 IU/L, Ca++:8.2 mg/dL, Mg++:2.0 mg/dL, PO4:3.2\\n mg/dL\\n Assessment and Plan\\n 55-year-old woman with\\n Respiratory failure\\n End-exp transpulmonary pressure: -2\\n End-insp transpulmonary pressure: +5\\n Esophageal pressures suggest that she is at safe pressures.\\n Traumatic thoracic spinal fracture\\n Eventual MRI. Too high-risk at present. Brace when out of\\n bed.\\n Probable VAP\\n Discuss GNRs with lab\\n Complete 8\\n 15d course of present ABX pending cultures\\n D/C vancomycin since no identified GPCs\\n D/C Flagyl since no CT or toxin evidence of C diff\\n Shock\\n now back on levophed\\n CVP is 20 mm Hg but Pes is ~25 cm H20\\n Re-assess SVV with Vigileo and consider volume challenge\\n Upper extremity DVT\\n Therapeutic heparin\\n Anemia\\n Follow\\n Possible tracheobronchomalacia (reason for transfer)\\n Incidental peri-appendiceal finding (will need eventual\\n follow-up)\\n Although differential remains open, the most compelling course of\\n events is probably that she required intubation at the outside hospital\\n (?sedation ?restriction from obesity/brace ?other) and subsequently\\n developed a GNR-related VAP. Her pattern of acute lung injury,\\n combined with obesity, is resulting in basilar and\\n posterior-predominant atelectasis/consolidation with a high proportion\\n of shunt. Given her very high PEEP, will try to avoid bronchoscopy if\\n possible.\\n Other issues as per ICU team note.\\n ICU Care\\n Nutrition: resume tube feeds\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n 20 Gauge - 01:36 AM\\n Arterial Line - 03:00 AM\\n Multi Lumen - 11:30 AM\\n Prophylaxis:\\n DVT: Boots(Systemic anticoagulation: Heparin gtt)\\n Stress ulcer: H2 blocker\\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds Comments:\\n Code status: Full code\\n Disposition :ICU\\n Total time spent: 60 minutes\\n Patient is critically ill\\n ------ Protected Section ------\\n CRITICAL CARE STAFF\\n 7p\\n Oxygenation has continued to improved throughout the day.\\n Remains on levophed.\\n Repeat baseline cortisol < 5.\\n Had relative oliguria for several hours.\\n Her baseline cortisol should be substantially higher than it is; she\\n should be maximally stimulated given her degree of illness. I\\n therefore think this represents meaningful cortisol deficiency. Since\\n she is vasopressor-requiring, we will treat for adrenal insufficiency.\\n We will wean FiO2 to 0.4. If tolerates, then wean PEEP.\\n These maneuvers are likely to help with urine output, as well. If they\\n do not, will increase levophed and see if higher blood pressures result\\n in higher UOP.\\n Critical Care Time: 30 minutes\\n ------ Protected Section Addendum Entered By: , MD\\n on: 19:13 ------\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2167-09-20 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 634099,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 2\\n Airway\\n Airway Placement Data\\n Known difficult intubation: No\\n Procedure location: Outside hospital\\n Tube Type\\n ETT:\\n Position: 19 cm at teeth\\n Route: Oral\\n Type: Standard\\n Size: 7.5mm\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Rhonchi\\n LUL Lung Sounds: Rhonchi\\n LLL Lung Sounds: Diminished\\n Secretions\\n Sputum color / consistency: Yellow / Thick\\n Sputum source/amount: Suctioned / Moderate\\n Ventilation Assessment\\n Level of breathing assistance: Continuous non-invasive ventilation\\n Visual assessment of breathing pattern: Normal quiet breathing;\\n Comments: Episodes of coughing with high pips, Bs clear, mdis and\\n sedation given, subsides.\\n Assessment of breathing comfort: No response (sleeping / sedated)\\n Invasive ventilation assessment:\\n Trigger work assessment: Triggering synchronously\\n Plan\\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\\n Utilize ARDSnet protocol, Maintain PEEP at current level and reduce\\n FiO2 as tolerated, Reduce PEEP as tolerated, Adjust Min. ventilation to\\n control pH; Comments: Further workup of Tracheal malacia status.\\n possible bronch\\n Reason for continuing current ventilatory support: Intolerant of\\n weaning attempts, Pending procedure / OR, Underlying illness not\\n resolved\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2167-09-20 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 634177,\n \"text\": \"Demographics\\n Day of intubation: \\n Day of mechanical ventilation: 2\\n Ideal body weight: 61.2 None\\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: No\\n Procedure location:\\n Reason:\\n Tube Type\\n ETT:\\n Position: cm at teeth\\n Route:\\n Type: Standard\\n Size: 7mm\\n Tracheostomy tube:\\n Type:\\n Manufacturer:\\n Size:\\n PMV:\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: cmH2O\\n Cuff volume: mL /\\n Airway problems:\\n Comments:\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Rhonchi\\n LUL Lung Sounds: Rhonchi\\n LLL Lung Sounds: Diminished\\n Comments:\\n Secretions\\n Sputum color / consistency: Yellow / Thick\\n Sputum source/amount: Suctioned / Small\\n Comments: Pt had a MINI BAL @ 1500hrs \\n Ventilation Assessment\\n Level of breathing assistance:\\n Visual assessment of breathing pattern:\\n Assessment of breathing comfort:\\n Non-invasive ventilation assessment:\\n Invasive ventilation assessment:\\n Trigger work assessment:\\n Dysynchrony assessment:\\n Comments:\\n Plan\\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\\n Reason for continuing current ventilatory support:\\n Respiratory Care Shift Procedures\\n Transports:\\n Destination (R/T)\\n Time\\n Complications\\n Comments\\n Bedside Procedures:\\n Bronchoscopy (1500hrs)\\n Comments: MINI BAL spec sent to micro\\n, RRT 16:44\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-09-20 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 634180,\n \"text\": \"Obese woman s/p t spine injury tx from Med for failure to wean\\n from mech ventilation and evaluation for stent for\\n tracheobronchomalacia.\\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\\n Assessment:\\n Pt cont w/ low grade fever.\\n Action:\\n Given tyelenol q6 h prn, pt pan cultured. PICC line and foley d/c\\n (new foley placed). IV antibiotics started.\\n Response:\\n Fever slightly improved to 99.\\n Plan:\\n Cont w/ q 6 hr tyelenol prn, closely monitor temp and f/u w/ cultures.\\n Fracture, other\\n Assessment:\\n Pt w/ T5-T8 compression fracture.\\n Action:\\n Pt on log-roll precautions, back brace at bedside- to be used when pt\\n is OOB.\\n Response:\\n Pt denies pain when asked.\\n Plan:\\n Cont on log roll precautions, Neuro- consult ordered to clarify\\n order for brace.\\n Anemia, other\\n Assessment:\\n HCT 25 from 30.0. No active bleeding noted.\\n Action:\\n Cont to check HCT and s/s of bleeding.\\n Response:\\n No action taken.\\n Plan:\\n Type & Screen to be collected. Cont to monitor HCT, guiac all stools.\\n Hypernatremia (high sodium)\\n Assessment:\\n NA level 150-> 147. No seizure activity.\\n Action:\\n Free H2O boluses q 4hrs were started, but currently on hold d/t high\\n residuals. Pt on D5W for 1L .\\n Response:\\n NA level slightly improved.\\n Plan:\\n Cont w/ free-water boluses as tolerated, cont to monitor lytes, bolus\\n w/ LR prn.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n LS rhonchorous throughout, diminished to bilateral bases, deep sxn\\n thick tan/bloody secretions.\\n Action:\\n Given MDIs, cont to be orally intubated on A/C, mini-BAL performed by\\n RT and sample sent to lab. Increased sedation for adequate\\n ventilation. Arterial line placed to Lt wrist.\\n Response:\\n Cont to be orally intubated and sedated.\\n Plan:\\n Consult w/ IP for eval for stent, wean vent as tolerated\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n RUE edematous\\n Action:\\n U/S done, RUE elevated, Pt cont on sq heparin\\n Response:\\n US + for DVT to RUE\\n Plan:\\n No blood draws or NBP to RUE, elevate RUE, cont w/ heparin sq\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-09-20 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 634181,\n \"text\": \"Obese woman s/p t spine injury tx from Med for failure to wean\\n from mechanical ventilation and evaluation for stent for\\n tracheobronchomalacia.\\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\\n Assessment:\\n Pt cont w/ low grade fever.\\n Action:\\n Given tyelenol q6 h prn, pt pan cultured. PICC line and foley d/c\\n (new foley placed). IV antibiotics started.\\n Response:\\n Fever slightly improved to 99.\\n Plan:\\n Cont w/ q 6 hr tyelenol prn, closely monitor temp and f/u w/ cultures.\\n Fracture, other\\n Assessment:\\n Pt w/ T5-T8 compression fracture.\\n Action:\\n Pt on log-roll precautions, back brace at bedside- to be used when pt\\n is OOB.\\n Response:\\n Pt denies pain when asked.\\n Plan:\\n Cont on log roll precautions, Neuro- consult ordered to clarify\\n order for brace.\\n Anemia, other\\n Assessment:\\n HCT 25 from 30.0. No active bleeding noted.\\n Action:\\n Cont to check HCT and s/s of bleeding.\\n Response:\\n No action taken.\\n Plan:\\n Type & Screen to be collected. Cont to monitor HCT, guiac all stools.\\n Hypernatremia (high sodium)\\n Assessment:\\n NA level 150-> 147. No seizure activity.\\n Action:\\n Free H2O boluses q 4hrs were started, but currently on hold d/t high\\n residuals. Pt on D5W for 1L .\\n Response:\\n NA level slightly improved.\\n Plan:\\n Cont w/ free-water boluses as tolerated, cont to monitor lytes, bolus\\n w/ LR prn.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n LS rhonchorous throughout, diminished to bilateral bases, deep sxn\\n thick tan/bloody secretions.\\n Action:\\n Given MDIs, cont to be orally intubated on A/C, mini-BAL performed by\\n RT and sample sent to lab. Increased sedation for adequate\\n ventilation. Arterial line placed to Lt wrist.\\n Response:\\n Cont to be orally intubated and sedated.\\n Plan:\\n Consult w/ IP for eval for stent, wean vent as tolerated\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n RUE edematous\\n Action:\\n U/S done, RUE elevated, Pt cont on sq heparin\\n Response:\\n US + for DVT to RUE\\n Plan:\\n No blood draws or NBP to RUE, elevate RUE, cont w/ heparin sq\\n Hypotension (not Shock)\\n Assessment:\\n Pt hypotensive into mid 80s systolic, SR/ST, HR 80s-120s. Low UOP\\n /h.\\n Action:\\n Given 500cc LR boluses x 3. Arterial line placed. EKG done-no change.\\n Response:\\n Minimal response to UOP. BP improved\\n> 100s-130s systolic.\\n Plan:\\n Central line to be placed, cont to bolus as needed.\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2167-09-24 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 634535,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 6\\n Ideal body weight: 61.2 None\\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: Unknown\\n Procedure location:\\n Reason:\\n Tube Type\\n ETT:\\n Position: cm at teeth\\n Route:\\n Type: Standard\\n Size: 7.5mm\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Diminished\\n Comments:\\n Secretions\\n Sputum color / consistency: White / Thick\\n Sputum source/amount: Suctioned / Small\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance:\\n Visual assessment of breathing pattern:\\n Assessment of breathing comfort:\\n Non-invasive ventilation assessment:\\n Invasive ventilation assessment:\\n Trigger work assessment:\\n Dysynchrony assessment:\\n Comments:\\n Plan\\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\\n tolerated\\n Reason for continuing current ventilatory support:\\n Respiratory Care Shift Procedures\\n Transports:\\n Destination (R/T)\\n Time\\n Complications\\n Comments\\n Bedside Procedures:\\n Comments: Pt received intubated and vented on AC . 400x22 23 peep and\\n 40%. peep was decreased 21 cmh20 and tolerated well.pt sp02 remains\\n 98-99. BS reveals rhonchi to auscultation,but clears with suctioning.\\n Sputum sample sent to lab d/t ^ temp. will continue to wean peep as\\n tolerated. Close monitoring will continue\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-09-25 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 634628,\n \"text\": \"Pt is a 55 yr old women admitted from OSH after she fell down the\\n stairs (did not have LOC per boyfriend) and had a traumatic T-spine\\n Fracture. Pt came to us with PNA from unknown etiology? VAP. Full\\n code, Allergies: PCN, tetracycline, sulfa. PMH: ETOH, smoker, Gerd, Hip\\n replacement. Pt afebrile during the night, was Pan cultured\\n yesterday. Pt brother is her spokesperson. Pt boyfriend was in last\\n night to see her, it is a 2 hr train ride from for him to get\\n here. Pt boyfriend reported on night that for the last 2 months\\n pt has been drinking 2 large bottles of wine almost every night and\\n that this is an increase from what she used to drink.\\n Bradycardia\\n Assessment:\\n HR 46-60\\ns, HR decreases when pt is asleep. Stays in the 45-50 range\\n when she is asleep. BP stable with low HR.\\n Action:\\n Monitor HR, monitor SBP with low HR\\n Response:\\n No action taken because vital sign have been stable.\\n Plan:\\n Cont to monitor\\n Alteration in Nutrition\\n Assessment:\\n Replete with fiber Goal rate 60ml/hr. distended firm belly but pt is\\n stooling now. Hypoactive bowel sounds.\\n Action:\\n Increased rate to 50ml/hr. cont to watch TF residuals. Pt did have past\\n problems with high residuals.\\n Response:\\n Residuals 10ml.\\n Plan:\\n Cont to advance TF as tolerated. Cont stool softners/monitor for high\\n residuals.\\n Deep Venous Thrombosis (DVT), Upper extremity,\\n Assessment:\\n RUE DVT, Pt on heparin gtt at 1700 units/hr. No blood draws or BP on\\n RUE.\\n Action:\\n PTT has been at therapeutic dose.\\n Response:\\n Repeat PTT in AM\\n Plan:\\n If PTT cont to be therapeutic cont to check PTT Q 24 hr., if not make\\n changes per protocol.\\n Fracture, other\\n Assessment:\\n Ortho reported that pt has T8 fracture. Pt does move all extremities,\\n needs to wear back brace when out of bed. Brace is in the room, pt no\\n longer on log roll precautions. Hard to tell if pt is in pain from\\n fracture but she is on fentanyl and versed gtts.\\n Action:\\n Per ortho pt will need MRI of the spine and CT scan of the C and L\\n portions of the spine to check for any other spinal injury. Ortho\\n states we can do this when pt is more stable.\\n Response:\\n Plan:\\n Will do MRI and CT at a later date.\\n Hypotension (not Shock)\\n Assessment:\\n SBP ranges 80-100\\ns with MAPs 55-70 Goal MAP >60. levophed off for\\n almost 24hr. pt did get total of 3 liters in fluid boluses over the\\n last 24 hr. CVP 12-14 but pt on 21 of peep. A-line very positional\\n and was just re-sited yesterday. Pt was on vigileo monitor but D/C\\n during the day because A-line tracing is so positional that the\\n accuracy of this monitoring is questionable.\\n Action:\\n Gave 500ml fluid bolus for MAP of 55. and low urine output 10-20ml/hr.\\n Response:\\n Urine output increased, and MAP/BP increased\\n Plan:\\n Cont to monitor BP and MAPs and urine output.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Suctioning clear/white thick secretions in-line, copious amounts of\\n clear secretions suctioned orally. Cough intact. Lung sounds clear\\n diminished, no vent setting changes, Vent mode CMV: 40%/400/22/21,\\n esophageal balloon in place.\\n Action:\\n VAP protocol: HOB 30 degrees, oral care. Suctioning, cont steroids.\\n Chest x-ray done in AM. Cont antibiotics.\\n Response:\\n Cont to needs lots of suctioning.\\n Plan:\\n Wean vent as ordered by the Micu team. Cont to check ABG\\ns when\\n indicated.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-09-25 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 634629,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n New A-line placed (left), good tracing but positional\\n Vanco restarted\\n Atrial EKG->p-waves\\n Multiple IVF boluses for MAPs < 65. Did not restart pressors\\n Brother came, confirmed history\\n Eye drops\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Metronidazole - 08:00 AM\\n Levofloxacin - 10:00 AM\\n Vancomycin - 08:09 PM\\n Aztreonam - 10:00 PM\\n Infusions:\\n Midazolam (Versed) - 4 mg/hour\\n Heparin Sodium - 1,700 units/hour\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 04:29 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.7\\nC (98.1\\n Tcurrent: 36.7\\nC (98.1\\n HR: 56 (45 - 63) bpm\\n BP: 103/54(72) {83/44(59) - 142/105(109)} mmHg\\n RR: 22 (0 - 22) insp/min\\n SpO2: 99%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 101 kg (admission): 94.2 kg\\n Height: 67 Inch\\n CVP: 12 (11 - 14)mmHg\\n Total In:\\n 4,750 mL\\n 868 mL\\n PO:\\n TF:\\n 773 mL\\n 223 mL\\n IVF:\\n 3,827 mL\\n 645 mL\\n Blood products:\\n Total out:\\n 2,365 mL\\n 60 mL\\n Urine:\\n 2,325 mL\\n 60 mL\\n NG:\\n 40 mL\\n Stool:\\n Drains:\\n Balance:\\n 2,385 mL\\n 808 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 400 (400 - 400) mL\\n RR (Set): 22\\n RR (Spontaneous): 0\\n PEEP: 21 cmH2O\\n FiO2: 40%\\n RSBI Deferred: PEEP > 10\\n PIP: 34 cmH2O\\n Plateau: 29 cmH2O\\n Compliance: 50 cmH2O/mL\\n SpO2: 99%\\n ABG: 7.46/38/96./23/2\\n Ve: 8.6 L/min\\n PaO2 / FiO2: 242\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 326 K/uL\\n 8.9 g/dL\\n 153 mg/dL\\n 0.6 mg/dL\\n 23 mEq/L\\n 4.2 mEq/L\\n 6 mg/dL\\n 113 mEq/L\\n 141 mEq/L\\n 28.6 %\\n 8.9 K/uL\\n [image002.jpg]\\n 09:14 PM\\n 01:04 AM\\n 05:54 AM\\n 06:11 AM\\n 11:07 PM\\n 03:51 AM\\n 06:17 AM\\n 07:00 AM\\n 08:18 AM\\n 04:18 PM\\n WBC\\n 8.1\\n 8.9\\n Hct\\n 28.0\\n 28.6\\n Plt\\n 358\\n 326\\n Cr\\n 0.7\\n 0.7\\n 0.6\\n TropT\\n <0.01\\n <0.01\\n TCO2\\n 28\\n 28\\n 26\\n 26\\n 21\\n 28\\n Glucose\\n 126\\n 151\\n 153\\n Other labs: PT / PTT / INR:24.3/68.6/2.4, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\\n Amylase / Lipase:, Differential-Neuts:82.5 %, Lymph:11.6 %,\\n Mono:3.3 %, Eos:2.2 %, Lactic Acid:0.7 mmol/L, Albumin:2.4 g/dL,\\n LDH:204 IU/L, Ca++:7.8 mg/dL, Mg++:2.1 mg/dL, PO4:2.6 mg/dL\\n Assessment and Plan\\n 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture with respiratory failure\\n and difficulty weaning from vent.\\n # Respiratory failure: Over the evening yesterday, were able to\\n decrease FiO2 and PEEP. Clinical and imaging suggestive of ARDS.\\n Initial precipitating factors were thought to be: sedation, hypovent\\n obesity, orthotic brace. Now thought to have VAP.\\n - Placed esophageal balloon on which will help guide PEEP settings.\\n - Given small size of effusion and high PEEP (risk of pneumothorax),\\n will not attempt to tap\\n - Appreciate IP recs. Will consider tracheomalacia workup when more\\n stable.\\n - Approaching 2-week intubation point (intubated ); Trach?\\n # VAP/ID: Re-spiked fever overnight. Stopped vanc yesterday, , as\\n treating for GNR infection. Current GS shows GPC\\n - Follow cultures\\n - Restart Vanc.\\n - Continue aztreonam, levofloxicin for 8 days pending speciation (at\\n that time can increase to 15 days if necessary)\\n - Also, stopped flagyl because had one neg c. diff toxin and CT did not\\n show evidence of colitis\\n - Will replace A-line today.\\n # EKG changes: Sinus bradycardia. Very low voltages and no change in\\n QRS morphology. P-waves are visible and prolonged PR interval is old.\\n CK and troponins flat. Likely related to increased vagal tone possibly\\n related to steroid replacement.\\n - Will avoid excessive alpha-agonism\\n - Continue to monitor\\n - could consider atrial EKG\\n .\\n # Hypotension: now off levophed, with good urine output. Hypovolemia\\n is possibly a factor- responded to a transfusion; HCT had been\\n dropping. However, SVV with Vigileo was 7, making her CO less likely\\n to respond to fluids. Held on giving any boluses overnight. Today CVP\\n is low given PEEP. Sepsis also a consideration\\n - continue on broad spectrum abs\\n - replete fluids.\\n - Restart pressors as needed. Consider dopamine over levophed given\\n bradycardia.\\n - Central line in place.\\n # Urine output: Previously oliguric, now with high urine output.\\n Concern for autodiuresis but BUN and Cr reassuring.\\n -Continue to monitor\\n # RUE DVT: Started on heparin gtt on .\\n -Therapeutic in one day; may be related to poor nutritional status.\\n Will continue to closely monitor\\n # Adrenal Insufficency:\\n -Random cortisol was approx 3 when it should have been maximally\\n stimulated.\\n -Started hydrocortisone and florinef. ? switch to methylpred\\n # Anemia:\\n - Trend HCT\\n - Gave 1 un pRBC with good results\\n - INR rising, now 2.0, may be nutritional\\n # Spine fracture: neurologically intact distal to the lesion. prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - CT of C, L spine when stable. Currently, unlikely to change\\n management and high risk for complications with transport.\\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\\n is low. Brace for OOB. Ok for anticoag per note.\\n # Hypernatremia, resolved: correcting with g tube free flush and D5W\\n -Continue to follow\\n # Communication:\\n - Brother has been with pt, although, live in boyfriend of 10 is\\n her HCP. Boyfriend will hopefully visit pt today\\n ICU Care\\n Nutrition: tube feed with free water when able\\n Glycemic Control: Regular insulin sliding scale\\n DVT: Theraputic Heparin gtt\\n Stress ulcer: H2 blocker\\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\\n Communication: ICU consent signed, (brother) \\n (boyfriend/POA) \\n Code status: Full code\\n Disposition: ICU\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 07:00 AM 50 mL/hour\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 11:30 AM\\n Arterial Line - 04:00 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-09-21 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 634224,\n \"text\": \"Respiratory failure, acute (not ARDS/)\\n Assessment:\\n LS cont rhonchi throughout, dim bilat in base, occ. bronchospasms with\\n care; abg showed resp. acidosis\\n Action:\\n Cont to suct for smll thick tan secretions, copious oral secretions\\n suctioned, vent settings changed to 18/500/80/10\\n Response:\\n ABG improved, O2 Sats 97-98%\\n Plan:\\n f/f with IP ? tracheabronchial malacia, abgs, neb tx as needed\\n Hypotension (not Shock)\\n Assessment:\\n Sbp down in high 90\\ns, Aline damped\\n Action:\\n pt bolused x 1L LR, 500mg NS for low urinary output, L-aline d/cd\\n Response:\\n R-wrist Aline placed, SBP 110-120\\n Plan:\\n Cont . VS, I &O; treat as ordered\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n +DVT\\n Action:\\n Cont SC heparin\\n Response:\\n Plan:\\n Cont SC heparin,\\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\\n Assessment:\\n TMax 99.2\\n Action:\\n Cont with IV ABX, second UA sent\\n Response:\\n Remains low grade temp\\n Plan:\\n f/u with pending cultures; attempt repeat sputum culture, treat temp as\\n ordered\\n Fracture, other\\n Assessment:\\n T7 fracture to fall on \\n Action:\\n Cont in Reverse Trend., log roll precautions HOB 30\\n Response:\\n Remains stable\\n Plan:\\n Cont log roll precautions, f/u with PT, ? specialty mattress??\\n Anemia, other\\n Assessment:\\n H/H 24.1/7.6, no active bleeding noted\\n Action:\\n Stool guiac negative\\n Response:\\n Plan:\\n Cont to Hct, guiac stools\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-09-21 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 634225,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Removed PICC line because RUE was noted to be warm and erythematous;\\n ultrasound revealed DVT. No definitive treatment was started given\\n difficulty obtaining central venous access.\\n Multiple attempts at central access; tried left and then right.\\n Acute episode of oxygen desat during first central line attempt. Pt\\n recovered, however, increased FiO2.\\n Decreased UOP (10-30mL/hr) and hypotension overnight. However,\\n lactate remains low.\\n Placed art line x 2. NBP and ABP similar\\n mini- BAL, sputum, urine, blood cultures pending. Yesterday, started\\n on levofloxicin and aztreonam instead of cefepime. Switched due to\\n question of PCN allergy\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Levofloxacin - 09:30 AM\\n Metronidazole - 12:00 AM\\n Vancomycin - 01:00 AM\\n Aztreonam - 04:00 AM\\n Infusions:\\n Midazolam (Versed) - 2 mg/hour\\n Fentanyl - 150 mcg/hour\\n Other ICU medications:\\n Ranitidine (Prophylaxis) - 08:00 AM\\n Midazolam (Versed) - 10:00 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:31 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.3\\nC (100.9\\nF at 10am on )\\n Tcurrent: 37.3\\nC (99.2\\n HR: 76 (71 - 116) bpm\\n BP: 116/51(70) {60/46(54) - 146/71(91)} mmHg\\n RR: 18 (12 - 24) insp/min\\n SpO2: 93%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 94.2 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 5,600 mL\\n 1,811 mL\\n PO:\\n TF:\\n 120 mL\\n IVF:\\n 4,700 mL\\n 1,511 mL\\n Blood products:\\n Total out:\\n 798 mL\\n 110 mL\\n Urine:\\n 798 mL\\n 110 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 4,802 mL\\n 1,701 mL\\n Respiratory support\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 500 (500 - 500) mL\\n RR (Set): 18\\n RR (Spontaneous): 0\\n PEEP: 10 cmH2O\\n FiO2: 80%\\n RSBI Deferred: PEEP > 10\\n PIP: 36 cmH2O\\n Plateau: 25 cmH2O\\n SpO2: 93%\\n ABG: 7.45/42/95./28/4\\n Ve: 9.5 L/min\\n PaO2 / FiO2: 120\\n Physical Examination\\n Gen: Appears uncomfortable on vent.\\n HEENT: Anicteric. Pupils 3 mm non-reactive bilaterally.\\n Resp: Symmetric expansion. Vesicular sounds throughout. Inspiratory\\n and expiratory tracheal sounds (?related to ET tube).\\n CV: Cannot see jugular veins due to neck size. RRR. Normal s1 and\\n s2. No M/G/R.\\n Abd: Quiet. Distended. Non-tender.\\n Ext: Edema in RUE, especially right hand. Mildly increased warmth of\\n RUE compared with LUE.\\n Peripheral vascular: Radial pulses 2+ bilaterally.\\n Neuro: Pupils as above. Moving all 4 extremities.\\n Labs / Radiology\\n 319 K/uL\\n 7.6 g/dL\\n 129 mg/dL\\n 0.6 mg/dL\\n 28 mEq/L\\n 4.3 mEq/L\\n 6 mg/dL\\n 109 mEq/L\\n 144 mEq/L\\n 24.1 %\\n 6.4 K/uL\\n [image002.jpg]\\n 11:54 PM\\n 01:00 AM\\n 06:14 AM\\n 08:56 AM\\n 08:57 AM\\n 05:01 PM\\n 08:03 PM\\n 11:00 PM\\n 03:01 AM\\n 03:13 AM\\n WBC\\n 9.7\\n 9.4\\n 7.6\\n 6.4\\n Hct\\n 30.7\\n 25.1\\n 24.1\\n 24.1\\n Plt\\n 333\\n 281\\n 306\\n 319\\n Cr\\n 0.6\\n 0.6\\n 0.7\\n 0.6\\n 0.6\\n TCO2\\n 32\\n 33\\n 35\\n 33\\n 30\\n Glucose\\n 103\\n 126\\n 126\\n 127\\n 129\\n Other labs: PT / PTT / INR:16.9/26.3/1.5, ALT / AST:27/18, Alk Phos / T\\n Bili:113/0.7, Differential-Neuts:76.9 %, Lymph:17.3 %, Mono:3.0 %,\\n Eos:2.5 %, Lactic Acid:0.7 mmol/L, Albumin:2.3 g/dL, LDH:154 IU/L,\\n Ca++:8.2 mg/dL, Mg++:2.6 mg/dL, PO4:3.1 mg/dL\\n RUE ultrasound:\\n - Non-occlusive right axillary deep vein thrombus\\n - Non-occlusive right basilic superficial thrombosis.\\n Assessment and Plan\\n 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture\\n # Respiratory failure: initial etiology unclear, likely multifactorial\\n including bronchspasm, hypoventilation from narcotics, potential\\n aspiration, infection. By report, had a neg evaluation for PE at OSH,\\n however, unable to open disc to confirm. Concern for VAP.\\n - Failed yesterday\\ns NIF; score was -15\\n - Increased FiO2 overnight. Had increased pCO2 which resolved with\\n increasing RR\\n - IP stopped by but will complete official consult today; suggested\\n repeating CT scan\\n - Need to contact Medical re previous CT scan. Can attempt to\\n resend disc. Otherwise, will most likely benefit from repeat CT to\\n look for acute pulm process such as PE or PNA.\\n # Fever: Likely due to combination of infection and DVT. Cultures\\n sent. Will treat with empiric antibiotics. Tylenol PRN for fever.\\n - Known RUE DVT\\n - Infectious etiologies include VAP, asp PNA, line infections. Removed\\n PICC yesterday and cultured tip. Mini-BAL- gram stain neg. Sputum\\n grew GPC in pairs and GPR. Flagyl, aztreonam, vancomycin, levofloxacin\\n for coverage of gram positives, gram negatives, anaerobes, MRSA. Urine\\n and blood cultures NGTD\\n - f/u blood, urine, and sputum cultures.\\n - Concern for abd cause; KUB unrevealing. High residuals. require\\n further imaging\\n # Transient hypotension: Has been somewhat fluid responsive; UOP \\n ccs/hr. Diff dx includes hypovolemia, sepsis, cardiogenic.\\n - Sepsis most likely given fever.\\n - HCT decreasing; ? stable at 24-25\\n - Unable to place central line despite multiple attempts. First tired\\n left IJ RUE DVT. 2^nd attempt in left IJ. Can place femoral if pt\\n requires more active repletion\\n # RUE DVT: Have held on starting treatment in light of need for central\\n access. Can start therapeutic heparin vs Lovenox with bridge to\\n coumadin.\\n # Abd distention:\\n -KUB unrevealing\\n -High residuals\\n - benefit from further imaging; if unstable consider ultrasound,\\n however, if pt can tolerate it, a CT scan might be more helpful. Can\\n also scan chest and pelvis.\\n # Anemia: On admission to Medical Center, Hct was ~40, now down\\n to 30 and then 25 w/o sign of active GI bleed or other source of blood\\n loss. be related to fluid administration, phlebotomy, anemia of\\n inflammation, active bleed still considered in differential.\\n - trend Hct\\n - guaiac stools\\n - S/p failed attempts at line placement; watch for neck hematomas\\n # Spine fracture: neurologically intact distal to the lesion. prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - monitor distal neurologic function\\n - cto brace x3 months unless supine in bed\\n - consult neurosurgery for further recs\\n # Hypernatremia: correcting with g tube free flush and D5W\\n -Holding on g tube feeds at present due to high residuals\\n -Replete lytes as necessary\\n ICU Care\\n Nutrition: tube feed with free water\\n Glycemic Control: Regular insulin sliding scale\\n DVT: SQ UF Heparin\\n Stress ulcer: H2 blocker\\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\\n Communication: Family meeting held , ICU consent signed, \\n (brother) (boyfriend/POA) \\n Code status: Full code\\n Disposition: ICU\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 01:16 AM\\n 20 Gauge - 01:36 AM\\n 22 Gauge - 02:00 PM\\n Arterial Line - 03:00 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-09-21 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 634226,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Removed PICC line because RUE was noted to be warm and erythematous;\\n ultrasound revealed DVT. No definitive treatment was started given\\n difficulty obtaining central venous access.\\n Multiple attempts at central access; tried left and then right.\\n Acute episode of oxygen desat during first central line attempt. Pt\\n recovered, however, increased FiO2.\\n Decreased UOP (10-30mL/hr) and hypotension overnight. However,\\n lactate remains low.\\n Placed art line x 2. NBP and ABP similar\\n mini- BAL, sputum, urine, blood cultures pending. Yesterday, started\\n on levofloxicin and aztreonam instead of cefepime. Switched due to\\n question of PCN allergy\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Levofloxacin - 09:30 AM\\n Metronidazole - 12:00 AM\\n Vancomycin - 01:00 AM\\n Aztreonam - 04:00 AM\\n Infusions:\\n Midazolam (Versed) - 2 mg/hour\\n Fentanyl - 150 mcg/hour\\n Other ICU medications:\\n Ranitidine (Prophylaxis) - 08:00 AM\\n Midazolam (Versed) - 10:00 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:31 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.3\\nC (100.9\\nF at 10am on )\\n Tcurrent: 37.3\\nC (99.2\\n HR: 76 (71 - 116) bpm\\n BP: 116/51(70) {60/46(54) - 146/71(91)} mmHg\\n RR: 18 (12 - 24) insp/min\\n SpO2: 93%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 94.2 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 5,600 mL\\n 1,811 mL\\n PO:\\n TF:\\n 120 mL\\n IVF:\\n 4,700 mL\\n 1,511 mL\\n Blood products:\\n Total out:\\n 798 mL\\n 110 mL\\n Urine:\\n 798 mL\\n 110 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 4,802 mL\\n 1,701 mL\\n Respiratory support\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 500 (500 - 500) mL\\n RR (Set): 18\\n RR (Spontaneous): 0\\n PEEP: 10 cmH2O\\n FiO2: 80%\\n RSBI Deferred: PEEP > 10\\n PIP: 36 cmH2O\\n Plateau: 25 cmH2O\\n SpO2: 93%\\n ABG: 7.45/42/95./28/4\\n Ve: 9.5 L/min\\n PaO2 / FiO2: 120\\n Physical Examination\\n Gen: Appears uncomfortable on vent.\\n HEENT: Anicteric. Pupils 3 mm non-reactive bilaterally.\\n Resp: Symmetric expansion. Vesicular sounds throughout. Inspiratory\\n and expiratory tracheal sounds (?related to ET tube).\\n CV: Cannot see jugular veins due to neck size. RRR. Normal s1 and\\n s2. No M/G/R.\\n Abd: Quiet. Distended. Non-tender.\\n Ext: Edema in RUE, especially right hand. Mildly increased warmth of\\n RUE compared with LUE.\\n Peripheral vascular: Radial pulses 2+ bilaterally.\\n Neuro: Pupils as above. Moving all 4 extremities.\\n Labs / Radiology\\n 319 K/uL\\n 7.6 g/dL\\n 129 mg/dL\\n 0.6 mg/dL\\n 28 mEq/L\\n 4.3 mEq/L\\n 6 mg/dL\\n 109 mEq/L\\n 144 mEq/L\\n 24.1 %\\n 6.4 K/uL\\n [image002.jpg]\\n 11:54 PM\\n 01:00 AM\\n 06:14 AM\\n 08:56 AM\\n 08:57 AM\\n 05:01 PM\\n 08:03 PM\\n 11:00 PM\\n 03:01 AM\\n 03:13 AM\\n WBC\\n 9.7\\n 9.4\\n 7.6\\n 6.4\\n Hct\\n 30.7\\n 25.1\\n 24.1\\n 24.1\\n Plt\\n 333\\n 281\\n 306\\n 319\\n Cr\\n 0.6\\n 0.6\\n 0.7\\n 0.6\\n 0.6\\n TCO2\\n 32\\n 33\\n 35\\n 33\\n 30\\n Glucose\\n 103\\n 126\\n 126\\n 127\\n 129\\n Other labs: PT / PTT / INR:16.9/26.3/1.5, ALT / AST:27/18, Alk Phos / T\\n Bili:113/0.7, Differential-Neuts:76.9 %, Lymph:17.3 %, Mono:3.0 %,\\n Eos:2.5 %, Lactic Acid:0.7 mmol/L, Albumin:2.3 g/dL, LDH:154 IU/L,\\n Ca++:8.2 mg/dL, Mg++:2.6 mg/dL, PO4:3.1 mg/dL\\n RUE ultrasound:\\n - Non-occlusive right axillary deep vein thrombus\\n - Non-occlusive right basilic superficial thrombosis.\\n Assessment and Plan\\n 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture\\n # Respiratory failure: initial etiology unclear, likely multifactorial\\n including bronchspasm, hypoventilation from narcotics, potential\\n aspiration, infection. By report, had a neg evaluation for PE at OSH,\\n however, unable to open disc to confirm. Concern for VAP.\\n - Failed yesterday\\ns NIF; score was -15\\n - Increased FiO2 overnight. Had increased pCO2 which resolved with\\n increasing RR\\n - IP stopped by but will complete official consult today; suggested\\n repeating CT scan\\n - Need to contact Medical re previous CT scan. Can attempt to\\n resend disc. Otherwise, will most likely benefit from repeat CT to\\n look for acute pulm process such as PE or PNA.\\n # Fever: Likely due to combination of infection and DVT. Cultures\\n sent. Will treat with empiric antibiotics. Tylenol PRN for fever.\\n - Known RUE DVT\\n - Infectious etiologies include VAP, asp PNA, line infections. Removed\\n PICC yesterday and cultured tip. Mini-BAL- gram stain neg. Sputum\\n grew GPC in pairs and GPR. Flagyl, aztreonam, vancomycin, levofloxacin\\n for coverage of gram positives, gram negatives, anaerobes, MRSA. Urine\\n and blood cultures NGTD\\n - f/u blood, urine, and sputum cultures.\\n - Concern for abd cause; KUB unrevealing. High residuals. require\\n further imaging\\n # Transient hypotension: Has been somewhat fluid responsive; UOP \\n ccs/hr. Diff dx includes hypovolemia, sepsis, cardiogenic.\\n - Sepsis most likely given fever.\\n - HCT decreasing; ? stable at 24-25\\n - Unable to place central line despite multiple attempts. First tired\\n left IJ RUE DVT. 2^nd attempt in left IJ. Can place femoral if pt\\n requires more active repletion\\n # RUE DVT: Have held on starting treatment in light of need for central\\n access. Can start therapeutic heparin vs Lovenox with bridge to\\n coumadin.\\n # Abd distention:\\n -KUB unrevealing\\n -High residuals\\n - benefit from further imaging; if unstable consider ultrasound,\\n however, if pt can tolerate it, a CT scan might be more helpful. Can\\n also scan chest and pelvis.\\n # Anemia: On admission to Medical Center, Hct was ~40, now down\\n to 30 and then 25 w/o sign of active GI bleed or other source of blood\\n loss. be related to fluid administration, phlebotomy, anemia of\\n inflammation, active bleed still considered in differential.\\n - trend Hct\\n - guaiac stools\\n - S/p failed attempts at line placement; watch for neck hematomas\\n # Spine fracture: neurologically intact distal to the lesion. prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - monitor distal neurologic function\\n - cto brace x3 months unless supine in bed\\n - consult neurosurgery for further recs\\n # Hypernatremia: correcting with g tube free flush and D5W\\n -Holding on g tube feeds at present due to high residuals\\n -Replete lytes as necessary\\n ICU Care\\n Nutrition: tube feed with free water\\n Glycemic Control: Regular insulin sliding scale\\n DVT: SQ UF Heparin\\n Stress ulcer: H2 blocker\\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\\n Communication: Family meeting held , ICU consent signed, \\n (brother) (boyfriend/POA) \\n Code status: Full code\\n Disposition: ICU\\n 55 year old woman with hx of obesity presented to Medical Center\\n on after falling down stairs while at home. She suffered a\\n traumatic T5-8 fracture with retropulsion of fragments. Per medical\\n records and discussion with her brother, she was awake for the fall (no\\n LOC) and the fall was triggered by unsteady gait, potentially\\n influenced by alcohol. Her fracture was managed concervatively. She\\n was placed in a torso brace but her course was complicated by\\n respiratory failure requiring intubation. At that time a CT was\\n negative for PE but showed bilateral bibasilar consolidations vs\\n atelectasis. At that time an ABG was 7.20/89/57 (unknown FIO2 but\\n likely >6L facemask). She was intubated on at 08:40. The\\n respiratory failure was thought likely to be related to pain med\\n induced hypoventilation, bronchospasm, or restricted breathing duet to\\n the back brace. The hospital course was complicated by\\n difficulty weaning form the ventilator. Her periodic agitation was\\n managed with seroquel. Prior to transfer her vent settings were: SIMV\\n 12x600 FIO2 0.45.\\n The neurosurgery service evaluated her and recommended concervative\\n management of her fracture including a back brace and outpatient\\n neurosurgery followup. The CT chest showed notable narrowing of her\\n central airways and the patient was referred for Interventional\\n Pulmonary evaluation for airway stenting.\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 01:16 AM\\n 20 Gauge - 01:36 AM\\n 22 Gauge - 02:00 PM\\n Arterial Line - 03:00 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-09-21 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 634231,\n \"text\": \"55yo admitted from OSH. Pt s/p fall , sustained T5-T8\\n fracture. Pt transf to failure to wean from vent. ? stent for\\n tracheobronchialmalacia.\\n Events: Pt had 2 attempts at Central line placement; unsuccessful at\\n this point; team will attempt for femoral line placement this am.\\n R-wrist Aline placed this am. Pt had KUB abdomen appears more\\n distended and firm, ? possible ABD CT today.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n LS cont rhonchi throughout, dim bilat in base, occ. bronchospasms with\\n care; abg showed resp. acidosis\\n Action:\\n Cont to suct for smll thick tan secretions, copious oral secretions\\n suctioned, vent settings changed to 18/500/80/10\\n Response:\\n ABG improved, PC02 42 ; O2 Sats 95-97%\\n Plan:\\n f/u with IP ? tracheabronchial malacia, abgs, neb tx as needed\\n Hypotension (not Shock)\\n Assessment:\\n Sbp down in high 90\\ns, Aline damped, cont wit low UO 15-30cc/hr\\n Action:\\n pt bolused x 1L LR, 500mg NS for low urinary output, L-aline d/cd\\n Response:\\n R-radial Aline placed, SBP 110-120\\n Plan:\\n Cont . VS, I &O; treat as ordered\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n +DVT\\n Action:\\n Cont SC heparin, no BP\\ns or Lab draws to R arm\\n Response:\\n Cont to elevate RUE\\n Plan:\\n Cont SC heparin,\\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\\n Assessment:\\n TMax 99.2\\n Action:\\n Cont with IV ABX, second UA sent\\n Response:\\n Remains low grade temp\\n Plan:\\n f/u with pending cultures; attempt repeat sputum culture, treat temp as\\n ordered\\n Fracture, other\\n Assessment:\\n T5-T8 fracture to fall on \\n Action:\\n Cont in Reverse Trend., log roll precautions HOB 30\\n Response:\\n No s/sx pain noted\\n Plan:\\n Cont log roll precautions, f/u with PT, ? specialty mattress??\\n Anemia, other\\n Assessment:\\n H/H 24.1/7.6, no active bleeding noted\\n Action:\\n Stool guiac negative\\n Response:\\n No action taken\\n Plan:\\n Cont to Hct, guiac stools\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-09-21 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 634244,\n \"text\": \"Chief Complaint: respiratory failure\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 24 Hour Events:\\n URINE CULTURE - At 08:09 AM\\n EKG - At 09:00 AM\\n PICC LINE - STOP 10:30 AM\\n BLOOD CULTURED - At 10:30 AM\\n ULTRASOUND - At 01:00 PM\\n U/S of RUE\\n URINE CULTURE - At 03:00 PM\\n UA/UC collected after new foley inserted.\\n BAL FLUID CULTURE - At 03:00 PM\\n mini-BAL\\n ARTERIAL LINE - START 04:45 PM\\n ARTERIAL LINE - STOP 02:03 AM\\n ARTERIAL LINE - START 03:00 AM\\n Multiple attempts at central access were unsuccessful due to\\n malposition and difficulty threading wire.\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Levofloxacin - 09:30 AM\\n Vancomycin - 01:00 AM\\n Aztreonam - 04:00 AM\\n Metronidazole - 08:50 AM\\n Infusions:\\n Midazolam (Versed) - 2 mg/hour\\n Fentanyl - 150 mcg/hour\\n Other ICU medications:\\n Ranitidine (Prophylaxis) - 08:00 AM\\n Midazolam (Versed) - 09:32 AM\\n Other medications:\\n colace, CHG, SQI, H2B, SQH, MDIs, Flagyl, vanco, levo, aztreonam,\\n versed, fentanyl\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 09:51 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.3\\nC (100.9\\n Tcurrent: 37.9\\nC (100.3\\n HR: 72 (70 - 116) bpm\\n BP: 100/48(60) {89/47(60) - 139/75(79)} mmHg\\n RR: 18 (12 - 24) insp/min\\n SpO2: 89%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 94.2 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Bladder pressure: 18 (18 - 18) mmHg\\n Total In:\\n 5,600 mL\\n 2,088 mL\\n PO:\\n TF:\\n 120 mL\\n IVF:\\n 4,700 mL\\n 1,728 mL\\n Blood products:\\n Total out:\\n 798 mL\\n 205 mL\\n Urine:\\n 798 mL\\n 205 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 4,802 mL\\n 1,883 mL\\n Respiratory support\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 500 (500 - 500) mL\\n RR (Set): 18\\n RR (Spontaneous): 0\\n PEEP: 10 cmH2O\\n FiO2: 80%\\n RSBI Deferred: PEEP > 10\\n PIP: 37 cmH2O\\n Plateau: 25 cmH2O\\n SpO2: 89%\\n ABG: 7.45/42/95./28/4\\n Ve: 9.1 L/min\\n PaO2 / FiO2: 96\\n Physical Examination\\n Sedated. Breath sounds are coarse. Heart sounds are distant. Abdomen\\n is protuberant with quiet breath sounds. Some peripheral edema. She\\n is not able to cooperate with peripheral strength or sensory exam.\\n Labs / Radiology\\n 7.6 g/dL\\n 319 K/uL\\n 129 mg/dL\\n 0.6 mg/dL\\n 28 mEq/L\\n 4.3 mEq/L\\n 6 mg/dL\\n 109 mEq/L\\n 144 mEq/L\\n 24.1 %\\n 6.4 K/uL\\n [image002.jpg]\\n 11:54 PM\\n 01:00 AM\\n 06:14 AM\\n 08:56 AM\\n 08:57 AM\\n 05:01 PM\\n 08:03 PM\\n 11:00 PM\\n 03:01 AM\\n 03:13 AM\\n WBC\\n 9.7\\n 9.4\\n 7.6\\n 6.4\\n Hct\\n 30.7\\n 25.1\\n 24.1\\n 24.1\\n Plt\\n 333\\n 281\\n 306\\n 319\\n Cr\\n 0.6\\n 0.6\\n 0.7\\n 0.6\\n 0.6\\n TCO2\\n 32\\n 33\\n 35\\n 33\\n 30\\n Glucose\\n 103\\n 126\\n 126\\n 127\\n 129\\n Other labs: PT / PTT / INR:16.9/26.3/1.5, ALT / AST:27/18, Alk Phos / T\\n Bili:113/0.7, Differential-Neuts:76.9 %, Lymph:17.3 %, Mono:3.0 %,\\n Eos:2.5 %, Lactic Acid:0.7 mmol/L, Albumin:2.3 g/dL, LDH:154 IU/L,\\n Ca++:8.2 mg/dL, Mg++:2.6 mg/dL, PO4:3.1 mg/dL\\n Imaging: CXR with bilateral opacities; ETT a little high. No PTX.\\n Assessment and Plan\\n 55-year-old woman with\\n Respiratory failure\\n Traumatic thoracic spinal fractures\\n Probable VAP\\n Upper extremity DVT\\n Oliguria\\n Anemia\\n Possible tracheobronchomalacia (reason for transfer)\\n I am uncertain about both the risks of anticoagulation and the risks of\\n moving to radiology (e.g. CT or IR) in the context of her spinal\\n fractures. Therefore we will consult spine surgery urgently for help\\n with these questions.\\n Her respiratory failure is likely multifactorial, including obesity,\\n probable VAP, probable PE, and possible tracheobronchomalacia. She may\\n also have weakness, but she is sedated and cannot cooperate with exam\\n at present. We will check an echo to examine her RV. We will\\n ventilate per ARDSnet; she may warrant esophageal-balloon-guided\\n therapy if she does not improve in the next few hours.\\n Oliguria is concerning, though BUN/Creatinine are reassuring. NG to\\n suction to relieve abdominal distention. We will check urine lytes and\\n assess stroke volume variation with the Vigileo. We will consider\\n volume challenge based on this result.\\n For central access, if we are able to safely move her we will ask I.R.\\n to help with central access.\\n We will continue broad antibiotics while awaiting cultures.\\n ICU Care\\n Nutrition: NPO for now\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n 18 Gauge - 01:16 AM\\n 20 Gauge - 01:36 AM\\n 22 Gauge - 02:00 PM\\n Arterial Line - 03:00 AM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin\\n Stress ulcer: H2 blocker\\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds Comments:\\n Code status: Full code\\n Disposition :ICU\\n Total time spent: 45 min\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-09-22 00:00:00.000\",\n \"description\": \"Resident / Attending Notes\",\n \"row_id\": 634383,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n -Neurosurg: ok to transport. Will decide on anticoagulation in AM\\n -Central line placed\\n -NGT to suction\\n -Bowel regimen\\n -Respiratory attempted to place esophageal ballon in order to measure\\n intrathoracic pressure, unsuccessful\\n -Desaturation around 23:00 to low 80s on 400/22/15/0.9 following turn.\\n Recruitment maneuver (PEEP to 30) done x2 with good effect, Sat came up\\n to 100%. PEEP left at 17\\n -Transfused 1 un pRBC\\n - Started levophed yesterday for hypotension\\n - No BM\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Levofloxacin - 10:00 AM\\n Aztreonam - 02:00 PM\\n Vancomycin - 12:00 AM\\n Metronidazole - 12:00 AM\\n Infusions:\\n Norepinephrine - 0.02 mcg/Kg/min\\n Fentanyl - 200 mcg/hour\\n Other ICU medications:\\n Ranitidine (Prophylaxis) - 08:00 AM\\n Midazolam (Versed) - 02:20 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:27 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.9\\nC (100.3\\n Tcurrent: 37.6\\nC (99.6\\n HR: 73 (64 - 96) bpm\\n BP: 119/48(69) {85/39(55) - 142/67(91)} mmHg\\n RR: 22 (11 - 22) insp/min\\n SpO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 94.2 kg (admission): 94.2 kg\\n Height: 67 Inch\\n CVP: 20 (11 - 21)mmHg\\n Bladder pressure: 14 (14 - 18) mmHg\\n Total In:\\n 3,482 mL\\n 465 mL\\n PO:\\n TF:\\n IVF:\\n 2,845 mL\\n 465 mL\\n Blood products:\\n 277 mL\\n Total out:\\n 580 mL\\n 65 mL\\n Urine:\\n 580 mL\\n 65 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 2,902 mL\\n 400 mL\\n Respiratory support\\n Ventilator mode: AC\\n Vt (Set): 400 (400 - 500) mL\\n RR (Set): 22\\n RR (Spontaneous): 0\\n PEEP: 17 cmH2O\\n FiO2: 80%\\n PIP: 33 cmH2O\\n Plateau: 30 cmH2O\\n Compliance: 30.8 cmH2O/mL\\n SpO2: 98%\\n ABG: 7.38/41/86./24/0\\n Ve: 9.1 L/min\\n PaO2 / FiO2: 109\\n Physical Examination\\n Gen: Does not arouse to voice\\n HEENT: Pupils 3 mm non-reactive bilaterally. Scleral edema bilat\\n Resp: Symmetric expansion. Vesicular sounds throughout. Inspiratory\\n and expiratory tracheal sounds (?related to ET tube).\\n CV: RRR.\\n Abd: Hypoactive bowel sounds. Distended.\\n Ext: Edema in bilat UE.\\n Peripheral vascular: Radial pulses 2+ bilaterally.\\n Neuro: Moving all 4 extremities.\\n Labs / Radiology\\n 376 K/uL\\n 9.0 g/dL\\n 120 mg/dL\\n 0.6 mg/dL\\n 24 mEq/L\\n 3.7 mEq/L\\n 4 mg/dL\\n 108 mEq/L\\n 141 mEq/L\\n 28.1 %\\n 8.4 K/uL\\n [image002.jpg]\\n ALT 24 PT 18.7\\n AST 16 PTT 25.4\\n AP 117 INR 1.7\\n Tbili 0.7\\n Alb 2.4\\n 08:03 PM\\n 11:00 PM\\n 03:01 AM\\n 03:13 AM\\n 12:05 PM\\n 06:08 PM\\n 06:11 PM\\n 07:53 PM\\n 02:02 AM\\n 03:59 AM\\n WBC\\n 7.6\\n 6.4\\n 8.4\\n Hct\\n 24.1\\n 24.1\\n 29.0\\n 28.1\\n Plt\\n \\n Cr\\n 0.6\\n 0.6\\n 0.6\\n TCO2\\n 33\\n 30\\n 29\\n 29\\n 25\\n 25\\n Glucose\\n 127\\n 129\\n 120\\n Differential-Neuts:80.8 %, Lymph:12.0 %, Mono:3.5 %, Eos:3.3 %\\n Ca++:8.2 mg/dL, Mg++:2.2 mg/dL, PO4:3.1 mg/dL, ion Ca++ () 1.16\\n Cortisol:\\n : 2:15am 24.2 Midnight 2.7\\n : 3am 4.5\\n Micro: neg or NGTD if not mentioned\\n : blood, \\n : urine, sputum-OP flora\\n : BAL, - coag neg staph, lactobacillus, cath tip, sputum- OP\\n flora, rare GNR, blood\\n U/a:\\n Color\\n Amber\\n Appear\\n Clear\\n SpecGr\\n 1.015\\n pH\\n 5.5\\n Urobil\\n 2\\n Bili\\n Mod\\n Leuk\\n Tr\\n Bld\\n Tr\\n Nitr\\n Pos\\n Prot\\n 100\\n Glu\\n Neg\\n Ket\\n 40\\n RBC\\n 0-2\\n WBC\\n 0-2\\n Bact\\n Few\\n Yeast\\n None\\n Epi\\n 0-2\\n Imaging:\\n Echo\\n post recruitment CXR showed deep sulcus but no pnumothorax per rads.\\n CT: Prelim Read\\n Right lower lobe consolidation, and superimposed atelectasis/lower lobe\\n collapse, and effusions. Acute T8 compression deformity, with no\\n posterior\\n retropulsion of fracture fragments. No associated hematoma.\\n Assessment and Plan\\n 55 year old woman with history of EtOH abuse presenting following\\n mechanical fall and traumatic T spine fracture\\n # Respiratory failure: initial etiology unclear, likely multifactorial\\n now with significant pneumonia. Had one sputum that showed GNR.\\n - Had a desat event yesterday. Responded positively to recruitment\\n maneuvers.\\n - Will attempt placement of an esophageal balloon; with knowledge of\\n intrathoracic pressures, can consider going up on PEEP\\n # Infectious process: Had been febrile, now resolved\\n - be aspiration or be VAP. Sputum from grew rare GNR;\\n awaiting speciation.\\n - Continues on Vanc, aztreonam, levofloxicin. Vanc trough pending today\\n - Also on flagyl for empiric coverage of c. diff\\n - Per CT, unlikely to be abdominal process\\n # Hypotension, requiring Levophed:\\n - Hypovolemia is possibly a factor- responded to a transfusion; HCT had\\n been dropping\\n - Sepsis also a factor- on broad spectrum abs\\n - Central line in place.\\n # Oliguria:\\n -BUN and Cr reassuring.\\n # RUE DVT: Have held on starting treatment in light of need for central\\n access. Can start therapeutic heparin vs Lovenox with bridge to\\n coumadin.\\n - No PE noted on CT scan.\\n # Abd distention:\\n - CT abd only showed appendiceal mucocele without inflammation, not\\n concerning, most likely chronic\\n - No BM in several days, continue bowel regimen, add fleets enema\\n - Can test for c.diff when pt stool\\ns. Continue flagyl empirically\\n - Check amylase and lipase\\n # Anemia:\\n - Trend HCT\\n - Gave 1 un pRBC with good results\\n - Will guiac stools when she has a BM\\n - INR rising, now 1.7, may be nutritional\\n # Spine fracture: neurologically intact distal to the lesion. prior\\n notes from MMC neurosurgeons indicated no surgical procedure needed and\\n would continue with spine brace.\\n - Will have spine see pt today for recs regarding pt movement and\\n anticoagulation\\n # Hypernatremia, resolved: correcting with g tube free flush and D5W\\n -Holding on g tube feeds at present due to high residuals\\n -Replete lytes as necessary\\n # Communication:\\n - Brother has been with pt, although, live in boyfriend of 10 is\\n her HCP. Boyfriend will hopefully visit pt today\\n ICU Care\\n Nutrition: tube feed with free water when able\\n Glycemic Control: Regular insulin sliding scale\\n DVT: SQ UF Heparin\\n Stress ulcer: H2 blocker\\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\\n Communication: ICU consent signed, (brother) \\n (boyfriend/POA) \\n Code status: Full code\\n Disposition: ICU\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 01:36 AM\\n 22 Gauge - 02:00 PM\\n Arterial Line - 03:00 AM\\n Multi Lumen - 11:30 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n ------ Protected Section ------\\n Critical Care Staff Addendum\\n 6:15pm\\n I saw and examined Ms. with the ICU team this morning and have\\n seen Ms. several times throughout the day; Dr. \\ns note\\n reflects my input. I would add/emphasize that she continues to have\\n severe hypoxemic respiratory failure. She has come off of her\\n vasopressor.\\n CT imaging did not show PE or an intrabdominal catastrophe. Spine\\n imaging confirms a compression fracture but did not detect\\n retropulsion. Her lungs shows basilar and posterior atelectasis that\\n is consistent with one of the CT patterns of ARDS [see Intensive Care\\n Med. ;26(7):857-69], probably exacerbated by\\n obesity/extra-pulmonary chest wall issues. In addition, there are\\n patchy, more-apical consolidations suggestive of pneumonia. There is\\n also a peri-appendiceal finding that will eventually need follow-up to\\n exclude malignancy.\\n CVP and stroke-volume variation suggest she is adequately\\n volume-replete.\\n Esophageal manometry confirmed the clinical impression that she has\\n substantial extrapulmonary contribution to her plateau pressures: at\\n PEEP 20, her end-expiratory transpulmonary pressure is -3 cm H2O. Her\\n end-inspiratory transpulmonary pressures are minimal on current Vt of\\n 400.\\n Sputum is growing GNR; speciation is pending.\\n Assessment and Plan\\n 55-year-old woman with\\n Respiratory failure\\n Traumatic thoracic spinal fracture\\n Probable VAP\\n Shock -- improved\\n Upper extremity DVT\\n Anemia\\n Possible tracheobronchomalacia (reason for transfer)\\n Incidental peri-appendiceal finding (will need eventual\\n follow-up)\\n Although differential remains open, the most compelling course of\\n events is probably that she required intubation at the outside hospital\\n (?sedation ?restriction from obesity/brace ?other) and subsequently\\n developed a GNR-related VAP. Her pattern of acute lung injury,\\n combined with obesity, is resulting in basilar and\\n posterior-predominant atelectasis/consolidation with a high proportion\\n of shunt.\\n We will\\n Continue broad antibiotics pending speciation of organisms\\n Ventilate with approximately 6 cc/kg predicted body weight\\n Use esophageal-manometry guideded PEEP, with goal of weaning\\n FiO2 to below 60% in next 12-24 hours. If unable to do so, will\\n increase PEEP to end-expiratory transpulmonary pressure of 0-+3 as long\\n as hemodynamics and intra-abdominal pressures allow\\n If OK with spine surgery, begin anticoagulation for her\\n PICC-related DVT\\n Prophylaxis: full-dose heparin, H2-blocker, HOB elevation,\\n oral care, CHG, etc.\\n Other issues as per ICU team note.\\n I discussed Ms. \\ns status with her brother at bedside, including\\n review of images and discussion of her critical status. All questions\\n answered.\\n CC Time: 75 minutes\\n ------ Protected Section Addendum Entered By: , MD\\n on: 18:35 ------\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-09-24 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 634617,\n \"text\": \"Synopsis per prior nursing note:\\n 55 yr old woman admitted from OSH after she fell down the stairs and\\n had traumatic T-spine fracture. Pt came to us with PNA from unknown\\n etiology? VAP. Full code, Allergies: PCN, tetracycline, Sulfa. PMH:\\n ETOH, smoker, Gerd, Hip replacement.\\n Alteration in Nutrition\\n Assessment:\\n Tube feeds increased to 40ml/hr. Residuals ~10ml. Hypoactive BS.\\n Continues to have brown, liquid stool.\\n Action:\\n Residuals and BS checked. Rate increased to 40ml/hr.\\n Response:\\n Residual continued at 10ml/hr, continued rate of 40cc/hr.\\n Plan:\\n Advance TF to goal as tolerated. Monitor BS.\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n RUE DVT, pt on heparin gtt at 1700units/hr.\\n Action:\\n Ptt was therapeutic x3. Heparin gtt continued.\\n Response:\\n No change to drip made, therapeutic dose.\\n Plan:\\n Cont heparin gtt, check PTT w/ am labs and adjust heparin gtt per\\n scale.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Suctioned moderate, thick white ET tube secretions and copious clear,\\n oral secretions. LS rhonchi w/ dim bases. Esophageal balloon in\\n place.\\n Action:\\n Continued to suction frequently, HOB >30, oral care. Continued\\n steroids.\\n Response:\\n ABG WNL. Continued to need suctioning. O2 sats >98%.\\n Plan:\\n Monitor LS. Suction as needed. Wean vent as tolerated.\\n Hypotension (not Shock)\\n Assessment:\\n BP 89-106/43-53. MAP 56-67. Goal MAP >60. Urine output>40cc/hr.\\n Action:\\n Levophed gtt weaned off. Given 2.5 L NS total in bolus\\n for low BP. New\\n A-line placed-positional.\\n Response:\\n MAPs continued to be ~60-65.\\n Plan:\\n Monitor BP. ?fluid bolus vs levophed gtt. ?need for new a-line.\\n Bradycardia\\n Assessment:\\n SB, HR 45-63. HR increased w/ activity.\\n Action:\\n HR monitored.\\n Response:\\n No intervention done because BP cont to be stable and all other vital\\n signs stable.\\n Plan:\\n Monitor HR. EKG if indicated.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-09-21 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 634229,\n \"text\": \"55yo admitted from OSH. Pt s/p fall , sustained T5-T8\\n fracture. Pt transf to failure to wean from vent. ? stent for\\n tracheobronchialmalacia.\\n Events: Pt had 2 attempts at Central line placement; unsuccessful at\\n this point; team will attempt for femoral line placement this am.\\n R-wrist Aline placed this am. Pt had KUB abdomen appears more\\n distended and firm, ? possible ABD CT today.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n LS cont rhonchi throughout, dim bilat in base, occ. bronchospasms with\\n care; abg showed resp. acidosis\\n Action:\\n Cont to suct for smll thick tan secretions, copious oral secretions\\n suctioned, vent settings changed to 18/500/80/10\\n Response:\\n ABG improved, PC02 42 ; O2 Sats 95-97%\\n Plan:\\n f/u with IP ? tracheabronchial malacia, abgs, neb tx as needed\\n Hypotension (not Shock)\\n Assessment:\\n Sbp down in high 90\\ns, Aline damped, cont wit low UO 15-30cc/hr\\n Action:\\n pt bolused x 1L LR, 500mg NS for low urinary output, L-aline d/cd\\n Response:\\n R-radial Aline placed, SBP 110-120\\n Plan:\\n Cont . VS, I &O; treat as ordered\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n +DVT\\n Action:\\n Cont SC heparin, no BP\\ns or Lab draws to R arm\\n Response:\\n Cont to elevate RUE\\n Plan:\\n Cont SC heparin,\\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\\n Assessment:\\n TMax 99.2\\n Action:\\n Cont with IV ABX, second UA sent\\n Response:\\n Remains low grade temp\\n Plan:\\n f/u with pending cultures; attempt repeat sputum culture, treat temp as\\n ordered\\n Fracture, other\\n Assessment:\\n T5-T8 fracture to fall on \\n Action:\\n Cont in Reverse Trend., log roll precautions HOB 30\\n Response:\\n No s/sx pain noted\\n Plan:\\n Cont log roll precautions, f/u with PT, ? specialty mattress??\\n Anemia, other\\n Assessment:\\n H/H 24.1/7.6, no active bleeding noted\\n Action:\\n Stool guiac negative\\n Response:\\n No action taken\\n Plan:\\n Cont to Hct, guiac stools\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-09-22 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 634295,\n \"text\": \"55 yr old women admitted from outside hospital. Patient fell down\\n stairs at home per boyfriend pt with fracture and placed in torso\\n brace at OSH, pt became hypoxic and was intubated (family requested a\\n second opinion and pt was trans to ) Pt admitted for Resp failure,\\n failure to wean, and ? trachial bronchial malacia. Full code,\\n Allergies: PCN, Tetracycline, Sulfta.\\n Per boyfriend tonight he reported that for the last two months pt has\\n been drinking 2 bottles of wine almost every night.\\n And that this is an increase from what she previously did which was a\\n couple of beers per night.\\n Alteration in Nutrition\\n Assessment:\\n Increase in residuals out of OG tube. Tube feeds have not been\\n restarted. Bowel sounds hypoactive, per family abdomen is about 30%\\n larger than normal, no BM since admission.\\n Action:\\n Senna and colace given. OG tube to low int. suction, was able to clamp\\n tube for 2hr but residuals returned.\\n Response:\\n 100 ml yellow-pinkish fluid out OG tube\\n Plan:\\n Cont to check residuals, restart tube feeds as tolerated, ? if raglan\\n would help. Increase bowel regimen if needed.\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n DVT in RUE\\n Action:\\n No BP or blood draws in RUE. Neuro to see pt in AM to see if we\\n can start heparin gtt (neuro to okay because of the spine\\n fracture)\\n Response:\\n Plan:\\n Wait for decision by Neuro and anticoagulate with heparin if\\n possible.\\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Fracture, other\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Anemia, other\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Hypotension (not Shock)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-09-22 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 634297,\n \"text\": \"55 yr old women admitted from outside hospital. Patient fell down\\n stairs at home per boyfriend pt with fracture and placed in torso\\n brace at OSH, pt became hypoxic and was intubated (family requested a\\n second opinion and pt was trans to ) Pt admitted for Resp failure,\\n failure to wean, and ? trachial bronchial malacia. Full code,\\n Allergies: PCN, Tetracycline, Sulfta. Pt on log roll precautions for\\n spine.\\n Per boyfriend tonight he reported that for the last two months pt has\\n been drinking 2 bottles of wine almost every night.\\n And that this is an increase from what she previously did which was a\\n couple of beers per night.\\n Alteration in Nutrition\\n Assessment:\\n Increase in residuals out of OG tube. Tube feeds have not been\\n restarted. Bowel sounds hypoactive, per family abdomen is about 30%\\n larger than normal, no BM since admission.\\n Action:\\n Senna and colace given. OG tube to low int. suction, was able to clamp\\n tube for 2hr but residuals returned.\\n Response:\\n 100 ml yellow-pinkish fluid out OG tube\\n Plan:\\n Cont to check residuals, restart tube feeds as tolerated, ? if raglan\\n would help. Increase bowel regimen if needed.\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n DVT in RUE\\n Action:\\n No BP or blood draws in RUE. Neuro to see pt in AM to see if we\\n can start heparin gtt (neuro to okay because of the spine\\n fracture)\\n Response:\\n Plan:\\n Wait for decision by Neuro and anticoagulate with heparin if\\n possible.\\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\\n Assessment:\\n T-max for this shift 99.6\\n Action:\\n Pt on Vanco, Aztreonam, Levoflaxacin, Flagyl.\\n Response:\\n Pt not spiking over 100\\n Plan:\\n Cont to monitor Temp, cont antibiotics, follow up cultures, re-culture\\n if pt does spike temp again.\\n Fracture, other\\n Assessment:\\n Reported that pt has a T5-T8 spinal fracture, Wet read from yesterdays\\n CT may show just a T-9 compression, still waiting for the true results\\n of this CT.\\n Action:\\n Log roll pt, pt increased with reverse trandelenburg positionsing,\\n back brace in room if pt OOB.\\n Response:\\n Pt not tolerating turning\\n Plan:\\n Consult with neuro /wait for true CT scan results to know if spine\\n is actually fractured or not and if not ? removing spine precautions.\\n Anemia, other\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Lung sounds clear/diminished, ? VAP and possibly ARDS on top of that.\\n small amounts thick yellow secretions, vent setting changed during the\\n night. Pt desats to 80% with turning and takes a long time to\\n recover. Face becomes blue/purple.\\n Action:\\n Did not turn pt during the night, Vent setting changed during night\\n currently CMV 80%/400/22/17. cont suctioning/oral care/ subglottal\\n suctioning. Resp tried to place esophageal balloon again tonight\\n Response:\\n Small secretions out of in-line suction. Last ABG better at 7.38/41/87,\\n esophageal balloon placement unsuccessful\\n Plan:\\n ? if team will have respiratory try to place esophageal balloon again,\\n wean vent as tolerated. Cont ABG\\ns with vent changes.\\n Hypotension (not Shock)\\n Assessment:\\n Pt received on 0.04 mcg/kg/min of norepi gtt.\\n Action:\\n Weaned gtt off in early evening but MAPs dropped <65\\n Response:\\n Turned norepi gtt back on at 0.02 mg/kg/min\\n Plan:\\n Cont to wean norepi gtt as tolerated.\\n Goals: switch pt to air mattress bed if okayed by neuro that pt\\n can be moved, start heparin gtt for RUE DVT if neuro okays. Wean\\n norepi gtt. Restart Tube feeds when tolerates, ? if team will try to\\n float esophageal balloon again.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-30 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 640202,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n - ENT team believes that vocal cord adductor dysfunction is NOT a risk\\n for aspiration, rather her increased secretions put her at risk for\\n aspiration. They will follow-up in clinic in two weeks with Dr.\\n , call in am to schedule appt.\\n - Psych recs: consider head CT if patient does not improve off\\n scopolamine and metoclopramide; address anemia and\\nerratic BP\\n consider increasing am dose of risperdal; monitor \\n - Pt continued to be agitated O/N (eg: pulled rectal tubex2 and\\n foleyx1, disoriented). To receive head CT this AM\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:00 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:28 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.6\\nC (97.9\\n Tcurrent: 36.6\\nC (97.9\\n HR: 77 (66 - 114) bpm\\n BP: 128/40(60) {90/37(31) - 164/75(87)} mmHg\\n RR: 23 (16 - 29) insp/min\\n SpO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 1,726 mL\\n 595 mL\\n PO:\\n TF:\\n 1,388 mL\\n 301 mL\\n IVF:\\n 249 mL\\n 105 mL\\n Blood products:\\n Total out:\\n 1,666 mL\\n 222 mL\\n Urine:\\n 836 mL\\n 222 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 60 mL\\n 373 mL\\n Respiratory support\\n O2 Delivery Device: Aerosol-cool\\n SpO2: 100%\\n ABG: ///34/\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 183 K/uL\\n 7.1 g/dL\\n 115 mg/dL\\n 0.5 mg/dL\\n 34 mEq/L\\n 3.6 mEq/L\\n 13 mg/dL\\n 106 mEq/L\\n 145 mEq/L\\n 22.8 %\\n 5.4 K/uL\\n [image002.jpg]\\n 04:00 AM\\n 05:45 AM\\n 03:51 AM\\n 04:45 PM\\n 04:00 AM\\n 07:37 PM\\n 04:05 AM\\n 06:05 PM\\n 03:23 AM\\n 02:54 AM\\n WBC\\n 8.0\\n 8.7\\n 5.5\\n 5.7\\n 5.8\\n 5.1\\n 5.4\\n Hct\\n 27.0\\n 28.7\\n 24.7\\n 25.2\\n 25.3\\n 23.7\\n 24.7\\n 23.7\\n 22.8\\n Plt\\n \\n 183\\n Cr\\n 0.7\\n 0.7\\n 0.5\\n 0.4\\n 0.5\\n 0.5\\n 0.5\\n 0.5\\n Glucose\\n 114\\n 112\\n 122\\n 145\\n 137\\n 149\\n 105\\n 115\\n Other labs: PT / PTT / INR:13.3/32.4/1.1, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.4 mg/dL, Mg++:1.9 mg/dL, PO4:3.6\\n mg/dL\\n Assessment and Plan\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n PICC Line - 01:30 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-30 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 640203,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Tube Feed goals increased from 30cc to 60cc/hr. No issues O/N with\\n regard to vomiting.\\n Calm overnight. Risperdal decreased from 0.5mg to 0.25mg qam.\\n runs of asymptomatic SVT peaking in 110-120\\ns, metoprolol 37.5mg\\n changed from TID\\nQID and first daily dose given early after runs;\\n decrease of HR to 80\\n Loose, brown, malodorous stools O/N, afebrile, C.dif cx sent.\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Enoxaparin (Lovenox) - 06:33 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:22 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37\\nC (98.6\\n Tcurrent: 36.5\\nC (97.7\\n HR: 114 (61 - 122) bpm\\n BP: 119/54(75) {91/36(50) - 167/84(101)} mmHg\\n RR: 19 (10 - 30) insp/min\\n SpO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 2,952 mL\\n 429 mL\\n PO:\\n TF:\\n 646 mL\\n 376 mL\\n IVF:\\n 950 mL\\n 54 mL\\n Blood products:\\n Total out:\\n 2,430 mL\\n 470 mL\\n Urine:\\n 2,430 mL\\n 240 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 522 mL\\n -41 mL\\n Respiratory support\\n O2 Delivery Device: Aerosol-cool\\n SpO2: 100%\\n ABG: ///35/\\n Physical Examination\\n Gen: Alert, NAD, lying in bed, comfortable, mouthing words, less\\n sedated than yest.\\n HEENT: No pallor in conjunctiva, MMM, TM in place\\n Resp: Transmitted upper airway sounds/coarse breath sounds.\\n Card: S1S2 tachycardic, no m/r/g\\n Abd: Obese, soft, mildly distended, decreased bowel sounds, G-Tube in\\n place with no erythema/induration\\n Exte: No edema, DP 2+ bil\\n NEURO: Alert, difficult to assess orientation due to poor voice\\n although pt oriented to year not place. MAE\\n Labs / Radiology\\n 187 K/uL\\n 7.2 g/dL\\n 105 mg/dL\\n 0.5 mg/dL\\n 35 mEq/L\\n 3.8 mEq/L\\n 17 mg/dL\\n 108 mEq/L\\n 147 mEq/L\\n 23.7 %\\n 5.1 K/uL\\n [image002.jpg]\\n 03:00 AM\\n 04:00 AM\\n 05:45 AM\\n 03:51 AM\\n 04:45 PM\\n 04:00 AM\\n 07:37 PM\\n 04:05 AM\\n 06:05 PM\\n 03:23 AM\\n WBC\\n 7.3\\n 8.0\\n 8.7\\n 5.5\\n 5.7\\n 5.8\\n 5.1\\n Hct\\n 27.3\\n 27.0\\n 28.7\\n 24.7\\n 25.2\\n 25.3\\n 23.7\\n 24.7\\n 23.7\\n Plt\\n 346\\n 316\\n 271\\n 249\\n 231\\n 203\\n 187\\n Cr\\n 0.7\\n 0.7\\n 0.7\\n 0.5\\n 0.4\\n 0.5\\n 0.5\\n 0.5\\n Glucose\\n 123\\n 114\\n 112\\n 122\\n 145\\n 137\\n 149\\n 105\\n Other labs: PT / PTT / INR:13.3/32.4/1.1, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.8 mg/dL, Mg++:2.1 mg/dL, PO4:3.5\\n mg/dL\\n Assessment and Plan\\n 56yoF s/p mechanical fall and traumatic T spine fracture transferred\\n from OSH to for TBM eval with hospitalization complicated by\\n respiratory failure and HAP, s/p trach/PEG, atrial tachycardia, ileus,\\n and delirium/agitation.\\n .\\n # Respiratory: s/p intubation/extubation, now on trach mask, FiO2 50%.\\n Tolerating well with good O2 sat in mid-high 90\\ns. Pt continues to be\\n at risk for aspiration given recent history of vomiting with tube feed\\n trials and increased secretions. ENT believes that the posterior gap is\\n not a risk factor for aspiration as this is a common finding in females\\n and that her increased secretions and edema pose a greater aspiration\\n threat; no intervention was recommended.\\n - Appreciate ENT and S&S input.\\n - ENT recs to f/u in 2wks with Dr. () for an\\n outpatient/clinic re-evaluation.\\n - ppi for aspiration prophylaxis, PMV precautions: \\nt use w/o\\n supervision, frequent suctioning\\n - TM as tolerated.\\n - d/c scopolamine as it was a cause for delirium.\\n - Holding sedation with exception of Risperidal 0.25mg qam PRN\\n # Delirium: Pt continues to be slightly agitated with paranoia and\\n disorientation. Delirium and agitation most likely secondary to long\\n hospital course and multiple psychotropic medications as well as hx of\\n EtOH abuse.\\n - Risperdal 0.25mg PO qam.\\n - continue to hold all benzos. opiates, and antihistamines. Will\\n decrease or d/c raglan and scopolamine.\\n - Appreciate psych. Will call and f/u psych recs.\\n -Follow EKG to assess for prolongation (last EKG ; 457).\\n #Loose Stools: Multiple, loose stools O/N; afebrile, tachycardia,\\n without abdominal pain\\n -F/u stool c.dif cultures\\n -f/u WBC and vital signs daily\\n -Hold bowel regimen\\n # Atrial Tachycardia: Compared to recent b/l, HR increased to max of\\n 120\\ns. Pt now on PO Amiodarone 200 TID and PO increased metoprolol\\n 37.5mg QID.\\n - Will continue amiodarone 200 TID for three weeks and then switch to\\n qday for 1week and then d/c amiodarone.\\n - Will need to schedule f/u in 4wks with Dr. upon d/c/transfer.\\n #Anemia: HCT low compared to b/l. No known etiology of blood loss.\\n -Will continue to follow HCT daily.\\n - Guaiac stools.\\n # Hypernatremia/Fluid Status: Mild hypernatramia resolving with free\\n water administration. On TPN/TF. Good UOP. Free water deficit of 2.8L\\n - increase D5W IVFx 1L from 10cc/hr to 150cc/hr, free water flushes\\n with TF\\n -Will f/u lytes in afternoon (5pm)\\n # UE DVT and h/o labile INR: Decision made to d/c Coumadin given her\\n labile INR, and start Lovenox . INR at 1.1\\n - Will flush L PICC with TPA if does not flush\\n - Daily coags\\n .\\n # Spine fracture: Stable. T5-T8.\\n - Brace for OOB.\\n - Pt to follow up with Dr. in .\\n .\\n # Tracheomalacia. Reevaluation bronchoscopy by IP as written above;\\n patient not a candidate for stent; pt to follow up as outpatient. No\\n new issues.\\n .\\n #. Thyroid Nodule on CT\\n - Outpatient follow up\\n .\\n # Glycemic control: SSI, well controlled\\n # FEN: Currently receiving TF at 50cc/hr, w/o issue.\\n - Appreciate GI input and S&S eval\\n -D/c Reglan for emesis precaution as pt is tolerating TF without\\n vomiting and Reglan increases agitation/delirium risk.\\n -meds via G-J tube,\\n .\\n # ACCESS: PIV x 1, L PICC\\n # Ppx: Lovenox, PPi , Bowel Regimen PRN\\n # Communication:\\n - (brother) is primary contact\\n - Boyfriend of 10 , but minimal contact has been maintained at\\n this point\\n - Social Work and Case management involved; have discussed situation\\n w/ brother and boyfriend.\\n # Code: Full\\n # Dispo: ICU, Will d/w case management re rehab facilities, likely d/c\\n today/tomorrow if insurance/bed confirmed\\n MSIV\\n PGY1 addendum: \\n Agree with assessment and plan in excellent MSIV note as detailed\\n above. Briefly, 56 F s/p fall with T spine fracture (T5-T8),\\n respiratory failure now s/p trach/PEG. Now on trach mask. Nutrition\\n issues continue; will follow up with psychiatry recs. Etiology of\\n delirium/agitation still unclear but likely prolonged hospital\\n course, illness and multiple medications. Currently discussing with CM\\n about potential placement to rehab.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-30 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 640204,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n - ENT team believes that vocal cord adductor dysfunction is NOT a risk\\n for aspiration, rather her increased secretions put her at risk for\\n aspiration. They will follow-up in clinic in two weeks with Dr.\\n , call in am to schedule appt.\\n - Psych recs: consider head CT if patient does not improve off\\n scopolamine and metoclopramide; address anemia and\\nerratic BP\\n consider increasing am dose of risperdal; monitor \\n - Pt continued to be agitated O/N (eg: pulled rectal tubex2 and\\n foleyx1, disoriented). To receive head CT this AM\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:00 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:28 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.6\\nC (97.9\\n Tcurrent: 36.6\\nC (97.9\\n HR: 77 (66 - 114) bpm\\n BP: 128/40(60) {90/37(31) - 164/75(87)} mmHg\\n RR: 23 (16 - 29) insp/min\\n SpO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 1,726 mL\\n 595 mL\\n PO:\\n TF:\\n 1,388 mL\\n 301 mL\\n IVF:\\n 249 mL\\n 105 mL\\n Blood products:\\n Total out:\\n 1,666 mL\\n 222 mL\\n Urine:\\n 836 mL\\n 222 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 60 mL\\n 373 mL\\n Respiratory support\\n O2 Delivery Device: Aerosol-cool\\n SpO2: 100%\\n ABG: ///34/\\n Physical Examination\\n Gen: Alert, NAD, lying in bed, comfortable, mouthing words, less\\n sedated than yest.\\n HEENT: No pallor in conjunctiva, MMM, TM in place\\n Resp: Transmitted upper airway sounds/coarse breath sounds.\\n Card: S1S2 tachycardic, no m/r/g\\n Abd: Obese, soft, mildly distended, decreased bowel sounds, G-Tube in\\n place with no erythema/induration\\n Exte: No edema, DP 2+ bil\\n NEURO: Alert, difficult to assess orientation due to poor voice\\n although pt oriented to year not place. MAE\\n Labs / Radiology\\n 183 K/uL\\n 7.1 g/dL\\n 115 mg/dL\\n 0.5 mg/dL\\n 34 mEq/L\\n 3.6 mEq/L\\n 13 mg/dL\\n 106 mEq/L\\n 145 mEq/L\\n 22.8 %\\n 5.4 K/uL\\n [image002.jpg]\\n 04:00 AM\\n 05:45 AM\\n 03:51 AM\\n 04:45 PM\\n 04:00 AM\\n 07:37 PM\\n 04:05 AM\\n 06:05 PM\\n 03:23 AM\\n 02:54 AM\\n WBC\\n 8.0\\n 8.7\\n 5.5\\n 5.7\\n 5.8\\n 5.1\\n 5.4\\n Hct\\n 27.0\\n 28.7\\n 24.7\\n 25.2\\n 25.3\\n 23.7\\n 24.7\\n 23.7\\n 22.8\\n Plt\\n \\n 183\\n Cr\\n 0.7\\n 0.7\\n 0.5\\n 0.4\\n 0.5\\n 0.5\\n 0.5\\n 0.5\\n Glucose\\n 114\\n 112\\n 122\\n 145\\n 137\\n 149\\n 105\\n 115\\n Other labs: PT / PTT / INR:13.3/32.4/1.1, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.4 mg/dL, Mg++:1.9 mg/dL, PO4:3.6\\n mg/dL\\n Assessment and Plan\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n PICC Line - 01:30 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-30 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 640206,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n - ENT team believes that vocal cord adductor dysfunction is NOT a risk\\n for aspiration, rather her increased secretions put her at risk for\\n aspiration. They will follow-up in clinic in two weeks with Dr.\\n , call in am to schedule appt.\\n - Psych recs: consider head CT if patient does not improve off\\n scopolamine and metoclopramide; address anemia and\\nerratic BP\\n consider increasing am dose of risperdal; monitor \\n - Pt continued to be agitated O/N (eg: pulled rectal tubex2 and\\n foleyx1, disoriented). To receive head CT this AM\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:00 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:28 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.6\\nC (97.9\\n Tcurrent: 36.6\\nC (97.9\\n HR: 77 (66 - 114) bpm\\n BP: 128/40(60) {90/37(31) - 164/75(87)} mmHg\\n RR: 23 (16 - 29) insp/min\\n SpO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 1,726 mL\\n 595 mL\\n PO:\\n TF:\\n 1,388 mL\\n 301 mL\\n IVF:\\n 249 mL\\n 105 mL\\n Blood products:\\n Total out:\\n 1,666 mL\\n 222 mL\\n Urine:\\n 836 mL\\n 222 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 60 mL\\n 373 mL\\n Respiratory support\\n O2 Delivery Device: Aerosol-cool\\n SpO2: 100%\\n ABG: ///34/\\n Physical Examination\\n Gen: Alert, NAD, lying in bed, comfortable, mouthing words, less\\n sedated than yest.\\n HEENT: No pallor in conjunctiva, MMM, TM in place\\n Resp: Transmitted upper airway sounds/coarse breath sounds.\\n Card: S1S2 tachycardic, no m/r/g\\n Abd: Obese, soft, mildly distended, decreased bowel sounds, G-Tube in\\n place with no erythema/induration\\n Exte: No edema, DP 2+ bil\\n NEURO: Alert, difficult to assess orientation due to poor voice\\n although pt oriented to year not place. MAE\\n Labs / Radiology\\n 183 K/uL\\n 7.1 g/dL\\n 115 mg/dL\\n 0.5 mg/dL\\n 34 mEq/L\\n 3.6 mEq/L\\n 13 mg/dL\\n 106 mEq/L\\n 145 mEq/L\\n 22.8 %\\n 5.4 K/uL\\n [image002.jpg]\\n 04:00 AM\\n 05:45 AM\\n 03:51 AM\\n 04:45 PM\\n 04:00 AM\\n 07:37 PM\\n 04:05 AM\\n 06:05 PM\\n 03:23 AM\\n 02:54 AM\\n WBC\\n 8.0\\n 8.7\\n 5.5\\n 5.7\\n 5.8\\n 5.1\\n 5.4\\n Hct\\n 27.0\\n 28.7\\n 24.7\\n 25.2\\n 25.3\\n 23.7\\n 24.7\\n 23.7\\n 22.8\\n Plt\\n \\n 183\\n Cr\\n 0.7\\n 0.7\\n 0.5\\n 0.4\\n 0.5\\n 0.5\\n 0.5\\n 0.5\\n Glucose\\n 114\\n 112\\n 122\\n 145\\n 137\\n 149\\n 105\\n 115\\n Other labs: PT / PTT / INR:13.3/32.4/1.1, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.4 mg/dL, Mg++:1.9 mg/dL, PO4:3.6\\n mg/dL\\n Assessment and Plan\\n 56yoF s/p mechanical fall and traumatic T spine fracture transferred\\n from OSH to for TBM eval with hospitalization complicated by\\n respiratory failure and HAP, s/p trach/PEG, atrial tachycardia, ileus,\\n and delirium/agitation.\\n .\\n # Respiratory: s/p intubation/extubation, now on trach mask, FiO2 50%.\\n Tolerating well with good O2 sat in mid-high 90\\ns. Pt continues to be\\n at risk for aspiration given recent history of vomiting with tube feed\\n trials and increased secretions. ENT believes that the posterior gap is\\n not a risk factor for aspiration as this is a common finding in females\\n and that her increased secretions and edema pose a greater aspiration\\n threat; no intervention was recommended.\\n - Appreciate ENT and S&S input.\\n - ENT recs to f/u in 2wks with Dr. () for an\\n outpatient/clinic re-evaluation.\\n - ppi for aspiration prophylaxis, PMV precautions: \\nt use w/o\\n supervision, frequent suctioning\\n - TM as tolerated.\\n - d/c scopolamine as it was a cause for delirium.\\n - Holding sedation with exception of Risperidal 0.25mg qam PRN\\n # Delirium: Pt continues to be slightly agitated with paranoia and\\n disorientation. Delirium and agitation most likely secondary to long\\n hospital course and multiple psychotropic medications as well as hx of\\n EtOH abuse.\\n - Risperdal 0.25mg PO qam.\\n - continue to hold all benzos. opiates, and antihistamines. Will\\n decrease or d/c raglan and scopolamine.\\n - Appreciate psych. Will call and f/u psych recs.\\n -Follow EKG to assess for prolongation (last EKG ; 457).\\n #Loose Stools: Multiple, loose stools O/N; afebrile, tachycardia,\\n without abdominal pain\\n -F/u stool c.dif cultures\\n -f/u WBC and vital signs daily\\n -Hold bowel regimen\\n # Atrial Tachycardia: Compared to recent b/l, HR increased to max of\\n 120\\ns. Pt now on PO Amiodarone 200 TID and PO increased metoprolol\\n 37.5mg QID.\\n - Will continue amiodarone 200 TID for three weeks and then switch to\\n qday for 1week and then d/c amiodarone.\\n - Will need to schedule f/u in 4wks with Dr. upon d/c/transfer.\\n #Anemia: HCT low compared to b/l. No known etiology of blood loss.\\n -Will continue to follow HCT daily.\\n - Guaiac stools.\\n # Hypernatremia/Fluid Status: Mild hypernatramia resolving with free\\n water administration. On TPN/TF. Good UOP. Free water deficit of 2.8L\\n - increase D5W IVFx 1L from 10cc/hr to 150cc/hr, free water flushes\\n with TF\\n -Will f/u lytes in afternoon (5pm)\\n # UE DVT and h/o labile INR: Decision made to d/c Coumadin given her\\n labile INR, and start Lovenox . INR at 1.1\\n - Will flush L PICC with TPA if does not flush\\n - Daily coags\\n .\\n # Spine fracture: Stable. T5-T8.\\n - Brace for OOB.\\n - Pt to follow up with Dr. in .\\n .\\n # Tracheomalacia. Reevaluation bronchoscopy by IP as written above;\\n patient not a candidate for stent; pt to follow up as outpatient. No\\n new issues.\\n .\\n #. Thyroid Nodule on CT\\n - Outpatient follow up\\n .\\n # Glycemic control: SSI, well controlled\\n # FEN: Currently receiving TF at 50cc/hr, w/o issue.\\n - Appreciate GI input and S&S eval\\n -D/c Reglan for emesis precaution as pt is tolerating TF without\\n vomiting and Reglan increases agitation/delirium risk.\\n -meds via G-J tube,\\n .\\n # ACCESS: PIV x 1, L PICC\\n # Ppx: Lovenox, PPi , Bowel Regimen PRN\\n # Communication:\\n - (brother) is primary contact\\n - Boyfriend of 10 , but minimal contact has been maintained at\\n this point\\n - Social Work and Case management involved; have discussed situation\\n w/ brother and boyfriend.\\n # Code: Full\\n # Dispo: ICU, Will d/w case management re rehab facilities, likely d/c\\n today/tomorrow if insurance/bed confirmed\\n MSIV\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n PICC Line - 01:30 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2167-10-29 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 640135,\n \"text\": \"Demographics\\n Ideal body weight: 61.2 None\\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: Yes\\n Tube Type\\n Tracheostomy tube:\\n Type: Cuffed\\n Manufacturer: Portex\\n Size: 7.0mm\\n PMV: Yes\\n Lung sounds\\n RLL Lung Sounds: Rhonchi\\n RUL Lung Sounds: Rhonchi\\n LUL Lung Sounds: Rhonchi\\n LLL Lung Sounds: Rhonchi\\n Secretions\\n Sputum color / consistency: White / Thick\\n Sputum source/amount: Suctioned / Copious\\n Comments: Pt continues to require frequent suctioning. Did wear PMV\\n for 15 mins today.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-28 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 639845,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n BRONCHOSCOPY by IP- At 09:43 AM. Tracheomalacia, lack of\\n posterior complete closure above cords resulting in possible etiology\\n of recurrent aspiration\\n Per nursing had increased secretions requiring deep suctioning\\n overnight\\n Restarted TF\\n Changed PPI to per IP recs\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:05 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:50 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37\\nC (98.6\\n Tcurrent: 36.1\\nC (97\\n HR: 86 (62 - 122) bpm\\n BP: 146/61(82) {87/42(53) - 152/87(98)} mmHg\\n RR: 23 (19 - 36) insp/min\\n SpO2: 95%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 3,692 mL\\n 1,252 mL\\n PO:\\n TF:\\n 116 mL\\n 116 mL\\n IVF:\\n 2,175 mL\\n 775 mL\\n Blood products:\\n Total out:\\n 3,790 mL\\n 400 mL\\n Urine:\\n 3,790 mL\\n 400 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -98 mL\\n 854 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask\\n SpO2: 95%\\n ABG: ///32/\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 203 K/uL\\n 7.5 g/dL\\n 137 mg/dL\\n 0.5 mg/dL\\n 32 mEq/L\\n 3.8 mEq/L\\n 13 mg/dL\\n 110 mEq/L\\n 148 mEq/L\\n 23.7 %\\n 5.8 K/uL\\n [image002.jpg]\\n 03:20 PM\\n 03:23 AM\\n 03:00 AM\\n 04:00 AM\\n 05:45 AM\\n 03:51 AM\\n 04:45 PM\\n 04:00 AM\\n 07:37 PM\\n 04:05 AM\\n WBC\\n 5.7\\n 7.3\\n 8.0\\n 8.7\\n 5.5\\n 5.7\\n 5.8\\n Hct\\n 30.0\\n 26.9\\n 27.3\\n 27.0\\n 28.7\\n 24.7\\n 25.2\\n 25.3\\n 23.7\\n Plt\\n 356\\n 346\\n 316\\n 271\\n 249\\n 231\\n 203\\n Cr\\n 0.7\\n 0.7\\n 0.7\\n 0.7\\n 0.5\\n 0.4\\n 0.5\\n Glucose\\n 129\\n 123\\n 114\\n 112\\n 122\\n 145\\n 137\\n Other labs: PT / PTT / INR:13.3/32.4/1.1, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.9 mg/dL, Mg++:2.1 mg/dL, PO4:3.6\\n mg/dL\\n Assessment and Plan\\n ICU Care\\n Nutrition:\\n Replete with Fiber () - 06:00 PM 20 mL/hour\\n TPN w/ Lipids - 06:02 PM 62.5 mL/hour\\n Glycemic Control:\\n Lines:\\n PICC Line - 01:30 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-28 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 639846,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n BRONCHOSCOPY by IP- At 09:43 AM. Severe diffuse\\n Tracheobronchomalacia, large gap posterior commisure above cords\\n resulting in possible etiology of recurrent aspiration\\n Seen by ENT, no attg note. Consider posterior augmentation\\n Per nursing had increased secretions requiring deep suctioning\\n overnight\\n Restarted TF\\n Changed PPI to per IP recs\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:05 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:50 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37\\nC (98.6\\n Tcurrent: 36.1\\nC (97\\n HR: 86 (62 - 122) bpm\\n BP: 146/61(82) {87/42(53) - 152/87(98)} mmHg\\n RR: 23 (19 - 36) insp/min\\n SpO2: 95%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 3,692 mL\\n 1,252 mL\\n PO:\\n TF:\\n 116 mL\\n 116 mL\\n IVF:\\n 2,175 mL\\n 775 mL\\n Blood products:\\n Total out:\\n 3,790 mL\\n 400 mL\\n Urine:\\n 3,790 mL\\n 400 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -98 mL\\n 854 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask\\n SpO2: 95%\\n ABG: ///32/\\n Physical Examination\\n Gen: Sedating post-bronchoscopy; Sleeping; pt would not wake for exam.\\n HEENT: No pallor in conjunctiva, MMM\\n Resp: Course breath sounds anteriorly, mild exp wheeze.\\n Card: S1S2 tachycardic, no m/r/g\\n Abd: Obese, soft, mildly distended, decreased bowel sounds, G-Tube in\\n place with no erythema/induration\\n Exte: No edema, DP 2+ bil\\n NEURO: Sedated\\n Labs / Radiology\\n 203 K/uL\\n 7.5 g/dL\\n 137 mg/dL\\n 0.5 mg/dL\\n 32 mEq/L\\n 3.8 mEq/L\\n 13 mg/dL\\n 110 mEq/L\\n 148 mEq/L\\n 23.7 %\\n 5.8 K/uL\\n [image002.jpg]\\n 03:20 PM\\n 03:23 AM\\n 03:00 AM\\n 04:00 AM\\n 05:45 AM\\n 03:51 AM\\n 04:45 PM\\n 04:00 AM\\n 07:37 PM\\n 04:05 AM\\n WBC\\n 5.7\\n 7.3\\n 8.0\\n 8.7\\n 5.5\\n 5.7\\n 5.8\\n Hct\\n 30.0\\n 26.9\\n 27.3\\n 27.0\\n 28.7\\n 24.7\\n 25.2\\n 25.3\\n 23.7\\n Plt\\n 356\\n 346\\n 316\\n 271\\n 249\\n 231\\n 203\\n Cr\\n 0.7\\n 0.7\\n 0.7\\n 0.7\\n 0.5\\n 0.4\\n 0.5\\n Glucose\\n 129\\n 123\\n 114\\n 112\\n 122\\n 145\\n 137\\n Other labs: PT / PTT / INR:13.3/32.4/1.1, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.9 mg/dL, Mg++:2.1 mg/dL, PO4:3.6\\n mg/dL\\n Assessment and Plan\\n 56yoF s/p mechanical fall and traumatic T spine fracture, now s/p\\n trach/PEG with resolving respiratory failure and HAP.\\n .\\n # Respiratory failure/Aspiration Risk: s/p intubation/extubation, now\\n on trach mask, FiO2 50%. Tolerating well with good O2 sat. No further\\n self-decanulations overnight. Pt continues to be at risk for aspiration\\n given new IP finding of opening defect in posterior vocal cord space\\n and given recent history of vomiting with tube feed trials.\\n - ENT consulted for evaluation of larynx and possible intervention;\\n will follow ENT recs\\n - increase ppi from qday to for aspiration prophylaxis\\n - Trach mask as tolerated.\\n - scopolamine patch q72hrs for secretions\\n - Holding sedation with exception of Risperidal 0.5mg PRN\\n - F/u CXR tomorrow\\n .\\n # Nutrition/Vomiting: Currently receiving TPN; BMx2 in past 24 hrs to\\n indicate possible improvement in ileus. TF tolerated during trial O/N\\n without emesis.\\n - Cont Reglan 20mg IV Q 8 hours; meds via G-J tube,\\n - Will obtain recommendations from Nutrition re TPN today and will\\n provide TF as tolerated\\n - Speech and Swallow eval today for Passy Muir valve eval;\\n - GI consult, will f/u recs\\n .\\n # Tachycardia: Improved HR max of 120\\ns versus 160s previously. Pt now\\n on PO Amiodarone 200 TID and PO metoprolol 37.5mg TID\\n - Continue current med regimen. Will continue amiodarone 200 TID for\\n three weeks and then switch to qday for 1week and then d/c amiodarone.\\n - Will need to schedule f/u in 4wks with Dr. upon d/c/transfer.\\n - f/u Cards recs\\n # Sedation/Anxiolysis/AlteredMS: Resolved O/N with risperdal. Previous\\n delirium and agitation most likely secondary to long hospital course\\n and multiple psychotropic medications as well as hx of EtOH abuse.\\n - started Risperdal 0.5mg PO BID PRN.\\n - continue to hold all benzos. opiates, and antihistamines\\n - Appreciate psych. Will call and f/u psych recs.\\n -Obtain EKG to assess for QTc prolongation.\\n #Anemia: HCT stable at 25. No known etiology of blood loss.\\n -Will repeat HCT in am .\\n # Hypernatremia/Fluid Status: Mild hypernatramia resolving with free\\n water administration. On TPN/TF. Good UOP.\\n - providing D5W IVFx 1L at 125cc/hr, free water flushes with TF\\n -Will f/u lytes in afternoon (5pm)\\n # UE DVT and elevated INR: Decision made to d/c Coumadin given her\\n labile INR, and start Lovenox .\\n - Will flush L PICC with TPA if does not flush\\n - Add coags to am labs\\n .\\n # Spine fracture: Stable\\n - Brace for OOB, need to discuss with Neurosurgery before d/c if\\n current brace is optimal for stabilization given her mobility.\\n - Pt to follow up with Dr. in weeks\\n .\\n # Tracheomalacia. Reevaluation bronchoscopy by IP as written above;\\n patient not a candidate for stent; pt to follow up as outpatient. No\\n new issues.\\n .\\n #. Thyroid Nodule on CT\\n - Outpatient follow up\\n .\\n # Glycemic control: SSI, well controlled\\n # ACCESS: PIV x 1, L PICC\\n # Ppx: Lovenox, PPi-to increase to , Bowel Regimen PRN\\n # Communication:\\n - Boyfriend of 10 \\n - Brother also involved\\n - Social Work and Case management involved; have discussed situation\\n w/ brother and boyfriend.\\n # Code: Full\\n # Dispo: ICU, Will d/w case management re rehab facilities.\\n MSIV\\n PGY2 addendum:\\n Agree with assessment and plan in MSIV note as detailed above.\\n Briefly, 56 F s/p fall with T spine fracture, respiratory failure now\\n s/p trach/PEG. Now on trach mask. Patient s/p bronch with IP today;\\n ENT to see and follow for ?intervention. Nutrition issues continue;\\n will receive TPN today plus possible restart of tube feeds as tolerated\\n (later today), continue reglan. Appreciate psych recs; continuing\\n risperidone for agitation. Etiology of delirium/agitation still\\n unclear. Likely eventual dispo to rehab facility directly from ICU\\n given high nursing requirements.\\n ICU Care\\n Nutrition:\\n Replete with Fiber () - 06:00 PM 20 mL/hour\\n TPN w/ Lipids - 06:02 PM 62.5 mL/hour\\n Glycemic Control:\\n Lines:\\n PICC Line - 01:30 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2167-10-28 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 639853,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 40\\n Ideal body weight: 61.2 None\\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: Yes\\n Procedure location:\\n Reason:\\n Tube Type\\n Tracheostomy tube:\\n Type: Cuffed\\n Manufacturer: Portex\\n Size: 7.0mm\\n PMV: No\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 23 cmH2O\\n Cuff volume: mL /\\n Airway problems:\\n Comments:\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Rhonchi\\n LUL Lung Sounds: Rhonchi\\n LLL Lung Sounds: Diminished\\n Comments:\\n Secretions\\n Sputum color / consistency: Tan / Thin\\n Sputum source/amount: Suctioned / Copious\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance: Unassisted spontaneous breathing\\n Visual assessment of breathing pattern: Normal quiet breathing\\n Assessment of breathing comfort:\\n Non-invasive ventilation assessment:\\n Invasive ventilation assessment:\\n Trigger work assessment:\\n Dysynchrony assessment:\\n Comments:\\n Plan\\n Next 24-48 hours:\\n Reason for continuing current ventilatory support:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-29 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 640120,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Tube Feed goals increased from 30cc to 60cc/hr. No issues O/N with\\n regard to vomiting.\\n Calm overnight. Risperdal decreased from 0.5mg to 0.25mg qam.\\n runs of asymptomatic SVT peaking in 110-120\\ns, metoprolol 37.5mg\\n changed from TID\\nQID and first daily dose given early after runs;\\n decrease of HR to 80\\n Loose, brown, malodorous stools O/N, afebrile, C.dif cx sent.\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Enoxaparin (Lovenox) - 06:33 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:22 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37\\nC (98.6\\n Tcurrent: 36.5\\nC (97.7\\n HR: 114 (61 - 122) bpm\\n BP: 119/54(75) {91/36(50) - 167/84(101)} mmHg\\n RR: 19 (10 - 30) insp/min\\n SpO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 2,952 mL\\n 429 mL\\n PO:\\n TF:\\n 646 mL\\n 376 mL\\n IVF:\\n 950 mL\\n 54 mL\\n Blood products:\\n Total out:\\n 2,430 mL\\n 470 mL\\n Urine:\\n 2,430 mL\\n 240 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 522 mL\\n -41 mL\\n Respiratory support\\n O2 Delivery Device: Aerosol-cool\\n SpO2: 100%\\n ABG: ///35/\\n Physical Examination\\n Gen: Alert, NAD, lying in bed, comfortable, mouthing words, less\\n sedated than yest.\\n HEENT: No pallor in conjunctiva, MMM, TM in place\\n Resp: Transmitted upper airway sounds/coarse breath sounds.\\n Card: S1S2 tachycardic, no m/r/g\\n Abd: Obese, soft, mildly distended, decreased bowel sounds, G-Tube in\\n place with no erythema/induration\\n Exte: No edema, DP 2+ bil\\n NEURO: Alert, difficult to assess orientation due to poor voice\\n although pt oriented to year not place. MAE\\n Labs / Radiology\\n 187 K/uL\\n 7.2 g/dL\\n 105 mg/dL\\n 0.5 mg/dL\\n 35 mEq/L\\n 3.8 mEq/L\\n 17 mg/dL\\n 108 mEq/L\\n 147 mEq/L\\n 23.7 %\\n 5.1 K/uL\\n [image002.jpg]\\n 03:00 AM\\n 04:00 AM\\n 05:45 AM\\n 03:51 AM\\n 04:45 PM\\n 04:00 AM\\n 07:37 PM\\n 04:05 AM\\n 06:05 PM\\n 03:23 AM\\n WBC\\n 7.3\\n 8.0\\n 8.7\\n 5.5\\n 5.7\\n 5.8\\n 5.1\\n Hct\\n 27.3\\n 27.0\\n 28.7\\n 24.7\\n 25.2\\n 25.3\\n 23.7\\n 24.7\\n 23.7\\n Plt\\n 346\\n 316\\n 271\\n 249\\n 231\\n 203\\n 187\\n Cr\\n 0.7\\n 0.7\\n 0.7\\n 0.5\\n 0.4\\n 0.5\\n 0.5\\n 0.5\\n Glucose\\n 123\\n 114\\n 112\\n 122\\n 145\\n 137\\n 149\\n 105\\n Other labs: PT / PTT / INR:13.3/32.4/1.1, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.8 mg/dL, Mg++:2.1 mg/dL, PO4:3.5\\n mg/dL\\n Assessment and Plan\\n 56yoF s/p mechanical fall and traumatic T spine fracture transferred\\n from OSH to for TBM eval with hospitalization complicated by\\n respiratory failure and HAP, s/p trach/PEG, atrial tachycardia, ileus,\\n and delirium/agitation.\\n .\\n # Respiratory: s/p intubation/extubation, now on trach mask, FiO2 50%.\\n Tolerating well with good O2 sat in mid-high 90\\ns. Pt continues to be\\n at risk for aspiration given recent history of vomiting with tube feed\\n trials and increased secretions. ENT believes that the posterior gap is\\n not a risk factor for aspiration as this is a common finding in females\\n and that her increased secretions and edema pose a greater aspiration\\n threat; no intervention was recommended.\\n - Appreciate ENT and S&S input.\\n - ENT recs to f/u in 2wks with Dr. () for an\\n outpatient/clinic re-evaluation.\\n - ppi for aspiration prophylaxis, PMV precautions: \\nt use w/o\\n supervision, frequent suctioning\\n - TM as tolerated.\\n - d/c scopolamine as it was a cause for delirium.\\n - Holding sedation with exception of Risperidal 0.25mg qam PRN\\n # Delirium: Pt continues to be slightly agitated with paranoia and\\n disorientation. Delirium and agitation most likely secondary to long\\n hospital course and multiple psychotropic medications as well as hx of\\n EtOH abuse.\\n - Risperdal 0.25mg PO qam.\\n - continue to hold all benzos. opiates, and antihistamines. Will\\n decrease or d/c raglan and scopolamine.\\n - Appreciate psych. Will call and f/u psych recs.\\n -Follow EKG to assess for QTc prolongation (last EKG ; QTc 457).\\n #Loose Stools: Multiple, loose stools O/N; afebrile, tachycardia,\\n without abdominal pain\\n -F/u stool c.dif cultures\\n -f/u WBC and vital signs daily\\n -Hold bowel regimen\\n # Atrial Tachycardia: Compared to recent b/l, HR increased to max of\\n 120\\ns. Pt now on PO Amiodarone 200 TID and PO increased metoprolol\\n 37.5mg QID.\\n - Will continue amiodarone 200 TID for three weeks and then switch to\\n qday for 1week and then d/c amiodarone.\\n - Will need to schedule f/u in 4wks with Dr. upon d/c/transfer.\\n #Anemia: HCT low compared to b/l. No known etiology of blood loss.\\n -Will continue to follow HCT daily.\\n - Guaiac stools.\\n # Hypernatremia/Fluid Status: Mild hypernatramia resolving with free\\n water administration. On TPN/TF. Good UOP. Free water deficit of 2.8L\\n - increase D5W IVFx 1L from 10cc/hr to 150cc/hr, free water flushes\\n with TF\\n -Will f/u lytes in afternoon (5pm)\\n # UE DVT and h/o labile INR: Decision made to d/c Coumadin given her\\n labile INR, and start Lovenox . INR at 1.1\\n - Will flush L PICC with TPA if does not flush\\n - Daily coags\\n .\\n # Spine fracture: Stable. T5-T8.\\n - Brace for OOB.\\n - Pt to follow up with Dr. in .\\n .\\n # Tracheomalacia. Reevaluation bronchoscopy by IP as written above;\\n patient not a candidate for stent; pt to follow up as outpatient. No\\n new issues.\\n .\\n #. Thyroid Nodule on CT\\n - Outpatient follow up\\n .\\n # Glycemic control: SSI, well controlled\\n # FEN: Currently receiving TF at 50cc/hr, w/o issue.\\n - Appreciate GI input and S&S eval\\n -D/c Reglan for emesis precaution as pt is tolerating TF without\\n vomiting and Reglan increases agitation/delirium risk.\\n -meds via G-J tube,\\n .\\n # ACCESS: PIV x 1, L PICC\\n # Ppx: Lovenox, PPi , Bowel Regimen PRN\\n # Communication:\\n - (brother) is primary contact\\n - Boyfriend of 10 , but minimal contact has been maintained at\\n this point\\n - Social Work and Case management involved; have discussed situation\\n w/ brother and boyfriend.\\n # Code: Full\\n # Dispo: ICU, Will d/w case management re rehab facilities, likely d/c\\n today/tomorrow if insurance/bed confirmed\\n MSIV\\n PGY2 addendum: , \\n Agree with assessment and plan in excellent MSIV note as detailed\\n above. Briefly, 56 F s/p fall with T spine fracture (T5-T8),\\n respiratory failure now s/p trach/PEG. Now on trach mask. Patient s/p\\n bronch with IP yesterday. Nutrition issues continue; have discontinued\\n TPN today and will continue tubefeeding to goal of 60cc/hr per\\n Nutrition. Will continue reglan until at goal feedings, and decrease\\n and d/c as able given potential for delirium. Appreciate psych recs;\\n continuing risperidone for agitation. Etiology of delirium/agitation\\n still unclear but likely prolonged hospital course, illness and\\n multiple medications. Currently discussing with CM about potential\\n placement to rehab tomorrow.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-29 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 640121,\n \"text\": \"Synopsis per prior nursing note:\\n 56 yr old woman, who was transferred from osh for evaluation of\\n tracheal bronchial malacia on .Pt presented to Medical\\n Center on s/p fall down a flight of stairs fracturing, t5-t8 with\\n propulsion treated conservatively with pain meds and back brace. She\\n developed resp distress requiring intubation on . Trach/PEG done\\n . Now with prolonged hospital course c/b by PNA, anxiety/altered\\n mental status, R&LUE DVT .Pt found to have small non occlusive clot on\\n her right axial vein via Ultrasound, now rec\\ning Lovenox. She has had\\n problems with vomiting tube feedings, so feeding tube passed through\\n g-tube to her jejunenum. However, she continued to intermit raise\\n gastric contents assoc with bronchospasm. Has not required ventilation\\n since , on humidified TM @ 50%. Presently on TPN and restarted on\\n TF\\nings at low rate via J-tube.\\n BRONCHOSCOPY by IP- At 09:43 AM. Severe diffuse\\n Tracheobronchomalacia, large gap posterior commisure above true vocal\\n cords resulting in possible etiology of recurrent aspiration\\n Airway Clearance, Impaired\\n Assessment:\\n LS-bilat rhonchi. O2 sat >95% on 50% trach collar. Suctioned large amts\\n of thick, white secretions. Passy-muir valve in only while being\\n evaluated by Psych d/t large amt of secretions.\\n Action:\\n Suctioned every one hour. Scolpolamine patch d/c\\nd d/t mental status.\\n Response:\\n Needed suctioning every 1hour.\\n Plan:\\n to monitor and clear airway as needed.\\n Alteration in Nutrition\\n Assessment:\\n Continues on replete w/fiber full strength.. Advance by 10ml q6 hours.\\n Flush w/ 100 ml hour every 4 hours. Denies nausea. No vomiting.\\n Mushroom cath in place.\\n Action:\\n J tube in place, unable to check resuduals. Increased TF as tolerated.\\n Reglan d/c\\nd d/t to mental status. Colace/senna/polyethylene glycol\\n held.\\n Response:\\n Continues to have liquid stool. Currently tolerating TF.\\n Plan:\\n Advance TF to goal as tolerated.\\n Fracture, other\\n Assessment:\\n Patient has a fracture of t5-t8. Denied pain. Brace on while OOB in\\n chair.\\n Action:\\n Changed position. Brace on while OOB.\\n Response:\\n Continued to deny pain.\\n Plan:\\n Assess/treat pain. Brace on while OOB.\\n Altered mental status (not Delirium)\\n Assessment:\\n When passy-muir valve on, patient had +VH and +AH. She was paranoid\\n about her brother in hallway (brother was not at hospital). Stated that\\n she will be driving her car home tomorrow. Stated that she is scared.\\n Follows commands. Continues to try to pull out lines/tubes. Continues\\n to throw her legs over the side of the bed.\\n Action:\\n w/ soft wrist restraints. Reoriented frequently. Assured patient\\n that she is safe in hospital.\\n Response:\\n Patient remains safe. Able to be calmed when told she is safe in\\n hospital.\\n Plan:\\n current safety plan. Reorient frequently. Psych will continue to\\n follow.\\n\"\n },\n {\n \"category\": \"Rehab Services\",\n \"chartdate\": \"2167-10-30 00:00:00.000\",\n \"description\": \"Physical Therapy Progress Note\",\n \"row_id\": 640295,\n \"text\": \"Subjective:\\n I thought I could stand but then I couldn't when I tried!\\n Objective:\\n Follow up PT visit to address goals of: . Patient seen today\\n for balance training, patient education\\n Updated medical status: improving mental status\\n Activity\\n Clarification\\n I\\n S\\n CG\\n Min\\n Mod\\n Max\\n Rolling:\\n\\n\\n\\n\\n\\n Supine/\\n Sidelying to Sit:\\n\\n\\n\\n\\n\\n Transfer:\\n\\n\\n\\n T\\n\\n Sit to Stand:\\n\\n\\n\\n T\\n\\n Ambulation:\\n\\n\\n\\n T\\n\\n Stairs:\\n\\n\\n\\n\\n\\n Aerobic Activity Response:\\n Position\\n HR\\n BP\\n RR\\n O[2] sat\\n RPE\\n Rest\\n Sit\\n 84\\n 100/44\\n Activity\\n Sit\\n 84\\n 186/64\\n Recovery\\n /\\n Total distance walked: 3 steps\\n Minutes:\\n Gait: able to bear wt B. took three steps bed-chair, chair-bed,\\n bed-chair. transfer performed x 3.\\n Balance: falling forward in standing with mod a to recover\\n Education / Communication: pt ed: role of PT\\n case discussed with rn\\n Other: strong congested cough productive for mod amounts of thick\\n sputum.\\n tlso attempted to fit brace but brace is too large excessive weight\\n loss\\n ms: oriented to self. following commands.\\n Assessment: 56 f s/p fall with T8fx presents with improved ability to\\n participate in PT today. She continues to require extensive rehab but\\n given improvements in mental status her potential is good to return to\\n ambulation. She may be limited by confusion. She needs to be fit for a\\n new brace as her most recent CT showed worsening vertebral body height.\\n Anticipated Discharge: Rehab\\n Plan: F/u if pt not d/c to rehab for new brace and continued mobility\\n and gait traininig.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-30 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 640278,\n \"text\": \"Chief Complaint: Delerium, respiratory failure (chronic)\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 24 Hour Events:\\n STOOL CULTURE - At 06:33 AM\\n Remains delerious, confused. Remains somewhat paranoid.\\n Up in chair.\\n History obtained from Medical records\\n Patient unable to provide history: Encephalopathy\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:00 PM\\n Enoxaparin (Lovenox) - 06:00 AM\\n Other medications:\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Constitutional: No(t) Fatigue, No(t) Fever, No(t) Weight loss\\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\\n No(t) Tachycardia, No(t) Orthopnea\\n Nutritional Support: No(t) NPO, Tube feeds, No(t) Parenteral nutrition\\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\\n No(t) Diarrhea, No(t) Constipation, PEG\\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\\n Integumentary (skin): No(t) Jaundice, No(t) Rash\\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\\n Heme / Lymph: No(t) Lymphadenopathy, No(t) Anemia, No(t) Coagulopathy\\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\\n No(t) Daytime somnolence\\n Allergy / Immunology: No(t) Immunocompromised, No(t) Influenza vaccine\\n Signs or concerns for abuse : No\\n Pain: No pain / appears comfortable\\n Flowsheet Data as of 12:02 PM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.6\\nC (97.9\\n Tcurrent: 36.1\\nC (96.9\\n HR: 70 (66 - 112) bpm\\n BP: 96/52(61) {90/37(31) - 164/75(87)} mmHg\\n RR: 22 (16 - 29) insp/min\\n SpO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 1,726 mL\\n 901 mL\\n PO:\\n TF:\\n 1,388 mL\\n 301 mL\\n IVF:\\n 249 mL\\n 330 mL\\n Blood products:\\n Total out:\\n 1,666 mL\\n 282 mL\\n Urine:\\n 836 mL\\n 282 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 60 mL\\n 619 mL\\n Respiratory support\\n O2 Delivery Device: Aerosol-cool\\n SpO2: 100%\\n ABG: ///34/\\n Physical Examination\\n General Appearance: No(t) Well nourished, No acute distress, Overweight\\n / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic\\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\\n pale, No(t) Sclera edema\\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\\n Endotracheal tube, No(t) NG tube, No(t) OG tube\\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\\n Cervical adenopathy\\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic,\\n No(t) Diastolic)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\\n (Breath Sounds: No(t) Clear : , No(t) Crackles : , No(t) Bronchial: ,\\n No(t) Wheezes : , No(t) Diminished: , No(t) Absent : , Rhonchorous: )\\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\\n No(t) Tender: , No(t) Obese\\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\\n Clubbing\\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\\n Skin: Warm, No(t) Rash: , No(t) Jaundice\\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\\n stimuli, Oriented (to): , Movement: Purposeful, No(t) Sedated, No(t)\\n Paralyzed, Tone: Normal\\n Labs / Radiology\\n 7.1 g/dL\\n 183 K/uL\\n 115 mg/dL\\n 0.5 mg/dL\\n 34 mEq/L\\n 3.6 mEq/L\\n 13 mg/dL\\n 106 mEq/L\\n 145 mEq/L\\n 22.8 %\\n 5.4 K/uL\\n [image002.jpg]\\n 04:00 AM\\n 05:45 AM\\n 03:51 AM\\n 04:45 PM\\n 04:00 AM\\n 07:37 PM\\n 04:05 AM\\n 06:05 PM\\n 03:23 AM\\n 02:54 AM\\n WBC\\n 8.0\\n 8.7\\n 5.5\\n 5.7\\n 5.8\\n 5.1\\n 5.4\\n Hct\\n 27.0\\n 28.7\\n 24.7\\n 25.2\\n 25.3\\n 23.7\\n 24.7\\n 23.7\\n 22.8\\n Plt\\n \\n 183\\n Cr\\n 0.7\\n 0.7\\n 0.5\\n 0.4\\n 0.5\\n 0.5\\n 0.5\\n 0.5\\n Glucose\\n 114\\n 112\\n 122\\n 145\\n 137\\n 149\\n 105\\n 115\\n Other labs: PT / PTT / INR:13.3/32.4/1.1, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.4 mg/dL, Mg++:1.9 mg/dL, PO4:3.6\\n mg/dL\\n Assessment and Plan\\n Delerium.\\n DELERIUM -- likely multifactorial. EtOH withdrawl-related,\\n medications, ICU psychosis.\\n RESPIRATORY FUNCTION -- stable with trach. Remains on trach collar.\\n TRACHEOBRONCHOMALACIA --\\n VOCAL CORD DYSFUNCTION -- adduction problem. need ENT f/u in\\n future.\\n NUTRITIONAL SUPPORT -- TF via PEG\\n FLUIDS -- euvolemic. Monitor I/O.\\n REHABILITATION placement in progress.\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n PICC Line - 01:30 PM\\n Prophylaxis:\\n DVT: Boots(Systemic anticoagulation: None)\\n Stress ulcer: PPI\\n VAP: HOB elevation\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :ICU\\n Total time spent: 55 minutes\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Nutrition\",\n \"chartdate\": \"2167-10-30 00:00:00.000\",\n \"description\": \"Clinical Nutrition Note\",\n \"row_id\": 640283,\n \"text\": \"Objective\\n Pertinent medications: noted\\n Labs:\\n Value\\n Date\\n Glucose\\n 115 mg/dL\\n 02:54 AM\\n Glucose Finger Stick\\n 111\\n 10:00 AM\\n BUN\\n 13 mg/dL\\n 02:54 AM\\n Creatinine\\n 0.5 mg/dL\\n 02:54 AM\\n Sodium\\n 145 mEq/L\\n 02:54 AM\\n Potassium\\n 3.6 mEq/L\\n 02:54 AM\\n Chloride\\n 106 mEq/L\\n 02:54 AM\\n TCO2\\n 34 mEq/L\\n 02:54 AM\\n PO2 (arterial)\\n 120 mm Hg\\n 03:36 AM\\n PO2 (venous)\\n 62 mm Hg\\n 02:35 AM\\n PCO2 (arterial)\\n 44 mm Hg\\n 03:36 AM\\n PCO2 (venous)\\n 58 mm Hg\\n 02:35 AM\\n pH (arterial)\\n 7.37 units\\n 03:36 AM\\n pH (venous)\\n 7.37 units\\n 02:35 AM\\n pH (urine)\\n 5.0 units\\n 03:05 AM\\n CO2 (Calc) arterial\\n 26 mEq/L\\n 03:36 AM\\n CO2 (Calc) venous\\n 35 mEq/L\\n 02:35 AM\\n Albumin\\n 3.1 g/dL\\n 03:23 AM\\n Calcium non-ionized\\n 8.4 mg/dL\\n 02:54 AM\\n Phosphorus\\n 3.6 mg/dL\\n 02:54 AM\\n Ionized Calcium\\n 1.24 mmol/L\\n 02:51 AM\\n Magnesium\\n 1.9 mg/dL\\n 02:54 AM\\n Current diet order / nutrition support: Replte c/ Fiber @60mL/hr (1440\\n kcals/89 graa)\\n GI: abd soft/+bs.+BM\\n Assessment of Nutritional Status\\n Specifics:\\n TF\\ns advanced over past 2 days, were infusing @ goal, until held p/\\n suctioned for thick mucous and ? possible aspiration. Per rounds plan\\n to resume TF\\ns this afternoon and advance back to goal slowly. IF pt\\n c/ continuous need to held TF\\ns will need to resume TPN to prevent\\n nutritional decline.\\n Medical Nutrition Therapy Plan - Recommend the Following\\n Multivitamin / Mineral supplement: via TF\\n Resume TF's as able c/ low threshold for resumption of TPN to avoid\\n nutritional decline\\n Aspiration precautions keep HOB .45 degrees when feeding\\n BG and lyte management as you are\\n Will follow- please call c/ ?\\ns #\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-30 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 640284,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n - ENT team believes that vocal cord adductor dysfunction is NOT a risk\\n for aspiration, rather her increased secretions put her at risk for\\n aspiration. They will follow-up in clinic in two weeks with Dr.\\n , call in am to schedule appt.\\n - Psych recs: consider head CT if patient does not improve off\\n scopolamine and metoclopramide; address anemia and\\nerratic BP\\n consider increasing am dose of risperdal; monitor \\n - Pt continued to be agitated O/N (eg: pulled rectal tubex2 and\\n foleyx1, disoriented). To receive head CT this AM\\n -HCT at 22.8 down 1pt with b/l in high 20\\n -Suctioned thick green mucus from mouth (not trach) this am, TF held.\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:00 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:28 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.6\\nC (97.9\\n Tcurrent: 36.6\\nC (97.9\\n HR: 77 (66 - 114) bpm\\n BP: 128/40(60) {90/37(31) - 164/75(87)} mmHg\\n RR: 23 (16 - 29) insp/min\\n SpO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 1,726 mL\\n 595 mL\\n PO:\\n TF:\\n 1,388 mL\\n 301 mL\\n IVF:\\n 249 mL\\n 105 mL\\n Blood products:\\n Total out:\\n 1,666 mL\\n 222 mL\\n Urine:\\n 836 mL\\n 222 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 60 mL\\n 373 mL\\n Respiratory support\\n O2 Delivery Device: Aerosol-cool\\n SpO2: 100%\\n ABG: ///34/\\n Physical Examination\\n Gen: NAD, lying in bed, comfortable, PMV on, able to vocalize. HEENT:\\n No pallor in conjunctiva, MMM, TM in place\\n Resp: Transmitted upper airway sounds/coarse breath sounds, improved\\n compared to yesterday.\\n Card: S1S2 tachycardic, no m/r/g\\n Abd: Obese, soft, mildly distended, decreased bowel sounds, G-Tube in\\n place with no s/s of infection\\n Exte: No edema, DP 2+ bil\\n NEURO: AxO to year (not to place or day-thinks it is\\nthe day before\\n \\n), MAE\\n Labs / Radiology\\n 183 K/uL\\n 7.1 g/dL\\n 115 mg/dL\\n 0.5 mg/dL\\n 34 mEq/L\\n 3.6 mEq/L\\n 13 mg/dL\\n 106 mEq/L\\n 145 mEq/L\\n 22.8 %\\n 5.4 K/uL\\n [image002.jpg]\\n C.dif negative x1; Cdif#2 pending. BCx and Urine Cx No Growth.\\n 04:00 AM\\n 05:45 AM\\n 03:51 AM\\n 04:45 PM\\n 04:00 AM\\n 07:37 PM\\n 04:05 AM\\n 06:05 PM\\n 03:23 AM\\n 02:54 AM\\n WBC\\n 8.0\\n 8.7\\n 5.5\\n 5.7\\n 5.8\\n 5.1\\n 5.4\\n Hct\\n 27.0\\n 28.7\\n 24.7\\n 25.2\\n 25.3\\n 23.7\\n 24.7\\n 23.7\\n 22.8\\n Plt\\n \\n 183\\n Cr\\n 0.7\\n 0.7\\n 0.5\\n 0.4\\n 0.5\\n 0.5\\n 0.5\\n 0.5\\n Glucose\\n 114\\n 112\\n 122\\n 145\\n 137\\n 149\\n 105\\n 115\\n Other labs: PT / PTT / INR:13.3/32.4/1.1, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.4 mg/dL, Mg++:1.9 mg/dL, PO4:3.6\\n mg/dL\\n Assessment and Plan\\n 56yoF s/p mechanical fall and traumatic T spine fracture transferred\\n from OSH to for TBM eval with hospitalization complicated by\\n respiratory failure and HAP, s/p trach/PEG, atrial tachycardia, ileus,\\n and delirium/agitation.\\n .\\n # Delirium: Pt continues to be agitated with paranoia, disorientation\\n and hallucinations. Most likely secondary to long hospital course and\\n recent multiple psychotropic medications. Other lab values (lytes, past\\n LFTs within normal limits), infections processes negative on culture.\\n CT of head at OSH negative. d/c\\ned Reglan and scopolamine.\\n - Appreciate psych. Will call and f/u psych recs.\\n -Consider CT of head with contrast if mental status does not improve\\n this am.\\n - Risperdal 0.25mg PO qam. Consider increasing per psych recs to 0.5mg\\n if continues to be agitated. Will d/w psych re any additional meds we\\n could use for night time agitation.\\n - continue to hold all benzos. opiates, and antihistamines.\\n -Follow EKG to assess for prolongation (last EKG ; 457).\\n #Anemia: HCT continues to decrease, currently at 22.8 from 23.7 with\\n b/l in high 20\\ns. No known etiology of blood loss.\\n -Will continue to follow HCT\\n - Guaiac stools.\\n # Respiratory: s/p trach on trach mask, FiO2 50%. Tolerating well with\\n good O2 sat in mid-high 90\\ns. Pt continues to be at risk for aspiration\\n given recent history of vomiting with tube feed trials and increased\\n secretions. ENT believes that the posterior gap is not a risk factor\\n for aspiration as this is a common finding in females and that her\\n increased secretions and edema pose a greater aspiration threat; no\\n intervention was recommended.\\n - Appreciate ENT and S&S input.\\n - Pt to f/u on ^th at 3:30pm with Dr. \\n () for an outpatient/clinic re-evaluation.\\n - ppi for aspiration prophylaxis, PMV precautions: \\nt use w/o\\n supervision, frequent suctioning\\n - TM as tolerated.\\n - Holding sedation with exception of Risperidal 0.25mg PO qam\\n #Loose Stools: rectal tube pulled out x2; afebrile, HD stable, without\\n abdominal pain. Stool cdif cx negativex1.\\n -F/u stool c.dif cultures\\n -f/u WBC and vital signs daily\\n -Hold bowel regimen\\n # Atrial Tachycardia: Stable without issue O/N. Pt now on PO Amiodarone\\n 200 TID and PO metoprolol 50mg TID\\n - Will continue amiodarone 200 TID for three weeks (start ) and\\n then switch to qday for 1week and then d/c amiodarone.\\n - Will need to schedule f/u in 4wks with Dr. upon d/c/transfer.\\n # Hypernatremia/Fluid Status: resolving after free water\\n administration. On TPN/TF. Free water deficit of 1.6L\\n - increase NS at 10cc/hr, water flushes with TF\\n -Will f/u lytes \\n # UE DVT and h/o labile INR: Decision made to d/c Coumadin given her\\n labile INR, and start Lovenox . INR at 1.1\\n - Will flush L PICC with TPA if does not flush\\n - Daily coags\\n .\\n # Spine fracture: Stable. T5-T8.\\n - Brace for OOB.\\n - Pt to follow up with Dr. in .\\n .\\n # Tracheomalacia. Reevaluation bronchoscopy by IP as written above;\\n patient not a candidate for stent; pt to follow up as outpatient. No\\n new issues.\\n .\\n #. Thyroid Nodule on CT\\n - Outpatient follow up\\n .\\n # Glycemic control: SSI, well controlled\\n # FEN: Currently TF held secondary to possible risk of aspiration O/N;\\n will increase TF back slowly to max goal.\\n - Appreciate GI input and S&S eval\\n -D/c\\ned Reglan for emesis precaution as pt is tolerating TF without\\n vomiting and Reglan increases agitation/delirium risk.\\n -meds via G-J tube\\n .\\n # ACCESS: L PICC\\n # Ppx: Lovenox, PPi , Bowel Regimen PRN currently held\\n # Communication:\\n - (brother) is primary contact; visiting\\n patient today and aware of status and disposition\\n - Boyfriend of 10 , but minimal contact has been maintained at\\n this point\\n - Social Work and Case management involved\\n # Code: Full\\n # Dispo: ICU, Will currently has bed at Rehab and waiting\\n insurance approval before transfer of care.\\n MSIV\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n PICC Line - 01:30 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-31 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 640438,\n \"text\": \"56yoF s/p mechanical fall and traumatic T spine fracture transferred\\n from OSH to for TBM eval with hospitalization complicated by\\n respiratory failure and HAP, s/p trach/PEG, atrial tachycardia, ileus,\\n and delirium/agitation.\\n Airway Clearance, Impaired\\n Assessment:\\n Cont on TM 50% O2 sats 96-94%, suct for copious amts of thin white\\n secretions, bilat rhonchi, dim bases.\\n Action:\\n Frequent suctioning, pt able to cough up some secretions on her own\\n Response:\\n Pt able to cough up secretions on her own at times\\n Plan:\\n Cont to resp status, encourage CDB\\n Altered mental status (not Delirium)\\n Assessment:\\n Alert/oriented with some confusion, follows commands consistently, but\\n requires frequent re-direction\\n Action:\\n Pt oriented to place/time\\n Response:\\n Pt still makes attempts to remove TM despite re-direction, pt remains\\n with bilat wrist restraints for safety\\n Plan:\\n Cont to orient pt, frequent monitor for safety\\n Alteration in Nutrition\\n Assessment:\\n TF restarted @ 0000, BS present x 4Quads, soft, NT\\n Action:\\n HOB 45 when TF on, TF off prior to turning, TF currently running at\\n goal\\n Response:\\n No n/v reported or witness, TTFW\\n Plan:\\n Cont to nutritional status\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-29 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 640018,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Tube Feed goals increased\\n Calm overnight\\n 3 runs of SVT peaking in 110s.\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Enoxaparin (Lovenox) - 06:33 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:22 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37\\nC (98.6\\n Tcurrent: 36.5\\nC (97.7\\n HR: 114 (61 - 122) bpm\\n BP: 119/54(75) {91/36(50) - 167/84(101)} mmHg\\n RR: 19 (10 - 30) insp/min\\n SpO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 2,952 mL\\n 429 mL\\n PO:\\n TF:\\n 646 mL\\n 376 mL\\n IVF:\\n 950 mL\\n 54 mL\\n Blood products:\\n Total out:\\n 2,430 mL\\n 470 mL\\n Urine:\\n 2,430 mL\\n 240 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 522 mL\\n -41 mL\\n Respiratory support\\n O2 Delivery Device: Aerosol-cool\\n SpO2: 100%\\n ABG: ///35/\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 187 K/uL\\n 7.2 g/dL\\n 105 mg/dL\\n 0.5 mg/dL\\n 35 mEq/L\\n 3.8 mEq/L\\n 17 mg/dL\\n 108 mEq/L\\n 147 mEq/L\\n 23.7 %\\n 5.1 K/uL\\n [image002.jpg]\\n 03:00 AM\\n 04:00 AM\\n 05:45 AM\\n 03:51 AM\\n 04:45 PM\\n 04:00 AM\\n 07:37 PM\\n 04:05 AM\\n 06:05 PM\\n 03:23 AM\\n WBC\\n 7.3\\n 8.0\\n 8.7\\n 5.5\\n 5.7\\n 5.8\\n 5.1\\n Hct\\n 27.3\\n 27.0\\n 28.7\\n 24.7\\n 25.2\\n 25.3\\n 23.7\\n 24.7\\n 23.7\\n Plt\\n 346\\n 316\\n 271\\n 249\\n 231\\n 203\\n 187\\n Cr\\n 0.7\\n 0.7\\n 0.7\\n 0.5\\n 0.4\\n 0.5\\n 0.5\\n 0.5\\n Glucose\\n 123\\n 114\\n 112\\n 122\\n 145\\n 137\\n 149\\n 105\\n Other labs: PT / PTT / INR:13.3/32.4/1.1, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.8 mg/dL, Mg++:2.1 mg/dL, PO4:3.5\\n mg/dL\\n Assessment and Plan\\n ICU Care\\n Nutrition:\\n Replete with Fiber () - 09:45 PM 40 mL/hour\\n Glycemic Control:\\n Lines:\\n PICC Line - 01:30 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-29 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 640020,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Tube Feed goals increased\\n Calm overnight\\n 3 runs of SVT peaking in 110s.\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Enoxaparin (Lovenox) - 06:33 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:22 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37\\nC (98.6\\n Tcurrent: 36.5\\nC (97.7\\n HR: 114 (61 - 122) bpm\\n BP: 119/54(75) {91/36(50) - 167/84(101)} mmHg\\n RR: 19 (10 - 30) insp/min\\n SpO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 2,952 mL\\n 429 mL\\n PO:\\n TF:\\n 646 mL\\n 376 mL\\n IVF:\\n 950 mL\\n 54 mL\\n Blood products:\\n Total out:\\n 2,430 mL\\n 470 mL\\n Urine:\\n 2,430 mL\\n 240 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 522 mL\\n -41 mL\\n Respiratory support\\n O2 Delivery Device: Aerosol-cool\\n SpO2: 100%\\n ABG: ///35/\\n Physical Examination\\n Gen: Alert, NAD, lying in bed, comfortable, mouthing words, less\\n sedated than yest.\\n HEENT: No pallor in conjunctiva, MMM, TM in place\\n Resp: Transmitted upper airway sounds/coarse breath sounds.\\n Card: S1S2 tachycardic, no m/r/g\\n Abd: Obese, soft, mildly distended, decreased bowel sounds, G-Tube in\\n place with no erythema/induration\\n Exte: No edema, DP 2+ bil\\n NEURO: Alert, difficult to assess orientation due to poor voice. MAE\\n Labs / Radiology\\n 187 K/uL\\n 7.2 g/dL\\n 105 mg/dL\\n 0.5 mg/dL\\n 35 mEq/L\\n 3.8 mEq/L\\n 17 mg/dL\\n 108 mEq/L\\n 147 mEq/L\\n 23.7 %\\n 5.1 K/uL\\n [image002.jpg]\\n 03:00 AM\\n 04:00 AM\\n 05:45 AM\\n 03:51 AM\\n 04:45 PM\\n 04:00 AM\\n 07:37 PM\\n 04:05 AM\\n 06:05 PM\\n 03:23 AM\\n WBC\\n 7.3\\n 8.0\\n 8.7\\n 5.5\\n 5.7\\n 5.8\\n 5.1\\n Hct\\n 27.3\\n 27.0\\n 28.7\\n 24.7\\n 25.2\\n 25.3\\n 23.7\\n 24.7\\n 23.7\\n Plt\\n 346\\n 316\\n 271\\n 249\\n 231\\n 203\\n 187\\n Cr\\n 0.7\\n 0.7\\n 0.7\\n 0.5\\n 0.4\\n 0.5\\n 0.5\\n 0.5\\n Glucose\\n 123\\n 114\\n 112\\n 122\\n 145\\n 137\\n 149\\n 105\\n Other labs: PT / PTT / INR:13.3/32.4/1.1, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.8 mg/dL, Mg++:2.1 mg/dL, PO4:3.5\\n mg/dL\\n Assessment and Plan\\n ICU Care\\n Nutrition:\\n Replete with Fiber () - 09:45 PM 40 mL/hour\\n Glycemic Control:\\n Lines:\\n PICC Line - 01:30 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-29 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 640021,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Tube Feed goals increased\\n Calm overnight\\n 3 runs of SVT peaking in 110s.\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Enoxaparin (Lovenox) - 06:33 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:22 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37\\nC (98.6\\n Tcurrent: 36.5\\nC (97.7\\n HR: 114 (61 - 122) bpm\\n BP: 119/54(75) {91/36(50) - 167/84(101)} mmHg\\n RR: 19 (10 - 30) insp/min\\n SpO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 2,952 mL\\n 429 mL\\n PO:\\n TF:\\n 646 mL\\n 376 mL\\n IVF:\\n 950 mL\\n 54 mL\\n Blood products:\\n Total out:\\n 2,430 mL\\n 470 mL\\n Urine:\\n 2,430 mL\\n 240 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 522 mL\\n -41 mL\\n Respiratory support\\n O2 Delivery Device: Aerosol-cool\\n SpO2: 100%\\n ABG: ///35/\\n Physical Examination\\n Gen: Alert, NAD, lying in bed, comfortable, mouthing words, less\\n sedated than yest.\\n HEENT: No pallor in conjunctiva, MMM, TM in place\\n Resp: Transmitted upper airway sounds/coarse breath sounds.\\n Card: S1S2 tachycardic, no m/r/g\\n Abd: Obese, soft, mildly distended, decreased bowel sounds, G-Tube in\\n place with no erythema/induration\\n Exte: No edema, DP 2+ bil\\n NEURO: Alert, difficult to assess orientation due to poor voice. MAE\\n Labs / Radiology\\n 187 K/uL\\n 7.2 g/dL\\n 105 mg/dL\\n 0.5 mg/dL\\n 35 mEq/L\\n 3.8 mEq/L\\n 17 mg/dL\\n 108 mEq/L\\n 147 mEq/L\\n 23.7 %\\n 5.1 K/uL\\n [image002.jpg]\\n 03:00 AM\\n 04:00 AM\\n 05:45 AM\\n 03:51 AM\\n 04:45 PM\\n 04:00 AM\\n 07:37 PM\\n 04:05 AM\\n 06:05 PM\\n 03:23 AM\\n WBC\\n 7.3\\n 8.0\\n 8.7\\n 5.5\\n 5.7\\n 5.8\\n 5.1\\n Hct\\n 27.3\\n 27.0\\n 28.7\\n 24.7\\n 25.2\\n 25.3\\n 23.7\\n 24.7\\n 23.7\\n Plt\\n 346\\n 316\\n 271\\n 249\\n 231\\n 203\\n 187\\n Cr\\n 0.7\\n 0.7\\n 0.7\\n 0.5\\n 0.4\\n 0.5\\n 0.5\\n 0.5\\n Glucose\\n 123\\n 114\\n 112\\n 122\\n 145\\n 137\\n 149\\n 105\\n Other labs: PT / PTT / INR:13.3/32.4/1.1, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.8 mg/dL, Mg++:2.1 mg/dL, PO4:3.5\\n mg/dL\\n Assessment and Plan\\n 56yoF s/p mechanical fall and traumatic T spine fracture with resolving\\n respiratory failure and HAP s/p trach with complicating TBM and s/p\\n PEG.\\n .\\n # Respiratory: s/p intubation/extubation, now on trach mask, FiO2 50%.\\n Tolerating well with good O2 sat in mid-high 90\\ns. Pt continues to be\\n at risk for aspiration given new IP finding of opening defect in\\n posterior vocal cord space and given recent history of vomiting with\\n tube feed trials.\\n - Appreciate ENT and S&S input.\\n - will follow ENT recs; awaiting input for possible intervention.\\n - ppi for aspiration prophylaxis, PMV precautions: \\nt use w/o\\n supervision, frequent suctioning\\n - TM as tolerated.\\n - continue scopolamine patch q72hrs for secretions\\n - Holding sedation with exception of Risperidal 0.5mg PRN\\n - F/u CXR tomorrow\\n # Sedation/Anxiolysis/AlteredMS: Resolved O/N with risperdal. Previous\\n delirium and agitation most likely secondary to long hospital course\\n and multiple psychotropic medications as well as hx of EtOH abuse.\\n - started Risperdal 0.5mg PO BID PRN.\\n - continue to hold all benzos. opiates, and antihistamines\\n - Appreciate psych. Will call and f/u psych recs.\\n -Obtain EKG to assess for QTc prolongation.\\n #Anemia: HCT low compared to b/l at 23.7. No known etiology of blood\\n loss.\\n -Will continue to follow HCT daily.\\n - Guaiac stools.\\n -f/u HCT this afternoon\\n -T&S\\n # Atrial Tachycardia: Improved HR max of 120\\ns versus 160s previously.\\n Pt now on PO Amiodarone 200 TID and PO metoprolol 37.5mg TID\\n - Will continue amiodarone 200 TID for three weeks and then switch to\\n qday for 1week and then d/c amiodarone.\\n - Will need to schedule f/u in 4wks with Dr. upon d/c/transfer.\\n # Hypernatremia/Fluid Status: Mild hypernatramia resolving with free\\n water administration. On TPN/TF. Good UOP.\\n - providing D5W IVFx 1L at 150cc/hr, free water flushes with TF\\n -Will f/u lytes in afternoon (5pm)\\n # UE DVT and h/o labile INR: Decision made to d/c Coumadin given her\\n labile INR, and start Lovenox . INR at 1.9\\n - Will flush L PICC with TPA if does not flush\\n - Daily coags\\n .\\n # Spine fracture: Stable. T5-T8.\\n - Brace for OOB, need to discuss with Neurosurgery before d/c if\\n current brace is optimal for stabilization given her mobility.\\n - Pt to follow up with Dr. in .\\n .\\n # Tracheomalacia. Reevaluation bronchoscopy by IP as written above;\\n patient not a candidate for stent; pt to follow up as outpatient. No\\n new issues.\\n .\\n #. Thyroid Nodule on CT\\n - Outpatient follow up\\n .\\n # Glycemic control: SSI, well controlled\\n # FEN: Currently receiving TPN, restarted TF yest, currently at\\n 20cc/hr, w/o issue.\\n - Appreciate GI input and S&S eval\\n -Cont Reglan 20mg IV Q 8 hours for emesis precaution; meds via G-J\\n tube,\\n -D/w GI; rec: continue bowel regimen if no BM\\n .\\n # ACCESS: PIV x 1, L PICC\\n # Ppx: Lovenox, PPi , Bowel Regimen PRN\\n # Communication:\\n - (brother) is primary contact\\n - Boyfriend of 10 , but minimal contact has been maintained at\\n this point\\n - Social Work and Case management involved; have discussed situation\\n w/ brother and boyfriend.\\n # Code: Full\\n # Dispo: ICU, Will d/w case management re rehab facilities, likely d/c\\n tomorrow if insurance/bed confirmed\\n MSIV\\n PGY2 addendum: , \\n Agree with assessment and plan in excellent MSIV note as detailed\\n above. Briefly, 56 F s/p fall with T spine fracture (T5-T8),\\n respiratory failure now s/p trach/PEG. Now on trach mask. Patient s/p\\n bronch with IP yesterday. Nutrition issues continue; have discontinued\\n TPN today and will continue tubefeeding to goal of 60cc/hr per\\n Nutrition. Will continue reglan until at goal feedings, and decrease\\n and d/c as able given potential for delirium. Appreciate psych recs;\\n continuing risperidone for agitation. Etiology of delirium/agitation\\n still unclear but likely prolonged hospital course, illness and\\n multiple medications. Currently discussing with CM about potential\\n placement to rehab tomorrow.\\n ICU Care\\n Nutrition:\\n Replete with Fiber () - 09:45 PM 40 mL/hour\\n Glycemic Control:\\n Lines:\\n PICC Line - 01:30 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-30 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 640182,\n \"text\": \"Synopsis per prior nursing note:\\n 56 yr old woman, who was transferred from osh for evaluation of\\n tracheal bronchial malacia on .Pt presented to Medical\\n Center on s/p fall down a flight of stairs fracturing, t5-t8 with\\n propulsion treated conservatively with pain meds and back brace. She\\n developed resp distress requiring intubation on . Trach/PEG done\\n . Now with prolonged hospital course c/b by PNA, anxiety/altered\\n mental status, R&LUE DVT .Pt found to have small non occlusive clot on\\n her right axial vein via Ultrasound, now rec\\ning Lovenox. She has had\\n problems with vomiting tube feedings, so feeding tube passed through\\n g-tube to her jejunenum. However, she continued to intermit raise\\n gastric contents assoc with bronchospasm. Has not required ventilation\\n since , on humidified TM @ 50%. Presently on TPN and restarted on\\n TF\\nings at low rate via J-tube.\\n Airway Clearance, Impaired\\n Assessment:\\n LS-bilat rhonchi. O2 sat >95% on 50% trach collar. Suctioned small to\\n moderate amts of thick, white secretions and pt clearing secretions\\n independently with strong cough. Passy-muir valve in only while being\\n evaluated by Psych d/t large amt of secretions.\\n Action:\\n Suctioned every one hour. Scolpolamine patch d/c\\nd d/t mental status.\\n Response:\\n Needed suctioning every 1hour.\\n Plan:\\n to monitor and clear airway as needed.\\n Alteration in Nutrition\\n Assessment:\\n Continues on replete w/fiber full strength.. Advance by 10ml q6 hours.\\n Flush w/ 100 ml hour every 4 hours. Denies nausea. No vomiting.\\n Mushroom cath in place.\\n Action:\\n J tube in place, unable to check resuduals. Increased TF as tolerated.\\n Reglan d/c\\nd d/t to mental status. Colace/senna/polyethylene glycol\\n held.\\n Response:\\n Continues to have liquid stool. Currently tolerating TF.\\n Plan:\\n Advance TF to goal as tolerated.\\n Fracture, other\\n Assessment:\\n Patient has a fracture of t5-t8. Denied pain. Brace on while OOB in\\n chair.\\n Action:\\n Changed position. Brace on while OOB.\\n Response:\\n Continued to deny pain.\\n Plan:\\n Assess/treat pain. Brace on while OOB.\\n Altered mental status (not Delirium)\\n Assessment:\\n When passy-muir valve on, patient had +VH and +AH. She was paranoid\\n about her brother in hallway (brother was not at hospital). Stated that\\n she will be driving her car home tomorrow. Stated that she is scared.\\n Follows commands. Continues to try to pull out lines/tubes. Continues\\n to throw her legs over the side of the bed.\\n Action:\\n w/ soft wrist restraints. Reoriented frequently. Assured patient\\n that she is safe in hospital.\\n Response:\\n Patient remains safe. Able to be calmed when told she is safe in\\n hospital.\\n Plan:\\n current safety plan. Reorient frequently. Psych will continue to\\n follow.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-30 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 640183,\n \"text\": \"Synopsis per prior nursing note:\\n 56 yr old woman, who was transferred from osh for evaluation of\\n tracheal bronchial malacia on .Pt presented to Medical\\n Center on s/p fall down a flight of stairs fracturing, t5-t8 with\\n propulsion treated conservatively with pain meds and back brace. She\\n developed resp distress requiring intubation on . Trach/PEG done\\n . Now with prolonged hospital course c/b by PNA, anxiety/altered\\n mental status, R&LUE DVT .Pt found to have small non occlusive clot on\\n her right axial vein via Ultrasound, now rec\\ning Lovenox. She has had\\n problems with vomiting tube feedings, so feeding tube passed through\\n g-tube to her jejunenum. However, she continued to intermit raise\\n gastric contents assoc with bronchospasm. Has not required ventilation\\n since , on humidified TM @ 50%. Presently on TPN and restarted on\\n TF\\nings at low rate via J-tube.\\n Airway Clearance, Impaired\\n Assessment:\\n LS-bilat rhonchi. O2 sat >95% on 50% humidified trach collar. Suctioned\\n small to moderate amts of frothy and thin, white secretions and pt\\n clearing secretions independently with strong cough.\\n Action:\\n Repositioned frequently and CPT. Suctioned q2-3hours.\\n Response:\\n n/a\\n Plan:\\n to monitor resp status and clear airway as needed.\\n Alteration in Nutrition\\n Assessment:\\n Continues on replete w/fiber full strength.. Advance by 10ml q6 hours.\\n Flush w/ 100 ml hour every 4 hours. Denies nausea. No vomiting.\\n Mushroom cath in place.\\n Action:\\n J tube in place, unable to check resuduals. Increased TF as tolerated.\\n Reglan d/c\\nd d/t to mental status. Colace/senna/polyethylene glycol\\n held.\\n Response:\\n Continues to have liquid stool. Currently tolerating TF.\\n Plan:\\n Advance TF to goal as tolerated.\\n Fracture, other\\n Assessment:\\n Patient has a fracture of t5-t8. Denied pain. Brace on while OOB in\\n chair.\\n Action:\\n Changed position. Brace on while OOB.\\n Response:\\n Continued to deny pain.\\n Plan:\\n Assess/treat pain. Brace on while OOB.\\n Altered mental status (not Delirium)\\n Assessment:\\n When passy-muir valve on, patient had +VH and +AH. She was paranoid\\n about her brother in hallway (brother was not at hospital). Stated that\\n she will be driving her car home tomorrow. Stated that she is scared.\\n Follows commands. Continues to try to pull out lines/tubes. Continues\\n to throw her legs over the side of the bed.\\n Action:\\n w/ soft wrist restraints. Reoriented frequently. Assured patient\\n that she is safe in hospital.\\n Response:\\n Patient remains safe. Able to be calmed when told she is safe in\\n hospital.\\n Plan:\\n current safety plan. Reorient frequently. Psych will continue to\\n follow.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-29 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 640111,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Tube Feed goals increased from 30cc to 60cc/hr. No issues O/N with\\n regard to vomiting.\\n Calm overnight. Risperdal decreased from 0.5mg to 0.25mg qam.\\n runs of asymptomatic SVT peaking in 110-120\\ns, metoprolol 37.5mg\\n changed from TID\\nQID and first daily dose given early after runs;\\n decrease of HR to 80\\n Loose, brown, malodorous stools O/N, afebrile, C.dif cx sent.\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Enoxaparin (Lovenox) - 06:33 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:22 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37\\nC (98.6\\n Tcurrent: 36.5\\nC (97.7\\n HR: 114 (61 - 122) bpm\\n BP: 119/54(75) {91/36(50) - 167/84(101)} mmHg\\n RR: 19 (10 - 30) insp/min\\n SpO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 2,952 mL\\n 429 mL\\n PO:\\n TF:\\n 646 mL\\n 376 mL\\n IVF:\\n 950 mL\\n 54 mL\\n Blood products:\\n Total out:\\n 2,430 mL\\n 470 mL\\n Urine:\\n 2,430 mL\\n 240 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 522 mL\\n -41 mL\\n Respiratory support\\n O2 Delivery Device: Aerosol-cool\\n SpO2: 100%\\n ABG: ///35/\\n Physical Examination\\n Gen: Alert, NAD, lying in bed, comfortable, mouthing words, less\\n sedated than yest.\\n HEENT: No pallor in conjunctiva, MMM, TM in place\\n Resp: Transmitted upper airway sounds/coarse breath sounds.\\n Card: S1S2 tachycardic, no m/r/g\\n Abd: Obese, soft, mildly distended, decreased bowel sounds, G-Tube in\\n place with no erythema/induration\\n Exte: No edema, DP 2+ bil\\n NEURO: Alert, difficult to assess orientation due to poor voice\\n although pt oriented to year not place. MAE\\n Labs / Radiology\\n 187 K/uL\\n 7.2 g/dL\\n 105 mg/dL\\n 0.5 mg/dL\\n 35 mEq/L\\n 3.8 mEq/L\\n 17 mg/dL\\n 108 mEq/L\\n 147 mEq/L\\n 23.7 %\\n 5.1 K/uL\\n [image002.jpg]\\n 03:00 AM\\n 04:00 AM\\n 05:45 AM\\n 03:51 AM\\n 04:45 PM\\n 04:00 AM\\n 07:37 PM\\n 04:05 AM\\n 06:05 PM\\n 03:23 AM\\n WBC\\n 7.3\\n 8.0\\n 8.7\\n 5.5\\n 5.7\\n 5.8\\n 5.1\\n Hct\\n 27.3\\n 27.0\\n 28.7\\n 24.7\\n 25.2\\n 25.3\\n 23.7\\n 24.7\\n 23.7\\n Plt\\n 346\\n 316\\n 271\\n 249\\n 231\\n 203\\n 187\\n Cr\\n 0.7\\n 0.7\\n 0.7\\n 0.5\\n 0.4\\n 0.5\\n 0.5\\n 0.5\\n Glucose\\n 123\\n 114\\n 112\\n 122\\n 145\\n 137\\n 149\\n 105\\n Other labs: PT / PTT / INR:13.3/32.4/1.1, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.8 mg/dL, Mg++:2.1 mg/dL, PO4:3.5\\n mg/dL\\n Assessment and Plan\\n 56yoF s/p mechanical fall and traumatic T spine fracture transferred\\n from OSH to for TBM eval with hospitalization complicated by\\n respiratory failure and HAP, s/p trach/PEG, atrial tachycardia, ileus,\\n and delirium/agitation.\\n .\\n # Respiratory: s/p intubation/extubation, now on trach mask, FiO2 50%.\\n Tolerating well with good O2 sat in mid-high 90\\ns. Pt continues to be\\n at risk for aspiration given recent history of vomiting with tube feed\\n trials and increased secretions. ENT believes that the posterior gap is\\n not a risk factor for aspiration as this is a common finding in females\\n and that her increased secretions and edema pose a greater aspiration\\n threat; no intervention was recommended.\\n - Appreciate ENT and S&S input.\\n - ENT recs to f/u in 2wks with Dr. () for an\\n outpatient/clinic re-evaluation.\\n - ppi for aspiration prophylaxis, PMV precautions: \\nt use w/o\\n supervision, frequent suctioning\\n - TM as tolerated.\\n - d/c\\ned scopolamine as it was a cause for delirium.\\n - Holding sedation with exception of Risperidal 0.25mg qam PRN\\n # Delirium/Anxiolysis/AlteredMS: Resolving although pt continues to be\\n slightly agitated. Previous delirium and agitation most likely\\n secondary to long hospital course and multiple psychotropic medications\\n as well as hx of EtOH abuse.\\n - Risperdal 0.25mg PO qam.\\n - continue to hold all benzos. opiates, and antihistamines. Will\\n decrease or d/c raglan and scopolamine.\\n - Appreciate psych. Will call and f/u psych recs.\\n -Follow EKG to assess for QTc prolongation (last EKG ; QTc 457).\\n #Loose Stools: Multiple, loose stools O/N; afebrile, tachycardia,\\n without abdominal pain\\n -F/u stool c.dif cultures\\n -f/u WBC and vital signs daily\\n -Hold bowel regimen\\n # Atrial Tachycardia: Compared to recent b/l, HR increased to max of\\n 120\\ns. Pt now on PO Amiodarone 200 TID and PO increased metoprolol\\n 37.5mg QID.\\n - Will continue amiodarone 200 TID for three weeks and then switch to\\n qday for 1week and then d/c amiodarone.\\n - Will need to schedule f/u in 4wks with Dr. upon d/c/transfer.\\n #Anemia: HCT low compared to b/l. No known etiology of blood loss.\\n -Will continue to follow HCT daily.\\n - Guaiac stools.\\n # Hypernatremia/Fluid Status: Mild hypernatramia resolving with free\\n water administration. On TPN/TF. Good UOP. Free water deficit of 2.8L\\n - increase D5W IVFx 1L from 10cc/hr to 150cc/hr, free water flushes\\n with TF\\n -Will f/u lytes in afternoon (5pm)\\n # UE DVT and h/o labile INR: Decision made to d/c Coumadin given her\\n labile INR, and start Lovenox . INR at 1.1\\n - Will flush L PICC with TPA if does not flush\\n - Daily coags\\n .\\n # Spine fracture: Stable. T5-T8.\\n - Brace for OOB.\\n - Pt to follow up with Dr. in .\\n .\\n # Tracheomalacia. Reevaluation bronchoscopy by IP as written above;\\n patient not a candidate for stent; pt to follow up as outpatient. No\\n new issues.\\n .\\n #. Thyroid Nodule on CT\\n - Outpatient follow up\\n .\\n # Glycemic control: SSI, well controlled\\n # FEN: Currently receiving TF at 50cc/hr, w/o issue.\\n - Appreciate GI input and S&S eval\\n -D/c Reglan for emesis precaution as pt is tolerating TF without\\n vomiting and Reglan increases agitation/delirium risk.\\n -meds via G-J tube,\\n .\\n # ACCESS: PIV x 1, L PICC\\n # Ppx: Lovenox, PPi , Bowel Regimen PRN\\n # Communication:\\n - (brother) is primary contact\\n - Boyfriend of 10 , but minimal contact has been maintained at\\n this point\\n - Social Work and Case management involved; have discussed situation\\n w/ brother and boyfriend.\\n # Code: Full\\n # Dispo: ICU, Will d/w case management re rehab facilities, likely d/c\\n today/tomorrow if insurance/bed confirmed\\n MSIV\\n PGY2 addendum: , \\n Agree with assessment and plan in excellent MSIV note as detailed\\n above. Briefly, 56 F s/p fall with T spine fracture (T5-T8),\\n respiratory failure now s/p trach/PEG. Now on trach mask. Patient s/p\\n bronch with IP yesterday. Nutrition issues continue; have discontinued\\n TPN today and will continue tubefeeding to goal of 60cc/hr per\\n Nutrition. Will continue reglan until at goal feedings, and decrease\\n and d/c as able given potential for delirium. Appreciate psych recs;\\n continuing risperidone for agitation. Etiology of delirium/agitation\\n still unclear but likely prolonged hospital course, illness and\\n multiple medications. Currently discussing with CM about potential\\n placement to rehab tomorrow.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-30 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 640235,\n \"text\": \"Synopsis per prior nursing note:\\n 56 yr old woman, who was transferred from osh for evaluation of\\n tracheal bronchial malacia on .Pt presented to Medical\\n Center on s/p fall down a flight of stairs fracturing, t5-t8 with\\n propulsion treated conservatively with pain meds and back brace. She\\n developed resp distress requiring intubation on . Trach/PEG done\\n . Now with prolonged hospital course c/b by PNA, anxiety/altered\\n mental status, R&LUE DVT .Pt found to have small non occlusive clot on\\n her right axial vein via Ultrasound, now rec\\ning Lovenox. She has had\\n problems with vomiting tube feedings, so feeding tube passed through\\n g-tube to her jejunenum. However, she continued to intermit raise\\n gastric contents assoc with bronchospasm. Has not required ventilation\\n since , on humidified TM @ 50%. Presently on TPN and restarted on\\n TF\\nings at low rate via J-tube.\\n Airway Clearance, Impaired\\n Assessment:\\n LS-bilat rhonchi. O2 sat >95% on 50% humidified trach collar. Suctioned\\n small to moderate amts of frothy and thin, white secretions and pt\\n clearing secretions independently with strong cough.\\n Action:\\n Repositioned frequently and CPT. Suctioned q2-3hours.\\n Response:\\n n/a\\n Plan:\\n Continue to monitor resp status, reposition, CPT as needed.\\n Alteration in Nutrition\\n Assessment:\\n Pt received with tube feeds at goal 60cc/hr and 50cc free water flush\\n q4hour via J-tube. Denies nausea, stomach pain or cramping. No\\n vomiting. K 3.6.\\n Action:\\n Unable to check residuals. Tube feeds stopped at 5AM after ?tube feeds\\n were suctioned from back of throat. Unlikely aspirated sats 100%.\\n Colace/senna/polyethylene glycol held for loose stool. Mushroom\\n catheter pulled out x2 this shift and not replaced after 2^nd time.\\n Stool #2 sent for c.diff. Repleted with 40 mEq KCl.\\n Response:\\n Currently TF stopped, team aware.\\n Plan:\\n Restart TF. Monitor labs and replete lytes as needed.\\n Altered mental status (not Delirium)\\n Assessment:\\n Alert and oriented x2. Continues to think she is in a hotel. Pt\\n restless and agitated many times throughout night. Pulled out rectal\\n tube x2 and foley x1 this shift. Follows commands. PERL brisk.\\n Action:\\n Soft wrist restraints for pt safetly to pulling at lines and hx to\\n decanulating herself. Bed locked in low position and bed alarm on.\\n Reoriented frequently. All meds and interventions explained.\\n Response:\\n Patient remains safe. Continues to throw her legs over the side of the\\n bed and pull at lines.\\n Plan:\\n Continue current safety plan. Reorient frequently. Psych consulting.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-30 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 640247,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n - ENT team believes that vocal cord adductor dysfunction is NOT a risk\\n for aspiration, rather her increased secretions put her at risk for\\n aspiration. They will follow-up in clinic in two weeks with Dr.\\n , call in am to schedule appt.\\n - Psych recs: consider head CT if patient does not improve off\\n scopolamine and metoclopramide; address anemia and\\nerratic BP\\n consider increasing am dose of risperdal; monitor \\n - Pt continued to be agitated O/N (eg: pulled rectal tubex2 and\\n foleyx1, disoriented). To receive head CT this AM\\n -HCT at 22.8 down 1pt with b/l in high 20\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:00 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:28 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.6\\nC (97.9\\n Tcurrent: 36.6\\nC (97.9\\n HR: 77 (66 - 114) bpm\\n BP: 128/40(60) {90/37(31) - 164/75(87)} mmHg\\n RR: 23 (16 - 29) insp/min\\n SpO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 1,726 mL\\n 595 mL\\n PO:\\n TF:\\n 1,388 mL\\n 301 mL\\n IVF:\\n 249 mL\\n 105 mL\\n Blood products:\\n Total out:\\n 1,666 mL\\n 222 mL\\n Urine:\\n 836 mL\\n 222 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 60 mL\\n 373 mL\\n Respiratory support\\n O2 Delivery Device: Aerosol-cool\\n SpO2: 100%\\n ABG: ///34/\\n Physical Examination\\n Gen: Alert, NAD, lying in bed, comfortable, mouthing words, less\\n sedated than yest.\\n HEENT: No pallor in conjunctiva, MMM, TM in place\\n Resp: Transmitted upper airway sounds/coarse breath sounds.\\n Card: S1S2 tachycardic, no m/r/g\\n Abd: Obese, soft, mildly distended, decreased bowel sounds, G-Tube in\\n place with no erythema/induration\\n Exte: No edema, DP 2+ bil\\n NEURO: Alert, difficult to assess orientation due to poor voice\\n although pt oriented to year not place. MAE\\n Labs / Radiology\\n 183 K/uL\\n 7.1 g/dL\\n 115 mg/dL\\n 0.5 mg/dL\\n 34 mEq/L\\n 3.6 mEq/L\\n 13 mg/dL\\n 106 mEq/L\\n 145 mEq/L\\n 22.8 %\\n 5.4 K/uL\\n [image002.jpg]\\n 04:00 AM\\n 05:45 AM\\n 03:51 AM\\n 04:45 PM\\n 04:00 AM\\n 07:37 PM\\n 04:05 AM\\n 06:05 PM\\n 03:23 AM\\n 02:54 AM\\n WBC\\n 8.0\\n 8.7\\n 5.5\\n 5.7\\n 5.8\\n 5.1\\n 5.4\\n Hct\\n 27.0\\n 28.7\\n 24.7\\n 25.2\\n 25.3\\n 23.7\\n 24.7\\n 23.7\\n 22.8\\n Plt\\n \\n 183\\n Cr\\n 0.7\\n 0.7\\n 0.5\\n 0.4\\n 0.5\\n 0.5\\n 0.5\\n 0.5\\n Glucose\\n 114\\n 112\\n 122\\n 145\\n 137\\n 149\\n 105\\n 115\\n Other labs: PT / PTT / INR:13.3/32.4/1.1, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.4 mg/dL, Mg++:1.9 mg/dL, PO4:3.6\\n mg/dL\\n Assessment and Plan\\n 56yoF s/p mechanical fall and traumatic T spine fracture transferred\\n from OSH to for TBM eval with hospitalization complicated by\\n respiratory failure and HAP, s/p trach/PEG, atrial tachycardia, ileus,\\n and delirium/agitation.\\n .\\n # Delirium: Pt continues to be agitated with paranoia and\\n disorientation with paranoia and hallucinations. Delirium and agitation\\n most likely secondary to long hospital course and multiple psychotropic\\n medications as well as hx of EtOH abuse; yet could also be due to\\n anemia. Other lab values (lytes, past LFTs within normal limits). CT of\\n head at OSH negative. d/c\\ned Reglan and scopolamine.\\n - Consider CT of head with contrast if mental status does not improve\\n this am.\\n - U/A\\n - Risperdal 0.25mg PO qam. Consider increasing per psych recs to 0.5mg\\n if continues to be agitated.\\n - continue to hold all benzos. opiates, and antihistamines. Will\\n decrease or d/c raglan and scopolamine.\\n - Appreciate psych. Will call and f/u psych recs.\\n -Follow EKG to assess for prolongation (last EKG ; 457).\\n #Anemia: HCT continues to decrease, currently at 22.8 from 23.7 with\\n b/l in high 20\\ns. No known etiology of blood loss.\\n -Will continue to follow HCT with 1pm HCT.\\n - Guaiac stools.\\n -T&S. Transfuse 1unit\\n # Respiratory: s/p trach on trach mask, FiO2 50%. Tolerating well with\\n good O2 sat in mid-high 90\\ns. Pt continues to be at risk for aspiration\\n given recent history of vomiting with tube feed trials and increased\\n secretions. ENT believes that the posterior gap is not a risk factor\\n for aspiration as this is a common finding in females and that her\\n increased secretions and edema pose a greater aspiration threat; no\\n intervention was recommended.\\n - Appreciate ENT and S&S input.\\n - ENT recs to f/u in 2wks with Dr. () for an\\n outpatient/clinic re-evaluation. Will schedule appt today.\\n - ppi for aspiration prophylaxis, PMV precautions: \\nt use w/o\\n supervision, frequent suctioning\\n - TM as tolerated.\\n - Holding sedation with exception of Risperidal 0.25mg PO qam\\n #Loose Stools: rectal tube pulled out x2; afebrile, HD stable, without\\n abdominal pain\\n -F/u stool c.dif cultures\\n -f/u WBC and vital signs daily\\n -Hold bowel regimen\\n # Atrial Tachycardia: Stable without issue O/N. Pt now on PO Amiodarone\\n 200 TID and PO metoprolol 50mg TID\\n - Will continue amiodarone 200 TID for three weeks (start ?) and\\n then switch to qday for 1week and then d/c amiodarone.\\n - Will need to schedule f/u in 4wks with Dr. upon d/c/transfer.\\n # Hypernatremia/Fluid Status: Mild hypernatramia resolving with free\\n water administration. On TPN/TF. Good UOP. Free water deficit of 2.8L\\n - increase D5W IVFx 1L from 10cc/hr to 150cc/hr, free water flushes\\n with TF\\n -Will f/u lytes in afternoon (5pm)\\n # UE DVT and h/o labile INR: Decision made to d/c Coumadin given her\\n labile INR, and start Lovenox . INR at 1.1\\n - Will flush L PICC with TPA if does not flush\\n - Daily coags\\n .\\n # Spine fracture: Stable. T5-T8.\\n - Brace for OOB.\\n - Pt to follow up with Dr. in .\\n .\\n # Tracheomalacia. Reevaluation bronchoscopy by IP as written above;\\n patient not a candidate for stent; pt to follow up as outpatient. No\\n new issues.\\n .\\n #. Thyroid Nodule on CT\\n - Outpatient follow up\\n .\\n # Glycemic control: SSI, well controlled\\n # FEN: Currently receiving TF at 50cc/hr, w/o issue.\\n - Appreciate GI input and S&S eval\\n -D/c Reglan for emesis precaution as pt is tolerating TF without\\n vomiting and Reglan increases agitation/delirium risk.\\n -meds via G-J tube,\\n .\\n # ACCESS: PIV x 1, L PICC\\n # Ppx: Lovenox, PPi , Bowel Regimen PRN\\n # Communication:\\n - (brother) is primary contact\\n - Boyfriend of 10 , but minimal contact has been maintained at\\n this point\\n - Social Work and Case management involved; have discussed situation\\n w/ brother and boyfriend.\\n # Code: Full\\n # Dispo: ICU, Will d/w case management re rehab facilities, likely d/c\\n today/tomorrow if insurance/bed confirmed\\n MSIV\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n PICC Line - 01:30 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-29 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 640108,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Tube Feed goals increased from 30cc to 60cc/hr. No issues O/N with\\n regard to vomiting.\\n Calm overnight. Risperdal decreased from 0.5mg to 0.25mg qam.\\n runs of asymptomatic SVT peaking in 110-120\\ns, metoprolol 37.5mg\\n changed from TID\\nQID and first daily dose given early after runs;\\n decrease of HR to 80\\n Loose, brown, malodorous stools O/N, afebrile, C.dif cx sent.\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Enoxaparin (Lovenox) - 06:33 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:22 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37\\nC (98.6\\n Tcurrent: 36.5\\nC (97.7\\n HR: 114 (61 - 122) bpm\\n BP: 119/54(75) {91/36(50) - 167/84(101)} mmHg\\n RR: 19 (10 - 30) insp/min\\n SpO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 2,952 mL\\n 429 mL\\n PO:\\n TF:\\n 646 mL\\n 376 mL\\n IVF:\\n 950 mL\\n 54 mL\\n Blood products:\\n Total out:\\n 2,430 mL\\n 470 mL\\n Urine:\\n 2,430 mL\\n 240 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 522 mL\\n -41 mL\\n Respiratory support\\n O2 Delivery Device: Aerosol-cool\\n SpO2: 100%\\n ABG: ///35/\\n Physical Examination\\n Gen: Alert, NAD, lying in bed, comfortable, mouthing words, less\\n sedated than yest.\\n HEENT: No pallor in conjunctiva, MMM, TM in place\\n Resp: Transmitted upper airway sounds/coarse breath sounds.\\n Card: S1S2 tachycardic, no m/r/g\\n Abd: Obese, soft, mildly distended, decreased bowel sounds, G-Tube in\\n place with no erythema/induration\\n Exte: No edema, DP 2+ bil\\n NEURO: Alert, difficult to assess orientation due to poor voice\\n although pt oriented to year not place. MAE\\n Labs / Radiology\\n 187 K/uL\\n 7.2 g/dL\\n 105 mg/dL\\n 0.5 mg/dL\\n 35 mEq/L\\n 3.8 mEq/L\\n 17 mg/dL\\n 108 mEq/L\\n 147 mEq/L\\n 23.7 %\\n 5.1 K/uL\\n [image002.jpg]\\n 03:00 AM\\n 04:00 AM\\n 05:45 AM\\n 03:51 AM\\n 04:45 PM\\n 04:00 AM\\n 07:37 PM\\n 04:05 AM\\n 06:05 PM\\n 03:23 AM\\n WBC\\n 7.3\\n 8.0\\n 8.7\\n 5.5\\n 5.7\\n 5.8\\n 5.1\\n Hct\\n 27.3\\n 27.0\\n 28.7\\n 24.7\\n 25.2\\n 25.3\\n 23.7\\n 24.7\\n 23.7\\n Plt\\n 346\\n 316\\n 271\\n 249\\n 231\\n 203\\n 187\\n Cr\\n 0.7\\n 0.7\\n 0.7\\n 0.5\\n 0.4\\n 0.5\\n 0.5\\n 0.5\\n Glucose\\n 123\\n 114\\n 112\\n 122\\n 145\\n 137\\n 149\\n 105\\n Other labs: PT / PTT / INR:13.3/32.4/1.1, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.8 mg/dL, Mg++:2.1 mg/dL, PO4:3.5\\n mg/dL\\n Assessment and Plan\\n 56yoF s/p mechanical fall and traumatic T spine fracture transferred\\n from OSH to for TBM eval with hospitalization complicated by\\n respiratory failure and HAP, s/p trach/PEG, atrial tachycardia, ileus,\\n and delirium/agitation.\\n .\\n # Respiratory: s/p intubation/extubation, now on trach mask, FiO2 50%.\\n Tolerating well with good O2 sat in mid-high 90\\ns. Pt continues to be\\n at risk for aspiration given recent history of vomiting with tube feed\\n trials and increased secretions. ENT believes that the posterior gap is\\n not a risk factor for aspiration as this is a common finding in females\\n and that her increased secretions and edema pose a greater aspiration\\n threat; no intervention was recommended.\\n - Appreciate ENT and S&S input.\\n - ENT recs to f/u in 2wks with Dr. () for an\\n outpatient/clinic re-evaluation.\\n - ppi for aspiration prophylaxis, PMV precautions: \\nt use w/o\\n supervision, frequent suctioning\\n - TM as tolerated.\\n - d/c\\ned scopolamine as it was a cause for delirium.\\n - Holding sedation with exception of Risperidal 0.25mg qam PRN\\n #Loose Stools: Multiple, loose stools O/N; afebrile, tachycardia,\\n without abdominal pain\\n -F/u stool c.dif cultures\\n -f/u WBC and vital signs daily\\n -Hold bowel regimen\\n # Atrial Tachycardia: Compared to recent b/l, HR increased to max of\\n 120\\ns. Pt now on PO Amiodarone 200 TID and PO increased metoprolol\\n 37.5mg QID.\\n - Will continue amiodarone 200 TID for three weeks and then switch to\\n qday for 1week and then d/c amiodarone.\\n - Will need to schedule f/u in 4wks with Dr. upon d/c/transfer.\\n # Delirium/Anxiolysis/AlteredMS: Resolving although pt continues to be\\n slightly agitated. Previous delirium and agitation most likely\\n secondary to long hospital course and multiple psychotropic medications\\n as well as hx of EtOH abuse.\\n - Risperdal 0.25mg PO qam.\\n - continue to hold all benzos. opiates, and antihistamines\\n - Appreciate psych. Will call and f/u psych recs.\\n -Follow EKG to assess for QTc prolongation (last EKG ; QTc 457).\\n #Anemia: HCT low compared to b/l. No known etiology of blood loss.\\n -Will continue to follow HCT daily.\\n - Guaiac stools.\\n # Hypernatremia/Fluid Status: Mild hypernatramia resolving with free\\n water administration. On TPN/TF. Good UOP. Free water deficit of 2.8L\\n - increase D5W IVFx 1L from 10cc/hr to 150cc/hr, free water flushes\\n with TF\\n -Will f/u lytes in afternoon (5pm)\\n # UE DVT and h/o labile INR: Decision made to d/c Coumadin given her\\n labile INR, and start Lovenox . INR at 1.1\\n - Will flush L PICC with TPA if does not flush\\n - Daily coags\\n .\\n # Spine fracture: Stable. T5-T8.\\n - Brace for OOB.\\n - Pt to follow up with Dr. in .\\n .\\n # Tracheomalacia. Reevaluation bronchoscopy by IP as written above;\\n patient not a candidate for stent; pt to follow up as outpatient. No\\n new issues.\\n .\\n #. Thyroid Nodule on CT\\n - Outpatient follow up\\n .\\n # Glycemic control: SSI, well controlled\\n # FEN: Currently receiving TF at 50cc/hr, w/o issue.\\n - Appreciate GI input and S&S eval\\n -D/c Reglan for emesis precaution as pt is tolerating TF without\\n vomiting and Reglan increases agitation/delirium risk.\\n -meds via G-J tube,\\n .\\n # ACCESS: PIV x 1, L PICC\\n # Ppx: Lovenox, PPi , Bowel Regimen PRN\\n # Communication:\\n - (brother) is primary contact\\n - Boyfriend of 10 , but minimal contact has been maintained at\\n this point\\n - Social Work and Case management involved; have discussed situation\\n w/ brother and boyfriend.\\n # Code: Full\\n # Dispo: ICU, Will d/w case management re rehab facilities, likely d/c\\n today/tomorrow if insurance/bed confirmed\\n MSIV\\n PGY2 addendum: , \\n Agree with assessment and plan in excellent MSIV note as detailed\\n above. Briefly, 56 F s/p fall with T spine fracture (T5-T8),\\n respiratory failure now s/p trach/PEG. Now on trach mask. Patient s/p\\n bronch with IP yesterday. Nutrition issues continue; have discontinued\\n TPN today and will continue tubefeeding to goal of 60cc/hr per\\n Nutrition. Will continue reglan until at goal feedings, and decrease\\n and d/c as able given potential for delirium. Appreciate psych recs;\\n continuing risperidone for agitation. Etiology of delirium/agitation\\n still unclear but likely prolonged hospital course, illness and\\n multiple medications. Currently discussing with CM about potential\\n placement to rehab tomorrow.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-29 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 640112,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Tube Feed goals increased from 30cc to 60cc/hr. No issues O/N with\\n regard to vomiting.\\n Calm overnight. Risperdal decreased from 0.5mg to 0.25mg qam.\\n runs of asymptomatic SVT peaking in 110-120\\ns, metoprolol 37.5mg\\n changed from TID\\nQID and first daily dose given early after runs;\\n decrease of HR to 80\\n Loose, brown, malodorous stools O/N, afebrile, C.dif cx sent.\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Enoxaparin (Lovenox) - 06:33 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:22 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37\\nC (98.6\\n Tcurrent: 36.5\\nC (97.7\\n HR: 114 (61 - 122) bpm\\n BP: 119/54(75) {91/36(50) - 167/84(101)} mmHg\\n RR: 19 (10 - 30) insp/min\\n SpO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 2,952 mL\\n 429 mL\\n PO:\\n TF:\\n 646 mL\\n 376 mL\\n IVF:\\n 950 mL\\n 54 mL\\n Blood products:\\n Total out:\\n 2,430 mL\\n 470 mL\\n Urine:\\n 2,430 mL\\n 240 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 522 mL\\n -41 mL\\n Respiratory support\\n O2 Delivery Device: Aerosol-cool\\n SpO2: 100%\\n ABG: ///35/\\n Physical Examination\\n Gen: Alert, NAD, lying in bed, comfortable, mouthing words, less\\n sedated than yest.\\n HEENT: No pallor in conjunctiva, MMM, TM in place\\n Resp: Transmitted upper airway sounds/coarse breath sounds.\\n Card: S1S2 tachycardic, no m/r/g\\n Abd: Obese, soft, mildly distended, decreased bowel sounds, G-Tube in\\n place with no erythema/induration\\n Exte: No edema, DP 2+ bil\\n NEURO: Alert, difficult to assess orientation due to poor voice\\n although pt oriented to year not place. MAE\\n Labs / Radiology\\n 187 K/uL\\n 7.2 g/dL\\n 105 mg/dL\\n 0.5 mg/dL\\n 35 mEq/L\\n 3.8 mEq/L\\n 17 mg/dL\\n 108 mEq/L\\n 147 mEq/L\\n 23.7 %\\n 5.1 K/uL\\n [image002.jpg]\\n 03:00 AM\\n 04:00 AM\\n 05:45 AM\\n 03:51 AM\\n 04:45 PM\\n 04:00 AM\\n 07:37 PM\\n 04:05 AM\\n 06:05 PM\\n 03:23 AM\\n WBC\\n 7.3\\n 8.0\\n 8.7\\n 5.5\\n 5.7\\n 5.8\\n 5.1\\n Hct\\n 27.3\\n 27.0\\n 28.7\\n 24.7\\n 25.2\\n 25.3\\n 23.7\\n 24.7\\n 23.7\\n Plt\\n 346\\n 316\\n 271\\n 249\\n 231\\n 203\\n 187\\n Cr\\n 0.7\\n 0.7\\n 0.7\\n 0.5\\n 0.4\\n 0.5\\n 0.5\\n 0.5\\n Glucose\\n 123\\n 114\\n 112\\n 122\\n 145\\n 137\\n 149\\n 105\\n Other labs: PT / PTT / INR:13.3/32.4/1.1, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.8 mg/dL, Mg++:2.1 mg/dL, PO4:3.5\\n mg/dL\\n Assessment and Plan\\n 56yoF s/p mechanical fall and traumatic T spine fracture transferred\\n from OSH to for TBM eval with hospitalization complicated by\\n respiratory failure and HAP, s/p trach/PEG, atrial tachycardia, ileus,\\n and delirium/agitation.\\n .\\n # Respiratory: s/p intubation/extubation, now on trach mask, FiO2 50%.\\n Tolerating well with good O2 sat in mid-high 90\\ns. Pt continues to be\\n at risk for aspiration given recent history of vomiting with tube feed\\n trials and increased secretions. ENT believes that the posterior gap is\\n not a risk factor for aspiration as this is a common finding in females\\n and that her increased secretions and edema pose a greater aspiration\\n threat; no intervention was recommended.\\n - Appreciate ENT and S&S input.\\n - ENT recs to f/u in 2wks with Dr. () for an\\n outpatient/clinic re-evaluation.\\n - ppi for aspiration prophylaxis, PMV precautions: \\nt use w/o\\n supervision, frequent suctioning\\n - TM as tolerated.\\n - d/c scopolamine as it was a cause for delirium.\\n - Holding sedation with exception of Risperidal 0.25mg qam PRN\\n # Delirium/Anxiolysis/AlteredMS: Resolving although pt continues to be\\n slightly agitated. Previous delirium and agitation most likely\\n secondary to long hospital course and multiple psychotropic medications\\n as well as hx of EtOH abuse.\\n - Risperdal 0.25mg PO qam.\\n - continue to hold all benzos. opiates, and antihistamines. Will\\n decrease or d/c raglan and scopolamine.\\n - Appreciate psych. Will call and f/u psych recs.\\n -Follow EKG to assess for QTc prolongation (last EKG ; QTc 457).\\n #Loose Stools: Multiple, loose stools O/N; afebrile, tachycardia,\\n without abdominal pain\\n -F/u stool c.dif cultures\\n -f/u WBC and vital signs daily\\n -Hold bowel regimen\\n # Atrial Tachycardia: Compared to recent b/l, HR increased to max of\\n 120\\ns. Pt now on PO Amiodarone 200 TID and PO increased metoprolol\\n 37.5mg QID.\\n - Will continue amiodarone 200 TID for three weeks and then switch to\\n qday for 1week and then d/c amiodarone.\\n - Will need to schedule f/u in 4wks with Dr. upon d/c/transfer.\\n #Anemia: HCT low compared to b/l. No known etiology of blood loss.\\n -Will continue to follow HCT daily.\\n - Guaiac stools.\\n # Hypernatremia/Fluid Status: Mild hypernatramia resolving with free\\n water administration. On TPN/TF. Good UOP. Free water deficit of 2.8L\\n - increase D5W IVFx 1L from 10cc/hr to 150cc/hr, free water flushes\\n with TF\\n -Will f/u lytes in afternoon (5pm)\\n # UE DVT and h/o labile INR: Decision made to d/c Coumadin given her\\n labile INR, and start Lovenox . INR at 1.1\\n - Will flush L PICC with TPA if does not flush\\n - Daily coags\\n .\\n # Spine fracture: Stable. T5-T8.\\n - Brace for OOB.\\n - Pt to follow up with Dr. in .\\n .\\n # Tracheomalacia. Reevaluation bronchoscopy by IP as written above;\\n patient not a candidate for stent; pt to follow up as outpatient. No\\n new issues.\\n .\\n #. Thyroid Nodule on CT\\n - Outpatient follow up\\n .\\n # Glycemic control: SSI, well controlled\\n # FEN: Currently receiving TF at 50cc/hr, w/o issue.\\n - Appreciate GI input and S&S eval\\n -D/c Reglan for emesis precaution as pt is tolerating TF without\\n vomiting and Reglan increases agitation/delirium risk.\\n -meds via G-J tube,\\n .\\n # ACCESS: PIV x 1, L PICC\\n # Ppx: Lovenox, PPi , Bowel Regimen PRN\\n # Communication:\\n - (brother) is primary contact\\n - Boyfriend of 10 , but minimal contact has been maintained at\\n this point\\n - Social Work and Case management involved; have discussed situation\\n w/ brother and boyfriend.\\n # Code: Full\\n # Dispo: ICU, Will d/w case management re rehab facilities, likely d/c\\n today/tomorrow if insurance/bed confirmed\\n MSIV\\n PGY2 addendum: , \\n Agree with assessment and plan in excellent MSIV note as detailed\\n above. Briefly, 56 F s/p fall with T spine fracture (T5-T8),\\n respiratory failure now s/p trach/PEG. Now on trach mask. Patient s/p\\n bronch with IP yesterday. Nutrition issues continue; have discontinued\\n TPN today and will continue tubefeeding to goal of 60cc/hr per\\n Nutrition. Will continue reglan until at goal feedings, and decrease\\n and d/c as able given potential for delirium. Appreciate psych recs;\\n continuing risperidone for agitation. Etiology of delirium/agitation\\n still unclear but likely prolonged hospital course, illness and\\n multiple medications. Currently discussing with CM about potential\\n placement to rehab tomorrow.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-31 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 640424,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Going to rehab 10am on Saturday\\n DC summary up to date\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Enoxaparin (Lovenox) - 06:00 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 04:47 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.7\\nC (98.1\\n Tcurrent: 36.2\\nC (97.2\\n HR: 72 (66 - 88) bpm\\n BP: 104/63(70) {78/34(48) - 186/71(98)} mmHg\\n RR: 25 (15 - 33) insp/min\\n SpO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 1,197 mL\\n 380 mL\\n PO:\\n TF:\\n 301 mL\\n 285 mL\\n IVF:\\n 577 mL\\n 95 mL\\n Blood products:\\n Total out:\\n 867 mL\\n 245 mL\\n Urine:\\n 867 mL\\n 245 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 330 mL\\n 135 mL\\n Respiratory support\\n SpO2: 98%\\n ABG: ///36/\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 197 K/uL\\n 7.1 g/dL\\n 117\\n 0.6 mg/dL\\n 36 mEq/L\\n 4.0 mEq/L\\n 11 mg/dL\\n 106 mEq/L\\n 146 mEq/L\\n 22.7 %\\n 4.9 K/uL\\n [image002.jpg]\\n 04:45 PM\\n 04:00 AM\\n 07:37 PM\\n 04:05 AM\\n 06:05 PM\\n 03:23 AM\\n 02:54 AM\\n 04:14 PM\\n 10:00 PM\\n 03:46 AM\\n WBC\\n 5.7\\n 5.8\\n 5.1\\n 5.4\\n 5.2\\n 4.9\\n Hct\\n 25.2\\n 25.3\\n 23.7\\n 24.7\\n 23.7\\n 22.8\\n 24.0\\n 22.7\\n Plt\\n 83\\n 185\\n 197\\n Cr\\n 0.4\\n 0.5\\n 0.5\\n 0.5\\n 0.5\\n 0.6\\n Glucose\\n 145\\n 137\\n 149\\n 105\\n 115\\n 95\\n 117\\n Other labs: PT / PTT / INR:13.2/23.9/1.1, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.9 mg/dL, Mg++:1.9 mg/dL, PO4:3.6\\n mg/dL\\n Assessment and Plan\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 12:00 AM 60 mL/hour\\n Glycemic Control:\\n Lines:\\n PICC Line - 01:30 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-31 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 640425,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Going to rehab 10am on Saturday\\n DC summary up to date\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Enoxaparin (Lovenox) - 06:00 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 04:47 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.7\\nC (98.1\\n Tcurrent: 36.2\\nC (97.2\\n HR: 72 (66 - 88) bpm\\n BP: 104/63(70) {78/34(48) - 186/71(98)} mmHg\\n RR: 25 (15 - 33) insp/min\\n SpO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 1,197 mL\\n 380 mL\\n PO:\\n TF:\\n 301 mL\\n 285 mL\\n IVF:\\n 577 mL\\n 95 mL\\n Blood products:\\n Total out:\\n 867 mL\\n 245 mL\\n Urine:\\n 867 mL\\n 245 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 330 mL\\n 135 mL\\n Respiratory support\\n SpO2: 98%\\n ABG: ///36/\\n Physical Examination\\n Gen: NAD, lying in bed, comfortable, PMV on, able to vocalize. HEENT:\\n No pallor in conjunctiva, MMM, TM in place\\n Resp: Transmitted upper airway sounds/coarse breath sounds, improved\\n compared to yesterday.\\n Card: S1S2 tachycardic, no m/r/g\\n Abd: Obese, soft, mildly distended, decreased bowel sounds, G-Tube in\\n place with no s/s of infection\\n Exte: No edema, DP 2+ bil\\n NEURO: AxO to year (not to place or day-thinks it is\\nthe day before\\n \\n), MAE\\n Labs / Radiology\\n 197 K/uL\\n 7.1 g/dL\\n 117\\n 0.6 mg/dL\\n 36 mEq/L\\n 4.0 mEq/L\\n 11 mg/dL\\n 106 mEq/L\\n 146 mEq/L\\n 22.7 %\\n 4.9 K/uL\\n [image002.jpg]\\n 04:45 PM\\n 04:00 AM\\n 07:37 PM\\n 04:05 AM\\n 06:05 PM\\n 03:23 AM\\n 02:54 AM\\n 04:14 PM\\n 10:00 PM\\n 03:46 AM\\n WBC\\n 5.7\\n 5.8\\n 5.1\\n 5.4\\n 5.2\\n 4.9\\n Hct\\n 25.2\\n 25.3\\n 23.7\\n 24.7\\n 23.7\\n 22.8\\n 24.0\\n 22.7\\n Plt\\n 83\\n 185\\n 197\\n Cr\\n 0.4\\n 0.5\\n 0.5\\n 0.5\\n 0.5\\n 0.6\\n Glucose\\n 145\\n 137\\n 149\\n 105\\n 115\\n 95\\n 117\\n Other labs: PT / PTT / INR:13.2/23.9/1.1, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.9 mg/dL, Mg++:1.9 mg/dL, PO4:3.6\\n mg/dL\\n Assessment and Plan\\n 56yoF s/p mechanical fall and traumatic T spine fracture transferred\\n from OSH to for TBM eval with hospitalization complicated by\\n respiratory failure and HAP, s/p trach/PEG, atrial tachycardia, ileus,\\n and delirium/agitation.\\n .\\n # Delirium: Pt continues to be agitated with paranoia, disorientation\\n and hallucinations. Most likely secondary to long hospital course and\\n recent multiple psychotropic medications. Other lab values (lytes, past\\n LFTs within normal limits), infections processes negative on culture.\\n CT of head at OSH negative. d/c\\ned Reglan and scopolamine.\\n - Appreciate psych. Will call and f/u psych recs.\\n -Consider CT of head with contrast if mental status does not improve\\n this am.\\n - Risperdal 0.25mg PO qam. Consider increasing per psych recs to 0.5mg\\n if continues to be agitated. Will d/w psych re any additional meds we\\n could use for night time agitation.\\n - continue to hold all benzos. opiates, and antihistamines.\\n -Follow EKG to assess for QTc prolongation (last EKG ; QTc 457).\\n #Anemia: HCT continues to decrease, currently at 22.8 from 23.7 with\\n b/l in high 20\\ns. No known etiology of blood loss.\\n -Will continue to follow HCT\\n - Guaiac stools.\\n # Respiratory: s/p trach on trach mask, FiO2 50%. Tolerating well with\\n good O2 sat in mid-high 90\\ns. Pt continues to be at risk for aspiration\\n given recent history of vomiting with tube feed trials and increased\\n secretions. ENT believes that the posterior gap is not a risk factor\\n for aspiration as this is a common finding in females and that her\\n increased secretions and edema pose a greater aspiration threat; no\\n intervention was recommended.\\n - Appreciate ENT and S&S input.\\n - Pt to f/u on ^th at 3:30pm with Dr. \\n () for an outpatient/clinic re-evaluation.\\n - ppi for aspiration prophylaxis, PMV precautions: \\nt use w/o\\n supervision, frequent suctioning\\n - TM as tolerated.\\n - Holding sedation with exception of Risperidal 0.25mg PO qam\\n #Loose Stools: rectal tube pulled out x2; afebrile, HD stable, without\\n abdominal pain. Stool cdif cx negativex1.\\n -F/u stool c.dif cultures\\n -f/u WBC and vital signs daily\\n -Hold bowel regimen\\n # Atrial Tachycardia: Stable without issue O/N. Pt now on PO Amiodarone\\n 200 TID and PO metoprolol 50mg TID\\n - Will continue amiodarone 200 TID for three weeks (start ) and\\n then switch to qday for 1week and then d/c amiodarone.\\n - Will need to schedule f/u in 4wks with Dr. upon d/c/transfer.\\n # Hypernatremia/Fluid Status: resolving after free water\\n administration. On TPN/TF. Free water deficit of 1.6L\\n - increase NS at 10cc/hr, water flushes with TF\\n -Will f/u lytes \\n # UE DVT and h/o labile INR: Decision made to d/c Coumadin given her\\n labile INR, and start Lovenox . INR at 1.1\\n - Will flush L PICC with TPA if does not flush\\n - Daily coags\\n .\\n # Spine fracture: Stable. T5-T8.\\n - Brace for OOB.\\n - Pt to follow up with Dr. in .\\n .\\n # Tracheomalacia. Reevaluation bronchoscopy by IP as written above;\\n patient not a candidate for stent; pt to follow up as outpatient. No\\n new issues.\\n .\\n #. Thyroid Nodule on CT\\n - Outpatient follow up\\n .\\n # Glycemic control: SSI, well controlled\\n # FEN: Currently TF held secondary to possible risk of aspiration O/N;\\n will increase TF back slowly to max goal.\\n - Appreciate GI input and S&S eval\\n -D/c\\ned Reglan for emesis precaution as pt is tolerating TF without\\n vomiting and Reglan increases agitation/delirium risk.\\n -meds via G-J tube\\n .\\n # ACCESS: L PICC\\n # Ppx: Lovenox, PPi , Bowel Regimen PRN currently held\\n # Communication:\\n - (brother) is primary contact; visiting\\n patient today and aware of status and disposition\\n - Boyfriend of 10 , but minimal contact has been maintained at\\n this point\\n - Social Work and Case management involved\\n # Code: Full\\n # Dispo: ICU, Will currently has bed at Rehab and waiting\\n insurance approval before transfer of care.\\n MSIV\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 12:00 AM 60 mL/hour\\n Glycemic Control:\\n Lines:\\n PICC Line - 01:30 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-28 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 639938,\n \"text\": \"56 yr old woman, who was transferred from osh for evaluation of\\n tracheal bronchial malacia on .Pt presented to Medical\\n Center on s/p fall down a flight of stairs fracturing, t5-t8 with\\n propulsion treated conservatively with pain meds and back brace. She\\n developed resp distress requiring intubation on . Trach/PEG done\\n . Now with prolonged hospital course c/b by PNA, anxiety/altered\\n mental status, R&LUE DVT .Pt found to have small non occlusive clot on\\n her right axial vein via Ultrasound, now rec\\ning Lovenox. She has had\\n problems with vomiting tube feedings, so feeding tube passed through\\n g-tube to her jejunenum. However, she continued to intermit raise\\n gastric contents assoc with bronchospasm. Has not required ventilation\\n since , on humidified TM @ 50%. Presently on TPN and restarted on\\n TF\\nings at low rate via J-tube.\\n Airway Clearance, Impaired\\n Assessment:\\n Pt conts to have a large amount of secreations, she has been requiring\\n q1 hr suctioning from her trache\\n light yellow in color. Her 02 SATs\\n have been in the upper 90s on 50% trache mask.\\n Action:\\n Scopolamine patch added, freaquent suctioning\\n Response:\\n Large amounts of secreations through the day\\n Plan:\\n Cont to watch, cont with the scopolamine patch\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt was somulent this morning but was awake enough this afternoon to\\n help us get her out of bed with 2 strong assists. She is able to\\n follow commands but continues to require wrist restraints to keep her\\n trache in place and her in bed.\\n Action:\\n Reperidol conts\\n Response:\\n Not as agitated as she has been, able to cooperate with some care\\n Plan:\\n Cont with the resperidol, cont to follow\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2167-10-30 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 640225,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 42\\n Ideal body weight: 61.2 None\\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\\n Tracheostomy tube:\\n Type: Standard, Cuffed, Inner Cannula\\n Manufacturer: Portex\\n Size: 7.0mm\\n PMV:\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 22 cmH2O\\n Cuff volume: mL /\\n Airway problems:\\n Comments:\\n Lung sounds\\n RLL Lung Sounds: Rhonchi\\n RUL Lung Sounds: Rhonchi\\n LUL Lung Sounds: Rhonchi\\n LLL Lung Sounds: Rhonchi\\n Comments:\\n Secretions\\n Sputum color / consistency: White / Thin\\n Sputum source/amount: Suctioned / Small\\n Comments:\\n Pt has not required ventiatory assistance over past several days.\\n Remains on 50% humidified trach collar.\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2167-10-28 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 639939,\n \"text\": \"Demographics\\n Ideal body weight: 61.2 None\\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: Yes\\n Tube Type\\n Tracheostomy tube:\\n Type: Standard, Cuffed\\n Manufacturer: Portex\\n Size: 7.0mm\\n PMV: as tolerated\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Diminished\\n Secretions\\n Sputum color / consistency: Yellow / Thick\\n Sputum source/amount: Suctioned / Copious\\n Visual assessment of breathing pattern: Pt off ventilatory support.\\n FiO2 = 50% via trach collar.\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2167-10-29 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 640003,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 41\\n Ideal body weight: 61.2 None\\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\\n Tracheostomy tube:\\n Type: Cuffed\\n Manufacturer: Portex\\n Size: 7.0mm\\n PMV:\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 22 cmH2O\\n Cuff volume: mL /\\n Airway problems:\\n Comments:\\n Lung sounds\\n RLL Lung Sounds: Rhonchi\\n RUL Lung Sounds: Rhonchi\\n LUL Lung Sounds: Rhonchi\\n LLL Lung Sounds: Rhonchi\\n Comments:\\n Secretions\\n Sputum color / consistency: Yellow / Thick\\n Sputum source/amount: Suctioned / Moderate\\n Patient required frequent suctioning overnight for thick yellow/white\\n sputum.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-30 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 640343,\n \"text\": \"Synopsis per prior nursing note:\\n 56 yr old woman, who was transferred from osh for evaluation of\\n tracheal bronchial malacia on .Pt presented to Medical\\n Center on s/p fall down a flight of stairs fracturing, t5-t8 with\\n propulsion treated conservatively with pain meds and back brace. She\\n developed resp distress requiring intubation on . Trach/PEG done\\n . Now with prolonged hospital course c/b by PNA, anxiety/altered\\n mental status, R&LUE DVT .Pt found to have small non occlusive clot on\\n her right axial vein via Ultrasound, now rec\\ning Lovenox. She has had\\n problems with vomiting tube feedings, so feeding tube passed through\\n g-tube to her jejunenum. However, she continued to intermit raise\\n gastric contents assoc with bronchospasm. Has not required ventilation\\n since , on humidified TM @ 50%. Presently on TPN and restarted on\\n TF\\nings at low rate via J-tube.\\n BRONCHOSCOPY by IP- At 09:43 AM. Severe diffuse\\n Tracheobronchomalacia, large gap posterior commisure above true vocal\\n cords resulting in possible etiology of recurrent aspiration\\n Airway Clearance, Impaired\\n Assessment:\\n LS-bilat rhonchi. O2 sat >95% on 50% trach collar. Suctioned small to\\n moderate amts of thick, white/dark yellow secretions. Passy-muir valve\\n on during day/while in chair. Able to cough secretions into tissue\\n when passy-muir valve on.\\n Action:\\n Suctioned every 2 hour. Encouraged to CDB.\\n Response:\\n Able to cough secretions into tissue. Need for suctioning decreased\\n throughout shift.\\n Plan:\\n to monitor and clear airway as needed. Encourage CDB.\\n Alteration in Nutrition\\n Assessment:\\n Continues on replete w/fiber full strength. Restarted @30cc/hr. Flush\\n w/ 100 ml hour every 4 hours. Denies nausea. No vomiting. Small loose\\n stool in am.\\n Action:\\n J tube in place, unable to check residuals. Colace/senna/polyethylene\\n glycol held.\\n Response:\\n Continues to have loose stool. Currently tolerating TF.\\n Plan:\\n Advance TF to goal as tolerated.\\n Fracture, other\\n Assessment:\\n Patient has a fracture of t5-t8. Denied pain. Brace on while OOB in\\n chair.\\n Action:\\n Changed position. Brace on while OOB.\\n Response:\\n Continued to deny pain.\\n Plan:\\n Assess/treat pain. Brace on while OOB. ? transfer to \\n @ Medical Center tomorrow @ 10am.\\n Altered mental status (not Delirium)\\n Assessment:\\n When passy-muir valve on, patient had +VH and +AH. Stated paranoid\\n thoughts. Stated that she is scared. She is starting to acknowledge\\n that hallucinations may not be real. Acknowledges that even though she\\n her friend die, she knows that her friend is alive. Follows\\n commands. Not pulling at lines/tubes very often.\\n Action:\\n w/ soft wrist restraints. Reoriented frequently. Assured patient\\n that she is safe in hospital. Feels more calm when told that she is\\n safe.\\n Response:\\n Patient remains safe. Able to be calmed when told she is safe in\\n hospital.\\n Plan:\\n current safety plan. Reorient frequently. Psych will continue to\\n follow.\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2167-10-27 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 639761,\n \"text\": \"Demographics\\n Ideal body weight: 61.2 None\\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: Yes\\n Tracheostomy tube:\\n Type: Standard, Cuffed\\n Manufacturer: Portex\\n Size: 7.0mm\\n PMV:Yes\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 23 cmH2O\\n Cuff volume: mL /\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Diminished\\n Secretions\\n Sputum color / consistency: White / Thin\\n Sputum source/amount: Suctioned / Moderate\\n Plan\\n Next 24-48 hours: Continue to monitor patients respiratory status; sxn\\n & tx as indicated.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-22 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 638886,\n \"text\": \"Nausea / vomiting\\n Assessment:\\n Tube feeds started Promote\\n @ 10cc/hr. via new jtube. Pt vomited ~ 1\\n hr after TF started ->>coffee grounds, TF, H2O(flush). Also\\n expectorating same from trach.\\n Action:\\n Tube feeds stopped. Zofran 4 mg.\\n Response:\\n No further vomiting, although pt coughing with copious thick tan\\n secretions after vomiting episode.\\n Plan:\\n NPO. Meds given IV for now. Pt to have tube study today.\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt very agitated attempting to get OOB, legs through side rails.\\n Mouthing words but difficlt to understand.\\n Action:\\n Frequent re-orientation. Zyprexa 5 mg x 2. MSO4 2 mg. Valium 2.5 mg.\\n Response:\\n 1^st dose Zyprexa seemed to have transient calming effect but then pt\\n agitated again, 2^nd dose with no effect. Valium with very good effect,\\n pt is sleeping but arouseable to voice.\\n Plan:\\n Zyprexa @ hs (usually effective). Valium 2.5 IV prn, please use\\n sparingly d/t ongoing delerium. Re-orientation, emotional support.\\n Hypernatremia (high sodium)\\n Assessment:\\n Na 148 last evening.\\n Action:\\n D5W c 40 KCL @ 100/hr x 1 liter. Repeat labs sent this AM.\\n Response:\\n Plan:\\n Continue to monitor lytes.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Coughing frequently with copious thick tan secretions after vomiting.\\n Asking to be suctioned, also coughing secretions to end of trach.\\n Action:\\n Frequent suctioning. Placed on CPAP 5/5 this AM to rest.\\n Response:\\n RR 22 on vent when sedated. Sats 100%\\n Plan:\\n Wean from vent as tolerated. Pulmonary hygiene.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-31 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 640414,\n \"text\": \"Airway Clearance, Impaired\\n Assessment:\\n Cont on TM 50% O2 sats 96-94%, suct for copious amts of thin white\\n secretions, bilat rhonchi, dim bases.\\n Action:\\n Frequent suctioning, pt able to cough up some secretions on her own\\n Response:\\n Pt able to cough up secretions on her own at times\\n Plan:\\n Cont to resp status, encourage CDB\\n Altered mental status (not Delirium)\\n Assessment:\\n Alert/oriented with some confusion, follows commands consistently, but\\n requires frequent re-direction\\n Action:\\n Pt oriented to place/time\\n Response:\\n Pt still makes attempts to remove TM despite re-direction, pt remains\\n with bilat wrist restraints for safety\\n Plan:\\n Cont to orient pt, frequent monitor for safety\\n Alteration in Nutrition\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-28 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 639825,\n \"text\": \"56 yr old woman, who was transferred from osh for evaluation of\\n tracheal bronchial malacia on .Pt presented to Medical\\n Center on s/p fall down a flight of stairs fracturing, t5-t8 with\\n propulsion treated conservatively with pain meds and back brace. She\\n developed resp distress requiring intubation on . Trach/PEG done\\n . Now with prolonged hospital course c/b by PNA, anxiety/altered\\n mental status, R&LUE DVT .Pt found to have small non occlusive clot on\\n her right axial vein via Ultrasound, now rec\\ning Lovenox. She has had\\n problems with vomiting tube feedings, so feeding tube passed through\\n g-tube to her jejunenum. However, she continued to intermit raise\\n gastric contents assoc with bronchospasm. Has not required ventilation\\n since , on humidified TM @ 50%. Presently on TPN and restarted on\\n TF\\nings at low rate via J-tube.\\n Airway Clearance, Impaired\\n Assessment:\\n On 50% trach collar overnight, 02 sats 92-100%\\n LS rhonchi upper, diminished bases.\\n Increased sputum production overnight, strong cough.\\n Episode of mucus plugging overnight with desat to <80%, quickly\\n recovered with 100% 02 and suctioning.\\n Action:\\n Suctioned q1-2 hrs for mod/copious amt thick tan secretions.\\n Trach care performed.\\n AM CXR done.\\n Response:\\n 02 sats remain 92-100%\\n Hemodynamically stable.\\n Plan:\\n Cont to monitor oxygenation and need for suctioning.\\n Altered mental status (not Delirium)\\n Assessment:\\n Opens eyes, follows commands (squeezes hands), swings legs over side of\\n bed, unable to assess orientation (did not use PM valve overnight r/t\\n increased secretions/plugging episode.)\\n Does move hands near airway and attempted to pull at J-tube/foley cath.\\n Action:\\n Remains in bilateral soft wrist restraints MD order.\\n Response:\\n Pt continues altered MS.\\n :\\n Cont to re-orient pt, monitor pt safety (bed low and locked, bed\\n alarm).\\n Evaluate need for restraints and obtain MD order.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-29 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 640099,\n \"text\": \"Chief Complaint: Delerium\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 24 Hour Events:\\n Remains with delerium.\\n Experienced episode of SVT --> responded to extra iv dose metoprolol.\\n History obtained from Medical records\\n Patient unable to provide history: Encephalopathy\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Constitutional: No(t) Fatigue, No(t) Fever, No(t) Weight loss\\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, OG / NG tube\\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\\n Tachycardia, No(t) Orthopnea\\n Nutritional Support: No(t) NPO, Tube feeds, No(t) Parenteral nutrition\\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\\n No(t) Diarrhea, No(t) Constipation\\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\\n Integumentary (skin): No(t) Jaundice, No(t) Rash\\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\\n Heme / Lymph: No(t) Lymphadenopathy, No(t) Anemia, No(t) Coagulopathy\\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\\n No(t) Daytime somnolence\\n Allergy / Immunology: No(t) Immunocompromised, No(t) Influenza vaccine\\n Signs or concerns for abuse : No\\n Pain: No pain / appears comfortable\\n Flowsheet Data as of 11:42 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37\\nC (98.6\\n Tcurrent: 36.2\\nC (97.2\\n HR: 78 (61 - 115) bpm\\n BP: 108/48(60) {91/36(50) - 156/79(101)} mmHg\\n RR: 24 (17 - 30) insp/min\\n SpO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 2,952 mL\\n 760 mL\\n PO:\\n TF:\\n 646 mL\\n 685 mL\\n IVF:\\n 950 mL\\n 75 mL\\n Blood products:\\n Total out:\\n 2,430 mL\\n 610 mL\\n Urine:\\n 2,430 mL\\n 380 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 522 mL\\n 150 mL\\n Respiratory support\\n SpO2: 100%\\n ABG: ///35/\\n Physical Examination\\n General Appearance: No(t) Well nourished, No acute distress, No(t)\\n Overweight / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic\\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\\n pale, No(t) Sclera edema\\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\\n Endotracheal tube, No(t) NG tube, No(t) OG tube\\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\\n Cervical adenopathy\\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic,\\n No(t) Diastolic)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric, Paradoxical), (Percussion:\\n Resonant : , No(t) Hyperresonant: , No(t) Dullness : ), (Breath Sounds:\\n Clear : , No(t) Crackles : , No(t) Bronchial: , No(t) Wheezes : , No(t)\\n Diminished: , No(t) Absent : , No(t) Rhonchorous: )\\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\\n No(t) Tender: , No(t) Obese\\n Extremities: No(t) Cyanosis, No(t) Clubbing\\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\\n Skin: Warm, No(t) Rash: , No(t) Jaundice\\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\\n stimuli, No(t) Oriented (to): , Movement: Purposeful, No(t) Sedated,\\n No(t) Paralyzed, Tone: Normal\\n Labs / Radiology\\n 7.2 g/dL\\n 187 K/uL\\n 105 mg/dL\\n 0.5 mg/dL\\n 35 mEq/L\\n 3.8 mEq/L\\n 17 mg/dL\\n 108 mEq/L\\n 147 mEq/L\\n 23.7 %\\n 5.1 K/uL\\n [image002.jpg]\\n 03:00 AM\\n 04:00 AM\\n 05:45 AM\\n 03:51 AM\\n 04:45 PM\\n 04:00 AM\\n 07:37 PM\\n 04:05 AM\\n 06:05 PM\\n 03:23 AM\\n WBC\\n 7.3\\n 8.0\\n 8.7\\n 5.5\\n 5.7\\n 5.8\\n 5.1\\n Hct\\n 27.3\\n 27.0\\n 28.7\\n 24.7\\n 25.2\\n 25.3\\n 23.7\\n 24.7\\n 23.7\\n Plt\\n 346\\n 316\\n 271\\n 249\\n 231\\n 203\\n 187\\n Cr\\n 0.7\\n 0.7\\n 0.7\\n 0.5\\n 0.4\\n 0.5\\n 0.5\\n 0.5\\n Glucose\\n 123\\n 114\\n 112\\n 122\\n 145\\n 137\\n 149\\n 105\\n Other labs: PT / PTT / INR:13.3/32.4/1.1, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.8 mg/dL, Mg++:2.1 mg/dL, PO4:3.5\\n mg/dL\\n Assessment and Plan\\n T-spine fracture, delerium.\\n DELERIUM -- persistent. Etiology may be related to prior EtOH use,\\n contribution of medications. Intermittently oriented. Continue\\n respiradol. Avoid medications that have psych complications or side\\n effects.\\n RESPIRATORY FAILURE -- s/p trach. Maintain trach for pulmonary\\n toilet/frequent suctioning.\\n TACHYCARDIA -- SVT. Continue amiodarone loading schedule. Continue\\n beta-blocker, with extra doses prn if needed.\\n NUTRITIONAL SUPPORT -- TF via PEJ approaching goal.\\n T-SPINE FRACTURE -- s/p fall. Tolerating back brace as per ortho\\n service. Activity as tolerated (up in chair).\\n ASPIRATION RISK -- poor adduction of vocal cords (post. portion).\\n Eventually may require intervention.\\n TRANCHEOBRONCHOMALACIA -- no interventions planned at present.\\n ICU Care\\n Nutrition:\\n Replete with Fiber () - 09:45 PM 50 mL/hour\\n Glycemic Control:\\n Lines:\\n PICC Line - 01:30 PM\\n Prophylaxis:\\n DVT: Boots(Systemic anticoagulation: None)\\n Stress ulcer: PPI\\n VAP: HOB elevation, Mouth care\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :ICU\\n Total time spent: 55 minutes\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-30 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 640220,\n \"text\": \"Synopsis per prior nursing note:\\n 56 yr old woman, who was transferred from osh for evaluation of\\n tracheal bronchial malacia on .Pt presented to Medical\\n Center on s/p fall down a flight of stairs fracturing, t5-t8 with\\n propulsion treated conservatively with pain meds and back brace. She\\n developed resp distress requiring intubation on . Trach/PEG done\\n . Now with prolonged hospital course c/b by PNA, anxiety/altered\\n mental status, R&LUE DVT .Pt found to have small non occlusive clot on\\n her right axial vein via Ultrasound, now rec\\ning Lovenox. She has had\\n problems with vomiting tube feedings, so feeding tube passed through\\n g-tube to her jejunenum. However, she continued to intermit raise\\n gastric contents assoc with bronchospasm. Has not required ventilation\\n since , on humidified TM @ 50%. Presently on TPN and restarted on\\n TF\\nings at low rate via J-tube.\\n Airway Clearance, Impaired\\n Assessment:\\n LS-bilat rhonchi. O2 sat >95% on 50% humidified trach collar. Suctioned\\n small to moderate amts of frothy and thin, white secretions and pt\\n clearing secretions independently with strong cough.\\n Action:\\n Repositioned frequently and CPT. Suctioned q2-3hours.\\n Response:\\n n/a\\n Plan:\\n Continue to monitor resp status, reposition, CPT as needed.\\n Alteration in Nutrition\\n Assessment:\\n Pt received with tube feeds at goal 60cc/hr and 50cc free water flush\\n q4hour via J-tube. Denies nausea, stomach pain or cramping. No\\n vomiting. K 3.6.\\n Action:\\n Unable to check residuals. Tube feeds stopped at 5AM after ?tube feeds\\n were suctioned from back of throat. Unlikely aspirated sats 100%.\\n Colace/senna/polyethylene glycol held for loose stool. Mushroom\\n catheter pulled out x2 this shift and not replaced after 2^nd time.\\n Stool #2 sent for c.diff. Repleted with 40 mEq KCl.\\n Response:\\n Currently TF stopped, team aware.\\n Plan:\\n Restart TF. Monitor labs and replete lytes as needed.\\n Altered mental status (not Delirium)\\n Assessment:\\n Alert and oriented x2. Continues to think she is in a hotel. Pt\\n restless and agitated many times throughout night. Pulled out rectal\\n tube x2 and foley x1 this shift. Follows commands. PERL brisk.\\n Action:\\n Soft wrist restraints for pt safetly to pulling at lines and hx to\\n decanulating herself. Bed locked in low position and bed alarm on.\\n Reoriented frequently. All meds and interventions explained.\\n Response:\\n Patient remains safe. Continues to throw her legs over the side of the\\n bed and pull at lines.\\n Plan:\\n Continue current safety plan. Reorient frequently. Psych consulting.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-28 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 639937,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n BRONCHOSCOPY by IP- At 09:43 AM. Severe diffuse\\n Tracheobronchomalacia, large gap posterior commisure above true vocal\\n cords resulting in possible etiology of recurrent aspiration\\n Seen by ENT, no note from attg (Dr. re possible posterior\\n augmentation.\\nWill require better exam in clinic with stroboscopic\\n video\\n S&S PMV Eval: Pt not to have PMV without supervision and only for short\\n periods of time aspiration risk and vocal cord edema with freq\\n suctioning when PMV in place. Per nursing had increased secretions\\n requiring deep suctioning overnight, otherwise pt is able to clear with\\n productive cough.\\n Restarted TF yest: 10\\n20cc/hr, no issues.\\n Changed PPI to per IP recs\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:05 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:50 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37\\nC (98.6\\n Tcurrent: 36.1\\nC (97\\n HR: 86 (62 - 122) bpm\\n BP: 146/61(82) {87/42(53) - 152/87(98)} mmHg\\n RR: 23 (19 - 36) insp/min\\n SpO2: 95%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 3,692 mL\\n 1,252 mL\\n PO:\\n TF:\\n 116 mL\\n 116 mL\\n IVF:\\n 2,175 mL\\n 775 mL\\n Blood products:\\n Total out:\\n 3,790 mL\\n 400 mL\\n Urine:\\n 3,790 mL\\n 400 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -98 mL\\n 854 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask\\n SpO2: 95%\\n ABG: ///32/\\n Physical Examination\\n Gen: Alert, NAD, lying in bed, comfortable, mouthing words, less\\n sedated than yest.\\n HEENT: No pallor in conjunctiva, MMM, TM in place\\n Resp: Transmitted upper airway sounds/coarse breath sounds.\\n Card: S1S2 tachycardic, no m/r/g\\n Abd: Obese, soft, mildly distended, decreased bowel sounds, G-Tube in\\n place with no erythema/induration\\n Exte: No edema, DP 2+ bil\\n NEURO: Alert, difficult to assess orientation due to poor voice. MAE\\n Labs / Radiology\\n 203 K/uL\\n 7.5 g/dL\\n 149 mg/dL\\n 0.5 mg/dL\\n 27 mEq/L\\n 4.1 mEq/L\\n 14 mg/dL\\n 108 mEq/L\\n 143 mEq/L\\n 23.7 %\\n 5.8 K/uL\\n [image002.jpg] Ca 8.6, Mg 2.0, P 3.7; PT/PTT/INR: 13.3/32.4/1.1\\n 03:20 PM\\n 03:23 AM\\n 03:00 AM\\n 04:00 AM\\n 05:45 AM\\n 03:51 AM\\n 04:45 PM\\n 04:00 AM\\n 07:37 PM\\n 04:05 AM\\n WBC\\n 5.7\\n 7.3\\n 8.0\\n 8.7\\n 5.5\\n 5.7\\n 5.8\\n Hct\\n 30.0\\n 26.9\\n 27.3\\n 27.0\\n 28.7\\n 24.7\\n 25.2\\n 25.3\\n 23.7\\n Plt\\n 356\\n 346\\n 316\\n 271\\n 249\\n 231\\n 203\\n Cr\\n 0.7\\n 0.7\\n 0.7\\n 0.7\\n 0.5\\n 0.4\\n 0.5\\n Glucose\\n 129\\n 123\\n 114\\n 112\\n 122\\n 145\\n 137\\n Other labs: PT / PTT / INR:13.3/32.4/1.1, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.9 mg/dL, Mg++:2.1 mg/dL, PO4:3.6\\n mg/dL\\n Assessment and Plan\\n 56yoF s/p mechanical fall and traumatic T spine fracture with resolving\\n respiratory failure and HAP s/p trach with complicating TBM and s/p\\n PEG.\\n .\\n # Respiratory: s/p intubation/extubation, now on trach mask, FiO2 50%.\\n Tolerating well with good O2 sat in mid-high 90\\ns. Pt continues to be\\n at risk for aspiration given new IP finding of opening defect in\\n posterior vocal cord space and given recent history of vomiting with\\n tube feed trials.\\n - Appreciate ENT and S&S input.\\n - will follow ENT recs; awaiting input for possible intervention.\\n - ppi for aspiration prophylaxis, PMV precautions: \\nt use w/o\\n supervision, frequent suctioning\\n - TM as tolerated.\\n - continue scopolamine patch q72hrs for secretions\\n - Holding sedation with exception of Risperidal 0.5mg PRN\\n - F/u CXR tomorrow\\n # Sedation/Anxiolysis/AlteredMS: Resolved O/N with risperdal. Previous\\n delirium and agitation most likely secondary to long hospital course\\n and multiple psychotropic medications as well as hx of EtOH abuse.\\n - started Risperdal 0.5mg PO BID PRN.\\n - continue to hold all benzos. opiates, and antihistamines\\n - Appreciate psych. Will call and f/u psych recs.\\n -Obtain EKG to assess for QTc prolongation.\\n #Anemia: HCT low compared to b/l at 23.7. No known etiology of blood\\n loss.\\n -Will continue to follow HCT daily.\\n - Guaiac stools.\\n -f/u HCT this afternoon\\n -T&S\\n # Atrial Tachycardia: Improved HR max of 120\\ns versus 160s previously.\\n Pt now on PO Amiodarone 200 TID and PO metoprolol 37.5mg TID\\n - Will continue amiodarone 200 TID for three weeks and then switch to\\n qday for 1week and then d/c amiodarone.\\n - Will need to schedule f/u in 4wks with Dr. upon d/c/transfer.\\n # Hypernatremia/Fluid Status: Mild hypernatramia resolving with free\\n water administration. On TPN/TF. Good UOP.\\n - providing D5W IVFx 1L at 150cc/hr, free water flushes with TF\\n -Will f/u lytes in afternoon (5pm)\\n # UE DVT and h/o labile INR: Decision made to d/c Coumadin given her\\n labile INR, and start Lovenox . INR at 1.9\\n - Will flush L PICC with TPA if does not flush\\n - Daily coags\\n .\\n # Spine fracture: Stable. T5-T8.\\n - Brace for OOB, need to discuss with Neurosurgery before d/c if\\n current brace is optimal for stabilization given her mobility.\\n - Pt to follow up with Dr. in .\\n .\\n # Tracheomalacia. Reevaluation bronchoscopy by IP as written above;\\n patient not a candidate for stent; pt to follow up as outpatient. No\\n new issues.\\n .\\n #. Thyroid Nodule on CT\\n - Outpatient follow up\\n .\\n # Glycemic control: SSI, well controlled\\n # FEN: Currently receiving TPN, restarted TF yest, currently at\\n 20cc/hr, w/o issue.\\n - Appreciate GI input and S&S eval\\n -Cont Reglan 20mg IV Q 8 hours for emesis precaution; meds via G-J\\n tube,\\n -D/w GI; rec: continue bowel regimen if no BM\\n .\\n # ACCESS: PIV x 1, L PICC\\n # Ppx: Lovenox, PPi , Bowel Regimen PRN\\n # Communication:\\n - (brother) is primary contact\\n - Boyfriend of 10 , but minimal contact has been maintained at\\n this point\\n - Social Work and Case management involved; have discussed situation\\n w/ brother and boyfriend.\\n # Code: Full\\n # Dispo: ICU, Will d/w case management re rehab facilities, likely d/c\\n tomorrow if insurance/bed confirmed\\n MSIV\\n PGY2 addendum: , \\n Agree with assessment and plan in excellent MSIV note as detailed\\n above. Briefly, 56 F s/p fall with T spine fracture (T5-T8),\\n respiratory failure now s/p trach/PEG. Now on trach mask. Patient s/p\\n bronch with IP yesterday. Nutrition issues continue; have discontinued\\n TPN today and will continue tubefeeding to goal of 60cc/hr per\\n Nutrition. Will continue reglan until at goal feedings, and decrease\\n and d/c as able given potential for delirium. Appreciate psych recs;\\n continuing risperidone for agitation. Etiology of delirium/agitation\\n still unclear but likely prolonged hospital course, illness and\\n multiple medications. Currently discussing with CM about potential\\n placement to rehab tomorrow.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-30 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 640328,\n \"text\": \"Chief Complaint: Delerium, respiratory failure (chronic)\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 24 Hour Events:\\n STOOL CULTURE - At 06:33 AM\\n Remains delerious, confused. Remains somewhat paranoid, but able to\\n reorient. Much less agitated.\\n Up in chair with brace.\\n History obtained from Medical records\\n Patient unable to provide history: Encephalopathy\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:00 PM\\n Enoxaparin (Lovenox) - 06:00 AM\\n Other medications:\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Constitutional: No(t) Fatigue, No(t) Fever, No(t) Weight loss\\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\\n No(t) Tachycardia, No(t) Orthopnea\\n Nutritional Support: No(t) NPO, Tube feeds, No(t) Parenteral nutrition\\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\\n No(t) Diarrhea, No(t) Constipation, PEG\\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\\n Integumentary (skin): No(t) Jaundice, No(t) Rash\\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\\n Heme / Lymph: No(t) Lymphadenopathy, No(t) Anemia, No(t) Coagulopathy\\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\\n No(t) Daytime somnolence\\n Allergy / Immunology: No(t) Immunocompromised, No(t) Influenza vaccine\\n Signs or concerns for abuse : No\\n Pain: No pain / appears comfortable\\n Flowsheet Data as of 12:02 PM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.6\\nC (97.9\\n Tcurrent: 36.1\\nC (96.9\\n HR: 70 (66 - 112) bpm\\n BP: 96/52(61) {90/37(31) - 164/75(87)} mmHg\\n RR: 22 (16 - 29) insp/min\\n SpO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 1,726 mL\\n 901 mL\\n PO:\\n TF:\\n 1,388 mL\\n 301 mL\\n IVF:\\n 249 mL\\n 330 mL\\n Blood products:\\n Total out:\\n 1,666 mL\\n 282 mL\\n Urine:\\n 836 mL\\n 282 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 60 mL\\n 619 mL\\n Respiratory support\\n O2 Delivery Device: Aerosol-cool\\n SpO2: 100%\\n ABG: ///34/\\n Physical Examination\\n General Appearance: No(t) Well nourished, No acute distress, Overweight\\n / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic\\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\\n pale, No(t) Sclera edema\\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\\n Endotracheal tube, No(t) NG tube, No(t) OG tube\\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\\n Cervical adenopathy\\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic,\\n No(t) Diastolic)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\\n (Breath Sounds: No(t) Clear : , No(t) Crackles : , No(t) Bronchial: ,\\n No(t) Wheezes : , No(t) Diminished: , No(t) Absent : , Rhonchorous: )\\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\\n No(t) Tender: , No(t) Obese\\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\\n Clubbing\\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\\n Skin: Warm, No(t) Rash: , No(t) Jaundice\\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\\n stimuli, Oriented (to): , Movement: Purposeful, No(t) Sedated, No(t)\\n Paralyzed, Tone: Normal\\n Labs / Radiology\\n 7.1 g/dL\\n 183 K/uL\\n 115 mg/dL\\n 0.5 mg/dL\\n 34 mEq/L\\n 3.6 mEq/L\\n 13 mg/dL\\n 106 mEq/L\\n 145 mEq/L\\n 22.8 %\\n 5.4 K/uL\\n [image002.jpg]\\n 04:00 AM\\n 05:45 AM\\n 03:51 AM\\n 04:45 PM\\n 04:00 AM\\n 07:37 PM\\n 04:05 AM\\n 06:05 PM\\n 03:23 AM\\n 02:54 AM\\n WBC\\n 8.0\\n 8.7\\n 5.5\\n 5.7\\n 5.8\\n 5.1\\n 5.4\\n Hct\\n 27.0\\n 28.7\\n 24.7\\n 25.2\\n 25.3\\n 23.7\\n 24.7\\n 23.7\\n 22.8\\n Plt\\n \\n 183\\n Cr\\n 0.7\\n 0.7\\n 0.5\\n 0.4\\n 0.5\\n 0.5\\n 0.5\\n 0.5\\n Glucose\\n 114\\n 112\\n 122\\n 145\\n 137\\n 149\\n 105\\n 115\\n Other labs: PT / PTT / INR:13.3/32.4/1.1, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.4 mg/dL, Mg++:1.9 mg/dL, PO4:3.6\\n mg/dL\\n Assessment and Plan\\n Delerium.\\n DELERIUM -- likely multifactorial. EtOH withdrawl-related,\\n medications, ICU psychosis.\\n RESPIRATORY FUNCTION -- stable with trach. Remains on trach collar.\\n T-SPINE Fx\\n will likely need new fitted brace (as pt. experienced much\\n weight loss since admission). Continue PT rehab.\\n TRACHEOBRONCHOMALACIA\\n no further immediate plans. Will need F/U with\\n IP service in future.\\n VOCAL CORD DYSFUNCTION -- adduction problem. need ENT f/u in\\n future.\\n NUTRITIONAL SUPPORT -- TF via PEG\\n FLUIDS -- euvolemic. Monitor I/O.\\n REHABILITATION placement in progress.\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n PICC Line - 01:30 PM\\n Prophylaxis:\\n DVT: Boots(Systemic anticoagulation: None)\\n Stress ulcer: PPI\\n VAP: HOB elevation\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :ICU\\n Total time spent: 55 minutes\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-22 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 639073,\n \"text\": \"56 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\\n with prolonged hospital course c/b by PNA, anxiety/altered mental\\n status, R&LUE DVT .Pt found to have small non occlusive Clot on her\\n right axial vein via Ultrasound.Yesterday. She has had problems with\\n vomiting tube feedings, feeding tube passed through g-tube (g-tube in\\n place with mushroom on inside so cannot pull out) to her jejunenum but\\n continues vomit.\\n Tachycardia, Other\\n Assessment:\\n HR better but still 110-130. Receiving 7.5mg lopressor IV Q4h\\n Action:\\n Heart rate better on lopressor. Lopressor increased to 10mg IV Q4h.\\n Response:\\n HR still up but is due to her agitation .\\n Plan:\\n Continue to monitor B/P and HR, do not hold lopressor but decrease the\\n dose (ask HO)\\n Assessment:\\n Pt had tube studies today, contrast injected into feeding tube, it\\n went into her jejuneum and went no furtere. Pt has had 2 xrayes to\\n see if it has advanced at all.\\n Action:\\n Pt has been restarted on raglan, narcotics and other meds that slow GI\\n motility have been D/C\\n Response:\\n Plan:\\n Altered mental status (not Delirium)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Hypernatremia (high sodium)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-27 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 639745,\n \"text\": \"Chief Complaint:\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n Aggitation, remains delerious.\\n Bedside bronchoscopy by IP service revealed inability of posterior\\n portion of vocal cords to adduct. Unclear etiology.\\n Sedated for bronchoscopy.\\n 24 Hour Events:\\n More awake this afternoon, less agitated, but remains confused.\\n Tolerating Passe-Muir valve -> speaking but not coherent.\\n History obtained from Medical records\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Enoxaparin (Lovenox) - 06:48 PM\\n Other medications:\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Constitutional: No(t) Fatigue, No(t) Fever, No(t) Weight loss\\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG\\n tube, Tracheotomy tube\\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\\n No(t) Tachycardia, No(t) Orthopnea\\n Nutritional Support: No(t) NPO, Tube feeds, No(t) Parenteral nutrition\\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\\n No(t) Diarrhea, No(t) Constipation\\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\\n Integumentary (skin): No(t) Jaundice, No(t) Rash\\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\\n Heme / Lymph: No(t) Lymphadenopathy, No(t) Anemia, No(t) Coagulopathy\\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\\n No(t) Daytime somnolence\\n Allergy / Immunology: No(t) Immunocompromised, No(t) Influenza vaccine\\n Signs or concerns for abuse : No\\n Pain: No pain / appears comfortable\\n Flowsheet Data as of 11:52 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.7\\nC (98.1\\n Tcurrent: 36.1\\nC (96.9\\n HR: 62 (62 - 123) bpm\\n BP: 87/42(53) {87/42(53) - 179/121(130)} mmHg\\n RR: 20 (18 - 31) insp/min\\n SpO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 4,004 mL\\n 2,070 mL\\n PO:\\n TF:\\n 137 mL\\n 51 mL\\n IVF:\\n 2,544 mL\\n 1,423 mL\\n Blood products:\\n Total out:\\n 3,813 mL\\n 1,380 mL\\n Urine:\\n 3,813 mL\\n 1,380 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 191 mL\\n 690 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask\\n SpO2: 98%\\n ABG: ///33/\\n Physical Examination\\n General Appearance: No(t) Well nourished, No(t) No acute distress,\\n No(t) Overweight / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic,\\n Sedated\\n Eyes / Conjunctiva: No(t) PERRL, No(t) Pupils dilated, No(t)\\n Conjunctiva pale, No(t) Sclera edema\\n Head, Ears, Nose, Throat: No(t) Normocephalic, No(t) Poor dentition,\\n No(t) Endotracheal tube, No(t) NG tube, No(t) OG tube, Tracheotomy tube\\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\\n Cervical adenopathy\\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic,\\n No(t) Diastolic)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\\n (Percussion: No(t) Resonant : , No(t) Hyperresonant: , No(t) Dullness :\\n ), (Breath Sounds: Clear : , No(t) Crackles : , Bronchial: Right base,\\n No(t) Wheezes : , No(t) Diminished: , No(t) Absent : , No(t)\\n Rhonchorous: )\\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended, No(t)\\n Tender: , No(t) Obese, PEG\\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\\n Clubbing\\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\\n Skin: Warm, No(t) Rash: , No(t) Jaundice\\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\\n to: Verbal stimuli, No(t) Oriented (to): , Movement: Purposeful, No(t)\\n Sedated, No(t) Paralyzed, Tone: Normal\\n Labs / Radiology\\n 7.7 g/dL\\n 231 K/uL\\n 145 mg/dL\\n 0.4 mg/dL\\n 33 mEq/L\\n 3.5 mEq/L\\n 11 mg/dL\\n 109 mEq/L\\n 146 mEq/L\\n 25.3 %\\n 5.7 K/uL\\n [image002.jpg]\\n 01:30 AM\\n 06:41 AM\\n 03:20 PM\\n 03:23 AM\\n 03:00 AM\\n 04:00 AM\\n 05:45 AM\\n 03:51 AM\\n 04:45 PM\\n 04:00 AM\\n WBC\\n 9.5\\n 5.7\\n 7.3\\n 8.0\\n 8.7\\n 5.5\\n 5.7\\n Hct\\n 28.6\\n 28.9\\n 30.0\\n 26.9\\n 27.3\\n 27.0\\n 28.7\\n 24.7\\n 25.2\\n 25.3\\n Plt\\n 528\\n 356\\n 346\\n \\n 231\\n Cr\\n 1.0\\n 0.7\\n 0.7\\n 0.7\\n 0.7\\n 0.5\\n 0.4\\n Glucose\\n 121\\n 129\\n 123\\n 114\\n 112\\n 122\\n 145\\n Other labs: PT / PTT / INR:13.6/31.1/1.2, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.6 mg/dL, Mg++:2.0 mg/dL, PO4:3.6\\n mg/dL\\n Assessment and Plan\\n Respiratory failure, delerium.\\n RESPIRATORY FAILURE -- chronic, s/p trach. Underlying\\n tracheobronchomalacia. Possible elevated right hemidiaphragm.\\n Continue current care, including aspiration precautions. Maintain\\n trach, monitor SaO2 --> maintain >90%.\\n TRACHEOBRONCOMALACIA -- no immediate plans for IP intervention.\\n VOCAL CORD dysfunction -- ENT to evaluate limited ability of posterior\\n portion of cords to adduct. consult ENT service.\\n RUE DVT -- anticoagulation with lovenox.\\n HYPERNATREMIA -- improved with free H2O repletion. Monitor.\\n A-FIB -- rate controlled on amioderone. Monitor HR.\\n DELERIUM -- currently sedated from procedure. Unclear etiology.\\n Concerns include medications and ICU psychosis. Psychiatry consulted.\\n Respiradol dose being adjusted.\\n NUTRITIONAL SUPPORT -- hope to transition TPN to TF via PEG.\\n T4-T8 VETEBRAL Fx -- suportive care. Will require rehabilitation.\\n ICU Care\\n Nutrition:\\n TPN without Lipids - 05:44 PM 43. mL/hour\\n Glycemic Control:\\n Lines:\\n PICC Line - 01:30 PM\\n 18 Gauge - 10:14 AM\\n Prophylaxis:\\n DVT: Boots(Systemic anticoagulation: None)\\n Stress ulcer: PPI\\n VAP: HOB elevation, Mouth care\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :ICU\\n Total time spent: 55 minutes\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Rehab Services\",\n \"chartdate\": \"2167-10-28 00:00:00.000\",\n \"description\": \"Physical Therapy Evaluation Note\",\n \"row_id\": 639900,\n \"text\": \"Attending Physician:\\n date: \\n Medical Diagnosis / ICD 9: /\\n Reason of :\\n History of Present Illness / Subjective Complaint: 55 yo F originally\\n admitted for questionable\\n alcohol-related fall from stairs sustaining T4-8 fracture. She\\n developed respiratory failure, aspiration, sepsis, ARDS, RUE DVT,\\n intubated then trached on . She has been in the MICU over a\\n month requiring ventilation, and has now been generally weaned to\\n trach mask. She has had recurrent aspiration and emesis even with\\n J-tube feeding, now requiring TPN\\n Past Medical / Surgical History:\\n Medications:\\n Radiology:\\n Labs:\\n 23.7\\n 7.5\\n 203\\n 5.8\\n [image002.jpg]\\n Other labs:\\n Activity Orders:\\n Social / Occupational History:\\n Living Environment:\\n Prior Functional Status / Activity Level:\\n Objective Test\\n Arousal / Attention / Cognition / Communication:\\n Hemodynamic Response\\n Aerobic Capacity\\n HR\\n BP\\n RR\\n O[2 ]sat\\n HR\\n BP\\n RR\\n O[2] sat\\n RPE\\n Supine\\n /\\n Rest\\n /\\n Sit\\n /\\n Activity\\n /\\n Stand\\n /\\n Recovery\\n /\\n Total distance walked:\\n Minutes:\\n Pulmonary Status:\\n Integumentary / Vascular:\\n Sensory Integrity:\\n Pain / Limiting Symptoms:\\n Posture:\\n Range of Motion\\n Muscle Performance\\n Motor Function:\\n Functional Status:\\n Activity\\n Clarification\\n I\\n S\\n CG\\n Min\\n Mod\\n Max\\n Gait, Locomotion:\\n Rolling:\\n\\n\\n\\n\\n\\n\\n Supine /\\n Sidelying to Sit:\\n\\n\\n\\n\\n\\n Transfer:\\n\\n\\n\\n\\n\\n Sit to Stand:\\n\\n\\n\\n\\n\\n Ambulation:\\n\\n\\n\\n\\n\\n Stairs:\\n\\n\\n\\n\\n\\n Balance:\\n Education / Communication:\\n Intervention:\\n Other:\\n Diagnosis:\\n 1.\\n Airway Clearance, Impaired\\n 2.\\n Arousal, Attention, and Cognition, Impaired\\n 3.\\n Balance, Impaired\\n 4.\\n Knowledge, Impaired\\n 5.\\n Respiration / Gas Exchange, Impaired\\n Clinical impression / Prognosis:\\n Goals\\n Time frame:\\n 1.\\n 2.\\n 3.\\n 4.\\n 5.\\n 6.\\n Anticipated Discharge: Rehab\\n Treatment Plan:\\n Frequency / Duration:\\n Patient agrees with the above goals and is willing to participate in\\n the rehabilitation program.\\n\"\n },\n {\n \"category\": \"Rehab Services\",\n \"chartdate\": \"2167-10-28 00:00:00.000\",\n \"description\": \"Physical Therapy Evaluation Note\",\n \"row_id\": 639905,\n \"text\": \"Attending Physician:\\n date: \\n Medical Diagnosis / ICD 9: /\\n Reason of :\\n History of Present Illness / Subjective Complaint: 55 yo F originally\\n admitted from OSH c fall from stairs sustaining T8 compression fx. She\\n developed respiratory failure, aspiration, sepsis, ARDS, RUE DVT,\\n required prolonged intubatation and then was trached on . She has\\n been in the MICU over a month requiring ventilation, and has weaned to\\n trach mask. She has had recurrent aspiration and emesis with J-tube\\n feeding, now requiring TPN. Pts mental status has waxed and waned since\\n sedation was lifted. Pt had recent broncoscopy which revealed TBM\\n Past Medical / Surgical History: See initial eval\\n Medications: Risperidone, TPN, midazolam, metoprolol\\n Radiology: Extensive basal atelectasis\\n Labs:\\n 23.7\\n 7.5\\n 203\\n 5.8\\n [image002.jpg]\\n Other labs:\\n Activity Orders: TLSO for OOB\\n Social / Occupational History: Has boyfriend\\n Environment: Lives in private home\\n Prior Functional Status / Activity Level: I PTA\\n Objective Test\\n Arousal / Attention / Cognition / Communication: Pt very lethargic,\\n eyes closed t/o 80% of evaluation. Pt following approx 50% of commands.\\n Hemodynamic Response\\n Aerobic Capacity\\n HR\\n BP\\n RR\\n O[2 ]sat\\n HR\\n BP\\n RR\\n O[2] sat\\n RPE\\n Supine\\n 68\\n 122/72\\n 24\\n 98% 50% TM\\n Rest\\n /\\n Sit\\n /\\n Activity\\n 78\\n /\\n 38\\n 87-98% 50% TM\\n Stand\\n /\\n Recovery\\n /\\n Total distance walked:\\n Minutes:\\n Pulmonary Status: Coarse upper airways, strong cough. Pt was suctioned\\n via trach with moderate amounts of thin white sputum.\\n Integumentary / Vascular: Trach, peg, foley, PICC\\n Sensory Integrity: withdraws to pain t/o\\n Pain / Limiting Symptoms: Pts mental status limited extent of\\n evaluation\\n Posture:\\n Range of Motion\\n Muscle Performance\\n B UE and LE \\n Pt actively moving B UE and LE in bed against gravity\\n Motor Function:\\n Functional Status:\\n Activity\\n Clarification\\n I\\n S\\n CG\\n Min\\n Mod\\n Max\\n Gait, Locomotion:\\n Rolling:\\n\\n\\n\\n\\n X 2\\n\\n Supine /\\n Sidelying to Sit:\\n NA\\n\\n\\n\\n\\n\\n\\n Transfer:\\n NA\\n\\n\\n\\n\\n\\n\\n Sit to Stand:\\n NA\\n\\n\\n\\n\\n\\n\\n Ambulation:\\n NA\\n\\n\\n\\n\\n\\n\\n Stairs:\\n NA\\n\\n\\n\\n\\n\\n\\n Balance: Unable to assess 2/2 pts mental status\\n Education / Communication: Pt status discussed with RN\\n Intervention:\\n Other:\\n Diagnosis:\\n 55 yo f s/p fall with resultant T8 fx, with hospital course significant\\n for respiratory failure and prolonged ICU stay requiring trach and peg.\\n Pt presents with above impairments c/w impaired gas exchange and\\n deconditioning. In comparison to prior treatment on pt shows a\\n decline in function and mental status, likely related to initiation of\\n new medications to treat delirium, however in this instance they have\\n sedated her to the point where she is unable to participate with PT.\\n Feel pt has good potential based on prior treatments to participate and\\n make gains with continued PT in rehab setting, as long as sedation from\\n current medications improves.\\n 1.\\n Airway Clearance, Impaired\\n 2.\\n Arousal, Attention, and Cognition, Impaired\\n 3.\\n Balance, Impaired\\n 4.\\n Knowledge, Impaired\\n 5.\\n Respiration / Gas Exchange, Impaired\\n Clinical impression / Prognosis:\\n Goals\\n Time frame:\\n 1.\\n Follow 100% of commands\\n 2.\\n Maintain eyes open t/o treatment\\n 3.\\n Sit at EOB c CG\\n 4.\\n CG for bed mobility\\n 5.\\n 6.\\n Anticipated Discharge: Rehab\\n Treatment Plan: f/u mobility, balance, cognitive training, pulm\\n hygiene.\\n Frequency / Duration:\\n 3-5xw/k\\n Patient agrees with the above goals and is willing to participate in\\n the rehabilitation program.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-28 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 639928,\n \"text\": \"Chief Complaint: Respriatory failure\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 24 Hour Events:\\n BRONCHOSCOPY - At 09:43 AM\\n More wake.\\n Less aggitated today.\\n Up in chair with back brace this afternoon.\\n Requiring more frequent suctioning, now every 1-2 hrs. Sputum thin,\\n slight yellow color.\\n History obtained from Medical records\\n Patient unable to provide history: Encephalopathy\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:05 PM\\n Enoxaparin (Lovenox) - 06:33 AM\\n Other medications:\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Constitutional: No(t) Fatigue, No(t) Fever, No(t) Weight loss\\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\\n No(t) Tachycardia, No(t) Orthopnea\\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\\n nutrition\\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\\n No(t) Diarrhea, No(t) Constipation\\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\\n Integumentary (skin): No(t) Jaundice, No(t) Rash\\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\\n Heme / Lymph: No(t) Lymphadenopathy, No(t) Anemia, No(t) Coagulopathy\\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\\n No(t) Daytime somnolence\\n Allergy / Immunology: No(t) Immunocompromised, No(t) Influenza vaccine\\n Signs or concerns for abuse : No\\n Pain: No pain / appears comfortable\\n Flowsheet Data as of 12:33 PM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37\\nC (98.6\\n Tcurrent: 36.9\\nC (98.5\\n HR: 71 (70 - 122) bpm\\n BP: 122/84(94) {115/48(66) - 167/87(98)} mmHg\\n RR: 10 (10 - 36) insp/min\\n SpO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 3,692 mL\\n 1,980 mL\\n PO:\\n TF:\\n 116 mL\\n 244 mL\\n IVF:\\n 2,175 mL\\n 832 mL\\n Blood products:\\n Total out:\\n 3,790 mL\\n 1,180 mL\\n Urine:\\n 3,790 mL\\n 1,180 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -98 mL\\n 800 mL\\n Respiratory support\\n O2 Delivery Device: Aerosol-cool\\n SpO2: 98%\\n ABG: ///27/\\n Physical Examination\\n General Appearance: No(t) Well nourished, No acute distress, No(t)\\n Overweight / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic\\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\\n pale, No(t) Sclera edema\\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\\n Endotracheal tube, No(t) NG tube, No(t) OG tube\\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\\n Cervical adenopathy\\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic,\\n No(t) Diastolic)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\\n (Breath Sounds: Clear : , No(t) Crackles : , No(t) Bronchial: , No(t)\\n Wheezes : , No(t) Diminished: , No(t) Absent : , No(t) Rhonchorous: )\\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\\n No(t) Tender: , No(t) Obese, PEG\\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis, No(t) Clubbing\\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\\n Skin: Warm, No(t) Rash: , No(t) Jaundice\\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\\n stimuli, No(t) Oriented (to): , Movement: Purposeful, No(t) Sedated,\\n No(t) Paralyzed, Tone: Normal\\n Labs / Radiology\\n 7.5 g/dL\\n 203 K/uL\\n 149 mg/dL\\n 0.5 mg/dL\\n 27 mEq/L\\n 4.1 mEq/L\\n 14 mg/dL\\n 108 mEq/L\\n 143 mEq/L\\n 23.7 %\\n 5.8 K/uL\\n [image002.jpg]\\n 03:20 PM\\n 03:23 AM\\n 03:00 AM\\n 04:00 AM\\n 05:45 AM\\n 03:51 AM\\n 04:45 PM\\n 04:00 AM\\n 07:37 PM\\n 04:05 AM\\n WBC\\n 5.7\\n 7.3\\n 8.0\\n 8.7\\n 5.5\\n 5.7\\n 5.8\\n Hct\\n 30.0\\n 26.9\\n 27.3\\n 27.0\\n 28.7\\n 24.7\\n 25.2\\n 25.3\\n 23.7\\n Plt\\n 356\\n 346\\n 316\\n 271\\n 249\\n 231\\n 203\\n Cr\\n 0.7\\n 0.7\\n 0.7\\n 0.7\\n 0.5\\n 0.4\\n 0.5\\n 0.5\\n Glucose\\n 129\\n 123\\n 114\\n 112\\n 122\\n 145\\n 137\\n 149\\n Other labs: PT / PTT / INR:13.3/32.4/1.1, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.6 mg/dL, Mg++:2.0 mg/dL, PO4:3.7\\n mg/dL\\n Assessment and Plan\\n Delerium.\\n RESPIRATORY FAILURE -- chronic, persistent. Tracheotomy tube in place,\\n with tach collar/mask. Use Passe-Muir valve as tolerated.\\n INCREASED SPUTUM production -- concern for evolving LLL pneumonia.\\n Monitor closely. COntinue frequent suctioning.\\n T-SPINE Fx -- Back brace. Up in chair as tolerated. Ortho to F/U.\\n TRACHEOBRONCHOMALAcIA -- no immediate plans for intervention at this\\n time.\\n VOCAL CORD DYSFUNCTION -- poor adduction of posterior portions of vocal\\n cords --> ENT to further assess.\\n NUTRITIONAL SUPPORT -- TF via PEG at low rate. ALso receiving TPN.\\n DELERIUM -- likely due to medications and ICU. Possible contribution\\n of EtOH withdraw/DT. Improved on Respiradol.\\n DVT\\n continue lovenox\\n REHABILITATION evaluation for transfer.\\n ICU Care\\n Nutrition:\\n Replete with Fiber () - 06:00 PM 20 mL/hour\\n TPN w/ Lipids - 06:02 PM 62.5 mL/hour\\n Glycemic Control:\\n Lines:\\n PICC Line - 01:30 PM\\n Prophylaxis:\\n DVT: Boots(Systemic anticoagulation: None)\\n Stress ulcer:\\n VAP: HOB elevation, Mouth care\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds Comments:\\n Code status: Full code\\n Disposition :ICU\\n Total time spent: 55 minutes\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-28 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 639934,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n BRONCHOSCOPY by IP- At 09:43 AM. Severe diffuse\\n Tracheobronchomalacia, large gap posterior commisure above true vocal\\n cords resulting in possible etiology of recurrent aspiration\\n Seen by ENT, no note from attg (Dr. re possible posterior\\n augmentation.\\nWill require better exam in clinic with stroboscopic\\n video\\n S&S PMV Eval: Pt not to have PMV without supervision and only for short\\n periods of time aspiration risk and vocal cord edema with freq\\n suctioning when PMV in place. Per nursing had increased secretions\\n requiring deep suctioning overnight, otherwise pt is able to clear with\\n productive cough.\\n Restarted TF yest: 10\\n20cc/hr, no issues.\\n Changed PPI to per IP recs\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:05 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:50 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37\\nC (98.6\\n Tcurrent: 36.1\\nC (97\\n HR: 86 (62 - 122) bpm\\n BP: 146/61(82) {87/42(53) - 152/87(98)} mmHg\\n RR: 23 (19 - 36) insp/min\\n SpO2: 95%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 3,692 mL\\n 1,252 mL\\n PO:\\n TF:\\n 116 mL\\n 116 mL\\n IVF:\\n 2,175 mL\\n 775 mL\\n Blood products:\\n Total out:\\n 3,790 mL\\n 400 mL\\n Urine:\\n 3,790 mL\\n 400 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -98 mL\\n 854 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask\\n SpO2: 95%\\n ABG: ///32/\\n Physical Examination\\n Gen: Alert, NAD, lying in bed, comfortable, mouthing words, less\\n sedated than yest.\\n HEENT: No pallor in conjunctiva, MMM, TM in place\\n Resp: Transmitted upper airway sounds/coarse breath sounds.\\n Card: S1S2 tachycardic, no m/r/g\\n Abd: Obese, soft, mildly distended, decreased bowel sounds, G-Tube in\\n place with no erythema/induration\\n Exte: No edema, DP 2+ bil\\n NEURO: Alert, difficult to assess orientation due to poor voice. MAE\\n Labs / Radiology\\n 203 K/uL\\n 7.5 g/dL\\n 149 mg/dL\\n 0.5 mg/dL\\n 27 mEq/L\\n 4.1 mEq/L\\n 14 mg/dL\\n 108 mEq/L\\n 143 mEq/L\\n 23.7 %\\n 5.8 K/uL\\n [image002.jpg] Ca 8.6, Mg 2.0, P 3.7; PT/PTT/INR: 13.3/32.4/1.1\\n 03:20 PM\\n 03:23 AM\\n 03:00 AM\\n 04:00 AM\\n 05:45 AM\\n 03:51 AM\\n 04:45 PM\\n 04:00 AM\\n 07:37 PM\\n 04:05 AM\\n WBC\\n 5.7\\n 7.3\\n 8.0\\n 8.7\\n 5.5\\n 5.7\\n 5.8\\n Hct\\n 30.0\\n 26.9\\n 27.3\\n 27.0\\n 28.7\\n 24.7\\n 25.2\\n 25.3\\n 23.7\\n Plt\\n 356\\n 346\\n 316\\n 271\\n 249\\n 231\\n 203\\n Cr\\n 0.7\\n 0.7\\n 0.7\\n 0.7\\n 0.5\\n 0.4\\n 0.5\\n Glucose\\n 129\\n 123\\n 114\\n 112\\n 122\\n 145\\n 137\\n Other labs: PT / PTT / INR:13.3/32.4/1.1, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.9 mg/dL, Mg++:2.1 mg/dL, PO4:3.6\\n mg/dL\\n Assessment and Plan\\n 56yoF s/p mechanical fall and traumatic T spine fracture with resolving\\n respiratory failure and HAP s/p trach with complicating TBM and s/p\\n PEG.\\n .\\n # Respiratory: s/p intubation/extubation, now on trach mask, FiO2 50%.\\n Tolerating well with good O2 sat in mid-high 90\\ns. Pt continues to be\\n at risk for aspiration given new IP finding of opening defect in\\n posterior vocal cord space and given recent history of vomiting with\\n tube feed trials.\\n - Appreciate ENT and S&S input.\\n - will follow ENT recs; awaiting input for possible intervention.\\n - ppi for aspiration prophylaxis, PMV precautions: \\nt use w/o\\n supervision, frequent suctioning\\n - TM as tolerated.\\n - continue scopolamine patch q72hrs for secretions\\n - Holding sedation with exception of Risperidal 0.5mg PRN\\n - F/u CXR tomorrow\\n .\\n # FEN: Currently receiving TPN, restarted TF yest, currently at\\n 20cc/hr, w/o issue.\\n - Appreciate GI input and S&S eval\\n -Cont Reglan 20mg IV Q 8 hours for emesis precaution; meds via G-J\\n tube,\\n -D/w GI; rec: continue bowel regimen if no BM\\n # Sedation/Anxiolysis/AlteredMS: Resolved O/N with risperdal. Previous\\n delirium and agitation most likely secondary to long hospital course\\n and multiple psychotropic medications as well as hx of EtOH abuse.\\n - started Risperdal 0.5mg PO BID PRN.\\n - continue to hold all benzos. opiates, and antihistamines\\n - Appreciate psych. Will call and f/u psych recs.\\n -Obtain EKG to assess for QTc prolongation.\\n #Anemia: HCT low compared to b/l at 23.7. No known etiology of blood\\n loss.\\n -Will continue to follow HCT daily.\\n - Guaiac stools.\\n -f/u HCT this afternoon\\n -T&S\\n # Tachycardia: Improved HR max of 120\\ns versus 160s previously. Pt now\\n on PO Amiodarone 200 TID and PO metoprolol 37.5mg TID\\n - Will continue amiodarone 200 TID for three weeks and then switch to\\n qday for 1week and then d/c amiodarone.\\n - Will need to schedule f/u in 4wks with Dr. upon d/c/transfer.\\n # Hypernatremia/Fluid Status: Mild hypernatramia resolving with free\\n water administration. On TPN/TF. Good UOP.\\n - providing D5W IVFx 1L at 150cc/hr, free water flushes with TF\\n -Will f/u lytes in afternoon (5pm)\\n # UE DVT and h/o labile INR: Decision made to d/c Coumadin given her\\n labile INR, and start Lovenox . INR at 1.9\\n - Will flush L PICC with TPA if does not flush\\n - Daily coags\\n .\\n # Spine fracture: Stable\\n - Brace for OOB, need to discuss with Neurosurgery before d/c if\\n current brace is optimal for stabilization given her mobility.\\n - Pt to follow up with Dr. in .\\n .\\n # Tracheomalacia. Reevaluation bronchoscopy by IP as written above;\\n patient not a candidate for stent; pt to follow up as outpatient. No\\n new issues.\\n .\\n #. Thyroid Nodule on CT\\n - Outpatient follow up\\n .\\n # Glycemic control: SSI, well controlled\\n # ACCESS: PIV x 1, L PICC\\n # Ppx: Lovenox, PPi , Bowel Regimen PRN\\n # Communication:\\n - Boyfriend of 10 \\n - Brother also involved\\n - Social Work and Case management involved; have discussed situation\\n w/ brother and boyfriend.\\n # Code: Full\\n # Dispo: ICU, Will d/w case management re rehab facilities. Need to\\n complete d/c summary.\\n MSIV\\n PGY2 addendum:\\n Agree with assessment and plan in MSIV note as detailed above.\\n Briefly, 56 F s/p fall with T spine fracture, respiratory failure now\\n s/p trach/PEG. Now on trach mask. Patient s/p bronch with IP today;\\n ENT to see and follow for ?intervention. Nutrition issues continue;\\n will receive TPN today plus possible restart of tube feeds as tolerated\\n (later today), continue reglan. Appreciate psych recs; continuing\\n risperidone for agitation. Etiology of delirium/agitation still\\n unclear. Likely eventual dispo to rehab facility directly from ICU\\n given high nursing requirements.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-29 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 640059,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Tube Feed goals increased from 30cc to 60cc/hr. No issues O/N with\\n regard to vomiting.\\n Calm overnight. Risperdal decreased from 0.5mg to 0.25mg qam.\\n 3 runs of SVT peaking in 110-120\\ns, metoprolol 37.5mg changed from\\n TID\\nQID; given with decrease of HR to 80\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Enoxaparin (Lovenox) - 06:33 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:22 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37\\nC (98.6\\n Tcurrent: 36.5\\nC (97.7\\n HR: 114 (61 - 122) bpm\\n BP: 119/54(75) {91/36(50) - 167/84(101)} mmHg\\n RR: 19 (10 - 30) insp/min\\n SpO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 2,952 mL\\n 429 mL\\n PO:\\n TF:\\n 646 mL\\n 376 mL\\n IVF:\\n 950 mL\\n 54 mL\\n Blood products:\\n Total out:\\n 2,430 mL\\n 470 mL\\n Urine:\\n 2,430 mL\\n 240 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 522 mL\\n -41 mL\\n Respiratory support\\n O2 Delivery Device: Aerosol-cool\\n SpO2: 100%\\n ABG: ///35/\\n Physical Examination\\n Gen: Alert, NAD, lying in bed, comfortable, mouthing words, less\\n sedated than yest.\\n HEENT: No pallor in conjunctiva, MMM, TM in place\\n Resp: Transmitted upper airway sounds/coarse breath sounds.\\n Card: S1S2 tachycardic, no m/r/g\\n Abd: Obese, soft, mildly distended, decreased bowel sounds, G-Tube in\\n place with no erythema/induration\\n Exte: No edema, DP 2+ bil\\n NEURO: Alert, difficult to assess orientation due to poor voice. MAE\\n Labs / Radiology\\n 187 K/uL\\n 7.2 g/dL\\n 105 mg/dL\\n 0.5 mg/dL\\n 35 mEq/L\\n 3.8 mEq/L\\n 17 mg/dL\\n 108 mEq/L\\n 147 mEq/L\\n 23.7 %\\n 5.1 K/uL\\n [image002.jpg]\\n 03:00 AM\\n 04:00 AM\\n 05:45 AM\\n 03:51 AM\\n 04:45 PM\\n 04:00 AM\\n 07:37 PM\\n 04:05 AM\\n 06:05 PM\\n 03:23 AM\\n WBC\\n 7.3\\n 8.0\\n 8.7\\n 5.5\\n 5.7\\n 5.8\\n 5.1\\n Hct\\n 27.3\\n 27.0\\n 28.7\\n 24.7\\n 25.2\\n 25.3\\n 23.7\\n 24.7\\n 23.7\\n Plt\\n 346\\n 316\\n 271\\n 249\\n 231\\n 203\\n 187\\n Cr\\n 0.7\\n 0.7\\n 0.7\\n 0.5\\n 0.4\\n 0.5\\n 0.5\\n 0.5\\n Glucose\\n 123\\n 114\\n 112\\n 122\\n 145\\n 137\\n 149\\n 105\\n Other labs: PT / PTT / INR:13.3/32.4/1.1, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.8 mg/dL, Mg++:2.1 mg/dL, PO4:3.5\\n mg/dL\\n Assessment and Plan\\n 56yoF s/p mechanical fall and traumatic T spine fracture with resolving\\n respiratory failure and HAP s/p trach with complicating TBM and s/p\\n PEG.\\n .\\n # Respiratory: s/p intubation/extubation, now on trach mask, FiO2 50%.\\n Tolerating well with good O2 sat in mid-high 90\\ns. Pt continues to be\\n at risk for aspiration given new IP finding of opening defect in\\n posterior vocal cord space and given recent history of vomiting with\\n tube feed trials.\\n - Appreciate ENT and S&S input.\\n - will follow ENT recs; awaiting input for possible intervention.\\n - ppi for aspiration prophylaxis, PMV precautions: \\nt use w/o\\n supervision, frequent suctioning\\n - TM as tolerated.\\n - continue scopolamine patch q72hrs for secretions\\n - Holding sedation with exception of Risperidal 0.25mg qam PRN\\n # Atrial Tachycardia: Compared to recent b/l, HR increased to max of\\n 120\\ns. Pt now on PO Amiodarone 200 TID and PO increased metoprolol\\n 37.5mg QID.\\n - Will continue amiodarone 200 TID for three weeks and then switch to\\n qday for 1week and then d/c amiodarone.\\n - Will need to schedule f/u in 4wks with Dr. upon d/c/transfer.\\n # Sedation/Anxiolysis/AlteredMS: Resolving. Previous delirium and\\n agitation most likely secondary to long hospital course and multiple\\n psychotropic medications as well as hx of EtOH abuse.\\n - Risperdal 0.25mg PO qam PRN.\\n - continue to hold all benzos. opiates, and antihistamines\\n - Appreciate psych. Will call and f/u psych recs.\\n -Follow EKG to assess for QTc prolongation (last EKG ; QTc 457).\\n #Anemia: HCT low compared to b/l at 23.7. No known etiology of blood\\n loss.\\n -Will continue to follow HCT daily.\\n - Guaiac stools.\\n -f/u HCT this afternoon\\n -T&S\\n # Hypernatremia/Fluid Status: Mild hypernatramia resolving with free\\n water administration. On TPN/TF. Good UOP.\\n - increase D5W IVFx 1L from 10cc/hr to 150cc/hr, free water flushes\\n with TF\\n -Will f/u lytes in afternoon (5pm)\\n # UE DVT and h/o labile INR: Decision made to d/c Coumadin given her\\n labile INR, and start Lovenox . INR at 1.1\\n - Will flush L PICC with TPA if does not flush\\n - Daily coags\\n .\\n # Spine fracture: Stable. T5-T8.\\n - Brace for OOB, need to discuss with Neurosurgery before d/c if\\n current brace is optimal for stabilization given her mobility.\\n - Pt to follow up with Dr. in .\\n .\\n # Tracheomalacia. Reevaluation bronchoscopy by IP as written above;\\n patient not a candidate for stent; pt to follow up as outpatient. No\\n new issues.\\n .\\n #. Thyroid Nodule on CT\\n - Outpatient follow up\\n .\\n # Glycemic control: SSI, well controlled\\n # FEN: Currently receiving TPN, restarted TF yest, currently at\\n 20cc/hr, w/o issue.\\n - Appreciate GI input and S&S eval\\n -Cont Reglan 20mg IV Q 8 hours for emesis precaution; meds via G-J\\n tube,\\n -D/w GI; rec: continue bowel regimen if no BM\\n .\\n # ACCESS: PIV x 1, L PICC\\n # Ppx: Lovenox, PPi , Bowel Regimen PRN\\n # Communication:\\n - (brother) is primary contact\\n - Boyfriend of 10 , but minimal contact has been maintained at\\n this point\\n - Social Work and Case management involved; have discussed situation\\n w/ brother and boyfriend.\\n # Code: Full\\n # Dispo: ICU, Will d/w case management re rehab facilities, likely d/c\\n tomorrow if insurance/bed confirmed\\n MSIV\\n PGY2 addendum: , \\n Agree with assessment and plan in excellent MSIV note as detailed\\n above. Briefly, 56 F s/p fall with T spine fracture (T5-T8),\\n respiratory failure now s/p trach/PEG. Now on trach mask. Patient s/p\\n bronch with IP yesterday. Nutrition issues continue; have discontinued\\n TPN today and will continue tubefeeding to goal of 60cc/hr per\\n Nutrition. Will continue reglan until at goal feedings, and decrease\\n and d/c as able given potential for delirium. Appreciate psych recs;\\n continuing risperidone for agitation. Etiology of delirium/agitation\\n still unclear but likely prolonged hospital course, illness and\\n multiple medications. Currently discussing with CM about potential\\n placement to rehab tomorrow.\\n ICU Care\\n Nutrition:\\n Replete with Fiber () - 09:45 PM 40 mL/hour\\n Glycemic Control:\\n Lines:\\n PICC Line - 01:30 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-28 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 639874,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n BRONCHOSCOPY by IP- At 09:43 AM. Severe diffuse\\n Tracheobronchomalacia, large gap posterior commisure above true vocal\\n cords resulting in possible etiology of recurrent aspiration\\n Seen by ENT, no note from attg (Dr. re possible posterior\\n augmentation.\\nWill require better exam in clinic with stroboscopic\\n video\\n S&S PMV Eval: Pt not to have PMV without supervision and only for short\\n periods of time aspiration risk and vocal cord edema with freq\\n suctioning when PMV in place. Per nursing had increased secretions\\n requiring deep suctioning overnight, otherwise pt is able to clear with\\n productive cough.\\n Restarted TF yest: 10\\n20cc/hr, no issues.\\n Changed PPI to per IP recs\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:05 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:50 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37\\nC (98.6\\n Tcurrent: 36.1\\nC (97\\n HR: 86 (62 - 122) bpm\\n BP: 146/61(82) {87/42(53) - 152/87(98)} mmHg\\n RR: 23 (19 - 36) insp/min\\n SpO2: 95%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 3,692 mL\\n 1,252 mL\\n PO:\\n TF:\\n 116 mL\\n 116 mL\\n IVF:\\n 2,175 mL\\n 775 mL\\n Blood products:\\n Total out:\\n 3,790 mL\\n 400 mL\\n Urine:\\n 3,790 mL\\n 400 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -98 mL\\n 854 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask\\n SpO2: 95%\\n ABG: ///32/\\n Physical Examination\\n Gen: Alert, NAD, lying in bed, comfortable, mouthing words, less\\n sedated than yest.\\n HEENT: No pallor in conjunctiva, MMM, TM in place\\n Resp: Transmitted upper airway sounds/coarse breath sounds.\\n Card: S1S2 tachycardic, no m/r/g\\n Abd: Obese, soft, mildly distended, decreased bowel sounds, G-Tube in\\n place with no erythema/induration\\n Exte: No edema, DP 2+ bil\\n NEURO: Alert, difficult to assess orientation due to poor voice.\\n Labs / Radiology\\n 203 K/uL\\n 7.5 g/dL\\n 149 mg/dL\\n 0.5 mg/dL\\n 27 mEq/L\\n 4.1 mEq/L\\n 14 mg/dL\\n 108 mEq/L\\n 143 mEq/L\\n 23.7 %\\n 5.8 K/uL\\n [image002.jpg] Ca 8.6, Mg 2.0, P 3.7; PT/PTT/INR: 13.3/32.4/1.1\\n 03:20 PM\\n 03:23 AM\\n 03:00 AM\\n 04:00 AM\\n 05:45 AM\\n 03:51 AM\\n 04:45 PM\\n 04:00 AM\\n 07:37 PM\\n 04:05 AM\\n WBC\\n 5.7\\n 7.3\\n 8.0\\n 8.7\\n 5.5\\n 5.7\\n 5.8\\n Hct\\n 30.0\\n 26.9\\n 27.3\\n 27.0\\n 28.7\\n 24.7\\n 25.2\\n 25.3\\n 23.7\\n Plt\\n 356\\n 346\\n 316\\n 271\\n 249\\n 231\\n 203\\n Cr\\n 0.7\\n 0.7\\n 0.7\\n 0.7\\n 0.5\\n 0.4\\n 0.5\\n Glucose\\n 129\\n 123\\n 114\\n 112\\n 122\\n 145\\n 137\\n Other labs: PT / PTT / INR:13.3/32.4/1.1, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.9 mg/dL, Mg++:2.1 mg/dL, PO4:3.6\\n mg/dL\\n Assessment and Plan\\n 56yoF s/p mechanical fall and traumatic T spine fracture with resolving\\n respiratory failure and HAP s/p trach with complicating TBM and s/p\\n PEG.\\n .\\n # Respiratory: s/p intubation/extubation, now on trach mask, FiO2 50%.\\n Tolerating well with good O2 sat in mid-high 90\\ns. Pt continues to be\\n at risk for aspiration given new IP finding of opening defect in\\n posterior vocal cord space and given recent history of vomiting with\\n tube feed trials.\\n - Appreciate ENT and S&S input.\\n - will follow ENT recs; awaiting input for possible intervention.\\n - ppi for aspiration prophylaxis\\n - Trach mask as tolerated.\\n - scopolamine patch q72hrs for secretions\\n - Holding sedation with exception of Risperidal 0.5mg PRN\\n - F/u CXR tomorrow\\n - PMV precautions: \\nt use w/o supervision, frequent suctioning\\n .\\n # FEN: Currently receiving TPN, restarted TF yest, currently at\\n 20cc/hr, w/o issue.\\n - Appreciate S&S eval\\n - Cont Reglan 20mg IV Q 8 hours for emesis precaution; meds via G-J\\n tube,\\n - Will f/u GI recs\\n .\\n # Tachycardia: Improved HR max of 120\\ns versus 160s previously. Pt now\\n on PO Amiodarone 200 TID and PO metoprolol 37.5mg TID\\n - Will continue amiodarone 200 TID for three weeks and then switch to\\n qday for 1week and then d/c amiodarone.\\n - Will need to schedule f/u in 4wks with Dr. upon d/c/transfer.\\n # Sedation/Anxiolysis/AlteredMS: Resolved O/N with risperdal. Previous\\n delirium and agitation most likely secondary to long hospital course\\n and multiple psychotropic medications as well as hx of EtOH abuse.\\n - started Risperdal 0.5mg PO BID PRN.\\n - continue to hold all benzos. opiates, and antihistamines\\n - Appreciate psych. Will call and f/u psych recs.\\n -Obtain EKG to assess for QTc prolongation.\\n #Anemia: HCT low compared to b/l at 23.7. No known etiology of blood\\n loss.\\n -Will continue to follow HCT daily.\\n # Hypernatremia/Fluid Status: Mild hypernatramia resolving with free\\n water administration. On TPN/TF. Good UOP.\\n - providing D5W IVFx 1L at 150cc/hr, free water flushes with TF\\n -Will f/u lytes in afternoon (5pm)\\n # UE DVT and h/o labile INR: Decision made to d/c Coumadin given her\\n labile INR, and start Lovenox . INR at 1.9\\n - Will flush L PICC with TPA if does not flush\\n - Daily coags\\n .\\n # Spine fracture: Stable\\n - Brace for OOB, need to discuss with Neurosurgery before d/c if\\n current brace is optimal for stabilization given her mobility.\\n - Pt to follow up with Dr. in .\\n .\\n # Tracheomalacia. Reevaluation bronchoscopy by IP as written above;\\n patient not a candidate for stent; pt to follow up as outpatient. No\\n new issues.\\n .\\n #. Thyroid Nodule on CT\\n - Outpatient follow up\\n .\\n # Glycemic control: SSI, well controlled\\n # ACCESS: PIV x 1, L PICC\\n # Ppx: Lovenox, PPi , Bowel Regimen PRN\\n # Communication:\\n - Boyfriend of 10 \\n - Brother also involved\\n - Social Work and Case management involved; have discussed situation\\n w/ brother and boyfriend.\\n # Code: Full\\n # Dispo: ICU, Will d/w case management re rehab facilities.\\n MSIV\\n PGY2 addendum:\\n Agree with assessment and plan in MSIV note as detailed above.\\n Briefly, 56 F s/p fall with T spine fracture, respiratory failure now\\n s/p trach/PEG. Now on trach mask. Patient s/p bronch with IP today;\\n ENT to see and follow for ?intervention. Nutrition issues continue;\\n will receive TPN today plus possible restart of tube feeds as tolerated\\n (later today), continue reglan. Appreciate psych recs; continuing\\n risperidone for agitation. Etiology of delirium/agitation still\\n unclear. Likely eventual dispo to rehab facility directly from ICU\\n given high nursing requirements.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-28 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 639909,\n \"text\": \"Chief Complaint: Respriatory failure\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 24 Hour Events:\\n BRONCHOSCOPY - At 09:43 AM\\n More wake.\\n Less aggitated today.\\n Up in chair with back brace this afternoon.\\n Requiring more frequent suctioning, now every 1-2 hrs. Sputum thin,\\n slight yellow color.\\n History obtained from Medical records\\n Patient unable to provide history: Encephalopathy\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:05 PM\\n Enoxaparin (Lovenox) - 06:33 AM\\n Other medications:\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Constitutional: No(t) Fatigue, No(t) Fever, No(t) Weight loss\\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\\n No(t) Tachycardia, No(t) Orthopnea\\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\\n nutrition\\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\\n No(t) Diarrhea, No(t) Constipation\\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\\n Integumentary (skin): No(t) Jaundice, No(t) Rash\\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\\n Heme / Lymph: No(t) Lymphadenopathy, No(t) Anemia, No(t) Coagulopathy\\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\\n No(t) Daytime somnolence\\n Allergy / Immunology: No(t) Immunocompromised, No(t) Influenza vaccine\\n Signs or concerns for abuse : No\\n Pain: No pain / appears comfortable\\n Flowsheet Data as of 12:33 PM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37\\nC (98.6\\n Tcurrent: 36.9\\nC (98.5\\n HR: 71 (70 - 122) bpm\\n BP: 122/84(94) {115/48(66) - 167/87(98)} mmHg\\n RR: 10 (10 - 36) insp/min\\n SpO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 3,692 mL\\n 1,980 mL\\n PO:\\n TF:\\n 116 mL\\n 244 mL\\n IVF:\\n 2,175 mL\\n 832 mL\\n Blood products:\\n Total out:\\n 3,790 mL\\n 1,180 mL\\n Urine:\\n 3,790 mL\\n 1,180 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -98 mL\\n 800 mL\\n Respiratory support\\n O2 Delivery Device: Aerosol-cool\\n SpO2: 98%\\n ABG: ///27/\\n Physical Examination\\n General Appearance: No(t) Well nourished, No acute distress, No(t)\\n Overweight / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic\\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\\n pale, No(t) Sclera edema\\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\\n Endotracheal tube, No(t) NG tube, No(t) OG tube\\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\\n Cervical adenopathy\\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic,\\n No(t) Diastolic)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\\n (Breath Sounds: Clear : , No(t) Crackles : , No(t) Bronchial: , No(t)\\n Wheezes : , No(t) Diminished: , No(t) Absent : , No(t) Rhonchorous: )\\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\\n No(t) Tender: , No(t) Obese, PEG\\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis, No(t) Clubbing\\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\\n Skin: Warm, No(t) Rash: , No(t) Jaundice\\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\\n stimuli, No(t) Oriented (to): , Movement: Purposeful, No(t) Sedated,\\n No(t) Paralyzed, Tone: Normal\\n Labs / Radiology\\n 7.5 g/dL\\n 203 K/uL\\n 149 mg/dL\\n 0.5 mg/dL\\n 27 mEq/L\\n 4.1 mEq/L\\n 14 mg/dL\\n 108 mEq/L\\n 143 mEq/L\\n 23.7 %\\n 5.8 K/uL\\n [image002.jpg]\\n 03:20 PM\\n 03:23 AM\\n 03:00 AM\\n 04:00 AM\\n 05:45 AM\\n 03:51 AM\\n 04:45 PM\\n 04:00 AM\\n 07:37 PM\\n 04:05 AM\\n WBC\\n 5.7\\n 7.3\\n 8.0\\n 8.7\\n 5.5\\n 5.7\\n 5.8\\n Hct\\n 30.0\\n 26.9\\n 27.3\\n 27.0\\n 28.7\\n 24.7\\n 25.2\\n 25.3\\n 23.7\\n Plt\\n 356\\n 346\\n 316\\n 271\\n 249\\n 231\\n 203\\n Cr\\n 0.7\\n 0.7\\n 0.7\\n 0.7\\n 0.5\\n 0.4\\n 0.5\\n 0.5\\n Glucose\\n 129\\n 123\\n 114\\n 112\\n 122\\n 145\\n 137\\n 149\\n Other labs: PT / PTT / INR:13.3/32.4/1.1, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.6 mg/dL, Mg++:2.0 mg/dL, PO4:3.7\\n mg/dL\\n Assessment and Plan\\n Delerium.\\n RESPIRATORY FAILURE -- chronic, persistent. Tracheotomy tube in place,\\n with tach collar/mask. Use Passe-Muir valve as tolerated.\\n INCREASED SPUTUM production -- concern for evolving LLL pneumonia.\\n Monitor closely. COntinue frequent suctioning.\\n T-SPINE Fx -- Back brace. Up in chair as tolerated. Ortho to F/U.\\n TRACHEOBRONCHOMALAcIA -- no immediate plans for intervention at this\\n time.\\n VOCAL CORD DYSFUNCTION -- poor adduction of posterior portions of vocal\\n cords --> ENT to further assess.\\n NUTRITIONAL SUPPORT -- TF via PEG at low rate. ALso receiving TPN.\\n DELERIUM -- likely due to medications and ICU. Possible contribution\\n Improved on Respiradol.\\n DVT -- lovenox\\n REHABILITATION evaluation for transfer.\\n ICU Care\\n Nutrition:\\n Replete with Fiber () - 06:00 PM 20 mL/hour\\n TPN w/ Lipids - 06:02 PM 62.5 mL/hour\\n Glycemic Control:\\n Lines:\\n PICC Line - 01:30 PM\\n Prophylaxis:\\n DVT: Boots(Systemic anticoagulation: None)\\n Stress ulcer:\\n VAP: HOB elevation, Mouth care\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds Comments:\\n Code status: Full code\\n Disposition :ICU\\n Total time spent: 55 minutes\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Nutrition\",\n \"chartdate\": \"2167-10-28 00:00:00.000\",\n \"description\": \"Clinical Nutrition Note\",\n \"row_id\": 639931,\n \"text\": \"Subjective\\n Pt sitting in chair, appears comfortable\\n Objective\\n Pertinent medications: noted\\n Labs:\\n Value\\n Date\\n Glucose\\n 149 mg/dL\\n 04:05 AM\\n Glucose Finger Stick\\n 134\\n 10:00 AM\\n BUN\\n 14 mg/dL\\n 04:05 AM\\n Creatinine\\n 0.5 mg/dL\\n 04:05 AM\\n Sodium\\n 143 mEq/L\\n 04:05 AM\\n Potassium\\n 4.1 mEq/L\\n 04:05 AM\\n Chloride\\n 108 mEq/L\\n 04:05 AM\\n Albumin\\n 3.1 g/dL\\n 03:23 AM\\n Calcium non-ionized\\n 8.6 mg/dL\\n 04:05 AM\\n Phosphorus\\n 3.7 mg/dL\\n 04:05 AM\\n Ionized Calcium\\n 1.24 mmol/L\\n 02:51 AM\\n Magnesium\\n 2.0 mg/dL\\n 04:05 AM\\n ALT\\n 25 IU/L\\n 07:34 AM\\n Alkaline Phosphate\\n 106 IU/L\\n 07:34 AM\\n AST\\n 19 IU/L\\n 07:34 AM\\n Amylase\\n 10 IU/L\\n 03:59 AM\\n Total Bilirubin\\n 0.2 mg/dL\\n 07:34 AM\\n Triglyceride\\n 109 mg/dL\\n 03:51 AM\\n WBC\\n 5.8 K/uL\\n 04:05 AM\\n Hgb\\n 7.5 g/dL\\n 04:05 AM\\n Hematocrit\\n 23.7 %\\n 04:05 AM\\n Current diet order / nutrition support: i/2 strength Replte c/ Fiber\\n @30mL/hr\\n GI: Abd obese/hypo bs\\n Assessment of Nutritional Status\\n Estimation of current intake: Adequate until TPN off at 6 pm\\n Specifics:\\n TF\\ns retrialed, were tolerated up to 20mL/hr-now off cannot infuse\\n c/ apparatus needed around torso while in chair. TPN rec were paged\\n this am as pt c/ long h/o intolerance to TF\\ns, to continue until TF\\n tolerance established. TPN ordered then d/c\\nd. Will need to change TF\\n goal rate to better meet needs and have low threshold for resuming TPN\\n if intolerance to TF occurs.\\n Medical Nutrition Therapy Plan - Recommend the Following\\n Multivitamin / Mineral supplement: TF\\n Tube feeding recommendations: Change TF to Replete c/ Fiber @60mL/hr\\n (1440 kcals/89 gr aa)\\n MOnitor tolerance via abd exam/pt complaints/BM's\\n BG management as you are\\n If pt does not tolerateTF's will need to resume TPN\\n Will follow- please call c/ ?\\ns #\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-28 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 639932,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n BRONCHOSCOPY by IP- At 09:43 AM. Severe diffuse\\n Tracheobronchomalacia, large gap posterior commisure above true vocal\\n cords resulting in possible etiology of recurrent aspiration\\n Seen by ENT, no note from attg (Dr. re possible posterior\\n augmentation.\\nWill require better exam in clinic with stroboscopic\\n video\\n S&S PMV Eval: Pt not to have PMV without supervision and only for short\\n periods of time aspiration risk and vocal cord edema with freq\\n suctioning when PMV in place. Per nursing had increased secretions\\n requiring deep suctioning overnight, otherwise pt is able to clear with\\n productive cough.\\n Restarted TF yest: 10\\n20cc/hr, no issues.\\n Changed PPI to per IP recs\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:05 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:50 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37\\nC (98.6\\n Tcurrent: 36.1\\nC (97\\n HR: 86 (62 - 122) bpm\\n BP: 146/61(82) {87/42(53) - 152/87(98)} mmHg\\n RR: 23 (19 - 36) insp/min\\n SpO2: 95%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 3,692 mL\\n 1,252 mL\\n PO:\\n TF:\\n 116 mL\\n 116 mL\\n IVF:\\n 2,175 mL\\n 775 mL\\n Blood products:\\n Total out:\\n 3,790 mL\\n 400 mL\\n Urine:\\n 3,790 mL\\n 400 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -98 mL\\n 854 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask\\n SpO2: 95%\\n ABG: ///32/\\n Physical Examination\\n Gen: Alert, NAD, lying in bed, comfortable, mouthing words, less\\n sedated than yest.\\n HEENT: No pallor in conjunctiva, MMM, TM in place\\n Resp: Transmitted upper airway sounds/coarse breath sounds.\\n Card: S1S2 tachycardic, no m/r/g\\n Abd: Obese, soft, mildly distended, decreased bowel sounds, G-Tube in\\n place with no erythema/induration\\n Exte: No edema, DP 2+ bil\\n NEURO: Alert, difficult to assess orientation due to poor voice. MAE\\n Labs / Radiology\\n 203 K/uL\\n 7.5 g/dL\\n 149 mg/dL\\n 0.5 mg/dL\\n 27 mEq/L\\n 4.1 mEq/L\\n 14 mg/dL\\n 108 mEq/L\\n 143 mEq/L\\n 23.7 %\\n 5.8 K/uL\\n [image002.jpg] Ca 8.6, Mg 2.0, P 3.7; PT/PTT/INR: 13.3/32.4/1.1\\n 03:20 PM\\n 03:23 AM\\n 03:00 AM\\n 04:00 AM\\n 05:45 AM\\n 03:51 AM\\n 04:45 PM\\n 04:00 AM\\n 07:37 PM\\n 04:05 AM\\n WBC\\n 5.7\\n 7.3\\n 8.0\\n 8.7\\n 5.5\\n 5.7\\n 5.8\\n Hct\\n 30.0\\n 26.9\\n 27.3\\n 27.0\\n 28.7\\n 24.7\\n 25.2\\n 25.3\\n 23.7\\n Plt\\n 356\\n 346\\n 316\\n 271\\n 249\\n 231\\n 203\\n Cr\\n 0.7\\n 0.7\\n 0.7\\n 0.7\\n 0.5\\n 0.4\\n 0.5\\n Glucose\\n 129\\n 123\\n 114\\n 112\\n 122\\n 145\\n 137\\n Other labs: PT / PTT / INR:13.3/32.4/1.1, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.9 mg/dL, Mg++:2.1 mg/dL, PO4:3.6\\n mg/dL\\n Assessment and Plan\\n 56yoF s/p mechanical fall and traumatic T spine fracture with resolving\\n respiratory failure and HAP s/p trach with complicating TBM and s/p\\n PEG.\\n .\\n # Respiratory: s/p intubation/extubation, now on trach mask, FiO2 50%.\\n Tolerating well with good O2 sat in mid-high 90\\ns. Pt continues to be\\n at risk for aspiration given new IP finding of opening defect in\\n posterior vocal cord space and given recent history of vomiting with\\n tube feed trials.\\n - Appreciate ENT and S&S input.\\n - will follow ENT recs; awaiting input for possible intervention.\\n - ppi for aspiration prophylaxis\\n - Trach mask as tolerated.\\n - scopolamine patch q72hrs for secretions\\n - Holding sedation with exception of Risperidal 0.5mg PRN\\n - F/u CXR tomorrow\\n - PMV precautions: \\nt use w/o supervision, frequent suctioning\\n .\\n # FEN: Currently receiving TPN, restarted TF yest, currently at\\n 20cc/hr, w/o issue.\\n - Appreciate S&S eval\\n - Cont Reglan 20mg IV Q 8 hours for emesis precaution; meds via G-J\\n tube,\\n - Will f/u GI recs\\n -D/w GI 00\\n .\\n # Tachycardia: Improved HR max of 120\\ns versus 160s previously. Pt now\\n on PO Amiodarone 200 TID and PO metoprolol 37.5mg TID\\n - Will continue amiodarone 200 TID for three weeks and then switch to\\n qday for 1week and then d/c amiodarone.\\n - Will need to schedule f/u in 4wks with Dr. upon d/c/transfer.\\n # Sedation/Anxiolysis/AlteredMS: Resolved O/N with risperdal. Previous\\n delirium and agitation most likely secondary to long hospital course\\n and multiple psychotropic medications as well as hx of EtOH abuse.\\n - started Risperdal 0.5mg PO BID PRN.\\n - continue to hold all benzos. opiates, and antihistamines\\n - Appreciate psych. Will call and f/u psych recs.\\n -Obtain EKG to assess for QTc prolongation.\\n #Anemia: HCT low compared to b/l at 23.7. No known etiology of blood\\n loss.\\n -Will continue to follow HCT daily.\\n # Hypernatremia/Fluid Status: Mild hypernatramia resolving with free\\n water administration. On TPN/TF. Good UOP.\\n - providing D5W IVFx 1L at 150cc/hr, free water flushes with TF\\n -Will f/u lytes in afternoon (5pm)\\n # UE DVT and h/o labile INR: Decision made to d/c Coumadin given her\\n labile INR, and start Lovenox . INR at 1.9\\n - Will flush L PICC with TPA if does not flush\\n - Daily coags\\n .\\n # Spine fracture: Stable\\n - Brace for OOB, need to discuss with Neurosurgery before d/c if\\n current brace is optimal for stabilization given her mobility.\\n - Pt to follow up with Dr. in .\\n .\\n # Tracheomalacia. Reevaluation bronchoscopy by IP as written above;\\n patient not a candidate for stent; pt to follow up as outpatient. No\\n new issues.\\n .\\n #. Thyroid Nodule on CT\\n - Outpatient follow up\\n .\\n # Glycemic control: SSI, well controlled\\n # ACCESS: PIV x 1, L PICC\\n # Ppx: Lovenox, PPi , Bowel Regimen PRN\\n # Communication:\\n - Boyfriend of 10 \\n - Brother also involved\\n - Social Work and Case management involved; have discussed situation\\n w/ brother and boyfriend.\\n # Code: Full\\n # Dispo: ICU, Will d/w case management re rehab facilities.\\n MSIV\\n PGY2 addendum:\\n Agree with assessment and plan in MSIV note as detailed above.\\n Briefly, 56 F s/p fall with T spine fracture, respiratory failure now\\n s/p trach/PEG. Now on trach mask. Patient s/p bronch with IP today;\\n ENT to see and follow for ?intervention. Nutrition issues continue;\\n will receive TPN today plus possible restart of tube feeds as tolerated\\n (later today), continue reglan. Appreciate psych recs; continuing\\n risperidone for agitation. Etiology of delirium/agitation still\\n unclear. Likely eventual dispo to rehab facility directly from ICU\\n given high nursing requirements.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-29 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 639980,\n \"text\": \"56 yr old woman, who was transferred from osh for evaluation of\\n tracheal bronchial malacia on .Pt presented to Medical\\n Center on s/p fall down a flight of stairs fracturing, t5-t8 with\\n propulsion treated conservatively with pain meds and back brace. She\\n developed resp distress requiring intubation on . Trach/PEG done\\n . Now with prolonged hospital course c/b by PNA, anxiety/altered\\n mental status, R&LUE DVT .Pt found to have small non occlusive clot on\\n her right axial vein via Ultrasound, now rec\\ning Lovenox. She has had\\n problems with vomiting tube feedings, so feeding tube passed through\\n g-tube to her jejunenum. However, she continued to intermit raise\\n gastric contents assoc with bronchospasm. Has not required ventilation\\n since , on humidified TM @ 50%. Presently on TPN and restarted on\\n TF\\nings at low rate via J-tube.\\n BRONCHOSCOPY by IP- At 09:43 AM. Severe diffuse\\n Tracheobronchomalacia, large gap posterior commisure above true vocal\\n cords resulting in possible etiology of recurrent aspiration\\n Airway Clearance, Impaired\\n Assessment:\\n Patients lung sounds are course bilat. O2 sat 95-100 on 50% trach\\n collar. She has a productive cough. Yellow , clear white sputum in\\n small to mod amounts.\\n Action:\\n Suctioned every one hour, in increase in secretion. She also has\\n scolpolamine patch on.\\n Response:\\n Sx every 1- 11/2 hours.\\n Plan:\\n to monitor and clear airway as needed.\\n Alteration in Nutrition\\n Assessment:\\n She did start promote 1/2 strength w/ fiber. Advance by 10ml q6 hours.\\n Flush w/ 50 ml hour every 4 hurs.\\n Action:\\n She has a J tube in place, so we are unable to check resuduals. Patient\\n had liquid brown stool over night.\\n Response:\\n colace and senna held. Mushroom cath placed.\\n Plan:\\n to advance to goal rate.\\n Fracture, other\\n Assessment:\\n Patient has a fracture of t5-t8. she c/o of pain. She was not able to\\n tell me where the pain was located.\\n Action:\\n Changed the position.\\n Response:\\n She did fall asleep for a few hours.\\n Plan:\\n Given Tylenol if she to c/o pain.\\n Altered mental status (not Delirium)\\n Assessment:\\n He is trached and appears confused at times. She will follow commands.\\n But she makes attempt to pull out her mushroom tube and iv line. In the\\n past she has pulled out her trach x2. she is also throwing her legs\\n over the side of the bed.\\n Action:\\n w/ soft wrist restraints.\\n Response:\\n Patient remains safe.\\n Plan:\\n current safety plan.\\n 02:34\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-25 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 639400,\n \"text\": \"Airway Clearance, Impaired\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Tachycardia, Other\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Alteration in Nutrition\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Hypernatremia (high sodium)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Altered mental status (not Delirium)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-25 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 639401,\n \"text\": \"56 yr old woman, who was transferred from osh for evaluation of\\n tracheal bronchial malacia on .Pt presented to Medical\\n Center on s/p fall down a flight of stairs fracturing, t5-t8 with\\n propulsion treated conservatively with pain meds and back brace. She\\n developed resp distress requiring intubation on . Trach/PEG done\\n . Now with prolonged hospital course c/b by PNA, anxiety/altered\\n mental status, R&LUE DVT .Pt found to have small non occlusive Clot on\\n her right axial vein via Ultrasound. She has had problems with\\n vomiting tube feedings, feeding tube passed through g-tube to her\\n jejunenum but she continues to vomit. Trach mask, has not required\\n ventilation since . Has also required 1:1 sitters since\\n decanulating herself twice, despite restraints.\\n Airway Clearance, Impaired\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Tachycardia, Other\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Alteration in Nutrition\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Hypernatremia (high sodium)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Altered mental status (not Delirium)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-29 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 639975,\n \"text\": \"56 yr old woman, who was transferred from osh for evaluation of\\n tracheal bronchial malacia on .Pt presented to Medical\\n Center on s/p fall down a flight of stairs fracturing, t5-t8 with\\n propulsion treated conservatively with pain meds and back brace. She\\n developed resp distress requiring intubation on . Trach/PEG done\\n . Now with prolonged hospital course c/b by PNA, anxiety/altered\\n mental status, R&LUE DVT .Pt found to have small non occlusive clot on\\n her right axial vein via Ultrasound, now rec\\ning Lovenox. She has had\\n problems with vomiting tube feedings, so feeding tube passed through\\n g-tube to her jejunenum. However, she continued to intermit raise\\n gastric contents assoc with bronchospasm. Has not required ventilation\\n since , on humidified TM @ 50%. Presently on TPN and restarted on\\n TF\\nings at low rate via J-tube.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-29 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 640038,\n \"text\": \"56 yr old woman, who was transferred from osh for evaluation of\\n tracheal bronchial malacia on .Pt presented to Medical\\n Center on s/p fall down a flight of stairs fracturing, t5-t8 with\\n propulsion treated conservatively with pain meds and back brace. She\\n developed resp distress requiring intubation on . Trach/PEG done\\n . Now with prolonged hospital course c/b by PNA, anxiety/altered\\n mental status, R&LUE DVT .Pt found to have small non occlusive clot on\\n her right axial vein via Ultrasound, now rec\\ning Lovenox. She has had\\n problems with vomiting tube feedings, so feeding tube passed through\\n g-tube to her jejunenum. However, she continued to intermit raise\\n gastric contents assoc with bronchospasm. Has not required ventilation\\n since , on humidified TM @ 50%. Presently on TPN and restarted on\\n TF\\nings at low rate via J-tube.\\n BRONCHOSCOPY by IP- At 09:43 AM. Severe diffuse\\n Tracheobronchomalacia, large gap posterior commisure above true vocal\\n cords resulting in possible etiology of recurrent aspiration\\n Airway Clearance, Impaired\\n Assessment:\\n Patients lung sounds are course bilat. O2 sat 95-100 on 50% trach\\n collar. She has a productive cough. Yellow , clear white sputum in\\n small to mod amounts.\\n Action:\\n Suctioned every one hour, in increase in secretion. She also has\\n scolpolamine patch on.\\n Response:\\n Sx every 1- 11/2 hours.\\n Plan:\\n to monitor and clear airway as needed.\\n Alteration in Nutrition\\n Assessment:\\n She did start promote 1/2 strength w/ fiber. Advance by 10ml q6 hours.\\n Flush w/ 50 ml hour every 4 hurs.\\n Action:\\n She has a J tube in place, so we are unable to check resuduals. Patient\\n had liquid brown stool over night.\\n Response:\\n colace and senna held. Mushroom cath placed.\\n Plan:\\n to advance to goal rate.\\n Fracture, other\\n Assessment:\\n Patient has a fracture of t5-t8. she c/o of pain. She was not able to\\n tell me where the pain was located.\\n Action:\\n Changed the position.\\n Response:\\n She did fall asleep for a few hours.\\n Plan:\\n Given Tylenol if she to c/o pain.\\n Altered mental status (not Delirium)\\n Assessment:\\n He is trached and appears confused at times. She will follow commands.\\n But she makes attempt to pull out her mushroom tube and iv line. In the\\n past she has pulled out her trach x2. she is also throwing her legs\\n over the side of the bed.\\n Action:\\n w/ soft wrist restraints.\\n Response:\\n Patient remains safe.\\n Plan:\\n current safety plan.\\n 02:34\\n ------ Protected Section ------\\n Patient put out 230ml of brown/gold colored liquid foul smelling\\n stool. The stool was sent for c diff. All Bowel meds held.\\n ------ Protected Section Addendum Entered By: ,\\n RN on: 06:13 ------\\n 06:13\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-29 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 640142,\n \"text\": \"Synopsis per prior nursing note:\\n 56 yr old woman, who was transferred from osh for evaluation of\\n tracheal bronchial malacia on .Pt presented to Medical\\n Center on s/p fall down a flight of stairs fracturing, t5-t8 with\\n propulsion treated conservatively with pain meds and back brace. She\\n developed resp distress requiring intubation on . Trach/PEG done\\n . Now with prolonged hospital course c/b by PNA, anxiety/altered\\n mental status, R&LUE DVT .Pt found to have small non occlusive clot on\\n her right axial vein via Ultrasound, now rec\\ning Lovenox. She has had\\n problems with vomiting tube feedings, so feeding tube passed through\\n g-tube to her jejunenum. However, she continued to intermit raise\\n gastric contents assoc with bronchospasm. Has not required ventilation\\n since , on humidified TM @ 50%. Presently on TPN and restarted on\\n TF\\nings at low rate via J-tube.\\n BRONCHOSCOPY by IP- At 09:43 AM. Severe diffuse\\n Tracheobronchomalacia, large gap posterior commisure above true vocal\\n cords resulting in possible etiology of recurrent aspiration\\n Airway Clearance, Impaired\\n Assessment:\\n LS-bilat rhonchi. O2 sat >95% on 50% trach collar. Suctioned large amts\\n of thick, white secretions. Passy-muir valve in only while being\\n evaluated by Psych d/t large amt of secretions.\\n Action:\\n Suctioned every one hour. Scolpolamine patch d/c\\nd d/t mental status.\\n Response:\\n Needed suctioning every 1hour.\\n Plan:\\n to monitor and clear airway as needed.\\n Alteration in Nutrition\\n Assessment:\\n Continues on replete w/fiber full strength.. Advance by 10ml q6 hours.\\n Flush w/ 100 ml hour every 4 hours. Denies nausea. No vomiting.\\n Mushroom cath in place.\\n Action:\\n J tube in place, unable to check resuduals. Increased TF as tolerated.\\n Reglan d/c\\nd d/t to mental status. Colace/senna/polyethylene glycol\\n held.\\n Response:\\n Continues to have liquid stool. Currently tolerating TF.\\n Plan:\\n Advance TF to goal as tolerated.\\n Fracture, other\\n Assessment:\\n Patient has a fracture of t5-t8. Denied pain. Brace on while OOB in\\n chair.\\n Action:\\n Changed position. Brace on while OOB.\\n Response:\\n Continued to deny pain.\\n Plan:\\n Assess/treat pain. Brace on while OOB.\\n Altered mental status (not Delirium)\\n Assessment:\\n When passy-muir valve on, patient had +VH and +AH. She was paranoid\\n about her brother in hallway (brother was not at hospital). Stated that\\n she will be driving her car home tomorrow. Stated that she is scared.\\n Follows commands. Continues to try to pull out lines/tubes. Continues\\n to throw her legs over the side of the bed.\\n Action:\\n w/ soft wrist restraints. Reoriented frequently. Assured patient\\n that she is safe in hospital.\\n Response:\\n Patient remains safe. Able to be calmed when told she is safe in\\n hospital.\\n Plan:\\n current safety plan. Reorient frequently. Psych will continue to\\n follow.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-30 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 640378,\n \"text\": \"Synopsis per prior nursing note:\\n 56 yr old woman, who was transferred from osh for evaluation of\\n tracheal bronchial malacia on .Pt presented to Medical\\n Center on s/p fall down a flight of stairs fracturing, t5-t8 with\\n propulsion treated conservatively with pain meds and back brace. She\\n developed resp distress requiring intubation on . Trach/PEG done\\n . Now with prolonged hospital course c/b by PNA, anxiety/altered\\n mental status, R&LUE DVT .Pt found to have small non occlusive clot on\\n her right axial vein via Ultrasound, now rec\\ning Lovenox. She has had\\n problems with vomiting tube feedings, so feeding tube passed through\\n g-tube to her jejunenum. However, she continued to intermit raise\\n gastric contents assoc with bronchospasm. Has not required ventilation\\n since , on humidified TM @ 50%. Presently on TPN and restarted on\\n TF\\nings at low rate via J-tube.\\n BRONCHOSCOPY by IP- At 09:43 AM. Severe diffuse\\n Tracheobronchomalacia, large gap posterior commisure above true vocal\\n cords resulting in possible etiology of recurrent aspiration\\n Airway Clearance, Impaired\\n Assessment:\\n LS-bilat rhonchi. O2 sat >95% on 50% trach collar. Suctioned small to\\n moderate amts of thick, white/dark yellow secretions. Passy-muir valve\\n on during day/while in chair. Able to cough secretions into tissue\\n when passy-muir valve on.\\n Action:\\n Suctioned every 2 hour. Encouraged to CDB.\\n Response:\\n Able to cough secretions into tissue. Need for suctioning decreased\\n throughout shift.\\n Plan:\\n to monitor and clear airway as needed. Encourage CDB.\\n Alteration in Nutrition\\n Assessment:\\n Continues on replete w/fiber full strength. Restarted @30cc/hr. Flush\\n w/ 100 ml hour every 4 hours. Denies nausea. No vomiting. Small loose\\n stool in am.\\n Action:\\n J tube in place, unable to check residuals. Colace/senna/polyethylene\\n glycol held.\\n Response:\\n Continues to have loose stool. Currently tolerating TF.\\n Plan:\\n Advance TF to goal as tolerated.\\n Fracture, other\\n Assessment:\\n Patient has a fracture of t5-t8. Denied pain. Brace on while OOB in\\n chair.\\n Action:\\n Changed position. Brace on while OOB.\\n Response:\\n Continued to deny pain.\\n Plan:\\n Assess/treat pain. Brace on while OOB. ? transfer to \\n @ Medical Center tomorrow @ 10am.\\n Altered mental status (not Delirium)\\n Assessment:\\n When passy-muir valve on, patient had +VH and +AH. Stated paranoid\\n thoughts. Stated that she is scared. She is starting to acknowledge\\n that hallucinations may not be real. Acknowledges that even though she\\n her friend die, she knows that her friend is alive. Follows\\n commands. Not pulling at lines/tubes very often.\\n Action:\\n w/ soft wrist restraints. Reoriented frequently. Assured patient\\n that she is safe in hospital. Feels more calm when told that she is\\n safe.\\n Response:\\n Patient remains safe. Able to be calmed when told she is safe in\\n hospital.\\n Plan:\\n current safety plan. Reorient frequently. Psych will continue to\\n follow.\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2167-10-24 00:00:00.000\",\n \"description\": \"Generic Note\",\n \"row_id\": 639299,\n \"text\": \"TITLE:\\n Respiratory Care:\\n Pt has #7 portex perc trach on 40% trach collar for the night and\\n tolerated well. Cuff is deflated. PMV removed. BS are coarse\\n bilaterally which clear when suctioned. Pt is being suctioned\\n frequently. MDI\\ns ald/atr being administered with no adverse\\n reactions. Sitter in room. Pt continues to be agitated. PMV worn\\n during the day. Pt not requiring the vent this night. Vent pulled.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-24 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 639302,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Pt decannulated herself x2 yesterday, the 1st episode she desatted to\\n the 80s, the second episode she desated and her heart rate decreased to\\n 39-40, before the trach could be replaced.\\n PICC line placed by IR, called to notify that there was clot in both\\n arms, placed in L arm more proximally than small Bacillis vein clot.\\n Coumadin restarted after PICC placement with 2mg\\n Per GI Recs: Reglan restarted at 20mg IV q 8 hours, and meds were\\n restarted via tube. No vomitting.\\n Per PSYCH recs: d/c'd all benzoes, (also requested d/c reglan if GI\\n ok), added Risperdal 0.5mg (and can add 0.5mg PRN, and titrate up\\n to total daily dose of 2-3mg if helping)\\n Per Cards recs: after 18hr of amiodaron drip. Start PO amiodarone 200mg\\n TID, which was done at 1am.\\n Brother visited\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:04 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.4\\nC (99.4\\n Tcurrent: 37.4\\nC (99.4\\n HR: 90 (73 - 121) bpm\\n BP: 155/49(75) {103/47(66) - 175/98(111)} mmHg\\n RR: 32 (14 - 32) insp/min\\n SpO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 2,151 mL\\n 293 mL\\n PO:\\n TF:\\n IVF:\\n 1,852 mL\\n 13 mL\\n Blood products:\\n Total out:\\n 2,460 mL\\n 820 mL\\n Urine:\\n 2,460 mL\\n 820 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -309 mL\\n -527 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask\\n Ventilator mode: Standby\\n Vt (Set): 0 (0 - 0) mL\\n Vt (Spontaneous): 360 (360 - 360) mL\\n PS : 10 cmH2O\\n RR (Set): 0\\n RR (Spontaneous): 21\\n FiO2: 40%\\n SpO2: 98%\\n ABG: ///33/\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 316 K/uL\\n 8.3 g/dL\\n 114 mg/dL\\n 0.7 mg/dL\\n 33 mEq/L\\n 4.0 mEq/L\\n 7 mg/dL\\n 111 mEq/L\\n 149 mEq/L\\n 27.0 %\\n 8.0 K/uL\\n [image002.jpg]\\n 03:43 AM\\n 05:02 PM\\n 03:36 AM\\n 02:30 AM\\n 01:30 AM\\n 06:41 AM\\n 03:20 PM\\n 03:23 AM\\n 03:00 AM\\n 04:00 AM\\n WBC\\n 7.1\\n 6.9\\n 7.6\\n 9.5\\n 5.7\\n 7.3\\n 8.0\\n Hct\\n 29.2\\n 27.8\\n 32.7\\n 28.6\\n 28.9\\n 30.0\\n 26.9\\n 27.3\\n 27.0\\n Plt\\n 452\\n 467\\n 548\\n 528\\n 356\\n 346\\n 316\\n Cr\\n 0.7\\n 0.8\\n 0.7\\n 0.8\\n 1.0\\n 0.7\\n 0.7\\n 0.7\\n Glucose\\n 104\\n 108\\n 131\\n 128\\n 121\\n 129\\n 123\\n 114\\n Other labs: PT / PTT / INR:13.2/22.4/1.1, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:9.0 mg/dL, Mg++:2.3 mg/dL, PO4:4.1\\n mg/dL\\n Assessment and Plan\\n ICU Care\\n Nutrition:\\n TPN without Lipids - 06:00 PM 41. mL/hour\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n PICC Line - 01:30 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-24 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 639304,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Pt decannulated herself x2 yesterday, the 1st episode she desatted to\\n the 80s, the second episode she desated and her heart rate decreased to\\n 39-40, before the trach could be replaced.\\n PICC line placed by IR, called to notify that there was clot in both\\n arms, placed in L arm more proximally than small Bacillis vein clot.\\n Coumadin restarted after PICC placement with 2mg\\n Per GI Recs: Reglan restarted at 20mg IV q 8 hours, and meds were\\n restarted via tube. No vomitting.\\n Per PSYCH recs: d/c'd all benzoes, (also requested d/c reglan if GI\\n ok), added Risperdal 0.5mg (and can add 0.5mg PRN, and titrate up\\n to total daily dose of 2-3mg if helping)\\n Per Cards recs: after 18hr of amiodaron drip. Start PO amiodarone 200mg\\n TID, which was done at 1am.\\n Brother visited\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:04 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.4\\nC (99.4\\n Tcurrent: 37.4\\nC (99.4\\n HR: 90 (73 - 121) bpm\\n BP: 155/49(75) {103/47(66) - 175/98(111)} mmHg\\n RR: 32 (14 - 32) insp/min\\n SpO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 2,151 mL\\n 293 mL\\n PO:\\n TF:\\n IVF:\\n 1,852 mL\\n 13 mL\\n Blood products:\\n Total out:\\n 2,460 mL\\n 820 mL\\n Urine:\\n 2,460 mL\\n 820 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -309 mL\\n -527 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask\\n Ventilator mode: Standby\\n Vt (Set): 0 (0 - 0) mL\\n Vt (Spontaneous): 360 (360 - 360) mL\\n PS : 10 cmH2O\\n RR (Set): 0\\n RR (Spontaneous): 21\\n FiO2: 40%\\n SpO2: 98%\\n ABG: ///33/\\n Physical Examination\\n Gen: Awake and alert this am, following commands, mildly agitated,\\n stated that she\\n wanted to get out of here\\n HEENT: PERRL, MMM\\n Resp: Diffuse rhonchi and transmitted airway sounds.\\n Card: S1S2 tachycardic, no m/r/g\\n Abd: Obese, soft, mildly distended, BS+\\n Exte: No edema, DP 2+ bil\\n NEURO: CNII\\nXII intact, reflexes 2+ bilaterally.\\n Labs / Radiology\\n 316 K/uL\\n 8.3 g/dL\\n 114 mg/dL\\n 0.7 mg/dL\\n 33 mEq/L\\n 4.0 mEq/L\\n 7 mg/dL\\n 111 mEq/L\\n 149 mEq/L\\n 27.0 %\\n 8.0 K/uL\\n [image002.jpg]\\n 03:43 AM\\n 05:02 PM\\n 03:36 AM\\n 02:30 AM\\n 01:30 AM\\n 06:41 AM\\n 03:20 PM\\n 03:23 AM\\n 03:00 AM\\n 04:00 AM\\n WBC\\n 7.1\\n 6.9\\n 7.6\\n 9.5\\n 5.7\\n 7.3\\n 8.0\\n Hct\\n 29.2\\n 27.8\\n 32.7\\n 28.6\\n 28.9\\n 30.0\\n 26.9\\n 27.3\\n 27.0\\n Plt\\n 452\\n 467\\n 548\\n 528\\n 356\\n 346\\n 316\\n Cr\\n 0.7\\n 0.8\\n 0.7\\n 0.8\\n 1.0\\n 0.7\\n 0.7\\n 0.7\\n Glucose\\n 104\\n 108\\n 131\\n 128\\n 121\\n 129\\n 123\\n 114\\n Other labs: PT / PTT / INR:13.2/22.4/1.1, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:9.0 mg/dL, Mg++:2.3 mg/dL, PO4:4.1\\n mg/dL\\n Assessment and Plan\\n 55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\\n trach, PEG placement now with respiratory failure secondary to\\n tracheomalacia , resolved HAP.\\n .\\n # Respiratory failure: Slowly improving, spending most of the day on\\n trach mask with short periods of rest on PSV at night and setbacks\\n from increased secretions to vomiting/aspiration events and her\\n self-decanulations.\\n - Continue to increase time on trach mask as tolerated.\\n - Discontinue all orders for sedation except for Zyprexa QHS.\\n - PMV with suctioning as tolerated\\n # Nutrition/Vomiting: Normal CT-abdomen, had FT placed via peg into\\n jejunum, but continued to vomit. Tube study yesterday showed\\n dysmotility in small bowel, but no obstruction, no retrograde flow.\\n Awaiting GI recs.\\n - Hold TFs\\n - GI consult, appreciate recs\\n - PICC line placement for parenteral nutrition this am\\n - Nutrition recs to start TPN today\\n # HAP vs Aspiration PNA: Had been afebrile for last several days, now\\n with new fever last night after having decanulated herself. Likely had\\n some aspiration. Chemical pneumonitis versus new aspiration PNA.\\n - CXR today\\n - F/u cx data\\n - If remains febrile, send sputum cx.\\n .\\n # Tachycardia: Pt in and out of SVT and sinus, increased BB seems to\\n help, but pt does not stay in sinus. Cards rec to start Amiodarone IV\\n drip, and then convert to PO, 200mg TID. Would consider EPS if\\n amiodarone not successful, though would wait until pt more stable for\\n GA.\\n - Changed to IV metoprolol to 10mg IV q4hr during the day and 7.5mg q4\\n hours at night.\\n - Amiodarone 0.5mg/min IV drip x 18 hours.\\n - Cards c/s, appreciate recs\\n # Sedation/Anxiolysis/AlteredMS: unclear etiology of her confusion and\\n agitation. Has had long hospital course and multiple psychotropic\\n medications as well as hx of EtOH abuse.\\n - Continue w Olanzapine QHS\\n - d/c all benzos, d/c all opiates given GI dysmotlitiy\\n - Psychiatry consulted, appreciate recs\\n # Adrenal Insufficency: Endocrine following. Pt does not appear to be\\n adrenally insufficient at baseline. Suggesting if the patient under\\n goes major stressors such as major surgery, sepsis, she may need stress\\n dosed steroids.\\n .\\n # Fluid Status: Likely approaching euvolemia, though still has mild\\n hypernatramia which may suggest is still intravascularly depleated.\\n - Monitoring urine output\\n - will provide D5W IVF as need for hypernatremia and follow lytes\\n # UE DVT and elevated INR: DVT in right UE has resolved, new\\n non-occlusive in left axillary vein. INR had risen quickly on coumadin,\\n likely to poor nutrition, resonded quickly to Vitamin K IV, but now\\n subtherapeutic again. Kept subtherapeutic today for PICC line placement\\n (for TPN), will restart w/ 2mg Coumadin after line placement.\\n - Restart coumadin after PICC line placement today\\n - Continue to follow INR closely to reach therapeutic INR.\\n .\\n #Hematemesis: Pt had small amt Hematemesis, after vomiting, 2 days ago.\\n None today. HCT stable.\\n -Will follow HCT.\\n - Guaiac stools\\n # Spine fracture: Stable\\n - Brace for OOB, will discuss with Neurosurgery if current brace is\\n optimal for stabilization given her mobility.\\n - Pt to follow up with Dr. in weeks\\n .\\n # Tracheomalacia. Was initially addressed with IP and they wanted to\\n follow up as outpatient. IP reevaluated and does not believe that a\\n stent would be feasible.\\n .\\n #. Thyroid Nodule on CT\\n - Outpatient follow up\\n .\\n # Glycemic control: SSI, well controlled\\n # ACCESS: PIV x 1, PICC placement\\n today.\\n # Ppx: subtherapeutic INR restarting coumadin today, Ranitidine, Bowel\\n Regimen PRN\\n # Communication:\\n - Boyfriend of 10 \\n - Brother also involved\\n - Social Work and Case management involved, have discussed situation\\n w/ brother and boyfriend.\\n # Code: Full\\n # Dispo: ICU, Screening for vent facilities\\n ICU Care\\n Nutrition:\\n TPN without Lipids - 06:00 PM 41. mL/hour\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n PICC Line - 01:30 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-24 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 639305,\n \"text\": \"Airway Clearance, Impaired\\n Assessment:\\n Secretions thick, white. LS coarse, diminished at bases.\\n Action:\\n Requiring frequent suctioning, at times q 30 minutes, clearing\\n initially and within minutes, pt rattling with secretions once again.\\n Response:\\n Secretions con\\nt to accumulate despite frequent suctioning.\\n Plan:\\n Con\\nt to pulmonary toilet , clear secretions as appropriate. Maintain\\n O2 Sat of greater than 94%.\\n Tachycardia, Other\\n Assessment:\\n HR maintained in the 80\\ns and 90\\ns for the most part. Up to110\\n immediately prior to receiving the lopressor.\\n Action:\\n Receiving lopressor 10 mg IV a4hr.\\n Response:\\n Maintaining HR below 100 successfully.\\n Plan:\\n Attempt to keep HR at 100 or lower.\\n Alteration in Nutrition\\n Assessment:\\n Hypoactive BS, TF\\ns on hold. J-tube intact, 2 small liquid stools.\\n Action:\\n TF\\ns on hold due to vomiting, Reglan increased to 20mg TID\\n Response:\\n No vomiting this shift.\\n Plan:\\n Monitor GI status,\\n Altered mental status (not Delirium)\\n Assessment:\\n Alert but confused, asking for boyfriend. Seems to be concerned about\\n some insurance. Encouraged to rest and get some sleep. 1:1 sitter in\\n at bedside all night. Pt very active, attempting to swing legs over\\n side rails at times. At one point, pt attempted to kick this RN.\\n Begun on resperidone 0.5 mg \\n Action:\\n Frequent re-orientation\\n Response:\\n Remains confused, poor STM\\n Plan:\\n Con\\nt with 1:1 sitters to maintain safety of pt, she will attempt to\\n grab tubes if unrestrained, Monitor effect to meds.\\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\\n Assessment:\\n Tmax 99.4 po\\n Action:\\n Receiving Tylenol 650 PR TID\\n Response:\\n Stable no change\\n Plan:\\n Pt to become normalize temp\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2167-10-17 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 638039,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 29\\n Ideal body weight: 61.2 None\\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: Yes\\n Tracheostomy tube:\\n Type: Standard, Cuffed\\n Manufacturer: Portex\\n Size: 7.0mm\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Rhonchi\\n LUL Lung Sounds: Rhonchi\\n LLL Lung Sounds: Diminished\\n Secretions\\n Sputum color / consistency: White / Thick\\n Sputum source/amount: Suctioned / Copious\\n Ventilation Assessment\\n Level of breathing assistance: Continuous invasive ventilation\\n Visual assessment of breathing pattern: Normal quiet breathing\\n Assessment of breathing comfort: No claim of dyspnea)\\n Invasive ventilation assessment:\\n Trigger work assessment: Triggering synchronously\\n Plan\\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\\n Reason for continuing current ventilatory support:\\n Note: On trach collar for most of shift, then placed on vent to rest.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-20 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 638536,\n \"text\": \"55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\\n trach, PEG, placement no with respiratory failure secondary to\\n tracheomalacia , resolving HAP.\\n Arousal, Attention, and Cognition, Impaired\\n Assessment:\\n Alert, mouthing words but very difficult to understand. Follows\\n commands. MAE on bed, attempting to get up. Restless last evening, did\\n eventually fall off to sleep this AM.\\n Action:\\n Zyprexa x 1 . Frequent re-orientation to place, situation. Soft wrist\\n restraints for patient safety.\\n Response:\\n Pt did eventually fall asleep. Re-orientation does have calming effect\\n however it is short term.\\n Plan:\\n No valium or benadryl per psych as this exacerbates delirium. Zyprexa\\n for agitation. pt prn.\\n Hypernatremia (high sodium)\\n Assessment:\\n Na 145 last night, 148 this AM.\\n Action:\\n Response:\\n Plan:\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Trach collar @ 50% O2 overnight until 4AM, Sats 90-97%. RR 17-20s.\\n Around 4AM RR in low 30s, sats low 90s while sleeping--? Fatiguing.\\n Strong cough, able to cough thick white ->tan secretions out of trach.\\n Occ suctioned for same. Lungs are rhonchorous throughout. Impaired gag.\\n Action:\\n Suctioned prn for copious secretions. MDIs. Placed back on vent @ 4AM\\n d/t fatigue.\\n Response:\\n Tolerated trach collar most of night, back on vent this AM d/t fatigue\\n with RR in teens, Sats 98%.\\n Plan:\\n Wean from vent as tolerated. MDIs, suction as needed.\\n Alteration in Nutrition\\n Assessment:\\n Tube feeds off overnight d/t constant vomiting. No vomiting overnight.\\n Action:\\n NPO. Reglan q 6 hrs.\\n Response:\\n No vomiting. Small brown stool x 1.\\n Plan:\\n NPO. ? may go to IR today to change Gtube to Jtube. Reglan. Meds via\\n Gtube.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-22 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 639041,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Increased Metoprolol to 7.5 IV q 4\\n Getting tube study in am\\n had J tube placed by IR via PEG, then had tube feeds at 10/hr which she\\n proceeded to vomit, TF held\\n Agitated so given Haldol, put back on pressure support\\n Na 148 but had not received D5W yet.\\n INR 2.3 after 10 IV Vit K\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:30 AM\\n Diazepam (Valium) - 02:24 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:35 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.9\\nC (98.4\\n Tcurrent: 35.7\\nC (96.2\\n HR: 107 (93 - 140) bpm\\n BP: 85/45(55) {83/40(51) - 148/101(105)} mmHg\\n RR: 23 (11 - 37) insp/min\\n SpO2: 100%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 3,808 mL\\n 557 mL\\n PO:\\n TF:\\n 4 mL\\n IVF:\\n 3,804 mL\\n 557 mL\\n Blood products:\\n Total out:\\n 1,650 mL\\n 385 mL\\n Urine:\\n 1,590 mL\\n 385 mL\\n NG:\\n 60 mL\\n Stool:\\n Drains:\\n Balance:\\n 2,158 mL\\n 172 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 169 (169 - 438) mL\\n PS : 5 cmH2O\\n RR (Spontaneous): 23\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n RSBI: 67\\n PIP: 10 cmH2O\\n SpO2: 100%\\n ABG: ///33/\\n Ve: 3.7 L/min\\n Physical Examination\\n Gen: Mildly obtunded in am, responsive to noxious stimuli, on MMV\\n through trach tube, but later in alert, responding normally.\\n HEENT: PERRL, MMM\\n Resp: Coarse BS anteriorly, no focal rales, rhonchi, or wheezing with\\n some referred upper airway noises from secretions.\\n Card: S1S2 tachycardic, no m/r/g\\n Abd: Obese, soft, mildly distended, BS+\\n Exte: No edema, DP 2+ bil.\\n NEURO: Toes downgoing bilaterally,\\n Labs / Radiology\\n 356 K/uL\\n 8.2 g/dL\\n 129 mg/dL\\n 0.7 mg/dL\\n 33 mEq/L\\n 3.6 mEq/L\\n 4 mg/dL\\n 110 mEq/L\\n 148 mEq/L\\n 26.9 %\\n 5.7 K/uL\\n [image002.jpg]\\n 06:22 AM\\n 02:58 AM\\n 03:43 AM\\n 05:02 PM\\n 03:36 AM\\n 02:30 AM\\n 01:30 AM\\n 06:41 AM\\n 03:20 PM\\n 03:23 AM\\n WBC\\n 7.0\\n 7.1\\n 7.1\\n 6.9\\n 7.6\\n 9.5\\n 5.7\\n Hct\\n 29.7\\n 28.9\\n 29.2\\n 27.8\\n 32.7\\n 28.6\\n 28.9\\n 30.0\\n 26.9\\n Plt\\n 395\\n 462\\n 452\\n 467\\n 548\\n 528\\n 356\\n Cr\\n 0.7\\n 0.6\\n 0.7\\n 0.8\\n 0.7\\n 0.8\\n 1.0\\n 0.7\\n Glucose\\n 126\\n 137\\n 104\\n 108\\n 131\\n 128\\n 121\\n 129\\n Other labs: PT / PTT / INR:15.2/24.6/1.3, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:8.7 mg/dL, Mg++:2.1 mg/dL, PO4:4.1\\n mg/dL\\n CXR: no sig change from previous. R hemidiaphragm remains elevated, L\\n hemidiaphragm remains obscured, some patchy opacities in L lobe,\\n ?atelectasis\\n Assessment and Plan\\n 55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\\n trach, PEG placement now with respiratory failure secondary to\\n tracheomalacia , resolved HAP.\\n .\\n # Respiratory failure: Slowly Improving. Intermittently on trach mask\\n for most of the day, with periods of pressure support of over night.\\n This am on MMV. Previously likely oversedated but Benadryl, Morhpine,\\n and Valium held now. Pt awake and alert at rounds, interactive, and\\n breathing comfortably on trach mask\\n - Continue to increase time on trach mask as tolerated.\\n - Decrease sedation and valium use\\n - PMV with suctioning\\n # Nutrition/Vomiting: Has had several days of vomiting up TFs but had\\n a normal CT abdoment. Yesterday she had a pediatric feeding tube placed\\n by GI through her PEG tube into her jejunum, and was given TFs last\\n night, which she vomited. Pt had a tube study this am that showed\\n dysmotility of her jejunum. GI continuing to follow study during the\\n day with KUBs. Unclear etiology of her ileus; pt has hx of GI problems\\n and chronic N/V and this may be her chronic baseline. Alternatively pt\\n has had long course of opiates during MICU stay, however, her opiates\\n have been decreased steady for the past week and she has had periods\\n where she tolerated TFs. Will need to provide parenteral nutrition at\\n this point.\\n - Hold TFs\\n - GI consulted\\n - F/u results of Tube study\\n - PICC line placement for parenteral nutrition\\n -.\\n # HAP vs Aspiration PNA: Afebrile without leukocytosis\\n - Completed course of ceftriaxone\\n - good O2 saturation on trach mask\\n .\\n # Tachycardia: Previously was assessed as sinus tach with occasional\\n runs of SVT and sources such as hypovolemia, PE, infection, and pain\\n were assessed as possibly etiologies. Per Cardiology, most likely AT\\n given transient response to Adenosine. HR occasionally decreases to\\n 70s-80s w/ stable BPs at times that might be associated with\\n administration of her BB and valium. Cards recommended titrating up her\\n beta blocker as tolerated. Dose increased to 50 yesterday and\\n intermittently responded but then had to hold PO meds given need to\\n hold PO. Changed PO to IV lopressor.\\n - EP consulted for SVT, appreciate recs, will change metoprololt o IV\\n and hopefully will be able to restart PO meds soon once able to\\n tolerate\\n - Changed to IV metoprolol 10mg q4hr during the day and 7.5mg q4 hours\\n at night.\\n - Per EP, after good trial on PO BB and recovery from current\\n hospitalization, would consider EP study or short course of\\n amiodarone..\\n .\\n # Sedation: Inconsistent response to sedation, unclear what is best\\n regime. Will continue to wean overall.\\n - Continue w Olanzapine QHS\\n - d/c all opiates given GI dysmotlitiy\\n .\\n # Adrenal Insufficency: Endocrine following. Pt does not appear to be\\n adrenally insufficient at baseline. Suggesting if the patient under\\n goes major stressors such as major surgery, sepsis, she may need stress\\n dosed steroids.\\n .\\n # Fluid Status: Likely approaching euvolemia, though still has mild\\n hypernatramia which may suggest is still intravascularly depleated.\\n - Monitoring urine output\\n - will provide D5W IVF as need for hypernatremia and follow lytes\\n .\\n # UE DVT and elevated INR: DVT in right UE has resolved, new\\n non-occlusive in left axillary vein. INR supratherapeutic yesterday at\\n 10.5 despite having stopped coumadin the day before. INR increase is\\n most likely continuing to rise nutritional deficiencies given\\n continued lack of PO intake. Pt was given Vitamin K IV yesterday, and\\n today INR is 1.3.\\n - Restart coumadin after PICC line placement today\\n - Continue to follow INR closely to reach therapeutic INR.\\n .\\n #Hematemesis: Pt had small amt Hematemesis, after vomiting, yesterday.\\n None today.\\n -Will follow HCT.\\n - Guaiac stools\\n # Spine fracture: Stable\\n - Brace for OOB, will discuss with Neurosurgery if current brace is\\n optimal for stabilization given her mobility.\\n - Pt to follow up with Dr. in weeks\\n .\\n # Tracheomalacia. Was initially addressed with IP and they wanted to\\n follow up as outpatient. IP reevaluated and does not believe that a\\n stent would be feasible.\\n .\\n #. Thyroid Nodule on CT\\n - Outpatient follow up\\n .\\n # Glycemic control: SSI, well controlled\\n # ACCESS: PIV x 1, PICC placement\\n today.\\n # Ppx: supratherapeutic INR, Ranitidine, Bowel Regimen PRN\\n # Communication:\\n - Boyfriend of 10 \\n - Brother also involved\\n - Social Work and Case management involved, have discussed situation\\n w/ brother and boyfriend.\\n # Code: Full\\n # Dispo: ICU, Screening for vent facilities\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n 18 Gauge - 04:00 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-23 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 639131,\n \"text\": \"56 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\\n with prolonged hospital course c/b by PNA, anxiety/altered mental\\n status, R&LUE DVT .Pt found to have small non occlusive Clot on her\\n right axial vein via Ultrasound.Yesterday. She has had problems with\\n vomiting tube feedings, feeding tube passed through g-tube (g-tube in\\n place with mushroom on inside so cannot pull out) to her jejunenum but\\n continues vomit.\\n Tachycardia, Other\\n Assessment:\\n HR continued to be 110-140, ST w/ rare PVC\\n Action:\\n Amiordarone 75mg bolus given, and drip started at 1mg/min\\n Response:\\n HR at rest now 100-120\\n Plan:\\n Will continue drip for 18 hr then titrate down to 0.5mg/min\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt very restless and agitated throughout night\\n Action:\\n Response:\\n Plan:\\n Alteration in Nutrition\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-24 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 639387,\n \"text\": \"56 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\\n with prolonged hospital course c/b by PNA, anxiety/altered mental\\n status, R&LUE DVT .Pt found to have small non occlusive Clot on her\\n right axial vein via Ultrasound . She has had problems with\\n vomiting tube feedings, feeding tube passed through g-tube (g-tube in\\n place with mushroom on inside so cannot pull out) to her jejunenum but\\n continued vomit.\\n At 7:30 pt pulled out her trach tube with staff 6feet away. Her\\n HR initially was 120\\ns, before an airway could be re-established her HR\\n had blocked down to 38 and she had lost consciousness. She returned as\\n soon as her airway was re-established. Sitter now @ bedside RTC.\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt very somulent most of shift, awake only from 1500-1700 when she\\n opened eyes spont and mouthed words as @ baseline. MAEE with good\\n strength. Gag and cough impaired while sleeping.\\n Action:\\n Pt stimulated with painful stimuli, and sitting upright in\\n bed-as-chair. AM Risperidone held. PRN Olanzipine D/C\\n Response:\\n Pt cont to be difficult to waken.\\n Plan:\\n Cont Risperidine when pt awake. Sitter and bilat wrist restraints\\n remain as pt mental status labile.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt has remained on humidified TM @ 50% all shift. RR 23-31 and regular\\n but occas shallow. Lung snds rhonchorous in upper lobes but clearing\\n after sxn\\ning. LL snds diminished. Trach site clean, well healed.\\n Action:\\n Pt suctioned freq for mod-copious amts thick white tenacious sputum.\\n Response:\\n O2 sat bouncing up to 100% after sxn\\ning.\\n Plan:\\n Cont aggressive pulm toilet.\\n Alteration in Nutrition\\n Assessment:\\n Rec\\nd pt on TPN via PICC line. J tube site clean/dry, tube clamped\\n except for meds. BS present, abd soft/obese.\\n Action:\\n Shortly after pt rec\\nd scheduled dose Reglan she was incont of lg amt\\n golden loose stool.\\n Response:\\n TF of\\n strength Promote with fiber restarted @ 10ml/hr, with goal\\n 40ml/hr. Water flush of 50ml Q4hrs.\\n Plan:\\n Cont to increase TF to goal as tolerated. Pt to receive TF only when\\n she is in sitting position with strict aspiration precautions.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-26 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 639533,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Pt agitated overnight given extra Risperidone 0.5 mg x 2 overnight.\\n (1.5mg total)\\n 1000 mL D5W for Hypernatremia\\n Changed B-Blocker from IV to PO, Metoprolol Tartrate 25 mg PO TID\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:17 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:47 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.8\\nC (98.2\\n Tcurrent: 36.7\\nC (98\\n HR: 120 (67 - 120) bpm\\n BP: 110/64(76) {109/47(60) - 141/115(118)} mmHg\\n RR: 26 (18 - 30) insp/min\\n SpO2: 100%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 3,820 mL\\n 856 mL\\n PO:\\n TF:\\n 117 mL\\n 20 mL\\n IVF:\\n 2,612 mL\\n 572 mL\\n Blood products:\\n Total out:\\n 2,460 mL\\n 1,180 mL\\n Urine:\\n 2,460 mL\\n 1,180 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,360 mL\\n -324 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask\\n SpO2: 100%\\n ABG: ///33/\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 249 K/uL\\n 8.0 g/dL\\n 122 mg/dL\\n 0.5 mg/dL\\n 33 mEq/L\\n 3.7 mEq/L\\n 13 mg/dL\\n 108 mEq/L\\n 146 mEq/L\\n 24.7 %\\n 5.5 K/uL\\n [image002.jpg]\\n 03:36 AM\\n 02:30 AM\\n 01:30 AM\\n 06:41 AM\\n 03:20 PM\\n 03:23 AM\\n 03:00 AM\\n 04:00 AM\\n 05:45 AM\\n 03:51 AM\\n WBC\\n 6.9\\n 7.6\\n 9.5\\n 5.7\\n 7.3\\n 8.0\\n 8.7\\n 5.5\\n Hct\\n 27.8\\n 32.7\\n 28.6\\n 28.9\\n 30.0\\n 26.9\\n 27.3\\n 27.0\\n 28.7\\n 24.7\\n Plt\\n 467\\n 548\\n 528\\n 356\\n 346\\n 316\\n 271\\n 249\\n Cr\\n 0.7\\n 0.8\\n 1.0\\n 0.7\\n 0.7\\n 0.7\\n 0.7\\n 0.5\\n Glucose\\n 131\\n 128\\n 121\\n 129\\n 123\\n 114\\n 112\\n 122\\n Other labs: PT / PTT / INR:13.6/31.1/1.2, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:9.0 mg/dL, Mg++:2.2 mg/dL, PO4:3.1\\n mg/dL\\n Assessment and Plan\\n 55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\\n trach, PEG with resolving respiratory failure and HAP.\\n .\\n # Respiratory failure: 36hrs off vent, now on trach mask. No further\\n self-decanulations overnight.\\n - Tach mask as tolerated.\\n - Holding sedation with exception of Risperidal 0.5mg .\\n - PMV with suctioning as tolerated\\n .\\n # Nutrition/Vomiting: TFs restarted yesterday while patient was not in\\n optimal positioning. One large BM in past 24 hrs to indicate potential\\n improvement in ileus.\\n - Cont Reglan 20mg IV Q 8 hours and restart meds via G-J tube,\\n - Slowly restarting TFs and will increase as tolerated.\\n - PICC line in place with TPN given when pt not tolerating.\\n - GI consult, appreciate recs\\n .\\n # Tachycardia: One episode of SVT overnight with improved HR max of\\n 100\\ns versus 160s previously. Pt now on PO Amiodarone 200 TID, and IV\\n metoprolol\\n - Will change IV metoprolol to metoprolol 25mg PO TID\\n - f/u Cards recs\\n # Sedation/Anxiolysis/AlteredMS: Improved alertness. Long hospital\\n course and multiple psychotropic medications as well as hx of EtOH\\n abuse.\\n - - started Risperdal 0.5mg PO BID\\n - continue to hold all benzos. opiates, and antihistamines\\n - f/u psych recs.\\n .\\n # Fluid Status: Mild hypernatramia with good UOP.\\n - providing D5W IVF PRN and follow lytes\\n # UE DVT and elevated INR: Decision made to d/c Coumadin given her\\n labile INR, and start Lovenox . L Picc difficult to flush this AM.\\n - Will flush L PICC with TPA\\n .\\n # Spine fracture: Stable\\n - Brace for OOB, will discuss with Neurosurgery if current brace is\\n optimal for stabilization given her mobility.\\n - Pt to follow up with Dr. in weeks\\n .\\n # Tracheomalacia. Was initially addressed with IP and they wanted to\\n follow up as outpatient. IP reevaluated and does not believe that a\\n stent would be feasible.\\n .\\n #. Thyroid Nodule on CT\\n - Outpatient follow up\\n .\\n # Glycemic control: SSI, well controlled\\n # ACCESS: PIV x 1, L PICC\\n # Ppx: Lovenox, PPi, Bowel Regimen PRN\\n # Communication:\\n - Boyfriend of 10 \\n - Brother also involved\\n - Social Work and Case management involved, have discussed situation\\n w/ brother and boyfriend.\\n # Code: Full\\n # Dispo: ICU, Screening for vent facilities\\n ICU Care\\n Nutrition:\\n TPN without Lipids - 07:10 PM 43. mL/hour\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n PICC Line - 01:30 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-26 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 639546,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Pt agitated overnight given extra Risperidone 0.5 mg x 2 overnight.\\n (1.5mg total)\\n 1000 mL D5W for Hypernatremia\\n Changed B-Blocker from IV to PO, Metoprolol Tartrate 25 mg PO TID\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:17 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:47 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.8\\nC (98.2\\n Tcurrent: 36.7\\nC (98\\n HR: 120 (67 - 120) bpm\\n BP: 110/64(76) {109/47(60) - 141/115(118)} mmHg\\n RR: 26 (18 - 30) insp/min\\n SpO2: 100%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 3,820 mL\\n 856 mL\\n PO:\\n TF:\\n 117 mL\\n 20 mL\\n IVF:\\n 2,612 mL\\n 572 mL\\n Blood products:\\n Total out:\\n 2,460 mL\\n 1,180 mL\\n Urine:\\n 2,460 mL\\n 1,180 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,360 mL\\n -324 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask\\n SpO2: 100%\\n ABG: ///33/\\n Physical Examination\\n Gen: Awake, Mouthing words, More agitated compared to previous\\n mornings.\\n HEENT: EOMI, No pallor in conjunctiva, MMM\\n Resp: CTA bilaterally, no rales, rhonchi, or wheezing, good airway\\n movement.\\n Card: S1S2 tachycardic, no m/r/g\\n Abd: Obese, soft, mildly distended, decreased bowel sounds,, G-Tube in\\n place with no erythema/induration\\n Exte: No edema, DP 2+ bil\\n NEURO: Gross Motor and Sensation in 4 extremities\\n Labs / Radiology\\n 249 K/uL\\n 8.0 g/dL\\n 122 mg/dL\\n 0.5 mg/dL\\n 33 mEq/L\\n 3.7 mEq/L\\n 13 mg/dL\\n 108 mEq/L\\n 146 mEq/L\\n 24.7 %\\n 5.5 K/uL\\n [image002.jpg]\\n 03:36 AM\\n 02:30 AM\\n 01:30 AM\\n 06:41 AM\\n 03:20 PM\\n 03:23 AM\\n 03:00 AM\\n 04:00 AM\\n 05:45 AM\\n 03:51 AM\\n WBC\\n 6.9\\n 7.6\\n 9.5\\n 5.7\\n 7.3\\n 8.0\\n 8.7\\n 5.5\\n Hct\\n 27.8\\n 32.7\\n 28.6\\n 28.9\\n 30.0\\n 26.9\\n 27.3\\n 27.0\\n 28.7\\n 24.7\\n Plt\\n 467\\n 548\\n 528\\n 356\\n 346\\n 316\\n 271\\n 249\\n Cr\\n 0.7\\n 0.8\\n 1.0\\n 0.7\\n 0.7\\n 0.7\\n 0.7\\n 0.5\\n Glucose\\n 131\\n 128\\n 121\\n 129\\n 123\\n 114\\n 112\\n 122\\n Other labs: PT / PTT / INR:13.6/31.1/1.2, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:9.0 mg/dL, Mg++:2.2 mg/dL, PO4:3.1\\n mg/dL\\n Assessment and Plan\\n 55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\\n trach, PEG with resolving respiratory failure and HAP.\\n .\\n # Respiratory failure: 36hrs off vent, now on trach mask, FiO2 70%. No\\n further self-decanulations overnight.\\n - Tach mask as tolerated.\\n - Holding sedation with exception of Risperidal 0.5mg .\\n - PMV with suctioning as tolerated\\n .\\n # Nutrition/Vomiting: TFs restarted yesterday while patient was not in\\n optimal positioning. One large BM in past 24 hrs to indicate potential\\n improvement in ileus.\\n - Cont Reglan 20mg IV Q 8 hours and restart meds via G-J tube,\\n - Increase TF as tolerated\\n - PICC line in place with TPN given when pt not tolerating TF\\n - GI consult, appreciate recs\\n .\\n # Tachycardia: One episode of SVT overnight with improved HR max of\\n 100\\ns versus 160s previously. Pt now on PO Amiodarone 200 TID, and IV\\n metoprolol\\n - Will change IV metoprolol to metoprolol 25mg PO TID\\n - f/u Cards recs\\n # Sedation/Anxiolysis/AlteredMS: Improved alertness. Long hospital\\n course and multiple psychotropic medications as well as hx of EtOH\\n abuse.\\n - - started Risperdal 0.5mg PO BID\\n - continue to hold all benzos. opiates, and antihistamines\\n - f/u psych recs.\\n .\\n # Fluid Status: Mild hypernatramia with good UOP.\\n - providing D5W IVF PRN and follow lytes\\n # UE DVT and elevated INR: Decision made to d/c Coumadin given her\\n labile INR, and start Lovenox . L Picc difficult to flush this AM.\\n - Will flush L PICC with TPA\\n .\\n # Spine fracture: Stable\\n - Brace for OOB, will discuss with Neurosurgery if current brace is\\n optimal for stabilization given her mobility.\\n - Pt to follow up with Dr. in weeks\\n .\\n # Tracheomalacia. Was initially addressed with IP and they wanted to\\n follow up as outpatient. IP reevaluated and does not believe that a\\n stent would be feasible.\\n .\\n #. Thyroid Nodule on CT\\n - Outpatient follow up\\n .\\n # Glycemic control: SSI, well controlled\\n # ACCESS: PIV x 1, L PICC\\n # Ppx: Lovenox, PPi, Bowel Regimen PRN\\n # Communication:\\n - Boyfriend of 10 \\n - Brother also involved\\n - Social Work and Case management involved, have discussed situation\\n w/ brother and boyfriend.\\n # Code: Full\\n # Dispo: ICU, Screening for vent facilities\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-26 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 639547,\n \"text\": \"TITLE:\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Rec\\nd pt on TM @ 70% with O2 sat mid 90\\ns-100%. Requiring tracheal\\n sxn\\ning approx Q1hr for mod-copious amts thick white tenacious\\n secretions. Pt with strong cough, but freq unable to clear secretions\\n herself. Lung snds rhonchorous in upper lobes, diminished in bases.\\n Action:\\n Freq sxn\\ning per above. Pt encouraged to C&DB. Pt in\\nchair\\n position\\n in bed with head @ 45-90degree angle.\\n Response:\\n Pt cont to have lg amt secretions requiring assist to clear.\\n Plan:\\n Cont aggressive pulm toilet.\\n Arousal, Attention, and Cognition, Impaired\\n Assessment:\\n Pt has been awake and alert . Pt chatty, but difficult to read her lips\\n and she has trouble writing clearly. Slept for ~ 2 hrs .Pt very\\n agitated since ~ 2am. Tryming to climb out of bed\\n Action:\\n BUE & lt LE restrained with soft restraints. Emotional support\\n provided, Risperidone 0.5 x 2 extra doses given.\\n Response:\\n Little effect with Med. Team aware.\\n Plan:\\n Speech/swallow consult needed re valve, ? if it is damaged. Cont\\n Risperidone. Cont soft wrist restraints and sitter @ bedside for pt\\n safety.\\n Alteration in Nutrition\\n Assessment:\\n Abd soft/obese with + BS. On J-tube feeds in upright position.\\n Action:\\n Pt on colace and senna, held the evening dose as pt had 2 BM\\ns during\\n the day.\\n Response:\\n Pt with lg loose yellow BM in am. TF started in afternoon @ 10ml/hr as\\n well as 50ml water Q4hrs, with HOB @ 45-90degree angle. Tolerated well.\\n Feeds stopped as she became agitated & had to be repositioned multiple\\n times to help her maintain a comfortable position, tried bed as chair,\\n tolerated for few minutes.\\n Plan:\\n Currently feed held. Cont to gently advance TF per order. Strict\\n aspiration orders, with pt rec\\ning TF ONLY when in sitting position.\\n Hypernatremia (high sodium)\\n Assessment:\\n Na 146 , K+ 3.7in am labs\\n Action:\\n Continued on D5 W@ 100 mls/hr for 1000 mls.\\n Response:\\n Awaiting order from team for K+ repletion.\\n Plan:\\n Replete As per orders & Monitor Lytes.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-27 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 639644,\n \"text\": \"56 yr old woman, who was transferred from osh for evaluation of\\n tracheal bronchial malacia on .Pt presented to Medical\\n Center on s/p fall down a flight of stairs fracturing, t5-t8 with\\n propulsion treated conservatively with pain meds and back brace. She\\n developed resp distress requiring intubation on . Trach/PEG done\\n . Now with prolonged hospital course c/b by PNA, anxiety/altered\\n mental status, R&LUE DVT .Pt found to have small non occlusive clot on\\n her right axial vein via Ultrasound, now rec\\ning Lovenox. She has had\\n problems with vomiting tube feedings, so feeding tube passed through\\n g-tube to her jejunenum. However, she continues to intermit raise\\n gastric contents assoc with bronchospasm. Has not required ventilation\\n since , on humidified TM @ 50%. Has required 1:1 sitters since\\n decanulating herself, twice, despite restraints.\\n Airway Clearance, Impaired\\n Assessment:\\n Pt cont on TM 50%, bilat rhonchi, diminished in bases. 02 SATS 94-95%\\n Action:\\n Pt requiring frequent suction, copious loose white secretions noted,\\n scolopamine patch applied to help with secretions\\n Response:\\n Cont to suction for copious secretions\\n Plan:\\n Cont to resp. status, suction as needed, s/swallow to re-evaluate\\n for bigger PMV in am\\n Alteration in Nutrition\\n Assessment:\\n Pt cont with restlessness, TF off 00 due to pts restlessness, BS\\n positive bilat, loose BM\\ns x 2\\n Action:\\n Pt placed on chair positin in bed, pt recvd scheduled Reglan, colace\\n Response:\\n Pt had two loose bm\\ns x 2,\\n Plan:\\n Re-start TF when pt more relaxed, cont with TPN 43.6 as ordered, cont\\n strict asp precautions :holding TF when pt not in upright position and\\n turning TF off for 15 mins before turning\\n Arousal, Attention, and Cognition, Impaired\\n Assessment:\\n Pt cont to be very restless in bed, cont with bilat wrist restraints\\n and 1:1 sitter @ bedside\\n Action:\\n Pt seen by psych @, Risperadol dosing increased\\n Response:\\n Pt cont to be restless despite increase in HS risperadol and prn dose\\n Plan:\\n Psych to re-evaluate in am, EKG to be taken in am\\n\"\n },\n {\n \"category\": \"Nutrition\",\n \"chartdate\": \"2167-10-20 00:00:00.000\",\n \"description\": \"Clinical Nutrition Note\",\n \"row_id\": 638616,\n \"text\": \"Subjective\\n Objective\\n Pertinent medications: noted\\n Labs:\\n Value\\n Date\\n Glucose\\n 128 mg/dL\\n 02:30 AM\\n Glucose Finger Stick\\n 142\\n 10:00 AM\\n BUN\\n 6 mg/dL\\n 02:30 AM\\n Creatinine\\n 0.8 mg/dL\\n 02:30 AM\\n Sodium\\n 148 mEq/L\\n 02:30 AM\\n Potassium\\n 4.1 mEq/L\\n 02:30 AM\\n Chloride\\n 105 mEq/L\\n 02:30 AM\\n TCO2\\n 36 mEq/L\\n 02:30 AM\\n Albumin\\n 3.5 g/dL\\n 03:00 AM\\n Calcium non-ionized\\n 10.0 mg/dL\\n 02:30 AM\\n Phosphorus\\n 4.3 mg/dL\\n 02:30 AM\\n Ionized Calcium\\n 1.24 mmol/L\\n 02:51 AM\\n Magnesium\\n 2.5 mg/dL\\n 02:30 AM\\n ALT\\n 25 IU/L\\n 07:34 AM\\n Alkaline Phosphate\\n 106 IU/L\\n 07:34 AM\\n AST\\n 19 IU/L\\n 07:34 AM\\n WBC\\n 7.6 K/uL\\n 02:30 AM\\n Hgb\\n 10.0 g/dL\\n 02:30 AM\\n Hematocrit\\n 32.7 %\\n 02:30 AM\\n Current diet order / nutrition support: NPO\\n GI: Abd soft/obese/hypo bs\\n Assessment of Nutritional Status\\n Estimation of previous intake: Adequate\\n Estimation of current intake: Inadequate\\n Specifics:\\n 55 y/o female c/ long hospital course,\\n Medical Nutrition Therapy Plan - Recommend the Following\\n Other: Will follow POC- access for resuming feeds, If unable to resume\\n enteral feeds in next 2-3 days, will need to consider PPN/TPN to avoid\\n nutritional decline\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-23 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 639120,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Pt pulled out her trach tube, tube replaced\\n PICC Line Placed\\n Seen By EP and started on Amiodarone Drip\\n Fever - 101.4\\nF Cultures sent\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Amiodarone - 1 mg/min\\n Other ICU medications:\\n Metoprolol - 01:00 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:40 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.6\\nC (101.4\\n Tcurrent: 36.9\\nC (98.5\\n HR: 107 (107 - 142) bpm\\n BP: 86/44(54) {82/39(49) - 181/113(122)} mmHg\\n RR: 22 (13 - 25) insp/min\\n SpO2: 97%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 2,127 mL\\n 537 mL\\n PO:\\n TF:\\n IVF:\\n 2,127 mL\\n 537 mL\\n Blood products:\\n Total out:\\n 995 mL\\n 400 mL\\n Urine:\\n 995 mL\\n 400 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,132 mL\\n 137 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask\\n Ventilator mode: Standby\\n Vt (Spontaneous): 208 (208 - 243) mL\\n RR (Spontaneous): 0\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n PIP: 0 cmH2O\\n SpO2: 97%\\n ABG: ///31/\\n Ve: 4.1 L/min\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 346 K/uL\\n 8.4 g/dL\\n 123 mg/dL\\n 0.7 mg/dL\\n 31 mEq/L\\n 3.8 mEq/L\\n 4 mg/dL\\n 107 mEq/L\\n 144 mEq/L\\n 27.3 %\\n 7.3 K/uL\\n [image002.jpg]\\n 02:58 AM\\n 03:43 AM\\n 05:02 PM\\n 03:36 AM\\n 02:30 AM\\n 01:30 AM\\n 06:41 AM\\n 03:20 PM\\n 03:23 AM\\n 03:00 AM\\n WBC\\n 7.1\\n 7.1\\n 6.9\\n 7.6\\n 9.5\\n 5.7\\n 7.3\\n Hct\\n 28.9\\n 29.2\\n 27.8\\n 32.7\\n 28.6\\n 28.9\\n 30.0\\n 26.9\\n 27.3\\n Plt\\n 462\\n 452\\n 467\\n 548\\n 528\\n 356\\n 346\\n Cr\\n 0.6\\n 0.7\\n 0.8\\n 0.7\\n 0.8\\n 1.0\\n 0.7\\n 0.7\\n Glucose\\n 137\\n 104\\n 108\\n 131\\n 128\\n 121\\n 129\\n 123\\n Other labs: PT / PTT / INR:14.1/23.7/1.2, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.8 mg/dL, Mg++:1.9 mg/dL, PO4:3.7\\n mg/dL\\n Assessment and Plan\\n 55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\\n trach, PEG placement now with respiratory failure secondary to\\n tracheomalacia , resolved HAP.\\n .\\n # Respiratory failure: Slowly Improving. Intermittently on trach mask\\n for most of the day, with periods of pressure support of over night.\\n This am on MMV. Previously likely oversedated but Benadryl, Morhpine,\\n and Valium held now. Pt awake and alert at rounds, interactive, and\\n breathing comfortably on trach mask\\n - Continue to increase time on trach mask as tolerated.\\n - Decrease sedation and valium use\\n - PMV with suctioning\\n # Nutrition/Vomiting: Has had several days of vomiting up TFs but had\\n a normal CT abdoment. Yesterday she had a pediatric feeding tube placed\\n by GI through her PEG tube into her jejunum, and was given TFs last\\n night, which she vomited. Pt had a tube study this am that showed\\n dysmotility of her jejunum. GI continuing to follow study during the\\n day with KUBs. Unclear etiology of her ileus; pt has hx of GI problems\\n and chronic N/V and this may be her chronic baseline. Alternatively pt\\n has had long course of opiates during MICU stay, however, her opiates\\n have been decreased steady for the past week and she has had periods\\n where she tolerated TFs. Will need to provide parenteral nutrition at\\n this point.\\n - Hold TFs\\n - GI consulted\\n - F/u results of Tube study\\n - PICC line placement for parenteral nutrition\\n -.\\n # HAP vs Aspiration PNA: Afebrile without leukocytosis\\n - Completed course of ceftriaxone\\n - good O2 saturation on trach mask\\n .\\n # Tachycardia: Previously was assessed as sinus tach with occasional\\n runs of SVT and sources such as hypovolemia, PE, infection, and pain\\n were assessed as possibly etiologies. Per Cardiology, most likely AT\\n given transient response to Adenosine. HR occasionally decreases to\\n 70s-80s w/ stable BPs at times that might be associated with\\n administration of her BB and valium. Cards recommended titrating up her\\n beta blocker as tolerated. Dose increased to 50 yesterday and\\n intermittently responded but then had to hold PO meds given need to\\n hold PO. Changed PO to IV lopressor.\\n - EP consulted for SVT, appreciate recs, will change metoprololt o IV\\n and hopefully will be able to restart PO meds soon once able to\\n tolerate\\n - Changed to IV metoprolol 10mg q4hr during the day and 7.5mg q4 hours\\n at night.\\n - Per EP, after good trial on PO BB and recovery from current\\n hospitalization, would consider EP study or short course of\\n amiodarone..\\n # Sedation: Inconsistent response to sedation, unclear what is best\\n regime. Will continue to wean overall.\\n - Continue w Olanzapine QHS\\n - d/c all opiates given GI dysmotlitiy\\n # Adrenal Insufficency: Endocrine following. Pt does not appear to be\\n adrenally insufficient at baseline. Suggesting if the patient under\\n goes major stressors such as major surgery, sepsis, she may need stress\\n dosed steroids.\\n .\\n # Fluid Status: Likely approaching euvolemia, though still has mild\\n hypernatramia which may suggest is still intravascularly depleated.\\n - Monitoring urine output\\n - will provide D5W IVF as need for hypernatremia and follow lytes\\n # UE DVT and elevated INR: DVT in right UE has resolved, new\\n non-occlusive in left axillary vein. INR supratherapeutic yesterday at\\n 10.5 despite having stopped coumadin the day before. INR increase is\\n most likely continuing to rise nutritional deficiencies given\\n continued lack of PO intake. Pt was given Vitamin K IV yesterday, and\\n today INR is 1.3.\\n - Restart coumadin after PICC line placement today\\n - Continue to follow INR closely to reach therapeutic INR.\\n .\\n #Hematemesis: Pt had small amt Hematemesis, after vomiting, yesterday.\\n None today.\\n -Will follow HCT.\\n - Guaiac stools\\n # Spine fracture: Stable\\n - Brace for OOB, will discuss with Neurosurgery if current brace is\\n optimal for stabilization given her mobility.\\n - Pt to follow up with Dr. in weeks\\n .\\n # Tracheomalacia. Was initially addressed with IP and they wanted to\\n follow up as outpatient. IP reevaluated and does not believe that a\\n stent would be feasible.\\n .\\n #. Thyroid Nodule on CT\\n - Outpatient follow up\\n .\\n # Glycemic control: SSI, well controlled\\n # ACCESS: PIV x 1, PICC placement today.\\n # Ppx: supratherapeutic INR, Ranitidine, Bowel Regimen PRN\\n # Communication:\\n - Boyfriend of 10 \\n - Brother also involved\\n - Social Work and Case management involved, have discussed situation\\n w/ brother and boyfriend.\\n # Code: Full\\n # Dispo: ICU, Screening for vent facilities\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n 18 Gauge - 04:00 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-17 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 638175,\n \"text\": \"Airway Clearance, Impaired\\n Assessment:\\n Pt placed on trach mask this am (on vent o/n). She continues to have\\n moderate amts of thick secretions, requiring frequent sxn. Pt does have\\n a strong/productive cough.\\n Action:\\n Sxn prn; chest pt; pt repositioned frequently (including OOB to chair)\\n to help mobilize secretions.\\n Response:\\n Unchanged at this time.\\n Plan:\\n Continue to sxn prn; chest pt prn; OOB as tolerated.\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt extremely restless/agitated today. Attempting to get OOB/chair. Very\\n difficult to redirect.\\n Action:\\n Pt reoriented frequently; Valium given prn; Morphine given per presumed\\n pain.\\n Response:\\n Pt had no improvement after Valium; however, she appeared more\\n calm/comfortable after Morphine administration.\\n Plan:\\n Medicate for agitation prn; continue to follow exam.\\n Alteration in Nutrition\\n Assessment:\\n Pt NPO for past few days ( recurrent aspiration/risk for). Pt with\\n one episode of emesis today (mod amt) after coughing episode.\\n Action:\\n Reglan given per orders; TFs restarted this am.\\n Response:\\n No residuals noted. No further emesis.\\n Plan:\\n Increase TFs to goal as tolerated; continue with Reglan.\\n Tachycardia, Other\\n Assessment:\\n HR 120\\ns-140\\ns today (baseline for ~ 1 week).\\n Action:\\n Lopressor given per orders.\\n Response:\\n HR in low 120\\ns after Morphine, but otherwise unchanged.\\n Plan:\\n Continue Lopressor; ? need to increase dose.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-21 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 638715,\n \"text\": \"Nausea / vomiting\\n Assessment:\\n NPO. Vomitted meds ~10\\n after given via gtube. Coughing same emesis\\n from tracheostomy. Later found to have vomited coffee ground emesis,\\n guiac +. Denies nausea every time although continues to dry heave,\\n vomit small amts clear emesis. BRB suctioned from back of throat also,\\n d/t irritation from frequent vomiting. Abd soft, hypoactive BS.\\n Action:\\n Tube feeds on hold. No residual aspirated from gtube, gtube\\n placed->>gravity. Stat Hct, coags T&S sent. Zofran x 1. HOB^^ 30. 2^nd\\n PIV placed.\\n Response:\\n On/off vomiting, coffee grounds x 1, with no c/o nausea. Hct 28.6,\\n baseline. INR 10.5 .\\n Plan:\\n Recheck Hct, FDP @ 7AM. Zofran. NPO. IV meds only. Needs gtube changed\\n to jtube.\\n Tachycardia, Other\\n Assessment:\\n ST 109-114, NSR 70s briefly. No lopressor given d/t BP<100 most of\\n night when pt sleeping.\\n Action:\\n Lopressor changed from PO->>IV prn d/t vomiting after meds.\\n Response:\\n ST 110s most of night.\\n Plan:\\n IV lopressor prn for HR>130.\\n Alteration in Nutrition\\n Assessment:\\n NPO. Na 146 x 2. D5W per orders. UOP decreased 10-20cc/hr with lower\\n BP.\\n Action:\\n D5W now @ 150cc/hr x 1 liter.\\n Response:\\n Na 146.\\n Plan:\\n Recheck Na @ 7AM. D5W x 1 liter.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n On 50% trach mask all day. RR ^^40 after first episode of vomiting last\\n night. Copious thick tan, dark brown secretions.\\n Action:\\n Placed on Vent MMV mode when tachypneic. Frequent suctioning.\\n Response:\\n Comfortable on vent, RR 12 (set), no spontaneous btreaths when asleep.\\n Apneic for a full minute during RSBI. Sats 100%.\\n Plan:\\n Wean from vent as tolerated. Suction as needed, MDIs.\\n Altered mental status (not Delirium)\\n Assessment:\\n Occaisionally restless, less so than night before. Slept most of night,\\n sometimes difficult to arouse. No zyprexa given. Opens eyes to voice,\\n follows commands. Mouthing words although difficult to understand.\\n Action:\\n Reorient pt prn. Emotional support.\\n Response:\\n Slept most of night, calmer than previous nights.\\n Plan:\\n No valium or benadryl per psych recommendations. Zyprexa HS prn for\\n agitation. Reorient prn. Emotional support.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-22 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 638903,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Increased Metoprolol to 7.5 IV q 4\\n Getting tube study in am\\n had J tube placed by IR via PEG, then had tube feeds at 10/hr which she\\n proceeded to vomit, TF held\\n Agitated so given Haldol, put back on pressure support\\n Na 148 but had not received D5W yet.\\n INR 2.3 after 10 IV Vit K\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:30 AM\\n Diazepam (Valium) - 02:24 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:35 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.9\\nC (98.4\\n Tcurrent: 35.7\\nC (96.2\\n HR: 107 (93 - 140) bpm\\n BP: 85/45(55) {83/40(51) - 148/101(105)} mmHg\\n RR: 23 (11 - 37) insp/min\\n SpO2: 100%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 3,808 mL\\n 557 mL\\n PO:\\n TF:\\n 4 mL\\n IVF:\\n 3,804 mL\\n 557 mL\\n Blood products:\\n Total out:\\n 1,650 mL\\n 385 mL\\n Urine:\\n 1,590 mL\\n 385 mL\\n NG:\\n 60 mL\\n Stool:\\n Drains:\\n Balance:\\n 2,158 mL\\n 172 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 169 (169 - 438) mL\\n PS : 5 cmH2O\\n RR (Spontaneous): 23\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n RSBI: 67\\n PIP: 10 cmH2O\\n SpO2: 100%\\n ABG: ///33/\\n Ve: 3.7 L/min\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 356 K/uL\\n 8.2 g/dL\\n 129 mg/dL\\n 0.7 mg/dL\\n 33 mEq/L\\n 3.6 mEq/L\\n 4 mg/dL\\n 110 mEq/L\\n 148 mEq/L\\n 26.9 %\\n 5.7 K/uL\\n [image002.jpg]\\n 06:22 AM\\n 02:58 AM\\n 03:43 AM\\n 05:02 PM\\n 03:36 AM\\n 02:30 AM\\n 01:30 AM\\n 06:41 AM\\n 03:20 PM\\n 03:23 AM\\n WBC\\n 7.0\\n 7.1\\n 7.1\\n 6.9\\n 7.6\\n 9.5\\n 5.7\\n Hct\\n 29.7\\n 28.9\\n 29.2\\n 27.8\\n 32.7\\n 28.6\\n 28.9\\n 30.0\\n 26.9\\n Plt\\n 395\\n 462\\n 452\\n 467\\n 548\\n 528\\n 356\\n Cr\\n 0.7\\n 0.6\\n 0.7\\n 0.8\\n 0.7\\n 0.8\\n 1.0\\n 0.7\\n Glucose\\n 126\\n 137\\n 104\\n 108\\n 131\\n 128\\n 121\\n 129\\n Other labs: PT / PTT / INR:15.2/24.6/1.3, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:8.7 mg/dL, Mg++:2.1 mg/dL, PO4:4.1\\n mg/dL\\n Assessment and Plan\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n 18 Gauge - 04:00 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-22 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 638904,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Increased Metoprolol to 7.5 IV q 4\\n Getting tube study in am\\n had J tube placed by IR via PEG, then had tube feeds at 10/hr which she\\n proceeded to vomit, TF held\\n Agitated so given Haldol, put back on pressure support\\n Na 148 but had not received D5W yet.\\n INR 2.3 after 10 IV Vit K\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:30 AM\\n Diazepam (Valium) - 02:24 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:35 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.9\\nC (98.4\\n Tcurrent: 35.7\\nC (96.2\\n HR: 107 (93 - 140) bpm\\n BP: 85/45(55) {83/40(51) - 148/101(105)} mmHg\\n RR: 23 (11 - 37) insp/min\\n SpO2: 100%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 3,808 mL\\n 557 mL\\n PO:\\n TF:\\n 4 mL\\n IVF:\\n 3,804 mL\\n 557 mL\\n Blood products:\\n Total out:\\n 1,650 mL\\n 385 mL\\n Urine:\\n 1,590 mL\\n 385 mL\\n NG:\\n 60 mL\\n Stool:\\n Drains:\\n Balance:\\n 2,158 mL\\n 172 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 169 (169 - 438) mL\\n PS : 5 cmH2O\\n RR (Spontaneous): 23\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n RSBI: 67\\n PIP: 10 cmH2O\\n SpO2: 100%\\n ABG: ///33/\\n Ve: 3.7 L/min\\n Physical Examination\\n Gen: Mildly obtunded in am, responsive to noxious stimuli, on MMV\\n through trach tube, but later in am responsive to voice, appropriate,\\n asking questions,\\n HEENT: PERRL, MMM\\n Resp: Coarse BS anteriorly, no focal rales, rhonchi, or wheezing with\\n some referred upper airway noises from secretions.\\n Card: S1S2 tachycardic, no m/r/g\\n Abd: Obese, soft, mildly distended, hypoactive BS\\n Exte: No edema, DP 2+ bil.\\n NEURO: Toes downgoing bilaterally,\\n Labs / Radiology\\n 356 K/uL\\n 8.2 g/dL\\n 129 mg/dL\\n 0.7 mg/dL\\n 33 mEq/L\\n 3.6 mEq/L\\n 4 mg/dL\\n 110 mEq/L\\n 148 mEq/L\\n 26.9 %\\n 5.7 K/uL\\n [image002.jpg]\\n 06:22 AM\\n 02:58 AM\\n 03:43 AM\\n 05:02 PM\\n 03:36 AM\\n 02:30 AM\\n 01:30 AM\\n 06:41 AM\\n 03:20 PM\\n 03:23 AM\\n WBC\\n 7.0\\n 7.1\\n 7.1\\n 6.9\\n 7.6\\n 9.5\\n 5.7\\n Hct\\n 29.7\\n 28.9\\n 29.2\\n 27.8\\n 32.7\\n 28.6\\n 28.9\\n 30.0\\n 26.9\\n Plt\\n 395\\n 462\\n 452\\n 467\\n 548\\n 528\\n 356\\n Cr\\n 0.7\\n 0.6\\n 0.7\\n 0.8\\n 0.7\\n 0.8\\n 1.0\\n 0.7\\n Glucose\\n 126\\n 137\\n 104\\n 108\\n 131\\n 128\\n 121\\n 129\\n Other labs: PT / PTT / INR:15.2/24.6/1.3, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:8.7 mg/dL, Mg++:2.1 mg/dL, PO4:4.1\\n mg/dL\\n Assessment and Plan\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n 18 Gauge - 04:00 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-22 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 638905,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Increased Metoprolol to 7.5 IV q 4\\n Getting tube study in am\\n had J tube placed by IR via PEG, then had tube feeds at 10/hr which she\\n proceeded to vomit, TF held\\n Agitated so given Haldol, put back on pressure support\\n Na 148 but had not received D5W yet.\\n INR 2.3 after 10 IV Vit K\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:30 AM\\n Diazepam (Valium) - 02:24 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:35 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.9\\nC (98.4\\n Tcurrent: 35.7\\nC (96.2\\n HR: 107 (93 - 140) bpm\\n BP: 85/45(55) {83/40(51) - 148/101(105)} mmHg\\n RR: 23 (11 - 37) insp/min\\n SpO2: 100%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 3,808 mL\\n 557 mL\\n PO:\\n TF:\\n 4 mL\\n IVF:\\n 3,804 mL\\n 557 mL\\n Blood products:\\n Total out:\\n 1,650 mL\\n 385 mL\\n Urine:\\n 1,590 mL\\n 385 mL\\n NG:\\n 60 mL\\n Stool:\\n Drains:\\n Balance:\\n 2,158 mL\\n 172 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 169 (169 - 438) mL\\n PS : 5 cmH2O\\n RR (Spontaneous): 23\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n RSBI: 67\\n PIP: 10 cmH2O\\n SpO2: 100%\\n ABG: ///33/\\n Ve: 3.7 L/min\\n Physical Examination\\n Gen: Mildly obtunded in am, responsive to noxious stimuli, on MMV\\n through trach tube, but later in am responsive to voice, appropriate,\\n asking questions,\\n HEENT: PERRL, MMM\\n Resp: Coarse BS anteriorly, no focal rales, rhonchi, or wheezing with\\n some referred upper airway noises from secretions.\\n Card: S1S2 tachycardic, no m/r/g\\n Abd: Obese, soft, mildly distended, hypoactive BS\\n Exte: No edema, DP 2+ bil.\\n NEURO: Toes downgoing bilaterally,\\n Labs / Radiology\\n 356 K/uL\\n 8.2 g/dL\\n 129 mg/dL\\n 0.7 mg/dL\\n 33 mEq/L\\n 3.6 mEq/L\\n 4 mg/dL\\n 110 mEq/L\\n 148 mEq/L\\n 26.9 %\\n 5.7 K/uL\\n [image002.jpg]\\n 06:22 AM\\n 02:58 AM\\n 03:43 AM\\n 05:02 PM\\n 03:36 AM\\n 02:30 AM\\n 01:30 AM\\n 06:41 AM\\n 03:20 PM\\n 03:23 AM\\n WBC\\n 7.0\\n 7.1\\n 7.1\\n 6.9\\n 7.6\\n 9.5\\n 5.7\\n Hct\\n 29.7\\n 28.9\\n 29.2\\n 27.8\\n 32.7\\n 28.6\\n 28.9\\n 30.0\\n 26.9\\n Plt\\n 395\\n 462\\n 452\\n 467\\n 548\\n 528\\n 356\\n Cr\\n 0.7\\n 0.6\\n 0.7\\n 0.8\\n 0.7\\n 0.8\\n 1.0\\n 0.7\\n Glucose\\n 126\\n 137\\n 104\\n 108\\n 131\\n 128\\n 121\\n 129\\n Other labs: PT / PTT / INR:15.2/24.6/1.3, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:8.7 mg/dL, Mg++:2.1 mg/dL, PO4:4.1\\n mg/dL\\n Assessment and Plan\\n 55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\\n trach, PEG placement now with respiratory failure secondary to\\n tracheomalacia , resolved HAP.\\n .\\n # Respiratory failure: Slowly Improving. Intermittently on trach mask\\n for most of the day, with periods of pressure support of over\\n night. This am on MMV. Previously likely oversedated but Benadryl,\\n Morhpine, and Valium held now. Pt awake and alert at rounds,\\n interactive, and breathing comfortably on trach mask\\n - Continue to increase time on trach mask as tolerated.\\n - Decrease sedation and valium use\\n - PMV with suctioning\\n .\\n # HAP vs Aspiration PNA: Afebrile without leukocytosis\\n - Completed course of ceftriaxone\\n - good O2 saturation on trach mask\\n .\\n # Tachycardia: Previously was assessed as sinus tach with occasional\\n runs of SVT and sources such as hypovolemia, PE, infection, and pain\\n were assessed as possibly etiologies. Per Cardiology, most likely AT\\n given transient response to Adenosine. HR occasionally decreases to\\n 70s-80s w/ stable BPs at times that might be associated with\\n administration of her BB and valium. Cards recommended titrating up her\\n beta blocker as tolerated. Dose increased to 50 yesterday and\\n intermittently responded but then had to hold PO meds given need to\\n hold PO. Changed PO to IV lopressor.\\n - EP consulted for SVT, appreciate recs, will change metoprololt o IV\\n and hopefully will be able to restart PO meds soon once able to\\n tolerate\\n - IV metoprolol 5 mg IV q 4\\n .\\n # Sedation: Inconsistent response to sedation, unclear what is best\\n regime. Will continue to wean overall.\\n - Continue w Olanzapine QHS\\n - Just valium 2.5 mg PRN.\\n # Nutrition/Vomiting: Pt has had several episodes of vomiting up her\\n TFs, reglan started to increase GI motility, but pt had another episode\\n of vomiting this am, not improved with zofran or reglan. Patient also\\n had hypoactive BS on exam, concern for obstruction given persistent\\n vomiting, inability to tolerate tube feeds.\\n - Hold TFs\\n - Thoracic surgery recs: 1) oral/nasal tube in post-piloric position,\\n or 2) IR to place a pediatric feeding tube through her PEG site to a\\n post-piloric position.\\n - Will attempt to coordinate thoracic surgery and IR for tube placement\\n ; will d/w thoracics\\n - CT scan did not reveal evidence of obstruction. Attempted to\\n coordinate tube study or UGI btu per Radiology would not be useful\\n studies since no obstruction or dysmotility evident on CT\\n - Reglan DCd since not helping\\n - Will decrease narcotics for possible cause of decreased motility\\n .\\n # Adrenal Insufficency: Endocrine following. Pt does not appear to be\\n adrenally insufficient at baseline. Suggesting if the patient under\\n goes major stressors such as major surgery, sepsis, she may need stress\\n dosed steroids.\\n .\\n # Fluid Status: Likely approaching euvolemia, though still has mild\\n hypernatramia which may suggest is still intravascularly depleated.\\n - Monitoring urine output\\n - will provide D5W IVF as need for hypernatremia and follow lytes\\n .\\n # UE DVT and elevated INR: DVT in right UE has resolved, new\\n non-occlusive in left axillary vein. INR supratherapeutic today and\\n trending upward. INR most likely continuing to rise nutritional\\n deficiencies given continued lack of PO intake\\n - Cumadin stopped.\\n - INR 10.5 today, up from 5.5, will give Vitamin K IV and reassess will\\n check PM coags and follow\\n - vitamin K IV x 1. Will likely need to continue with SC, follow coags\\n .\\n #Hematemesis: Pt had small amt Hematemesis this am. Concerning in\\n setting of elevated INR. Will give IV Vitamin K and may need continued\\n dosing\\n - Vit K IV x 1\\n -\\n # Spine fracture: Stable\\n - Brace for OOB, will discuss with Neurosurgery if current brace is\\n optimal for stabilization given her mobility.\\n - Pt to follow up with Dr. in weeks\\n .\\n # Tracheomalacia. Was initially addressed with IP and they wanted to\\n follow up as outpatient. IP reevaluated and does not believe that a\\n stent would be feasible.\\n .\\n #. Thyroid Nodule on CT\\n - Outpatient follow up\\n .\\n # Glycemic control: SSI, well controlled\\n # PIV x 1\\n # Ppx: supratherapeutic INR, Ranitidine, Bowel Regimen PRN\\n # Communication:\\n - Boyfriend of 10 \\n - Brother also involved\\n - Will contact Social and Case management today\\n # Code: Full\\n # Dispo: ICU, Screening for vent facilities\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n 18 Gauge - 04:00 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Social Work\",\n \"chartdate\": \"2167-10-22 00:00:00.000\",\n \"description\": \"Social Work Progress Note\",\n \"row_id\": 639036,\n \"text\": \"Social Work:\\n Discussed with legal department brother\\ns questions re whether the\\n hospital should pursue guardianship for pt. Also discussed with MICU\\n attending, resident, and RNCM. Per discussion with all of the above,\\n shared with pt\\ns brother that it does not appear necessary for the\\n hospital to pursue guardianship at this time given that, as pt\\ns legal\\n , brother has been available, communicating regularly with team, and\\n making decisions re her healthcare on her behalf\\n decisions that also\\n appear to be aligned with what pt\\ns boyfriend understands pt would\\n want. Per RNCM, there is also no indication at this time that, with\\n pt\\ns legal acting on pt\\ns behalf, guardianship would be necessary\\n for her for disposition/placement purposes. Reminded brother that he\\n can address any further questions or concerns about disposition-related\\n issues with RNCM. Brother states he agrees that communication re pt\\n medical care is going smoothly. He reiterates from our phone\\n conversation yesterday that his questions about guardianship \\n largely from his concern about how pt\\ns finances are being managed or\\n will be managed should she remain unable to attend to them herself.\\n Encouraged him to discuss this with pt\\ns boyfriend, as it seems\\n boyfriend has been trying to manage these matters in recent weeks.\\n Brother states he plans to fly in from tomorrow and will come\\n to the hospital in the afternoon to visit pt and meet with MICU team.\\n Arranged family meeting with MICU team for 3:30 Friday. ,\\n , be available to attend along with team. Discussed with\\n RN. Please page as needed.\\n , LCSW, #\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-27 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 639727,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n -hypernatremia: Repeat Na 148-->146 (this am), continuing D5W at\\n 125cc/hr\\n -TF up to 30cc/hr; tolerated O/N; stopped at 12am\\n -Psych recs: Gave risperidone m-tab 1mg PO x1 HS last night and will\\n continue risperdone 0.5mg qam and 0.5 PRN; f/u EKG in am;\\n -Changed Metoprolol 25 to 37.5mg TID given tach to 110-120\\ns; gave 5mg\\n x1\\n -GI recs: pending\\n -IP: seen by IP this am for eval of possible stent placement, pt not a\\n candidate as she is at risk of aspiration given opening defect\\n posterior to vocal cords; recommended d/w ENT and increase ppi to .\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:30 AM\\n Enoxaparin (Lovenox) - 06:48 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:54 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.7\\nC (98.1\\n Tcurrent: 36.7\\nC (98.1\\n HR: 79 (68 - 124) bpm\\n BP: 134/57(75) {124/52(70) - 179/121(130)} mmHg\\n RR: 27 (18 - 31) insp/min\\n SpO2: 99%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 4,004 mL\\n 1,084 mL\\n PO:\\n TF:\\n 137 mL\\n 51 mL\\n IVF:\\n 2,544 mL\\n 729 mL\\n Blood products:\\n Total out:\\n 3,813 mL\\n 1,000 mL\\n Urine:\\n 3,813 mL\\n 1,000 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 191 mL\\n 84 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask 40-50%\\n SpO2: 99%\\n ABG: ///33/\\n Physical Examination\\n Gen: Sedating post-bronchoscopy; Sleeping; pt would not wake for exam.\\n HEENT: No pallor in conjunctiva, MMM\\n Resp: Course breath sounds anteriorly, mild exp wheeze.\\n Card: S1S2 tachycardic, no m/r/g\\n Abd: Obese, soft, mildly distended, decreased bowel sounds, G-Tube in\\n place with no erythema/induration\\n Exte: No edema, DP 2+ bil\\n NEURO: Sedated\\n Labs / Radiology\\n 231 K/uL\\n 7.7 g/dL\\n 145 mg/dL\\n 0.4 mg/dL\\n 33 mEq/L\\n 3.5 mEq/L\\n 11 mg/dL\\n 109 mEq/L\\n 146 mEq/L\\n 25.3 %\\n 5.7 K/uL\\n [image002.jpg]\\n 01:30 AM\\n 06:41 AM\\n 03:20 PM\\n 03:23 AM\\n 03:00 AM\\n 04:00 AM\\n 05:45 AM\\n 03:51 AM\\n 04:45 PM\\n 04:00 AM\\n WBC\\n 9.5\\n 5.7\\n 7.3\\n 8.0\\n 8.7\\n 5.5\\n 5.7\\n Hct\\n 28.6\\n 28.9\\n 30.0\\n 26.9\\n 27.3\\n 27.0\\n 28.7\\n 24.7\\n 25.2\\n 25.3\\n Plt\\n 528\\n 356\\n 346\\n \\n 231\\n Cr\\n 1.0\\n 0.7\\n 0.7\\n 0.7\\n 0.7\\n 0.5\\n 0.4\\n Glucose\\n 121\\n 129\\n 123\\n 114\\n 112\\n 122\\n 145\\n Other labs: PT / PTT / INR:13.6/31.1/1.2, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.6 mg/dL, Mg++:2.0 mg/dL, PO4:3.6\\n mg/dL\\n Assessment and Plan\\n 56yoF s/p mechanical fall and traumatic T spine fracture, now s/p\\n trach/PEG with resolving respiratory failure and HAP.\\n .\\n # Respiratory failure/Aspiration Risk: s/p intubation/extubation, now\\n on trach mask, FiO2 50%. Tolerating well with good O2 sat. No further\\n self-decanulations overnight. Pt continues to be at risk for aspiration\\n given new IP finding of opening defect in posterior vocal cord space\\n and given recent history of vomiting with tube feed trials.\\n - ENT consulted for evaluation of larynx and possible intervention;\\n will follow ENT recs\\n - increase ppi from qday to for aspiration prophylaxis\\n - Trach mask as tolerated.\\n - scopolamine patch q72hrs for secretions\\n - Holding sedation with exception of Risperidal 0.5mg PRN\\n - F/u CXR tomorrow\\n .\\n # Nutrition/Vomiting: Currently receiving TPN; BMx2 in past 24 hrs to\\n indicate possible improvement in ileus. TF tolerated during trial O/N\\n without emesis.\\n - Cont Reglan 20mg IV Q 8 hours; meds via G-J tube,\\n - Will obtain recommendations from Nutrition re TPN today and will\\n provide TF as tolerated\\n - Speech and Swallow eval today for Passy Muir valve eval;\\n - GI consult, will f/u recs\\n .\\n # Tachycardia: Improved HR max of 120\\ns versus 160s previously. Pt now\\n on PO Amiodarone 200 TID and PO metoprolol 37.5mg TID\\n - Continue current med regimen. Will continue amiodarone 200 TID for\\n three weeks and then switch to qday for 1week and then d/c amiodarone.\\n - Will need to schedule f/u in 4wks with Dr. upon d/c/transfer.\\n - f/u Cards recs\\n # Sedation/Anxiolysis/AlteredMS: Resolved O/N with risperdal. Previous\\n delirium and agitation most likely secondary to long hospital course\\n and multiple psychotropic medications as well as hx of EtOH abuse.\\n - started Risperdal 0.5mg PO BID PRN.\\n - continue to hold all benzos. opiates, and antihistamines\\n - Appreciate psych. Will call and f/u psych recs.\\n -Obtain EKG to assess for QTc prolongation.\\n #Anemia: HCT stable at 25. No known etiology of blood loss.\\n -Will repeat HCT in am .\\n # Hypernatremia/Fluid Status: Mild hypernatramia resolving with free\\n water administration. On TPN/TF. Good UOP.\\n - providing D5W IVFx 1L at 125cc/hr, free water flushes with TF\\n -Will f/u lytes in afternoon (5pm)\\n # UE DVT and elevated INR: Decision made to d/c Coumadin given her\\n labile INR, and start Lovenox .\\n - Will flush L PICC with TPA if does not flush\\n - Add coags to am labs\\n .\\n # Spine fracture: Stable\\n - Brace for OOB, need to discuss with Neurosurgery before d/c if\\n current brace is optimal for stabilization given her mobility.\\n - Pt to follow up with Dr. in weeks\\n .\\n # Tracheomalacia. Reevaluation bronchoscopy by IP as written above;\\n patient not a candidate for stent; pt to follow up as outpatient. No\\n new issues.\\n .\\n #. Thyroid Nodule on CT\\n - Outpatient follow up\\n .\\n # Glycemic control: SSI, well controlled\\n # ACCESS: PIV x 1, L PICC\\n # Ppx: Lovenox, PPi-to increase to , Bowel Regimen PRN\\n # Communication:\\n - Boyfriend of 10 \\n - Brother also involved\\n - Social Work and Case management involved; have discussed situation\\n w/ brother and boyfriend.\\n # Code: Full\\n # Dispo: ICU, Will d/w case management re rehab facilities.\\n MSIV\\n PGY2 addendum:\\n Agree with assessment and plan in MSIV note as detailed above.\\n Briefly, 56 F s/p fall with T spine fracture, respiratory failure now\\n s/p trach/PEG. Now on trach mask. Patient s/p bronch with IP today;\\n ENT to see and follow for ?intervention. Nutrition issues continue;\\n will receive TPN today plus possible restart of tube feeds as tolerated\\n (later today), continue reglan. Appreciate psych recs; continuing\\n risperidone for agitation. Etiology of delirium/agitation still\\n unclear. Likely eventual dispo to rehab facility directly from ICU\\n given high nursing requirements.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-20 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 638599,\n \"text\": \"Chief Complaint: resp failure\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 24 Hour Events:\\n CARDIOVERSION/DEFIBRILLATION - At 11:50 AM\\n aqdenosine 6mg given X 1 by cardiologist to assess pt's rhythm. Pt\\n tolerated well.\\n Held Valium ansd Benedryl and has done well without\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 11:48 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.5\\nC (97.7\\n Tcurrent: 36.5\\nC (97.7\\n HR: 118 (76 - 144) bpm\\n BP: 131/72(85) {93/43(0) - 154/134(138)} mmHg\\n RR: 26 (12 - 36) insp/min\\n SpO2: 94%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 1,945 mL\\n 680 mL\\n PO:\\n TF:\\n IVF:\\n 1,800 mL\\n 560 mL\\n Blood products:\\n Total out:\\n 2,300 mL\\n 680 mL\\n Urine:\\n 2,245 mL\\n 680 mL\\n NG:\\n 55 mL\\n Stool:\\n Drains:\\n Balance:\\n -355 mL\\n 0 mL\\n Respiratory support\\n O2 Delivery Device: High flow neb, Tracheostomy tube\\n Ventilator mode: MMV/PSV/AutoFlow\\n Vt (Set): 500 (500 - 500) mL\\n Vt (Spontaneous): 319 (319 - 319) mL\\n PS : 10 cmH2O\\n RR (Set): 12\\n RR (Spontaneous): 15\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n RSBI Deferred: No Spon Resp\\n PIP: 15 cmH2O\\n SpO2: 94%\\n ABG: ///36/\\n Ve: 5.5 L/min\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 10.0 g/dL\\n 548 K/uL\\n 128 mg/dL\\n 0.8 mg/dL\\n 36 mEq/L\\n 4.1 mEq/L\\n 6 mg/dL\\n 105 mEq/L\\n 148 mEq/L\\n 32.7 %\\n 7.6 K/uL\\n [image002.jpg]\\n 05:00 AM\\n 02:06 AM\\n 07:34 AM\\n 03:50 AM\\n 06:22 AM\\n 02:58 AM\\n 03:43 AM\\n 05:02 PM\\n 03:36 AM\\n 02:30 AM\\n WBC\\n 5.9\\n 7.5\\n 5.6\\n 6.1\\n 7.0\\n 7.1\\n 7.1\\n 6.9\\n 7.6\\n Hct\\n 27.2\\n 26.8\\n 27.0\\n 27.0\\n 29.7\\n 28.9\\n 29.2\\n 27.8\\n 32.7\\n Plt\\n 296\\n 306\\n 335\\n \\n 452\\n 467\\n 548\\n Cr\\n 0.7\\n 0.6\\n 0.5\\n 0.7\\n 0.7\\n 0.6\\n 0.7\\n 0.8\\n 0.7\\n 0.8\\n Glucose\\n 134\\n 134\\n 121\\n \\n 104\\n 108\\n 131\\n 128\\n Other labs: PT / PTT / INR:48.3/33.3/5.5, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:10.0 mg/dL, Mg++:2.5 mg/dL,\\n PO4:4.3 mg/dL\\n Assessment and Plan\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :ICU\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-20 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 638600,\n \"text\": \"Chief Complaint: resp failure\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 24 Hour Events:\\n CARDIOVERSION/DEFIBRILLATION - At 11:50 AM\\n aqdenosine 6mg given X 1 by cardiologist to assess pt's rhythm. Pt\\n tolerated well.\\n Held Valium ansd Benedryl and has done well without\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 11:48 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.5\\nC (97.7\\n Tcurrent: 36.5\\nC (97.7\\n HR: 118 (76 - 144) bpm\\n BP: 131/72(85) {93/43(0) - 154/134(138)} mmHg\\n RR: 26 (12 - 36) insp/min\\n SpO2: 94%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 1,945 mL\\n 680 mL\\n PO:\\n TF:\\n IVF:\\n 1,800 mL\\n 560 mL\\n Blood products:\\n Total out:\\n 2,300 mL\\n 680 mL\\n Urine:\\n 2,245 mL\\n 680 mL\\n NG:\\n 55 mL\\n Stool:\\n Drains:\\n Balance:\\n -355 mL\\n 0 mL\\n Respiratory support\\n O2 Delivery Device: High flow neb, Tracheostomy tube\\n Ventilator mode: MMV/PSV/AutoFlow\\n Vt (Set): 500 (500 - 500) mL\\n Vt (Spontaneous): 319 (319 - 319) mL\\n PS : 10 cmH2O\\n RR (Set): 12\\n RR (Spontaneous): 15\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n RSBI Deferred: No Spon Resp\\n PIP: 15 cmH2O\\n SpO2: 94%\\n ABG: ///36/\\n Ve: 5.5 L/min\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 10.0 g/dL\\n 548 K/uL\\n 128 mg/dL\\n 0.8 mg/dL\\n 36 mEq/L\\n 4.1 mEq/L\\n 6 mg/dL\\n 105 mEq/L\\n 148 mEq/L\\n 32.7 %\\n 7.6 K/uL\\n [image002.jpg]\\n 05:00 AM\\n 02:06 AM\\n 07:34 AM\\n 03:50 AM\\n 06:22 AM\\n 02:58 AM\\n 03:43 AM\\n 05:02 PM\\n 03:36 AM\\n 02:30 AM\\n WBC\\n 5.9\\n 7.5\\n 5.6\\n 6.1\\n 7.0\\n 7.1\\n 7.1\\n 6.9\\n 7.6\\n Hct\\n 27.2\\n 26.8\\n 27.0\\n 27.0\\n 29.7\\n 28.9\\n 29.2\\n 27.8\\n 32.7\\n Plt\\n 296\\n 306\\n 335\\n \\n 452\\n 467\\n 548\\n Cr\\n 0.7\\n 0.6\\n 0.5\\n 0.7\\n 0.7\\n 0.6\\n 0.7\\n 0.8\\n 0.7\\n 0.8\\n Glucose\\n 134\\n 134\\n 121\\n \\n 104\\n 108\\n 131\\n 128\\n Other labs: PT / PTT / INR:48.3/33.3/5.5, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:10.0 mg/dL, Mg++:2.5 mg/dL,\\n PO4:4.3 mg/dL\\n Assessment and Plan\\n 1. Tachycardia: runs of atach versus AVNRT. On bblocker be not very\\n effective- EP consult for ? is there an ablatable focus.\\n 2. Resp Failure\\n Trach mask trials as tolerating (needing QHS support at\\n present)\\n PMV trials\\n S/P rx for pan Klebs PNA.\\n Per IP not stent planned as technically not possible to\\n place into her airway\\n 3. DVT and coagulopathy On warfarin but high inr. Hold warfarin until\\n inr 2-2.5 range or bridge with loveox if may get procedures\\n 4. Feeding tube Getting reglan trial but still with emesis. Need to\\n coordinate IR advance of G to J tube with Thoracics\\n 5. Hypernatremia Replete free water.\\n Please see today\\ns ICU team note for other issues.\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :ICU\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-20 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 638602,\n \"text\": \"Chief Complaint: resp failure\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 24 Hour Events:\\n CARDIOVERSION/DEFIBRILLATION - At 11:50 AM\\n aqdenosine 6mg given X 1 by cardiologist to assess pt's rhythm. Pt\\n tolerated well.\\n Held Valium ansd Benedryl and has done well without\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 11:48 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.5\\nC (97.7\\n Tcurrent: 36.5\\nC (97.7\\n HR: 118 (76 - 144) bpm\\n BP: 131/72(85) {93/43(0) - 154/134(138)} mmHg\\n RR: 26 (12 - 36) insp/min\\n SpO2: 94%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 1,945 mL\\n 680 mL\\n PO:\\n TF:\\n IVF:\\n 1,800 mL\\n 560 mL\\n Blood products:\\n Total out:\\n 2,300 mL\\n 680 mL\\n Urine:\\n 2,245 mL\\n 680 mL\\n NG:\\n 55 mL\\n Stool:\\n Drains:\\n Balance:\\n -355 mL\\n 0 mL\\n Respiratory support\\n O2 Delivery Device: High flow neb, Tracheostomy tube\\n Ventilator mode: MMV/PSV/AutoFlow\\n Vt (Set): 500 (500 - 500) mL\\n Vt (Spontaneous): 319 (319 - 319) mL\\n PS : 10 cmH2O\\n RR (Set): 12\\n RR (Spontaneous): 15\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n RSBI Deferred: No Spon Resp\\n PIP: 15 cmH2O\\n SpO2: 94%\\n ABG: ///36/\\n Ve: 5.5 L/min\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 10.0 g/dL\\n 548 K/uL\\n 128 mg/dL\\n 0.8 mg/dL\\n 36 mEq/L\\n 4.1 mEq/L\\n 6 mg/dL\\n 105 mEq/L\\n 148 mEq/L\\n 32.7 %\\n 7.6 K/uL\\n [image002.jpg]\\n 05:00 AM\\n 02:06 AM\\n 07:34 AM\\n 03:50 AM\\n 06:22 AM\\n 02:58 AM\\n 03:43 AM\\n 05:02 PM\\n 03:36 AM\\n 02:30 AM\\n WBC\\n 5.9\\n 7.5\\n 5.6\\n 6.1\\n 7.0\\n 7.1\\n 7.1\\n 6.9\\n 7.6\\n Hct\\n 27.2\\n 26.8\\n 27.0\\n 27.0\\n 29.7\\n 28.9\\n 29.2\\n 27.8\\n 32.7\\n Plt\\n 296\\n 306\\n 335\\n \\n 452\\n 467\\n 548\\n Cr\\n 0.7\\n 0.6\\n 0.5\\n 0.7\\n 0.7\\n 0.6\\n 0.7\\n 0.8\\n 0.7\\n 0.8\\n Glucose\\n 134\\n 134\\n 121\\n \\n 104\\n 108\\n 131\\n 128\\n Other labs: PT / PTT / INR:48.3/33.3/5.5, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:10.0 mg/dL, Mg++:2.5 mg/dL,\\n PO4:4.3 mg/dL\\n Assessment and Plan\\n 1. Tachycardia: runs of attach Appreciate EP consult\\n will increase\\n bblocker. If fails may need EP study for further study and ? ablatable\\n focus.\\n 2. Persistent Nausea/Vomiting: very poor bowel sounds, get ABD ct to\\n look for SBO, talk with GI about EGD or tube study to look for more\\n proximal gastric outlet obstruction.\\n 2. Resp Failure\\n Trach mask trials all day, PSV\\n PMV trials\\n S/P rx for pan Klebs PNA.\\n Per IP not stent planned as technically not possible to\\n place into her airway\\n 3. DVT and coagulopathy: On warfarin but high inr. Hold warfarin until\\n inr 2-2.5 range or bridge with loveox if may get procedures\\n 4. Feeding tube Getting reglan trial but still with emesis. Need to\\n coordinate IR advance of G to J tube with Thoracics\\n 5. Hypernatremia Replete free water.\\n Please see today\\ns ICU team note for other issues.\\n ICU Care\\n Nutrition: NPPO while sorting out gi obstruction issues\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n Prophylaxis:\\n DVT: coumadin\\n Stress ulcer: PPI\\n Communication: Comments:\\n Code status: Full code\\n Disposition :ICU\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Rehab Services\",\n \"chartdate\": \"2167-10-22 00:00:00.000\",\n \"description\": \"Physical Therapy Progress Note\",\n \"row_id\": 639038,\n \"text\": \"Subjective:\\n \\\"I think they are trying to kill me here\\\"\\n Objective:\\n Follow up PT visit to address goals of: .\\n Updated medical status: PMV\\n Activity\\n Clarification\\n I\\n S\\n CG\\n Min\\n Mod\\n Max\\n Rolling:\\n T\\n\\n\\n\\n\\n\\n Supine/\\n Sidelying to Sit:\\n\\n\\n T\\n\\n\\n Transfer:\\n\\n\\n\\n T\\n\\n Sit to Stand:\\n\\n\\n\\n T\\n\\n Ambulation:\\n\\n\\n\\n\\n\\n Stairs:\\n\\n\\n\\n\\n\\n Aerobic Activity Response:\\n Position\\n HR\\n BP\\n RR\\n O[2] sat\\n RPE\\n Rest\\n Supine\\n 110-125\\n 142/80\\n 99% 50% TM\\n Activity\\n /\\n Recovery\\n Sit\\n 110-130s\\n 138/80\\n 96-99% TM\\n Total distance walked:\\n Minutes:\\n Gait: Attempted ambulation, pt unable to advance LEs, was mod x 2 to\\n take 2 small steps forward, and Max A to take 2 steps back. Mod A x 1\\n to stand pivot to chair.\\n Balance: Pt has fair sitting balance. Retropulsive in standing.\\n Education / Communication: Pt status discussed with RN\\n Other: Pt making nonsensical statements t/o treatment. A and O x 2,\\n person and year not month, date or place.\\n Pulm: Pt with strong productive cough, thick yellow sputum. Tolerated\\n PMV t/o treatment.\\n Pt performed sit to stand x 3 with mod A x 2\\n Assessment: 56 yo f s/p fall with T8 fx and complicated hospital course\\n due to resp distress. Pt continues to be functioning below baseline,\\n from both cognitive and mobility stand points. Pt would benefit from OT\\n consult and continue PT in rehab setting upon d/c to optimize function\\n and independence\\n Anticipated Discharge: Rehab\\n Plan: f/u progress mobility, advance ambulation.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-23 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 639111,\n \"text\": \"Tachycardia, Other\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Altered mental status (not Delirium)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Alteration in Nutrition\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-23 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 639114,\n \"text\": \"56 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\\n with prolonged hospital course c/b by PNA, anxiety/altered mental\\n status, R&LUE DVT .Pt found to have small non occlusive Clot on her\\n right axial vein via Ultrasound.Yesterday. She has had problems with\\n vomiting tube feedings, feeding tube passed through g-tube (g-tube in\\n place with mushroom on inside so cannot pull out) to her jejunenum but\\n continues vomit.\\n Tachycardia, Other\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Altered mental status (not Delirium)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Alteration in Nutrition\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-27 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 639639,\n \"text\": \"Airway Clearance, Impaired\\n Assessment:\\n Pt cont on TM 50%, bilat rhonchi, diminished in bases. 02 SATS 94-95%\\n Action:\\n Pt requiring frequent suction, copious loose white secretions noted,\\n scolopamine patch applied to help with secretions\\n Response:\\n Cont to suction for copious secretions\\n Plan:\\n Cont to resp. status, suction as needed, s/swallow to re-evaluate\\n for bigger PMV in am\\n Alteration in Nutrition\\n Assessment:\\n Pt cont with restlessness, TF off 00 due to pts restlessness, BS\\n positive bilat, loose BM\\ns x 2\\n Action:\\n Pt placed on chair positin in bed, pt recvd scheduled Reglan, colace\\n Response:\\n Pt had two loose bm\\ns x 2,\\n Plan:\\n Re-start TF when pt more relaxed, cont with TPN 43.6 as ordered, cont\\n strict asp precautions :holding TF when pt not in upright position and\\n turning TF off for 15 mins before turning\\n Arousal, Attention, and Cognition, Impaired\\n Assessment:\\n Pt cont to be very restless in bed, cont with bilat wrist restraints\\n and 1:1 sitter @ bedside\\n Action:\\n Pt seen by psych @, Risperadol dosing increased\\n Response:\\n Pt cont to be restless despite increase in HS risperadol and prn dose\\n Plan:\\n Psych to re-evaluate in am, EKG to be taken in am\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-27 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 639709,\n \"text\": \"Chief Complaint:\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n Aggitation, remains delerious.\\n Bedside bronchoscopy by IP service revealed inability of posterior\\n portion of vocal cords to adduct. Unclear etiology.\\n Sedated for bronchoscopy.\\n 24 Hour Events:\\n History obtained from Medical records\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Enoxaparin (Lovenox) - 06:48 PM\\n Other medications:\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Constitutional: No(t) Fatigue, No(t) Fever, No(t) Weight loss\\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG\\n tube, Tracheotomy tube\\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\\n No(t) Tachycardia, No(t) Orthopnea\\n Nutritional Support: No(t) NPO, Tube feeds, No(t) Parenteral nutrition\\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\\n No(t) Diarrhea, No(t) Constipation\\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\\n Integumentary (skin): No(t) Jaundice, No(t) Rash\\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\\n Heme / Lymph: No(t) Lymphadenopathy, No(t) Anemia, No(t) Coagulopathy\\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\\n No(t) Daytime somnolence\\n Allergy / Immunology: No(t) Immunocompromised, No(t) Influenza vaccine\\n Signs or concerns for abuse : No\\n Pain: No pain / appears comfortable\\n Flowsheet Data as of 11:52 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.7\\nC (98.1\\n Tcurrent: 36.1\\nC (96.9\\n HR: 62 (62 - 123) bpm\\n BP: 87/42(53) {87/42(53) - 179/121(130)} mmHg\\n RR: 20 (18 - 31) insp/min\\n SpO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 4,004 mL\\n 2,070 mL\\n PO:\\n TF:\\n 137 mL\\n 51 mL\\n IVF:\\n 2,544 mL\\n 1,423 mL\\n Blood products:\\n Total out:\\n 3,813 mL\\n 1,380 mL\\n Urine:\\n 3,813 mL\\n 1,380 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 191 mL\\n 690 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask\\n SpO2: 98%\\n ABG: ///33/\\n Physical Examination\\n General Appearance: No(t) Well nourished, No(t) No acute distress,\\n No(t) Overweight / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic,\\n Sedated\\n Eyes / Conjunctiva: No(t) PERRL, No(t) Pupils dilated, No(t)\\n Conjunctiva pale, No(t) Sclera edema\\n Head, Ears, Nose, Throat: No(t) Normocephalic, No(t) Poor dentition,\\n No(t) Endotracheal tube, No(t) NG tube, No(t) OG tube, Tracheotomy tube\\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\\n Cervical adenopathy\\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic,\\n No(t) Diastolic)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\\n (Percussion: No(t) Resonant : , No(t) Hyperresonant: , No(t) Dullness :\\n ), (Breath Sounds: Clear : , No(t) Crackles : , Bronchial: Right base,\\n No(t) Wheezes : , No(t) Diminished: , No(t) Absent : , No(t)\\n Rhonchorous: )\\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended, No(t)\\n Tender: , No(t) Obese, PEG\\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\\n Clubbing\\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\\n Skin: Warm, No(t) Rash: , No(t) Jaundice\\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\\n to: Verbal stimuli, No(t) Oriented (to): , Movement: Purposeful, No(t)\\n Sedated, No(t) Paralyzed, Tone: Normal\\n Labs / Radiology\\n 7.7 g/dL\\n 231 K/uL\\n 145 mg/dL\\n 0.4 mg/dL\\n 33 mEq/L\\n 3.5 mEq/L\\n 11 mg/dL\\n 109 mEq/L\\n 146 mEq/L\\n 25.3 %\\n 5.7 K/uL\\n [image002.jpg]\\n 01:30 AM\\n 06:41 AM\\n 03:20 PM\\n 03:23 AM\\n 03:00 AM\\n 04:00 AM\\n 05:45 AM\\n 03:51 AM\\n 04:45 PM\\n 04:00 AM\\n WBC\\n 9.5\\n 5.7\\n 7.3\\n 8.0\\n 8.7\\n 5.5\\n 5.7\\n Hct\\n 28.6\\n 28.9\\n 30.0\\n 26.9\\n 27.3\\n 27.0\\n 28.7\\n 24.7\\n 25.2\\n 25.3\\n Plt\\n 528\\n 356\\n 346\\n \\n 231\\n Cr\\n 1.0\\n 0.7\\n 0.7\\n 0.7\\n 0.7\\n 0.5\\n 0.4\\n Glucose\\n 121\\n 129\\n 123\\n 114\\n 112\\n 122\\n 145\\n Other labs: PT / PTT / INR:13.6/31.1/1.2, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.6 mg/dL, Mg++:2.0 mg/dL, PO4:3.6\\n mg/dL\\n Assessment and Plan\\n Respiratory failure, delerium.\\n RESPIRATORY FAILURE -- chronic, s/p trach. Underlying\\n tracheobronchomalacia. Possible elevated right hemidiaphragm.\\n Continue current care, including aspiration precautions. Maintain\\n trach, monitor SaO2 --> maintain >90%.\\n TRACHEOBRONCOMALACIA -- no immediate plans for IP intervention.\\n VOCAL CORD dysfunction -- ENT to evaluate limited ability of posterior\\n portion of cords to adduct. consult ENT service.\\n RUE DVT -- anticoagulation with lovenox.\\n HYPERNATREMIA -- improved with free H2O repletion. Monitor.\\n A-FIB -- rate controlled on amioderone.\\n DELERIUM -- currently sedated from procedure. Unclear etiology.\\n Concerns include medications and ICU psychosis. Psychiatry consulted.\\n Respiradol dose being adjusted.\\n NUTRITIONAL SUPPORT -- hope to transition TPN to TF via PEG.\\n T4-T8 VETEBRAL Fx -- suportive care. Will require rehabilitation.\\n ICU Care\\n Nutrition:\\n TPN without Lipids - 05:44 PM 43. mL/hour\\n Glycemic Control:\\n Lines:\\n PICC Line - 01:30 PM\\n 18 Gauge - 10:14 AM\\n Prophylaxis:\\n DVT: Boots(Systemic anticoagulation: None)\\n Stress ulcer: PPI\\n VAP: HOB elevation, Mouth care\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :ICU\\n Total time spent: 55 minutes\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-27 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 639711,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n -hypernatremia: Repeat Na 148-->146 (this am), continuing D5W at\\n 125cc/hr\\n -TF up to 30cc/hr; tolerated O/N; stopped at 12am\\n -Psych recs: Gave risperidone m-tab 1mg PO x1 HS last night and will\\n continue risperdone 0.5mg qam and 0.5 PRN; f/u EKG in am;\\n -Changed Metoprolol 25 to 37.5mg TID given tach to 110-120\\ns; gave 5mg\\n x1\\n -GI recs: pending\\n -IP: seen by IP this am for eval of possible stent placement, pt not a\\n candidate as she is at risk of aspiration given opening defect\\n posterior to vocal cords; recommended d/w ENT and increase ppi to .\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:30 AM\\n Enoxaparin (Lovenox) - 06:48 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:54 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.7\\nC (98.1\\n Tcurrent: 36.7\\nC (98.1\\n HR: 79 (68 - 124) bpm\\n BP: 134/57(75) {124/52(70) - 179/121(130)} mmHg\\n RR: 27 (18 - 31) insp/min\\n SpO2: 99%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 4,004 mL\\n 1,084 mL\\n PO:\\n TF:\\n 137 mL\\n 51 mL\\n IVF:\\n 2,544 mL\\n 729 mL\\n Blood products:\\n Total out:\\n 3,813 mL\\n 1,000 mL\\n Urine:\\n 3,813 mL\\n 1,000 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 191 mL\\n 84 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask 40-50%\\n SpO2: 99%\\n ABG: ///33/\\n Physical Examination\\n Gen: Sedating post-bronchoscopy; Sleeping; pt would not wake for exam.\\n HEENT: No pallor in conjunctiva, MMM\\n Resp: Course breath sounds anteriorly, mild exp wheeze.\\n Card: S1S2 tachycardic, no m/r/g\\n Abd: Obese, soft, mildly distended, decreased bowel sounds, G-Tube in\\n place with no erythema/induration\\n Exte: No edema, DP 2+ bil\\n NEURO: Sedated\\n Labs / Radiology\\n 231 K/uL\\n 7.7 g/dL\\n 145 mg/dL\\n 0.4 mg/dL\\n 33 mEq/L\\n 3.5 mEq/L\\n 11 mg/dL\\n 109 mEq/L\\n 146 mEq/L\\n 25.3 %\\n 5.7 K/uL\\n [image002.jpg]\\n 01:30 AM\\n 06:41 AM\\n 03:20 PM\\n 03:23 AM\\n 03:00 AM\\n 04:00 AM\\n 05:45 AM\\n 03:51 AM\\n 04:45 PM\\n 04:00 AM\\n WBC\\n 9.5\\n 5.7\\n 7.3\\n 8.0\\n 8.7\\n 5.5\\n 5.7\\n Hct\\n 28.6\\n 28.9\\n 30.0\\n 26.9\\n 27.3\\n 27.0\\n 28.7\\n 24.7\\n 25.2\\n 25.3\\n Plt\\n 528\\n 356\\n 346\\n \\n 231\\n Cr\\n 1.0\\n 0.7\\n 0.7\\n 0.7\\n 0.7\\n 0.5\\n 0.4\\n Glucose\\n 121\\n 129\\n 123\\n 114\\n 112\\n 122\\n 145\\n Other labs: PT / PTT / INR:13.6/31.1/1.2, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.6 mg/dL, Mg++:2.0 mg/dL, PO4:3.6\\n mg/dL\\n Assessment and Plan\\n 56yoF s/p mechanical fall and traumatic T spine fracture, now s/p\\n trach/PEG with resolving respiratory failure and HAP.\\n .\\n # Respiratory failure/Aspiration Risk: s/p intubation/extubation, now\\n on trach mask, FiO2 50%. Tolerating well with good O2 sat. No further\\n self-decanulations overnight. Pt continues to be at risk for aspiration\\n given new IP finding of opening defect in posterior vocal cord space\\n and given recent history of vomiting with tube feed trials.\\n - ENT consulted for evaluation of larynx and possible intervention;\\n will follow ENT recs\\n - increase ppi from qday to for aspiration prophylaxis\\n - Trach mask as tolerated.\\n - scopolamine patch q72hrs for secretions\\n - Holding sedation with exception of Risperidal 0.5mg PRN\\n - F/u CXR tomorrow\\n .\\n # Nutrition/Vomiting: Currently receiving TPN; BMx2 in past 24 hrs to\\n indicate possible improvement in ileus. TF tolerated during trial O/N\\n without emesis.\\n - Cont Reglan 20mg IV Q 8 hours; meds via G-J tube,\\n - Will obtain recommendations from Nutrition re TPN today and will\\n provide TF as tolerated\\n - Speech and Swallow eval today for Passy Muir valve eval;\\n - GI consult, will f/u recs\\n .\\n # Tachycardia: Improved HR max of 120\\ns versus 160s previously. Pt now\\n on PO Amiodarone 200 TID and PO metoprolol 25mg TID\\n - Continue current med regimen. Will continue amiodarone 200 TID for\\n three weeks and then switch to qday.\\n - Will need to schedule f/u in 4wks with Dr. upon d/c/transfer.\\n - f/u Cards recs\\n # Sedation/Anxiolysis/AlteredMS: Resolved O/N. Previous delirium and\\n agitation most likely secondary to long hospital course and multiple\\n psychotropic medications as well as hx of EtOH abuse. Risperdal given\\n O/N per Psych recs.\\n - started Risperdal 0.5mg PO BID PRN.\\n - continue to hold all benzos. opiates, and antihistamines\\n - Appreciate psych. Will call and f/u psych recs.\\n #Anemia: HCT stable at 25. No known etiology of blood loss.\\n -Will repeat HCT in am .\\n # Hypernatremia/Fluid Status: Mild hypernatramia resolving with free\\n water administration. On TPN/TF. Good UOP.\\n - providing D5W IVF, free water flushes with TF\\n -Will f/u lytes in afternoon (5pm)\\n # UE DVT and elevated INR: Decision made to d/c Coumadin given her\\n labile INR, and start Lovenox .\\n - Will flush L PICC with TPA if does not flush\\n - Add coags to am labs\\n .\\n # Spine fracture: Stable\\n - Brace for OOB, need to discuss with Neurosurgery before d/c if\\n current brace is optimal for stabilization given her mobility.\\n - Pt to follow up with Dr. in weeks\\n .\\n # Tracheomalacia. Was initially addressed with IP and they wanted to\\n follow up as outpatient. IP reevaluated and does not believe that a\\n stent would be feasible. No new issues.\\n .\\n #. Thyroid Nodule on CT\\n - Outpatient follow up\\n .\\n # Glycemic control: SSI, well controlled\\n # ACCESS: PIV x 1, L PICC\\n # Ppx: Lovenox, PPi, Bowel Regimen PRN\\n # Communication:\\n - Boyfriend of 10 \\n - Brother also involved\\n - Social Work and Case management involved, have discussed situation\\n w/ brother and boyfriend.\\n # Code: Full\\n # Dispo: ICU, Will d/w case management re rehab facilities.\\n ICU Care\\n Nutrition:\\n TPN without Lipids - 05:44 PM 43. mL/hour\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n PICC Line - 01:30 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-27 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 639715,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n -hypernatremia: Repeat Na 148-->146 (this am), continuing D5W at\\n 125cc/hr\\n -TF up to 30cc/hr; tolerated O/N; stopped at 12am\\n -Psych recs: Gave risperidone m-tab 1mg PO x1 HS last night and will\\n continue risperdone 0.5mg qam and 0.5 PRN; f/u EKG in am;\\n -Changed Metoprolol 25 to 37.5mg TID given tach to 110-120\\ns; gave 5mg\\n x1\\n -GI recs: pending\\n -IP: seen by IP this am for eval of possible stent placement, pt not a\\n candidate as she is at risk of aspiration given opening defect\\n posterior to vocal cords; recommended d/w ENT and increase ppi to .\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:30 AM\\n Enoxaparin (Lovenox) - 06:48 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:54 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.7\\nC (98.1\\n Tcurrent: 36.7\\nC (98.1\\n HR: 79 (68 - 124) bpm\\n BP: 134/57(75) {124/52(70) - 179/121(130)} mmHg\\n RR: 27 (18 - 31) insp/min\\n SpO2: 99%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 4,004 mL\\n 1,084 mL\\n PO:\\n TF:\\n 137 mL\\n 51 mL\\n IVF:\\n 2,544 mL\\n 729 mL\\n Blood products:\\n Total out:\\n 3,813 mL\\n 1,000 mL\\n Urine:\\n 3,813 mL\\n 1,000 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 191 mL\\n 84 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask 40-50%\\n SpO2: 99%\\n ABG: ///33/\\n Physical Examination\\n Gen: Sedating post-bronchoscopy; Sleeping; pt would not wake for exam.\\n HEENT: No pallor in conjunctiva, MMM\\n Resp: Course breath sounds anteriorly, mild exp wheeze.\\n Card: S1S2 tachycardic, no m/r/g\\n Abd: Obese, soft, mildly distended, decreased bowel sounds, G-Tube in\\n place with no erythema/induration\\n Exte: No edema, DP 2+ bil\\n NEURO: Sedated\\n Labs / Radiology\\n 231 K/uL\\n 7.7 g/dL\\n 145 mg/dL\\n 0.4 mg/dL\\n 33 mEq/L\\n 3.5 mEq/L\\n 11 mg/dL\\n 109 mEq/L\\n 146 mEq/L\\n 25.3 %\\n 5.7 K/uL\\n [image002.jpg]\\n 01:30 AM\\n 06:41 AM\\n 03:20 PM\\n 03:23 AM\\n 03:00 AM\\n 04:00 AM\\n 05:45 AM\\n 03:51 AM\\n 04:45 PM\\n 04:00 AM\\n WBC\\n 9.5\\n 5.7\\n 7.3\\n 8.0\\n 8.7\\n 5.5\\n 5.7\\n Hct\\n 28.6\\n 28.9\\n 30.0\\n 26.9\\n 27.3\\n 27.0\\n 28.7\\n 24.7\\n 25.2\\n 25.3\\n Plt\\n 528\\n 356\\n 346\\n \\n 231\\n Cr\\n 1.0\\n 0.7\\n 0.7\\n 0.7\\n 0.7\\n 0.5\\n 0.4\\n Glucose\\n 121\\n 129\\n 123\\n 114\\n 112\\n 122\\n 145\\n Other labs: PT / PTT / INR:13.6/31.1/1.2, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.6 mg/dL, Mg++:2.0 mg/dL, PO4:3.6\\n mg/dL\\n Assessment and Plan\\n 56yoF s/p mechanical fall and traumatic T spine fracture, now s/p\\n trach/PEG with resolving respiratory failure and HAP.\\n .\\n # Respiratory failure/Aspiration Risk: s/p intubation/extubation, now\\n on trach mask, FiO2 50%. Tolerating well with good O2 sat. No further\\n self-decanulations overnight. Pt continues to be at risk for aspiration\\n given new IP finding of opening defect in posterior vocal cord space\\n and given recent history of vomiting with tube feed trials.\\n - ENT consulted for evaluation of larynx and possible intervention;\\n will follow ENT recs\\n - increase ppi from qday to for aspiration prophylaxis\\n - Trach mask as tolerated.\\n - scopolamine patch q72hrs for secretions\\n - Holding sedation with exception of Risperidal 0.5mg PRN\\n - F/u CXR tomorrow\\n .\\n # Nutrition/Vomiting: Currently receiving TPN; BMx2 in past 24 hrs to\\n indicate possible improvement in ileus. TF tolerated during trial O/N\\n without emesis.\\n - Cont Reglan 20mg IV Q 8 hours; meds via G-J tube,\\n - Will obtain recommendations from Nutrition re TPN today and will\\n provide TF as tolerated\\n - Speech and Swallow eval today for Passy Muir valve eval;\\n - GI consult, will f/u recs\\n .\\n # Tachycardia: Improved HR max of 120\\ns versus 160s previously. Pt now\\n on PO Amiodarone 200 TID and PO metoprolol 37.5mg TID\\n - Continue current med regimen. Will continue amiodarone 200 TID for\\n three weeks and then switch to qday for 1week and then d/c amiodarone.\\n - Will need to schedule f/u in 4wks with Dr. upon d/c/transfer.\\n - f/u Cards recs\\n # Sedation/Anxiolysis/AlteredMS: Resolved O/N with risperdal. Previous\\n delirium and agitation most likely secondary to long hospital course\\n and multiple psychotropic medications as well as hx of EtOH abuse.\\n - started Risperdal 0.5mg PO BID PRN.\\n - continue to hold all benzos. opiates, and antihistamines\\n - Appreciate psych. Will call and f/u psych recs.\\n -Obtain EKG to assess for QTc prolongation.\\n #Anemia: HCT stable at 25. No known etiology of blood loss.\\n -Will repeat HCT in am .\\n # Hypernatremia/Fluid Status: Mild hypernatramia resolving with free\\n water administration. On TPN/TF. Good UOP.\\n - providing D5W IVFx 1L at 125cc/hr, free water flushes with TF\\n -Will f/u lytes in afternoon (5pm)\\n # UE DVT and elevated INR: Decision made to d/c Coumadin given her\\n labile INR, and start Lovenox .\\n - Will flush L PICC with TPA if does not flush\\n - Add coags to am labs\\n .\\n # Spine fracture: Stable\\n - Brace for OOB, need to discuss with Neurosurgery before d/c if\\n current brace is optimal for stabilization given her mobility.\\n - Pt to follow up with Dr. in weeks\\n .\\n # Tracheomalacia. Reevaluation bronchoscopy by IP as written above;\\n patient not a candidate for stent; pt to follow up as outpatient. No\\n new issues.\\n .\\n #. Thyroid Nodule on CT\\n - Outpatient follow up\\n .\\n # Glycemic control: SSI, well controlled\\n # ACCESS: PIV x 1, L PICC\\n # Ppx: Lovenox, PPi-to increase to , Bowel Regimen PRN\\n # Communication:\\n - Boyfriend of 10 \\n - Brother also involved\\n - Social Work and Case management involved; have discussed situation\\n w/ brother and boyfriend.\\n # Code: Full\\n # Dispo: ICU, Will d/w case management re rehab facilities.\\n MSIV\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-20 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 638525,\n \"text\": \"55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\\n trach, PEG, placement no with respiratory failure secondary to\\n tracheomalacia , resolving HAP.\\n Arousal, Attention, and Cognition, Impaired\\n Assessment:\\n Alert, mouthing words but very difficult to understand. Follows\\n commands. MAE on bed, attempting to get up. Restless last evening, did\\n eventually fall off to sleep this AM.\\n Action:\\n Zyprexa x 1 . Frequent re-orientation to place, situation. Soft wrist\\n restraints for patient safety.\\n Response:\\n Pt did eventually fall asleep. Re-orientation does have calming effect\\n however it is short term.\\n Plan:\\n No valium or benadryl per psych as this exacerbates delirium. Zyprexa\\n for agitation. pt prn.\\n Hypernatremia (high sodium)\\n Assessment:\\n Na 145 last night, 148 this AM.\\n Action:\\n Response:\\n Plan:\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Trach collar @ 50% O2 overnight. Sats 90-97%. RR 17-20s. Strong cough,\\n able to cough thick white ->tan secretions out of trach. Occ suctioned\\n for same. Lungs are rhonchorous throughout. Impaired gag.\\n Action:\\n Suctioned prn for copious secretions. MDIs.\\n Response:\\n Trach collar overnight.\\n Plan:\\n Wean from vent as tolerated. MDIs, suction as needed.\\n Alteration in Nutrition\\n Assessment:\\n NPO overnight d/t constant vomiting. No vomiting overnight.\\n Action:\\n NPO. Reglan q 6 hrs.\\n Response:\\n No vomiting. Small brown stool x 1.\\n Plan:\\n NPO. ? may go to IR today to change Gtube to Jtube.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-20 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 638657,\n \"text\": \"Tachycardia, Other\\n Assessment:\\n Pt has remained in ST , with HR 90-140. B/P has remained 110-140/\\n 50-70\\n Action:\\n Lopressor increased to 50mg 4x/day\\n Response:\\n Pt has been vomiting throughout day, ? amt of lopressor absorbed.\\n Lopressor 5mg IV given\\n Plan:\\n Alteration in Nutrition\\n Assessment:\\n ABD soft, not distended, very hypoactive bowel sounds, TF on hold.\\n NA 148\\n Action:\\n D5W infusing at 125cc/hr then decreased to 75cc/hr. Abd CT done,\\n poorly prepped , vomited Bari-kat. reconsulted, ? placement of\\n Jtube\\nif CT negative for SBO/illeus.\\n Response:\\n NA level at 1600 =>146, CT scan results pending\\n Plan:\\n Continue to monitor lytes, continue D5W\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt has been very restless thru the day despite frequent reorientation.\\n Pt attempting to mouth words but difficult to interpret. Unable to PMV\\n secondary to increased secretions. Pt follows commands, but unable to\\n use call light appropriately\\n.needs verbal cueing.\\n Action:\\n Pt OOB to chair , but remained restless.\\n Response:\\n Pt remains confused and restless\\n Plan:\\n Continue to reorient\\n Nausea / vomiting\\n Assessment:\\n During am assessment pt was found to be gagging and vomited about\\n 50-75cc/hr. Pt pre-medicated w/ Zofran 8mg IV prior to am meds. Pt\\n given 60cc fluids w/ am via PEG. Pt vomited about 15 minutes after\\n meds. Abd as noted above is soft, NO BM >24hr and BS very distant and\\n hypoactive.\\n Action:\\n Team into assess, CT of abd ordered. Pt was unable to tolerate prep\\n and vomited prep. Zofran 4mg given.\\n Response:\\n Awaiting CT results\\n Plan:\\n Airway Clearance, Impaired\\n Assessment:\\n Pt has a very congested cough, w/ bronchial and rhonchi noted in upper\\n airway. Sat\\ns on trach collar 95-100%\\n Action:\\n Trach care done and suctioned Q\\n-1hr for sm-moderate amts of thin\\n yellow sectretions\\n Response:\\n Sat\\ns have remained stable on 50% trach mask 95-100%\\n Plan:\\n Continue to monitor\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2167-10-23 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 639217,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 35\\n Ideal body weight: 61.2 None\\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: Yes\\n Procedure location:\\n Reason:\\n Tube Type\\n ETT:\\n Position: cm at teeth\\n Route:\\n Type:\\n Size:\\n Tracheostomy tube:\\n Type: Standard\\n Manufacturer: Portex\\n Size: 7.0mm\\n PMV:\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 23 cmH2O\\n Cuff volume: mL /\\n Airway problems:\\n Comments:\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Rhonchi\\n LUL Lung Sounds: Rhonchi\\n LLL Lung Sounds: Diminished\\n Comments:\\n Secretions\\n Sputum color / consistency: White / Thick\\n Sputum source/amount: Suctioned / Moderate\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance: Unassisted spontaneous breathing\\n Visual assessment of breathing pattern: Normal quiet breathing\\n Assessment of breathing comfort:\\n Non-invasive ventilation assessment:\\n Invasive ventilation assessment:\\n Trigger work assessment:\\n Dysynchrony assessment:\\n Comments:\\n Plan\\n Next 24-48 hours:\\n Reason for continuing current ventilatory support:\\n Respiratory Care Shift Procedures\\n Transports:\\n Destination (R/T)\\n Time\\n Complications\\n Comments\\n Bedside Procedures:\\n Comments:\\n Patient decannulated herself at approximately 0730. New tracheostomy\\n tube placed in a timley manner. Placed on mechanical ventilation for\\n several hours during recover period. Then placed on trach collar.\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2167-10-21 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 638708,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 33\\n Ideal body weight: 61.2 None\\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: Yes\\n Tube Type\\n Tracheostomy tube:\\n Type: Standard\\n Manufacturer: Portex\\n Size: 8.0mm\\n PMV: No\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 25 cmH2O\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Rhonchi\\n LUL Lung Sounds: Rhonchi\\n LLL Lung Sounds: Diminished\\n Secretions\\n Sputum color / consistency: Tan / Thick\\n Sputum source/amount: Suctioned / Moderate\\n Ventilation Assessment\\n Level of breathing assistance: Continuous invasive ventilation\\n Visual assessment of breathing pattern: Normal quiet breathing;\\n Comments: Back to MMV last eve for ?aspiration & increased WOB.\\n Assessment of breathing comfort: No response (sleeping / sedated)\\n Non-invasive ventilation assessment:\\n Invasive ventilation assessment:\\n Trigger work assessment: Not triggering\\n Plan\\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\\n Comments: No spont resp this morning/ Back to Tc as tolerated.\\n Reason for continuing current ventilatory support:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-24 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 639281,\n \"text\": \"Airway Clearance, Impaired\\n Assessment:\\n Secretions thick, white. LS coarse, diminished at bases.\\n Action:\\n Requiring frequent suctioning, at times q 30 minutes, clearing\\n initially and within minutes, pt rattling with secretions once again.\\n Response:\\n Secretions con\\nt to accumulate despite frequent suctioning.\\n Plan:\\n Con\\nt to pulmonary toilet , clear secretions as appropriate. Maintain\\n O2 Sat of greater than 94%.\\n Tachycardia, Other\\n Assessment:\\n HR maintained in the 80\\ns and 90\\ns for the most part. Up to110\\n immediately prior to receiving the lopressor.\\n Action:\\n Rec\\n Response:\\n Maintaining HR below 100 successfully.\\n Plan:\\n Alteration in Nutrition\\n Assessment:\\n Hypoactive BS, TF\\ns on hold. J-tube ind\\n Action:\\n Response:\\n Plan:\\n Altered mental status (not Delirium)\\n Assessment:\\n Alert but confused, re\\n Action:\\n Frequent re-orientation\\n Response:\\n Plan:\\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\\n Assessment:\\n Tmax 99.4 po\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-25 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 639434,\n \"text\": \"56 yr old woman, who was transferred from osh for evaluation of\\n tracheal bronchial malacia on .Pt presented to Medical\\n Center on s/p fall down a flight of stairs fracturing, t5-t8 with\\n propulsion treated conservatively with pain meds and back brace. She\\n developed resp distress requiring intubation on . Trach/PEG done\\n . Now with prolonged hospital course c/b by PNA, anxiety/altered\\n mental status, R&LUE DVT .Pt found to have small non occlusive Clot on\\n her right axial vein via Ultrasound. She has had problems with\\n vomiting tube feedings, feeding tube passed through g-tube to her\\n jejunenum but she continues to vomit. Trach mask, has not required\\n ventilation since . Has also required 1:1 sitters since\\n decanulating herself twice, despite restraints. Events of the last\\n 12hrs include, restarted TF\\ns, however, infused for ~7 hrs, then began\\n suctioning bile-like fluid from trach after pt experienced a prolonged\\n coughing jag. TF\\ns placed on hold.\\n Airway Clearance, Impaired\\n Assessment:\\n Requiring frequent suctioning ~q15 minutes to 1hr. Secretions\\n initially white, changing to greenish and back to whitish yellow. LS\\n coarse, diminished at bases\\n Action:\\n CPT, frequent suctioning,\\n Response:\\n CXR, maintain patent airway\\n Plan:\\n F/U with CXR results, CPT\\n Tachycardia, Other\\n Assessment:\\n Becoming tachy in the 110\\ns approx 30 minutes prior receiving standard\\n lopressor dose. HR basically in the 70\\ns the entire shift.\\n Action:\\n Lopressor 10 mg IV q4hr, amiodarone\\n Response:\\n Tolerating meds\\n Plan:\\n Monitor VS,\\n Alteration in Nutrition\\n Assessment:\\n TF\\ns infusing at rate of 10cc/hr. ~2240, pt began coughing. Required\\n suctioning. Pt noted to have thin greenish secretions from trach tube.\\n Action:\\n TF\\ns placed on hold.\\n Response:\\n Not tolerating feedings\\n Plan:\\n Con\\nt to administer bowel meds as ordered, reglan as ordered.\\n Hypernatremia (high sodium)\\n Assessment:\\n Na+ elevated at 148\\n Action:\\n Receiving an additional 1L of D5W at 150cc/hr\\n Response:\\n F/U with am lab levels\\n Plan:\\n Con\\nt to monitor Na+ levels, Attempt free H2O bolus\\n this am.\\n Altered mental status (not Delirium)\\n Assessment:\\n Some agitation noted in the beginning of the shift. Settling down by\\n ~2100. At times attempting to mouth full conversations, but since pt\\n has so many secretions, PMV was not placed. She is confused, asking\\n for the phone, requiring frequent re-orientation, 1:1 sitter at\\n bedside, soft wrist restraints intact.\\n Action:\\n Re-orient as appropriate\\n Response:\\n Remains confused, requiring sitters for safety.\\n Plan:\\n Assess MS\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-20 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 638568,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n CARDIOVERSION/DEFIBRILLATION - At 11:50 AM\\n aqdenosine 6mg given X 1 by cardiologist to assess pt's rhythm. Pt\\n tolerated well.\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:24 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:45 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.6\\nC (97.8\\n Tcurrent: 36\\nC (96.8\\n HR: 114 (85 - 144) bpm\\n BP: 111/59(69) {84/42(0) - 154/134(138)} mmHg\\n RR: 12 (12 - 36) insp/min\\n SpO2: 100%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 1,945 mL\\n 274 mL\\n PO:\\n TF:\\n IVF:\\n 1,800 mL\\n 154 mL\\n Blood products:\\n Total out:\\n 2,300 mL\\n 500 mL\\n Urine:\\n 2,245 mL\\n 500 mL\\n NG:\\n 55 mL\\n Stool:\\n Drains:\\n Balance:\\n -355 mL\\n -226 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: MMV/PSV/AutoFlow\\n Vt (Set): 500 (500 - 500) mL\\n Vt (Spontaneous): 319 (319 - 319) mL\\n PS : 10 cmH2O\\n RR (Set): 12\\n RR (Spontaneous): 15\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n RSBI Deferred: No Spon Resp\\n PIP: 15 cmH2O\\n SpO2: 100%\\n ABG: ///36/\\n Ve: 5.5 L/min\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 548 K/uL\\n 10.0 g/dL\\n 128 mg/dL\\n 0.8 mg/dL\\n 36 mEq/L\\n 4.1 mEq/L\\n 6 mg/dL\\n 105 mEq/L\\n 148 mEq/L\\n 32.7 %\\n 7.6 K/uL\\n [image002.jpg]\\n 05:00 AM\\n 02:06 AM\\n 07:34 AM\\n 03:50 AM\\n 06:22 AM\\n 02:58 AM\\n 03:43 AM\\n 05:02 PM\\n 03:36 AM\\n 02:30 AM\\n WBC\\n 5.9\\n 7.5\\n 5.6\\n 6.1\\n 7.0\\n 7.1\\n 7.1\\n 6.9\\n 7.6\\n Hct\\n 27.2\\n 26.8\\n 27.0\\n 27.0\\n 29.7\\n 28.9\\n 29.2\\n 27.8\\n 32.7\\n Plt\\n 296\\n 306\\n 335\\n \\n 452\\n 467\\n 548\\n Cr\\n 0.7\\n 0.6\\n 0.5\\n 0.7\\n 0.7\\n 0.6\\n 0.7\\n 0.8\\n 0.7\\n 0.8\\n Glucose\\n 134\\n 134\\n 121\\n \\n 104\\n 108\\n 131\\n 128\\n Other labs: PT / PTT / INR:48.3/33.3/5.5, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:10.0 mg/dL, Mg++:2.5 mg/dL,\\n PO4:4.3 mg/dL\\n Assessment and Plan\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-20 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 638569,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n CARDIOVERSION/DEFIBRILLATION - At 11:50 AM\\n aqdenosine 6mg given X 1 by cardiologist to assess pt's rhythm. Pt\\n tolerated well.\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:24 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:45 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.6\\nC (97.8\\n Tcurrent: 36\\nC (96.8\\n HR: 114 (85 - 144) bpm\\n BP: 111/59(69) {84/42(0) - 154/134(138)} mmHg\\n RR: 12 (12 - 36) insp/min\\n SpO2: 100%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 1,945 mL\\n 274 mL\\n PO:\\n TF:\\n IVF:\\n 1,800 mL\\n 154 mL\\n Blood products:\\n Total out:\\n 2,300 mL\\n 500 mL\\n Urine:\\n 2,245 mL\\n 500 mL\\n NG:\\n 55 mL\\n Stool:\\n Drains:\\n Balance:\\n -355 mL\\n -226 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: MMV/PSV/AutoFlow\\n Vt (Set): 500 (500 - 500) mL\\n Vt (Spontaneous): 319 (319 - 319) mL\\n PS : 10 cmH2O\\n RR (Set): 12\\n RR (Spontaneous): 15\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n RSBI Deferred: No Spon Resp\\n PIP: 15 cmH2O\\n SpO2: 100%\\n ABG: ///36/\\n Ve: 5.5 L/min\\n Physical Examination\\n Gen: Obtunded this am, not responsive to voice, minimally responsive to\\n noxious stimuli, on MMV through trach tube\\n HEENT: PERRL, MMM,\\n Resp: Limited by patients mobility, but CTA anteriorly and laterally,\\n no rales, rhonchi, or wheezing, some referred upper airway noises from\\n secretions.\\n Card: S1S2 tachicardic, no m/r/g\\n Abd: Obese, soft, Non-distended, BS+\\n Exte: No edema, DP 2+, RP2+ bil.\\n NEURO: Toes downgoing bilaterally, patellar reflexs 2+ bil, biceps 2+\\n bil,\\n Labs / Radiology\\n 548 K/uL\\n 10.0 g/dL\\n 128 mg/dL\\n 0.8 mg/dL\\n 36 mEq/L\\n 4.1 mEq/L\\n 6 mg/dL\\n 105 mEq/L\\n 148 mEq/L\\n 32.7 %\\n 7.6 K/uL\\n [image002.jpg]\\n 05:00 AM\\n 02:06 AM\\n 07:34 AM\\n 03:50 AM\\n 06:22 AM\\n 02:58 AM\\n 03:43 AM\\n 05:02 PM\\n 03:36 AM\\n 02:30 AM\\n WBC\\n 5.9\\n 7.5\\n 5.6\\n 6.1\\n 7.0\\n 7.1\\n 7.1\\n 6.9\\n 7.6\\n Hct\\n 27.2\\n 26.8\\n 27.0\\n 27.0\\n 29.7\\n 28.9\\n 29.2\\n 27.8\\n 32.7\\n Plt\\n 296\\n 306\\n 335\\n \\n 452\\n 467\\n 548\\n Cr\\n 0.7\\n 0.6\\n 0.5\\n 0.7\\n 0.7\\n 0.6\\n 0.7\\n 0.8\\n 0.7\\n 0.8\\n Glucose\\n 134\\n 134\\n 121\\n \\n 104\\n 108\\n 131\\n 128\\n Other labs: PT / PTT / INR:48.3/33.3/5.5, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:10.0 mg/dL, Mg++:2.5 mg/dL,\\n PO4:4.3 mg/dL\\n Assessment and Plan\\n 55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\\n trach, PEG, placement no with respiratory failure secondary to\\n tracheomalacia , resolving HAP.\\n .\\n # Respiratory failure: Slowly Improving. Now remaining on trach mask\\n for most of the day and night, with periods of pressure support of \\n over night. Last night required MMV and was not breathing well while\\n asleep, likely oversedated with Benadryl, Morhpine, and Valium\\n administered in the early morning. Pt awake and alert at rounds,\\n interactive, and breathing comfortably on trach mask\\n - Continue to increase time on trach mask as tolerated.\\n - Decrease sedation and valium use see Sedation below\\n - PMV with suctioning again today.\\n .\\n # HAP vs Aspiration PNA: Afebrile without leukocytosis\\n - Completed course of ceftriaxone\\n - good O2 saturation on trach mask\\n - Continue to f/u cultures\\n .\\n # Tachycardia: Previously was assessed as sinus tach with occasional\\n runs of SVT and sources such as hypovolemia, PE, infection, and pain\\n were assessed as possibly etiologies. But, now appears to be SVT for\\n much of time, rhythm/rate nonresponsive to carotid massage. HR\\n occaisonaly decreases to 70s-80s w/ stable BPs at times that might be\\n associated with administration of her BB and valium. Rhythm strip shows\\n conversion from a narrow complex SVT to normal sinus rhythm and then\\n back. Metroprolol was increased from 25mg TID to QID yesterday, without\\n any affect on the SVT.\\n - EP consulted for conversion of SVT, appreciate recs\\n .\\n # Sedation: Inconsistent response to sedation, unclear what is best\\n regime. Will continue to wean overall.\\n - Continue w Olanzapine QHS\\n - D/d valium to 2.5 mg TID and leave just valium 2.5 mg PRN.\\n # Nutrition: Pt has had several episodes of vomiting up her TFs,\\n reglan started to increase GI motility, but pt had another episode of\\n vomiting last night.\\n - Hold TFs\\n - Thoracic surgery recs: 1) oral/nasal tube in post-piloric position,\\n or 2) IR to place a pediatric feeding tube through her PEG site to a\\n post-piloric position.\\n - Will attempt to coordinate thoracic surgery and IR for tube placement\\n tomorrow.\\n .\\n # Adrenal Insufficency: Endocrine following. Pt does not appear to be\\n adrenally insufficient at baseline. Suggesting if the patient under\\n goes major stressors such as major surgery, sepsis, she may need stress\\n dosed steroids.\\n .\\n # Fluid Status: Likely approaching euvolemia, though still has mild\\n hypernatramia which may suggest is still intravascularly depleated.\\n - Monitoring urine output\\n - FW flushes w/ tube feeds held due to vomitting\\n - will provide D5W IVF as need for hypernatremia and follow lytes\\n .\\n # UE DVT and elevated INR: DVT in right UE has resolved, new\\n non-occlusive in left axillary vein. INR supratherapeutic today\\n - COumadin held, will restart at low dose when INR approaches\\n therapeutic range.\\n - INR 4.2 today, will check PM coags and consider restarting at a low\\n dose tonight or tomorrow morning.\\n .\\n # Spine fracture: Stable\\n - Brace for OOB, will discuss with Neurosurgery if current brace is\\n optimal for stabilization given her mobility.\\n - Pt to follow up with Dr. in weeks\\n .\\n # Tracheomalacia. Was initially addressed with IP and they wanted to\\n follow up as outpatient. IP reevaluated and does not believe that a\\n stent would be feasible.\\n .\\n #. Thyroid Nodule on CT\\n - Outpatient follow up\\n .\\n # Glycemic control: SSI, well controlled\\n # PIV x 1\\n # Ppx: Coumadin, Ranitidine, Bowel Regimen PRN\\n # Communication:\\n - Boyfriend of 10 \\n - Brother also involved\\n - Will contact Social and Case management today\\n # Code: Full\\n # Dispo: ICU, Screening for vent facilities\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2167-10-22 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 638899,\n \"text\": \"Demographics\\n Day of mechanical ventilation: 34\\n Ideal body weight: 61.2 None\\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\\n Airway\\n Tracheostomy tube:\\n Type: Standard\\n Manufacturer: Portex\\n Size: 7.0mm\\n Cuff Management:\\n Cuff pressure: 23 cmH2O\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Diminished\\n Comments:\\n Secretions\\n Sputum color / consistency: Brown / Thick\\n Sputum source/amount: Suctioned / Moderate\\n Ventilation Assessment\\n Level of breathing assistance:\\n Visual assessment of breathing pattern: Normal quiet breathing;\\n Comments: Pt tolerated t/c all day and then placed on psv 5/5/50% to\\n rest noc. RSBI=67. Will continue with t/c trials in am\\n Assessment of breathing comfort: comfortable\\n Invasive ventilation assessment:\\n Trigger work assessment:\\n Dysynchrony assessment: none\\n :\\n Plan\\n Next 24-48 hours: continue with t/c trials\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-26 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 639504,\n \"text\": \"TITLE:\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Rec\\nd pt on TM @ 70% with O2 sat mid 90\\ns-100%. Requiring tracheal\\n sxn\\ning approx Q1hr for mod-copious amts thick white tenacious\\n secretions. Pt with strong cough, but freq unable to clear secretions\\n herself. Lung snds rhonchorous in upper lobes, diminished in bases.\\n Action:\\n Freq sxn\\ning per above. Pt encouraged to C&DB. Pt in\\nchair\\n position\\n in bed with head @ 45-90degree angle.\\n Response:\\n Pt cont to have lg amt secretions requiring assist to clear.\\n Plan:\\n Cont aggressive pulm toilet.\\n Arousal, Attention, and Cognition, Impaired\\n Assessment:\\n Pt has been awake and alert . Pt chatty, but difficult to read her lips\\n and she has trouble writing clearly.\\n Action:\\n Emotional support provided, Pt was able to yes as to feeling cold\\n & nodded yes for warm blanket & was comfortable after she had the warm\\n blanket.\\n Response:\\n Pt slept for couple of hours , until awakened for care & assessment.\\n Plan:\\n Speech/swallow consult needed re valve, ? if it is damaged. Cont\\n Risperidone. Cont soft wrist restraints and sitter @ bedside for pt\\n safety.\\n Alteration in Nutrition\\n Assessment:\\n Abd soft/obese with + BS. On J-tube feeds in upright position.\\n Action:\\n Pt on colace and senna, held the night dose as pt had 2 BM\\ns during the\\n day.\\n Response:\\n Pt with lg loose yellow BM in am. TF started in afternoon @ 10ml/hr as\\n well as 50ml water Q4hrs, with HOB @ 45-90degree angle. Tolerated well.\\n Plan:\\n Cont to gently advance TF per order. Strict aspiration orders, with pt\\n rec\\ning TF ONLY when in sitting position.\\n Hypernatremia (high sodium)\\n Assessment:\\n Na 147 in pm labs.\\n Action:\\n Continued on D5 W@ 100 mls/hr for 1000 mls.\\n Response:\\n AM labs pending.\\n Plan:\\n Follow up on am labs.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-26 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 639615,\n \"text\": \"56 yr old woman, who was transferred from osh for evaluation of\\n tracheal bronchial malacia on .Pt presented to Medical\\n Center on s/p fall down a flight of stairs fracturing, t5-t8 with\\n propulsion treated conservatively with pain meds and back brace. She\\n developed resp distress requiring intubation on . Trach/PEG done\\n . Now with prolonged hospital course c/b by PNA, anxiety/altered\\n mental status, R&LUE DVT .Pt found to have small non occlusive clot on\\n her right axial vein via Ultrasound, now rec\\ning Lovenox. She has had\\n problems with vomiting tube feedings, so feeding tube passed through\\n g-tube to her jejunenum. However, she continues to intermit raise\\n gastric contents assoc with bronchospasm. Has not required ventilation\\n since , on humidified TM @ 50%. Has required 1:1 sitters since\\n decanulating herself, twice, despite restraints.\\n Airway Clearance, Impaired\\n Assessment:\\n Rec\\nd pt on humidified TM @ 70% with O2 sat 97-100%. RR 22-31 and\\n regular. Lung snds rhonchorous in upper lobes, clearing with sxn\\ning.\\n Lower lobe snds diminished bilat.\\n Action:\\n FiO2 \\nd to 50%. Pt requiring tracheal sxn\\ning Q30-60mins, producing\\n mod-copious amts thick white tenacious secretions. Pt generally unable\\n to fully raise and expectorate secretions.\\n Response:\\n O2 sat has remained 99-100%, but drops to high 80\\ns when requires\\n sxn\\ning.\\n Plan:\\n Cont to encourage pt to deep breathe and cough. Cont aggressive pulm\\n toilet.\\n Alteration in Nutrition\\n Assessment:\\n Per noc shift nurse, TF off overnight as pt too restless to maintain in\\n upright position per strict aspiration precautions. BS +, abd\\n soft/obese.\\n Action:\\n Pt placed on chair position in bed and TF restarted @ 0830 @\\n 10ml/hr+50ml free water Q4hrs. She rec\\nd her scheduled doses Reglan\\n 20mg and colace, senna.\\n Response:\\n Pt tolerated TF well (but unable to check residuals), so TF inc\\nd to\\n 20ml/hr @ 1230. Small loose yellow BM today X1.\\n Plan:\\n Cont strict aspiration prec, holding TF when pt not in upright position\\n and turning TF off for 15mins before turning.\\n Arousal, Attention, and Cognition, Impaired\\n Assessment:\\n Pt rec\\nd very restless in bed, attempting to exit despite bilat soft\\n wrist restraints and sitter @ bedside. When PMV in place pt\\n disoriented X 2, and reported she had been in a hotel and could pay\\n $3000 cash to leave. When told she was in a hospital bed, she asked,\\nWhere\\ns the bed\\n, unconvinced that she was lying in bed.\\n Action:\\n Pt rec\\nd scheduled 0800 dose Resperadine. EKG taken.\\n Response:\\n Pt slept for 90mins until woken by team for am rounds. She has appeared\\n sleepy since but resistant to falling asleep. Intermit attempting to\\n exit bed. QT interval WNL.\\n Plan:\\n Psych to consult and eval pt/meds.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-27 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 639684,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n -hypernatremia: Repeat Na 148-->146 (this am), continuing D5W at\\n 125cc/hr\\n -TF up to 30cc/hr; tolerated O/N\\n -Per psych recs: Gave risperidone m-tab 1mg PO x1 HS and will continue\\n risperdone 0.5mg qam and 0.5 PRN; gave scopolamine patch q72hrs;\\n f/u EKG in am\\n -Changed Metoprolol 25 to 37.5mg TID; gave 5mg x1\\n -GI recs: pending\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:30 AM\\n Enoxaparin (Lovenox) - 06:48 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:54 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.7\\nC (98.1\\n Tcurrent: 36.7\\nC (98.1\\n HR: 79 (68 - 124) bpm\\n BP: 134/57(75) {124/52(70) - 179/121(130)} mmHg\\n RR: 27 (18 - 31) insp/min\\n SpO2: 99%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 4,004 mL\\n 1,084 mL\\n PO:\\n TF:\\n 137 mL\\n 51 mL\\n IVF:\\n 2,544 mL\\n 729 mL\\n Blood products:\\n Total out:\\n 3,813 mL\\n 1,000 mL\\n Urine:\\n 3,813 mL\\n 1,000 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 191 mL\\n 84 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask\\n SpO2: 99%\\n ABG: ///33/\\n Physical Examination\\n Gen: Awake, Mouthing words, More agitated compared to previous\\n mornings.\\n HEENT: EOMI, No pallor in conjunctiva, MMM\\n Resp: CTAB, no rales, rhonchi, or wheezing, good airway movement.\\n Card: S1S2 tachycardic, no m/r/g\\n Abd: Obese, soft, mildly distended, decreased bowel sounds,, G-Tube in\\n place with no erythema/induration\\n Exte: No edema, DP 2+ bil\\n NEURO: Gross Motor and Sensation in 4 extremities\\n Labs / Radiology\\n 231 K/uL\\n 7.7 g/dL\\n 145 mg/dL\\n 0.4 mg/dL\\n 33 mEq/L\\n 3.5 mEq/L\\n 11 mg/dL\\n 109 mEq/L\\n 146 mEq/L\\n 25.3 %\\n 5.7 K/uL\\n [image002.jpg]\\n 01:30 AM\\n 06:41 AM\\n 03:20 PM\\n 03:23 AM\\n 03:00 AM\\n 04:00 AM\\n 05:45 AM\\n 03:51 AM\\n 04:45 PM\\n 04:00 AM\\n WBC\\n 9.5\\n 5.7\\n 7.3\\n 8.0\\n 8.7\\n 5.5\\n 5.7\\n Hct\\n 28.6\\n 28.9\\n 30.0\\n 26.9\\n 27.3\\n 27.0\\n 28.7\\n 24.7\\n 25.2\\n 25.3\\n Plt\\n 528\\n 356\\n 346\\n \\n 231\\n Cr\\n 1.0\\n 0.7\\n 0.7\\n 0.7\\n 0.7\\n 0.5\\n 0.4\\n Glucose\\n 121\\n 129\\n 123\\n 114\\n 112\\n 122\\n 145\\n Other labs: PT / PTT / INR:13.6/31.1/1.2, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.6 mg/dL, Mg++:2.0 mg/dL, PO4:3.6\\n mg/dL\\n Assessment and Plan\\n 56yoF s/p mechanical fall and traumatic T spine fracture, now s/p\\n trach/PEG with resolving respiratory failure and HAP.\\n .\\n # Respiratory failure: s/p intubation/extubation, now on trach mask,\\n FiO2 50%. Tolerating well with good O2 sat. No further\\n self-decanulations overnight.\\n - Trach mask as tolerated.\\n - Holding sedation with exception of Risperidal 0.5mg PRN\\n - F/u CXR tomorrow\\n .\\n # Nutrition/Vomiting: Currently receiving TPN;. One large BM in past\\n 24 hrs to indicate potential improvement in ileus.\\n - Cont Reglan 20mg IV Q 8 hours; meds via G-J tube,\\n - Will obtain recommendations from Nutrition re TPN today\\n - TF as tolerated\\n - Speech and Swallow eval today for Passy Muir valve eval;\\n - PICC line in place with TPN given when pt not tolerating TF\\n - GI consult, will f/u recs\\n .\\n # Tachycardia: Improved HR max of 120\\ns versus 160s previously. Pt now\\n on PO Amiodarone 200 TID and PO metoprolol 25mg TID\\n - Continue current med regimen. Will continue amiodarone 200 TID for\\n three weeks and then switch to qday.\\n - Will need to schedule f/u in 4wks with Dr. upon d/c/transfer.\\n - f/u Cards recs\\n # Sedation/Anxiolysis/AlteredMS: Resolved O/N. Previous delirium and\\n agitation most likely secondary to long hospital course and multiple\\n psychotropic medications as well as hx of EtOH abuse. Risperdal given\\n O/N per Psych recs.\\n - started Risperdal 0.5mg PO BID PRN.\\n - continue to hold all benzos. opiates, and antihistamines\\n - Appreciate psych. Will call and f/u psych recs.\\n #Anemia: HCT stable at 25. No known etiology of blood loss.\\n -Will repeat HCT in am .\\n # Hypernatremia/Fluid Status: Mild hypernatramia resolving with free\\n water administration. On TPN/TF. Good UOP.\\n - providing D5W IVF, free water flushes with TF\\n -Will f/u lytes in afternoon (5pm)\\n # UE DVT and elevated INR: Decision made to d/c Coumadin given her\\n labile INR, and start Lovenox .\\n - Will flush L PICC with TPA if does not flush\\n - Add coags to am labs\\n .\\n # Spine fracture: Stable\\n - Brace for OOB, need to discuss with Neurosurgery before d/c if\\n current brace is optimal for stabilization given her mobility.\\n - Pt to follow up with Dr. in weeks\\n .\\n # Tracheomalacia. Was initially addressed with IP and they wanted to\\n follow up as outpatient. IP reevaluated and does not believe that a\\n stent would be feasible. No new issues.\\n .\\n #. Thyroid Nodule on CT\\n - Outpatient follow up\\n .\\n # Glycemic control: SSI, well controlled\\n # ACCESS: PIV x 1, L PICC\\n # Ppx: Lovenox, PPi, Bowel Regimen PRN\\n # Communication:\\n - Boyfriend of 10 \\n - Brother also involved\\n - Social Work and Case management involved, have discussed situation\\n w/ brother and boyfriend.\\n # Code: Full\\n # Dispo: ICU, Will d/w case management re rehab facilities.\\n ICU Care\\n Nutrition:\\n TPN without Lipids - 05:44 PM 43. mL/hour\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n PICC Line - 01:30 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-27 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 639686,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n -hypernatremia: Repeat Na 148-->146 (this am), continuing D5W at\\n 125cc/hr\\n -TF up to 30cc/hr; tolerated O/N\\n -Per psych recs: Gave risperidone m-tab 1mg PO x1 HS and will continue\\n risperdone 0.5mg qam and 0.5 PRN; f/u EKG in am\\n -Changed Metoprolol 25 to 37.5mg TID; gave 5mg x1\\n -GI recs: pending\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:30 AM\\n Enoxaparin (Lovenox) - 06:48 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:54 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.7\\nC (98.1\\n Tcurrent: 36.7\\nC (98.1\\n HR: 79 (68 - 124) bpm\\n BP: 134/57(75) {124/52(70) - 179/121(130)} mmHg\\n RR: 27 (18 - 31) insp/min\\n SpO2: 99%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 4,004 mL\\n 1,084 mL\\n PO:\\n TF:\\n 137 mL\\n 51 mL\\n IVF:\\n 2,544 mL\\n 729 mL\\n Blood products:\\n Total out:\\n 3,813 mL\\n 1,000 mL\\n Urine:\\n 3,813 mL\\n 1,000 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 191 mL\\n 84 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask\\n SpO2: 99%\\n ABG: ///33/\\n Physical Examination\\n Gen: Awake, Mouthing words, More agitated compared to previous\\n mornings.\\n HEENT: EOMI, No pallor in conjunctiva, MMM\\n Resp: CTAB, no rales, rhonchi, or wheezing, good airway movement.\\n Card: S1S2 tachycardic, no m/r/g\\n Abd: Obese, soft, mildly distended, decreased bowel sounds,, G-Tube in\\n place with no erythema/induration\\n Exte: No edema, DP 2+ bil\\n NEURO: Gross Motor and Sensation in 4 extremities\\n Labs / Radiology\\n 231 K/uL\\n 7.7 g/dL\\n 145 mg/dL\\n 0.4 mg/dL\\n 33 mEq/L\\n 3.5 mEq/L\\n 11 mg/dL\\n 109 mEq/L\\n 146 mEq/L\\n 25.3 %\\n 5.7 K/uL\\n [image002.jpg]\\n 01:30 AM\\n 06:41 AM\\n 03:20 PM\\n 03:23 AM\\n 03:00 AM\\n 04:00 AM\\n 05:45 AM\\n 03:51 AM\\n 04:45 PM\\n 04:00 AM\\n WBC\\n 9.5\\n 5.7\\n 7.3\\n 8.0\\n 8.7\\n 5.5\\n 5.7\\n Hct\\n 28.6\\n 28.9\\n 30.0\\n 26.9\\n 27.3\\n 27.0\\n 28.7\\n 24.7\\n 25.2\\n 25.3\\n Plt\\n 528\\n 356\\n 346\\n \\n 231\\n Cr\\n 1.0\\n 0.7\\n 0.7\\n 0.7\\n 0.7\\n 0.5\\n 0.4\\n Glucose\\n 121\\n 129\\n 123\\n 114\\n 112\\n 122\\n 145\\n Other labs: PT / PTT / INR:13.6/31.1/1.2, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.6 mg/dL, Mg++:2.0 mg/dL, PO4:3.6\\n mg/dL\\n Assessment and Plan\\n 56yoF s/p mechanical fall and traumatic T spine fracture, now s/p\\n trach/PEG with resolving respiratory failure and HAP.\\n .\\n # Respiratory failure: s/p intubation/extubation, now on trach mask,\\n FiO2 50%. Tolerating well with good O2 sat. No further\\n self-decanulations overnight.\\n - Trach mask as tolerated.\\n - gave scopolamine patch q72hrs for secretions\\n - Holding sedation with exception of Risperidal 0.5mg PRN\\n - F/u CXR tomorrow\\n .\\n # Nutrition/Vomiting: Currently receiving TPN;. One large BM in past\\n 24 hrs to indicate potential improvement in ileus.\\n - Cont Reglan 20mg IV Q 8 hours; meds via G-J tube,\\n - Will obtain recommendations from Nutrition re TPN today\\n - TF as tolerated\\n - Speech and Swallow eval today for Passy Muir valve eval;\\n - PICC line in place with TPN given when pt not tolerating TF\\n - GI consult, will f/u recs\\n .\\n # Tachycardia: Improved HR max of 120\\ns versus 160s previously. Pt now\\n on PO Amiodarone 200 TID and PO metoprolol 25mg TID\\n - Continue current med regimen. Will continue amiodarone 200 TID for\\n three weeks and then switch to qday.\\n - Will need to schedule f/u in 4wks with Dr. upon d/c/transfer.\\n - f/u Cards recs\\n # Sedation/Anxiolysis/AlteredMS: Resolved O/N. Previous delirium and\\n agitation most likely secondary to long hospital course and multiple\\n psychotropic medications as well as hx of EtOH abuse. Risperdal given\\n O/N per Psych recs.\\n - started Risperdal 0.5mg PO BID PRN.\\n - continue to hold all benzos. opiates, and antihistamines\\n - Appreciate psych. Will call and f/u psych recs.\\n #Anemia: HCT stable at 25. No known etiology of blood loss.\\n -Will repeat HCT in am .\\n # Hypernatremia/Fluid Status: Mild hypernatramia resolving with free\\n water administration. On TPN/TF. Good UOP.\\n - providing D5W IVF, free water flushes with TF\\n -Will f/u lytes in afternoon (5pm)\\n # UE DVT and elevated INR: Decision made to d/c Coumadin given her\\n labile INR, and start Lovenox .\\n - Will flush L PICC with TPA if does not flush\\n - Add coags to am labs\\n .\\n # Spine fracture: Stable\\n - Brace for OOB, need to discuss with Neurosurgery before d/c if\\n current brace is optimal for stabilization given her mobility.\\n - Pt to follow up with Dr. in weeks\\n .\\n # Tracheomalacia. Was initially addressed with IP and they wanted to\\n follow up as outpatient. IP reevaluated and does not believe that a\\n stent would be feasible. No new issues.\\n .\\n #. Thyroid Nodule on CT\\n - Outpatient follow up\\n .\\n # Glycemic control: SSI, well controlled\\n # ACCESS: PIV x 1, L PICC\\n # Ppx: Lovenox, PPi, Bowel Regimen PRN\\n # Communication:\\n - Boyfriend of 10 \\n - Brother also involved\\n - Social Work and Case management involved, have discussed situation\\n w/ brother and boyfriend.\\n # Code: Full\\n # Dispo: ICU, Will d/w case management re rehab facilities.\\n ICU Care\\n Nutrition:\\n TPN without Lipids - 05:44 PM 43. mL/hour\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n PICC Line - 01:30 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-20 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 638556,\n \"text\": \"55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\\n trach, PEG, placement no with respiratory failure secondary to\\n tracheomalacia , resolving HAP.\\n Arousal, Attention, and Cognition, Impaired\\n Assessment:\\n Alert, mouthing words but very difficult to understand. Follows\\n commands. MAE on bed, attempting to get up. Restless last evening, did\\n eventually fall off to sleep this AM.\\n Action:\\n Zyprexa x 1 . Frequent re-orientation to place, situation. Soft wrist\\n restraints for patient safety.\\n Response:\\n Pt did eventually fall asleep. Re-orientation does have calming effect\\n however it is short term.\\n Plan:\\n No valium or benadryl per psych as this exacerbates delirium. Zyprexa\\n for agitation. pt prn.\\n Hypernatremia (high sodium)\\n Assessment:\\n Na 145 last night, 148 this AM.\\n Action:\\n D5W x 500cc @ 125/hr\\n Response:\\n Not known yet, will need to recheck Na later today.\\n Plan:\\n Follow lytes.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Trach collar @ 50% O2 overnight until 4AM, Sats 90-97%. RR 17-20s.\\n Around 4AM RR in low 30s, sats low 90s while sleeping--? Fatiguing.\\n Strong cough, able to cough thick white ->tan secretions out of trach.\\n Occ suctioned for same. Lungs are rhonchorous throughout. Impaired gag.\\n Action:\\n Suctioned prn for copious secretions. MDIs. Placed back on vent @ 4AM\\n d/t fatigue.\\n Response:\\n Tolerated trach collar most of night, back on vent this AM d/t fatigue\\n with RR in teens, Sats 98-100%.\\n Plan:\\n Wean from vent as tolerated. MDIs, suction as needed.\\n Alteration in Nutrition\\n Assessment:\\n Tube feeds off overnight d/t constant vomiting. No vomiting overnight.\\n Action:\\n NPO. Reglan q 6 hrs.\\n Response:\\n No vomiting. Small brown stool x 1.\\n Plan:\\n NPO. ? may go to IR today to change Gtube to Jtube. Reglan. Meds via\\n Gtube.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-20 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 638648,\n \"text\": \"Tachycardia, Other\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Alteration in Nutrition\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Altered mental status (not Delirium)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-22 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 638896,\n \"text\": \"Nausea / vomiting\\n Assessment:\\n Tube feeds started Promote\\n @ 10cc/hr. via new jtube. Pt vomited ~ 1\\n hr after TF started ->>coffee grounds, TF, H2O(flush). Also\\n expectorating same from trach.\\n Action:\\n Tube feeds stopped. Zofran 4 mg.\\n Response:\\n No further vomiting, although pt coughing with copious thick tan\\n secretions after vomiting episode.\\n Plan:\\n NPO. Meds given IV for now. Pt to have tube study today.\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt very agitated attempting to get OOB, legs through side rails.\\n Mouthing words but difficlt to understand.\\n Action:\\n Frequent re-orientation. Zyprexa 5 mg x 2. MSO4 2 mg. Valium 2.5 mg.\\n Response:\\n 1^st dose Zyprexa seemed to have transient calming effect but then pt\\n agitated again, 2^nd dose with no effect. Valium with very good effect,\\n pt is sleeping but arouseable to voice.\\n Plan:\\n Zyprexa @ hs (usually effective). Valium 2.5 IV prn, please use\\n sparingly d/t ongoing delerium. Re-orientation, emotional support.\\n Hypernatremia (high sodium)\\n Assessment:\\n Na 148 last evening.\\n Action:\\n D5W c 40 KCL @ 100/hr x 1 liter. Repeat labs sent this AM.\\n Response:\\n AM Na 148\\n Plan:\\n Continue to monitor lytes. Free H2O.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Coughing frequently with copious thick tan/brown secretions after\\n vomiting. Asking to be suctioned, also coughing secretions to end of\\n trach.\\n Action:\\n Frequent suctioning. Placed on CPAP 5/5 this AM to rest.\\n Response:\\n RR 22 on vent when sedated. Sats 100%\\n Plan:\\n Wean from vent as tolerated. Pulmonary hygiene.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-19 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 638502,\n \"text\": \"56yo woman admitted 1 month ago with unstentable tracheal malacia,\\n failure to wean.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Rec\\nd pt on MMV settings, no spont resp. Pt unarousable per below until\\n 0830 when she woke and was placed on TM with high flow neb@ 50%. RR\\n 16-25 and regular, with O2 sat 96-99%. Afebrile.Very bronchospastic\\n upon awakening, vomiting mod amt clear/thick X 1 after cuff let down to\\n try PMV. Lung snds rhonchorous in upper lobes, diminished in bases. Pt\\n with congested/productive cough of mod-copious amts thick white\\n secretions.\\n Action:\\n Pt encouraged to freq C&DB. Suctionned PRN for mod-copious amts thick\\n white secretions which pt was unable to fully raise.\\n Response:\\n Pt cont to intermit require ET sxn\\ning. She remains on TM @ this time,\\n denies SOB.\\n Plan:\\n Cont TM, but may return to vent support overnight if again becomes\\n somulent with apneic periods.\\n Tachycardia, Other\\n Assessment:\\n Rec\\nd pt unresponsive to pain in am with HR 80\\ns SR. However, when\\n woken HR returned to 130\\ns without VEA. BP 92/46-151/78.\\n Action:\\n At 1140 cardiologists used Adenosine 6mg to eval her heart rhythm,\\n which appeared to be AT per attending.\\n Response:\\n Pt\\ns rate slowed to 80\\ns but without extended pause, and pt responsive\\n throughout administration of Adenosine.\\n Plan:\\n Lopressor inc\\nd to 37.5mg Q6hrs.\\n Arousal, Attention, and Cognition, Impaired\\n Assessment:\\n Rec\\nd pt very difficult to rouse after rec\\ning Benadryl, Morphine,\\n Zyprexa, and Valium overnight. Pt woke @ 0830 and instantly alert and\\n restless. Pt has required presence of nurse most of shift to keep her\\n safe, despite bilat soft wrist restraints and waist restraint. Pt\\n putting legs over/between siderail. Pt not cooperative with\\n redirecting. However, she is mouthing words more approp: requesting\\n bedpan for BM, that she is afraid she is dying, and wants to go home.\\n She did appear to have visual hallucinations, asking who the man\\n outside the window was, and smiling @ blank wall.\\n Action:\\n Restraints and bedside sitter when available from MICU staff. Pt\\n constantly reoriented. Psych nurse consulted and eval done.\\n Response:\\n Psych nurse recommended D/C\\ning Valium and Benadryl as they may\\n aggravate her delirium.\\n Plan:\\n Sitter may be available if pt cont to put self @ risk. Zyprexa @ HS.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-22 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 638998,\n \"text\": \"Chief Complaint: resp failure\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 24 Hour Events:\\n increased bblocker\\n J tube placed by IR through PEG- restarted TF and vomiting\\n Went for tube study - dysmotility - contrast sat in stomach\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Diazepam (Valium) - 02:24 AM\\n Other medications:\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 12:17 PM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.7\\nC (98.1\\n Tcurrent: 35.6\\nC (96.1\\n HR: 118 (93 - 140) bpm\\n BP: 153/58(79) {82/39(49) - 153/101(105)} mmHg\\n RR: 23 (14 - 37) insp/min\\n SpO2: 99%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 3,808 mL\\n 1,119 mL\\n PO:\\n TF:\\n 4 mL\\n IVF:\\n 3,804 mL\\n 1,119 mL\\n Blood products:\\n Total out:\\n 1,650 mL\\n 520 mL\\n Urine:\\n 1,590 mL\\n 520 mL\\n NG:\\n 60 mL\\n Stool:\\n Drains:\\n Balance:\\n 2,158 mL\\n 599 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 243 (169 - 281) mL\\n PS : 5 cmH2O\\n RR (Spontaneous): 17\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n RSBI: 67\\n PIP: 11 cmH2O\\n SpO2: 99%\\n ABG: ///33/\\n Ve: 4.1 L/min\\n Physical Examination\\n Labs / Radiology\\n 8.2 g/dL\\n 356 K/uL\\n 129 mg/dL\\n 0.7 mg/dL\\n 33 mEq/L\\n 3.6 mEq/L\\n 4 mg/dL\\n 110 mEq/L\\n 148 mEq/L\\n 26.9 %\\n 5.7 K/uL\\n [image002.jpg]\\n 06:22 AM\\n 02:58 AM\\n 03:43 AM\\n 05:02 PM\\n 03:36 AM\\n 02:30 AM\\n 01:30 AM\\n 06:41 AM\\n 03:20 PM\\n 03:23 AM\\n WBC\\n 7.0\\n 7.1\\n 7.1\\n 6.9\\n 7.6\\n 9.5\\n 5.7\\n Hct\\n 29.7\\n 28.9\\n 29.2\\n 27.8\\n 32.7\\n 28.6\\n 28.9\\n 30.0\\n 26.9\\n Plt\\n 395\\n 462\\n 452\\n 467\\n 548\\n 528\\n 356\\n Cr\\n 0.7\\n 0.6\\n 0.7\\n 0.8\\n 0.7\\n 0.8\\n 1.0\\n 0.7\\n Glucose\\n 126\\n 137\\n 104\\n 108\\n 131\\n 128\\n 121\\n 129\\n Other labs: PT / PTT / INR:15.2/24.6/1.3, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.7 mg/dL, Mg++:2.1 mg/dL, PO4:4.1\\n mg/dL\\n Assessment and Plan\\n 1. Tachycardia: runs of attach Appreciate EP consult\\n will increase\\n bblocker. Have to convert to metoprolol 7.5mg IV Q4 because unable to\\n take pos.\\n 2. Persistent Nausea/Vomiting: we have ruled out\\n pSBO/SBO, very poor\\n bowel sounds, tube study this AM shows contrast not moving out of the\\n jejunum. get emptying study and if unrevealing consult GI to discuss\\n EGD. Place PICC for TPN as she has not had nurtrition.\\n 2. Resp Failure\\n Trach mask trials all day, PSV\\n PMV trials\\n Per IP not stent planned as technically not possible to\\n place into her airway\\n 3. DVT and coagulopathy: reversed with IV Vit k\\n hold coumadin today\\n 4. Hypernatremia Replete free water.\\n Please see today\\ns ICU team note for other issues.\\n ICU Care\\n Nutrition: plan for TPN\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n 18 Gauge - 04:00 AM\\n Prophylaxis:\\n DVT: plan for coumadin\\n Stress ulcer: ppi\\n Communication: spoke with son and\\n status: Full code\\n Disposition : ICU\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-24 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 639361,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Pt decannulated herself x2 yesterday, the 1st episode she desatted to\\n the 80s, the second episode she desated and her heart rate decreased to\\n 39-40, before the trach could be replaced.\\n PICC line placed by IR, called to notify that there was clot in both\\n arms, placed in L arm more proximally than small Bacillis vein clot.\\n Coumadin restarted after PICC placement with 2mg\\n Per GI Recs: Reglan restarted at 20mg IV q 8 hours, and meds were\\n restarted via tube. No vomitting.\\n Per PSYCH recs: d/c'd all benzoes, (also requested d/c reglan if GI\\n ok), added Risperdal 0.5mg (and can add 0.5mg PRN, and titrate up\\n to total daily dose of 2-3mg if helping)\\n Per Cards recs: after 18hr of amiodaron drip. Start PO amiodarone 200mg\\n TID, which was done at 1am.\\n Brother visited\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:04 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.4\\nC (99.4\\n Tcurrent: 37.4\\nC (99.4\\n HR: 90 (73 - 121) bpm\\n BP: 155/49(75) {103/47(66) - 175/98(111)} mmHg\\n RR: 32 (14 - 32) insp/min\\n SpO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 2,151 mL\\n 293 mL\\n PO:\\n TF:\\n IVF:\\n 1,852 mL\\n 13 mL\\n Blood products:\\n Total out:\\n 2,460 mL\\n 820 mL\\n Urine:\\n 2,460 mL\\n 820 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -309 mL\\n -527 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask\\n Ventilator mode: Standby\\n Vt (Set): 0 (0 - 0) mL\\n Vt (Spontaneous): 360 (360 - 360) mL\\n PS : 10 cmH2O\\n RR (Set): 0\\n RR (Spontaneous): 21\\n FiO2: 40%\\n SpO2: 98%\\n ABG: ///33/\\n Physical Examination\\n Gen: Asleep, unarousable, responds minimally to noxious stimuli\\n HEENT: PERRL, MMM\\n Resp: CTA bilaterally, no rales, rhonchi, or wheezing, small\\n inspirations.\\n Card: S1S2 tachycardic, no m/r/g\\n Abd: Obese, soft, mildly distended, BS+\\n Exte: No edema, DP 2+ bil\\n NEURO: reflexes 2+ bilaterally.\\n Labs / Radiology\\n 316 K/uL\\n 8.3 g/dL\\n 114 mg/dL\\n 0.7 mg/dL\\n 33 mEq/L\\n 4.0 mEq/L\\n 7 mg/dL\\n 111 mEq/L\\n 149 mEq/L\\n 27.0 %\\n 8.0 K/uL\\n [image002.jpg]\\n 03:43 AM\\n 05:02 PM\\n 03:36 AM\\n 02:30 AM\\n 01:30 AM\\n 06:41 AM\\n 03:20 PM\\n 03:23 AM\\n 03:00 AM\\n 04:00 AM\\n WBC\\n 7.1\\n 6.9\\n 7.6\\n 9.5\\n 5.7\\n 7.3\\n 8.0\\n Hct\\n 29.2\\n 27.8\\n 32.7\\n 28.6\\n 28.9\\n 30.0\\n 26.9\\n 27.3\\n 27.0\\n Plt\\n 452\\n 467\\n 548\\n 528\\n 356\\n 346\\n 316\\n Cr\\n 0.7\\n 0.8\\n 0.7\\n 0.8\\n 1.0\\n 0.7\\n 0.7\\n 0.7\\n Glucose\\n 104\\n 108\\n 131\\n 128\\n 121\\n 129\\n 123\\n 114\\n Other labs: PT / PTT / INR:13.2/22.4/1.1, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:9.0 mg/dL, Mg++:2.3 mg/dL, PO4:4.1\\n mg/dL\\n Assessment and Plan\\n 55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\\n trach, PEG placement now with respiratory failure secondary to\\n tracheomalacia , resolved HAP.\\n .\\n # Respiratory failure: Slowly improving, spending most of the day on\\n trach mask with short periods of rest on PSV at night and setbacks\\n from increased secretions to vomiting/aspiration events and her\\n self-decanulations.\\n - Continue to increase time on trach mask as tolerated.\\n - Discontinue all orders for sedation except for Risperdal QHS.\\n - PMV with suctioning as tolerated\\n # Nutrition/Vomiting: Normal CT-abdomen, had FT placed via peg into\\n jejunum, but continued to vomit. Tube study showed dysmotility in small\\n bowel, but no obstruction, no retrograde flow. GI recs Reglan 20mg IV Q\\n 8 hours and restart meds via G-J tube, if tolerated slowly restart TFs.\\n PICC line placed yesterday and TPN started.\\n - GI consult, appreciate recs\\n - Small volume TFs start today\\n - Continue TPN today\\n # HAP vs Aspiration PNA: Had been afebrile for last several days, now\\n with new fever two nights ago after having decanulated herself. Likely\\n had some aspiration. Chemical pneumonitis versus new aspiration PNA.\\n Now Afebrile for past 24 hours.\\n - f/u daily CXR\\n - F/u cx data\\n - If remains febrile, send sputum cx, otherwise hold on abx.\\n .\\n # Tachycardia: Pt in and out of SVT and sinus, increased BB seems to\\n help, but pt does not stay in sinus. Cards rec to start Amiodarone IV\\n drip, and then convert to PO, 200mg TID. Would consider EPS if\\n amiodarone not successful, though would wait until pt more stable for\\n general anesthesia.\\n - Changed to IV metoprolol to 10mg IV q4hr.\\n - Completed amiodarone 0.5mg/min IV drip x 18 hours, and converted to\\n 200mg PO TID..\\n - Cards c/s, appreciate recs\\n # Sedation/Anxiolysis/AlteredMS: unclear etiology of her confusion and\\n agitation. Has had long hospital course and multiple psychotropic\\n medications as well as hx of EtOH abuse.\\n - d/c all benzos. opiates, and antihistamines\\n - Psychiatry consulted, appreciate recs\\n - started Risperdal 0.5mg PO BID, d/c zyprexa.\\n # Adrenal Insufficency: Endocrine following. Pt does not appear to be\\n adrenally insufficient at baseline. Suggesting if the patient under\\n goes major stressors such as major surgery, sepsis, she may need stress\\n dosed steroids.\\n .\\n # Fluid Status: Likely approaching euvolemia, though still has mild\\n hypernatramia which may suggest is still intravascularly depleated.\\n - Monitoring urine output\\n - will provide D5W IVF as need for hypernatremia and follow lytes\\n # UE DVT and elevated INR: DVT in right UE has resolved, new\\n non-occlusive in left axillary vein. INR has been volatile, likely from\\n drug interactions and poor nutritional status. Have been unable to keep\\n her appropariately therapeutic.\\n - d/c coumadin\\n - start Lovenox, maintain until GI issues resolved and can restart\\n coumadin\\n .\\n #Hematemesis: Pt had small amt Hematemesis, after vomiting, last week.\\n None today. HCT stable.\\n -Will follow HCT.\\n - Guaiac stools\\n # Spine fracture: Stable\\n - Brace for OOB, will discuss with Neurosurgery if current brace is\\n optimal for stabilization given her mobility.\\n - Pt to follow up with Dr. in weeks\\n .\\n # Tracheomalacia. Was initially addressed with IP and they wanted to\\n follow up as outpatient. IP reevaluated and does not believe that a\\n stent would be feasible.\\n .\\n #. Thyroid Nodule on CT\\n - Outpatient follow up\\n .\\n # Glycemic control: SSI, well controlled\\n # ACCESS: PIV x 1, PICC placement\\n yesterday.\\n # Ppx: subtherapeutic INR restarting coumadin today, Ranitidine, Bowel\\n Regimen PRN\\n # Communication:\\n - Boyfriend of 10 \\n - Brother also involved\\n - Social Work and Case management involved, have discussed situation\\n w/ brother and boyfriend.\\n # Code: Full\\n # Dispo: ICU, Screening for vent facilities\\n ICU Care\\n Nutrition:\\n TPN without Lipids - 06:00 PM 41. mL/hour\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n PICC Line - 01:30 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n ------ Protected Section ------\\n MICU Attending Addendum:\\n On this day I examined the patient and was present for the key portions\\n of the services provided. I have reviewed Dr \\ns note above and I\\n agree with the findings and plan of care. I would only add/emphasize\\n the following: Ms has done well of late on a trache collar,\\n able to go all night without the vent. The active issues now are\\n chiefly GI, cardiac, and pychiatric. Her hypomotility may be a bit\\n better now that she is on high dose Reglan, and we will gingerly start\\n feedings via her J in G tube, while continuing TPN for the present. Her\\n SVT has for now converted to NSR on Amiodarone and Metoprolol. Her\\n delirium is being addressed with the help of psychiatry, and we\\n started Risperdal at their suggestion. Once these issues are stable\\n she should be able to move to a resp rehab facility.\\n , MD\\n 30 min spent in the care of this critically ill patient\\n ------ Protected Section Addendum Entered By: , MD\\n on: 16:43 ------\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-25 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 639502,\n \"text\": \"56 yr old woman, who was transferred from osh for evaluation of\\n tracheal bronchial malacia on .Pt presented to Medical\\n Center on s/p fall down a flight of stairs fracturing, t5-t8 with\\n propulsion treated conservatively with pain meds and back brace. She\\n developed resp distress requiring intubation on . Trach/PEG done\\n . Now with prolonged hospital course c/b by PNA, anxiety/altered\\n mental status, R&LUE DVT .Pt found to have small non occlusive Clot on\\n her right axial vein via Ultrasound. She has had problems with\\n vomiting tube feedings, so feeding tube passed through g-tube to her\\n jejunenum but she continues to vomit. Trach mask, has not required\\n ventilation since . Has also required 1:1 sitters since\\n decanulating herself twice, despite restraints. Overnight ,\\n restarted TF\\ns, however, infused for ~7 hrs, then began suctioning\\n bile-like fluid from trach after pt experienced a prolonged coughing\\n jag. TF\\ns placed on hold.\\n Tachycardia, Other\\n Assessment:\\n HR 67-118ST without VEA. BP 110/59-140/58. Pt rec\\ning lopressor 10mg IV\\n Q4hrs, as well as Amio via GT.\\n Action:\\n Lopressor changes to po TiD.\\n Response:\\n VSS.\\n Plan:\\n Cont present course of cardiac meds.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Rec\\nd pt on TM @ 70% with O2 sat 99-100%. Rare desat to 80\\ns related to\\n inc\\nd secretions. Requiring tracheal sxn\\ning approx Q1hr for\\n mod-copious amts thick white tenacious secretions. Pt with strong\\n cough, but freq unable to clear secretions herself. Lung snds\\n rhonchorous in upper lobes, diminished in bases.\\n Action:\\n Freq sxn\\ning per above. Pt encouraged to C&DB. Pt in\\nchair\\n position\\n in bed with head @ 45-90degree angle.\\n Response:\\n Pt cont to have lg amt secretions requiring assist to clear.\\n Plan:\\n Cont aggressive pulm toilet.\\n Arousal, Attention, and Cognition, Impaired\\n Assessment:\\n Pt very somulent in am, but has been awake and alert since approx 1100.\\n Pt chatty, but difficult to read her lips and she has trouble writing\\n clearly. Pt intermit very angry, with ? confusion re nurse\\ns identity.\\n Friend from visited () and pt recognized her.\\n Action:\\n Passy Muir Valve tried several times.\\n Response:\\n Pt not able to speak clearly with valve on. Also, D/T lg amt secretions\\n could not leave valve on for more than a few minutes.\\n Plan:\\n Speech/swallow consult needed re valve, ? if it is damaged. Cont\\n Risperidone. Cont soft wrist restraints and sitter @ bedside for pt\\n safety.\\n Alteration in Nutrition\\n Assessment:\\n Abd soft/obese with + BS. J tube clamped except for meds.\\n Action:\\n Pt rec\\ning reglan, as well as colace and senna. Miralx held in am.\\n Response:\\n Pt with lg loose yellow BM in am. TF started in afternoon @ 10ml/hr as\\n well as 50ml water Q4hrs, with HOB @ 45-90degree angle. Tolerated well.\\n Plan:\\n Cont to gently advance TF per order. Strict aspiration orders, with pt\\n rec\\ning TF ONLY when in sitting position.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-20 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 638549,\n \"text\": \"55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\\n trach, PEG, placement no with respiratory failure secondary to\\n tracheomalacia , resolving HAP.\\n Arousal, Attention, and Cognition, Impaired\\n Assessment:\\n Alert, mouthing words but very difficult to understand. Follows\\n commands. MAE on bed, attempting to get up. Restless last evening, did\\n eventually fall off to sleep this AM.\\n Action:\\n Zyprexa x 1 . Frequent re-orientation to place, situation. Soft wrist\\n restraints for patient safety.\\n Response:\\n Pt did eventually fall asleep. Re-orientation does have calming effect\\n however it is short term.\\n Plan:\\n No valium or benadryl per psych as this exacerbates delirium. Zyprexa\\n for agitation. pt prn.\\n Hypernatremia (high sodium)\\n Assessment:\\n Na 145 last night, 148 this AM.\\n Action:\\n Response:\\n Plan:\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Trach collar @ 50% O2 overnight until 4AM, Sats 90-97%. RR 17-20s.\\n Around 4AM RR in low 30s, sats low 90s while sleeping--? Fatiguing.\\n Strong cough, able to cough thick white ->tan secretions out of trach.\\n Occ suctioned for same. Lungs are rhonchorous throughout. Impaired gag.\\n Action:\\n Suctioned prn for copious secretions. MDIs. Placed back on vent @ 4AM\\n d/t fatigue.\\n Response:\\n Tolerated trach collar most of night, back on vent this AM d/t fatigue\\n with RR in teens, Sats 98%.\\n Plan:\\n Wean from vent as tolerated. MDIs, suction as needed.\\n Alteration in Nutrition\\n Assessment:\\n Tube feeds off overnight d/t constant vomiting. No vomiting overnight.\\n Action:\\n NPO. Reglan q 6 hrs.\\n Response:\\n No vomiting. Small brown stool x 1.\\n Plan:\\n NPO. ? may go to IR today to change Gtube to Jtube. Reglan. Meds via\\n Gtube.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-20 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 638643,\n \"text\": \"Chief Complaint: resp failure\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 24 Hour Events:\\n CARDIOVERSION/DEFIBRILLATION - At 11:50 AM\\n aqdenosine 6mg given X 1 by cardiologist to assess pt's rhythm. Pt\\n tolerated well.\\n Held Valium ansd Benedryl and has done well without\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 11:48 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.5\\nC (97.7\\n Tcurrent: 36.5\\nC (97.7\\n HR: 118 (76 - 144) bpm\\n BP: 131/72(85) {93/43(0) - 154/134(138)} mmHg\\n RR: 26 (12 - 36) insp/min\\n SpO2: 94%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 1,945 mL\\n 680 mL\\n PO:\\n TF:\\n IVF:\\n 1,800 mL\\n 560 mL\\n Blood products:\\n Total out:\\n 2,300 mL\\n 680 mL\\n Urine:\\n 2,245 mL\\n 680 mL\\n NG:\\n 55 mL\\n Stool:\\n Drains:\\n Balance:\\n -355 mL\\n 0 mL\\n Respiratory support\\n O2 Delivery Device: High flow neb, Tracheostomy tube\\n Ventilator mode: MMV/PSV/AutoFlow\\n Vt (Set): 500 (500 - 500) mL\\n Vt (Spontaneous): 319 (319 - 319) mL\\n PS : 10 cmH2O\\n RR (Set): 12\\n RR (Spontaneous): 15\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n RSBI Deferred: No Spon Resp\\n PIP: 15 cmH2O\\n SpO2: 94%\\n ABG: ///36/\\n Ve: 5.5 L/min\\n Physical Examination\\n Gen: lying in bed, alert, responding to questions\\n CV; tachy RR\\n Chest: bibasilar decreased BS, faint exo wheeze\\n Abd: soft NT\\n Ext: no edema:\\n Labs / Radiology\\n 10.0 g/dL\\n 548 K/uL\\n 128 mg/dL\\n 0.8 mg/dL\\n 36 mEq/L\\n 4.1 mEq/L\\n 6 mg/dL\\n 105 mEq/L\\n 148 mEq/L\\n 32.7 %\\n 7.6 K/uL\\n [image002.jpg]\\n 05:00 AM\\n 02:06 AM\\n 07:34 AM\\n 03:50 AM\\n 06:22 AM\\n 02:58 AM\\n 03:43 AM\\n 05:02 PM\\n 03:36 AM\\n 02:30 AM\\n WBC\\n 5.9\\n 7.5\\n 5.6\\n 6.1\\n 7.0\\n 7.1\\n 7.1\\n 6.9\\n 7.6\\n Hct\\n 27.2\\n 26.8\\n 27.0\\n 27.0\\n 29.7\\n 28.9\\n 29.2\\n 27.8\\n 32.7\\n Plt\\n 296\\n 306\\n 335\\n \\n 452\\n 467\\n 548\\n Cr\\n 0.7\\n 0.6\\n 0.5\\n 0.7\\n 0.7\\n 0.6\\n 0.7\\n 0.8\\n 0.7\\n 0.8\\n Glucose\\n 134\\n 134\\n 121\\n \\n 104\\n 108\\n 131\\n 128\\n Other labs: PT / PTT / INR:48.3/33.3/5.5, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:10.0 mg/dL, Mg++:2.5 mg/dL,\\n PO4:4.3 mg/dL\\n Assessment and Plan\\n 1. Tachycardia: runs of attach Appreciate EP consult\\n will increase\\n bblocker. If fails may need EP study for further study and ? ablatable\\n focus.\\n 2. Persistent Nausea/Vomiting: very poor bowel sounds, get ABD ct to\\n look for SBO, talk with GI about EGD or tube study to look for more\\n proximal gastric outlet obstruction.\\n 2. Resp Failure\\n Trach mask trials all day, PSV\\n PMV trials\\n S/P rx for pan Klebs PNA.\\n Per IP not stent planned as technically not possible to\\n place into her airway\\n 3. DVT and coagulopathy: On warfarin but high inr. Hold warfarin until\\n inr 2-2.5 range or bridge with loveonx if may get procedures\\n 4. Hypernatremia Replete free water.\\n Please see today\\ns ICU team note for other issues.\\n ICU Care\\n Nutrition: NPO while sorting out gi obstruction issues\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n Prophylaxis:\\n DVT: coumadin\\n Stress ulcer: PPI\\n Communication: Comments:\\n Code status: Full code\\n Disposition :ICU\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-14 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 637600,\n \"text\": \"Tachycardia, Other\\n Assessment:\\n Hr has been in sinus tachycardia all day at 130-140\\ns, Hr noted to also\\n stay elevated in the 130\\ns while at rest also. SBP has been elevated\\n throughout the day at 150-170\\ns while awake and 120-130\\ns while at\\n rest. Pt also very restless.\\n Action:\\n No med to be given for tachycardia or BP MD. Pt given Morphine and\\n haldol for restlessness w/o effect. Pt also on valium ATC w/little\\n effect. CTA done to r/o pe as a source of tachycardia.\\n Response:\\n Results pending on CTA.\\n Plan:\\n Continue to evaluate HR and BP for need of treatment.\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Pt has a known DVT to RUE. Today pt had a US of LUE to R/O DVT as a\\n source of tachycardia.\\n Action:\\n After DVT found, IVF stopped.\\n Response:\\n Pt found to have a clot to Lt ax vein and MD notified.\\n Plan:\\n Pt to cont coumadin tonight, awaiting dosage for inr 1.4 . ? Access now\\n that Lt arm has a DVT.\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt has been restless most of the day. Pt only follow direct commands.\\n When asked to keep her hand off the TC, she will for only 3sec, and\\n then she will reach for it again.\\n Action:\\n Pt given valium, morphine and haldol prn.\\n Response:\\n Little effect noted from sedations.\\n Plan:\\n Continue to eval MS.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt placed on TC this am at 8am and was placed back on CPAP at 3pm after\\n pt became tachypnic and tachycardic (150\\ns). Pt has had a strong prod\\n cough with mod amounts of thick yellow secretions. LS coarse before sx\\n and CTA after sx. Pt found several times disconnecting herself from the\\n vent (even though she is in restraints), and she will desat to 80%\\n within seconds.\\n Action:\\n Cont pulm toilet as needed. Pt in need of freq oral care.\\n Response:\\n Plan:\\n Continue to wean pt off vent and place on TC once pt can tol it again.\\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\\n Assessment:\\n Temp 99.1 this am and now 99.5 .\\n Action:\\n Pt continues on IV ABx.\\n Response:\\n Awaiting effect from IV ABXs.\\n Plan:\\n Follow up cultures.\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2167-10-21 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 638813,\n \"text\": \"Demographics\\n Day of mechanical ventilation: 33\\n Ideal body weight: 61.2 None\\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: Yes\\n Tracheostomy tube:\\n Type: Standard, Cuffed, Inner Cannula\\n Manufacturer: Portex\\n Size: 8.0mm\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 25 cmH2O\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Rhonchi\\n LUL Lung Sounds: Rhonchi\\n LLL Lung Sounds: Diminished\\n Secretions\\n Sputum color / consistency: Yellow / Thick\\n Sputum source/amount: Suctioned / Scant\\n Ventilation Assessment\\n Level of breathing assistance: Intermittent invasive ventilation\\n Visual assessment of breathing pattern: Pt weaned to trach collar,\\n tolerating well.\\n Assessment of breathing comfort: No claim of dyspnea\\n Plan\\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\\n Comments: stay on trach collar as tolerated.\\n Reason for continuing current ventilatory support:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-21 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 638816,\n \"text\": \"Chief Complaint: resp failure\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 24 Hour Events:\\n rising INR to 10.5\\n small volume hemetemesis\\n abd CT\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:30 AM\\n Other medications:\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 09:44 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.9\\nC (98.4\\n Tcurrent: 36.9\\nC (98.4\\n HR: 114 (88 - 136) bpm\\n BP: 120/65(80) {80/40(49) - 149/88(92)} mmHg\\n RR: 11 (11 - 33) insp/min\\n SpO2: 100%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 2,241 mL\\n 1,802 mL\\n PO:\\n TF:\\n IVF:\\n 1,941 mL\\n 1,802 mL\\n Blood products:\\n Total out:\\n 1,860 mL\\n 260 mL\\n Urine:\\n 1,830 mL\\n 210 mL\\n NG:\\n 30 mL\\n 50 mL\\n Stool:\\n Drains:\\n Balance:\\n 381 mL\\n 1,542 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: CPAP/PSV\\n Vt (Set): 500 (500 - 500) mL\\n Vt (Spontaneous): 438 (300 - 1,054) mL\\n PS : 10 cmH2O\\n RR (Set): 12\\n RR (Spontaneous): 13\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n RSBI Deferred: No Spon Resp\\n PIP: 16 cmH2O\\n Plateau: 15 cmH2O\\n SpO2: 100%\\n ABG: ///35/\\n Ve: 5.4 L/min\\n Physical Examination\\n Gen: lying in bed, alert, responding to questions\\n CV; tachy RR\\n Chest: bibasilar decreased BS, faint exp wheeze\\n Abd: soft NT+BS\\n Ext: no edema\\n Labs / Radiology\\n 9.2 g/dL\\n 528 K/uL\\n 121 mg/dL\\n 1.0 mg/dL\\n 35 mEq/L\\n 3.4 mEq/L\\n 6 mg/dL\\n 103 mEq/L\\n 144 mEq/L\\n 28.9 %\\n 9.5 K/uL\\n [image002.jpg]\\n 07:34 AM\\n 03:50 AM\\n 06:22 AM\\n 02:58 AM\\n 03:43 AM\\n 05:02 PM\\n 03:36 AM\\n 02:30 AM\\n 01:30 AM\\n 06:41 AM\\n WBC\\n 5.6\\n 6.1\\n 7.0\\n 7.1\\n 7.1\\n 6.9\\n 7.6\\n 9.5\\n Hct\\n 27.0\\n 27.0\\n 29.7\\n 28.9\\n 29.2\\n 27.8\\n 32.7\\n 28.6\\n 28.9\\n Plt\\n 335\\n 321\\n 395\\n 462\\n 452\\n 467\\n 548\\n 528\\n Cr\\n 0.5\\n 0.7\\n 0.7\\n 0.6\\n 0.7\\n 0.8\\n 0.7\\n 0.8\\n 1.0\\n Glucose\\n 121\\n 619\\n 126\\n 137\\n 104\\n 108\\n 131\\n 128\\n 121\\n Other labs: PT / PTT / INR:82.1/35.9/10.5, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:9.7 mg/dL, Mg++:2.4 mg/dL, PO4:2.9\\n mg/dL\\n Assessment and Plan\\n 1. Tachycardia: runs of attach Appreciate EP consult\\n will increase\\n bblocker. Have to convert to metoprolol 5mg IV Q4 because unable to\\n take pos\\n 2. Persistent Nausea/Vomiting: we have ruled out\\n pSBO/SBO, very poor\\n bowel sounds, get emptying study and if unrevealing consult GI to\\n discuss EGD. We will need to pursue NG dophoff by IR if cannot snake\\n pedi tube into existing g tube. Was guiac + but in setting of high INR\\n HCT stable. Will will reverse inr.\\n 2. Resp Failure\\n Trach mask trials all day, PSV\\n PMV trials\\n Per IP not stent planned as technically not possible to\\n place into her airway\\n 3. DVT and coagulopathy: reverre with IV VIt K today, then maintain\\n daily SC Vit K until Inr less than 2\\n 4. Hypernatremia Replete free water.\\n Please see today\\ns ICU team note for other issues.\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n 18 Gauge - 04:00 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n Communication: with pt and spoke at length with brother who would like\\n to possibily become her guardian or power of atty to facilitate her\\n care and finances. Her partner is alos interested in guardianship.\\n We may need ot refer to legal for clarification.\\n Code status: Full code\\n Disposition : ICU\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-26 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 639604,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Pt agitated overnight given extra Risperidone 0.5 mg x 2 overnight.\\n (1.5mg total)\\n 1000 mL D5W for Hypernatremia\\n Changed B-Blocker from IV to PO, Metoprolol Tartrate 25 mg PO TID\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:17 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:47 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.8\\nC (98.2\\n Tcurrent: 36.7\\nC (98\\n HR: 120 (67 - 120) bpm\\n BP: 110/64(76) {109/47(60) - 141/115(118)} mmHg\\n RR: 26 (18 - 30) insp/min\\n SpO2: 100%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 3,820 mL\\n 856 mL\\n PO:\\n TF:\\n 117 mL\\n 20 mL\\n IVF:\\n 2,612 mL\\n 572 mL\\n Blood products:\\n Total out:\\n 2,460 mL\\n 1,180 mL\\n Urine:\\n 2,460 mL\\n 1,180 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,360 mL\\n -324 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask\\n SpO2: 100%\\n ABG: ///33/\\n Physical Examination\\n Gen: Awake, Mouthing words, More agitated compared to previous\\n mornings.\\n HEENT: EOMI, No pallor in conjunctiva, MMM\\n Resp: CTAB, no rales, rhonchi, or wheezing, good airway movement.\\n Card: S1S2 tachycardic, no m/r/g\\n Abd: Obese, soft, mildly distended, decreased bowel sounds,, G-Tube in\\n place with no erythema/induration\\n Exte: No edema, DP 2+ bil\\n NEURO: Gross Motor and Sensation in 4 extremities\\n Labs / Radiology\\n 249 K/uL\\n 8.0 g/dL\\n 122 mg/dL\\n 0.5 mg/dL\\n 33 mEq/L\\n 3.7 mEq/L\\n 13 mg/dL\\n 108 mEq/L\\n 146 mEq/L\\n 24.7 %\\n 5.5 K/uL\\n [image002.jpg] CXR: L Picc, trach tip at midline, bibasilar\\n opacities, low lung volumes, Bil pleural effusions.\\n 03:36 AM\\n 02:30 AM\\n 01:30 AM\\n 06:41 AM\\n 03:20 PM\\n 03:23 AM\\n 03:00 AM\\n 04:00 AM\\n 05:45 AM\\n 03:51 AM\\n WBC\\n 6.9\\n 7.6\\n 9.5\\n 5.7\\n 7.3\\n 8.0\\n 8.7\\n 5.5\\n Hct\\n 27.8\\n 32.7\\n 28.6\\n 28.9\\n 30.0\\n 26.9\\n 27.3\\n 27.0\\n 28.7\\n 24.7\\n Plt\\n 467\\n 548\\n 528\\n 356\\n 346\\n 316\\n 271\\n 249\\n Cr\\n 0.7\\n 0.8\\n 1.0\\n 0.7\\n 0.7\\n 0.7\\n 0.7\\n 0.5\\n Glucose\\n 131\\n 128\\n 121\\n 129\\n 123\\n 114\\n 112\\n 122\\n Other labs: PT / PTT / INR:13.6/31.1/1.2, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:9.0 mg/dL, Mg++:2.2 mg/dL, PO4:3.1\\n mg/dL\\n Assessment and Plan\\n 56yoF s/p mechanical fall and traumatic T spine fracture, now s/p\\n trach/PEG with resolving respiratory failure and HAP.\\n .\\n # Respiratory failure: s/p intubation/extubation, now on trach mask,\\n FiO2 70%. Tolerating well with good O2 sat. No further\\n self-decanulations overnight.\\n - Tach mask as tolerated.\\n - Holding sedation with exception of Risperidal 0.5mg .\\n - F/u CXR tomorrow\\n .\\n # Nutrition/Vomiting: Currently receiving TPN;. One large BM in past\\n 24 hrs to indicate potential improvement in ileus.\\n - Cont Reglan 20mg IV Q 8 hours; meds via G-J tube,\\n - Will obtain recommendations from Nutrition re TPN before starting TPN\\n tomorrow\\n - TF as tolerated\\n - Speech and Swallow eval\\n - PICC line in place with TPN given when pt not tolerating TF\\n - GI consult, appreciate recs\\n .\\n # Tachycardia: Improved HR max of 120\\ns versus 160s previously;\\n elevated this am secondary to agitation. Pt now on PO Amiodarone 200\\n TID and PO metoprolol 25mg TID\\n - Continue current med regimen. Will continue amiodarone 200 TID for\\n three weeks and then switch to qday.\\n - Will schedule f/u in 4wks with Dr. upon d/c/transfer.\\n - f/u Cards recs\\n # Sedation/Anxiolysis/AlteredMS: Agitation O/N, continues to be\\n agitated most likely secondary to long hospital course and multiple\\n psychotropic medications as well as hx of EtOH abuse. Risperdal given\\n O/N.\\n - started Risperdal 0.5mg PO BID\\n - continue to hold all benzos. opiates, and antihistamines\\n - Appreciate psych. Will call and f/u psych recs.\\n #Anemia: Decrease in HCT from 28\\n24; tachycardia. No known etiology of\\n blood loss, most likely related to variaton\\n -Will repeat HCT check this afternoon.\\n # Hypernatremia/Fluid Status: Mild hypernatramia with good UOP\\n (hypervolemic hypernatremia). On TPN/TF.\\n - providing D5W IVF, free water flushes with TF\\n -Will f/u lytes (Na) this afternoon at 5pm.\\n # UE DVT and elevated INR: Decision made to d/c Coumadin given her\\n labile INR, and start Lovenox . Current INR 1.2.\\n - Will flush L PICC with TPA if does not flush\\n .\\n # Spine fracture: Stable\\n - Brace for OOB, need to discuss with Neurosurgery before d/c if\\n current brace is optimal for stabilization given her mobility.\\n - Pt to follow up with Dr. in weeks\\n .\\n # Tracheomalacia. Was initially addressed with IP and they wanted to\\n follow up as outpatient. IP reevaluated and does not believe that a\\n stent would be feasible. No new issues.\\n .\\n #. Thyroid Nodule on CT\\n - Outpatient follow up\\n .\\n # Glycemic control: SSI, well controlled\\n # ACCESS: PIV x 1, L PICC\\n # Ppx: Lovenox, PPi, Bowel Regimen PRN\\n # Communication:\\n - Boyfriend of 10 \\n - Brother also involved\\n - Social Work and Case management involved, have discussed situation\\n w/ brother and boyfriend.\\n # Code: Full\\n # Dispo: ICU, Will d/w case management re rehab facilities.\\n PGY2 Addendum\\n Agree with excellent MS4 PN. Will touch base with psychiatry re:\\n sedating meds and EP re: atrial tachycardia. Will obtain EKG to\\n reassess QTc. Ordered for TPN. Giving d5W for hypernatremia. Re-consult\\n S/S for PMV re-fitting. transfer to LTAC.\\n \\n PGY2\\n ------ Protected Section ------\\n MICU Attending Addendum:\\n ------ Protected Section Addendum Entered By: , MD\\n on: 16:21 ------\\n MICU ATTENDING ADDENDUM:\\n On this day I examined the patient and was present for the key portions\\n of the services provided. I have reviewed the note above and agree with\\n the findings and plan of care. I would add the following:\\n Ms remains stable, on her trache mask, off the vent for 3 days.\\n Secretions improved and she is using the PMV to talk in short spells.\\n Her ileus seems better, with a good BM and good bowel sounds and no\\n clear cut emesis. So TFs will be restarted and advanced. She remains\\n on high dose raglan.\\n We will rediscuss her case with psychiatry as her mentation varies from\\n very alert to more somnolent and she is still confused.\\n All in all, however, she is close to being able to go to resp rehab\\n facility and we\\nll talk to case manager tomorrow.\\n , MD\\n ------ Protected Section Addendum Entered By: , MD\\n on: 17:10 ------\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2167-10-26 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 639607,\n \"text\": \"Demographics\\n Day of mechanical ventilation: 38\\n Ideal body weight: 61.2 None\\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: Yes\\n Tube Type\\n Tracheostomy tube:\\n Type: Cuffed, Perc Trach\\n Manufacturer: Portex\\n Size: 7.0mm\\n PMV: Yes\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 23 cmH2O\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Diminished\\n Secretions\\n Sputum color / consistency: White / Thick\\n Sputum source/amount: Suctioned / Moderate\\n Pt on 50% cool aerosol, SpO2 97-99%.\\n\"\n },\n {\n \"category\": \"Social Work\",\n \"chartdate\": \"2167-10-21 00:00:00.000\",\n \"description\": \"Social Work Progress Note\",\n \"row_id\": 638808,\n \"text\": \"Social Work:\\n Received phone message from pt\\ns brother, (c: ),\\n and called back to discuss his questions and concerns re pt\\ns prolonged\\n hospitalization. He is in on business at this time, but has\\n been calling regularly to speak with MICU team for updates. He\\ndefinitely\\n plans on coming into the hospital next Thursday and Friday\\n ( and ) and is also trying to come earlier on his way back\\n from , perhaps this weekend. He will call to inform MICU team\\n of whether this will be possible, and if it is, he hopes to be able to\\n meet with pt\\ns doctors at that time to discuss prognosis and plan of\\n care. He also raises questions re whether it makes sense to pursue\\n temporary guardianship for pt. SW discussed with MICU Attending, and\\n further assessment of pt\\ns medical condition and mental status is\\n needed before a clear recommendation can be made. Of note, brother\\n expresses his wish to become temporary guardian for pt, if necessary,\\n and he expresses some concern about the possibility of pt\\ns boyfriend\\n taking this role.\\n At this time, pt is unable to communicate clearly. SW met with her in\\n MICU, and she presents as sitting up in a chair, awake and alert.\\n While she is mouthing words, it is very difficult to discern what she\\n is trying to say. SW provided her with paper and pen, and she tried to\\n write with a loose grip, but her words are mostly incomprehensible in\\n writing as well. She appears frustrated and agitated. SW attempted\\n to offer emotional support, though it is unclear how much she\\n understands.\\n SW also called pt\\ns boyfriend, (), to assess\\n and support coping. He states he is doing well,\\nin better spirits\\n than when we last talked,\\n as he reports he has been able to\\nmake ends\\n meat\\n more easily than he had anticipated. He states he has gotten a\\n 90 day reprieve on pt\\ns car loan, has gotten an extension on her car\\n insurance payments, and has managed to pay her other bills. He also\\n raises the question of pursuing temporary guardianship, stating he has\\n looked into this online and talked about it with friends and\\n . states that he is\\nnot in a rush\\n to do this now, as he\\n has been able to attend to pt\\ns financial affairs as needed, but he\\n wonders if it might be useful in the future if pt remains unable to\\n communicate for herself. SW informed him that pt\\ns brother has also\\n raised this question and that team will be continuing to assess pt\\n condition with this in mind. Of note, boyfriend states he still has\\n not been able to visit pt in the hospital due to his own health\\n problems (PVD, having surgery in a week and a half). He states he has\\n been calling periodically to get updates from RN\\ns re pt\\ns care. SW\\n put him in touch with MICU resident today for update.\\n Plan:\\n - SW will plan to discuss with legal department the question\\n of pursuing temporary guardianship for pt.\\n - Will remain available to both brother and boyfriend for\\n continued emotional support and facilitation re team communication.\\n Please page with any questions or concerns.\\n , LCSW, #\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-22 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 638991,\n \"text\": \"Chief Complaint: resp failure\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 24 Hour Events:\\n increased bblocker\\n J tube placed by IR through PEG- restarted TF and vomiting\\n Went for tube study - dysmotility - contrast sat in stomach\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Diazepam (Valium) - 02:24 AM\\n Other medications:\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 12:17 PM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.7\\nC (98.1\\n Tcurrent: 35.6\\nC (96.1\\n HR: 118 (93 - 140) bpm\\n BP: 153/58(79) {82/39(49) - 153/101(105)} mmHg\\n RR: 23 (14 - 37) insp/min\\n SpO2: 99%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 3,808 mL\\n 1,119 mL\\n PO:\\n TF:\\n 4 mL\\n IVF:\\n 3,804 mL\\n 1,119 mL\\n Blood products:\\n Total out:\\n 1,650 mL\\n 520 mL\\n Urine:\\n 1,590 mL\\n 520 mL\\n NG:\\n 60 mL\\n Stool:\\n Drains:\\n Balance:\\n 2,158 mL\\n 599 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 243 (169 - 281) mL\\n PS : 5 cmH2O\\n RR (Spontaneous): 17\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n RSBI: 67\\n PIP: 11 cmH2O\\n SpO2: 99%\\n ABG: ///33/\\n Ve: 4.1 L/min\\n Physical Examination\\n Labs / Radiology\\n 8.2 g/dL\\n 356 K/uL\\n 129 mg/dL\\n 0.7 mg/dL\\n 33 mEq/L\\n 3.6 mEq/L\\n 4 mg/dL\\n 110 mEq/L\\n 148 mEq/L\\n 26.9 %\\n 5.7 K/uL\\n [image002.jpg]\\n 06:22 AM\\n 02:58 AM\\n 03:43 AM\\n 05:02 PM\\n 03:36 AM\\n 02:30 AM\\n 01:30 AM\\n 06:41 AM\\n 03:20 PM\\n 03:23 AM\\n WBC\\n 7.0\\n 7.1\\n 7.1\\n 6.9\\n 7.6\\n 9.5\\n 5.7\\n Hct\\n 29.7\\n 28.9\\n 29.2\\n 27.8\\n 32.7\\n 28.6\\n 28.9\\n 30.0\\n 26.9\\n Plt\\n 395\\n 462\\n 452\\n 467\\n 548\\n 528\\n 356\\n Cr\\n 0.7\\n 0.6\\n 0.7\\n 0.8\\n 0.7\\n 0.8\\n 1.0\\n 0.7\\n Glucose\\n 126\\n 137\\n 104\\n 108\\n 131\\n 128\\n 121\\n 129\\n Other labs: PT / PTT / INR:15.2/24.6/1.3, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.7 mg/dL, Mg++:2.1 mg/dL, PO4:4.1\\n mg/dL\\n Assessment and Plan\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n 18 Gauge - 04:00 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :ICU\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-23 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 639210,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Pt pulled out her trach tube, tube replaced\\n Seen By EP and started on Amiodarone Drip\\n Fever - 101.4\\nF Cultures sent\\n Self-decanulated again this am during rounds, bradycardia down to\\n 39-40, desated, tube was replaced and vitals normalized. Pt placed in\\n 8-point restraints.\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Amiodarone - 1 mg/min\\n Other ICU medications:\\n Metoprolol - 01:00 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:40 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.6\\nC (101.4\\n Tcurrent: 36.9\\nC (98.5\\n HR: 107 (107 - 142) bpm\\n BP: 86/44(54) {82/39(49) - 181/113(122)} mmHg\\n RR: 22 (13 - 25) insp/min\\n SpO2: 97%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 2,127 mL\\n 537 mL\\n PO:\\n TF:\\n IVF:\\n 2,127 mL\\n 537 mL\\n Blood products:\\n Total out:\\n 995 mL\\n 400 mL\\n Urine:\\n 995 mL\\n 400 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,132 mL\\n 137 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask\\n Ventilator mode: Standby\\n Vt (Spontaneous): 208 (208 - 243) mL\\n RR (Spontaneous): 0\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n PIP: 0 cmH2O\\n SpO2: 97%\\n ABG: ///31/\\n Ve: 4.1 L/min\\n Physical Examination\\n Gen: Awake and alert this am, following commands, mildly agitated,\\n stated that she\\n wanted to get out of here\\n HEENT: PERRL, MMM\\n Resp: Diffuse rhonchi and transmitted airway sounds.\\n Card: S1S2 tachycardic, no m/r/g\\n Abd: Obese, soft, mildly distended, BS+\\n Exte: No edema, DP 2+ bil\\n NEURO: CNII\\nXII intact, reflexes 2+ bilaterally.\\n Labs / Radiology\\n 346 K/uL\\n 8.4 g/dL\\n 123 mg/dL\\n 0.7 mg/dL\\n 31 mEq/L\\n 3.8 mEq/L\\n 4 mg/dL\\n 107 mEq/L\\n 144 mEq/L\\n 27.3 %\\n 7.3 K/uL\\n [image002.jpg]\\n 02:58 AM\\n 03:43 AM\\n 05:02 PM\\n 03:36 AM\\n 02:30 AM\\n 01:30 AM\\n 06:41 AM\\n 03:20 PM\\n 03:23 AM\\n 03:00 AM\\n WBC\\n 7.1\\n 7.1\\n 6.9\\n 7.6\\n 9.5\\n 5.7\\n 7.3\\n Hct\\n 28.9\\n 29.2\\n 27.8\\n 32.7\\n 28.6\\n 28.9\\n 30.0\\n 26.9\\n 27.3\\n Plt\\n 462\\n 452\\n 467\\n 548\\n 528\\n 356\\n 346\\n Cr\\n 0.6\\n 0.7\\n 0.8\\n 0.7\\n 0.8\\n 1.0\\n 0.7\\n 0.7\\n Glucose\\n 137\\n 104\\n 108\\n 131\\n 128\\n 121\\n 129\\n 123\\n Other labs: PT / PTT / INR:14.1/23.7/1.2, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.8 mg/dL, Mg++:1.9 mg/dL, PO4:3.7\\n mg/dL\\n Assessment and Plan\\n 55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\\n trach, PEG placement now with respiratory failure secondary to\\n tracheomalacia , resolved HAP.\\n .\\n # Respiratory failure: Slowly improving, spending most of the day on\\n trach mask with short periods of rest on PSV at night and setbacks\\n from increased secretions to vomiting/aspiration events and her\\n self-decanulations.\\n - Continue to increase time on trach mask as tolerated.\\n - Discontinue all orders for sedation except for Zyprexa QHS.\\n - PMV with suctioning as tolerated\\n # Nutrition/Vomiting: Normal CT-abdomen, had FT placed via peg into\\n jejunum, but continued to vomit. Tube study yesterday showed\\n dysmotility in small bowel, but no obstruction, no retrograde flow.\\n Awaiting GI recs.\\n - Hold TFs\\n - GI consult, appreciate recs\\n - PICC line placement for parenteral nutrition this am\\n - Nutrition recs to start TPN today\\n # HAP vs Aspiration PNA: Had been afebrile for last several days, now\\n with new fever last night after having decanulated herself. Likely had\\n some aspiration. Chemical pneumonitis versus new aspiration PNA.\\n - CXR today\\n - F/u cx data\\n - If remains febrile, send sputum cx.\\n .\\n # Tachycardia: Pt in and out of SVT and sinus, increased BB seems to\\n help, but pt does not stay in sinus. Cards rec to start Amiodarone IV\\n drip, and then convert to PO, 200mg TID. Would consider EPS if\\n amiodarone not successful, though would wait until pt more stable for\\n GA.\\n - Changed to IV metoprolol to 10mg IV q4hr during the day and 7.5mg q4\\n hours at night.\\n - Amiodarone 0.5mg/min IV drip x 18 hours.\\n - Cards c/s, appreciate recs\\n # Sedation/Anxiolysis/AlteredMS: unclear etiology of her confusion and\\n agitation. Has had long hospital course and multiple psychotropic\\n medications as well as hx of EtOH abuse.\\n - Continue w Olanzapine QHS\\n - d/c all benzos, d/c all opiates given GI dysmotlitiy\\n - Psychiatry consulted, appreciate recs\\n # Adrenal Insufficency: Endocrine following. Pt does not appear to be\\n adrenally insufficient at baseline. Suggesting if the patient under\\n goes major stressors such as major surgery, sepsis, she may need stress\\n dosed steroids.\\n .\\n # Fluid Status: Likely approaching euvolemia, though still has mild\\n hypernatramia which may suggest is still intravascularly depleated.\\n - Monitoring urine output\\n - will provide D5W IVF as need for hypernatremia and follow lytes\\n # UE DVT and elevated INR: DVT in right UE has resolved, new\\n non-occlusive in left axillary vein. INR had risen quickly on coumadin,\\n likely to poor nutrition, resonded quickly to Vitamin K IV, but now\\n subtherapeutic again. Kept subtherapeutic today for PICC line placement\\n (for TPN), will restart w/ 2mg Coumadin after line placement.\\n - Restart coumadin after PICC line placement today\\n - Continue to follow INR closely to reach therapeutic INR.\\n .\\n #Hematemesis: Pt had small amt Hematemesis, after vomiting, 2 days ago.\\n None today. HCT stable.\\n -Will follow HCT.\\n - Guaiac stools\\n # Spine fracture: Stable\\n - Brace for OOB, will discuss with Neurosurgery if current brace is\\n optimal for stabilization given her mobility.\\n - Pt to follow up with Dr. in weeks\\n .\\n # Tracheomalacia. Was initially addressed with IP and they wanted to\\n follow up as outpatient. IP reevaluated and does not believe that a\\n stent would be feasible.\\n .\\n #. Thyroid Nodule on CT\\n - Outpatient follow up\\n .\\n # Glycemic control: SSI, well controlled\\n # ACCESS: PIV x 1, PICC placement\\n today.\\n # Ppx: subtherapeutic INR restarting coumadin today, Ranitidine, Bowel\\n Regimen PRN\\n # Communication:\\n - Boyfriend of 10 \\n - Brother also involved\\n - Social Work and Case management involved, have discussed situation\\n w/ brother and boyfriend.\\n # Code: Full\\n # Dispo: ICU, Screening for vent facilities\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n 18 Gauge - 04:00 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-27 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 639661,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n -hypernatremia: Repeat Na 148-->146 (this am), continuing D5W at\\n 125cc/hr\\n -TF up to 30cc/hr; tolerated O/N\\n -Per psych recs: Gave risperidone m-tab 1mg PO x1 HS and will continue\\n risperdone 0.5mg qam and 0.5 PRN; gave scopolamine patch q72hrs;\\n f/u EKG in am\\n -Changed Metoprolol 25 to 37.5mg TID; gave 5mg x1\\n -GI recs: pending\\n -S&S re-eval: for Passy Muir valve eval;\\n -Call case management \\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:30 AM\\n Enoxaparin (Lovenox) - 06:48 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:54 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.7\\nC (98.1\\n Tcurrent: 36.7\\nC (98.1\\n HR: 79 (68 - 124) bpm\\n BP: 134/57(75) {124/52(70) - 179/121(130)} mmHg\\n RR: 27 (18 - 31) insp/min\\n SpO2: 99%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 4,004 mL\\n 1,084 mL\\n PO:\\n TF:\\n 137 mL\\n 51 mL\\n IVF:\\n 2,544 mL\\n 729 mL\\n Blood products:\\n Total out:\\n 3,813 mL\\n 1,000 mL\\n Urine:\\n 3,813 mL\\n 1,000 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 191 mL\\n 84 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask\\n SpO2: 99%\\n ABG: ///33/\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 231 K/uL\\n 7.7 g/dL\\n 145 mg/dL\\n 0.4 mg/dL\\n 33 mEq/L\\n 3.5 mEq/L\\n 11 mg/dL\\n 109 mEq/L\\n 146 mEq/L\\n 25.3 %\\n 5.7 K/uL\\n [image002.jpg]\\n 01:30 AM\\n 06:41 AM\\n 03:20 PM\\n 03:23 AM\\n 03:00 AM\\n 04:00 AM\\n 05:45 AM\\n 03:51 AM\\n 04:45 PM\\n 04:00 AM\\n WBC\\n 9.5\\n 5.7\\n 7.3\\n 8.0\\n 8.7\\n 5.5\\n 5.7\\n Hct\\n 28.6\\n 28.9\\n 30.0\\n 26.9\\n 27.3\\n 27.0\\n 28.7\\n 24.7\\n 25.2\\n 25.3\\n Plt\\n 528\\n 356\\n 346\\n \\n 231\\n Cr\\n 1.0\\n 0.7\\n 0.7\\n 0.7\\n 0.7\\n 0.5\\n 0.4\\n Glucose\\n 121\\n 129\\n 123\\n 114\\n 112\\n 122\\n 145\\n Other labs: PT / PTT / INR:13.6/31.1/1.2, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.6 mg/dL, Mg++:2.0 mg/dL, PO4:3.6\\n mg/dL\\n Assessment and Plan\\n ICU Care\\n Nutrition:\\n TPN without Lipids - 05:44 PM 43. mL/hour\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n PICC Line - 01:30 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-27 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 639662,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n -hypernatremia: Repeat Na 148-->146 (this am), continuing D5W at\\n 125cc/hr\\n -TF up to 30cc/hr; tolerated O/N\\n -Per psych recs: Gave risperidone m-tab 1mg PO x1 HS and will continue\\n risperdone 0.5mg qam and 0.5 PRN; gave scopolamine patch q72hrs;\\n f/u EKG in am\\n -Changed Metoprolol 25 to 37.5mg TID; gave 5mg x1\\n -GI recs: pending\\n -S&S re-eval: for Passy Muir valve eval;\\n -Call case management \\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:30 AM\\n Enoxaparin (Lovenox) - 06:48 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:54 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.7\\nC (98.1\\n Tcurrent: 36.7\\nC (98.1\\n HR: 79 (68 - 124) bpm\\n BP: 134/57(75) {124/52(70) - 179/121(130)} mmHg\\n RR: 27 (18 - 31) insp/min\\n SpO2: 99%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 4,004 mL\\n 1,084 mL\\n PO:\\n TF:\\n 137 mL\\n 51 mL\\n IVF:\\n 2,544 mL\\n 729 mL\\n Blood products:\\n Total out:\\n 3,813 mL\\n 1,000 mL\\n Urine:\\n 3,813 mL\\n 1,000 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 191 mL\\n 84 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask\\n SpO2: 99%\\n ABG: ///33/\\n Physical Examination\\n Gen: Awake, Mouthing words, More agitated compared to previous\\n mornings.\\n HEENT: EOMI, No pallor in conjunctiva, MMM\\n Resp: CTAB, no rales, rhonchi, or wheezing, good airway movement.\\n Card: S1S2 tachycardic, no m/r/g\\n Abd: Obese, soft, mildly distended, decreased bowel sounds,, G-Tube in\\n place with no erythema/induration\\n Exte: No edema, DP 2+ bil\\n NEURO: Gross Motor and Sensation in 4 extremities\\n Labs / Radiology\\n 231 K/uL\\n 7.7 g/dL\\n 145 mg/dL\\n 0.4 mg/dL\\n 33 mEq/L\\n 3.5 mEq/L\\n 11 mg/dL\\n 109 mEq/L\\n 146 mEq/L\\n 25.3 %\\n 5.7 K/uL\\n [image002.jpg]\\n 01:30 AM\\n 06:41 AM\\n 03:20 PM\\n 03:23 AM\\n 03:00 AM\\n 04:00 AM\\n 05:45 AM\\n 03:51 AM\\n 04:45 PM\\n 04:00 AM\\n WBC\\n 9.5\\n 5.7\\n 7.3\\n 8.0\\n 8.7\\n 5.5\\n 5.7\\n Hct\\n 28.6\\n 28.9\\n 30.0\\n 26.9\\n 27.3\\n 27.0\\n 28.7\\n 24.7\\n 25.2\\n 25.3\\n Plt\\n 528\\n 356\\n 346\\n \\n 231\\n Cr\\n 1.0\\n 0.7\\n 0.7\\n 0.7\\n 0.7\\n 0.5\\n 0.4\\n Glucose\\n 121\\n 129\\n 123\\n 114\\n 112\\n 122\\n 145\\n Other labs: PT / PTT / INR:13.6/31.1/1.2, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.6 mg/dL, Mg++:2.0 mg/dL, PO4:3.6\\n mg/dL\\n Assessment and Plan\\n ICU Care\\n Nutrition:\\n TPN without Lipids - 05:44 PM 43. mL/hour\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n PICC Line - 01:30 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-27 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 639663,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n -hypernatremia: Repeat Na 148-->146 (this am), continuing D5W at\\n 125cc/hr\\n -TF up to 30cc/hr; tolerated O/N\\n -Per psych recs: Gave risperidone m-tab 1mg PO x1 HS and will continue\\n risperdone 0.5mg qam and 0.5 PRN; gave scopolamine patch q72hrs;\\n f/u EKG in am\\n -Changed Metoprolol 25 to 37.5mg TID; gave 5mg x1\\n -GI recs: pending\\n -S&S re-eval: for Passy Muir valve eval;\\n -Call case management \\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:30 AM\\n Enoxaparin (Lovenox) - 06:48 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:54 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.7\\nC (98.1\\n Tcurrent: 36.7\\nC (98.1\\n HR: 79 (68 - 124) bpm\\n BP: 134/57(75) {124/52(70) - 179/121(130)} mmHg\\n RR: 27 (18 - 31) insp/min\\n SpO2: 99%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 4,004 mL\\n 1,084 mL\\n PO:\\n TF:\\n 137 mL\\n 51 mL\\n IVF:\\n 2,544 mL\\n 729 mL\\n Blood products:\\n Total out:\\n 3,813 mL\\n 1,000 mL\\n Urine:\\n 3,813 mL\\n 1,000 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 191 mL\\n 84 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask\\n SpO2: 99%\\n ABG: ///33/\\n Physical Examination\\n Gen: Awake, Mouthing words, More agitated compared to previous\\n mornings.\\n HEENT: EOMI, No pallor in conjunctiva, MMM\\n Resp: CTAB, no rales, rhonchi, or wheezing, good airway movement.\\n Card: S1S2 tachycardic, no m/r/g\\n Abd: Obese, soft, mildly distended, decreased bowel sounds,, G-Tube in\\n place with no erythema/induration\\n Exte: No edema, DP 2+ bil\\n NEURO: Gross Motor and Sensation in 4 extremities\\n Labs / Radiology\\n 231 K/uL\\n 7.7 g/dL\\n 145 mg/dL\\n 0.4 mg/dL\\n 33 mEq/L\\n 3.5 mEq/L\\n 11 mg/dL\\n 109 mEq/L\\n 146 mEq/L\\n 25.3 %\\n 5.7 K/uL\\n [image002.jpg]\\n 01:30 AM\\n 06:41 AM\\n 03:20 PM\\n 03:23 AM\\n 03:00 AM\\n 04:00 AM\\n 05:45 AM\\n 03:51 AM\\n 04:45 PM\\n 04:00 AM\\n WBC\\n 9.5\\n 5.7\\n 7.3\\n 8.0\\n 8.7\\n 5.5\\n 5.7\\n Hct\\n 28.6\\n 28.9\\n 30.0\\n 26.9\\n 27.3\\n 27.0\\n 28.7\\n 24.7\\n 25.2\\n 25.3\\n Plt\\n 528\\n 356\\n 346\\n \\n 231\\n Cr\\n 1.0\\n 0.7\\n 0.7\\n 0.7\\n 0.7\\n 0.5\\n 0.4\\n Glucose\\n 121\\n 129\\n 123\\n 114\\n 112\\n 122\\n 145\\n Other labs: PT / PTT / INR:13.6/31.1/1.2, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.6 mg/dL, Mg++:2.0 mg/dL, PO4:3.6\\n mg/dL\\n Assessment and Plan\\n 56yoF s/p mechanical fall and traumatic T spine fracture, now s/p\\n trach/PEG with resolving respiratory failure and HAP.\\n .\\n # Respiratory failure: s/p intubation/extubation, now on trach mask,\\n FiO2 70%. Tolerating well with good O2 sat. No further\\n self-decanulations overnight.\\n - Tach mask as tolerated.\\n - Holding sedation with exception of Risperidal 0.5mg .\\n - F/u CXR tomorrow\\n .\\n # Nutrition/Vomiting: Currently receiving TPN;. One large BM in past\\n 24 hrs to indicate potential improvement in ileus.\\n - Cont Reglan 20mg IV Q 8 hours; meds via G-J tube,\\n - Will obtain recommendations from Nutrition re TPN before starting TPN\\n tomorrow\\n - TF as tolerated\\n - Speech and Swallow eval\\n - PICC line in place with TPN given when pt not tolerating TF\\n - GI consult, appreciate recs\\n .\\n # Tachycardia: Improved HR max of 120\\ns versus 160s previously;\\n elevated this am secondary to agitation. Pt now on PO Amiodarone 200\\n TID and PO metoprolol 25mg TID\\n - Continue current med regimen. Will continue amiodarone 200 TID for\\n three weeks and then switch to qday.\\n - Will schedule f/u in 4wks with Dr. upon d/c/transfer.\\n - f/u Cards recs\\n # Sedation/Anxiolysis/AlteredMS: Agitation O/N, continues to be\\n agitated most likely secondary to long hospital course and multiple\\n psychotropic medications as well as hx of EtOH abuse. Risperdal given\\n O/N.\\n - started Risperdal 0.5mg PO BID\\n - continue to hold all benzos. opiates, and antihistamines\\n - Appreciate psych. Will call and f/u psych recs.\\n #Anemia: Decrease in HCT from 28\\n24; tachycardia. No known etiology of\\n blood loss, most likely related to variaton\\n -Will repeat HCT check this afternoon.\\n # Hypernatremia/Fluid Status: Mild hypernatramia with good UOP\\n (hypervolemic hypernatremia). On TPN/TF.\\n - providing D5W IVF, free water flushes with TF\\n -Will f/u lytes (Na) this afternoon at 5pm.\\n # UE DVT and elevated INR: Decision made to d/c Coumadin given her\\n labile INR, and start Lovenox . Current INR 1.2.\\n - Will flush L PICC with TPA if does not flush\\n .\\n # Spine fracture: Stable\\n - Brace for OOB, need to discuss with Neurosurgery before d/c if\\n current brace is optimal for stabilization given her mobility.\\n - Pt to follow up with Dr. in weeks\\n .\\n # Tracheomalacia. Was initially addressed with IP and they wanted to\\n follow up as outpatient. IP reevaluated and does not believe that a\\n stent would be feasible. No new issues.\\n .\\n #. Thyroid Nodule on CT\\n - Outpatient follow up\\n .\\n # Glycemic control: SSI, well controlled\\n # ACCESS: PIV x 1, L PICC\\n # Ppx: Lovenox, PPi, Bowel Regimen PRN\\n # Communication:\\n - Boyfriend of 10 \\n - Brother also involved\\n - Social Work and Case management involved, have discussed situation\\n w/ brother and boyfriend.\\n # Code: Full\\n # Dispo: ICU, Will d/w case management re rehab facilities.\\n ICU Care\\n Nutrition:\\n TPN without Lipids - 05:44 PM 43. mL/hour\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n PICC Line - 01:30 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-20 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 638634,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n CARDIOVERSION/DEFIBRILLATION - At 11:50 AM\\n aqdenosine 6mg given X 1 by cardiologist to assess pt's rhythm. Pt\\n tolerated well, transiently converted.\\n Valium, Benadryl held overnight which pt tolerated.\\n Emesis again this am so TF held.\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:24 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:45 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.6\\nC (97.8\\n Tcurrent: 36\\nC (96.8\\n HR: 114 (85 - 144) bpm\\n BP: 111/59(69) {84/42(0) - 154/134(138)} mmHg\\n RR: 12 (12 - 36) insp/min\\n SpO2: 100%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 1,945 mL\\n 274 mL\\n PO:\\n TF:\\n IVF:\\n 1,800 mL\\n 154 mL\\n Blood products:\\n Total out:\\n 2,300 mL\\n 500 mL\\n Urine:\\n 2,245 mL\\n 500 mL\\n NG:\\n 55 mL\\n Stool:\\n Drains:\\n Balance:\\n -355 mL\\n -226 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: MMV/PSV/AutoFlow\\n Vt (Set): 500 (500 - 500) mL\\n Vt (Spontaneous): 319 (319 - 319) mL\\n PS : 10 cmH2O\\n RR (Set): 12\\n RR (Spontaneous): 15\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n RSBI Deferred: No Spon Resp\\n PIP: 15 cmH2O\\n SpO2: 100%\\n ABG: ///36/\\n Ve: 5.5 L/min\\n Physical Examination\\n Gen: Obtunded this am, not responsive to voice, minimally responsive to\\n noxious stimuli, on MMV through trach tube, but later responsive to\\n voice, appropriate, asking questions, mouthing responses\\n HEENT: PERRL, MMM,\\n Resp: Coarse BS anteriorly, no focal rales, rhonchi, or wheezing with\\n some referred upper airway noises from secretions.\\n Card: S1S2 tachycardic, no m/r/g\\n Abd: Obese, soft, mildly distended, hypoactive BS\\n Exte: No edema, DP 2+ bil.\\n NEURO: Toes downgoing bilaterally,\\n Labs / Radiology\\n 548 K/uL\\n 10.0 g/dL\\n 128 mg/dL\\n 0.8 mg/dL\\n 36 mEq/L\\n 4.1 mEq/L\\n 6 mg/dL\\n 105 mEq/L\\n 148 mEq/L\\n 32.7 %\\n 7.6 K/uL\\n [image002.jpg]\\n , 10/2 blood cx NGTD\\n 05:00 AM\\n 02:06 AM\\n 07:34 AM\\n 03:50 AM\\n 06:22 AM\\n 02:58 AM\\n 03:43 AM\\n 05:02 PM\\n 03:36 AM\\n 02:30 AM\\n WBC\\n 5.9\\n 7.5\\n 5.6\\n 6.1\\n 7.0\\n 7.1\\n 7.1\\n 6.9\\n 7.6\\n Hct\\n 27.2\\n 26.8\\n 27.0\\n 27.0\\n 29.7\\n 28.9\\n 29.2\\n 27.8\\n 32.7\\n Plt\\n 296\\n 306\\n 335\\n \\n 452\\n 467\\n 548\\n Cr\\n 0.7\\n 0.6\\n 0.5\\n 0.7\\n 0.7\\n 0.6\\n 0.7\\n 0.8\\n 0.7\\n 0.8\\n Glucose\\n 134\\n 134\\n 121\\n \\n 104\\n 108\\n 131\\n 128\\n Other labs: PT / PTT / INR:48.3/33.3/5.5, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:10.0 mg/dL, Mg++:2.5 mg/dL,\\n PO4:4.3 mg/dL\\n Assessment and Plan\\n 55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\\n trach, PEG placement now with respiratory failure secondary to\\n tracheomalacia , resolved HAP.\\n .\\n # Respiratory failure: Slowly Improving. Now remaining on trach mask\\n for most of the day, with periods of pressure support of over\\n night. This am on MMV. Previously likely oversedated with Benadryl,\\n Morhpine, and Valium which were held overnight. Pt awake and alert at\\n rounds, interactive, and breathing comfortably on trach mask\\n - Continue to increase time on trach mask as tolerated.\\n - Decrease sedation and valium use\\n - PMV with suctioning\\n .\\n # HAP vs Aspiration PNA: Afebrile without leukocytosis\\n - Completed course of ceftriaxone\\n - good O2 saturation on trach mask\\n - Continue to f/u cultures\\n .\\n # Tachycardia: Previously was assessed as sinus tach with occasional\\n runs of SVT and sources such as hypovolemia, PE, infection, and pain\\n were assessed as possibly etiologies. Per Cardiology, most likely AT\\n given transient response to Adenosine. HR occasionally decreases to\\n 70s-80s w/ stable BPs at times that might be associated with\\n administration of her BB and valium. Cards recommended titating up her\\n beta blocker as tolerated. Dose increased to 37.5 yesterday but still\\n tachycardic.\\n - EP consulted for conversion of SVT, appreciate recs\\n - Increase metoprolol to 50 PO QID with holding parameters\\n .\\n # Sedation: Inconsistent response to sedation, unclear what is best\\n regime. Will continue to wean overall.\\n - Continue w Olanzapine QHS\\n - Just valium 2.5 mg PRN.\\n # Nutrition/Vomiting: Pt has had several episodes of vomiting up her\\n TFs, reglan started to increase GI motility, but pt had another episode\\n of vomiting this am, not improved with zofran or reglan. Pateint also\\n had hypoactive BS on exam, concern for obstruction given persistent\\n vomiting, inability to tolerate tube feeds.\\n - Hold TFs\\n - Thoracic surgery recs: 1) oral/nasal tube in post-piloric position,\\n or 2) IR to place a pediatric feeding tube through her PEG site to a\\n post-piloric position.\\n - Will attempt to coordinate thoracic surgery and IR for tube placement\\n ; will d/w thoracics. IR will not do further intervention due to disk\\n on G tube\\n - CT scan to evaluate for obstruction, etiology of persistent emesis,\\n consider tube study as well\\n .\\n # Adrenal Insufficency: Endocrine following. Pt does not appear to be\\n adrenally insufficient at baseline. Suggesting if the patient under\\n goes major stressors such as major surgery, sepsis, she may need stress\\n dosed steroids.\\n .\\n # Fluid Status: Likely approaching euvolemia, though still has mild\\n hypernatramia which may suggest is still intravascularly depleated.\\n - Monitoring urine output\\n - FW flushes w/ tube feeds held due to vomitting\\n - will provide D5W IVF as need for hypernatremia and follow lytes\\n .\\n # UE DVT and elevated INR: DVT in right UE has resolved, new\\n non-occlusive in left axillary vein. INR supratherapeutic today and\\n trending upward. INR most likely continuing to rise nutritional\\n deficiencies given lack of PO intake\\n - Cumadin held, will restart at low dose when INR approaches\\n therapeutic range.\\n - INR 5.5 today, will check PM coags and follow\\n .\\n # Spine fracture: Stable\\n - Brace for OOB, will discuss with Neurosurgery if current brace is\\n optimal for stabilization given her mobility.\\n - Pt to follow up with Dr. in weeks\\n .\\n # Tracheomalacia. Was initially addressed with IP and they wanted to\\n follow up as outpatient. IP reevaluated and does not believe that a\\n stent would be feasible.\\n .\\n #. Thyroid Nodule on CT\\n - Outpatient follow up\\n .\\n # Glycemic control: SSI, well controlled\\n # PIV x 1\\n # Ppx: supratherapeutic INR, Ranitidine, Bowel Regimen PRN\\n # Communication:\\n - Boyfriend of 10 \\n - Brother also involved\\n - Will contact Social and Case management today\\n # Code: Full\\n # Dispo: ICU, Screening for vent facilities\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-21 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 638760,\n \"text\": \"Chief Complaint: resp failure\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 24 Hour Events:\\n rising INR to 10.5\\n small volume hemetemesis\\n abd CT\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:30 AM\\n Other medications:\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 09:44 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.9\\nC (98.4\\n Tcurrent: 36.9\\nC (98.4\\n HR: 114 (88 - 136) bpm\\n BP: 120/65(80) {80/40(49) - 149/88(92)} mmHg\\n RR: 11 (11 - 33) insp/min\\n SpO2: 100%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 2,241 mL\\n 1,802 mL\\n PO:\\n TF:\\n IVF:\\n 1,941 mL\\n 1,802 mL\\n Blood products:\\n Total out:\\n 1,860 mL\\n 260 mL\\n Urine:\\n 1,830 mL\\n 210 mL\\n NG:\\n 30 mL\\n 50 mL\\n Stool:\\n Drains:\\n Balance:\\n 381 mL\\n 1,542 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: CPAP/PSV\\n Vt (Set): 500 (500 - 500) mL\\n Vt (Spontaneous): 438 (300 - 1,054) mL\\n PS : 10 cmH2O\\n RR (Set): 12\\n RR (Spontaneous): 13\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n RSBI Deferred: No Spon Resp\\n PIP: 16 cmH2O\\n Plateau: 15 cmH2O\\n SpO2: 100%\\n ABG: ///35/\\n Ve: 5.4 L/min\\n Physical Examination\\n Gen\\n HEENt\\n CV\\n Chest\\n Abd\\n Ext\\n Labs / Radiology\\n 9.2 g/dL\\n 528 K/uL\\n 121 mg/dL\\n 1.0 mg/dL\\n 35 mEq/L\\n 3.4 mEq/L\\n 6 mg/dL\\n 103 mEq/L\\n 144 mEq/L\\n 28.9 %\\n 9.5 K/uL\\n [image002.jpg]\\n 07:34 AM\\n 03:50 AM\\n 06:22 AM\\n 02:58 AM\\n 03:43 AM\\n 05:02 PM\\n 03:36 AM\\n 02:30 AM\\n 01:30 AM\\n 06:41 AM\\n WBC\\n 5.6\\n 6.1\\n 7.0\\n 7.1\\n 7.1\\n 6.9\\n 7.6\\n 9.5\\n Hct\\n 27.0\\n 27.0\\n 29.7\\n 28.9\\n 29.2\\n 27.8\\n 32.7\\n 28.6\\n 28.9\\n Plt\\n 335\\n 321\\n 395\\n 462\\n 452\\n 467\\n 548\\n 528\\n Cr\\n 0.5\\n 0.7\\n 0.7\\n 0.6\\n 0.7\\n 0.8\\n 0.7\\n 0.8\\n 1.0\\n Glucose\\n 121\\n 619\\n 126\\n 137\\n 104\\n 108\\n 131\\n 128\\n 121\\n Other labs: PT / PTT / INR:82.1/35.9/10.5, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:9.7 mg/dL, Mg++:2.4 mg/dL, PO4:2.9\\n mg/dL\\n Assessment and Plan\\n 1. Tachycardia: runs of attach Appreciate EP consult\\n will increase\\n bblocker. Have to convert to metoprolol 5mg IV Q4.\\n 2. Persistent Nausea/Vomiting: we have ruled out\\n pSBO/SBO, very poor\\n bowel sounds, get emptying study and if unrevealing consult GI to\\n discuss EGD. We will need to pursue NG dophoff by IR\\n 2. Resp Failure\\n Trach mask trials all day, PSV\\n PMV trials\\n S/P rx for pan Klebs PNA.\\n Per IP not stent planned as technically not possible to\\n place into her airway\\n 3. DVT and coagulopathy: revsre with IV VIt K today, then maintain\\n daily SC Vit K until Inr less than 2\\n 4. Hypernatremia Replete free water.\\n Please see today\\ns ICU team note for other issues.\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n 18 Gauge - 04:00 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n Communication: with pt and spoke at length with brother who would like\\n to possibily become her guardian or power of atty to facilitate her\\n care and finances\\n Code status: Full code\\n Disposition : ICU\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-21 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 638800,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Multiple vomitting episodes, not improved much w/ zofran.\\n Unable to tolerate anything through her PEG\\n Had an Abdominal CT w/contrast, but vomitted up most of the constrast.\\n limited study. Prelim read: no obstruction, PEG in place\\n Nurse positive coffe-grounds emesis and w/ a later\\n episode, clear emesis with some small blood when she suctioned the\\n posterior pharynx. HCT stable\\n TFs were held\\n Dr. had a conversation with the pt\\ns brother.\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:44 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.8\\nC (98.2\\n Tcurrent: 36.7\\nC (98\\n HR: 110 (76 - 136) bpm\\n BP: 98/63(60) {80/40(49) - 149/88(92)} mmHg\\n RR: 12 (12 - 33) insp/min\\n SpO2: 100%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 2,241 mL\\n 1,335 mL\\n PO:\\n TF:\\n IVF:\\n 1,941 mL\\n 1,335 mL\\n Blood products:\\n Total out:\\n 1,860 mL\\n 140 mL\\n Urine:\\n 1,830 mL\\n 90 mL\\n NG:\\n 30 mL\\n 50 mL\\n Stool:\\n Drains:\\n Balance:\\n 381 mL\\n 1,195 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: MMV/PSV/AutoFlow\\n Vt (Set): 500 (500 - 500) mL\\n Vt (Spontaneous): 809 (300 - 1,054) mL\\n PS : 10 cmH2O\\n RR (Set): 12\\n RR (Spontaneous): 0\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n RSBI Deferred: No Spon Resp\\n PIP: 21 cmH2O\\n Plateau: 15 cmH2O\\n SpO2: 100%\\n ABG: ///35/\\n Ve: 5.8 L/min\\n Physical Examination\\n Gen: Mildly obtunded in am, responsive to noxious stimuli, on MMV\\n through trach tube, but later in am responsive to voice, appropriate,\\n asking questions,\\n HEENT: PERRL, MMM\\n Resp: Coarse BS anteriorly, no focal rales, rhonchi, or wheezing with\\n some referred upper airway noises from secretions.\\n Card: S1S2 tachycardic, no m/r/g\\n Abd: Obese, soft, mildly distended, hypoactive BS\\n Exte: No edema, DP 2+ bil.\\n NEURO: Toes downgoing bilaterally,\\n Labs / Radiology\\n 528 K/uL\\n 9.2 g/dL\\n 121 mg/dL\\n 1.0 mg/dL\\n 35 mEq/L\\n 3.4 mEq/L\\n 6 mg/dL\\n 103 mEq/L\\n 146 mEq/L\\n 28.6 %\\n 9.5 K/uL\\n [image002.jpg]\\n CT: No evidence of obstruction or acute intraabdominal process\\n 02:06 AM\\n 07:34 AM\\n 03:50 AM\\n 06:22 AM\\n 02:58 AM\\n 03:43 AM\\n 05:02 PM\\n 03:36 AM\\n 02:30 AM\\n 01:30 AM\\n WBC\\n 7.5\\n 5.6\\n 6.1\\n 7.0\\n 7.1\\n 7.1\\n 6.9\\n 7.6\\n 9.5\\n Hct\\n 26.8\\n 27.0\\n 27.0\\n 29.7\\n 28.9\\n 29.2\\n 27.8\\n 32.7\\n 28.6\\n Plt\\n 95\\n 462\\n 452\\n 467\\n 548\\n 528\\n Cr\\n 0.6\\n 0.5\\n 0.7\\n 0.7\\n 0.6\\n 0.7\\n 0.8\\n 0.7\\n 0.8\\n 1.0\\n Glucose\\n 134\\n 121\\n 619\\n 126\\n 137\\n 104\\n 108\\n 131\\n 128\\n 121\\n Other labs: PT / PTT / INR:82.1/35.9/10.5, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:9.7 mg/dL, Mg++:2.4 mg/dL, PO4:2.9\\n mg/dL\\n Assessment and Plan\\n 55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\\n trach, PEG placement now with respiratory failure secondary to\\n tracheomalacia , resolved HAP.\\n .\\n # Respiratory failure: Slowly Improving. Intermittently on trach mask\\n for most of the day, with periods of pressure support of over\\n night. This am on MMV. Previously likely oversedated but Benadryl,\\n Morhpine, and Valium held now. Pt awake and alert at rounds,\\n interactive, and breathing comfortably on trach mask\\n - Continue to increase time on trach mask as tolerated.\\n - Decrease sedation and valium use\\n - PMV with suctioning\\n .\\n # HAP vs Aspiration PNA: Afebrile without leukocytosis\\n - Completed course of ceftriaxone\\n - good O2 saturation on trach mask\\n .\\n # Tachycardia: Previously was assessed as sinus tach with occasional\\n runs of SVT and sources such as hypovolemia, PE, infection, and pain\\n were assessed as possibly etiologies. Per Cardiology, most likely AT\\n given transient response to Adenosine. HR occasionally decreases to\\n 70s-80s w/ stable BPs at times that might be associated with\\n administration of her BB and valium. Cards recommended titrating up her\\n beta blocker as tolerated. Dose increased to 50 yesterday and\\n intermittently responded but then had to hold PO meds given need to\\n hold PO. Changed PO to IV lopressor.\\n - EP consulted for SVT, appreciate recs, will change metoprololt o IV\\n and hopefully will be able to restart PO meds soon once able to\\n tolerate\\n - IV metoprolol 5 mg IV q 4\\n .\\n # Sedation: Inconsistent response to sedation, unclear what is best\\n regime. Will continue to wean overall.\\n - Continue w Olanzapine QHS\\n - Just valium 2.5 mg PRN.\\n # Nutrition/Vomiting: Pt has had several episodes of vomiting up her\\n TFs, reglan started to increase GI motility, but pt had another episode\\n of vomiting this am, not improved with zofran or reglan. Patient also\\n had hypoactive BS on exam, concern for obstruction given persistent\\n vomiting, inability to tolerate tube feeds.\\n - Hold TFs\\n - Thoracic surgery recs: 1) oral/nasal tube in post-piloric position,\\n or 2) IR to place a pediatric feeding tube through her PEG site to a\\n post-piloric position.\\n - Will attempt to coordinate thoracic surgery and IR for tube placement\\n ; will d/w thoracics\\n - CT scan did not reveal evidence of obstruction. Attempted to\\n coordinate tube study or UGI btu per Radiology would not be useful\\n studies since no obstruction or dysmotility evident on CT\\n - Reglan DCd since not helping\\n - Will decrease narcotics for possible cause of decreased motility\\n .\\n # Adrenal Insufficency: Endocrine following. Pt does not appear to be\\n adrenally insufficient at baseline. Suggesting if the patient under\\n goes major stressors such as major surgery, sepsis, she may need stress\\n dosed steroids.\\n .\\n # Fluid Status: Likely approaching euvolemia, though still has mild\\n hypernatramia which may suggest is still intravascularly depleated.\\n - Monitoring urine output\\n - will provide D5W IVF as need for hypernatremia and follow lytes\\n .\\n # UE DVT and elevated INR: DVT in right UE has resolved, new\\n non-occlusive in left axillary vein. INR supratherapeutic today and\\n trending upward. INR most likely continuing to rise nutritional\\n deficiencies given continued lack of PO intake\\n - Cumadin stopped.\\n - INR 10.5 today, up from 5.5, will give Vitamin K IV and reassess will\\n check PM coags and follow\\n - vitamin K IV x 1. Will likely need to continue with SC, follow coags\\n .\\n #Hematemesis: Pt had small amt Hematemesis this am. Concerning in\\n setting of elevated INR. Will give IV Vitamin K and may need continued\\n dosing\\n - Vit K IV x 1\\n -\\n # Spine fracture: Stable\\n - Brace for OOB, will discuss with Neurosurgery if current brace is\\n optimal for stabilization given her mobility.\\n - Pt to follow up with Dr. in weeks\\n .\\n # Tracheomalacia. Was initially addressed with IP and they wanted to\\n follow up as outpatient. IP reevaluated and does not believe that a\\n stent would be feasible.\\n .\\n #. Thyroid Nodule on CT\\n - Outpatient follow up\\n .\\n # Glycemic control: SSI, well controlled\\n # PIV x 1\\n # Ppx: supratherapeutic INR, Ranitidine, Bowel Regimen PRN\\n # Communication:\\n - Boyfriend of 10 \\n - Brother also involved\\n - Will contact Social and Case management today\\n # Code: Full\\n # Dispo: ICU, Screening for vent facilities\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n 18 Gauge - 04:00 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-22 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 638870,\n \"text\": \"Nausea / vomiting\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Altered mental status (not Delirium)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Hypernatremia (high sodium)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-22 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 639078,\n \"text\": \"56 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\\n with prolonged hospital course c/b by PNA, anxiety/altered mental\\n status, R&LUE DVT .Pt found to have small non occlusive Clot on her\\n right axial vein via Ultrasound.Yesterday. She has had problems with\\n vomiting tube feedings, feeding tube passed through g-tube (g-tube in\\n place with mushroom on inside so cannot pull out) to her jejunenum but\\n continues vomit.\\n Tachycardia, Other\\n Assessment:\\n HR better but still 110-130. Receiving 7.5mg lopressor IV Q4h\\n Action:\\n Heart rate better on lopressor. Lopressor increased to 10mg IV Q4h.\\n Response:\\n HR still up but is due to her agitation .\\n Plan:\\n Continue to monitor B/P and HR, do not hold lopressor but decrease the\\n dose (ask HO)\\n Assessment:\\n Pt had tube studies today, contrast injected into feeding tube, it\\n went into her jejuneum and went no furtere. Pt has had 2 xrayes to\\n see if it has advanced at all.\\n Action:\\n Pt has been restarted on raglan, narcotics and other meds that slow GI\\n motility have been D/C\\n Response:\\n Pt has not had a stool .\\n Plan:\\n Continue to monitor for movement of of monelity\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt was OOB to the chair most of the day and has been on the trach mask\\n since 9am. She had the passey-muir valve place. She was pleasantly\\n confused and stated that she is not in any pain. She stated that she\\n was in Boson and in , and was not making any sense most of the\\n time. She has no short term memory so needs constant reinforcement to\\n stay safe. At 1550 she was found to have pulled out her trach tube and\\n pulled apart her trach .\\n Action:\\n A new trach tube was placed, she is restrained so that she cannot pull\\n anything.\\n Response:\\n She is able to move and all tubes, wires and catheters are out of her\\n reach, under sheets and out of sight. She remains restraint so she\\n cannot harm herself.\\n Plan:\\n Hypernatremia (high sodium)\\n Assessment:\\n Na down to 146, K+ 4.3.\\n Action:\\n IV D5w with 20meq Kcl at 100cc/hr stopped and D5W started at 75cc/hr\\n Response:\\n Na down, K+ better\\n Plan:\\n Continue to monitor.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-22 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 639079,\n \"text\": \"56 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\\n with prolonged hospital course c/b by PNA, anxiety/altered mental\\n status, R&LUE DVT .Pt found to have small non occlusive Clot on her\\n right axial vein via Ultrasound.Yesterday. She has had problems with\\n vomiting tube feedings, feeding tube passed through g-tube (g-tube in\\n place with mushroom on inside so cannot pull out) to her jejunenum but\\n continues vomit.\\n Tachycardia, Other\\n Assessment:\\n HR better but still 110-130. Receiving 7.5mg lopressor IV Q4h\\n Action:\\n Heart rate better on lopressor. Lopressor increased to 10mg IV Q4h.\\n Response:\\n HR still up but is due to her agitation .\\n Plan:\\n Continue to monitor B/P and HR, do not hold lopressor but decrease the\\n dose (ask HO)\\n Assessment:\\n Pt had tube studies today, contrast injected into feeding tube, it\\n went into her jejuneum and went no furtere. Pt has had 2 xrayes to\\n see if it has advanced at all.\\n Action:\\n Pt has been restarted on raglan, narcotics and other meds that slow GI\\n motility have been D/C\\n Response:\\n Pt has not had a stool .\\n Plan:\\n Continue to monitor for movement of of monelity\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt was OOB to the chair most of the day and has been on the trach mask\\n since 9am. She had the passey-muir valve place. She was pleasantly\\n confused and stated that she is not in any pain. She stated that she\\n was in Boson and in , and was not making any sense most of the\\n time. She has no short term memory so needs constant reinforcement to\\n stay safe. At 1550 she was found to have pulled out her trach tube and\\n pulled apart her trach .\\n Action:\\n A new trach tube was placed, she is restrained so that she cannot pull\\n anything.\\n Response:\\n She is able to move and all tubes, wires and catheters are out of her\\n reach, under sheets and out of sight. She remains restraint so she\\n cannot harm herself.\\n Plan:\\n Hypernatremia (high sodium)\\n Assessment:\\n Na down to 146, K+ 4.3.\\n Action:\\n IV D5w with 20meq Kcl at 100cc/hr stopped and D5W started at 75cc/hr\\n Response:\\n Na down, K+ better\\n Plan:\\n Continue to monitor.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-23 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 639168,\n \"text\": \"Chief Complaint: resp failure\\n HPI:\\n 24 Hour Events:\\n UNPLANNED EXTUBATION (PATIENT-INITIATED) - At 03:50 PM\\n Pt pulled out her trach tube, tube replaced\\n FEVER - 101.4\\nF - 12:00 AM\\n 7 AM pulled out trach again , bradycardia, replaced.\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Amiodarone - 0.5 mg/min\\n Other ICU medications:\\n Metoprolol - 01:00 AM\\n Other medications:\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Constitutional: Fever\\n Flowsheet Data as of 10:26 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.6\\nC (101.4\\n Tcurrent: 36.8\\nC (98.2\\n HR: 116 (84 - 142) bpm\\n BP: 147/84(96) {86/39(53) - 181/113(137)} mmHg\\n RR: 23 (13 - 27) insp/min\\n SpO2: 99%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 2,127 mL\\n 988 mL\\n PO:\\n TF:\\n IVF:\\n 2,127 mL\\n 988 mL\\n Blood products:\\n Total out:\\n 995 mL\\n 900 mL\\n Urine:\\n 995 mL\\n 900 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,132 mL\\n 88 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask\\n Ventilator mode: CPAP/PPS\\n Vt (Set): 0 (0 - 0) mL\\n Vt (Spontaneous): 360 (208 - 360) mL\\n PS : 10 cmH2O\\n RR (Set): 0\\n RR (Spontaneous): 21\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n PIP: 0 cmH2O\\n SpO2: 99%\\n ABG: ///31/\\n Physical Examination\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Respiratory / Chest: (Breath Sounds: Clear : )\\n Abdominal: Soft, Non-tender, Bowel sounds present, g tube\\n Skin: warm\\n Neurologic: Responds to voice\\n Labs / Radiology\\n 8.4 g/dL\\n 346 K/uL\\n 123 mg/dL\\n 0.7 mg/dL\\n 31 mEq/L\\n 3.8 mEq/L\\n 4 mg/dL\\n 107 mEq/L\\n 144 mEq/L\\n 27.3 %\\n 7.3 K/uL\\n [image002.jpg]\\n 02:58 AM\\n 03:43 AM\\n 05:02 PM\\n 03:36 AM\\n 02:30 AM\\n 01:30 AM\\n 06:41 AM\\n 03:20 PM\\n 03:23 AM\\n 03:00 AM\\n WBC\\n 7.1\\n 7.1\\n 6.9\\n 7.6\\n 9.5\\n 5.7\\n 7.3\\n Hct\\n 28.9\\n 29.2\\n 27.8\\n 32.7\\n 28.6\\n 28.9\\n 30.0\\n 26.9\\n 27.3\\n Plt\\n 462\\n 452\\n 467\\n 548\\n 528\\n 356\\n 346\\n Cr\\n 0.6\\n 0.7\\n 0.8\\n 0.7\\n 0.8\\n 1.0\\n 0.7\\n 0.7\\n Glucose\\n 137\\n 104\\n 108\\n 131\\n 128\\n 121\\n 129\\n 123\\n Other labs: PT / PTT / INR:14.1/23.7/1.2, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.8 mg/dL, Mg++:1.9 mg/dL, PO4:3.7\\n mg/dL\\n Assessment and Plan\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n 18 Gauge - 06:31 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :ICU\\n Total time spent: 40 minutes\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-23 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 639170,\n \"text\": \"Chief Complaint: resp failure\\n HPI:\\n 24 Hour Events:\\n UNPLANNED EXTUBATION (PATIENT-INITIATED) - At 03:50 PM\\n Pt pulled out her trach tube, tube replaced\\n FEVER - 101.4\\nF - 12:00 AM\\n 7 AM pulled out trach again , bradycardia, replaced.\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Amiodarone - 0.5 mg/min\\n Other ICU medications:\\n Metoprolol - 01:00 AM\\n Other medications:\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Constitutional: Fever\\n Flowsheet Data as of 10:26 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.6\\nC (101.4\\n Tcurrent: 36.8\\nC (98.2\\n HR: 116 (84 - 142) bpm\\n BP: 147/84(96) {86/39(53) - 181/113(137)} mmHg\\n RR: 23 (13 - 27) insp/min\\n SpO2: 99%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 2,127 mL\\n 988 mL\\n PO:\\n TF:\\n IVF:\\n 2,127 mL\\n 988 mL\\n Blood products:\\n Total out:\\n 995 mL\\n 900 mL\\n Urine:\\n 995 mL\\n 900 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,132 mL\\n 88 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask\\n Ventilator mode: CPAP/PPS\\n Vt (Set): 0 (0 - 0) mL\\n Vt (Spontaneous): 360 (208 - 360) mL\\n PS : 10 cmH2O\\n RR (Set): 0\\n RR (Spontaneous): 21\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n PIP: 0 cmH2O\\n SpO2: 99%\\n ABG: ///31/\\n Physical Examination\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Respiratory / Chest: (Breath Sounds: Clear : )\\n Abdominal: Soft, Non-tender, Bowel sounds present, g tube\\n Skin: warm\\n Neurologic: Responds to voice\\n Labs / Radiology\\n 8.4 g/dL\\n 346 K/uL\\n 123 mg/dL\\n 0.7 mg/dL\\n 31 mEq/L\\n 3.8 mEq/L\\n 4 mg/dL\\n 107 mEq/L\\n 144 mEq/L\\n 27.3 %\\n 7.3 K/uL\\n [image002.jpg]\\n 02:58 AM\\n 03:43 AM\\n 05:02 PM\\n 03:36 AM\\n 02:30 AM\\n 01:30 AM\\n 06:41 AM\\n 03:20 PM\\n 03:23 AM\\n 03:00 AM\\n WBC\\n 7.1\\n 7.1\\n 6.9\\n 7.6\\n 9.5\\n 5.7\\n 7.3\\n Hct\\n 28.9\\n 29.2\\n 27.8\\n 32.7\\n 28.6\\n 28.9\\n 30.0\\n 26.9\\n 27.3\\n Plt\\n 462\\n 452\\n 467\\n 548\\n 528\\n 356\\n 346\\n Cr\\n 0.6\\n 0.7\\n 0.8\\n 0.7\\n 0.8\\n 1.0\\n 0.7\\n 0.7\\n Glucose\\n 137\\n 104\\n 108\\n 131\\n 128\\n 121\\n 129\\n 123\\n Other labs: PT / PTT / INR:14.1/23.7/1.2, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.8 mg/dL, Mg++:1.9 mg/dL, PO4:3.7\\n mg/dL\\n Assessment and Plan\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n 18 Gauge - 06:31 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :ICU\\n Total time spent: 40 minutes\\n ------ Protected Section------\\n ------ Protected Section Error Entered By: , MD\\n on: 10:46 ------\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-23 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 639260,\n \"text\": \"56 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\\n with prolonged hospital course c/b by PNA, anxiety/altered mental\\n status, R&LUE DVT .Pt found to have small non occlusive Clot on her\\n right axial vein via Ultrasound.Yesterday. She has had problems with\\n vomiting tube feedings, feeding tube passed through g-tube (g-tube in\\n place with mushroom on inside so cannot pull out) to her jejunenum but\\n continues vomit.\\n At 7:30 this am pt pulled out her trach tube with staff 6feet away.\\n Her HR initially was 120\\ns, before an airway could be re-established\\n her HR had blocked down to 38 and she had lost consciousness. She\\n returned as soon as her airway was re-established.\\n Tachycardia, Other\\n Assessment:\\n Pt amiodarone gtt decreased to .5mg/min as ordered at 8am. Following\\n incident described above her HR returned to 80\\ns SR. She remains\\n hemodynamically stable.\\n Action:\\n Continued the amiodarone at .5mg.min for the next 18h\\n Response:\\n Her HR has been 80-94, B/P 138-154/70\\n Plan:\\n Transition her to PO amiodarone at midnight.\\n Alteration in Nutrition\\n Assessment:\\n Pt still has hypoactive bowel sounds. She did have a small loose\\n golden stool at 8am. She remains NPO except for meds\\n Action:\\n Pt on raglan, dose increased to 20mg q6h.\\n Response:\\n Pt still has hypoactive bowel sounds.\\n Plan:\\n Give raglan 20mg as ordered, give dose of lactulose.\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Pt has DVT\\ns in both upper extremities.\\n Action:\\n PICC place in left upper arm, for TPN.\\n Response:\\n Pt restarted on coumadin 2mg as ordered\\n Plan:\\n Monitor INR, given coumadin as ordered\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt continues to be very delirious pulling at everything. She has no\\n memory and will continue to pull at tubes even when standing right next\\n to her.\\n Action:\\n Pt in restraints, with bilateral soft wrist, mitts, and sheet to\\n protect her brace when up in chair.\\n Response:\\n Pt started on 1:1 sitters for her safety, Psych consult done and\\n risperidone ordered.\\n Plan:\\n Given risperidone as ordered with use of zyprexia and safety\\n restraints.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-25 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 639412,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n TF held for vomiting\\n Given D5W x 2 liters for hypernatremia\\n Lovenox 100mg SC BID for DVTs started rather than trying to titrate\\n coumadin, follow INR\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:17 AM\\n Enoxaparin (Lovenox) - 06:00 PM\\n Metoprolol - 06:00 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:23 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.1\\nC (98.8\\n Tcurrent: 36.3\\nC (97.4\\n HR: 68 (64 - 104) bpm\\n BP: 116/51(66) {105/45(44) - 151/74(89)} mmHg\\n RR: 24 (21 - 38) insp/min\\n SpO2: 96%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 2,676 mL\\n 776 mL\\n PO:\\n TF:\\n 61 mL\\n IVF:\\n 1,418 mL\\n 540 mL\\n Blood products:\\n Total out:\\n 1,910 mL\\n 195 mL\\n Urine:\\n 1,910 mL\\n 195 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 766 mL\\n 581 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask\\n SpO2: 96%\\n ABG: ////\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 316 K/uL\\n 8.3 g/dL\\n 114 mg/dL\\n 0.7 mg/dL\\n 33 mEq/L\\n 4.0 mEq/L\\n 7 mg/dL\\n 110 mEq/L\\n 148 mEq/L\\n 27.0 %\\n 8.0 K/uL\\n [image002.jpg]\\n 03:43 AM\\n 05:02 PM\\n 03:36 AM\\n 02:30 AM\\n 01:30 AM\\n 06:41 AM\\n 03:20 PM\\n 03:23 AM\\n 03:00 AM\\n 04:00 AM\\n WBC\\n 7.1\\n 6.9\\n 7.6\\n 9.5\\n 5.7\\n 7.3\\n 8.0\\n Hct\\n 29.2\\n 27.8\\n 32.7\\n 28.6\\n 28.9\\n 30.0\\n 26.9\\n 27.3\\n 27.0\\n Plt\\n 452\\n 467\\n 548\\n 528\\n 356\\n 346\\n 316\\n Cr\\n 0.7\\n 0.8\\n 0.7\\n 0.8\\n 1.0\\n 0.7\\n 0.7\\n 0.7\\n Glucose\\n 104\\n 108\\n 131\\n 128\\n 121\\n 129\\n 123\\n 114\\n Other labs: PT / PTT / INR:13.2/22.4/1.1, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:9.0 mg/dL, Mg++:2.3 mg/dL, PO4:4.1\\n mg/dL\\n Assessment and Plan\\n ICU Care\\n Nutrition:\\n TPN without Lipids - 06:10 PM 43. mL/hour\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n PICC Line - 01:30 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-26 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 639599,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Pt agitated overnight given extra Risperidone 0.5 mg x 2 overnight.\\n (1.5mg total)\\n 1000 mL D5W for Hypernatremia\\n Changed B-Blocker from IV to PO, Metoprolol Tartrate 25 mg PO TID\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:17 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:47 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.8\\nC (98.2\\n Tcurrent: 36.7\\nC (98\\n HR: 120 (67 - 120) bpm\\n BP: 110/64(76) {109/47(60) - 141/115(118)} mmHg\\n RR: 26 (18 - 30) insp/min\\n SpO2: 100%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 3,820 mL\\n 856 mL\\n PO:\\n TF:\\n 117 mL\\n 20 mL\\n IVF:\\n 2,612 mL\\n 572 mL\\n Blood products:\\n Total out:\\n 2,460 mL\\n 1,180 mL\\n Urine:\\n 2,460 mL\\n 1,180 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,360 mL\\n -324 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask\\n SpO2: 100%\\n ABG: ///33/\\n Physical Examination\\n Gen: Awake, Mouthing words, More agitated compared to previous\\n mornings.\\n HEENT: EOMI, No pallor in conjunctiva, MMM\\n Resp: CTAB, no rales, rhonchi, or wheezing, good airway movement.\\n Card: S1S2 tachycardic, no m/r/g\\n Abd: Obese, soft, mildly distended, decreased bowel sounds,, G-Tube in\\n place with no erythema/induration\\n Exte: No edema, DP 2+ bil\\n NEURO: Gross Motor and Sensation in 4 extremities\\n Labs / Radiology\\n 249 K/uL\\n 8.0 g/dL\\n 122 mg/dL\\n 0.5 mg/dL\\n 33 mEq/L\\n 3.7 mEq/L\\n 13 mg/dL\\n 108 mEq/L\\n 146 mEq/L\\n 24.7 %\\n 5.5 K/uL\\n [image002.jpg] CXR: L Picc, trach tip at midline, bibasilar\\n opacities, low lung volumes, Bil pleural effusions.\\n 03:36 AM\\n 02:30 AM\\n 01:30 AM\\n 06:41 AM\\n 03:20 PM\\n 03:23 AM\\n 03:00 AM\\n 04:00 AM\\n 05:45 AM\\n 03:51 AM\\n WBC\\n 6.9\\n 7.6\\n 9.5\\n 5.7\\n 7.3\\n 8.0\\n 8.7\\n 5.5\\n Hct\\n 27.8\\n 32.7\\n 28.6\\n 28.9\\n 30.0\\n 26.9\\n 27.3\\n 27.0\\n 28.7\\n 24.7\\n Plt\\n 467\\n 548\\n 528\\n 356\\n 346\\n 316\\n 271\\n 249\\n Cr\\n 0.7\\n 0.8\\n 1.0\\n 0.7\\n 0.7\\n 0.7\\n 0.7\\n 0.5\\n Glucose\\n 131\\n 128\\n 121\\n 129\\n 123\\n 114\\n 112\\n 122\\n Other labs: PT / PTT / INR:13.6/31.1/1.2, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:9.0 mg/dL, Mg++:2.2 mg/dL, PO4:3.1\\n mg/dL\\n Assessment and Plan\\n 56yoF s/p mechanical fall and traumatic T spine fracture, now s/p\\n trach/PEG with resolving respiratory failure and HAP.\\n .\\n # Respiratory failure: s/p intubation/extubation, now on trach mask,\\n FiO2 70%. Tolerating well with good O2 sat. No further\\n self-decanulations overnight.\\n - Tach mask as tolerated.\\n - Holding sedation with exception of Risperidal 0.5mg .\\n - F/u CXR tomorrow\\n .\\n # Nutrition/Vomiting: Currently receiving TPN;. One large BM in past\\n 24 hrs to indicate potential improvement in ileus.\\n - Cont Reglan 20mg IV Q 8 hours; meds via G-J tube,\\n - Will obtain recommendations from Nutrition re TPN before starting TPN\\n tomorrow\\n - TF as tolerated\\n - Speech and Swallow eval\\n - PICC line in place with TPN given when pt not tolerating TF\\n - GI consult, appreciate recs\\n .\\n # Tachycardia: Improved HR max of 120\\ns versus 160s previously;\\n elevated this am secondary to agitation. Pt now on PO Amiodarone 200\\n TID and PO metoprolol 25mg TID\\n - Continue current med regimen. Will continue amiodarone 200 TID for\\n three weeks and then switch to qday.\\n - Will schedule f/u in 4wks with Dr. upon d/c/transfer.\\n - f/u Cards recs\\n # Sedation/Anxiolysis/AlteredMS: Agitation O/N, continues to be\\n agitated most likely secondary to long hospital course and multiple\\n psychotropic medications as well as hx of EtOH abuse. Risperdal given\\n O/N.\\n - started Risperdal 0.5mg PO BID\\n - continue to hold all benzos. opiates, and antihistamines\\n - Appreciate psych. Will call and f/u psych recs.\\n #Anemia: Decrease in HCT from 28\\n24; tachycardia. No known etiology of\\n blood loss, most likely related to variaton\\n -Will repeat HCT check this afternoon.\\n # Hypernatremia/Fluid Status: Mild hypernatramia with good UOP\\n (hypervolemic hypernatremia). On TPN/TF.\\n - providing D5W IVF, free water flushes with TF\\n -Will f/u lytes (Na) this afternoon at 5pm.\\n # UE DVT and elevated INR: Decision made to d/c Coumadin given her\\n labile INR, and start Lovenox . Current INR 1.2.\\n - Will flush L PICC with TPA if does not flush\\n .\\n # Spine fracture: Stable\\n - Brace for OOB, need to discuss with Neurosurgery before d/c if\\n current brace is optimal for stabilization given her mobility.\\n - Pt to follow up with Dr. in weeks\\n .\\n # Tracheomalacia. Was initially addressed with IP and they wanted to\\n follow up as outpatient. IP reevaluated and does not believe that a\\n stent would be feasible. No new issues.\\n .\\n #. Thyroid Nodule on CT\\n - Outpatient follow up\\n .\\n # Glycemic control: SSI, well controlled\\n # ACCESS: PIV x 1, L PICC\\n # Ppx: Lovenox, PPi, Bowel Regimen PRN\\n # Communication:\\n - Boyfriend of 10 \\n - Brother also involved\\n - Social Work and Case management involved, have discussed situation\\n w/ brother and boyfriend.\\n # Code: Full\\n # Dispo: ICU, Will d/w case management re rehab facilities.\\n PGY2 Addendum\\n Agree with excellent MS4 PN. Will touch base with psychiatry re:\\n sedating meds and EP re: atrial tachycardia. Will obtain EKG to\\n reassess QTc. Ordered for TPN. Giving d5W for hypernatremia. Re-consult\\n S/S for PMV re-fitting. transfer to LTAC.\\n \\n PGY2\\n ------ Protected Section ------\\n MICU Attending Addendum:\\n ------ Protected Section Addendum Entered By: , MD\\n on: 16:21 ------\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-19 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 638487,\n \"text\": \"56yo woman admitted 1 month ago with unstentable tracheal malacia,\\n failure to wean.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Rec\\nd pt on MMV settings, no spont resp. Pt unarousable per below until\\n 0830 when she woke and was placed on TM with high flow neb@ 50%.\\n Action:\\n Response:\\n Plan:\\n Tachycardia, Other\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Arousal, Attention, and Cognition, Impaired\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-21 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 638680,\n \"text\": \"Nausea / vomiting\\n Assessment:\\n NPO. Vomitted meds ~10\\n after given via gtube. Coughing same emesis\\n from tracheostomy. Later found to have vomited coffee ground emesis,\\n guiac +. Denies nausea every time although continues to dry heave,\\n vomit small amts clear emesis. BRB suctioned from back of throat also,\\n d/t irritation from frequent vomiting. Abd soft, hypoactive BS.\\n Action:\\n Tube feeds on hold. No residual aspirated from gtube, gtube\\n placed->>gravity. Stat Hct, coags T&S sent. Zofran x 1. HOB^^ 30. 2^nd\\n PIV placed.\\n Response:\\n On/off vomiting, coffee grounds x 1, with no c/o nausea. Hct 28.6,\\n baseline. INR 10.5 .\\n Plan:\\n Recheck Hct, FDP @ 7AM. Zofran. NPO. IV meds only. Needs gtube changed\\n to jtube.\\n Tachycardia, Other\\n Assessment:\\n ST 109-114, NSR 70s briefly. No lopressor given d/t BP<100 most of\\n night when pt sleeping.\\n Action:\\n Lopressor changed from PO->>IV prn d/t vomiting after meds.\\n Response:\\n ST 110s most of night.\\n Plan:\\n IV lopressor prn for HR>130.\\n Alteration in Nutrition\\n Assessment:\\n NPO. Na 146 x 2. D5W per orders. UOP decreased 10-20cc/hr with lower\\n BP.\\n Action:\\n D5W now @ 150cc/hr x 1 liter.\\n Response:\\n Na 146.\\n Plan:\\n Recheck Na @ 7AM. D5W x 1 liter.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n On 50% trach mask all day. RR ^^40 after first episode of vomiting last\\n night. Copious thick tan, dark brown secretions.\\n Action:\\n Placed on Vent MMV mode when tachypneic. Frequent suctioning.\\n Response:\\n Comfortable on vent, RR 12 (set), Sats 100%.\\n Plan:\\n Wean from vent as tolerated. Suction as needed, MDIs.\\n Altered mental status (not Delirium)\\n Assessment:\\n Occaisionally restless, less so than night before. Slept most of night,\\n sometimes difficult to arouse. No zyprexa given. Opens eyes to voice,\\n follows commands. Mouthing words although difficult to understand.\\n Action:\\n Reorient pt prn. Emotional support.\\n Response:\\n Slept most of night, calmer than previous nights.\\n Plan:\\n No valium or benadryl per psych recommendations. Zyprexa HS prn for\\n agitation. Reorient prn. Emotional support.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-21 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 638681,\n \"text\": \"Nausea / vomiting\\n Assessment:\\n NPO. Vomitted meds ~10\\n after given via gtube. Coughing same emesis\\n from tracheostomy. Later found to have vomited coffee ground emesis,\\n guiac +. Denies nausea every time although continues to dry heave,\\n vomit small amts clear emesis. BRB suctioned from back of throat also,\\n d/t irritation from frequent vomiting. Abd soft, hypoactive BS.\\n Action:\\n Tube feeds on hold. No residual aspirated from gtube, gtube\\n placed->>gravity. Stat Hct, coags T&S sent. Zofran x 1. HOB^^ 30. 2^nd\\n PIV placed.\\n Response:\\n On/off vomiting, coffee grounds x 1, with no c/o nausea. Hct 28.6,\\n baseline. INR 10.5 .\\n Plan:\\n Recheck Hct, FDP @ 7AM. Zofran. NPO. IV meds only. Needs gtube changed\\n to jtube.\\n Tachycardia, Other\\n Assessment:\\n ST 109-114, NSR 70s briefly. No lopressor given d/t BP<100 most of\\n night when pt sleeping.\\n Action:\\n Lopressor changed from PO->>IV prn d/t vomiting after meds.\\n Response:\\n ST 110s most of night.\\n Plan:\\n IV lopressor prn for HR>130.\\n Alteration in Nutrition\\n Assessment:\\n NPO. Na 146 x 2. D5W per orders. UOP decreased 10-20cc/hr with lower\\n BP.\\n Action:\\n D5W now @ 150cc/hr x 1 liter.\\n Response:\\n Na 146.\\n Plan:\\n Recheck Na @ 7AM. D5W x 1 liter.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n On 50% trach mask all day. RR ^^40 after first episode of vomiting last\\n night. Copious thick tan, dark brown secretions.\\n Action:\\n Placed on Vent MMV mode when tachypneic. Frequent suctioning.\\n Response:\\n Comfortable on vent, RR 12 (set), Sats 100%.\\n Plan:\\n Wean from vent as tolerated. Suction as needed, MDIs.\\n Altered mental status (not Delirium)\\n Assessment:\\n Occaisionally restless, less so than night before. Slept most of night,\\n sometimes difficult to arouse. No zyprexa given. Opens eyes to voice,\\n follows commands. Mouthing words although difficult to understand.\\n Action:\\n Reorient pt prn. Emotional support.\\n Response:\\n Slept most of night, calmer than previous nights.\\n Plan:\\n No valium or benadryl per psych recommendations. Zyprexa HS prn for\\n agitation. Reorient prn. Emotional support.\\n\"\n },\n {\n \"category\": \"Nutrition\",\n \"chartdate\": \"2167-10-23 00:00:00.000\",\n \"description\": \"Clinical Nutrition Note\",\n \"row_id\": 639158,\n \"text\": \"Objective\\n Pertinent medications: thiamine, folic acid, hep, protonix, colace,\\n senna, reglan, D5w at 75ml/hr, others noted\\n Labs:\\n Value\\n Date\\n Glucose\\n 123 mg/dL\\n 03:00 AM\\n Glucose Finger Stick\\n 121\\n 04:00 AM\\n BUN\\n 4 mg/dL\\n 03:00 AM\\n Creatinine\\n 0.7 mg/dL\\n 03:00 AM\\n Sodium\\n 144 mEq/L\\n 03:00 AM\\n Potassium\\n 3.8 mEq/L\\n 03:00 AM\\n Chloride\\n 107 mEq/L\\n 03:00 AM\\n TCO2\\n 31 mEq/L\\n 03:00 AM\\n PO2 (arterial)\\n 120 mm Hg\\n 03:36 AM\\n PO2 (venous)\\n 62 mm Hg\\n 02:35 AM\\n PCO2 (arterial)\\n 44 mm Hg\\n 03:36 AM\\n PCO2 (venous)\\n 58 mm Hg\\n 02:35 AM\\n pH (arterial)\\n 7.37 units\\n 03:36 AM\\n pH (venous)\\n 7.37 units\\n 02:35 AM\\n pH (urine)\\n 5.0 units\\n 03:05 AM\\n CO2 (Calc) arterial\\n 26 mEq/L\\n 03:36 AM\\n CO2 (Calc) venous\\n 35 mEq/L\\n 02:35 AM\\n Albumin\\n 3.1 g/dL\\n 03:23 AM\\n Calcium non-ionized\\n 8.8 mg/dL\\n 03:00 AM\\n Phosphorus\\n 3.7 mg/dL\\n 03:00 AM\\n Ionized Calcium\\n 1.24 mmol/L\\n 02:51 AM\\n Magnesium\\n 1.9 mg/dL\\n 03:00 AM\\n ALT\\n 25 IU/L\\n 07:34 AM\\n Alkaline Phosphate\\n 106 IU/L\\n 07:34 AM\\n AST\\n 19 IU/L\\n 07:34 AM\\n Amylase\\n 10 IU/L\\n 03:59 AM\\n Total Bilirubin\\n 0.2 mg/dL\\n 07:34 AM\\n WBC\\n 7.3 K/uL\\n 03:00 AM\\n Hgb\\n 8.4 g/dL\\n 03:00 AM\\n Hematocrit\\n 27.3 %\\n 03:00 AM\\n Current diet order / nutrition support: NPO\\n GI:\\n Assessment of Nutritional Status\\n Estimation of previous intake: Inadequate\\n Estimation of current intake: Inadequate\\n Specifics:\\n 55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\\n trach, PEG placement now with respiratory failure secondary to\\n tracheomalacia. Pt has not been tol TF since last wk, pt s/p\\n pediatric feeding tube placed by GI through her PEG tube into her\\n jejunum, and was given TFs last night, which pt vomited. Pt also s/p\\n tube study this am that showed dysmotility of her jejunum, etiology of\\n ileus unclear and ? pt' s chronic baseline or d/t long course of\\n opiates during MICU stay. PICC line ordered to place and will need to\\n start TPN today.\\n Medical Nutrition Therapy Plan - Recommend the Following\\n Multivitamin / Mineral supplement: in NS, d/c outside folic acid and\\n thiamine\\n TPN recommendations: start day 1 (150dex/70aa), 70NaCl, 10KCl, 30KPhos,\\n 10Mg, 10Ca, thiamine and folic acid in tpn\\n Check chemistry 10 panel daily, replete prn\\n Check triglycerides\\n Start regular insulin sliding scale if serum glucose >150 mg/dL\\n Change to non-dextrose IV fluids once TPN starts\\n Provided BG < 150 and Trig < 400, can cont to adv TPN to goal of 60kg\\n 3-in-1 to provide 1500kcal/day in the next few days\\n Retrial TF with Vivonex ( low fat, elemental formula) at 10ml/hr if\\n medically allowed\\n Please page if has ?\\n\"\n },\n {\n \"category\": \"Nutrition\",\n \"chartdate\": \"2167-10-23 00:00:00.000\",\n \"description\": \"Clinical Nutrition Note\",\n \"row_id\": 639159,\n \"text\": \"Objective\\n Pertinent medications: thiamine, folic acid, hep, protonix, colace,\\n senna, reglan, D5w at 75ml/hr, others noted\\n Labs:\\n Value\\n Date\\n Glucose\\n 123 mg/dL\\n 03:00 AM\\n Glucose Finger Stick\\n 121\\n 04:00 AM\\n BUN\\n 4 mg/dL\\n 03:00 AM\\n Creatinine\\n 0.7 mg/dL\\n 03:00 AM\\n Sodium\\n 144 mEq/L\\n 03:00 AM\\n Potassium\\n 3.8 mEq/L\\n 03:00 AM\\n Chloride\\n 107 mEq/L\\n 03:00 AM\\n TCO2\\n 31 mEq/L\\n 03:00 AM\\n PO2 (arterial)\\n 120 mm Hg\\n 03:36 AM\\n PO2 (venous)\\n 62 mm Hg\\n 02:35 AM\\n PCO2 (arterial)\\n 44 mm Hg\\n 03:36 AM\\n PCO2 (venous)\\n 58 mm Hg\\n 02:35 AM\\n pH (arterial)\\n 7.37 units\\n 03:36 AM\\n pH (venous)\\n 7.37 units\\n 02:35 AM\\n pH (urine)\\n 5.0 units\\n 03:05 AM\\n CO2 (Calc) arterial\\n 26 mEq/L\\n 03:36 AM\\n CO2 (Calc) venous\\n 35 mEq/L\\n 02:35 AM\\n Albumin\\n 3.1 g/dL\\n 03:23 AM\\n Calcium non-ionized\\n 8.8 mg/dL\\n 03:00 AM\\n Phosphorus\\n 3.7 mg/dL\\n 03:00 AM\\n Ionized Calcium\\n 1.24 mmol/L\\n 02:51 AM\\n Magnesium\\n 1.9 mg/dL\\n 03:00 AM\\n ALT\\n 25 IU/L\\n 07:34 AM\\n Alkaline Phosphate\\n 106 IU/L\\n 07:34 AM\\n AST\\n 19 IU/L\\n 07:34 AM\\n Amylase\\n 10 IU/L\\n 03:59 AM\\n Total Bilirubin\\n 0.2 mg/dL\\n 07:34 AM\\n WBC\\n 7.3 K/uL\\n 03:00 AM\\n Hgb\\n 8.4 g/dL\\n 03:00 AM\\n Hematocrit\\n 27.3 %\\n 03:00 AM\\n Current diet order / nutrition support: NPO\\n Assessment of Nutritional Status\\n Estimation of previous intake: Inadequate\\n Estimation of current intake: Inadequate\\n Specifics:\\n 55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\\n trach, PEG placement now with respiratory failure secondary to\\n tracheomalacia. Pt has not been tol TF since last wk, pt s/p\\n pediatric feeding tube placed by GI through her PEG tube into her\\n jejunum, and was given TFs last night, which pt vomited. Pt also s/p\\n tube study this am that showed dysmotility of her jejunum, etiology of\\n ileus unclear and ? pt' s chronic baseline or d/t long course of\\n opiates during MICU stay. PICC line ordered to place and will need to\\n start TPN today. Noted pt with elevated Na, currently on D5w, need to\\n monitor BG closely.\\n Medical Nutrition Therapy Plan - Recommend the Following\\n Multivitamin / Mineral supplement: in NS, d/c outside folic acid and\\n thiamine\\n TPN recommendations: start day 1 (150dex/70aa), 50NaCl, 10KCl, 30KPhos,\\n 10Mg, 10Ca, thiamine and folic acid in tpn\\n Check chemistry 10 panel daily, replete prn\\n Check triglycerides\\n Cont bg management\\n Change to non-dextrose IV fluids once TPN starts if Na comes down,\\n Provided BG < 150 and Trig < 400, can cont to adv TPN to goal of 60kg\\n 3-in-1 to provide 1500kcal/day in the next few days\\n Retrial TF with Vivonex ( low fat, elemental formula) at 10ml/hr if\\n medically allowed\\n Please page if has ?\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-25 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 639414,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n TF held for vomiting\\n Given D5W x 2 liters for hypernatremia\\n Lovenox 100mg SC BID for DVTs started rather than trying to titrate\\n coumadin, follow INR\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:17 AM\\n Enoxaparin (Lovenox) - 06:00 PM\\n Metoprolol - 06:00 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:23 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.1\\nC (98.8\\n Tcurrent: 36.3\\nC (97.4\\n HR: 68 (64 - 104) bpm\\n BP: 116/51(66) {105/45(44) - 151/74(89)} mmHg\\n RR: 24 (21 - 38) insp/min\\n SpO2: 96%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 2,676 mL\\n 776 mL\\n PO:\\n TF:\\n 61 mL\\n IVF:\\n 1,418 mL\\n 540 mL\\n Blood products:\\n Total out:\\n 1,910 mL\\n 195 mL\\n Urine:\\n 1,910 mL\\n 195 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 766 mL\\n 581 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask\\n SpO2: 96%\\n ABG: ////\\n Physical Examination\\n Gen: Asleep, unarousable, responds minimally to noxious stimuli\\n HEENT: PERRL, MMM\\n Resp: CTA bilaterally, no rales, rhonchi, or wheezing, small\\n inspirations.\\n Card: S1S2 tachycardic, no m/r/g\\n Abd: Obese, soft, mildly distended, BS+\\n Exte: No edema, DP 2+ bil\\n NEURO: reflexes 2+ bilaterally.\\n Labs / Radiology\\n 316 K/uL\\n 8.3 g/dL\\n 114 mg/dL\\n 0.7 mg/dL\\n 33 mEq/L\\n 4.0 mEq/L\\n 7 mg/dL\\n 110 mEq/L\\n 148 mEq/L\\n 27.0 %\\n 8.0 K/uL\\n [image002.jpg]\\n 03:43 AM\\n 05:02 PM\\n 03:36 AM\\n 02:30 AM\\n 01:30 AM\\n 06:41 AM\\n 03:20 PM\\n 03:23 AM\\n 03:00 AM\\n 04:00 AM\\n WBC\\n 7.1\\n 6.9\\n 7.6\\n 9.5\\n 5.7\\n 7.3\\n 8.0\\n Hct\\n 29.2\\n 27.8\\n 32.7\\n 28.6\\n 28.9\\n 30.0\\n 26.9\\n 27.3\\n 27.0\\n Plt\\n 452\\n 467\\n 548\\n 528\\n 356\\n 346\\n 316\\n Cr\\n 0.7\\n 0.8\\n 0.7\\n 0.8\\n 1.0\\n 0.7\\n 0.7\\n 0.7\\n Glucose\\n 104\\n 108\\n 131\\n 128\\n 121\\n 129\\n 123\\n 114\\n Other labs: PT / PTT / INR:13.2/22.4/1.1, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:9.0 mg/dL, Mg++:2.3 mg/dL, PO4:4.1\\n mg/dL\\n Assessment and Plan\\n 55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\\n trach, PEG placement now with respiratory failure secondary to\\n tracheomalacia , resolved HAP.\\n .\\n # Respiratory failure: Slowly improving, spending most of the day on\\n trach mask with short periods of rest on PSV at night and setbacks\\n from increased secretions to vomiting/aspiration events and her\\n self-decanulations.\\n - Continue to increase time on trach mask as tolerated.\\n - Discontinue all orders for sedation except for Risperdal QHS.\\n - PMV with suctioning as tolerated\\n # Nutrition/Vomiting: Normal CT-abdomen, had FT placed via peg into\\n jejunum, but continued to vomit. Tube study showed dysmotility in small\\n bowel, but no obstruction, no retrograde flow. GI recs Reglan 20mg IV Q\\n 8 hours and restart meds via G-J tube, if tolerated slowly restart TFs.\\n PICC line placed yesterday and TPN started.\\n - GI consult, appreciate recs\\n - Small volume TFs start today\\n - Continue TPN today\\n # HAP vs Aspiration PNA: Had been afebrile for last several days, now\\n with new fever two nights ago after having decanulated herself. Likely\\n had some aspiration. Chemical pneumonitis versus new aspiration PNA.\\n Now Afebrile for past 24 hours.\\n - f/u daily CXR\\n - F/u cx data\\n - If remains febrile, send sputum cx, otherwise hold on abx.\\n .\\n # Tachycardia: Pt in and out of SVT and sinus, increased BB seems to\\n help, but pt does not stay in sinus. Cards rec to start Amiodarone IV\\n drip, and then convert to PO, 200mg TID. Would consider EPS if\\n amiodarone not successful, though would wait until pt more stable for\\n general anesthesia.\\n - Changed to IV metoprolol to 10mg IV q4hr.\\n - Completed amiodarone 0.5mg/min IV drip x 18 hours, and converted to\\n 200mg PO TID..\\n - Cards c/s, appreciate recs\\n # Sedation/Anxiolysis/AlteredMS: unclear etiology of her confusion and\\n agitation. Has had long hospital course and multiple psychotropic\\n medications as well as hx of EtOH abuse.\\n - d/c all benzos. opiates, and antihistamines\\n - Psychiatry consulted, appreciate recs\\n - started Risperdal 0.5mg PO BID, d/c zyprexa.\\n # Adrenal Insufficency: Endocrine following. Pt does not appear to be\\n adrenally insufficient at baseline. Suggesting if the patient under\\n goes major stressors such as major surgery, sepsis, she may need stress\\n dosed steroids.\\n .\\n # Fluid Status: Likely approaching euvolemia, though still has mild\\n hypernatramia which may suggest is still intravascularly depleated.\\n - Monitoring urine output\\n - will provide D5W IVF as need for hypernatremia and follow lytes\\n # UE DVT and elevated INR: DVT in right UE has resolved, new\\n non-occlusive in left axillary vein. INR has been volatile, likely from\\n drug interactions and poor nutritional status. Have been unable to keep\\n her appropariately therapeutic.\\n - d/c coumadin\\n - start Lovenox, maintain until GI issues resolved and can restart\\n coumadin\\n .\\n #Hematemesis: Pt had small amt Hematemesis, after vomiting, last week.\\n None today. HCT stable.\\n -Will follow HCT.\\n - Guaiac stools\\n # Spine fracture: Stable\\n - Brace for OOB, will discuss with Neurosurgery if current brace is\\n optimal for stabilization given her mobility.\\n - Pt to follow up with Dr. in weeks\\n .\\n # Tracheomalacia. Was initially addressed with IP and they wanted to\\n follow up as outpatient. IP reevaluated and does not believe that a\\n stent would be feasible.\\n .\\n #. Thyroid Nodule on CT\\n - Outpatient follow up\\n .\\n # Glycemic control: SSI, well controlled\\n # ACCESS: PIV x 1, PICC placement yesterday.\\n # Ppx: subtherapeutic INR restarting coumadin today, Ranitidine, Bowel\\n Regimen PRN\\n # Communication:\\n - Boyfriend of 10 \\n - Brother also involved\\n - Social Work and Case management involved, have discussed situation\\n w/ brother and boyfriend.\\n # Code: Full\\n # Dispo: ICU, Screening for vent facilities\\n ICU Care\\n Nutrition:\\n TPN without Lipids - 06:10 PM 43. mL/hour\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n PICC Line - 01:30 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2167-10-20 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 638539,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 32\\n Ideal body weight: 61.2 None\\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: Yes\\n Tracheostomy tube:\\n Type: Standard, Cuffed, Inner Cannula\\n Manufacturer: Portex\\n Size: 8.0mm\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Rhonchi\\n LUL Lung Sounds: Rhonchi\\n LLL Lung Sounds: Diminished\\n Secretions\\n Sputum color / consistency: White / Thick\\n Sputum source/amount: Suctioned / Moderate\\n Ventilation Assessment\\n Level of breathing assistance: Continuous invasive ventilation\\n Visual assessment of breathing pattern: Normal quiet breathing\\n Assessment of breathing comfort: No claim of dyspnea); Comments: Pt on\\n trach collar for most of the night. Dipping sats and high RR, pt then\\n placed on vent to \\\"rest\\\"\\n Invasive ventilation assessment:\\n Trigger work assessment: Triggering synchronously\\n Plan\\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\\n Periodic SBT's for conditioning; Comments: Continue with trach trials\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-21 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 638738,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Multiple vomitting episodes, not improved much w/ zofran.\\n Unable to tolerate anything through her PEG\\n Had an Abdominal CT w/contrast, but vomitted up most of the constrast.\\n limited study. Prelim read: no obstruction, PEG in place\\n Nurse positive coffe-grounds emesis and w/ a later\\n episode, clear emesis with some small blood when she suctioned the\\n posterior pharynx.\\n TFs were held\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:44 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.8\\nC (98.2\\n Tcurrent: 36.7\\nC (98\\n HR: 110 (76 - 136) bpm\\n BP: 98/63(60) {80/40(49) - 149/88(92)} mmHg\\n RR: 12 (12 - 33) insp/min\\n SpO2: 100%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 2,241 mL\\n 1,335 mL\\n PO:\\n TF:\\n IVF:\\n 1,941 mL\\n 1,335 mL\\n Blood products:\\n Total out:\\n 1,860 mL\\n 140 mL\\n Urine:\\n 1,830 mL\\n 90 mL\\n NG:\\n 30 mL\\n 50 mL\\n Stool:\\n Drains:\\n Balance:\\n 381 mL\\n 1,195 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: MMV/PSV/AutoFlow\\n Vt (Set): 500 (500 - 500) mL\\n Vt (Spontaneous): 809 (300 - 1,054) mL\\n PS : 10 cmH2O\\n RR (Set): 12\\n RR (Spontaneous): 0\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n RSBI Deferred: No Spon Resp\\n PIP: 21 cmH2O\\n Plateau: 15 cmH2O\\n SpO2: 100%\\n ABG: ///35/\\n Ve: 5.8 L/min\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 528 K/uL\\n 9.2 g/dL\\n 121 mg/dL\\n 1.0 mg/dL\\n 35 mEq/L\\n 3.4 mEq/L\\n 6 mg/dL\\n 103 mEq/L\\n 146 mEq/L\\n 28.6 %\\n 9.5 K/uL\\n [image002.jpg]\\n 02:06 AM\\n 07:34 AM\\n 03:50 AM\\n 06:22 AM\\n 02:58 AM\\n 03:43 AM\\n 05:02 PM\\n 03:36 AM\\n 02:30 AM\\n 01:30 AM\\n WBC\\n 7.5\\n 5.6\\n 6.1\\n 7.0\\n 7.1\\n 7.1\\n 6.9\\n 7.6\\n 9.5\\n Hct\\n 26.8\\n 27.0\\n 27.0\\n 29.7\\n 28.9\\n 29.2\\n 27.8\\n 32.7\\n 28.6\\n Plt\\n 95\\n 462\\n 452\\n 467\\n 548\\n 528\\n Cr\\n 0.6\\n 0.5\\n 0.7\\n 0.7\\n 0.6\\n 0.7\\n 0.8\\n 0.7\\n 0.8\\n 1.0\\n Glucose\\n 134\\n 121\\n 619\\n 126\\n 137\\n 104\\n 108\\n 131\\n 128\\n 121\\n Other labs: PT / PTT / INR:82.1/35.9/10.5, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:9.7 mg/dL, Mg++:2.4 mg/dL, PO4:2.9\\n mg/dL\\n Assessment and Plan\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n 18 Gauge - 04:00 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-21 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 638740,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Multiple vomitting episodes, not improved much w/ zofran.\\n Unable to tolerate anything through her PEG\\n Had an Abdominal CT w/contrast, but vomitted up most of the constrast.\\n limited study. Prelim read: no obstruction, PEG in place\\n Nurse positive coffe-grounds emesis and w/ a later\\n episode, clear emesis with some small blood when she suctioned the\\n posterior pharynx.\\n TFs were held\\n Dr. had a conversation with the pt\\ns brother.\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:44 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.8\\nC (98.2\\n Tcurrent: 36.7\\nC (98\\n HR: 110 (76 - 136) bpm\\n BP: 98/63(60) {80/40(49) - 149/88(92)} mmHg\\n RR: 12 (12 - 33) insp/min\\n SpO2: 100%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 2,241 mL\\n 1,335 mL\\n PO:\\n TF:\\n IVF:\\n 1,941 mL\\n 1,335 mL\\n Blood products:\\n Total out:\\n 1,860 mL\\n 140 mL\\n Urine:\\n 1,830 mL\\n 90 mL\\n NG:\\n 30 mL\\n 50 mL\\n Stool:\\n Drains:\\n Balance:\\n 381 mL\\n 1,195 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: MMV/PSV/AutoFlow\\n Vt (Set): 500 (500 - 500) mL\\n Vt (Spontaneous): 809 (300 - 1,054) mL\\n PS : 10 cmH2O\\n RR (Set): 12\\n RR (Spontaneous): 0\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n RSBI Deferred: No Spon Resp\\n PIP: 21 cmH2O\\n Plateau: 15 cmH2O\\n SpO2: 100%\\n ABG: ///35/\\n Ve: 5.8 L/min\\n Physical Examination\\n Gen: Obtunded this am, not responsive to voice, minimally responsive to\\n noxious stimuli, on MMV through trach tube, but later responsive to\\n voice, appropriate, asking questions, mouthing responses\\n HEENT: PERRL, MMM,\\n Resp: Coarse BS anteriorly, no focal rales, rhonchi, or wheezing with\\n some referred upper airway noises from secretions.\\n Card: S1S2 tachycardic, no m/r/g\\n Abd: Obese, soft, mildly distended, hypoactive BS\\n Exte: No edema, DP 2+ bil.\\n NEURO: Toes downgoing bilaterally,\\n Labs / Radiology\\n 528 K/uL\\n 9.2 g/dL\\n 121 mg/dL\\n 1.0 mg/dL\\n 35 mEq/L\\n 3.4 mEq/L\\n 6 mg/dL\\n 103 mEq/L\\n 146 mEq/L\\n 28.6 %\\n 9.5 K/uL\\n [image002.jpg]\\n 02:06 AM\\n 07:34 AM\\n 03:50 AM\\n 06:22 AM\\n 02:58 AM\\n 03:43 AM\\n 05:02 PM\\n 03:36 AM\\n 02:30 AM\\n 01:30 AM\\n WBC\\n 7.5\\n 5.6\\n 6.1\\n 7.0\\n 7.1\\n 7.1\\n 6.9\\n 7.6\\n 9.5\\n Hct\\n 26.8\\n 27.0\\n 27.0\\n 29.7\\n 28.9\\n 29.2\\n 27.8\\n 32.7\\n 28.6\\n Plt\\n 95\\n 462\\n 452\\n 467\\n 548\\n 528\\n Cr\\n 0.6\\n 0.5\\n 0.7\\n 0.7\\n 0.6\\n 0.7\\n 0.8\\n 0.7\\n 0.8\\n 1.0\\n Glucose\\n 134\\n 121\\n 619\\n 126\\n 137\\n 104\\n 108\\n 131\\n 128\\n 121\\n Other labs: PT / PTT / INR:82.1/35.9/10.5, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:9.7 mg/dL, Mg++:2.4 mg/dL, PO4:2.9\\n mg/dL\\n Assessment and Plan\\n 55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\\n trach, PEG placement now with respiratory failure secondary to\\n tracheomalacia , resolved HAP.\\n .\\n # Respiratory failure: Slowly Improving. Now remaining on trach mask\\n for most of the day, with periods of pressure support of over\\n night. This am on MMV. Previously likely oversedated with Benadryl,\\n Morhpine, and Valium which were held overnight. Pt awake and alert at\\n rounds, interactive, and breathing comfortably on trach mask\\n - Continue to increase time on trach mask as tolerated.\\n - Decrease sedation and valium use\\n - PMV with suctioning\\n .\\n # HAP vs Aspiration PNA: Afebrile without leukocytosis\\n - Completed course of ceftriaxone\\n - good O2 saturation on trach mask\\n - Continue to f/u cultures\\n .\\n # Tachycardia: Previously was assessed as sinus tach with occasional\\n runs of SVT and sources such as hypovolemia, PE, infection, and pain\\n were assessed as possibly etiologies. Per Cardiology, most likely AT\\n given transient response to Adenosine. HR occasionally decreases to\\n 70s-80s w/ stable BPs at times that might be associated with\\n administration of her BB and valium. Cards recommended titating up her\\n beta blocker as tolerated. Dose increased to 37.5 yesterday but still\\n tachycardic.\\n - EP consulted for conversion of SVT, appreciate recs\\n - Increase metoprolol to 50 PO QID with holding parameters\\n .\\n # Sedation: Inconsistent response to sedation, unclear what is best\\n regime. Will continue to wean overall.\\n - Continue w Olanzapine QHS\\n - Just valium 2.5 mg PRN.\\n # Nutrition/Vomiting: Pt has had several episodes of vomiting up her\\n TFs, reglan started to increase GI motility, but pt had another episode\\n of vomiting this am, not improved with zofran or reglan. Pateint also\\n had hypoactive BS on exam, concern for obstruction given persistent\\n vomiting, inability to tolerate tube feeds.\\n - Hold TFs\\n - Thoracic surgery recs: 1) oral/nasal tube in post-piloric position,\\n or 2) IR to place a pediatric feeding tube through her PEG site to a\\n post-piloric position.\\n - Will attempt to coordinate thoracic surgery and IR for tube placement\\n ; will d/w thoracics. IR will not do further intervention due to disk\\n on G tube\\n - CT scan to evaluate for obstruction, etiology of persistent emesis,\\n consider tube study as well\\n .\\n # Adrenal Insufficency: Endocrine following. Pt does not appear to be\\n adrenally insufficient at baseline. Suggesting if the patient under\\n goes major stressors such as major surgery, sepsis, she may need stress\\n dosed steroids.\\n .\\n # Fluid Status: Likely approaching euvolemia, though still has mild\\n hypernatramia which may suggest is still intravascularly depleated.\\n - Monitoring urine output\\n - FW flushes w/ tube feeds held due to vomitting\\n - will provide D5W IVF as need for hypernatremia and follow lytes\\n .\\n # UE DVT and elevated INR: DVT in right UE has resolved, new\\n non-occlusive in left axillary vein. INR supratherapeutic today and\\n trending upward. INR most likely continuing to rise nutritional\\n deficiencies given lack of PO intake\\n - Cumadin held, will restart at low dose when INR approaches\\n therapeutic range.\\n - INR 5.5 today, will check PM coags and follow\\n .\\n # Spine fracture: Stable\\n - Brace for OOB, will discuss with Neurosurgery if current brace is\\n optimal for stabilization given her mobility.\\n - Pt to follow up with Dr. in weeks\\n .\\n # Tracheomalacia. Was initially addressed with IP and they wanted to\\n follow up as outpatient. IP reevaluated and does not believe that a\\n stent would be feasible.\\n .\\n #. Thyroid Nodule on CT\\n - Outpatient follow up\\n .\\n # Glycemic control: SSI, well controlled\\n # PIV x 1\\n # Ppx: supratherapeutic INR, Ranitidine, Bowel Regimen PRN\\n # Communication:\\n - Boyfriend of 10 \\n - Brother also involved\\n - Will contact Social and Case management today\\n # Code: Full\\n # Dispo: ICU, Screening for vent facilities\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n 18 Gauge - 04:00 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-21 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 638755,\n \"text\": \"Chief Complaint: resp failure\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 24 Hour Events:\\n rising INR to 10.5\\n small volume hemetemesis\\n abd CT\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:30 AM\\n Other medications:\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 09:44 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.9\\nC (98.4\\n Tcurrent: 36.9\\nC (98.4\\n HR: 114 (88 - 136) bpm\\n BP: 120/65(80) {80/40(49) - 149/88(92)} mmHg\\n RR: 11 (11 - 33) insp/min\\n SpO2: 100%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 2,241 mL\\n 1,802 mL\\n PO:\\n TF:\\n IVF:\\n 1,941 mL\\n 1,802 mL\\n Blood products:\\n Total out:\\n 1,860 mL\\n 260 mL\\n Urine:\\n 1,830 mL\\n 210 mL\\n NG:\\n 30 mL\\n 50 mL\\n Stool:\\n Drains:\\n Balance:\\n 381 mL\\n 1,542 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: CPAP/PSV\\n Vt (Set): 500 (500 - 500) mL\\n Vt (Spontaneous): 438 (300 - 1,054) mL\\n PS : 10 cmH2O\\n RR (Set): 12\\n RR (Spontaneous): 13\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n RSBI Deferred: No Spon Resp\\n PIP: 16 cmH2O\\n Plateau: 15 cmH2O\\n SpO2: 100%\\n ABG: ///35/\\n Ve: 5.4 L/min\\n Physical Examination\\n Gen\\n HEENt\\n CV\\n Chest\\n Abd\\n Ext\\n Labs / Radiology\\n 9.2 g/dL\\n 528 K/uL\\n 121 mg/dL\\n 1.0 mg/dL\\n 35 mEq/L\\n 3.4 mEq/L\\n 6 mg/dL\\n 103 mEq/L\\n 144 mEq/L\\n 28.9 %\\n 9.5 K/uL\\n [image002.jpg]\\n 07:34 AM\\n 03:50 AM\\n 06:22 AM\\n 02:58 AM\\n 03:43 AM\\n 05:02 PM\\n 03:36 AM\\n 02:30 AM\\n 01:30 AM\\n 06:41 AM\\n WBC\\n 5.6\\n 6.1\\n 7.0\\n 7.1\\n 7.1\\n 6.9\\n 7.6\\n 9.5\\n Hct\\n 27.0\\n 27.0\\n 29.7\\n 28.9\\n 29.2\\n 27.8\\n 32.7\\n 28.6\\n 28.9\\n Plt\\n 335\\n 321\\n 395\\n 462\\n 452\\n 467\\n 548\\n 528\\n Cr\\n 0.5\\n 0.7\\n 0.7\\n 0.6\\n 0.7\\n 0.8\\n 0.7\\n 0.8\\n 1.0\\n Glucose\\n 121\\n 619\\n 126\\n 137\\n 104\\n 108\\n 131\\n 128\\n 121\\n Other labs: PT / PTT / INR:82.1/35.9/10.5, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:9.7 mg/dL, Mg++:2.4 mg/dL, PO4:2.9\\n mg/dL\\n Assessment and Plan\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n 18 Gauge - 04:00 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-21 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 638862,\n \"text\": \"Tachycardia, Other\\n Assessment:\\n ST120-140 with anxiety, BP stayed in 120- 140 systoli8caly.No Ectopy\\n noted\\n Action:\\n Lopressor changed from PO->>IV prn d/t vomiting after meds.\\n Response:\\n Given lopressor 5mg IV evening, cont ST most of the time.\\n Plan:\\n IV lopressor 7.5 mg Q4H for Tachycardia.\\n Alteration in Nutrition\\n Assessment:\\n Pt was until went for procedure . Na 144 this morning,^ this evening\\n 148. K was low this morning 3.4,Pt also started autodiuresing this\\n morning.\\n Action:\\n D5 with 40 K at 50cc/hr . x1000cc.Pt went down and had New feeding tube\\n inside Peg tube,sutured securely with 150 fentanyl and 4mg Versed.\\n Response:\\n Will follow up with Labs,TF?.HCt stayed stable\\n Plan:\\n Recheck K and NA later tonight. Start TF and titrate as tol,erate\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Put On 50% trach mask most of the day.. Copious thick tan, dark brown\\n secretions.\\n Action:\\n Placed on Vent onetime MMV mode when tachypneic. Frequent suctioning.\\n Response:\\n Cont be same, got breathing rx.\\n Plan:\\n Cont monitor resp status. Suction as needed, MDIs.\\n Altered mental status (not Delirium)\\n Assessment:\\n Restless all day,follow commands intermittently,Mouthing words although\\n difficult to understand.\\n Action:\\n Gave her Haldol and vaslium IV as per order , Reorient pt prn.\\n Emotional support.Soft restraints still on.Her brother called this\\n evening,will here Friday .\\n Response:\\n Cont same.\\n Plan:\\n Valium and Haldol PRN?. Zyprexa HS prn for agitation. Reorient prn.\\n Emotional support to pt and family.\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2167-10-22 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 639062,\n \"text\": \"Demographics\\n Day of mechanical ventilation: 34\\n Ideal body weight: 61.2 None\\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: Yes\\n Tracheostomy tube:\\n Type: Standard, Cuffed\\n Manufacturer: Portex\\n Size: 7.0mm\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 23 cmH2O\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Diminished\\n Secretions\\n Sputum color / consistency: Yellow / Thick\\n Sputum source/amount: Suctioned / Moderate\\n Ventilation Assessment\\n Level of breathing assistance: Intermittent invasive ventilation\\n Visual assessment of breathing pattern: Pt on Trach collar this am,\\n after 2 hrs pt desating to 87%, suctioned for copious thick brownish\\n secretions, did not recover on 100% O2, needed to go back on Vent.\\n Currently pt on Trach collar.\\n Plan\\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\\n Comments: Trach collar as tolerated.\\n Reason for continuing current ventilatory support: Cannot protect\\n airway, Cannot manage secretions, pt desaturates and does not recover\\n with O2 only.\\n Respiratory Care Shift Procedures\\n Bedside Procedures:\\n 1550\\n Comments: Pt decannulated herself, desated to 87%, Trach tube portex #\\n 7 re-inserted by this RRT, no complication, Easy cap good color change\\n to yellow, Good bilateral lung sounds, no bleeding from trach.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-23 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 639138,\n \"text\": \"56 yr old lady who was transferred from osh for evaluation of tracheal\\n bronchial malacia on .Pt presented to medical centre on\\n s/p fall down stairs fracturing t5-t8 with propulsion treated\\n conservatively with pain meds and back brace. Developed resp distress\\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\\n to fail to wean from vent and was transferred for evaluation and poss\\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\\n with prolonged hospital course c/b by PNA, anxiety/altered mental\\n status, R&LUE DVT .Pt found to have small non occlusive Clot on her\\n right axial vein via Ultrasound.Yesterday. She has had problems with\\n vomiting tube feedings, feeding tube passed through g-tube (g-tube in\\n place with mushroom on inside so cannot pull out) to her jejunenum but\\n continues vomit.\\n Tachycardia, Other\\n Assessment:\\n HR continued to be 110-140, ST w/ rare PVC\\n Action:\\n Amiordarone 75mg bolus given, and drip started at 1mg/min\\n Response:\\n HR at rest now 100-120\\n Plan:\\n Will continue drip for 18 hr then titrate down to 0.5mg/min\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt very restless and agitated throughout night, pt has slept less than\\n 2 hours. Zyprexa given w/ minimal effect. Pt seems very disoriented\\n despite frequent reorientation. Pt has short term menmory deficits.\\n Pt continues to grab at lines if hand are not restrained.\\n Action:\\n Zyprexa given and frequent reorientation and 1:1 time\\n Response:\\n Pt continues to be agitated\\n Plan:\\n Alteration in Nutrition\\n Assessment:\\n Remains NPO, IVF at 75cc/hr. Abd soft, distant hYPOactive BS. No\\n vomiting noted\\n Action:\\n Continue to monitor for nausea\\n Response:\\n Plan:\\n ? start PPN today if KUB + illeus\\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\\n Assessment:\\n Tmax this shift 101.4 rectally\\n Action:\\n BC x2 sent and U/A C+S sent . Tylenol supp given\\n Response:\\n Temp down to 98.5\\n Plan:\\n Await BC results and urine culture results\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-22 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 639065,\n \"text\": \"Tachycardia, Other\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Alteration in Nutrition\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Altered mental status (not Delirium)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Hypernatremia (high sodium)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-16 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 637887,\n \"text\": \"Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Left hand to elbow area with edema 2mm\\nknown DVT to left axillary vein;\\n US of right arm\\n Action:\\n DL PICC d/c\\nd; left arm elevated on pillow; US results pnd for right\\n arm\\n Response:\\n PIV placed for access issues to right arm; edema unchanged;\\n Plan:\\n Cont to monitor left arm status; no BP/blood draws left arm. NIBP cuff\\n to right calf. F/U w/ team Re: right arm status\\n Hypernatremia (high sodium)\\n Assessment:\\n hypernatremic\\n Action:\\n Free water boluses cont; bloused with D5W/500cc\\n Response:\\n Remains hypernatremic with min improvement\\n Plan:\\n Cont with free water boluses; check labs am\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Restless, anxious am\\n Action:\\n Trach collar placed 70% early am--\\n Response:\\n Brief episode of desaturation to mid 80\\ns requiring increase of Fi02 to\\n 100% briefly (approx 20min); placed on 70% remainder of shift with\\n adequate o2 sats in low 90\\ns;NOTE: pt vomited approx 50cc clear liquid\\n prior to going to IR also had some clear lix come from trach\\npossible\\n aspiration\\nteam notified. Placed on PSV at 1840 to rest\\n Plan:\\n Rest overnight; ?aspiration. Hold TF for now\\nf/u team re: free water\\n boluses. CXR am. Monitor resp status closely.\\n Tachycardia, Other\\n Assessment:\\n Tachy to 130-140\\ns continuous while awake; Hr stayed 90- 120 sound\\n asleep\\n Action:\\n Standing valium decreased; cont with fent patch; morphine and haldol\\n prn.Bilateral restraints on\\n Response:\\n No significant change in level of restlessness/anxiety; freq pulling at\\n any objects/lines with short term memory issues. She keeps\\n disconnecting from vent,desat to low 80s within seconds.\\n Plan:\\n Cont to closely monitor mental status; maintain safety w/use of\\n restraints, soft wrist restraints and bed alarm. PRN Haldol or\\n Morphine.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-26 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 639594,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Pt agitated overnight given extra Risperidone 0.5 mg x 2 overnight.\\n (1.5mg total)\\n 1000 mL D5W for Hypernatremia\\n Changed B-Blocker from IV to PO, Metoprolol Tartrate 25 mg PO TID\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:17 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:47 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.8\\nC (98.2\\n Tcurrent: 36.7\\nC (98\\n HR: 120 (67 - 120) bpm\\n BP: 110/64(76) {109/47(60) - 141/115(118)} mmHg\\n RR: 26 (18 - 30) insp/min\\n SpO2: 100%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 3,820 mL\\n 856 mL\\n PO:\\n TF:\\n 117 mL\\n 20 mL\\n IVF:\\n 2,612 mL\\n 572 mL\\n Blood products:\\n Total out:\\n 2,460 mL\\n 1,180 mL\\n Urine:\\n 2,460 mL\\n 1,180 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,360 mL\\n -324 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask\\n SpO2: 100%\\n ABG: ///33/\\n Physical Examination\\n Gen: Awake, Mouthing words, More agitated compared to previous\\n mornings.\\n HEENT: EOMI, No pallor in conjunctiva, MMM\\n Resp: CTAB, no rales, rhonchi, or wheezing, good airway movement.\\n Card: S1S2 tachycardic, no m/r/g\\n Abd: Obese, soft, mildly distended, decreased bowel sounds,, G-Tube in\\n place with no erythema/induration\\n Exte: No edema, DP 2+ bil\\n NEURO: Gross Motor and Sensation in 4 extremities\\n Labs / Radiology\\n 249 K/uL\\n 8.0 g/dL\\n 122 mg/dL\\n 0.5 mg/dL\\n 33 mEq/L\\n 3.7 mEq/L\\n 13 mg/dL\\n 108 mEq/L\\n 146 mEq/L\\n 24.7 %\\n 5.5 K/uL\\n [image002.jpg] CXR: L Picc, trach tip at midline, bibasilar\\n opacities, low lung volumes, Bil pleural effusions.\\n 03:36 AM\\n 02:30 AM\\n 01:30 AM\\n 06:41 AM\\n 03:20 PM\\n 03:23 AM\\n 03:00 AM\\n 04:00 AM\\n 05:45 AM\\n 03:51 AM\\n WBC\\n 6.9\\n 7.6\\n 9.5\\n 5.7\\n 7.3\\n 8.0\\n 8.7\\n 5.5\\n Hct\\n 27.8\\n 32.7\\n 28.6\\n 28.9\\n 30.0\\n 26.9\\n 27.3\\n 27.0\\n 28.7\\n 24.7\\n Plt\\n 467\\n 548\\n 528\\n 356\\n 346\\n 316\\n 271\\n 249\\n Cr\\n 0.7\\n 0.8\\n 1.0\\n 0.7\\n 0.7\\n 0.7\\n 0.7\\n 0.5\\n Glucose\\n 131\\n 128\\n 121\\n 129\\n 123\\n 114\\n 112\\n 122\\n Other labs: PT / PTT / INR:13.6/31.1/1.2, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:9.0 mg/dL, Mg++:2.2 mg/dL, PO4:3.1\\n mg/dL\\n Assessment and Plan\\n 56yoF s/p mechanical fall and traumatic T spine fracture, now s/p\\n trach/PEG with resolving respiratory failure and HAP.\\n .\\n # Respiratory failure: s/p intubation/extubation, now on trach mask,\\n FiO2 70%. Tolerating well with good O2 sat. No further\\n self-decanulations overnight.\\n - Tach mask as tolerated.\\n - Holding sedation with exception of Risperidal 0.5mg .\\n - F/u CXR tomorrow\\n .\\n # Nutrition/Vomiting: Currently receiving TPN;. One large BM in past\\n 24 hrs to indicate potential improvement in ileus.\\n - Cont Reglan 20mg IV Q 8 hours; meds via G-J tube,\\n - Will obtain recommendations from Nutrition re TPN before starting TPN\\n tomorrow\\n - TF as tolerated\\n - Speech and Swallow eval\\n - PICC line in place with TPN given when pt not tolerating TF\\n - GI consult, appreciate recs\\n .\\n # Tachycardia: Improved HR max of 120\\ns versus 160s previously;\\n elevated this am secondary to agitation. Pt now on PO Amiodarone 200\\n TID and PO metoprolol 25mg TID\\n - Continue current med regimen. Will continue amiodarone 200 TID for\\n three weeks and then switch to qday.\\n - Will schedule f/u in 4wks with Dr. upon d/c/transfer.\\n - f/u Cards recs\\n # Sedation/Anxiolysis/AlteredMS: Agitation O/N, continues to be\\n agitated most likely secondary to long hospital course and multiple\\n psychotropic medications as well as hx of EtOH abuse. Risperdal given\\n O/N.\\n - started Risperdal 0.5mg PO BID\\n - continue to hold all benzos. opiates, and antihistamines\\n - Appreciate psych. Will call and f/u psych recs.\\n #Anemia: Decrease in HCT from 28\\n24; tachycardia. No known etiology of\\n blood loss, most likely related to variaton\\n -Will repeat HCT check this afternoon.\\n # Hypernatremia/Fluid Status: Mild hypernatramia with good UOP\\n (hypervolemic hypernatremia). On TPN/TF.\\n - providing D5W IVF, free water flushes with TF\\n -Will f/u lytes (Na) this afternoon at 5pm.\\n # UE DVT and elevated INR: Decision made to d/c Coumadin given her\\n labile INR, and start Lovenox . Current INR 1.2.\\n - Will flush L PICC with TPA if does not flush\\n .\\n # Spine fracture: Stable\\n - Brace for OOB, need to discuss with Neurosurgery before d/c if\\n current brace is optimal for stabilization given her mobility.\\n - Pt to follow up with Dr. in weeks\\n .\\n # Tracheomalacia. Was initially addressed with IP and they wanted to\\n follow up as outpatient. IP reevaluated and does not believe that a\\n stent would be feasible. No new issues.\\n .\\n #. Thyroid Nodule on CT\\n - Outpatient follow up\\n .\\n # Glycemic control: SSI, well controlled\\n # ACCESS: PIV x 1, L PICC\\n # Ppx: Lovenox, PPi, Bowel Regimen PRN\\n # Communication:\\n - Boyfriend of 10 \\n - Brother also involved\\n - Social Work and Case management involved, have discussed situation\\n w/ brother and boyfriend.\\n # Code: Full\\n # Dispo: ICU, Will d/w case management re rehab facilities.\\n PGY2 Addendum\\n Agree with excellent MS4 PN. Will touch base with psychiatry re:\\n sedating meds and EP re: atrial tachycardia. Will obtain EKG to\\n reassess QTc. Ordered for TPN. Giving d5W for hypernatremia. Re-consult\\n S/S for PMV re-fitting. transfer to LTAC.\\n \\n PGY2\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-26 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 639597,\n \"text\": \"56 yr old woman, who was transferred from osh for evaluation of\\n tracheal bronchial malacia on .Pt presented to Medical\\n Center on s/p fall down a flight of stairs fracturing, t5-t8 with\\n propulsion treated conservatively with pain meds and back brace. She\\n developed resp distress requiring intubation on . Trach/PEG done\\n . Now with prolonged hospital course c/b by PNA, anxiety/altered\\n mental status, R&LUE DVT .Pt found to have small non occlusive clot on\\n her right axial vein via Ultrasound, now rec\\ning Lovenox. She has had\\n problems with vomiting tube feedings, so feeding tube passed through\\n g-tube to her jejunenum. However, she continues to intermit raise\\n gastric contents assoc with bronchospasm. Has not required ventilation\\n since , on humidified TM @ 50%. Has required 1:1 sitters since\\n decanulating herself, twice, despite restraints.\\n Airway Clearance, Impaired\\n Assessment:\\n Rec\\nd pt on humidified TM @ 70% with O2 sat 97-100%. RR 22-31 and\\n regular. Lung snds rhonchorous in upper lobes, clearing with sxn\\ning.\\n Lower lobe snds diminished bilat.\\n Action:\\n FiO2 \\nd to 50%. Pt requiring tracheal sxn\\ning Q30-60mins, producing\\n mod-copious amts thick white tenacious secretions. Pt generally unable\\n to fully raise and expectorate secretions.\\n Response:\\n O2 sat has remained 99-100%, but drops to high 80\\ns when requires\\n sxn\\ning.\\n Plan:\\n Cont to encourage pt to deep breathe and cough. Cont aggressive pulm\\n toilet.\\n Alteration in Nutrition\\n Assessment:\\n Per noc shift nurse, TF off overnight as pt too restless to maintain in\\n upright position per strict aspiration precautions. BS +, abd\\n soft/obese.\\n Action:\\n Pt placed on chair position in bed and TF restarted @ 0830 @\\n 10ml/hr+50ml free water Q4hrs. She rec\\nd her scheduled doses Reglan\\n 20mg and colace, senna.\\n Response:\\n Pt tolerated TF well with no residuals, so TF inc\\nd to 20ml/hr @ 1230.\\n No BM yet today, but pt having flatus.\\n Plan:\\n Cont strict aspiration prec, holding TF when pt not in upright position\\n and turning TF off for 15mins before turning.\\n Arousal, Attention, and Cognition, Impaired\\n Assessment:\\n Pt rec\\nd very restless in bed, attempting to exit despite bilat soft\\n wrist restraints and sitter @ bedside. When PMV in place pt\\n disoriented X 2, and reported she had been in a hotel and could pay\\n $3000 cash to leave. When told she was in a hospital bed, she asked,\\nWhere\\ns the bed\\n, unconvinced that she was lying in bed.\\n Action:\\n Pt rec\\nd scheduled 0800 dose Resperadine. EKG taken.\\n Response:\\n Pt slept for 90mins until woken by team for am rounds. She has appeared\\n sleepy since but resistant to falling asleep. QT interval WNL.\\n Plan:\\n Psych to consult and eval meds.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-22 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 639058,\n \"text\": \"Chief Complaint: resp failure\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 24 Hour Events:\\n increased bblocker\\n J tube placed by IR through PEG- restarted TF and vomiting\\n Went for tube study - dysmotility - contrast sat in stomach\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Diazepam (Valium) - 02:24 AM\\n Other medications:\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 12:17 PM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.7\\nC (98.1\\n Tcurrent: 35.6\\nC (96.1\\n HR: 118 (93 - 140) bpm\\n BP: 153/58(79) {82/39(49) - 153/101(105)} mmHg\\n RR: 23 (14 - 37) insp/min\\n SpO2: 99%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 3,808 mL\\n 1,119 mL\\n PO:\\n TF:\\n 4 mL\\n IVF:\\n 3,804 mL\\n 1,119 mL\\n Blood products:\\n Total out:\\n 1,650 mL\\n 520 mL\\n Urine:\\n 1,590 mL\\n 520 mL\\n NG:\\n 60 mL\\n Stool:\\n Drains:\\n Balance:\\n 2,158 mL\\n 599 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 243 (169 - 281) mL\\n PS : 5 cmH2O\\n RR (Spontaneous): 17\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n RSBI: 67\\n PIP: 11 cmH2O\\n SpO2: 99%\\n ABG: ///33/\\n Ve: 4.1 L/min\\n Physical Examination\\n Gen: lying in bed, alert, responding to questions\\n CV; tachy RR\\n Chest: bibasilar decreased BS, faint exp wheeze\\n Abd: soft NT+BS\\n Ext: no edema\\n Labs / Radiology\\n 8.2 g/dL\\n 356 K/uL\\n 129 mg/dL\\n 0.7 mg/dL\\n 33 mEq/L\\n 3.6 mEq/L\\n 4 mg/dL\\n 110 mEq/L\\n 148 mEq/L\\n 26.9 %\\n 5.7 K/uL\\n [image002.jpg]\\n 06:22 AM\\n 02:58 AM\\n 03:43 AM\\n 05:02 PM\\n 03:36 AM\\n 02:30 AM\\n 01:30 AM\\n 06:41 AM\\n 03:20 PM\\n 03:23 AM\\n WBC\\n 7.0\\n 7.1\\n 7.1\\n 6.9\\n 7.6\\n 9.5\\n 5.7\\n Hct\\n 29.7\\n 28.9\\n 29.2\\n 27.8\\n 32.7\\n 28.6\\n 28.9\\n 30.0\\n 26.9\\n Plt\\n 395\\n 462\\n 452\\n 467\\n 548\\n 528\\n 356\\n Cr\\n 0.7\\n 0.6\\n 0.7\\n 0.8\\n 0.7\\n 0.8\\n 1.0\\n 0.7\\n Glucose\\n 126\\n 137\\n 104\\n 108\\n 131\\n 128\\n 121\\n 129\\n Other labs: PT / PTT / INR:15.2/24.6/1.3, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.7 mg/dL, Mg++:2.1 mg/dL, PO4:4.1\\n mg/dL\\n Assessment and Plan\\n 1. Tachycardia: runs of attach Appreciate EP consult\\n will increase\\n bblocker. Have to convert to metoprolol 7.5mg IV Q4 because unable to\\n take pos.\\n 2. Persistent Nausea/Vomiting: we have ruled out\\n pSBO/SBO, very poor\\n bowel sounds, tube study this AM shows contrast not moving out of the\\n jejunum. GI consult to discuss any role for EGD. Place PICC for TPN as\\n she has not had nutrition.\\n 2. Resp Failure\\n Trach mask trials all day, PSV\\n PMV trials\\n Per IP not stent planned as technically not possible to\\n place into her airway\\n 3. DVT and coagulopathy: reversed with IV Vit k\\n hold coumadin today\\n 4. Hypernatremia Replete free water.\\n Please see today\\ns ICU team note for other issues.\\n ICU Care\\n Nutrition: plan for TPN\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n 18 Gauge - 04:00 AM\\n Prophylaxis:\\n DVT: plan for coumadin\\n Stress ulcer: ppi\\n Communication: spoke with son and\\n status: Full code\\n Disposition : ICU\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-24 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 639334,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Pt decannulated herself x2 yesterday, the 1st episode she desatted to\\n the 80s, the second episode she desated and her heart rate decreased to\\n 39-40, before the trach could be replaced.\\n PICC line placed by IR, called to notify that there was clot in both\\n arms, placed in L arm more proximally than small Bacillis vein clot.\\n Coumadin restarted after PICC placement with 2mg\\n Per GI Recs: Reglan restarted at 20mg IV q 8 hours, and meds were\\n restarted via tube. No vomitting.\\n Per PSYCH recs: d/c'd all benzoes, (also requested d/c reglan if GI\\n ok), added Risperdal 0.5mg (and can add 0.5mg PRN, and titrate up\\n to total daily dose of 2-3mg if helping)\\n Per Cards recs: after 18hr of amiodaron drip. Start PO amiodarone 200mg\\n TID, which was done at 1am.\\n Brother visited\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:04 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.4\\nC (99.4\\n Tcurrent: 37.4\\nC (99.4\\n HR: 90 (73 - 121) bpm\\n BP: 155/49(75) {103/47(66) - 175/98(111)} mmHg\\n RR: 32 (14 - 32) insp/min\\n SpO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 2,151 mL\\n 293 mL\\n PO:\\n TF:\\n IVF:\\n 1,852 mL\\n 13 mL\\n Blood products:\\n Total out:\\n 2,460 mL\\n 820 mL\\n Urine:\\n 2,460 mL\\n 820 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -309 mL\\n -527 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask\\n Ventilator mode: Standby\\n Vt (Set): 0 (0 - 0) mL\\n Vt (Spontaneous): 360 (360 - 360) mL\\n PS : 10 cmH2O\\n RR (Set): 0\\n RR (Spontaneous): 21\\n FiO2: 40%\\n SpO2: 98%\\n ABG: ///33/\\n Physical Examination\\n Gen: Asleep, unarousable, responds minimally to noxious stimuli\\n HEENT: PERRL, MMM\\n Resp: CTA bilaterally, no rales, rhonchi, or wheezing, small\\n inspirations.\\n Card: S1S2 tachycardic, no m/r/g\\n Abd: Obese, soft, mildly distended, BS+\\n Exte: No edema, DP 2+ bil\\n NEURO: reflexes 2+ bilaterally.\\n Labs / Radiology\\n 316 K/uL\\n 8.3 g/dL\\n 114 mg/dL\\n 0.7 mg/dL\\n 33 mEq/L\\n 4.0 mEq/L\\n 7 mg/dL\\n 111 mEq/L\\n 149 mEq/L\\n 27.0 %\\n 8.0 K/uL\\n [image002.jpg]\\n 03:43 AM\\n 05:02 PM\\n 03:36 AM\\n 02:30 AM\\n 01:30 AM\\n 06:41 AM\\n 03:20 PM\\n 03:23 AM\\n 03:00 AM\\n 04:00 AM\\n WBC\\n 7.1\\n 6.9\\n 7.6\\n 9.5\\n 5.7\\n 7.3\\n 8.0\\n Hct\\n 29.2\\n 27.8\\n 32.7\\n 28.6\\n 28.9\\n 30.0\\n 26.9\\n 27.3\\n 27.0\\n Plt\\n 452\\n 467\\n 548\\n 528\\n 356\\n 346\\n 316\\n Cr\\n 0.7\\n 0.8\\n 0.7\\n 0.8\\n 1.0\\n 0.7\\n 0.7\\n 0.7\\n Glucose\\n 104\\n 108\\n 131\\n 128\\n 121\\n 129\\n 123\\n 114\\n Other labs: PT / PTT / INR:13.2/22.4/1.1, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:9.0 mg/dL, Mg++:2.3 mg/dL, PO4:4.1\\n mg/dL\\n Assessment and Plan\\n 55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\\n trach, PEG placement now with respiratory failure secondary to\\n tracheomalacia , resolved HAP.\\n .\\n # Respiratory failure: Slowly improving, spending most of the day on\\n trach mask with short periods of rest on PSV at night and setbacks\\n from increased secretions to vomiting/aspiration events and her\\n self-decanulations.\\n - Continue to increase time on trach mask as tolerated.\\n - Discontinue all orders for sedation except for Risperdal QHS.\\n - PMV with suctioning as tolerated\\n # Nutrition/Vomiting: Normal CT-abdomen, had FT placed via peg into\\n jejunum, but continued to vomit. Tube study showed dysmotility in small\\n bowel, but no obstruction, no retrograde flow. GI recs Reglan 20mg IV Q\\n 8 hours and restart meds via G-J tube, if tolerated slowly restart TFs.\\n PICC line placed yesterday and TPN started.\\n - GI consult, appreciate recs\\n - Small volume TFs start today\\n - Continue TPN today\\n # HAP vs Aspiration PNA: Had been afebrile for last several days, now\\n with new fever two nights ago after having decanulated herself. Likely\\n had some aspiration. Chemical pneumonitis versus new aspiration PNA.\\n Now Afebrile for past 24 hours.\\n - f/u daily CXR\\n - F/u cx data\\n - If remains febrile, send sputum cx, otherwise hold on abx.\\n .\\n # Tachycardia: Pt in and out of SVT and sinus, increased BB seems to\\n help, but pt does not stay in sinus. Cards rec to start Amiodarone IV\\n drip, and then convert to PO, 200mg TID. Would consider EPS if\\n amiodarone not successful, though would wait until pt more stable for\\n general anesthesia.\\n - Changed to IV metoprolol to 10mg IV q4hr.\\n - Completed amiodarone 0.5mg/min IV drip x 18 hours, and converted to\\n 200mg PO TID..\\n - Cards c/s, appreciate recs\\n # Sedation/Anxiolysis/AlteredMS: unclear etiology of her confusion and\\n agitation. Has had long hospital course and multiple psychotropic\\n medications as well as hx of EtOH abuse.\\n - d/c all benzos. opiates, and antihistamines\\n - Psychiatry consulted, appreciate recs\\n - started Risperdal 0.5mg PO BID, d/c zyprexa.\\n # Adrenal Insufficency: Endocrine following. Pt does not appear to be\\n adrenally insufficient at baseline. Suggesting if the patient under\\n goes major stressors such as major surgery, sepsis, she may need stress\\n dosed steroids.\\n .\\n # Fluid Status: Likely approaching euvolemia, though still has mild\\n hypernatramia which may suggest is still intravascularly depleated.\\n - Monitoring urine output\\n - will provide D5W IVF as need for hypernatremia and follow lytes\\n # UE DVT and elevated INR: DVT in right UE has resolved, new\\n non-occlusive in left axillary vein. INR has been volatile, likely from\\n drug interactions and poor nutritional status. Have been unable to keep\\n her appropariately therapeutic.\\n - d/c coumadin\\n - start Lovenox, maintain until GI issues resolved and can restart\\n coumadin\\n .\\n #Hematemesis: Pt had small amt Hematemesis, after vomiting, last week.\\n None today. HCT stable.\\n -Will follow HCT.\\n - Guaiac stools\\n # Spine fracture: Stable\\n - Brace for OOB, will discuss with Neurosurgery if current brace is\\n optimal for stabilization given her mobility.\\n - Pt to follow up with Dr. in weeks\\n .\\n # Tracheomalacia. Was initially addressed with IP and they wanted to\\n follow up as outpatient. IP reevaluated and does not believe that a\\n stent would be feasible.\\n .\\n #. Thyroid Nodule on CT\\n - Outpatient follow up\\n .\\n # Glycemic control: SSI, well controlled\\n # ACCESS: PIV x 1, PICC placement\\n yesterday.\\n # Ppx: subtherapeutic INR restarting coumadin today, Ranitidine, Bowel\\n Regimen PRN\\n # Communication:\\n - Boyfriend of 10 \\n - Brother also involved\\n - Social Work and Case management involved, have discussed situation\\n w/ brother and boyfriend.\\n # Code: Full\\n # Dispo: ICU, Screening for vent facilities\\n ICU Care\\n Nutrition:\\n TPN without Lipids - 06:00 PM 41. mL/hour\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n PICC Line - 01:30 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-20 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 638537,\n \"text\": \"55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\\n trach, PEG, placement no with respiratory failure secondary to\\n tracheomalacia , resolving HAP.\\n Arousal, Attention, and Cognition, Impaired\\n Assessment:\\n Alert, mouthing words but very difficult to understand. Follows\\n commands. MAE on bed, attempting to get up. Restless last evening, did\\n eventually fall off to sleep this AM.\\n Action:\\n Zyprexa x 1 . Frequent re-orientation to place, situation. Soft wrist\\n restraints for patient safety.\\n Response:\\n Pt did eventually fall asleep. Re-orientation does have calming effect\\n however it is short term.\\n Plan:\\n No valium or benadryl per psych as this exacerbates delirium. Zyprexa\\n for agitation. pt prn.\\n Hypernatremia (high sodium)\\n Assessment:\\n Na 145 last night, 148 this AM.\\n Action:\\n Response:\\n Plan:\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Trach collar @ 50% O2 overnight until 4AM, Sats 90-97%. RR 17-20s.\\n Around 4AM RR in low 30s, sats low 90s while sleeping--? Fatiguing.\\n Strong cough, able to cough thick white ->tan secretions out of trach.\\n Occ suctioned for same. Lungs are rhonchorous throughout. Impaired gag.\\n Action:\\n Suctioned prn for copious secretions. MDIs. Placed back on vent @ 4AM\\n d/t fatigue.\\n Response:\\n Tolerated trach collar most of night, back on vent this AM d/t fatigue\\n with RR in teens, Sats 98%.\\n Plan:\\n Wean from vent as tolerated. MDIs, suction as needed.\\n Alteration in Nutrition\\n Assessment:\\n Tube feeds off overnight d/t constant vomiting. No vomiting overnight.\\n Action:\\n NPO. Reglan q 6 hrs.\\n Response:\\n No vomiting. Small brown stool x 1.\\n Plan:\\n NPO. ? may go to IR today to change Gtube to Jtube. Reglan. Meds via\\n Gtube.\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2167-10-23 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 639134,\n \"text\": \"Demographics\\n Day of mechanical ventilation: 35\\n Ideal body weight: 61.2 None\\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: Yes\\n Tube Type\\n Tracheostomy tube:\\n Type: Standard\\n Manufacturer: Portex\\n Size: 7.0mm\\n PMV:\\n Cuff Management:\\n Cuff pressure: 23 cmH2O\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Rhonchi\\n LLL Lung Sounds: Diminished\\n Comments:\\n Secretions\\n Sputum color / consistency: Yellow / Thick\\n Sputum source/amount: Suctioned / Small\\n Comments: pt has spc can expectorate secretions as well\\n Ventilation Assessment\\n Level of breathing assistance: Unassisted spontaneous breathing\\n Visual assessment of breathing pattern: pt remained on t/c noc as\\n tolerated.\\n Plan\\n Next 24-48 hours: continue with t/c as tolerates, has periods of ^ wob\\n then return to vent. Remain on t/c noc.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-23 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 639232,\n \"text\": \"Chief Complaint: resp distress\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 24 Hour Events:\\n UNPLANNED EXTUBATION (PATIENT-INITIATED) - At 03:50 PM\\n Pt pulled out her trach tube, tube replaced\\n POulled out trach again at 7:15 AM complicated by bradycardia and\\n profound desaturation\\n FEVER - 101.4\\nF - 12:00 AM\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Amiodarone - 0.5 mg/min\\n Other ICU medications:\\n Metoprolol - 01:00 AM\\n Other medications:\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 10:40 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.6\\nC (101.4\\n Tcurrent: 36.8\\nC (98.2\\n HR: 116 (84 - 142) bpm\\n BP: 147/84(96) {86/39(53) - 181/113(137)} mmHg\\n RR: 23 (13 - 27) insp/min\\n SpO2: 99%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 2,127 mL\\n 994 mL\\n PO:\\n TF:\\n IVF:\\n 2,127 mL\\n 994 mL\\n Blood products:\\n Total out:\\n 995 mL\\n 900 mL\\n Urine:\\n 995 mL\\n 900 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,132 mL\\n 94 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask\\n Ventilator mode: CPAP/PPS\\n Vt (Set): 0 (0 - 0) mL\\n Vt (Spontaneous): 360 (208 - 360) mL\\n PS : 10 cmH2O\\n RR (Set): 0\\n RR (Spontaneous): 21\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n PIP: 0 cmH2O\\n SpO2: 99%\\n ABG: ///31/\\n Physical Examination\\n Gen: lying in bed, alert, responding to questions, PMV placed\\n CV; tachy RR\\n Chest: bibasilar decreased BS, faint exp wheeze\\n Abd: soft NT+BS\\n Ext: no edema\\n Skin: warm\\n Neurologic: confused, stating that p[eople are trying to kill her\\n Labs / Radiology\\n 8.4 g/dL\\n 346 K/uL\\n 123 mg/dL\\n 0.7 mg/dL\\n 31 mEq/L\\n 3.8 mEq/L\\n 4 mg/dL\\n 107 mEq/L\\n 144 mEq/L\\n 27.3 %\\n 7.3 K/uL\\n [image002.jpg]\\n 02:58 AM\\n 03:43 AM\\n 05:02 PM\\n 03:36 AM\\n 02:30 AM\\n 01:30 AM\\n 06:41 AM\\n 03:20 PM\\n 03:23 AM\\n 03:00 AM\\n WBC\\n 7.1\\n 7.1\\n 6.9\\n 7.6\\n 9.5\\n 5.7\\n 7.3\\n Hct\\n 28.9\\n 29.2\\n 27.8\\n 32.7\\n 28.6\\n 28.9\\n 30.0\\n 26.9\\n 27.3\\n Plt\\n 462\\n 452\\n 467\\n 548\\n 528\\n 356\\n 346\\n Cr\\n 0.6\\n 0.7\\n 0.8\\n 0.7\\n 0.8\\n 1.0\\n 0.7\\n 0.7\\n Glucose\\n 137\\n 104\\n 108\\n 131\\n 128\\n 121\\n 129\\n 123\\n Other labs: PT / PTT / INR:14.1/23.7/1.2, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.8 mg/dL, Mg++:1.9 mg/dL, PO4:3.7\\n mg/dL\\n Assessment and Plan\\n 1. Tachycardia: runs of attach Appreciate EP consult\\n trying IV Amio.\\n will increase bblocker. Have to convert to metoprolol 10 mg IV Q4\\n because unable to take pos.\\n 2. Persistent Nausea/Vomiting: we have ruled out\\n pSBO/SBO, very poor\\n bowel sounds, tube study this AM shows contrast not moving out of the\\n jejunum. GI consult to discuss any role for EGD. Place PICC for TPN as\\n she has not had nutrition.\\n 3. Agitation: delirium- trying to wean off narcotics- Will call psych\\n as she is no harmful to self with pulling out trach x 2 and very\\n paranoid. 1:1 sitter for safety\\n 2. Resp Failure\\n Trach mask trials all day, PSV\\n PMV trials\\n Per IP not stent planned as technically not possible to\\n place into her airway\\n 3. DVT and coagulopathy: reversed with IV Vit k\\n hold coumadin today\\n 4. Hypernatremia Replete free water.\\n Please see today\\ns ICU team note for other issues.\\n ICU Care\\n Nutrition: start TPN after PICC\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n 18 Gauge - 06:31 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n Communication: met with brother for 30 minutes this afternoon and\\n reviewed medical and social issues\\n Code status: Full code\\n Disposition :ICU\\n Total time spent: 45\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2167-10-23 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 639244,\n \"text\": \"Tachycardia, Other\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Alteration in Nutrition\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Deep Venous Thrombosis (DVT), Upper extremity\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Altered mental status (not Delirium)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-25 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 639475,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n TF were restarted in afternoon and held after one episode of a coughing\\n fit in the evening. Pt was suctioned, CXR unchanged. AVSS.\\n One episode of SVT to the low 100\\ns overnight from 2:30 to 3:15am.\\n Given D5W x 2 liters for hypernatremia\\n Lovenox 100mg SC BID for prior UE DVT\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:17 AM\\n Enoxaparin (Lovenox) - 06:00 PM\\n Metoprolol - 06:00 PM\\n Other medications:\\n Changes to medical and family history: No additional\\n Review of systems is unchanged from admission except as noted below\\n Review of systems: Pt mouthing words but team unable to understand.\\n Flowsheet Data as of 05:23 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.1\\nC (98.8\\n Tcurrent: 36.3\\nC (97.4\\n HR: 68 (64 - 104) bpm\\n BP: 116/51(66) {105/45(44) - 151/74(89)} mmHg\\n RR: 24 (21 - 38) insp/min\\n SpO2: 96%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 2,676 mL\\n 776 mL\\n PO:\\n TF:\\n 61 mL\\n IVF:\\n 1,418 mL\\n 540 mL\\n Blood products:\\n Total out:\\n 1,910 mL\\n 195 mL\\n Urine:\\n 1,910 mL\\n 195 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 766 mL\\n 581 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask\\n SpO2: 96%\\n ABG: ////\\n Physical Examination\\n Gen: Awake, Mouthing words\\n HEENT: PERRL, MMM\\n Resp: CTA bilaterally, no rales, rhonchi, or wheezing, small\\n inspirations.\\n Card: S1S2 tachycardic, no m/r/g\\n Abd: Obese, soft, mildly distended, BS+\\n Exte: No edema, DP 2+ bil\\n NEURO: Gross Motor and Sensation in 4 extremities\\n Labs / Radiology\\n 316 K/uL\\n 8.3 g/dL\\n 114 mg/dL\\n 0.7 mg/dL\\n 33 mEq/L\\n 4.0 mEq/L\\n 7 mg/dL\\n 110 mEq/L\\n 148 mEq/L\\n 27.0 %\\n 8.0 K/uL\\n [image002.jpg]\\n 03:43 AM\\n 05:02 PM\\n 03:36 AM\\n 02:30 AM\\n 01:30 AM\\n 06:41 AM\\n 03:20 PM\\n 03:23 AM\\n 03:00 AM\\n 04:00 AM\\n WBC\\n 7.1\\n 6.9\\n 7.6\\n 9.5\\n 5.7\\n 7.3\\n 8.0\\n Hct\\n 29.2\\n 27.8\\n 32.7\\n 28.6\\n 28.9\\n 30.0\\n 26.9\\n 27.3\\n 27.0\\n Plt\\n 452\\n 467\\n 548\\n 528\\n 356\\n 346\\n 316\\n Cr\\n 0.7\\n 0.8\\n 0.7\\n 0.8\\n 1.0\\n 0.7\\n 0.7\\n 0.7\\n Glucose\\n 104\\n 108\\n 131\\n 128\\n 121\\n 129\\n 123\\n 114\\n Other labs: PT / PTT / INR:13.2/22.4/1.1, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:9.0 mg/dL, Mg++:2.3 mg/dL, PO4:4.1\\n mg/dL\\n Assessment and Plan\\n 55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\\n trach, PEG with resolving respiratory failure and HAP.\\n .\\n # Respiratory failure: 36hrs off vent, now on trach mask. No further\\n self-decanulations overnight.\\n - Tach mask as tolerated.\\n - Holding sedation with exception of Risperidal 0.5mg .\\n - PMV with suctioning as tolerated\\n .\\n # Nutrition/Vomiting: TFs restarted yesterday while patient was not in\\n optimal positioning. One large BM in past 24 hrs to indicate potential\\n improvement in ileus.\\n - Cont Reglan 20mg IV Q 8 hours and restart meds via G-J tube,\\n - Slowly restarting TFs and will increase as tolerated.\\n - PICC line in place with TPN given when pt not tolerating.\\n - GI consult, appreciate recs\\n .\\n # Tachycardia: One episode of SVT overnight with improved HR max of\\n 100\\ns versus 160s previously. Pt now on PO Amiodarone 200 TID, and IV\\n metoprolol\\n - Will change IV metoprolol to metoprolol 25mg PO TID\\n - f/u Cards recs\\n # Sedation/Anxiolysis/AlteredMS: Improved alertness. Long hospital\\n course and multiple psychotropic medications as well as hx of EtOH\\n abuse.\\n - - started Risperdal 0.5mg PO BID\\n - continue to hold all benzos. opiates, and antihistamines\\n - f/u psych recs.\\n .\\n # Fluid Status: Mild hypernatramia with good UOP.\\n - providing D5W IVF PRN and follow lytes\\n # UE DVT and elevated INR: Decision made to d/c Coumadin given her\\n labile INR, and start Lovenox . L Picc difficult to flush this AM.\\n - Will flush L PICC with TPA\\n .\\n # Spine fracture: Stable\\n - Brace for OOB, will discuss with Neurosurgery if current brace is\\n optimal for stabilization given her mobility.\\n - Pt to follow up with Dr. in weeks\\n .\\n # Tracheomalacia. Was initially addressed with IP and they wanted to\\n follow up as outpatient. IP reevaluated and does not believe that a\\n stent would be feasible.\\n .\\n #. Thyroid Nodule on CT\\n - Outpatient follow up\\n .\\n # Glycemic control: SSI, well controlled\\n # ACCESS: PIV x 1, L PICC\\n # Ppx: Lovenox, PPi, Bowel Regimen PRN\\n # Communication:\\n - Boyfriend of 10 \\n - Brother also involved\\n - Social Work and Case management involved, have discussed situation\\n w/ brother and boyfriend.\\n # Code: Full\\n # Dispo: ICU, Screening for vent facilities\\n ICU Care\\n Nutrition:\\n TPN without Lipids - 06:10 PM 43. mL/hour\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n PICC Line - 01:30 PM\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-25 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 639476,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n TF were restarted in afternoon and held after one episode of a coughing\\n fit in the evening. Pt was suctioned, CXR unchanged. AVSS.\\n One episode of SVT to the low 100\\ns overnight from 2:30 to 3:15am.\\n Given D5W x 2 liters for hypernatremia\\n Lovenox 100mg SC BID for prior UE DVT\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:17 AM\\n Enoxaparin (Lovenox) - 06:00 PM\\n Metoprolol - 06:00 PM\\n Other medications:\\n Changes to medical and family history: No additional\\n Review of systems is unchanged from admission except as noted below\\n Review of systems: Pt mouthing words but team unable to understand.\\n Flowsheet Data as of 05:23 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.1\\nC (98.8\\n Tcurrent: 36.3\\nC (97.4\\n HR: 68 (64 - 104) bpm\\n BP: 116/51(66) {105/45(44) - 151/74(89)} mmHg\\n RR: 24 (21 - 38) insp/min\\n SpO2: 96%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 2,676 mL\\n 776 mL\\n PO:\\n TF:\\n 61 mL\\n IVF:\\n 1,418 mL\\n 540 mL\\n Blood products:\\n Total out:\\n 1,910 mL\\n 195 mL\\n Urine:\\n 1,910 mL\\n 195 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 766 mL\\n 581 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask\\n SpO2: 96%\\n ABG: ////\\n Physical Examination\\n Gen: Awake, Mouthing words\\n HEENT: PERRL, MMM\\n Resp: CTA bilaterally, no rales, rhonchi, or wheezing, small\\n inspirations.\\n Card: S1S2 tachycardic, no m/r/g\\n Abd: Obese, soft, mildly distended, BS+\\n Exte: No edema, DP 2+ bil\\n NEURO: Gross Motor and Sensation in 4 extremities\\n Labs / Radiology\\n 316 K/uL\\n 8.3 g/dL\\n 114 mg/dL\\n 0.7 mg/dL\\n 33 mEq/L\\n 4.0 mEq/L\\n 7 mg/dL\\n 110 mEq/L\\n 148 mEq/L\\n 27.0 %\\n 8.0 K/uL\\n [image002.jpg]\\n 03:43 AM\\n 05:02 PM\\n 03:36 AM\\n 02:30 AM\\n 01:30 AM\\n 06:41 AM\\n 03:20 PM\\n 03:23 AM\\n 03:00 AM\\n 04:00 AM\\n WBC\\n 7.1\\n 6.9\\n 7.6\\n 9.5\\n 5.7\\n 7.3\\n 8.0\\n Hct\\n 29.2\\n 27.8\\n 32.7\\n 28.6\\n 28.9\\n 30.0\\n 26.9\\n 27.3\\n 27.0\\n Plt\\n 452\\n 467\\n 548\\n 528\\n 356\\n 346\\n 316\\n Cr\\n 0.7\\n 0.8\\n 0.7\\n 0.8\\n 1.0\\n 0.7\\n 0.7\\n 0.7\\n Glucose\\n 104\\n 108\\n 131\\n 128\\n 121\\n 129\\n 123\\n 114\\n Other labs: PT / PTT / INR:13.2/22.4/1.1, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:9.0 mg/dL, Mg++:2.3 mg/dL, PO4:4.1\\n mg/dL\\n Assessment and Plan\\n 55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\\n trach, PEG with resolving respiratory failure and HAP.\\n .\\n # Respiratory failure: 36hrs off vent, now on trach mask. No further\\n self-decanulations overnight.\\n - Tach mask as tolerated.\\n - Holding sedation with exception of Risperidal 0.5mg .\\n - PMV with suctioning as tolerated\\n .\\n # Nutrition/Vomiting: TFs restarted yesterday while patient was not in\\n optimal positioning. One large BM in past 24 hrs to indicate potential\\n improvement in ileus.\\n - Cont Reglan 20mg IV Q 8 hours and restart meds via G-J tube,\\n - Slowly restarting TFs and will increase as tolerated.\\n - PICC line in place with TPN given when pt not tolerating.\\n - GI consult, appreciate recs\\n .\\n # Tachycardia: One episode of SVT overnight with improved HR max of\\n 100\\ns versus 160s previously. Pt now on PO Amiodarone 200 TID, and IV\\n metoprolol\\n - Will change IV metoprolol to metoprolol 25mg PO TID\\n - f/u Cards recs\\n # Sedation/Anxiolysis/AlteredMS: Improved alertness. Long hospital\\n course and multiple psychotropic medications as well as hx of EtOH\\n abuse.\\n - - started Risperdal 0.5mg PO BID\\n - continue to hold all benzos. opiates, and antihistamines\\n - f/u psych recs.\\n .\\n # Fluid Status: Mild hypernatramia with good UOP.\\n - providing D5W IVF PRN and follow lytes\\n # UE DVT and elevated INR: Decision made to d/c Coumadin given her\\n labile INR, and start Lovenox . L Picc difficult to flush this AM.\\n - Will flush L PICC with TPA\\n .\\n # Spine fracture: Stable\\n - Brace for OOB, will discuss with Neurosurgery if current brace is\\n optimal for stabilization given her mobility.\\n - Pt to follow up with Dr. in weeks\\n .\\n # Tracheomalacia. Was initially addressed with IP and they wanted to\\n follow up as outpatient. IP reevaluated and does not believe that a\\n stent would be feasible.\\n .\\n #. Thyroid Nodule on CT\\n - Outpatient follow up\\n .\\n # Glycemic control: SSI, well controlled\\n # ACCESS: PIV x 1, L PICC\\n # Ppx: Lovenox, PPi, Bowel Regimen PRN\\n # Communication:\\n - Boyfriend of 10 \\n - Brother also involved\\n - Social Work and Case management involved, have discussed situation\\n w/ brother and boyfriend.\\n # Code: Full\\n # Dispo: ICU, Screening for vent facilities\\n ICU Care\\n Nutrition:\\n TPN without Lipids - 06:10 PM 43. mL/hour\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n PICC Line - 01:30 PM\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n ------ Protected Section ------\\n MICU ATTENDING ADDENDUM:\\n On this day I examined the patient and was present for the key portions\\n of the services provided. I have reviewed Dr \\ns note above and\\n agree with the findings and plan of care. I would emphasize that Ms\\n has done well, and is off the ventilator now for over 36\\n straight hours. Today she is awake, animated, but unable to talk as\\n PMV is not in place due to secretions. Tube feeds had been held due to\\n possible aspiration, but without clear cut evidence of such. So with\\n the need for enteral nutrition and good bowel sounds, we will restart\\n TFs today. For her emotional benefit, we will keep her well suctioned\\n and allow her short periods on the PMV so that she can communicate and\\n be less frustrated. The goal will be to have her remain stable so\\n that transfer to pulm rehab can occur early this work week.\\n , MD\\n ------ Protected Section Addendum Entered By: , MD\\n on: 14:29 ------\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-26 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 639550,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Pt agitated overnight given extra Risperidone 0.5 mg x 2 overnight.\\n (1.5mg total)\\n 1000 mL D5W for Hypernatremia\\n Changed B-Blocker from IV to PO, Metoprolol Tartrate 25 mg PO TID\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:17 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:47 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.8\\nC (98.2\\n Tcurrent: 36.7\\nC (98\\n HR: 120 (67 - 120) bpm\\n BP: 110/64(76) {109/47(60) - 141/115(118)} mmHg\\n RR: 26 (18 - 30) insp/min\\n SpO2: 100%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 3,820 mL\\n 856 mL\\n PO:\\n TF:\\n 117 mL\\n 20 mL\\n IVF:\\n 2,612 mL\\n 572 mL\\n Blood products:\\n Total out:\\n 2,460 mL\\n 1,180 mL\\n Urine:\\n 2,460 mL\\n 1,180 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,360 mL\\n -324 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask\\n SpO2: 100%\\n ABG: ///33/\\n Physical Examination\\n Gen: Awake, Mouthing words, More agitated compared to previous\\n mornings.\\n HEENT: EOMI, No pallor in conjunctiva, MMM\\n Resp: CTA bilaterally, no rales, rhonchi, or wheezing, good airway\\n movement.\\n Card: S1S2 tachycardic, no m/r/g\\n Abd: Obese, soft, mildly distended, decreased bowel sounds,, G-Tube in\\n place with no erythema/induration\\n Exte: No edema, DP 2+ bil\\n NEURO: Gross Motor and Sensation in 4 extremities\\n Labs / Radiology\\n 249 K/uL\\n 8.0 g/dL\\n 122 mg/dL\\n 0.5 mg/dL\\n 33 mEq/L\\n 3.7 mEq/L\\n 13 mg/dL\\n 108 mEq/L\\n 146 mEq/L\\n 24.7 %\\n 5.5 K/uL\\n [image002.jpg] CXR: L Picc, trach tip at midline, bibasilar\\n opacities, low lung volumes, Bil pleural effusions.\\n 03:36 AM\\n 02:30 AM\\n 01:30 AM\\n 06:41 AM\\n 03:20 PM\\n 03:23 AM\\n 03:00 AM\\n 04:00 AM\\n 05:45 AM\\n 03:51 AM\\n WBC\\n 6.9\\n 7.6\\n 9.5\\n 5.7\\n 7.3\\n 8.0\\n 8.7\\n 5.5\\n Hct\\n 27.8\\n 32.7\\n 28.6\\n 28.9\\n 30.0\\n 26.9\\n 27.3\\n 27.0\\n 28.7\\n 24.7\\n Plt\\n 467\\n 548\\n 528\\n 356\\n 346\\n 316\\n 271\\n 249\\n Cr\\n 0.7\\n 0.8\\n 1.0\\n 0.7\\n 0.7\\n 0.7\\n 0.7\\n 0.5\\n Glucose\\n 131\\n 128\\n 121\\n 129\\n 123\\n 114\\n 112\\n 122\\n Other labs: PT / PTT / INR:13.6/31.1/1.2, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:9.0 mg/dL, Mg++:2.2 mg/dL, PO4:3.1\\n mg/dL\\n Assessment and Plan\\n 55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\\n trach, PEG with resolving respiratory failure and HAP.\\n .\\n # Respiratory failure: 36hrs off vent, now on trach mask, FiO2 70%. No\\n further self-decanulations overnight.\\n - Tach mask as tolerated.\\n - Holding sedation with exception of Risperidal 0.5mg .\\n - PMV with suctioning as tolerated\\n - F/u CXR tomorrow\\n .\\n # Nutrition/Vomiting: TFs restarted yesterday while patient was not in\\n optimal positioning. One large BM in past 24 hrs to indicate potential\\n improvement in ileus.\\n - Cont Reglan 20mg IV Q 8 hours and restart meds via G-J tube,\\n - Increase TF as tolerated\\n - PICC line in place with TPN given when pt not tolerating TF\\n - GI consult, appreciate recs\\n .\\n # Tachycardia: Improved HR max of 120\\ns versus 160s previously;\\n elevated this am secondary to agitation. Pt now on PO Amiodarone 200\\n TID and PO metoprolol 25mg TID\\n - Continue current med regimen. Will continue amiodarone 200 TID for\\n three weeks and then switch to qday.\\n - Will schedule f/u in 4wks with Dr. upon d/c.\\n - f/u Cards recs\\n # Sedation/Anxiolysis/AlteredMS: Agitation O/N, continues to be\\n agitated most likely secondary to long hospital course and multiple\\n psychotropic medications as well as hx of EtOH abuse. Risperdal given\\n O/N.\\n - started Risperdal 0.5mg PO BID\\n - continue to hold all benzos. opiates, and antihistamines\\n - Appreciate psych. Will f/u psych recs.\\n .\\n # Hypernatremia/Fluid Status: Mild hypernatramia with good UOP\\n (hypervolemic hypernatremia). On TPN/TF.\\n - providing D5W IVF PRN and follow lytes (check Na this afternoon).\\n # UE DVT and elevated INR: Decision made to d/c Coumadin given her\\n labile INR, and start Lovenox . Current INR 1.2.\\n - Will flush L PICC with TPA\\n .\\n # Spine fracture: Stable\\n - Brace for OOB, will discuss with Neurosurgery if current brace is\\n optimal for stabilization given her mobility.\\n - Pt to follow up with Dr. in weeks\\n .\\n # Tracheomalacia. Was initially addressed with IP and they wanted to\\n follow up as outpatient. IP reevaluated and does not believe that a\\n stent would be feasible.\\n .\\n #. Thyroid Nodule on CT\\n - Outpatient follow up\\n .\\n # Glycemic control: SSI, well controlled\\n # ACCESS: PIV x 1, L PICC\\n # Ppx: Lovenox, PPi, Bowel Regimen PRN\\n # Communication:\\n - Boyfriend of 10 \\n - Brother also involved\\n - Social Work and Case management involved, have discussed situation\\n w/ brother and boyfriend.\\n # Code: Full\\n # Dispo: ICU, Screening for vent facilities\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2167-10-26 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 639588,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Pt agitated overnight given extra Risperidone 0.5 mg x 2 overnight.\\n (1.5mg total)\\n 1000 mL D5W for Hypernatremia\\n Changed B-Blocker from IV to PO, Metoprolol Tartrate 25 mg PO TID\\n Allergies:\\n Penicillins\\n Rash; blisters;\\n Tetracycline\\n Rash;\\n Sulfa (Sulfonamides)\\n Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:17 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:47 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.8\\nC (98.2\\n Tcurrent: 36.7\\nC (98\\n HR: 120 (67 - 120) bpm\\n BP: 110/64(76) {109/47(60) - 141/115(118)} mmHg\\n RR: 26 (18 - 30) insp/min\\n SpO2: 100%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 106 kg (admission): 94.2 kg\\n Height: 67 Inch\\n Total In:\\n 3,820 mL\\n 856 mL\\n PO:\\n TF:\\n 117 mL\\n 20 mL\\n IVF:\\n 2,612 mL\\n 572 mL\\n Blood products:\\n Total out:\\n 2,460 mL\\n 1,180 mL\\n Urine:\\n 2,460 mL\\n 1,180 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,360 mL\\n -324 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask\\n SpO2: 100%\\n ABG: ///33/\\n Physical Examination\\n Gen: Awake, Mouthing words, More agitated compared to previous\\n mornings.\\n HEENT: EOMI, No pallor in conjunctiva, MMM\\n Resp: CTAB, no rales, rhonchi, or wheezing, good airway movement.\\n Card: S1S2 tachycardic, no m/r/g\\n Abd: Obese, soft, mildly distended, decreased bowel sounds,, G-Tube in\\n place with no erythema/induration\\n Exte: No edema, DP 2+ bil\\n NEURO: Gross Motor and Sensation in 4 extremities\\n Labs / Radiology\\n 249 K/uL\\n 8.0 g/dL\\n 122 mg/dL\\n 0.5 mg/dL\\n 33 mEq/L\\n 3.7 mEq/L\\n 13 mg/dL\\n 108 mEq/L\\n 146 mEq/L\\n 24.7 %\\n 5.5 K/uL\\n [image002.jpg] CXR: L Picc, trach tip at midline, bibasilar\\n opacities, low lung volumes, Bil pleural effusions.\\n 03:36 AM\\n 02:30 AM\\n 01:30 AM\\n 06:41 AM\\n 03:20 PM\\n 03:23 AM\\n 03:00 AM\\n 04:00 AM\\n 05:45 AM\\n 03:51 AM\\n WBC\\n 6.9\\n 7.6\\n 9.5\\n 5.7\\n 7.3\\n 8.0\\n 8.7\\n 5.5\\n Hct\\n 27.8\\n 32.7\\n 28.6\\n 28.9\\n 30.0\\n 26.9\\n 27.3\\n 27.0\\n 28.7\\n 24.7\\n Plt\\n 467\\n 548\\n 528\\n 356\\n 346\\n 316\\n 271\\n 249\\n Cr\\n 0.7\\n 0.8\\n 1.0\\n 0.7\\n 0.7\\n 0.7\\n 0.7\\n 0.5\\n Glucose\\n 131\\n 128\\n 121\\n 129\\n 123\\n 114\\n 112\\n 122\\n Other labs: PT / PTT / INR:13.6/31.1/1.2, CK / CKMB /\\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:9.0 mg/dL, Mg++:2.2 mg/dL, PO4:3.1\\n mg/dL\\n Assessment and Plan\\n 56yoF s/p mechanical fall and traumatic T spine fracture, now s/p\\n trach/PEG with resolving respiratory failure and HAP.\\n .\\n # Respiratory failure: s/p intubation/extubation, now on trach mask,\\n FiO2 70%. Tolerating well with good O2 sat. No further\\n self-decanulations overnight.\\n - Tach mask as tolerated.\\n - Holding sedation with exception of Risperidal 0.5mg .\\n - F/u CXR tomorrow\\n .\\n # Nutrition/Vomiting: Currently receiving TPN;. One large BM in past\\n 24 hrs to indicate potential improvement in ileus.\\n - Cont Reglan 20mg IV Q 8 hours; meds via G-J tube,\\n - Will obtain recommendations from Nutrition re TPN before starting TPN\\n tomorrow\\n - TF as tolerated\\n - Speech and Swallow eval\\n - PICC line in place with TPN given when pt not tolerating TF\\n - GI consult, appreciate recs\\n .\\n # Tachycardia: Improved HR max of 120\\ns versus 160s previously;\\n elevated this am secondary to agitation. Pt now on PO Amiodarone 200\\n TID and PO metoprolol 25mg TID\\n - Continue current med regimen. Will continue amiodarone 200 TID for\\n three weeks and then switch to qday.\\n - Will schedule f/u in 4wks with Dr. upon d/c/transfer.\\n - f/u Cards recs\\n # Sedation/Anxiolysis/AlteredMS: Agitation O/N, continues to be\\n agitated most likely secondary to long hospital course and multiple\\n psychotropic medications as well as hx of EtOH abuse. Risperdal given\\n O/N.\\n - started Risperdal 0.5mg PO BID\\n - continue to hold all benzos. opiates, and antihistamines\\n - Appreciate psych. Will call and f/u psych recs.\\n #Anemia: Decrease in HCT from 28\\n24; tachycardia. No known etiology of\\n blood loss, most likely related to variaton\\n -Will repeat HCT check this afternoon.\\n # Hypernatremia/Fluid Status: Mild hypernatramia with good UOP\\n (hypervolemic hypernatremia). On TPN/TF.\\n - providing D5W IVF, free water flushes with TF\\n -Will f/u lytes (Na) this afternoon at 5pm.\\n # UE DVT and elevated INR: Decision made to d/c Coumadin given her\\n labile INR, and start Lovenox . Current INR 1.2.\\n - Will flush L PICC with TPA if does not flush\\n .\\n # Spine fracture: Stable\\n - Brace for OOB, need to discuss with Neurosurgery before d/c if\\n current brace is optimal for stabilization given her mobility.\\n - Pt to follow up with Dr. in weeks\\n .\\n # Tracheomalacia. Was initially addressed with IP and they wanted to\\n follow up as outpatient. IP reevaluated and does not believe that a\\n stent would be feasible. No new issues.\\n .\\n #. Thyroid Nodule on CT\\n - Outpatient follow up\\n .\\n # Glycemic control: SSI, well controlled\\n # ACCESS: PIV x 1, L PICC\\n # Ppx: Lovenox, PPi, Bowel Regimen PRN\\n # Communication:\\n - Boyfriend of 10 \\n - Brother also involved\\n - Social Work and Case management involved, have discussed situation\\n w/ brother and boyfriend.\\n # Code: Full\\n # Dispo: ICU, Will d/w case management re rehab facilities.\\n\"\n },\n {\n \"category\": \"Nutrition\",\n \"chartdate\": \"2167-10-20 00:00:00.000\",\n \"description\": \"Clinical Nutrition Note\",\n \"row_id\": 638618,\n \"text\": \"Objective\\n Pertinent medications: noted\\n Labs:\\n Value\\n Date\\n Glucose\\n 128 mg/dL\\n 02:30 AM\\n Glucose Finger Stick\\n 142\\n 10:00 AM\\n BUN\\n 6 mg/dL\\n 02:30 AM\\n Creatinine\\n 0.8 mg/dL\\n 02:30 AM\\n Sodium\\n 148 mEq/L\\n 02:30 AM\\n Potassium\\n 4.1 mEq/L\\n 02:30 AM\\n Chloride\\n 105 mEq/L\\n 02:30 AM\\n TCO2\\n 36 mEq/L\\n 02:30 AM\\n Albumin\\n 3.5 g/dL\\n 03:00 AM\\n Calcium non-ionized\\n 10.0 mg/dL\\n 02:30 AM\\n Phosphorus\\n 4.3 mg/dL\\n 02:30 AM\\n Ionized Calcium\\n 1.24 mmol/L\\n 02:51 AM\\n Magnesium\\n 2.5 mg/dL\\n 02:30 AM\\n ALT\\n 25 IU/L\\n 07:34 AM\\n Alkaline Phosphate\\n 106 IU/L\\n 07:34 AM\\n AST\\n 19 IU/L\\n 07:34 AM\\n WBC\\n 7.6 K/uL\\n 02:30 AM\\n Hgb\\n 10.0 g/dL\\n 02:30 AM\\n Hematocrit\\n 32.7 %\\n 02:30 AM\\n Current diet order / nutrition support: NPO\\n GI: Abd soft/obese/hypo bs\\n Assessment of Nutritional Status\\n Estimation of previous intake: Adequate\\n Estimation of current intake: Inadequate\\n Specifics:\\n 55 y/o female s/p mechanical fall c/ T5-T8 fx c/ long hospital course,\\n now s/p trach and PEG. Pt currently not receiving TF\\ns development\\n of N/V while TF\\ns were infusing, despite addition of reglan. Ongoing\\n discussion re changing FT to post-pyloric/JT, and the best way to do\\n this. Hypernatremia since feeds/flushes held. Noted 500mL D5W\\n given.\\n Medical Nutrition Therapy Plan - Recommend the Following\\n Will follow POC- ability to obtain access for resuming feeds, If unable\\n to resume enteral feeds in next 2-3 days, will need to consider PPN/TPN\\n to avoid nutritional decline\\n Continue to monitor hydration status and give fluid prn\\n Please page c/ ?\\ns #\\n\"\n }\n]"}}},{"rowIdx":385,"cells":{"subject_id":{"kind":"number","value":30725,"string":"30,725"},"hadm_id":{"kind":"number","value":137529,"string":"137,529"},"target_text":{"kind":"string","value":"1) Hypertension Patient had ran out of her medication 2 weeks prior to presentation. No chest pain or dyspnea. Initially started on nitro-drip, could quickly wean off and change to PO medication. BPs hard to control after that, several dose increases were necessary to achieve goal of systolic BP around 150-170. Renal service was consulted to rule out secondary causes of hypertension. They did not feel a CT scan for renal artery stenosis was necessary at this point. Serum cortisol was normal with 28.1. Per patient's PCP, workup for pheochromocytoma had been negative. Patient wanted to leave the hospital before her BPs were stable with the new regimen (amlodipine, lisinopril, HCTZ, labetalol). She will need to be seen very soon as outpatient. Also, she was hypokalemic to 3.2 and was repleted on day of discharge (likely in setting of new diuretics). Her K+ should be rechecked soon. . 2) Hemoptysis Unclear etiology, patient with one episode of hemopytsis/spitting up blood. No more episodes during hospital course. Hct was stable. CTA was unremarkable, PPD had been negative in the past. Stools were OB negative, no melena. If necessary, will need outpatient work-up. . 3) Renal failure. Creatinine stable at 1.3. Unclear baseline. Likely renal insufficiency in setting of uncontrolled hypertension. Will need outpatient follow-up."},"extractive_notes_summ":{"kind":"string","value":"c/o nausea x 1, resolved with no intervention. Nurisng Note MICU-7 7A-7P:Neuro: Patient is withdrawn, flat affect. VOIDED 250CC THIS SHIFT, OOB TO COMMODE TIMES ONE.GI: TAKING PO'S WELL, NO C/O'S PAIN, NO STOOL. Informed pt of the request for nasal CPAP. 12:41 AM CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # Reason: HEMOPTYSIS, SOB Contrast: OPTIRAY Amt: 90 MEDICAL CONDITION: 27 yo f with hemoptysis and sob REASON FOR THIS EXAMINATION: eval for pe No contraindications for IV contrast WET READ: MPtb MON 2:31 AM No PE, essentially unremarkable study. Zofran given with good effect.Skin: w/d/iA/P: HTN- PO meds titrated up. no need for breakthrough meds o/n.. had sbp 180 x 1, repeate check was 150's. Team cosidering bronch on outpatient basis, once bp better controlled. Quiet, soft spoken.CV: NSR-ST. 82-110. PT STATES THAT SHE HAS HER PERIOD.GU: PT VOIDED IN THE ED BUT HAS NOT VOIDED HERE IN THE MICU.SKIN: PT'S SKIN IS INTACT.ACCESS: PT HAS 2 # 18 PIV'S, THE ONE ON THE LEFT HAND IS CLOTTED.SOCIAL: PT IS A FULL CODE. Respiratory TherapyPt presents left lat High position soft snorous respirations. No cough or sob noted.GI/GU: abd obese, soft, +BS. GU: voiding via bsc. 'ING SLEEP APNEA. PT IS AFEBRILE.GI: PT C/O NAUSEA SHORTLY AFTER ARRIVAL TO THE UNIT. AT THIS TIME GOAL IS TO GET BP DOWN WITH PO MEDS. to start labetolol in am and lopressor was dc'd. Complained of difficulty breathing @ 1600, upon examination lungs clear, breathing 12-15 bpm, unlabored. PT HAD CTA DONE WHICH R/O PE. Patient received PO anti-hypertensives this AM, IVP hydralizine Q6hrs PRN. CV: sbp 150's-160's, HR 70's -80's nsr. Afeb.Resp: LS CTA. unclear who told her this.Hemoptysis- No further hemoptysis, CT negative for PE. BP VERY HYPERTENSIVE 170-190'S AT THIS TIME. NPN MICU- 7AM-7PM28 YO FEMALE WITH HTN.S/O: RESPIR: ON RA O2 SATS 93-97%, RR 16-22, L/S CLEAR TO DIMINISHED @ BASES, BUT WHEN ASLEEP DOES DESATS TO 88-90%, ? most likely c/o to floor today. REsP: trialed on nasal bipap. Respiratory TherapyIntermittent use of nasal CPAP. trialed nasal bipap o/n. The heart size and mediastinal contours are within normal limits. NO SOB.C/V: BP IN THE AM 180-190'S/90'S, WAS DUE FOR HER AM MEDS, AND LOPRESSOR WAS INCREASED TO 100MG, NOW BP 160-178'S/70, HR- 70-80'S SR NO ECTOPY NOTED.RENAL: LOW U/O WITH CRE UP TO 1.6 ? The lungs are essentially clear excepting for mild basilar atelectasis on the left. NTG DRIP D/C'D ON ARRIVAL TO THE MICU.RESP: PT ARRIVED FROM THE ED WITH 3LNC WITH O2 SAT'S IN THE HIGH 90'S. Long acting Toprol changed to Lopressor TID for ease of titration. PT 4MG ZOFRAN IVP. Independently transfers to commode and back to bed without problem. Sinus rhythmLeft ventricular hypertrophy with ST-T abnormalitiesThe ST-T changes are diffuse - clinical correlation is suggestedNo previous tracing available for comparison LUNG SOUNDS CLEAR AND HAS NOT COUGH UP ANY BLOOD SINCE ARRIVAL.CV: PT IN NSR WITH HR IN THE 80'S. PT VOMITED AMT OF CLEAR WITH SOME DK MATERIAL. Given Hydralazine as above with fair effect. then fell asleep without it.. overall wore mask sporadically and for brief intervals. no gross motor defecits noted. no c/o sob. IMPRESSION: No acute cardiopulmonary process. Essentially unremarkable study. PT C/O HA WHICH WAS PROBABLY CAUSED BY THE NTG DRIP. No stool this shift.GU: Voiding clear yellow urine per commode.Plan: Called out for floor, awaiting bed. PT HAS A JOB AND LIVES ALONE.REVIEW OF SYSTEMS:NEURO: PT ALERT AND ORIENTED X 3. UNABLE TO DO SO D/T HER NAUSEA. PT STARTED ON NTG DRIP AND NTG PASTE AND LABETOLOL IVP WHICH BROUGHT HER BP DOWN TO 150'S. +BS. GI: ab obese, bs +. CHECK LYTES. Patient has received no sedating medication this shift.Resp: SAT 96-99% on room air. NPN 7p-7a: Nuero: pt A+O x 3. continues with HA, treated with 650mg po tylenol, then 5mg oxycodone po with relief. No c/o HA or pain. No ectopy noted. NPN 1900-0700:Neuro: alert, oriented x3, pleasant and cooperative with care, c/o headache received Tylenol as PRN with good effect, c/o nausea, received antiemetic PRN with good effect, following commands consistently.Resp: breathing regularly on NC 3 LPM, sat 91-96, yet desats to 80s when pulling the O2 out, LS CTA, RR 14-20.CV: NSR-ST HR 80-102, BP was 183/90 when received at 1900, received a dose of lopressor po as ordered and BP has stable for the rest of the night, hydralazine was ordered PRN but not needed, with 2 PIV lines, palpable peripheral pulses.GI/GU: eating with very good appetite, BS present, voiding freely (in bed-pan) and adequately.Integ: intact skin integrity, T max 98.7.Social: full code, mother and cousin visited and updated on .Plan: monitor and control BP, HO will contact where the pt use to receive tx, yet she came this time to because is full. Lung sounds clear but diminished due to size. Sbp 164-198. Oriented pt to purpose of mask and how it might feel.Pt then acclimated well to silicone med nasal mask CPAP 5/5. So far has tol mask for 2 hrs.,however has off and on to use the commode. NPN 7a-7pFull CodePlease see carevue and FHP for additional data.NKDANeuro: AOx3. a/P: pt now within goal bp range. Then noted to have continued nausea. PT IS VERY OBESE, ABD SOFT DISTENDED WITH POS BOWEL SOUNDS. PT THEN FELL ASLEEP AND IS QUIET AT THIS TIME. pt was not very compliant.. removing mask and leaving it on bed frequently. RR teens, O2 sats low to mid 90's. stated patient kept closing eyes and drifting off during conversation. CT OF THE CHEST WITH IV CONTRAST: The pulmonary arterial tree opacifies well without evidence of pulmonary embolism."},"n_notes":{"kind":"number","value":13,"string":"13"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2180-07-23 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":975649,"text":" 11:02 PM\n CHEST (PORTABLE AP) Clip # \n Reason: STAT CXR, eval asp, acute process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old woman with hematemesis\n REASON FOR THIS EXAMINATION:\n STAT CXR, eval asp, acute process\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 27-year-old female with hematemesis.\n\n COMPARISON: No prior study available.\n\n CHEST, PORTABLE UPRIGHT AP VIEW: This study is limited by underpenetration\n due to the patient's large body habitus. The heart size and mediastinal\n contours are within normal limits. There is normal pulmonary vascularity.\n The lungs are grossly clear. No pleural effusion or pneumothorax is seen.\n\n IMPRESSION: No acute cardiopulmonary process.\n\n\n"},{"category":"Radiology","chartdate":"2180-07-24 00:00:00.000","description":"CTA CHEST W&W/O C&RECONS, NON-CORONARY","row_id":975652,"text":" 12:41 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: HEMOPTYSIS, SOB\n Contrast: OPTIRAY Amt: 90\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 yo f with hemoptysis and sob\n REASON FOR THIS EXAMINATION:\n eval for pe\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MPtb MON 2:31 AM\n No PE, essentially unremarkable study.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 27-year-old female with hemoptysis and difficulty breathing and\n concern for pulmonary embolism.\n\n COMPARISON: No prior study available.\n\n TECHNIQUE: MDCT continuously acquired axial images of the chest were obtained\n after a rapid bolus of 100 mL Optiray IV contrast per the chest pain protocol.\n Multiplanar reformations were obtained.\n\n CT OF THE CHEST WITH IV CONTRAST: The pulmonary arterial tree opacifies well\n without evidence of pulmonary embolism. The abdominal aorta is normal in\n caliber without traumatic injury. There is no pathologic mediastinal, hilar\n or axillary lymphadenopathy. The lungs are essentially clear excepting for\n mild basilar atelectasis on the left. There is no focal consolidation,\n pleural effusion, or pneumothorax. Limited evaluation of the upper abdomen\n demonstrates no significant abnormality.\n\n BONE WINDOWS: No suspicious osteoblastic or osteolytic lesions are seen.\n\n IMPRESSION: No evidence of pulmonary embolism. Essentially unremarkable\n study.\n\n ER dashboard wet read placed at 2:30 a.m. on .\n\n\n"},{"category":"Nursing/other","chartdate":"2180-07-24 00:00:00.000","description":"Report","row_id":1656878,"text":"NURSING PROGRESS NOTE:\nCODE STATUS: FULL CODE.\n\nALLERGY: NKDA\n\nPRECAUTION: UNIVERSAL\n\nCHIEF COMPL: HEMOPTOSIS, SOB.\n\nTHIS IS A 28 YO FEMALE WHO WAS ADM WITH HEMOPTOSIS AND WAS FOUND TO BE IN HYPERTENSIVE CRISIS IN THE ED WITH BP GREATER THAN 250. IN THE PT FILLED BOX OF TISSUE WITH APPOX 100CC BRB. PT STARTED ON NTG DRIP AND NTG PASTE AND LABETOLOL IVP WHICH BROUGHT HER BP DOWN TO 150'S. PT HAD CTA DONE WHICH R/O PE. PT STATED THAT SHE HAD RUN OUT OF HER BP MEDICATIONS FOR OVER A WEEK. PT HAS A JOB AND LIVES ALONE.\n\nREVIEW OF SYSTEMS:\n\nNEURO: PT ALERT AND ORIENTED X 3. VERY SOFT SPOKEN AND SHY. PT ABLE TO MOVE ALL EXTREMETIES. PT C/O HA WHICH WAS PROBABLY CAUSED BY THE NTG DRIP. NTG DRIP D/C'D ON ARRIVAL TO THE MICU.\n\nRESP: PT ARRIVED FROM THE ED WITH 3LNC WITH O2 SAT'S IN THE HIGH 90'S. LUNG SOUNDS CLEAR AND HAS NOT COUGH UP ANY BLOOD SINCE ARRIVAL.\n\nCV: PT IN NSR WITH HR IN THE 80'S. BP VERY HYPERTENSIVE 170-190'S AT THIS TIME. PT GIVEN LOPRESSOR 5MG IVP. PT IS AFEBRILE.\n\nGI: PT C/O NAUSEA SHORTLY AFTER ARRIVAL TO THE UNIT. PT 4MG ZOFRAN IVP. PT VOMITED AMT OF CLEAR WITH SOME DK MATERIAL. PT THEN FELL ASLEEP AND IS QUIET AT THIS TIME. PT IS VERY OBESE, ABD SOFT DISTENDED WITH POS BOWEL SOUNDS. PT STATES THAT SHE HAS HER PERIOD.\n\nGU: PT VOIDED IN THE ED BUT HAS NOT VOIDED HERE IN THE MICU.\n\nSKIN: PT'S SKIN IS INTACT.\n\nACCESS: PT HAS 2 # 18 PIV'S, THE ONE ON THE LEFT HAND IS CLOTTED.\n\nSOCIAL: PT IS A FULL CODE. NO CONTACT WITH FAMILY MEMBERS. PT NEEDS TEACHING ABOUT THE IMPORTANCE OF TAKING HER MEDS. NOT SURE WHY SHE COULDN'T GET THEM. ALSO SHOULD HAVE A NUTRITIONIST SPEAK WITH HER. AT THIS TIME GOAL IS TO GET BP DOWN WITH PO MEDS. UNABLE TO DO SO D/T HER NAUSEA.\n"},{"category":"Nursing/other","chartdate":"2180-07-27 00:00:00.000","description":"Report","row_id":1656887,"text":"Discharge note\n28 yo with HTN, who wanted to go home today, was d/c'd to home with PCP f/u appt already made date- Monday-, date printed on D/C papers, along with medication scripts and medication infomation, was reviewed with pt with handouts on each med. Stated that she understood the importance of follow-up with PCP and the importance of taking her meds as directed. Was d/c'd home with mother.\n"},{"category":"Nursing/other","chartdate":"2180-07-26 00:00:00.000","description":"Report","row_id":1656883,"text":"Nurisng Note MICU-7 7A-7P:\n\nNeuro: Patient is withdrawn, flat affect. Sleeping most of shift, or lying in bed with eyes closed. C/o headache @ 1600, Tylenol 650mg PO. Independently transfers to commode and back to bed without problem. Initially refused to speak with Social Worker because of \"pain\". When questioned by RN, stated her IV in her hand hurt. Encouraged pt. to speak with social worker; patient agreed, but then cut meeting short after only a couple minutes stating she could not go on. stated patient kept closing eyes and drifting off during conversation. Patient has received no sedating medication this shift.\n\nResp: SAT 96-99% on room air. Sleeping much of shift with head elevated without drop in SAT. Renal consult recommends CPAP at night for probable sleep apnea. Lung sounds clear but diminished due to size. No cough. Complained of difficulty breathing @ 1600, upon examination lungs clear, breathing 12-15 bpm, unlabored. SAT 99% on room air.\n\nCV: NSR 70's. Skin warm, dry, intact. Palp. pedal pulses. Patient received PO anti-hypertensives this AM, IVP hydralizine Q6hrs PRN. SBP 135-175. IV R hand painful flush, unable to place now peripheral, IV team called, unable to find vein for new IV.\n\nGI: Patient complained of nausea this morning, Compazine IV given @1000. Patient ate 100% of breakfast and lunch. Nutrition consult to speak with patient regarding low sodium diet, food choices. Abdomen obese, soft. +BS. No stool this shift.\n\nGU: Voiding clear yellow urine per commode.\n\nPlan: Called out for floor, awaiting bed.\n"},{"category":"Nursing/other","chartdate":"2180-07-26 00:00:00.000","description":"Report","row_id":1656884,"text":"Respiratory Therapy\nPt presents left lat High position soft snorous respirations. Informed pt of the request for nasal CPAP. Oriented pt to purpose of mask and how it might feel.Pt then acclimated well to silicone med nasal mask CPAP 5/5. So far has tol mask for 2 hrs.,however has off and on to use the commode. Suggest formal sleep study to titrate pressures and provide the best appliance for optimal pt compliance.\n"},{"category":"Nursing/other","chartdate":"2180-07-27 00:00:00.000","description":"Report","row_id":1656885,"text":"NPN 7p-7a:\n Nuero: pt A+O x 3. continues with HA, treated with 650mg po tylenol, then 5mg oxycodone po with relief. pt reporting hands have been trembling lately, and she is having trouble doing things like holding a pen/silverware, etc. no gross motor defecits noted. team made aware.\n CV: sbp 150's-160's, HR 70's -80's nsr. to start labetolol in am and lopressor was dc'd. no need for breakthrough meds o/n.. had sbp 180 x 1, repeate check was 150's.\n REsP: trialed on nasal bipap. pt was not very compliant.. removing mask and leaving it on bed frequently. then fell asleep without it.. overall wore mask sporadically and for brief intervals. RR teens, O2 sats low to mid 90's. no c/o sob.\n GI: ab obese, bs +. tolerated dinner. c/o nausea x 1, resolved with no intervention.\n GU: voiding via bsc. urine sent for protein.\n no iv access. team aware. am bloods drawn by phlebotomy.\n integ; intact.\n social: pt's mom called and spoke to pt.\n a/P: pt now within goal bp range. trialed nasal bipap o/n. most likely c/o to floor today.\n"},{"category":"Nursing/other","chartdate":"2180-07-27 00:00:00.000","description":"Report","row_id":1656886,"text":"Respiratory Therapy\nIntermittent use of nasal CPAP. fragmented sleep. Suggest Pulmonary consult and formal sleep study.\n"},{"category":"Nursing/other","chartdate":"2180-07-25 00:00:00.000","description":"Report","row_id":1656881,"text":"NPN MICU- 7AM-7PM\n28 YO FEMALE WITH HTN.\n\nS/O: RESPIR: ON RA O2 SATS 93-97%, RR 16-22, L/S CLEAR TO DIMINISHED @ BASES, BUT WHEN ASLEEP DOES DESATS TO 88-90%, ?'ING SLEEP APNEA. NO SOB.\n\nC/V: BP IN THE AM 180-190'S/90'S, WAS DUE FOR HER AM MEDS, AND LOPRESSOR WAS INCREASED TO 100MG, NOW BP 160-178'S/70, HR- 70-80'S SR NO ECTOPY NOTED.\n\nRENAL: LOW U/O WITH CRE UP TO 1.6 ?'ING BASELINE LEVEL. BUN-16. TAKING PO'S WELL BUT HAD A CTA YESTERDAY SO REC'D 500CC NS. VOIDED 250CC THIS SHIFT, OOB TO COMMODE TIMES ONE.\n\nGI: TAKING PO'S WELL, NO C/O'S PAIN, NO STOOL. HCT-36.9.\n\nNEURO: A&OX3. OOB TO CHAIR TIMES ONE FOR 3HRS.\n\nAWAITING BED ON THE FLOOR.\n\nA/P: CONTINUE TO MONITOR BP, ADMINISTER ANTI-HYPERTENSIVES, ASSESS I&OS'S. CHECK LYTES.\n"},{"category":"Nursing/other","chartdate":"2180-07-26 00:00:00.000","description":"Report","row_id":1656882,"text":"NPN 1900-0700:\nNeuro: alert, oriented x3, c/o headache given Tylenol with no relief then Oxycodone with good effect, vomited about 600cc, given zofran, then c/o nauses given compazine, going out of bed to the commode without assistance.\n\nResp: breathing regularly on RA, sating well, however she desated to high 80s, O2 NC applied at 3 LPM raised sat to high 90s, but pt pulled it out immediately, RR 11-23, sat 92-100%, LS CTA.\n\nCV: NSR HR 68-82, BP 150-191/85-129, with one PIV line, BP increased to 201 systolic responded to Hydralazine 20 mg IV, started on PO captopril, still on Lopressor Po too.\n\nGI/GU: pt is eating with excellent appetite, obese, BS present, voiding freely and adequately in the commode independently.\n\nInteg: T max 98.5, intact skin integrity.\n\nSocial: full code, asking to be discharged tomorrow and to come back to work next Tuesday because she's not paid by her employer if she's not working, needs a paper from physician proving she's been in hospital, social worker consulted, pt needs a ride or a ticket for a cab due to financial issues.\n\nPlan: continue monitoring BP, control BP, headache, nausea, and vomiting, urine is to be sent for VMA to R/O pheocromocytoma.\n\nN.B: pt is called out, transfer note written.\n"},{"category":"Nursing/other","chartdate":"2180-07-24 00:00:00.000","description":"Report","row_id":1656879,"text":"NPN 7a-7p\nFull Code\nPlease see carevue and FHP for additional data.\nNKDA\n\nNeuro: AOx3. Pleasant, cooperative with care. MAE. No c/o HA or pain. Quiet, soft spoken.\nCV: NSR-ST. 82-110. No ectopy noted. Sbp 164-198. Received 10mg total of 40mg iv Hydralazine in divided doses for bp control. Also received one time order of 5mg of Amlodipine. Fair effect noted. Long acting Toprol changed to Lopressor TID for ease of titration. Goal sbp 150-160's. Afeb.\nResp: LS CTA. Sats 89-98%. Noted to drop to 89% when sleeping, ? OSA. No cough or sob noted.\nGI/GU: abd obese, soft, +BS. No stool. Diet advanced, pt ordered hamburger, salad, corn, and ice cream. Then noted to have continued nausea. Zofran given with good effect.\nSkin: w/d/i\nA/P: HTN- PO meds titrated up. Given Hydralazine as above with fair effect. Goal sbp 150-160's. Patient stated that she was told that she had to see her doctor before she could refill her bp med. script. unclear who told her this.\nHemoptysis- No further hemoptysis, CT negative for PE. Team cosidering bronch on outpatient basis, once bp better controlled. ? nutrition consult.\nCont. providing supportive care.\n\n"},{"category":"Nursing/other","chartdate":"2180-07-25 00:00:00.000","description":"Report","row_id":1656880,"text":"NPN 1900-0700:\nNeuro: alert, oriented x3, pleasant and cooperative with care, c/o headache received Tylenol as PRN with good effect, c/o nausea, received antiemetic PRN with good effect, following commands consistently.\n\nResp: breathing regularly on NC 3 LPM, sat 91-96, yet desats to 80s when pulling the O2 out, LS CTA, RR 14-20.\n\nCV: NSR-ST HR 80-102, BP was 183/90 when received at 1900, received a dose of lopressor po as ordered and BP has stable for the rest of the night, hydralazine was ordered PRN but not needed, with 2 PIV lines, palpable peripheral pulses.\n\nGI/GU: eating with very good appetite, BS present, voiding freely (in bed-pan) and adequately.\n\nInteg: intact skin integrity, T max 98.7.\n\nSocial: full code, mother and cousin visited and updated on .\n\nPlan: monitor and control BP, HO will contact where the pt use to receive tx, yet she came this time to because is full. Pt ran out of meds for 2 weeks the reason her BP raised so high, HO will f/U on what work has been done at and continue tx from there, R/O pheocromocytoma, hyperaldosteronism, and other conditions leading to hypertensive crisis.\n"},{"category":"ECG","chartdate":"2180-07-24 00:00:00.000","description":"Report","row_id":181390,"text":"Sinus rhythm\nLeft ventricular hypertrophy with ST-T abnormalities\nThe ST-T changes are diffuse - clinical correlation is suggested\nNo previous tracing available for comparison\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2180-07-23 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 975649,\n \"text\": \" 11:02 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: STAT CXR, eval asp, acute process\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 27 year old woman with hematemesis\\n REASON FOR THIS EXAMINATION:\\n STAT CXR, eval asp, acute process\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 27-year-old female with hematemesis.\\n\\n COMPARISON: No prior study available.\\n\\n CHEST, PORTABLE UPRIGHT AP VIEW: This study is limited by underpenetration\\n due to the patient's large body habitus. The heart size and mediastinal\\n contours are within normal limits. There is normal pulmonary vascularity.\\n The lungs are grossly clear. No pleural effusion or pneumothorax is seen.\\n\\n IMPRESSION: No acute cardiopulmonary process.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2180-07-24 00:00:00.000\",\n \"description\": \"CTA CHEST W&W/O C&RECONS, NON-CORONARY\",\n \"row_id\": 975652,\n \"text\": \" 12:41 AM\\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \\n Reason: HEMOPTYSIS, SOB\\n Contrast: OPTIRAY Amt: 90\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 27 yo f with hemoptysis and sob\\n REASON FOR THIS EXAMINATION:\\n eval for pe\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: MPtb MON 2:31 AM\\n No PE, essentially unremarkable study.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 27-year-old female with hemoptysis and difficulty breathing and\\n concern for pulmonary embolism.\\n\\n COMPARISON: No prior study available.\\n\\n TECHNIQUE: MDCT continuously acquired axial images of the chest were obtained\\n after a rapid bolus of 100 mL Optiray IV contrast per the chest pain protocol.\\n Multiplanar reformations were obtained.\\n\\n CT OF THE CHEST WITH IV CONTRAST: The pulmonary arterial tree opacifies well\\n without evidence of pulmonary embolism. The abdominal aorta is normal in\\n caliber without traumatic injury. There is no pathologic mediastinal, hilar\\n or axillary lymphadenopathy. The lungs are essentially clear excepting for\\n mild basilar atelectasis on the left. There is no focal consolidation,\\n pleural effusion, or pneumothorax. Limited evaluation of the upper abdomen\\n demonstrates no significant abnormality.\\n\\n BONE WINDOWS: No suspicious osteoblastic or osteolytic lesions are seen.\\n\\n IMPRESSION: No evidence of pulmonary embolism. Essentially unremarkable\\n study.\\n\\n ER dashboard wet read placed at 2:30 a.m. on .\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2180-07-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1656878,\n \"text\": \"NURSING PROGRESS NOTE:\\nCODE STATUS: FULL CODE.\\n\\nALLERGY: NKDA\\n\\nPRECAUTION: UNIVERSAL\\n\\nCHIEF COMPL: HEMOPTOSIS, SOB.\\n\\nTHIS IS A 28 YO FEMALE WHO WAS ADM WITH HEMOPTOSIS AND WAS FOUND TO BE IN HYPERTENSIVE CRISIS IN THE ED WITH BP GREATER THAN 250. IN THE PT FILLED BOX OF TISSUE WITH APPOX 100CC BRB. PT STARTED ON NTG DRIP AND NTG PASTE AND LABETOLOL IVP WHICH BROUGHT HER BP DOWN TO 150'S. PT HAD CTA DONE WHICH R/O PE. PT STATED THAT SHE HAD RUN OUT OF HER BP MEDICATIONS FOR OVER A WEEK. PT HAS A JOB AND LIVES ALONE.\\n\\nREVIEW OF SYSTEMS:\\n\\nNEURO: PT ALERT AND ORIENTED X 3. VERY SOFT SPOKEN AND SHY. PT ABLE TO MOVE ALL EXTREMETIES. PT C/O HA WHICH WAS PROBABLY CAUSED BY THE NTG DRIP. NTG DRIP D/C'D ON ARRIVAL TO THE MICU.\\n\\nRESP: PT ARRIVED FROM THE ED WITH 3LNC WITH O2 SAT'S IN THE HIGH 90'S. LUNG SOUNDS CLEAR AND HAS NOT COUGH UP ANY BLOOD SINCE ARRIVAL.\\n\\nCV: PT IN NSR WITH HR IN THE 80'S. BP VERY HYPERTENSIVE 170-190'S AT THIS TIME. PT GIVEN LOPRESSOR 5MG IVP. PT IS AFEBRILE.\\n\\nGI: PT C/O NAUSEA SHORTLY AFTER ARRIVAL TO THE UNIT. PT 4MG ZOFRAN IVP. PT VOMITED AMT OF CLEAR WITH SOME DK MATERIAL. PT THEN FELL ASLEEP AND IS QUIET AT THIS TIME. PT IS VERY OBESE, ABD SOFT DISTENDED WITH POS BOWEL SOUNDS. PT STATES THAT SHE HAS HER PERIOD.\\n\\nGU: PT VOIDED IN THE ED BUT HAS NOT VOIDED HERE IN THE MICU.\\n\\nSKIN: PT'S SKIN IS INTACT.\\n\\nACCESS: PT HAS 2 # 18 PIV'S, THE ONE ON THE LEFT HAND IS CLOTTED.\\n\\nSOCIAL: PT IS A FULL CODE. NO CONTACT WITH FAMILY MEMBERS. PT NEEDS TEACHING ABOUT THE IMPORTANCE OF TAKING HER MEDS. NOT SURE WHY SHE COULDN'T GET THEM. ALSO SHOULD HAVE A NUTRITIONIST SPEAK WITH HER. AT THIS TIME GOAL IS TO GET BP DOWN WITH PO MEDS. UNABLE TO DO SO D/T HER NAUSEA.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2180-07-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1656887,\n \"text\": \"Discharge note\\n28 yo with HTN, who wanted to go home today, was d/c'd to home with PCP f/u appt already made date- Monday-, date printed on D/C papers, along with medication scripts and medication infomation, was reviewed with pt with handouts on each med. Stated that she understood the importance of follow-up with PCP and the importance of taking her meds as directed. Was d/c'd home with mother.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2180-07-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1656883,\n \"text\": \"Nurisng Note MICU-7 7A-7P:\\n\\nNeuro: Patient is withdrawn, flat affect. Sleeping most of shift, or lying in bed with eyes closed. C/o headache @ 1600, Tylenol 650mg PO. Independently transfers to commode and back to bed without problem. Initially refused to speak with Social Worker because of \\\"pain\\\". When questioned by RN, stated her IV in her hand hurt. Encouraged pt. to speak with social worker; patient agreed, but then cut meeting short after only a couple minutes stating she could not go on. stated patient kept closing eyes and drifting off during conversation. Patient has received no sedating medication this shift.\\n\\nResp: SAT 96-99% on room air. Sleeping much of shift with head elevated without drop in SAT. Renal consult recommends CPAP at night for probable sleep apnea. Lung sounds clear but diminished due to size. No cough. Complained of difficulty breathing @ 1600, upon examination lungs clear, breathing 12-15 bpm, unlabored. SAT 99% on room air.\\n\\nCV: NSR 70's. Skin warm, dry, intact. Palp. pedal pulses. Patient received PO anti-hypertensives this AM, IVP hydralizine Q6hrs PRN. SBP 135-175. IV R hand painful flush, unable to place now peripheral, IV team called, unable to find vein for new IV.\\n\\nGI: Patient complained of nausea this morning, Compazine IV given @1000. Patient ate 100% of breakfast and lunch. Nutrition consult to speak with patient regarding low sodium diet, food choices. Abdomen obese, soft. +BS. No stool this shift.\\n\\nGU: Voiding clear yellow urine per commode.\\n\\nPlan: Called out for floor, awaiting bed.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2180-07-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1656884,\n \"text\": \"Respiratory Therapy\\nPt presents left lat High position soft snorous respirations. Informed pt of the request for nasal CPAP. Oriented pt to purpose of mask and how it might feel.Pt then acclimated well to silicone med nasal mask CPAP 5/5. So far has tol mask for 2 hrs.,however has off and on to use the commode. Suggest formal sleep study to titrate pressures and provide the best appliance for optimal pt compliance.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2180-07-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1656885,\n \"text\": \"NPN 7p-7a:\\n Nuero: pt A+O x 3. continues with HA, treated with 650mg po tylenol, then 5mg oxycodone po with relief. pt reporting hands have been trembling lately, and she is having trouble doing things like holding a pen/silverware, etc. no gross motor defecits noted. team made aware.\\n CV: sbp 150's-160's, HR 70's -80's nsr. to start labetolol in am and lopressor was dc'd. no need for breakthrough meds o/n.. had sbp 180 x 1, repeate check was 150's.\\n REsP: trialed on nasal bipap. pt was not very compliant.. removing mask and leaving it on bed frequently. then fell asleep without it.. overall wore mask sporadically and for brief intervals. RR teens, O2 sats low to mid 90's. no c/o sob.\\n GI: ab obese, bs +. tolerated dinner. c/o nausea x 1, resolved with no intervention.\\n GU: voiding via bsc. urine sent for protein.\\n no iv access. team aware. am bloods drawn by phlebotomy.\\n integ; intact.\\n social: pt's mom called and spoke to pt.\\n a/P: pt now within goal bp range. trialed nasal bipap o/n. most likely c/o to floor today.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2180-07-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1656886,\n \"text\": \"Respiratory Therapy\\nIntermittent use of nasal CPAP. fragmented sleep. Suggest Pulmonary consult and formal sleep study.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2180-07-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1656881,\n \"text\": \"NPN MICU- 7AM-7PM\\n28 YO FEMALE WITH HTN.\\n\\nS/O: RESPIR: ON RA O2 SATS 93-97%, RR 16-22, L/S CLEAR TO DIMINISHED @ BASES, BUT WHEN ASLEEP DOES DESATS TO 88-90%, ?'ING SLEEP APNEA. NO SOB.\\n\\nC/V: BP IN THE AM 180-190'S/90'S, WAS DUE FOR HER AM MEDS, AND LOPRESSOR WAS INCREASED TO 100MG, NOW BP 160-178'S/70, HR- 70-80'S SR NO ECTOPY NOTED.\\n\\nRENAL: LOW U/O WITH CRE UP TO 1.6 ?'ING BASELINE LEVEL. BUN-16. TAKING PO'S WELL BUT HAD A CTA YESTERDAY SO REC'D 500CC NS. VOIDED 250CC THIS SHIFT, OOB TO COMMODE TIMES ONE.\\n\\nGI: TAKING PO'S WELL, NO C/O'S PAIN, NO STOOL. HCT-36.9.\\n\\nNEURO: A&OX3. OOB TO CHAIR TIMES ONE FOR 3HRS.\\n\\nAWAITING BED ON THE FLOOR.\\n\\nA/P: CONTINUE TO MONITOR BP, ADMINISTER ANTI-HYPERTENSIVES, ASSESS I&OS'S. CHECK LYTES.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2180-07-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1656882,\n \"text\": \"NPN 1900-0700:\\nNeuro: alert, oriented x3, c/o headache given Tylenol with no relief then Oxycodone with good effect, vomited about 600cc, given zofran, then c/o nauses given compazine, going out of bed to the commode without assistance.\\n\\nResp: breathing regularly on RA, sating well, however she desated to high 80s, O2 NC applied at 3 LPM raised sat to high 90s, but pt pulled it out immediately, RR 11-23, sat 92-100%, LS CTA.\\n\\nCV: NSR HR 68-82, BP 150-191/85-129, with one PIV line, BP increased to 201 systolic responded to Hydralazine 20 mg IV, started on PO captopril, still on Lopressor Po too.\\n\\nGI/GU: pt is eating with excellent appetite, obese, BS present, voiding freely and adequately in the commode independently.\\n\\nInteg: T max 98.5, intact skin integrity.\\n\\nSocial: full code, asking to be discharged tomorrow and to come back to work next Tuesday because she's not paid by her employer if she's not working, needs a paper from physician proving she's been in hospital, social worker consulted, pt needs a ride or a ticket for a cab due to financial issues.\\n\\nPlan: continue monitoring BP, control BP, headache, nausea, and vomiting, urine is to be sent for VMA to R/O pheocromocytoma.\\n\\nN.B: pt is called out, transfer note written.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2180-07-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1656879,\n \"text\": \"NPN 7a-7p\\nFull Code\\nPlease see carevue and FHP for additional data.\\nNKDA\\n\\nNeuro: AOx3. Pleasant, cooperative with care. MAE. No c/o HA or pain. Quiet, soft spoken.\\nCV: NSR-ST. 82-110. No ectopy noted. Sbp 164-198. Received 10mg total of 40mg iv Hydralazine in divided doses for bp control. Also received one time order of 5mg of Amlodipine. Fair effect noted. Long acting Toprol changed to Lopressor TID for ease of titration. Goal sbp 150-160's. Afeb.\\nResp: LS CTA. Sats 89-98%. Noted to drop to 89% when sleeping, ? OSA. No cough or sob noted.\\nGI/GU: abd obese, soft, +BS. No stool. Diet advanced, pt ordered hamburger, salad, corn, and ice cream. Then noted to have continued nausea. Zofran given with good effect.\\nSkin: w/d/i\\nA/P: HTN- PO meds titrated up. Given Hydralazine as above with fair effect. Goal sbp 150-160's. Patient stated that she was told that she had to see her doctor before she could refill her bp med. script. unclear who told her this.\\nHemoptysis- No further hemoptysis, CT negative for PE. Team cosidering bronch on outpatient basis, once bp better controlled. ? nutrition consult.\\nCont. providing supportive care.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2180-07-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1656880,\n \"text\": \"NPN 1900-0700:\\nNeuro: alert, oriented x3, pleasant and cooperative with care, c/o headache received Tylenol as PRN with good effect, c/o nausea, received antiemetic PRN with good effect, following commands consistently.\\n\\nResp: breathing regularly on NC 3 LPM, sat 91-96, yet desats to 80s when pulling the O2 out, LS CTA, RR 14-20.\\n\\nCV: NSR-ST HR 80-102, BP was 183/90 when received at 1900, received a dose of lopressor po as ordered and BP has stable for the rest of the night, hydralazine was ordered PRN but not needed, with 2 PIV lines, palpable peripheral pulses.\\n\\nGI/GU: eating with very good appetite, BS present, voiding freely (in bed-pan) and adequately.\\n\\nInteg: intact skin integrity, T max 98.7.\\n\\nSocial: full code, mother and cousin visited and updated on .\\n\\nPlan: monitor and control BP, HO will contact where the pt use to receive tx, yet she came this time to because is full. Pt ran out of meds for 2 weeks the reason her BP raised so high, HO will f/U on what work has been done at and continue tx from there, R/O pheocromocytoma, hyperaldosteronism, and other conditions leading to hypertensive crisis.\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2180-07-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 181390,\n \"text\": \"Sinus rhythm\\nLeft ventricular hypertrophy with ST-T abnormalities\\nThe ST-T changes are diffuse - clinical correlation is suggested\\nNo previous tracing available for comparison\\n\\n\"\n }\n]"}}},{"rowIdx":386,"cells":{"subject_id":{"kind":"number","value":45319,"string":"45,319"},"hadm_id":{"kind":"number","value":194809,"string":"194,809"},"target_text":{"kind":"string","value":"# Cardiac arrest: based on history most likely etiology was aspiration event resulting in likely PEA arrest. Evidence of bilateral multifocal pneumonia on CTA is consistent with this possibility. Patient without evidence of cardiac ischemia by ECG or cardiac biomarkers. CPR initiated in the field with return of pulses. Reportedly, in the emergency room a family member said the patient was full code. Therefore, hypothermia protocol was initiated in the ED, and patient remained intubated. In the morning, the patient's power of attorney (Mr. ) called to report patient was DNr/DNI. The paperwork making him POA were faxed to the MICU. Mr. was spoken to over the phone (he resides out of state) and confirmed the patient was DNR/DNI prior to her arrest. The patient was thus rewarmed using the re-warming protocol. according to the patient's prior wishes she was extubated and died at 5:24pm. The family declined autopsy but the medical examiner accepted the case. The NEOB was contact but did not deem her a candidate for organ donation."},"extractive_notes_summ":{"kind":"string","value":"Unchanged retrocardiac atelectasis. Increased small right pleural effusion and decreased small left pleural effusion. The Q-T interval is prolonged.There is minimal ST segment elevation in the inferior leads. The aorta contains moderate atherosclerotic calcification. The retrocardiac atelectasis is unchanged. Non-specificST-T wave changes. There is a small increased right pleural effusion and small decreased left effusion. Right IJ catheter was presumably removed. TECHNIQUE: Non-contrast head CT with axial, coronal, sagittal reformations. There is mitral annular calcification. Compared to the previous tracing of sinus rhythm has been restored and right bundle-branch block and left anteriorfascicular block have resolved. The endotracheal tube ends 1.2 cm above the carina. Left axis deviation.Right bundle-branch block with left anterior fascicular block. Bilateral lower lobe opacity with prominence of the right hilum. ONE VIEW OF THE CHEST: The lungs are low in volume and show bilateral lower lobe and right middle lobe opacity. There is persistent pulmonary edema that is in a different distribution, although the degree of pulmonary edema is unchanged. The heart is borderline enlarged but unchanged in size. Sinus rhythm. Sinus bradycardia. An ET tube terminates 1.8 cm above the carina. Minimal mucosal thickening within the ethmoid sinus as well. IMPRESSION: 1. IMPRESSION: 1. IMPRESSION: 1. Probable junctional rhythm versus a rhythm originating in the posteriorfascicle of the left-sided conduction system. The cardiac silhouette shows mitral annular calcifications. FINDINGS: There is relatively little overall change in the appearance of the heart and lungs. Status post cardiac arrest. The imaged paranasal sinuses are notable for a small fluid level within the left sphenoid sinus. The hilar contours show prominence of the right hilum. Low voltage in the limb leads. ETT tip positioned 1.5 cm above the carina, recommend slight retraction. The mastoid air cells and middle ear cavities are well aerated. No pleural effusions. Vascular calcifications along the carotid siphon noted. There is persistent bilateral perihilar haze. Motion artifact limits evaluation. Coronary artery calcification also noted. There is relatively little overall change in the appearance of the lungs. Clinicalcorrelation is suggested. TECHNIQUE: MDCT helical images were acquired through the chest with and without IV contrast: Multiplanar reformations were obtained and reviewed. In addition, scattered opacities in the lungs anteriorly are noted likely reflecting additional aspiration. Question ICH. An NG tube terminates within the stomach. Could be secondary to aspiration. ET tube terminates 1.8 cm above the carina and should be retracted by about 1 cm. FINDINGS: Motion artifact limits evaluation. No intracranial hemorrhage. IMPRESSION: Chronic microvascular ischemic disease, no hemorrhage, left sphenoid sinus disease. Extensive bilateral predominantly posterior pulmonary consolidations, likely the sequela of aspiration. The NG tube extends into the stomach and out of the field of view. Bony calvarium appears intact. Lung volumes remain low, but are slightly increased. REASON FOR THIS EXAMINATION: Any interval change? There is no associated retrosternal hematoma. Involutional changes are age-appropriate. Apparent sternal fracture for which clinical correlation is advised to determine acuity. (Over) 7:27 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # Reason: r/o PE Field of view: 36 Contrast: OPTIRAY Amt: FINAL REPORT (Cont) 3. No pleural effusions are present. Heart size appears normal and there is no pericardial effusion. No other acute intracranial process. COMPARISON: Chest radiograph from . OSSEOUS STRUCTURES: The osseous structures show no suspicious lytic or blastic lesions. OGT positioned appropriately. No previous tracing availablefor comparison.TRACING #1 No PE. No PE. COMPARISON: None available. COMPARISON: None available. 3. S/p cardiac arrest. ST segment elevation is new.TRACING #3 2. 2. 2. CT OF THE CHEST WITH IV CONTRAST: An ET tube is noted with tip 1.5 cm above the carina. Although this examination was not intended for subdiaphragmatic evaluation, the partially imaged abdomen appears unremarkable. 4. There is no pulmonary arterial filling defect to suggest PE. FINAL REPORT INDICATION: Multifocal pneumonia versus ARDS. Periventricular white matter hypodensities are compatible with chronic microvascular ischemic disease. 3:23 AM CHEST (PORTABLE AP) Clip # Reason: Any interval change? Extensive consolidation in the posterior lungs, primary the lower lobes is suggestive of aspiration sequelae. There are decreased opacities in the right mid and lower lungs but increased opacities in the left mid and lower lungs, consistent with redistribution of edema. Allowing for this, there is no intracranial hemorrhage, edema, shift of normally midline structures, or hydrocephalus. If the outside hospital report was definitive, please provide location. Increased bronchial cuffing is noted. Compared to the previous tracing these findings are new.TRACING #2 There is no lymphadenopathy. OGT extends into the stomach. Artifact is present. ICH on OSH study limited by artifact REASON FOR THIS EXAMINATION: r/o ICH No contraindications for IV contrast WET READ: ASpf WED 8:18 PM Motion degrades study. Multifocal pneumonia is not likely given the rapid decrease in the right lung opacities. A sternal deformity is noted on the sagittal reformats, image 27, possibly a fracture related to CPR though clinical correlation advised. Also noted are healed nondisplaced fractures of the right seventh and sixth ribs. Please refer to subsequent chest CT for further details. There is no pneumothorax identified. FINAL REPORT INDICATION: 84-year-old woman with status post arrest with low sats despite intubation. 7:27 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # Reason: r/o PE Field of view: 36 Contrast: OPTIRAY Amt: MEDICAL CONDITION: 84 year old woman with s/p arrest w/ low sat despite intubation and neg CXR at OSH REASON FOR THIS EXAMINATION: r/o PE No contraindications for IV contrast WET READ: ASpf WED 8:17 PM Bilateral multifocal consolidations worse in the lung bases representing pneumonia."},"n_notes":{"kind":"number","value":7,"string":"7"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2119-12-14 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1171146,"text":" 3:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Any interval change?\n Admitting Diagnosis: PNEUMONIA;S/P CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with multifocal pneumonia vs. ARDS. S/p cardiac arrest.\n REASON FOR THIS EXAMINATION:\n Any interval change?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Multifocal pneumonia versus ARDS. Status post cardiac arrest.\n\n COMPARISON: Chest radiograph from .\n\n FINDINGS: There is relatively little overall change in the appearance of the\n heart and lungs. The endotracheal tube ends 1.2 cm above the carina. The NG\n tube extends into the stomach and out of the field of view. The heart is\n borderline enlarged but unchanged in size. There is a small increased right\n pleural effusion and small decreased left effusion. Increased bronchial\n cuffing is noted. There is persistent bilateral perihilar haze. There are\n decreased opacities in the right mid and lower lungs but increased opacities\n in the left mid and lower lungs, consistent with redistribution of edema.\n Lung volumes remain low, but are slightly increased. There is no pneumothorax\n identified. The retrocardiac atelectasis is unchanged.\n\n IMPRESSION:\n 1. There is relatively little overall change in the appearance of the lungs.\n There is persistent pulmonary edema that is in a different distribution,\n although the degree of pulmonary edema is unchanged. Multifocal pneumonia is\n not likely given the rapid decrease in the right lung opacities.\n 2. Unchanged retrocardiac atelectasis.\n 3. Increased small right pleural effusion and decreased small left pleural\n effusion.\n\n"},{"category":"Radiology","chartdate":"2119-12-13 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1171119,"text":" 7:17 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ETT placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with intubation and low O2 sat\n REASON FOR THIS EXAMINATION:\n ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 84-year-old woman with intubation and low O2 sat.\n\n COMPARISON: None available.\n\n ONE VIEW OF THE CHEST: The lungs are low in volume and show bilateral lower\n lobe and right middle lobe opacity. The cardiac silhouette shows mitral\n annular calcifications. The hilar contours show prominence of the right\n hilum. No pleural effusions are present. An NG tube terminates within the\n stomach. An ET tube terminates 1.8 cm above the carina.\n\n IMPRESSION:\n 1. Bilateral lower lobe opacity with prominence of the right hilum. Please\n refer to subsequent chest CT for further details.\n 2. ET tube terminates 1.8 cm above the carina and should be retracted by\n about 1 cm.\n\n"},{"category":"Radiology","chartdate":"2119-12-13 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":1171120,"text":" 7:26 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o ICH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with s/p arrest ? ICH on OSH study limited by artifact\n REASON FOR THIS EXAMINATION:\n r/o ICH\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ASpf WED 8:18 PM\n Motion degrades study. No intracranial hemorrhage. If the outside hospital\n report was definitive, please provide location. No other acute intracranial\n process.\n ______________________________________________________________________________\n FINAL REPORT\n NON-CONTRAST HEAD CT PERFORMED ON \n\n CLINICAL HISTORY: 84-year-old woman status post arrest, question outside\n hospital study ICH, artifact limited. Question ICH.\n\n TECHNIQUE: Non-contrast head CT with axial, coronal, sagittal reformations.\n\n FINDINGS: Motion artifact limits evaluation. Allowing for this, there is no\n intracranial hemorrhage, edema, shift of normally midline structures, or\n hydrocephalus. Periventricular white matter hypodensities are compatible with\n chronic microvascular ischemic disease. Vascular calcifications along the\n carotid siphon noted. Involutional changes are age-appropriate. The imaged\n paranasal sinuses are notable for a small fluid level within the left sphenoid\n sinus. Minimal mucosal thickening within the ethmoid sinus as well. The\n mastoid air cells and middle ear cavities are well aerated. Bony calvarium\n appears intact.\n\n IMPRESSION: Chronic microvascular ischemic disease, no hemorrhage, left\n sphenoid sinus disease. Motion artifact limits evaluation.\n\n\n"},{"category":"Radiology","chartdate":"2119-12-13 00:00:00.000","description":"CTA CHEST W&W/O C&RECONS, NON-CORONARY","row_id":1171121,"text":" 7:27 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: r/o PE\n Field of view: 36 Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with s/p arrest w/ low sat despite intubation and neg CXR at\n OSH\n REASON FOR THIS EXAMINATION:\n r/o PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ASpf WED 8:17 PM\n Bilateral multifocal consolidations worse in the lung bases representing\n pneumonia. Could be secondary to aspiration. No PE. Right IJ catheter was\n presumably removed.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 84-year-old woman with status post arrest with low sats despite\n intubation.\n\n COMPARISON: None available.\n\n TECHNIQUE: MDCT helical images were acquired through the chest with and\n without IV contrast: Multiplanar reformations were obtained and reviewed.\n\n CT OF THE CHEST WITH IV CONTRAST: An ET tube is noted with tip 1.5 cm above\n the carina. OGT extends into the stomach. There is no pulmonary arterial\n filling defect to suggest PE. The aorta contains moderate atherosclerotic\n calcification. Coronary artery calcification also noted. There is mitral\n annular calcification. Heart size appears normal and there is no pericardial\n effusion. There is no lymphadenopathy.\n\n Extensive consolidation in the posterior lungs, primary the lower lobes is\n suggestive of aspiration sequelae. In addition, scattered opacities in the\n lungs anteriorly are noted likely reflecting additional aspiration. No pleural\n effusions.\n\n Although this examination was not intended for subdiaphragmatic evaluation,\n the partially imaged abdomen appears unremarkable.\n\n OSSEOUS STRUCTURES: The osseous structures show no suspicious lytic or blastic\n lesions. A sternal deformity is noted on the sagittal reformats, image 27,\n possibly a fracture related to CPR though clinical correlation advised. There\n is no associated retrosternal hematoma. Also noted are healed nondisplaced\n fractures of the right seventh and sixth ribs.\n\n IMPRESSION:\n\n 1. Extensive bilateral predominantly posterior pulmonary consolidations,\n likely the sequela of aspiration.\n\n 2. No PE.\n (Over)\n\n 7:27 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: r/o PE\n Field of view: 36 Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 3. Apparent sternal fracture for which clinical correlation is advised to\n determine acuity.\n\n 4. ETT tip positioned 1.5 cm above the carina, recommend slight retraction.\n OGT positioned appropriately.\n\n"},{"category":"ECG","chartdate":"2119-12-14 00:00:00.000","description":"Report","row_id":261469,"text":"Artifact is present. Sinus bradycardia. The Q-T interval is prolonged.\nThere is minimal ST segment elevation in the inferior leads. Clinical\ncorrelation is suggested. Compared to the previous tracing of \nsinus rhythm has been restored and right bundle-branch block and left anterior\nfascicular block have resolved. ST segment elevation is new.\nTRACING #3\n\n"},{"category":"ECG","chartdate":"2119-12-14 00:00:00.000","description":"Report","row_id":261470,"text":"Probable junctional rhythm versus a rhythm originating in the posterior\nfascicle of the left-sided conduction system. Left axis deviation.\nRight bundle-branch block with left anterior fascicular block. Non-specific\nST-T wave changes. Compared to the previous tracing these findings are new.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2119-12-13 00:00:00.000","description":"Report","row_id":261471,"text":"Sinus rhythm. Low voltage in the limb leads. No previous tracing available\nfor comparison.\nTRACING #1\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2119-12-14 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1171146,\n \"text\": \" 3:23 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Any interval change?\\n Admitting Diagnosis: PNEUMONIA;S/P CARDIAC ARREST\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 84 year old woman with multifocal pneumonia vs. ARDS. S/p cardiac arrest.\\n REASON FOR THIS EXAMINATION:\\n Any interval change?\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Multifocal pneumonia versus ARDS. Status post cardiac arrest.\\n\\n COMPARISON: Chest radiograph from .\\n\\n FINDINGS: There is relatively little overall change in the appearance of the\\n heart and lungs. The endotracheal tube ends 1.2 cm above the carina. The NG\\n tube extends into the stomach and out of the field of view. The heart is\\n borderline enlarged but unchanged in size. There is a small increased right\\n pleural effusion and small decreased left effusion. Increased bronchial\\n cuffing is noted. There is persistent bilateral perihilar haze. There are\\n decreased opacities in the right mid and lower lungs but increased opacities\\n in the left mid and lower lungs, consistent with redistribution of edema.\\n Lung volumes remain low, but are slightly increased. There is no pneumothorax\\n identified. The retrocardiac atelectasis is unchanged.\\n\\n IMPRESSION:\\n 1. There is relatively little overall change in the appearance of the lungs.\\n There is persistent pulmonary edema that is in a different distribution,\\n although the degree of pulmonary edema is unchanged. Multifocal pneumonia is\\n not likely given the rapid decrease in the right lung opacities.\\n 2. Unchanged retrocardiac atelectasis.\\n 3. Increased small right pleural effusion and decreased small left pleural\\n effusion.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2119-12-13 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1171119,\n \"text\": \" 7:17 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ETT placement\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 84 year old woman with intubation and low O2 sat\\n REASON FOR THIS EXAMINATION:\\n ETT placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 84-year-old woman with intubation and low O2 sat.\\n\\n COMPARISON: None available.\\n\\n ONE VIEW OF THE CHEST: The lungs are low in volume and show bilateral lower\\n lobe and right middle lobe opacity. The cardiac silhouette shows mitral\\n annular calcifications. The hilar contours show prominence of the right\\n hilum. No pleural effusions are present. An NG tube terminates within the\\n stomach. An ET tube terminates 1.8 cm above the carina.\\n\\n IMPRESSION:\\n 1. Bilateral lower lobe opacity with prominence of the right hilum. Please\\n refer to subsequent chest CT for further details.\\n 2. ET tube terminates 1.8 cm above the carina and should be retracted by\\n about 1 cm.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2119-12-13 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 1171120,\n \"text\": \" 7:26 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: r/o ICH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 84 year old woman with s/p arrest ? ICH on OSH study limited by artifact\\n REASON FOR THIS EXAMINATION:\\n r/o ICH\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: ASpf WED 8:18 PM\\n Motion degrades study. No intracranial hemorrhage. If the outside hospital\\n report was definitive, please provide location. No other acute intracranial\\n process.\\n ______________________________________________________________________________\\n FINAL REPORT\\n NON-CONTRAST HEAD CT PERFORMED ON \\n\\n CLINICAL HISTORY: 84-year-old woman status post arrest, question outside\\n hospital study ICH, artifact limited. Question ICH.\\n\\n TECHNIQUE: Non-contrast head CT with axial, coronal, sagittal reformations.\\n\\n FINDINGS: Motion artifact limits evaluation. Allowing for this, there is no\\n intracranial hemorrhage, edema, shift of normally midline structures, or\\n hydrocephalus. Periventricular white matter hypodensities are compatible with\\n chronic microvascular ischemic disease. Vascular calcifications along the\\n carotid siphon noted. Involutional changes are age-appropriate. The imaged\\n paranasal sinuses are notable for a small fluid level within the left sphenoid\\n sinus. Minimal mucosal thickening within the ethmoid sinus as well. The\\n mastoid air cells and middle ear cavities are well aerated. Bony calvarium\\n appears intact.\\n\\n IMPRESSION: Chronic microvascular ischemic disease, no hemorrhage, left\\n sphenoid sinus disease. Motion artifact limits evaluation.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2119-12-13 00:00:00.000\",\n \"description\": \"CTA CHEST W&W/O C&RECONS, NON-CORONARY\",\n \"row_id\": 1171121,\n \"text\": \" 7:27 PM\\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \\n Reason: r/o PE\\n Field of view: 36 Contrast: OPTIRAY Amt:\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 84 year old woman with s/p arrest w/ low sat despite intubation and neg CXR at\\n OSH\\n REASON FOR THIS EXAMINATION:\\n r/o PE\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: ASpf WED 8:17 PM\\n Bilateral multifocal consolidations worse in the lung bases representing\\n pneumonia. Could be secondary to aspiration. No PE. Right IJ catheter was\\n presumably removed.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 84-year-old woman with status post arrest with low sats despite\\n intubation.\\n\\n COMPARISON: None available.\\n\\n TECHNIQUE: MDCT helical images were acquired through the chest with and\\n without IV contrast: Multiplanar reformations were obtained and reviewed.\\n\\n CT OF THE CHEST WITH IV CONTRAST: An ET tube is noted with tip 1.5 cm above\\n the carina. OGT extends into the stomach. There is no pulmonary arterial\\n filling defect to suggest PE. The aorta contains moderate atherosclerotic\\n calcification. Coronary artery calcification also noted. There is mitral\\n annular calcification. Heart size appears normal and there is no pericardial\\n effusion. There is no lymphadenopathy.\\n\\n Extensive consolidation in the posterior lungs, primary the lower lobes is\\n suggestive of aspiration sequelae. In addition, scattered opacities in the\\n lungs anteriorly are noted likely reflecting additional aspiration. No pleural\\n effusions.\\n\\n Although this examination was not intended for subdiaphragmatic evaluation,\\n the partially imaged abdomen appears unremarkable.\\n\\n OSSEOUS STRUCTURES: The osseous structures show no suspicious lytic or blastic\\n lesions. A sternal deformity is noted on the sagittal reformats, image 27,\\n possibly a fracture related to CPR though clinical correlation advised. There\\n is no associated retrosternal hematoma. Also noted are healed nondisplaced\\n fractures of the right seventh and sixth ribs.\\n\\n IMPRESSION:\\n\\n 1. Extensive bilateral predominantly posterior pulmonary consolidations,\\n likely the sequela of aspiration.\\n\\n 2. No PE.\\n (Over)\\n\\n 7:27 PM\\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \\n Reason: r/o PE\\n Field of view: 36 Contrast: OPTIRAY Amt:\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n 3. Apparent sternal fracture for which clinical correlation is advised to\\n determine acuity.\\n\\n 4. ETT tip positioned 1.5 cm above the carina, recommend slight retraction.\\n OGT positioned appropriately.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2119-12-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 261469,\n \"text\": \"Artifact is present. Sinus bradycardia. The Q-T interval is prolonged.\\nThere is minimal ST segment elevation in the inferior leads. Clinical\\ncorrelation is suggested. Compared to the previous tracing of \\nsinus rhythm has been restored and right bundle-branch block and left anterior\\nfascicular block have resolved. ST segment elevation is new.\\nTRACING #3\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2119-12-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 261470,\n \"text\": \"Probable junctional rhythm versus a rhythm originating in the posterior\\nfascicle of the left-sided conduction system. Left axis deviation.\\nRight bundle-branch block with left anterior fascicular block. Non-specific\\nST-T wave changes. Compared to the previous tracing these findings are new.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2119-12-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 261471,\n \"text\": \"Sinus rhythm. Low voltage in the limb leads. No previous tracing available\\nfor comparison.\\nTRACING #1\\n\\n\"\n }\n]"}}},{"rowIdx":387,"cells":{"subject_id":{"kind":"number","value":24586,"string":"24,586"},"hadm_id":{"kind":"number","value":194720,"string":"194,720"},"target_text":{"kind":"string","value":"23 yo female with a history of depression, PTSD, and borderline personality disorder who was admitted with an aspirin overdose, c/b metabolic acidosis and respiratory acidosis. . Patient had an aspirin overdose of approximately 200 pills, with peak aspirin level of 127. Patient was emergently hemodialyzed for her aspirin overdose to which she responded well. She also received charcoal and was started on a bicarbonate drip. Patient was followed by toxicology. Her metabolic acidosis and respiratory alkalosis was monitored closely by serial ABGs and normalized over the course of 24 hours. Patient's aspirin level was negative. . Patient had a femoral line placed for dialysis. Patient had a groin hematoma at the site. She was also noted to have a >10 point hematocrit drop. Patient had a CT scan performed for RP bleed which was negative. She had a hematocrit that then stabilized, and had no further drops over the next 72 hours. Patient was also noted to have an elevated amylase and lipase, thought to be secondary to a salicylate induced pancreatitis. She complained of nausea. She had no epigastric tenderness to palpation. Patient was tolerating pos and did not require pain medications. Her amylase and lipase trended downward. . Patient was seen by psychiatry as an inpatient, and was recommended to have a 1:1 sitter. She was restarted on Lamictal for mood stabilization. She was also placed on antidepressants with fluoxetine and Klonopin. Patient refused all her doses of her medications, stating that she could not tolerate pills. She was felt to be severely depressed, and patient was transferred to inpatient psychiatry for further management."},"extractive_notes_summ":{"kind":"string","value":"Head CT completed and reported as neg. still suicidal risk and needs 1:1 sitterResp: RA w/ lungs CTA and stable sats. No cough noted.CV: SR-ST w/ HR 90-120's. for bleed, Hct sent and unchanged from am= 26. HR=86-93 NSR no ectopy noted. No SOBCV: A-line/Quinton cath d/c. TECHNIQUE: Non-contrast head CT. and WNL.Cardiac: HR= 70-80's SR with no ecotpy noted. Sinus rhythmDiffuse nonspecific T wave abnormalitiesSince previous tracing of , diffuse T wave changes present No obvious skin breakdown.LABS: Please see flowsheet for latest labs as pt. SINGLE PORTABLE AP UPRIGHT CHEST RADIOGRAPH: The cardiac, mediastinal, and hilar contours are within normal limits. 12:31 AM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: HCT DROP S/P RT GROIN LINE PLACEMENT. Visualized heart and pericardium appear unremarkable. Will obtain non-contrast CT (? SBP 90-100, HR 80-100, NSR--no ectopy. The uterus, adnexa, and rectum appear unremarkable. IMPRESSION: No acute cardiopulmonary process. peripherial pulses x 4.GI/GU: + BS noted. IMPRESSION: No intracranial hemorrhage. 7a-7p nursing notePt. No SOB of dyspnea noted. \"B\" Nsg Progress Note:CVS: Afebrile. PEARL, moves all extremities, no acute neuro changes. Fluid boluses given via HD. No cardiac c/o. Appears depressed and withdrawn.RESP: LS CTA bil. Foley in place w/ adequate UO (decreasing this afternoon).Skin: Numerous self mutilations to arms and left heel w/ the word 'FAT' self carved into heel. TECHNIQUE: Non-contrast CT of the abdomen and pelvis. The bowel gas pattern in the upper abdomen is nonspecific. IMPRESSION: No evidence of retroperitoneal hematoma. #18 LUE, RH, sites WNL--NS KVO. Pt with sig. The kidneys appear symmetric without evidence of hydronephrosis. No dilated loops of bowel are identified. No edema noted. No hx of HAs. Not needed for clinical questions. RR regular and shallow. +DP/PT bil. 1:1 sitter as pt. Initial salicyate level 127 and now, 23. Psych in for eval. 1:1 sitter at bedside.Cardiac: HR= 60-80's SR with no ectopy noted. Continue 1:1 Sitter on floor. Cont'd w/ hypotension requiring a total of 4.8 liter of NS given during HD.Review of Systems:Neuro: lethargic, but arousable to voice. SINGLE PORTABLE AP SUPINE ABDOMINAL RADIOGRAPH: No radiopaque foreign bodies are identified. to be hypotensive w/ IVF at NS w/ 20mequ KCL at 125/hr. MICU Nursing Note 2300-0700Events: Please refer to previous note. bleed from ASA ingestion) and repeat hct. HD x 6hrs for ASA removal. ICa=1.07, given 2amps CaGluconate IV also. Lack of intravenous contrast limits assessment of intraabdominal organs. scars LUE and abd. No BM. Hemodynamically stable.Neuro: A+Ox3, cooperative, flat affect, follows all commands, C/O H/A and medicated with 650mg. The osseous structures demonstrate no concerning lytic or sclerotic lesions. No dilated loops of small or large bowel are identified. Right groin site dressing D/ISocial: No contact from family or friendsPlan: Monitor for bleeding, Monitor HCT Q 4hr---next due at 0830, Continue 1:1 sitter at bedside, Transfuse prn, ? T-max 98.4GI: Tol. is soft, NT, ND. N/V prior to my arrive, but none since. Monitor per protocol:--cont. of transferring to medical floor if no further bleeding, Support pt. called out--Please see transfer note for hx and current assessment.GCS: 15, calm & cooperative. PIV's x 2 (#20) and R groin HD cath. IMPRESSION: Air and stool throughout the colon. Psych evaluated and pt. The osseous and soft tissue structures appear unremarkable. No pathologic mesenteric or retroperitoneal lymphadenopathy is identified. for sudden c/o severe HA. c/o severe frontal \"migraine\" HA relieved temporarily with Tylenol/morphine x 1. No other breakdown noted. The liver, gallbladder, adrenal glands, spleen, and pancreas appear unremarkable. No pleural effusions or pneumothoraces are identified. Conts. No dilated loops of small or large bowel. COMPARISON: None. COMPARISON: None. MICU Intern placed R rad A-line. There is no free intraperitoneal air. The osseous structures appear unremarkable. No free air or free fluid is seen in the abdomen. BP= 89-109/40-50. Afebrile. Stable evening.Neuro: A+OX3, moves all extremities, follows all commands, OOB to w/c with minimal assist, PEARl, c/o H/A---HO aware---medicated with an additional 325mg. Palp. There is no acute major vascular territorial infarct. Oriented x 2 w/ slurred speech and pupils slightly unequal. U/A sent to lab this am.Neuro: No deficits noted.Skin: areas of self mutilation as previously noted, no new areas.Safety: Pt has 1:1 sitter, is calm and cooperative but did awaken twice suddenly with a nightmare.Plan: Continue to monitor labs and replete electrolytes as needed. Denies SOB.GI: Abd soft with + bowel sounds all quads, No BM, taking sips without difficulty.GU: Foley to CD draining clear yellow urine, U/O > 30 ml/hr.Skin: unchanged from previous note.Social: no contact from family and friends during evening.Safety: Siderails up while in bed, 1:1 Sitter at bedside.Plan: Transfer to CC7- for further medical management. There is no intracranial hemorrhage, shift of normally midline structures, mass effect, or hydrocephalus. There is no evidence of retroperitoneal hematoma. Mult. COMPARISON: Chest x-ray from . addendum to 7a-7p shiftDr. 4pm K=3.4 Mg=1.4,phos=0.7, pt given 3GMs MgSO4 IV, 33mmol KPhos IV over 6hrs. Pt again travelled to CT scan of pelvis to rule out RP bleed...negative. BP= 80-100's/40-50's, PIV flushed and patent.Resp: Lungs clear to bases bilat, RA Sat= 98-100%. RA Sats= 98-100%. for bleed. A pressure dressing appears to overlie the right groin. CT OF THE ABDOMEN: The lung bases are clear. po well--. (2) PIV sites--both patent. FINDINGS: There are no studies for comparison. Tylenol as ordered with fair relief. appetite, one episode of nausea--self limitingNo BM.GU: Foley cath draining clear yellow urine QSLABS: NA-140, K-3.6, BUN-19, Cr- .7, mg 1.9, alb-1.7SOCIAL: Mother unaware of pt's admission per pt request. and feels pt not ready medically to transfer to psych facility.PLAN: Continue to monitor labs, behavior, psych needs, transfer out when bed available."},"n_notes":{"kind":"number","value":11,"string":"11"},"notes":{"kind":"list like","value":[{"category":"Nursing/other","chartdate":"2149-06-20 00:00:00.000","description":"Report","row_id":1581682,"text":"MICU NURSING Note 1900-2300\nEvents: Head CT completed and reported as neg. for bleed, Hct sent and unchanged from am= 26. Stable evening.\n\nNeuro: A+OX3, moves all extremities, follows all commands, OOB to w/c with minimal assist, PEARl, c/o H/A---HO aware---medicated with an additional 325mg. Tylenol as ordered with fair relief. Head CT completed and reported as neg. for bleed. and WNL.\n\nCardiac: HR= 70-80's SR with no ecotpy noted. BP= 80-100's/40-50's, PIV flushed and patent.\n\nResp: Lungs clear to bases bilat, RA Sat= 98-100%. Denies SOB.\n\nGI: Abd soft with + bowel sounds all quads, No BM, taking sips without difficulty.\n\nGU: Foley to CD draining clear yellow urine, U/O > 30 ml/hr.\n\nSkin: unchanged from previous note.\n\nSocial: no contact from family and friends during evening.\n\nSafety: Siderails up while in bed, 1:1 Sitter at bedside.\n\nPlan: Transfer to CC7- for further medical management. Continue 1:1 Sitter on floor.\n"},{"category":"Nursing/other","chartdate":"2149-06-21 00:00:00.000","description":"Report","row_id":1581683,"text":"MICU Nursing Note 2300-0700\nEvents: Please refer to previous note. Pt was scheduled for transfer to floor and critical care fellow was assessing pt prior to writing transfer orders when pt started to bleed from old Quinton cath site that had been discontinued yesterday afternoon---pt with moderate-sized bleed requiring 15 minutes of manual pressure followed by pressure dressing and application of IV bag placed over site to add pressure with no further episodes of bleeding. Pt again travelled to CT scan of pelvis to rule out RP bleed...negative. Transfer to floor placed on hold overnight. Hemodynamically stable.\n\nNeuro: A+Ox3, cooperative, flat affect, follows all commands, C/O H/A and medicated with 650mg. Tylenol with good effect. PEARL, moves all extremities, no acute neuro changes. 1:1 sitter at bedside.\n\nCardiac: HR= 60-80's SR with no ectopy noted. BP= 89-109/40-50. (2) PIV sites--both patent. Pt with sig. bleed from right groin quinton cath site---required 15 minutes of manual pressure followed by a pressure dressing and pt with reminders to keep RLL straight overnight, No further bleeding from site. HCT=26.9 at 12:30 am and current HCT= 25.2. Blood products available in blood bank.\n\nResp: Lungs clear to bases bilat. RA Sats= 98-100%. No SOB\n\nGI: Abd soft with + bowel sounds all quads, no BM, tolerating house diet.\n\nGU: Foley to CD draining clear yellow urine > 30 ml/hr\n\nSkin: Pt with numerous scars on bilat forearms due to prior \"cutting\" incidents. No other breakdown noted. Right groin site dressing D/I\n\nSocial: No contact from family or friends\n\nPlan: Monitor for bleeding, Monitor HCT Q 4hr---next due at 0830, Continue 1:1 sitter at bedside, Transfuse prn, ? of transferring to medical floor if no further bleeding, Support pt.\n"},{"category":"Nursing/other","chartdate":"2149-06-19 00:00:00.000","description":"Report","row_id":1581678,"text":"Admitting and Nursing Progress Notes for 7a-7p: Full Code NKDA\n\nThis is a 23 y/o lady who lives at a group home who presented to EW after ingesting approx. 200 tablets of Aspirin in an attempted suicide. She has extensive past psych. issues since childhood with previous suicidal ideations and attempts requiring numerous hospital admissions. Being admitted to MICU 6 for further management and closer monitor of this ASA OD.\n\n Please See carevue flowsheet for more obejctive data\n\nEvents: Rec'd report from night nurse and assumed care of pt. Initially, pt. found to be agitated and tearful requesting po fluids. Renal fellow in early this AM for HD evaluation and placed a R groin HD catheter. MICU Intern placed R rad A-line. HD x 6hrs for ASA removal. Initial salicyate level 127 and now, 23. Cont'd w/ hypotension requiring a total of 4.8 liter of NS given during HD.\n\nReview of Systems:\n\nNeuro: lethargic, but arousable to voice. Oriented x 2 w/ slurred speech and pupils slightly unequal. Psych evaluated and pt. still suicidal risk and needs 1:1 sitter\n\nResp: RA w/ lungs CTA and stable sats. RR regular and shallow. No cough noted.\n\nCV: SR-ST w/ HR 90-120's. Afebrile. No edema noted. PIV's x 2 (#20) and R groin HD cath. at noted above. Conts. to be hypotensive w/ IVF at NS w/ 20mequ KCL at 125/hr. Fluid boluses given via HD. Palp. peripherial pulses x 4.\n\nGI/GU: + BS noted. N/V prior to my arrive, but none since. NPO except for ice chips. Abd. is soft, NT, ND. No BM. Foley in place w/ adequate UO (decreasing this afternoon).\n\nSkin: Numerous self mutilations to arms and left heel w/ the word 'FAT' self carved into heel. No obvious skin breakdown.\n\nLABS: Please see flowsheet for latest labs as pt. had q1hr abg's and frequents draws throughout the day.\n\nPlan: Cont. to monitor pH via ABG's and salicylate levels. Monitor per protocol:\n--cont. 1:1 sitter as pt. is still marked suicide risk as she verbally makes clear that she wants to die.\n--Address need for central line if hypotension persists.\n--TEAM tolerating MAP > 55.\n--Social Work consult\n--Case management needs to be involved for placement\n"},{"category":"Nursing/other","chartdate":"2149-06-20 00:00:00.000","description":"Report","row_id":1581679,"text":" \"B\" Nsg Progress Note:\n\nCVS: Afebrile. HR=86-93 NSR no ectopy noted. SBP=83-96 with MAP>64 but aline is somewhat positional. 4pm K=3.4 Mg=1.4,phos=0.7, pt given 3GMs MgSO4 IV, 33mmol KPhos IV over 6hrs. ICa=1.07, given 2amps CaGluconate IV also. Salicylate level=16. amylase/lipase elevated.\n\nResp: Sats=98-100% on room air. No SOB of dyspnea noted. Lung sounds clear.\n\nGI: Tolerating ice chips, +bowel sounds, no c/o distress, abdomen soft nontender.\n\nGU: u/o was brownish at first is now clear yellow, 40-120ml/hr. U/A sent to lab this am.\n\nNeuro: No deficits noted.\n\nSkin: areas of self mutilation as previously noted, no new areas.\n\nSafety: Pt has 1:1 sitter, is calm and cooperative but did awaken twice suddenly with a nightmare.\n\nPlan: Continue to monitor labs and replete electrolytes as needed.\n"},{"category":"Nursing/other","chartdate":"2149-06-20 00:00:00.000","description":"Report","row_id":1581680,"text":"7a-7p nursing note\nPt. called out--Please see transfer note for hx and current assessment.\n\nGCS: 15, calm & cooperative. c/o severe frontal \"migraine\" HA relieved temporarily with Tylenol/morphine x 1. No hx of HAs. Appears depressed and withdrawn.\n\nRESP: LS CTA bil. on RA pox 95-98%. No SOB\n\nCV: A-line/Quinton cath d/c. SBP 90-100, HR 80-100, NSR--no ectopy. No cardiac c/o. #18 LUE, RH, sites WNL--NS KVO. Mult. scars LUE and abd. from previous cutting. +DP/PT bil. T-max 98.4\n\nGI: Tol. po well--. appetite, one episode of nausea--self limiting\nNo BM.\n\nGU: Foley cath draining clear yellow urine QS\n\nLABS: NA-140, K-3.6, BUN-19, Cr- .7, mg 1.9, alb-1.7\n\nSOCIAL: Mother unaware of pt's admission per pt request. Psych in for eval. and feels pt not ready medically to transfer to psych facility.\n\nPLAN: Continue to monitor labs, behavior, psych needs, transfer out when bed available.\n"},{"category":"Nursing/other","chartdate":"2149-06-20 00:00:00.000","description":"Report","row_id":1581681,"text":"addendum to 7a-7p shift\nDr. in to evaluate pt. for sudden c/o severe HA. Will obtain non-contrast CT (? bleed from ASA ingestion) and repeat hct. Tylenol 650 mg. given po at 1835\n\n"},{"category":"ECG","chartdate":"2149-06-19 00:00:00.000","description":"Report","row_id":126856,"text":"Sinus rhythm\nDiffuse nonspecific T wave abnormalities\nSince previous tracing of , diffuse T wave changes present\n\n"},{"category":"Radiology","chartdate":"2149-06-18 00:00:00.000","description":"PORTABLE ABDOMEN","row_id":915977,"text":" 11:42 PM\n PORTABLE ABDOMEN Clip # \n Reason: assess for concretion\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old woman with s/p polysubstance ingestion\n REASON FOR THIS EXAMINATION:\n assess for concretion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Polysubstance ingestion.\n\n COMPARISON: None.\n\n SINGLE PORTABLE AP SUPINE ABDOMINAL RADIOGRAPH: No radiopaque foreign bodies\n are identified. Air and stool is seen throughout the colon. There is a\n tampon in the vagina, and a foley catheter is seen. No dilated loops of small\n or large bowel are identified. The osseous structures appear unremarkable.\n\n IMPRESSION: Air and stool throughout the colon. No dilated loops of small or\n large bowel.\n\n\n\n\n"},{"category":"Radiology","chartdate":"2149-06-19 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":915981,"text":" 12:32 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for lung injury - ASA OD\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old woman with ASA ingestion\n REASON FOR THIS EXAMINATION:\n eval for lung injury - ASA OD\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Aspirin ingestion.\n\n COMPARISON: Chest x-ray from .\n\n SINGLE PORTABLE AP UPRIGHT CHEST RADIOGRAPH: The cardiac, mediastinal, and\n hilar contours are within normal limits. The lungs are clear. No pleural\n effusions or pneumothoraces are identified. There is no free intraperitoneal\n air. The bowel gas pattern in the upper abdomen is nonspecific. The osseous\n and soft tissue structures appear unremarkable.\n\n IMPRESSION: No acute cardiopulmonary process.\n\n\n"},{"category":"Radiology","chartdate":"2149-06-21 00:00:00.000","description":"CT ABDOMEN W/O CONTRAST","row_id":916286,"text":" 12:31 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: HCT DROP S/P RT GROIN LINE PLACEMENT. R/O RP BLEED\n Admitting Diagnosis: ASPIRIN OVERDOSE\n Field of view: 36\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old woman with recent HD line on right groin after ASA overdose now\n with acute hct drop and bleeding from HD catheter site, assess for RP bleed\n REASON FOR THIS EXAMINATION:\n rule out RP bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KLMn SAT 4:11 AM\n no retroperitoneal hematoma.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Recent right groin hemodialysis line, now with bleeding from the\n site, assess for retroperitoneal hematoma.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast CT of the abdomen and pelvis.\n\n CT OF THE ABDOMEN: The lung bases are clear. Visualized heart and\n pericardium appear unremarkable. Lack of intravenous contrast limits\n assessment of intraabdominal organs. The liver, gallbladder, adrenal glands,\n spleen, and pancreas appear unremarkable. The kidneys appear symmetric\n without evidence of hydronephrosis. No dilated loops of bowel are identified.\n No pathologic mesenteric or retroperitoneal lymphadenopathy is identified. No\n free air or free fluid is seen in the abdomen.\n\n CT OF THE PELVIS: A Foley catheter is seen within the bladder lumen, as well\n as non-dependent air. The uterus, adnexa, and rectum appear unremarkable.\n There is no evidence of retroperitoneal hematoma. There is a small amount of\n stranding in the right groin. A pressure dressing appears to overlie the\n right groin.\n\n The osseous structures demonstrate no concerning lytic or sclerotic lesions.\n\n IMPRESSION: No evidence of retroperitoneal hematoma.\n\n\n\n\n"},{"category":"Radiology","chartdate":"2149-06-20 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":916257,"text":" 7:29 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ASPIRIN OD.R/O BLEED\n Admitting Diagnosis: ASPIRIN OVERDOSE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old woman with severe headache following aspirin overdose.\n REASON FOR THIS EXAMINATION:\n evaluate for hemorrhage\n CONTRAINDICATIONS for IV CONTRAST:\n ASA overdose, recently dialyzed. Not needed for clinical questions.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Severe headache following aspirin overdose.\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: There are no studies for comparison. There is no intracranial\n hemorrhage, shift of normally midline structures, mass effect, or\n hydrocephalus. The -white matter differentiation is preserved. There is\n no acute major vascular territorial infarct. The osseous structures are\n normal. The paranasal sinuses are well aerated.\n\n IMPRESSION: No intracranial hemorrhage.\n\n\n"}],"string":"[\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2149-06-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1581682,\n \"text\": \"MICU NURSING Note 1900-2300\\nEvents: Head CT completed and reported as neg. for bleed, Hct sent and unchanged from am= 26. Stable evening.\\n\\nNeuro: A+OX3, moves all extremities, follows all commands, OOB to w/c with minimal assist, PEARl, c/o H/A---HO aware---medicated with an additional 325mg. Tylenol as ordered with fair relief. Head CT completed and reported as neg. for bleed. and WNL.\\n\\nCardiac: HR= 70-80's SR with no ecotpy noted. BP= 80-100's/40-50's, PIV flushed and patent.\\n\\nResp: Lungs clear to bases bilat, RA Sat= 98-100%. Denies SOB.\\n\\nGI: Abd soft with + bowel sounds all quads, No BM, taking sips without difficulty.\\n\\nGU: Foley to CD draining clear yellow urine, U/O > 30 ml/hr.\\n\\nSkin: unchanged from previous note.\\n\\nSocial: no contact from family and friends during evening.\\n\\nSafety: Siderails up while in bed, 1:1 Sitter at bedside.\\n\\nPlan: Transfer to CC7- for further medical management. Continue 1:1 Sitter on floor.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2149-06-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1581683,\n \"text\": \"MICU Nursing Note 2300-0700\\nEvents: Please refer to previous note. Pt was scheduled for transfer to floor and critical care fellow was assessing pt prior to writing transfer orders when pt started to bleed from old Quinton cath site that had been discontinued yesterday afternoon---pt with moderate-sized bleed requiring 15 minutes of manual pressure followed by pressure dressing and application of IV bag placed over site to add pressure with no further episodes of bleeding. Pt again travelled to CT scan of pelvis to rule out RP bleed...negative. Transfer to floor placed on hold overnight. Hemodynamically stable.\\n\\nNeuro: A+Ox3, cooperative, flat affect, follows all commands, C/O H/A and medicated with 650mg. Tylenol with good effect. PEARL, moves all extremities, no acute neuro changes. 1:1 sitter at bedside.\\n\\nCardiac: HR= 60-80's SR with no ectopy noted. BP= 89-109/40-50. (2) PIV sites--both patent. Pt with sig. bleed from right groin quinton cath site---required 15 minutes of manual pressure followed by a pressure dressing and pt with reminders to keep RLL straight overnight, No further bleeding from site. HCT=26.9 at 12:30 am and current HCT= 25.2. Blood products available in blood bank.\\n\\nResp: Lungs clear to bases bilat. RA Sats= 98-100%. No SOB\\n\\nGI: Abd soft with + bowel sounds all quads, no BM, tolerating house diet.\\n\\nGU: Foley to CD draining clear yellow urine > 30 ml/hr\\n\\nSkin: Pt with numerous scars on bilat forearms due to prior \\\"cutting\\\" incidents. No other breakdown noted. Right groin site dressing D/I\\n\\nSocial: No contact from family or friends\\n\\nPlan: Monitor for bleeding, Monitor HCT Q 4hr---next due at 0830, Continue 1:1 sitter at bedside, Transfuse prn, ? of transferring to medical floor if no further bleeding, Support pt.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2149-06-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1581678,\n \"text\": \"Admitting and Nursing Progress Notes for 7a-7p: Full Code NKDA\\n\\nThis is a 23 y/o lady who lives at a group home who presented to EW after ingesting approx. 200 tablets of Aspirin in an attempted suicide. She has extensive past psych. issues since childhood with previous suicidal ideations and attempts requiring numerous hospital admissions. Being admitted to MICU 6 for further management and closer monitor of this ASA OD.\\n\\n Please See carevue flowsheet for more obejctive data\\n\\nEvents: Rec'd report from night nurse and assumed care of pt. Initially, pt. found to be agitated and tearful requesting po fluids. Renal fellow in early this AM for HD evaluation and placed a R groin HD catheter. MICU Intern placed R rad A-line. HD x 6hrs for ASA removal. Initial salicyate level 127 and now, 23. Cont'd w/ hypotension requiring a total of 4.8 liter of NS given during HD.\\n\\nReview of Systems:\\n\\nNeuro: lethargic, but arousable to voice. Oriented x 2 w/ slurred speech and pupils slightly unequal. Psych evaluated and pt. still suicidal risk and needs 1:1 sitter\\n\\nResp: RA w/ lungs CTA and stable sats. RR regular and shallow. No cough noted.\\n\\nCV: SR-ST w/ HR 90-120's. Afebrile. No edema noted. PIV's x 2 (#20) and R groin HD cath. at noted above. Conts. to be hypotensive w/ IVF at NS w/ 20mequ KCL at 125/hr. Fluid boluses given via HD. Palp. peripherial pulses x 4.\\n\\nGI/GU: + BS noted. N/V prior to my arrive, but none since. NPO except for ice chips. Abd. is soft, NT, ND. No BM. Foley in place w/ adequate UO (decreasing this afternoon).\\n\\nSkin: Numerous self mutilations to arms and left heel w/ the word 'FAT' self carved into heel. No obvious skin breakdown.\\n\\nLABS: Please see flowsheet for latest labs as pt. had q1hr abg's and frequents draws throughout the day.\\n\\nPlan: Cont. to monitor pH via ABG's and salicylate levels. Monitor per protocol:\\n--cont. 1:1 sitter as pt. is still marked suicide risk as she verbally makes clear that she wants to die.\\n--Address need for central line if hypotension persists.\\n--TEAM tolerating MAP > 55.\\n--Social Work consult\\n--Case management needs to be involved for placement\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2149-06-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1581679,\n \"text\": \" \\\"B\\\" Nsg Progress Note:\\n\\nCVS: Afebrile. HR=86-93 NSR no ectopy noted. SBP=83-96 with MAP>64 but aline is somewhat positional. 4pm K=3.4 Mg=1.4,phos=0.7, pt given 3GMs MgSO4 IV, 33mmol KPhos IV over 6hrs. ICa=1.07, given 2amps CaGluconate IV also. Salicylate level=16. amylase/lipase elevated.\\n\\nResp: Sats=98-100% on room air. No SOB of dyspnea noted. Lung sounds clear.\\n\\nGI: Tolerating ice chips, +bowel sounds, no c/o distress, abdomen soft nontender.\\n\\nGU: u/o was brownish at first is now clear yellow, 40-120ml/hr. U/A sent to lab this am.\\n\\nNeuro: No deficits noted.\\n\\nSkin: areas of self mutilation as previously noted, no new areas.\\n\\nSafety: Pt has 1:1 sitter, is calm and cooperative but did awaken twice suddenly with a nightmare.\\n\\nPlan: Continue to monitor labs and replete electrolytes as needed.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2149-06-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1581680,\n \"text\": \"7a-7p nursing note\\nPt. called out--Please see transfer note for hx and current assessment.\\n\\nGCS: 15, calm & cooperative. c/o severe frontal \\\"migraine\\\" HA relieved temporarily with Tylenol/morphine x 1. No hx of HAs. Appears depressed and withdrawn.\\n\\nRESP: LS CTA bil. on RA pox 95-98%. No SOB\\n\\nCV: A-line/Quinton cath d/c. SBP 90-100, HR 80-100, NSR--no ectopy. No cardiac c/o. #18 LUE, RH, sites WNL--NS KVO. Mult. scars LUE and abd. from previous cutting. +DP/PT bil. T-max 98.4\\n\\nGI: Tol. po well--. appetite, one episode of nausea--self limiting\\nNo BM.\\n\\nGU: Foley cath draining clear yellow urine QS\\n\\nLABS: NA-140, K-3.6, BUN-19, Cr- .7, mg 1.9, alb-1.7\\n\\nSOCIAL: Mother unaware of pt's admission per pt request. Psych in for eval. and feels pt not ready medically to transfer to psych facility.\\n\\nPLAN: Continue to monitor labs, behavior, psych needs, transfer out when bed available.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2149-06-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1581681,\n \"text\": \"addendum to 7a-7p shift\\nDr. in to evaluate pt. for sudden c/o severe HA. Will obtain non-contrast CT (? bleed from ASA ingestion) and repeat hct. Tylenol 650 mg. given po at 1835\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2149-06-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 126856,\n \"text\": \"Sinus rhythm\\nDiffuse nonspecific T wave abnormalities\\nSince previous tracing of , diffuse T wave changes present\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2149-06-18 00:00:00.000\",\n \"description\": \"PORTABLE ABDOMEN\",\n \"row_id\": 915977,\n \"text\": \" 11:42 PM\\n PORTABLE ABDOMEN Clip # \\n Reason: assess for concretion\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 23 year old woman with s/p polysubstance ingestion\\n REASON FOR THIS EXAMINATION:\\n assess for concretion\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Polysubstance ingestion.\\n\\n COMPARISON: None.\\n\\n SINGLE PORTABLE AP SUPINE ABDOMINAL RADIOGRAPH: No radiopaque foreign bodies\\n are identified. Air and stool is seen throughout the colon. There is a\\n tampon in the vagina, and a foley catheter is seen. No dilated loops of small\\n or large bowel are identified. The osseous structures appear unremarkable.\\n\\n IMPRESSION: Air and stool throughout the colon. No dilated loops of small or\\n large bowel.\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2149-06-19 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 915981,\n \"text\": \" 12:32 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for lung injury - ASA OD\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 23 year old woman with ASA ingestion\\n REASON FOR THIS EXAMINATION:\\n eval for lung injury - ASA OD\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Aspirin ingestion.\\n\\n COMPARISON: Chest x-ray from .\\n\\n SINGLE PORTABLE AP UPRIGHT CHEST RADIOGRAPH: The cardiac, mediastinal, and\\n hilar contours are within normal limits. The lungs are clear. No pleural\\n effusions or pneumothoraces are identified. There is no free intraperitoneal\\n air. The bowel gas pattern in the upper abdomen is nonspecific. The osseous\\n and soft tissue structures appear unremarkable.\\n\\n IMPRESSION: No acute cardiopulmonary process.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2149-06-21 00:00:00.000\",\n \"description\": \"CT ABDOMEN W/O CONTRAST\",\n \"row_id\": 916286,\n \"text\": \" 12:31 AM\\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \\n Reason: HCT DROP S/P RT GROIN LINE PLACEMENT. R/O RP BLEED\\n Admitting Diagnosis: ASPIRIN OVERDOSE\\n Field of view: 36\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 23 year old woman with recent HD line on right groin after ASA overdose now\\n with acute hct drop and bleeding from HD catheter site, assess for RP bleed\\n REASON FOR THIS EXAMINATION:\\n rule out RP bleed\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: KLMn SAT 4:11 AM\\n no retroperitoneal hematoma.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Recent right groin hemodialysis line, now with bleeding from the\\n site, assess for retroperitoneal hematoma.\\n\\n COMPARISON: None.\\n\\n TECHNIQUE: Non-contrast CT of the abdomen and pelvis.\\n\\n CT OF THE ABDOMEN: The lung bases are clear. Visualized heart and\\n pericardium appear unremarkable. Lack of intravenous contrast limits\\n assessment of intraabdominal organs. The liver, gallbladder, adrenal glands,\\n spleen, and pancreas appear unremarkable. The kidneys appear symmetric\\n without evidence of hydronephrosis. No dilated loops of bowel are identified.\\n No pathologic mesenteric or retroperitoneal lymphadenopathy is identified. No\\n free air or free fluid is seen in the abdomen.\\n\\n CT OF THE PELVIS: A Foley catheter is seen within the bladder lumen, as well\\n as non-dependent air. The uterus, adnexa, and rectum appear unremarkable.\\n There is no evidence of retroperitoneal hematoma. There is a small amount of\\n stranding in the right groin. A pressure dressing appears to overlie the\\n right groin.\\n\\n The osseous structures demonstrate no concerning lytic or sclerotic lesions.\\n\\n IMPRESSION: No evidence of retroperitoneal hematoma.\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2149-06-20 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 916257,\n \"text\": \" 7:29 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: ASPIRIN OD.R/O BLEED\\n Admitting Diagnosis: ASPIRIN OVERDOSE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 23 year old woman with severe headache following aspirin overdose.\\n REASON FOR THIS EXAMINATION:\\n evaluate for hemorrhage\\n CONTRAINDICATIONS for IV CONTRAST:\\n ASA overdose, recently dialyzed. Not needed for clinical questions.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Severe headache following aspirin overdose.\\n\\n TECHNIQUE: Non-contrast head CT.\\n\\n FINDINGS: There are no studies for comparison. There is no intracranial\\n hemorrhage, shift of normally midline structures, mass effect, or\\n hydrocephalus. The -white matter differentiation is preserved. There is\\n no acute major vascular territorial infarct. The osseous structures are\\n normal. The paranasal sinuses are well aerated.\\n\\n IMPRESSION: No intracranial hemorrhage.\\n\\n\\n\"\n }\n]"}}},{"rowIdx":388,"cells":{"subject_id":{"kind":"number","value":15243,"string":"15,243"},"hadm_id":{"kind":"number","value":190128,"string":"190,128"},"target_text":{"kind":"string","value":"71F CAD s/p 3v-Cabg, CHF EF 50%, 3+MR/MS, DM2, CRI, HTN presented with respiratory failure likely CHF and PNA . # CAD: Pt with known CAD s/p 3VD s/p CABG. Found to have troponin leak in setting of CHF and renal failure. Patient remained chest pain free during hospitalization. She underwent cardiac catheterization on without intervention (see cath report above). Continued aspirin, statin, and nitrates. Clopidogreal was continued until after CT surgeon's requested it be held prior to surgery. This was discussed with Dr. and it was felt to be okay to hold/stop this medication for now as > 1year since most recent stent. . # PUMP: volume overloaded on admission, and diuresed. She had episodes post op of overload requiring reintubation once and mask ventilation the second time. She has had no further episodes and continues to be diuresised aggressively and blood pressure control goal SBP <125. Monitored ins and outs and daily weights. . #Complete heart block - after receiving lopressor went into complete heart block that did not resolving requiring insertion of permanent pacemaker. . # VALVES: severe mitral degenerative dz with MS and MR. 1.0-1.5cm2 on echo (1.3cm2 on cath). Mitral disease felt to be contributing to recurrent bouts of CHF requiring hospitalization. CT surgery was consulted for consideration of mitral valve replacement. She had a panorex film and and dental consult for pre-operative assessment. They recommended oral surgery consult and teeth extraction on . She received ampicillin prior to oral surgery. There was concern that she also had a lesion on her right hand middle finger and Rheumatology was consulted. It was felt most likely to be either resolving gout/pseudogout(with tophi) vs resolving infection. Her uric acid was elevated at 10.2. Mitral Valve replacement was performed on . . # PNA: Felt to contribute to her respiratory failure and MICU hospitalization. Resolved leukocytosis, now afebrile and breathing comfortably on room air. Completed 10 day levofloxacin course. . # Anemia: Guaiac negative. Hematocrit stable. She did receive 2 units pRBC blood transfusion for Hct > 30. . # DM: Continued RISS and home regimen of NPH 22 in AM and 8 in PM and regular insulin 8 in AM and 8 in PM. Glipizide held while an inpatient. . # Acute on CRI: recent baseline 1.1 to 1.3. Creatinine did increase to highest 1.9. Prequired natrecor and lasix for diuresis. . # Social: history of abuse in past. Report was filed. Social work following."},"extractive_notes_summ":{"kind":"string","value":"The patient is status post median sternotomy, as before. Patient is status post sternotomy and CABG, and moderate cardiomegaly is unchanged. Right internal jugular vascular sheath has been removed and a right PICC line has been placed with tip terminating in the upper superior vena cava. REASON FOR THIS EXAMINATION: eval inf FINAL REPORT PORTABLE CHEST OF COMPARISON: INDICATION: Status post mitral valve replacement. REASON FOR THIS EXAMINATION: assess for infiltrate, effusions, edema FINAL REPORT REASON FOR EXAM: CHF SINGLE AP PORTABLE VIEW CHEST. The patient is post-CABG, with sternotomy wires unchanged. Swan-Ganz catheter has been removed with residual internal jugular vascular sheath terminating in the superior vena cava. Abnormal septalmotion/position.AORTA: Normal aortic diameter at the sinus level. Simple atheroma in ascending aorta. The ascending aorta is mildlydilated. Overall left ventricular systolic functionis mildly depresed with inferior hypokinesis (views suboptimal). Moderatelydepressed LVEF.LV WALL MOTION: Regional LV wall motion abnormalities include: basalanteroseptal - hypo; mid anteroseptal - hypo; septal apex - hypo; apex - hypo;RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level. Mild (1+)mitral regurgitation is seen. Moderatelydepressed EF with inferior akinesis and abnormal septal motion (post-op). Atrial fibrillation with a regular ventricular response suggesting anindependent junctional or idioventricular rhythm with right bundle branchblock/left posterior fascicular block configurationSince previous tracing of , sinus bradycardia and left bundle branchblock now absent There are simple atheromain the aortic arch. Normal sinus rhythm with marked A-V conduction delay. Normal ascending aortadiameter. Normal aortic arch diameter.Simple atheroma in aortic arch. Normal descending aorta diameter. Normal PAsystolic pressure.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor echo windows.Conclusions:The left atrium is mildly dilated. Albuterol/atrovent nebs started. + PERIPHERAL EDEMA. COUMADIN GIVEN. Left bundle-branch block and secondary ST-T waveabnormalities. pt has distant hrt sounds S1S2 w/ systolic murmur. at present sr60s bp 110s/60s ntg off. lactate 4.3, pt received vanco, ceftriaxone, and flagyl. DOSE DISCUSSED WITH MD, WILL CONTINUE TO FOLLOW PT/PTT/INRRESP BREATH SOUNDS CLEAR, DIMINISHED IN BASES. NATRECOR CONTINUOUS AT 0.01MCG. Left anteriorfascicular block. Regular rhythm, mechanism uncertain, may be sinus or ectopic atrial rhythm withfirst degree A-V delay. Resp. Sinus rhythmLeft atrial abnormalityLeft bundle branch blockSince previous tracing of , ST-T wave changes less prominent and Q-Tcinterval appears shorter Probable sinus rhythm. Sinus rhythm. Sinus rhythm. Sinus rhythm. Sinus rhythm. Compared to the previous tracing of atrial fibrillationis no longer present.TRACING #1 Respiratory Care:Pt. ls rhonchi to coarse bs. ABG's WNL. Occasional atrial premature beats. LASIX OR DOSE FOR DIURESIS. A-V conduction delay. Left atrial abnormality. Q-T interval prolongation.Since the previous tracing of the precordial T wave inversions are moreprominent. HR = 69 BP = 128/41 RR = 17 O2 Sat. On fixed dosing of NPH and regular along with sliding scale of humulog.ID: Tmax= 99.1. Resp Care: Pt continues intubated #7.5 oett secured @ 22 @ lip and on ventilatory support, changed to a/c for overnoc rest d/t agitation/bucking vent, currently back on cpap with minimal psv maintaining abg wnl; bs clear to coarse, sxn thick brown/blood tinged secretions, rx with mdi albuterol/atrovent, rsbi 61, will attempt wean to extubate this am. Right fem line d/c'd.GI - Tolerating PO clears, Abd soft, +BS. WBC-14.5CV: 90-110 ST then converted to aflutter/fib with V pacing-rate 60-70's. Cr 1.5.GI: Abd soft, NT, ND with hypo BS. BUN/cr cont to increase 27/1.3.Skin - Bruised areas on back (2) unchanged.ID - Afebrile. COUMADIN DOSING PER INR. Neuro: A&O x3; calm & cooperative; MAE's, following commands consistentlyCV: AV paced/V-paced @ 60; afebrile; SBP 110's-130's, hydralazine given x1; K & Ca repleted; +2 general edema on LE bilat, TEDs on; palpable pulses x4Resp: Lung sound clear, fine crackles @ bases; non-productive cough; 2L NC, sat 98%GI: Tolerating PO diet; abd soft, non-tender, +bowel sound; +flatusGU: Foley draining clear yellow urine; good diuresis with metolazone & lasixInteg: see carevuePain: denies painSocial: no calls from familyPlan: monitor hemodynamics & resp status; pulm toilet; monitor I&O, keep -; transfer to 2 in AM CXR done.Resp: Extub in am. + EDEMA NOTED. + palpable pulses.Resp: LS clear diminished. EKG done. +diuresis. +2 BILAT LE PITTING EDEMA. NPO p midnoc. DIURESIS. Sternal dsg cdi. Type I DM. SBP 130-140s/ 20-30s, NP aware of diastolic, see carevue. IV LASIX, PO METOLAZONE WITH (+)DIURESIS. Min-mod serosang CT output. pp by doppler. Monitor resp. MD UPDATED BY NP. LYTES PRN. TOLERATING PO METOPROLOL, CAPTOPRIL, AMIO. using ISgi/gu: pt with + bs. ABD SNT (+)HYPOACTIVE BS. CONTINUE DIURESING. CT dc'd. NESIRITIDE CONTINUES @ 0.010MCG/KG/MIN. NPNPT W/ RESP DISTRESS AND INTUBATION ON 2. U/O CURRENTLY IS MARGINAL-PA NILLSON NOTIFIED. Cont afib. Perrla. PERRLA. Epi gtt weaned off with CI>2, svo2s 60s- swan dc'd. 2 FFP admin by anesthesia for INR 3.1. neuro intact, 1 assist to getting oob. CRI (baseline 1.2). ABGs stable on SIMV; sedation off switched to PSV; will repeat ABG. CI remained <2, 1 prbcs ordered. Hydralazine to continue NP . HCT stable. Neuro) Pt. Cont wean PSV and extub today. Last ABG WNL with adequate oxygenation on present settings. LUNGS DIMINSIHED BASES, SX'D FOR SCANT AMT THIN WHITE SECRETIONS.CV: NSR WITH OCC PVC'S, HR 65-80'S. HR UP TO MAX OF 61 WHILE AMB, OTHERWISE 40'S-50'S, CHB.RESP: LUNGS CLEAR, DIMINISHED @ BASES. CONTINUE DIURESIS. BP 136/40.Pulm: 2Lnc in place, lungs clear, decreased at bases. Wean sedation and plan to extubate in am. cdb done.GI/GU: abd soft, +bowel sounds. REMAINS HYPERTENSIVE DESPITE PO & IV PRN HYDRALAZINE. o2sats>96%/RAgi/gu: abd soft, +bowel sounds. BS essentially clear sxing for minimal secretions. Continue on natrecor/lasix/milrinone as ordered. IS to 750 with direction.GI: Abd soft,NT,ND with +BS. v-wires pace and sense, remain set at v-demand at 30; a-wires sense but don't capture.resp: ls clear bilat, uses is, coughs and deep breathes. LUNGS CLEAR W/DIM BASES. ls clear->rhonchorous-> clear. Lopressor iv q4hr. Albumin TID. foley reinserted per . Remains on natrecor at 0.01mcg, no change.Resp: Lungs clear, slightly dim at base. continue pulm hygiene. Received extra sedation for TEE, Versed 2mg , morphine 2mg, and propfol boluses.CV: HR 70-90's nsr with prolonged PR>.32."},"n_notes":{"kind":"number","value":106,"string":"106"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2155-05-18 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":956978,"text":" 10:42 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval. for interval change\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman s/p Redo-Sternotomy, MVR.\n\n REASON FOR THIS EXAMINATION:\n Eval. for interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST\n\n HISTORY: MVR, sternotomy.\n\n One view. Comparison with the previous study done . There is\n continued evidence of mild pulmonary edema and a moderate right and small left\n pleural effusion. Pleural effusions appeared to have increased somewhat in\n the interval. The heart appears large as demonstrated previously. The\n patient is status post median sternotomy, as before. The patient has been\n extubated and a nasogastric tube has been removed. A bipolar transvenous\n pacemaker and Swan-Ganz catheter remain in place.\n\n IMPRESSION: Mild pulmonary edema. Interval increase in bilateral pleural\n effusions. No other definite change.\n\n\n"},{"category":"Radiology","chartdate":"2155-05-20 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":957167,"text":" 7:46 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval inf\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman s/p Redo-Sternotomy, MVR.\n\n REASON FOR THIS EXAMINATION:\n eval inf\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST OF \n\n COMPARISON: \n\n INDICATION: Status post mitral valve replacement.\n\n Swan-Ganz catheter has been removed with residual internal jugular vascular\n sheath terminating in the superior vena cava. Cardiac silhouette is enlarged,\n but has decreased in size from a recent study. Previously reported pulmonary\n edema has nearly resolved with mild residual interstitial edema remaining. A\n moderate right and small left pleural effusions are present. Middle and lower\n lobe opacities adjacent to right effusion probably reflect atelectasis, but\n underlying infection should also be considered in the appropriate clinical\n setting.\n\n\n"},{"category":"Radiology","chartdate":"2155-05-23 00:00:00.000","description":"PICC W/O PORT","row_id":957646,"text":" 10:01 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: pt. needs double lumen PICC IV RN\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;SEPSIS\n Contrast: OPTIRAY Amt: 15\n ********************************* CPT Codes ********************************\n * PICC W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with s/p cabg/mvr\n REASON FOR THIS EXAMINATION:\n pt. needs double lumen PICC IV RN\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Needs double lumen PICC for access.\n\n The procedure was explained to the patient. A timeout was performed.\n\n RADIOLOGISTS: Drs. and Dr. , the attending radiologist,\n was present and supervising throughout.\n\n TECHNIQUE/PROCEDURE: Using sterile technique and local anesthesia, the right\n brachial vein was punctured under direct ultrasound guidance using\n micropuncture set. Hard copies of ultrasound images were obtained before and\n immediately after establishing intravenous access. Peel-away sheath was then\n placed over a guide wire and a 37 cm double lumen PICC line was then placed\n through the peel-away sheath with its tip positioned in the SVC under\n fluoroscopic guidance. Position of the catheter was confirmed by fluoroscopic\n spot film of the chest. Peel-away sheath and guide wire were removed.\n Catheter was secured to the skin, flushed, and sterile dressing applied.\n Patient tolerated the procedure well with no immediate complications.\n\n IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided 37 cm double\n lumen PICC line placement via right brachial approach. Tip positioned in the\n SVC, line ready for use.\n\n"},{"category":"Radiology","chartdate":"2155-05-26 00:00:00.000","description":"CHEST (PA & LAT)","row_id":958012,"text":" 1:59 PM\n CHEST (PA & LAT) Clip # \n Reason: evaluate for effusion\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with s/p MVR\n REASON FOR THIS EXAMINATION:\n evaluate for effusion\n ______________________________________________________________________________\n FINAL REPORT\n TWO VIEW CHEST of .\n\n COMPARISON: .\n\n INDICATION: Evaluate for pleural effusion following mitral valve surgery.\n\n Right internal jugular vascular sheath has been removed and a right PICC line\n has been placed with tip terminating in the upper superior vena cava. A\n permanent pacemaker is unchanged in position, and cardiac and mediastinal\n contours are stable. Small-to-moderate right pleural effusion has decreased\n in size, and small left pleural effusion is unchanged. Interstitial edema has\n nearly resolved.\n\n IMPRESSION: Resolving interstitial edema and improving right pleural\n effusion.\n\n\n"},{"category":"Radiology","chartdate":"2155-04-19 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":953056,"text":" 10:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: acute cardiopulmonary process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with sob\n REASON FOR THIS EXAMINATION:\n acute cardiopulmonary process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Shortness of breath. Evaluate for acute cardiopulmonary process.\n\n COMPARISON: .\n\n SUPINE AP CHEST: An endotracheal tube is in place, with the tip approximately\n 2.9 cm from the carina. The patient is post-CABG, with sternotomy wires\n unchanged. The superiormost wire is discontinued, as seen on multiple prior\n exams. There is mild cardiomegaly, which is slightly more apparent than seen\n on the prior study. There is severe pulmonary edema. There is no pleural\n effusion or evidence of pneumothorax in this supine patient.\n\n IMPRESSION:\n\n Severe pulmonary edema. Endotracheal tube in place.\n\n\n"},{"category":"Radiology","chartdate":"2155-04-23 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":953494,"text":" 7:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for infiltrate, effusions\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with CHF, CAD, intubated for resp distress, extubated\n yesterday, now with chest pain\n REASON FOR THIS EXAMINATION:\n assess for infiltrate, effusions\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: CAD and CHF with chest pain.\n\n AP BEDSIDE CHEST. The heart is borderline enlarged with previous CABG. No\n vascular congestion, consolidations, or effusions. Allowing for technical\n differences, there is little change from supine exam one day ago.\n\n IMPRESSION: No CHF or other acute process.\n\n\n"},{"category":"Radiology","chartdate":"2155-04-22 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":953333,"text":" 1:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for infiltrate, effusions, edema\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with CHF, CAD, intubated for resp distress, extubated\n yesterday.\n REASON FOR THIS EXAMINATION:\n assess for infiltrate, effusions, edema\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: CHF\n\n SINGLE AP PORTABLE VIEW CHEST. Compared to prior study performed the day\n before, mild pulmonary edema has almost completely resolved. There is no\n pneumothorax or sizable pleural effusion. Cardiac size is top normal. Patient\n is post median sternotomy and CABG.\n\n"},{"category":"Radiology","chartdate":"2155-04-25 00:00:00.000","description":"R HAND (AP, LAT & OBLIQUE) RIGHT","row_id":953856,"text":" 5:46 PM\n HAND (AP, LAT & OBLIQUE) RIGHT Clip # \n Reason: evaluate for changes suggestive of osteomyelitis\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with right middle finger DIP swelling\n REASON FOR THIS EXAMINATION:\n evaluate for changes suggestive of osteomyelitis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Right middle finger DIP swelling, evaluate for osteomyelitis.\n\n No prior examinations.\n\n RIGHT HAND, THREE VIEWS: Extensive osteoarthritic changes are seen at the\n second, third, fourth and fifth DIP as well as the fifth PIP, with joint space\n narrowing, osteophyte formation and subchondral sclerosis. On the lateral\n view, it appears there is near fusion of the second and fourth DIPs. At the\n third DIP, in the region of the patient's swelling, there is no evidence of\n cortical destruction or periosteal reaction to suggest osteomyelitis. A tiny\n soft tissue calcification is noted dorsal to the third distal phalanyx . No\n radiopaque foreign body identified.\n\n IMPRESSION: Osteoarthritic changes of the DIPs and fifth PIP. No\n radiographic evidence of osteomyelitis.\n\n\n"},{"category":"Radiology","chartdate":"2155-04-20 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":953115,"text":" 3:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for edema, infiltrate\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with CHF, CAD, here with resp failure.\n\n REASON FOR THIS EXAMINATION:\n evaluate for edema, infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE SEMI-UPRIGHT CHEST, \n\n COMPARISON: .\n\n INDICATION: Respiratory failure.\n\n Endotracheal tube and nasogastric tube remain in standard position. Allowing\n for differences in technique, there has not been a substantial change in the\n appearance of the chest with persistent CHF, bibasilar atelectasis, and small\n pleural effusions. However, as compared to the earlier radiograph of \n at 10 a.m., there has been interval improvement in the severity of edema.\n\n\n"},{"category":"Radiology","chartdate":"2155-04-19 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":953099,"text":" 6:30 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: interval change\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with CHF, CAD, here with resp failure.\n\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST ON AT 18:45\n\n INDICATION: Respiratory failure.\n\n COMPARISON: \n\n FINDINGS: The ETT remains in place. There is much better aeration compared\n to the prior film and less distension of pulmonary vasculature and diminished\n interstitial markings. No new focal consolidations are seen. Cardiomegaly\n persists, and ETT remains in place. There is an NGT with the tip extending\n below the confines of the film, but clearly below the left hemidiaphragm.\n\n IMPRESSION: Improving CHF with some persistence.\n\n\n"},{"category":"Radiology","chartdate":"2155-04-21 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":953196,"text":" 3:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess for infiltrates.\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with CHF, CAD, here with resp failure.\n\n REASON FOR THIS EXAMINATION:\n Please assess for infiltrates.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: CHF, CAD, and SOB.\n\n AP BEDSIDE CHEST. The heart is enlarged with previous sternotomy and apparent\n CABG. ET and NG tubes are satisfactorily positioned (tip of NG tube not\n visualized). No overt vascular congestion and no consolidations. Equivocal\n subsegmental atelectasis at the left base. I doubt the presence of effusions.\n Since exam one day previous, the vascular congestion and layering pleural\n effusions have improved and possibly resolved. Lungs remain well inflated and\n I suspect this patient has underlying emphysema.\n\n IMPRESSION: Short interval improvement/resolution of CHF.\n\n\n"},{"category":"Radiology","chartdate":"2155-05-06 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":955285,"text":" 11:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o ptx\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman s/p Redo-Sternotomy, MVR. and ct removal\n REASON FOR THIS EXAMINATION:\n r/o ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old woman status post redo-sternotomy and chest tube\n removal.\n\n COMPARISON: Study from .\n\n PORTABLE AP CHEST RADIOGRAPH: Multiple lines and tubes have been removed.\n There is a right IJ sheath with the tip in the upper SVC. No pneumothorax is\n seen. There is stable cardiomegaly. There is mild pulmonary vascular\n congestion. There is small left pleural effusion and left retrocardiac\n opacity representing areas of atelectasis and/or consolidation. No\n pneumothorax.\n\n IMPRESSION: Small left pleural effusion and left retrocardiac opacity\n representing atelectasis and/or consolidation. No pneumothorax. Mild\n pulmonary vascular congestion.\n\n"},{"category":"Radiology","chartdate":"2155-05-16 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":956726,"text":" 10:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate effusion\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman s/p Redo-Sternotomy, MVR.\n\n REASON FOR THIS EXAMINATION:\n evaluate effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post mitral valve repair.\n\n PORTABLE CHEST: Multiple lines and tubes are unchanged in position. Dual\n lead pacemaker overlying the left hemithorax is unchanged in position.\n Patient is status post sternotomy and valve replacement.\n\n Compared to a day prior, there is mild improvement in the degree of pulmonary\n edema. Layering moderate right pleural effusion appears unchanged. Moderate\n cardiomegaly again noted.\n\n IMPRESSION: Mild improvement in pulmonary edema with persistent moderate\n layering right pleural effusion and associated atelectasis.\n\n\n"},{"category":"Radiology","chartdate":"2155-05-15 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":956646,"text":" 6:42 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: line and ETT placement\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman s/p Redo-Sternotomy, MVR.\n\n REASON FOR THIS EXAMINATION:\n line and ETT placement\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION: 71-year-old female status post sternotomy revision and mitral\n valve replacement. Please evaluate line and endotracheal tube placement.\n\n FINDINGS: Single portable AP supine radiograph is reviewed and compared to\n . There has been interval placement of endotracheal tube, which lies\n 5.5 cm above the carina. There has also been placement of Swan-Ganz catheter,\n with catheter tip overlying the distal main pulmonary artery. There is no\n pneumothorax. Moderate cardiomegaly is unchanged. There is perihilar\n haziness, upper-zone redistribution, and Kerley B lines consistent with mild\n pulmonary edema. There are small left and moderate right pleural effusions.\n Note is again made of sternotomy wires and clips representing prior cardiac\n surgery. There is also a prosthetic mitral valve.\n\n IMPRESSION:\n\n 1. Status post placement of endotracheal tube and Swan-Ganz catheter. No\n pneumothorax.\n\n 2. Moderate cardiomegaly, with mild pulmonary edema, and small left and\n moderate right pleural effusions.\n\n"},{"category":"Radiology","chartdate":"2155-05-15 00:00:00.000","description":"R UNILAT LOWER EXT VEINS RIGHT","row_id":956605,"text":" 2:50 PM\n UNILAT LOWER EXT VEINS RIGHT Clip # \n Reason: eval for DVT in pt with new LE edema and new pacer\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman s/p mitral valve\n REASON FOR THIS EXAMINATION:\n eval for DVT in pt with new LE edema and new pacer\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old woman with new lower extremity edema.\n\n Grayscale and color-flow Doppler images of the right lower extremity were\n obtained. The right common femoral vein, right superficial vein, right\n popliteal vein, and greater saphenous vein demonstrate normal compressibility,\n respiratory varaiation in venous flow, and venous segmentation. The left\n lower extremity was not assessed since the patient developed severe shortness\n of breath.\n\n IMPRESSION: No deep vein thrombosis in the right lower extremity. The left\n lower extremity was not assessed due to the patient's severe shortness of\n breath.\n\n These findings were discussed with Dr. at the time of dictation.\n\n"},{"category":"Radiology","chartdate":"2155-04-30 00:00:00.000","description":"L RIB UNILAT, W/ AP CHEST LEFT","row_id":954429,"text":" 2:14 PM\n RIB UNILAT, W/ AP CHEST LEFT Clip # \n Reason: evaluate for rib fracture\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with left sided rib pain after trauma to this area\n REASON FOR THIS EXAMINATION:\n evaluate for rib fracture\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pain.\n\n Three radiographs of the chest and left ribs demonstrate displaced fracture\n involving the lateral left seventh rib. There is equivocal evidence of a\n nondisplaced fracture involving the lateral left eighth rib. The patient is\n status post CABG. No pneumothorax is detected. There is a moderate\n left-sided effusion. No consolidation is identified. Trachea is midline.\n The rib fractures are not evident on the chest radiograph dated ,\n although assessment is limited by technique of the prior study.\n\n IMPRESSION:\n\n Left lateral seventh and eighth rib fractures. No pneumothorax.\n\n Moderate left-sided pleural effusion.\n\n\n"},{"category":"Radiology","chartdate":"2155-05-14 00:00:00.000","description":"CHEST (PA & LAT)","row_id":956373,"text":" 9:05 AM\n CHEST (PA & LAT) Clip # \n Reason: s/p pacer insertion-check lead placement\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with s/p dualc chamber pacemaker implantation\n\n REASON FOR THIS EXAMINATION:\n s/p pacer insertion-check lead placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate pacemaker lead placement.\n\n PA AND LATERAL CHEST: Compared to , a pacemaker has been placed\n with dual leads appropriately positioned in the right atrium and right\n ventricle. Patient is status post sternotomy and CABG, and moderate\n cardiomegaly is unchanged. Pulmonary vasculature is normal. Small bilateral\n pleural effusions persist and retrocardiac atelectasis continues to resolve.\n No definite pneumothorax.\n\n IMPRESSION: Satisfactory placement of dual lead pacemaker with small\n bilateral pleural effusions.\n\n"},{"category":"Radiology","chartdate":"2155-05-05 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":955180,"text":" 6:21 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: r/o PTX/Effusion/Tamponade\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman s/p Redo-Sternotomy, MVR. Please page at \n with abnormalities. Pt still in the OR, please perform when in the CSRU.\n REASON FOR THIS EXAMINATION:\n r/o PTX/Effusion/Tamponade\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old woman with recent surgery. Please rule out\n pneumothorax, excisional component.\n\n Comparisons available from the prior study done on .\n\n SINGLE AP VIEW OF THE CHEST:\n Since the prior study there has been interval placement of the right-sided\n Swan-Ganz catheter with its tip projecting in the main pulmonary artery. The\n endotracheal tube tip is projecting at least 5 cm above the carina, in\n satisfactory position. The NG tube side-port projecs within the stomach. The\n right-sided chest tube is in the proper position. The heart and mediastinal\n contours are mildly enlarged which is not an uncommon finding after recent\n surgery. Note is made of bibasilar increased opacities suggestive of\n bibasilar atelectasis. Increased interstitial markings likely pulmonary\n edema.\n\n IMPRESSION:\n 1. Status post placement of endotracheal tube, Swan-Ganz catheter, NG tube\n and right-sided chest tube in proper position.\n 2. Mild enlargement in the size of the cardiomediastinal silhouette which is\n not an uncommon finding after recent thoracic surgery and is suggestive of\n postsurgical changes.\n 3. Increased interstitial markings reaching the lung periphery suggestive of\n pulmonary edema.\n\n"},{"category":"Radiology","chartdate":"2155-05-09 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":955714,"text":" 7:39 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate effusion\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman s/p Redo-Sternotomy, MVR.\n REASON FOR THIS EXAMINATION:\n evaluate effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old status post redo sternotomy for MVR.\n\n COMPARISONS: .\n\n PORTABLE AP CHEST RADIOGRAPH: There is stable change related to prior CABG\n and stable cardiomegaly. There has been interval removal of a right IJ\n sheath. There is bibasilar atelectasis. There is partial improvement in left\n retrocardiac opacity, consistent with improved aeration left lower lobe.\n There may be small pleural effusion.\n\n IMPRESSION: Improved aeration in comparison to prior study. Possible small\n left pleural effusion.\n\n\n"},{"category":"Radiology","chartdate":"2155-05-17 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":956862,"text":" 7:58 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval. for interval change\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman s/p Redo-Sternotomy, MVR.\n\n REASON FOR THIS EXAMINATION:\n Eval. for interval change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: ST redo sternotomy, MVR.\n\n SINGLE AP PORTABLE VIEW OF THE CHEST:.\n ET tube is in standard position. Swan- Ganz catheter remains in the main\n pulmonary artery. NG tube tip is out of view below the diaphragm. Left-sided\n pacemaker leads terminate in standard position in the right atrium and right\n ventricle. Patient is post median sternotomy and MVR. Compared to prior study\n moderate right pleural effusion is unchanged. Moderate cardiomegaly is\n stable. Mild pulmonary edema is stable. Small left pleural effusion is new.\n\n"},{"category":"Echo","chartdate":"2155-05-21 00:00:00.000","description":"Report","row_id":94889,"text":"PATIENT/TEST INFORMATION:\nIndication: Mitral valve replacement\nHeight: (in) 64\nWeight (lb): 163\nBSA (m2): 1.79 m2\nBP (mm Hg): 131/32\nHR (bpm): 63\nStatus: Inpatient\nDate/Time: at 15:38\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. A catheter or pacing\nwire is seen in the RA and extending into the RV.\n\nLEFT VENTRICLE: Normal LV wall thicknesses and cavity size. Suboptimal\ntechnical quality, a focal LV wall motion abnormality cannot be fully\nexcluded.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion. Abnormal septal\nmotion/position.\n\nAORTA: Normal aortic diameter at the sinus level. Mildly dilated ascending\naorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Bioprosthetic mitral valve prosthesis (MVR). MVR well seated,\nwith normal leaflet/disc motion and transvalvular gradients. No MR. [Due to\nacoustic shadowing, the severity of MR may be significantly UNDERestimated.]\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\nIndeterminate PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: The patient is in a ventricularly paced rhythm.\n\nConclusions:\nThe left atrium is elongated. The right atrium is moderately dilated. Left\nventricular wall thicknesses and cavity size are normal. Septal motion is\ndysnchronous, but the remaining segments appear to contract well. Due to\nsuboptimal technical quality, a focal wall motion abnormality cannot be fully\nexcluded. Right ventricular chamber size and free wall motion are normal.\nThere is abnormal septal motion/position. The ascending aorta is mildly\ndilated. The aortic valve leaflets (3) are mildly thickened. No aortic valve\nstenosis is seen. Trace aortic regurgitation is seen. A bioprosthetic mitral\nvalve prosthesis is present with normal gradient and mobile leaflets. No\nmitral regurgitation is seen. [Due to acoustic shadowing, the severity of\nmitral regurgitation may be significantly UNDERestimated.] The pulmonary\nartery systolic pressure could not be determined. There is no pericardial\neffusion.\n\nCompared with the prior study (images reviewed) of , biventricular\nsystolic function is improved. The heart rate is also much lower on the\ncurrent study.\n\nCLINICAL IMPLICATIONS:\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate a high risk (prophylaxis strongly recommended). Clinical decisions\nregarding the need for prophylaxis should be based on clinical and\nechocardiographic data.\"\n\n\n"},{"category":"Echo","chartdate":"2155-05-16 00:00:00.000","description":"Report","row_id":94890,"text":"PATIENT/TEST INFORMATION:\nIndication: Mitral valve disease. valve function.\nHeight: (in) 64\nWeight (lb): 163\nBSA (m2): 1.79 m2\nBP (mm Hg): 105/37\nHR (bpm): 71\nStatus: Inpatient\nDate/Time: at 18:10\nTest: Portable TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nICU nursing staff monitored the patient during the procedure. The patient was\non a propofol drip and was given an additional 40 mcg of propofol.\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA\nand extending into the RV.\n\nLEFT VENTRICLE: Mild-moderate regional LV systolic dysfunction. Mildly\ndepressed LVEF.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior\n- akinetic; mid inferior - akinetic;\n\nRIGHT VENTRICLE: Paradoxic septal motion consistent with prior cardiac\nsurgery.\n\nAORTA: Complex (>4mm) atheroma in the aortic arch. Complex (>4mm) atheroma in\nthe descending thoracic aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Bioprosthetic mitral valve prosthesis (MVR). Normal MVR\nleaflets. No mass or vegetation on mitral valve. No MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was monitored\nby a nurse throughout the procedure. The patient appears to be\nin sinus rhythm.\n\nConclusions:\nThere is mild to moderate regional left ventricular systolic dysfunction with\ninferior akinesis and abnormal septal motion (post-op) (ejection fraction\n?45%). Overall left ventricular systolic function is mildly depressed. There\nare complex (>4mm) atheroma in the aortic arch. There are complex (>4mm)\natheroma in the descending thoracic aorta. The aortic valve leaflets (3) are\nmildly thickened. There is no aortic valve stenosis. Trace aortic\nregurgitation is seen. A bioprosthetic mitral valve prosthesis is present. The\n mitral leaflets appear with upper normal gradientsl. No\nobstruction, mass or vegetation is seen on the mitral valve. No mitral\nregurgitation is seen.\n\n\nIMPRESSION: Normally functioning bioprosthetic mitral valve. Moderately\ndepressed EF with inferior akinesis and abnormal septal motion (post-op).\n\n\n"},{"category":"Echo","chartdate":"2155-05-15 00:00:00.000","description":"Report","row_id":94961,"text":"PATIENT/TEST INFORMATION:\nIndication: New pulmonary edema and peripheral edema. Recent MVR and pacer.\nHeight: (in) 64\nWeight (lb): 186\nBSA (m2): 1.90 m2\nBP (mm Hg): 136/50\nHR (bpm): 60\nStatus: Inpatient\nDate/Time: at 16:44\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA\nand extending into the RV.\n\nLEFT VENTRICLE: Severe global LV hypokinesis.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion. Paradoxic septal\nmotion consistent with conduction abnormality/ventricular pacing.\n\nAORTIC VALVE: Aortic valve not well seen.\n\nMITRAL VALVE: Bioprosthetic mitral valve prosthesis (MVR). Increased MVR\ngradient. MR present but cannot be quantified.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion. There is an anterior\nspace which most likely represents a fat pad, though a loculated anterior\npericardial effusion cannot be excluded.\n\nConclusions:\nThere is severe global left ventricular hypokinesis (ejection fraction 20-30\npercent) (at least partly due to intraventricular contractile dysynchrony).\nRight ventricular chamber size and free wall motion are normal. The aortic\nvalve is not well seen. A bioprosthetic mitral valve prosthesis is present.\nThe gradients are higher than expected for this type of prosthesis. Mitral\nregurgitation is present but cannot be quantified. There is a\ntrivial/physiologic pericardial effusion. There is an anterior space which\nmost likely represents a fat pad.\n\nCompared with the findings of the prior study (images reviewed) of , a right ventricular pacing wire is now present, and the left ventricular\nejection fraction is markedly reduced, with evidence of intraventricular\nmechanical dysynchrony; consider biventricular pacing to address this problem.\n\n\n"},{"category":"Echo","chartdate":"2155-05-09 00:00:00.000","description":"Report","row_id":94962,"text":"PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. H/O cardiac surgery. S/p MVR.\nHeight: (in) 64\nWeight (lb): 186\nBSA (m2): 1.90 m2\nBP (mm Hg): 157/58\nHR (bpm): 60\nStatus: Inpatient\nDate/Time: at 16:42\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nLEFT VENTRICLE: Mild regional LV systolic dysfunction. Mildly depressed LVEF.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior\n- akinetic; mid inferior - akinetic;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion. Paradoxic septal\nmotion consistent with prior cardiac surgery.\n\nAORTA: Mildly dilated aortic sinus. Mildly dilated ascending aorta.\n\nAORTIC VALVE: Aortic valve not well seen.\n\nMITRAL VALVE: Bioprosthetic mitral valve prosthesis (MVR). Increased MVR\ngradient.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal PA\nsystolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nThe left atrium is mildly dilated. Overall left ventricular systolic function\nis mildly depresed with inferior hypokinesis (views suboptimal). Right\nventricular chamber size and free wall motion are normal. The aortic root is\nmildly dilated at the sinus level. The ascending aorta is mildly dilated. The\naortic valve is not well seen. There is a mild left ventricular/aortic outflow\ngradient which is likely due to mild outflow obstruction from the mitral valve\nprosthesis (outflow gradient was not fully assessed in this study). A\nbioprosthetic mitral valve prosthesis is present and appears well seated. The\ngradients are slightly higher than expected for this type of prosthesis. The\nestimated pulmonary artery systolic pressure is normal. There is no\npericardial effusion.\n\nCompared with the prior study (images reviewed) of , mitral valve has\nnow been replaced. Elevated aortic/left ventricular outflow velocities are\nnew. Ventricular function appears similar.\n\n\n"},{"category":"Echo","chartdate":"2155-05-05 00:00:00.000","description":"Report","row_id":94963,"text":"PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure. Coronary artery disease. Mitral valve disease. Shortness of breath. Intraop TEE for MVR\nHeight: (in) 64\nWeight (lb): 150\nBSA (m2): 1.73 m2\nBP (mm Hg): 108/45\nHR (bpm): 77\nStatus: Inpatient\nDate/Time: at 14:01\nTest: TEE (Complete)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA\nand extending into the RV. No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Mild-moderate regional LV systolic dysfunction. Moderately\ndepressed LVEF.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal\nanteroseptal - hypo; mid anteroseptal - hypo; septal apex - hypo; apex - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter. Simple atheroma in ascending aorta. Normal aortic arch diameter.\nSimple atheroma in aortic arch. Normal descending aorta diameter. Simple\natheroma in descending aorta.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. Mildly thickened\naortic valve leaflets (3). No AS. No AS. No AR.\n\nMITRAL VALVE: Moderately thickened mitral valve leaflets. Moderate mitral\nannular calcification. Moderate MS (MVA 1.0-1.5cm2) Moderate to severe (3+)\nMR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. No TEE related\ncomplications. The patient was under general anesthesia throughout the\nprocedure. The patient appears to be in sinus rhythm. Results were personally\nreviewed with the MD caring for the patient.\n\nConclusions:\nPRE-BYPASS:\n\n1. No atrial septal defect is seen by 2D or color Doppler.\n\n2.There is mild to moderate regional left ventricular systolic dysfunction\nwith mild to moderate hypokinesia of the mid and apical portions of the septum\nand anterior septum.. Overall left ventricular systolic function is moderately\ndepressed.\n\n3.Right ventricular chamber size and free wall motion are normal.\n\n4.There are simple atheroma in the ascending aorta. There are simple atheroma\nin the aortic arch. There are simple atheroma in the descending thoracic\naorta.\n\n5.The aortic valve leaflets (3) appear structurally normal with good leaflet\nexcursion and no aortic regurgitation. The aortic valve leaflets (3) are\nmildly thickened but aortic stenosis is not present. No aortic regurgitation\nis seen.\n\n6.The mitral valve leaflets are moderately thickened. There is moderate mitral\nstenosis (area 1.0-1.5cm2). Moderate to severe (3+) mitral regurgitation is\nseen. The posterior leaflet is very restricted. MR jet is posteriorly\ndirected.\n\n7.There is no pericardial effusion.\n\nPOST BYPASS\n\n1. Patient is being AV paced and receiving an infusion of epinephrine and\nphenylephrine.\n\n2. RV systolic function is moderately depressed.\n\n3. LV systolic function is moderately depressed. Anterior wall,septum and\nanterior septum are moderately depressed.\n\n4. Bioprosthetic valve seen in the mitral position. Leaflets open well and the\nvalve appears well seated. Trace mitral regurgitation present. Mean gradient\nacross the mitral valve is 5 mm Hg. Prominent struts seen in the LVOT. No\nsignificant gradient across the LVOT.\n\n5. Aorta intact post decannulation.\n\n\n"},{"category":"Echo","chartdate":"2155-04-21 00:00:00.000","description":"Report","row_id":94964,"text":"PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Mitral valve disease. Shortness of breath.\nWeight (lb): 176\nBP (mm Hg): 162/52\nHR (bpm): 71\nStatus: Inpatient\nDate/Time: at 11:59\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Suboptimal\ntechnical quality, a focal LV wall motion abnormality cannot be fully\nexcluded. Overall normal LVEF (>55%).\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior\n- hypo; mid inferior - hypo; basal inferolateral - hypo; mid inferolateral -\nhypo; inferior apex - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets. No AS. No AR.\n\nMITRAL VALVE: Severely thickened/deformed mitral valve leaflets. Severe mitral\nannular calcification. Moderate MS (MVA 1.0-1.5cm2) Mild (1+) MR. [Due to\nacoustic shadowing, the severity of MR may be significantly UNDERestimated.]\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nThe left atrium is moderately dilated. There is mild symmetric left\nventricular hypertrophy. The left ventricular cavity size is normal. Overall\nleft ventricular systolic function is normal (LVEF>55%). Cannot exclude\ninferior hypokinesis (views suboptimal). Right ventricular chamber size and\nfree wall motion are normal. The aortic valve leaflets are mildly thickened.\nThere is no aortic valve stenosis. No aortic regurgitation is seen. The mitral\nvalve leaflets are severely thickened/deformed. There is severe mitral annular\ncalcification. There is moderate mitral stenosis (area 1.0-1.5cm2). Mild (1+)\nmitral regurgitation is seen. [Due to acoustic shadowing, the severity of\nmitral regurgitation may be significantly UNDERestimated.] There is no\npericardial effusion.\n\n\n"},{"category":"ECG","chartdate":"2155-05-13 00:00:00.000","description":"Report","row_id":270168,"text":"Atrial fibrillation with ventricular rhythm\nSince previous tracing of , ventricular paced rhythm present\n\n"},{"category":"ECG","chartdate":"2155-05-12 00:00:00.000","description":"Report","row_id":270169,"text":"Atrial fibrillation with slow ventricular response\nLeft bundle branch block\nSince previous tracing of , ventricular response is now irregular with\nleft bundle branch block configuration\n\n"},{"category":"ECG","chartdate":"2155-05-10 00:00:00.000","description":"Report","row_id":270170,"text":"Atrial fibrillation with a regular ventricular response suggesting an\nindependent junctional or idioventricular rhythm with right bundle branch\nblock/left posterior fascicular block configuration\nSince previous tracing of , sinus bradycardia and left bundle branch\nblock now absent\n\n"},{"category":"ECG","chartdate":"2155-05-09 00:00:00.000","description":"Report","row_id":270171,"text":"Sinus bradycardia. Intraventricular conduction delay of the left bundle-branch\nblock variety. Secondary ST-T wave abnormalities. Compared to the previous\ntracing of no change.\n\n"},{"category":"ECG","chartdate":"2155-05-08 00:00:00.000","description":"Report","row_id":270172,"text":"Sinus bradycardia. P-R interval 0.18. Since the previous tracing of the\nrate has slowed and T waves are inverted in leads III and aVF, which may be\nconsistent with inferior myocardial infarction in the presence of left\nbundle-branch block. One ventricular premature beat is noted.\n\n"},{"category":"ECG","chartdate":"2155-05-05 00:00:00.000","description":"Report","row_id":270173,"text":"Sinus rhythm with first degree A-V block. Left bundle-branch block. Since the\nprevious tracing of the rate is increased but no other changes have\noccurred.\n\n"},{"category":"ECG","chartdate":"2155-04-27 00:00:00.000","description":"Report","row_id":270174,"text":"Sinus rhythm. Consider left atrial abnormality. Left bundle-branch block.\nCompared to the previous tracing no change.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2155-05-16 00:00:00.000","description":"Report","row_id":270166,"text":"Normal sinus rhythm with marked A-V conduction delay. Left bundle-branch block.\nLeft atrial abnormality. Occasional premature ventricular contractions.\nCompared to tracing #1 no diagnostic interim change.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2155-05-14 00:00:00.000","description":"Report","row_id":270167,"text":"Atrial fibrillation\nIntermittent ventricular premature beats\nLeft bundle branch block\nSince previous tracing of , ventricular pacing intermittent\n\n"},{"category":"ECG","chartdate":"2155-04-26 00:00:00.000","description":"Report","row_id":270175,"text":"Sinus bradycardia. Consider left atrial abnormality. Left bundle-branch block.\nSince the previous tracing no change.\nTRACING #1\n\n"},{"category":"ECG","chartdate":"2155-04-24 00:00:00.000","description":"Report","row_id":270176,"text":"Baseline artifact. Sinus rhythm. Leftward axis. Left bundle-branch block. Since\nthe previous tracing of the rate has decreased. ST-T wave abnormalities\nare less.\n\n"},{"category":"ECG","chartdate":"2155-04-22 00:00:00.000","description":"Report","row_id":270177,"text":"Sinus rhythm\nLeft atrial abnormality\nLeft bundle branch block\nSince previous tracing of , ST-T wave changes less prominent and Q-Tc\ninterval appears shorter\n\n"},{"category":"ECG","chartdate":"2155-04-21 00:00:00.000","description":"Report","row_id":270178,"text":"Baseline artifact. Probable sinus rhythm. Left axis deviation. Left anterior\nfascicular block. Left bundle-branch block type. Q-T interval prolongation.\nSince the previous tracing of the precordial T wave inversions are more\nprominent. Clinical correlation is suggested.\n\n"},{"category":"ECG","chartdate":"2155-04-20 00:00:00.000","description":"Report","row_id":270179,"text":"Sinus rhythm. Sinus rhythm. Compared to tracing #2 the heart rate has\nsignificantly normalized.\nTRACING #3\n\n"},{"category":"ECG","chartdate":"2155-04-19 00:00:00.000","description":"Report","row_id":270180,"text":"Sinus tachycardia. Occasional atrial premature beats. Compared to tracing #1\nthe heart rate hias decreased but significant tachycardia persists. Clinical\ncorrelation is suggested.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2155-04-19 00:00:00.000","description":"Report","row_id":270181,"text":"Sinus tachycardia. Left atrial abnormality. Left axis deviation. Left\nbundle-branch block. Compared to the previous tracing of the heart rate\nhas significantly increased. Clinical correlation is suggested.\nTRACING #1\n\n"},{"category":"ECG","chartdate":"2155-05-27 00:00:00.000","description":"Report","row_id":273792,"text":"Right may be sinus with marked left atrial abnormality and first degree\nA-V delay. Consider ectopic atrial rhythm. Left bundle-branch block. Since the\nprevious tracing of the rate is slower and the intraventricular\nconduction delay and ST-T wave abnormalities are less prominent.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2155-05-27 00:00:00.000","description":"Report","row_id":273793,"text":"Regular rhythm, mechanism uncertain, may be sinus or ectopic atrial rhythm with\nfirst degree A-V delay. Left bundle-branch block. Since the previous tracing\nof the rate is faster.\nTRACING #1\n\n"},{"category":"ECG","chartdate":"2155-05-20 00:00:00.000","description":"Report","row_id":273794,"text":"Sinus rhythm. A-V conduction delay. Left bundle-branch block. Compared to the\nprevious tracing of ventricular ectopy is absent and the rate has\nslowed. Otherwise, no diagnostic interim change.\n\n"},{"category":"ECG","chartdate":"2155-05-14 00:00:00.000","description":"Report","row_id":273795,"text":"Sinus tachycardia. Left bundle-branch block and secondary ST-T wave\nabnormalities. Compared to the previous tracing of atrial fibrillation\nis no longer present.\nTRACING #1\n\n"},{"category":"Nursing/other","chartdate":"2155-05-18 00:00:00.000","description":"Report","row_id":1460561,"text":"Neuro: A&O x3; sleepy @ beginning of shift, dozing on & off, more awake in PM; MAE's; follow commands consistently\n\nCV: Underlying atrial flutter with V-paced beats @ 60 by perm pacer; SBP 100's-130's; tolerating captopril & lopressor; SvO2 >65, CO decreased from 3.9 to 3.3 in PM, MD , CCO recaled, mixed venous 70 per careweb, fick CI 2.99, OK to pulled swan per Dr ; natrecor infusing @ 0.01 mcg/kg/min; changed to 750 units/hr @ 1100, evening PTT result pending; R fem a line DC'd, pressure applied for 15 minutes until hemostasis attained; new 20g placed on R wrist\n\nResp: Lung clear, slight crackles @ bases; 2L NC sat 98%; non-productive cough\n\nGI: Tolerating clear liquids & pills; +bowel sound\n\nGU: Foley draining clear yellow urine, 30-45 ml/hr; will not start MD and will let pt self diurese first, pt is \"dry\" MD \n\nInteg: Intact\n\nPain: Denies pain\n\nEndo: Cover per humalog sliding scale; q4h BG\n\nSocial: Multiple calls from daughter, stating needs to talk about extremely important issues with patient, explained patient is in intesive care unit and needed rest & phone is not accessible in room; ex-husband in for visit withoout calling @ door; only voisitor allowed is daughter per patient\n\nPlan: moniotr hemodynamics, resp status & labs; get OOB/sit up in bed after 6 hrs (2300) post fem a line removal; monitor renal status & UO; advanced diet as tol; inc activity as tol; social services follow up\n"},{"category":"Nursing/other","chartdate":"2155-05-19 00:00:00.000","description":"Report","row_id":1460562,"text":"NEURO: A&O X 3, MAE, FOLLOWS COMMANDS, COOPERATIVE WITH CARE.\n\nPULM: N/C AT 2L, SATS > 98%. LUNGS CRACKLEY IN BASES.\n\nCV: V PACED AT 60 ALL SHIFT, UNDERLYING RHYTHM ATRIAL FLUTTER. AT 750 UNITS/HR UNTIL 0630 WHEN PTT 91.4, PT 22.0/INR 2.2. NATRECOR CONTINUOUS AT 0.01MCG. PEDAL PULSES PALPATED. + PERIPHERAL EDEMA. TOLERATING LOPRESSOR AND CAPTOPRIL.\n\nENDO: Q4H BS WITH HUMALOG INSULIN SLIDING SCALE COVERAGE.\n\nGI: ABDOMEN SOFT, + BS. NO BM.\n\nGU: FOLEY TO CD DRAINING MARGINAL HOURLY AMBER URINE. MD AWARE. WEIGHT UP 0.5KG.\n\nSOCIAL: NO VISITORS OR PHONE INQUIRIES.\n\nPLAN: ? PICC LINE FOR ACCESS THEN DC RIJ. ? DC NATRECOR TODAY. ? LASIX OR DOSE FOR DIURESIS. OOB TO CHAIR THIS AM.\n\n\n"},{"category":"Nursing/other","chartdate":"2155-05-19 00:00:00.000","description":"Report","row_id":1460563,"text":"NEURO ALERT ORIENTED GENERALIZED WEAKNESS NO NEURO DEFECITS NOTED\n\nC/V VPACED B/P STABLE PALP PULSES GENERALIZED EDEMA EXTREMTIES HEP DC/ MD. COUMADIN GIVEN. DOSE DISCUSSED WITH MD, WILL CONTINUE TO FOLLOW PT/PTT/INR\n\nRESP BREATH SOUNDS CLEAR, DIMINISHED IN BASES. USING IS WITH MODERATE VOLUMES. NONPRODUCTIVE COUGH. NC 2L TOL WELL SATS 98-100%\n\nGU/GI ABD SOFT INCREASED DIET TO CARDIAC/2GM NA TOL WELL. MODERATE URINE 40CC HOUR NATRECOR DC/ MD LASIX IV BID STARTED WITH GOOD OUTPUT.\n\nPLAN CONTINUE TO CLOSELY MONITOR I/O AND RESP STATUS. INCREASED ACTIVITY\n"},{"category":"Nursing/other","chartdate":"2155-04-21 00:00:00.000","description":"Report","row_id":1460523,"text":"Respiratory Care:\nPt. successfully extubated to a 40% cool mist mask. Appears to be doing well. MDI's given prior to extubation. HR = 69 BP = 128/41 RR = 17 O2 Sat. = 100%. Was OET suctioned for a large plug just before the tube was removed; chest sounds were clear after suctioning.\n\n"},{"category":"Nursing/other","chartdate":"2155-04-19 00:00:00.000","description":"Report","row_id":1460515,"text":"Nursing progress notes\n71 yr old pt w/ long hx (please see fhp) sob x 1 week w/ worsening. daughter called ems, to intubated d/t rr<6 and obtunded. pcxr shows chf lasix given 60mg ivp w/ approx 500cc out this shift. placed on ntg gtt at 3mcq/min for hypertension of sbp 200, given asa and tylenol for temp 103 rectal. lactate 4.3, pt received vanco, ceftriaxone, and flagyl. bs 500 and urine glucose 1000 pt received 6 units of regular insulin iv. to micu. bs 450 insulin gtt started. pt intubated 7.5 orally at 22cm lip line. on ac16/400/100%/5 o2 decreased to 50% sats cont at 100% abg attempted but team and resp therapist unable to obtain.\n\nNeuro: pt sedated on diprivan gtt 40mcq/kg/min able to mae follow commands nods to simple questions.\n\nresp: intubated as above. team to attempt aline later this evening. ls rhonchi to coarse bs. suctioned up thick tan secretions sent for c/s pt on droplet precautions to r/o influenza. pcxr in ed shows pul edema, 2nd pcxr obtain at present.\n\ncv: tele upon arrival to unit hrt rate 90-100 st w/ lbbb. at present sr60s bp 110s/60s ntg off. pt has distant hrt sounds S1S2 w/ systolic murmur. labs ordered for 1800. ck 52 w/ troponin .03, cont to cycle enzymes. cardiac cath on shows ef 60% w/ 2+ mr was stented.\nall cardiac meds on hold for now ? sepsis. uop dropped off x 2 hrs bolus of 500cc ns given at 1730\n\ngi ogt in place tube feeding order needed. abd soft bs+\n\ngu: foley put out yellow urine, ua lytes obtained.\n\nskin: pt has several bruises noted one on her left upper back, one on her right buttock and right shoulder blade. micu team aware\n\nendo: pt on insulin gtt titrate bs for 120\n\nid: pan cx in ed. on vanco levofloxacin and flagyl, lactate 3.4, svo2 74 now afebrile\n\ncode: full\n\nsocial: lives w/ daughter and grandson. daughter called this afternoon and was updated.\n\nprecautions: droplet\n\nPlan:\ncont to monitor uop\nlab pending\ncont to sedate w/ diprivan gtt\n? tube feedings\naline\n"},{"category":"Nursing/other","chartdate":"2155-04-20 00:00:00.000","description":"Report","row_id":1460516,"text":"MICU Nursing Note 1900-0700\nEvents: Pt R/I for MI with Trop= 0.39---started on IV Heparin gtt, hypertensive---started on IV Labetolol gtt as per cardiology, remains on droplet precautions. IV Insulin gtt weaned to off.\n\nNeuro: Mildly sedated on IV Propofol at 40mcgs/kg/min, pt easily arouseable, follows all commands, moving all extremities when stimulated, denies pain when asked, c/o fear and anxiety when asked, calm and sleeping when not stimulated. Bilat soft wrist restraints to prevent pt from pulling at lines and tubes.\n\nCardiac: HR= 60-96 SR with no ectopy noted, new right radial Aline placed by MICU team with good waveform and correlation, BP= 102-162/30-50's, Started on IV Labetolol gtt at 0.5mg/min at Midnight and weaned to off at 4am for BP down to 103/39--restarted at 5am for BP trending back up to 140's. #2 set of cardiac enzymes with positive troponin= 0.39, CPK= 146 with MB= 16 and index= 11%. # 3 set pending. Started on IV Heparin weight based protocol at MN with am PTT pending.\n\nResp: Remains intubated with current vent settings: AC 400-40%-16 with PEEP= 5. Overbreathing vent by 3-4 breaths, MV= , Sats= 98-100%, lungs coarse at bases, good ABG= 7.38-40-137-25. Remains on Droplet precautions to r/o flu---specimen obtained by RT and sent this am. Pt with epitaxis this am ---pressure applied to both nares with bleeding subsiding. Hct= 30.\n\nGI: Abd soft with +bowel sounds, med brown BM x 1, OGtube placement checked by ausculatation and clamped at present, tube feedings held d/t possible extubation this am.\n\nGU: Foley to CD draining clear yellow urine, 20-40ml/hr\n\nEndo: insulin gtt d/c'd, 10pm fingerstick= 117---no coverage required, am fingerstick pending.\n\nID: Tmax= 99.8, WBC= 10.1, continues on Levofloxacin, vanco, and Flagyl\n\nSocial: No contact from family or friends overnight\n\nPlan: Wean sedation as tolerated,Possible wean and extubate this am, If remains intubated then start tube feedings as ordered, monitor for bleeding, wean labetolol as tolerated, continue sliding scale insulin,Support pt and family\n"},{"category":"Nursing/other","chartdate":"2155-04-20 00:00:00.000","description":"Report","row_id":1460517,"text":"Respiratory care:\nPatient remains intubated and mechanically vented. Vent checked and alarms functioning per respiratory department protocol. Fio2 weaned this eve to 40%. Current settings: A/C 400*16 5 peep 40%. RSBI this am 42. Breathsounds are coarse. Albuterol/atrovent nebs started. Please see respiratory care section of carevue for further data.\nPlan: Continue mechanical ventilation. Wean as tolerated. RSBI 42.\n"},{"category":"Nursing/other","chartdate":"2155-04-20 00:00:00.000","description":"Report","row_id":1460518,"text":"Resp. Care Note\nPt received intubated and vented on AC settings as charted on resp flowsheet. RSBI 42 today. Changed to PSV and is currently on 10 of PSV with TV 400's and RR <20. ABG's WNL. ruled out for flu today. Cont current support, reassess in AM for rediness to wean and extubate.\n"},{"category":"Nursing/other","chartdate":"2155-04-22 00:00:00.000","description":"Report","row_id":1460524,"text":"MICU nursing progress note 7P-7A\nEvents - Pt c/o mid-sternal chest pressure. Denies nausea, a little SOB. O2 placed, EKG unchanged. VSS. SL Ntg x 1 with some decrease in pain , Maalox resulted with total pain relief. CKs drawn -troponin .2, CKs flat. CXR showed slight ^^ pulm edema. Lasix 60 mg with fair diuresis-UOP had tapered off to<8cc/hr prior to lasix.\n\nNeuro - A&Ox3, MAE, assists with turns in bed. Transient discomfort over left lower rib cage, refused tylenol.\n\nResp - Lungs clear, diminished at bases. O2 weaned 40% FT-->NC 2L. No resp distress, Sats 95-100%, RR teens.\n\nCV - ABP 95-140/39-49. NSR 70s-80s, rare PVC. Tolerating BP med regime, Ntg gtt remains off. BP was in low 90s for awhile after captopril then increased to 120s. Trace edema in LE. Hct 26.6 (30.6). Right fem line d/c'd.\n\nGI - Tolerating PO clears, Abd soft, +BS. + flatus, no stool. Insulin gtt titrated to FSBS- BS 64, gtt off, OJ given with BS^^ 200, gtt restarted.\n\nGU -- UOP 80->8cc/hr. Now ^^ after 60 lasix IVP. Pt was ~300cc neg at midnite, now a little positive. BUN/cr cont to increase 27/1.3.\n\nSkin - Bruised areas on back (2) unchanged.\n\nID - Afebrile. On vanco, levoflox.\n\nPlan - Monitor response BP med regime, goal SBP 120s. Diuresis prn. Replete lytes prn. Cyckle CKs, 2nd set due 8:30AM. Titrate insulin to BS. Cardiology following, will address whether needs tranfusion with them. ? cath lab to evaluate pulmomary edema.\n"},{"category":"Nursing/other","chartdate":"2155-04-22 00:00:00.000","description":"Report","row_id":1460525,"text":"NURSING NOTE 0700HRS - 1700HRS\n\n\nNEURO...A/O X3, NO FURTHER CHEST PAIN BUT IS C/O SOME DISCOMFORT RT SIDE OF RIB CAGE, PATEINT REFUSES PO ANLAGESIA ? REALTED TO BRUISING NEAR THAT AREA..PATIENT APPEARS MORE COMFORTABLE THIS PM IN THE CHAIR\n\n\nRESP..RECEIVED ON 2 L SATS @ 100%..N/C REMOVED SATS @ 98% GOOD COUGH/DEEP BREATH, SOME CRACKLES AND CXR SHOWS CHF [ LASIX GIVEN AS BELOW]..EXPECTORATING SMALL AMOUNT OF SPUTUM\n\n\n\n\nCVS...B/P STABLE 110-120 SYSTOLC ON REDUCE DOSE OF ACE, BBLOCKERS CONTINUE TO HOLD FOR PARAMETERS...HR 62-68BPM..K STABLE THIS PM @ 4.1..REPEAT HCT @ 27 [ DOWN FROM 30 YESTERDAY BUT TEAM AWARE] CONTINUE TO OBSERVE....CK'S CONTINUE TO BE CYCLED POST CENTRAL CHEST PAIN LAST PM [ STABLE], TROP @ 0.3 TEAM AWARE... PATIENT HAS R/I FOR NSTEMI ON THIS ADMISSION CONTINUES ASPRIN/PLAVIX/SC HEPARIN..\nAFEBRILE..VANC D/C BUT LEVO CONTINUES..\n\n\nENDO...INSULIN DRIP CONTINUED THIS AM BUT D/C POST COMMENCEMENT OF NPH WITH S/S..CONTINUING TO MONITOR CLOSELY...STABLE AT PRESENT...\n\n\nGI..TAKEN DIET VERY WELL..BOWEL SOUNDS PRESENT NO BOWEL MOTION SINCE ADMISSION\n\n\nGU...GIVEN PO LASIX/SPIROLACTONE THIS AM WITH LITTLE EFFECT..AIM FOR NEG BALANCE 500-1L NEG..RECEIVED IV LASIX THIS PM BUT CONTINUES MINIMAL EFFECT AND WILL RE-REVIEW WITH TEAM...\n\n\n\nSKIN..BRUISES [ X3 AREAS MARKED], BUT SKIN INTACT\n\n\nLINES..ART REMIANS IN PLACE, NEW PIV PLACED...\n\n\n\n\nSOCIAL...SOCIAL WORKER SPOKE WITH TODAY RE CONCERNS ..PATIENT ADMITS TO VERBAL ABUSE BY DAUGHTER IN THE HOME AND GRANDSON ALSO HAVING ANGER MANAGEMENT ISSUES [ RECENTLY THREW A BOTTLE OF CLEANING FLUID AT PATIENT]..DAUGHTER PRESENTLY ADHERING TO REHAB PROGRAMME AND GRANDSON IS TO SEE COUNSELLOR FOR ANGER MANAGEMENT...SOCILA WORKER INFORMED ELDER SERVICES WHO WILL COME AND INTERVIEW PATEINT...THE PATIENT WISHES ARE AT PRESENT FOR THE DAUGHTER NOT TO BE INFORMED OF ANY OF THE ABOVE ACTION AND THAT SHE WISHES FOR HER TO VISIT...PATEINT AWARE TO INFORM OF ANY CONCERNS RE: SECURITY WHILST IN THE HOSPITAL...AWAIT ELDER SERVICES VISIT\n\n\n\n\nPLAN...MONIOTOR RESP STATUS/B/P HR///U/O...AIM FOR NEG BALANCE...AWAIT ELDER SERVICES, OFFER SUPPORT TO PATIENT/FAMILY AT THIS DIFFICULT TIME....CALL OUT TO FLOOR\n"},{"category":"Nursing/other","chartdate":"2155-04-22 00:00:00.000","description":"Report","row_id":1460526,"text":"Micu Nursing Transfer Addendum\nEvents: Pt with 7 beat run VT---self-limiting and asymptomatic, no further ectopy noted. Hemodynamically stable at present, Diuresing from earlier dose IV Lasix.\n\nNeuro: A+OX3 pleasant and cooperative, moving all extremities and following all commands, somewhat weepy when discussing her plan of care and potential need for heart surgery in future.\n\nCardiac: HR= 70's SR with 7 beat run VT at 1900---asymptomatic and no further ectopy noted, BP= 140's/40's, given lopressor at 7pm---dose was held at 4pm d/t borderline BP. Denies CP\n\nResp: Lungs clear bilat but diminished at bases, RA Sats= 97-100%, denies SOB, nonprod. cough noted.\n\nGI: Abd soft with + bowel sounds all quads, no BM, + flatus, good po intake\n\nGU: Foley to CD draining clear yellow urine---diuresing from earlier IV dose of lasix, 8pm po dose of lasix held\n\nSkin: intact, ecchymotic areas on back unchanged.\n\nSocial: Pt has been in contact with daughter and grandson via phone this evening. No visitors this .\n\nPlan: Transfer to 6 for further medical and cardiology workup, Monitor closely for CHF and diurese prn, Increase activity as tolerated, replace lytes prn, due at 12 am for cardiac enzymes, Elder Services to come and speak with pt regarding abuse at home---pt requests strict confidentiality and that daughter and grandson are not informed of this, Support pt and family.\n"},{"category":"Nursing/other","chartdate":"2155-05-17 00:00:00.000","description":"Report","row_id":1460557,"text":"Respiratory Care:\n\nPatient intubated on PSV. Vent settings initially PSV 10, Peep 5, Fio2 40%. PSV weaned to 5cm this morning. Spont vols 500's with RR mid teens. O2 sat 100%. BS clear bilaterally. Sx'd for sm amounts of thick white secretions. RSBI 28. Pt. appear comfortable on PSV 5.\nPlan: Will repeat ABG. ? Extubation later this morning.\n"},{"category":"Nursing/other","chartdate":"2155-05-17 00:00:00.000","description":"Report","row_id":1460558,"text":"Resp Care\nPt extubated this morning to 40% cool aerosol face tent. BLBS post extubation clear though slightly diminished. Pt had audible cuff leak and no stridor post extubation. Pt was weaned to 2L after several hours and is currently satting >96% on NC.\n"},{"category":"Nursing/other","chartdate":"2155-05-17 00:00:00.000","description":"Report","row_id":1460559,"text":"NPN:\n\nNeuro: Awake and following commands in am. After extubation pt cooperative but sleepy and lethargic. At 17pm pt with increased alertness. Asking questions about what happened to her-remembers going to US and having trouble breathing. MAE and follows commands. Continues with 2+ edema.\nSocial: HCP- called to check on patient-He will be away a few days and can be reached by cell phone-. Daughter called requesting to speak on phone with patient stating she had a serious issue. Request denied-encouraged daughter that patient was not able to speak on phone and if needed to see her she should visit. Also recieved call from -stating he was patients ex husband.\nID: Afebrile. Last dose of Vancomycin given. WBC-14.5\nCV: 90-110 ST then converted to aflutter/fib with V pacing-rate 60-70's. Rare PVC seen. K repleted. Continues on Amio 400mg , lopressor inreased to 37.5 mg tid and captopril increased to 12.5 tid. BP labile at times-hypertensive to 160-190's/ then 90-100's/. Natrecor continues at .01. at 900u/hr with stable PTT 71. Coumadin 4mg given at 16pm. Has L fem aline. Feet with 2-3+ pitting edema. Skin warm and dry. Pulses by doppler.\nResp: Extubated at 9am to 40% FTN with good ABG's-weaned to 2L nc with sats > 97%. Cough fair-productive of thick pale yellow secretions. CXR done today. Lungs -diminished in bases.\nGU: Foley. Diuresing on lasix at 10mg/hr-UO-decreased requiring diuril. Cr 1.5.\nGI: Abd soft, NT, ND with hypo BS. OGT dc'd with extubation. Tolerating small amounts water and diet gingerale.\nEndo: Glucoses high-190-220's. Changed to humalog sliding scale q 4 hrs. ? to restart standing insulin doses.\nComfort: C/o back pain -treated with morphine X1.\nActivity: Turned side to side in bed.\nIncisions: Sternum and L shoulder with DSD-D/I.\nA: Extubated but sleepy most of day. Social service notified\nP: Reorient prn, social work following ptient and family, Continue diuresis with lasix and natrecor-diuril prn-discuss weaning gtts in am, Swan remains in for IV access. Replete lytes prn. /coumadin. ? stop in am to dc fem aline. Restart rehab\n"},{"category":"Nursing/other","chartdate":"2155-04-20 00:00:00.000","description":"Report","row_id":1460519,"text":"Nursing progress notes\nReview of systems:\n\nNeuro: pt sedated on 50mcq/kg/min of diprivan increased from 40mcq for vent adaption and comfort. pt awakens to voice and nods to simple questions. mae.\n\nREsp: orally intubated 7.5 22 at lip line retaped to right side of mouth. vent settings psv 10/5 40% abg on these settings 7.41/42/163/29/99% LS clear to coarse w/ diminished bases. suctioning thick tan secretions from ett. pt had copious bldy oral secretions this am w/ multyple med size clots probably induced by nasal influenza spec. pressure applied to nares and heparin gtt stopped and dc'd. one med size clot removed at 1800, but no further bleeding. probable extubation in am.\n\ncv: tele sb 50s - sr60s w/ LBBB. abp 108-150s/60s hrt sounds distant s1s2 w/ systolic murmur. hct stable 30 this am then rechecked at 0830 after bleeding 31.6. heparin gtt dc'd ptt this afternoon 25 inr 1.1, ck cycled at 1300 85 w/ troponin .31 next set at 2100. pt now on heparin sq. pt's own cardiologist in to see her today and will f/u w/ her in am. bb and ace inhibitor added this am.\n\ngi: abd soft bs+ tube feeds at 40cc/hr residual 10cc. no stool this shift.\n\ngu: uop via foley poor this am <20cc/hr lasix 40mg ivp given pt uop picked up to >50cc/hr goal to have pt -500cc at midnight at present pt +700cc and 1500 for los.\n\nendo: insulin gtt on for short time this am d/t bs 300 now on own home regiment. nph 22 am and 8 units at pm w/ reg insulin 8 units am and pm w/ additional humalog sliding scale\n\nid: vanco and levo cont flagyl dc'd bc pending, urine, sputum neg influenza neg pt off of droplet precautions.\n\nsocial: daughter and grandson for a short time and was updated emotional support given\n\ncode full\n\nPlan:\ncont to wean vent as tolerated\nmonitor for nasal and oral bleeding\nmonitor bs x 24 hrs on this regiment and team will reassess in am\nextubate in am.\nnext labs at 2100\n"},{"category":"Nursing/other","chartdate":"2155-04-21 00:00:00.000","description":"Report","row_id":1460520,"text":"MICU Nursing Note 1900-0700\nEvents: Bleeding subsiding from nose and mouth, Didn't tolerate CPAP+PS during late evening and rested on CMV overnight, mild diuresis, BP up--required IV Hydralazine\n\nNeuro: Sedated on IV Propofol, mild restlessness with BP elevated during evening---propofol increased to 60 mcg/kg/min with good effect and titrated back to 50mcg/kg/min this am, With propofol off for 10 minutes pt awake and moving all extremities and following commands, otherwise pt arouses briefly to voice and increased stimulation. Bilat soft wrist restraints to prevent pt from pulling at lines and tubes.\n\nCardiac: HR= 57-70's SB/SR with rare PVC, BP 130-188/40-70's. Received 20 mg. IV Hydralazine for BP 180's with good effect and BP down to 140's. Again BP up to 170's this am---Captopril dose increased to 25 mg. TID and first dose given with BP slowly trending down. #4 set cardiac enzymes with CPK down to 71 and Troponin down to 0.24. Receiving SC Heparin. Lasix 40 mg. x 1. Right radial Aline with good waveform and correlation and site WNL. Right Femoral TLC site C/D/I and all ports patent\n\nResp: Remains intubated. Tolerated CPAP+PS until 8pm and then tachypneic and hypertensive with low MV ---placed back on CMV overnight with ABG this am=7.45-44-170 and RSBI= 62. Lungs coarse bilat to bases, ETtube suctioned for mod amts thick whitish sputum and occasionally suctioned for brown plugs, Orally suctioned for small old bloody clots and serous fluid at back of throat.\n\nGI: OGtube placement checked by auscultation, tube feedings infusing at 40 ml/hr until MN and then off for high residuals, pt with increasing bilous residuals during night and OGtube placed to LSW for total of 200ml. green bile. OGtube clamped at present and feedings held both for high resids and for potential extubation this am. Abd softly distended with + hypoactive bowel sounds.\n\nGU: Foley to CD draining clear yellow urine. Mild diuresis from 40 mg. IV Lasix. Pt neg. 100ml at MN and another 300 ml since MN. Remains > 1 liter positive for LOS.\n\nSkin: Grossly intact. No change in ecchymotic areas over back.\n\nEndo: Fingesticks remains elevated 178-304 overnight. On fixed dosing of NPH and regular along with sliding scale of humulog.\n\nID: Tmax= 99.1. WBC= 11.4. All antibx d/c'd\n\nSocial: Pt's daughter called during evening and was updated on pt's condition and plan of care.\n\nPlan: Wean Propofol gtt as tolerated and Attempt to wean vent and extubate, ? if need to diurese pt further prior to extubation attempt, If does not extubate consider restarting tube feeds at slower rate and monitor for high residuals, ? of need to change femoral line soon?, Continue aggressive pulmonary toiletting, Support pt and family.\n"},{"category":"Nursing/other","chartdate":"2155-04-21 00:00:00.000","description":"Report","row_id":1460521,"text":"Resp Care: Pt continues intubated #7.5 oett secured @ 22 @ lip and on ventilatory support, changed to a/c for overnoc rest d/t agitation/bucking vent, currently back on cpap with minimal psv maintaining abg wnl; bs clear to coarse, sxn thick brown/blood tinged secretions, rx with mdi albuterol/atrovent, rsbi 61, will attempt wean to extubate this am.\n"},{"category":"Nursing/other","chartdate":"2155-04-21 00:00:00.000","description":"Report","row_id":1460522,"text":"NURSING NOTE 0700HRS - 1700HRS\n\nPATIENT HAS EXTENSIVE CARDIAC HISTORY AND FREQUENT EPISODES OF FLASH PULOMARY OEDEMA [ WELL KNOWN TO CARDIOLOGISTS HERE]..PATIENT ADMIT WITH FOR PULMONARY OEDEAM ? SECONDARY TO HIGH B/P AND LLL PNEUMONIA\n\nEVENTS..REQUIRED FURTHER LASIX X2 DOSES FOR LOW URINE OUTPUT AND PENDING EXTUBATION...RECEIVED INCREASED PO MEDS FOR B/P CONTROL..HIGH BILIUOS RESIDUALS PLUS ABSENT BOWEL SOUNDS IMPROVED OVER THE COURSE OF THE DAY..PATIENT EXTUBATED WITH NITRO DRIP FOR B/P CONTROL @ 17.15HRS\n\n\n\n\n\nNEURO...RECEIVED ON PROPOFOL DRIP THIS AM AND DRIP TITRATED DOWN TO WHERE PATIENT WAS AWAKE BUT COMFORTABLE...SWITCHED OF FOR EXTUBATION..SINCE EXTUBATION LETHARGIC BUT ORIENATATED X3..MOVEMENT IN ALL 4 LIMBS, NO COMPLAINTS OF PAIN BUT THROAT SORE AND ICE CHIPS GIVEN...\n\n\n\n\nRESP...RECEIVED ON CPAP/PS..PATIENT WEANED AND EXTUBATED AT 17.15HRS WITH GOOD AB'S..PATIENT HAS COUGH...OLD BLOOD TINGED SECRETIONS EXPECTOATED [ FROM PREVIUOS NOSE BLEED WHILST INTUBATED]..ABLE TO COUGH DEEP BREATH WELL..SATS @ 100% AND LUNGS SOUND CLEAR..FOR CHECK ABG...\n\n\nCVS..PATIENT HAD ELEVATED TROP ON THIS ADMISSION ? NSTEMI AND INIITLLY COMMENCED ON IV HEPARIN, HEP D/C SECONDARY TO PREVIUOS EPISTAXIS NOW ON S/C HEP/ASPRIN/PLAVIX...HR SINUS RHTHM 68-75BPM WITH RARE PVC'S K THIS AM REPETED AND AGAIN PM CHECK K @ 3.6 AND REPLETED WITH 40 IV, WILL REQUIRE CHECK K PM....PATIENT IS IN L BBB ON EKG, ECHO PERFOMED THIS AM AND CARDIOLOGY FOLLOWING...\nB/P HAS BEEN ONGOING ISSUE FOR CONTROL AIM < 140..RECEIVED @ 160 THIS AM DESPITE PO MEDS THEREFORE PATIENT RECEIVED STAT DOSE OF HYDRAL..AGAIN MEDS TITRATED UP FOR ACE AND BBLOCKER..PATIENT HAD IV NITRO IN PROGRESS FOR EXTUBATION NO STOPPED AS SYSTOLIC < 140...\n\n\nENDO..B/S ^^^ THIS AM ..PATEINT COMMENCED ON HOME REGIME LAST PM BUT NOT COVERING B/S THEREFORE INSULIN DRIP RE-COMMENCED TODAY AND IS IMPROVING..\n\n\nID..WBC @ 11 THIS AM..PATEINT LOOKS FLUSHED BUT NOT FEBRILE..AB'S CONTINUE FOR LLL PNEUMONIA..? REQIURES VANC LEVEL TOMORROW\n\n\nGI...FEED STOPPED DURING THE NIGHT DUE TO HIGH BILIOUS RESIDUALS..UPON RECEIVING PATIENT THIS AM NO B/S PRESENT BUT BELLY SOFT..BILIUOS SECRETIONS IMPROVED OVER THE COURSE OF THE DAY AND PATIENT NOW HAS HYPOACTIVE B/S..CONTINUE TO MONITOR..ICE CHIPS TAKEN POST EXTUBATION\n\n\nGU....RECEIVED X2 DOSES OF LASIX FOR LOW U/O AND PENDING EXTUBATION WITH SOME RESPONSE [ PATEINT NORMALLY ON LASIX AND SPIROLACTONE AT HOME]...CONTINUE TO MONITOR .. ? EXPECTATION FOR FLUID BALANCE NOW EXTUABATED...\n\n\nSKIN..BRUISING NOTED ON HER BACK AND AREAS MARKED ?? CAUSE BUT TEAM AEA AWARE\n\n\nLINES...SECOND PERIPHERAL PLACED TODAY ? FOR GROIN CENTRAL LINE REMOVAL THIS EVE...\n\n\nSOCIAL..DAUGHTER HAS VISITED THIS AM..SOCIAL WORKER WILL TALK TO HER TOMORROW\n\n\nPLAN...FOLLOW RESP STATUS..MONITOR B/S WITH INSULIN DRIP ? SWITCH TO HOME REGIME..MONITOR K POST DIURESIS...MONITOR BOWEL SOUNDS.? COMMENCE PO'S THIS EVE..MONITOR B/P GIVE PO MEDS\n"},{"category":"Nursing/other","chartdate":"2155-05-18 00:00:00.000","description":"Report","row_id":1460560,"text":"NEURO: ALERT, LETHARGIC/WEAK. ORIENTED X 3, MAE, FOLLOWS COMMANDS. VOICE STRONGER MORE FACIAL ANIMATION AFTER SLEEPING. NO SEDATIVES OR NARCOTICS GIVEN.\n\nPULM: N/C AT 2L, SATS > 97%. LUNGS DIMINISHED BASES ? CRACKLES LLL. EUPNEIC.\n\nCV: ATRIAL FLUTTER TO PACED RATE 60-65. CCO SWAN VIA RIJ CORDIS, CI 1.8-2.4, SVO2 65-70, MV02 67. BP'S MONITORED VIA L FEM ALINE, GOOD WAVE FORM. PEDAL PULSES DOPPLED. DECREASED TO 850 UNITS/HR AT 0430 FOR PTT 89.7. NATRECOR AT 0.01MCG.\n\nENDO: Q4H FSBS WITH HUMALOG INSULIN COVERAGE.\n\nGI: ABDOMEN SOFT, + BS. TAKNG CLEAR LIQUIDS, COUGHS SOMETIMES WITH DRINKING.\n\nGU: FOLEY TO CD DRAINING QS AMTS URINE. LASIX DC'D AT 2100. DIURIL 500MG IV AT 2400.\n\nSOCIAL: DAUGHTER CALLED IN FOR UPDATE. ASKING TO TALK ON THE PHONE WITH HER MOTHER ABOUT SOME \"EXTREMELY IMPORTANT LEGAL ISSUES.\". THAT PT IS TOO WEAK TO TALK AT THIS TIME.\n\nPLAN: VENOUS ACCESS TO PLACE PERIHERAL LINE OR PICC TODAY THEN DC CORDIS. COUMADIN DOSING PER INR. WEAN OFF WHEN INR THERAPEUTIC. OOB TO CHAIR. PHYSICAL THERAPY. ? DC NATRECOR TODAY. SOCIAL SERVICE TO FOLLOW PT CLOSELY.\n"},{"category":"Nursing/other","chartdate":"2155-04-19 00:00:00.000","description":"Report","row_id":1460514,"text":"Respiratory Therapy\n\nPt received from ER orally intubated, on full mechanical support. Continues on A/C ventilation 400*16 +5PEEP 50%. ABG by RRT and MD w/out success. SpO2 90s. ETT #7.5 secure/patent. See resp flowsheet for specific vent settings/data/changes.\n\nPlan: maintain support\n"},{"category":"Nursing/other","chartdate":"2155-05-22 00:00:00.000","description":"Report","row_id":1460571,"text":"NEURO: PT. ALERT, ORIENT X3, OOB TO CHAIR WITH PT, OBEYS COMMANDS.\n\nCV: PT. AV PACED AT RATE OF 60, SBP 120-130, NO ECTOPY NOTED.\n\nRESP: PT. OXYGENATION >95% ON 2LNC. PT. OXYGENATION DECREASE TO 88% WITH REMOVAL OF O2 DURING PIVOT TURN FROM BED TO CHAIR. OXYGENATION IMMEDIATELY PLACED WITH RECOVERY IN O2 SATS.\n\nGI/GU/ENDO: PT. ABD SOFT, +BS, TOLERATING REGULAR DIET, ONE LARGE LOOSE, BROWN BM, +FLATUS, FOLEY DRAINING CLEAR, YELLOW URINE- GOOD U/O. NPH GIVEN THIS AM (20 UNITS)- BLOOD SUGARS TREATED PER PERSONAL SLIDING SCALE.\n\nPAIN: PT. DENIES PAIN.\n\nSOCIAL: PT. DAUGHTER CALLED TODAY- UPDATED.\nPLAN: CONTINUE TO MONITOR RESPIRATORY STATUS, MONITOR FLUID STATUS AND KEEP ON A NEGATIVE FLUID BALANCE, POSSIBLE 2 TOMORROW.\n"},{"category":"Nursing/other","chartdate":"2155-05-22 00:00:00.000","description":"Report","row_id":1460572,"text":" 11a-7p\nneuro: a+o x3, mae, follows commands, up to chair with assist x1, ambulated once around unit without c/o cp, mild sob recovered with rest, perrlaa\n\ncv: v paced/av paced 60-70 no ectopy, sbp 100-134, afeb\n\nresp: lungs clear to upper lobes, fine crackles to bases, is 205-500ml, moderate strength nonproductive cough, 02 sats >95% on 2L nc, 86-88% on RA\n\ngi: positive bowel sounds, tolerating small amounts regular diet, fingersticks ssri, large bm this am\n\ngu: foley to gravity draining uop>30ml/hr, good reaction to lasix\n\nassess: stable\n\nplan: pulmonary toilet, increase activity, continue diuresis, transfer to 2 tomorrow\n"},{"category":"Nursing/other","chartdate":"2155-05-23 00:00:00.000","description":"Report","row_id":1460573,"text":"Neuro: A&O x3; calm & cooperative; MAE's, following commands consistently\n\nCV: AV paced/V-paced @ 60; afebrile; SBP 110's-130's, hydralazine given x1; K & Ca repleted; +2 general edema on LE bilat, TEDs on; palpable pulses x4\n\nResp: Lung sound clear, fine crackles @ bases; non-productive cough; 2L NC, sat 98%\n\nGI: Tolerating PO diet; abd soft, non-tender, +bowel sound; +flatus\n\nGU: Foley draining clear yellow urine; good diuresis with metolazone & lasix\n\nInteg: see carevue\n\nPain: denies pain\n\nSocial: no calls from family\n\nPlan: monitor hemodynamics & resp status; pulm toilet; monitor I&O, keep -; transfer to 2 in AM\n"},{"category":"Nursing/other","chartdate":"2155-05-21 00:00:00.000","description":"Report","row_id":1460568,"text":"Neuro: alert and oriented, pleasant\nCV: NSR, PR .28 60's. NTG weaned off. BP <130. Palp pulses. Cont on Natrecor. Pitting pedal edema, teds on. COumadin on hold due to high INR\nResp: Lungs decreased bases rt>lt. Scattered crackles. Sats>97% , O2 decreased to 2l. Pt denies SOB\nGI: +BS, no bm. No nausea. Tolerating reg diet.\nGU: DIuresisng 100-200cc/hr after zaroxyln, lasix, and aldactone. foley patent\nEndo: Bs elevated. Covered with ssr, NPH this am\nAct: OOB to ch without difficulty\nPlan: Cont assess cardio/resp status. Cont aggressive diuresis. Increase activity and wean o2 as tol\n\n"},{"category":"Nursing/other","chartdate":"2155-05-21 00:00:00.000","description":"Report","row_id":1460569,"text":" 7a-7p\nneuro: pleasant, a+o x3, mae, follows commands, up to chair with assist x2, steady on feet, very drowsy today, fell asleep in chair, fell asleep once returned to bed, good assist with turns, no c/o pain\n\ncv: sr/av paced intermittently, sbp 112-131, captopril dose 50mg tid now 75mg tid (tell team if sbp drops below 110, goal sbp 110-120), afeb\n\nresp: crackles to bases bilaterally, clear uppers, 02 sats >94% on 2l nc, is 250-500ml, moderate strength cough productive of thick yellow sputum\n\ngi: positive bowel sounds, tolerating small amounts regular diet, ssri and fixed dose increased today for fingersticks in the 200s, restarted glyburide\n\ngu: foley to gravity draining light amber urine, good uop on bnp with lasix ivp and metolazone po, (bnp now d/ced)\n\nassess: stable\n\nplan: goal sbp 112-131, transfer to 2 tomorrow if bp and respiratory stable overnight, increase activity, pulmonary toilet\n"},{"category":"Nursing/other","chartdate":"2155-05-22 00:00:00.000","description":"Report","row_id":1460570,"text":" nursing update\nsystolic elevated to high 140s despite increase in captopril to 75 tid, lopressor 5mg iv given md with minimal response, hydralazine 10mg iv given with good effect. AVpaced 60/NSR low 60s, no ectopy seen. INR remained elevated to 4, medics aware. saturating >95% on 2l/nc, desats to low 90s on air. no signs of resp distress, lungs clear, with scattered crackles at both bases. non productive cough, still unable to raise IS for >500mls. neuro intact, turns independently/ or minimal support. pleasant and cooperative, no complaints of pain, slept well overnight. no problems swallowing, glucose dropped to 57, and improved to 121 after o.j. ~200cc. on lasix and spironolactone for diuresis, no bowel movements. rashes at perineal areas and inner thighs improving, miconazole continued. all procedures explained, no phone calls from rels. overnight\n\nplan: keep sbp 100-120mmhg, ? increase captopril further\n ^diets and activity as tolerated\n cont plan of care\n ?transfer to \n"},{"category":"Nursing/other","chartdate":"2155-05-06 00:00:00.000","description":"Report","row_id":1460530,"text":"Nursing\nNeuro: A&Ox3. OOB to chair x3hrs w/2 assist. IVP morphine and po percocet for c/o incisional pain.\n\nCV: Initally nsr w/freq pacs- ivb mag admin. Nitro gtt for hypertension. PO lopressor & IV hydralazine started, nitro gtt off. Goal sbp <130. bradycardic to 50s. NP aware. HCT stable. A's wires don't sense. Pacer box set @ VVI 40. Epi gtt weaned off with CI>2, svo2s 60s- swan dc'd. CT dc'd. CXR done.\n\nResp: Extub in am. Weaned from FT to 2L NC. Sat 98-100%. Lungs cta, dim in bases. Expectorated lg amts thick sputum. Uses IS to 500cc with encouragement.\n\nGi: Tol clear liqs. Hypo bowel sounds. No c/o n/v.\nGu: Started ivp lasix. +diuresis. adequate huo.\nEndo: Titrating insulin gtt. Pt type I DM, not taking adequate POs.\nSkin: Intact. See carevue for incisions.\n\nSocial: SW has long history following pt for concerns at home- see SW note. informed of pt and is collaborating w/SW from previous unit. Daughter called and updated by RN w/pt's permission. Daughter stated on phone she would visit this afternoon.\n\nPlan: BP management. Pulm toilet. Pain management. Advance diet & exercise. ?F2 in am. F/U w/social work.\n"},{"category":"Nursing/other","chartdate":"2155-05-07 00:00:00.000","description":"Report","row_id":1460531,"text":"NEURO: PT. ALERT, ORIENT X3, MAE, OBEYS COMMANDS.\n\nCV: PT. NSR, RARE PAC'S NOTED, RARE PVC'S NOTED, HR 70'S, SBP 95-120, PACER CHECKED AND V WIRES SENSE/CAPTURE. PACER ON VDEMAND RATE OF 40. PT. HR DIPS INTO LOW 50'S-TEAM AWARE. PO LOPRESSOR GIVEN AND TOLERATED BY PATIENT.\n\nRESP: PT. LUNGS CTA, DIMINISHED IN LOWER LOBES, OXYGENATION 98-100% ON 2LNC, +COUGH, NO EXPECTORATION.\n\nGI/GU/ENDO: PT. ABD SOFT, HYPOACTIVE BOWEL SOUNDS, TOLERATING CLEAR LIQUIDS, FOLEY DRAINING CLEAR, YELLOW URINE- 20MG IV LASIX GIVEN AT 2400 WITH SMALL RESPONSE IN U/O. LYTES REPLETED. U/O CURRENTLY IS MARGINAL-PA NILLSON NOTIFIED. INSULIN GTT DC/D IN AM- BLOOD SUGARS TREATED PER RISS.\n\nPAIN: PT. C/O INCISIONAL PAIN- 2 PERCOCET GIVEN AND TOLERATED.\n\nPLAN: 2?, MONITOR SBP AND HR, CONTINUE VDEMAND, ANTICOAGULATION?, PULMONARY HYGIENE.\n"},{"category":"Nursing/other","chartdate":"2155-05-05 00:00:00.000","description":"Report","row_id":1460527,"text":"Nursing\nPMH: MI, CABG w/occluded vein grafts, PCTA, stents. Type I DM. CRI (baseline 1.2). S/P Redo sternotomy & MVR, mechanical valve. Report received from anesthesia. Post EF 30%, ^RV hypokinesis, epi gtt was started coming off pump, increased in OR. 2 FFP admin by anesthesia for INR 3.1. Poor PIV access, trouble placing PA line pre-op, able to place CCO swan post-op. Fem a-line. Arrived in csru AV paced, hypothermic-> bair hugger applied.\n\nReceived on epi, prop, insulin & neo gtt. Neo switched to nitro in CSRU. Reverse T- and increase in prop gtt to keep SBP <110 MD . IVP morphine & increased nitro for ^SBP. CI 1.8, fluid bolus admin- PADs and CVPs low 20s. CI remained <2, 1 prbcs ordered. Mixed venous O2 sat 77%, fluid infusing. ACT 150, 50mg protamine. Peep increased to 10 NP . Min-mod serosang CT output. Slight serosang oozing on sternal dsd. AV asychronous pacing paused. Underlying rhythm afib 70-90s. Amio bolus ordered, held d/t brief spontaneous junctional 50s. Cont afib. A wires don't capture per anesthesia, Vs work. Received on 100% fio2, weaned to 50%. Peep remains 10. Vent RR increased for resp acidosis. Insulin gtt increased for blood sugars 130s. Creat 0.8, will replete K+.\n\nPlan: Keep sedated MD . Attempt neuro check & resedate. Maintain SBP <110.\n"},{"category":"Nursing/other","chartdate":"2155-05-06 00:00:00.000","description":"Report","row_id":1460528,"text":"Resp Care Note:\n\nPt cont intub with OETT and on mech vent as per Carevue. Lung sounds coarse improve with suct mod th off white sput. ABGs stable on SIMV; sedation off switched to PSV; will repeat ABG. Cont wean PSV and extub today.\n"},{"category":"Nursing/other","chartdate":"2155-05-20 00:00:00.000","description":"Report","row_id":1460564,"text":" nursing update\nVpaced overnight, continued on captopril and lopressor. distal pulses palpable, +2 edema to both LE. verbalized laboured breathing, crackles to both lower bases, extra dose of lasix 40mg given with good effect, pt verbalized breathing much better. coughing out thick tan secretions, but pt only able to raise IS up to <500 even with much encouragement. sats 97% and better allthroughout, RR eupnic. neuro intact, 1 assist to getting oob. bld glucose covered with s/s humalog, not on lantus, medics aware. on lasix 80mg iv bid, diuresis adequate but not excessive, kcl 20meqs given. no bowel movement but passing gas. pressure areas unchanged, rashes to perineal areas and both inner thighs kept dry, miconazole applied\n\nplan: ? lantus fixed dose\n pulmonary toilet\n ^diets/activity as tolerated\n monitor uop\n cont plan of care\n"},{"category":"Nursing/other","chartdate":"2155-05-20 00:00:00.000","description":"Report","row_id":1460565,"text":"Resp Care\n\nPt was placed on NIV while in pulmonary edema. Tolerated well. While on NIV rr and wob decreased\n"},{"category":"Nursing/other","chartdate":"2155-05-20 00:00:00.000","description":"Report","row_id":1460566,"text":"NEURO: Alert, awake, oriented x3, transfer to chair/commode/bed with 2 person assist, denies any pain\n\nRESP: Pt had SOB with RR in 40s at 1300, lung sounds crackles throughout, Sats low 90s, placed ventilator with mask, diuresed with 100mg Lasix/5mg Metolazone, also given 2mg Morphine, restarted 0.01mcg/kg Nesiritide at 1700 with 75mcg bolus\n\nCV: Vpaced to NSR, Cardiology consulted to reeval pacer, EKG done shows p waves, HR in 60s, during SOB episode, SBP rose to 170s, started on Nitro drip (currently at 2.0mcg), increased Captopril, Lasix, restarted Nesiritide, pedal pulses palpable, +3 pitting edema on lower EXTs, INR was 4.3 this AM, no Coumadin given\n\nGI/GU: Tolerating reg diet & PO meds, abd soft, + BS, large formed/brown stools, along with SOB episode c/o nausea which resolved itself; Foley in place draining yellow/clear urine, on increased Lasix/Nesiritide, repleted K.\n\nENDO: Started on NPH (breakfast/bedtime) & SSRI\n\nSOCIAL: Daughter/sister called and updated on status/plan of care\n\nPLAN: Continue to monitor resp, cv, urine outputs, LABS, increase activity as tolerated, monitor I/Os\n"},{"category":"Nursing/other","chartdate":"2155-05-21 00:00:00.000","description":"Report","row_id":1460567,"text":"7P-7A\nNEURO: A/OX3. PERRLA. MAE. PLEASANT AND COOPERATIVE WITH NURSING CARE. NO C/O PAIN. AFEBRILE.\n\nCV: NSR 60-70S. NO ECTOPY NOTED. LYTES PRN. NTG CONTINUES TO MAINTAIN SBP<140. TOLERATING PO METOPROLOL, CAPTOPRIL, AMIO. PALPABLE PULSES BILAT. +2 BILAT LE PITTING EDEMA. NESIRITIDE CONTINUES @ 0.010MCG/KG/MIN. INR 5.4 PA AWARE.\n\nRESP: FAINT CRACKLES AT BASE, CLEAR OTHERWISE. 02SAT >96% 3L NC.\n\nGU/GI: FOLEY TO GRAVITY WITH MARGINAL HUO. IV LASIX, PO METOLAZONE WITH (+)DIURESIS. ABD SNT (+)HYPOACTIVE BS. PPI FOR GI PROPHYLAXIS.\n\nSEE CAREVUE FOR SKIN ASSESSMENT\n\nENDO: ELEVATED GLUCOSE LEVELS CONTINUE. COVERAGE PER ORDERED RISS AND NPH QAM/QPM.\n\nPLAN: CONTINUE BP MANAGEMENT. MONITOR INR. CONTINUE DIURESING. PULMONARY TOILET. ? START LANTUS\n"},{"category":"Nursing/other","chartdate":"2155-05-06 00:00:00.000","description":"Report","row_id":1460529,"text":"Neuro) Pt. kept lightly sedated overnight with one attempt at waking pt. at 2330 whereby pt. opened eyes but then became hypertensive to SBP 140-160's. Pt. did not have a gag or cough at that time. Re-sedated with Propofol until ~ 0400 when pt. awakend calmly off Propofol and able to follow commands and MAE.\n\nCV)Nitroglycerin titrated to keep SBP 110 although lower Syst kept MAP in the 50's. Allowed SBP in the 110-120 range as to maintain renal perfusion in view of huo 25cc x1 hour and baseline creat > 1.0.\nEpi weaned as CI maintained >2.0. SvO2 71% when machine recal.Apaced due to infrequent episodes of nodal rhtyhm.\n\nPulm) vent weaned to CPAP this morning with slow IPS wean from 15. All ABG's wnl.\n\nGI) bile from OGT. Tol clamping well.\n\nGU) adequate HUO.\n\nEndocrine) insulin on and titrated to protocol.\n\nHeme) stable HCT after one prbc given for CI <2.0.\n\nPlan) extubate this morning. Monitor SBP ~110. Insulin protocol and wean epi as tol by hemodynamics.\n\n"},{"category":"Nursing/other","chartdate":"2155-05-08 00:00:00.000","description":"Report","row_id":1460535,"text":"Shift update\nNeuro: Pt alert and oriented x3, c/o being tired, NP aware. Perrla. MAE. Denies the need for pain med at this time, see carevue.\n\nCV: HR 48-50s CHB, NP aware, keep pt w/ own intrisinic rate. Backup V pace 40s, sense and capture appropriately. SBP 130-140s/ 20-30s, NP aware of diastolic, see carevue. Hydralazine to continue NP . Sternal dsg cdi. + palpable pulses.\n\nResp: LS clear diminished. Sats >98%. Encouraged IS and coughing and deep breathing. Denies CP/SOB.\n\nGI/GU: Abd soft, +flatus per pt. +BS. Tolerating po's ate 3/4th of breakfast. Foley draining clear yellow 20-80cc/hr. Lasix 80mg ivp given at 0830. ? increase pm dose per team during am rounds.\n\nEndo: BS 91 this am, ok to give NPH 20units sc and glipizide 10mg po NP , pt ate 3/4th of breakfast (corn muffin, yogurt,hot cocoa and coffee). Continue monitor BS.\n\nPlan: Monitor hemodynamics. Monitor resp. status. Pain control. Follow BS.\n\n\n\n"},{"category":"Nursing/other","chartdate":"2155-05-08 00:00:00.000","description":"Report","row_id":1460536,"text":"Neuro: A&O x3, calm & cooperative, MAE's, following commands consistently; anxious with activities, calm with instructions & reassurance\n\nCV: Afebrile; CHB 50's, pacer set @ back-up VVI @ 30 NP ; SBP 140, NP awared, tolerating PO hydralazine 25 mg q6 hours; Am hct 26, type and screeen sent, will trnasfuse 1 unit PRBC when product is ready, only have 2 22g , one is due to change , do not pull NP, will get new by NP ; EP following\n\nResp: Lung sound clear, fine crackles @ bases; non-productive cough; O2 weaned to RA, sat 94%\n\nGI: Abd soft, non-tender, bowel sound x4, +flatus; tolerating diet\n\nGU: Foley drainig clear yellow/amber urine; UO tapering off, NP awared, give lasix after transfusion\n\nInteg: Intact, c/o itciness on back & arms, sarna lotion applied with good efect\n\nPain: denies pain\n\nEndo: 1200 BG BG 291, NP awared, revised sliding scale and AM NPH regimen\n\nSocial: family in for visit\n\nPlan: monitor hemodynamics, resp status & lab; get new access tomorrow; pulm toilet; monitor BG\n"},{"category":"Nursing/other","chartdate":"2155-05-12 00:00:00.000","description":"Report","row_id":1460545,"text":"NEURO: alert, oriented. following commands. moves well- transfered chair to bed with x1 assist. very fatigued with minimal exertion. no pain control issues.\nCV: complete heart block 40's-50. period of nsr 60's. hypertensive at all times. SBP 150's. with exertion sbp up to 170's, resolved with 5 min. rest. ntg paste applied with good result. epicardial wires v wires sense and pace. set to v demand 35.\nRESP:lungs clear bilat. no O2 requirement. some exertional wheezes, resolve on own.\nGI/GU: abd soft, +bowel sounds. tolerating PB and crackers snack. NPO p midnoc. foley with clear yellow urine.\nENDO: blood glucose wnl. no RISS/PO coverage d/t NPO.\nSKIN: sternal incision approximated, small amount old apearing sang drainage from incision. dsd changed. chest tube site cdi, dsd changed. pressure points intact. sarna lotion to back.\nA/P: continue to monitor cv, resp, lytes and blood glucose. NPO for pacer today. ?transfer to floor p pacer.\n"},{"category":"Nursing/other","chartdate":"2155-05-12 00:00:00.000","description":"Report","row_id":1460546,"text":"See transfer note for details.\n\nPlan: perm pacer placement tomorrow AM, 1/2 dose NPH in AM, NPO after midnight; ambulated ~30ft x1, brief episodes of DOE, resolved with rest\n"},{"category":"Nursing/other","chartdate":"2155-05-12 00:00:00.000","description":"Report","row_id":1460547,"text":"Foley DC'd @ 1800, DTV 0200\n"},{"category":"Nursing/other","chartdate":"2155-05-13 00:00:00.000","description":"Report","row_id":1460548,"text":"NEURO- A&O X3. PLEASANT &COOPERATIVE WITH CARE.MINIMAL ASSIST WITH CARE.\n\nCV- CONTINUES IN CHB WITH PAC'S RATE CONTROLLED. INCREASING AMOUNT OF PVC'S THIS AM WITH NO CHANGE IN RATE. UNABLE TO DRAW LABS TO DIFFICULTY WITH VENOUS STATUS. DEFIB PADS IN PLACE.EPICARDIAL WIRES SENSE AND CAPTURE. DOE BUT TOLERABLE IF TASKS TAKEN IN STEPS.\n\nRESP- LSC. RA=96%. DOE.\n\nGI- ABD SOFT. +BS.MEDIUM LOOSE STOOL THIS AM. NPO AFTER MN FOR PROCEDURE IN AM.\n\nGU-VOIDED X2 AFTER FOLEY DCD. URINE VERY ODIFEROUS. PERI AREA RED WITH YEAST PRESENT.\n\nNO LABS DRAWN THIS AM. NO C/O PAIN.\n\n PT TO HAVE PPM PLACED TODAY. KEEP NPO UNTIL THEN. CONTINUE TO MONITOR CHB. BEGIN P/O TEACHING WITH DISCHARGE PLANNING.\n"},{"category":"Nursing/other","chartdate":"2155-05-15 00:00:00.000","description":"Report","row_id":1460549,"text":" NPN\nPT W/ RESP DISTRESS AND INTUBATION ON 2. FAMILY UPDATED BY PA. IN , PT SEDATE ON PROPOFOL. TEAM AT BEDSIDE. SWAN LINE PLACED AND AT PRESENT FEM ART LINE ATTEMPTS. VSS/HEMOS STABLE AS PER FLOWSHEET. + EDEMA NOTED. MD UPDATED BY NP. NO NEW ISSUES, AWAITING ABG RESULTS. GLUCOSE ELEVATED.\nASSESS: STABLE POST INTUBATION.\nPLAN: ART LINE INSERT, OBTAIN LABS. INSULIN GTT. DIURESIS. BEGIN NATRECOR.\n\n"},{"category":"Nursing/other","chartdate":"2155-05-15 00:00:00.000","description":"Report","row_id":1460550,"text":"Resp CAre\nPt intubated on floor for resp distress then transfered to . Pt has #7.5 ETT 21@lip. BLBS course, suctioned for mod amt of thick pale yellow secretions. Pt currently on A/C, no abgs since intubation MDs currently placing a-line. Plan to obtain abg and wean vent settings as tolerated.\n"},{"category":"Nursing/other","chartdate":"2155-05-07 00:00:00.000","description":"Report","row_id":1460532,"text":"7am-7pm update\nneuro: pt alert and orientated x3. MAE and able to follow commands.\n\nCV: pt initally 1st degree AV block with occasional PAC's noted. around 9 am the pt had 1 breif episode of CHB -> BP stable -> team aware -> lopressor dc'd. pt went back into 1st degree av block. around 1pm the pt went back into CHB and has stayed in CBH since. ventricular rate in the 60's. EKG done. BP stable. BP 100-130's/20-30's. pt continues on hydralazine for BP control. cardiology following -> ?? need for PPM in future. temp pacer on VVI at 40 (A wires do not capture - team aware). pp by doppler. plavix restarted today.\n\nresp: LS clear, fine crackles noted in RLL this afternoon. pt on 2 L nc, o2 sats > 95%. pt with non productive cough. using IS\n\ngi/gu: pt with + bs. no stool. poor appetite. foley dc'd at 11 am - pt has not voided since. pt on lasix. creatinine 1.2 this am (pt with history of chronic renal failure)\n\nendo: pt on insulin gtt at 3 u/hr this am -> pt given 6 units of reg insulin + 12 NPH (as ordered and gtt was dc'd 1 hr later). glusoce 2 hrs later was 275 -> pt given 12 units reg insulin and 5 mg glipizide PO. glucose 2 hrs later was 237 -> pt given 9 units reg insulin SC. bs 2 hrs later was 288 -> pt restarted on insulin gtt per team. plan to continue on insulin gtt and given NPH and glipizide in addition to inuslin gtt. team increasing NPH dose\n\nactivity/comfort: pt given percocets for pain control. pt oob to chair with 2 assist.\n\nsocial: social work following d/t safety issues at home.\n\nplan: monitor rhythm and BP, ?? need for PPM in future, pulm toleit, pain control, monitor glucose levels -> continue insulin gtt, NHP and glipizide, social work continue to follow\n"},{"category":"Nursing/other","chartdate":"2155-05-07 00:00:00.000","description":"Report","row_id":1460533,"text":"update at 1900\n pt had not voided since 11 am (when foley was removed). foley reinserted per . foley re inserted without any issues -> pt put of 150 cc's yellow urine with sediment when catheter inserted. pt also c/o \"itchiness\" on trunk and bil arms -> no rash noted, skin pink in color - team aware -> sarna lotion ordered.\n"},{"category":"Nursing/other","chartdate":"2155-05-08 00:00:00.000","description":"Report","row_id":1460534,"text":"NPN:\n\nNeuro: Alert and oriented X3, MAE with equal strength. Very pleasant and cooperative.\nCV: 50's CHB with stable BP-117-140's/40-60's. Hydralazine for HTN. Pedal pulses palp. Ca repleted.\nResp: Lungs diminished in bases. O2 sats> 98% on 2l nc O2. IS to 750 with direction.\nGI: Abd soft,NT,ND with +BS. No N/V. Tolerating liquids.\nGU: Foley reinserted at 1900pm for 150cc uo. Diuresed with lasix 40 mg IV minimal response so dose increased to 80mg IV bid-given additional 40mg at 22pm with marginal response. Dr aware. Will cont to monitor.\nEndo: Glucoses improved to 126-60. Insulin gtt off and low sugar treated with OJ.\nComfort: Percocet 1 po at 22pm with good effect.\nActivity: Turned side to side with 2 assists.\nIncisions: Sternum and CT -clean and dry-DSD's changed.\nA: With stable CHB -adequate ventricular rate and BP\nP: EPS following, Cont to diurese and observe for return of SR. Replete lytes prn. Pulmonary toilet. Cardiac rehab\n"},{"category":"Nursing/other","chartdate":"2155-05-16 00:00:00.000","description":"Report","row_id":1460551,"text":"NEURO-Sedated on propofol @ 70mcgkgmin but decreased to 50mcgkgmin due to\ndecreasing bp.Continued to be adequately sedated with no hypertensive episodes with stimulation. pt is able to nod head \"yes\" to her name when asked if she can hear us,but is unable to follow any more commands.\n\n Pt has PPM which is a-sensing/v-pacing at rate between 65-75, rare ventricular ectopy. K=3.7-> 20meq kcl iv x1.Hemodynamically unstable with core temp=95.7 ,co/ci=3.5/1.8,hypotensive bp=94/35(53).Bair huggar applied,milrinone bolus with gtt,natrecor bolus with gtt and levophed gtts started. Pt improved hemodynamically but u/o remained scant.Lasix 140mg iv x1 given with minimal oputput. Lasix gtt started @5mg/hr. u/o =45cc/hr.Pt given another 40mg IVP lasix which she diuresed 100cc x1 and continued to have steady u/o.Core temp/Mvo2/co/ci all improved with gtts. (see carevue)\n\nResp-Remained on CMV 40% x00x12x5. Overbreathing by 6-8bpm. sats=99%. ls clear->rhonchorous-> clear. sxing small amt clear thick sputum.\n\nGI-Abd soft with hyperactive bs. ogt-> lcwsx drg thin bilious secretions.\n\nGU/LAB-stated above in CV.\n\nEndo- insulin gtt titrated to glucose levels and protocol. Glucose level decrased to 84, gtt dcd.\n\nI.D.-Pan Cx for hypothermia with poor cardiac function. wbc=11.0 Pt has 2 more days (1dose qd x2d)of vancomycin post pacemaker placement.\n\nPain- No s/s pain seen, pt sedated on propofol gtt.\n\nPlan- TEE TODAY. wean vent settings after. Titrated gtts for maximum support with minimal infusion. monitor cardiac/resp/renal functions.\n\n\n\n\n\n\n\n"},{"category":"Nursing/other","chartdate":"2155-05-16 00:00:00.000","description":"Report","row_id":1460552,"text":"RESP CARE: Pt remains intubated/on vent on settings per carevue flowsheet. No changes overnight. ABGs acceptable with excellent oxygenation.Lungs ess. clear. Sxd early in shift for thick clear secretions. RSBI-31. Wean as tol.\n"},{"category":"Nursing/other","chartdate":"2155-05-16 00:00:00.000","description":"Report","row_id":1460553,"text":"ADDENDUM:\n\nPT 2UPRBC FOR HCT=23.0 POST TRANSFUSION HCT=29.0\n\nTYPOGRAPHICAL ERROR MADE IN RESP SECTION OF NOTE: PT 2 SETTING IS 50%. NOT 00%.\n"},{"category":"Nursing/other","chartdate":"2155-05-16 00:00:00.000","description":"Report","row_id":1460554,"text":"Neuro: Pt sedated on propofol, but arousable. Follows commands and moves all extrem to command. PERRLA. Received extra sedation for TEE, Versed 2mg , morphine 2mg, and propfol boluses.\nCV: HR 70-90's nsr with prolonged PR>.32. EP interrogated pacer, confirmed SR. This am pt with rare AV pacing this am at 60 followed by vpacing now sr with rare PVC. Lopressor iv q4hr. INcreased VEA with faster rate. Milrinone weaned to 0.125mcg to remain there overnight per and to start on ace inhibitor. SVO2>70, CI >2. PA systolic low 50's, CVP low teens. BP 110-150, stable. dopplerable pedal pulses. Temp >36. TEE done showed improved EF of ~40% ( milrinone 0.2mcg) up from yesterday will no MR. started at 1400 at 1000units/hour. Albumin TID. Remains on natrecor at 0.01mcg, no change.\nResp: Lungs clear, slightly dim at base. Sx scant white thick secretions. Weaned vent to CPAP Fio2 40%, sats>98%, abg wnl. To remain intubated overnight per Dr. and may extubate in am if appropriate.\nGI: OGT to LCWS, mod bilious drng. Abd soft, hypoactive BS. Pt denies nausea. OGT replaced post TEE, placement confirmed by auscultation\nGU: Foley patent, urine clear yellow. Adequate uop but not great on lasix 10mg/hr, ranging 30cc-200cc/hr. Team aware. Plan is for pt to be negative as much as possible.\nEndo: BS stable this am off , but now elevate post antibiotics. Attempting SC sliding scale, if necessary will restart .\nSocial: Daughter into see pt, very emotional \"They took my son away from me, and now I am losing my mother\" Emotional support provided. SW who has been following up to see family, spoke with her for 15minutes. Will continue to follow\nPlan: CHeck PTT at , continue assess cardio/resp status. Wean sedation and plan to extubate in am. Continue on natrecor/lasix/milrinone as ordered. Start captoril tonight.\n"},{"category":"Nursing/other","chartdate":"2155-05-16 00:00:00.000","description":"Report","row_id":1460555,"text":"Resp Care\n\nPt remains intubated and currently vented on PSV 10/5 tol well with Vt around 400-500cc and RR in the mid to low 20s. BS essentially clear sxing for minimal secretions. Last ABG WNL with adequate oxygenation on present settings. Will cont with vent support and reassess for further wean with extubation tomorrow morning.\n"},{"category":"Nursing/other","chartdate":"2155-05-17 00:00:00.000","description":"Report","row_id":1460556,"text":"NEURO: SEDATED ON PROPOFOL , AROUSED TO STIMULATION, SQUEEZED MY HANDS AND WIGGLED HER TOES ON COMMAND. EASILY HYPERTENSIVE.\n\nPULM: INTUBATED TO CPAP MODE 40%, PS 10/5 PEEP ALL SHIFT. WILL WEAN PS TO 5 AND WEAN OFF PROPOFOL FOR PLANNED EXTUBATION THIS AM. LUNGS DIMINSIHED BASES, SX'D FOR SCANT AMT THIN WHITE SECRETIONS.\n\nCV: NSR WITH OCC PVC'S, HR 65-80'S. SBP UP TO 160'S AT TIMES, METOPROLOL 5MG IV Q4H, CAPTOPRIL 6.25MG PO Q6H, HYDRALAZINE 2.5MG IV X 2. PEDAL PULSES DOPPLED. CCO SWAN VIA RIJ CORDIS, SVO2'S 70'S-80'S, CI 2.1-3.0. L FEMORAL ALINE WNL. + PERIPHERAL EDEMA.\n\nENDO: BS 152 A 2400, 6 UNITS REGULAR INSULIN SC AT 0030.\n\nGI: ABDOMEN SOFT, HYPOACTIVE BS. OGT TO LCS DRAINING BILIOUS FLUID.\n\nGU: LOW UO AT ONSET OF SHIFT, 500MG IV DIURIL AT WITH GOOD DIURESIS. NEGATIVE ~1.2 LITERS AT 2400.\n\nSOCIAL: DAUGHTER CALLED AT 2200 FOR UPDATE.\n\nPLAN: WEAN AND EXTUBATE THIS AM. CONTINUE DIURESIS. AGGRESSIVE MANAGEMENT OF BP. SOCIAL SERVICE FOLLOWING.\n"},{"category":"Nursing/other","chartdate":"2155-05-08 00:00:00.000","description":"Report","row_id":1460537,"text":"BS CTAB. Remains on 35% trach collar with NAD. Suctioned for moderate amount white secretions with some plugging. Inner cannula changed. Continue to monitor.\n"},{"category":"Nursing/other","chartdate":"2155-05-10 00:00:00.000","description":"Report","row_id":1460542,"text":"See data, MD notes/orders.\nNeuro: A&O x3, follows commands and communicates appropriately. No pain voice when asked.\nCV: Afib with ventricular rate in 50's, VVI temporary pacer wires intact, rate set at 30. BP 136/40.\nPulm: 2Lnc in place, lungs clear, decreased at bases. Pt uses IS q2-3hrs with good effort. 02 sat 99%.\nGU: Uo 5-45cc/hr clear yellow. Furosesemide changed to po dose taken at home with little change in uo.\nGI: Abd soft, bs presetn, formed stool on bsc this afternoon, appetite improving.\nEndo: Ssc with regular insulin along with NPH and glipizide.\nSkin: Surfaces grossly intact. Right index finger with red,inflamed joint, pt states is \"tender to touch\" and has been ongoing x 1 month. MD aware of same. Peripheral pulses palpable.\nAct: Oob several times today, some exertional wheezes audible resolving with rest.\nSoc: No visitors today.\nP: Keep in ICU over weekend with ?of PPM placement on Monday. Keep pt up to date on poc, incr activity as tolerated.\n\n"},{"category":"Nursing/other","chartdate":"2155-05-11 00:00:00.000","description":"Report","row_id":1460543,"text":"NEURO: alert, Ox3. MAE, following commands. moves well in bed. no pain control issues.\nCV: CHB with Vpacing and pvc's. epicardial wires set to VVI 35. SBP 130's-150's. tolerating hydral. and lasix PO. skin warm, dry. DP/PT palp- differ in strength between feet.\nRESP: lungs clear with diminished bases. sats 98-99% 2L nasal cannula. some exertional wheezing on turning in bed, resolves on own no drop in sats. good effort on I/S. cdb done.\nGI/GU: abd soft, +bowel sounds. tolerated PB toast and juice. foley with clear yellow urine, output borderline 30cc/hr most of shift.\nENDO: no glucose coverage with RISS . 2300 blood glucose 51. pt able to take PO's. following snack blood glucose 115.\nSKIN: sternal incision approximated no drainage, mediastinal chest tube site approximated with scant amount of serosang drainage. dsd changed.\nA/P: continue to monitor cv, resp, blood glucose and lytes. continue to advance diet and activity. continue pulm hygiene. plan permanent pacer monday.\n"},{"category":"Nursing/other","chartdate":"2155-05-11 00:00:00.000","description":"Report","row_id":1460544,"text":"UPDATE\nNEURO: PLEASANT, COOPERATIVE. STATES SHE FEELS TIRED EVEN THOUGH SHE SLEPT WELL LAST NIGHT. DENIES PAIN.\n\nACTIVITY: OOB TO CHAIR. AMB APPROX 70 FT USING W/C FOR BALANCE. STARTED OUT @ BRISK PACE BUT SOON TIRED AND HAD TO STOP X 3 TO REST.\n\nCV: SBP @ REST BREAK WHILE STANDING 225. DENIED ANY SX OTHER THAN SOB. BACK TO CHAIR TO REST, SBP DOWN TO 170 AFTER 10 MIN. BP CONT TO REMAIN >160. DR. NOTIFIED AND 1 IN NTP GIVEN IN ADDITION TO USUAL HYDRALAZINE DOSE (LITTLE EFFECT FROM A.M. DOSE). LATEST SBP DOWN TO 155. HR UP TO MAX OF 61 WHILE AMB, OTHERWISE 40'S-50'S, CHB.\n\nRESP: LUNGS CLEAR, DIMINISHED @ BASES. NONPRODUCTIVE COUGH. SPO2 96-97% ON RA.\n\nG.I.: EATING MEALS W/ GD APPETITE. HAD LG, FORMED B.M. ON COMMODE THIS AFTERNOON.\n\nG.U.: ADEQ HUO VIA FOLEY.\n\nENDO: AFTERNOON GLUCOSE DOWN TO 70, PT ASYMPTOMATIC. OJ GIVEN. EVENING NPH AND GLYBURIDE DOSES HELD SINCE PT TO BE NPO AFTER MN FOR PROCEDURE.\n\nSOCIAL: FAMILY IN TO VISIT THIS .\n\nA/P: DOE W/ AMBULATION AFTER MOD DISTANCE. WENT FURTHER THAN YESTERDAY. HYPERTENSION PERSISTS AFTER SUPPLEMENTAL HYDRALAZINE BUT IMPROVED AFTER NTP. NPO AFTER MN FOR PACER PLCMT TOMORROW. PT TO GET IV VANCO ON CALL. CATH LAB TO PLACE LUE IV IF NEEDED.\n"},{"category":"Nursing/other","chartdate":"2155-05-09 00:00:00.000","description":"Report","row_id":1460538,"text":"7p-7a\nneuro: pt alert, oriented x3, acting appropriately, MAE with equal strength, follows commands. speech clear. po percocet given x1 with good effect.\n\ncv: had run of 8 beat v-tach then converted to SR from the complete heart block. remains hypertensive 140-160, prn iv hydralazine added with minimal effect. palpable pulses. v-wires pace and sense, remain set at v-demand at 30; a-wires sense but don't capture.\n\nresp: ls clear bilat, uses is, coughs and deep breathes. o2sats>96%/RA\n\ngi/gu: abd soft, +bowel sounds. no BM, +flatulance. indwelling cath draining clear yellow urine to gravity, diurese with lasix.\n\nendo: pt's sliding scale and fixed dose nph\n\nplan: continue to monitor cv; blood pressure management. continue to advance diet and activity as tolerating.\n"},{"category":"Nursing/other","chartdate":"2155-05-09 00:00:00.000","description":"Report","row_id":1460539,"text":"Neuro: A&O x3, calm & cooperative, MAE's, following commands consistently\n\nCV: T max 100.2, SB 50's till ~1000, back into CHB 50's, SBP 130's-150's, team awared, getting PO hydralazine and IV hydralazine with minimal effect; palpable pulses x4; cardiac echo done, plan to have perm pacer on Mon; 2A 2V wires, pacer set @ back-up VVI 30, V wires sensing & capturing; 500 ml NS bolus given; atrial tracing done\n\nResp: Lung sound clear, dim @ bases, IS ~750, non-productive cough; RA sat 93-95%; c/o SOB @ ~1810, put on 2L NC, sit pt up with improvement\n\nGI: Tolerating diet; abd soft, non-tender, bowel sound x4; +flatus, LBM \n\nGU: Foley draining minimal clear yellow urine, poor diuresis after AM lasix\n\nInteg: Intact\n\nEndo: Cover per sliding scale & fixed dose with oral agents\n\nSocial: Family in for visit\n\nActivity: OOB to chair, ambulated ~25 ft x1\n\nPlan: monitor hemodynamics, resp status; pulm toilet; inc activity as tol; encouraged PO intake\n"},{"category":"Nursing/other","chartdate":"2155-05-09 00:00:00.000","description":"Report","row_id":1460540,"text":"PO hydralazine increased to 50 mg, held PM dose lasix for tonight\n"},{"category":"Nursing/other","chartdate":"2155-05-10 00:00:00.000","description":"Report","row_id":1460541,"text":"CSRU NPN\nSEE CAREVUE FOR DETAILED VS/ASSESSMENTS/INTERVENTIONS.\n\nNEURO: A/O X 3. VERY ANXIOUS/UPSET AT BEGINNING OF SHIFT DURING/AFTER VISIT FROM DAUGHTER & GRANDSON. GIVEN ATIVAN 0.5MG PO W/EFFECT. MAE, REPOSITIONS SELF IN BED.\n\nCV: GOES BETWEEN CHB & 1ST DEGREE AVB W/RATE IN 50S. REMAINS HYPERTENSIVE DESPITE PO & IV PRN HYDRALAZINE. PACER SET TO VVI.\n\nRESP: ON 2LNC, SPO2 AS DOCUMENTED. LUNGS CLEAR W/DIM BASES. BEGINNING TO COUGH UP SECRETIONS.\n\nGI: TOLERATING LIQUIDS/PILLS W/O NAUSEA. PT STATES \"I HAVE NO APPETITE.\" + BS, NO STOOL.\n\nGU: FOLEY PATENT, HUO MARGINAL. SEE CAREVUE.\n\nENDO: HAS OWN ORDERS FOR INSULIN COVERAGE.\n\nSOCIAL: VISITED BY DAUGHTER/GRANDSON AS STATED ABOVE. BECAME ANXIOUS/UPSET DURING AND AFTER VISIT. SOCIAL SERVICES ALREADY INVOLVED.\n\nPLAN: PPM ON MONDAY. B/P MANAGEMENT. PULMONARY HYGEINE. INCREASE ACTIVITY. CONTINUE WITH CSRU PLAN OF CARE.\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2155-05-18 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 956978,\n \"text\": \" 10:42 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Eval. for interval change\\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 71 year old woman s/p Redo-Sternotomy, MVR.\\n\\n REASON FOR THIS EXAMINATION:\\n Eval. for interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST\\n\\n HISTORY: MVR, sternotomy.\\n\\n One view. Comparison with the previous study done . There is\\n continued evidence of mild pulmonary edema and a moderate right and small left\\n pleural effusion. Pleural effusions appeared to have increased somewhat in\\n the interval. The heart appears large as demonstrated previously. The\\n patient is status post median sternotomy, as before. The patient has been\\n extubated and a nasogastric tube has been removed. A bipolar transvenous\\n pacemaker and Swan-Ganz catheter remain in place.\\n\\n IMPRESSION: Mild pulmonary edema. Interval increase in bilateral pleural\\n effusions. No other definite change.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2155-05-20 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 957167,\n \"text\": \" 7:46 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval inf\\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 71 year old woman s/p Redo-Sternotomy, MVR.\\n\\n REASON FOR THIS EXAMINATION:\\n eval inf\\n ______________________________________________________________________________\\n FINAL REPORT\\n PORTABLE CHEST OF \\n\\n COMPARISON: \\n\\n INDICATION: Status post mitral valve replacement.\\n\\n Swan-Ganz catheter has been removed with residual internal jugular vascular\\n sheath terminating in the superior vena cava. Cardiac silhouette is enlarged,\\n but has decreased in size from a recent study. Previously reported pulmonary\\n edema has nearly resolved with mild residual interstitial edema remaining. A\\n moderate right and small left pleural effusions are present. Middle and lower\\n lobe opacities adjacent to right effusion probably reflect atelectasis, but\\n underlying infection should also be considered in the appropriate clinical\\n setting.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2155-05-23 00:00:00.000\",\n \"description\": \"PICC W/O PORT\",\n \"row_id\": 957646,\n \"text\": \" 10:01 AM\\n PICC LINE PLACMENT SCH Clip # \\n Reason: pt. needs double lumen PICC IV RN\\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;SEPSIS\\n Contrast: OPTIRAY Amt: 15\\n ********************************* CPT Codes ********************************\\n * PICC W/O FLUORO GUID PLCT/REPLCT/REMOVE *\\n * US GUID FOR VAS. ACCESS *\\n ****************************************************************************\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 71 year old woman with s/p cabg/mvr\\n REASON FOR THIS EXAMINATION:\\n pt. needs double lumen PICC IV RN\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Needs double lumen PICC for access.\\n\\n The procedure was explained to the patient. A timeout was performed.\\n\\n RADIOLOGISTS: Drs. and Dr. , the attending radiologist,\\n was present and supervising throughout.\\n\\n TECHNIQUE/PROCEDURE: Using sterile technique and local anesthesia, the right\\n brachial vein was punctured under direct ultrasound guidance using\\n micropuncture set. Hard copies of ultrasound images were obtained before and\\n immediately after establishing intravenous access. Peel-away sheath was then\\n placed over a guide wire and a 37 cm double lumen PICC line was then placed\\n through the peel-away sheath with its tip positioned in the SVC under\\n fluoroscopic guidance. Position of the catheter was confirmed by fluoroscopic\\n spot film of the chest. Peel-away sheath and guide wire were removed.\\n Catheter was secured to the skin, flushed, and sterile dressing applied.\\n Patient tolerated the procedure well with no immediate complications.\\n\\n IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided 37 cm double\\n lumen PICC line placement via right brachial approach. Tip positioned in the\\n SVC, line ready for use.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2155-05-26 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 958012,\n \"text\": \" 1:59 PM\\n CHEST (PA & LAT) Clip # \\n Reason: evaluate for effusion\\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 71 year old woman with s/p MVR\\n REASON FOR THIS EXAMINATION:\\n evaluate for effusion\\n ______________________________________________________________________________\\n FINAL REPORT\\n TWO VIEW CHEST of .\\n\\n COMPARISON: .\\n\\n INDICATION: Evaluate for pleural effusion following mitral valve surgery.\\n\\n Right internal jugular vascular sheath has been removed and a right PICC line\\n has been placed with tip terminating in the upper superior vena cava. A\\n permanent pacemaker is unchanged in position, and cardiac and mediastinal\\n contours are stable. Small-to-moderate right pleural effusion has decreased\\n in size, and small left pleural effusion is unchanged. Interstitial edema has\\n nearly resolved.\\n\\n IMPRESSION: Resolving interstitial edema and improving right pleural\\n effusion.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2155-04-19 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 953056,\n \"text\": \" 10:19 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: acute cardiopulmonary process\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 71 year old woman with sob\\n REASON FOR THIS EXAMINATION:\\n acute cardiopulmonary process\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Shortness of breath. Evaluate for acute cardiopulmonary process.\\n\\n COMPARISON: .\\n\\n SUPINE AP CHEST: An endotracheal tube is in place, with the tip approximately\\n 2.9 cm from the carina. The patient is post-CABG, with sternotomy wires\\n unchanged. The superiormost wire is discontinued, as seen on multiple prior\\n exams. There is mild cardiomegaly, which is slightly more apparent than seen\\n on the prior study. There is severe pulmonary edema. There is no pleural\\n effusion or evidence of pneumothorax in this supine patient.\\n\\n IMPRESSION:\\n\\n Severe pulmonary edema. Endotracheal tube in place.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2155-04-23 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 953494,\n \"text\": \" 7:24 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: assess for infiltrate, effusions\\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 71 year old woman with CHF, CAD, intubated for resp distress, extubated\\n yesterday, now with chest pain\\n REASON FOR THIS EXAMINATION:\\n assess for infiltrate, effusions\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: CAD and CHF with chest pain.\\n\\n AP BEDSIDE CHEST. The heart is borderline enlarged with previous CABG. No\\n vascular congestion, consolidations, or effusions. Allowing for technical\\n differences, there is little change from supine exam one day ago.\\n\\n IMPRESSION: No CHF or other acute process.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2155-04-22 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 953333,\n \"text\": \" 1:31 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: assess for infiltrate, effusions, edema\\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 71 year old woman with CHF, CAD, intubated for resp distress, extubated\\n yesterday.\\n REASON FOR THIS EXAMINATION:\\n assess for infiltrate, effusions, edema\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAM: CHF\\n\\n SINGLE AP PORTABLE VIEW CHEST. Compared to prior study performed the day\\n before, mild pulmonary edema has almost completely resolved. There is no\\n pneumothorax or sizable pleural effusion. Cardiac size is top normal. Patient\\n is post median sternotomy and CABG.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2155-04-25 00:00:00.000\",\n \"description\": \"R HAND (AP, LAT & OBLIQUE) RIGHT\",\n \"row_id\": 953856,\n \"text\": \" 5:46 PM\\n HAND (AP, LAT & OBLIQUE) RIGHT Clip # \\n Reason: evaluate for changes suggestive of osteomyelitis\\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 71 year old woman with right middle finger DIP swelling\\n REASON FOR THIS EXAMINATION:\\n evaluate for changes suggestive of osteomyelitis\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Right middle finger DIP swelling, evaluate for osteomyelitis.\\n\\n No prior examinations.\\n\\n RIGHT HAND, THREE VIEWS: Extensive osteoarthritic changes are seen at the\\n second, third, fourth and fifth DIP as well as the fifth PIP, with joint space\\n narrowing, osteophyte formation and subchondral sclerosis. On the lateral\\n view, it appears there is near fusion of the second and fourth DIPs. At the\\n third DIP, in the region of the patient's swelling, there is no evidence of\\n cortical destruction or periosteal reaction to suggest osteomyelitis. A tiny\\n soft tissue calcification is noted dorsal to the third distal phalanyx . No\\n radiopaque foreign body identified.\\n\\n IMPRESSION: Osteoarthritic changes of the DIPs and fifth PIP. No\\n radiographic evidence of osteomyelitis.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2155-04-20 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 953115,\n \"text\": \" 3:06 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: evaluate for edema, infiltrate\\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 71 year old woman with CHF, CAD, here with resp failure.\\n\\n REASON FOR THIS EXAMINATION:\\n evaluate for edema, infiltrate\\n ______________________________________________________________________________\\n FINAL REPORT\\n PORTABLE SEMI-UPRIGHT CHEST, \\n\\n COMPARISON: .\\n\\n INDICATION: Respiratory failure.\\n\\n Endotracheal tube and nasogastric tube remain in standard position. Allowing\\n for differences in technique, there has not been a substantial change in the\\n appearance of the chest with persistent CHF, bibasilar atelectasis, and small\\n pleural effusions. However, as compared to the earlier radiograph of \\n at 10 a.m., there has been interval improvement in the severity of edema.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2155-04-19 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 953099,\n \"text\": \" 6:30 PM\\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \\n Reason: interval change\\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 71 year old woman with CHF, CAD, here with resp failure.\\n\\n REASON FOR THIS EXAMINATION:\\n interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n PORTABLE CHEST ON AT 18:45\\n\\n INDICATION: Respiratory failure.\\n\\n COMPARISON: \\n\\n FINDINGS: The ETT remains in place. There is much better aeration compared\\n to the prior film and less distension of pulmonary vasculature and diminished\\n interstitial markings. No new focal consolidations are seen. Cardiomegaly\\n persists, and ETT remains in place. There is an NGT with the tip extending\\n below the confines of the film, but clearly below the left hemidiaphragm.\\n\\n IMPRESSION: Improving CHF with some persistence.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2155-04-21 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 953196,\n \"text\": \" 3:09 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Please assess for infiltrates.\\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 71 year old woman with CHF, CAD, here with resp failure.\\n\\n REASON FOR THIS EXAMINATION:\\n Please assess for infiltrates.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: CHF, CAD, and SOB.\\n\\n AP BEDSIDE CHEST. The heart is enlarged with previous sternotomy and apparent\\n CABG. ET and NG tubes are satisfactorily positioned (tip of NG tube not\\n visualized). No overt vascular congestion and no consolidations. Equivocal\\n subsegmental atelectasis at the left base. I doubt the presence of effusions.\\n Since exam one day previous, the vascular congestion and layering pleural\\n effusions have improved and possibly resolved. Lungs remain well inflated and\\n I suspect this patient has underlying emphysema.\\n\\n IMPRESSION: Short interval improvement/resolution of CHF.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2155-05-06 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 955285,\n \"text\": \" 11:23 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: r/o ptx\\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 71 year old woman s/p Redo-Sternotomy, MVR. and ct removal\\n REASON FOR THIS EXAMINATION:\\n r/o ptx\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 71-year-old woman status post redo-sternotomy and chest tube\\n removal.\\n\\n COMPARISON: Study from .\\n\\n PORTABLE AP CHEST RADIOGRAPH: Multiple lines and tubes have been removed.\\n There is a right IJ sheath with the tip in the upper SVC. No pneumothorax is\\n seen. There is stable cardiomegaly. There is mild pulmonary vascular\\n congestion. There is small left pleural effusion and left retrocardiac\\n opacity representing areas of atelectasis and/or consolidation. No\\n pneumothorax.\\n\\n IMPRESSION: Small left pleural effusion and left retrocardiac opacity\\n representing atelectasis and/or consolidation. No pneumothorax. Mild\\n pulmonary vascular congestion.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2155-05-16 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 956726,\n \"text\": \" 10:13 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: evaluate effusion\\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 71 year old woman s/p Redo-Sternotomy, MVR.\\n\\n REASON FOR THIS EXAMINATION:\\n evaluate effusion\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Status post mitral valve repair.\\n\\n PORTABLE CHEST: Multiple lines and tubes are unchanged in position. Dual\\n lead pacemaker overlying the left hemithorax is unchanged in position.\\n Patient is status post sternotomy and valve replacement.\\n\\n Compared to a day prior, there is mild improvement in the degree of pulmonary\\n edema. Layering moderate right pleural effusion appears unchanged. Moderate\\n cardiomegaly again noted.\\n\\n IMPRESSION: Mild improvement in pulmonary edema with persistent moderate\\n layering right pleural effusion and associated atelectasis.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2155-05-15 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 956646,\n \"text\": \" 6:42 PM\\n CHEST PORT. LINE PLACEMENT Clip # \\n Reason: line and ETT placement\\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 71 year old woman s/p Redo-Sternotomy, MVR.\\n\\n REASON FOR THIS EXAMINATION:\\n line and ETT placement\\n ______________________________________________________________________________\\n FINAL REPORT (REVISED)\\n INDICATION: 71-year-old female status post sternotomy revision and mitral\\n valve replacement. Please evaluate line and endotracheal tube placement.\\n\\n FINDINGS: Single portable AP supine radiograph is reviewed and compared to\\n . There has been interval placement of endotracheal tube, which lies\\n 5.5 cm above the carina. There has also been placement of Swan-Ganz catheter,\\n with catheter tip overlying the distal main pulmonary artery. There is no\\n pneumothorax. Moderate cardiomegaly is unchanged. There is perihilar\\n haziness, upper-zone redistribution, and Kerley B lines consistent with mild\\n pulmonary edema. There are small left and moderate right pleural effusions.\\n Note is again made of sternotomy wires and clips representing prior cardiac\\n surgery. There is also a prosthetic mitral valve.\\n\\n IMPRESSION:\\n\\n 1. Status post placement of endotracheal tube and Swan-Ganz catheter. No\\n pneumothorax.\\n\\n 2. Moderate cardiomegaly, with mild pulmonary edema, and small left and\\n moderate right pleural effusions.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2155-05-15 00:00:00.000\",\n \"description\": \"R UNILAT LOWER EXT VEINS RIGHT\",\n \"row_id\": 956605,\n \"text\": \" 2:50 PM\\n UNILAT LOWER EXT VEINS RIGHT Clip # \\n Reason: eval for DVT in pt with new LE edema and new pacer\\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 71 year old woman s/p mitral valve\\n REASON FOR THIS EXAMINATION:\\n eval for DVT in pt with new LE edema and new pacer\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 71-year-old woman with new lower extremity edema.\\n\\n Grayscale and color-flow Doppler images of the right lower extremity were\\n obtained. The right common femoral vein, right superficial vein, right\\n popliteal vein, and greater saphenous vein demonstrate normal compressibility,\\n respiratory varaiation in venous flow, and venous segmentation. The left\\n lower extremity was not assessed since the patient developed severe shortness\\n of breath.\\n\\n IMPRESSION: No deep vein thrombosis in the right lower extremity. The left\\n lower extremity was not assessed due to the patient's severe shortness of\\n breath.\\n\\n These findings were discussed with Dr. at the time of dictation.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2155-04-30 00:00:00.000\",\n \"description\": \"L RIB UNILAT, W/ AP CHEST LEFT\",\n \"row_id\": 954429,\n \"text\": \" 2:14 PM\\n RIB UNILAT, W/ AP CHEST LEFT Clip # \\n Reason: evaluate for rib fracture\\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 71 year old woman with left sided rib pain after trauma to this area\\n REASON FOR THIS EXAMINATION:\\n evaluate for rib fracture\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Pain.\\n\\n Three radiographs of the chest and left ribs demonstrate displaced fracture\\n involving the lateral left seventh rib. There is equivocal evidence of a\\n nondisplaced fracture involving the lateral left eighth rib. The patient is\\n status post CABG. No pneumothorax is detected. There is a moderate\\n left-sided effusion. No consolidation is identified. Trachea is midline.\\n The rib fractures are not evident on the chest radiograph dated ,\\n although assessment is limited by technique of the prior study.\\n\\n IMPRESSION:\\n\\n Left lateral seventh and eighth rib fractures. No pneumothorax.\\n\\n Moderate left-sided pleural effusion.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2155-05-14 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 956373,\n \"text\": \" 9:05 AM\\n CHEST (PA & LAT) Clip # \\n Reason: s/p pacer insertion-check lead placement\\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 71 year old woman with s/p dualc chamber pacemaker implantation\\n\\n REASON FOR THIS EXAMINATION:\\n s/p pacer insertion-check lead placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Evaluate pacemaker lead placement.\\n\\n PA AND LATERAL CHEST: Compared to , a pacemaker has been placed\\n with dual leads appropriately positioned in the right atrium and right\\n ventricle. Patient is status post sternotomy and CABG, and moderate\\n cardiomegaly is unchanged. Pulmonary vasculature is normal. Small bilateral\\n pleural effusions persist and retrocardiac atelectasis continues to resolve.\\n No definite pneumothorax.\\n\\n IMPRESSION: Satisfactory placement of dual lead pacemaker with small\\n bilateral pleural effusions.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2155-05-05 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 955180,\n \"text\": \" 6:21 PM\\n CHEST PORT. LINE PLACEMENT Clip # \\n Reason: r/o PTX/Effusion/Tamponade\\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 71 year old woman s/p Redo-Sternotomy, MVR. Please page at \\n with abnormalities. Pt still in the OR, please perform when in the CSRU.\\n REASON FOR THIS EXAMINATION:\\n r/o PTX/Effusion/Tamponade\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 71-year-old woman with recent surgery. Please rule out\\n pneumothorax, excisional component.\\n\\n Comparisons available from the prior study done on .\\n\\n SINGLE AP VIEW OF THE CHEST:\\n Since the prior study there has been interval placement of the right-sided\\n Swan-Ganz catheter with its tip projecting in the main pulmonary artery. The\\n endotracheal tube tip is projecting at least 5 cm above the carina, in\\n satisfactory position. The NG tube side-port projecs within the stomach. The\\n right-sided chest tube is in the proper position. The heart and mediastinal\\n contours are mildly enlarged which is not an uncommon finding after recent\\n surgery. Note is made of bibasilar increased opacities suggestive of\\n bibasilar atelectasis. Increased interstitial markings likely pulmonary\\n edema.\\n\\n IMPRESSION:\\n 1. Status post placement of endotracheal tube, Swan-Ganz catheter, NG tube\\n and right-sided chest tube in proper position.\\n 2. Mild enlargement in the size of the cardiomediastinal silhouette which is\\n not an uncommon finding after recent thoracic surgery and is suggestive of\\n postsurgical changes.\\n 3. Increased interstitial markings reaching the lung periphery suggestive of\\n pulmonary edema.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2155-05-09 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 955714,\n \"text\": \" 7:39 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: evaluate effusion\\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 71 year old woman s/p Redo-Sternotomy, MVR.\\n REASON FOR THIS EXAMINATION:\\n evaluate effusion\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 71-year-old status post redo sternotomy for MVR.\\n\\n COMPARISONS: .\\n\\n PORTABLE AP CHEST RADIOGRAPH: There is stable change related to prior CABG\\n and stable cardiomegaly. There has been interval removal of a right IJ\\n sheath. There is bibasilar atelectasis. There is partial improvement in left\\n retrocardiac opacity, consistent with improved aeration left lower lobe.\\n There may be small pleural effusion.\\n\\n IMPRESSION: Improved aeration in comparison to prior study. Possible small\\n left pleural effusion.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2155-05-17 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 956862,\n \"text\": \" 7:58 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Eval. for interval change\\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 71 year old woman s/p Redo-Sternotomy, MVR.\\n\\n REASON FOR THIS EXAMINATION:\\n Eval. for interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAM: ST redo sternotomy, MVR.\\n\\n SINGLE AP PORTABLE VIEW OF THE CHEST:.\\n ET tube is in standard position. Swan- Ganz catheter remains in the main\\n pulmonary artery. NG tube tip is out of view below the diaphragm. Left-sided\\n pacemaker leads terminate in standard position in the right atrium and right\\n ventricle. Patient is post median sternotomy and MVR. Compared to prior study\\n moderate right pleural effusion is unchanged. Moderate cardiomegaly is\\n stable. Mild pulmonary edema is stable. Small left pleural effusion is new.\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2155-05-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 94889,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Mitral valve replacement\\nHeight: (in) 64\\nWeight (lb): 163\\nBSA (m2): 1.79 m2\\nBP (mm Hg): 131/32\\nHR (bpm): 63\\nStatus: Inpatient\\nDate/Time: at 15:38\\nTest: TTE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Suboptimal\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT ATRIUM: Elongated LA.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. A catheter or pacing\\nwire is seen in the RA and extending into the RV.\\n\\nLEFT VENTRICLE: Normal LV wall thicknesses and cavity size. Suboptimal\\ntechnical quality, a focal LV wall motion abnormality cannot be fully\\nexcluded.\\n\\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion. Abnormal septal\\nmotion/position.\\n\\nAORTA: Normal aortic diameter at the sinus level. Mildly dilated ascending\\naorta.\\n\\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR.\\n\\nMITRAL VALVE: Bioprosthetic mitral valve prosthesis (MVR). MVR well seated,\\nwith normal leaflet/disc motion and transvalvular gradients. No MR. [Due to\\nacoustic shadowing, the severity of MR may be significantly UNDERestimated.]\\n\\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\\nIndeterminate PA systolic pressure.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\\nphysiologic PR.\\n\\nPERICARDIUM: No pericardial effusion.\\n\\nGENERAL COMMENTS: The patient is in a ventricularly paced rhythm.\\n\\nConclusions:\\nThe left atrium is elongated. The right atrium is moderately dilated. Left\\nventricular wall thicknesses and cavity size are normal. Septal motion is\\ndysnchronous, but the remaining segments appear to contract well. Due to\\nsuboptimal technical quality, a focal wall motion abnormality cannot be fully\\nexcluded. Right ventricular chamber size and free wall motion are normal.\\nThere is abnormal septal motion/position. The ascending aorta is mildly\\ndilated. The aortic valve leaflets (3) are mildly thickened. No aortic valve\\nstenosis is seen. Trace aortic regurgitation is seen. A bioprosthetic mitral\\nvalve prosthesis is present with normal gradient and mobile leaflets. No\\nmitral regurgitation is seen. [Due to acoustic shadowing, the severity of\\nmitral regurgitation may be significantly UNDERestimated.] The pulmonary\\nartery systolic pressure could not be determined. There is no pericardial\\neffusion.\\n\\nCompared with the prior study (images reviewed) of , biventricular\\nsystolic function is improved. The heart rate is also much lower on the\\ncurrent study.\\n\\nCLINICAL IMPLICATIONS:\\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\\nindicate a high risk (prophylaxis strongly recommended). Clinical decisions\\nregarding the need for prophylaxis should be based on clinical and\\nechocardiographic data.\\\"\\n\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2155-05-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 94890,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Mitral valve disease. valve function.\\nHeight: (in) 64\\nWeight (lb): 163\\nBSA (m2): 1.79 m2\\nBP (mm Hg): 105/37\\nHR (bpm): 71\\nStatus: Inpatient\\nDate/Time: at 18:10\\nTest: Portable TEE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nICU nursing staff monitored the patient during the procedure. The patient was\\non a propofol drip and was given an additional 40 mcg of propofol.\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA\\nand extending into the RV.\\n\\nLEFT VENTRICLE: Mild-moderate regional LV systolic dysfunction. Mildly\\ndepressed LVEF.\\n\\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior\\n- akinetic; mid inferior - akinetic;\\n\\nRIGHT VENTRICLE: Paradoxic septal motion consistent with prior cardiac\\nsurgery.\\n\\nAORTA: Complex (>4mm) atheroma in the aortic arch. Complex (>4mm) atheroma in\\nthe descending thoracic aorta.\\n\\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR.\\n\\nMITRAL VALVE: Bioprosthetic mitral valve prosthesis (MVR). Normal MVR\\nleaflets. No mass or vegetation on mitral valve. No MR.\\n\\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.\\n\\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\\nI was present in compliance with HCFA regulations. The patient was monitored\\nby a nurse throughout the procedure. The patient appears to be\\nin sinus rhythm.\\n\\nConclusions:\\nThere is mild to moderate regional left ventricular systolic dysfunction with\\ninferior akinesis and abnormal septal motion (post-op) (ejection fraction\\n?45%). Overall left ventricular systolic function is mildly depressed. There\\nare complex (>4mm) atheroma in the aortic arch. There are complex (>4mm)\\natheroma in the descending thoracic aorta. The aortic valve leaflets (3) are\\nmildly thickened. There is no aortic valve stenosis. Trace aortic\\nregurgitation is seen. A bioprosthetic mitral valve prosthesis is present. The\\n mitral leaflets appear with upper normal gradientsl. No\\nobstruction, mass or vegetation is seen on the mitral valve. No mitral\\nregurgitation is seen.\\n\\n\\nIMPRESSION: Normally functioning bioprosthetic mitral valve. Moderately\\ndepressed EF with inferior akinesis and abnormal septal motion (post-op).\\n\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2155-05-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 94961,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: New pulmonary edema and peripheral edema. Recent MVR and pacer.\\nHeight: (in) 64\\nWeight (lb): 186\\nBSA (m2): 1.90 m2\\nBP (mm Hg): 136/50\\nHR (bpm): 60\\nStatus: Inpatient\\nDate/Time: at 16:44\\nTest: Portable TTE (Focused views)\\nDoppler: Limited Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA\\nand extending into the RV.\\n\\nLEFT VENTRICLE: Severe global LV hypokinesis.\\n\\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion. Paradoxic septal\\nmotion consistent with conduction abnormality/ventricular pacing.\\n\\nAORTIC VALVE: Aortic valve not well seen.\\n\\nMITRAL VALVE: Bioprosthetic mitral valve prosthesis (MVR). Increased MVR\\ngradient. MR present but cannot be quantified.\\n\\nPERICARDIUM: Trivial/physiologic pericardial effusion. There is an anterior\\nspace which most likely represents a fat pad, though a loculated anterior\\npericardial effusion cannot be excluded.\\n\\nConclusions:\\nThere is severe global left ventricular hypokinesis (ejection fraction 20-30\\npercent) (at least partly due to intraventricular contractile dysynchrony).\\nRight ventricular chamber size and free wall motion are normal. The aortic\\nvalve is not well seen. A bioprosthetic mitral valve prosthesis is present.\\nThe gradients are higher than expected for this type of prosthesis. Mitral\\nregurgitation is present but cannot be quantified. There is a\\ntrivial/physiologic pericardial effusion. There is an anterior space which\\nmost likely represents a fat pad.\\n\\nCompared with the findings of the prior study (images reviewed) of , a right ventricular pacing wire is now present, and the left ventricular\\nejection fraction is markedly reduced, with evidence of intraventricular\\nmechanical dysynchrony; consider biventricular pacing to address this problem.\\n\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2155-05-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 94962,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Left ventricular function. H/O cardiac surgery. S/p MVR.\\nHeight: (in) 64\\nWeight (lb): 186\\nBSA (m2): 1.90 m2\\nBP (mm Hg): 157/58\\nHR (bpm): 60\\nStatus: Inpatient\\nDate/Time: at 16:42\\nTest: Portable TTE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Suboptimal\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nThis study was compared to the prior study of .\\n\\n\\nLEFT ATRIUM: Mild LA enlargement.\\n\\nLEFT VENTRICLE: Mild regional LV systolic dysfunction. Mildly depressed LVEF.\\n\\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior\\n- akinetic; mid inferior - akinetic;\\n\\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion. Paradoxic septal\\nmotion consistent with prior cardiac surgery.\\n\\nAORTA: Mildly dilated aortic sinus. Mildly dilated ascending aorta.\\n\\nAORTIC VALVE: Aortic valve not well seen.\\n\\nMITRAL VALVE: Bioprosthetic mitral valve prosthesis (MVR). Increased MVR\\ngradient.\\n\\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal PA\\nsystolic pressure.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\\n\\nPERICARDIUM: No pericardial effusion.\\n\\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\\n\\nConclusions:\\nThe left atrium is mildly dilated. Overall left ventricular systolic function\\nis mildly depresed with inferior hypokinesis (views suboptimal). Right\\nventricular chamber size and free wall motion are normal. The aortic root is\\nmildly dilated at the sinus level. The ascending aorta is mildly dilated. The\\naortic valve is not well seen. There is a mild left ventricular/aortic outflow\\ngradient which is likely due to mild outflow obstruction from the mitral valve\\nprosthesis (outflow gradient was not fully assessed in this study). A\\nbioprosthetic mitral valve prosthesis is present and appears well seated. The\\ngradients are slightly higher than expected for this type of prosthesis. The\\nestimated pulmonary artery systolic pressure is normal. There is no\\npericardial effusion.\\n\\nCompared with the prior study (images reviewed) of , mitral valve has\\nnow been replaced. Elevated aortic/left ventricular outflow velocities are\\nnew. Ventricular function appears similar.\\n\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2155-05-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 94963,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Congestive heart failure. Coronary artery disease. Mitral valve disease. Shortness of breath. Intraop TEE for MVR\\nHeight: (in) 64\\nWeight (lb): 150\\nBSA (m2): 1.73 m2\\nBP (mm Hg): 108/45\\nHR (bpm): 77\\nStatus: Inpatient\\nDate/Time: at 14:01\\nTest: TEE (Complete)\\nDoppler: Limited Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Suboptimal\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA\\nand extending into the RV. No ASD by 2D or color Doppler.\\n\\nLEFT VENTRICLE: Mild-moderate regional LV systolic dysfunction. Moderately\\ndepressed LVEF.\\n\\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal\\nanteroseptal - hypo; mid anteroseptal - hypo; septal apex - hypo; apex - hypo;\\n\\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\\n\\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\\ndiameter. Simple atheroma in ascending aorta. Normal aortic arch diameter.\\nSimple atheroma in aortic arch. Normal descending aorta diameter. Simple\\natheroma in descending aorta.\\n\\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. Mildly thickened\\naortic valve leaflets (3). No AS. No AS. No AR.\\n\\nMITRAL VALVE: Moderately thickened mitral valve leaflets. Moderate mitral\\nannular calcification. Moderate MS (MVA 1.0-1.5cm2) Moderate to severe (3+)\\nMR.\\n\\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\\nphysiologic PR.\\n\\nPERICARDIUM: No pericardial effusion.\\n\\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\\nI was present in compliance with HCFA regulations. No TEE related\\ncomplications. The patient was under general anesthesia throughout the\\nprocedure. The patient appears to be in sinus rhythm. Results were personally\\nreviewed with the MD caring for the patient.\\n\\nConclusions:\\nPRE-BYPASS:\\n\\n1. No atrial septal defect is seen by 2D or color Doppler.\\n\\n2.There is mild to moderate regional left ventricular systolic dysfunction\\nwith mild to moderate hypokinesia of the mid and apical portions of the septum\\nand anterior septum.. Overall left ventricular systolic function is moderately\\ndepressed.\\n\\n3.Right ventricular chamber size and free wall motion are normal.\\n\\n4.There are simple atheroma in the ascending aorta. There are simple atheroma\\nin the aortic arch. There are simple atheroma in the descending thoracic\\naorta.\\n\\n5.The aortic valve leaflets (3) appear structurally normal with good leaflet\\nexcursion and no aortic regurgitation. The aortic valve leaflets (3) are\\nmildly thickened but aortic stenosis is not present. No aortic regurgitation\\nis seen.\\n\\n6.The mitral valve leaflets are moderately thickened. There is moderate mitral\\nstenosis (area 1.0-1.5cm2). Moderate to severe (3+) mitral regurgitation is\\nseen. The posterior leaflet is very restricted. MR jet is posteriorly\\ndirected.\\n\\n7.There is no pericardial effusion.\\n\\nPOST BYPASS\\n\\n1. Patient is being AV paced and receiving an infusion of epinephrine and\\nphenylephrine.\\n\\n2. RV systolic function is moderately depressed.\\n\\n3. LV systolic function is moderately depressed. Anterior wall,septum and\\nanterior septum are moderately depressed.\\n\\n4. Bioprosthetic valve seen in the mitral position. Leaflets open well and the\\nvalve appears well seated. Trace mitral regurgitation present. Mean gradient\\nacross the mitral valve is 5 mm Hg. Prominent struts seen in the LVOT. No\\nsignificant gradient across the LVOT.\\n\\n5. Aorta intact post decannulation.\\n\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2155-04-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 94964,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Left ventricular function. Mitral valve disease. Shortness of breath.\\nWeight (lb): 176\\nBP (mm Hg): 162/52\\nHR (bpm): 71\\nStatus: Inpatient\\nDate/Time: at 11:59\\nTest: Portable TTE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT ATRIUM: Moderate LA enlargement.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\\n\\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Suboptimal\\ntechnical quality, a focal LV wall motion abnormality cannot be fully\\nexcluded. Overall normal LVEF (>55%).\\n\\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior\\n- hypo; mid inferior - hypo; basal inferolateral - hypo; mid inferolateral -\\nhypo; inferior apex - hypo;\\n\\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\\n\\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\\ndiameter.\\n\\nAORTIC VALVE: Mildly thickened aortic valve leaflets. No AS. No AR.\\n\\nMITRAL VALVE: Severely thickened/deformed mitral valve leaflets. Severe mitral\\nannular calcification. Moderate MS (MVA 1.0-1.5cm2) Mild (1+) MR. [Due to\\nacoustic shadowing, the severity of MR may be significantly UNDERestimated.]\\n\\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\\n\\nPERICARDIUM: No pericardial effusion.\\n\\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\\n\\nConclusions:\\nThe left atrium is moderately dilated. There is mild symmetric left\\nventricular hypertrophy. The left ventricular cavity size is normal. Overall\\nleft ventricular systolic function is normal (LVEF>55%). Cannot exclude\\ninferior hypokinesis (views suboptimal). Right ventricular chamber size and\\nfree wall motion are normal. The aortic valve leaflets are mildly thickened.\\nThere is no aortic valve stenosis. No aortic regurgitation is seen. The mitral\\nvalve leaflets are severely thickened/deformed. There is severe mitral annular\\ncalcification. There is moderate mitral stenosis (area 1.0-1.5cm2). Mild (1+)\\nmitral regurgitation is seen. [Due to acoustic shadowing, the severity of\\nmitral regurgitation may be significantly UNDERestimated.] There is no\\npericardial effusion.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2155-05-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 270168,\n \"text\": \"Atrial fibrillation with ventricular rhythm\\nSince previous tracing of , ventricular paced rhythm present\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2155-05-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 270169,\n \"text\": \"Atrial fibrillation with slow ventricular response\\nLeft bundle branch block\\nSince previous tracing of , ventricular response is now irregular with\\nleft bundle branch block configuration\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2155-05-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 270170,\n \"text\": \"Atrial fibrillation with a regular ventricular response suggesting an\\nindependent junctional or idioventricular rhythm with right bundle branch\\nblock/left posterior fascicular block configuration\\nSince previous tracing of , sinus bradycardia and left bundle branch\\nblock now absent\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2155-05-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 270171,\n \"text\": \"Sinus bradycardia. Intraventricular conduction delay of the left bundle-branch\\nblock variety. Secondary ST-T wave abnormalities. Compared to the previous\\ntracing of no change.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2155-05-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 270172,\n \"text\": \"Sinus bradycardia. P-R interval 0.18. Since the previous tracing of the\\nrate has slowed and T waves are inverted in leads III and aVF, which may be\\nconsistent with inferior myocardial infarction in the presence of left\\nbundle-branch block. One ventricular premature beat is noted.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2155-05-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 270173,\n \"text\": \"Sinus rhythm with first degree A-V block. Left bundle-branch block. Since the\\nprevious tracing of the rate is increased but no other changes have\\noccurred.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2155-04-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 270174,\n \"text\": \"Sinus rhythm. Consider left atrial abnormality. Left bundle-branch block.\\nCompared to the previous tracing no change.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2155-05-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 270166,\n \"text\": \"Normal sinus rhythm with marked A-V conduction delay. Left bundle-branch block.\\nLeft atrial abnormality. Occasional premature ventricular contractions.\\nCompared to tracing #1 no diagnostic interim change.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2155-05-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 270167,\n \"text\": \"Atrial fibrillation\\nIntermittent ventricular premature beats\\nLeft bundle branch block\\nSince previous tracing of , ventricular pacing intermittent\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2155-04-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 270175,\n \"text\": \"Sinus bradycardia. Consider left atrial abnormality. Left bundle-branch block.\\nSince the previous tracing no change.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2155-04-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 270176,\n \"text\": \"Baseline artifact. Sinus rhythm. Leftward axis. Left bundle-branch block. Since\\nthe previous tracing of the rate has decreased. ST-T wave abnormalities\\nare less.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2155-04-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 270177,\n \"text\": \"Sinus rhythm\\nLeft atrial abnormality\\nLeft bundle branch block\\nSince previous tracing of , ST-T wave changes less prominent and Q-Tc\\ninterval appears shorter\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2155-04-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 270178,\n \"text\": \"Baseline artifact. Probable sinus rhythm. Left axis deviation. Left anterior\\nfascicular block. Left bundle-branch block type. Q-T interval prolongation.\\nSince the previous tracing of the precordial T wave inversions are more\\nprominent. Clinical correlation is suggested.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2155-04-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 270179,\n \"text\": \"Sinus rhythm. Sinus rhythm. Compared to tracing #2 the heart rate has\\nsignificantly normalized.\\nTRACING #3\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2155-04-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 270180,\n \"text\": \"Sinus tachycardia. Occasional atrial premature beats. Compared to tracing #1\\nthe heart rate hias decreased but significant tachycardia persists. Clinical\\ncorrelation is suggested.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2155-04-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 270181,\n \"text\": \"Sinus tachycardia. Left atrial abnormality. Left axis deviation. Left\\nbundle-branch block. Compared to the previous tracing of the heart rate\\nhas significantly increased. Clinical correlation is suggested.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2155-05-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 273792,\n \"text\": \"Right may be sinus with marked left atrial abnormality and first degree\\nA-V delay. Consider ectopic atrial rhythm. Left bundle-branch block. Since the\\nprevious tracing of the rate is slower and the intraventricular\\nconduction delay and ST-T wave abnormalities are less prominent.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2155-05-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 273793,\n \"text\": \"Regular rhythm, mechanism uncertain, may be sinus or ectopic atrial rhythm with\\nfirst degree A-V delay. Left bundle-branch block. Since the previous tracing\\nof the rate is faster.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2155-05-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 273794,\n \"text\": \"Sinus rhythm. A-V conduction delay. Left bundle-branch block. Compared to the\\nprevious tracing of ventricular ectopy is absent and the rate has\\nslowed. Otherwise, no diagnostic interim change.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2155-05-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 273795,\n \"text\": \"Sinus tachycardia. Left bundle-branch block and secondary ST-T wave\\nabnormalities. Compared to the previous tracing of atrial fibrillation\\nis no longer present.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2155-05-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1460561,\n \"text\": \"Neuro: A&O x3; sleepy @ beginning of shift, dozing on & off, more awake in PM; MAE's; follow commands consistently\\n\\nCV: Underlying atrial flutter with V-paced beats @ 60 by perm pacer; SBP 100's-130's; tolerating captopril & lopressor; SvO2 >65, CO decreased from 3.9 to 3.3 in PM, MD , CCO recaled, mixed venous 70 per careweb, fick CI 2.99, OK to pulled swan per Dr ; natrecor infusing @ 0.01 mcg/kg/min; changed to 750 units/hr @ 1100, evening PTT result pending; R fem a line DC'd, pressure applied for 15 minutes until hemostasis attained; new 20g placed on R wrist\\n\\nResp: Lung clear, slight crackles @ bases; 2L NC sat 98%; non-productive cough\\n\\nGI: Tolerating clear liquids & pills; +bowel sound\\n\\nGU: Foley draining clear yellow urine, 30-45 ml/hr; will not start MD and will let pt self diurese first, pt is \\\"dry\\\" MD \\n\\nInteg: Intact\\n\\nPain: Denies pain\\n\\nEndo: Cover per humalog sliding scale; q4h BG\\n\\nSocial: Multiple calls from daughter, stating needs to talk about extremely important issues with patient, explained patient is in intesive care unit and needed rest & phone is not accessible in room; ex-husband in for visit withoout calling @ door; only voisitor allowed is daughter per patient\\n\\nPlan: moniotr hemodynamics, resp status & labs; get OOB/sit up in bed after 6 hrs (2300) post fem a line removal; monitor renal status & UO; advanced diet as tol; inc activity as tol; social services follow up\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2155-05-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1460562,\n \"text\": \"NEURO: A&O X 3, MAE, FOLLOWS COMMANDS, COOPERATIVE WITH CARE.\\n\\nPULM: N/C AT 2L, SATS > 98%. LUNGS CRACKLEY IN BASES.\\n\\nCV: V PACED AT 60 ALL SHIFT, UNDERLYING RHYTHM ATRIAL FLUTTER. AT 750 UNITS/HR UNTIL 0630 WHEN PTT 91.4, PT 22.0/INR 2.2. NATRECOR CONTINUOUS AT 0.01MCG. PEDAL PULSES PALPATED. + PERIPHERAL EDEMA. TOLERATING LOPRESSOR AND CAPTOPRIL.\\n\\nENDO: Q4H BS WITH HUMALOG INSULIN SLIDING SCALE COVERAGE.\\n\\nGI: ABDOMEN SOFT, + BS. NO BM.\\n\\nGU: FOLEY TO CD DRAINING MARGINAL HOURLY AMBER URINE. MD AWARE. WEIGHT UP 0.5KG.\\n\\nSOCIAL: NO VISITORS OR PHONE INQUIRIES.\\n\\nPLAN: ? PICC LINE FOR ACCESS THEN DC RIJ. ? DC NATRECOR TODAY. ? LASIX OR DOSE FOR DIURESIS. OOB TO CHAIR THIS AM.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2155-05-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1460563,\n \"text\": \"NEURO ALERT ORIENTED GENERALIZED WEAKNESS NO NEURO DEFECITS NOTED\\n\\nC/V VPACED B/P STABLE PALP PULSES GENERALIZED EDEMA EXTREMTIES HEP DC/ MD. COUMADIN GIVEN. DOSE DISCUSSED WITH MD, WILL CONTINUE TO FOLLOW PT/PTT/INR\\n\\nRESP BREATH SOUNDS CLEAR, DIMINISHED IN BASES. USING IS WITH MODERATE VOLUMES. NONPRODUCTIVE COUGH. NC 2L TOL WELL SATS 98-100%\\n\\nGU/GI ABD SOFT INCREASED DIET TO CARDIAC/2GM NA TOL WELL. MODERATE URINE 40CC HOUR NATRECOR DC/ MD LASIX IV BID STARTED WITH GOOD OUTPUT.\\n\\nPLAN CONTINUE TO CLOSELY MONITOR I/O AND RESP STATUS. INCREASED ACTIVITY\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2155-04-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1460523,\n \"text\": \"Respiratory Care:\\nPt. successfully extubated to a 40% cool mist mask. Appears to be doing well. MDI's given prior to extubation. HR = 69 BP = 128/41 RR = 17 O2 Sat. = 100%. Was OET suctioned for a large plug just before the tube was removed; chest sounds were clear after suctioning.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2155-04-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1460515,\n \"text\": \"Nursing progress notes\\n71 yr old pt w/ long hx (please see fhp) sob x 1 week w/ worsening. daughter called ems, to intubated d/t rr<6 and obtunded. pcxr shows chf lasix given 60mg ivp w/ approx 500cc out this shift. placed on ntg gtt at 3mcq/min for hypertension of sbp 200, given asa and tylenol for temp 103 rectal. lactate 4.3, pt received vanco, ceftriaxone, and flagyl. bs 500 and urine glucose 1000 pt received 6 units of regular insulin iv. to micu. bs 450 insulin gtt started. pt intubated 7.5 orally at 22cm lip line. on ac16/400/100%/5 o2 decreased to 50% sats cont at 100% abg attempted but team and resp therapist unable to obtain.\\n\\nNeuro: pt sedated on diprivan gtt 40mcq/kg/min able to mae follow commands nods to simple questions.\\n\\nresp: intubated as above. team to attempt aline later this evening. ls rhonchi to coarse bs. suctioned up thick tan secretions sent for c/s pt on droplet precautions to r/o influenza. pcxr in ed shows pul edema, 2nd pcxr obtain at present.\\n\\ncv: tele upon arrival to unit hrt rate 90-100 st w/ lbbb. at present sr60s bp 110s/60s ntg off. pt has distant hrt sounds S1S2 w/ systolic murmur. labs ordered for 1800. ck 52 w/ troponin .03, cont to cycle enzymes. cardiac cath on shows ef 60% w/ 2+ mr was stented.\\nall cardiac meds on hold for now ? sepsis. uop dropped off x 2 hrs bolus of 500cc ns given at 1730\\n\\ngi ogt in place tube feeding order needed. abd soft bs+\\n\\ngu: foley put out yellow urine, ua lytes obtained.\\n\\nskin: pt has several bruises noted one on her left upper back, one on her right buttock and right shoulder blade. micu team aware\\n\\nendo: pt on insulin gtt titrate bs for 120\\n\\nid: pan cx in ed. on vanco levofloxacin and flagyl, lactate 3.4, svo2 74 now afebrile\\n\\ncode: full\\n\\nsocial: lives w/ daughter and grandson. daughter called this afternoon and was updated.\\n\\nprecautions: droplet\\n\\nPlan:\\ncont to monitor uop\\nlab pending\\ncont to sedate w/ diprivan gtt\\n? tube feedings\\naline\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2155-04-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1460516,\n \"text\": \"MICU Nursing Note 1900-0700\\nEvents: Pt R/I for MI with Trop= 0.39---started on IV Heparin gtt, hypertensive---started on IV Labetolol gtt as per cardiology, remains on droplet precautions. IV Insulin gtt weaned to off.\\n\\nNeuro: Mildly sedated on IV Propofol at 40mcgs/kg/min, pt easily arouseable, follows all commands, moving all extremities when stimulated, denies pain when asked, c/o fear and anxiety when asked, calm and sleeping when not stimulated. Bilat soft wrist restraints to prevent pt from pulling at lines and tubes.\\n\\nCardiac: HR= 60-96 SR with no ectopy noted, new right radial Aline placed by MICU team with good waveform and correlation, BP= 102-162/30-50's, Started on IV Labetolol gtt at 0.5mg/min at Midnight and weaned to off at 4am for BP down to 103/39--restarted at 5am for BP trending back up to 140's. #2 set of cardiac enzymes with positive troponin= 0.39, CPK= 146 with MB= 16 and index= 11%. # 3 set pending. Started on IV Heparin weight based protocol at MN with am PTT pending.\\n\\nResp: Remains intubated with current vent settings: AC 400-40%-16 with PEEP= 5. Overbreathing vent by 3-4 breaths, MV= , Sats= 98-100%, lungs coarse at bases, good ABG= 7.38-40-137-25. Remains on Droplet precautions to r/o flu---specimen obtained by RT and sent this am. Pt with epitaxis this am ---pressure applied to both nares with bleeding subsiding. Hct= 30.\\n\\nGI: Abd soft with +bowel sounds, med brown BM x 1, OGtube placement checked by ausculatation and clamped at present, tube feedings held d/t possible extubation this am.\\n\\nGU: Foley to CD draining clear yellow urine, 20-40ml/hr\\n\\nEndo: insulin gtt d/c'd, 10pm fingerstick= 117---no coverage required, am fingerstick pending.\\n\\nID: Tmax= 99.8, WBC= 10.1, continues on Levofloxacin, vanco, and Flagyl\\n\\nSocial: No contact from family or friends overnight\\n\\nPlan: Wean sedation as tolerated,Possible wean and extubate this am, If remains intubated then start tube feedings as ordered, monitor for bleeding, wean labetolol as tolerated, continue sliding scale insulin,Support pt and family\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2155-04-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1460517,\n \"text\": \"Respiratory care:\\nPatient remains intubated and mechanically vented. Vent checked and alarms functioning per respiratory department protocol. Fio2 weaned this eve to 40%. Current settings: A/C 400*16 5 peep 40%. RSBI this am 42. Breathsounds are coarse. Albuterol/atrovent nebs started. Please see respiratory care section of carevue for further data.\\nPlan: Continue mechanical ventilation. Wean as tolerated. RSBI 42.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2155-04-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1460518,\n \"text\": \"Resp. Care Note\\nPt received intubated and vented on AC settings as charted on resp flowsheet. RSBI 42 today. Changed to PSV and is currently on 10 of PSV with TV 400's and RR <20. ABG's WNL. ruled out for flu today. Cont current support, reassess in AM for rediness to wean and extubate.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2155-04-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1460524,\n \"text\": \"MICU nursing progress note 7P-7A\\nEvents - Pt c/o mid-sternal chest pressure. Denies nausea, a little SOB. O2 placed, EKG unchanged. VSS. SL Ntg x 1 with some decrease in pain , Maalox resulted with total pain relief. CKs drawn -troponin .2, CKs flat. CXR showed slight ^^ pulm edema. Lasix 60 mg with fair diuresis-UOP had tapered off to<8cc/hr prior to lasix.\\n\\nNeuro - A&Ox3, MAE, assists with turns in bed. Transient discomfort over left lower rib cage, refused tylenol.\\n\\nResp - Lungs clear, diminished at bases. O2 weaned 40% FT-->NC 2L. No resp distress, Sats 95-100%, RR teens.\\n\\nCV - ABP 95-140/39-49. NSR 70s-80s, rare PVC. Tolerating BP med regime, Ntg gtt remains off. BP was in low 90s for awhile after captopril then increased to 120s. Trace edema in LE. Hct 26.6 (30.6). Right fem line d/c'd.\\n\\nGI - Tolerating PO clears, Abd soft, +BS. + flatus, no stool. Insulin gtt titrated to FSBS- BS 64, gtt off, OJ given with BS^^ 200, gtt restarted.\\n\\nGU -- UOP 80->8cc/hr. Now ^^ after 60 lasix IVP. Pt was ~300cc neg at midnite, now a little positive. BUN/cr cont to increase 27/1.3.\\n\\nSkin - Bruised areas on back (2) unchanged.\\n\\nID - Afebrile. On vanco, levoflox.\\n\\nPlan - Monitor response BP med regime, goal SBP 120s. Diuresis prn. Replete lytes prn. Cyckle CKs, 2nd set due 8:30AM. Titrate insulin to BS. Cardiology following, will address whether needs tranfusion with them. ? cath lab to evaluate pulmomary edema.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2155-04-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1460525,\n \"text\": \"NURSING NOTE 0700HRS - 1700HRS\\n\\n\\nNEURO...A/O X3, NO FURTHER CHEST PAIN BUT IS C/O SOME DISCOMFORT RT SIDE OF RIB CAGE, PATEINT REFUSES PO ANLAGESIA ? REALTED TO BRUISING NEAR THAT AREA..PATIENT APPEARS MORE COMFORTABLE THIS PM IN THE CHAIR\\n\\n\\nRESP..RECEIVED ON 2 L SATS @ 100%..N/C REMOVED SATS @ 98% GOOD COUGH/DEEP BREATH, SOME CRACKLES AND CXR SHOWS CHF [ LASIX GIVEN AS BELOW]..EXPECTORATING SMALL AMOUNT OF SPUTUM\\n\\n\\n\\n\\nCVS...B/P STABLE 110-120 SYSTOLC ON REDUCE DOSE OF ACE, BBLOCKERS CONTINUE TO HOLD FOR PARAMETERS...HR 62-68BPM..K STABLE THIS PM @ 4.1..REPEAT HCT @ 27 [ DOWN FROM 30 YESTERDAY BUT TEAM AWARE] CONTINUE TO OBSERVE....CK'S CONTINUE TO BE CYCLED POST CENTRAL CHEST PAIN LAST PM [ STABLE], TROP @ 0.3 TEAM AWARE... PATIENT HAS R/I FOR NSTEMI ON THIS ADMISSION CONTINUES ASPRIN/PLAVIX/SC HEPARIN..\\nAFEBRILE..VANC D/C BUT LEVO CONTINUES..\\n\\n\\nENDO...INSULIN DRIP CONTINUED THIS AM BUT D/C POST COMMENCEMENT OF NPH WITH S/S..CONTINUING TO MONITOR CLOSELY...STABLE AT PRESENT...\\n\\n\\nGI..TAKEN DIET VERY WELL..BOWEL SOUNDS PRESENT NO BOWEL MOTION SINCE ADMISSION\\n\\n\\nGU...GIVEN PO LASIX/SPIROLACTONE THIS AM WITH LITTLE EFFECT..AIM FOR NEG BALANCE 500-1L NEG..RECEIVED IV LASIX THIS PM BUT CONTINUES MINIMAL EFFECT AND WILL RE-REVIEW WITH TEAM...\\n\\n\\n\\nSKIN..BRUISES [ X3 AREAS MARKED], BUT SKIN INTACT\\n\\n\\nLINES..ART REMIANS IN PLACE, NEW PIV PLACED...\\n\\n\\n\\n\\nSOCIAL...SOCIAL WORKER SPOKE WITH TODAY RE CONCERNS ..PATIENT ADMITS TO VERBAL ABUSE BY DAUGHTER IN THE HOME AND GRANDSON ALSO HAVING ANGER MANAGEMENT ISSUES [ RECENTLY THREW A BOTTLE OF CLEANING FLUID AT PATIENT]..DAUGHTER PRESENTLY ADHERING TO REHAB PROGRAMME AND GRANDSON IS TO SEE COUNSELLOR FOR ANGER MANAGEMENT...SOCILA WORKER INFORMED ELDER SERVICES WHO WILL COME AND INTERVIEW PATEINT...THE PATIENT WISHES ARE AT PRESENT FOR THE DAUGHTER NOT TO BE INFORMED OF ANY OF THE ABOVE ACTION AND THAT SHE WISHES FOR HER TO VISIT...PATEINT AWARE TO INFORM OF ANY CONCERNS RE: SECURITY WHILST IN THE HOSPITAL...AWAIT ELDER SERVICES VISIT\\n\\n\\n\\n\\nPLAN...MONIOTOR RESP STATUS/B/P HR///U/O...AIM FOR NEG BALANCE...AWAIT ELDER SERVICES, OFFER SUPPORT TO PATIENT/FAMILY AT THIS DIFFICULT TIME....CALL OUT TO FLOOR\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2155-04-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1460526,\n \"text\": \"Micu Nursing Transfer Addendum\\nEvents: Pt with 7 beat run VT---self-limiting and asymptomatic, no further ectopy noted. Hemodynamically stable at present, Diuresing from earlier dose IV Lasix.\\n\\nNeuro: A+OX3 pleasant and cooperative, moving all extremities and following all commands, somewhat weepy when discussing her plan of care and potential need for heart surgery in future.\\n\\nCardiac: HR= 70's SR with 7 beat run VT at 1900---asymptomatic and no further ectopy noted, BP= 140's/40's, given lopressor at 7pm---dose was held at 4pm d/t borderline BP. Denies CP\\n\\nResp: Lungs clear bilat but diminished at bases, RA Sats= 97-100%, denies SOB, nonprod. cough noted.\\n\\nGI: Abd soft with + bowel sounds all quads, no BM, + flatus, good po intake\\n\\nGU: Foley to CD draining clear yellow urine---diuresing from earlier IV dose of lasix, 8pm po dose of lasix held\\n\\nSkin: intact, ecchymotic areas on back unchanged.\\n\\nSocial: Pt has been in contact with daughter and grandson via phone this evening. No visitors this .\\n\\nPlan: Transfer to 6 for further medical and cardiology workup, Monitor closely for CHF and diurese prn, Increase activity as tolerated, replace lytes prn, due at 12 am for cardiac enzymes, Elder Services to come and speak with pt regarding abuse at home---pt requests strict confidentiality and that daughter and grandson are not informed of this, Support pt and family.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2155-05-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1460557,\n \"text\": \"Respiratory Care:\\n\\nPatient intubated on PSV. Vent settings initially PSV 10, Peep 5, Fio2 40%. PSV weaned to 5cm this morning. Spont vols 500's with RR mid teens. O2 sat 100%. BS clear bilaterally. Sx'd for sm amounts of thick white secretions. RSBI 28. Pt. appear comfortable on PSV 5.\\nPlan: Will repeat ABG. ? Extubation later this morning.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2155-05-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1460558,\n \"text\": \"Resp Care\\nPt extubated this morning to 40% cool aerosol face tent. BLBS post extubation clear though slightly diminished. Pt had audible cuff leak and no stridor post extubation. Pt was weaned to 2L after several hours and is currently satting >96% on NC.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2155-05-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1460559,\n \"text\": \"NPN:\\n\\nNeuro: Awake and following commands in am. After extubation pt cooperative but sleepy and lethargic. At 17pm pt with increased alertness. Asking questions about what happened to her-remembers going to US and having trouble breathing. MAE and follows commands. Continues with 2+ edema.\\nSocial: HCP- called to check on patient-He will be away a few days and can be reached by cell phone-. Daughter called requesting to speak on phone with patient stating she had a serious issue. Request denied-encouraged daughter that patient was not able to speak on phone and if needed to see her she should visit. Also recieved call from -stating he was patients ex husband.\\nID: Afebrile. Last dose of Vancomycin given. WBC-14.5\\nCV: 90-110 ST then converted to aflutter/fib with V pacing-rate 60-70's. Rare PVC seen. K repleted. Continues on Amio 400mg , lopressor inreased to 37.5 mg tid and captopril increased to 12.5 tid. BP labile at times-hypertensive to 160-190's/ then 90-100's/. Natrecor continues at .01. at 900u/hr with stable PTT 71. Coumadin 4mg given at 16pm. Has L fem aline. Feet with 2-3+ pitting edema. Skin warm and dry. Pulses by doppler.\\nResp: Extubated at 9am to 40% FTN with good ABG's-weaned to 2L nc with sats > 97%. Cough fair-productive of thick pale yellow secretions. CXR done today. Lungs -diminished in bases.\\nGU: Foley. Diuresing on lasix at 10mg/hr-UO-decreased requiring diuril. Cr 1.5.\\nGI: Abd soft, NT, ND with hypo BS. OGT dc'd with extubation. Tolerating small amounts water and diet gingerale.\\nEndo: Glucoses high-190-220's. Changed to humalog sliding scale q 4 hrs. ? to restart standing insulin doses.\\nComfort: C/o back pain -treated with morphine X1.\\nActivity: Turned side to side in bed.\\nIncisions: Sternum and L shoulder with DSD-D/I.\\nA: Extubated but sleepy most of day. Social service notified\\nP: Reorient prn, social work following ptient and family, Continue diuresis with lasix and natrecor-diuril prn-discuss weaning gtts in am, Swan remains in for IV access. Replete lytes prn. /coumadin. ? stop in am to dc fem aline. Restart rehab\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2155-04-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1460519,\n \"text\": \"Nursing progress notes\\nReview of systems:\\n\\nNeuro: pt sedated on 50mcq/kg/min of diprivan increased from 40mcq for vent adaption and comfort. pt awakens to voice and nods to simple questions. mae.\\n\\nREsp: orally intubated 7.5 22 at lip line retaped to right side of mouth. vent settings psv 10/5 40% abg on these settings 7.41/42/163/29/99% LS clear to coarse w/ diminished bases. suctioning thick tan secretions from ett. pt had copious bldy oral secretions this am w/ multyple med size clots probably induced by nasal influenza spec. pressure applied to nares and heparin gtt stopped and dc'd. one med size clot removed at 1800, but no further bleeding. probable extubation in am.\\n\\ncv: tele sb 50s - sr60s w/ LBBB. abp 108-150s/60s hrt sounds distant s1s2 w/ systolic murmur. hct stable 30 this am then rechecked at 0830 after bleeding 31.6. heparin gtt dc'd ptt this afternoon 25 inr 1.1, ck cycled at 1300 85 w/ troponin .31 next set at 2100. pt now on heparin sq. pt's own cardiologist in to see her today and will f/u w/ her in am. bb and ace inhibitor added this am.\\n\\ngi: abd soft bs+ tube feeds at 40cc/hr residual 10cc. no stool this shift.\\n\\ngu: uop via foley poor this am <20cc/hr lasix 40mg ivp given pt uop picked up to >50cc/hr goal to have pt -500cc at midnight at present pt +700cc and 1500 for los.\\n\\nendo: insulin gtt on for short time this am d/t bs 300 now on own home regiment. nph 22 am and 8 units at pm w/ reg insulin 8 units am and pm w/ additional humalog sliding scale\\n\\nid: vanco and levo cont flagyl dc'd bc pending, urine, sputum neg influenza neg pt off of droplet precautions.\\n\\nsocial: daughter and grandson for a short time and was updated emotional support given\\n\\ncode full\\n\\nPlan:\\ncont to wean vent as tolerated\\nmonitor for nasal and oral bleeding\\nmonitor bs x 24 hrs on this regiment and team will reassess in am\\nextubate in am.\\nnext labs at 2100\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2155-04-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1460520,\n \"text\": \"MICU Nursing Note 1900-0700\\nEvents: Bleeding subsiding from nose and mouth, Didn't tolerate CPAP+PS during late evening and rested on CMV overnight, mild diuresis, BP up--required IV Hydralazine\\n\\nNeuro: Sedated on IV Propofol, mild restlessness with BP elevated during evening---propofol increased to 60 mcg/kg/min with good effect and titrated back to 50mcg/kg/min this am, With propofol off for 10 minutes pt awake and moving all extremities and following commands, otherwise pt arouses briefly to voice and increased stimulation. Bilat soft wrist restraints to prevent pt from pulling at lines and tubes.\\n\\nCardiac: HR= 57-70's SB/SR with rare PVC, BP 130-188/40-70's. Received 20 mg. IV Hydralazine for BP 180's with good effect and BP down to 140's. Again BP up to 170's this am---Captopril dose increased to 25 mg. TID and first dose given with BP slowly trending down. #4 set cardiac enzymes with CPK down to 71 and Troponin down to 0.24. Receiving SC Heparin. Lasix 40 mg. x 1. Right radial Aline with good waveform and correlation and site WNL. Right Femoral TLC site C/D/I and all ports patent\\n\\nResp: Remains intubated. Tolerated CPAP+PS until 8pm and then tachypneic and hypertensive with low MV ---placed back on CMV overnight with ABG this am=7.45-44-170 and RSBI= 62. Lungs coarse bilat to bases, ETtube suctioned for mod amts thick whitish sputum and occasionally suctioned for brown plugs, Orally suctioned for small old bloody clots and serous fluid at back of throat.\\n\\nGI: OGtube placement checked by auscultation, tube feedings infusing at 40 ml/hr until MN and then off for high residuals, pt with increasing bilous residuals during night and OGtube placed to LSW for total of 200ml. green bile. OGtube clamped at present and feedings held both for high resids and for potential extubation this am. Abd softly distended with + hypoactive bowel sounds.\\n\\nGU: Foley to CD draining clear yellow urine. Mild diuresis from 40 mg. IV Lasix. Pt neg. 100ml at MN and another 300 ml since MN. Remains > 1 liter positive for LOS.\\n\\nSkin: Grossly intact. No change in ecchymotic areas over back.\\n\\nEndo: Fingesticks remains elevated 178-304 overnight. On fixed dosing of NPH and regular along with sliding scale of humulog.\\n\\nID: Tmax= 99.1. WBC= 11.4. All antibx d/c'd\\n\\nSocial: Pt's daughter called during evening and was updated on pt's condition and plan of care.\\n\\nPlan: Wean Propofol gtt as tolerated and Attempt to wean vent and extubate, ? if need to diurese pt further prior to extubation attempt, If does not extubate consider restarting tube feeds at slower rate and monitor for high residuals, ? of need to change femoral line soon?, Continue aggressive pulmonary toiletting, Support pt and family.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2155-04-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1460521,\n \"text\": \"Resp Care: Pt continues intubated #7.5 oett secured @ 22 @ lip and on ventilatory support, changed to a/c for overnoc rest d/t agitation/bucking vent, currently back on cpap with minimal psv maintaining abg wnl; bs clear to coarse, sxn thick brown/blood tinged secretions, rx with mdi albuterol/atrovent, rsbi 61, will attempt wean to extubate this am.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2155-04-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1460522,\n \"text\": \"NURSING NOTE 0700HRS - 1700HRS\\n\\nPATIENT HAS EXTENSIVE CARDIAC HISTORY AND FREQUENT EPISODES OF FLASH PULOMARY OEDEMA [ WELL KNOWN TO CARDIOLOGISTS HERE]..PATIENT ADMIT WITH FOR PULMONARY OEDEAM ? SECONDARY TO HIGH B/P AND LLL PNEUMONIA\\n\\nEVENTS..REQUIRED FURTHER LASIX X2 DOSES FOR LOW URINE OUTPUT AND PENDING EXTUBATION...RECEIVED INCREASED PO MEDS FOR B/P CONTROL..HIGH BILIUOS RESIDUALS PLUS ABSENT BOWEL SOUNDS IMPROVED OVER THE COURSE OF THE DAY..PATIENT EXTUBATED WITH NITRO DRIP FOR B/P CONTROL @ 17.15HRS\\n\\n\\n\\n\\n\\nNEURO...RECEIVED ON PROPOFOL DRIP THIS AM AND DRIP TITRATED DOWN TO WHERE PATIENT WAS AWAKE BUT COMFORTABLE...SWITCHED OF FOR EXTUBATION..SINCE EXTUBATION LETHARGIC BUT ORIENATATED X3..MOVEMENT IN ALL 4 LIMBS, NO COMPLAINTS OF PAIN BUT THROAT SORE AND ICE CHIPS GIVEN...\\n\\n\\n\\n\\nRESP...RECEIVED ON CPAP/PS..PATIENT WEANED AND EXTUBATED AT 17.15HRS WITH GOOD AB'S..PATIENT HAS COUGH...OLD BLOOD TINGED SECRETIONS EXPECTOATED [ FROM PREVIUOS NOSE BLEED WHILST INTUBATED]..ABLE TO COUGH DEEP BREATH WELL..SATS @ 100% AND LUNGS SOUND CLEAR..FOR CHECK ABG...\\n\\n\\nCVS..PATIENT HAD ELEVATED TROP ON THIS ADMISSION ? NSTEMI AND INIITLLY COMMENCED ON IV HEPARIN, HEP D/C SECONDARY TO PREVIUOS EPISTAXIS NOW ON S/C HEP/ASPRIN/PLAVIX...HR SINUS RHTHM 68-75BPM WITH RARE PVC'S K THIS AM REPETED AND AGAIN PM CHECK K @ 3.6 AND REPLETED WITH 40 IV, WILL REQUIRE CHECK K PM....PATIENT IS IN L BBB ON EKG, ECHO PERFOMED THIS AM AND CARDIOLOGY FOLLOWING...\\nB/P HAS BEEN ONGOING ISSUE FOR CONTROL AIM < 140..RECEIVED @ 160 THIS AM DESPITE PO MEDS THEREFORE PATIENT RECEIVED STAT DOSE OF HYDRAL..AGAIN MEDS TITRATED UP FOR ACE AND BBLOCKER..PATIENT HAD IV NITRO IN PROGRESS FOR EXTUBATION NO STOPPED AS SYSTOLIC < 140...\\n\\n\\nENDO..B/S ^^^ THIS AM ..PATEINT COMMENCED ON HOME REGIME LAST PM BUT NOT COVERING B/S THEREFORE INSULIN DRIP RE-COMMENCED TODAY AND IS IMPROVING..\\n\\n\\nID..WBC @ 11 THIS AM..PATEINT LOOKS FLUSHED BUT NOT FEBRILE..AB'S CONTINUE FOR LLL PNEUMONIA..? REQIURES VANC LEVEL TOMORROW\\n\\n\\nGI...FEED STOPPED DURING THE NIGHT DUE TO HIGH BILIOUS RESIDUALS..UPON RECEIVING PATIENT THIS AM NO B/S PRESENT BUT BELLY SOFT..BILIUOS SECRETIONS IMPROVED OVER THE COURSE OF THE DAY AND PATIENT NOW HAS HYPOACTIVE B/S..CONTINUE TO MONITOR..ICE CHIPS TAKEN POST EXTUBATION\\n\\n\\nGU....RECEIVED X2 DOSES OF LASIX FOR LOW U/O AND PENDING EXTUBATION WITH SOME RESPONSE [ PATEINT NORMALLY ON LASIX AND SPIROLACTONE AT HOME]...CONTINUE TO MONITOR .. ? EXPECTATION FOR FLUID BALANCE NOW EXTUABATED...\\n\\n\\nSKIN..BRUISING NOTED ON HER BACK AND AREAS MARKED ?? CAUSE BUT TEAM AEA AWARE\\n\\n\\nLINES...SECOND PERIPHERAL PLACED TODAY ? FOR GROIN CENTRAL LINE REMOVAL THIS EVE...\\n\\n\\nSOCIAL..DAUGHTER HAS VISITED THIS AM..SOCIAL WORKER WILL TALK TO HER TOMORROW\\n\\n\\nPLAN...FOLLOW RESP STATUS..MONITOR B/S WITH INSULIN DRIP ? SWITCH TO HOME REGIME..MONITOR K POST DIURESIS...MONITOR BOWEL SOUNDS.? COMMENCE PO'S THIS EVE..MONITOR B/P GIVE PO MEDS\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2155-05-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1460560,\n \"text\": \"NEURO: ALERT, LETHARGIC/WEAK. ORIENTED X 3, MAE, FOLLOWS COMMANDS. VOICE STRONGER MORE FACIAL ANIMATION AFTER SLEEPING. NO SEDATIVES OR NARCOTICS GIVEN.\\n\\nPULM: N/C AT 2L, SATS > 97%. LUNGS DIMINISHED BASES ? CRACKLES LLL. EUPNEIC.\\n\\nCV: ATRIAL FLUTTER TO PACED RATE 60-65. CCO SWAN VIA RIJ CORDIS, CI 1.8-2.4, SVO2 65-70, MV02 67. BP'S MONITORED VIA L FEM ALINE, GOOD WAVE FORM. PEDAL PULSES DOPPLED. DECREASED TO 850 UNITS/HR AT 0430 FOR PTT 89.7. NATRECOR AT 0.01MCG.\\n\\nENDO: Q4H FSBS WITH HUMALOG INSULIN COVERAGE.\\n\\nGI: ABDOMEN SOFT, + BS. TAKNG CLEAR LIQUIDS, COUGHS SOMETIMES WITH DRINKING.\\n\\nGU: FOLEY TO CD DRAINING QS AMTS URINE. LASIX DC'D AT 2100. DIURIL 500MG IV AT 2400.\\n\\nSOCIAL: DAUGHTER CALLED IN FOR UPDATE. ASKING TO TALK ON THE PHONE WITH HER MOTHER ABOUT SOME \\\"EXTREMELY IMPORTANT LEGAL ISSUES.\\\". THAT PT IS TOO WEAK TO TALK AT THIS TIME.\\n\\nPLAN: VENOUS ACCESS TO PLACE PERIHERAL LINE OR PICC TODAY THEN DC CORDIS. COUMADIN DOSING PER INR. WEAN OFF WHEN INR THERAPEUTIC. OOB TO CHAIR. PHYSICAL THERAPY. ? DC NATRECOR TODAY. SOCIAL SERVICE TO FOLLOW PT CLOSELY.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2155-04-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1460514,\n \"text\": \"Respiratory Therapy\\n\\nPt received from ER orally intubated, on full mechanical support. Continues on A/C ventilation 400*16 +5PEEP 50%. ABG by RRT and MD w/out success. SpO2 90s. ETT #7.5 secure/patent. See resp flowsheet for specific vent settings/data/changes.\\n\\nPlan: maintain support\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2155-05-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1460571,\n \"text\": \"NEURO: PT. ALERT, ORIENT X3, OOB TO CHAIR WITH PT, OBEYS COMMANDS.\\n\\nCV: PT. AV PACED AT RATE OF 60, SBP 120-130, NO ECTOPY NOTED.\\n\\nRESP: PT. OXYGENATION >95% ON 2LNC. PT. OXYGENATION DECREASE TO 88% WITH REMOVAL OF O2 DURING PIVOT TURN FROM BED TO CHAIR. OXYGENATION IMMEDIATELY PLACED WITH RECOVERY IN O2 SATS.\\n\\nGI/GU/ENDO: PT. ABD SOFT, +BS, TOLERATING REGULAR DIET, ONE LARGE LOOSE, BROWN BM, +FLATUS, FOLEY DRAINING CLEAR, YELLOW URINE- GOOD U/O. NPH GIVEN THIS AM (20 UNITS)- BLOOD SUGARS TREATED PER PERSONAL SLIDING SCALE.\\n\\nPAIN: PT. DENIES PAIN.\\n\\nSOCIAL: PT. DAUGHTER CALLED TODAY- UPDATED.\\nPLAN: CONTINUE TO MONITOR RESPIRATORY STATUS, MONITOR FLUID STATUS AND KEEP ON A NEGATIVE FLUID BALANCE, POSSIBLE 2 TOMORROW.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2155-05-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1460572,\n \"text\": \" 11a-7p\\nneuro: a+o x3, mae, follows commands, up to chair with assist x1, ambulated once around unit without c/o cp, mild sob recovered with rest, perrlaa\\n\\ncv: v paced/av paced 60-70 no ectopy, sbp 100-134, afeb\\n\\nresp: lungs clear to upper lobes, fine crackles to bases, is 205-500ml, moderate strength nonproductive cough, 02 sats >95% on 2L nc, 86-88% on RA\\n\\ngi: positive bowel sounds, tolerating small amounts regular diet, fingersticks ssri, large bm this am\\n\\ngu: foley to gravity draining uop>30ml/hr, good reaction to lasix\\n\\nassess: stable\\n\\nplan: pulmonary toilet, increase activity, continue diuresis, transfer to 2 tomorrow\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2155-05-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1460573,\n \"text\": \"Neuro: A&O x3; calm & cooperative; MAE's, following commands consistently\\n\\nCV: AV paced/V-paced @ 60; afebrile; SBP 110's-130's, hydralazine given x1; K & Ca repleted; +2 general edema on LE bilat, TEDs on; palpable pulses x4\\n\\nResp: Lung sound clear, fine crackles @ bases; non-productive cough; 2L NC, sat 98%\\n\\nGI: Tolerating PO diet; abd soft, non-tender, +bowel sound; +flatus\\n\\nGU: Foley draining clear yellow urine; good diuresis with metolazone & lasix\\n\\nInteg: see carevue\\n\\nPain: denies pain\\n\\nSocial: no calls from family\\n\\nPlan: monitor hemodynamics & resp status; pulm toilet; monitor I&O, keep -; transfer to 2 in AM\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2155-05-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1460568,\n \"text\": \"Neuro: alert and oriented, pleasant\\nCV: NSR, PR .28 60's. NTG weaned off. BP <130. Palp pulses. Cont on Natrecor. Pitting pedal edema, teds on. COumadin on hold due to high INR\\nResp: Lungs decreased bases rt>lt. Scattered crackles. Sats>97% , O2 decreased to 2l. Pt denies SOB\\nGI: +BS, no bm. No nausea. Tolerating reg diet.\\nGU: DIuresisng 100-200cc/hr after zaroxyln, lasix, and aldactone. foley patent\\nEndo: Bs elevated. Covered with ssr, NPH this am\\nAct: OOB to ch without difficulty\\nPlan: Cont assess cardio/resp status. Cont aggressive diuresis. Increase activity and wean o2 as tol\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2155-05-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1460569,\n \"text\": \" 7a-7p\\nneuro: pleasant, a+o x3, mae, follows commands, up to chair with assist x2, steady on feet, very drowsy today, fell asleep in chair, fell asleep once returned to bed, good assist with turns, no c/o pain\\n\\ncv: sr/av paced intermittently, sbp 112-131, captopril dose 50mg tid now 75mg tid (tell team if sbp drops below 110, goal sbp 110-120), afeb\\n\\nresp: crackles to bases bilaterally, clear uppers, 02 sats >94% on 2l nc, is 250-500ml, moderate strength cough productive of thick yellow sputum\\n\\ngi: positive bowel sounds, tolerating small amounts regular diet, ssri and fixed dose increased today for fingersticks in the 200s, restarted glyburide\\n\\ngu: foley to gravity draining light amber urine, good uop on bnp with lasix ivp and metolazone po, (bnp now d/ced)\\n\\nassess: stable\\n\\nplan: goal sbp 112-131, transfer to 2 tomorrow if bp and respiratory stable overnight, increase activity, pulmonary toilet\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2155-05-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1460570,\n \"text\": \" nursing update\\nsystolic elevated to high 140s despite increase in captopril to 75 tid, lopressor 5mg iv given md with minimal response, hydralazine 10mg iv given with good effect. AVpaced 60/NSR low 60s, no ectopy seen. INR remained elevated to 4, medics aware. saturating >95% on 2l/nc, desats to low 90s on air. no signs of resp distress, lungs clear, with scattered crackles at both bases. non productive cough, still unable to raise IS for >500mls. neuro intact, turns independently/ or minimal support. pleasant and cooperative, no complaints of pain, slept well overnight. no problems swallowing, glucose dropped to 57, and improved to 121 after o.j. ~200cc. on lasix and spironolactone for diuresis, no bowel movements. rashes at perineal areas and inner thighs improving, miconazole continued. all procedures explained, no phone calls from rels. overnight\\n\\nplan: keep sbp 100-120mmhg, ? increase captopril further\\n ^diets and activity as tolerated\\n cont plan of care\\n ?transfer to \\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2155-05-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1460530,\n \"text\": \"Nursing\\nNeuro: A&Ox3. OOB to chair x3hrs w/2 assist. IVP morphine and po percocet for c/o incisional pain.\\n\\nCV: Initally nsr w/freq pacs- ivb mag admin. Nitro gtt for hypertension. PO lopressor & IV hydralazine started, nitro gtt off. Goal sbp <130. bradycardic to 50s. NP aware. HCT stable. A's wires don't sense. Pacer box set @ VVI 40. Epi gtt weaned off with CI>2, svo2s 60s- swan dc'd. CT dc'd. CXR done.\\n\\nResp: Extub in am. Weaned from FT to 2L NC. Sat 98-100%. Lungs cta, dim in bases. Expectorated lg amts thick sputum. Uses IS to 500cc with encouragement.\\n\\nGi: Tol clear liqs. Hypo bowel sounds. No c/o n/v.\\nGu: Started ivp lasix. +diuresis. adequate huo.\\nEndo: Titrating insulin gtt. Pt type I DM, not taking adequate POs.\\nSkin: Intact. See carevue for incisions.\\n\\nSocial: SW has long history following pt for concerns at home- see SW note. informed of pt and is collaborating w/SW from previous unit. Daughter called and updated by RN w/pt's permission. Daughter stated on phone she would visit this afternoon.\\n\\nPlan: BP management. Pulm toilet. Pain management. Advance diet & exercise. ?F2 in am. F/U w/social work.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2155-05-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1460531,\n \"text\": \"NEURO: PT. ALERT, ORIENT X3, MAE, OBEYS COMMANDS.\\n\\nCV: PT. NSR, RARE PAC'S NOTED, RARE PVC'S NOTED, HR 70'S, SBP 95-120, PACER CHECKED AND V WIRES SENSE/CAPTURE. PACER ON VDEMAND RATE OF 40. PT. HR DIPS INTO LOW 50'S-TEAM AWARE. PO LOPRESSOR GIVEN AND TOLERATED BY PATIENT.\\n\\nRESP: PT. LUNGS CTA, DIMINISHED IN LOWER LOBES, OXYGENATION 98-100% ON 2LNC, +COUGH, NO EXPECTORATION.\\n\\nGI/GU/ENDO: PT. ABD SOFT, HYPOACTIVE BOWEL SOUNDS, TOLERATING CLEAR LIQUIDS, FOLEY DRAINING CLEAR, YELLOW URINE- 20MG IV LASIX GIVEN AT 2400 WITH SMALL RESPONSE IN U/O. LYTES REPLETED. U/O CURRENTLY IS MARGINAL-PA NILLSON NOTIFIED. INSULIN GTT DC/D IN AM- BLOOD SUGARS TREATED PER RISS.\\n\\nPAIN: PT. C/O INCISIONAL PAIN- 2 PERCOCET GIVEN AND TOLERATED.\\n\\nPLAN: 2?, MONITOR SBP AND HR, CONTINUE VDEMAND, ANTICOAGULATION?, PULMONARY HYGIENE.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2155-05-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1460527,\n \"text\": \"Nursing\\nPMH: MI, CABG w/occluded vein grafts, PCTA, stents. Type I DM. CRI (baseline 1.2). S/P Redo sternotomy & MVR, mechanical valve. Report received from anesthesia. Post EF 30%, ^RV hypokinesis, epi gtt was started coming off pump, increased in OR. 2 FFP admin by anesthesia for INR 3.1. Poor PIV access, trouble placing PA line pre-op, able to place CCO swan post-op. Fem a-line. Arrived in csru AV paced, hypothermic-> bair hugger applied.\\n\\nReceived on epi, prop, insulin & neo gtt. Neo switched to nitro in CSRU. Reverse T- and increase in prop gtt to keep SBP <110 MD . IVP morphine & increased nitro for ^SBP. CI 1.8, fluid bolus admin- PADs and CVPs low 20s. CI remained <2, 1 prbcs ordered. Mixed venous O2 sat 77%, fluid infusing. ACT 150, 50mg protamine. Peep increased to 10 NP . Min-mod serosang CT output. Slight serosang oozing on sternal dsd. AV asychronous pacing paused. Underlying rhythm afib 70-90s. Amio bolus ordered, held d/t brief spontaneous junctional 50s. Cont afib. A wires don't capture per anesthesia, Vs work. Received on 100% fio2, weaned to 50%. Peep remains 10. Vent RR increased for resp acidosis. Insulin gtt increased for blood sugars 130s. Creat 0.8, will replete K+.\\n\\nPlan: Keep sedated MD . Attempt neuro check & resedate. Maintain SBP <110.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2155-05-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1460528,\n \"text\": \"Resp Care Note:\\n\\nPt cont intub with OETT and on mech vent as per Carevue. Lung sounds coarse improve with suct mod th off white sput. ABGs stable on SIMV; sedation off switched to PSV; will repeat ABG. Cont wean PSV and extub today.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2155-05-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1460564,\n \"text\": \" nursing update\\nVpaced overnight, continued on captopril and lopressor. distal pulses palpable, +2 edema to both LE. verbalized laboured breathing, crackles to both lower bases, extra dose of lasix 40mg given with good effect, pt verbalized breathing much better. coughing out thick tan secretions, but pt only able to raise IS up to <500 even with much encouragement. sats 97% and better allthroughout, RR eupnic. neuro intact, 1 assist to getting oob. bld glucose covered with s/s humalog, not on lantus, medics aware. on lasix 80mg iv bid, diuresis adequate but not excessive, kcl 20meqs given. no bowel movement but passing gas. pressure areas unchanged, rashes to perineal areas and both inner thighs kept dry, miconazole applied\\n\\nplan: ? lantus fixed dose\\n pulmonary toilet\\n ^diets/activity as tolerated\\n monitor uop\\n cont plan of care\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2155-05-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1460565,\n \"text\": \"Resp Care\\n\\nPt was placed on NIV while in pulmonary edema. Tolerated well. While on NIV rr and wob decreased\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2155-05-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1460566,\n \"text\": \"NEURO: Alert, awake, oriented x3, transfer to chair/commode/bed with 2 person assist, denies any pain\\n\\nRESP: Pt had SOB with RR in 40s at 1300, lung sounds crackles throughout, Sats low 90s, placed ventilator with mask, diuresed with 100mg Lasix/5mg Metolazone, also given 2mg Morphine, restarted 0.01mcg/kg Nesiritide at 1700 with 75mcg bolus\\n\\nCV: Vpaced to NSR, Cardiology consulted to reeval pacer, EKG done shows p waves, HR in 60s, during SOB episode, SBP rose to 170s, started on Nitro drip (currently at 2.0mcg), increased Captopril, Lasix, restarted Nesiritide, pedal pulses palpable, +3 pitting edema on lower EXTs, INR was 4.3 this AM, no Coumadin given\\n\\nGI/GU: Tolerating reg diet & PO meds, abd soft, + BS, large formed/brown stools, along with SOB episode c/o nausea which resolved itself; Foley in place draining yellow/clear urine, on increased Lasix/Nesiritide, repleted K.\\n\\nENDO: Started on NPH (breakfast/bedtime) & SSRI\\n\\nSOCIAL: Daughter/sister called and updated on status/plan of care\\n\\nPLAN: Continue to monitor resp, cv, urine outputs, LABS, increase activity as tolerated, monitor I/Os\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2155-05-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1460567,\n \"text\": \"7P-7A\\nNEURO: A/OX3. PERRLA. MAE. PLEASANT AND COOPERATIVE WITH NURSING CARE. NO C/O PAIN. AFEBRILE.\\n\\nCV: NSR 60-70S. NO ECTOPY NOTED. LYTES PRN. NTG CONTINUES TO MAINTAIN SBP<140. TOLERATING PO METOPROLOL, CAPTOPRIL, AMIO. PALPABLE PULSES BILAT. +2 BILAT LE PITTING EDEMA. NESIRITIDE CONTINUES @ 0.010MCG/KG/MIN. INR 5.4 PA AWARE.\\n\\nRESP: FAINT CRACKLES AT BASE, CLEAR OTHERWISE. 02SAT >96% 3L NC.\\n\\nGU/GI: FOLEY TO GRAVITY WITH MARGINAL HUO. IV LASIX, PO METOLAZONE WITH (+)DIURESIS. ABD SNT (+)HYPOACTIVE BS. PPI FOR GI PROPHYLAXIS.\\n\\nSEE CAREVUE FOR SKIN ASSESSMENT\\n\\nENDO: ELEVATED GLUCOSE LEVELS CONTINUE. COVERAGE PER ORDERED RISS AND NPH QAM/QPM.\\n\\nPLAN: CONTINUE BP MANAGEMENT. MONITOR INR. CONTINUE DIURESING. PULMONARY TOILET. ? START LANTUS\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2155-05-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1460529,\n \"text\": \"Neuro) Pt. kept lightly sedated overnight with one attempt at waking pt. at 2330 whereby pt. opened eyes but then became hypertensive to SBP 140-160's. Pt. did not have a gag or cough at that time. Re-sedated with Propofol until ~ 0400 when pt. awakend calmly off Propofol and able to follow commands and MAE.\\n\\nCV)Nitroglycerin titrated to keep SBP 110 although lower Syst kept MAP in the 50's. Allowed SBP in the 110-120 range as to maintain renal perfusion in view of huo 25cc x1 hour and baseline creat > 1.0.\\nEpi weaned as CI maintained >2.0. SvO2 71% when machine recal.Apaced due to infrequent episodes of nodal rhtyhm.\\n\\nPulm) vent weaned to CPAP this morning with slow IPS wean from 15. All ABG's wnl.\\n\\nGI) bile from OGT. Tol clamping well.\\n\\nGU) adequate HUO.\\n\\nEndocrine) insulin on and titrated to protocol.\\n\\nHeme) stable HCT after one prbc given for CI <2.0.\\n\\nPlan) extubate this morning. Monitor SBP ~110. Insulin protocol and wean epi as tol by hemodynamics.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2155-05-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1460535,\n \"text\": \"Shift update\\nNeuro: Pt alert and oriented x3, c/o being tired, NP aware. Perrla. MAE. Denies the need for pain med at this time, see carevue.\\n\\nCV: HR 48-50s CHB, NP aware, keep pt w/ own intrisinic rate. Backup V pace 40s, sense and capture appropriately. SBP 130-140s/ 20-30s, NP aware of diastolic, see carevue. Hydralazine to continue NP . Sternal dsg cdi. + palpable pulses.\\n\\nResp: LS clear diminished. Sats >98%. Encouraged IS and coughing and deep breathing. Denies CP/SOB.\\n\\nGI/GU: Abd soft, +flatus per pt. +BS. Tolerating po's ate 3/4th of breakfast. Foley draining clear yellow 20-80cc/hr. Lasix 80mg ivp given at 0830. ? increase pm dose per team during am rounds.\\n\\nEndo: BS 91 this am, ok to give NPH 20units sc and glipizide 10mg po NP , pt ate 3/4th of breakfast (corn muffin, yogurt,hot cocoa and coffee). Continue monitor BS.\\n\\nPlan: Monitor hemodynamics. Monitor resp. status. Pain control. Follow BS.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2155-05-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1460536,\n \"text\": \"Neuro: A&O x3, calm & cooperative, MAE's, following commands consistently; anxious with activities, calm with instructions & reassurance\\n\\nCV: Afebrile; CHB 50's, pacer set @ back-up VVI @ 30 NP ; SBP 140, NP awared, tolerating PO hydralazine 25 mg q6 hours; Am hct 26, type and screeen sent, will trnasfuse 1 unit PRBC when product is ready, only have 2 22g , one is due to change , do not pull NP, will get new by NP ; EP following\\n\\nResp: Lung sound clear, fine crackles @ bases; non-productive cough; O2 weaned to RA, sat 94%\\n\\nGI: Abd soft, non-tender, bowel sound x4, +flatus; tolerating diet\\n\\nGU: Foley drainig clear yellow/amber urine; UO tapering off, NP awared, give lasix after transfusion\\n\\nInteg: Intact, c/o itciness on back & arms, sarna lotion applied with good efect\\n\\nPain: denies pain\\n\\nEndo: 1200 BG BG 291, NP awared, revised sliding scale and AM NPH regimen\\n\\nSocial: family in for visit\\n\\nPlan: monitor hemodynamics, resp status & lab; get new access tomorrow; pulm toilet; monitor BG\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2155-05-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1460545,\n \"text\": \"NEURO: alert, oriented. following commands. moves well- transfered chair to bed with x1 assist. very fatigued with minimal exertion. no pain control issues.\\nCV: complete heart block 40's-50. period of nsr 60's. hypertensive at all times. SBP 150's. with exertion sbp up to 170's, resolved with 5 min. rest. ntg paste applied with good result. epicardial wires v wires sense and pace. set to v demand 35.\\nRESP:lungs clear bilat. no O2 requirement. some exertional wheezes, resolve on own.\\nGI/GU: abd soft, +bowel sounds. tolerating PB and crackers snack. NPO p midnoc. foley with clear yellow urine.\\nENDO: blood glucose wnl. no RISS/PO coverage d/t NPO.\\nSKIN: sternal incision approximated, small amount old apearing sang drainage from incision. dsd changed. chest tube site cdi, dsd changed. pressure points intact. sarna lotion to back.\\nA/P: continue to monitor cv, resp, lytes and blood glucose. NPO for pacer today. ?transfer to floor p pacer.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2155-05-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1460546,\n \"text\": \"See transfer note for details.\\n\\nPlan: perm pacer placement tomorrow AM, 1/2 dose NPH in AM, NPO after midnight; ambulated ~30ft x1, brief episodes of DOE, resolved with rest\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2155-05-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1460547,\n \"text\": \"Foley DC'd @ 1800, DTV 0200\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2155-05-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1460548,\n \"text\": \"NEURO- A&O X3. PLEASANT &COOPERATIVE WITH CARE.MINIMAL ASSIST WITH CARE.\\n\\nCV- CONTINUES IN CHB WITH PAC'S RATE CONTROLLED. INCREASING AMOUNT OF PVC'S THIS AM WITH NO CHANGE IN RATE. UNABLE TO DRAW LABS TO DIFFICULTY WITH VENOUS STATUS. DEFIB PADS IN PLACE.EPICARDIAL WIRES SENSE AND CAPTURE. DOE BUT TOLERABLE IF TASKS TAKEN IN STEPS.\\n\\nRESP- LSC. RA=96%. DOE.\\n\\nGI- ABD SOFT. +BS.MEDIUM LOOSE STOOL THIS AM. NPO AFTER MN FOR PROCEDURE IN AM.\\n\\nGU-VOIDED X2 AFTER FOLEY DCD. URINE VERY ODIFEROUS. PERI AREA RED WITH YEAST PRESENT.\\n\\nNO LABS DRAWN THIS AM. NO C/O PAIN.\\n\\n PT TO HAVE PPM PLACED TODAY. KEEP NPO UNTIL THEN. CONTINUE TO MONITOR CHB. BEGIN P/O TEACHING WITH DISCHARGE PLANNING.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2155-05-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1460549,\n \"text\": \" NPN\\nPT W/ RESP DISTRESS AND INTUBATION ON 2. FAMILY UPDATED BY PA. IN , PT SEDATE ON PROPOFOL. TEAM AT BEDSIDE. SWAN LINE PLACED AND AT PRESENT FEM ART LINE ATTEMPTS. VSS/HEMOS STABLE AS PER FLOWSHEET. + EDEMA NOTED. MD UPDATED BY NP. NO NEW ISSUES, AWAITING ABG RESULTS. GLUCOSE ELEVATED.\\nASSESS: STABLE POST INTUBATION.\\nPLAN: ART LINE INSERT, OBTAIN LABS. INSULIN GTT. DIURESIS. BEGIN NATRECOR.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2155-05-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1460550,\n \"text\": \"Resp CAre\\nPt intubated on floor for resp distress then transfered to . Pt has #7.5 ETT 21@lip. BLBS course, suctioned for mod amt of thick pale yellow secretions. Pt currently on A/C, no abgs since intubation MDs currently placing a-line. Plan to obtain abg and wean vent settings as tolerated.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2155-05-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1460532,\n \"text\": \"7am-7pm update\\nneuro: pt alert and orientated x3. MAE and able to follow commands.\\n\\nCV: pt initally 1st degree AV block with occasional PAC's noted. around 9 am the pt had 1 breif episode of CHB -> BP stable -> team aware -> lopressor dc'd. pt went back into 1st degree av block. around 1pm the pt went back into CHB and has stayed in CBH since. ventricular rate in the 60's. EKG done. BP stable. BP 100-130's/20-30's. pt continues on hydralazine for BP control. cardiology following -> ?? need for PPM in future. temp pacer on VVI at 40 (A wires do not capture - team aware). pp by doppler. plavix restarted today.\\n\\nresp: LS clear, fine crackles noted in RLL this afternoon. pt on 2 L nc, o2 sats > 95%. pt with non productive cough. using IS\\n\\ngi/gu: pt with + bs. no stool. poor appetite. foley dc'd at 11 am - pt has not voided since. pt on lasix. creatinine 1.2 this am (pt with history of chronic renal failure)\\n\\nendo: pt on insulin gtt at 3 u/hr this am -> pt given 6 units of reg insulin + 12 NPH (as ordered and gtt was dc'd 1 hr later). glusoce 2 hrs later was 275 -> pt given 12 units reg insulin and 5 mg glipizide PO. glucose 2 hrs later was 237 -> pt given 9 units reg insulin SC. bs 2 hrs later was 288 -> pt restarted on insulin gtt per team. plan to continue on insulin gtt and given NPH and glipizide in addition to inuslin gtt. team increasing NPH dose\\n\\nactivity/comfort: pt given percocets for pain control. pt oob to chair with 2 assist.\\n\\nsocial: social work following d/t safety issues at home.\\n\\nplan: monitor rhythm and BP, ?? need for PPM in future, pulm toleit, pain control, monitor glucose levels -> continue insulin gtt, NHP and glipizide, social work continue to follow\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2155-05-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1460533,\n \"text\": \"update at 1900\\n pt had not voided since 11 am (when foley was removed). foley reinserted per . foley re inserted without any issues -> pt put of 150 cc's yellow urine with sediment when catheter inserted. pt also c/o \\\"itchiness\\\" on trunk and bil arms -> no rash noted, skin pink in color - team aware -> sarna lotion ordered.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2155-05-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1460534,\n \"text\": \"NPN:\\n\\nNeuro: Alert and oriented X3, MAE with equal strength. Very pleasant and cooperative.\\nCV: 50's CHB with stable BP-117-140's/40-60's. Hydralazine for HTN. Pedal pulses palp. Ca repleted.\\nResp: Lungs diminished in bases. O2 sats> 98% on 2l nc O2. IS to 750 with direction.\\nGI: Abd soft,NT,ND with +BS. No N/V. Tolerating liquids.\\nGU: Foley reinserted at 1900pm for 150cc uo. Diuresed with lasix 40 mg IV minimal response so dose increased to 80mg IV bid-given additional 40mg at 22pm with marginal response. Dr aware. Will cont to monitor.\\nEndo: Glucoses improved to 126-60. Insulin gtt off and low sugar treated with OJ.\\nComfort: Percocet 1 po at 22pm with good effect.\\nActivity: Turned side to side with 2 assists.\\nIncisions: Sternum and CT -clean and dry-DSD's changed.\\nA: With stable CHB -adequate ventricular rate and BP\\nP: EPS following, Cont to diurese and observe for return of SR. Replete lytes prn. Pulmonary toilet. Cardiac rehab\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2155-05-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1460551,\n \"text\": \"NEURO-Sedated on propofol @ 70mcgkgmin but decreased to 50mcgkgmin due to\\ndecreasing bp.Continued to be adequately sedated with no hypertensive episodes with stimulation. pt is able to nod head \\\"yes\\\" to her name when asked if she can hear us,but is unable to follow any more commands.\\n\\n Pt has PPM which is a-sensing/v-pacing at rate between 65-75, rare ventricular ectopy. K=3.7-> 20meq kcl iv x1.Hemodynamically unstable with core temp=95.7 ,co/ci=3.5/1.8,hypotensive bp=94/35(53).Bair huggar applied,milrinone bolus with gtt,natrecor bolus with gtt and levophed gtts started. Pt improved hemodynamically but u/o remained scant.Lasix 140mg iv x1 given with minimal oputput. Lasix gtt started @5mg/hr. u/o =45cc/hr.Pt given another 40mg IVP lasix which she diuresed 100cc x1 and continued to have steady u/o.Core temp/Mvo2/co/ci all improved with gtts. (see carevue)\\n\\nResp-Remained on CMV 40% x00x12x5. Overbreathing by 6-8bpm. sats=99%. ls clear->rhonchorous-> clear. sxing small amt clear thick sputum.\\n\\nGI-Abd soft with hyperactive bs. ogt-> lcwsx drg thin bilious secretions.\\n\\nGU/LAB-stated above in CV.\\n\\nEndo- insulin gtt titrated to glucose levels and protocol. Glucose level decrased to 84, gtt dcd.\\n\\nI.D.-Pan Cx for hypothermia with poor cardiac function. wbc=11.0 Pt has 2 more days (1dose qd x2d)of vancomycin post pacemaker placement.\\n\\nPain- No s/s pain seen, pt sedated on propofol gtt.\\n\\nPlan- TEE TODAY. wean vent settings after. Titrated gtts for maximum support with minimal infusion. monitor cardiac/resp/renal functions.\\n\\n\\n\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2155-05-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1460552,\n \"text\": \"RESP CARE: Pt remains intubated/on vent on settings per carevue flowsheet. No changes overnight. ABGs acceptable with excellent oxygenation.Lungs ess. clear. Sxd early in shift for thick clear secretions. RSBI-31. Wean as tol.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2155-05-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1460553,\n \"text\": \"ADDENDUM:\\n\\nPT 2UPRBC FOR HCT=23.0 POST TRANSFUSION HCT=29.0\\n\\nTYPOGRAPHICAL ERROR MADE IN RESP SECTION OF NOTE: PT 2 SETTING IS 50%. NOT 00%.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2155-05-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1460554,\n \"text\": \"Neuro: Pt sedated on propofol, but arousable. Follows commands and moves all extrem to command. PERRLA. Received extra sedation for TEE, Versed 2mg , morphine 2mg, and propfol boluses.\\nCV: HR 70-90's nsr with prolonged PR>.32. EP interrogated pacer, confirmed SR. This am pt with rare AV pacing this am at 60 followed by vpacing now sr with rare PVC. Lopressor iv q4hr. INcreased VEA with faster rate. Milrinone weaned to 0.125mcg to remain there overnight per and to start on ace inhibitor. SVO2>70, CI >2. PA systolic low 50's, CVP low teens. BP 110-150, stable. dopplerable pedal pulses. Temp >36. TEE done showed improved EF of ~40% ( milrinone 0.2mcg) up from yesterday will no MR. started at 1400 at 1000units/hour. Albumin TID. Remains on natrecor at 0.01mcg, no change.\\nResp: Lungs clear, slightly dim at base. Sx scant white thick secretions. Weaned vent to CPAP Fio2 40%, sats>98%, abg wnl. To remain intubated overnight per Dr. and may extubate in am if appropriate.\\nGI: OGT to LCWS, mod bilious drng. Abd soft, hypoactive BS. Pt denies nausea. OGT replaced post TEE, placement confirmed by auscultation\\nGU: Foley patent, urine clear yellow. Adequate uop but not great on lasix 10mg/hr, ranging 30cc-200cc/hr. Team aware. Plan is for pt to be negative as much as possible.\\nEndo: BS stable this am off , but now elevate post antibiotics. Attempting SC sliding scale, if necessary will restart .\\nSocial: Daughter into see pt, very emotional \\\"They took my son away from me, and now I am losing my mother\\\" Emotional support provided. SW who has been following up to see family, spoke with her for 15minutes. Will continue to follow\\nPlan: CHeck PTT at , continue assess cardio/resp status. Wean sedation and plan to extubate in am. Continue on natrecor/lasix/milrinone as ordered. Start captoril tonight.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2155-05-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1460555,\n \"text\": \"Resp Care\\n\\nPt remains intubated and currently vented on PSV 10/5 tol well with Vt around 400-500cc and RR in the mid to low 20s. BS essentially clear sxing for minimal secretions. Last ABG WNL with adequate oxygenation on present settings. Will cont with vent support and reassess for further wean with extubation tomorrow morning.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2155-05-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1460556,\n \"text\": \"NEURO: SEDATED ON PROPOFOL , AROUSED TO STIMULATION, SQUEEZED MY HANDS AND WIGGLED HER TOES ON COMMAND. EASILY HYPERTENSIVE.\\n\\nPULM: INTUBATED TO CPAP MODE 40%, PS 10/5 PEEP ALL SHIFT. WILL WEAN PS TO 5 AND WEAN OFF PROPOFOL FOR PLANNED EXTUBATION THIS AM. LUNGS DIMINSIHED BASES, SX'D FOR SCANT AMT THIN WHITE SECRETIONS.\\n\\nCV: NSR WITH OCC PVC'S, HR 65-80'S. SBP UP TO 160'S AT TIMES, METOPROLOL 5MG IV Q4H, CAPTOPRIL 6.25MG PO Q6H, HYDRALAZINE 2.5MG IV X 2. PEDAL PULSES DOPPLED. CCO SWAN VIA RIJ CORDIS, SVO2'S 70'S-80'S, CI 2.1-3.0. L FEMORAL ALINE WNL. + PERIPHERAL EDEMA.\\n\\nENDO: BS 152 A 2400, 6 UNITS REGULAR INSULIN SC AT 0030.\\n\\nGI: ABDOMEN SOFT, HYPOACTIVE BS. OGT TO LCS DRAINING BILIOUS FLUID.\\n\\nGU: LOW UO AT ONSET OF SHIFT, 500MG IV DIURIL AT WITH GOOD DIURESIS. NEGATIVE ~1.2 LITERS AT 2400.\\n\\nSOCIAL: DAUGHTER CALLED AT 2200 FOR UPDATE.\\n\\nPLAN: WEAN AND EXTUBATE THIS AM. CONTINUE DIURESIS. AGGRESSIVE MANAGEMENT OF BP. SOCIAL SERVICE FOLLOWING.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2155-05-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1460537,\n \"text\": \"BS CTAB. Remains on 35% trach collar with NAD. Suctioned for moderate amount white secretions with some plugging. Inner cannula changed. Continue to monitor.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2155-05-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1460542,\n \"text\": \"See data, MD notes/orders.\\nNeuro: A&O x3, follows commands and communicates appropriately. No pain voice when asked.\\nCV: Afib with ventricular rate in 50's, VVI temporary pacer wires intact, rate set at 30. BP 136/40.\\nPulm: 2Lnc in place, lungs clear, decreased at bases. Pt uses IS q2-3hrs with good effort. 02 sat 99%.\\nGU: Uo 5-45cc/hr clear yellow. Furosesemide changed to po dose taken at home with little change in uo.\\nGI: Abd soft, bs presetn, formed stool on bsc this afternoon, appetite improving.\\nEndo: Ssc with regular insulin along with NPH and glipizide.\\nSkin: Surfaces grossly intact. Right index finger with red,inflamed joint, pt states is \\\"tender to touch\\\" and has been ongoing x 1 month. MD aware of same. Peripheral pulses palpable.\\nAct: Oob several times today, some exertional wheezes audible resolving with rest.\\nSoc: No visitors today.\\nP: Keep in ICU over weekend with ?of PPM placement on Monday. Keep pt up to date on poc, incr activity as tolerated.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2155-05-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1460543,\n \"text\": \"NEURO: alert, Ox3. MAE, following commands. moves well in bed. no pain control issues.\\nCV: CHB with Vpacing and pvc's. epicardial wires set to VVI 35. SBP 130's-150's. tolerating hydral. and lasix PO. skin warm, dry. DP/PT palp- differ in strength between feet.\\nRESP: lungs clear with diminished bases. sats 98-99% 2L nasal cannula. some exertional wheezing on turning in bed, resolves on own no drop in sats. good effort on I/S. cdb done.\\nGI/GU: abd soft, +bowel sounds. tolerated PB toast and juice. foley with clear yellow urine, output borderline 30cc/hr most of shift.\\nENDO: no glucose coverage with RISS . 2300 blood glucose 51. pt able to take PO's. following snack blood glucose 115.\\nSKIN: sternal incision approximated no drainage, mediastinal chest tube site approximated with scant amount of serosang drainage. dsd changed.\\nA/P: continue to monitor cv, resp, blood glucose and lytes. continue to advance diet and activity. continue pulm hygiene. plan permanent pacer monday.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2155-05-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1460544,\n \"text\": \"UPDATE\\nNEURO: PLEASANT, COOPERATIVE. STATES SHE FEELS TIRED EVEN THOUGH SHE SLEPT WELL LAST NIGHT. DENIES PAIN.\\n\\nACTIVITY: OOB TO CHAIR. AMB APPROX 70 FT USING W/C FOR BALANCE. STARTED OUT @ BRISK PACE BUT SOON TIRED AND HAD TO STOP X 3 TO REST.\\n\\nCV: SBP @ REST BREAK WHILE STANDING 225. DENIED ANY SX OTHER THAN SOB. BACK TO CHAIR TO REST, SBP DOWN TO 170 AFTER 10 MIN. BP CONT TO REMAIN >160. DR. NOTIFIED AND 1 IN NTP GIVEN IN ADDITION TO USUAL HYDRALAZINE DOSE (LITTLE EFFECT FROM A.M. DOSE). LATEST SBP DOWN TO 155. HR UP TO MAX OF 61 WHILE AMB, OTHERWISE 40'S-50'S, CHB.\\n\\nRESP: LUNGS CLEAR, DIMINISHED @ BASES. NONPRODUCTIVE COUGH. SPO2 96-97% ON RA.\\n\\nG.I.: EATING MEALS W/ GD APPETITE. HAD LG, FORMED B.M. ON COMMODE THIS AFTERNOON.\\n\\nG.U.: ADEQ HUO VIA FOLEY.\\n\\nENDO: AFTERNOON GLUCOSE DOWN TO 70, PT ASYMPTOMATIC. OJ GIVEN. EVENING NPH AND GLYBURIDE DOSES HELD SINCE PT TO BE NPO AFTER MN FOR PROCEDURE.\\n\\nSOCIAL: FAMILY IN TO VISIT THIS .\\n\\nA/P: DOE W/ AMBULATION AFTER MOD DISTANCE. WENT FURTHER THAN YESTERDAY. HYPERTENSION PERSISTS AFTER SUPPLEMENTAL HYDRALAZINE BUT IMPROVED AFTER NTP. NPO AFTER MN FOR PACER PLCMT TOMORROW. PT TO GET IV VANCO ON CALL. CATH LAB TO PLACE LUE IV IF NEEDED.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2155-05-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1460538,\n \"text\": \"7p-7a\\nneuro: pt alert, oriented x3, acting appropriately, MAE with equal strength, follows commands. speech clear. po percocet given x1 with good effect.\\n\\ncv: had run of 8 beat v-tach then converted to SR from the complete heart block. remains hypertensive 140-160, prn iv hydralazine added with minimal effect. palpable pulses. v-wires pace and sense, remain set at v-demand at 30; a-wires sense but don't capture.\\n\\nresp: ls clear bilat, uses is, coughs and deep breathes. o2sats>96%/RA\\n\\ngi/gu: abd soft, +bowel sounds. no BM, +flatulance. indwelling cath draining clear yellow urine to gravity, diurese with lasix.\\n\\nendo: pt's sliding scale and fixed dose nph\\n\\nplan: continue to monitor cv; blood pressure management. continue to advance diet and activity as tolerating.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2155-05-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1460539,\n \"text\": \"Neuro: A&O x3, calm & cooperative, MAE's, following commands consistently\\n\\nCV: T max 100.2, SB 50's till ~1000, back into CHB 50's, SBP 130's-150's, team awared, getting PO hydralazine and IV hydralazine with minimal effect; palpable pulses x4; cardiac echo done, plan to have perm pacer on Mon; 2A 2V wires, pacer set @ back-up VVI 30, V wires sensing & capturing; 500 ml NS bolus given; atrial tracing done\\n\\nResp: Lung sound clear, dim @ bases, IS ~750, non-productive cough; RA sat 93-95%; c/o SOB @ ~1810, put on 2L NC, sit pt up with improvement\\n\\nGI: Tolerating diet; abd soft, non-tender, bowel sound x4; +flatus, LBM \\n\\nGU: Foley draining minimal clear yellow urine, poor diuresis after AM lasix\\n\\nInteg: Intact\\n\\nEndo: Cover per sliding scale & fixed dose with oral agents\\n\\nSocial: Family in for visit\\n\\nActivity: OOB to chair, ambulated ~25 ft x1\\n\\nPlan: monitor hemodynamics, resp status; pulm toilet; inc activity as tol; encouraged PO intake\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2155-05-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1460540,\n \"text\": \"PO hydralazine increased to 50 mg, held PM dose lasix for tonight\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2155-05-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1460541,\n \"text\": \"CSRU NPN\\nSEE CAREVUE FOR DETAILED VS/ASSESSMENTS/INTERVENTIONS.\\n\\nNEURO: A/O X 3. VERY ANXIOUS/UPSET AT BEGINNING OF SHIFT DURING/AFTER VISIT FROM DAUGHTER & GRANDSON. GIVEN ATIVAN 0.5MG PO W/EFFECT. MAE, REPOSITIONS SELF IN BED.\\n\\nCV: GOES BETWEEN CHB & 1ST DEGREE AVB W/RATE IN 50S. REMAINS HYPERTENSIVE DESPITE PO & IV PRN HYDRALAZINE. PACER SET TO VVI.\\n\\nRESP: ON 2LNC, SPO2 AS DOCUMENTED. LUNGS CLEAR W/DIM BASES. BEGINNING TO COUGH UP SECRETIONS.\\n\\nGI: TOLERATING LIQUIDS/PILLS W/O NAUSEA. PT STATES \\\"I HAVE NO APPETITE.\\\" + BS, NO STOOL.\\n\\nGU: FOLEY PATENT, HUO MARGINAL. SEE CAREVUE.\\n\\nENDO: HAS OWN ORDERS FOR INSULIN COVERAGE.\\n\\nSOCIAL: VISITED BY DAUGHTER/GRANDSON AS STATED ABOVE. BECAME ANXIOUS/UPSET DURING AND AFTER VISIT. SOCIAL SERVICES ALREADY INVOLVED.\\n\\nPLAN: PPM ON MONDAY. B/P MANAGEMENT. PULMONARY HYGEINE. INCREASE ACTIVITY. CONTINUE WITH CSRU PLAN OF CARE.\\n\"\n }\n]"}}},{"rowIdx":389,"cells":{"subject_id":{"kind":"number","value":30277,"string":"30,277"},"hadm_id":{"kind":"number","value":198836,"string":"198,836"},"target_text":{"kind":"string","value":"27 yoM with multiple lumbar spinous processes and transverse process fractures with disc herniation at L5-S1. He was placed in a brace for concern of ligamentous injury. Upon follow-up slip was noted to progress radiographically and patient was admitted following scheduled/elective procedure listed above. Post-operative course was without complication. He received routine perioperative antibiotics and DVT prophylaxis throughout hospitilization with teds/pneumoboots. He was noted to have no change in neurologic examination post-operatively. Pain was controlled with IV and then po narcotics. Hemovac was d/c'ed when output was <30cc/8 hours. Incisions were noted to be clean/dry/intact upon discharge. Physical therapy evaluated the patient during hospitilization. He was made activity as tolerated, warm and form brace for comfort with no bending/twisting or lifting >5 lbs. He was discharged to home in stable condition when cleared by PT and medically stable."},"extractive_notes_summ":{"kind":"string","value":"An anterior interbody fusion device is seen at L4-L5. Transitional anatomy is again noted, with sacralization of the L5 vertebral body. Laminectomies have been performed at L4 and L5. FINDINGS: A series of 11 intraoperative radiographs of the lumbar spine demonstrate posterior fusion at L4-L5 in progress. Bilateral pedicle screws are inserted at L4 and L5; the L5 pedicle screws approach the superior endplate but do not appear to transgress the endplate. ; SPINAL FLUORO WITHOUT RADIOLOGIST IN O.R.Clip # Reason: L4-L5-S1 POSTERIOR SPINE FUSION Admitting Diagnosis: TRAUMATIC SPONDYLOLISTHESIS/SDA FINAL REPORT LUMBAR SPINE, 11 VIEWS INDICATION: L5-S1 posterior fusion. 7:51 PM L-SPINE (AP & LAT) IN O.R."},"n_notes":{"kind":"number","value":1,"string":"1"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2156-10-06 00:00:00.000","description":"O L-SPINE (AP & LAT) IN O.R.","row_id":1038810,"text":" 7:51 PM\n L-SPINE (AP & LAT) IN O.R.; SPINAL FLUORO WITHOUT RADIOLOGIST IN O.R.Clip # \n Reason: L4-L5-S1 POSTERIOR SPINE FUSION\n Admitting Diagnosis: TRAUMATIC SPONDYLOLISTHESIS/SDA\n ______________________________________________________________________________\n FINAL REPORT\n LUMBAR SPINE, 11 VIEWS\n\n INDICATION: L5-S1 posterior fusion.\n\n FINDINGS: A series of 11 intraoperative radiographs of the lumbar spine\n demonstrate posterior fusion at L4-L5 in progress. Transitional anatomy is\n again noted, with sacralization of the L5 vertebral body. Laminectomies have\n been performed at L4 and L5. Bilateral pedicle screws are inserted at L4 and\n L5; the L5 pedicle screws approach the superior endplate but do not appear to\n transgress the endplate. An anterior interbody fusion device is seen at\n L4-L5. Please refer to operative report for full details.\n\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2156-10-06 00:00:00.000\",\n \"description\": \"O L-SPINE (AP & LAT) IN O.R.\",\n \"row_id\": 1038810,\n \"text\": \" 7:51 PM\\n L-SPINE (AP & LAT) IN O.R.; SPINAL FLUORO WITHOUT RADIOLOGIST IN O.R.Clip # \\n Reason: L4-L5-S1 POSTERIOR SPINE FUSION\\n Admitting Diagnosis: TRAUMATIC SPONDYLOLISTHESIS/SDA\\n ______________________________________________________________________________\\n FINAL REPORT\\n LUMBAR SPINE, 11 VIEWS\\n\\n INDICATION: L5-S1 posterior fusion.\\n\\n FINDINGS: A series of 11 intraoperative radiographs of the lumbar spine\\n demonstrate posterior fusion at L4-L5 in progress. Transitional anatomy is\\n again noted, with sacralization of the L5 vertebral body. Laminectomies have\\n been performed at L4 and L5. Bilateral pedicle screws are inserted at L4 and\\n L5; the L5 pedicle screws approach the superior endplate but do not appear to\\n transgress the endplate. An anterior interbody fusion device is seen at\\n L4-L5. Please refer to operative report for full details.\\n\\n\\n\"\n }\n]"}}},{"rowIdx":390,"cells":{"subject_id":{"kind":"number","value":7358,"string":"7,358"},"hadm_id":{"kind":"number","value":170121,"string":"170,121"},"target_text":{"kind":"string","value":"The patient is an 83 yo woman with a h/o DM, HTN, chol, CAD, CHF, afib on coumadin, who was found in her apt on bed, with left hemiplegia and right gaze deviation. As she was minimally responsive whe was intubated. A head CT showed a right ACA/superior division MCA stroke with hemorrhagic transformation. CXR suggested LLL atelectasis vs consolidation. . Neuro: Exam upon dishcarge: the patient can be woken up. She has an eye opening aparaxia, which makes it impossible for her to open her eyes to command. She is able to wiggle her R-toes and squeeze her R-hand/show her R thumb when asked. She has hemiplegia in her L-arm and leg, with only minimal movement in her L-leg to noxious stimuli and no movement in her L-arm. The patient is non-verbal. The patient underwent a R-hemicraniotomy as a 1cm midline shift was noted shortly after presentation. The skull is currently preserved in her abdominal wall. Repositing of the skull by neurosurgery should be planned for in wks after the craniotomy (see follow up appointment). To protect her brain, she should wear a helmet. In addition, she is on seizure prophylaxis (dilantin; goal 15-20; please follow level regularly taking into account her albumin level). She will need to be on prophylaxis for a few years. An MRI/MRA should be scheduled in weeks to look for a possible underlying cause of the stroke. Repeat CT's of the head ( and (/8) showed no interval change apart from progressive reduction of the edema. CTA of carotids showed no stenosis and a TTE did not show a thromboembolic source or wall motion abnormalities. . Respiratory: The patient remained dependent on ventilator support. She tolerated CPAP well, but has episode of apnea (30sec) that might be central of origin. She was trached on . Please continue tracheotomy care. . Cardiovascular: The patient has a history of Afibb. She was in NSR during most of the hospitalization but returned to on . At this point the metoprolol was increased. Amiodarone was not give as her rate remained well controled. Coumadin should be kept on hold given the large intracranial hemorrhages. Aspirin may be restarted for secondary stroke prophylaxix in 4 weeks. . Endocrine: The patient has DM. She was maintained on a ISS and NPH 18 units in AM and 18 units PM. Her FSBS were reasonably controlled. Further adjustments to the NPH should be made depending on her FSBS. . Infectious disease: The patient received cefazolin peri-operative. She was started on levaquin for a LLL PNA. She developed a fever on after which her CVL was discontinued (bacteremia). Final results of the cultures are pending. A PICC line was inserted and other lines d/c-ed at that point. Levaquin to be continued for 4 more days. . Haematology: The patient's Hct dropped to 26.6 on . There were no signs of GI bleed and this drop might have been related to the bacteremia that was noted that day. Her Hct has remained stable otherwise around 30. She received GI prophylaxis. . Renal: Upon admission her creatinin and sodium were markedly elevated secondary to dehydration. Creatinin and sodium normalized slowly after sufficient rehydration. The patient needs diuresis PRN, based on her daily weigth. . Prophylaxis: Please continue penumo boots, PPI, heparin sc TID and a bowel regimen (including senna, dulcolax and colace). . FEN: Tube feeds per PEG tube at goal rate. PEG placed . PICC placed . . Code: full; HCP is nephew cell , home "},"extractive_notes_summ":{"kind":"string","value":"ABG's showing resolving alkolosis. Lungs clear to diminished at the bases. Lungs clear.Plan: Cont. Diuresing. Resp CarePt remains on PSV-parameters noted. Lung sounds clear and equal / diminished at bases. Mild mitralannular calcification. Cont on dilantin. Will continue on CPAP as tol. Remains in afib rate of 95-118. CARE: PT. RESP. Cont PSV. CONTINUE TO MONITER NEURO AND MENTAL STATUS. Mild [1+] TR.Normal PA systolic pressure.PERICARDIUM: Small pericardial effusion. Resp: Trach #9 portex, simv PS 14/ Vt 600/ fi02 .40/ peep 5. BP stable.GI: Abdomen obese with present BS. CONTINUE TO MONITER HEMODYNAMICS, NEURO STATUS. Mild to moderate (+) mitral regurgitation is seen. Pt had stable shift , plan to cont with current tx. bowel sounds hypoactive.Resp: cont .on vent. Tolerates FS Probalance at goal. Pt becomes HTN with stimuli and then settles on her own w/o and intervention. + BS No BM this shift. Resp CarePt remains on mech vent-parameters noted. PLACED ON SIMV WITH A RATE OF 10, PS AND PEEP UNCHANGED. Reg. Pt remains afebrile pulses are dopplerable. REMAINS ON VENT.SUPPORT. Pt in NARD; no vent changes required overnoc. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Will continue mech vent and wean as tol. On phenytoin (gtube) and level on = 11.5. NPH . BP stable and systolic between 110-130's. Covered with RISS. with current nursing care. HR remains SB-NSR with PAC's. SICU nursing progress notePlease refer to flowsheet for specific info.NEuro: Unchanged from previous assessment. Resp Care Note:Pt cont intub with OETT and on mech vent as per Carevue. s/p Right hemicraniotomy. Report given to at # . Wean from vent. Mild to moderate (+) MR.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. (proxy)called. BP 128/68. PERL. There is a small pericardial effusion. Resp Care, cont on settings as noted, no vent changes. Multiple doses of lopressor given as ordered with fair effect. Follows commands intermittently. LS clear and equal bilaterally, decreased at bases. Continues to follow commands as previously noted. CONTINUE WITH DIURESIS. Cont PSV. resp. Resp. Resp. PT WITH MET ALKOLIS THIS AM. MANNITOL STARTED. 2 U FFP GIVEN AND 1 U PRBC'S GIVEN. PERRL. HEPARIN SC/CLS.RESP: LS-CLEAR-DIMISHED BIBASILER. SKIN W+D. lungs clear to diminished at the bases.GI/GU: OGT clamped. HEAD DSG C/D/I. CONDITION UPDATEVSS. HAD ECHO TODAY.RESP-REMAINS VENTED ON CMV. DISCHARGE PLANNING. Cont support. +RADIAL/PT/DP X2. WHEN IN SINUS, PT HAS PACS. PBOOTS ON. Cont PSV ? MONITOR LYTES/HCT/ABG'S PRN. FOLLOW HCT/COAGS/ABG. transported to ctscan and then to O.r. +PP. WEAN FROM VENT AS TOLERATES. MIN MOVEMENT NOTED LFOOT - NO MOVEMENT LARM. Afebrile. Pt with met. + BOWEL SOUNDS. Cont. vent. HEAD INCSION APRROXIMATED AND SUTURES CDI.CV: PT WITH GENERALIZED EDEMA. REMAINS ON KEFZOL.A-STABLE S/P CRANIECTOMY.P-CON'T WITH CURRENT PLAN. WEAN VENT SETTINGS AS TOLERATED. PERLA. U/O QS VIA FOLEY. TRACH/PEG IN AM GU: MARGINAL UO. +BS. AS PER ORDERS. Diuressing after lasix. trach today. HAD CAROTID FLOW STUDY TODAY.CV-REMAINS IN/OUT OF AFIB. Cont with current plan of care carept continues with mech. Will continue mech vent and wean as tol. OGT IN PLACE, CLAMPED. RATE DECREASED, WILL FOLLOW ABG. Resp Care Note:Pt cont intub with OETT and on mech vent as per carevue. Resp Care Note:Pt cont intub with OETT and on mech vent as per Carevue. Resp Care Note:Pt cont intub with OETT and on mech vent as per Carevue. Pt traveled to CT and then directly to OR. Respiratory CarePt remains on CPAP/PSV, bilateral breath sounds diminished with scattered rhonchi. Cont with ICU care. Resp CarePt remains on mech vent-parameters noted. pt cool temp 95.9 hugger on. TMAX 103 - PAN CULTURED. HCT-STABLE. KEEP SBP <140. continue to wean to trach mask when awake. TEMP 99.6. LUNGS CLEAR TO COARSE. CONT CURRENT ICU CARE AND ASSESSMENTS. Corneal reflex intact.CV: Parameter SBP 100-140. placed on full vent support for trach/sedation. + gag. OGT-PLACEMENT CONFIRMED AND TOLERATING PROBALANCE AT GOAL. DILANTIN LEVEL LOW, BOLUS GIVEN. CONTINUNES ON LOPRESSOR. PALP PP RESP: VENT SETTINGS AND ABGT PER FLOW , HO AWARE AND NO CHANGE.SX FOR A SMALL AMOUNT OF THICK TO THIN TAN TO WHITE SPUTUM. Compared to the previous tracing of sinus rhythm andfrequent atrial ectopy have appeared. There is again demonstrated an endotracheal tube in stable position. Returned to baseline and Dr. notified. Respiratory CarePt remains on present careview settings, suction for small amount thick white secreations. Compared to theprevious tracing of atrial bigeminy is no longer present.TRACING #1 There is unchanged mucosal thickening in the maxillary sinuses, left greater than right. TECHNIQUE: Noncontrast head CT. Urine output adequate.GI: bowel sounds hypoactive. MORMOTENSIVE, NIPRIDE GTTS REMAIN OFF. An opacity at the left lung base is again demonstrated, which is unchanged in the short interval. Persistent left lung base opacity, which again could represent atelectasis or consolidation. ABGs metabolic alkalosis worsening ventilation and oxygenation stable. Resp Care Note:Pt cont intub with OETT and on mech vent as per Careevue. SAme vent settings, A.M. blood gases pending.Plan: Cont. Sinus rhythm and atrial bigeminy. Lung sounds ess clear after suct sm th white sput. Tube feeds continue at goal.REsp: Lungs clear. There is extensive surrounding edema with resulting shift of the septum pellucidum and third ventricle to the left, unchanged compared to 6 hours earlier. Resp Care Note:Pt cont intub with OETT and on mech vent as per Carevue. IMPRESSION: Stable appearance of right-sided parenchymal hemorrhage with extensive associated edema. Sinus rhythm. REASON FOR THIS EXAMINATION: PTX FINAL REPORT INDICATION: Unresponsive. Right axis deviation. Slight right axis deviation. FINDINGS: Multiple right frontal parenchymal hematomas appear unchanged. Cont PSV. The scout image reveals an endotracheal tube and an orogastric tube. Atrial fibrillationInferior T wave changes are nonspecificRepolarization changes may be partly due to rhythmSince previous tracing, supraventricular tachycardia rhythm now atrialfibrillation Atrial ectopy. Left lower lobe atelectasis and consolidation is still present. HR NSR W/ PAC'S."},"n_notes":{"kind":"number","value":55,"string":"55"},"notes":{"kind":"list like","value":[{"category":"Echo","chartdate":"2131-09-19 00:00:00.000","description":"Report","row_id":105266,"text":"PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 62\nWeight (lb): 187\nBSA (m2): 1.86 m2\nBP (mm Hg): 107/57\nHR (bpm): 64\nStatus: Inpatient\nDate/Time: at 11:14\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: Saline\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. No ASD or PFO by 2D,\ncolor Doppler or saline contrast with maneuvers.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and systolic\nfunction (LVEF>55%). No resting LVOT gradient. No LV mass/thrombus.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter. Normal ascending aorta diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Mild to moderate (+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR.\nNormal PA systolic pressure.\n\nPERICARDIUM: Small pericardial effusion. No echocardiographic signs of\ntamponade.\n\nGENERAL COMMENTS: Contrast study was performed with 1 iv injection of 8 ccs of\nagitated normal saline at rest.\n\nConclusions:\nThe left atrium is elongated. The right atrium is moderately dilated. No\natrial septal defect or patent foramen ovale is seen by 2D, color Doppler or\nsaline contrast with maneuvers. There is mild symmetric left ventricular\nhypertrophy with normal cavity size and systolic function (LVEF>55%). No\nmasses or thrombi are seen in the left ventricle. Right ventricular chamber\nsize and free wall motion are normal. The aortic valve leaflets (3) are mildly\nthickened but aortic stenosis is not present. No aortic regurgitation is seen.\nThe mitral valve leaflets are mildly thickened. There is no mitral valve\nprolapse. Mild to moderate (+) mitral regurgitation is seen. The tricuspid\nvalve leaflets are mildly thickened. The estimated pulmonary artery systolic\npressure is normal. There is a small pericardial effusion. There are no\nechocardiographic signs of tamponade.\n\nCompared with the findings of the prior report (tape unavailable for review)\nof , significant pulmonary hypertension is no longer detected.\nOtherwise, probably no change.\n\n\n"},{"category":"Nursing/other","chartdate":"2131-10-02 00:00:00.000","description":"Report","row_id":1360472,"text":"SICU\nPlease refer to flowsheet and page 2 for specific info. Patient being transfered to Rehab. facility. Neuro status remains unchanged from previous assessment and continues to follow commands and move extremeties as noted. Helmut on for moving patient. s/p Right hemicraniotomy. Do not position on right side. On phenytoin (gtube) and level on = 11.5. Cont to be in atrial fibrillation with rate 85-110/ min. BP 128/68. Aline and TLC d/c'd, left arm and hand with good perfusion brisk cap refill <2 sec. Resp: Trach #9 portex, simv PS 14/ Vt 600/ fi02 .40/ peep 5. Lung sounds clear and equal / diminished at bases. Sxn via trach for thick tan secretions q 2-4 hours. Oral secretions clear, nares draining thick yellow at times overnight. Gtube with probalance at 55cc/hour. glucose level at 10am 205 NPH 18 units. Reg. 15 units SQ. No further changes from previous assessment. Transfer with ALS / paramedic ambulance. Report given to at # .\n"},{"category":"Nursing/other","chartdate":"2131-09-22 00:00:00.000","description":"Report","row_id":1360438,"text":"Nursing Note 7p-7a:\nNursing Assessment:\n\nNeuro: Pt attempts to open eyes to voice, at times opens Right eye to pain. Pupils continue unequal and sluggish. Moves right extremities only, strong grasp on right hand. Occasionally follows commands. Afebrile.\n\nCV/GU: urine output adequate, bp and hr stable.\n\nGI: tube feeds continue, tolerating well. bowel sounds hypoactive.\n\nResp: cont .on vent. am labs alkalotic ph co2 36, Dr. notified and rate decreased. New ABG pending. Lungs clear.\n\nPlan: Cont. with current nursing care. Monitor urine output and resp on vent.\n\nPlease refer to carevue for details.\n"},{"category":"Nursing/other","chartdate":"2131-09-22 00:00:00.000","description":"Report","row_id":1360439,"text":"focus data update\nsee careview for details\n\nNEURO: neuro exam unchanged, decreased periorbital edema noted, morphine given for comfort\n\nRESP: Vent changed to CPAP, tol well, abg's done post vent change, suctioned for mod amt of thick white secretions both orally and ett\n\nCV: HR NSR, sys b/p < 160, off gtt's, a-line patent, multi-lumen central line patent, NA decreased 151, serum osmo 317, labs redrawn @ 1600 awaiting results\n\nGI: tol TF @ goal, no BM\n\nGU: adequate hourly u/o\n\nA/P: continue to assess and treat, continue both emotional and education support to both patient and family\n\n"},{"category":"Nursing/other","chartdate":"2131-09-23 00:00:00.000","description":"Report","row_id":1360440,"text":"Resp Care Note:\n\nPt cont intub with OETT and on mech vent as per Carevue. Lung sounds coarse suct sm th white sput. Pt in NARD; no vent changes required overnoc. Cont PSV.\n"},{"category":"Nursing/other","chartdate":"2131-09-30 00:00:00.000","description":"Report","row_id":1360466,"text":"Resp Care\nPt remains on PSV-parameters noted. Pt continues to have periods of apnea. Blood gas shows metabolic alkalosis and vitals are stable. Will continue on CPAP as tol.\n"},{"category":"Nursing/other","chartdate":"2131-10-01 00:00:00.000","description":"Report","row_id":1360467,"text":"NURSING\n SEE CARE VUE FOR SPECIFICS. INCREASED DOSE OF LOPRESSOR VIA G TUBE HAS DECREASED RATE BUT CONTINUES IN A-FIBB.MAGNESIUM REPLETED THIS AM, OTHER LYTES WNL. DAY 2 OF ACETAZOLIMIDE, CONTINUES WITH LASIX .\n NEURO SIGNS UNCHANGED WITH THE EXCEPTION OF PERIODS OF APNEA WHICH INCREASED OVER THE DAY AND NIGHT TO >30 SECONDS. PLACED ON SIMV WITH A RATE OF 10, PS AND PEEP UNCHANGED. ABG AFTER SIMV CHANGE WNL.\n CONTINUE TO MONITER NEURO AND MENTAL STATUS. FOLLOW LABS, CONINTUE WITH NPH INSULIN AND SLIDING SCALE. ATTEMPT TO BEGIN TO WEAN OFF VENT AGAIN TODAY\n"},{"category":"Nursing/other","chartdate":"2131-10-01 00:00:00.000","description":"Report","row_id":1360468,"text":"Resp Care, cont on settings as noted, no vent changes. Pt had stable shift , plan to cont with current tx.\n"},{"category":"Nursing/other","chartdate":"2131-10-01 00:00:00.000","description":"Report","row_id":1360469,"text":"SICU nursing progress note\nPlease refer to flowsheet for specific info.\n\nNEuro: Unchanged from previous assessment. Continues to follow commands as previously noted. Cont on dilantin. Level 11.7 today. Helmut on for positioning, turning only to left and supine r/t right hemi- craniotomy.\n\nResp: Sxned via trach for thick tan secretions. LS clear and equal bilaterally, decreased at bases. Sat's >98%/ ABG this morning wnl.\n\nCV: Cont to be in Afib. BP stable and systolic between 110-130's. Lopressor 50mg given via gtube and approx. 1 hour afterwards had a pause with HR to 20/min. Returned to baseline hr of 80 quickly without immediate intervention. Lopressor decreased to 37.5mg q 12.\n\nLytes/ Endo: glucose continues to be treated by sliding scale coverage. Lytes: K+ replenished with 40 meq KCL x 1. Other labs wnl.\n\nGI: On goal tube feedings through Gtube, probalance formula. Medium formed stool today x 1, yellow brown in color.\n\nGU: 20 mg cont to be given with good effect. UOP >30 / hour, and after lasix ^120cc/ hour.\n\nSocial: Spokesperson called and updated and verbalizing understanding. Family meeting may be scheduled for tomorrow/ Tuesday. Social Services updated. Meeting time not set at this time.\n\nPlan: Cont to check neuro status q 2 hours and prn, Follow glucose/ fingerstick's for sliding scale regular insulin coverage q 6 hours. NPH . Cont to update, support spokesperson. D/c plan is ongoing.\n"},{"category":"Nursing/other","chartdate":"2131-10-02 00:00:00.000","description":"Report","row_id":1360470,"text":"assessment as noted\n\nRES: CLEAR/DIM LS WITH THICK TAN SPUTUM SUCTIONED Q 4H, +STRONG COUGH-CONGESTED, NO VENT CHANGES, ABG WNL, CONSISTENT NASAL DRAINAGE-YELLOW THICK FROM BOTH NOSTRILS-?SINUSITIS\n\nCV: IN AFIB, +WEAK PEDAL PULSES, BP STABLE\n\nNEURO: NO EYE OPENING, INCONSISTANTLY FOLLOWS SIMPLE COMMANDS, PERL, L.ARM FLACCID, NO SEZURE ACTIVITY NOTED, ON DILANTIN AS ORDERED\n\nGU: 20/H MOST OF THE NIGHT, 200+ WITH LASIX\n\nGI: HAD BM X 1(SENT TO OB), TOLERATES TF WELL\n\nLABD: RISS INUSE, MAG WAS REPLETED\n\nPLAN: SYMPTOMSTIC TREATMENT, TRY TO WEAN VENT DOWN\n"},{"category":"Nursing/other","chartdate":"2131-10-02 00:00:00.000","description":"Report","row_id":1360471,"text":"resp care\npt remained on imv 600x10 40% 5peep with 0-10 spont breaths. BS coarse bil. Suct for thick yellow sput.ABG acceptable this am.Will follow.\n"},{"category":"Nursing/other","chartdate":"2131-09-28 00:00:00.000","description":"Report","row_id":1360460,"text":"STATUS\nD: NEURO UNCHANGED..MOVES RT SIDE & SL MOVEMENT OF LF LEG..NO MOVEMENT OF MLF ARM..WILL FOLLOW SOME SIMPLE COMMANDS BUT ON OCCASSION NEEDS MUCH ENCOURAGEMENT\nA: VENT WEANED TO C-PAP..SUCTIONED FOR MOD AMT THICK RUST COLORED.. LF SUBCLAVIAN LINE CHANGED OVER WIRE & TIP SENT FOR CULT..X-RAY DONE.. TF'S WELL..INCREASED HUO AFTER LASIX..PT PLACED ON LF SIDE>>RAPID A FIB 140-150'S>>ABG/LAB'S SENT>>EKG DONE>>5MGM LOPRESSOR GIVEN>>SR WITH PAC'S & OCC BURST'S A FIB..HELMET ON\nR: AWAITING LAB RESULTS\nP: WILL REPLETE ALL LOW LAB'S..CONTINUE TO MONITOR VS CLOSELY\n"},{"category":"Nursing/other","chartdate":"2131-09-29 00:00:00.000","description":"Report","row_id":1360461,"text":"RESP. CARE:\n PT. REMAINS ON VENT.SUPPORT. PLEASE SEE FLOW SHEET. NO CHANGES IN RESP. STATUS OVERNIGHT. =159.\n"},{"category":"Nursing/other","chartdate":"2131-09-29 00:00:00.000","description":"Report","row_id":1360462,"text":"Resp Care\nPt remains on mech vent-parameters noted. Attempted wean to PS, but 12, but pt did not tol. Returned to 14 of PS. Suction for thick tan secretions. Will continue mech vent and wean as tol.\n"},{"category":"Nursing/other","chartdate":"2131-09-29 00:00:00.000","description":"Report","row_id":1360463,"text":"Nursing care note\nSee careview for specifics\n\nNeuro: Follows commands intermittenly by moving right side. Purposeful RUE. PERL. Does not open eyes. No movement with LUE.\nResp: Remains on CPAP+PS mode of ventilation. Attempted to decrease PS to 12. RR increased to 40's and TV's decreased to 200's. Returned to PS 14. O2 sats 100%.\nCV: Low grade temp. NSR no ectopy. Normotensive.\nGI: Tolerating TF at goal via PEG tube. No stool.\nGU: Foley. Diuresing with lasix and diamox.\nSkin: Neurosurg at the bedside to remove head sutures and abdominal sutures. All incisions approximated.\nPlan: Pulmonary toilet. Turning pt to left side only.\n"},{"category":"Nursing/other","chartdate":"2131-09-20 00:00:00.000","description":"Report","row_id":1360431,"text":"Nursing Progress Note\nPlease See carvue for specifics:\nNeuro: Pt mostly arouses to voice. Eyes have open spontaneously and to speech. Moves only Right side. Only withdraws to pain on right side. Does follow commands. Gag reflex impaired. Pupils equal and brisk.\nCV: BP 90-140. Maintaining well. Pt becomes HTN with stimuli and then settles on her own w/o and intervention. CVP ^^ at start of shift. IVF stopped and pt given 10mg of lasix with results. CVP currently 17 MD aware. No new orders at this time. HR remains SB-NSR with PAC's. Pt remains afebrile pulses are dopplerable. NA ^^ 153 given 250 D5W bolus\nResp: vent settings unchanged remains on CMV 600X10 5/PEEP. Lungs clear to diminished at the bases. ABG's showing resolving alkolosis. Sats remai >95%.\nGI/GU: Abd soft NT. + BS No BM this shift. OGT remains clamped. Foley patent drng clear yellow urine.\nID: Remains of Kefzol\nEndo: RISS\nPlan: Cont with Q1hr neuro exam. ? Wean from vent. ? Tube feedings.\n"},{"category":"Nursing/other","chartdate":"2131-09-20 00:00:00.000","description":"Report","row_id":1360432,"text":"Respiratory Care\nPt remaiins on mechanical ventilation, attempting CPAP/PSV with poor inspiratory efforts. Remaining on AC. Tube rotated. To CT for scan of the head planned for this afternoon.\n"},{"category":"Nursing/other","chartdate":"2131-09-30 00:00:00.000","description":"Report","row_id":1360464,"text":"NURSING\n SEE CARE VUE FOR SPECIFICS.VSS, LOW GRADE TEMPS OVERNIGHT, 99.6 MAX. NO CHANGES OVERNIGHT IN NEURO STATUS. NO EVENTS.\n CONTINUE TO MONITER HEMODYNAMICS, NEURO STATUS. FOLLOW LABS. CONTINUE ATTEMPT TO WEAN TO TRACH MASK.\n"},{"category":"Nursing/other","chartdate":"2131-09-30 00:00:00.000","description":"Report","row_id":1360465,"text":"Nursing care note\nSee careview for specifics.\nNeuro: PERL. Follows commands intermittently. Remains unable to move LUE.\nResp: No vent changes. Has periods of apnea inbetween periods of tacchypnea that are lasting 2-4 seconds. ABG remains acceptable. O2 sats stable at 100% on CPAP +14PS mode of ventilation. Suctioning for small amounts of thick yellow material. NT suctioned for small amounts thick yellow material.\nCV: Low grade temps. Remains in afib rate of 95-118. Multiple doses of lopressor given as ordered with fair effect. PO dose increased. BP stable.\nGI: Abdomen obese with present BS. Tolerates FS Probalance at goal. Scant amount of stool.\nGU: Foley. Diuresing. Rec's lasix and diamox.\nEndo: Glucoses elevated. Covered with RISS. NPH dose increased this am\nActivity: Pt's bed put in chair position. Pt became tacchycardic, tacchypnic (rate in the 40's). Tolerated <1 hour.\nSocial: Daughter and cousin at the bedside. (proxy)called. Updated on all information. Family requesting a family meeting for possibly Tuesday . Email sent to Dr , Dr , and .\nAll above events/information reported to Dr .\nPlan: Pulmonary toilet. Reposition pt to left side and back only. ?Family meeting.\n\n\n\n\n"},{"category":"Nursing/other","chartdate":"2131-09-20 00:00:00.000","description":"Report","row_id":1360433,"text":"focus update note\nafebrile t max 97.4 warm blankets applied to pt and room temperature increased, EKG perfromed, nsr- sb with pacs, no a fib today seen, sbp goal libralized per neurosurg/icu team to 100-160, nipride gtt weaned off at 1200, currently heartrate 70s nsr, with pacs, SBP 120/60\n\nresp: vent weaning attempted pt exhibited poor effort, making some small breaths on own, poor gag, thick white secretions, pt bites on tube and mouth care is difficult to provide, ETT rotated, lsc to coarse, o2sat 100%\n\nneuro: opens eyes to voice at times spontaneously, pupils slugish bilaterally, neurosurgery/icu team aware, right hand exhibits purposeful movement, reaching for abdomen incision, follows commands consistently on right side, performs \"thumbs up \"sign when asked, moves toes on bed, unable to illicit response from left UE or LE and no spontaneous movement seen, mannitol on hold, free h2o bolus per ogt q 6 hours initiated for increased na 156, serum osmoalities taken q 6 hours last 337,\n\nplan: wean ventilation as tolerated , monitor neuro status closely, head ct this shift, monitor INR, HCT, serum osmoality, na and lytes q 6 hours, goal inr 1.4, goal hct above 30\n\n"},{"category":"Nursing/other","chartdate":"2131-09-21 00:00:00.000","description":"Report","row_id":1360434,"text":"Resp Care Note:\n\nPt cont intub with OETT and on mech vent as per Carevue. Lung counds scat rhonchi improve with suct sm=>mod th pale yellow sput. Pt in NARD on present vent settings; no vent changes required overnoc. Cont mech vent support.\n"},{"category":"Nursing/other","chartdate":"2131-09-19 00:00:00.000","description":"Report","row_id":1360428,"text":"Nursing Progress Note\nPlease see carvue for specifics:\nPt received on call to OR for hemi-craniectomy. Central line and aline placed and pt given 2units of FFP prior to OR. Pt traveled to CT and then directly to OR. Pt received from OR approx 0310 am.\nNEURO: Pt received from OR paralyzed not reversed on prop gtt at 15mcg. No skull on right side. Skull placed in abd. Pupils pinpoint. No movement/response to pain. Prop gtt off at 4am. Pt opening eyes to voice. Pupils 2-3mm brisk on right. Sluggish on left. Slightly withdraws to pain on right side only. Otherwise no noted spontaneous movement. Pt does not follow commands. + gag. Corneal reflex intact.\nCV: Parameter SBP 100-140. HR NSR with frequent PAC's. pt cool temp 95.9 hugger on. BP slowing dropping to high 80's neuro made aware and MD with high 80's to low 90's. MAP remains >60. Pt S/p total of 4units FFP. total since 7p .\nREsp: Remains intubated on A/C TV 600/18 5-peep. Fio2 decreased to 50%. ABG's-met alkolosis Team is aware no intervention. lungs clear to diminished at the bases.\nGI/GU: OGT clamped. + BS + BM in OR. Foley patent drng yellow urine\nID: IV abx\nEndo: RISS\nPlan: Cont with Q1hr neuro checks. Cont with current plan of care\n"},{"category":"Nursing/other","chartdate":"2131-09-26 00:00:00.000","description":"Report","row_id":1360453,"text":"Condition Update B:\nPlease refer to careview and remarks for details.\n\nNeuro exam remains unchanged, following commands with RE's, flacid and no response to painful stimuli LE's. Does not open ou, even to noxius stimuli. PERL 3mm/3mm brisk. Morphine 2mg amdin x2 for resp/pain comfort with effect.\n\nLS dim. Suctioned for small/mod amounts yeelow thick secretions. RR cont in low 30's. Morphine IV amdin xone for RR 35-40 with effect.\n\nPassed large hard stool gauaic neg. Tol TF at goal. No residuals. Diuressing after lasix. -1L at 0700.\n\nMonitoring glucose levels, using RISS and NPH.\n\nDaughter, , is requesting Family meeting with Neuro Med and NSURG. Email sent to SW, , to facilitate meeting.\n\nPLAN: Trach/PEG this week. Glucose levels and effect of NPH and RISS. Neuro checks. Family meeting. Cont with ICU care.\n"},{"category":"Nursing/other","chartdate":"2131-09-26 00:00:00.000","description":"Report","row_id":1360454,"text":"Resp. Care Note\nPt remains intubated and vented on settings as per resp flowsheet. No vent changes made this shift. No ABG's, sats 100%. Plan to cont vent support, ?trache soon.\n"},{"category":"Nursing/other","chartdate":"2131-09-26 00:00:00.000","description":"Report","row_id":1360455,"text":"STATUS\nD: FOLLOWS SIMPLE COMMANDS..NO MOVEMENT OF LF SIDE..DOESN'T OPEN EYES..P=RL\nA: NO VENT CHANGES..SUCTIONED FOR MOD AMT THICK WHITE..ET TUBE MOVED TO LF SIDE..SUCTIONED ORALLY FOR MOD AMT..INCISIONS C&D..LASIX X1 WITH GOOD DIURESES\nR: STABLE\nP: ? TRACH/PEG IN AM\n"},{"category":"Nursing/other","chartdate":"2131-09-27 00:00:00.000","description":"Report","row_id":1360456,"text":"resp. care\npt continues with mech. vent. 9.0 portex placed at bedside. placed on full vent support for trach/sedation. continue to wean to trach mask when awake. see rt flowsheet for more.\n"},{"category":"Nursing/other","chartdate":"2131-09-27 00:00:00.000","description":"Report","row_id":1360457,"text":"STATUS\nD: FOLLOWS SOME SIMPLE COMMANDS MOVES RT SIDE & MIN MOVEMENT OF LF FOOT..P=RL\nA: TF'S ON HOLD..#9 PERC TRACH/PEG PLACED WITHOUT PROB..VEC/FENT/PROP GIVEN FOR PROCEDURE..X-RAY DONE.. PLACED ON AC AFTER UNTIL MEDS WEAR OFF..LASIX GIVEN WITH GOOD EFFECT..STARTING TO WAKE & FOLLOW SOME SIMPLE COMMANDS WITH MUCH ENCOURAGEMENT\nR: STABLE\nP: WILL PLACE BACK ON C-PAP WHEN MORE AWAKE\n"},{"category":"Nursing/other","chartdate":"2131-09-19 00:00:00.000","description":"Report","row_id":1360429,"text":"nsg note\nSEE FLOWSHEET FOR SPECIFICS.\n\nNEURO-PT OPENS EYES TO VOICE. PERRL, RIGHT BRISKER THAN LEFT. PT WIGGLES RIGHT TOES TO COMMAND AND OCC RIGHT FINGERS TO COMMAND. MOVES SL ON BED SPONT ON RIGHT SIDE. NO RESPONSE/MOVEMENT ON LEFT, EVEN TO PAIN. DILANTIN LEVEL LOW, BOLUS GIVEN. MANNITOL STARTED. HEAD DSG C/D/I. HAD CAROTID FLOW STUDY TODAY.\n\nCV-REMAINS IN/OUT OF AFIB. WHEN IN SINUS, PT HAS PACS. SBP MAINTAINED <140. SKIN W+D. +PP. PBOOTS ON. 2 U FFP GIVEN AND 1 U PRBC'S GIVEN. REPEAT LABS PENDING. HAD ECHO TODAY.\n\nRESP-REMAINS VENTED ON CMV. PT WITH MET ALKOLIS THIS AM. RATE DECREASED, WILL FOLLOW ABG. LS CLEAR, DECREASED AT BASES. SXN PRN FOR SM AMT THICK YELLOW SPUTUM.\n\nGI-ABD SOFT, NT/ND. +BS. OGT IN PLACE, CLAMPED. ABD DSG C/D/I.\n\nGU-VOIDING VIA FOLEY ADEQ AMTS CL YELLOW URINE.\n\nENDO-SSRI.\n\nID-AFEB. REMAINS ON KEFZOL.\n\nA-STABLE S/P CRANIECTOMY.\n\nP-CON'T WITH CURRENT PLAN. KEEP SBP <140. FOLLOW HCT/COAGS/ABG. NEURO CHECKS. SUPPORT.\n"},{"category":"Nursing/other","chartdate":"2131-09-19 00:00:00.000","description":"Report","row_id":1360430,"text":"Resp. Care Note\nPt remains intubated and vented on settings as charted on resp flowsheet. Pt with met. alkalosis on ABG's. FiO2 decreased from 50-40% and rate decreased from 15-10 this shift. No oother changes made. Cont support.\n"},{"category":"Nursing/other","chartdate":"2131-09-28 00:00:00.000","description":"Report","row_id":1360458,"text":"CONDITION UPDATE\nVSS. TMAX 103 - PAN CULTURED. NEURO UNCHANGED COMPARED TO PREVIOUS DOCUMENTATION. FOLLOWS COMMANDS INCONSISTENTLY ON RSIDE. MIN MOVEMENT NOTED LFOOT - NO MOVEMENT LARM. PUPILS EQUAL AND BRISKLY REACTIVE. LUNGS CLEAR TO COARSE. OCC SUCTIONING FOR THICK TAN/BLD TINGED SPUTUM. ABD SOFT. NO STOOL THIS SHIFT. U/O QS VIA FOLEY. CTSCAN DONE OF MD'S ORDERS.\nCONT CLOSE NEURO ASSESSMENT. WEAN FROM VENT AS TOLERATES. DISCHARGE PLANNING. FAMILY TEACHING AND SUPPORT. CONT CURRENT ICU CARE AND ASSESSMENTS.\n"},{"category":"Nursing/other","chartdate":"2131-09-28 00:00:00.000","description":"Report","row_id":1360459,"text":"Resp Care\nPt remains on mech vent-parameters noted. Pt has metabolic alkalosis. Suction for thick white secretions. Coarse breath sounds bilat. Will continue mech vent and wean as tol.\n"},{"category":"Nursing/other","chartdate":"2131-09-24 00:00:00.000","description":"Report","row_id":1360447,"text":"ALTERED NEURO STATUS\nO: NEURO : PERL, NO MOVEMENT OF LEFT SIDE, MORE EDEMATOUS THAN RIGHT. RIGHT GRASP STRONG , MOVES RIGHT TOES UPON COMMAND, WILL NOT/CAN NOT OPEN EYES. ABD DSG REMOVED BY NEURO ATTENDING TO LEAVE OTA, NO DRAINAGE. SMALL AMOUNT OF SEROSANG DRAINAGE FROM SKULL INCISION. NO FURTHER DRAINAGE NOTED. SUTURES INTACT. CT NO CHANGE PER HO.\n CARDIAC: SR 70-80'S WITHOUT ATRIAL OR VENTRICULAR TACHYCARDIAS, SBP WITH SX WOULD RISE 180'S RECIEVED LOPRESSOR AS PER ORDERS. SBP 120-140'S. EXTREMITIES WARM. TEMP 99.6. PALP PP\n RESP: VENT SETTINGS AND ABGT PER FLOW , HO AWARE AND NO CHANGE.\nSX FOR A SMALL AMOUNT OF THICK TO THIN TAN TO WHITE SPUTUM. RR TWENTIES TO LOW THIRTIES. O2 SAT> 97%.\n GI: TOLERATING TF AT GOAL. NO STOOL. ABD SOFT. + BOWEL SOUNDS.\n GU: MARGINAL UO.\n ENDO: INSULIN GTT\n PAIN: NO GRIMACING NOTED\n SEIZURE: NO SEIZURE ACTIVITY NOTED, DILANTIN TO BE CHECKED PRIOR TO NEXT DOSE.\n SOCIAL: NEPHEW AND DAUGHTER TO ARRIVE AT 1600 FOR A FAMILY MEETING .\nA: STABLE\nP: MONITOR COMFORT, HR AND RYTHYM, SBP, RESP STATUS, NEURO STATUS- CHECK DILANTIN LEVEL, I+O-UO,LABS. AS PER ORDERS.\n\n\n"},{"category":"Nursing/other","chartdate":"2131-09-25 00:00:00.000","description":"Report","row_id":1360448,"text":"Resp Care Note:\n\nPt cont intub with OETT and on mech vent as per Carevue. Lung sounds ess clear after suct for sm th off white sput. ABGs stable; no vent changes made overnoc. Cont PSV.\n"},{"category":"Nursing/other","chartdate":"2131-09-25 00:00:00.000","description":"Report","row_id":1360449,"text":"Nursing Note 7p-7a:\nNursing Assessment:\n\nPt stable overnight. Moving right side only. Afebrile. PERLA. Tube feeds at goal. Cont. same vent settings. Plan: family meeting at 4pm discuss plan of care and prognosis.\n\nPlease refer to carevue for details/specifics.\n"},{"category":"Nursing/other","chartdate":"2131-09-25 00:00:00.000","description":"Report","row_id":1360450,"text":"Respiratory Care\nPt remains on CPAP/PSV, bilateral breath sounds diminished with scattered rhonchi. Improved aeration after suctioning. Spontaneous respiratory rate upper 20's to mid 30's.\n"},{"category":"Nursing/other","chartdate":"2131-09-25 00:00:00.000","description":"Report","row_id":1360451,"text":"CONDITION UPDATE: SE CARE VUE FOR OJECTIVE DATA AND TRENDS\n\nNEURO: PT UNABLE TO OPEN EYES. PERRL. ABLE TO FOLLOW A FEW SIMPLE COMMANDS. STRONG RIGHT HAND GRASP AND RIGHT FOOT PUSH. NO MOVEMET OF LEFT SIDE. HEAD INCSION APRROXIMATED AND SUTURES CDI.\n\nCV: PT WITH GENERALIZED EDEMA. L-ARM EDEMA GREATER THAN RIGHT. NSR-NO ECTOPY. HR-80-90'S. SBP-150'S/60'S. CONTINUNES ON LOPRESSOR. CVP'S-16-18. PT STARTED ON LASIX . +RADIAL/PT/DP X2. HCT-STABLE. HEPARIN SC/CLS.\n\nRESP: LS-CLEAR-DIMISHED BIBASILER. CONTINUES ON CPAP 5/5. ABD SHOWING GOOD OXGENATION. SAT'S: >95%. SX FOR MODERATE AMTS OF WHITE/YELLOW THICK SPUTUMN.\n\nGI: SD, +BS,S,NT. OGT-PLACEMENT CONFIRMED AND TOLERATING PROBALANCE AT GOAL. R-ABD INCISION APPROXIMATED AND CDI.\n\nGU: FOLEY WITH QS URINE.\n\nENDO: FS QID-COVERAGE PER RISS. STARTED ON NPH .\n\nSKIN: WDI.\n\nSOCIAL: HCP AND DAUGHTER IN TO VISIT. MET WITH SICU TEAM TO DICUSS TRACH AND PEG PLACEMENT-CONSENT GIVEN. BOTH, WOULD LIKE TO SCHEDULE A MEETING OR PHONE CONVERSTAION WITH NEURO .\n\nPLAN: CONTINUE TO MONITOR HEMODYNAMICS AND MANTAIN SBP<160. WEAN VENT SETTINGS AS TOLERATED. CONTINUE WITH DIURESIS. MONITOR LYTES/HCT/ABG'S PRN. PROVIDE EMTOITONAL SUPPORT TO FAMILY.\n"},{"category":"Nursing/other","chartdate":"2131-09-26 00:00:00.000","description":"Report","row_id":1360452,"text":"Resp Care Note:\n\nPt cont intub with OETT and on mech vent as per carevue. Lung sounds ess clear after suct sm th off white sput. ABGs compensated resp acidosis with good oxygenation. Cont PSV ? trach today.\n"},{"category":"Nursing/other","chartdate":"2131-09-19 00:00:00.000","description":"Report","row_id":1360427,"text":"resp care\nremains intub/vented in ac mode. transported to ctscan and then to O.r. s/p hemicraniotomy/evacuation of bleed. presently off sedation but not yet awake enough for , reassess. abg with metabolic alkalosis,pco2 35. c/w airway mgmt/vent support.\n"},{"category":"Nursing/other","chartdate":"2131-09-23 00:00:00.000","description":"Report","row_id":1360441,"text":"Nursing Note 7p-7a:\nNursing assessment:\n\nNeuro: No neuro changes. No movement on left side, no eye opening except to pain, sqeezes eyes shut to voice. Afebrile. Strong right hand grasp. Edema to left upper extremity, elevated on pillows.\n\nCV/GU: On turning and washing, pt began to cough and had Sustained Vtach of 170 for a few minutes and elevated SBP of 230. Returned to baseline and Dr. notified. NO further episodes during night. BP to 170s with coughing and suctioning. Urine output adequate.\n\nGI: bowel sounds hypoactive. Abd. DSD Clean and dry. Tube feeds continue at goal.\n\nREsp: Lungs clear. Suctioned infrequently for thick white secretions. SAme vent settings, A.M. blood gases pending.\n\nPlan: Cont. to monitor neuro exam and CV status. FAmily meeting to be planned tommorrow with neuro to discuss trach/peg and pt's prognosis.\n\nPlease refer to carevue for details.\n"},{"category":"Nursing/other","chartdate":"2131-09-23 00:00:00.000","description":"Report","row_id":1360442,"text":"Respiratory Care\nPt remains on present careview settings, suction for small amount thick white secreations. No changes noted to patient status.\n"},{"category":"Nursing/other","chartdate":"2131-09-23 00:00:00.000","description":"Report","row_id":1360443,"text":"SEE CAREVIEW FOR DETAILS\nFOCUS DATA UPDATE\n\nNEURO: PT ABLE TO OPEN EYES ONCE TODAY, STILL UNABLE TO MOVE LEFT SIDE, MORPHINE GIVEN FOR COMFORT\n\nRESP: ROUTINE CXR TODAY, REMAINS ON CPAP VENT SETTINGS UNCHANGED\n\nCV: AFEBRILE SYS B/P 170, LOPRESSOR 5MG'S GIVEN IVP, LABS SODIUM DECREASED TO 146, SERUM OSMO 303, NEURO- RESIDENT CALLED DOES NOT WANT TO RESTART MANITOL AT THIS TIME CVP INCREASED , MAG AND KCL REPLACEMENT GIVEN\n\nGI: TOL TF'S @ GOAL, NO BM, ABD DSG CLEAN DRY AND INTACT\n\nGU: ADEQUATE HOURLY U/O\n\nA/P: CONTINUE WITH CURRENT PLAN OF CARE\n\n"},{"category":"Nursing/other","chartdate":"2131-09-24 00:00:00.000","description":"Report","row_id":1360444,"text":"Resp Care Note:\n\nPt cont intub with OETT and on mech vent as per Careevue. Lung sounds coarse improve with suct sm th off white sput. ABGs compensated resp acidosis with good oxygenation. Cont PSV.\n"},{"category":"Nursing/other","chartdate":"2131-09-24 00:00:00.000","description":"Report","row_id":1360445,"text":"Nursing nOTe 7p-7a:\nNursing Assessment:\n\nPt is unchanged neurologically and continues to have no movement on left side. Afebrile. Vent no changes, blood gas pending. Suctioned for thick white secretions infrequently. Bp and hr stable tonight. ? Discuss tighter blood sugar control with team, sugars tonight 200-234. ? Insulin gtt. cont. to monitor urine output, dwindling at times. Monitor neuro status.\n\nPlease refer to carevue for specifics.\n"},{"category":"Nursing/other","chartdate":"2131-09-24 00:00:00.000","description":"Report","row_id":1360446,"text":"Respiratory Care\nPt remains on CPAP/PSV, current careview settings throughout the shift. Transported to CT for head scan without incident. Suction for small amounts of thick pale tan secreations.\n"},{"category":"Nursing/other","chartdate":"2131-09-21 00:00:00.000","description":"Report","row_id":1360435,"text":"NURSING UPDATE\nCV:\n TMAX 98.6. MORMOTENSIVE, NIPRIDE GTTS REMAIN OFF. HR NSR W/ PAC'S. FFP 2U TO CORRECT INR 1.5, FOLLOW UP INR PENDING.\n\nRESP:\n SATS 100% CONSISTENTLY. SXN FOR MOD THICK YELLOW SECRETIONS, BREATH SOUNDS CLEAR AFTER SUCTION. NO VENT CHANGES OVERNOC.\n\nNEURO:\n NO NEURO CHANGES. SERUM OSMOLALITY AND SODIUM LEVELS REMAIN ELEVATED...FREE WATER BOLUSES INEFFECTIVE.\n\nGI:\n TUBE FEED AND H2O BOLUS TOLERATED WELL WITH ZERO GASSTRIC RESIDUALS. TUBE FEED UP TO 50CC/H AT THIS TIME. GLUCOSE LEVELS ELEVATED AND TREATED WITH SLIDING SCALE REGULAR INSULIN AS PER ORDER.\n\nPLAN:\nREEVAL SLIDING SCALE TO BETTER CONTROL GLUCOSE.\nCONTINUE ATTEMPTS TO DECREASE SERUM SODIUM AND OSMOLALITY.\nCHANGE TUBE FEED TO LOW SODIUM FORMULA.\n\nDR PRESENT ON UNIT THROUGHOUT SHIFT AND NOTIFIED OF ALL PATIENT DATA.\nSEE CAREVUE FLOWSHEETS FOR DETAILED DATA.\n"},{"category":"Nursing/other","chartdate":"2131-09-21 00:00:00.000","description":"Report","row_id":1360436,"text":"focus data update\nsee careview for details\n\nNEURO: ATTEMPTING TO OPEN EYES UNABLE R/T PERIORBITAL EDEMA, MORPHINE GIVEN FOR COMFORT, RIGHT CRANIAL INCISION CLEAN DRY AND INTACT, MOVING EXT'S ON RIGHT SIDE, UNABLE TO MOVE EXT'S ON LEFT SIDE\n\nRESP: PCO2 GOAL 35, VENT RATE INCREASED, REPEAT ABG'S PENDING\n\nCV: AFEBRILE, NA 156, SERUM OSMO 328, K 3.4 REPLACEMENT K GIVEN,\nSYS GOAL B/P 100-160, NIPRIDE OFF\n\nGI: TF CHANGED TO PROBALANCE, 250CC'S FREE H2O GIVEN Q6, NO BM\n\nGU: ADEQUATE HOURLY U/O\n\nA/P: CONTINUE TO MONITOR, ASSESS AND RX\n"},{"category":"Nursing/other","chartdate":"2131-09-22 00:00:00.000","description":"Report","row_id":1360437,"text":"Resp Care Note:\n\nPt cont intub with OETT and on mech vent as per Carevue. Lung sounds ess clear after suct sm th white sput. ABGs metabolic alkalosis worsening ventilation and oxygenation stable. Cont mech vent support.\n"},{"category":"Radiology","chartdate":"2131-09-18 00:00:00.000","description":"BY SAME PHYSICIAN","row_id":879367,"text":" 9:34 PM\n CT HEAD W/O CONTRAST; -76 BY SAME PHYSICIAN # \n Reason: interval change.\n Admitting Diagnosis: RIGHT FRONTAL LOBE STROKE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with bleed.\n REASON FOR THIS EXAMINATION:\n interval change.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Intracranial hemorrhage. Assess interval change.\n\n COMPARISON: Six hours prior on .\n\n TECHNIQUE: Noncontrast head CT.\n\n FINDINGS: Multiple right frontal parenchymal hematomas appear unchanged.\n There is extensive surrounding edema with resulting shift of the septum\n pellucidum and third ventricle to the left, unchanged compared to 6 hours\n earlier. There is persistent compression of the right frontal and occipital\n horns of the lateral ventricle. There is no evidence of new hemorrhage since\n the previous study. The visualized osseous structures appear unremarkable.\n There is unchanged mucosal thickening in the maxillary sinuses, left greater\n than right. The scout image reveals an endotracheal tube and an orogastric\n tube.\n\n IMPRESSION: Stable appearance of right-sided parenchymal hemorrhage with\n extensive associated edema.\n\n DFDkq\n\n"},{"category":"Radiology","chartdate":"2131-09-18 00:00:00.000","description":"BY DIFFERENT PHYSICIAN","row_id":879366,"text":" 9:16 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: PTX\n Admitting Diagnosis: RIGHT FRONTAL LOBE STROKE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with unresponsive s/p Left CVL placement.\n\n REASON FOR THIS EXAMINATION:\n PTX\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Unresponsive.\n\n Comparison made to the chest x-ray obtained earlier on the same day.\n\n FINDINGS: AP supine portal view of the chest was obtained. There is again\n demonstrated an endotracheal tube in stable position. There has been interval\n placement of a left subclavian central venous catheter with the tip\n terminating at the entrance of the SVC. There is no evidence of pneumothorax.\n There is stable cardiomegaly and prominence of the pulmonary arteries. An\n opacity at the left lung base is again demonstrated, which is unchanged in the\n short interval. A left breast prosthesis is also noted.\n\n IMPRESSION:\n 1. Interval placement of left subclavian central venous catheter without\n evidence of pneumothorax.\n 2. Persistent left lung base opacity, which again could represent atelectasis\n or consolidation.\n\n"},{"category":"Radiology","chartdate":"2131-09-24 00:00:00.000","description":"BY SAME PHYSICIAN","row_id":879998,"text":" 3:57 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: CHF lung congestion\n Admitting Diagnosis: RIGHT FRONTAL LOBE STROKE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with hemmorhagic stroke. Now with pressors and fever.\n\n REASON FOR THIS EXAMINATION:\n CHF lung congestion\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Hemorrhagic stroke, now on pressors.\n\n CHEST: The heart remains enlarged. No failure is seen. The left\n hemidiaphragm is obscured suggesting the presence of consolidation or\n atelectasis in the left lower lobe. The position of the various support lines\n and tubes is unchanged since the prior chest x-ray of 8 hours before.\n\n IMPRESSION: No significant change. Left lower lobe atelectasis and\n consolidation is still present.\n\n\n"},{"category":"ECG","chartdate":"2131-09-28 00:00:00.000","description":"Report","row_id":308556,"text":"Supraventricular tachycardia, rate 145, with one failure of P wave conduction\nwithout apparent warning. P-R interval is slightly prolonged. The P wave is on\nthe T wave. With history of atrial bigeminy and atrial premature beats, there\nhas been predisposition to sustained atrial arrhythmia.\nTRACING 32\n\n"},{"category":"ECG","chartdate":"2131-09-28 00:00:00.000","description":"Report","row_id":308557,"text":"Sinus rhythm. Atrial ectopy. Slight right axis deviation. Compared to the\nprevious tracing of atrial bigeminy is no longer present.\nTRACING #1\n\n"},{"category":"ECG","chartdate":"2131-09-20 00:00:00.000","description":"Report","row_id":308558,"text":"Sinus rhythm and atrial bigeminy. Right axis deviation. Diffuse ST-T wave\nflattening. Compared to the previous tracing of sinus rhythm and\nfrequent atrial ectopy have appeared. The previously recorded ST segment\ndepression has diminished. Clinical correlation is suggested.\n\n"},{"category":"ECG","chartdate":"2131-09-18 00:00:00.000","description":"Report","row_id":308559,"text":"Atrial fibrillation with rapid ventricular response\nDiffuse nonspecific ST-T wave abnormalities\nClinical correlation is suggested\nSince previous tracing of , ventricular rate faster and further ST-T\nwave changes present\n\n"},{"category":"ECG","chartdate":"2131-10-01 00:00:00.000","description":"Report","row_id":308555,"text":"Atrial fibrillation\nInferior T wave changes are nonspecific\nRepolarization changes may be partly due to rhythm\nSince previous tracing, supraventricular tachycardia rhythm now atrial\nfibrillation\n\n"}],"string":"[\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2131-09-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 105266,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Left ventricular function.\\nHeight: (in) 62\\nWeight (lb): 187\\nBSA (m2): 1.86 m2\\nBP (mm Hg): 107/57\\nHR (bpm): 64\\nStatus: Inpatient\\nDate/Time: at 11:14\\nTest: TTE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: Saline\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT ATRIUM: Elongated LA.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. No ASD or PFO by 2D,\\ncolor Doppler or saline contrast with maneuvers.\\n\\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and systolic\\nfunction (LVEF>55%). No resting LVOT gradient. No LV mass/thrombus.\\n\\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\\n\\nAORTA: Normal aortic root diameter. Normal ascending aorta diameter.\\n\\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\\n\\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\\nannular calcification. Mild to moderate (+) MR.\\n\\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR.\\nNormal PA systolic pressure.\\n\\nPERICARDIUM: Small pericardial effusion. No echocardiographic signs of\\ntamponade.\\n\\nGENERAL COMMENTS: Contrast study was performed with 1 iv injection of 8 ccs of\\nagitated normal saline at rest.\\n\\nConclusions:\\nThe left atrium is elongated. The right atrium is moderately dilated. No\\natrial septal defect or patent foramen ovale is seen by 2D, color Doppler or\\nsaline contrast with maneuvers. There is mild symmetric left ventricular\\nhypertrophy with normal cavity size and systolic function (LVEF>55%). No\\nmasses or thrombi are seen in the left ventricle. Right ventricular chamber\\nsize and free wall motion are normal. The aortic valve leaflets (3) are mildly\\nthickened but aortic stenosis is not present. No aortic regurgitation is seen.\\nThe mitral valve leaflets are mildly thickened. There is no mitral valve\\nprolapse. Mild to moderate (+) mitral regurgitation is seen. The tricuspid\\nvalve leaflets are mildly thickened. The estimated pulmonary artery systolic\\npressure is normal. There is a small pericardial effusion. There are no\\nechocardiographic signs of tamponade.\\n\\nCompared with the findings of the prior report (tape unavailable for review)\\nof , significant pulmonary hypertension is no longer detected.\\nOtherwise, probably no change.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-10-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1360472,\n \"text\": \"SICU\\nPlease refer to flowsheet and page 2 for specific info. Patient being transfered to Rehab. facility. Neuro status remains unchanged from previous assessment and continues to follow commands and move extremeties as noted. Helmut on for moving patient. s/p Right hemicraniotomy. Do not position on right side. On phenytoin (gtube) and level on = 11.5. Cont to be in atrial fibrillation with rate 85-110/ min. BP 128/68. Aline and TLC d/c'd, left arm and hand with good perfusion brisk cap refill <2 sec. Resp: Trach #9 portex, simv PS 14/ Vt 600/ fi02 .40/ peep 5. Lung sounds clear and equal / diminished at bases. Sxn via trach for thick tan secretions q 2-4 hours. Oral secretions clear, nares draining thick yellow at times overnight. Gtube with probalance at 55cc/hour. glucose level at 10am 205 NPH 18 units. Reg. 15 units SQ. No further changes from previous assessment. Transfer with ALS / paramedic ambulance. Report given to at # .\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1360438,\n \"text\": \"Nursing Note 7p-7a:\\nNursing Assessment:\\n\\nNeuro: Pt attempts to open eyes to voice, at times opens Right eye to pain. Pupils continue unequal and sluggish. Moves right extremities only, strong grasp on right hand. Occasionally follows commands. Afebrile.\\n\\nCV/GU: urine output adequate, bp and hr stable.\\n\\nGI: tube feeds continue, tolerating well. bowel sounds hypoactive.\\n\\nResp: cont .on vent. am labs alkalotic ph co2 36, Dr. notified and rate decreased. New ABG pending. Lungs clear.\\n\\nPlan: Cont. with current nursing care. Monitor urine output and resp on vent.\\n\\nPlease refer to carevue for details.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1360439,\n \"text\": \"focus data update\\nsee careview for details\\n\\nNEURO: neuro exam unchanged, decreased periorbital edema noted, morphine given for comfort\\n\\nRESP: Vent changed to CPAP, tol well, abg's done post vent change, suctioned for mod amt of thick white secretions both orally and ett\\n\\nCV: HR NSR, sys b/p < 160, off gtt's, a-line patent, multi-lumen central line patent, NA decreased 151, serum osmo 317, labs redrawn @ 1600 awaiting results\\n\\nGI: tol TF @ goal, no BM\\n\\nGU: adequate hourly u/o\\n\\nA/P: continue to assess and treat, continue both emotional and education support to both patient and family\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1360440,\n \"text\": \"Resp Care Note:\\n\\nPt cont intub with OETT and on mech vent as per Carevue. Lung sounds coarse suct sm th white sput. Pt in NARD; no vent changes required overnoc. Cont PSV.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1360466,\n \"text\": \"Resp Care\\nPt remains on PSV-parameters noted. Pt continues to have periods of apnea. Blood gas shows metabolic alkalosis and vitals are stable. Will continue on CPAP as tol.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-10-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1360467,\n \"text\": \"NURSING\\n SEE CARE VUE FOR SPECIFICS. INCREASED DOSE OF LOPRESSOR VIA G TUBE HAS DECREASED RATE BUT CONTINUES IN A-FIBB.MAGNESIUM REPLETED THIS AM, OTHER LYTES WNL. DAY 2 OF ACETAZOLIMIDE, CONTINUES WITH LASIX .\\n NEURO SIGNS UNCHANGED WITH THE EXCEPTION OF PERIODS OF APNEA WHICH INCREASED OVER THE DAY AND NIGHT TO >30 SECONDS. PLACED ON SIMV WITH A RATE OF 10, PS AND PEEP UNCHANGED. ABG AFTER SIMV CHANGE WNL.\\n CONTINUE TO MONITER NEURO AND MENTAL STATUS. FOLLOW LABS, CONINTUE WITH NPH INSULIN AND SLIDING SCALE. ATTEMPT TO BEGIN TO WEAN OFF VENT AGAIN TODAY\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-10-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1360468,\n \"text\": \"Resp Care, cont on settings as noted, no vent changes. Pt had stable shift , plan to cont with current tx.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-10-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1360469,\n \"text\": \"SICU nursing progress note\\nPlease refer to flowsheet for specific info.\\n\\nNEuro: Unchanged from previous assessment. Continues to follow commands as previously noted. Cont on dilantin. Level 11.7 today. Helmut on for positioning, turning only to left and supine r/t right hemi- craniotomy.\\n\\nResp: Sxned via trach for thick tan secretions. LS clear and equal bilaterally, decreased at bases. Sat's >98%/ ABG this morning wnl.\\n\\nCV: Cont to be in Afib. BP stable and systolic between 110-130's. Lopressor 50mg given via gtube and approx. 1 hour afterwards had a pause with HR to 20/min. Returned to baseline hr of 80 quickly without immediate intervention. Lopressor decreased to 37.5mg q 12.\\n\\nLytes/ Endo: glucose continues to be treated by sliding scale coverage. Lytes: K+ replenished with 40 meq KCL x 1. Other labs wnl.\\n\\nGI: On goal tube feedings through Gtube, probalance formula. Medium formed stool today x 1, yellow brown in color.\\n\\nGU: 20 mg cont to be given with good effect. UOP >30 / hour, and after lasix ^120cc/ hour.\\n\\nSocial: Spokesperson called and updated and verbalizing understanding. Family meeting may be scheduled for tomorrow/ Tuesday. Social Services updated. Meeting time not set at this time.\\n\\nPlan: Cont to check neuro status q 2 hours and prn, Follow glucose/ fingerstick's for sliding scale regular insulin coverage q 6 hours. NPH . Cont to update, support spokesperson. D/c plan is ongoing.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-10-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1360470,\n \"text\": \"assessment as noted\\n\\nRES: CLEAR/DIM LS WITH THICK TAN SPUTUM SUCTIONED Q 4H, +STRONG COUGH-CONGESTED, NO VENT CHANGES, ABG WNL, CONSISTENT NASAL DRAINAGE-YELLOW THICK FROM BOTH NOSTRILS-?SINUSITIS\\n\\nCV: IN AFIB, +WEAK PEDAL PULSES, BP STABLE\\n\\nNEURO: NO EYE OPENING, INCONSISTANTLY FOLLOWS SIMPLE COMMANDS, PERL, L.ARM FLACCID, NO SEZURE ACTIVITY NOTED, ON DILANTIN AS ORDERED\\n\\nGU: 20/H MOST OF THE NIGHT, 200+ WITH LASIX\\n\\nGI: HAD BM X 1(SENT TO OB), TOLERATES TF WELL\\n\\nLABD: RISS INUSE, MAG WAS REPLETED\\n\\nPLAN: SYMPTOMSTIC TREATMENT, TRY TO WEAN VENT DOWN\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-10-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1360471,\n \"text\": \"resp care\\npt remained on imv 600x10 40% 5peep with 0-10 spont breaths. BS coarse bil. Suct for thick yellow sput.ABG acceptable this am.Will follow.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1360460,\n \"text\": \"STATUS\\nD: NEURO UNCHANGED..MOVES RT SIDE & SL MOVEMENT OF LF LEG..NO MOVEMENT OF MLF ARM..WILL FOLLOW SOME SIMPLE COMMANDS BUT ON OCCASSION NEEDS MUCH ENCOURAGEMENT\\nA: VENT WEANED TO C-PAP..SUCTIONED FOR MOD AMT THICK RUST COLORED.. LF SUBCLAVIAN LINE CHANGED OVER WIRE & TIP SENT FOR CULT..X-RAY DONE.. TF'S WELL..INCREASED HUO AFTER LASIX..PT PLACED ON LF SIDE>>RAPID A FIB 140-150'S>>ABG/LAB'S SENT>>EKG DONE>>5MGM LOPRESSOR GIVEN>>SR WITH PAC'S & OCC BURST'S A FIB..HELMET ON\\nR: AWAITING LAB RESULTS\\nP: WILL REPLETE ALL LOW LAB'S..CONTINUE TO MONITOR VS CLOSELY\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1360461,\n \"text\": \"RESP. CARE:\\n PT. REMAINS ON VENT.SUPPORT. PLEASE SEE FLOW SHEET. NO CHANGES IN RESP. STATUS OVERNIGHT. =159.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1360462,\n \"text\": \"Resp Care\\nPt remains on mech vent-parameters noted. Attempted wean to PS, but 12, but pt did not tol. Returned to 14 of PS. Suction for thick tan secretions. Will continue mech vent and wean as tol.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1360463,\n \"text\": \"Nursing care note\\nSee careview for specifics\\n\\nNeuro: Follows commands intermittenly by moving right side. Purposeful RUE. PERL. Does not open eyes. No movement with LUE.\\nResp: Remains on CPAP+PS mode of ventilation. Attempted to decrease PS to 12. RR increased to 40's and TV's decreased to 200's. Returned to PS 14. O2 sats 100%.\\nCV: Low grade temp. NSR no ectopy. Normotensive.\\nGI: Tolerating TF at goal via PEG tube. No stool.\\nGU: Foley. Diuresing with lasix and diamox.\\nSkin: Neurosurg at the bedside to remove head sutures and abdominal sutures. All incisions approximated.\\nPlan: Pulmonary toilet. Turning pt to left side only.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1360431,\n \"text\": \"Nursing Progress Note\\nPlease See carvue for specifics:\\nNeuro: Pt mostly arouses to voice. Eyes have open spontaneously and to speech. Moves only Right side. Only withdraws to pain on right side. Does follow commands. Gag reflex impaired. Pupils equal and brisk.\\nCV: BP 90-140. Maintaining well. Pt becomes HTN with stimuli and then settles on her own w/o and intervention. CVP ^^ at start of shift. IVF stopped and pt given 10mg of lasix with results. CVP currently 17 MD aware. No new orders at this time. HR remains SB-NSR with PAC's. Pt remains afebrile pulses are dopplerable. NA ^^ 153 given 250 D5W bolus\\nResp: vent settings unchanged remains on CMV 600X10 5/PEEP. Lungs clear to diminished at the bases. ABG's showing resolving alkolosis. Sats remai >95%.\\nGI/GU: Abd soft NT. + BS No BM this shift. OGT remains clamped. Foley patent drng clear yellow urine.\\nID: Remains of Kefzol\\nEndo: RISS\\nPlan: Cont with Q1hr neuro exam. ? Wean from vent. ? Tube feedings.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1360432,\n \"text\": \"Respiratory Care\\nPt remaiins on mechanical ventilation, attempting CPAP/PSV with poor inspiratory efforts. Remaining on AC. Tube rotated. To CT for scan of the head planned for this afternoon.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1360464,\n \"text\": \"NURSING\\n SEE CARE VUE FOR SPECIFICS.VSS, LOW GRADE TEMPS OVERNIGHT, 99.6 MAX. NO CHANGES OVERNIGHT IN NEURO STATUS. NO EVENTS.\\n CONTINUE TO MONITER HEMODYNAMICS, NEURO STATUS. FOLLOW LABS. CONTINUE ATTEMPT TO WEAN TO TRACH MASK.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1360465,\n \"text\": \"Nursing care note\\nSee careview for specifics.\\nNeuro: PERL. Follows commands intermittently. Remains unable to move LUE.\\nResp: No vent changes. Has periods of apnea inbetween periods of tacchypnea that are lasting 2-4 seconds. ABG remains acceptable. O2 sats stable at 100% on CPAP +14PS mode of ventilation. Suctioning for small amounts of thick yellow material. NT suctioned for small amounts thick yellow material.\\nCV: Low grade temps. Remains in afib rate of 95-118. Multiple doses of lopressor given as ordered with fair effect. PO dose increased. BP stable.\\nGI: Abdomen obese with present BS. Tolerates FS Probalance at goal. Scant amount of stool.\\nGU: Foley. Diuresing. Rec's lasix and diamox.\\nEndo: Glucoses elevated. Covered with RISS. NPH dose increased this am\\nActivity: Pt's bed put in chair position. Pt became tacchycardic, tacchypnic (rate in the 40's). Tolerated <1 hour.\\nSocial: Daughter and cousin at the bedside. (proxy)called. Updated on all information. Family requesting a family meeting for possibly Tuesday . Email sent to Dr , Dr , and .\\nAll above events/information reported to Dr .\\nPlan: Pulmonary toilet. Reposition pt to left side and back only. ?Family meeting.\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1360433,\n \"text\": \"focus update note\\nafebrile t max 97.4 warm blankets applied to pt and room temperature increased, EKG perfromed, nsr- sb with pacs, no a fib today seen, sbp goal libralized per neurosurg/icu team to 100-160, nipride gtt weaned off at 1200, currently heartrate 70s nsr, with pacs, SBP 120/60\\n\\nresp: vent weaning attempted pt exhibited poor effort, making some small breaths on own, poor gag, thick white secretions, pt bites on tube and mouth care is difficult to provide, ETT rotated, lsc to coarse, o2sat 100%\\n\\nneuro: opens eyes to voice at times spontaneously, pupils slugish bilaterally, neurosurgery/icu team aware, right hand exhibits purposeful movement, reaching for abdomen incision, follows commands consistently on right side, performs \\\"thumbs up \\\"sign when asked, moves toes on bed, unable to illicit response from left UE or LE and no spontaneous movement seen, mannitol on hold, free h2o bolus per ogt q 6 hours initiated for increased na 156, serum osmoalities taken q 6 hours last 337,\\n\\nplan: wean ventilation as tolerated , monitor neuro status closely, head ct this shift, monitor INR, HCT, serum osmoality, na and lytes q 6 hours, goal inr 1.4, goal hct above 30\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1360434,\n \"text\": \"Resp Care Note:\\n\\nPt cont intub with OETT and on mech vent as per Carevue. Lung counds scat rhonchi improve with suct sm=>mod th pale yellow sput. Pt in NARD on present vent settings; no vent changes required overnoc. Cont mech vent support.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1360428,\n \"text\": \"Nursing Progress Note\\nPlease see carvue for specifics:\\nPt received on call to OR for hemi-craniectomy. Central line and aline placed and pt given 2units of FFP prior to OR. Pt traveled to CT and then directly to OR. Pt received from OR approx 0310 am.\\nNEURO: Pt received from OR paralyzed not reversed on prop gtt at 15mcg. No skull on right side. Skull placed in abd. Pupils pinpoint. No movement/response to pain. Prop gtt off at 4am. Pt opening eyes to voice. Pupils 2-3mm brisk on right. Sluggish on left. Slightly withdraws to pain on right side only. Otherwise no noted spontaneous movement. Pt does not follow commands. + gag. Corneal reflex intact.\\nCV: Parameter SBP 100-140. HR NSR with frequent PAC's. pt cool temp 95.9 hugger on. BP slowing dropping to high 80's neuro made aware and MD with high 80's to low 90's. MAP remains >60. Pt S/p total of 4units FFP. total since 7p .\\nREsp: Remains intubated on A/C TV 600/18 5-peep. Fio2 decreased to 50%. ABG's-met alkolosis Team is aware no intervention. lungs clear to diminished at the bases.\\nGI/GU: OGT clamped. + BS + BM in OR. Foley patent drng yellow urine\\nID: IV abx\\nEndo: RISS\\nPlan: Cont with Q1hr neuro checks. Cont with current plan of care\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1360453,\n \"text\": \"Condition Update B:\\nPlease refer to careview and remarks for details.\\n\\nNeuro exam remains unchanged, following commands with RE's, flacid and no response to painful stimuli LE's. Does not open ou, even to noxius stimuli. PERL 3mm/3mm brisk. Morphine 2mg amdin x2 for resp/pain comfort with effect.\\n\\nLS dim. Suctioned for small/mod amounts yeelow thick secretions. RR cont in low 30's. Morphine IV amdin xone for RR 35-40 with effect.\\n\\nPassed large hard stool gauaic neg. Tol TF at goal. No residuals. Diuressing after lasix. -1L at 0700.\\n\\nMonitoring glucose levels, using RISS and NPH.\\n\\nDaughter, , is requesting Family meeting with Neuro Med and NSURG. Email sent to SW, , to facilitate meeting.\\n\\nPLAN: Trach/PEG this week. Glucose levels and effect of NPH and RISS. Neuro checks. Family meeting. Cont with ICU care.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1360454,\n \"text\": \"Resp. Care Note\\nPt remains intubated and vented on settings as per resp flowsheet. No vent changes made this shift. No ABG's, sats 100%. Plan to cont vent support, ?trache soon.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1360455,\n \"text\": \"STATUS\\nD: FOLLOWS SIMPLE COMMANDS..NO MOVEMENT OF LF SIDE..DOESN'T OPEN EYES..P=RL\\nA: NO VENT CHANGES..SUCTIONED FOR MOD AMT THICK WHITE..ET TUBE MOVED TO LF SIDE..SUCTIONED ORALLY FOR MOD AMT..INCISIONS C&D..LASIX X1 WITH GOOD DIURESES\\nR: STABLE\\nP: ? TRACH/PEG IN AM\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1360456,\n \"text\": \"resp. care\\npt continues with mech. vent. 9.0 portex placed at bedside. placed on full vent support for trach/sedation. continue to wean to trach mask when awake. see rt flowsheet for more.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1360457,\n \"text\": \"STATUS\\nD: FOLLOWS SOME SIMPLE COMMANDS MOVES RT SIDE & MIN MOVEMENT OF LF FOOT..P=RL\\nA: TF'S ON HOLD..#9 PERC TRACH/PEG PLACED WITHOUT PROB..VEC/FENT/PROP GIVEN FOR PROCEDURE..X-RAY DONE.. PLACED ON AC AFTER UNTIL MEDS WEAR OFF..LASIX GIVEN WITH GOOD EFFECT..STARTING TO WAKE & FOLLOW SOME SIMPLE COMMANDS WITH MUCH ENCOURAGEMENT\\nR: STABLE\\nP: WILL PLACE BACK ON C-PAP WHEN MORE AWAKE\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1360429,\n \"text\": \"nsg note\\nSEE FLOWSHEET FOR SPECIFICS.\\n\\nNEURO-PT OPENS EYES TO VOICE. PERRL, RIGHT BRISKER THAN LEFT. PT WIGGLES RIGHT TOES TO COMMAND AND OCC RIGHT FINGERS TO COMMAND. MOVES SL ON BED SPONT ON RIGHT SIDE. NO RESPONSE/MOVEMENT ON LEFT, EVEN TO PAIN. DILANTIN LEVEL LOW, BOLUS GIVEN. MANNITOL STARTED. HEAD DSG C/D/I. HAD CAROTID FLOW STUDY TODAY.\\n\\nCV-REMAINS IN/OUT OF AFIB. WHEN IN SINUS, PT HAS PACS. SBP MAINTAINED <140. SKIN W+D. +PP. PBOOTS ON. 2 U FFP GIVEN AND 1 U PRBC'S GIVEN. REPEAT LABS PENDING. HAD ECHO TODAY.\\n\\nRESP-REMAINS VENTED ON CMV. PT WITH MET ALKOLIS THIS AM. RATE DECREASED, WILL FOLLOW ABG. LS CLEAR, DECREASED AT BASES. SXN PRN FOR SM AMT THICK YELLOW SPUTUM.\\n\\nGI-ABD SOFT, NT/ND. +BS. OGT IN PLACE, CLAMPED. ABD DSG C/D/I.\\n\\nGU-VOIDING VIA FOLEY ADEQ AMTS CL YELLOW URINE.\\n\\nENDO-SSRI.\\n\\nID-AFEB. REMAINS ON KEFZOL.\\n\\nA-STABLE S/P CRANIECTOMY.\\n\\nP-CON'T WITH CURRENT PLAN. KEEP SBP <140. FOLLOW HCT/COAGS/ABG. NEURO CHECKS. SUPPORT.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1360430,\n \"text\": \"Resp. Care Note\\nPt remains intubated and vented on settings as charted on resp flowsheet. Pt with met. alkalosis on ABG's. FiO2 decreased from 50-40% and rate decreased from 15-10 this shift. No oother changes made. Cont support.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1360458,\n \"text\": \"CONDITION UPDATE\\nVSS. TMAX 103 - PAN CULTURED. NEURO UNCHANGED COMPARED TO PREVIOUS DOCUMENTATION. FOLLOWS COMMANDS INCONSISTENTLY ON RSIDE. MIN MOVEMENT NOTED LFOOT - NO MOVEMENT LARM. PUPILS EQUAL AND BRISKLY REACTIVE. LUNGS CLEAR TO COARSE. OCC SUCTIONING FOR THICK TAN/BLD TINGED SPUTUM. ABD SOFT. NO STOOL THIS SHIFT. U/O QS VIA FOLEY. CTSCAN DONE OF MD'S ORDERS.\\nCONT CLOSE NEURO ASSESSMENT. WEAN FROM VENT AS TOLERATES. DISCHARGE PLANNING. FAMILY TEACHING AND SUPPORT. CONT CURRENT ICU CARE AND ASSESSMENTS.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1360459,\n \"text\": \"Resp Care\\nPt remains on mech vent-parameters noted. Pt has metabolic alkalosis. Suction for thick white secretions. Coarse breath sounds bilat. Will continue mech vent and wean as tol.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1360447,\n \"text\": \"ALTERED NEURO STATUS\\nO: NEURO : PERL, NO MOVEMENT OF LEFT SIDE, MORE EDEMATOUS THAN RIGHT. RIGHT GRASP STRONG , MOVES RIGHT TOES UPON COMMAND, WILL NOT/CAN NOT OPEN EYES. ABD DSG REMOVED BY NEURO ATTENDING TO LEAVE OTA, NO DRAINAGE. SMALL AMOUNT OF SEROSANG DRAINAGE FROM SKULL INCISION. NO FURTHER DRAINAGE NOTED. SUTURES INTACT. CT NO CHANGE PER HO.\\n CARDIAC: SR 70-80'S WITHOUT ATRIAL OR VENTRICULAR TACHYCARDIAS, SBP WITH SX WOULD RISE 180'S RECIEVED LOPRESSOR AS PER ORDERS. SBP 120-140'S. EXTREMITIES WARM. TEMP 99.6. PALP PP\\n RESP: VENT SETTINGS AND ABGT PER FLOW , HO AWARE AND NO CHANGE.\\nSX FOR A SMALL AMOUNT OF THICK TO THIN TAN TO WHITE SPUTUM. RR TWENTIES TO LOW THIRTIES. O2 SAT> 97%.\\n GI: TOLERATING TF AT GOAL. NO STOOL. ABD SOFT. + BOWEL SOUNDS.\\n GU: MARGINAL UO.\\n ENDO: INSULIN GTT\\n PAIN: NO GRIMACING NOTED\\n SEIZURE: NO SEIZURE ACTIVITY NOTED, DILANTIN TO BE CHECKED PRIOR TO NEXT DOSE.\\n SOCIAL: NEPHEW AND DAUGHTER TO ARRIVE AT 1600 FOR A FAMILY MEETING .\\nA: STABLE\\nP: MONITOR COMFORT, HR AND RYTHYM, SBP, RESP STATUS, NEURO STATUS- CHECK DILANTIN LEVEL, I+O-UO,LABS. AS PER ORDERS.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1360448,\n \"text\": \"Resp Care Note:\\n\\nPt cont intub with OETT and on mech vent as per Carevue. Lung sounds ess clear after suct for sm th off white sput. ABGs stable; no vent changes made overnoc. Cont PSV.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1360449,\n \"text\": \"Nursing Note 7p-7a:\\nNursing Assessment:\\n\\nPt stable overnight. Moving right side only. Afebrile. PERLA. Tube feeds at goal. Cont. same vent settings. Plan: family meeting at 4pm discuss plan of care and prognosis.\\n\\nPlease refer to carevue for details/specifics.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1360450,\n \"text\": \"Respiratory Care\\nPt remains on CPAP/PSV, bilateral breath sounds diminished with scattered rhonchi. Improved aeration after suctioning. Spontaneous respiratory rate upper 20's to mid 30's.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1360451,\n \"text\": \"CONDITION UPDATE: SE CARE VUE FOR OJECTIVE DATA AND TRENDS\\n\\nNEURO: PT UNABLE TO OPEN EYES. PERRL. ABLE TO FOLLOW A FEW SIMPLE COMMANDS. STRONG RIGHT HAND GRASP AND RIGHT FOOT PUSH. NO MOVEMET OF LEFT SIDE. HEAD INCSION APRROXIMATED AND SUTURES CDI.\\n\\nCV: PT WITH GENERALIZED EDEMA. L-ARM EDEMA GREATER THAN RIGHT. NSR-NO ECTOPY. HR-80-90'S. SBP-150'S/60'S. CONTINUNES ON LOPRESSOR. CVP'S-16-18. PT STARTED ON LASIX . +RADIAL/PT/DP X2. HCT-STABLE. HEPARIN SC/CLS.\\n\\nRESP: LS-CLEAR-DIMISHED BIBASILER. CONTINUES ON CPAP 5/5. ABD SHOWING GOOD OXGENATION. SAT'S: >95%. SX FOR MODERATE AMTS OF WHITE/YELLOW THICK SPUTUMN.\\n\\nGI: SD, +BS,S,NT. OGT-PLACEMENT CONFIRMED AND TOLERATING PROBALANCE AT GOAL. R-ABD INCISION APPROXIMATED AND CDI.\\n\\nGU: FOLEY WITH QS URINE.\\n\\nENDO: FS QID-COVERAGE PER RISS. STARTED ON NPH .\\n\\nSKIN: WDI.\\n\\nSOCIAL: HCP AND DAUGHTER IN TO VISIT. MET WITH SICU TEAM TO DICUSS TRACH AND PEG PLACEMENT-CONSENT GIVEN. BOTH, WOULD LIKE TO SCHEDULE A MEETING OR PHONE CONVERSTAION WITH NEURO .\\n\\nPLAN: CONTINUE TO MONITOR HEMODYNAMICS AND MANTAIN SBP<160. WEAN VENT SETTINGS AS TOLERATED. CONTINUE WITH DIURESIS. MONITOR LYTES/HCT/ABG'S PRN. PROVIDE EMTOITONAL SUPPORT TO FAMILY.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1360452,\n \"text\": \"Resp Care Note:\\n\\nPt cont intub with OETT and on mech vent as per carevue. Lung sounds ess clear after suct sm th off white sput. ABGs compensated resp acidosis with good oxygenation. Cont PSV ? trach today.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1360427,\n \"text\": \"resp care\\nremains intub/vented in ac mode. transported to ctscan and then to O.r. s/p hemicraniotomy/evacuation of bleed. presently off sedation but not yet awake enough for , reassess. abg with metabolic alkalosis,pco2 35. c/w airway mgmt/vent support.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1360441,\n \"text\": \"Nursing Note 7p-7a:\\nNursing assessment:\\n\\nNeuro: No neuro changes. No movement on left side, no eye opening except to pain, sqeezes eyes shut to voice. Afebrile. Strong right hand grasp. Edema to left upper extremity, elevated on pillows.\\n\\nCV/GU: On turning and washing, pt began to cough and had Sustained Vtach of 170 for a few minutes and elevated SBP of 230. Returned to baseline and Dr. notified. NO further episodes during night. BP to 170s with coughing and suctioning. Urine output adequate.\\n\\nGI: bowel sounds hypoactive. Abd. DSD Clean and dry. Tube feeds continue at goal.\\n\\nREsp: Lungs clear. Suctioned infrequently for thick white secretions. SAme vent settings, A.M. blood gases pending.\\n\\nPlan: Cont. to monitor neuro exam and CV status. FAmily meeting to be planned tommorrow with neuro to discuss trach/peg and pt's prognosis.\\n\\nPlease refer to carevue for details.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1360442,\n \"text\": \"Respiratory Care\\nPt remains on present careview settings, suction for small amount thick white secreations. No changes noted to patient status.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1360443,\n \"text\": \"SEE CAREVIEW FOR DETAILS\\nFOCUS DATA UPDATE\\n\\nNEURO: PT ABLE TO OPEN EYES ONCE TODAY, STILL UNABLE TO MOVE LEFT SIDE, MORPHINE GIVEN FOR COMFORT\\n\\nRESP: ROUTINE CXR TODAY, REMAINS ON CPAP VENT SETTINGS UNCHANGED\\n\\nCV: AFEBRILE SYS B/P 170, LOPRESSOR 5MG'S GIVEN IVP, LABS SODIUM DECREASED TO 146, SERUM OSMO 303, NEURO- RESIDENT CALLED DOES NOT WANT TO RESTART MANITOL AT THIS TIME CVP INCREASED , MAG AND KCL REPLACEMENT GIVEN\\n\\nGI: TOL TF'S @ GOAL, NO BM, ABD DSG CLEAN DRY AND INTACT\\n\\nGU: ADEQUATE HOURLY U/O\\n\\nA/P: CONTINUE WITH CURRENT PLAN OF CARE\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1360444,\n \"text\": \"Resp Care Note:\\n\\nPt cont intub with OETT and on mech vent as per Careevue. Lung sounds coarse improve with suct sm th off white sput. ABGs compensated resp acidosis with good oxygenation. Cont PSV.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1360445,\n \"text\": \"Nursing nOTe 7p-7a:\\nNursing Assessment:\\n\\nPt is unchanged neurologically and continues to have no movement on left side. Afebrile. Vent no changes, blood gas pending. Suctioned for thick white secretions infrequently. Bp and hr stable tonight. ? Discuss tighter blood sugar control with team, sugars tonight 200-234. ? Insulin gtt. cont. to monitor urine output, dwindling at times. Monitor neuro status.\\n\\nPlease refer to carevue for specifics.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1360446,\n \"text\": \"Respiratory Care\\nPt remains on CPAP/PSV, current careview settings throughout the shift. Transported to CT for head scan without incident. Suction for small amounts of thick pale tan secreations.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1360435,\n \"text\": \"NURSING UPDATE\\nCV:\\n TMAX 98.6. MORMOTENSIVE, NIPRIDE GTTS REMAIN OFF. HR NSR W/ PAC'S. FFP 2U TO CORRECT INR 1.5, FOLLOW UP INR PENDING.\\n\\nRESP:\\n SATS 100% CONSISTENTLY. SXN FOR MOD THICK YELLOW SECRETIONS, BREATH SOUNDS CLEAR AFTER SUCTION. NO VENT CHANGES OVERNOC.\\n\\nNEURO:\\n NO NEURO CHANGES. SERUM OSMOLALITY AND SODIUM LEVELS REMAIN ELEVATED...FREE WATER BOLUSES INEFFECTIVE.\\n\\nGI:\\n TUBE FEED AND H2O BOLUS TOLERATED WELL WITH ZERO GASSTRIC RESIDUALS. TUBE FEED UP TO 50CC/H AT THIS TIME. GLUCOSE LEVELS ELEVATED AND TREATED WITH SLIDING SCALE REGULAR INSULIN AS PER ORDER.\\n\\nPLAN:\\nREEVAL SLIDING SCALE TO BETTER CONTROL GLUCOSE.\\nCONTINUE ATTEMPTS TO DECREASE SERUM SODIUM AND OSMOLALITY.\\nCHANGE TUBE FEED TO LOW SODIUM FORMULA.\\n\\nDR PRESENT ON UNIT THROUGHOUT SHIFT AND NOTIFIED OF ALL PATIENT DATA.\\nSEE CAREVUE FLOWSHEETS FOR DETAILED DATA.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1360436,\n \"text\": \"focus data update\\nsee careview for details\\n\\nNEURO: ATTEMPTING TO OPEN EYES UNABLE R/T PERIORBITAL EDEMA, MORPHINE GIVEN FOR COMFORT, RIGHT CRANIAL INCISION CLEAN DRY AND INTACT, MOVING EXT'S ON RIGHT SIDE, UNABLE TO MOVE EXT'S ON LEFT SIDE\\n\\nRESP: PCO2 GOAL 35, VENT RATE INCREASED, REPEAT ABG'S PENDING\\n\\nCV: AFEBRILE, NA 156, SERUM OSMO 328, K 3.4 REPLACEMENT K GIVEN,\\nSYS GOAL B/P 100-160, NIPRIDE OFF\\n\\nGI: TF CHANGED TO PROBALANCE, 250CC'S FREE H2O GIVEN Q6, NO BM\\n\\nGU: ADEQUATE HOURLY U/O\\n\\nA/P: CONTINUE TO MONITOR, ASSESS AND RX\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1360437,\n \"text\": \"Resp Care Note:\\n\\nPt cont intub with OETT and on mech vent as per Carevue. Lung sounds ess clear after suct sm th white sput. ABGs metabolic alkalosis worsening ventilation and oxygenation stable. Cont mech vent support.\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2131-09-18 00:00:00.000\",\n \"description\": \"BY SAME PHYSICIAN\",\n \"row_id\": 879367,\n \"text\": \" 9:34 PM\\n CT HEAD W/O CONTRAST; -76 BY SAME PHYSICIAN # \\n Reason: interval change.\\n Admitting Diagnosis: RIGHT FRONTAL LOBE STROKE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 83 year old woman with bleed.\\n REASON FOR THIS EXAMINATION:\\n interval change.\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Intracranial hemorrhage. Assess interval change.\\n\\n COMPARISON: Six hours prior on .\\n\\n TECHNIQUE: Noncontrast head CT.\\n\\n FINDINGS: Multiple right frontal parenchymal hematomas appear unchanged.\\n There is extensive surrounding edema with resulting shift of the septum\\n pellucidum and third ventricle to the left, unchanged compared to 6 hours\\n earlier. There is persistent compression of the right frontal and occipital\\n horns of the lateral ventricle. There is no evidence of new hemorrhage since\\n the previous study. The visualized osseous structures appear unremarkable.\\n There is unchanged mucosal thickening in the maxillary sinuses, left greater\\n than right. The scout image reveals an endotracheal tube and an orogastric\\n tube.\\n\\n IMPRESSION: Stable appearance of right-sided parenchymal hemorrhage with\\n extensive associated edema.\\n\\n DFDkq\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2131-09-18 00:00:00.000\",\n \"description\": \"BY DIFFERENT PHYSICIAN\",\n \"row_id\": 879366,\n \"text\": \" 9:16 PM\\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \\n Reason: PTX\\n Admitting Diagnosis: RIGHT FRONTAL LOBE STROKE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 83 year old woman with unresponsive s/p Left CVL placement.\\n\\n REASON FOR THIS EXAMINATION:\\n PTX\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Unresponsive.\\n\\n Comparison made to the chest x-ray obtained earlier on the same day.\\n\\n FINDINGS: AP supine portal view of the chest was obtained. There is again\\n demonstrated an endotracheal tube in stable position. There has been interval\\n placement of a left subclavian central venous catheter with the tip\\n terminating at the entrance of the SVC. There is no evidence of pneumothorax.\\n There is stable cardiomegaly and prominence of the pulmonary arteries. An\\n opacity at the left lung base is again demonstrated, which is unchanged in the\\n short interval. A left breast prosthesis is also noted.\\n\\n IMPRESSION:\\n 1. Interval placement of left subclavian central venous catheter without\\n evidence of pneumothorax.\\n 2. Persistent left lung base opacity, which again could represent atelectasis\\n or consolidation.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2131-09-24 00:00:00.000\",\n \"description\": \"BY SAME PHYSICIAN\",\n \"row_id\": 879998,\n \"text\": \" 3:57 PM\\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \\n Reason: CHF lung congestion\\n Admitting Diagnosis: RIGHT FRONTAL LOBE STROKE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 83 year old woman with hemmorhagic stroke. Now with pressors and fever.\\n\\n REASON FOR THIS EXAMINATION:\\n CHF lung congestion\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL HISTORY: Hemorrhagic stroke, now on pressors.\\n\\n CHEST: The heart remains enlarged. No failure is seen. The left\\n hemidiaphragm is obscured suggesting the presence of consolidation or\\n atelectasis in the left lower lobe. The position of the various support lines\\n and tubes is unchanged since the prior chest x-ray of 8 hours before.\\n\\n IMPRESSION: No significant change. Left lower lobe atelectasis and\\n consolidation is still present.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2131-09-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 308556,\n \"text\": \"Supraventricular tachycardia, rate 145, with one failure of P wave conduction\\nwithout apparent warning. P-R interval is slightly prolonged. The P wave is on\\nthe T wave. With history of atrial bigeminy and atrial premature beats, there\\nhas been predisposition to sustained atrial arrhythmia.\\nTRACING 32\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2131-09-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 308557,\n \"text\": \"Sinus rhythm. Atrial ectopy. Slight right axis deviation. Compared to the\\nprevious tracing of atrial bigeminy is no longer present.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2131-09-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 308558,\n \"text\": \"Sinus rhythm and atrial bigeminy. Right axis deviation. Diffuse ST-T wave\\nflattening. Compared to the previous tracing of sinus rhythm and\\nfrequent atrial ectopy have appeared. The previously recorded ST segment\\ndepression has diminished. Clinical correlation is suggested.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2131-09-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 308559,\n \"text\": \"Atrial fibrillation with rapid ventricular response\\nDiffuse nonspecific ST-T wave abnormalities\\nClinical correlation is suggested\\nSince previous tracing of , ventricular rate faster and further ST-T\\nwave changes present\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2131-10-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 308555,\n \"text\": \"Atrial fibrillation\\nInferior T wave changes are nonspecific\\nRepolarization changes may be partly due to rhythm\\nSince previous tracing, supraventricular tachycardia rhythm now atrial\\nfibrillation\\n\\n\"\n }\n]"}}},{"rowIdx":391,"cells":{"subject_id":{"kind":"number","value":88180,"string":"88,180"},"hadm_id":{"kind":"number","value":106166,"string":"106,166"},"target_text":{"kind":"string","value":"This is an 84 y.o woman with a history of HTN who presents with multiple falls of unknown etiology, orbital/facial fractures, found to have a small SDH and hyponatremia. She is also confirmed to have bilateral brain calcifications in the basal ganglia and cerebellum seen on her recent admission, which are concerning for Fahr's disease and could at least partially explain the patient's reported gait abnormalities and recurrent falls. Decreased oral intake in the setting of her recent facial fracture, as well as now-discontinued HCTZ likely contributed to the fall leading to this admission, as well. . # Falls: As noted, there is a strong suspicion that the patient's falls may be related to the calcifications noted on imaging, and the clarification of the diagnosis will require close neurology follow-up. We discussed with the patient and her HCP that we do not yet have a prognosis associated with the possible diagnosis, but that this should be forthcoming as her outpatient work-up continues. Per the patient's and her daughter's story of the falls, they appear to be due to a worsening unsteady gait leading to mechanical falls. The patient has little recollection of the falls, but per her daughter she does not lose consciousness prior to falling. The unsteady gait may be associated with the significant basal ganglia and cerebellum calcifications, likely representing Fahr's disease, as noted below. She was evaluated by neurology who did not note a clear movement disorder or ataxia. While inpatient, cardiac causes for falls were ruled out with a normal EKG and no events on telemetry. She had an EEG which did not have evidence of epilepsy; however, given her daughter's descriptions of \"spacing out\" seizures remain possible. While inpatient, she was maintained on largely due to the subdural hematoma (see below), but will continue this until her outpatient neurology follow up in a month. While inpatient she also worked with physical therapy to build up her strength and was given a walker to use at home; she will continue with outpatient physical therapy at home and will be re-evaluated by neurology in one month to reassess her gait. . # Calcifications in basal ganglia and cerebellum: Noted on CT, likely Fahr's disease. She had a metabolic work up to determine other causes of calcification, which revealed a mildly elevated PTH determined to be due to vitamin D deficiency, but this was not felt adequate to explain the degree of calcifications. She was started on vitamin D repletion, per below. Per neurology, if the calcifications do represent Fahr's disease, there may not be a specific treatment to reverse this condition. . # Vitamin D deficiency: Normal Ca and Phos, mildly elevated PTH, consistent with secondary hyperparathyroidism due to vitamin D deficiency, will likely resolve with repletion of vitamin D. Started on vitamin D units daily, to be continued on discharge. . # Hyponatremia: Given urine electrolytes and euvolemia, likely secondary to SIADH associated with the SDH, in the setting of recently-started HCTZ. Improved from 125 to 135 with a 1200 cc fluid restriction, which was then stable on the last day despite liberalizing the restriction to cc daily. Her HCTZ was also held, as this was likely contributing to the hyponatremia, and we suggested that this not be restarted in the future to the patient and family. . # SDH: Right occipital SDH and right parietal SDH initially visualized at an OSH. Most recent head CT on showed that \"the right occipital subdural hematoma is now barely visible and the larger right parietal subdural hematoma has also decreased in size, with a maximum depth of 7 mm.\" She had no focal deficits or evidence of seizure. She was started on 750 mg for seizure ppx and will continue for one month after discharge. . # Right eye injury: The patient had a recent facial/orbital fracture with repair and plate placement by plastic surgery on . She was seen by plastic surgery on this admission, who noted no new fractures and confirmed that the plate remained in place. She was also seen by ophthalmology in the ED. She was continued on dorzolamide eye drops throughout her admission, and her right eye improved significantly, with improvement both in swelling and in vision. . # HTN: Has been on atenolol and more recently added losartan and HCTZ at home. In hospital, HCTZ stopped due to hyponatremia. Losartan was continued on her home dose. Her atenolol was also decreased to 12.5 mg daily because her blood pressure had been running low; now with SBP in the 120s-130s on day of discharge. . # Hyperlipidemia: Stable, continued home atorvastatin. . # GERD: Stable, continued home omeprazole. . # RUL pulmonary nodule: Incidental finding on CT at last admission; patient reminded of this finding and encouraged to follow up with PCP. . # Left breast mass (incidental finding): Incidental finding on CT at last admission; patient reminded of this finding and encouraged to follow up with PCP. . # Goals of care: Confirmed full code. Primary contact is daughter or cell ; second contact is (ok to leave messages) . # Transitions 1) Sodium to be rechecked outpatient 2) Home PT, new assistive device (walker) 3) Follow up with neurology in 1 month for further discussion of potential diagnosis and prognosis. 4) Now on , likely will be able to discontinue this medication in 1 month at neurology follow up 5) Blood pressure medications decreased to continue home losartan, continue atenolol but at lower dose (12.5 mg daily), and stop HCTZ given hyponatremia 6) On continued fluid restriction at cc daily; will need to be monitored by PCP 7) Incidental findings on CT at last admission that need follow up: left breast mass and RUL pulmonary nodule"},"extractive_notes_summ":{"kind":"string","value":"There is persistent minimal mass effect from the subdural hematoma in the form of regional sulcal effacement. interval change from this AM No contraindications for IV contrast WET READ: TXPb TUE 9:47 PM Interval resorption/redistribution of right SDH. TECHNIQUE: MDCT acquired contiguous axial images were obtained through the head without contrast. Bilateral corona radiata, basal ganglionic and cerebellar dentate nuclear mineralization is most consistent with underlying Fahr disease or, less likely, hyper- or hypoparathyroidism, as before. Multiple fractures of the right orbit, maxilla, and zygomatic process appear stable. FINDINGS: The right occipital subdural hematoma is now barely visible and the larger right parietal subdural hematoma has also decreased in size, with a maximum depth of 7 mm. Left axis deviation, likely due to left anterior fascicularblock. The ventricles and sulci are otherwise normal in size and configuration. Sinus rhythm. There is no shift of normally midline structures. Interval decrease in size of right convexity subdural hematoma due to redistribution/resorption. No new hemorrhage or acute process. IMPRESSION: 1. Coronal and sagittal images reviewed. Compared to the previous tracing of the axis is more leftward.The other findings are similar. WET READ VERSION #1 FINAL REPORT INDICATION: New mental status decline in the patient status post trauma with right subdural hematoma. No new acute intracranial process to explain patient's clinical decline is identified. 8:27 PM CT HEAD W/O CONTRAST; -77 BY DIFFERENT PHYSICIAN # Reason: ? The mastoid air cells and middle ear cavities are clear. There is no evidence of acute vascular territorial infarction. Likely underlying Fahr disease; correlate with clinical evidence of movement disorder. 3. 2. COMPARISON: NECT of the head from at 7:30 a.m."},"n_notes":{"kind":"number","value":2,"string":"2"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2191-08-16 00:00:00.000","description":"BY DIFFERENT PHYSICIAN","row_id":1247589,"text":" 8:27 PM\n CT HEAD W/O CONTRAST; -77 BY DIFFERENT PHYSICIAN # \n Reason: ? interval change from this AM\n Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with R SDH, new mental status decline\n REASON FOR THIS EXAMINATION:\n ? interval change from this AM\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: TXPb TUE 9:47 PM\n Interval resorption/redistribution of right SDH. No new hemorrhage or acute\n process.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: New mental status decline in the patient status post trauma with\n right subdural hematoma.\n\n COMPARISON: NECT of the head from at 7:30 a.m.\n\n TECHNIQUE: MDCT acquired contiguous axial images were obtained through the\n head without contrast. Coronal and sagittal images reviewed.\n\n FINDINGS: The right occipital subdural hematoma is now barely visible and the\n larger right parietal subdural hematoma has also decreased in size, with a\n maximum depth of 7 mm. There is persistent minimal mass effect from the\n subdural hematoma in the form of regional sulcal effacement. There is no\n shift of normally midline structures. The ventricles and sulci are otherwise\n normal in size and configuration. Bilateral corona radiata, basal ganglionic\n and cerebellar dentate nuclear mineralization is most consistent with\n underlying Fahr disease or, less likely, hyper- or hypoparathyroidism, as\n before. There is no evidence of acute vascular territorial infarction.\n Multiple fractures of the right orbit, maxilla, and zygomatic process appear\n stable. The mastoid air cells and middle ear cavities are clear.\n\n IMPRESSION:\n 1. Interval decrease in size of right convexity subdural hematoma due to\n redistribution/resorption.\n 2. No new acute intracranial process to explain patient's clinical decline is\n identified.\n 3. Likely underlying Fahr disease; correlate with clinical evidence of\n movement disorder.\n\n"},{"category":"ECG","chartdate":"2191-08-18 00:00:00.000","description":"Report","row_id":306552,"text":"Sinus rhythm. Left axis deviation, likely due to left anterior fascicular\nblock. Compared to the previous tracing of the axis is more leftward.\nThe other findings are similar.\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2191-08-16 00:00:00.000\",\n \"description\": \"BY DIFFERENT PHYSICIAN\",\n \"row_id\": 1247589,\n \"text\": \" 8:27 PM\\n CT HEAD W/O CONTRAST; -77 BY DIFFERENT PHYSICIAN # \\n Reason: ? interval change from this AM\\n Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 84 year old woman with R SDH, new mental status decline\\n REASON FOR THIS EXAMINATION:\\n ? interval change from this AM\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: TXPb TUE 9:47 PM\\n Interval resorption/redistribution of right SDH. No new hemorrhage or acute\\n process.\\n\\n WET READ VERSION #1\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: New mental status decline in the patient status post trauma with\\n right subdural hematoma.\\n\\n COMPARISON: NECT of the head from at 7:30 a.m.\\n\\n TECHNIQUE: MDCT acquired contiguous axial images were obtained through the\\n head without contrast. Coronal and sagittal images reviewed.\\n\\n FINDINGS: The right occipital subdural hematoma is now barely visible and the\\n larger right parietal subdural hematoma has also decreased in size, with a\\n maximum depth of 7 mm. There is persistent minimal mass effect from the\\n subdural hematoma in the form of regional sulcal effacement. There is no\\n shift of normally midline structures. The ventricles and sulci are otherwise\\n normal in size and configuration. Bilateral corona radiata, basal ganglionic\\n and cerebellar dentate nuclear mineralization is most consistent with\\n underlying Fahr disease or, less likely, hyper- or hypoparathyroidism, as\\n before. There is no evidence of acute vascular territorial infarction.\\n Multiple fractures of the right orbit, maxilla, and zygomatic process appear\\n stable. The mastoid air cells and middle ear cavities are clear.\\n\\n IMPRESSION:\\n 1. Interval decrease in size of right convexity subdural hematoma due to\\n redistribution/resorption.\\n 2. No new acute intracranial process to explain patient's clinical decline is\\n identified.\\n 3. Likely underlying Fahr disease; correlate with clinical evidence of\\n movement disorder.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2191-08-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 306552,\n \"text\": \"Sinus rhythm. Left axis deviation, likely due to left anterior fascicular\\nblock. Compared to the previous tracing of the axis is more leftward.\\nThe other findings are similar.\\n\\n\"\n }\n]"}}},{"rowIdx":392,"cells":{"subject_id":{"kind":"number","value":25475,"string":"25,475"},"hadm_id":{"kind":"number","value":104621,"string":"104,621"},"target_text":{"kind":"string","value":"As noted above, the patient was initially admitted to the Neurology . After being transferred to the Neurology floor on , he was continued on Mannitol with an osmolality of 308. The patient's mental status did not improve on Mannitol. His edema did not resolve on CT. He was therefore tried on an empiric course of Decadron, a 10 mg bolus followed by 4 mg p.o. q.6 hours. The patient's alertness improved on the Decadron, and follow-up head CT demonstrated somewhat less edema with decreased flattening of the ventricle. The patient became more alert, and the Decadron was tapered over two weeks. The patient's Oxacillin was discontinued after a ten-day course. He has had no further issues with pneumonia. The patient continue to make progress. He was more alert, although still not moving the left side of his body which has remained hemiplegic. He was not taking adequate oral intake, so he was evaluated by Gastroenterology for placement of PEG tube. The PEG tube could not be placed because of his ascites which was noted on ultrasound, and gastroesophageal varices which was seen on EGD. His current examination shows that he is awake and alert. He does not know the date but knows that he was in . His eye movements are full to both sides. His pupil are equal. He has a left facial droop, and his head was turned to the right. He is hemiplegic on the left side. His toes are upgoing in the left. The patient will be discharged to rehabilitation on ."},"extractive_notes_summ":{"kind":"string","value":"There is a 1cm focal area of polypoid mucosal thickening within the left lateral aspect of the sphenoid sinus, unchanged from the prior study. There is a large right-sided basal ganglia hemorrhage, with minimal surrounding edema, and mild shift of the normally mid-line structures to the left. REASON FOR THIS EXAMINATION: please evaluate for hydrocephalus/expansion of bleed No contraindications for IV contrast FINAL REPORT INDICATION: Right basal ganglia hemorrhage. FINDINGS: There is marked, but stable polychamber cardiac enlargement. No contraindications for IV contrast FINAL REPORT HEAD CT, INDICATION: Right basal ganglia hemorrhage, please assess progression TECHNIQUE: Non-contrast head CT FINDINGS: Comparison is made to a prior head CT from . Of notice there is a mild stenosis of the bulb of the right internal carotid artery in both AP and lateral projections. IMPRESSION: There is a mild stenosis of the right ICA at the bifurcation. TECHNIQUE: Noncontrast head CT. There is still a mild amount of surrounding edema, slight shift of the midline structures to the left and blood within the dependent portions of both lateral ventricles. TECHNIQUE: Non-contrast head CT. TECHNIQUE: Noncontrast CT of the head. Otherwise normal cerebral angiogram in particular of the right internal and external carotid artery branches, of the left internal and external carotid artery branches and of both vertebral and basilar artery complex and their branches. Since no suitable superficial veins were visible, ultrasound was used for localization of a suitable vein. There is a right-sided IJ central venous line in place with its distal tip in the SVC. REASON FOR THIS EXAMINATION: please evaluate for infiltrate FINAL REPORT INDICATION: History of intracranial hemorrhage, now with shortness of breath and gurgling. IMPRESSION: Right middle lobe atelectasis, prominent pulmonary vasculature may be related to positioning, but slight LV failure cannot be excluded. IMPRESSION: Worsening surrounding edema involving the large right basal ganglia hemorrhage with further effacement of the right lateral ventricle and minimal worsening of the midline shift to the left as indicated. Injection of contrast in the right common carotid artery demonstrates normal opacification of the intracranial portions of the internal carotid artery with normal visualization of the lacerum, petrous, cavernous and supraclinoid portion or internal carotid artery and its branches. FINDINGS: There has been interval decrease in size of the hypedense region large right basal ganglia hemorrhage, compatible with partial resorption of the acute hemorrhagic components.. No new areas of hemorrhage are identified. O2SATS AND ABG STABLE.CV: AFEBRILE. Cont w/ generalized non pit edema. Resp Care,Pt. Resp Care,Pt. MD INFORMED.GI: ABD SOFT. TF cont. TO TOLERATE EXTUBATION. suction prn. PERRLA. PERRLA. for extubation ?. sputum cx sent. Plan to extubate. MD INFORMED.RESP: LS CLEAR, BUT OCCASIONALLY COASRE AT UPPER AIRWAY. CONT PER CURRENT MGMT. R fem. WITHDRAWS TO NAILBED PRESSURE W/LE. LOPRESSOR HELD. angio site C&D w/ + doppler pulses in RLE. RSR' pattern inlead V1. MANNITOL STARTED. NG - +placement, minimal residual. SAID \"\" ONCE OTHERWISE . cont. cont. +corneal reflex. tube fdg held due to ?extubation today. Murble words. MOD. Move RLE and RUE. ABD S/NT. BS sl. NPN UPDATEPT . Abd lg round, soft w/ hypoactive BS. Move RUE - strong. +gag reflex. U/O QS VIA FOLEY. BM THIS AM. MAINTAIN BP PER PARAMETERS. update to signaificant other. focus hemodynmicsdata: vss. FAINT BS. Sx'd for mod. ABD SOFT, NT. NEURO: PT . Arouse to voice. Foley patent. Chest PT and vibration. neuro updatept cont. Eyes - PERL, reddish - MD notify. soft abd, +BS X4. 7p-7a: Full assessment in flow sheet.Lethargic. ET SUCTIONED FOR MODERATE TO LARGE AMT TAN SPUTUM. LUNGS CLEAR TO COARSE, DIMINISHED AT BASES. TOLERATING TUBE FEEDS, W/ NO SIGNIFICANT RESIDUAL. CPT/DB/COUGH DONE TO MAINT. ON RARE OCCASSION. FOLLOWS COMMANDS. Inc BP when turn and position. OPENS EYES SPONT. bp 130-140's., hr 50-80's, remains on a labetatolol gtt. Pt at (R) upper extremity attempting to pull at ETT. SBP 120-150/45-60. Cont w/ current plan of care. Afib 70-110. Warm, dry, general edema +1. Atrial fibrillation with a moderate ventricular response. Afib without ectopy. RECEIVED 1 UNIT FFP FPR INR 1.4. Lytes replenish.Plan; Continue to monitor. See vent flowsheet. LS OCCASIONALLY COARSE @ BASES, PT NEEDS ASSIST WITH PULM HYGEINE. Mannitol given for Osmality less than 310. LS COARSE. Answer inconsistent verbally appropriately - able to say last name (). MOVING RSIDE W/ NL STRENGTH - NO MOVEMENT NOTED LEFT. MAINTAIN BP 140 OR LESS. REPEAT INR 1.5. 7P-7A: Full assessment in flow sheet.neuro: Arouse to voice. normal strength on the right. Right pedal and femoral pulses palpable. TRANSFER TO FLOOR WHEN STABLE, MD'S ORDERS. to hold per team. Weak RLE. W/ L-SIDED WEAKNESS. Maintain SBP <140 with Hydralazine ivpX2. cont on labetolol drip to keep sbp 140.Resp. CURRENTLY IN AFIB W/ RATE 70-90'S & SBP 130-150'S. Monitor sbp and labetalol gtt. CVP 21-24. PUPILS EQUAL AND REACTIVE. PUPILS EQUAL AND REACTIVE. CONTINUE WITH CURRENT CLOSE MONITORING. Please see carrevue for further vent inqueries. Condition Update A:ROS - Please refer to careview for specifics.NEURO: Cont w/ somulance, arouse to voice, attempts to open eyes. Move left feet to stimuli in LLE. FOLLOWING COMMANDS. Plan to extubate today. neuro statusD: pt is lethargic but . Garble and mumble of words. Right side normal - strong. Follow commands. Follow directions. palpable fem pulse. Continue to monitor. Continue to monitor. HYDRALAZINE PRN TO MAINTAIN SBP<150. ABGS: 7.43/29/120/20/96% MINIMAL MOVEMENT OF LEFT EXTREMTIES TO COMMAND."},"n_notes":{"kind":"number","value":40,"string":"40"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2124-11-03 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":773091,"text":" 7:52 PM\n CHEST (PORTABLE AP) Clip # \n Reason: NG tube replaced - check position\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with IC hemorrhage now with shortness of breath and gurgling\n on exam.\n REASON FOR THIS EXAMINATION:\n NG tube replaced - check position\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST AT 19:44\n\n INDICATION: Shortness of breath. Nasogastric tube replaced.\n\n FINDINGS: The current study has cut off the apices from view. The visualized\n lung fields are clear. While I can see parts of the nasogastric tube, the tip\n cannot be definitely visualized due to underpenetration nature of the film\n however, the tube does distend below the level of the diaphragm. A left sided\n central venous catheter is seen with tip in the SVC. The heart size appears\n mildly prominent but the shallow level of inspiration could exaggerate that.\n\n IMPRESSION:\n\n 1. Nasogastric tube below the diaphragm. No acute airspace disease in the\n visualized portions of the lungs.\n\n"},{"category":"Radiology","chartdate":"2124-10-30 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":772679,"text":" 5:35 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: please evaluate for worsening shift\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with putaminal hemorrhage and shift noted yesterday.\n REASON FOR THIS EXAMINATION:\n please evaluate for worsening shift\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HEAD CT WITHOUT CONTRAST:\n\n INDICATION: Question worsening basal ganglia hemorrhage.\n\n Multiple axial images were obtained from base to vertex without IV contrast\n administration. Comparison is made to the prior exam of . There is\n worsening surrounding edema involving the large right-sided basal ganglia\n hemorrhage with mass effect on the anterior and posterior limbs of the\n internal capsule. There is worsening mass effect on the right lateral\n ventricle with an estimated 9 mm midline shift to the left. There is also\n effacement of the superior aspect of the perimesencephalic cistern. No\n hydrocephalus is seen. No new areas of hemorrhage could be identified.\n\n IMPRESSION: Worsening surrounding edema involving the large right basal\n ganglia hemorrhage with further effacement of the right lateral ventricle and\n minimal worsening of the midline shift to the left as indicated. Further\n clinical correlation and follow up are recommended.\n\n"},{"category":"Radiology","chartdate":"2124-10-29 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":772566,"text":" 11:29 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: please evaluate for hydrocephalus/expansion of bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with right putaminal hemorrhage transferred from intensive care\n unit.\n REASON FOR THIS EXAMINATION:\n please evaluate for hydrocephalus/expansion of bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Right basal ganglia hemorrhage. Please assess for progression.\n\n TECHNIQUE: Noncontrast head CT.\n\n FINDINGS: Comparison is made to the prior head CT from . There has\n been slight decrease in the size of the large right basal ganglia hemorrhage.\n However, surrounding edema has slightly increased with obliteration of right\n ambient cistern. without evidence of significant change in the mass effect and\n leftward shift. There is no evidence of a hydrocephalus. There is no new area\n of hemorrhage.\n\n IMPRESSION: There is slight decrease in the size of the large right basal\n ganglia hemorrhage and slight increase in edema when compared to the prior\n study.\n\n"},{"category":"Radiology","chartdate":"2124-11-01 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":772829,"text":" 7:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with IC hemorrhage now with shortness of breath and gurgling\n on exam.\n REASON FOR THIS EXAMINATION:\n please evaluate for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of intracranial hemorrhage, now with shortness of breath\n and gurgling. Please evaluate for infiltrate.\n\n COMPARISONS: AP chest radiograph .\n\n FINDINGS: There is marked, but stable polychamber cardiac enlargement. There\n is minimal evidence for upper lung zone redistribution which may be postural\n in nature but which could also represent mild failure. The aorta is unfolded\n and tortuous. No focal lung opacities are present to suggest aspiration or\n pneumonia. No pleural effusions are present. The osseous structures are\n unremarkable.\n\n IMPRESSION: Stable cardiomegaly, no acute cardiopulmonary changes.\n\n"},{"category":"Radiology","chartdate":"2124-11-06 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":773242,"text":" 4:48 AM\n CHEST (PORTABLE AP) Clip # \n Reason: check position of NG tube on patient, who is difficult to tr\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with IC hemorrhage now with shortness of breath and gurgling\n REASON FOR THIS EXAMINATION:\n check position of NG tube on patient, who is difficult to transport s/p stroke\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Check position of NG tube.\n\n COMPARISONS: AP chest radiograph from .\n\n SUPINE AP CHEST RADIOGRAPH: An NG tube is demonstrated, with the tip below the\n diaphragm, but not visualized on today's study. Stable, marked biventricular\n cardiomegaly is again demonstrated. The aorta is unfolded. Allowing for the\n supine positioning, the pulmonary vasculature is difficult to assess, but\n slight left ventricular failure cannot be excluded. There is a focal opacity\n within the right middle lobe which likely represents atelectasis. No pleural\n effusions are present. The osseous structures are unremarkable.\n\n IMPRESSION: Right middle lobe atelectasis, prominent pulmonary vasculature may\n be related to positioning, but slight LV failure cannot be excluded.\n\n"},{"category":"Radiology","chartdate":"2124-11-06 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":773327,"text":" 9:16 PM\n CHEST (PORTABLE AP) Clip # \n Reason: NG tube placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with IC hemorrhage\n REASON FOR THIS EXAMINATION:\n NG tube placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: NG tube placement.\n\n COMPARISON: @ 5:46 A.M.\n\n PORTABLE UPRIGHT CHEST @ 9 P.M.: The tip of the NG tube is difficult\n to visualize but appears to be within the stomach. There is a left PICC with\n tip in the SVC. There is mild cardiomegaly. The aorta is tortuous. There is no\n evidence of vascular congestion or pleural effusions. There are patchy\n opacities at the lung bases which probably represent atelectasis vs.\n aspiration. No pneumothorax.\n\n IMPRESSION: 1) Tip of the NG tube difficult to visualize but appears to be\n within the stomach. If clinically indicated, a dedicated abdominal film\n is suggested to confirm.\n\n 2) Patchy bibasilar opacities, probably atelectasis, however, aspiration\n should also be considered.\n\n"},{"category":"Radiology","chartdate":"2124-11-08 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":773530,"text":" 7:51 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate ngt placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with IC hemorrhage no w s/p new ngt placement.\n\n REASON FOR THIS EXAMINATION:\n please evaluate ngt placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Intracranial hemorrhage. New NG tube placement.\n\n PORTABLE SUPINE CHEST, 1 VIEW: Comparison . There is an NG tube\n extending below the diaphragm, tip not visualized. The heart is enlarged. The\n left lateral CP angle is not included on this exam. Allowing for technique,\n there is no CHF, focal consolidation, or large pleural effusion.\n\n IMPRESSION: NG tube extending below the diaphragm, tip not visualized.\n\n"},{"category":"Radiology","chartdate":"2124-10-31 00:00:00.000","description":"CVL/PICC","row_id":772805,"text":" 4:06 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: please place picc line\n ********************************* CPT Codes ********************************\n * CVL/PICC UD GUID FOR NEEDLE PLACMENT *\n * C1751 CATH ,/CENT/MID(NOT D C1894 INT.SHTH NOT/GUID,EP,NONLASER *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with right putaminal hemorrhage requires picc line for iv meds.\n IV service has tried but unsuccessful.\n REASON FOR THIS EXAMINATION:\n please place picc line\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Right putaminal hemorrhage, requires access for IV medications.\n The IV access team was unsuccessful in placing a PICC line.\n\n PHYSICIANS: Drs. and . Dr. , the attending\n radiologist, was present and supervising. Dr. reviewed the case.\n\n PROCEDURE: The left upper arm was prepped in a sterile fashion. Since no\n suitable superficial veins were visible, ultrasound was used for localization\n of a suitable vein. The basilic vein was patent and compressible. After\n local anesthesia with 1% Lidocaine, the basilic vein was entered under\n ultrasonographic guidance with a 21 g. needle. A .018 guidewire was advanced\n under fluoroscopy into the superior vena cava. Based on the markers on the\n guidewire it was determined that a length of 57.5 cm would be suitable. The\n PICC line was trimmed to line and advanced over a 4 French introducer sheath\n under fluoroscopic guidance into the superior vena cava. The sheath was\n removed. The catheter was flushed. A final chest x-ray was obtained. This\n film demonstrates the tip to be in the superior vena cava, just above the\n atrium. The line is ready for use.\n\n A stat-lock was applied and the line was hep-locked.\n\n IMPRESSION: Successful placement of a 4 French, single lumen, 57.5 cm total\n length PICC line with tip at the superior vena cava/RA junction. The line is\n ready for use.\n\n\n"},{"category":"Radiology","chartdate":"2124-10-23 00:00:00.000","description":"SEL CATH 2ND ORDER","row_id":772010,"text":" 8:11 AM\n CAROT/CEREB Clip # \n Reason: CEREBRAL HEMORRHAGE\n Contrast: OPTIRAY Amt: 90\n ********************************* CPT Codes ********************************\n * SEL CATH 3RD ORDER SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE CAROTID/CEREBRAL BILAT *\n * EXT CAROTID BILAT VERT/CAROTID A-GRAM *\n ****************************************************************************\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Mr. is a 58-year-old man who developed a right\n putaminal hemorrhage. The hemorrhage was felt to be due to hypertension.\n However, while the patient has been normotensive on intravenous\n antihypertensive medication, the hemorrhage significantly enlarged and the\n patient developed seizures. After consultation with Neurosurgery it was\n decided to proceed with a cerebral angiogram to rule out an underlying\n vascular malformation or an aneurysm. The assessment and plan were thoroughly\n discussed with the Neurosurgery staff as well as with the Neurology staff.\n\n PROCEDURE: Informed consent was obtained from the patient's significant other\n after explanation of risks, benefits, indication and alternative management.\n The patient's significant other read the consent form, asked appropriate\n questions, understood and signed. The patient was already intubated in the\n SICU. He was thereofre transported from the Surgical Intensive Care Unit to\n the Neurointerventional Suite and placed under general anesthesia. The\n patient had an arterial line and vital parameters were constantly monitored by\n the Anesthesia staff.\n\n The patient was placed supine on the table. Both groins were prepped and\n draped in usual sterile fashion. The right femoral artery was accessed by a\n single wall puncture needle. After visualization of bright pulsatile blood a\n .035 J-wire was inserted into the femoral artery and advanced into the\n abdominal aorta. At this point a 4 Fr short sheath was inserted into the right\n femoral artery using the J wire as a guide.\n\n Under fluoroscopic guidance, a 4 Fr Barenstein catheter in conjunction with\n Terumo guidewire was advanced into the aortic arch and subsequently used to\n select the right common carotid artery. Injection of contrast at this level\n demonstrates normal opacification of the origin of the right internal and\n right external carotid artery and their branches. Of notice there is a mild\n stenosis of the bulb of the right internal carotid artery in both AP and\n lateral projections.\n\n Subsequently, attention was paid to the intracranial branches of the right\n internal carotid artery. Injection of contrast in the right common carotid\n artery demonstrates normal opacification of the intracranial portions of the\n internal carotid artery with normal visualization of the lacerum, petrous,\n cavernous and supraclinoid portion or internal carotid artery and its\n branches. A magnified view of the intracranial circulation demonstrated normal\n opacification of the anterior cerebral, middle cerebral and posterior\n communicating artery and their branches in both AP and lateral projections.\n (Over)\n\n 8:11 AM\n CAROT/CEREB Clip # \n Reason: CEREBRAL HEMORRHAGE\n Contrast: OPTIRAY Amt: 90\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Subsequently, the catheter was advanced into the external carotid artery and\n attention was paid to the branches of the external carotid artery. Injection\n of contrast shows normal opacification of the branches of both superficial and\n deep of the external carotid artery in particular the temporal, occipital\n arteries and their branches as well as the internal maxillary with no evidence\n of arteriovenous malformations.\n\n Subsequently the 4 Fr Barenstein catheter in conjunction with a Terumo\n glidewire was slowly advanced to select the left common carotid artery.\n Particular attention at this level was paid to the intracranial branches.\n Injection of contrast via the left common carotid artery shows normal\n opacification intracranial branches and all the segments of the intracranial\n internal carotid artery. There was also normal opacification of the anterior\n cerebral artery and middle cerebral artery and their branches. Of note, the\n contralateral anterior cerebral artery is also opacified with this injection\n as well. There is also normal parenchymal venous phase in both AP and lateral\n projections.\n\n At this level particular attention was also paid to the branches of the\n external carotid artery. Injection of contrast in the left external carotid\n artery also shows normal opacifications of the external and the superficial\n and the branches of the external carotid artery with no evidence of vascular\n malformations.\n\n Subsequently the 4 Fr Barenstein catheter in conjunction with Terumo glidewire\n was withdrawn to select the left vertebral artery. Injection of contrast in\n the left vertebral artery demonstrates normal opacification of the\n intracranial segment of the left vertebral artery basilar artery and \n branches in both AP and lateral projections. The contralateral right vertebral\n artery is also opacified with this injection. There is normal parenchymal and\n venous phase in both AP and lateral projection at this level.\n\n Dr. reviewed the case with Dr. and Dr. .\n\n IMPRESSION: There is a mild stenosis of the right ICA at the bifurcation.\n Otherwise normal cerebral angiogram in particular of the right internal and\n external carotid artery branches, of the left internal and external carotid\n artery branches and of both vertebral and basilar artery complex and their\n branches. There is no evidence of vascular malformations or cerebral\n aneurysms.\n\n"},{"category":"Radiology","chartdate":"2124-10-24 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":772130,"text":" 10:55 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: assess for progression of bleed/ shift?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with ?ICH\n\n REASON FOR THIS EXAMINATION:\n assess for progression of bleed/ shift?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HEAD CT, \n\n INDICATION: Right basal ganglia hemorrhage, please assess progression\n\n TECHNIQUE: Non-contrast head CT\n\n FINDINGS: Comparison is made to a prior head CT from . Since that\n time there has been no change in the size of the large right basal ganglia\n hemorrhage, but there has been slight increase in the mass effect and leftward\n shift. Perihemorrhage edema is slightly more prominent now. There is no\n hydrocephalus, but blood is still seen in the dependent portions of the\n lateral ventricles bilaterally. No new areas of hemorrhage are seen. Again\n seen is fluid within the right maxillary sinus, consistent with patient's\n intubation.\n\n IMPRESSION: Slight increase in mass effect and leftward shift from right\n basal ganglia hemorrhage. These findings were communicated to ,\n MD, at the time of the exam.\n\n\n\n\n\n\n"},{"category":"Radiology","chartdate":"2124-10-21 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":771891,"text":" 2:39 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: status of bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with ?ICH\n\n REASON FOR THIS EXAMINATION:\n status of bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Reassess intracranial hemorrhage.\n\n TECHNIQUE: Noncontrast CT of the head.\n\n COMPARISON: Head CT .\n\n FINDINGS: There has been no significant interval change in the previously\n described large hemorrhage in the region of the right basal ganglia. There is\n still a mild amount of surrounding edema, slight shift of the midline\n structures to the left and blood within the dependent portions of both lateral\n ventricles. There is no evidence of new intra/extra-axial hemorrhages or mass\n affect. The ventricles, cisterns and sulci are stable in appearance. Again\n noted is thickening of the ethmoid air cells and a probable retention cyst\n within the left sphenoid sinus. There is a new small air fluid level within\n the right maxillary sinus, which may be secondary to the patient's intubated\n state.\n\n IMPRESSION: No significant interval change in the size/appearance of the\n previously described right basal ganglia hemorrhage. No new intra/extra-axial\n hemorrhages or mass affect.\n\n\n"},{"category":"Radiology","chartdate":"2124-10-20 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":771773,"text":" 8:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: New right IJ CVL placed, r/o pneumo/hemothorax.Thanks\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with IC hemorrhage\n REASON FOR THIS EXAMINATION:\n New right IJ CVL placed, r/o pneumo/hemothorax.Thanks\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 58 year old male with intracranial hemorrhage and line placement.\n Evaluate for pneumothorax/hemothorax.\n\n FINDINGS: There are no studies available for comparison.\n\n There is an endotracheal tube in good position. There is a right-sided IJ\n central venous line in place with its distal tip in the SVC. There is a\n nasogastric tube in place that passes beneath the diaphragm. The distal tip\n of this nasogastric tube is not visualized. There is no evidence of failure,\n focal infiltrate, or pleural effusion. The heart size is increased. There is\n no pneumothorax.\n\n IMPRESSION:\n\n 1. Placement of right IJ central venous line with no evidence of pneumothorax\n or other acute cardiopulmonary process.\n\n 2. Increased heart size without evidence of heart failure.\n\n\n"},{"category":"Radiology","chartdate":"2124-10-20 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":771786,"text":" 9:47 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: ICH ASSESS BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with ?ICH\n REASON FOR THIS EXAMINATION:\n r/o hemorrhage\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Intracranial hemorrhage, please assess bleed.\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: There are no prior studies for comparison, so it is not possible to\n assess the progression of this patient's intracranial hemorrhage. There is a\n large right-sided basal ganglia hemorrhage, with minimal surrounding edema,\n and mild shift of the normally mid-line structures to the left. Hemorrhage is\n also seen within the occipital of both lateral ventricles, right greater\n than left. No extra-axial collections are seen. There is atrophy of the\n frontal lobes bilaterally. No hydrocephalus.\n\n There is mucosal thickening within the ethmoid sinuses as well as a polyp\n versus mucus retention cyst within the left sphenoid sinus. The visualized\n osseous structures are unremarkable.\n\n IMPRESSION: Large right-sided basal ganglia hemorrhage with smaller amounts\n of hemorrhage within both occipital horns of the lateral ventricles. These\n findings were communicated directly to Dr. , one of the SICU fellows, on\n the morning of .\n\n"},{"category":"Radiology","chartdate":"2124-11-15 00:00:00.000","description":"P ABDOMEN U.S. (COMPLETE STUDY) PORT","row_id":774096,"text":" 2:34 PM\n ABDOMEN U.S. (COMPLETE STUDY) PORT Clip # \n Reason: ABNORMAL LFT,S ,EVAL FOR LIVER PATHOLOGY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n As above.\n REASON FOR THIS EXAMINATION:\n Patient is a 58 year-old man s/p right putaminal hemorrhage, h/o\n alcoholism--now has elevated LFTs, palpably enlarged spleen and liver, please\n eval for ascites prior to PEG placement.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Alcoholism, elevated liver function tests.\n\n FINDINGS: A small nodular liver that is increased in echogenicity is\n identified. This is consistent with cirrhosis. There is normal hepatopetal\n flow within the patent portal vein. There is no intrahepatic or extrahepatic\n biliary dilatation. Multiple gallstones and a nondistended gallbladder are\n identified. There is gallbladder wall thickening, probably related to the\n ascites and hypoalbuminemia. The pancreas is not well visualized. There is\n enlargement of the spleen, with no focal lesions. The right kidney measures\n 12.6 cm and the left kidney measures 12.8 cm. There is no hydronephrosis or\n nephrolithiasis. There are small amounts of ascites. A patent portal vein is\n identified.\n\n IMPRESSION:\n\n 1. Cirrhotic liver.\n\n 2. Cholelithiasis.\n\n 3. Small amounts of ascites.\n\n\n"},{"category":"Radiology","chartdate":"2124-11-14 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":773963,"text":" 12:00 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Infectious (lung) process underlying waxing and (wani\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year-old man 3wks s/p R-putaminal bleed.\n REASON FOR THIS EXAMINATION:\n Infectious (lung) process underlying waxing and ( today) mental\n status?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Mental status changes.\n\n COMPARISON: .\n\n SINGLE VIEW CHEST: There is a left PICC with tip in the SVC. There are low\n lung volumes. There is mild cardiomegaly. The aorta is tortuous. There is\n no evidence of vascular congestion, pleural effusion, or focal consolidation.\n Discoid atelectasis is seen at the right base. The right CP angle is not\n included on this film.\n\n IMPRESSION: Right lower lobe atelectasis.\n\n"},{"category":"Radiology","chartdate":"2124-11-14 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":774001,"text":" 5:00 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Is there further edema and/or are we able to better visualiz\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with R-putaminal hemorrhage--failing to improve 3 weeks after\n event.\n REASON FOR THIS EXAMINATION:\n Is there further edema and/or are we able to better visualize the etiology of\n the patient's significant edema (is there a tumor underlying this hemorrhage?)?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION: 58 year old man with right putamenal hemorrhage failing to improve\n after 3 weeks.\n\n CT OF THE HEAD WITHOUT CONTRAST\n\n COMPARISON: Comparison is made with prior study performed .\n\n TECHNIQUE: CT of the head without contrast.\n\n FINDINGS: There has been interval decrease in size of the hypedense region\n large right basal ganglia hemorrhage, compatible with partial resorption of\n the acute hemorrhagic components.. No new areas of hemorrhage are identified.\n However, there is still considerable surrounding edema, with compression\n of the right lateral ventricle. No hydrocephalus is seen.\n\n There is a 1cm focal area of polypoid mucosal thickening within the left\n lateral aspect of the sphenoid sinus, unchanged from the prior study. The\n visualized paranasal sinuses and mastoid air cells are otherwise well aerated.\n\n IMPRESSION: Interval decrease in size in the large right basal ganglia\n hemorrhage with only minor interval decrease in mass effect. There is\n prominent, persistent edema surrounding the hemorrhage.\n\n COMMNENT: Both studies show a moderate degree of bifrontal peripheral\n cerebral atrophy.\n\n"},{"category":"Radiology","chartdate":"2124-11-16 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":774186,"text":" 9:53 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess for GT placement.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year-old man 3wks s/p R-putaminal bleed.\n\n REASON FOR THIS EXAMINATION:\n Please assess for GT placement.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Assess gastric tube placement.\n\n COMPARISON: AP chest radiograph from .\n\n SEMI-UPRIGHT AP CHEST RADIOGRAPH: This study is limited by motion. The tip\n of the NG tube is not clearly visualized for technical reasons, but is likely\n within the stomach. Again identified is a left sided subclavian PICC line\n with the tip in the superior vena cava. There is cardiomegaly without\n evidence of left ventricular failure. No focal lung opacities are identified.\n The osseous structures are unchanged.\n\n IMPRESSION: Feeding tube tip likely within the stomach, but not visualized\n secondary to technical reasons. Cardiomegaly without evidence of failure.\n\n\n"},{"category":"Radiology","chartdate":"2124-11-17 00:00:00.000","description":"VIDEO OROPHARYNGEAL SWALLOW","row_id":774223,"text":" 10:28 AM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: ASPIRATION\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Aspiration.\n\n VIDEO OROPHARYNGEAL SWALLOW: The demonstrated frank aspiration of thin\n liquids with spontaneous but weak cough and inaffective clearing. No\n structural abnormalities are seen.\n\n IMPRESSION: Please see the full report of the speech and swallowing division\n for full details and recommendations.\n\n"},{"category":"Nursing/other","chartdate":"2124-10-20 00:00:00.000","description":"Report","row_id":1594560,"text":"ADMIT NOTE\n58 Y.O. MALE WITH HX CVA, ASTHMA, AFIB, APPENDECTOMY, ETOH- ALLERGY TO SULFA- PRESENTED TO HOSPITAL WITH LEFT SIDED WEAKNESSWAS FOUND TO HAVE RIGHT POST FRONTAL PARIETAL THALMIC BLEED ON HEAD CT- WAS ADMITTED TO FLOOR AT BH- WAS PLACED ON BED REST- FOUND ON FLOOR IN PRONE POSITION AT 1230AM WITH LEFT BROW LACERATION 1.5CM AND RIGHT HAND INFILTRATE- WENT TO HEAD CT - REVEALED EXTENDED PT CAME BACK FROM CT WITH FOLLOWING SYMPTOMS. LEFT LOWER LEG WEAKNESS. FLACID LEFT ARM, SLURRED SPEECH, INCREASED BP 150-180/90-100, PT CYCLED FOR CARDIAC ENZYMES. PT ADMITTED DIRECTLY TO UNIT FROM HOSPITAL AT 0545 AM.\n\nON ADMIT, PT AFIB 100S- SBP 170/58- LABETALOL DRIP STARTED TO KEEP SBP BELOW 140- 2 INCHES NITRO PLACED TO CW- ALINE PLACED/ PERIPERAL IV STARTED.\n\nNEURO: INITIALLY PT RESPONDING TO QUESTIONS- ALERT TO NAME ONLY NOT TO PLACE OR TIME, FULL STRENGTH NOTED ON RIGHT SIDE- NO MOVEMENT OF LEFT ARM AND SLIGHT MOVEMENT NOTED AT LEFT LEG- NO SENSATION NOTED ON LEFT SIDE PER PT, PT DENIES VISUAL DIFFICULTY ALTHOUGH WHEN 5 FINGERS ARE HELD IN FRONT OF PT- HE STATES THERE IS ONLY ONE. PT UNABLE TO PERFORM LATERAL MOVMENT OF EYES TO LEFT- EXHIBITING SLURRED SPEECH.\n\nAT 0600 PT HAD GENERALIZED SEIZURE LASTING MINITES AND CONTINUED TO HAVE 3 MORE SIEZURES OVER THE NEXT PT WAS GIVEN 4 MG ATIVAN WITH NO EFFECT PT CONTINUES TO HAVE SIEZURES TO HAVE LOADING DOSE OF DILANTIN. PT LETHARGIC AND UNRESPONSIVE TO QUESTIONS FOLLOWING SEIZURE.\n\nRESP: PT TO BE INTUBATED SHORTLY\n\nGU/GI: FOLEY CATH PLACED FOR CLEAR YELLOW URINE- BS POSITIVE- OBESE ABDOMEN- NGT PLACED TO LWS\n\nPLAN: PT TO HAVE EMERGENT HEAD CT, TO BE INTUBATED, TO HAVE LINE PLACED, AND HAVE EEG\n"},{"category":"Nursing/other","chartdate":"2124-10-20 00:00:00.000","description":"Report","row_id":1594561,"text":"NEURO; MOVES RT HAND AND LEG RANDOMLY AND WITHDRAWS TO STIMULATION, MOVES LEFT HAND SLIGHTLY TOWARD TORSO WHEN NAILBED PRESSURE APPLIED, OCCAS MOVES LEFT FOOT BUT ONLY SLIGHTLY AND NOT TO NAILBED PRESSURE, NEURO AND SICU MD'S INFORMED, PERL #6, BRISKK, POSITIVE CORNEAL, POSITIVE GAG, PT HAS BECOME MORE RESTLESS SINCE LATE PM AND MOVING RT SIDE MORE FREQUENTLY, NEURO TEAM IN TO EVALUATE AND PT DID DISPLAY TWO FINGERS WITH RT HAND, AND WIGGLED TOES RT FOOT TO COMMAND, DOES NOT DO SO WITH LEFT, PT DOES NOT SPONT OPEN EYES, IS LOCALIZING MORE WITH RT ARM, CAT SCAN THIS AM, VERBAL REPORT WAS LEFT BASAL GANGLION HEMORRHAGE, L VENTRICLE-MASS EFFECT, REPORTED TO SICU H.O. AND NEUROLOGY, SEEN BY NEUROSURGERY TODAY FOR ? VENT DRAIN PLACEMENT, BUT WILL BE DEFERRED\nWITNESSED SEIZURE AT 0745 THIS AM, SPASTIC TREMORS OF LEFT ARM AND LEG, LASTED 3-4 MINUTES, MEDIC WITH ATIVAN 2 MGM AND RT LEG BECAME SPASTIC FOR 2 MINUTES AND THEN SUBSIDED.\nCARDIOVASCULAR; HR 70'S-80'S A FIB, LABETOLOL ON THIS AM FOR SYS GOAL OF < 140, HAS BEEN OFF SINCE 9 AM SINCE BP SYS HAS BEEN LOW L110'S-140, (GOAL ACCORDING TO NEUROLOGY IS SYS > 100 AND < 140), LEFT FOOT SL COOLER THAN RT BUT PEDAL AND PT PULSES WEAKLY PALPABLE, THIS PM PEDAL PULSE STRONGER THAN RT,\n\nRESPIR; ON CMV MODE, ABGS REFLECT METAB ALKALOSIS, SUCTIONED FOR SMALL THIN CLEAR SECRETIONS\n\nLABS; K 3.4, REPLETED WITH 40 MEQ KCL, MG REPLETED, ION CA 1.11-NO REPLETION ORDERED, SLIDING SCALE INSULIN BS 207-COVERED WITH 2 UNITS REGULAR, LAST BS 149 AT 1800\n\nGI: BLOOD-TINED BILIOUS DGE FROM NG TUBE, PT WILL START ON PROTONIX TONOC\n"},{"category":"Nursing/other","chartdate":"2124-10-21 00:00:00.000","description":"Report","row_id":1594562,"text":"Respiratory care\nPt remains intubated and tolerating wean to CPAP/PSV 5/5. Please see carevue flowsheet for further info. Pt traveled to Ct scan this afternoon and placed back on vent with current settings. Pt sx for thick yellow throughout day, plan to continue with current settings and wean to extubate.\n"},{"category":"Nursing/other","chartdate":"2124-10-21 00:00:00.000","description":"Report","row_id":1594563,"text":"NEURO; PERL # , BOTH REACT BRISKLY TO LIGHT, POSITVE CORNEALS, STRONGER GAG REFLEX THAN YESTERDAY, ATTEMPTS TO OPEN EYES AT TIMES, ABLE TO SHOW TWO FINGERS ON RT HAND, LIFTS AND HOLDS RT ARM AND RT LEG, LEFT SIDE WEAKER, MOVES LEFT FOOT ONLY SLIGHTLY IN BED, AND MOVES FINGERS OF LEFT HAND VERY SLIGHTLY,\n\nCARDIOVASCULAR; HR 70'S-80'S A FIB, STARTED BACK ON LABETOLOL TO KEEP SYS 140 OR LESS SYS, LABETOLOL PRESENTLY AT 0.8 MGM/MIN, LEFT FOOT WARMER THAN YESTERDAY, PEDAL AND PT PULSES PALPABLE,\n\nRESPIR; WEANED TO C-PAP MODE, 5 OF PRESSURE SUPPORT AND PEEP, SPON TV 520-550, ABG'S STABLE WITH PH 7.44, PC02 45, P02 95, AND BICARB 35, SHOWN TO DR. , PT TO 90% SHORTLY AFTER ABGS DRAWN, SUCTIONED FOR THICK TAN-DEEP YELLOW SECRETIONS, 02 SAT PRESENTLY 96%\n\nLABS: CA AND K REPLETIONS TODAY, BS 142-NOT COVERED WITH SLIDING SCALE\n\n; U/O 30-40/HR, CONCENTRATED, NEED TO KEEP MONITORING\n"},{"category":"Nursing/other","chartdate":"2124-10-22 00:00:00.000","description":"Report","row_id":1594564,"text":"Resp Care,\nPt. remains intubated on CPAP IPS5/.4/5peep. VT400-500, RR18. Plan to extubate. See vent flowsheet.\n"},{"category":"Nursing/other","chartdate":"2124-10-22 00:00:00.000","description":"Report","row_id":1594565,"text":"NEURO: PT . AROUSABLE TO VOICE, BUT DOES NOT OPEN EYES. FOLLOWS COMMANDS. MOVES RIGHT EXTREMTITIES PURPOSEFULLY. MINIMAL MOVEMENT OF LEFT EXTREMTIES TO COMMAND. PUPILS BRISK AND REACTIVE LEFT LARGER THAN RIGHT. RIGHT PUPIL 3-4MM, LEFT 5-7MM. MD INFORMED.\nRESP: LS CLEAR, BUT OCCASIONALLY COASRE AT UPPER AIRWAY. ET SUCTIONED FOR MODERATE TO LARGE AMT TAN SPUTUM. O2SATS AND ABG STABLE.\nCV: AFEBRILE. AFIB CONTINUES 70S TO 80S. LABETOLOL GTT TITRATED UP TO 1MG/MIN TO MAINTAINE SBP <140. RECEIVED 1 UNIT FFP FPR INR 1.4. REPEAT INR 1.5. MD INFORMED.\nGI: ABD SOFT. FAINT BS. TF'S OF IMPACT WITH FIBER STARTED AT 10CC/HOUR WITH MINIMAL RESIDUALS. NOT ADVANCED PER ORDER.\nGU: FOLEY INTACT AND PATENT FOR MINIMAL U/O 30-50CC/HOUR, AMBER IN COLOR.\nPLAN: CONT TO MONITOR NEURO STATUS CLOSELY. CONT PER CURRENT MGMT.\n"},{"category":"Nursing/other","chartdate":"2124-10-22 00:00:00.000","description":"Report","row_id":1594566,"text":"Condition Update A:\nROS - Please refer to careview for specifics.\nNEURO: Cont w/ somulance, arouse to voice, attempts to open eyes. PERL 4-5/4-5 brisk. Displays two fingers to command. No spontanous mvmnt of (L) extremities. Pt at (R) upper extremity attempting to pull at ETT. No seizure activity. Sitter present at bedside.\nCV: Afebrile. Cont a-fib no PVC or PAC seen. Cont w/ generalized non pit edema. CVP 21-24. Cont on labetalol to keep SBP <140.\nRESP: Ambu/lavage/sx x2 for tan plugs, as well as prn for thick tan secretions.\nGI: TF via NGT remains clamped, reviewed w/ Dr. . ABD S/NT. No stool.\nGU: u/o amber clear 25-45cc/h. Dr. of decreased u/o.\nSKIN: Laceration to os C/D/I.\n\nPLAN: Monitor resp status w/ possible extubation . Monitor sbp and labetalol gtt. Monitor MS and for seizure activity. Cont w/ current plan of care.\n"},{"category":"Nursing/other","chartdate":"2124-10-23 00:00:00.000","description":"Report","row_id":1594567,"text":"Resp Care,\nPt. remains intubated on CPAP IPS5/.4/5peep. VT 600's, RR18. Plan to extubate today.\n"},{"category":"Nursing/other","chartdate":"2124-10-23 00:00:00.000","description":"Report","row_id":1594568,"text":"focus hemodynmics\ndata: vss. bp 130-140's., hr 50-80's, remains on a labetatolol gtt. u.o 25-50cc amber colored urine. suctioned for copius amts of tan thick sputum. pt does not move l side. moves r side off the bed. show 2 fingers upon command. tube fdg held due to ?extubation today. incontinent of lg amt of stool. sitter at the bedside.\naction: labs prn. suction prn. neuro signs q1-2hrs. labetolol gtt for bp control. update to signaificant other. sitters cont at the bedside.\nresponse: monitor closely.\n"},{"category":"Nursing/other","chartdate":"2124-10-23 00:00:00.000","description":"Report","row_id":1594569,"text":"Resp Care: Pt remains intubated via #8 ETT secured 24cm at lip. BS sl. coarse bilat. Sx'd for mod. amt thick yellow sputum. No vent changes made this shift. Please see carrevue for further vent inqueries.\n"},{"category":"Nursing/other","chartdate":"2124-10-23 00:00:00.000","description":"Report","row_id":1594570,"text":"neuro update\npt cont. to follow commands w/ RE's, but is not opening eyes spont. PERRLA. +corneal reflex. +gag reflex. no movement w/ LUE & slight movement w/ painful stimulus to LLE. s/p angio this afternoon which pt ruled out for AVM/aneurysm per Dr. . R fem. angio site C&D w/ + doppler pulses in RLE. palpable fem pulse. HR 50 - 90's Afib w/ occ episodes of flutter. cont on labetolol drip to keep sbp 140.Resp. coarse & diminished in bases. sxn'd for thick tan secretions in moderate amounts. sputum cx sent. cont. on CPAP w/ PSV 5/5. Abd lg round, soft w/ hypoactive BS. TF cont. to hold per team. wife @ bedside for part of afternoon.\n\nplan is for EEG in am for further neuro w/u. cont. to monitor ABG's, resp status, & neuro status in prep. for extubation ?.\n"},{"category":"Nursing/other","chartdate":"2124-10-24 00:00:00.000","description":"Report","row_id":1594571,"text":"Nursing update - See carevue for patient assessment throughout the shift. Right femoral angio site clean with no ecchymosis. Right pedal and femoral pulses palpable. Does not open eyes. Purposeful movements with right hand. Restart tube feedings and advanced to 20 cc/hr. Labetolol infusion titrated to keep systolic bp less than 140. No family contact.\n"},{"category":"Nursing/other","chartdate":"2124-10-24 00:00:00.000","description":"Report","row_id":1594572,"text":"NPN UPDATE\nPT . W/ L-SIDED WEAKNESS. RUE/RLE 5/5 STRENGTH. LUE/LLE SLIGHT WITHDRAWAL FROM PAINFUL STIMULUS ONLY. PERRLA. FOLLOWING COMMANDS. NONVERBAL. OPENS EYES SPONT. ON RARE OCCASSION. HEAD CT THIS AM SHOWED NO FURTHER BLEED, BUT INC. EDEMA PER SICU TEAM. PT @ 1430. SPO2 98% ON FT @ 35%/10L. LS COARSE. SXN FOR THICK TAN SPUTUM. STARTED ON VANCO FOR GRAM+ SPUTUM CX. CPT/DB/COUGH DONE TO MAINT. SATS>92%. HR IN 50'S AFIB W/ SBP 100-117 THIS AM. LOPRESSOR HELD. LABETOLOL GTT D/C'd HYDRALAZINE PRN GIVEN FOR BRIEF EPISODES OF SBP >150 W/ GOOD EFFECT. CURRENTLY IN AFIB W/ RATE 70-90'S & SBP 130-150'S. MOD. BM THIS AM. PT TO RESTART TF IMPACT W/ FIBER @ GOAL OF 60CC/HR VIA NGT IF . TO TOLERATE EXTUBATION. WIFE @ BEDSIDE WITH PT FOR MOST OF DAY.\n"},{"category":"Nursing/other","chartdate":"2124-10-24 00:00:00.000","description":"Report","row_id":1594573,"text":"Pt place on 50% cool mist. ABGS: 7.43/29/120/20/96%\n\n"},{"category":"Nursing/other","chartdate":"2124-10-25 00:00:00.000","description":"Report","row_id":1594574,"text":"7P-7A: Full assessment in flow sheet.\n\nneuro: Arouse to voice. Open eyes inconsistently. PERL - 3 - 4 mm brisk. Follow directions. Right side normal - strong. Left arm and leg - slight movement to verbal and stimuli (leg stronger than arm). Good gag and cough reflex.\n\ncv: Afib 50-90. SBP 120-150/45-60. Nipride ivp X2 given for SBP 150. Warm, dry, general edema +1, +2 edema bilateral lower extremeties.\n\nresp; Lung sound coarse. RR 16-24, SaO2-94-100%. Encourage to cough and deep breath. Chest percussion and vibration done.\n\ngu/gi; large, soft abd. +BS X4, large bowel movement (negative guiac). TF- +placement, 10-15 cc residual, tolerate goal 60 cc/hr. Foley patent - >40 cc/hr.\n\nint; Skin intact.\n\nAM lab done. Lytes replenish.\n\nPlan; Continue to monitor. Respiratory toileting done.\n\n"},{"category":"Nursing/other","chartdate":"2124-10-25 00:00:00.000","description":"Report","row_id":1594575,"text":"FOCUS: STATUS UPDATE\nDATA:\nPT TO VOICE BUT ONLY OPENS EYES TO STRONG STIMULI--ATTEMPTED TO OPEN TO VOICEX1. LETHARGIC. MOVING RUE FREELY IN BED, LIFTING AND HOLDING RLE. NO MOVEMENT NOTED LE'S. WITHDRAWS TO NAILBED PRESSURE W/LE. PERL, HIPPUS NOTED ON SEVERAL OCCASIONS. SAID \"\" ONCE OTHERWISE . NON-VERBAL. MANNITOL STARTED. ON DILATIN W/INCREASED DOSAGE FOR 8.3 DILANTIN LEVEL.\n\nBP MAINTAINED 140 AND BELOW W/PRN HYDRALAZINE WHICH HAS BEEN INCREASED TO 10MG.\n\nLUNGS CLEAR TO COARSE BILAT BASES. STRONG PRODUCTIVE COUGH. SATS 95-100. REMAINS ON HUMIDIFIED FM AT 40%.\n\nABD SOFT, NON-TENDER, POSITIVE BS, OBESE. TOLERATING TF AT NEW GOAL OF 75ML/HR.\n\nURINE OUTPUT ADEQUATE, LASIX X1 GIVEN. CONTINUES TO BE POSITIVE I/O.\n\nPLAN:\nCONTINUE TO MONITOR I/O, NEURO. MAINTAIN BP 140 OR LESS.\n"},{"category":"Nursing/other","chartdate":"2124-10-26 00:00:00.000","description":"Report","row_id":1594576,"text":"7p-7a; Full assessment in flow sheet.\n\nSleep most of night. Follow commands. Open eyes to painful stimuli only. Move RUE - strong. Weak RLE. Withdrawal slightly to pain in LUE. Move left feet to stimuli in LLE. Strong gag and cough. PERL - 3mm brisk. Murble words. Yes and no not appropriate to questions. Afib without ectopy. SBP maintain under 140 with hydralazine ivp. Lung sound coarse in lower lobes - suction tan/thick secretions. Deep breath and cough. Chest PT and vibration. soft abd, +BS X4. no bm. Foley patent. Lasix 40 ivp given - diuresis well - >100 cc/hr. Skin intact. Continue to monitor.\n"},{"category":"Nursing/other","chartdate":"2124-10-26 00:00:00.000","description":"Report","row_id":1594577,"text":"CONDITION UPDATE\nASSESSMENT:\n PT TO VOICE, ATTEMPTS TO OPEN EYES, BUT UNABLE TO COMMUNICATE BY SPEECH. PUPILS EQUAL AND REACTIVE. PT STILL WITHOUT MOVEMENT OF LEFT EXTREMITIES AND NORMAL STRENGTH OF RIGHT EXTREMITIES.\nCONTINUED WITH MANNITOL, NO EVIDENCE OF NEURO CHANGES.\n ABP ELEVATED THIS AM TO 160'S/80'S WITH HR 100-110 AFIB. HR 70-80'S AFTER AM LOPRESSOR AND IV HYDRALAZINE GIVEN WITH +EFFECT. ABP WAS MAINTAINED 140'S/70'S (GOAL TO KEEP SBP<150). CVP SLIGHTLY INCREASED , PT CONTINUES WITH LG HRLY OUTPUT (>120CC/HR).\n PT WITH STRONG COUGH, OCCASIONALLY PRODUCTIVE (THICK, TAN SPUTUM). SP02 > 97% WITH 40% FT, AND BREATHING APPEARS UNLABORED. LS OCCASIONALLY COARSE @ BASES, PT NEEDS ASSIST WITH PULM HYGEINE.\n PLAN:\n CONTINUE TO FOLLOW NEURO STATUS CLOSELY. HYDRALAZINE PRN TO MAINTAIN SBP<150. CONTINUE WITH CURRENT CLOSE MONITORING.\n"},{"category":"Nursing/other","chartdate":"2124-10-27 00:00:00.000","description":"Report","row_id":1594578,"text":"7p-7a: Full assessment in flow sheet.\n\nLethargic. Arouse to voice. Answer inconsistent verbally appropriately - able to say last name (). Garble and mumble of words. Good cough and gag reflex. Very hard for pt to open eyes - painful stimuli only. Eyes - PERL, reddish - MD notify. Move RLE and RUE. Only withdrawal slight to pain LUE and LLE. Pt slept most of night. Afib 70-110. Inc BP when turn and position. Maintain SBP <140 with Hydralazine ivpX2. Chest PT and vibration, deep breath and cough for coarse lung sound - thick/tan small secretion. Large abd, +BS X4. no BM. Foley patent >40 cc/hr. NG - +placement, minimal residual. Mannitol given for Osmality less than 310. Warm, dry, general edema +1. AM lab done. Continue to monitor.\n\n"},{"category":"Nursing/other","chartdate":"2124-10-27 00:00:00.000","description":"Report","row_id":1594579,"text":"CONDITION UPDATE\nS/O: LETHARGIC THIS AM, MORE ALERT AS SHIFT PROGRESSED. AT TIMES ANSWERING ONE WORD QUESTIONS APPROPRIATELY - SPEECH SOMEWHAT GARBLED. PUPILS EQUAL AND REACTIVE. MOVING RSIDE W/ NL STRENGTH - NO MOVEMENT NOTED LEFT. VSS - W/ EXCEPTION OF HIGH BLOOD PRESSURE. HYDRALAZINE AND LOPRESSOR DOSES INCREASED W/ EFFECT. LUNGS CLEAR TO COARSE, DIMINISHED AT BASES. ORALLY SUCTIONED - FOR THICK, TAN SPUTUM. ABD SOFT, NT. TOLERATING TUBE FEEDS, W/ NO SIGNIFICANT RESIDUAL. U/O QS VIA FOLEY. NO STOOL THIS SHIFT.\nA/P: CLOSE NEURO ASSESSMENT. MAINTAIN BP PER PARAMETERS. TRANSFER TO FLOOR WHEN STABLE, MD'S ORDERS. ICU CARE AND TREATMENTS.\n\n"},{"category":"Nursing/other","chartdate":"2124-10-28 00:00:00.000","description":"Report","row_id":1594580,"text":"neuro status\nD: pt is lethargic but . pupils are equal and reactive to light. no movement of the left side. normal strength on the right. pt unable to state date or place but continuously follows commands. urine output remains adequate. pt coughing and raising to back of throat. suctioned for thick tan sputum from the back of throat. pt tolerating tube feeds of impact with fiber at 75cc/hr.\na: pt treated with ntp for sabp greater than 140. s\nr: sbp 140-160. pt continues on current antihypertenssive medication. neuro status is unchanged. no further desating and pt remains on 3l and 50% face tent.\n"},{"category":"ECG","chartdate":"2124-10-21 00:00:00.000","description":"Report","row_id":170579,"text":"Atrial fibrillation with a moderate ventricular response. RSR' pattern in\nlead V1. Slight ST segment depressions noted in leads V1-V6 suggest possible\nlateral ischemia. Clinical correlation is suggested. No previous tracing\navailable for comparison.\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2124-11-03 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 773091,\n \"text\": \" 7:52 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: NG tube replaced - check position\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 58 year old man with IC hemorrhage now with shortness of breath and gurgling\\n on exam.\\n REASON FOR THIS EXAMINATION:\\n NG tube replaced - check position\\n ______________________________________________________________________________\\n FINAL REPORT\\n PORTABLE CHEST AT 19:44\\n\\n INDICATION: Shortness of breath. Nasogastric tube replaced.\\n\\n FINDINGS: The current study has cut off the apices from view. The visualized\\n lung fields are clear. While I can see parts of the nasogastric tube, the tip\\n cannot be definitely visualized due to underpenetration nature of the film\\n however, the tube does distend below the level of the diaphragm. A left sided\\n central venous catheter is seen with tip in the SVC. The heart size appears\\n mildly prominent but the shallow level of inspiration could exaggerate that.\\n\\n IMPRESSION:\\n\\n 1. Nasogastric tube below the diaphragm. No acute airspace disease in the\\n visualized portions of the lungs.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2124-10-30 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 772679,\n \"text\": \" 5:35 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: please evaluate for worsening shift\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 58 year old man with putaminal hemorrhage and shift noted yesterday.\\n REASON FOR THIS EXAMINATION:\\n please evaluate for worsening shift\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n HEAD CT WITHOUT CONTRAST:\\n\\n INDICATION: Question worsening basal ganglia hemorrhage.\\n\\n Multiple axial images were obtained from base to vertex without IV contrast\\n administration. Comparison is made to the prior exam of . There is\\n worsening surrounding edema involving the large right-sided basal ganglia\\n hemorrhage with mass effect on the anterior and posterior limbs of the\\n internal capsule. There is worsening mass effect on the right lateral\\n ventricle with an estimated 9 mm midline shift to the left. There is also\\n effacement of the superior aspect of the perimesencephalic cistern. No\\n hydrocephalus is seen. No new areas of hemorrhage could be identified.\\n\\n IMPRESSION: Worsening surrounding edema involving the large right basal\\n ganglia hemorrhage with further effacement of the right lateral ventricle and\\n minimal worsening of the midline shift to the left as indicated. Further\\n clinical correlation and follow up are recommended.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2124-10-29 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 772566,\n \"text\": \" 11:29 AM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: please evaluate for hydrocephalus/expansion of bleed\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 58 year old man with right putaminal hemorrhage transferred from intensive care\\n unit.\\n REASON FOR THIS EXAMINATION:\\n please evaluate for hydrocephalus/expansion of bleed\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Right basal ganglia hemorrhage. Please assess for progression.\\n\\n TECHNIQUE: Noncontrast head CT.\\n\\n FINDINGS: Comparison is made to the prior head CT from . There has\\n been slight decrease in the size of the large right basal ganglia hemorrhage.\\n However, surrounding edema has slightly increased with obliteration of right\\n ambient cistern. without evidence of significant change in the mass effect and\\n leftward shift. There is no evidence of a hydrocephalus. There is no new area\\n of hemorrhage.\\n\\n IMPRESSION: There is slight decrease in the size of the large right basal\\n ganglia hemorrhage and slight increase in edema when compared to the prior\\n study.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2124-11-01 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 772829,\n \"text\": \" 7:09 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: please evaluate for infiltrate\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 58 year old man with IC hemorrhage now with shortness of breath and gurgling\\n on exam.\\n REASON FOR THIS EXAMINATION:\\n please evaluate for infiltrate\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: History of intracranial hemorrhage, now with shortness of breath\\n and gurgling. Please evaluate for infiltrate.\\n\\n COMPARISONS: AP chest radiograph .\\n\\n FINDINGS: There is marked, but stable polychamber cardiac enlargement. There\\n is minimal evidence for upper lung zone redistribution which may be postural\\n in nature but which could also represent mild failure. The aorta is unfolded\\n and tortuous. No focal lung opacities are present to suggest aspiration or\\n pneumonia. No pleural effusions are present. The osseous structures are\\n unremarkable.\\n\\n IMPRESSION: Stable cardiomegaly, no acute cardiopulmonary changes.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2124-11-06 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 773242,\n \"text\": \" 4:48 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: check position of NG tube on patient, who is difficult to tr\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 58 year old man with IC hemorrhage now with shortness of breath and gurgling\\n REASON FOR THIS EXAMINATION:\\n check position of NG tube on patient, who is difficult to transport s/p stroke\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Check position of NG tube.\\n\\n COMPARISONS: AP chest radiograph from .\\n\\n SUPINE AP CHEST RADIOGRAPH: An NG tube is demonstrated, with the tip below the\\n diaphragm, but not visualized on today's study. Stable, marked biventricular\\n cardiomegaly is again demonstrated. The aorta is unfolded. Allowing for the\\n supine positioning, the pulmonary vasculature is difficult to assess, but\\n slight left ventricular failure cannot be excluded. There is a focal opacity\\n within the right middle lobe which likely represents atelectasis. No pleural\\n effusions are present. The osseous structures are unremarkable.\\n\\n IMPRESSION: Right middle lobe atelectasis, prominent pulmonary vasculature may\\n be related to positioning, but slight LV failure cannot be excluded.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2124-11-06 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 773327,\n \"text\": \" 9:16 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: NG tube placement\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 58 year old man with IC hemorrhage\\n REASON FOR THIS EXAMINATION:\\n NG tube placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: NG tube placement.\\n\\n COMPARISON: @ 5:46 A.M.\\n\\n PORTABLE UPRIGHT CHEST @ 9 P.M.: The tip of the NG tube is difficult\\n to visualize but appears to be within the stomach. There is a left PICC with\\n tip in the SVC. There is mild cardiomegaly. The aorta is tortuous. There is no\\n evidence of vascular congestion or pleural effusions. There are patchy\\n opacities at the lung bases which probably represent atelectasis vs.\\n aspiration. No pneumothorax.\\n\\n IMPRESSION: 1) Tip of the NG tube difficult to visualize but appears to be\\n within the stomach. If clinically indicated, a dedicated abdominal film\\n is suggested to confirm.\\n\\n 2) Patchy bibasilar opacities, probably atelectasis, however, aspiration\\n should also be considered.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2124-11-08 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 773530,\n \"text\": \" 7:51 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: please evaluate ngt placement\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 58 year old man with IC hemorrhage no w s/p new ngt placement.\\n\\n REASON FOR THIS EXAMINATION:\\n please evaluate ngt placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Intracranial hemorrhage. New NG tube placement.\\n\\n PORTABLE SUPINE CHEST, 1 VIEW: Comparison . There is an NG tube\\n extending below the diaphragm, tip not visualized. The heart is enlarged. The\\n left lateral CP angle is not included on this exam. Allowing for technique,\\n there is no CHF, focal consolidation, or large pleural effusion.\\n\\n IMPRESSION: NG tube extending below the diaphragm, tip not visualized.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2124-10-31 00:00:00.000\",\n \"description\": \"CVL/PICC\",\n \"row_id\": 772805,\n \"text\": \" 4:06 PM\\n PICC LINE PLACMENT SCH Clip # \\n Reason: please place picc line\\n ********************************* CPT Codes ********************************\\n * CVL/PICC UD GUID FOR NEEDLE PLACMENT *\\n * C1751 CATH ,/CENT/MID(NOT D C1894 INT.SHTH NOT/GUID,EP,NONLASER *\\n ****************************************************************************\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 58 year old man with right putaminal hemorrhage requires picc line for iv meds.\\n IV service has tried but unsuccessful.\\n REASON FOR THIS EXAMINATION:\\n please place picc line\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Right putaminal hemorrhage, requires access for IV medications.\\n The IV access team was unsuccessful in placing a PICC line.\\n\\n PHYSICIANS: Drs. and . Dr. , the attending\\n radiologist, was present and supervising. Dr. reviewed the case.\\n\\n PROCEDURE: The left upper arm was prepped in a sterile fashion. Since no\\n suitable superficial veins were visible, ultrasound was used for localization\\n of a suitable vein. The basilic vein was patent and compressible. After\\n local anesthesia with 1% Lidocaine, the basilic vein was entered under\\n ultrasonographic guidance with a 21 g. needle. A .018 guidewire was advanced\\n under fluoroscopy into the superior vena cava. Based on the markers on the\\n guidewire it was determined that a length of 57.5 cm would be suitable. The\\n PICC line was trimmed to line and advanced over a 4 French introducer sheath\\n under fluoroscopic guidance into the superior vena cava. The sheath was\\n removed. The catheter was flushed. A final chest x-ray was obtained. This\\n film demonstrates the tip to be in the superior vena cava, just above the\\n atrium. The line is ready for use.\\n\\n A stat-lock was applied and the line was hep-locked.\\n\\n IMPRESSION: Successful placement of a 4 French, single lumen, 57.5 cm total\\n length PICC line with tip at the superior vena cava/RA junction. The line is\\n ready for use.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2124-10-23 00:00:00.000\",\n \"description\": \"SEL CATH 2ND ORDER\",\n \"row_id\": 772010,\n \"text\": \" 8:11 AM\\n CAROT/CEREB Clip # \\n Reason: CEREBRAL HEMORRHAGE\\n Contrast: OPTIRAY Amt: 90\\n ********************************* CPT Codes ********************************\\n * SEL CATH 3RD ORDER SEL CATH 2ND ORDER *\\n * -59 DISTINCT PROCEDURAL SERVICE SEL CATH 2ND ORDER *\\n * -59 DISTINCT PROCEDURAL SERVICE CAROTID/CEREBRAL BILAT *\\n * EXT CAROTID BILAT VERT/CAROTID A-GRAM *\\n ****************************************************************************\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL HISTORY: Mr. is a 58-year-old man who developed a right\\n putaminal hemorrhage. The hemorrhage was felt to be due to hypertension.\\n However, while the patient has been normotensive on intravenous\\n antihypertensive medication, the hemorrhage significantly enlarged and the\\n patient developed seizures. After consultation with Neurosurgery it was\\n decided to proceed with a cerebral angiogram to rule out an underlying\\n vascular malformation or an aneurysm. The assessment and plan were thoroughly\\n discussed with the Neurosurgery staff as well as with the Neurology staff.\\n\\n PROCEDURE: Informed consent was obtained from the patient's significant other\\n after explanation of risks, benefits, indication and alternative management.\\n The patient's significant other read the consent form, asked appropriate\\n questions, understood and signed. The patient was already intubated in the\\n SICU. He was thereofre transported from the Surgical Intensive Care Unit to\\n the Neurointerventional Suite and placed under general anesthesia. The\\n patient had an arterial line and vital parameters were constantly monitored by\\n the Anesthesia staff.\\n\\n The patient was placed supine on the table. Both groins were prepped and\\n draped in usual sterile fashion. The right femoral artery was accessed by a\\n single wall puncture needle. After visualization of bright pulsatile blood a\\n .035 J-wire was inserted into the femoral artery and advanced into the\\n abdominal aorta. At this point a 4 Fr short sheath was inserted into the right\\n femoral artery using the J wire as a guide.\\n\\n Under fluoroscopic guidance, a 4 Fr Barenstein catheter in conjunction with\\n Terumo guidewire was advanced into the aortic arch and subsequently used to\\n select the right common carotid artery. Injection of contrast at this level\\n demonstrates normal opacification of the origin of the right internal and\\n right external carotid artery and their branches. Of notice there is a mild\\n stenosis of the bulb of the right internal carotid artery in both AP and\\n lateral projections.\\n\\n Subsequently, attention was paid to the intracranial branches of the right\\n internal carotid artery. Injection of contrast in the right common carotid\\n artery demonstrates normal opacification of the intracranial portions of the\\n internal carotid artery with normal visualization of the lacerum, petrous,\\n cavernous and supraclinoid portion or internal carotid artery and its\\n branches. A magnified view of the intracranial circulation demonstrated normal\\n opacification of the anterior cerebral, middle cerebral and posterior\\n communicating artery and their branches in both AP and lateral projections.\\n (Over)\\n\\n 8:11 AM\\n CAROT/CEREB Clip # \\n Reason: CEREBRAL HEMORRHAGE\\n Contrast: OPTIRAY Amt: 90\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n Subsequently, the catheter was advanced into the external carotid artery and\\n attention was paid to the branches of the external carotid artery. Injection\\n of contrast shows normal opacification of the branches of both superficial and\\n deep of the external carotid artery in particular the temporal, occipital\\n arteries and their branches as well as the internal maxillary with no evidence\\n of arteriovenous malformations.\\n\\n Subsequently the 4 Fr Barenstein catheter in conjunction with a Terumo\\n glidewire was slowly advanced to select the left common carotid artery.\\n Particular attention at this level was paid to the intracranial branches.\\n Injection of contrast via the left common carotid artery shows normal\\n opacification intracranial branches and all the segments of the intracranial\\n internal carotid artery. There was also normal opacification of the anterior\\n cerebral artery and middle cerebral artery and their branches. Of note, the\\n contralateral anterior cerebral artery is also opacified with this injection\\n as well. There is also normal parenchymal venous phase in both AP and lateral\\n projections.\\n\\n At this level particular attention was also paid to the branches of the\\n external carotid artery. Injection of contrast in the left external carotid\\n artery also shows normal opacifications of the external and the superficial\\n and the branches of the external carotid artery with no evidence of vascular\\n malformations.\\n\\n Subsequently the 4 Fr Barenstein catheter in conjunction with Terumo glidewire\\n was withdrawn to select the left vertebral artery. Injection of contrast in\\n the left vertebral artery demonstrates normal opacification of the\\n intracranial segment of the left vertebral artery basilar artery and \\n branches in both AP and lateral projections. The contralateral right vertebral\\n artery is also opacified with this injection. There is normal parenchymal and\\n venous phase in both AP and lateral projection at this level.\\n\\n Dr. reviewed the case with Dr. and Dr. .\\n\\n IMPRESSION: There is a mild stenosis of the right ICA at the bifurcation.\\n Otherwise normal cerebral angiogram in particular of the right internal and\\n external carotid artery branches, of the left internal and external carotid\\n artery branches and of both vertebral and basilar artery complex and their\\n branches. There is no evidence of vascular malformations or cerebral\\n aneurysms.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2124-10-24 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 772130,\n \"text\": \" 10:55 AM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: assess for progression of bleed/ shift?\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 58 year old man with ?ICH\\n\\n REASON FOR THIS EXAMINATION:\\n assess for progression of bleed/ shift?\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n HEAD CT, \\n\\n INDICATION: Right basal ganglia hemorrhage, please assess progression\\n\\n TECHNIQUE: Non-contrast head CT\\n\\n FINDINGS: Comparison is made to a prior head CT from . Since that\\n time there has been no change in the size of the large right basal ganglia\\n hemorrhage, but there has been slight increase in the mass effect and leftward\\n shift. Perihemorrhage edema is slightly more prominent now. There is no\\n hydrocephalus, but blood is still seen in the dependent portions of the\\n lateral ventricles bilaterally. No new areas of hemorrhage are seen. Again\\n seen is fluid within the right maxillary sinus, consistent with patient's\\n intubation.\\n\\n IMPRESSION: Slight increase in mass effect and leftward shift from right\\n basal ganglia hemorrhage. These findings were communicated to ,\\n MD, at the time of the exam.\\n\\n\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2124-10-21 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 771891,\n \"text\": \" 2:39 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: status of bleed\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 58 year old man with ?ICH\\n\\n REASON FOR THIS EXAMINATION:\\n status of bleed\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Reassess intracranial hemorrhage.\\n\\n TECHNIQUE: Noncontrast CT of the head.\\n\\n COMPARISON: Head CT .\\n\\n FINDINGS: There has been no significant interval change in the previously\\n described large hemorrhage in the region of the right basal ganglia. There is\\n still a mild amount of surrounding edema, slight shift of the midline\\n structures to the left and blood within the dependent portions of both lateral\\n ventricles. There is no evidence of new intra/extra-axial hemorrhages or mass\\n affect. The ventricles, cisterns and sulci are stable in appearance. Again\\n noted is thickening of the ethmoid air cells and a probable retention cyst\\n within the left sphenoid sinus. There is a new small air fluid level within\\n the right maxillary sinus, which may be secondary to the patient's intubated\\n state.\\n\\n IMPRESSION: No significant interval change in the size/appearance of the\\n previously described right basal ganglia hemorrhage. No new intra/extra-axial\\n hemorrhages or mass affect.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2124-10-20 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 771773,\n \"text\": \" 8:26 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: New right IJ CVL placed, r/o pneumo/hemothorax.Thanks\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 58 year old man with IC hemorrhage\\n REASON FOR THIS EXAMINATION:\\n New right IJ CVL placed, r/o pneumo/hemothorax.Thanks\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 58 year old male with intracranial hemorrhage and line placement.\\n Evaluate for pneumothorax/hemothorax.\\n\\n FINDINGS: There are no studies available for comparison.\\n\\n There is an endotracheal tube in good position. There is a right-sided IJ\\n central venous line in place with its distal tip in the SVC. There is a\\n nasogastric tube in place that passes beneath the diaphragm. The distal tip\\n of this nasogastric tube is not visualized. There is no evidence of failure,\\n focal infiltrate, or pleural effusion. The heart size is increased. There is\\n no pneumothorax.\\n\\n IMPRESSION:\\n\\n 1. Placement of right IJ central venous line with no evidence of pneumothorax\\n or other acute cardiopulmonary process.\\n\\n 2. Increased heart size without evidence of heart failure.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2124-10-20 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 771786,\n \"text\": \" 9:47 AM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: ICH ASSESS BLEED\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 58 year old man with ?ICH\\n REASON FOR THIS EXAMINATION:\\n r/o hemorrhage\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Intracranial hemorrhage, please assess bleed.\\n\\n TECHNIQUE: Non-contrast head CT.\\n\\n FINDINGS: There are no prior studies for comparison, so it is not possible to\\n assess the progression of this patient's intracranial hemorrhage. There is a\\n large right-sided basal ganglia hemorrhage, with minimal surrounding edema,\\n and mild shift of the normally mid-line structures to the left. Hemorrhage is\\n also seen within the occipital of both lateral ventricles, right greater\\n than left. No extra-axial collections are seen. There is atrophy of the\\n frontal lobes bilaterally. No hydrocephalus.\\n\\n There is mucosal thickening within the ethmoid sinuses as well as a polyp\\n versus mucus retention cyst within the left sphenoid sinus. The visualized\\n osseous structures are unremarkable.\\n\\n IMPRESSION: Large right-sided basal ganglia hemorrhage with smaller amounts\\n of hemorrhage within both occipital horns of the lateral ventricles. These\\n findings were communicated directly to Dr. , one of the SICU fellows, on\\n the morning of .\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2124-11-15 00:00:00.000\",\n \"description\": \"P ABDOMEN U.S. (COMPLETE STUDY) PORT\",\n \"row_id\": 774096,\n \"text\": \" 2:34 PM\\n ABDOMEN U.S. (COMPLETE STUDY) PORT Clip # \\n Reason: ABNORMAL LFT,S ,EVAL FOR LIVER PATHOLOGY\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n As above.\\n REASON FOR THIS EXAMINATION:\\n Patient is a 58 year-old man s/p right putaminal hemorrhage, h/o\\n alcoholism--now has elevated LFTs, palpably enlarged spleen and liver, please\\n eval for ascites prior to PEG placement.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Alcoholism, elevated liver function tests.\\n\\n FINDINGS: A small nodular liver that is increased in echogenicity is\\n identified. This is consistent with cirrhosis. There is normal hepatopetal\\n flow within the patent portal vein. There is no intrahepatic or extrahepatic\\n biliary dilatation. Multiple gallstones and a nondistended gallbladder are\\n identified. There is gallbladder wall thickening, probably related to the\\n ascites and hypoalbuminemia. The pancreas is not well visualized. There is\\n enlargement of the spleen, with no focal lesions. The right kidney measures\\n 12.6 cm and the left kidney measures 12.8 cm. There is no hydronephrosis or\\n nephrolithiasis. There are small amounts of ascites. A patent portal vein is\\n identified.\\n\\n IMPRESSION:\\n\\n 1. Cirrhotic liver.\\n\\n 2. Cholelithiasis.\\n\\n 3. Small amounts of ascites.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2124-11-14 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 773963,\n \"text\": \" 12:00 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Infectious (lung) process underlying waxing and (wani\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 58 year-old man 3wks s/p R-putaminal bleed.\\n REASON FOR THIS EXAMINATION:\\n Infectious (lung) process underlying waxing and ( today) mental\\n status?\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Mental status changes.\\n\\n COMPARISON: .\\n\\n SINGLE VIEW CHEST: There is a left PICC with tip in the SVC. There are low\\n lung volumes. There is mild cardiomegaly. The aorta is tortuous. There is\\n no evidence of vascular congestion, pleural effusion, or focal consolidation.\\n Discoid atelectasis is seen at the right base. The right CP angle is not\\n included on this film.\\n\\n IMPRESSION: Right lower lobe atelectasis.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2124-11-14 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 774001,\n \"text\": \" 5:00 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: Is there further edema and/or are we able to better visualiz\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 58 year old man with R-putaminal hemorrhage--failing to improve 3 weeks after\\n event.\\n REASON FOR THIS EXAMINATION:\\n Is there further edema and/or are we able to better visualize the etiology of\\n the patient's significant edema (is there a tumor underlying this hemorrhage?)?\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT (REVISED)\\n INDICATION: 58 year old man with right putamenal hemorrhage failing to improve\\n after 3 weeks.\\n\\n CT OF THE HEAD WITHOUT CONTRAST\\n\\n COMPARISON: Comparison is made with prior study performed .\\n\\n TECHNIQUE: CT of the head without contrast.\\n\\n FINDINGS: There has been interval decrease in size of the hypedense region\\n large right basal ganglia hemorrhage, compatible with partial resorption of\\n the acute hemorrhagic components.. No new areas of hemorrhage are identified.\\n However, there is still considerable surrounding edema, with compression\\n of the right lateral ventricle. No hydrocephalus is seen.\\n\\n There is a 1cm focal area of polypoid mucosal thickening within the left\\n lateral aspect of the sphenoid sinus, unchanged from the prior study. The\\n visualized paranasal sinuses and mastoid air cells are otherwise well aerated.\\n\\n IMPRESSION: Interval decrease in size in the large right basal ganglia\\n hemorrhage with only minor interval decrease in mass effect. There is\\n prominent, persistent edema surrounding the hemorrhage.\\n\\n COMMNENT: Both studies show a moderate degree of bifrontal peripheral\\n cerebral atrophy.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2124-11-16 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 774186,\n \"text\": \" 9:53 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Please assess for GT placement.\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 58 year-old man 3wks s/p R-putaminal bleed.\\n\\n REASON FOR THIS EXAMINATION:\\n Please assess for GT placement.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Assess gastric tube placement.\\n\\n COMPARISON: AP chest radiograph from .\\n\\n SEMI-UPRIGHT AP CHEST RADIOGRAPH: This study is limited by motion. The tip\\n of the NG tube is not clearly visualized for technical reasons, but is likely\\n within the stomach. Again identified is a left sided subclavian PICC line\\n with the tip in the superior vena cava. There is cardiomegaly without\\n evidence of left ventricular failure. No focal lung opacities are identified.\\n The osseous structures are unchanged.\\n\\n IMPRESSION: Feeding tube tip likely within the stomach, but not visualized\\n secondary to technical reasons. Cardiomegaly without evidence of failure.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2124-11-17 00:00:00.000\",\n \"description\": \"VIDEO OROPHARYNGEAL SWALLOW\",\n \"row_id\": 774223,\n \"text\": \" 10:28 AM\\n VIDEO OROPHARYNGEAL SWALLOW Clip # \\n Reason: ASPIRATION\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATIONS: Aspiration.\\n\\n VIDEO OROPHARYNGEAL SWALLOW: The demonstrated frank aspiration of thin\\n liquids with spontaneous but weak cough and inaffective clearing. No\\n structural abnormalities are seen.\\n\\n IMPRESSION: Please see the full report of the speech and swallowing division\\n for full details and recommendations.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2124-10-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1594560,\n \"text\": \"ADMIT NOTE\\n58 Y.O. MALE WITH HX CVA, ASTHMA, AFIB, APPENDECTOMY, ETOH- ALLERGY TO SULFA- PRESENTED TO HOSPITAL WITH LEFT SIDED WEAKNESSWAS FOUND TO HAVE RIGHT POST FRONTAL PARIETAL THALMIC BLEED ON HEAD CT- WAS ADMITTED TO FLOOR AT BH- WAS PLACED ON BED REST- FOUND ON FLOOR IN PRONE POSITION AT 1230AM WITH LEFT BROW LACERATION 1.5CM AND RIGHT HAND INFILTRATE- WENT TO HEAD CT - REVEALED EXTENDED PT CAME BACK FROM CT WITH FOLLOWING SYMPTOMS. LEFT LOWER LEG WEAKNESS. FLACID LEFT ARM, SLURRED SPEECH, INCREASED BP 150-180/90-100, PT CYCLED FOR CARDIAC ENZYMES. PT ADMITTED DIRECTLY TO UNIT FROM HOSPITAL AT 0545 AM.\\n\\nON ADMIT, PT AFIB 100S- SBP 170/58- LABETALOL DRIP STARTED TO KEEP SBP BELOW 140- 2 INCHES NITRO PLACED TO CW- ALINE PLACED/ PERIPERAL IV STARTED.\\n\\nNEURO: INITIALLY PT RESPONDING TO QUESTIONS- ALERT TO NAME ONLY NOT TO PLACE OR TIME, FULL STRENGTH NOTED ON RIGHT SIDE- NO MOVEMENT OF LEFT ARM AND SLIGHT MOVEMENT NOTED AT LEFT LEG- NO SENSATION NOTED ON LEFT SIDE PER PT, PT DENIES VISUAL DIFFICULTY ALTHOUGH WHEN 5 FINGERS ARE HELD IN FRONT OF PT- HE STATES THERE IS ONLY ONE. PT UNABLE TO PERFORM LATERAL MOVMENT OF EYES TO LEFT- EXHIBITING SLURRED SPEECH.\\n\\nAT 0600 PT HAD GENERALIZED SEIZURE LASTING MINITES AND CONTINUED TO HAVE 3 MORE SIEZURES OVER THE NEXT PT WAS GIVEN 4 MG ATIVAN WITH NO EFFECT PT CONTINUES TO HAVE SIEZURES TO HAVE LOADING DOSE OF DILANTIN. PT LETHARGIC AND UNRESPONSIVE TO QUESTIONS FOLLOWING SEIZURE.\\n\\nRESP: PT TO BE INTUBATED SHORTLY\\n\\nGU/GI: FOLEY CATH PLACED FOR CLEAR YELLOW URINE- BS POSITIVE- OBESE ABDOMEN- NGT PLACED TO LWS\\n\\nPLAN: PT TO HAVE EMERGENT HEAD CT, TO BE INTUBATED, TO HAVE LINE PLACED, AND HAVE EEG\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2124-10-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1594561,\n \"text\": \"NEURO; MOVES RT HAND AND LEG RANDOMLY AND WITHDRAWS TO STIMULATION, MOVES LEFT HAND SLIGHTLY TOWARD TORSO WHEN NAILBED PRESSURE APPLIED, OCCAS MOVES LEFT FOOT BUT ONLY SLIGHTLY AND NOT TO NAILBED PRESSURE, NEURO AND SICU MD'S INFORMED, PERL #6, BRISKK, POSITIVE CORNEAL, POSITIVE GAG, PT HAS BECOME MORE RESTLESS SINCE LATE PM AND MOVING RT SIDE MORE FREQUENTLY, NEURO TEAM IN TO EVALUATE AND PT DID DISPLAY TWO FINGERS WITH RT HAND, AND WIGGLED TOES RT FOOT TO COMMAND, DOES NOT DO SO WITH LEFT, PT DOES NOT SPONT OPEN EYES, IS LOCALIZING MORE WITH RT ARM, CAT SCAN THIS AM, VERBAL REPORT WAS LEFT BASAL GANGLION HEMORRHAGE, L VENTRICLE-MASS EFFECT, REPORTED TO SICU H.O. AND NEUROLOGY, SEEN BY NEUROSURGERY TODAY FOR ? VENT DRAIN PLACEMENT, BUT WILL BE DEFERRED\\nWITNESSED SEIZURE AT 0745 THIS AM, SPASTIC TREMORS OF LEFT ARM AND LEG, LASTED 3-4 MINUTES, MEDIC WITH ATIVAN 2 MGM AND RT LEG BECAME SPASTIC FOR 2 MINUTES AND THEN SUBSIDED.\\nCARDIOVASCULAR; HR 70'S-80'S A FIB, LABETOLOL ON THIS AM FOR SYS GOAL OF < 140, HAS BEEN OFF SINCE 9 AM SINCE BP SYS HAS BEEN LOW L110'S-140, (GOAL ACCORDING TO NEUROLOGY IS SYS > 100 AND < 140), LEFT FOOT SL COOLER THAN RT BUT PEDAL AND PT PULSES WEAKLY PALPABLE, THIS PM PEDAL PULSE STRONGER THAN RT,\\n\\nRESPIR; ON CMV MODE, ABGS REFLECT METAB ALKALOSIS, SUCTIONED FOR SMALL THIN CLEAR SECRETIONS\\n\\nLABS; K 3.4, REPLETED WITH 40 MEQ KCL, MG REPLETED, ION CA 1.11-NO REPLETION ORDERED, SLIDING SCALE INSULIN BS 207-COVERED WITH 2 UNITS REGULAR, LAST BS 149 AT 1800\\n\\nGI: BLOOD-TINED BILIOUS DGE FROM NG TUBE, PT WILL START ON PROTONIX TONOC\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2124-10-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1594562,\n \"text\": \"Respiratory care\\nPt remains intubated and tolerating wean to CPAP/PSV 5/5. Please see carevue flowsheet for further info. Pt traveled to Ct scan this afternoon and placed back on vent with current settings. Pt sx for thick yellow throughout day, plan to continue with current settings and wean to extubate.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2124-10-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1594563,\n \"text\": \"NEURO; PERL # , BOTH REACT BRISKLY TO LIGHT, POSITVE CORNEALS, STRONGER GAG REFLEX THAN YESTERDAY, ATTEMPTS TO OPEN EYES AT TIMES, ABLE TO SHOW TWO FINGERS ON RT HAND, LIFTS AND HOLDS RT ARM AND RT LEG, LEFT SIDE WEAKER, MOVES LEFT FOOT ONLY SLIGHTLY IN BED, AND MOVES FINGERS OF LEFT HAND VERY SLIGHTLY,\\n\\nCARDIOVASCULAR; HR 70'S-80'S A FIB, STARTED BACK ON LABETOLOL TO KEEP SYS 140 OR LESS SYS, LABETOLOL PRESENTLY AT 0.8 MGM/MIN, LEFT FOOT WARMER THAN YESTERDAY, PEDAL AND PT PULSES PALPABLE,\\n\\nRESPIR; WEANED TO C-PAP MODE, 5 OF PRESSURE SUPPORT AND PEEP, SPON TV 520-550, ABG'S STABLE WITH PH 7.44, PC02 45, P02 95, AND BICARB 35, SHOWN TO DR. , PT TO 90% SHORTLY AFTER ABGS DRAWN, SUCTIONED FOR THICK TAN-DEEP YELLOW SECRETIONS, 02 SAT PRESENTLY 96%\\n\\nLABS: CA AND K REPLETIONS TODAY, BS 142-NOT COVERED WITH SLIDING SCALE\\n\\n; U/O 30-40/HR, CONCENTRATED, NEED TO KEEP MONITORING\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2124-10-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1594564,\n \"text\": \"Resp Care,\\nPt. remains intubated on CPAP IPS5/.4/5peep. VT400-500, RR18. Plan to extubate. See vent flowsheet.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2124-10-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1594565,\n \"text\": \"NEURO: PT . AROUSABLE TO VOICE, BUT DOES NOT OPEN EYES. FOLLOWS COMMANDS. MOVES RIGHT EXTREMTITIES PURPOSEFULLY. MINIMAL MOVEMENT OF LEFT EXTREMTIES TO COMMAND. PUPILS BRISK AND REACTIVE LEFT LARGER THAN RIGHT. RIGHT PUPIL 3-4MM, LEFT 5-7MM. MD INFORMED.\\nRESP: LS CLEAR, BUT OCCASIONALLY COASRE AT UPPER AIRWAY. ET SUCTIONED FOR MODERATE TO LARGE AMT TAN SPUTUM. O2SATS AND ABG STABLE.\\nCV: AFEBRILE. AFIB CONTINUES 70S TO 80S. LABETOLOL GTT TITRATED UP TO 1MG/MIN TO MAINTAINE SBP <140. RECEIVED 1 UNIT FFP FPR INR 1.4. REPEAT INR 1.5. MD INFORMED.\\nGI: ABD SOFT. FAINT BS. TF'S OF IMPACT WITH FIBER STARTED AT 10CC/HOUR WITH MINIMAL RESIDUALS. NOT ADVANCED PER ORDER.\\nGU: FOLEY INTACT AND PATENT FOR MINIMAL U/O 30-50CC/HOUR, AMBER IN COLOR.\\nPLAN: CONT TO MONITOR NEURO STATUS CLOSELY. CONT PER CURRENT MGMT.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2124-10-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1594566,\n \"text\": \"Condition Update A:\\nROS - Please refer to careview for specifics.\\nNEURO: Cont w/ somulance, arouse to voice, attempts to open eyes. PERL 4-5/4-5 brisk. Displays two fingers to command. No spontanous mvmnt of (L) extremities. Pt at (R) upper extremity attempting to pull at ETT. No seizure activity. Sitter present at bedside.\\nCV: Afebrile. Cont a-fib no PVC or PAC seen. Cont w/ generalized non pit edema. CVP 21-24. Cont on labetalol to keep SBP <140.\\nRESP: Ambu/lavage/sx x2 for tan plugs, as well as prn for thick tan secretions.\\nGI: TF via NGT remains clamped, reviewed w/ Dr. . ABD S/NT. No stool.\\nGU: u/o amber clear 25-45cc/h. Dr. of decreased u/o.\\nSKIN: Laceration to os C/D/I.\\n\\nPLAN: Monitor resp status w/ possible extubation . Monitor sbp and labetalol gtt. Monitor MS and for seizure activity. Cont w/ current plan of care.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2124-10-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1594567,\n \"text\": \"Resp Care,\\nPt. remains intubated on CPAP IPS5/.4/5peep. VT 600's, RR18. Plan to extubate today.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2124-10-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1594568,\n \"text\": \"focus hemodynmics\\ndata: vss. bp 130-140's., hr 50-80's, remains on a labetatolol gtt. u.o 25-50cc amber colored urine. suctioned for copius amts of tan thick sputum. pt does not move l side. moves r side off the bed. show 2 fingers upon command. tube fdg held due to ?extubation today. incontinent of lg amt of stool. sitter at the bedside.\\naction: labs prn. suction prn. neuro signs q1-2hrs. labetolol gtt for bp control. update to signaificant other. sitters cont at the bedside.\\nresponse: monitor closely.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2124-10-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1594569,\n \"text\": \"Resp Care: Pt remains intubated via #8 ETT secured 24cm at lip. BS sl. coarse bilat. Sx'd for mod. amt thick yellow sputum. No vent changes made this shift. Please see carrevue for further vent inqueries.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2124-10-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1594570,\n \"text\": \"neuro update\\npt cont. to follow commands w/ RE's, but is not opening eyes spont. PERRLA. +corneal reflex. +gag reflex. no movement w/ LUE & slight movement w/ painful stimulus to LLE. s/p angio this afternoon which pt ruled out for AVM/aneurysm per Dr. . R fem. angio site C&D w/ + doppler pulses in RLE. palpable fem pulse. HR 50 - 90's Afib w/ occ episodes of flutter. cont on labetolol drip to keep sbp 140.Resp. coarse & diminished in bases. sxn'd for thick tan secretions in moderate amounts. sputum cx sent. cont. on CPAP w/ PSV 5/5. Abd lg round, soft w/ hypoactive BS. TF cont. to hold per team. wife @ bedside for part of afternoon.\\n\\nplan is for EEG in am for further neuro w/u. cont. to monitor ABG's, resp status, & neuro status in prep. for extubation ?.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2124-10-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1594571,\n \"text\": \"Nursing update - See carevue for patient assessment throughout the shift. Right femoral angio site clean with no ecchymosis. Right pedal and femoral pulses palpable. Does not open eyes. Purposeful movements with right hand. Restart tube feedings and advanced to 20 cc/hr. Labetolol infusion titrated to keep systolic bp less than 140. No family contact.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2124-10-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1594572,\n \"text\": \"NPN UPDATE\\nPT . W/ L-SIDED WEAKNESS. RUE/RLE 5/5 STRENGTH. LUE/LLE SLIGHT WITHDRAWAL FROM PAINFUL STIMULUS ONLY. PERRLA. FOLLOWING COMMANDS. NONVERBAL. OPENS EYES SPONT. ON RARE OCCASSION. HEAD CT THIS AM SHOWED NO FURTHER BLEED, BUT INC. EDEMA PER SICU TEAM. PT @ 1430. SPO2 98% ON FT @ 35%/10L. LS COARSE. SXN FOR THICK TAN SPUTUM. STARTED ON VANCO FOR GRAM+ SPUTUM CX. CPT/DB/COUGH DONE TO MAINT. SATS>92%. HR IN 50'S AFIB W/ SBP 100-117 THIS AM. LOPRESSOR HELD. LABETOLOL GTT D/C'd HYDRALAZINE PRN GIVEN FOR BRIEF EPISODES OF SBP >150 W/ GOOD EFFECT. CURRENTLY IN AFIB W/ RATE 70-90'S & SBP 130-150'S. MOD. BM THIS AM. PT TO RESTART TF IMPACT W/ FIBER @ GOAL OF 60CC/HR VIA NGT IF . TO TOLERATE EXTUBATION. WIFE @ BEDSIDE WITH PT FOR MOST OF DAY.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2124-10-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1594573,\n \"text\": \"Pt place on 50% cool mist. ABGS: 7.43/29/120/20/96%\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2124-10-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1594574,\n \"text\": \"7P-7A: Full assessment in flow sheet.\\n\\nneuro: Arouse to voice. Open eyes inconsistently. PERL - 3 - 4 mm brisk. Follow directions. Right side normal - strong. Left arm and leg - slight movement to verbal and stimuli (leg stronger than arm). Good gag and cough reflex.\\n\\ncv: Afib 50-90. SBP 120-150/45-60. Nipride ivp X2 given for SBP 150. Warm, dry, general edema +1, +2 edema bilateral lower extremeties.\\n\\nresp; Lung sound coarse. RR 16-24, SaO2-94-100%. Encourage to cough and deep breath. Chest percussion and vibration done.\\n\\ngu/gi; large, soft abd. +BS X4, large bowel movement (negative guiac). TF- +placement, 10-15 cc residual, tolerate goal 60 cc/hr. Foley patent - >40 cc/hr.\\n\\nint; Skin intact.\\n\\nAM lab done. Lytes replenish.\\n\\nPlan; Continue to monitor. Respiratory toileting done.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2124-10-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1594575,\n \"text\": \"FOCUS: STATUS UPDATE\\nDATA:\\nPT TO VOICE BUT ONLY OPENS EYES TO STRONG STIMULI--ATTEMPTED TO OPEN TO VOICEX1. LETHARGIC. MOVING RUE FREELY IN BED, LIFTING AND HOLDING RLE. NO MOVEMENT NOTED LE'S. WITHDRAWS TO NAILBED PRESSURE W/LE. PERL, HIPPUS NOTED ON SEVERAL OCCASIONS. SAID \\\"\\\" ONCE OTHERWISE . NON-VERBAL. MANNITOL STARTED. ON DILATIN W/INCREASED DOSAGE FOR 8.3 DILANTIN LEVEL.\\n\\nBP MAINTAINED 140 AND BELOW W/PRN HYDRALAZINE WHICH HAS BEEN INCREASED TO 10MG.\\n\\nLUNGS CLEAR TO COARSE BILAT BASES. STRONG PRODUCTIVE COUGH. SATS 95-100. REMAINS ON HUMIDIFIED FM AT 40%.\\n\\nABD SOFT, NON-TENDER, POSITIVE BS, OBESE. TOLERATING TF AT NEW GOAL OF 75ML/HR.\\n\\nURINE OUTPUT ADEQUATE, LASIX X1 GIVEN. CONTINUES TO BE POSITIVE I/O.\\n\\nPLAN:\\nCONTINUE TO MONITOR I/O, NEURO. MAINTAIN BP 140 OR LESS.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2124-10-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1594576,\n \"text\": \"7p-7a; Full assessment in flow sheet.\\n\\nSleep most of night. Follow commands. Open eyes to painful stimuli only. Move RUE - strong. Weak RLE. Withdrawal slightly to pain in LUE. Move left feet to stimuli in LLE. Strong gag and cough. PERL - 3mm brisk. Murble words. Yes and no not appropriate to questions. Afib without ectopy. SBP maintain under 140 with hydralazine ivp. Lung sound coarse in lower lobes - suction tan/thick secretions. Deep breath and cough. Chest PT and vibration. soft abd, +BS X4. no bm. Foley patent. Lasix 40 ivp given - diuresis well - >100 cc/hr. Skin intact. Continue to monitor.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2124-10-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1594577,\n \"text\": \"CONDITION UPDATE\\nASSESSMENT:\\n PT TO VOICE, ATTEMPTS TO OPEN EYES, BUT UNABLE TO COMMUNICATE BY SPEECH. PUPILS EQUAL AND REACTIVE. PT STILL WITHOUT MOVEMENT OF LEFT EXTREMITIES AND NORMAL STRENGTH OF RIGHT EXTREMITIES.\\nCONTINUED WITH MANNITOL, NO EVIDENCE OF NEURO CHANGES.\\n ABP ELEVATED THIS AM TO 160'S/80'S WITH HR 100-110 AFIB. HR 70-80'S AFTER AM LOPRESSOR AND IV HYDRALAZINE GIVEN WITH +EFFECT. ABP WAS MAINTAINED 140'S/70'S (GOAL TO KEEP SBP<150). CVP SLIGHTLY INCREASED , PT CONTINUES WITH LG HRLY OUTPUT (>120CC/HR).\\n PT WITH STRONG COUGH, OCCASIONALLY PRODUCTIVE (THICK, TAN SPUTUM). SP02 > 97% WITH 40% FT, AND BREATHING APPEARS UNLABORED. LS OCCASIONALLY COARSE @ BASES, PT NEEDS ASSIST WITH PULM HYGEINE.\\n PLAN:\\n CONTINUE TO FOLLOW NEURO STATUS CLOSELY. HYDRALAZINE PRN TO MAINTAIN SBP<150. CONTINUE WITH CURRENT CLOSE MONITORING.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2124-10-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1594578,\n \"text\": \"7p-7a: Full assessment in flow sheet.\\n\\nLethargic. Arouse to voice. Answer inconsistent verbally appropriately - able to say last name (). Garble and mumble of words. Good cough and gag reflex. Very hard for pt to open eyes - painful stimuli only. Eyes - PERL, reddish - MD notify. Move RLE and RUE. Only withdrawal slight to pain LUE and LLE. Pt slept most of night. Afib 70-110. Inc BP when turn and position. Maintain SBP <140 with Hydralazine ivpX2. Chest PT and vibration, deep breath and cough for coarse lung sound - thick/tan small secretion. Large abd, +BS X4. no BM. Foley patent >40 cc/hr. NG - +placement, minimal residual. Mannitol given for Osmality less than 310. Warm, dry, general edema +1. AM lab done. Continue to monitor.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2124-10-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1594579,\n \"text\": \"CONDITION UPDATE\\nS/O: LETHARGIC THIS AM, MORE ALERT AS SHIFT PROGRESSED. AT TIMES ANSWERING ONE WORD QUESTIONS APPROPRIATELY - SPEECH SOMEWHAT GARBLED. PUPILS EQUAL AND REACTIVE. MOVING RSIDE W/ NL STRENGTH - NO MOVEMENT NOTED LEFT. VSS - W/ EXCEPTION OF HIGH BLOOD PRESSURE. HYDRALAZINE AND LOPRESSOR DOSES INCREASED W/ EFFECT. LUNGS CLEAR TO COARSE, DIMINISHED AT BASES. ORALLY SUCTIONED - FOR THICK, TAN SPUTUM. ABD SOFT, NT. TOLERATING TUBE FEEDS, W/ NO SIGNIFICANT RESIDUAL. U/O QS VIA FOLEY. NO STOOL THIS SHIFT.\\nA/P: CLOSE NEURO ASSESSMENT. MAINTAIN BP PER PARAMETERS. TRANSFER TO FLOOR WHEN STABLE, MD'S ORDERS. ICU CARE AND TREATMENTS.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2124-10-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1594580,\n \"text\": \"neuro status\\nD: pt is lethargic but . pupils are equal and reactive to light. no movement of the left side. normal strength on the right. pt unable to state date or place but continuously follows commands. urine output remains adequate. pt coughing and raising to back of throat. suctioned for thick tan sputum from the back of throat. pt tolerating tube feeds of impact with fiber at 75cc/hr.\\na: pt treated with ntp for sabp greater than 140. s\\nr: sbp 140-160. pt continues on current antihypertenssive medication. neuro status is unchanged. no further desating and pt remains on 3l and 50% face tent.\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2124-10-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 170579,\n \"text\": \"Atrial fibrillation with a moderate ventricular response. RSR' pattern in\\nlead V1. Slight ST segment depressions noted in leads V1-V6 suggest possible\\nlateral ischemia. Clinical correlation is suggested. No previous tracing\\navailable for comparison.\\n\\n\"\n }\n]"}}},{"rowIdx":393,"cells":{"subject_id":{"kind":"number","value":20172,"string":"20,172"},"hadm_id":{"kind":"number","value":129844,"string":"129,844"},"target_text":{"kind":"string","value":"Given the above, the patient was hydrated and her hypotension was thought to be secondary to the verapamil she received the morning she was transferred to the CCU. She was given two units of blood with improvement in her hematocrit. A rectal exam was performed which showed that she was guaiac negative, and with this chronic history of anemia which subsequently stabilized, the patient was deemed stable for discharge. She was discharged to home and will follow-up with Dr. in one week's time, and follow-up with her PCP. was given copies of her catheterization report, and she was continued all of her previous medications except lasix, hydrochlorothiazide, lisinopril, and her Imdur dose was halved to 30 mg po qd. The other medications would be restarted by her PCP as her blood pressure was monitored. The patient was discharged in stable condition. , M.D. Dictated By: MEDQUIST36 D: 21:00 T: 09:29 JOB#: "},"extractive_notes_summ":{"kind":"string","value":"Sinus rhythm- first degree A-V blockLateral ST-T changes are nonspecificLeft atrial abnormalitySince previous tracing of : ST-T wave changes slightly less prominent CONTRAINDICATIONS for IV CONTRAST: s/p renal artrery stent;s/p renal artery stent FINAL REPORT INDICATION: Status post right renal artery stenting. Dopamine d/c. wheeze.left groin site D/I. CT PELVIS WITH INTRAVENOUS CONTRAST: The distal ureters, urinary bladder, and rectum are unremarkable. IMPRESSION: Unremarkable abdominal and pelvic CT. No evidence of retroperitoneal bleed. sbp 70. given 1lns w/ no change in bp. TECHNIQUE: Helically acquired axial images were obtained from the lung bases to the pubic symphysis without intravenous contrast. Visualized small and large bowel loops are unremarkable. LS diminished bases. started on dopamine. extrem. There is a tiny nonobstructing renal stone within the pelvis of the right kidney. foley draining cl yellow urine qs.A: hypotensive, w/ hct drop s/p l renal artery stent hemodynamically stable at this time.P: monitor BP, follow HCT. CCU NPN 1900-0700S: \" I feel achy all over \"O: pt. monitor responce to isordil. BP since has been 101/36-124/49. The liver, gallbladder, pancreas, spleen, adrenals, and kidneys are unremarkable. Nausea with hypotension. There is evidence of minimal atelectasis at the base bilaterally without evidence of pulmonary nodules or infiltrate. 3:06 PM CT PELVIS W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # Reason: RT RENAL ARTERY STENT NOW HYPOTENSIVE Field of view: 36 MEDICAL CONDITION: 68 year old woman s/p R renal artery stenting now c hypotension, nausea, and hct drop. audible exp. took all meds except lactulose in eve.isordil to start in AM.PLAN: follow am labs, d/c foley in Am. Pt given one unit prbc and transferred to CCU.Pt arrived ~ 1330 awake, alert cooperative in NAD. cath for dyspnea/CHF: LM 30%, LAD 30-40% prox, D1 ostial 40%, RCA w/ widely open stents, mod pulmonary hypertension, EF 75%,severe left ventricular diastolic dysfunction,labile HTN, PVD, Hyperlipidemiaallergies: full dose asa, codine, percocet, betablockers-> bronchospasmPt underwent stent to l renal artery , plan to d/c today. Hct stable at 30.2.She was discharged home w/ VNA following her. c/o generalized body ache/discomfort ~ 0300. given tylenol and ambien with good relief. Pt getting up this am -> dizzy, lightheaded. There is a stent placement of the right renal artery. warm.foley draining 100-200cc/hr. CCU NSG D/C NOTEPt has remained hemodynamically stable. occas. hr 70-80's sr. 2nd unit PRBC currently being administered. Pt went to CT scan for abd/pelvic scan to r/o bleeding.Lungs cta, o2 2lnc-> sats 95%. able to fall asleep.afeb. There is no significant retroperitoneal or mesenteric lymphadenopathy. There is no pelvic free fluid or pelvic lymphadenopathy. No evidence of hydronephrosis. OOB. HCT noted to be 22, down from 28. pulses 2+. There is no free air or free fluid within the abdomen. Dopamine infusing at 5 mcg/kg/min, bp 119/34. CCU NSG ADMIT NOTEPt is 68 yo woman admitted to for renal artery angiogram and stent to l renal artery.PMH: cad, \"90 RCA PTCA, mid RCA ISR rx w/ PTCA, 80% mid RCA which was PTCA'd and stented. There is no evidence of retroperitoneal bleeding. HR 80's SR. BP 101-117/40's.sats 95% on 2lnc. anticipate transfer to floor if stable. Bone windows demonstrate no evidence of suspicious lytic or blastic lesions. REASON FOR THIS EXAMINATION: Signs of bleeding? There is extensive vascular calcification involving the aorta. (-) 1liter at 12am.post transfusion HCT 30.1.ate for late dinner."},"n_notes":{"kind":"number","value":5,"string":"5"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2183-10-08 00:00:00.000","description":"CT PELVIS W/O CONTRAST","row_id":772273,"text":" 3:06 PM\n CT PELVIS W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n Reason: RT RENAL ARTERY STENT NOW HYPOTENSIVE\n Field of view: 36\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman s/p R renal artery stenting now c hypotension, nausea, and\n hct drop.\n REASON FOR THIS EXAMINATION:\n Signs of bleeding?\n CONTRAINDICATIONS for IV CONTRAST:\n s/p renal artrery stent;s/p renal artery stent\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post right renal artery stenting. Nausea with\n hypotension.\n\n TECHNIQUE: Helically acquired axial images were obtained from the lung bases\n to the pubic symphysis without intravenous contrast. There is evidence of\n minimal atelectasis at the base bilaterally without evidence of pulmonary\n nodules or infiltrate. The liver, gallbladder, pancreas, spleen, adrenals,\n and kidneys are unremarkable. There is a tiny nonobstructing renal stone\n within the pelvis of the right kidney. There is a stent placement of the\n right renal artery. No evidence of hydronephrosis. There is extensive\n vascular calcification involving the aorta. There is no evidence of\n retroperitoneal bleeding. There is no free air or free fluid within the\n abdomen. Visualized small and large bowel loops are unremarkable. There is\n no significant retroperitoneal or mesenteric lymphadenopathy.\n\n CT PELVIS WITH INTRAVENOUS CONTRAST: The distal ureters, urinary bladder, and\n rectum are unremarkable. There is no pelvic free fluid or pelvic\n lymphadenopathy.\n\n Bone windows demonstrate no evidence of suspicious lytic or blastic lesions.\n\n IMPRESSION: Unremarkable abdominal and pelvic CT. No evidence of\n retroperitoneal bleed.\n\n"},{"category":"ECG","chartdate":"2183-10-08 00:00:00.000","description":"Report","row_id":269974,"text":"Sinus rhythm\n- first degree A-V block\nLateral ST-T changes are nonspecific\nLeft atrial abnormality\nSince previous tracing of : ST-T wave changes slightly less prominent\n\n"},{"category":"Nursing/other","chartdate":"2183-10-08 00:00:00.000","description":"Report","row_id":1527405,"text":"CCU NSG ADMIT NOTE\nPt is 68 yo woman admitted to for renal artery angiogram and stent to l renal artery.\n\nPMH: cad, \"90 RCA PTCA, mid RCA ISR rx w/ PTCA, 80% mid RCA which was PTCA'd and stented. cath for dyspnea/CHF: LM 30%, LAD 30-40% prox, D1 ostial 40%, RCA w/ widely open stents, mod pulmonary hypertension, EF 75%,severe left ventricular diastolic dysfunction,\nlabile HTN, PVD, Hyperlipidemia\n\nallergies: full dose asa, codine, percocet, betablockers-> bronchospasm\n\nPt underwent stent to l renal artery , plan to d/c today. Pt getting up this am -> dizzy, lightheaded. sbp 70. given 1lns w/ no change in bp. started on dopamine. HCT noted to be 22, down from 28. Pt given one unit prbc and transferred to CCU.\nPt arrived ~ 1330 awake, alert cooperative in NAD. Dopamine infusing at 5 mcg/kg/min, bp 119/34. Dopamine d/c. BP since has been 101/36-124/49. hr 70-80's sr. 2nd unit PRBC currently being administered. Pt went to CT scan for abd/pelvic scan to r/o bleeding.\nLungs cta, o2 2lnc-> sats 95%. foley draining cl yellow urine qs.\n\nA: hypotensive, w/ hct drop s/p l renal artery stent\n hemodynamically stable at this time.\nP: monitor BP, follow HCT.\n"},{"category":"Nursing/other","chartdate":"2183-10-09 00:00:00.000","description":"Report","row_id":1527406,"text":"CCU NPN 1900-0700\nS: \" I feel achy all over \"\nO: pt. c/o generalized body ache/discomfort ~ 0300. given tylenol and ambien with good relief. able to fall asleep.\n\nafeb. HR 80's SR. BP 101-117/40's.\nsats 95% on 2lnc. LS diminished bases. occas. audible exp. wheeze.\n\nleft groin site D/I. pulses 2+. extrem. warm.\n\nfoley draining 100-200cc/hr. (-) 1liter at 12am.\n\npost transfusion HCT 30.1.\n\nate for late dinner. took all meds except lactulose in eve.\n\nisordil to start in AM.\n\nPLAN: follow am labs, d/c foley in Am. OOB. anticipate transfer to floor if stable. monitor responce to isordil.\n"},{"category":"Nursing/other","chartdate":"2183-10-09 00:00:00.000","description":"Report","row_id":1527407,"text":"CCU NSG D/C NOTE\nPt has remained hemodynamically stable. Hct stable at 30.2.She was discharged home w/ VNA following her. She was given scripts and instructions re: taking meds, she will see her primary care ms in 1 wk, and f/u w/ Dr in 6 weeks, She will also get a sma7 prior to seeing Dr. .\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2183-10-08 00:00:00.000\",\n \"description\": \"CT PELVIS W/O CONTRAST\",\n \"row_id\": 772273,\n \"text\": \" 3:06 PM\\n CT PELVIS W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \\n Reason: RT RENAL ARTERY STENT NOW HYPOTENSIVE\\n Field of view: 36\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 68 year old woman s/p R renal artery stenting now c hypotension, nausea, and\\n hct drop.\\n REASON FOR THIS EXAMINATION:\\n Signs of bleeding?\\n CONTRAINDICATIONS for IV CONTRAST:\\n s/p renal artrery stent;s/p renal artery stent\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Status post right renal artery stenting. Nausea with\\n hypotension.\\n\\n TECHNIQUE: Helically acquired axial images were obtained from the lung bases\\n to the pubic symphysis without intravenous contrast. There is evidence of\\n minimal atelectasis at the base bilaterally without evidence of pulmonary\\n nodules or infiltrate. The liver, gallbladder, pancreas, spleen, adrenals,\\n and kidneys are unremarkable. There is a tiny nonobstructing renal stone\\n within the pelvis of the right kidney. There is a stent placement of the\\n right renal artery. No evidence of hydronephrosis. There is extensive\\n vascular calcification involving the aorta. There is no evidence of\\n retroperitoneal bleeding. There is no free air or free fluid within the\\n abdomen. Visualized small and large bowel loops are unremarkable. There is\\n no significant retroperitoneal or mesenteric lymphadenopathy.\\n\\n CT PELVIS WITH INTRAVENOUS CONTRAST: The distal ureters, urinary bladder, and\\n rectum are unremarkable. There is no pelvic free fluid or pelvic\\n lymphadenopathy.\\n\\n Bone windows demonstrate no evidence of suspicious lytic or blastic lesions.\\n\\n IMPRESSION: Unremarkable abdominal and pelvic CT. No evidence of\\n retroperitoneal bleed.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2183-10-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 269974,\n \"text\": \"Sinus rhythm\\n- first degree A-V block\\nLateral ST-T changes are nonspecific\\nLeft atrial abnormality\\nSince previous tracing of : ST-T wave changes slightly less prominent\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2183-10-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1527405,\n \"text\": \"CCU NSG ADMIT NOTE\\nPt is 68 yo woman admitted to for renal artery angiogram and stent to l renal artery.\\n\\nPMH: cad, \\\"90 RCA PTCA, mid RCA ISR rx w/ PTCA, 80% mid RCA which was PTCA'd and stented. cath for dyspnea/CHF: LM 30%, LAD 30-40% prox, D1 ostial 40%, RCA w/ widely open stents, mod pulmonary hypertension, EF 75%,severe left ventricular diastolic dysfunction,\\nlabile HTN, PVD, Hyperlipidemia\\n\\nallergies: full dose asa, codine, percocet, betablockers-> bronchospasm\\n\\nPt underwent stent to l renal artery , plan to d/c today. Pt getting up this am -> dizzy, lightheaded. sbp 70. given 1lns w/ no change in bp. started on dopamine. HCT noted to be 22, down from 28. Pt given one unit prbc and transferred to CCU.\\nPt arrived ~ 1330 awake, alert cooperative in NAD. Dopamine infusing at 5 mcg/kg/min, bp 119/34. Dopamine d/c. BP since has been 101/36-124/49. hr 70-80's sr. 2nd unit PRBC currently being administered. Pt went to CT scan for abd/pelvic scan to r/o bleeding.\\nLungs cta, o2 2lnc-> sats 95%. foley draining cl yellow urine qs.\\n\\nA: hypotensive, w/ hct drop s/p l renal artery stent\\n hemodynamically stable at this time.\\nP: monitor BP, follow HCT.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2183-10-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1527406,\n \"text\": \"CCU NPN 1900-0700\\nS: \\\" I feel achy all over \\\"\\nO: pt. c/o generalized body ache/discomfort ~ 0300. given tylenol and ambien with good relief. able to fall asleep.\\n\\nafeb. HR 80's SR. BP 101-117/40's.\\nsats 95% on 2lnc. LS diminished bases. occas. audible exp. wheeze.\\n\\nleft groin site D/I. pulses 2+. extrem. warm.\\n\\nfoley draining 100-200cc/hr. (-) 1liter at 12am.\\n\\npost transfusion HCT 30.1.\\n\\nate for late dinner. took all meds except lactulose in eve.\\n\\nisordil to start in AM.\\n\\nPLAN: follow am labs, d/c foley in Am. OOB. anticipate transfer to floor if stable. monitor responce to isordil.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2183-10-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1527407,\n \"text\": \"CCU NSG D/C NOTE\\nPt has remained hemodynamically stable. Hct stable at 30.2.She was discharged home w/ VNA following her. She was given scripts and instructions re: taking meds, she will see her primary care ms in 1 wk, and f/u w/ Dr in 6 weeks, She will also get a sma7 prior to seeing Dr. .\\n\"\n }\n]"}}},{"rowIdx":394,"cells":{"subject_id":{"kind":"number","value":44064,"string":"44,064"},"hadm_id":{"kind":"number","value":126583,"string":"126,583"},"target_text":{"kind":"string","value":"84 year-old M with high-grade cardiac lymphoma (left atrial mass), currently receiving treatment (cycle 4,day 15) with R- who presented from home with low-grade fevers and progressive dyspnea."},"extractive_notes_summ":{"kind":"string","value":"Caridiac ischemia also a possibility as pt has alleed hx of a silent inferior MI in . likewise deferred ICU consent until acute anxiety has resolved Prophylaxis: DVT: SQ UF Heparin, IVC filter Stress ulcer: PPI VAP: Comments: Communication: Comments: Code status: Full code Disposition: ICU ------ Protected Section ------ ADDENDUM TO PLAN: Assessment and plan initially changed this am as cardiac enzymes positive and ECHO showing significant new focal wall motion abnormaiilities. likewise deferred ICU consent until acute anxiety has resolved Prophylaxis: DVT: SQ UF Heparin, IVC filter Stress ulcer: PPI VAP: Comments: Communication: Comments: Code status: Full code Disposition: ICU likewise deferred ICU consent until acute anxiety has resolved Prophylaxis: DVT: SQ UF Heparin, IVC filter Stress ulcer: PPI VAP: Comments: Communication: Comments: Code status: Full code Disposition: ICU - will d/w pt and BMT # Hx of DVT: Per previous DC summary, pt has had a recent DVT in setting of ongoing malignancy and has IVC filter in place--by report has contraindication to systemic anticoagulation. - will d/w pt and BMT # Hx of DVT: Per previous DC summary, pt has had a recent DVT in setting of ongoing malignancy and has IVC filter in place--by report has contraindication to systemic anticoagulation. - will d/w pt and BMT # Hx of DVT: Per previous DC summary, pt has had a recent DVT in setting of ongoing malignancy and has IVC filter in place--by report has contraindication to systemic anticoagulation. - will d/w pt and BMT # Hx of DVT: Per previous DC summary, pt has had a recent DVT in setting of ongoing malignancy and has IVC filter in place--by report has contraindication to systemic anticoagulation. Caridiac ischemia also a possibility as pt has reported hx of a silent inferior MI in , curently not on ASA, BB, statin. Caridiac ischemia also a possibility as pt has reported hx of a silent inferior MI in , curently not on ASA, BB, statin. Caridiac ischemia also a possibility as pt has reported hx of a silent inferior MI in , curently not on ASA, BB, statin. He has had a substantial worsening of cardiac fxn w/o clear ECG changes and echo read sounds c/w takasubo He has paraflu on nasal wash which seems consistent with his presentation. Albuterol MDI, and neb treatments given . Moderate [2+] tricuspid regurgitation is seen.There is no pericardial effusion.Compared with the prior study (images reviewed) of , biventrricularsystolic function is now depressed with regionality. Caridiac ischemia also a possibility as pt has reported hx of a silent inferior MI in , curently not on ASA, BB, statin. Mild tomoderate (+) MR.TRICUSPID VALVE: Tricuspid valve not well visualized. Mild tomoderate (+) mitral regurgitation is seen. Indeterminate PAsystolic pressure.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor echo windows.Conclusions:The left atrium is elongated. PATIENT/TEST INFORMATION:Indication: Left ventricular function.Height: (in) 68Weight (lb): 144BSA (m2): 1.78 m2BP (mm Hg): 155/70HR (bpm): 93Status: InpatientDate/Time: at 12:30Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Elongated LA.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Pericardial effusion.Height: (in) 68Weight (lb): 139BSA (m2): 1.75 m2BP (mm Hg): 124/79HR (bpm): 100Status: InpatientDate/Time: at 13:20Test: Portable TTE (Complete)Doppler: Limited Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .LEFT VENTRICLE: Moderately depressed LVEF.RIGHT VENTRICLE: RV function depressed.MITRAL VALVE: Mildly thickened mitral valve leaflets. Narrowing of the superior vena cava by this mass is unchanged. Normal interatrial septum.No ASD by 2D or color Doppler.LEFT VENTRICLE: Mild symmetric LVH. Myocardial infarction, acute (AMI, STEMI, NSTEMI) Assessment: Pt ruled in for NSTEMI with positive triponins. Denies any pain.received ativan from ER. Moderate (2+) MR.TRICUSPID VALVE: Moderate [2+] TR.PERICARDIUM: No pericardial effusion.Conclusions:Overall left ventricular systolic function is moderately depressed (LVEF=30-35 %) with akinesis of the distal LV/apex. There is mild symmetric left ventricular hypertrophy. Atherosclerotic calcifications involve the thoracic aorta and its branches, though the thoracic aorta is of normal caliber. likewise deferred ICU consent until acute anxiety has resolved Prophylaxis: DVT: SQ UF Heparin, IVC filter Stress ulcer: PPI VAP: Comments: Communication: Comments: Code status: Full code Disposition: ICU ------ Protected Section ------ ADDENDUM TO PLAN: Assessment and plan initially changed this am as cardiac enzymes positive and ECHO showing significant new focal wall motion abnormaiilities. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Perhaps slight decrease in size of cardiac mass compared to CT from , with persistent mass effect on superior vena cava. RV with depressed free wallcontractility. Elevation of right hemidiaphragm unchanged since at least . IMPRESSION: AP chest compared to : Mild vascular congestion has developed in the right lung base. - will d/w pt and BMT # Hx of DVT: Per previous DC summary, pt has had a recent DVT in setting of ongoing malignancy and has IVC filter in place--by report has contraindication to systemic anticoagulation. The aortic valve leaflets (3) are mildly thickened but aorticstenosis is not present. Moderate (2+)mitral regurgitation is seen."},"n_notes":{"kind":"number","value":28,"string":"28"},"notes":{"kind":"list like","value":[{"category":"General","chartdate":"2200-04-22 00:00:00.000","description":"Generic Note","row_id":678967,"text":"TITLE: Critical Care\n Present for the key portions of the resident\ns history and exam. Agree\n substantially with assessment and plan as outlined on multidisciplinary\n rounds this morning. Much more comfortable\n breathless with talking\n or minimal movement but substantially better than yesterday.\n 97.6 102 95/50\n Chest\n prolonged exhalation, mid insp crackles\n Abd\n soft\n WBC 8.7\n Trop down to 0.17\n Much improved. Still somewhat unclear what has happened but it appears\n he has a parainfluenza inf c/b some cardiac event\n unclear if this is\n demand ischemia or Takasubo\ns. We are stopping iv heparin and starting\n sq heparin. Continues to get nebs with some relief. No evidence of\n bacterial inf so we are d/cing abx.\n Time spent 30 min\n"},{"category":"Physician ","chartdate":"2200-04-21 00:00:00.000","description":"Physician Resident Admission Note","row_id":678697,"text":"Chief Complaint: worsening shortness of breath over past 2-3 days, low\n grade fevers at home\n HPI:\n Mr. is an 84 yo man with a high-grade cardiac B-cell\n lymphoma for which he is now undergoing R- chemotherapy and a\n history of COPD, DVT s/p IVC filter, and pneumonia with\n respiratory failure requiring endotracheal intubation in . Today is\n Day 15 of Cycle 4 or R-, which he received during his hospital\n admission from . He received Neulasta on . following\n his discharge, he has been feeling generally well; however, he admits\n to increasing exertional dyspnea overthe past 2-3 days. He explains\n that very light activity, such as changing his clothes or walking short\n distances, has resulted in significant shortness of breath. He denies\n cough, sputum production, orthopnea, paroxysmal nocturnal dyspnea, and\n swelling/pain of the arms or legs. He admits to low-grade fevers today;\n while visiting, his daughter noted that he had a temperature of 100.4\n degrees. For this reason, he was advised to report to the Emergency\n Room for evaluation.\n Upon arrival in the Emergency Department, had temperature of 99.6\n degrees. He was tachycardic to 118 and tachypneic (RR 30-40) with\n oxygen saturations of 95% on room air. During the first several\n minutesof is Emergency Department course, he developed rapidly\n increasing work of breathing. A CXR demonstrated no evidence\n ofpneumonia or effusion; furthermore, an echocardiogram showed no\n pericardial effusion. He was noted to have a WBC of 8.8 with 26%\n neutrophils and 36% bands. Due to progressive respiratorydistress\n without hypoxia, he was started on BiPAP. In addition, he was given IV\n solumderol 125mg, ASA 325mg, bronchodilators, piperacillin-tazobactam,\n and vancomycin. Also received total of 1.25mg of ativan in ED.\n Despite a fairly normal blood gas and presumbaly secondary to worsening\n dyspnea and tachynpnea, pt was started on BIPAP which he tolerated\n during his transfer to the . On arrival, he insisted that it be\n removed and then resumed. He was agitated and extremely anxious\n repeating \"I need air,\" peripheral sats were in the 93-100% range on\n room air. Seemed to be more comfortable leaning forward and placing\n his weight on his upper ext's. His HR rose in propotion to his\n tachypnea and gitation to a rate of 140's transiently. Agitation/anxiey\n waxed and waned with pt sleeping intermittently.\n ONCOLOGIC HISTORY (Per recent note by Dr : \n initially presented on , with anewly identified 8\n cm right atrial soft tissue mass. He underwent biopsy of this on\n , and pathology showed high-grade aggressive diffuse large\n B-cell lymphoma, staining positive for CD20, bcl-2, and bcl-6 in a\n small subset. Cells were negative for cytokeratins, CD138, bcl-1, and\n bcl-6. MIB fraction was 95-100%. Bcl-2 co-expression and lack of CD10\n argued against Burkitt's lymphoma; however, FISH studies were positive\n for c-myc rearrangement. He was diagnosed with high-grade cardiac\n lymphoma on the spectrum of diffuse large B-cell to Burkitt's\n lymphoma. No other sites of disease were identified by torso CT and\n bone marrow biopsy. He has begun R- chemotherapy on .\n Treatment course has been complicated by a DVT status post IVC filter\n in and pneumonia requiring intubation for hypoxia in .\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Terazosin\n Mental status c\n Last dose of Antibiotics:\n Vancomycin - 03:31 AM\n Piperacillin/Tazobactam (Zosyn) - 03:31 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n 1. cardiac lymphoma as above\n 2. Left Peroneal DVT s/p IVC filter placement \n 3. COPD\n 4. Hyperlipidemia\n 5. Hypertension\n 6. History of anxiety\n 7. History of rib fracture\n 8. History of silent MI \n 9. Left Shoulder Weakness\n 10. External Hemorrhoids\n 11. Benign Prostatic Hypertrophy\n nc\n Occupation: retired\n Drugs:\n Tobacco: 60 pk yr hx, quit 6 years ago\n Alcohol:\n Other: currently in rehab, living independently up until recent\n admission\n Review of systems:\n Constitutional: Fever\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n Tachycardia, No(t) Orthopnea\n Respiratory: No(t) Cough, Dyspnea, Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Diarrhea\n Genitourinary: No(t) Dysuria\n Neurologic: No(t) Headache\n Flowsheet Data as of 06:28 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.9\nC (96.6\n Tcurrent: 35.9\nC (96.6\n HR: 121 (121 - 121) bpm\n BP: 128/77(89) {128/75(89) - 155/77(96)} mmHg\n RR: 32 (25 - 32) insp/min\n SpO2: 95%\n Total In:\n 2,300 mL\n PO:\n TF:\n IVF:\n 300 mL\n Blood products:\n Total out:\n 0 mL\n 800 mL\n Urine:\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,500 mL\n Respiratory\n O2 Delivery Device: Other\n SpO2: 95%\n Physical Examination\n General Appearance: Thin, Anxious\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), tachycardic\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: dull BS bilaterally with prolonged expiratory\n pahse and use of abdominal muscles during expiration\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis\n Musculoskeletal: Muscle wasting\n Skin: Not assessed, No(t) Rash:\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): , Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n [image002.jpg]\n Imaging: ADMISSION CXR: The right hemidiaphragm remains persistently\n elevated. The\n cardiomediastinal silhouette is stable. There is no focal pulmonary\n consolidation. An IVC filter is seen in the upper abdomen.\n CONCLUSION: No acute cardiopulmonary process.\n CTA (ADMISSION):PRELIM: No PE. New focal right basilar consolidation-?\n pneumonia though may represent\n aspiration with ariway secretions seen on right. Perhaps slight\n dcecrease in\n size of cardiac mass.\n Microbiology: Bcx x2 and Ucx NGTD\n ECG: sinus tachycadia, left axis deviation, low voltages diffusely, old\n inferior infarct, no stt changes from previous\n Assessment and Plan\n ASSESSMENT AND PLAN:\n 84 year-old M with high-grade cardiac lymphoma (left atrial mass),\n currently receiving treatment (cycle 4,day 15) with R- presents\n from home with low-grade fevers and progressive dyspnea; despite\n marked tachypnea and dyspnea, pt's images and blood gas look\n remarkably good suggesting a strong contribution from anxiety. That\n said, he has an atypical WBC diff and is s/p recent chemotherapy and\n thus in a relatively immunocompromised state demanding empiric broad\n coverage with Abx. Physical Exam is most suggestive of COPD\n exacerbation, but dyspnea is out of proportion to boreline (if any)\n hypoxia.\n # Dyspnea / Tachypnea: From what can be gathered of his ED course, it\n seems that it was similar to how he has been in the . Dyspnea is\n out of proportion to hypoxia. Have been thus far unable to repeat\n blood gas secondary to agitation, but peripheral sats in mid to high\n 90s even on room air. When he has used Bipap, settings hve been 17/5\n on room air--he intermittently prefers this to face mask. Bedside echo\n in the ED notable for absence of effusion/tamponade. LV function\n grossly intact. CXR without pulmonary edema. CTA ruled out PE and\n showed ONLY Opacity in RLL which may represent early bacterial PNA vs\n aspiration. Pt does have Hx of DVT, but IVC filter is in place and no\n exam finding to suggest current DVT. Overall, it seems that anxiety\n may be contributing strongly to this presentation--although does not\n seem to be on home anxiolytics other than low dose ativan for nausea.\n His positional preference and prolonged expiratory phase are suggestive\n of COPD exacerbation (FVC 50%, FEV1 40% Predicted), but again dyspnea\n out of proportion to hypoxia. Caridiac ischemia also a possibility as\n pt has alleed hx of a silent inferior MI in .\n - add BNP to admission labs; may be elevated in setting of atrial mass,\n but if negative still useful to r/o failure\n - repeat CXR this am\n - formal ECHO by tech ordered\n - repeat blood gas when tolerats\n - Trend cardiac enzymes\n - albuterol/ipratropium nebs (holding home spiriva); continuing advair;\n will d/w BMT regarding +/- of systemic steroids in this lymphoma pt\n undergoing tx\n - NIPPV on RA vs 2L face-mask per pt preference; O2 sats adeqquate on\n either\n # Low-Grade Fevers / Bandemia: Bandemia present on , but not to\n the prounced degree that it is now. Pt's fevers at home were\n low-grade, was afebrile in ED and on floor. There is a concern for\n relative immunocompromise as he is currently receiving tx for lymphoma.\n Pt is s/p PNA requiring intubation during a recent hospitalization.\n Some concern for infectious process on admission CTA, but RLL findings\n not particulary striking. UA clean.\n - Blood cultures x2 pending, Urine Cx pending, Sputum ordered. Repaet\n Cx if spikes.\n - Nasal aspirate for respiratory viruses: (influenza,paraninfluenza,\n RSV)\n - D/w BMT whether atypical Diff is expected with pt's recent treatemnts\n or whether it is more concerning for infxn. Smear ordered.\n - Empiric therapy for HAP Vanco/Zosyn per BMT\n # Cardiac lymphoma: The patient appears to have had an excellent\n response to therapy to date, with a decline in his LDH and shrinkage of\n his cardiac mass on cardiac MRI. He will be due for his 5th cycle of\n next week, and his ability to receive his chemotherapy safelywill\n be determined by his recover from his present illness.\n - d/w BMT\n # Hx of CAD: Alleged silent MI in . Not in our records and pt\n currently unbale to discuss. EKG suggestive of prior infarct, but ECHO\n is not. Unusual that he is not on home ASA, BB, or statin.\n - will d/w pt and BMT\n # Hx of DVT: Per previous DC summary, pt has had a recent DVT in\n setting of ongoing malignancy and has IVC filter in place--by report\n has contraindication to systemic anticoagulation.\n - d/w BMT\n ICU Care\n Nutrition: npo currently\n Glycemic Control:\n Lines:\n 18 Gauge - 03:37 AM\n 20 Gauge - 03:37 AM\n Comments: code status confirmed by onc fellow in ED. deferred currently\n as acutely agitated/anxious. likewise deferred ICU consent until acute\n anxiety has resolved\n Prophylaxis:\n DVT: SQ UF Heparin, IVC filter\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"},{"category":"Physician ","chartdate":"2200-04-21 00:00:00.000","description":"Physician Resident Admission Note","row_id":678698,"text":"Chief Complaint: worsening shortness of breath over past 2-3 days, low\n grade fevers at home\n HPI:\n Mr. is an 84 yo man with a high-grade cardiac B-cell\n lymphoma for which he is now undergoing R- chemotherapy and a\n history of COPD, DVT s/p IVC filter, and pneumonia with\n respiratory failure requiring endotracheal intubation in . Today is\n Day 15 of Cycle 4 or R-, which he received during his hospital\n admission from . He received Neulasta on . following\n his discharge, he has been feeling generally well; however, he admits\n to increasing exertional dyspnea overthe past 2-3 days. He explains\n that very light activity, such as changing his clothes or walking short\n distances, has resulted in significant shortness of breath. He denies\n cough, sputum production, orthopnea, paroxysmal nocturnal dyspnea, and\n swelling/pain of the arms or legs. He admits to low-grade fevers today;\n while visiting, his daughter noted that he had a temperature of 100.4\n degrees. For this reason, he was advised to report to the Emergency\n Room for evaluation.\n Upon arrival in the Emergency Department, had temperature of 99.6\n degrees. He was tachycardic to 118 and tachypneic (RR 30-40) with\n oxygen saturations of 95% on room air. During the first several\n minutesof is Emergency Department course, he developed rapidly\n increasing work of breathing. A CXR demonstrated no evidence\n ofpneumonia or effusion; furthermore, an echocardiogram showed no\n pericardial effusion. He was noted to have a WBC of 8.8 with 26%\n neutrophils and 36% bands. Due to progressive respiratorydistress\n without hypoxia, he was started on BiPAP. In addition, he was given IV\n solumderol 125mg, ASA 325mg, bronchodilators, piperacillin-tazobactam,\n and vancomycin. Also received total of 1.25mg of ativan in ED.\n Despite a fairly normal blood gas and presumbaly secondary to worsening\n dyspnea and tachynpnea, pt was started on BIPAP which he tolerated\n during his transfer to the . On arrival, he insisted that it be\n removed and then resumed. He was agitated and extremely anxious\n repeating \"I need air,\" peripheral sats were in the 93-100% range on\n room air. Seemed to be more comfortable leaning forward and placing\n his weight on his upper ext's. His HR rose in propotion to his\n tachypnea and gitation to a rate of 140's transiently. Agitation/anxiey\n waxed and waned with pt sleeping intermittently.\n ONCOLOGIC HISTORY (Per recent note by Dr : \n initially presented on , with anewly identified 8\n cm right atrial soft tissue mass. He underwent biopsy of this on\n , and pathology showed high-grade aggressive diffuse large\n B-cell lymphoma, staining positive for CD20, bcl-2, and bcl-6 in a\n small subset. Cells were negative for cytokeratins, CD138, bcl-1, and\n bcl-6. MIB fraction was 95-100%. Bcl-2 co-expression and lack of CD10\n argued against Burkitt's lymphoma; however, FISH studies were positive\n for c-myc rearrangement. He was diagnosed with high-grade cardiac\n lymphoma on the spectrum of diffuse large B-cell to Burkitt's\n lymphoma. No other sites of disease were identified by torso CT and\n bone marrow biopsy. He has begun R- chemotherapy on .\n Treatment course has been complicated by a DVT status post IVC filter\n in and pneumonia requiring intubation for hypoxia in .\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Terazosin\n Mental status c\n Last dose of Antibiotics:\n Vancomycin - 03:31 AM\n Piperacillin/Tazobactam (Zosyn) - 03:31 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n 1. cardiac lymphoma as above\n 2. Left Peroneal DVT s/p IVC filter placement \n 3. COPD\n 4. Hyperlipidemia\n 5. Hypertension\n 6. History of anxiety\n 7. History of rib fracture\n 8. History of silent MI \n 9. Left Shoulder Weakness\n 10. External Hemorrhoids\n 11. Benign Prostatic Hypertrophy\n nc\n Occupation: retired\n Drugs:\n Tobacco: 60 pk yr hx, quit 6 years ago\n Alcohol:\n Other: currently in rehab, living independently up until recent\n admission\n Review of systems:\n Constitutional: Fever\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n Tachycardia, No(t) Orthopnea\n Respiratory: No(t) Cough, Dyspnea, Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Diarrhea\n Genitourinary: No(t) Dysuria\n Neurologic: No(t) Headache\n Flowsheet Data as of 06:28 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.9\nC (96.6\n Tcurrent: 35.9\nC (96.6\n HR: 121 (121 - 121) bpm\n BP: 128/77(89) {128/75(89) - 155/77(96)} mmHg\n RR: 32 (25 - 32) insp/min\n SpO2: 95%\n Total In:\n 2,300 mL\n PO:\n TF:\n IVF:\n 300 mL\n Blood products:\n Total out:\n 0 mL\n 800 mL\n Urine:\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,500 mL\n Respiratory\n O2 Delivery Device: Other\n SpO2: 95%\n Physical Examination\n General Appearance: Thin, Anxious\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), tachycardic\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: dull BS bilaterally with prolonged expiratory\n pahse and use of abdominal muscles during expiration\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis\n Musculoskeletal: Muscle wasting\n Skin: Not assessed, No(t) Rash:\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): , Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n [image002.jpg]\n Imaging: ADMISSION CXR: The right hemidiaphragm remains persistently\n elevated. The\n cardiomediastinal silhouette is stable. There is no focal pulmonary\n consolidation. An IVC filter is seen in the upper abdomen.\n CONCLUSION: No acute cardiopulmonary process.\n CTA (ADMISSION):PRELIM: No PE. New focal right basilar consolidation-?\n pneumonia though may represent\n aspiration with ariway secretions seen on right. Perhaps slight\n dcecrease in\n size of cardiac mass.\n Microbiology: Bcx x2 and Ucx NGTD\n ECG: sinus tachycadia, left axis deviation, low voltages diffusely, old\n inferior infarct, no stt changes from previous\n Assessment and Plan\n ASSESSMENT AND PLAN:\n 84 year-old M with high-grade cardiac lymphoma (left atrial mass),\n currently receiving treatment (cycle 4,day 15) with R- presents\n from home with low-grade fevers and progressive dyspnea; despite\n marked tachypnea and dyspnea, pt's images and blood gas look\n remarkably good suggesting a strong contribution from anxiety. That\n said, he has an atypical WBC diff and is s/p recent chemotherapy and\n thus in a relatively immunocompromised state demanding empiric broad\n coverage with Abx. Physical Exam is most suggestive of COPD\n exacerbation, but dyspnea is out of proportion to boreline (if any)\n hypoxia.\n # Dyspnea / Tachypnea: From what can be gathered of his ED course, it\n seems that it was similar to how he has been in the . Dyspnea is\n out of proportion to hypoxia. Have been thus far unable to repeat\n blood gas secondary to agitation, but peripheral sats in mid to high\n 90s even on room air. When he has used Bipap, settings hve been 17/5\n on room air--he intermittently prefers this to face mask. Bedside echo\n in the ED notable for absence of effusion/tamponade. LV function\n grossly intact. CXR without pulmonary edema. CTA ruled out PE and\n showed ONLY Opacity in RLL which may represent early bacterial PNA vs\n aspiration. Pt does have Hx of DVT, but IVC filter is in place and no\n exam finding to suggest current DVT. Overall, it seems that anxiety\n may be contributing strongly to this presentation--although does not\n seem to be on home anxiolytics other than low dose ativan for nausea.\n His positional preference and prolonged expiratory phase are suggestive\n of COPD exacerbation (FVC 50%, FEV1 40% Predicted), but again dyspnea\n out of proportion to hypoxia. Caridiac ischemia also a possibility as\n pt has reported hx of a silent inferior MI in , curently not on\n ASA, BB, statin.\n - add BNP to admission labs; may be elevated in setting of atrial mass,\n but if negative still useful to r/o failure\n - repeat CXR this am\n - formal ECHO by tech ordered\n - repeat blood gas when tolerats\n - Trend cardiac enzymes\n - albuterol/ipratropium nebs (holding home spiriva); continuing advair;\n will d/w BMT regarding +/- of systemic steroids in this lymphoma pt\n undergoing tx\n - NIPPV on RA vs 2L face-mask per pt preference; O2 sats adeqquate on\n either\n # Low-Grade Fevers / Bandemia: Bandemia present on , but not to\n the prounced degree that it is now. Pt's fevers at home were\n low-grade, was afebrile in ED and on floor. There is a concern for\n relative immunocompromise as he is currently receiving tx for lymphoma.\n Pt is s/p PNA requiring intubation during a recent hospitalization.\n Some concern for infectious process on admission CTA, but RLL findings\n not particulary striking. UA clean.\n - Blood cultures x2 pending, Urine Cx pending, Sputum ordered. Repaet\n Cx if spikes.\n - Nasal aspirate for respiratory viruses: (influenza,paraninfluenza,\n RSV)\n - D/w BMT whether atypical Diff is expected with pt's recent treatemnts\n or whether it is more concerning for infxn. Smear ordered.\n - Empiric therapy for HAP Vanco/Zosyn per BMT\n # Cardiac lymphoma: The patient appears to have had an excellent\n response to therapy to date, with a decline in his LDH and shrinkage of\n his cardiac mass on cardiac MRI. He will be due for his 5th cycle of\n next week, and his ability to receive his chemotherapy safelywill\n be determined by his recover from his present illness.\n - d/w BMT\n # Hx of CAD: Alleged silent MI in . Not in our records and pt\n currently unbale to discuss. EKG suggestive of prior infarct, but ECHO\n is not. Unusual that he is not on home ASA, BB, or statin.\n - will d/w pt and BMT\n # Hx of DVT: Per previous DC summary, pt has had a recent DVT in\n setting of ongoing malignancy and has IVC filter in place--by report\n has contraindication to systemic anticoagulation.\n - d/w BMT\n ICU Care\n Nutrition: npo currently\n Glycemic Control:\n Lines:\n 18 Gauge - 03:37 AM\n 20 Gauge - 03:37 AM\n Comments: code status confirmed by onc fellow in ED. deferred currently\n as acutely agitated/anxious. likewise deferred ICU consent until acute\n anxiety has resolved\n Prophylaxis:\n DVT: SQ UF Heparin, IVC filter\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"},{"category":"Nursing","chartdate":"2200-04-21 00:00:00.000","description":"Nursing Progress Note","row_id":678822,"text":"84 yo male pt with PMH ,Rt atrial tumour , lyphoma , recent\n chemotherapy ,PNA, presented to ER with SOB, N/V anxious, ?\n neutropenic. pt with worsening SOB, received vanco, zosyn ,solumedrol\n ,ativan and aspirin from ER, 2litres of fluid in. ? PE . CT done. neg\n for PE, ? PNA, slight decrease in the size of cardiac mass. put on\n BIPAP .tolerated well. transfered to for further monitoring and\n management.\n Pt is alert and oriented but has very little patience and is easily\n agitated, becoming SOB with activity. He is not comfortable in bed and\n has been OOB to chair most of the shift. Was in bed for cardiac echo,\n then back to chair. Ambulates with assist of one to chair. Family\n calling in frequently for updates. is spokesperson.\n He denies complaints of chest pain or pressure but is ruling in for MI\n by enzymes with elevated triponin to 2.23 at noon today. He has been\n started on lopressor for rate control, heparin drip and aspirin. He was\n also started on simvastatin. Cardiac consult in place.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt with severe complaints of dyspnea and becomes tachypneic when in\n bed. Maintains O2 sat but becomes agitated and feels like he is\n trapped in a cage.\n Once in the chair he was calmer and less anxious\n with improved Resp rate and agitation.\n Action:\n Weaned O2 from 100% down to 3L N/C with good O2 sat. RT sent specimens\n for viral antigens. Pt is positive for parainfluenza. He is on droplet\n precautions but team is not sure if we need them for this diagnosis.\n Response:\n Remains in the chair but still becomes anxious and restless at times\n and is on the call light frequently for small things.\n Plan:\n Provide support and reassurance for this pt who is easily agitated.\n Ordered for small doses morphine or ativan can be used PRN. Has an\n order for 1mg IV haldol on one time sheet which was never given yet.\n Altered mental status (not Delirium)\n Assessment:\n Pt with periods of agitation and anxiety refused to stay in bed,\n becoming acutely agitated, restless and tachypneic.\n Action:\n Given .5mg iV morphine, assisted to chair and pt reassured.\n Response:\n Improved agitation but continues to ask the same questions about his\n illness andhis care.\n Plan:\n Follow mental status, continue to provide emotional support. Use PRN\n morphine, ativan as needed.\n .H/O lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n Pt is currently undergoing chemo treatment for lymphoma\n Action:\n Heme/onc service consulted and will not give chemo while he is being\n treated for an acute MI\n Response:\n Will reassess need for chemo once pt is stable.\n Plan:\n Continue to follow-up with heme/onc for recommendations. Next set of\n enzymes due at 1800.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Pt ruled in for NSTEMI with positive triponins. No EKG changes were\n noted. Echo done at bedside today showed some new wall abnormalities\n but full report is yet to follow. He denies chest pain and pressure.\n Action:\n Pt given one aspirin tablet and was started on metoprolol 12.5mg then\n increased to 25mg PO. Pt also started on heparin drip at 11:45 at\n 750Units/hr. He was also started on simvastatin and remains on O2 3L.\n Stat echo and EKG was done. Pt given morphine for acute anxiety\n episode.\n Response:\n Vital signs remain stable with improved resp status in chair. Family\n have been updated and remain informed of plan of care. Pt started to\n have hematuria at 1600 and small pool of blood noted on pink pad under\n pt. Pt found to have some bleeding from around urethral meatus. Seen\n and noted by team.\n Plan:\n Follow labs, PTT Q6hrs to titrate heparin drip. Follow pt for further\n signs of bleeding.\n"},{"category":"Nursing","chartdate":"2200-04-22 00:00:00.000","description":"Nursing Progress Note","row_id":678873,"text":"84 yo male pt with PMH ,Rt atrial tumour , lyphoma , recent\n chemotherapy ,PNA, presented to ER with SOB, N/V anxious, pt with\n worsening SOB, received vanco, zosyn ,solumedrol ,ativan and aspirin\n from ER, 2litres of fluid in. CT done. neg for PE, ? PNA, slight\n decrease in the size of cardiac mass. put on BIPAP .tolerated well.\n transfered to for further monitoring and management. He denies\n complaints of chest pain or pressure but is ruling in for MI by enzymes\n with elevated triponin to 2.23 yesterday. He has been started on\n lopressor for rate control, heparin drip aspirin and simvastatin.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n r/o MI from Elevated cardiac enzymes from yesterday.\n Action:\n Pt on heparin gtt and po aspirin. Lopressor for rate control. PTT q6hr.\n cardiac echo done yesterday. Cardiology consult.\n Response:\n f/u with cardiology, continue heparin per protocol. PTT q 6hrs.\n Plan:\n Continue with heparin per protocol. PTT q 6hrs.\n Altered mental status (not Delirium)\n Assessment:\n Pt alert oriented x 3, calm and quiet most of the time, but get\n restless and anxious very quickly. Slept during the night. Pt states\n he can\nt breath while he is anxious.\n Action:\n Ativan 0.5mg po/iv PRN. Stayed on bed during the night. On NC O2\n 3lit/min. LS Diminished. Neb treatments /MDI as ordered.\n Response:\n Good effect with ativan. Sats > 96%\n Plan:\n Continue with ativan /morphine PRN. Monitor mental status.\n Foley to gravity, urine clear,pink in colout.? Traumatic vs heparin\n gtt.\n"},{"category":"Physician ","chartdate":"2200-04-22 00:00:00.000","description":"Physician Resident Progress Note","row_id":678935,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 09:39 AM\n EKG - At 11:25 AM\n Allergies:\n Terazosin\n Mental status c\n Last dose of Antibiotics:\n Vancomycin - 08:18 PM\n Piperacillin/Tazobactam (Zosyn) - 06:33 AM\n Infusions:\n Heparin Sodium - 750 units/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:31 AM\n Heparin Sodium (Prophylaxis) - 08:31 AM\n Morphine Sulfate - 10:28 AM\n Heparin Sodium - 11:23 AM\n Lorazepam (Ativan) - 12:15 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.7\nC (98.1\n HR: 103 (88 - 104) bpm\n BP: 136/68(89) {91/43(51) - 139/79(94)} mmHg\n RR: 39 (17 - 39) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,446 mL\n 233 mL\n PO:\n 120 mL\n TF:\n IVF:\n 1,326 mL\n 233 mL\n Blood products:\n Total out:\n 2,690 mL\n 580 mL\n Urine:\n 2,090 mL\n 580 mL\n NG:\n Stool:\n Drains:\n Balance:\n 756 mL\n -347 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///27/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 161 K/uL\n 8.5 g/dL\n 100 mg/dL\n 0.7 mg/dL\n 27 mEq/L\n 3.4 mEq/L\n 11 mg/dL\n 104 mEq/L\n 140 mEq/L\n 24.1 %\n 8.7 K/uL\n [image002.jpg]\n 04:18 AM\n 11:11 AM\n 05:48 PM\n 05:46 AM\n WBC\n 12.3\n 8.7\n Hct\n 29.2\n 24.1\n Plt\n 182\n 161\n Cr\n 0.8\n 0.7\n TropT\n 0.27\n 0.23\n 0.17\n Glucose\n 152\n 100\n Other labs: PT / PTT / INR:12.2/76.2/1.0, CK / CKMB /\n Troponin-T:136/14/0.17, ALT / AST:20/28, Alk Phos / T Bili:90/0.2,\n Differential-Neuts:82.0 %, Band:6.0 %, Lymph:3.0 %, Mono:4.0 %, Eos:0.0\n %, Albumin:3.5 g/dL, LDH:250 IU/L, Ca++:8.6 mg/dL, Mg++:2.2 mg/dL,\n PO4:3.5 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, NSTEMI)\n .H/O LYMPHOMA (CANCER, MALIGNANT NEOPLASM, LYMPHOID)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n ASSESSMENT AND PLAN:\n 84 year-old M with high-grade cardiac lymphoma (left atrial mass),\n currently receiving treatment (cycle 4,day 15) with R- presents\n from home with low-grade fevers and progressive dyspnea; despite\n marked tachypnea and dyspnea, pt's images and blood gas look\n remarkably good suggesting a strong contribution from anxiety. That\n said, he has an atypical WBC diff and is s/p recent chemotherapy and\n thus in a relatively immunocompromised state demanding empiric broad\n coverage with Abx. Physical Exam is most suggestive of COPD\n exacerbation, but dyspnea is out of proportion to boreline (if any)\n hypoxia.\n # Dyspnea / Tachypnea: From what can be gathered of his ED course, it\n seems that it was similar to how he has been in the . Dyspnea is\n out of proportion to hypoxia. Have been thus far unable to repeat\n blood gas secondary to agitation, but peripheral sats in mid to high\n 90s even on room air. When he has used Bipap, settings hve been 17/5\n on room air--he intermittently prefers this to face mask. Bedside echo\n in the ED notable for absence of effusion/tamponade. LV function\n grossly intact. CXR without pulmonary edema. CTA ruled out PE and\n showed ONLY Opacity in RLL which may represent early bacterial PNA vs\n aspiration. Pt does have Hx of DVT, but IVC filter is in place and no\n exam finding to suggest current DVT. Overall, it seems that anxiety\n may be contributing strongly to this presentation--although does not\n seem to be on home anxiolytics other than low dose ativan for nausea.\n His positional preference and prolonged expiratory phase are suggestive\n of COPD exacerbation (FVC 50%, FEV1 40% Predicted), but again dyspnea\n out of proportion to hypoxia. Caridiac ischemia also a possibility as\n pt has reported hx of a silent inferior MI in , curently not on\n ASA, BB, statin.\n - add BNP to admission labs; may be elevated in setting of atrial mass,\n but if negative still useful to r/o failure\n - repeat CXR this am\n - formal ECHO by tech ordered\n - repeat blood gas when tolerats\n - Trend cardiac enzymes\n - albuterol/ipratropium nebs (holding home spiriva); continuing advair;\n will d/w BMT regarding +/- of systemic steroids in this lymphoma pt\n undergoing tx\n - NIPPV on RA vs 2L face-mask per pt preference; O2 sats adeqquate on\n either\n # Low-Grade Fevers / Bandemia: Bandemia present on , but not to\n the prounced degree that it is now. Pt's fevers at home were\n low-grade, was afebrile in ED and on floor. There is a concern for\n relative immunocompromise as he is currently receiving tx for lymphoma.\n Pt is s/p PNA requiring intubation during a recent hospitalization.\n Some concern for infectious process on admission CTA, but RLL findings\n not particulary striking. UA clean.\n - Blood cultures x2 pending, Urine Cx pending, Sputum ordered. Repaet\n Cx if spikes.\n - Nasal aspirate for respiratory viruses: (influenza,paraninfluenza,\n RSV)\n - D/w BMT whether atypical Diff is expected with pt's recent treatemnts\n or whether it is more concerning for infxn. Smear ordered.\n - Empiric therapy for HAP Vanco/Zosyn per BMT\n # Cardiac lymphoma: The patient appears to have had an excellent\n response to therapy to date, with a decline in his LDH and shrinkage of\n his cardiac mass on cardiac MRI. He will be due for his 5th cycle of\n next week, and his ability to receive his chemotherapy safelywill\n be determined by his recover from his present illness.\n - d/w BMT\n # Hx of CAD: Alleged silent MI in . Not in our records and pt\n currently unbale to discuss. EKG suggestive of prior infarct, but ECHO\n is not. Unusual that he is not on home ASA, BB, or statin.\n - will d/w pt and BMT\n # Hx of DVT: Per previous DC summary, pt has had a recent DVT in\n setting of ongoing malignancy and has IVC filter in place--by report\n has contraindication to systemic anticoagulation.\n - d/w BMT\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:54 AM\n 18 Gauge - 05:57 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Nursing","chartdate":"2200-04-21 00:00:00.000","description":"Nursing Progress Note","row_id":678689,"text":"84 yo male pt with PMH ,Rt atrial tumour , lyphoma , recent\n chemotherapy ,PNA, presented to ER with SOB, N/V anxious, ?\n neutropenic. pt with worsening SOB, received vanco, zosyn ,solumedrol\n ,ativan and aspirin from ER, 2litres of fluid in. ? PE . CT done. neg\n for PE, ? PNA, slight decrease in the size of cardiac mass. put on\n BIPAP .tolerated well. transfered to for further monitoring and\n management.\n Neuro: alert and oriented , restless initially . following commands.\n Denies any pain.received ativan from ER. Very restless and says\n can\nt breath\n and likes to sit with legs dangling down . so made him\n to sit on the cardiac chair. Slept after morphine 1mg and 0.5mg\n ativan iv.\n CVS: HR ,with occasional PVC\ns. BP stable. bilateral pedal\n pulse palpable.\n Resp: Tachypoenic, RR high 20\ns ,initially with BIPAP mask ,then\n changed to 100% face mask.sats 100%. LS with insp/ exp wheeze.\n Albuterol MDI, and neb treatments given . ABG to do later on.\n GU/GI: abd soft ,BS present. Foley to gravity,adequate urine output.\n Skin; intact.\n Social; no family contact after admission . remains full code.\n Plan; follow up with am labs. Monitor resp /neuro status. f/u with\n blood gas. O2 as needed.\n"},{"category":"Nursing","chartdate":"2200-04-22 00:00:00.000","description":"Nursing Progress Note","row_id":678874,"text":"84 yo male pt with PMH ,Rt atrial tumour , lyphoma , recent\n chemotherapy ,PNA, presented to ER with SOB, N/V anxious, pt with\n worsening SOB, received vanco, zosyn ,solumedrol ,ativan and aspirin\n from ER, 2litres of fluid in. CT done. neg for PE, ? PNA, slight\n decrease in the size of cardiac mass. put on BIPAP .tolerated well.\n transfered to for further monitoring and management. He denies\n complaints of chest pain or pressure but is ruling in for MI by enzymes\n with elevated triponin to 2.23 yesterday. He has been started on\n lopressor for rate control, heparin drip aspirin and simvastatin.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n r/o MI from Elevated cardiac enzymes from yesterday.\n Action:\n Pt on heparin gtt and po aspirin. Lopressor for rate control. PTT q6hr.\n cardiac echo done yesterday. Cardiology consult.\n Response:\n f/u with cardiology, continue heparin per protocol. PTT q 6hrs. last\n 2two consecutive PTT\ns 66.5 and 61, both within therapeutic level.\n Plan:\n Continue with heparin per protocol. need PTT daily now.\n Altered mental status (not Delirium)\n Assessment:\n Pt alert oriented x 3, calm and quiet most of the time, but get\n restless and anxious very quickly. Slept during the night. Pt states\n he can\nt breath while he is anxious.\n Action:\n Ativan 0.5mg po/iv PRN. Stayed on bed during the night. On NC O2\n 3lit/min. LS Diminished. Neb treatments /MDI as ordered.\n Response:\n Good effect with ativan. Sats > 96%\n Plan:\n Continue with ativan /morphine PRN. Monitor mental status.\n Foley to gravity, urine clear,pink in colout.? Traumatic vs heparin\n gtt.\n"},{"category":"General","chartdate":"2200-04-21 00:00:00.000","description":"Generic Note","row_id":678684,"text":"TITLE:\n Respiratory Care:\n Pt arrives from ED with SOB, pneumonia, fever, lymphoma (now undergoing\n chemo), cardiac tumor. PMH of COPD DVT (filter placed), MI ,\n intubated for pneumonia . Placed on bipap\n 17/5 and tolerating\n well, but very anxious. Has nebs ordered.\n"},{"category":"Nursing","chartdate":"2200-04-21 00:00:00.000","description":"Nursing Progress Note","row_id":678811,"text":"84 yo male pt with PMH ,Rt atrial tumour , lyphoma , recent\n chemotherapy ,PNA, presented to ER with SOB, N/V anxious, ?\n neutropenic. pt with worsening SOB, received vanco, zosyn ,solumedrol\n ,ativan and aspirin from ER, 2litres of fluid in. ? PE . CT done. neg\n for PE, ? PNA, slight decrease in the size of cardiac mass. put on\n BIPAP .tolerated well. transfered to for further monitoring and\n management.\n Pt is alert and oriented but has very little patience and is easily\n agitated, becoming SOB with activity. He is not comfortable in bed and\n has been OOB to chair most of the shift. Was in bed for cardiac echo,\n then back to chair. Ambulates with assist of one to chair.\n He denies complaints of chest pain or pressure but is ruling in for MI\n by enzymes with elevated triponin to 2.23 at noon today. He has been\n started on lopressor for rate control, heparin drip and aspirain. He\n was also started on simvastatin. Cardiac consult in place.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt with severe complaints of dyspnea and becomes tachypneic when in\n bed. Maintains O2 sat but becomes agitated and feels like he is\n trapped in a cage.\n Once in the chair he was calmer and less anxious\n with improved Resp rate and agitation.\n Action:\n Weaned O2 from 100% down to 3L N/C with good O2 sat.\n Response:\n Remains in the chair but still becomes anxious and restless at times\n and is on the call light frequently for small things.\n Plan:\n Provide support and reassurance for this pt who is easily agitated.\n Ordered for small doses morphine or ativan can be used PRN\n Altered mental status (not Delirium)\n Assessment:\n Pt with periods of agitation and anxiety refused to stay in bed,\n becoming acutely agitated, restless and tachypneic.\n Action:\n Given .5mg iV morphine, assisted to chair and pt reassured.\n Response:\n Improved agitation but continues to ask the same questions about his\n illness andhis care.\n Plan:\n Follow mental status, continue to provide emotional support.\n .H/O lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n Pt is currently undergoing chemo treatment for lymphoma\n Action:\n Heme/onc service consulted and will not give chemo while he is being\n treated for an acute MI\n Response:\n Will reassess need for chemo once pt is stable.\n Plan:\n Continue to follow-up with heme/onc for recommendations.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2200-04-21 00:00:00.000","description":"Nursing Progress Note","row_id":678798,"text":"84 yo male pt with PMH ,Rt atrial tumour , lyphoma , recent\n chemotherapy ,PNA, presented to ER with SOB, N/V anxious, ?\n neutropenic. pt with worsening SOB, received vanco, zosyn ,solumedrol\n ,ativan and aspirin from ER, 2litres of fluid in. ? PE . CT done. neg\n for PE, ? PNA, slight decrease in the size of cardiac mass. put on\n BIPAP .tolerated well. transfered to for further monitoring and\n management.\n Pt is alert and oriented but has very little patience and is easily\n agitated, becoming SOB with activity. He is not comfortable in bed and\n has been OOB to chair most of the shift. Was in bed for cardiac echo,\n then back to chair. Ambulates with assist of one to chair.\n He denies complaints of chest pain or pressure but is ruling in for MI\n by enzymes with elevated triponin to 2.23 at noon today. He has been\n started on lopressor for rate control, heparin drip and aspirain. He\n was also started on simvastatin. Cardiac consult in place.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt with severe complaints of dyspnea and becomes tachypneic when in\n bed. Maintains O2 sat but becomes agitated and feels like he is trapped\n in a cage. Once in the chair he was calmer and less anxious with\n improved\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n Action:\n Response:\n Plan:\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2200-04-21 00:00:00.000","description":"Nursing Progress Note","row_id":678861,"text":"84 yo male pt with PMH ,Rt atrial tumour , lyphoma , recent\n chemotherapy ,PNA, presented to ER with SOB, N/V anxious, ?\n neutropenic. pt with worsening SOB, received vanco, zosyn ,solumedrol\n ,ativan and aspirin from ER, 2litres of fluid in. ? PE . CT done. neg\n for PE, ? PNA, slight decrease in the size of cardiac mass. put on\n BIPAP .tolerated well. transfered to for further monitoring and\n management.\n Pt is alert and oriented but has very little patience and is easily\n agitated, becoming SOB with activity. He is not comfortable in bed and\n has been OOB to chair most of the shift. Was in bed for cardiac echo,\n then back to chair. Ambulates with assist of one to chair. Family\n calling in frequently for updates. is spokesperson.\n He denies complaints of chest pain or pressure but is ruling in for MI\n by enzymes with elevated triponin to 2.23 at noon today. He has been\n started on lopressor for rate control, heparin drip and aspirin. He was\n also started on simvastatin. Cardiac consult in place.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt with severe complaints of dyspnea and becomes tachypneic when in\n bed. Maintains O2 sat but becomes agitated and feels like he is\n trapped in a cage.\n Once in the chair he was calmer and less anxious\n with improved Resp rate and agitation.\n Action:\n Weaned O2 from 100% down to 3L N/C with good O2 sat. RT sent specimens\n for viral antigens. Pt is positive for parainfluenza. He is on droplet\n precautions but team is not sure if we need them for this diagnosis.\n Response:\n Remains in the chair but still becomes anxious and restless at times\n and is on the call light frequently for small things.\n Plan:\n Provide support and reassurance for this pt who is easily agitated.\n Ordered for small doses morphine or ativan can be used PRN. Has an\n order for 1mg IV haldol on one time sheet which was never given yet.\n Altered mental status (not Delirium)\n Assessment:\n Pt with periods of agitation and anxiety refused to stay in bed,\n becoming acutely agitated, restless and tachypneic.\n Action:\n Given .5mg iV morphine, assisted to chair and pt reassured.\n Response:\n Improved agitation but continues to ask the same questions about his\n illness andhis care.\n Plan:\n Follow mental status, continue to provide emotional support. Use PRN\n morphine, ativan as needed.\n .H/O lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n Pt is currently undergoing chemo treatment for lymphoma\n Action:\n Heme/onc service consulted and will not give chemo while he is being\n treated for an acute MI\n Response:\n Will reassess need for chemo once pt is stable.\n Plan:\n Continue to follow-up with heme/onc for recommendations. Next set of\n enzymes due at 1800.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Pt ruled in for NSTEMI with positive triponins. No EKG changes were\n noted. Echo done at bedside today showed some new wall abnormalities\n but full report is yet to follow. He denies chest pain and pressure.\n Action:\n Pt given one aspirin tablet and was started on metoprolol 12.5mg then\n increased to 25mg PO. Pt also started on heparin drip at 11:45 at\n 750Units/hr. He was also started on simvastatin and remains on O2 3L.\n Stat echo and EKG was done. Pt given morphine for acute anxiety\n episode.\n Response:\n Vital signs remain stable with improved resp status in chair. Family\n have been updated and remain informed of plan of care. Pt started to\n have hematuria at 1600 and small pool of blood noted on pink pad under\n pt. Pt found to have some bleeding from around urethral meatus. Seen\n and noted by team.\n Plan:\n Follow labs, PTT Q6hrs to titrate heparin drip. Follow pt for further\n signs of bleeding.\n Assisted back to bed at 1800. Pt looks a little more distressed in bed\n but asked for some ativan to see if it could help him relax. Pt remains\n in bed at present.\n"},{"category":"Physician ","chartdate":"2200-04-21 00:00:00.000","description":"Physician Resident Admission Note","row_id":678862,"text":"Chief Complaint: worsening shortness of breath over past 2-3 days, low\n grade fevers at home\n HPI:\n Mr. is an 84 yo man with a high-grade cardiac B-cell\n lymphoma for which he is now undergoing R- chemotherapy and a\n history of COPD, DVT s/p IVC filter, and pneumonia with\n respiratory failure requiring endotracheal intubation in . Today is\n Day 15 of Cycle 4 or R-, which he received during his hospital\n admission from . He received Neulasta on . following\n his discharge, he has been feeling generally well; however, he admits\n to increasing exertional dyspnea overthe past 2-3 days. He explains\n that very light activity, such as changing his clothes or walking short\n distances, has resulted in significant shortness of breath. He denies\n cough, sputum production, orthopnea, paroxysmal nocturnal dyspnea, and\n swelling/pain of the arms or legs. He admits to low-grade fevers today;\n while visiting, his daughter noted that he had a temperature of 100.4\n degrees. For this reason, he was advised to report to the Emergency\n Room for evaluation.\n Upon arrival in the Emergency Department, had temperature of 99.6\n degrees. He was tachycardic to 118 and tachypneic (RR 30-40) with\n oxygen saturations of 95% on room air. During the first several\n minutesof is Emergency Department course, he developed rapidly\n increasing work of breathing. A CXR demonstrated no evidence\n ofpneumonia or effusion; furthermore, an echocardiogram showed no\n pericardial effusion. He was noted to have a WBC of 8.8 with 26%\n neutrophils and 36% bands. Due to progressive respiratorydistress\n without hypoxia, he was started on BiPAP. In addition, he was given IV\n solumderol 125mg, ASA 325mg, bronchodilators, piperacillin-tazobactam,\n and vancomycin. Also received total of 1.25mg of ativan in ED.\n Despite a fairly normal blood gas and presumbaly secondary to worsening\n dyspnea and tachynpnea, pt was started on BIPAP which he tolerated\n during his transfer to the . On arrival, he insisted that it be\n removed and then resumed. He was agitated and extremely anxious\n repeating \"I need air,\" peripheral sats were in the 93-100% range on\n room air. Seemed to be more comfortable leaning forward and placing\n his weight on his upper ext's. His HR rose in propotion to his\n tachypnea and gitation to a rate of 140's transiently. Agitation/anxiey\n waxed and waned with pt sleeping intermittently.\n ONCOLOGIC HISTORY (Per recent note by Dr : \n initially presented on , with anewly identified 8\n cm right atrial soft tissue mass. He underwent biopsy of this on\n , and pathology showed high-grade aggressive diffuse large\n B-cell lymphoma, staining positive for CD20, bcl-2, and bcl-6 in a\n small subset. Cells were negative for cytokeratins, CD138, bcl-1, and\n bcl-6. MIB fraction was 95-100%. Bcl-2 co-expression and lack of CD10\n argued against Burkitt's lymphoma; however, FISH studies were positive\n for c-myc rearrangement. He was diagnosed with high-grade cardiac\n lymphoma on the spectrum of diffuse large B-cell to Burkitt's\n lymphoma. No other sites of disease were identified by torso CT and\n bone marrow biopsy. He has begun R- chemotherapy on .\n Treatment course has been complicated by a DVT status post IVC filter\n in and pneumonia requiring intubation for hypoxia in .\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Terazosin\n Mental status c\n Last dose of Antibiotics:\n Vancomycin - 03:31 AM\n Piperacillin/Tazobactam (Zosyn) - 03:31 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n 1. cardiac lymphoma as above\n 2. Left Peroneal DVT s/p IVC filter placement \n 3. COPD\n 4. Hyperlipidemia\n 5. Hypertension\n 6. History of anxiety\n 7. History of rib fracture\n 8. History of silent MI \n 9. Left Shoulder Weakness\n 10. External Hemorrhoids\n 11. Benign Prostatic Hypertrophy\n nc\n Occupation: retired\n Drugs:\n Tobacco: 60 pk yr hx, quit 6 years ago\n Alcohol:\n Other: currently in rehab, living independently up until recent\n admission\n Review of systems:\n Constitutional: Fever\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n Tachycardia, No(t) Orthopnea\n Respiratory: No(t) Cough, Dyspnea, Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Diarrhea\n Genitourinary: No(t) Dysuria\n Neurologic: No(t) Headache\n Flowsheet Data as of 06:28 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.9\nC (96.6\n Tcurrent: 35.9\nC (96.6\n HR: 121 (121 - 121) bpm\n BP: 128/77(89) {128/75(89) - 155/77(96)} mmHg\n RR: 32 (25 - 32) insp/min\n SpO2: 95%\n Total In:\n 2,300 mL\n PO:\n TF:\n IVF:\n 300 mL\n Blood products:\n Total out:\n 0 mL\n 800 mL\n Urine:\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,500 mL\n Respiratory\n O2 Delivery Device: Other\n SpO2: 95%\n Physical Examination\n General Appearance: Thin, Anxious\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), tachycardic\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: dull BS bilaterally with prolonged expiratory\n pahse and use of abdominal muscles during expiration\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis\n Musculoskeletal: Muscle wasting\n Skin: Not assessed, No(t) Rash:\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): , Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n [image002.jpg]\n Imaging: ADMISSION CXR: The right hemidiaphragm remains persistently\n elevated. The\n cardiomediastinal silhouette is stable. There is no focal pulmonary\n consolidation. An IVC filter is seen in the upper abdomen.\n CONCLUSION: No acute cardiopulmonary process.\n CTA (ADMISSION):PRELIM: No PE. New focal right basilar consolidation-?\n pneumonia though may represent\n aspiration with ariway secretions seen on right. Perhaps slight\n dcecrease in\n size of cardiac mass.\n Microbiology: Bcx x2 and Ucx NGTD\n ECG: sinus tachycadia, left axis deviation, low voltages diffusely, old\n inferior infarct, no stt changes from previous\n Assessment and Plan\n ASSESSMENT AND PLAN:\n 84 year-old M with high-grade cardiac lymphoma (left atrial mass),\n currently receiving treatment (cycle 4,day 15) with R- presents\n from home with low-grade fevers and progressive dyspnea; despite\n marked tachypnea and dyspnea, pt's images and blood gas look\n remarkably good suggesting a strong contribution from anxiety. That\n said, he has an atypical WBC diff and is s/p recent chemotherapy and\n thus in a relatively immunocompromised state demanding empiric broad\n coverage with Abx. Physical Exam is most suggestive of COPD\n exacerbation, but dyspnea is out of proportion to boreline (if any)\n hypoxia.\n # Dyspnea / Tachypnea: From what can be gathered of his ED course, it\n seems that it was similar to how he has been in the . Dyspnea is\n out of proportion to hypoxia. Have been thus far unable to repeat\n blood gas secondary to agitation, but peripheral sats in mid to high\n 90s even on room air. When he has used Bipap, settings hve been 17/5\n on room air--he intermittently prefers this to face mask. Bedside echo\n in the ED notable for absence of effusion/tamponade. LV function\n grossly intact. CXR without pulmonary edema. CTA ruled out PE and\n showed ONLY Opacity in RLL which may represent early bacterial PNA vs\n aspiration. Pt does have Hx of DVT, but IVC filter is in place and no\n exam finding to suggest current DVT. Overall, it seems that anxiety\n may be contributing strongly to this presentation--although does not\n seem to be on home anxiolytics other than low dose ativan for nausea.\n His positional preference and prolonged expiratory phase are suggestive\n of COPD exacerbation (FVC 50%, FEV1 40% Predicted), but again dyspnea\n out of proportion to hypoxia. Caridiac ischemia also a possibility as\n pt has reported hx of a silent inferior MI in , curently not on\n ASA, BB, statin.\n - add BNP to admission labs; may be elevated in setting of atrial mass,\n but if negative still useful to r/o failure\n - repeat CXR this am\n - formal ECHO by tech ordered\n - repeat blood gas when tolerats\n - Trend cardiac enzymes\n - albuterol/ipratropium nebs (holding home spiriva); continuing advair;\n will d/w BMT regarding +/- of systemic steroids in this lymphoma pt\n undergoing tx\n - NIPPV on RA vs 2L face-mask per pt preference; O2 sats adeqquate on\n either\n # Low-Grade Fevers / Bandemia: Bandemia present on , but not to\n the prounced degree that it is now. Pt's fevers at home were\n low-grade, was afebrile in ED and on floor. There is a concern for\n relative immunocompromise as he is currently receiving tx for lymphoma.\n Pt is s/p PNA requiring intubation during a recent hospitalization.\n Some concern for infectious process on admission CTA, but RLL findings\n not particulary striking. UA clean.\n - Blood cultures x2 pending, Urine Cx pending, Sputum ordered. Repaet\n Cx if spikes.\n - Nasal aspirate for respiratory viruses: (influenza,paraninfluenza,\n RSV)\n - D/w BMT whether atypical Diff is expected with pt's recent treatemnts\n or whether it is more concerning for infxn. Smear ordered.\n - Empiric therapy for HAP Vanco/Zosyn per BMT\n # Cardiac lymphoma: The patient appears to have had an excellent\n response to therapy to date, with a decline in his LDH and shrinkage of\n his cardiac mass on cardiac MRI. He will be due for his 5th cycle of\n next week, and his ability to receive his chemotherapy safelywill\n be determined by his recover from his present illness.\n - d/w BMT\n # Hx of CAD: Alleged silent MI in . Not in our records and pt\n currently unbale to discuss. EKG suggestive of prior infarct, but ECHO\n is not. Unusual that he is not on home ASA, BB, or statin.\n - will d/w pt and BMT\n # Hx of DVT: Per previous DC summary, pt has had a recent DVT in\n setting of ongoing malignancy and has IVC filter in place--by report\n has contraindication to systemic anticoagulation.\n - d/w BMT\n ICU Care\n Nutrition: npo currently\n Glycemic Control:\n Lines:\n 18 Gauge - 03:37 AM\n 20 Gauge - 03:37 AM\n Comments: code status confirmed by onc fellow in ED. deferred currently\n as acutely agitated/anxious. likewise deferred ICU consent until acute\n anxiety has resolved\n Prophylaxis:\n DVT: SQ UF Heparin, IVC filter\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n ------ Protected Section ------\n ADDENDUM TO PLAN:\n Assessment and plan initially changed this am as cardiac enzymes\n positive and ECHO showing significant new focal wall motion\n abnormaiilities. These findings are c/w either ACS (plaque rupture) vs\n very significant demand ischemia secondary to a poorly defined acute\n stressor (see above differential). Pt now on ASA, BB (with goal\n HR~60), Statin (declined lipitor given hx of muscle pains, given\n simvastatin 80). Heparin drip started w/o bolus. Per BMT, seems that\n only contraindication to anticoag (unclear this am) has been concern\n that this right atrial mass would bleed into pericardial space. Still\n believe that pt\ns resp status compromised by COPD given exam, but heart\n failure secondary to active ischemia likely also contributing.\n -- cardiology consulted, f/u recommendations\n -- remainder of plan largely as outlined above: treat COPD, cont broad\n Abx coverage\n ------ Protected Section Addendum Entered By: , MD\n on: 14:05 ------\n Critical Care\n Present for the key portions of the resident\ns history and exam. Agree\n substantially with assessment and plan that was elaborated on\n multidisciplinary rounds this morning. He has been agitated, unable to\n get comfortable. Tolerating O2 but not able to use mask vent.\n Describes breathlessness as different from prior episodes of\n bronchitis.\n 121 128/77 26\n Chest is quiet with insp and exp wheezing\n HS distant w/ holosyst m\n Tr edema\n Troponin 0.26\n Echo apical dyskinesis EF 35% down from 55% with 2+ MR from 1+ MR\n Very difficult presentation. He has had a substantial worsening of\n cardiac fxn w/o clear ECG changes and echo read sounds c/w takasubo\n He has paraflu on nasal wash which seems consistent with his\n presentation. We are supporting oxygen, trying to manage his\n agitation, starting beta blockade given rapid HR and poor syst fxn. He\n does not seem to be in signif CHF on exam or CXR. We are monitoring\n closely\n is at signif risk for resp decomp. Not clear how to explain\n rising LD and nl but still LFTs.\n Time spent 65 min\n Critically ill\n ------ Protected Section Addendum Entered By: , MD\n on: 18:36 ------\n"},{"category":"Nursing","chartdate":"2200-04-22 00:00:00.000","description":"Nursing Progress Note","row_id":678914,"text":"84 yo male pt with PMH ,Rt atrial tumour , lyphoma , recent\n chemotherapy ,PNA, presented to ER with SOB, N/V anxious, pt with\n worsening SOB, received vanco, zosyn ,solumedrol ,ativan and aspirin\n from ER, 2litres of fluid in. CT done. neg for PE, ? PNA, slight\n decrease in the size of cardiac mass. put on BIPAP .tolerated well.\n transfered to for further monitoring and management. He denies\n complaints of chest pain or pressure but is ruling in for MI by enzymes\n with elevated triponin to 2.23 yesterday. He has been started on\n lopressor for rate control, heparin drip aspirin and simvastatin.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n r/o MI from Elevated cardiac enzymes from yesterday.\n Action:\n Pt on heparin gtt and po aspirin. Lopressor for rate control. PTT q6hr.\n cardiac echo done yesterday. Cardiology consult.\n Response:\n f/u with cardiology, continue heparin per protocol. PTT q 6hrs. last\n 2two consecutive PTT\ns 66.5 and 61, both within therapeutic level.\n Plan:\n Continue with heparin per protocol. need PTT daily now.\n Altered mental status (not Delirium)\n Assessment:\n Pt alert oriented x 3, calm and quiet most of the time, but get\n restless and anxious very quickly. Slept during the night. Pt states\n he can\nt breath while he is anxious.\n Action:\n Ativan 0.5mg po/iv PRN. Stayed on bed during the night. On NC O2\n 3lit/min. LS Diminished. Neb treatments /MDI as ordered.\n Response:\n Good effect with ativan. Sats > 96% .slept well .pt feels better .\n Plan:\n Continue with ativan /morphine PRN. Monitor mental status.\n Foley to gravity, urine clear,pink in colout.? Traumatic vs due to\n heparin gtt.\n Skin intact except bruises on both hands.\n"},{"category":"Nursing","chartdate":"2200-04-22 00:00:00.000","description":"Nursing Progress Note","row_id":678984,"text":"84 year-old M with high-grade cardiac lymphoma (left atrial mass),\n currently receiving treatment (cycle 4,day 15) with R- presents\n from home with low-grade fevers and progressive dyspnea; despite\n marked tachypnea and dyspnea, pt's images and blood gas look\n remarkably good suggesting a strong contribution from anxiety.\n"},{"category":"Nursing","chartdate":"2200-04-21 00:00:00.000","description":"Nursing Progress Note","row_id":678662,"text":"84 yo male pt with PMH ,Rt atrial tumour , lyphoma , recent\n chemotherapy ,PNA, presented to ER with SOB, N/V anxious, ?\n neutropenic. pt with worsening SOB, received vanco, zosyn ,solumedrol\n ,ativan and aspirin from ER, 2litres of fluid in. ? PE . CT done. neg\n for PE, ? PNA, slight decrease in the size of cardiac mass. put on\n BIPAP .tolerated well. transfered to for further monitoring and\n management.\n Neuro: alert and oriented , restless initially . following commands.\n Denies any pain.received ativan from ER. Slept after sometime.\n CVS: HR ,with occasional PVC\ns. BP stable.\n"},{"category":"Physician ","chartdate":"2200-04-21 00:00:00.000","description":"Physician Resident Admission Note","row_id":678786,"text":"Chief Complaint: worsening shortness of breath over past 2-3 days, low\n grade fevers at home\n HPI:\n Mr. is an 84 yo man with a high-grade cardiac B-cell\n lymphoma for which he is now undergoing R- chemotherapy and a\n history of COPD, DVT s/p IVC filter, and pneumonia with\n respiratory failure requiring endotracheal intubation in . Today is\n Day 15 of Cycle 4 or R-, which he received during his hospital\n admission from . He received Neulasta on . following\n his discharge, he has been feeling generally well; however, he admits\n to increasing exertional dyspnea overthe past 2-3 days. He explains\n that very light activity, such as changing his clothes or walking short\n distances, has resulted in significant shortness of breath. He denies\n cough, sputum production, orthopnea, paroxysmal nocturnal dyspnea, and\n swelling/pain of the arms or legs. He admits to low-grade fevers today;\n while visiting, his daughter noted that he had a temperature of 100.4\n degrees. For this reason, he was advised to report to the Emergency\n Room for evaluation.\n Upon arrival in the Emergency Department, had temperature of 99.6\n degrees. He was tachycardic to 118 and tachypneic (RR 30-40) with\n oxygen saturations of 95% on room air. During the first several\n minutesof is Emergency Department course, he developed rapidly\n increasing work of breathing. A CXR demonstrated no evidence\n ofpneumonia or effusion; furthermore, an echocardiogram showed no\n pericardial effusion. He was noted to have a WBC of 8.8 with 26%\n neutrophils and 36% bands. Due to progressive respiratorydistress\n without hypoxia, he was started on BiPAP. In addition, he was given IV\n solumderol 125mg, ASA 325mg, bronchodilators, piperacillin-tazobactam,\n and vancomycin. Also received total of 1.25mg of ativan in ED.\n Despite a fairly normal blood gas and presumbaly secondary to worsening\n dyspnea and tachynpnea, pt was started on BIPAP which he tolerated\n during his transfer to the . On arrival, he insisted that it be\n removed and then resumed. He was agitated and extremely anxious\n repeating \"I need air,\" peripheral sats were in the 93-100% range on\n room air. Seemed to be more comfortable leaning forward and placing\n his weight on his upper ext's. His HR rose in propotion to his\n tachypnea and gitation to a rate of 140's transiently. Agitation/anxiey\n waxed and waned with pt sleeping intermittently.\n ONCOLOGIC HISTORY (Per recent note by Dr : \n initially presented on , with anewly identified 8\n cm right atrial soft tissue mass. He underwent biopsy of this on\n , and pathology showed high-grade aggressive diffuse large\n B-cell lymphoma, staining positive for CD20, bcl-2, and bcl-6 in a\n small subset. Cells were negative for cytokeratins, CD138, bcl-1, and\n bcl-6. MIB fraction was 95-100%. Bcl-2 co-expression and lack of CD10\n argued against Burkitt's lymphoma; however, FISH studies were positive\n for c-myc rearrangement. He was diagnosed with high-grade cardiac\n lymphoma on the spectrum of diffuse large B-cell to Burkitt's\n lymphoma. No other sites of disease were identified by torso CT and\n bone marrow biopsy. He has begun R- chemotherapy on .\n Treatment course has been complicated by a DVT status post IVC filter\n in and pneumonia requiring intubation for hypoxia in .\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Terazosin\n Mental status c\n Last dose of Antibiotics:\n Vancomycin - 03:31 AM\n Piperacillin/Tazobactam (Zosyn) - 03:31 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n 1. cardiac lymphoma as above\n 2. Left Peroneal DVT s/p IVC filter placement \n 3. COPD\n 4. Hyperlipidemia\n 5. Hypertension\n 6. History of anxiety\n 7. History of rib fracture\n 8. History of silent MI \n 9. Left Shoulder Weakness\n 10. External Hemorrhoids\n 11. Benign Prostatic Hypertrophy\n nc\n Occupation: retired\n Drugs:\n Tobacco: 60 pk yr hx, quit 6 years ago\n Alcohol:\n Other: currently in rehab, living independently up until recent\n admission\n Review of systems:\n Constitutional: Fever\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n Tachycardia, No(t) Orthopnea\n Respiratory: No(t) Cough, Dyspnea, Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Diarrhea\n Genitourinary: No(t) Dysuria\n Neurologic: No(t) Headache\n Flowsheet Data as of 06:28 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.9\nC (96.6\n Tcurrent: 35.9\nC (96.6\n HR: 121 (121 - 121) bpm\n BP: 128/77(89) {128/75(89) - 155/77(96)} mmHg\n RR: 32 (25 - 32) insp/min\n SpO2: 95%\n Total In:\n 2,300 mL\n PO:\n TF:\n IVF:\n 300 mL\n Blood products:\n Total out:\n 0 mL\n 800 mL\n Urine:\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,500 mL\n Respiratory\n O2 Delivery Device: Other\n SpO2: 95%\n Physical Examination\n General Appearance: Thin, Anxious\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), tachycardic\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: dull BS bilaterally with prolonged expiratory\n pahse and use of abdominal muscles during expiration\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis\n Musculoskeletal: Muscle wasting\n Skin: Not assessed, No(t) Rash:\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): , Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n [image002.jpg]\n Imaging: ADMISSION CXR: The right hemidiaphragm remains persistently\n elevated. The\n cardiomediastinal silhouette is stable. There is no focal pulmonary\n consolidation. An IVC filter is seen in the upper abdomen.\n CONCLUSION: No acute cardiopulmonary process.\n CTA (ADMISSION):PRELIM: No PE. New focal right basilar consolidation-?\n pneumonia though may represent\n aspiration with ariway secretions seen on right. Perhaps slight\n dcecrease in\n size of cardiac mass.\n Microbiology: Bcx x2 and Ucx NGTD\n ECG: sinus tachycadia, left axis deviation, low voltages diffusely, old\n inferior infarct, no stt changes from previous\n Assessment and Plan\n ASSESSMENT AND PLAN:\n 84 year-old M with high-grade cardiac lymphoma (left atrial mass),\n currently receiving treatment (cycle 4,day 15) with R- presents\n from home with low-grade fevers and progressive dyspnea; despite\n marked tachypnea and dyspnea, pt's images and blood gas look\n remarkably good suggesting a strong contribution from anxiety. That\n said, he has an atypical WBC diff and is s/p recent chemotherapy and\n thus in a relatively immunocompromised state demanding empiric broad\n coverage with Abx. Physical Exam is most suggestive of COPD\n exacerbation, but dyspnea is out of proportion to boreline (if any)\n hypoxia.\n # Dyspnea / Tachypnea: From what can be gathered of his ED course, it\n seems that it was similar to how he has been in the . Dyspnea is\n out of proportion to hypoxia. Have been thus far unable to repeat\n blood gas secondary to agitation, but peripheral sats in mid to high\n 90s even on room air. When he has used Bipap, settings hve been 17/5\n on room air--he intermittently prefers this to face mask. Bedside echo\n in the ED notable for absence of effusion/tamponade. LV function\n grossly intact. CXR without pulmonary edema. CTA ruled out PE and\n showed ONLY Opacity in RLL which may represent early bacterial PNA vs\n aspiration. Pt does have Hx of DVT, but IVC filter is in place and no\n exam finding to suggest current DVT. Overall, it seems that anxiety\n may be contributing strongly to this presentation--although does not\n seem to be on home anxiolytics other than low dose ativan for nausea.\n His positional preference and prolonged expiratory phase are suggestive\n of COPD exacerbation (FVC 50%, FEV1 40% Predicted), but again dyspnea\n out of proportion to hypoxia. Caridiac ischemia also a possibility as\n pt has reported hx of a silent inferior MI in , curently not on\n ASA, BB, statin.\n - add BNP to admission labs; may be elevated in setting of atrial mass,\n but if negative still useful to r/o failure\n - repeat CXR this am\n - formal ECHO by tech ordered\n - repeat blood gas when tolerats\n - Trend cardiac enzymes\n - albuterol/ipratropium nebs (holding home spiriva); continuing advair;\n will d/w BMT regarding +/- of systemic steroids in this lymphoma pt\n undergoing tx\n - NIPPV on RA vs 2L face-mask per pt preference; O2 sats adeqquate on\n either\n # Low-Grade Fevers / Bandemia: Bandemia present on , but not to\n the prounced degree that it is now. Pt's fevers at home were\n low-grade, was afebrile in ED and on floor. There is a concern for\n relative immunocompromise as he is currently receiving tx for lymphoma.\n Pt is s/p PNA requiring intubation during a recent hospitalization.\n Some concern for infectious process on admission CTA, but RLL findings\n not particulary striking. UA clean.\n - Blood cultures x2 pending, Urine Cx pending, Sputum ordered. Repaet\n Cx if spikes.\n - Nasal aspirate for respiratory viruses: (influenza,paraninfluenza,\n RSV)\n - D/w BMT whether atypical Diff is expected with pt's recent treatemnts\n or whether it is more concerning for infxn. Smear ordered.\n - Empiric therapy for HAP Vanco/Zosyn per BMT\n # Cardiac lymphoma: The patient appears to have had an excellent\n response to therapy to date, with a decline in his LDH and shrinkage of\n his cardiac mass on cardiac MRI. He will be due for his 5th cycle of\n next week, and his ability to receive his chemotherapy safelywill\n be determined by his recover from his present illness.\n - d/w BMT\n # Hx of CAD: Alleged silent MI in . Not in our records and pt\n currently unbale to discuss. EKG suggestive of prior infarct, but ECHO\n is not. Unusual that he is not on home ASA, BB, or statin.\n - will d/w pt and BMT\n # Hx of DVT: Per previous DC summary, pt has had a recent DVT in\n setting of ongoing malignancy and has IVC filter in place--by report\n has contraindication to systemic anticoagulation.\n - d/w BMT\n ICU Care\n Nutrition: npo currently\n Glycemic Control:\n Lines:\n 18 Gauge - 03:37 AM\n 20 Gauge - 03:37 AM\n Comments: code status confirmed by onc fellow in ED. deferred currently\n as acutely agitated/anxious. likewise deferred ICU consent until acute\n anxiety has resolved\n Prophylaxis:\n DVT: SQ UF Heparin, IVC filter\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n ------ Protected Section ------\n ADDENDUM TO PLAN:\n Assessment and plan initially changed this am as cardiac enzymes\n positive and ECHO showing significant new focal wall motion\n abnormaiilities. These findings are c/w either ACS (plaque rupture) vs\n very significant demand ischemia secondary to a poorly defined acute\n stressor (see above differential). Pt now on ASA, BB (with goal\n HR~60), Statin (declined lipitor given hx of muscle pains, given\n simvastatin 80). Heparin drip started w/o bolus. Per BMT, seems that\n only contraindication to anticoag (unclear this am) has been concern\n that this right atrial mass would bleed into pericardial space. Still\n believe that pt\ns resp status compromised by COPD given exam, but heart\n failure secondary to active ischemia likely also contributing.\n -- cardiology consulted, f/u recommendations\n -- remainder of plan largely as outlined above: treat COPD, cont broad\n Abx coverage\n ------ Protected Section Addendum Entered By: , MD\n on: 14:05 ------\n"},{"category":"Social Work","chartdate":"2200-04-21 00:00:00.000","description":"Social Work Admission Note","row_id":678764,"text":"Family Information\n Next of :\n Health Care Proxy appointed:\n Family Spokesperson designated:\n Communication or visitation restriction:\n Patient Information:\n Previous living situation:\n Previous level of functioning: Required assistance with care\n Previous or other hospital admissions:\n Past psychiatric history: anxiety\n Past addictions history:\n Employment status: Retired\n Legal involvement:\n Mandated Reporting Information:\n Additional Information:\n Patient / Family Assessment:\n Clergy Contact:\n Communication with Team:\n Plan / Follow up:\n Pt is a pleasant 84 yo widowed male who lives alone in . His\n wife died from breast cancer when his children were young and he raised\n them as a single working father. His adult children are very devoted to\n him. Since initial diagnosis of Lymphoma pt has been in the hospital or\n rehab until his last hospitalization when pt returned home. He was very\n nervous about being home, but was quite happy to be there. He tells me\n he had RN, PT and home health aide. His children visited daily and\n provided meals.\n I will follow for emotional support and am available for questions or\n concerns.\n , LICSW\n X73442/ #\n"},{"category":"Nursing","chartdate":"2200-04-21 00:00:00.000","description":"Nursing Progress Note","row_id":678782,"text":"84 yo male pt with PMH ,Rt atrial tumour , lyphoma , recent\n chemotherapy ,PNA, presented to ER with SOB, N/V anxious, ?\n neutropenic. pt with worsening SOB, received vanco, zosyn ,solumedrol\n ,ativan and aspirin from ER, 2litres of fluid in. ? PE . CT done. neg\n for PE, ? PNA, slight decrease in the size of cardiac mass. put on\n BIPAP .tolerated well. transfered to for further monitoring and\n management.\n Pt is alert and oriented but has very little patience and is easily\n agitated, becoming SOB with activity. He is not comfortable in bed and\n has been OOB to chair most of the shift. Was in bed for cardiac echo,\n then back to chair. Ambulates with assist of one to chair.\n He denies complaints of chest pain or pressure but is ruling in for MI\n by enzymes with elevated triponin to 2.23 at noon today. He has been\n started on lopressor for rate control, heparin drip and aspirain. He\n was also started on simvastatin. Cardiac consult in place.\n"},{"category":"Nursing","chartdate":"2200-04-22 00:00:00.000","description":"Nursing Progress Note","row_id":679000,"text":"84 year-old M with high-grade cardiac lymphoma (left atrial mass),\n currently receiving treatment (cycle 4,day 15) with R- presents\n from home with low-grade fevers and progressive dyspnea; despite\n marked tachypnea and dyspnea, pt's images and blood gas look\n remarkably good suggesting a strong contribution from anxiety.\n .H/O lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n Pt is currently undergoing chemo treatment for lymphoma\n Action:\n Heme/onc service consulted and will not give chemo while he is being\n treated for an acute MI\n Response:\n Will reassess need for chemo once pt is stable.\n Plan:\n Continue to follow-up with heme/onc for recommendations. Next set of\n enzymes due at 1800.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Pt ruled in for NSTEMI with positive triponins. No EKG changes were\n noted. Echo done at bedside showed some new wall abnormalities but\n full report is yet to follow. He denies chest pain and pressure. On\n Heparin gtt this morning with positive hematuria.\n Action:\n Aspirin and on metoprolol 25mg PO. He was also started on simvastatin\n and remains on O2.\n Response:\n Vital signs remain stable. Heparin d/c\ned due to hematuria.\n Plan:\n Cont. to monitor followed by cardiology.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n FEVER\n Code status:\n Full code\n Height:\n Admission weight:\n 60 kg\n Daily weight:\n Allergies/Reactions:\n Terazosin\n Mental status c\n Precautions: Contact\n PMH:\n CV-PMH:\n Additional history: Lymphoma, L atrial tumour ,recent chemotherapy ,\n PNA. s/p IVC filter .\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:114\n D:64\n Temperature:\n 97.6\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 26 insp/min\n Heart Rate:\n 107 bpm\n Heart rhythm:\n ST (Sinus Tachycardia)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 99% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 793 mL\n 24h total out:\n 905 mL\n Pertinent Lab Results:\n Sodium:\n 140 mEq/L\n 05:46 AM\n Potassium:\n 3.4 mEq/L\n 05:46 AM\n Chloride:\n 104 mEq/L\n 05:46 AM\n CO2:\n 27 mEq/L\n 05:46 AM\n BUN:\n 11 mg/dL\n 05:46 AM\n Creatinine:\n 0.7 mg/dL\n 05:46 AM\n Glucose:\n 100 mg/dL\n 05:46 AM\n Hematocrit:\n 24.1 %\n 05:46 AM\n Additional pertinent labs:\n Lines / Tubes / Drains:\n 2 PIVs\n Valuables / Signature\n Patient valuables: Glasses\n Other valuables:\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: 412\n Transferred to: 1281\n Date & time of Transfer: 12:00 AM\n"},{"category":"Echo","chartdate":"2200-04-23 00:00:00.000","description":"Report","row_id":102037,"text":"PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 68\nWeight (lb): 144\nBSA (m2): 1.78 m2\nBP (mm Hg): 155/70\nHR (bpm): 93\nStatus: Inpatient\nDate/Time: at 12:30\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal interatrial septum.\nNo ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Suboptimal\ntechnical quality, a focal LV wall motion abnormality cannot be fully\nexcluded. Low normal LVEF. No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal aortic arch diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Mild thickening of mitral valve chordae. No MS. Mild to\nmoderate (+) MR.\n\nTRICUSPID VALVE: Tricuspid valve not well visualized. Indeterminate PA\nsystolic pressure.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nThe left atrium is elongated. No atrial septal defect is seen by 2D or color\nDoppler. There is mild symmetric left ventricular hypertrophy. The left\nventricular cavity size is normal. Due to suboptimal technical quality, a\nfocal wall motion abnormality cannot be fully excluded. Overall left\nventricular systolic function is probably normal (LVEF 50-55%). There is no\nventricular septal defect. Right ventricular chamber size and free wall motion\nare normal. The aortic valve leaflets (3) are mildly thickened but aortic\nstenosis is not present. No aortic regurgitation is seen. The mitral valve\nleaflets are mildly thickened. There is no mitral valve prolapse. Mild to\nmoderate (+) mitral regurgitation is seen. The pulmonary artery systolic\npressure could not be determined. There is no pericardial effusion.\n\nCompared with the prior study (images reviewed) of , the LVEF has\nprobably improved (suboptimal image quality and distal LV/apex porrly seen on\ncurrent study). If clinically indicated, a repeat study with echo contrast\n(dDefinity) may help evaluate regional and global LV systolic function.\n\n\n"},{"category":"Echo","chartdate":"2200-04-21 00:00:00.000","description":"Report","row_id":102038,"text":"PATIENT/TEST INFORMATION:\nIndication: Left ventricular function/wall motion abnormalities. Pericardial effusion.\nHeight: (in) 68\nWeight (lb): 139\nBSA (m2): 1.75 m2\nBP (mm Hg): 124/79\nHR (bpm): 100\nStatus: Inpatient\nDate/Time: at 13:20\nTest: Portable TTE (Complete)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT VENTRICLE: Moderately depressed LVEF.\n\nRIGHT VENTRICLE: RV function depressed.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate (2+) MR.\n\nTRICUSPID VALVE: Moderate [2+] TR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nOverall left ventricular systolic function is moderately depressed (LVEF=\n30-35 %) with akinesis of the distal LV/apex. RV with depressed free wall\ncontractility. The mitral valve leaflets are mildly thickened. Moderate (2+)\nmitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen.\nThere is no pericardial effusion.\n\nCompared with the prior study (images reviewed) of , biventrricular\nsystolic function is now depressed with regionality. The degree of MR \nhave increased.\n\n\n"},{"category":"Radiology","chartdate":"2200-04-22 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1081500,"text":" 5:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: worsening effusions\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old man with high grade lymphoma, pleural effusions\n REASON FOR THIS EXAMINATION:\n worsening effusions\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 84-year-old man with high-grade lymphoma, pleural effusions.\n\n COMPARISON: , .\n\n SINGLE PORTABLE SUPINE CHEST RADIOGRAPH: Positioning limits evaluation of the\n apices. There is persistent elevation of the right hemidiaphragm. There is\n again bibasilar atelectasis but no effusion. Within the limitations of the\n film there is no pneumothorax. The cardiomediastinal silhouette is unchanged.\n The aorta is calcified.\n\n IMPRESSION: No pleural effusion. Bibasilar atelectasis.\n\n\n"},{"category":"Radiology","chartdate":"2200-04-20 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1081277,"text":" 8:43 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old man with hx of lymphoma, pneumonia. Low grade fever today and\n increased fatigue.\n REASON FOR THIS EXAMINATION:\n r/o infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 84-year-old male with history of lymphoma, pneumonia and low-grade\n fever, to assess for a cardiopulmonary process.\n\n TECHNIQUE: Single portable AP radiograph of the chest was performed.\n Comparison is made with prior radiograph of .\n\n FINDINGS: The right hemidiaphragm remains persistently elevated. The\n cardiomediastinal silhouette is stable. There is no focal pulmonary\n consolidation. An IVC filter is seen in the upper abdomen.\n\n CONCLUSION: No acute cardiopulmonary process.\n\n"},{"category":"Radiology","chartdate":"2200-04-20 00:00:00.000","description":"CTA CHEST W&W/O C&RECONS, NON-CORONARY","row_id":1081284,"text":" 11:13 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: DYSPNEA\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old man with acute onset dyspnea, maintaining good O2 sats but w/ air\n hunger. on BiPap. history of cardiac lymphoma. has IVC filter\n REASON FOR THIS EXAMINATION:\n concern for PE, early pneumonia\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ARHb MON 12:35 AM\n No PE. New focal right basilar consolidation-? pneumonia though may represent\n aspiration with ariway secretions seen on right. Perhaps slight dcecrease in\n size of cardiac mass.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 84-year-old male with acute onset of dyspnea with history of\n cardiac lymphoma.\n\n COMPARISON: CT chest .\n\n TECHNIQUE: Non-contrast and contrast-enhanced axial images of the chest are\n obtained with multiplanar reformatted images.\n\n CTA CHEST: Although respiratory motion of the lower lobes limits evaluation\n of subsegmental vessels, there is no evidence for central main lobar or\n segmental pulmonary emboli. Additionally, there are no secondary signs of\n emboli including no evidence of right-sided heart strain. Atherosclerotic\n calcifications involve the thoracic aorta and its branches, though the\n thoracic aorta is of normal caliber. Several partially calcified mediastinal\n and left hilar lymph nodes represent prior granulomatous exposure. There is\n no pericardial or pleural effusion. The known soft tissue mass with epicenter\n at the level of the right atrium measures approximately 4.4 x 1.8 cm (3:72)\n compared to 4.3 x 2.4 cm on . Narrowing of the superior vena cava\n by this mass is unchanged.\n\n A new small focal consolidation is noted at the right lung base medially. The\n left lung remains clear. A 4-mm right lower lobe lung nodule (3:65) is not\n significantly changed. A small amount of secretions are noted in the right\n mainstem bronchus. Otherwise, the airways appear patent to the subsegmental\n level.\n\n Although this exam is not tailored to evaluate subdiaphragmatic structures,\n limited evaluation of the upper abdomen reveals multiple stones within the\n kidney. A left upper pole renal cyst is partially imaged, with a smaller\n cysts noted in the right interpolar region. 1.8 cm right adrenal mass is\n unchanged in size.\n\n Bone windows again reveal high-grade compression deformity in the mid thoracic\n spine, unchanged. Old healed left posterolateral fracture deformity of the\n tenth rib is unchanged.\n (Over)\n\n 11:13 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: DYSPNEA\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n IMPRESSION:\n 1. No pulmonary embolism.\n 2. New small consolidation at right lung base may represent pneumonic\n consolidation or, in the setting of airway secretions, aspiration.\n 3. Perhaps slight decrease in size of cardiac mass compared to CT from , with persistent mass effect on superior vena cava.\n 4. No change in size of right adrenal mass and right lower lobe lung nodule.\n\n"},{"category":"Radiology","chartdate":"2200-04-21 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1081300,"text":" 4:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: now more tachypneic, interval change?, any sign of plum vasc\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old man with cardiac (atrial) lymphoma presents with 2-3 days of\n worsening SOB\n REASON FOR THIS EXAMINATION:\n now more tachypneic, interval change?, any sign of plum vasc congestion?\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 6:22 \n\n HISTORY: Cardiac lymphoma. Worsening shortness of breath.\n\n IMPRESSION: AP chest compared to :\n\n Mild vascular congestion has developed in the right lung base. Lungs are\n otherwise clear. Heart size is normal. Elevation of right hemidiaphragm\n unchanged since at least .\n\n"},{"category":"ECG","chartdate":"2200-04-21 00:00:00.000","description":"Report","row_id":296684,"text":"Sinus tachycardia\nLow limb lead QRS voltages\nLeft axis deviation may be due to left anterior fascicular block\nModest T wave changes\nDelayed R wave progression with late precordial QRS transition\nThese findings are nonspecific but clinical correlation is suggested\nSince previous tracing of the same date, further T waves changes present\n\n"},{"category":"ECG","chartdate":"2200-04-21 00:00:00.000","description":"Report","row_id":296685,"text":"Sinus tachycardia\nLow limb lead QRS voltages\nLeft axis deviation may be due to left anterior fascicular block\nModest T wave changes\nDelayed R wave progression with late precordial QRS transition\nThese findings are nonspecific but clinical correlation is suggested\n\n"}],"string":"[\n {\n \"category\": \"General\",\n \"chartdate\": \"2200-04-22 00:00:00.000\",\n \"description\": \"Generic Note\",\n \"row_id\": 678967,\n \"text\": \"TITLE: Critical Care\\n Present for the key portions of the resident\\ns history and exam. Agree\\n substantially with assessment and plan as outlined on multidisciplinary\\n rounds this morning. Much more comfortable\\n breathless with talking\\n or minimal movement but substantially better than yesterday.\\n 97.6 102 95/50\\n Chest\\n prolonged exhalation, mid insp crackles\\n Abd\\n soft\\n WBC 8.7\\n Trop down to 0.17\\n Much improved. Still somewhat unclear what has happened but it appears\\n he has a parainfluenza inf c/b some cardiac event\\n unclear if this is\\n demand ischemia or Takasubo\\ns. We are stopping iv heparin and starting\\n sq heparin. Continues to get nebs with some relief. No evidence of\\n bacterial inf so we are d/cing abx.\\n Time spent 30 min\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2200-04-21 00:00:00.000\",\n \"description\": \"Physician Resident Admission Note\",\n \"row_id\": 678697,\n \"text\": \"Chief Complaint: worsening shortness of breath over past 2-3 days, low\\n grade fevers at home\\n HPI:\\n Mr. is an 84 yo man with a high-grade cardiac B-cell\\n lymphoma for which he is now undergoing R- chemotherapy and a\\n history of COPD, DVT s/p IVC filter, and pneumonia with\\n respiratory failure requiring endotracheal intubation in . Today is\\n Day 15 of Cycle 4 or R-, which he received during his hospital\\n admission from . He received Neulasta on . following\\n his discharge, he has been feeling generally well; however, he admits\\n to increasing exertional dyspnea overthe past 2-3 days. He explains\\n that very light activity, such as changing his clothes or walking short\\n distances, has resulted in significant shortness of breath. He denies\\n cough, sputum production, orthopnea, paroxysmal nocturnal dyspnea, and\\n swelling/pain of the arms or legs. He admits to low-grade fevers today;\\n while visiting, his daughter noted that he had a temperature of 100.4\\n degrees. For this reason, he was advised to report to the Emergency\\n Room for evaluation.\\n Upon arrival in the Emergency Department, had temperature of 99.6\\n degrees. He was tachycardic to 118 and tachypneic (RR 30-40) with\\n oxygen saturations of 95% on room air. During the first several\\n minutesof is Emergency Department course, he developed rapidly\\n increasing work of breathing. A CXR demonstrated no evidence\\n ofpneumonia or effusion; furthermore, an echocardiogram showed no\\n pericardial effusion. He was noted to have a WBC of 8.8 with 26%\\n neutrophils and 36% bands. Due to progressive respiratorydistress\\n without hypoxia, he was started on BiPAP. In addition, he was given IV\\n solumderol 125mg, ASA 325mg, bronchodilators, piperacillin-tazobactam,\\n and vancomycin. Also received total of 1.25mg of ativan in ED.\\n Despite a fairly normal blood gas and presumbaly secondary to worsening\\n dyspnea and tachynpnea, pt was started on BIPAP which he tolerated\\n during his transfer to the . On arrival, he insisted that it be\\n removed and then resumed. He was agitated and extremely anxious\\n repeating \\\"I need air,\\\" peripheral sats were in the 93-100% range on\\n room air. Seemed to be more comfortable leaning forward and placing\\n his weight on his upper ext's. His HR rose in propotion to his\\n tachypnea and gitation to a rate of 140's transiently. Agitation/anxiey\\n waxed and waned with pt sleeping intermittently.\\n ONCOLOGIC HISTORY (Per recent note by Dr : \\n initially presented on , with anewly identified 8\\n cm right atrial soft tissue mass. He underwent biopsy of this on\\n , and pathology showed high-grade aggressive diffuse large\\n B-cell lymphoma, staining positive for CD20, bcl-2, and bcl-6 in a\\n small subset. Cells were negative for cytokeratins, CD138, bcl-1, and\\n bcl-6. MIB fraction was 95-100%. Bcl-2 co-expression and lack of CD10\\n argued against Burkitt's lymphoma; however, FISH studies were positive\\n for c-myc rearrangement. He was diagnosed with high-grade cardiac\\n lymphoma on the spectrum of diffuse large B-cell to Burkitt's\\n lymphoma. No other sites of disease were identified by torso CT and\\n bone marrow biopsy. He has begun R- chemotherapy on .\\n Treatment course has been complicated by a DVT status post IVC filter\\n in and pneumonia requiring intubation for hypoxia in .\\n Patient admitted from: ER\\n History obtained from Medical records\\n Allergies:\\n Terazosin\\n Mental status c\\n Last dose of Antibiotics:\\n Vancomycin - 03:31 AM\\n Piperacillin/Tazobactam (Zosyn) - 03:31 AM\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Past medical history:\\n Family history:\\n Social History:\\n 1. cardiac lymphoma as above\\n 2. Left Peroneal DVT s/p IVC filter placement \\n 3. COPD\\n 4. Hyperlipidemia\\n 5. Hypertension\\n 6. History of anxiety\\n 7. History of rib fracture\\n 8. History of silent MI \\n 9. Left Shoulder Weakness\\n 10. External Hemorrhoids\\n 11. Benign Prostatic Hypertrophy\\n nc\\n Occupation: retired\\n Drugs:\\n Tobacco: 60 pk yr hx, quit 6 years ago\\n Alcohol:\\n Other: currently in rehab, living independently up until recent\\n admission\\n Review of systems:\\n Constitutional: Fever\\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\\n Tachycardia, No(t) Orthopnea\\n Respiratory: No(t) Cough, Dyspnea, Tachypnea, No(t) Wheeze\\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Diarrhea\\n Genitourinary: No(t) Dysuria\\n Neurologic: No(t) Headache\\n Flowsheet Data as of 06:28 AM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since 12 AM\\n Tmax: 35.9\\nC (96.6\\n Tcurrent: 35.9\\nC (96.6\\n HR: 121 (121 - 121) bpm\\n BP: 128/77(89) {128/75(89) - 155/77(96)} mmHg\\n RR: 32 (25 - 32) insp/min\\n SpO2: 95%\\n Total In:\\n 2,300 mL\\n PO:\\n TF:\\n IVF:\\n 300 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 800 mL\\n Urine:\\n 200 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n 1,500 mL\\n Respiratory\\n O2 Delivery Device: Other\\n SpO2: 95%\\n Physical Examination\\n General Appearance: Thin, Anxious\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: Normocephalic\\n Cardiovascular: (S1: Normal), (S2: Normal), tachycardic\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: dull BS bilaterally with prolonged expiratory\\n pahse and use of abdominal muscles during expiration\\n Abdominal: Soft, Non-tender, Bowel sounds present\\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis\\n Musculoskeletal: Muscle wasting\\n Skin: Not assessed, No(t) Rash:\\n Neurologic: Attentive, Follows simple commands, Responds to: Not\\n assessed, Oriented (to): , Movement: Not assessed, Tone: Not assessed\\n Labs / Radiology\\n [image002.jpg]\\n Imaging: ADMISSION CXR: The right hemidiaphragm remains persistently\\n elevated. The\\n cardiomediastinal silhouette is stable. There is no focal pulmonary\\n consolidation. An IVC filter is seen in the upper abdomen.\\n CONCLUSION: No acute cardiopulmonary process.\\n CTA (ADMISSION):PRELIM: No PE. New focal right basilar consolidation-?\\n pneumonia though may represent\\n aspiration with ariway secretions seen on right. Perhaps slight\\n dcecrease in\\n size of cardiac mass.\\n Microbiology: Bcx x2 and Ucx NGTD\\n ECG: sinus tachycadia, left axis deviation, low voltages diffusely, old\\n inferior infarct, no stt changes from previous\\n Assessment and Plan\\n ASSESSMENT AND PLAN:\\n 84 year-old M with high-grade cardiac lymphoma (left atrial mass),\\n currently receiving treatment (cycle 4,day 15) with R- presents\\n from home with low-grade fevers and progressive dyspnea; despite\\n marked tachypnea and dyspnea, pt's images and blood gas look\\n remarkably good suggesting a strong contribution from anxiety. That\\n said, he has an atypical WBC diff and is s/p recent chemotherapy and\\n thus in a relatively immunocompromised state demanding empiric broad\\n coverage with Abx. Physical Exam is most suggestive of COPD\\n exacerbation, but dyspnea is out of proportion to boreline (if any)\\n hypoxia.\\n # Dyspnea / Tachypnea: From what can be gathered of his ED course, it\\n seems that it was similar to how he has been in the . Dyspnea is\\n out of proportion to hypoxia. Have been thus far unable to repeat\\n blood gas secondary to agitation, but peripheral sats in mid to high\\n 90s even on room air. When he has used Bipap, settings hve been 17/5\\n on room air--he intermittently prefers this to face mask. Bedside echo\\n in the ED notable for absence of effusion/tamponade. LV function\\n grossly intact. CXR without pulmonary edema. CTA ruled out PE and\\n showed ONLY Opacity in RLL which may represent early bacterial PNA vs\\n aspiration. Pt does have Hx of DVT, but IVC filter is in place and no\\n exam finding to suggest current DVT. Overall, it seems that anxiety\\n may be contributing strongly to this presentation--although does not\\n seem to be on home anxiolytics other than low dose ativan for nausea.\\n His positional preference and prolonged expiratory phase are suggestive\\n of COPD exacerbation (FVC 50%, FEV1 40% Predicted), but again dyspnea\\n out of proportion to hypoxia. Caridiac ischemia also a possibility as\\n pt has alleed hx of a silent inferior MI in .\\n - add BNP to admission labs; may be elevated in setting of atrial mass,\\n but if negative still useful to r/o failure\\n - repeat CXR this am\\n - formal ECHO by tech ordered\\n - repeat blood gas when tolerats\\n - Trend cardiac enzymes\\n - albuterol/ipratropium nebs (holding home spiriva); continuing advair;\\n will d/w BMT regarding +/- of systemic steroids in this lymphoma pt\\n undergoing tx\\n - NIPPV on RA vs 2L face-mask per pt preference; O2 sats adeqquate on\\n either\\n # Low-Grade Fevers / Bandemia: Bandemia present on , but not to\\n the prounced degree that it is now. Pt's fevers at home were\\n low-grade, was afebrile in ED and on floor. There is a concern for\\n relative immunocompromise as he is currently receiving tx for lymphoma.\\n Pt is s/p PNA requiring intubation during a recent hospitalization.\\n Some concern for infectious process on admission CTA, but RLL findings\\n not particulary striking. UA clean.\\n - Blood cultures x2 pending, Urine Cx pending, Sputum ordered. Repaet\\n Cx if spikes.\\n - Nasal aspirate for respiratory viruses: (influenza,paraninfluenza,\\n RSV)\\n - D/w BMT whether atypical Diff is expected with pt's recent treatemnts\\n or whether it is more concerning for infxn. Smear ordered.\\n - Empiric therapy for HAP Vanco/Zosyn per BMT\\n # Cardiac lymphoma: The patient appears to have had an excellent\\n response to therapy to date, with a decline in his LDH and shrinkage of\\n his cardiac mass on cardiac MRI. He will be due for his 5th cycle of\\n next week, and his ability to receive his chemotherapy safelywill\\n be determined by his recover from his present illness.\\n - d/w BMT\\n # Hx of CAD: Alleged silent MI in . Not in our records and pt\\n currently unbale to discuss. EKG suggestive of prior infarct, but ECHO\\n is not. Unusual that he is not on home ASA, BB, or statin.\\n - will d/w pt and BMT\\n # Hx of DVT: Per previous DC summary, pt has had a recent DVT in\\n setting of ongoing malignancy and has IVC filter in place--by report\\n has contraindication to systemic anticoagulation.\\n - d/w BMT\\n ICU Care\\n Nutrition: npo currently\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 03:37 AM\\n 20 Gauge - 03:37 AM\\n Comments: code status confirmed by onc fellow in ED. deferred currently\\n as acutely agitated/anxious. likewise deferred ICU consent until acute\\n anxiety has resolved\\n Prophylaxis:\\n DVT: SQ UF Heparin, IVC filter\\n Stress ulcer: PPI\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition: ICU\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2200-04-21 00:00:00.000\",\n \"description\": \"Physician Resident Admission Note\",\n \"row_id\": 678698,\n \"text\": \"Chief Complaint: worsening shortness of breath over past 2-3 days, low\\n grade fevers at home\\n HPI:\\n Mr. is an 84 yo man with a high-grade cardiac B-cell\\n lymphoma for which he is now undergoing R- chemotherapy and a\\n history of COPD, DVT s/p IVC filter, and pneumonia with\\n respiratory failure requiring endotracheal intubation in . Today is\\n Day 15 of Cycle 4 or R-, which he received during his hospital\\n admission from . He received Neulasta on . following\\n his discharge, he has been feeling generally well; however, he admits\\n to increasing exertional dyspnea overthe past 2-3 days. He explains\\n that very light activity, such as changing his clothes or walking short\\n distances, has resulted in significant shortness of breath. He denies\\n cough, sputum production, orthopnea, paroxysmal nocturnal dyspnea, and\\n swelling/pain of the arms or legs. He admits to low-grade fevers today;\\n while visiting, his daughter noted that he had a temperature of 100.4\\n degrees. For this reason, he was advised to report to the Emergency\\n Room for evaluation.\\n Upon arrival in the Emergency Department, had temperature of 99.6\\n degrees. He was tachycardic to 118 and tachypneic (RR 30-40) with\\n oxygen saturations of 95% on room air. During the first several\\n minutesof is Emergency Department course, he developed rapidly\\n increasing work of breathing. A CXR demonstrated no evidence\\n ofpneumonia or effusion; furthermore, an echocardiogram showed no\\n pericardial effusion. He was noted to have a WBC of 8.8 with 26%\\n neutrophils and 36% bands. Due to progressive respiratorydistress\\n without hypoxia, he was started on BiPAP. In addition, he was given IV\\n solumderol 125mg, ASA 325mg, bronchodilators, piperacillin-tazobactam,\\n and vancomycin. Also received total of 1.25mg of ativan in ED.\\n Despite a fairly normal blood gas and presumbaly secondary to worsening\\n dyspnea and tachynpnea, pt was started on BIPAP which he tolerated\\n during his transfer to the . On arrival, he insisted that it be\\n removed and then resumed. He was agitated and extremely anxious\\n repeating \\\"I need air,\\\" peripheral sats were in the 93-100% range on\\n room air. Seemed to be more comfortable leaning forward and placing\\n his weight on his upper ext's. His HR rose in propotion to his\\n tachypnea and gitation to a rate of 140's transiently. Agitation/anxiey\\n waxed and waned with pt sleeping intermittently.\\n ONCOLOGIC HISTORY (Per recent note by Dr : \\n initially presented on , with anewly identified 8\\n cm right atrial soft tissue mass. He underwent biopsy of this on\\n , and pathology showed high-grade aggressive diffuse large\\n B-cell lymphoma, staining positive for CD20, bcl-2, and bcl-6 in a\\n small subset. Cells were negative for cytokeratins, CD138, bcl-1, and\\n bcl-6. MIB fraction was 95-100%. Bcl-2 co-expression and lack of CD10\\n argued against Burkitt's lymphoma; however, FISH studies were positive\\n for c-myc rearrangement. He was diagnosed with high-grade cardiac\\n lymphoma on the spectrum of diffuse large B-cell to Burkitt's\\n lymphoma. No other sites of disease were identified by torso CT and\\n bone marrow biopsy. He has begun R- chemotherapy on .\\n Treatment course has been complicated by a DVT status post IVC filter\\n in and pneumonia requiring intubation for hypoxia in .\\n Patient admitted from: ER\\n History obtained from Medical records\\n Allergies:\\n Terazosin\\n Mental status c\\n Last dose of Antibiotics:\\n Vancomycin - 03:31 AM\\n Piperacillin/Tazobactam (Zosyn) - 03:31 AM\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Past medical history:\\n Family history:\\n Social History:\\n 1. cardiac lymphoma as above\\n 2. Left Peroneal DVT s/p IVC filter placement \\n 3. COPD\\n 4. Hyperlipidemia\\n 5. Hypertension\\n 6. History of anxiety\\n 7. History of rib fracture\\n 8. History of silent MI \\n 9. Left Shoulder Weakness\\n 10. External Hemorrhoids\\n 11. Benign Prostatic Hypertrophy\\n nc\\n Occupation: retired\\n Drugs:\\n Tobacco: 60 pk yr hx, quit 6 years ago\\n Alcohol:\\n Other: currently in rehab, living independently up until recent\\n admission\\n Review of systems:\\n Constitutional: Fever\\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\\n Tachycardia, No(t) Orthopnea\\n Respiratory: No(t) Cough, Dyspnea, Tachypnea, No(t) Wheeze\\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Diarrhea\\n Genitourinary: No(t) Dysuria\\n Neurologic: No(t) Headache\\n Flowsheet Data as of 06:28 AM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since 12 AM\\n Tmax: 35.9\\nC (96.6\\n Tcurrent: 35.9\\nC (96.6\\n HR: 121 (121 - 121) bpm\\n BP: 128/77(89) {128/75(89) - 155/77(96)} mmHg\\n RR: 32 (25 - 32) insp/min\\n SpO2: 95%\\n Total In:\\n 2,300 mL\\n PO:\\n TF:\\n IVF:\\n 300 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 800 mL\\n Urine:\\n 200 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n 1,500 mL\\n Respiratory\\n O2 Delivery Device: Other\\n SpO2: 95%\\n Physical Examination\\n General Appearance: Thin, Anxious\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: Normocephalic\\n Cardiovascular: (S1: Normal), (S2: Normal), tachycardic\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: dull BS bilaterally with prolonged expiratory\\n pahse and use of abdominal muscles during expiration\\n Abdominal: Soft, Non-tender, Bowel sounds present\\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis\\n Musculoskeletal: Muscle wasting\\n Skin: Not assessed, No(t) Rash:\\n Neurologic: Attentive, Follows simple commands, Responds to: Not\\n assessed, Oriented (to): , Movement: Not assessed, Tone: Not assessed\\n Labs / Radiology\\n [image002.jpg]\\n Imaging: ADMISSION CXR: The right hemidiaphragm remains persistently\\n elevated. The\\n cardiomediastinal silhouette is stable. There is no focal pulmonary\\n consolidation. An IVC filter is seen in the upper abdomen.\\n CONCLUSION: No acute cardiopulmonary process.\\n CTA (ADMISSION):PRELIM: No PE. New focal right basilar consolidation-?\\n pneumonia though may represent\\n aspiration with ariway secretions seen on right. Perhaps slight\\n dcecrease in\\n size of cardiac mass.\\n Microbiology: Bcx x2 and Ucx NGTD\\n ECG: sinus tachycadia, left axis deviation, low voltages diffusely, old\\n inferior infarct, no stt changes from previous\\n Assessment and Plan\\n ASSESSMENT AND PLAN:\\n 84 year-old M with high-grade cardiac lymphoma (left atrial mass),\\n currently receiving treatment (cycle 4,day 15) with R- presents\\n from home with low-grade fevers and progressive dyspnea; despite\\n marked tachypnea and dyspnea, pt's images and blood gas look\\n remarkably good suggesting a strong contribution from anxiety. That\\n said, he has an atypical WBC diff and is s/p recent chemotherapy and\\n thus in a relatively immunocompromised state demanding empiric broad\\n coverage with Abx. Physical Exam is most suggestive of COPD\\n exacerbation, but dyspnea is out of proportion to boreline (if any)\\n hypoxia.\\n # Dyspnea / Tachypnea: From what can be gathered of his ED course, it\\n seems that it was similar to how he has been in the . Dyspnea is\\n out of proportion to hypoxia. Have been thus far unable to repeat\\n blood gas secondary to agitation, but peripheral sats in mid to high\\n 90s even on room air. When he has used Bipap, settings hve been 17/5\\n on room air--he intermittently prefers this to face mask. Bedside echo\\n in the ED notable for absence of effusion/tamponade. LV function\\n grossly intact. CXR without pulmonary edema. CTA ruled out PE and\\n showed ONLY Opacity in RLL which may represent early bacterial PNA vs\\n aspiration. Pt does have Hx of DVT, but IVC filter is in place and no\\n exam finding to suggest current DVT. Overall, it seems that anxiety\\n may be contributing strongly to this presentation--although does not\\n seem to be on home anxiolytics other than low dose ativan for nausea.\\n His positional preference and prolonged expiratory phase are suggestive\\n of COPD exacerbation (FVC 50%, FEV1 40% Predicted), but again dyspnea\\n out of proportion to hypoxia. Caridiac ischemia also a possibility as\\n pt has reported hx of a silent inferior MI in , curently not on\\n ASA, BB, statin.\\n - add BNP to admission labs; may be elevated in setting of atrial mass,\\n but if negative still useful to r/o failure\\n - repeat CXR this am\\n - formal ECHO by tech ordered\\n - repeat blood gas when tolerats\\n - Trend cardiac enzymes\\n - albuterol/ipratropium nebs (holding home spiriva); continuing advair;\\n will d/w BMT regarding +/- of systemic steroids in this lymphoma pt\\n undergoing tx\\n - NIPPV on RA vs 2L face-mask per pt preference; O2 sats adeqquate on\\n either\\n # Low-Grade Fevers / Bandemia: Bandemia present on , but not to\\n the prounced degree that it is now. Pt's fevers at home were\\n low-grade, was afebrile in ED and on floor. There is a concern for\\n relative immunocompromise as he is currently receiving tx for lymphoma.\\n Pt is s/p PNA requiring intubation during a recent hospitalization.\\n Some concern for infectious process on admission CTA, but RLL findings\\n not particulary striking. UA clean.\\n - Blood cultures x2 pending, Urine Cx pending, Sputum ordered. Repaet\\n Cx if spikes.\\n - Nasal aspirate for respiratory viruses: (influenza,paraninfluenza,\\n RSV)\\n - D/w BMT whether atypical Diff is expected with pt's recent treatemnts\\n or whether it is more concerning for infxn. Smear ordered.\\n - Empiric therapy for HAP Vanco/Zosyn per BMT\\n # Cardiac lymphoma: The patient appears to have had an excellent\\n response to therapy to date, with a decline in his LDH and shrinkage of\\n his cardiac mass on cardiac MRI. He will be due for his 5th cycle of\\n next week, and his ability to receive his chemotherapy safelywill\\n be determined by his recover from his present illness.\\n - d/w BMT\\n # Hx of CAD: Alleged silent MI in . Not in our records and pt\\n currently unbale to discuss. EKG suggestive of prior infarct, but ECHO\\n is not. Unusual that he is not on home ASA, BB, or statin.\\n - will d/w pt and BMT\\n # Hx of DVT: Per previous DC summary, pt has had a recent DVT in\\n setting of ongoing malignancy and has IVC filter in place--by report\\n has contraindication to systemic anticoagulation.\\n - d/w BMT\\n ICU Care\\n Nutrition: npo currently\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 03:37 AM\\n 20 Gauge - 03:37 AM\\n Comments: code status confirmed by onc fellow in ED. deferred currently\\n as acutely agitated/anxious. likewise deferred ICU consent until acute\\n anxiety has resolved\\n Prophylaxis:\\n DVT: SQ UF Heparin, IVC filter\\n Stress ulcer: PPI\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition: ICU\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2200-04-21 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 678822,\n \"text\": \"84 yo male pt with PMH ,Rt atrial tumour , lyphoma , recent\\n chemotherapy ,PNA, presented to ER with SOB, N/V anxious, ?\\n neutropenic. pt with worsening SOB, received vanco, zosyn ,solumedrol\\n ,ativan and aspirin from ER, 2litres of fluid in. ? PE . CT done. neg\\n for PE, ? PNA, slight decrease in the size of cardiac mass. put on\\n BIPAP .tolerated well. transfered to for further monitoring and\\n management.\\n Pt is alert and oriented but has very little patience and is easily\\n agitated, becoming SOB with activity. He is not comfortable in bed and\\n has been OOB to chair most of the shift. Was in bed for cardiac echo,\\n then back to chair. Ambulates with assist of one to chair. Family\\n calling in frequently for updates. is spokesperson.\\n He denies complaints of chest pain or pressure but is ruling in for MI\\n by enzymes with elevated triponin to 2.23 at noon today. He has been\\n started on lopressor for rate control, heparin drip and aspirin. He was\\n also started on simvastatin. Cardiac consult in place.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt with severe complaints of dyspnea and becomes tachypneic when in\\n bed. Maintains O2 sat but becomes agitated and feels like he is\\n trapped in a cage.\\n Once in the chair he was calmer and less anxious\\n with improved Resp rate and agitation.\\n Action:\\n Weaned O2 from 100% down to 3L N/C with good O2 sat. RT sent specimens\\n for viral antigens. Pt is positive for parainfluenza. He is on droplet\\n precautions but team is not sure if we need them for this diagnosis.\\n Response:\\n Remains in the chair but still becomes anxious and restless at times\\n and is on the call light frequently for small things.\\n Plan:\\n Provide support and reassurance for this pt who is easily agitated.\\n Ordered for small doses morphine or ativan can be used PRN. Has an\\n order for 1mg IV haldol on one time sheet which was never given yet.\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt with periods of agitation and anxiety refused to stay in bed,\\n becoming acutely agitated, restless and tachypneic.\\n Action:\\n Given .5mg iV morphine, assisted to chair and pt reassured.\\n Response:\\n Improved agitation but continues to ask the same questions about his\\n illness andhis care.\\n Plan:\\n Follow mental status, continue to provide emotional support. Use PRN\\n morphine, ativan as needed.\\n .H/O lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\\n Assessment:\\n Pt is currently undergoing chemo treatment for lymphoma\\n Action:\\n Heme/onc service consulted and will not give chemo while he is being\\n treated for an acute MI\\n Response:\\n Will reassess need for chemo once pt is stable.\\n Plan:\\n Continue to follow-up with heme/onc for recommendations. Next set of\\n enzymes due at 1800.\\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\\n Assessment:\\n Pt ruled in for NSTEMI with positive triponins. No EKG changes were\\n noted. Echo done at bedside today showed some new wall abnormalities\\n but full report is yet to follow. He denies chest pain and pressure.\\n Action:\\n Pt given one aspirin tablet and was started on metoprolol 12.5mg then\\n increased to 25mg PO. Pt also started on heparin drip at 11:45 at\\n 750Units/hr. He was also started on simvastatin and remains on O2 3L.\\n Stat echo and EKG was done. Pt given morphine for acute anxiety\\n episode.\\n Response:\\n Vital signs remain stable with improved resp status in chair. Family\\n have been updated and remain informed of plan of care. Pt started to\\n have hematuria at 1600 and small pool of blood noted on pink pad under\\n pt. Pt found to have some bleeding from around urethral meatus. Seen\\n and noted by team.\\n Plan:\\n Follow labs, PTT Q6hrs to titrate heparin drip. Follow pt for further\\n signs of bleeding.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2200-04-22 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 678873,\n \"text\": \"84 yo male pt with PMH ,Rt atrial tumour , lyphoma , recent\\n chemotherapy ,PNA, presented to ER with SOB, N/V anxious, pt with\\n worsening SOB, received vanco, zosyn ,solumedrol ,ativan and aspirin\\n from ER, 2litres of fluid in. CT done. neg for PE, ? PNA, slight\\n decrease in the size of cardiac mass. put on BIPAP .tolerated well.\\n transfered to for further monitoring and management. He denies\\n complaints of chest pain or pressure but is ruling in for MI by enzymes\\n with elevated triponin to 2.23 yesterday. He has been started on\\n lopressor for rate control, heparin drip aspirin and simvastatin.\\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\\n Assessment:\\n r/o MI from Elevated cardiac enzymes from yesterday.\\n Action:\\n Pt on heparin gtt and po aspirin. Lopressor for rate control. PTT q6hr.\\n cardiac echo done yesterday. Cardiology consult.\\n Response:\\n f/u with cardiology, continue heparin per protocol. PTT q 6hrs.\\n Plan:\\n Continue with heparin per protocol. PTT q 6hrs.\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt alert oriented x 3, calm and quiet most of the time, but get\\n restless and anxious very quickly. Slept during the night. Pt states\\n he can\\nt breath while he is anxious.\\n Action:\\n Ativan 0.5mg po/iv PRN. Stayed on bed during the night. On NC O2\\n 3lit/min. LS Diminished. Neb treatments /MDI as ordered.\\n Response:\\n Good effect with ativan. Sats > 96%\\n Plan:\\n Continue with ativan /morphine PRN. Monitor mental status.\\n Foley to gravity, urine clear,pink in colout.? Traumatic vs heparin\\n gtt.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2200-04-22 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 678935,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n TRANSTHORACIC ECHO - At 09:39 AM\\n EKG - At 11:25 AM\\n Allergies:\\n Terazosin\\n Mental status c\\n Last dose of Antibiotics:\\n Vancomycin - 08:18 PM\\n Piperacillin/Tazobactam (Zosyn) - 06:33 AM\\n Infusions:\\n Heparin Sodium - 750 units/hour\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:31 AM\\n Heparin Sodium (Prophylaxis) - 08:31 AM\\n Morphine Sulfate - 10:28 AM\\n Heparin Sodium - 11:23 AM\\n Lorazepam (Ativan) - 12:15 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:36 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.7\\nC (98.1\\n Tcurrent: 36.7\\nC (98.1\\n HR: 103 (88 - 104) bpm\\n BP: 136/68(89) {91/43(51) - 139/79(94)} mmHg\\n RR: 39 (17 - 39) insp/min\\n SpO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 3,446 mL\\n 233 mL\\n PO:\\n 120 mL\\n TF:\\n IVF:\\n 1,326 mL\\n 233 mL\\n Blood products:\\n Total out:\\n 2,690 mL\\n 580 mL\\n Urine:\\n 2,090 mL\\n 580 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 756 mL\\n -347 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 100%\\n ABG: ///27/\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 161 K/uL\\n 8.5 g/dL\\n 100 mg/dL\\n 0.7 mg/dL\\n 27 mEq/L\\n 3.4 mEq/L\\n 11 mg/dL\\n 104 mEq/L\\n 140 mEq/L\\n 24.1 %\\n 8.7 K/uL\\n [image002.jpg]\\n 04:18 AM\\n 11:11 AM\\n 05:48 PM\\n 05:46 AM\\n WBC\\n 12.3\\n 8.7\\n Hct\\n 29.2\\n 24.1\\n Plt\\n 182\\n 161\\n Cr\\n 0.8\\n 0.7\\n TropT\\n 0.27\\n 0.23\\n 0.17\\n Glucose\\n 152\\n 100\\n Other labs: PT / PTT / INR:12.2/76.2/1.0, CK / CKMB /\\n Troponin-T:136/14/0.17, ALT / AST:20/28, Alk Phos / T Bili:90/0.2,\\n Differential-Neuts:82.0 %, Band:6.0 %, Lymph:3.0 %, Mono:4.0 %, Eos:0.0\\n %, Albumin:3.5 g/dL, LDH:250 IU/L, Ca++:8.6 mg/dL, Mg++:2.2 mg/dL,\\n PO4:3.5 mg/dL\\n Assessment and Plan\\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, NSTEMI)\\n .H/O LYMPHOMA (CANCER, MALIGNANT NEOPLASM, LYMPHOID)\\n ALTERED MENTAL STATUS (NOT DELIRIUM)\\n ASSESSMENT AND PLAN:\\n 84 year-old M with high-grade cardiac lymphoma (left atrial mass),\\n currently receiving treatment (cycle 4,day 15) with R- presents\\n from home with low-grade fevers and progressive dyspnea; despite\\n marked tachypnea and dyspnea, pt's images and blood gas look\\n remarkably good suggesting a strong contribution from anxiety. That\\n said, he has an atypical WBC diff and is s/p recent chemotherapy and\\n thus in a relatively immunocompromised state demanding empiric broad\\n coverage with Abx. Physical Exam is most suggestive of COPD\\n exacerbation, but dyspnea is out of proportion to boreline (if any)\\n hypoxia.\\n # Dyspnea / Tachypnea: From what can be gathered of his ED course, it\\n seems that it was similar to how he has been in the . Dyspnea is\\n out of proportion to hypoxia. Have been thus far unable to repeat\\n blood gas secondary to agitation, but peripheral sats in mid to high\\n 90s even on room air. When he has used Bipap, settings hve been 17/5\\n on room air--he intermittently prefers this to face mask. Bedside echo\\n in the ED notable for absence of effusion/tamponade. LV function\\n grossly intact. CXR without pulmonary edema. CTA ruled out PE and\\n showed ONLY Opacity in RLL which may represent early bacterial PNA vs\\n aspiration. Pt does have Hx of DVT, but IVC filter is in place and no\\n exam finding to suggest current DVT. Overall, it seems that anxiety\\n may be contributing strongly to this presentation--although does not\\n seem to be on home anxiolytics other than low dose ativan for nausea.\\n His positional preference and prolonged expiratory phase are suggestive\\n of COPD exacerbation (FVC 50%, FEV1 40% Predicted), but again dyspnea\\n out of proportion to hypoxia. Caridiac ischemia also a possibility as\\n pt has reported hx of a silent inferior MI in , curently not on\\n ASA, BB, statin.\\n - add BNP to admission labs; may be elevated in setting of atrial mass,\\n but if negative still useful to r/o failure\\n - repeat CXR this am\\n - formal ECHO by tech ordered\\n - repeat blood gas when tolerats\\n - Trend cardiac enzymes\\n - albuterol/ipratropium nebs (holding home spiriva); continuing advair;\\n will d/w BMT regarding +/- of systemic steroids in this lymphoma pt\\n undergoing tx\\n - NIPPV on RA vs 2L face-mask per pt preference; O2 sats adeqquate on\\n either\\n # Low-Grade Fevers / Bandemia: Bandemia present on , but not to\\n the prounced degree that it is now. Pt's fevers at home were\\n low-grade, was afebrile in ED and on floor. There is a concern for\\n relative immunocompromise as he is currently receiving tx for lymphoma.\\n Pt is s/p PNA requiring intubation during a recent hospitalization.\\n Some concern for infectious process on admission CTA, but RLL findings\\n not particulary striking. UA clean.\\n - Blood cultures x2 pending, Urine Cx pending, Sputum ordered. Repaet\\n Cx if spikes.\\n - Nasal aspirate for respiratory viruses: (influenza,paraninfluenza,\\n RSV)\\n - D/w BMT whether atypical Diff is expected with pt's recent treatemnts\\n or whether it is more concerning for infxn. Smear ordered.\\n - Empiric therapy for HAP Vanco/Zosyn per BMT\\n # Cardiac lymphoma: The patient appears to have had an excellent\\n response to therapy to date, with a decline in his LDH and shrinkage of\\n his cardiac mass on cardiac MRI. He will be due for his 5th cycle of\\n next week, and his ability to receive his chemotherapy safelywill\\n be determined by his recover from his present illness.\\n - d/w BMT\\n # Hx of CAD: Alleged silent MI in . Not in our records and pt\\n currently unbale to discuss. EKG suggestive of prior infarct, but ECHO\\n is not. Unusual that he is not on home ASA, BB, or statin.\\n - will d/w pt and BMT\\n # Hx of DVT: Per previous DC summary, pt has had a recent DVT in\\n setting of ongoing malignancy and has IVC filter in place--by report\\n has contraindication to systemic anticoagulation.\\n - d/w BMT\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:54 AM\\n 18 Gauge - 05:57 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2200-04-21 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 678689,\n \"text\": \"84 yo male pt with PMH ,Rt atrial tumour , lyphoma , recent\\n chemotherapy ,PNA, presented to ER with SOB, N/V anxious, ?\\n neutropenic. pt with worsening SOB, received vanco, zosyn ,solumedrol\\n ,ativan and aspirin from ER, 2litres of fluid in. ? PE . CT done. neg\\n for PE, ? PNA, slight decrease in the size of cardiac mass. put on\\n BIPAP .tolerated well. transfered to for further monitoring and\\n management.\\n Neuro: alert and oriented , restless initially . following commands.\\n Denies any pain.received ativan from ER. Very restless and says\\n can\\nt breath\\n and likes to sit with legs dangling down . so made him\\n to sit on the cardiac chair. Slept after morphine 1mg and 0.5mg\\n ativan iv.\\n CVS: HR ,with occasional PVC\\ns. BP stable. bilateral pedal\\n pulse palpable.\\n Resp: Tachypoenic, RR high 20\\ns ,initially with BIPAP mask ,then\\n changed to 100% face mask.sats 100%. LS with insp/ exp wheeze.\\n Albuterol MDI, and neb treatments given . ABG to do later on.\\n GU/GI: abd soft ,BS present. Foley to gravity,adequate urine output.\\n Skin; intact.\\n Social; no family contact after admission . remains full code.\\n Plan; follow up with am labs. Monitor resp /neuro status. f/u with\\n blood gas. O2 as needed.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2200-04-22 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 678874,\n \"text\": \"84 yo male pt with PMH ,Rt atrial tumour , lyphoma , recent\\n chemotherapy ,PNA, presented to ER with SOB, N/V anxious, pt with\\n worsening SOB, received vanco, zosyn ,solumedrol ,ativan and aspirin\\n from ER, 2litres of fluid in. CT done. neg for PE, ? PNA, slight\\n decrease in the size of cardiac mass. put on BIPAP .tolerated well.\\n transfered to for further monitoring and management. He denies\\n complaints of chest pain or pressure but is ruling in for MI by enzymes\\n with elevated triponin to 2.23 yesterday. He has been started on\\n lopressor for rate control, heparin drip aspirin and simvastatin.\\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\\n Assessment:\\n r/o MI from Elevated cardiac enzymes from yesterday.\\n Action:\\n Pt on heparin gtt and po aspirin. Lopressor for rate control. PTT q6hr.\\n cardiac echo done yesterday. Cardiology consult.\\n Response:\\n f/u with cardiology, continue heparin per protocol. PTT q 6hrs. last\\n 2two consecutive PTT\\ns 66.5 and 61, both within therapeutic level.\\n Plan:\\n Continue with heparin per protocol. need PTT daily now.\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt alert oriented x 3, calm and quiet most of the time, but get\\n restless and anxious very quickly. Slept during the night. Pt states\\n he can\\nt breath while he is anxious.\\n Action:\\n Ativan 0.5mg po/iv PRN. Stayed on bed during the night. On NC O2\\n 3lit/min. LS Diminished. Neb treatments /MDI as ordered.\\n Response:\\n Good effect with ativan. Sats > 96%\\n Plan:\\n Continue with ativan /morphine PRN. Monitor mental status.\\n Foley to gravity, urine clear,pink in colout.? Traumatic vs heparin\\n gtt.\\n\"\n },\n {\n \"category\": \"General\",\n \"chartdate\": \"2200-04-21 00:00:00.000\",\n \"description\": \"Generic Note\",\n \"row_id\": 678684,\n \"text\": \"TITLE:\\n Respiratory Care:\\n Pt arrives from ED with SOB, pneumonia, fever, lymphoma (now undergoing\\n chemo), cardiac tumor. PMH of COPD DVT (filter placed), MI ,\\n intubated for pneumonia . Placed on bipap\\n 17/5 and tolerating\\n well, but very anxious. Has nebs ordered.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2200-04-21 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 678811,\n \"text\": \"84 yo male pt with PMH ,Rt atrial tumour , lyphoma , recent\\n chemotherapy ,PNA, presented to ER with SOB, N/V anxious, ?\\n neutropenic. pt with worsening SOB, received vanco, zosyn ,solumedrol\\n ,ativan and aspirin from ER, 2litres of fluid in. ? PE . CT done. neg\\n for PE, ? PNA, slight decrease in the size of cardiac mass. put on\\n BIPAP .tolerated well. transfered to for further monitoring and\\n management.\\n Pt is alert and oriented but has very little patience and is easily\\n agitated, becoming SOB with activity. He is not comfortable in bed and\\n has been OOB to chair most of the shift. Was in bed for cardiac echo,\\n then back to chair. Ambulates with assist of one to chair.\\n He denies complaints of chest pain or pressure but is ruling in for MI\\n by enzymes with elevated triponin to 2.23 at noon today. He has been\\n started on lopressor for rate control, heparin drip and aspirain. He\\n was also started on simvastatin. Cardiac consult in place.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt with severe complaints of dyspnea and becomes tachypneic when in\\n bed. Maintains O2 sat but becomes agitated and feels like he is\\n trapped in a cage.\\n Once in the chair he was calmer and less anxious\\n with improved Resp rate and agitation.\\n Action:\\n Weaned O2 from 100% down to 3L N/C with good O2 sat.\\n Response:\\n Remains in the chair but still becomes anxious and restless at times\\n and is on the call light frequently for small things.\\n Plan:\\n Provide support and reassurance for this pt who is easily agitated.\\n Ordered for small doses morphine or ativan can be used PRN\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt with periods of agitation and anxiety refused to stay in bed,\\n becoming acutely agitated, restless and tachypneic.\\n Action:\\n Given .5mg iV morphine, assisted to chair and pt reassured.\\n Response:\\n Improved agitation but continues to ask the same questions about his\\n illness andhis care.\\n Plan:\\n Follow mental status, continue to provide emotional support.\\n .H/O lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\\n Assessment:\\n Pt is currently undergoing chemo treatment for lymphoma\\n Action:\\n Heme/onc service consulted and will not give chemo while he is being\\n treated for an acute MI\\n Response:\\n Will reassess need for chemo once pt is stable.\\n Plan:\\n Continue to follow-up with heme/onc for recommendations.\\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2200-04-21 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 678798,\n \"text\": \"84 yo male pt with PMH ,Rt atrial tumour , lyphoma , recent\\n chemotherapy ,PNA, presented to ER with SOB, N/V anxious, ?\\n neutropenic. pt with worsening SOB, received vanco, zosyn ,solumedrol\\n ,ativan and aspirin from ER, 2litres of fluid in. ? PE . CT done. neg\\n for PE, ? PNA, slight decrease in the size of cardiac mass. put on\\n BIPAP .tolerated well. transfered to for further monitoring and\\n management.\\n Pt is alert and oriented but has very little patience and is easily\\n agitated, becoming SOB with activity. He is not comfortable in bed and\\n has been OOB to chair most of the shift. Was in bed for cardiac echo,\\n then back to chair. Ambulates with assist of one to chair.\\n He denies complaints of chest pain or pressure but is ruling in for MI\\n by enzymes with elevated triponin to 2.23 at noon today. He has been\\n started on lopressor for rate control, heparin drip and aspirain. He\\n was also started on simvastatin. Cardiac consult in place.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt with severe complaints of dyspnea and becomes tachypneic when in\\n bed. Maintains O2 sat but becomes agitated and feels like he is trapped\\n in a cage. Once in the chair he was calmer and less anxious with\\n improved\\n Action:\\n Response:\\n Plan:\\n Altered mental status (not Delirium)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n .H/O lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2200-04-21 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 678861,\n \"text\": \"84 yo male pt with PMH ,Rt atrial tumour , lyphoma , recent\\n chemotherapy ,PNA, presented to ER with SOB, N/V anxious, ?\\n neutropenic. pt with worsening SOB, received vanco, zosyn ,solumedrol\\n ,ativan and aspirin from ER, 2litres of fluid in. ? PE . CT done. neg\\n for PE, ? PNA, slight decrease in the size of cardiac mass. put on\\n BIPAP .tolerated well. transfered to for further monitoring and\\n management.\\n Pt is alert and oriented but has very little patience and is easily\\n agitated, becoming SOB with activity. He is not comfortable in bed and\\n has been OOB to chair most of the shift. Was in bed for cardiac echo,\\n then back to chair. Ambulates with assist of one to chair. Family\\n calling in frequently for updates. is spokesperson.\\n He denies complaints of chest pain or pressure but is ruling in for MI\\n by enzymes with elevated triponin to 2.23 at noon today. He has been\\n started on lopressor for rate control, heparin drip and aspirin. He was\\n also started on simvastatin. Cardiac consult in place.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt with severe complaints of dyspnea and becomes tachypneic when in\\n bed. Maintains O2 sat but becomes agitated and feels like he is\\n trapped in a cage.\\n Once in the chair he was calmer and less anxious\\n with improved Resp rate and agitation.\\n Action:\\n Weaned O2 from 100% down to 3L N/C with good O2 sat. RT sent specimens\\n for viral antigens. Pt is positive for parainfluenza. He is on droplet\\n precautions but team is not sure if we need them for this diagnosis.\\n Response:\\n Remains in the chair but still becomes anxious and restless at times\\n and is on the call light frequently for small things.\\n Plan:\\n Provide support and reassurance for this pt who is easily agitated.\\n Ordered for small doses morphine or ativan can be used PRN. Has an\\n order for 1mg IV haldol on one time sheet which was never given yet.\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt with periods of agitation and anxiety refused to stay in bed,\\n becoming acutely agitated, restless and tachypneic.\\n Action:\\n Given .5mg iV morphine, assisted to chair and pt reassured.\\n Response:\\n Improved agitation but continues to ask the same questions about his\\n illness andhis care.\\n Plan:\\n Follow mental status, continue to provide emotional support. Use PRN\\n morphine, ativan as needed.\\n .H/O lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\\n Assessment:\\n Pt is currently undergoing chemo treatment for lymphoma\\n Action:\\n Heme/onc service consulted and will not give chemo while he is being\\n treated for an acute MI\\n Response:\\n Will reassess need for chemo once pt is stable.\\n Plan:\\n Continue to follow-up with heme/onc for recommendations. Next set of\\n enzymes due at 1800.\\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\\n Assessment:\\n Pt ruled in for NSTEMI with positive triponins. No EKG changes were\\n noted. Echo done at bedside today showed some new wall abnormalities\\n but full report is yet to follow. He denies chest pain and pressure.\\n Action:\\n Pt given one aspirin tablet and was started on metoprolol 12.5mg then\\n increased to 25mg PO. Pt also started on heparin drip at 11:45 at\\n 750Units/hr. He was also started on simvastatin and remains on O2 3L.\\n Stat echo and EKG was done. Pt given morphine for acute anxiety\\n episode.\\n Response:\\n Vital signs remain stable with improved resp status in chair. Family\\n have been updated and remain informed of plan of care. Pt started to\\n have hematuria at 1600 and small pool of blood noted on pink pad under\\n pt. Pt found to have some bleeding from around urethral meatus. Seen\\n and noted by team.\\n Plan:\\n Follow labs, PTT Q6hrs to titrate heparin drip. Follow pt for further\\n signs of bleeding.\\n Assisted back to bed at 1800. Pt looks a little more distressed in bed\\n but asked for some ativan to see if it could help him relax. Pt remains\\n in bed at present.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2200-04-21 00:00:00.000\",\n \"description\": \"Physician Resident Admission Note\",\n \"row_id\": 678862,\n \"text\": \"Chief Complaint: worsening shortness of breath over past 2-3 days, low\\n grade fevers at home\\n HPI:\\n Mr. is an 84 yo man with a high-grade cardiac B-cell\\n lymphoma for which he is now undergoing R- chemotherapy and a\\n history of COPD, DVT s/p IVC filter, and pneumonia with\\n respiratory failure requiring endotracheal intubation in . Today is\\n Day 15 of Cycle 4 or R-, which he received during his hospital\\n admission from . He received Neulasta on . following\\n his discharge, he has been feeling generally well; however, he admits\\n to increasing exertional dyspnea overthe past 2-3 days. He explains\\n that very light activity, such as changing his clothes or walking short\\n distances, has resulted in significant shortness of breath. He denies\\n cough, sputum production, orthopnea, paroxysmal nocturnal dyspnea, and\\n swelling/pain of the arms or legs. He admits to low-grade fevers today;\\n while visiting, his daughter noted that he had a temperature of 100.4\\n degrees. For this reason, he was advised to report to the Emergency\\n Room for evaluation.\\n Upon arrival in the Emergency Department, had temperature of 99.6\\n degrees. He was tachycardic to 118 and tachypneic (RR 30-40) with\\n oxygen saturations of 95% on room air. During the first several\\n minutesof is Emergency Department course, he developed rapidly\\n increasing work of breathing. A CXR demonstrated no evidence\\n ofpneumonia or effusion; furthermore, an echocardiogram showed no\\n pericardial effusion. He was noted to have a WBC of 8.8 with 26%\\n neutrophils and 36% bands. Due to progressive respiratorydistress\\n without hypoxia, he was started on BiPAP. In addition, he was given IV\\n solumderol 125mg, ASA 325mg, bronchodilators, piperacillin-tazobactam,\\n and vancomycin. Also received total of 1.25mg of ativan in ED.\\n Despite a fairly normal blood gas and presumbaly secondary to worsening\\n dyspnea and tachynpnea, pt was started on BIPAP which he tolerated\\n during his transfer to the . On arrival, he insisted that it be\\n removed and then resumed. He was agitated and extremely anxious\\n repeating \\\"I need air,\\\" peripheral sats were in the 93-100% range on\\n room air. Seemed to be more comfortable leaning forward and placing\\n his weight on his upper ext's. His HR rose in propotion to his\\n tachypnea and gitation to a rate of 140's transiently. Agitation/anxiey\\n waxed and waned with pt sleeping intermittently.\\n ONCOLOGIC HISTORY (Per recent note by Dr : \\n initially presented on , with anewly identified 8\\n cm right atrial soft tissue mass. He underwent biopsy of this on\\n , and pathology showed high-grade aggressive diffuse large\\n B-cell lymphoma, staining positive for CD20, bcl-2, and bcl-6 in a\\n small subset. Cells were negative for cytokeratins, CD138, bcl-1, and\\n bcl-6. MIB fraction was 95-100%. Bcl-2 co-expression and lack of CD10\\n argued against Burkitt's lymphoma; however, FISH studies were positive\\n for c-myc rearrangement. He was diagnosed with high-grade cardiac\\n lymphoma on the spectrum of diffuse large B-cell to Burkitt's\\n lymphoma. No other sites of disease were identified by torso CT and\\n bone marrow biopsy. He has begun R- chemotherapy on .\\n Treatment course has been complicated by a DVT status post IVC filter\\n in and pneumonia requiring intubation for hypoxia in .\\n Patient admitted from: ER\\n History obtained from Medical records\\n Allergies:\\n Terazosin\\n Mental status c\\n Last dose of Antibiotics:\\n Vancomycin - 03:31 AM\\n Piperacillin/Tazobactam (Zosyn) - 03:31 AM\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Past medical history:\\n Family history:\\n Social History:\\n 1. cardiac lymphoma as above\\n 2. Left Peroneal DVT s/p IVC filter placement \\n 3. COPD\\n 4. Hyperlipidemia\\n 5. Hypertension\\n 6. History of anxiety\\n 7. History of rib fracture\\n 8. History of silent MI \\n 9. Left Shoulder Weakness\\n 10. External Hemorrhoids\\n 11. Benign Prostatic Hypertrophy\\n nc\\n Occupation: retired\\n Drugs:\\n Tobacco: 60 pk yr hx, quit 6 years ago\\n Alcohol:\\n Other: currently in rehab, living independently up until recent\\n admission\\n Review of systems:\\n Constitutional: Fever\\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\\n Tachycardia, No(t) Orthopnea\\n Respiratory: No(t) Cough, Dyspnea, Tachypnea, No(t) Wheeze\\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Diarrhea\\n Genitourinary: No(t) Dysuria\\n Neurologic: No(t) Headache\\n Flowsheet Data as of 06:28 AM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since 12 AM\\n Tmax: 35.9\\nC (96.6\\n Tcurrent: 35.9\\nC (96.6\\n HR: 121 (121 - 121) bpm\\n BP: 128/77(89) {128/75(89) - 155/77(96)} mmHg\\n RR: 32 (25 - 32) insp/min\\n SpO2: 95%\\n Total In:\\n 2,300 mL\\n PO:\\n TF:\\n IVF:\\n 300 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 800 mL\\n Urine:\\n 200 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n 1,500 mL\\n Respiratory\\n O2 Delivery Device: Other\\n SpO2: 95%\\n Physical Examination\\n General Appearance: Thin, Anxious\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: Normocephalic\\n Cardiovascular: (S1: Normal), (S2: Normal), tachycardic\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: dull BS bilaterally with prolonged expiratory\\n pahse and use of abdominal muscles during expiration\\n Abdominal: Soft, Non-tender, Bowel sounds present\\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis\\n Musculoskeletal: Muscle wasting\\n Skin: Not assessed, No(t) Rash:\\n Neurologic: Attentive, Follows simple commands, Responds to: Not\\n assessed, Oriented (to): , Movement: Not assessed, Tone: Not assessed\\n Labs / Radiology\\n [image002.jpg]\\n Imaging: ADMISSION CXR: The right hemidiaphragm remains persistently\\n elevated. The\\n cardiomediastinal silhouette is stable. There is no focal pulmonary\\n consolidation. An IVC filter is seen in the upper abdomen.\\n CONCLUSION: No acute cardiopulmonary process.\\n CTA (ADMISSION):PRELIM: No PE. New focal right basilar consolidation-?\\n pneumonia though may represent\\n aspiration with ariway secretions seen on right. Perhaps slight\\n dcecrease in\\n size of cardiac mass.\\n Microbiology: Bcx x2 and Ucx NGTD\\n ECG: sinus tachycadia, left axis deviation, low voltages diffusely, old\\n inferior infarct, no stt changes from previous\\n Assessment and Plan\\n ASSESSMENT AND PLAN:\\n 84 year-old M with high-grade cardiac lymphoma (left atrial mass),\\n currently receiving treatment (cycle 4,day 15) with R- presents\\n from home with low-grade fevers and progressive dyspnea; despite\\n marked tachypnea and dyspnea, pt's images and blood gas look\\n remarkably good suggesting a strong contribution from anxiety. That\\n said, he has an atypical WBC diff and is s/p recent chemotherapy and\\n thus in a relatively immunocompromised state demanding empiric broad\\n coverage with Abx. Physical Exam is most suggestive of COPD\\n exacerbation, but dyspnea is out of proportion to boreline (if any)\\n hypoxia.\\n # Dyspnea / Tachypnea: From what can be gathered of his ED course, it\\n seems that it was similar to how he has been in the . Dyspnea is\\n out of proportion to hypoxia. Have been thus far unable to repeat\\n blood gas secondary to agitation, but peripheral sats in mid to high\\n 90s even on room air. When he has used Bipap, settings hve been 17/5\\n on room air--he intermittently prefers this to face mask. Bedside echo\\n in the ED notable for absence of effusion/tamponade. LV function\\n grossly intact. CXR without pulmonary edema. CTA ruled out PE and\\n showed ONLY Opacity in RLL which may represent early bacterial PNA vs\\n aspiration. Pt does have Hx of DVT, but IVC filter is in place and no\\n exam finding to suggest current DVT. Overall, it seems that anxiety\\n may be contributing strongly to this presentation--although does not\\n seem to be on home anxiolytics other than low dose ativan for nausea.\\n His positional preference and prolonged expiratory phase are suggestive\\n of COPD exacerbation (FVC 50%, FEV1 40% Predicted), but again dyspnea\\n out of proportion to hypoxia. Caridiac ischemia also a possibility as\\n pt has reported hx of a silent inferior MI in , curently not on\\n ASA, BB, statin.\\n - add BNP to admission labs; may be elevated in setting of atrial mass,\\n but if negative still useful to r/o failure\\n - repeat CXR this am\\n - formal ECHO by tech ordered\\n - repeat blood gas when tolerats\\n - Trend cardiac enzymes\\n - albuterol/ipratropium nebs (holding home spiriva); continuing advair;\\n will d/w BMT regarding +/- of systemic steroids in this lymphoma pt\\n undergoing tx\\n - NIPPV on RA vs 2L face-mask per pt preference; O2 sats adeqquate on\\n either\\n # Low-Grade Fevers / Bandemia: Bandemia present on , but not to\\n the prounced degree that it is now. Pt's fevers at home were\\n low-grade, was afebrile in ED and on floor. There is a concern for\\n relative immunocompromise as he is currently receiving tx for lymphoma.\\n Pt is s/p PNA requiring intubation during a recent hospitalization.\\n Some concern for infectious process on admission CTA, but RLL findings\\n not particulary striking. UA clean.\\n - Blood cultures x2 pending, Urine Cx pending, Sputum ordered. Repaet\\n Cx if spikes.\\n - Nasal aspirate for respiratory viruses: (influenza,paraninfluenza,\\n RSV)\\n - D/w BMT whether atypical Diff is expected with pt's recent treatemnts\\n or whether it is more concerning for infxn. Smear ordered.\\n - Empiric therapy for HAP Vanco/Zosyn per BMT\\n # Cardiac lymphoma: The patient appears to have had an excellent\\n response to therapy to date, with a decline in his LDH and shrinkage of\\n his cardiac mass on cardiac MRI. He will be due for his 5th cycle of\\n next week, and his ability to receive his chemotherapy safelywill\\n be determined by his recover from his present illness.\\n - d/w BMT\\n # Hx of CAD: Alleged silent MI in . Not in our records and pt\\n currently unbale to discuss. EKG suggestive of prior infarct, but ECHO\\n is not. Unusual that he is not on home ASA, BB, or statin.\\n - will d/w pt and BMT\\n # Hx of DVT: Per previous DC summary, pt has had a recent DVT in\\n setting of ongoing malignancy and has IVC filter in place--by report\\n has contraindication to systemic anticoagulation.\\n - d/w BMT\\n ICU Care\\n Nutrition: npo currently\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 03:37 AM\\n 20 Gauge - 03:37 AM\\n Comments: code status confirmed by onc fellow in ED. deferred currently\\n as acutely agitated/anxious. likewise deferred ICU consent until acute\\n anxiety has resolved\\n Prophylaxis:\\n DVT: SQ UF Heparin, IVC filter\\n Stress ulcer: PPI\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition: ICU\\n ------ Protected Section ------\\n ADDENDUM TO PLAN:\\n Assessment and plan initially changed this am as cardiac enzymes\\n positive and ECHO showing significant new focal wall motion\\n abnormaiilities. These findings are c/w either ACS (plaque rupture) vs\\n very significant demand ischemia secondary to a poorly defined acute\\n stressor (see above differential). Pt now on ASA, BB (with goal\\n HR~60), Statin (declined lipitor given hx of muscle pains, given\\n simvastatin 80). Heparin drip started w/o bolus. Per BMT, seems that\\n only contraindication to anticoag (unclear this am) has been concern\\n that this right atrial mass would bleed into pericardial space. Still\\n believe that pt\\ns resp status compromised by COPD given exam, but heart\\n failure secondary to active ischemia likely also contributing.\\n -- cardiology consulted, f/u recommendations\\n -- remainder of plan largely as outlined above: treat COPD, cont broad\\n Abx coverage\\n ------ Protected Section Addendum Entered By: , MD\\n on: 14:05 ------\\n Critical Care\\n Present for the key portions of the resident\\ns history and exam. Agree\\n substantially with assessment and plan that was elaborated on\\n multidisciplinary rounds this morning. He has been agitated, unable to\\n get comfortable. Tolerating O2 but not able to use mask vent.\\n Describes breathlessness as different from prior episodes of\\n bronchitis.\\n 121 128/77 26\\n Chest is quiet with insp and exp wheezing\\n HS distant w/ holosyst m\\n Tr edema\\n Troponin 0.26\\n Echo apical dyskinesis EF 35% down from 55% with 2+ MR from 1+ MR\\n Very difficult presentation. He has had a substantial worsening of\\n cardiac fxn w/o clear ECG changes and echo read sounds c/w takasubo\\n He has paraflu on nasal wash which seems consistent with his\\n presentation. We are supporting oxygen, trying to manage his\\n agitation, starting beta blockade given rapid HR and poor syst fxn. He\\n does not seem to be in signif CHF on exam or CXR. We are monitoring\\n closely\\n is at signif risk for resp decomp. Not clear how to explain\\n rising LD and nl but still LFTs.\\n Time spent 65 min\\n Critically ill\\n ------ Protected Section Addendum Entered By: , MD\\n on: 18:36 ------\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2200-04-22 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 678914,\n \"text\": \"84 yo male pt with PMH ,Rt atrial tumour , lyphoma , recent\\n chemotherapy ,PNA, presented to ER with SOB, N/V anxious, pt with\\n worsening SOB, received vanco, zosyn ,solumedrol ,ativan and aspirin\\n from ER, 2litres of fluid in. CT done. neg for PE, ? PNA, slight\\n decrease in the size of cardiac mass. put on BIPAP .tolerated well.\\n transfered to for further monitoring and management. He denies\\n complaints of chest pain or pressure but is ruling in for MI by enzymes\\n with elevated triponin to 2.23 yesterday. He has been started on\\n lopressor for rate control, heparin drip aspirin and simvastatin.\\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\\n Assessment:\\n r/o MI from Elevated cardiac enzymes from yesterday.\\n Action:\\n Pt on heparin gtt and po aspirin. Lopressor for rate control. PTT q6hr.\\n cardiac echo done yesterday. Cardiology consult.\\n Response:\\n f/u with cardiology, continue heparin per protocol. PTT q 6hrs. last\\n 2two consecutive PTT\\ns 66.5 and 61, both within therapeutic level.\\n Plan:\\n Continue with heparin per protocol. need PTT daily now.\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt alert oriented x 3, calm and quiet most of the time, but get\\n restless and anxious very quickly. Slept during the night. Pt states\\n he can\\nt breath while he is anxious.\\n Action:\\n Ativan 0.5mg po/iv PRN. Stayed on bed during the night. On NC O2\\n 3lit/min. LS Diminished. Neb treatments /MDI as ordered.\\n Response:\\n Good effect with ativan. Sats > 96% .slept well .pt feels better .\\n Plan:\\n Continue with ativan /morphine PRN. Monitor mental status.\\n Foley to gravity, urine clear,pink in colout.? Traumatic vs due to\\n heparin gtt.\\n Skin intact except bruises on both hands.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2200-04-22 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 678984,\n \"text\": \"84 year-old M with high-grade cardiac lymphoma (left atrial mass),\\n currently receiving treatment (cycle 4,day 15) with R- presents\\n from home with low-grade fevers and progressive dyspnea; despite\\n marked tachypnea and dyspnea, pt's images and blood gas look\\n remarkably good suggesting a strong contribution from anxiety.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2200-04-21 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 678662,\n \"text\": \"84 yo male pt with PMH ,Rt atrial tumour , lyphoma , recent\\n chemotherapy ,PNA, presented to ER with SOB, N/V anxious, ?\\n neutropenic. pt with worsening SOB, received vanco, zosyn ,solumedrol\\n ,ativan and aspirin from ER, 2litres of fluid in. ? PE . CT done. neg\\n for PE, ? PNA, slight decrease in the size of cardiac mass. put on\\n BIPAP .tolerated well. transfered to for further monitoring and\\n management.\\n Neuro: alert and oriented , restless initially . following commands.\\n Denies any pain.received ativan from ER. Slept after sometime.\\n CVS: HR ,with occasional PVC\\ns. BP stable.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2200-04-21 00:00:00.000\",\n \"description\": \"Physician Resident Admission Note\",\n \"row_id\": 678786,\n \"text\": \"Chief Complaint: worsening shortness of breath over past 2-3 days, low\\n grade fevers at home\\n HPI:\\n Mr. is an 84 yo man with a high-grade cardiac B-cell\\n lymphoma for which he is now undergoing R- chemotherapy and a\\n history of COPD, DVT s/p IVC filter, and pneumonia with\\n respiratory failure requiring endotracheal intubation in . Today is\\n Day 15 of Cycle 4 or R-, which he received during his hospital\\n admission from . He received Neulasta on . following\\n his discharge, he has been feeling generally well; however, he admits\\n to increasing exertional dyspnea overthe past 2-3 days. He explains\\n that very light activity, such as changing his clothes or walking short\\n distances, has resulted in significant shortness of breath. He denies\\n cough, sputum production, orthopnea, paroxysmal nocturnal dyspnea, and\\n swelling/pain of the arms or legs. He admits to low-grade fevers today;\\n while visiting, his daughter noted that he had a temperature of 100.4\\n degrees. For this reason, he was advised to report to the Emergency\\n Room for evaluation.\\n Upon arrival in the Emergency Department, had temperature of 99.6\\n degrees. He was tachycardic to 118 and tachypneic (RR 30-40) with\\n oxygen saturations of 95% on room air. During the first several\\n minutesof is Emergency Department course, he developed rapidly\\n increasing work of breathing. A CXR demonstrated no evidence\\n ofpneumonia or effusion; furthermore, an echocardiogram showed no\\n pericardial effusion. He was noted to have a WBC of 8.8 with 26%\\n neutrophils and 36% bands. Due to progressive respiratorydistress\\n without hypoxia, he was started on BiPAP. In addition, he was given IV\\n solumderol 125mg, ASA 325mg, bronchodilators, piperacillin-tazobactam,\\n and vancomycin. Also received total of 1.25mg of ativan in ED.\\n Despite a fairly normal blood gas and presumbaly secondary to worsening\\n dyspnea and tachynpnea, pt was started on BIPAP which he tolerated\\n during his transfer to the . On arrival, he insisted that it be\\n removed and then resumed. He was agitated and extremely anxious\\n repeating \\\"I need air,\\\" peripheral sats were in the 93-100% range on\\n room air. Seemed to be more comfortable leaning forward and placing\\n his weight on his upper ext's. His HR rose in propotion to his\\n tachypnea and gitation to a rate of 140's transiently. Agitation/anxiey\\n waxed and waned with pt sleeping intermittently.\\n ONCOLOGIC HISTORY (Per recent note by Dr : \\n initially presented on , with anewly identified 8\\n cm right atrial soft tissue mass. He underwent biopsy of this on\\n , and pathology showed high-grade aggressive diffuse large\\n B-cell lymphoma, staining positive for CD20, bcl-2, and bcl-6 in a\\n small subset. Cells were negative for cytokeratins, CD138, bcl-1, and\\n bcl-6. MIB fraction was 95-100%. Bcl-2 co-expression and lack of CD10\\n argued against Burkitt's lymphoma; however, FISH studies were positive\\n for c-myc rearrangement. He was diagnosed with high-grade cardiac\\n lymphoma on the spectrum of diffuse large B-cell to Burkitt's\\n lymphoma. No other sites of disease were identified by torso CT and\\n bone marrow biopsy. He has begun R- chemotherapy on .\\n Treatment course has been complicated by a DVT status post IVC filter\\n in and pneumonia requiring intubation for hypoxia in .\\n Patient admitted from: ER\\n History obtained from Medical records\\n Allergies:\\n Terazosin\\n Mental status c\\n Last dose of Antibiotics:\\n Vancomycin - 03:31 AM\\n Piperacillin/Tazobactam (Zosyn) - 03:31 AM\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Past medical history:\\n Family history:\\n Social History:\\n 1. cardiac lymphoma as above\\n 2. Left Peroneal DVT s/p IVC filter placement \\n 3. COPD\\n 4. Hyperlipidemia\\n 5. Hypertension\\n 6. History of anxiety\\n 7. History of rib fracture\\n 8. History of silent MI \\n 9. Left Shoulder Weakness\\n 10. External Hemorrhoids\\n 11. Benign Prostatic Hypertrophy\\n nc\\n Occupation: retired\\n Drugs:\\n Tobacco: 60 pk yr hx, quit 6 years ago\\n Alcohol:\\n Other: currently in rehab, living independently up until recent\\n admission\\n Review of systems:\\n Constitutional: Fever\\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\\n Tachycardia, No(t) Orthopnea\\n Respiratory: No(t) Cough, Dyspnea, Tachypnea, No(t) Wheeze\\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Diarrhea\\n Genitourinary: No(t) Dysuria\\n Neurologic: No(t) Headache\\n Flowsheet Data as of 06:28 AM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since 12 AM\\n Tmax: 35.9\\nC (96.6\\n Tcurrent: 35.9\\nC (96.6\\n HR: 121 (121 - 121) bpm\\n BP: 128/77(89) {128/75(89) - 155/77(96)} mmHg\\n RR: 32 (25 - 32) insp/min\\n SpO2: 95%\\n Total In:\\n 2,300 mL\\n PO:\\n TF:\\n IVF:\\n 300 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 800 mL\\n Urine:\\n 200 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n 1,500 mL\\n Respiratory\\n O2 Delivery Device: Other\\n SpO2: 95%\\n Physical Examination\\n General Appearance: Thin, Anxious\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: Normocephalic\\n Cardiovascular: (S1: Normal), (S2: Normal), tachycardic\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: dull BS bilaterally with prolonged expiratory\\n pahse and use of abdominal muscles during expiration\\n Abdominal: Soft, Non-tender, Bowel sounds present\\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis\\n Musculoskeletal: Muscle wasting\\n Skin: Not assessed, No(t) Rash:\\n Neurologic: Attentive, Follows simple commands, Responds to: Not\\n assessed, Oriented (to): , Movement: Not assessed, Tone: Not assessed\\n Labs / Radiology\\n [image002.jpg]\\n Imaging: ADMISSION CXR: The right hemidiaphragm remains persistently\\n elevated. The\\n cardiomediastinal silhouette is stable. There is no focal pulmonary\\n consolidation. An IVC filter is seen in the upper abdomen.\\n CONCLUSION: No acute cardiopulmonary process.\\n CTA (ADMISSION):PRELIM: No PE. New focal right basilar consolidation-?\\n pneumonia though may represent\\n aspiration with ariway secretions seen on right. Perhaps slight\\n dcecrease in\\n size of cardiac mass.\\n Microbiology: Bcx x2 and Ucx NGTD\\n ECG: sinus tachycadia, left axis deviation, low voltages diffusely, old\\n inferior infarct, no stt changes from previous\\n Assessment and Plan\\n ASSESSMENT AND PLAN:\\n 84 year-old M with high-grade cardiac lymphoma (left atrial mass),\\n currently receiving treatment (cycle 4,day 15) with R- presents\\n from home with low-grade fevers and progressive dyspnea; despite\\n marked tachypnea and dyspnea, pt's images and blood gas look\\n remarkably good suggesting a strong contribution from anxiety. That\\n said, he has an atypical WBC diff and is s/p recent chemotherapy and\\n thus in a relatively immunocompromised state demanding empiric broad\\n coverage with Abx. Physical Exam is most suggestive of COPD\\n exacerbation, but dyspnea is out of proportion to boreline (if any)\\n hypoxia.\\n # Dyspnea / Tachypnea: From what can be gathered of his ED course, it\\n seems that it was similar to how he has been in the . Dyspnea is\\n out of proportion to hypoxia. Have been thus far unable to repeat\\n blood gas secondary to agitation, but peripheral sats in mid to high\\n 90s even on room air. When he has used Bipap, settings hve been 17/5\\n on room air--he intermittently prefers this to face mask. Bedside echo\\n in the ED notable for absence of effusion/tamponade. LV function\\n grossly intact. CXR without pulmonary edema. CTA ruled out PE and\\n showed ONLY Opacity in RLL which may represent early bacterial PNA vs\\n aspiration. Pt does have Hx of DVT, but IVC filter is in place and no\\n exam finding to suggest current DVT. Overall, it seems that anxiety\\n may be contributing strongly to this presentation--although does not\\n seem to be on home anxiolytics other than low dose ativan for nausea.\\n His positional preference and prolonged expiratory phase are suggestive\\n of COPD exacerbation (FVC 50%, FEV1 40% Predicted), but again dyspnea\\n out of proportion to hypoxia. Caridiac ischemia also a possibility as\\n pt has reported hx of a silent inferior MI in , curently not on\\n ASA, BB, statin.\\n - add BNP to admission labs; may be elevated in setting of atrial mass,\\n but if negative still useful to r/o failure\\n - repeat CXR this am\\n - formal ECHO by tech ordered\\n - repeat blood gas when tolerats\\n - Trend cardiac enzymes\\n - albuterol/ipratropium nebs (holding home spiriva); continuing advair;\\n will d/w BMT regarding +/- of systemic steroids in this lymphoma pt\\n undergoing tx\\n - NIPPV on RA vs 2L face-mask per pt preference; O2 sats adeqquate on\\n either\\n # Low-Grade Fevers / Bandemia: Bandemia present on , but not to\\n the prounced degree that it is now. Pt's fevers at home were\\n low-grade, was afebrile in ED and on floor. There is a concern for\\n relative immunocompromise as he is currently receiving tx for lymphoma.\\n Pt is s/p PNA requiring intubation during a recent hospitalization.\\n Some concern for infectious process on admission CTA, but RLL findings\\n not particulary striking. UA clean.\\n - Blood cultures x2 pending, Urine Cx pending, Sputum ordered. Repaet\\n Cx if spikes.\\n - Nasal aspirate for respiratory viruses: (influenza,paraninfluenza,\\n RSV)\\n - D/w BMT whether atypical Diff is expected with pt's recent treatemnts\\n or whether it is more concerning for infxn. Smear ordered.\\n - Empiric therapy for HAP Vanco/Zosyn per BMT\\n # Cardiac lymphoma: The patient appears to have had an excellent\\n response to therapy to date, with a decline in his LDH and shrinkage of\\n his cardiac mass on cardiac MRI. He will be due for his 5th cycle of\\n next week, and his ability to receive his chemotherapy safelywill\\n be determined by his recover from his present illness.\\n - d/w BMT\\n # Hx of CAD: Alleged silent MI in . Not in our records and pt\\n currently unbale to discuss. EKG suggestive of prior infarct, but ECHO\\n is not. Unusual that he is not on home ASA, BB, or statin.\\n - will d/w pt and BMT\\n # Hx of DVT: Per previous DC summary, pt has had a recent DVT in\\n setting of ongoing malignancy and has IVC filter in place--by report\\n has contraindication to systemic anticoagulation.\\n - d/w BMT\\n ICU Care\\n Nutrition: npo currently\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 03:37 AM\\n 20 Gauge - 03:37 AM\\n Comments: code status confirmed by onc fellow in ED. deferred currently\\n as acutely agitated/anxious. likewise deferred ICU consent until acute\\n anxiety has resolved\\n Prophylaxis:\\n DVT: SQ UF Heparin, IVC filter\\n Stress ulcer: PPI\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition: ICU\\n ------ Protected Section ------\\n ADDENDUM TO PLAN:\\n Assessment and plan initially changed this am as cardiac enzymes\\n positive and ECHO showing significant new focal wall motion\\n abnormaiilities. These findings are c/w either ACS (plaque rupture) vs\\n very significant demand ischemia secondary to a poorly defined acute\\n stressor (see above differential). Pt now on ASA, BB (with goal\\n HR~60), Statin (declined lipitor given hx of muscle pains, given\\n simvastatin 80). Heparin drip started w/o bolus. Per BMT, seems that\\n only contraindication to anticoag (unclear this am) has been concern\\n that this right atrial mass would bleed into pericardial space. Still\\n believe that pt\\ns resp status compromised by COPD given exam, but heart\\n failure secondary to active ischemia likely also contributing.\\n -- cardiology consulted, f/u recommendations\\n -- remainder of plan largely as outlined above: treat COPD, cont broad\\n Abx coverage\\n ------ Protected Section Addendum Entered By: , MD\\n on: 14:05 ------\\n\"\n },\n {\n \"category\": \"Social Work\",\n \"chartdate\": \"2200-04-21 00:00:00.000\",\n \"description\": \"Social Work Admission Note\",\n \"row_id\": 678764,\n \"text\": \"Family Information\\n Next of :\\n Health Care Proxy appointed:\\n Family Spokesperson designated:\\n Communication or visitation restriction:\\n Patient Information:\\n Previous living situation:\\n Previous level of functioning: Required assistance with care\\n Previous or other hospital admissions:\\n Past psychiatric history: anxiety\\n Past addictions history:\\n Employment status: Retired\\n Legal involvement:\\n Mandated Reporting Information:\\n Additional Information:\\n Patient / Family Assessment:\\n Clergy Contact:\\n Communication with Team:\\n Plan / Follow up:\\n Pt is a pleasant 84 yo widowed male who lives alone in . His\\n wife died from breast cancer when his children were young and he raised\\n them as a single working father. His adult children are very devoted to\\n him. Since initial diagnosis of Lymphoma pt has been in the hospital or\\n rehab until his last hospitalization when pt returned home. He was very\\n nervous about being home, but was quite happy to be there. He tells me\\n he had RN, PT and home health aide. His children visited daily and\\n provided meals.\\n I will follow for emotional support and am available for questions or\\n concerns.\\n , LICSW\\n X73442/ #\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2200-04-21 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 678782,\n \"text\": \"84 yo male pt with PMH ,Rt atrial tumour , lyphoma , recent\\n chemotherapy ,PNA, presented to ER with SOB, N/V anxious, ?\\n neutropenic. pt with worsening SOB, received vanco, zosyn ,solumedrol\\n ,ativan and aspirin from ER, 2litres of fluid in. ? PE . CT done. neg\\n for PE, ? PNA, slight decrease in the size of cardiac mass. put on\\n BIPAP .tolerated well. transfered to for further monitoring and\\n management.\\n Pt is alert and oriented but has very little patience and is easily\\n agitated, becoming SOB with activity. He is not comfortable in bed and\\n has been OOB to chair most of the shift. Was in bed for cardiac echo,\\n then back to chair. Ambulates with assist of one to chair.\\n He denies complaints of chest pain or pressure but is ruling in for MI\\n by enzymes with elevated triponin to 2.23 at noon today. He has been\\n started on lopressor for rate control, heparin drip and aspirain. He\\n was also started on simvastatin. Cardiac consult in place.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2200-04-22 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 679000,\n \"text\": \"84 year-old M with high-grade cardiac lymphoma (left atrial mass),\\n currently receiving treatment (cycle 4,day 15) with R- presents\\n from home with low-grade fevers and progressive dyspnea; despite\\n marked tachypnea and dyspnea, pt's images and blood gas look\\n remarkably good suggesting a strong contribution from anxiety.\\n .H/O lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\\n Assessment:\\n Pt is currently undergoing chemo treatment for lymphoma\\n Action:\\n Heme/onc service consulted and will not give chemo while he is being\\n treated for an acute MI\\n Response:\\n Will reassess need for chemo once pt is stable.\\n Plan:\\n Continue to follow-up with heme/onc for recommendations. Next set of\\n enzymes due at 1800.\\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\\n Assessment:\\n Pt ruled in for NSTEMI with positive triponins. No EKG changes were\\n noted. Echo done at bedside showed some new wall abnormalities but\\n full report is yet to follow. He denies chest pain and pressure. On\\n Heparin gtt this morning with positive hematuria.\\n Action:\\n Aspirin and on metoprolol 25mg PO. He was also started on simvastatin\\n and remains on O2.\\n Response:\\n Vital signs remain stable. Heparin d/c\\ned due to hematuria.\\n Plan:\\n Cont. to monitor followed by cardiology.\\n Demographics\\n Attending MD:\\n \\n Admit diagnosis:\\n FEVER\\n Code status:\\n Full code\\n Height:\\n Admission weight:\\n 60 kg\\n Daily weight:\\n Allergies/Reactions:\\n Terazosin\\n Mental status c\\n Precautions: Contact\\n PMH:\\n CV-PMH:\\n Additional history: Lymphoma, L atrial tumour ,recent chemotherapy ,\\n PNA. s/p IVC filter .\\n Surgery / Procedure and date:\\n Latest Vital Signs and I/O\\n Non-invasive BP:\\n S:114\\n D:64\\n Temperature:\\n 97.6\\n Arterial BP:\\n S:\\n D:\\n Respiratory rate:\\n 26 insp/min\\n Heart Rate:\\n 107 bpm\\n Heart rhythm:\\n ST (Sinus Tachycardia)\\n O2 delivery device:\\n Nasal cannula\\n O2 saturation:\\n 99% %\\n O2 flow:\\n 2 L/min\\n FiO2 set:\\n 24h total in:\\n 793 mL\\n 24h total out:\\n 905 mL\\n Pertinent Lab Results:\\n Sodium:\\n 140 mEq/L\\n 05:46 AM\\n Potassium:\\n 3.4 mEq/L\\n 05:46 AM\\n Chloride:\\n 104 mEq/L\\n 05:46 AM\\n CO2:\\n 27 mEq/L\\n 05:46 AM\\n BUN:\\n 11 mg/dL\\n 05:46 AM\\n Creatinine:\\n 0.7 mg/dL\\n 05:46 AM\\n Glucose:\\n 100 mg/dL\\n 05:46 AM\\n Hematocrit:\\n 24.1 %\\n 05:46 AM\\n Additional pertinent labs:\\n Lines / Tubes / Drains:\\n 2 PIVs\\n Valuables / Signature\\n Patient valuables: Glasses\\n Other valuables:\\n Clothes: Transferred with patient\\n Wallet / Money:\\n No money / wallet\\n Cash / Credit cards sent home with:\\n Jewelry:\\n Transferred from: 412\\n Transferred to: 1281\\n Date & time of Transfer: 12:00 AM\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2200-04-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 102037,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Left ventricular function.\\nHeight: (in) 68\\nWeight (lb): 144\\nBSA (m2): 1.78 m2\\nBP (mm Hg): 155/70\\nHR (bpm): 93\\nStatus: Inpatient\\nDate/Time: at 12:30\\nTest: Portable TTE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Suboptimal\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nThis study was compared to the prior study of .\\n\\n\\nLEFT ATRIUM: Elongated LA.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal interatrial septum.\\nNo ASD by 2D or color Doppler.\\n\\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Suboptimal\\ntechnical quality, a focal LV wall motion abnormality cannot be fully\\nexcluded. Low normal LVEF. No resting LVOT gradient. No VSD.\\n\\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\\n\\nAORTA: Normal aortic diameter at the sinus level. Normal aortic arch diameter.\\n\\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\\n\\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\\nannular calcification. Mild thickening of mitral valve chordae. No MS. Mild to\\nmoderate (+) MR.\\n\\nTRICUSPID VALVE: Tricuspid valve not well visualized. Indeterminate PA\\nsystolic pressure.\\n\\nPERICARDIUM: No pericardial effusion.\\n\\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\\n\\nConclusions:\\nThe left atrium is elongated. No atrial septal defect is seen by 2D or color\\nDoppler. There is mild symmetric left ventricular hypertrophy. The left\\nventricular cavity size is normal. Due to suboptimal technical quality, a\\nfocal wall motion abnormality cannot be fully excluded. Overall left\\nventricular systolic function is probably normal (LVEF 50-55%). There is no\\nventricular septal defect. Right ventricular chamber size and free wall motion\\nare normal. The aortic valve leaflets (3) are mildly thickened but aortic\\nstenosis is not present. No aortic regurgitation is seen. The mitral valve\\nleaflets are mildly thickened. There is no mitral valve prolapse. Mild to\\nmoderate (+) mitral regurgitation is seen. The pulmonary artery systolic\\npressure could not be determined. There is no pericardial effusion.\\n\\nCompared with the prior study (images reviewed) of , the LVEF has\\nprobably improved (suboptimal image quality and distal LV/apex porrly seen on\\ncurrent study). If clinically indicated, a repeat study with echo contrast\\n(dDefinity) may help evaluate regional and global LV systolic function.\\n\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2200-04-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 102038,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Left ventricular function/wall motion abnormalities. Pericardial effusion.\\nHeight: (in) 68\\nWeight (lb): 139\\nBSA (m2): 1.75 m2\\nBP (mm Hg): 124/79\\nHR (bpm): 100\\nStatus: Inpatient\\nDate/Time: at 13:20\\nTest: Portable TTE (Complete)\\nDoppler: Limited Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nThis study was compared to the prior study of .\\n\\n\\nLEFT VENTRICLE: Moderately depressed LVEF.\\n\\nRIGHT VENTRICLE: RV function depressed.\\n\\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate (2+) MR.\\n\\nTRICUSPID VALVE: Moderate [2+] TR.\\n\\nPERICARDIUM: No pericardial effusion.\\n\\nConclusions:\\nOverall left ventricular systolic function is moderately depressed (LVEF=\\n30-35 %) with akinesis of the distal LV/apex. RV with depressed free wall\\ncontractility. The mitral valve leaflets are mildly thickened. Moderate (2+)\\nmitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen.\\nThere is no pericardial effusion.\\n\\nCompared with the prior study (images reviewed) of , biventrricular\\nsystolic function is now depressed with regionality. The degree of MR \\nhave increased.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2200-04-22 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1081500,\n \"text\": \" 5:00 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: worsening effusions\\n Admitting Diagnosis: FEVER\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 84 year old man with high grade lymphoma, pleural effusions\\n REASON FOR THIS EXAMINATION:\\n worsening effusions\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 84-year-old man with high-grade lymphoma, pleural effusions.\\n\\n COMPARISON: , .\\n\\n SINGLE PORTABLE SUPINE CHEST RADIOGRAPH: Positioning limits evaluation of the\\n apices. There is persistent elevation of the right hemidiaphragm. There is\\n again bibasilar atelectasis but no effusion. Within the limitations of the\\n film there is no pneumothorax. The cardiomediastinal silhouette is unchanged.\\n The aorta is calcified.\\n\\n IMPRESSION: No pleural effusion. Bibasilar atelectasis.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2200-04-20 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1081277,\n \"text\": \" 8:43 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: r/o infiltrate\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 84 year old man with hx of lymphoma, pneumonia. Low grade fever today and\\n increased fatigue.\\n REASON FOR THIS EXAMINATION:\\n r/o infiltrate\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 84-year-old male with history of lymphoma, pneumonia and low-grade\\n fever, to assess for a cardiopulmonary process.\\n\\n TECHNIQUE: Single portable AP radiograph of the chest was performed.\\n Comparison is made with prior radiograph of .\\n\\n FINDINGS: The right hemidiaphragm remains persistently elevated. The\\n cardiomediastinal silhouette is stable. There is no focal pulmonary\\n consolidation. An IVC filter is seen in the upper abdomen.\\n\\n CONCLUSION: No acute cardiopulmonary process.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2200-04-20 00:00:00.000\",\n \"description\": \"CTA CHEST W&W/O C&RECONS, NON-CORONARY\",\n \"row_id\": 1081284,\n \"text\": \" 11:13 PM\\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \\n Reason: DYSPNEA\\n Contrast: OPTIRAY Amt: 100\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 84 year old man with acute onset dyspnea, maintaining good O2 sats but w/ air\\n hunger. on BiPap. history of cardiac lymphoma. has IVC filter\\n REASON FOR THIS EXAMINATION:\\n concern for PE, early pneumonia\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: ARHb MON 12:35 AM\\n No PE. New focal right basilar consolidation-? pneumonia though may represent\\n aspiration with ariway secretions seen on right. Perhaps slight dcecrease in\\n size of cardiac mass.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 84-year-old male with acute onset of dyspnea with history of\\n cardiac lymphoma.\\n\\n COMPARISON: CT chest .\\n\\n TECHNIQUE: Non-contrast and contrast-enhanced axial images of the chest are\\n obtained with multiplanar reformatted images.\\n\\n CTA CHEST: Although respiratory motion of the lower lobes limits evaluation\\n of subsegmental vessels, there is no evidence for central main lobar or\\n segmental pulmonary emboli. Additionally, there are no secondary signs of\\n emboli including no evidence of right-sided heart strain. Atherosclerotic\\n calcifications involve the thoracic aorta and its branches, though the\\n thoracic aorta is of normal caliber. Several partially calcified mediastinal\\n and left hilar lymph nodes represent prior granulomatous exposure. There is\\n no pericardial or pleural effusion. The known soft tissue mass with epicenter\\n at the level of the right atrium measures approximately 4.4 x 1.8 cm (3:72)\\n compared to 4.3 x 2.4 cm on . Narrowing of the superior vena cava\\n by this mass is unchanged.\\n\\n A new small focal consolidation is noted at the right lung base medially. The\\n left lung remains clear. A 4-mm right lower lobe lung nodule (3:65) is not\\n significantly changed. A small amount of secretions are noted in the right\\n mainstem bronchus. Otherwise, the airways appear patent to the subsegmental\\n level.\\n\\n Although this exam is not tailored to evaluate subdiaphragmatic structures,\\n limited evaluation of the upper abdomen reveals multiple stones within the\\n kidney. A left upper pole renal cyst is partially imaged, with a smaller\\n cysts noted in the right interpolar region. 1.8 cm right adrenal mass is\\n unchanged in size.\\n\\n Bone windows again reveal high-grade compression deformity in the mid thoracic\\n spine, unchanged. Old healed left posterolateral fracture deformity of the\\n tenth rib is unchanged.\\n (Over)\\n\\n 11:13 PM\\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \\n Reason: DYSPNEA\\n Contrast: OPTIRAY Amt: 100\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n IMPRESSION:\\n 1. No pulmonary embolism.\\n 2. New small consolidation at right lung base may represent pneumonic\\n consolidation or, in the setting of airway secretions, aspiration.\\n 3. Perhaps slight decrease in size of cardiac mass compared to CT from , with persistent mass effect on superior vena cava.\\n 4. No change in size of right adrenal mass and right lower lobe lung nodule.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2200-04-21 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1081300,\n \"text\": \" 4:29 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: now more tachypneic, interval change?, any sign of plum vasc\\n Admitting Diagnosis: FEVER\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 84 year old man with cardiac (atrial) lymphoma presents with 2-3 days of\\n worsening SOB\\n REASON FOR THIS EXAMINATION:\\n now more tachypneic, interval change?, any sign of plum vasc congestion?\\n ______________________________________________________________________________\\n FINAL REPORT\\n AP CHEST, 6:22 \\n\\n HISTORY: Cardiac lymphoma. Worsening shortness of breath.\\n\\n IMPRESSION: AP chest compared to :\\n\\n Mild vascular congestion has developed in the right lung base. Lungs are\\n otherwise clear. Heart size is normal. Elevation of right hemidiaphragm\\n unchanged since at least .\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2200-04-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 296684,\n \"text\": \"Sinus tachycardia\\nLow limb lead QRS voltages\\nLeft axis deviation may be due to left anterior fascicular block\\nModest T wave changes\\nDelayed R wave progression with late precordial QRS transition\\nThese findings are nonspecific but clinical correlation is suggested\\nSince previous tracing of the same date, further T waves changes present\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2200-04-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 296685,\n \"text\": \"Sinus tachycardia\\nLow limb lead QRS voltages\\nLeft axis deviation may be due to left anterior fascicular block\\nModest T wave changes\\nDelayed R wave progression with late precordial QRS transition\\nThese findings are nonspecific but clinical correlation is suggested\\n\\n\"\n }\n]"}}},{"rowIdx":395,"cells":{"subject_id":{"kind":"number","value":11638,"string":"11,638"},"hadm_id":{"kind":"number","value":155878,"string":"155,878"},"target_text":{"kind":"string","value":"71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial fibrillation, CKD, with past history of DVT and PE on Coumadin who was recently discharged from the CCU () for CHF exacerbation c/b C.diff infection and on for septic joint washout c/b failure to extubate CHF exacerbation, who was admitted from clinic with total body fluid overload. . # Acute on Chronic Systolic Heart Failure: Patient has endstage systolic heart failure ischemic , 10%, s/p BiV ICD ( Concerto C154DWK) with EF 10%, presenting with significant fluid overload. She was diuresed 9L of fluid during her stay in the CCU with symptomatic improvement. Her blood pressure and forward cardiac flow were maintained initially with neosynephrine, then with a milrinone drip for two days. After a trial of stopping the milrinone drip, systolic blood pressures dropped from 90s to 70s, so milrinone was restarted for one more day. Milrinone was again stopped after the primary goal of care became comfort measures only. Patient had been made aware of her endstage condition by her primary cardiologist, Dr. , during past hospitalizations; on presentation at this admission, her long term goals were comfort. Her ICD was turned off during her stay in the CCU. The primary CCU team and Dr. held a family meeting, at which the goals of care were made clear to be comfort measures only. Palliative Care was also consulted to help with the transition to comfort measures. After milrinone was discontinued the second time, patient's blood pressures were maintained in the 90s systolic. The patient should not be hospitalized further for congestive heart failure. Her anticoagulation was stopped, and she will remain on po antibiotics for her septic joints to prevent pain associated with worsening infection which would cause further pain. Her pain medications may be uptitrated as necessary. She is maintained currently on 20mg torsemide once daily. If she develops shortness of breath, she may be given morphine for comfort. . # Septic Joints: Patient with history +staph aureus in left shoulder treated by washout and vancomycin, 4 weeks of monotherapy by the time of this admission. She has had no positive blood cultures since before . Her pain was controled on ultram, standing tylenol, and long-acting morphine. On , the vancomycin course finished, and she was switched to oral doxycycline for indefinite prophylaxis. . # Sacral Decubitus Ulcer: Patient has unstageable decubitus ulcer, which she had prior to admission. Her pain is being controlled with standing ultram, standing tylenol, MS Contin, and immediate release morphine. Her pain worsens significantly when moved. These pain medications may be uptitrated as necessary. . # Hx of CAD: Patient has right dominant system, hx of mild instent re-stenois of the LAD BM stent and occluded RCA. Patient's blood pressures could not tolerate beta blocker, and beta blocker was discontinued after she was made comfort measures only. . # Hx Atrial Fibrillation: Patient with h/o atrial fibrillation, s/p BiV ICD ( Concerto C154DWK) , on coumadin. Her amiodarone and metoprolol have been stopped, but she has been continued on her digoxin. Her coumadin has been stopped as well so that she will not have to get frequent blood draws to follow INR. . # Hx of DVT/PE: Patient has hx of DVT/PE and was on coumadin with filter in place. Her coumadin was stopped after she was made comfort measures only in order to prevent frequent INR draws. . # Hypothyroidism: Levothyroxine was discontinued after patient was made comfort measures only. . # Gout: Allopurinol was discontinued after patient was made comfort measures only. . # ACCESS: Patient had Right midline, Right IJ central line, and Left EJ during this hospitalization, which were removed prior to discharge. . # PROPHYLAXIS: on coumadin . # CODE: DNR/DNI, made Comfort Measures Only GOALS OF CARE: Patient should not be hospitalized further for heart failure. Her pain should be kept under control by uptitrating the morphine as needed. She is now on comfort measures. She will continue on the medications as listed. Medications on Admission: #. Aspirin 81 mg Tablet daily #. Allopurinol 100 mg daily #. Amiodarone 200 mg daily #. Levothyroxine 150 mcg daily #. Digoxin 62.5 mcg qOD #. Simvastatin 20 mg daily #. Nexium 40 mg daily #. Metoprolol SR 25 daily #. Warfarin 2 mg daily #. Torsemide 20 mg #. Lasix 20mg daily #. Tylenol 975 mg q8 #. Ultram 50 mg QID # Vancomycin 500 mg q24 # MVI w/Minerals # Zinc 200mg Daily # Vitamin C 500 mg Discharge Medications: 1. Morphine 10 mg/5 mL Solution Sig: Five (5) mg PO every 2 hours as needed for mild pain. 2. Morphine 10 mg/5 mL Solution Sig: Ten (10) mg PO every 2 hours as needed for moderate pain. 3. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO every eight (8) hours. 4. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical (2 times a day) as needed for dry skin. 5. Morphine Concentrate 20 mg/mL Solution Sig: 5-20 mg PO q 2 hours as needed for severe pain or respiratory distress: For terminal care, may give sublingual if needed. 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 7. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) as needed for fever or pain. 8. Digoxin 125 mcg Tablet Sig: 0.5 Tablet PO EVERY OTHER DAY (Every Other Day). 9. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours) as needed for itching. 10. Torsemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours): to be given indefinitely. Discharge Disposition: Extended Care Facility: House Nursing & Rehabilitation Center - Discharge Diagnosis: Primary Diagnosis: Acute on Chronic Systolic Heart Failure Secondary Diagnoses: Septic Arthritis Sacral Decubitus Ulcer Urinary Tract Infection Discharge Condition: Stable. Alert and oriented x3 Activity Status:Out of Bed with assistance to chair or wheelchair Level of Consciousness:Alert and interactive Mental Status:Clear and coherent Discharge Instructions: Dear Ms. , You were admitted to the hospital because you were fluid overloaded, having an exacerbation of your heart failure. You were given medicines to urinate out a significant amount of fluid which helped your breathing. You were also given more pain medications to help control the pain in your joints and from your pressure ulcer. You were found to have a urinary tract infection, for which you were also treated with antibiotics. After discussion with Dr. , and our Palliative care team, you have chosen to be treated with comfort measures only. You will continue on your torsemide and digoxin to help your heart work better but most of your other scheduled medicines have been discontinued. You will get morphine as needed for pain and trouble breathing and it was decided that you would not return to for aggressive treatment of your heart disease. The following changes were made to your medications: 1. We have discontinued Allopurinol, amiodarone, aspirin, levothyroxine, Lisinopril, Metoprolol, omeprazole, simvastatin, tramadol and warfarin. 2. Vancomycin course was finished, you were started on doxycycline pills to prevent the MRSA from coming back. 3. We changed the oxycodone to morphine long and short acting. . Pt is DNR/DNI as per attending Dr. Followup Instructions: none"},"extractive_notes_summ":{"kind":"string","value":"# CORONARIES: Patient with h/o CAD w/ right dominant system, mild instent re-stenois of the LAD BM stent and occluded RCA. # CORONARIES: Patient with h/o CAD w/ right dominant system, mild instent re-stenois of the LAD BM stent and occluded RCA. # CORONARIES: Patient with h/o CAD w/ right dominant system, mild instent re-stenois of the LAD BM stent and occluded RCA. # CORONARIES: Patient with h/o CAD w/ right dominant system, mild instent re-stenois of the LAD BM stent and occluded RCA. 71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention, Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on coumadin, hypothyroidism, CKD, OA. 71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention, Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on coumadin, hypothyroidism, CKD, OA. 71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention, Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on coumadin, hypothyroidism, CKD, OA. 71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention, Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on coumadin, hypothyroidism, CKD, OA. # Hx CAD: Patient with h/o CAD w/ right dominant system, mild instent re-stenois of the LAD BM stent and occluded RCA. # PROPHYLAXIS: on coumadin . Trace aortic regurgitation is seen. Response: Excellent effect Plan: .H/O heart failure (CHF), Systolic, Acute on Chronic Assessment: Off lasix gtt since . # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a filter in place. # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a filter in place. # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a filter in place. # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a filter in place. # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a filter in place. # CODE: DNR, can intubate, briefly . Milrinone restarted d/t BP and U/O decrease. INR mildly subtherapeutic despite Cipro - continue Coumadin - monitor INR ICU Care Nutrition: Glycemic Control: Lines: Multi Lumen - 05:34 PM Midline - 05:34 PM Prophylaxis: DVT: coumadin Stress ulcer: lansoprazole VAP: Comments: Communication: Comments: Code status: DNR / DNI Disposition: # Hx CAD: Patient with h/o CAD w/ right dominant system, mild instent re-stenois of the LAD BM stent and occluded RCA. # Hx CAD: Patient with h/o CAD w/ right dominant system, mild instent re-stenois of the LAD BM stent and occluded RCA. # PROPHYLAXIS: on coumadin . # PROPHYLAXIS: on coumadin . # PROPHYLAXIS: on coumadin . Patient is currently on milrinone and phenylephrine. # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a filter in place. # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a filter in place. # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a filter in place. # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a filter in place. # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a filter in place. # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a filter in place. # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a filter in place. INR mildly subtherapeutic despite Cipro - continue Coumadin - monitor INR ICU Care Nutrition: Glycemic Control: Lines: midline, right IJ Multi Lumen - 05:34 PM Midline - 05:34 PM Prophylaxis: DVT: coumadin Stress ulcer: lansoprazole VAP: Comments: Communication: Comments: Code status: DNR / DNI Disposition: INR mildly subtherapeutic despite Cipro - continue Coumadin - monitor INR ICU Care Nutrition: Glycemic Control: Lines: midline, right IJ Multi Lumen - 05:34 PM Midline - 05:34 PM Prophylaxis: DVT: coumadin Stress ulcer: lansoprazole VAP: Comments: Communication: Comments: Code status: DNR / DNI Disposition: Right IJ catheter terminates in lower SVC. **** Impaired Skin Integrity Assessment: Pt. LS clear to diminished. Admit to CCU for aggressive diuresis. Out to rehab . Out to rehab . Out to rehab . Out to rehab . Out to rehab . Out to rehab . Out to rehab . Out to rehab . Out to rehab . tolerating medication. tolerating medication. 71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention, Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on coumadin, hypothyroidism, CKD, OA. 71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention, Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on coumadin, hypothyroidism, CKD, OA. 71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention, Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on coumadin, hypothyroidism, CKD, OA. 71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention, Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on coumadin, hypothyroidism, CKD, OA."},"n_notes":{"kind":"number","value":98,"string":"98"},"notes":{"kind":"list like","value":[{"category":"ECG","chartdate":"2180-01-12 00:00:00.000","description":"Report","row_id":173437,"text":"Ventricular paced rhythm with intermittent intrinsic A-V conduction as\ncompared with prior tracing of .\n\n"},{"category":"Nursing","chartdate":"2180-01-12 00:00:00.000","description":"Nursing Progress Note","row_id":399681,"text":"Pt is a 71 yo female with PMH: BM stent to LAD ', Occluded RCA\n without intervention, Ischemic CM (EF 10-25%), BiV ICD, AF, PVD, DVT\n s/p IVC filter, coumadin, hypothyroidism, CKD, OA. adm for HF\n (milrinone/lasix) MRSA in L shoulder, L hip and R knuckle. Out to\n rehab . Today went from rehab to see Dr. , sent to EW with\n hypotension. SBP 70 in EW, transiently on dopa, but cardiology d/c'd.\n Rxd with NS 250 cc with SBP 92. Pt has been in rehab since d/c from\n with septic arthritis in L shoulder, hip and R knuckle.\n On Vanco followed by ID.\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n SBP 90-100, HR 80-100 V paced, with VEA, lungs clear, sats >95% on \n Rehab called for date and time of last medications\n Plan:\n To begin on milrinone with bolus/ neo on stand by. Then to begin lasix\n gtt. Once hemodynamically stable on milrinone, can add morphine to\n pain control as needed\n Impaired Skin Integrity\n Assessment:\n 5X 7 cm stage 3 decube on coccyx, surrounded by yellow slough.\n Surrounding tissue macerated. Heels pink, boggy\n Action:\n Intern in to assess wound.\n Offered kinair bed to patient but she refused\n Wound cleansed with wound spray, covered by mepilex dsg\n Multipodous boots ordered\n Turned off of back\n Pt refusing dinner\n Plan:\n Please obtain wound consult for wound care recommendations and\n suggestions on pressure reducing mattress, enc po\ns, have nutritionist\n consult.\n Pain control (acute pain, chronic pain)\n Assessment:\n pain over coccyx, given Tylenol in EW without relief\n Action/Response:\n Ultram 50 mg qid\n Plan:\n Once milrinone bolus finished, can begin IV morphine. Ultram qid and\n Tylenol tid as ordered\n"},{"category":"Nursing","chartdate":"2180-01-17 00:00:00.000","description":"Nursing Progress Note","row_id":400111,"text":"71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\n : Sent to ED from clinic w/ hypotension\n transiently on\n dopa, Tx\nd w/ NS 250 cc w/ SBP ^ 92.\n Admit to CCU for aggressive diuresis.She was started on Milrinone\n and lasix gtt. And has been diuresing well. She has lg coccyx decub\n that is a source of chronic pain. She is DNR/DNI and defibrillator has\n been shut off.\n GI: Pt had a few episode of nausea yesterday and one today. It was very\n transient with no vomiting. She ate very well today. She received\n lactalose but no bM. Foley changed today.\n SOCIAL: Family in to visit. Pts HCP, her 38y old neice is very ill\n creating problem for this stressed family.\n Pain control (acute pain, chronic pain)\n Assessment:\n Plan is to transition to oral forms of pain control in preparation for\n pt going to rehab. She had received MS contin at 0600, but pill was\n ground and pt had nausea. She received 4mg IV morphine at 6am as well.\n She continues on standing acetominofen and ultram\n Action:\n MS contin will be given in to 15mg pills, which are smaller and can\n take them without having them crushed. Morphine immediate release has\n been ordered for breakthrough pain. It is also a small pill that she\n can take without crushing. She had 15mg immediate release at 1300 . She\n has had no IV morphine sulfate since 1030.\n Response:\n Pt has been pain free except when turned since then. She will have\n acute pain with position change, but it will settle down and go away\n within a few minutes. She received MS contin at 1800 and was able to\n swallow them without problem\n :\n Continue to try to control pain with oral medications. Give immediate\n release morphine for breakthrough pain.\n Impaired Skin Integrity\n Assessment:\n Sacral wound getting worse and remains very painful. Mepilex dsg oozing\n through. Acuacel added. Know MRSA infection on R knuckle and R elbow\n appear to be much more reddened than last week. Over all skin is dry\n and itchy.\n Action:\n Wound care nurse came to evaluate wound. Area is now cleansed with\n wound cleanser and dried. Criticade antifungal is applied to wound\n edges and peri-wound area. The wound is covered with aquacel AG and\n then small soft-sorb pad. It is secured with medipore tape on skin that\n has been prepped with barrier wipe. Finger and elbow are washed with\n soap and water. Area kept lubricated. oil used in water. Moisture\n barrier clean applied to body. Heels elevated off bed.\n Response:\n Skin less itchy. No further worsening of skin condition.\n Plan:\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Pt being transition for transfer back to rehab. Milrinone and lasix\n drips stopped at 1030. Pt was V-paced with wide complex and blood\n pressure prior to stopping meds was mid 90s with maps in mid 60s. She\n received KCL 20meq in AM She received torsemide 40mg and metolazone\n 5mg with urine output ~ 30-40cc/hr. Blood pressure dropped to the high\n 70s to mid 80s with maps in the low 50s.\n Action:\n After discussions with Dr she was restarted on Milrinone\n .5mic/kilo with bolus of 25mic/kilo given. Labs drawn in afternoon.\n Response:\n Blood pressure more stable with maps in low 60s after Milrinone\n restarted. She is ~400cc neg for the day. BUN creat 33/1.1, stable.\n Plan:\n Family deciding if pt will now be CMO and go to extended care facility\n with hospice.\n"},{"category":"Nursing","chartdate":"2180-01-17 00:00:00.000","description":"Nursing Progress Note","row_id":400112,"text":"Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2180-01-12 00:00:00.000","description":"Nursing Progress Note","row_id":399678,"text":"Pt is a 71 yo female with PMH: BM stent to LAD ', Occluded RCA\n without intervention, Ischemic CM (EF 10-25%), BiV ICD, AF, PVD, DVT\n s/p IVC filter, coumadin, hypothyroidism, CKD, OA. adm for HF\n (milrinone/lasix) MRSA in L shoulder, L hip and R knuckle. Out to\n rehab . Today went from rehab to see Dr. , sent to EW with\n hypotension. SBP 70 in EW, transiently on dopa, but cardiology d/c'd.\n Rxd with NS 250 cc with SBP 92. Pt has been in rehab since d/c from\n with septic arthritis in L shoulder, hip and R knuckle.\n On Vanco followed by ID.\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n SBP 90-100, HR 80-100 V paced, lungs clear, sats >95% on RA\n Action:\n Response:\n Plan:\n To begin on milrinone with bolus/ neo on stand by. Then to begin lasix\n gtt. Once hemodynamically stable on milrinone, can add morphine to\n pain control as needed\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2180-01-12 00:00:00.000","description":"Nursing Progress Note","row_id":399679,"text":"Pt is a 71 yo female with PMH: BM stent to LAD ', Occluded RCA\n without intervention, Ischemic CM (EF 10-25%), BiV ICD, AF, PVD, DVT\n s/p IVC filter, coumadin, hypothyroidism, CKD, OA. adm for HF\n (milrinone/lasix) MRSA in L shoulder, L hip and R knuckle. Out to\n rehab . Today went from rehab to see Dr. , sent to EW with\n hypotension. SBP 70 in EW, transiently on dopa, but cardiology d/c'd.\n Rxd with NS 250 cc with SBP 92. Pt has been in rehab since d/c from\n with septic arthritis in L shoulder, hip and R knuckle.\n On Vanco followed by ID.\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n SBP 90-100, HR 80-100 V paced, with VEA, lungs clear, sats >95% on RA\n Plan:\n To begin on milrinone with bolus/ neo on stand by. Then to begin lasix\n gtt. Once hemodynamically stable on milrinone, can add morphine to\n pain control as needed\n Impaired Skin Integrity\n Assessment:\n 5X 7 cm stage 3 decube on coccyx, surrounded by yellow slough.\n Surrounding tissue macerated. Heels pink, boggy\n Action:\n Intern in to assess wound.\n Offered kinair bed to patient but she refused\n Wound cleansed with wound spray, covered by mepilex dsg\n Multipodous boots ordered\n Turned off of back\n Pt refusing dinner\n Plan:\n Please obtain wound consult for wound care recommendations and\n suggestions on pressure reducing mattress, enc po\ns, have nutritionist\n consult.\n Pain control (acute pain, chronic pain)\n Assessment:\n pain over coccyx, given Tylenol in EW without relief\n Action/Response:\n Ultram 50 mg qid\n Plan:\n Once milrinone bolus finished, can begin IV morphine\n"},{"category":"Nursing","chartdate":"2180-01-17 00:00:00.000","description":"Nursing Progress Note","row_id":400113,"text":"71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\n : Sent to ED from clinic w/ hypotension\n transiently on\n dopa, Tx\nd w/ NS 250 cc w/ SBP ^ 92.\n Admit to CCU for aggressive diuresis.She was started on Milrinone\n and lasix gtt. And has been diuresing well. She has lg coccyx decub\n that is a source of chronic pain. She is DNR/DNI and defibrillator has\n been shut off.\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2180-01-14 00:00:00.000","description":"Nursing Progress Note","row_id":399802,"text":"Pt is a 71 yo female with PMH: BM stent to LAD ', Occluded RCA\n without intervention, Ischemic CM (EF 10-25%), BiV ICD, AF, PVD, DVT\n s/p IVC filter, coumadin, hypothyroidism, CKD, OA. adm for HF\n (milrinone/lasix) MRSA in L shoulder, L hip and R knuckle. Out to\n rehab . went from rehab to see Dr. , sent to EW with\n hypotension. SBP 70 in EW, transiently on dopa, but cardiology d/c'd.\n Rxd with NS 250 cc with SBP 92. Pt has been in rehab since d/c from\n with septic arthritis in L shoulder, hip and R knuckle.\n On Vanco followed by ID.\n She was started on milrinone .375 after bolus and lasix drip also begun\n at 2.5mg/hr. The lasix dose was increased to 5mg overnight, but urine\n output has remained poor, though she is negative.\n GI: Pt has poor apetite and eats very little.\n SOCIAL: Family in the visit in afternoon. Pt in good spirits, visiting\n with brother and his family.\n CODE STATUS: Dr had discussion with both patient and health care\n proxy and all are in agreement that she be DNR/DNI. Additionally the\n defibrillator part of AICD/pacer was shut off.\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Physician ","chartdate":"2180-01-14 00:00:00.000","description":"Physician Resident Progress Note","row_id":399815,"text":"Chief Complaint:\n 24 Hour Events:\n - confirmed DNR, acemaker turned off\n - despite lasix gtt, diuresis poor yesterday\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Ciprofloxacin - 08:00 AM\n Infusions:\n Other ICU medications:\n Coumadin (Warfarin) - 04:00 PM\n Lansoprazole (Prevacid) - 04:00 PM\n Morphine Sulfate - 05:05 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.4\nC (97.5\n HR: 99 (66 - 104) bpm\n BP: 91/50(60) {82/42(45) - 101/67(120)} mmHg\n RR: 12 (11 - 23) insp/min\n SpO2: 99%\n Heart rhythm: V Paced\n Wgt (current): 82.2 kg (admission): 82.2 kg\n Total In:\n 1,554 mL\n 456 mL\n PO:\n 900 mL\n 60 mL\n TF:\n IVF:\n 654 mL\n 396 mL\n Blood products:\n Total out:\n 1,628 mL\n 1,505 mL\n Urine:\n 1,628 mL\n 1,505 mL\n NG:\n Stool:\n Drains:\n Balance:\n -74 mL\n -1,049 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///27/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 159 K/uL\n 10.0 g/dL\n 104 mg/dL\n 1.4 mg/dL\n 27 mEq/L\n 3.8 mEq/L\n 42 mg/dL\n 98 mEq/L\n 134 mEq/L\n 31.9 %\n 4.7 K/uL\n [image002.jpg]\n 05:44 AM\n 04:46 AM\n WBC\n 6.1\n 4.7\n Hct\n 32.1\n 31.9\n Plt\n 156\n 159\n Cr\n 1.3\n 1.4\n Glucose\n 83\n 104\n Other labs: PT / PTT / INR:16.8/29.3/1.5, Ca++:8.0 mg/dL, Mg++:2.1\n mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 05:34 PM\n Midline - 05:34 PM\n 18 Gauge - 05:35 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Physician ","chartdate":"2180-01-14 00:00:00.000","description":"Physician Resident Progress Note","row_id":399816,"text":"Chief Complaint:\n 24 Hour Events:\n - confirmed DNR, acemaker turned off\n - despite lasix gtt, diuresis poor yesterday\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Ciprofloxacin - 08:00 AM\n Infusions:\n Other ICU medications:\n Coumadin (Warfarin) - 04:00 PM\n Lansoprazole (Prevacid) - 04:00 PM\n Morphine Sulfate - 05:05 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.4\nC (97.5\n HR: 99 (66 - 104) bpm\n BP: 91/50(60) {82/42(45) - 101/67(120)} mmHg\n RR: 12 (11 - 23) insp/min\n SpO2: 99%\n Heart rhythm: V Paced\n Wgt (current): 82.2 kg (admission): 82.2 kg\n Total In:\n 1,554 mL\n 456 mL\n PO:\n 900 mL\n 60 mL\n TF:\n IVF:\n 654 mL\n 396 mL\n Blood products:\n Total out:\n 1,628 mL\n 1,505 mL\n Urine:\n 1,628 mL\n 1,505 mL\n NG:\n Stool:\n Drains:\n Balance:\n -74 mL\n -1,049 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///27/\n Physical Examination\n General Appearance: No acute distress, thin, cachectic\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: II/VI systolic murmur best at apex. MI is laterally\n displaced\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Breath Sounds: Clear : anteriorly)\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+\n Skin: Not assessed, Stage 3 sacral decubitus ulcer\n Neurologic: Attentive, Responds to: Not assessed, Oriented (to): x3\n Labs / Radiology\n 159 K/uL\n 10.0 g/dL\n 104 mg/dL\n 1.4 mg/dL\n 27 mEq/L\n 3.8 mEq/L\n 42 mg/dL\n 98 mEq/L\n 134 mEq/L\n 31.9 %\n 4.7 K/uL\n [image002.jpg]\n 05:44 AM\n 04:46 AM\n WBC\n 6.1\n 4.7\n Hct\n 32.1\n 31.9\n Plt\n 156\n 159\n Cr\n 1.3\n 1.4\n Glucose\n 83\n 104\n Other labs: PT / PTT / INR:16.8/29.3/1.5, Ca++:8.0 mg/dL, Mg++:2.1\n mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 05:34 PM\n Midline - 05:34 PM\n 18 Gauge - 05:35 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Physician ","chartdate":"2180-01-14 00:00:00.000","description":"Physician Resident Progress Note","row_id":399817,"text":"Chief Complaint:\n 24 Hour Events:\n - confirmed DNR, acemaker turned off\n - despite lasix gtt, diuresis poor yesterday\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Ciprofloxacin - 08:00 AM\n Infusions:\n Other ICU medications:\n Coumadin (Warfarin) - 04:00 PM\n Lansoprazole (Prevacid) - 04:00 PM\n Morphine Sulfate - 05:05 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.4\nC (97.5\n HR: 99 (66 - 104) bpm\n BP: 91/50(60) {82/42(45) - 101/67(120)} mmHg\n RR: 12 (11 - 23) insp/min\n SpO2: 99%\n Heart rhythm: V Paced\n Wgt (current): 82.2 kg (admission): 82.2 kg\n Total In:\n 1,554 mL\n 456 mL\n PO:\n 900 mL\n 60 mL\n TF:\n IVF:\n 654 mL\n 396 mL\n Blood products:\n Total out:\n 1,628 mL\n 1,505 mL\n Urine:\n 1,628 mL\n 1,505 mL\n NG:\n Stool:\n Drains:\n Balance:\n -74 mL\n -1,049 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///27/\n Physical Examination\n General Appearance: No acute distress, thin, cachectic\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: II/VI systolic murmur best at apex. MI is laterally\n displaced\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Breath Sounds: Clear : anteriorly)\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+\n Skin: Not assessed, Stage 3 sacral decubitus ulcer\n Neurologic: Attentive, Responds to: Not assessed, Oriented (to): x3\n Labs / Radiology\n 159 K/uL\n 10.0 g/dL\n 104 mg/dL\n 1.4 mg/dL\n 27 mEq/L\n 3.8 mEq/L\n 42 mg/dL\n 98 mEq/L\n 134 mEq/L\n 31.9 %\n 4.7 K/uL\n [image002.jpg]\n 05:44 AM\n 04:46 AM\n WBC\n 6.1\n 4.7\n Hct\n 32.1\n 31.9\n Plt\n 156\n 159\n Cr\n 1.3\n 1.4\n Glucose\n 83\n 104\n Other labs: PT / PTT / INR:16.8/29.3/1.5, Ca++:8.0 mg/dL, Mg++:2.1\n mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\n recently discharged from the CCU () for CHF exacerbation c/b\n C.diff infection and on for septic joint washout c/b failure to\n extubate CHF exacerbation, who is now being admitted from \n clinic with total body fluid overload.\n .\n # Anasarca: Patient has history of CHF ischemic , 10%, s/p\n BiV ICD ( Concerto C154DWK) 1/08with EF 10% which is the\n likely cause of her fluid overload. Her rapid accumulation underpins\n the severity of her condition and her severely unfavourable\n hemodynamics. Her long term goals are comfort, though she still wishes\n to participate in rehab. Her family recognizes that she is dying. Our\n goal is diuresis which we will attempt aggressively, reassessing our\n progress dynamically. She put out very little o/n on lasix gtt. This\n could reflect limitatin of diuresis or the importance of a bolus (we\n withheld bolus to avoid instability)\n -- milrinone with bolus\n -- neosynephrine for pressure support, goal MAP of > 60\n -- slow uptitration of lasix with goal near-continuous diuresis while\n avoiding MAP < 60\n -- strict i/o's with foley\n -- can switch to levophed if low UOP on Neo with need for pressor\n support\n -- family meeting with HCP to assess goals in AM after diuresis\n attempted\n .\n # Septic Joints: Patient with history +staph aureus in left shoulder\n treated by washout and vancomycin, thus far 4 weeks of monotherapy. No\n + blood cx since before . Major issue now is pain control.\n -- send Vanco level in AM, was recently on 500 mg q12 and switched to\n q24 for high troughs\n -- ultram q6, Tylenol q8, Morphine for breakthrough (1-3 mg).\n - Will consider ms contin if no control\n .\n # Sacral Decub - stage 3-4.\n - wound care\n - pain control.\n .\n # UTI: positive UA, no history of culture positive UA's in system\n - treating empirically with cipro\n - watch INR on abx\n .\n # CORONARIES: Patient with h/o CAD w/ right dominant system, mild\n instent re-stenois of the LAD BM stent and occluded RCA.\n - bb as tolerated\n .\n # RHYTHM: Patient with h/o atrial fibrillation, s/p BiV ICD (\n Concerto C154DWK) , on coumadin. Now in paced rhythm\n - cont home dose meds (amio, metoprolol)\n - cont coumadin\n - f/u INR\n .\n # Chronic Kidney Disease: Baseline 1.3 creatinine. At baseline\n - trend\n .\n # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a\n filter in place.\n - cont coumadin\n - f/u INR\n .\n # Hypothyroidism: Continue Levothyroxine.\n .\n # Gout: continue allopurinol\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 05:34 PM\n Midline - 05:34 PM\n 18 Gauge - 05:35 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Nursing","chartdate":"2180-01-16 00:00:00.000","description":"Nursing Progress Note","row_id":400035,"text":"Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Ineffective Coping\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2180-01-16 00:00:00.000","description":"Nursing Progress Note","row_id":400036,"text":"71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\n : Sent to ED from clinic w/ hypotension\n transiently on\n dopa, Tx\nd w/ NS 250 cc w/ SBP ^ 92. Admit to CCU for aggressive\n diuresis.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt needing less doses IV Morphine since MS Contin increased to 30mg \n this morning\n Pt consistently states pain is at coccyx\n immediate area of pressure\n ulcer and nowhere else\n Action:\n Received MS Contin 15mg x 2 this AM\n Continues on Tylenol 1000mg po TID, Ultram 50mg QID\n Received Morphine IV 4mg approx every 2 hours this am x total 4 doses\n none since approx 1245\n Response:\n Pt appears more comfortable this PM\n able to turn w/o premedicating with IV Morphine\n Pt states pain is which she states is good for her\n Plan:\n Cont assess pain, cont ATC meds and supplement with IV Morphine as\n needed\n ? etiology of severe pain\n ESR ordered to r/o osteo\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Pt asystomatic\n no SOB with stable VS\n Action:\n Milrinone remains at 0,5mcgs/kg/min\n Lasix increased from 5 to 10mg/hr\n Response:\n Initial urine output ~ 200cc/hr in AM\n now decreased to 20-40cc/hr,\n Lasix gtt titrated back to 10mg/hr with slight increase output\n Plan:\n Cont IV Lasix/Mirinone overnight and D/C in AM\n Transition to oral regimen, Assess response\n Impaired Skin Integrity\n Assessment:\n Large unstageable pressur ulcer on coccyx unchanged\n Bilat heels remain reddened but blanchble\n Old abrasion to r elbow\n Action:\n dressing coming off\n cleansed and redressed this AM-duoderm\n gel/Mepilex,\n mod amt sero-sanguinous drainage; redness/maceration to surrounding\n tissue\n severe pain at site\n see above\n Response:\n Site remains unchanged\n Plan:\n Cont keep PU clean with intact dressing, frequent turns avoiding back\n except when pt sitting upright for meals\n Wound care RN consult in AM\n Roho cushion ordered from PT\n unavailable today\n Ineffective Coping\n Assessment:\n Pt continues to have periods in day when she has difficulty coping with\n plan to return to rehab\n Action:\n Pt allowed to verbalize feelings about rehab, realizes she is unable to\n return home\n Response:\n Pt appears to have periods of\nmeltdown\n with periods of rational\n thought regarding needs and abilities going forward\n Plan:\n Case Manager consult in AM\n Social Service consult in AM.\n Cont to provide emotional support for patient.\n"},{"category":"Nursing","chartdate":"2180-01-19 00:00:00.000","description":"Nursing Progress Note","row_id":400187,"text":"Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2180-01-14 00:00:00.000","description":"Nursing Progress Note","row_id":399880,"text":"Pt is a 71 yo female with PMH: BM stent to LAD ', Occluded RCA\n without intervention, Ischemic CM (EF 10-25%), BiV ICD, AF, PVD, DVT\n s/p IVC filter, coumadin, hypothyroidism, CKD, OA. adm for HF\n (milrinone/lasix) MRSA in L shoulder, L hip and R knuckle. Out to\n rehab . went from rehab to see Dr. , sent to EW with\n hypotension. SBP 70 in EW, transiently on dopa, but cardiology d/c'd.\n Rxd with NS 250 cc with SBP 92. Pt has been in rehab since d/c from\n with septic arthritis in L shoulder, hip and R knuckle.\n On Vanco followed by ID.\n She was started on milrinone .375 after bolus and lasix drip also begun\n at 2.5mg/hr. The lasix dose was increased to 10 but urine output\n has remained poor, though she is negative.\n GI: Pt has good apetite and has been eating well, but still no BM. She\n has pills ground up in applesauce.\n SOCIAL: Family in the visit in the am and early afternoon. She slept\n most of the afternoon.\n CODE STATUS: Dr had discussion with both patient and health care\n proxy and all are in agreement that she be DNR/DNI. Additionally the\n defibrillator part of AICD/pacer was shut off.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pain is much better contolled now that she can receive prn morphine in\n addition to standing ultram and Tylenol. The coccyx decubitis is what\n causes the most discomfort. She is most uncomfortable on her L side and\n cannot sleep or rest on that side.\n Action:\n She required more morphine in the am and received 7 2mg doses between\n 8am and 1500. She has not been turned on L side except for dsg and bed\n change. She goes from back to R side and is doing better with this.\n Response:\n She was awake and conversant with family all morning, able to eat and\n interact. She has slept most of the afternoon since 1500. She awoke at\n 1800 and was pain free and ready to eat.\n Plan:\n Continue standing ultram and give morphine prn. Change position as\n tolerated.\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n She has her lasix drip increased to 15mg overnight and remains on\n milrinone .5mic/kilo. She has a once a day metolazone 5mg po added. She\n has no audible rales, just decresed breath sounds at the bases. Her\n blood pressure has been adequate with maps over the 60s. She has no\n c/o of cp or acute SOB. Her bilateral leg edema is decreasing. She\n received 20 meq KCL IV this am.\n Action:\n She continues on above medications and is now responding with excellent\n diuresis. She is over 2 liters negative for the day! Lopressor was\n increased to 25mg .\n Response:\n Lytes within nl limits. Goal to to continue pushing diuresis for over\n 10 liters negative.\n Plan:\n Keep careful I & O. Monitor lytes\n Impaired Skin Integrity\n Assessment:\n Pt has large stage 3 decubitus ulcer on coccyx. This is covered with\n mepilex. Her heels are reddened, but . Her skin is very dry and\n thin with a number of discolored areas. She has almost no abilty to\n change her position on her own.\n Action:\n Mepilex dsg had drainage oozing through and was changed. Area has white\n slough covering most of it. The surrounding tissue is red. There is a\n lateral area that looks like granulation tissue. The edges are rounded.\n Area was sprayed with wound cleanser and dried. Peri-wound area had\n aloevesta moisture barrier applied and mepilex applied and remains in\n tact. It is draining enough it needs to be changed daily. Her heels\n have been kept elevated on pillows and she has been well lubricated.\n Her position is changed from R to upright as often as she tolerates.\n Response:\n No new lesions noted. The ducub is no worse than yesterday.\n Plan:\n Monitor wound and change dsg as needed. Add aquacel if draining\n increases. Change position as tolerated.\n"},{"category":"Nursing","chartdate":"2180-01-17 00:00:00.000","description":"Nursing Progress Note","row_id":400105,"text":"71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\n : Sent to ED from clinic w/ hypotension\n transiently on\n dopa, Tx\nd w/ NS 250 cc w/ SBP ^ 92.\n Admit to CCU for aggressive diuresis.She was started on Milrinone\n and lasix gtt. And has been diuresing well. She has lg coccyx decub\n that is a source of chronic pain. She is DNR/DNI and defibrillator has\n been shut off. She has excellent apetite.\n Pain control (acute pain, chronic pain)\n Assessment:\n Plan is to transition to oral forms of pain control in preparation for\n pt going to rehab. She had received MS contin at 0600, but pill was\n ground and pt had nausea. She received 4mg IV morphine at 6am as well.\n She continues on standing acetominofen and ultram\n Action:\n MS contin will be given in to 15mg pills, which are smaller and can\n take them without having them crushed. Morphine immediate release has\n been ordered for breakthrough pain. It is also a small pill that she\n can take without crushing. She had 15mg immediate release at 1300 . She\n has had no IV morphine sulfate since 1030.\n Response:\n Pt has been pain free except when turned since then. She will have\n acute pain with position change, but it will settle down and go away\n within a few minutes. She received MS contin at 1800 and was able to\n swallow them without problem\n :\n Continue to try to control pain with oral medications. Give immediate\n release morphine for breakthrough pain.\n Impaired Skin Integrity\n Assessment:\n Sacral wound getting worse and remains very painful. Mepilex dsg oozing\n through. Acuacel added. Know MRSA infection on R knuckle and R elbow\n appear to be much more reddened than last week. Over all skin is dry\n and itchy.\n Action:\n Wound care nurse came to evaluate wound. Area is now cleansed with\n wound cleanser and dried. Criticade antifungal is applied to wound\n edges and peri-wound area. The wound is covered with aquacel AG and\n then small soft-sorb pad. It is secured with medipore tape on skin that\n has been prepped with barrier wipe. Finger and elbow are washed with\n soap and water. Area kept lubricated. oil used in water. Moisture\n barrier clean applied to body. Heels elevated off bed.\n Response:\n Skin less itchy. No further worsening of skin condition.\n Plan:\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Pt being transition for transfer back to rehab. Milrinone and lasix\n drips stopped at 1030. Pt was V-paced with wide complex and blood\n pressure prior to stopping meds was mid 90s with maps in mid 60s. She\n received KCL 20meq in AM She received torsemide 40mg and metolazone\n 5mg with urine output ~ 30-40cc/hr. Blood pressure dropped to the high\n 70s to mid 80s with maps in the low 50s.\n Action:\n After discussions with Dr she was restarted on Milrinone\n .5mic/kilo with bolus of 25mic/kilo given.\n Response:\n Blood pressure more stable with maps in low 60s after Milrinone\n restarted.\n Plan:\n"},{"category":"Nursing","chartdate":"2180-01-17 00:00:00.000","description":"Nursing Progress Note","row_id":400106,"text":"71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\n : Sent to ED from clinic w/ hypotension\n transiently on\n dopa, Tx\nd w/ NS 250 cc w/ SBP ^ 92.\n Admit to CCU for aggressive diuresis.She was started on Milrinone\n and lasix gtt. And has been diuresing well. She has lg coccyx decub\n that is a source of chronic pain. She is DNR/DNI and defibrillator has\n been shut off.\n GI: Pt had a few episode of nausea yesterday and one today. It was very\n transient with no vomiting. She ate very well today. She received\n lactalose but no bM. Foley changed today.\n SOCIAL: Family in to visit. Pts HCP, her 38y old neice is very ill\n creating problem for this stressed family.\n Pain control (acute pain, chronic pain)\n Assessment:\n Plan is to transition to oral forms of pain control in preparation for\n pt going to rehab. She had received MS contin at 0600, but pill was\n ground and pt had nausea. She received 4mg IV morphine at 6am as well.\n She continues on standing acetominofen and ultram\n Action:\n MS contin will be given in to 15mg pills, which are smaller and can\n take them without having them crushed. Morphine immediate release has\n been ordered for breakthrough pain. It is also a small pill that she\n can take without crushing. She had 15mg immediate release at 1300 . She\n has had no IV morphine sulfate since 1030.\n Response:\n Pt has been pain free except when turned since then. She will have\n acute pain with position change, but it will settle down and go away\n within a few minutes. She received MS contin at 1800 and was able to\n swallow them without problem\n :\n Continue to try to control pain with oral medications. Give immediate\n release morphine for breakthrough pain.\n Impaired Skin Integrity\n Assessment:\n Sacral wound getting worse and remains very painful. Mepilex dsg oozing\n through. Acuacel added. Know MRSA infection on R knuckle and R elbow\n appear to be much more reddened than last week. Over all skin is dry\n and itchy.\n Action:\n Wound care nurse came to evaluate wound. Area is now cleansed with\n wound cleanser and dried. Criticade antifungal is applied to wound\n edges and peri-wound area. The wound is covered with aquacel AG and\n then small soft-sorb pad. It is secured with medipore tape on skin that\n has been prepped with barrier wipe. Finger and elbow are washed with\n soap and water. Area kept lubricated. oil used in water. Moisture\n barrier clean applied to body. Heels elevated off bed.\n Response:\n Skin less itchy. No further worsening of skin condition.\n Plan:\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Pt being transition for transfer back to rehab. Milrinone and lasix\n drips stopped at 1030. Pt was V-paced with wide complex and blood\n pressure prior to stopping meds was mid 90s with maps in mid 60s. She\n received KCL 20meq in AM She received torsemide 40mg and metolazone\n 5mg with urine output ~ 30-40cc/hr. Blood pressure dropped to the high\n 70s to mid 80s with maps in the low 50s.\n Action:\n After discussions with Dr she was restarted on Milrinone\n .5mic/kilo with bolus of 25mic/kilo given. Labs drawn in afternoon.\n Response:\n Blood pressure more stable with maps in low 60s after Milrinone\n restarted. She is ~400cc neg for the day. BUN creat 33/1.1, stable.\n Plan:\n Family deciding if pt will now be CMO and go to extended care facility\n with hospice.\n"},{"category":"Physician ","chartdate":"2180-01-16 00:00:00.000","description":"Physician Resident Progress Note","row_id":400013,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n - MS Contin 15 , was getting 22 mg IV morph qday\n - pulled EJ\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 08:00 AM\n Vancomycin - 09:36 AM\n Infusions:\n Furosemide (Lasix) - 5 mg/hour\n Milrinone - 0.5 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 06:40 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.8\n HR: 70 (62 - 75) bpm\n BP: 88/57(63) {78/43(52) - 106/66(76)} mmHg\n RR: 23 (9 - 35) insp/min\n SpO2: 97%\n Heart rhythm: AV Paced\n Wgt (current): 77.3 kg (admission): 82.2 kg\n Total In:\n 1,335 mL\n 121 mL\n PO:\n 420 mL\n TF:\n IVF:\n 915 mL\n 121 mL\n Blood products:\n Total out:\n 5,565 mL\n 880 mL\n Urine:\n 5,565 mL\n 880 mL\n NG:\n Stool:\n Drains:\n Balance:\n -4,230 mL\n -759 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///33/\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Diminished: )\n Abdominal: Soft, Obese\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 146 K/uL\n 10.7 g/dL\n 115 mg/dL\n 1.1 mg/dL\n 33 mEq/L\n 3.8 mEq/L\n 39 mg/dL\n 92 mEq/L\n 133 mEq/L\n 33.1 %\n 5.1 K/uL\n [image002.jpg]\n 05:44 AM\n 04:46 AM\n 04:00 PM\n 03:05 AM\n 03:17 PM\n WBC\n 6.1\n 4.7\n 5.1\n Hct\n 32.1\n 31.9\n 33.1\n Plt\n 156\n 159\n 146\n Cr\n 1.3\n 1.4\n 1.3\n 1.2\n 1.1\n Glucose\n 83\n 104\n 155\n 115\n Other labs:\n PT / PTT / INR:18.4/29.1/1.7,\n Ca++:8.3 mg/dL, Mg++:2.0 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\n recently discharged from the CCU () for CHF exacerbation c/b\n C.diff infection and on for septic joint washout c/b failure to\n extubate CHF exacerbation, who is now being admitted from \n clinic with total body fluid overload.\n .\n # sCHF exacerbation: Patient has history of CHF ischemic , \n 10%, s/p BiV ICD ( Concerto C154DWK) 1/08with EF 10% which is\n the likely cause of her fluid overload. Her rapid accumulation\n underpins the severity of her condition and her severely unfavourable\n hemodynamics. Her long term goals are comfort, though she still wishes\n to participate in rehab. Her family recognizes that she is dying. Our\n goal is diuresis which we will attempt aggressively, reassessing our\n progress dynamically. She diuresed well on Lasix gtt on with net\n neg 4L balance. LOS fluid balance -5L.\n -- goal diuresis 5 to 10L total\n -- continue milrinone\n -- continue metoprolol tartrate 12.5mg PO BID\n -- slow uptitration of lasix gtt with goal near-continuous diuresis\n while avoiding MAP < 60\n -- strict i/o's with foley\n -- replete K to 5\n -- PM electrolytes\n -- family meeting with HCP prn\n .\n # Septic Joints: Patient with history +staph aureus in left shoulder\n treated by washout and vancomycin, thus far 4 weeks of monotherapy. No\n + blood cx since before . Major issue now is pain control.\n -- continue vanc, was recently on 500 mg q12 and switched to q24 for\n high troughs\n -- continue MS contin 15mg \n -- ultram q6, Tylenol q8, Morphine for breakthrough (2-4 mg).\n .\n # Sacral Decub - stage 3-4.\n - wound care\n - pain control\n .\n # UTI: positive UA, no history of culture positive UA's in system\n - treating empirically with cipro day 1 was . Last dose tomorrow\n morning (Morning of ^st)\n - watch INR on abx\n .\n # CORONARIES: Patient with h/o CAD w/ right dominant system, mild\n instent re-stenois of the LAD BM stent and occluded RCA.\n - bb as tolerated\n .\n # RHYTHM: Patient with h/o atrial fibrillation, s/p BiV ICD (\n Concerto C154DWK) , on coumadin. Now in paced rhythm\n - cont home dose meds (amio, metoprolol)\n - cont coumadin\n .\n # Chronic Kidney Disease: Baseline Creatinine 1.3. Creatinine 1.1\n today.\n - trend\n .\n # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a\n filter in place.\n - continue Coumadin\n .\n # Hypothyroidism: Continue Levothyroxine\n .\n # Gout: continue Allopurinol\n ICU Care\n Nutrition:\n Low Na diet\n Glycemic Control: not on insulin\n Lines:\n Multi Lumen - 05:34 PM\n Midline - 05:34 PM\n 18 Gauge - 05:35 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: DNR / DNI\n Disposition:ICU\n"},{"category":"Physician ","chartdate":"2180-01-16 00:00:00.000","description":"Physician Resident Progress Note","row_id":400015,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n - MS Contin 15 , was getting 22 mg IV morph qday\n - pulled EJ\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 08:00 AM\n Vancomycin - 09:36 AM\n Infusions:\n Furosemide (Lasix) - 5 mg/hour\n Milrinone - 0.5 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 06:40 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.8\n HR: 70 (62 - 75) bpm\n BP: 88/57(63) {78/43(52) - 106/66(76)} mmHg\n RR: 23 (9 - 35) insp/min\n SpO2: 97%\n Heart rhythm: AV Paced\n Wgt (current): 77.3 kg (admission): 82.2 kg\n Total In:\n 1,335 mL\n 121 mL\n PO:\n 420 mL\n TF:\n IVF:\n 915 mL\n 121 mL\n Blood products:\n Total out:\n 5,565 mL\n 880 mL\n Urine:\n 5,565 mL\n 880 mL\n NG:\n Stool:\n Drains:\n Balance:\n -4,230 mL\n -759 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///33/\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Diminished: )\n Abdominal: Soft, Obese\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 146 K/uL\n 10.7 g/dL\n 115 mg/dL\n 1.1 mg/dL\n 33 mEq/L\n 3.8 mEq/L\n 39 mg/dL\n 92 mEq/L\n 133 mEq/L\n 33.1 %\n 5.1 K/uL\n [image002.jpg]\n 05:44 AM\n 04:46 AM\n 04:00 PM\n 03:05 AM\n 03:17 PM\n WBC\n 6.1\n 4.7\n 5.1\n Hct\n 32.1\n 31.9\n 33.1\n Plt\n 156\n 159\n 146\n Cr\n 1.3\n 1.4\n 1.3\n 1.2\n 1.1\n Glucose\n 83\n 104\n 155\n 115\n Other labs:\n PT / PTT / INR:18.4/29.1/1.7,\n Ca++:8.3 mg/dL, Mg++:2.0 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\n recently discharged from the CCU () for CHF exacerbation c/b\n C.diff infection and on for septic joint washout c/b failure to\n extubate CHF exacerbation, who is now being admitted from \n clinic with total body fluid overload.\n .\n # sCHF exacerbation: Patient has history of CHF ischemic , \n 10%, s/p BiV ICD ( Concerto C154DWK) 1/08with EF 10% which is\n the likely cause of her fluid overload. Her rapid accumulation\n underpins the severity of her condition and her severely unfavourable\n hemodynamics. Her long term goals are comfort, though she still wishes\n to participate in rehab. Her family recognizes that she is dying. Our\n goal is diuresis which we will attempt aggressively, reassessing our\n progress dynamically. She diuresed well on Lasix gtt on with net\n neg 4L balance. LOS fluid balance -5L.\n -- goal diuresis 5 to 10L total\n -- continue milrinone\n -- continue metoprolol tartrate 12.5mg PO BID\n -- slow uptitration of lasix gtt with goal near-continuous diuresis\n while avoiding MAP < 60\n -- strict i/o's with foley\n -- replete K to 5\n -- PM electrolytes\n -- family meeting with HCP prn\n .\n # Septic Joints: Patient with history +staph aureus in left shoulder\n treated by washout and vancomycin, thus far 4 weeks of monotherapy. No\n + blood cx since before . Major issue now is pain control.\n -- continue vanc, was recently on 500 mg q12 and switched to q24 for\n high troughs\n -- continue cipro\n -- continue MS contin 15mg \n -- ultram q6, Tylenol q8, Morphine for breakthrough (2-4 mg).\n .\n # Sacral Decub - stage 3-4.\n - wound care\n - pain control\n .\n # UTI: positive UA, no history of culture positive UA's in system\n - treating empirically with cipro day 1 was . Last dose tomorrow\n morning (Morning of ^st)\n - watch INR on abx\n .\n # CORONARIES: Patient with h/o CAD w/ right dominant system, mild\n instent re-stenois of the LAD BM stent and occluded RCA.\n - bb as tolerated\n .\n # RHYTHM: Patient with h/o atrial fibrillation, s/p BiV ICD (\n Concerto C154DWK) , on coumadin. Now in paced rhythm\n - cont home dose meds (amio, metoprolol)\n - cont coumadin\n .\n # Chronic Kidney Disease: Baseline Creatinine 1.3. Creatinine 1.1\n today.\n - trend\n .\n # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a\n filter in place.\n - continue Coumadin\n .\n # Hypothyroidism: Continue Levothyroxine\n .\n # Gout: continue Allopurinol\n ICU Care\n Nutrition:\n Low Na diet\n Glycemic Control: not on insulin\n Lines:\n Multi Lumen - 05:34 PM\n Midline - 05:34 PM\n 18 Gauge - 05:35 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: DNR / DNI\n Disposition:ICU\n"},{"category":"Physician ","chartdate":"2180-01-16 00:00:00.000","description":"Physician Resident Progress Note","row_id":400016,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n - MS Contin 15 , was getting 22 mg IV morph qday\n - pulled EJ\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 08:00 AM\n Vancomycin - 09:36 AM\n Infusions:\n Furosemide (Lasix) - 5 mg/hour\n Milrinone - 0.5 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 06:40 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.8\n HR: 70 (62 - 75) bpm\n BP: 88/57(63) {78/43(52) - 106/66(76)} mmHg\n RR: 23 (9 - 35) insp/min\n SpO2: 97%\n Heart rhythm: AV Paced\n Wgt (current): 77.3 kg (admission): 82.2 kg\n Total In:\n 1,335 mL\n 121 mL\n PO:\n 420 mL\n TF:\n IVF:\n 915 mL\n 121 mL\n Blood products:\n Total out:\n 5,565 mL\n 880 mL\n Urine:\n 5,565 mL\n 880 mL\n NG:\n Stool:\n Drains:\n Balance:\n -4,230 mL\n -759 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///33/\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Diminished: )\n Abdominal: Soft, Obese\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 146 K/uL\n 10.7 g/dL\n 115 mg/dL\n 1.1 mg/dL\n 33 mEq/L\n 3.8 mEq/L\n 39 mg/dL\n 92 mEq/L\n 133 mEq/L\n 33.1 %\n 5.1 K/uL\n [image002.jpg]\n 05:44 AM\n 04:46 AM\n 04:00 PM\n 03:05 AM\n 03:17 PM\n WBC\n 6.1\n 4.7\n 5.1\n Hct\n 32.1\n 31.9\n 33.1\n Plt\n 156\n 159\n 146\n Cr\n 1.3\n 1.4\n 1.3\n 1.2\n 1.1\n Glucose\n 83\n 104\n 155\n 115\n Other labs:\n PT / PTT / INR:18.4/29.1/1.7,\n Ca++:8.3 mg/dL, Mg++:2.0 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\n recently discharged from the CCU () for CHF exacerbation c/b\n C.diff infection and on for septic joint washout c/b failure to\n extubate CHF exacerbation, who is now being admitted from \n clinic with total body fluid overload.\n .\n # sCHF exacerbation: Patient has history of CHF ischemic , \n 10%, s/p BiV ICD ( Concerto C154DWK) 1/08with EF 10% which is\n the likely cause of her fluid overload. Her rapid accumulation\n underpins the severity of her condition and her severely unfavourable\n hemodynamics. Her long term goals are comfort, though she still wishes\n to participate in rehab. Her family recognizes that she is dying. Our\n goal is diuresis which we will attempt aggressively, reassessing our\n progress dynamically. She diuresed well on Lasix gtt on with net\n neg 4L balance. LOS fluid balance -5L.\n -- goal diuresis 5 to 10L total\n -- continue milrinone\n -- continue metolazone 5mg daily\n -- continue metoprolol tartrate 12.5mg PO BID\n -- slow uptitration of lasix gtt with goal near-continuous diuresis\n while avoiding MAP < 60\n -- strict i/o's with foley\n -- replete K to 5\n -- PM electrolytes\n -- family meeting with HCP prn\n .\n # Septic Joints: Patient with history +staph aureus in left shoulder\n treated by washout and vancomycin, thus far 4 weeks of monotherapy. No\n + blood cx since before . Major issue now is pain control.\n -- continue vanc, was recently on 500 mg q12 and switched to q24 for\n high troughs\n -- continue cipro\n -- continue MS contin 15mg \n -- ultram q6, Tylenol q8, Morphine for breakthrough (2-4 mg).\n .\n # Sacral Decub - stage 3-4.\n - wound care\n - pain control\n .\n # UTI: positive UA, no history of culture positive UA's in system\n - treating empirically with cipro day 1 was . Last dose tomorrow\n morning (Morning of ^st)\n - watch INR on abx\n .\n # CORONARIES: Patient with h/o CAD w/ right dominant system, mild\n instent re-stenois of the LAD BM stent and occluded RCA.\n - bb as tolerated\n .\n # RHYTHM: Patient with h/o atrial fibrillation, s/p BiV ICD (\n Concerto C154DWK) , on coumadin. Now in paced rhythm\n - cont home dose meds (amio, metoprolol)\n - cont coumadin\n .\n # Chronic Kidney Disease: Baseline Creatinine 1.3. Creatinine 1.1\n today.\n - trend\n .\n # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a\n filter in place.\n - continue Coumadin\n .\n # Hypothyroidism: Continue Levothyroxine\n .\n # Gout: continue Allopurinol\n ICU Care\n Nutrition:\n Low Na diet\n Glycemic Control: not on insulin\n Lines:\n Multi Lumen - 05:34 PM\n Midline - 05:34 PM\n 18 Gauge - 05:35 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: DNR / DNI\n Disposition:ICU\n"},{"category":"Nursing","chartdate":"2180-01-17 00:00:00.000","description":"Nursing Progress Note","row_id":400098,"text":"71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\n : Sent to ED from clinic w/ hypotension\n transiently on\n dopa, Tx\nd w/ NS 250 cc w/ SBP ^ 92.\n Admit to CCU for aggressive diuresis.She was started on Milrinone\n and lasix gtt. And has been diuresing well. She has lg coccyx decub\n that is a source of chronic pain. She is DNR/DNI and defibrillator has\n been shut off. She has excellent apetite.\n Pain control (acute pain, chronic pain)\n Assessment:\n Plan is to transition to oral forms of pain control in preparation for\n pt going to rehab. She had received MS contin at 0600, but pill was\n ground and pt had nausea. She received 4mg IV morphine at 6am as well.\n She continues on standing acetominofen and ultram\n Action:\n MS contin will be given in to 15mg pills, which are smaller and can\n take them without having them crushed. Morphine immediate release has\n been ordered for breakthrough pain. It is also a small pill that she\n can take without crushing. She had 15mg immediate release at 1300 . She\n has had no IV morphine sulfate since 1030.\n Response:\n Pt has been pain free except when turned since then. She will have\n acute pain with position change, but it will settle down and go away\n within a few minutes. She received MS contin at 1800\n Plan:\n Continue to try to control pain with oral medications. Give immediate\n release morphine for breakthrough pain.\n Impaired Skin Integrity\n Assessment:\n Sacral wound getting worse and remains very painful. Mepilex dsg oozing\n through. Acuacel added. Know MRSA infection on R knuckle and R elbow\n appear to be much more reddened than last week. Over all skin is dry\n and itchy.\n Action:\n Wound care nurse came to evaluate wound. Area is now cleansed with\n wound cleanser and dried. Criticade antifungal is applied to wound\n edges and peri-wound area. The wound is covered with aquacel AG and\n then small soft-sorb pad. It is secured with medipore tape on skin that\n has been prepped with barrier wipe. Finger and elbow are washed with\n soap and water. Area kept lubricated. oil used in water. Moisture\n barrier clean applied to body. Heels elevated off bed.\n Response:\n Skin less itchy. No further worsening of skin condition.\n Plan:\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Pt being transition for transfer back to rehab. Milrinone and lasix\n drips stopped at 1030.\n Action:\n At noon she received dose of torsemide 40mg po and metolazone 5mg po.\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2180-01-16 00:00:00.000","description":"Nursing Progress Note","row_id":400017,"text":"71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\n recently discharged from the CCU () for CHF exacerbation c/b\n C.diff infection and on for septic joint washout c/b failure to\n extubate CHF exacerbation, who is now being admitted from \n clinic with total body fluid overload.\n .\n Pain control (acute pain, chronic pain)\n Assessment:\n Patent\ns primary wish is her comfort. Continues to favor her DNR/DNI\n status.\n Action:\n Premedicated with 4 mg of MSO4 prior to all positon changes. Pain\n med has been increased to 2-4 mg q1 hour if needed. Ms contin 15 mg q12\n Response:\n Moaning with position changes especially to the left side\n Plan:\n Discussions on going with patient and Dr regarding plan of care\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n HR 70 AVP ..SBP 80\ns/40\n Action:\n Lasix decreased to 5 mg/hr as urine output >200 cc q1 hour\n Response:\n 4200 cc negative at mdnight\n Plan:\n Continue on milrinone and lasix for fluid over load\n"},{"category":"Physician ","chartdate":"2180-01-16 00:00:00.000","description":"Physician Resident Progress Note","row_id":400027,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n - MS Contin 15 , was getting 22 mg IV morph qday\n - pulled EJ\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 08:00 AM\n Vancomycin - 09:36 AM\n Infusions:\n Furosemide (Lasix) - 5 mg/hour\n Milrinone - 0.5 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 06:40 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.8\n HR: 70 (62 - 75) bpm\n BP: 88/57(63) {78/43(52) - 106/66(76)} mmHg\n RR: 23 (9 - 35) insp/min\n SpO2: 97%\n Heart rhythm: AV Paced\n Wgt (current): 77.3 kg (admission): 82.2 kg\n Total In:\n 1,335 mL\n 121 mL\n PO:\n 420 mL\n TF:\n IVF:\n 915 mL\n 121 mL\n Blood products:\n Total out:\n 5,565 mL\n 880 mL\n Urine:\n 5,565 mL\n 880 mL\n NG:\n Stool:\n Drains:\n Balance:\n -4,230 mL\n -759 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///33/\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Diminished: )\n Abdominal: Soft, Obese\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 146 K/uL\n 10.7 g/dL\n 115 mg/dL\n 1.1 mg/dL\n 33 mEq/L\n 3.8 mEq/L\n 39 mg/dL\n 92 mEq/L\n 133 mEq/L\n 33.1 %\n 5.1 K/uL\n [image002.jpg]\n 05:44 AM\n 04:46 AM\n 04:00 PM\n 03:05 AM\n 03:17 PM\n WBC\n 6.1\n 4.7\n 5.1\n Hct\n 32.1\n 31.9\n 33.1\n Plt\n 156\n 159\n 146\n Cr\n 1.3\n 1.4\n 1.3\n 1.2\n 1.1\n Glucose\n 83\n 104\n 155\n 115\n Other labs:\n PT / PTT / INR:18.4/29.1/1.7,\n Ca++:8.3 mg/dL, Mg++:2.0 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\n recently discharged from the CCU () for CHF exacerbation c/b\n C.diff infection and on for septic joint washout c/b failure to\n extubate CHF exacerbation, who is now being admitted from \n clinic with total body fluid overload.\n .\n # sCHF exacerbation: Patient has history of CHF ischemic , \n 10%, s/p BiV ICD ( Concerto C154DWK) 1/08with EF 10% which is\n the likely cause of her fluid overload. Her rapid accumulation\n underpins the severity of her condition and her severely unfavourable\n hemodynamics. Her long term goals are comfort, though she still wishes\n to participate in rehab. Her family recognizes that she is dying. Our\n goal is diuresis which we will attempt aggressively, reassessing our\n progress dynamically. She diuresed well on Lasix gtt on with net\n neg 4L balance. LOS fluid balance -5L.\n -- goal diuresis 1L negative today with lasix gtt\n -- continue milrinone\n -- continue metolazone 5mg daily\n -- continue metoprolol tartrate 12.5mg PO BID\n -- strict i/o's with foley\n -- replete K to 5\n -- PM electrolytes\n -- family meeting with HCP prn\n .\n # Septic Joints: Patient with history +staph aureus in left shoulder\n treated by washout and vancomycin, thus far 4 weeks of monotherapy. No\n + blood cx since before . Major issue now is pain control.\n -- continue vanc, was recently on 500 mg q12 and switched to q24 for\n high troughs\n -- continue cipro\n -- increase MS contin to 30mg \n -- ultram q6, Tylenol q8, Morphine for breakthrough (2-4 mg).\n .\n # Sacral Decub - stage 3-4.\n - wound care\n - increase MS contin to 30mg \n - pain control\n .\n # UTI: positive UA, no history of culture positive UA's in system\n - treating empirically with cipro day 1 was . Last dose tomorrow\n morning (Morning of ^st)\n - watch INR on abx\n .\n # CORONARIES: Patient with h/o CAD w/ right dominant system, mild\n instent re-stenois of the LAD BM stent and occluded RCA.\n - bb as tolerated\n .\n # RHYTHM: Patient with h/o atrial fibrillation, s/p BiV ICD (\n Concerto C154DWK) , on coumadin. Now in paced rhythm\n - cont home dose meds (amio, metoprolol)\n - cont coumadin\n .\n # Chronic Kidney Disease: Baseline Creatinine 1.3. Creatinine 1.1\n today.\n - trend\n .\n # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a\n filter in place.\n - continue Coumadin\n .\n # Hypothyroidism: Continue Levothyroxine\n .\n # Gout: continue Allopurinol\n ICU Care\n Nutrition:\n Low Na diet\n Glycemic Control: not on insulin\n Lines:\n Multi Lumen - 05:34 PM\n Midline - 05:34 PM\n 18 Gauge - 05:35 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: DNR / DNI\n Disposition:ICU\n"},{"category":"Physician ","chartdate":"2180-01-16 00:00:00.000","description":"Physician Resident Progress Note","row_id":400029,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n - MS Contin 15 , was getting 22 mg IV morph qday\n - pulled EJ\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 08:00 AM\n Vancomycin - 09:36 AM\n Infusions:\n Furosemide (Lasix) - 5 mg/hour\n Milrinone - 0.5 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 06:40 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.8\n HR: 70 (62 - 75) bpm\n BP: 88/57(63) {78/43(52) - 106/66(76)} mmHg\n RR: 23 (9 - 35) insp/min\n SpO2: 97%\n Heart rhythm: AV Paced\n Wgt (current): 77.3 kg (admission): 82.2 kg\n Total In:\n 1,335 mL\n 121 mL\n PO:\n 420 mL\n TF:\n IVF:\n 915 mL\n 121 mL\n Blood products:\n Total out:\n 5,565 mL\n 880 mL\n Urine:\n 5,565 mL\n 880 mL\n NG:\n Stool:\n Drains:\n Balance:\n -4,230 mL\n -759 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///33/\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Diminished: )\n Abdominal: Soft, Obese\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 146 K/uL\n 10.7 g/dL\n 115 mg/dL\n 1.1 mg/dL\n 33 mEq/L\n 3.8 mEq/L\n 39 mg/dL\n 92 mEq/L\n 133 mEq/L\n 33.1 %\n 5.1 K/uL\n [image002.jpg]\n 05:44 AM\n 04:46 AM\n 04:00 PM\n 03:05 AM\n 03:17 PM\n WBC\n 6.1\n 4.7\n 5.1\n Hct\n 32.1\n 31.9\n 33.1\n Plt\n 156\n 159\n 146\n Cr\n 1.3\n 1.4\n 1.3\n 1.2\n 1.1\n Glucose\n 83\n 104\n 155\n 115\n Other labs:\n PT / PTT / INR:18.4/29.1/1.7,\n Ca++:8.3 mg/dL, Mg++:2.0 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\n recently discharged from the CCU () for CHF exacerbation c/b\n C.diff infection and on for septic joint washout c/b failure to\n extubate CHF exacerbation, who is now being admitted from \n clinic with total body fluid overload.\n .\n # sCHF exacerbation: Patient has history of CHF ischemic , \n 10%, s/p BiV ICD ( Concerto C154DWK) 1/08with EF 10% which is\n the likely cause of her fluid overload. Her rapid accumulation\n underpins the severity of her condition and her severely unfavourable\n hemodynamics. Her long term goals are comfort, though she still wishes\n to participate in rehab. Her family recognizes that she is dying. Our\n goal is diuresis which we will attempt aggressively, reassessing our\n progress dynamically. She diuresed well on Lasix gtt on with net\n neg 4L balance. LOS fluid balance -5L.\n -- goal diuresis 1L negative today with lasix gtt\n -- continue milrinone\n -- continue metolazone 5mg daily\n -- continue metoprolol tartrate 12.5mg PO BID\n -- strict i/o's with foley\n -- replete K to 5\n -- PM electrolytes\n -- family meeting with HCP prn\n .\n # Septic Joints: Patient with history +staph aureus in left shoulder\n treated by washout and vancomycin, thus far 4 weeks of monotherapy. No\n + blood cx since before . Major issue now is pain control.\n -- continue vanc, was recently on 500 mg q12 and switched to q24 for\n high troughs\n -- continue cipro\n -- increase MS contin to 30mg \n -- ultram q6, Tylenol q8, Morphine for breakthrough (2-4 mg).\n .\n # Sacral Decub - stage 3-4.\n - wound care\n - increase MS contin to 30mg \n - pain control\n .\n # UTI: positive UA, no history of culture positive UA's in system\n - treating empirically with cipro day 1 was . Last dose tomorrow\n morning (Morning of ^st)\n - watch INR on abx\n .\n # CORONARIES: Patient with h/o CAD w/ right dominant system, mild\n instent re-stenois of the LAD BM stent and occluded RCA.\n - bb as tolerated\n .\n # RHYTHM: Patient with h/o atrial fibrillation, s/p BiV ICD (\n Concerto C154DWK) , on coumadin. Now in paced rhythm\n - cont home dose meds (amio, metoprolol)\n - cont coumadin\n .\n # Chronic Kidney Disease: Baseline Creatinine 1.3. Creatinine 1.1\n today.\n - trend\n .\n # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a\n filter in place.\n - continue Coumadin\n .\n # Hypothyroidism: Continue Levothyroxine\n .\n # Gout: continue Allopurinol\n ICU Care\n Nutrition:\n Low Na diet\n Glycemic Control: not on insulin\n Lines:\n Multi Lumen - 05:34 PM\n Midline - 05:34 PM\n 18 Gauge - 05:35 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: DNR / DNI\n Disposition:ICU\n ------ Protected Section ------\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I would add the following remarks:\n Above discussed extensively with patient.\n DNR status discussed. DNR.\n Total time spent on patient care: 45 minutes.\n Additional comments:\n Approaching 10 liters net negative fluid balance, which was our goal.\n She is remarkably better in terms of appetite, breathing, and general\n comfort level. Plan is for another 24 h milrinone plus Lasix gtt.\n Then shut off milrinone and switch to torsemide 40 mg po bid plus\n metolazone 2.5 mg qam. Anticipate discharge to rehab on Tuesday\n ------ Protected Section Addendum Entered By: on:\n 11:28 ------\n"},{"category":"Social Work","chartdate":"2180-01-17 00:00:00.000","description":"Social Work Progress Note","row_id":400096,"text":"SOCIAL WORK: Following pt for coping with hospitalization and illness.\n Pt know to this writer from previous admission in . Spoke with\n pt's nurse . RN reports pt has had palliative care consult today.\n Met w/ pt in her room on the CCU. niece was also\n present. Pt was alert and oriented x3, made good eye contact. Pt\n repeatedly states that she is very pleased with care at and\n regrets that she cannot return to rehab. Pt gave limited\n responses around her understanding of palliative care approach. She\n deferred questions to her family members who help her with medical\n decisions. Pt concerned about dispo plan. SW reassured pt that case\n management will work with her family to make acceptable plan and SW\n will communicate family's wishes.\n Obtained contact numbers for all decision makers, HCP is \n (pt's niece) ( (H), (\n (C). Sister (, sister P. ( and niece . Family expressed wish that pt\n go to House in .\n Plan: -SW to provide emotional support for pt coping with the\n transition from the hospital\n -SW to further explore and provide support around palliative\n care approach presented today\n , MSW Intern\n Pager \n 05:36 PM\n"},{"category":"Nursing","chartdate":"2180-01-18 00:00:00.000","description":"Nursing Progress Note","row_id":400171,"text":"71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\n : Sent to ED from clinic admit to CCU for aggressive\n diuresis. She was started on Milrinone and lasix gtt, lasix and\n milrinone gtts turned to off . Milrinone restarted d/t BP and U/O\n decrease. Large Stage III decube on coccyx decub that is a source of\n chronic pain. She is DNR/DNI and defibrillator has been shut off. Able\n to swallow pills whole, with either applesauce or custard.\n SOCIAL: Family in to visit. Pts HCP is in and intubated,\n pt\ns sister is alternate HCP.\n control (acute pain, chronic pain)\n Assessment:\n On standing dose of morphine SR, ultram and Tylenol.\n Action/Response:\n Pain rated to be this am, then later in day .\n Given supplemental IR morphine once and 2mg IV morphine once with\n relief of pain.\n Repositioned for comfort\n Plan:\n Continue pain control with oral medications. Give immediate release\n morphine for breakthrough pain.\n Impaired Skin Integrity\n Assessment:\n Stage III PU on coccyx, foul smelling, yellow sanguinous drainage,\n edges of wound yellow with areas of necrosis. Surrounding skin\n macerated. Pt. refusing kinair bed\n Action/Response:\n Dressing changed according to wound care RN\ns recs:\n anti-fungal barrier criticaid to macerated skin surrounding wound,\n acqua cell-AG to coccyx, covered in soft sorb dsg, medipore tape.\n Aloe Vesta to skin\n Offered repositioning q 2 hours, often times refusing as she\n is comfortable\n Po\ns encouraged, patient drinking hot chocolate, custard,\n applesauce.\n Plan:\n QD dressing change as above. Aloe vesta to skin. Reposition q2 hours\n or according to pt\ns wishes.\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Pt DNR/DNI. SBP 90\ns. Milrinone @ 0.5mcg/kg/min. U/O ~ 100cc q\n 2hours.\n Action/Response:\n Dr. in to talk with patient and family extensively.\n Milrinone turned to off. Torsemide and metzolone d/c\n Palliative care MD in to talk with pt and\n family.\n Patient\ns sisters at bedside most of afternoon.\n SBP decreasing to low 80\ns and then 70\ns off milrinone, U/O\n also tapering off. CCU resident notified, will hold off on IV fluids\n unless pt c/o dizziness. Did c/o nausea X1\nzofran with relief\n Plan:\n To remain in hospital for now. Will monitor off of milrinone with plan\n to give IV NS 250 cc for hypotension as per Dr. . No other changes\n in medications for now. Focus on comfort. Continue to support patient\n and family.\n"},{"category":"Nursing","chartdate":"2180-01-13 00:00:00.000","description":"Nursing Progress Note","row_id":399691,"text":"Pt is a 71 yo female with PMH: BM stent to LAD ', Occluded RCA\n without intervention, Ischemic CM (EF 10-25%), BiV ICD, AF, PVD, DVT\n s/p IVC filter, coumadin, hypothyroidism, CKD, OA. adm for HF\n (milrinone/lasix) MRSA in L shoulder, L hip and R knuckle. Out to\n rehab . Today went from rehab to see Dr. , sent to EW with\n hypotension. SBP 70 in EW, transiently on dopa, but cardiology d/c'd.\n Rxd with NS 250 cc with SBP 92. Pt has been in rehab since d/c from\n with septic arthritis in L shoulder, hip and R knuckle.\n On Vanco followed by ID.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt given ultram/Tylenol at bedtime for overall pain and pain at coccyx\n wound site. Appears comfortable and sleeping most of nite.\n Action:\n Given ultram and Tylenol as ordered- no prn MSO4 this shift.\n Response:\n Sleeping comfortably. Easy to fall back asleep, comfortable, even after\n changing postion frequently throughout nite.\n Plan:\n Continue to closely monitor pain level. Medicate, reposition, emotional\n support. Attempt to keep pt free of pain.\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Pt w long standing ESHD currently admitted from PCP office for LE\n edema/hypotension for inotropy/diuresis.\n Action:\n Pt started on milrinone 0.375 gtt after 50 mcg/kg bolus- started on low\n dose lasix gtt for diuresis once established that hemodynamics remained\n stable w initiaton of milrinone gtt.\n Response:\n Pt\ns hemodynamics remaining stable after milrinone gtt started- HR-\n 70\ns V paced, no significant VEA. BP 90/40\n goal MAP > 60 met this\n shift. Fair uo from lasix- increased from 2.5-5 mg/hr per team ordered.\n Plan:\n Continue to closely monitor hemodynamics, level of edema/volume\n overload and attempt to diurese w lasix gtt. Consider bolus? Of lasix\n as well as increasing gtt and/or adding zaroxylin to augment response\n to lasix gtt. Keep pt and family aware of plan of care, current\n progress.\n Impaired Skin Integrity\n Assessment:\n Pt admitted to CCU w stage 3 coccyx wound. Currently dressed w mepiplex\n after cleaning site. Dressing remains dry/intact.\n Action:\n Frequent turning side to side w 2 assist- fair tolerance of turning,\n not assisting w turning, and wanting to be\nleft alone and let me\n sleep\n. Applied aloe vesta to back/hips/bony prominences. Applied\n waffle boots to bilateral feet to prevent edematous heels from breaking\n down.\n Response:\n Dressing remains dry/intact.\n Plan:\n Continue to protect skin at risk. Continue to treat current wound w\n dressing as currently are doing. Consult w skin care RN. Of note- pt\n refuses kinair bed.\n"},{"category":"Nursing","chartdate":"2180-01-14 00:00:00.000","description":"Nursing Progress Note","row_id":399764,"text":"Pt is a 71 yo female with PMH: BM stent to LAD ', Occluded RCA\n without intervention, Ischemic CM (EF 10-25%), BiV ICD, AF, PVD, DVT\n s/p IVC filter, coumadin, hypothyroidism, CKD, OA. adm for HF\n (milrinone/lasix) MRSA in L shoulder, L hip and R knuckle. Out to\n rehab . went from rehab to see Dr. , sent to EW with\n hypotension. SBP 70 in EW, transiently on dopa, but cardiology d/c'd.\n Rxd with NS 250 cc with SBP 92. Pt has been in rehab since d/c from\n with septic arthritis in L shoulder, hip and R knuckle.\n On Vanco followed by ID.\n She was started on milrinone .375 after bolus and lasix drip also begun\n at 2.5mg/hr. The lasix dose was increased to 5mg overnight, but urine\n output has remained poor, though she is negative.\n GI: Pt has poor apetite and eats very little.\n SOCIAL: Family in the visit in afternoon. Pt in good spirits, visiting\n with brother and his family.\n CODE STATUS: Dr had discussion with both patient and health care\n proxy and all are in agreement that she be DNR/DNI. Additionally the\n defibrillator part of AICD/pacer was shut off.\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Physician ","chartdate":"2180-01-12 00:00:00.000","description":"Physician Resident Admission Note","row_id":399684,"text":"Chief Complaint: Fluid overload\n HPI:\n 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\n recently discharged from the CCU () for CHF exacerbation c/b\n C.diff infection and on for septic joint washout c/b failure to\n extubate CHF exacerbation, who is now being admitted from \n clinic with total body fluid overload.\n .\n Ms. is a resident at NE where she is convalescing from a\n polyarticular MRSA septic arthritis. She has NYHA IV CHF at baseline\n but over the last 4 days has developed 4+ LE edema and ascites where\n there was previously none. She was presented with the choice to pursue\n cardiac transplantation more than 12 years ago when given the diagnosis\n of end-stage CHF. She opted against that.\n .\n Per her recent visit note at clinic, she continues to have L\n shoulder pain, though significantly improved from a few weks ago. She\n continues to work with PT to improve her ROM. She has no pain at her R\n 3rd MCP, though has difficulty extending her finger at that joint. She\n continues to have mild pain and significant weakness at her L\n hip, though improved since hospital discharge. She has had no\n F/C/NS, and no problems with her midline. She has had progression\n of a sacral decub, which gives her the majority of her pain.\n There has not been concern on the part of her rehab for\n superinfection, and it is being treated with local wound care and\n frequent turning. Her sister is hoping to transfer her to \n within the next several days.\n Patient admitted from: ER\n History obtained from Patient, Family / Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Milrinone - 0.375 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension\n 2. CARDIAC HISTORY:\n -CABG: None\n -PERCUTANEOUS CORONARY INTERVENTIONS: BM stent to the LAD in ,\n Occluded RCA/no intervention\n -PACING/ICD: Ischemic cardiomyopathy (EF 10%) s/p BiV ICD and atrial\n fibrillation\n 3. H/o PE secondary to DVT s/p IVC filter on Coumadin\n 4. PVD\n 5. Small VSD\n OTHER\n # Septic Polyarticular Arthritis s/p irrigation and debridement left\n shoulder via anterolateral deltopectoral miniarthrotomy, aspiration\n left hip joint and irrigation and debridement of 3rd\n metacarpophalangeal joint\n 6. Hypothyroidism\n 7. CKD\n 8. Osteoarthritis\n Mother had MI at age 50, maternal uncle died of MI in his 50's.\n No family history of arrhythmia, cardiomyopathies, or sudden cardiac\n death; otherwise non-contributory.\n Occupation: retired\n Drugs: none\n Tobacco: 20 pack year history, however she quit 30 yrs ago\n Alcohol: none\n Other: Pt lives alone but currently resides at NE . She is not\n married. She is cared for primarily by her Niece and sister, both\n nurses.\n Review of systems:\n Constitutional: Fatigue\n Integumentary (skin): painful decub's\n Flowsheet Data as of 08:40 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 35.4\nC (95.8\n Tcurrent: 35.4\nC (95.8\n HR: 70 (70 - 108) bpm\n BP: 83/50(58) {83/50(58) - 109/76(84)} mmHg\n RR: 12 (11 - 18) insp/min\n SpO2: 100%\n Heart rhythm: V Paced\n Wgt (current): 82.2 kg (admission): 82.2 kg\n Total In:\n 284 mL\n PO:\n 30 mL\n TF:\n IVF:\n 4 mL\n Blood products:\n Total out:\n 0 mL\n 350 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -66 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 100%\n Physical Examination\n General Appearance: Thin, Anxious, Cachectic, tearful\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic), II/VI\n systolic murmur best at apex. PMI is laterally displaced\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear :\n anteriorly)\n Abdominal: Soft, Non-tender, Distended, +fluid wave\n Extremities: Right lower extremity edema: 4+, Left lower extremity\n edema: 4+, cool, dry\n Skin: Cool, Stage 3+ sacral decub\n Neurologic: Attentive, Responds to: Not assessed, Oriented (to): x3,\n Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n [image002.jpg]\n Imaging: TTE :\n The left atrium is elongated. The right atrium is markedly dilated. The\n interatrial septum is aneurysmal. The estimated right atrial pressure\n is 10-20mmHg. Left ventricular wall thicknesses are normal. The left\n ventricular cavity is moderately dilated with severe global\n hypokinesis. The basal inferolateral wall contracts best (LVEF = 20 %).\n The estimated cardiac index is borderline low (2.0-2.5L/min/m2). No\n masses or thrombi are seen in the left ventricle. The right ventricular\n cavity is moderately dilated with severe global free wall hypokinesis.\n [Intrinsic right ventricular systolic function is likely more depressed\n given the severity of tricuspid regurgitation.] The ascending aorta is\n mildly dilated. The aortic valve leaflets (3) are mildly thickened but\n aortic stenosis is not present. Trace aortic regurgitation is seen. The\n mitral valve leaflets are mildly thickened. There is no mitral valve\n prolapse. Mild to moderate (+) mitral regurgitation is seen.\n Moderate to severe [3+] tricuspid regurgitation is seen. There is\n moderate pulmonary artery systolic hypertension. Significant pulmonic\n regurgitation is seen. There is a very small circumferential\n pericardial effusion without echocardiographic signs of tamponade.\n Compared with the prior study (images reviewed) of ,\n estimated pulmonary artery systolic pressure is now higher.\n .\n ETT: \n INTERPRETATION: This 64 year old woman with a history of CAD, atrial\n fibrillation and CHF was referred to the lab for evaluation. The\n patient exercised for 4.25 minutes of a modified protocol and\n requested the test be stopped for nausea. The resting oxygen\n consumption was 3.2 ml/kg/min with a respiratory exchange ratio of\n 0.75. At peak exercise, her oxygen consumption increased to 11.0\n ml/kg/min with an expiratory exchange ratio of 0.86. The peak oxygen\n consumption was 45 % of predicted. The oxygen consumption at the onset\n of the anerobic threshold was 9.9 ml/kg/min. This test was not limited\n by muscle fatigue. No arm, neck, back or chest discomfort was reported\n by the patient throughout the study. The ST segments are\n uninterpretable for ischemia in the setting of the baseline LBBB. The\n rhythm was atrial fibrillation with several isolated vpbs and 2\n ventricular couplets. Blunted systolic BP response to exercise.\n IMPRESSION: Very limited physical working capacity in the absence of\n angina.\n .\n CARDIAC CATH:\n LHC/RHC :\n 1. Selective coronary angiography of this right dominant system\n revealed one vessel coronary artery disease. The LMCA had no\n angiographically apparent disease. The LAD had mild instent restenosis\n of the prior stent. The LCx had no angiographically apparent disease.\n The RCA was occluded and similar to prior.\n 2. Resting hemodynamics on milrinone therapy revealed moderately\n elevated right and left sided filling pressures with an RVEDP of\n 15 mmHg and PCWP of 20 mmHg. There was moderate pulmonary hypertension\n with a PASP of 42/20 mmHg. There was normal systemic blood pressure\n with central pressure of 108/63 mmHg. There was a low-normal cardiac\n index of 2.1 L/min/m2. There was no transaortic valve gradient on\n careful pullback from LV to aorta.\n 3. Peripheral angiography revealed patent renal arteries bilaterally.\n .\n MYOCARDIAL VIABILITY STUDY :\n Within limitation of current study, fixed defects in distal anterior\n and apical walls are consistent with scarring. Improvement of inferior\n wall defect with correction is suggestive of myocardial viability.\n Microbiology: Hx of MRSA bacteremia, septic arthritis\n Assessment and Plan\n ASSESSMENT AND PLAN\n 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\n recently discharged from the CCU () for CHF exacerbation c/b\n C.diff infection and on for septic joint washout c/b failure to\n extubate CHF exacerbation, who is now being admitted from \n clinic with total body fluid overload.\n .\n # Anasarca: Patient has history of CHF ischemic , 10%, s/p\n BiV ICD ( Concerto C154DWK) 1/08with EF 10% which is the\n likely cause of her fluid overload. Her rapid accumulation underpins\n the severity of her condition and her severely unfavourable\n hemodynamics. Her long term goals are comfort, though she still wishes\n to participate in rehab. Her family recognizes that she is dying. Our\n goal is diuresis which we will attempt aggressively, reassessing our\n progress dynamically.\n -- milrinone with bolus\n -- neosynephrine for pressure support, goal MAP of > 60\n -- slow uptitration of lasix with goal near-continuous diuresis while\n avoiding MAP < 60\n -- strict i/o's with foley\n -- can switch to levophed if low UOP on Neo with need for pressor\n support\n -- family meeting with HCP to assess goals in AM after diuresis\n attempted\n .\n # Septic Joints: Patient with history +staph aureus in left shoulder\n treated by washout and vancomycin, thus far 4 weeks of monotherapy. No\n + blood cx since before . Major issue now is pain control.\n -- send Vanco level in AM, was recently on 500 mg q12 and switched to\n q24 for high troughs\n -- ultram q6, Tylenol q8, Morphine for breakthrough (1-3 mg).\n - Will consider ms contin if no control\n .\n # CORONARIES: Patient with h/o CAD w/ right dominant system, mild\n instent re-stenois of the LAD BM stent and occluded RCA.\n - bb as tolerated\n .\n # RHYTHM: Patient with h/o atrial fibrillation, s/p BiV ICD (\n Concerto C154DWK) , on coumadin. Now in paced rhythm\n - cont home dose meds (amio, metoprolol)\n - cont coumadin\n - f/u INR\n .\n # Chronic Kidney Disease: Baseline 1.3 creatinine. At baseline\n - trend\n .\n # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a\n filter in place.\n - cont coumadin\n - f/u INR\n .\n # Hypothyroidism: Continue Levothyroxine.\n .\n # Gout: continue allopurionl\n .\n # FEN: low sodium diet\n .\n # ACCESS: Right PICC, right IJ, Left EJ\n .\n # PROPHYLAXIS: on coumadin\n .\n # CODE: DNR, can intubate, briefly\n .\n # DISPO: CCU for now.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 05:34 PM\n Midline - 05:34 PM\n 18 Gauge - 05:35 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition: ICU\n"},{"category":"Nursing","chartdate":"2180-01-12 00:00:00.000","description":"Nursing Progress Note","row_id":399685,"text":"Pt is a 71 yo female with PMH: BM stent to LAD ', Occluded RCA\n without intervention, Ischemic CM (EF 10-25%), BiV ICD, AF, PVD, DVT\n s/p IVC filter, coumadin, hypothyroidism, CKD, OA. adm for HF\n (milrinone/lasix) MRSA in L shoulder, L hip and R knuckle. Out to\n rehab . Today went from rehab to see Dr. , sent to EW with\n hypotension. SBP 70 in EW, transiently on dopa, but cardiology d/c'd.\n Rxd with NS 250 cc with SBP 92. Pt has been in rehab since d/c from\n with septic arthritis in L shoulder, hip and R knuckle.\n On Vanco followed by ID.\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2180-01-17 00:00:00.000","description":"Nursing Progress Note","row_id":400114,"text":"71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\n : Sent to ED from clinic w/ hypotension\n transiently on\n dopa, Tx\nd w/ NS 250 cc w/ SBP ^ 92.\n Admit to CCU for aggressive diuresis.She was started on Milrinone\n and lasix gtt. And has been diuresing well. She has lg coccyx decub\n that is a source of chronic pain. She is DNR/DNI and defibrillator has\n been shut off.\n Pain control (acute pain, chronic pain)\n Assessment:\n Family deciding if pt will now be CMO and go to extended care facility\n with hospice.\n Action:\n Response:\n Plan:\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Physician ","chartdate":"2180-01-14 00:00:00.000","description":"Physician Resident Progress Note","row_id":399833,"text":"Chief Complaint:\n 24 Hour Events:\n - confirmed DNR, acemaker turned off\n - despite lasix gtt, diuresis poor yesterday\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Ciprofloxacin - 08:00 AM\n Infusions:\n Other ICU medications:\n Coumadin (Warfarin) - 04:00 PM\n Lansoprazole (Prevacid) - 04:00 PM\n Morphine Sulfate - 05:05 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.4\nC (97.5\n HR: 99 (66 - 104) bpm\n BP: 91/50(60) {82/42(45) - 101/67(120)} mmHg\n RR: 12 (11 - 23) insp/min\n SpO2: 99%\n Heart rhythm: V Paced\n Wgt (current): 82.2 kg (admission): 82.2 kg\n Total In:\n 1,554 mL\n 456 mL\n PO:\n 900 mL\n 60 mL\n TF:\n IVF:\n 654 mL\n 396 mL\n Blood products:\n Total out:\n 1,628 mL\n 1,505 mL\n Urine:\n 1,628 mL\n 1,505 mL\n NG:\n Stool:\n Drains:\n Balance:\n -74 mL\n -1,049 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///27/\n Physical Examination\n General Appearance: No acute distress, thin, cachectic\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: II/VI systolic murmur best at apex. MI is laterally\n displaced\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Breath Sounds: Clear : anteriorly)\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+\n Skin: Not assessed, Stage 3 sacral decubitus ulcer\n Neurologic: Attentive, Responds to: Not assessed, Oriented (to): x3\n Labs / Radiology\n 159 K/uL\n 10.0 g/dL\n 104 mg/dL\n 1.4 mg/dL\n 27 mEq/L\n 3.8 mEq/L\n 42 mg/dL\n 98 mEq/L\n 134 mEq/L\n 31.9 %\n 4.7 K/uL\n [image002.jpg]\n 05:44 AM\n 04:46 AM\n WBC\n 6.1\n 4.7\n Hct\n 32.1\n 31.9\n Plt\n 156\n 159\n Cr\n 1.3\n 1.4\n Glucose\n 83\n 104\n Other labs: PT / PTT / INR:16.8/29.3/1.5, Ca++:8.0 mg/dL, Mg++:2.1\n mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\n recently discharged from the CCU () for CHF exacerbation c/b\n C.diff infection and on for septic joint washout c/b failure to\n extubate CHF exacerbation, who is now being admitted from \n clinic with total body fluid overload.\n .\n # sCHF exacerbation: Patient has history of CHF ischemic , \n 10%, s/p BiV ICD ( Concerto C154DWK) 1/08with EF 10% which is\n the likely cause of her fluid overload. Her rapid accumulation\n underpins the severity of her condition and her severely unfavourable\n hemodynamics. Her long term goals are comfort, though she still wishes\n to participate in rehab. Her family recognizes that she is dying. Our\n goal is diuresis which we will attempt aggressively, reassessing our\n progress dynamically. She put out very little o/n on lasix gtt. This\n could reflect limitatin of diuresis or the importance of a bolus (we\n withheld bolus to avoid instability)\n -- goal diuresis 5 to 10L total\n -- milrinone with bolus\n -- metoprolol tartrate 12.5mg PO BID\n -- slow uptitration of lasix gtt with goal near-continuous diuresis\n while avoiding MAP < 60\n -- strict i/o's with foley\n -- replete K to 5\n -- PM electrolytes\n -- can switch to levophed if low UOP on Neo with need for pressor\n support\n -- family meeting with HCP to assess goals in AM after diuresis\n attempted\n .\n # Septic Joints: Patient with history +staph aureus in left shoulder\n treated by washout and vancomycin, thus far 4 weeks of monotherapy. No\n + blood cx since before . Major issue now is pain control.\n -- send Vanco level in AM, was recently on 500 mg q12 and switched to\n q24 for high troughs\n -- ultram q6, Tylenol q8, Morphine for breakthrough (2-4 mg).\n - Will consider ms contin if no control\n .\n # Sacral Decub - stage 3-4.\n - wound care\n - pain control.\n .\n # UTI: positive UA, no history of culture positive UA's in system\n - treating empirically with cipro\n - watch INR on abx\n .\n # CORONARIES: Patient with h/o CAD w/ right dominant system, mild\n instent re-stenois of the LAD BM stent and occluded RCA.\n - bb as tolerated\n .\n # RHYTHM: Patient with h/o atrial fibrillation, s/p BiV ICD (\n Concerto C154DWK) , on coumadin. Now in paced rhythm\n - cont home dose meds (amio, metoprolol)\n - cont coumadin\n - f/u INR\n .\n # Chronic Kidney Disease: Baseline 1.3 creatinine. At baseline\n - trend\n .\n # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a\n filter in place.\n - continue Coumadin\n - f/u INR\n .\n # Hypothyroidism: Continue Levothyroxine\n .\n # Gout: continue Allopurinol\n ICU Care\n Nutrition: cardiac diet\n Glycemic Control: None\n Lines:\n Multi Lumen - 05:34 PM\n Midline - 05:34 PM\n 18 Gauge - 05:35 PM\n Prophylaxis:\n DVT: Coumadin\n Stress ulcer: Lansoprazole\n VAP:\n Comments:\n Communication: patient\n Code status: DNR/DNI\n Disposition:\n"},{"category":"Nursing","chartdate":"2180-01-16 00:00:00.000","description":"Nursing Progress Note","row_id":400046,"text":"71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\n : Sent to ED from clinic w/ hypotension\n transiently on\n dopa, Tx\nd w/ NS 250 cc w/ SBP ^ 92. Admit to CCU for aggressive\n diuresis.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt needing less doses IV Morphine since MS Contin increased to 30mg \n this morning\n Pt consistently states pain is at coccyx\n immediate area of pressure\n ulcer and nowhere else\n Action:\n Received MS Contin 15mg x 2 this AM\n Continues on Tylenol 1000mg po TID, Ultram 50mg QID\n Received Morphine IV 4mg approx every 2 hours this am x total 4 doses\n none since approx 1245\n Response:\n Pt appears more comfortable this PM\n able to turn w/o premedicating with IV Morphine\n Pt states pain is which she states is good for her\n Plan:\n Cont assess pain, cont ATC meds and supplement with IV Morphine as\n needed\n ? etiology of severe pain\n ESR ordered to r/o osteo\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Pt asystomatic\n no SOB with stable VS\n Action:\n Milrinone remains at 0,5mcgs/kg/min\n Lasix increased from 5 to 10mg/hr\n Response:\n Initial urine output ~ 200cc/hr in AM\n now decreased to 20-40cc/hr,\n Lasix gtt titrated back to 10mg/hr with slight increase output\n Plan:\n Cont IV Lasix/Mirinone overnight and D/C in AM\n Transition to oral regimen, Assess response\n Impaired Skin Integrity\n Assessment:\n Large unstageable pressur ulcer on coccyx unchanged\n Bilat heels remain reddened but blanchble\n Old abrasion to r elbow\n Action:\n dressing coming off\n cleansed and redressed this AM-duoderm\n gel/Mepilex,\n mod amt sero-sanguinous drainage; redness/maceration to surrounding\n tissue\n severe pain at site\n see above\n Response:\n Site remains unchanged\n Plan:\n Cont keep PU clean with intact dressing, frequent turns avoiding back\n except when pt sitting upright for meals\n Wound care RN consult in AM\n Roho cushion ordered from PT\n unavailable today\n Ineffective Coping\n Assessment:\n Pt continues to have periods in day when she has difficulty coping with\n plan to return to rehab\n Action:\n Pt allowed to verbalize feelings about rehab, realizes she is unable to\n return home\n Response:\n Pt appears to have periods of\nmeltdown\n with periods of rational\n thought regarding needs and abilities going forward\n Plan:\n Case Manager consult in AM\n Social Service consult in AM.\n Cont to provide emotional support for patient.\n Of note, pt w/o bowel movement x 4 days, appetite good, abdomen soft,\n non-tender with + BS, lots of belching at dinner, Senna given 3x since\n yesterday; Plan: increase bowel regimen given ^ nacotics; cont to\n follow.\n"},{"category":"Nursing","chartdate":"2180-01-19 00:00:00.000","description":"Nursing Transfer Note","row_id":400237,"text":"71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\n coumadin, hypothyroidism, CKD, OA. admitted for septic joint\n washout- MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\n On pt. was sent to ED from clinic w/ hypotension\n transiently on dopa, Tx\nd w/ NS 250 cc w/ SBP ^ 92.\n Admit to CCU for aggressive diuresis. She was started on\n Milrinone and lasix gtt. She has large coccyx decub that is a source\n of chronic pain. She is DNR/DNI and defibrillator has been shut off.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt. with history of pain in left shoulder, left hip (septic joints) and\n coccyx (decub.).\n Action:\n MS , morphine IR 15mg for breakthrough pain, given this x2\n today. Pt. also given 2mg IV morphine prior to all activity/turning\n today. Pt. receiving ultram qid.\n Response:\n Pt. has denied pain today until 1500\n she reported pain after turning\n despite premedicating. Tolerating above with no ill-effects.\n Plan:\n Continue present around-the-clock and prn regimen.\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Off lasix gtt since , and milrinone since . AV paced at 70 with\n BP 90\ns/60\ns today. LS essentially clear, some fine ?dependent\n crackles noted at bases. Skin warm, dry. UO approximately 20cc/hr.\n Action:\n Given all meds this a.m. Assessment ongoing.\n Response:\n Pt. tolerating medication. Assessment unchanged.\n Plan:\n Continue to monitor and treat as indicated. Transfer to floor today.\n Impaired Skin Integrity\n Assessment:\n Pt. with sacral decub as documented in metavision.\n Action:\n Dressing changed today at noon per skin care recs. Pt. turned side to\n side as documented.\n Response:\n Pt. tolerated dressing change, premedicated with morphine IV.\n Moderated amt. yellow-white slough noted. Small amounts drainage\n noted.\n Plan:\n Continue daily dressing changes skin RN. Continue turning as pt.\n tolerates, avoid pressure points.\n"},{"category":"Nursing","chartdate":"2180-01-19 00:00:00.000","description":"Nursing Transfer Note","row_id":400224,"text":"71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\n coumadin, hypothyroidism, CKD, OA. admitted for septic joint\n washout- MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\n On pt. was sent to ED from clinic w/ hypotension\n transiently on dopa, Tx\nd w/ NS 250 cc w/ SBP ^ 92.\n Admit to CCU for aggressive diuresis. She was started on\n Milrinone and lasix gtt. She has large coccyx decub that is a source\n of chronic pain. She is DNR/DNI and defibrillator has been shut off.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt. with history of pain in left shoulder, left hip (septic joints) and\n coccyx (decub.).\n Action:\n MS , morphine IR 15mg for breakthrough pain, given this\n a.m. Pt. also given 2mg IV morphine prior to all activity/turning\n today. Pt. receiving ultram qid.\n Response:\n Pt. has denied pain today, tolerating above with no ill-effects.\n Plan:\n Continue present around-the-clock and prn regimen.\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Off lasix gtt since , and milrinone since . AV paced at 70 with\n BP 90\ns/60\ns today. LS essentially clear, some fine dependent crackles\n noted at bases. Skin warm, dry.\n Action:\n P\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Physician ","chartdate":"2180-01-19 00:00:00.000","description":"Physician Resident Progress Note","row_id":400225,"text":"Chief Complaint: Congestive heart failure\n 24 Hour Events:\n - DCed milrinone and diuretics 11:30am\n - Family mtg held with patient's 3 sisters and multiple other family\n members, Dr. , then (P&PC) Dr. --> everybody in\n agreement w plan to DC milrinone, to give small 250cc boluses as needed\n if BP drops and morphine for symptoms if lungs become overloaded w\n fluid ; Hold on Rehab for now\n - Likely transfer pt to floor tomorrow w PPC following\n - BPs still stable 88-96 SBP (maps>60) at 1am, though family had been\n concerned occasionally that she looked like she had more difficulty\n breathing or increased apneic episodes, though nursing does not feel\n that she has had any difficulty breathing (pt has not needed any 250cc\n boluses at this point)\n - 0430am systolic BPs low 70s, but mentating well, not symptomatic -->\n 1 bag 250ccs NS\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Ciprofloxacin - 10:00 AM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 06:31 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 35.6\nC (96\n HR: 71 (68 - 101) bpm\n BP: 79/58(62) {73/42(51) - 107/73(77)} mmHg\n RR: 11 (9 - 23) insp/min\n SpO2: 92%\n Heart rhythm: V Paced\n Wgt (current): 73.6 kg (admission): 82.2 kg\n Height: 60 Inch\n Total In:\n 743 mL\n 370 mL\n PO:\n 600 mL\n 120 mL\n TF:\n IVF:\n 143 mL\n 250 mL\n Blood products:\n Total out:\n 1,190 mL\n 200 mL\n Urine:\n 1,190 mL\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n -447 mL\n 170 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 92%\n ABG: ////\n Physical Examination\n Gen: alert, oriented x3, pleasant, cachectic chronically ill appearing\n woman. In no acute distress.\n HEENT: dry mucus membranes\n NECK: JVP unable to be assessed secondary to line\n CHEST: clear to auscultation bilaterally\n ABD: mildly distended, soft, nontender\n EXT: + pitting edema lower extremity edema bilaterally\n Labs / Radiology\n 116 K/uL\n 10.2 g/dL\n 93 mg/dL\n 1.0 mg/dL\n 35 mEq/L\n 3.8 mEq/L\n 32 mg/dL\n 91 mEq/L\n 132 mEq/L\n 31.2 %\n 4.6 K/uL\n [image002.jpg]\n 05:44 AM\n 04:46 AM\n 04:00 PM\n 03:05 AM\n 03:17 PM\n 03:05 AM\n 05:03 PM\n 05:22 AM\n 05:25 PM\n 05:40 AM\n WBC\n 6.1\n 4.7\n 5.1\n 4.4\n 4.2\n 4.6\n Hct\n 32.1\n 31.9\n 33.1\n 32.2\n 30.9\n 31.2\n Plt\n 156\n 159\n 146\n 134\n 106\n 116\n Cr\n 1.3\n 1.4\n 1.3\n 1.2\n 1.1\n 1.0\n 1.0\n 1.0\n 1.1\n 1.0\n Glucose\n 83\n 104\n 155\n 115\n 98\n 107\n 86\n 93\n Other labs: PT / PTT / INR:19.1/29.7/1.7, Ca++:8.1 mg/dL, Mg++:2.1\n mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\n recently discharged from the CCU () for CHF exacerbation c/b\n C.diff infection and on for septic joint washout c/b failure to\n extubate CHF exacerbation, who was admitted from clinic with\n total body fluid overload.\n .\n # sCHF Exacerbation:\n Patient has history of CHF ischemic , 10%, s/p BiV ICD\n ( Concerto C154DWK) with EF 10% which was the likely\n cause of her fluid overload. Appears euvolemic currently. Has\n diuresed well -9L on length of stay. Responding well to torsemide with\n metolazone while on milrinone, but urine output had dropped without\n milrinone on . Diuresed net -500cc over last day. Breathing\n comfortably currently.\n - blood pressure maintained without milrinone, will continue to support\n with IV fluids as needed\n - will start on 20mg torsemide daily for maintenance of volume status.\n .\n # Goals of Care:\n End-stage CHF with long term goals are comfort, though she still wishes\n to participate in rehab. Her family recognizes that she is dying. Pain\n and Palliative Care consulted on for pain control and goals of\n care.\n - appreciate palliative care recommendations\n - call-out to floor on for continued comfort measures. Current\n status remains to continue interventions for acute treatable problems,\n but not to re-escalate treatment for CHF with milrinone.\n - will consider disconnecting IJ for comfort\n .\n # Septic Joints: Patient with history +staph aureus in left shoulder\n treated by washout and vancomycin, thus far 4 weeks of monotherapy. No\n + blood cx since before . Major issue now is pain control.\n - continue vancomycin until , then suppression with doxycycline\n - appreciate ID recommendations.\n -- continue MS contin 30mg and reassess pain med needs\n -- standing ultram q6, Tylenol q8\n .\n # Sacral Decub - stage 3-4. Focusing on Pain control. Pain and\n Palliative Care following with patient. Switched to oral breakthrough\n Morphine with IV as backup. Patient required IV morphine this morning\n while moving.\n - wound care\n - standing ultram Q6h, Tylenol Q8h\n - reassess patient\ns pain requirements\n - continue with oral morphine, will use IV as needed now that patient\n primary goal is comfort.\n .\n # UTI: positive UA, no history of culture positive UA's in system.\n Will do 10day course because of chronic foley.\n - treating empirically with cipro ; day 1 of 10 day course was \n - watch INR on abx\n .\n # Hx CAD:\n Patient with h/o CAD w/ right dominant system, mild instent re-stenois\n of the LAD BM stent and occluded RCA.\n - continue metoprolol 25mg \n .\n # Hx Afib:\n Patient with h/o atrial fibrillation, s/p BiV ICD ( Concerto\n C154DWK) , on coumadin. Now in paced rhythm\n - cont home dose meds (amio, metoprolol)\n - cont coumadin, at current dose.\n - trend INR\n .\n # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a\n filter in place. INR mildly subtherapeutic despite Cipro\n - continue Coumadin\n - monitor INR\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 05:34 PM\n Midline - 05:34 PM\n Prophylaxis:\n DVT: coumadin\n Stress ulcer: lansoprazole\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"},{"category":"Nursing","chartdate":"2180-01-19 00:00:00.000","description":"Nursing Transfer Note","row_id":400226,"text":"71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\n coumadin, hypothyroidism, CKD, OA. admitted for septic joint\n washout- MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\n On pt. was sent to ED from clinic w/ hypotension\n transiently on dopa, Tx\nd w/ NS 250 cc w/ SBP ^ 92.\n Admit to CCU for aggressive diuresis. She was started on\n Milrinone and lasix gtt. She has large coccyx decub that is a source\n of chronic pain. She is DNR/DNI and defibrillator has been shut off.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt. with history of pain in left shoulder, left hip (septic joints) and\n coccyx (decub.).\n Action:\n MS , morphine IR 15mg for breakthrough pain, given this\n a.m. Pt. also given 2mg IV morphine prior to all activity/turning\n today. Pt. receiving ultram qid.\n Response:\n Pt. has denied pain today, tolerating above with no ill-effects.\n Plan:\n Continue present around-the-clock and prn regimen.\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Off lasix gtt since , and milrinone since . AV paced at 70 with\n BP 90\ns/60\ns today. LS essentially clear, some fine dependent crackles\n noted at bases. Skin warm, dry.\n Action:\n Given all meds this a.m. Assessment ongoing.\n Response:\n Pt. tolerating medication. Assessment unchanged.\n Plan:\n Continue to monitor and treat as indicated. Transfer to floor today.\n Impaired Skin Integrity\n Assessment:\n Pt. with sacral decub as documented in metavision.\n Action:\n Dressing changed today at noon per skin care recs. Pt. turned side to\n side as documented.\n Response:\n Pt. tolerated dressing change, premedicated with morphine IV.\n Moderated amt. yellow-white slough noted. Small amounts drainage\n noted.\n Plan:\n Continue daily dressing changes skin RN. Continue turning as pt.\n tolerates, avoid pressure points.\n"},{"category":"Nursing","chartdate":"2180-01-19 00:00:00.000","description":"Nursing Transfer Note","row_id":400223,"text":"71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\n coumadin, hypothyroidism, CKD, OA. admitted for septic joint\n washout- MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\n On pt. was sent to ED from clinic w/ hypotension\n transiently on dopa, Tx\nd w/ NS 250 cc w/ SBP ^ 92.\n Admit to CCU for aggressive diuresis. She was started on\n Milrinone and lasix gtt. She has large coccyx decub that is a source\n of chronic pain. She is DNR/DNI and defibrillator has been shut off.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt. with history of pain in left shoulder, left hip (septic joints) and\n coccyx (decub.).\n Action:\n MS . Morphine IR 15mg for breakthrough pain, given this\n a.m. Pt. given 2mg IV morphine prior to all activity/turning today.\n Pt. receiving ultram qid.\n Response:\n Excellent effect\n Plan:\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Off lasix gtt since . restarted on milrinone at .5mcq/k/min. for\n low u/o.\n HR 60-70 Vpaced. Occas. PVC. BP 80\ns-90\ns/ MAP 55-60.\n Action:\n Lopressor held for SBP<80.\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2180-01-19 00:00:00.000","description":"Nursing Progress Note","row_id":400205,"text":"71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\n : Sent to ED from clinic w/ hypotension\n transiently on\n dopa, Tx\nd w/ NS 250 cc w/ SBP ^ 92.\n Admit to CCU for aggressive diuresis.She was started on Milrinone\n and lasix gtt. And has been diuresing well. She has lg coccyx decub\n that is a source of chronic pain. She is DNR/DNI and defibrillator has\n been shut off.\n Family meeting with Dr. . Decision made to d/c milrinone,\n torsimide and metalazone. Feeling that pt. intravas. Dry. Focus is on\n comfort. Palliative care following.\n Pain control (acute pain, chronic pain)\n Assessment:\n Currently on SR morphine , ultram QID and Tylenol RTC.\n Supplementing with IR morphine 15mg as needed as well as IV morphine as\n needed for breakthrough pain.\n c/o pain in back d/t sacral decub wound. Grimaces with turning\n /position change. Generally pain subsides once repositioned but\n occas. requires additional pain medication.\n 0600: after turning. Pt. stating pain- not relieved after 10mn.\n Action:\n IR morphine 15mg x1. repositioned q3-4 hours or as needed/requested by\n pt.\n 0600: med with 2mg IV morphine followed by additional 2mg IV at 0630 w\n Response:\n Pt. reports good pain control. Sleeping when left alone. Wakes easily\n and is lucid.\n Able to take pills whole with applesause.\n Plan:\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n HR 70\ns Vpaced. Occas. PVC. BP 80\ns-90/50\ns. dipping to 73-79/\n maps 50 when asleep.\n Action:\n Gave NSB 250cc at 0500 x1 (this treatment plan was discussed on rounds\n with Dr. \n Held PM lopressor dose\n Response:\n Good response\n BP BP 86/56 map 64.\n u/o 20-30cc/hr.\n LS diminished bases. Sats 94-96% when awake. Dipping to 80\ns when\n asleep. Noted for periods of apnea.\n Plan:\n Monitor u/o, sats. Monitor for worsening heart failure symptoms.\n Impaired Skin Integrity\n Assessment:\n Stage 3 decub on coccyx. Followed by wound care RN. Dsg changed QD.\n Not visualized .\n DSD remains intact. No drainage.\n c/o some itching but states not as bad as last night.\n Action:\n Barrier cream to all areas.\n Response:Plan\n Change dsg daily. Sarana lotion prn.\n"},{"category":"Nursing","chartdate":"2180-01-19 00:00:00.000","description":"Nursing Progress Note","row_id":400207,"text":"71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\n : Sent to ED from clinic w/ hypotension\n transiently on\n dopa, Tx\nd w/ NS 250 cc w/ SBP ^ 92.\n Admit to CCU for aggressive diuresis.She was started on Milrinone\n and lasix gtt. And has been diuresing well. She has lg coccyx decub\n that is a source of chronic pain. She is DNR/DNI and defibrillator has\n been shut off.\n Family meeting with Dr. . Decision made to d/c milrinone,\n torsimide and metalazone. Feeling that pt. intravas. Dry. Focus is on\n comfort. Palliative care following.\n Pain control (acute pain, chronic pain)\n Assessment:\n Currently on SR morphine , ultram QID and Tylenol RTC.\n Supplementing with IR morphine 15mg as needed as well as IV morphine as\n needed for breakthrough pain.\n c/o pain in back d/t sacral decub wound. Grimaces with turning\n /position change. Generally pain subsides once repositioned but\n occas. requires additional pain medication.\n 0600: after turning. Pt. stating pain- not relieved after 10mn.\n Action:\n IR morphine 15mg x1. repositioned q3-4 hours or as needed/requested by\n pt.\n 0600: med with 2mg IV morphine followed by additional 2mg IV at 0630\n Response:\n Pt. reports good pain control. Sleeping when left alone. Wakes easily\n and is lucid.\n Able to take pills whole with applesause.\n 0645: reports pain . reposttioned\n Plan:\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n HR 70\ns Vpaced. Occas. PVC. BP 80\ns-90/50\ns. dipping to 73-79/\n maps 50 when asleep.\n Action:\n Gave NSB 250cc at 0500 x1 (this treatment plan was discussed on rounds\n with Dr. \n Held PM lopressor dose\n Response:\n Good response\n BP BP 86/56 map 64.\n u/o 20-30cc/hr.\n LS diminished bases. Sats 94-96% when awake. Dipping to 80\ns when\n asleep. Noted for periods of apnea.\n Plan:\n Monitor u/o, sats. Monitor for worsening heart failure symptoms.\n Impaired Skin Integrity\n Assessment:\n Stage 3 decub on coccyx. Followed by wound care RN. Dsg changed QD.\n Not visualized .\n DSD remains intact. No drainage.\n c/o some itching but states not as bad as last night.\n Action:\n Barrier cream to all areas.\n Response:Plan\n Change dsg daily. Sarana lotion prn.\n"},{"category":"Physician ","chartdate":"2180-01-19 00:00:00.000","description":"Physician Resident Progress Note","row_id":400208,"text":"Chief Complaint: Congestive heart failure\n 24 Hour Events:\n - DCed milrinone and diuretics 11:30am\n - Family mtg held with patient's 3 sisters and multiple other family\n members, Dr. , then (P&PC) Dr. --> everybody in\n agreement w plan to DC milrinone, to give small 250cc boluses as needed\n if BP drops and morphine for symptoms if lungs become overloaded w\n fluid ; Hold on Rehab for now\n - Likely transfer pt to floor tomorrow w PPC following\n - BPs still stable 88-96 SBP (maps>60) at 1am, though family had been\n concerned occasionally that she looked like she had more difficulty\n breathing or increased apneic episodes, though nursing does not feel\n that she has had any difficulty breathing (pt has not needed any 250cc\n boluses at this point)\n - 0430am systolic BPs low 70s, but mentating well, not symptomatic -->\n 1 bag 250ccs NS\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Ciprofloxacin - 10:00 AM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 06:31 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 35.6\nC (96\n HR: 71 (68 - 101) bpm\n BP: 79/58(62) {73/42(51) - 107/73(77)} mmHg\n RR: 11 (9 - 23) insp/min\n SpO2: 92%\n Heart rhythm: V Paced\n Wgt (current): 73.6 kg (admission): 82.2 kg\n Height: 60 Inch\n Total In:\n 743 mL\n 370 mL\n PO:\n 600 mL\n 120 mL\n TF:\n IVF:\n 143 mL\n 250 mL\n Blood products:\n Total out:\n 1,190 mL\n 200 mL\n Urine:\n 1,190 mL\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n -447 mL\n 170 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 92%\n ABG: ////\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 116 K/uL\n 10.2 g/dL\n 93 mg/dL\n 1.0 mg/dL\n 35 mEq/L\n 3.8 mEq/L\n 32 mg/dL\n 91 mEq/L\n 132 mEq/L\n 31.2 %\n 4.6 K/uL\n [image002.jpg]\n 05:44 AM\n 04:46 AM\n 04:00 PM\n 03:05 AM\n 03:17 PM\n 03:05 AM\n 05:03 PM\n 05:22 AM\n 05:25 PM\n 05:40 AM\n WBC\n 6.1\n 4.7\n 5.1\n 4.4\n 4.2\n 4.6\n Hct\n 32.1\n 31.9\n 33.1\n 32.2\n 30.9\n 31.2\n Plt\n 156\n 159\n 146\n 134\n 106\n 116\n Cr\n 1.3\n 1.4\n 1.3\n 1.2\n 1.1\n 1.0\n 1.0\n 1.0\n 1.1\n 1.0\n Glucose\n 83\n 104\n 155\n 115\n 98\n 107\n 86\n 93\n Other labs: PT / PTT / INR:19.1/29.7/1.7, Ca++:8.1 mg/dL, Mg++:2.1\n mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\n recently discharged from the CCU () for CHF exacerbation c/b\n C.diff infection and on for septic joint washout c/b failure to\n extubate CHF exacerbation, who was admitted from clinic with\n total body fluid overload.\n .\n # sCHF Exacerbation:\n Patient has history of CHF ischemic , 10%, s/p BiV ICD\n ( Concerto C154DWK) with EF 10% which was the likely\n cause of her fluid overload. Appears intravascularly dry on exam. Has\n diuresed well -9L on length of stay. Responding well to torsemide with\n metolazone while on milrinone, but urine output had dropped without\n milrinone yesterday. Diuresed net -500cc over last day. Milrinone is\n keeping her blood pressures up.\n - DC milrinone\n - With no milrinone, she needs help with filling pressures, so\n will DC diuretics b/c appears dry on exam\n - If blood pressure drops without milrinone,, she may benefit\n from 250cc IVF boluses as needed\n - Continue strict I/Os\n - Continue to replete K\n .\n # Goals of Care:\n End-stage CHF with long term goals are comfort, though she still wishes\n to participate in rehab. Her family recognizes that she is dying. Pain\n and Palliative Care consulted yesterday for pain control and goals of\n care.\n - family meeting at 1pm today\n .\n # Septic Joints: Patient with history +staph aureus in left shoulder\n treated by washout and vancomycin, thus far 4 weeks of monotherapy. No\n + blood cx since before . Major issue now is pain control.\n - continue vancomycin until , then suppression with doxycycline\n -- continue MS contin 30mg and reassess pain med needs\n -- standing ultram q6, Tylenol q8\n .\n # Sacral Decub - stage 3-4. Focusing on Pain control. Pain and\n Palliative Care following with patient. Switched to oral breakthrough\n Morphine with IV as backup, but patient was not requiring IV backup.\n - wound care\n - standing ultram Q6h, Tylenol Q8h\n - reassess patient\ns pain requirements\n - goals of care family meeting 1pm today\n .\n # UTI: positive UA, no history of culture positive UA's in system.\n Will do 10day course because of chronic foley.\n - treating empirically with cipro ; day 1 of 10 day course was \n - watch INR on abx\n .\n # Hx CAD:\n Patient with h/o CAD w/ right dominant system, mild instent re-stenois\n of the LAD BM stent and occluded RCA.\n - continue metoprolol 25mg \n .\n # Hx Afib:\n Patient with h/o atrial fibrillation, s/p BiV ICD ( Concerto\n C154DWK) , on coumadin. Now in paced rhythm\n - cont home dose meds (amio, metoprolol)\n - cont coumadin\n - trend INR\n .\n # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a\n filter in place. INR mildly subtherapeutic despite Cipro\n - continue Coumadin\n - monitor INR\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 05:34 PM\n Midline - 05:34 PM\n Prophylaxis:\n DVT: coumadin\n Stress ulcer: lansoprazole\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"},{"category":"Physician ","chartdate":"2180-01-19 00:00:00.000","description":"Physician Resident Progress Note","row_id":400214,"text":"Chief Complaint: Congestive heart failure\n 24 Hour Events:\n - DCed milrinone and diuretics 11:30am\n - Family mtg held with patient's 3 sisters and multiple other family\n members, Dr. , then (P&PC) Dr. --> everybody in\n agreement w plan to DC milrinone, to give small 250cc boluses as needed\n if BP drops and morphine for symptoms if lungs become overloaded w\n fluid ; Hold on Rehab for now\n - Likely transfer pt to floor tomorrow w PPC following\n - BPs still stable 88-96 SBP (maps>60) at 1am, though family had been\n concerned occasionally that she looked like she had more difficulty\n breathing or increased apneic episodes, though nursing does not feel\n that she has had any difficulty breathing (pt has not needed any 250cc\n boluses at this point)\n - 0430am systolic BPs low 70s, but mentating well, not symptomatic -->\n 1 bag 250ccs NS\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Ciprofloxacin - 10:00 AM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 06:31 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 35.6\nC (96\n HR: 71 (68 - 101) bpm\n BP: 79/58(62) {73/42(51) - 107/73(77)} mmHg\n RR: 11 (9 - 23) insp/min\n SpO2: 92%\n Heart rhythm: V Paced\n Wgt (current): 73.6 kg (admission): 82.2 kg\n Height: 60 Inch\n Total In:\n 743 mL\n 370 mL\n PO:\n 600 mL\n 120 mL\n TF:\n IVF:\n 143 mL\n 250 mL\n Blood products:\n Total out:\n 1,190 mL\n 200 mL\n Urine:\n 1,190 mL\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n -447 mL\n 170 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 92%\n ABG: ////\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 116 K/uL\n 10.2 g/dL\n 93 mg/dL\n 1.0 mg/dL\n 35 mEq/L\n 3.8 mEq/L\n 32 mg/dL\n 91 mEq/L\n 132 mEq/L\n 31.2 %\n 4.6 K/uL\n [image002.jpg]\n 05:44 AM\n 04:46 AM\n 04:00 PM\n 03:05 AM\n 03:17 PM\n 03:05 AM\n 05:03 PM\n 05:22 AM\n 05:25 PM\n 05:40 AM\n WBC\n 6.1\n 4.7\n 5.1\n 4.4\n 4.2\n 4.6\n Hct\n 32.1\n 31.9\n 33.1\n 32.2\n 30.9\n 31.2\n Plt\n 156\n 159\n 146\n 134\n 106\n 116\n Cr\n 1.3\n 1.4\n 1.3\n 1.2\n 1.1\n 1.0\n 1.0\n 1.0\n 1.1\n 1.0\n Glucose\n 83\n 104\n 155\n 115\n 98\n 107\n 86\n 93\n Other labs: PT / PTT / INR:19.1/29.7/1.7, Ca++:8.1 mg/dL, Mg++:2.1\n mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\n recently discharged from the CCU () for CHF exacerbation c/b\n C.diff infection and on for septic joint washout c/b failure to\n extubate CHF exacerbation, who was admitted from clinic with\n total body fluid overload.\n .\n # sCHF Exacerbation:\n Patient has history of CHF ischemic , 10%, s/p BiV ICD\n ( Concerto C154DWK) with EF 10% which was the likely\n cause of her fluid overload. Appears euvolemic currently. Has\n diuresed well -9L on length of stay. Responding well to torsemide with\n metolazone while on milrinone, but urine output had dropped without\n milrinone on . Diuresed net -500cc over last day. Breathing\n comfortably currently.\n - blood pressure maintained without milrinone, will continue to support\n with IV fluids as needed\n - no diuretics currently, although will re-assess if she becomes\n dyspneic. More likely will use morphine though for comfort.\n .\n # Goals of Care:\n End-stage CHF with long term goals are comfort, though she still wishes\n to participate in rehab. Her family recognizes that she is dying. Pain\n and Palliative Care consulted on for pain control and goals of\n care.\n - appreciate palliative care recommendations\n - likely call-out to floor on for continued comfort measures.\n - will consider disconnecting IJ for comfort\n .\n # Septic Joints: Patient with history +staph aureus in left shoulder\n treated by washout and vancomycin, thus far 4 weeks of monotherapy. No\n + blood cx since before . Major issue now is pain control.\n - continue vancomycin until , then suppression with doxycycline\n -- continue MS contin 30mg and reassess pain med needs\n -- standing ultram q6, Tylenol q8\n .\n # Sacral Decub - stage 3-4. Focusing on Pain control. Pain and\n Palliative Care following with patient. Switched to oral breakthrough\n Morphine with IV as backup. Patient required IV morphine this morning\n while moving.\n - wound care\n - standing ultram Q6h, Tylenol Q8h\n - reassess patient\ns pain requirements\n - continue with oral morphine, will use IV as needed now that patient\n primary goal is comfort.\n .\n # UTI: positive UA, no history of culture positive UA's in system.\n Will do 10day course because of chronic foley.\n - treating empirically with cipro ; day 1 of 10 day course was \n - watch INR on abx\n .\n # Hx CAD:\n Patient with h/o CAD w/ right dominant system, mild instent re-stenois\n of the LAD BM stent and occluded RCA.\n - continue metoprolol 25mg \n .\n # Hx Afib:\n Patient with h/o atrial fibrillation, s/p BiV ICD ( Concerto\n C154DWK) , on coumadin. Now in paced rhythm\n - cont home dose meds (amio, metoprolol)\n - cont coumadin, at current dose.\n - trend INR\n .\n # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a\n filter in place. INR mildly subtherapeutic despite Cipro\n - continue Coumadin\n - monitor INR\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 05:34 PM\n Midline - 05:34 PM\n Prophylaxis:\n DVT: coumadin\n Stress ulcer: lansoprazole\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"},{"category":"Nursing","chartdate":"2180-01-19 00:00:00.000","description":"Nursing Progress Note","row_id":400199,"text":"71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\n : Sent to ED from clinic w/ hypotension\n transiently on\n dopa, Tx\nd w/ NS 250 cc w/ SBP ^ 92.\n Admit to CCU for aggressive diuresis.She was started on Milrinone\n and lasix gtt. And has been diuresing well. She has lg coccyx decub\n that is a source of chronic pain. She is DNR/DNI and defibrillator has\n been shut off.\n Family meeting with Dr. . Decision made to d/c milrinone,\n torsimide and metalazone. Feeling that pt. intravas. Dry. Focus is on\n comfort. Palliative care following.\n Pain control (acute pain, chronic pain)\n Assessment:\n Currently on SR morphine , ultram QID and Tylenol RTC.\n Supplementing with IR morphine 15mg as needed as well as IV morphine as\n needed for breakthrough pain.\n c/o pain in back d/t sacral decub wound. Grimaces with turning\n /position change. Generally pain subsides once repositioned but\n occas. requires additional pain medication.\n Action:\n IR morphine 15mg x1. repositioned q3-4 hours or as needed/requested by\n pt.\n Response:\n Pt. reports good pain control. Sleeping when left alone. Wakes easily\n and is lucid.\n Able to take pills whole with applesause.\n Plan:\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n HR 70\ns Vpaced. Occas. PVC. BP 80\ns-90/50\ns. dipping to 73-79/\n maps 50 when asleep.\n Action:\n Gave NSB 250cc at 0500 x1 (this treatment plan was discussed on rounds\n with Dr. \n Held PM lopressor dose\n Response:\n Good response\n BP BP 86/56 map 64.\n u/o 20-30cc/hr.\n LS diminished bases. Sats 94-96% when awake. Dipping to 80\ns when\n asleep. Noted for periods of apnea.\n Plan:\n Monitor u/o, sats. Monitor for worsening heart failure symptoms.\n Impaired Skin Integrity\n Assessment:\n Stage 3 decub on coccyx. Followed by wound care RN. Dsg changed QD.\n Not visualized .\n DSD remains intact. No drainage.\n c/o some itching but states not as bad as last night.\n Action:\n Barrier cream to all areas.\n Response:Plan\n Change dsg daily. Sarana lotion prn.\n"},{"category":"Nursing","chartdate":"2180-01-19 00:00:00.000","description":"Nursing Progress Note","row_id":400197,"text":"71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\n : Sent to ED from clinic w/ hypotension\n transiently on\n dopa, Tx\nd w/ NS 250 cc w/ SBP ^ 92.\n Admit to CCU for aggressive diuresis.She was started on Milrinone\n and lasix gtt. And has been diuresing well. She has lg coccyx decub\n that is a source of chronic pain. She is DNR/DNI and defibrillator has\n been shut off.\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2180-01-13 00:00:00.000","description":"Nursing Progress Note","row_id":399736,"text":"Pt is a 71 yo female with PMH: BM stent to LAD ', Occluded RCA\n without intervention, Ischemic CM (EF 10-25%), BiV ICD, AF, PVD, DVT\n s/p IVC filter, coumadin, hypothyroidism, CKD, OA. adm for HF\n (milrinone/lasix) MRSA in L shoulder, L hip and R knuckle. Out to\n rehab . went from rehab to see Dr. , sent to EW with\n hypotension. SBP 70 in EW, transiently on dopa, but cardiology d/c'd.\n Rxd with NS 250 cc with SBP 92. Pt has been in rehab since d/c from\n with septic arthritis in L shoulder, hip and R knuckle.\n On Vanco followed by ID.\n She was started on milrinone .375 after bolus and lasix drip also begun\n at 2.5mg/hr. The lasix dose was increased to 5mg overnight, but urine\n output has remained poor, though she is negative.\n GI: Pt has poor apetite and eats very little.\n CODE STATUS: Dr had discussion with both patient and health care\n proxy and all are in agreement that she be DNR/DNI. Additionally the\n defibrillator part of AICD/pacer was shut off.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt has a number of sources of pain. She has joint pain in shoulders and\n especially R elbow from septic arthritis. The most uncomfortable area\n is the decubitus ulcer on her coccyx area. She receive standing ultran\n for that. She requires frequent position changes, but seems most\n uncomfortable on L side. By 1000 she was very uncomfortable.\n Action:\n She received 2mg IV morpnine sulfate at 1230 and had shift in position\n and was comfortable until noon when pain recurred. She received another\n 2mg morphine sulfate and position change.\n Response:\n She slept until\n Plan:\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Pt on Milrinone .375mic/kilo and lasix 5mg/hr. Urine output\n ~30-50cc/hr. Hr in 70s AV paced with rare PVCs . BP 85-100/50-60s,\n lower after morphine. Pt sating 98-100% on 3L NP and lungs are mostly\n clear. She has no c/o of SOB. She has 2+ edema in legs.\n Action:\n At 1030 lasix was increased to 10mg/hr and at 1100 milrinone was\n increased to .5mic/kilo. Legs are kept elevated.\n Response:\n She is ~800cc negative for the day. The skin on her legs show signs\n Plan:\n Impaired Skin Integrity\n Assessment:\n Pt has multiple skin lesions. Most prominent is coccyx decub. It has\n mepelix on it that was leaking through and pulling loose in am. Both\n heels are reddened, though they . She has dry skin on all\n extremities with some small abraded areas.\n Action:\n Coccyx dsg changed. Area primarily covered with slough. The edges are\n rounded and pink. Area cleansed with wound cleaner, dried and new\n mepelix applied. All limbs were lubricated frequently. Her position was\n changed, at times only slightly throughout the day. She does become\n uncomfortable if she is in the same position for too long,but also has\n difficulty on the L side. She finds the waffle boots uncomfortable and\n prefers having her legs elevated on pillows.\n Response:\n No new skin lesions have developed.\n Plan:\n Continue with turning, lubricating and keeping heels elevated. Monitor\n mepilex to ensure it is in place.\n"},{"category":"Social Work","chartdate":"2180-01-19 00:00:00.000","description":"Social Work Progress Note","row_id":400241,"text":"SOCIAL WORK: Following pt for emotional support around pt\ncoping. Reviewed notes from palliative care service and\ndiscussed pt's progress with RN . A family meeting was\nheld yesterday with the attending physician and palliative care\nservice to review pt's progress and goals of care.\nPt is sitting up in bed finishing her breakfast at present. Pt\nis somnolent; her eyes closing at times. Pt speech is slow and\nmeasured, as are her movements. She engages readily with SW, but\nstops herself when speaking, easily losing her concentration. Pt\npresents today with the same sad affect from prior\nhospitalization in . Pt's mood is congruent: \"worried.\"\nPt reports she is very concerned about her niece (primary HCP)\nwho is currently hospitalized in the MICU. Pt states, \"I wish it\nwas me, if anything bad was going to happen, it wouldn't matter.\"\nPt reports that her discussion with the doctors yesterday was\n\"not entirely unexpected\". Pt understands that doctors 't\nknow what is going to happen and if her present medication\nregimen is going to work. Pt elaborates, \"But, I am not in a\nhurry to leave tomorrow.\"\nPt is comforted most by her family being close to her, especially\nnow due to her niece's illness. Pt is looking forward to seeing\nthem later today. Pt gave permission to contact family members.\nMessages left for (sister/Alt. HCP) and (niece) whom\nSW met Monday .\nA/P: Pt is exhibiting normative distress over her niece and\nshows signs of fatigue and discouragement over lengthy\nhospitalization and course of illness. Pt appears to have some\ninsight into her prognosis , but cannot recall specific details\nat this point.\n-SW will continue to follow the pt to provide opportunity to talk\nabout not only death and dying, but provide opportunity to make\nmeaning through life review.\n-SW will continue to provide emotional support around pt's\nconcerns over her own illness and her niece's condition.\n-SW will build rapport with family to provide emotional support\nthrough this process.\n , MSW Intern\nPager \n"},{"category":"Nursing","chartdate":"2180-01-19 00:00:00.000","description":"Nursing Transfer Note","row_id":400242,"text":"71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\n coumadin, hypothyroidism, CKD, OA. admitted for septic joint\n washout- MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\n On pt. was sent to ED from clinic w/ hypotension\n transiently on dopa, Tx\nd w/ NS 250 cc w/ SBP ^ 92.\n Admit to CCU for aggressive diuresis. She was started on\n Milrinone and lasix gtt. She has large coccyx decub that is a source\n of chronic pain. She is DNR/DNI and defibrillator has been shut off.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt. with history of pain in left shoulder, left hip (septic joints) and\n coccyx (decub.).\n Action:\n MS , morphine IR 15mg for breakthrough pain, given this x2\n today. Pt. also given 2mg IV morphine prior to all activity/turning\n today. Pt. receiving ultram qid.\n Response:\n Pt. has denied pain today until 1500\n she reported pain after turning\n despite premedicating. Tolerating above with no ill-effects. Pt.\n painfree by 1600.\n Plan:\n Continue present around-the-clock and aggressive prn regimen.\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Off lasix gtt since , and milrinone since . AV paced at 70 with\n BP 90\ns/60\ns today. LS essentially clear, some fine ?dependent\n crackles noted at bases. Skin warm, dry. UO approximately 20cc/hr.\n Pt. slightly confused this afternoon per family.\n Action:\n Assessment ongoing. Torsemide started.\n Response:\n Pt. tolerating medication. Assessment largely unchanged.\n Plan:\n Continue to monitor and treat as indicated. Transfer to floor today.\n Impaired Skin Integrity\n Assessment:\n Pt. with sacral decub as documented in metavision.\n Action:\n Dressing changed today at noon per skin care recs. Pt. turned side to\n side as documented.\n Response:\n Pt. tolerated dressing change, premedicated with morphine IV.\n Moderated amt. yellow-white slough noted. Small amounts drainage\n noted.\n Plan:\n Continue daily dressing changes skin RN. Continue turning as pt.\n tolerates, avoid pressure points.\n"},{"category":"Nursing","chartdate":"2180-01-19 00:00:00.000","description":"Nursing Progress Note","row_id":400243,"text":"71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\n coumadin, hypothyroidism, CKD, OA. admitted for septic joint\n washout- MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\n On pt. was sent to ED from clinic w/ hypotension\n transiently on dopa, Tx\nd w/ NS 250 cc w/ SBP ^ 92.\n Admit to CCU for aggressive diuresis. She was started on\n Milrinone and lasix gtt. She has large coccyx decub that is a source\n of chronic pain. She is DNR/DNI and defibrillator has been shut off.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt. with history of pain in left shoulder, left hip (septic joints) and\n coccyx (decub.).\n Action:\n MS , morphine IR 15mg for breakthrough pain, given this x2\n today. Pt. also given 2mg IV morphine prior to all activity/turning\n today. Pt. receiving ultram qid.\n Response:\n Pt. has denied pain today until 1500\n she reported pain after turning\n despite premedicating. Tolerating above with no ill-effects. Pt.\n painfree by 1600.\n Plan:\n Continue present around-the-clock and aggressive prn regimen.\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Off lasix gtt since , and milrinone since . AV paced at 70 with\n BP 85-90\ns/50-60\ns today. LS essentially clear, some fine crackles\n noted at bases this afternoon. Skin warm, dry. UO approximately\n 20cc/hr. Pt. slightly confused this afternoon per family.\n Action:\n Assessment ongoing. Torsemide started.\n Response:\n Pt. tolerating medication. Assessment largely unchanged.\n Plan:\n Continue to monitor and treat as indicated. Transfer to floor today.\n Impaired Skin Integrity\n Assessment:\n Pt. with sacral decub as documented in metavision.\n Action:\n Dressing changed today at noon per skin care recs. Pt. turned side to\n side as documented.\n Response:\n Pt. tolerated dressing change, premedicated with morphine IV.\n Moderated amt. yellow-white slough noted. Small amounts drainage\n noted.\n Plan:\n Continue daily dressing changes skin RN. Continue turning as pt.\n tolerates, avoid pressure points.\n"},{"category":"Social Work","chartdate":"2180-01-19 00:00:00.000","description":"Social Work Progress Note","row_id":400244,"text":"SOCIAL WORK: Following pt for emotional support around pt\ncoping. Reviewed notes from palliative care service and\ndiscussed pt's progress with RN . A family meeting was\nheld yesterday with the attending physician and palliative care\nservice to review pt's progress and goals of care.\nPt is sitting up in bed finishing her breakfast at present. Pt\nis somnolent; her eyes closing at times. Pt speech is slow and\nmeasured, as are her movements. She engages readily with SW, but\nstops herself when speaking, easily losing her concentration. Pt\npresents today with the same sad affect from prior\nhospitalization in . Pt's mood is congruent: \"worried.\"\nPt reports she is very concerned about her niece (primary HCP)\nwho is currently hospitalized in the MICU. Pt states, \"I wish it\nwas me, if anything bad was going to happen, it wouldn't matter.\"\nPt reports that her discussion with the doctors yesterday was\n\"not entirely unexpected\". Pt understands that doctors 't\nknow what is going to happen and if her present medication\nregimen is going to work. Pt elaborates, \"But, I am not in a\nhurry to leave tomorrow.\"\nPt is comforted most by her family being close to her, especially\nnow due to her niece's illness. Pt is looking forward to seeing\nthem later today. Pt gave permission to contact family members.\nMessages left for (sister/Alt. HCP) and (niece) whom\nSW met Monday .\nA/P: Pt is exhibiting normative distress over her niece and\nshows signs of fatigue and discouragement over lengthy\nhospitalization and course of illness. Pt appears to have some\ninsight into her prognosis , but cannot recall specific details\nat this point.\n-SW will continue to follow the pt to provide opportunity to talk\nabout not only death and dying, but provide opportunity to make\nmeaning through life review.\n-SW will continue to provide emotional support around pt's\nconcerns over her own illness and her niece's condition.\n-SW will build rapport with family to provide emotional support\nthrough this process.\n , MSW Intern\nPager \n 05:11 PM\n"},{"category":"Physician ","chartdate":"2180-01-13 00:00:00.000","description":"Physician Resident Admission Note","row_id":399713,"text":"Chief Complaint: Fluid overload\n HPI:\n 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\n recently discharged from the CCU () for CHF exacerbation c/b\n C.diff infection and on for septic joint washout c/b failure to\n extubate CHF exacerbation, who is now being admitted from \n clinic with total body fluid overload.\n .\n Ms. is a resident at NE where she is convalescing from a\n polyarticular MRSA septic arthritis. She has NYHA IV CHF at baseline\n but over the last 4 days has developed 4+ LE edema and ascites where\n there was previously none. She was presented with the choice to pursue\n cardiac transplantation more than 12 years ago when given the diagnosis\n of end-stage CHF. She opted against that.\n .\n Per her recent visit note at clinic, she continues to have L\n shoulder pain, though significantly improved from a few weks ago. She\n continues to work with PT to improve her ROM. She has no pain at her R\n 3rd MCP, though has difficulty extending her finger at that joint. She\n continues to have mild pain and significant weakness at her L\n hip, though improved since hospital discharge. She has had no\n F/C/NS, and no problems with her midline. She has had progression\n of a sacral decub, which gives her the majority of her pain.\n There has not been concern on the part of her rehab for\n superinfection, and it is being treated with local wound care and\n frequent turning. Her sister is hoping to transfer her to \n within the next several days.\n Patient admitted from: ER\n History obtained from Patient, Family / Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Milrinone - 0.375 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension\n 2. CARDIAC HISTORY:\n -CABG: None\n -PERCUTANEOUS CORONARY INTERVENTIONS: BM stent to the LAD in ,\n Occluded RCA/no intervention\n -PACING/ICD: Ischemic cardiomyopathy (EF 10%) s/p BiV ICD and atrial\n fibrillation\n 3. H/o PE secondary to DVT s/p IVC filter on Coumadin\n 4. PVD\n 5. Small VSD\n OTHER\n # Septic Polyarticular Arthritis s/p irrigation and debridement left\n shoulder via anterolateral deltopectoral miniarthrotomy, aspiration\n left hip joint and irrigation and debridement of 3rd\n metacarpophalangeal joint\n 6. Hypothyroidism\n 7. CKD\n 8. Osteoarthritis\n Mother had MI at age 50, maternal uncle died of MI in his 50's.\n No family history of arrhythmia, cardiomyopathies, or sudden cardiac\n death; otherwise non-contributory.\n Occupation: retired\n Drugs: none\n Tobacco: 20 pack year history, however she quit 30 yrs ago\n Alcohol: none\n Other: Pt lives alone but currently resides at NE . She is not\n married. She is cared for primarily by her Niece and sister, both\n nurses.\n Review of systems:\n Constitutional: Fatigue\n Integumentary (skin): painful decub's\n Flowsheet Data as of 08:40 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 35.4\nC (95.8\n Tcurrent: 35.4\nC (95.8\n HR: 70 (70 - 108) bpm\n BP: 83/50(58) {83/50(58) - 109/76(84)} mmHg\n RR: 12 (11 - 18) insp/min\n SpO2: 100%\n Heart rhythm: V Paced\n Wgt (current): 82.2 kg (admission): 82.2 kg\n Total In:\n 284 mL\n PO:\n 30 mL\n TF:\n IVF:\n 4 mL\n Blood products:\n Total out:\n 0 mL\n 350 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -66 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 100%\n Physical Examination\n General Appearance: Thin, Anxious, Cachectic, tearful\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic), II/VI\n systolic murmur best at apex. PMI is laterally displaced\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear :\n anteriorly)\n Abdominal: Soft, Non-tender, Distended, +fluid wave\n Extremities: Right lower extremity edema: 4+, Left lower extremity\n edema: 4+, cool, dry\n Skin: Cool, Stage 3+ sacral decub\n Neurologic: Attentive, Responds to: Not assessed, Oriented (to): x3,\n Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n [image002.jpg]\n Imaging: TTE :\n The left atrium is elongated. The right atrium is markedly dilated. The\n interatrial septum is aneurysmal. The estimated right atrial pressure\n is 10-20mmHg. Left ventricular wall thicknesses are normal. The left\n ventricular cavity is moderately dilated with severe global\n hypokinesis. The basal inferolateral wall contracts best (LVEF = 20 %).\n The estimated cardiac index is borderline low (2.0-2.5L/min/m2). No\n masses or thrombi are seen in the left ventricle. The right ventricular\n cavity is moderately dilated with severe global free wall hypokinesis.\n [Intrinsic right ventricular systolic function is likely more depressed\n given the severity of tricuspid regurgitation.] The ascending aorta is\n mildly dilated. The aortic valve leaflets (3) are mildly thickened but\n aortic stenosis is not present. Trace aortic regurgitation is seen. The\n mitral valve leaflets are mildly thickened. There is no mitral valve\n prolapse. Mild to moderate (+) mitral regurgitation is seen.\n Moderate to severe [3+] tricuspid regurgitation is seen. There is\n moderate pulmonary artery systolic hypertension. Significant pulmonic\n regurgitation is seen. There is a very small circumferential\n pericardial effusion without echocardiographic signs of tamponade.\n Compared with the prior study (images reviewed) of ,\n estimated pulmonary artery systolic pressure is now higher.\n .\n ETT: \n INTERPRETATION: This 64 year old woman with a history of CAD, atrial\n fibrillation and CHF was referred to the lab for evaluation. The\n patient exercised for 4.25 minutes of a modified protocol and\n requested the test be stopped for nausea. The resting oxygen\n consumption was 3.2 ml/kg/min with a respiratory exchange ratio of\n 0.75. At peak exercise, her oxygen consumption increased to 11.0\n ml/kg/min with an expiratory exchange ratio of 0.86. The peak oxygen\n consumption was 45 % of predicted. The oxygen consumption at the onset\n of the anerobic threshold was 9.9 ml/kg/min. This test was not limited\n by muscle fatigue. No arm, neck, back or chest discomfort was reported\n by the patient throughout the study. The ST segments are\n uninterpretable for ischemia in the setting of the baseline LBBB. The\n rhythm was atrial fibrillation with several isolated vpbs and 2\n ventricular couplets. Blunted systolic BP response to exercise.\n IMPRESSION: Very limited physical working capacity in the absence of\n angina.\n .\n CARDIAC CATH:\n LHC/RHC :\n 1. Selective coronary angiography of this right dominant system\n revealed one vessel coronary artery disease. The LMCA had no\n angiographically apparent disease. The LAD had mild instent restenosis\n of the prior stent. The LCx had no angiographically apparent disease.\n The RCA was occluded and similar to prior.\n 2. Resting hemodynamics on milrinone therapy revealed moderately\n elevated right and left sided filling pressures with an RVEDP of\n 15 mmHg and PCWP of 20 mmHg. There was moderate pulmonary hypertension\n with a PASP of 42/20 mmHg. There was normal systemic blood pressure\n with central pressure of 108/63 mmHg. There was a low-normal cardiac\n index of 2.1 L/min/m2. There was no transaortic valve gradient on\n careful pullback from LV to aorta.\n 3. Peripheral angiography revealed patent renal arteries bilaterally.\n .\n MYOCARDIAL VIABILITY STUDY :\n Within limitation of current study, fixed defects in distal anterior\n and apical walls are consistent with scarring. Improvement of inferior\n wall defect with correction is suggestive of myocardial viability.\n Microbiology: Hx of MRSA bacteremia, septic arthritis\n Assessment and Plan\n ASSESSMENT AND PLAN\n 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\n recently discharged from the CCU () for CHF exacerbation c/b\n C.diff infection and on for septic joint washout c/b failure to\n extubate CHF exacerbation, who is now being admitted from \n clinic with total body fluid overload.\n .\n # Anasarca: Patient has history of CHF ischemic , 10%, s/p\n BiV ICD ( Concerto C154DWK) 1/08with EF 10% which is the\n likely cause of her fluid overload. Her rapid accumulation underpins\n the severity of her condition and her severely unfavourable\n hemodynamics. Her long term goals are comfort, though she still wishes\n to participate in rehab. Her family recognizes that she is dying. Our\n goal is diuresis which we will attempt aggressively, reassessing our\n progress dynamically.\n -- milrinone with bolus\n -- neosynephrine for pressure support, goal MAP of > 60\n -- slow uptitration of lasix with goal near-continuous diuresis while\n avoiding MAP < 60\n -- strict i/o's with foley\n -- can switch to levophed if low UOP on Neo with need for pressor\n support\n -- family meeting with HCP to assess goals in AM after diuresis\n attempted\n .\n # Septic Joints: Patient with history +staph aureus in left shoulder\n treated by washout and vancomycin, thus far 4 weeks of monotherapy. No\n + blood cx since before . Major issue now is pain control.\n -- send Vanco level in AM, was recently on 500 mg q12 and switched to\n q24 for high troughs\n -- ultram q6, Tylenol q8, Morphine for breakthrough (1-3 mg).\n - Will consider ms contin if no control\n .\n # CORONARIES: Patient with h/o CAD w/ right dominant system, mild\n instent re-stenois of the LAD BM stent and occluded RCA.\n - bb as tolerated\n .\n # RHYTHM: Patient with h/o atrial fibrillation, s/p BiV ICD (\n Concerto C154DWK) , on coumadin. Now in paced rhythm\n - cont home dose meds (amio, metoprolol)\n - cont coumadin\n - f/u INR\n .\n # Chronic Kidney Disease: Baseline 1.3 creatinine. At baseline\n - trend\n .\n # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a\n filter in place.\n - cont coumadin\n - f/u INR\n .\n # Hypothyroidism: Continue Levothyroxine.\n .\n # Gout: continue allopurionl\n .\n # FEN: low sodium diet\n .\n # ACCESS: Right PICC, right IJ, Left EJ\n .\n # PROPHYLAXIS: on coumadin\n .\n # CODE: DNR, can intubate, briefly\n .\n # DISPO: CCU for now.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 05:34 PM\n Midline - 05:34 PM\n 18 Gauge - 05:35 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition: ICU\n ------ Protected Section ------\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I would add the following remarks:\n Above discussed extensively with patient.\n DNR status discussed. DNR.\n Total time spent on patient care: 45 minutes.\n Additional comments:\n Patient with end-stage ischemic cmp admitted for milrinone and Lasix\n gtt in setting of severe volume overload and hypotension; prognosis is\n end-stage\n Signed on for service provided \n ------ Protected Section Addendum Entered By: on:\n 11:18 ------\n"},{"category":"Physician ","chartdate":"2180-01-13 00:00:00.000","description":"Physician Resident Progress Note","row_id":399714,"text":"Chief Complaint: anasarca\n 24 Hour Events:\n MULTI LUMEN - START 05:34 PM\n MIDLINE - START 05:34 PM\n - poor UOP to 2.5 and 5mg/hr lasix drip.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Milrinone - 0.375 mcg/Kg/min\n Furosemide (Lasix) - 5 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue\n Flowsheet Data as of 06:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.1\nC (97\n Tcurrent: 36\nC (96.8\n HR: 72 (70 - 108) bpm\n BP: 97/52(64) {77/44(52) - 113/76(84)} mmHg\n RR: 13 (11 - 18) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 82.2 kg (admission): 82.2 kg\n Total In:\n 417 mL\n 156 mL\n PO:\n 120 mL\n 60 mL\n TF:\n IVF:\n 47 mL\n 96 mL\n Blood products:\n Total out:\n 550 mL\n 410 mL\n Urine:\n 200 mL\n 410 mL\n NG:\n Stool:\n Drains:\n Balance:\n -133 mL\n -254 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ///26/\n Physical Examination\n General Appearance: No acute distress, Thin, cachectic\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: II/VI systolic murmur best at apex. PMI is laterally\n displaces\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Breath Sounds: Clear : anteriors)\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended, fluid\n wave\n Extremities: Right lower extremity edema: 4+, Left lower extremity\n edema: 4+\n Skin: Not assessed, Stage 3 sacral decub\n Neurologic: Attentive, Responds to: Not assessed, Oriented (to): x3,\n Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 156 K/uL\n 10.0 g/dL\n 83 mg/dL\n 1.3 mg/dL\n 26 mEq/L\n 4.3 mEq/L\n 46 mg/dL\n 99 mEq/L\n 137 mEq/L\n 32.1 %\n 6.1 K/uL\n [image002.jpg]\n 05:44 AM\n WBC\n 6.1\n Hct\n 32.1\n Plt\n 156\n Cr\n 1.3\n Glucose\n 83\n Other labs: PT / PTT / INR:15.7/36.8/1.4, Mg++:2.1 mg/dL\n Fluid analysis / Other labs: UA = WBC + clumps. Mod Bacteria\n Assessment and Plan\n 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\n recently discharged from the CCU () for CHF exacerbation c/b\n C.diff infection and on for septic joint washout c/b failure to\n extubate CHF exacerbation, who is now being admitted from \n clinic with total body fluid overload.\n .\n # Anasarca: Patient has history of CHF ischemic , 10%, s/p\n BiV ICD ( Concerto C154DWK) 1/08with EF 10% which is the\n likely cause of her fluid overload. Her rapid accumulation underpins\n the severity of her condition and her severely unfavourable\n hemodynamics. Her long term goals are comfort, though she still wishes\n to participate in rehab. Her family recognizes that she is dying. Our\n goal is diuresis which we will attempt aggressively, reassessing our\n progress dynamically. She put out very little o/n on lasix gtt. This\n could reflect limitatin of diuresis or the importance of a bolus (we\n withheld bolus to avoid instability)\n -- milrinone with bolus\n -- neosynephrine for pressure support, goal MAP of > 60\n -- slow uptitration of lasix with goal near-continuous diuresis while\n avoiding MAP < 60\n -- strict i/o's with foley\n -- can switch to levophed if low UOP on Neo with need for pressor\n support\n -- family meeting with HCP to assess goals in AM after diuresis\n attempted\n .\n # Septic Joints: Patient with history +staph aureus in left shoulder\n treated by washout and vancomycin, thus far 4 weeks of monotherapy. No\n + blood cx since before . Major issue now is pain control.\n -- send Vanco level in AM, was recently on 500 mg q12 and switched to\n q24 for high troughs\n -- ultram q6, Tylenol q8, Morphine for breakthrough (1-3 mg).\n - Will consider ms contin if no control\n .\n # Sacral Decub - stage 3-4.\n - wound care\n - pain control.\n .\n # UTI: positive UA, no history of culture positive UA's in system\n - treating empirically with cipro\n - watch INR on abx\n .\n # CORONARIES: Patient with h/o CAD w/ right dominant system, mild\n instent re-stenois of the LAD BM stent and occluded RCA.\n - bb as tolerated\n .\n # RHYTHM: Patient with h/o atrial fibrillation, s/p BiV ICD (\n Concerto C154DWK) , on coumadin. Now in paced rhythm\n - cont home dose meds (amio, metoprolol)\n - cont coumadin\n - f/u INR\n .\n # Chronic Kidney Disease: Baseline 1.3 creatinine. At baseline\n - trend\n .\n # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a\n filter in place.\n - cont coumadin\n - f/u INR\n .\n # Hypothyroidism: Continue Levothyroxine.\n .\n # Gout: continue allopurionl\n .\n # FEN: low sodium diet\n .\n # ACCESS: Right PICC, right IJ, Left EJ\n .\n # PROPHYLAXIS: on coumadin\n .\n # CODE: DNR/DNI\n .\n # DISPO: CCU for now.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 05:34 PM\n Midline - 05:34 PM\n 18 Gauge - 05:35 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:ICU\n ------ Protected Section ------\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I would add the following remarks:\n Above discussed extensively with patient.\n DNR status discussed: DNR/DNI/defibrillator deactivated. DNR.\n Total time spent on patient care: 60 minutes.\n Additional comments:\n although we have madee some minimal progress in diuresis, the outlook\n is poor\n after 20 min discussion with pt we have reaffirmed DNR/DNI status\n In addition, as per patient's wish we will deactivate the defibrillator\n shocking function of her ICD\n ------ Protected Section Addendum Entered By: on:\n 11:20 ------\n"},{"category":"Nursing","chartdate":"2180-01-13 00:00:00.000","description":"Nursing Progress Note","row_id":399730,"text":"Pt is a 71 yo female with PMH: BM stent to LAD ', Occluded RCA\n without intervention, Ischemic CM (EF 10-25%), BiV ICD, AF, PVD, DVT\n s/p IVC filter, coumadin, hypothyroidism, CKD, OA. adm for HF\n (milrinone/lasix) MRSA in L shoulder, L hip and R knuckle. Out to\n rehab . went from rehab to see Dr. , sent to EW with\n hypotension. SBP 70 in EW, transiently on dopa, but cardiology d/c'd.\n Rxd with NS 250 cc with SBP 92. Pt has been in rehab since d/c from\n with septic arthritis in L shoulder, hip and R knuckle.\n On Vanco followed by ID.\n She was started on milrinone .375 after bolus and lasix drip also begun\n at 2.5mg/hr. The lasix dose was increased to 5mg overnight, but urine\n output has remained poor, though she is negative.\n GI: Pt has poor apetite and eats very little.\n CODE STATUS: Dr had discussion with both patient and health care\n proxy and all are in agreement that she be DNR/DNI. Additionally the\n defibrillator part of AICD/pacer was shut off.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt has a number of sources of pain. She has joint pain in shoulders and\n especially R elbow from septic arthritis. The most uncomfortable area\n is the decubitus ulcer on her coccyx area. She receive standing ultran\n for that. She requires frequent position changes, but seems most\n uncomfortable on L side. By 1000 she was very uncomfortable.\n Action:\n She received 2mg IV morpnine sulfate at 1230 and had shift in position\n and was comfortable until noon when pain recurred. She received another\n 2mg morphine sulfate and position change.\n Response:\n She slept until\n Plan:\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Pt on Milrinone .375mic/kilo and lasix 5mg/hr. Urine output\n ~30-50cc/hr. Hr in 70s AV paced with rare PVCs . BP 85-100/50-60s,\n lower after morphine. Pt sating 98-100% on 3L NP and lungs are mostly\n clear. She has no c/o of SOB. She has 2+ edema in legs.\n Action:\n At 1030 lasix was increased to 10mg/hr and at 1100 milrinone was\n increased to .5mic/kilo. Legs are kept elevated.\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Pt has multiple skin lesions. Most prominent is coccyx decub. It has\n mepelix on it that was sloughing off in am\n Action:\n Coccyx dsg changed. Area primarily covered with slough. The edges are\n rounded and pink. Area cleansed with wound cleaner, dried and new\n mepelix applied.\n Response:\n Plan:\n"},{"category":"Physician ","chartdate":"2180-01-15 00:00:00.000","description":"Physician Resident Progress Note","row_id":399948,"text":"Chief Complaint:\n 24 Hour Events:\n - confirmed DNR, acemaker turned off\n - despite lasix gtt, diuresis poor yesterday\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Ciprofloxacin - 08:00 AM\n Infusions:\n Other ICU medications:\n Coumadin (Warfarin) - 04:00 PM\n Lansoprazole (Prevacid) - 04:00 PM\n Morphine Sulfate - 05:05 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.4\nC (97.5\n HR: 99 (66 - 104) bpm\n BP: 91/50(60) {82/42(45) - 101/67(120)} mmHg\n RR: 12 (11 - 23) insp/min\n SpO2: 99%\n Heart rhythm: V Paced\n Wgt (current): 82.2 kg (admission): 82.2 kg\n Total In:\n 1,554 mL\n 456 mL\n PO:\n 900 mL\n 60 mL\n TF:\n IVF:\n 654 mL\n 396 mL\n Blood products:\n Total out:\n 1,628 mL\n 1,505 mL\n Urine:\n 1,628 mL\n 1,505 mL\n NG:\n Stool:\n Drains:\n Balance:\n -74 mL\n -1,049 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///27/\n Physical Examination\n General Appearance: No acute distress, thin, cachectic\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: II/VI systolic murmur best at apex. MI is laterally\n displaced\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Breath Sounds: Clear : anteriorly)\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+\n Skin: Not assessed, Stage 3 sacral decubitus ulcer\n Neurologic: Attentive, Responds to: Not assessed, Oriented (to): x3\n Labs / Radiology\n 159 K/uL\n 10.0 g/dL\n 104 mg/dL\n 1.4 mg/dL\n 27 mEq/L\n 3.8 mEq/L\n 42 mg/dL\n 98 mEq/L\n 134 mEq/L\n 31.9 %\n 4.7 K/uL\n [image002.jpg]\n 05:44 AM\n 04:46 AM\n WBC\n 6.1\n 4.7\n Hct\n 32.1\n 31.9\n Plt\n 156\n 159\n Cr\n 1.3\n 1.4\n Glucose\n 83\n 104\n Other labs: PT / PTT / INR:16.8/29.3/1.5, Ca++:8.0 mg/dL, Mg++:2.1\n mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\n recently discharged from the CCU () for CHF exacerbation c/b\n C.diff infection and on for septic joint washout c/b failure to\n extubate CHF exacerbation, who is now being admitted from \n clinic with total body fluid overload.\n .\n # sCHF exacerbation: Patient has history of CHF ischemic , \n 10%, s/p BiV ICD ( Concerto C154DWK) 1/08with EF 10% which is\n the likely cause of her fluid overload. Her rapid accumulation\n underpins the severity of her condition and her severely unfavourable\n hemodynamics. Her long term goals are comfort, though she still wishes\n to participate in rehab. Her family recognizes that she is dying. Our\n goal is diuresis which we will attempt aggressively, reassessing our\n progress dynamically. She put out very little o/n on lasix gtt. This\n could reflect limitatin of diuresis or the importance of a bolus (we\n withheld bolus to avoid instability)\n -- goal diuresis 5 to 10L total\n -- milrinone with bolus\n -- metoprolol tartrate 12.5mg PO BID\n -- slow uptitration of lasix gtt with goal near-continuous diuresis\n while avoiding MAP < 60\n -- strict i/o's with foley\n -- replete K to 5\n -- PM electrolytes\n -- can switch to levophed if low UOP on Neo with need for pressor\n support\n -- family meeting with HCP to assess goals in AM after diuresis\n attempted\n .\n # Septic Joints: Patient with history +staph aureus in left shoulder\n treated by washout and vancomycin, thus far 4 weeks of monotherapy. No\n + blood cx since before . Major issue now is pain control.\n -- send Vanco level in AM, was recently on 500 mg q12 and switched to\n q24 for high troughs\n -- ultram q6, Tylenol q8, Morphine for breakthrough (2-4 mg).\n - Will consider ms contin if no control\n .\n # Sacral Decub - stage 3-4.\n - wound care\n - pain control.\n .\n # UTI: positive UA, no history of culture positive UA's in system\n - treating empirically with cipro\n - watch INR on abx\n .\n # CORONARIES: Patient with h/o CAD w/ right dominant system, mild\n instent re-stenois of the LAD BM stent and occluded RCA.\n - bb as tolerated\n .\n # RHYTHM: Patient with h/o atrial fibrillation, s/p BiV ICD (\n Concerto C154DWK) , on coumadin. Now in paced rhythm\n - cont home dose meds (amio, metoprolol)\n - cont coumadin\n - f/u INR\n .\n # Chronic Kidney Disease: Baseline 1.3 creatinine. At baseline\n - trend\n .\n # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a\n filter in place.\n - continue Coumadin\n - f/u INR\n .\n # Hypothyroidism: Continue Levothyroxine\n .\n # Gout: continue Allopurinol\n ICU Care\n Nutrition: cardiac diet\n Glycemic Control: None\n Lines:\n Multi Lumen - 05:34 PM\n Midline - 05:34 PM\n 18 Gauge - 05:35 PM\n Prophylaxis:\n DVT: Coumadin\n Stress ulcer: Lansoprazole\n VAP:\n Comments:\n Communication: patient\n Code status: DNR/DNI\n Disposition:\n ------ Protected Section ------\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I would add the following remarks:\n Above discussed extensively with patient. Above discussed extensively\n with family member, next of or health care proxy. Progress reviewed\n extensively during family meeting.\n DNR status discussed. DNR.\n Total time spent on patient care: 60 minutes.\n Additional comments:\n diuresing well\n DNR/DNI/defibrillator off\n anticipate return to rehab in days\n signed on for service performed on \n ------ Protected Section Addendum Entered By: on:\n 11:05 ------\n"},{"category":"Physician ","chartdate":"2180-01-15 00:00:00.000","description":"Physician Resident Progress Note","row_id":399949,"text":"Chief Complaint:\n 24 Hour Events:\n :\n - diuresed ~2L over the day\n - PM lytes & Cr solid\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Ciprofloxacin - 08:00 AM\n Infusions:\n Milrinone - 0.5 mcg/Kg/min\n Other ICU medications:\n Coumadin (Warfarin) - 04:00 PM\n Lansoprazole (Prevacid) - 04:00 PM\n Morphine Sulfate - 03:25 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.4\nC (97.5\n HR: 65 (63 - 99) bpm\n BP: 94/54(65) {76/49(56) - 100/62(70)} mmHg\n RR: 13 (10 - 26) insp/min\n SpO2: 98%\n Heart rhythm: AV Paced\n Wgt (current): 82.2 kg (admission): 82.2 kg\n Total In:\n 2,299 mL\n 162 mL\n PO:\n 1,340 mL\n TF:\n IVF:\n 959 mL\n 162 mL\n Blood products:\n Total out:\n 5,030 mL\n 1,760 mL\n Urine:\n 5,030 mL\n 1,760 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,731 mL\n -1,598 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///28/\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Diminished: )\n Abdominal: Soft, Obese\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 146 K/uL\n 10.7 g/dL\n 115 mg/dL\n 1.2 mg/dL\n 28 mEq/L\n 3.7 mEq/L\n 38 mg/dL\n 94 mEq/L\n 132 mEq/L\n 33.1 %\n 5.1 K/uL\n [image002.jpg]\n 05:44 AM\n 04:46 AM\n 04:00 PM\n 03:05 AM\n WBC\n 6.1\n 4.7\n 5.1\n Hct\n 32.1\n 31.9\n 33.1\n Plt\n 156\n 159\n 146\n Cr\n 1.3\n 1.4\n 1.3\n 1.2\n Glucose\n 83\n 104\n 155\n 115\n Other labs: PT / PTT / INR:18.4/29.1/1.7, Ca++:8.3 mg/dL, Mg++:2.1\n mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\n recently discharged from the CCU () for CHF exacerbation c/b\n C.diff infection and on for septic joint washout c/b failure to\n extubate CHF exacerbation, who is now being admitted from \n clinic with total body fluid overload.\n .\n # sCHF exacerbation: Patient has history of CHF ischemic , \n 10%, s/p BiV ICD ( Concerto C154DWK) 1/08with EF 10% which is\n the likely cause of her fluid overload. Her rapid accumulation\n underpins the severity of her condition and her severely unfavourable\n hemodynamics. Her long term goals are comfort, though she still wishes\n to participate in rehab. Her family recognizes that she is dying. Our\n goal is diuresis which we will attempt aggressively, reassessing our\n progress dynamically. She put out very little o/n on lasix gtt. This\n could reflect limitatin of diuresis or the importance of a bolus (we\n withheld bolus to avoid instability)\n -- goal diuresis 5 to 10L total\n -- continue milrinone\n -- metoprolol tartrate 12.5mg PO BID\n -- slow uptitration of lasix gtt with goal near-continuous diuresis\n while avoiding MAP < 60\n -- strict i/o's with foley\n -- replete K to 5\n -- PM electrolytes\n -- can switch to levophed if low UOP on Neo with need for pressor\n support\n -- family meeting with HCP prn\n .\n # Septic Joints: Patient with history +staph aureus in left shoulder\n treated by washout and vancomycin, thus far 4 weeks of monotherapy. No\n + blood cx since before . Major issue now is pain control.\n -- send Vanco level in AM, was recently on 500 mg q12 and switched to\n q24 for high troughs\n -- ultram q6, Tylenol q8, Morphine for breakthrough (2-4 mg).\n - Will consider ms contin if no control\n .\n # Sacral Decub - stage 3-4.\n - wound care\n - pain control.\n .\n # UTI: positive UA, no history of culture positive UA's in system\n - treating empirically with cipro day 1 was . Last dose Morning of\n \n - watch INR on abx\n .\n # CORONARIES: Patient with h/o CAD w/ right dominant system, mild\n instent re-stenois of the LAD BM stent and occluded RCA.\n - bb as tolerated\n .\n # RHYTHM: Patient with h/o atrial fibrillation, s/p BiV ICD (\n Concerto C154DWK) , on coumadin. Now in paced rhythm\n - cont home dose meds (amio, metoprolol)\n - cont coumadin\n .\n # Chronic Kidney Disease: Baseline 1.3 creatinine. At baseline (1.2)\n - trend\n .\n # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a\n filter in place.\n - continue Coumadin\n .\n # Hypothyroidism: Continue Levothyroxine\n .\n # Gout: continue Allopurinol\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 05:34 PM\n Midline - 05:34 PM\n 18 Gauge - 05:35 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: DNR / DNI\n Disposition:ICU\n ------ Protected Section ------\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I would add the following remarks:\n Above discussed extensively with patient.\n DNR status discussed. DNR.\n Total time spent on patient care: 45 minutes.\n Additional comments:\n diuresing very well; > 5 liters off net los\n anticipate 24-48 hours more volume unloading (until creat shows rise)\n plan to return to rehab\n ------ Protected Section Addendum Entered By: on:\n 11:06 ------\n"},{"category":"General","chartdate":"2180-01-13 00:00:00.000","description":"Code Discussion","row_id":399725,"text":"TITLE:\n Discussion of code status:\n Dr. discussed patient\ns code status with her this morning.\n Code status was confirmed with the patient to be DNR/DNI. In addition,\n after discussing with the patient, we will deactivate the defibrillator\n shocking function of her ICD.\n Furthermore, we have confirmed with the patient that, moving forward,\n no escalation of care will be initiated. Patient is currently on\n milrinone and phenylephrine. If patient has increased pain requiring\n more morphine which results in more pressor requirements, or if patient\n clinically worsens requiring more pressor support, will transition\n patient to CMO.\n This discussion was undertaken between the patient and Dr. ,\n in the presence of the CCU fellow and house staff.\n"},{"category":"Physician ","chartdate":"2180-01-15 00:00:00.000","description":"Physician Resident Progress Note","row_id":399922,"text":"Chief Complaint:\n 24 Hour Events:\n :\n - diuresed ~2L over the day\n - PM lytes & Cr solid\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Ciprofloxacin - 08:00 AM\n Infusions:\n Milrinone - 0.5 mcg/Kg/min\n Other ICU medications:\n Coumadin (Warfarin) - 04:00 PM\n Lansoprazole (Prevacid) - 04:00 PM\n Morphine Sulfate - 03:25 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.4\nC (97.5\n HR: 65 (63 - 99) bpm\n BP: 94/54(65) {76/49(56) - 100/62(70)} mmHg\n RR: 13 (10 - 26) insp/min\n SpO2: 98%\n Heart rhythm: AV Paced\n Wgt (current): 82.2 kg (admission): 82.2 kg\n Total In:\n 2,299 mL\n 162 mL\n PO:\n 1,340 mL\n TF:\n IVF:\n 959 mL\n 162 mL\n Blood products:\n Total out:\n 5,030 mL\n 1,760 mL\n Urine:\n 5,030 mL\n 1,760 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,731 mL\n -1,598 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///28/\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Diminished: )\n Abdominal: Soft, Obese\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 146 K/uL\n 10.7 g/dL\n 115 mg/dL\n 1.2 mg/dL\n 28 mEq/L\n 3.7 mEq/L\n 38 mg/dL\n 94 mEq/L\n 132 mEq/L\n 33.1 %\n 5.1 K/uL\n [image002.jpg]\n 05:44 AM\n 04:46 AM\n 04:00 PM\n 03:05 AM\n WBC\n 6.1\n 4.7\n 5.1\n Hct\n 32.1\n 31.9\n 33.1\n Plt\n 156\n 159\n 146\n Cr\n 1.3\n 1.4\n 1.3\n 1.2\n Glucose\n 83\n 104\n 155\n 115\n Other labs: PT / PTT / INR:18.4/29.1/1.7, Ca++:8.3 mg/dL, Mg++:2.1\n mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\n recently discharged from the CCU () for CHF exacerbation c/b\n C.diff infection and on for septic joint washout c/b failure to\n extubate CHF exacerbation, who is now being admitted from \n clinic with total body fluid overload.\n .\n # sCHF exacerbation: Patient has history of CHF ischemic , \n 10%, s/p BiV ICD ( Concerto C154DWK) 1/08with EF 10% which is\n the likely cause of her fluid overload. Her rapid accumulation\n underpins the severity of her condition and her severely unfavourable\n hemodynamics. Her long term goals are comfort, though she still wishes\n to participate in rehab. Her family recognizes that she is dying. Our\n goal is diuresis which we will attempt aggressively, reassessing our\n progress dynamically. She put out very little o/n on lasix gtt. This\n could reflect limitatin of diuresis or the importance of a bolus (we\n withheld bolus to avoid instability)\n -- goal diuresis 5 to 10L total\n -- continue milrinone\n -- metoprolol tartrate 12.5mg PO BID\n -- slow uptitration of lasix gtt with goal near-continuous diuresis\n while avoiding MAP < 60\n -- strict i/o's with foley\n -- replete K to 5\n -- PM electrolytes\n -- can switch to levophed if low UOP on Neo with need for pressor\n support\n -- family meeting with HCP prn\n .\n # Septic Joints: Patient with history +staph aureus in left shoulder\n treated by washout and vancomycin, thus far 4 weeks of monotherapy. No\n + blood cx since before . Major issue now is pain control.\n -- send Vanco level in AM, was recently on 500 mg q12 and switched to\n q24 for high troughs\n -- ultram q6, Tylenol q8, Morphine for breakthrough (2-4 mg).\n - Will consider ms contin if no control\n .\n # Sacral Decub - stage 3-4.\n - wound care\n - pain control.\n .\n # UTI: positive UA, no history of culture positive UA's in system\n - treating empirically with cipro day 1 was . Last dose Morning of\n \n - watch INR on abx\n .\n # CORONARIES: Patient with h/o CAD w/ right dominant system, mild\n instent re-stenois of the LAD BM stent and occluded RCA.\n - bb as tolerated\n .\n # RHYTHM: Patient with h/o atrial fibrillation, s/p BiV ICD (\n Concerto C154DWK) , on coumadin. Now in paced rhythm\n - cont home dose meds (amio, metoprolol)\n - cont coumadin\n .\n # Chronic Kidney Disease: Baseline 1.3 creatinine. At baseline (1.2)\n - trend\n .\n # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a\n filter in place.\n - continue Coumadin\n .\n # Hypothyroidism: Continue Levothyroxine\n .\n # Gout: continue Allopurinol\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 05:34 PM\n Midline - 05:34 PM\n 18 Gauge - 05:35 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: DNR / DNI\n Disposition:ICU\n"},{"category":"Nursing","chartdate":"2180-01-15 00:00:00.000","description":"Nursing Progress Note","row_id":399992,"text":"71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\n : Sent to ED from clinic w/ hypotension\n transiently on\n dopa, Tx\nd w/ NS 250 cc w/ SBP ^ 92. Admit to CCU for aggressive\n diuresis.\n Ineffective Coping\n Assessment:\n Pt having difficulty coping with chronicity of illness and inevitable\n return to rehab/nursing home\n Action:\n Pt very weepy today after Cardiology team talked to pt about returning\n to rehab once she is better\n RN allowed pt to voice feelings about illness\n conversation about hospice with RN after it was brought up by CHF\n attending\n Response:\n less weepy, visiting with family members, interactive\n :\n Social service, Case Management consults on Monday AM\n Cont encourage pt to vent feelings, Cont to provide emotional support\n for patient.\n Pain control (acute pain, chronic pain)\n Assessment:\n pt with acute pain at wound site on coccyx, increases when pt sitting\n up in bed for meals\n of note, pt states pain is tolerable at 8/10\n severe at \n Action:\n receiving Ultram, Acetaminophen ATC, MSO4 2mg IV prn, MS Contin 15mg po\n added\n Response:\n pt in most pain while sitting upright for meals; sleeping well in naps\n while lying on right side\n Plan:\n Assess response to MS Contin; Assess/Re-assess pain;\n ? pressure reducing cushion for periods when pt sits upright\n refusing to wear waffle boots; does not want kinair bed.\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n diuresing well on Lasiv 10mg iv and Milrinone 0.5mcgs/kg/min\n Action:\n Lasix decreased to 10mg/hr secondary to u/o > 300/hr\n Response:\n remains with urine > 100ml/hr\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2180-01-15 00:00:00.000","description":"Nursing Progress Note","row_id":399993,"text":"71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\n : Sent to ED from clinic w/ hypotension\n transiently on\n dopa, Tx\nd w/ NS 250 cc w/ SBP ^ 92. Admit to CCU for aggressive\n diuresis.\n Ineffective Coping\n Assessment:\n Pt having difficulty coping with chronicity of illness and inevitable\n return to rehab/nursing home\n Action:\n Pt very weepy today after Cardiology team talked to pt about returning\n to rehab once she is better\n RN allowed pt to voice feelings about illness\n conversation about hospice with RN after it was brought up by CHF\n attending\n Response:\n less weepy, visiting with family members, interactive\n :\n Social service, Case Management consults on Monday AM\n Cont encourage pt to vent feelings, Cont to provide emotional support\n for patient.\n Pain control (acute pain, chronic pain)\n Assessment:\n pt with acute pain at wound site on coccyx, increases when pt sitting\n up in bed for meals\n of note, pt states pain is tolerable at 8/10\n severe at \n Action:\n receiving Ultram, Acetaminophen ATC, MSO4 2mg IV prn, MS Contin 15mg po\n added\n Response:\n pt in most pain while sitting upright for meals; sleeping well in naps\n while lying on right side\n Plan:\n Assess response to MS Contin; Assess/Re-assess pain;\n ? pressure reducing cushion for periods when pt sits upright\n refusing to wear waffle boots; does not want kinair bed.\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n diuresing well on Lasix 10mg iv and Milrinone 0.5mcgs/kg/min\n Action:\n Lasix decreased to 10mg/hr secondary to u/o > 300/hr\n Response:\n remains with urine > 100ml/hr; 6 liters LOS negative\n Plan:\n Cont gentle diuresis until CR bumps or BP drops per Dr \n Replace lytes as needed\n Impaired Skin Integrity\n Assessment:\n large pressure ulcer on coccyx area 5.5X6cm base yellow/black\n Action:\n duoderm gel/Mepilex reapplied today\n Response:\n site unchanged\n Plan:\n Cont frequent turns, keep off back as much as possible however, pt\n needs to sit upright in bed to eat\n pt refusing waffle boots, pressure reducing bed\n Wound care consult on Monday AM.\n"},{"category":"Nursing","chartdate":"2180-01-15 00:00:00.000","description":"Nursing Progress Note","row_id":399927,"text":"71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\n : Sent to ED from clinic w/ hypotension\n transiently on\n dopa, Tx\nd w/ NS 250 cc w/ SBP ^ 92. Admit to CCU for aggressive\n diuresis.\n Heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n + pitting edema BLE\non lasix gtt 15mg/hr & milrinone 0.5mcg/k/min.\n LS clr, dim at bases.\n Action:\n 1^st dose 25mg PO lopressor given\n Response:\n BPs lower when asleep and after morphine, MAPs >55 (of note: BPs taken\n on L upper arm, pt mosly positioned on R side). K+ 3.7\nto be repleted,\n and Mg+ 2.1. Neg 2L since MN. Neg 5L LOS. Rare short runs AIVR.\n Plan:\n CHF management, aggressive diuresis w/ lasix & daily\n metolazone-- goal NEG 5-10L overall, strict I/Os, Low Na+ diet, daily\n wts, monitor & replete lytes as indicated\n DNR/DNI-ICD turned off after fam mtg. Both pt and HCP\n are in agreement that pt would like to be comfortable to be able to\n participate in rehab.\n Impaired Skin Integrity\n Assessment:\n *Lg stage 3 vs. unstageable decub to coccyx, covered w/ yellow slough &\n red blanching borders--sm amt serous dsg\n mepilex intact, placed \n *Red, blanching heels.\n *Dry and thin skin w/ discolored areas.\n *Good appetite. Declines Kinair bed/waffle boots\n Action:\n Mepilex dsg peeled to check skin--Duoderm hydroactive gel\n applied per wound care recs .\n Heels elevated on pillows, skin/pressure area well\n lubricated.\n Slight freq position changes avoiding back and L side.\n Response:\n Skin unchanged\n Plan:\n Monitor for changes, prevent further breathdown. Change\n position freq as tolerated as pt mobility/able to turn self is very\n limited.\n Change mepilex w/ duoderm gel daily drainage\n Pain control (chronic pain)\n Assessment:\n Very uncomfortable w/ turning and w/ laying on L side\n Action:\n Standing order ultram & Tylenol Q6hrs, 2mg Morphine sulfate\n IVP for breakthrough pain\n Pt positioned mostly far on R side w/ slight position\n changes, placed supine for short periods only.\n Response:\n Pt allowed to rest in btwn necessary nsg interventions, Slept well all\n night.\n Plan:\n Continue current pain control regimen, medicate w/ morphine\n prior to turning side to side\n GI: NO BM, takes pills crushed in applesauce\n"},{"category":"Physician ","chartdate":"2180-01-13 00:00:00.000","description":"Physician Resident Progress Note","row_id":399698,"text":"Chief Complaint: anasarca\n 24 Hour Events:\n MULTI LUMEN - START 05:34 PM\n MIDLINE - START 05:34 PM\n - poor UOP to 2.5 and 5mg/hr lasix drip.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Milrinone - 0.375 mcg/Kg/min\n Furosemide (Lasix) - 5 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue\n Flowsheet Data as of 06:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.1\nC (97\n Tcurrent: 36\nC (96.8\n HR: 72 (70 - 108) bpm\n BP: 97/52(64) {77/44(52) - 113/76(84)} mmHg\n RR: 13 (11 - 18) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 82.2 kg (admission): 82.2 kg\n Total In:\n 417 mL\n 156 mL\n PO:\n 120 mL\n 60 mL\n TF:\n IVF:\n 47 mL\n 96 mL\n Blood products:\n Total out:\n 550 mL\n 410 mL\n Urine:\n 200 mL\n 410 mL\n NG:\n Stool:\n Drains:\n Balance:\n -133 mL\n -254 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ///26/\n Physical Examination\n General Appearance: No acute distress, Thin, cachectic\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: II/VI systolic murmur best at apex. PMI is laterally\n displaces\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Breath Sounds: Clear : anteriors)\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended, fluid\n wave\n Extremities: Right lower extremity edema: 4+, Left lower extremity\n edema: 4+\n Skin: Not assessed, Stage 3 sacral decub\n Neurologic: Attentive, Responds to: Not assessed, Oriented (to): x3,\n Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 156 K/uL\n 10.0 g/dL\n 83 mg/dL\n 1.3 mg/dL\n 26 mEq/L\n 4.3 mEq/L\n 46 mg/dL\n 99 mEq/L\n 137 mEq/L\n 32.1 %\n 6.1 K/uL\n [image002.jpg]\n 05:44 AM\n WBC\n 6.1\n Hct\n 32.1\n Plt\n 156\n Cr\n 1.3\n Glucose\n 83\n Other labs: PT / PTT / INR:15.7/36.8/1.4, Mg++:2.1 mg/dL\n Fluid analysis / Other labs: UA = WBC + clumps. Mod Bacteria\n Assessment and Plan\n 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\n recently discharged from the CCU () for CHF exacerbation c/b\n C.diff infection and on for septic joint washout c/b failure to\n extubate CHF exacerbation, who is now being admitted from \n clinic with total body fluid overload.\n .\n # Anasarca: Patient has history of CHF ischemic , 10%, s/p\n BiV ICD ( Concerto C154DWK) 1/08with EF 10% which is the\n likely cause of her fluid overload. Her rapid accumulation underpins\n the severity of her condition and her severely unfavourable\n hemodynamics. Her long term goals are comfort, though she still wishes\n to participate in rehab. Her family recognizes that she is dying. Our\n goal is diuresis which we will attempt aggressively, reassessing our\n progress dynamically. She put out very little o/n on lasix gtt. This\n could reflect limitatin of diuresis or the importance of a bolus (we\n withheld bolus to avoid instability)\n -- milrinone with bolus\n -- neosynephrine for pressure support, goal MAP of > 60\n -- slow uptitration of lasix with goal near-continuous diuresis while\n avoiding MAP < 60\n -- strict i/o's with foley\n -- can switch to levophed if low UOP on Neo with need for pressor\n support\n -- family meeting with HCP to assess goals in AM after diuresis\n attempted\n .\n # Septic Joints: Patient with history +staph aureus in left shoulder\n treated by washout and vancomycin, thus far 4 weeks of monotherapy. No\n + blood cx since before . Major issue now is pain control.\n -- send Vanco level in AM, was recently on 500 mg q12 and switched to\n q24 for high troughs\n -- ultram q6, Tylenol q8, Morphine for breakthrough (1-3 mg).\n - Will consider ms contin if no control\n .\n # Sacral Decub - stage 3-4.\n - wound care\n - pain control.\n .\n # UTI: positive UA, no history of culture positive UA's in system\n - treating empirically with cipro\n - watch INR on abx\n .\n # CORONARIES: Patient with h/o CAD w/ right dominant system, mild\n instent re-stenois of the LAD BM stent and occluded RCA.\n - bb as tolerated\n .\n # RHYTHM: Patient with h/o atrial fibrillation, s/p BiV ICD (\n Concerto C154DWK) , on coumadin. Now in paced rhythm\n - cont home dose meds (amio, metoprolol)\n - cont coumadin\n - f/u INR\n .\n # Chronic Kidney Disease: Baseline 1.3 creatinine. At baseline\n - trend\n .\n # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a\n filter in place.\n - cont coumadin\n - f/u INR\n .\n # Hypothyroidism: Continue Levothyroxine.\n .\n # Gout: continue allopurionl\n .\n # FEN: low sodium diet\n .\n # ACCESS: Right PICC, right IJ, Left EJ\n .\n # PROPHYLAXIS: on coumadin\n .\n # CODE: DNR/DNI\n .\n # DISPO: CCU for now.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 05:34 PM\n Midline - 05:34 PM\n 18 Gauge - 05:35 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:ICU\n"},{"category":"Nursing","chartdate":"2180-01-13 00:00:00.000","description":"Nursing Progress Note","row_id":399702,"text":"Pt is a 71 yo female with PMH: BM stent to LAD ', Occluded RCA\n without intervention, Ischemic CM (EF 10-25%), BiV ICD, AF, PVD, DVT\n s/p IVC filter, coumadin, hypothyroidism, CKD, OA. adm for HF\n (milrinone/lasix) MRSA in L shoulder, L hip and R knuckle. Out to\n rehab . went from rehab to see Dr. , sent to EW with\n hypotension. SBP 70 in EW, transiently on dopa, but cardiology d/c'd.\n Rxd with NS 250 cc with SBP 92. Pt has been in rehab since d/c from\n with septic arthritis in L shoulder, hip and R knuckle.\n On Vanco followed by ID.\n She was started on milrinone .375 after bolus\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Physician ","chartdate":"2180-01-17 00:00:00.000","description":"Physician Resident Progress Note","row_id":400075,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n - MS contin increased to 30mg last night, received 2 doses w pills\n crushed, complained of nausea after each\n - Has not had a BM for four days\n - PT ordered yesterday\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 08:00 AM\n Vancomycin - 09:36 AM\n Infusions:\n Furosemide (Lasix) - 10 mg/hour\n Milrinone - 0.5 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 12:45 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.6\nC (97.8\n HR: 68 (63 - 75) bpm\n BP: 91/52(62) {75/44(51) - 98/61(70)} mmHg\n RR: 9 (9 - 29) insp/min\n SpO2: 99%\n Heart rhythm: AV Paced\n Wgt (current): 77.3 kg (admission): 82.2 kg\n Total In:\n 1,004 mL\n 146 mL\n PO:\n 440 mL\n TF:\n IVF:\n 564 mL\n 146 mL\n Blood products:\n Total out:\n 2,410 mL\n 420 mL\n Urine:\n 2,410 mL\n 420 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,406 mL\n -274 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///34/\n Physical Examination\n Gen: alert, oriented x3 but appears to have psychomotor retardation and\n easily confused\n HEENT: slightly dry mucus membranes\n CHEST: regular rhythm ; dry basilar crackles\n ABD: mildly distended, soft, nontender\n EXT: + pitting edema bilaterally\n Labs / Radiology\n 106 K/uL\n 10.0 g/dL\n 86 mg/dL\n 1.0 mg/dL\n 34 mEq/L\n 3.7 mEq/L\n 33 mg/dL\n 92 mEq/L\n 134 mEq/L\n 30.9 %\n 4.2 K/uL\n [image002.jpg]\n 05:44 AM\n 04:46 AM\n 04:00 PM\n 03:05 AM\n 03:17 PM\n 03:05 AM\n 05:03 PM\n 05:22 AM\n WBC\n 6.1\n 4.7\n 5.1\n 4.4\n 4.2\n Hct\n 32.1\n 31.9\n 33.1\n 32.2\n 30.9\n Plt\n 156\n 159\n 146\n 134\n 106\n Cr\n 1.3\n 1.4\n 1.3\n 1.2\n 1.1\n 1.0\n 1.0\n 1.0\n Glucose\n 83\n 104\n 155\n 115\n 98\n 107\n 86\n Other labs: PT / PTT / INR:20.2/33.1/1.9, Ca++:8.1 mg/dL, Mg++:2.1\n mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\n recently discharged from the CCU () for CHF exacerbation c/b\n C.diff infection and on for septic joint washout c/b failure to\n extubate CHF exacerbation, who is now being admitted from \n clinic with total body fluid overload.\n .\n # sCHF exacerbation:\n Patient has history of CHF ischemic , 10%, s/p BiV ICD\n ( Concerto C154DWK) with EF 10% which is the likely cause\n of her fluid overload. Her rapid accumulation underpins the severity of\n her condition and her severely unfavourable hemodynamics. Her long term\n goals are comfort, though she still wishes to participate in rehab. Her\n family recognizes that she is dying. Our goal is diuresis which we will\n attempt aggressively, reassessing our progress dynamically. She\n diuresed well on Lasix gtt on with net neg 4L balance. LOS fluid\n balance -5L.\n -- goal diuresis 1L negative today with lasix gtt\n -- continue milrinone\n -- continue metolazone 5mg daily\n -- continue metoprolol tartrate 12.5mg PO BID\n -- strict i/o's with foley\n -- replete K to 5\n -- PM electrolytes\n -- family meeting with HCP prn\n .\n # Septic Joints: Patient with history +staph aureus in left shoulder\n treated by washout and vancomycin, thus far 4 weeks of monotherapy. No\n + blood cx since before . Major issue now is pain control.\n -- continue vanc, was recently on 500 mg q12 and switched to q24 for\n high troughs\n -- continue cipro\n -- increase MS contin to 30mg \n -- ultram q6, Tylenol q8, Morphine for breakthrough (2-4 mg).\n .\n # Sacral Decub - stage 3-4.\n - wound care\n - increase MS contin to 30mg \n - pain control\n .\n # UTI: positive UA, no history of culture positive UA's in system\n - treating empirically with cipro day 1 was . Last dose tomorrow\n morning (Morning of ^st)\n - watch INR on abx\n .\n # CORONARIES: Patient with h/o CAD w/ right dominant system, mild\n instent re-stenois of the LAD BM stent and occluded RCA.\n - bb as tolerated\n .\n # RHYTHM: Patient with h/o atrial fibrillation, s/p BiV ICD (\n Concerto C154DWK) , on coumadin. Now in paced rhythm\n - cont home dose meds (amio, metoprolol)\n - cont coumadin\n .\n # Chronic Kidney Disease: Baseline Creatinine 1.3. Creatinine 1.1\n today.\n - trend\n .\n # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a\n filter in place.\n - continue Coumadin\n .\n # Hypothyroidism: Continue Levothyroxine\n .\n # Gout: continue Allopurinol\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 05:34 PM\n Midline - 05:34 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"},{"category":"Nursing","chartdate":"2180-01-17 00:00:00.000","description":"Nursing Progress Note","row_id":400083,"text":"71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\n : Sent to ED from clinic w/ hypotension\n transiently on\n dopa, Tx\nd w/ NS 250 cc w/ SBP ^ 92.\n Admit to CCU for aggressive diuresis.She was started on Milrinone\n and lasix gtt. And has been diuresing well. She has lg coccyx decub\n that is a source of chronic pain. She is DNR/DNI and defibrillator has\n been shut off. She has excellent apetite.\n Pain control (acute pain, chronic pain)\n Assessment:\n Plan is to transition to oral forms of pain control in preparation for\n pt going to rehab. She had received MS contin at 0600, but pill was\n ground and pt had nausea. She received 4mg IV morphine at 6am as well.\n Action:\n MS contin will be given in to 15mg pills, which are smaller and can\n take them without having them crushed. Morphine immediate release has\n been ordered for breakthrough pain. It is also a small pill that she\n can take without crushing..\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Pt being transition for transfer back to rehab. Milrinone and lasix\n drips stopped at 1030.\n Action:\n At noon she received dose of torsemide 40mg po and metolazone 5mg po.\n Response:\n Plan:\n"},{"category":"General","chartdate":"2180-01-18 00:00:00.000","description":"Generic Note","row_id":400135,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n - lasix gtt stopped and pt started on torsemide 40mg + metolazone\n 5mg daily (needs to drop to 2.5mg daily metolazone tomorrow)\n - started IR morphine po for breakthrough 15mg 4h prn (w IV as backup)\n - Pain and Palliative Care consulted -- leave pain regimen as is for\n now, will reassess 24hr needs tomorrow; MD had discussion w patient\n about Do-Not-Hospitalize, and pt would like HCP/family to be a part of\n that discussion rather than herself--> need to discuss w dr. also\n - milrinone stopped in AM, but restarted milrinone bc blood pressures\n not maintained otherwise (dropped to 70s systolic without) and urine\n output decreased.\n - family meeting scheduled for at 1pm - will need Dr. and\n palliative care present.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Ciprofloxacin - 10:00 AM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 10:32 AM\n Coumadin (Warfarin) - 04:00 PM\n Omeprazole (Prilosec) - 04:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.9\nC (98.4\n HR: 69 (55 - 71) bpm\n BP: 85/56(63) {74/43(53) - 97/62(69)} mmHg\n RR: 13 (9 - 20) insp/min\n SpO2: 96%\n Heart rhythm: V Paced\n Wgt (current): 74 kg (admission): 82.2 kg\n Height: 60 Inch\n Total In:\n 1,052 mL\n 201 mL\n PO:\n 450 mL\n 120 mL\n TF:\n IVF:\n 602 mL\n 81 mL\n Blood products:\n Total out:\n 1,571 mL\n 320 mL\n Urine:\n 1,571 mL\n 320 mL\n NG:\n Stool:\n Drains:\n Balance:\n -519 mL\n -119 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ///35/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 116 K/uL\n 10.2 g/dL\n 93 mg/dL\n 1.0 mg/dL\n 35 mEq/L\n 3.8 mEq/L\n 32 mg/dL\n 91 mEq/L\n 132 mEq/L\n 31.2 %\n 4.6 K/uL\n [image002.jpg]\n 05:44 AM\n 04:46 AM\n 04:00 PM\n 03:05 AM\n 03:17 PM\n 03:05 AM\n 05:03 PM\n 05:22 AM\n 05:25 PM\n 05:40 AM\n WBC\n 6.1\n 4.7\n 5.1\n 4.4\n 4.2\n 4.6\n Hct\n 32.1\n 31.9\n 33.1\n 32.2\n 30.9\n 31.2\n Plt\n 156\n 159\n 146\n 134\n 106\n 116\n Cr\n 1.3\n 1.4\n 1.3\n 1.2\n 1.1\n 1.0\n 1.0\n 1.0\n 1.1\n 1.0\n Glucose\n 83\n 104\n 155\n 115\n 98\n 107\n 86\n 93\n Other labs: PT / PTT / INR:19.1/29.7/1.7, Ca++:8.1 mg/dL, Mg++:2.1\n mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\n recently discharged from the CCU () for CHF exacerbation c/b\n C.diff infection and on for septic joint washout c/b failure to\n extubate CHF exacerbation, who was admitted from clinic with\n total body fluid overload.\n .\n # sCHF Exacerbation:\n Patient has history of CHF ischemic , 10%, s/p BiV ICD\n ( Concerto C154DWK) with EF 10% which was the likely\n cause of her fluid overload. Appears intravascularly euvolemic on\n exam, no need to continue lasix gtt. Has diuresed well -9L on length\n of stay. Responding well to torsemide with metolazone while on\n milrinone, but urine output had dropped without milrinone yesterday.\n Diuresed net -500cc over last day.\n - Continue milrinone for now\n - Continue torsemide 40mg with metolazone 5mg for now\n - Continue strict I/Os\n - Continue to replete K\n .\n # Goals of Care:\n End-stage CHF with long term goals are comfort, though she still wishes\n to participate in rehab. Her family recognizes that she is dying. Pain\n and Palliative Care consulted yesterday for pain control and goals of\n care.\n - family meeting at 1pm today\n .\n # Septic Joints: Patient with history +staph aureus in left shoulder\n treated by washout and vancomycin, thus far 4 weeks of monotherapy. No\n + blood cx since before . Major issue now is pain control.\n - continue vancomycin until , then suppression with doxycycline\n -- continue MS contin 30mg and reassess pain med needs\n -- standing ultram q6, Tylenol q8\n .\n # Sacral Decub - stage 3-4. Focusing on Pain control. Pain and\n Palliative Care following with patient. Switched to oral breakthrough\n Morphine with IV as backup, but patient was not requiring IV backup.\n - wound care\n - standing ultram Q6h, Tylenol Q8h\n - reassess patient\ns pain requirements\n - goals of care family meeting 1pm today\n .\n # UTI: positive UA, no history of culture positive UA's in system.\n Will do 10day course because of chronic foley.\n - treating empirically with cipro ; day 1 of 10 day course was \n - watch INR on abx\n .\n # Hx CAD:\n Patient with h/o CAD w/ right dominant system, mild instent re-stenois\n of the LAD BM stent and occluded RCA.\n - continue metoprolol 25mg \n .\n # Hx Afib:\n Patient with h/o atrial fibrillation, s/p BiV ICD ( Concerto\n C154DWK) , on coumadin. Now in paced rhythm\n - cont home dose meds (amio, metoprolol)\n - cont coumadin\n - trend INR\n .\n # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a\n filter in place. INR mildly subtherapeutic despite Cipro\n - continue Coumadin\n - monitor INR\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines: midline, right IJ\n Multi Lumen - 05:34 PM\n Midline - 05:34 PM\n Prophylaxis:\n DVT: coumadin\n Stress ulcer: lansoprazole\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"},{"category":"General","chartdate":"2180-01-18 00:00:00.000","description":"Generic Note","row_id":400139,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n - lasix gtt stopped and pt started on torsemide 40mg + metolazone\n 5mg daily\n - started IR morphine po for breakthrough 15mg 4h prn (w IV as backup)\n yesterday, and patient did not require IV backup\n - Pain and Palliative Care consulted\n - milrinone stopped yesterday AM, but restarted milrinone bc blood\n pressures not maintained otherwise (dropped to 70s systolic without)\n and urine output decreased.\n - family meeting scheduled for at 1pm - will need Dr. and\n palliative care present\n - does not have any complaints of pain or sob this AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Ciprofloxacin - 10:00 AM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 10:32 AM\n Coumadin (Warfarin) - 04:00 PM\n Omeprazole (Prilosec) - 04:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.9\nC (98.4\n HR: 69 (55 - 71) bpm\n BP: 85/56(63) {74/43(53) - 97/62(69)} mmHg\n RR: 13 (9 - 20) insp/min\n SpO2: 96%\n Heart rhythm: V Paced\n Wgt (current): 74 kg (admission): 82.2 kg\n Height: 60 Inch\n Total In:\n 1,052 mL\n 201 mL\n PO:\n 450 mL\n 120 mL\n TF:\n IVF:\n 602 mL\n 81 mL\n Blood products:\n Total out:\n 1,571 mL\n 320 mL\n Urine:\n 1,571 mL\n 320 mL\n NG:\n Stool:\n Drains:\n Balance:\n -519 mL\n -119 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ///35/\n Physical Examination\n Gen: sleepy but easily awakened, oriented x3, easily confused, appears\n to have psychomotor slowing\n HEENT: dry mucus membranes\n NECK: JVP not elevated\n CHEST: regular rhythm ; mild dry basilar crackles laterally\n ABD: mildly distended, soft, nontender\n EXT: + pitting edema bilaterally\n Labs / Radiology\n 116 K/uL\n 10.2 g/dL\n 93 mg/dL\n 1.0 mg/dL\n 35 mEq/L\n 3.8 mEq/L\n 32 mg/dL\n 91 mEq/L\n 132 mEq/L\n 31.2 %\n 4.6 K/uL\n [image002.jpg]\n 05:44 AM\n 04:46 AM\n 04:00 PM\n 03:05 AM\n 03:17 PM\n 03:05 AM\n 05:03 PM\n 05:22 AM\n 05:25 PM\n 05:40 AM\n WBC\n 6.1\n 4.7\n 5.1\n 4.4\n 4.2\n 4.6\n Hct\n 32.1\n 31.9\n 33.1\n 32.2\n 30.9\n 31.2\n Plt\n 156\n 159\n 146\n 134\n 106\n 116\n Cr\n 1.3\n 1.4\n 1.3\n 1.2\n 1.1\n 1.0\n 1.0\n 1.0\n 1.1\n 1.0\n Glucose\n 83\n 104\n 155\n 115\n 98\n 107\n 86\n 93\n Other labs: PT / PTT / INR:19.1/29.7/1.7, Ca++:8.1 mg/dL, Mg++:2.1\n mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\n recently discharged from the CCU () for CHF exacerbation c/b\n C.diff infection and on for septic joint washout c/b failure to\n extubate CHF exacerbation, who was admitted from clinic with\n total body fluid overload.\n .\n # sCHF Exacerbation:\n Patient has history of CHF ischemic , 10%, s/p BiV ICD\n ( Concerto C154DWK) with EF 10% which was the likely\n cause of her fluid overload. Appears intravascularly euvolemic on\n exam, no need to continue lasix gtt. Has diuresed well -9L on length\n of stay. Responding well to torsemide with metolazone while on\n milrinone, but urine output had dropped without milrinone yesterday.\n Diuresed net -500cc over last day.\n - Continue milrinone for now\n - Continue torsemide 40mg with metolazone 5mg for now\n - Continue strict I/Os\n - Continue to replete K\n .\n # Goals of Care:\n End-stage CHF with long term goals are comfort, though she still wishes\n to participate in rehab. Her family recognizes that she is dying. Pain\n and Palliative Care consulted yesterday for pain control and goals of\n care.\n - family meeting at 1pm today\n .\n # Septic Joints: Patient with history +staph aureus in left shoulder\n treated by washout and vancomycin, thus far 4 weeks of monotherapy. No\n + blood cx since before . Major issue now is pain control.\n - continue vancomycin until , then suppression with doxycycline\n -- continue MS contin 30mg and reassess pain med needs\n -- standing ultram q6, Tylenol q8\n .\n # Sacral Decub - stage 3-4. Focusing on Pain control. Pain and\n Palliative Care following with patient. Switched to oral breakthrough\n Morphine with IV as backup, but patient was not requiring IV backup.\n - wound care\n - standing ultram Q6h, Tylenol Q8h\n - reassess patient\ns pain requirements\n - goals of care family meeting 1pm today\n .\n # UTI: positive UA, no history of culture positive UA's in system.\n Will do 10day course because of chronic foley.\n - treating empirically with cipro ; day 1 of 10 day course was \n - watch INR on abx\n .\n # Hx CAD:\n Patient with h/o CAD w/ right dominant system, mild instent re-stenois\n of the LAD BM stent and occluded RCA.\n - continue metoprolol 25mg \n .\n # Hx Afib:\n Patient with h/o atrial fibrillation, s/p BiV ICD ( Concerto\n C154DWK) , on coumadin. Now in paced rhythm\n - cont home dose meds (amio, metoprolol)\n - cont coumadin\n - trend INR\n .\n # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a\n filter in place. INR mildly subtherapeutic despite Cipro\n - continue Coumadin\n - monitor INR\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines: midline, right IJ\n Multi Lumen - 05:34 PM\n Midline - 05:34 PM\n Prophylaxis:\n DVT: coumadin\n Stress ulcer: lansoprazole\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"},{"category":"Nursing","chartdate":"2180-01-18 00:00:00.000","description":"Nursing Progress Note","row_id":400147,"text":"71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\n : Sent to ED from clinic w/ hypotension\n transiently on\n dopa, Tx\nd w/ NS 250 cc w/ SBP ^ 92.\n Admit to CCU for aggressive diuresis.She was started on Milrinone\n and lasix gtt. And has been diuresing well. She has lg coccyx decub\n that is a source of chronic pain. She is DNR/DNI and defibrillator has\n been shut off.\n GI: Pt had a few episode of nausea yesterday and one today. It was very\n transient with no vomiting. She ate very well today. She received\n lactalose but no bM. Foley changed today.\n SOCIAL: Family in to visit. Pts HCP, her 38y old neice is very ill\n creating problem for this stressed family.\n Pain control (acute pain, chronic pain)\n Assessment:\n Plan is to transition to oral forms of pain control in preparation for\n pt going to rehab. She had received MS contin at 0600, but pill was\n ground and pt had nausea. She received 4mg IV morphine at 6am as well.\n She continues on standing acetominofen and ultram\n Action:\n MS contin will be given in to 15mg pills, which are smaller and can\n take them without having them crushed. Morphine immediate release has\n been ordered for breakthrough pain. It is also a small pill that she\n can take without crushing. She had 15mg immediate release at 1300 . She\n has had no IV morphine sulfate since 1030.\n Response:\n Pt has been pain free except when turned since then. She will have\n acute pain with position change, but it will settle down and go away\n within a few minutes. She received MS contin at 1800 and was able to\n swallow them without problem\n :\n Continue to try to control pain with oral medications. Give immediate\n release morphine for breakthrough pain.\n Impaired Skin Integrity\n Assessment:\n Sacral wound getting worse and remains very painful. Mepilex dsg oozing\n through. Acuacel added. Know MRSA infection on R knuckle and R elbow\n appear to be much more reddened than last week. Over all skin is dry\n and itchy.\n Action:\n Wound care nurse came to evaluate wound. Area is now cleansed with\n wound cleanser and dried. Criticade antifungal is applied to wound\n edges and peri-wound area. The wound is covered with aquacel AG and\n then small soft-sorb pad. It is secured with medipore tape on skin that\n has been prepped with barrier wipe. Finger and elbow are washed with\n soap and water. Area kept lubricated. oil used in water. Moisture\n barrier clean applied to body. Heels elevated off bed.\n Response:\n Skin less itchy. No further worsening of skin condition.\n Plan:\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Pt being transition for transfer back to rehab. Milrinone and lasix\n drips stopped at 1030. Pt was V-paced with wide complex and blood\n pressure prior to stopping meds was mid 90s with maps in mid 60s. She\n received KCL 20meq in AM She received torsemide 40mg and metolazone\n 5mg with urine output ~ 30-40cc/hr. Blood pressure dropped to the high\n 70s to mid 80s with maps in the low 50s.\n Action:\n After discussions with Dr she was restarted on Milrinone\n .5mic/kilo with bolus of 25mic/kilo given. Labs drawn in afternoon.\n Response:\n Blood pressure more stable with maps in low 60s after Milrinone\n restarted. She is ~400cc neg for the day. BUN creat 33/1.1, stable.\n Plan:\n Family deciding if pt will now be CMO and go to extended care facility\n with hospice.\n"},{"category":"General","chartdate":"2180-01-18 00:00:00.000","description":"Generic Note","row_id":400148,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n - lasix gtt stopped and pt started on torsemide 40mg + metolazone\n 5mg daily\n - started IR morphine po for breakthrough 15mg 4h prn (w IV as backup)\n yesterday, and patient did not require IV backup\n - Pain and Palliative Care consulted\n - milrinone stopped yesterday AM, but restarted milrinone bc blood\n pressures not maintained otherwise (dropped to 70s systolic without)\n and urine output decreased.\n - family meeting scheduled for at 1pm - will need Dr. and\n palliative care present\n - does not have any complaints of pain or sob this AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Ciprofloxacin - 10:00 AM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 10:32 AM\n Coumadin (Warfarin) - 04:00 PM\n Omeprazole (Prilosec) - 04:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.9\nC (98.4\n HR: 69 (55 - 71) bpm\n BP: 85/56(63) {74/43(53) - 97/62(69)} mmHg\n RR: 13 (9 - 20) insp/min\n SpO2: 96%\n Heart rhythm: V Paced\n Wgt (current): 74 kg (admission): 82.2 kg\n Height: 60 Inch\n Total In:\n 1,052 mL\n 201 mL\n PO:\n 450 mL\n 120 mL\n TF:\n IVF:\n 602 mL\n 81 mL\n Blood products:\n Total out:\n 1,571 mL\n 320 mL\n Urine:\n 1,571 mL\n 320 mL\n NG:\n Stool:\n Drains:\n Balance:\n -519 mL\n -119 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ///35/\n Physical Examination\n Gen: sleepy but easily awakened, oriented x3, easily confused, appears\n to have psychomotor slowing\n HEENT: dry mucus membranes\n NECK: JVP not elevated\n CHEST: regular rhythm ; mild dry basilar crackles laterally\n ABD: mildly distended, soft, nontender\n EXT: + pitting edema bilaterally\n Labs / Radiology\n 116 K/uL\n 10.2 g/dL\n 93 mg/dL\n 1.0 mg/dL\n 35 mEq/L\n 3.8 mEq/L\n 32 mg/dL\n 91 mEq/L\n 132 mEq/L\n 31.2 %\n 4.6 K/uL\n [image002.jpg]\n 05:44 AM\n 04:46 AM\n 04:00 PM\n 03:05 AM\n 03:17 PM\n 03:05 AM\n 05:03 PM\n 05:22 AM\n 05:25 PM\n 05:40 AM\n WBC\n 6.1\n 4.7\n 5.1\n 4.4\n 4.2\n 4.6\n Hct\n 32.1\n 31.9\n 33.1\n 32.2\n 30.9\n 31.2\n Plt\n 156\n 159\n 146\n 134\n 106\n 116\n Cr\n 1.3\n 1.4\n 1.3\n 1.2\n 1.1\n 1.0\n 1.0\n 1.0\n 1.1\n 1.0\n Glucose\n 83\n 104\n 155\n 115\n 98\n 107\n 86\n 93\n Other labs: PT / PTT / INR:19.1/29.7/1.7, Ca++:8.1 mg/dL, Mg++:2.1\n mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\n recently discharged from the CCU () for CHF exacerbation c/b\n C.diff infection and on for septic joint washout c/b failure to\n extubate CHF exacerbation, who was admitted from clinic with\n total body fluid overload.\n .\n # sCHF Exacerbation:\n Patient has history of CHF ischemic , 10%, s/p BiV ICD\n ( Concerto C154DWK) with EF 10% which was the likely\n cause of her fluid overload. Appears intravascularly dry on exam. Has\n diuresed well -9L on length of stay. Responding well to torsemide with\n metolazone while on milrinone, but urine output had dropped without\n milrinone yesterday. Diuresed net -500cc over last day. Milrinone is\n keeping her blood pressures up.\n - DC milrinone\n - With no milrinone, she needs help with filling pressures, so\n will DC diuretics b/c appears dry on exam\n - If blood pressure drops without milrinone,, she may benefit\n from 250cc IVF boluses as needed\n - Continue strict I/Os\n - Continue to replete K\n .\n # Goals of Care:\n End-stage CHF with long term goals are comfort, though she still wishes\n to participate in rehab. Her family recognizes that she is dying. Pain\n and Palliative Care consulted yesterday for pain control and goals of\n care.\n - family meeting at 1pm today\n .\n # Septic Joints: Patient with history +staph aureus in left shoulder\n treated by washout and vancomycin, thus far 4 weeks of monotherapy. No\n + blood cx since before . Major issue now is pain control.\n - continue vancomycin until , then suppression with doxycycline\n -- continue MS contin 30mg and reassess pain med needs\n -- standing ultram q6, Tylenol q8\n .\n # Sacral Decub - stage 3-4. Focusing on Pain control. Pain and\n Palliative Care following with patient. Switched to oral breakthrough\n Morphine with IV as backup, but patient was not requiring IV backup.\n - wound care\n - standing ultram Q6h, Tylenol Q8h\n - reassess patient\ns pain requirements\n - goals of care family meeting 1pm today\n .\n # UTI: positive UA, no history of culture positive UA's in system.\n Will do 10day course because of chronic foley.\n - treating empirically with cipro ; day 1 of 10 day course was \n - watch INR on abx\n .\n # Hx CAD:\n Patient with h/o CAD w/ right dominant system, mild instent re-stenois\n of the LAD BM stent and occluded RCA.\n - continue metoprolol 25mg \n .\n # Hx Afib:\n Patient with h/o atrial fibrillation, s/p BiV ICD ( Concerto\n C154DWK) , on coumadin. Now in paced rhythm\n - cont home dose meds (amio, metoprolol)\n - cont coumadin\n - trend INR\n .\n # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a\n filter in place. INR mildly subtherapeutic despite Cipro\n - continue Coumadin\n - monitor INR\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines: midline, right IJ\n Multi Lumen - 05:34 PM\n Midline - 05:34 PM\n Prophylaxis:\n DVT: coumadin\n Stress ulcer: lansoprazole\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"},{"category":"Physician ","chartdate":"2180-01-18 00:00:00.000","description":"progress note","row_id":400149,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n - lasix gtt stopped and pt started on torsemide 40mg + metolazone\n 5mg daily\n - started IR morphine po for breakthrough 15mg 4h prn (w IV as backup)\n yesterday, and patient did not require IV backup\n - Pain and Palliative Care consulted\n - milrinone stopped yesterday AM, but restarted milrinone bc blood\n pressures not maintained otherwise (dropped to 70s systolic without)\n and urine output decreased.\n - family meeting scheduled for at 1pm - will need Dr. and\n palliative care present\n - does not have any complaints of pain or sob this AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Ciprofloxacin - 10:00 AM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 10:32 AM\n Coumadin (Warfarin) - 04:00 PM\n Omeprazole (Prilosec) - 04:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.9\nC (98.4\n HR: 69 (55 - 71) bpm\n BP: 85/56(63) {74/43(53) - 97/62(69)} mmHg\n RR: 13 (9 - 20) insp/min\n SpO2: 96%\n Heart rhythm: V Paced\n Wgt (current): 74 kg (admission): 82.2 kg\n Height: 60 Inch\n Total In:\n 1,052 mL\n 201 mL\n PO:\n 450 mL\n 120 mL\n TF:\n IVF:\n 602 mL\n 81 mL\n Blood products:\n Total out:\n 1,571 mL\n 320 mL\n Urine:\n 1,571 mL\n 320 mL\n NG:\n Stool:\n Drains:\n Balance:\n -519 mL\n -119 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ///35/\n Physical Examination\n Gen: sleepy but easily awakened, oriented x3, easily confused, appears\n to have psychomotor slowing\n HEENT: dry mucus membranes\n NECK: JVP not elevated\n CHEST: regular rhythm ; mild dry basilar crackles laterally\n ABD: mildly distended, soft, nontender\n EXT: + pitting edema bilaterally\n Labs / Radiology\n 116 K/uL\n 10.2 g/dL\n 93 mg/dL\n 1.0 mg/dL\n 35 mEq/L\n 3.8 mEq/L\n 32 mg/dL\n 91 mEq/L\n 132 mEq/L\n 31.2 %\n 4.6 K/uL\n [image002.jpg]\n 05:44 AM\n 04:46 AM\n 04:00 PM\n 03:05 AM\n 03:17 PM\n 03:05 AM\n 05:03 PM\n 05:22 AM\n 05:25 PM\n 05:40 AM\n WBC\n 6.1\n 4.7\n 5.1\n 4.4\n 4.2\n 4.6\n Hct\n 32.1\n 31.9\n 33.1\n 32.2\n 30.9\n 31.2\n Plt\n 156\n 159\n 146\n 134\n 106\n 116\n Cr\n 1.3\n 1.4\n 1.3\n 1.2\n 1.1\n 1.0\n 1.0\n 1.0\n 1.1\n 1.0\n Glucose\n 83\n 104\n 155\n 115\n 98\n 107\n 86\n 93\n Other labs: PT / PTT / INR:19.1/29.7/1.7, Ca++:8.1 mg/dL, Mg++:2.1\n mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\n recently discharged from the CCU () for CHF exacerbation c/b\n C.diff infection and on for septic joint washout c/b failure to\n extubate CHF exacerbation, who was admitted from clinic with\n total body fluid overload.\n .\n # sCHF Exacerbation:\n Patient has history of CHF ischemic , 10%, s/p BiV ICD\n ( Concerto C154DWK) with EF 10% which was the likely\n cause of her fluid overload. Appears intravascularly dry on exam. Has\n diuresed well -9L on length of stay. Responding well to torsemide with\n metolazone while on milrinone, but urine output had dropped without\n milrinone yesterday. Diuresed net -500cc over last day. Milrinone is\n keeping her blood pressures up.\n - DC milrinone\n - With no milrinone, she needs help with filling pressures, so\n will DC diuretics b/c appears dry on exam\n - If blood pressure drops without milrinone,, she may benefit\n from 250cc IVF boluses as needed\n - Continue strict I/Os\n - Continue to replete K\n .\n # Goals of Care:\n End-stage CHF with long term goals are comfort, though she still wishes\n to participate in rehab. Her family recognizes that she is dying. Pain\n and Palliative Care consulted yesterday for pain control and goals of\n care.\n - family meeting at 1pm today\n .\n # Septic Joints: Patient with history +staph aureus in left shoulder\n treated by washout and vancomycin, thus far 4 weeks of monotherapy. No\n + blood cx since before . Major issue now is pain control.\n - continue vancomycin until , then suppression with doxycycline\n -- continue MS contin 30mg and reassess pain med needs\n -- standing ultram q6, Tylenol q8\n .\n # Sacral Decub - stage 3-4. Focusing on Pain control. Pain and\n Palliative Care following with patient. Switched to oral breakthrough\n Morphine with IV as backup, but patient was not requiring IV backup.\n - wound care\n - standing ultram Q6h, Tylenol Q8h\n - reassess patient\ns pain requirements\n - goals of care family meeting 1pm today\n .\n # UTI: positive UA, no history of culture positive UA's in system.\n Will do 10day course because of chronic foley.\n - treating empirically with cipro ; day 1 of 10 day course was \n - watch INR on abx\n .\n # Hx CAD:\n Patient with h/o CAD w/ right dominant system, mild instent re-stenois\n of the LAD BM stent and occluded RCA.\n - continue metoprolol 25mg \n .\n # Hx Afib:\n Patient with h/o atrial fibrillation, s/p BiV ICD ( Concerto\n C154DWK) , on coumadin. Now in paced rhythm\n - cont home dose meds (amio, metoprolol)\n - cont coumadin\n - trend INR\n .\n # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a\n filter in place. INR mildly subtherapeutic despite Cipro\n - continue Coumadin\n - monitor INR\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines: midline, right IJ\n Multi Lumen - 05:34 PM\n Midline - 05:34 PM\n Prophylaxis:\n DVT: coumadin\n Stress ulcer: lansoprazole\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n ------ Protected Section ------\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I would add the following remarks:\n Above discussed extensively with patient. Above discussed extensively\n with family member, next of or health care proxy. Progress reviewed\n extensively during family meeting.\n DNR status discussed: comfort measures. DNR.\n Total time spent on patient care: 90 minutes.\n Additional comments:\n 45 minutes (13:00 - 13:45) spent in family meeting discussing end-stage\n nature of the heart condition and lack of further treatment options.\n Pt will now be CMO. All family in agreement.\n ------ Protected Section Addendum Entered By: on:\n 13:44 ------\n"},{"category":"Nursing","chartdate":"2180-01-18 00:00:00.000","description":"Nursing Progress Note","row_id":400153,"text":"71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\n : Sent to ED from clinic admit to CCU for aggressive\n diuresis. She was started on Milrinone and lasix gtt, lasix and\n milrinone gtts turned to off . Milrinone restarted d/t BP and U/O\n decrease. Large Stage III decube on coccyx decub that is a source of\n chronic pain. She is DNR/DNI and defibrillator has been shut off. Able\n to swallow pills whole, with either applesauce or custard.\n SOCIAL: Family in to visit. Pts HCP is in and intubated,\n pt\ns sister is alternate HCP.\n control (acute pain, chronic pain)\n Assessment:\n On standing dose of morphine SR, ultram and Tylenol. Also receiving\n supplemental morpine IR and IV.\n Action/Response:\n Pain rated to be this am, then later in day \n Repositioned for comfort\n Plan:\n Continue pain control with oral medications. Give immediate release\n morphine for breakthrough pain.\n Impaired Skin Integrity\n Assessment:\n Stage III PU on coccyx, foul smelling, yellow sanguinous drainage,\n edges of wound yellow with areas of necrosis. Surrounding skin\n macerated. Pt. refusing kinair bed\n Action/Response:\n Dressing changed according to wound care RN\ns recs:\n anti-fungal barrier criticaid to macerated skin surrounding wound,\n acqua cell-AG to coccyx, covered in soft sorb dsg, medipore tape.\n Aloe Vesta to skin\n Repositioned\n Po\ns encouraged, patient drinking hot chocolate, custard,\n applesauce.\n Plan:\n QD dressing change as above. Aloe vesta to skin. Reposition q2 hours\n or according to pt\ns wishes.\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Pt DNR/DNI. SBP 90\ns. Milrinone @ 0.5mcg/kg/min. U/O ~ 100cc q\n 2hours.\n Action/Response:\n Dr. in to talk with patient and family extensively.\n Milrinone turned to off. Torsemide and metzolone d/c\n Palliative care MD in to talk with pt and family.\n Plan:\n To remain in hospital for now. Will monitor off of milrinone with plan\n to give IV NS 250 cc for hypotension as per Dr. . Focus on\n comfort.\n"},{"category":"Nursing","chartdate":"2180-01-18 00:00:00.000","description":"Nursing Progress Note","row_id":400162,"text":"71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\n : Sent to ED from clinic admit to CCU for aggressive\n diuresis. She was started on Milrinone and lasix gtt, lasix and\n milrinone gtts turned to off . Milrinone restarted d/t BP and U/O\n decrease. Large Stage III decube on coccyx decub that is a source of\n chronic pain. She is DNR/DNI and defibrillator has been shut off. Able\n to swallow pills whole, with either applesauce or custard.\n SOCIAL: Family in to visit. Pts HCP is in and intubated,\n pt\ns sister is alternate HCP.\n control (acute pain, chronic pain)\n Assessment:\n On standing dose of morphine SR, ultram and Tylenol.\n Action/Response:\n Pain rated to be this am, then later in day .\n Given supplemental IR morphine and 2mg IV morphine with relief of pain.\n Repositioned for comfort\n Plan:\n Continue pain control with oral medications. Give immediate release\n morphine for breakthrough pain.\n Impaired Skin Integrity\n Assessment:\n Stage III PU on coccyx, foul smelling, yellow sanguinous drainage,\n edges of wound yellow with areas of necrosis. Surrounding skin\n macerated. Pt. refusing kinair bed\n Action/Response:\n Dressing changed according to wound care RN\ns recs:\n anti-fungal barrier criticaid to macerated skin surrounding wound,\n acqua cell-AG to coccyx, covered in soft sorb dsg, medipore tape.\n Aloe Vesta to skin\n Repositioned\n Po\ns encouraged, patient drinking hot chocolate, custard,\n applesauce.\n Plan:\n QD dressing change as above. Aloe vesta to skin. Reposition q2 hours\n or according to pt\ns wishes.\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Pt DNR/DNI. SBP 90\ns. Milrinone @ 0.5mcg/kg/min. U/O ~ 100cc q\n 2hours.\n Action/Response:\n Dr. in to talk with patient and family extensively.\n Milrinone turned to off. Torsemide and metzolone d/c\n Palliative care MD in to talk with pt and family.\n SBP decreasing to low 80\ns and then 76 off mirinone, U/O\n also tapering off. CCU resident notified, will hold off on IV fluids\n unless pt c/o dizziness.\n Plan:\n To remain in hospital for now. Will monitor off of milrinone with plan\n to give IV NS 250 cc for hypotension as per Dr. . No other changes\n in medications for now. Focus on comfort.\n"},{"category":"Nursing","chartdate":"2180-01-15 00:00:00.000","description":"Nursing Progress Note","row_id":399906,"text":"71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\n : Sent to ED from clinic w/ hypotension\n transiently on\n dopa, Tx\nd w/ NS 250 cc w/ SBP ^ 92. Admit to CCU for aggressive\n diuresis.\n Heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n + pitting edema BLE\non lasix gtt 15mg/hr & milrinone 0.5mcg/k/min.\n LS clr, dim at bases.\n Action:\n 1^st dose 25mg PO lopressor given\n Response:\n BPs lower when asleep and after morphine, MAPs >55. Lytes. Rare short\n runs AIVR.\n Plan:\n CHF management, aggressive diuresis w/ lasix & daily\n metolazone-- goal NEG 5-10L overall, strict I/Os, Low Na+ diet, daily\n wts, monitor & replete lytes as indicated\n DNR/DNI-ICD turned off after fam mtg. Both pt and HCP\n are in agreement that pt would like to be comfortable to be able to\n participate in rehab.\n Impaired Skin Integrity\n Assessment:\n *Lg stage 3 vs. unstageable decub to coccyx, covered w/ yellow slough &\n red blanching borders--sm amt serous dsg\n mepilex intact, placed \n *Red, blanching heels.\n *Dry and thin skin w/ discolored areas.\n *Good appetite. Declines Kinair bed/waffle boots\n Action:\n Mepilex dsg peeled to check skin--Duoderm hydroactive gel\n applied per wound care recs .\n Heels elevated on pillows, skin/pressure area well\n lubricated.\n Slight freq position changes avoiding back and L side.\n Response:\n Skin unchanged\n Plan:\n Monitor for changes, prevent further breathdown. Change\n position freq as tolerated as pt mobility/able to turn self is very\n limited.\n Change mepilex w/ duoderm gel daily drainage\n Pain control (chronic pain)\n Assessment:\n Very uncomfortable w/ turning and w/ laying on L side\n Action:\n Standing order ultram & Tylenol Q6hrs, 2mg Morphine sulfate\n IVP for breakthrough pain\n Pt positioned mostly far on R side w/ slight position\n changes, placed supine for short periods only.\n Response:\n Pt allowed to rest in btwn necessary nsg interventions, Slept well all\n night.\n Plan:\n Continue current pain control regimen, medicate w/ morphine\n prior to turning side to side\n GI: NO BM, takes pills crushed in applesauce\n"},{"category":"Nursing","chartdate":"2180-01-17 00:00:00.000","description":"Nursing Progress Note","row_id":400071,"text":"71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\n : Sent to ED from clinic w/ hypotension\n transiently on\n dopa, Tx\nd w/ NS 250 cc w/ SBP ^ 92.\n Admit to CCU for aggressive diuresis.She was started on Milrinone\n and lasix gtt. And has been diuresing well. She has lg coccyx decub\n that is a source of chronic pain. She is DNR/DNI and defibrillator has\n been shut off. She has excellent apetite.\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nutrition","chartdate":"2180-01-17 00:00:00.000","description":"Clinical Nutrition Note","row_id":400081,"text":"Ht: 60\n Admit wt: 82.2kg\n Current wt: 74kg\n Diet: Low sodium, 3 gram\n PMHx: 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension\n 2. CARDIAC HISTORY:\n -CABG: None\n -PERCUTANEOUS CORONARY INTERVENTIONS: BM stent to the LAD in ,\n Occluded RCA/no intervention\n -PACING/ICD: Ischemic cardiomyopathy (EF 10%) s/p BiV ICD and atrial\n fibrillation\n 3. H/o PE secondary to DVT s/p IVC filter on Coumadin\n 4. PVD\n 5. Small VSD\n OTHER\n # Septic Polyarticular Arthritis s/p irrigation and debridement left\n shoulder via anterolateral deltopectoral miniarthrotomy, aspiration\n left hip joint and irrigation and debridement of 3rd\n metacarpophalangeal joint\n 6. Hypothyroidism\n 7. CKD\n 8. Osteoarthritis\n Meds: Lasix drip, Milrinone drip, ABX, Potassium Chloride (20mEq\n repletion), bowel regimen\n Potential for nutrition risk. Patient being monitored. Current\n intervention if any, listed below:\n 71 YO female admitted from rehab with volume overload consistent with\n CHF exacerbation. Noted code status changed to DNR/ DNI, pacemaker\n turned off. Reports eating Rice Krispies with milk at breakfast and\n improved appetite here compared to at rehab. Liked po shake from last\n admit, but does not recall the name of it. Question accuracy of\n weights, patient looks thin. Noted unstageable pressure ulcer.\n Recommendations:\n 1. Encourage po\n 2. Will send Carnation Instant Breakfast shakes with milk/ice\n cream\n 3. Lytes and BS management\n 4. Will follow, page if questions *\n 5. Electronically signed by , RD, LDN\n 10:26\n 6.\n 7.\n"},{"category":"Physician ","chartdate":"2180-01-17 00:00:00.000","description":"Physician Resident Progress Note","row_id":400082,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n - MS contin increased to 30mg last night, received 2 doses w pills\n crushed, complained of nausea after each\n - complains of pain at 8/10\n - Has not had a BM for four days\n - PT ordered yesterday\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 08:00 AM\n Vancomycin - 09:36 AM\n Infusions:\n Furosemide (Lasix) - 10 mg/hour\n Milrinone - 0.5 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 12:45 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.6\nC (97.8\n HR: 68 (63 - 75) bpm\n BP: 91/52(62) {75/44(51) - 98/61(70)} mmHg\n RR: 9 (9 - 29) insp/min\n SpO2: 99%\n Heart rhythm: AV Paced\n Wgt (current): 77.3 kg (admission): 82.2 kg\n Total In:\n 1,004 mL\n 146 mL\n PO:\n 440 mL\n TF:\n IVF:\n 564 mL\n 146 mL\n Blood products:\n Total out:\n 2,410 mL\n 420 mL\n Urine:\n 2,410 mL\n 420 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,406 mL\n -274 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///34/\n Physical Examination\n Gen: alert, oriented x3 but appears to have psychomotor retardation and\n easily confused\n HEENT: slightly dry mucus membranes\n CHEST: regular rhythm ; dry basilar crackles\n ABD: mildly distended, soft, nontender\n EXT: + pitting edema bilaterally\n Labs / Radiology\n 106 K/uL\n 10.0 g/dL\n 86 mg/dL\n 1.0 mg/dL\n 34 mEq/L\n 3.7 mEq/L\n 33 mg/dL\n 92 mEq/L\n 134 mEq/L\n 30.9 %\n 4.2 K/uL\n [image002.jpg]\n 05:44 AM\n 04:46 AM\n 04:00 PM\n 03:05 AM\n 03:17 PM\n 03:05 AM\n 05:03 PM\n 05:22 AM\n WBC\n 6.1\n 4.7\n 5.1\n 4.4\n 4.2\n Hct\n 32.1\n 31.9\n 33.1\n 32.2\n 30.9\n Plt\n 156\n 159\n 146\n 134\n 106\n Cr\n 1.3\n 1.4\n 1.3\n 1.2\n 1.1\n 1.0\n 1.0\n 1.0\n Glucose\n 83\n 104\n 155\n 115\n 98\n 107\n 86\n Other labs: PT / PTT / INR:20.2/33.1/1.9, Ca++:8.1 mg/dL, Mg++:2.1\n mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\n recently discharged from the CCU () for CHF exacerbation c/b\n C.diff infection and on for septic joint washout c/b failure to\n extubate CHF exacerbation, who was admitted from clinic with\n total body fluid overload.\n .\n # sCHF exacerbation:\n Patient has history of CHF ischemic , 10%, s/p BiV ICD\n ( Concerto C154DWK) with EF 10% which was the likely\n cause of her fluid overload. Appears intravascularly euvolemic on\n exam, no need to continue lasix gtt. Has diuresed well -9L on length\n of stay. Diuresed -1.5L over last day.\n - DC lasix gtt\n - DC milrinone\n - Start torsemide 40mg , on which she will be discharged\n - Metolazone 5mg once today, then switch to metolazone 2.5mg\n daily w first dose of torsemide tomorrow\n - Continue strict I/Os\n - Continue to replete K\n .\n # Goals of Care:\n End-stage CHF with long term goals are comfort, though she still wishes\n to participate in rehab. Her family recognizes that she is dying.\n - Consult Pain and Palliative Care\n .\n # Septic Joints: Patient with history +staph aureus in left shoulder\n treated by washout and vancomycin, thus far 4 weeks of monotherapy. No\n + blood cx since before . Major issue now is pain control.\n -- continue vanc 500 mg q24 ; will need to monitor vanc troughs on\n discharge\n -- MS contin increased to 30mg yesterday\n -- standing ultram q6, Tylenol q8\n .\n # Sacral Decub - stage 3-4.\n Pain control very important\n - switch to oral breakthrough Morphine , but leave IV as backup\n - wound care\n - standing ultram Q6h, Tylenol Q8h\n - continue MS contin to 30mg (with smaller 15mg pills x2 so she can\n swallow)\n - Consulting Pain and Palliative Care\n .\n # UTI: positive UA, no history of culture positive UA's in system.\n Will do 10day course because of chronic foley.\n - treating empirically with cipro ; day 1 of 10 day course was \n - watch INR on abx\n .\n # Hx CAD:\n Patient with h/o CAD w/ right dominant system, mild instent re-stenois\n of the LAD BM stent and occluded RCA.\n - continue metoprolol 25mg \n .\n # Hx Afib:\n Patient with h/o atrial fibrillation, s/p BiV ICD ( Concerto\n C154DWK) , on coumadin. Now in paced rhythm\n - cont home dose meds (amio, metoprolol)\n - cont coumadin\n - trend INR\n .\n # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a\n filter in place. INR mildly subtherapeutic despite Cipro\n - continue Coumadin and monitor INR\n .\n # Hypothyroidism: Continue Levothyroxine\n .\n # Gout: continue Allopurinol\n ICU Care\n Nutrition: tolerating po well\n Glycemic Control:\n Lines: midline, right IJ (will consider taking out RIJ tomorrow\n if does not need milrinone again)\n Multi Lumen - 05:34 PM\n Midline - 05:34 PM\n Prophylaxis:\n DVT: coumadin\n Stress ulcer: lansoprazole\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"},{"category":"Nursing","chartdate":"2180-01-18 00:00:00.000","description":"Nursing Progress Note","row_id":400129,"text":"71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\n : Sent to ED from clinic w/ hypotension\n transiently on\n dopa, Tx\nd w/ NS 250 cc w/ SBP ^ 92.\n Admit to CCU for aggressive diuresis.She was started on Milrinone\n and lasix gtt. And has been diuresing well. She has lg coccyx decub\n that is a source of chronic pain. She is DNR/DNI and defibrillator has\n been shut off.\n Pain control (acute pain, chronic pain)\n Assessment:\n Contin. with acute pain with turning. Pain is at decub site/coccyx.\n Pt. also has severe arthritis in legs/hips/shoulders\n Action:\n MS . Supplemented with morphine IR 15mg x2 overnight-\n both times with turning.\n Tylenol and ultram RTC.\n Response:\n Acute pain resolves and pt. able to be comfortable and sleep.\n Plan:\n Family deciding if pt will now be CMO and go to extended care facility\n with hospice- speaking with MD \n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Started on milrinone 0.5mcq\n restarted after u/o dropped to 0cc .\n HR 60-70\ns Vpaced, wide complex. BP maps 53-60. SBP 80-90\n Action:\n Milrinone 0.5mcq/,\n Po amio, metalazone, torsemide po.\n Response:\n u/o 30-60cc/hr. LS clear to diminished. Sats 95-99% on RA. Denies\n SOB.\n Plan:\n Contin. meds as ordered. Monitor u/o.\n Impaired Skin Integrity\n Assessment:\n Skin care plan changed . see wound care note.\n DSD intact over coccyx. Wound not visualized. No drainage or\n saturation.\n Action:\n Maintained integrity of DSD. Turn/position q3hr as tolerated. Barrier\n cream to all other areas.\n Response:\n Pt. states itchy skin is improved.\n Plan:\n Wound care per current plan. See orders\n"},{"category":"Physician ","chartdate":"2180-01-18 00:00:00.000","description":"Physician Resident Progress Note","row_id":400142,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n - MS contin increased to 30mg last night, received 2 doses w pills\n crushed, complained of nausea after each\n - complains of pain at 8/10\n - Has not had a BM for four days\n - PT ordered yesterday\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 08:00 AM\n Vancomycin - 09:36 AM\n Infusions:\n Furosemide (Lasix) - 10 mg/hour\n Milrinone - 0.5 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 12:45 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.6\nC (97.8\n HR: 68 (63 - 75) bpm\n BP: 91/52(62) {75/44(51) - 98/61(70)} mmHg\n RR: 9 (9 - 29) insp/min\n SpO2: 99%\n Heart rhythm: AV Paced\n Wgt (current): 77.3 kg (admission): 82.2 kg\n Total In:\n 1,004 mL\n 146 mL\n PO:\n 440 mL\n TF:\n IVF:\n 564 mL\n 146 mL\n Blood products:\n Total out:\n 2,410 mL\n 420 mL\n Urine:\n 2,410 mL\n 420 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,406 mL\n -274 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///34/\n Physical Examination\n Gen: alert, oriented x3 but appears to have psychomotor retardation and\n easily confused\n HEENT: slightly dry mucus membranes\n CHEST: regular rhythm ; dry basilar crackles\n ABD: mildly distended, soft, nontender\n EXT: + pitting edema bilaterally\n Labs / Radiology\n 106 K/uL\n 10.0 g/dL\n 86 mg/dL\n 1.0 mg/dL\n 34 mEq/L\n 3.7 mEq/L\n 33 mg/dL\n 92 mEq/L\n 134 mEq/L\n 30.9 %\n 4.2 K/uL\n [image002.jpg]\n 05:44 AM\n 04:46 AM\n 04:00 PM\n 03:05 AM\n 03:17 PM\n 03:05 AM\n 05:03 PM\n 05:22 AM\n WBC\n 6.1\n 4.7\n 5.1\n 4.4\n 4.2\n Hct\n 32.1\n 31.9\n 33.1\n 32.2\n 30.9\n Plt\n 156\n 159\n 146\n 134\n 106\n Cr\n 1.3\n 1.4\n 1.3\n 1.2\n 1.1\n 1.0\n 1.0\n 1.0\n Glucose\n 83\n 104\n 155\n 115\n 98\n 107\n 86\n Other labs: PT / PTT / INR:20.2/33.1/1.9, Ca++:8.1 mg/dL, Mg++:2.1\n mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\n recently discharged from the CCU () for CHF exacerbation c/b\n C.diff infection and on for septic joint washout c/b failure to\n extubate CHF exacerbation, who was admitted from clinic with\n total body fluid overload.\n .\n # sCHF exacerbation:\n Patient has history of CHF ischemic , 10%, s/p BiV ICD\n ( Concerto C154DWK) with EF 10% which was the likely\n cause of her fluid overload. Appears intravascularly euvolemic on\n exam, no need to continue lasix gtt. Has diuresed well -9L on length\n of stay. Diuresed -1.5L over last day.\n - DC lasix gtt\n - DC milrinone\n - Start torsemide 40mg , on which she will be discharged\n - Metolazone 5mg once today, then switch to metolazone 2.5mg\n daily w first dose of torsemide tomorrow\n - Continue strict I/Os\n - Continue to replete K\n .\n # Goals of Care:\n End-stage CHF with long term goals are comfort, though she still wishes\n to participate in rehab. Her family recognizes that she is dying.\n - Consult Pain and Palliative Care\n .\n # Septic Joints: Patient with history +staph aureus in left shoulder\n treated by washout and vancomycin, thus far 4 weeks of monotherapy. No\n + blood cx since before . Major issue now is pain control.\n -- continue vanc 500 mg q24 ; will need to monitor vanc troughs on\n discharge\n -- MS contin increased to 30mg yesterday\n -- standing ultram q6, Tylenol q8\n .\n # Sacral Decub - stage 3-4.\n Pain control very important\n - switch to oral breakthrough Morphine , but leave IV as backup\n - wound care\n - standing ultram Q6h, Tylenol Q8h\n - continue MS contin to 30mg (with smaller 15mg pills x2 so she can\n swallow)\n - Consulting Pain and Palliative Care\n .\n # UTI: positive UA, no history of culture positive UA's in system.\n Will do 10day course because of chronic foley.\n - treating empirically with cipro ; day 1 of 10 day course was \n - watch INR on abx\n .\n # Hx CAD:\n Patient with h/o CAD w/ right dominant system, mild instent re-stenois\n of the LAD BM stent and occluded RCA.\n - continue metoprolol 25mg \n .\n # Hx Afib:\n Patient with h/o atrial fibrillation, s/p BiV ICD ( Concerto\n C154DWK) , on coumadin. Now in paced rhythm\n - cont home dose meds (amio, metoprolol)\n - cont coumadin\n - trend INR\n .\n # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a\n filter in place. INR mildly subtherapeutic despite Cipro\n - continue Coumadin and monitor INR\n .\n # Hypothyroidism: Continue Levothyroxine\n .\n # Gout: continue Allopurinol\n ICU Care\n Nutrition: tolerating po well\n Glycemic Control:\n Lines: midline, right IJ (will consider taking out RIJ tomorrow\n if does not need milrinone again)\n Multi Lumen - 05:34 PM\n Midline - 05:34 PM\n Prophylaxis:\n DVT: coumadin\n Stress ulcer: lansoprazole\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n ------ Protected Section ------\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I would add the following remarks:\n Above discussed extensively with patient. Above discussed extensively\n with family member, next of or health care proxy.\n DNR status discussed. DNR.\n Total time spent on patient care: 45 minutes.\n Additional comments:\n signed on for service provided on \n plan to shut off milrinone and furosemide drips and switch to po\n ------ Protected Section Addendum Entered By: on:\n 09:59 ------\n"},{"category":"Nursing","chartdate":"2180-01-18 00:00:00.000","description":"Nursing Progress Note","row_id":400158,"text":"71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\n : Sent to ED from clinic admit to CCU for aggressive\n diuresis. She was started on Milrinone and lasix gtt, lasix and\n milrinone gtts turned to off . Milrinone restarted d/t BP and U/O\n decrease. Large Stage III decube on coccyx decub that is a source of\n chronic pain. She is DNR/DNI and defibrillator has been shut off. Able\n to swallow pills whole, with either applesauce or custard.\n SOCIAL: Family in to visit. Pts HCP is in and intubated,\n pt\ns sister is alternate HCP.\n control (acute pain, chronic pain)\n Assessment:\n On standing dose of morphine SR, ultram and Tylenol.\n Action/Response:\n Pain rated to be this am, then later in day .\n Given supplemental IR morphine and 2mg IV morphine with relief of pain.\n Repositioned for comfort\n Plan:\n Continue pain control with oral medications. Give immediate release\n morphine for breakthrough pain.\n Impaired Skin Integrity\n Assessment:\n Stage III PU on coccyx, foul smelling, yellow sanguinous drainage,\n edges of wound yellow with areas of necrosis. Surrounding skin\n macerated. Pt. refusing kinair bed\n Action/Response:\n Dressing changed according to wound care RN\ns recs:\n anti-fungal barrier criticaid to macerated skin surrounding wound,\n acqua cell-AG to coccyx, covered in soft sorb dsg, medipore tape.\n Aloe Vesta to skin\n Repositioned\n Po\ns encouraged, patient drinking hot chocolate, custard,\n applesauce.\n Plan:\n QD dressing change as above. Aloe vesta to skin. Reposition q2 hours\n or according to pt\ns wishes.\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Pt DNR/DNI. SBP 90\ns. Milrinone @ 0.5mcg/kg/min. U/O ~ 100cc q\n 2hours.\n Action/Response:\n Dr. in to talk with patient and family extensively.\n Milrinone turned to off. Torsemide and metzolone d/c\n Palliative care MD in to talk with pt and family.\n SBP decreasing to low 80\ns off mirinone, U/O also tapering\n off.\n Plan:\n To remain in hospital for now. Will monitor off of milrinone with plan\n to give IV NS 250 cc for hypotension as per Dr. . No other changes\n in medications for now. Focus on comfort.\n"},{"category":"Nursing","chartdate":"2180-01-15 00:00:00.000","description":"Nursing Progress Note","row_id":399911,"text":"71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\n : Sent to ED from clinic w/ hypotension\n transiently on\n dopa, Tx\nd w/ NS 250 cc w/ SBP ^ 92. Admit to CCU for aggressive\n diuresis.\n Heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n + pitting edema BLE\non lasix gtt 15mg/hr & milrinone 0.5mcg/k/min.\n LS clr, dim at bases.\n Action:\n 1^st dose 25mg PO lopressor given\n Response:\n BPs lower when asleep and after morphine, MAPs >55 (of note: BPs taken\n on L upper arm, pt mosly positioned on R side). Lytes. Rare short runs\n AIVR.\n Plan:\n CHF management, aggressive diuresis w/ lasix & daily\n metolazone-- goal NEG 5-10L overall, strict I/Os, Low Na+ diet, daily\n wts, monitor & replete lytes as indicated\n DNR/DNI-ICD turned off after fam mtg. Both pt and HCP\n are in agreement that pt would like to be comfortable to be able to\n participate in rehab.\n Impaired Skin Integrity\n Assessment:\n *Lg stage 3 vs. unstageable decub to coccyx, covered w/ yellow slough &\n red blanching borders--sm amt serous dsg\n mepilex intact, placed \n *Red, blanching heels.\n *Dry and thin skin w/ discolored areas.\n *Good appetite. Declines Kinair bed/waffle boots\n Action:\n Mepilex dsg peeled to check skin--Duoderm hydroactive gel\n applied per wound care recs .\n Heels elevated on pillows, skin/pressure area well\n lubricated.\n Slight freq position changes avoiding back and L side.\n Response:\n Skin unchanged\n Plan:\n Monitor for changes, prevent further breathdown. Change\n position freq as tolerated as pt mobility/able to turn self is very\n limited.\n Change mepilex w/ duoderm gel daily drainage\n Pain control (chronic pain)\n Assessment:\n Very uncomfortable w/ turning and w/ laying on L side\n Action:\n Standing order ultram & Tylenol Q6hrs, 2mg Morphine sulfate\n IVP for breakthrough pain\n Pt positioned mostly far on R side w/ slight position\n changes, placed supine for short periods only.\n Response:\n Pt allowed to rest in btwn necessary nsg interventions, Slept well all\n night.\n Plan:\n Continue current pain control regimen, medicate w/ morphine\n prior to turning side to side\n GI: NO BM, takes pills crushed in applesauce\n"},{"category":"Nursing","chartdate":"2180-01-17 00:00:00.000","description":"Nursing Progress Note","row_id":400072,"text":"71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\n : Sent to ED from clinic w/ hypotension\n transiently on\n dopa, Tx\nd w/ NS 250 cc w/ SBP ^ 92. Admit to CCU for aggressive\n diuresis.\n Pain control (acute pain, chronic pain)\n Assessment:\n Remains on 30 mg of ms contin for coccyx pain associated with turning.\n Although, hips/lower back disarticulating with side to side activity.\n Action:\n Pre-mediated with 4 mg of iv ms04 prior to turning\n Continues on Tylenol 1000mg po TID, Ultram 50mg QID\n Response:\n Pre-medication decreases pain with turning per patient\n Plan:\n Cont assess pain, cont ATC meds and supplement with IV Morphine as\n needed\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Pt asystomatic\n no SOB with stable VS\n Action:\n Milrinone remains at 0,5mcgs/kg/min\n Lasix increased from 5 to 10mg/hr\n Response:\n 1.8 liters negative at midnight\n Plan:\n Plan to transition heart failure meds to po route\n Impaired Skin Integrity\n Assessment:\n Large unstageable pressur ulcer on coccyx unchanged\n Bilat heels remain reddened but blanchble\n Action:\n duoderm gel/Mepilex, changed on \n mod amt sero-sanguinous drainage; redness/maceration to surrounding\n tissue\n severe pain at site\n see above\n Response:\n Site remains unchanged\n Plan:\n Cont with frequent turns\n Wound care RN .. social work, case manager and palliative consult to\n assist with rehab destination\n"},{"category":"Physician ","chartdate":"2180-01-17 00:00:00.000","description":"Physician Resident Progress Note","row_id":400065,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 08:00 AM\n Vancomycin - 09:36 AM\n Infusions:\n Furosemide (Lasix) - 10 mg/hour\n Milrinone - 0.5 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 12:45 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.6\nC (97.8\n HR: 68 (63 - 75) bpm\n BP: 91/52(62) {75/44(51) - 98/61(70)} mmHg\n RR: 9 (9 - 29) insp/min\n SpO2: 99%\n Heart rhythm: AV Paced\n Wgt (current): 77.3 kg (admission): 82.2 kg\n Total In:\n 1,004 mL\n 146 mL\n PO:\n 440 mL\n TF:\n IVF:\n 564 mL\n 146 mL\n Blood products:\n Total out:\n 2,410 mL\n 420 mL\n Urine:\n 2,410 mL\n 420 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,406 mL\n -274 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///34/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 106 K/uL\n 10.0 g/dL\n 86 mg/dL\n 1.0 mg/dL\n 34 mEq/L\n 3.7 mEq/L\n 33 mg/dL\n 92 mEq/L\n 134 mEq/L\n 30.9 %\n 4.2 K/uL\n [image002.jpg]\n 05:44 AM\n 04:46 AM\n 04:00 PM\n 03:05 AM\n 03:17 PM\n 03:05 AM\n 05:03 PM\n 05:22 AM\n WBC\n 6.1\n 4.7\n 5.1\n 4.4\n 4.2\n Hct\n 32.1\n 31.9\n 33.1\n 32.2\n 30.9\n Plt\n 156\n 159\n 146\n 134\n 106\n Cr\n 1.3\n 1.4\n 1.3\n 1.2\n 1.1\n 1.0\n 1.0\n 1.0\n Glucose\n 83\n 104\n 155\n 115\n 98\n 107\n 86\n Other labs: PT / PTT / INR:20.2/33.1/1.9, Ca++:8.1 mg/dL, Mg++:2.1\n mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n INEFFECTIVE COPING\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n .H/O HEART FAILURE (CHF), SYSTOLIC, ACUTE ON CHRONIC\n IMPAIRED SKIN INTEGRITY\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 05:34 PM\n Midline - 05:34 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"},{"category":"Physician ","chartdate":"2180-01-17 00:00:00.000","description":"Physician Resident Progress Note","row_id":400066,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 08:00 AM\n Vancomycin - 09:36 AM\n Infusions:\n Furosemide (Lasix) - 10 mg/hour\n Milrinone - 0.5 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 12:45 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.6\nC (97.8\n HR: 68 (63 - 75) bpm\n BP: 91/52(62) {75/44(51) - 98/61(70)} mmHg\n RR: 9 (9 - 29) insp/min\n SpO2: 99%\n Heart rhythm: AV Paced\n Wgt (current): 77.3 kg (admission): 82.2 kg\n Total In:\n 1,004 mL\n 146 mL\n PO:\n 440 mL\n TF:\n IVF:\n 564 mL\n 146 mL\n Blood products:\n Total out:\n 2,410 mL\n 420 mL\n Urine:\n 2,410 mL\n 420 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,406 mL\n -274 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///34/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 106 K/uL\n 10.0 g/dL\n 86 mg/dL\n 1.0 mg/dL\n 34 mEq/L\n 3.7 mEq/L\n 33 mg/dL\n 92 mEq/L\n 134 mEq/L\n 30.9 %\n 4.2 K/uL\n [image002.jpg]\n 05:44 AM\n 04:46 AM\n 04:00 PM\n 03:05 AM\n 03:17 PM\n 03:05 AM\n 05:03 PM\n 05:22 AM\n WBC\n 6.1\n 4.7\n 5.1\n 4.4\n 4.2\n Hct\n 32.1\n 31.9\n 33.1\n 32.2\n 30.9\n Plt\n 156\n 159\n 146\n 134\n 106\n Cr\n 1.3\n 1.4\n 1.3\n 1.2\n 1.1\n 1.0\n 1.0\n 1.0\n Glucose\n 83\n 104\n 155\n 115\n 98\n 107\n 86\n Other labs: PT / PTT / INR:20.2/33.1/1.9, Ca++:8.1 mg/dL, Mg++:2.1\n mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n INEFFECTIVE COPING\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n .H/O HEART FAILURE (CHF), SYSTOLIC, ACUTE ON CHRONIC\n IMPAIRED SKIN INTEGRITY\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 05:34 PM\n Midline - 05:34 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"},{"category":"Nursing","chartdate":"2180-01-17 00:00:00.000","description":"Nursing Progress Note","row_id":400070,"text":"71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\n : Sent to ED from clinic w/ hypotension\n transiently on\n dopa, Tx\nd w/ NS 250 cc w/ SBP ^ 92. Admit to CCU for aggressive\n diuresis.She was started on Milrinone and lasix gtt. And has been\n diuresing well. She has lg coccyx decub that is a source of chronic\n pain.\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2180-01-18 00:00:00.000","description":"Nursing Progress Note","row_id":400119,"text":"71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\n : Sent to ED from clinic w/ hypotension\n transiently on\n dopa, Tx\nd w/ NS 250 cc w/ SBP ^ 92.\n Admit to CCU for aggressive diuresis.She was started on Milrinone\n and lasix gtt. And has been diuresing well. She has lg coccyx decub\n that is a source of chronic pain. She is DNR/DNI and defibrillator has\n been shut off.\n Pain control (acute pain, chronic pain)\n Assessment:\n Contin. with acute pain with turning. Pain is at decub site/coccyx.\n Action:\n MS . Supplemented with morphine IR 15mg x2 overnight-\n both times with turning.\n Tylenol and ultram RTC.\n Response:\n Acute pain resolves and pt. able to be comfortable and sleep.\n Plan:\n Family deciding if pt will now be CMO and go to extended care facility\n with hospice- speaking with MD \n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Started on milrinone 0.5mcq\n restarted after u/o dropped to 0cc .\n HR 60-70\ns Vpaced, wide complex. BP maps 53-60. SBP 80-90\n Action:\n Milrinone 0.5mcq/,\n Po amio, metalazone, torsemide po.\n Response:\n u/o 30-50cc/hr. LS clear to diminished. Sats 95-99% on RA. Denies\n SOB.\n Plan:\n Contin. meds as ordered. Monitor u/o.\n Impaired Skin Integrity\n Assessment:\n Skin care plan changed . see wound care note.\n DSD intact over coccyx. Wound not visualized. No drainage or\n saturation.\n Action:\n Maintained integrity of DSD. Turn/position q3hr as tolerated. Barrier\n cream to all other areas.\n Response:\n Pt. states itchy skin is improved.\n Plan:\n"},{"category":"Nursing","chartdate":"2180-01-12 00:00:00.000","description":"Nursing Progress Note","row_id":399675,"text":"Pt is a 71 yo female with PMH: BM stent to LAD ', Occluded RCA\n without intervention, Ischemic CM (EF 10-25%), BiV ICD, AF, PVD, DVT\n s/p IVC filter, coumadin, hypothyroidism, CKD, OA. adm for HF\n (milrinone/lasix) MRSA in L shoulder, L hip and R knuckle. Out to\n rehab . Today went from rehab to see Dr. , sent to EW with\n hypotension. SBP 70 in EW, transiently on dopa, but cardiology d/c'd.\n Rxd with NS 250 cc with SBP 92. Pt has been in rehab since d/c from\n with septic arthritis in L shoulder, hip and R knuckle.\n On Vanco followed by ID.\n"},{"category":"Nursing","chartdate":"2180-01-12 00:00:00.000","description":"Nursing Progress Note","row_id":399676,"text":"Pt is a 71 yo female with PMH: BM stent to LAD ', Occluded RCA\n without intervention, Ischemic CM (EF 10-25%), BiV ICD, AF, PVD, DVT\n s/p IVC filter, coumadin, hypothyroidism, CKD, OA. adm for HF\n (milrinone/lasix) MRSA in L shoulder, L hip and R knuckle. Out to\n rehab . Today went from rehab to see Dr. , sent to EW with\n hypotension. SBP 70 in EW, transiently on dopa, but cardiology d/c'd.\n Rxd with NS 250 cc with SBP 92. Pt has been in rehab since d/c from\n with septic arthritis in L shoulder, hip and R knuckle.\n On Vanco followed by ID.\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2180-01-13 00:00:00.000","description":"Nursing Progress Note","row_id":399746,"text":"Pt is a 71 yo female with PMH: BM stent to LAD ', Occluded RCA\n without intervention, Ischemic CM (EF 10-25%), BiV ICD, AF, PVD, DVT\n s/p IVC filter, coumadin, hypothyroidism, CKD, OA. adm for HF\n (milrinone/lasix) MRSA in L shoulder, L hip and R knuckle. Out to\n rehab . went from rehab to see Dr. , sent to EW with\n hypotension. SBP 70 in EW, transiently on dopa, but cardiology d/c'd.\n Rxd with NS 250 cc with SBP 92. Pt has been in rehab since d/c from\n with septic arthritis in L shoulder, hip and R knuckle.\n On Vanco followed by ID.\n She was started on milrinone .375 after bolus and lasix drip also begun\n at 2.5mg/hr. The lasix dose was increased to 5mg overnight, but urine\n output has remained poor, though she is negative.\n GI: Pt has poor apetite and eats very little.\n SOCIAL: Family in the visit in afternoon. Pt in good spirits, visiting\n with brother and his family.\n CODE STATUS: Dr had discussion with both patient and health care\n proxy and all are in agreement that she be DNR/DNI. Additionally the\n defibrillator part of AICD/pacer was shut off.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt has a number of sources of pain. She has joint pain in shoulders and\n especially R elbow from septic arthritis. The most uncomfortable area\n is the decubitus ulcer on her coccyx area. She receive standing ultran\n for that. She requires frequent position changes, but seems most\n uncomfortable on L side. By 1000 she was very uncomfortable.\n Action:\n She received 2mg IV morpnine sulfate at 1230 and had shift in position\n and was comfortable until noon when pain recurred. She received another\n 2mg morphine sulfate and position change.\n Response:\n She slept until\n Plan:\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Pt on Milrinone .375mic/kilo and lasix 5mg/hr. Urine output\n ~30-50cc/hr. Hr in 70s AV paced with rare PVCs . BP 85-100/50-60s,\n lower after morphine. Pt sating 98-100% on 3L NP and lungs are mostly\n clear. She has no c/o of SOB. She has 2+ edema in legs.\n Action:\n At 1030 lasix was increased to 10mg/hr and at 1100 milrinone was\n increased to .5mic/kilo. Legs are kept elevated. 02 has been off most\n of the day and she is sating 96-98% on RA.\n Response:\n She is ~280cc negative for the day. The skin on her legs show signs\n that they have lost fluid.\n Plan:\n Continue with Milrinone and lasix. Keep careful I & O\n Impaired Skin Integrity\n Assessment:\n Pt has multiple skin lesions. Most prominent is coccyx decub. It has\n mepelix on it that was leaking through and pulling loose in am. Both\n heels are reddened, though they . She has dry skin on all\n extremities with some small abraded areas.\n Action:\n Coccyx dsg changed. Area primarily covered with slough. The edges are\n rounded and pink. Area cleansed with wound cleaner, dried and new\n mepelix applied. All limbs were lubricated frequently. Her position was\n changed, at times only slightly throughout the day. She does become\n uncomfortable if she is in the same position for too long,but also has\n difficulty on the L side. She finds the waffle boots uncomfortable and\n prefers having her legs elevated on pillows.\n Response:\n No new skin lesions have developed.\n Plan:\n Continue with turning, lubricating and keeping heels elevated. Monitor\n mepilex to ensure it is in place.\n"},{"category":"Nursing","chartdate":"2180-01-13 00:00:00.000","description":"Nursing Progress Note","row_id":399747,"text":"Pt is a 71 yo female with PMH: BM stent to LAD ', Occluded RCA\n without intervention, Ischemic CM (EF 10-25%), BiV ICD, AF, PVD, DVT\n s/p IVC filter, coumadin, hypothyroidism, CKD, OA. adm for HF\n (milrinone/lasix) MRSA in L shoulder, L hip and R knuckle. Out to\n rehab . went from rehab to see Dr. , sent to EW with\n hypotension. SBP 70 in EW, transiently on dopa, but cardiology d/c'd.\n Rxd with NS 250 cc with SBP 92. Pt has been in rehab since d/c from\n with septic arthritis in L shoulder, hip and R knuckle.\n On Vanco followed by ID.\n She was started on milrinone .375 after bolus and lasix drip also begun\n at 2.5mg/hr. The lasix dose was increased to 5mg overnight, but urine\n output has remained poor, though she is negative.\n GI: Pt has poor apetite and eats very little.\n SOCIAL: Family in the visit in afternoon. Pt in good spirits, visiting\n with brother and his family.\n CODE STATUS: Dr had discussion with both patient and health care\n proxy and all are in agreement that she be DNR/DNI. Additionally the\n defibrillator part of AICD/pacer was shut off.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt has a number of sources of pain. She has joint pain in shoulders and\n especially R elbow from septic arthritis. The most uncomfortable area\n is the decubitus ulcer on her coccyx area. She receive standing ultran\n for that. She requires frequent position changes, but seems most\n uncomfortable on L side. By 1000 she was very uncomfortable.\n Action:\n She received 2mg IV morpnine sulfate at 1230 and had shift in position\n and was comfortable until noon when pain recurred. She received another\n 2mg morphine sulfate and position change.\n Response:\n She slept until\n Plan:\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Pt on Milrinone .375mic/kilo and lasix 5mg/hr. Urine output\n ~30-50cc/hr. Hr in 70s AV paced with rare PVCs . BP 85-100/50-60s,\n lower after morphine. Pt sating 98-100% on 3L NP and lungs are mostly\n clear. She has no c/o of SOB. She has 2+ edema in legs.\n Action:\n At 1030 lasix was increased to 10mg/hr and at 1100 milrinone was\n increased to .5mic/kilo. Legs are kept elevated. 02 has been off most\n of the day and she is sating 96-98% on RA.\n Response:\n She is ~280cc negative for the day. The skin on her legs show signs\n that they have lost fluid.\n Plan:\n Continue with Milrinone and lasix. Keep careful I & O\n Impaired Skin Integrity\n Assessment:\n Pt has multiple skin lesions. Most prominent is coccyx decub. It has\n mepelix on it that was leaking through and pulling loose in am. Both\n heels are reddened, though they . She has dry skin on all\n extremities with some small abraded areas.\n Action:\n Coccyx dsg changed. Area primarily covered with slough. The edges are\n rounded and pink. Area cleansed with wound cleaner, dried and new\n mepelix applied. All limbs were lubricated frequently. Her position was\n changed, at times only slightly throughout the day. She does become\n uncomfortable if she is in the same position for too long,but also has\n difficulty on the L side. She finds the waffle boots uncomfortable and\n prefers having her legs elevated on pillows.\n Response:\n No new skin lesions have developed.\n Plan:\n Continue with turning, lubricating and keeping heels elevated. Monitor\n mepilex to ensure it is in place.\n"},{"category":"Physician ","chartdate":"2180-01-12 00:00:00.000","description":"CCU Fellow Addendum","row_id":399668,"text":"TITLE: CCU Fellow Addendum\n Patient seen and plan discussed with CCU housestaff. For details, see\n CCU resident H&P. Briefly, the patient is a 71 year old woman with PMH\n of CAD, ischemic CMY (EF 10%) s/p -V ICD, atrial fibrillation, CKD,\n with past history of DVT and PE on Coumadin, sacral decubitus ulcers\n and R shoulder sepsis s/p washout, who returns from rehab with volume\n overload consistent with her prior CHF exacerbations. The patient has\n had some chest burning consistent with her angina in the days up to\n today, but none currently. Her primary complaint has been severe\n sacral and shoulder pains, which continue to cause her significant\n agitation. On exam, she is hypotensive with cool extremities and\n slightly dyspneic, consistent with cardiogenic etiology. Plan will be\n for aggressive diuresis, with milrinone and neosynephrine for BP\n support, as well as aggressive pain control. Plan discussed with Dr.\n .\n"},{"category":"Nursing","chartdate":"2180-01-19 00:00:00.000","description":"Nursing Transfer Note","row_id":400261,"text":"71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\n coumadin, hypothyroidism, CKD, OA. admitted for septic joint\n washout- MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\n On pt. was sent to ED from clinic w/ hypotension\n transiently on dopa, Tx\nd w/ NS 250 cc w/ SBP ^ 92.\n Admit to CCU for aggressive diuresis. She was started on\n Milrinone and lasix gtt. She has large coccyx decub that is a source\n of chronic pain. She is DNR/DNI and defibrillator has been shut off.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt. with history of pain in left shoulder, left hip (septic joints) and\n coccyx (decub.).\n Action:\n MS , morphine IR 15mg for breakthrough pain, given this x2\n today. Pt. also given 2mg IV morphine prior to all activity/turning\n today. Pt. receiving ultram qid.\n Response:\n Pt. has denied pain today until 1500\n she reported pain after turning\n despite premedicating. Tolerating above with no ill-effects. Pt.\n painfree by 1600.\n Plan:\n Continue present around-the-clock and aggressive prn regimen.\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Off lasix gtt since , and milrinone since . AV paced at 70 with\n BP 90\ns/60\ns today. LS essentially clear, some fine ?dependent\n crackles noted at bases. Skin warm, dry. UO approximately 20cc/hr.\n Pt. slightly confused this afternoon per family.\n Action:\n Assessment ongoing. Torsemide started.\n Response:\n Pt. tolerating medication. Assessment largely unchanged.\n Plan:\n Continue to monitor and treat as indicated. Transfer to floor today.\n **** Goals towards comfort.****\n Impaired Skin Integrity\n Assessment:\n Pt. with sacral decub as documented in metavision.\n Action:\n Dressing changed today at noon per skin care recs. Pt. turned side to\n side as documented.\n Response:\n Pt. tolerated dressing change, premedicated with morphine IV.\n Moderated amt. yellow-white slough noted. Small amounts drainage\n noted.\n Plan:\n Continue daily dressing changes skin RN. Continue turning as pt.\n tolerates, avoid pressure points.\n"},{"category":"Nursing","chartdate":"2180-01-19 00:00:00.000","description":"Nursing Transfer Note","row_id":400262,"text":"71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\n coumadin, hypothyroidism, CKD, OA. admitted for septic joint\n washout- MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\n On pt. was sent to ED from clinic w/ hypotension\n transiently on dopa, Tx\nd w/ NS 250 cc w/ SBP ^ 92.\n Admit to CCU for aggressive diuresis w/ Milrinone and lasix gtt.\n She has large coccyx decub that is a source of chronic pain. She is\n DNR/DNI--defibrillator has been shut off \n Pain control (acute pain, chronic pain)\n Assessment:\n Pt. with history of pain in left shoulder, left hip (septic joints) and\n coccyx (decub.).\n Action:\n MS ,\n morphine IR 15mg for breakthrough pain--2mg IV morphine\n prior to all activity/turning today.\n ultram QID, Tylenol TID\n Response:\n Pt. has denied pain today until 1500\n she reported pain after turning\n despite premedicating. Tolerating above with no ill-effects. Pt.\n painfree by 1600.\n Plan:\n Continue present around-the-clock and aggressive prn regimen.\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Off lasix gtt since , and milrinone since . AV paced at 70 with\n BP 85-90\ns/50-60\ns today. LS essentially clear, some fine crackles\n noted at bases this afternoon. Skin warm, dry. UO approximately\n 20cc/hr. Pt. slightly confused this afternoon per family.\n Action:\n Assessment ongoing. Torsemide started.\n Response:\n Pt. tolerating medication. Assessment largely unchanged.\n Plan:\n Continue to monitor and treat as indicated. Transfer to floor today.\n Impaired Skin Integrity\n Assessment:\n Pt. with sacral decub as documented in metavision.\n Action:\n Dressing changed today at noon per skin care recs ( critic-aid\n anti-fungal to peri-wound, covered w/ aquacel AG & sm soft soft pads\n secured w/ soft tape w/ skin barrier wipe). Pt. turned side to side\n as documented.\n Response:\n Pt. tolerated dressing change, premedicated with morphine IV.\n Moderated amt. yellow-white slough noted. Small amounts drainage\n noted.\n Plan:\n Continue daily dressing changes skin RN. Continue turning as pt.\n tolerates, avoid pressure points.\n 19:00-20:30\n Sleepy, a&Ox3. RR 8-12 w/ some periods of apnea ? r/t to\n pain meds. 20:00 dose of MS contin HELD. Currently comfortable and\n pain-free. SBPs generally mid 70s-90s\nASYMPTOMATIC.\n ACCESS: R brachial midline (previously PICC placd )\n RIJ TLC placed : Medial port clotted\n CIPRO for UTI\n Demographics\n Attending MD:\n \n Admit diagnosis:\n CONGESTIVE HEART FAILURE\n Code status:\n DNR / DNI\n Height:\n 60 Inch\n Admission weight:\n 82.2 kg\n Daily weight:\n 73.6 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: Contact (+ CDiff ; MRSA L shoulder, L hip and R\n knuckle )\n PMH:\n CV-PMH: Arrhythmias, CAD, CHF, Hypertension, MI, Pacemaker, PVD\n Additional history: BM stent to LAD ', Occluded RCA without\n intervention, Ischemic CM (EF 10-25%), BiV ICD, AF, PVD, DVT s/p IVC\n filter, coumadin, hypothyroidism, CKD, OA. adm for MRSA in L\n shoulder, L hip and R knuckle.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:99\n D:64\n Temperature:\n 96.6\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 16 insp/min\n Heart Rate:\n 70 bpm\n Heart rhythm:\n AV Paced\n O2 delivery device:\n None\n O2 saturation:\n 90%\n O2 flow:\n 3 L/min\n FiO2 set:\n 24h total in:\n 670 mL\n 24h total out:\n 500 mL\n Pertinent Lab Results:\n Sodium:\n 132 mEq/L\n 05:40 AM\n Potassium:\n 3.8 mEq/L\n 05:40 AM\n Chloride:\n 91 mEq/L\n 05:40 AM\n CO2:\n 35 mEq/L\n 05:40 AM\n BUN:\n 32 mg/dL\n 05:40 AM\n Creatinine:\n 1.0 mg/dL\n 05:40 AM\n Glucose:\n 93 mg/dL\n 05:40 AM\n Hematocrit:\n 31.2 %\n 05:40 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: w/ dtr\n / :\n No money / \n Cash / Credit cards sent home with:\n Jewelry: watch on pt R wrist\n Transferred from: CCU \n Transferred to: 3\n Date & time of Transfer: 21:00\n"},{"category":"Nursing","chartdate":"2180-01-13 00:00:00.000","description":"Nursing Progress Note","row_id":399738,"text":"Pt is a 71 yo female with PMH: BM stent to LAD ', Occluded RCA\n without intervention, Ischemic CM (EF 10-25%), BiV ICD, AF, PVD, DVT\n s/p IVC filter, coumadin, hypothyroidism, CKD, OA. adm for HF\n (milrinone/lasix) MRSA in L shoulder, L hip and R knuckle. Out to\n rehab . went from rehab to see Dr. , sent to EW with\n hypotension. SBP 70 in EW, transiently on dopa, but cardiology d/c'd.\n Rxd with NS 250 cc with SBP 92. Pt has been in rehab since d/c from\n with septic arthritis in L shoulder, hip and R knuckle.\n On Vanco followed by ID.\n She was started on milrinone .375 after bolus and lasix drip also begun\n at 2.5mg/hr. The lasix dose was increased to 5mg overnight, but urine\n output has remained poor, though she is negative.\n GI: Pt has poor apetite and eats very little.\n SOCIAL: Family in the visit in afternoon. Pt in good spirits, visiting\n with brother and his family.\n CODE STATUS: Dr had discussion with both patient and health care\n proxy and all are in agreement that she be DNR/DNI. Additionally the\n defibrillator part of AICD/pacer was shut off.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt has a number of sources of pain. She has joint pain in shoulders and\n especially R elbow from septic arthritis. The most uncomfortable area\n is the decubitus ulcer on her coccyx area. She receive standing ultran\n for that. She requires frequent position changes, but seems most\n uncomfortable on L side. By 1000 she was very uncomfortable.\n Action:\n She received 2mg IV morpnine sulfate at 1230 and had shift in position\n and was comfortable until noon when pain recurred. She received another\n 2mg morphine sulfate and position change.\n Response:\n She slept until\n Plan:\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Pt on Milrinone .375mic/kilo and lasix 5mg/hr. Urine output\n ~30-50cc/hr. Hr in 70s AV paced with rare PVCs . BP 85-100/50-60s,\n lower after morphine. Pt sating 98-100% on 3L NP and lungs are mostly\n clear. She has no c/o of SOB. She has 2+ edema in legs.\n Action:\n At 1030 lasix was increased to 10mg/hr and at 1100 milrinone was\n increased to .5mic/kilo. Legs are kept elevated. 02 has been off most\n of the day and she is sating 96-98% on RA.\n Response:\n She is ~800cc negative for the day. The skin on her legs show signs\n that they have lost fluid.\n Plan:\n Continue with Milrinone and lasix. Keep careful I & O\n Impaired Skin Integrity\n Assessment:\n Pt has multiple skin lesions. Most prominent is coccyx decub. It has\n mepelix on it that was leaking through and pulling loose in am. Both\n heels are reddened, though they . She has dry skin on all\n extremities with some small abraded areas.\n Action:\n Coccyx dsg changed. Area primarily covered with slough. The edges are\n rounded and pink. Area cleansed with wound cleaner, dried and new\n mepelix applied. All limbs were lubricated frequently. Her position was\n changed, at times only slightly throughout the day. She does become\n uncomfortable if she is in the same position for too long,but also has\n difficulty on the L side. She finds the waffle boots uncomfortable and\n prefers having her legs elevated on pillows.\n Response:\n No new skin lesions have developed.\n Plan:\n Continue with turning, lubricating and keeping heels elevated. Monitor\n mepilex to ensure it is in place.\n"},{"category":"Nursing","chartdate":"2180-01-14 00:00:00.000","description":"Nursing Progress Note","row_id":399793,"text":"Pt is a 71 yo female with PMH: BM stent to LAD ', Occluded RCA\n without intervention, Ischemic CM (EF 10-25%), BiV ICD, AF, PVD, DVT\n s/p IVC filter, coumadin, hypothyroidism, CKD, OA. adm for HF\n (milrinone/lasix) MRSA in L shoulder, L hip and R knuckle. Out to\n rehab . went from rehab to see Dr. , sent to EW with\n hypotension. SBP 70 in EW, transiently on dopa, but cardiology d/c'd.\n Rxd with NS 250 cc with SBP 92. Pt has been in rehab since d/c from\n with septic arthritis in L shoulder, hip and R knuckle.\n On Vanco followed by ID.\n She was started on milrinone .375 after bolus and lasix drip also begun\n at 2.5mg/hr. The lasix dose was increased to 5mg overnight, but urine\n output has remained poor, though she is negative.\n GI: Pt has poor apetite and eats very little.\n SOCIAL: Family in the visit in afternoon. Pt in good spirits, visiting\n with brother and his family.\n CODE STATUS: Dr had discussion with both patient and health care\n proxy and all are in agreement that she be DNR/DNI. Additionally the\n defibrillator part of AICD/pacer was shut off.\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Action:\n Response:\n Plan:\n ------ Protected Section ------\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt w large\n Action:\n Response:\n Plan:\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n ------ Protected Section Addendum Entered By: , RN\n on: 06:13 AM ------\n"},{"category":"Nursing","chartdate":"2180-01-14 00:00:00.000","description":"Nursing Progress Note","row_id":399794,"text":"Pt is a 71 yo female with PMH: BM stent to LAD ', Occluded RCA\n without intervention, Ischemic CM (EF 10-25%), BiV ICD, AF, PVD, DVT\n s/p IVC filter, coumadin, hypothyroidism, CKD, OA. adm for HF\n (milrinone/lasix) MRSA in L shoulder, L hip and R knuckle. Out to\n rehab . went from rehab to see Dr. , sent to EW with\n hypotension. SBP 70 in EW, transiently on dopa, but cardiology d/c'd.\n Rxd with NS 250 cc with SBP 92. Pt has been in rehab since d/c from\n with septic arthritis in L shoulder, hip and R knuckle.\n On Vanco followed by ID.\n She was started on milrinone .375 after bolus and lasix drip also begun\n at 2.5mg/hr. The lasix dose was increased to 5mg overnight, but urine\n output has remained poor, though she is negative.\n GI: Pt has poor apetite and eats very little.\n SOCIAL: Family in the visit in afternoon. Pt in good spirits, visiting\n with brother and his family.\n CODE STATUS: Dr had discussion with both patient and health care\n proxy and all are in agreement that she be DNR/DNI. Additionally the\n defibrillator part of AICD/pacer was shut off.\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Action:\n Response:\n Plan:\n ------ Protected Section ------\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt w large\n Action:\n Response:\n Plan:\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n ------ Protected Section Addendum Entered By: , RN\n on: 06:13 AM ------\n ------ Protected Section Error Entered By: , RN\n on: 06:17 AM ------\n"},{"category":"Nursing","chartdate":"2180-01-14 00:00:00.000","description":"Nursing Progress Note","row_id":399797,"text":"Pt is a 71 yo female with PMH: BM stent to LAD ', Occluded RCA\n without intervention, Ischemic CM (EF 10-25%), BiV ICD, AF, PVD, DVT\n s/p IVC filter, coumadin, hypothyroidism, CKD, OA. adm for HF\n (milrinone/lasix) MRSA in L shoulder, L hip and R knuckle. Out to\n rehab . went from rehab to see Dr. , sent to EW with\n hypotension. SBP 70 in EW, transiently on dopa, but cardiology d/c'd.\n Rxd with NS 250 cc with SBP 92. Pt has been in rehab since d/c from\n with septic arthritis in L shoulder, hip and R knuckle.\n On Vanco followed by ID.\n She was started on milrinone .375 after bolus and lasix drip also begun\n at 2.5mg/hr. The lasix dose was increased to 5mg overnight, but urine\n output has remained poor, though she is negative.\n GI: Pt has poor apetite and eats very little.\n SOCIAL: Family in the visit in afternoon. Pt in good spirits, visiting\n with brother and his family.\n CODE STATUS: Dr had discussion with both patient and health care\n proxy and all are in agreement that she be DNR/DNI. Additionally the\n defibrillator part of AICD/pacer was shut off.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt w large painful coccyx wound given ultram/Tylenol as ordered as well\n as prn MSO4 for pain control.\n Action:\n See above- QHS Tylenol 1 GM, ultram. MSO4 2 mg x 3 doses this shift.\n Turning side to side and repositioning w less discomfort. Unable to\n tolerate being on left side for very long- describes increased coccyx\n pain/hp pain.\n Response:\n Pt sleeping well, more comfortable w MS IVP.\n Plan:\n Continue to make pt as comfortable as possible. Medicate, reposition,\n emotional support as needed.\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Pt w longstanding ESHD- currently on Mlrinone 0.5 and lasix gtt up to\n 15 mg in attempts to maximize heart function /unloading.\n Action:\n Given 5 metalozone PO x 1 and increased lasix to 15 mg for I/O\n unchanged, even as of MN. No changes to milrinone gtt.\n Response:\n Better diuresis w increased lasix. (-) 800cc as of 6am. HR remains\n 70-100 AVP. Minimal VEA. No runs. Of note defib fx of ICD has been\n turned off. BP- 90-100/50\ns. No hypotension this shift.\n Plan:\n Continue to attempt to duirese without dropping BP, affecting\n hemodynamics. Continue milrinone gtt as ordered. Continue plan of care,\n DNR, keep pt comfortable. Keep pt aware of plan of care as well as\n family .\n Impaired Skin Integrity\n Assessment:\n Pt admitted from rehab for hypotension, heart failure\n admitted w\n large coccyx decubitus. Pain at site.\n Action:\n Pt remains on medications to keep comfortable currently- MS, ultram,\n Tylenol. Repositioning frequently to keep pt off coccyx. Changed dsg x\n 1\n cleaned wound w wound spray- see flow for details. No drainage\n apparent.\n Response:\n Changed coccyx wound dressing. Appears to be clean without drainage.\n Plan:\n Continue wound care per plan. Keep pt off wound site w repositioning as\n able. Comfort/pain control.\n"},{"category":"Nursing","chartdate":"2180-01-14 00:00:00.000","description":"Nursing Progress Note","row_id":399877,"text":"Pt is a 71 yo female with PMH: BM stent to LAD ', Occluded RCA\n without intervention, Ischemic CM (EF 10-25%), BiV ICD, AF, PVD, DVT\n s/p IVC filter, coumadin, hypothyroidism, CKD, OA. adm for HF\n (milrinone/lasix) MRSA in L shoulder, L hip and R knuckle. Out to\n rehab . went from rehab to see Dr. , sent to EW with\n hypotension. SBP 70 in EW, transiently on dopa, but cardiology d/c'd.\n Rxd with NS 250 cc with SBP 92. Pt has been in rehab since d/c from\n with septic arthritis in L shoulder, hip and R knuckle.\n On Vanco followed by ID.\n She was started on milrinone .375 after bolus and lasix drip also begun\n at 2.5mg/hr. The lasix dose was increased to 10 but urine output\n has remained poor, though she is negative.\n GI: Pt has good apetite and has been eating well, but still no BM. She\n has pills ground up in applesauce.\n SOCIAL: Family in the visit in the am and early afternoon. She slept\n most of the afternoon.\n CODE STATUS: Dr had discussion with both patient and health care\n proxy and all are in agreement that she be DNR/DNI. Additionally the\n defibrillator part of AICD/pacer was shut off.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pain is much better contolled now that she can receive prn morphine in\n addition to standing ultram and Tylenol. The coccyx decubitis is what\n causes the most discomfort. She is most uncomfortable on her L side and\n cannot sleep or rest on that side.\n Action:\n She required more morphine in the am and received 7 2mg doses between\n 8am and 1500. She has not been turned on L side except for dsg and bed\n change. She goes from back to R side and is doing better with this.\n Response:\n She was awake and conversant with family all morning, able to eat and\n interact. She has slept most of the afternoon since 1500. She awoke at\n 1800 and was pain free and ready to eat.\n Plan:\n Continue standing ultram and give morphine prn. Change position as\n tolerated.\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n She has her lasix drip increased to 15mg overnight and remains on\n milrinone .5mic/kilo. She has a once a day metolazone 5mg po added. She\n has no audible rales, just decresed breath sounds at the bases. Her\n blood pressure has been adequate with maps over the 60s. She has no\n c/o of cp or acute SOB. Her bilateral leg edema is decreasing. She\n received 20 meq KCL IV this am.\n Action:\n She continues on above medications and is now responding with excellent\n diuresis. She is over 2 liters negative for the day! Lopressor was\n increased to 25mg .\n Response:\n Lytes within nl limits. Goal to to continue pushing diuresis for over\n 10 liters negative.\n Plan:\n Keep careful I & O. Monitor lytes\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Radiology","chartdate":"2180-01-12 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1118390,"text":" 1:08 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for acute process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with chf\n REASON FOR THIS EXAMINATION:\n eval for acute process\n ______________________________________________________________________________\n WET READ: RBLd WED 2:35 PM\n high riding right PICC line, terminates in right subclavian vein. recommend\n repositioning or removal.\n\n persistent severe cdm. small left effusion + atelect. possible trace right\n effusion.\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: Chest, single AP upright portable view.\n\n CLINICAL INFORMATION: 71-year-old female with history of CHF.\n\n COMPARISON: .\n\n FINDINGS: A dual-lead left-sided AICD is seen with leads extending to the\n expected positions of the right atrium and right ventricle. A right-sided\n PICC findings seen, high in position, terminating in the region of the right\n subclavian vein. Recommend repositioning or removal. The cardiac silhouette\n is markedly enlarged without significant interval change from the prior study.\n The aorta is calcified and tortuous. There is blunting of the left\n costophrenic angle and obscuration of the left hemidiaphragm suggesting left\n pleural effusion with overlying atelectasis. Minimal blunting of the right\n costophrenic angle also suggests a trace right pleural effusion and/or\n thickening.\n\n IMPRESSION:\n 1. High lying right PICC line, terminating in the region of the right\n subclavian vein. Recommend repositioning or removal.\n 2. Persistent severe cardiomegaly.\n 3. Small left pleural effusion with overlying atelectasis.\n 4. Mild blunting of the right costophrenic angle, may be due to a trace\n effusion and/or thickening.\n\n\n"},{"category":"Radiology","chartdate":"2180-01-12 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":1118410,"text":" 2:22 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: eval for placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with new R IJ\n REASON FOR THIS EXAMINATION:\n eval for placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 71-year-old woman with new right IJ line.\n\n COMPARISON: Chest radiograph one hour prior.\n\n CHEST, UPRIGHT AP PORTABLE VIEW: A right IJ catheter has been placed,\n terminating in the lower SVC. The right PICC line is unchanged, terminating\n at the expected location of the right subclavian vein. The left-sided ICD\n device is unchanged. The cardiac silhouette remains enlarged. Small\n bilateral pleural effusions are unchanged. Perihilar interstitial prominence\n is indicating mild interstitial edema, unchanged. There is no pneumothorax.\n Retrocardiac opacity persists.\n\n IMPRESSION:\n 1. Right IJ catheter terminates in lower SVC.\n\n 2. Unchanged high riding right PICC line terminating in the expected location\n of the right subclavian vein. Recommend repositioning or removal.\n\n 3. Otherwise unchanged from one hour prior.\n\n"},{"category":"Radiology","chartdate":"2180-01-13 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1118513,"text":" 7:49 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval improvement\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with CHF\n REASON FOR THIS EXAMINATION:\n interval improvement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71 year-old woman with CHF.\n\n COMPARISON: Multiple prior chest radiographs, the most recent performed 12\n hours prior.\n\n AP UPRIGHT CHEST RADIOGRAPH: Marked cardiomegaly is stable. A right internal\n jugular catheter with its tip in the low SVC, a right-sided venous catheter\n with its tip in the subclavian vein and left-sided AICD with its leads\n overlying the right atrium and right ventricle are unchanged. Small bilateral\n effusions are stable. There is slight increase in vascular engorgement since\n hours prior. There is no consolidation or pneumothorax.\n\n IMPRESSION: Mild increase in vascular engorgement, otherwise no change since\n hours prior.\n\n"}],"string":"[\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2180-01-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 173437,\n \"text\": \"Ventricular paced rhythm with intermittent intrinsic A-V conduction as\\ncompared with prior tracing of .\\n\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2180-01-12 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 399681,\n \"text\": \"Pt is a 71 yo female with PMH: BM stent to LAD ', Occluded RCA\\n without intervention, Ischemic CM (EF 10-25%), BiV ICD, AF, PVD, DVT\\n s/p IVC filter, coumadin, hypothyroidism, CKD, OA. adm for HF\\n (milrinone/lasix) MRSA in L shoulder, L hip and R knuckle. Out to\\n rehab . Today went from rehab to see Dr. , sent to EW with\\n hypotension. SBP 70 in EW, transiently on dopa, but cardiology d/c'd.\\n Rxd with NS 250 cc with SBP 92. Pt has been in rehab since d/c from\\n with septic arthritis in L shoulder, hip and R knuckle.\\n On Vanco followed by ID.\\n .H/O heart failure (CHF), Systolic, Acute on Chronic\\n Assessment:\\n SBP 90-100, HR 80-100 V paced, with VEA, lungs clear, sats >95% on \\n Rehab called for date and time of last medications\\n Plan:\\n To begin on milrinone with bolus/ neo on stand by. Then to begin lasix\\n gtt. Once hemodynamically stable on milrinone, can add morphine to\\n pain control as needed\\n Impaired Skin Integrity\\n Assessment:\\n 5X 7 cm stage 3 decube on coccyx, surrounded by yellow slough.\\n Surrounding tissue macerated. Heels pink, boggy\\n Action:\\n Intern in to assess wound.\\n Offered kinair bed to patient but she refused\\n Wound cleansed with wound spray, covered by mepilex dsg\\n Multipodous boots ordered\\n Turned off of back\\n Pt refusing dinner\\n Plan:\\n Please obtain wound consult for wound care recommendations and\\n suggestions on pressure reducing mattress, enc po\\ns, have nutritionist\\n consult.\\n Pain control (acute pain, chronic pain)\\n Assessment:\\n pain over coccyx, given Tylenol in EW without relief\\n Action/Response:\\n Ultram 50 mg qid\\n Plan:\\n Once milrinone bolus finished, can begin IV morphine. Ultram qid and\\n Tylenol tid as ordered\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2180-01-17 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 400111,\n \"text\": \"71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\\n : Sent to ED from clinic w/ hypotension\\n transiently on\\n dopa, Tx\\nd w/ NS 250 cc w/ SBP ^ 92.\\n Admit to CCU for aggressive diuresis.She was started on Milrinone\\n and lasix gtt. And has been diuresing well. She has lg coccyx decub\\n that is a source of chronic pain. She is DNR/DNI and defibrillator has\\n been shut off.\\n GI: Pt had a few episode of nausea yesterday and one today. It was very\\n transient with no vomiting. She ate very well today. She received\\n lactalose but no bM. Foley changed today.\\n SOCIAL: Family in to visit. Pts HCP, her 38y old neice is very ill\\n creating problem for this stressed family.\\n Pain control (acute pain, chronic pain)\\n Assessment:\\n Plan is to transition to oral forms of pain control in preparation for\\n pt going to rehab. She had received MS contin at 0600, but pill was\\n ground and pt had nausea. She received 4mg IV morphine at 6am as well.\\n She continues on standing acetominofen and ultram\\n Action:\\n MS contin will be given in to 15mg pills, which are smaller and can\\n take them without having them crushed. Morphine immediate release has\\n been ordered for breakthrough pain. It is also a small pill that she\\n can take without crushing. She had 15mg immediate release at 1300 . She\\n has had no IV morphine sulfate since 1030.\\n Response:\\n Pt has been pain free except when turned since then. She will have\\n acute pain with position change, but it will settle down and go away\\n within a few minutes. She received MS contin at 1800 and was able to\\n swallow them without problem\\n :\\n Continue to try to control pain with oral medications. Give immediate\\n release morphine for breakthrough pain.\\n Impaired Skin Integrity\\n Assessment:\\n Sacral wound getting worse and remains very painful. Mepilex dsg oozing\\n through. Acuacel added. Know MRSA infection on R knuckle and R elbow\\n appear to be much more reddened than last week. Over all skin is dry\\n and itchy.\\n Action:\\n Wound care nurse came to evaluate wound. Area is now cleansed with\\n wound cleanser and dried. Criticade antifungal is applied to wound\\n edges and peri-wound area. The wound is covered with aquacel AG and\\n then small soft-sorb pad. It is secured with medipore tape on skin that\\n has been prepped with barrier wipe. Finger and elbow are washed with\\n soap and water. Area kept lubricated. oil used in water. Moisture\\n barrier clean applied to body. Heels elevated off bed.\\n Response:\\n Skin less itchy. No further worsening of skin condition.\\n Plan:\\n .H/O heart failure (CHF), Systolic, Acute on Chronic\\n Assessment:\\n Pt being transition for transfer back to rehab. Milrinone and lasix\\n drips stopped at 1030. Pt was V-paced with wide complex and blood\\n pressure prior to stopping meds was mid 90s with maps in mid 60s. She\\n received KCL 20meq in AM She received torsemide 40mg and metolazone\\n 5mg with urine output ~ 30-40cc/hr. Blood pressure dropped to the high\\n 70s to mid 80s with maps in the low 50s.\\n Action:\\n After discussions with Dr she was restarted on Milrinone\\n .5mic/kilo with bolus of 25mic/kilo given. Labs drawn in afternoon.\\n Response:\\n Blood pressure more stable with maps in low 60s after Milrinone\\n restarted. She is ~400cc neg for the day. BUN creat 33/1.1, stable.\\n Plan:\\n Family deciding if pt will now be CMO and go to extended care facility\\n with hospice.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2180-01-17 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 400112,\n \"text\": \"Pain control (acute pain, chronic pain)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n .H/O heart failure (CHF), Systolic, Acute on Chronic\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Impaired Skin Integrity\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2180-01-12 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 399678,\n \"text\": \"Pt is a 71 yo female with PMH: BM stent to LAD ', Occluded RCA\\n without intervention, Ischemic CM (EF 10-25%), BiV ICD, AF, PVD, DVT\\n s/p IVC filter, coumadin, hypothyroidism, CKD, OA. adm for HF\\n (milrinone/lasix) MRSA in L shoulder, L hip and R knuckle. Out to\\n rehab . Today went from rehab to see Dr. , sent to EW with\\n hypotension. SBP 70 in EW, transiently on dopa, but cardiology d/c'd.\\n Rxd with NS 250 cc with SBP 92. Pt has been in rehab since d/c from\\n with septic arthritis in L shoulder, hip and R knuckle.\\n On Vanco followed by ID.\\n .H/O heart failure (CHF), Systolic, Acute on Chronic\\n Assessment:\\n SBP 90-100, HR 80-100 V paced, lungs clear, sats >95% on RA\\n Action:\\n Response:\\n Plan:\\n To begin on milrinone with bolus/ neo on stand by. Then to begin lasix\\n gtt. Once hemodynamically stable on milrinone, can add morphine to\\n pain control as needed\\n Impaired Skin Integrity\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2180-01-12 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 399679,\n \"text\": \"Pt is a 71 yo female with PMH: BM stent to LAD ', Occluded RCA\\n without intervention, Ischemic CM (EF 10-25%), BiV ICD, AF, PVD, DVT\\n s/p IVC filter, coumadin, hypothyroidism, CKD, OA. adm for HF\\n (milrinone/lasix) MRSA in L shoulder, L hip and R knuckle. Out to\\n rehab . Today went from rehab to see Dr. , sent to EW with\\n hypotension. SBP 70 in EW, transiently on dopa, but cardiology d/c'd.\\n Rxd with NS 250 cc with SBP 92. Pt has been in rehab since d/c from\\n with septic arthritis in L shoulder, hip and R knuckle.\\n On Vanco followed by ID.\\n .H/O heart failure (CHF), Systolic, Acute on Chronic\\n Assessment:\\n SBP 90-100, HR 80-100 V paced, with VEA, lungs clear, sats >95% on RA\\n Plan:\\n To begin on milrinone with bolus/ neo on stand by. Then to begin lasix\\n gtt. Once hemodynamically stable on milrinone, can add morphine to\\n pain control as needed\\n Impaired Skin Integrity\\n Assessment:\\n 5X 7 cm stage 3 decube on coccyx, surrounded by yellow slough.\\n Surrounding tissue macerated. Heels pink, boggy\\n Action:\\n Intern in to assess wound.\\n Offered kinair bed to patient but she refused\\n Wound cleansed with wound spray, covered by mepilex dsg\\n Multipodous boots ordered\\n Turned off of back\\n Pt refusing dinner\\n Plan:\\n Please obtain wound consult for wound care recommendations and\\n suggestions on pressure reducing mattress, enc po\\ns, have nutritionist\\n consult.\\n Pain control (acute pain, chronic pain)\\n Assessment:\\n pain over coccyx, given Tylenol in EW without relief\\n Action/Response:\\n Ultram 50 mg qid\\n Plan:\\n Once milrinone bolus finished, can begin IV morphine\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2180-01-17 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 400113,\n \"text\": \"71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\\n : Sent to ED from clinic w/ hypotension\\n transiently on\\n dopa, Tx\\nd w/ NS 250 cc w/ SBP ^ 92.\\n Admit to CCU for aggressive diuresis.She was started on Milrinone\\n and lasix gtt. And has been diuresing well. She has lg coccyx decub\\n that is a source of chronic pain. She is DNR/DNI and defibrillator has\\n been shut off.\\n Pain control (acute pain, chronic pain)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n .H/O heart failure (CHF), Systolic, Acute on Chronic\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Impaired Skin Integrity\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2180-01-14 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 399802,\n \"text\": \"Pt is a 71 yo female with PMH: BM stent to LAD ', Occluded RCA\\n without intervention, Ischemic CM (EF 10-25%), BiV ICD, AF, PVD, DVT\\n s/p IVC filter, coumadin, hypothyroidism, CKD, OA. adm for HF\\n (milrinone/lasix) MRSA in L shoulder, L hip and R knuckle. Out to\\n rehab . went from rehab to see Dr. , sent to EW with\\n hypotension. SBP 70 in EW, transiently on dopa, but cardiology d/c'd.\\n Rxd with NS 250 cc with SBP 92. Pt has been in rehab since d/c from\\n with septic arthritis in L shoulder, hip and R knuckle.\\n On Vanco followed by ID.\\n She was started on milrinone .375 after bolus and lasix drip also begun\\n at 2.5mg/hr. The lasix dose was increased to 5mg overnight, but urine\\n output has remained poor, though she is negative.\\n GI: Pt has poor apetite and eats very little.\\n SOCIAL: Family in the visit in afternoon. Pt in good spirits, visiting\\n with brother and his family.\\n CODE STATUS: Dr had discussion with both patient and health care\\n proxy and all are in agreement that she be DNR/DNI. Additionally the\\n defibrillator part of AICD/pacer was shut off.\\n Pain control (acute pain, chronic pain)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n .H/O heart failure (CHF), Systolic, Acute on Chronic\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Impaired Skin Integrity\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2180-01-14 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 399815,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n - confirmed DNR, acemaker turned off\\n - despite lasix gtt, diuresis poor yesterday\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Vancomycin - 08:00 AM\\n Ciprofloxacin - 08:00 AM\\n Infusions:\\n Other ICU medications:\\n Coumadin (Warfarin) - 04:00 PM\\n Lansoprazole (Prevacid) - 04:00 PM\\n Morphine Sulfate - 05:05 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 08:40 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 36.6\\nC (97.9\\n Tcurrent: 36.4\\nC (97.5\\n HR: 99 (66 - 104) bpm\\n BP: 91/50(60) {82/42(45) - 101/67(120)} mmHg\\n RR: 12 (11 - 23) insp/min\\n SpO2: 99%\\n Heart rhythm: V Paced\\n Wgt (current): 82.2 kg (admission): 82.2 kg\\n Total In:\\n 1,554 mL\\n 456 mL\\n PO:\\n 900 mL\\n 60 mL\\n TF:\\n IVF:\\n 654 mL\\n 396 mL\\n Blood products:\\n Total out:\\n 1,628 mL\\n 1,505 mL\\n Urine:\\n 1,628 mL\\n 1,505 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -74 mL\\n -1,049 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 99%\\n ABG: ///27/\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 159 K/uL\\n 10.0 g/dL\\n 104 mg/dL\\n 1.4 mg/dL\\n 27 mEq/L\\n 3.8 mEq/L\\n 42 mg/dL\\n 98 mEq/L\\n 134 mEq/L\\n 31.9 %\\n 4.7 K/uL\\n [image002.jpg]\\n 05:44 AM\\n 04:46 AM\\n WBC\\n 6.1\\n 4.7\\n Hct\\n 32.1\\n 31.9\\n Plt\\n 156\\n 159\\n Cr\\n 1.3\\n 1.4\\n Glucose\\n 83\\n 104\\n Other labs: PT / PTT / INR:16.8/29.3/1.5, Ca++:8.0 mg/dL, Mg++:2.1\\n mg/dL, PO4:3.3 mg/dL\\n Assessment and Plan\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 05:34 PM\\n Midline - 05:34 PM\\n 18 Gauge - 05:35 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2180-01-14 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 399816,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n - confirmed DNR, acemaker turned off\\n - despite lasix gtt, diuresis poor yesterday\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Vancomycin - 08:00 AM\\n Ciprofloxacin - 08:00 AM\\n Infusions:\\n Other ICU medications:\\n Coumadin (Warfarin) - 04:00 PM\\n Lansoprazole (Prevacid) - 04:00 PM\\n Morphine Sulfate - 05:05 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 08:40 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 36.6\\nC (97.9\\n Tcurrent: 36.4\\nC (97.5\\n HR: 99 (66 - 104) bpm\\n BP: 91/50(60) {82/42(45) - 101/67(120)} mmHg\\n RR: 12 (11 - 23) insp/min\\n SpO2: 99%\\n Heart rhythm: V Paced\\n Wgt (current): 82.2 kg (admission): 82.2 kg\\n Total In:\\n 1,554 mL\\n 456 mL\\n PO:\\n 900 mL\\n 60 mL\\n TF:\\n IVF:\\n 654 mL\\n 396 mL\\n Blood products:\\n Total out:\\n 1,628 mL\\n 1,505 mL\\n Urine:\\n 1,628 mL\\n 1,505 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -74 mL\\n -1,049 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 99%\\n ABG: ///27/\\n Physical Examination\\n General Appearance: No acute distress, thin, cachectic\\n Head, Ears, Nose, Throat: Normocephalic\\n Cardiovascular: II/VI systolic murmur best at apex. MI is laterally\\n displaced\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\\n Respiratory / Chest: (Breath Sounds: Clear : anteriorly)\\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\\n Extremities: Right lower extremity edema: 2+, Left lower extremity\\n edema: 2+\\n Skin: Not assessed, Stage 3 sacral decubitus ulcer\\n Neurologic: Attentive, Responds to: Not assessed, Oriented (to): x3\\n Labs / Radiology\\n 159 K/uL\\n 10.0 g/dL\\n 104 mg/dL\\n 1.4 mg/dL\\n 27 mEq/L\\n 3.8 mEq/L\\n 42 mg/dL\\n 98 mEq/L\\n 134 mEq/L\\n 31.9 %\\n 4.7 K/uL\\n [image002.jpg]\\n 05:44 AM\\n 04:46 AM\\n WBC\\n 6.1\\n 4.7\\n Hct\\n 32.1\\n 31.9\\n Plt\\n 156\\n 159\\n Cr\\n 1.3\\n 1.4\\n Glucose\\n 83\\n 104\\n Other labs: PT / PTT / INR:16.8/29.3/1.5, Ca++:8.0 mg/dL, Mg++:2.1\\n mg/dL, PO4:3.3 mg/dL\\n Assessment and Plan\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 05:34 PM\\n Midline - 05:34 PM\\n 18 Gauge - 05:35 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2180-01-14 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 399817,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n - confirmed DNR, acemaker turned off\\n - despite lasix gtt, diuresis poor yesterday\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Vancomycin - 08:00 AM\\n Ciprofloxacin - 08:00 AM\\n Infusions:\\n Other ICU medications:\\n Coumadin (Warfarin) - 04:00 PM\\n Lansoprazole (Prevacid) - 04:00 PM\\n Morphine Sulfate - 05:05 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 08:40 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 36.6\\nC (97.9\\n Tcurrent: 36.4\\nC (97.5\\n HR: 99 (66 - 104) bpm\\n BP: 91/50(60) {82/42(45) - 101/67(120)} mmHg\\n RR: 12 (11 - 23) insp/min\\n SpO2: 99%\\n Heart rhythm: V Paced\\n Wgt (current): 82.2 kg (admission): 82.2 kg\\n Total In:\\n 1,554 mL\\n 456 mL\\n PO:\\n 900 mL\\n 60 mL\\n TF:\\n IVF:\\n 654 mL\\n 396 mL\\n Blood products:\\n Total out:\\n 1,628 mL\\n 1,505 mL\\n Urine:\\n 1,628 mL\\n 1,505 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -74 mL\\n -1,049 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 99%\\n ABG: ///27/\\n Physical Examination\\n General Appearance: No acute distress, thin, cachectic\\n Head, Ears, Nose, Throat: Normocephalic\\n Cardiovascular: II/VI systolic murmur best at apex. MI is laterally\\n displaced\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\\n Respiratory / Chest: (Breath Sounds: Clear : anteriorly)\\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\\n Extremities: Right lower extremity edema: 2+, Left lower extremity\\n edema: 2+\\n Skin: Not assessed, Stage 3 sacral decubitus ulcer\\n Neurologic: Attentive, Responds to: Not assessed, Oriented (to): x3\\n Labs / Radiology\\n 159 K/uL\\n 10.0 g/dL\\n 104 mg/dL\\n 1.4 mg/dL\\n 27 mEq/L\\n 3.8 mEq/L\\n 42 mg/dL\\n 98 mEq/L\\n 134 mEq/L\\n 31.9 %\\n 4.7 K/uL\\n [image002.jpg]\\n 05:44 AM\\n 04:46 AM\\n WBC\\n 6.1\\n 4.7\\n Hct\\n 32.1\\n 31.9\\n Plt\\n 156\\n 159\\n Cr\\n 1.3\\n 1.4\\n Glucose\\n 83\\n 104\\n Other labs: PT / PTT / INR:16.8/29.3/1.5, Ca++:8.0 mg/dL, Mg++:2.1\\n mg/dL, PO4:3.3 mg/dL\\n Assessment and Plan\\n 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\\n recently discharged from the CCU () for CHF exacerbation c/b\\n C.diff infection and on for septic joint washout c/b failure to\\n extubate CHF exacerbation, who is now being admitted from \\n clinic with total body fluid overload.\\n .\\n # Anasarca: Patient has history of CHF ischemic , 10%, s/p\\n BiV ICD ( Concerto C154DWK) 1/08with EF 10% which is the\\n likely cause of her fluid overload. Her rapid accumulation underpins\\n the severity of her condition and her severely unfavourable\\n hemodynamics. Her long term goals are comfort, though she still wishes\\n to participate in rehab. Her family recognizes that she is dying. Our\\n goal is diuresis which we will attempt aggressively, reassessing our\\n progress dynamically. She put out very little o/n on lasix gtt. This\\n could reflect limitatin of diuresis or the importance of a bolus (we\\n withheld bolus to avoid instability)\\n -- milrinone with bolus\\n -- neosynephrine for pressure support, goal MAP of > 60\\n -- slow uptitration of lasix with goal near-continuous diuresis while\\n avoiding MAP < 60\\n -- strict i/o's with foley\\n -- can switch to levophed if low UOP on Neo with need for pressor\\n support\\n -- family meeting with HCP to assess goals in AM after diuresis\\n attempted\\n .\\n # Septic Joints: Patient with history +staph aureus in left shoulder\\n treated by washout and vancomycin, thus far 4 weeks of monotherapy. No\\n + blood cx since before . Major issue now is pain control.\\n -- send Vanco level in AM, was recently on 500 mg q12 and switched to\\n q24 for high troughs\\n -- ultram q6, Tylenol q8, Morphine for breakthrough (1-3 mg).\\n - Will consider ms contin if no control\\n .\\n # Sacral Decub - stage 3-4.\\n - wound care\\n - pain control.\\n .\\n # UTI: positive UA, no history of culture positive UA's in system\\n - treating empirically with cipro\\n - watch INR on abx\\n .\\n # CORONARIES: Patient with h/o CAD w/ right dominant system, mild\\n instent re-stenois of the LAD BM stent and occluded RCA.\\n - bb as tolerated\\n .\\n # RHYTHM: Patient with h/o atrial fibrillation, s/p BiV ICD (\\n Concerto C154DWK) , on coumadin. Now in paced rhythm\\n - cont home dose meds (amio, metoprolol)\\n - cont coumadin\\n - f/u INR\\n .\\n # Chronic Kidney Disease: Baseline 1.3 creatinine. At baseline\\n - trend\\n .\\n # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a\\n filter in place.\\n - cont coumadin\\n - f/u INR\\n .\\n # Hypothyroidism: Continue Levothyroxine.\\n .\\n # Gout: continue allopurinol\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 05:34 PM\\n Midline - 05:34 PM\\n 18 Gauge - 05:35 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2180-01-16 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 400035,\n \"text\": \"Pain control (acute pain, chronic pain)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n .H/O heart failure (CHF), Systolic, Acute on Chronic\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Impaired Skin Integrity\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Ineffective Coping\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2180-01-16 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 400036,\n \"text\": \"71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\\n : Sent to ED from clinic w/ hypotension\\n transiently on\\n dopa, Tx\\nd w/ NS 250 cc w/ SBP ^ 92. Admit to CCU for aggressive\\n diuresis.\\n Pain control (acute pain, chronic pain)\\n Assessment:\\n Pt needing less doses IV Morphine since MS Contin increased to 30mg \\n this morning\\n Pt consistently states pain is at coccyx\\n immediate area of pressure\\n ulcer and nowhere else\\n Action:\\n Received MS Contin 15mg x 2 this AM\\n Continues on Tylenol 1000mg po TID, Ultram 50mg QID\\n Received Morphine IV 4mg approx every 2 hours this am x total 4 doses\\n none since approx 1245\\n Response:\\n Pt appears more comfortable this PM\\n able to turn w/o premedicating with IV Morphine\\n Pt states pain is which she states is good for her\\n Plan:\\n Cont assess pain, cont ATC meds and supplement with IV Morphine as\\n needed\\n ? etiology of severe pain\\n ESR ordered to r/o osteo\\n .H/O heart failure (CHF), Systolic, Acute on Chronic\\n Assessment:\\n Pt asystomatic\\n no SOB with stable VS\\n Action:\\n Milrinone remains at 0,5mcgs/kg/min\\n Lasix increased from 5 to 10mg/hr\\n Response:\\n Initial urine output ~ 200cc/hr in AM\\n now decreased to 20-40cc/hr,\\n Lasix gtt titrated back to 10mg/hr with slight increase output\\n Plan:\\n Cont IV Lasix/Mirinone overnight and D/C in AM\\n Transition to oral regimen, Assess response\\n Impaired Skin Integrity\\n Assessment:\\n Large unstageable pressur ulcer on coccyx unchanged\\n Bilat heels remain reddened but blanchble\\n Old abrasion to r elbow\\n Action:\\n dressing coming off\\n cleansed and redressed this AM-duoderm\\n gel/Mepilex,\\n mod amt sero-sanguinous drainage; redness/maceration to surrounding\\n tissue\\n severe pain at site\\n see above\\n Response:\\n Site remains unchanged\\n Plan:\\n Cont keep PU clean with intact dressing, frequent turns avoiding back\\n except when pt sitting upright for meals\\n Wound care RN consult in AM\\n Roho cushion ordered from PT\\n unavailable today\\n Ineffective Coping\\n Assessment:\\n Pt continues to have periods in day when she has difficulty coping with\\n plan to return to rehab\\n Action:\\n Pt allowed to verbalize feelings about rehab, realizes she is unable to\\n return home\\n Response:\\n Pt appears to have periods of\\nmeltdown\\n with periods of rational\\n thought regarding needs and abilities going forward\\n Plan:\\n Case Manager consult in AM\\n Social Service consult in AM.\\n Cont to provide emotional support for patient.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2180-01-19 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 400187,\n \"text\": \"Pain control (acute pain, chronic pain)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n .H/O heart failure (CHF), Systolic, Acute on Chronic\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Impaired Skin Integrity\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2180-01-14 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 399880,\n \"text\": \"Pt is a 71 yo female with PMH: BM stent to LAD ', Occluded RCA\\n without intervention, Ischemic CM (EF 10-25%), BiV ICD, AF, PVD, DVT\\n s/p IVC filter, coumadin, hypothyroidism, CKD, OA. adm for HF\\n (milrinone/lasix) MRSA in L shoulder, L hip and R knuckle. Out to\\n rehab . went from rehab to see Dr. , sent to EW with\\n hypotension. SBP 70 in EW, transiently on dopa, but cardiology d/c'd.\\n Rxd with NS 250 cc with SBP 92. Pt has been in rehab since d/c from\\n with septic arthritis in L shoulder, hip and R knuckle.\\n On Vanco followed by ID.\\n She was started on milrinone .375 after bolus and lasix drip also begun\\n at 2.5mg/hr. The lasix dose was increased to 10 but urine output\\n has remained poor, though she is negative.\\n GI: Pt has good apetite and has been eating well, but still no BM. She\\n has pills ground up in applesauce.\\n SOCIAL: Family in the visit in the am and early afternoon. She slept\\n most of the afternoon.\\n CODE STATUS: Dr had discussion with both patient and health care\\n proxy and all are in agreement that she be DNR/DNI. Additionally the\\n defibrillator part of AICD/pacer was shut off.\\n Pain control (acute pain, chronic pain)\\n Assessment:\\n Pain is much better contolled now that she can receive prn morphine in\\n addition to standing ultram and Tylenol. The coccyx decubitis is what\\n causes the most discomfort. She is most uncomfortable on her L side and\\n cannot sleep or rest on that side.\\n Action:\\n She required more morphine in the am and received 7 2mg doses between\\n 8am and 1500. She has not been turned on L side except for dsg and bed\\n change. She goes from back to R side and is doing better with this.\\n Response:\\n She was awake and conversant with family all morning, able to eat and\\n interact. She has slept most of the afternoon since 1500. She awoke at\\n 1800 and was pain free and ready to eat.\\n Plan:\\n Continue standing ultram and give morphine prn. Change position as\\n tolerated.\\n .H/O heart failure (CHF), Systolic, Acute on Chronic\\n Assessment:\\n She has her lasix drip increased to 15mg overnight and remains on\\n milrinone .5mic/kilo. She has a once a day metolazone 5mg po added. She\\n has no audible rales, just decresed breath sounds at the bases. Her\\n blood pressure has been adequate with maps over the 60s. She has no\\n c/o of cp or acute SOB. Her bilateral leg edema is decreasing. She\\n received 20 meq KCL IV this am.\\n Action:\\n She continues on above medications and is now responding with excellent\\n diuresis. She is over 2 liters negative for the day! Lopressor was\\n increased to 25mg .\\n Response:\\n Lytes within nl limits. Goal to to continue pushing diuresis for over\\n 10 liters negative.\\n Plan:\\n Keep careful I & O. Monitor lytes\\n Impaired Skin Integrity\\n Assessment:\\n Pt has large stage 3 decubitus ulcer on coccyx. This is covered with\\n mepilex. Her heels are reddened, but . Her skin is very dry and\\n thin with a number of discolored areas. She has almost no abilty to\\n change her position on her own.\\n Action:\\n Mepilex dsg had drainage oozing through and was changed. Area has white\\n slough covering most of it. The surrounding tissue is red. There is a\\n lateral area that looks like granulation tissue. The edges are rounded.\\n Area was sprayed with wound cleanser and dried. Peri-wound area had\\n aloevesta moisture barrier applied and mepilex applied and remains in\\n tact. It is draining enough it needs to be changed daily. Her heels\\n have been kept elevated on pillows and she has been well lubricated.\\n Her position is changed from R to upright as often as she tolerates.\\n Response:\\n No new lesions noted. The ducub is no worse than yesterday.\\n Plan:\\n Monitor wound and change dsg as needed. Add aquacel if draining\\n increases. Change position as tolerated.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2180-01-17 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 400105,\n \"text\": \"71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\\n : Sent to ED from clinic w/ hypotension\\n transiently on\\n dopa, Tx\\nd w/ NS 250 cc w/ SBP ^ 92.\\n Admit to CCU for aggressive diuresis.She was started on Milrinone\\n and lasix gtt. And has been diuresing well. She has lg coccyx decub\\n that is a source of chronic pain. She is DNR/DNI and defibrillator has\\n been shut off. She has excellent apetite.\\n Pain control (acute pain, chronic pain)\\n Assessment:\\n Plan is to transition to oral forms of pain control in preparation for\\n pt going to rehab. She had received MS contin at 0600, but pill was\\n ground and pt had nausea. She received 4mg IV morphine at 6am as well.\\n She continues on standing acetominofen and ultram\\n Action:\\n MS contin will be given in to 15mg pills, which are smaller and can\\n take them without having them crushed. Morphine immediate release has\\n been ordered for breakthrough pain. It is also a small pill that she\\n can take without crushing. She had 15mg immediate release at 1300 . She\\n has had no IV morphine sulfate since 1030.\\n Response:\\n Pt has been pain free except when turned since then. She will have\\n acute pain with position change, but it will settle down and go away\\n within a few minutes. She received MS contin at 1800 and was able to\\n swallow them without problem\\n :\\n Continue to try to control pain with oral medications. Give immediate\\n release morphine for breakthrough pain.\\n Impaired Skin Integrity\\n Assessment:\\n Sacral wound getting worse and remains very painful. Mepilex dsg oozing\\n through. Acuacel added. Know MRSA infection on R knuckle and R elbow\\n appear to be much more reddened than last week. Over all skin is dry\\n and itchy.\\n Action:\\n Wound care nurse came to evaluate wound. Area is now cleansed with\\n wound cleanser and dried. Criticade antifungal is applied to wound\\n edges and peri-wound area. The wound is covered with aquacel AG and\\n then small soft-sorb pad. It is secured with medipore tape on skin that\\n has been prepped with barrier wipe. Finger and elbow are washed with\\n soap and water. Area kept lubricated. oil used in water. Moisture\\n barrier clean applied to body. Heels elevated off bed.\\n Response:\\n Skin less itchy. No further worsening of skin condition.\\n Plan:\\n .H/O heart failure (CHF), Systolic, Acute on Chronic\\n Assessment:\\n Pt being transition for transfer back to rehab. Milrinone and lasix\\n drips stopped at 1030. Pt was V-paced with wide complex and blood\\n pressure prior to stopping meds was mid 90s with maps in mid 60s. She\\n received KCL 20meq in AM She received torsemide 40mg and metolazone\\n 5mg with urine output ~ 30-40cc/hr. Blood pressure dropped to the high\\n 70s to mid 80s with maps in the low 50s.\\n Action:\\n After discussions with Dr she was restarted on Milrinone\\n .5mic/kilo with bolus of 25mic/kilo given.\\n Response:\\n Blood pressure more stable with maps in low 60s after Milrinone\\n restarted.\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2180-01-17 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 400106,\n \"text\": \"71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\\n : Sent to ED from clinic w/ hypotension\\n transiently on\\n dopa, Tx\\nd w/ NS 250 cc w/ SBP ^ 92.\\n Admit to CCU for aggressive diuresis.She was started on Milrinone\\n and lasix gtt. And has been diuresing well. She has lg coccyx decub\\n that is a source of chronic pain. She is DNR/DNI and defibrillator has\\n been shut off.\\n GI: Pt had a few episode of nausea yesterday and one today. It was very\\n transient with no vomiting. She ate very well today. She received\\n lactalose but no bM. Foley changed today.\\n SOCIAL: Family in to visit. Pts HCP, her 38y old neice is very ill\\n creating problem for this stressed family.\\n Pain control (acute pain, chronic pain)\\n Assessment:\\n Plan is to transition to oral forms of pain control in preparation for\\n pt going to rehab. She had received MS contin at 0600, but pill was\\n ground and pt had nausea. She received 4mg IV morphine at 6am as well.\\n She continues on standing acetominofen and ultram\\n Action:\\n MS contin will be given in to 15mg pills, which are smaller and can\\n take them without having them crushed. Morphine immediate release has\\n been ordered for breakthrough pain. It is also a small pill that she\\n can take without crushing. She had 15mg immediate release at 1300 . She\\n has had no IV morphine sulfate since 1030.\\n Response:\\n Pt has been pain free except when turned since then. She will have\\n acute pain with position change, but it will settle down and go away\\n within a few minutes. She received MS contin at 1800 and was able to\\n swallow them without problem\\n :\\n Continue to try to control pain with oral medications. Give immediate\\n release morphine for breakthrough pain.\\n Impaired Skin Integrity\\n Assessment:\\n Sacral wound getting worse and remains very painful. Mepilex dsg oozing\\n through. Acuacel added. Know MRSA infection on R knuckle and R elbow\\n appear to be much more reddened than last week. Over all skin is dry\\n and itchy.\\n Action:\\n Wound care nurse came to evaluate wound. Area is now cleansed with\\n wound cleanser and dried. Criticade antifungal is applied to wound\\n edges and peri-wound area. The wound is covered with aquacel AG and\\n then small soft-sorb pad. It is secured with medipore tape on skin that\\n has been prepped with barrier wipe. Finger and elbow are washed with\\n soap and water. Area kept lubricated. oil used in water. Moisture\\n barrier clean applied to body. Heels elevated off bed.\\n Response:\\n Skin less itchy. No further worsening of skin condition.\\n Plan:\\n .H/O heart failure (CHF), Systolic, Acute on Chronic\\n Assessment:\\n Pt being transition for transfer back to rehab. Milrinone and lasix\\n drips stopped at 1030. Pt was V-paced with wide complex and blood\\n pressure prior to stopping meds was mid 90s with maps in mid 60s. She\\n received KCL 20meq in AM She received torsemide 40mg and metolazone\\n 5mg with urine output ~ 30-40cc/hr. Blood pressure dropped to the high\\n 70s to mid 80s with maps in the low 50s.\\n Action:\\n After discussions with Dr she was restarted on Milrinone\\n .5mic/kilo with bolus of 25mic/kilo given. Labs drawn in afternoon.\\n Response:\\n Blood pressure more stable with maps in low 60s after Milrinone\\n restarted. She is ~400cc neg for the day. BUN creat 33/1.1, stable.\\n Plan:\\n Family deciding if pt will now be CMO and go to extended care facility\\n with hospice.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2180-01-16 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 400013,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n - MS Contin 15 , was getting 22 mg IV morph qday\\n - pulled EJ\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Ciprofloxacin - 08:00 AM\\n Vancomycin - 09:36 AM\\n Infusions:\\n Furosemide (Lasix) - 5 mg/hour\\n Milrinone - 0.5 mcg/Kg/min\\n Other ICU medications:\\n Morphine Sulfate - 06:40 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:58 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 36.6\\nC (97.9\\n Tcurrent: 36.6\\nC (97.8\\n HR: 70 (62 - 75) bpm\\n BP: 88/57(63) {78/43(52) - 106/66(76)} mmHg\\n RR: 23 (9 - 35) insp/min\\n SpO2: 97%\\n Heart rhythm: AV Paced\\n Wgt (current): 77.3 kg (admission): 82.2 kg\\n Total In:\\n 1,335 mL\\n 121 mL\\n PO:\\n 420 mL\\n TF:\\n IVF:\\n 915 mL\\n 121 mL\\n Blood products:\\n Total out:\\n 5,565 mL\\n 880 mL\\n Urine:\\n 5,565 mL\\n 880 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -4,230 mL\\n -759 mL\\n Respiratory support\\n O2 Delivery Device: None\\n SpO2: 97%\\n ABG: ///33/\\n Physical Examination\\n General Appearance: Well nourished, Overweight / Obese\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: Normocephalic\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Breath Sounds: Diminished: )\\n Abdominal: Soft, Obese\\n Extremities: Right lower extremity edema: Trace, Left lower extremity\\n edema: Trace\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 146 K/uL\\n 10.7 g/dL\\n 115 mg/dL\\n 1.1 mg/dL\\n 33 mEq/L\\n 3.8 mEq/L\\n 39 mg/dL\\n 92 mEq/L\\n 133 mEq/L\\n 33.1 %\\n 5.1 K/uL\\n [image002.jpg]\\n 05:44 AM\\n 04:46 AM\\n 04:00 PM\\n 03:05 AM\\n 03:17 PM\\n WBC\\n 6.1\\n 4.7\\n 5.1\\n Hct\\n 32.1\\n 31.9\\n 33.1\\n Plt\\n 156\\n 159\\n 146\\n Cr\\n 1.3\\n 1.4\\n 1.3\\n 1.2\\n 1.1\\n Glucose\\n 83\\n 104\\n 155\\n 115\\n Other labs:\\n PT / PTT / INR:18.4/29.1/1.7,\\n Ca++:8.3 mg/dL, Mg++:2.0 mg/dL, PO4:2.9 mg/dL\\n Assessment and Plan\\n 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\\n recently discharged from the CCU () for CHF exacerbation c/b\\n C.diff infection and on for septic joint washout c/b failure to\\n extubate CHF exacerbation, who is now being admitted from \\n clinic with total body fluid overload.\\n .\\n # sCHF exacerbation: Patient has history of CHF ischemic , \\n 10%, s/p BiV ICD ( Concerto C154DWK) 1/08with EF 10% which is\\n the likely cause of her fluid overload. Her rapid accumulation\\n underpins the severity of her condition and her severely unfavourable\\n hemodynamics. Her long term goals are comfort, though she still wishes\\n to participate in rehab. Her family recognizes that she is dying. Our\\n goal is diuresis which we will attempt aggressively, reassessing our\\n progress dynamically. She diuresed well on Lasix gtt on with net\\n neg 4L balance. LOS fluid balance -5L.\\n -- goal diuresis 5 to 10L total\\n -- continue milrinone\\n -- continue metoprolol tartrate 12.5mg PO BID\\n -- slow uptitration of lasix gtt with goal near-continuous diuresis\\n while avoiding MAP < 60\\n -- strict i/o's with foley\\n -- replete K to 5\\n -- PM electrolytes\\n -- family meeting with HCP prn\\n .\\n # Septic Joints: Patient with history +staph aureus in left shoulder\\n treated by washout and vancomycin, thus far 4 weeks of monotherapy. No\\n + blood cx since before . Major issue now is pain control.\\n -- continue vanc, was recently on 500 mg q12 and switched to q24 for\\n high troughs\\n -- continue MS contin 15mg \\n -- ultram q6, Tylenol q8, Morphine for breakthrough (2-4 mg).\\n .\\n # Sacral Decub - stage 3-4.\\n - wound care\\n - pain control\\n .\\n # UTI: positive UA, no history of culture positive UA's in system\\n - treating empirically with cipro day 1 was . Last dose tomorrow\\n morning (Morning of ^st)\\n - watch INR on abx\\n .\\n # CORONARIES: Patient with h/o CAD w/ right dominant system, mild\\n instent re-stenois of the LAD BM stent and occluded RCA.\\n - bb as tolerated\\n .\\n # RHYTHM: Patient with h/o atrial fibrillation, s/p BiV ICD (\\n Concerto C154DWK) , on coumadin. Now in paced rhythm\\n - cont home dose meds (amio, metoprolol)\\n - cont coumadin\\n .\\n # Chronic Kidney Disease: Baseline Creatinine 1.3. Creatinine 1.1\\n today.\\n - trend\\n .\\n # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a\\n filter in place.\\n - continue Coumadin\\n .\\n # Hypothyroidism: Continue Levothyroxine\\n .\\n # Gout: continue Allopurinol\\n ICU Care\\n Nutrition:\\n Low Na diet\\n Glycemic Control: not on insulin\\n Lines:\\n Multi Lumen - 05:34 PM\\n Midline - 05:34 PM\\n 18 Gauge - 05:35 PM\\n Prophylaxis:\\n DVT: SQ UF Heparin\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Family meeting held , ICU consent signed Comments:\\n Code status: DNR / DNI\\n Disposition:ICU\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2180-01-16 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 400015,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n - MS Contin 15 , was getting 22 mg IV morph qday\\n - pulled EJ\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Ciprofloxacin - 08:00 AM\\n Vancomycin - 09:36 AM\\n Infusions:\\n Furosemide (Lasix) - 5 mg/hour\\n Milrinone - 0.5 mcg/Kg/min\\n Other ICU medications:\\n Morphine Sulfate - 06:40 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:58 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 36.6\\nC (97.9\\n Tcurrent: 36.6\\nC (97.8\\n HR: 70 (62 - 75) bpm\\n BP: 88/57(63) {78/43(52) - 106/66(76)} mmHg\\n RR: 23 (9 - 35) insp/min\\n SpO2: 97%\\n Heart rhythm: AV Paced\\n Wgt (current): 77.3 kg (admission): 82.2 kg\\n Total In:\\n 1,335 mL\\n 121 mL\\n PO:\\n 420 mL\\n TF:\\n IVF:\\n 915 mL\\n 121 mL\\n Blood products:\\n Total out:\\n 5,565 mL\\n 880 mL\\n Urine:\\n 5,565 mL\\n 880 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -4,230 mL\\n -759 mL\\n Respiratory support\\n O2 Delivery Device: None\\n SpO2: 97%\\n ABG: ///33/\\n Physical Examination\\n General Appearance: Well nourished, Overweight / Obese\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: Normocephalic\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Breath Sounds: Diminished: )\\n Abdominal: Soft, Obese\\n Extremities: Right lower extremity edema: Trace, Left lower extremity\\n edema: Trace\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 146 K/uL\\n 10.7 g/dL\\n 115 mg/dL\\n 1.1 mg/dL\\n 33 mEq/L\\n 3.8 mEq/L\\n 39 mg/dL\\n 92 mEq/L\\n 133 mEq/L\\n 33.1 %\\n 5.1 K/uL\\n [image002.jpg]\\n 05:44 AM\\n 04:46 AM\\n 04:00 PM\\n 03:05 AM\\n 03:17 PM\\n WBC\\n 6.1\\n 4.7\\n 5.1\\n Hct\\n 32.1\\n 31.9\\n 33.1\\n Plt\\n 156\\n 159\\n 146\\n Cr\\n 1.3\\n 1.4\\n 1.3\\n 1.2\\n 1.1\\n Glucose\\n 83\\n 104\\n 155\\n 115\\n Other labs:\\n PT / PTT / INR:18.4/29.1/1.7,\\n Ca++:8.3 mg/dL, Mg++:2.0 mg/dL, PO4:2.9 mg/dL\\n Assessment and Plan\\n 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\\n recently discharged from the CCU () for CHF exacerbation c/b\\n C.diff infection and on for septic joint washout c/b failure to\\n extubate CHF exacerbation, who is now being admitted from \\n clinic with total body fluid overload.\\n .\\n # sCHF exacerbation: Patient has history of CHF ischemic , \\n 10%, s/p BiV ICD ( Concerto C154DWK) 1/08with EF 10% which is\\n the likely cause of her fluid overload. Her rapid accumulation\\n underpins the severity of her condition and her severely unfavourable\\n hemodynamics. Her long term goals are comfort, though she still wishes\\n to participate in rehab. Her family recognizes that she is dying. Our\\n goal is diuresis which we will attempt aggressively, reassessing our\\n progress dynamically. She diuresed well on Lasix gtt on with net\\n neg 4L balance. LOS fluid balance -5L.\\n -- goal diuresis 5 to 10L total\\n -- continue milrinone\\n -- continue metoprolol tartrate 12.5mg PO BID\\n -- slow uptitration of lasix gtt with goal near-continuous diuresis\\n while avoiding MAP < 60\\n -- strict i/o's with foley\\n -- replete K to 5\\n -- PM electrolytes\\n -- family meeting with HCP prn\\n .\\n # Septic Joints: Patient with history +staph aureus in left shoulder\\n treated by washout and vancomycin, thus far 4 weeks of monotherapy. No\\n + blood cx since before . Major issue now is pain control.\\n -- continue vanc, was recently on 500 mg q12 and switched to q24 for\\n high troughs\\n -- continue cipro\\n -- continue MS contin 15mg \\n -- ultram q6, Tylenol q8, Morphine for breakthrough (2-4 mg).\\n .\\n # Sacral Decub - stage 3-4.\\n - wound care\\n - pain control\\n .\\n # UTI: positive UA, no history of culture positive UA's in system\\n - treating empirically with cipro day 1 was . Last dose tomorrow\\n morning (Morning of ^st)\\n - watch INR on abx\\n .\\n # CORONARIES: Patient with h/o CAD w/ right dominant system, mild\\n instent re-stenois of the LAD BM stent and occluded RCA.\\n - bb as tolerated\\n .\\n # RHYTHM: Patient with h/o atrial fibrillation, s/p BiV ICD (\\n Concerto C154DWK) , on coumadin. Now in paced rhythm\\n - cont home dose meds (amio, metoprolol)\\n - cont coumadin\\n .\\n # Chronic Kidney Disease: Baseline Creatinine 1.3. Creatinine 1.1\\n today.\\n - trend\\n .\\n # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a\\n filter in place.\\n - continue Coumadin\\n .\\n # Hypothyroidism: Continue Levothyroxine\\n .\\n # Gout: continue Allopurinol\\n ICU Care\\n Nutrition:\\n Low Na diet\\n Glycemic Control: not on insulin\\n Lines:\\n Multi Lumen - 05:34 PM\\n Midline - 05:34 PM\\n 18 Gauge - 05:35 PM\\n Prophylaxis:\\n DVT: SQ UF Heparin\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Family meeting held , ICU consent signed Comments:\\n Code status: DNR / DNI\\n Disposition:ICU\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2180-01-16 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 400016,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n - MS Contin 15 , was getting 22 mg IV morph qday\\n - pulled EJ\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Ciprofloxacin - 08:00 AM\\n Vancomycin - 09:36 AM\\n Infusions:\\n Furosemide (Lasix) - 5 mg/hour\\n Milrinone - 0.5 mcg/Kg/min\\n Other ICU medications:\\n Morphine Sulfate - 06:40 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:58 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 36.6\\nC (97.9\\n Tcurrent: 36.6\\nC (97.8\\n HR: 70 (62 - 75) bpm\\n BP: 88/57(63) {78/43(52) - 106/66(76)} mmHg\\n RR: 23 (9 - 35) insp/min\\n SpO2: 97%\\n Heart rhythm: AV Paced\\n Wgt (current): 77.3 kg (admission): 82.2 kg\\n Total In:\\n 1,335 mL\\n 121 mL\\n PO:\\n 420 mL\\n TF:\\n IVF:\\n 915 mL\\n 121 mL\\n Blood products:\\n Total out:\\n 5,565 mL\\n 880 mL\\n Urine:\\n 5,565 mL\\n 880 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -4,230 mL\\n -759 mL\\n Respiratory support\\n O2 Delivery Device: None\\n SpO2: 97%\\n ABG: ///33/\\n Physical Examination\\n General Appearance: Well nourished, Overweight / Obese\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: Normocephalic\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Breath Sounds: Diminished: )\\n Abdominal: Soft, Obese\\n Extremities: Right lower extremity edema: Trace, Left lower extremity\\n edema: Trace\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 146 K/uL\\n 10.7 g/dL\\n 115 mg/dL\\n 1.1 mg/dL\\n 33 mEq/L\\n 3.8 mEq/L\\n 39 mg/dL\\n 92 mEq/L\\n 133 mEq/L\\n 33.1 %\\n 5.1 K/uL\\n [image002.jpg]\\n 05:44 AM\\n 04:46 AM\\n 04:00 PM\\n 03:05 AM\\n 03:17 PM\\n WBC\\n 6.1\\n 4.7\\n 5.1\\n Hct\\n 32.1\\n 31.9\\n 33.1\\n Plt\\n 156\\n 159\\n 146\\n Cr\\n 1.3\\n 1.4\\n 1.3\\n 1.2\\n 1.1\\n Glucose\\n 83\\n 104\\n 155\\n 115\\n Other labs:\\n PT / PTT / INR:18.4/29.1/1.7,\\n Ca++:8.3 mg/dL, Mg++:2.0 mg/dL, PO4:2.9 mg/dL\\n Assessment and Plan\\n 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\\n recently discharged from the CCU () for CHF exacerbation c/b\\n C.diff infection and on for septic joint washout c/b failure to\\n extubate CHF exacerbation, who is now being admitted from \\n clinic with total body fluid overload.\\n .\\n # sCHF exacerbation: Patient has history of CHF ischemic , \\n 10%, s/p BiV ICD ( Concerto C154DWK) 1/08with EF 10% which is\\n the likely cause of her fluid overload. Her rapid accumulation\\n underpins the severity of her condition and her severely unfavourable\\n hemodynamics. Her long term goals are comfort, though she still wishes\\n to participate in rehab. Her family recognizes that she is dying. Our\\n goal is diuresis which we will attempt aggressively, reassessing our\\n progress dynamically. She diuresed well on Lasix gtt on with net\\n neg 4L balance. LOS fluid balance -5L.\\n -- goal diuresis 5 to 10L total\\n -- continue milrinone\\n -- continue metolazone 5mg daily\\n -- continue metoprolol tartrate 12.5mg PO BID\\n -- slow uptitration of lasix gtt with goal near-continuous diuresis\\n while avoiding MAP < 60\\n -- strict i/o's with foley\\n -- replete K to 5\\n -- PM electrolytes\\n -- family meeting with HCP prn\\n .\\n # Septic Joints: Patient with history +staph aureus in left shoulder\\n treated by washout and vancomycin, thus far 4 weeks of monotherapy. No\\n + blood cx since before . Major issue now is pain control.\\n -- continue vanc, was recently on 500 mg q12 and switched to q24 for\\n high troughs\\n -- continue cipro\\n -- continue MS contin 15mg \\n -- ultram q6, Tylenol q8, Morphine for breakthrough (2-4 mg).\\n .\\n # Sacral Decub - stage 3-4.\\n - wound care\\n - pain control\\n .\\n # UTI: positive UA, no history of culture positive UA's in system\\n - treating empirically with cipro day 1 was . Last dose tomorrow\\n morning (Morning of ^st)\\n - watch INR on abx\\n .\\n # CORONARIES: Patient with h/o CAD w/ right dominant system, mild\\n instent re-stenois of the LAD BM stent and occluded RCA.\\n - bb as tolerated\\n .\\n # RHYTHM: Patient with h/o atrial fibrillation, s/p BiV ICD (\\n Concerto C154DWK) , on coumadin. Now in paced rhythm\\n - cont home dose meds (amio, metoprolol)\\n - cont coumadin\\n .\\n # Chronic Kidney Disease: Baseline Creatinine 1.3. Creatinine 1.1\\n today.\\n - trend\\n .\\n # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a\\n filter in place.\\n - continue Coumadin\\n .\\n # Hypothyroidism: Continue Levothyroxine\\n .\\n # Gout: continue Allopurinol\\n ICU Care\\n Nutrition:\\n Low Na diet\\n Glycemic Control: not on insulin\\n Lines:\\n Multi Lumen - 05:34 PM\\n Midline - 05:34 PM\\n 18 Gauge - 05:35 PM\\n Prophylaxis:\\n DVT: SQ UF Heparin\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Family meeting held , ICU consent signed Comments:\\n Code status: DNR / DNI\\n Disposition:ICU\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2180-01-17 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 400098,\n \"text\": \"71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\\n : Sent to ED from clinic w/ hypotension\\n transiently on\\n dopa, Tx\\nd w/ NS 250 cc w/ SBP ^ 92.\\n Admit to CCU for aggressive diuresis.She was started on Milrinone\\n and lasix gtt. And has been diuresing well. She has lg coccyx decub\\n that is a source of chronic pain. She is DNR/DNI and defibrillator has\\n been shut off. She has excellent apetite.\\n Pain control (acute pain, chronic pain)\\n Assessment:\\n Plan is to transition to oral forms of pain control in preparation for\\n pt going to rehab. She had received MS contin at 0600, but pill was\\n ground and pt had nausea. She received 4mg IV morphine at 6am as well.\\n She continues on standing acetominofen and ultram\\n Action:\\n MS contin will be given in to 15mg pills, which are smaller and can\\n take them without having them crushed. Morphine immediate release has\\n been ordered for breakthrough pain. It is also a small pill that she\\n can take without crushing. She had 15mg immediate release at 1300 . She\\n has had no IV morphine sulfate since 1030.\\n Response:\\n Pt has been pain free except when turned since then. She will have\\n acute pain with position change, but it will settle down and go away\\n within a few minutes. She received MS contin at 1800\\n Plan:\\n Continue to try to control pain with oral medications. Give immediate\\n release morphine for breakthrough pain.\\n Impaired Skin Integrity\\n Assessment:\\n Sacral wound getting worse and remains very painful. Mepilex dsg oozing\\n through. Acuacel added. Know MRSA infection on R knuckle and R elbow\\n appear to be much more reddened than last week. Over all skin is dry\\n and itchy.\\n Action:\\n Wound care nurse came to evaluate wound. Area is now cleansed with\\n wound cleanser and dried. Criticade antifungal is applied to wound\\n edges and peri-wound area. The wound is covered with aquacel AG and\\n then small soft-sorb pad. It is secured with medipore tape on skin that\\n has been prepped with barrier wipe. Finger and elbow are washed with\\n soap and water. Area kept lubricated. oil used in water. Moisture\\n barrier clean applied to body. Heels elevated off bed.\\n Response:\\n Skin less itchy. No further worsening of skin condition.\\n Plan:\\n .H/O heart failure (CHF), Systolic, Acute on Chronic\\n Assessment:\\n Pt being transition for transfer back to rehab. Milrinone and lasix\\n drips stopped at 1030.\\n Action:\\n At noon she received dose of torsemide 40mg po and metolazone 5mg po.\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2180-01-16 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 400017,\n \"text\": \"71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\\n recently discharged from the CCU () for CHF exacerbation c/b\\n C.diff infection and on for septic joint washout c/b failure to\\n extubate CHF exacerbation, who is now being admitted from \\n clinic with total body fluid overload.\\n .\\n Pain control (acute pain, chronic pain)\\n Assessment:\\n Patent\\ns primary wish is her comfort. Continues to favor her DNR/DNI\\n status.\\n Action:\\n Premedicated with 4 mg of MSO4 prior to all positon changes. Pain\\n med has been increased to 2-4 mg q1 hour if needed. Ms contin 15 mg q12\\n Response:\\n Moaning with position changes especially to the left side\\n Plan:\\n Discussions on going with patient and Dr regarding plan of care\\n .H/O heart failure (CHF), Systolic, Acute on Chronic\\n Assessment:\\n HR 70 AVP ..SBP 80\\ns/40\\n Action:\\n Lasix decreased to 5 mg/hr as urine output >200 cc q1 hour\\n Response:\\n 4200 cc negative at mdnight\\n Plan:\\n Continue on milrinone and lasix for fluid over load\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2180-01-16 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 400027,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n - MS Contin 15 , was getting 22 mg IV morph qday\\n - pulled EJ\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Ciprofloxacin - 08:00 AM\\n Vancomycin - 09:36 AM\\n Infusions:\\n Furosemide (Lasix) - 5 mg/hour\\n Milrinone - 0.5 mcg/Kg/min\\n Other ICU medications:\\n Morphine Sulfate - 06:40 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:58 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 36.6\\nC (97.9\\n Tcurrent: 36.6\\nC (97.8\\n HR: 70 (62 - 75) bpm\\n BP: 88/57(63) {78/43(52) - 106/66(76)} mmHg\\n RR: 23 (9 - 35) insp/min\\n SpO2: 97%\\n Heart rhythm: AV Paced\\n Wgt (current): 77.3 kg (admission): 82.2 kg\\n Total In:\\n 1,335 mL\\n 121 mL\\n PO:\\n 420 mL\\n TF:\\n IVF:\\n 915 mL\\n 121 mL\\n Blood products:\\n Total out:\\n 5,565 mL\\n 880 mL\\n Urine:\\n 5,565 mL\\n 880 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -4,230 mL\\n -759 mL\\n Respiratory support\\n O2 Delivery Device: None\\n SpO2: 97%\\n ABG: ///33/\\n Physical Examination\\n General Appearance: Well nourished, Overweight / Obese\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: Normocephalic\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Breath Sounds: Diminished: )\\n Abdominal: Soft, Obese\\n Extremities: Right lower extremity edema: Trace, Left lower extremity\\n edema: Trace\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 146 K/uL\\n 10.7 g/dL\\n 115 mg/dL\\n 1.1 mg/dL\\n 33 mEq/L\\n 3.8 mEq/L\\n 39 mg/dL\\n 92 mEq/L\\n 133 mEq/L\\n 33.1 %\\n 5.1 K/uL\\n [image002.jpg]\\n 05:44 AM\\n 04:46 AM\\n 04:00 PM\\n 03:05 AM\\n 03:17 PM\\n WBC\\n 6.1\\n 4.7\\n 5.1\\n Hct\\n 32.1\\n 31.9\\n 33.1\\n Plt\\n 156\\n 159\\n 146\\n Cr\\n 1.3\\n 1.4\\n 1.3\\n 1.2\\n 1.1\\n Glucose\\n 83\\n 104\\n 155\\n 115\\n Other labs:\\n PT / PTT / INR:18.4/29.1/1.7,\\n Ca++:8.3 mg/dL, Mg++:2.0 mg/dL, PO4:2.9 mg/dL\\n Assessment and Plan\\n 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\\n recently discharged from the CCU () for CHF exacerbation c/b\\n C.diff infection and on for septic joint washout c/b failure to\\n extubate CHF exacerbation, who is now being admitted from \\n clinic with total body fluid overload.\\n .\\n # sCHF exacerbation: Patient has history of CHF ischemic , \\n 10%, s/p BiV ICD ( Concerto C154DWK) 1/08with EF 10% which is\\n the likely cause of her fluid overload. Her rapid accumulation\\n underpins the severity of her condition and her severely unfavourable\\n hemodynamics. Her long term goals are comfort, though she still wishes\\n to participate in rehab. Her family recognizes that she is dying. Our\\n goal is diuresis which we will attempt aggressively, reassessing our\\n progress dynamically. She diuresed well on Lasix gtt on with net\\n neg 4L balance. LOS fluid balance -5L.\\n -- goal diuresis 1L negative today with lasix gtt\\n -- continue milrinone\\n -- continue metolazone 5mg daily\\n -- continue metoprolol tartrate 12.5mg PO BID\\n -- strict i/o's with foley\\n -- replete K to 5\\n -- PM electrolytes\\n -- family meeting with HCP prn\\n .\\n # Septic Joints: Patient with history +staph aureus in left shoulder\\n treated by washout and vancomycin, thus far 4 weeks of monotherapy. No\\n + blood cx since before . Major issue now is pain control.\\n -- continue vanc, was recently on 500 mg q12 and switched to q24 for\\n high troughs\\n -- continue cipro\\n -- increase MS contin to 30mg \\n -- ultram q6, Tylenol q8, Morphine for breakthrough (2-4 mg).\\n .\\n # Sacral Decub - stage 3-4.\\n - wound care\\n - increase MS contin to 30mg \\n - pain control\\n .\\n # UTI: positive UA, no history of culture positive UA's in system\\n - treating empirically with cipro day 1 was . Last dose tomorrow\\n morning (Morning of ^st)\\n - watch INR on abx\\n .\\n # CORONARIES: Patient with h/o CAD w/ right dominant system, mild\\n instent re-stenois of the LAD BM stent and occluded RCA.\\n - bb as tolerated\\n .\\n # RHYTHM: Patient with h/o atrial fibrillation, s/p BiV ICD (\\n Concerto C154DWK) , on coumadin. Now in paced rhythm\\n - cont home dose meds (amio, metoprolol)\\n - cont coumadin\\n .\\n # Chronic Kidney Disease: Baseline Creatinine 1.3. Creatinine 1.1\\n today.\\n - trend\\n .\\n # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a\\n filter in place.\\n - continue Coumadin\\n .\\n # Hypothyroidism: Continue Levothyroxine\\n .\\n # Gout: continue Allopurinol\\n ICU Care\\n Nutrition:\\n Low Na diet\\n Glycemic Control: not on insulin\\n Lines:\\n Multi Lumen - 05:34 PM\\n Midline - 05:34 PM\\n 18 Gauge - 05:35 PM\\n Prophylaxis:\\n DVT: SQ UF Heparin\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Family meeting held , ICU consent signed Comments:\\n Code status: DNR / DNI\\n Disposition:ICU\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2180-01-16 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 400029,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n - MS Contin 15 , was getting 22 mg IV morph qday\\n - pulled EJ\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Ciprofloxacin - 08:00 AM\\n Vancomycin - 09:36 AM\\n Infusions:\\n Furosemide (Lasix) - 5 mg/hour\\n Milrinone - 0.5 mcg/Kg/min\\n Other ICU medications:\\n Morphine Sulfate - 06:40 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:58 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 36.6\\nC (97.9\\n Tcurrent: 36.6\\nC (97.8\\n HR: 70 (62 - 75) bpm\\n BP: 88/57(63) {78/43(52) - 106/66(76)} mmHg\\n RR: 23 (9 - 35) insp/min\\n SpO2: 97%\\n Heart rhythm: AV Paced\\n Wgt (current): 77.3 kg (admission): 82.2 kg\\n Total In:\\n 1,335 mL\\n 121 mL\\n PO:\\n 420 mL\\n TF:\\n IVF:\\n 915 mL\\n 121 mL\\n Blood products:\\n Total out:\\n 5,565 mL\\n 880 mL\\n Urine:\\n 5,565 mL\\n 880 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -4,230 mL\\n -759 mL\\n Respiratory support\\n O2 Delivery Device: None\\n SpO2: 97%\\n ABG: ///33/\\n Physical Examination\\n General Appearance: Well nourished, Overweight / Obese\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: Normocephalic\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Breath Sounds: Diminished: )\\n Abdominal: Soft, Obese\\n Extremities: Right lower extremity edema: Trace, Left lower extremity\\n edema: Trace\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 146 K/uL\\n 10.7 g/dL\\n 115 mg/dL\\n 1.1 mg/dL\\n 33 mEq/L\\n 3.8 mEq/L\\n 39 mg/dL\\n 92 mEq/L\\n 133 mEq/L\\n 33.1 %\\n 5.1 K/uL\\n [image002.jpg]\\n 05:44 AM\\n 04:46 AM\\n 04:00 PM\\n 03:05 AM\\n 03:17 PM\\n WBC\\n 6.1\\n 4.7\\n 5.1\\n Hct\\n 32.1\\n 31.9\\n 33.1\\n Plt\\n 156\\n 159\\n 146\\n Cr\\n 1.3\\n 1.4\\n 1.3\\n 1.2\\n 1.1\\n Glucose\\n 83\\n 104\\n 155\\n 115\\n Other labs:\\n PT / PTT / INR:18.4/29.1/1.7,\\n Ca++:8.3 mg/dL, Mg++:2.0 mg/dL, PO4:2.9 mg/dL\\n Assessment and Plan\\n 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\\n recently discharged from the CCU () for CHF exacerbation c/b\\n C.diff infection and on for septic joint washout c/b failure to\\n extubate CHF exacerbation, who is now being admitted from \\n clinic with total body fluid overload.\\n .\\n # sCHF exacerbation: Patient has history of CHF ischemic , \\n 10%, s/p BiV ICD ( Concerto C154DWK) 1/08with EF 10% which is\\n the likely cause of her fluid overload. Her rapid accumulation\\n underpins the severity of her condition and her severely unfavourable\\n hemodynamics. Her long term goals are comfort, though she still wishes\\n to participate in rehab. Her family recognizes that she is dying. Our\\n goal is diuresis which we will attempt aggressively, reassessing our\\n progress dynamically. She diuresed well on Lasix gtt on with net\\n neg 4L balance. LOS fluid balance -5L.\\n -- goal diuresis 1L negative today with lasix gtt\\n -- continue milrinone\\n -- continue metolazone 5mg daily\\n -- continue metoprolol tartrate 12.5mg PO BID\\n -- strict i/o's with foley\\n -- replete K to 5\\n -- PM electrolytes\\n -- family meeting with HCP prn\\n .\\n # Septic Joints: Patient with history +staph aureus in left shoulder\\n treated by washout and vancomycin, thus far 4 weeks of monotherapy. No\\n + blood cx since before . Major issue now is pain control.\\n -- continue vanc, was recently on 500 mg q12 and switched to q24 for\\n high troughs\\n -- continue cipro\\n -- increase MS contin to 30mg \\n -- ultram q6, Tylenol q8, Morphine for breakthrough (2-4 mg).\\n .\\n # Sacral Decub - stage 3-4.\\n - wound care\\n - increase MS contin to 30mg \\n - pain control\\n .\\n # UTI: positive UA, no history of culture positive UA's in system\\n - treating empirically with cipro day 1 was . Last dose tomorrow\\n morning (Morning of ^st)\\n - watch INR on abx\\n .\\n # CORONARIES: Patient with h/o CAD w/ right dominant system, mild\\n instent re-stenois of the LAD BM stent and occluded RCA.\\n - bb as tolerated\\n .\\n # RHYTHM: Patient with h/o atrial fibrillation, s/p BiV ICD (\\n Concerto C154DWK) , on coumadin. Now in paced rhythm\\n - cont home dose meds (amio, metoprolol)\\n - cont coumadin\\n .\\n # Chronic Kidney Disease: Baseline Creatinine 1.3. Creatinine 1.1\\n today.\\n - trend\\n .\\n # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a\\n filter in place.\\n - continue Coumadin\\n .\\n # Hypothyroidism: Continue Levothyroxine\\n .\\n # Gout: continue Allopurinol\\n ICU Care\\n Nutrition:\\n Low Na diet\\n Glycemic Control: not on insulin\\n Lines:\\n Multi Lumen - 05:34 PM\\n Midline - 05:34 PM\\n 18 Gauge - 05:35 PM\\n Prophylaxis:\\n DVT: SQ UF Heparin\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Family meeting held , ICU consent signed Comments:\\n Code status: DNR / DNI\\n Disposition:ICU\\n ------ Protected Section ------\\n Cardiology Teaching Physician Note\\n On this day I saw, examined and was physically present with the\\n resident / fellow for the key portions of the services provided. I\\n agree with the above note and plans.\\n I would add the following remarks:\\n Above discussed extensively with patient.\\n DNR status discussed. DNR.\\n Total time spent on patient care: 45 minutes.\\n Additional comments:\\n Approaching 10 liters net negative fluid balance, which was our goal.\\n She is remarkably better in terms of appetite, breathing, and general\\n comfort level. Plan is for another 24 h milrinone plus Lasix gtt.\\n Then shut off milrinone and switch to torsemide 40 mg po bid plus\\n metolazone 2.5 mg qam. Anticipate discharge to rehab on Tuesday\\n ------ Protected Section Addendum Entered By: on:\\n 11:28 ------\\n\"\n },\n {\n \"category\": \"Social Work\",\n \"chartdate\": \"2180-01-17 00:00:00.000\",\n \"description\": \"Social Work Progress Note\",\n \"row_id\": 400096,\n \"text\": \"SOCIAL WORK: Following pt for coping with hospitalization and illness.\\n Pt know to this writer from previous admission in . Spoke with\\n pt's nurse . RN reports pt has had palliative care consult today.\\n Met w/ pt in her room on the CCU. niece was also\\n present. Pt was alert and oriented x3, made good eye contact. Pt\\n repeatedly states that she is very pleased with care at and\\n regrets that she cannot return to rehab. Pt gave limited\\n responses around her understanding of palliative care approach. She\\n deferred questions to her family members who help her with medical\\n decisions. Pt concerned about dispo plan. SW reassured pt that case\\n management will work with her family to make acceptable plan and SW\\n will communicate family's wishes.\\n Obtained contact numbers for all decision makers, HCP is \\n (pt's niece) ( (H), (\\n (C). Sister (, sister P. ( and niece . Family expressed wish that pt\\n go to House in .\\n Plan: -SW to provide emotional support for pt coping with the\\n transition from the hospital\\n -SW to further explore and provide support around palliative\\n care approach presented today\\n , MSW Intern\\n Pager \\n 05:36 PM\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2180-01-18 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 400171,\n \"text\": \"71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\\n : Sent to ED from clinic admit to CCU for aggressive\\n diuresis. She was started on Milrinone and lasix gtt, lasix and\\n milrinone gtts turned to off . Milrinone restarted d/t BP and U/O\\n decrease. Large Stage III decube on coccyx decub that is a source of\\n chronic pain. She is DNR/DNI and defibrillator has been shut off. Able\\n to swallow pills whole, with either applesauce or custard.\\n SOCIAL: Family in to visit. Pts HCP is in and intubated,\\n pt\\ns sister is alternate HCP.\\n control (acute pain, chronic pain)\\n Assessment:\\n On standing dose of morphine SR, ultram and Tylenol.\\n Action/Response:\\n Pain rated to be this am, then later in day .\\n Given supplemental IR morphine once and 2mg IV morphine once with\\n relief of pain.\\n Repositioned for comfort\\n Plan:\\n Continue pain control with oral medications. Give immediate release\\n morphine for breakthrough pain.\\n Impaired Skin Integrity\\n Assessment:\\n Stage III PU on coccyx, foul smelling, yellow sanguinous drainage,\\n edges of wound yellow with areas of necrosis. Surrounding skin\\n macerated. Pt. refusing kinair bed\\n Action/Response:\\n Dressing changed according to wound care RN\\ns recs:\\n anti-fungal barrier criticaid to macerated skin surrounding wound,\\n acqua cell-AG to coccyx, covered in soft sorb dsg, medipore tape.\\n Aloe Vesta to skin\\n Offered repositioning q 2 hours, often times refusing as she\\n is comfortable\\n Po\\ns encouraged, patient drinking hot chocolate, custard,\\n applesauce.\\n Plan:\\n QD dressing change as above. Aloe vesta to skin. Reposition q2 hours\\n or according to pt\\ns wishes.\\n .H/O heart failure (CHF), Systolic, Acute on Chronic\\n Assessment:\\n Pt DNR/DNI. SBP 90\\ns. Milrinone @ 0.5mcg/kg/min. U/O ~ 100cc q\\n 2hours.\\n Action/Response:\\n Dr. in to talk with patient and family extensively.\\n Milrinone turned to off. Torsemide and metzolone d/c\\n Palliative care MD in to talk with pt and\\n family.\\n Patient\\ns sisters at bedside most of afternoon.\\n SBP decreasing to low 80\\ns and then 70\\ns off milrinone, U/O\\n also tapering off. CCU resident notified, will hold off on IV fluids\\n unless pt c/o dizziness. Did c/o nausea X1\\nzofran with relief\\n Plan:\\n To remain in hospital for now. Will monitor off of milrinone with plan\\n to give IV NS 250 cc for hypotension as per Dr. . No other changes\\n in medications for now. Focus on comfort. Continue to support patient\\n and family.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2180-01-13 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 399691,\n \"text\": \"Pt is a 71 yo female with PMH: BM stent to LAD ', Occluded RCA\\n without intervention, Ischemic CM (EF 10-25%), BiV ICD, AF, PVD, DVT\\n s/p IVC filter, coumadin, hypothyroidism, CKD, OA. adm for HF\\n (milrinone/lasix) MRSA in L shoulder, L hip and R knuckle. Out to\\n rehab . Today went from rehab to see Dr. , sent to EW with\\n hypotension. SBP 70 in EW, transiently on dopa, but cardiology d/c'd.\\n Rxd with NS 250 cc with SBP 92. Pt has been in rehab since d/c from\\n with septic arthritis in L shoulder, hip and R knuckle.\\n On Vanco followed by ID.\\n Pain control (acute pain, chronic pain)\\n Assessment:\\n Pt given ultram/Tylenol at bedtime for overall pain and pain at coccyx\\n wound site. Appears comfortable and sleeping most of nite.\\n Action:\\n Given ultram and Tylenol as ordered- no prn MSO4 this shift.\\n Response:\\n Sleeping comfortably. Easy to fall back asleep, comfortable, even after\\n changing postion frequently throughout nite.\\n Plan:\\n Continue to closely monitor pain level. Medicate, reposition, emotional\\n support. Attempt to keep pt free of pain.\\n .H/O heart failure (CHF), Systolic, Acute on Chronic\\n Assessment:\\n Pt w long standing ESHD currently admitted from PCP office for LE\\n edema/hypotension for inotropy/diuresis.\\n Action:\\n Pt started on milrinone 0.375 gtt after 50 mcg/kg bolus- started on low\\n dose lasix gtt for diuresis once established that hemodynamics remained\\n stable w initiaton of milrinone gtt.\\n Response:\\n Pt\\ns hemodynamics remaining stable after milrinone gtt started- HR-\\n 70\\ns V paced, no significant VEA. BP 90/40\\n goal MAP > 60 met this\\n shift. Fair uo from lasix- increased from 2.5-5 mg/hr per team ordered.\\n Plan:\\n Continue to closely monitor hemodynamics, level of edema/volume\\n overload and attempt to diurese w lasix gtt. Consider bolus? Of lasix\\n as well as increasing gtt and/or adding zaroxylin to augment response\\n to lasix gtt. Keep pt and family aware of plan of care, current\\n progress.\\n Impaired Skin Integrity\\n Assessment:\\n Pt admitted to CCU w stage 3 coccyx wound. Currently dressed w mepiplex\\n after cleaning site. Dressing remains dry/intact.\\n Action:\\n Frequent turning side to side w 2 assist- fair tolerance of turning,\\n not assisting w turning, and wanting to be\\nleft alone and let me\\n sleep\\n. Applied aloe vesta to back/hips/bony prominences. Applied\\n waffle boots to bilateral feet to prevent edematous heels from breaking\\n down.\\n Response:\\n Dressing remains dry/intact.\\n Plan:\\n Continue to protect skin at risk. Continue to treat current wound w\\n dressing as currently are doing. Consult w skin care RN. Of note- pt\\n refuses kinair bed.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2180-01-14 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 399764,\n \"text\": \"Pt is a 71 yo female with PMH: BM stent to LAD ', Occluded RCA\\n without intervention, Ischemic CM (EF 10-25%), BiV ICD, AF, PVD, DVT\\n s/p IVC filter, coumadin, hypothyroidism, CKD, OA. adm for HF\\n (milrinone/lasix) MRSA in L shoulder, L hip and R knuckle. Out to\\n rehab . went from rehab to see Dr. , sent to EW with\\n hypotension. SBP 70 in EW, transiently on dopa, but cardiology d/c'd.\\n Rxd with NS 250 cc with SBP 92. Pt has been in rehab since d/c from\\n with septic arthritis in L shoulder, hip and R knuckle.\\n On Vanco followed by ID.\\n She was started on milrinone .375 after bolus and lasix drip also begun\\n at 2.5mg/hr. The lasix dose was increased to 5mg overnight, but urine\\n output has remained poor, though she is negative.\\n GI: Pt has poor apetite and eats very little.\\n SOCIAL: Family in the visit in afternoon. Pt in good spirits, visiting\\n with brother and his family.\\n CODE STATUS: Dr had discussion with both patient and health care\\n proxy and all are in agreement that she be DNR/DNI. Additionally the\\n defibrillator part of AICD/pacer was shut off.\\n Pain control (acute pain, chronic pain)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Impaired Skin Integrity\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n .H/O heart failure (CHF), Systolic, Acute on Chronic\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2180-01-12 00:00:00.000\",\n \"description\": \"Physician Resident Admission Note\",\n \"row_id\": 399684,\n \"text\": \"Chief Complaint: Fluid overload\\n HPI:\\n 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\\n recently discharged from the CCU () for CHF exacerbation c/b\\n C.diff infection and on for septic joint washout c/b failure to\\n extubate CHF exacerbation, who is now being admitted from \\n clinic with total body fluid overload.\\n .\\n Ms. is a resident at NE where she is convalescing from a\\n polyarticular MRSA septic arthritis. She has NYHA IV CHF at baseline\\n but over the last 4 days has developed 4+ LE edema and ascites where\\n there was previously none. She was presented with the choice to pursue\\n cardiac transplantation more than 12 years ago when given the diagnosis\\n of end-stage CHF. She opted against that.\\n .\\n Per her recent visit note at clinic, she continues to have L\\n shoulder pain, though significantly improved from a few weks ago. She\\n continues to work with PT to improve her ROM. She has no pain at her R\\n 3rd MCP, though has difficulty extending her finger at that joint. She\\n continues to have mild pain and significant weakness at her L\\n hip, though improved since hospital discharge. She has had no\\n F/C/NS, and no problems with her midline. She has had progression\\n of a sacral decub, which gives her the majority of her pain.\\n There has not been concern on the part of her rehab for\\n superinfection, and it is being treated with local wound care and\\n frequent turning. Her sister is hoping to transfer her to \\n within the next several days.\\n Patient admitted from: ER\\n History obtained from Patient, Family / Medical records\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Milrinone - 0.375 mcg/Kg/min\\n Other ICU medications:\\n Other medications:\\n Past medical history:\\n Family history:\\n Social History:\\n 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension\\n 2. CARDIAC HISTORY:\\n -CABG: None\\n -PERCUTANEOUS CORONARY INTERVENTIONS: BM stent to the LAD in ,\\n Occluded RCA/no intervention\\n -PACING/ICD: Ischemic cardiomyopathy (EF 10%) s/p BiV ICD and atrial\\n fibrillation\\n 3. H/o PE secondary to DVT s/p IVC filter on Coumadin\\n 4. PVD\\n 5. Small VSD\\n OTHER\\n # Septic Polyarticular Arthritis s/p irrigation and debridement left\\n shoulder via anterolateral deltopectoral miniarthrotomy, aspiration\\n left hip joint and irrigation and debridement of 3rd\\n metacarpophalangeal joint\\n 6. Hypothyroidism\\n 7. CKD\\n 8. Osteoarthritis\\n Mother had MI at age 50, maternal uncle died of MI in his 50's.\\n No family history of arrhythmia, cardiomyopathies, or sudden cardiac\\n death; otherwise non-contributory.\\n Occupation: retired\\n Drugs: none\\n Tobacco: 20 pack year history, however she quit 30 yrs ago\\n Alcohol: none\\n Other: Pt lives alone but currently resides at NE . She is not\\n married. She is cared for primarily by her Niece and sister, both\\n nurses.\\n Review of systems:\\n Constitutional: Fatigue\\n Integumentary (skin): painful decub's\\n Flowsheet Data as of 08:40 PM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since AM\\n Tmax: 35.4\\nC (95.8\\n Tcurrent: 35.4\\nC (95.8\\n HR: 70 (70 - 108) bpm\\n BP: 83/50(58) {83/50(58) - 109/76(84)} mmHg\\n RR: 12 (11 - 18) insp/min\\n SpO2: 100%\\n Heart rhythm: V Paced\\n Wgt (current): 82.2 kg (admission): 82.2 kg\\n Total In:\\n 284 mL\\n PO:\\n 30 mL\\n TF:\\n IVF:\\n 4 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 350 mL\\n Urine:\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n -66 mL\\n Respiratory\\n O2 Delivery Device: None\\n SpO2: 100%\\n Physical Examination\\n General Appearance: Thin, Anxious, Cachectic, tearful\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: Normocephalic\\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic), II/VI\\n systolic murmur best at apex. PMI is laterally displaced\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear :\\n anteriorly)\\n Abdominal: Soft, Non-tender, Distended, +fluid wave\\n Extremities: Right lower extremity edema: 4+, Left lower extremity\\n edema: 4+, cool, dry\\n Skin: Cool, Stage 3+ sacral decub\\n Neurologic: Attentive, Responds to: Not assessed, Oriented (to): x3,\\n Movement: Not assessed, Tone: Not assessed\\n Labs / Radiology\\n [image002.jpg]\\n Imaging: TTE :\\n The left atrium is elongated. The right atrium is markedly dilated. The\\n interatrial septum is aneurysmal. The estimated right atrial pressure\\n is 10-20mmHg. Left ventricular wall thicknesses are normal. The left\\n ventricular cavity is moderately dilated with severe global\\n hypokinesis. The basal inferolateral wall contracts best (LVEF = 20 %).\\n The estimated cardiac index is borderline low (2.0-2.5L/min/m2). No\\n masses or thrombi are seen in the left ventricle. The right ventricular\\n cavity is moderately dilated with severe global free wall hypokinesis.\\n [Intrinsic right ventricular systolic function is likely more depressed\\n given the severity of tricuspid regurgitation.] The ascending aorta is\\n mildly dilated. The aortic valve leaflets (3) are mildly thickened but\\n aortic stenosis is not present. Trace aortic regurgitation is seen. The\\n mitral valve leaflets are mildly thickened. There is no mitral valve\\n prolapse. Mild to moderate (+) mitral regurgitation is seen.\\n Moderate to severe [3+] tricuspid regurgitation is seen. There is\\n moderate pulmonary artery systolic hypertension. Significant pulmonic\\n regurgitation is seen. There is a very small circumferential\\n pericardial effusion without echocardiographic signs of tamponade.\\n Compared with the prior study (images reviewed) of ,\\n estimated pulmonary artery systolic pressure is now higher.\\n .\\n ETT: \\n INTERPRETATION: This 64 year old woman with a history of CAD, atrial\\n fibrillation and CHF was referred to the lab for evaluation. The\\n patient exercised for 4.25 minutes of a modified protocol and\\n requested the test be stopped for nausea. The resting oxygen\\n consumption was 3.2 ml/kg/min with a respiratory exchange ratio of\\n 0.75. At peak exercise, her oxygen consumption increased to 11.0\\n ml/kg/min with an expiratory exchange ratio of 0.86. The peak oxygen\\n consumption was 45 % of predicted. The oxygen consumption at the onset\\n of the anerobic threshold was 9.9 ml/kg/min. This test was not limited\\n by muscle fatigue. No arm, neck, back or chest discomfort was reported\\n by the patient throughout the study. The ST segments are\\n uninterpretable for ischemia in the setting of the baseline LBBB. The\\n rhythm was atrial fibrillation with several isolated vpbs and 2\\n ventricular couplets. Blunted systolic BP response to exercise.\\n IMPRESSION: Very limited physical working capacity in the absence of\\n angina.\\n .\\n CARDIAC CATH:\\n LHC/RHC :\\n 1. Selective coronary angiography of this right dominant system\\n revealed one vessel coronary artery disease. The LMCA had no\\n angiographically apparent disease. The LAD had mild instent restenosis\\n of the prior stent. The LCx had no angiographically apparent disease.\\n The RCA was occluded and similar to prior.\\n 2. Resting hemodynamics on milrinone therapy revealed moderately\\n elevated right and left sided filling pressures with an RVEDP of\\n 15 mmHg and PCWP of 20 mmHg. There was moderate pulmonary hypertension\\n with a PASP of 42/20 mmHg. There was normal systemic blood pressure\\n with central pressure of 108/63 mmHg. There was a low-normal cardiac\\n index of 2.1 L/min/m2. There was no transaortic valve gradient on\\n careful pullback from LV to aorta.\\n 3. Peripheral angiography revealed patent renal arteries bilaterally.\\n .\\n MYOCARDIAL VIABILITY STUDY :\\n Within limitation of current study, fixed defects in distal anterior\\n and apical walls are consistent with scarring. Improvement of inferior\\n wall defect with correction is suggestive of myocardial viability.\\n Microbiology: Hx of MRSA bacteremia, septic arthritis\\n Assessment and Plan\\n ASSESSMENT AND PLAN\\n 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\\n recently discharged from the CCU () for CHF exacerbation c/b\\n C.diff infection and on for septic joint washout c/b failure to\\n extubate CHF exacerbation, who is now being admitted from \\n clinic with total body fluid overload.\\n .\\n # Anasarca: Patient has history of CHF ischemic , 10%, s/p\\n BiV ICD ( Concerto C154DWK) 1/08with EF 10% which is the\\n likely cause of her fluid overload. Her rapid accumulation underpins\\n the severity of her condition and her severely unfavourable\\n hemodynamics. Her long term goals are comfort, though she still wishes\\n to participate in rehab. Her family recognizes that she is dying. Our\\n goal is diuresis which we will attempt aggressively, reassessing our\\n progress dynamically.\\n -- milrinone with bolus\\n -- neosynephrine for pressure support, goal MAP of > 60\\n -- slow uptitration of lasix with goal near-continuous diuresis while\\n avoiding MAP < 60\\n -- strict i/o's with foley\\n -- can switch to levophed if low UOP on Neo with need for pressor\\n support\\n -- family meeting with HCP to assess goals in AM after diuresis\\n attempted\\n .\\n # Septic Joints: Patient with history +staph aureus in left shoulder\\n treated by washout and vancomycin, thus far 4 weeks of monotherapy. No\\n + blood cx since before . Major issue now is pain control.\\n -- send Vanco level in AM, was recently on 500 mg q12 and switched to\\n q24 for high troughs\\n -- ultram q6, Tylenol q8, Morphine for breakthrough (1-3 mg).\\n - Will consider ms contin if no control\\n .\\n # CORONARIES: Patient with h/o CAD w/ right dominant system, mild\\n instent re-stenois of the LAD BM stent and occluded RCA.\\n - bb as tolerated\\n .\\n # RHYTHM: Patient with h/o atrial fibrillation, s/p BiV ICD (\\n Concerto C154DWK) , on coumadin. Now in paced rhythm\\n - cont home dose meds (amio, metoprolol)\\n - cont coumadin\\n - f/u INR\\n .\\n # Chronic Kidney Disease: Baseline 1.3 creatinine. At baseline\\n - trend\\n .\\n # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a\\n filter in place.\\n - cont coumadin\\n - f/u INR\\n .\\n # Hypothyroidism: Continue Levothyroxine.\\n .\\n # Gout: continue allopurionl\\n .\\n # FEN: low sodium diet\\n .\\n # ACCESS: Right PICC, right IJ, Left EJ\\n .\\n # PROPHYLAXIS: on coumadin\\n .\\n # CODE: DNR, can intubate, briefly\\n .\\n # DISPO: CCU for now.\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 05:34 PM\\n Midline - 05:34 PM\\n 18 Gauge - 05:35 PM\\n Prophylaxis:\\n DVT: (Systemic anticoagulation: Coumadin)\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: DNR (do not resuscitate)\\n Disposition: ICU\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2180-01-12 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 399685,\n \"text\": \"Pt is a 71 yo female with PMH: BM stent to LAD ', Occluded RCA\\n without intervention, Ischemic CM (EF 10-25%), BiV ICD, AF, PVD, DVT\\n s/p IVC filter, coumadin, hypothyroidism, CKD, OA. adm for HF\\n (milrinone/lasix) MRSA in L shoulder, L hip and R knuckle. Out to\\n rehab . Today went from rehab to see Dr. , sent to EW with\\n hypotension. SBP 70 in EW, transiently on dopa, but cardiology d/c'd.\\n Rxd with NS 250 cc with SBP 92. Pt has been in rehab since d/c from\\n with septic arthritis in L shoulder, hip and R knuckle.\\n On Vanco followed by ID.\\n Pain control (acute pain, chronic pain)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n .H/O heart failure (CHF), Systolic, Acute on Chronic\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Impaired Skin Integrity\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2180-01-17 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 400114,\n \"text\": \"71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\\n : Sent to ED from clinic w/ hypotension\\n transiently on\\n dopa, Tx\\nd w/ NS 250 cc w/ SBP ^ 92.\\n Admit to CCU for aggressive diuresis.She was started on Milrinone\\n and lasix gtt. And has been diuresing well. She has lg coccyx decub\\n that is a source of chronic pain. She is DNR/DNI and defibrillator has\\n been shut off.\\n Pain control (acute pain, chronic pain)\\n Assessment:\\n Family deciding if pt will now be CMO and go to extended care facility\\n with hospice.\\n Action:\\n Response:\\n Plan:\\n .H/O heart failure (CHF), Systolic, Acute on Chronic\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Impaired Skin Integrity\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2180-01-14 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 399833,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n - confirmed DNR, acemaker turned off\\n - despite lasix gtt, diuresis poor yesterday\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Vancomycin - 08:00 AM\\n Ciprofloxacin - 08:00 AM\\n Infusions:\\n Other ICU medications:\\n Coumadin (Warfarin) - 04:00 PM\\n Lansoprazole (Prevacid) - 04:00 PM\\n Morphine Sulfate - 05:05 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 08:40 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 36.6\\nC (97.9\\n Tcurrent: 36.4\\nC (97.5\\n HR: 99 (66 - 104) bpm\\n BP: 91/50(60) {82/42(45) - 101/67(120)} mmHg\\n RR: 12 (11 - 23) insp/min\\n SpO2: 99%\\n Heart rhythm: V Paced\\n Wgt (current): 82.2 kg (admission): 82.2 kg\\n Total In:\\n 1,554 mL\\n 456 mL\\n PO:\\n 900 mL\\n 60 mL\\n TF:\\n IVF:\\n 654 mL\\n 396 mL\\n Blood products:\\n Total out:\\n 1,628 mL\\n 1,505 mL\\n Urine:\\n 1,628 mL\\n 1,505 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -74 mL\\n -1,049 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 99%\\n ABG: ///27/\\n Physical Examination\\n General Appearance: No acute distress, thin, cachectic\\n Head, Ears, Nose, Throat: Normocephalic\\n Cardiovascular: II/VI systolic murmur best at apex. MI is laterally\\n displaced\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\\n Respiratory / Chest: (Breath Sounds: Clear : anteriorly)\\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\\n Extremities: Right lower extremity edema: 2+, Left lower extremity\\n edema: 2+\\n Skin: Not assessed, Stage 3 sacral decubitus ulcer\\n Neurologic: Attentive, Responds to: Not assessed, Oriented (to): x3\\n Labs / Radiology\\n 159 K/uL\\n 10.0 g/dL\\n 104 mg/dL\\n 1.4 mg/dL\\n 27 mEq/L\\n 3.8 mEq/L\\n 42 mg/dL\\n 98 mEq/L\\n 134 mEq/L\\n 31.9 %\\n 4.7 K/uL\\n [image002.jpg]\\n 05:44 AM\\n 04:46 AM\\n WBC\\n 6.1\\n 4.7\\n Hct\\n 32.1\\n 31.9\\n Plt\\n 156\\n 159\\n Cr\\n 1.3\\n 1.4\\n Glucose\\n 83\\n 104\\n Other labs: PT / PTT / INR:16.8/29.3/1.5, Ca++:8.0 mg/dL, Mg++:2.1\\n mg/dL, PO4:3.3 mg/dL\\n Assessment and Plan\\n 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\\n recently discharged from the CCU () for CHF exacerbation c/b\\n C.diff infection and on for septic joint washout c/b failure to\\n extubate CHF exacerbation, who is now being admitted from \\n clinic with total body fluid overload.\\n .\\n # sCHF exacerbation: Patient has history of CHF ischemic , \\n 10%, s/p BiV ICD ( Concerto C154DWK) 1/08with EF 10% which is\\n the likely cause of her fluid overload. Her rapid accumulation\\n underpins the severity of her condition and her severely unfavourable\\n hemodynamics. Her long term goals are comfort, though she still wishes\\n to participate in rehab. Her family recognizes that she is dying. Our\\n goal is diuresis which we will attempt aggressively, reassessing our\\n progress dynamically. She put out very little o/n on lasix gtt. This\\n could reflect limitatin of diuresis or the importance of a bolus (we\\n withheld bolus to avoid instability)\\n -- goal diuresis 5 to 10L total\\n -- milrinone with bolus\\n -- metoprolol tartrate 12.5mg PO BID\\n -- slow uptitration of lasix gtt with goal near-continuous diuresis\\n while avoiding MAP < 60\\n -- strict i/o's with foley\\n -- replete K to 5\\n -- PM electrolytes\\n -- can switch to levophed if low UOP on Neo with need for pressor\\n support\\n -- family meeting with HCP to assess goals in AM after diuresis\\n attempted\\n .\\n # Septic Joints: Patient with history +staph aureus in left shoulder\\n treated by washout and vancomycin, thus far 4 weeks of monotherapy. No\\n + blood cx since before . Major issue now is pain control.\\n -- send Vanco level in AM, was recently on 500 mg q12 and switched to\\n q24 for high troughs\\n -- ultram q6, Tylenol q8, Morphine for breakthrough (2-4 mg).\\n - Will consider ms contin if no control\\n .\\n # Sacral Decub - stage 3-4.\\n - wound care\\n - pain control.\\n .\\n # UTI: positive UA, no history of culture positive UA's in system\\n - treating empirically with cipro\\n - watch INR on abx\\n .\\n # CORONARIES: Patient with h/o CAD w/ right dominant system, mild\\n instent re-stenois of the LAD BM stent and occluded RCA.\\n - bb as tolerated\\n .\\n # RHYTHM: Patient with h/o atrial fibrillation, s/p BiV ICD (\\n Concerto C154DWK) , on coumadin. Now in paced rhythm\\n - cont home dose meds (amio, metoprolol)\\n - cont coumadin\\n - f/u INR\\n .\\n # Chronic Kidney Disease: Baseline 1.3 creatinine. At baseline\\n - trend\\n .\\n # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a\\n filter in place.\\n - continue Coumadin\\n - f/u INR\\n .\\n # Hypothyroidism: Continue Levothyroxine\\n .\\n # Gout: continue Allopurinol\\n ICU Care\\n Nutrition: cardiac diet\\n Glycemic Control: None\\n Lines:\\n Multi Lumen - 05:34 PM\\n Midline - 05:34 PM\\n 18 Gauge - 05:35 PM\\n Prophylaxis:\\n DVT: Coumadin\\n Stress ulcer: Lansoprazole\\n VAP:\\n Comments:\\n Communication: patient\\n Code status: DNR/DNI\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2180-01-16 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 400046,\n \"text\": \"71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\\n : Sent to ED from clinic w/ hypotension\\n transiently on\\n dopa, Tx\\nd w/ NS 250 cc w/ SBP ^ 92. Admit to CCU for aggressive\\n diuresis.\\n Pain control (acute pain, chronic pain)\\n Assessment:\\n Pt needing less doses IV Morphine since MS Contin increased to 30mg \\n this morning\\n Pt consistently states pain is at coccyx\\n immediate area of pressure\\n ulcer and nowhere else\\n Action:\\n Received MS Contin 15mg x 2 this AM\\n Continues on Tylenol 1000mg po TID, Ultram 50mg QID\\n Received Morphine IV 4mg approx every 2 hours this am x total 4 doses\\n none since approx 1245\\n Response:\\n Pt appears more comfortable this PM\\n able to turn w/o premedicating with IV Morphine\\n Pt states pain is which she states is good for her\\n Plan:\\n Cont assess pain, cont ATC meds and supplement with IV Morphine as\\n needed\\n ? etiology of severe pain\\n ESR ordered to r/o osteo\\n .H/O heart failure (CHF), Systolic, Acute on Chronic\\n Assessment:\\n Pt asystomatic\\n no SOB with stable VS\\n Action:\\n Milrinone remains at 0,5mcgs/kg/min\\n Lasix increased from 5 to 10mg/hr\\n Response:\\n Initial urine output ~ 200cc/hr in AM\\n now decreased to 20-40cc/hr,\\n Lasix gtt titrated back to 10mg/hr with slight increase output\\n Plan:\\n Cont IV Lasix/Mirinone overnight and D/C in AM\\n Transition to oral regimen, Assess response\\n Impaired Skin Integrity\\n Assessment:\\n Large unstageable pressur ulcer on coccyx unchanged\\n Bilat heels remain reddened but blanchble\\n Old abrasion to r elbow\\n Action:\\n dressing coming off\\n cleansed and redressed this AM-duoderm\\n gel/Mepilex,\\n mod amt sero-sanguinous drainage; redness/maceration to surrounding\\n tissue\\n severe pain at site\\n see above\\n Response:\\n Site remains unchanged\\n Plan:\\n Cont keep PU clean with intact dressing, frequent turns avoiding back\\n except when pt sitting upright for meals\\n Wound care RN consult in AM\\n Roho cushion ordered from PT\\n unavailable today\\n Ineffective Coping\\n Assessment:\\n Pt continues to have periods in day when she has difficulty coping with\\n plan to return to rehab\\n Action:\\n Pt allowed to verbalize feelings about rehab, realizes she is unable to\\n return home\\n Response:\\n Pt appears to have periods of\\nmeltdown\\n with periods of rational\\n thought regarding needs and abilities going forward\\n Plan:\\n Case Manager consult in AM\\n Social Service consult in AM.\\n Cont to provide emotional support for patient.\\n Of note, pt w/o bowel movement x 4 days, appetite good, abdomen soft,\\n non-tender with + BS, lots of belching at dinner, Senna given 3x since\\n yesterday; Plan: increase bowel regimen given ^ nacotics; cont to\\n follow.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2180-01-19 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 400237,\n \"text\": \"71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\\n coumadin, hypothyroidism, CKD, OA. admitted for septic joint\\n washout- MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\\n On pt. was sent to ED from clinic w/ hypotension\\n transiently on dopa, Tx\\nd w/ NS 250 cc w/ SBP ^ 92.\\n Admit to CCU for aggressive diuresis. She was started on\\n Milrinone and lasix gtt. She has large coccyx decub that is a source\\n of chronic pain. She is DNR/DNI and defibrillator has been shut off.\\n Pain control (acute pain, chronic pain)\\n Assessment:\\n Pt. with history of pain in left shoulder, left hip (septic joints) and\\n coccyx (decub.).\\n Action:\\n MS , morphine IR 15mg for breakthrough pain, given this x2\\n today. Pt. also given 2mg IV morphine prior to all activity/turning\\n today. Pt. receiving ultram qid.\\n Response:\\n Pt. has denied pain today until 1500\\n she reported pain after turning\\n despite premedicating. Tolerating above with no ill-effects.\\n Plan:\\n Continue present around-the-clock and prn regimen.\\n .H/O heart failure (CHF), Systolic, Acute on Chronic\\n Assessment:\\n Off lasix gtt since , and milrinone since . AV paced at 70 with\\n BP 90\\ns/60\\ns today. LS essentially clear, some fine ?dependent\\n crackles noted at bases. Skin warm, dry. UO approximately 20cc/hr.\\n Action:\\n Given all meds this a.m. Assessment ongoing.\\n Response:\\n Pt. tolerating medication. Assessment unchanged.\\n Plan:\\n Continue to monitor and treat as indicated. Transfer to floor today.\\n Impaired Skin Integrity\\n Assessment:\\n Pt. with sacral decub as documented in metavision.\\n Action:\\n Dressing changed today at noon per skin care recs. Pt. turned side to\\n side as documented.\\n Response:\\n Pt. tolerated dressing change, premedicated with morphine IV.\\n Moderated amt. yellow-white slough noted. Small amounts drainage\\n noted.\\n Plan:\\n Continue daily dressing changes skin RN. Continue turning as pt.\\n tolerates, avoid pressure points.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2180-01-19 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 400224,\n \"text\": \"71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\\n coumadin, hypothyroidism, CKD, OA. admitted for septic joint\\n washout- MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\\n On pt. was sent to ED from clinic w/ hypotension\\n transiently on dopa, Tx\\nd w/ NS 250 cc w/ SBP ^ 92.\\n Admit to CCU for aggressive diuresis. She was started on\\n Milrinone and lasix gtt. She has large coccyx decub that is a source\\n of chronic pain. She is DNR/DNI and defibrillator has been shut off.\\n Pain control (acute pain, chronic pain)\\n Assessment:\\n Pt. with history of pain in left shoulder, left hip (septic joints) and\\n coccyx (decub.).\\n Action:\\n MS , morphine IR 15mg for breakthrough pain, given this\\n a.m. Pt. also given 2mg IV morphine prior to all activity/turning\\n today. Pt. receiving ultram qid.\\n Response:\\n Pt. has denied pain today, tolerating above with no ill-effects.\\n Plan:\\n Continue present around-the-clock and prn regimen.\\n .H/O heart failure (CHF), Systolic, Acute on Chronic\\n Assessment:\\n Off lasix gtt since , and milrinone since . AV paced at 70 with\\n BP 90\\ns/60\\ns today. LS essentially clear, some fine dependent crackles\\n noted at bases. Skin warm, dry.\\n Action:\\n P\\n Response:\\n Plan:\\n Impaired Skin Integrity\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2180-01-19 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 400225,\n \"text\": \"Chief Complaint: Congestive heart failure\\n 24 Hour Events:\\n - DCed milrinone and diuretics 11:30am\\n - Family mtg held with patient's 3 sisters and multiple other family\\n members, Dr. , then (P&PC) Dr. --> everybody in\\n agreement w plan to DC milrinone, to give small 250cc boluses as needed\\n if BP drops and morphine for symptoms if lungs become overloaded w\\n fluid ; Hold on Rehab for now\\n - Likely transfer pt to floor tomorrow w PPC following\\n - BPs still stable 88-96 SBP (maps>60) at 1am, though family had been\\n concerned occasionally that she looked like she had more difficulty\\n breathing or increased apneic episodes, though nursing does not feel\\n that she has had any difficulty breathing (pt has not needed any 250cc\\n boluses at this point)\\n - 0430am systolic BPs low 70s, but mentating well, not symptomatic -->\\n 1 bag 250ccs NS\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Vancomycin - 08:00 AM\\n Ciprofloxacin - 10:00 AM\\n Infusions:\\n Other ICU medications:\\n Morphine Sulfate - 06:31 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:54 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 36.7\\nC (98.1\\n Tcurrent: 35.6\\nC (96\\n HR: 71 (68 - 101) bpm\\n BP: 79/58(62) {73/42(51) - 107/73(77)} mmHg\\n RR: 11 (9 - 23) insp/min\\n SpO2: 92%\\n Heart rhythm: V Paced\\n Wgt (current): 73.6 kg (admission): 82.2 kg\\n Height: 60 Inch\\n Total In:\\n 743 mL\\n 370 mL\\n PO:\\n 600 mL\\n 120 mL\\n TF:\\n IVF:\\n 143 mL\\n 250 mL\\n Blood products:\\n Total out:\\n 1,190 mL\\n 200 mL\\n Urine:\\n 1,190 mL\\n 200 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -447 mL\\n 170 mL\\n Respiratory support\\n O2 Delivery Device: None\\n SpO2: 92%\\n ABG: ////\\n Physical Examination\\n Gen: alert, oriented x3, pleasant, cachectic chronically ill appearing\\n woman. In no acute distress.\\n HEENT: dry mucus membranes\\n NECK: JVP unable to be assessed secondary to line\\n CHEST: clear to auscultation bilaterally\\n ABD: mildly distended, soft, nontender\\n EXT: + pitting edema lower extremity edema bilaterally\\n Labs / Radiology\\n 116 K/uL\\n 10.2 g/dL\\n 93 mg/dL\\n 1.0 mg/dL\\n 35 mEq/L\\n 3.8 mEq/L\\n 32 mg/dL\\n 91 mEq/L\\n 132 mEq/L\\n 31.2 %\\n 4.6 K/uL\\n [image002.jpg]\\n 05:44 AM\\n 04:46 AM\\n 04:00 PM\\n 03:05 AM\\n 03:17 PM\\n 03:05 AM\\n 05:03 PM\\n 05:22 AM\\n 05:25 PM\\n 05:40 AM\\n WBC\\n 6.1\\n 4.7\\n 5.1\\n 4.4\\n 4.2\\n 4.6\\n Hct\\n 32.1\\n 31.9\\n 33.1\\n 32.2\\n 30.9\\n 31.2\\n Plt\\n 156\\n 159\\n 146\\n 134\\n 106\\n 116\\n Cr\\n 1.3\\n 1.4\\n 1.3\\n 1.2\\n 1.1\\n 1.0\\n 1.0\\n 1.0\\n 1.1\\n 1.0\\n Glucose\\n 83\\n 104\\n 155\\n 115\\n 98\\n 107\\n 86\\n 93\\n Other labs: PT / PTT / INR:19.1/29.7/1.7, Ca++:8.1 mg/dL, Mg++:2.1\\n mg/dL, PO4:2.8 mg/dL\\n Assessment and Plan\\n 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\\n recently discharged from the CCU () for CHF exacerbation c/b\\n C.diff infection and on for septic joint washout c/b failure to\\n extubate CHF exacerbation, who was admitted from clinic with\\n total body fluid overload.\\n .\\n # sCHF Exacerbation:\\n Patient has history of CHF ischemic , 10%, s/p BiV ICD\\n ( Concerto C154DWK) with EF 10% which was the likely\\n cause of her fluid overload. Appears euvolemic currently. Has\\n diuresed well -9L on length of stay. Responding well to torsemide with\\n metolazone while on milrinone, but urine output had dropped without\\n milrinone on . Diuresed net -500cc over last day. Breathing\\n comfortably currently.\\n - blood pressure maintained without milrinone, will continue to support\\n with IV fluids as needed\\n - will start on 20mg torsemide daily for maintenance of volume status.\\n .\\n # Goals of Care:\\n End-stage CHF with long term goals are comfort, though she still wishes\\n to participate in rehab. Her family recognizes that she is dying. Pain\\n and Palliative Care consulted on for pain control and goals of\\n care.\\n - appreciate palliative care recommendations\\n - call-out to floor on for continued comfort measures. Current\\n status remains to continue interventions for acute treatable problems,\\n but not to re-escalate treatment for CHF with milrinone.\\n - will consider disconnecting IJ for comfort\\n .\\n # Septic Joints: Patient with history +staph aureus in left shoulder\\n treated by washout and vancomycin, thus far 4 weeks of monotherapy. No\\n + blood cx since before . Major issue now is pain control.\\n - continue vancomycin until , then suppression with doxycycline\\n - appreciate ID recommendations.\\n -- continue MS contin 30mg and reassess pain med needs\\n -- standing ultram q6, Tylenol q8\\n .\\n # Sacral Decub - stage 3-4. Focusing on Pain control. Pain and\\n Palliative Care following with patient. Switched to oral breakthrough\\n Morphine with IV as backup. Patient required IV morphine this morning\\n while moving.\\n - wound care\\n - standing ultram Q6h, Tylenol Q8h\\n - reassess patient\\ns pain requirements\\n - continue with oral morphine, will use IV as needed now that patient\\n primary goal is comfort.\\n .\\n # UTI: positive UA, no history of culture positive UA's in system.\\n Will do 10day course because of chronic foley.\\n - treating empirically with cipro ; day 1 of 10 day course was \\n - watch INR on abx\\n .\\n # Hx CAD:\\n Patient with h/o CAD w/ right dominant system, mild instent re-stenois\\n of the LAD BM stent and occluded RCA.\\n - continue metoprolol 25mg \\n .\\n # Hx Afib:\\n Patient with h/o atrial fibrillation, s/p BiV ICD ( Concerto\\n C154DWK) , on coumadin. Now in paced rhythm\\n - cont home dose meds (amio, metoprolol)\\n - cont coumadin, at current dose.\\n - trend INR\\n .\\n # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a\\n filter in place. INR mildly subtherapeutic despite Cipro\\n - continue Coumadin\\n - monitor INR\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 05:34 PM\\n Midline - 05:34 PM\\n Prophylaxis:\\n DVT: coumadin\\n Stress ulcer: lansoprazole\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: DNR / DNI\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2180-01-19 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 400226,\n \"text\": \"71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\\n coumadin, hypothyroidism, CKD, OA. admitted for septic joint\\n washout- MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\\n On pt. was sent to ED from clinic w/ hypotension\\n transiently on dopa, Tx\\nd w/ NS 250 cc w/ SBP ^ 92.\\n Admit to CCU for aggressive diuresis. She was started on\\n Milrinone and lasix gtt. She has large coccyx decub that is a source\\n of chronic pain. She is DNR/DNI and defibrillator has been shut off.\\n Pain control (acute pain, chronic pain)\\n Assessment:\\n Pt. with history of pain in left shoulder, left hip (septic joints) and\\n coccyx (decub.).\\n Action:\\n MS , morphine IR 15mg for breakthrough pain, given this\\n a.m. Pt. also given 2mg IV morphine prior to all activity/turning\\n today. Pt. receiving ultram qid.\\n Response:\\n Pt. has denied pain today, tolerating above with no ill-effects.\\n Plan:\\n Continue present around-the-clock and prn regimen.\\n .H/O heart failure (CHF), Systolic, Acute on Chronic\\n Assessment:\\n Off lasix gtt since , and milrinone since . AV paced at 70 with\\n BP 90\\ns/60\\ns today. LS essentially clear, some fine dependent crackles\\n noted at bases. Skin warm, dry.\\n Action:\\n Given all meds this a.m. Assessment ongoing.\\n Response:\\n Pt. tolerating medication. Assessment unchanged.\\n Plan:\\n Continue to monitor and treat as indicated. Transfer to floor today.\\n Impaired Skin Integrity\\n Assessment:\\n Pt. with sacral decub as documented in metavision.\\n Action:\\n Dressing changed today at noon per skin care recs. Pt. turned side to\\n side as documented.\\n Response:\\n Pt. tolerated dressing change, premedicated with morphine IV.\\n Moderated amt. yellow-white slough noted. Small amounts drainage\\n noted.\\n Plan:\\n Continue daily dressing changes skin RN. Continue turning as pt.\\n tolerates, avoid pressure points.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2180-01-19 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 400223,\n \"text\": \"71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\\n coumadin, hypothyroidism, CKD, OA. admitted for septic joint\\n washout- MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\\n On pt. was sent to ED from clinic w/ hypotension\\n transiently on dopa, Tx\\nd w/ NS 250 cc w/ SBP ^ 92.\\n Admit to CCU for aggressive diuresis. She was started on\\n Milrinone and lasix gtt. She has large coccyx decub that is a source\\n of chronic pain. She is DNR/DNI and defibrillator has been shut off.\\n Pain control (acute pain, chronic pain)\\n Assessment:\\n Pt. with history of pain in left shoulder, left hip (septic joints) and\\n coccyx (decub.).\\n Action:\\n MS . Morphine IR 15mg for breakthrough pain, given this\\n a.m. Pt. given 2mg IV morphine prior to all activity/turning today.\\n Pt. receiving ultram qid.\\n Response:\\n Excellent effect\\n Plan:\\n .H/O heart failure (CHF), Systolic, Acute on Chronic\\n Assessment:\\n Off lasix gtt since . restarted on milrinone at .5mcq/k/min. for\\n low u/o.\\n HR 60-70 Vpaced. Occas. PVC. BP 80\\ns-90\\ns/ MAP 55-60.\\n Action:\\n Lopressor held for SBP<80.\\n Response:\\n Plan:\\n Impaired Skin Integrity\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2180-01-19 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 400205,\n \"text\": \"71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\\n : Sent to ED from clinic w/ hypotension\\n transiently on\\n dopa, Tx\\nd w/ NS 250 cc w/ SBP ^ 92.\\n Admit to CCU for aggressive diuresis.She was started on Milrinone\\n and lasix gtt. And has been diuresing well. She has lg coccyx decub\\n that is a source of chronic pain. She is DNR/DNI and defibrillator has\\n been shut off.\\n Family meeting with Dr. . Decision made to d/c milrinone,\\n torsimide and metalazone. Feeling that pt. intravas. Dry. Focus is on\\n comfort. Palliative care following.\\n Pain control (acute pain, chronic pain)\\n Assessment:\\n Currently on SR morphine , ultram QID and Tylenol RTC.\\n Supplementing with IR morphine 15mg as needed as well as IV morphine as\\n needed for breakthrough pain.\\n c/o pain in back d/t sacral decub wound. Grimaces with turning\\n /position change. Generally pain subsides once repositioned but\\n occas. requires additional pain medication.\\n 0600: after turning. Pt. stating pain- not relieved after 10mn.\\n Action:\\n IR morphine 15mg x1. repositioned q3-4 hours or as needed/requested by\\n pt.\\n 0600: med with 2mg IV morphine followed by additional 2mg IV at 0630 w\\n Response:\\n Pt. reports good pain control. Sleeping when left alone. Wakes easily\\n and is lucid.\\n Able to take pills whole with applesause.\\n Plan:\\n .H/O heart failure (CHF), Systolic, Acute on Chronic\\n Assessment:\\n HR 70\\ns Vpaced. Occas. PVC. BP 80\\ns-90/50\\ns. dipping to 73-79/\\n maps 50 when asleep.\\n Action:\\n Gave NSB 250cc at 0500 x1 (this treatment plan was discussed on rounds\\n with Dr. \\n Held PM lopressor dose\\n Response:\\n Good response\\n BP BP 86/56 map 64.\\n u/o 20-30cc/hr.\\n LS diminished bases. Sats 94-96% when awake. Dipping to 80\\ns when\\n asleep. Noted for periods of apnea.\\n Plan:\\n Monitor u/o, sats. Monitor for worsening heart failure symptoms.\\n Impaired Skin Integrity\\n Assessment:\\n Stage 3 decub on coccyx. Followed by wound care RN. Dsg changed QD.\\n Not visualized .\\n DSD remains intact. No drainage.\\n c/o some itching but states not as bad as last night.\\n Action:\\n Barrier cream to all areas.\\n Response:Plan\\n Change dsg daily. Sarana lotion prn.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2180-01-19 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 400207,\n \"text\": \"71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\\n : Sent to ED from clinic w/ hypotension\\n transiently on\\n dopa, Tx\\nd w/ NS 250 cc w/ SBP ^ 92.\\n Admit to CCU for aggressive diuresis.She was started on Milrinone\\n and lasix gtt. And has been diuresing well. She has lg coccyx decub\\n that is a source of chronic pain. She is DNR/DNI and defibrillator has\\n been shut off.\\n Family meeting with Dr. . Decision made to d/c milrinone,\\n torsimide and metalazone. Feeling that pt. intravas. Dry. Focus is on\\n comfort. Palliative care following.\\n Pain control (acute pain, chronic pain)\\n Assessment:\\n Currently on SR morphine , ultram QID and Tylenol RTC.\\n Supplementing with IR morphine 15mg as needed as well as IV morphine as\\n needed for breakthrough pain.\\n c/o pain in back d/t sacral decub wound. Grimaces with turning\\n /position change. Generally pain subsides once repositioned but\\n occas. requires additional pain medication.\\n 0600: after turning. Pt. stating pain- not relieved after 10mn.\\n Action:\\n IR morphine 15mg x1. repositioned q3-4 hours or as needed/requested by\\n pt.\\n 0600: med with 2mg IV morphine followed by additional 2mg IV at 0630\\n Response:\\n Pt. reports good pain control. Sleeping when left alone. Wakes easily\\n and is lucid.\\n Able to take pills whole with applesause.\\n 0645: reports pain . reposttioned\\n Plan:\\n .H/O heart failure (CHF), Systolic, Acute on Chronic\\n Assessment:\\n HR 70\\ns Vpaced. Occas. PVC. BP 80\\ns-90/50\\ns. dipping to 73-79/\\n maps 50 when asleep.\\n Action:\\n Gave NSB 250cc at 0500 x1 (this treatment plan was discussed on rounds\\n with Dr. \\n Held PM lopressor dose\\n Response:\\n Good response\\n BP BP 86/56 map 64.\\n u/o 20-30cc/hr.\\n LS diminished bases. Sats 94-96% when awake. Dipping to 80\\ns when\\n asleep. Noted for periods of apnea.\\n Plan:\\n Monitor u/o, sats. Monitor for worsening heart failure symptoms.\\n Impaired Skin Integrity\\n Assessment:\\n Stage 3 decub on coccyx. Followed by wound care RN. Dsg changed QD.\\n Not visualized .\\n DSD remains intact. No drainage.\\n c/o some itching but states not as bad as last night.\\n Action:\\n Barrier cream to all areas.\\n Response:Plan\\n Change dsg daily. Sarana lotion prn.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2180-01-19 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 400208,\n \"text\": \"Chief Complaint: Congestive heart failure\\n 24 Hour Events:\\n - DCed milrinone and diuretics 11:30am\\n - Family mtg held with patient's 3 sisters and multiple other family\\n members, Dr. , then (P&PC) Dr. --> everybody in\\n agreement w plan to DC milrinone, to give small 250cc boluses as needed\\n if BP drops and morphine for symptoms if lungs become overloaded w\\n fluid ; Hold on Rehab for now\\n - Likely transfer pt to floor tomorrow w PPC following\\n - BPs still stable 88-96 SBP (maps>60) at 1am, though family had been\\n concerned occasionally that she looked like she had more difficulty\\n breathing or increased apneic episodes, though nursing does not feel\\n that she has had any difficulty breathing (pt has not needed any 250cc\\n boluses at this point)\\n - 0430am systolic BPs low 70s, but mentating well, not symptomatic -->\\n 1 bag 250ccs NS\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Vancomycin - 08:00 AM\\n Ciprofloxacin - 10:00 AM\\n Infusions:\\n Other ICU medications:\\n Morphine Sulfate - 06:31 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:54 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 36.7\\nC (98.1\\n Tcurrent: 35.6\\nC (96\\n HR: 71 (68 - 101) bpm\\n BP: 79/58(62) {73/42(51) - 107/73(77)} mmHg\\n RR: 11 (9 - 23) insp/min\\n SpO2: 92%\\n Heart rhythm: V Paced\\n Wgt (current): 73.6 kg (admission): 82.2 kg\\n Height: 60 Inch\\n Total In:\\n 743 mL\\n 370 mL\\n PO:\\n 600 mL\\n 120 mL\\n TF:\\n IVF:\\n 143 mL\\n 250 mL\\n Blood products:\\n Total out:\\n 1,190 mL\\n 200 mL\\n Urine:\\n 1,190 mL\\n 200 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -447 mL\\n 170 mL\\n Respiratory support\\n O2 Delivery Device: None\\n SpO2: 92%\\n ABG: ////\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 116 K/uL\\n 10.2 g/dL\\n 93 mg/dL\\n 1.0 mg/dL\\n 35 mEq/L\\n 3.8 mEq/L\\n 32 mg/dL\\n 91 mEq/L\\n 132 mEq/L\\n 31.2 %\\n 4.6 K/uL\\n [image002.jpg]\\n 05:44 AM\\n 04:46 AM\\n 04:00 PM\\n 03:05 AM\\n 03:17 PM\\n 03:05 AM\\n 05:03 PM\\n 05:22 AM\\n 05:25 PM\\n 05:40 AM\\n WBC\\n 6.1\\n 4.7\\n 5.1\\n 4.4\\n 4.2\\n 4.6\\n Hct\\n 32.1\\n 31.9\\n 33.1\\n 32.2\\n 30.9\\n 31.2\\n Plt\\n 156\\n 159\\n 146\\n 134\\n 106\\n 116\\n Cr\\n 1.3\\n 1.4\\n 1.3\\n 1.2\\n 1.1\\n 1.0\\n 1.0\\n 1.0\\n 1.1\\n 1.0\\n Glucose\\n 83\\n 104\\n 155\\n 115\\n 98\\n 107\\n 86\\n 93\\n Other labs: PT / PTT / INR:19.1/29.7/1.7, Ca++:8.1 mg/dL, Mg++:2.1\\n mg/dL, PO4:2.8 mg/dL\\n Assessment and Plan\\n 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\\n recently discharged from the CCU () for CHF exacerbation c/b\\n C.diff infection and on for septic joint washout c/b failure to\\n extubate CHF exacerbation, who was admitted from clinic with\\n total body fluid overload.\\n .\\n # sCHF Exacerbation:\\n Patient has history of CHF ischemic , 10%, s/p BiV ICD\\n ( Concerto C154DWK) with EF 10% which was the likely\\n cause of her fluid overload. Appears intravascularly dry on exam. Has\\n diuresed well -9L on length of stay. Responding well to torsemide with\\n metolazone while on milrinone, but urine output had dropped without\\n milrinone yesterday. Diuresed net -500cc over last day. Milrinone is\\n keeping her blood pressures up.\\n - DC milrinone\\n - With no milrinone, she needs help with filling pressures, so\\n will DC diuretics b/c appears dry on exam\\n - If blood pressure drops without milrinone,, she may benefit\\n from 250cc IVF boluses as needed\\n - Continue strict I/Os\\n - Continue to replete K\\n .\\n # Goals of Care:\\n End-stage CHF with long term goals are comfort, though she still wishes\\n to participate in rehab. Her family recognizes that she is dying. Pain\\n and Palliative Care consulted yesterday for pain control and goals of\\n care.\\n - family meeting at 1pm today\\n .\\n # Septic Joints: Patient with history +staph aureus in left shoulder\\n treated by washout and vancomycin, thus far 4 weeks of monotherapy. No\\n + blood cx since before . Major issue now is pain control.\\n - continue vancomycin until , then suppression with doxycycline\\n -- continue MS contin 30mg and reassess pain med needs\\n -- standing ultram q6, Tylenol q8\\n .\\n # Sacral Decub - stage 3-4. Focusing on Pain control. Pain and\\n Palliative Care following with patient. Switched to oral breakthrough\\n Morphine with IV as backup, but patient was not requiring IV backup.\\n - wound care\\n - standing ultram Q6h, Tylenol Q8h\\n - reassess patient\\ns pain requirements\\n - goals of care family meeting 1pm today\\n .\\n # UTI: positive UA, no history of culture positive UA's in system.\\n Will do 10day course because of chronic foley.\\n - treating empirically with cipro ; day 1 of 10 day course was \\n - watch INR on abx\\n .\\n # Hx CAD:\\n Patient with h/o CAD w/ right dominant system, mild instent re-stenois\\n of the LAD BM stent and occluded RCA.\\n - continue metoprolol 25mg \\n .\\n # Hx Afib:\\n Patient with h/o atrial fibrillation, s/p BiV ICD ( Concerto\\n C154DWK) , on coumadin. Now in paced rhythm\\n - cont home dose meds (amio, metoprolol)\\n - cont coumadin\\n - trend INR\\n .\\n # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a\\n filter in place. INR mildly subtherapeutic despite Cipro\\n - continue Coumadin\\n - monitor INR\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 05:34 PM\\n Midline - 05:34 PM\\n Prophylaxis:\\n DVT: coumadin\\n Stress ulcer: lansoprazole\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: DNR / DNI\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2180-01-19 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 400214,\n \"text\": \"Chief Complaint: Congestive heart failure\\n 24 Hour Events:\\n - DCed milrinone and diuretics 11:30am\\n - Family mtg held with patient's 3 sisters and multiple other family\\n members, Dr. , then (P&PC) Dr. --> everybody in\\n agreement w plan to DC milrinone, to give small 250cc boluses as needed\\n if BP drops and morphine for symptoms if lungs become overloaded w\\n fluid ; Hold on Rehab for now\\n - Likely transfer pt to floor tomorrow w PPC following\\n - BPs still stable 88-96 SBP (maps>60) at 1am, though family had been\\n concerned occasionally that she looked like she had more difficulty\\n breathing or increased apneic episodes, though nursing does not feel\\n that she has had any difficulty breathing (pt has not needed any 250cc\\n boluses at this point)\\n - 0430am systolic BPs low 70s, but mentating well, not symptomatic -->\\n 1 bag 250ccs NS\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Vancomycin - 08:00 AM\\n Ciprofloxacin - 10:00 AM\\n Infusions:\\n Other ICU medications:\\n Morphine Sulfate - 06:31 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:54 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 36.7\\nC (98.1\\n Tcurrent: 35.6\\nC (96\\n HR: 71 (68 - 101) bpm\\n BP: 79/58(62) {73/42(51) - 107/73(77)} mmHg\\n RR: 11 (9 - 23) insp/min\\n SpO2: 92%\\n Heart rhythm: V Paced\\n Wgt (current): 73.6 kg (admission): 82.2 kg\\n Height: 60 Inch\\n Total In:\\n 743 mL\\n 370 mL\\n PO:\\n 600 mL\\n 120 mL\\n TF:\\n IVF:\\n 143 mL\\n 250 mL\\n Blood products:\\n Total out:\\n 1,190 mL\\n 200 mL\\n Urine:\\n 1,190 mL\\n 200 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -447 mL\\n 170 mL\\n Respiratory support\\n O2 Delivery Device: None\\n SpO2: 92%\\n ABG: ////\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 116 K/uL\\n 10.2 g/dL\\n 93 mg/dL\\n 1.0 mg/dL\\n 35 mEq/L\\n 3.8 mEq/L\\n 32 mg/dL\\n 91 mEq/L\\n 132 mEq/L\\n 31.2 %\\n 4.6 K/uL\\n [image002.jpg]\\n 05:44 AM\\n 04:46 AM\\n 04:00 PM\\n 03:05 AM\\n 03:17 PM\\n 03:05 AM\\n 05:03 PM\\n 05:22 AM\\n 05:25 PM\\n 05:40 AM\\n WBC\\n 6.1\\n 4.7\\n 5.1\\n 4.4\\n 4.2\\n 4.6\\n Hct\\n 32.1\\n 31.9\\n 33.1\\n 32.2\\n 30.9\\n 31.2\\n Plt\\n 156\\n 159\\n 146\\n 134\\n 106\\n 116\\n Cr\\n 1.3\\n 1.4\\n 1.3\\n 1.2\\n 1.1\\n 1.0\\n 1.0\\n 1.0\\n 1.1\\n 1.0\\n Glucose\\n 83\\n 104\\n 155\\n 115\\n 98\\n 107\\n 86\\n 93\\n Other labs: PT / PTT / INR:19.1/29.7/1.7, Ca++:8.1 mg/dL, Mg++:2.1\\n mg/dL, PO4:2.8 mg/dL\\n Assessment and Plan\\n 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\\n recently discharged from the CCU () for CHF exacerbation c/b\\n C.diff infection and on for septic joint washout c/b failure to\\n extubate CHF exacerbation, who was admitted from clinic with\\n total body fluid overload.\\n .\\n # sCHF Exacerbation:\\n Patient has history of CHF ischemic , 10%, s/p BiV ICD\\n ( Concerto C154DWK) with EF 10% which was the likely\\n cause of her fluid overload. Appears euvolemic currently. Has\\n diuresed well -9L on length of stay. Responding well to torsemide with\\n metolazone while on milrinone, but urine output had dropped without\\n milrinone on . Diuresed net -500cc over last day. Breathing\\n comfortably currently.\\n - blood pressure maintained without milrinone, will continue to support\\n with IV fluids as needed\\n - no diuretics currently, although will re-assess if she becomes\\n dyspneic. More likely will use morphine though for comfort.\\n .\\n # Goals of Care:\\n End-stage CHF with long term goals are comfort, though she still wishes\\n to participate in rehab. Her family recognizes that she is dying. Pain\\n and Palliative Care consulted on for pain control and goals of\\n care.\\n - appreciate palliative care recommendations\\n - likely call-out to floor on for continued comfort measures.\\n - will consider disconnecting IJ for comfort\\n .\\n # Septic Joints: Patient with history +staph aureus in left shoulder\\n treated by washout and vancomycin, thus far 4 weeks of monotherapy. No\\n + blood cx since before . Major issue now is pain control.\\n - continue vancomycin until , then suppression with doxycycline\\n -- continue MS contin 30mg and reassess pain med needs\\n -- standing ultram q6, Tylenol q8\\n .\\n # Sacral Decub - stage 3-4. Focusing on Pain control. Pain and\\n Palliative Care following with patient. Switched to oral breakthrough\\n Morphine with IV as backup. Patient required IV morphine this morning\\n while moving.\\n - wound care\\n - standing ultram Q6h, Tylenol Q8h\\n - reassess patient\\ns pain requirements\\n - continue with oral morphine, will use IV as needed now that patient\\n primary goal is comfort.\\n .\\n # UTI: positive UA, no history of culture positive UA's in system.\\n Will do 10day course because of chronic foley.\\n - treating empirically with cipro ; day 1 of 10 day course was \\n - watch INR on abx\\n .\\n # Hx CAD:\\n Patient with h/o CAD w/ right dominant system, mild instent re-stenois\\n of the LAD BM stent and occluded RCA.\\n - continue metoprolol 25mg \\n .\\n # Hx Afib:\\n Patient with h/o atrial fibrillation, s/p BiV ICD ( Concerto\\n C154DWK) , on coumadin. Now in paced rhythm\\n - cont home dose meds (amio, metoprolol)\\n - cont coumadin, at current dose.\\n - trend INR\\n .\\n # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a\\n filter in place. INR mildly subtherapeutic despite Cipro\\n - continue Coumadin\\n - monitor INR\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 05:34 PM\\n Midline - 05:34 PM\\n Prophylaxis:\\n DVT: coumadin\\n Stress ulcer: lansoprazole\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: DNR / DNI\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2180-01-19 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 400199,\n \"text\": \"71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\\n : Sent to ED from clinic w/ hypotension\\n transiently on\\n dopa, Tx\\nd w/ NS 250 cc w/ SBP ^ 92.\\n Admit to CCU for aggressive diuresis.She was started on Milrinone\\n and lasix gtt. And has been diuresing well. She has lg coccyx decub\\n that is a source of chronic pain. She is DNR/DNI and defibrillator has\\n been shut off.\\n Family meeting with Dr. . Decision made to d/c milrinone,\\n torsimide and metalazone. Feeling that pt. intravas. Dry. Focus is on\\n comfort. Palliative care following.\\n Pain control (acute pain, chronic pain)\\n Assessment:\\n Currently on SR morphine , ultram QID and Tylenol RTC.\\n Supplementing with IR morphine 15mg as needed as well as IV morphine as\\n needed for breakthrough pain.\\n c/o pain in back d/t sacral decub wound. Grimaces with turning\\n /position change. Generally pain subsides once repositioned but\\n occas. requires additional pain medication.\\n Action:\\n IR morphine 15mg x1. repositioned q3-4 hours or as needed/requested by\\n pt.\\n Response:\\n Pt. reports good pain control. Sleeping when left alone. Wakes easily\\n and is lucid.\\n Able to take pills whole with applesause.\\n Plan:\\n .H/O heart failure (CHF), Systolic, Acute on Chronic\\n Assessment:\\n HR 70\\ns Vpaced. Occas. PVC. BP 80\\ns-90/50\\ns. dipping to 73-79/\\n maps 50 when asleep.\\n Action:\\n Gave NSB 250cc at 0500 x1 (this treatment plan was discussed on rounds\\n with Dr. \\n Held PM lopressor dose\\n Response:\\n Good response\\n BP BP 86/56 map 64.\\n u/o 20-30cc/hr.\\n LS diminished bases. Sats 94-96% when awake. Dipping to 80\\ns when\\n asleep. Noted for periods of apnea.\\n Plan:\\n Monitor u/o, sats. Monitor for worsening heart failure symptoms.\\n Impaired Skin Integrity\\n Assessment:\\n Stage 3 decub on coccyx. Followed by wound care RN. Dsg changed QD.\\n Not visualized .\\n DSD remains intact. No drainage.\\n c/o some itching but states not as bad as last night.\\n Action:\\n Barrier cream to all areas.\\n Response:Plan\\n Change dsg daily. Sarana lotion prn.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2180-01-19 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 400197,\n \"text\": \"71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\\n : Sent to ED from clinic w/ hypotension\\n transiently on\\n dopa, Tx\\nd w/ NS 250 cc w/ SBP ^ 92.\\n Admit to CCU for aggressive diuresis.She was started on Milrinone\\n and lasix gtt. And has been diuresing well. She has lg coccyx decub\\n that is a source of chronic pain. She is DNR/DNI and defibrillator has\\n been shut off.\\n Pain control (acute pain, chronic pain)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n .H/O heart failure (CHF), Systolic, Acute on Chronic\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Impaired Skin Integrity\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2180-01-13 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 399736,\n \"text\": \"Pt is a 71 yo female with PMH: BM stent to LAD ', Occluded RCA\\n without intervention, Ischemic CM (EF 10-25%), BiV ICD, AF, PVD, DVT\\n s/p IVC filter, coumadin, hypothyroidism, CKD, OA. adm for HF\\n (milrinone/lasix) MRSA in L shoulder, L hip and R knuckle. Out to\\n rehab . went from rehab to see Dr. , sent to EW with\\n hypotension. SBP 70 in EW, transiently on dopa, but cardiology d/c'd.\\n Rxd with NS 250 cc with SBP 92. Pt has been in rehab since d/c from\\n with septic arthritis in L shoulder, hip and R knuckle.\\n On Vanco followed by ID.\\n She was started on milrinone .375 after bolus and lasix drip also begun\\n at 2.5mg/hr. The lasix dose was increased to 5mg overnight, but urine\\n output has remained poor, though she is negative.\\n GI: Pt has poor apetite and eats very little.\\n CODE STATUS: Dr had discussion with both patient and health care\\n proxy and all are in agreement that she be DNR/DNI. Additionally the\\n defibrillator part of AICD/pacer was shut off.\\n Pain control (acute pain, chronic pain)\\n Assessment:\\n Pt has a number of sources of pain. She has joint pain in shoulders and\\n especially R elbow from septic arthritis. The most uncomfortable area\\n is the decubitus ulcer on her coccyx area. She receive standing ultran\\n for that. She requires frequent position changes, but seems most\\n uncomfortable on L side. By 1000 she was very uncomfortable.\\n Action:\\n She received 2mg IV morpnine sulfate at 1230 and had shift in position\\n and was comfortable until noon when pain recurred. She received another\\n 2mg morphine sulfate and position change.\\n Response:\\n She slept until\\n Plan:\\n .H/O heart failure (CHF), Systolic, Acute on Chronic\\n Assessment:\\n Pt on Milrinone .375mic/kilo and lasix 5mg/hr. Urine output\\n ~30-50cc/hr. Hr in 70s AV paced with rare PVCs . BP 85-100/50-60s,\\n lower after morphine. Pt sating 98-100% on 3L NP and lungs are mostly\\n clear. She has no c/o of SOB. She has 2+ edema in legs.\\n Action:\\n At 1030 lasix was increased to 10mg/hr and at 1100 milrinone was\\n increased to .5mic/kilo. Legs are kept elevated.\\n Response:\\n She is ~800cc negative for the day. The skin on her legs show signs\\n Plan:\\n Impaired Skin Integrity\\n Assessment:\\n Pt has multiple skin lesions. Most prominent is coccyx decub. It has\\n mepelix on it that was leaking through and pulling loose in am. Both\\n heels are reddened, though they . She has dry skin on all\\n extremities with some small abraded areas.\\n Action:\\n Coccyx dsg changed. Area primarily covered with slough. The edges are\\n rounded and pink. Area cleansed with wound cleaner, dried and new\\n mepelix applied. All limbs were lubricated frequently. Her position was\\n changed, at times only slightly throughout the day. She does become\\n uncomfortable if she is in the same position for too long,but also has\\n difficulty on the L side. She finds the waffle boots uncomfortable and\\n prefers having her legs elevated on pillows.\\n Response:\\n No new skin lesions have developed.\\n Plan:\\n Continue with turning, lubricating and keeping heels elevated. Monitor\\n mepilex to ensure it is in place.\\n\"\n },\n {\n \"category\": \"Social Work\",\n \"chartdate\": \"2180-01-19 00:00:00.000\",\n \"description\": \"Social Work Progress Note\",\n \"row_id\": 400241,\n \"text\": \"SOCIAL WORK: Following pt for emotional support around pt\\ncoping. Reviewed notes from palliative care service and\\ndiscussed pt's progress with RN . A family meeting was\\nheld yesterday with the attending physician and palliative care\\nservice to review pt's progress and goals of care.\\nPt is sitting up in bed finishing her breakfast at present. Pt\\nis somnolent; her eyes closing at times. Pt speech is slow and\\nmeasured, as are her movements. She engages readily with SW, but\\nstops herself when speaking, easily losing her concentration. Pt\\npresents today with the same sad affect from prior\\nhospitalization in . Pt's mood is congruent: \\\"worried.\\\"\\nPt reports she is very concerned about her niece (primary HCP)\\nwho is currently hospitalized in the MICU. Pt states, \\\"I wish it\\nwas me, if anything bad was going to happen, it wouldn't matter.\\\"\\nPt reports that her discussion with the doctors yesterday was\\n\\\"not entirely unexpected\\\". Pt understands that doctors 't\\nknow what is going to happen and if her present medication\\nregimen is going to work. Pt elaborates, \\\"But, I am not in a\\nhurry to leave tomorrow.\\\"\\nPt is comforted most by her family being close to her, especially\\nnow due to her niece's illness. Pt is looking forward to seeing\\nthem later today. Pt gave permission to contact family members.\\nMessages left for (sister/Alt. HCP) and (niece) whom\\nSW met Monday .\\nA/P: Pt is exhibiting normative distress over her niece and\\nshows signs of fatigue and discouragement over lengthy\\nhospitalization and course of illness. Pt appears to have some\\ninsight into her prognosis , but cannot recall specific details\\nat this point.\\n-SW will continue to follow the pt to provide opportunity to talk\\nabout not only death and dying, but provide opportunity to make\\nmeaning through life review.\\n-SW will continue to provide emotional support around pt's\\nconcerns over her own illness and her niece's condition.\\n-SW will build rapport with family to provide emotional support\\nthrough this process.\\n , MSW Intern\\nPager \\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2180-01-19 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 400242,\n \"text\": \"71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\\n coumadin, hypothyroidism, CKD, OA. admitted for septic joint\\n washout- MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\\n On pt. was sent to ED from clinic w/ hypotension\\n transiently on dopa, Tx\\nd w/ NS 250 cc w/ SBP ^ 92.\\n Admit to CCU for aggressive diuresis. She was started on\\n Milrinone and lasix gtt. She has large coccyx decub that is a source\\n of chronic pain. She is DNR/DNI and defibrillator has been shut off.\\n Pain control (acute pain, chronic pain)\\n Assessment:\\n Pt. with history of pain in left shoulder, left hip (septic joints) and\\n coccyx (decub.).\\n Action:\\n MS , morphine IR 15mg for breakthrough pain, given this x2\\n today. Pt. also given 2mg IV morphine prior to all activity/turning\\n today. Pt. receiving ultram qid.\\n Response:\\n Pt. has denied pain today until 1500\\n she reported pain after turning\\n despite premedicating. Tolerating above with no ill-effects. Pt.\\n painfree by 1600.\\n Plan:\\n Continue present around-the-clock and aggressive prn regimen.\\n .H/O heart failure (CHF), Systolic, Acute on Chronic\\n Assessment:\\n Off lasix gtt since , and milrinone since . AV paced at 70 with\\n BP 90\\ns/60\\ns today. LS essentially clear, some fine ?dependent\\n crackles noted at bases. Skin warm, dry. UO approximately 20cc/hr.\\n Pt. slightly confused this afternoon per family.\\n Action:\\n Assessment ongoing. Torsemide started.\\n Response:\\n Pt. tolerating medication. Assessment largely unchanged.\\n Plan:\\n Continue to monitor and treat as indicated. Transfer to floor today.\\n Impaired Skin Integrity\\n Assessment:\\n Pt. with sacral decub as documented in metavision.\\n Action:\\n Dressing changed today at noon per skin care recs. Pt. turned side to\\n side as documented.\\n Response:\\n Pt. tolerated dressing change, premedicated with morphine IV.\\n Moderated amt. yellow-white slough noted. Small amounts drainage\\n noted.\\n Plan:\\n Continue daily dressing changes skin RN. Continue turning as pt.\\n tolerates, avoid pressure points.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2180-01-19 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 400243,\n \"text\": \"71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\\n coumadin, hypothyroidism, CKD, OA. admitted for septic joint\\n washout- MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\\n On pt. was sent to ED from clinic w/ hypotension\\n transiently on dopa, Tx\\nd w/ NS 250 cc w/ SBP ^ 92.\\n Admit to CCU for aggressive diuresis. She was started on\\n Milrinone and lasix gtt. She has large coccyx decub that is a source\\n of chronic pain. She is DNR/DNI and defibrillator has been shut off.\\n Pain control (acute pain, chronic pain)\\n Assessment:\\n Pt. with history of pain in left shoulder, left hip (septic joints) and\\n coccyx (decub.).\\n Action:\\n MS , morphine IR 15mg for breakthrough pain, given this x2\\n today. Pt. also given 2mg IV morphine prior to all activity/turning\\n today. Pt. receiving ultram qid.\\n Response:\\n Pt. has denied pain today until 1500\\n she reported pain after turning\\n despite premedicating. Tolerating above with no ill-effects. Pt.\\n painfree by 1600.\\n Plan:\\n Continue present around-the-clock and aggressive prn regimen.\\n .H/O heart failure (CHF), Systolic, Acute on Chronic\\n Assessment:\\n Off lasix gtt since , and milrinone since . AV paced at 70 with\\n BP 85-90\\ns/50-60\\ns today. LS essentially clear, some fine crackles\\n noted at bases this afternoon. Skin warm, dry. UO approximately\\n 20cc/hr. Pt. slightly confused this afternoon per family.\\n Action:\\n Assessment ongoing. Torsemide started.\\n Response:\\n Pt. tolerating medication. Assessment largely unchanged.\\n Plan:\\n Continue to monitor and treat as indicated. Transfer to floor today.\\n Impaired Skin Integrity\\n Assessment:\\n Pt. with sacral decub as documented in metavision.\\n Action:\\n Dressing changed today at noon per skin care recs. Pt. turned side to\\n side as documented.\\n Response:\\n Pt. tolerated dressing change, premedicated with morphine IV.\\n Moderated amt. yellow-white slough noted. Small amounts drainage\\n noted.\\n Plan:\\n Continue daily dressing changes skin RN. Continue turning as pt.\\n tolerates, avoid pressure points.\\n\"\n },\n {\n \"category\": \"Social Work\",\n \"chartdate\": \"2180-01-19 00:00:00.000\",\n \"description\": \"Social Work Progress Note\",\n \"row_id\": 400244,\n \"text\": \"SOCIAL WORK: Following pt for emotional support around pt\\ncoping. Reviewed notes from palliative care service and\\ndiscussed pt's progress with RN . A family meeting was\\nheld yesterday with the attending physician and palliative care\\nservice to review pt's progress and goals of care.\\nPt is sitting up in bed finishing her breakfast at present. Pt\\nis somnolent; her eyes closing at times. Pt speech is slow and\\nmeasured, as are her movements. She engages readily with SW, but\\nstops herself when speaking, easily losing her concentration. Pt\\npresents today with the same sad affect from prior\\nhospitalization in . Pt's mood is congruent: \\\"worried.\\\"\\nPt reports she is very concerned about her niece (primary HCP)\\nwho is currently hospitalized in the MICU. Pt states, \\\"I wish it\\nwas me, if anything bad was going to happen, it wouldn't matter.\\\"\\nPt reports that her discussion with the doctors yesterday was\\n\\\"not entirely unexpected\\\". Pt understands that doctors 't\\nknow what is going to happen and if her present medication\\nregimen is going to work. Pt elaborates, \\\"But, I am not in a\\nhurry to leave tomorrow.\\\"\\nPt is comforted most by her family being close to her, especially\\nnow due to her niece's illness. Pt is looking forward to seeing\\nthem later today. Pt gave permission to contact family members.\\nMessages left for (sister/Alt. HCP) and (niece) whom\\nSW met Monday .\\nA/P: Pt is exhibiting normative distress over her niece and\\nshows signs of fatigue and discouragement over lengthy\\nhospitalization and course of illness. Pt appears to have some\\ninsight into her prognosis , but cannot recall specific details\\nat this point.\\n-SW will continue to follow the pt to provide opportunity to talk\\nabout not only death and dying, but provide opportunity to make\\nmeaning through life review.\\n-SW will continue to provide emotional support around pt's\\nconcerns over her own illness and her niece's condition.\\n-SW will build rapport with family to provide emotional support\\nthrough this process.\\n , MSW Intern\\nPager \\n 05:11 PM\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2180-01-13 00:00:00.000\",\n \"description\": \"Physician Resident Admission Note\",\n \"row_id\": 399713,\n \"text\": \"Chief Complaint: Fluid overload\\n HPI:\\n 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\\n recently discharged from the CCU () for CHF exacerbation c/b\\n C.diff infection and on for septic joint washout c/b failure to\\n extubate CHF exacerbation, who is now being admitted from \\n clinic with total body fluid overload.\\n .\\n Ms. is a resident at NE where she is convalescing from a\\n polyarticular MRSA septic arthritis. She has NYHA IV CHF at baseline\\n but over the last 4 days has developed 4+ LE edema and ascites where\\n there was previously none. She was presented with the choice to pursue\\n cardiac transplantation more than 12 years ago when given the diagnosis\\n of end-stage CHF. She opted against that.\\n .\\n Per her recent visit note at clinic, she continues to have L\\n shoulder pain, though significantly improved from a few weks ago. She\\n continues to work with PT to improve her ROM. She has no pain at her R\\n 3rd MCP, though has difficulty extending her finger at that joint. She\\n continues to have mild pain and significant weakness at her L\\n hip, though improved since hospital discharge. She has had no\\n F/C/NS, and no problems with her midline. She has had progression\\n of a sacral decub, which gives her the majority of her pain.\\n There has not been concern on the part of her rehab for\\n superinfection, and it is being treated with local wound care and\\n frequent turning. Her sister is hoping to transfer her to \\n within the next several days.\\n Patient admitted from: ER\\n History obtained from Patient, Family / Medical records\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Milrinone - 0.375 mcg/Kg/min\\n Other ICU medications:\\n Other medications:\\n Past medical history:\\n Family history:\\n Social History:\\n 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension\\n 2. CARDIAC HISTORY:\\n -CABG: None\\n -PERCUTANEOUS CORONARY INTERVENTIONS: BM stent to the LAD in ,\\n Occluded RCA/no intervention\\n -PACING/ICD: Ischemic cardiomyopathy (EF 10%) s/p BiV ICD and atrial\\n fibrillation\\n 3. H/o PE secondary to DVT s/p IVC filter on Coumadin\\n 4. PVD\\n 5. Small VSD\\n OTHER\\n # Septic Polyarticular Arthritis s/p irrigation and debridement left\\n shoulder via anterolateral deltopectoral miniarthrotomy, aspiration\\n left hip joint and irrigation and debridement of 3rd\\n metacarpophalangeal joint\\n 6. Hypothyroidism\\n 7. CKD\\n 8. Osteoarthritis\\n Mother had MI at age 50, maternal uncle died of MI in his 50's.\\n No family history of arrhythmia, cardiomyopathies, or sudden cardiac\\n death; otherwise non-contributory.\\n Occupation: retired\\n Drugs: none\\n Tobacco: 20 pack year history, however she quit 30 yrs ago\\n Alcohol: none\\n Other: Pt lives alone but currently resides at NE . She is not\\n married. She is cared for primarily by her Niece and sister, both\\n nurses.\\n Review of systems:\\n Constitutional: Fatigue\\n Integumentary (skin): painful decub's\\n Flowsheet Data as of 08:40 PM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since AM\\n Tmax: 35.4\\nC (95.8\\n Tcurrent: 35.4\\nC (95.8\\n HR: 70 (70 - 108) bpm\\n BP: 83/50(58) {83/50(58) - 109/76(84)} mmHg\\n RR: 12 (11 - 18) insp/min\\n SpO2: 100%\\n Heart rhythm: V Paced\\n Wgt (current): 82.2 kg (admission): 82.2 kg\\n Total In:\\n 284 mL\\n PO:\\n 30 mL\\n TF:\\n IVF:\\n 4 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 350 mL\\n Urine:\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n -66 mL\\n Respiratory\\n O2 Delivery Device: None\\n SpO2: 100%\\n Physical Examination\\n General Appearance: Thin, Anxious, Cachectic, tearful\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: Normocephalic\\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic), II/VI\\n systolic murmur best at apex. PMI is laterally displaced\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear :\\n anteriorly)\\n Abdominal: Soft, Non-tender, Distended, +fluid wave\\n Extremities: Right lower extremity edema: 4+, Left lower extremity\\n edema: 4+, cool, dry\\n Skin: Cool, Stage 3+ sacral decub\\n Neurologic: Attentive, Responds to: Not assessed, Oriented (to): x3,\\n Movement: Not assessed, Tone: Not assessed\\n Labs / Radiology\\n [image002.jpg]\\n Imaging: TTE :\\n The left atrium is elongated. The right atrium is markedly dilated. The\\n interatrial septum is aneurysmal. The estimated right atrial pressure\\n is 10-20mmHg. Left ventricular wall thicknesses are normal. The left\\n ventricular cavity is moderately dilated with severe global\\n hypokinesis. The basal inferolateral wall contracts best (LVEF = 20 %).\\n The estimated cardiac index is borderline low (2.0-2.5L/min/m2). No\\n masses or thrombi are seen in the left ventricle. The right ventricular\\n cavity is moderately dilated with severe global free wall hypokinesis.\\n [Intrinsic right ventricular systolic function is likely more depressed\\n given the severity of tricuspid regurgitation.] The ascending aorta is\\n mildly dilated. The aortic valve leaflets (3) are mildly thickened but\\n aortic stenosis is not present. Trace aortic regurgitation is seen. The\\n mitral valve leaflets are mildly thickened. There is no mitral valve\\n prolapse. Mild to moderate (+) mitral regurgitation is seen.\\n Moderate to severe [3+] tricuspid regurgitation is seen. There is\\n moderate pulmonary artery systolic hypertension. Significant pulmonic\\n regurgitation is seen. There is a very small circumferential\\n pericardial effusion without echocardiographic signs of tamponade.\\n Compared with the prior study (images reviewed) of ,\\n estimated pulmonary artery systolic pressure is now higher.\\n .\\n ETT: \\n INTERPRETATION: This 64 year old woman with a history of CAD, atrial\\n fibrillation and CHF was referred to the lab for evaluation. The\\n patient exercised for 4.25 minutes of a modified protocol and\\n requested the test be stopped for nausea. The resting oxygen\\n consumption was 3.2 ml/kg/min with a respiratory exchange ratio of\\n 0.75. At peak exercise, her oxygen consumption increased to 11.0\\n ml/kg/min with an expiratory exchange ratio of 0.86. The peak oxygen\\n consumption was 45 % of predicted. The oxygen consumption at the onset\\n of the anerobic threshold was 9.9 ml/kg/min. This test was not limited\\n by muscle fatigue. No arm, neck, back or chest discomfort was reported\\n by the patient throughout the study. The ST segments are\\n uninterpretable for ischemia in the setting of the baseline LBBB. The\\n rhythm was atrial fibrillation with several isolated vpbs and 2\\n ventricular couplets. Blunted systolic BP response to exercise.\\n IMPRESSION: Very limited physical working capacity in the absence of\\n angina.\\n .\\n CARDIAC CATH:\\n LHC/RHC :\\n 1. Selective coronary angiography of this right dominant system\\n revealed one vessel coronary artery disease. The LMCA had no\\n angiographically apparent disease. The LAD had mild instent restenosis\\n of the prior stent. The LCx had no angiographically apparent disease.\\n The RCA was occluded and similar to prior.\\n 2. Resting hemodynamics on milrinone therapy revealed moderately\\n elevated right and left sided filling pressures with an RVEDP of\\n 15 mmHg and PCWP of 20 mmHg. There was moderate pulmonary hypertension\\n with a PASP of 42/20 mmHg. There was normal systemic blood pressure\\n with central pressure of 108/63 mmHg. There was a low-normal cardiac\\n index of 2.1 L/min/m2. There was no transaortic valve gradient on\\n careful pullback from LV to aorta.\\n 3. Peripheral angiography revealed patent renal arteries bilaterally.\\n .\\n MYOCARDIAL VIABILITY STUDY :\\n Within limitation of current study, fixed defects in distal anterior\\n and apical walls are consistent with scarring. Improvement of inferior\\n wall defect with correction is suggestive of myocardial viability.\\n Microbiology: Hx of MRSA bacteremia, septic arthritis\\n Assessment and Plan\\n ASSESSMENT AND PLAN\\n 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\\n recently discharged from the CCU () for CHF exacerbation c/b\\n C.diff infection and on for septic joint washout c/b failure to\\n extubate CHF exacerbation, who is now being admitted from \\n clinic with total body fluid overload.\\n .\\n # Anasarca: Patient has history of CHF ischemic , 10%, s/p\\n BiV ICD ( Concerto C154DWK) 1/08with EF 10% which is the\\n likely cause of her fluid overload. Her rapid accumulation underpins\\n the severity of her condition and her severely unfavourable\\n hemodynamics. Her long term goals are comfort, though she still wishes\\n to participate in rehab. Her family recognizes that she is dying. Our\\n goal is diuresis which we will attempt aggressively, reassessing our\\n progress dynamically.\\n -- milrinone with bolus\\n -- neosynephrine for pressure support, goal MAP of > 60\\n -- slow uptitration of lasix with goal near-continuous diuresis while\\n avoiding MAP < 60\\n -- strict i/o's with foley\\n -- can switch to levophed if low UOP on Neo with need for pressor\\n support\\n -- family meeting with HCP to assess goals in AM after diuresis\\n attempted\\n .\\n # Septic Joints: Patient with history +staph aureus in left shoulder\\n treated by washout and vancomycin, thus far 4 weeks of monotherapy. No\\n + blood cx since before . Major issue now is pain control.\\n -- send Vanco level in AM, was recently on 500 mg q12 and switched to\\n q24 for high troughs\\n -- ultram q6, Tylenol q8, Morphine for breakthrough (1-3 mg).\\n - Will consider ms contin if no control\\n .\\n # CORONARIES: Patient with h/o CAD w/ right dominant system, mild\\n instent re-stenois of the LAD BM stent and occluded RCA.\\n - bb as tolerated\\n .\\n # RHYTHM: Patient with h/o atrial fibrillation, s/p BiV ICD (\\n Concerto C154DWK) , on coumadin. Now in paced rhythm\\n - cont home dose meds (amio, metoprolol)\\n - cont coumadin\\n - f/u INR\\n .\\n # Chronic Kidney Disease: Baseline 1.3 creatinine. At baseline\\n - trend\\n .\\n # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a\\n filter in place.\\n - cont coumadin\\n - f/u INR\\n .\\n # Hypothyroidism: Continue Levothyroxine.\\n .\\n # Gout: continue allopurionl\\n .\\n # FEN: low sodium diet\\n .\\n # ACCESS: Right PICC, right IJ, Left EJ\\n .\\n # PROPHYLAXIS: on coumadin\\n .\\n # CODE: DNR, can intubate, briefly\\n .\\n # DISPO: CCU for now.\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 05:34 PM\\n Midline - 05:34 PM\\n 18 Gauge - 05:35 PM\\n Prophylaxis:\\n DVT: (Systemic anticoagulation: Coumadin)\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: DNR (do not resuscitate)\\n Disposition: ICU\\n ------ Protected Section ------\\n Cardiology Teaching Physician Note\\n On this day I saw, examined and was physically present with the\\n resident / fellow for the key portions of the services provided. I\\n agree with the above note and plans.\\n I would add the following remarks:\\n Above discussed extensively with patient.\\n DNR status discussed. DNR.\\n Total time spent on patient care: 45 minutes.\\n Additional comments:\\n Patient with end-stage ischemic cmp admitted for milrinone and Lasix\\n gtt in setting of severe volume overload and hypotension; prognosis is\\n end-stage\\n Signed on for service provided \\n ------ Protected Section Addendum Entered By: on:\\n 11:18 ------\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2180-01-13 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 399714,\n \"text\": \"Chief Complaint: anasarca\\n 24 Hour Events:\\n MULTI LUMEN - START 05:34 PM\\n MIDLINE - START 05:34 PM\\n - poor UOP to 2.5 and 5mg/hr lasix drip.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Milrinone - 0.375 mcg/Kg/min\\n Furosemide (Lasix) - 5 mg/hour\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Constitutional: Fatigue\\n Flowsheet Data as of 06:49 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 36.1\\nC (97\\n Tcurrent: 36\\nC (96.8\\n HR: 72 (70 - 108) bpm\\n BP: 97/52(64) {77/44(52) - 113/76(84)} mmHg\\n RR: 13 (11 - 18) insp/min\\n SpO2: 96%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 82.2 kg (admission): 82.2 kg\\n Total In:\\n 417 mL\\n 156 mL\\n PO:\\n 120 mL\\n 60 mL\\n TF:\\n IVF:\\n 47 mL\\n 96 mL\\n Blood products:\\n Total out:\\n 550 mL\\n 410 mL\\n Urine:\\n 200 mL\\n 410 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -133 mL\\n -254 mL\\n Respiratory support\\n O2 Delivery Device: None\\n SpO2: 96%\\n ABG: ///26/\\n Physical Examination\\n General Appearance: No acute distress, Thin, cachectic\\n Head, Ears, Nose, Throat: Normocephalic\\n Cardiovascular: II/VI systolic murmur best at apex. PMI is laterally\\n displaces\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\\n Respiratory / Chest: (Breath Sounds: Clear : anteriors)\\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended, fluid\\n wave\\n Extremities: Right lower extremity edema: 4+, Left lower extremity\\n edema: 4+\\n Skin: Not assessed, Stage 3 sacral decub\\n Neurologic: Attentive, Responds to: Not assessed, Oriented (to): x3,\\n Movement: Not assessed, Tone: Not assessed\\n Labs / Radiology\\n 156 K/uL\\n 10.0 g/dL\\n 83 mg/dL\\n 1.3 mg/dL\\n 26 mEq/L\\n 4.3 mEq/L\\n 46 mg/dL\\n 99 mEq/L\\n 137 mEq/L\\n 32.1 %\\n 6.1 K/uL\\n [image002.jpg]\\n 05:44 AM\\n WBC\\n 6.1\\n Hct\\n 32.1\\n Plt\\n 156\\n Cr\\n 1.3\\n Glucose\\n 83\\n Other labs: PT / PTT / INR:15.7/36.8/1.4, Mg++:2.1 mg/dL\\n Fluid analysis / Other labs: UA = WBC + clumps. Mod Bacteria\\n Assessment and Plan\\n 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\\n recently discharged from the CCU () for CHF exacerbation c/b\\n C.diff infection and on for septic joint washout c/b failure to\\n extubate CHF exacerbation, who is now being admitted from \\n clinic with total body fluid overload.\\n .\\n # Anasarca: Patient has history of CHF ischemic , 10%, s/p\\n BiV ICD ( Concerto C154DWK) 1/08with EF 10% which is the\\n likely cause of her fluid overload. Her rapid accumulation underpins\\n the severity of her condition and her severely unfavourable\\n hemodynamics. Her long term goals are comfort, though she still wishes\\n to participate in rehab. Her family recognizes that she is dying. Our\\n goal is diuresis which we will attempt aggressively, reassessing our\\n progress dynamically. She put out very little o/n on lasix gtt. This\\n could reflect limitatin of diuresis or the importance of a bolus (we\\n withheld bolus to avoid instability)\\n -- milrinone with bolus\\n -- neosynephrine for pressure support, goal MAP of > 60\\n -- slow uptitration of lasix with goal near-continuous diuresis while\\n avoiding MAP < 60\\n -- strict i/o's with foley\\n -- can switch to levophed if low UOP on Neo with need for pressor\\n support\\n -- family meeting with HCP to assess goals in AM after diuresis\\n attempted\\n .\\n # Septic Joints: Patient with history +staph aureus in left shoulder\\n treated by washout and vancomycin, thus far 4 weeks of monotherapy. No\\n + blood cx since before . Major issue now is pain control.\\n -- send Vanco level in AM, was recently on 500 mg q12 and switched to\\n q24 for high troughs\\n -- ultram q6, Tylenol q8, Morphine for breakthrough (1-3 mg).\\n - Will consider ms contin if no control\\n .\\n # Sacral Decub - stage 3-4.\\n - wound care\\n - pain control.\\n .\\n # UTI: positive UA, no history of culture positive UA's in system\\n - treating empirically with cipro\\n - watch INR on abx\\n .\\n # CORONARIES: Patient with h/o CAD w/ right dominant system, mild\\n instent re-stenois of the LAD BM stent and occluded RCA.\\n - bb as tolerated\\n .\\n # RHYTHM: Patient with h/o atrial fibrillation, s/p BiV ICD (\\n Concerto C154DWK) , on coumadin. Now in paced rhythm\\n - cont home dose meds (amio, metoprolol)\\n - cont coumadin\\n - f/u INR\\n .\\n # Chronic Kidney Disease: Baseline 1.3 creatinine. At baseline\\n - trend\\n .\\n # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a\\n filter in place.\\n - cont coumadin\\n - f/u INR\\n .\\n # Hypothyroidism: Continue Levothyroxine.\\n .\\n # Gout: continue allopurionl\\n .\\n # FEN: low sodium diet\\n .\\n # ACCESS: Right PICC, right IJ, Left EJ\\n .\\n # PROPHYLAXIS: on coumadin\\n .\\n # CODE: DNR/DNI\\n .\\n # DISPO: CCU for now.\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 05:34 PM\\n Midline - 05:34 PM\\n 18 Gauge - 05:35 PM\\n Prophylaxis:\\n DVT: (Systemic anticoagulation: Coumadin)\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: DNR (do not resuscitate)\\n Disposition:ICU\\n ------ Protected Section ------\\n Cardiology Teaching Physician Note\\n On this day I saw, examined and was physically present with the\\n resident / fellow for the key portions of the services provided. I\\n agree with the above note and plans.\\n I would add the following remarks:\\n Above discussed extensively with patient.\\n DNR status discussed: DNR/DNI/defibrillator deactivated. DNR.\\n Total time spent on patient care: 60 minutes.\\n Additional comments:\\n although we have madee some minimal progress in diuresis, the outlook\\n is poor\\n after 20 min discussion with pt we have reaffirmed DNR/DNI status\\n In addition, as per patient's wish we will deactivate the defibrillator\\n shocking function of her ICD\\n ------ Protected Section Addendum Entered By: on:\\n 11:20 ------\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2180-01-13 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 399730,\n \"text\": \"Pt is a 71 yo female with PMH: BM stent to LAD ', Occluded RCA\\n without intervention, Ischemic CM (EF 10-25%), BiV ICD, AF, PVD, DVT\\n s/p IVC filter, coumadin, hypothyroidism, CKD, OA. adm for HF\\n (milrinone/lasix) MRSA in L shoulder, L hip and R knuckle. Out to\\n rehab . went from rehab to see Dr. , sent to EW with\\n hypotension. SBP 70 in EW, transiently on dopa, but cardiology d/c'd.\\n Rxd with NS 250 cc with SBP 92. Pt has been in rehab since d/c from\\n with septic arthritis in L shoulder, hip and R knuckle.\\n On Vanco followed by ID.\\n She was started on milrinone .375 after bolus and lasix drip also begun\\n at 2.5mg/hr. The lasix dose was increased to 5mg overnight, but urine\\n output has remained poor, though she is negative.\\n GI: Pt has poor apetite and eats very little.\\n CODE STATUS: Dr had discussion with both patient and health care\\n proxy and all are in agreement that she be DNR/DNI. Additionally the\\n defibrillator part of AICD/pacer was shut off.\\n Pain control (acute pain, chronic pain)\\n Assessment:\\n Pt has a number of sources of pain. She has joint pain in shoulders and\\n especially R elbow from septic arthritis. The most uncomfortable area\\n is the decubitus ulcer on her coccyx area. She receive standing ultran\\n for that. She requires frequent position changes, but seems most\\n uncomfortable on L side. By 1000 she was very uncomfortable.\\n Action:\\n She received 2mg IV morpnine sulfate at 1230 and had shift in position\\n and was comfortable until noon when pain recurred. She received another\\n 2mg morphine sulfate and position change.\\n Response:\\n She slept until\\n Plan:\\n .H/O heart failure (CHF), Systolic, Acute on Chronic\\n Assessment:\\n Pt on Milrinone .375mic/kilo and lasix 5mg/hr. Urine output\\n ~30-50cc/hr. Hr in 70s AV paced with rare PVCs . BP 85-100/50-60s,\\n lower after morphine. Pt sating 98-100% on 3L NP and lungs are mostly\\n clear. She has no c/o of SOB. She has 2+ edema in legs.\\n Action:\\n At 1030 lasix was increased to 10mg/hr and at 1100 milrinone was\\n increased to .5mic/kilo. Legs are kept elevated.\\n Response:\\n Plan:\\n Impaired Skin Integrity\\n Assessment:\\n Pt has multiple skin lesions. Most prominent is coccyx decub. It has\\n mepelix on it that was sloughing off in am\\n Action:\\n Coccyx dsg changed. Area primarily covered with slough. The edges are\\n rounded and pink. Area cleansed with wound cleaner, dried and new\\n mepelix applied.\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2180-01-15 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 399948,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n - confirmed DNR, acemaker turned off\\n - despite lasix gtt, diuresis poor yesterday\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Vancomycin - 08:00 AM\\n Ciprofloxacin - 08:00 AM\\n Infusions:\\n Other ICU medications:\\n Coumadin (Warfarin) - 04:00 PM\\n Lansoprazole (Prevacid) - 04:00 PM\\n Morphine Sulfate - 05:05 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 08:40 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 36.6\\nC (97.9\\n Tcurrent: 36.4\\nC (97.5\\n HR: 99 (66 - 104) bpm\\n BP: 91/50(60) {82/42(45) - 101/67(120)} mmHg\\n RR: 12 (11 - 23) insp/min\\n SpO2: 99%\\n Heart rhythm: V Paced\\n Wgt (current): 82.2 kg (admission): 82.2 kg\\n Total In:\\n 1,554 mL\\n 456 mL\\n PO:\\n 900 mL\\n 60 mL\\n TF:\\n IVF:\\n 654 mL\\n 396 mL\\n Blood products:\\n Total out:\\n 1,628 mL\\n 1,505 mL\\n Urine:\\n 1,628 mL\\n 1,505 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -74 mL\\n -1,049 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 99%\\n ABG: ///27/\\n Physical Examination\\n General Appearance: No acute distress, thin, cachectic\\n Head, Ears, Nose, Throat: Normocephalic\\n Cardiovascular: II/VI systolic murmur best at apex. MI is laterally\\n displaced\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\\n Respiratory / Chest: (Breath Sounds: Clear : anteriorly)\\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\\n Extremities: Right lower extremity edema: 2+, Left lower extremity\\n edema: 2+\\n Skin: Not assessed, Stage 3 sacral decubitus ulcer\\n Neurologic: Attentive, Responds to: Not assessed, Oriented (to): x3\\n Labs / Radiology\\n 159 K/uL\\n 10.0 g/dL\\n 104 mg/dL\\n 1.4 mg/dL\\n 27 mEq/L\\n 3.8 mEq/L\\n 42 mg/dL\\n 98 mEq/L\\n 134 mEq/L\\n 31.9 %\\n 4.7 K/uL\\n [image002.jpg]\\n 05:44 AM\\n 04:46 AM\\n WBC\\n 6.1\\n 4.7\\n Hct\\n 32.1\\n 31.9\\n Plt\\n 156\\n 159\\n Cr\\n 1.3\\n 1.4\\n Glucose\\n 83\\n 104\\n Other labs: PT / PTT / INR:16.8/29.3/1.5, Ca++:8.0 mg/dL, Mg++:2.1\\n mg/dL, PO4:3.3 mg/dL\\n Assessment and Plan\\n 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\\n recently discharged from the CCU () for CHF exacerbation c/b\\n C.diff infection and on for septic joint washout c/b failure to\\n extubate CHF exacerbation, who is now being admitted from \\n clinic with total body fluid overload.\\n .\\n # sCHF exacerbation: Patient has history of CHF ischemic , \\n 10%, s/p BiV ICD ( Concerto C154DWK) 1/08with EF 10% which is\\n the likely cause of her fluid overload. Her rapid accumulation\\n underpins the severity of her condition and her severely unfavourable\\n hemodynamics. Her long term goals are comfort, though she still wishes\\n to participate in rehab. Her family recognizes that she is dying. Our\\n goal is diuresis which we will attempt aggressively, reassessing our\\n progress dynamically. She put out very little o/n on lasix gtt. This\\n could reflect limitatin of diuresis or the importance of a bolus (we\\n withheld bolus to avoid instability)\\n -- goal diuresis 5 to 10L total\\n -- milrinone with bolus\\n -- metoprolol tartrate 12.5mg PO BID\\n -- slow uptitration of lasix gtt with goal near-continuous diuresis\\n while avoiding MAP < 60\\n -- strict i/o's with foley\\n -- replete K to 5\\n -- PM electrolytes\\n -- can switch to levophed if low UOP on Neo with need for pressor\\n support\\n -- family meeting with HCP to assess goals in AM after diuresis\\n attempted\\n .\\n # Septic Joints: Patient with history +staph aureus in left shoulder\\n treated by washout and vancomycin, thus far 4 weeks of monotherapy. No\\n + blood cx since before . Major issue now is pain control.\\n -- send Vanco level in AM, was recently on 500 mg q12 and switched to\\n q24 for high troughs\\n -- ultram q6, Tylenol q8, Morphine for breakthrough (2-4 mg).\\n - Will consider ms contin if no control\\n .\\n # Sacral Decub - stage 3-4.\\n - wound care\\n - pain control.\\n .\\n # UTI: positive UA, no history of culture positive UA's in system\\n - treating empirically with cipro\\n - watch INR on abx\\n .\\n # CORONARIES: Patient with h/o CAD w/ right dominant system, mild\\n instent re-stenois of the LAD BM stent and occluded RCA.\\n - bb as tolerated\\n .\\n # RHYTHM: Patient with h/o atrial fibrillation, s/p BiV ICD (\\n Concerto C154DWK) , on coumadin. Now in paced rhythm\\n - cont home dose meds (amio, metoprolol)\\n - cont coumadin\\n - f/u INR\\n .\\n # Chronic Kidney Disease: Baseline 1.3 creatinine. At baseline\\n - trend\\n .\\n # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a\\n filter in place.\\n - continue Coumadin\\n - f/u INR\\n .\\n # Hypothyroidism: Continue Levothyroxine\\n .\\n # Gout: continue Allopurinol\\n ICU Care\\n Nutrition: cardiac diet\\n Glycemic Control: None\\n Lines:\\n Multi Lumen - 05:34 PM\\n Midline - 05:34 PM\\n 18 Gauge - 05:35 PM\\n Prophylaxis:\\n DVT: Coumadin\\n Stress ulcer: Lansoprazole\\n VAP:\\n Comments:\\n Communication: patient\\n Code status: DNR/DNI\\n Disposition:\\n ------ Protected Section ------\\n Cardiology Teaching Physician Note\\n On this day I saw, examined and was physically present with the\\n resident / fellow for the key portions of the services provided. I\\n agree with the above note and plans.\\n I would add the following remarks:\\n Above discussed extensively with patient. Above discussed extensively\\n with family member, next of or health care proxy. Progress reviewed\\n extensively during family meeting.\\n DNR status discussed. DNR.\\n Total time spent on patient care: 60 minutes.\\n Additional comments:\\n diuresing well\\n DNR/DNI/defibrillator off\\n anticipate return to rehab in days\\n signed on for service performed on \\n ------ Protected Section Addendum Entered By: on:\\n 11:05 ------\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2180-01-15 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 399949,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n :\\n - diuresed ~2L over the day\\n - PM lytes & Cr solid\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Vancomycin - 08:00 AM\\n Ciprofloxacin - 08:00 AM\\n Infusions:\\n Milrinone - 0.5 mcg/Kg/min\\n Other ICU medications:\\n Coumadin (Warfarin) - 04:00 PM\\n Lansoprazole (Prevacid) - 04:00 PM\\n Morphine Sulfate - 03:25 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:20 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 36.9\\nC (98.4\\n Tcurrent: 36.4\\nC (97.5\\n HR: 65 (63 - 99) bpm\\n BP: 94/54(65) {76/49(56) - 100/62(70)} mmHg\\n RR: 13 (10 - 26) insp/min\\n SpO2: 98%\\n Heart rhythm: AV Paced\\n Wgt (current): 82.2 kg (admission): 82.2 kg\\n Total In:\\n 2,299 mL\\n 162 mL\\n PO:\\n 1,340 mL\\n TF:\\n IVF:\\n 959 mL\\n 162 mL\\n Blood products:\\n Total out:\\n 5,030 mL\\n 1,760 mL\\n Urine:\\n 5,030 mL\\n 1,760 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -2,731 mL\\n -1,598 mL\\n Respiratory support\\n O2 Delivery Device: None\\n SpO2: 98%\\n ABG: ///28/\\n Physical Examination\\n General Appearance: Well nourished, Overweight / Obese\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: Normocephalic\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Breath Sounds: Diminished: )\\n Abdominal: Soft, Obese\\n Extremities: Right lower extremity edema: Trace, Left lower extremity\\n edema: Trace\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 146 K/uL\\n 10.7 g/dL\\n 115 mg/dL\\n 1.2 mg/dL\\n 28 mEq/L\\n 3.7 mEq/L\\n 38 mg/dL\\n 94 mEq/L\\n 132 mEq/L\\n 33.1 %\\n 5.1 K/uL\\n [image002.jpg]\\n 05:44 AM\\n 04:46 AM\\n 04:00 PM\\n 03:05 AM\\n WBC\\n 6.1\\n 4.7\\n 5.1\\n Hct\\n 32.1\\n 31.9\\n 33.1\\n Plt\\n 156\\n 159\\n 146\\n Cr\\n 1.3\\n 1.4\\n 1.3\\n 1.2\\n Glucose\\n 83\\n 104\\n 155\\n 115\\n Other labs: PT / PTT / INR:18.4/29.1/1.7, Ca++:8.3 mg/dL, Mg++:2.1\\n mg/dL, PO4:2.9 mg/dL\\n Assessment and Plan\\n 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\\n recently discharged from the CCU () for CHF exacerbation c/b\\n C.diff infection and on for septic joint washout c/b failure to\\n extubate CHF exacerbation, who is now being admitted from \\n clinic with total body fluid overload.\\n .\\n # sCHF exacerbation: Patient has history of CHF ischemic , \\n 10%, s/p BiV ICD ( Concerto C154DWK) 1/08with EF 10% which is\\n the likely cause of her fluid overload. Her rapid accumulation\\n underpins the severity of her condition and her severely unfavourable\\n hemodynamics. Her long term goals are comfort, though she still wishes\\n to participate in rehab. Her family recognizes that she is dying. Our\\n goal is diuresis which we will attempt aggressively, reassessing our\\n progress dynamically. She put out very little o/n on lasix gtt. This\\n could reflect limitatin of diuresis or the importance of a bolus (we\\n withheld bolus to avoid instability)\\n -- goal diuresis 5 to 10L total\\n -- continue milrinone\\n -- metoprolol tartrate 12.5mg PO BID\\n -- slow uptitration of lasix gtt with goal near-continuous diuresis\\n while avoiding MAP < 60\\n -- strict i/o's with foley\\n -- replete K to 5\\n -- PM electrolytes\\n -- can switch to levophed if low UOP on Neo with need for pressor\\n support\\n -- family meeting with HCP prn\\n .\\n # Septic Joints: Patient with history +staph aureus in left shoulder\\n treated by washout and vancomycin, thus far 4 weeks of monotherapy. No\\n + blood cx since before . Major issue now is pain control.\\n -- send Vanco level in AM, was recently on 500 mg q12 and switched to\\n q24 for high troughs\\n -- ultram q6, Tylenol q8, Morphine for breakthrough (2-4 mg).\\n - Will consider ms contin if no control\\n .\\n # Sacral Decub - stage 3-4.\\n - wound care\\n - pain control.\\n .\\n # UTI: positive UA, no history of culture positive UA's in system\\n - treating empirically with cipro day 1 was . Last dose Morning of\\n \\n - watch INR on abx\\n .\\n # CORONARIES: Patient with h/o CAD w/ right dominant system, mild\\n instent re-stenois of the LAD BM stent and occluded RCA.\\n - bb as tolerated\\n .\\n # RHYTHM: Patient with h/o atrial fibrillation, s/p BiV ICD (\\n Concerto C154DWK) , on coumadin. Now in paced rhythm\\n - cont home dose meds (amio, metoprolol)\\n - cont coumadin\\n .\\n # Chronic Kidney Disease: Baseline 1.3 creatinine. At baseline (1.2)\\n - trend\\n .\\n # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a\\n filter in place.\\n - continue Coumadin\\n .\\n # Hypothyroidism: Continue Levothyroxine\\n .\\n # Gout: continue Allopurinol\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 05:34 PM\\n Midline - 05:34 PM\\n 18 Gauge - 05:35 PM\\n Prophylaxis:\\n DVT: SQ UF Heparin\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Family meeting held , ICU consent signed Comments:\\n Code status: DNR / DNI\\n Disposition:ICU\\n ------ Protected Section ------\\n Cardiology Teaching Physician Note\\n On this day I saw, examined and was physically present with the\\n resident / fellow for the key portions of the services provided. I\\n agree with the above note and plans.\\n I would add the following remarks:\\n Above discussed extensively with patient.\\n DNR status discussed. DNR.\\n Total time spent on patient care: 45 minutes.\\n Additional comments:\\n diuresing very well; > 5 liters off net los\\n anticipate 24-48 hours more volume unloading (until creat shows rise)\\n plan to return to rehab\\n ------ Protected Section Addendum Entered By: on:\\n 11:06 ------\\n\"\n },\n {\n \"category\": \"General\",\n \"chartdate\": \"2180-01-13 00:00:00.000\",\n \"description\": \"Code Discussion\",\n \"row_id\": 399725,\n \"text\": \"TITLE:\\n Discussion of code status:\\n Dr. discussed patient\\ns code status with her this morning.\\n Code status was confirmed with the patient to be DNR/DNI. In addition,\\n after discussing with the patient, we will deactivate the defibrillator\\n shocking function of her ICD.\\n Furthermore, we have confirmed with the patient that, moving forward,\\n no escalation of care will be initiated. Patient is currently on\\n milrinone and phenylephrine. If patient has increased pain requiring\\n more morphine which results in more pressor requirements, or if patient\\n clinically worsens requiring more pressor support, will transition\\n patient to CMO.\\n This discussion was undertaken between the patient and Dr. ,\\n in the presence of the CCU fellow and house staff.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2180-01-15 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 399922,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n :\\n - diuresed ~2L over the day\\n - PM lytes & Cr solid\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Vancomycin - 08:00 AM\\n Ciprofloxacin - 08:00 AM\\n Infusions:\\n Milrinone - 0.5 mcg/Kg/min\\n Other ICU medications:\\n Coumadin (Warfarin) - 04:00 PM\\n Lansoprazole (Prevacid) - 04:00 PM\\n Morphine Sulfate - 03:25 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:20 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 36.9\\nC (98.4\\n Tcurrent: 36.4\\nC (97.5\\n HR: 65 (63 - 99) bpm\\n BP: 94/54(65) {76/49(56) - 100/62(70)} mmHg\\n RR: 13 (10 - 26) insp/min\\n SpO2: 98%\\n Heart rhythm: AV Paced\\n Wgt (current): 82.2 kg (admission): 82.2 kg\\n Total In:\\n 2,299 mL\\n 162 mL\\n PO:\\n 1,340 mL\\n TF:\\n IVF:\\n 959 mL\\n 162 mL\\n Blood products:\\n Total out:\\n 5,030 mL\\n 1,760 mL\\n Urine:\\n 5,030 mL\\n 1,760 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -2,731 mL\\n -1,598 mL\\n Respiratory support\\n O2 Delivery Device: None\\n SpO2: 98%\\n ABG: ///28/\\n Physical Examination\\n General Appearance: Well nourished, Overweight / Obese\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: Normocephalic\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Breath Sounds: Diminished: )\\n Abdominal: Soft, Obese\\n Extremities: Right lower extremity edema: Trace, Left lower extremity\\n edema: Trace\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 146 K/uL\\n 10.7 g/dL\\n 115 mg/dL\\n 1.2 mg/dL\\n 28 mEq/L\\n 3.7 mEq/L\\n 38 mg/dL\\n 94 mEq/L\\n 132 mEq/L\\n 33.1 %\\n 5.1 K/uL\\n [image002.jpg]\\n 05:44 AM\\n 04:46 AM\\n 04:00 PM\\n 03:05 AM\\n WBC\\n 6.1\\n 4.7\\n 5.1\\n Hct\\n 32.1\\n 31.9\\n 33.1\\n Plt\\n 156\\n 159\\n 146\\n Cr\\n 1.3\\n 1.4\\n 1.3\\n 1.2\\n Glucose\\n 83\\n 104\\n 155\\n 115\\n Other labs: PT / PTT / INR:18.4/29.1/1.7, Ca++:8.3 mg/dL, Mg++:2.1\\n mg/dL, PO4:2.9 mg/dL\\n Assessment and Plan\\n 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\\n recently discharged from the CCU () for CHF exacerbation c/b\\n C.diff infection and on for septic joint washout c/b failure to\\n extubate CHF exacerbation, who is now being admitted from \\n clinic with total body fluid overload.\\n .\\n # sCHF exacerbation: Patient has history of CHF ischemic , \\n 10%, s/p BiV ICD ( Concerto C154DWK) 1/08with EF 10% which is\\n the likely cause of her fluid overload. Her rapid accumulation\\n underpins the severity of her condition and her severely unfavourable\\n hemodynamics. Her long term goals are comfort, though she still wishes\\n to participate in rehab. Her family recognizes that she is dying. Our\\n goal is diuresis which we will attempt aggressively, reassessing our\\n progress dynamically. She put out very little o/n on lasix gtt. This\\n could reflect limitatin of diuresis or the importance of a bolus (we\\n withheld bolus to avoid instability)\\n -- goal diuresis 5 to 10L total\\n -- continue milrinone\\n -- metoprolol tartrate 12.5mg PO BID\\n -- slow uptitration of lasix gtt with goal near-continuous diuresis\\n while avoiding MAP < 60\\n -- strict i/o's with foley\\n -- replete K to 5\\n -- PM electrolytes\\n -- can switch to levophed if low UOP on Neo with need for pressor\\n support\\n -- family meeting with HCP prn\\n .\\n # Septic Joints: Patient with history +staph aureus in left shoulder\\n treated by washout and vancomycin, thus far 4 weeks of monotherapy. No\\n + blood cx since before . Major issue now is pain control.\\n -- send Vanco level in AM, was recently on 500 mg q12 and switched to\\n q24 for high troughs\\n -- ultram q6, Tylenol q8, Morphine for breakthrough (2-4 mg).\\n - Will consider ms contin if no control\\n .\\n # Sacral Decub - stage 3-4.\\n - wound care\\n - pain control.\\n .\\n # UTI: positive UA, no history of culture positive UA's in system\\n - treating empirically with cipro day 1 was . Last dose Morning of\\n \\n - watch INR on abx\\n .\\n # CORONARIES: Patient with h/o CAD w/ right dominant system, mild\\n instent re-stenois of the LAD BM stent and occluded RCA.\\n - bb as tolerated\\n .\\n # RHYTHM: Patient with h/o atrial fibrillation, s/p BiV ICD (\\n Concerto C154DWK) , on coumadin. Now in paced rhythm\\n - cont home dose meds (amio, metoprolol)\\n - cont coumadin\\n .\\n # Chronic Kidney Disease: Baseline 1.3 creatinine. At baseline (1.2)\\n - trend\\n .\\n # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a\\n filter in place.\\n - continue Coumadin\\n .\\n # Hypothyroidism: Continue Levothyroxine\\n .\\n # Gout: continue Allopurinol\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 05:34 PM\\n Midline - 05:34 PM\\n 18 Gauge - 05:35 PM\\n Prophylaxis:\\n DVT: SQ UF Heparin\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Family meeting held , ICU consent signed Comments:\\n Code status: DNR / DNI\\n Disposition:ICU\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2180-01-15 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 399992,\n \"text\": \"71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\\n : Sent to ED from clinic w/ hypotension\\n transiently on\\n dopa, Tx\\nd w/ NS 250 cc w/ SBP ^ 92. Admit to CCU for aggressive\\n diuresis.\\n Ineffective Coping\\n Assessment:\\n Pt having difficulty coping with chronicity of illness and inevitable\\n return to rehab/nursing home\\n Action:\\n Pt very weepy today after Cardiology team talked to pt about returning\\n to rehab once she is better\\n RN allowed pt to voice feelings about illness\\n conversation about hospice with RN after it was brought up by CHF\\n attending\\n Response:\\n less weepy, visiting with family members, interactive\\n :\\n Social service, Case Management consults on Monday AM\\n Cont encourage pt to vent feelings, Cont to provide emotional support\\n for patient.\\n Pain control (acute pain, chronic pain)\\n Assessment:\\n pt with acute pain at wound site on coccyx, increases when pt sitting\\n up in bed for meals\\n of note, pt states pain is tolerable at 8/10\\n severe at \\n Action:\\n receiving Ultram, Acetaminophen ATC, MSO4 2mg IV prn, MS Contin 15mg po\\n added\\n Response:\\n pt in most pain while sitting upright for meals; sleeping well in naps\\n while lying on right side\\n Plan:\\n Assess response to MS Contin; Assess/Re-assess pain;\\n ? pressure reducing cushion for periods when pt sits upright\\n refusing to wear waffle boots; does not want kinair bed.\\n .H/O heart failure (CHF), Systolic, Acute on Chronic\\n Assessment:\\n diuresing well on Lasiv 10mg iv and Milrinone 0.5mcgs/kg/min\\n Action:\\n Lasix decreased to 10mg/hr secondary to u/o > 300/hr\\n Response:\\n remains with urine > 100ml/hr\\n Plan:\\n Impaired Skin Integrity\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2180-01-15 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 399993,\n \"text\": \"71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\\n : Sent to ED from clinic w/ hypotension\\n transiently on\\n dopa, Tx\\nd w/ NS 250 cc w/ SBP ^ 92. Admit to CCU for aggressive\\n diuresis.\\n Ineffective Coping\\n Assessment:\\n Pt having difficulty coping with chronicity of illness and inevitable\\n return to rehab/nursing home\\n Action:\\n Pt very weepy today after Cardiology team talked to pt about returning\\n to rehab once she is better\\n RN allowed pt to voice feelings about illness\\n conversation about hospice with RN after it was brought up by CHF\\n attending\\n Response:\\n less weepy, visiting with family members, interactive\\n :\\n Social service, Case Management consults on Monday AM\\n Cont encourage pt to vent feelings, Cont to provide emotional support\\n for patient.\\n Pain control (acute pain, chronic pain)\\n Assessment:\\n pt with acute pain at wound site on coccyx, increases when pt sitting\\n up in bed for meals\\n of note, pt states pain is tolerable at 8/10\\n severe at \\n Action:\\n receiving Ultram, Acetaminophen ATC, MSO4 2mg IV prn, MS Contin 15mg po\\n added\\n Response:\\n pt in most pain while sitting upright for meals; sleeping well in naps\\n while lying on right side\\n Plan:\\n Assess response to MS Contin; Assess/Re-assess pain;\\n ? pressure reducing cushion for periods when pt sits upright\\n refusing to wear waffle boots; does not want kinair bed.\\n .H/O heart failure (CHF), Systolic, Acute on Chronic\\n Assessment:\\n diuresing well on Lasix 10mg iv and Milrinone 0.5mcgs/kg/min\\n Action:\\n Lasix decreased to 10mg/hr secondary to u/o > 300/hr\\n Response:\\n remains with urine > 100ml/hr; 6 liters LOS negative\\n Plan:\\n Cont gentle diuresis until CR bumps or BP drops per Dr \\n Replace lytes as needed\\n Impaired Skin Integrity\\n Assessment:\\n large pressure ulcer on coccyx area 5.5X6cm base yellow/black\\n Action:\\n duoderm gel/Mepilex reapplied today\\n Response:\\n site unchanged\\n Plan:\\n Cont frequent turns, keep off back as much as possible however, pt\\n needs to sit upright in bed to eat\\n pt refusing waffle boots, pressure reducing bed\\n Wound care consult on Monday AM.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2180-01-15 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 399927,\n \"text\": \"71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\\n : Sent to ED from clinic w/ hypotension\\n transiently on\\n dopa, Tx\\nd w/ NS 250 cc w/ SBP ^ 92. Admit to CCU for aggressive\\n diuresis.\\n Heart failure (CHF), Systolic, Acute on Chronic\\n Assessment:\\n + pitting edema BLE\\non lasix gtt 15mg/hr & milrinone 0.5mcg/k/min.\\n LS clr, dim at bases.\\n Action:\\n 1^st dose 25mg PO lopressor given\\n Response:\\n BPs lower when asleep and after morphine, MAPs >55 (of note: BPs taken\\n on L upper arm, pt mosly positioned on R side). K+ 3.7\\nto be repleted,\\n and Mg+ 2.1. Neg 2L since MN. Neg 5L LOS. Rare short runs AIVR.\\n Plan:\\n CHF management, aggressive diuresis w/ lasix & daily\\n metolazone-- goal NEG 5-10L overall, strict I/Os, Low Na+ diet, daily\\n wts, monitor & replete lytes as indicated\\n DNR/DNI-ICD turned off after fam mtg. Both pt and HCP\\n are in agreement that pt would like to be comfortable to be able to\\n participate in rehab.\\n Impaired Skin Integrity\\n Assessment:\\n *Lg stage 3 vs. unstageable decub to coccyx, covered w/ yellow slough &\\n red blanching borders--sm amt serous dsg\\n mepilex intact, placed \\n *Red, blanching heels.\\n *Dry and thin skin w/ discolored areas.\\n *Good appetite. Declines Kinair bed/waffle boots\\n Action:\\n Mepilex dsg peeled to check skin--Duoderm hydroactive gel\\n applied per wound care recs .\\n Heels elevated on pillows, skin/pressure area well\\n lubricated.\\n Slight freq position changes avoiding back and L side.\\n Response:\\n Skin unchanged\\n Plan:\\n Monitor for changes, prevent further breathdown. Change\\n position freq as tolerated as pt mobility/able to turn self is very\\n limited.\\n Change mepilex w/ duoderm gel daily drainage\\n Pain control (chronic pain)\\n Assessment:\\n Very uncomfortable w/ turning and w/ laying on L side\\n Action:\\n Standing order ultram & Tylenol Q6hrs, 2mg Morphine sulfate\\n IVP for breakthrough pain\\n Pt positioned mostly far on R side w/ slight position\\n changes, placed supine for short periods only.\\n Response:\\n Pt allowed to rest in btwn necessary nsg interventions, Slept well all\\n night.\\n Plan:\\n Continue current pain control regimen, medicate w/ morphine\\n prior to turning side to side\\n GI: NO BM, takes pills crushed in applesauce\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2180-01-13 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 399698,\n \"text\": \"Chief Complaint: anasarca\\n 24 Hour Events:\\n MULTI LUMEN - START 05:34 PM\\n MIDLINE - START 05:34 PM\\n - poor UOP to 2.5 and 5mg/hr lasix drip.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Milrinone - 0.375 mcg/Kg/min\\n Furosemide (Lasix) - 5 mg/hour\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Constitutional: Fatigue\\n Flowsheet Data as of 06:49 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 36.1\\nC (97\\n Tcurrent: 36\\nC (96.8\\n HR: 72 (70 - 108) bpm\\n BP: 97/52(64) {77/44(52) - 113/76(84)} mmHg\\n RR: 13 (11 - 18) insp/min\\n SpO2: 96%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 82.2 kg (admission): 82.2 kg\\n Total In:\\n 417 mL\\n 156 mL\\n PO:\\n 120 mL\\n 60 mL\\n TF:\\n IVF:\\n 47 mL\\n 96 mL\\n Blood products:\\n Total out:\\n 550 mL\\n 410 mL\\n Urine:\\n 200 mL\\n 410 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -133 mL\\n -254 mL\\n Respiratory support\\n O2 Delivery Device: None\\n SpO2: 96%\\n ABG: ///26/\\n Physical Examination\\n General Appearance: No acute distress, Thin, cachectic\\n Head, Ears, Nose, Throat: Normocephalic\\n Cardiovascular: II/VI systolic murmur best at apex. PMI is laterally\\n displaces\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\\n Respiratory / Chest: (Breath Sounds: Clear : anteriors)\\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended, fluid\\n wave\\n Extremities: Right lower extremity edema: 4+, Left lower extremity\\n edema: 4+\\n Skin: Not assessed, Stage 3 sacral decub\\n Neurologic: Attentive, Responds to: Not assessed, Oriented (to): x3,\\n Movement: Not assessed, Tone: Not assessed\\n Labs / Radiology\\n 156 K/uL\\n 10.0 g/dL\\n 83 mg/dL\\n 1.3 mg/dL\\n 26 mEq/L\\n 4.3 mEq/L\\n 46 mg/dL\\n 99 mEq/L\\n 137 mEq/L\\n 32.1 %\\n 6.1 K/uL\\n [image002.jpg]\\n 05:44 AM\\n WBC\\n 6.1\\n Hct\\n 32.1\\n Plt\\n 156\\n Cr\\n 1.3\\n Glucose\\n 83\\n Other labs: PT / PTT / INR:15.7/36.8/1.4, Mg++:2.1 mg/dL\\n Fluid analysis / Other labs: UA = WBC + clumps. Mod Bacteria\\n Assessment and Plan\\n 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\\n recently discharged from the CCU () for CHF exacerbation c/b\\n C.diff infection and on for septic joint washout c/b failure to\\n extubate CHF exacerbation, who is now being admitted from \\n clinic with total body fluid overload.\\n .\\n # Anasarca: Patient has history of CHF ischemic , 10%, s/p\\n BiV ICD ( Concerto C154DWK) 1/08with EF 10% which is the\\n likely cause of her fluid overload. Her rapid accumulation underpins\\n the severity of her condition and her severely unfavourable\\n hemodynamics. Her long term goals are comfort, though she still wishes\\n to participate in rehab. Her family recognizes that she is dying. Our\\n goal is diuresis which we will attempt aggressively, reassessing our\\n progress dynamically. She put out very little o/n on lasix gtt. This\\n could reflect limitatin of diuresis or the importance of a bolus (we\\n withheld bolus to avoid instability)\\n -- milrinone with bolus\\n -- neosynephrine for pressure support, goal MAP of > 60\\n -- slow uptitration of lasix with goal near-continuous diuresis while\\n avoiding MAP < 60\\n -- strict i/o's with foley\\n -- can switch to levophed if low UOP on Neo with need for pressor\\n support\\n -- family meeting with HCP to assess goals in AM after diuresis\\n attempted\\n .\\n # Septic Joints: Patient with history +staph aureus in left shoulder\\n treated by washout and vancomycin, thus far 4 weeks of monotherapy. No\\n + blood cx since before . Major issue now is pain control.\\n -- send Vanco level in AM, was recently on 500 mg q12 and switched to\\n q24 for high troughs\\n -- ultram q6, Tylenol q8, Morphine for breakthrough (1-3 mg).\\n - Will consider ms contin if no control\\n .\\n # Sacral Decub - stage 3-4.\\n - wound care\\n - pain control.\\n .\\n # UTI: positive UA, no history of culture positive UA's in system\\n - treating empirically with cipro\\n - watch INR on abx\\n .\\n # CORONARIES: Patient with h/o CAD w/ right dominant system, mild\\n instent re-stenois of the LAD BM stent and occluded RCA.\\n - bb as tolerated\\n .\\n # RHYTHM: Patient with h/o atrial fibrillation, s/p BiV ICD (\\n Concerto C154DWK) , on coumadin. Now in paced rhythm\\n - cont home dose meds (amio, metoprolol)\\n - cont coumadin\\n - f/u INR\\n .\\n # Chronic Kidney Disease: Baseline 1.3 creatinine. At baseline\\n - trend\\n .\\n # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a\\n filter in place.\\n - cont coumadin\\n - f/u INR\\n .\\n # Hypothyroidism: Continue Levothyroxine.\\n .\\n # Gout: continue allopurionl\\n .\\n # FEN: low sodium diet\\n .\\n # ACCESS: Right PICC, right IJ, Left EJ\\n .\\n # PROPHYLAXIS: on coumadin\\n .\\n # CODE: DNR/DNI\\n .\\n # DISPO: CCU for now.\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 05:34 PM\\n Midline - 05:34 PM\\n 18 Gauge - 05:35 PM\\n Prophylaxis:\\n DVT: (Systemic anticoagulation: Coumadin)\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: DNR (do not resuscitate)\\n Disposition:ICU\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2180-01-13 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 399702,\n \"text\": \"Pt is a 71 yo female with PMH: BM stent to LAD ', Occluded RCA\\n without intervention, Ischemic CM (EF 10-25%), BiV ICD, AF, PVD, DVT\\n s/p IVC filter, coumadin, hypothyroidism, CKD, OA. adm for HF\\n (milrinone/lasix) MRSA in L shoulder, L hip and R knuckle. Out to\\n rehab . went from rehab to see Dr. , sent to EW with\\n hypotension. SBP 70 in EW, transiently on dopa, but cardiology d/c'd.\\n Rxd with NS 250 cc with SBP 92. Pt has been in rehab since d/c from\\n with septic arthritis in L shoulder, hip and R knuckle.\\n On Vanco followed by ID.\\n She was started on milrinone .375 after bolus\\n Pain control (acute pain, chronic pain)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n .H/O heart failure (CHF), Systolic, Acute on Chronic\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Impaired Skin Integrity\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2180-01-17 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 400075,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n - MS contin increased to 30mg last night, received 2 doses w pills\\n crushed, complained of nausea after each\\n - Has not had a BM for four days\\n - PT ordered yesterday\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Ciprofloxacin - 08:00 AM\\n Vancomycin - 09:36 AM\\n Infusions:\\n Furosemide (Lasix) - 10 mg/hour\\n Milrinone - 0.5 mcg/Kg/min\\n Other ICU medications:\\n Morphine Sulfate - 12:45 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:41 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 36.8\\nC (98.3\\n Tcurrent: 36.6\\nC (97.8\\n HR: 68 (63 - 75) bpm\\n BP: 91/52(62) {75/44(51) - 98/61(70)} mmHg\\n RR: 9 (9 - 29) insp/min\\n SpO2: 99%\\n Heart rhythm: AV Paced\\n Wgt (current): 77.3 kg (admission): 82.2 kg\\n Total In:\\n 1,004 mL\\n 146 mL\\n PO:\\n 440 mL\\n TF:\\n IVF:\\n 564 mL\\n 146 mL\\n Blood products:\\n Total out:\\n 2,410 mL\\n 420 mL\\n Urine:\\n 2,410 mL\\n 420 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,406 mL\\n -274 mL\\n Respiratory support\\n O2 Delivery Device: None\\n SpO2: 99%\\n ABG: ///34/\\n Physical Examination\\n Gen: alert, oriented x3 but appears to have psychomotor retardation and\\n easily confused\\n HEENT: slightly dry mucus membranes\\n CHEST: regular rhythm ; dry basilar crackles\\n ABD: mildly distended, soft, nontender\\n EXT: + pitting edema bilaterally\\n Labs / Radiology\\n 106 K/uL\\n 10.0 g/dL\\n 86 mg/dL\\n 1.0 mg/dL\\n 34 mEq/L\\n 3.7 mEq/L\\n 33 mg/dL\\n 92 mEq/L\\n 134 mEq/L\\n 30.9 %\\n 4.2 K/uL\\n [image002.jpg]\\n 05:44 AM\\n 04:46 AM\\n 04:00 PM\\n 03:05 AM\\n 03:17 PM\\n 03:05 AM\\n 05:03 PM\\n 05:22 AM\\n WBC\\n 6.1\\n 4.7\\n 5.1\\n 4.4\\n 4.2\\n Hct\\n 32.1\\n 31.9\\n 33.1\\n 32.2\\n 30.9\\n Plt\\n 156\\n 159\\n 146\\n 134\\n 106\\n Cr\\n 1.3\\n 1.4\\n 1.3\\n 1.2\\n 1.1\\n 1.0\\n 1.0\\n 1.0\\n Glucose\\n 83\\n 104\\n 155\\n 115\\n 98\\n 107\\n 86\\n Other labs: PT / PTT / INR:20.2/33.1/1.9, Ca++:8.1 mg/dL, Mg++:2.1\\n mg/dL, PO4:2.7 mg/dL\\n Assessment and Plan\\n 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\\n recently discharged from the CCU () for CHF exacerbation c/b\\n C.diff infection and on for septic joint washout c/b failure to\\n extubate CHF exacerbation, who is now being admitted from \\n clinic with total body fluid overload.\\n .\\n # sCHF exacerbation:\\n Patient has history of CHF ischemic , 10%, s/p BiV ICD\\n ( Concerto C154DWK) with EF 10% which is the likely cause\\n of her fluid overload. Her rapid accumulation underpins the severity of\\n her condition and her severely unfavourable hemodynamics. Her long term\\n goals are comfort, though she still wishes to participate in rehab. Her\\n family recognizes that she is dying. Our goal is diuresis which we will\\n attempt aggressively, reassessing our progress dynamically. She\\n diuresed well on Lasix gtt on with net neg 4L balance. LOS fluid\\n balance -5L.\\n -- goal diuresis 1L negative today with lasix gtt\\n -- continue milrinone\\n -- continue metolazone 5mg daily\\n -- continue metoprolol tartrate 12.5mg PO BID\\n -- strict i/o's with foley\\n -- replete K to 5\\n -- PM electrolytes\\n -- family meeting with HCP prn\\n .\\n # Septic Joints: Patient with history +staph aureus in left shoulder\\n treated by washout and vancomycin, thus far 4 weeks of monotherapy. No\\n + blood cx since before . Major issue now is pain control.\\n -- continue vanc, was recently on 500 mg q12 and switched to q24 for\\n high troughs\\n -- continue cipro\\n -- increase MS contin to 30mg \\n -- ultram q6, Tylenol q8, Morphine for breakthrough (2-4 mg).\\n .\\n # Sacral Decub - stage 3-4.\\n - wound care\\n - increase MS contin to 30mg \\n - pain control\\n .\\n # UTI: positive UA, no history of culture positive UA's in system\\n - treating empirically with cipro day 1 was . Last dose tomorrow\\n morning (Morning of ^st)\\n - watch INR on abx\\n .\\n # CORONARIES: Patient with h/o CAD w/ right dominant system, mild\\n instent re-stenois of the LAD BM stent and occluded RCA.\\n - bb as tolerated\\n .\\n # RHYTHM: Patient with h/o atrial fibrillation, s/p BiV ICD (\\n Concerto C154DWK) , on coumadin. Now in paced rhythm\\n - cont home dose meds (amio, metoprolol)\\n - cont coumadin\\n .\\n # Chronic Kidney Disease: Baseline Creatinine 1.3. Creatinine 1.1\\n today.\\n - trend\\n .\\n # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a\\n filter in place.\\n - continue Coumadin\\n .\\n # Hypothyroidism: Continue Levothyroxine\\n .\\n # Gout: continue Allopurinol\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 05:34 PM\\n Midline - 05:34 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: DNR / DNI\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2180-01-17 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 400083,\n \"text\": \"71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\\n : Sent to ED from clinic w/ hypotension\\n transiently on\\n dopa, Tx\\nd w/ NS 250 cc w/ SBP ^ 92.\\n Admit to CCU for aggressive diuresis.She was started on Milrinone\\n and lasix gtt. And has been diuresing well. She has lg coccyx decub\\n that is a source of chronic pain. She is DNR/DNI and defibrillator has\\n been shut off. She has excellent apetite.\\n Pain control (acute pain, chronic pain)\\n Assessment:\\n Plan is to transition to oral forms of pain control in preparation for\\n pt going to rehab. She had received MS contin at 0600, but pill was\\n ground and pt had nausea. She received 4mg IV morphine at 6am as well.\\n Action:\\n MS contin will be given in to 15mg pills, which are smaller and can\\n take them without having them crushed. Morphine immediate release has\\n been ordered for breakthrough pain. It is also a small pill that she\\n can take without crushing..\\n Response:\\n Plan:\\n Impaired Skin Integrity\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n .H/O heart failure (CHF), Systolic, Acute on Chronic\\n Assessment:\\n Pt being transition for transfer back to rehab. Milrinone and lasix\\n drips stopped at 1030.\\n Action:\\n At noon she received dose of torsemide 40mg po and metolazone 5mg po.\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"General\",\n \"chartdate\": \"2180-01-18 00:00:00.000\",\n \"description\": \"Generic Note\",\n \"row_id\": 400135,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n - lasix gtt stopped and pt started on torsemide 40mg + metolazone\\n 5mg daily (needs to drop to 2.5mg daily metolazone tomorrow)\\n - started IR morphine po for breakthrough 15mg 4h prn (w IV as backup)\\n - Pain and Palliative Care consulted -- leave pain regimen as is for\\n now, will reassess 24hr needs tomorrow; MD had discussion w patient\\n about Do-Not-Hospitalize, and pt would like HCP/family to be a part of\\n that discussion rather than herself--> need to discuss w dr. also\\n - milrinone stopped in AM, but restarted milrinone bc blood pressures\\n not maintained otherwise (dropped to 70s systolic without) and urine\\n output decreased.\\n - family meeting scheduled for at 1pm - will need Dr. and\\n palliative care present.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Vancomycin - 08:00 AM\\n Ciprofloxacin - 10:00 AM\\n Infusions:\\n Other ICU medications:\\n Morphine Sulfate - 10:32 AM\\n Coumadin (Warfarin) - 04:00 PM\\n Omeprazole (Prilosec) - 04:00 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:51 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 36.9\\nC (98.4\\n Tcurrent: 36.9\\nC (98.4\\n HR: 69 (55 - 71) bpm\\n BP: 85/56(63) {74/43(53) - 97/62(69)} mmHg\\n RR: 13 (9 - 20) insp/min\\n SpO2: 96%\\n Heart rhythm: V Paced\\n Wgt (current): 74 kg (admission): 82.2 kg\\n Height: 60 Inch\\n Total In:\\n 1,052 mL\\n 201 mL\\n PO:\\n 450 mL\\n 120 mL\\n TF:\\n IVF:\\n 602 mL\\n 81 mL\\n Blood products:\\n Total out:\\n 1,571 mL\\n 320 mL\\n Urine:\\n 1,571 mL\\n 320 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -519 mL\\n -119 mL\\n Respiratory support\\n O2 Delivery Device: None\\n SpO2: 96%\\n ABG: ///35/\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 116 K/uL\\n 10.2 g/dL\\n 93 mg/dL\\n 1.0 mg/dL\\n 35 mEq/L\\n 3.8 mEq/L\\n 32 mg/dL\\n 91 mEq/L\\n 132 mEq/L\\n 31.2 %\\n 4.6 K/uL\\n [image002.jpg]\\n 05:44 AM\\n 04:46 AM\\n 04:00 PM\\n 03:05 AM\\n 03:17 PM\\n 03:05 AM\\n 05:03 PM\\n 05:22 AM\\n 05:25 PM\\n 05:40 AM\\n WBC\\n 6.1\\n 4.7\\n 5.1\\n 4.4\\n 4.2\\n 4.6\\n Hct\\n 32.1\\n 31.9\\n 33.1\\n 32.2\\n 30.9\\n 31.2\\n Plt\\n 156\\n 159\\n 146\\n 134\\n 106\\n 116\\n Cr\\n 1.3\\n 1.4\\n 1.3\\n 1.2\\n 1.1\\n 1.0\\n 1.0\\n 1.0\\n 1.1\\n 1.0\\n Glucose\\n 83\\n 104\\n 155\\n 115\\n 98\\n 107\\n 86\\n 93\\n Other labs: PT / PTT / INR:19.1/29.7/1.7, Ca++:8.1 mg/dL, Mg++:2.1\\n mg/dL, PO4:2.8 mg/dL\\n Assessment and Plan\\n 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\\n recently discharged from the CCU () for CHF exacerbation c/b\\n C.diff infection and on for septic joint washout c/b failure to\\n extubate CHF exacerbation, who was admitted from clinic with\\n total body fluid overload.\\n .\\n # sCHF Exacerbation:\\n Patient has history of CHF ischemic , 10%, s/p BiV ICD\\n ( Concerto C154DWK) with EF 10% which was the likely\\n cause of her fluid overload. Appears intravascularly euvolemic on\\n exam, no need to continue lasix gtt. Has diuresed well -9L on length\\n of stay. Responding well to torsemide with metolazone while on\\n milrinone, but urine output had dropped without milrinone yesterday.\\n Diuresed net -500cc over last day.\\n - Continue milrinone for now\\n - Continue torsemide 40mg with metolazone 5mg for now\\n - Continue strict I/Os\\n - Continue to replete K\\n .\\n # Goals of Care:\\n End-stage CHF with long term goals are comfort, though she still wishes\\n to participate in rehab. Her family recognizes that she is dying. Pain\\n and Palliative Care consulted yesterday for pain control and goals of\\n care.\\n - family meeting at 1pm today\\n .\\n # Septic Joints: Patient with history +staph aureus in left shoulder\\n treated by washout and vancomycin, thus far 4 weeks of monotherapy. No\\n + blood cx since before . Major issue now is pain control.\\n - continue vancomycin until , then suppression with doxycycline\\n -- continue MS contin 30mg and reassess pain med needs\\n -- standing ultram q6, Tylenol q8\\n .\\n # Sacral Decub - stage 3-4. Focusing on Pain control. Pain and\\n Palliative Care following with patient. Switched to oral breakthrough\\n Morphine with IV as backup, but patient was not requiring IV backup.\\n - wound care\\n - standing ultram Q6h, Tylenol Q8h\\n - reassess patient\\ns pain requirements\\n - goals of care family meeting 1pm today\\n .\\n # UTI: positive UA, no history of culture positive UA's in system.\\n Will do 10day course because of chronic foley.\\n - treating empirically with cipro ; day 1 of 10 day course was \\n - watch INR on abx\\n .\\n # Hx CAD:\\n Patient with h/o CAD w/ right dominant system, mild instent re-stenois\\n of the LAD BM stent and occluded RCA.\\n - continue metoprolol 25mg \\n .\\n # Hx Afib:\\n Patient with h/o atrial fibrillation, s/p BiV ICD ( Concerto\\n C154DWK) , on coumadin. Now in paced rhythm\\n - cont home dose meds (amio, metoprolol)\\n - cont coumadin\\n - trend INR\\n .\\n # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a\\n filter in place. INR mildly subtherapeutic despite Cipro\\n - continue Coumadin\\n - monitor INR\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines: midline, right IJ\\n Multi Lumen - 05:34 PM\\n Midline - 05:34 PM\\n Prophylaxis:\\n DVT: coumadin\\n Stress ulcer: lansoprazole\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: DNR / DNI\\n Disposition:\\n\"\n },\n {\n \"category\": \"General\",\n \"chartdate\": \"2180-01-18 00:00:00.000\",\n \"description\": \"Generic Note\",\n \"row_id\": 400139,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n - lasix gtt stopped and pt started on torsemide 40mg + metolazone\\n 5mg daily\\n - started IR morphine po for breakthrough 15mg 4h prn (w IV as backup)\\n yesterday, and patient did not require IV backup\\n - Pain and Palliative Care consulted\\n - milrinone stopped yesterday AM, but restarted milrinone bc blood\\n pressures not maintained otherwise (dropped to 70s systolic without)\\n and urine output decreased.\\n - family meeting scheduled for at 1pm - will need Dr. and\\n palliative care present\\n - does not have any complaints of pain or sob this AM\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Vancomycin - 08:00 AM\\n Ciprofloxacin - 10:00 AM\\n Infusions:\\n Other ICU medications:\\n Morphine Sulfate - 10:32 AM\\n Coumadin (Warfarin) - 04:00 PM\\n Omeprazole (Prilosec) - 04:00 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:51 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 36.9\\nC (98.4\\n Tcurrent: 36.9\\nC (98.4\\n HR: 69 (55 - 71) bpm\\n BP: 85/56(63) {74/43(53) - 97/62(69)} mmHg\\n RR: 13 (9 - 20) insp/min\\n SpO2: 96%\\n Heart rhythm: V Paced\\n Wgt (current): 74 kg (admission): 82.2 kg\\n Height: 60 Inch\\n Total In:\\n 1,052 mL\\n 201 mL\\n PO:\\n 450 mL\\n 120 mL\\n TF:\\n IVF:\\n 602 mL\\n 81 mL\\n Blood products:\\n Total out:\\n 1,571 mL\\n 320 mL\\n Urine:\\n 1,571 mL\\n 320 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -519 mL\\n -119 mL\\n Respiratory support\\n O2 Delivery Device: None\\n SpO2: 96%\\n ABG: ///35/\\n Physical Examination\\n Gen: sleepy but easily awakened, oriented x3, easily confused, appears\\n to have psychomotor slowing\\n HEENT: dry mucus membranes\\n NECK: JVP not elevated\\n CHEST: regular rhythm ; mild dry basilar crackles laterally\\n ABD: mildly distended, soft, nontender\\n EXT: + pitting edema bilaterally\\n Labs / Radiology\\n 116 K/uL\\n 10.2 g/dL\\n 93 mg/dL\\n 1.0 mg/dL\\n 35 mEq/L\\n 3.8 mEq/L\\n 32 mg/dL\\n 91 mEq/L\\n 132 mEq/L\\n 31.2 %\\n 4.6 K/uL\\n [image002.jpg]\\n 05:44 AM\\n 04:46 AM\\n 04:00 PM\\n 03:05 AM\\n 03:17 PM\\n 03:05 AM\\n 05:03 PM\\n 05:22 AM\\n 05:25 PM\\n 05:40 AM\\n WBC\\n 6.1\\n 4.7\\n 5.1\\n 4.4\\n 4.2\\n 4.6\\n Hct\\n 32.1\\n 31.9\\n 33.1\\n 32.2\\n 30.9\\n 31.2\\n Plt\\n 156\\n 159\\n 146\\n 134\\n 106\\n 116\\n Cr\\n 1.3\\n 1.4\\n 1.3\\n 1.2\\n 1.1\\n 1.0\\n 1.0\\n 1.0\\n 1.1\\n 1.0\\n Glucose\\n 83\\n 104\\n 155\\n 115\\n 98\\n 107\\n 86\\n 93\\n Other labs: PT / PTT / INR:19.1/29.7/1.7, Ca++:8.1 mg/dL, Mg++:2.1\\n mg/dL, PO4:2.8 mg/dL\\n Assessment and Plan\\n 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\\n recently discharged from the CCU () for CHF exacerbation c/b\\n C.diff infection and on for septic joint washout c/b failure to\\n extubate CHF exacerbation, who was admitted from clinic with\\n total body fluid overload.\\n .\\n # sCHF Exacerbation:\\n Patient has history of CHF ischemic , 10%, s/p BiV ICD\\n ( Concerto C154DWK) with EF 10% which was the likely\\n cause of her fluid overload. Appears intravascularly euvolemic on\\n exam, no need to continue lasix gtt. Has diuresed well -9L on length\\n of stay. Responding well to torsemide with metolazone while on\\n milrinone, but urine output had dropped without milrinone yesterday.\\n Diuresed net -500cc over last day.\\n - Continue milrinone for now\\n - Continue torsemide 40mg with metolazone 5mg for now\\n - Continue strict I/Os\\n - Continue to replete K\\n .\\n # Goals of Care:\\n End-stage CHF with long term goals are comfort, though she still wishes\\n to participate in rehab. Her family recognizes that she is dying. Pain\\n and Palliative Care consulted yesterday for pain control and goals of\\n care.\\n - family meeting at 1pm today\\n .\\n # Septic Joints: Patient with history +staph aureus in left shoulder\\n treated by washout and vancomycin, thus far 4 weeks of monotherapy. No\\n + blood cx since before . Major issue now is pain control.\\n - continue vancomycin until , then suppression with doxycycline\\n -- continue MS contin 30mg and reassess pain med needs\\n -- standing ultram q6, Tylenol q8\\n .\\n # Sacral Decub - stage 3-4. Focusing on Pain control. Pain and\\n Palliative Care following with patient. Switched to oral breakthrough\\n Morphine with IV as backup, but patient was not requiring IV backup.\\n - wound care\\n - standing ultram Q6h, Tylenol Q8h\\n - reassess patient\\ns pain requirements\\n - goals of care family meeting 1pm today\\n .\\n # UTI: positive UA, no history of culture positive UA's in system.\\n Will do 10day course because of chronic foley.\\n - treating empirically with cipro ; day 1 of 10 day course was \\n - watch INR on abx\\n .\\n # Hx CAD:\\n Patient with h/o CAD w/ right dominant system, mild instent re-stenois\\n of the LAD BM stent and occluded RCA.\\n - continue metoprolol 25mg \\n .\\n # Hx Afib:\\n Patient with h/o atrial fibrillation, s/p BiV ICD ( Concerto\\n C154DWK) , on coumadin. Now in paced rhythm\\n - cont home dose meds (amio, metoprolol)\\n - cont coumadin\\n - trend INR\\n .\\n # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a\\n filter in place. INR mildly subtherapeutic despite Cipro\\n - continue Coumadin\\n - monitor INR\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines: midline, right IJ\\n Multi Lumen - 05:34 PM\\n Midline - 05:34 PM\\n Prophylaxis:\\n DVT: coumadin\\n Stress ulcer: lansoprazole\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: DNR / DNI\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2180-01-18 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 400147,\n \"text\": \"71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\\n : Sent to ED from clinic w/ hypotension\\n transiently on\\n dopa, Tx\\nd w/ NS 250 cc w/ SBP ^ 92.\\n Admit to CCU for aggressive diuresis.She was started on Milrinone\\n and lasix gtt. And has been diuresing well. She has lg coccyx decub\\n that is a source of chronic pain. She is DNR/DNI and defibrillator has\\n been shut off.\\n GI: Pt had a few episode of nausea yesterday and one today. It was very\\n transient with no vomiting. She ate very well today. She received\\n lactalose but no bM. Foley changed today.\\n SOCIAL: Family in to visit. Pts HCP, her 38y old neice is very ill\\n creating problem for this stressed family.\\n Pain control (acute pain, chronic pain)\\n Assessment:\\n Plan is to transition to oral forms of pain control in preparation for\\n pt going to rehab. She had received MS contin at 0600, but pill was\\n ground and pt had nausea. She received 4mg IV morphine at 6am as well.\\n She continues on standing acetominofen and ultram\\n Action:\\n MS contin will be given in to 15mg pills, which are smaller and can\\n take them without having them crushed. Morphine immediate release has\\n been ordered for breakthrough pain. It is also a small pill that she\\n can take without crushing. She had 15mg immediate release at 1300 . She\\n has had no IV morphine sulfate since 1030.\\n Response:\\n Pt has been pain free except when turned since then. She will have\\n acute pain with position change, but it will settle down and go away\\n within a few minutes. She received MS contin at 1800 and was able to\\n swallow them without problem\\n :\\n Continue to try to control pain with oral medications. Give immediate\\n release morphine for breakthrough pain.\\n Impaired Skin Integrity\\n Assessment:\\n Sacral wound getting worse and remains very painful. Mepilex dsg oozing\\n through. Acuacel added. Know MRSA infection on R knuckle and R elbow\\n appear to be much more reddened than last week. Over all skin is dry\\n and itchy.\\n Action:\\n Wound care nurse came to evaluate wound. Area is now cleansed with\\n wound cleanser and dried. Criticade antifungal is applied to wound\\n edges and peri-wound area. The wound is covered with aquacel AG and\\n then small soft-sorb pad. It is secured with medipore tape on skin that\\n has been prepped with barrier wipe. Finger and elbow are washed with\\n soap and water. Area kept lubricated. oil used in water. Moisture\\n barrier clean applied to body. Heels elevated off bed.\\n Response:\\n Skin less itchy. No further worsening of skin condition.\\n Plan:\\n .H/O heart failure (CHF), Systolic, Acute on Chronic\\n Assessment:\\n Pt being transition for transfer back to rehab. Milrinone and lasix\\n drips stopped at 1030. Pt was V-paced with wide complex and blood\\n pressure prior to stopping meds was mid 90s with maps in mid 60s. She\\n received KCL 20meq in AM She received torsemide 40mg and metolazone\\n 5mg with urine output ~ 30-40cc/hr. Blood pressure dropped to the high\\n 70s to mid 80s with maps in the low 50s.\\n Action:\\n After discussions with Dr she was restarted on Milrinone\\n .5mic/kilo with bolus of 25mic/kilo given. Labs drawn in afternoon.\\n Response:\\n Blood pressure more stable with maps in low 60s after Milrinone\\n restarted. She is ~400cc neg for the day. BUN creat 33/1.1, stable.\\n Plan:\\n Family deciding if pt will now be CMO and go to extended care facility\\n with hospice.\\n\"\n },\n {\n \"category\": \"General\",\n \"chartdate\": \"2180-01-18 00:00:00.000\",\n \"description\": \"Generic Note\",\n \"row_id\": 400148,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n - lasix gtt stopped and pt started on torsemide 40mg + metolazone\\n 5mg daily\\n - started IR morphine po for breakthrough 15mg 4h prn (w IV as backup)\\n yesterday, and patient did not require IV backup\\n - Pain and Palliative Care consulted\\n - milrinone stopped yesterday AM, but restarted milrinone bc blood\\n pressures not maintained otherwise (dropped to 70s systolic without)\\n and urine output decreased.\\n - family meeting scheduled for at 1pm - will need Dr. and\\n palliative care present\\n - does not have any complaints of pain or sob this AM\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Vancomycin - 08:00 AM\\n Ciprofloxacin - 10:00 AM\\n Infusions:\\n Other ICU medications:\\n Morphine Sulfate - 10:32 AM\\n Coumadin (Warfarin) - 04:00 PM\\n Omeprazole (Prilosec) - 04:00 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:51 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 36.9\\nC (98.4\\n Tcurrent: 36.9\\nC (98.4\\n HR: 69 (55 - 71) bpm\\n BP: 85/56(63) {74/43(53) - 97/62(69)} mmHg\\n RR: 13 (9 - 20) insp/min\\n SpO2: 96%\\n Heart rhythm: V Paced\\n Wgt (current): 74 kg (admission): 82.2 kg\\n Height: 60 Inch\\n Total In:\\n 1,052 mL\\n 201 mL\\n PO:\\n 450 mL\\n 120 mL\\n TF:\\n IVF:\\n 602 mL\\n 81 mL\\n Blood products:\\n Total out:\\n 1,571 mL\\n 320 mL\\n Urine:\\n 1,571 mL\\n 320 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -519 mL\\n -119 mL\\n Respiratory support\\n O2 Delivery Device: None\\n SpO2: 96%\\n ABG: ///35/\\n Physical Examination\\n Gen: sleepy but easily awakened, oriented x3, easily confused, appears\\n to have psychomotor slowing\\n HEENT: dry mucus membranes\\n NECK: JVP not elevated\\n CHEST: regular rhythm ; mild dry basilar crackles laterally\\n ABD: mildly distended, soft, nontender\\n EXT: + pitting edema bilaterally\\n Labs / Radiology\\n 116 K/uL\\n 10.2 g/dL\\n 93 mg/dL\\n 1.0 mg/dL\\n 35 mEq/L\\n 3.8 mEq/L\\n 32 mg/dL\\n 91 mEq/L\\n 132 mEq/L\\n 31.2 %\\n 4.6 K/uL\\n [image002.jpg]\\n 05:44 AM\\n 04:46 AM\\n 04:00 PM\\n 03:05 AM\\n 03:17 PM\\n 03:05 AM\\n 05:03 PM\\n 05:22 AM\\n 05:25 PM\\n 05:40 AM\\n WBC\\n 6.1\\n 4.7\\n 5.1\\n 4.4\\n 4.2\\n 4.6\\n Hct\\n 32.1\\n 31.9\\n 33.1\\n 32.2\\n 30.9\\n 31.2\\n Plt\\n 156\\n 159\\n 146\\n 134\\n 106\\n 116\\n Cr\\n 1.3\\n 1.4\\n 1.3\\n 1.2\\n 1.1\\n 1.0\\n 1.0\\n 1.0\\n 1.1\\n 1.0\\n Glucose\\n 83\\n 104\\n 155\\n 115\\n 98\\n 107\\n 86\\n 93\\n Other labs: PT / PTT / INR:19.1/29.7/1.7, Ca++:8.1 mg/dL, Mg++:2.1\\n mg/dL, PO4:2.8 mg/dL\\n Assessment and Plan\\n 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\\n recently discharged from the CCU () for CHF exacerbation c/b\\n C.diff infection and on for septic joint washout c/b failure to\\n extubate CHF exacerbation, who was admitted from clinic with\\n total body fluid overload.\\n .\\n # sCHF Exacerbation:\\n Patient has history of CHF ischemic , 10%, s/p BiV ICD\\n ( Concerto C154DWK) with EF 10% which was the likely\\n cause of her fluid overload. Appears intravascularly dry on exam. Has\\n diuresed well -9L on length of stay. Responding well to torsemide with\\n metolazone while on milrinone, but urine output had dropped without\\n milrinone yesterday. Diuresed net -500cc over last day. Milrinone is\\n keeping her blood pressures up.\\n - DC milrinone\\n - With no milrinone, she needs help with filling pressures, so\\n will DC diuretics b/c appears dry on exam\\n - If blood pressure drops without milrinone,, she may benefit\\n from 250cc IVF boluses as needed\\n - Continue strict I/Os\\n - Continue to replete K\\n .\\n # Goals of Care:\\n End-stage CHF with long term goals are comfort, though she still wishes\\n to participate in rehab. Her family recognizes that she is dying. Pain\\n and Palliative Care consulted yesterday for pain control and goals of\\n care.\\n - family meeting at 1pm today\\n .\\n # Septic Joints: Patient with history +staph aureus in left shoulder\\n treated by washout and vancomycin, thus far 4 weeks of monotherapy. No\\n + blood cx since before . Major issue now is pain control.\\n - continue vancomycin until , then suppression with doxycycline\\n -- continue MS contin 30mg and reassess pain med needs\\n -- standing ultram q6, Tylenol q8\\n .\\n # Sacral Decub - stage 3-4. Focusing on Pain control. Pain and\\n Palliative Care following with patient. Switched to oral breakthrough\\n Morphine with IV as backup, but patient was not requiring IV backup.\\n - wound care\\n - standing ultram Q6h, Tylenol Q8h\\n - reassess patient\\ns pain requirements\\n - goals of care family meeting 1pm today\\n .\\n # UTI: positive UA, no history of culture positive UA's in system.\\n Will do 10day course because of chronic foley.\\n - treating empirically with cipro ; day 1 of 10 day course was \\n - watch INR on abx\\n .\\n # Hx CAD:\\n Patient with h/o CAD w/ right dominant system, mild instent re-stenois\\n of the LAD BM stent and occluded RCA.\\n - continue metoprolol 25mg \\n .\\n # Hx Afib:\\n Patient with h/o atrial fibrillation, s/p BiV ICD ( Concerto\\n C154DWK) , on coumadin. Now in paced rhythm\\n - cont home dose meds (amio, metoprolol)\\n - cont coumadin\\n - trend INR\\n .\\n # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a\\n filter in place. INR mildly subtherapeutic despite Cipro\\n - continue Coumadin\\n - monitor INR\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines: midline, right IJ\\n Multi Lumen - 05:34 PM\\n Midline - 05:34 PM\\n Prophylaxis:\\n DVT: coumadin\\n Stress ulcer: lansoprazole\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: DNR / DNI\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2180-01-18 00:00:00.000\",\n \"description\": \"progress note\",\n \"row_id\": 400149,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n - lasix gtt stopped and pt started on torsemide 40mg + metolazone\\n 5mg daily\\n - started IR morphine po for breakthrough 15mg 4h prn (w IV as backup)\\n yesterday, and patient did not require IV backup\\n - Pain and Palliative Care consulted\\n - milrinone stopped yesterday AM, but restarted milrinone bc blood\\n pressures not maintained otherwise (dropped to 70s systolic without)\\n and urine output decreased.\\n - family meeting scheduled for at 1pm - will need Dr. and\\n palliative care present\\n - does not have any complaints of pain or sob this AM\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Vancomycin - 08:00 AM\\n Ciprofloxacin - 10:00 AM\\n Infusions:\\n Other ICU medications:\\n Morphine Sulfate - 10:32 AM\\n Coumadin (Warfarin) - 04:00 PM\\n Omeprazole (Prilosec) - 04:00 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:51 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 36.9\\nC (98.4\\n Tcurrent: 36.9\\nC (98.4\\n HR: 69 (55 - 71) bpm\\n BP: 85/56(63) {74/43(53) - 97/62(69)} mmHg\\n RR: 13 (9 - 20) insp/min\\n SpO2: 96%\\n Heart rhythm: V Paced\\n Wgt (current): 74 kg (admission): 82.2 kg\\n Height: 60 Inch\\n Total In:\\n 1,052 mL\\n 201 mL\\n PO:\\n 450 mL\\n 120 mL\\n TF:\\n IVF:\\n 602 mL\\n 81 mL\\n Blood products:\\n Total out:\\n 1,571 mL\\n 320 mL\\n Urine:\\n 1,571 mL\\n 320 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -519 mL\\n -119 mL\\n Respiratory support\\n O2 Delivery Device: None\\n SpO2: 96%\\n ABG: ///35/\\n Physical Examination\\n Gen: sleepy but easily awakened, oriented x3, easily confused, appears\\n to have psychomotor slowing\\n HEENT: dry mucus membranes\\n NECK: JVP not elevated\\n CHEST: regular rhythm ; mild dry basilar crackles laterally\\n ABD: mildly distended, soft, nontender\\n EXT: + pitting edema bilaterally\\n Labs / Radiology\\n 116 K/uL\\n 10.2 g/dL\\n 93 mg/dL\\n 1.0 mg/dL\\n 35 mEq/L\\n 3.8 mEq/L\\n 32 mg/dL\\n 91 mEq/L\\n 132 mEq/L\\n 31.2 %\\n 4.6 K/uL\\n [image002.jpg]\\n 05:44 AM\\n 04:46 AM\\n 04:00 PM\\n 03:05 AM\\n 03:17 PM\\n 03:05 AM\\n 05:03 PM\\n 05:22 AM\\n 05:25 PM\\n 05:40 AM\\n WBC\\n 6.1\\n 4.7\\n 5.1\\n 4.4\\n 4.2\\n 4.6\\n Hct\\n 32.1\\n 31.9\\n 33.1\\n 32.2\\n 30.9\\n 31.2\\n Plt\\n 156\\n 159\\n 146\\n 134\\n 106\\n 116\\n Cr\\n 1.3\\n 1.4\\n 1.3\\n 1.2\\n 1.1\\n 1.0\\n 1.0\\n 1.0\\n 1.1\\n 1.0\\n Glucose\\n 83\\n 104\\n 155\\n 115\\n 98\\n 107\\n 86\\n 93\\n Other labs: PT / PTT / INR:19.1/29.7/1.7, Ca++:8.1 mg/dL, Mg++:2.1\\n mg/dL, PO4:2.8 mg/dL\\n Assessment and Plan\\n 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\\n recently discharged from the CCU () for CHF exacerbation c/b\\n C.diff infection and on for septic joint washout c/b failure to\\n extubate CHF exacerbation, who was admitted from clinic with\\n total body fluid overload.\\n .\\n # sCHF Exacerbation:\\n Patient has history of CHF ischemic , 10%, s/p BiV ICD\\n ( Concerto C154DWK) with EF 10% which was the likely\\n cause of her fluid overload. Appears intravascularly dry on exam. Has\\n diuresed well -9L on length of stay. Responding well to torsemide with\\n metolazone while on milrinone, but urine output had dropped without\\n milrinone yesterday. Diuresed net -500cc over last day. Milrinone is\\n keeping her blood pressures up.\\n - DC milrinone\\n - With no milrinone, she needs help with filling pressures, so\\n will DC diuretics b/c appears dry on exam\\n - If blood pressure drops without milrinone,, she may benefit\\n from 250cc IVF boluses as needed\\n - Continue strict I/Os\\n - Continue to replete K\\n .\\n # Goals of Care:\\n End-stage CHF with long term goals are comfort, though she still wishes\\n to participate in rehab. Her family recognizes that she is dying. Pain\\n and Palliative Care consulted yesterday for pain control and goals of\\n care.\\n - family meeting at 1pm today\\n .\\n # Septic Joints: Patient with history +staph aureus in left shoulder\\n treated by washout and vancomycin, thus far 4 weeks of monotherapy. No\\n + blood cx since before . Major issue now is pain control.\\n - continue vancomycin until , then suppression with doxycycline\\n -- continue MS contin 30mg and reassess pain med needs\\n -- standing ultram q6, Tylenol q8\\n .\\n # Sacral Decub - stage 3-4. Focusing on Pain control. Pain and\\n Palliative Care following with patient. Switched to oral breakthrough\\n Morphine with IV as backup, but patient was not requiring IV backup.\\n - wound care\\n - standing ultram Q6h, Tylenol Q8h\\n - reassess patient\\ns pain requirements\\n - goals of care family meeting 1pm today\\n .\\n # UTI: positive UA, no history of culture positive UA's in system.\\n Will do 10day course because of chronic foley.\\n - treating empirically with cipro ; day 1 of 10 day course was \\n - watch INR on abx\\n .\\n # Hx CAD:\\n Patient with h/o CAD w/ right dominant system, mild instent re-stenois\\n of the LAD BM stent and occluded RCA.\\n - continue metoprolol 25mg \\n .\\n # Hx Afib:\\n Patient with h/o atrial fibrillation, s/p BiV ICD ( Concerto\\n C154DWK) , on coumadin. Now in paced rhythm\\n - cont home dose meds (amio, metoprolol)\\n - cont coumadin\\n - trend INR\\n .\\n # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a\\n filter in place. INR mildly subtherapeutic despite Cipro\\n - continue Coumadin\\n - monitor INR\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines: midline, right IJ\\n Multi Lumen - 05:34 PM\\n Midline - 05:34 PM\\n Prophylaxis:\\n DVT: coumadin\\n Stress ulcer: lansoprazole\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: DNR / DNI\\n Disposition:\\n ------ Protected Section ------\\n Cardiology Teaching Physician Note\\n On this day I saw, examined and was physically present with the\\n resident / fellow for the key portions of the services provided. I\\n agree with the above note and plans.\\n I would add the following remarks:\\n Above discussed extensively with patient. Above discussed extensively\\n with family member, next of or health care proxy. Progress reviewed\\n extensively during family meeting.\\n DNR status discussed: comfort measures. DNR.\\n Total time spent on patient care: 90 minutes.\\n Additional comments:\\n 45 minutes (13:00 - 13:45) spent in family meeting discussing end-stage\\n nature of the heart condition and lack of further treatment options.\\n Pt will now be CMO. All family in agreement.\\n ------ Protected Section Addendum Entered By: on:\\n 13:44 ------\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2180-01-18 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 400153,\n \"text\": \"71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\\n : Sent to ED from clinic admit to CCU for aggressive\\n diuresis. She was started on Milrinone and lasix gtt, lasix and\\n milrinone gtts turned to off . Milrinone restarted d/t BP and U/O\\n decrease. Large Stage III decube on coccyx decub that is a source of\\n chronic pain. She is DNR/DNI and defibrillator has been shut off. Able\\n to swallow pills whole, with either applesauce or custard.\\n SOCIAL: Family in to visit. Pts HCP is in and intubated,\\n pt\\ns sister is alternate HCP.\\n control (acute pain, chronic pain)\\n Assessment:\\n On standing dose of morphine SR, ultram and Tylenol. Also receiving\\n supplemental morpine IR and IV.\\n Action/Response:\\n Pain rated to be this am, then later in day \\n Repositioned for comfort\\n Plan:\\n Continue pain control with oral medications. Give immediate release\\n morphine for breakthrough pain.\\n Impaired Skin Integrity\\n Assessment:\\n Stage III PU on coccyx, foul smelling, yellow sanguinous drainage,\\n edges of wound yellow with areas of necrosis. Surrounding skin\\n macerated. Pt. refusing kinair bed\\n Action/Response:\\n Dressing changed according to wound care RN\\ns recs:\\n anti-fungal barrier criticaid to macerated skin surrounding wound,\\n acqua cell-AG to coccyx, covered in soft sorb dsg, medipore tape.\\n Aloe Vesta to skin\\n Repositioned\\n Po\\ns encouraged, patient drinking hot chocolate, custard,\\n applesauce.\\n Plan:\\n QD dressing change as above. Aloe vesta to skin. Reposition q2 hours\\n or according to pt\\ns wishes.\\n .H/O heart failure (CHF), Systolic, Acute on Chronic\\n Assessment:\\n Pt DNR/DNI. SBP 90\\ns. Milrinone @ 0.5mcg/kg/min. U/O ~ 100cc q\\n 2hours.\\n Action/Response:\\n Dr. in to talk with patient and family extensively.\\n Milrinone turned to off. Torsemide and metzolone d/c\\n Palliative care MD in to talk with pt and family.\\n Plan:\\n To remain in hospital for now. Will monitor off of milrinone with plan\\n to give IV NS 250 cc for hypotension as per Dr. . Focus on\\n comfort.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2180-01-18 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 400162,\n \"text\": \"71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\\n : Sent to ED from clinic admit to CCU for aggressive\\n diuresis. She was started on Milrinone and lasix gtt, lasix and\\n milrinone gtts turned to off . Milrinone restarted d/t BP and U/O\\n decrease. Large Stage III decube on coccyx decub that is a source of\\n chronic pain. She is DNR/DNI and defibrillator has been shut off. Able\\n to swallow pills whole, with either applesauce or custard.\\n SOCIAL: Family in to visit. Pts HCP is in and intubated,\\n pt\\ns sister is alternate HCP.\\n control (acute pain, chronic pain)\\n Assessment:\\n On standing dose of morphine SR, ultram and Tylenol.\\n Action/Response:\\n Pain rated to be this am, then later in day .\\n Given supplemental IR morphine and 2mg IV morphine with relief of pain.\\n Repositioned for comfort\\n Plan:\\n Continue pain control with oral medications. Give immediate release\\n morphine for breakthrough pain.\\n Impaired Skin Integrity\\n Assessment:\\n Stage III PU on coccyx, foul smelling, yellow sanguinous drainage,\\n edges of wound yellow with areas of necrosis. Surrounding skin\\n macerated. Pt. refusing kinair bed\\n Action/Response:\\n Dressing changed according to wound care RN\\ns recs:\\n anti-fungal barrier criticaid to macerated skin surrounding wound,\\n acqua cell-AG to coccyx, covered in soft sorb dsg, medipore tape.\\n Aloe Vesta to skin\\n Repositioned\\n Po\\ns encouraged, patient drinking hot chocolate, custard,\\n applesauce.\\n Plan:\\n QD dressing change as above. Aloe vesta to skin. Reposition q2 hours\\n or according to pt\\ns wishes.\\n .H/O heart failure (CHF), Systolic, Acute on Chronic\\n Assessment:\\n Pt DNR/DNI. SBP 90\\ns. Milrinone @ 0.5mcg/kg/min. U/O ~ 100cc q\\n 2hours.\\n Action/Response:\\n Dr. in to talk with patient and family extensively.\\n Milrinone turned to off. Torsemide and metzolone d/c\\n Palliative care MD in to talk with pt and family.\\n SBP decreasing to low 80\\ns and then 76 off mirinone, U/O\\n also tapering off. CCU resident notified, will hold off on IV fluids\\n unless pt c/o dizziness.\\n Plan:\\n To remain in hospital for now. Will monitor off of milrinone with plan\\n to give IV NS 250 cc for hypotension as per Dr. . No other changes\\n in medications for now. Focus on comfort.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2180-01-15 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 399906,\n \"text\": \"71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\\n : Sent to ED from clinic w/ hypotension\\n transiently on\\n dopa, Tx\\nd w/ NS 250 cc w/ SBP ^ 92. Admit to CCU for aggressive\\n diuresis.\\n Heart failure (CHF), Systolic, Acute on Chronic\\n Assessment:\\n + pitting edema BLE\\non lasix gtt 15mg/hr & milrinone 0.5mcg/k/min.\\n LS clr, dim at bases.\\n Action:\\n 1^st dose 25mg PO lopressor given\\n Response:\\n BPs lower when asleep and after morphine, MAPs >55. Lytes. Rare short\\n runs AIVR.\\n Plan:\\n CHF management, aggressive diuresis w/ lasix & daily\\n metolazone-- goal NEG 5-10L overall, strict I/Os, Low Na+ diet, daily\\n wts, monitor & replete lytes as indicated\\n DNR/DNI-ICD turned off after fam mtg. Both pt and HCP\\n are in agreement that pt would like to be comfortable to be able to\\n participate in rehab.\\n Impaired Skin Integrity\\n Assessment:\\n *Lg stage 3 vs. unstageable decub to coccyx, covered w/ yellow slough &\\n red blanching borders--sm amt serous dsg\\n mepilex intact, placed \\n *Red, blanching heels.\\n *Dry and thin skin w/ discolored areas.\\n *Good appetite. Declines Kinair bed/waffle boots\\n Action:\\n Mepilex dsg peeled to check skin--Duoderm hydroactive gel\\n applied per wound care recs .\\n Heels elevated on pillows, skin/pressure area well\\n lubricated.\\n Slight freq position changes avoiding back and L side.\\n Response:\\n Skin unchanged\\n Plan:\\n Monitor for changes, prevent further breathdown. Change\\n position freq as tolerated as pt mobility/able to turn self is very\\n limited.\\n Change mepilex w/ duoderm gel daily drainage\\n Pain control (chronic pain)\\n Assessment:\\n Very uncomfortable w/ turning and w/ laying on L side\\n Action:\\n Standing order ultram & Tylenol Q6hrs, 2mg Morphine sulfate\\n IVP for breakthrough pain\\n Pt positioned mostly far on R side w/ slight position\\n changes, placed supine for short periods only.\\n Response:\\n Pt allowed to rest in btwn necessary nsg interventions, Slept well all\\n night.\\n Plan:\\n Continue current pain control regimen, medicate w/ morphine\\n prior to turning side to side\\n GI: NO BM, takes pills crushed in applesauce\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2180-01-17 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 400071,\n \"text\": \"71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\\n : Sent to ED from clinic w/ hypotension\\n transiently on\\n dopa, Tx\\nd w/ NS 250 cc w/ SBP ^ 92.\\n Admit to CCU for aggressive diuresis.She was started on Milrinone\\n and lasix gtt. And has been diuresing well. She has lg coccyx decub\\n that is a source of chronic pain. She is DNR/DNI and defibrillator has\\n been shut off. She has excellent apetite.\\n Pain control (acute pain, chronic pain)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Impaired Skin Integrity\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n .H/O heart failure (CHF), Systolic, Acute on Chronic\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nutrition\",\n \"chartdate\": \"2180-01-17 00:00:00.000\",\n \"description\": \"Clinical Nutrition Note\",\n \"row_id\": 400081,\n \"text\": \"Ht: 60\\n Admit wt: 82.2kg\\n Current wt: 74kg\\n Diet: Low sodium, 3 gram\\n PMHx: 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension\\n 2. CARDIAC HISTORY:\\n -CABG: None\\n -PERCUTANEOUS CORONARY INTERVENTIONS: BM stent to the LAD in ,\\n Occluded RCA/no intervention\\n -PACING/ICD: Ischemic cardiomyopathy (EF 10%) s/p BiV ICD and atrial\\n fibrillation\\n 3. H/o PE secondary to DVT s/p IVC filter on Coumadin\\n 4. PVD\\n 5. Small VSD\\n OTHER\\n # Septic Polyarticular Arthritis s/p irrigation and debridement left\\n shoulder via anterolateral deltopectoral miniarthrotomy, aspiration\\n left hip joint and irrigation and debridement of 3rd\\n metacarpophalangeal joint\\n 6. Hypothyroidism\\n 7. CKD\\n 8. Osteoarthritis\\n Meds: Lasix drip, Milrinone drip, ABX, Potassium Chloride (20mEq\\n repletion), bowel regimen\\n Potential for nutrition risk. Patient being monitored. Current\\n intervention if any, listed below:\\n 71 YO female admitted from rehab with volume overload consistent with\\n CHF exacerbation. Noted code status changed to DNR/ DNI, pacemaker\\n turned off. Reports eating Rice Krispies with milk at breakfast and\\n improved appetite here compared to at rehab. Liked po shake from last\\n admit, but does not recall the name of it. Question accuracy of\\n weights, patient looks thin. Noted unstageable pressure ulcer.\\n Recommendations:\\n 1. Encourage po\\n 2. Will send Carnation Instant Breakfast shakes with milk/ice\\n cream\\n 3. Lytes and BS management\\n 4. Will follow, page if questions *\\n 5. Electronically signed by , RD, LDN\\n 10:26\\n 6.\\n 7.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2180-01-17 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 400082,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n - MS contin increased to 30mg last night, received 2 doses w pills\\n crushed, complained of nausea after each\\n - complains of pain at 8/10\\n - Has not had a BM for four days\\n - PT ordered yesterday\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Ciprofloxacin - 08:00 AM\\n Vancomycin - 09:36 AM\\n Infusions:\\n Furosemide (Lasix) - 10 mg/hour\\n Milrinone - 0.5 mcg/Kg/min\\n Other ICU medications:\\n Morphine Sulfate - 12:45 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:41 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 36.8\\nC (98.3\\n Tcurrent: 36.6\\nC (97.8\\n HR: 68 (63 - 75) bpm\\n BP: 91/52(62) {75/44(51) - 98/61(70)} mmHg\\n RR: 9 (9 - 29) insp/min\\n SpO2: 99%\\n Heart rhythm: AV Paced\\n Wgt (current): 77.3 kg (admission): 82.2 kg\\n Total In:\\n 1,004 mL\\n 146 mL\\n PO:\\n 440 mL\\n TF:\\n IVF:\\n 564 mL\\n 146 mL\\n Blood products:\\n Total out:\\n 2,410 mL\\n 420 mL\\n Urine:\\n 2,410 mL\\n 420 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,406 mL\\n -274 mL\\n Respiratory support\\n O2 Delivery Device: None\\n SpO2: 99%\\n ABG: ///34/\\n Physical Examination\\n Gen: alert, oriented x3 but appears to have psychomotor retardation and\\n easily confused\\n HEENT: slightly dry mucus membranes\\n CHEST: regular rhythm ; dry basilar crackles\\n ABD: mildly distended, soft, nontender\\n EXT: + pitting edema bilaterally\\n Labs / Radiology\\n 106 K/uL\\n 10.0 g/dL\\n 86 mg/dL\\n 1.0 mg/dL\\n 34 mEq/L\\n 3.7 mEq/L\\n 33 mg/dL\\n 92 mEq/L\\n 134 mEq/L\\n 30.9 %\\n 4.2 K/uL\\n [image002.jpg]\\n 05:44 AM\\n 04:46 AM\\n 04:00 PM\\n 03:05 AM\\n 03:17 PM\\n 03:05 AM\\n 05:03 PM\\n 05:22 AM\\n WBC\\n 6.1\\n 4.7\\n 5.1\\n 4.4\\n 4.2\\n Hct\\n 32.1\\n 31.9\\n 33.1\\n 32.2\\n 30.9\\n Plt\\n 156\\n 159\\n 146\\n 134\\n 106\\n Cr\\n 1.3\\n 1.4\\n 1.3\\n 1.2\\n 1.1\\n 1.0\\n 1.0\\n 1.0\\n Glucose\\n 83\\n 104\\n 155\\n 115\\n 98\\n 107\\n 86\\n Other labs: PT / PTT / INR:20.2/33.1/1.9, Ca++:8.1 mg/dL, Mg++:2.1\\n mg/dL, PO4:2.7 mg/dL\\n Assessment and Plan\\n 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\\n recently discharged from the CCU () for CHF exacerbation c/b\\n C.diff infection and on for septic joint washout c/b failure to\\n extubate CHF exacerbation, who was admitted from clinic with\\n total body fluid overload.\\n .\\n # sCHF exacerbation:\\n Patient has history of CHF ischemic , 10%, s/p BiV ICD\\n ( Concerto C154DWK) with EF 10% which was the likely\\n cause of her fluid overload. Appears intravascularly euvolemic on\\n exam, no need to continue lasix gtt. Has diuresed well -9L on length\\n of stay. Diuresed -1.5L over last day.\\n - DC lasix gtt\\n - DC milrinone\\n - Start torsemide 40mg , on which she will be discharged\\n - Metolazone 5mg once today, then switch to metolazone 2.5mg\\n daily w first dose of torsemide tomorrow\\n - Continue strict I/Os\\n - Continue to replete K\\n .\\n # Goals of Care:\\n End-stage CHF with long term goals are comfort, though she still wishes\\n to participate in rehab. Her family recognizes that she is dying.\\n - Consult Pain and Palliative Care\\n .\\n # Septic Joints: Patient with history +staph aureus in left shoulder\\n treated by washout and vancomycin, thus far 4 weeks of monotherapy. No\\n + blood cx since before . Major issue now is pain control.\\n -- continue vanc 500 mg q24 ; will need to monitor vanc troughs on\\n discharge\\n -- MS contin increased to 30mg yesterday\\n -- standing ultram q6, Tylenol q8\\n .\\n # Sacral Decub - stage 3-4.\\n Pain control very important\\n - switch to oral breakthrough Morphine , but leave IV as backup\\n - wound care\\n - standing ultram Q6h, Tylenol Q8h\\n - continue MS contin to 30mg (with smaller 15mg pills x2 so she can\\n swallow)\\n - Consulting Pain and Palliative Care\\n .\\n # UTI: positive UA, no history of culture positive UA's in system.\\n Will do 10day course because of chronic foley.\\n - treating empirically with cipro ; day 1 of 10 day course was \\n - watch INR on abx\\n .\\n # Hx CAD:\\n Patient with h/o CAD w/ right dominant system, mild instent re-stenois\\n of the LAD BM stent and occluded RCA.\\n - continue metoprolol 25mg \\n .\\n # Hx Afib:\\n Patient with h/o atrial fibrillation, s/p BiV ICD ( Concerto\\n C154DWK) , on coumadin. Now in paced rhythm\\n - cont home dose meds (amio, metoprolol)\\n - cont coumadin\\n - trend INR\\n .\\n # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a\\n filter in place. INR mildly subtherapeutic despite Cipro\\n - continue Coumadin and monitor INR\\n .\\n # Hypothyroidism: Continue Levothyroxine\\n .\\n # Gout: continue Allopurinol\\n ICU Care\\n Nutrition: tolerating po well\\n Glycemic Control:\\n Lines: midline, right IJ (will consider taking out RIJ tomorrow\\n if does not need milrinone again)\\n Multi Lumen - 05:34 PM\\n Midline - 05:34 PM\\n Prophylaxis:\\n DVT: coumadin\\n Stress ulcer: lansoprazole\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: DNR / DNI\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2180-01-18 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 400129,\n \"text\": \"71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\\n : Sent to ED from clinic w/ hypotension\\n transiently on\\n dopa, Tx\\nd w/ NS 250 cc w/ SBP ^ 92.\\n Admit to CCU for aggressive diuresis.She was started on Milrinone\\n and lasix gtt. And has been diuresing well. She has lg coccyx decub\\n that is a source of chronic pain. She is DNR/DNI and defibrillator has\\n been shut off.\\n Pain control (acute pain, chronic pain)\\n Assessment:\\n Contin. with acute pain with turning. Pain is at decub site/coccyx.\\n Pt. also has severe arthritis in legs/hips/shoulders\\n Action:\\n MS . Supplemented with morphine IR 15mg x2 overnight-\\n both times with turning.\\n Tylenol and ultram RTC.\\n Response:\\n Acute pain resolves and pt. able to be comfortable and sleep.\\n Plan:\\n Family deciding if pt will now be CMO and go to extended care facility\\n with hospice- speaking with MD \\n .H/O heart failure (CHF), Systolic, Acute on Chronic\\n Assessment:\\n Started on milrinone 0.5mcq\\n restarted after u/o dropped to 0cc .\\n HR 60-70\\ns Vpaced, wide complex. BP maps 53-60. SBP 80-90\\n Action:\\n Milrinone 0.5mcq/,\\n Po amio, metalazone, torsemide po.\\n Response:\\n u/o 30-60cc/hr. LS clear to diminished. Sats 95-99% on RA. Denies\\n SOB.\\n Plan:\\n Contin. meds as ordered. Monitor u/o.\\n Impaired Skin Integrity\\n Assessment:\\n Skin care plan changed . see wound care note.\\n DSD intact over coccyx. Wound not visualized. No drainage or\\n saturation.\\n Action:\\n Maintained integrity of DSD. Turn/position q3hr as tolerated. Barrier\\n cream to all other areas.\\n Response:\\n Pt. states itchy skin is improved.\\n Plan:\\n Wound care per current plan. See orders\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2180-01-18 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 400142,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n - MS contin increased to 30mg last night, received 2 doses w pills\\n crushed, complained of nausea after each\\n - complains of pain at 8/10\\n - Has not had a BM for four days\\n - PT ordered yesterday\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Ciprofloxacin - 08:00 AM\\n Vancomycin - 09:36 AM\\n Infusions:\\n Furosemide (Lasix) - 10 mg/hour\\n Milrinone - 0.5 mcg/Kg/min\\n Other ICU medications:\\n Morphine Sulfate - 12:45 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:41 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 36.8\\nC (98.3\\n Tcurrent: 36.6\\nC (97.8\\n HR: 68 (63 - 75) bpm\\n BP: 91/52(62) {75/44(51) - 98/61(70)} mmHg\\n RR: 9 (9 - 29) insp/min\\n SpO2: 99%\\n Heart rhythm: AV Paced\\n Wgt (current): 77.3 kg (admission): 82.2 kg\\n Total In:\\n 1,004 mL\\n 146 mL\\n PO:\\n 440 mL\\n TF:\\n IVF:\\n 564 mL\\n 146 mL\\n Blood products:\\n Total out:\\n 2,410 mL\\n 420 mL\\n Urine:\\n 2,410 mL\\n 420 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,406 mL\\n -274 mL\\n Respiratory support\\n O2 Delivery Device: None\\n SpO2: 99%\\n ABG: ///34/\\n Physical Examination\\n Gen: alert, oriented x3 but appears to have psychomotor retardation and\\n easily confused\\n HEENT: slightly dry mucus membranes\\n CHEST: regular rhythm ; dry basilar crackles\\n ABD: mildly distended, soft, nontender\\n EXT: + pitting edema bilaterally\\n Labs / Radiology\\n 106 K/uL\\n 10.0 g/dL\\n 86 mg/dL\\n 1.0 mg/dL\\n 34 mEq/L\\n 3.7 mEq/L\\n 33 mg/dL\\n 92 mEq/L\\n 134 mEq/L\\n 30.9 %\\n 4.2 K/uL\\n [image002.jpg]\\n 05:44 AM\\n 04:46 AM\\n 04:00 PM\\n 03:05 AM\\n 03:17 PM\\n 03:05 AM\\n 05:03 PM\\n 05:22 AM\\n WBC\\n 6.1\\n 4.7\\n 5.1\\n 4.4\\n 4.2\\n Hct\\n 32.1\\n 31.9\\n 33.1\\n 32.2\\n 30.9\\n Plt\\n 156\\n 159\\n 146\\n 134\\n 106\\n Cr\\n 1.3\\n 1.4\\n 1.3\\n 1.2\\n 1.1\\n 1.0\\n 1.0\\n 1.0\\n Glucose\\n 83\\n 104\\n 155\\n 115\\n 98\\n 107\\n 86\\n Other labs: PT / PTT / INR:20.2/33.1/1.9, Ca++:8.1 mg/dL, Mg++:2.1\\n mg/dL, PO4:2.7 mg/dL\\n Assessment and Plan\\n 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\\n recently discharged from the CCU () for CHF exacerbation c/b\\n C.diff infection and on for septic joint washout c/b failure to\\n extubate CHF exacerbation, who was admitted from clinic with\\n total body fluid overload.\\n .\\n # sCHF exacerbation:\\n Patient has history of CHF ischemic , 10%, s/p BiV ICD\\n ( Concerto C154DWK) with EF 10% which was the likely\\n cause of her fluid overload. Appears intravascularly euvolemic on\\n exam, no need to continue lasix gtt. Has diuresed well -9L on length\\n of stay. Diuresed -1.5L over last day.\\n - DC lasix gtt\\n - DC milrinone\\n - Start torsemide 40mg , on which she will be discharged\\n - Metolazone 5mg once today, then switch to metolazone 2.5mg\\n daily w first dose of torsemide tomorrow\\n - Continue strict I/Os\\n - Continue to replete K\\n .\\n # Goals of Care:\\n End-stage CHF with long term goals are comfort, though she still wishes\\n to participate in rehab. Her family recognizes that she is dying.\\n - Consult Pain and Palliative Care\\n .\\n # Septic Joints: Patient with history +staph aureus in left shoulder\\n treated by washout and vancomycin, thus far 4 weeks of monotherapy. No\\n + blood cx since before . Major issue now is pain control.\\n -- continue vanc 500 mg q24 ; will need to monitor vanc troughs on\\n discharge\\n -- MS contin increased to 30mg yesterday\\n -- standing ultram q6, Tylenol q8\\n .\\n # Sacral Decub - stage 3-4.\\n Pain control very important\\n - switch to oral breakthrough Morphine , but leave IV as backup\\n - wound care\\n - standing ultram Q6h, Tylenol Q8h\\n - continue MS contin to 30mg (with smaller 15mg pills x2 so she can\\n swallow)\\n - Consulting Pain and Palliative Care\\n .\\n # UTI: positive UA, no history of culture positive UA's in system.\\n Will do 10day course because of chronic foley.\\n - treating empirically with cipro ; day 1 of 10 day course was \\n - watch INR on abx\\n .\\n # Hx CAD:\\n Patient with h/o CAD w/ right dominant system, mild instent re-stenois\\n of the LAD BM stent and occluded RCA.\\n - continue metoprolol 25mg \\n .\\n # Hx Afib:\\n Patient with h/o atrial fibrillation, s/p BiV ICD ( Concerto\\n C154DWK) , on coumadin. Now in paced rhythm\\n - cont home dose meds (amio, metoprolol)\\n - cont coumadin\\n - trend INR\\n .\\n # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a\\n filter in place. INR mildly subtherapeutic despite Cipro\\n - continue Coumadin and monitor INR\\n .\\n # Hypothyroidism: Continue Levothyroxine\\n .\\n # Gout: continue Allopurinol\\n ICU Care\\n Nutrition: tolerating po well\\n Glycemic Control:\\n Lines: midline, right IJ (will consider taking out RIJ tomorrow\\n if does not need milrinone again)\\n Multi Lumen - 05:34 PM\\n Midline - 05:34 PM\\n Prophylaxis:\\n DVT: coumadin\\n Stress ulcer: lansoprazole\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: DNR / DNI\\n Disposition:\\n ------ Protected Section ------\\n Cardiology Teaching Physician Note\\n On this day I saw, examined and was physically present with the\\n resident / fellow for the key portions of the services provided. I\\n agree with the above note and plans.\\n I would add the following remarks:\\n Above discussed extensively with patient. Above discussed extensively\\n with family member, next of or health care proxy.\\n DNR status discussed. DNR.\\n Total time spent on patient care: 45 minutes.\\n Additional comments:\\n signed on for service provided on \\n plan to shut off milrinone and furosemide drips and switch to po\\n ------ Protected Section Addendum Entered By: on:\\n 09:59 ------\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2180-01-18 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 400158,\n \"text\": \"71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\\n : Sent to ED from clinic admit to CCU for aggressive\\n diuresis. She was started on Milrinone and lasix gtt, lasix and\\n milrinone gtts turned to off . Milrinone restarted d/t BP and U/O\\n decrease. Large Stage III decube on coccyx decub that is a source of\\n chronic pain. She is DNR/DNI and defibrillator has been shut off. Able\\n to swallow pills whole, with either applesauce or custard.\\n SOCIAL: Family in to visit. Pts HCP is in and intubated,\\n pt\\ns sister is alternate HCP.\\n control (acute pain, chronic pain)\\n Assessment:\\n On standing dose of morphine SR, ultram and Tylenol.\\n Action/Response:\\n Pain rated to be this am, then later in day .\\n Given supplemental IR morphine and 2mg IV morphine with relief of pain.\\n Repositioned for comfort\\n Plan:\\n Continue pain control with oral medications. Give immediate release\\n morphine for breakthrough pain.\\n Impaired Skin Integrity\\n Assessment:\\n Stage III PU on coccyx, foul smelling, yellow sanguinous drainage,\\n edges of wound yellow with areas of necrosis. Surrounding skin\\n macerated. Pt. refusing kinair bed\\n Action/Response:\\n Dressing changed according to wound care RN\\ns recs:\\n anti-fungal barrier criticaid to macerated skin surrounding wound,\\n acqua cell-AG to coccyx, covered in soft sorb dsg, medipore tape.\\n Aloe Vesta to skin\\n Repositioned\\n Po\\ns encouraged, patient drinking hot chocolate, custard,\\n applesauce.\\n Plan:\\n QD dressing change as above. Aloe vesta to skin. Reposition q2 hours\\n or according to pt\\ns wishes.\\n .H/O heart failure (CHF), Systolic, Acute on Chronic\\n Assessment:\\n Pt DNR/DNI. SBP 90\\ns. Milrinone @ 0.5mcg/kg/min. U/O ~ 100cc q\\n 2hours.\\n Action/Response:\\n Dr. in to talk with patient and family extensively.\\n Milrinone turned to off. Torsemide and metzolone d/c\\n Palliative care MD in to talk with pt and family.\\n SBP decreasing to low 80\\ns off mirinone, U/O also tapering\\n off.\\n Plan:\\n To remain in hospital for now. Will monitor off of milrinone with plan\\n to give IV NS 250 cc for hypotension as per Dr. . No other changes\\n in medications for now. Focus on comfort.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2180-01-15 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 399911,\n \"text\": \"71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\\n : Sent to ED from clinic w/ hypotension\\n transiently on\\n dopa, Tx\\nd w/ NS 250 cc w/ SBP ^ 92. Admit to CCU for aggressive\\n diuresis.\\n Heart failure (CHF), Systolic, Acute on Chronic\\n Assessment:\\n + pitting edema BLE\\non lasix gtt 15mg/hr & milrinone 0.5mcg/k/min.\\n LS clr, dim at bases.\\n Action:\\n 1^st dose 25mg PO lopressor given\\n Response:\\n BPs lower when asleep and after morphine, MAPs >55 (of note: BPs taken\\n on L upper arm, pt mosly positioned on R side). Lytes. Rare short runs\\n AIVR.\\n Plan:\\n CHF management, aggressive diuresis w/ lasix & daily\\n metolazone-- goal NEG 5-10L overall, strict I/Os, Low Na+ diet, daily\\n wts, monitor & replete lytes as indicated\\n DNR/DNI-ICD turned off after fam mtg. Both pt and HCP\\n are in agreement that pt would like to be comfortable to be able to\\n participate in rehab.\\n Impaired Skin Integrity\\n Assessment:\\n *Lg stage 3 vs. unstageable decub to coccyx, covered w/ yellow slough &\\n red blanching borders--sm amt serous dsg\\n mepilex intact, placed \\n *Red, blanching heels.\\n *Dry and thin skin w/ discolored areas.\\n *Good appetite. Declines Kinair bed/waffle boots\\n Action:\\n Mepilex dsg peeled to check skin--Duoderm hydroactive gel\\n applied per wound care recs .\\n Heels elevated on pillows, skin/pressure area well\\n lubricated.\\n Slight freq position changes avoiding back and L side.\\n Response:\\n Skin unchanged\\n Plan:\\n Monitor for changes, prevent further breathdown. Change\\n position freq as tolerated as pt mobility/able to turn self is very\\n limited.\\n Change mepilex w/ duoderm gel daily drainage\\n Pain control (chronic pain)\\n Assessment:\\n Very uncomfortable w/ turning and w/ laying on L side\\n Action:\\n Standing order ultram & Tylenol Q6hrs, 2mg Morphine sulfate\\n IVP for breakthrough pain\\n Pt positioned mostly far on R side w/ slight position\\n changes, placed supine for short periods only.\\n Response:\\n Pt allowed to rest in btwn necessary nsg interventions, Slept well all\\n night.\\n Plan:\\n Continue current pain control regimen, medicate w/ morphine\\n prior to turning side to side\\n GI: NO BM, takes pills crushed in applesauce\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2180-01-17 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 400072,\n \"text\": \"71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\\n : Sent to ED from clinic w/ hypotension\\n transiently on\\n dopa, Tx\\nd w/ NS 250 cc w/ SBP ^ 92. Admit to CCU for aggressive\\n diuresis.\\n Pain control (acute pain, chronic pain)\\n Assessment:\\n Remains on 30 mg of ms contin for coccyx pain associated with turning.\\n Although, hips/lower back disarticulating with side to side activity.\\n Action:\\n Pre-mediated with 4 mg of iv ms04 prior to turning\\n Continues on Tylenol 1000mg po TID, Ultram 50mg QID\\n Response:\\n Pre-medication decreases pain with turning per patient\\n Plan:\\n Cont assess pain, cont ATC meds and supplement with IV Morphine as\\n needed\\n .H/O heart failure (CHF), Systolic, Acute on Chronic\\n Assessment:\\n Pt asystomatic\\n no SOB with stable VS\\n Action:\\n Milrinone remains at 0,5mcgs/kg/min\\n Lasix increased from 5 to 10mg/hr\\n Response:\\n 1.8 liters negative at midnight\\n Plan:\\n Plan to transition heart failure meds to po route\\n Impaired Skin Integrity\\n Assessment:\\n Large unstageable pressur ulcer on coccyx unchanged\\n Bilat heels remain reddened but blanchble\\n Action:\\n duoderm gel/Mepilex, changed on \\n mod amt sero-sanguinous drainage; redness/maceration to surrounding\\n tissue\\n severe pain at site\\n see above\\n Response:\\n Site remains unchanged\\n Plan:\\n Cont with frequent turns\\n Wound care RN .. social work, case manager and palliative consult to\\n assist with rehab destination\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2180-01-17 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 400065,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Ciprofloxacin - 08:00 AM\\n Vancomycin - 09:36 AM\\n Infusions:\\n Furosemide (Lasix) - 10 mg/hour\\n Milrinone - 0.5 mcg/Kg/min\\n Other ICU medications:\\n Morphine Sulfate - 12:45 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:41 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 36.8\\nC (98.3\\n Tcurrent: 36.6\\nC (97.8\\n HR: 68 (63 - 75) bpm\\n BP: 91/52(62) {75/44(51) - 98/61(70)} mmHg\\n RR: 9 (9 - 29) insp/min\\n SpO2: 99%\\n Heart rhythm: AV Paced\\n Wgt (current): 77.3 kg (admission): 82.2 kg\\n Total In:\\n 1,004 mL\\n 146 mL\\n PO:\\n 440 mL\\n TF:\\n IVF:\\n 564 mL\\n 146 mL\\n Blood products:\\n Total out:\\n 2,410 mL\\n 420 mL\\n Urine:\\n 2,410 mL\\n 420 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,406 mL\\n -274 mL\\n Respiratory support\\n O2 Delivery Device: None\\n SpO2: 99%\\n ABG: ///34/\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 106 K/uL\\n 10.0 g/dL\\n 86 mg/dL\\n 1.0 mg/dL\\n 34 mEq/L\\n 3.7 mEq/L\\n 33 mg/dL\\n 92 mEq/L\\n 134 mEq/L\\n 30.9 %\\n 4.2 K/uL\\n [image002.jpg]\\n 05:44 AM\\n 04:46 AM\\n 04:00 PM\\n 03:05 AM\\n 03:17 PM\\n 03:05 AM\\n 05:03 PM\\n 05:22 AM\\n WBC\\n 6.1\\n 4.7\\n 5.1\\n 4.4\\n 4.2\\n Hct\\n 32.1\\n 31.9\\n 33.1\\n 32.2\\n 30.9\\n Plt\\n 156\\n 159\\n 146\\n 134\\n 106\\n Cr\\n 1.3\\n 1.4\\n 1.3\\n 1.2\\n 1.1\\n 1.0\\n 1.0\\n 1.0\\n Glucose\\n 83\\n 104\\n 155\\n 115\\n 98\\n 107\\n 86\\n Other labs: PT / PTT / INR:20.2/33.1/1.9, Ca++:8.1 mg/dL, Mg++:2.1\\n mg/dL, PO4:2.7 mg/dL\\n Assessment and Plan\\n INEFFECTIVE COPING\\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\\n .H/O HEART FAILURE (CHF), SYSTOLIC, ACUTE ON CHRONIC\\n IMPAIRED SKIN INTEGRITY\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 05:34 PM\\n Midline - 05:34 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: DNR / DNI\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2180-01-17 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 400066,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Ciprofloxacin - 08:00 AM\\n Vancomycin - 09:36 AM\\n Infusions:\\n Furosemide (Lasix) - 10 mg/hour\\n Milrinone - 0.5 mcg/Kg/min\\n Other ICU medications:\\n Morphine Sulfate - 12:45 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:41 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 36.8\\nC (98.3\\n Tcurrent: 36.6\\nC (97.8\\n HR: 68 (63 - 75) bpm\\n BP: 91/52(62) {75/44(51) - 98/61(70)} mmHg\\n RR: 9 (9 - 29) insp/min\\n SpO2: 99%\\n Heart rhythm: AV Paced\\n Wgt (current): 77.3 kg (admission): 82.2 kg\\n Total In:\\n 1,004 mL\\n 146 mL\\n PO:\\n 440 mL\\n TF:\\n IVF:\\n 564 mL\\n 146 mL\\n Blood products:\\n Total out:\\n 2,410 mL\\n 420 mL\\n Urine:\\n 2,410 mL\\n 420 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,406 mL\\n -274 mL\\n Respiratory support\\n O2 Delivery Device: None\\n SpO2: 99%\\n ABG: ///34/\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 106 K/uL\\n 10.0 g/dL\\n 86 mg/dL\\n 1.0 mg/dL\\n 34 mEq/L\\n 3.7 mEq/L\\n 33 mg/dL\\n 92 mEq/L\\n 134 mEq/L\\n 30.9 %\\n 4.2 K/uL\\n [image002.jpg]\\n 05:44 AM\\n 04:46 AM\\n 04:00 PM\\n 03:05 AM\\n 03:17 PM\\n 03:05 AM\\n 05:03 PM\\n 05:22 AM\\n WBC\\n 6.1\\n 4.7\\n 5.1\\n 4.4\\n 4.2\\n Hct\\n 32.1\\n 31.9\\n 33.1\\n 32.2\\n 30.9\\n Plt\\n 156\\n 159\\n 146\\n 134\\n 106\\n Cr\\n 1.3\\n 1.4\\n 1.3\\n 1.2\\n 1.1\\n 1.0\\n 1.0\\n 1.0\\n Glucose\\n 83\\n 104\\n 155\\n 115\\n 98\\n 107\\n 86\\n Other labs: PT / PTT / INR:20.2/33.1/1.9, Ca++:8.1 mg/dL, Mg++:2.1\\n mg/dL, PO4:2.7 mg/dL\\n Assessment and Plan\\n INEFFECTIVE COPING\\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\\n .H/O HEART FAILURE (CHF), SYSTOLIC, ACUTE ON CHRONIC\\n IMPAIRED SKIN INTEGRITY\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 05:34 PM\\n Midline - 05:34 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: DNR / DNI\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2180-01-17 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 400070,\n \"text\": \"71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\\n : Sent to ED from clinic w/ hypotension\\n transiently on\\n dopa, Tx\\nd w/ NS 250 cc w/ SBP ^ 92. Admit to CCU for aggressive\\n diuresis.She was started on Milrinone and lasix gtt. And has been\\n diuresing well. She has lg coccyx decub that is a source of chronic\\n pain.\\n Pain control (acute pain, chronic pain)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Impaired Skin Integrity\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n .H/O heart failure (CHF), Systolic, Acute on Chronic\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2180-01-18 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 400119,\n \"text\": \"71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\\n : Sent to ED from clinic w/ hypotension\\n transiently on\\n dopa, Tx\\nd w/ NS 250 cc w/ SBP ^ 92.\\n Admit to CCU for aggressive diuresis.She was started on Milrinone\\n and lasix gtt. And has been diuresing well. She has lg coccyx decub\\n that is a source of chronic pain. She is DNR/DNI and defibrillator has\\n been shut off.\\n Pain control (acute pain, chronic pain)\\n Assessment:\\n Contin. with acute pain with turning. Pain is at decub site/coccyx.\\n Action:\\n MS . Supplemented with morphine IR 15mg x2 overnight-\\n both times with turning.\\n Tylenol and ultram RTC.\\n Response:\\n Acute pain resolves and pt. able to be comfortable and sleep.\\n Plan:\\n Family deciding if pt will now be CMO and go to extended care facility\\n with hospice- speaking with MD \\n .H/O heart failure (CHF), Systolic, Acute on Chronic\\n Assessment:\\n Started on milrinone 0.5mcq\\n restarted after u/o dropped to 0cc .\\n HR 60-70\\ns Vpaced, wide complex. BP maps 53-60. SBP 80-90\\n Action:\\n Milrinone 0.5mcq/,\\n Po amio, metalazone, torsemide po.\\n Response:\\n u/o 30-50cc/hr. LS clear to diminished. Sats 95-99% on RA. Denies\\n SOB.\\n Plan:\\n Contin. meds as ordered. Monitor u/o.\\n Impaired Skin Integrity\\n Assessment:\\n Skin care plan changed . see wound care note.\\n DSD intact over coccyx. Wound not visualized. No drainage or\\n saturation.\\n Action:\\n Maintained integrity of DSD. Turn/position q3hr as tolerated. Barrier\\n cream to all other areas.\\n Response:\\n Pt. states itchy skin is improved.\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2180-01-12 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 399675,\n \"text\": \"Pt is a 71 yo female with PMH: BM stent to LAD ', Occluded RCA\\n without intervention, Ischemic CM (EF 10-25%), BiV ICD, AF, PVD, DVT\\n s/p IVC filter, coumadin, hypothyroidism, CKD, OA. adm for HF\\n (milrinone/lasix) MRSA in L shoulder, L hip and R knuckle. Out to\\n rehab . Today went from rehab to see Dr. , sent to EW with\\n hypotension. SBP 70 in EW, transiently on dopa, but cardiology d/c'd.\\n Rxd with NS 250 cc with SBP 92. Pt has been in rehab since d/c from\\n with septic arthritis in L shoulder, hip and R knuckle.\\n On Vanco followed by ID.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2180-01-12 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 399676,\n \"text\": \"Pt is a 71 yo female with PMH: BM stent to LAD ', Occluded RCA\\n without intervention, Ischemic CM (EF 10-25%), BiV ICD, AF, PVD, DVT\\n s/p IVC filter, coumadin, hypothyroidism, CKD, OA. adm for HF\\n (milrinone/lasix) MRSA in L shoulder, L hip and R knuckle. Out to\\n rehab . Today went from rehab to see Dr. , sent to EW with\\n hypotension. SBP 70 in EW, transiently on dopa, but cardiology d/c'd.\\n Rxd with NS 250 cc with SBP 92. Pt has been in rehab since d/c from\\n with septic arthritis in L shoulder, hip and R knuckle.\\n On Vanco followed by ID.\\n .H/O heart failure (CHF), Systolic, Acute on Chronic\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Impaired Skin Integrity\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2180-01-13 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 399746,\n \"text\": \"Pt is a 71 yo female with PMH: BM stent to LAD ', Occluded RCA\\n without intervention, Ischemic CM (EF 10-25%), BiV ICD, AF, PVD, DVT\\n s/p IVC filter, coumadin, hypothyroidism, CKD, OA. adm for HF\\n (milrinone/lasix) MRSA in L shoulder, L hip and R knuckle. Out to\\n rehab . went from rehab to see Dr. , sent to EW with\\n hypotension. SBP 70 in EW, transiently on dopa, but cardiology d/c'd.\\n Rxd with NS 250 cc with SBP 92. Pt has been in rehab since d/c from\\n with septic arthritis in L shoulder, hip and R knuckle.\\n On Vanco followed by ID.\\n She was started on milrinone .375 after bolus and lasix drip also begun\\n at 2.5mg/hr. The lasix dose was increased to 5mg overnight, but urine\\n output has remained poor, though she is negative.\\n GI: Pt has poor apetite and eats very little.\\n SOCIAL: Family in the visit in afternoon. Pt in good spirits, visiting\\n with brother and his family.\\n CODE STATUS: Dr had discussion with both patient and health care\\n proxy and all are in agreement that she be DNR/DNI. Additionally the\\n defibrillator part of AICD/pacer was shut off.\\n Pain control (acute pain, chronic pain)\\n Assessment:\\n Pt has a number of sources of pain. She has joint pain in shoulders and\\n especially R elbow from septic arthritis. The most uncomfortable area\\n is the decubitus ulcer on her coccyx area. She receive standing ultran\\n for that. She requires frequent position changes, but seems most\\n uncomfortable on L side. By 1000 she was very uncomfortable.\\n Action:\\n She received 2mg IV morpnine sulfate at 1230 and had shift in position\\n and was comfortable until noon when pain recurred. She received another\\n 2mg morphine sulfate and position change.\\n Response:\\n She slept until\\n Plan:\\n .H/O heart failure (CHF), Systolic, Acute on Chronic\\n Assessment:\\n Pt on Milrinone .375mic/kilo and lasix 5mg/hr. Urine output\\n ~30-50cc/hr. Hr in 70s AV paced with rare PVCs . BP 85-100/50-60s,\\n lower after morphine. Pt sating 98-100% on 3L NP and lungs are mostly\\n clear. She has no c/o of SOB. She has 2+ edema in legs.\\n Action:\\n At 1030 lasix was increased to 10mg/hr and at 1100 milrinone was\\n increased to .5mic/kilo. Legs are kept elevated. 02 has been off most\\n of the day and she is sating 96-98% on RA.\\n Response:\\n She is ~280cc negative for the day. The skin on her legs show signs\\n that they have lost fluid.\\n Plan:\\n Continue with Milrinone and lasix. Keep careful I & O\\n Impaired Skin Integrity\\n Assessment:\\n Pt has multiple skin lesions. Most prominent is coccyx decub. It has\\n mepelix on it that was leaking through and pulling loose in am. Both\\n heels are reddened, though they . She has dry skin on all\\n extremities with some small abraded areas.\\n Action:\\n Coccyx dsg changed. Area primarily covered with slough. The edges are\\n rounded and pink. Area cleansed with wound cleaner, dried and new\\n mepelix applied. All limbs were lubricated frequently. Her position was\\n changed, at times only slightly throughout the day. She does become\\n uncomfortable if she is in the same position for too long,but also has\\n difficulty on the L side. She finds the waffle boots uncomfortable and\\n prefers having her legs elevated on pillows.\\n Response:\\n No new skin lesions have developed.\\n Plan:\\n Continue with turning, lubricating and keeping heels elevated. Monitor\\n mepilex to ensure it is in place.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2180-01-13 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 399747,\n \"text\": \"Pt is a 71 yo female with PMH: BM stent to LAD ', Occluded RCA\\n without intervention, Ischemic CM (EF 10-25%), BiV ICD, AF, PVD, DVT\\n s/p IVC filter, coumadin, hypothyroidism, CKD, OA. adm for HF\\n (milrinone/lasix) MRSA in L shoulder, L hip and R knuckle. Out to\\n rehab . went from rehab to see Dr. , sent to EW with\\n hypotension. SBP 70 in EW, transiently on dopa, but cardiology d/c'd.\\n Rxd with NS 250 cc with SBP 92. Pt has been in rehab since d/c from\\n with septic arthritis in L shoulder, hip and R knuckle.\\n On Vanco followed by ID.\\n She was started on milrinone .375 after bolus and lasix drip also begun\\n at 2.5mg/hr. The lasix dose was increased to 5mg overnight, but urine\\n output has remained poor, though she is negative.\\n GI: Pt has poor apetite and eats very little.\\n SOCIAL: Family in the visit in afternoon. Pt in good spirits, visiting\\n with brother and his family.\\n CODE STATUS: Dr had discussion with both patient and health care\\n proxy and all are in agreement that she be DNR/DNI. Additionally the\\n defibrillator part of AICD/pacer was shut off.\\n Pain control (acute pain, chronic pain)\\n Assessment:\\n Pt has a number of sources of pain. She has joint pain in shoulders and\\n especially R elbow from septic arthritis. The most uncomfortable area\\n is the decubitus ulcer on her coccyx area. She receive standing ultran\\n for that. She requires frequent position changes, but seems most\\n uncomfortable on L side. By 1000 she was very uncomfortable.\\n Action:\\n She received 2mg IV morpnine sulfate at 1230 and had shift in position\\n and was comfortable until noon when pain recurred. She received another\\n 2mg morphine sulfate and position change.\\n Response:\\n She slept until\\n Plan:\\n .H/O heart failure (CHF), Systolic, Acute on Chronic\\n Assessment:\\n Pt on Milrinone .375mic/kilo and lasix 5mg/hr. Urine output\\n ~30-50cc/hr. Hr in 70s AV paced with rare PVCs . BP 85-100/50-60s,\\n lower after morphine. Pt sating 98-100% on 3L NP and lungs are mostly\\n clear. She has no c/o of SOB. She has 2+ edema in legs.\\n Action:\\n At 1030 lasix was increased to 10mg/hr and at 1100 milrinone was\\n increased to .5mic/kilo. Legs are kept elevated. 02 has been off most\\n of the day and she is sating 96-98% on RA.\\n Response:\\n She is ~280cc negative for the day. The skin on her legs show signs\\n that they have lost fluid.\\n Plan:\\n Continue with Milrinone and lasix. Keep careful I & O\\n Impaired Skin Integrity\\n Assessment:\\n Pt has multiple skin lesions. Most prominent is coccyx decub. It has\\n mepelix on it that was leaking through and pulling loose in am. Both\\n heels are reddened, though they . She has dry skin on all\\n extremities with some small abraded areas.\\n Action:\\n Coccyx dsg changed. Area primarily covered with slough. The edges are\\n rounded and pink. Area cleansed with wound cleaner, dried and new\\n mepelix applied. All limbs were lubricated frequently. Her position was\\n changed, at times only slightly throughout the day. She does become\\n uncomfortable if she is in the same position for too long,but also has\\n difficulty on the L side. She finds the waffle boots uncomfortable and\\n prefers having her legs elevated on pillows.\\n Response:\\n No new skin lesions have developed.\\n Plan:\\n Continue with turning, lubricating and keeping heels elevated. Monitor\\n mepilex to ensure it is in place.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2180-01-12 00:00:00.000\",\n \"description\": \"CCU Fellow Addendum\",\n \"row_id\": 399668,\n \"text\": \"TITLE: CCU Fellow Addendum\\n Patient seen and plan discussed with CCU housestaff. For details, see\\n CCU resident H&P. Briefly, the patient is a 71 year old woman with PMH\\n of CAD, ischemic CMY (EF 10%) s/p -V ICD, atrial fibrillation, CKD,\\n with past history of DVT and PE on Coumadin, sacral decubitus ulcers\\n and R shoulder sepsis s/p washout, who returns from rehab with volume\\n overload consistent with her prior CHF exacerbations. The patient has\\n had some chest burning consistent with her angina in the days up to\\n today, but none currently. Her primary complaint has been severe\\n sacral and shoulder pains, which continue to cause her significant\\n agitation. On exam, she is hypotensive with cool extremities and\\n slightly dyspneic, consistent with cardiogenic etiology. Plan will be\\n for aggressive diuresis, with milrinone and neosynephrine for BP\\n support, as well as aggressive pain control. Plan discussed with Dr.\\n .\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2180-01-19 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 400261,\n \"text\": \"71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\\n coumadin, hypothyroidism, CKD, OA. admitted for septic joint\\n washout- MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\\n On pt. was sent to ED from clinic w/ hypotension\\n transiently on dopa, Tx\\nd w/ NS 250 cc w/ SBP ^ 92.\\n Admit to CCU for aggressive diuresis. She was started on\\n Milrinone and lasix gtt. She has large coccyx decub that is a source\\n of chronic pain. She is DNR/DNI and defibrillator has been shut off.\\n Pain control (acute pain, chronic pain)\\n Assessment:\\n Pt. with history of pain in left shoulder, left hip (septic joints) and\\n coccyx (decub.).\\n Action:\\n MS , morphine IR 15mg for breakthrough pain, given this x2\\n today. Pt. also given 2mg IV morphine prior to all activity/turning\\n today. Pt. receiving ultram qid.\\n Response:\\n Pt. has denied pain today until 1500\\n she reported pain after turning\\n despite premedicating. Tolerating above with no ill-effects. Pt.\\n painfree by 1600.\\n Plan:\\n Continue present around-the-clock and aggressive prn regimen.\\n .H/O heart failure (CHF), Systolic, Acute on Chronic\\n Assessment:\\n Off lasix gtt since , and milrinone since . AV paced at 70 with\\n BP 90\\ns/60\\ns today. LS essentially clear, some fine ?dependent\\n crackles noted at bases. Skin warm, dry. UO approximately 20cc/hr.\\n Pt. slightly confused this afternoon per family.\\n Action:\\n Assessment ongoing. Torsemide started.\\n Response:\\n Pt. tolerating medication. Assessment largely unchanged.\\n Plan:\\n Continue to monitor and treat as indicated. Transfer to floor today.\\n **** Goals towards comfort.****\\n Impaired Skin Integrity\\n Assessment:\\n Pt. with sacral decub as documented in metavision.\\n Action:\\n Dressing changed today at noon per skin care recs. Pt. turned side to\\n side as documented.\\n Response:\\n Pt. tolerated dressing change, premedicated with morphine IV.\\n Moderated amt. yellow-white slough noted. Small amounts drainage\\n noted.\\n Plan:\\n Continue daily dressing changes skin RN. Continue turning as pt.\\n tolerates, avoid pressure points.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2180-01-19 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 400262,\n \"text\": \"71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\\n coumadin, hypothyroidism, CKD, OA. admitted for septic joint\\n washout- MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\\n On pt. was sent to ED from clinic w/ hypotension\\n transiently on dopa, Tx\\nd w/ NS 250 cc w/ SBP ^ 92.\\n Admit to CCU for aggressive diuresis w/ Milrinone and lasix gtt.\\n She has large coccyx decub that is a source of chronic pain. She is\\n DNR/DNI--defibrillator has been shut off \\n Pain control (acute pain, chronic pain)\\n Assessment:\\n Pt. with history of pain in left shoulder, left hip (septic joints) and\\n coccyx (decub.).\\n Action:\\n MS ,\\n morphine IR 15mg for breakthrough pain--2mg IV morphine\\n prior to all activity/turning today.\\n ultram QID, Tylenol TID\\n Response:\\n Pt. has denied pain today until 1500\\n she reported pain after turning\\n despite premedicating. Tolerating above with no ill-effects. Pt.\\n painfree by 1600.\\n Plan:\\n Continue present around-the-clock and aggressive prn regimen.\\n .H/O heart failure (CHF), Systolic, Acute on Chronic\\n Assessment:\\n Off lasix gtt since , and milrinone since . AV paced at 70 with\\n BP 85-90\\ns/50-60\\ns today. LS essentially clear, some fine crackles\\n noted at bases this afternoon. Skin warm, dry. UO approximately\\n 20cc/hr. Pt. slightly confused this afternoon per family.\\n Action:\\n Assessment ongoing. Torsemide started.\\n Response:\\n Pt. tolerating medication. Assessment largely unchanged.\\n Plan:\\n Continue to monitor and treat as indicated. Transfer to floor today.\\n Impaired Skin Integrity\\n Assessment:\\n Pt. with sacral decub as documented in metavision.\\n Action:\\n Dressing changed today at noon per skin care recs ( critic-aid\\n anti-fungal to peri-wound, covered w/ aquacel AG & sm soft soft pads\\n secured w/ soft tape w/ skin barrier wipe). Pt. turned side to side\\n as documented.\\n Response:\\n Pt. tolerated dressing change, premedicated with morphine IV.\\n Moderated amt. yellow-white slough noted. Small amounts drainage\\n noted.\\n Plan:\\n Continue daily dressing changes skin RN. Continue turning as pt.\\n tolerates, avoid pressure points.\\n 19:00-20:30\\n Sleepy, a&Ox3. RR 8-12 w/ some periods of apnea ? r/t to\\n pain meds. 20:00 dose of MS contin HELD. Currently comfortable and\\n pain-free. SBPs generally mid 70s-90s\\nASYMPTOMATIC.\\n ACCESS: R brachial midline (previously PICC placd )\\n RIJ TLC placed : Medial port clotted\\n CIPRO for UTI\\n Demographics\\n Attending MD:\\n \\n Admit diagnosis:\\n CONGESTIVE HEART FAILURE\\n Code status:\\n DNR / DNI\\n Height:\\n 60 Inch\\n Admission weight:\\n 82.2 kg\\n Daily weight:\\n 73.6 kg\\n Allergies/Reactions:\\n No Known Drug Allergies\\n Precautions: Contact (+ CDiff ; MRSA L shoulder, L hip and R\\n knuckle )\\n PMH:\\n CV-PMH: Arrhythmias, CAD, CHF, Hypertension, MI, Pacemaker, PVD\\n Additional history: BM stent to LAD ', Occluded RCA without\\n intervention, Ischemic CM (EF 10-25%), BiV ICD, AF, PVD, DVT s/p IVC\\n filter, coumadin, hypothyroidism, CKD, OA. adm for MRSA in L\\n shoulder, L hip and R knuckle.\\n Surgery / Procedure and date:\\n Latest Vital Signs and I/O\\n Non-invasive BP:\\n S:99\\n D:64\\n Temperature:\\n 96.6\\n Arterial BP:\\n S:\\n D:\\n Respiratory rate:\\n 16 insp/min\\n Heart Rate:\\n 70 bpm\\n Heart rhythm:\\n AV Paced\\n O2 delivery device:\\n None\\n O2 saturation:\\n 90%\\n O2 flow:\\n 3 L/min\\n FiO2 set:\\n 24h total in:\\n 670 mL\\n 24h total out:\\n 500 mL\\n Pertinent Lab Results:\\n Sodium:\\n 132 mEq/L\\n 05:40 AM\\n Potassium:\\n 3.8 mEq/L\\n 05:40 AM\\n Chloride:\\n 91 mEq/L\\n 05:40 AM\\n CO2:\\n 35 mEq/L\\n 05:40 AM\\n BUN:\\n 32 mg/dL\\n 05:40 AM\\n Creatinine:\\n 1.0 mg/dL\\n 05:40 AM\\n Glucose:\\n 93 mg/dL\\n 05:40 AM\\n Hematocrit:\\n 31.2 %\\n 05:40 AM\\n Valuables / Signature\\n Patient valuables:\\n Other valuables:\\n Clothes: w/ dtr\\n / :\\n No money / \\n Cash / Credit cards sent home with:\\n Jewelry: watch on pt R wrist\\n Transferred from: CCU \\n Transferred to: 3\\n Date & time of Transfer: 21:00\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2180-01-13 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 399738,\n \"text\": \"Pt is a 71 yo female with PMH: BM stent to LAD ', Occluded RCA\\n without intervention, Ischemic CM (EF 10-25%), BiV ICD, AF, PVD, DVT\\n s/p IVC filter, coumadin, hypothyroidism, CKD, OA. adm for HF\\n (milrinone/lasix) MRSA in L shoulder, L hip and R knuckle. Out to\\n rehab . went from rehab to see Dr. , sent to EW with\\n hypotension. SBP 70 in EW, transiently on dopa, but cardiology d/c'd.\\n Rxd with NS 250 cc with SBP 92. Pt has been in rehab since d/c from\\n with septic arthritis in L shoulder, hip and R knuckle.\\n On Vanco followed by ID.\\n She was started on milrinone .375 after bolus and lasix drip also begun\\n at 2.5mg/hr. The lasix dose was increased to 5mg overnight, but urine\\n output has remained poor, though she is negative.\\n GI: Pt has poor apetite and eats very little.\\n SOCIAL: Family in the visit in afternoon. Pt in good spirits, visiting\\n with brother and his family.\\n CODE STATUS: Dr had discussion with both patient and health care\\n proxy and all are in agreement that she be DNR/DNI. Additionally the\\n defibrillator part of AICD/pacer was shut off.\\n Pain control (acute pain, chronic pain)\\n Assessment:\\n Pt has a number of sources of pain. She has joint pain in shoulders and\\n especially R elbow from septic arthritis. The most uncomfortable area\\n is the decubitus ulcer on her coccyx area. She receive standing ultran\\n for that. She requires frequent position changes, but seems most\\n uncomfortable on L side. By 1000 she was very uncomfortable.\\n Action:\\n She received 2mg IV morpnine sulfate at 1230 and had shift in position\\n and was comfortable until noon when pain recurred. She received another\\n 2mg morphine sulfate and position change.\\n Response:\\n She slept until\\n Plan:\\n .H/O heart failure (CHF), Systolic, Acute on Chronic\\n Assessment:\\n Pt on Milrinone .375mic/kilo and lasix 5mg/hr. Urine output\\n ~30-50cc/hr. Hr in 70s AV paced with rare PVCs . BP 85-100/50-60s,\\n lower after morphine. Pt sating 98-100% on 3L NP and lungs are mostly\\n clear. She has no c/o of SOB. She has 2+ edema in legs.\\n Action:\\n At 1030 lasix was increased to 10mg/hr and at 1100 milrinone was\\n increased to .5mic/kilo. Legs are kept elevated. 02 has been off most\\n of the day and she is sating 96-98% on RA.\\n Response:\\n She is ~800cc negative for the day. The skin on her legs show signs\\n that they have lost fluid.\\n Plan:\\n Continue with Milrinone and lasix. Keep careful I & O\\n Impaired Skin Integrity\\n Assessment:\\n Pt has multiple skin lesions. Most prominent is coccyx decub. It has\\n mepelix on it that was leaking through and pulling loose in am. Both\\n heels are reddened, though they . She has dry skin on all\\n extremities with some small abraded areas.\\n Action:\\n Coccyx dsg changed. Area primarily covered with slough. The edges are\\n rounded and pink. Area cleansed with wound cleaner, dried and new\\n mepelix applied. All limbs were lubricated frequently. Her position was\\n changed, at times only slightly throughout the day. She does become\\n uncomfortable if she is in the same position for too long,but also has\\n difficulty on the L side. She finds the waffle boots uncomfortable and\\n prefers having her legs elevated on pillows.\\n Response:\\n No new skin lesions have developed.\\n Plan:\\n Continue with turning, lubricating and keeping heels elevated. Monitor\\n mepilex to ensure it is in place.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2180-01-14 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 399793,\n \"text\": \"Pt is a 71 yo female with PMH: BM stent to LAD ', Occluded RCA\\n without intervention, Ischemic CM (EF 10-25%), BiV ICD, AF, PVD, DVT\\n s/p IVC filter, coumadin, hypothyroidism, CKD, OA. adm for HF\\n (milrinone/lasix) MRSA in L shoulder, L hip and R knuckle. Out to\\n rehab . went from rehab to see Dr. , sent to EW with\\n hypotension. SBP 70 in EW, transiently on dopa, but cardiology d/c'd.\\n Rxd with NS 250 cc with SBP 92. Pt has been in rehab since d/c from\\n with septic arthritis in L shoulder, hip and R knuckle.\\n On Vanco followed by ID.\\n She was started on milrinone .375 after bolus and lasix drip also begun\\n at 2.5mg/hr. The lasix dose was increased to 5mg overnight, but urine\\n output has remained poor, though she is negative.\\n GI: Pt has poor apetite and eats very little.\\n SOCIAL: Family in the visit in afternoon. Pt in good spirits, visiting\\n with brother and his family.\\n CODE STATUS: Dr had discussion with both patient and health care\\n proxy and all are in agreement that she be DNR/DNI. Additionally the\\n defibrillator part of AICD/pacer was shut off.\\n Pain control (acute pain, chronic pain)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Impaired Skin Integrity\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n .H/O heart failure (CHF), Systolic, Acute on Chronic\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n ------ Protected Section ------\\n Pain control (acute pain, chronic pain)\\n Assessment:\\n Pt w large\\n Action:\\n Response:\\n Plan:\\n .H/O heart failure (CHF), Systolic, Acute on Chronic\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Impaired Skin Integrity\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n ------ Protected Section Addendum Entered By: , RN\\n on: 06:13 AM ------\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2180-01-14 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 399794,\n \"text\": \"Pt is a 71 yo female with PMH: BM stent to LAD ', Occluded RCA\\n without intervention, Ischemic CM (EF 10-25%), BiV ICD, AF, PVD, DVT\\n s/p IVC filter, coumadin, hypothyroidism, CKD, OA. adm for HF\\n (milrinone/lasix) MRSA in L shoulder, L hip and R knuckle. Out to\\n rehab . went from rehab to see Dr. , sent to EW with\\n hypotension. SBP 70 in EW, transiently on dopa, but cardiology d/c'd.\\n Rxd with NS 250 cc with SBP 92. Pt has been in rehab since d/c from\\n with septic arthritis in L shoulder, hip and R knuckle.\\n On Vanco followed by ID.\\n She was started on milrinone .375 after bolus and lasix drip also begun\\n at 2.5mg/hr. The lasix dose was increased to 5mg overnight, but urine\\n output has remained poor, though she is negative.\\n GI: Pt has poor apetite and eats very little.\\n SOCIAL: Family in the visit in afternoon. Pt in good spirits, visiting\\n with brother and his family.\\n CODE STATUS: Dr had discussion with both patient and health care\\n proxy and all are in agreement that she be DNR/DNI. Additionally the\\n defibrillator part of AICD/pacer was shut off.\\n Pain control (acute pain, chronic pain)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Impaired Skin Integrity\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n .H/O heart failure (CHF), Systolic, Acute on Chronic\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n ------ Protected Section ------\\n Pain control (acute pain, chronic pain)\\n Assessment:\\n Pt w large\\n Action:\\n Response:\\n Plan:\\n .H/O heart failure (CHF), Systolic, Acute on Chronic\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Impaired Skin Integrity\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n ------ Protected Section Addendum Entered By: , RN\\n on: 06:13 AM ------\\n ------ Protected Section Error Entered By: , RN\\n on: 06:17 AM ------\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2180-01-14 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 399797,\n \"text\": \"Pt is a 71 yo female with PMH: BM stent to LAD ', Occluded RCA\\n without intervention, Ischemic CM (EF 10-25%), BiV ICD, AF, PVD, DVT\\n s/p IVC filter, coumadin, hypothyroidism, CKD, OA. adm for HF\\n (milrinone/lasix) MRSA in L shoulder, L hip and R knuckle. Out to\\n rehab . went from rehab to see Dr. , sent to EW with\\n hypotension. SBP 70 in EW, transiently on dopa, but cardiology d/c'd.\\n Rxd with NS 250 cc with SBP 92. Pt has been in rehab since d/c from\\n with septic arthritis in L shoulder, hip and R knuckle.\\n On Vanco followed by ID.\\n She was started on milrinone .375 after bolus and lasix drip also begun\\n at 2.5mg/hr. The lasix dose was increased to 5mg overnight, but urine\\n output has remained poor, though she is negative.\\n GI: Pt has poor apetite and eats very little.\\n SOCIAL: Family in the visit in afternoon. Pt in good spirits, visiting\\n with brother and his family.\\n CODE STATUS: Dr had discussion with both patient and health care\\n proxy and all are in agreement that she be DNR/DNI. Additionally the\\n defibrillator part of AICD/pacer was shut off.\\n Pain control (acute pain, chronic pain)\\n Assessment:\\n Pt w large painful coccyx wound given ultram/Tylenol as ordered as well\\n as prn MSO4 for pain control.\\n Action:\\n See above- QHS Tylenol 1 GM, ultram. MSO4 2 mg x 3 doses this shift.\\n Turning side to side and repositioning w less discomfort. Unable to\\n tolerate being on left side for very long- describes increased coccyx\\n pain/hp pain.\\n Response:\\n Pt sleeping well, more comfortable w MS IVP.\\n Plan:\\n Continue to make pt as comfortable as possible. Medicate, reposition,\\n emotional support as needed.\\n .H/O heart failure (CHF), Systolic, Acute on Chronic\\n Assessment:\\n Pt w longstanding ESHD- currently on Mlrinone 0.5 and lasix gtt up to\\n 15 mg in attempts to maximize heart function /unloading.\\n Action:\\n Given 5 metalozone PO x 1 and increased lasix to 15 mg for I/O\\n unchanged, even as of MN. No changes to milrinone gtt.\\n Response:\\n Better diuresis w increased lasix. (-) 800cc as of 6am. HR remains\\n 70-100 AVP. Minimal VEA. No runs. Of note defib fx of ICD has been\\n turned off. BP- 90-100/50\\ns. No hypotension this shift.\\n Plan:\\n Continue to attempt to duirese without dropping BP, affecting\\n hemodynamics. Continue milrinone gtt as ordered. Continue plan of care,\\n DNR, keep pt comfortable. Keep pt aware of plan of care as well as\\n family .\\n Impaired Skin Integrity\\n Assessment:\\n Pt admitted from rehab for hypotension, heart failure\\n admitted w\\n large coccyx decubitus. Pain at site.\\n Action:\\n Pt remains on medications to keep comfortable currently- MS, ultram,\\n Tylenol. Repositioning frequently to keep pt off coccyx. Changed dsg x\\n 1\\n cleaned wound w wound spray- see flow for details. No drainage\\n apparent.\\n Response:\\n Changed coccyx wound dressing. Appears to be clean without drainage.\\n Plan:\\n Continue wound care per plan. Keep pt off wound site w repositioning as\\n able. Comfort/pain control.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2180-01-14 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 399877,\n \"text\": \"Pt is a 71 yo female with PMH: BM stent to LAD ', Occluded RCA\\n without intervention, Ischemic CM (EF 10-25%), BiV ICD, AF, PVD, DVT\\n s/p IVC filter, coumadin, hypothyroidism, CKD, OA. adm for HF\\n (milrinone/lasix) MRSA in L shoulder, L hip and R knuckle. Out to\\n rehab . went from rehab to see Dr. , sent to EW with\\n hypotension. SBP 70 in EW, transiently on dopa, but cardiology d/c'd.\\n Rxd with NS 250 cc with SBP 92. Pt has been in rehab since d/c from\\n with septic arthritis in L shoulder, hip and R knuckle.\\n On Vanco followed by ID.\\n She was started on milrinone .375 after bolus and lasix drip also begun\\n at 2.5mg/hr. The lasix dose was increased to 10 but urine output\\n has remained poor, though she is negative.\\n GI: Pt has good apetite and has been eating well, but still no BM. She\\n has pills ground up in applesauce.\\n SOCIAL: Family in the visit in the am and early afternoon. She slept\\n most of the afternoon.\\n CODE STATUS: Dr had discussion with both patient and health care\\n proxy and all are in agreement that she be DNR/DNI. Additionally the\\n defibrillator part of AICD/pacer was shut off.\\n Pain control (acute pain, chronic pain)\\n Assessment:\\n Pain is much better contolled now that she can receive prn morphine in\\n addition to standing ultram and Tylenol. The coccyx decubitis is what\\n causes the most discomfort. She is most uncomfortable on her L side and\\n cannot sleep or rest on that side.\\n Action:\\n She required more morphine in the am and received 7 2mg doses between\\n 8am and 1500. She has not been turned on L side except for dsg and bed\\n change. She goes from back to R side and is doing better with this.\\n Response:\\n She was awake and conversant with family all morning, able to eat and\\n interact. She has slept most of the afternoon since 1500. She awoke at\\n 1800 and was pain free and ready to eat.\\n Plan:\\n Continue standing ultram and give morphine prn. Change position as\\n tolerated.\\n .H/O heart failure (CHF), Systolic, Acute on Chronic\\n Assessment:\\n She has her lasix drip increased to 15mg overnight and remains on\\n milrinone .5mic/kilo. She has a once a day metolazone 5mg po added. She\\n has no audible rales, just decresed breath sounds at the bases. Her\\n blood pressure has been adequate with maps over the 60s. She has no\\n c/o of cp or acute SOB. Her bilateral leg edema is decreasing. She\\n received 20 meq KCL IV this am.\\n Action:\\n She continues on above medications and is now responding with excellent\\n diuresis. She is over 2 liters negative for the day! Lopressor was\\n increased to 25mg .\\n Response:\\n Lytes within nl limits. Goal to to continue pushing diuresis for over\\n 10 liters negative.\\n Plan:\\n Keep careful I & O. Monitor lytes\\n Impaired Skin Integrity\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2180-01-12 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1118390,\n \"text\": \" 1:08 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for acute process\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 71 year old woman with chf\\n REASON FOR THIS EXAMINATION:\\n eval for acute process\\n ______________________________________________________________________________\\n WET READ: RBLd WED 2:35 PM\\n high riding right PICC line, terminates in right subclavian vein. recommend\\n repositioning or removal.\\n\\n persistent severe cdm. small left effusion + atelect. possible trace right\\n effusion.\\n ______________________________________________________________________________\\n FINAL REPORT\\n EXAM: Chest, single AP upright portable view.\\n\\n CLINICAL INFORMATION: 71-year-old female with history of CHF.\\n\\n COMPARISON: .\\n\\n FINDINGS: A dual-lead left-sided AICD is seen with leads extending to the\\n expected positions of the right atrium and right ventricle. A right-sided\\n PICC findings seen, high in position, terminating in the region of the right\\n subclavian vein. Recommend repositioning or removal. The cardiac silhouette\\n is markedly enlarged without significant interval change from the prior study.\\n The aorta is calcified and tortuous. There is blunting of the left\\n costophrenic angle and obscuration of the left hemidiaphragm suggesting left\\n pleural effusion with overlying atelectasis. Minimal blunting of the right\\n costophrenic angle also suggests a trace right pleural effusion and/or\\n thickening.\\n\\n IMPRESSION:\\n 1. High lying right PICC line, terminating in the region of the right\\n subclavian vein. Recommend repositioning or removal.\\n 2. Persistent severe cardiomegaly.\\n 3. Small left pleural effusion with overlying atelectasis.\\n 4. Mild blunting of the right costophrenic angle, may be due to a trace\\n effusion and/or thickening.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2180-01-12 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 1118410,\n \"text\": \" 2:22 PM\\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \\n Reason: eval for placement\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 71 year old woman with new R IJ\\n REASON FOR THIS EXAMINATION:\\n eval for placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 71-year-old woman with new right IJ line.\\n\\n COMPARISON: Chest radiograph one hour prior.\\n\\n CHEST, UPRIGHT AP PORTABLE VIEW: A right IJ catheter has been placed,\\n terminating in the lower SVC. The right PICC line is unchanged, terminating\\n at the expected location of the right subclavian vein. The left-sided ICD\\n device is unchanged. The cardiac silhouette remains enlarged. Small\\n bilateral pleural effusions are unchanged. Perihilar interstitial prominence\\n is indicating mild interstitial edema, unchanged. There is no pneumothorax.\\n Retrocardiac opacity persists.\\n\\n IMPRESSION:\\n 1. Right IJ catheter terminates in lower SVC.\\n\\n 2. Unchanged high riding right PICC line terminating in the expected location\\n of the right subclavian vein. Recommend repositioning or removal.\\n\\n 3. Otherwise unchanged from one hour prior.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2180-01-13 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1118513,\n \"text\": \" 7:49 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: interval improvement\\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 71 year old woman with CHF\\n REASON FOR THIS EXAMINATION:\\n interval improvement\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 71 year-old woman with CHF.\\n\\n COMPARISON: Multiple prior chest radiographs, the most recent performed 12\\n hours prior.\\n\\n AP UPRIGHT CHEST RADIOGRAPH: Marked cardiomegaly is stable. A right internal\\n jugular catheter with its tip in the low SVC, a right-sided venous catheter\\n with its tip in the subclavian vein and left-sided AICD with its leads\\n overlying the right atrium and right ventricle are unchanged. Small bilateral\\n effusions are stable. There is slight increase in vascular engorgement since\\n hours prior. There is no consolidation or pneumothorax.\\n\\n IMPRESSION: Mild increase in vascular engorgement, otherwise no change since\\n hours prior.\\n\\n\"\n }\n]"}}},{"rowIdx":396,"cells":{"subject_id":{"kind":"number","value":96260,"string":"96,260"},"hadm_id":{"kind":"number","value":131106,"string":"131,106"},"target_text":{"kind":"string","value":"50 y.o woman with history of adult onset still's disease with HIV who presented to the hospital with signs and symptoms consistent with a flare of her disease, as evidenced by fever, pharyngitis, rash, arthralgias, and facial swelling. She appears to have quite brittle disease as this flare seems to have flared due to her recent decrease in her Anakaria. It is a quite fulminant flare causing hypotension which required pressor support and ICU admission. . Still's disease: The patient received 10mg of dexamethasone in the ED, as well as a dose of her anakinra. Rheumatology was consulted. IV fluid boluses of Normal Saline, and eventually LR to help maintain pressure. She was started on vasopression and norepinephrine for further pressure support and an arterial-line, and triple lumen internal jugular catheter were placed for monitoring. ESR and CRP were ordered, which were 56 and 53.7 (which have both been higher in the past). She was started on prednisone 60mg/day, Anakinra was given on a daily basis, and her fevers were managed with Tyelnol prn. Her fibrin split products were negative. Her ferritin levels were also monitored. Over the course of her hospitalization, her Still's symptoms improved with gradual resolution of the rash, dimished swelling, reduced arthralgias and minimal pain. Pt will continue with a long course of Prednisone 60mg and Anakaria daily until Rheum follow up. Pt was ambulating on her own, comfortable, afebrile, tolerating regular diet by the time of discharge. . Hypotension: The patient's Still's flares appear to manifest in this fulminant manner on a regular basis that appears in many ways like sepsis. While it appears to be that a medication change that triggered this current attack, occult infection was considered given the patient's recent decrease in WBC count and HIV status. Vancomycin and Cefepime were started for broad coverage and completed a 7 day course (end on ). Additionally a CT of her neck was obtained to rule out an abscess, given that she had submandibular swelling. This CT was negative for signs of infection (as was an ultrasound). As mentioned above her pressure was supported with vasopressin and norepi for approximately two days, and then she was able to be weaned off the pressors with fluid support only and then eventually she was able to maintain her own pressures. . Thrombocytopenia: Concern was raised for general cell line suppression from her bactrim PCP prophylaxis, so this was changed to atovaquone which she tolerated well. Additionally, given that her platelets dropped 50% in the setting of heparin use, heparin was stopped and HIT labs were sent off. Hematology was consulted for advice. PF4 was positive with serotonin release assay pending. The PF4 study had low optical density, making HIT less likely. Pt did have suspicious filling defect of jugular vein on CT, however follow up Ultrasound showed no signs of clot. It was reccomended by the hematology service that patient avoid Heparin products in the future given this one episode of questionable HIT. . Diarrhea: Pt had diahrea early during hospitalization. Given that she is immunosuppressed and has been on antibiotics recently, concern was high for cdiff, however tests were negative. Additionally, stool for O&P were also negative and ecoli. Her electrolytes were monitored and repleted as needed with sliding scales. As pts diet advanced to solids, her diahrea resolved. . HIV: recent CD4 count was 444, although has been lower than 200 in the past per records. Her atripla was continued. As mentioned above, bactrim was discontinued and changed to atovaquone. . Hypothyroidism: Pt has history of sp ablation and was on levothyroxine 150 mcg daily supplementation. Now with TSH <0.02 in the MICU. Free T4 1.8. Pt was continued on levothyroxine 150mcg. She should fu outpatient to check her TSH and free T4. If TSH still low, would benefit from endocrinology opionion about possible relapse of . . Pending Labs/Studies: -Serotonin release assay - cultures"},"extractive_notes_summ":{"kind":"string","value":"IMPRESSION: Fluid-filled loops of small and large bowel with no dilation or wall thickening is nonspecific, may represent a component of enteritis. There are multiple level 1 lymph nodes visualized, none of which appear enlarged by CT size criteria. FINDINGS: The parotid glands are symmetric, without evidence of lymphadenopathy. The more distal portion of the brachiocephalic vein are not evaluated. IMPRESSION: Normal left subclavian, internal jugular and origin of brachiocephalic veins. CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST Other than dependent atelectasis, the lung bases are clear with no focal consolidations, pleural effusions, or pulmonary nodules. Overlying EKG leads noted. The cardiomediastinal silhouette is unchanged. T wave abnormalities. Lungs are clear bilaterally without focal consolidation, effusion, or pneumothorax. ST-T wave abnormalities are less prominent. Fluid within small bowel and colon is non-specific may represent a component of enteritis. Sinus tachycardia. Sinus tachycardia. COMPARISON: CT from . This, as well as the distal luminal narrowing of the left brachiocephalic vein suggests partial occlusion of that vein. IMPRESSION: No acute intrathoracic process. These veins are followed to their confluence, namely the origin of the brachiocephalic vein which also appears normal. CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The rectum, sigmoid colon, uterus, bilateral adnexa and bladder with Foley catheter and air within it are unremarkable. No evidence of abnormal focus of enhancement, or fluid collection. The cardiomediastinal silhouette is normal. The internal jugular and subclavian veins are widely patent, with normal wall-to-wall flow on color Doppler analysis. The visualized osseous structures are unremarkable. Osseous structures reveal no suspicious sclerotic or lytic lesions. Imaged portions of the lung apices are normal. FRONTAL CHEST RADIOGRAPH: There has been placement of a right internal jugular central venous line with tip in the distal SVC. No evidence of lymphadenopathy by CT size criteria. Note that the medial and distal portions of the left brachiocephalic vein are not visible by son and were seen to better effect on the comparison CT from the same day. Sinus rhythm. Note is made of a significant amount of fluid within the colon that may indicate a component of nonspecific fluid within the small bowel and colon that may indicate a component of enteritis. The thyroid is not visualized. The aerodigestive tract appears symmetric. No evidence of colitis. There are multiple scattered retroperitoneal lymph nodes numerous in quantity, though none that meet size criteria for pathologic enlargement. This appears related to a luminal narrowing of the distal left brachiocephalic vein near the confluence of the brachiocephalic veins. No pleural effusion or pneumothorax is seen. There is no pelvic free fluid. FINDINGS: Targeted son of the left internal jugular vein, subclavian vein and brachiocephalic veins were performed. The imaged paranasal sinuses reveal trace mucosal thickening of the maxillary sinuses bilaterally. Subtle detail through the left neck is limited by extensive streak artifact. Since the previous tracing of therate is slower. TECHNIQUE: Helically acquired axial images were obtained from the lung bases to the pubic symphysis after the uneventful administration of 100 mL of Optiray intravenous contrast. FINDINGS: AP upright portable chest radiograph is obtained. TECHNIQUE: Axial CT images were acquired through the neck following the uneventful administration of 90 cc of intravenous Optiray contrast. The liver, gallbladder, spleen, pancreas, both adrenal glands, both kidneys, both ureters, and visualized portions of intra-abdominal small and large bowel are unremarkable. Overall, there is no abnormal focus of enhancement. There is no pelvic or inguinal lymphadenopathy. There is no intra-abdominal free air or free fluid. Clinical correlationis suggested. There is no pneumothorax. There is no focal consolidation, pneumothorax, or effusion. Extensive reflux of injected contrast from the left brachiocephalic vein into the left jugular vein. EXAMINATION: CT of the abdomen and pelvis with intravenous contrast. (Over) 9:53 PM CT ABD & PELVIS WITH CONTRAST Clip # Reason: please eval r/o colitis Contrast: OPTIRAY Amt: 130 FINAL REPORT (Cont) BONE WINDOWS: There are no suspicious lytic or sclerotic foci. There are also numerous cervical level 2 through 4 lymph nodes, again none of which appear enlarged by size criteria. This artifact is related to extensive reflux of injected contrast material from the brachiocephalic vein into the left internal jugular vein. The imaged osseous structures are intact. Coronal and sagittal reformations are provided for review. The submandibular and sublingual glands are also symmetric. Coronal and sagittal reformats are also reviewed. IMPRESSION: 1. The imaged mastoid air cells are clear. Evaluate for colitis. DFDdp COMPARISONS: . 10:22 AM CT NECK W/CONTRAST (EG:PAROTIDS) Clip # Reason: r/o abscess,deep neck space infection Admitting Diagnosis: FEVER Contrast: OPTIRAY Amt: 90 MEDICAL CONDITION: 50 F w/ Stills dz, HIV here w/ fevers, hypotension w/ submandibular LAD and odynophagia REASON FOR THIS EXAMINATION: r/o abscess,deep neck space infection No contraindications for IV contrast FINAL REPORT INDICATION: Fever, hypotension, as well as submandibular lymphadenopathy and odynophagia in a patient with a history of HIV. Compared to the previous tracing of the rate hasincreased. COMPARISON: ."},"n_notes":{"kind":"number","value":8,"string":"8"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2195-03-06 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1178715,"text":" 8:28 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval r/o acute process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old woman with fever\n REASON FOR THIS EXAMINATION:\n please eval r/o acute process\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH PERFORMED ON \n\n Comparison is made with a prior chest radiograph from as well as a\n prior chest CT from .\n\n CLINICAL HISTORY: Fever, question pneumonia.\n\n FINDINGS: AP upright portable chest radiograph is obtained. Overlying EKG\n leads noted. Lungs are clear bilaterally without focal consolidation,\n effusion, or pneumothorax. The cardiomediastinal silhouette is normal. No\n pleural effusion or pneumothorax is seen. The imaged osseous structures are\n intact.\n\n IMPRESSION: No acute intrathoracic process.\n SESHa\n\n"},{"category":"Radiology","chartdate":"2195-03-06 00:00:00.000","description":"CT ABD & PELVIS WITH CONTRAST","row_id":1178724,"text":" 9:53 PM\n CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: please eval r/o colitis\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old woman with abd pain\n REASON FOR THIS EXAMINATION:\n please eval r/o colitis\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DLrc SAT 12:01 AM\n No evidence of colitis. Fluid within small bowel and colon is non-specific may\n represent a component of enteritis.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: The patient is a 50-year-old female with abdominal pain.\n Evaluate for colitis.\n\n EXAMINATION: CT of the abdomen and pelvis with intravenous contrast.\n\n COMPARISONS: .\n\n TECHNIQUE: Helically acquired axial images were obtained from the lung bases\n to the pubic symphysis after the uneventful administration of 100 mL of\n Optiray intravenous contrast. Coronal and sagittal reformations are provided\n for review.\n\n FINDINGS:\n\n Upon additional review of patient's record, the patient is also noted to be\n HIV positive.\n\n CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST\n\n Other than dependent atelectasis, the lung bases are clear with no focal\n consolidations, pleural effusions, or pulmonary nodules.\n\n The liver, gallbladder, spleen, pancreas, both adrenal glands, both kidneys,\n both ureters, and visualized portions of intra-abdominal small and large bowel\n are unremarkable. There is no intra-abdominal free air or free fluid. Note\n is made of a significant amount of fluid within the colon that may indicate a\n component of nonspecific fluid within the small bowel and colon that may\n indicate a component of enteritis. There are multiple scattered\n retroperitoneal lymph nodes numerous in quantity, though none that meet size\n criteria for pathologic enlargement.\n\n CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The rectum, sigmoid colon,\n uterus, bilateral adnexa and bladder with Foley catheter and air within it are\n unremarkable. There is no pelvic free fluid. There is no pelvic or inguinal\n lymphadenopathy.\n (Over)\n\n 9:53 PM\n CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: please eval r/o colitis\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n BONE WINDOWS: There are no suspicious lytic or sclerotic foci. The\n visualized osseous structures are unremarkable.\n\n IMPRESSION: Fluid-filled loops of small and large bowel with no dilation or\n wall thickening is nonspecific, may represent a component of enteritis. No\n evidence of colitis.\n\n"},{"category":"Radiology","chartdate":"2195-03-08 00:00:00.000","description":"CT NECK W/CONTRAST (EG:PAROTIDS)","row_id":1178933,"text":" 10:22 AM\n CT NECK W/CONTRAST (EG:PAROTIDS) Clip # \n Reason: r/o abscess,deep neck space infection\n Admitting Diagnosis: FEVER\n Contrast: OPTIRAY Amt: 90\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 F w/ Stills dz, HIV here w/ fevers, hypotension w/ submandibular LAD and\n odynophagia\n REASON FOR THIS EXAMINATION:\n r/o abscess,deep neck space infection\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fever, hypotension, as well as submandibular lymphadenopathy and\n odynophagia in a patient with a history of HIV.\n\n COMPARISON: .\n\n TECHNIQUE: Axial CT images were acquired through the neck following the\n uneventful administration of 90 cc of intravenous Optiray contrast. Coronal\n and sagittal reformats are also reviewed.\n\n FINDINGS: The parotid glands are symmetric, without evidence of\n lymphadenopathy. The submandibular and sublingual glands are also symmetric.\n There are multiple level 1 lymph nodes visualized, none of which appear\n enlarged by CT size criteria. There are also numerous cervical level 2\n through 4 lymph nodes, again none of which appear enlarged by size criteria.\n Subtle detail through the left neck is limited by extensive streak artifact.\n This artifact is related to extensive reflux of injected contrast material\n from the brachiocephalic vein into the left internal jugular vein. This\n appears related to a luminal narrowing of the distal left brachiocephalic vein\n near the confluence of the brachiocephalic veins. Overall, there is no\n abnormal focus of enhancement. The aerodigestive tract appears symmetric.\n The thyroid is not visualized. Imaged portions of the lung apices are normal.\n Osseous structures reveal no suspicious sclerotic or lytic lesions. The\n imaged paranasal sinuses reveal trace mucosal thickening of the maxillary\n sinuses bilaterally. Note is also made of a right bullosa. The imaged\n mastoid air cells are clear.\n\n IMPRESSION:\n 1. No evidence of abnormal focus of enhancement, or fluid collection.\n 2. No evidence of lymphadenopathy by CT size criteria.\n 3. Extensive reflux of injected contrast from the left brachiocephalic vein\n into the left jugular vein. This, as well as the distal luminal narrowing of\n the left brachiocephalic vein suggests partial occlusion of that vein.\n\n\n"},{"category":"Radiology","chartdate":"2195-03-07 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":1178740,"text":" 1:36 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: please eval placement\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old woman with line placement\n REASON FOR THIS EXAMINATION:\n please eval placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Line placement.\n\n COMPARISON: .\n\n FRONTAL CHEST RADIOGRAPH: There has been placement of a right internal\n jugular central venous line with tip in the distal SVC. There is no\n pneumothorax. The cardiomediastinal silhouette is unchanged. There is no\n focal consolidation, pneumothorax, or effusion.\n\n\n"},{"category":"Radiology","chartdate":"2195-03-08 00:00:00.000","description":"L UNILAT UP EXT VEINS US LEFT","row_id":1178981,"text":" 6:00 PM\n UNILAT UP EXT VEINS US LEFT Clip # \n Reason: EVAL LT IJV AND LT BRACHIOCEPHALIC V FOR THROMBUS SEEN IN CT SCAN\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year-old female with Stills, currently on pressors via right IJ; CT neck\n today, ordered for neck pain, with concern for occluded left brachiocephalic to\n jugular\n REASON FOR THIS EXAMINATION:\n Please evaluate for DVT; please include in imaging left brachiocephalic,\n jugular\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Question of obstruction of the left brachiocephalic vein.\n\n COMPARISON: CT from .\n\n FINDINGS: Targeted son of the left internal jugular vein, subclavian\n vein and brachiocephalic veins were performed. The internal jugular and\n subclavian veins are widely patent, with normal wall-to-wall flow on color\n Doppler analysis. These veins are followed to their confluence, namely the\n origin of the brachiocephalic vein which also appears normal. The more distal\n portion of the brachiocephalic vein are not evaluated.\n\n IMPRESSION: Normal left subclavian, internal jugular and origin of\n brachiocephalic veins. Note that the medial and distal portions of the left\n brachiocephalic vein are not visible by son and were seen to better\n effect on the comparison CT from the same day.\n DFDdp\n\n"},{"category":"ECG","chartdate":"2195-03-12 00:00:00.000","description":"Report","row_id":195293,"text":"Sinus tachycardia. Compared to the previous tracing of the rate has\nincreased.\n\n"},{"category":"ECG","chartdate":"2195-03-07 00:00:00.000","description":"Report","row_id":195294,"text":"Sinus rhythm. T wave abnormalities. Since the previous tracing of the\nrate is slower. ST-T wave abnormalities are less prominent.\n\n"},{"category":"ECG","chartdate":"2195-03-06 00:00:00.000","description":"Report","row_id":195295,"text":"Sinus tachycardia. T wave inversions in the inferolateral leads raising\nconsideration of possible ischemia, likely rate-related. Clinical correlation\nis suggested. Compared to the previous tracing of the ventricular rate\nhas increased and the ST segment changes are new.\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2195-03-06 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1178715,\n \"text\": \" 8:28 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: please eval r/o acute process\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 50 year old woman with fever\\n REASON FOR THIS EXAMINATION:\\n please eval r/o acute process\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST RADIOGRAPH PERFORMED ON \\n\\n Comparison is made with a prior chest radiograph from as well as a\\n prior chest CT from .\\n\\n CLINICAL HISTORY: Fever, question pneumonia.\\n\\n FINDINGS: AP upright portable chest radiograph is obtained. Overlying EKG\\n leads noted. Lungs are clear bilaterally without focal consolidation,\\n effusion, or pneumothorax. The cardiomediastinal silhouette is normal. No\\n pleural effusion or pneumothorax is seen. The imaged osseous structures are\\n intact.\\n\\n IMPRESSION: No acute intrathoracic process.\\n SESHa\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2195-03-06 00:00:00.000\",\n \"description\": \"CT ABD & PELVIS WITH CONTRAST\",\n \"row_id\": 1178724,\n \"text\": \" 9:53 PM\\n CT ABD & PELVIS WITH CONTRAST Clip # \\n Reason: please eval r/o colitis\\n Contrast: OPTIRAY Amt: 130\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 50 year old woman with abd pain\\n REASON FOR THIS EXAMINATION:\\n please eval r/o colitis\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: DLrc SAT 12:01 AM\\n No evidence of colitis. Fluid within small bowel and colon is non-specific may\\n represent a component of enteritis.\\n\\n WET READ VERSION #1\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: The patient is a 50-year-old female with abdominal pain.\\n Evaluate for colitis.\\n\\n EXAMINATION: CT of the abdomen and pelvis with intravenous contrast.\\n\\n COMPARISONS: .\\n\\n TECHNIQUE: Helically acquired axial images were obtained from the lung bases\\n to the pubic symphysis after the uneventful administration of 100 mL of\\n Optiray intravenous contrast. Coronal and sagittal reformations are provided\\n for review.\\n\\n FINDINGS:\\n\\n Upon additional review of patient's record, the patient is also noted to be\\n HIV positive.\\n\\n CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST\\n\\n Other than dependent atelectasis, the lung bases are clear with no focal\\n consolidations, pleural effusions, or pulmonary nodules.\\n\\n The liver, gallbladder, spleen, pancreas, both adrenal glands, both kidneys,\\n both ureters, and visualized portions of intra-abdominal small and large bowel\\n are unremarkable. There is no intra-abdominal free air or free fluid. Note\\n is made of a significant amount of fluid within the colon that may indicate a\\n component of nonspecific fluid within the small bowel and colon that may\\n indicate a component of enteritis. There are multiple scattered\\n retroperitoneal lymph nodes numerous in quantity, though none that meet size\\n criteria for pathologic enlargement.\\n\\n CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The rectum, sigmoid colon,\\n uterus, bilateral adnexa and bladder with Foley catheter and air within it are\\n unremarkable. There is no pelvic free fluid. There is no pelvic or inguinal\\n lymphadenopathy.\\n (Over)\\n\\n 9:53 PM\\n CT ABD & PELVIS WITH CONTRAST Clip # \\n Reason: please eval r/o colitis\\n Contrast: OPTIRAY Amt: 130\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n BONE WINDOWS: There are no suspicious lytic or sclerotic foci. The\\n visualized osseous structures are unremarkable.\\n\\n IMPRESSION: Fluid-filled loops of small and large bowel with no dilation or\\n wall thickening is nonspecific, may represent a component of enteritis. No\\n evidence of colitis.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2195-03-08 00:00:00.000\",\n \"description\": \"CT NECK W/CONTRAST (EG:PAROTIDS)\",\n \"row_id\": 1178933,\n \"text\": \" 10:22 AM\\n CT NECK W/CONTRAST (EG:PAROTIDS) Clip # \\n Reason: r/o abscess,deep neck space infection\\n Admitting Diagnosis: FEVER\\n Contrast: OPTIRAY Amt: 90\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 50 F w/ Stills dz, HIV here w/ fevers, hypotension w/ submandibular LAD and\\n odynophagia\\n REASON FOR THIS EXAMINATION:\\n r/o abscess,deep neck space infection\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Fever, hypotension, as well as submandibular lymphadenopathy and\\n odynophagia in a patient with a history of HIV.\\n\\n COMPARISON: .\\n\\n TECHNIQUE: Axial CT images were acquired through the neck following the\\n uneventful administration of 90 cc of intravenous Optiray contrast. Coronal\\n and sagittal reformats are also reviewed.\\n\\n FINDINGS: The parotid glands are symmetric, without evidence of\\n lymphadenopathy. The submandibular and sublingual glands are also symmetric.\\n There are multiple level 1 lymph nodes visualized, none of which appear\\n enlarged by CT size criteria. There are also numerous cervical level 2\\n through 4 lymph nodes, again none of which appear enlarged by size criteria.\\n Subtle detail through the left neck is limited by extensive streak artifact.\\n This artifact is related to extensive reflux of injected contrast material\\n from the brachiocephalic vein into the left internal jugular vein. This\\n appears related to a luminal narrowing of the distal left brachiocephalic vein\\n near the confluence of the brachiocephalic veins. Overall, there is no\\n abnormal focus of enhancement. The aerodigestive tract appears symmetric.\\n The thyroid is not visualized. Imaged portions of the lung apices are normal.\\n Osseous structures reveal no suspicious sclerotic or lytic lesions. The\\n imaged paranasal sinuses reveal trace mucosal thickening of the maxillary\\n sinuses bilaterally. Note is also made of a right bullosa. The imaged\\n mastoid air cells are clear.\\n\\n IMPRESSION:\\n 1. No evidence of abnormal focus of enhancement, or fluid collection.\\n 2. No evidence of lymphadenopathy by CT size criteria.\\n 3. Extensive reflux of injected contrast from the left brachiocephalic vein\\n into the left jugular vein. This, as well as the distal luminal narrowing of\\n the left brachiocephalic vein suggests partial occlusion of that vein.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2195-03-07 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 1178740,\n \"text\": \" 1:36 AM\\n CHEST PORT. LINE PLACEMENT Clip # \\n Reason: please eval placement\\n Admitting Diagnosis: FEVER\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 50 year old woman with line placement\\n REASON FOR THIS EXAMINATION:\\n please eval placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Line placement.\\n\\n COMPARISON: .\\n\\n FRONTAL CHEST RADIOGRAPH: There has been placement of a right internal\\n jugular central venous line with tip in the distal SVC. There is no\\n pneumothorax. The cardiomediastinal silhouette is unchanged. There is no\\n focal consolidation, pneumothorax, or effusion.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2195-03-08 00:00:00.000\",\n \"description\": \"L UNILAT UP EXT VEINS US LEFT\",\n \"row_id\": 1178981,\n \"text\": \" 6:00 PM\\n UNILAT UP EXT VEINS US LEFT Clip # \\n Reason: EVAL LT IJV AND LT BRACHIOCEPHALIC V FOR THROMBUS SEEN IN CT SCAN\\n Admitting Diagnosis: FEVER\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 50 year-old female with Stills, currently on pressors via right IJ; CT neck\\n today, ordered for neck pain, with concern for occluded left brachiocephalic to\\n jugular\\n REASON FOR THIS EXAMINATION:\\n Please evaluate for DVT; please include in imaging left brachiocephalic,\\n jugular\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Question of obstruction of the left brachiocephalic vein.\\n\\n COMPARISON: CT from .\\n\\n FINDINGS: Targeted son of the left internal jugular vein, subclavian\\n vein and brachiocephalic veins were performed. The internal jugular and\\n subclavian veins are widely patent, with normal wall-to-wall flow on color\\n Doppler analysis. These veins are followed to their confluence, namely the\\n origin of the brachiocephalic vein which also appears normal. The more distal\\n portion of the brachiocephalic vein are not evaluated.\\n\\n IMPRESSION: Normal left subclavian, internal jugular and origin of\\n brachiocephalic veins. Note that the medial and distal portions of the left\\n brachiocephalic vein are not visible by son and were seen to better\\n effect on the comparison CT from the same day.\\n DFDdp\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2195-03-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 195293,\n \"text\": \"Sinus tachycardia. Compared to the previous tracing of the rate has\\nincreased.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2195-03-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 195294,\n \"text\": \"Sinus rhythm. T wave abnormalities. Since the previous tracing of the\\nrate is slower. ST-T wave abnormalities are less prominent.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2195-03-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 195295,\n \"text\": \"Sinus tachycardia. T wave inversions in the inferolateral leads raising\\nconsideration of possible ischemia, likely rate-related. Clinical correlation\\nis suggested. Compared to the previous tracing of the ventricular rate\\nhas increased and the ST segment changes are new.\\n\\n\"\n }\n]"}}},{"rowIdx":397,"cells":{"subject_id":{"kind":"number","value":64619,"string":"64,619"},"hadm_id":{"kind":"number","value":191726,"string":"191,726"},"target_text":{"kind":"string","value":"ICU Course: Patient was transferred to the ICU on with respiratory distress and tachycardia in the setting of known MDS and squamous cell malignancy involving the bone marrow and overall poor prognosis. He was intubated for hypoxic respiratory failure. He developed a septic picture. Patient with known C.dif colitis, so, since no other source of infection was found, presumed to have fulminant C.dif colitis. Patient was on Vancomycin PO, IV and PR for C.dif colitis as well as broad spectrum antibiotics to cover essentially any infectious source. Despite this, patient's blood pressure continued to decline. He was started on pressors, and maxxed out on Levophed, Neo, Vasopressin. Despite agressive treatment, he was unable to maintain adequate blood pressures and passed away on . . This is a 74 yo M with PMHx of HTN, HLD, DM-2 and MDS-RAEB-II s/p 6 cycles of vidaza who presents with 3 days of lethargy, subjective fevers and diarrhea. . #Clostridium difficile colitis: Pt was admitted with diarrhea and subjective fevers and fatigue following recent discharge during which he was treated with vancomycin/cefepime for neutropenic fevers and sent home with lovenox for CAP and fluconazole and acyclovir for prophylaxis. On admission he was found to be febrile with and Cdiff stool toxin assay was positive so he was started on PO flagyl. He began to describe pain in his throat making it difficult for him to swallow so his antibiotics were switched to IV. He then began spiking fevers to 102 despite IV flagyl and was started on IV vanc and cefepime. He then triggered on for tachypnea, labored breathing, tachycardia to the 130's and hypotension as low as the high 80's systolically. He was treated with bolused fluids and his pressures improved, he desatted to 88 on RA and was started on O2 and began satting well but remained tachycardic and continued to have labored respirations. He was also started on PO vancomycin. CXR demonstrated worsening of a left pleural effusion and ABG demonstrated mixed respiratory alkalosis and non-gap metabolic acidosis which we assessed as a combination of sepsis and diarrhea. We had mild concern for PE but felt he was too unstable for CT scanner. Abdominal XR showed no free air and was not concerning. He was transferred to the overnight. . #RLE weakness: Pt was admitted complaining of RLE weakness but had equivalent strength on exam but continued R hip pain which has been a chronic issue following a hip replacement ~20 years ago. He had a bone marrow biopsy at the right pelvis during his recent admission and had mild tenderness at the site but no signs or symptoms otherwise concerning for infection. XR of the R hip was normal and our clinical suspicion wasn't high enough to perform MRI to look for osteomyelitis. His CRP and ESR were severely elevated but this was felt to be related to his Cdiff colitis as above. . Worsening Pancytopenia: Pt with poor production from severe MDS and new diagnosis of invasive squamous carcinoma (presumably from lung primary but primary unknown) infiltrating his bone marrow rendering him transfusion dependent over the past several months. Hemolysis labs negative, reticulocyte index low, iron studies suggestive of anemia of chronic disease. He was transfused RBC's and platelets with the threshold of plt >10 and Hct >21 to maintain perfusion and hemostasis. During blood transfusion he spiked fevers likely related to his Cdiff or other underlying infectious processes and blood transfusions were held pending resolution of fevers. Pt also severely neutropenic and was maintained on acyclovir and fluconazole prophylaxis, started on IV Vanc/Cefepime as described above. . #: Pt admitted in , likely prerenal from diarrheal losses and poor PO intake which resolved with IV fluids and blood. . #Elevated D-dimer: Pt with elevated D-Dimer on admission, possibly due to MDS vs. solid carcinoma activity. We also considered possibility of DVT yet patient did not have si/sx concerning for DVT or PE by history or exam. During his trigger on we had suspicion for possible PE but felt he was unstable for CT imaging. . Hyperbilirubinemia: Likely gradual RBC breakdown. Stable and down from prior hospitalization. ."},"extractive_notes_summ":{"kind":"string","value":"Sinus tachycardia with atrial premature beats. Small right and moderate left pleural effusions are unchanged associated with adjacent bibasilar opacities likely atelectasis. The right internal jugular line terminates at upper SVC. FINDINGS: Supine abdominal radiographs were obtained. Non-specificdilated loop of likely large bowel in the left mid abdomen, though non-specific. FINDINGS: A portable supine abdominal radiograph was obtained. FINDINGS: Again noted is left lower lobe atelectasis with likely at least the subpulmonic component of the previously noted left pleural effusion remaining in place. Worsened moderate-large effusion and right lower lung atelectasis. FINDINGS: There are bilateral pleural effusions, left greater than right with atelectasis both in the left lower and right lower lungs. Multifocal atrial tachycardia. A left lower lobe opacification was described in prior chest radiograph. Multifocal atrialtachycardia is now seen. IMPRESSION: Centralized bowel which may be seen potentially with ascites. Mildly dilated loops of small bowel and large bowel suggestive of ileus. IMPRESSION: Mildly dilated loops of small and large bowel suggestive of ileus. Endotracheal tube, right jugular catheter and esophageal catheter with tip out of view of the radiograph appear similar. New right IJ catheter tip is in the mid SVC. There are mildly dilated loops of small bowel, with presence of a loop of bowel of 7.3 cm of diameter in the lower abdomen that it is unclear whether it is small or large bowel given absence of folds but is probably colonic. Comparisons were made with prior chest radiographs through , with the most recent from . Mediastinal lymphadenopathy is better seen in prior CT from . The right intermediate bronchus cannot be traced beyond its origin and this in conjunction with loss of right heart border and increased density in the right paramediastinal region sugest middle lobe collapse. COMPARISON: Multiple prior examinations, most recent radiograph dated , and correlation with CT of the chest dated . COMPARISON: Portable abdominal radiograph . FINDINGS: An upright abdominal radiograph was obtained. Degenerative changes are seen throughout the thoracic spine and in the included right shoulder. Small lung nodules in the right lung are better seen in prior CT from . Centralization of the bowel may suggest ascites. Quality of the film is compromised by bliurriness and the exclusion from the image of nearly the totality of the right hemi-abdomen. IMPRESSION: Left lower lobe atelectasis with a persistent left pleural effusion likely subpulmonic. Left lower lobe opacification can be better assessed in prior chest radiographs. TECHNIQUE: Single frontal radiograph of the chest. Non-specific bowel gas pattern. COMPARISON: Portable chest radiographs from and . There are borderline dilated loops of small bowel in the mid abdomen, with a loop of bowel adjacent to it of approximately 7.5 cm that is likely colon. 4:53 PM CHEST (PORTABLE AP) Clip # Reason: infiltrates, other? Degenerative changes of the left hip is seen with spur in the superolateral acetabula. Diffuse small lung nodules located mainly in the right lung are better seen also on prior CT. There is a normal bowel gas pattern without evidence of dilatation. FINAL REPORT INDICATION: 74-year-old man with Clostridium difficile worsening shortness of breath. Right pleural effusion and right lower lobe atelectasis have also worsened since . TECHNIQUE: Portable semi-upright radiograph of the chest. The cardiac silhouette is within normal limits for size. Right middle lobe collapse is new since . Endotracheal tube is approximately 3.4 cm above the carina with the neck in flexed position and is appropriate. A small right and moderate left pleural effusions have increased with increasing adjacent atelectasis. Short-term follow-up radiographs may be helpful if clinically indicated. Patient with squamous cell CA, intubated, to look for interval changes. The mediastinum is otherwise unremarkable. IMPRESSION: Large left pleural effusion has worsened with increased lung atelectasis. Assessment of the cardiomediastinum was limited because of large effusions and collapse leading to loss of the cardiac silhouette margins. Baseline artifact makesST-T wave interpretation difficult. The distal tip is out of view below the diaphragm. 8:24 PM CHEST (PORTABLE AP) Clip # Reason: cardioplum process? FINDINGS: Since the prior chest radiograph dated , left pleural effusion has significantly increased and is severe. There is a right total hip arthroplasty. COMPARISON: Multiple priors, the most recent dated . No abnormally dilated bowel loops. Assess ET tube and NG tube. This study is essentially unchanged from prior abdominal radiograph performed approximately 24 hours ago. Suggest repeat ECG. Admitting Diagnosis: THROMBOCYTOPENIA;NEUTROPENIA MEDICAL CONDITION: 74 year old man with MDS and possible metastatic lung CA, and Cdiff with fevers and hypotension and labored respirations REASON FOR THIS EXAMINATION: cardioplum process? If concern for obstruction CT is recommended for further evaluation. LINE PLACEMENT; -76 BY SAME PHYSICIAN # Reason: verification of positioning of RIJ central line Admitting Diagnosis: THROMBOCYTOPENIA;NEUTROPENIA MEDICAL CONDITION: 74 year old man with MDS and new pleural effusion REASON FOR THIS EXAMINATION: verification of positioning of RIJ central line FINAL REPORT SINGLE AP PORTABLE VIEW OF THE CHEST REASON FOR EXAM: Assess line."},"n_notes":{"kind":"number","value":12,"string":"12"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2149-10-08 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1204146,"text":" 12:45 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ETT and NGT placement verification\n Admitting Diagnosis: THROMBOCYTOPENIA;NEUTROPENIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with MDS and new pleural effusion per recent cxr\n REASON FOR THIS EXAMINATION:\n ETT and NGT placement verification\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: MDS, new pleural effusion. Assess ET tube and NG tube.\n\n ET tube is in standard position. The tip is 4.1 cm above the carina. The\n distal tip is out of view below the diaphragm. Cardiac size is normal. Small\n right and moderate left pleural effusions are unchanged associated with\n adjacent bibasilar opacities likely atelectasis. Small lung nodules in the\n right lung are better seen in prior CT from . There is no\n pneumothorax.\n\n"},{"category":"Radiology","chartdate":"2149-10-04 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1203722,"text":" 4:53 PM\n CHEST (PORTABLE AP) Clip # \n Reason: infiltrates, other?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with MDS s/p BM trasplant, in with dfever\n REASON FOR THIS EXAMINATION:\n infiltrates, other?\n ______________________________________________________________________________\n FINAL REPORT\n AP PORTABLE CHEST, AT 17:00 HOURS.\n\n HISTORY: Myelodysplastic syndrome post bone marrow transplant with fever.\n\n COMPARISON: Multiple priors, the most recent dated .\n\n FINDINGS: Again noted is left lower lobe atelectasis with likely at least the\n subpulmonic component of the previously noted left pleural effusion remaining\n in place. No focal consolidation or superimposed edema is noted. The\n mediastinum is otherwise unremarkable. The cardiac silhouette is within\n normal limits for size. Degenerative changes are seen throughout the thoracic\n spine and in the included right shoulder.\n\n IMPRESSION: Left lower lobe atelectasis with a persistent left pleural\n effusion likely subpulmonic. No definite focal consolidation identified.\n\n\n"},{"category":"Radiology","chartdate":"2149-10-05 00:00:00.000","description":"PELVIS (AP ONLY)","row_id":1203781,"text":" 10:12 AM\n PELVIS (AP ONLY) Clip # \n Reason: r/o pelvic osteo\n Admitting Diagnosis: THROMBOCYTOPENIA;NEUTROPENIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with mds and possible osteo from bmb\n REASON FOR THIS EXAMINATION:\n r/o pelvic osteo\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP pelvis, .\n\n CLINICAL HISTORY: 74-year-old man with possible pelvic osteomyelitis.\n\n FINDINGS: No previous studies for comparison.\n\n There is a right total hip arthroplasty. There are no signs for\n hardware-related complications. Heterotopic bone formation is seen laterally.\n There are no acute fractures or dislocations. Degenerative changes of the\n left hip is seen with spur in the superolateral acetabula. Degenerative\n changes of lower lumbar spine are also identified.\n\n"},{"category":"Radiology","chartdate":"2149-10-07 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1204139,"text":" 8:24 PM\n CHEST (PORTABLE AP) Clip # \n Reason: cardioplum process?\n Admitting Diagnosis: THROMBOCYTOPENIA;NEUTROPENIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with MDS and possible metastatic lung CA, and Cdiff with fevers\n and hypotension and labored respirations\n REASON FOR THIS EXAMINATION:\n cardioplum process?\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: MDS and possible metastatic lung cancer, assess lungs.\n\n Comparison is made with prior study .\n\n Cardiac size is normal. Mediastinal lymphadenopathy is better seen in prior\n CT from . A small right and moderate left pleural effusions have\n increased with increasing adjacent atelectasis. Diffuse small lung nodules\n located mainly in the right lung are better seen also on prior CT. There is\n no evident pneumothorax.\n\n\n"},{"category":"Radiology","chartdate":"2149-10-08 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":1204160,"text":" 4:41 AM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: verification of positioning of RIJ central line\n Admitting Diagnosis: THROMBOCYTOPENIA;NEUTROPENIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with MDS and new pleural effusion\n REASON FOR THIS EXAMINATION:\n verification of positioning of RIJ central line\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Assess line.\n\n Comparison is made with prior study performed a day earlier.\n\n New right IJ catheter tip is in the mid SVC. There is no evident\n pneumothorax. There are no other interval changes.\n\n"},{"category":"Radiology","chartdate":"2149-10-07 00:00:00.000","description":"PORTABLE ABDOMEN","row_id":1204141,"text":" 9:31 PM\n PORTABLE ABDOMEN Clip # \n Reason: Please assess for free air for megacolon\n Admitting Diagnosis: THROMBOCYTOPENIA;NEUTROPENIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with C. diff and worsening SOB\n REASON FOR THIS EXAMINATION:\n Please assess for free air for megacolon\n ______________________________________________________________________________\n WET READ: SJBj WED 3:20 AM\n No free air. Air filled stomach. No abnormally dilated bowel loops.\n limited study. Non-specific bowel gas pattern.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 74-year-old man with Clostridium difficile worsening shortness of\n breath. Please assess for free air or megacolon.\n\n COMPARISON: Portable chest radiographs from and .\n\n FINDINGS: An upright abdominal radiograph was obtained. Quality of the film\n is compromised by bliurriness and the exclusion from the image of nearly the\n totality of the right hemi-abdomen. There is a normal bowel gas pattern\n without evidence of dilatation. No evidence of free air or abnormal\n calcifications. A left lower lobe opacification was described in prior chest\n radiograph.\n\n IMPRESSION: No evidence of megacolon or free air.\n\n"},{"category":"Radiology","chartdate":"2149-10-09 00:00:00.000","description":"P ABDOMEN (SUPINE ONLY) PORT","row_id":1204402,"text":" 1:34 PM\n ABDOMEN (SUPINE ONLY) PORT Clip # \n Reason: ?interval change\n Admitting Diagnosis: THROMBOCYTOPENIA;NEUTROPENIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with MDS, squamous cell ca, septic, intubated, with c.dif\n REASON FOR THIS EXAMINATION:\n ?interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 74-year-old man with squamous cell carcinoma, septic, intubated,\n with Clostridium difficile. Please evaluate for interval change.\n\n COMPARISON: Portable abdominal radiograph .\n\n FINDINGS: A portable supine abdominal radiograph was obtained. There are\n borderline dilated loops of small bowel in the mid abdomen, with a loop of\n bowel adjacent to it of approximately 7.5 cm that is likely colon. No\n evidence of free air, no abnormal calcifications.\n\n IMPRESSION: Mildly dilated loops of small and large bowel suggestive of\n ileus. This study is essentially unchanged from prior abdominal radiograph\n performed approximately 24 hours ago.\n\n"},{"category":"Radiology","chartdate":"2149-10-10 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1204484,"text":" 5:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess for megacolon, interval change\n Admitting Diagnosis: THROMBOCYTOPENIA;NEUTROPENIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with MDS, squamous cell ca, c.dif, sepsis, intubated on\n pressors\n REASON FOR THIS EXAMINATION:\n please assess for megacolon, interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST X-RAY\n\n INDICATION: Please assess for the megacolon interval changes. Patient with\n squamous cell CA, intubated, to look for interval changes.\n\n TECHNIQUE: Portable semi-upright radiograph of the chest.\n\n Comparisons were made with prior chest radiographs through ,\n with the most recent from .\n\n FINDINGS: Since the prior chest radiograph dated , left\n pleural effusion has significantly increased and is severe. The right\n intermediate bronchus cannot be traced beyond its origin and this in\n conjunction with loss of right heart border and increased density in the right\n paramediastinal region sugest middle lobe collapse. Right pleural effusion\n and right lower lobe atelectasis have also worsened since .\n Endotracheal tube is approximately 3.4 cm above the carina with the neck in\n flexed position and is appropriate. The right internal jugular line\n terminates at upper SVC. Assessment of the cardiomediastinum was limited\n because of large effusions and collapse leading to loss of the cardiac\n silhouette margins.\n\n IMPRESSION: Large left pleural effusion has worsened with increased lung\n atelectasis. Right middle lobe collapse is new since .\n Worsened moderate-large effusion and right lower lung atelectasis.\n\n"},{"category":"Radiology","chartdate":"2149-10-09 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1204364,"text":" 10:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for interval change\n Admitting Diagnosis: THROMBOCYTOPENIA;NEUTROPENIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with MDS and metastatic squamous cell carcinoma, now intubated\n with hypoxic respiratory failure\n REASON FOR THIS EXAMINATION:\n evaluate for interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 74-year-old male with known metastatic squamous cell carcinoma\n and myelodysplastic syndrome. Interval evaluation.\n\n TECHNIQUE: Single frontal radiograph of the chest.\n\n COMPARISON: Multiple prior examinations, most recent radiograph dated , and correlation with CT of the chest dated .\n\n FINDINGS: There are bilateral pleural effusions, left greater than right with\n atelectasis both in the left lower and right lower lungs. Accounting for\n differences in position, these do not appear significantly changed from the\n prior examination though the presence of infection would be difficult to\n exclude. No pneumothorax is seen. Endotracheal tube, right jugular catheter\n and esophageal catheter with tip out of view of the radiograph appear similar.\n\n\n"},{"category":"Radiology","chartdate":"2149-10-08 00:00:00.000","description":"PORTABLE ABDOMEN","row_id":1204285,"text":" 7:20 PM\n PORTABLE ABDOMEN Clip # \n Reason: please assess for interval change, megacolon\n Admitting Diagnosis: THROMBOCYTOPENIA;NEUTROPENIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with MDS, squamous cell ca, c.dif, sepsis, intubated on\n pressors\n REASON FOR THIS EXAMINATION:\n please assess for interval change, megacolon\n ______________________________________________________________________________\n WET READ: DLrc WED 11:01 PM\n Centralized bowel indicative of ascites. Non-specificdilated loop of likely\n large bowel in the left mid abdomen, though non-specific. If concern for\n obstruction CT is recommended for further evaluation.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 74-year-old man with squamous cell carcinoma, Clostridium\n difficile, sepsis, intubated, and on pressors, please assess for interval\n change.\n\n COMPARISON: .\n\n FINDINGS: Supine abdominal radiographs were obtained. There are mildly\n dilated loops of small bowel, with presence of a loop of bowel of 7.3 cm of\n diameter in the lower abdomen that it is unclear whether it is small or large\n bowel given absence of folds but is probably colonic. Centralization of the\n bowel may suggest ascites. Otherwise, no evidence of free air. Left lower\n lobe opacification can be better assessed in prior chest radiographs.\n\n IMPRESSION: Centralized bowel which may be seen potentially with ascites.\n Mildly dilated loops of small bowel and large bowel suggestive of ileus.\n Short-term follow-up radiographs may be helpful if clinically indicated.\n\n\n"},{"category":"ECG","chartdate":"2149-10-07 00:00:00.000","description":"Report","row_id":236974,"text":"Multifocal atrial tachycardia. Low voltage. ST-T wave abnormalities.\nSince the previous tracing of the rate is faster. Multifocal atrial\ntachycardia is now seen. Clinical correlation is suggested.\n\n"},{"category":"ECG","chartdate":"2149-10-04 00:00:00.000","description":"Report","row_id":236975,"text":"Sinus tachycardia with atrial premature beats. Baseline artifact makes\nST-T wave interpretation difficult. Suggest repeat ECG. No previous tracing\navailable for comparison.\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2149-10-08 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1204146,\n \"text\": \" 12:45 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ETT and NGT placement verification\\n Admitting Diagnosis: THROMBOCYTOPENIA;NEUTROPENIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 74 year old man with MDS and new pleural effusion per recent cxr\\n REASON FOR THIS EXAMINATION:\\n ETT and NGT placement verification\\n ______________________________________________________________________________\\n FINAL REPORT\\n SINGLE AP PORTABLE VIEW OF THE CHEST\\n\\n REASON FOR EXAM: MDS, new pleural effusion. Assess ET tube and NG tube.\\n\\n ET tube is in standard position. The tip is 4.1 cm above the carina. The\\n distal tip is out of view below the diaphragm. Cardiac size is normal. Small\\n right and moderate left pleural effusions are unchanged associated with\\n adjacent bibasilar opacities likely atelectasis. Small lung nodules in the\\n right lung are better seen in prior CT from . There is no\\n pneumothorax.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2149-10-04 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1203722,\n \"text\": \" 4:53 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: infiltrates, other?\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 74 year old man with MDS s/p BM trasplant, in with dfever\\n REASON FOR THIS EXAMINATION:\\n infiltrates, other?\\n ______________________________________________________________________________\\n FINAL REPORT\\n AP PORTABLE CHEST, AT 17:00 HOURS.\\n\\n HISTORY: Myelodysplastic syndrome post bone marrow transplant with fever.\\n\\n COMPARISON: Multiple priors, the most recent dated .\\n\\n FINDINGS: Again noted is left lower lobe atelectasis with likely at least the\\n subpulmonic component of the previously noted left pleural effusion remaining\\n in place. No focal consolidation or superimposed edema is noted. The\\n mediastinum is otherwise unremarkable. The cardiac silhouette is within\\n normal limits for size. Degenerative changes are seen throughout the thoracic\\n spine and in the included right shoulder.\\n\\n IMPRESSION: Left lower lobe atelectasis with a persistent left pleural\\n effusion likely subpulmonic. No definite focal consolidation identified.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2149-10-05 00:00:00.000\",\n \"description\": \"PELVIS (AP ONLY)\",\n \"row_id\": 1203781,\n \"text\": \" 10:12 AM\\n PELVIS (AP ONLY) Clip # \\n Reason: r/o pelvic osteo\\n Admitting Diagnosis: THROMBOCYTOPENIA;NEUTROPENIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 74 year old man with mds and possible osteo from bmb\\n REASON FOR THIS EXAMINATION:\\n r/o pelvic osteo\\n ______________________________________________________________________________\\n FINAL REPORT\\n STUDY: AP pelvis, .\\n\\n CLINICAL HISTORY: 74-year-old man with possible pelvic osteomyelitis.\\n\\n FINDINGS: No previous studies for comparison.\\n\\n There is a right total hip arthroplasty. There are no signs for\\n hardware-related complications. Heterotopic bone formation is seen laterally.\\n There are no acute fractures or dislocations. Degenerative changes of the\\n left hip is seen with spur in the superolateral acetabula. Degenerative\\n changes of lower lumbar spine are also identified.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2149-10-07 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1204139,\n \"text\": \" 8:24 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: cardioplum process?\\n Admitting Diagnosis: THROMBOCYTOPENIA;NEUTROPENIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 74 year old man with MDS and possible metastatic lung CA, and Cdiff with fevers\\n and hypotension and labored respirations\\n REASON FOR THIS EXAMINATION:\\n cardioplum process?\\n ______________________________________________________________________________\\n FINAL REPORT\\n SINGLE AP PORTABLE VIEW OF THE CHEST\\n\\n REASON FOR EXAM: MDS and possible metastatic lung cancer, assess lungs.\\n\\n Comparison is made with prior study .\\n\\n Cardiac size is normal. Mediastinal lymphadenopathy is better seen in prior\\n CT from . A small right and moderate left pleural effusions have\\n increased with increasing adjacent atelectasis. Diffuse small lung nodules\\n located mainly in the right lung are better seen also on prior CT. There is\\n no evident pneumothorax.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2149-10-08 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 1204160,\n \"text\": \" 4:41 AM\\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \\n Reason: verification of positioning of RIJ central line\\n Admitting Diagnosis: THROMBOCYTOPENIA;NEUTROPENIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 74 year old man with MDS and new pleural effusion\\n REASON FOR THIS EXAMINATION:\\n verification of positioning of RIJ central line\\n ______________________________________________________________________________\\n FINAL REPORT\\n SINGLE AP PORTABLE VIEW OF THE CHEST\\n\\n REASON FOR EXAM: Assess line.\\n\\n Comparison is made with prior study performed a day earlier.\\n\\n New right IJ catheter tip is in the mid SVC. There is no evident\\n pneumothorax. There are no other interval changes.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2149-10-07 00:00:00.000\",\n \"description\": \"PORTABLE ABDOMEN\",\n \"row_id\": 1204141,\n \"text\": \" 9:31 PM\\n PORTABLE ABDOMEN Clip # \\n Reason: Please assess for free air for megacolon\\n Admitting Diagnosis: THROMBOCYTOPENIA;NEUTROPENIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 74 year old man with C. diff and worsening SOB\\n REASON FOR THIS EXAMINATION:\\n Please assess for free air for megacolon\\n ______________________________________________________________________________\\n WET READ: SJBj WED 3:20 AM\\n No free air. Air filled stomach. No abnormally dilated bowel loops.\\n limited study. Non-specific bowel gas pattern.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 74-year-old man with Clostridium difficile worsening shortness of\\n breath. Please assess for free air or megacolon.\\n\\n COMPARISON: Portable chest radiographs from and .\\n\\n FINDINGS: An upright abdominal radiograph was obtained. Quality of the film\\n is compromised by bliurriness and the exclusion from the image of nearly the\\n totality of the right hemi-abdomen. There is a normal bowel gas pattern\\n without evidence of dilatation. No evidence of free air or abnormal\\n calcifications. A left lower lobe opacification was described in prior chest\\n radiograph.\\n\\n IMPRESSION: No evidence of megacolon or free air.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2149-10-09 00:00:00.000\",\n \"description\": \"P ABDOMEN (SUPINE ONLY) PORT\",\n \"row_id\": 1204402,\n \"text\": \" 1:34 PM\\n ABDOMEN (SUPINE ONLY) PORT Clip # \\n Reason: ?interval change\\n Admitting Diagnosis: THROMBOCYTOPENIA;NEUTROPENIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 74 year old man with MDS, squamous cell ca, septic, intubated, with c.dif\\n REASON FOR THIS EXAMINATION:\\n ?interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 74-year-old man with squamous cell carcinoma, septic, intubated,\\n with Clostridium difficile. Please evaluate for interval change.\\n\\n COMPARISON: Portable abdominal radiograph .\\n\\n FINDINGS: A portable supine abdominal radiograph was obtained. There are\\n borderline dilated loops of small bowel in the mid abdomen, with a loop of\\n bowel adjacent to it of approximately 7.5 cm that is likely colon. No\\n evidence of free air, no abnormal calcifications.\\n\\n IMPRESSION: Mildly dilated loops of small and large bowel suggestive of\\n ileus. This study is essentially unchanged from prior abdominal radiograph\\n performed approximately 24 hours ago.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2149-10-10 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1204484,\n \"text\": \" 5:31 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: please assess for megacolon, interval change\\n Admitting Diagnosis: THROMBOCYTOPENIA;NEUTROPENIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 74 year old man with MDS, squamous cell ca, c.dif, sepsis, intubated on\\n pressors\\n REASON FOR THIS EXAMINATION:\\n please assess for megacolon, interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST X-RAY\\n\\n INDICATION: Please assess for the megacolon interval changes. Patient with\\n squamous cell CA, intubated, to look for interval changes.\\n\\n TECHNIQUE: Portable semi-upright radiograph of the chest.\\n\\n Comparisons were made with prior chest radiographs through ,\\n with the most recent from .\\n\\n FINDINGS: Since the prior chest radiograph dated , left\\n pleural effusion has significantly increased and is severe. The right\\n intermediate bronchus cannot be traced beyond its origin and this in\\n conjunction with loss of right heart border and increased density in the right\\n paramediastinal region sugest middle lobe collapse. Right pleural effusion\\n and right lower lobe atelectasis have also worsened since .\\n Endotracheal tube is approximately 3.4 cm above the carina with the neck in\\n flexed position and is appropriate. The right internal jugular line\\n terminates at upper SVC. Assessment of the cardiomediastinum was limited\\n because of large effusions and collapse leading to loss of the cardiac\\n silhouette margins.\\n\\n IMPRESSION: Large left pleural effusion has worsened with increased lung\\n atelectasis. Right middle lobe collapse is new since .\\n Worsened moderate-large effusion and right lower lung atelectasis.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2149-10-09 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1204364,\n \"text\": \" 10:00 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: evaluate for interval change\\n Admitting Diagnosis: THROMBOCYTOPENIA;NEUTROPENIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 74 year old man with MDS and metastatic squamous cell carcinoma, now intubated\\n with hypoxic respiratory failure\\n REASON FOR THIS EXAMINATION:\\n evaluate for interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 74-year-old male with known metastatic squamous cell carcinoma\\n and myelodysplastic syndrome. Interval evaluation.\\n\\n TECHNIQUE: Single frontal radiograph of the chest.\\n\\n COMPARISON: Multiple prior examinations, most recent radiograph dated , and correlation with CT of the chest dated .\\n\\n FINDINGS: There are bilateral pleural effusions, left greater than right with\\n atelectasis both in the left lower and right lower lungs. Accounting for\\n differences in position, these do not appear significantly changed from the\\n prior examination though the presence of infection would be difficult to\\n exclude. No pneumothorax is seen. Endotracheal tube, right jugular catheter\\n and esophageal catheter with tip out of view of the radiograph appear similar.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2149-10-08 00:00:00.000\",\n \"description\": \"PORTABLE ABDOMEN\",\n \"row_id\": 1204285,\n \"text\": \" 7:20 PM\\n PORTABLE ABDOMEN Clip # \\n Reason: please assess for interval change, megacolon\\n Admitting Diagnosis: THROMBOCYTOPENIA;NEUTROPENIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 74 year old man with MDS, squamous cell ca, c.dif, sepsis, intubated on\\n pressors\\n REASON FOR THIS EXAMINATION:\\n please assess for interval change, megacolon\\n ______________________________________________________________________________\\n WET READ: DLrc WED 11:01 PM\\n Centralized bowel indicative of ascites. Non-specificdilated loop of likely\\n large bowel in the left mid abdomen, though non-specific. If concern for\\n obstruction CT is recommended for further evaluation.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 74-year-old man with squamous cell carcinoma, Clostridium\\n difficile, sepsis, intubated, and on pressors, please assess for interval\\n change.\\n\\n COMPARISON: .\\n\\n FINDINGS: Supine abdominal radiographs were obtained. There are mildly\\n dilated loops of small bowel, with presence of a loop of bowel of 7.3 cm of\\n diameter in the lower abdomen that it is unclear whether it is small or large\\n bowel given absence of folds but is probably colonic. Centralization of the\\n bowel may suggest ascites. Otherwise, no evidence of free air. Left lower\\n lobe opacification can be better assessed in prior chest radiographs.\\n\\n IMPRESSION: Centralized bowel which may be seen potentially with ascites.\\n Mildly dilated loops of small bowel and large bowel suggestive of ileus.\\n Short-term follow-up radiographs may be helpful if clinically indicated.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2149-10-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 236974,\n \"text\": \"Multifocal atrial tachycardia. Low voltage. ST-T wave abnormalities.\\nSince the previous tracing of the rate is faster. Multifocal atrial\\ntachycardia is now seen. Clinical correlation is suggested.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2149-10-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 236975,\n \"text\": \"Sinus tachycardia with atrial premature beats. Baseline artifact makes\\nST-T wave interpretation difficult. Suggest repeat ECG. No previous tracing\\navailable for comparison.\\n\\n\"\n }\n]"}}},{"rowIdx":398,"cells":{"subject_id":{"kind":"number","value":31235,"string":"31,235"},"hadm_id":{"kind":"number","value":180780,"string":"180,780"},"target_text":{"kind":"string","value":"21-year-old woman with DM1 who presented with severe DKA and unresponsiveness. Hospital course by problem:"},"extractive_notes_summ":{"kind":"string","value":"FINDINGS: Endotracheal tube is terminating in standard location. A right subclavian catheter is terminating slightly below the anticipated cavoatrial junction, unchanged. Moderate retrocardiac atelectasis, no secure evidence of pleural effusions. Unchanged retrocardiac atelectasis is again noted. On the axial susceptibility images, there is a small focus of susceptibility, in the right anteroinferior frontal or subcortical in location (series 5, image 16), which corresponds to a punctate hyperdense focus on the CT, and can represent early calcification or microhemorrhage. Bilateral moderate pleural effusions. FINDINGS: Endotracheal tube is in standard position, nasogastric tube passes into the stomach and out of the field of view, and a right jugular line ends in the upper right atrium. FINDINGS: There are bilateral pleural effusions and associated atelectasis, right more so than left. Unchanged small bilateral pleural effusions. This collection appears separate from the bladder, which is collapsed and contains a foley catheter. Again seen are patchy bilateral alveolar infiltrates, some of which have a rounded configuration and could represent septic emboli. The right subclavian catheter is terminating in the distal SVC. In the absence of intravenous contrast enhancement, measurement of central lymph nodes is difficult, but range up to 17 mm in the left hilus, smaller in the right hilus, and insignificant in the mediastinum. Small non-hemorrhagic pleural effusions layer posteriorly. Visualized pancreas is unremarkable. Contrast has passed to the level of the right colon. Again are noted multifocal peribronchial nodular consolidations, some in subpleural distribution and others more central, worse than the recent CT. RSBI this am 160. remains on CPAP+PS tol well.CVS: NSR w/ no ectopy ABP 140-160's/ 70-90's. Mild(1+) mitral regurgitation is seen. Normal ascending aortadiameter. R rad aline and R s/c CVL intact w/ good BR.GI: abd soft/ nontender, +BS x 4quads, TF at goal rate via OGT tol well. sedation restarted r/t pt not extubating today.Pulm\r: LS coarse bilat. no vent changes ordered.GI: abd soft, bs+, tf @ goal w/ min resid. Normal interatrial septum. There are filamentousstrands on the aortic leaflets consistent with Lambl's excrescences (normalvariant; seen on clips 113 and 114). Nephrology is following pt.GI) Abd soft with + BS. Mild mitral and tricuspid regurgitation. Mild (1+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets. ABP's ~20pts higher, K+ repleted as above.GI: OGT removed w/ extubation, abd soft nontender +BS x 4quads. R subclavian quad lumen line intact.RESP: No vent changes overnight. EEG done, non-specific secondary to propofol. remains on IV Vanc/ Cefepime for multifocal pna. Mild [1+] TR. PT became hypertensive w/ SBP 160's and tachycardic w/ HR 140's. Recieved pt on Propofol and stopped for brief time as noted above. Mild [1+] TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. PATIENT/TEST INFORMATION:Indication: Endocarditis.Height: (in) 66Weight (lb): 198BSA (m2): 1.99 m2BP (mm Hg): 129/76HR (bpm): 115Status: InpatientDate/Time: at 15:03Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. L femoral a-line dampened and NIBP started. B/P 120-150/70-90.Resp- Remains orally intubated, see care-vue for trended ABG's. ABGs as noted in care vue.GI) Abd soft with + BS. Head CT done -> prelim wet read unremarkable. + bilat DP/PTResp: remains intubated, ETtube advanced 3 cm and now at lip 23cm---awaiting am CXR, ETtube suctioned for mod. Pt was acidotic on admission and given Bicarb....continues to be slightly acidotic @7.27. Follow up Na level.GU) Goal diuresing (-) 1-2 liters q day with lasix gtt. K level has been replaced multiple times, and needs follow up 2/2 lasix gtt.Resp) LS coarse and clear after deep sx. Pt continues to have gen edema. Bilat soft wrist restraints to prevent pt from pulling at lines and tubes upon awakening.Cardiac: HR= 120-130's ST with no ecotpy noted, Left femoral Aline intact and with good waveform and correlation to NBP, BP= 100-125/80's with MAP's >70's, IV Vasopressin and IV Levophed weaned to off, episode of sBP 80's with Map= 60 following turning and repositioning once off of vasopressors---Levophed restarted at 0.03 mcgs/kg/min with good effect and able to wean off after 1 hour and currently remains off, new right SC multi-lumen central line placed and confirmed by Xray---right femoral TLC d/c'd and tip sent for cx, CVP= . Stool lgr amts of loose stool guiac +. A-line continues dampened but with good blood return.RESP: No vent changes and adequate abg. If need to restart insulin gtt take note that pt has Lantus on board.ID: WBC= 11.5, low grade temp with Tmax= 99, continues on IV Cipro. Lasix gtt weaned off. Diurese and replete lytes as indicated. Keep NPO after midnoc.I/D- Tmax 100.3. BUN 98 and Creatine slight down to 5.7 (peaked ).ID) Pt on IV ABxs for multifocal pna. Pt given diflucan po. Last ABG 7.22/24/121/10. Pt's RR 49 at end of - pt placed back on with slowing of RR. NS, dopa, levo, and vasopressin infusing. CXR done this am. A-line and CVL d/c'd. Vanco level pending. K replaced as noted. ETT repositioned and retaped. Levophed gtt weaning down. + palp peripheral pulses. Begun on vasopressin and dopa. Continue to wean pt off vent as tolerated.GI) Abd soft with + BS. HD on hold for now.Skin) see care vue for details. MICU NPN 0700-1900Events: Dopamine gtt titrated off. Bs cl;aer to coarse. Continues on +10PSV/+5PEEP w/ Vt 600s RR 20s Ve 14-16L/M. Ceftriaxone and vanco given at OSH. CVP 11-14.GI - Abd soft. ABP 1409-160/80-92. Receiving multiple IVABX. LS rhonchorus. Lungs coarse, w/ rhonchi..suctioned for increased oral and deep secretions as compared w/ yesterday. Please refer to carevue for FS results. Full Code.CV) Pt is in ST (100-110) w/o ectopy noted. PM chemistries pnding. A-line wave form remains dampened and following NIBP for BP readings. Shut off for ~1hr and restarted ~0500. Pt has ^RR with desats when sedation off, resp distress-biting ett. b/p stable 130's-150's/ 60's-70's. Flatus +. Hourly BS. A-line and CVL removed, PIV x1 in L A/C patent flushed. Rectal tube placed after episode of liq/loose brown stool."},"n_notes":{"kind":"number","value":65,"string":"65"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2173-05-30 00:00:00.000","description":"P ABDOMEN U.S. (COMPLETE STUDY) PORT","row_id":1015801,"text":" 1:25 PM\n ABDOMEN U.S. (COMPLETE STUDY) PORT Clip # \n Reason: r/o intrabdominal source of sepsis,\n Admitting Diagnosis: DIABETIC KETOACIDOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old woman with dka, sepsis of unknown source\n REASON FOR THIS EXAMINATION:\n r/o intrabdominal source of sepsis,\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 21-year-old female with DKA, sepsis of unknown source. Rule out\n intra-abdominal source.\n\n No prior studies for comparison.\n\n FINDINGS: The liver demonstrates normal echogenicity, without a focal lesion.\n The portal vein is patent with hepatopetal flow. Gallbladder is normal,\n without evidence of gallstones. There is no intra- or extra-hepatic biliary\n ductal dilatation, with the CBD measuring 5 mm. The right kidney measures 13\n cm. The left kidney measures 10 cm. No stones, hydronephrosis, or mass is\n identified. The spleen is unremarkable. Visualized pancreas is unremarkable.\n\n Within the pelvis, there is a large fluid collection, of unknown source. This\n collection appears separate from the bladder, which is collapsed and contains\n a foley catheter.\n\n IMPRESSION: Fluid collection within the pelvis, of unknown source. A CT is\n recommended for further evaluation to exclude the presence of an abscess.\n\n Dr. was paged at the time of this dictation.\n\n"},{"category":"Radiology","chartdate":"2173-05-31 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":1015930,"text":" 3:02 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? anoxic brain injury, cerebral edema?\n Admitting Diagnosis: DIABETIC KETOACIDOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old woman with DKA, found down\n REASON FOR THIS EXAMINATION:\n ? anoxic brain injury, cerebral edema?\n CONTRAINDICATIONS for IV CONTRAST:\n renal failure\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 21-year-old female with diabetic ketoacidosis who was \"found down.\"\n\n COMPARISON: No prior exam is available for comparison.\n\n TECHNIQUE: Contiguous axial imaging was performed through the brain without\n administration of IV contrast.\n\n CT HEAD: There is no evidence of acute intracranial hemorrhage, edema, mass,\n mass effect, hydrocephalus, or of large vascular territory infarction. In\n particular, the -white matter differentiation appears to be preserved. The\n basal cisterns are also preserved. Fluid is seen within the mastoid air\n cells. A small amount of mucosal thickening and layering fluid is also noted\n in the sphenoid sinuses. These likely relate to recent intubation.\n\n IMPRESSION: No CT evidence of acute intracranial process. However, as CT\n would not be sensitive to early or less extensive anoxic brain injury,\n followup would be recommended as clinically indicated.\n\n"},{"category":"Radiology","chartdate":"2173-06-05 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1016585,"text":" 11:25 AM\n CHEST (PORTABLE AP) Clip # \n Reason: check ett placement\n Admitting Diagnosis: DIABETIC KETOACIDOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old woman with dka, resp failure, intubated\n REASON FOR THIS EXAMINATION:\n check ett placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE VIEW ON \n\n HISTORY: Respiratory failure.\n\n REFERENCE EXAM: .\n\n FINDINGS: The ET tube is 3 cm above the carina. Right subclavian line tip is\n in the right atrium. The heart is mildly enlarged and is increased in size\n compared to prior. There are patchy alveolar infiltrates that have progressed\n compared to the film from two days ago. Some of these have a rounded\n appearance and septic emboli cannot be totally excluded. The NG tube has been\n removed.\n\n IMPRESSION: Worsening bilateral infiltrates some of which have a rounded\n appearance.\n\n\n"},{"category":"Radiology","chartdate":"2173-06-07 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1016718,"text":" 3:15 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval changes\n Admitting Diagnosis: DIABETIC KETOACIDOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old woman with respiratory failure, DKA, multifocal pna\n REASON FOR THIS EXAMINATION:\n interval changes\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Single portable AP chest radiograph.\n\n INDICATION: 21-year-old female with respiratory failure, and multifocal\n pneumonia.\n\n COMPARISON: .\n\n FINDINGS: Endotracheal tube is approximately 2 cm from the carina. NG tube\n courses through the mediastinum below the diaphragm with tip out of the field\n of view. Lung volumes are again low. Multifocal opacities demonstrate mild\n improvement from recent comparison. No significant pleural effusion or\n pneumothorax appreciated.\n\n IMPRESSION: Mild improvement in multifocal opacities. No new opacities\n appreciated.\n\n"},{"category":"Radiology","chartdate":"2173-06-01 00:00:00.000","description":"MR HEAD W/O CONTRAST","row_id":1016101,"text":" 8:13 PM\n MR HEAD W/O CONTRAST Clip # \n Reason: please eval for ?anoxic brain injury, edema\n Admitting Diagnosis: DIABETIC KETOACIDOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old woman with DKA, renal failure, respiratory failure,\n unresponsiveness\n REASON FOR THIS EXAMINATION:\n please eval for ?anoxic brain injury, edema\n CONTRAINDICATIONS for IV CONTRAST:\n renal failure\n\n Yes to Choyke questions.\n ______________________________________________________________________________\n WET READ: YMf TUE 11:45 PM\n No intraparenchymal lesions or areas of restricted diffusion. No mass, edema\n or hydrocephalus.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 21-year-old female patient, with DKA, renal failure, respiratory\n failure, unresponsiveness, to evaluate for anoxic brain injury, edema.\n\n COMPARISON: CT of the head done on .\n\n TECHNIQUE: Multiplanar T1- and T2-weighted imaging of the brain was performed\n without IV contrast.\n\n FINDINGS:\n\n On the sagittal T1-weighted sequence, the nasopharyngeal soft tissues, likely\n related to the lymphoid tissue (adenoids), were prominent (series 2, image\n 12), which may be appropriate in a patient of this age. However, these are\n not adequately evaluated on the present study. There are no focal lesions,\n noted on the axial FLAIR. On the axial susceptibility images, there is a\n small focus of susceptibility, in the right anteroinferior frontal or\n subcortical in location (series 5, image 16), which corresponds to a punctate\n hyperdense focus on the CT, and can represent early calcification or\n microhemorrhage. There is no restricted diffusion, to suggest acute\n infarction. The ventricles and extra-axial CSF spaces are unremarkable. There\n is moderate increased signal, in the mastoid air cells on both sides, likely\n related to fluid versus mucosal thickening. There is also moderate amount of\n mucosal thickening, along with fluid in the sphenoid sinus and minimal in the\n right maxillary sinus.\n\n No major vascular flow voids are noted.\n\n IMPRESSION:\n 1. No acute infarction.\n 2. Punctate focus of susceptibility in the right anteroinferior frontal lobe,\n which can represent small focus of early calcification or microhemorrhage.\n (Subcortical in location).\n 3. Moderate amount of fluid versus mucosal thickening in the mastoid air\n (Over)\n\n 8:13 PM\n MR HEAD W/O CONTRAST Clip # \n Reason: please eval for ?anoxic brain injury, edema\n Admitting Diagnosis: DIABETIC KETOACIDOSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n cells on both sides, sphenoid sinus and minimal in the right maxillary sinus.\n\n Additional details:\n\n The study was reviewed with Dr. by Dr. on at 4pm as\n the clinical team was concerned about possible diffuse cortical hyperintensity\n on DWI related to hypoxic injury. Apparently, the areas that were of concern\n appear to be related to artifacts from brain-bone interface in the left\n inferior frontal lobe (series 6, im 72) and as a continuous rim in the\n peripheral cortex, which is not hyperintense enough on DWI to be called as\n abnormal and does not have associated corresponding abnormality on ADC and\n FLAIR hyperintensity. Opinion was also sought from 2 senior radiologists of\n the section who agreed that these were artifacts and do not represent acute\n infarction. So, based on the present study, there is no evidence of acute\n infarction. If there is continued concern about encephalopathic changes or\n infarction, a follow-up study can be considered at clinical discretion.\n\n\n\n"},{"category":"Radiology","chartdate":"2173-06-01 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1015974,"text":" 2:48 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? line placements, change\n Admitting Diagnosis: DIABETIC KETOACIDOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old woman with intubation\n REASON FOR THIS EXAMINATION:\n ? line placements, change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 21-year-old woman with intubation, question line placement and\n change.\n\n COMPARISON: .\n\n SEMI-UPRIGHT BEDSIDE RADIOGRAPH OF THE CHEST: The ET tube is terminating 2.2\n cm above the carina. The right subclavian catheter is terminating below the\n anticipated cavoatrial junction, could be partly explained by low lung\n volumes. NG tube is extending into the pyloric end of stomach, unchanged.\n\n Focal opacities in the left mid and lower lung are more confluent today, could\n reflect interval aspiration however pneumonia cannot be excluded. There is\n mild volume overload. The main pulmonary trunk is distended indicating\n pulmonary hypertension. Dense retrocardiac atelectasis is worse. Small\n bilateral pleural effusions are unchanged.\n\n IMPRESSION:\n 1. Worsening confluent left mid and lower lobe opacities could represent\n interval aspiration however pneumonia cannot be excluded. Unchanged small\n bilateral pleural effusions.\n 2. Prominent main pulmonary artery trunk suggesting pulmonary hypertension\n which in the right clinical settings could reflect pulmonary embolism.\n\n In discussion with patient's referring physician . , a non-\n contrast chest CT to further evaluate the above changes will be considered,\n given patient's acute renal failure limits contrast administration.\n\n"},{"category":"Radiology","chartdate":"2173-06-03 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1016273,"text":" 3:12 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o interval change\n Admitting Diagnosis: DIABETIC KETOACIDOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old woman with ards, ? pna, intubation\n REASON FOR THIS EXAMINATION:\n r/o interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 21-year-old woman with ARDS, questionable pneumonia; evaluate for\n interval change.\n\n COMPARISON: .\n\n SEMI-UPRIGHT BEDSIDE RADIOGRAPH OF THE CHEST AT 3:45 A.M.: Endotracheal tube\n is terminating 2.3 cm above the carina. NG tube is extending into the stomach\n and out of the field of view. A right subclavian catheter is terminating\n slightly below the anticipated cavoatrial junction, unchanged.\n\n There is interval improvement in the multifocal consolidations with persistent\n retrocardiac atelectasis. Small bilateral pleural effusions are unchanged.\n There are no new consolidations. There is mild interstitial edema which is\n also improved. Heart size is normal. Previously noted prominence of the\n pulmonary trunk has also improved.\n\n IMPRESSION: Mild pulmonary edema with marked interval improvement in the\n multifocal consolidations with persistent small bilateral pleural effusions.\n\n"},{"category":"Radiology","chartdate":"2173-06-11 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":1017428,"text":" 2:42 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: s/p right 48cm picc\n Admitting Diagnosis: DIABETIC KETOACIDOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old woman with\n REASON FOR THIS EXAMINATION:\n s/p right 48cm picc\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Line placement.\n\n FINDINGS: Bedside frontal chest radiograph is compared to . The\n right PICC tip terminates in the lower SVC. The patient has been extubated.\n Prior pulmonary consolidations have markedly improved.\n\n IMPRESSION: PICC tip terminating in the lower SVC.\n\n\n"},{"category":"Radiology","chartdate":"2173-05-30 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1015769,"text":" 8:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Tube placements\n Admitting Diagnosis: DIABETIC KETOACIDOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old woman with NG tube placed\n REASON FOR THIS EXAMINATION:\n Tube placements\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST ON AT 8:12\n\n INDICATION: Tube placements.\n\n COMPARISON: at 0058.\n\n FINDINGS:\n\n The tip of the ETT is 4.9 cm above the carina. An NGT is visualized below the\n diaphragm with its tip in the body of the stomach. Compared to the prior\n study, there is continued distention of pulmonary vessels. The latter appear\n more prominent but positioning differences could be contributory. No definite\n new consolidations.\n\n\n"},{"category":"Radiology","chartdate":"2173-05-30 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":1015826,"text":" 7:56 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: eval R subclavian line placement\n Admitting Diagnosis: DIABETIC KETOACIDOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old woman with DKA, respiratory failure, ventilated, s/p R subclavian\n line placement\n REASON FOR THIS EXAMINATION:\n eval R subclavian line placement\n ______________________________________________________________________________\n WET READ: CXWc SUN 8:56 PM\n Right SCC terminates in the lower SVC. No pneumothorax. ETT 6.9 cm from\n carina, at thoracic inlet - advance by 2-3 cm for standard positioning.\n Persistent bilateral pleural effusions, pulmonary vascular engorgement and\n cardiomegaly, indicating heart failure, unchanged.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 21-year-old woman with diabetic ketoacidosis, respiratory\n failure, ventilated status post right subclavian line placement. Evaluate for\n line placement.\n\n COMPARISON: , (8:12 a.m.).\n\n SINGLE SUPINE BEDSIDE RADIOGRAPH AT 8:19 P.M.: Endotracheal tube is\n terminating 6.9 cm above the carina higher than the prior radiograph. There\n are bilateral pleural effusions associated with bilateral mild vascular\n congestion, slightly worse than prior study. Unchanged retrocardiac\n atelectasis is again noted. There are no new focal consolidations. There is\n mild atelectasis at the right lung base.\n\n The right subclavian catheter is terminating in the distal SVC. There is no\n pneumothorax. NG tube is extending into the stomach and out of the field of\n view.\n\n IMPRESSION:\n 1. Mild vascular congestion with small bilateral pleural effusions and\n bibasilar atelectasis, slightly worse than this morning.\n 2. ET tube terminating 6.9 cm above the carina. Position of the ET tube was\n communicated to Dr. .\n\n\n"},{"category":"Radiology","chartdate":"2173-05-30 00:00:00.000","description":"CT ABDOMEN W/O CONTRAST","row_id":1015833,"text":" 10:16 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: r/o fluid collection\n Admitting Diagnosis: DIABETIC KETOACIDOSIS\n Field of view: 42\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old woman with sepsis, dka, free fluid in pelvis seen on u/s\n REASON FOR THIS EXAMINATION:\n r/o fluid collection\n CONTRAINDICATIONS for IV CONTRAST:\n arf\n ______________________________________________________________________________\n FINAL REPORT\n CT ABDOMEN AND PELVIS\n\n CLINICAL HISTORY: Recent hypotensive episode secondary to DKA with subsequent\n sepsis. Abnormal fluid seen in pelvis on recent ultrasound.\n\n TECHNIQUE: Helical acquisition of CT images performed from the lung\n bases through the ischial tuberosities following administration of oral\n contrast only, decreased renal function precludes use of IV contrast.\n\n No prior studies available for comparison.\n\n FINDINGS: There are bilateral pleural effusions and associated atelectasis,\n right more so than left. There are scattered nodular opacities seen\n throughout both lung bases, and more focal consolidation seen at the right\n lung base, all of which may represent aspiration and subsequent developing\n pneumonia. There is a nasogastric tube which terminates in the gastric antrum.\n Central venous line tip terminates in the right atrium. Additionally a left\n femoral venous line is present with its tip in the external iliac vein.\n\n Non-contrast evaluation of the liver, spleen, pancreas and adrenal glands is\n unremarkable. Gallbladder is present, there may be biliary sludge, as there\n is increased attenuation within the decompressed gallbladder. No biliary\n dilatation.\n\n There are no dilated loops of bowel. There is a moderate amount of free fluid\n tracking along the right paracolic gutter extending to the deep pelvis, with\n thickening of the circumferential bowel wall thickening involving the right\n colon and proximal transverse colon. Contrast has passed to the level of the\n right colon. There is no abscess or organizing fluid collection. No\n pneumatosis is evident.\n\n There is a Foley catheter within decompressed bladder. Uterus and adnexal\n structures are unremarkable.\n\n Bony structures are unremarkable.\n\n IMPRESSION:\n\n 1. Bilateral pleural effusions with likely aspiration and developing\n (Over)\n\n 10:16 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: r/o fluid collection\n Admitting Diagnosis: DIABETIC KETOACIDOSIS\n Field of view: 42\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n consolidation at the right lung base.\n\n 2. Free fluid tracking along the paracolic gutter with associated bowel wall\n thickening, the possibility of ischemic bowel is raised given the recent\n hypotensive episode. Infectious and inflammatory etiologies also should be\n considered. No dilated loops or pneumatosis.\n\n 3. Likely biliary sludge.\n\n"},{"category":"Radiology","chartdate":"2173-05-30 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1015746,"text":" 1:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval tube. r/o effusions or PNA\n Admitting Diagnosis: DIABETIC KETOACIDOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old woman with DKA s/p intubation\n REASON FOR THIS EXAMINATION:\n eval tube. r/o effusions or PNA\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, , 00:58\n\n\n INDICATION: Recent intubation.\n\n FINDINGS:\n\n Tip of the ETT is 4.3 cm above the carina. The pulmonary vasculature appears\n somewhat prominent and there is bilateral blunting of the costophrenic sulci\n consistent with effusions. Heart size is top normal and there is no evidence\n of focal consolidation. No pneumothorax.\n\n IMPRESSION: Intubation with an element of fluid overload.\n\n\n"},{"category":"Radiology","chartdate":"2173-06-04 00:00:00.000","description":"CT CHEST W/O CONTRAST","row_id":1016526,"text":" 6:07 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: pls eval interval changes\n Admitting Diagnosis: DIABETIC KETOACIDOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old woman with DKA, respiratory failure, unresponsiveness and recent CT\n showing diffuse nodular opacities\n REASON FOR THIS EXAMINATION:\n pls eval interval changes\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 21-year-old woman with DKA, respiratory failure, unresponsiveness\n and recent CT showing diffuse nodular opacities, evaluate for interval\n changes.\n\n COMPARISON: .\n\n TECHNIQUE: Volumetric axial CT acquisition of the lungs without intravenous\n contrast. 5- and 1.25-mm thick axial slices were obtained. Multiplanar\n reformations were generated.\n\n FINDINGS: Endotracheal tube is terminating in standard location. NG tube is\n extending into the stomach. Right jugular venous catheter is terminating\n within the right atrium, all of these are unchanged.\n\n No mediastinal or axillary adenopathy. Evaluation of hilar structures is\n limited in the non-contrast setting. Heart and the great vessels are grossly\n unremarkable.\n\n Lung windows demonstrate large bilateral pleural effusions, worse than prior\n study. Again are noted multifocal peribronchial nodular consolidations, some\n in subpleural distribution and others more central, worse than the recent CT.\n There is also worsening bibasilar atelectasis.\n\n The study is not designed for subdiaphragmatic diagnosis and limited non-\n contrast evaluation of the imaged portions of the abdomen is grossly\n unremarkable.\n\n No suspicious lytic or sclerotic osseous lesions are noted.\n\n IMPRESSION: Worse multifocal peribronchial nodular opacities with\n increasing large bilateral pleural effusions and bibasilar atelectasis.\n Multifocal pneumonia remains the likely etiology. The distribution and\n morphology are not typical for pulmonary infarction or septic emboli, which\n are differential considerations.\n\n"},{"category":"Radiology","chartdate":"2173-06-05 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1016611,"text":" 3:58 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for OG tube placement\n Admitting Diagnosis: DIABETIC KETOACIDOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old woman admitted w/DKA, AMS, intubated w/OG tube\n REASON FOR THIS EXAMINATION:\n please eval for OG tube placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE VIEW ON \n\n HISTORY: New OG tube.\n\n FINDINGS: There is a new OG tube with tip in the stomach. The endotracheal\n tube tip is 5 cm above the carina. There is a right subclavian line with tip\n in the right atrium. Again seen are patchy bilateral alveolar infiltrates,\n some of which have a rounded configuration and could represent septic emboli.\n There is small right pleural effusion. Motion artifact limits this\n assessment.\n\n\n"},{"category":"Radiology","chartdate":"2173-06-01 00:00:00.000","description":"CT CHEST W/O CONTRAST","row_id":1016108,"text":" 9:10 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: characterize pulmonary process--ARDS? Radiology concerned r\n Admitting Diagnosis: DIABETIC KETOACIDOSIS\n Field of view: 36\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old woman with DKA, obtunded, ventilated, left infiltrate, pulmonary\n infiltration on CXR\n REASON FOR THIS EXAMINATION:\n characterize pulmonary process--ARDS? Radiology concerned regarding PE\n CONTRAINDICATIONS for IV CONTRAST:\n renal failure\n ______________________________________________________________________________\n WET READ: YMf TUE 10:40 PM\n Bilateral multifocal air space process, the appearance is non-specific and\n likely reflect presence of multifocal infection or aspiration, differential\n diagnosis includes pulmonary hemorrhage or ARDS. Bilateral moderate pleural\n effusions. Not able to evaluate for pulmonary embolism given lack of\n intravenous contrast.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST CT, \n\n HISTORY: DKA. Obtunded. Lung infiltrates and large hila and pulmonary\n arteries.\n\n TECHNIQUE: Multidetector helical scanning of the chest was performed without\n intravenous contrast because of patient's renal insufficiency, reconstructed\n as contiguous 5 and 1.25 mm thick axial and 5 mm thick coronal images.\n\n There are no prior chest CTs for comparison, but the study is read in\n conjunction with chest radiographs, through .\n\n FINDINGS:\n\n Endotracheal tube is in standard position, nasogastric tube passes into the\n stomach and out of the field of view, and a right jugular line ends in the\n upper right atrium.\n\n Multifocal, nodular areas of peribronchial consolidation is all lobes of both\n lungs, and extensive lobar consolidation in the left lower lobe, superior and\n posterior and anterior basal segments are probably infectious; a smaller\n region of posterior consolidation in the right lower lobe is probably\n atelectasis.\n\n In the absence of intravenous contrast enhancement, measurement of central\n lymph nodes is difficult, but range up to 17 mm in the left hilus, smaller in\n the right hilus, and insignificant in the mediastinum. Small non-hemorrhagic\n pleural effusions layer posteriorly. There is no pericardial effusion. Main\n pulmonary artery is equivalent in diameter to the aorta, 31 mm, probably\n larger than baseline, but not so large as to raise concern for pulmonary\n hypertension.\n (Over)\n\n 9:10 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: characterize pulmonary process--ARDS? Radiology concerned r\n Admitting Diagnosis: DIABETIC KETOACIDOSIS\n Field of view: 36\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n IMPRESSION:\n 1. Multifocal pneumonia. No evidence of ARDS. Pulmonary embolism cannot be\n excluded by this non-contrast examination, but findings do not suggest\n pulmonary infarctions.\n\n 2. Hilar adenopathy, small bilateral pleural effusions, probably reactive to\n pulmonary infection.\n\n Findings were discussed by telephone with the house officer caring for this\n patient at the time of this dictation.\n\n\n\n\n\n\n\n\n\n"},{"category":"Radiology","chartdate":"2173-06-08 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1016861,"text":" 3:07 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: DIABETIC KETOACIDOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old woman with intubation, PNA\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Status post intubation, evaluation for interval change.\n\n As compared to the previous radiograph, there is no relevant change. The\n monitoring and support devices are in unchanged position. The multifocal\n areas of opacities are unmodified. Moderate retrocardiac atelectasis, no\n secure evidence of pleural effusions.\n\n\n"},{"category":"Radiology","chartdate":"2173-06-06 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1016648,"text":" 3:41 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess interval change\n Admitting Diagnosis: DIABETIC KETOACIDOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old woman with resp failure, dka\n REASON FOR THIS EXAMINATION:\n assess interval change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Diabetic ketoacidosis and respiratory failure in a\n 21-year-old woman.\n\n Portable AP chest radiograph was compared to a chest CT from and chest\n radiographs from till .\n\n Multiple parenchymal consolidations some of them rounded in shape did not\n significantly change over period of last three days, but did\n slightly progress since . The current radiograph demonstrate a\n bilateral perihilar opacities which are most likely consistent with pulmonary\n edema and are unchanged since . There is bilateral pleural\n effusion and bibasal retrocardiac atelectasis which are also stable.\n\n The ET tube tip, the NG tube, the right subclavian line are in standard\n position.\n\n IMPRESSION: Multiple consolidations some of them rounded consistent with\n infectious process.\n\n Superimposed pulmonary edema.\n\n Pleural effusions and retrocardiac atelectasis.\n\n\n"},{"category":"Echo","chartdate":"2173-06-05 00:00:00.000","description":"Report","row_id":85254,"text":"PATIENT/TEST INFORMATION:\nIndication: ?Septic pulmonary emboli.\nBP (mm Hg): 200/100\nHR (bpm): 120\nStatus: Inpatient\nDate/Time: at 09:14\nTest: Portable TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: No spontaneous echo contrast or thrombus in the LA/LAA or the\nRA/RAA. Good (>20 cm/s) LAA ejection velocity.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA.\nNormal interatrial septum. No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal ascending, transverse and descending thoracic aorta with no\natherosclerotic plaque.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. No masses or\nvegetations on aortic valve. Filamentous strands on the aortic leaflets c/with\nLambl's excresences (normal variant).\n\nMITRAL VALVE: Normal mitral valve leaflets. No mass or vegetation on mitral\nvalve. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. No mass or vegetation on\ntricuspid valve. Mild [1+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR. No vegetation/mass on pulmonic valve.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was monitored\nby a nurse throughout the procedure. The patient was monitored\nby a nurse throughout the procedure. Local anesthesia was\nprovided by benzocaine topical spray. The patient was sedated for the TEE.\nMedications and dosages are listed above (see Test Information section). 0.2\nmg of IV glycopyrrolate was given as an antisialogogue prior to TEE probe\ninsertion. No TEE related complications. Ascites.\n\nConclusions:\nNo spontaneous echo contrast or thrombus is seen in the body of the left\natrium/left atrial appendage or the body of the right atrium/right atrial\nappendage. No atrial septal defect is seen by 2D or color Doppler. Overall\nleft ventricular systolic function is normal (LVEF>55%). Right ventricular\nchamber size and free wall motion are normal. The ascending, transverse and\ndescending thoracic aorta are normal in diameter and free of atherosclerotic\nplaque to 40 cm from the incisors. The aortic valve leaflets (3) appear\nstructurally normal with good leaflet excursion and no aortic regurgitation.\nNo masses or vegetations are seen on the aortic valve. There are filamentous\nstrands on the aortic leaflets consistent with Lambl's excrescences (normal\nvariant; seen on clips 113 and 114). The mitral valve leaflets are\nstructurally normal. No mass or vegetation is seen on the mitral valve. Mild\n(1+) mitral regurgitation is seen. No vegetation/mass is seen on the pulmonic\nvalve. There is no pericardial effusion.\n\nIMPRESSION: No echocardiographic evidence of endocarditis, abscess or valvular\nmass. Normal biventricular function. Mild mitral and tricuspid regurgitation.\n\n\n"},{"category":"Echo","chartdate":"2173-06-02 00:00:00.000","description":"Report","row_id":85255,"text":"PATIENT/TEST INFORMATION:\nIndication: Endocarditis.\nHeight: (in) 66\nWeight (lb): 198\nBSA (m2): 1.99 m2\nBP (mm Hg): 129/76\nHR (bpm): 115\nStatus: Inpatient\nDate/Time: at 15:03\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal interatrial septum. No\nASD by 2D or color Doppler. Normal IVC diameter (<2.1cm) with >55% decrease\nduring respiration (estimated RAP (0-5mmHg).\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Suboptimal technical\nquality, a focal LV wall motion abnormality cannot be fully excluded. Low\nnormal LVEF. No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter. No 2D or Doppler evidence of distal arch coarctation.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. No masses or\nvegetations on aortic valve.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. mass or\nvegetation on mitral valve.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. No mass or vegetation on\ntricuspid valve. Mild [1+] TR. Normal PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR. No vegetation/mass on pulmonic valve.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Resting tachycardia (HR>100bpm).\n\nConclusions:\nThe left atrium is normal in size. No atrial septal defect is seen by 2D or\ncolor Doppler. The estimated right atrial pressure is 0-5 mmHg. Left\nventricular wall thicknesses and cavity size are normal. Due to suboptimal\ntechnical quality, a focal wall motion abnormality cannot be fully excluded.\nOverall left ventricular systolic function is low normal (LVEF 55%). There is\nno ventricular septal defect. Right ventricular chamber size and free wall\nmotion are normal. The aortic valve leaflets (3) appear structurally normal\nwith good leaflet excursion and no aortic regurgitation. No masses or\nvegetations are seen on the aortic valve. The mitral valve appears\nstructurally normal with trivial mitral regurgitation. No mass or vegetation\nis seen on the mitral valve. The estimated pulmonary artery systolic pressure\nis normal. No vegetation/mass is seen on the pulmonic valve. There is no\npericardial effusion.\n\nIMPRESSION: No valvular vegetations seen.\n\n\n"},{"category":"Nursing/other","chartdate":"2173-06-08 00:00:00.000","description":"Report","row_id":1661558,"text":"7pm to 7am:\n\nROS:\n\nNeuro) Pt remains intubated with propofol gtt for sedtion with good efffect. Pt found in the beginning of the shift to be VERY somulent and sedation decreased. Pt became awake and following commands, but agitated at times, and sedation increased again. MD aware of current neuro status. While awake, pt was following simple commands, had = hand grips, MAE and able to answer yes and no by non-verbal ques. Neuro is following pt. No contact from family on this shift. Full Code.\n\nID) Afebrile. WBC 10 this am. On IV ABxs for multifocal pna. Pt has had large amounts of liq stool and stool sample sent for C-diff R/O. Needs 2 more sent off and . Vanco level this am 12.5 .\n\nCV) Pt is in NSR while at sleep and ST (100-110) while awake. No ectopy noted. A-line VERY positional and is now using NIBP for readings. A-line with very poor blood return. MD aware. Gen edema continues. K level has been aggressivly replaced throughout the shift, and is now NL at 4.3. Please follow closely diuresis and diarrhea. Hct dropping. ? need for blood transfusion or epogen RF. Na level now NL after H2O flushes. ? decrease amounts of flushes.\n\nGU) Good respond from lasix gtt. Goal net (-) 100 cc/hr. Pt is currently (+) 14 liters for LOS. Pt currently on bicarb gtt for RF, with now corrected PH and Co2...? Creatine and BUN decreasing. DC gtt. Nephrology is following pt.\n\nGI) Abd soft with + BS. TF at goal at 25 cc/hr. Pt continues to have lg amounts of liq brown stool via rectal tube. Insulin gtt as noted with still very labile BS results. D10 gtt as noted.\n\nResp) LS coarse throughout the shift, but improved after deep sx. No changes made to vent settings. ABGs WNLs.\n\nSkin) body rash improved. See care vue for details.\n\n"},{"category":"Nursing/other","chartdate":"2173-06-08 00:00:00.000","description":"Report","row_id":1661559,"text":"resp care\npt extubated after successful . strong cough prod mostly whitish/lt yellow secretions. abg acceptable on face tent. refer to flow sheet for further documentation.\n"},{"category":"Nursing/other","chartdate":"2173-06-08 00:00:00.000","description":"Report","row_id":1661560,"text":"MICU nurse progress note 0700-1900\nEvents: pt cont to diurese well, lasix gtt now at 12mg/hr. K+ repleted w/ a total of 60meq today. last K+ at 15:30 was 4.3... propofol and TF off, pt extubated today at 13:00, tol well, 02 sat now 95-100% on R/A... insulin gtt at 2units/hr, D10 at 100ml/hr, FSBS 104-137.\n\nROS:\nNeuro: A/O x 2 MS clearing, weepy at times, following commands. all ext strong/= PERRLS. no c/o pain.\n\nPulm: extubated as above, was initially on 40% face tent, now on R/A tol well 02 sat 95-100%. LS remain coarse throughout, strong/ productive cough. remains on IV Vanc/ Cefepime for multifocal pna. day 10 of 14.\n\nCVS: NSR/ST w/ no ectopy HR 80's-110's. b/p stable 120's-140's/ 70's. ABP's ~20pts higher, K+ repleted as above.\n\nGI: OGT removed w/ extubation, abd soft nontender +BS x 4quads. pt NPO post extubation. Speech eval in am. mushroom cath intact draining liq brown stool.\n\nGU: foley cath patent draining clear yellow urine. lasix gtt at 12mg/hr. UOP 250-400ml/hr. goal UOP is net neg ~100ml/hr. BUN/CR improving.\n\nsocial: family at bedside, updated r/t POC/ pt cond by RN and MD.\n"},{"category":"Nursing/other","chartdate":"2173-06-05 00:00:00.000","description":"Report","row_id":1661549,"text":"Micu Nursing note \n\nNeuro: Propofol drip stopped at 2 pm. pt more resposive following simple commands, nodding head, try to go for ett, was able to keeppt off propofol for and hour and a half, then palced her back on drip because of ^ rr and acidosis\nCv pt hemodynamcally stable aline and cuff more accurate now that tranduced is taped to pt leg, BP 120-150/60-80 hr 89-113\npulses in leg by doppler\nResp pt changed form ac-ps now on 40%/14/5peeps tv 400-700, rr 20-2g while on propofol off propofol rr ^ 32, pt suctioned for small -mad amount of white secreations, lung course, sats 100%\nGi and soft non tender will restate tube feeds at 10 cc/hr retal tube in place passing small amount of brown liquid\nGU foley in place, pt started on lasix drip which is now at 10mg/hr. goal to make pt a liter neg today so far only 400 neg\npt also started on a bicarb drip which is at 150 /hr, they will change consintration so that we can lower volume about and hopefully get to neg goal, ph slighly better( see objective data ) pt will also start on po bicarb tabs this evening\nid t max 99.7 pt cultured blood x2 urine and sputum, added flagyl for more coverage\nendo Blood sugars difficult to control at one point bs down to 71 given amp of d5 and repeat bs 140, held insulin drip until this afternoon when bs > 300 and was restarted on drip now at 5 units and hour\nA/P\nNeuro status much improved and pt able to folllow commands off propofol\nacidosis r/t renal failer now on bicarb drip and lasix drip\n attempt to correct ph, renal following if over next 2 days no improvement in acidosis, will consider hd line\nblood sugars difficult to control remains on insulin drip will start tube feeds follow bs q1 hr.\n"},{"category":"Nursing/other","chartdate":"2173-06-05 00:00:00.000","description":"Report","row_id":1661546,"text":"7pm to 7am:\n\nEvents: Pt has had an uneventful night. Plan for a TEE today and continue to wean pt off vent as tolerated.\n\nROS:\n\nNeuro) Pt remains intubated with propofol gtt for sedation with good effect. When stimulated HR and BP has improved today. When doing oral care, pt will slightly open eyes, have facial grimaces and noted to have decerebrate movements to upper EXTs. Although, pt will not respond to painful touch (nail bed pinch). Neuro exam as noted in care vue. No contact from family at this time. ? need for family meeting in near future regarding pt's progress. Full code.\n\nCV) Pt in SR (80-90's) while at rest and ST (100-110) with stimulation. Aline to Lt Fem with dampened wave form, and using NIBP for BP readings. SBP 120-130's with MAP >65. CVP 14->12. Am labs pending. NPO for TEE this am at 8am.\n\nENDO) Pt remains on insuling gtt with D5W at KVO.\n\nResp) Pt has been deep sx'd for sml-mod amounts of white secretions. Ls has improved throughout the night, now CTA. Pt in AC mode with worsening ABGs as noted in care vue (met acidosis..awaiting am labs for renal function).\n\nGI) Abd obese with + BS. Pt continues to have liq brown stool via rectal tube. NPO. OGT w/o residuals and clamped.\n\nGU) Good U/O via foley catheter. Pt is now +16.6 liters for LOS.\n\nSkin) see care vue for details.\n\n"},{"category":"Nursing/other","chartdate":"2173-06-05 00:00:00.000","description":"Report","row_id":1661547,"text":"Resp Care\nRemains intubated and ventilated on a/c with no remarkable changes overnight. ABGs with continued metaboloic acidosis, good oxygenation. Lungs clear to auscultation. RSBI this morning = 103.\n"},{"category":"Nursing/other","chartdate":"2173-06-05 00:00:00.000","description":"Report","row_id":1661548,"text":"Respiratory Care Note\nPt received on AC as noted. BS slightly coarse with expiratory wheezes in LUL which clears with suctioning. Pt suctioned for small amt thick, tan secretions. Pt weaned to PSV 14/5 as noted. Pt tolerating fairly well with VT ranges in 500's and RR mid to high 20's. Pt becomes tachypneic 35-40 with care. Plan to continue on PSV as tolerated at this time.\n"},{"category":"Nursing/other","chartdate":"2173-06-07 00:00:00.000","description":"Report","row_id":1661555,"text":"Respiratory Care\nPatient remains intubated, and on mechanical ventilatory support, breath sounds bilaterally clear throughout shift, suctioned intermittently for moderate to small amounts of thick white secretions, SPO2 remains in the upper 90s, patient did no tolerate tried for few minutes by MD, became tachypneic, put back on previous settings, no ABGs nor vent changes made up to the present, will continue to be followed.\n"},{"category":"Nursing/other","chartdate":"2173-06-07 00:00:00.000","description":"Report","row_id":1661556,"text":"MICU Nurse Progress Note 0700-1900\nEvents: pt cont on lasix gtt at 14mg/hr, diuresing well. started on D10 at 100ml/hr x 2L for DKA/ hypernatremia. insulin gtt increased to 8units/hr per protocol. propofol increased r/t agitation. Neuro f/u done today. Aline resited to R wrist.\n\nROS\r:\nNeuro: pt resp to verb stim, able to follow commands. MAE, PERRLS. sedation turned off for Neuro f/u consult/ exam. pt able tro consistently follow commands. sedation restarted r/t pt not extubating today.\n\nPulm\r: LS coarse bilat. suctioned for msm-mod amt thick whitee secretions. RSBI this am 160. remains on CPAP+PS tol well.\n\nCVS: NSR w/ no ectopy ABP 140-160's/ 70-90's. repeat K+ 3.8 pt repleted w/ 20meq KCL IVPB. needs f/u this eve. R rad aline and R s/c CVL intact w/ good BR.\n\nGI: abd soft/ nontender, +BS x 4quads, TF at goal rate via OGT tol well. Mush cath intact draining liq brown stool.\n\nGU: foley cath patent draining clear yellow urine, UOP 200-350ml/hr, net neg ~1.5L since midnight. lasix gtt 14mg/hr.\n\nID: cont on cefepime r/t multifocal PNA\n\nsocial: pt father called, updated r/t pt cond/ POC.\n\n\n"},{"category":"Nursing/other","chartdate":"2173-06-08 00:00:00.000","description":"Report","row_id":1661557,"text":"Respiratory Therapy\nPt device: Pt remained on CPAP+PS 14/5 t/o the night and tol well. Pt would get tachypnic with RR up to 40 when sedation was lightened. RSBI was 91.7 this AM.\n\nLungs: BBS clear but coarse at times. Sx for large amount of thick white secretioins.\n\nGas Exchange: ABG normal\n\nPlan: wean as tolerated and extubate.\n"},{"category":"Nursing/other","chartdate":"2173-06-01 00:00:00.000","description":"Report","row_id":1661533,"text":"Nursing note 7a-7p\nEvents: pt in resp distress on cpap, after being on cpap for over 24 hrs. placed on CMV. cxr worse on Left, requiring CT chest. EEG done, non-specific secondary to propofol. MRI rx'd, however unable to do on day shift, due to pt needing 2 IV pumps while down in MRI dept.\n\nNeuro: pt opens eyes off propofol for ~20 min. unclear as to if pt is following, because she is unable to repeat commands consistently; however, pt was able to turn her head towards my voice on command and move her legs x2 on command. + gag, + cough, no focus, no upper ext movement noted today(purposeful or non-purposeful).\n\nCV: ST, no ectopy. S1, S2. 2+ gen edema. Pt is up almost 20 kg since admission. palp pulses x4 ext. L fem Aline over damp. SBP correlating w/ NIBP. CVP continues to be elevated around 14.\n\nPulm: Pt on CMV 18/TV 550/Fio2 .40/PEEP5. lungs coarse bilat after suctioning for small-mod amt thin white secretions. Last abg consistent. no vent changes ordered.\n\nGI: abd soft, bs+, tf @ goal w/ min resid. incont small loose, brown stool x3.\n\nGU: foley draining marginal amts cloudy, pale yellow urine. pt on menses.\n\ninteg: L flank & abd ecchymosis, peri redness, however, no longer cottage cheese-like drng. tape burn to RAC, ear spacer holes scabbed-bacitracin applied. L chest bar piercing site scabbed.\n\nIV: RSC TLC patent. no redness. old sang drng.\n\nendocrine: pt remains on insulin gtt 2-3 units/hr all shift.\n\npain: no s/sx of pain. grimaces only with sternal rub and oral care.\n\nSocial: pt's parents home for the day to shower and nap. no other phone inquiries.\n\nID: urine, sputum and wond cxs neg. bc x2 pending.\n\nPlan: MRI of brain, CT chest tonight. daily wake-ups. Neuro consult. monitor neuro status, resp and renal functions.\n"},{"category":"Nursing/other","chartdate":"2173-06-02 00:00:00.000","description":"Report","row_id":1661534,"text":"MICU 6 NPN:\nNEURO: PERL 3-4mm and sluggish. Taken off propofol to assess neuro status and pt. noted to move only LEs and head. No following commands. Opens eyes but no tracking or focusing. Becomes very agitated off propofol. Agitated throughout night with tachypnea, biting tube and hypertension- propofol increased to 50mcg/kg/min with good effect. Pt. received head MRI and chest CT overnight with results pending.\nCV: Afeb. HR 90s-110s SR/ST, no ectopy noted. L femoral a-line dampened and NIBP started. BP wnl. R subclavian quad lumen line intact.\nRESP: No vent changes overnight. O2 Sat >95% and acceptable abgs. Sx'd for scant secretions. LS coarse and diminished at bases.\nGI/GU: Abd. soft with positive bowel sounds. Large loose BM - trace guiac positive. TF continue at goal. Insulin gtt currently at 1unit/hour and monitoring blood glucose q1/2-1hr. Glucose dropped to 54 overnight and given amp d50. Foley with cloudy yellow urine 20-30cc/hr. BUN/Cr rising.\nSKIN: Peri area with yeast rash- antifungal cream applied. Backside intact. Generalized edema. Would benefit from kinair air mattress.\nOTHER: Plan for read of MRI/chest CT. Daily wake-up to assess neuro exam. Would benefit from neuro consult.\n"},{"category":"Nursing/other","chartdate":"2173-06-02 00:00:00.000","description":"Report","row_id":1661535,"text":"RESP CARE NOTE\n21 YO F ADMITTED FOR DKA NOW BEING SEEN FOR INCREASING SEPSIS. SX MODERATE AMOUNT THICK WHITE. BS DECREASED AT BASES WITH FINE CRACKLES @ L BASE. ETT REPOSITIONED AND TAPED @ 23. RSBI 150\n"},{"category":"Nursing/other","chartdate":"2173-06-02 00:00:00.000","description":"Report","row_id":1661536,"text":"resp care - Pt remains intubated and on full vent support. No changes were made in vent settings this shift. Coarse BS cleared somewhat on suctioning of small amounts of thick, white secretions. Bronch was done for BAL. Sample of secretions were sent to the lab. Plan is to continue resp support.\n"},{"category":"Nursing/other","chartdate":"2173-06-02 00:00:00.000","description":"Report","row_id":1661537,"text":"0700-1900 MICU PROGRESS NOTE\n\n21yo female admitted from , admitted on after being found down for unknown length of time. PT was intubated at OSH and blood sugar >600. At OSH pupils were fixed and dilated and rectal temp was 88. Pt required pressors and >5L IVF, for hyPOtension intially. Anion Gap 21 and blood sugars >400 intially and placed on insulin gtt. Pt was very acidotic on admission and given several doses of Bicarb. PMH IDDM and alopecia.\n\n\nEvents- Propofol was shut off at 11:45 today and by noon pt agitated. Pt was coughing and on ETT. Sat's dropped to 88-90% when biting tube. PT became hypertensive w/ SBP 160's and tachycardic w/ HR 140's. Dr into eval neuro status, pt UNresponsive to painful or verbal stimuli. Pt NOT following commands. Propofol restarted per team. Bronch completed and BAL sent. Echo completed.\n\n Recieved pt on Propofol and stopped for brief time as noted above. Pt would NOT withdraw to painful stimuli or turn head to verbal stimuli. Pt did bite on ETT and cause sat's to drop. Pt moves legs slightly on bed. Pupils 4cm and sluggish to lights.\n\nC/V- Tmax 99.7 rectally. HR 90-120, NSR/ST w/o ectopy. Pt has 2+ pitting edema. Aline wave dampened and does not correlate well w/ NIBP. Team aware. B/P 120-150/70-90.\n\nResp- Remains orally intubated, see care-vue for trended ABG's. pH 7.30-7.35 and team aware...will monitor. No vent changes made. Sat's remain 97-100% on current vent settings. Lungs coarse w/ rhonchi at bases, suctioned for small amts of thick white sputum. Ct chest last night showed new nodules probable infectious in nature and antibiotic coverage changed.\n\nG/U- Bun/Creat elevated 74/5.4, renal following. Will monitor..dialysis not indicated at this time. Foley clear yellow but decreased amounts...15-50cc/hr.\n\nG/ Pt at goal for TF 25cc/hr. Remains on insulin drip. Blood sugars have been 130-200. Pt has had 2 loose liquid brown stool.\n\nPLAN-\nAWAITING ECHO RESULTS\nBAL AND SPUTUM SPEC SENT , FOLLOW-UP RESULTS\nCONTINUE TO TREND ABG'S, GOAL pH 7.30-7.35\nFUNGAL CULTURES SENT\nSTOP PROPOFOL TONIGHT TO ASSESS NEURO STATUS\nMONITOR ELECTROLTES AND REPLETE AS NEEDED\n\n"},{"category":"Nursing/other","chartdate":"2173-06-03 00:00:00.000","description":"Report","row_id":1661538,"text":"MICU 6 NPN:\nNEURO: Taken off propofol x 15min for neuro exam. Pt. does not open eyes to painful stimuli. No following of commands. Withdraws LEs to painful stimuli but not UEs. Moving head back and forth in bed but no movement of UEs noted. PERL 3-4mm and sluggish. Positive cough and gag but no corneal reflexes noted.\nCV: Afeb. Received 1G vanco last pm for level of 20. HR 90s-110s SR/ST, no ectopy noted. BP stable via cuff pressures. A-line continues dampened but with good blood return.\nRESP: No vent changes and adequate abg. TCo2 14. LS coarse and diminished at bases. Minimal secretions.\nGI/GU: Abd. soft with positive bowel sounds, loose BM x1. TF continue at goal with minimal residuals. Continues on insulin gtt at 2units/hour. Foley draining clear yellow urine >50cc/hr.\nSKIN: Multiple blisters to UEs and reddened areas around tape. Will try to minimize tape due to pt's sensitivity. Peri-area red with yeast rash- criticaid antifungal cream applied. Scant blood vaginal drainage from menses.\nOTHER: No calls or visitors this shift.\n"},{"category":"Nursing/other","chartdate":"2173-06-03 00:00:00.000","description":"Report","row_id":1661539,"text":"RESP CARE NOTE\nPT REMAINED ON SAME AC SETTINGS OF 18/550/+5/40%. ABG 7.34/24/175/14. BS CS AND DIMINISHED AT BASES. SX'D SMALL AMTS OF THICK YELLOW SECRETIONS. ROTATED AND RETAPED OETT @23CMS. MORNING RSBI 130\nPLAN: CONT FULL VENTILATORY SUPPORT\n"},{"category":"Nursing/other","chartdate":"2173-06-03 00:00:00.000","description":"Report","row_id":1661540,"text":"0700-1900 MICU Progress Note\n\n\n21 yo female admitted from on after being found down for unknown length of time. Only PMH is alopecia and IDDM since 7yo. Pt was intubated at OSH and blood sugar found to be greater than 600. Neuro exam at OSH ..pupils fixed and dilated, rectal temp 88 and unresponsive to painful stimuli. Pt was transferred to Tox screen negative for drugs/ETOH B/P 70 palp and required pressors and greater than 5L IVF. Intial anion Gap 21, now 12. Pt continues on insulin gtt and blood sugars have been 100-200, on 1-2units per/hr. Pt was acidotic on admission and given Bicarb....continues to be slightly acidotic @7.27. Team aware and no treatment at this time. Renal function has been worsening slightly(BUN/Creat 81/5.5), renal following...probable ATN and will monitor.continue to follow up with labs. MRI intially read by radiology as normal, but was reviewed by neuro service today and probable anoxic injury noted, awaiting official neuro note. Family NOT aware of new findings, team will address tomorrow. Pt had \"wake-up\" 2x today and was eval by neuro service.\n\nNeuro- As stated above, propofol off 2x today and evaluated by Neuro. Off propofol for 30-1hr and pt became tachycardic w/ HR 120-140 and hYPERtensive. Pt thrashing in bed, gagging and coughing. PT LIFTING BOTH LEGS AND ARMS OFF BED, BUT NO PURPOSEFUL MOVEMENT. Pt does not withdraw from painful stimuli. Pt not opening eyes, or moving head to voice. Pt will bite on ETT off propofol, and sat's drop tp the 80's. Pt place back on propofol..will continue to attempt wake-up and follow neuro rec's when available. Pupils 4cm and sluggish.\n\nI/D- CT chest 2 days ago showed nodules, ? septic emboli. ECHO WNL..PLAN TTE IN AM, WILL KEEP NPO after midnoc. Continues on daily dosed vanco and cefepime. Tmax 100. BAL and sputum spec pending.\n\nC/V- Remains ST/NSR, no ectopy. >17L pos for LOS, +2 edema noted in all extremities and peri-orbital. Aline wave dampened and does not correlate w/ NIBP, team aware. Will keep as access for lab/ABG's. B/P 120-140/60-70. TTE in am.\n\nResp- Vent changed to pressure support and tolerated well. RR 20-30(RR increases to 40's off propofol) and sat's have remained 95-100% on PS. See care-vue for ABG's . Suctionedfor large amount of clear oral secretions and thin white sputum via ETT. Lungs coarse rhonchi,which clears somewhat w/ suctioning.\n\nG/U- Foley draining clear yellow urine and has somewhat increased as compared to yesterday. U/O 50-70cc/hr.\n\nG/I- TF, Nutren Pulm at goal 25cc/hr, tolerated well, no residuals. Pt had 2 loose stool today, hypoactive bowel sounds. NPO after midnoc for TTE. Remains on Insulin GTT at 1unit/hr.\n\n Pt is very sensitive to tape and has multi small fluid filled blisters and arms, and small abrasions. A+D oint applied to open area. Peri-rectal and groin area reddened, criticaid w/ nystatin applied.\n\nPLAN-\nCONTINUE TO MONITOR ABG'S AND ACIDOSIS...GOA\n"},{"category":"Nursing/other","chartdate":"2173-06-03 00:00:00.000","description":"Report","row_id":1661541,"text":"(Continued)\nL 7.28-7.35\nMONITOR NEURO STATUS AND CONTINUE TRIALS OFF PROPOFOL\nTTE IN AM\nAWAITING NEURO REC'S\nFUNGAL, BAL AND SPUTUM SPEC PENDING\nMONITOR ELECTROLYTES\n"},{"category":"Nursing/other","chartdate":"2173-06-06 00:00:00.000","description":"Report","row_id":1661552,"text":"Micu Nursing note \n\nNeuro: Propofol drip off this am, pt able to follow simple commands grasp hands, and move legs on bed, seems to understand questions and nods. pt placed back on propofol drip because at present no plans to\nextubate.\n\nCv Pt hemodynamically stable BP 120-150/ 60-80 hr 80-110 st, pulses present and palpable,\nResp pt remains on ps14/5 peep/ rr 23-40. fio240%, sats 100% lungs course, pt scutioned s4 for thick tan secreations needing n/s lavage first, secreations are very thick because she is dry.\nattempted to go to 0/5 and pt rr ^ 50, only lasted 5 min and was placed back to previous setting.\n\nGi abd soft non tender, still passing brown liquid stool, tube feeds at goal of 25/hr on nutran plum, residuals 35 cc,\n pt continues to have good urine output, however, we at present are not reaching our negative goal becayse of replacement of free water,\nlytes pending na this am 150, may need to restart lasix drip this eveing, it was stopped early this am because of ^ na level\nid tmax 99.1\naccess, R tlc, and L fent aline\nskin L fa area small blisters drying area cleaned with n/s and dsd applies, R ankle area cleaned and left open to air\nrash improving on body less reddened back and buttock much better\nA/P\nimproving mental status\nat present no plans to extubate until we imporove fluid balance and correct sodium level\nrenal following no plans for hd line, dicarb drip decreased to 12.5 cc/hr, improving ph\nfollow lytes, free water added, may need lasix restarted at the same time as giving free water to reach negative fluid goal.\n"},{"category":"Nursing/other","chartdate":"2173-06-06 00:00:00.000","description":"Report","row_id":1661553,"text":"Respiratory Care Note\nPt received on PSV 14/5 as noted. BS coarse bilaterally. Pt suctioned for small amt thick secretions. Pt placed on trial 5/0. Pt became tachypneic with RR 40-45 after 5 min - pt placed back on PSV 14/5. Plan to continue on current settings at this time.\n"},{"category":"Nursing/other","chartdate":"2173-06-07 00:00:00.000","description":"Report","row_id":1661554,"text":"7pm to 7am:\n\nEvents:\n Pt has had an uneventful night.\n\nROS:\n\nNeuro) Pt remains intubated with propofol gtt for sedation with good effect. Pt will open eyes and will follow simple commands. Sometimes it takes her a few seconds to respond. Pt has = hand grip. Pupils=and reactive. Pt's neuro status has improved greatly over the last few days. See care vue for further neuro evaluation. No contact from family on this shift.\n\nID) Pt is afebrile. Pt on IV ABXs for multi focal pna. CXR done this am. Pt continues to have a body rash, but improved since .\n\nCV) Pt is in SR(80-90's) at rest and ST (100-106) with activity. SBP stable and a-line and NIBP correlate as noted. Pt continues to have gen edema. Am labs as noted. K level has been replaced multiple times, and needs follow up 2/2 lasix gtt.\n\nResp) LS coarse and clear after deep sx. Pt on CPAP+PS and is tolerating it well. Plan to diurese pt further before extubation takes place. ABGs as noted in care vue.\n\nGI) Abd soft with + BS. Pt continues to have liq brown stool via rectal tube. TF at goal at 25 cc/hr w/o residuals. Pt given H2O fluses for NA level with some effect. Follow up Na level.\n\nGU) Goal diuresing (-) 1-2 liters q day with lasix gtt. . Pt is now + 5.6 liters for LOS (1 liter - for the last 24 hrs). Sodium bicarb gtt as noted. Wean off as tolerating. PH NL and Co2 improved.\n\nSkin) skin as noted in care vue.\n\nSoc) ? family meeting soon.\n\n"},{"category":"Nursing/other","chartdate":"2173-06-10 00:00:00.000","description":"Report","row_id":1661563,"text":"MICU Nursing Note 1900-0700\nEvents: Transfer to floor cancelled d/t high sugars and anion gap at 2200, gap now closed this am, received 500ml IVF bolus x 110-120's, mild anxiety at times\n\nNeuro: A+O x 3, pleasant and cooperative, anxious with care at times, weepy at other times, moving all extremities, following all commands, asking appropriate questions, OOB til 11pm last night, PEARL, denies pain\n\nCardiac: Pt with HR up 110-120's ST at shift change---received 500ml IV NS bolus with fair effect, second IV NS 500 ml infused with fair effect with HR down to 100-110's ST, BP stable 130-150's/60-70's, pt with (2) PIV's\n\nResp: Denies SOB, RR= 13-20. Lungs clear bilat upper lobes and diminished at bilat lower lobes, occasional scattered rhonchi noted, junky sounding productive cough of thick white sputum, room air Sats with trend down to 90-92%---encouraged to TCDB, placed on 2 L NC with Sats up to 94-97%.\n\nGI: Abd soft with + bowel sounds all quads, poor PO appetite and needs encouragement, taking po fluids well, Mushroom cath draining mod. amts liquid brown stool. C/O nausea at 11pm when BS elevated---resolved after insulin administration.\n\nGU: Foley to CD draining clear yellow urine > 50ml/hr. Creat down to 2.6 this am. Pt currently positive 10.3 L for LOS.\n\nSkin: intact\n\nEndo: Blood sugar up to 401 at 2200----med. with 12 units regular insulin and 25 units Lantus as ordered, team aware and chem panel sent which revealed Gap=16. Fingersticks checked Q 1 hour overnight and 3am Chem panel revealed Gap=10. Blood sugars trending down all night and now currently under 200. If need to restart insulin gtt take note that pt has Lantus on board.\n\nID: WBC= 11.5, low grade temp with Tmax= 99, continues on IV Cipro. random vanco level=16 this am.\n\nSocial: Pt's parents in to visit during evening hours and were updated on pt's care. No further contact overnight.\n\nPlan: Call out to medicine if blood sugars remain under 200, continue freq. glucose checks, increase lantus dose to pt's pre-hospital dose as her po intake improves, increase activity as tolerated---pt is a 2 person max. assist to chair, await PT eval, start pt with incentive spirometer and wean 02 as tolerated, pulmonary toiletting, support pt and family\n"},{"category":"Nursing/other","chartdate":"2173-06-10 00:00:00.000","description":"Report","row_id":1661564,"text":"Nursing MICU note addendum\no2 d/c'd and pt with Sats > 95%, using incentive spirometer x 1000ml,\nincontinent of stool---mushroom d/c'd, Fingerstick=182---covered with 2 units SC insulin\n"},{"category":"Nursing/other","chartdate":"2173-06-10 00:00:00.000","description":"Report","row_id":1661565,"text":"0700-1800 MICU transfer note\n\n21yo female admitted with DKA on .Pt had been intubated/sedated on Propofol gtt. Pt previously on an insulin gtt/ which has since then been dc'd. Pt is /Oriented x3, pt is weepy at times. Lung sounds coarse, with occassional congestive cough producing thick white secretions, encourged to Pt compliant with using incentive spirometer. O2 sats 95% on room air. Pts appetite remains poor, with about 25% of meals eaten. Pt has been incontient of loose green stools today times 3. Pt OOB to chair for most of the day, pt worked with physical therapy and tolerated it well. Pt continues to complain of headaches, receiving tylenol with minimal effect; team aware. Blood sugars have been between 150-200's covered with ssi. Hct 22, pt to be transfused with 1UPRBC when available. Pt has been called out, due to be transferred to CC7.\n"},{"category":"Nursing/other","chartdate":"2173-05-31 00:00:00.000","description":"Report","row_id":1661525,"text":"Resp Care: Pt continues intubated #7 oett, advanced & secured @ 23 @ lip per cxr, on ventilatory support with psv maintaining Vt 5-600 ml with Ve 9-12 L, improving metabolic acidosis with good oxygenation; bs clear to coarse, sxn thick yell secretions, rsbi 51, will cont support.\n"},{"category":"Nursing/other","chartdate":"2173-05-31 00:00:00.000","description":"Report","row_id":1661526,"text":"MICU Nursing Note 1900-0700\nEvents: Abd CT scan completed and preliminary report is scan was WNL with fluid collections d/t previous fluid resuscitation, Acidosis slowly correcting, NaHC03 gtt infusing, vasopressin and levophed both weaned to off overnight, remains on IV insulin gtt, sedated with versed and fentanyl.\n\nNeuro: moving lower extremities with stimulation, turns head side to side, responds to painful stimuli, attempts to open eyes with stimulation---unable d/t periorbital edema, + gag, + cough reflex, does not follow commands, swallowing and tongue-ing tube with increased stimulation, IV Versed gtt infusing at 5mg/hr, required a few bolus doses of 2mg for travel to CT scan, IV Fentanyl infusing at 50mcgs/hr. PEARL. Bilat soft wrist restraints to prevent pt from pulling at lines and tubes upon awakening.\n\nCardiac: HR= 120-130's ST with no ecotpy noted, Left femoral Aline intact and with good waveform and correlation to NBP, BP= 100-125/80's with MAP's >70's, IV Vasopressin and IV Levophed weaned to off, episode of sBP 80's with Map= 60 following turning and repositioning once off of vasopressors---Levophed restarted at 0.03 mcgs/kg/min with good effect and able to wean off after 1 hour and currently remains off, new right SC multi-lumen central line placed and confirmed by Xray---right femoral TLC d/c'd and tip sent for cx, CVP= . IV D5W with 3 amps NaHCO3- infusing at 150ml/hr. Last CO2=11. + bilat DP/PT\n\nResp: remains intubated, ETtube advanced 3 cm and now at lip 23cm---awaiting am CXR, ETtube suctioned for mod. amts thick yellow sputum Q1-2hr, tolerated CPAP+PS at 40% with PS=10 and Peep=5. TV=600's, MV= , Sats= 96-100%. ABG improving throughout night with last ABG= 7.30-24-124. Lungs clear bilat upper lobes and with rhonchi at bilat bases.\n\nGI: Abd soft, intially not able to auscultate bowel sounds---now with distant hypoactive bowel sounds, no BM, OGtube placement checked by ausculation, OGtube with 140ml of green bile removed prior to instillation of baricat, after CT scan OGtube placed to LWS for total of 450 ml of baricat removal. Currently OGtube clamped. NPO\n\nGU: Foley to CD draining cloudy yellow urine 10-30ml/hr, Cr up to 3.3 this am, positive 13.7 liters for LOS\n\nEndo: Remains on insulin gtt---currently at 7 units/hr with fingersticks ranging 87-149. Requiring higher dose of insulin while bicarb gtt infusing---will need to titrate insulin closely once off bicarb gtt. Gap closed....last level=13.\n\nID: afebrile, WBC down to 13.3, lactate = 1.3, continues on aztreonam, fluconazole, vanco.\n\nSkin: pt with multiple ecchymotic areas noted over various parts of her body such as thigh, side, rib area---MICU team aware and assessed. Perineum exoriated and red raw---cream and protective barrier applied. continues with menses---no tampon in place.\n\nSocial: No contact from family or friends overnight.\n\nPlan: Continue fingersticks Q1hr, ABG's Q4hr, replace lytes prn, aggressive pulmonary toiletting, blood sugar dropped quickly whe\n"},{"category":"Nursing/other","chartdate":"2173-05-31 00:00:00.000","description":"Report","row_id":1661527,"text":"MICU Nursing Note 1900-0700\n(Continued)\nn D5W with bicarb gtt stopped earlier---will need to half insulin dose at that time, need CXR to check repositioning of ETtube, Wean sedation as tolerated, Support pt and family\n"},{"category":"Nursing/other","chartdate":"2173-05-31 00:00:00.000","description":"Report","row_id":1661528,"text":"Resp Care\nPt remains intubated. Current vent settings: PSV 10/5 40%. PS increased to 15 due to increased WOB and then decreased back to 10. Pt tolerating change well. Pt taken to CT for head scan. No other changes noted.\n"},{"category":"Nursing/other","chartdate":"2173-05-31 00:00:00.000","description":"Report","row_id":1661529,"text":"Micu 6 Nursing Progress Note 0700-1900\nNEURO--Midaz and Fent off. Started on propofol gtt now at 30 mcg/kg/min. When light, MAE. Did not follow commands. Did not track with eyes or make eye contact. purposeful movement. Head CT done -> prelim wet read unremarkable. Initially pupils did not respond. They now are 2-3 mm and respond sluggishly.\n\nCARDIAC-- HR 120's all day. SBP 110-120's/70's. No observed ectopy. Not on any gtts.\n\nRESP--Lungs are coarse in upper airways and diminished in bases bilaterally. SaO2 >97%. Presently on CPAP/IPS . Sx q2hrs for moderate amts of thick tan sputum.\n\nGI--to start tube feeds after mn. Plan was to attempt extubation but that is not happening tonight so start tube feeds. Stool lgr amts of loose stool guiac +. B owelS present.\n\nGU--CR rising. UO decreasing to 5-10 cc hr via foley cath.\n\nENDO--remains on insulin gtt. BS all over the place with insulin gtt changing. bs 70-150 with insulin gtt .5-6units/hr. K+ repleted with 40 meq. CA++ repleted with 2 gms cal. gluconate.\n\nSKIN--Several areas of eccymoisis on torso. Knees are warm and blanched. Buttocks without breakdown. Site on chest from piercing look purulent. Pt with menses. Very edematous.\n\nCOPING--Family in all day and have been updated by this RN and attending. They are aware that kidneys are injured with possibility of permanent damage. They are also aware that further w/u needs to be done on brain. i.e. eeg and maybe MRI. They are grieving. Per pts' mom and dad, pt is non-compliant with her insulin needs.\n\nPAIN--Does not appear to be in pain. Of note, pt is not on any pain medication at present, only propofol.\n\nA--Remains unresponsive,not following commands. No purposeful movements. Holding own RR and BP.\n\nP--COn't to monitor. Wake up to assess neuro status. Offer support to pt and family. Plan for EEG and ? whether MRI is needed. Start tube feeds after mn.\n"},{"category":"Nursing/other","chartdate":"2173-06-01 00:00:00.000","description":"Report","row_id":1661530,"text":"MICU Nursing Note 1900-0700\nEvents: Started on Tube feeds and tolerating, low grade temps, Tachypneic on CPAP+PS but ABG good, urine output remains poor and creatinine continues to rise, sedated on propofol with minimal response after propofol off x 30 minutes.\n\nNeuro: PEARL, sedated on 30mcgs/kg/min of propofol, propofol off x 30 minutes and pt moving LE/not opening eyes/not following commands, biting tube with stimulation, Head CT reported as WNL as per MICU team.\n\nCardiac: HR= 110-126 ST with no ectopy noted, Left femoral Aline with good waveform and correlation to NBP, BP= 120-150's/90's, right SC multi-lumen line patent and CVP= , remains off vasopressors.\n\nResp: remains intubated and tolerating CPAP+PS with good ABG, tachypneic overnight, biting tube with stimulation, lungs coarse bilat upper lobes and diminished at bilat bases, + cough reflex, ETtube suctioned for mod. amts thick whitish/yellowish/tan sputum, Current vent settings include CPAP+PS with PS=10 and Peep=5 at 40%. Sats= 97-100%, ABG= 7.34-27-129. RSBI this am > 100\n\nGI: ABd soft with + bowel sounds all quads, small brown BM x 1, OGtube placement checked by auscultation, Started on tube feedings FS Pulmonary Nutren at 10ml/hr---tolerating with minimal residuals and rate increased to 20ml/hr.\n\nGU: Foley to CD draining cloudy yellow urine in scant amts 5-15ml/hr, Creatinine continues to rise =4.3 this am, positive 15.5 L for LOS\n\nSkin: Perineum rash less red today. Ecchymotic areas unchanged. No further breakdown noted.\n\nEndo: Insulin gtt continues and infusing between 0.5-2.0 units/hr and titrated to fingersticks and scale, Fingersticks 97-149.\n\nID: Low grade temp with Tmax=99.2, WBC= 12.7, continues on IV aztreonam and acyclovir.\n\nSocial: Pt's parents in to visit all evening and both are staying at hospital overnight in ICU waiting area.\n\nPlan: Await Neuro consult, possible EEG, possible MRI, wean sedation and vent as tolerated, increase tube feeds as tolerated, replace lytes prn, renal failure---high potential for HD, support pt and family\n"},{"category":"Nursing/other","chartdate":"2173-06-01 00:00:00.000","description":"Report","row_id":1661531,"text":"RESP CARE NOTE\nPT REMAINED ON SAME SETTINGS OF PSV 10/5/40%. ABG SHOWING COMPENSATED METABOLIC ACIDOSIS. BS ESSENTIALLY CLEAR BILATERALLY. SUCTIONED SMALL AMTS OF THICK YELL/WHITE SECRETIONS. OETT ROTATED AND RETAPED AT 23CMS. MORNING RSBI 106.3.\nPLAN: WEAN AS TOLERATED.\n"},{"category":"Nursing/other","chartdate":"2173-06-01 00:00:00.000","description":"Report","row_id":1661532,"text":"Resp Care\nPt remains intubated, currently on CMV. Pt has ^RR with desats when sedation off, resp distress-biting ett. Sx for mod thick white, plan to monitor nuero status and travel for Head CT/MRI.\n"},{"category":"Nursing/other","chartdate":"2173-06-04 00:00:00.000","description":"Report","row_id":1661542,"text":"7pm to 7am:\n\nEvents:\nPt has had an uneventful shift. NPO for TEE today.\n\nROS:\n\nNeuro) Pt remains intubated with propofol gtt for sedation with good effect. Pt has been keeping eyes closed, even when stimulated. Pupils = and reactive to light (brisk). Pt will move head back and forth with oral care and move all ext's with non-purposeful movements. Pt does NOT respond to any painful stimuli accept oral care. Pt does not follow any commands. Pt noted to become tachycardic and tachypnic with stimulation, which has minimized after headphones with music placed. Neuro team is following pt. No contact from family.\n\nID) Tmax 99.2 as of 4am. No changes done to IV ABxs. Vanco level pending. Urine cx negatve. Wound culture negative. Sputum culture with NGTD and gram stain negative.\n\nCV) Pt in sr while at rest and ST with minor stimulation(100-117). SBP stable at 120-130's with MAP >65. A-line with dampened wave form and using NIBP for BP readings. CVP 10-13. Am labs pending. Pt is NPO for TEE today.\n\nResp) Pt placed back on AC mode after pt becoming more and more tachypnic at 4am, with good effect. Pt has been deep sx'd for moderate amounts of thick white secretions.\n\nGI) Abd obese with + BS x 4. Flatus +. Rectal tube placed after episode of liq/loose brown stool. NPO for TEE today. Pt remains on insulin gtt as noted, with now stable BS.\n\nGU) Good U/O via foley catheter at 50-75 cc/hr. Pt is now +17 liters for LOS. Renal team is following pt regarding RF. HD on hold for now.\n\nSkin) see care vue for details. Air bed ordered for pt due to skin break down noted around rectum.\n"},{"category":"Nursing/other","chartdate":"2173-06-04 00:00:00.000","description":"Report","row_id":1661543,"text":"Respiratory Care:\n\nPt remain orally intubated & sedated on PSV. WE switched to vent support o/n for tacypnea r>40pm & tachycardis, responded well. Bs cl;aer to coarse. RSBI ~97. WE ARE SXTN FOR MOD AMT OF THICK WHITE SECRETIONS FROM ETT. PLAN: AWAITING FAMILY MREETING THIS NORNING, DE CAREVIEW FOR FUTHER DETAILS. A\n"},{"category":"Nursing/other","chartdate":"2173-06-04 00:00:00.000","description":"Report","row_id":1661544,"text":"0700-1900 MICU PROGRESS NOTE\n\n21 yo female admitted from OSH on after being found down, unresponsive at home. Please see nursing noted on for detailed past events while in MICU.\n\nEvents- Attempted to wean down propofol gtt, pt unable to tolerate.. on ETT, RR increased to the 40-50's, and HR increased to the 120-130's. Pt moving extremities more while on propofol. Pt has required several small boluses of propofol and dose increased to 60mcg. Wake-up performed this morning and mental status assessed by team. Pt noted to have increased response to painful stimuli, pt now able to cross legs past midline. Pt opening eyes to painful stimuli but unable to track. Pt noted to have purposeful movement towards ETT with hands. Off sedation pt has increased secretions, cough and seems to Gag on ETT. Pt not grasping with hands or following commands. Pt will respond to sternal rub, by withdrawing. Pt did not have TEE today, will have tomorrow at 8:30a. Keep NPO after midnoc.\n\nI/D- Tmax 100.3. Vanco random yester 33.2, continues on Cefepime daily. Repeat chest CT today f/u pulm nodules, results pending.\n\nC/V- Remains ST/NSR w/ no ectopy. remains >16L pos LOS, but U/O increasing slightly. Extremities remain edematous and swelling noted peri-orbital. Aline continues to be dampened, w/ good blood return. Team aware, site WNL...no plans to re-site at this time. Pt was very difficult to obtain. TEE in am.\n\nResp- SBT attempted today, 5/0..tolerated for @ 15 min and became tachypnec w/ RR in the 50's. Sat's dropped to 87-90's and breathing became labored. ABG's drawn thru day, continues to be acidotic secondary to impaired kidney function. Will monitor and no treatment at this time. Lungs coarse, w/ rhonchi..suctioned for increased oral and deep secretions as compared w/ yesterday. Thin white sputum.\n\nGU/Renal- Bun/creat rising but U/O also increasing. Seen by renal, no dialysis at this time..will continue to monitor..? large 1X lasix dose as test. U/O 50-70cc/hr.\n\nG/ Pt has been NPO thru day, KVO changed to D5W to support insulin gtt while NPO. BS 100-200. Will restart TF and D/C at midnight. Rectal tube draining minimal amts of liquid brown stool.\n\nSkin- ? yeast infection groins and buttocks..pink non-raised rash. team aware and nystatin cream ordered. Multi small blister and broke blisters draining serous fluid..A+D oint applied.\n\nPlan-\nTEE in am, keep NPO after midnoc\nContinue trial off propofol and wean down as tolerated\nMonitor MS closely\nMonitor ABG's and acidosis\n?F/U MRI prior to extubation\n"},{"category":"Nursing/other","chartdate":"2173-06-04 00:00:00.000","description":"Report","row_id":1661545,"text":"Respiratory Care Note\nPt received on PSV 8/5 as noted. BS coarse bilaterally. RSBI was 80 with a VT 437 and RR 35. started at 3:50p and ended at 4:20p secondary to tachypnea. Pt's RR 49 at end of - pt placed back on with slowing of RR. Plan to continue on current settings at this time.\n"},{"category":"Nursing/other","chartdate":"2173-06-06 00:00:00.000","description":"Report","row_id":1661550,"text":"7pm to 7am:\n\nEvents: Uneventful night. Pt on Bicarb gtt and lasix gtt in order to correct renal status with little changes. Renal team following pt.\n\nROS:\n\nNeuro) Pt remains intubated with propofol gtt for sedation. Pt occ in need of sedation boluses before turns due to being very bronchospastic. Pt will occ open eyes to voice and will follow directions inconsistantly. Pt will squeeze hands when asked to. Pt also noted to MAE. No contact from family on this shift. Neuro is following pt. Full Code.\n\nCV) Pt is in ST (100-110) w/o ectopy noted. Hr will increase to 115 with stimulation. SBP stable at 120-130's. A-line wave form remains dampened and following NIBP for BP readings. CVP14->12. Pt has gen edema and exts elevated on pillows. K replaced as noted. Follow K level lasix gtt for diuresis.\n\nGU) Pt is being diuresed with lasix gtt for goal of (-) 2 liters q day or (-) 100 cc/hr. Pt is now + 16.6 liters for LOS (No change since ). Pt is also on bicarb gtt and Sodium bicarbonate PO to correct met acidosis RF with minimal effect. ? need for HD sooner than thought. BUN 98 and Creatine slight down to 5.7 (peaked ).\n\nID) Pt on IV ABxs for multifocal pna. Pt was started on flagyl, but noted to have developed a body rash at 8pm and flagyl DC'd. Tmax 99.1 as of 4am. Vanco level this am 20. Needs another sputum sample.\n\nResp) Pt intubated on CPAP+PS at 40%/. Pt has been deep sx'd for scant amounts white thick secretions. CXR done this am. No vent changes made. Hard time advancing sx catheter with sx, RT to eval, but unable to improve. Continue to wean pt off vent as tolerated.\n\nGI) Abd soft with + BS. TF at goal at 25 cc/hr w/o residuals as noted. Insulin gtt as noted. rectal tube in place for liq brown stool.\n\nSkin) see care vue for details.\n"},{"category":"Nursing/other","chartdate":"2173-06-09 00:00:00.000","description":"Report","row_id":1661561,"text":"7p to 7a Micu Progress Note\n\nNeuro - Pt alert, oriented to person and place, occasionally year. Confused and tearful at times. MAE. Able to raise and hold upper and lower exts. PERL. Impaired gag reflex. No restraints utilized. Denies pain.\n\nResp - LS coarse to clear, diminished at bases. Strong cough. Expectorated sm amt thick white sputum. RR 17-23. 02 sat > 93 on RA. ABG on RA 7.44/41/83/3/29.\n\nC-V- HR 84-105 ST, no ectopy noted. ABP 1409-160/80-92. + palp peripheral pulses. Hct low but stable at 22.9. CVP 11-14.\n\nGI - Abd soft. +BS. NPO. Passing mod amt liquid brown stool via mushroom catheter. Plan is for speech and swallow eval today.\n\nF/E - TFB neg ~2200ccs yest. Diuresed with lasix gtt, currently infusing at 8 mg/hr to obtain goal net neg 100ccs/hr. Repleted with 60 meq kcl iv overnight. K 4.2 this am. BUN and Cr improving at 73/3.4 respectively. IV d5w infusing at 100ccs/hr.\n\nID - Afeb. WBC 10.9. PNA covered with IV cipro.\n\nEndo - Remains on insulin gtt, currently infusing at 2.5 units/hr. FSBS labile at 110-167.\n\nSocial - Parents visiting at bedside last eve.\n\nA+P - Continue to monitor neuro status. Diurese and replete lytes as indicated. Speech and swallow eval today. Monitor FSBS q1hr while pt remains on insulin gtt. Emotional support to pt and family.\n"},{"category":"Nursing/other","chartdate":"2173-06-09 00:00:00.000","description":"Report","row_id":1661562,"text":"MICU Nurse Progress Note 0700-1900\nEvents: pt cont to improve, MS cleared now A/Ox3, OOB->x6hrs, tol well. insulin and lasix gtt off. cleared by speech therapy, taking PO's well, appetitie fair. A-line and CVL d/c'd. pt to be c/o to floor.\n\nROS:\nNeuro: A/O x3 follows commands, all ext strong/=. OOB->chair as above. PERRLS. No c/o pain at this time.\n\nPulm: LS remain coarse bilat w/ dim bases, pt 02sat 95-100% on RA, strong prod cough noted.\n\nCVS: NSR/ST w/ no ectopy. b/p stable 130's-150's/ 60's-70's. A-line and CVL removed, PIV x1 in L A/C patent flushed. afternoon K+ 3.7 repleted w/ 20meq KCL.\n\nGI: PO intake tol well, appetite fair. Abd soft distended w/ +BSx4quads, pt started on /Gluten free diet. Mushroom cath intact draining liq brown stool. C-Diff neg.\n\nGU: foley cath patent draining clear light yellow urine. Lasix gtt weaned off. UOP 75-150ml/hr since off lasix. pt neg ~3.5L since midnight still +8.5L for LOS.\n\nEndo: insulin gtt and D10 stopped, pt given 10 units NPH at 1300 and started on SS w/ lantus consult.\n\nsocial: family at bedside, updated r/t pt cond/ by RN.\n\nPlan: lytes, replete as needed\nlantus and Reg insulin per SS.\nc/o to floor pendin g bed availability.\n"},{"category":"Nursing/other","chartdate":"2173-05-30 00:00:00.000","description":"Report","row_id":1661522,"text":"MICU Nursing Admission Note 0300-0700\n PMH: IDDM since age 7, alopecia, multiple piercings\n\n Pt is a 21yo female who had been out with friends the night of the . she wasn't feeling well and left to go home ~0130 . A friend came by her home ~12 noon on the 31st, to check on her and found the door locked and someone moaning. Police were called and pt was found down without a palpable pulse. Arrived to in DKA, with a SBP of 72/. Over the next few hours, pt received ~5 liters IVF, IVABX: vanco and ceftrixone. She was found to be hypothermic with a core temp of 88. Her pupils were ~6mm, fixed and dialated. Tox screen was neg. CAT scan with no intercranial hemorrhage and an LP was done. She was then transferred to ~12am. Begun on vasopressin and dopa. She became tachycardic and levo was initiated with hopes of titrating dopa.\n\n Arrived to MICU ~0300. Pt was immediately placed on PS ventilation. NS, dopa, levo, and vasopressin infusing. Right groin line intact, as well as (2) add'l peripherals. A third peripheral was placed as well as a left groin arterial line. Both radial pulses were weak.\n\n Systems Review:\n\nResp: LS CTA, Intubated and ventilated, placed on PSV with improved ventilation. PSV 40%/ 5 Peep/ 10 PS. RR 20-24 with TV's 570-580.\n\nNeuro: Pt was normo-thermic upon arrival. Pupils were ~2-3mm,equal in size and responsive to light. She was moving all extremities, but not purposefully. Not following commands. +Gag and + cough.\n\nCV: Hypotensive on vasopressin 2.4 units/hr, levophed 0.30 mcg/kg/min\nand dopa 2.2 mcg/kg/min. Attempting to wean dopa off due to pt's tachycardia, (into the 130's) However, her BP has only been in the 90's-low 100's, with MAP's in the 40's. Recieved an additional 5 liters of IV NS since 0300-0700.\n\nGI: NGT placed, auscultated and +GI aspirates. Awaiting X-ray confirmation. Hypoactive BS, no stool.\n\nGU: Urine specs sent off for cultures. Only 20cc's from 0330-0600. Urine cloudy. +yeast infection in perianal area. Meds to be ordered. Pt + for menses, peri pad intact.\n\nEndo: Pt arrived with insulin gtt of 12 units/hr. Shut off for ~1hr and restarted ~0500. Please refer to carevue for FS results. Currently infusing at 6 units per hr. Will con't to check Q1hr FS and titrate as appropriate. Anion Gap originally 25, down to 18 by 0600.\n\nID: WBC initially 30, down to 18 by am. Receiving multiple IVABX. Ceftriaxone and vanco given at OSH. Sputum and urine cultures sent.\n\nF/E: K+ 2.7, Ca 6.2. Receiving electrolyte replacement as appropriate. 60 meq KCL and 4 gms Ca+ thus far.\n\nSocial: Pt lives between her parents who are divorced. They both reside in . The pt was at the father's home when she became ill. He was out of town and flew in from to be with the pt. Both her parents are here at the hospital and are appropriately concerned.\n"},{"category":"Nursing/other","chartdate":"2173-05-30 00:00:00.000","description":"Report","row_id":1661523,"text":"Respiratory Therapy\n\nPt remains orally intubated on PSV. No vent changes made this shift. Continues on +10PSV/+5PEEP w/ Vt 600s RR 20s Ve 14-16L/M. ABG shows continues metabolic acidosis. SpO2 90s, suctioned for small amounts of thick pale yellow secretions. ETT secure/patent. See resp flowsheet for specific vent settings/data.\n\nPlan: maintain support\n"},{"category":"Nursing/other","chartdate":"2173-05-30 00:00:00.000","description":"Report","row_id":1661524,"text":"MICU NPN 0700-1900\n\nEvents: Dopamine gtt titrated off. Levophed gtt weaning down. Acidosis slowly resolving. Please see carevue for all objective data.\n\nNeuro: Pt sedated on fentanyl and versed. PERRL. Pt has non purposeful movement to stimuli. Pt did not open eyes or follow commands today.\n\nResp: Pt remains vented on CPAP/PS 10/5. Last ABG 7.22/24/121/10. LS rhonchorus. Sxned for thick yellow secretions.\n\nCV: Levophed and vasopressin infusing. Able to slowly wean down levophed. Multiple lyte repletion throughout the day. PM chemistries pnding. HR 130's-140's. BP 105-140/86-58. MAP goals >60. Team is placing a SC CVL currently. Left groin a-line remains in. Unable to place radial.\n\nGI: US of abdomen showed free air in the belly. Pt needs CT abdomentonight without contrast (but please give 2 bottles of baricet). Abdomen soft. Pt grimaces with abdomen palpation. No BM today.\n\nGU: Minimal u/o via foley 10-30cc/hr. Pt is net pos. approx. 11 liters since admission.\n\nID: vaginal yeast infection noted. Pt given diflucan po. Pt on broad coverage antibx. Cultures pnding. afebrile.\n\nEndo: Pt on insulin gtt. Hourly BS. Titrating s/s.\n\nSocial: mother and father at bedside most of the day. Appropriately tearful and concerned. Pt had many friends/family visiting.\n\nDispO: Remain in Micu. FUll Code.\n\n"},{"category":"Nursing/other","chartdate":"2173-06-06 00:00:00.000","description":"Report","row_id":1661551,"text":"Resp Care\nRemains intubated and ventilated on cpap/psv with no remarkable changes overnight. Breath sounds coarse, suctioning small amounts of white sputum. Suction cateter sometimes difficult to advance. ETT repositioned and retaped. ABGS still with severe met. acicosis.\n"},{"category":"ECG","chartdate":"2173-05-30 00:00:00.000","description":"Report","row_id":214207,"text":"Sinus tachycardia\nNonspecific ST-T wave changes - baseline artifact makes assessment difficult\nSince previous tracing of the same date, tachycardia rate faster\n\n"},{"category":"ECG","chartdate":"2173-05-30 00:00:00.000","description":"Report","row_id":214208,"text":"Sinus tachycardia. Diffuse non-specific ST-T wave changes. No previous\ntracing available for comparison.\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2173-05-30 00:00:00.000\",\n \"description\": \"P ABDOMEN U.S. (COMPLETE STUDY) PORT\",\n \"row_id\": 1015801,\n \"text\": \" 1:25 PM\\n ABDOMEN U.S. (COMPLETE STUDY) PORT Clip # \\n Reason: r/o intrabdominal source of sepsis,\\n Admitting Diagnosis: DIABETIC KETOACIDOSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 21 year old woman with dka, sepsis of unknown source\\n REASON FOR THIS EXAMINATION:\\n r/o intrabdominal source of sepsis,\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 21-year-old female with DKA, sepsis of unknown source. Rule out\\n intra-abdominal source.\\n\\n No prior studies for comparison.\\n\\n FINDINGS: The liver demonstrates normal echogenicity, without a focal lesion.\\n The portal vein is patent with hepatopetal flow. Gallbladder is normal,\\n without evidence of gallstones. There is no intra- or extra-hepatic biliary\\n ductal dilatation, with the CBD measuring 5 mm. The right kidney measures 13\\n cm. The left kidney measures 10 cm. No stones, hydronephrosis, or mass is\\n identified. The spleen is unremarkable. Visualized pancreas is unremarkable.\\n\\n Within the pelvis, there is a large fluid collection, of unknown source. This\\n collection appears separate from the bladder, which is collapsed and contains\\n a foley catheter.\\n\\n IMPRESSION: Fluid collection within the pelvis, of unknown source. A CT is\\n recommended for further evaluation to exclude the presence of an abscess.\\n\\n Dr. was paged at the time of this dictation.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2173-05-31 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 1015930,\n \"text\": \" 3:02 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: ? anoxic brain injury, cerebral edema?\\n Admitting Diagnosis: DIABETIC KETOACIDOSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 21 year old woman with DKA, found down\\n REASON FOR THIS EXAMINATION:\\n ? anoxic brain injury, cerebral edema?\\n CONTRAINDICATIONS for IV CONTRAST:\\n renal failure\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 21-year-old female with diabetic ketoacidosis who was \\\"found down.\\\"\\n\\n COMPARISON: No prior exam is available for comparison.\\n\\n TECHNIQUE: Contiguous axial imaging was performed through the brain without\\n administration of IV contrast.\\n\\n CT HEAD: There is no evidence of acute intracranial hemorrhage, edema, mass,\\n mass effect, hydrocephalus, or of large vascular territory infarction. In\\n particular, the -white matter differentiation appears to be preserved. The\\n basal cisterns are also preserved. Fluid is seen within the mastoid air\\n cells. A small amount of mucosal thickening and layering fluid is also noted\\n in the sphenoid sinuses. These likely relate to recent intubation.\\n\\n IMPRESSION: No CT evidence of acute intracranial process. However, as CT\\n would not be sensitive to early or less extensive anoxic brain injury,\\n followup would be recommended as clinically indicated.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2173-06-05 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1016585,\n \"text\": \" 11:25 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: check ett placement\\n Admitting Diagnosis: DIABETIC KETOACIDOSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 21 year old woman with dka, resp failure, intubated\\n REASON FOR THIS EXAMINATION:\\n check ett placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST SINGLE VIEW ON \\n\\n HISTORY: Respiratory failure.\\n\\n REFERENCE EXAM: .\\n\\n FINDINGS: The ET tube is 3 cm above the carina. Right subclavian line tip is\\n in the right atrium. The heart is mildly enlarged and is increased in size\\n compared to prior. There are patchy alveolar infiltrates that have progressed\\n compared to the film from two days ago. Some of these have a rounded\\n appearance and septic emboli cannot be totally excluded. The NG tube has been\\n removed.\\n\\n IMPRESSION: Worsening bilateral infiltrates some of which have a rounded\\n appearance.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2173-06-07 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1016718,\n \"text\": \" 3:15 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: interval changes\\n Admitting Diagnosis: DIABETIC KETOACIDOSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 21 year old woman with respiratory failure, DKA, multifocal pna\\n REASON FOR THIS EXAMINATION:\\n interval changes\\n ______________________________________________________________________________\\n FINAL REPORT\\n STUDY: Single portable AP chest radiograph.\\n\\n INDICATION: 21-year-old female with respiratory failure, and multifocal\\n pneumonia.\\n\\n COMPARISON: .\\n\\n FINDINGS: Endotracheal tube is approximately 2 cm from the carina. NG tube\\n courses through the mediastinum below the diaphragm with tip out of the field\\n of view. Lung volumes are again low. Multifocal opacities demonstrate mild\\n improvement from recent comparison. No significant pleural effusion or\\n pneumothorax appreciated.\\n\\n IMPRESSION: Mild improvement in multifocal opacities. No new opacities\\n appreciated.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2173-06-01 00:00:00.000\",\n \"description\": \"MR HEAD W/O CONTRAST\",\n \"row_id\": 1016101,\n \"text\": \" 8:13 PM\\n MR HEAD W/O CONTRAST Clip # \\n Reason: please eval for ?anoxic brain injury, edema\\n Admitting Diagnosis: DIABETIC KETOACIDOSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 21 year old woman with DKA, renal failure, respiratory failure,\\n unresponsiveness\\n REASON FOR THIS EXAMINATION:\\n please eval for ?anoxic brain injury, edema\\n CONTRAINDICATIONS for IV CONTRAST:\\n renal failure\\n\\n Yes to Choyke questions.\\n ______________________________________________________________________________\\n WET READ: YMf TUE 11:45 PM\\n No intraparenchymal lesions or areas of restricted diffusion. No mass, edema\\n or hydrocephalus.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 21-year-old female patient, with DKA, renal failure, respiratory\\n failure, unresponsiveness, to evaluate for anoxic brain injury, edema.\\n\\n COMPARISON: CT of the head done on .\\n\\n TECHNIQUE: Multiplanar T1- and T2-weighted imaging of the brain was performed\\n without IV contrast.\\n\\n FINDINGS:\\n\\n On the sagittal T1-weighted sequence, the nasopharyngeal soft tissues, likely\\n related to the lymphoid tissue (adenoids), were prominent (series 2, image\\n 12), which may be appropriate in a patient of this age. However, these are\\n not adequately evaluated on the present study. There are no focal lesions,\\n noted on the axial FLAIR. On the axial susceptibility images, there is a\\n small focus of susceptibility, in the right anteroinferior frontal or\\n subcortical in location (series 5, image 16), which corresponds to a punctate\\n hyperdense focus on the CT, and can represent early calcification or\\n microhemorrhage. There is no restricted diffusion, to suggest acute\\n infarction. The ventricles and extra-axial CSF spaces are unremarkable. There\\n is moderate increased signal, in the mastoid air cells on both sides, likely\\n related to fluid versus mucosal thickening. There is also moderate amount of\\n mucosal thickening, along with fluid in the sphenoid sinus and minimal in the\\n right maxillary sinus.\\n\\n No major vascular flow voids are noted.\\n\\n IMPRESSION:\\n 1. No acute infarction.\\n 2. Punctate focus of susceptibility in the right anteroinferior frontal lobe,\\n which can represent small focus of early calcification or microhemorrhage.\\n (Subcortical in location).\\n 3. Moderate amount of fluid versus mucosal thickening in the mastoid air\\n (Over)\\n\\n 8:13 PM\\n MR HEAD W/O CONTRAST Clip # \\n Reason: please eval for ?anoxic brain injury, edema\\n Admitting Diagnosis: DIABETIC KETOACIDOSIS\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n cells on both sides, sphenoid sinus and minimal in the right maxillary sinus.\\n\\n Additional details:\\n\\n The study was reviewed with Dr. by Dr. on at 4pm as\\n the clinical team was concerned about possible diffuse cortical hyperintensity\\n on DWI related to hypoxic injury. Apparently, the areas that were of concern\\n appear to be related to artifacts from brain-bone interface in the left\\n inferior frontal lobe (series 6, im 72) and as a continuous rim in the\\n peripheral cortex, which is not hyperintense enough on DWI to be called as\\n abnormal and does not have associated corresponding abnormality on ADC and\\n FLAIR hyperintensity. Opinion was also sought from 2 senior radiologists of\\n the section who agreed that these were artifacts and do not represent acute\\n infarction. So, based on the present study, there is no evidence of acute\\n infarction. If there is continued concern about encephalopathic changes or\\n infarction, a follow-up study can be considered at clinical discretion.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2173-06-01 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1015974,\n \"text\": \" 2:48 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ? line placements, change\\n Admitting Diagnosis: DIABETIC KETOACIDOSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 21 year old woman with intubation\\n REASON FOR THIS EXAMINATION:\\n ? line placements, change\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 21-year-old woman with intubation, question line placement and\\n change.\\n\\n COMPARISON: .\\n\\n SEMI-UPRIGHT BEDSIDE RADIOGRAPH OF THE CHEST: The ET tube is terminating 2.2\\n cm above the carina. The right subclavian catheter is terminating below the\\n anticipated cavoatrial junction, could be partly explained by low lung\\n volumes. NG tube is extending into the pyloric end of stomach, unchanged.\\n\\n Focal opacities in the left mid and lower lung are more confluent today, could\\n reflect interval aspiration however pneumonia cannot be excluded. There is\\n mild volume overload. The main pulmonary trunk is distended indicating\\n pulmonary hypertension. Dense retrocardiac atelectasis is worse. Small\\n bilateral pleural effusions are unchanged.\\n\\n IMPRESSION:\\n 1. Worsening confluent left mid and lower lobe opacities could represent\\n interval aspiration however pneumonia cannot be excluded. Unchanged small\\n bilateral pleural effusions.\\n 2. Prominent main pulmonary artery trunk suggesting pulmonary hypertension\\n which in the right clinical settings could reflect pulmonary embolism.\\n\\n In discussion with patient's referring physician . , a non-\\n contrast chest CT to further evaluate the above changes will be considered,\\n given patient's acute renal failure limits contrast administration.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2173-06-03 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1016273,\n \"text\": \" 3:12 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: r/o interval change\\n Admitting Diagnosis: DIABETIC KETOACIDOSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 21 year old woman with ards, ? pna, intubation\\n REASON FOR THIS EXAMINATION:\\n r/o interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 21-year-old woman with ARDS, questionable pneumonia; evaluate for\\n interval change.\\n\\n COMPARISON: .\\n\\n SEMI-UPRIGHT BEDSIDE RADIOGRAPH OF THE CHEST AT 3:45 A.M.: Endotracheal tube\\n is terminating 2.3 cm above the carina. NG tube is extending into the stomach\\n and out of the field of view. A right subclavian catheter is terminating\\n slightly below the anticipated cavoatrial junction, unchanged.\\n\\n There is interval improvement in the multifocal consolidations with persistent\\n retrocardiac atelectasis. Small bilateral pleural effusions are unchanged.\\n There are no new consolidations. There is mild interstitial edema which is\\n also improved. Heart size is normal. Previously noted prominence of the\\n pulmonary trunk has also improved.\\n\\n IMPRESSION: Mild pulmonary edema with marked interval improvement in the\\n multifocal consolidations with persistent small bilateral pleural effusions.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2173-06-11 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 1017428,\n \"text\": \" 2:42 PM\\n CHEST PORT. LINE PLACEMENT Clip # \\n Reason: s/p right 48cm picc\\n Admitting Diagnosis: DIABETIC KETOACIDOSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 21 year old woman with\\n REASON FOR THIS EXAMINATION:\\n s/p right 48cm picc\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Line placement.\\n\\n FINDINGS: Bedside frontal chest radiograph is compared to . The\\n right PICC tip terminates in the lower SVC. The patient has been extubated.\\n Prior pulmonary consolidations have markedly improved.\\n\\n IMPRESSION: PICC tip terminating in the lower SVC.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2173-05-30 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1015769,\n \"text\": \" 8:02 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Tube placements\\n Admitting Diagnosis: DIABETIC KETOACIDOSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 21 year old woman with NG tube placed\\n REASON FOR THIS EXAMINATION:\\n Tube placements\\n ______________________________________________________________________________\\n FINAL REPORT\\n PORTABLE CHEST ON AT 8:12\\n\\n INDICATION: Tube placements.\\n\\n COMPARISON: at 0058.\\n\\n FINDINGS:\\n\\n The tip of the ETT is 4.9 cm above the carina. An NGT is visualized below the\\n diaphragm with its tip in the body of the stomach. Compared to the prior\\n study, there is continued distention of pulmonary vessels. The latter appear\\n more prominent but positioning differences could be contributory. No definite\\n new consolidations.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2173-05-30 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 1015826,\n \"text\": \" 7:56 PM\\n CHEST PORT. LINE PLACEMENT Clip # \\n Reason: eval R subclavian line placement\\n Admitting Diagnosis: DIABETIC KETOACIDOSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 21 year old woman with DKA, respiratory failure, ventilated, s/p R subclavian\\n line placement\\n REASON FOR THIS EXAMINATION:\\n eval R subclavian line placement\\n ______________________________________________________________________________\\n WET READ: CXWc SUN 8:56 PM\\n Right SCC terminates in the lower SVC. No pneumothorax. ETT 6.9 cm from\\n carina, at thoracic inlet - advance by 2-3 cm for standard positioning.\\n Persistent bilateral pleural effusions, pulmonary vascular engorgement and\\n cardiomegaly, indicating heart failure, unchanged.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 21-year-old woman with diabetic ketoacidosis, respiratory\\n failure, ventilated status post right subclavian line placement. Evaluate for\\n line placement.\\n\\n COMPARISON: , (8:12 a.m.).\\n\\n SINGLE SUPINE BEDSIDE RADIOGRAPH AT 8:19 P.M.: Endotracheal tube is\\n terminating 6.9 cm above the carina higher than the prior radiograph. There\\n are bilateral pleural effusions associated with bilateral mild vascular\\n congestion, slightly worse than prior study. Unchanged retrocardiac\\n atelectasis is again noted. There are no new focal consolidations. There is\\n mild atelectasis at the right lung base.\\n\\n The right subclavian catheter is terminating in the distal SVC. There is no\\n pneumothorax. NG tube is extending into the stomach and out of the field of\\n view.\\n\\n IMPRESSION:\\n 1. Mild vascular congestion with small bilateral pleural effusions and\\n bibasilar atelectasis, slightly worse than this morning.\\n 2. ET tube terminating 6.9 cm above the carina. Position of the ET tube was\\n communicated to Dr. .\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2173-05-30 00:00:00.000\",\n \"description\": \"CT ABDOMEN W/O CONTRAST\",\n \"row_id\": 1015833,\n \"text\": \" 10:16 PM\\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \\n Reason: r/o fluid collection\\n Admitting Diagnosis: DIABETIC KETOACIDOSIS\\n Field of view: 42\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 21 year old woman with sepsis, dka, free fluid in pelvis seen on u/s\\n REASON FOR THIS EXAMINATION:\\n r/o fluid collection\\n CONTRAINDICATIONS for IV CONTRAST:\\n arf\\n ______________________________________________________________________________\\n FINAL REPORT\\n CT ABDOMEN AND PELVIS\\n\\n CLINICAL HISTORY: Recent hypotensive episode secondary to DKA with subsequent\\n sepsis. Abnormal fluid seen in pelvis on recent ultrasound.\\n\\n TECHNIQUE: Helical acquisition of CT images performed from the lung\\n bases through the ischial tuberosities following administration of oral\\n contrast only, decreased renal function precludes use of IV contrast.\\n\\n No prior studies available for comparison.\\n\\n FINDINGS: There are bilateral pleural effusions and associated atelectasis,\\n right more so than left. There are scattered nodular opacities seen\\n throughout both lung bases, and more focal consolidation seen at the right\\n lung base, all of which may represent aspiration and subsequent developing\\n pneumonia. There is a nasogastric tube which terminates in the gastric antrum.\\n Central venous line tip terminates in the right atrium. Additionally a left\\n femoral venous line is present with its tip in the external iliac vein.\\n\\n Non-contrast evaluation of the liver, spleen, pancreas and adrenal glands is\\n unremarkable. Gallbladder is present, there may be biliary sludge, as there\\n is increased attenuation within the decompressed gallbladder. No biliary\\n dilatation.\\n\\n There are no dilated loops of bowel. There is a moderate amount of free fluid\\n tracking along the right paracolic gutter extending to the deep pelvis, with\\n thickening of the circumferential bowel wall thickening involving the right\\n colon and proximal transverse colon. Contrast has passed to the level of the\\n right colon. There is no abscess or organizing fluid collection. No\\n pneumatosis is evident.\\n\\n There is a Foley catheter within decompressed bladder. Uterus and adnexal\\n structures are unremarkable.\\n\\n Bony structures are unremarkable.\\n\\n IMPRESSION:\\n\\n 1. Bilateral pleural effusions with likely aspiration and developing\\n (Over)\\n\\n 10:16 PM\\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \\n Reason: r/o fluid collection\\n Admitting Diagnosis: DIABETIC KETOACIDOSIS\\n Field of view: 42\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n consolidation at the right lung base.\\n\\n 2. Free fluid tracking along the paracolic gutter with associated bowel wall\\n thickening, the possibility of ischemic bowel is raised given the recent\\n hypotensive episode. Infectious and inflammatory etiologies also should be\\n considered. No dilated loops or pneumatosis.\\n\\n 3. Likely biliary sludge.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2173-05-30 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1015746,\n \"text\": \" 1:00 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval tube. r/o effusions or PNA\\n Admitting Diagnosis: DIABETIC KETOACIDOSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 21 year old woman with DKA s/p intubation\\n REASON FOR THIS EXAMINATION:\\n eval tube. r/o effusions or PNA\\n ______________________________________________________________________________\\n FINAL REPORT\\n PORTABLE CHEST, , 00:58\\n\\n\\n INDICATION: Recent intubation.\\n\\n FINDINGS:\\n\\n Tip of the ETT is 4.3 cm above the carina. The pulmonary vasculature appears\\n somewhat prominent and there is bilateral blunting of the costophrenic sulci\\n consistent with effusions. Heart size is top normal and there is no evidence\\n of focal consolidation. No pneumothorax.\\n\\n IMPRESSION: Intubation with an element of fluid overload.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2173-06-04 00:00:00.000\",\n \"description\": \"CT CHEST W/O CONTRAST\",\n \"row_id\": 1016526,\n \"text\": \" 6:07 PM\\n CT CHEST W/O CONTRAST Clip # \\n Reason: pls eval interval changes\\n Admitting Diagnosis: DIABETIC KETOACIDOSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 21 year old woman with DKA, respiratory failure, unresponsiveness and recent CT\\n showing diffuse nodular opacities\\n REASON FOR THIS EXAMINATION:\\n pls eval interval changes\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 21-year-old woman with DKA, respiratory failure, unresponsiveness\\n and recent CT showing diffuse nodular opacities, evaluate for interval\\n changes.\\n\\n COMPARISON: .\\n\\n TECHNIQUE: Volumetric axial CT acquisition of the lungs without intravenous\\n contrast. 5- and 1.25-mm thick axial slices were obtained. Multiplanar\\n reformations were generated.\\n\\n FINDINGS: Endotracheal tube is terminating in standard location. NG tube is\\n extending into the stomach. Right jugular venous catheter is terminating\\n within the right atrium, all of these are unchanged.\\n\\n No mediastinal or axillary adenopathy. Evaluation of hilar structures is\\n limited in the non-contrast setting. Heart and the great vessels are grossly\\n unremarkable.\\n\\n Lung windows demonstrate large bilateral pleural effusions, worse than prior\\n study. Again are noted multifocal peribronchial nodular consolidations, some\\n in subpleural distribution and others more central, worse than the recent CT.\\n There is also worsening bibasilar atelectasis.\\n\\n The study is not designed for subdiaphragmatic diagnosis and limited non-\\n contrast evaluation of the imaged portions of the abdomen is grossly\\n unremarkable.\\n\\n No suspicious lytic or sclerotic osseous lesions are noted.\\n\\n IMPRESSION: Worse multifocal peribronchial nodular opacities with\\n increasing large bilateral pleural effusions and bibasilar atelectasis.\\n Multifocal pneumonia remains the likely etiology. The distribution and\\n morphology are not typical for pulmonary infarction or septic emboli, which\\n are differential considerations.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2173-06-05 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1016611,\n \"text\": \" 3:58 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: please eval for OG tube placement\\n Admitting Diagnosis: DIABETIC KETOACIDOSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 21 year old woman admitted w/DKA, AMS, intubated w/OG tube\\n REASON FOR THIS EXAMINATION:\\n please eval for OG tube placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST, SINGLE VIEW ON \\n\\n HISTORY: New OG tube.\\n\\n FINDINGS: There is a new OG tube with tip in the stomach. The endotracheal\\n tube tip is 5 cm above the carina. There is a right subclavian line with tip\\n in the right atrium. Again seen are patchy bilateral alveolar infiltrates,\\n some of which have a rounded configuration and could represent septic emboli.\\n There is small right pleural effusion. Motion artifact limits this\\n assessment.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2173-06-01 00:00:00.000\",\n \"description\": \"CT CHEST W/O CONTRAST\",\n \"row_id\": 1016108,\n \"text\": \" 9:10 PM\\n CT CHEST W/O CONTRAST Clip # \\n Reason: characterize pulmonary process--ARDS? Radiology concerned r\\n Admitting Diagnosis: DIABETIC KETOACIDOSIS\\n Field of view: 36\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 21 year old woman with DKA, obtunded, ventilated, left infiltrate, pulmonary\\n infiltration on CXR\\n REASON FOR THIS EXAMINATION:\\n characterize pulmonary process--ARDS? Radiology concerned regarding PE\\n CONTRAINDICATIONS for IV CONTRAST:\\n renal failure\\n ______________________________________________________________________________\\n WET READ: YMf TUE 10:40 PM\\n Bilateral multifocal air space process, the appearance is non-specific and\\n likely reflect presence of multifocal infection or aspiration, differential\\n diagnosis includes pulmonary hemorrhage or ARDS. Bilateral moderate pleural\\n effusions. Not able to evaluate for pulmonary embolism given lack of\\n intravenous contrast.\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST CT, \\n\\n HISTORY: DKA. Obtunded. Lung infiltrates and large hila and pulmonary\\n arteries.\\n\\n TECHNIQUE: Multidetector helical scanning of the chest was performed without\\n intravenous contrast because of patient's renal insufficiency, reconstructed\\n as contiguous 5 and 1.25 mm thick axial and 5 mm thick coronal images.\\n\\n There are no prior chest CTs for comparison, but the study is read in\\n conjunction with chest radiographs, through .\\n\\n FINDINGS:\\n\\n Endotracheal tube is in standard position, nasogastric tube passes into the\\n stomach and out of the field of view, and a right jugular line ends in the\\n upper right atrium.\\n\\n Multifocal, nodular areas of peribronchial consolidation is all lobes of both\\n lungs, and extensive lobar consolidation in the left lower lobe, superior and\\n posterior and anterior basal segments are probably infectious; a smaller\\n region of posterior consolidation in the right lower lobe is probably\\n atelectasis.\\n\\n In the absence of intravenous contrast enhancement, measurement of central\\n lymph nodes is difficult, but range up to 17 mm in the left hilus, smaller in\\n the right hilus, and insignificant in the mediastinum. Small non-hemorrhagic\\n pleural effusions layer posteriorly. There is no pericardial effusion. Main\\n pulmonary artery is equivalent in diameter to the aorta, 31 mm, probably\\n larger than baseline, but not so large as to raise concern for pulmonary\\n hypertension.\\n (Over)\\n\\n 9:10 PM\\n CT CHEST W/O CONTRAST Clip # \\n Reason: characterize pulmonary process--ARDS? Radiology concerned r\\n Admitting Diagnosis: DIABETIC KETOACIDOSIS\\n Field of view: 36\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n IMPRESSION:\\n 1. Multifocal pneumonia. No evidence of ARDS. Pulmonary embolism cannot be\\n excluded by this non-contrast examination, but findings do not suggest\\n pulmonary infarctions.\\n\\n 2. Hilar adenopathy, small bilateral pleural effusions, probably reactive to\\n pulmonary infection.\\n\\n Findings were discussed by telephone with the house officer caring for this\\n patient at the time of this dictation.\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2173-06-08 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1016861,\n \"text\": \" 3:07 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: interval change\\n Admitting Diagnosis: DIABETIC KETOACIDOSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 21 year old woman with intubation, PNA\\n REASON FOR THIS EXAMINATION:\\n interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST RADIOGRAPH\\n\\n INDICATION: Status post intubation, evaluation for interval change.\\n\\n As compared to the previous radiograph, there is no relevant change. The\\n monitoring and support devices are in unchanged position. The multifocal\\n areas of opacities are unmodified. Moderate retrocardiac atelectasis, no\\n secure evidence of pleural effusions.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2173-06-06 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1016648,\n \"text\": \" 3:41 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: assess interval change\\n Admitting Diagnosis: DIABETIC KETOACIDOSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 21 year old woman with resp failure, dka\\n REASON FOR THIS EXAMINATION:\\n assess interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAMINATION: Diabetic ketoacidosis and respiratory failure in a\\n 21-year-old woman.\\n\\n Portable AP chest radiograph was compared to a chest CT from and chest\\n radiographs from till .\\n\\n Multiple parenchymal consolidations some of them rounded in shape did not\\n significantly change over period of last three days, but did\\n slightly progress since . The current radiograph demonstrate a\\n bilateral perihilar opacities which are most likely consistent with pulmonary\\n edema and are unchanged since . There is bilateral pleural\\n effusion and bibasal retrocardiac atelectasis which are also stable.\\n\\n The ET tube tip, the NG tube, the right subclavian line are in standard\\n position.\\n\\n IMPRESSION: Multiple consolidations some of them rounded consistent with\\n infectious process.\\n\\n Superimposed pulmonary edema.\\n\\n Pleural effusions and retrocardiac atelectasis.\\n\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2173-06-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 85254,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: ?Septic pulmonary emboli.\\nBP (mm Hg): 200/100\\nHR (bpm): 120\\nStatus: Inpatient\\nDate/Time: at 09:14\\nTest: Portable TEE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT ATRIUM: No spontaneous echo contrast or thrombus in the LA/LAA or the\\nRA/RAA. Good (>20 cm/s) LAA ejection velocity.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA.\\nNormal interatrial septum. No ASD by 2D or color Doppler.\\n\\nLEFT VENTRICLE: Overall normal LVEF (>55%).\\n\\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\\n\\nAORTA: Normal ascending, transverse and descending thoracic aorta with no\\natherosclerotic plaque.\\n\\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. No masses or\\nvegetations on aortic valve. Filamentous strands on the aortic leaflets c/with\\nLambl's excresences (normal variant).\\n\\nMITRAL VALVE: Normal mitral valve leaflets. No mass or vegetation on mitral\\nvalve. Mild (1+) MR.\\n\\nTRICUSPID VALVE: Normal tricuspid valve leaflets. No mass or vegetation on\\ntricuspid valve. Mild [1+] TR.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\\nPhysiologic PR. No vegetation/mass on pulmonic valve.\\n\\nPERICARDIUM: No pericardial effusion.\\n\\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\\nI was present in compliance with HCFA regulations. The patient was monitored\\nby a nurse throughout the procedure. The patient was monitored\\nby a nurse throughout the procedure. Local anesthesia was\\nprovided by benzocaine topical spray. The patient was sedated for the TEE.\\nMedications and dosages are listed above (see Test Information section). 0.2\\nmg of IV glycopyrrolate was given as an antisialogogue prior to TEE probe\\ninsertion. No TEE related complications. Ascites.\\n\\nConclusions:\\nNo spontaneous echo contrast or thrombus is seen in the body of the left\\natrium/left atrial appendage or the body of the right atrium/right atrial\\nappendage. No atrial septal defect is seen by 2D or color Doppler. Overall\\nleft ventricular systolic function is normal (LVEF>55%). Right ventricular\\nchamber size and free wall motion are normal. The ascending, transverse and\\ndescending thoracic aorta are normal in diameter and free of atherosclerotic\\nplaque to 40 cm from the incisors. The aortic valve leaflets (3) appear\\nstructurally normal with good leaflet excursion and no aortic regurgitation.\\nNo masses or vegetations are seen on the aortic valve. There are filamentous\\nstrands on the aortic leaflets consistent with Lambl's excrescences (normal\\nvariant; seen on clips 113 and 114). The mitral valve leaflets are\\nstructurally normal. No mass or vegetation is seen on the mitral valve. Mild\\n(1+) mitral regurgitation is seen. No vegetation/mass is seen on the pulmonic\\nvalve. There is no pericardial effusion.\\n\\nIMPRESSION: No echocardiographic evidence of endocarditis, abscess or valvular\\nmass. Normal biventricular function. Mild mitral and tricuspid regurgitation.\\n\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2173-06-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 85255,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Endocarditis.\\nHeight: (in) 66\\nWeight (lb): 198\\nBSA (m2): 1.99 m2\\nBP (mm Hg): 129/76\\nHR (bpm): 115\\nStatus: Inpatient\\nDate/Time: at 15:03\\nTest: Portable TTE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT ATRIUM: Normal LA size.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal interatrial septum. No\\nASD by 2D or color Doppler. Normal IVC diameter (<2.1cm) with >55% decrease\\nduring respiration (estimated RAP (0-5mmHg).\\n\\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Suboptimal technical\\nquality, a focal LV wall motion abnormality cannot be fully excluded. Low\\nnormal LVEF. No resting LVOT gradient. No VSD.\\n\\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\\n\\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\\ndiameter. No 2D or Doppler evidence of distal arch coarctation.\\n\\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. No masses or\\nvegetations on aortic valve.\\n\\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. mass or\\nvegetation on mitral valve.\\n\\nTRICUSPID VALVE: Normal tricuspid valve leaflets. No mass or vegetation on\\ntricuspid valve. Mild [1+] TR. Normal PA systolic pressure.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\\nPhysiologic PR. No vegetation/mass on pulmonic valve.\\n\\nPERICARDIUM: No pericardial effusion.\\n\\nGENERAL COMMENTS: Resting tachycardia (HR>100bpm).\\n\\nConclusions:\\nThe left atrium is normal in size. No atrial septal defect is seen by 2D or\\ncolor Doppler. The estimated right atrial pressure is 0-5 mmHg. Left\\nventricular wall thicknesses and cavity size are normal. Due to suboptimal\\ntechnical quality, a focal wall motion abnormality cannot be fully excluded.\\nOverall left ventricular systolic function is low normal (LVEF 55%). There is\\nno ventricular septal defect. Right ventricular chamber size and free wall\\nmotion are normal. The aortic valve leaflets (3) appear structurally normal\\nwith good leaflet excursion and no aortic regurgitation. No masses or\\nvegetations are seen on the aortic valve. The mitral valve appears\\nstructurally normal with trivial mitral regurgitation. No mass or vegetation\\nis seen on the mitral valve. The estimated pulmonary artery systolic pressure\\nis normal. No vegetation/mass is seen on the pulmonic valve. There is no\\npericardial effusion.\\n\\nIMPRESSION: No valvular vegetations seen.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2173-06-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1661558,\n \"text\": \"7pm to 7am:\\n\\nROS:\\n\\nNeuro) Pt remains intubated with propofol gtt for sedtion with good efffect. Pt found in the beginning of the shift to be VERY somulent and sedation decreased. Pt became awake and following commands, but agitated at times, and sedation increased again. MD aware of current neuro status. While awake, pt was following simple commands, had = hand grips, MAE and able to answer yes and no by non-verbal ques. Neuro is following pt. No contact from family on this shift. Full Code.\\n\\nID) Afebrile. WBC 10 this am. On IV ABxs for multifocal pna. Pt has had large amounts of liq stool and stool sample sent for C-diff R/O. Needs 2 more sent off and . Vanco level this am 12.5 .\\n\\nCV) Pt is in NSR while at sleep and ST (100-110) while awake. No ectopy noted. A-line VERY positional and is now using NIBP for readings. A-line with very poor blood return. MD aware. Gen edema continues. K level has been aggressivly replaced throughout the shift, and is now NL at 4.3. Please follow closely diuresis and diarrhea. Hct dropping. ? need for blood transfusion or epogen RF. Na level now NL after H2O flushes. ? decrease amounts of flushes.\\n\\nGU) Good respond from lasix gtt. Goal net (-) 100 cc/hr. Pt is currently (+) 14 liters for LOS. Pt currently on bicarb gtt for RF, with now corrected PH and Co2...? Creatine and BUN decreasing. DC gtt. Nephrology is following pt.\\n\\nGI) Abd soft with + BS. TF at goal at 25 cc/hr. Pt continues to have lg amounts of liq brown stool via rectal tube. Insulin gtt as noted with still very labile BS results. D10 gtt as noted.\\n\\nResp) LS coarse throughout the shift, but improved after deep sx. No changes made to vent settings. ABGs WNLs.\\n\\nSkin) body rash improved. See care vue for details.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2173-06-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1661559,\n \"text\": \"resp care\\npt extubated after successful . strong cough prod mostly whitish/lt yellow secretions. abg acceptable on face tent. refer to flow sheet for further documentation.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2173-06-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1661560,\n \"text\": \"MICU nurse progress note 0700-1900\\nEvents: pt cont to diurese well, lasix gtt now at 12mg/hr. K+ repleted w/ a total of 60meq today. last K+ at 15:30 was 4.3... propofol and TF off, pt extubated today at 13:00, tol well, 02 sat now 95-100% on R/A... insulin gtt at 2units/hr, D10 at 100ml/hr, FSBS 104-137.\\n\\nROS:\\nNeuro: A/O x 2 MS clearing, weepy at times, following commands. all ext strong/= PERRLS. no c/o pain.\\n\\nPulm: extubated as above, was initially on 40% face tent, now on R/A tol well 02 sat 95-100%. LS remain coarse throughout, strong/ productive cough. remains on IV Vanc/ Cefepime for multifocal pna. day 10 of 14.\\n\\nCVS: NSR/ST w/ no ectopy HR 80's-110's. b/p stable 120's-140's/ 70's. ABP's ~20pts higher, K+ repleted as above.\\n\\nGI: OGT removed w/ extubation, abd soft nontender +BS x 4quads. pt NPO post extubation. Speech eval in am. mushroom cath intact draining liq brown stool.\\n\\nGU: foley cath patent draining clear yellow urine. lasix gtt at 12mg/hr. UOP 250-400ml/hr. goal UOP is net neg ~100ml/hr. BUN/CR improving.\\n\\nsocial: family at bedside, updated r/t POC/ pt cond by RN and MD.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2173-06-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1661549,\n \"text\": \"Micu Nursing note \\n\\nNeuro: Propofol drip stopped at 2 pm. pt more resposive following simple commands, nodding head, try to go for ett, was able to keeppt off propofol for and hour and a half, then palced her back on drip because of ^ rr and acidosis\\nCv pt hemodynamcally stable aline and cuff more accurate now that tranduced is taped to pt leg, BP 120-150/60-80 hr 89-113\\npulses in leg by doppler\\nResp pt changed form ac-ps now on 40%/14/5peeps tv 400-700, rr 20-2g while on propofol off propofol rr ^ 32, pt suctioned for small -mad amount of white secreations, lung course, sats 100%\\nGi and soft non tender will restate tube feeds at 10 cc/hr retal tube in place passing small amount of brown liquid\\nGU foley in place, pt started on lasix drip which is now at 10mg/hr. goal to make pt a liter neg today so far only 400 neg\\npt also started on a bicarb drip which is at 150 /hr, they will change consintration so that we can lower volume about and hopefully get to neg goal, ph slighly better( see objective data ) pt will also start on po bicarb tabs this evening\\nid t max 99.7 pt cultured blood x2 urine and sputum, added flagyl for more coverage\\nendo Blood sugars difficult to control at one point bs down to 71 given amp of d5 and repeat bs 140, held insulin drip until this afternoon when bs > 300 and was restarted on drip now at 5 units and hour\\nA/P\\nNeuro status much improved and pt able to folllow commands off propofol\\nacidosis r/t renal failer now on bicarb drip and lasix drip\\n attempt to correct ph, renal following if over next 2 days no improvement in acidosis, will consider hd line\\nblood sugars difficult to control remains on insulin drip will start tube feeds follow bs q1 hr.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2173-06-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1661546,\n \"text\": \"7pm to 7am:\\n\\nEvents: Pt has had an uneventful night. Plan for a TEE today and continue to wean pt off vent as tolerated.\\n\\nROS:\\n\\nNeuro) Pt remains intubated with propofol gtt for sedation with good effect. When stimulated HR and BP has improved today. When doing oral care, pt will slightly open eyes, have facial grimaces and noted to have decerebrate movements to upper EXTs. Although, pt will not respond to painful touch (nail bed pinch). Neuro exam as noted in care vue. No contact from family at this time. ? need for family meeting in near future regarding pt's progress. Full code.\\n\\nCV) Pt in SR (80-90's) while at rest and ST (100-110) with stimulation. Aline to Lt Fem with dampened wave form, and using NIBP for BP readings. SBP 120-130's with MAP >65. CVP 14->12. Am labs pending. NPO for TEE this am at 8am.\\n\\nENDO) Pt remains on insuling gtt with D5W at KVO.\\n\\nResp) Pt has been deep sx'd for sml-mod amounts of white secretions. Ls has improved throughout the night, now CTA. Pt in AC mode with worsening ABGs as noted in care vue (met acidosis..awaiting am labs for renal function).\\n\\nGI) Abd obese with + BS. Pt continues to have liq brown stool via rectal tube. NPO. OGT w/o residuals and clamped.\\n\\nGU) Good U/O via foley catheter. Pt is now +16.6 liters for LOS.\\n\\nSkin) see care vue for details.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2173-06-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1661547,\n \"text\": \"Resp Care\\nRemains intubated and ventilated on a/c with no remarkable changes overnight. ABGs with continued metaboloic acidosis, good oxygenation. Lungs clear to auscultation. RSBI this morning = 103.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2173-06-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1661548,\n \"text\": \"Respiratory Care Note\\nPt received on AC as noted. BS slightly coarse with expiratory wheezes in LUL which clears with suctioning. Pt suctioned for small amt thick, tan secretions. Pt weaned to PSV 14/5 as noted. Pt tolerating fairly well with VT ranges in 500's and RR mid to high 20's. Pt becomes tachypneic 35-40 with care. Plan to continue on PSV as tolerated at this time.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2173-06-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1661555,\n \"text\": \"Respiratory Care\\nPatient remains intubated, and on mechanical ventilatory support, breath sounds bilaterally clear throughout shift, suctioned intermittently for moderate to small amounts of thick white secretions, SPO2 remains in the upper 90s, patient did no tolerate tried for few minutes by MD, became tachypneic, put back on previous settings, no ABGs nor vent changes made up to the present, will continue to be followed.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2173-06-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1661556,\n \"text\": \"MICU Nurse Progress Note 0700-1900\\nEvents: pt cont on lasix gtt at 14mg/hr, diuresing well. started on D10 at 100ml/hr x 2L for DKA/ hypernatremia. insulin gtt increased to 8units/hr per protocol. propofol increased r/t agitation. Neuro f/u done today. Aline resited to R wrist.\\n\\nROS\\r:\\nNeuro: pt resp to verb stim, able to follow commands. MAE, PERRLS. sedation turned off for Neuro f/u consult/ exam. pt able tro consistently follow commands. sedation restarted r/t pt not extubating today.\\n\\nPulm\\r: LS coarse bilat. suctioned for msm-mod amt thick whitee secretions. RSBI this am 160. remains on CPAP+PS tol well.\\n\\nCVS: NSR w/ no ectopy ABP 140-160's/ 70-90's. repeat K+ 3.8 pt repleted w/ 20meq KCL IVPB. needs f/u this eve. R rad aline and R s/c CVL intact w/ good BR.\\n\\nGI: abd soft/ nontender, +BS x 4quads, TF at goal rate via OGT tol well. Mush cath intact draining liq brown stool.\\n\\nGU: foley cath patent draining clear yellow urine, UOP 200-350ml/hr, net neg ~1.5L since midnight. lasix gtt 14mg/hr.\\n\\nID: cont on cefepime r/t multifocal PNA\\n\\nsocial: pt father called, updated r/t pt cond/ POC.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2173-06-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1661557,\n \"text\": \"Respiratory Therapy\\nPt device: Pt remained on CPAP+PS 14/5 t/o the night and tol well. Pt would get tachypnic with RR up to 40 when sedation was lightened. RSBI was 91.7 this AM.\\n\\nLungs: BBS clear but coarse at times. Sx for large amount of thick white secretioins.\\n\\nGas Exchange: ABG normal\\n\\nPlan: wean as tolerated and extubate.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2173-06-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1661533,\n \"text\": \"Nursing note 7a-7p\\nEvents: pt in resp distress on cpap, after being on cpap for over 24 hrs. placed on CMV. cxr worse on Left, requiring CT chest. EEG done, non-specific secondary to propofol. MRI rx'd, however unable to do on day shift, due to pt needing 2 IV pumps while down in MRI dept.\\n\\nNeuro: pt opens eyes off propofol for ~20 min. unclear as to if pt is following, because she is unable to repeat commands consistently; however, pt was able to turn her head towards my voice on command and move her legs x2 on command. + gag, + cough, no focus, no upper ext movement noted today(purposeful or non-purposeful).\\n\\nCV: ST, no ectopy. S1, S2. 2+ gen edema. Pt is up almost 20 kg since admission. palp pulses x4 ext. L fem Aline over damp. SBP correlating w/ NIBP. CVP continues to be elevated around 14.\\n\\nPulm: Pt on CMV 18/TV 550/Fio2 .40/PEEP5. lungs coarse bilat after suctioning for small-mod amt thin white secretions. Last abg consistent. no vent changes ordered.\\n\\nGI: abd soft, bs+, tf @ goal w/ min resid. incont small loose, brown stool x3.\\n\\nGU: foley draining marginal amts cloudy, pale yellow urine. pt on menses.\\n\\ninteg: L flank & abd ecchymosis, peri redness, however, no longer cottage cheese-like drng. tape burn to RAC, ear spacer holes scabbed-bacitracin applied. L chest bar piercing site scabbed.\\n\\nIV: RSC TLC patent. no redness. old sang drng.\\n\\nendocrine: pt remains on insulin gtt 2-3 units/hr all shift.\\n\\npain: no s/sx of pain. grimaces only with sternal rub and oral care.\\n\\nSocial: pt's parents home for the day to shower and nap. no other phone inquiries.\\n\\nID: urine, sputum and wond cxs neg. bc x2 pending.\\n\\nPlan: MRI of brain, CT chest tonight. daily wake-ups. Neuro consult. monitor neuro status, resp and renal functions.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2173-06-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1661534,\n \"text\": \"MICU 6 NPN:\\nNEURO: PERL 3-4mm and sluggish. Taken off propofol to assess neuro status and pt. noted to move only LEs and head. No following commands. Opens eyes but no tracking or focusing. Becomes very agitated off propofol. Agitated throughout night with tachypnea, biting tube and hypertension- propofol increased to 50mcg/kg/min with good effect. Pt. received head MRI and chest CT overnight with results pending.\\nCV: Afeb. HR 90s-110s SR/ST, no ectopy noted. L femoral a-line dampened and NIBP started. BP wnl. R subclavian quad lumen line intact.\\nRESP: No vent changes overnight. O2 Sat >95% and acceptable abgs. Sx'd for scant secretions. LS coarse and diminished at bases.\\nGI/GU: Abd. soft with positive bowel sounds. Large loose BM - trace guiac positive. TF continue at goal. Insulin gtt currently at 1unit/hour and monitoring blood glucose q1/2-1hr. Glucose dropped to 54 overnight and given amp d50. Foley with cloudy yellow urine 20-30cc/hr. BUN/Cr rising.\\nSKIN: Peri area with yeast rash- antifungal cream applied. Backside intact. Generalized edema. Would benefit from kinair air mattress.\\nOTHER: Plan for read of MRI/chest CT. Daily wake-up to assess neuro exam. Would benefit from neuro consult.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2173-06-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1661535,\n \"text\": \"RESP CARE NOTE\\n21 YO F ADMITTED FOR DKA NOW BEING SEEN FOR INCREASING SEPSIS. SX MODERATE AMOUNT THICK WHITE. BS DECREASED AT BASES WITH FINE CRACKLES @ L BASE. ETT REPOSITIONED AND TAPED @ 23. RSBI 150\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2173-06-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1661536,\n \"text\": \"resp care - Pt remains intubated and on full vent support. No changes were made in vent settings this shift. Coarse BS cleared somewhat on suctioning of small amounts of thick, white secretions. Bronch was done for BAL. Sample of secretions were sent to the lab. Plan is to continue resp support.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2173-06-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1661537,\n \"text\": \"0700-1900 MICU PROGRESS NOTE\\n\\n21yo female admitted from , admitted on after being found down for unknown length of time. PT was intubated at OSH and blood sugar >600. At OSH pupils were fixed and dilated and rectal temp was 88. Pt required pressors and >5L IVF, for hyPOtension intially. Anion Gap 21 and blood sugars >400 intially and placed on insulin gtt. Pt was very acidotic on admission and given several doses of Bicarb. PMH IDDM and alopecia.\\n\\n\\nEvents- Propofol was shut off at 11:45 today and by noon pt agitated. Pt was coughing and on ETT. Sat's dropped to 88-90% when biting tube. PT became hypertensive w/ SBP 160's and tachycardic w/ HR 140's. Dr into eval neuro status, pt UNresponsive to painful or verbal stimuli. Pt NOT following commands. Propofol restarted per team. Bronch completed and BAL sent. Echo completed.\\n\\n Recieved pt on Propofol and stopped for brief time as noted above. Pt would NOT withdraw to painful stimuli or turn head to verbal stimuli. Pt did bite on ETT and cause sat's to drop. Pt moves legs slightly on bed. Pupils 4cm and sluggish to lights.\\n\\nC/V- Tmax 99.7 rectally. HR 90-120, NSR/ST w/o ectopy. Pt has 2+ pitting edema. Aline wave dampened and does not correlate well w/ NIBP. Team aware. B/P 120-150/70-90.\\n\\nResp- Remains orally intubated, see care-vue for trended ABG's. pH 7.30-7.35 and team aware...will monitor. No vent changes made. Sat's remain 97-100% on current vent settings. Lungs coarse w/ rhonchi at bases, suctioned for small amts of thick white sputum. Ct chest last night showed new nodules probable infectious in nature and antibiotic coverage changed.\\n\\nG/U- Bun/Creat elevated 74/5.4, renal following. Will monitor..dialysis not indicated at this time. Foley clear yellow but decreased amounts...15-50cc/hr.\\n\\nG/ Pt at goal for TF 25cc/hr. Remains on insulin drip. Blood sugars have been 130-200. Pt has had 2 loose liquid brown stool.\\n\\nPLAN-\\nAWAITING ECHO RESULTS\\nBAL AND SPUTUM SPEC SENT , FOLLOW-UP RESULTS\\nCONTINUE TO TREND ABG'S, GOAL pH 7.30-7.35\\nFUNGAL CULTURES SENT\\nSTOP PROPOFOL TONIGHT TO ASSESS NEURO STATUS\\nMONITOR ELECTROLTES AND REPLETE AS NEEDED\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2173-06-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1661538,\n \"text\": \"MICU 6 NPN:\\nNEURO: Taken off propofol x 15min for neuro exam. Pt. does not open eyes to painful stimuli. No following of commands. Withdraws LEs to painful stimuli but not UEs. Moving head back and forth in bed but no movement of UEs noted. PERL 3-4mm and sluggish. Positive cough and gag but no corneal reflexes noted.\\nCV: Afeb. Received 1G vanco last pm for level of 20. HR 90s-110s SR/ST, no ectopy noted. BP stable via cuff pressures. A-line continues dampened but with good blood return.\\nRESP: No vent changes and adequate abg. TCo2 14. LS coarse and diminished at bases. Minimal secretions.\\nGI/GU: Abd. soft with positive bowel sounds, loose BM x1. TF continue at goal with minimal residuals. Continues on insulin gtt at 2units/hour. Foley draining clear yellow urine >50cc/hr.\\nSKIN: Multiple blisters to UEs and reddened areas around tape. Will try to minimize tape due to pt's sensitivity. Peri-area red with yeast rash- criticaid antifungal cream applied. Scant blood vaginal drainage from menses.\\nOTHER: No calls or visitors this shift.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2173-06-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1661539,\n \"text\": \"RESP CARE NOTE\\nPT REMAINED ON SAME AC SETTINGS OF 18/550/+5/40%. ABG 7.34/24/175/14. BS CS AND DIMINISHED AT BASES. SX'D SMALL AMTS OF THICK YELLOW SECRETIONS. ROTATED AND RETAPED OETT @23CMS. MORNING RSBI 130\\nPLAN: CONT FULL VENTILATORY SUPPORT\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2173-06-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1661540,\n \"text\": \"0700-1900 MICU Progress Note\\n\\n\\n21 yo female admitted from on after being found down for unknown length of time. Only PMH is alopecia and IDDM since 7yo. Pt was intubated at OSH and blood sugar found to be greater than 600. Neuro exam at OSH ..pupils fixed and dilated, rectal temp 88 and unresponsive to painful stimuli. Pt was transferred to Tox screen negative for drugs/ETOH B/P 70 palp and required pressors and greater than 5L IVF. Intial anion Gap 21, now 12. Pt continues on insulin gtt and blood sugars have been 100-200, on 1-2units per/hr. Pt was acidotic on admission and given Bicarb....continues to be slightly acidotic @7.27. Team aware and no treatment at this time. Renal function has been worsening slightly(BUN/Creat 81/5.5), renal following...probable ATN and will monitor.continue to follow up with labs. MRI intially read by radiology as normal, but was reviewed by neuro service today and probable anoxic injury noted, awaiting official neuro note. Family NOT aware of new findings, team will address tomorrow. Pt had \\\"wake-up\\\" 2x today and was eval by neuro service.\\n\\nNeuro- As stated above, propofol off 2x today and evaluated by Neuro. Off propofol for 30-1hr and pt became tachycardic w/ HR 120-140 and hYPERtensive. Pt thrashing in bed, gagging and coughing. PT LIFTING BOTH LEGS AND ARMS OFF BED, BUT NO PURPOSEFUL MOVEMENT. Pt does not withdraw from painful stimuli. Pt not opening eyes, or moving head to voice. Pt will bite on ETT off propofol, and sat's drop tp the 80's. Pt place back on propofol..will continue to attempt wake-up and follow neuro rec's when available. Pupils 4cm and sluggish.\\n\\nI/D- CT chest 2 days ago showed nodules, ? septic emboli. ECHO WNL..PLAN TTE IN AM, WILL KEEP NPO after midnoc. Continues on daily dosed vanco and cefepime. Tmax 100. BAL and sputum spec pending.\\n\\nC/V- Remains ST/NSR, no ectopy. >17L pos for LOS, +2 edema noted in all extremities and peri-orbital. Aline wave dampened and does not correlate w/ NIBP, team aware. Will keep as access for lab/ABG's. B/P 120-140/60-70. TTE in am.\\n\\nResp- Vent changed to pressure support and tolerated well. RR 20-30(RR increases to 40's off propofol) and sat's have remained 95-100% on PS. See care-vue for ABG's . Suctionedfor large amount of clear oral secretions and thin white sputum via ETT. Lungs coarse rhonchi,which clears somewhat w/ suctioning.\\n\\nG/U- Foley draining clear yellow urine and has somewhat increased as compared to yesterday. U/O 50-70cc/hr.\\n\\nG/I- TF, Nutren Pulm at goal 25cc/hr, tolerated well, no residuals. Pt had 2 loose stool today, hypoactive bowel sounds. NPO after midnoc for TTE. Remains on Insulin GTT at 1unit/hr.\\n\\n Pt is very sensitive to tape and has multi small fluid filled blisters and arms, and small abrasions. A+D oint applied to open area. Peri-rectal and groin area reddened, criticaid w/ nystatin applied.\\n\\nPLAN-\\nCONTINUE TO MONITOR ABG'S AND ACIDOSIS...GOA\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2173-06-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1661541,\n \"text\": \"(Continued)\\nL 7.28-7.35\\nMONITOR NEURO STATUS AND CONTINUE TRIALS OFF PROPOFOL\\nTTE IN AM\\nAWAITING NEURO REC'S\\nFUNGAL, BAL AND SPUTUM SPEC PENDING\\nMONITOR ELECTROLYTES\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2173-06-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1661552,\n \"text\": \"Micu Nursing note \\n\\nNeuro: Propofol drip off this am, pt able to follow simple commands grasp hands, and move legs on bed, seems to understand questions and nods. pt placed back on propofol drip because at present no plans to\\nextubate.\\n\\nCv Pt hemodynamically stable BP 120-150/ 60-80 hr 80-110 st, pulses present and palpable,\\nResp pt remains on ps14/5 peep/ rr 23-40. fio240%, sats 100% lungs course, pt scutioned s4 for thick tan secreations needing n/s lavage first, secreations are very thick because she is dry.\\nattempted to go to 0/5 and pt rr ^ 50, only lasted 5 min and was placed back to previous setting.\\n\\nGi abd soft non tender, still passing brown liquid stool, tube feeds at goal of 25/hr on nutran plum, residuals 35 cc,\\n pt continues to have good urine output, however, we at present are not reaching our negative goal becayse of replacement of free water,\\nlytes pending na this am 150, may need to restart lasix drip this eveing, it was stopped early this am because of ^ na level\\nid tmax 99.1\\naccess, R tlc, and L fent aline\\nskin L fa area small blisters drying area cleaned with n/s and dsd applies, R ankle area cleaned and left open to air\\nrash improving on body less reddened back and buttock much better\\nA/P\\nimproving mental status\\nat present no plans to extubate until we imporove fluid balance and correct sodium level\\nrenal following no plans for hd line, dicarb drip decreased to 12.5 cc/hr, improving ph\\nfollow lytes, free water added, may need lasix restarted at the same time as giving free water to reach negative fluid goal.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2173-06-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1661553,\n \"text\": \"Respiratory Care Note\\nPt received on PSV 14/5 as noted. BS coarse bilaterally. Pt suctioned for small amt thick secretions. Pt placed on trial 5/0. Pt became tachypneic with RR 40-45 after 5 min - pt placed back on PSV 14/5. Plan to continue on current settings at this time.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2173-06-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1661554,\n \"text\": \"7pm to 7am:\\n\\nEvents:\\n Pt has had an uneventful night.\\n\\nROS:\\n\\nNeuro) Pt remains intubated with propofol gtt for sedation with good effect. Pt will open eyes and will follow simple commands. Sometimes it takes her a few seconds to respond. Pt has = hand grip. Pupils=and reactive. Pt's neuro status has improved greatly over the last few days. See care vue for further neuro evaluation. No contact from family on this shift.\\n\\nID) Pt is afebrile. Pt on IV ABXs for multi focal pna. CXR done this am. Pt continues to have a body rash, but improved since .\\n\\nCV) Pt is in SR(80-90's) at rest and ST (100-106) with activity. SBP stable and a-line and NIBP correlate as noted. Pt continues to have gen edema. Am labs as noted. K level has been replaced multiple times, and needs follow up 2/2 lasix gtt.\\n\\nResp) LS coarse and clear after deep sx. Pt on CPAP+PS and is tolerating it well. Plan to diurese pt further before extubation takes place. ABGs as noted in care vue.\\n\\nGI) Abd soft with + BS. Pt continues to have liq brown stool via rectal tube. TF at goal at 25 cc/hr w/o residuals. Pt given H2O fluses for NA level with some effect. Follow up Na level.\\n\\nGU) Goal diuresing (-) 1-2 liters q day with lasix gtt. . Pt is now + 5.6 liters for LOS (1 liter - for the last 24 hrs). Sodium bicarb gtt as noted. Wean off as tolerating. PH NL and Co2 improved.\\n\\nSkin) skin as noted in care vue.\\n\\nSoc) ? family meeting soon.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2173-06-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1661563,\n \"text\": \"MICU Nursing Note 1900-0700\\nEvents: Transfer to floor cancelled d/t high sugars and anion gap at 2200, gap now closed this am, received 500ml IVF bolus x 110-120's, mild anxiety at times\\n\\nNeuro: A+O x 3, pleasant and cooperative, anxious with care at times, weepy at other times, moving all extremities, following all commands, asking appropriate questions, OOB til 11pm last night, PEARL, denies pain\\n\\nCardiac: Pt with HR up 110-120's ST at shift change---received 500ml IV NS bolus with fair effect, second IV NS 500 ml infused with fair effect with HR down to 100-110's ST, BP stable 130-150's/60-70's, pt with (2) PIV's\\n\\nResp: Denies SOB, RR= 13-20. Lungs clear bilat upper lobes and diminished at bilat lower lobes, occasional scattered rhonchi noted, junky sounding productive cough of thick white sputum, room air Sats with trend down to 90-92%---encouraged to TCDB, placed on 2 L NC with Sats up to 94-97%.\\n\\nGI: Abd soft with + bowel sounds all quads, poor PO appetite and needs encouragement, taking po fluids well, Mushroom cath draining mod. amts liquid brown stool. C/O nausea at 11pm when BS elevated---resolved after insulin administration.\\n\\nGU: Foley to CD draining clear yellow urine > 50ml/hr. Creat down to 2.6 this am. Pt currently positive 10.3 L for LOS.\\n\\nSkin: intact\\n\\nEndo: Blood sugar up to 401 at 2200----med. with 12 units regular insulin and 25 units Lantus as ordered, team aware and chem panel sent which revealed Gap=16. Fingersticks checked Q 1 hour overnight and 3am Chem panel revealed Gap=10. Blood sugars trending down all night and now currently under 200. If need to restart insulin gtt take note that pt has Lantus on board.\\n\\nID: WBC= 11.5, low grade temp with Tmax= 99, continues on IV Cipro. random vanco level=16 this am.\\n\\nSocial: Pt's parents in to visit during evening hours and were updated on pt's care. No further contact overnight.\\n\\nPlan: Call out to medicine if blood sugars remain under 200, continue freq. glucose checks, increase lantus dose to pt's pre-hospital dose as her po intake improves, increase activity as tolerated---pt is a 2 person max. assist to chair, await PT eval, start pt with incentive spirometer and wean 02 as tolerated, pulmonary toiletting, support pt and family\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2173-06-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1661564,\n \"text\": \"Nursing MICU note addendum\\no2 d/c'd and pt with Sats > 95%, using incentive spirometer x 1000ml,\\nincontinent of stool---mushroom d/c'd, Fingerstick=182---covered with 2 units SC insulin\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2173-06-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1661565,\n \"text\": \"0700-1800 MICU transfer note\\n\\n21yo female admitted with DKA on .Pt had been intubated/sedated on Propofol gtt. Pt previously on an insulin gtt/ which has since then been dc'd. Pt is /Oriented x3, pt is weepy at times. Lung sounds coarse, with occassional congestive cough producing thick white secretions, encourged to Pt compliant with using incentive spirometer. O2 sats 95% on room air. Pts appetite remains poor, with about 25% of meals eaten. Pt has been incontient of loose green stools today times 3. Pt OOB to chair for most of the day, pt worked with physical therapy and tolerated it well. Pt continues to complain of headaches, receiving tylenol with minimal effect; team aware. Blood sugars have been between 150-200's covered with ssi. Hct 22, pt to be transfused with 1UPRBC when available. Pt has been called out, due to be transferred to CC7.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2173-05-31 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1661525,\n \"text\": \"Resp Care: Pt continues intubated #7 oett, advanced & secured @ 23 @ lip per cxr, on ventilatory support with psv maintaining Vt 5-600 ml with Ve 9-12 L, improving metabolic acidosis with good oxygenation; bs clear to coarse, sxn thick yell secretions, rsbi 51, will cont support.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2173-05-31 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1661526,\n \"text\": \"MICU Nursing Note 1900-0700\\nEvents: Abd CT scan completed and preliminary report is scan was WNL with fluid collections d/t previous fluid resuscitation, Acidosis slowly correcting, NaHC03 gtt infusing, vasopressin and levophed both weaned to off overnight, remains on IV insulin gtt, sedated with versed and fentanyl.\\n\\nNeuro: moving lower extremities with stimulation, turns head side to side, responds to painful stimuli, attempts to open eyes with stimulation---unable d/t periorbital edema, + gag, + cough reflex, does not follow commands, swallowing and tongue-ing tube with increased stimulation, IV Versed gtt infusing at 5mg/hr, required a few bolus doses of 2mg for travel to CT scan, IV Fentanyl infusing at 50mcgs/hr. PEARL. Bilat soft wrist restraints to prevent pt from pulling at lines and tubes upon awakening.\\n\\nCardiac: HR= 120-130's ST with no ecotpy noted, Left femoral Aline intact and with good waveform and correlation to NBP, BP= 100-125/80's with MAP's >70's, IV Vasopressin and IV Levophed weaned to off, episode of sBP 80's with Map= 60 following turning and repositioning once off of vasopressors---Levophed restarted at 0.03 mcgs/kg/min with good effect and able to wean off after 1 hour and currently remains off, new right SC multi-lumen central line placed and confirmed by Xray---right femoral TLC d/c'd and tip sent for cx, CVP= . IV D5W with 3 amps NaHCO3- infusing at 150ml/hr. Last CO2=11. + bilat DP/PT\\n\\nResp: remains intubated, ETtube advanced 3 cm and now at lip 23cm---awaiting am CXR, ETtube suctioned for mod. amts thick yellow sputum Q1-2hr, tolerated CPAP+PS at 40% with PS=10 and Peep=5. TV=600's, MV= , Sats= 96-100%. ABG improving throughout night with last ABG= 7.30-24-124. Lungs clear bilat upper lobes and with rhonchi at bilat bases.\\n\\nGI: Abd soft, intially not able to auscultate bowel sounds---now with distant hypoactive bowel sounds, no BM, OGtube placement checked by ausculation, OGtube with 140ml of green bile removed prior to instillation of baricat, after CT scan OGtube placed to LWS for total of 450 ml of baricat removal. Currently OGtube clamped. NPO\\n\\nGU: Foley to CD draining cloudy yellow urine 10-30ml/hr, Cr up to 3.3 this am, positive 13.7 liters for LOS\\n\\nEndo: Remains on insulin gtt---currently at 7 units/hr with fingersticks ranging 87-149. Requiring higher dose of insulin while bicarb gtt infusing---will need to titrate insulin closely once off bicarb gtt. Gap closed....last level=13.\\n\\nID: afebrile, WBC down to 13.3, lactate = 1.3, continues on aztreonam, fluconazole, vanco.\\n\\nSkin: pt with multiple ecchymotic areas noted over various parts of her body such as thigh, side, rib area---MICU team aware and assessed. Perineum exoriated and red raw---cream and protective barrier applied. continues with menses---no tampon in place.\\n\\nSocial: No contact from family or friends overnight.\\n\\nPlan: Continue fingersticks Q1hr, ABG's Q4hr, replace lytes prn, aggressive pulmonary toiletting, blood sugar dropped quickly whe\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2173-05-31 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1661527,\n \"text\": \"MICU Nursing Note 1900-0700\\n(Continued)\\nn D5W with bicarb gtt stopped earlier---will need to half insulin dose at that time, need CXR to check repositioning of ETtube, Wean sedation as tolerated, Support pt and family\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2173-05-31 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1661528,\n \"text\": \"Resp Care\\nPt remains intubated. Current vent settings: PSV 10/5 40%. PS increased to 15 due to increased WOB and then decreased back to 10. Pt tolerating change well. Pt taken to CT for head scan. No other changes noted.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2173-05-31 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1661529,\n \"text\": \"Micu 6 Nursing Progress Note 0700-1900\\nNEURO--Midaz and Fent off. Started on propofol gtt now at 30 mcg/kg/min. When light, MAE. Did not follow commands. Did not track with eyes or make eye contact. purposeful movement. Head CT done -> prelim wet read unremarkable. Initially pupils did not respond. They now are 2-3 mm and respond sluggishly.\\n\\nCARDIAC-- HR 120's all day. SBP 110-120's/70's. No observed ectopy. Not on any gtts.\\n\\nRESP--Lungs are coarse in upper airways and diminished in bases bilaterally. SaO2 >97%. Presently on CPAP/IPS . Sx q2hrs for moderate amts of thick tan sputum.\\n\\nGI--to start tube feeds after mn. Plan was to attempt extubation but that is not happening tonight so start tube feeds. Stool lgr amts of loose stool guiac +. B owelS present.\\n\\nGU--CR rising. UO decreasing to 5-10 cc hr via foley cath.\\n\\nENDO--remains on insulin gtt. BS all over the place with insulin gtt changing. bs 70-150 with insulin gtt .5-6units/hr. K+ repleted with 40 meq. CA++ repleted with 2 gms cal. gluconate.\\n\\nSKIN--Several areas of eccymoisis on torso. Knees are warm and blanched. Buttocks without breakdown. Site on chest from piercing look purulent. Pt with menses. Very edematous.\\n\\nCOPING--Family in all day and have been updated by this RN and attending. They are aware that kidneys are injured with possibility of permanent damage. They are also aware that further w/u needs to be done on brain. i.e. eeg and maybe MRI. They are grieving. Per pts' mom and dad, pt is non-compliant with her insulin needs.\\n\\nPAIN--Does not appear to be in pain. Of note, pt is not on any pain medication at present, only propofol.\\n\\nA--Remains unresponsive,not following commands. No purposeful movements. Holding own RR and BP.\\n\\nP--COn't to monitor. Wake up to assess neuro status. Offer support to pt and family. Plan for EEG and ? whether MRI is needed. Start tube feeds after mn.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2173-06-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1661530,\n \"text\": \"MICU Nursing Note 1900-0700\\nEvents: Started on Tube feeds and tolerating, low grade temps, Tachypneic on CPAP+PS but ABG good, urine output remains poor and creatinine continues to rise, sedated on propofol with minimal response after propofol off x 30 minutes.\\n\\nNeuro: PEARL, sedated on 30mcgs/kg/min of propofol, propofol off x 30 minutes and pt moving LE/not opening eyes/not following commands, biting tube with stimulation, Head CT reported as WNL as per MICU team.\\n\\nCardiac: HR= 110-126 ST with no ectopy noted, Left femoral Aline with good waveform and correlation to NBP, BP= 120-150's/90's, right SC multi-lumen line patent and CVP= , remains off vasopressors.\\n\\nResp: remains intubated and tolerating CPAP+PS with good ABG, tachypneic overnight, biting tube with stimulation, lungs coarse bilat upper lobes and diminished at bilat bases, + cough reflex, ETtube suctioned for mod. amts thick whitish/yellowish/tan sputum, Current vent settings include CPAP+PS with PS=10 and Peep=5 at 40%. Sats= 97-100%, ABG= 7.34-27-129. RSBI this am > 100\\n\\nGI: ABd soft with + bowel sounds all quads, small brown BM x 1, OGtube placement checked by auscultation, Started on tube feedings FS Pulmonary Nutren at 10ml/hr---tolerating with minimal residuals and rate increased to 20ml/hr.\\n\\nGU: Foley to CD draining cloudy yellow urine in scant amts 5-15ml/hr, Creatinine continues to rise =4.3 this am, positive 15.5 L for LOS\\n\\nSkin: Perineum rash less red today. Ecchymotic areas unchanged. No further breakdown noted.\\n\\nEndo: Insulin gtt continues and infusing between 0.5-2.0 units/hr and titrated to fingersticks and scale, Fingersticks 97-149.\\n\\nID: Low grade temp with Tmax=99.2, WBC= 12.7, continues on IV aztreonam and acyclovir.\\n\\nSocial: Pt's parents in to visit all evening and both are staying at hospital overnight in ICU waiting area.\\n\\nPlan: Await Neuro consult, possible EEG, possible MRI, wean sedation and vent as tolerated, increase tube feeds as tolerated, replace lytes prn, renal failure---high potential for HD, support pt and family\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2173-06-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1661531,\n \"text\": \"RESP CARE NOTE\\nPT REMAINED ON SAME SETTINGS OF PSV 10/5/40%. ABG SHOWING COMPENSATED METABOLIC ACIDOSIS. BS ESSENTIALLY CLEAR BILATERALLY. SUCTIONED SMALL AMTS OF THICK YELL/WHITE SECRETIONS. OETT ROTATED AND RETAPED AT 23CMS. MORNING RSBI 106.3.\\nPLAN: WEAN AS TOLERATED.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2173-06-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1661532,\n \"text\": \"Resp Care\\nPt remains intubated, currently on CMV. Pt has ^RR with desats when sedation off, resp distress-biting ett. Sx for mod thick white, plan to monitor nuero status and travel for Head CT/MRI.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2173-06-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1661542,\n \"text\": \"7pm to 7am:\\n\\nEvents:\\nPt has had an uneventful shift. NPO for TEE today.\\n\\nROS:\\n\\nNeuro) Pt remains intubated with propofol gtt for sedation with good effect. Pt has been keeping eyes closed, even when stimulated. Pupils = and reactive to light (brisk). Pt will move head back and forth with oral care and move all ext's with non-purposeful movements. Pt does NOT respond to any painful stimuli accept oral care. Pt does not follow any commands. Pt noted to become tachycardic and tachypnic with stimulation, which has minimized after headphones with music placed. Neuro team is following pt. No contact from family.\\n\\nID) Tmax 99.2 as of 4am. No changes done to IV ABxs. Vanco level pending. Urine cx negatve. Wound culture negative. Sputum culture with NGTD and gram stain negative.\\n\\nCV) Pt in sr while at rest and ST with minor stimulation(100-117). SBP stable at 120-130's with MAP >65. A-line with dampened wave form and using NIBP for BP readings. CVP 10-13. Am labs pending. Pt is NPO for TEE today.\\n\\nResp) Pt placed back on AC mode after pt becoming more and more tachypnic at 4am, with good effect. Pt has been deep sx'd for moderate amounts of thick white secretions.\\n\\nGI) Abd obese with + BS x 4. Flatus +. Rectal tube placed after episode of liq/loose brown stool. NPO for TEE today. Pt remains on insulin gtt as noted, with now stable BS.\\n\\nGU) Good U/O via foley catheter at 50-75 cc/hr. Pt is now +17 liters for LOS. Renal team is following pt regarding RF. HD on hold for now.\\n\\nSkin) see care vue for details. Air bed ordered for pt due to skin break down noted around rectum.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2173-06-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1661543,\n \"text\": \"Respiratory Care:\\n\\nPt remain orally intubated & sedated on PSV. WE switched to vent support o/n for tacypnea r>40pm & tachycardis, responded well. Bs cl;aer to coarse. RSBI ~97. WE ARE SXTN FOR MOD AMT OF THICK WHITE SECRETIONS FROM ETT. PLAN: AWAITING FAMILY MREETING THIS NORNING, DE CAREVIEW FOR FUTHER DETAILS. A\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2173-06-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1661544,\n \"text\": \"0700-1900 MICU PROGRESS NOTE\\n\\n21 yo female admitted from OSH on after being found down, unresponsive at home. Please see nursing noted on for detailed past events while in MICU.\\n\\nEvents- Attempted to wean down propofol gtt, pt unable to tolerate.. on ETT, RR increased to the 40-50's, and HR increased to the 120-130's. Pt moving extremities more while on propofol. Pt has required several small boluses of propofol and dose increased to 60mcg. Wake-up performed this morning and mental status assessed by team. Pt noted to have increased response to painful stimuli, pt now able to cross legs past midline. Pt opening eyes to painful stimuli but unable to track. Pt noted to have purposeful movement towards ETT with hands. Off sedation pt has increased secretions, cough and seems to Gag on ETT. Pt not grasping with hands or following commands. Pt will respond to sternal rub, by withdrawing. Pt did not have TEE today, will have tomorrow at 8:30a. Keep NPO after midnoc.\\n\\nI/D- Tmax 100.3. Vanco random yester 33.2, continues on Cefepime daily. Repeat chest CT today f/u pulm nodules, results pending.\\n\\nC/V- Remains ST/NSR w/ no ectopy. remains >16L pos LOS, but U/O increasing slightly. Extremities remain edematous and swelling noted peri-orbital. Aline continues to be dampened, w/ good blood return. Team aware, site WNL...no plans to re-site at this time. Pt was very difficult to obtain. TEE in am.\\n\\nResp- SBT attempted today, 5/0..tolerated for @ 15 min and became tachypnec w/ RR in the 50's. Sat's dropped to 87-90's and breathing became labored. ABG's drawn thru day, continues to be acidotic secondary to impaired kidney function. Will monitor and no treatment at this time. Lungs coarse, w/ rhonchi..suctioned for increased oral and deep secretions as compared w/ yesterday. Thin white sputum.\\n\\nGU/Renal- Bun/creat rising but U/O also increasing. Seen by renal, no dialysis at this time..will continue to monitor..? large 1X lasix dose as test. U/O 50-70cc/hr.\\n\\nG/ Pt has been NPO thru day, KVO changed to D5W to support insulin gtt while NPO. BS 100-200. Will restart TF and D/C at midnight. Rectal tube draining minimal amts of liquid brown stool.\\n\\nSkin- ? yeast infection groins and buttocks..pink non-raised rash. team aware and nystatin cream ordered. Multi small blister and broke blisters draining serous fluid..A+D oint applied.\\n\\nPlan-\\nTEE in am, keep NPO after midnoc\\nContinue trial off propofol and wean down as tolerated\\nMonitor MS closely\\nMonitor ABG's and acidosis\\n?F/U MRI prior to extubation\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2173-06-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1661545,\n \"text\": \"Respiratory Care Note\\nPt received on PSV 8/5 as noted. BS coarse bilaterally. RSBI was 80 with a VT 437 and RR 35. started at 3:50p and ended at 4:20p secondary to tachypnea. Pt's RR 49 at end of - pt placed back on with slowing of RR. Plan to continue on current settings at this time.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2173-06-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1661550,\n \"text\": \"7pm to 7am:\\n\\nEvents: Uneventful night. Pt on Bicarb gtt and lasix gtt in order to correct renal status with little changes. Renal team following pt.\\n\\nROS:\\n\\nNeuro) Pt remains intubated with propofol gtt for sedation. Pt occ in need of sedation boluses before turns due to being very bronchospastic. Pt will occ open eyes to voice and will follow directions inconsistantly. Pt will squeeze hands when asked to. Pt also noted to MAE. No contact from family on this shift. Neuro is following pt. Full Code.\\n\\nCV) Pt is in ST (100-110) w/o ectopy noted. Hr will increase to 115 with stimulation. SBP stable at 120-130's. A-line wave form remains dampened and following NIBP for BP readings. CVP14->12. Pt has gen edema and exts elevated on pillows. K replaced as noted. Follow K level lasix gtt for diuresis.\\n\\nGU) Pt is being diuresed with lasix gtt for goal of (-) 2 liters q day or (-) 100 cc/hr. Pt is now + 16.6 liters for LOS (No change since ). Pt is also on bicarb gtt and Sodium bicarbonate PO to correct met acidosis RF with minimal effect. ? need for HD sooner than thought. BUN 98 and Creatine slight down to 5.7 (peaked ).\\n\\nID) Pt on IV ABxs for multifocal pna. Pt was started on flagyl, but noted to have developed a body rash at 8pm and flagyl DC'd. Tmax 99.1 as of 4am. Vanco level this am 20. Needs another sputum sample.\\n\\nResp) Pt intubated on CPAP+PS at 40%/. Pt has been deep sx'd for scant amounts white thick secretions. CXR done this am. No vent changes made. Hard time advancing sx catheter with sx, RT to eval, but unable to improve. Continue to wean pt off vent as tolerated.\\n\\nGI) Abd soft with + BS. TF at goal at 25 cc/hr w/o residuals as noted. Insulin gtt as noted. rectal tube in place for liq brown stool.\\n\\nSkin) see care vue for details.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2173-06-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1661561,\n \"text\": \"7p to 7a Micu Progress Note\\n\\nNeuro - Pt alert, oriented to person and place, occasionally year. Confused and tearful at times. MAE. Able to raise and hold upper and lower exts. PERL. Impaired gag reflex. No restraints utilized. Denies pain.\\n\\nResp - LS coarse to clear, diminished at bases. Strong cough. Expectorated sm amt thick white sputum. RR 17-23. 02 sat > 93 on RA. ABG on RA 7.44/41/83/3/29.\\n\\nC-V- HR 84-105 ST, no ectopy noted. ABP 1409-160/80-92. + palp peripheral pulses. Hct low but stable at 22.9. CVP 11-14.\\n\\nGI - Abd soft. +BS. NPO. Passing mod amt liquid brown stool via mushroom catheter. Plan is for speech and swallow eval today.\\n\\nF/E - TFB neg ~2200ccs yest. Diuresed with lasix gtt, currently infusing at 8 mg/hr to obtain goal net neg 100ccs/hr. Repleted with 60 meq kcl iv overnight. K 4.2 this am. BUN and Cr improving at 73/3.4 respectively. IV d5w infusing at 100ccs/hr.\\n\\nID - Afeb. WBC 10.9. PNA covered with IV cipro.\\n\\nEndo - Remains on insulin gtt, currently infusing at 2.5 units/hr. FSBS labile at 110-167.\\n\\nSocial - Parents visiting at bedside last eve.\\n\\nA+P - Continue to monitor neuro status. Diurese and replete lytes as indicated. Speech and swallow eval today. Monitor FSBS q1hr while pt remains on insulin gtt. Emotional support to pt and family.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2173-06-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1661562,\n \"text\": \"MICU Nurse Progress Note 0700-1900\\nEvents: pt cont to improve, MS cleared now A/Ox3, OOB->x6hrs, tol well. insulin and lasix gtt off. cleared by speech therapy, taking PO's well, appetitie fair. A-line and CVL d/c'd. pt to be c/o to floor.\\n\\nROS:\\nNeuro: A/O x3 follows commands, all ext strong/=. OOB->chair as above. PERRLS. No c/o pain at this time.\\n\\nPulm: LS remain coarse bilat w/ dim bases, pt 02sat 95-100% on RA, strong prod cough noted.\\n\\nCVS: NSR/ST w/ no ectopy. b/p stable 130's-150's/ 60's-70's. A-line and CVL removed, PIV x1 in L A/C patent flushed. afternoon K+ 3.7 repleted w/ 20meq KCL.\\n\\nGI: PO intake tol well, appetite fair. Abd soft distended w/ +BSx4quads, pt started on /Gluten free diet. Mushroom cath intact draining liq brown stool. C-Diff neg.\\n\\nGU: foley cath patent draining clear light yellow urine. Lasix gtt weaned off. UOP 75-150ml/hr since off lasix. pt neg ~3.5L since midnight still +8.5L for LOS.\\n\\nEndo: insulin gtt and D10 stopped, pt given 10 units NPH at 1300 and started on SS w/ lantus consult.\\n\\nsocial: family at bedside, updated r/t pt cond/ by RN.\\n\\nPlan: lytes, replete as needed\\nlantus and Reg insulin per SS.\\nc/o to floor pendin g bed availability.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2173-05-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1661522,\n \"text\": \"MICU Nursing Admission Note 0300-0700\\n PMH: IDDM since age 7, alopecia, multiple piercings\\n\\n Pt is a 21yo female who had been out with friends the night of the . she wasn't feeling well and left to go home ~0130 . A friend came by her home ~12 noon on the 31st, to check on her and found the door locked and someone moaning. Police were called and pt was found down without a palpable pulse. Arrived to in DKA, with a SBP of 72/. Over the next few hours, pt received ~5 liters IVF, IVABX: vanco and ceftrixone. She was found to be hypothermic with a core temp of 88. Her pupils were ~6mm, fixed and dialated. Tox screen was neg. CAT scan with no intercranial hemorrhage and an LP was done. She was then transferred to ~12am. Begun on vasopressin and dopa. She became tachycardic and levo was initiated with hopes of titrating dopa.\\n\\n Arrived to MICU ~0300. Pt was immediately placed on PS ventilation. NS, dopa, levo, and vasopressin infusing. Right groin line intact, as well as (2) add'l peripherals. A third peripheral was placed as well as a left groin arterial line. Both radial pulses were weak.\\n\\n Systems Review:\\n\\nResp: LS CTA, Intubated and ventilated, placed on PSV with improved ventilation. PSV 40%/ 5 Peep/ 10 PS. RR 20-24 with TV's 570-580.\\n\\nNeuro: Pt was normo-thermic upon arrival. Pupils were ~2-3mm,equal in size and responsive to light. She was moving all extremities, but not purposefully. Not following commands. +Gag and + cough.\\n\\nCV: Hypotensive on vasopressin 2.4 units/hr, levophed 0.30 mcg/kg/min\\nand dopa 2.2 mcg/kg/min. Attempting to wean dopa off due to pt's tachycardia, (into the 130's) However, her BP has only been in the 90's-low 100's, with MAP's in the 40's. Recieved an additional 5 liters of IV NS since 0300-0700.\\n\\nGI: NGT placed, auscultated and +GI aspirates. Awaiting X-ray confirmation. Hypoactive BS, no stool.\\n\\nGU: Urine specs sent off for cultures. Only 20cc's from 0330-0600. Urine cloudy. +yeast infection in perianal area. Meds to be ordered. Pt + for menses, peri pad intact.\\n\\nEndo: Pt arrived with insulin gtt of 12 units/hr. Shut off for ~1hr and restarted ~0500. Please refer to carevue for FS results. Currently infusing at 6 units per hr. Will con't to check Q1hr FS and titrate as appropriate. Anion Gap originally 25, down to 18 by 0600.\\n\\nID: WBC initially 30, down to 18 by am. Receiving multiple IVABX. Ceftriaxone and vanco given at OSH. Sputum and urine cultures sent.\\n\\nF/E: K+ 2.7, Ca 6.2. Receiving electrolyte replacement as appropriate. 60 meq KCL and 4 gms Ca+ thus far.\\n\\nSocial: Pt lives between her parents who are divorced. They both reside in . The pt was at the father's home when she became ill. He was out of town and flew in from to be with the pt. Both her parents are here at the hospital and are appropriately concerned.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2173-05-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1661523,\n \"text\": \"Respiratory Therapy\\n\\nPt remains orally intubated on PSV. No vent changes made this shift. Continues on +10PSV/+5PEEP w/ Vt 600s RR 20s Ve 14-16L/M. ABG shows continues metabolic acidosis. SpO2 90s, suctioned for small amounts of thick pale yellow secretions. ETT secure/patent. See resp flowsheet for specific vent settings/data.\\n\\nPlan: maintain support\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2173-05-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1661524,\n \"text\": \"MICU NPN 0700-1900\\n\\nEvents: Dopamine gtt titrated off. Levophed gtt weaning down. Acidosis slowly resolving. Please see carevue for all objective data.\\n\\nNeuro: Pt sedated on fentanyl and versed. PERRL. Pt has non purposeful movement to stimuli. Pt did not open eyes or follow commands today.\\n\\nResp: Pt remains vented on CPAP/PS 10/5. Last ABG 7.22/24/121/10. LS rhonchorus. Sxned for thick yellow secretions.\\n\\nCV: Levophed and vasopressin infusing. Able to slowly wean down levophed. Multiple lyte repletion throughout the day. PM chemistries pnding. HR 130's-140's. BP 105-140/86-58. MAP goals >60. Team is placing a SC CVL currently. Left groin a-line remains in. Unable to place radial.\\n\\nGI: US of abdomen showed free air in the belly. Pt needs CT abdomentonight without contrast (but please give 2 bottles of baricet). Abdomen soft. Pt grimaces with abdomen palpation. No BM today.\\n\\nGU: Minimal u/o via foley 10-30cc/hr. Pt is net pos. approx. 11 liters since admission.\\n\\nID: vaginal yeast infection noted. Pt given diflucan po. Pt on broad coverage antibx. Cultures pnding. afebrile.\\n\\nEndo: Pt on insulin gtt. Hourly BS. Titrating s/s.\\n\\nSocial: mother and father at bedside most of the day. Appropriately tearful and concerned. Pt had many friends/family visiting.\\n\\nDispO: Remain in Micu. FUll Code.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2173-06-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1661551,\n \"text\": \"Resp Care\\nRemains intubated and ventilated on cpap/psv with no remarkable changes overnight. Breath sounds coarse, suctioning small amounts of white sputum. Suction cateter sometimes difficult to advance. ETT repositioned and retaped. ABGS still with severe met. acicosis.\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2173-05-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 214207,\n \"text\": \"Sinus tachycardia\\nNonspecific ST-T wave changes - baseline artifact makes assessment difficult\\nSince previous tracing of the same date, tachycardia rate faster\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2173-05-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 214208,\n \"text\": \"Sinus tachycardia. Diffuse non-specific ST-T wave changes. No previous\\ntracing available for comparison.\\n\\n\"\n }\n]"}}},{"rowIdx":399,"cells":{"subject_id":{"kind":"number","value":15012,"string":"15,012"},"hadm_id":{"kind":"number","value":175711,"string":"175,711"},"target_text":{"kind":"string","value":"1. Neurologic: The patient was initially on the Neurology Service. Head CT scan showed a right medial thalamic, subacute, small lacunar infarct. MRA showed mild stenosis on the left vertebral and mid basilar system. Etiology was thought to be either cardiac embolus or arterial embolus. The patient was initially managed conservatively with aspirin and Aggrenox. The patient's neurological deficits improved slowly throughout the course of his stay in the hospital. 2. Cardiovascular: The patient was hypertensive with systolic blood pressure up to 200 during his initial presentation in the hospital. His blood pressure remained elevated despite being on a Nipride drip and multiple other anti-hypertensives, including hydralazine, hydrochlorothiazide, and Aldomet. Additionally, the patient was found to be bradycardic to the 30s. Despite these cardiovascular abnormalities, the patient was completely asymptomatic. He was seen by Electrophysiology who recommended putting a pacer in and a pacer was placed subsequently. He was eventually weaned off the Nipride drip and his blood pressure slowly decreased on oral medications. The patient was seen by the Renal Service and a gadolinium MRI showed equal sized kidneys with no hydronephrosis or renal artery stenosis."},"extractive_notes_summ":{"kind":"string","value":"with uncontrolled HTN on multiple anti-hypetensives. with uncontrolled HTN on multiple anti-hypetensives. WILL RECHECK K+ THIS PM.RESP-LS ESSENTIALLY CTA. attempts to get oob as sedation wears off. EKG SHOWS A-FIB. PT ALERT AND ORIENTED X3 ALTHOUGH LETHARGIC. BR MAINTAINED.COMFORT-DENIES PAIN.A-SEIZURE THIS AM. TECHNIQUE: T1 axial in and out of phase. Norvasc and clonidine added to regimen. (+ CIGS/ETOH )PLAN: PER NEURO. AFTER EPISODE RESOLVED PT A+OX3. team made aware.GI:ABd softly distended, +BM x2, soft formed. Coronal HASTE, pre and post injection of contrast VIBE sequences were performed. Resp CarePt. Slow rise in Creatinine also noted. LAST K 3.9--WILL RECHECK AFTER DIURESIS. LABILE BP.P-CON'T WITH CURRENT PLAN. Irregularities of the iliacs was noted. Continuing with scheduled oral agents and Nipride. Atrial fibrillation with ventricular response of 60Since last ECG, ST-T changes less evidentAbnormal ECG Nipride changed to nitro to keep sys <180. CHIEF C/O DROWSINESS.NEURO: A+O X3 BUT NEEDS PRODING. ho aware, pt remains in fib flutter. SERAX STARTED FOR DT PREVENTION. NIPRIDE GTT. IMPRESSION: 1) There is a subacute lacune in the medial aspect of the right thalamus inferiorly. for albuterol nebs which wre given with good effect. Stroke.Height: (in) 71Weight (lb): 197BSA (m2): 2.10 m2BP (mm Hg): 179/91Status: InpatientDate/Time: at 15:32Test: Portable TTE(Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is mildly dilated.LEFT VENTRICLE: There is mild symmetric left ventricular hypertrophy. There is mild symmetric left ventricularhypertrophy. The aortic valve leaflets are mildlythickened. GLYCOPYRROLATE GIVEN BY DR. . Views are technicallysuboptimal for assessment of ventricular systolic function. The left, right and main portal veins are patent with appropriate hepatopetal flow. LAST B/P 132/59. haldol given, pt calmer after several minutes, but a-line had been dislodged, as well as periph iv. Continues to be medicated with schedule Serax with associated lethargy. There is irregularity of the distal left vertebral artery and the mid basilar artery suggesting mild stenoses. The appearance is consistent with a subacute lacune. Atrial fibrillation with a slow ventricular response. TECHNIQUE: Multiplanar T1-weighted images, axial T2-weighted, proton density, FLAIR, susceptibility and diffusion-weighted images were obtained. UA sent with lytes per rec's. RECHECK K+. DENIED NEURO COMPLAINTS. Evaluation for secondary causes of hypertension. Punctate hemosiderin is noted near the left MCA infarct and in the left thalamus. NPN-Condition updateSee ICU flowsheet. FOLEY CATH PATENT. There is nosignificant aortic valve stenosis. The diffusion- weighted images show a small area of impaired diffusion in the anterior medial right thalamus. NIPRIDE GTT TITRATED ACCORDINGLY TO KEEP SBP 150-170. There is an old lacune in the left corona radiata and old lacunes in both thalami dorsally. cuff bp's are lower than a-line bp's, ntg drip is off. HO NOTIFIED TO EVALUATE. Pt reamins on serax for etoh withdrawal. +PP. DENIES CARDIAC COMPLAINTS. PUPILS EQUAL, 1MM, REACTIVE. Compared to the previoustracing of the axis is now leftward. renal follwoing-proable u/s tomorrow.Pain:none.Endo: borderline BS-covered per s.s. given albuterol 2.5mg/atrovent5cc neb x3 on noc. HTN CONTINUES DESPITE AGENTS. MONITOR FOR DT. Hydralazine and adamet increased.RESP:periodic wheezing noted with act. Sleepy but easily arousable.CV:Remains hypertensive to 240's over 120's. +BS. Mild (1+) mitralregurgitation is seen.TRICUSPID VALVE: The pulmonary artery systolic pressure could not bedetermined.PULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appearstructurally normal with physiologic pulmonic regurgitation.GENERAL COMMENTS: Suboptimal image quality due to poor echo windows.Suboptimal image quality as the patient was difficult to position.Conclusions:The left atrium is mildly dilated. NEEDS PT CONSULT. Bs: diminished to audible exp wheezes, with sats 94-100% on ra.Has gd. STARTED ON PO MEDS WITH MUCH EFFORT. HO AND NEURO MED SERVICE AWARE OF INABILITY TO WEAN SNP.A: WILL CONTINUE TO INCREASE HYDRALAZINE. ARRIVED IN ED WITH SLURRED SPEECH, DROWSINESS, UNSTEADY GAIT. neb given x1. b lower by cuff, ntg remains off . Being worked up for secondary causes of HTN. REASON FOR THIS EXAMINATION: Pt. PLAN ABD MRI IN AM CHECKLIST HAS BEEN SENT, ORDER ON FILE. Admitted for sub acute R thalamic lacunar infarct; has had uncontrolled HTN on multiple meds. IMPRESSION: 1. IMPRESSION: 1. Pt. O2 SAT 98% 2LNC.GI-ABD ROUND, SOFTLY DISTENDED, NT. DENIES HA OR PAIN. Please perform RUQ US as well. SERAX AS ORDERED. GOAL IS TO TRANSFER TO FLOOR AFTER BLOOD PRESSURE IS BETTER CONTROLLED. The hepatic veins are patent with appropriate flow. THEN MRI DONE SHOWED NEW INFARCT R MEDIAL THALAMIC. Probable new dx of DM per team. B/P WAS AN ISSUE AND PT WAS MEDICATED FISRT LINE NIPRIDE WHICH HAD MINIMAL EFFECT ON B/P AND IT WAS THOUGHT PATIENT WOULD DO BETTER ON NITRO DRIP. Hypertensionremains extremely labile with systolics >200. No aortic regurgitation is seen.MITRAL VALVE: The mitral valve leaflets are mildly thickened. WILL NEED NEW PIV FOR CONTRAST. K+ 3.3 THIS AM. NARD, RR 10'S. K+ THEN 3.7. MRA OF THE HEAD CLINICAL HISTORY: CVA. PERLA. Appropriate portal blood flow. Breath sounds sl course at rest but does become dyspneic with audible insp/exp wheezes. IV SITE WNL. AT THAT TIME HE MAINTAINED A B/P SYSTOLICALLY 150'S TO 200'S AND THAT WAS ACCEPTABLE BY MDS. N.O. MONITOR NEURO STATUS. MRA of the abdominal aorta and the renal arteries demonstrated irregularities of the aorta intrarenally. HR AND SBP IMPROVED. HAD HEAD CT WHICH WAS WITHOUT CHANGES. 1:1 SITTER FOR SAFETY. There is variation in precordiallead placement and a generalized decrease in voltage which may be due to thelatter. CONDITION UPDATE PATIENT CONTINUES ON ATC SERAX FOR WITHDRAWAL WITH GOOD EFFECT. Evaluate for ascites and portal blood flow. WILL R/O WITH SERIAL CK'S AND CHECK TROPONIN LEVELNO MAJOR RESP ISSUES SAO2 ON 4L NP ~ 98-100%; CTA BILGU/GI: ELEVATED BUN/CR 32/2.5. TOL PO'S WITHOUT N/V. CUFF COMPRABLE TO A LINE. IMPRESSION: There is slight motion artifact. Mild(1+) mitral regurgitation is seen.No cardiac source of embolus identified but cannot exclude. PATIENT/TEST INFORMATION:Indication: Left ventricular function. ADMITTED TO SICU FROM ER ON ON SNP FOR BLOOD PRESSURE CONTROL. The leftventricular cavity size is normal.AORTA: The aortic root is normal in diameter.AORTIC VALVE: The aortic valve leaflets are mildly thickened."},"n_notes":{"kind":"number","value":17,"string":"17"},"notes":{"kind":"list like","value":[{"category":"Echo","chartdate":"2114-08-22 00:00:00.000","description":"Report","row_id":100732,"text":"PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Stroke.\nHeight: (in) 71\nWeight (lb): 197\nBSA (m2): 2.10 m2\nBP (mm Hg): 179/91\nStatus: Inpatient\nDate/Time: at 15:32\nTest: Portable TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is mildly dilated.\n\nLEFT VENTRICLE: There is mild symmetric left ventricular hypertrophy. The left\nventricular cavity size is normal.\n\nAORTA: The aortic root is normal in diameter.\n\nAORTIC VALVE: The aortic valve leaflets are mildly thickened. There is no\nsignificant aortic valve stenosis. No aortic regurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. Mild (1+) mitral\nregurgitation is seen.\n\nTRICUSPID VALVE: The pulmonary artery systolic pressure could not be\ndetermined.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appear\nstructurally normal with physiologic pulmonic regurgitation.\n\nGENERAL COMMENTS: Suboptimal image quality due to poor echo windows.\nSuboptimal image quality as the patient was difficult to position.\n\nConclusions:\nThe left atrium is mildly dilated. There is mild symmetric left ventricular\nhypertrophy. The left ventricular cavity size is normal. Views are technically\nsuboptimal for assessment of ventricular systolic function. There may be\ninferior/inferolateral hypokinesis but segments are not well visualized\n(estimated ejection fraction ?45-50%). The aortic valve leaflets are mildly\nthickened. There is no significant aortic valve stenosis. No aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. Mild\n(1+) mitral regurgitation is seen.\nNo cardiac source of embolus identified but cannot exclude.\n\n\n"},{"category":"ECG","chartdate":"2114-08-23 00:00:00.000","description":"Report","row_id":293302,"text":"Atrial fibrillation with ventricular response of 60\nSince last ECG, ST-T changes less evident\nAbnormal ECG\n\n"},{"category":"ECG","chartdate":"2114-08-21 00:00:00.000","description":"Report","row_id":293303,"text":"Atrial fibrillation with a slow ventricular response. Compared to the previous\ntracing of the axis is now leftward. There is variation in precordial\nlead placement and a generalized decrease in voltage which may be due to the\nlatter. No diagnostic change.\n\n"},{"category":"Radiology","chartdate":"2114-08-23 00:00:00.000","description":"DUPLEX DOPP ABD/PEL","row_id":741468,"text":" 8:20 AM\n US ABD LIMIT, SINGLE ORGAN; DUPLEX DOPP ABD/PEL Clip # \n Reason: H/O ESOPHAGEAL VARICES ,ETOH,CIRRHOSIS ,EVAL FOR ASCITES ,PV PATENCY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with h/o varices and etoh abuse\n REASON FOR THIS EXAMINATION:\n Patient with h/o esophageal varices and etoh abuse. Please evaluate for\n ascities and portal blood flow. Please perform RUQ US as well.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of esophageal varices and alcohol abuse. Evaluate for\n ascites and portal blood flow.\n\n FINDINGS: A limited ultrasound examination of the liver was performed with\n Doppler flow studies. The parenchyma of the liver has increased echogenicity\n consistent with fatty infiltration. The left, right and main portal veins are\n patent with appropriate hepatopetal flow. The hepatic veins are patent with\n appropriate flow. There is no ascites present.\n\n IMPRESSION:\n\n 1. Appropriate portal blood flow.\n\n 2. No ascites.\n\n 3. Echogenic liver consistent with fatty infiltration. Other forms of liver\n disease and more advanced liver disease, including significant hepatic\n fibrosis/cirrhosis, cannot be excluded on this study.\n\n\n"},{"category":"Radiology","chartdate":"2114-08-21 00:00:00.000","description":"MR HEAD NEURO","row_id":741378,"text":" 4:08 PM\n MR-ANGIO HEAD; MR HEAD NEURO Clip # \n MR RECONSTRUCTION IMAGING\n Reason: r/o acute stroke...3 hours of slurred speech, left facial dr\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with ?stroke\n REASON FOR THIS EXAMINATION:\n r/o acute stroke...3 hours of slurred speech, left facial droop, left upper\n extremity weakness..drowsiness..\n\n needs MRI with DWI and MRA\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Acute onset of slurred speech, left facial droop and left\n upper extremity weakness.\n\n TECHNIQUE: Multiplanar T1-weighted images, axial T2-weighted, proton density,\n FLAIR, susceptibility and diffusion-weighted images were obtained.\n\n FINDINGS: There is slight motion on several of the images. The diffusion-\n weighted images show a small area of impaired diffusion in the anterior medial\n right thalamus. Only faint hyperintensity is seen in this region on the FLAIR\n images and no T2 hyperintensities seen. The appearance is consistent with a\n subacute lacune.\n\n No acute cerebral cortical infarct is seen. As seen on the CT there are old\n infarcts within both MCA territories, more extensive on the right than the\n left. Punctate hemosiderin is noted near the left MCA infarct and in the left\n thalamus. There is an old lacune in the left corona radiata and old lacunes in\n both thalami dorsally.\n\n IMPRESSION:\n 1) There is a subacute lacune in the medial aspect of the right thalamus\n inferiorly.\n 2) There are old infarcts in both MCA territories as well as old bilateral\n lacunes.\n\n MRA OF THE HEAD\n\n CLINICAL HISTORY: CVA.\n\n TECHNIQUE: A 3D time of flight study was derived from overlapping axial slabs\n through the inferior cranium. There is slight motion artifact.\n\n Allowing for the artifact there is good flow in the distal internal carotid\n arteries, the distal vertebral arteries, and the basilar artery. There is\n irregularity of the distal left vertebral artery and the mid basilar artery\n suggesting mild stenoses. There is symmetric flow in the proximal cerebral\n arteries.\n\n IMPRESSION: There is slight motion artifact. There is probably a mild\n mid basilar stenosis and possible stenosis in the distal left vertebral\n (Over)\n\n 4:08 PM\n MR-ANGIO HEAD; MR HEAD NEURO Clip # \n MR RECONSTRUCTION IMAGING\n Reason: r/o acute stroke...3 hours of slurred speech, left facial dr\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n artery.\n\n\n"},{"category":"Radiology","chartdate":"2114-08-27 00:00:00.000","description":"MR KIDNEY W &W/O CONTRAST","row_id":741669,"text":" 10:16 AM\n MR KIDNEY ANGIOGRAM; MR KIDNEY W &W/O CONTRAST Clip # \n MR RECONSTRUCTION IMAGING\n Reason: Pt. with uncontrolled HTN on multiple anti-hypetensives. \n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with s/p CVA, A-fib, and HTN. Admitted for sub acute R thalamic\n lacunar infarct; has had uncontrolled HTN on multiple meds. Slow rise in\n Creatinine also noted. Being worked up for secondary causes of HTN.\n REASON FOR THIS EXAMINATION:\n Pt. with uncontrolled HTN on multiple anti-hypetensives. Need to get gadolinium\n MRA to assess for renal artery stenosis.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72 year old man status post CVA, atrial fibrillation and\n hypertension. Admitted for acute right lacunar infarct with uncontrolled\n hypertension on multiple medications. Evaluation for secondary causes of\n hypertension.\n\n TECHNIQUE: T1 axial in and out of phase. Coronal HASTE, pre and post injection\n of contrast VIBE sequences were performed. Reformatted images of the renal\n arteries were obtained using MPR and MIP.\n\n Findings: The left kidney measures 10.2 cm without hydronephrosis. The right\n kidney measures 10 cm in its sagittal length without hydronephrosis. MRA of\n the abdominal aorta and the renal arteries demonstrated irregularities of the\n aorta intrarenally. Irregularities of the iliacs was noted. Single renal\n arteries were found on both sides without evidence of narrowing of the renal\n arteries. At the lower pole of the left kidney a wedge shaped region was found\n without evidence of enhancement corresponding presumably To an old infarct. In\n the left kidney on the posterior medial and at the upper pole an hypointense\n lesion relative to the renal parenchyma was found on the HASTE sequence\n measuring about 1 cm. This area showed early\n arterial enhancement. This was evident also on the venous phase. The liver\n pancreas and spleen are unremarkable.\n\n IMPRESSION: 1. Atheromatous changes in the infrarenal portion of the abdominal\n aorta without evidence of renal artery stenosis.\n 2. 1 cm lesion with hypointense signal on the HASTE sequence in the medial\n upper posterior part of the left kidney. This lesion shows early enhancement\n - 6 month follow up is recommended.\n\n\n\n\n"},{"category":"Nursing/other","chartdate":"2114-08-25 00:00:00.000","description":"Report","row_id":1457492,"text":"focus: neuro\ndaata: pt becoming confused, staating thaaat he was being kidnapped and kept in the hospital against his will. pt tried to get oob in repeated attempts. posey belt applied. pt actually untied the belt and continued to attempt to get oob. nursing co-worker sitting in room witgh pt, when he began to pull out his aline and become combative. five nurses, resp therapist in room, ho called. attempt to med pt with haldol difficult due to tenuous iv. haldol given, pt calmer after several minutes, but a-line had been dislodged, as well as periph iv. cuff bp's are lower than a-line bp's, ntg drip is off. pt is sedate now, sleeping soundly. he awakens with stimulation, but remains quite sleepy.\n"},{"category":"Nursing/other","chartdate":"2114-08-25 00:00:00.000","description":"Report","row_id":1457493,"text":"Resp Care\nPt. given albuterol 2.5mg/atrovent5cc neb x3 on noc. Bs: diminished to audible exp wheezes, with sats 94-100% on ra.Has gd. responce to tx, will follow. Pt. attempts to get oob as sedation wears off.\n"},{"category":"Nursing/other","chartdate":"2114-08-25 00:00:00.000","description":"Report","row_id":1457494,"text":"cardiovascular\ndata: hr drops into the 20's at times. ho aware, pt remains in fib flutter. b lower by cuff, ntg remains off . pt continues to be confused.\n"},{"category":"Nursing/other","chartdate":"2114-08-25 00:00:00.000","description":"Report","row_id":1457495,"text":"CONDITION UPDATE\n PATIENT CONTINUES ON ATC SERAX FOR WITHDRAWAL WITH GOOD EFFECT. 1:1 SITTER FOR SAFETY. DENIES HA OR PAIN. EQUAL STRENGTH BILATERALLY.\n B/P WITH BETTER CONTROL TAKING PO MEDS WITH ENCOURAGEMENT.\n TRANSFER TO FLOOR WHEN BED AVAILABLE\n CONTINUE TO MONITOR ALL PARAMETERS\n"},{"category":"Nursing/other","chartdate":"2114-08-26 00:00:00.000","description":"Report","row_id":1457496,"text":"CONTINUES WITH LOW HEART RATE ( HIGH TEENS, LOW 20'S AND UP TO 40'S) IN AFIB PER MP AND EKG. HO NOTIFIED TO EVALUATE. PADS PLACED AND CODE MASTER SET IN THE EVENT OF PACER NEED. ATROPINE AT THE BEDSIDE. HTN CONTINUES DESPITE AGENTS. PT ALERT AND ORIENTED X3 ALTHOUGH LETHARGIC. SAO2 98-100% URINE OUTS SUFFICIENT\n"},{"category":"Nursing/other","chartdate":"2114-08-26 00:00:00.000","description":"Report","row_id":1457497,"text":"TRANSFER NOTE\n PATIENT A 72 YO MAN WITH HISTORY OF CVA ,HTN, ETOH ABUSE, AFIB , AND ESOPH VARICES. ARRIVED IN ED WITH SLURRED SPEECH, DROWSINESS, UNSTEADY GAIT. BECAUSE OF DROWSINESS HE HAD HEAD CT WHICH SHOWED OLD CVA AND ATROPHY. NO NEW EVENT NOTED. THEN MRI DONE SHOWED NEW INFARCT R MEDIAL THALAMIC. HOWEVER EXAM SHOWED MINIMAL DEFICITS.\n B/P WAS AN ISSUE AND PT WAS MEDICATED FISRT LINE NIPRIDE WHICH HAD MINIMAL EFFECT ON B/P AND IT WAS THOUGHT PATIENT WOULD DO BETTER ON NITRO DRIP. HE CONTINUED ON DRIP UNTIL MIDNOC FRIDAY WHEN HE BECAME UNRULY AND PULLED OUT HIS IV AND A-LINE. AT THAT TIME HE MAINTAINED A B/P SYSTOLICALLY 150'S TO 200'S AND THAT WAS ACCEPTABLE BY MDS. STARTED ON PO MEDS WITH MUCH EFFORT. DOSES CHANGED AND AFTER A TROUBLE SOME DAY SATURDAY WITH PRESSURES TO 200'S/ 90'S AND HEART RATE TO THE TEENS TODAY HE SEEMS MUCH BETTER BOTH PHYSICALLY AND MENTALLY.\n COOP WITH ALL CARE TODAY TAKING MEDS AND FOOD TOLERATING BOTH WELL.\nCLEARER WITH SPEECH AND THOUGHTS. A&OX3 PERLA EQUAL STRENGTH BIL.\n PLAN ABD MRI IN AM CHECKLIST HAS BEEN SENT, ORDER ON FILE. WILL NEED NEW PIV FOR CONTRAST. NEEDS PT CONSULT. 24 HOUR URINE COLLECTION NEEDS TO BE DONE. HE WAS UP TO CHAIR ALL DAY HEART RATE IN 30'S TO 40'S . LAST B/P 132/59. AFEBRILE SAT 100 % RA. NO C/O PAI. FOLEY CATH PATENT. IF HE DOES AN INCIDENT OF BRADYCARDIA TO TEENS AND TWENTYS HE NEED PACEMAKER. HOWEVER HIS PRIMARY CARE MD WANTS TO GIVE HIM 48-72 HOURS TO BOUNCE BACK HIMSELF.\n\n"},{"category":"Nursing/other","chartdate":"2114-08-23 00:00:00.000","description":"Report","row_id":1457489,"text":"NSG PROGRESS NOTE\nSEE FLOWSHEET FOR SPECIFICS\n\nNEURO-PT HAD SEIZURE THIS AM LASTING APPROX 30 SECS. NO CLONIC/TONIC MOVEMENT NOTED. TEAM AWARE AND IN TO WITNESS. HR DOWN TO 30'S, SBP FELL TO 60. GLYCOPYRROLATE GIVEN BY DR. . HR AND SBP IMPROVED. AFTER EPISODE RESOLVED PT A+OX3. MAE. NORMAL EQUAL STRENGTH. PUPILS EQUAL, 1MM, REACTIVE. DENIED NEURO COMPLAINTS. HAD HEAD CT WHICH WAS WITHOUT CHANGES. NO FURTHER EPISODES NOTED. SERAX STARTED FOR DT PREVENTION. TCD DONE.\n\nCV-PT IN AFLUTTER, RATE 50-60'S. SBP VERY LABILE, DOWN TO 90 WHEN ASLEEP THEN UP TO 200'S AT TIMES. NIPRIDE GTT TITRATED ACCORDINGLY TO KEEP SBP 150-170. DENIES CARDIAC COMPLAINTS. +PP. IV SITE WNL. K+ 3.3 THIS AM. 40 MEQ PO KCL GIVEN. K+ THEN 3.7. ADDITIONAL 40MEQ KCL GIVEN. WILL RECHECK K+ THIS PM.\n\nRESP-LS ESSENTIALLY CTA. NARD, RR 10'S. O2 SAT 98% 2LNC.\n\nGI-ABD ROUND, SOFTLY DISTENDED, NT. +BS. TOL PO'S WITHOUT N/V. HAD ABD U/S TODAY.\n\nGU-VOIDED SPONT VIA URINAL ADEQ AMT CL YELLOW URINE.\n\nACT-MAE. MOVES I IN BED. BR MAINTAINED.\n\nCOMFORT-DENIES PAIN.\n\nA-SEIZURE THIS AM. CON'T IN AFIB. LABILE BP.\n\nP-CON'T WITH CURRENT PLAN. MONITOR FOR CHANGES. MONITOR NEURO STATUS. NIPRIDE GTT. RECHECK K+. MONITOR FOR DT. SERAX AS ORDERED.\n"},{"category":"Nursing/other","chartdate":"2114-08-24 00:00:00.000","description":"Report","row_id":1457490,"text":"NPN-Condition update\nSee ICU flowsheet. No seizure activity noted. Continues to be medicated with schedule Serax with associated lethargy. Does become irritated at staff while providing necessary cares. Hypertensionremains extremely labile with systolics >200. Continuing with scheduled oral agents and Nipride. Plan is to increase oral agents today. Breath sounds sl course at rest but does become dyspneic with audible insp/exp wheezes. N.O. for albuterol nebs which wre given with good effect. NPO tonight for possible upper GI today. Voiding clear light amber urine.\n"},{"category":"Nursing/other","chartdate":"2114-08-24 00:00:00.000","description":"Report","row_id":1457491,"text":"nursing update\nNeuro:remains neurologically intact. PERLA. no weakness or numbness noted. No seizure activy noted. no withdrawal symotoms notes. Pt reamins on serax for etoh withdrawal. Sleepy but easily arousable.\nCV:Remains hypertensive to 240's over 120's. Nipride changed to nitro to keep sys <180. Norvasc and clonidine added to regimen. Hydralazine and adamet increased.\nRESP:periodic wheezing noted with act. neb given x1. lasix 20 mg po for +crackles at bases. Mod prod cough of thick white sputum. ? of aspiration noted during lunch and dinner- Pt coughing on food. WIfe states he does this at home sometimes-coughs up food in bathroom after eating. team made aware.\nGI:ABd softly distended, +BM x2, soft formed. Tol 1800 diet. no nausea/vomiting.\nGU:voided x1 today. pt feeling urge but unable to void. foley placed for 200cc dark yellow urine. UA sent with lytes per rec's. renal follwoing-proable u/s tomorrow.\nPain:none.\nEndo: borderline BS-covered per s.s. Probable new dx of DM per team.\n\n\n"},{"category":"Nursing/other","chartdate":"2114-08-22 00:00:00.000","description":"Report","row_id":1457487,"text":"PT ADMITTED TO SICU IN NAD ACCOMPANIED WITH WIFE. CHIEF C/O DROWSINESS.\nNEURO: A+O X3 BUT NEEDS PRODING. SPEECH IMPROVED. PERL BRISKLY, EQUAL STRENGTH BIL. MOVES SIDE TO SIDE INDEPENDANT.\n\nCARDIO/PULM: PER MP A-FLUTTER WITH RATE DROPS TO 35 RANGE. NO CHANGE IN BP. EKG SHOWS A-FIB. WILL R/O WITH SERIAL CK'S AND CHECK TROPONIN LEVEL\nNO MAJOR RESP ISSUES SAO2 ON 4L NP ~ 98-100%; CTA BIL\n\nGU/GI: ELEVATED BUN/CR 32/2.5. WILL NEED TO EVALUATE H/O ESPHAGEAL VARICES AND CHECK IF PT IS COUMADIN CANDIDATE IN VIEW OF HIS KNOW ALCOHOL ABUSE\n\nSHX: RETIRED POLICE, LIVES WITH WIFE. (+ CIGS/ETOH )\n\nPLAN: PER NEURO. WILL MONITOR NEURO STATUS CLOSELY AND CONTINUE NIPRIDE FOR BP CONTROL.\n"},{"category":"Nursing/other","chartdate":"2114-08-22 00:00:00.000","description":"Report","row_id":1457488,"text":"FOCUS: CONDITION UPDATE\nD: PATIENT S/P EMBOLIC STROKE (SEEN ON MRI). ADMITTED TO SICU FROM ER ON ON SNP FOR BLOOD PRESSURE CONTROL. ON NEURO-MED SERVICE. TODAY PATIENT HAS BEEN ALERT AND ORIENTED TIMES THREE. HAS REMAINED ON SNP FROM 0.4-0.8 MCG/KG/MIN. UNABLE TO WEAN OFF. GOAL IS TO KEEP SBP<180, YET BP GOES AS HIGH AS 225/ WHEN WEANING SNP. CURRENTLY ON HYDRALAZINE (30 MG PO Q 6)/ALDOMET/COSAR AND RECEIVED LASIX 20 MG IVP AT 1800. CUFF COMPRABLE TO A LINE. HO AND NEURO MED SERVICE AWARE OF INABILITY TO WEAN SNP.\nA: WILL CONTINUE TO INCREASE HYDRALAZINE. MONITOR URINE OUTPUT. LAST K 3.9--WILL RECHECK AFTER DIURESIS. NEUROLOGICALY STABLE. GOAL IS TO TRANSFER TO FLOOR AFTER BLOOD PRESSURE IS BETTER CONTROLLED.\n"}],"string":"[\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2114-08-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 100732,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Left ventricular function. Stroke.\\nHeight: (in) 71\\nWeight (lb): 197\\nBSA (m2): 2.10 m2\\nBP (mm Hg): 179/91\\nStatus: Inpatient\\nDate/Time: at 15:32\\nTest: Portable TTE(Complete)\\nDoppler: Complete pulse and color flow\\nContrast: None\\nTechnical Quality: Suboptimal\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT ATRIUM: The left atrium is mildly dilated.\\n\\nLEFT VENTRICLE: There is mild symmetric left ventricular hypertrophy. The left\\nventricular cavity size is normal.\\n\\nAORTA: The aortic root is normal in diameter.\\n\\nAORTIC VALVE: The aortic valve leaflets are mildly thickened. There is no\\nsignificant aortic valve stenosis. No aortic regurgitation is seen.\\n\\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. Mild (1+) mitral\\nregurgitation is seen.\\n\\nTRICUSPID VALVE: The pulmonary artery systolic pressure could not be\\ndetermined.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appear\\nstructurally normal with physiologic pulmonic regurgitation.\\n\\nGENERAL COMMENTS: Suboptimal image quality due to poor echo windows.\\nSuboptimal image quality as the patient was difficult to position.\\n\\nConclusions:\\nThe left atrium is mildly dilated. There is mild symmetric left ventricular\\nhypertrophy. The left ventricular cavity size is normal. Views are technically\\nsuboptimal for assessment of ventricular systolic function. There may be\\ninferior/inferolateral hypokinesis but segments are not well visualized\\n(estimated ejection fraction ?45-50%). The aortic valve leaflets are mildly\\nthickened. There is no significant aortic valve stenosis. No aortic\\nregurgitation is seen. The mitral valve leaflets are mildly thickened. Mild\\n(1+) mitral regurgitation is seen.\\nNo cardiac source of embolus identified but cannot exclude.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2114-08-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 293302,\n \"text\": \"Atrial fibrillation with ventricular response of 60\\nSince last ECG, ST-T changes less evident\\nAbnormal ECG\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2114-08-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 293303,\n \"text\": \"Atrial fibrillation with a slow ventricular response. Compared to the previous\\ntracing of the axis is now leftward. There is variation in precordial\\nlead placement and a generalized decrease in voltage which may be due to the\\nlatter. No diagnostic change.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2114-08-23 00:00:00.000\",\n \"description\": \"DUPLEX DOPP ABD/PEL\",\n \"row_id\": 741468,\n \"text\": \" 8:20 AM\\n US ABD LIMIT, SINGLE ORGAN; DUPLEX DOPP ABD/PEL Clip # \\n Reason: H/O ESOPHAGEAL VARICES ,ETOH,CIRRHOSIS ,EVAL FOR ASCITES ,PV PATENCY\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 72 year old man with h/o varices and etoh abuse\\n REASON FOR THIS EXAMINATION:\\n Patient with h/o esophageal varices and etoh abuse. Please evaluate for\\n ascities and portal blood flow. Please perform RUQ US as well.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: History of esophageal varices and alcohol abuse. Evaluate for\\n ascites and portal blood flow.\\n\\n FINDINGS: A limited ultrasound examination of the liver was performed with\\n Doppler flow studies. The parenchyma of the liver has increased echogenicity\\n consistent with fatty infiltration. The left, right and main portal veins are\\n patent with appropriate hepatopetal flow. The hepatic veins are patent with\\n appropriate flow. There is no ascites present.\\n\\n IMPRESSION:\\n\\n 1. Appropriate portal blood flow.\\n\\n 2. No ascites.\\n\\n 3. Echogenic liver consistent with fatty infiltration. Other forms of liver\\n disease and more advanced liver disease, including significant hepatic\\n fibrosis/cirrhosis, cannot be excluded on this study.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2114-08-21 00:00:00.000\",\n \"description\": \"MR HEAD NEURO\",\n \"row_id\": 741378,\n \"text\": \" 4:08 PM\\n MR-ANGIO HEAD; MR HEAD NEURO Clip # \\n MR RECONSTRUCTION IMAGING\\n Reason: r/o acute stroke...3 hours of slurred speech, left facial dr\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 72 year old man with ?stroke\\n REASON FOR THIS EXAMINATION:\\n r/o acute stroke...3 hours of slurred speech, left facial droop, left upper\\n extremity weakness..drowsiness..\\n\\n needs MRI with DWI and MRA\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL HISTORY: Acute onset of slurred speech, left facial droop and left\\n upper extremity weakness.\\n\\n TECHNIQUE: Multiplanar T1-weighted images, axial T2-weighted, proton density,\\n FLAIR, susceptibility and diffusion-weighted images were obtained.\\n\\n FINDINGS: There is slight motion on several of the images. The diffusion-\\n weighted images show a small area of impaired diffusion in the anterior medial\\n right thalamus. Only faint hyperintensity is seen in this region on the FLAIR\\n images and no T2 hyperintensities seen. The appearance is consistent with a\\n subacute lacune.\\n\\n No acute cerebral cortical infarct is seen. As seen on the CT there are old\\n infarcts within both MCA territories, more extensive on the right than the\\n left. Punctate hemosiderin is noted near the left MCA infarct and in the left\\n thalamus. There is an old lacune in the left corona radiata and old lacunes in\\n both thalami dorsally.\\n\\n IMPRESSION:\\n 1) There is a subacute lacune in the medial aspect of the right thalamus\\n inferiorly.\\n 2) There are old infarcts in both MCA territories as well as old bilateral\\n lacunes.\\n\\n MRA OF THE HEAD\\n\\n CLINICAL HISTORY: CVA.\\n\\n TECHNIQUE: A 3D time of flight study was derived from overlapping axial slabs\\n through the inferior cranium. There is slight motion artifact.\\n\\n Allowing for the artifact there is good flow in the distal internal carotid\\n arteries, the distal vertebral arteries, and the basilar artery. There is\\n irregularity of the distal left vertebral artery and the mid basilar artery\\n suggesting mild stenoses. There is symmetric flow in the proximal cerebral\\n arteries.\\n\\n IMPRESSION: There is slight motion artifact. There is probably a mild\\n mid basilar stenosis and possible stenosis in the distal left vertebral\\n (Over)\\n\\n 4:08 PM\\n MR-ANGIO HEAD; MR HEAD NEURO Clip # \\n MR RECONSTRUCTION IMAGING\\n Reason: r/o acute stroke...3 hours of slurred speech, left facial dr\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n artery.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2114-08-27 00:00:00.000\",\n \"description\": \"MR KIDNEY W &W/O CONTRAST\",\n \"row_id\": 741669,\n \"text\": \" 10:16 AM\\n MR KIDNEY ANGIOGRAM; MR KIDNEY W &W/O CONTRAST Clip # \\n MR RECONSTRUCTION IMAGING\\n Reason: Pt. with uncontrolled HTN on multiple anti-hypetensives. \\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 72 year old man with s/p CVA, A-fib, and HTN. Admitted for sub acute R thalamic\\n lacunar infarct; has had uncontrolled HTN on multiple meds. Slow rise in\\n Creatinine also noted. Being worked up for secondary causes of HTN.\\n REASON FOR THIS EXAMINATION:\\n Pt. with uncontrolled HTN on multiple anti-hypetensives. Need to get gadolinium\\n MRA to assess for renal artery stenosis.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 72 year old man status post CVA, atrial fibrillation and\\n hypertension. Admitted for acute right lacunar infarct with uncontrolled\\n hypertension on multiple medications. Evaluation for secondary causes of\\n hypertension.\\n\\n TECHNIQUE: T1 axial in and out of phase. Coronal HASTE, pre and post injection\\n of contrast VIBE sequences were performed. Reformatted images of the renal\\n arteries were obtained using MPR and MIP.\\n\\n Findings: The left kidney measures 10.2 cm without hydronephrosis. The right\\n kidney measures 10 cm in its sagittal length without hydronephrosis. MRA of\\n the abdominal aorta and the renal arteries demonstrated irregularities of the\\n aorta intrarenally. Irregularities of the iliacs was noted. Single renal\\n arteries were found on both sides without evidence of narrowing of the renal\\n arteries. At the lower pole of the left kidney a wedge shaped region was found\\n without evidence of enhancement corresponding presumably To an old infarct. In\\n the left kidney on the posterior medial and at the upper pole an hypointense\\n lesion relative to the renal parenchyma was found on the HASTE sequence\\n measuring about 1 cm. This area showed early\\n arterial enhancement. This was evident also on the venous phase. The liver\\n pancreas and spleen are unremarkable.\\n\\n IMPRESSION: 1. Atheromatous changes in the infrarenal portion of the abdominal\\n aorta without evidence of renal artery stenosis.\\n 2. 1 cm lesion with hypointense signal on the HASTE sequence in the medial\\n upper posterior part of the left kidney. This lesion shows early enhancement\\n - 6 month follow up is recommended.\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2114-08-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1457492,\n \"text\": \"focus: neuro\\ndaata: pt becoming confused, staating thaaat he was being kidnapped and kept in the hospital against his will. pt tried to get oob in repeated attempts. posey belt applied. pt actually untied the belt and continued to attempt to get oob. nursing co-worker sitting in room witgh pt, when he began to pull out his aline and become combative. five nurses, resp therapist in room, ho called. attempt to med pt with haldol difficult due to tenuous iv. haldol given, pt calmer after several minutes, but a-line had been dislodged, as well as periph iv. cuff bp's are lower than a-line bp's, ntg drip is off. pt is sedate now, sleeping soundly. he awakens with stimulation, but remains quite sleepy.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2114-08-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1457493,\n \"text\": \"Resp Care\\nPt. given albuterol 2.5mg/atrovent5cc neb x3 on noc. Bs: diminished to audible exp wheezes, with sats 94-100% on ra.Has gd. responce to tx, will follow. Pt. attempts to get oob as sedation wears off.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2114-08-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1457494,\n \"text\": \"cardiovascular\\ndata: hr drops into the 20's at times. ho aware, pt remains in fib flutter. b lower by cuff, ntg remains off . pt continues to be confused.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2114-08-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1457495,\n \"text\": \"CONDITION UPDATE\\n PATIENT CONTINUES ON ATC SERAX FOR WITHDRAWAL WITH GOOD EFFECT. 1:1 SITTER FOR SAFETY. DENIES HA OR PAIN. EQUAL STRENGTH BILATERALLY.\\n B/P WITH BETTER CONTROL TAKING PO MEDS WITH ENCOURAGEMENT.\\n TRANSFER TO FLOOR WHEN BED AVAILABLE\\n CONTINUE TO MONITOR ALL PARAMETERS\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2114-08-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1457496,\n \"text\": \"CONTINUES WITH LOW HEART RATE ( HIGH TEENS, LOW 20'S AND UP TO 40'S) IN AFIB PER MP AND EKG. HO NOTIFIED TO EVALUATE. PADS PLACED AND CODE MASTER SET IN THE EVENT OF PACER NEED. ATROPINE AT THE BEDSIDE. HTN CONTINUES DESPITE AGENTS. PT ALERT AND ORIENTED X3 ALTHOUGH LETHARGIC. SAO2 98-100% URINE OUTS SUFFICIENT\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2114-08-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1457497,\n \"text\": \"TRANSFER NOTE\\n PATIENT A 72 YO MAN WITH HISTORY OF CVA ,HTN, ETOH ABUSE, AFIB , AND ESOPH VARICES. ARRIVED IN ED WITH SLURRED SPEECH, DROWSINESS, UNSTEADY GAIT. BECAUSE OF DROWSINESS HE HAD HEAD CT WHICH SHOWED OLD CVA AND ATROPHY. NO NEW EVENT NOTED. THEN MRI DONE SHOWED NEW INFARCT R MEDIAL THALAMIC. HOWEVER EXAM SHOWED MINIMAL DEFICITS.\\n B/P WAS AN ISSUE AND PT WAS MEDICATED FISRT LINE NIPRIDE WHICH HAD MINIMAL EFFECT ON B/P AND IT WAS THOUGHT PATIENT WOULD DO BETTER ON NITRO DRIP. HE CONTINUED ON DRIP UNTIL MIDNOC FRIDAY WHEN HE BECAME UNRULY AND PULLED OUT HIS IV AND A-LINE. AT THAT TIME HE MAINTAINED A B/P SYSTOLICALLY 150'S TO 200'S AND THAT WAS ACCEPTABLE BY MDS. STARTED ON PO MEDS WITH MUCH EFFORT. DOSES CHANGED AND AFTER A TROUBLE SOME DAY SATURDAY WITH PRESSURES TO 200'S/ 90'S AND HEART RATE TO THE TEENS TODAY HE SEEMS MUCH BETTER BOTH PHYSICALLY AND MENTALLY.\\n COOP WITH ALL CARE TODAY TAKING MEDS AND FOOD TOLERATING BOTH WELL.\\nCLEARER WITH SPEECH AND THOUGHTS. A&OX3 PERLA EQUAL STRENGTH BIL.\\n PLAN ABD MRI IN AM CHECKLIST HAS BEEN SENT, ORDER ON FILE. WILL NEED NEW PIV FOR CONTRAST. NEEDS PT CONSULT. 24 HOUR URINE COLLECTION NEEDS TO BE DONE. HE WAS UP TO CHAIR ALL DAY HEART RATE IN 30'S TO 40'S . LAST B/P 132/59. AFEBRILE SAT 100 % RA. NO C/O PAI. FOLEY CATH PATENT. IF HE DOES AN INCIDENT OF BRADYCARDIA TO TEENS AND TWENTYS HE NEED PACEMAKER. HOWEVER HIS PRIMARY CARE MD WANTS TO GIVE HIM 48-72 HOURS TO BOUNCE BACK HIMSELF.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2114-08-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1457489,\n \"text\": \"NSG PROGRESS NOTE\\nSEE FLOWSHEET FOR SPECIFICS\\n\\nNEURO-PT HAD SEIZURE THIS AM LASTING APPROX 30 SECS. NO CLONIC/TONIC MOVEMENT NOTED. TEAM AWARE AND IN TO WITNESS. HR DOWN TO 30'S, SBP FELL TO 60. GLYCOPYRROLATE GIVEN BY DR. . HR AND SBP IMPROVED. AFTER EPISODE RESOLVED PT A+OX3. MAE. NORMAL EQUAL STRENGTH. PUPILS EQUAL, 1MM, REACTIVE. DENIED NEURO COMPLAINTS. HAD HEAD CT WHICH WAS WITHOUT CHANGES. NO FURTHER EPISODES NOTED. SERAX STARTED FOR DT PREVENTION. TCD DONE.\\n\\nCV-PT IN AFLUTTER, RATE 50-60'S. SBP VERY LABILE, DOWN TO 90 WHEN ASLEEP THEN UP TO 200'S AT TIMES. NIPRIDE GTT TITRATED ACCORDINGLY TO KEEP SBP 150-170. DENIES CARDIAC COMPLAINTS. +PP. IV SITE WNL. K+ 3.3 THIS AM. 40 MEQ PO KCL GIVEN. K+ THEN 3.7. ADDITIONAL 40MEQ KCL GIVEN. WILL RECHECK K+ THIS PM.\\n\\nRESP-LS ESSENTIALLY CTA. NARD, RR 10'S. O2 SAT 98% 2LNC.\\n\\nGI-ABD ROUND, SOFTLY DISTENDED, NT. +BS. TOL PO'S WITHOUT N/V. HAD ABD U/S TODAY.\\n\\nGU-VOIDED SPONT VIA URINAL ADEQ AMT CL YELLOW URINE.\\n\\nACT-MAE. MOVES I IN BED. BR MAINTAINED.\\n\\nCOMFORT-DENIES PAIN.\\n\\nA-SEIZURE THIS AM. CON'T IN AFIB. LABILE BP.\\n\\nP-CON'T WITH CURRENT PLAN. MONITOR FOR CHANGES. MONITOR NEURO STATUS. NIPRIDE GTT. RECHECK K+. MONITOR FOR DT. SERAX AS ORDERED.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2114-08-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1457490,\n \"text\": \"NPN-Condition update\\nSee ICU flowsheet. No seizure activity noted. Continues to be medicated with schedule Serax with associated lethargy. Does become irritated at staff while providing necessary cares. Hypertensionremains extremely labile with systolics >200. Continuing with scheduled oral agents and Nipride. Plan is to increase oral agents today. Breath sounds sl course at rest but does become dyspneic with audible insp/exp wheezes. N.O. for albuterol nebs which wre given with good effect. NPO tonight for possible upper GI today. Voiding clear light amber urine.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2114-08-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1457491,\n \"text\": \"nursing update\\nNeuro:remains neurologically intact. PERLA. no weakness or numbness noted. No seizure activy noted. no withdrawal symotoms notes. Pt reamins on serax for etoh withdrawal. Sleepy but easily arousable.\\nCV:Remains hypertensive to 240's over 120's. Nipride changed to nitro to keep sys <180. Norvasc and clonidine added to regimen. Hydralazine and adamet increased.\\nRESP:periodic wheezing noted with act. neb given x1. lasix 20 mg po for +crackles at bases. Mod prod cough of thick white sputum. ? of aspiration noted during lunch and dinner- Pt coughing on food. WIfe states he does this at home sometimes-coughs up food in bathroom after eating. team made aware.\\nGI:ABd softly distended, +BM x2, soft formed. Tol 1800 diet. no nausea/vomiting.\\nGU:voided x1 today. pt feeling urge but unable to void. foley placed for 200cc dark yellow urine. UA sent with lytes per rec's. renal follwoing-proable u/s tomorrow.\\nPain:none.\\nEndo: borderline BS-covered per s.s. Probable new dx of DM per team.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2114-08-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1457487,\n \"text\": \"PT ADMITTED TO SICU IN NAD ACCOMPANIED WITH WIFE. CHIEF C/O DROWSINESS.\\nNEURO: A+O X3 BUT NEEDS PRODING. SPEECH IMPROVED. PERL BRISKLY, EQUAL STRENGTH BIL. MOVES SIDE TO SIDE INDEPENDANT.\\n\\nCARDIO/PULM: PER MP A-FLUTTER WITH RATE DROPS TO 35 RANGE. NO CHANGE IN BP. EKG SHOWS A-FIB. WILL R/O WITH SERIAL CK'S AND CHECK TROPONIN LEVEL\\nNO MAJOR RESP ISSUES SAO2 ON 4L NP ~ 98-100%; CTA BIL\\n\\nGU/GI: ELEVATED BUN/CR 32/2.5. WILL NEED TO EVALUATE H/O ESPHAGEAL VARICES AND CHECK IF PT IS COUMADIN CANDIDATE IN VIEW OF HIS KNOW ALCOHOL ABUSE\\n\\nSHX: RETIRED POLICE, LIVES WITH WIFE. (+ CIGS/ETOH )\\n\\nPLAN: PER NEURO. WILL MONITOR NEURO STATUS CLOSELY AND CONTINUE NIPRIDE FOR BP CONTROL.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2114-08-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1457488,\n \"text\": \"FOCUS: CONDITION UPDATE\\nD: PATIENT S/P EMBOLIC STROKE (SEEN ON MRI). ADMITTED TO SICU FROM ER ON ON SNP FOR BLOOD PRESSURE CONTROL. ON NEURO-MED SERVICE. TODAY PATIENT HAS BEEN ALERT AND ORIENTED TIMES THREE. HAS REMAINED ON SNP FROM 0.4-0.8 MCG/KG/MIN. UNABLE TO WEAN OFF. GOAL IS TO KEEP SBP<180, YET BP GOES AS HIGH AS 225/ WHEN WEANING SNP. CURRENTLY ON HYDRALAZINE (30 MG PO Q 6)/ALDOMET/COSAR AND RECEIVED LASIX 20 MG IVP AT 1800. CUFF COMPRABLE TO A LINE. HO AND NEURO MED SERVICE AWARE OF INABILITY TO WEAN SNP.\\nA: WILL CONTINUE TO INCREASE HYDRALAZINE. MONITOR URINE OUTPUT. LAST K 3.9--WILL RECHECK AFTER DIURESIS. NEUROLOGICALY STABLE. GOAL IS TO TRANSFER TO FLOOR AFTER BLOOD PRESSURE IS BETTER CONTROLLED.\\n\"\n }\n]"}}}],"truncated":false,"partial":false},"paginationData":{"pageIndex":3,"numItemsPerPage":100,"numTotalItems":24993,"offset":300,"length":100}},"jwt":"eyJhbGciOiJFZERTQSJ9.eyJyZWFkIjp0cnVlLCJwZXJtaXNzaW9ucyI6eyJyZXBvLmNvbnRlbnQucmVhZCI6dHJ1ZX0sImlhdCI6MTczODk0NTAwNCwic3ViIjoiL2RhdGFzZXRzL2RtYWNyZXMvbWltaWNpaWktaG9zcGl0YWxjb3Vyc2UtbWV0YSIsImV4cCI6MTczODk0ODYwNCwiaXNzIjoiaHR0cHM6Ly9odWdnaW5nZmFjZS5jbyJ9.sgdqfNoy_snHE-FRYMXIY2c9AvyAO5mjwDqSQZAe0avg66ThUP2cm1-YUZ4B2nJkHgH_xySzm7wZRTbuCVJ3CQ","displayUrls":true},"discussionsStats":{"closed":0,"open":1,"total":1},"fullWidth":true,"hasGatedAccess":true,"hasFullAccess":true,"isEmbedded":false}">
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7,809 | 114,751 | In summary, Ms. is a 54 year old female with type 1 DM complicated gastroparesis and neuropathy, HTN, HCV, admitted to MICU with DKA in setting of gastroparesis flare. . Diabetic Ketoacidosis: Patient intially presented with DKA and AG of 37. Patient had gastroparesis flare and unclear if she was less compliant with her insulin. Infectious workup was unrevealing. Patient was treated with IVF, insulin drip with D5W, and antiemetics. Patient was transitioned from insulin drip to glargine with insulin sliding scale. She was transferred to the floor once her gap closed. On the floor, she continued to use glargine and a humalog sliding scale. She was followed by while in house and will follow up with them on the after discharge. . Type I DM: Patient was diagnosed with Type 1 diabetes 6 years ago. She was found most recently to have a HgA1C of 11.0. She has had multiple recent admission for DKA and her diabetes is complicated by peripheral neuropathy and gastroparesis. She was initially on an insulin drip but then trasitioned to glargine and sliding scale. She was followed by and will follow up. . Gastroparesis: Patient complains of nausea, and abdominal pain due to gastroparesis. Gastric emptying study in showed markedly delayed gastric emptying and esophageal stasis. She was started on hyocyamine SL, an anticholinergic that causes GI smooth muscle relaxation. She was started on standing tylenol with PRN NSAIDS and oxycodone. She was continued on standing reglan. She was treated with zofran as needed for nausea. . Peripheral neuropathy: Patient reported severe leg pain due to peripheral neuropathy. She was continued on gabapentin and amytriptyline. She was also placed on standing tylenol with PRN NSAIDS and oxycodone for pain control. . Grave's Disease: Patient has history of disease s/p radioablation. Patient's TSH has alternated from being suppressed and being elevated over the past year. On admission, TSH was found to be undetectable with elevated free T4 but normal T3. It was difficult to interpret these result in the setting of acute illness. There was concern for medication noncompliance at home. She was continued on methimazole at 15 mg and started on propanolol to inhibit convesion of T4 to T3. She did not appear thyrotoxic on exam. She was followed by endocrine. She will need outpatient radioablation as she is refusing surgery. She will need her TFTs checked as an outpatient. She will needs outpatient opthalmology follow-up. Her outpatient physician at who follows her thyroid was made aware. . Depression: Patient is on amitryptyline at home, however serum tox was negative for TCAs on admission, suggesting that patient is either noncompliant or was unable to tolerate it due to gastroparesis/DKA. Patient's utox also positive for Benzos though patients was not known to be prescribed benzos. She was followed by social work because there was concern that an unstable home environment contributed her her multiple admissions. Social work filled out paperwork for the patient to obtain "The Ride" so she is able to get to her appointments. . Asthma: Albuterol was initially held due to hyperkalemia. She was continued on home fluticasone, montelukast. . CAD: Patient had negative stress in and normal echo with EF of 60-70% in . However, she is at risk for cardiac events given her severe and poorly controlled diabetes. She was continued on aspirin and statin. . Seronegative arthritis: Patient has a history of arthritis with normal rheumatoid factor. She was continued on sulfasalazine. . Anemia: Patient admitted with Hct of 40 which fell to 25 in setting of aggressive IVF hydration. It remains difficult to determine her baseline hematocrit given that patient is frequently admitted for dehydration in setting of DKA and then agressively resucitated causing Hct to be hemoconcentrated and then diluted. Colonoscopy in showed only internal hemorrhoids. Anemia is likely from chronic disease and dilution from IVF. Labs on discharge appear consistent with iron deficiency anemia. The patient will need outpatient follow up for her anemia. . HCV: LFTs were checked and found to be within normal limits. No history of antiviral medications. . Urinary tract infection: The patient was found to have a coag positive staph UTI while in the hospital. She was discharged to complete a course of antibiotics. VNA will obtain a repeat UA and culture to check that her urine has cleared of infection. These results will be faxed to her primary care doctor. . Communication: HCP daughter , cell . | Pt started on 1mg IV propanolol q6hour with some effect. MICU 6 NPN 0700-1900No significant events this shift.Pt Full .See carevue for all objective data.Neuro: Pt is A+Ox3 with flat affect. PLAN FOR PICC INSERTION TODAY.GI/GU : ABD SOFT, TENDER, S/P GASTROPARESIS. CONTINUED ON METHIMAZOLE.SOCIAL : NO CONTACT FROM FAMILY THIS SHIFT.PLAN :MONITOR MS/BP.MONITOR LYTES & REPLETE AS NEEDED.MONITOR TEMP CURVE,FOLLOW UP ON CULTURES.PICC INSERTION/ REMOVAL OF FEMORAL LINE. Ph repleted with KPh.Resp: LSCTA bilat with sats 99-100% on RA.GI: Abd with pos bowel sounds is soft and tender. MORPHINE 2 MGS IV GIVEN FOR ABD PAIN WITH MODERATE EFFECT.NEURO : LETHARGIC, COOPERATIVE WITH CARE, ORIENTED X 3, MOVES INDEPENDENTLY IN BED.CONTINUED ON GABAPENTIN, AMITIPTYLINE, HYOSCYAMINE.RESP : ON RA, SPO2 HIGH 90'S. Received 1mg morphine times (2) with good relief.GU: Adequate u/o via foley cath. NOT ON ANTIBIOTIC.SKIN : GROSSLY INTACT.ENDO : CONTINUED ON INSULIN DRIP, TITRATED FOR A GOAL OF 120 TO 140. MICU 2100-0700Events: Insulin gtt discontinued ~2300.Endo: Received pt on insulin gtt, infusing at 1unit/hr. O2 sats on RA.CV: BP at times in the low 90's, HR stable, no ectopy.Neuro: Alert and oriented. She did state she had severe abd pain and was given Zophran, Reglan, and 2mg IV morphine.CV: Pt tachycardic and hypertensive, No C/O CP, dizziness, or SOB. Pt given Zophran, and has Reglan q6hr. B/P 100-130/50-60, denies dizziness. She was started on an insulin gtt and sent to MICU 6 for further evaluations.Neuro: Pt fatigued, A and Ox3 but resistant to answerring questions and personal care. CONT ON REGLAN, WAS NAUSEOUS ONCE, ONDASTERON IV GIVEN. PMHx of asthma and has PRN albuterol if needed.GI/GU: hypoactive bowel sounds, abd is soft and tender. tachycardia d/t dehydration, pain, withdrawl, or thyroid disfunction.GI/GU: Pt NPO, N/V pt does have zofran ordered, Foley clear yellow urine 50-100/hr, Abd soft hypoactive bowel sounds, NG tube refused by patient yesterdayAccess: Triple lumen R fem central line, 0.9NS KVO, Insulin 2.5 units/hr current blood sugars in 160's.Pain: Pt will complain of belly pain, reglan and morphine ordered.Plan: Goal blood sugars 120-140. monitor electrolytes replace as needed, monitor cardiac enzymes, monitor pain. LYTES MONITORED.ACCESS : RT FEMORAL 3 LUMEN . HR 70-110 remains in NSR/ST w/o ectopy noted. Mg and Phos replaced early in the night.Neuro: pt alert when you wake her but very lethargic when left alone, verbalizes needs, slept through the night, able to follow commands.Resp: RR 20's, clear lung sounds, no coughCardio: Sinus tachy HR 120-130's, SBP 150-170's hydralazine given for bp with success, SBP staying in 150's. Worked w/ physical therapy and able to transfer B->C w/ min assist. pos pedal pulses bilat, no edema noted. LS CLEAR.CVS : ST/NSR, 98 TO 120'S, NO PVC NOTED. Continues to have constant abd pain, Morphine PRN(has been requiring dose 2-3x/day) Pt has TLC femoral line, plan IV to attempt PICC line at bedside today.G/U- Foley draining clear yellow urine..U/O 50-100cc/hrSkin- Grossly intact Pt has been on the phone throughout the day. Tmax remains 99, will continue to followResp- lungs diminished but clear...no SOB noted Sat's 96-100% on R/AG/ Pt started to eat today, Diabetic diet. Tmax 99.5 Ax, blood and urine cultures sent.Resp: LSCTA bilat with sats 100 on RA. IV fluids NS infusing at 999/hr. Tmax 100.8 and blood cultures sent. FS con't to be checked frequently..(please check carevue for results). Started on colace and senna PRN. MICU NURSING NOTES:REVIEW CAREVUE FOR DETAILS.EVENTS : BP ^, STARTED ON LOSARTAN, ^ IV PROPANOLOL TO 2 MGS Q 6 HRLY.K 3.6, REPLETED WITH 40 MEQ IV KCL.PICC NURSE IN TO ASSESS,WILL BE BACK TODAY FOR PICC INSERTION. Spoke to MD, and he will need to tighten sliding scale parameter.Resp: LS CTA. Peripheral pulses easily palpable, Tmax 100.0, no edema noted. Of note ..Pt request SQ heparin be given in arm only, team aware. MAE in bed with equal strength bilat.CV: HR tachy 120s-130s NSR with no ectopy. TYLENOL. Abd soft +BS, No BM today. Pt admitted to MICU for DKA. Hep C+ from previous blood transfusion.Events: Toxicology screen blood and urine + for benzos, peripheral blood cultures unable to obtain house staff aware, Goal Blood sugars 120-140, OT consult for Cognitive eval, social work consult for discharge placement ordered. BS range 116-200 on insulin gtt. Psych into eval patient, awaiting rec's. SW spoke w/ patient re: discharge needs and coping. +emesis. Speech clearC/V- B/P under better control after losartan started. She c/o abd pain and was given 2 mg IV morphine with good effect. T waves areimproved. Gtt titrated per guideline (see Carevue for details).Social: Social work consulted and case management involved with pt's dispo. Compared to the previous tracing of the rate hasincreased. Pt had extensive PMH, see care-vue for details. Pleasant and cooperative.Social: No contact from family this shift.IV: PICC line intact.GI: + BS, c/o some abdominal discomfort after eating some crackers. NO REMAINS NPO EXCEPT FOR PO MEDS.CAN HAVE ICE CHIPS. No edema noted, palpable pedal pulses. She did refuse to eat anything today stating she will try to take some soup tomorrow.GU: Foley patent drainning sufficient amounts of clear yellow urine.Access: Right femoral TLC, Pt in for PICC line eval.Endo: Pt on insulin gtt with q1hour finger sticks. Pt has complicate family and financial issues, SW working with patient and family.Events- After being very lethargic since admissions, pt alert and able to sit up in chair. FOLEY DRAINING ADEQUATE AMTS OF CLEAR YELLOW URINE.ID : T-0 MAX 100.3, URINE CULTURE SENT. if she is taking her medication. Daughter also spoke with MDs about .Plan:Continue on insulin gtt and monitor Q1hour blood sugars.Assess pt for pain and medicate approptiately.Monitor for nausea/vomitting.Routine ICU monitorring.Provide emotional support to pt and family. NBP 139/84-166/83 with MAP 94-108. | 7 | [
{
"category": "Nursing/other",
"chartdate": "2133-02-11 00:00:00.000",
"description": "Report",
"row_id": 1367063,
"text": "MICU 6 admit note\nPt is a 54 year old female with a history of IDDM, gastroparesis, HTN, hep c, asthma, depression, , and arthritis. She had been experiencing nausea and vomitting with abd pain x2 days. Pt came into ED with weakness and fatigue and a blood sugar greater than 500. She was started on an insulin gtt and sent to MICU 6 for further evaluations.\n\nNeuro: Pt fatigued, A and Ox3 but resistant to answerring questions and personal care. She MAE with equal strength bilat. She did state she had severe abd pain and was given Zophran, Reglan, and 2mg IV morphine.\n\nCV: Pt tachycardic and hypertensive, No C/O CP, dizziness, or SOB. IV fluids NS infusing at 999/hr. No edema noted, palpable pedal pulses. Tmax 99.5 Ax, blood and urine cultures sent.\n\nResp: LSCTA bilat with sats 100 on RA. No cough noted. PMHx of asthma and has PRN albuterol if needed.\n\nGI/GU: hypoactive bowel sounds, abd is soft and tender. +emesis. Pt given Zophran, and has Reglan q6hr. Foley patent drainning sufficient amounts of clear yellow urine.\n\nAccess: Right groin TLC, Right arm PIV\n\nSocial: Pt's daughter (health care proxy) up to ICU with pt and spoke with MDs.\n\nEndo: Pt on insulin gtt with q1hr finger sticks.\n\nPlan:\nRouting ICU monitorring.\nProvide emotional support to pt and family.\nContinue pt on insulin gtt and titrate per guideline.\nMonitor for pain, nausea, and vomitting and medicate appropriately.\n"
},
{
"category": "Nursing/other",
"chartdate": "2133-02-12 00:00:00.000",
"description": "Report",
"row_id": 1367064,
"text": "MICU Progress Note 1900-0700\nPt is a 54 yr old women admitted to ICU for Diabetic Ketoacidosis, from pt record she is frequently admitted for this, ? if she is taking her medication. Pt is full code. Upon admission to ER pt complaining of chest pain, enzymes are being checked so far they are negative. Hep C+ from previous blood transfusion.\n\nEvents: Toxicology screen blood and urine + for benzos, peripheral blood cultures unable to obtain house staff aware, Goal Blood sugars 120-140, OT consult for Cognitive eval, social work consult for discharge placement ordered. Mg and Phos replaced early in the night.\n\nNeuro: pt alert when you wake her but very lethargic when left alone, verbalizes needs, slept through the night, able to follow commands.\n\nResp: RR 20's, clear lung sounds, no cough\n\nCardio: Sinus tachy HR 120-130's, SBP 150-170's hydralazine given for bp with success, SBP staying in 150's. Peripheral pulses easily palpable, Tmax 100.0, no edema noted. ? tachycardia d/t dehydration, pain, withdrawl, or thyroid disfunction.\n\nGI/GU: Pt NPO, N/V pt does have zofran ordered, Foley clear yellow urine 50-100/hr, Abd soft hypoactive bowel sounds, NG tube refused by patient yesterday\n\nAccess: Triple lumen R fem central line, 0.9NS KVO, Insulin 2.5 units/hr current blood sugars in 160's.\n\nPain: Pt will complain of belly pain, reglan and morphine ordered.\n\nPlan: Goal blood sugars 120-140. monitor electrolytes replace as needed, monitor cardiac enzymes, monitor pain.\n"
},
{
"category": "Nursing/other",
"chartdate": "2133-02-13 00:00:00.000",
"description": "Report",
"row_id": 1367067,
"text": "0700-1900 MICU PROGRESS NOTE\n\n\n54 yo female admitted on after being very lethargic at home with increasing N/V noted at home. Pt also had increasing abd pain at home. BS on admission greater than 500. Pt admitted to MICU for DKA. Pt had extensive PMH, see care-vue for details. Pt has complicate family and financial issues, SW working with patient and family.\n\n\nEvents- After being very lethargic since admissions, pt alert and able to sit up in chair. Pt oriented x3. Worked w/ physical therapy and able to transfer B->C w/ min assist.\n\n\n Pt is alert and oriented x3, following commands. No neuro deficit noted, no confusion noted. Speech clear\n\nC/V- B/P under better control after losartan started. Propanolol changed to PO. B/P 100-130/50-60, denies dizziness. HR 70-110 remains in NSR/ST w/o ectopy noted. Lytes drawn at 4pm , pending at time of note. Of note ..Pt request SQ heparin be given in arm only, team aware. Tmax remains 99, will continue to follow\n\nResp- lungs diminished but clear...no SOB noted Sat's 96-100% on R/A\n\nG/ Pt started to eat today, Diabetic diet. Tolerated salad and soup, w/o nausea or vomiting. Plan wean off insulin gtt and start LANTUS INSULIN tonight at dinner if she continues to eat. BS range 116-200 on insulin gtt. Abd soft +BS, No BM today. Started on colace and senna PRN. Continues to have constant abd pain, Morphine PRN(has been requiring dose 2-3x/day)\n\n Pt has TLC femoral line, plan IV to attempt PICC line at bedside today.\n\nG/U- Foley draining clear yellow urine..U/O 50-100cc/hr\n\nSkin- Grossly intact\n\n Pt has been on the phone throughout the day. Psych into eval patient, awaiting rec's. SW spoke w/ patient re: discharge needs and coping. No calls from family recieved\n\nPlan\nPICC line today\nMonitor B/P\nSW will continue to follow and assist\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2133-02-14 00:00:00.000",
"description": "Report",
"row_id": 1367068,
"text": "MICU 2100-0700\nEvents: Insulin gtt discontinued ~2300.\n\nEndo: Received pt on insulin gtt, infusing at 1unit/hr. ~2300, FS was 80, therefore gtt d/c'd. FS con't to be checked frequently..(please check carevue for results). Anion Gap added on to am labs, 10. Latest FS 189. Spoke to MD, and he will need to tighten sliding scale parameter.\n\nResp: LS CTA. No resp distress. O2 sats on RA.\n\nCV: BP at times in the low 90's, HR stable, no ectopy.\n\nNeuro: Alert and oriented. Pleasant and cooperative.\n\nSocial: No contact from family this shift.\n\nIV: PICC line intact.\n\nGI: + BS, c/o some abdominal discomfort after eating some crackers. Received 1mg morphine times (2) with good relief.\n\nGU: Adequate u/o via foley cath.\n"
},
{
"category": "Nursing/other",
"chartdate": "2133-02-12 00:00:00.000",
"description": "Report",
"row_id": 1367065,
"text": "MICU 6 NPN 0700-1900\n\nNo significant events this shift.\nPt Full .\nSee carevue for all objective data.\n\nNeuro: Pt is A+Ox3 with flat affect. Lethargic and slept for most of the day. Speech appropriate and she is cooperative with care. PERL pinpoint and . MAE in bed with equal strength bilat.\n\nCV: HR tachy 120s-130s NSR with no ectopy. NBP 139/84-166/83 with MAP 94-108. Pt started on 1mg IV propanolol q6hour with some effect. No C/O CP, SOB, lightheadedness or dizziness. Tmax 100.8 and blood cultures sent. pos pedal pulses bilat, no edema noted. Ph repleted with KPh.\n\nResp: LSCTA bilat with sats 99-100% on RA.\n\nGI: Abd with pos bowel sounds is soft and tender. She c/o abd pain and was given 2 mg IV morphine with good effect. Pt did take a few pills with water and was given 8mg zophran IV concurrently to reduce nausea. Pt had no nausea or vomitting this shift. She had no BM. She did refuse to eat anything today stating she will try to take some soup tomorrow.\n\nGU: Foley patent drainning sufficient amounts of clear yellow urine.\n\nAccess: Right femoral TLC, Pt in for PICC line eval.\n\nEndo: Pt on insulin gtt with q1hour finger sticks. Gtt titrated per guideline (see Carevue for details).\n\nSocial: Social work consulted and case management involved with pt's dispo. Social work did speak with daughter (Health Care Proxy) today and will be meeting with pt's daughter tomorrow (). Daughter also spoke with MDs about .\n\nPlan:\nContinue on insulin gtt and monitor Q1hour blood sugars.\nAssess pt for pain and medicate approptiately.\nMonitor for nausea/vomitting.\nRoutine ICU monitorring.\nProvide emotional support to pt and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2133-02-13 00:00:00.000",
"description": "Report",
"row_id": 1367066,
"text": "MICU NURSING NOTES:\n\nREVIEW CAREVUE FOR DETAILS.\n\nEVENTS : BP ^, STARTED ON LOSARTAN, ^ IV PROPANOLOL TO 2 MGS Q 6 HRLY.\nK 3.6, REPLETED WITH 40 MEQ IV KCL.PICC NURSE IN TO ASSESS,WILL BE BACK TODAY FOR PICC INSERTION. MORPHINE 2 MGS IV GIVEN FOR ABD PAIN WITH MODERATE EFFECT.\n\nNEURO : LETHARGIC, COOPERATIVE WITH CARE, ORIENTED X 3, MOVES INDEPENDENTLY IN BED.CONTINUED ON GABAPENTIN, AMITIPTYLINE, HYOSCYAMINE.\n\nRESP : ON RA, SPO2 HIGH 90'S. LS CLEAR.\n\nCVS : ST/NSR, 98 TO 120'S, NO PVC NOTED. SBP 140'S TO 170'S , MAP IN 100'S. LYTES MONITORED.\n\nACCESS : RT FEMORAL 3 LUMEN . PLAN FOR PICC INSERTION TODAY.\n\nGI/GU : ABD SOFT, TENDER, S/P GASTROPARESIS. CONT ON REGLAN, WAS NAUSEOUS ONCE, ONDASTERON IV GIVEN. NO REMAINS NPO EXCEPT FOR PO MEDS.CAN HAVE ICE CHIPS. FOLEY DRAINING ADEQUATE AMTS OF CLEAR YELLOW URINE.\n\nID : T-0 MAX 100.3, URINE CULTURE SENT. MD TO DECIDE ON ? TYLENOL. CULTURES PENDING. NOT ON ANTIBIOTIC.\n\nSKIN : GROSSLY INTACT.\n\nENDO : CONTINUED ON INSULIN DRIP, TITRATED FOR A GOAL OF 120 TO 140. CONTINUED ON METHIMAZOLE.\n\nSOCIAL : NO CONTACT FROM FAMILY THIS SHIFT.\n\nPLAN :\nMONITOR MS/BP.\nMONITOR LYTES & REPLETE AS NEEDED.\nMONITOR TEMP CURVE,FOLLOW UP ON CULTURES.\nPICC INSERTION/ REMOVAL OF FEMORAL LINE.\n"
},
{
"category": "ECG",
"chartdate": "2133-02-11 00:00:00.000",
"description": "Report",
"row_id": 274731,
"text": "Sinus tachycardia. Compared to the previous tracing of the rate has\nincreased. Lateral precordial QRS voltage has decreased. T waves are\nimproved.\n\n"
}
] |
26,721 | 140,504 | there. In brief, he presented to Hospital complaining of shortness of breath for two days following a recent upper respiratory tract infection two weeks prior to admission. On admission he was tachypneic to the 40s, hypoxic to 93% on 100% nonrebreather, tachycardiac to 180 and hypotensive. Labs were notable for a white blood count of 5 with 49% neutrophils and 40% bands. Chest x-ray revealed left lower lobe and possibly right lower lobe infiltrates. Blood cultures grew out six out of six bottles with Streptococcus pneumoniae. He was begun empirically on Unasyn and the Azithromycin which was subsequently switched to Vancomycin when an organism was identified. On , he was switched to Penicillin when the organism was found to be pansensitive. Despite therapy, he continued to spike fevers to 101 to 102 on a daily basis despite subsequent cultures being negative. He had an exhaustive workup for alternative etiology of his persistent fevers including right upper quadrant ultrasound which was negative for cholecystitis, lower extremity noninvasives which were negative for deep vein thrombosis, chest computerized tomography scan which was negative for empyema. An echocardiogram was negative for endocarditis. He did have a head computerized axial tomography scan which revealed sinusitis. Gram stain and cultures of sputum and nasal swabs revealed Pseudomonas aeruginosa and so Levofloxacin was added to his regimen. On , per Infectious Disease consult recommendation, Penicillin and Levofloxacin were discontinued and he was switched to Ceftazidime and Gentamicin to treat his pneumococcal pneumonia and Pseudomonas sinusitis. On the day of transfer, he was also started on empirically on Flagyl and p.o. Vancomycin for oppression of Clostridium difficile, however, Clostridium difficile toxin subsequently returned negative. Despite all of these treatments, he continued to spike fevers on a daily basis. His hospital course at was also notable for respiratory failure. He was intubated on admission for hypoxic respiratory failure which was felt to be due to his pneumonia, presumably from pneumococcus, although this organism was never cultured from his sputum, only from his blood. It is not clear whether he was attempted to be weaned from the ventilator, but he required persistent sedation, due to tachypnea to the 50s and desaturation whenever attempts at weaning sedation were made. His tachycardia and hypotension on admission was felt likely due to sepsis. His hemodynamics stabilized with fluids, Dopamine, and antibiotics by hospital day #3 and he was able to be weaned off of Dopamine at that time. He ruled out for a myocardial infarction and echocardiogram revealed ejection fraction of 75% with mild left ventricular hypokinesis. Mr. was transferred to for persistent fevers and inability to wean from the ventilator. PAST MEDICAL HISTORY: 1. History of supraventricular tachycardia 2. Hypothyroidism, status post thyroidectomy in 3. Hypercholesterolemia 4. Neuralgia ALLERGIES: No known drug allergies on admission. During admission Haldol was noted to cause seizures. MEDICATIONS ON TRANSFER: 1. Ceftazidime 1 gm intravenously q. 8 hours (day #2) 2. Gentamicin 160 mg intravenously q. 12 hours (day #2) 3. Vancomycin 250 mg p.o. q. 6 hours, (day #1) 4. Flagyl 500 mg intravenously q. 6 hours (day #1) 5. Albuterol metered dose inhaler 4 to 6 puffs q.i.d. prn 6. Tylenol prn 7. Propofol drip (3 mcg/kg) 8. Ativan drip (3 mg/hr) 9. Pepcid 20 mg q.d. 10. Heparin 5000 units subcutaneously b.i.d. 11. Haldol prn agitation 12. Total parenteral nutrition SOCIAL HISTORY: Mr. works as a history professor at a nearby community college. He smokes two packs per day. He drinks occasional alcohol. He has a wife and two children. FAMILY HISTORY: Mother has diabetes mellitus and coronary artery disease. PHYSICAL EXAMINATION: On admission he was intubated and sedated. Temperature is 101.4, heartrate 78, blood pressure 128/50, respiratory rate 20 to 30. Ventilatory settings were pressure support 20, positive end-expiratory pressure 5, FIO2 40%, pulling title volumes of 850 cc. Pupils were equal, round, and reactive to light. Neck was supple. There was no jugulovenous distension or lymphadenopathy. Heart had a regular rate and rhythm with normal S1 and S2 and no murmurs, rubs or gallops. Lungs had decreased breathsounds at the left base with bronchial breathsounds in the left lower lobe. Abdomen had normoactive bowel sounds, was obese and soft. There was no hepatosplenomegaly. Extremities showed no edema, clubbing or cyanosis. On neurological examination he was sedated without spontaneous movements. LABORATORY DATA: (On transfer) White blood cell count was 8.9, hematocrit 27.5, platelets 415, sodium 142, potassium 3.7, chloride 109, bicarbonate 24, BUN 27, creatinine 0.8, glucose 166, calcium 8, magnesium 2.1, phosphate 3.6. Arterial blood gases showed pH 7.46, pCO2 31, pO2 128. Culture data and imaging studies as in history of present illness and hospital course. HOSPITAL COURSE: (By system) 1. Infectious disease - On transfer his antibiotics were switched to Levofloxacin 500 mg intravenously q.d. and Ceftazidime 1 gm intravenously q. 8 hours. It was issued adequately that two organisms had been cultured to date - 1. Streptococcus pneumoniae which had been cultured from his blood at and was presumed for sepsis pneumonia and sepsis; 2. Pseudomonas which had been cultured from endotracheal secretions at and was felt to be a cause of sinusitis. Despite this coverage, he remained persistently febrile to 101 to 102 on a daily basis. The Infectious Disease Service was consulted, and an exhaustive workup was continued to determine the source of these fevers. He underwent a chest computerized tomography scan to evaluate for possible empyema, which revealed resolving left lower lobe infiltrate and only small uncomplicated pleural effusion, not enough fluid to tap safely. Sinus computerized tomography scan was repeated here which did reveal sinusitis and Otorhinolaryngology was consulted. They were not too impressed with the sinusitis as the cause of his fevers. An abdominal computerized tomography scan was negative for any intra-abdominal source. The lumbar puncture was negative. Head magnetic resonance imaging scan was negative for intracranial source other than the known sinusitis. Transthoracic and transesophageal echocardiograms were negative for endocarditis. All of his lines were switched on more than one occasion. He was repeatedly pancultured and all cultures were negative at this hospital, with the exception of one culture from an arterial line which subsequently grew out Staphylococcus epidermidis-the arterial line was discontinued and Vancomycin was begun on . Sputum cultures from also grew out Methicillin-resistant Staphylococcus aureus, and this in the setting of increasing respiratory secretion became an indication for continuing Vancomycin for Methicillin-resistant Staphylococcus aureus tracheobronchitis. Furthermore, when he developed worsening purulent nasal secretions on and head imaging revealed worsening sinusitis, Otorhinolaryngology was reconsulted and performed maxillary sinus biopsy. The gram stain was negative, but the culture subsequently grew out Methicillin-resistant Staphylococcus aureus. Drugs were also considered as a cause of his fevers and on , Ceftazidime was discontinued given that the Pseudomonas was only grown from endotracheal suctioning at an outside hospital and was not felt to be a pathogen. Finally, chest computerized tomography scan on was positive for bilateral pulmonary emboli suggesting this as a possible contributing source of his fevers. In summary, his fevers were felt to be multifactorial due to pneumococcal pneumonia and sepsis initially followed by pulmonary emboli and Methicillin-resistant Staphylococcus aureus tracheobronchitis. There also might have been some contribution of a reaction to medications. By , his fever curve had decreased to only lowgrade temperature to 99. He did have a transient fever spike to 102 in the setting of a seizure on , but has since defervesced. At the present time, he had only lowgrade fevers to 99 and his white blood cell count is normal. He finished a 21 day course of Levofloxacin for pneumococcal pneumonia and sepsis on , and a one course of Vancomycin for Methicillin-resistant Staphylococcus aureus tracheobronchitis . Finally, he is being anticoagulated for pulmonary emboli. 2. Respiratory - He was intubated on admission to Hospital for hypoxic respiratory failure felt to be due to pneumococcal pneumonia and sepsis. At he remained sedated and unable to be weaned from the ventilator due to tachypnea and desaturation. Upon transfer to his sedation was weaned but he was noted to have difficulty weaning from the ventilator due to rapid shallow breathing. He was subsequently diagnosed with bilateral pulmonary emboli by chest computed tomographic angiography and begun on heparin. Despite heparin treatment for his pulmonary emboli and antibiotics for his pneumonia with evidence of resolving pneumonia by computerized tomography scan, he remained unable to be weaned due to rapid shallow breathing. It was felt that there was also a component of muscular weakness to prolonged illness and intubation contributing to this difficulty. He is status post tracheostomy . By he was able to be weaned off of the ventilator and doing well on tracheostomy mask. He was transiently placed back on the ventilator to in the setting of a seizure, but has since been transitioned back to the tracheostomy mask on which he is doing well. 3. Cardiovascular - He has been stable from a cardiovascular standpoint throughout his hospitalization at on Lopressor 50 mg b.i.d. for hypertension and paroxysmal supraventricular tachycardia. 4. Hematologic - As noted above, he had chest computed tomographic angiography , which was positive for bilateral pulmonary emboli. He was begun on a heparin drip. On , once all procedures were felt to be completed, he was started on Coumadin load. He was also switched from a heparin drip to low molecular weight heparin subcutaneously to prepare him for discharge until his coumadin is therapeutic. On he was transfused with 2 units of packed red blood cells for slowly declining hematocrit felt to be due to prolonged hospital stay and phlebotomy. 5. Neurology - On he had new onset of three generalized tonic clonic seizures in the setting of respiratory distress from mucous plugging and 8 mg of Haldol the night prior for agitation. He was loaded on Dilantin given the recurrent seizures. He underwent extensive workup to look for etiologies of his seizures including head computerized tomography scan which was negative for bleed, lumbar puncture, head magnetic resonance imaging scan, electroencephalogram all of which are negative. He was also evaluated by the Neurology Service. It is felt that the seizures were likely due to hypoxia/respiratory distress in combination with lowered seizure threshold from Haldol in the setting of prolonged illness. It is recommended that he continue on Dilantin for six months and then be re-evaluated by the neurologist at which time he will likely be able to come off of this medication. 6. Nutrition - For unclear reasons, he was unable to tolerate tube feeds via nasogastric or orogastric tube throughout his hospital stay both at and here at . Abdominal computerized tomography scan was negative for evidence of obstruction and he has been passing stool. He was maintained on daily total parenteral nutrition while unable to give tube feeds. He is status post J-tube placement on and was started on Promote with fiber tube feeds on . He has been advanced to his goal which is 80 cc/hr which he has been tolerating well. He has been evaluated by the Speech and Swallow Service here and they recommend trying judiciously some custard and sips of water p.o. and advancing his diet slowly as tolerated. 7. Endocrine - He has a history of hypothyroidism status post thyroidectomy, however, he was not on thyroid replacement medication on admission. TSH and free T4 were checked and were within normal limits. 8. Access - He currently has a right arm PICC line which was placed on . DISPOSITION: Mr. was discharged to Rehabilitation in stable condition. | admin albuterol q4h. Mild tricuspid [1+]regurgitation is seen. admin albuterol qid prn. 7a-7p NPN addendumElect: K 3.3 40meq kcl iv given. LP done with cl fluid returned. Resp Careremains intub/vented in spont mode. REPEAT PTT DUE @ 2100.RESP: LS COARSE AND DIMINISHED BIBISAILAR. Overallleft ventricular systolic function is preserved with ? PEG DSG REMAINS CD&I. admitted for vent dependence; LLL consolidation ? Min OGT asp. NGT changed to OGT d/t known sinusitis. The aortic root is moderatelydilated. pg2, d/c summary completed. Resp. Last ABG good. 1GM VANCO GIVEN. Sedation off x2hrs. + B.S. Suboptimalimage quality. BS essentially clear and dimin. Remains on vanco.SKIN: Intact.DISPO: Pt. LUNGS CLEAR, BASES DIMINSHED. conts. Conts. Conts. Plan- wean Ativan, keep Propofol gtt ? tube feedings advanced to goal this am, tpn d/c'd. Stool sent for c. diff (neg at OSH). LS- clear upper right, otherwise diminished. extubation in short while...Resp: Current vent settings; PSV 20, PEEP 5, fiO2 40%, TV 800-1L, RR 18-26. There is mild symmetric left ventricularhypertrophy. Cont to follow FSs.Min stool. abx. RESPONDED WELL TO ATIVAN BOLUS. SMA AIR LEAK IN CUFF AND RESOLVED WITH 1 CC AIR INSTALATION.GI: ABD SOFT AND DISTENDED. PASSIVE R.O.M. Eval by neuro at this time. Passing mod. FC DNG GOOD AMT CLR DK YLLW URINE. Specs sent.Limbs remain flaccid. The mitral valve appears structurally normal withtrivial mitral regurgitation. 3 PM PTT THERAPEUTIC AND HEPARIN GTT REMAINS @ 2100U/HR. is 1L positive. RR BACK TO BASELINE.C/V: HD STABLE.RESP: REMAINS OF CPAP/PS 20,PEEP 8, TV @700, FIO2 30%. Min OGT aspirates. RR 40'S SBP 180'S HR 120'S AND DIAPHORETIC. high 20's suctioned with ambu for scatn amt. TURNED BACK ON BACK AND ATIVAN BOLUS GIVEN. Tol TFs with min asp. ls dim to coarse.gi: tpn infusing as ordered. Resp Careremains trached/on spont mode with present settings ps 18/peep 5/30%. NGT IN PLACE, CLAMPED.ACCESS: LEFT IJ ML CATH IN PLACE. 7p-7a NPNNeuro: Ativan continues at 1mg/hr for sedation. ATIVAN AND PROPOFOL BOLUSES GIVEN. Sputum now with MRSA. one episode of tachypnea/desat in conjunction with turning for cpt. Echocardiogram was done.GI: OGT placed on intermittent suction, tan billirious secretions noted. SAMPLE SENT FOR C.DIFF. ECG NSR WITH FREQUENT PVC'S AND PAC'S.REVIEW OF SYSTEMS:NEURO: PT IS SEDATED ON PROPOFOL AND ATIVAN GTT. Mod to lg amts. Second stool sent for c-diff. CONT ON CEFTAZ AND LEVO. Currently weaning Propofol to off by am. TEMP UP TO 102.4. RESP PT. TX WITH FLAGLY FOR ?C.DIFF. @AFTER 30MIN, PT CALMED DOWN AND RR DOWN TO BASELINE.ID: TMAX 102.6. Episode repeated itself in ~45 min and received addtional 2mg Ativan and was placed back on back. +B.S. A-LINE PLACED MD. FSs changed to . NEURO: OFF PROPOPHOL @ 0600. RT AND MD NOTIFIED. Continues off Propofol. add to TPN. TPN RUNNING AT 114CC/HR.SKIN: SKIN INTACT.PLAN: MD WOULD LIKE TO WEAN ATIVAN AND GO UP ON PROPOFOL IF PT. Receiving q6hr SSRI coverage. pt repositioned. PT BEING FOLLOWED BY I-D AND ENT WAS CONSULTED FOR EVAL.NEURO-VASC: + CSM +PP BILAT SDC BOOTS INTACT. bp stable via abp dampened at times 1teeens-130's sys. rhonchi t/o , clearing after sx'ing. admin albuterol q4prn. admin albuterol q4prn. PTT@0530 80.3 and therapeutic. Hm shows sinus tachy to sinus rhythm throughout shift, 0 ectopy noted. Lg residuals this am. bs remain hypoactive, og dng lg amt bilious hemocult +. sputum cx sent. NPNPt sedated on Ativan 1mg/hr and propofol currently at 43mcg/kg/min. Resp Careremains intub/vented ac 700x16x.4/10 peep. NPNPt sedated with Ativan 2mg/hr and Propofol40mcg/kg/min. RN PROGRESS NOTE 600AMNEURO; PT CONT ON SEDATION. nsr, 0 ectopy noted. bag applied.id--febrile this am to 102.2 rectally, conts on levoquin, to be changed to iv d/t high residuals. hypoactive bs. Turned off for residual of 100cc. ent in today, tapped sinuses. T max 100.6 po. micu/sicu npn 0700-1900ros--neuro--sedated. BS +GU UO 60-200CC/HR NO LASIX GIVEN.ID TEMP MAX 101.1 ORAL. Sx'ed for mod amt tan secretions from trach. OGT dc'd during trach placement. Pt started on multiple abx. Min mvmt. OCCN. SINCE PROPOFOL GTT OFF, PT AWAKE, TRACKING WITH EYES, MAE, FOLLOWING SOME SIMPLE COMMANDS INCONSISTENTLY.C/V: HD STABLE OVERNIGHT. SHORT PERIODS OF TACHYPNEA HM SHOWS SINUS RYTHM,0 ECTOPY NOTED. Started on heparin for PE. FSs sstable. sm amts tan sputum. Ativan weaned down to 1mg/hr as per plan. EXTS. conts to have moderate amts of secretions requiring lavage/ambu. Levoflox changed to IV d/t ?po absorbtion. micu/sicu npn 0700-1500pt remains sedated on propofol 30mcg/kg/min, ativan decreased to 2mg/hr. T max 100.4. ls have occn course sounds, dimin in bases, essentially clear. REASON FOR THIS EXAMINATION: CT angio to r/o PE. While getting new trach ready, pt had tonic clonic siezure x ~1min which resolved on own. There is apparent thickening of the right colon and cecum with no surrounding stranding, and a normal appearing appendix, therefore most likely represents the appearance of a nondistended cecal tip. TECHNIQUE: CT images of the head were acquired without and with 100cc of IV Optiray contrast. 2:57 PM CHEST CTA WITH CONTRAST; CT 150CC NONIONIC CONTRAST Clip # CT RECONSTRUCTION Reason: CT angio to r/o PE. IMPRESSION: Left lower lobe consolidation/atelectasis with a small amount of pleural effusion. Patchy right base opacifications. A postprocedure plain film of the abodmen was obtained. LS coarse t/oGI: TF @ 80cc/hr. RR 34 HR 106 BP127/63. CTA to rule out PE or left lower lobe collapse. Left atrial abnormality.ST segment depressions in leads V5-V6 consistent with possible lateralischemia. REASON FOR THIS EXAMINATION: Percutaneous jejunostomy tube placement FINAL REPORT INDICATION: Failure to wean from vent. Optiray was administered due to general debillitation. Left lower lobe consolidation with small left pleural effusion. The postprocedure plain film of the abdomen demonstrated appropriate positioning of the tip of the tube in the proximal jujunum, well beyond the Ligament of Trietz, with no extravasation of contrast from the bowel lumen. | 73 | [
{
"category": "Echo",
"chartdate": "2132-12-03 00:00:00.000",
"description": "Report",
"row_id": 62806,
"text": "PATIENT/TEST INFORMATION:\nIndication: Evaluate for endocarditis.\nHeight: (in) 70\nWeight (lb): 280\nBSA (m2): 2.41 m2\nBP (mm Hg): 138/74\nHR (bpm): 69\nStatus: Inpatient\nDate/Time: at 13:43\nTest: Portable TEE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nPropafol 250 mg iv given\nLEFT ATRIUM: The left atrium is normal in size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size. The\ninteratrial septum is normal. No atrial septal defect is seen by 2D or color\nDoppler.\n\nLEFT VENTRICLE: Left ventricular wall thickness, cavity size, and systolic\nfunction are normal (LVEF>55%).\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTA: The ascending, transverse and descending thoracic aorta are normal in\ndiameter and free of atherosclerotic plaque.\n\nAORTIC VALVE: The aortic valve leaflets (3) appear structurally normal with\ngood leaflet excursion and no aortic regurgitation.\n\nMITRAL VALVE: The mitral valve appears structurally normal with trivial mitral\nregurgitation.\n\nTRICUSPID VALVE: The tricuspid valve appears structurally normal with trivial\ntricuspid regurgitaton.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appear\nstructurally normal with physiologic pulmonic regurgitation.\n\nPERICARDIUM: There is no pericardial effusion.\n\nGENERAL COMMENTS: A transesophageal echocardiogram was performed in the\nlocation listed above. I certify I was present in compliance with HCFA\nregulations. The patient was monitored by a nurse throughout the\nprocedure. The patient was sedated for the TEE. Medications and dosages are\nlisted above (see Test Information section). Local anesthesia was provided by\nlidocaine spray. There were no TEE related complications.\n\nConclusions:\nThe left atrium is normal in size. No atrial septal defect is seen by 2D or\ncolor Doppler. Left ventricular wall thickness, cavity size, and systolic\nfunction are normal (LVEF>55%). Right ventricular chamber size and free wall\nmotion are normal. The ascending, transverse and descending thoracic aorta are\nnormal in diameter and free of atherosclerotic plaque. The aortic valve\nleaflets (3) appear structurally normal with good leaflet excursion and no\naortic regurgitation. The mitral valve appears structurally normal with\ntrivial mitral regurgitation. There is no pericardial effusion. No vegetations\nor masses seen.\n\nImpression: normal study\n\n\n"
},
{
"category": "Echo",
"chartdate": "2132-12-02 00:00:00.000",
"description": "Report",
"row_id": 62863,
"text": "PATIENT/TEST INFORMATION:\nIndication: ? Endocarditis.\nWeight (lb): 280\nBP (mm Hg): 156/85\nStatus: Inpatient\nDate/Time: at 10:59\nTest: Portable TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nThe patient's Hct on was 24.4.\nChamber sizes not corrected for patient size.\nLEFT ATRIUM: The left atrium is normal in size.\n\nLEFT VENTRICLE: There is mild symmetric left ventricular hypertrophy. The left\nventricular cavity is dilated.\n\nRIGHT VENTRICLE: The right ventricular cavity is dilated. Right ventricular\nsystolic function is normal.\n\nAORTA: The aortic root is moderately dilated. There are focal calcifications\nin the aortic root. The ascending aorta is mildly dilated.\n\nAORTIC VALVE: The aortic valve leaflets (3) appear structurally normal with\ngood leaflet excursion. There is no significant aortic valve stenosis.\n\nMITRAL VALVE: The mitral valve leaflets are structurally normal. There is no\nmitral valve prolapse. Mild (1+) mitral regurgitation is seen.\n\nTRICUSPID VALVE: The tricuspid valve leaflets are normal. Mild tricuspid [1+]\nregurgitation is seen. The pulmonary artery systolic pressure could not be\ndetermined.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve is not well seen.\n\nPERICARDIUM: There is no pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality due to body habitus. Suboptimal\nimage quality. The patient was on a ventilator.\n\nConclusions:\nThe left atrium is normal in size. There is mild symmetric left ventricular\nhypertrophy. The left ventricular cavity is at least mildly dilated. Overall\nleft ventricular systolic function is preserved with ? hypokinesis of the\nbasal inferior wall. The right ventricular cavity is dilated. Right\nventricular systolic function is normal. The aortic root is moderately\ndilated. The ascending aorta is mildly dilated. The aorti leaflets (3) appear\nstructurally normal with good leaflet excursion. There is no definite aortic\nregurgitation. The mitral leaflets are structurally normal. There is no mitral\nvalve prolapse. Mild (1+) mitral regurgitation is seen.\nNo vegetations are visualized but would be better assessed by TEE if\nclinically indicated.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-12-04 00:00:00.000",
"description": "Report",
"row_id": 1612306,
"text": "micu npn 1900-0700\npt remains vented via trache on cpap+ps18/peep5. stv's 780-900cc, rr 15-mid 20's. appeared comfortable overnight. freq suctioning for thick tan secretions. cont on vanco for mrsa in sputum/sinuses. levoquin d/c'd after last eve dose. a febrile overnight. received 2nd of 2 u prbc's for dropping hct over last few days w/o incident. pt with 7-10 beat run of vt vs. probable abharrency with turning/repositioning. lytes checked per dr. . only port to draw was where blood was transfusing. despite lg discard, k was >7.0 x2 draws. given 2 amps ca gluc, ecg normal. after transfusion ended repeat k shown to be 3.6. pt received 40 meq kcl via gtube this am. tube feeds, replete w/fiber advanded to 40cc/hr this am, tolerating , to keep adv to goal as tol. rectal bag replaced overnight, draining golden brown liq stool. foley draining cl yellow gd amts. neuro status conts to improve slowly, pt following commands, appears to be clearing slowly, mae. family in last eve, pleased w/his progress.\nto check on rehab status today w/case mgmt as pt is close to having medical clearance to be d/c'd\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-11-27 00:00:00.000",
"description": "Report",
"row_id": 1612284,
"text": "NEURO: PT REMAINS SEDATE ON ATIVAN GTT @ 2MG/HR AND PROPOPHOL GTT @ 40MCG/KG/MIN. + GAG +PERRLA NOTED. PASSIVE R.O.M. X4 EXTREMITIES.\nCV: MONITOR SHOWS NSR WITH NO ECTOPY. 3 PM PTT THERAPEUTIC AND HEPARIN GTT REMAINS @ 2100U/HR. REPEAT PTT DUE @ 2100.\nRESP: LS COARSE AND DIMINISHED BIBISAILAR. SMA AIR LEAK IN CUFF AND RESOLVED WITH 1 CC AIR INSTALATION.\nGI: ABD SOFT AND DISTENDED. + B.S. NOTED. TF @ A0 CC/HR WITH 30 CC'S RESIDUAL NOTED. FECAL BAG INTACT WITH NO STOOL.\nGU: FOLEY INTACT AND PATENT DRAINING AMBER URINE WITH SEDIMENTATION.\nENDO: CONT ON FINGERSTICKS Q 6HR SECONDARY TO TPN.\nNEURO-VASC: +CSM + PP BILAT SDC BOOTS INTACT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-11-27 00:00:00.000",
"description": "Report",
"row_id": 1612285,
"text": "Resp Care\nremains intub/vented in spont mode. ps 20/peep 5/30%> volumes are large when not agitated..>900 cc's. sxning scant secretions this eve. admin albuterol q4h. c/w vent support. wean ps?\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-12-04 00:00:00.000",
"description": "Report",
"row_id": 1612307,
"text": "PMICU Nursing Progress Note\n\nCNS: Pt. awake, able to follow simple commands, more interactive. No episodes of agitation/tachycardia/hypertension today.\n\nGI: TPN rate decreased to 42cc/hr as tube feedings advanced. Tolerating feeds well, no aspirates, minimal stool.\n\nCVS: Heart rate 75-100 NSR with one brief burst of SVT. B/P 160-160/syst.\n\nRESP: Remains on PSV 15/5 with sats of >96%. frequently for thick, purulent sputum...often requiring NS lavage/ambu. Coarse breath sounds throughout.\n\nF and E: Adequate urine output although pt. is 1L positive. No additional electrolyte replacement required.\n\nID: T max of 100.7po. Remains on vanco.\n\nSKIN: Intact.\n\nDISPO: Pt. being screened by several rehab facilities. Wife in today and met with .\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-12-04 00:00:00.000",
"description": "Report",
"row_id": 1612308,
"text": "Resp Care\nremains vented on psv mode. present settings ps 15/5/30%. Vt usually in 600's, rr 20's, occas up to 40 with coughing/sxning.etc. takes a little while to settle back down. admin albuterol qid prn. increased sxning requirements today. screening for rehab. ordered for passy-muir valve for . c/w slow ps wean.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-12-05 00:00:00.000",
"description": "Report",
"row_id": 1612309,
"text": "micu npn 1900-0700\npatient remains on cpap+ps 15/peep5. continues to tolerate well. suctioning continues to be q1-3 hours for thick white/tan sputum. vss. tube feedings advanced to goal this am, tpn d/c'd. conts to put out sm amts liquid brown stool. awaiting word on if pt has a bed at rehab. pg2, d/c summary completed. please see carevue for further details.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-12-05 00:00:00.000",
"description": "Report",
"row_id": 1612310,
"text": "NURSING NOTE\n\nPT AWAKE AND ALERT, FOLLOWING COMMANDS, CONFUSED AT TIMES, REORIENTED AS NEEDED, VSS TMAX 99.0, HR 70'S SR, SBP 130/60'S- 170/70'S, LUNGS COARSE, LARGE AMTS TAN SECRETIONS, PT WEANED FROM CPAP PS 15 TO 40% TC, TOLERATING WELL, POX 95-98%, PASSEMUIR VALVE IN PLACE AT THIS TIME, L PEG TUBE IN PLACE, TF INFUSING @ GOAL 80CC/HR, ABD ROUND SOFT, +BS, R PICC IN PLACE, PT REHAB PLACEMENT, FAMILY AT BEDSIDE AT THIS TIME, SEE CAREVUE FOR FULL ASSESSMENTS\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-12-02 00:00:00.000",
"description": "Report",
"row_id": 1612299,
"text": "Resp. Note. Pt maintianed on CPAP 5/PSV 20 Fio2 30%. Sats 95-100 Vt 400-800 with RR 12-50 when agitated. Attempted to wean PSV to 15 not tolerated well. Pt with increased agitation/RR. Placed back on PSV 20/sedation increased. Increased sputum prod.-bloody /sputum sent for gram stain. Peg placement done in early evening. Pt transported to and from special procedures without incident. MDI was given as ordered Q4\nPt now resting quietly.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-12-02 00:00:00.000",
"description": "Report",
"row_id": 1612300,
"text": "7A-7P ADDENDUM\n PT returned from IR at 6pm with recommendatations to hold heparin and may start tube feeding immediately if possible. HO is aware and order to start heparin in 6hrs with no bolus.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-12-02 00:00:00.000",
"description": "Report",
"row_id": 1612301,
"text": "7a-7p NPN addendum\nElect: K 3.3 40meq kcl iv given.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-12-03 00:00:00.000",
"description": "Report",
"row_id": 1612302,
"text": "NSG PROGRESS NOTE\n\nEASILY AROUSABLE.OPENS EYES WITH VERBAL STIM. OCCN PURPOSEFUL MOVEMENTS,APPEARS TO ATTEMPT TO FOLLOW COMMANDS.LS CLEAR UPPER FIELDS, COURSE IN LOWER FIELDS, O2 SATS 96-100%. NO CHANGE IN VENT SETTINGS,SXN SEVERAL TIMES FOR SM AMTS THICK TAN WITH TINGE OF BLOOD. HYPERACTIVE BS, NG GOOD PLACEMENT WITH AUSCULTATION. FC DNG GOOD AMT CLR DK YLLW URINE. COCCYX APPEARS SL REDDENED WITH SOME DRY SKIN,NO NOTICABLE CHANGES. ATIVAN AT 1MG/HR.TPN AT 83CC/HR,NS AT 20CC/HR. HEPARIN RESTARTED AT 2230 PER DR . , PTT DRAWN AT 0430. PEG DSG REMAINS CD&I. OCCN PERIODS OF AGITATION. MEDICATED WITH 2 MG OF MSO4 AT 0230 FOR PAIN INDICATION, NONSPECIFIC AREA,? PEG TUBE. NO STOOL IN FECAL BAG. WIFE CALLED THIS AM. FS 123 THIS AM\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-11-21 00:00:00.000",
"description": "Report",
"row_id": 1612264,
"text": "NPN 7p-7a\n\nPt. admitted for vent dependence; LLL consolidation ? empyema vs. persistent pneumonia and RLL consolidation and persistent high fevers despite mult. abx. Pt. transferred from Hospital. Pt. has been intubated about 12 days.\n\nPt. hemodynamically stable overnoc. Conts. to spike fevers. Conts. to require PSV 20 and moderate sedation.\n\nReview of Systems:\n\nNeuro: Pt. sedated on Propofol and Ativan. Ativan decreased to 2.5mg/ hr from 3.0mg. No change in MS. One episode of tachypnea; ? r/t repositioning in bed or vent change; did not tolerate and required 1mg bolus of Ativan and 10cc bolus of Propofol to decrease RR. Pt. not responsive to voice or deep stimuli. Pt. not currently restrained. Plan- wean Ativan, keep Propofol gtt ? extubation in short while...\n\nResp: Current vent settings; PSV 20, PEEP 5, fiO2 40%, TV 800-1L, RR 18-26. Sat'ing 97%. Last ABG good. Attempted to bring PSV down to 15; did not tolerate at time as mentioned above. LS- clear upper right, otherwise diminished. Sx'd for scant amounts of white secretions that resemble oral secretions. Much drainage from oralpharynx and nose. Plan- wean PSV as tol.\n\nCV: VSS despite frequent PVC's and PAC's. HR 60-80 NSR. BP 110-130/ 60-80. A-line currently positional and relying on NBP cuff pressures which correlate. Edema throughout. + pulses. Skin intact.\n\nGI: Abd. soft, obese. Passing mod. amounts of brown loose stool through rectal foley cath. Stool sent for c. diff (neg at OSH). NGT changed to OGT d/t known sinusitis. Pt. conts. on TPN. Not using gut to feed...\n\nGU: F/C draining adequate amounts of clear urine.\n\nID: Spiked to 101.8 and was pan cultured then given PR Tyelenol.\n\nAccess: TLC unclear when placed from OSH. A-line (positional).\n\nSocial: Wife, sister and daughter in tonight will visit again today. Appropriately anxious for loved one to get better...\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-11-21 00:00:00.000",
"description": "Report",
"row_id": 1612265,
"text": "Resp care note 7p-7a\nPt remains on PSV 20/5 fio2 40%. RR teens-twenty's. Attempted to wean psv to 15 over night, RR increased to 30's-40's so increased psv back to 20. BS essentially clear and dimin. Sx small pale secretions. Will follow, wean psv as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-11-21 00:00:00.000",
"description": "Report",
"row_id": 1612266,
"text": "S. ETT AND SEDATED\nNEURO ATTEMPTING TO DECREASE SEDATION PRESENTLY PROPOFOL 25 MCG ATIVAN AT 2.5MG Q HR PT OPENING EYES TO STIMULI PEARLA 3MM BRISK MOVES EXTREMITIES TO PAINFUL STIMULI\nCARDIAC HR 80'S NSR WITH OCC PVC AND PAC BP 130/-150/ HCT 26.9 K+ 3.8 NA 140 SKIN W+D PP +4\nRESP ON CPAP PS 20 PEEP 10 WITH TV 800-900 O2 SAT 97% RR 18 FI02 .4 ATTEMPTED TO DECREASE PS TO 15 WITH INCREASE RR 50 DECREASE TV 400'S PUT BACK ON 20 PS SX MIN SX WHITE BS CLEAR UPPER LOBES BRONCHIAL LOWER LOBE ESP LLL. ON LEVOQUIN AND CEFTAZADINE FOR GRAM + ROD AND PSEUDOMONAS AND STREP PNEUMONIA\nGI OGT ABD SNT BS+ RECTAL TUBE DIARRHEA BROWN\nGU FOLEY IN PLACE U/O> 100 QHR BUN 28 CR .7\nNUTRITION RECEIVING TPN\nSKIN INTACT\nID TEMP MAX 102.8 AXIL WBC WNL\nACCESS ALINE RT RADIAL LT IJ TRIPLE LUMEN\nA. FEVERS UNCLEAR SOURCE POSSIBLE SINUS, EMPYHEMA, RESP\nP. REPEAT HEAD CT OBTAIN SINUS CT\nNASAL DECONGEST\nAWAIT CX REPORT MONITOR TEMP\nANTIBX AS ORDERED\nCOOLING BLANKET\nATTEMPT TO DECREASE SEDATION AND WEAN FROM VENT\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-11-21 00:00:00.000",
"description": "Report",
"row_id": 1612267,
"text": "CT HEAD DONE UPON RETURN TO FLOOR RECTAL FOLEY DISCONNECTED PT HAD A LARGE CLOT REMOVED FROM FOLEY HO NOTIFIED WILL DRAW REPEAT HCT\nENDO BS 304 TX 4U REG INSULIN\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-11-25 00:00:00.000",
"description": "Report",
"row_id": 1612278,
"text": "MICU/SICU NPN 0700-1900\n\nRemains on 20PS 10 PEEP. Gd O2sats. ABGs stable. Secretions thick yellow, sm-mod amts. Plan to decrease PEEP to 7.5.\n\nTmax 99.8 PO. LP done with cl fluid returned. Specs sent.\n\nLimbs remain flaccid. Sedation off x2hrs. RR inc to 40s and pt would intermittently open eyes to pain. Eval by neuro at this time. MRI on hol per neuro. Attempted to restart sedation with Ativan only. Rate inc to 8 mg with RR 40s still. Inc to 10mg with sl drop in RR 32. ? a higher rate would have been successful for sedation but added Propofol back for LP and Ativan weaned back to 5mg/hr. Plan to use Ativan only and dc Propofol at some point.\n\nSSRI w/Insulin in TPN. 12p FSs 200s and covered w/SSRI. Cont to follow FSs.\n\nMin stool. Min OGT asp. + bow sds.\n\nWife called 4-5x today inquiring about MRI and LP. Aware of present situation of LP and MRI on hold. Will not be in this eve.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-11-26 00:00:00.000",
"description": "Report",
"row_id": 1612279,
"text": "NURSING PROGRESS NOTE:\n\nNEURO: REMAINS SEDATED ON PROPOFOL AND ATIVAN GTT. NO EYE OPENING, GRIMACES TO PAINFUL STIMULI ONLY. REQUIRED ATIVAN BOLUSES DURING BATH. BECAME VERY TACHYPNEIC, RR 40'S, WITH DECREASED TV. RESPONDED WELL TO ATIVAN BOLUS. RR BACK TO BASELINE.\n\nC/V: HD STABLE.\n\nRESP: REMAINS OF CPAP/PS 20,PEEP 8, TV @700, FIO2 30%. TOLERATING WELL WITH O2 SAT'S >95. LUNGS CLEAR, BASES DIMINSHED. SUCTIONED 2X FOR SMALL, THICK PALE YELLOW SECRETIONS. ABG TO BE DRAWN WITH AM LABS.\n\nGI: CRITICARE TF STARTED AT 10CC/HR PER NGT. RESIDUALS @60CC AT 0500. TF HELD FOR 1 HR. WILL RECHECK RESIDUALS.\n\nID: MICRO LAB CALLED WITH +BLOOD CULTURE; GRAM+ COCCI, PAIRS AND CLUSTERS. DR. NOTIFIED. 1GM VANCO GIVEN. TMAX 102.8. MED WITH 650 TYLENOL AND GIVEN COOL BATH. TEMP 102 @0400.\n\nSOC: TALKED TO WIFE IN AM, CALLED IN FOR AN UPDATE.\nNO OTHER UPDATES AT THIS TIME.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-12-03 00:00:00.000",
"description": "Report",
"row_id": 1612303,
"text": "ADDENDUM\n\nHEPARIN INC TO 2850 UNITS PER HR, BOLUSED WITH 2400U FOR PTT OF 54.8.\nNEXT PTT DUE AT 1230\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-12-03 00:00:00.000",
"description": "Report",
"row_id": 1612304,
"text": "Resp Care\nremains trached/on spont mode with present settings ps 18/peep 5/30%. did not tolerate trial of x2 today with big drop in vt to 200's with rr high 30's. sxning sm tan to bld tinged secretions. more calm today. one episode of tachypnea/desat in conjunction with turning for cpt. also noted to have overinflated cuff...decreased to minimal occluding volume which is 11 cc's. Dr. to evaluate.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-12-03 00:00:00.000",
"description": "Report",
"row_id": 1612305,
"text": "NURSING NOTE\n\nPT MORE ALERT TODAY, EYES OPEN SPONTAN, ATIVAN GTT D/C'D THIS AM, R IJ FELL OUT THIS AM HEPARIN GTT D/ PT STARTED ON LOVENOX AND COUMADIN, R ARM PICC PLACED AT BEDSIDE TODAY, VSS HR SR 70-100'S NO ECTOPY NOTED, SBP 118/57-184/92, TMAX 100.6 PT TRANSFUSED WITH 2 UTS PRBC FOR HCT 23.4, 2ND UNIT TO START NOW, TYLENOL GIVEN PRIOR TO PRBC TRANSFUSION, BP ELEVATED WHEN PT ANXIOUS, PT THIS AM, LARGE AMTS TAN SECRETIONS, LUNGS SOUNDS COARSE RHONCHI BILAT, PT CONTINUED ON VANCO FOR MRSA TRACHEOBRONCHITIS, SINUS BIOPSY ALSO GROWING MRSA AS MD NOTE, POX 98-100% ON CURRENT VENT SETTINGS CPAP PS 18, 30% FIO2, PT APPEARS MORE COMFORTABLE THIS AFTERNOON, BEDSIDE TEE DONE THIS AFTERNOON, PT MEDICATED AT THAT TIME WITH PROPOFOL AND VERSED, TEE NEG. FOR VEGETATION, PT WITH ONE EPISODE OF DESATURATION TO 55% WHEN TURNED TODAY FOR CPT PT BAGGED AND SATS IMMEDIATELY IMPROVED TO 100%, FAMILY @ BEDSIDE PT APPEARS COMFORTABLE SEE CAREVUE FOR FULL ASSESSMENTS\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-11-26 00:00:00.000",
"description": "Report",
"row_id": 1612280,
"text": "ADDENDUM:\n\nCONTINUES TO HAVE LARGE AMT. OF THICK YELLOW DRAINAGE FROM RIGHT AND LEFT NARES. ?POSSIBLE CULTURE NEEDED. ALSO, TF RESTARTED AT 0600. NO RESIDUALS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-11-26 00:00:00.000",
"description": "Report",
"row_id": 1612281,
"text": "pt remains sedated.occn furrowing eyebrows or sl movement of extremities when being repositioned or manipulated. Withdraw's from painful stimuli. nsr w/o ectopy, occn st w/o ectopy, rate 80-90's. some peripheral edema,esp. hands. lung sounds essentially clear upper fields, dimin bases with occn course sounds. Several episodes of tachypnea this am, tx with boluses of propofol and sxn. sxn several times for sm or moderate amts of thick tan. bs remain hypoactive softly distended abd. fecal bag replaced, dng brown liquid stool. foley catheter dng mod amts clear dk yellow urine. coccyx remains sl reddened with dry skin, eucerin cream and repositioned q 2 hrs. ativan drip rate decreased by 20%, down to 4mg/hr, to be weaned by 20% qd. propofol inc to 20mcg/min this am and further inc to 25mcg/min this pm at 1600. vent settings fio2 30%,ps20,and tv 700, rr 15-28 with occn tachypnea. pt had ct of chest to r/o pe. Will be going to mri for head mri. plan is to wean pt off of ativan, inc propofol as needed. pt will be trached and peg'ed at somepoint this week.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-12-01 00:00:00.000",
"description": "Report",
"row_id": 1612294,
"text": "****MRSA IN SPUTUM**** PLACED ON CONTACT PRECAUTIONS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-12-01 00:00:00.000",
"description": "Report",
"row_id": 1612295,
"text": "RESP NOTE:\nPt remains on CPAP/PSV ( see carevue flowsheet for vent settings) mov. vol. 800-900 with rr 20s. Sats 98-100% Trach secure and patent. MDIS given as ordered. Plan to maintain on current settings.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-12-01 00:00:00.000",
"description": "Report",
"row_id": 1612296,
"text": "MICU/SICU NPN 0700-1900\n\n Remains on CPAP. No vent changes. Suct q2-4hrs for thick brown,at times bloody sputum. Mod to lg amts. 1 episode of tachypnea w/ RR 50 and drop in O2 sats to 50%. Bagged and then bagged further with eventual relief. Pt later turned on R side and had another episode. Min vent unchanged with drop in TV, to 600, compensated by inc in RR to 30s. Eventually rate up to 40s and pt diaphoretic requiring 2mg Ativan. Episode repeated itself in ~45 min and received addtional 2mg Ativan and was placed back on back. Currently RR 12 and TVs 1L. Also started on Lopressor as BP has been consistently 170s/80s all afternoon.\n Ativan gtt decreased to 1mg from 2mg this am. Continues off Propofol.\n No insulin required this shift. FSs changed to .\n Spiked to 101 this am and was pan cultured. Second stool sent for c-diff. Sputum now with MRSA. Placed on contact precautions.\n Wife in x2 today.\n Tol TFs with min asp. Currently at 30cc/hr. Cont to titrate to goal. Will need case mgmt involved tomorrow for rehab planning.\n Plan for PEG in IR tomorrow. NPO after mn. IR will call when they want Heparin shut off.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-11-20 00:00:00.000",
"description": "Report",
"row_id": 1612262,
"text": "RESP PT. TRANSFFERED FROM OSH TO MICU PLACED ON THE VENT PS 20 PEEP 5 45% FIO2, TOLL OK AT THIS TIME, SPON TV 700 - 900 CC, SPON RR 17 - 22, SPO2 96%.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-11-20 00:00:00.000",
"description": "Report",
"row_id": 1612263,
"text": "NURSING ADMISSION NOTE:\n\nPT. IS A 54 Y/O MALE WHO TRANSFERRED FROM OSH( HOSPITAL) FOR FURTHER MANAGEMENT OF SEVERE PNEUMONIA, (STREP PNEUMO., PSEUDOMONOUS)\nAND FAILURE TO WEAN.\n\nPAST HX:\n HYPOTHYROIDISM (S/P THYROIDECTOMY)\n HYPERLIPIDEMIA\n COPD (SMOKER, 3PPD)\n SVT DX. \n OBESE (RECENT 30 LB WEIGHT GAIN\n\nHISTORY OF HOSPITAL STAY:\n ADMITTED TO ER ON WITH C/O CP AND SOB. ON ADMISSION HR 180'S. TX WITH ADENOSINE AND ESMOLOL GTT. DECOMPENSATED, REQUIRING INTUBATION. +SPUTUM AND SINUS CULTURES FOR PSEUDOMONOUS, STREP PNEUMO. 3+BLOOD CULTURES. TX WITH MULTIPILE ANTIBIOTICS. RECENT BLOOD CULTUES NEGATIVE (), BUT CONTINUES TO SPIKE TEMP. 104. TX WITH FLAGLY FOR ?C.DIFF. CHEST CT FROM SHOWING FLUID IN LEFT LUNG. HAS BEEN HD STABLE DURING HOSPITAL STAY. ECG NSR WITH FREQUENT PVC'S AND PAC'S.\n\nREVIEW OF SYSTEMS:\n\nNEURO: PT IS SEDATED ON PROPOFOL AND ATIVAN GTT. NO EYE OPENING TO VERBAL, TACTILE STIMULI. GRIMACES AND COUGHS WHEN SUCTIONED. PUPILS, EQUAL AND REACTIVE.\n\nC/V: ECG SHOWING NSR WIHT FREQUENT PAC'S, PVC'S WITH FRQUENT PERIODS OF TRIGEMINY. B/P STABLE 120/60'S\n\nRESP: BILAT LUNGS DIMINISHED THROUGHOUT. CURRENT VENT SETTINGS OF CPAP/PS20, PEEP5, FI0245%, TV 700-800, O2 SAT>95%. A-LINE PLACED MD. NEEDS ABG DRAWN AND RESP. CULTURE TONIGHT.\n\nGI: ABD SOFT. +BS. LARGE AMT OF BROWN LIQUID STOOL. RECTAL TUBE PLACED. SAMPLE SENT FOR C.DIFF. NGT IN PLACE, CLAMPED.\n\nACCESS: LEFT IJ ML CATH IN PLACE. TPN RUNNING AT 114CC/HR.\n\nSKIN: SKIN INTACT.\n\nPLAN: MD WOULD LIKE TO WEAN ATIVAN AND GO UP ON PROPOFOL IF PT. TOLERATES, WEAN VENT IF POOSIBLE.\n\nFAMILY: NO FAMILY CONTACT AT THIS TIME.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-12-02 00:00:00.000",
"description": "Report",
"row_id": 1612297,
"text": "NURSING PROGRESS NOTE:\n\nNEURO: REMAINS ON 1 MG ATIVAN FOR SEDATION. PT RESPONDS TO VOICE BY OPENING EYES AND TRACKING. HOWEVER, DOES NOT FOLLOW COMMANDS. MAE, SPONTANEOUSLY. PT AWAKE ON/OFF THROUGHOUT THE NIGHT, RESLTESS AT TIMES.\n\nC/V: HD STABLE OVERNIGHT. REMAINS ON HEPARIN GTT AT 2600U/HR.\n\nRESP: REMAINS ON CPAP/PS 20, PEEP 5, TV 800-1000, FI02 30%. TOLERATING WELL. O2 SAT'S 97-99%. FOR LARGE AMT THICK TAN SECRETIONS, BLOODY TINGED AT TIMES. @1HR AFTER PT BATHED AND TURNED TO THE LEFT, HAD INCREASED RR 30-40'S AND LOWERED TV. BAGGED AND WITHOUT IMPROVEMENT. TURNED BACK ON BACK AND ATIVAN BOLUS GIVEN. @AFTER 30MIN, PT CALMED DOWN AND RR DOWN TO BASELINE.\n\nID: TMAX 102.6. 650 TYLENOL GIVEN. TEMP DOWN TO 100.4 AT 0400.\n\nGI: TF ON HOLD AFTER MN FOR PEG PLACEMENT IN THE AM.\n\nSKIN: BATH DONE. NO SKIN BREAKDOWN NOTED.\n\nPLAN: PEG TUBE PLACEMENT THIS AM. IR TO CALL WHEN HEPARIN TO BE STOPPED.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-12-02 00:00:00.000",
"description": "Report",
"row_id": 1612298,
"text": "7p-7a NPN\nNeuro: Ativan continues at 1mg/hr for sedation. Around 12:30Pm, after Am care, pt became very tachypneic and tachycardic. Ativan 1mg bolus given and repeated x3 within 3hr with no effect. Than Ms04 2mg ivp administered per Dr order resulted in good effect.\n\nResp: Pt remains on CPAP, Peep 5 .Attempted to decrease ps to 15, but pt became tachypneic than setting was increased to 20. almost hourly small amount bloody tinged secretions. Gram stain culture taken. RR 16-34, O2 sat 96-100%.\n\nCV: Occasionally hypertensive and tachycardic when pt became agitated but otherwise stable. Echocardiogram was done.\n\nGI: OGT placed on intermittent suction, tan billirious secretions noted. Remains on TPN at 83cc/hr. At 415pm pt was taken to IR for peg placement. Heparin gtts stopped at 11am and stool for c-diff taken.\n\nGU: Foley cath in place u/o adequate amts of clear yellow urine.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-11-24 00:00:00.000",
"description": "Report",
"row_id": 1612274,
"text": "MICU/SICU NPN 1900-700\n\nRemains intub and sedated. No vent changes. Suctioned q4hr for sm amt white-yellow sputum. Gd O2sats. T spike to 101.4. Recultured and given Tylenol. Currently weaning Propofol to off by am. Will increase Ativan prn. He is now sluggishly opening eyes but not following commands. FSs remain in mid 200s. Receiving q6hr SSRI coverage. ? add to TPN. No stool. Min OGT aspirates.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-11-24 00:00:00.000",
"description": "Report",
"row_id": 1612275,
"text": "NEURO: OFF PROPOPHOL @ 0600. OPENS EYES SPONT BUT UNABLE TO FOLLOW COMMANDS. NO SPONTANEOUS MOVEMENT OF EXTREMITIES NOTED AND EXTREMITIES APPEAR FLACCID. + GAG, + COUGH, AND +PERRLA NOTED. PLAN FOR MRI OF HEAD, NECK AND SPINE THIS EVE.\nCV: MONITOR SHOWS NSR-ST WITH NO ECTOPY. R RADIAL A-LINE WITH GOOD WAVEFORM AND ACC TO CUFF PRESSURES. 1L NS BOLUS GIVEN FOR INCREASED HR AND COPIOUS SECRETIONS.\nRESP: LS COARSE AND DIMINISHED BIBASILAR. SXN FOR MOD AMTS OF THICK WHITISH-YELLOWISH SECRETIONS VIA ETT AND COPIOUS AMOUNTS OF CLEAR ORAL AND NASAL SECRETIONS. PT PLACED ON SIMV AND DID NOT TOLERATE WELL. RR 40'S SBP 180'S HR 120'S AND DIAPHORETIC. PT CURRENTLY ON A/C 700X14X.30 WITH 10 PEEP AND TOLERATING WELL.\nGI: ABD SOFT AND LARGE. +B.S. NOTED AND FECAL BAG DRAINING LOOSE GOLDEN BROWN STOOL.\nGU: FOLEY INTACT AND PATENT DRAINING YELLOW URINE WITH SEDIMENTAION NOTED.\nENDO: CONT N FINGERSTICKS Q6HR WITH S/S COVERAGE.\nI-D: REMAINS FEBRILE AND PAN CX ON NOCS. CONT ON CEFTAZ AND LEVO. PT BEING FOLLOWED BY I-D AND ENT WAS CONSULTED FOR EVAL.\nNEURO-VASC: + CSM +PP BILAT SDC BOOTS INTACT.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-11-24 00:00:00.000",
"description": "Report",
"row_id": 1612276,
"text": "TEMP UP TO 102.4. B/P AND RR INCREASED, SEE FLOWSHEET. DR. NOTIFIED. 650 TYLENOL GIVEN AND ATIVAN BOLUS AND PROPOFOL GTT INCREASED TO 15CC/HR.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-11-29 00:00:00.000",
"description": "Report",
"row_id": 1612290,
"text": "NURSING NOTE\n\nPT REMAINS SEDATED, ATIVAN GTT DECREASED TO .5 MG/HR, PROPOFOL GTT INFUSING @ 35 MCQ, RESPONDS TO STIMULUS, OPENS EYES WHEN PROPOFOL OFF FOR FEW MINUTES, CURRENT VENT SETTINGS CPAP PS 15, TV 700, PT MAINTAINING TV 680-800, THICK YELLOW TO TAN SECRETIONS, THICK PLUG THIS AFTERNOON, LUNGS COARSE, TRACH IN PLACE, SM AMT BLD OOZING AT SITE AFTER DRSG AND ,\n\nPT STARTED ON VIVONEX TF @ 10CC/HR THIS AFTERNOON GOAL 40CC, ABD ROUND SOFT AND DISTENDED, + BS, INCONTIN LOOSE BMS, RECTAL INCONTIN BAG IN PLACE, PT FOR POSSIBLE PEG TUBE ON TUES, TPN INFUSING @ 72CC/HR,\n\nHEPARIN GTT INFUSING @ 2600UTS/HR, PTT THERAPEUTIC 71-85, NEXT PTT TO BE DRAWN IN THE AM,\n\nFAMILY IN TO VISIT WITH PT TODAY, SEE CAREVUE FOR FULL ASSESSMENTS\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-11-25 00:00:00.000",
"description": "Report",
"row_id": 1612277,
"text": "rn progress note\n 630am\nneuro; at 2200 pt overbreathing vent b/p and hr inc. ativan bolus 2mg and inc to 4mg additional propofol also given. pt repositioned. cool bath given pt settled down hr and b/p to wnl. rr to 24 to 25.\n\ncad: following incident hr 70's b/p 130/60.\n\nresp: vent to ps20 peep 10 305 rr settled in to 24-25 for rest of shift. prev at 2200 pt breath. high 20's suctioned with ambu for scatn amt. secretions. ls dim to coarse.\n\ngi: tpn infusing as ordered. rectal bag intact. liquid brown stool.\n\ngu: uo 60-100cc/hr K+ am labs 3.5\n\nendo last glucose 189\n\ntemp: temp max on eves 102.4 pt given tylenolx2 curre=nt temp 99.5\n\nplan: mri this am to determine poss. change in mental status or sedation, monitor resp status, ? need to place pt on nph or higher reg ssi due to prev. bs >200.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-11-30 00:00:00.000",
"description": "Report",
"row_id": 1612291,
"text": "NURSING PROGRESS NOTE:\n\nNEURO: REMAINS ON ATIVAN AND PROPOFOL GTT FOR SEDATION. GRIMACES TO PAINFUL STIMULI, ATTEMPTS TO OPEN EYES. NO EXTREMITY MOVEMENT NOTED.\n\nC/V: HD STABLE.\n\nRESP: REMAINS ON CPAP/PS. DID NOT TOLERATE DECREASING PS TO 12, RR UP TO 30-35, TV 600'S. PS BACK UP TO 15. AFTER BEING WASHED AND TURNED @0230. PT BECAME TACHYPNEIC, RR 40-50, DECREASED TV. ATIVAN AND PROPOFOL BOLUSES GIVEN. FOR THICK OLD BLOODY SECRETIONS. RR CONTINUED TO REMAIN HIGH. RT AND MD NOTIFIED. PS NOW UP TO 20. RR RATE NOW , O2 SAT'S @97-99%.\n\nGI: TF HELD FOR @1HR FOR RESIDUAL OF 80CC/HR. TF RESTARTED AFTER 1HR @20CC/HR. TOLERATING WELL.\n\nSKIN: NO SKIN BREAKDOWN NOTED. FECAL BAG INTACT WITH LOOSE BROWN STOOL.\n\nSOC: WIFE CALLED THIS AM, UPDATED.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-11-30 00:00:00.000",
"description": "Report",
"row_id": 1612292,
"text": "NURSING NOTE\n\nPT REMAINS SEDATED, VSS, TEMP SPIKE TO 101.3, TYLENOL GIVEN FOR TEMPS, LUNGS COARSE WITH DECREASED BS @ BASES, COPIOUS TAN TO YELLOW SECRETIONS, POX 98-100%, PROPOFOL GTT INFUSING @ 36MCQ/KG, ATIVAN GTT @ .5MG/HR, PT REMAINS ON CPAP PS20, P5, 30%FIO2, TV700, HEPARIN GTT INFUSING @2600UTS/HR, PT BECOMES TO 40-50'S AFTER SUCTIONING AND REPOSITIONING, TAKES PT TIME TO SETTLE AFTER THIS, PT BAGGED AND THIS AFTERNOON FOR THICK LARGE AMTS OF SECRETIONS, TF TURNED OFF THIS AM SECONDARY TO LARGE AMTS RESIDUALS, TPN MAINTAINED, ABD LARGE SOFT, +BS, INCONTIN LOOSE BROWN STOOL, STOOL SENT FOR CDIFF TODAY, FOLEY CATH IN PLACE, DRAINING CLEAR YELLOW URINE ADEQUATE AMTS, SEE CAREVUE FOR FULL ASSESSMENTS\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-12-01 00:00:00.000",
"description": "Report",
"row_id": 1612293,
"text": "NURSING PROGRESS NOTE:\n\nNEURO: PROPOFOL GTT WEANED OFF OVERNIGHT. ATIVAN GTT INCREASED TO 2MG/HR FOR SEDATION ( TITRATE UP TO 5MG/HR FOR SEDATION). SINCE PROPOFOL GTT OFF, PT AWAKE, TRACKING WITH EYES, MAE, FOLLOWING SOME SIMPLE COMMANDS INCONSISTENTLY.\n\nC/V: HD STABLE OVERNIGHT. REMAINS ON HEPARIN GTT AT 2600U/HR.\n\nRESP: REMAINS ON CPAP/PS 20, PEEP 5, TV 800-900, FI02 30%. TOLERATING WELL, O2 SAT'S 98-99%. FREQUENTLY FOR LARGE THICK TAN SECRETIONS, AT TIMES BLOOD TINGED. ONLY 1 EPISODE TACHYPENIA WHICH RESOLVED AFTER BEING FOR LARGE AMT OF SECRETIONS.\n\nGI: TF RESTARTED AT 10CC/HR @MN. SO FAR TOLERATING WELL, SMALL RESIDUALS @10CC.. RECTAL BAG REMAINS INTACT WITH LIQUID BROWN STOOL\n\nID: TMAX 100.6. NEEDS ID APPROVAL TO CONTINUE VANCO DOSING.\n\nPLAN: CONTINUE TO WEAN VENT. PEG TUBE PLACEMENT PLANNED FOR TUESDAY.\n\nFAMILY: NO CONTACT WITH FAMILY OVERNIGHT.\nNO OTHER UPDATES.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-12-09 00:00:00.000",
"description": "Report",
"row_id": 1612321,
"text": "RESP CARE\nPt remains intubated and ventilated with a puritan vent which has been checked for leaks and alarms tested according to dept policy. Currently pt is on psv12/peep5 and fio2 50%. Spont vt 480-650cc and rate inc from 10 to 24. BS coarse bil. Pt transported to and from mri without problem. follow as needed,\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-12-09 00:00:00.000",
"description": "Report",
"row_id": 1612322,
"text": "NURSING NOTE\n\nPT MORE AWAKE AND ALERT TODAY, FOLLOWS COMMANDS, OPENS EYES , PT OFF SEDATION TODAY, CURRENTLY ON 40% TC POX 97%, LARGE AMTS TAN/YELLOW SECRETIONS, SPUTUM CX SENT FOR GM ST& CX, PT TOLERATING VALVE, LUNGS COARSE, DECREASED BS @ BASES, 1L NSS FLUID BOLUS GIVEN THIS AFTERNOON FOR DECREASED , IMPROVED, PT LOADED WITH 500 DILANTIN AGAIN TODAY, NO SEIZURE ACTIVITY NOTED, ABD SOFT, TOLERATING TF, FOLEY CATH IN PLACE DRAINING CLEAR YELLOW URINE, R PICC IN PLACE, U/S GUIDED THORACENTESIS ATTEMPTED @ BEDSIDE, UNABLE TO DO SECONDARY TO SMALL AMT FLUID, CLOSE TO SPLEEN, K+ 3.4 THIS AM, REPLETED WITH 20MEQ, PT RESTARTED ON LOVENOX AND COUMADIN THIS AFTERNOON, PT SLEEPING @ THIS TIME, SEE CAREVUE FOR FULL ASSESSMENTS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-12-09 00:00:00.000",
"description": "Report",
"row_id": 1612323,
"text": "resp Care\nreceived pt on psv mode with ps 12/peep 5...changed after rounds/usn to trach collar. rr up to 30's...apparently the last time he was weaned off vent he was somewhat tachypneic also. sxning thick yellow but also has a strong cough..able to expectorate a good amt of secretions. passy muir trial done..good vocalization. will use when visitors present. c/w trach collar as tolerates. vent on standby.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-12-10 00:00:00.000",
"description": "Report",
"row_id": 1612324,
"text": "MICU NURSING PROGRESS NOTE\n\nAWAKENS SPONTANEOUSLY, AROUSES EASILY, APPEARS ALERT AND ORIENTED TO PLACE AND SITUATION, INDICATES UNDERSTANDING BY NODDING HEAD, FOLLOWS COMMANDS WELL. PT RESTLESS WHILE SLEEPING. CONTINUES WITH LOW GRADE TEMPS OF 99.9,99.5 LUNG SOUNDS COURSE THROUGHOUT,02 SAT 95-100% ON TRACH MASK, PRODUCING SM AMTS OF THICK TAN SPUTUM THROUGH TRACH EACH HOUR. RR VERY VARIABLE. OCCN. SHORT PERIODS OF TACHYPNEA HM SHOWS SINUS RYTHM,0 ECTOPY NOTED. + BOWEL SOUNDS, TUBE FEEDING RUNNING AT 80CC/HR, TOLERATING WELL. MODERATE SOFT STOOL X 1,GUIAC NEGATIVE. FOLEY CATHETER DNG PINK,SEDIMENT FILLED URINE IN MODERATE AMTS, DR NOTIFIED. GIVEN 500 CC NS BOLUS. BGM 119 @ 0500. INDICATED RT SHOULDER DISCOMFORT, MEDICATED WITH MS04, INDICATED GOOD EFFECT. ATIVAN FOR RESTLESSNESS, DOES NOT APPEAR TO HAVE BEEN VERY EFFECTIVE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-11-28 00:00:00.000",
"description": "Report",
"row_id": 1612286,
"text": "NPN\nPt sedated with Ativan 2mg/hr and Propofol40mcg/kg/min. Appears comfortable. Opened eyes once while washing hair. PERL\n\nSR 70-90's SBP130-140's Skin warm and flush. Generalized edema to extremities. Started on heparin for PE. Heparin gtt currently@2350units/hr. PTT@0530 80.3 and therapeutic. Needs second consecutive therapeutic PTT@1000\n\nNo vent changes made. Remains on CPAP+PS20 peep5 30% TVs800-1000 RR 10's No distress or tachypnea episodes. scant to no secretions. Plan is that with heparin being therapeutic pt is more likely able to be weaned and not trached.\n\nPt receiving TPN. TF@10cc/hr and not tolerating at0400. Turned off for residual of 100cc. Will resume @0600 if <100. No new stool in rectal bag.\n\nAdequate clear amber urine\n\nTmax101.2 WBC12 this am Tylenol given X1\nGlucose checked Q6hrs.\nPt bathed, linens changed and hair washed. No breakdown noted.\nCont to wean sedation and vent as tolerated.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-11-22 00:00:00.000",
"description": "Report",
"row_id": 1612268,
"text": "NPN (NOC): PT REMAINS INTUBATED. CURRENT VENT SETTINGS: PS 20X40%. RR IN TEENS, VT'S 800- 800, STAS IN HIGH 90'S. BS'S COURSE. SX'D SEVERAL TIMES FOR THICK SECRETIONS. TEMP HAS BEEN IN 99'S OVERNCO W/O TYLENOL. SEDATION IS UNCHANGED. PT SLEPT, UNTIL AM CARE GIVEN, PT'S RR UP TO HIGH 30'S REQ SEVERAL PROPAFOL AND ATIVAN BOLUSES TO QUELL.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-11-22 00:00:00.000",
"description": "Report",
"row_id": 1612269,
"text": "micu/sicu npn 0700-1900\nros--\nneuro--sedated. +cough, gag impaired. perl.\nresp--patient remains intubated and sedated on ativan and propofol. this am, pt beacme tachypnic to 45-50's, out of synch with the vent. ativan increased to 3.5mg/hr and propofol increased to 50mcg/kg/min. pt much more comfortable, also switched to a/c 700/x1640%, peep5.\nvery thick white/tan sections via ett q4hrs (w/ambu and lavage). +cough.\ncv--hr 60's this pm after defervecing and on increased propofol, was in 80-90's this am. bp stable via abp dampened at times 1teeens-130's sys. no ectopy seen.\ngi/gu--ogt on lcs this am, 375cc bilious out. tf's on hold. reglan started. hypoactive bs. scant amt ob+ liquid stool. mushroom catheter out this am, noted red clots in tubing, ho aware. bag applied.\nid--febrile this am to 102.2 rectally, conts on levoquin, to be changed to iv d/t high residuals. cooling blanket on/tylenol given,. pt afebrile this afternoon. chest/abd and sinus ct done this eve, attempted diagnostic pleural tap, but not enough fluid seen on u/s. tlc to be attempted this afternoon. ? date of tlc from osh. to send tip for cx.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-11-28 00:00:00.000",
"description": "Report",
"row_id": 1612287,
"text": "MICU/SICU NPN 0700-1900\n Episode of tachypnea w/RR 50. Propofol inc and is currently at 60ucgs. Ativan weaned down to 1mg/hr as per plan. No further episodes of inc RR.\n No vent changes. O2sats did drop to 90% transiently when placed on R side. Average O2SAT 94 ON 30% FIO2. Scant secretions this am. # 8 portex trach placed at 1300. Tol procedure well. Later for thick bloody sputum sputum,mod amts. Stoma site without bleeding or drainage at this time.\n Remains on TPN. Lg residuals this am. +bow sds. OGT dc'd during trach placement. MD aware. Min stooling. FSs sstable. No insulin given.\n T max 100.6 po. No changes made.\n Wife called x1. Aware of trach.\n Hep gtt held for trach and restarted at 1600 without bolus per Dr. . Check ptt at 2200 per protocol. Monitor for increase tracheal bleeding.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-11-29 00:00:00.000",
"description": "Report",
"row_id": 1612288,
"text": "NPN\nPt sedated on Ativan 1mg/hr and propofol currently at 43mcg/kg/min. Weaning Ativan off daily. Titrating propofol. Pt does open eyes with stimulation. PERL No movement to extremities noted, only flicker with left arm.\nVSS SR70-90's No ectopy\nPt had episode of tachypnea-rr 30's TV down. Placed on CPAP+PS20 peep5 55% TV improved and RR 10's. Maintained sats. Propofol increased at that time as well. mod amt of tan secretions via trach. No bleeding from stoma.\nConts on TPN. Scheduled PEG on Tues. Fingersticks Q6hrs-no coverage given.\nAdequate clear yellow urine.\nTmax101\nHeparin gtt at 2600 units/hr per protocol. PTT due @0730 per protocol. No overt bleeding.\nCont to wean sedation and vent as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-11-29 00:00:00.000",
"description": "Report",
"row_id": 1612289,
"text": "Respiratory Care Note\nPt started shift on SIMV. Pt switched to CPAP +5 P/S 20 FIO2 30%. TV's 600-700, RR 17-22. Pt appears comfortable. Sx'ed for mod amt tan secretions from trach. B.S. rhonchi t/o , clearing after sx'ing.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-11-22 00:00:00.000",
"description": "Report",
"row_id": 1612270,
"text": "Resp Care\npt remains full ventilatory support..changed to ac mode 700x16x.4/10 peep. high (18-19) VE requirement. sedation increased to improve ventilation. admin albuterol q4prn. sxned sm amts thick yellowish. transported to radiology for abd ct. c/w full vent support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-11-23 00:00:00.000",
"description": "Report",
"row_id": 1612271,
"text": "MICU/SICU 1900-0700\nUneventful night. No change in sedation. Occ opens eyes sl to stimuli. Min mvmt. Suct x3 for sm-mod amt thick white sputum. Gd O2sats. No vent changes. UO adequate. L IJ line dc'd,tip sent for culture. T max 100.4. Cooling blanket dc'd. Min gag,impaired cough. Yellow drainage from L nares. ?sinusitis. Levoflox changed to IV d/t ?po absorbtion. NGT to LIS yielding ~50cc/hr bile aspirates.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-11-23 00:00:00.000",
"description": "Report",
"row_id": 1612272,
"text": "micu/sicu npn 7am-7pm\npt remains sedated,withdraws from painful stim. occn change in facial expression. nsr, 0 ectopy noted. ls have occn course sounds, dimin in bases, essentially clear. sxn several times for scant amts thick tan. bs remain hypoactive, og dng lg amt bilious hemocult +. scant amt of liquid brown stool in fecal bag. foley cath intact,dng good amt dk yllw urine. skin intact, coccyx appears dry, sl reddening and dry skin. ativan decreased to 2.5 mg, weaning 20% qd, propofol remains at 50 mcg. sputum cx sent. maintained low grade fever throughout day.id consult done\n\n\n RN\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-11-23 00:00:00.000",
"description": "Report",
"row_id": 1612273,
"text": "Resp Care\nremains intub/vented ac 700x16x.4/10 peep. sm amts tan sputum. admin albuterol q4prn. no weaning indicated at this time. LLL consolidation. no abg, stable sats.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-11-27 00:00:00.000",
"description": "Report",
"row_id": 1612282,
"text": "RN PROGRESS NOTE\n 600AM\nNEURO; PT CONT ON SEDATION. AT BEGIN. OF SHIFT INC RR USING ACCESSORY MUSCLES DIPRIVAN BOLUS GIVNE X2 AN GTT INC TO 30MCG. NO OTHER SEDATION GINVE. PT GRIMACING WITH ORAL SUCTIONING. EXTS. FLACCID.\n\nCAD HR 80-90'S B/P 'S/50-60'S\n\nRESP: NO VENT CHANGES MADE. REMAINS ON PS20. RR TEENS SATS HIGH 90'S MOST OF SHIFT. PT Q3 WITH BETTER SUCCESS SEEN WITH PRIOR AMBUING.\n\nGI; TF OFF ? TEE THIS AM. NO BM THIS SHIFT. BS +\n\nGU UO 60-200CC/HR NO LASIX GIVEN.\n\nID TEMP MAX 101.1 ORAL. TYLENOL GIVEN X 2 DOSES ANTB. TX GIVEN.\n\nPLAN; ?TEE THIS AM. ? WEANING SEDATION FURTHER. MONITOR VS, LABS AND FLUID STATUS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-11-27 00:00:00.000",
"description": "Report",
"row_id": 1612283,
"text": "micu/sicu npn 0700-1500\npt remains sedated on propofol 30mcg/kg/min, ativan decreased to 2mg/hr. plan to decrease gtt slowly 0.5mg/hr q day to off. patient has received several propofol bolus' d/t tachypnea episodes w/rr of 40-50's, -- team attributing this to the pe's seen on cta done yesterday. heparin started this am, ptt due at 3pm. heparin orders per protocol in front of blue chart. trache on hold until next week, the thought being that maybe he can wean once he is theraputic on heparin and not having these episodes.. head mri from yesterday was negative for neurological problems but did show the large sinusitis he has also a mastoiditis per mri. ent in today, tapped sinuses. sent for gram stain. conts to have moderate amts of secretions requiring lavage/ambu. vss. low grade temps, conts on vanco. criticare tube feeds started today at 10cc/hr, to advance as tolerated. please see carevue for further details.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-12-08 00:00:00.000",
"description": "Report",
"row_id": 1612319,
"text": "NURSING NOTE\n\n PT THIS AM, S/P SEIZURE ACTIVITY THIS AM, GENERALIZED SEIZURE LASTING 1 MIN- 1MIN 45 SECS, EYES DEVIATED TO RIGHT, WITH L LEG EXTERNAL ROTATION, BP 202/107, PT MED WITH ATIVAN, LOADED WITH FOSPHENYTOIN, PT SENT FOR CT SCAN OF HEAD, NEG FOR BLEED, EEG DONE AT BEDSIDE, LP PUNCTURE DONE AT BEDSIDE, PT SPIKED TEMP TO 101.8 THIS AM, R PICC BLD CX SENT, AGAIN THIS AFTERNOON PT SPIKED TO 102.7 L HAND PERIP BLD CX SENT, URINE CX SENT, LARGE AMTS THICK TAN SECRETIONS, TRACH CHANGED AT BEDSIDE THIS AM, SECONDARY TO PT PULLING BALLOON OUT THIS AM, PT STARTED ON PROPOFOL GTT THIS AFTERNOON FOR LP, GTT CURRENTLY INFUSING @ 20MCQ, TITRATED TO BP, BP 80/40'S WHEN PROPOFOL STARTED, LOVENOX HELD TODAY FOR ? BLD, RESTARTED THIS AFTERNOON @ 1600, COUMADIN GIVEN AS ORDERED, PT SCHEDULED FOR MRI TO BE DONE TODAY, PT TURNED AND REPOSIT FREQ, ABD SOFT, + BS, TF CONTINUES @ 80CC/HR, PT PLACED ON VENT CPAP PS 14 THIS AM SECONDARY TO SEIZURE ACTIVITY, PT SEDATED AT THIS TIME, NEURO IN TO SEE PT, SEE CAREVUE FOR FULL ASSESSMENTS\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-12-09 00:00:00.000",
"description": "Report",
"row_id": 1612320,
"text": "micu nursing progress note\n\nOpens eyes to verbal stimulus,occn nonpurposeful movement of extrem.no attempts at verbalization, does not follow commands. Occn periods of restlessness early in shift, propofol inc to 25 mcg/min, ativan for restlessness. Pupils at start of shift 3mm and sluggish, then 5mm and brisk later in shift. Hm shows sinus tachy to sinus rhythm throughout shift, 0 ectopy noted. Ekg done at 0500 this am. lung sounds course throughout with no change, 02 sat 96-100%,pressure support decreased to 12. noted occn periods of apnea, Dr. aware,abgs drawn and sent, wnl. Tube feeding off for most of shift, restarted at 0430 at 80cc/hr. Abd remains softly distended with + bs throughout. 0 stool overnight. foley catheter patent,dng decreasing amts of amber urine with inc sediment,appears to have hematuria, ua sent at 0400. Abd x ray done to ensure 0 metal in j tube, no noted. MRI completed, diff to complete due to restlessness and lability of blood pressure. labs drawn and sent incl cpk. Propofol stopped at 0215 for hypotension, remains off as pt appears to be asymptomatic at this time. Pt started on multiple abx.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-12-08 00:00:00.000",
"description": "Report",
"row_id": 1612317,
"text": "MICU-NPN\n\nNEURO: Pt. is alert but confused, reoriented to place. Pt. very restless, continually pulling ECG leads off, trying to climb out of bed, posey on for safety. Haldol given x3 (total 8mg) for sleep with no effect.\n\nCV: Tmax 99.1, HR 107-103 no ectopy noted, 147-110/65-77.\n\nRESP: pt. off vent over night, on trach mask, tolerated well, O2sat's in the mid to high 90's. Pt. repeatedly found with O2 on floor - Sat's remained 92 - 95%\n\nGI: Abdomen soft and distended, +BS, TF infusing at 80cc/hr, tolerating well.\n\nGU: Foley draining adequate amt's amber urine with sediment.\n\nPlan: to be discharged to Rehab facility today.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-12-08 00:00:00.000",
"description": "Report",
"row_id": 1612318,
"text": "event note\n\n0700 noted to be tachypneic w/RR 40. Awake but not following commands. Placed on 100% ambu. Attempted to inflate cuff for bagging but unable to find pilot. Later it was found on floor. O2sat 96%. HR 120s and BP 200/70. ABG sent by MD. While getting new trach ready, pt had tonic clonic siezure x ~1min which resolved on own. Did receive 2mg ativan as seizure was ending. New trach inserted. ABG pnd. Pt currently appears post ictal. RR 34 HR 106 BP127/63. Labs pnd.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-12-06 00:00:00.000",
"description": "Report",
"row_id": 1612311,
"text": "pt.will go back on cool mist with speaking valve in am/ put on 5 cpap-15 ips-40%+fb for noc @ /decreased ips to 10 @ 0400/tol.well/sat.97-100%, vt.480-740 on own, rr.14-26, sx for tan secretions, mdi albuterol given as ordered, uneventful noc.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-12-06 00:00:00.000",
"description": "Report",
"row_id": 1612312,
"text": "NURSING PROGRESS NOTE:\n\nPT ALERT,CALM & COOPERATIVE, FOLLOWS COMMANDS. NO C/O. SLEPT ON AND OFF LAST NIGHT. HEMODYANMICALLY STABLE OVERNIGHT. PLACED BACK ON VENT @, TO REST OVERNIGHT. REMAINED ON CPAP/PS. CURRENT SETTINGS OF PS 10, PEEP 5, FO240%, TV 800-1L. @2400, PT FOUND COUGH UP LARGE AMT OF SECRETIONS, FOR LARGE AMT OF THICK TAN SECRETIONS. O2 SAT DROPPED TO @60%. ?MUCOUS PLUG. PT BAGGED AND AGAIN AND O2 SAT RETURNED TO >95%. PC INCREASED TO 15 AT THIS TIME. PC BACK DOWN TO 10 @0400. PT. WILL BE PLACED BACK ON TRACH COLLAR THIS AM. PT ACCEPTED TO REHAB, WAITING FOR BED?\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-12-06 00:00:00.000",
"description": "Report",
"row_id": 1612313,
"text": "MICU NUrsing Note\n\nNeuro:Pt is alert ,speech is garbled and some content is unintelligible although there are times when his wife and his friend are able to understand what he is saying\nPupils \nPt needs continuous reminders about the day and place, and time\nTowards the end of the afternoon he appeared teary because he said he realized that he was very sick.\n\nCV:HR 69-80 NSR, B/P 110-130, maps 80\nGI: Tube feeds at 80cc hour\nContinues to have loose yellow stool\nGU: U.O.> 100cc hour\nID Tmax 98.9 po\nEndocrine finger stick 110 at 6pm\nCOntinue to mobilize pt tomorrowe we will get him out of bed\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-12-07 00:00:00.000",
"description": "Report",
"row_id": 1612314,
"text": "Resp care note 7p-7a\nPt remails on 40% trach mask over night. RR in 20's, O2 sats in mid 90's. BBS coarse->clear. Sx mod thick tan secretions. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-12-07 00:00:00.000",
"description": "Report",
"row_id": 1612315,
"text": "MICU-NPN\n\nNEURO: Pt. alert and oriented to person, reoriented to place and time, very restless t/o noc. Found trying to get out of bed, ECG leads pulled off, reoriented to place.\n\nCV: HR 73-86, no ectopy noted, BP 132-166/63-92\n\nRESP: pt. remained on trach mask @40% t/o noc, tolerated well. O2sats 94 -98%. Pt for moderate amt's of thick tan secretions. pt. has a strong cough. LS coarse t/o\n\nGI: TF @ 80cc/hr. tolerating well, abd. soft and distended, rectal bag removed due to irritation to area. continues with yellow soft stool.\n\nGU: U/O adequate, >100cc/hr clear, yellow urine.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-12-07 00:00:00.000",
"description": "Report",
"row_id": 1612316,
"text": "micu nursing note\n\nCV:HR 70-80 nsr, b/p 150-160, Lopressor 50mg po\nPULM:Pt continues to thrive on 35% trach mask, once for thick tan secretions, however pt able to expectorate secretions thru the day, SAts 98% and 95% on room air\n\nGI: Tube feeds at 80cc hour/ tolerated well/ some small gold soft stool\n\nGU: U.O. >100cc hour\nPt out of bed to chair from 9 to 2 pm and tolerated well\nNeuro: pt alert x 1 , attempted to get out of bed and required soft waist posey for safety/ pt reoriented to time and place consistently throughout the day and family teaching includeing the necessity to reorient tge patient frequently.\n"
},
{
"category": "ECG",
"chartdate": "2132-12-09 00:00:00.000",
"description": "Report",
"row_id": 119771,
"text": "Sinus rhythm\nLow limb leads voltage\nEarly R wave progressing\nConsider biventrivular hypertrophy\nNormal ECG\n\n"
},
{
"category": "ECG",
"chartdate": "2132-12-09 00:00:00.000",
"description": "Report",
"row_id": 119772,
"text": "Sinus rhythm. Compared to tracing #1, the rate has diminished and the\nST segment changes in the left precordial leads have resolved.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2132-12-08 00:00:00.000",
"description": "Report",
"row_id": 119773,
"text": "Sinus tachycardia. Poor R wave progression. Left atrial abnormality.\nST segment depressions in leads V5-V6 consistent with possible lateral\nischemia. Compared to the previous tracing of , the rate has increased.\nThe ventricular premature beats are no longer present.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2132-11-21 00:00:00.000",
"description": "Report",
"row_id": 119774,
"text": "Sinus rhythm\nFrequent ventricular premature complexes\nInferior+ant/septal T wave change may be due to myocardial ischemia\nLow limb leads voltage\nShort PR interval\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-11-26 00:00:00.000",
"description": "CT 150CC NONIONIC CONTRAST",
"row_id": 746021,
"text": " 2:57 PM\n CHEST CTA WITH CONTRAST; CT 150CC NONIONIC CONTRAST Clip # \n CT RECONSTRUCTION\n Reason: CT angio to r/o PE. Also evaluate for left lower lobe collap\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with recent pneumococcal pneumonia, perisistent fevers and high\n respiratory drive of unclear etiology.\n REASON FOR THIS EXAMINATION:\n CT angio to r/o PE. Also evaluate for left lower lobe collapse\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 54 year old with recent pneumococcal pneumonia, persistent\n fevers. CTA to rule out PE or left lower lobe collapse.\n\n CT ANGIOGRAM OF THE CHEST:\n\n TECHNIQUE: Helical scanning was peformed during dynamic injection of 150\n Optiray. Optiray was used due to a fast injection rate. The heart and\n pericardium are unremarkable. The mediastinal vessels are normal. Several\n filling defects are identified in the segmental pulmonary arteries throughout\n all lobes. There is a small left pleural effusion and consolidations noted in\n the left lower lobe.\n\n IMPRESSION:\n\n 1. Several pulmonary emboli in the segmental and subsegmental branches\n bilateraly.\n\n 2. Left lower lobe consolidation with small left pleural effusion.\n\n\n\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-11-21 00:00:00.000",
"description": "CT 100CC NON IONIC CONTRAST",
"row_id": 745765,
"text": " 6:28 PM\n CT HEAD W/ & W/O CONTRAST; CT 100CC NON IONIC CONTRAST Clip # \n Reason: 64 yo male with history of psuedomonas sinusitis, s. pneumo\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with intubated, rx for s. pneumo pna\n REASON FOR THIS EXAMINATION:\n 64 yo male with history of psuedomonas sinusitis, s. pneumo pna, with\n persistent fevers despite abx. Previous CT showed pan sinusitis. Pls eval for\n loculation or abcess formation that might explain persistent fevers.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Pansinusitis, persistent fevers despite antibiotics.\n\n TECHNIQUE: CT images of the head were acquired without and with 100cc of IV\n Optiray contrast.\n\n FINDINGS: There is no intraparenchymal or extra-axial hemorrhage. There is no\n shift of the normal midline structures. The /white matter differentiation\n is preserved. Ventricles, sulci and cisterns are unremarkable, without\n effacement. There is soft tissue density within the ethmoid air cells,\n sphenoid sinus, mastoid sinuses, and maxillary sinuses.\n\n IMPRESSION: No evidende of intracranial abscess. Poly-sinus disease.\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-11-22 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 745815,
"text": " 3:01 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST\n Reason: assess pleural effusion/pneumonia\n Field of view: 46 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with pneumoccocal pneumonai, perisistent fevers\n REASON FOR THIS EXAMINATION:\n assess pleural effusion/pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Pneumococcal pneumonia, fever, assess pleural effusion/pneumonia\n and possible source of infection in the abdomen.\n\n COMPARISON: None available.\n\n TECHNIQUE: CT torso with IV contrast. Optiray was administered due to general\n debillitation.\n\n CT CHEST WITH IV CONTRAST: Soft tissue windows reveal a left subclavian\n catheter, ET tube and NG tube placement. There is no significant mediastinal,\n hilar or axillary lymph node enlargement. A small left pleural effusion is\n present. The heart size is enlarged. The pericardium and great vessels are\n unremarkable.\n\n Lung windows reveal consolidation and volume loss of the left lower lobe with\n a small amount of small pleural effusion. There is also patchy air space\n opacification at the right lung base. Airbronchogram is demonstrated in the\n consolidated left lower lobe.\n\n CT ABDOMEN WITH IV CONTRAST: No focal lesion is identified in the liver or\n spleen. The liver appears generous in size. The gallbladder is collapsed. The\n adrenal glands, spleen, pancreas and left kidney appear unremarkable. The\n right kidney demonstrates a tiny non obstructing stone and a small cyst. There\n is apparent thickening of the right colon and cecum with no surrounding\n stranding, and a normal appearing appendix, therefore most likely represents\n the appearance of a nondistended cecal tip. Otherwise the abdominal bowel\n loops appear unremarkable. There is no evidence of ascites or abscess.\n\n CT PELVIS WITH IV CONTRAST: The distal ureters and urinary bladder appear\n unremarkable. Foley catheter is seen placed. There is no pelvic fluid. The\n pelvic bowel loops appear unremarkable.\n\n Bone windows reveal no significant abnormality.\n\n IMPRESSION: Left lower lobe consolidation/atelectasis with a small amount of\n pleural effusion. Patchy right base opacifications. No evidence of\n intraabdominal abscess.\n\n (Over)\n\n 3:01 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST\n Reason: assess pleural effusion/pneumonia\n Field of view: 46 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-12-02 00:00:00.000",
"description": "PLCT GJ TUBE",
"row_id": 746293,
"text": " 9:06 AM\n PERC G/G-J TUBE PLMT Clip # \n Reason: Percutaneous jejunostomy tube placement\n Contrast: CONRAY Amt: 20\n ********************************* CPT Codes ********************************\n * PERC PLCMT GASTROMY TUBE PLCT GJ TUBE *\n * -59 DISTINCT PROCEDURAL SERVICE PERC PLCMT ENTROCLYSIS TUBE *\n * IV CONSCIOUTIOUS SEDATION PRO *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with pneumococcal pneumonia, PE, failure to wean from vent s/p\n trach. Has not tolerated tube feeds via NGtube for unclear reasons so prefer\n jejunostomy tube. Of note on heparin for PE.\n REASON FOR THIS EXAMINATION:\n Percutaneous jejunostomy tube placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Failure to wean from vent. Requires G-J tube for long-term\n feeding.\n\n RADIOLOGISTS: Drs. and . Dr. , the staff\n radiologist, was present throughout the entire procedure.\n\n TECHNIQUE: Informed consent was obtained from the patient's wife by phone.\n The patient was placed on the Angio table in the supine position, and the left\n upper quadrant was prepped and draped in the usual sterile fashion. Air was\n insufflated into the stomach via an OG tube, which had been placed prior to\n the patient's arrival in Radiology. The intended access site was confirmed in\n multiple projections with fluoroscopy. The site was then anesthetized with 1%\n Lidocaine. The stomach was accessed with a 19 gauge needle, through which a\n stiff guide wire was advanced. The needle was exchanged for a 7 French\n sheath. The wire was then advanced with an end-hole guide catheter through\n the pylorus and duodenum into the proximal jejunum. Both the catheter and\n sheath were then removed and the percutaneous tract was progressively dilated\n to 12 French. A 12 French gastrojejunostomy tube was then\n advanced over the wire into the proximal jejunum. The wire was removed and a\n small amount of Conray contrast was administered via the G-J tube for\n confirmation of tip location. A postprocedure plain film of the abodmen was\n obtained. The G-J tube was then sutured to the skin with 0-Prolene and\n affixed with a Flexitrak device.\n\n MEDICATIONS: 1% Lidocaine was utilized for local anesthesia. The patient\n received 1 g IV Glucacon. 75 mcg Fentanyl was administered IV in divided\n doses for conscious sedation under continuous hemodynamic monitoring.\n\n FINDINGS: Initial fluoroscopic evaluation of the abdomen revealed a normal\n appearing stomach in the left upper quadrant. No hiatal hernia was detected.\n The stomach was accessed without difficulty and the G-J tube advanced with\n ease through the pylorus and duodenum into the proximal jejunum. The\n postprocedure plain film of the abdomen demonstrated appropriate positioning\n of the tip of the tube in the proximal jujunum, well beyond the Ligament of\n Trietz, with no extravasation of contrast from the bowel lumen.\n (Over)\n\n 9:06 AM\n PERC G/G-J TUBE PLMT Clip # \n Reason: Percutaneous jejunostomy tube placement\n Contrast: CONRAY Amt: 20\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n COMPLICATIONS: None.\n\n IMPRESSION: Successful placement of 12 French G-J tube with tip appropriately\n located in the proximal jejunum.\n\n\n"
}
] |
10,659 | 127,473 | 1. CARDIOVASCULAR: A - Rhythm. The patient's bradycardia was thought to be due to either a vagal episode induced by hypoxemia or induced by recurrent right coronary artery disease. He was admitted to the CCU and monitored on Telemetry. He had no further episodes of bradycardia during hospitalization. His blood pressure was controlled with an IV Nitroglycerin drip and he was started on low dose Captopril. His beta blocker was held because of his bradycardia. He was taken to the Cath Lab on because of his inability to lie flat. A right radial approach was undertaken. Cath revealed elevated right sided pressures with a pulmonary artery pressure of 61/34 and a mean of 46. Wedge pressure was 22. Cardiac output and index were 6.2 and 2.9 respectively. SVR was 1148. His LV ejection fraction was 64%. Coronary angiography revealed a patent RCA stent, 50% OM2 lesion and 40% proximal LAD lesion. He also had 1 to 2+ AR. It was felt that his bradycardia was not cardiac in origin. More than likely it was due to a hypoxemic event as his O2 saturation was found to be in the 70s when the event occurred and hypoxemia may have lead to a vagal response causing his bradycardia and subsequent symptoms of dizziness, diaphoresis and nausea. Prior to discharge the patient walked in the with Physical Therapy and found that his heart rate elevated to 140. Because of that, he was continued on his Atenolol. Because of his preserved ejection fraction, it was felt that he did not require afterload reduction to the degree that he had prior to admission. His Isordil was discontinued, but he was continued on his 5 mg of Lisinopril. He was also continued on daily aspirin of 325 mg and Lasix 20 mg b.i.d. 2. PULMONARY: Patient has a long standing history of severe chronic obstructive pulmonary disease. Upon arrival to the CCU, his initial O2 sat was 78% which came up to the mid to high 80s on five to six liters of oxygen by nasal cannula. Blood gas at the time revealed a pH of 7.44, pCO2 of 35 and pO2 of 41%. Blood gas was repeated revealing similar numbers and in looking back at his blood gasses from previous admissions, this is his baseline pO2. After mild diuresis and Albuterol, Atrovent nebulizers, his O2 saturation increased to 91% on five liters which is his baseline. He was continued on his Combivent inhaler and received Albuterol and Atrovent nebs p.r.n. Upon admission it was felt that perhaps he was having an acute flare of his chronic obstructive pulmonary disease and was given Solu-Medrol in the Emergency Department 100 mg. He was changed to p.o. Prednisone at 80 mg and then tapered which will continue after discharge. 3. HEMATOLOGY: Patient's hematocrit on admission was 51.9 and felt likely to be due to chronic hypoxemia and compensation for that. After his cath, CBC was checked and his blood level was stable. Upon presentation to the Emergency Department, he was started on a heparin drip. This was continued through the catheterization and then stopped immediately afterwards. 4. ENDOCRINE: While on steroids for his chronic obstructive pulmonary disease exacerbation, the patient was covered with an insulin sliding scale. This will be discontinued once his Prednisone taper is complete. | Prn diuresis. HCT 53.9. TNG/heparin contin. started captopril, ntg weaned down. CPK, lytes and PTT. continue tng/hep. inhalers changed to nebs q4hrs. steroid taper. Admit BUN/CREAT 11/1.1. CCU NPN 2300-0700O: afeb.. HR 90-100ST , trending down to 70's-80's SR when pt. Cont on NTG at .19ug/kg/min, IV hep at 1200U/hr. Maintain IV Heparin/NTG until R/O. AM labs pnd at 0600.pt. There is cardiomegaly with mild upper zone redistribution. pt. Pt. IMPRESSION: Findings consistent with CHF superimposed on COPD. BP ranges now 109-120/50-60. 1l neg from mn. IMPRESSION: 1. BP ranges initially 140-150/60-70, treated with restart of IV NTG titrated and presently at 1.13 mcg/kg/min. NPO for cath today. Tachypenic with RR mid 20's. monitor vs/hemodynamics/volume status. Solumedrol changed to prednisone.Endo: gluc running in the 200's, no h/o DM.ID: afebrile, po Levo was dc'd.A/P: hemodynamically stable, CP free, awaiting cath in AM, some anxiety, ativan prn. tol well. wakes easily.FS 191 at 2300. rx with 2u SSRI. Bilateral lower lobe atelectasis or consolidations. states breathing is at his baseline. There is flattening of the diaphragms consistent with CHF. bp 90-100/60 via nbp. NPO. COMPARISONS: and . LS clear. HR 70-80'S NSR, no vea noted. Cardiomegaly with mild interstial edema. Abdomen soft and distended, bowel sounds active. to start prednisone taper today. K+ 3.6 repleted with 40meq po KCL with repeat K+ 4.1. Sats low 80's, abg drawn by team on 5L, 41/35/7.44/25/0 80%, repeat 44/35/7.42/23/0. R/T CAD.P: Cont to monitor resp. RR 18-28. BP 90-100's/50. heparin at 1200u/hr, ptt 73.7. ck flat x2, 3rd pend.gi: diet advanced to cardiac. status, maintain sat in the high 80's-90. sats drop to low 80s w activity otherwise 86-88 on 5l nc. Follow up with am labs, esp. follow FS. steroids changed to po prednisone.cv: hr 80s sr, no vea. cath today. remains on 5l n/c. CCU NPN 3-11PMCV: Pt denies CP, HR 80-100 NSR, BP 120/60, K= 3.7, given 40 mEq KCL po. Sinus rhythm - borderline first degree A-V blockPossible left atrial abnormalityMarked right axis deviationConsider right ventricular hypertrophySince previous tracing of : probably no significant change IV Heparin at 1200u/hour with 0500 PTT and am labs pnd. cath tomorrow/npo p mn. anticipate insulin needs to decrease.A/P: stable. Sinus rhythmMarked right axis deviationConsider right ventricular hypertrophyLeft atrial abnormalitySince previous tracing ofsame date: no significant change will redose lasix this eve.id: afeb. 2. MAE. no n/v.gu: uop 10-20cc/hr. Lungs with fine bibasilar rales, diminished breathe sounds with poor airation throughout. REASON FOR THIS EXAMINATION: Please eval for interval change in interstitial edema, basilar opacities FINAL REPORT CHEST SINGLE AP FILM: HISTORY: COPD and coronary artery disease with bradycardia and diminished oxygen saturation. Was given .5mg Ativan po with good effect, may be repeated x2, written for sleeper for overnight. sats 88-92% on 5lnc. These could represent atelectasis or consolidation. NPO after MN for cath tomorrow.Resp: LS clear, O2 sat 87-91% on 5 L NC, one episode of desaturation to 80% with subjective feeling of being unable to cath breath, relieved by enc pt to take sl deep breaths through nose. Diuresed well to IV Lasix given in EW (reportedly received 40mg IVP). denies CP. AP PORTABLE: The cardiac silhouette is enlarged. Mucous membrane dry. able to sleep with meds. No stool this shift.NEURO: Pt. support/teaching to pt. lip breathing. ccu nursing progress notes: my breathing is better..close to baselineo: pls see carevue flowsheet for compelte vs/data/eventsresp: rr 12-20. sob w activity. took additional .5po ativan at 2330 to sleep with good results. The costophrenic angles are sharp. Recheck CXR in am, cont Solumedrol 80mg IV BID, due at 1000. events of hospitalization.CVS: Hemodynamically stable and painfree. 1st CPK in EW 68, 2nd set sent at 0500 pnd.Resp; PT arrived from EW on 5L n/c, (his usual flow rate at home). Comfort and emotional support to Pt. There is mild blurring of the pulmonary vasculature consistent with interstitial edema. Slept at short intervals.ID: afebrile, started on po Levofloxacin 500mg po qd for questionable acute pulmonary process.Access: 2 #18 peripheral IV's in place, patent and intact.A: severe emphysema at baseline with acute exacerbation ? There is bilateral lower lobe opacities which on the left obscures a portion of the left hemidiaphragm and on the right obscures a portion of the right heart border. States breathing is improved since EW and more like his baseline. Sats improved to 86-89% and Pt. CCU NURSING ADMIT NOTEPlease see ICU ADMIT NOTE/FHPA for details of Pmhx. The lung volumes are low. bs w crackles at bases. asleep. Serum C02 25.GI:GU: NPO except for ice-chips and sips with meds. Given 40mg Lasix at 1800, diuresed well, -2L for the day. Conversing easily with RN despite labored breathing. There is crowding of the pulmonary vasculature. anxious about procedure today. 7:30 AM CHEST (PORTABLE AP) Clip # Reason: Please eval for interval change in interstitial edema, MEDICAL CONDITION: 60 year old man with h/o COPD and CAD admitted with symptomatic bradycardia and poor O2 sat. To evaluate for CHF or pneumonia. No pulmonary consolidation. A/A/Ox3, pleasant and cooperative. levoflox dc'd.social: friends visiting.a: copd flare vs. chfp: monitor resp exam/follow sats. Voiding qs via foley clear, light yellow urine. Pt had been having feelings of increased anxiety just prior to this. no episodes of SOB. The visualized bones are unremarkable. Sitting up 45^ in bed. No evidence for pneumonia. | 8 | [
{
"category": "Radiology",
"chartdate": "2177-10-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 774835,
"text": " 10:19 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o PTX, pneumonia\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with h/o CPOD and MI now with SSCP and SOB with O2 sat 70%\n\n patient in \n REASON FOR THIS EXAMINATION:\n r/o PTX, pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 60 year old man with COPD, MI, now with chest pain and shortness of\n breath setting at 70%.\n\n COMPARISONS: and .\n\n AP PORTABLE: The cardiac silhouette is enlarged. The lung volumes are low.\n There is crowding of the pulmonary vasculature. There is mild blurring of the\n pulmonary vasculature consistent with interstitial edema. There is bilateral\n lower lobe opacities which on the left obscures a portion of the left\n hemidiaphragm and on the right obscures a portion of the right heart border.\n These could represent atelectasis or consolidation. The costophrenic angles\n are sharp. The visualized bones are unremarkable.\n\n IMPRESSION:\n 1. Bilateral lower lobe atelectasis or consolidations.\n 2. Cardiomegaly with mild interstial edema.\n\n"
},
{
"category": "Radiology",
"chartdate": "2177-10-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 774850,
"text": " 7:30 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for interval change in interstitial edema, \n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with h/o COPD and CAD admitted with symptomatic bradycardia\n and poor O2 sat.\n REASON FOR THIS EXAMINATION:\n Please eval for interval change in interstitial edema, basilar opacities\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE AP FILM:\n\n HISTORY: COPD and coronary artery disease with bradycardia and diminished\n oxygen saturation. To evaluate for CHF or pneumonia.\n\n There is cardiomegaly with mild upper zone redistribution. There is\n flattening of the diaphragms consistent with CHF. No pulmonary consolidation.\n\n\n IMPRESSION: Findings consistent with CHF superimposed on COPD. No evidence\n for pneumonia.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2177-10-26 00:00:00.000",
"description": "Report",
"row_id": 119600,
"text": "Sinus rhythm\nMarked right axis deviation\nConsider right ventricular hypertrophy\nLeft atrial abnormality\nSince previous tracing ofsame date: no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2177-10-26 00:00:00.000",
"description": "Report",
"row_id": 119601,
"text": "Sinus rhythm\n - borderline first degree A-V block\nPossible left atrial abnormality\nMarked right axis deviation\nConsider right ventricular hypertrophy\nSince previous tracing of : probably no significant change\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-10-27 00:00:00.000",
"description": "Report",
"row_id": 1403072,
"text": "CCU NURSING ADMIT NOTE\nPlease see ICU ADMIT NOTE/FHPA for details of Pmhx. events of hospitalization.\n\nCVS: Hemodynamically stable and painfree. HR 70-80'S NSR, no vea noted. K+ 3.6 repleted with 40meq po KCL with repeat K+ 4.1. BP ranges initially 140-150/60-70, treated with restart of IV NTG titrated and presently at 1.13 mcg/kg/min. BP ranges now 109-120/50-60. IV Heparin at 1200u/hour with 0500 PTT and am labs pnd. 1st CPK in EW 68, 2nd set sent at 0500 pnd.\n\nResp; PT arrived from EW on 5L n/c, (his usual flow rate at home). Tachypenic with RR mid 20's. lip breathing. Sats low 80's, abg drawn by team on 5L, 41/35/7.44/25/0 80%, repeat 44/35/7.42/23/0. Pt. mentating and conversing with RN and CCU team. States breathing is improved since EW and more like his baseline. Sats improved to 86-89% and Pt. remains on 5l n/c. Diuresed well to IV Lasix given in EW (reportedly received 40mg IVP). Lungs with fine bibasilar rales, diminished breathe sounds with poor airation throughout. RR 18-28. Serum C02 25.\n\nGI:GU: NPO except for ice-chips and sips with meds. Mucous membrane dry. Admit BUN/CREAT 11/1.1. HCT 53.9. Voiding qs via foley clear, light yellow urine. Abdomen soft and distended, bowel sounds active. No stool this shift.\n\nNEURO: Pt. A/A/Ox3, pleasant and cooperative. Conversing easily with RN despite labored breathing. MAE. Slept at short intervals.\n\nID: afebrile, started on po Levofloxacin 500mg po qd for questionable acute pulmonary process.\n\nAccess: 2 #18 peripheral IV's in place, patent and intact.\n\nA: severe emphysema at baseline with acute exacerbation ? R/T CAD.\n\nP: Cont to monitor resp. status, maintain sat in the high 80's-90. Recheck CXR in am, cont Solumedrol 80mg IV BID, due at 1000. Prn diuresis. Follow up with am labs, esp. CPK, lytes and PTT. Maintain IV Heparin/NTG until R/O. Comfort and emotional support to Pt.\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-10-27 00:00:00.000",
"description": "Report",
"row_id": 1403073,
"text": "ccu nursing progress note\ns: my breathing is better..close to baseline\no: pls see carevue flowsheet for compelte vs/data/events\nresp: rr 12-20. sob w activity. sats drop to low 80s w activity otherwise 86-88 on 5l nc. bs w crackles at bases. inhalers changed to nebs q4hrs. steroids changed to po prednisone.\ncv: hr 80s sr, no vea. bp 90-100/60 via nbp. started captopril, ntg weaned down. heparin at 1200u/hr, ptt 73.7. ck flat x2, 3rd pend.\ngi: diet advanced to cardiac. tol well. no n/v.\ngu: uop 10-20cc/hr. 1l neg from mn. will redose lasix this eve.\nid: afeb. levoflox dc'd.\nsocial: friends visiting.\na: copd flare vs. chf\np: monitor resp exam/follow sats. monitor vs/hemodynamics/volume status. support/teaching to pt. cath tomorrow/npo p mn.\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-10-27 00:00:00.000",
"description": "Report",
"row_id": 1403074,
"text": "CCU NPN 3-11PM\nCV: Pt denies CP, HR 80-100 NSR, BP 120/60, K= 3.7, given 40 mEq KCL po. Given 40mg Lasix at 1800, diuresed well, -2L for the day. Cont on NTG at .19ug/kg/min, IV hep at 1200U/hr. NPO after MN for cath tomorrow.\n\nResp: LS clear, O2 sat 87-91% on 5 L NC, one episode of desaturation to 80% with subjective feeling of being unable to cath breath, relieved by enc pt to take sl deep breaths through nose. Pt had been having feelings of increased anxiety just prior to this. Was given .5mg Ativan po with good effect, may be repeated x2, written for sleeper for overnight. LS clear. Sitting up 45^ in bed. Solumedrol changed to prednisone.\n\nEndo: gluc running in the 200's, no h/o DM.\n\nID: afebrile, po Levo was dc'd.\n\nA/P: hemodynamically stable, CP free, awaiting cath in AM, some anxiety, ativan prn.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-10-28 00:00:00.000",
"description": "Report",
"row_id": 1403075,
"text": "CCU NPN 2300-0700\nO: afeb.. HR 90-100ST , trending down to 70's-80's SR when pt. asleep. BP 90-100's/50. TNG/heparin contin. AM labs pnd at 0600.\npt. took additional .5po ativan at 2330 to sleep with good results. sats 88-92% on 5lnc. states breathing is at his baseline. no episodes of SOB. denies CP. NPO for cath today. slept sitting up with 2 pillows. pt. anxious about procedure today. able to sleep with meds. wakes easily.\n\nFS 191 at 2300. rx with 2u SSRI. to start prednisone taper today. anticipate insulin needs to decrease.\n\nA/P: stable. cath today. continue tng/hep. NPO. follow FS. steroid taper.\n"
}
] |
48,812 | 157,663 | MICU course: The patient was admitted to the MICU after aggressive resuscitation in the ED to include >5L crystalloid, CVL, vancomycin, cefepime, levofloxacin and pan culture. Once arriving in the MICU her vital signs stabilized with resolution of her significant tachycardia and stabilization of her BP (no pressors were required). Her Tmax was 100.7. As she continued to improve her antibiotics were narrowed to vancomycin/levofloxacin. The patient did develop a diffuse macular rash on her back and abdomen, improved only by hydroxyzine but not sarna or denoside cream. The cause of her rash was thought to be related to her cefepime, though it was not clear. On transfer to the floor, her micro data was negative with negative C. diff and legionella. She was continued on PO vanco for her history of C.diff colitis. . Medicine Floor course: . # Fever/ Leukocytosis/ Sepsis - Normotensive in MICU and on floor, afebrile, all cultures negative (BCx from negative to date but still pending as of ). Leukocytosis resolved. Antibiotics scaled back, IV Vanco, Cefepime d/c, patient did well on PO Levoquin and PO Vanco. Had ID see her inpatient who recommended 7d course of Levofloxacin 500mg QD with PO Vanco coverage during that period and for 2 weeks after for CDiff prophylaxis. CXR and CT showed no focal infiltrate, but patient with bronchial thickening and productive cough and in setting of fever and leukocytosis seen on admission, Abx course is warrented. Of note, Legionella Ag was negative. . # Tachycardia - Persistent sinus tachycardia in the MICU and on the inpatient medicine floor. HR down to 80's, 90's during the last 2 days of admission. EKG showed sinus tachycardia. Patient asymptomatic. CTA performed after D-dimer was markedly elevated which was negative for PE but showed an enlarged supraclavicular lymph node and a small thyroid nodule. . # ARF. Mild renal impairment - volume depletion/hypotension most likely. Resolved with hydration. . # Hypoxia. With concern for pneumonia as above; initially was on O2 in MICU but during time on inpatient floor patient was without O2 requirement. . # Thyroid nodule. Seen incidentally on CTA - patient w/out SSx of hyperthyroid except for sinus tachycardia. TSH sent. Pending at time of D/C, needs to be f/u by PCP. . # Code status. Full . # Comms with pt's daughter/son . # Dispo. Seen and cleared by PT, at home with family following closely. Safe for d/c tomorrow if tachycardia resolved and pt afebrile. | Also on PO Vanc for h/o refractory C diff. # Hypotension/Sepsis: Resolved. Trace aortic regurgitation isseen. ARF: Resolved with volume resuscitation. ARF: Resolved with volume resuscitation. ARF: Resolved with volume resuscitation. - Management of sepsis as above. - Management of sepsis as above. - Management of sepsis as above. - Management of sepsis as above. - Management of sepsis as above. Follow UOP / creatinine. Follow UOP / creatinine. Follow UOP / creatinine. - management of sepsis as above; broad coverage abx. - management of sepsis as above; broad coverage abx. - management of sepsis as above; broad coverage abx. - management of sepsis as above; broad coverage abx. - management of sepsis as above; broad coverage abx. - Consider sending cortisol/stim (mainly prognostic value). - Consider sending cortisol/stim (mainly prognostic value). - Consider sending cortisol/stim (mainly prognostic value). - Consider sending cortisol/stim (mainly prognostic value). - Consider sending cortisol/stim (mainly prognostic value). - C. difficile, refractory since - Depression. - C. difficile, refractory since - Depression. - C. difficile, refractory since - Depression. Hypotension: Hemodynamic issues appear to be due to a SIRS response. In the ER received vanco/cefepim/levo and oral vanco after discussion with ID given her refractory c.diff. In the ER received vanco/cefepim/levo and oral vanco after discussion with ID given her refractory c.diff. - Check legionella. - Check legionella. - Check legionella. - Check legionella. - Check legionella. WBCs concerning for recurrence of C.diff as well. WBCs concerning for recurrence of C.diff as well. WBCs concerning for recurrence of C.diff as well. WBCs concerning for recurrence of C.diff as well. WBCs concerning for recurrence of C.diff as well. # Hypotension. # Hypotension. # Hypotension. # Hypotension. # Hypotension. Acute respiratory distress/hypoxia from PNA, +/- contribution from fluid overload- on supplmental oxygen, will wean as tolerated 4. Clinically imroved. Mildmitral annular calcification. Acute respiratory distress: Still on 2L NC. # Hypoxia. # Hypoxia. # Hypoxia. # Hypoxia. # Hypoxia. Found to have WBCs 16.5, lactate 2.1, mild ARF with creatinine 1.2 (from 0.9). Found to have WBCs 16.5, lactate 2.1, mild ARF with creatinine 1.2 (from 0.9). Found to have WBCs 16.5, lactate 2.1, mild ARF with creatinine 1.2 (from 0.9). There is an anterior space which most likelyrepresents a fat pad.IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved globaland regional biventricular systolic function. Likely pre-renal in the setting of sepsis - Foley to gravity, monitor I/O. - Abx as above. - Abx as above. - Abx as above. - Abx as above. - Abx as above. Treat infection as per above . Agree with TTE to assess EF and for any valvular abnormalties, particularly given SEM concerning for AS. + wheezes. + wheezes. Also on PO Vanc for h/o refractory C diff. Also on PO Vanc for h/o refractory C diff. Also on PO Vanc for h/o refractory C diff. Continue Rx for refractory C. diff. ARF: Resolved with volume resuscitation. ARF: Resolved with volume resuscitation. ARF: Resolved with volume resuscitation. ARF: Resolved with volume resuscitation. ARF: Resolved with volume resuscitation. Follow UOP / creatinine. Follow UOP / creatinine. Follow UOP / creatinine. Follow UOP / creatinine. Follow UOP / creatinine. Acute respiratory distress: Still on 2L NC. Acute respiratory distress: Still on 2L NC. Acute respiratory distress: Still on 2L NC. Response: T current 98.5 good u/o afebrile. Response: T current 98.5 good u/o afebrile. Ab: Positive BSs, NT/ND Ext: 1+ pitting edema. Ab: Positive BSs, NT/ND Ext: 1+ pitting edema. Ab: Positive BSs, NT/ND Ext: 1+ pitting edema. Ab: Positive BSs, NT/ND Ext: 1+ pitting edema. Ab: Positive BSs, NT/ND Ext: 1+ pitting edema. Access: Will d/c CVL given clinical stability. Access: Will d/c CVL given clinical stability. Access: Will d/c CVL given clinical stability. Response: T current 97.5,good urine output,afebrile, Plan: Cont to monitor resp status, CVP, cont abx, guaifenesin prn for assist w/ expectorant. Oral Vanco for hx C.diff (ordered by ID). Oral Vanco for hx C.diff (ordered by ID). Agree with TTE to assess EF and for any valvular abnormalties, particularly given SEM concerning for AS. Agree with TTE to assess EF and for any valvular abnormalties, particularly given SEM concerning for AS. Tegaderm and paper tape OK. Tegaderm and paper tape OK. Tegaderm and paper tape OK. Continue treating with hydroxyzone or Benadryl PRN. Continue treating with hydroxyzone or Benadryl PRN. Continue treating with hydroxyzone or Benadryl PRN. In the ED, P 120, BP 120/52, sats 89-94%, WBC 16.5, lactate 2.1, Cr 1.2 (baseline 1). In the ED, P 120, BP 120/52, sats 89-94%, WBC 16.5, lactate 2.1, Cr 1.2 (baseline 1). She received Vanco/Cefipime/Levaquin and also po Vanco (recommended by ID due to her refractory CDiff.) She received Vanco/Cefipime/Levaquin and also po Vanco (recommended by ID due to her refractory CDiff.) She received Vanco/Cefipime/Levaquin and also po Vanco (recommended by ID due to her refractory CDiff.) She received Vanco/Cefipime/Levaquin and also po Vanco (recommended by ID due to her refractory CDiff.) She received Vanco/Cefipime/Levaquin and also po Vanco (recommended by ID due to her refractory CDiff.) She received Vanco/Cefipime/Levaquin and also po Vanco (recommended by ID due to her refractory CDiff.) She received Vanco/Cefipime/Levaquin and also po Vanco (recommended by ID due to her refractory CDiff.) | 36 | [
{
"category": "Echo",
"chartdate": "2126-04-15 00:00:00.000",
"description": "Report",
"row_id": 98932,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Murmur. Sepsis.\nHeight: (in) 58\nWeight (lb): 165\nBSA (m2): 1.68 m2\nBP (mm Hg): 140/80\nHR (bpm): 100\nStatus: Inpatient\nDate/Time: at 11:00\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA and RA cavity sizes.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global\nsystolic function (LVEF>55%). TDI E/e' >15, suggesting PCWP>18mmHg. No resting\nLVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root. Mildly dilated ascending aorta. Normal aortic arch diameter.\n\nAORTIC VALVE: Moderately thickened aortic valve leaflets. Mild AS (AoVA\n1.2-1.9cm2). Trace AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. Mild\nmitral annular calcification. Calcified tips of papillary muscles.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Mild PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: There is an anterior space which most likely represents a fat\npad, though a loculated anterior pericardial effusion cannot be excluded.\n\nConclusions:\nThe left atrium and right atrium are normal in cavity size. There is mild\nsymmetric left ventricular hypertrophy with normal cavity size and\nregional/global systolic function (LVEF>55%). Tissue Doppler imaging suggests\nan increased left ventricular filling pressure (PCWP>18mmHg). Right\nventricular chamber size and free wall motion are normal. The ascending aorta\nis mildly dilated. The aortic valve leaflets are moderately thickened. There\nis mild aortic valve stenosis (area 1.2-1.9cm2). Trace aortic regurgitation is\nseen. The mitral valve appears structurally normal with trivial mitral\nregurgitation. There is no mitral valve prolapse. There is mild pulmonary\nartery systolic hypertension. There is an anterior space which most likely\nrepresents a fat pad.\n\nIMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global\nand regional biventricular systolic function. Mild aortic valve stenosis. Mild\npulmonary artery systolic hypertension.\n\nCLINICAL IMPLICATIONS:\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate prophylaxis is NOT recommended. Clinical decisions regarding the need\nfor prophylaxis should be based on clinical and echocardiographic data.\n\n\n"
},
{
"category": "Physician ",
"chartdate": "2126-04-13 00:00:00.000",
"description": "Physician Attending Admission Note - MICU",
"row_id": 566239,
"text": "Chief Complaint: hypotension, shortness of breath\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n yo female with refractory Cdiff, Alzheimer's dementia with cough x\n several days productive of green sputum, and wheezing. In clinic\n she had a HR in the 120-130's, tEmp 103.8, sats 89% RA, SBP 120's. In\n the ED, P 120, BP 120/52, sats 89-94%, WBC 16.5, lactate 2.1, Cr 1.2\n (base 1). CXR showed bilateral opacities. She received\n Vanco/Cefipime/Levaquin and also po Vanco (recommended by ID due to her\n refractory CDiff.) In the ED, SBP kept intemittently dropping to the\n 70-80's therefore requiring 5 liters NS resucitation. After fluid\n resuscitation, O2 sats dropped to 91% 3 liters n.c.\n Patient admitted from: ER\n Allergies:\n Mercury\n Ammoniated\n Unknown;\n Shellfish\n Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 01:00 AM\n Heparin Sodium (Prophylaxis) - 01:00 AM\n Other medications:\n nasal calcitonin, Aricept, mirtazapine, Ca/vit D, omega 3, MVI\n Past medical history:\n Family history:\n Social History:\n Alzheimer's dementia\n Hx Cdiff since , last hospitalizaiton (recently vanco/rif)\n Depression\n Hx hip fracture\n HTN\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Lives at home with family, attends adult day care; uses walker,\n independent with ADL's\n Review of systems:\n Constitutional: No(t) Fatigue, Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Orthopnea\n Nutritional Support: No(t) NPO\n Respiratory: Cough, Dyspnea, Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, No(t) Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, No(t) Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: No(t) Immunocompromised\n Signs or concerns for abuse : No\n Flowsheet Data as of 03:27 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.8\nC (98.2\n HR: 93 (85 - 100) bpm\n BP: 115/46(64) {95/46(60) - 122/59(74)} mmHg\n RR: 22 (22 - 25) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 12 (12 - 15)mmHg\n Total In:\n 5,000 mL\n 150 mL\n PO:\n 120 mL\n TF:\n IVF:\n 30 mL\n Blood products:\n Total out:\n 850 mL\n 400 mL\n Urine:\n 550 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,150 mL\n -250 mL\n Respiratory\n O2 Delivery Device: Aerosol-cool, Face tent\n SpO2: 97% on 50% FT\n ABG: ////\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube, \n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\n Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical), (Breath\n Sounds: Crackles : , Wheezes : , Rhonchorous: ), bilateral rhonchi \n way up lung fields R>L\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis, No(t) Clubbing\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Purposeful, No(t) Sedated, No(t) Paralyzed, Tone:\n Normal\n Labs / Radiology\n 295\n 36.5\n 148\n 1.2\n 23\n 26\n 98\n 4.5\n 135\n 16.5\n [image002.jpg]\n Other labs: PT / PTT / INR:wnl, CK / CKMB / Troponin-T:94/pending,\n Differential-Neuts:85, Band:0, Lymph:12, Lactic Acid:2.1\n Fluid analysis / Other labs:\n U/A negative\n Imaging: CXR: read as ?atelectasis.\n low lung volume, left HD partially obscured\n Microbiology: Blood and urine cultures drawn in ED\n ECG: , 1 AVB\n Assessment and Plan\n yo female with Alzheimer's dementia admitted with sepsis resulting\n in acute respiratory distress and hypotension\n 1. Hypotension: suspect SIRS/sepsis\n Given resp symptoms, lung appears source. No current sx's of diarrhea\n to suggest recurrent Cdiff\n Change to CAP coverage\n Blood cultures pending\n Re-check lactate\n BP better since arriving to ICU- monitor and fluid resuscitate as\n needed\n 2. ARF: improving with fluid resuscitation- continue to follow\n 3. Acute respiratory distress/hypoxia from PNA, +/- contribution from\n fluid overload- on supplmental oxygen, will wean as tolerated\n 4. Alzheimer's dementia, depression- resume home meds.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n Multi Lumen - 12:00 AM\n 16 Gauge - 12:00 AM\n 18 Gauge - 12:00 AM\n Comments:\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2126-04-13 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 566240,
"text": "Chief Complaint: fever, cough, hypotension\n HPI:\n 92F with history of refractory C.diff with recent d/c of oral vanco;\n dementia, admit with fever, cough, and hypotension. Patient was seen\n for urgent visit in geriatrics today with cough and fatigue and found\n to have HR 133 (BP 122/60), T 103.8, and O2 sat 89% on RA. Sent from\n clinic to the emergency room with concern of pneumonia. Patient\n reports cough productive of green sputum today. No dyspnea or CP. +\n wheezes.\n .\n In the ED, vitals T 102.6, HR 124, BP 128/52, R22, O2 sat 89-94%.\n Found to have WBCs 16.5, lactate 2.1, mild ARF with creatinine 1.2\n (from 0.9). Received vanco, cefepime, and levofloxacin, and PO Vanc\n 125 mg x1. CXR with bilateral opacities, atelectasis vs. pneumonia.\n SBP to 80s at times (also 75/41 once), got 5L fluids total. CVL\n placed. At transfer BP 112/48 with HR 105. O2 sat dropped to 91% on\n 3L so placed on NRB with sats 100%.\n Patient admitted from: ER\n History obtained from Patient, Family / Medical records\n Allergies:\n Mercury\n Ammoniated\n Unknown;\n Shellfish\n Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n CALCITONIN 200 unit/dose 1 spray once daily\n DONEPEZIL 10 mg Tablet atbedtime\n MIRTAZAPINE 15 mg Tablet daily\n CALCIUM CARBONATE-VITAMIN twice a day\n MULTIVITAMIN once a day\n OMEGA-3 FATTY ACIDS once a day\n Recently on Xifaxin and PO vancomycin\n Past medical history:\n Family history:\n Social History:\n - Alzheimer's dementia - mild\n - Right hip fracture s/p ORIF in status post fall.\n - C. difficile, refractory since \n - Depression.\n - OA\n - s/p wrist fracture\n - Osteopenia\n - cataract surgery\n Hypertension. No other significant illnesses.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: No tobacco, alcohol, IV drug use. Lives near her five children\n who are very involved in her care. Independent with her ADLs. Goes to\n an adult daycare five days a week.\n Review of systems:\n Constitutional: Fatigue, No(t) Weight loss\n Eyes: No(t) Blurry vision\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Orthopnea\n Respiratory: Cough, No(t) Dyspnea, Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria\n Musculoskeletal: No(t) Joint pain\n Integumentary (skin): No(t) Rash\n Neurologic: No(t) Headache\n Flowsheet Data as of 02:14 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (96.9\n Tcurrent: 36.1\nC (96.9\n HR: 90 (85 - 100) bpm\n BP: 122/59(74) {95/48(60) - 122/59(74)} mmHg\n RR: 24 (22 - 25) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 13 (13 - 15)mmHg\n Total In:\n 5,000 mL\n 20 mL\n PO:\n TF:\n IVF:\n 20 mL\n Blood products:\n Total out:\n 850 mL\n 300 mL\n Urine:\n 550 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,150 mL\n -280 mL\n Respiratory\n O2 Delivery Device: Aerosol-cool, Face tent\n SpO2: 99%\n Physical Examination\n General Appearance: Well nourished, No acute distress, No(t) Anxious,\n No(t) Diaphoretic\n Eyes / Conjunctiva: No(t) Pupils dilated, R surgical pupil, L reactive.\n face generally slightly edematous\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL, Supraclavicular WNL, No(t) Cervical adenopathy\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic), loud\n systolic murmur throughout precordium, radiates to carotids.\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n bilaterally, greatest at bases, Wheezes : few wheezes at L base)\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n denies TTP\n Extremities: Right: 1+, Left: 1+ edema.\n Skin: Not assessed, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): x 3 (though was not oriented to time 10\n minutes prior with RN), Movement: Purposeful, Tone: Not assessed\n Labs / Radiology\n 295\n 148\n 1.2\n 23\n 26\n 98\n 4.5\n 135\n 36.5\n 16.5\n [image002.jpg]\n Other labs: PT / PTT / INR:/23.4/1.1, Differential-Neuts:85, Lymph:12,\n Mono:2.5, Lactic Acid:2.1\n Fluid analysis / Other labs: UA 1.020, 100 protein, neg LE/nitrate, 0-2\n WBCs, RBCs\n Imaging: CXR : Low lung volumes are present. Cardiac silhouette\n is within normal limits. The aorta is slightly unfolded with aortic\n knob calcifications present. The pulmonary vascularity is normal, as\n are the hilar contours. Bibasilar patchy opacities likely reflect\n atelectasis, but pneumonia or aspiration is not completely excluded.\n There is blunting of the right costophrenic sulcus, suggestive of a\n small pleural effusion. No pneumothorax. Degenerative changes are seen\n within the left hip as well as within the lumbosacral spine.\n .\n CXR post line placement - LIJ in satisfactory position.\n Microbiology: urine culture, blood culture x 2 sent\n ECG: ECG: sinus tach with first degree AV block, at 123, NANI, TWF/TWI\n in III, avF (slight change from prior), no ST changes, overall\n unchanged from prior.\n Assessment and Plan\n F with history of refractory C.diff recently off PO vancomycin; admit\n with fever and hypotension, likely septic shock.\n .\n # Hypotension. With fever, leukocytosis; most likely represents septic\n shock, as has been refractory to adequate fluid resuscitation (5L).\n Possible infectious sources include pneumonia (infiltrate on CXR),\n C.diff (given strong history though benign current exam),\n bacteremia/endocarditis (no known risk factors), urosepsis (though UA\n benign). Other possible causes or contributors to hypotension include\n cardiogenic (ACS or CHF), PE, though less likely in setting of other\n findings.\n - CVL in place; goal CVP 8-12, bolus prn.\n - If continues to be hypotensive despite adequate CVP, will start\n norepinephrine, goal MAP > 60-65. A line placement if persistently\n hypotensive.\n - Send central venous sat off line.\n - Broad spectrum abx for coverage of CAP, gram positives, gram\n negatives, C.diff - vanco/cefepime/PO vanc/levoflox. Does not clearly\n have pseudomonal risk factors; consider change from cefepime to\n ceftriaxone.\n - Send cardiac enzymes, though if positive likely reflects demand\n picture.\n - Consider sending cortisol/stim (mainly prognostic value).\n - Consider APC if meets APACHE criteria.\n .\n # Pneumonia - CAP vs. HCAP. Also consider aspiration.\n - Abx as above.\n - Management of sepsis as above.\n - Check legionella. Sputum culture.\n .\n # Fever/leukocytosis. Likely infectious as above. WBCs concerning for\n recurrence of C.diff as well.\n - f/u urine and blood cultures.\n - send c.diff; if positive or develops abdominal symptoms consider\n further abdominal imaging.\n - management of sepsis as above; broad coverage abx.\n - C.diff coverage with vanco while on broad spectrums.\n .\n # ARF. Mild renal impairment - volume depletion/hypotension most\n likely. At this point prerenal vs. ATN.\n - Foley to gravity, monitor I/O.\n - s/p 5 L hydration as above.\n - Avoid hypotension and nephrotoxins.\n .\n # Hypoxia. With concern for pneumonia as above. Also s/p 5 L IVFs,\n though no cardiac history.\n - Treatment of pneumonia.\n - Wean O2 if tolerated.\n - Consider Aline placement.\n .\n # Dementia. Mild.\n - Family desires continuation of remeron and donepezil; okay\n for now.\n # Heart murmur. No prior TTEs in our system. ?AS murmur.\n - will check TTE, eval for valvular disease, rule out vegetations.\n ICU Care\n Nutrition:\n Comments: regular if can safely tolerate PO\n Glycemic Control: Blood sugar well controlled, Comments: start insulin\n if glucoses elevated\n Lines:\n Multi Lumen - 12:00 AM\n 16 Gauge - 12:00 AM\n 18 Gauge - 12:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: Full code\n discussed at length with patient and entire\n family ; patient is full code with all interventions possible but would\n likely not continue care if prognosis poor.\n Disposition: ICU until pressures and O2 sats stabilize\n"
},
{
"category": "Physician ",
"chartdate": "2126-04-13 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 566236,
"text": "Chief Complaint: fever, cough, hypotension\n HPI:\n 92F with history of refractory C.diff with recent d/c of oral vanco;\n dementia, admit with fever, cough, and hypotension. Patient was seen\n for urgent visit in geriatrics today with cough and fatigue and found\n to have HR 133 (BP 122/60), T 103.8, and O2 sat 89% on RA. Sent from\n clinic to the emergency room with concern of pneumonia. Patient\n reports cough productive of green sputum today. No dyspnea or CP. +\n wheezes.\n .\n In the ED, vitals T 102.6, HR 124, BP 128/52, R22, O2 sat 89-94%.\n Found to have WBCs 16.5, lactate 2.1, mild ARF with creatinine 1.2\n (from 0.9). Received vanco, cefepime, and levofloxacin, and PO Vanc\n 125 mg x1. CXR with bilateral opacities, atelectasis vs. pneumonia.\n SBP to 80s at times (also 75/41 once), got 5L fluids total. CVL\n placed. At transfer BP 112/48 with HR 105. O2 sat dropped to 91% on\n 3L so placed on NRB with sats 100%.\n In the ER received vanco/cefepim/levo and oral vanco after discussion\n with ID given her refractory c.diff. A left IJ was placed.\n Patient admitted from: ER\n History obtained from Patient, Family / Medical records\n Allergies:\n Mercury\n Ammoniated\n Unknown;\n Shellfish\n Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n CALCITONIN 200 unit/dose 1 spray once daily\n DONEPEZIL 10 mg Tablet atbedtime\n MIRTAZAPINE 15 mg Tablet daily\n CALCIUM CARBONATE-VITAMIN twice a day\n MULTIVITAMIN once a day\n OMEGA-3 FATTY ACIDS once a day\n Recently on Xifaxin and PO vancomycin\n Past medical history:\n Family history:\n Social History:\n - Alzheimer's dementia - mild\n - Right hip fracture s/p ORIF in status post fall.\n - C. difficile, refractory since \n - Depression.\n - OA\n - s/p wrist fracture\n - Osteopenia\n - cataract surgery\n Hypertension. No other significant illnesses.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: No tobacco, alcohol, IV drug use. Lives near her five children\n who are very involved in her care. Independent with her ADLs. Goes to\n an adult daycare five days a week.\n Review of systems:\n Constitutional: Fatigue, No(t) Weight loss\n Eyes: No(t) Blurry vision\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Orthopnea\n Respiratory: Cough, No(t) Dyspnea, Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria\n Musculoskeletal: No(t) Joint pain\n Integumentary (skin): No(t) Rash\n Neurologic: No(t) Headache\n Flowsheet Data as of 02:14 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (96.9\n Tcurrent: 36.1\nC (96.9\n HR: 90 (85 - 100) bpm\n BP: 122/59(74) {95/48(60) - 122/59(74)} mmHg\n RR: 24 (22 - 25) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 13 (13 - 15)mmHg\n Total In:\n 5,000 mL\n 20 mL\n PO:\n TF:\n IVF:\n 20 mL\n Blood products:\n Total out:\n 850 mL\n 300 mL\n Urine:\n 550 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,150 mL\n -280 mL\n Respiratory\n O2 Delivery Device: Aerosol-cool, Face tent\n SpO2: 99%\n Physical Examination\n General Appearance: Well nourished, No acute distress, No(t) Anxious,\n No(t) Diaphoretic\n Eyes / Conjunctiva: No(t) Pupils dilated, R surgical pupil, L reactive.\n face generally slightly edematous\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL, Supraclavicular WNL, No(t) Cervical adenopathy\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic), loud\n systolic murmur throughout precordium, radiates to carotids.\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n bilaterally, greatest at bases, Wheezes : few wheezes at L base)\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n denies TTP\n Extremities: Right: 1+, Left: 1+ edema.\n Skin: Not assessed, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): x 3 (though was not oriented to time 10\n minutes prior with RN), Movement: Purposeful, Tone: Not assessed\n Labs / Radiology\n 295\n 148\n 1.2\n 23\n 26\n 98\n 4.5\n 135\n 36.5\n 16.5\n [image002.jpg]\n Other labs: PT / PTT / INR:/23.4/1.1, Differential-Neuts:85, Lymph:12,\n Mono:2.5, Lactic Acid:2.1\n Fluid analysis / Other labs: UA 1.020, 100 protein, neg LE/nitrate, 0-2\n WBCs, RBCs\n Imaging: CXR : Low lung volumes are present. Cardiac silhouette\n is within normal limits. The aorta is slightly unfolded with aortic\n knob calcifications present. The pulmonary vascularity is normal, as\n are the hilar contours. Bibasilar patchy opacities likely reflect\n atelectasis, but pneumonia or aspiration is not completely excluded.\n There is blunting of the right costophrenic sulcus, suggestive of a\n small pleural effusion. No pneumothorax. Degenerative changes are seen\n within the left hip as well as within the lumbosacral spine.\n .\n CXR post line placement - LIJ in satisfactory position.\n Microbiology: urine culture, blood culture x 2 sent\n ECG: ECG: sinus tach with first degree AV block, at 123, NANI, no\n TEF/TWI in III, avF (slight change from prior), no ST changes, overall\n unchanged from prior.\n Assessment and Plan\n F with history of refractory C.diff recently off PO vancomycin; admit\n with fever and hypotension, likely septic shock.\n .\n # Hypotension. With fever, leukocytosis; most likely represents septic\n shock, as has been refractory to adequate fluid resuscitation (5L).\n Possible infectious sources include pneumonia (infiltrate on CXR),\n C.diff (given strong history though benign current exam),\n bacteremia/endocarditis (no known risk factors), urosepsis (though UA\n benign). Other possible causes or contributors to hypotension include\n cardiogenic (ACS or CHF), PE, though less likely in setting of other\n findings.\n - CVL in place; goal CVP 8-12, bolus prn.\n - If continues to be hypotensive despite adequate CVP, will start\n norepinephrine, goal MAP > 60-65. A line placement if persistently\n hypotensive.\n - Send central venous sat off line.\n - Broad spectrum abx for coverage of CAP, gram positives, gram\n negatives, C.diff - vanco/cefepime/PO vanc/levoflox. Does not clearly\n have pseudomonal risk factors; consider change from cefepime to\n ceftriaxone.\n - Send cardiac enzymes, though if positive likely reflects demand\n picture.\n - Consider sending cortisol/stim (mainly prognostic value).\n - Consider APC if meets APACHE criteria.\n .\n # Pneumonia - CAP vs. HCAP. Also consider aspiration.\n - Abx as above.\n - Management of sepsis as above.\n - Check legionella.\n .\n # Fever/leukocytosis. Likely infectious as above. WBCs concerning for\n recurrence of C.diff as well.\n - f/u urine and blood cultures.\n - send c.diff; if positive or develops abdominal symptoms consider\n further abdominal imaging.\n - management of sepsis as above; broad coverage abx.\n - C.diff coverage with vanco while on broad spectrums.\n .\n # ARF. Mild renal impairment - volume depletion/hypotension most\n likely. At this point prerenal vs. ATN.\n - Foley to gravity, monitor I/O.\n - s/p 5 L hydration as above.\n - Avoid hypotension and nephrotoxins.\n .\n # Hypoxia. With concern for pneumonia as above. Also s/p 5 L IVFs,\n though no cardiac history.\n - Treatment of pneumonia.\n - Wean O2 if tolerated.\n - Consider Aline placement.\n .\n # Dementia. Mild.\n - Family desires continuation of remeron and donepezil; okay\n for now.\n # Heart murmur. No prior TTEs in our system. ?AS murmur.\n - will check TTE, eval for valvular disease, rule out vegetations.\n ICU Care\n Nutrition:\n Comments: regular if can safely tolerate PO\n Glycemic Control: Blood sugar well controlled, Comments: start insulin\n if glucoses elevated\n Lines:\n Multi Lumen - 12:00 AM\n 16 Gauge - 12:00 AM\n 18 Gauge - 12:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: Full code\n discussed at length with patient and entire\n family ; patient is full code with all interventions possible but would\n likely not continue care if prognosis poor.\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2126-04-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 566242,
"text": " yo female with refractory Cdiff, Alzheimer's dementia with cough x\n several days productive of green sputum, and wheezing. In clinic\n she had a HR in the 120-130's, tEmp 103.8, sats 89% RA, SBP 120's. In\n the ED, P 120, BP 120/52, sats 89-94%, WBC 16.5, lactate 2.1, Cr 1.2\n (base 1). CXR showed bilateral opacities. She received\n Vanco/Cefipime/Levaquin and also po Vanco (recommended by ID due to her\n refractory CDiff.) In the ED, SBP kept intemittently dropping to the\n 70-80's therefore requiring 5 liters NS resucitation. After fluid\n resuscitation, O2 sats dropped to 91% 3 liters n.c.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Arrived on NRB, SATS 100%\n Lungs with scattered rhonchi\n RR 18-24 no distress, denies SOB\n Afebrile although febrile in ED and urine and blood cultures sent\n + nonproductive cough\n SR-ST HR 90-100\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2126-04-13 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 566233,
"text": "Chief Complaint: fever, cough, hypotension\n HPI:\n 92F with history of refractory C.diff with recent d/c of oral vanco;\n dementia, admit with fever, cough, and hypotension. Patient was seen\n for urgent visit in geriatrics today with cough and fatigue and found\n to have HR 133 (BP 122/60), T 103.8, and O2 sat 89% on RA. Sent from\n clinic to the emergency room with concern of pneumonia.\n .\n In the ED, vitals T 102.6, HR 124, BP 128/52, R22, O2 sat 89-94%.\n Found to have WBCs 16.5, lactate 2.1, mild ARF with creatinine 1.2\n (from 0.9). Received vanco, cefepime, and levofloxacin, and PO Vanc\n 125 mg x1. CXR with bilateral opacities, atelectasis vs. pneumonia.\n SBP to 80s at times (also 75/41 once), got 5L fluids total. CVL\n placed. At transfer BP 112/48 with HR 105. O2 sat dropped to 91% on\n 3L so placed on NRB with sats 100%.\n In the ER received vanco/cefepim/levo and oral vanco after discussion\n with ID given her refractory c.diff. A left IJ was placed.\n Patient admitted from: ER\n History obtained from Patient, Family / Medical records\n Allergies:\n Mercury\n Ammoniated\n Unknown;\n Shellfish\n Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n CALCITONIN 200 unit/dose 1 spray once daily\n DONEPEZIL 10 mg Tablet atbedtime\n MIRTAZAPINE 15 mg Tablet daily\n CALCIUM CARBONATE-VITAMIN twice a day\n MULTIVITAMIN once a day\n OMEGA-3 FATTY ACIDS once a day\n Recently on Xifaxin and PO vancomycin\n Past medical history:\n Family history:\n Social History:\n - Alzheimer's dementia - mild\n - Right hip fracture s/p ORIF in status post fall.\n - C. difficile, refractory since \n - Depression.\n - OA\n - s/p wrist fracture\n - Osteopenia\n - cataract surgery\n Hypertension. No other significant illnesses.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: No tobacco, alcohol, IV drug use. Lives near her five children\n who are very involved in her care. Independent with her ADLs. Goes to\n an adult daycare five days a week.\n Review of systems:\n Constitutional: Fatigue, No(t) Weight loss\n Eyes: No(t) Blurry vision\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Orthopnea\n Respiratory: Cough, No(t) Dyspnea, Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria\n Musculoskeletal: No(t) Joint pain\n Integumentary (skin): No(t) Rash\n Neurologic: No(t) Headache\n Flowsheet Data as of 02:14 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (96.9\n Tcurrent: 36.1\nC (96.9\n HR: 90 (85 - 100) bpm\n BP: 122/59(74) {95/48(60) - 122/59(74)} mmHg\n RR: 24 (22 - 25) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 13 (13 - 15)mmHg\n Total In:\n 5,000 mL\n 20 mL\n PO:\n TF:\n IVF:\n 20 mL\n Blood products:\n Total out:\n 850 mL\n 300 mL\n Urine:\n 550 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,150 mL\n -280 mL\n Respiratory\n O2 Delivery Device: Aerosol-cool, Face tent\n SpO2: 99%\n Physical Examination\n General Appearance: Well nourished, No acute distress, No(t) Anxious,\n No(t) Diaphoretic\n Eyes / Conjunctiva: No(t) Pupils dilated, R surgical pupil, L reactive.\n face generally slightly edematous\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL, Supraclavicular WNL, No(t) Cervical adenopathy\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic), loud\n systolic murmur throughout precordium, radiates to carotids.\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n bilaterally, greatest at bases, Wheezes : few wheezes at L base)\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n denies TTP\n Extremities: Right: 1+, Left: 1+\n Skin: Not assessed, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): x 3 (though was not oriented to time 10\n minutes prior with RN), Movement: Purposeful, Tone: Not assessed\n Labs / Radiology\n 295\n 148\n 1.2\n 23\n 26\n 98\n 4.5\n 135\n 36.5\n 16.5\n [image002.jpg]\n Other labs: PT / PTT / INR:/23.4/1.1, Differential-Neuts:85, Lymph:12,\n Mono:2.5, Lactic Acid:2.1\n Fluid analysis / Other labs: UA 1.020, 100 protein, neg LE/nitrate, 0-2\n WBCs, RBCs\n Imaging: CXR : Low lung volumes are present. Cardiac silhouette\n is within normal limits. The aorta is slightly unfolded with aortic\n knob calcifications present. The pulmonary vascularity is normal, as\n are the hilar contours. Bibasilar patchy opacities likely reflect\n atelectasis, but pneumonia or aspiration is not completely excluded.\n There is blunting of the right costophrenic sulcus, suggestive of a\n small pleural effusion. No pneumothorax. Degenerative changes are seen\n within the left hip as well as within the lumbosacral spine.\n .\n CXR post line placement - LIJ in satisfactory position.\n Microbiology: urine culture, blood culture x 2 sent\n ECG: ECG: sinus tach with first degree AV block, at 123, NANI, no\n TEF/TWI in III, avF (slight change from prior), no ST changes, overall\n unchanged from prior.\n Assessment and Plan\n F with history of refractory C.diff recently off PO vancomycin; admit\n with fever and hypotension, likely septic shock.\n .\n # Hypotension. With fever, leukocytosis; most likely represents septic\n shock, as has been refractory to adequate fluid resuscitation (5L).\n Possible infectious sources include pneumonia (infiltrate on CXR),\n C.diff (given strong history though benign current exam),\n bacteremia/endocarditis (no known risk factors), urosepsis (though UA\n benign). Other possible causes or contributors to hypotension include\n cardiogenic (ACS or CHF), PE, though less likely in setting of other\n findings.\n - CVL in place; goal CVP 8-12, bolus prn.\n - If continues to be hypotensive despite adequate CVP, will start\n norepinephrine, goal MAP > 60-65. A line placement if persistently\n hypotensive.\n - Send central venous sat off line.\n - Broad spectrum abx for coverage of CAP, gram positives, gram\n negatives, C.diff - vanco/cefepime/PO vanc/levoflox.\n - Send cardiac enzymes, though if positive likely reflects demand\n picture.\n - Consider sending cortisol/stim (mainly prognostic value).\n - Consider APC if meets APACHE criteria.\n .\n # Pneumonia - CAP vs. HCAP. Also consider aspiration.\n - Abx as above.\n - Management of sepsis as above.\n - Check legionella.\n .\n # Fever/leukocytosis. Likely infectious as above. WBCs concerning for\n recurrence of C.diff as well.\n - f/u urine and blood cultures.\n - send c.diff; if positive or develops abdominal symptoms consider\n further abdominal imaging.\n - management of sepsis as above; broad coverage abx.\n - C.diff coverage with vanco while on broad spectrums.\n .\n # ARF. Mild renal impairment - volume depletion/hypotension most\n likely. At this point prerenal vs. ATN.\n - Foley to gravity, monitor I/O.\n - s/p 5 L hydration as above.\n - Avoid hypotension and nephrotoxins.\n .\n # Hypoxia. With concern for pneumonia as above. Also s/p 5 L IVFs,\n though no cardiac history.\n - Treatment of pneumonia.\n - Wean O2 if tolerated.\n - Consider Aline placement.\n .\n # Dementia. Mild.\n - Family desires continuation of remeron and donepezil; okay for now.\n ICU Care\n Nutrition:\n Comments: regular if can safely tolerate PO\n Glycemic Control: Blood sugar well controlled, Comments: start insulin\n if glucoses elevated\n Lines:\n Multi Lumen - 12:00 AM\n 16 Gauge - 12:00 AM\n 18 Gauge - 12:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2126-04-14 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 566499,
"text": "Chief Complaint:\n 24 Hour Events:\n D/Cd cefepime, cont vanco, levo\n put in for TTE, not done\n History obtained from Patient\n Allergies:\n History obtained from PatientMercury\n Ammoniated\n Unknown;\n Shellfish\n Hives;\n Last dose of Antibiotics:\n Vancomycin - 06:02 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:35 AM\n Famotidine (Pepcid) - 12:35 AM\n Other medications:\n Changes to medical and family history: no change\n Review of systems is unchanged from admission except as noted below\n Review of systems: unchanged\n Flowsheet Data as of 08:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 36.9\nC (98.5\n HR: 89 (83 - 117) bpm\n BP: 118/61(74) {82/45(52) - 165/84(97)} mmHg\n RR: 17 (14 - 33) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 7 (6 - 11)mmHg\n Total In:\n 1,460 mL\n 320 mL\n PO:\n 670 mL\n 240 mL\n TF:\n IVF:\n 790 mL\n 80 mL\n Blood products:\n Total out:\n 3,275 mL\n 590 mL\n Urine:\n 3,275 mL\n 590 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,815 mL\n -270 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///23/\n Physical Examination\n Gen: awake and alert, NAD\n HEENT: icteric sclera, MM dry, PERRL\n Neck: CVL intact\n Heart: Regular, no m/r/g\n Lungs: Clear anteriorly\n Abd: distended, firm, mild tenderness, + BS, surgical scar sclen\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds Awake and alert, no asterixis\n Labs / Radiology\n 224 K/uL\n 10.0 g/dL\n 111 mg/dL\n 0.9 mg/dL\n 23 mEq/L\n 3.9 mEq/L\n 13 mg/dL\n 108 mEq/L\n 136 mEq/L\n 29.3 %\n 9.3 K/uL\n [image002.jpg]\n 04:06 AM\n 03:08 PM\n 03:38 AM\n WBC\n 10.7\n 9.3\n Hct\n 29.9\n 30.1\n 29.3\n Plt\n 234\n 224\n Cr\n 0.9\n 0.9\n 0.9\n TropT\n <0.01\n Glucose\n 111\n 141\n 111\n Other labs: PT / PTT / INR:15.2/33.7/1.3, CK / CKMB /\n Troponin-T:112/4/<0.01, Differential-Neuts:80.4 %, Lymph:15.7 %,\n Mono:1.5 %, Eos:2.4 %, Lactic Acid:1.3 mmol/L, Ca++:7.9 mg/dL, Mg++:2.1\n mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n RASH\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n F with history of refractory C.diff recently off PO vancomycin; admit\n with fever and hypotension, likely septic shock.\n .\n # Pneumonia - CAP vs. HCAP. Also consider aspiration. Clinically\n imroved. Not producing much sputum. Cultures NGTD. Legionella neg\n - Cont Vanco, levo\n - Will increase vanco to 1g q24 and monitor troughs\n - fu micro\n - pulm toilet, chest PT prn\n - wean 02\n .\n # Hypotension/Sepsis: Resolved. Not on pressors. Likely related to\n penumonia. Making good urine output\n - Cont to monitor CVP while here, goal >10\n - I/Os\n - IVF prn\n - Treat infection as above\n .\n # Fever/leukocytosis. Resolved. Likely infectious as above. WBCs\n concerning for recurrence of C.diff as well though no increase in BMs\n or abd pain. Likely related to PNA.\n - f/u urine and blood cultures.\n - C. dfif negative\n - Cont to trend. Treat infection as per above\n .\n # Rash: Developed after receiving antibiotics. ? cefepime vs. vanco.\n Intervally improved with budesonide and hydroxyzine\n - Cont to monitor\n - Cont steroid cream and low dose hydroxyzine prn\n .\n # Chronic C. diff: Stable. Will cont PO vanco empirically while on\n antbx for PNA\n .\n # ARF. Improved. Likely pre-renal in the setting of sepsis\n - Foley to gravity, monitor I/O.\n - s/p 5 L hydration as above.\n - Avoid hypotension and nephrotoxins.\n # Dementia. Mild.\n - Family desires continuation of remeron and donepezil; okay for now.\n # Heart murmur. No prior TTEs in our system. ?AS murmur.\n - will check TTE, eval for valvular disease, rule out vegetations.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines: IJ\n Multi Lumen - 12:00 AM\n 18 Gauge - 12:00 AM\n Prophylaxis:\n DVT: heparin, pneumoboots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: call out to floor\n"
},
{
"category": "Nursing",
"chartdate": "2126-04-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 566418,
"text": " yo female with refractory Cdiff, Alzheimer's dementia with cough x\n several days productive of green sputum, and wheezing. In clinic\n she had a HR in the 120-130's, tEmp 103.8, sats 89% RA, SBP 120's. In\n the ED, P 120, BP 120/52, sats 89-94%, WBC 16.5, lactate 2.1, Cr 1.2\n (base 1). CXR showed bilateral opacities. She received\n Vanco/Cefipime/Levaquin and also po Vanco (recommended by ID due to her\n refractory CDiff.) In the ED, SBP kept intemittently dropping to the\n 70-80's therefore requiring 5 liters NS resucitation. After fluid\n resuscitation, O2 sats dropped to 91% 3 liters n.c.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Received the pt on 2L nc,sats high 90\ns,diminished breath sounds at\n base,productive cough,using the yaunker suction well,t max 99.7\n Action:\n Contd the current abx,received guanifensin x1\n Response:\n T current 97.5,good urine output,stable 02 requirement.\n Plan:\n Cont to monitor resp status, CVP, cont abx, guaifenesin prn for assist\n w/ expectorant.\n Others:pt had brown formed stool in this shift,guiac neg,specimen sent\n for c diff.\n"
},
{
"category": "Physician ",
"chartdate": "2126-04-13 00:00:00.000",
"description": "Physician Fellow / Attending Progress Note - MICU",
"row_id": 566303,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n NASAL SWAB - At 12:00 AM\n MRSA swab\n MULTI LUMEN - START 12:00 AM\n SPUTUM CULTURE - At 04:00 AM\n URINE CULTURE - At 04:00 AM\n legonella\n Allergies:\n Mercury\n Ammoniated\n Unknown;\n Shellfish\n Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pepcid - 01:00 AM\n Heparin Prophylaxis - 01:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.6\n Tcurrent: 37.4\nC (99.4\n HR: 103 (85 - 105) bpm\n BP: 123/53(68) {95/46(60) - 123/59(74)} mmHg\n RR: 21 (18 - 25) insp/min\n SpO2: 95%\n Heart rhythm: Sinus Tach\n CVP: 7 (7 - 15)mmHg\n Total In:\n 5,000 mL\n 208 mL\n PO:\n 120 mL\n TF:\n IVF:\n 88 mL\n Blood products:\n Total out:\n 850 mL\n 855 mL\n Urine:\n 550 mL\n 855 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,150 mL\n -647 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///19/\n Physical Examination\n General:\n HEENT:\n CV:\n Lungs:\n Ab:\n Ext:\n Neuro:\n Labs / Radiology\n 10.1 g/dL\n 234 K/uL\n 111 mg/dL\n 0.9 mg/dL\n 19 mEq/L\n 4.0 mEq/L\n 18 mg/dL\n 112 mEq/L\n 139 mEq/L\n 29.9 %\n 10.7 K/uL\n [image002.jpg]\n 04:06 AM\n WBC\n 10.7\n Hct\n 29.9\n Plt\n 234\n Cr\n 0.9\n TropT\n <0.01\n Glucose\n 111\n Other labs: PT / PTT / INR:14.7/42.9/1.3, CK / CKMB /\n Troponin-T:112/4/<0.01, Differential-Neuts:83.4 %, Lymph:14.5 %,\n Mono:1.6 %, Eos:0.4 %, Lactic Acid:1.3 mmol/L, Ca++:7.7 mg/dL, Mg++:1.4\n mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:00 AM\n 16 Gauge - 12:00 AM\n 18 Gauge - 12:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2126-04-13 00:00:00.000",
"description": "Physician Fellow / Attending Progress Note - MICU",
"row_id": 566304,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n yo female with refractory C diff, Alzheimer's dementia with cough x\n several days productive of green sputum, and wheezing. In clinic\n she had a HR in the 120-130's, temp 103.8, sats 89% RA, SBP 120's. In\n the ED, P 120, BP 120/52, sats 89-94%, WBC 16.5, lactate 2.1, Cr 1.2\n (base 1). CXR showed bilateral opacities. She received\n Vanco/Cefipime/Levaquin and also po Vanco (recommended by ID due to her\n refractory CDiff.) In the ED, SBP kept intemittently dropping to the\n 70-80's therefore requiring 5 liters NS resucitation. After fluid\n resuscitation, O2 sats dropped to 91% 3 liters n.c.\n 24 Hour Events:\n NASAL SWAB - At 12:00 AM\n MRSA swab\n MULTI LUMEN - START 12:00 AM\n SPUTUM CULTURE - At 04:00 AM\n URINE CULTURE - At 04:00 AM\n legonella\n Allergies:\n Mercury\n unknown;\n Shellfish\n hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pepcid - 01:00 AM\n Heparin Prophylaxis - 01:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.6\n Tcurrent: 37.4\nC (99.4\n HR: 103 (85 - 105) bpm\n BP: 123/53(68) {95/46(60) - 123/59(74)} mmHg\n RR: 21 (18 - 25) insp/min\n SpO2: 95%\n Heart rhythm: Sinus Tach\n CVP: 7 (7 - 15)mmHg\n Total In:\n 5,000 mL\n 208 mL\n PO:\n 120 mL\n TF:\n IVF:\n 88 mL\n Blood products:\n Total out:\n 850 mL\n 855 mL\n Urine:\n 550 mL\n 855 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,150 mL\n -647 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///19/\n Physical Examination\n General:\n HEENT:\n CV:\n Lungs:\n Ab:\n Ext:\n Neuro:\n Labs / Radiology\n 10.1 g/dL\n 234 K/uL\n 111 mg/dL\n 0.9 mg/dL\n 19 mEq/L\n 4.0 mEq/L\n 18 mg/dL\n 112 mEq/L\n 139 mEq/L\n 29.9 %\n 10.7 K/uL\n [image002.jpg]\n 04:06 AM\n WBC\n 10.7\n Hct\n 29.9\n Plt\n 234\n Cr\n 0.9\n TropT\n <0.01\n Glucose\n 111\n Other labs: PT / PTT / INR:14.7/42.9/1.3, CK / CKMB /\n Troponin-T:112/4/<0.01, Differential-Neuts:83.4 %, Lymph:14.5 %,\n Mono:1.6 %, Eos:0.4 %, Lactic Acid:1.3 mmol/L, Ca++:7.7 mg/dL, Mg++:1.4\n mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n yo female with Alzheimer's dementia admitted with sepsis resulting\n in acute respiratory distress and hypotension\n 1. Hypotension:\n 2. ARF:\n 3. Acute respiratory distress:\n 4. Alzheimer's dementia:\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:00 AM\n 16 Gauge - 12:00 AM\n 18 Gauge - 12:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2126-04-13 00:00:00.000",
"description": "Physician Fellow / Attending Progress Note - MICU",
"row_id": 566321,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his\n note above, including assessment and plan.\n HPI:\n yo female with refractory C diff, Alzheimer's dementia with cough for\n several days productive of green sputum, and wheezing.\n She was seen in clinic yesterday () where she had a HR in the\n 120-130's, temp 103.8, sats 89% RA, SBP 120's. In the ED, P 120, BP\n 120/52, sats 89-94%, WBC 16.5, lactate 2.1, Cr 1.2 (baseline 1). CXR\n showed bilateral opacities. She received Vanco/Cefipime/Levaquin and\n also PO Vanco (recommended by ID due to her refractory CDiff.) In the\n ED, SBP kept intemittently dropping to the 70-80's requiring 5 liters\n NS resucitation. After fluid resuscitation, O2 sats dropped to 91% 3\n liters NC. CVL was placed in the ED.\n Overnight, her oxygen requirement decreased to 50% face mask then to 2L\n NC. She was monitored overnight. CVP this AM was ~6. .\n 24 Hour Events:\n NASAL SWAB - At 12:00 AM\n MRSA swab\n MULTI LUMEN - START 12:00 AM\n Placed in ED on\n presentation.\n SPUTUM CULTURE - At 04:00 AM\n URINE CULTURE - At 04:00 AM (Urine legionella antigen)\n Allergies:\n Mercury\n unknown;\n Shellfish\n hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pepcid - 01:00 AM\n Heparin Prophylaxis - 01:00 AM\n Other medications:\n Vanc\n Levaquin\n Calcitonin\n MVI\n KCl\n Aricept\n Cefepime\n Changes to medical and family history: No changes from admission H&P.\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.6\n Tcurrent: 37.4\nC (99.4\n HR: 103 (85 - 105) bpm\n BP: 123/53 {95/46 - 123/59} mmHg\n RR: 21 (18 - 25) insp/min\n SpO2: 95%\n Heart rhythm: Sinus Tach\n CVP: 7 (7 - 15)mmHg\n Total In:\n 5,000 mL\n 208 mL\n PO:\n 120 mL\n TF:\n IVF:\n 88 mL\n Blood products:\n Total out:\n 850 mL\n 855 mL\n Urine:\n 550 mL\n 855 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,150 mL\n -647 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n Physical Examination\n General: Mildly uncomfortable, but non-toxic. Breathing comfortably,\n occasionally coughing.\n HEENT: OP clear.\n CV: S1S2 RRR w/o appreciable m/r/g\n Lungs: CTA with right > left crackles. No wheezing.\n Ab: Positive BS\ns, NT/ND\n Ext: 1+ pitting edema. No c/c.\n Neuro: Alert, interactive, oriented to place / time.\n Labs / Radiology\n 10.1 g/dL\n 234 K/uL\n 111 mg/dL\n 0.9 mg/dL\n 19 mEq/L\n 4.0 mEq/L\n 18 mg/dL\n 112 mEq/L\n 139 mEq/L\n 29.9 %\n 10.7 K/uL\n [image002.jpg]\n Differential-Neuts:83.4 %, Lymph:14.5 %, Mono:1.6 %, Eos:0.4 %\n VBG: 7.33 / 43 / 80\n 04:06 AM\n WBC\n 10.7\n Hct\n 29.9\n Plt\n 234\n Cr\n 0.9\n TropT\n <0.01\n Glucose\n 111\n Other labs: PT / PTT / INR:14.7/42.9/1.3, \\\n CK / CKMB / Troponin-T:112/4/<0.01\n Lactic Acid:1.3 mmol/L,\n Ca++:7.7 mg/dL, Mg++:1.4 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n yo female with Alzheimer's dementia admitted with sepsis resulting\n in acute respiratory distress and hypotension\n 1. Hypotension: Hemodynamic issues appear to be due to a SIRS response.\n The most likely source of her SIRS response would be an apparent\n pneumonia\n she has e/o bibasilar infiltrates on her chest x-ray this\n morning. Her urinalysis was without e/o UTI. No cutaneous rashes\n concerning for cellulitis. No decubs. Will adjust antibiotic coverage\n for community acquired pneumonia; no known risk factors for HCAP or\n nosocomial pneumonia. Given, however, her refractory C diff she may\n have had exposure to other resistant / nosocomial pathogens we will\n continue Vancomycin for now with plans for de-escalate within 48 hours.\n Continue Levaquin. Continue PO Vanc. Will monitor CVP with goal \n for now\n plan for 500cc bolus this AM.\n 2. ARF: Resolved with volume resuscitation. Follow UOP / creatinine.\n 3. Acute respiratory distress: Down to 2L NC this AM. Follow\n respiratory status.\n 4. Alzheimer's dementia: On Aricept. Stable with regard to MS.\n 5. F/E/N: Enteral diet. Follow / replete\nlytes as needed.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:00 AM\n 16 Gauge - 12:00 AM\n 18 Gauge - 12:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2126-04-13 00:00:00.000",
"description": "Physician Fellow / Attending Progress Note - MICU",
"row_id": 566331,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his\n note above, including assessment and plan.\n HPI:\n yo female with refractory C diff, Alzheimer's dementia with cough for\n several days productive of green sputum, and wheezing.\n She had symptoms of a URI with a cough that was initially\n non-productive over the course of the past week. Her symptoms were\n initially thought to be allergies; however, she did not respond to\n Benadryl and symptomatically worsened with shortness of breath and\n prgressive cough that became productive.\n She was seen in clinic yesterday () where she had a HR in the\n 120-130's, temp 103.8, sats 89% RA, SBP 120's. In the ED, P 120, BP\n 120/52, sats 89-94%, WBC 16.5, lactate 2.1, Cr 1.2 (baseline 1). CXR\n showed bilateral opacities. WBC was 16.5 (no bands.) She received\n Vanco/Cefipime/Levaquin and also PO Vanco (recommended by ID due to her\n refractory CDiff.) In the ED, SBP kept intemittently dropping to the\n 70-80's requiring 5 liters NS resucitation. After fluid resuscitation,\n O2 sats dropped to 91% 3 liters NC. CVL was placed in the ED.\n Overnight, her oxygen requirement decreased to 50% face mask then to 2L\n NC. She was monitored overnight. CVP this AM was ~6. She received a\n total of ~4.5 liters since presentation in the ED.\n 24 Hour Events:\n NASAL SWAB - At 12:00 AM\nMRSA swab\n MULTI LUMEN - START 12:00 AM\n Placed in ED on\n presentation.\n SPUTUM CULTURE - At 04:00 AM\n URINE CULTURE - At 04:00 AM\n (Urine legionella antigen -- NEGATIVE)\n Allergies:\n Mercury\n unknown;\n Shellfish\n hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pepcid - 01:00 AM\n Heparin Prophylaxis - 01:00 AM\n Other medications:\n Vanc\n Levaquin\n Calcitonin\n MVI\n KCl\n Aricept\n Cefepime\n Changes to medical and family history: No changes from admission H&P.\n Review of systems is unchanged from admission except as noted below\n Review of systems: No new complaints.\n Flowsheet Data as of 07:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.6\n Tcurrent: 37.4\nC (99.4\n HR: 103 (85 - 105) bpm\n BP: 123/53 {95/46 - 123/59} mmHg\n RR: 21 (18 - 25) insp/min\n SpO2: 95%\n Heart rhythm: Sinus Tach\n CVP: 6 (7 - 15)mmHg\n Total In:\n 5,000 mL\n 208 mL\n PO:\n 120 mL\n TF:\n IVF:\n 88 mL\n Blood products:\n Total out:\n 850 mL\n 855 mL\n Urine:\n 550 mL\n 855 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,150 mL\n -647 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n Physical Examination\n General: Mildly uncomfortable, but non-toxic. Breathing comfortably,\n occasionally coughing.\n HEENT: OP clear.\n CV: S1S2 RRR w/o appreciable r/g\ns. III/VI SEM at LUSB c/w AS.\n Lungs: CTA with right > left crackles. No wheezing.\n Ab: Positive BS\ns, NT/ND\n Ext: 1+ pitting edema. No c/c.\n Neuro: Alert, interactive, oriented to place / time.\n Labs / Radiology\n 10.1 g/dL\n 234 K/uL\n 111 mg/dL\n 0.9 mg/dL\n 19 mEq/L\n 4.0 mEq/L\n 18 mg/dL\n 112 mEq/L\n 139 mEq/L\n 29.9 %\n 10.7 K/uL\n [image002.jpg]\n Differential-Neuts:83.4 %, Lymph:14.5 %, Mono:1.6 %, Eos:0.4 %\n VBG: 7.33 / 43 / 80\n 04:06 AM\n WBC\n 10.7\n Hct\n 29.9\n Plt\n 234\n Cr\n 0.9\n TropT\n <0.01\n Glucose\n 111\n Other labs: PT / PTT / INR:14.7/42.9/1.3, \\\n CK / CKMB / Troponin-T:112/4/<0.01\n Lactic Acid:1.3 mmol/L,\n Ca++:7.7 mg/dL, Mg++:1.4 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n yo female with Alzheimer's dementia admitted with sepsis resulting\n in acute respiratory distress and hypotension\n 1. Hypotension: Initial hemodynamic instability (tachycardia /\n hypotension) appears to have been due to SIRS. The most likely cause of\n her SIRS is her apparent pneumonia\n she has bibasilar infiltrates on\n her chest x-ray this morning which have progressed from her prior film.\n Her urinalysis was without e/o UTI. No cutaneous rashes concerning for\n cellulitis. No decubs. Will adjust antibiotic coverage for community\n acquired pneumonia; no known risk factors for HCAP or nosocomial\n pneumonia. Given, however, her refractory C diff she may have had\n exposure to other resistant / nosocomial pathogens we will continue\n Vancomycin for now with plans for de-escalate within 48 hours if MRSA\n swab and cultures are negative. Continue Levaquin. Continue PO Vanc.\n Will monitor CVP with goal for now\n plan for 500cc bolus this AM\n and will follow throughout the day. Her lactate has decreased from 2.1\n on presentation to 1.3 this morning, c/w improved tissue perfusion.\n Will not check SvO2\n unclear how this would alter management at this\n time. Agree with TTE to assess EF and for any valvular abnormalties,\n particularly given SEM concerning for AS.\n 2. ARF: Resolved with volume resuscitation. Follow UOP / creatinine.\n 3. Acute respiratory distress: Down to 2L NC this AM. Follow\n respiratory status.\n 4. Alzheimer's dementia: On Aricept. Stable with regard to MS.\n 5. F/E/N: Enteral diet. Follow / replete\nlytes as needed.\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:00 AM\n 16 Gauge - 12:00 AM\n 18 Gauge - 12:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : ICU for now\n if stable this afternoon, can consider\n transfer to the floor.\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2126-04-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 566408,
"text": " yo female with refractory Cdiff, Alzheimer's dementia with cough x\n several days productive of green sputum, and wheezing. In clinic\n she had a HR in the 120-130's, tEmp 103.8, sats 89% RA, SBP 120's. In\n the ED, P 120, BP 120/52, sats 89-94%, WBC 16.5, lactate 2.1, Cr 1.2\n (base 1). CXR showed bilateral opacities. She received\n Vanco/Cefipime/Levaquin and also po Vanco (recommended by ID due to her\n refractory CDiff.) In the ED, SBP kept intemittently dropping to the\n 70-80's therefore requiring 5 liters NS resucitation. After fluid\n resuscitation, O2 sats dropped to 91% 3 liters n.c.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Received the pt on 2L nc,sats high 90\ns,diminished breath sounds at\n base,productive cough,using the yaunker suction well,t max 99.7\n Action:\n Contd the current abx,received guanifensin x1\n Response:\n T current 97.5,good urine output,stable 02 requirement.\n Plan:\n Cont to monitor resp status, CVP, cont abx, guaifenesin prn for assist\n w/ expectorant.\n"
},
{
"category": "Nursing",
"chartdate": "2126-04-14 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 566561,
"text": " yo female with refractory Cdiff, Alzheimer's dementia with cough x\n several days productive of green sputum, and wheezing. In clinic\n she had a HR in the 120-130's, tEmp 103.8, sats 89% RA, SBP 120's. In\n the ED, P 120, BP 120/52, sats 89-94%, WBC 16.5, lactate 2.1, Cr 1.2\n (base 1). CXR showed bilateral opacities.\n Rash\n Assessment:\n Pt c/o of severe itching on trunk and upper extremeties. Bright red\n rash noted on chest, abdomen, upper extremeties and back.\n Action:\n MICU team aware. Tx\nd with Sarna lotion, Desonide cream and\n hydroxyzine.\n Response:\n Pt c/o of increased puritis s/p both Sarna and Desonide creams.\n Hydroxyzine provided moderate relieve.\n Plan:\n Discontinue Sarna and Desonide. Continue treating with hydroxyzone or\n Benadryl PRN. Monitor rash closely. Avoid adhesive, latex,\n citris-based foods, iodine, shellfish, mercury. Tegaderm and paper tape\n OK.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Pt on 2L NC, sats 100%, LS clear/crackles, strong productive cough. IV\n and PO antibiotics being given.\n Action:\n Discontinue NC. Encourage CDB, reposition frequently, HOB > 30 degrees.\n Response:\n Pt saturation > 95% on RA, breathing comfortably.\n Plan:\n Increase activity as tolerated/OOBTC. Continue with abx course as\n indicated.\n"
},
{
"category": "Physician ",
"chartdate": "2126-04-14 00:00:00.000",
"description": "Physician Fellow / Attending Progress Note - MICU",
"row_id": 566469,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Allergies:\n Mercury\n Ammoniated\n Unknown;\n Shellfish\n Hives;\n Last dose of Antibiotics:\n Vancomycin - 06:02 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:35 AM\n Famotidine (Pepcid) - 12:35 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:17 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 36.9\nC (98.5\n HR: 89 (83 - 117) bpm\n BP: 118/61(74) {82/45(52) - 165/84(97)} mmHg\n RR: 17 (14 - 33) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 7 (6 - 11)mmHg\n Total In:\n 1,460 mL\n 313 mL\n PO:\n 670 mL\n 240 mL\n TF:\n IVF:\n 790 mL\n 73 mL\n Blood products:\n Total out:\n 3,275 mL\n 590 mL\n Urine:\n 3,275 mL\n 590 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,815 mL\n -277 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///23/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 10.0 g/dL\n 224 K/uL\n 111 mg/dL\n 0.9 mg/dL\n 23 mEq/L\n 3.9 mEq/L\n 13 mg/dL\n 108 mEq/L\n 136 mEq/L\n 29.3 %\n 9.3 K/uL\n [image002.jpg]\n 04:06 AM\n 03:08 PM\n 03:38 AM\n WBC\n 10.7\n 9.3\n Hct\n 29.9\n 30.1\n 29.3\n Plt\n 234\n 224\n Cr\n 0.9\n 0.9\n 0.9\n TropT\n <0.01\n Glucose\n 111\n 141\n 111\n Other labs: PT / PTT / INR:15.2/33.7/1.3, CK / CKMB /\n Troponin-T:112/4/<0.01, Differential-Neuts:80.4 %, Lymph:15.7 %,\n Mono:1.5 %, Eos:2.4 %, Lactic Acid:1.3 mmol/L, Ca++:7.9 mg/dL, Mg++:2.1\n mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n RASH\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:00 AM\n 18 Gauge - 12:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2126-04-14 00:00:00.000",
"description": "Physician Fellow / Attending Progress Note - MICU",
"row_id": 566471,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n yo female with refractory C diff, Alzheimer's dementia with cough for\n several days productive of green sputum, and wheezing. On presentation\n to Geritrician, she was tachycardic (120s) and hypoxic (SpO2 89% on\n RA.) In ED, WBC 16.5 (no bands), lactact 2.1. Volume resuscitated (5L\n total in first 12 hours for CVP 6-8) and started on Vanc / Cefepime /\n Levaquin (titrated to Vanc / Levaquin in MICU.) Clinically improving.\n 24 Hour Events:\n Allergies:\n Mercury\n unknown\n Shellfish\n hives\n Last dose of Antibiotics:\n Vancomycin - 06:02 AM\n Infusions:\n Other ICU medications:\n Pepcid - 12:35 AM\n Heparin Prophylaxis - 12:35 AM\n Other medications:\n Vanc\n Levaquin\n Calcitonin\n MVI\n KCl\n Aricept\n Cefepime\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:17 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 36.9\nC (98.5\n HR: 89 (83 - 117) bpm\n BP: 118/61 {82/45 - 165/84} mmHg\n RR: 17 (14 - 33) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 7 (6 - 11)mmHg\n Total In:\n 1,460 mL\n 313 mL\n PO:\n 670 mL\n 240 mL\n TF:\n IVF:\n 790 mL\n 73 mL\n Blood products:\n Total out:\n 3,275 mL\n 590 mL\n Urine:\n 3,275 mL\n 590 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,815 mL\n -277 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n Physical Examination\n General: Mildly uncomfortable, but non-toxic. Breathing comfortably,\n occasionally coughing.\n HEENT: OP clear.\n CV: S1S2 RRR w/o appreciable r/g\ns. III/VI SEM at LUSB c/w AS.\n Lungs: CTA with right > left crackles. No wheezing.\n Ab: Positive BS\ns, NT/ND\n Ext: 1+ pitting edema. No c/c.\n Neuro: Alert, interactive, oriented to place / time.\n Labs / Radiology\n 10.0 g/dL\n 224 K/uL\n 111 mg/dL\n 0.9 mg/dL\n 23 mEq/L\n 3.9 mEq/L\n 13 mg/dL\n 108 mEq/L\n 136 mEq/L\n 29.3 %\n 9.3 K/uL\n [image002.jpg]\n Differential-Neuts:80.4 %, Lymph:15.7 %, Mono:1.5 %, Eos:2.4 %,\n 04:06 AM\n 03:08 PM\n 03:38 AM\n WBC\n 10.7\n 9.3\n Hct\n 29.9\n 30.1\n 29.3\n Plt\n 234\n 224\n Cr\n 0.9\n 0.9\n 0.9\n TropT\n <0.01\n Glucose\n 111\n 141\n 111\n Other labs:\n PT / PTT / INR:15.2/33.7/1.3,\n CK / CKMB / Troponin-T:112/4/<0.01,\n Lactic Acid:1.3 mmol/L,\n Ca++:7.9 mg/dL, Mg++:2.1 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n yo female with Alzheimer's dementia admitted with sepsis resulting\n in acute respiratory distress and hypotension\n 1. Hypotension: ISIRS due to pneumonia . Treating with Vancomycin until\n swabs / cultures are negative and Levaquin for community acquired\n pathogens. Also on PO Vanc for h/o refractory C diff.\n 2. ARF: Resolved with volume resuscitation. Follow UOP / creatinine.\n 3. Acute respiratory distress: Still on 2L NC. Follow respiratory\n status.\n 4. Alzheimer's dementia: On Aricept. Stable with regard to MS.\n 5. F/E/N: Enteral diet. Follow / replete\nlytes as needed.\n RASH\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:00 AM\n 18 Gauge - 12:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2126-04-14 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 566480,
"text": "Chief Complaint:\n 24 Hour Events:\n History obtained from Patient\n Allergies:\n History obtained from PatientMercury\n Ammoniated\n Unknown;\n Shellfish\n Hives;\n Last dose of Antibiotics:\n Vancomycin - 06:02 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:35 AM\n Famotidine (Pepcid) - 12:35 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 36.9\nC (98.5\n HR: 89 (83 - 117) bpm\n BP: 118/61(74) {82/45(52) - 165/84(97)} mmHg\n RR: 17 (14 - 33) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 7 (6 - 11)mmHg\n Total In:\n 1,460 mL\n 320 mL\n PO:\n 670 mL\n 240 mL\n TF:\n IVF:\n 790 mL\n 80 mL\n Blood products:\n Total out:\n 3,275 mL\n 590 mL\n Urine:\n 3,275 mL\n 590 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,815 mL\n -270 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///23/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 224 K/uL\n 10.0 g/dL\n 111 mg/dL\n 0.9 mg/dL\n 23 mEq/L\n 3.9 mEq/L\n 13 mg/dL\n 108 mEq/L\n 136 mEq/L\n 29.3 %\n 9.3 K/uL\n [image002.jpg]\n 04:06 AM\n 03:08 PM\n 03:38 AM\n WBC\n 10.7\n 9.3\n Hct\n 29.9\n 30.1\n 29.3\n Plt\n 234\n 224\n Cr\n 0.9\n 0.9\n 0.9\n TropT\n <0.01\n Glucose\n 111\n 141\n 111\n Other labs: PT / PTT / INR:15.2/33.7/1.3, CK / CKMB /\n Troponin-T:112/4/<0.01, Differential-Neuts:80.4 %, Lymph:15.7 %,\n Mono:1.5 %, Eos:2.4 %, Lactic Acid:1.3 mmol/L, Ca++:7.9 mg/dL, Mg++:2.1\n mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n RASH\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n F with history of refractory C.diff recently off PO vancomycin; admit\n with fever and hypotension, likely septic shock.\n .\n # Hypotension. With fever, leukocytosis; most likely represents septic\n shock, as has been refractory to adequate fluid resuscitation (5L).\n Possible infectious sources include pneumonia (infiltrate on CXR),\n C.diff (given strong history though benign current exam),\n bacteremia/endocarditis (no known risk factors), urosepsis (though UA\n benign). Other possible causes or contributors to hypotension include\n cardiogenic (ACS or CHF), PE, though less likely in setting of other\n findings.\n - CVL in place; goal CVP 8-12, bolus prn.\n - If continues to be hypotensive despite adequate CVP, will start\n norepinephrine, goal MAP > 60-65. A line placement if persistently\n hypotensive.\n - Send central venous sat off line.\n - Broad spectrum abx for coverage of CAP, gram positives, gram\n negatives, C.diff - vanco/cefepime/PO vanc/levoflox. Does not clearly\n have pseudomonal risk factors; consider change from cefepime to\n ceftriaxone.\n - Send cardiac enzymes, though if positive likely reflects demand\n picture.\n - Consider sending cortisol/stim (mainly prognostic value).\n - Consider APC if meets APACHE criteria.\n .\n # Pneumonia - CAP vs. HCAP. Also consider aspiration.\n - Abx as above.\n - Management of sepsis as above.\n - Check legionella. Sputum culture.\n .\n # Fever/leukocytosis. Likely infectious as above. WBCs concerning for\n recurrence of C.diff as well.\n - f/u urine and blood cultures.\n - send c.diff; if positive or develops abdominal symptoms consider\n further abdominal imaging.\n - management of sepsis as above; broad coverage abx.\n - C.diff coverage with vanco while on broad spectrums.\n .\n # ARF. Mild renal impairment - volume depletion/hypotension most\n likely. At this point prerenal vs. ATN.\n - Foley to gravity, monitor I/O.\n - s/p 5 L hydration as above.\n - Avoid hypotension and nephrotoxins.\n .\n # Hypoxia. With concern for pneumonia as above. Also s/p 5 L IVFs,\n though no cardiac history.\n - Treatment of pneumonia.\n - Wean O2 if tolerated.\n - Consider Aline placement.\n .\n # Dementia. Mild.\n - Family desires continuation of remeron and donepezil; okay\n for now.\n # Heart murmur. No prior TTEs in our system. ?AS murmur.\n - will check TTE, eval for valvular disease, rule out vegetations.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:00 AM\n 18 Gauge - 12:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2126-04-14 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 566482,
"text": "Chief Complaint:\n 24 Hour Events:\n History obtained from Patient\n Allergies:\n History obtained from PatientMercury\n Ammoniated\n Unknown;\n Shellfish\n Hives;\n Last dose of Antibiotics:\n Vancomycin - 06:02 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:35 AM\n Famotidine (Pepcid) - 12:35 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 36.9\nC (98.5\n HR: 89 (83 - 117) bpm\n BP: 118/61(74) {82/45(52) - 165/84(97)} mmHg\n RR: 17 (14 - 33) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 7 (6 - 11)mmHg\n Total In:\n 1,460 mL\n 320 mL\n PO:\n 670 mL\n 240 mL\n TF:\n IVF:\n 790 mL\n 80 mL\n Blood products:\n Total out:\n 3,275 mL\n 590 mL\n Urine:\n 3,275 mL\n 590 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,815 mL\n -270 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///23/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 224 K/uL\n 10.0 g/dL\n 111 mg/dL\n 0.9 mg/dL\n 23 mEq/L\n 3.9 mEq/L\n 13 mg/dL\n 108 mEq/L\n 136 mEq/L\n 29.3 %\n 9.3 K/uL\n [image002.jpg]\n 04:06 AM\n 03:08 PM\n 03:38 AM\n WBC\n 10.7\n 9.3\n Hct\n 29.9\n 30.1\n 29.3\n Plt\n 234\n 224\n Cr\n 0.9\n 0.9\n 0.9\n TropT\n <0.01\n Glucose\n 111\n 141\n 111\n Other labs: PT / PTT / INR:15.2/33.7/1.3, CK / CKMB /\n Troponin-T:112/4/<0.01, Differential-Neuts:80.4 %, Lymph:15.7 %,\n Mono:1.5 %, Eos:2.4 %, Lactic Acid:1.3 mmol/L, Ca++:7.9 mg/dL, Mg++:2.1\n mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n RASH\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n F with history of refractory C.diff recently off PO vancomycin; admit\n with fever and hypotension, likely septic shock.\n .\n # Hypotension. With fever, leukocytosis; most likely represents septic\n shock, as has been refractory to adequate fluid resuscitation (5L).\n Possible infectious sources include pneumonia (infiltrate on CXR),\n C.diff (given strong history though benign current exam),\n bacteremia/endocarditis (no known risk factors), urosepsis (though UA\n benign). Other possible causes or contributors to hypotension include\n cardiogenic (ACS or CHF), PE, though less likely in setting of other\n findings.\n - CVL in place; goal CVP 8-12, bolus prn.\n - If continues to be hypotensive despite adequate CVP, will start\n norepinephrine, goal MAP > 60-65. A line placement if persistently\n hypotensive.\n - Send central venous sat off line.\n - Broad spectrum abx for coverage of CAP, gram positives, gram\n negatives, C.diff - vanco/cefepime/PO vanc/levoflox. Does not clearly\n have pseudomonal risk factors; consider change from cefepime to\n ceftriaxone.\n - Send cardiac enzymes, though if positive likely reflects demand\n picture.\n - Consider sending cortisol/stim (mainly prognostic value).\n - Consider APC if meets APACHE criteria.\n .\n # Pneumonia - CAP vs. HCAP. Also consider aspiration.\n - Abx as above.\n - Management of sepsis as above.\n - Check legionella. Sputum culture.\n .\n # Fever/leukocytosis. Likely infectious as above. WBCs concerning for\n recurrence of C.diff as well.\n - f/u urine and blood cultures.\n - send c.diff; if positive or develops abdominal symptoms consider\n further abdominal imaging.\n - management of sepsis as above; broad coverage abx.\n - C.diff coverage with vanco while on broad spectrums.\n .\n # ARF. Mild renal impairment - volume depletion/hypotension most\n likely. At this point prerenal vs. ATN.\n - Foley to gravity, monitor I/O.\n - s/p 5 L hydration as above.\n - Avoid hypotension and nephrotoxins.\n .\n # Hypoxia. With concern for pneumonia as above. Also s/p 5 L IVFs,\n though no cardiac history.\n - Treatment of pneumonia.\n - Wean O2 if tolerated.\n - Consider Aline placement.\n .\n # Dementia. Mild.\n - Family desires continuation of remeron and donepezil; okay\n for now.\n # Heart murmur. No prior TTEs in our system. ?AS murmur.\n - will check TTE, eval for valvular disease, rule out vegetations.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:00 AM\n 18 Gauge - 12:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2126-04-14 00:00:00.000",
"description": "Physician Fellow / Attending Progress Note - MICU",
"row_id": 566492,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his\n note above, including assessment and plan.\n HPI:\n yo female with refractory C diff, Alzheimer's dementia with cough for\n several days productive of green sputum, and wheezing. On presentation\n to Geritrician, she was tachycardic (120s) and hypoxic (SpO2 89% on\n RA.) In ED, WBC 16.5 (no bands), lactact 2.1. Volume resuscitated (5L\n total in first 12 hours for CVP 6-8) and started on Vanc / Cefepime /\n Levaquin (titrated to Vanc / Levaquin in MICU.) Clinically improving.\n 24 Hour Events:\n TTE pending.\n Clinically stable.\n Allergies:\n Mercury\n unknown\n Shellfish\n hives\n Last dose of Antibiotics:\n Vancomycin - 06:02 AM\n Infusions: None currently.\n Other ICU medications:\n Pepcid - 12:35 AM\n Heparin Prophylaxis - 12:35 AM\n Other medications:\n Vanc oral solution ( - )\n Vanc IV ( - )\n Levaquin ( - )\n Calcitonin\n MVI\n KCl\n Remeron\n Aricept\n Changes to medical and family history: No changes from admission note.\n Review of systems is unchanged from admission except as noted below\n Flowsheet Data as of 07:17 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 36.9\nC (98.5\n HR: 89 (83 - 117) bpm\n BP: 118/61 {82/45 - 165/84} mmHg\n RR: 17 (14 - 33) insp/min\n SpO2: 98% 2L NC\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 7 (6 - 11)mmHg\n Total In:\n 1,460 mL\n 313 mL\n PO:\n 670 mL\n 240 mL\n TF:\n IVF:\n 790 mL\n 73 mL\n Blood products:\n Total out:\n 3,275 mL\n 590 mL\n Urine:\n 3,275 mL\n 590 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,815 mL\n -277 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n Physical Examination\n General: Mildly uncomfortable, but non-toxic. Breathing comfortably,\n occasionally coughing.\n HEENT: OP clear.\n CV: S1S2 RRR w/o appreciable r/g\ns. III/VI SEM at LUSB c/w AS.\n Lungs: CTA with persistent left basilar crackles. No wheezing. Good air\n movement.\n Ab: Positive BS\ns, NT/ND\n Ext: 1+ pitting edema. No c/c.\n Neuro: Alert, interactive, oriented to place / time.\n Labs / Radiology\n 10.0 g/dL\n 224 K/uL\n 111 mg/dL\n 0.9 mg/dL\n 23 mEq/L\n 3.9 mEq/L\n 13 mg/dL\n 108 mEq/L\n 136 mEq/L\n 29.3 %\n 9.3 K/uL\n [image002.jpg]\n Differential-Neuts:80.4 %, Lymph:15.7 %, Mono:1.5 %, Eos:2.4 %,\n 04:06 AM\n 03:08 PM\n 03:38 AM\n WBC\n 10.7\n 9.3\n Hct\n 29.9\n 30.1\n 29.3\n Plt\n 234\n 224\n Cr\n 0.9\n 0.9\n 0.9\n TropT\n <0.01\n Glucose\n 111\n 141\n 111\n Other labs:\n PT / PTT / INR:15.2 / 33.7 / 1.3\n CK / CKMB / Troponin-T:112 / 4 / <0.01\n Lactic Acid: 1.3 mmol/L\n Ca++: 7.9 mg/dL, Mg++: 2.1 mg/dL, PO4: 2.8 mg/dL\n Vanc level: 3\n Micro:\n C diff negative\n Legionella urine antigen negative\n No sputum cultures pending\n MRSA swab pending\n No new imaging\n Assessment and Plan\n yo female with Alzheimer's dementia admitted with sepsis resulting\n in acute respiratory distress and hypotension; clinically improved\n since admission.\n 1. Hypotension: ISIRS due to pneumonia . Treating with Vancomycin until\n swabs / cultures are negative and Levaquin for community acquired\n pathogens. Also on PO Vanc for h/o refractory C diff.\n 2. ARF: Resolved with volume resuscitation. Follow UOP / creatinine.\n 3. Acute respiratory distress: Still on 2L NC. Follow respiratory\n status.\n 4. Alzheimer's dementia: On Aricept. Stable with regard to MS.\n 5. F/E/N: Enteral diet. Follow / replete\nlytes as needed.\n 6. Rash: Clinically appears to be most c/w a drug rash\n possibilities\n include Cefepime, less likely Vanc. No other obvious culprit meds. Will\n continue topical symptomatic treatment.\n 7. Access: Will d/c CVL given clinical stability.\n RASH\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:00 AM\n 18 Gauge - 12:00 AM\n Prophylaxis:\n DVT: SCDs / heparin subQ\n Stress ulcer: Pepcid\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : Stable for transfer to the floor today.\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2126-04-14 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 566571,
"text": " yo female with refractory Cdiff, Alzheimer's dementia with cough x\n several days productive of green sputum, and wheezing. In clinic\n she had a HR in the 120-130's, tEmp 103.8, sats 89% RA, SBP 120's. In\n the ED, P 120, BP 120/52, sats 89-94%, WBC 16.5, lactate 2.1, Cr 1.2\n (base 1). CXR showed bilateral opacities.\n Rash\n Assessment:\n Pt c/o of severe itching on trunk and upper extremeties. Bright red\n rash noted on chest, abdomen, upper extremeties and back.\n Action:\n MICU team aware. Tx\nd with Sarna lotion, Desonide cream and\n hydroxyzine.\n Response:\n Pt c/o of increased puritis s/p both Sarna and Desonide creams.\n Hydroxyzine provided moderate relieve.\n Plan:\n Discontinue Sarna and Desonide. Continue treating with hydroxyzone or\n Benadryl PRN. Monitor rash closely. Avoid adhesive, latex,\n citris-based foods, iodine, shellfish, mercury. Tegaderm and paper tape\n OK.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Pt on 2L NC, sats 100%, LS clear/crackles, strong productive cough. IV\n and PO antibiotics being given.\n Action:\n Discontinue NC. Encourage CDB, reposition frequently, HOB > 30 degrees.\n Response:\n Pt saturation > 95% on RA, breathing comfortably.\n Plan:\n Increase activity as tolerated/OOBTC. Continue with abx course as\n indicated.\n Demographics\n Attending MD:\n Admit diagnosis:\n Code status:\n Height:\n Admission weight:\n Daily weight:\n Allergies/Reactions:\n Precautions:\n PMH:\n CV-PMH:\n Additional history:\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:\n D:\n Temperature:\n Arterial BP:\n S:\n D:\n Respiratory rate:\n Heart Rate:\n Heart rhythm:\n O2 delivery device:\n O2 saturation:\n O2 flow:\n FiO2 set:\n 24h total in:\n 24h total out:\n Pacer Data\n Pertinent Lab Results:\n Additional pertinent labs:\n Lines / Tubes / Drains:\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes:\n Wallet / Money:\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from:\n Transferred to:\n Date & time of Transfer:\n Demographics\n Attending MD:\n F.\n Admit diagnosis:\n PNEUMONIA\n Code status:\n Full code\n Height:\n Admission weight:\n 75.5 kg\n Daily weight:\n Allergies/Reactions:\n Mercury\n Ammoniated\n Unknown;\n Shellfish\n Hives;\n Precautions: Contact\n PMH:\n CV-PMH:\n Additional history: Alzheimers dementia, CDIFF\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:124\n D:58\n Temperature:\n 98.5\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 21 insp/min\n Heart Rate:\n 110 bpm\n Heart rhythm:\n ST (Sinus Tachycardia)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 95% %\n O2 flow:\n 1 L/min\n FiO2 set:\n 50% %\n 24h total in:\n 1,261 mL\n 24h total out:\n 1,805 mL\n Pertinent Lab Results:\n Sodium:\n 136 mEq/L\n 03:38 AM\n Potassium:\n 3.9 mEq/L\n 03:38 AM\n Chloride:\n 108 mEq/L\n 03:38 AM\n CO2:\n 23 mEq/L\n 03:38 AM\n BUN:\n 13 mg/dL\n 03:38 AM\n Creatinine:\n 0.9 mg/dL\n 03:38 AM\n Glucose:\n 111 mg/dL\n 03:38 AM\n Hematocrit:\n 29.3 %\n 03:38 AM\n Finger Stick Glucose:\n 148\n 12:00 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: micu 7\n Transferred to: cc7 719\n Date & time of Transfer: 2130\n"
},
{
"category": "Nursing",
"chartdate": "2126-04-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 566458,
"text": " yo female with refractory Cdiff, Alzheimer's dementia with cough x\n several days productive of green sputum, and wheezing. In clinic\n she had a HR in the 120-130's, tEmp 103.8, sats 89% RA, SBP 120's. In\n the ED, P 120, BP 120/52, sats 89-94%, WBC 16.5, lactate 2.1, Cr 1.2\n (base 1). CXR showed bilateral opacities. She received\n Vanco/Cefipime/Levaquin and also po Vanco (recommended by ID due to her\n refractory CDiff.) In the ED, SBP kept intemittently dropping to the\n 70-80's therefore requiring 5 liters NS resucitation. After fluid\n resuscitation, O2 sats dropped to 91% 3 liters n.c.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Received the pt on 2L nc,sats high 90\ns,diminished breath sounds at\n base,productive cough,using the yaunker suction well,t max 99.7\n Action:\n Contd the current abx,received guanifensin x1,02 weaned to 1L.\n Response:\n T current 98.5 good u/o afebrile.\n Plan:\n Cont to monitor resp status, CVP, cont abx, guaifenesin prn for assist\n w/ expectorant. ,follow vanco trough\n Rash\n Assessment:\n c/o itching on the back,o/e noted diffuse rash over the back extending\n to left thight with severe itching,over the course of night the rash\n spread over the ant abd and chest,pt received vanco/levo/cefipime at\n the time of admission\n Action:\n Applied sarna lotion.hydroxyzine 12.5 given\n Response:\n Contd itching and seems extending\n Plan:\n Contd sarna application,plan to apply Desonide cream locally\n Others:pt had brown formed stool in this shift,guiac neg,specimen sent\n for c diff.\n"
},
{
"category": "Nursing",
"chartdate": "2126-04-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 566456,
"text": " yo female with refractory Cdiff, Alzheimer's dementia with cough x\n several days productive of green sputum, and wheezing. In clinic\n she had a HR in the 120-130's, tEmp 103.8, sats 89% RA, SBP 120's. In\n the ED, P 120, BP 120/52, sats 89-94%, WBC 16.5, lactate 2.1, Cr 1.2\n (base 1). CXR showed bilateral opacities. She received\n Vanco/Cefipime/Levaquin and also po Vanco (recommended by ID due to her\n refractory CDiff.) In the ED, SBP kept intemittently dropping to the\n 70-80's therefore requiring 5 liters NS resucitation. After fluid\n resuscitation, O2 sats dropped to 91% 3 liters n.c.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Received the pt on 2L nc,sats high 90\ns,diminished breath sounds at\n base,productive cough,using the yaunker suction well,t max 99.7\n Action:\n Contd the current abx,received guanifensin x1,02 weaned to 1L.\n Response:\n T current 98.5 good u/o afebrile.\n Plan:\n Cont to monitor resp status, CVP, cont abx, guaifenesin prn for assist\n w/ expectorant. ,follow vanco trough\n Rash\n Assessment:\n c/o itching on the back,o/e noted diffuse rash over the back extending\n to left thight with severe itching,over the course of night the rash\n spread over the ant abd and chest,pt received vanco/levo/cefipime at\n the time of admission\n Action:\n Applied sarna lotion.hydroxyzine 12.5 given\n Response:\n Contd itching and seems extending\n Plan:\n Contd sarna application,plan to apply Desonide cream locally\n Others:pt had brown formed stool in this shift,guiac neg,specimen sent\n for c diff.\n"
},
{
"category": "Physician ",
"chartdate": "2126-04-14 00:00:00.000",
"description": "Physician Fellow / Attending Progress Note - MICU",
"row_id": 566542,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his\n note above, including assessment and plan.\n HPI:\n yo female with refractory C diff, Alzheimer's dementia with cough for\n several days productive of green sputum, and wheezing. On presentation\n to Geritrician, she was tachycardic (120s) and hypoxic (SpO2 89% on\n RA.) In ED, WBC 16.5 (no bands), lactact 2.1. Volume resuscitated (5L\n total in first 12 hours for CVP 6-8) and started on Vanc / Cefepime /\n Levaquin (titrated to Vanc / Levaquin in MICU.) Clinically improving.\n 24 Hour Events:\n TTE pending.\n Clinically stable.\n Allergies:\n Mercury\n unknown\n Shellfish\n hives\n Last dose of Antibiotics:\n Vancomycin - 06:02 AM\n Infusions: None currently.\n Other ICU medications:\n Pepcid - 12:35 AM\n Heparin Prophylaxis - 12:35 AM\n Other medications:\n Vanc oral solution ( - )\n Vanc IV ( - )\n Levaquin ( - )\n Calcitonin\n MVI\n KCl\n Remeron\n Aricept\n Changes to medical and family history: No changes from admission note.\n Review of systems is unchanged from admission except as noted below\n Flowsheet Data as of 07:17 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 36.9\nC (98.5\n HR: 89 (83 - 117) bpm\n BP: 118/61 {82/45 - 165/84} mmHg\n RR: 17 (14 - 33) insp/min\n SpO2: 98% 2L NC\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 7 (6 - 11)mmHg\n Total In:\n 1,460 mL\n 313 mL\n PO:\n 670 mL\n 240 mL\n TF:\n IVF:\n 790 mL\n 73 mL\n Blood products:\n Total out:\n 3,275 mL\n 590 mL\n Urine:\n 3,275 mL\n 590 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,815 mL\n -277 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n Physical Examination\n General: Mildly uncomfortable, but non-toxic. Breathing comfortably,\n occasionally coughing.\n HEENT: OP clear.\n CV: S1S2 RRR w/o appreciable r/g\ns. III/VI SEM at LUSB c/w AS.\n Lungs: CTA with persistent left basilar crackles. No wheezing. Good air\n movement.\n Ab: Positive BS\ns, NT/ND\n Ext: 1+ pitting edema. No c/c.\n Neuro: Alert, interactive, oriented to place / time.\n Labs / Radiology\n 10.0 g/dL\n 224 K/uL\n 111 mg/dL\n 0.9 mg/dL\n 23 mEq/L\n 3.9 mEq/L\n 13 mg/dL\n 108 mEq/L\n 136 mEq/L\n 29.3 %\n 9.3 K/uL\n [image002.jpg]\n Differential-Neuts:80.4 %, Lymph:15.7 %, Mono:1.5 %, Eos:2.4 %,\n 04:06 AM\n 03:08 PM\n 03:38 AM\n WBC\n 10.7\n 9.3\n Hct\n 29.9\n 30.1\n 29.3\n Plt\n 234\n 224\n Cr\n 0.9\n 0.9\n 0.9\n TropT\n <0.01\n Glucose\n 111\n 141\n 111\n Other labs:\n PT / PTT / INR:15.2 / 33.7 / 1.3\n CK / CKMB / Troponin-T:112 / 4 / <0.01\n Lactic Acid: 1.3 mmol/L\n Ca++: 7.9 mg/dL, Mg++: 2.1 mg/dL, PO4: 2.8 mg/dL\n Vanc level: 3\n Micro:\n C diff negative\n Legionella urine antigen negative\n No sputum cultures pending\n MRSA swab pending\n No new imaging\n Assessment and Plan\n yo female with Alzheimer's dementia admitted with sepsis resulting\n in acute respiratory distress and hypotension; clinically improved\n since admission.\n 1. Hypotension: ISIRS due to pneumonia . Treating with Vancomycin until\n swabs / cultures are negative and Levaquin for community acquired\n pathogens. Also on PO Vanc for h/o refractory C diff.\n 2. ARF: Resolved with volume resuscitation. Follow UOP / creatinine.\n 3. Acute respiratory distress: Still on 2L NC. Follow respiratory\n status.\n 4. Alzheimer's dementia: On Aricept. Stable with regard to MS.\n 5. F/E/N: Enteral diet. Follow / replete\nlytes as needed.\n 6. Rash: Clinically appears to be most c/w a drug rash\n possibilities\n include Cefepime, less likely Vanc. No other obvious culprit meds. Will\n continue topical symptomatic treatment.\n 7. Access: Will d/c CVL given clinical stability.\n RASH\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:00 AM\n 18 Gauge - 12:00 AM\n Prophylaxis:\n DVT: SCDs / heparin subQ\n Stress ulcer: Pepcid\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : Stable for transfer to the floor today.\n Total time spent:\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n Dr. note above, including the Assessment and Plan. I would\n emphasize and add the following points:\n yof now with pneumonia and sepsis. Good clinical response to\n current level of care.\n Exam notable for ETT intubation, lungs with good air movement.\n Extensive sacral decubitus ulcer.\n Assessment/Plans -- Respiratory failure, aspiration pneumonia, sepsis.\n Plan continue antimicrobials. Continue Rx for refractory C. diff.\n Monitor rash (presumed drug rash).\n Plans otherwise as outlined in Dr. note above.\n Patient is critically ill.\n Total time providing ICU care: 35 minutes\n ------ Protected Section Addendum Entered By: , MD\n on: 15:59 ------\n"
},
{
"category": "Nursing",
"chartdate": "2126-04-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 566451,
"text": " yo female with refractory Cdiff, Alzheimer's dementia with cough x\n several days productive of green sputum, and wheezing. In clinic\n she had a HR in the 120-130's, tEmp 103.8, sats 89% RA, SBP 120's. In\n the ED, P 120, BP 120/52, sats 89-94%, WBC 16.5, lactate 2.1, Cr 1.2\n (base 1). CXR showed bilateral opacities. She received\n Vanco/Cefipime/Levaquin and also po Vanco (recommended by ID due to her\n refractory CDiff.) In the ED, SBP kept intemittently dropping to the\n 70-80's therefore requiring 5 liters NS resucitation. After fluid\n resuscitation, O2 sats dropped to 91% 3 liters n.c.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Received the pt on 2L nc,sats high 90\ns,diminished breath sounds at\n base,productive cough,using the yaunker suction well,t max 99.7\n Action:\n Contd the current abx,received guanifensin x1,02 weaned to 1L.\n Response:\n T current 97.5,good urine output,afebrile,\n Plan:\n Cont to monitor resp status, CVP, cont abx, guaifenesin prn for assist\n w/ expectorant. ,follow vanco trough\n Others:pt had brown formed stool in this shift,guiac neg,specimen sent\n for c diff.\n Skin:diffuse rash started on the back,now moving anteriorly with\n itching noted,sarna lotion applied\n"
},
{
"category": "Radiology",
"chartdate": "2126-04-12 00:00:00.000",
"description": "BY DIFFERENT PHYSICIAN",
"row_id": 1071368,
"text": " 10:13 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: check line placement\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with new triple lumen in L neck\n REASON FOR THIS EXAMINATION:\n check line placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: New triple-lumen left neck, check line placement.\n\n FINDINGS: A single frontal chest radiograph is compared to earlier .\n There is interval placement of a left IJ line, with the tip terminating at the\n confluence of the brachiocephalic veins or the very proximal SVC. There is\n mildly increased prominence of the pulmonary interstitium, likely chronic.\n There are linear bibasilar opacities, likely atelectasis. There is mild\n prominence of the cardiac silhouette. There are degenerative changes of the\n spine.\n\n IMPRESSION: New left IJ line tip projects at the confluence of the\n brachiocephalic veins or very proximal SVC. Linear bibasilar airspace\n opacities, likely atelectasis. Mild prominence of the cardiac silhouette.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2126-04-12 00:00:00.000",
"description": "Report",
"row_id": 281331,
"text": "TRACING IS SUBMITTED LATE AND OUT OF SEQUENCE. Sinus tachycardia, rate 126.\nLeftward axis. Consider inferior myocardial infarction of undetermined age.\nCompared to the subsequent tracing of no diagnostic interval change.\n\n"
},
{
"category": "ECG",
"chartdate": "2126-04-12 00:00:00.000",
"description": "Report",
"row_id": 281332,
"text": "Sinus tachycardia. Leftward axis. Compared to the previous tracing of \nthe overall rate has increased. Otherwise, no diagnostic interim change.\n\n"
},
{
"category": "Nursing",
"chartdate": "2126-04-14 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 566534,
"text": "Rash\n Assessment:\n Pt c/o of severe itching on trunk and upper extremeties. Bright red\n rash noted on chest, abdomen, upper extremeties and back.\n Action:\n MICU team aware. Tx\nd with Sarna lotion, Desonide cream and\n hydroxyzine.\n Response:\n Pt c/o of increased puritis s/p both Sarna and Desonide creams.\n Hydroxyzine provided moderate relieve.\n Plan:\n Discontinue Sarna and Desonide. Continue treating with hydroxyzone or\n Benadryl PRN. Monitor rash closely. Avoid adhesive, latex,\n citris-based foods, iodine, shellfish, mercury. Tegaderm and paper tape\n OK.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Pt on 2L NC, sats 100%, LS clear/crackles, strong productive cough. IV\n and PO antibiotics being given.\n Action:\n Discontinue NC. Encourage CDB, reposition frequently, HOB > 30 degrees.\n Response:\n Pt saturation > 95% on RA, breathing comfortably.\n Plan:\n Increase activity as tolerated/OOBTC. Continue with abx course as\n indicated.\n"
},
{
"category": "Nursing",
"chartdate": "2126-04-14 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 566535,
"text": " yo female with refractory Cdiff, Alzheimer's dementia with cough x\n several days productive of green sputum, and wheezing. In clinic\n she had a HR in the 120-130's, tEmp 103.8, sats 89% RA, SBP 120's. In\n the ED, P 120, BP 120/52, sats 89-94%, WBC 16.5, lactate 2.1, Cr 1.2\n (base 1). CXR showed bilateral opacities.\n Rash\n Assessment:\n Pt c/o of severe itching on trunk and upper extremeties. Bright red\n rash noted on chest, abdomen, upper extremeties and back.\n Action:\n MICU team aware. Tx\nd with Sarna lotion, Desonide cream and\n hydroxyzine.\n Response:\n Pt c/o of increased puritis s/p both Sarna and Desonide creams.\n Hydroxyzine provided moderate relieve.\n Plan:\n Discontinue Sarna and Desonide. Continue treating with hydroxyzone or\n Benadryl PRN. Monitor rash closely. Avoid adhesive, latex,\n citris-based foods, iodine, shellfish, mercury. Tegaderm and paper tape\n OK.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Pt on 2L NC, sats 100%, LS clear/crackles, strong productive cough. IV\n and PO antibiotics being given.\n Action:\n Discontinue NC. Encourage CDB, reposition frequently, HOB > 30 degrees.\n Response:\n Pt saturation > 95% on RA, breathing comfortably.\n Plan:\n Increase activity as tolerated/OOBTC. Continue with abx course as\n indicated.\n"
},
{
"category": "Nursing",
"chartdate": "2126-04-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 566264,
"text": " yo female with refractory Cdiff, Alzheimer's dementia with cough x\n several days productive of green sputum, and wheezing. In clinic\n she had a HR in the 120-130's, tEmp 103.8, sats 89% RA, SBP 120's. In\n the ED, P 120, BP 120/52, sats 89-94%, WBC 16.5, lactate 2.1, Cr 1.2\n (base 1). CXR showed bilateral opacities. She received\n Vanco/Cefipime/Levaquin and also po Vanco (recommended by ID due to her\n refractory CDiff.) In the ED, SBP kept intemittently dropping to the\n 70-80's therefore requiring 5 liters NS resucitation. After fluid\n resuscitation, O2 sats dropped to 91% 3 liters n.c.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Arrived on NRB, SATS 100%\n Lungs with scattered rhonchi\n RR 18-24 no distress, denies SOB\n Afebrile although febrile in ED and urine and blood cultures sent\n + nonproductive cough\n SR-ST HR 90-100\n Action:\n Placed on shovel mask upon arrival and weaned down, currently on\n 2liters NC\n Sputum CX sent\n Response:\n Resp status improved overnight\n Temp up to 100.6 this am\n Lactate 1.3 this am, BUN/Creat down and WBC down this am\n Continues to make good urine\n Plan:\n Cont to monitor resp status, fluid status, f/u on am CXR, provide\n support.\n"
},
{
"category": "Nursing",
"chartdate": "2126-04-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 566385,
"text": " yo female with refractory Cdiff, Alzheimer's dementia with cough x\n several days productive of green sputum, and wheezing. In clinic\n she had a HR in the 120-130's, tEmp 103.8, sats 89% RA, SBP 120's. In\n the ED, P 120, BP 120/52, sats 89-94%, WBC 16.5, lactate 2.1, Cr 1.2\n (base 1). CXR showed bilateral opacities. She received\n Vanco/Cefipime/Levaquin and also po Vanco (recommended by ID due to her\n refractory CDiff.) In the ED, SBP kept intemittently dropping to the\n 70-80's therefore requiring 5 liters NS resucitation. After fluid\n resuscitation, O2 sats dropped to 91% 3 liters n.c.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Received pt on 2L NC w/ o2sat >97%, productive cough. BP stable, CVP\n 5-6.\n Action:\n 500cc IVFB for CVP goal >8. Guaifenesin to assist w/ expectorant.\n Response:\n Afebrile, U/O good, coughing up secretions and suctioning w/ jankaur on\n own, remains on 2L, no cx results on bld to date, but U/A was neg.\n Plan:\n Cont to monitor resp status, CVP, cont abx, guaifenesin prn for assist\n w/ expectorant.\n ECHO ordered to eval heart murmur; not yet done.\n Oral Vanco for hx C.diff (ordered by ID). Pt has not yet stooled. Will\n need stool cx sent when available.\n Daughter and brother and other fam members visited today.\n"
},
{
"category": "Physician ",
"chartdate": "2126-04-14 00:00:00.000",
"description": "Physician Fellow / Attending Progress Note - MICU",
"row_id": 566530,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his\n note above, including assessment and plan.\n HPI:\n yo female with refractory C diff, Alzheimer's dementia with cough for\n several days productive of green sputum, and wheezing. On presentation\n to Geritrician, she was tachycardic (120s) and hypoxic (SpO2 89% on\n RA.) In ED, WBC 16.5 (no bands), lactact 2.1. Volume resuscitated (5L\n total in first 12 hours for CVP 6-8) and started on Vanc / Cefepime /\n Levaquin (titrated to Vanc / Levaquin in MICU.) Clinically improving.\n 24 Hour Events:\n TTE pending.\n Clinically stable.\n Allergies:\n Mercury\n unknown\n Shellfish\n hives\n Last dose of Antibiotics:\n Vancomycin - 06:02 AM\n Infusions: None currently.\n Other ICU medications:\n Pepcid - 12:35 AM\n Heparin Prophylaxis - 12:35 AM\n Other medications:\n Vanc oral solution ( - )\n Vanc IV ( - )\n Levaquin ( - )\n Calcitonin\n MVI\n KCl\n Remeron\n Aricept\n Changes to medical and family history: No changes from admission note.\n Review of systems is unchanged from admission except as noted below\n Flowsheet Data as of 07:17 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 36.9\nC (98.5\n HR: 89 (83 - 117) bpm\n BP: 118/61 {82/45 - 165/84} mmHg\n RR: 17 (14 - 33) insp/min\n SpO2: 98% 2L NC\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 7 (6 - 11)mmHg\n Total In:\n 1,460 mL\n 313 mL\n PO:\n 670 mL\n 240 mL\n TF:\n IVF:\n 790 mL\n 73 mL\n Blood products:\n Total out:\n 3,275 mL\n 590 mL\n Urine:\n 3,275 mL\n 590 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,815 mL\n -277 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n Physical Examination\n General: Mildly uncomfortable, but non-toxic. Breathing comfortably,\n occasionally coughing.\n HEENT: OP clear.\n CV: S1S2 RRR w/o appreciable r/g\ns. III/VI SEM at LUSB c/w AS.\n Lungs: CTA with persistent left basilar crackles. No wheezing. Good air\n movement.\n Ab: Positive BS\ns, NT/ND\n Ext: 1+ pitting edema. No c/c.\n Neuro: Alert, interactive, oriented to place / time.\n Labs / Radiology\n 10.0 g/dL\n 224 K/uL\n 111 mg/dL\n 0.9 mg/dL\n 23 mEq/L\n 3.9 mEq/L\n 13 mg/dL\n 108 mEq/L\n 136 mEq/L\n 29.3 %\n 9.3 K/uL\n [image002.jpg]\n Differential-Neuts:80.4 %, Lymph:15.7 %, Mono:1.5 %, Eos:2.4 %,\n 04:06 AM\n 03:08 PM\n 03:38 AM\n WBC\n 10.7\n 9.3\n Hct\n 29.9\n 30.1\n 29.3\n Plt\n 234\n 224\n Cr\n 0.9\n 0.9\n 0.9\n TropT\n <0.01\n Glucose\n 111\n 141\n 111\n Other labs:\n PT / PTT / INR:15.2 / 33.7 / 1.3\n CK / CKMB / Troponin-T:112 / 4 / <0.01\n Lactic Acid: 1.3 mmol/L\n Ca++: 7.9 mg/dL, Mg++: 2.1 mg/dL, PO4: 2.8 mg/dL\n Vanc level: 3\n Micro:\n C diff negative\n Legionella urine antigen negative\n No sputum cultures pending\n MRSA swab pending\n No new imaging\n Assessment and Plan\n yo female with Alzheimer's dementia admitted with sepsis resulting\n in acute respiratory distress and hypotension; clinically improved\n since admission.\n 1. Hypotension: ISIRS due to pneumonia . Treating with Vancomycin until\n swabs / cultures are negative and Levaquin for community acquired\n pathogens. Also on PO Vanc for h/o refractory C diff.\n 2. ARF: Resolved with volume resuscitation. Follow UOP / creatinine.\n 3. Acute respiratory distress: Still on 2L NC. Follow respiratory\n status.\n 4. Alzheimer's dementia: On Aricept. Stable with regard to MS.\n 5. F/E/N: Enteral diet. Follow / replete\nlytes as needed.\n 6. Rash: Clinically appears to be most c/w a drug rash\n possibilities\n include Cefepime, less likely Vanc. No other obvious culprit meds. Will\n continue topical symptomatic treatment.\n 7. Access: Will d/c CVL given clinical stability.\n RASH\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:00 AM\n 18 Gauge - 12:00 AM\n Prophylaxis:\n DVT: SCDs / heparin subQ\n Stress ulcer: Pepcid\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : Stable for transfer to the floor today.\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2126-04-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 566371,
"text": " yo female with refractory Cdiff, Alzheimer's dementia with cough x\n several days productive of green sputum, and wheezing. In clinic\n she had a HR in the 120-130's, tEmp 103.8, sats 89% RA, SBP 120's. In\n the ED, P 120, BP 120/52, sats 89-94%, WBC 16.5, lactate 2.1, Cr 1.2\n (base 1). CXR showed bilateral opacities. She received\n Vanco/Cefipime/Levaquin and also po Vanco (recommended by ID due to her\n refractory CDiff.) In the ED, SBP kept intemittently dropping to the\n 70-80's therefore requiring 5 liters NS resucitation. After fluid\n resuscitation, O2 sats dropped to 91% 3 liters n.c.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Received pt on 2L NC w/ o2sat >97%, productive cough. BP stable, CVP\n 5-6.\n Action:\n 500cc IVFB for CVP goal >8. Guaifenesin to assist w/ expectorant.\n Response:\n Afebrile, U/O good, coughing up secretions and suctioning w/ jankaur on\n own, remains on 2L, no cx results on bld to date, but U/A was neg.\n Plan:\n Cont to monitor resp status, CVP, cont abx, guaifenesin prn for assist\n w/ expectorant.\n ECHO ordered to eval heart murmur; not yet done.\n Oral Vanco for hx C.diff (ordered by ID). Pt has not yet stooled. Will\n need stool cx sent when available.\n Daughter and brother and other fam members visited today.\n"
},
{
"category": "Physician ",
"chartdate": "2126-04-13 00:00:00.000",
"description": "Physician Fellow / Attending Progress Note - MICU",
"row_id": 566372,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his\n note above, including assessment and plan.\n HPI:\n yo female with refractory C diff, Alzheimer's dementia with cough for\n several days productive of green sputum, and wheezing.\n She had symptoms of a URI with a cough that was initially\n non-productive over the course of the past week. Her symptoms were\n initially thought to be allergies; however, she did not respond to\n Benadryl and symptomatically worsened with shortness of breath and\n prgressive cough that became productive.\n She was seen in clinic yesterday () where she had a HR in the\n 120-130's, temp 103.8, sats 89% RA, SBP 120's. In the ED, P 120, BP\n 120/52, sats 89-94%, WBC 16.5, lactate 2.1, Cr 1.2 (baseline 1). CXR\n showed bilateral opacities. WBC was 16.5 (no bands.) She received\n Vanco/Cefipime/Levaquin and also PO Vanco (recommended by ID due to her\n refractory CDiff.) In the ED, SBP kept intemittently dropping to the\n 70-80's requiring 5 liters NS resucitation. After fluid resuscitation,\n O2 sats dropped to 91% 3 liters NC. CVL was placed in the ED.\n Overnight, her oxygen requirement decreased to 50% face mask then to 2L\n NC. She was monitored overnight. CVP this AM was ~6. She received a\n total of ~4.5 liters since presentation in the ED.\n 24 Hour Events:\n NASAL SWAB - At 12:00 AM\nMRSA swab\n MULTI LUMEN - START 12:00 AM\n Placed in ED on\n presentation.\n SPUTUM CULTURE - At 04:00 AM\n URINE CULTURE - At 04:00 AM\n (Urine legionella antigen -- NEGATIVE)\n Allergies:\n Mercury\n unknown;\n Shellfish\n hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pepcid - 01:00 AM\n Heparin Prophylaxis - 01:00 AM\n Other medications:\n Vanc\n Levaquin\n Calcitonin\n MVI\n KCl\n Aricept\n Cefepime\n Changes to medical and family history: No changes from admission H&P.\n Review of systems is unchanged from admission except as noted below\n Review of systems: No new complaints.\n Flowsheet Data as of 07:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.6\n Tcurrent: 37.4\nC (99.4\n HR: 103 (85 - 105) bpm\n BP: 123/53 {95/46 - 123/59} mmHg\n RR: 21 (18 - 25) insp/min\n SpO2: 95%\n Heart rhythm: Sinus Tach\n CVP: 6 (7 - 15)mmHg\n Total In:\n 5,000 mL\n 208 mL\n PO:\n 120 mL\n TF:\n IVF:\n 88 mL\n Blood products:\n Total out:\n 850 mL\n 855 mL\n Urine:\n 550 mL\n 855 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,150 mL\n -647 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n Physical Examination\n General: Mildly uncomfortable, but non-toxic. Breathing comfortably,\n occasionally coughing.\n HEENT: OP clear.\n CV: S1S2 RRR w/o appreciable r/g\ns. III/VI SEM at LUSB c/w AS.\n Lungs: CTA with right > left crackles. No wheezing.\n Ab: Positive BS\ns, NT/ND\n Ext: 1+ pitting edema. No c/c.\n Neuro: Alert, interactive, oriented to place / time.\n Labs / Radiology\n 10.1 g/dL\n 234 K/uL\n 111 mg/dL\n 0.9 mg/dL\n 19 mEq/L\n 4.0 mEq/L\n 18 mg/dL\n 112 mEq/L\n 139 mEq/L\n 29.9 %\n 10.7 K/uL\n [image002.jpg]\n Differential-Neuts:83.4 %, Lymph:14.5 %, Mono:1.6 %, Eos:0.4 %\n VBG: 7.33 / 43 / 80\n 04:06 AM\n WBC\n 10.7\n Hct\n 29.9\n Plt\n 234\n Cr\n 0.9\n TropT\n <0.01\n Glucose\n 111\n Other labs: PT / PTT / INR:14.7/42.9/1.3, \\\n CK / CKMB / Troponin-T:112/4/<0.01\n Lactic Acid:1.3 mmol/L,\n Ca++:7.7 mg/dL, Mg++:1.4 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n yo female with Alzheimer's dementia admitted with sepsis resulting\n in acute respiratory distress and hypotension\n 1. Hypotension: Initial hemodynamic instability (tachycardia /\n hypotension) appears to have been due to SIRS. The most likely cause of\n her SIRS is her apparent pneumonia\n she has bibasilar infiltrates on\n her chest x-ray this morning which have progressed from her prior film.\n Her urinalysis was without e/o UTI. No cutaneous rashes concerning for\n cellulitis. No decubs. Will adjust antibiotic coverage for community\n acquired pneumonia; no known risk factors for HCAP or nosocomial\n pneumonia. Given, however, her refractory C diff she may have had\n exposure to other resistant / nosocomial pathogens we will continue\n Vancomycin for now with plans for de-escalate within 48 hours if MRSA\n swab and cultures are negative. Continue Levaquin. Continue PO Vanc.\n Will monitor CVP with goal for now\n plan for 500cc bolus this AM\n and will follow throughout the day. Her lactate has decreased from 2.1\n on presentation to 1.3 this morning, c/w improved tissue perfusion.\n Will not check SvO2\n unclear how this would alter management at this\n time. Agree with TTE to assess EF and for any valvular abnormalties,\n particularly given SEM concerning for AS.\n 2. ARF: Resolved with volume resuscitation. Follow UOP / creatinine.\n 3. Acute respiratory distress: Down to 2L NC this AM. Follow\n respiratory status.\n 4. Alzheimer's dementia: On Aricept. Stable with regard to MS.\n 5. F/E/N: Enteral diet. Follow / replete\nlytes as needed.\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:00 AM\n 16 Gauge - 12:00 AM\n 18 Gauge - 12:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : ICU for now\n if stable this afternoon, can consider\n transfer to the floor.\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2126-04-13 00:00:00.000",
"description": "Physician Fellow / Attending Progress Note - MICU",
"row_id": 566377,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his\n note above, including assessment and plan.\n HPI:\n yo female with refractory C diff, Alzheimer's dementia with cough for\n several days productive of green sputum, and wheezing.\n She had symptoms of a URI with a cough that was initially\n non-productive over the course of the past week. Her symptoms were\n initially thought to be allergies; however, she did not respond to\n Benadryl and symptomatically worsened with shortness of breath and\n prgressive cough that became productive.\n She was seen in clinic yesterday () where she had a HR in the\n 120-130's, temp 103.8, sats 89% RA, SBP 120's. In the ED, P 120, BP\n 120/52, sats 89-94%, WBC 16.5, lactate 2.1, Cr 1.2 (baseline 1). CXR\n showed bilateral opacities. WBC was 16.5 (no bands.) She received\n Vanco/Cefipime/Levaquin and also PO Vanco (recommended by ID due to her\n refractory CDiff.) In the ED, SBP kept intemittently dropping to the\n 70-80's requiring 5 liters NS resucitation. After fluid resuscitation,\n O2 sats dropped to 91% 3 liters NC. CVL was placed in the ED.\n Overnight, her oxygen requirement decreased to 50% face mask then to 2L\n NC. She was monitored overnight. CVP this AM was ~6. She received a\n total of ~4.5 liters since presentation in the ED.\n 24 Hour Events:\n NASAL SWAB - At 12:00 AM\nMRSA swab\n MULTI LUMEN - START 12:00 AM\n Placed in ED on\n presentation.\n SPUTUM CULTURE - At 04:00 AM\n URINE CULTURE - At 04:00 AM\n (Urine legionella antigen -- NEGATIVE)\n Allergies:\n Mercury\n unknown;\n Shellfish\n hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pepcid - 01:00 AM\n Heparin Prophylaxis - 01:00 AM\n Other medications:\n Vanc\n Levaquin\n Calcitonin\n MVI\n KCl\n Aricept\n Cefepime\n Changes to medical and family history: No changes from admission H&P.\n Review of systems is unchanged from admission except as noted below\n Review of systems: No new complaints.\n Flowsheet Data as of 07:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.6\n Tcurrent: 37.4\nC (99.4\n HR: 103 (85 - 105) bpm\n BP: 123/53 {95/46 - 123/59} mmHg\n RR: 21 (18 - 25) insp/min\n SpO2: 95%\n Heart rhythm: Sinus Tach\n CVP: 6 (7 - 15)mmHg\n Total In:\n 5,000 mL\n 208 mL\n PO:\n 120 mL\n TF:\n IVF:\n 88 mL\n Blood products:\n Total out:\n 850 mL\n 855 mL\n Urine:\n 550 mL\n 855 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,150 mL\n -647 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n Physical Examination\n General: Mildly uncomfortable, but non-toxic. Breathing comfortably,\n occasionally coughing.\n HEENT: OP clear.\n CV: S1S2 RRR w/o appreciable r/g\ns. III/VI SEM at LUSB c/w AS.\n Lungs: CTA with right > left crackles. No wheezing.\n Ab: Positive BS\ns, NT/ND\n Ext: 1+ pitting edema. No c/c.\n Neuro: Alert, interactive, oriented to place / time.\n Labs / Radiology\n 10.1 g/dL\n 234 K/uL\n 111 mg/dL\n 0.9 mg/dL\n 19 mEq/L\n 4.0 mEq/L\n 18 mg/dL\n 112 mEq/L\n 139 mEq/L\n 29.9 %\n 10.7 K/uL\n [image002.jpg]\n Differential-Neuts:83.4 %, Lymph:14.5 %, Mono:1.6 %, Eos:0.4 %\n VBG: 7.33 / 43 / 80\n 04:06 AM\n WBC\n 10.7\n Hct\n 29.9\n Plt\n 234\n Cr\n 0.9\n TropT\n <0.01\n Glucose\n 111\n Other labs: PT / PTT / INR:14.7/42.9/1.3, \\\n CK / CKMB / Troponin-T:112/4/<0.01\n Lactic Acid:1.3 mmol/L,\n Ca++:7.7 mg/dL, Mg++:1.4 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n yo female with Alzheimer's dementia admitted with sepsis resulting\n in acute respiratory distress and hypotension\n 1. Hypotension: Initial hemodynamic instability (tachycardia /\n hypotension) appears to have been due to SIRS. The most likely cause of\n her SIRS is her apparent pneumonia\n she has bibasilar infiltrates on\n her chest x-ray this morning which have progressed from her prior film.\n Her urinalysis was without e/o UTI. No cutaneous rashes concerning for\n cellulitis. No decubs. Will adjust antibiotic coverage for community\n acquired pneumonia; no known risk factors for HCAP or nosocomial\n pneumonia. Given, however, her refractory C diff she may have had\n exposure to other resistant / nosocomial pathogens we will continue\n Vancomycin for now with plans for de-escalate within 48 hours if MRSA\n swab and cultures are negative. Continue Levaquin. Continue PO Vanc.\n Will monitor CVP with goal for now\n plan for 500cc bolus this AM\n and will follow throughout the day. Her lactate has decreased from 2.1\n on presentation to 1.3 this morning, c/w improved tissue perfusion.\n Will not check SvO2\n unclear how this would alter management at this\n time. Agree with TTE to assess EF and for any valvular abnormalties,\n particularly given SEM concerning for AS.\n 2. ARF: Resolved with volume resuscitation. Follow UOP / creatinine.\n 3. Acute respiratory distress: Down to 2L NC this AM. Follow\n respiratory status.\n 4. Alzheimer's dementia: On Aricept. Stable with regard to MS.\n 5. F/E/N: Enteral diet. Follow / replete\nlytes as needed.\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:00 AM\n 16 Gauge - 12:00 AM\n 18 Gauge - 12:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : ICU for now\n if stable this afternoon, can consider\n transfer to the floor.\n Total time spent:\n ------ Protected Section ------\n ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n fellow for key portions of the services provided. I agree with his\n note above, including assessment and plan. PMH, SH, FH and ROS are\n unchanged from admission except where noted above.\n Key issues: yo woman with CAP, admitted with resp failure and ARF,\n now improved.\n * Hypotension, ARF, elevated lactate resolved after receiving 5L\n fluids\n * Minimal supplemental oxygen requirement\n * CXR worse despite better inflation on today\ns film, showing\n bibasilar opacification with air bronchograms, but may be partly\n attributable to large volume crystalloid\n * ------ Protected Section Addendum Entered By: , MD\n on: 05:29 PM ------\n *\n *\n * Electronically signed by , MD 05:29 PM\n *\n *\n"
},
{
"category": "Nursing",
"chartdate": "2126-04-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 566419,
"text": " yo female with refractory Cdiff, Alzheimer's dementia with cough x\n several days productive of green sputum, and wheezing. In clinic\n she had a HR in the 120-130's, tEmp 103.8, sats 89% RA, SBP 120's. In\n the ED, P 120, BP 120/52, sats 89-94%, WBC 16.5, lactate 2.1, Cr 1.2\n (base 1). CXR showed bilateral opacities. She received\n Vanco/Cefipime/Levaquin and also po Vanco (recommended by ID due to her\n refractory CDiff.) In the ED, SBP kept intemittently dropping to the\n 70-80's therefore requiring 5 liters NS resucitation. After fluid\n resuscitation, O2 sats dropped to 91% 3 liters n.c.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Received the pt on 2L nc,sats high 90\ns,diminished breath sounds at\n base,productive cough,using the yaunker suction well,t max 99.7\n Action:\n Contd the current abx,received guanifensin x1,02 weaned to 1L.\n Response:\n T current 97.5,good urine output,stable 02 requirement.\n Plan:\n Cont to monitor resp status, CVP, cont abx, guaifenesin prn for assist\n w/ expectorant.\n Others:pt had brown formed stool in this shift,guiac neg,specimen sent\n for c diff.\n"
}
] |
59,839 | 157,281 | 72yo man with metastatic melanoma, hx of DVT on warfarin, and prostate CA (not treated) admitted for left proximal leg pain with weight bearing x1-2wks, fever. Also foley catheter placed prior to admission for urinary retention while on morphine. MRI demonstrated inflammation of his left iliopsoas muscle and a left hip effusion. Ortho was and upon discussion, it was initially decided that no operative intervention was necessary. Infectious Disease was and Interventional Radiology aspirated the left hip, which showed a WBC > 20,000 and GPCs (eventually speciated to MSSA). He was taken urgently to the OR for wash out. During surgery, the severity of the infection led to a left femoral head resection. He tolerated the procedure without intra-operative complication, and was transferred to the floor per routine. Pain was intially controlled with parenteral narcotics with assistance from the Palliative Care service. Eventually, he was transitioned to a PO pain regimen to good effect. Once MSSA was speciated, vancomycin was changed to nafcillin after a successful nafcillin desensitization in the ICU without hives, edema, or anaphylaxis. Repeat MRI did not show any remaining joint effusion. . On POD#3, Mr. creatinine rose to 1.2 from baseline 0.7, and subsequently to 2.2 on POD#4. The renal service was and his antibiotics were changed from nafcillin to daptomycin. He was transferred back to the Hospitalist Oncology service on POD#6 for continued management of his kidney issues, which subsequently stabilized. He was restarted on warfarin with an enoxaparin bridge for DVT treatment considering his past histories of DVTs and PE. Fevers persisted for about one week post-op, but repeat cultures and CXR remained negative. He also required RBC transfusions for anemia of inflammation. He was transferred to rehab once afebrile with the plan to continue daptomycin for six weeks total, then follow-up with Orthopedics for a hip replacement. . # MSSA septic hip and infective myositis: Hip wash out and femoral head resection . Nafcillin changed to daptomycin due to . ID and ortho . Repeat MRI without evidence of fluid re-accumulation. Plan to continue daptomycin x6wks total while checking CK qwk, next . Physical therapy: No weight bearing to left hip changed to weight bearing as tolerated. Ortho and reconstructive surgery F/U in weeks with repeat MRI +/- arthrocentesis prior to hip replacement. . # Fever: Due to septic joint and infective myositis. Repeat CXR negative X2. C. diff negative x1. Echo negative. LE doppler U/S negative. Repeat ESR and CRP still elevated. Repeat cultures no growth to date. . # Nafcillin desensitization: In the , Mr. nafcillin densensitization and received a total of 3 doses of nafcillin while in the without hives, edema, or anaphylaxis. He was also hemodynamically stable without periods of hypotension throughout the desensitization. . # Acute renal failure: Stable. Due to AIN from nafcillin vs. ATN due to sepsis/pre-renal vs. obstruction (urinary retention). Renal service . Nafcillin switched to daptomycin . . # Hyponatremia: Resolved with IV fluids. . # Metastatic melanoma: Dr. is planning to enroll Mr. into a clinical trial after resolution of current infection. Asymptomatic from cancer disease. . # Prostate CA: PSA 19.2, increased from 10.5 on 12/. Follow-up as outpatient. Continued calcium and vitamin D. . # UTI: MSSA and coag-negative Staph, 10,000-100,000 ORGANISMS/ML. Foley catheter removed. Changed nitrofurantoin to vancomycin for MSSA UTI and septic arthritis, then to nafcillin with sensitivities, then to daptomycin due to . Repeat U/A negative. . # Hyperglycemia: Mild. HbA1c 6.5. Insulin sliding scale stopped. . # Urinary retention: Developed in setting of narcotic analgesia. Foley catheter placed prior to admission. Resolved with tamsulosin. Foley removed. . # DVT: Warfarin increased to 6mg daily and bridged with enoxaparin while subtherapeutic. INR goal 2.5-3.0 per ortho. . # Macrocytic anemia: Transfused 1U pRBC and 1U . Adequate B12 and folate. Low retic suggested decreased production, likely anemia of inflammation. . # Pain (LLE): OxyContin 10mg with prn oxycodone. . # FEN: Regular diet. . # DVT PPx: On chronic antociagulation for h/o DVT/PE. . # GI PPx: PPI and bowel regimen. . # Precautions: Fall. . # Lines: PICC line. . # CODE: FULL. | The low T1 high T2 signal lesions in the left greater trochanter, right proximal femus and right inferior pubic ramus are unchanged, likley representing metastases. Mild osseous edema in medial and posterior left acetabulum. There is an incompletely seen intramuscular edematous process involving the obturator externus, pectineus, adductor muscle group, iliopsoas, gluteus minimus and iliacus musculature when correlated with MRI pelvis examination from the same day. remote prior resection, possibly for a left inguinal flap) of the over lying subuctaneous fat and the adjoining skin is thckened. FINDINGS: Grayscale and color Doppler son of the bilateral lower extremities demonstrates normal compressibility and flow in the bilateral common femoral, superficial femoral, popliteal, posterior tibial and peroneal veins without evidence of DVT. Unchanged sclerotic metastasis in the upper thoracic spine. Another small T1 hypointense 1.3 cm right posterior inferior pubic ramus lesion is identified demonstrating minimal enhancement. The partially imaged abdomen shows diverticulosis of the sigmoid colon without diverticulitis. Also compared with CT right lower extremity dated . The patient appears to be in sinus rhythm.Resting tachycardia (HR>100bpm).Conclusions:The left ventricular cavity is small. COMPARISON: MRI pelvis without and with contrast from the same day. Minimal tortuosity of the thoracic aorta. TECHNIQUE: Noninvasive bilateral lower extremity venous evaluation. ChemoHeight: (in) 69Weight (lb): 165BSA (m2): 1.91 m2BP (mm Hg): 124/68HR (bpm): 113Status: InpatientDate/Time: at 14:00Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:LEFT VENTRICLE: Small LV cavity. Physiologic TR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Stable-sized possibly metastatic intraosseous lesions involving the proximal right femur and left femur. Small left hip joint effusion with likely reactive edema in the medial and posterior left acetabulum. Separate from this, the left sartorius and gracilis muscles abut the skin, with loss (? A sclerotic vertebral body is noted in the upper thoracic spine, unchanged. Essentially stable-sized intraosseous lesion at the inferior left femoral neck measuring approximately 1.5 cm. Interval development of a small amount of presacral edema. The remaining osseous marrow signal is grossly within normal limits. Small, hyperdynamic left ventricle In addition, there are small locules of rounded fluid in the left iliacus muscle posteriorly, which demonstrate non-enhancement centrally with the largest pocket with layering debris measuring approximately 1.3 x 2.3 cm. Interval girdlestone procedure with removal of left femoral head. Consider prior inferior myocardial infarction as recordedon . There is a small amount of presacral edema. Interval decrease in size of the intramuscular iliacus abscess. Trivial mitral regurgitation is seen. The inferior extent of the aforementioned process involving the musculature of the left hemipelvis and left proximal thigh is incompletely seen and also further evaluated on left thigh MRI from same day. The frontal sinuses are under-pneumatized. Right upper lobe mass is not visible on the current examination. The edema in the iliopsoas muscles is stable; however, the necrotic portion in the iliacus muscle is smaller on today's examination. TECHNIQUE: MDCT images were acquired through the left hip without IV contrast. FINDINGS: In comparison with study of , there is blunting of the left costophrenic angle, suggestive of pleural effusion. 6:08 PM MR THIGH W&W/O CONTRAST LEFT Clip # Reason: Unstable lytic lesion? Hyperdynamic LVEF >75%.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.MITRAL VALVE: Mitral valve leaflets not well seen. Left femoral neck likely osseous metastatic lesion is stable in size in comparison to prior comparisons. FINAL REPORT INDICATION: Metastatic melanoma, unresponsive following orthopedic washout. Minimal plate-like areas of atelectasis at the left lung base. FINDINGS: Sclerotic foci in the right L5 vertebral body (2:7) measuring 10 mm (previously measuring 9 mm), left ilium (2:7) measuring 13 mm (previously measuring 14 mm), left greater trochanter mixed lytic and sclerotic (2:57) measuring 5 mm (prior measuring 5 mm) and left proximal femur mixed lytic/sclerotic (2:67) measuring 13 mm (prior measuring 11 mm) are essentially unchanged in size to slightly increased in appearance compared to the prior examination. No contraindications for IV contrast WET READ: JMNk MON 9:57 PM Extensive edema of the left psoas muscle, left obdurator internus. Fluid seen in left psoas without enhancing wall but still concerning for infection. Right ventricular chamber size and free wall motion arenormal. FINDINGS: Please correlate with MRI pelvis without and with contrast dictation from same day for further anatomic details. There is edema and fluid in the surgical cavity with some susceptibility artifact in keeping with small pockets of air. Ill-defined radiopacity in the right upper lobe overlying the intersection of the first with the fifth rib was observed. Please correlate with MRI pelvis without and with contrast dictation from same day for further details of the proximal extent of this process. Again demonstrated are essentially stable-sized marrow osseous lesions in the proximal right femur with decreased T1 weighted signal intensity and increased T2 weighted signal intensity in the diaphysis of the proximal right femur measuring approximately 1.7 cm. IMPRESSION: (Over) 6:08 PM MR THIGH W&W/O CONTRAST LEFT Clip # Reason: Unstable lytic lesion? The mitral valve leaflets are not well seen (mitral valve prolapse isprobably present). | 16 | [
{
"category": "Radiology",
"chartdate": "2136-06-22 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1198550,
"text": " 2:52 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: 44cm right basilic PICCIsabel #\n Admitting Diagnosis: LEG PAIN FROM LYTIC LESIONS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with septic hip req. abx\n REASON FOR THIS EXAMINATION:\n 44cm right basilic PICCIsabel #\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient with history of septic hip. Please check placement of\n PICC line.\n\n COMPARISON: Multiple chest radiographs spanning from -, the latest\n one on .\n\n TECHNIQUE: Portable chest x-ray.\n\n FINDINGS: The right-sided PICC line is observed with the tip approximately 6\n cm below the cavoatrial junction. Compared with prior radiograph there is poor\n lung expansion causing vascular crowding in the right lower lobe. Linear\n opacities obscuring of the left heart border are secondary to lingular\n atelectasis. Cardiomediastinal and hilar contours are unchanged from prior\n exam, although comparison is difficult due to patient positioning and\n technique. No evidence of pleural effusion or pneumothorax.\n\n IMPRESSION:\n 1. Tip of the PICC is approximately 6 cm below the cavoatrial junction. IV\n staff advised to pull line accordingly.\n 2. No evidence of acute cardiopulmonary disease. Chest radiograph is stable\n compared with prior exam.\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-06-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1199442,
"text": " 11:36 PM\n CHEST (PORTABLE AP) Clip # \n Reason: infectious w/u\n Admitting Diagnosis: LEG PAIN FROM LYTIC LESIONS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with septic hip\n REASON FOR THIS EXAMINATION:\n infectious w/u\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient with septic hip and undergoing an infectious workup. rule\n out pneumonia\n\n COMPARISONS: PA and lateral chest radiograph from , CT of the\n torso with contrast, .\n\n FINDINGS: Mild bibasilar plate-like atelectasis are present. Ill-defined\n radiopacity in the right upper lobe overlying the intersection of the first\n with the fifth rib was observed. This lung mass has been formerly assessed by\n CT and has been stable since at least , which decreases the chances\n of it being a metastatic melanoma. Otherwise, lungs are clear.\n Cardiomediastinal and hilar contours are unremarkable. No evidence of pleural\n effusion or pneumothorax. PICC line in stable position.\n\n IMPRESSION: Mild bibasilar atelectasis. No evidence of acute cardiopulmonary\n disease.\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-07-02 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1199959,
"text": " 9:17 PM\n CHEST (PA & LAT) Clip # \n Reason: Infiltrate?\n Admitting Diagnosis: LEG PAIN FROM LYTIC LESIONS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with metastatic melanoma and prostate CA admitted for septic\n hip s/p washout and resection of femoral head. Continued fevers.\n REASON FOR THIS EXAMINATION:\n Infiltrate?\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH.\n\n INDICATION: Metastatic melanoma, continued fevers, questionable pneumonia.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is no relevant\n change. Minimal plate-like areas of atelectasis at the left lung base. No\n focal parenchymal opacity suggesting pneumonia. No pleural effusions.\n Pulmonary edema. Unchanged normal size of the cardiac silhouette. Minimal\n tortuosity of the thoracic aorta. Unchanged right-sided PICC line.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-06-26 00:00:00.000",
"description": "MRI PELVIS W/O CONTRAST",
"row_id": 1199097,
"text": " 6:46 PM\n MRI PELVIS W/O CONTRAST Clip # \n Reason: L psoas muscle inflammation interval f/u\n Admitting Diagnosis: LEG PAIN FROM LYTIC LESIONS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with L septic hip, L psoas muscle inflammation\n REASON FOR THIS EXAMINATION:\n L psoas muscle inflammation interval f/u\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: IMBc TUE 10:45 PM\n 1. Contrast not administered.\n 2. Interval girdlestone procedure with removal of left femoral head. Fluid in\n left actebulum and surrounding greater trochanter may be post surgical\n 3. Persistent high signal in left iliacus muscle on STIR imaging in keeping\n with intramuscular edema but muscle expansion has decreased with further\n decreases in size of intramuscular fluid locules.\n 4. Stable bone mets in right upper femur and right inferior pubic ramus.\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n MR PELVIS ON .\n\n COMPARISON: .\n\n TECHNIQUE: Multiplanar, multisequence MR imaging through the pelvis with\n axial T1, T2 and STIR, coronal T1 and STIR, axial 3D T1 gradient. No contrast\n was given due to decreased GFR 25 as per clinical team.\n\n FINDINGS:\n\n Since the previous examination, the patient has had a Girdlestone's procedure\n with resection of the femoral head and neck. There are post-surgical changes\n with superolateral migration of the remaining femur. There is edema and\n fluid in the surgical cavity with some susceptibility artifact in keeping with\n small pockets of air. There is increased gluteal edema in keeping with\n post-surgical change.\n\n The edema in the iliopsoas muscles is stable; however, the necrotic portion in\n the iliacus muscle is smaller on today's examination. Edema in the adductor\n muscles is stable.\n\n The low T1 high T2 signal lesions in the left greater trochanter, right\n proximal femus and right inferior pubic ramus are unchanged, likley\n representing metastases.\n\n There is a small amount of presacral edema. No other significant change.\n\n IMPRESSION:\n 1. Interval decrease in size of the intramuscular iliacus abscess.\n 2. Post-surgical changes related to Girdlestone's procedure.\n 3. Interval development of a small amount of presacral edema.\n (Over)\n\n 6:46 PM\n MRI PELVIS W/O CONTRAST Clip # \n Reason: L psoas muscle inflammation interval f/u\n Admitting Diagnosis: LEG PAIN FROM LYTIC LESIONS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 4. Multiple bone metastases.\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-06-29 00:00:00.000",
"description": "BILAT LOWER EXT VEINS",
"row_id": 1199579,
"text": " 4:32 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: SWELLING ASSESS FOR DVT\n Admitting Diagnosis: LEG PAIN FROM LYTIC LESIONS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with h/o met melanoma and h/o DVTs s/p hip surgery with fever\n of unclera \n REASON FOR THIS EXAMINATION:\n eval for DVT\n ______________________________________________________________________________\n WET READ: SHSf FRI 11:07 PM\n No DVT in bilateral LE. Left GSV not seen due to artifact likely from hip\n surgery.\n Changes d/w Dr. by Dr. 2305\n\n WET READ VERSION #1\n WET READ VERSION #2 SHSf FRI 5:36 PM\n No DVT in bilateral LE.\n\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Metastatic melanoma with DVTs in prior hip surgery and fever of\n unclear etiology. Assess for DVT.\n\n TECHNIQUE: Noninvasive bilateral lower extremity venous evaluation.\n\n COMPARISONS: Left lower extremity Doppler, .\n\n FINDINGS: Grayscale and color Doppler son of the bilateral lower\n extremities demonstrates normal compressibility and flow in the bilateral\n common femoral, superficial femoral, popliteal, posterior tibial and peroneal\n veins without evidence of DVT. The left greater saphenous vein was not well\n imaged due to artifact, likely from recent hip surgery.\n\n IMPRESSION: No evidence of bilateral lower extremity DVT with\n nonvisualization of the left GSV.\n\n Change to the initial wet read were discussed with Dr. by Dr. \n at 23:05 on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-06-27 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1199214,
"text": " 1:33 PM\n CHEST (PA & LAT) Clip # \n Reason: fever\n Admitting Diagnosis: LEG PAIN FROM LYTIC LESIONS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with fever\n REASON FOR THIS EXAMINATION:\n fever\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Fever.\n\n FINDINGS: In comparison with study of , there is blunting of the left\n costophrenic angle, suggestive of pleural effusion. However, no evidence of\n acute focal pneumonia or vascular congestion.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2136-06-21 00:00:00.000",
"description": "Report",
"row_id": 64266,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Right ventricular function. Chemo\nHeight: (in) 69\nWeight (lb): 165\nBSA (m2): 1.91 m2\nBP (mm Hg): 124/68\nHR (bpm): 113\nStatus: Inpatient\nDate/Time: at 14:00\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: Small LV cavity. Hyperdynamic LVEF >75%.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nMITRAL VALVE: Mitral valve leaflets not well seen. Trivial MR.\n\nTRICUSPID VALVE: Tricuspid valve not well visualized. Physiologic TR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality - body habitus. The patient appears to be in sinus rhythm.\nResting tachycardia (HR>100bpm).\n\nConclusions:\nThe left ventricular cavity is small. Left ventricular systolic function is\nhyperdynamic (EF 80%). Right ventricular chamber size and free wall motion are\nnormal. The mitral valve leaflets are not well seen (mitral valve prolapse is\nprobably present). Trivial mitral regurgitation is seen. There is no\npericardial effusion.\n\nIMPRESSION: Suboptimal image quality. Small, hyperdynamic left ventricle\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-06-21 00:00:00.000",
"description": "LP HIP UNILAT MIN 2 VIEWS LEFT PORT",
"row_id": 1198445,
"text": " 9:53 PM\n HIP UNILAT MIN 2 VIEWS LEFT PORT Clip # \n Reason: L girdlestone arthroplasty\n Admitting Diagnosis: LEG PAIN FROM LYTIC LESIONS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with L girdlestone arthroplasty\n REASON FOR THIS EXAMINATION:\n L girdlestone arthroplasty\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Left hip, .\n\n CLINICAL HISTORY: 72-year-old man with left Girdlestone procedure for septic\n hip.\n\n FINDINGS: Comparison is made to previous study from and MRI from\n .\n\n Since the previous study, there has been removal of the femoral head and neck,\n consistent with a Girdlestone procedure. There is elevation of the proximal\n femur in relation to the left hip joint. There are lateral surgical skin\n staples and soft tissue swelling consistent with the recent surgery.\n\n There is again seen an area of sclerosis in the right proximal femur, which is\n stable. Similar area of sclerosis within the left intertrochanteric region is\n also seen and partly obscured by the postoperative changes.\n\n IMPRESSION\n\n Girdlestone procedure of the left femur for septic arthritis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-06-18 00:00:00.000",
"description": "MR PELVIS W&W/O CONTRAST",
"row_id": 1197989,
"text": " 6:08 PM\n MR PELVIS W&W/O CONTRAST Clip # \n Reason: Unstable mets?\n Admitting Diagnosis: LEG PAIN FROM LYTIC LESIONS\n Contrast: MAGNEVIST Amt: 14\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with metastatic melanoma and prostate CA admitted for left\n hip/leg pain, unable to wght bear.\n REASON FOR THIS EXAMINATION:\n Unstable mets?\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JMNk MON 9:57 PM\n Extensive edema of the left psoas muscle, left obdurator internus. Small\n effusion left hip. Fluid seen in left psoas without enhancing wall but still\n concerning for infection. Multiple bony lesions c/w mets. Left femoral neck\n lesion <50% of bone, cortex intact. Proximal right femur lesion involves\n entire width of bone but cortex intact. Findings discussed with Dr. \n @ 10pm JNiM \n ______________________________________________________________________________\n FINAL REPORT\n MRI PELVIS WITH AND WITHOUT CONTRAST DATED \n\n CLINICAL INDICATION: 72-year-old man with metastatic melanoma and prostate\n cancer, admitted for left hip/thigh pain, unable to bear weight.\n\n COMPARISON: Left thigh MRI from same day and left lower extremity CT dated\n , left hip and femur radiographs dated , and CT torso\n dated . Also compared with CT right lower extremity dated\n . Approximately 14 cc of Magnevist contrast material was\n administered without reported complication.\n\n PROCEDURE: Pre- and post-contrast MRI of the pelvis utilizing standard\n departmental protocol with post-contrast imaging in the axial and coronal\n plane.\n\n FINDINGS:\n\n Multiple osseous lesions are again identified with a T1 hypointense and T2\n hyperintense approximately 1.4 cm lesion at the left inferolateral femoral\n neck, which demonstrates contrast enhancement. No definite associated\n pathologic fracture. This is stable in comparison to prior recent\n examinations. Another small T1 hypointense 1.3 cm right posterior inferior\n pubic ramus lesion is identified demonstrating minimal enhancement. No other\n definite osseous lesions are appreciated on current exam.\n\n Intramuscular edema and thickening is noted in the left iliacus muscle, which\n is asymmetrically expanded in comparison to the right. The left iliacus\n muscle also demonstrates multiple rounded locules of fluid signal intensity\n with the largest measuring approximately 1.3 x 2.3 cm on series 6:9 with\n increased T2-weighted signal intensity anteriorly and decreased signal\n intensity posteriorly. No intrinsic T1 weighted hyper-intensity is noted in\n (Over)\n\n 6:08 PM\n MR PELVIS W&W/O CONTRAST Clip # \n Reason: Unstable mets?\n Admitting Diagnosis: LEG PAIN FROM LYTIC LESIONS\n Contrast: MAGNEVIST Amt: 14\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n this region to suggest subacute blood products. Post-contrast images\n demonstrate lack of enhancement in this same region. This muscle edema in the\n left iliacus muscle also extends to involve the medial inferior aspect of the\n left psoas muscle and extends inferiorly to also involve the left iliopsoas,\n obturator externus, pectineus muscle, adductor musculature, partly the\n quadratus femoris, and gluteus minimus musculature. Post-contrast images also\n demonstrate asymmetric enhancement of this musculature in comparison to the\n right side with areas of non-enhancement within previously described rounded\n locules within the left iliacus muscle posteriorly. The inferior extent of\n the aforementioned process involving the musculature of the left hemipelvis\n and left proximal thigh is incompletely seen and also further evaluated on\n left thigh MRI from same day.\n\n There is a small left hip joint effusion. The medial and posterior left\n acetabulum marrow also demonstrates mild marrow edema with increased fluid\n signal intensity.\n\n No other soft tissue masses or lesions are identified. The sacroiliac joints\n appear within normal limits. No significant free dependent pelvic fluid.\n\n IMPRESSION:\n\n 1. Asymmetric enhancement and edema extending from the medial inferior left\n psoas muscle, majority of left iliacus muscle with extension into the proximal\n left thigh to involve the left iliopsoas, left obturator externus, pectineus,\n adductor muscle group, quadratus femoris and gluteus minimus musculature with\n mild enhancement and edematous changes. In addition, there are small locules\n of rounded fluid in the left iliacus muscle posteriorly, which demonstrate\n non-enhancement centrally with the largest pocket with layering debris\n measuring approximately 1.3 x 2.3 cm. This constellation of findings is\n concerning for an infectious or inflammatory process in the correct clinical\n setting. Inflammatory neoplastic process is also a possible consideration.\n\n 2. Left femoral neck likely osseous metastatic lesion is stable in size in\n comparison to prior comparisons. No pathologic fracture.\n\n 3. Small left hip joint effusion with likely reactive edema in the medial and\n posterior left acetabulum. An infectious etiology is not entirely excluded\n given adjacent edematous marrow and soft tissues.\n\n Important preliminary findings were discussed by the radiology fellow on call\n with Dr. at 10 p.m. on . Please see separate report\n of thigh MRI exam obtained the same day.\n\n (Over)\n\n 6:08 PM\n MR PELVIS W&W/O CONTRAST Clip # \n Reason: Unstable mets?\n Admitting Diagnosis: LEG PAIN FROM LYTIC LESIONS\n Contrast: MAGNEVIST Amt: 14\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-06-18 00:00:00.000",
"description": "L MR THIGH W&W/O CONTRAST LEFT",
"row_id": 1197990,
"text": " 6:08 PM\n MR THIGH W&W/O CONTRAST LEFT Clip # \n Reason: Unstable lytic lesion?\n Admitting Diagnosis: LEG PAIN FROM LYTIC LESIONS\n Contrast: MAGNEVIST Amt: 14\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with metastatic melanoma and prostate CA admitted for left\n hip/leg pain, unable to wght bear.\n REASON FOR THIS EXAMINATION:\n Unstable lytic lesion?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n LEFT THIGH MRI PERFORMED \n\n CLINICAL INDICATION: 72-year-old man with metastatic melanoma and prostate\n cancer, admitted for left hip/leg pain, unable to bear weight. Question of\n unstable lytic lesion.\n\n COMPARISON: MRI pelvis without and with contrast from the same day.\n Additional comparisons made with CT left lower extremity dated ,\n left hip and femur x-rays from and CT torso date .\n\n FINDINGS: Please correlate with MRI pelvis without and with contrast\n dictation from same day for further anatomic details.\n\n Again demonstrated are essentially stable-sized marrow osseous lesions in the\n proximal right femur with decreased T1 weighted signal intensity and increased\n T2 weighted signal intensity in the diaphysis of the proximal right femur\n measuring approximately 1.7 cm. Essentially stable-sized intraosseous lesion\n at the inferior left femoral neck measuring approximately 1.5 cm. No\n pathologic fracture. Mild osseous edema in medial and posterior left\n acetabulum.\n\n The remaining osseous marrow signal is grossly within normal limits.\n\n There is an incompletely seen intramuscular edematous process involving the\n obturator externus, pectineus, adductor muscle group, iliopsoas, gluteus\n minimus and iliacus musculature when correlated with MRI pelvis examination\n from the same day. There is mild enhancement of these regions as well in\n comparison to the right. There is a small left hip joint effusion. This\n process is confined to the proximal medial left thigh and does not extend to\n the mid or distal thigh anterior or posterior compartments. Separate from\n this, the left sartorius and gracilis muscles abut the skin, with loss (?\n remote prior resection, possibly for a left inguinal flap) of the over lying\n subuctaneous fat and the adjoining skin is thckened. There is minimal edema in\n this area -- soe of the high signal seen on the fat saturated T2W images may\n actually be artifact. No other soft tissue abnormalities are appreciated on\n the current examination.\n\n IMPRESSION:\n\n (Over)\n\n 6:08 PM\n MR THIGH W&W/O CONTRAST LEFT Clip # \n Reason: Unstable lytic lesion?\n Admitting Diagnosis: LEG PAIN FROM LYTIC LESIONS\n Contrast: MAGNEVIST Amt: 14\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 1. Extensive edematous and possibly inflammatory process involving the\n proximal left thigh musculature, iliacus and iliopsoas, as detailed above with\n an associated small left hip joint effusion. Constellation of findings are\n concerning for an infectious and/or inflammatory process in the proper\n clinical setting. Inflammatory neoplastic process is an alternative\n consideration. Please correlate with MRI pelvis without and with contrast\n dictation from same day for further details of the proximal extent of this\n process.\n\n 2. Stable-sized possibly metastatic intraosseous lesions involving the\n proximal right femur and left femur. No pathologic fracture.\n\n 3. Probable post-operative changes in left mid-thigh medially.\n\n Important preliminary findings were rendered by the radiology fellow on call\n to Dr. at 10 p.m. on . The final interpretation\n agrees with the preliminary interpretation.\n\n Please see separate report of pelvic mri obtained the same day.\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-06-16 00:00:00.000",
"description": "L CT LOW WXT W/C LEFT",
"row_id": 1197726,
"text": " 4:21 PM\n CT LOW WXT W/C LEFT Clip # \n Reason: METASTATIC MELANOMA, PROGRESSIVE LEFT PROXIMAL LEG PAIN NOW UNABLE TO BEAR WEIGHT WITH LIMITED ROM, LYTIC LESION, EVALUATE FOR PATHOLOGIC FX\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with metastatic melanoma w/ progressive left proximal leg pain,\n now unable to bear weight and w/ limited ROM, recent x-ray showed femur lytic\n lesions\n REASON FOR THIS EXAMINATION:\n please evaluate for pathologic fracture\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ASpf SAT 4:50 PM\n Lytic lesion in the left superior trochanter with surrounding sclerosis. No\n fracture.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old man with metastatic melanoma, progressive left\n proximal leg pain, now unable to bear weight and with limited range of motion.\n\n COMPARISON: Radiographs from .\n\n TECHNIQUE: MDCT images were acquired through the left hip without IV\n contrast. Bone kernel reconstructions and multiplanar reformations were\n obtained and reviewed.\n\n FINDINGS:\n\n Sclerotic foci in the right L5 vertebral body (2:7) measuring 10 mm\n (previously measuring 9 mm), left ilium (2:7) measuring 13 mm (previously\n measuring 14 mm), left greater trochanter mixed lytic and sclerotic (2:57)\n measuring 5 mm (prior measuring 5 mm) and left proximal femur mixed\n lytic/sclerotic (2:67) measuring 13 mm (prior measuring 11 mm) are essentially\n unchanged in size to slightly increased in appearance compared to the prior\n examination. No acute fracture is seen.\n\n The partially imaged abdomen shows diverticulosis of the sigmoid colon without\n diverticulitis. A Foley catheter is within the bladder.\n Atherosclerotic calcifications are seen.\n\n IMPRESSION:\n\n Multiple osseous lesions, as above, consistent with known history of\n metastasis, stable to slightly increased. No acute fracture.\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-06-20 00:00:00.000",
"description": "INJ/ASP MAJOR JT W/FLUORO",
"row_id": 1198234,
"text": " 1:05 PM\n INJ/ASP MAJOR JT W/FLUORO Clip # \n Reason: Left hip tap for cultures, cell counts, cytology. Concern f\n Admitting Diagnosis: LEG PAIN FROM LYTIC LESIONS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with metastatic melanoma admitted for left hip pain and fever.\n REASON FOR THIS EXAMINATION:\n Left hip tap for cultures, cell counts, cytology. Concern for septic\n arthritis.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n LEFT HIP JOINT ASPIRATION ON \n\n CLINICAL HISTORY: Metastatic melanoma with left hip pain and fever. Query\n septic arthritis.\n\n PROCEDURE: Fluoroscopic guided left hip joint aspiration.\n\n TECHNIQUE: The risks, benefits, and alternatives of the procedure were\n explained to the patient and written informed consent was obtained. A\n preprocedural timeout confirmed the patient identity, site and side of the\n procedure to be performed.\n\n An appropriate spot was chosen and marked for left hip joint aspiration. The\n area was prepped and draped in the standard sterile fashion. 1% lidocaine was\n used to anesthetize the skin and subcutaneous soft tissues. Under\n fluoroscopic guidance, an 18-gauge spinal needle was advanced into the left\n hip joint. Approximately 5 mL of cloudy, serosanguineous fluid was aspirated.\n Appropriate position was then confirmed by injection of small amount of\n Optiray-240 contrast material.\n\n The needle was removed, hemostasis was achieved and a sterile dry bandage was\n placed.\n\n The patient tolerated the procedure well and left the department in good\n condition. There were no immediate postprocedural complications.\n\n FINDINGS: Fluoroscopic spot images demonstrate contrast material within the\n left hip joint.\n\n Dr. , the attending radiologist, was present and supervised the entire\n procedure.\n\n IMPRESSION: Successful left hip joint aspiration. The samples were sent to\n the laboratory for culture, gram stain, and cell count/differential analysis\n as requested.\n\n\n (Over)\n\n 1:05 PM\n INJ/ASP MAJOR JT W/FLUORO Clip # \n Reason: Left hip tap for cultures, cell counts, cytology. Concern f\n Admitting Diagnosis: LEG PAIN FROM LYTIC LESIONS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-06-22 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1198450,
"text": " 12:50 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: pls evaluate for acute intracranial process\n Admitting Diagnosis: LEG PAIN FROM LYTIC LESIONS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with metastatic melanoma now unresponsive following orthopedic\n washout.\n REASON FOR THIS EXAMINATION:\n pls evaluate for acute intracranial process\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AJy FRI 2:06 AM\n No intracranial hemorrhage, edema, or mass effect. No evidence of metastatic\n disease. MRI with and without contrast would be more sensitive if there is\n high clinical concern.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Metastatic melanoma, unresponsive following orthopedic washout.\n\n COMPARISON: MRI brain, .\n\n NON-CONTRAST HEAD CT:\n\n There is no intracranial hemorrhage, edema, or mass effect. Scattered white\n matter hypodensities likely represent sequelae of chronic small vessel\n ischemia, as seen on recent MRI. There is no CT evidence of territorial\n infarct. There are no abnormal extra-axial fluid collections. There is no\n shift of midline structures. The basal cisterns are patent. There are no\n lytic or sclerotic osseous lesions to suggest metastases. Paranasal sinuses\n are normally aerated with only minimal mucosal thickening seen in the ethmoid\n air cells. The frontal sinuses are under-pneumatized. The globes, orbits,\n and extracranial soft tissues are unremarkable.\n\n IMPRESSION: No intracranial hemorrhage, edema, or mass effect. No evidence\n of metastatic disease. MRI with and without contrast would be more sensitive\n if there is high clinical concern.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-06-22 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1198451,
"text": ", D. OMED 11R 12:50 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: pls evaluate for acute intracranial process\n Admitting Diagnosis: LEG PAIN FROM LYTIC LESIONS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with metastatic melanoma now unresponsive following orthopedic\n washout.\n REASON FOR THIS EXAMINATION:\n pls evaluate for acute intracranial process\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n No intracranial hemorrhage, edema, or mass effect. No evidence of metastatic\n disease. MRI with and without contrast would be more sensitive if there is\n high clinical concern.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-06-20 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1198201,
"text": " 10:03 AM\n CHEST (PA & LAT) Clip # \n Reason: Infiltrate?\n Admitting Diagnosis: LEG PAIN FROM LYTIC LESIONS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with metastatic melanoma admitted for left hip pain and fever.\n REASON FOR THIS EXAMINATION:\n Infiltrate?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old man with metastatic melanoma, admitted for left hip\n pain and fever, question infiltrate.\n\n COMPARISON: CT of the torso from and chest radiograph from\n .\n\n TWO VIEWS OF THE CHEST:\n\n The lungs are well expanded and clear. The cardiomediastinal silhouette,\n hilar contours and pleural surfaces are normal. No pleural effusion or\n pneumothorax is present. Right upper lobe mass is not visible on the current\n examination. A sclerotic vertebral body is noted in the upper thoracic spine,\n unchanged.\n\n IMPRESSION:\n\n No acute intrathoracic process. Unchanged sclerotic metastasis in the upper\n thoracic spine.\n\n"
},
{
"category": "ECG",
"chartdate": "2136-06-12 00:00:00.000",
"description": "Report",
"row_id": 125848,
"text": "Sinus arrhythmia. Consider prior inferior myocardial infarction as recorded\non . Otherwise, no diagnostic interim change.\n\n"
}
] |
9,973 | 122,229 | BP INSTABILITY: Initial hypotension likely due to overnarcotization in the setting of multiple blood pressure medications. Patient responded well to IV fluids and narcan, and hypotension resolved by . Amlodipine and Lisinopril were held in the setting of hypotension; IV lasix was given. Patient's blood pressures were elevated to 200/100 and pulse to 110 on , and it was felt that autonomic dysfunction from MS could be contributing to blood pressure lability. After consult with neurology, clonidine 0.1mg was started on , and patient's home Lasix (40mg PO qday) was resumed. The patient responded well. Lisinopril was re-started at 15mg. He BP should be maintained between 100-150/60-100 ideally, though any abnormal blood pressure readings should be repeated and he should be assessed clinically. . UTI/NEUROGENIC BLADDER: Patient has had suprapubic catheter since due to neurogenic bladder; has had a history of UTIs since then. Urine culture from most recent UTI () grew out enterobacter and proteus both sensitive to meropenem, which was begun on to treat probable UTI given UA results with WBC >50 and moderate bacteria. Because enterobacter and proteus from infection were also susceptible to ciprofloxacin, IV meropenem was d/c'd on and PO ciprofloxacin started for a total of seven days of antibiotics. He completed his course without incident. His oxybutynin was continued. Urology was consulted for suprapubic catheter replacement. Urology did not feel it absolutely necessary to have the catheter replaced. We could not obtain the right catheter to replace the older one, and was deferred to the outpatient setting. The patient's wife replaces his catheter at home, and will do so upon discharge. . MENTAL STATUS CHANGES: Likely due to overnarcotization, hemodynamic instability, resolving UTI, and pain. Fentanyl patch was restarted on to help with pain control; other narcotics were held. UTI and hemodynamic instability were addressed as described above. His neurontin was also held. His mental status returned to baseline. He was discharged on his fentanyl patch. His neurontin can be re-started at his neurologists/PCP discretion though his pain was well controlled without it at discharge. Oral narcotics should be avoided. . MULTIPLE SCLEROSIS: Baclofen pump was retained; narcotics and gabapentin held in the setting of overnarcotization and hypotension. Fentanyl patch was restarted on and Vicodin 1-2 tabs q4-6 hours as needed for pain. His vicodin was stopped due to mental status changes which resolved. Re-starting his neurontin can be addressed as an outpatient. Evaluated by OT, recommended relief cushion for support, pain relief. . DEPRESSION: Paroxetine was continued. . ANEMIA: Stable throughout admission. His PPI was continued . CODE: FULL for this admission . . To Do: 1. Monitor BP, adjust regimen as needed (i.e. lisinopril, norvasc) 2. Monitor pain, consider re-starting Neurontin, oxazepam 3. Home PT/OT - relief cushion 4. Suprapubic cath care 5. Neurology follow up | pna, chf, hypothermia ( is close to baseline.) Antihypertensives remain on hold. Conts on baclophen intrathecal pump. Pain med prn. Pt no longer hypotensive, and may be trending towardshypertension, on antibiotics.p: monitor pt for pain, follow neuro and resp status, frequent position changes. U/A sent.ID: Afebrile today. Sinus rhythm. FINDINGS: The evaluation is somewhat limited due to patient motion. Tele sinus rhythm. TECHNIQUE: Head CT without contrast: Comparison is made with a prior head CT dated . CT negative. Rule out ICH. LE remain contracted. Slightly more confluent opacity is noted in the retrocardiac region. Intraventricular conduction defect. There is likely a small left pleural effusion. IMPRESSION: Somewhat limited study, without evidence of acute intracranial hemorrhage. The cardiac silhouette is within normal limits accounting for patient and technical factors. K 4.2 this am.Resp: Lungs CTA. The opacity in the left lung base may be confluent edema although a focus for early infection cannot be excluded. Suprapubic catheter draining CYU. Cont antibiotic coverage. Passive ROM. He was given levoquin at , rocephin, vanco and ceftazadime here. IMPRESSION: Diffuse worsening pulmonary edema. Cont to monitor hemodynamics. Compared to the previoustracing of no significant diagnostic change. Minimal movement in upper extremities. Bld cultures pending. FINDINGS: Diffuse pulmonary edema has slightly worsened since the prior examination. Note is made of mucosal thickening in ethmoid sinus. No definite right effusion is seen. COMPARISON: Multiple priors, the most recent dated . fan in room for pt comfort, frequent repositioning, feet are red at heels and pt refused multipodus boots at this time.A: pt here with narcotic OD, ? Repeat radiography following appropriate diuresis is recommended to assess for underlying infection. There is right apical pleural thickening. Abd is soft with bowel sounds present. The mediastinum is unremarkable. s: " my hips hurt"o: please see care view for vitals, admission note, and other data.pt came from ER admitted first to hospital then to forhypotension, lethargy, confusion, hypothermia. Urine culture sent. The osseous structure is unremarkable. Nursing Progress NoteO: Please see flow sheet for objective data. ? remains on hold. Pt is OX2 -3, asking appropriate questions. HISTORY: MS, asymptomatic hypertension, concern for pneumonia. SBP labile throughout the day. Transfer to floor when bed available. No shift of normally midline structure is noted. No definite effusion or pneumothorax is seen. PT baseline temp per family is 95 F, here temp is 96.0-96.4 po and pt co feeling hot. Pt is able to follow commands. O2 sats > 95% on 2l NP.Neuro: Pt is alert and oriented x's 3. asp pna.Pt was initialy given 4L ns at then 2 liters here for hypotension and presumed sepsis, however er nurse patch ( and there is a question if there were two patches on pt) BP came up to normal and after narcan, pt woke up but remained confused. There is no mass effect. wife will be visiting .A&P: 56yo man with progressive MS admitted with hypotension, hypothermia and mental status changes. we are also treating him for CHF on CXR and pt received 20 mg lasix with brisk response.Neuro- currently OX3, moves both hands to commands, pupils equal but non reative, (eye surgery).CV- sr 80-90 bp varies, pt has not been hypotensive here in ccu, BP 126/72--159/80.respiratory- overall diminished, but crackles at bases.GI- positive BS, obese abd.pain: pt co hip pain, vicodin given at 0500, pt may need further pain meds. conts on Vancomycin, ceftazidine dc'd and started on Meropenem 500mg Q 6hrs.Social: Son in to visit. There is no pneumothorax. House staff aware. Pt arrived on 100 percent FM, changed to 2-3 L nc, with good sats. Receiving Vicodan prn with good effect for hip pain.GI/GU: Appetite is good requiring total assistance with meals. 7:28 PM CT HEAD W/O CONTRAST Clip # Reason: ich MEDICAL CONDITION: 56 year old man with somnolence after hypotension REASON FOR THIS EXAMINATION: ich No contraindications for IV contrast WET READ: MNIa WED 8:42 PM Limited study due to morion, no bleed. FINAL REPORT INDICATION: 56-year-old man with hypotension. There is no evidence of intracranial hemorrhage. follow I/o, labs, Md spoke with wife early this AM, keep pt and family updated on POC as discussed in ccu multidiciplanary rounds. | 5 | [
{
"category": "ECG",
"chartdate": "2140-11-02 00:00:00.000",
"description": "Report",
"row_id": 139967,
"text": "Sinus rhythm. Intraventricular conduction defect. Compared to the previous\ntracing of no significant diagnostic change.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2140-11-03 00:00:00.000",
"description": "Report",
"row_id": 1393657,
"text": "Nursing Progress Note\n\nO: Please see flow sheet for objective data. Tele sinus rhythm. SBP labile throughout the day. House staff aware. Antihypertensives remain on hold. K 4.2 this am.\n\nResp: Lungs CTA. O2 sats > 95% on 2l NP.\n\nNeuro: Pt is alert and oriented x's 3. Pt is able to follow commands. LE remain contracted. Minimal movement in upper extremities. Passive ROM. Conts on baclophen intrathecal pump. remains on hold. Receiving Vicodan prn with good effect for hip pain.\n\nGI/GU: Appetite is good requiring total assistance with meals. Abd is soft with bowel sounds present. Suprapubic catheter draining CYU. U/A sent.\n\nID: Afebrile today. conts on Vancomycin, ceftazidine dc'd and started on Meropenem 500mg Q 6hrs.\n\nSocial: Son in to visit. wife will be visiting .\n\nA&P: 56yo man with progressive MS admitted with hypotension, hypothermia and mental status changes. CT negative. Bld cultures pending. Urine culture sent. Cont antibiotic coverage. Cont to monitor hemodynamics. Pain med prn. Transfer to floor when bed available.\n"
},
{
"category": "Nursing/other",
"chartdate": "2140-11-03 00:00:00.000",
"description": "Report",
"row_id": 1393656,
"text": "s: \" my hips hurt\"\n\no: please see care view for vitals, admission note, and other data.\n\npt came from ER admitted first to hospital then to for\nhypotension, lethargy, confusion, hypothermia. ? asp pna.\nPt was initialy given 4L ns at then 2 liters here for hypotension and presumed sepsis, however er nurse patch ( and there is a question if there were two patches on pt) BP came up to normal and after narcan, pt woke up but remained confused. Pt arrived on 100 percent FM, changed to 2-3 L nc, with good sats. Pt is OX2 -3, asking appropriate questions. He was given levoquin at , rocephin, vanco and ceftazadime here. PT baseline temp per family is 95 F, here temp is 96.0-96.4 po and pt co feeling hot. we are also treating him for CHF on CXR and pt received 20 mg lasix with brisk response.\n\nNeuro- currently OX3, moves both hands to commands, pupils equal but non reative, (eye surgery).\n\nCV- sr 80-90 bp varies, pt has not been hypotensive here in ccu, BP 126/72--159/80.\n\nrespiratory- overall diminished, but crackles at bases.\n\nGI- positive BS, obese abd.\n\npain: pt co hip pain, vicodin given at 0500, pt may need further pain meds. fan in room for pt comfort, frequent repositioning, feet are red\n at heels and pt refused multipodus boots at this time.\n\nA: pt here with narcotic OD, ? pna, chf, hypothermia ( is close to baseline.) Pt no longer hypotensive, and may be trending towards\nhypertension, on antibiotics.\n\np: monitor pt for pain, follow neuro and resp status, frequent position changes. follow I/o, labs, Md spoke with wife early this AM, keep pt and family updated on POC as discussed in ccu multidiciplanary rounds.\n"
},
{
"category": "Radiology",
"chartdate": "2140-11-02 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 939845,
"text": " 7:28 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ich\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with somnolence after hypotension\n REASON FOR THIS EXAMINATION:\n ich\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MNIa WED 8:42 PM\n Limited study due to morion, no bleed.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 56-year-old man with hypotension. Rule out ICH.\n\n TECHNIQUE: Head CT without contrast: Comparison is made with a prior head CT\n dated .\n\n FINDINGS: The evaluation is somewhat limited due to patient motion. There is\n no evidence of intracranial hemorrhage. There is no mass effect. No shift of\n normally midline structure is noted. Note is made of mucosal thickening in\n ethmoid sinus. The osseous structure is unremarkable.\n\n IMPRESSION: Somewhat limited study, without evidence of acute intracranial\n hemorrhage.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-11-02 00:00:00.000",
"description": "CHEST (SINGLE VIEW)",
"row_id": 939853,
"text": " 8:18 PM\n CHEST (SINGLE VIEW) Clip # \n Reason: pneumonia\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with MS, asymptomatic hypotension and concern for pneumonia\n REASON FOR THIS EXAMINATION:\n pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, AT HOURS.\n\n HISTORY: MS, asymptomatic hypertension, concern for pneumonia.\n\n COMPARISON: Multiple priors, the most recent dated .\n\n FINDINGS: Diffuse pulmonary edema has slightly worsened since the prior\n examination. Slightly more confluent opacity is noted in the retrocardiac\n region. No definite effusion or pneumothorax is seen. The mediastinum is\n unremarkable. The cardiac silhouette is within normal limits accounting for\n patient and technical factors. There is likely a small left pleural effusion.\n No definite right effusion is seen. There is no pneumothorax. There is right\n apical pleural thickening.\n\n IMPRESSION: Diffuse worsening pulmonary edema. The opacity in the left lung\n base may be confluent edema although a focus for early infection cannot be\n excluded. Repeat radiography following appropriate diuresis is recommended to\n assess for underlying infection.\n\n\n"
}
] |
84,934 | 164,675 | 72 yo M with h/o CAD, new evidence of cirrhosis and worsening thrombocytopenia presents s/p fall and found to be hypotensive likely d/t pneumonia. # Hypotension. Mostly likely dehydration in the setting of fever from pneumonia, recent diarrhea, with likely poorer po intake. He responded to 3L of NS. C. diff was negative. Urine legionella antigen was negative. His lactate improved over course of ICU stay. BP meds were held while in the ICU. His blood pressure improved on the medical and was well controlled. BP medications were restarted on discharge. # Community acquired pneumonia. Based on clinical history and radiological findings. Patient was started on ceftriaxone and azithromycin on . While in the ICU, his O2 requirement remained stable at 2-3L NC. His cough was managed symptomatically with antitussives. He improved, albeit slowly, with ceftriaxone and azithromycin (7 days of therapy) - on discharge he was prescribed cefpodoxime to complete a 10 day course of antibiotics. # GPC in blood culture. sets, growing coag negative staph. Most likely from contamination. Vancomycin was discontinued on after return of this speciation. He did not manifest symptoms of bacteremia (no recurrent fevers) # Throbocytopenia. He has multiple stigmata of portal HTN. It is likely that worsening thrombocytopenia is from the progression of his portal HTN and cirrhosis, although cirrhosis work up was not completed. Other possible etiology include destruction, bone marrow suppression from alcohol use. His platelets have been slowly declining over the last 10 years. However, it remained stable since admission with stable Hct. Cardiology was curbsided with recommendation to continue with ASA 81 mg given his CAD with h/o DES. ASA 81 mg was restarted on . Follow up with the liver center arranged (see below). There was no overt bleeding during the hospitalization. # Ascites. Found on CT of the abd/pelvis. Most consistent with cirrhosis and portal HTN. SBP unlikely given absence of tenderness on exam. Given the small amount, no paracentesis was performed while in the ICU; u/s repeated on the , but only small amt of periportal ascites seen again, so paracentesis not pursued. | Underlying atelectasis or pleural effusion not excluded. Minimal mucosal thickening is seen in the right sphenoid sinus. Unchanged loss of height of the L4 and L5 vertebral bodies. Loss of height of the L4 and L5 vertebral bodies is unchanged. There is near-complete opacification of the left maxillary sinus, not significantly changed compared to the prior exam from . Extensive paranasal sinus dx and opacification of multiple left mastoid air cells, not significantly changed compared to the prior study from . Bilateral carotid calcifications are noted. Small amount of perihepatic ascites. Small amount of perihepatic ascites. There is new small volume perihepatic and perisplenic ascites as well as a small quantity of fluid tracking in the right paracolic gutter. Extensive paranasal sinus disease, not significantly changed compared to the prior exam from . Compared to the previous tracingof ventricular premature beats are not seen. Opacification of scattered left mastoid air cells has not significantly changed compared to head CT from . Opacification of multiple left mastoid air cells, not significantly changed. No definite focal hepatic lesions. No definite focal hepatic lesions. PELVIS CT: A moderate amount of free fluid is seen within the pelvis. FINDINGS: Single AP upright portable view of the chest was obtained. Small amount of perihepatic ascites is seen. There is minimal mucosal thickening in the frontal sinuses. There is no definite focal hepatic lesion. Opacification of multiple anterior left ethmoidal air cells is noted. Grade 1 anterolisthesis of L5 on S1 is unchanged. Opacification of multiple left mastoid air cells has not significantly changed compared to . Occasional atrial premature beats. (Over) 4:53 PM CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST Clip # Reason: eval for intra-abdominal or intrathoracic process Contrast: OPTIRAY Amt: 130 FINAL REPORT (Cont) BONE WINDOW: There is loss of height of the L4 and L5 vertebral bodies, not significantly changed compared to CT from . Opacification of multiple left mastoid air cells is not significantly changed compared to the prior exam. The gallbladder is normally distended. Calcifications of the bilateral cavernous carotid arteries are noted. The heart is unremarkable aside from coronary artery calcifications. Pleural calcification at the right apex is noted. The airways are patent to the subsegmental levels bilaterally. The main, right and left portal veins are noted with normal antegrade flow. At C3-4, there is no significant spinal canal narrowing. Aside from minimal bilateral dependent atelectasis, the visualized portions of the lungs are normal. The appendix is unremarkable. Compared to the previoustracing of right bundle-branch block persists. COMPARISON: CT head from . Mildly nodular liver, new ascites, and a splenorenal porto-systemic venous shunt are consistent with cirrhosis and portal hypertension. There are no pathologically enlarged lymph nodes. At C7-T1, there is no significant spinal canal or neural foraminal narrowing. Mild splenomegaly. dysphagia FINAL REPORT INDICATION: Dysphagia. There is mild dependent atelectasis. There is mild gallbladder wall thickening, compatible with cirrhosis. At C6-7, there is no significant spinal canal or neural foraminal narrowing. The gallbladder is distended, although there is no evidence of gallbladder wall thickening or cholelithiasis. Patent portal and hepatic veins. Patent portal and hepatic veins. No acute intracranial process. Left base opacity and obscuration of the left hemidiaphragm are seen, which may be due to left base consolidation and/or combination of pleural effusion and atelectasis. The main, right, and left hepatic veins are patent with wall-to-wall flow. At C2-3, there is no significant spinal canal or neural foraminal narrowing. There is no significant neural foraminal narrowing at this level. At C5-6, there is no significant narrowing of the spinal canal. Mild disc space narrowing is seen at C5-6. COMPARISON: CT chest from . Multiple small bilateral cervical lymph nodes do not meet CT size criteria. The stomach, small bowel, and colon are unremarkable. The imaged osseous structures are unremarkable. Sinus rhythm. Sinus rhythm. The spleen is normal in size. The cardiac silhouette is not optimally evaluated due the left base opacity, although grossly stable. Aerosolized secretions are seen in the left posterior ethmoidal air cells and left sphenoid sinus. TECHNIQUE: Sequential axial images were acquired through the head without administration of intravenous contrast. Atrial ectopy is new. There are no pathologically enlarged lymph nodes in the mediastinum, hila, or axillae. There are no pathologically enlarged lymph nodes in the abdomen. An 8-mm right paratracheal lymph node does not meet CT size criteria. The right mastoid air cells are well aerated. Periventricular and subcortical white matter hypodensities are consistent with chronic small vessel ischemic disease. CT abdomen and pelvis from , . No evidence of intrahepatic thrombosis. No evidence of intrahepatic thrombosis. FINDINGS: Barium passes freely through the oropharynx and esophagus without evidence of obstruction. The other findings aresimilar. There is no prevertebral edema or hematoma. The lungs are otherwise clear. The right lung is clear. The bladder is unremarkable. Splenomegaly. ABDOMEN CT: The liver contour is slightly nodular and there is slight hypertrophy of the caudate lobe, findings suggestive of cirrhosis. The thyroid gland is unremarkable. The thyroid gland is unremarkable. There was no gross aspiration or penetration. The pancreas, adrenal glands, and kidneys are normal. Aerosolized secretions in the sphenoid sinuses. There is no intrahepatic or extrahepatic biliary ductal dilatation. Evaluate for intra-abdominal or intrathoracic process. Multiple consistencies of barium were administered. There is no evidence of pulmonary embolism to the subsegmental levels bilaterally. | 8 | [
{
"category": "Radiology",
"chartdate": "2146-05-17 00:00:00.000",
"description": "VIDEO OROPHARYNGEAL SWALLOW",
"row_id": 1193864,
"text": " 1:06 PM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: 72 year old man with ? dysphagia\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with ? dysphagia\n REASON FOR THIS EXAMINATION:\n 72 year old man with ? dysphagia\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Dysphagia.\n\n COMPARISON: None.\n\n TECHNIQUE: Oropharyngeal swallowing video fluoroscopy was performed in\n conjunction with the speech and swallow division. Multiple consistencies of\n barium were administered.\n\n FINDINGS: Barium passes freely through the oropharynx and esophagus without\n evidence of obstruction. There was no gross aspiration or penetration. For\n details, please refer to speech and swallow division note in OMR.\n\n IMPRESSION: Normal oropharyngeal swallowing video fluoroscopy.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-05-16 00:00:00.000",
"description": "DUPLEX DOP ABD/PEL LIMITED",
"row_id": 1193611,
"text": " 9:01 AM\n DUPLEX DOP ABD/PEL LIMITED; US ABD LIMIT, SINGLE ORGAN Clip # \n -59 DISTINCT PROCEDURAL SERVICE\n Reason: evaluate for hepatic or portal vein thrombosis with doppler\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with ascites, possible cirrhosis\n REASON FOR THIS EXAMINATION:\n evaluate for hepatic or portal vein thrombosis with doppler\n ______________________________________________________________________________\n WET READ: ENYa MON 11:50 AM\n 1. Patent portal and hepatic veins. No evidence of intrahepatic thrombosis.\n 2. Macronodular liver with heterogeneous echotexture compatible with\n cirrhosis. No definite focal hepatic lesions.\n 3. Splenomegaly. Small amount of perihepatic ascites.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 72-year-old man, with known ascites and possible cirrhosis. Assess\n for hepatic or portal vein thrombosis with Doppler.\n\n COMPARISON: Multiple prior CT abdomen studies with the latest on .\n\n RIGHT UPPER QUADRANT ULTRASOUND WITH LIVER DOPPLER: The macronodular liver is\n echogenic in echotexture, highly suggestive of cirrhosis. There is no\n definite focal hepatic lesion. There is no intrahepatic or extrahepatic\n biliary ductal dilatation. The normal CBD measures 4 mm in diameter. The\n gallbladder is normally distended. There is mild gallbladder wall thickening,\n compatible with cirrhosis. Small amount of perihepatic ascites is seen.\n\n The main, right, and left hepatic veins are patent with wall-to-wall flow.\n The main, right and left portal veins are noted with normal antegrade flow.\n The spleen measures 13.5 cm.\n\n IMPRESSION:\n 1. Patent portal and hepatic veins. No evidence of intrahepatic thrombosis.\n 2. Macronodular liver with heterogeneous echotexture highly suggestive of\n cirrhosis. No definite focal hepatic lesions.\n 3. Mild splenomegaly. Small amount of perihepatic ascites.\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-05-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1193253,
"text": " 3:31 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pneumonia\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with cough, fever and hypotension to 70s.\n REASON FOR THIS EXAMINATION:\n eval for pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: Chest, single AP upright portable view.\n\n CLINICAL INFORMATION: 72-year-old male with history of cough, fever, and\n hypotension.\n\n COMPARISON: .\n\n FINDINGS: Single AP upright portable view of the chest was obtained. Left\n base opacity and obscuration of the left hemidiaphragm are seen, which may be\n due to left base consolidation and/or combination of pleural effusion and\n atelectasis. Dedicated PA and lateral views of the chest would be helpful.\n The right lung is clear. No evidence of pneumothorax is seen. The cardiac\n silhouette is not optimally evaluated due the left base opacity, although\n grossly stable. The mediastinal contours are stable.\n\n IMPRESSION: Left base opacity worrisome for consolidation; given history\n possibly pneumonia. Underlying atelectasis or pleural effusion not excluded.\n Recommend dedicated PA and lateral views for better evaluation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-05-13 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1193268,
"text": " 4:52 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for ICH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with fall yesterday and reported thrombocytopenia\n REASON FOR THIS EXAMINATION:\n eval for ICH\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: FRI 6:13 PM\n No acute intracranial process. Extensive paranasal sinus dx and opacification\n of multiple left mastoid air cells, not significantly changed compared to the\n prior study from .\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post fall yesterday with reported thrombocytopenia.\n Evaluate for intracranial hemorrhage.\n\n COMPARISON: CT head from . MR head from .\n\n TECHNIQUE: Sequential axial images were acquired through the head without\n administration of intravenous contrast. Multiplanar reformations were\n performed.\n\n FINDINGS: There is no evidence of intracranial hemorrhage, edema, shift of\n normally midline structures, hydrocephalus, or acute large vascular\n territorial infarction. Periventricular and subcortical white matter\n hypodensities are consistent with chronic small vessel ischemic disease.\n Prominence of the ventricles and sulci are consistent with age-related\n involutional change. There is near-complete opacification of the left\n maxillary sinus, not significantly changed compared to the prior exam from\n . Opacification of multiple anterior left ethmoidal air cells\n is noted. There is also scattered mucosal thickening and opacification of the\n right ethmoidal air cells. Aerosolized secretions are seen in the left\n posterior ethmoidal air cells and left sphenoid sinus. Minimal mucosal\n thickening is seen in the right sphenoid sinus. There is minimal mucosal\n thickening in the frontal sinuses. Opacification of multiple left mastoid air\n cells is not significantly changed compared to the prior exam. The right\n mastoid air cells are well aerated. Calcifications of the bilateral cavernous\n carotid arteries are noted. There has been prior bilateral lens surgery. The\n imaged osseous structures are unremarkable.\n\n IMPRESSION:\n\n 1. No acute intracranial process.\n\n 2. Extensive paranasal sinus disease, not significantly changed compared to\n the prior exam from .\n\n 3. Opacification of multiple left mastoid air cells, not significantly\n changed.\n (Over)\n\n 4:52 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for ICH\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-05-13 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 1193269,
"text": " 4:53 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: eval for fracture or dislocation\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with fall yesterday and unknown LOC\n REASON FOR THIS EXAMINATION:\n eval for fracture or dislocation\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: FRI 7:23 PM\n No evidence of acute fracture or malalignment. Mild multilevel degenerative\n changes including a posterior disc bulge at C4-5 that causes mild narrowing of\n the spinal canal.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post fall yesterday with unknown loss of consciousness.\n Evaluate for fracture or dislocation.\n\n TECHNIQUE: MDCT axial images were acquired through the cervical spine without\n administration of intravenous contrast. Multiplanar reformations were\n performed.\n\n COMPARISON: None.\n\n FINDINGS: There is no evidence of fracture or malalignment. There is no\n prevertebral edema or hematoma. Mild disc space narrowing is seen at C5-6.\n\n At C2-3, there is no significant spinal canal or neural foraminal narrowing.\n\n At C3-4, there is no significant spinal canal narrowing. Facet joint\n hypertrophy causes mild neural foraminal narrowing on the right.\n\n At C4-5, a posterior disc bulge causes mild narrowing of the spinal canal.\n Facet joint hypertrophy causes mild narrowing of the left neural foramen at\n this level.\n\n At C5-6, there is no significant narrowing of the spinal canal. There is no\n significant neural foraminal narrowing at this level.\n\n At C6-7, there is no significant spinal canal or neural foraminal narrowing.\n\n At C7-T1, there is no significant spinal canal or neural foraminal narrowing.\n\n The thyroid gland is unremarkable. Multiple small bilateral cervical lymph\n nodes do not meet CT size criteria. Aside from minimal bilateral dependent\n atelectasis, the visualized portions of the lungs are normal. Pleural\n calcification at the right apex is noted. Bilateral carotid calcifications\n are noted. Aerosolized secretions are seen within the sphenoid sinuses.\n Opacification of scattered left mastoid air cells has not significantly\n changed compared to head CT from . This study was not\n optimized for evaluation of the intracranial structures. Please see the\n accompanying head CT from , for details regarding the\n (Over)\n\n 4:53 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: eval for fracture or dislocation\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n intracranial contents.\n\n IMPRESSION:\n\n 1. No evidence of fracture or malalignment.\n\n 2. Mild multilevel degenerative changes of the cervical spine including a\n posterior disc bulge at C4-5 that causes mild narrowing of the spinal canal.\n\n 3. Aerosolized secretions in the sphenoid sinuses.\n\n 4. Opacification of multiple left mastoid air cells has not significantly\n changed compared to .\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-05-13 00:00:00.000",
"description": "CT CHEST W/CONTRAST",
"row_id": 1193270,
"text": " 4:53 PM\n CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: eval for intra-abdominal or intrathoracic process\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with fall yesterday, fevers and hypotension today and ?free\n fluid on FAST\n REASON FOR THIS EXAMINATION:\n eval for intra-abdominal or intrathoracic process\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: FRI 7:46 PM\n Left lower lobe and lingular pneumonia. Evidence of cirrhosis and portal\n hypertension with a nodular liver, ascites, and a spleno-renal shunt. Loss of\n height of the L4 and L5 vertebral bodies is unchanged.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fall yesterday with fevers and hypotension today and free fluid\n on past exam. Evaluate for intra-abdominal or intrathoracic process.\n\n TECHNIQUE: MDCT axial images were acquired from the thoracic inlet through\n the ischial tuberosities during infusion of 130 cc of intravenous Optiray\n contrast material. Multiplanar reformations were performed.\n\n COMPARISON: CT chest from . CT abdomen and pelvis from , .\n\n CHEST CT: Consolidation in the left lower lobe with additional left lower\n lobe and lingular ground-glass opacities are consistent with pneumonia. There\n is mild dependent atelectasis. The lungs are otherwise clear. The airways\n are patent to the subsegmental levels bilaterally. There is no evidence of\n pulmonary embolism to the subsegmental levels bilaterally. The heart is\n unremarkable aside from coronary artery calcifications. An 8-mm right\n paratracheal lymph node does not meet CT size criteria. There are no\n pathologically enlarged lymph nodes in the mediastinum, hila, or axillae. The\n thyroid gland is unremarkable.\n\n ABDOMEN CT: The liver contour is slightly nodular and there is slight\n hypertrophy of the caudate lobe, findings suggestive of cirrhosis. The spleen\n is normal in size. There is new small volume perihepatic and perisplenic\n ascites as well as a small quantity of fluid tracking in the right paracolic\n gutter. Large perisplenic varices are noted, emptying into the left renal\n vein.\n\n The gallbladder is distended, although there is no evidence of gallbladder\n wall thickening or cholelithiasis. The pancreas, adrenal glands, and kidneys\n are normal. The stomach, small bowel, and colon are unremarkable. The\n appendix is unremarkable. There are no pathologically enlarged lymph nodes in\n the abdomen.\n\n PELVIS CT: A moderate amount of free fluid is seen within the pelvis. The\n bladder is unremarkable. There are no pathologically enlarged lymph nodes.\n (Over)\n\n 4:53 PM\n CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: eval for intra-abdominal or intrathoracic process\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n BONE WINDOW: There is loss of height of the L4 and L5 vertebral bodies, not\n significantly changed compared to CT from . Grade 1\n anterolisthesis of L5 on S1 is unchanged. Additional multilevel degenerative\n changes of the spine are noted including multilevel anterior bridging\n osteophytes.\n\n IMPRESSION:\n\n 1. Left lower lobe and lingular pneumonia.\n\n 2. Mildly nodular liver, new ascites, and a splenorenal porto-systemic venous\n shunt are consistent with cirrhosis and portal hypertension.\n\n 3. Unchanged loss of height of the L4 and L5 vertebral bodies.\n\n"
},
{
"category": "ECG",
"chartdate": "2146-05-18 00:00:00.000",
"description": "Report",
"row_id": 119366,
"text": "Sinus rhythm. Occasional atrial premature beats. Compared to the previous\ntracing of right bundle-branch block persists. Atrial ectopy is new.\n\n"
},
{
"category": "ECG",
"chartdate": "2146-05-13 00:00:00.000",
"description": "Report",
"row_id": 119367,
"text": "Sinus rhythm. Right bundle-branch block. Compared to the previous tracing\nof ventricular premature beats are not seen. The other findings are\nsimilar.\n\n"
}
] |
97,598 | 148,929 | # Anterior wall cellulitis/Mediastinitis: Patient has anterior chest cellulitis with e/o mediastinal involvement and edema of neck strap muscles and underwent debridement and removal of clavicle, manubrium, and pectoralis muscle on . Blood cultured remained negative at , but grew MSSA at OSH. Patient was initially managed on Nafcillin, Cefepime and Clindamycin, but narrowed to Nafcillin and Clindamycin prior to transfer from the MICU to the surgical floor. Patient was extubated on and tolerated well. Intraoperative cultures from abscess cavities and bone returned positive for MSSA, suggestive of osteomyelitis. The wound was inspected daily and dressing changes continued. Patient was taken to the OR on with the plastic surgery service. A right latissimus flap reconstruction of right chest wound and right chest local advancement flap closure was performed. Patient tolerated the operation well. The flap was monitored closely and remained viable. At the most medial tip of the flap there a small, dark area of ischemia that did not change over time. The right posterior latissimus area remained flat and intact and all drains remained productive with serous output. . # Septic knee/SC joint: Pt had complained of R knee pain after steroid injection and had MSSA from joint fluid as well as ? purulence from R sternocalvicular joint per D/C summary. Underwent joint washout on . Followed along by orthopedics. Physical therapy continued to work with patient for range of motion and ambulation. . # Hypercarbic Respiratory Failure: Patient with episode of hypercarbia day prior to transfer am in setting of somnolence, likely from receiving ativan for ETOH withdrawal and narcotics for pain. also have undiagnosed sleep apnea given wife??????s reports of gasping arousals and snoring. Also concern that neck muscle edema resulting in airway obstruction although was never reportedly stridorous. Repeat ABG without hypercarbia. Extubated on after no procedures were felt necessary. . #. MSSA bacteremia: Patient with MSSA bacteremia and MSSA R knee tap consistent with septic arthritis. Also with area of cellulitis anterior chest so it was unclear which came first and if separate processes. Possible etiology is introduction of bacteria into joint space when had steroid injection resulting in MSSA bacteremia. TEE negative for endocarditis. Patient was initially managed with nafcillin and clindamycin for toxin inhibition. His clindamycin was discontinued after 5 days, and he was then maintained on nafcillin. He then continued to have high fevers, and possibly a rash, and, given concern that nafcillin was the cause of his persistent fevers, his nafcillin was discontinued. His rash-- present only on his flanks-- resolved quite quickly (in less than 12 hours) but his fevers continued despite a normal leukocyte count. He was febrile for days, and ultimately, after an extensive work-up, his fevers were felt maybe to be secondary to his famotidine. However, patient was treated with Vancomycin IV for the remainder of his stay which he tolerated well. The ID service will follow him as an outpatient for a total of 6 weeks of IV antibiotic therapy. A PICC line was inserted to left upper extremity for this purpose. . # DKA: Pt initially presented to OSH with DKA now with blood sugars 100s-200s. Sugars well controlled on NPH. consulted for recommendations. He has maintained normoglycemic on current regimen of lantus and insulin sliding scale. . #. ETOH abuse: MVI, thiamine, folic acid. No signs of withdrawal and no therapy indicated. . # Thrush: Treated with fluconazole 100 mg IV x1. HIV test negative at OSH. | There are simple atheroma in the aortic arch and descendingthoracic aorta. Mildly heterogeneous enhancement, especially within the right strap muscles can represent edema versus early muscular necrosis. Mildly heterogeneous enhancement, especially within the right strap muscles can represent edema versus early muscular necrosis. FINDINGS: Grayscale and color Doppler son of the right common femoral, superficial femoral, and popliteal veins were obtained. Trace aortic regurgitation is seen. Mildly heterogeneous enhancement, especially within the right strap muscles can represent edema versus early myonecrosis. The medial portion of the right clavicle has been resected and a sharp vertical interface along the upper right mediastinum is noted. 2)Bibasilar atelectasis with a small right pleural effusion. NEW BILAT PLEURAL EFFUSION AND ATX AND ASPIRATION-PNA R>L. NEW BILAT PLEURAL EFFUSION AND ATX AND ASPIRATION-PNA R>L. The lesion lies anterior to the plane of the left brachiocephalic vein, which is probably intact, though not opacified because of contralateral contrast infusion. Mild (1+)mitral regurgitation is seen. An endotracheal tube with the tip approximately 1.1 cm above the carina (better seen on chest CT from same date) is noted, and repositioning is recommended. Right pleural effusion and medial right lower lobe atelectasis are better seen in prior CT from . However, there is a superficial vein in the right mid forarm, where line is placed with segmental thrombosis at the site where line goes in. Trace left pleural effusion. Additionally, there is a somewhat linear, horizontally oriented region of increased uptake in the right chest anteriorly, just inferior to the expected location of the clavicle. Subcutaneous emphysema in the right upper chest is unchanged. Mild linear atelectasis in the right upper lobe just below the area of resection contains surgical clips probably due to clipping of the internal thoracic vessels. Simple atheroma in descending aorta.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). IMPRESSION: AP chest compared to : Drains overlie the right upper and lower chest, probably external. Minimal aortic arch calcifications are present. FINDINGS: As compared to the previous radiograph, a new PICC line has been placed over the left upper extremity. Fluid within the nasopharynx and oropharynx is likely secondary to recent intubation. Mild atelectasis is present in the right lung base. TECHNIQUE: Venous ultrasound of the right upper extremity. Septic right sternoclavicular joint. FINDINGS: A large defect is present in the right anterior chest wall, involving partial resection of the clavicle and the right hemimanubrium. Novegetation/mass on pulmonic valve.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: A TEE was performed in the location listed above. STUDY: PA, lateral and oblique chest radiographs. FINDINGS: Interval improvement in degree of atelectasis in the right mid and both lower lungs with minimal residual linear foci of atelectasis remaining. Post-surgical changes from prior right anterior chest wall resection are stable. Post-surgical changes from prior right anterior chest wall resection are stable. Post-surgical changes from prior right anterior chest wall resection are stable. The (Over) 9:43 AM CT CHEST W/CONTRAST Clip # Reason: eval for source of infection around large open right chest w Admitting Diagnosis: SEPSIS;MEDIASTINITIS Contrast: OPTIRAY Amt: 75 FINAL REPORT (Cont) previously seen trace right pleural effusion has largely resolved. Deviation of the trachea to the left is likely from mass effect of markedly edematous right neck musculature. There has been debridement of the anterior chest wall muscles and soft tissue with now exposure of the mediastinal structures and vasculature to the exterior. The right sternoclavicular joint has been resected in addition to the medial half of the right clavicle with partial resection of the manubrium sterni and the anterior chest wall muscle and soft tissues have been partially debrided. A small right pleural effusion is dependent and nonhemorrhagic with overlying compressive atelectasis, and linear atelectasis is also mild in the right lower lobe. FINDINGS: In comparison with study of , there is either subcutaneous gas or gas trapped under a bandage overlying the right shoulder and upper chest. Mild short-term increase in abnormal soft tissue-attenuation collection extending into the inferior neck and surrounding the thyroid gland. The trachea is displaced to the left, likely secondary to mass effect from soft tissue infiltration of the right sternocleidomastoid and strap muscles. Unchanged right basal atelectasis, unchanged status post right clavicular and first rib resection. The patient has had resection of the proximal right clavicle. Fluid within the trachea is noted. PATIENT/TEST INFORMATION:Indication: Endocarditis.Height: (in) 71Weight (lb): 200BSA (m2): 2.11 m2BP (mm Hg): 120/76HR (bpm): 80Status: InpatientDate/Time: at 16:35Test: Portable TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA and RA cavity sizes.RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.LEFT VENTRICLE: Overall normal LVEF (>55%).RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Simple atheroma in aortic arch. The aortic valve leaflets (3) are mildly thickened but aorticstenosis is not present. The lungs are hyperinflated and the diaphragms are flattened, consistent with COPD. Marked asymmetric enlargement of the right-sided pectoralis, sternocleidomastoid and strap muscles with effacement of fat planes and surrounding fat stranding and mildly heterogeneous enhancement is concerning for infection with pyomyositis. | 19 | [
{
"category": "Radiology",
"chartdate": "2115-05-21 00:00:00.000",
"description": "CHEST (PA, LAT & OBLIQUES)",
"row_id": 1142047,
"text": ", T. PSURG CC6A 12:01 PM\n CHEST (PA, LAT & OBLIQUES) Clip # \n Reason: Please confirm PICC line placement. thanks!\n Admitting Diagnosis: SEPSIS;MEDIASTINITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with Left arm PICC line pulled back 5 cm.\n REASON FOR THIS EXAMINATION:\n Please confirm PICC line placement. thanks!\n ______________________________________________________________________________\n PFI REPORT\n PFI: Left PICC tip at the cavoatrial junction.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-05-06 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1139420,
"text": " 10:07 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Pt had a left sided picc line placed,57cm and needs tip conf\n Admitting Diagnosis: SEPSIS;MEDIASTINITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with PICC who needs it for IV anibiotics.\n REASON FOR THIS EXAMINATION:\n Pt had a left sided picc line placed,57cm and needs tip confirmation please\n page at with wet read,thanks.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: PICC placement.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, a new PICC line has been\n placed over the left upper extremity. The course of the line is unremarkable.\n The tip of the line projects over the right atrium. The line should be pulled\n back by approximately 4-5 cm.\n\n There is no evidence of complications, notably no pneumothorax.\n\n Unchanged right basal atelectasis, unchanged status post right clavicular and\n first rib resection.\n\n The IV nurse as requested.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-05-10 00:00:00.000",
"description": "IN-111 WHITE BLOOD CELL STUDY",
"row_id": 1139976,
"text": "IN-111 WHITE BLOOD CELL STUDY Clip # \n Reason: OSTEO MULTIPLE SITES OF MRSA S/P R SHOULDER RESECTION R KNEE WASHOUT W/PERSISTENT FEVERS EVAL FOR INFECTED POCKET\n ______________________________________________________________________________\n FINAL REPORT\n\n RADIOPHARMACEUTICAL DATA:\n 327.0 uCi In-111 WBCs ();\n HISTORY: 54 year old male with multifocal MRSA infection, status post right\n knee washout and right sternoclavicular resection.\n\n INTERPRETATION: Following the injection of autologous white blood cells labeled\n with In-111, images of the whole body were obtained at 24 hours.\n\n These images show marked increased tracer activity about the right knee.\n Additionally, there is a somewhat linear, horizontally oriented region of\n increased uptake in the right chest anteriorly, just inferior to the expected\n location of the clavicle.\n\n The above findings are consistent with infectious process involving the right\n knee and right anterior chest wall.\n\n IMPRESSION: Positive In-111 WBC scan demonstrating increased uptake in the\n right knee and right anterior chest wall compatible with infection in these\n locations.\n\n Discussed with .\n\n\n , M.D.\n , M.D. Approved: MON 3:55 PM\n\n\n\n\n RADLINE ; A radiology consult service.\n To hear preliminary results, prior to transcription, call the\n Radiology Listen Line .\n"
},
{
"category": "Radiology",
"chartdate": "2115-05-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1138985,
"text": " 5:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: SEPSIS;MEDIASTINITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with MSSA bacteremia s/p thoracotomy for infected sternum and\n pec muscle\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 5:12 \n\n HISTORY: Bacteremia after thoracotomy for infected sternum and musculature,\n evaluate interval change.\n\n IMPRESSION: AP chest compared to and 10:\n\n There is no pneumothorax or pleural effusion. Residual atelectasis at the\n lung bases, left greater than right is relatively mild. Upper lungs clear.\n Heart size normal. The patient has had resection of the proximal right\n clavicle.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-05-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1140742,
"text": " 4:56 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Upright Chest xray\n Admitting Diagnosis: SEPSIS;MEDIASTINITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man s/p chest wall recon with lat flap\n REASON FOR THIS EXAMINATION:\n Upright Chest xray\n ______________________________________________________________________________\n WET READ: JXKc MON 7:38 PM\n Left basilar subsegmental atelectasis without focal consolidation. No\n evidence of pneumothorax. Several catheters overlie the right hemi-thorax,\n likely external.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 5:12 \n\n HISTORY: Chest wall reconstruction.\n\n IMPRESSION:\n AP chest compared to :\n\n Drains overlie the right upper and lower chest, probably external. Lungs are\n clear and there is no definite pleural abnormality. Normal cardiomediastinal\n silhouette.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-05-07 00:00:00.000",
"description": "CT CHEST W/CONTRAST",
"row_id": 1139642,
"text": " 12:04 PM\n CT CHEST W/CONTRAST Clip # \n Reason: evaluation for fluid collection, infect\n Admitting Diagnosis: SEPSIS;MEDIASTINITIS\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with s/p Resection of medial half of right\n clavicle,sternoclavicular joint and partial resection of manubrium.Debridement\n of subcutaneous tissue and chest wall muscle. w/persistent fevers\n REASON FOR THIS EXAMINATION:\n evaluation for fluid collection, infect\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: CT chest with contrast.\n\n REASON FOR EXAM: Evaluate for fluid collection post-resection of anterior\n chest wall.\n\n TECHNIQUE: MDCT chest was performed with IV contrast. 5-mm and 1.25-mm axial\n slices were acquired with coronal and sagittal reformats.\n\n FINDINGS:\n\n There is a large defect in the anterior chest wall which is filled with\n surgical packing material. The right sternoclavicular joint has been resected\n in addition to the medial half of the right clavicle with partial resection of\n the manubrium sterni and the anterior chest wall muscle and soft tissues have\n been partially debrided. Small pockets of air are in the lower anterior chest\n wall (3.17) and in the left intercostal space (3.18). No fluid collection or\n pneumothorax. Mild linear atelectasis in the right upper lobe just below the\n area of resection contains surgical clips probably due to clipping of the\n internal thoracic vessels. The lungs are clear without consolidation. A small\n right pleural effusion is dependent and nonhemorrhagic with overlying\n compressive atelectasis, and linear atelectasis is also mild in the right\n lower lobe. The left lung is grossly normal aside from a minor area of\n dependent atelectasis in the left lung base.\n\n No pathologically enlarged mediastinal or axillary lymph nodes by CT size\n criteria. The aorta, pulmonary artery, and heart size are normal. No\n pericardial effusion. Central airways are widely patent. A small calcified\n plaque is at the origin of the left anterior descending artery.\n\n Although this examination was not designed for subdiaphragmatic evaluation,\n assessment of the upper abdominal organs is unremarkable with clips in the\n gallbladder fossa from prior cholecystectomy and an area of hypodensity\n surrounding the falciform ligament which could be due to focal fatty sparing,\n unchanged.\n\n Aside from the surgical resection, the bones are unremarkable with no evidence\n of osteomyelitis.\n\n (Over)\n\n 12:04 PM\n CT CHEST W/CONTRAST Clip # \n Reason: evaluation for fluid collection, infect\n Admitting Diagnosis: SEPSIS;MEDIASTINITIS\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION:\n\n 1)Post-surgical changes in right anterior chest wall following surgical\n debridement of the soft tissues, sternoclavicular joint, and partial resection\n of the manubrium with no postoperative fluid collection.\n\n 2)Bibasilar atelectasis with a small right pleural effusion. No lung\n consolidation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-05-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1138822,
"text": " 5:12 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: SEPSIS;MEDIASTINITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with DM, and mssa bacteremia s/p thoracotomy, and also\n intubated\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Bacteremia and intubated patient.\n\n Comparison is made with prior study performed a day earlier.\n\n ET tube is in standard position. NG tube tip is in the stomach. Cardiac size\n is normal. Left lower lobe atelectasis is unchanged. Right pleural effusion\n and medial right lower lobe atelectasis are better seen in prior CT from . Subcutaneous emphysema in the right upper chest is unchanged. Evaluation\n of the presence of pneumothorax is limited.\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-05-21 00:00:00.000",
"description": "CHEST (PA, LAT & OBLIQUES)",
"row_id": 1142046,
"text": " 12:01 PM\n CHEST (PA, LAT & OBLIQUES) Clip # \n Reason: Please confirm PICC line placement. thanks!\n Admitting Diagnosis: SEPSIS;MEDIASTINITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with Left arm PICC line pulled back 5 cm.\n REASON FOR THIS EXAMINATION:\n Please confirm PICC line placement. thanks!\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JEKh TUE 1:43 PM\n PFI: Left PICC tip at the cavoatrial junction.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 54-year-old male with left arm PICC.\n\n STUDY: PA, lateral and oblique chest radiographs.\n\n COMPARISON: .\n\n FINDINGS: The heart and mediastinal contours appear normal. The hila are\n normal appearing bilaterally. The lungs are clear of masses or\n consolidations. Surgical clips project over the lower aspect of the right\n lung. There is no large pleural effusion or pneumothorax. Previously\n described left PICC tip is best seen on oblique views and appears to be at the\n cavoatrial junction. The osseous structures are grossly intact.\n\n IMPRESSION: Left PICC tip at the cavoatrial junction.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-05-05 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1139313,
"text": " 2:13 PM\n CHEST (PA & LAT) Clip # \n Reason: interval change\n Admitting Diagnosis: SEPSIS;MEDIASTINITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with mediastinal infection and rib resection\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Mediastinal infection and rib resection, question interval change.\n\n CHEST, TWO VIEWS.\n\n The lungs are hyperinflated and the diaphragms are flattened, consistent with\n COPD. Mediastinum remains midline. The medial portion of the right clavicle\n has been resected and a sharp vertical interface along the upper right\n mediastinum is noted. There are clips in the right suprahilar region and\n plate-like atelectasis at the right base medially. No CHF, frank\n consolidation or gross effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-04-30 00:00:00.000",
"description": "CT CHEST W/CONTRAST",
"row_id": 1138631,
"text": " 10:36 PM\n CT CHEST W/CONTRAST Clip # \n Reason: necrotizing fasciaitis? mediastinitis?\n Admitting Diagnosis: SEPSIS;MEDIASTINITIS\n Field of view: 48 Contrast: OPTIRAY Amt: 70\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man p/w DKA and ? necrotizing fasciatis to ant. mediastinum, and\n pectoralis. Has septic R SC joint and shoulder. blood cx possitive for MSSA\n REASON FOR THIS EXAMINATION:\n necrotizing fasciaitis? mediastinitis?\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: SHfd WED 12:00 AM\n 1. ETT 1.1 CM ABOVE CARINA. RECOMMEND REPOSITIONING.\n 2. MILDLY INCREASED EXTENT OF ENLAGEMENT/EDEMA/INFILTRATION OF R PECTORALIS\n AND SCM AND NECK STRAP MUSCLES AS WELL AS ANTERIOR MEDIASTINAL AND INFERIOR\n NECK INFILTRATION AS COMPARED TO PRIOR STUDY. HETEROGENEOUS ENHANCEMENT OF\n PEC/SCM/STRAP MUSCLES CAN REPRESENT EARLY NECROSIS OR EDEMA.\n 3. NEW BILAT PLEURAL EFFUSION AND ATX AND ASPIRATION-PNA R>L.\n 4. wIDENING OF STERNOCLAVICULAR JOINTS AND POSSIBLE EARLY OSTEOLYSIS\n CONCERNING FOR INFECTION (SEPTIC JOINT-OSTEOMYELITIS).\n 5. SPLENOMEGALY\n 6. SEE NECK CT FOR ADDITIONAL FINDINGS\n WET READ VERSION #1 SHfd TUE 11:59 PM\n 1. ETT 1.1 CM ABOVE CARINA. RECOMMEND REPOSITIONING.\n 2. MILDLY INCREASED EXTENT OF ENLAGEMENT/EDEMA/INFILTRATION OF R PECTORALIS\n AND SCM AND NECK STRAP MUSCLES AS WELL AS ANTERIOR MEDIASTINAL AND INFERIOR\n NECK INFILTRATION AS COMPARED TO PRIOR STUDY. HETEROGENEOUS ENHANCEMENT OF\n PEC/SCM/STRAP MUSCLES CAN REPRESENT EARLY NECROSIS OR EDEMA.\n 3. NEW BILAT PLEURAL EFFUSION AND ATX AND ASPIRATION-PNA R>L.\n 4. wIDENING OF STERNOCLAVICULAR JOINTS AND POSSIBLE EARLY OSTEOLYSIS\n CONCERNING FOR INFECTION (SEPTIC JOINT-OSTEOMYELITIS).\n 5. SPLENOMEGALY\n ______________________________________________________________________________\n FINAL REPORT\n CHEST CT ON :\n\n HISTORY: 54-year-old man with DKA. Septic right sternoclavicular joint.\n Positive blood cultures. Suspect fasciitis and mediastinitis.\n\n TECHNIQUE: Multidetector helical scanning of the chest was coordinated with\n intravenous infusion of 60 ml Optiray 350 entering the chest from the right,\n reconstructed is contiguous 5- and 1.25-mm thick axial and 5-mm thick coronal\n and parasagittal images, read in conjunction with a neck CT reported\n separately compared to chest CT dated performed at .\n\n FINDINGS:\n\n There is no bone destruction or clear effusion at the right sternoclavicular\n joint. There is, however, extensive and severe expansile induration of the\n right chest wall musculature, predominantly the pectoralis major, extending to\n (Over)\n\n 10:36 PM\n CT CHEST W/CONTRAST Clip # \n Reason: necrotizing fasciaitis? mediastinitis?\n Admitting Diagnosis: SEPSIS;MEDIASTINITIS\n Field of view: 48 Contrast: OPTIRAY Amt: 70\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n the right shoulder due to extensive myositis and probably fasciitis. The\n muscle enhances strongly, but contains within it large relatively\n regions that could be incipient abscesses, for example a roughly\n 6 x 4 cm region at the inferolateral margin of the indurated muscle, 2:21,\n and a 5 x 3.5 cm region more superiorly at the level of the first rib in a\n paramedian location. Increasing thickness of the affected muscle and the\n extent of edema in the adjacent subcutaneous fat at the level of the\n sternoclavicular joint are indications of active infection.\n\n In the prevascular mediastinum a relatively circumscribed soft tissue opacity\n extending from the level of the sternal notch to the left brachiocephalic vein\n is 67 x 34 mm (4:85) today, compared to 75 x 33 mm on (6:46). The\n lesion lies anterior to the plane of the left brachiocephalic vein, which is\n probably intact, though not opacified because of contralateral contrast\n infusion. However, there is more stranding and edema in the prevascular\n mediastinum at that level consistent with worsening mediastinitis, and\n contiguous with the upper end of the substernal phlegmon is a bilobed lesion\n that deforms the right thyroid lobe, now 19 x 38 mm at 2:8, previously 15 x 34\n mm at 6:21.\n\n There is no pericardial effusion. Small bilateral layering nonhemorrhagic\n pleural effusion is new, but is more likely a function of new bibasilar\n atelectasis than infection. The lungs are grossly clear. Tip of the\n endotracheal tube is less than 2 cm from the carina, 2 cm below optimal\n position. Nasogastric tube ends in the region of the pylorus.\n\n There is no pathologic enlargement of central lymph nodes. The study is not\n designed for subdiaphragmatic evaluation except to note a region of relative\n in the right lobe of the liver adjacent to the falciform\n ligament, roughly 21 mm wide (4:212), which could be a region of either focal\n fatty infiltration or developing infection and would require dedicated\n abdominal imaging in followup.\n\n IMPRESSION:\n 1. Severe progressive right anterior chest wall infection involving at least\n the pectoralis major muscle in its entirety and probable subcutaneous tissue\n to the cervicothoracic junction.\n\n 2. Large phlegmon with a stable prevascular component is enlarging superiorly\n at the base of the neck anterior to the thyroid gland Inferior to the\n phlegmon, likely mediastinitis has progressed.\n\n 3. New small bilateral pleural effusion probably attributable to interval\n development of bibasilar atelectasis.\n\n (Over)\n\n 10:36 PM\n CT CHEST W/CONTRAST Clip # \n Reason: necrotizing fasciaitis? mediastinitis?\n Admitting Diagnosis: SEPSIS;MEDIASTINITIS\n Field of view: 48 Contrast: OPTIRAY Amt: 70\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Dr. discussed these findings by telephone at the time of dictation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-04-30 00:00:00.000",
"description": "CT NECK W/CONTRAST (EG:PAROTIDS)",
"row_id": 1138632,
"text": " 10:37 PM\n CT NECK W/CONTRAST (EG:PAROTIDS) Clip # \n Reason: interval change *please perform scan tonight\n Admitting Diagnosis: SEPSIS;MEDIASTINITIS\n Contrast: OPTIRAY Amt: 60\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with severe SC joint cellulitis and mediastinal infection\n REASON FOR THIS EXAMINATION:\n interval change *please perform scan tonight\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SHfd WED 12:23 AM\n PFI:\n\n 1. Marked enlargement of the right pectoralis muscles, sternocleidomastoid\n muscle as well as the strap muscles with surrounding fat stranding and mildly\n heterogeneous enhancement is concerning for infectious etiology. Mildly\n heterogeneous enhancement, especially within the right strap muscles can\n represent edema versus early muscular necrosis.\n\n 2. Widening of the sternoclavicular joints and apparent erosive changes can\n represent infection. This appearance is at least partially secondary to\n degenerative change.\n\n 3. Mild increase in superior mediastinal soft tissue attenuating collection\n extending into the inferior neck and surrounding the thyroid gland. There is\n no peripheral enhancement; however, this can represent a complex fluid\n collection.\n\n 4. Endotracheal tube is only 1 cm above the carina. Repositioning is\n recommended. Deviation of the trachea to the left is likely from mass effect\n of neck musculature edema - enlargement.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Sternoclavicular joint and mediastinal infection. Clinical\n concern for interval change since Chest CT from , from .\n\n TECHNIQUE: Multidetector CT images of the neck after administration of IV\n contrast with coronal and sagittal reformats were submitted for\n interpretation.\n\n FINDINGS: Again seen is enlargement of the right pectoralis and\n sternocleidomastoid muscles as well as the right strap muscles with mildly\n heterogeneous enhancement and surrounding fat stranding and skin thickening,\n mildly increased since prior exam. The thickening of the right strap muscles\n has increased since prior exam with area of decreased enhancement inferiorly\n (2:90-92), which can represent edema or early fibrosis. A 7.4 x 3.6 x 6 cm\n soft tissue-attenuation process within the anterior mediastinum extends into\n through the thoracic inlet, into the anterior low neck where it merges with\n the process involving the strap muscles. Though there is no peripherally-\n enhancing or other discrete fluid collection, this may represent a phlegmon.\n (Over)\n\n 10:37 PM\n CT NECK W/CONTRAST (EG:PAROTIDS) Clip # \n Reason: interval change *please perform scan tonight\n Admitting Diagnosis: SEPSIS;MEDIASTINITIS\n Contrast: OPTIRAY Amt: 60\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Edema is also noted surrounding this area of soft tissue extending from the\n anterior mediastinum into the neck anterior to the thyroid gland.\n\n The lung apices are unremarkable. An endotracheal tube with the tip\n approximately 1.1 cm above the carina (better seen on chest CT from same date)\n is noted, and repositioning is recommended. An NG tube is also seen. Fluid\n within the trachea is noted. The trachea is displaced to the left, likely\n secondary to mass effect from soft tissue infiltration of the right\n sternocleidomastoid and strap muscles. A few cervical lymph nodes with the\n largest measuring 8 mm (2:54) are not enlarged by size criteria. Widening of\n the sternoclavicular joints bilaterally with apparent erosive changes can be\n infectious in nature. Irregularity of the proximal clavicular cortex can be\n partially secondary to degenerative change. The imaged vasculature is grossly\n patent. Imaged portions of the brain are grossly unremarkable. There is\n complete opacification of the left maxillary sinus. Fluid within the\n nasopharynx and oropharynx is likely secondary to recent intubation.\n\n IMPRESSION:\n\n 1. Marked asymmetric enlargement of the right-sided pectoralis,\n sternocleidomastoid and strap muscles with effacement of fat planes and\n surrounding fat stranding and mildly heterogeneous enhancement is concerning\n for infection with pyomyositis. Mildly heterogeneous enhancement, especially\n within the right strap muscles can represent edema versus early myonecrosis.\n\n 2. Widening of the sternoclavicular joints and apparent erosive changes,\n particularly involving the dorsal aspect of the sternum, is suspicious for\n septic arthritis; there may also be a component of chronic degenerative\n change.\n\n 3. Mild short-term increase in abnormal soft tissue-attenuation collection\n extending into the inferior neck and surrounding the thyroid gland. There is\n no peripheral enhancement; however, in this setting, this is highly\n suspicious for infectious phlegmon.\n\n 4. Endotracheal tube is only 1 cm above the carina. Repositioning is\n recommended. Deviation of the trachea to the left is likely from mass effect\n of markedly edematous right neck musculature.\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-04-30 00:00:00.000",
"description": "CT NECK W/CONTRAST (EG:PAROTIDS)",
"row_id": 1138633,
"text": ", P. -7 10:37 PM\n CT NECK W/CONTRAST (EG:PAROTIDS) Clip # \n Reason: interval change *please perform scan tonight\n Admitting Diagnosis: SEPSIS;MEDIASTINITIS\n Contrast: OPTIRAY Amt: 60\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with severe SC joint cellulitis and mediastinal infection\n REASON FOR THIS EXAMINATION:\n interval change *please perform scan tonight\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI:\n\n 1. Marked enlargement of the right pectoralis muscles, sternocleidomastoid\n muscle as well as the strap muscles with surrounding fat stranding and mildly\n heterogeneous enhancement is concerning for infectious etiology. Mildly\n heterogeneous enhancement, especially within the right strap muscles can\n represent edema versus early muscular necrosis.\n\n 2. Widening of the sternoclavicular joints and apparent erosive changes can\n represent infection. This appearance is at least partially secondary to\n degenerative change.\n\n 3. Mild increase in superior mediastinal soft tissue attenuating collection\n extending into the inferior neck and surrounding the thyroid gland. There is\n no peripheral enhancement; however, this can represent a complex fluid\n collection.\n\n 4. Endotracheal tube is only 1 cm above the carina. Repositioning is\n recommended. Deviation of the trachea to the left is likely from mass effect\n of neck musculature edema - enlargement.\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-05-04 00:00:00.000",
"description": "R UNILAT UP EXT VEINS US RIGHT",
"row_id": 1139192,
"text": " 4:54 PM\n UNILAT UP EXT VEINS US RIGHT Clip # \n Reason: evaluate for RUE DVT\n Admitting Diagnosis: SEPSIS;MEDIASTINITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with DKA and mediastinitis, MSSA sepsis s/p mediastinum wash\n out, I/D, POD 3 s/p resection of sternal head of ribs 1,2 and sc joint\n REASON FOR THIS EXAMINATION:\n evaluate for RUE DVT\n ______________________________________________________________________________\n WET READ: IPf SAT 6:01 PM\n R jugular, axillary, brachialis, cephalic, and basilic are open.\n However, there is a superficial vein in the right mid forarm, where line is\n placed with segmental thrombosis at the site where line goes in.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 54-year-old man with diabetic ketoacidosis and mediastinitis and\n sepsis, status post mediastinal washout and status post resection of sternal\n head and ribs with a line in place and edema of the right upper extremity.\n\n TECHNIQUE: Venous ultrasound of the right upper extremity.\n\n FINDINGS: Grayscale and color Doppler images of the right jugular,\n subclavian, axillary, cephalic, basilic, and brachialis vein show normal\n compressibility, flow and augmentation with no evidence of DVT.\n\n In the forearm, there is a superficial vein with line in place and clot around\n the line in the segmental portion of a superficial vein (median cubital vein).\n The superficial vein connects proximally to the brachial vein which is patent\n and free of clot.\n\n Findings were communicated and discussed with Dr. from surgery.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-05-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1138761,
"text": " 3:49 PM\n CHEST (PORTABLE AP) Clip # \n Reason: rule out ptx\n Admitting Diagnosis: SEPSIS;MEDIASTINITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man s/p rib resection for mediastinitis\n REASON FOR THIS EXAMINATION:\n rule out ptx\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Rib resection for mediastinitis, to evaluate for pneumothorax.\n\n FINDINGS: In comparison with study of , there is either subcutaneous gas\n or gas trapped under a bandage overlying the right shoulder and upper chest.\n This makes evaluating for pneumothorax somewhat difficult. However, a\n definite pneumothorax is not appreciated.\n\n Endotracheal tube tip lies approximately 2.6 cm above the carina. Nasogastric\n tube extends to the distal stomach. Opacification at the left base is\n consistent with atelectasis and effusion. Where it passes the lower border of\n the image, atelectatic changes and possible effusion are seen on the left with\n obscuration of the hemidiaphragm, though this area is ___.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-05-10 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1140283,
"text": " 6:46 PM\n CHEST (PA & LAT) Clip # \n Reason: assess for any infectious process\n Admitting Diagnosis: SEPSIS;MEDIASTINITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man POD 9 I/D and resection of sternal head of ribs 1,2 and sc\n joint\n REASON FOR THIS EXAMINATION:\n assess for any infectious process\n ______________________________________________________________________________\n WET READ: EAGg FRI 8:33 PM\n No focal consolidation. Trace left pleural effusion. Right basilar\n atelectasis.\n ______________________________________________________________________________\n FINAL REPORT\n TWO VIEW CHEST\n\n COMPARISON: .\n\n FINDINGS: Interval improvement in degree of atelectasis in the right mid and\n both lower lungs with minimal residual linear foci of atelectasis remaining.\n Postoperative changes are demonstrated with evidence of previous partial rib\n and clavicular resection on the right. No pneumothorax or pleural effusion.\n\n IMPRESSION: Improving multifocal atelectasis. No evidence of pneumonia.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-05-12 00:00:00.000",
"description": "CT CHEST W/CONTRAST",
"row_id": 1140490,
"text": " 9:43 AM\n CT CHEST W/CONTRAST Clip # \n Reason: eval for source of infection around large open right chest w\n Admitting Diagnosis: SEPSIS;MEDIASTINITIS\n Contrast: OPTIRAY Amt: 75\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with right SC joint removal for abscess with continued fevers.\n REASON FOR THIS EXAMINATION:\n eval for source of infection around large open right chest wound. **The last\n CT scan had IV contrast pushed through the R peripheral and there was a lot of\n scatter and the images were not very clear around the R shoulder. Can we please\n trouble shoot this, either give contrast through L picc or shoot images later,\n please call me to discuss \n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): PXDb SUN 11:36 AM\n No evidence of fluid collection or abscess or other signs of soft tissue\n infection. Post-surgical changes from prior right anterior chest wall\n resection are stable.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Right sternoclavicular joint removal for abscess with continued\n fevers, evaluate for infection around the open large right chest wound.\n\n Previous chest CT had injection through the right side with significant\n scatter, limiting evaluation in this region.\n\n COMPARISON: .\n\n TECHNIQUE: Helical CT acquisition from the top of the lungs to upper abdomen\n with intravenous contrast. On this occasion contrast was injected through the\n left arm. Multiplanar reformations were generated.\n\n FINDINGS: A large defect is present in the right anterior chest wall,\n involving partial resection of the clavicle and the right hemimanubrium. The\n right sternoclavicular joint is completely removed. There is no focal fluid\n collection, or soft tissue abnormalities or areas of abnormal enhancement at\n the resection margins. Surgical dressing or gauze is seen within the\n resection cavity. There has been debridement of the anterior chest wall\n muscles and soft tissue with now exposure of the mediastinal structures and\n vasculature to the exterior. Small subcutaneous air in the right anterior\n chest wall (2:16), is unchanged since the prior study. There is mild\n stranding of the mediastinal fat superiorly; however, there is no fluid\n collection, abscess and the minimal stranding is likely related to\n post-operative changes. The heart and the great vessels are normal in\n appearance. There is no pericardial effusion. Minimal aortic arch\n calcifications are present. Small subcentimeter mediastinal nodes with fatty\n hilum are morphologically normal.\n\n Lung windows demonstrate no evidence of pulmonary consolidation, suspicious\n pulmonary nodules, pleural effusion. Mild atelectasis is present in the right\n lung base. An area of linear scarring is seen at the left lung base. The\n (Over)\n\n 9:43 AM\n CT CHEST W/CONTRAST Clip # \n Reason: eval for source of infection around large open right chest w\n Admitting Diagnosis: SEPSIS;MEDIASTINITIS\n Contrast: OPTIRAY Amt: 75\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n previously seen trace right pleural effusion has largely resolved. There is\n also improved aeration at the right lung base. The tracheobronchial tree is\n patent to the subsegmental levels.\n\n The imaged upper abdomen demonstrates post-cholecystectomy changes. Otherwise\n is grossly unremarkable. No suspicious osteolytic or osteosclerotic lesions\n are present.\n\n IMPRESSION: No evidence of fluid collection or abscess or other signs of soft\n tissue infection. Post-surgical changes from prior right anterior chest wall\n resection are stable.\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-05-12 00:00:00.000",
"description": "CT CHEST W/CONTRAST",
"row_id": 1140491,
"text": ", S. CSURG FA9A 9:43 AM\n CT CHEST W/CONTRAST Clip # \n Reason: eval for source of infection around large open right chest w\n Admitting Diagnosis: SEPSIS;MEDIASTINITIS\n Contrast: OPTIRAY Amt: 75\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with right SC joint removal for abscess with continued fevers.\n REASON FOR THIS EXAMINATION:\n eval for source of infection around large open right chest wound. **The last\n CT scan had IV contrast pushed through the R peripheral and there was a lot of\n scatter and the images were not very clear around the R shoulder. Can we please\n trouble shoot this, either give contrast through L picc or shoot images later,\n please call me to discuss \n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n No evidence of fluid collection or abscess or other signs of soft tissue\n infection. Post-surgical changes from prior right anterior chest wall\n resection are stable.\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-05-09 00:00:00.000",
"description": "R UNILAT LOWER EXT VEINS RIGHT",
"row_id": 1139983,
"text": " 10:27 AM\n UNILAT LOWER EXT VEINS RIGHT Clip # \n Reason: r/o DVT\n Admitting Diagnosis: SEPSIS;MEDIASTINITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with R arthroscopy for R knee infection increased edema RLE\n REASON FOR THIS EXAMINATION:\n r/o DVT\n ______________________________________________________________________________\n WET READ: 10:56 AM\n No DVT right lower extremity.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Right knee arthroscopy for infection, with increased edema.\n\n COMPARISON: None.\n\n FINDINGS: Grayscale and color Doppler son of the right common femoral,\n superficial femoral, and popliteal veins were obtained. There is normal\n compressibility, flow, and augmentation without evidence of DVT. Compression\n was demonstrated in the posterior tibial and peroneal veins within the calf,\n without evidence for thrombus.\n\n IMPRESSION: No evidence of DVT of the right lower extremity.\n\n"
},
{
"category": "Echo",
"chartdate": "2115-05-01 00:00:00.000",
"description": "Report",
"row_id": 90928,
"text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis.\nHeight: (in) 71\nWeight (lb): 200\nBSA (m2): 2.11 m2\nBP (mm Hg): 120/76\nHR (bpm): 80\nStatus: Inpatient\nDate/Time: at 16:35\nTest: Portable TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA and RA cavity sizes.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Simple atheroma in aortic arch. Simple atheroma in descending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No masses or\nvegetations on aortic valve. No aortic valve abscess. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No mass or vegetation on\nmitral valve. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. No mass or\nvegetation on tricuspid valve.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. No\nvegetation/mass on pulmonic valve.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was monitored\nby a nurse throughout the procedure. The patient was sedated for\nthe TEE. Medications and dosages are listed above (see Test Information\nsection). The patient was under general anesthesia throughout the procedure.\nNo TEE related complications.\n\nConclusions:\nThe left atrium and right atrium are normal in cavity size. No atrial septal\ndefect is seen by 2D or color Doppler. Overall left ventricular systolic\nfunction is normal (LVEF>55%). Right ventricular chamber size and free wall\nmotion are normal. There are simple atheroma in the aortic arch and descending\nthoracic aorta. The aortic valve leaflets (3) are mildly thickened but aortic\nstenosis is not present. No masses or vegetations are seen on the aortic\nvalve. Trace aortic regurgitation is seen. The mitral valve leaflets are\nmildly thickened. No mass or vegetation is seen on the mitral valve. Mild (1+)\nmitral regurgitation is seen. No vegetation/mass is seen on the pulmonic\nvalve. There is no pericardial effusion.\n\nIMPRESSION: No echocardiographic evidence of endocarditis.\n\n\n"
}
] |
28,529 | 122,111 | The patient was admitted on 5/708 s/p mechanical fall at home. A CT of the C-spine and head were negative. Right lower extremity X-rays revealed a markedly comminuted and impacted right subtrochanteric femur fracture, with extension into right lesser trochanter, large butterfly fragments, and varus angulation. She was admitted to the trauma service. A medicine consult was called for pre-operative evaluation since she has multiple medical issues. Conservative medica therapy was recommended. On HD 2, she was taken to the OR with orthopedics for her RLE. Please see operative note for details. Post-operatively, she was found to be dysarthric, confused, and unable to move the left side of her body. An emergent stroke consult was called. A CT of the head showed contrast enhancement of right basal ganglia and posterior frontal infarct versus hemorrhagic conversion. She was unable to have an MRI because she has a pacemaker. She was taken emergently to neuroradiology for emergent stenting of her right internal carotid artery and mechanical and chemical thrombolysis of her distal ICA and right middle cerebral artery. Please see operative note for full details. The right common carotid artery was found to be occluded. She was dianosed with a right MCA stroke. The mechanism was thought to be cardioembolic or carotid thromboembolism. The sheath was left in her right groin. Later that night, her RLE became pulseless and ischemic. She was taken emergently to the OR for a right femoral thrombectomy, right femoral bovine patch profundaplasty, right external iliac stenting, and pelvic arteriogram and right lower extremity angiogram. Please see operative note for full details. She was then transferred back to the ICU. Her RLE regained a pulse and looked good. She did not recover neurologically. She had minimal movement of her extremities and was minimally responsive. Her SBP was kept < 180, she was started on aspirin and plavix. Repeat head CT scans showed an evolving right MCA infarct. Tube feeds were started via an NG tube. She was on peri-operative ancef. She was started on a heparin drip. An echo did not reveal any intracardiac thrombus. On , she was extubated. She did require suctioning as she was unable to control her secretions. On she was transferred to step down. A family meeting was held on with her son, the health care proxy. At that time, we were made aware of her living will, which clearly stated that she would want to be made in this difficult situation. Therefore, she was made . Palliative care was consulted. Ethics was consulted because the patient does have a daughter who may not want her to be . She was screened for a skilled nursing facility witrh end of life care. | Calcification at the aortic arch, and calcific densities in the right axilla, likely representing small lymph nodes are unchanged. No contraindications for IV contrast FINAL REPORT INDICATION: Hemorrhagic conversion of right MCA infarct. Patient has occlusion of the right ICA. IMPRESSION: AP chest compared to and 8: ET tube is in standard placement, nasogastric tube passes into nondistended stomach and out of view. PREOPERATIVE DIAGNOSIS: Right hemispheric stroke. Right common carotid artery arteriogram status post angioplasty of the distal stented area shows no residual stenosis. ET tube is in standard placement, its cuff mildly distending the trachea. ?ischemia/stroke No contraindications for IV contrast FINAL REPORT INDICATION: Change of neuro status. Right-sided pacemaker and two intracardiac leads are unchanged. Minimal left-sided pleural effusion, minimal retrocardiac atelectasis. ModeratePA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. TECHNIQUE: Non-contrast head CT. NON-CONTRAST HEAD CT: Previously seen high-density material within the right basal ganglia is much less apparent suggesting interval reabsorption and redistribution of IV contrast secondary to the patient's angiographic procedure. FINDINGS: There is a hypoattenuating area in the right basal ganglia and posterior frontal lobe which could represent contrast enhancement of the right-sided infarct, although a hemorrhagic conversion cannot be excluded. There is some sulcal effacement of the right posterior frontal lobe with no appreciable midline shift. Theaortic valve leaflets (3) are mildly thickened but aortic stenosis is notpresent. New small left pleural effusion with adjacent left basilar atelectasis is demonstrated. Admitting Diagnosis: S/P FALL Contrast: OPTIRAY Amt: 251 FINAL REPORT (Cont) Right internal carotid artery arteriogram status post stenting shows distal ICA terminus occlusion with reflux into the right vertebrobasilar artery and collateral filling of the left internal carotid artery and its branches. There was no distal recanalization and we could see reflux into the right vertebral artery and filling the left internal carotid artery and its branches. There is slight persistent effacement of the right lateral ventricle, but no major midline shift. Following this, the middle cerebral artery branches were open except for a superior division which still remained occluded. Runs were done now demonstrating complete occlusion of the right internal carotid artery. Mild mitral annularcalcification. Note is made of moderate vascular calcification and aortobifemoral graft material in place. Mild (1+) mitralregurgitation is seen. The right common carotid is calcified at the origin and then is occluded at the bifurcation and this occlusion is total and there is no flow to the circle of via the right internal carotid. DP/PT pulses dopplerable bil. distr, tol ok at this time. CONT DILT. Cont PO dilt. FBS treated per RISS. FBS tx per RISS. Resp. Resp. Resp. ABG post ambu and sxn adequate. care note - Pt. care note - Pt. care note - Pt. CV: Afebrile. extubate. AFLUTTER W/OCC PVC'S. DILT GTT. EDEMA IN BUE. HUO marginal, requiring fluid bolus x one with result. Cont PT/OT, OOB as tol. Heparin titrated per protocol. start rehab screeening. ABG WNL. Sheaths removed with return of DP pulses. Plan was to extubate. Repeat head CT this am. Afebrile. V-Paced w/underlying A-flutter. A-line discontiued per Dr . TEAM AWARE OF MARGINAL U/O, WILL CONT TO MONITOR.ENDO: RISS, REQUIRING MIN COVERAGE.SKIN/ORTHO: SKIN INTACT. K 4.0 after repletion. NGT clamped. SICU NPNS-Sedated.SEE CAREVUE FOR ALL OBJECTIVE DATA AND TRENDS IN FLOWSHEETS.O-Recieved w/ Propofol off. Spoke w/ MD. + PP. ND. ND. ND. ND. ABG WNL (7.34/40/98/23/-3). Diltiazem gtt off, started PO Diltiazem. Started on Neo. Dr aware. V-Paced. Restarted TF via Dobhoff, goal 60cc/hr. MONITOR HOURLY U/O. GI/ENDO: ABD soft. + BS. + BS. + BS. + BS. Making adequate CYU via foley. Updated.POC: Pulm toilet. Neo on/off for majority of nihgt. Will wean as tolerated. LUNGS CTAB. PTT from 0400 pending.BUE remain edematous. NT. NT. NT. NT. Remains on RISS. See careview for furher details. Notify HO with changes. Resp carePt remains intubated, On PSV and tol well. Call HO w/any changes. Call HO w/any changes. Monitor I&O's. MAEs except for LUE. FBS tx per RISS, minimal coverage required.GU: Making adequate CYU via foley. Arterial and venous sheaths in place, pulses dopplerable throughout until 0200. Dtr calling and updated by RN.A/P:78 yo s/p fall c/b hip fx later c/b embolic CVA with meric procedure performed with result. + FEM PULSES. BS are dim & clear bil. HO aware of above, call w/any changes. NPO. Hourly u/o approx. HR 60's, some PVC's. ?dc when pt again on po Lopressor. HR 60's, occ PVC's. doplarable pulses on rt foot,lt leg post. RSBI=43, last ABG 7.36/38/186/22/-3. SBP 140-160 (pts goal), as high as 180 w/pain.GI/ENDO: ABD soft. Lytes repleted. Tube was moved down 1cm (21@lip). We are sxtn for scant secretions from ETT. bs rhonchorous with upper airway congestion. PROGRESS NOTESEE CAREVUE FOR SPECIFICSNEURO: Essentially unchanged. ? ? ? ? ? TF at goal and tolerating well. Hemostasis at 0405. Plan: Cont with current plan of care. PT diffuse with non-consistent pulse. RSBI 42. SBP <160. SUCTIONING FOR MOD AMTS CLEAR/WHITE THIN SECRETIONS. GU: Making CYU via Foley. Hands slightly edematous. : Pulm toilet. WBC MILDLY ELEVATED FROM 12 TO 15.2GI/GU: ABD SOFT. HO AWARE OF ABOVE, WILL CALL W/ANY CHANGES. Gag impaired.CV: V-Paced, underlying Aflutter. Monitor heme. 4L(+) from MN. Pupils Right 3mm, Left 4mm. NBP 140-170 systolically, recieving prn Hydralazine x2 for SBP >160. Right 3mm, Left 4mm. Lungs clear, diminished at bases. MD decided to wait. Abd soft. ABD soft. HR 60. Last PTT 52. | 40 | [
{
"category": "Radiology",
"chartdate": "2134-04-28 00:00:00.000",
"description": "CHEST (PRE-OP AP ONLY)",
"row_id": 1012338,
"text": " 9:50 PM\n CHEST (PRE-OP AP ONLY) Clip # \n Reason: FX RIGHT HIP/PRE OP\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Preoperative for planned procedure.\n\n FINDINGS: Single portable supine chest radiograph is reviewed and compared to\n . Cardiac silhouette remains prominent, though limited by portable\n supine technique. Right-sided pacemaker and two intracardiac leads are\n unchanged. Calcification at the aortic arch, and calcific densities in the\n right axilla, likely representing small lymph nodes are unchanged.\n Calcification in the left hilus is also evident, possibly suggesting\n additional focus of calcified lymph nodes. Allowing for technique, lungs are\n grossly clear, though there is apparent hyperinflation which could suggest\n underlying emphysema. There is no pleural effusion or pneumothorax.\n\n IMPRESSION: Unchanged cardiomegaly. Possible emphysema.\n\n"
},
{
"category": "Radiology",
"chartdate": "2134-05-01 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1012719,
"text": " 9:25 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Change of neuro status. ?ischemia/stroke\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with R ICA occlusion\n REASON FOR THIS EXAMINATION:\n Change of neuro status. ?ischemia/stroke\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Change of neuro status.\n\n COMPARISON: , .\n\n TECHNIQUE: CT HEAD WITHOUT IV CONTRAST:\n\n There is no new hyperdense focus indicative of new hemorrhage. The previously\n seen high-density material within the right basal ganglia has now decreased,\n suggesting continued interval contrast resorption s/p procedure. Again seen\n is sulcal effacement in the right parietal lobe posteriorly. There is\n increased area of hypodensity along the right frontal lobe and right parietal\n lobe, suggesting evolving infarct. There is slight persistent effacement of\n the right lateral ventricle, but no major midline shift. The ventricles,\n sulci and cisterns remain essentially unchanged. Osseous structures are\n unchanged.\n\n IMPRESSION: No new infarct, although MR is more sensitive at detecting acute\n stroke. Continued resorption of extravasated contrast material. Evolving\n infarct involving the right MCA territory.\n\n"
},
{
"category": "Radiology",
"chartdate": "2134-05-01 00:00:00.000",
"description": "R HIP UNILAT MIN 2 VIEWS RIGHT",
"row_id": 1012738,
"text": " 1:02 PM\n HIP UNILAT MIN 2 VIEWS RIGHT Clip # \n Reason: evaluate fixation\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with hip fracture\n REASON FOR THIS EXAMINATION:\n evaluate fixation\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Hip fracture with fixation.\n\n FINDINGS: In comparison with the study of , there is little change in the\n appearance of the metallic fixation device about the comminuted fracture of\n the subtrochanteric fracture. No evidence of hardware loosening.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2134-04-29 00:00:00.000",
"description": "RO HIP UNILAT MIN 2 VIEWS RIGHT IN O.R.",
"row_id": 1012404,
"text": " 10:27 AM\n HIP UNILAT MIN 2 VIEWS RIGHT IN O.R.; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST RIGHT IN O.R.Clip # \n Reason: RIGHT HIP ORIF\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: Right hip ORIF.\n\n COMPARISON: \n\n FINDINGS: Seven fluoroscopic intraoperative films were submitted for review\n without the radiologist present. These show placement of an intramedullary\n rod and gamma nail across a right subtrochanteric fracture. For further\n details please see the operative report.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2134-05-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1012913,
"text": " 5:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: dobhoff placement\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with stroke\n REASON FOR THIS EXAMINATION:\n dobhoff placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Dobbhoff placement.\n\n COMPARISON: .\n\n PORTABLE CHEST RADIOGRAPH: There has been placement of a new Dobbhoff tube,\n projecting to at least the distal stomach, incompletely imaged. The tip is\n not imaged. Cardiac and mediastinal contours appear unchanged. Pulmonary\n vascularity remains stable. No new focal consolidations are identified.\n Slightly improved aeration at the left base.\n\n IMPRESSION: Dobbhoff tube seen coiled in the stomach, tip not imaged on\n this study. Otherwise, little changed from prior.\n\n"
},
{
"category": "Radiology",
"chartdate": "2134-04-29 00:00:00.000",
"description": "CTA NECK W&W/OC & RECONS",
"row_id": 1012438,
"text": " 12:35 PM\n CTA NECK W&W/OC & RECONS; CTA HEAD W&W/O C & RECONS Clip # \n CT BRAIN PERFUSION\n Reason: Please evaluate for stroke\n Admitting Diagnosis: S/P FALL\n Field of view: 25 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with change in motor exam - L hemiplegia and L facial droop.\n Is in PACU\n REASON FOR THIS EXAMINATION:\n Please evaluate for stroke\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Change in motor exam, now with left hemiplegia and left facial\n droop in PACU, evaluate for stroke.\n\n COMPARISON: CT head .\n\n TECHNIQUE: Contiguous axial images were obtained through the brain without\n contrast material. Subsequently, rapid axial imaging was performed from the\n aortic arch through the brain during the infusion of Omnipaque intravenous\n contrast material. The images were processed on a separate workstation with\n display of curved reformats, volume-rendered images, and maximum-intensity\n projection images.\n\n FINDINGS:\n\n HEAD CT: There is no evidence of hemorrhage, edema, masses, mass effect, or\n infarction. The ventricles and sulci are normal in caliber and configuration.\n No fractures are identified. The mastoid air cells and visualized paranasal\n sinuses are clear. There is atherosclerotic calcification of the vessels of\n the base of the skull.\n\n HEAD AND NECK CTA: The right vertebral artery is stenotic at its origin to\n about 50% and distally atherosclerotic calcification is seen. The left\n vertebral artery is also calcified and is notably irregular likely due to\n diffuse atherosclerotic disease. The right common carotid is calcified at the\n origin and then is occluded at the bifurcation and this occlusion is total and\n there is no flow to the circle of via the right internal carotid. There\n is reconstitution of flow at the supraclinoid portion probably due to\n collaterals. The left common carotid demonstrates no flow at its origin and\n then it is reconstituted more distally. There are calcifications of the\n cavernous carotid segments bilaterally. There is an aneurysm at the ACom and\n left A1 measuring 6 mm. Perfusion images demonstrate a greatly increased\n mean transit time and a slightly decreased blood volume in right MCA territory\n consistent with ischemic penumbra with small infarct.\n\n IMPRESSION:\n 1. Occlusion of the right common and right internal carotid arteries with\n large region of penumbra in the right MCA territory.\n 2. Aneurysm of the ACom and left A1 measuring to 6 mm.\n (Over)\n\n 12:35 PM\n CTA NECK W&W/OC & RECONS; CTA HEAD W&W/O C & RECONS Clip # \n CT BRAIN PERFUSION\n Reason: Please evaluate for stroke\n Admitting Diagnosis: S/P FALL\n Field of view: 25 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n COMMENT: These results were communicated to the neurointerventional lab at\n the time of dictation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2134-04-28 00:00:00.000",
"description": "HIP (UNILAT 2 VIEW) W/PELVIS (1 VIEW)",
"row_id": 1012335,
"text": " 9:27 PM\n HIP (UNILAT 2 VIEW) W/PELVIS (1 VIEW) Clip # \n Reason: plesae evaluate RLE for fx/dislocation.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with ? intertroch fx. Please evaluate\n REASON FOR THIS EXAMINATION:\n plesae evaluate RLE for fx/dislocation.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 78-year-old female with possible intertrochanteric fracture.\n Please evaluate.\n\n FINDINGS: Three views of the right hip and pelvis are reviewed without\n comparison. There is a markedly comminuted and impacted right subtrochanteric\n fracture, with extension into the lesser trochanter, and large butterfly\n fragments. There is marked varus angulation of near 90 degrees. No\n dislocation. No additional fractures are seen. Sacroiliac joints are intact.\n Visualized bowel gas pattern is normal. Note is made of moderate vascular\n calcification and aortobifemoral graft material in place.\n\n IMPRESSION: Markedly comminuted and impacted right subtrochanteric femur\n fracture, with extension into right lesser trochanter, large butterfly\n fragments, and varus angulation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2134-04-29 00:00:00.000",
"description": "STENT CERVICAL/CAROTID W/O EMBOLIC PROTECTION",
"row_id": 1012452,
"text": " 2:01 PM\n CAROT/CEREB Clip # \n Reason: Evaluate and treat right ICA occlusion.\n Admitting Diagnosis: S/P FALL\n Contrast: OPTIRAY Amt: 251\n ********************************* CPT Codes ********************************\n * STENT CERVICAL/CAROTID W/O EMB PRIMARY MECH THROMBECTOMY ART/ *\n * PRIMARY MECH THROMBECTOMY ART/ EXT BILAT A-GRAM *\n * -59 DISTINCT PROCEDURAL SERVICE -52 REDUCED SERVICES *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with acute right MCA stroke. Patient has occlusion of the\n right ICA.\n REASON FOR THIS EXAMINATION:\n Evaluate and treat right ICA occlusion.\n ______________________________________________________________________________\n FINAL REPORT\n DATE OF SERVICE: .\n\n PREOPERATIVE DIAGNOSIS: Right hemispheric stroke.\n\n PROCEDURE PERFORMED: Right common carotid artery arteriogram, right internal\n carotid artery arteriogram, right middle cerebral artery arteriogram.\n\n INTERVENTIONAL PROCEDURE PERFORMED: Right internal carotid artery stenting,\n right internal carotid artery intra-arterial chemical thrombolysis with TPA,\n right middle cerebral artery chemical thrombolysis with TPA, right internal\n carotid artery terminus mechanical thrombolysis with Merci L6 device, right M1\n segment of the MCA mechanical thrombolysis with L4 Merci device.\n\n ATTENDING:\n ASSISTANT: Dr. and Dr. .\n\n INDICATIONS: The patient is a 78-year-old woman who is a severe vasculopath\n who was undergoing right hip surgery and woke up with a right hemispheric\n stroke. She had a previously documented high-grade stenosis of the right\n internal carotid artery in and had occlusion of her right superficial\n femoral artery on a CTA done in .\n\n The patient was brought to the angiography suite and intubated. Following\n this general anesthesia was given and both groins were prepped and draped in a\n sterile fashion. I gained access to the left common femoral vein for IV\n access. This was connected to an IV infusion and given to the\n anesthesiologist. We now palpated a pulse in the right common femoral artery\n area. After discussing with Dr. , we accessed this using a Seldinger\n technique and a micropuncture set. We used wire to gain access into\n the distal aorta and an 8 French long sheath was placed over this into the\n distal aorta and connected to a saline infusion. Runs were done which\n demonstrated obliteration of the right SFA and our sheath had gone to the\n right profunda femoris. We decided to proceed as this was considered an\n emergency and patient was at risk of infarcting her right hemisphere.\n (Over)\n\n 2:01 PM\n CAROT/CEREB Clip # \n Reason: Evaluate and treat right ICA occlusion.\n Admitting Diagnosis: S/P FALL\n Contrast: OPTIRAY Amt: 251\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 2 catheter was guided coaxially over an 038 glidewire into the\n aortic arch into the right common carotid artery. Runs were done now\n demonstrating complete occlusion of the right internal carotid artery. There\n was no distal recanalization and we could see reflux into the right vertebral\n artery and filling the left internal carotid artery and its branches. At this\n point, we decided to explore the right internal carotid artery with an 038\n guidewire and the wire easily went into the internal carotid artery. Therefore\n at this point, we placed an 038 exchange length glidewire into the right\n internal carotid artery. A balloon mounted stent was used to open up the\n right internal carotid artery. Following this, we saw clot in the distal ICA.\n Therefore we decided to place a Merci 8 French catheter into the right\n internal carotid artery. Prior to this, the distal portion of the stented\n carotid was stenotic and post-end angioplasty was done to open up this area,\n so as to enable an 8 French Merci catheter to pass through. We were now able\n to put an SL 10 microcatheter into the distal ICA at the terminus through the\n 8 French Merci catheter and 6 units of IA TPA was given. Following this, an\n 18L Merci microcatheter and a L6 device was deployed in the distal ICA and the\n device deployed and removed under constant suctioning. This opened up the ICA\n terminus, however, there was clot in the right MCA. Therefore, the 18L\n catheter was again deployed in the distal MCA and another four units of TPA\n was given there. Following this, an L4 Merci device was deployed there and\n pulled back. Following this, the middle cerebral artery branches were open\n except for a superior division which still remained occluded. At this point,\n we felt sufficient intervention had been done and patient also received IV\n Integrilin and further aggressive therapy was not warranted. After discussion\n with Dr. we removed the Merci catheter. Runs again demonstrated an\n open right internal carotid artery and the right ICA terminus was open along\n with the middle cerebral artery branches. A decision was made to leave the\n right common femoral artery sheath in place as the patient had already\n received IV Integrilin and we felt it not prudent to take out the sheath.\n\n FINDINGS: Distal aortic runoff demonstrates a patent common iliac and\n external iliac artery on the right side with what appears to be occlusion of\n the superficial femoral artery with the catheter traversing the profunda\n femoris. On the left side, there is significant stenosis of the common iliac\n artery midway with significant stenosis of the internal iliac artery origin.\n Right common femoral artery arteriogram shows occlusion of the right internal\n carotid artery just distal to the bifurcation with no evidence of distal\n recanalization. The right external carotid artery and its branches fill well.\n Right common carotid artery arteriogram status post stenting of the right\n internal carotid artery shows residual stenosis at the distal portion of the\n stent. Right common carotid artery arteriogram status post angioplasty of the\n distal stented area shows no residual stenosis.\n\n (Over)\n\n 2:01 PM\n CAROT/CEREB Clip # \n Reason: Evaluate and treat right ICA occlusion.\n Admitting Diagnosis: S/P FALL\n Contrast: OPTIRAY Amt: 251\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Right internal carotid artery arteriogram status post stenting shows distal\n ICA terminus occlusion with reflux into the right vertebrobasilar artery and\n collateral filling of the left internal carotid artery and its branches. The\n right internal carotid artery arteriogram status post mechanical and chemical\n thrombolysis shows a fully patent right internal carotid artery with filling\n of the right middle cerebral artery and its branches. A superior division of\n the right middle cerebral artery is partially occluded.\n\n Right middle cerebral artery arteriogram demonstrates significant thrombus in\n the distal MI and M2 branches\n\n IMPRESSION: underwent emergent stenting of her right internal\n carotid artery and mechanical and chemical thrombolysis of her distal ICA and\n right middle cerebral artery.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2134-04-29 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1012482,
"text": " 4:11 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Does she have hemorrhagic conversion of inferior right MCA i\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with inferior right MCA infarct who is status post right ICA\n stent, and IA TPA and MERCI retrieval.\n REASON FOR THIS EXAMINATION:\n Does she have hemorrhagic conversion of inferior right MCA infarct? Extension\n of ischemic infarct?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hemorrhagic conversion of right MCA infarct. Query extension of\n ischemic infarct.\n\n COMPARISON: , at 12:57.\n\n TECHNIQUE: CT head without intravenous contrast.\n\n FINDINGS: There is a hypoattenuating area in the right basal ganglia and\n posterior frontal lobe which could represent contrast enhancement of the\n right-sided infarct, although a hemorrhagic conversion cannot be excluded. No\n other areas of hemorrhage are seen. There is some sulcal effacement of the\n right posterior frontal lobe with no appreciable midline shift. There is some\n effacement of the right lateral ventricle. There is no loss of -white\n matter differentiation. Osseous structures are grossly unremarkable.\n\n IMPRESSION: Contrast enhancement of right basal ganglia and posterior frontal\n infarct versus hemorrhagic conversion; consider MR.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2134-04-30 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1012620,
"text": " 2:14 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: evaluate for new hemorrhage, interval change. PLEASE PERFORM\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman presented with acute R MCA syndrome, found to have R ICA\n occlusion, underwent R ICA stenting, IA tPA, MERCI retrieval.\n REASON FOR THIS EXAMINATION:\n evaluate for new hemorrhage, interval change. PLEASE PERFORM AT 2 PM on \n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 78-year-old with acute right MCA syndrome, status post right ICA\n stenting and retrieval of right MCA clot. Evaluate for interval change.\n\n COMPARISON: Multiple prior CTs from one day prior.\n\n NON-CONTRAST HEAD CT: Previously seen high-density material within the right\n basal ganglia is much less apparent suggesting interval reabsorption and\n redistribution of IV contrast secondary to the patient's angiographic\n procedure. There is a small blush of residual hyperintensity within the right\n basal ganglia. There is evidence of sulcal effacement and loss of -white\n matter differentiation within the right MCA territory suggesting evolving\n infarction. No evidence of acute intracranial hemorrhage. There is minimal\n mass effect with 3 mm of leftward midline shift. The ventricles and sulci are\n prominent consistent with age-related involutional changes. There is no\n evidence of intraventricular blood. The basal cisterns are patent. The\n visualized paranasal sinuses and mastoid air cells are normally pneumatized\n and aerated.\n\n IMPRESSION: Redistribution and absorption of extravasated contrast material.\n No new hemorrhage. Moderate right cerebral edema in the MCA territory, likely\n due to evolving infarct. No new mass effect.\n\n"
},
{
"category": "Radiology",
"chartdate": "2134-05-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1012852,
"text": " 12:23 PM\n CHEST (PORTABLE AP) Clip # \n Reason: infiltrates\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with stroke\n REASON FOR THIS EXAMINATION:\n infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n COMPARISON: \n\n INDICATION: Stroke.\n\n Tracheal tube and nasogastric tube have been removed. Pacer remains in\n standard position. Heart is mildly enlarged, unchanged. New small left\n pleural effusion with adjacent left basilar atelectasis is demonstrated.\n Coexisting infection cannot be excluded. The right lung remains clear.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2134-04-30 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1012585,
"text": " 10:41 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ett placement\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with orif, stroke, occluded left iliac.\n REASON FOR THIS EXAMINATION:\n ett placement\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 10:55 A.M., \n\n HISTORY: Stroke. Check line placement.\n\n IMPRESSION: AP chest compared to and 8:\n\n ET tube is in standard placement, nasogastric tube passes into nondistended\n stomach and out of view. Mild cardiomegaly is stable. Lungs are fully\n expanded and clear. Pleural effusion, minimal, if any. No pneumothorax.\n Transvenous right atrial and right ventricular pacer leads are continuous from\n the right axillary pacemaker following their expected courses.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2134-05-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1013270,
"text": " 10:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for CHF\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman s/p right femur repair, stroke\n REASON FOR THIS EXAMINATION:\n eval for CHF\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post femur repair and stroke, to evaluate for failure.\n\n FINDINGS: In comparison with study of , the cardiac silhouette is again\n somewhat prominent, though there is no evidence of vascular congestion,\n pleural effusion, or acute pneumonia. The Dobbhoff tube has been pulled back\n so that its tip is in the upper body of the stomach. Pacemaker device remains\n in place.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2134-04-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1012501,
"text": " 6:10 PM\n CHEST (PORTABLE AP) Clip # \n Reason: post op CXR, ETT placement\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78F s/p R ICA stenting, received IA tPA, and MERCI clot retrieval still\n intubated\n REASON FOR THIS EXAMINATION:\n post op CXR, ETT placement\n ______________________________________________________________________________\n WET READ: 10:01 PM\n ETT 5.5 cm from the carina in standard position. NGT in good position below\n the diaphragm. Lungs remain clear. New stent in right neck consistent with\n history of R ICA stent placement.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 6:35 P.M. ON \n\n HISTORY: Recently intubated. Following clot retrieval.\n\n IMPRESSION: AP chest compared to .\n\n Lungs are clear, hyperinflated suggesting small airways obstruction, but there\n has been no recurrence of previous pulmonary vascular congestion or pleural\n effusion despite chronic moderate-to-severe cardiomegaly. ET tube is in\n standard placement, its cuff mildly distending the trachea. Nasogastric tube\n passes into a nondilated stomach and out of view. Transvenous right atrial\n and right ventricular pacer leads are continuous from the right axillary\n pacemaker following the expected courses. No pneumothorax or pleural\n effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2134-05-03 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1012955,
"text": " 11:03 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: f/u cerebral ischemia\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with stroke, R ICA occlusion\n REASON FOR THIS EXAMINATION:\n f/u cerebral ischemia\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HEAD CT\n\n HISTORY: 78-year-old woman with right ICA occlusion and right infarct.\n\n TECHNIQUE: Contiguous axial images were obtained from the skull base to the\n vertex.\n\n FINDINGS: Comparison is made to multiple prior CT scans dating back to \n with the most recent comparison being .\n\n There is continued evolution of previously seen infarct with hypodensities\n involving the right frontal, parietal, occipital, and temporal lobes largely\n within the watershed distribution. Small hypodensities of the right insula\n and basal ganglia are also seen as before. There has been complete resolution\n of the previously seen contrast enhancement.\n\n No intracranial hemorrhages are identified.\n\n Scattered white matter hypodensities are again seen consistent with chronic\n microangiopathic change. The ventricles are unchanged in size.\n\n Calcifications of the carotid siphons of the vertebral arteries are seen\n bilaterally.\n\n IMPRESSION: Continued evolution of right MCA and watershed infarcts. No\n intracranial hemorrhages and no new infarcts.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2134-04-28 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1012342,
"text": " 11:42 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with s/p fall\n REASON FOR THIS EXAMINATION:\n eval for acute process\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 78-year-old female status post fall. Please evaluate for acute\n process.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: There is no evidence of hemorrhage, edema, mass, mass effect, or\n acute vascular territorial infarction. Ventricles and sulci are mildly\n prominent, most consistent with age-related atrophy. There is mild\n periventricular white matter hypodensity, most consistent with chronic small\n vessel ischemic disease.\n\n There is no fracture. The paranasal sinuses are normally aerated. There are\n bilateral carotid and vertebral artery calcifications.\n\n IMPRESSION: No acute intracranial process.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2134-04-28 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 1012343,
"text": " 11:42 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with fall today at home, no loc. seen at osh with ?c6 fx. no\n films sent. eval for fracture\n REASON FOR THIS EXAMINATION:\n eval for fracture\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 2:08 AM\n no fracture or malalignment. mild . change.\n\n Agree w/ above. No fracture is seen.: , MD\n WET READ VERSION #1 12:26 AM\n no fracture or malalignment. mild . change.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 78-year-old female with fall today at home, no loss of\n consciousness. seen at outside hospital with possible C6 fracture, but no\n films for comparison.\n\n COMPARISON: None.\n\n TECHNIQUE: Routine non-contrast CT of the cervical spine with multiplanar\n reformations.\n\n FINDINGS: There is no cervical spine fracture or malalignment. Prevertebral\n and paraspinal soft tissues are not enlarged. Visualized outline of the\n thecal sac appears normal, but please note that CT is unable to provide\n intrathecal detail comparable to MRI.\n\n There is mild uncovertebral joint osteophytosis at multiple levels, without\n significant neural foraminal narrowing. Small broad-based calcified disc\n protrusion at C5-6 is seen, which mildly narrows the central canal, and\n slightly indents the ventral aspect of the thecal sac.\n\n Note is made of prominent bilateral vertebral artery calcifications, and\n carotid bifurcation calcifications.\n\n Centrilobular emphysematous changes are seen at the lung apices.\n\n IMPRESSION:\n\n 1. No fracture or cervical spine malalignment.\n\n 2. Mild multilevel degenerative change as described above.\n\n 3. Emphysema.\n\n (Over)\n\n 11:42 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: FALL\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Echo",
"chartdate": "2134-05-01 00:00:00.000",
"description": "Report",
"row_id": 67631,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Preoperative assessment.\nHeight: (in) 66\nWeight (lb): 124\nBSA (m2): 1.63 m2\nBP (mm Hg): 145/47\nHR (bpm): 111\nStatus: Inpatient\nDate/Time: at 14:36\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: LA volume markedly increased (>32ml/m2).\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. A catheter or pacing wire\nis seen in the RA and extending into the RV.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. No MVP. Mild mitral annular\ncalcification. Calcified tips of papillary muscles. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate [2+] TR. Moderate\nPA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: The rhythm appears to be atrial flutter.\n\nConclusions:\nThe left atrial volume is markedly increased (>32ml/m2). Left ventricular wall\nthickness, cavity size and regional/global systolic function are normal (LVEF\n>55%) Right ventricular chamber size and free wall motion are normal. The\naortic valve leaflets (3) are mildly thickened but aortic stenosis is not\npresent. No aortic regurgitation is seen. The mitral valve leaflets are\nstructurally normal. There is no mitral valve prolapse. Mild (1+) mitral\nregurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is\nmoderate pulmonary artery systolic hypertension. There is no pericardial\neffusion.\n\nCompared with the prior study (images reviewed) of , the findings are\nsimilar.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2134-05-06 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1013453,
"text": " 9:56 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: 52cm SL L basilic placed - ? tip\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with\n REASON FOR THIS EXAMINATION:\n 52cm SL L basilic placed - ? tip\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Follow up.\n\n COMPARISON: .\n\n As compared to the previous radiograph, the size of the cardiac silhouette is\n unchanged. Minimal left-sided pleural effusion, minimal retrocardiac\n atelectasis. The Dobbhoff tube has been advanced by approximately 10 cm in\n comparison to the previous examination. A PICC line has been newly inserted\n over the left upper extremity. The tip of the PICC line is in the lower third\n of the superior vena cava. No pneumothorax.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-04-29 00:00:00.000",
"description": "Report",
"row_id": 1634261,
"text": "Respiratory Care Note\nCalled to Neuroangio to set up ventilator for pt. Pt placed on AC 400x10 +5cmpeep 100%. Pt transported to CT Scan for evaluation of head and then transported to SICU - both were without incident. BS are clear and equal. ETT retaped upon arrival to unit. Plan to remain intubated and mechanically ventilated at this time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-04-29 00:00:00.000",
"description": "Report",
"row_id": 1634262,
"text": "Nursing Progress Note\nPt admitted from IR at 1700. See FHP/Carevue for assessment.\n\nPlan: Continue neuro checks, angio site checks per protocol, repeat CT in am.\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-04-30 00:00:00.000",
"description": "Report",
"row_id": 1634263,
"text": "Respiratory note:\nPt received on full ventilatory support 400/10/5 with 60%. Later wean to PSV, and FiO2 down to 40, pt appeared comfortable. Tube was moved down 1cm (21@lip). Sx for white thick secretions. RSBI=43, last ABG 7.36/38/186/22/-3. Plan was to extubate. MD decided to wait. Will continue to monitor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-05-02 00:00:00.000",
"description": "Report",
"row_id": 1634273,
"text": "Resp care\nPt remains intubated, On PSV and tol well. Bilateral breath sounds diminished rhonchi suctioned for moderate thick to thin white secretions. will keep monitoring pt.\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-05-02 00:00:00.000",
"description": "Report",
"row_id": 1634274,
"text": "Resp. care note - Pt. weaned and extubated then placed on mask vent 2y to resp. distr, tol ok at this time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-05-02 00:00:00.000",
"description": "Report",
"row_id": 1634275,
"text": "Nsg.progress notes:\nSee flow sheet for specific:\n\nNeuro: Patient is lethargic, opening eyes to call & some times spont too,pupils rt 4mm and lt 5mm briskly reactive to light, pupils turned to 5 & 6mm x1 when pt coughs and SBP >180 hydralazine given and Dr. informed of the same.moving rt UE spont, withdrawing all extrimities to pain. for Ct head tomorrow.\n\nCV: Stll in A flutter, rate controlled at 60's. SBP goal 140-180, hydralazine x3 for SBP >180 with good effect. started w/ Enalaprilate today, Lasix 20mg x1 with good effect. palpable PP, but checked hrly with doplar, IVF kvo'd, 40mmol kcl replacing for K 3.3,++ edema on UE with bluish discoloration underneath the skin, Dr. aware and seen by him.\n\nResp: Was on vent cpap /ps 5/5 at begining, then extubated at 1000, abg was boarder line, noted in distress, NT suction with white thin secretion & started with BIPAP mask ventilation at 1215, abg good now, comfortable since then.LS clear, o2 sat 99-100%, good cough, impaired gag.\n\nGI: Abd soft, OGT removed during extubation, No feeding tube now Dr. aware.PO meds all given this am via OGT.nPO now, no BM, +BS.can try dobhoff once pt is stable with resp stataus.\n\nGU: foley cath patent with yellow clear urine , lasix 20mg with good effect.\n\nEndo: Bld sug q6h, on SSRI.\n\nID: Afebrile, sputum and urine c/s& UA sent today. No anbx. ^ WBc rechecked CBC pnd report.\n\nAct: Turned in bed from side to side, skin intact, post op femoral site DSD intact, s/ ortho MD, xray hip seen, okay per Dr. no new orders, for rt leg( ext rotation).not to use any splint or wedge.rt groin dressing changed.\n\nSocial: Visited by her husband, two sons, one of them is the HCP, daughter and grand children, updated by RN, HCP brought an official DNR/CMO document, informed Dr. about it, he was in discussed the pOC with family members, revised the DNR order, now DNR only,pls see the for and orderv in the chart.\n\n\nPlan: cont monitoirng, pulm hygiene, abg's, cont BIPAP, CT head tomorrow.check pulses LE, neuro checks q1h.support to pt and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-05-01 00:00:00.000",
"description": "Report",
"row_id": 1634267,
"text": "NURSING PROGRESS NOTE\n\nPLEASE SEE CAREVUE FOR DETAILS.\n\n NEURO: Opens eyes to voice. Inconsistently following commands to wriggle toes/move legs. Not following commands when prompted for upper extremity movements. Noted spontaneous movement w/feet, ? spastic movements. Purposeful movement noted x1, pt appeared to be trying to move pillow out from under arm using right arm. Unable to nod to yes/no questions. Pupils brisk & reactive. Right 3mm, Left 4mm.\n RESP: Cont Cpap/PS 5/5, FiO2 to 30%. ABG WNL (7.34/40/98/23/-3). Lungs clear, diminished at bases. Suctioning for scant thick white/yellow.\n CV: Afebrile. SBP 130-160, recieved Hydralazine x1 for SBP 165 (Goal 140-160. To restart Neo if SBP </= 90, to tx w/fluid boluses first). V-Paced. HR 60, ectopy noted rarely. PT/Dorsal pulses palpable, weak at times. Fem pulses palpable. Extremities cool-warm, normal in color. Hands slightly edematous. Fluid bolus x1 for low urine output.\n GI/ENDO: ABD soft. NT. ND. + BS. No BM. TF at goal, no residuals. FBS tx per RISS.\n GU: Making CYU via Foley. Hourly u/o approx. 20-25cc. Received 250cc bolus x1 for u/o 15cc, slight effect.\n\nSOCIAL: Daughter called. Flying in today from .\n\nPOC: SBP 140-160. Monitor I&O's. Cardiac Echo scheduled for today. Monitor pain/comfort. Hourly Neuro checks. Hourly pulse checks. ? extubate. HO aware of above, call w/any changes.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-05-01 00:00:00.000",
"description": "Report",
"row_id": 1634268,
"text": "Respiratory Care:\n\nPt remain orally intubated & sedated on minimal spontaneous ventilation. RSBI done ~51. BS are dim & clear bil. We are sxtn for scant secretions from ETT. Plan: awaiting to see if Pt can get more awake. See careview for furher details.\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-05-01 00:00:00.000",
"description": "Report",
"row_id": 1634269,
"text": "ADDENDUM\n\nAdditional fluid bolus for low urine output. Dr aware. Accepting hourly urine output of 20-25cc, will discuss further on am rounds, ? pt dry. Also pt recieved 1MG Morphine, slighly tachycardic, grimacing, inc. in sbp to high 160s, givne w/effect.\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-05-01 00:00:00.000",
"description": "Report",
"row_id": 1634270,
"text": "Resp. care note - Pt. remaines intubated and vented, transffered to CT and back to SICU without incident.\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-05-05 00:00:00.000",
"description": "Report",
"row_id": 1634281,
"text": "resp care\nbronchodilator via neb given, pt suctioned for tannish sputum. bs rhonchorous with upper airway congestion. strong cough when stimulated. follow for bronchopulmonary hygiene.\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-05-03 00:00:00.000",
"description": "Report",
"row_id": 1634276,
"text": "Nursing Progress Note\nSee Carevue for specifics\n\nPt opens eyes to voice. PERRL 4mm bil-occasionally unequal-team aware. Spontaneously lifts BUE, moves feet on bed, not to command.\nRemains afebrile. WBC trending down. Cultures pending from .\nV-paced with underlying A flutter. Rare PVC's. K 4.0 after repletion. HR 60. Currently on Dilt gtt at 5mg/hr. ?dc when pt again on po Lopressor. Hep gtt at 850 units/hr. Last PTT 52. Goal PTT 50-70. PTT from 0400 pending.\nBUE remain edematous. DP/PT pulses dopplerable bil. Strong palpable fem/ pulses. ext's warm and nml in color. Right fem angio site covered with DSD-no hematoma or drainage noted. Right hip incision covered with DSD-C/D/I no drainage noted.\nLSCTA. Sats 100% on face tent 70%. Will wean as tolerated. NT suctioned for moderate amts thick white secretions.\n+BS. Abd soft. po meds held per Dr. insert Dobhoff this am to resume Tf's and po meds.\nFoley draining adequate amts CYU.\n\nPlan: Cont pulm toilet, neuro checks, hemodynamics, wean dilt as tolerated, pulse checks, Hep gtt, follow labs. Repeat head CT this am. ?family meeting today. Notify HO with changes.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-05-03 00:00:00.000",
"description": "Report",
"row_id": 1634277,
"text": "PROGRESS NOTE\n\nSEE CAREVUE FOR SPECIFICS\n\nNEURO: Essentially unchanged. Arouses opening eyes to voice. Pupils unequal, Right 3mm, Left 4mm, both brisk & reactive to light. Not following commands. Nonpurposeful spontaneous movement noted at times on RUE only. Recieved prn Morphine x2 w/effect. OT/PT consulted, worked w/pt sitting on side of bed, will cont to follow. Head CT done this am.\nRESP: Face tent, sat's 95-99% 50% FiO2. Lungs clear, coarse at times, suctioning for small amt. thick white secretions using yankeur. Pt w/strong cough, constant clearing of throat sounds. Gag impaired.\nCV: V-Paced, underlying Aflutter. HR 60's, occ PVC's. Diltiazem gtt off, started PO Diltiazem. Cont Heparin gtt for PTT 50-70. SBP 140-160 (pts goal), as high as 180 w/pain.\nGI/ENDO: ABD soft. NT. ND. No BM. + BS. Restarted TF via Dobhoff, goal 60cc/hr. FBS tx per RISS, minimal coverage required.\nGU: Making adequate CYU via foley. Started on Lasix twice daily.\nSOCIAL: Daughter into visit. Spoke w/ MD. Updated.\n\nPOC: Pulm toilet. Hourly neuro & pulse checks. Monitor heme. PTT checks every 6 hours for Heparin gtt. Closely follow labs since starting Lasix, tx as needed. Monitor pain/comfort. Call HO w/any changes.\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-04-30 00:00:00.000",
"description": "Report",
"row_id": 1634264,
"text": "SICU NPN\nS-Sedated.\n\nSEE CAREVUE FOR ALL OBJECTIVE DATA AND TRENDS IN FLOWSHEETS.\n\nO-Recieved w/ Propofol off. Arousing to voice and following simple commands inconsistently. MAEs except for LUE. SBPs to be maintained between 160-180, SBP falling to 130s. Started on Neo. Neo on/off for majority of nihgt. Arterial and venous sheaths in place, pulses dopplerable throughout until 0200. During check RLE noted to be cold and mottled to knee. Unable to obtain pulses. Dr. notified and contacting , Neuromedicine, Dr. , cheif resident in house(Dr. and IR on call. Agreement to pull sheaths. Sheaths pulled at 0325. Hemostasis at 0405. No hematoma palpated. DSD intact. DP pulse returning at 0500. PT diffuse with non-consistent pulse. Vascular consulted with plant to take to OR this morning for possible thrombectomy. Weaned to CPAP on evening shift and tolerating well. RSBI 42. HUO marginal, requiring fluid bolus x one with result. Maintenance continues at 75cc/hr. 4L(+) from MN. Lytes repleted. NPO. NGT clamped. Afebrile. No issues. Dtr calling and updated by RN.\n\nA/P:78 yo s/p fall c/b hip fx later c/b embolic CVA with meric procedure performed with result. Sheaths left in place overnight. Pulses lost overnight in RLE. Sheaths removed with return of DP pulses. Vascular consulted and pt to go to OR for throbectomy.\n\nCn call to OR\nKeep SBP 160-180\nFollow pulses hourly\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-04-30 00:00:00.000",
"description": "Report",
"row_id": 1634265,
"text": "Resp. care note - Pt. remaines intubated and vented, transffered to CT and back to SICU without incident.\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-05-01 00:00:00.000",
"description": "Report",
"row_id": 1634271,
"text": "Nsg.progresss notes:\nSee flow sheet for specific:\n\nNeuro: Patient is more awake towards afternoon, opening eyes spont now, moving rt arm spont, lt hnad to pain, wiggled the toes few times when asked, but not consistently,also noted spont movement of feet,? non purposeful.pupils rt 3-4mm, lt 4-5mm both briskly reactive to light.Ct head this morning, unchanged per neuro med team.\n\nCV: V paced HR in 60's, in a flutter @ 1215, Dr. informed, lopressor 2.5mg x2 ,followed by 15mg bolus with rate controlled to 70's, then satrted with gtt, and heparin gtt addedd per cardiology,PTT q6h.SBP 140-150.hydralazine x1 for SBP >180 with good effect.pulses felt weak, checked by doplar hrly.IVF ns at 40ml/hr.EKG done when in flutter and bed side cardiac echo was done today.\n\nResp: remains on vent, no vent changes today, Ls clear, sxn thick white secretion,O2 sat 98-100%.\n\nGI: Abd soft, +BS, no Bm today. Tf at goal with minimal residue.\n\nGU: foley cath patent with yellow clear urine 15-25ml/hr teamn aware.\n\nEndo: Bld sug q6h, on SSRI.\n\nID: Afebrile. no anbx.\n\nAct:Turned from side to side, skin intact, post op dressing changed by ortho MD,? noted external rotation og rt leg, informed Dr. ortho MD, s/b him, xray hip ordered and done.no restriction in movement per ortho team, dressing in the rt groin with old blood, unchanged.\n\nSocial; Visited by pt's daughter, updated by RN, requested SICU MD or primary team for updates,whole family is planning to visit tomorrow.\n\nPlan:cont monitoring, pulm hygiene, neuro checks q1h, check for PP,PTT q6h, heparin per wt based scale, titrate to keep Hr ~60,support to patient and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-05-02 00:00:00.000",
"description": "Report",
"row_id": 1634272,
"text": "NURSING PROGRESS NOTE\n\nSEE CAREVUE FOR DETAILS.\n\nNEURO: AROUSES EASILY TO VOICE OPENING EYES. NO TRACKING. PUPILS BRISK & REACTIVE, RIGHT 3MM, LEFT 4-5MM, DR AWARE. NOT FOLLOWING COMMANDS. OCCASIONALLY NOTING RIGHT ARM MOVING SPONTANEOUSLY ON BED. WITHDRAWS ALL EXTREMITIES TO NAIL BED PRESSURE, LEFT ARM TAKING SLIGHTLY LONGER TO RESPOND IN COMPARISON TO RIGHT. GRIMACING IN PAIN AT TIMES, RECIEVING PRN MORPHINE W/EFFECT (SBP ALSO INCREASES W/GRIMACE).\n\nRESP: NO VENT CHANGES. ABG WNL. LUNGS CTAB. SUCTIONING FOR MOD AMTS CLEAR/WHITE THIN SECRETIONS. STRONG COUGH BRINGING UP FAIR AMT OF ORAL SECRETIONS.\n\nCV: SBP 140-160 (GOAL SBP 140-160, CURRENTLY ONLY TO RESTART NEO IF SBP <90), INC TO 180 W/PAIN. AFLUTTER W/OCC PVC'S. CONT DILT. TITRATING HEPARIN FOR GOAL PTT 60-100 PER HEPARIN SS, CHECKING PTT LEVELS EVERY 6 HRS. + PP. + FEM PULSES. EXTREMITIES WARM. BUE SWOLLEN, ELEVATED ON PILLOWS.\n\nID: AFEBRILE. WBC MILDLY ELEVATED FROM 12 TO 15.2\n\nGI/GU: ABD SOFT. NT. ND. + BS. NO BM. TF AT GOAL, NO RESIDUALS. HOURLY U/O 15-30CC CYU VIA FOLEY. TEAM AWARE OF MARGINAL U/O, WILL CONT TO MONITOR.\n\nENDO: RISS, REQUIRING MIN COVERAGE.\n\nSKIN/ORTHO: SKIN INTACT. EDEMA IN BUE. LEFT LIP W/SM ABRASION. RIGHT HIP DRESSING C/D/I, LEG REMAINS TURNED OUT, REPOSITIONING TO KEEP LEG IN LINE. ? NEED FOR BRACE OR WEDGE.\n\nPOC: PULM TOILET. MONITOR HEMODYNAMICS. TITRATE HEPARIN CHECKING PTT EVERY 6 HRS (NEXT DUE AT 0800). DILT GTT. NEURO & PULSE CHECKS HOURLY.\nFOLLOW & TX LABS AS NEEDED. MONITOR HOURLY U/O. ? EVALUATION FOR LEG BRACE OR WEDGE. HO AWARE OF ABOVE, WILL CALL W/ANY CHANGES.\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-04-30 00:00:00.000",
"description": "Report",
"row_id": 1634266,
"text": "Nsg.progress notes:\nsee flow sheet for specific:\n\nReceived the patient from OR at 0845 s/p rt femoral throbectomy & patch angioplasty and rt iliac stent, on neo gtt sedated and paralized not reversed ,neo turned off in 30min upon arrival to sicu.doplarable pulses on rt leg both dorsal and post tibial, lt leg only dorsal doplarable, vascular and sicu team aware.\n\n\nNeuro: OFF all sedation, opening eyes to call, following commands very inconsistently, did squeeze the hands few times moving the feet spontaneously, nods no to pain.morphine x1 this morning for pain, PERL,CT head done with report in, very lethargic.\n\nCV: V paced rhythm with occational pvc's, SBP goal 140-160, to restart neo if sbp <90 only per neuro med,to treat with fluids if <140. doplarable pulses on rt foot,lt leg post. tibial not doplarable both vascular(Dr. & Dr.) and sicu MD DR. aware.LE was cool and pale upon arrival now improved with temp and color.++ edema ,IVF NS at 75ml/hr. enzymes 3'rd sample send.\n\nResp: Remains on vent, mode changed to CPAP/PS, ABG still acidotic, LS clear and diminished at bases, O2 sat 98-100%.\n\nGI: Abd soft, +BS, no BM, NPO still, oGT to gravity with brown drainage. PO meds via OGT.\n\nGU: Foley cath patent with yellow clear urine 20-40ml/hr, SICU MD aware.\n\nEndo: Bld sug q6h, wnl.\n\nID: On cefazoline x3 doses post op.afebrile.\n\nAct: No restriction in movement per ortho, turned from side to side, skin intact.\n\nSocial; pt's grand daughter called up this am, updated, no other contacts.\n\nPlan: Cont monitoring, pulm hygiene, neuro checks q1h, pulse checks LE q1h, monitor for any changes, report to HO with any changes, SBP goal 140 -160,angio site with blood soaked dressing with small hematoma , vascular team aware. to watch.\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-05-04 00:00:00.000",
"description": "Report",
"row_id": 1634278,
"text": "Nursing Progress NOte\nPlease see carvue for specifics:\nPt remains neuro unchanged. Pt did require PRN hydral X1 overnoc for increased SBP with effect. Pt with one episode of desaturation overnoc to 87-91. Pt NTS for thick white secretions. Sats only to low 90's post sxn. Pt then given albuteral nebs and ambu's and then sxn again for mod thick secretions. Sats post ambu and sxn 96-100%. Pt Fi02 remains at .50%. Lungs remains clear to coarse at x's. Slightly diminshed at the bases. ABG post ambu and sxn adequate. Otherwise pt stable. Heparin titrated per protocol. TF at goal and tolerating well. Remains on RISS. Plan: Cont with current plan of care. ? start rehab screeening. Supportive care to pt and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-05-04 00:00:00.000",
"description": "Report",
"row_id": 1634279,
"text": "PROGRESS NOTE\n\nSEE CAREVUE FOR DETAILS.\n\nNEURO: Not following commands. Pupils Right 3mm, Left 4mm. Right arm w/nonpurposeful movments on bed. Withdraws all extremities to pain. Appears more alert, eyes open majority of day. OT worked w/pt, stating slightly improved since yesterday. Hoyered to chair x2 hrs. Prn Morphine w/effect.\n\nLungs clear, diminished at bases. Coarse at times. Suctioning for thick white secretions. Strong cough. Sat's 97-100% face mask w/50% FiO2. V-Paced w/underlying A-flutter. Cont PO dilt. HR 60's, some PVC's. A-line discontiued per Dr . NBP 140-170 systolically, recieving prn Hydralazine x2 for SBP >160. Heparin gtt remains at 1100 (goal PTT 50-70). TF cont at goal. ABD soft. NT. ND. No BM. + BS. FBS treated per RISS. Making adequate CYU via foley. BUE remain swollen.\n\nSOCIAL: Dr spoke w/pts son regarding pts w/possible PEG & rehab screening, will hold on PEG until Thursday during scheduled famly meeting.\n\n: Pulm toilet. Nuero checks every 2 hrs. SBP <160. Cont PT/OT, OOB as tol. PTT every 6 hrs, Heparin gtt. Monitor pain/comfort. Family meeting Thursday. ? PEG in future to start Rehab screen. Call HO w/any changes.\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-05-05 00:00:00.000",
"description": "Report",
"row_id": 1634280,
"text": "NPN\nPlease see carevue for specifics:\n\nPt overnight; sbp into 180's around 0200 requiring hydralazine 20mg IV with a good response back to 160's, HR vpaced in aflutter rate controlled in the 60's, tmax 97.4, and rr 20's with 02 sat 97-100% on cool neb mask 40%. Pt resting well overnight; opening eyes to speech and motions in th room, not tracking or following commands, pupils 3-4mm on right and 4mm on left briskly reactive to light, moves all extremities on bed to nailbed pressure. LS coarse throught out at times, requiring heavy NT suctioning with large amounts of thick tan secretions removed and lung sounds clear. +bs x4 and +flatus overnight with no BM; tubefeeds remain at goal and tolerating well. dopplerable pulses dp/pt and palpable femoral pulses; extremities warm. Left arm swollen; placed on pillows to help decrease swelling. Foley draining adequate amounts of CYU. Am PTT 67.5 (withing goal range 50-70) an heparin remains at 1000u/hr; all other am labs as patients baseline, continues with hypophosphatemia. Daughter called and aware of plan of care and that no neurological improvements were seen overnight. Continue to monitor labs, vs, i/o's, and give family psychosocial support; plan for fmaily meeting on Thursday.\n"
}
] |
23,226 | 185,457 | Pt is a 49 YOM with known CAD/CM who presents after v fib arrest. . 1) CAD/V fib arrest: Patient collapsed in mall and was found to be in vfib when EMS arrived. He received bystander CPR with estimated time between collapse and EMS arrival of 15 minutes. Was shocked and became asystolic and then was given epi/atropine and returned to narrow complex rhythm. Has h/o CAD s/p 4 vessel CABG and ischemic cardiomyopathy. EKG done afterwards did not look ischemic, however may have had acute occlusion of one of his grafts causing his arrythmia without EKG findings currently. Had signs of anoxic brain injury on arrival to the CCU including myoclonus and posturing which are poor prognostic indicators. Neurology was consulted. He was loaded with IV valproic acid for sz ppx and placed on versed drip. Given the patient had an hospital arrest and he was within 6 hours of his arrest the decision was made to treat with therapeutic hypothermia to reduce cerebral metabolic needs. He was placed on Vecuronium to reduce shivering during the cooling process. He was cooled down to 89 degrees for 18 hours per protocol and then slowly rewarmed. Given the possibility of an ischemic event he was placed on IV heparin and continued on ASA. He had been started on amiodarone prior to arrival which was stopped due to prolonged QT interval. He was continued on BB which was uptitrated. . 2) Resp: Patient was intubated in the field for airway protection. Has no history of lung disease. Was found to have an aspiration PNA which was treated as below. During the hospitalization he did not tolerate his ETT, specifically, when attempting to wean him off of sedation he would cough violently and become very agitated. Given his poor neurologic status and likely need for prolonged intubation Interventional Pulmonology was consulted regarding trach placement. A trach was placed on . He continued to have a strong cough despite anesthetics and cough suppressants. He was changed to PS ventilation and tolerated this well and was then weaned to trach mask. With improvement in his PNA he was able to be weaned to NC and his trach was capped. . 3) DM: Normally on inuslin pump at home. Sugars initially elevated to 400 with gap acidosis. Likely DKA in setting of arrest and no insulin pump. Bolused with 1L NS and placed on insulin gtt. His anion gap resolved and he was maintained on the insulin gtt for tight glucose control. was consulted for assistance in transition to SC insulin. Once TFs were stabilized he was switched to Glargine and RISS. His long-acting insulin was uptitrated to 50U to be given at lunchtime daily. . 4) Renal insufficency - On admission the patient's Cr was slightly elevated to 1.3. Etiology was likely poor perfusion in setting of cardiac arrest. His Cr returned to baseline and remained stable. . 5) Fever: Patient developed high fevers on HD#2 up to 102. Initially felt to be either central fevers vs. infection, however he then developed bandemia suggestive of acute infection. He was pan-cultured. CXR was consistant with either aspiration pneumonitis vs. PNA so he was started on ceftriaxone and flagyl. Sputum culture grew out pan-sensitive Klebsiella so his flagyl was discontinued. He had recurrent fevers a week into treatment and was recultured. CXR showed worsening of his PNA and given the concern for hospital acquired pathogens and VAP his antibiotics were broadened to vanc/zosyn. Repeat sputum culure grew out MSSA and the vanco was discontinued. All urine and blood cultures were NGTD. Zosyn, which was started on , needs to be continued for a total of two weeks. . 6) FEN: NPO initially given patient was paralyzed. TFs were initiated and PEG was placed for permanant feeding. . 7) PPX: heparin gtt transiently, then heparin sc, PPI . 8) Access: R subclavian, left A line . 9) Code: DNR/I | The normal vascular flow voids are present. There is mild symmetric left ventricularhypertrophy. The left ventricular cavity size is top normal/borderlinedilated. Consider left ventricular hypertrophy although this isnon-diagnostic. slight ST wsegment depression inleads I, II and aVL. Mild PAsystolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR.PERICARDIUM: No pericardial effusion.Conclusions:The left atrium is mildly dilated. The previously seen subgaleal hematoma has resolved. Top normal/borderline dilated LV cavitysize. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Overall left ventricular systolic function is mildly depressed withinferolateral hypokinesis/akinesis. Sinus rhythmNonspecific ST-T abnormalitiesSince previous tracing of , no significant change Trivial mitral regurgitation is seen.There is mild pulmonary artery systolic hypertension. Mild [1+] TR. Downsloping ST segment depressions in leads V2-V6 suggestpossible anterior ischemia. Trivial MR.TRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate-sized left parietal subgaleal hematoma. No resting LVOT gradient.LV WALL MOTION: Regional LV wall motion abnormalities include: midinferolateral - hypo; lateral apex - hypo;RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level. Also,ventricular ectopy is no longer evident. Sinus rhythm and occasional ventriciular ectopy. Possibleinferior wall myocardial infarction of indeterminate age, possibily acute.Non-specific inferolateral repolarization changes consistent with ischemia.Compared to the previous tracing of there is subtle ST segmentelevation in leads III and aVF consistent with ongoing acute ischemia. Sinus rhythmHigh voltageInferior/lateral ST-T changes are nonspecificSince previous tracing of , no significant change Compared to the previoustracing of the ST segment elevations in the inferior leads have largelyresolved. Compared to theprevious tracing of subtle ST segment elevations in leads III and aVFare no longer present and the QTc interval is shorter. There is gross patchy consolidation of the right lower lobe as well as the lateral portion of the middle lobe. Probable left ventricular hypertrophy with secondaryST-T wave abnormalities. Non-specific inferolateral T wave changes. Sinus bradycardia with marked Q-T interval prolongation. Mildly depressed LVEF. S/p V-Fib Arrest.Weight (lb): 218BP (mm Hg): 142/65HR (bpm): 79Status: InpatientDate/Time: at 11:26Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Mild LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Mild symmetric LVH. There is a left parietal subgaleal hematoma present. Borderline abrreviated P-R interval. Left atrialabnormality. Normal sinus rhythm. Normal sinus rhythm. Normal brain parenchymal signal. IMPRESSION: Normal MRA. Non-specific ST-T wave changes with prolonged QTc interval andprominent U waves. TECHNIQUE: T1 sagittal, T2, FLAIR, diffusion weighted, gradient echo axial images of the brain were obtained without contrast. TECHNIQUE: FINDINGS: There is no slow diffusion to indicate an acute infarct. Since the previous tracing of probably nosignificant change. These changes represent someresolution of the ischemic appearing ST-T wave abnormalities recorded onthe tracing of . Downsloping ST segmentdepression in the anterolateral leads suggest possible inferior ischemia.Compared to the previous tracing of the marked Q-T intervalprolongation is new. The aortic valve leaflets (3) appear structurallynormal with good leaflet excursion and no aortic regurgitation. ST segment flattening and lowamplitude T waves in the limb leads. Sinus tachycardia. Right ventricular chamber size and freewall motion are normal. Sinus rhythm. Sinus rhythm. Normal MRA of the brain. Sinus tachycardia with T wave inversions and ST segment depressions inleads I, aVL and V2-V6 suggest possible anterior and lateral ischemia. Upsloping ST segment depressions in the anterolateralleads likely secondary to left ventricular hypertrophy. Compared to the previous tracing of no change.TRACING #2 PATIENT/TEST INFORMATION:Indication: Left ventricular function. Normal ascending aortadiameter.AORTIC VALVE: Normal aortic valve leaflets (3). FINDINGS: The vertebral arteries are symmetric. The brain parenchymal signal is normal with no evidence of midline shift or herniation. In addition, the rate has slowed. The upper lung fields are reasonably well aerated. Q-T interval prolongation. Rule out infarction.Followup and clinical correlation are suggested. compared to the previous tracing of theST-T wave abnormalities are more prominent. There are no areas of abnormally restricted diffusion or new hemorrhage. Clinicalcorrelation is suggested. Clinicalcorrelation is suggested. Cannot exclude drug/electrolyte/metabolic effect. Unresponsive. Evaluate for mass and infarct. IMPRESSION: No infarct or mass effect. No AS. Normal sinus rhythm, rate 80. IMPRESSION: No evidence of injury to the brain. There is no absence of normal flow signal. MRA OF THE BRAIN: No areas of aneurysmal dilation or significant stenosis are noted. s/p trach REASON FOR THIS EXAMINATION: Evaluate trach position FINAL REPORT Chest and single AP view of the chest in comparison with 05/20 reveals the endotracheal tube to have been replaced with a tracheostomy tube. Tip of a subclavian placed catheter is in the SVC. Clinical correlation is suggested. The mitralvalve leaflets are mildly thickened. ST segment depressions and T wave inversions inleads V3-V5 with ST-T wave flattening in lead V6. There is no pericardialeffusion. Fluid is seen within several paranasal sinuses, nasopharynx, as well as within scattered mastoid air cells consistent with the patient's intubated status. No previous tracing available for comparison.TRACING #1 There is opacification of all of the paranasal sinuses which could be due to intubation. Clinical correlation is suggested.TRACING #3 MRA: TECHNIQUE: 3D time-of-flight MRA of the circle of . The overall appearance of the chest shows more intense consolidation in the right base lower lobe in comparison with the previous examination, which could have been related to positive pressure. There is no evidence of an aneurysm or intracranial stenosis. MRI OF THE BRAIN: There are no anatomic or signal abnormalities within the brain parenchyma. MRA of the circle of was performed with three-dimensional reconstructions. There is no evidence of a pneumothorax. COMPARISON: MRI/MRA of the brain from . There is also patchy consolidation in the left lower lobe as well. 8:53 PM MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # Reason: evaluate for anoxic brain injury, focal injury, mass, infarc Admitting Diagnosis: CARDIAC ARREST MEDICAL CONDITION: 49 year old man with DM, CAD s/p CABG who presented after v-fib arrest, now unresponsive REASON FOR THIS EXAMINATION: evaluate for anoxic brain injury, focal injury, mass, infarct FINAL REPORT INDICATION: Diabetes, coronary artery disease status post CABG who presented after V-fib arrest, now unresponsive, evaluate for anoxic brain injury. | 15 | [
{
"category": "Radiology",
"chartdate": "2190-04-26 00:00:00.000",
"description": "BY DIFFERENT PHYSICIAN",
"row_id": 962018,
"text": " 12:58 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Evaluate trach position\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with v fib arrest, intubated, with Klebsiella\n aspiration PNA. s/p trach\n REASON FOR THIS EXAMINATION:\n Evaluate trach position\n ______________________________________________________________________________\n FINAL REPORT\n Chest and single AP view of the chest in comparison with 05/20 reveals the\n endotracheal tube to have been replaced with a tracheostomy tube. There is\n gross patchy consolidation of the right lower lobe as well as the lateral\n portion of the middle lobe. There is also patchy consolidation in the left\n lower lobe as well. The upper lung fields are reasonably well aerated. The\n overall appearance of the chest shows more intense consolidation in the right\n base lower lobe in comparison with the previous examination, which could have\n been related to positive pressure. Tip of a subclavian placed catheter is in\n the SVC. There is no evidence of a pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2190-04-24 00:00:00.000",
"description": "MR HEAD W/O CONTRAST",
"row_id": 961798,
"text": " 2:40 PM\n MRA BRAIN W/O CONTRAST; MR HEAD W/O CONTRAST Clip # \n Reason: please evaluate for focal injury\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old man with DM, CAD s/p CABG who presented after v-fib arrest, now\n unresponsive\n REASON FOR THIS EXAMINATION:\n please evaluate for focal injury\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 49-year-old man who presents after V fib arrest. Unresponsive.\n\n COMPARISON: MRI/MRA of the brain from .\n\n TECHNIQUE: T1 sagittal, T2, FLAIR, diffusion weighted, gradient echo axial\n images of the brain were obtained without contrast. MRA of the circle of\n was performed with three-dimensional reconstructions.\n\n MRI OF THE BRAIN: There are no anatomic or signal abnormalities within the\n brain parenchyma. There are no areas of abnormally restricted diffusion or\n new hemorrhage. The previously seen subgaleal hematoma has resolved.\n\n Fluid is seen within several paranasal sinuses, nasopharynx, as well as within\n scattered mastoid air cells consistent with the patient's intubated status.\n\n MRA OF THE BRAIN: No areas of aneurysmal dilation or significant stenosis are\n noted.\n\n IMPRESSION: No evidence of injury to the brain. Normal MRA of the brain.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2190-04-19 00:00:00.000",
"description": "MRA BRAIN W/O CONTRAST",
"row_id": 961085,
"text": " 8:53 PM\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: evaluate for anoxic brain injury, focal injury, mass, infarc\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old man with DM, CAD s/p CABG who presented after v-fib arrest, now\n unresponsive\n REASON FOR THIS EXAMINATION:\n evaluate for anoxic brain injury, focal injury, mass, infarct\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Diabetes, coronary artery disease status post CABG who presented\n after V-fib arrest, now unresponsive, evaluate for anoxic brain injury.\n Evaluate for mass and infarct.\n\n TECHNIQUE:\n\n FINDINGS: There is no slow diffusion to indicate an acute infarct. There is\n a left parietal subgaleal hematoma present. The brain parenchymal signal is\n normal with no evidence of midline shift or herniation. There is\n opacification of all of the paranasal sinuses which could be due to\n intubation. The normal vascular flow voids are present.\n\n IMPRESSION:\n\n No infarct or mass effect. Normal brain parenchymal signal.\n\n Moderate-sized left parietal subgaleal hematoma.\n\n MRA:\n\n TECHNIQUE: 3D time-of-flight MRA of the circle of .\n\n FINDINGS: The vertebral arteries are symmetric. There is no evidence of an\n aneurysm or intracranial stenosis.\n\n There is no absence of normal flow signal.\n\n IMPRESSION:\n\n Normal MRA.\n\n\n\n"
},
{
"category": "Echo",
"chartdate": "2190-04-21 00:00:00.000",
"description": "Report",
"row_id": 101578,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. S/p V-Fib Arrest.\nWeight (lb): 218\nBP (mm Hg): 142/65\nHR (bpm): 79\nStatus: Inpatient\nDate/Time: at 11:26\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Mild symmetric LVH. Top normal/borderline dilated LV cavity\nsize. Mildly depressed LVEF. No resting LVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: mid\ninferolateral - hypo; lateral apex - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Mild PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is mildly dilated. There is mild symmetric left ventricular\nhypertrophy. The left ventricular cavity size is top normal/borderline\ndilated. Overall left ventricular systolic function is mildly depressed with\ninferolateral hypokinesis/akinesis. Right ventricular chamber size and free\nwall motion are normal. The aortic valve leaflets (3) appear structurally\nnormal with good leaflet excursion and no aortic regurgitation. The mitral\nvalve leaflets are mildly thickened. Trivial mitral regurgitation is seen.\nThere is mild pulmonary artery systolic hypertension. There is no pericardial\neffusion.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2190-04-17 00:00:00.000",
"description": "Report",
"row_id": 302133,
"text": "Normal sinus rhythm. Probable left ventricular hypertrophy with secondary\nST-T wave abnormalities. Upsloping ST segment depressions in the anterolateral\nleads likely secondary to left ventricular hypertrophy. Left atrial\nabnormality. No previous tracing available for comparison.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2190-04-18 00:00:00.000",
"description": "Report",
"row_id": 302134,
"text": "Sinus tachycardia. Compared to the previous tracing of no change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2190-04-18 00:00:00.000",
"description": "Report",
"row_id": 302135,
"text": "Sinus bradycardia with marked Q-T interval prolongation. Downsloping ST segment\ndepression in the anterolateral leads suggest possible inferior ischemia.\nCompared to the previous tracing of the marked Q-T interval\nprolongation is new. Clinical correlation is suggested.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2190-04-19 00:00:00.000",
"description": "Report",
"row_id": 302353,
"text": "Normal sinus rhythm. Downsloping ST segment depressions in leads V2-V6 suggest\npossible anterior ischemia. Q-T interval prolongation. Compared to the previous\ntracing of the ST segment elevations in the inferior leads have largely\nresolved. Clinical correlation is suggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2190-04-20 00:00:00.000",
"description": "Report",
"row_id": 302354,
"text": "Sinus tachycardia with T wave inversions and ST segment depressions in\nleads I, aVL and V2-V6 suggest possible anterior and lateral ischemia. Clinical\ncorrelation is suggested. compared to the previous tracing of the\nST-T wave abnormalities are more prominent.\n\n"
},
{
"category": "ECG",
"chartdate": "2190-04-28 00:00:00.000",
"description": "Report",
"row_id": 302360,
"text": "Sinus rhythm\nHigh voltage\nInferior/lateral ST-T changes are nonspecific\nSince previous tracing of , no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2190-04-21 00:00:00.000",
"description": "Report",
"row_id": 302355,
"text": "Sinus rhythm and occasional ventriciular ectopy. ST segment flattening and low\namplitude T waves in the limb leads. slight ST wsegment depression in\nleads I, II and aVL. ST segment depressions and T wave inversions in\nleads V3-V5 with ST-T wave flattening in lead V6. These changes represent some\nresolution of the ischemic appearing ST-T wave abnormalities recorded on\nthe tracing of . In addition, the rate has slowed. Rule out infarction.\nFollowup and clinical correlation are suggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2190-04-22 00:00:00.000",
"description": "Report",
"row_id": 302356,
"text": "Normal sinus rhythm, rate 80. Borderline abrreviated P-R interval. Possible\ninferior wall myocardial infarction of indeterminate age, possibily acute.\nNon-specific inferolateral repolarization changes consistent with ischemia.\nCompared to the previous tracing of there is subtle ST segment\nelevation in leads III and aVF consistent with ongoing acute ischemia. Also,\nventricular ectopy is no longer evident.\n\n"
},
{
"category": "ECG",
"chartdate": "2190-04-25 00:00:00.000",
"description": "Report",
"row_id": 302357,
"text": "Sinus rhythm. Non-specific inferolateral T wave changes. Compared to the\nprevious tracing of subtle ST segment elevations in leads III and aVF\nare no longer present and the QTc interval is shorter.\n\n"
},
{
"category": "ECG",
"chartdate": "2190-04-26 00:00:00.000",
"description": "Report",
"row_id": 302358,
"text": "Sinus rhythm\nNonspecific ST-T abnormalities\nSince previous tracing of , no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2190-04-27 00:00:00.000",
"description": "Report",
"row_id": 302359,
"text": "Sinus rhythm. Consider left ventricular hypertrophy although this is\nnon-diagnostic. Non-specific ST-T wave changes with prolonged QTc interval and\nprominent U waves. Cannot exclude drug/electrolyte/metabolic effect. Clinical\ncorrelation is suggested. Since the previous tracing of probably no\nsignificant change.\n\n"
}
] |
6,474 | 180,301 | A/P: 75 yo originally presented to OSH with syncope and later developed NSTEMI. At , 3VD via cath and post sclerosis of gastric ulcer. . #Cardiac: #Ischemia: - NSTEMI at OSH - 3VD - via cath on -> PTCA of OM1 -> CT surgery being put off till next week because of her gastric ulcer. She needs to stay in house because of the 3VD to monitor - On ASA, statin, BBlocker (titrated down for hypotension) - if BP can tolerate, consider adding on Lisinopril - holding heparin and integrilin in setting of GI bleed . # Pump - ECHO showed 45% EF with akinesis/hypokinesis of inferior and inferiolateral segments; mild-symmetric LVH - CI: 3.2 on - low central pressures - probably indicative of GI bleed or dehydration. - IABP -> pulled on . # Rhythm: Sinus tach to 100s . # GIB: - EGD from showed esophagitis and gastric ulcer that was sclerosed - continue Protonix gtt and needs rescope in 6 weeks - got 4U PRBC on - 2 for hypotension/low hct and 2 more for hct<30. - hct goal>30 for CT surgery - q6 Hcts - started on clears as per GI . - probably a result from the combination of heparin, integrilin, ASA, 300mg Plavix - Lavage returned dark blood; Guaiac positive, but no frank blood on glove - patient Hct 34 at OSH; 18.5 here at found after cath - : 3U PRBC - : 4 Units PRBC . # DM - Hold glucotrol - Started insulin drip on . # PPX: - Protonix gtt - SC heparin - NPO for procedure . # FEN: - NPO . # Syncope: - likely from GIB/MI . Currently AAOx3. . # Code: - full code IABP removed prior to surgery. GI consult obtained- EGD showed gastric ulcer. Underwent cabg x3 on by Dr. . Transferred to the CSRU in stable condition on epinephrine and propofol drips. Extubated that evening and Swan DCed on POD #1. Gentle diuresis was started and neo drip weaned off. Chest tubes removed on POD #2 and transferred to the floor. She went into Afib that evening and was started on amiodarone. Beta blockade was titrated for rate control. Converted to SR on POD #4 and pacing wires were removed without incident. She made good progress increasing her activity level and was discharged to home with VNA on POD #6. She will need f/u with the GI service for repeat endoscopy in 4 weeks. | HIT antibody result pending.RESP: Lungs clear in apices, diminished bibasilarly. add'l fluid infusing & low dose neo started with resolution. Neo weaned off. Protonix drip dc'd. UOP improved w/ maintenance IVF - awaiting AM Na+ results. GI consult this AM - poss. GLUCOTROL RESTARTED TODAY. + pulses to lower ext by doppler. Generalized edema noted. K repleted per protocol, last K 4.4. MAE, +CSM. MAE, +CSM. MAE, +CSM. cont with Protonix drip. There isa trivial/physiologic pericardial effusion. Received 1L NS IVFB and transfused 2U PRBCs (repeat Hct at 2300: 28.8) w/ slight improvement in SBP/MAP. Trivial mitral regurgitation is seen. Encouraged to DBC/IS. ENCOURAGED DEEP BREATHING AND IS.CVS- NSR WITH OCCASSIONAL PVCS.HR-80-100. Chest dsg D+I. Cortisol stim test completed. To start dosing. Infuse bld per orders. Respiratory CarePt. ENCOURAGE PULMONARY REHAB.LABILE BP RESOLVED. Medicated for pain X1. Continue pulm. Good inspiratory effort for spirocare. +Pulses - pedal pulses +1, confirmed by doppler. Epinephrine titrated to current rate of 0.01mcg/kg/min per . Further IVFB for hypovolemia? remains asymptomatic - radial a-line insertion ? will advance to percocet as tolerated. Tolerating clear liquids w/o difficulty. WEANED PHENYLEPHRINE OFF,MAINTAINING SBP>90.MEDISTINAL TUBES REMOVED,PLEURAL ON SUCTION,MINIMAL TO MODERATE DRAINAGE.CXR DONE.PULSES DOPPERABLE BILATERALLY,LEFT DP WEAK DOPPLER000.GI/GU- TOLERATED PO INTAKE. Intrinsically SR w/PAC's/PVC's. CONTINUE ICU INTERVENTIONS. PACs and respiratory variation. Protonix infusion changed to dosing. EGD? cont to monitor hct. CSRU NSG:NEURO: A&OX3, appropriate. K and Mg levels pending as of this writing. ABLE TO PIVOT WITHOUT DIFF TO CHAIR.A: NSTEMI C/ NEWLY DIAGNOSED 3VD-PT DID IABP,PRESSOR SUPPORT, AWAITING CABG .P: CONT. distal pulses by doppler. "O: See CareVue flowsheet for complete assessment detailsCV: HR 80s-90s, SR w/ freq. Lungs clear bilaterally/diminished at the bases. Tolerated well R groin is C&D with sm old hematoma. EGD done this pm by GI large ulcer noted which was cauterized. Tolerating IABP 1:2 w/ MAP > 60 - continue to wean w/ poss. L groin is is C&D. BS's Rx per SSRI protocol.Assessment: Neo for BP. CR 0.6.GI: Abdomen soft, NT, +BSX4Q.ID: Afebrile, WBC 17.3.INTEG: Skin intact. OOB to chair when de-lined. There is mild symmetric left ventricularhypertrophy. Advance diet as tolerated. afebrile. ENCOURAGE PO INTAKE. Improved after 2 percocets given. AM Hct (post 2U PRBC transfusion) pending. Pt. Pt. Pt. Pt. Glyburide 2.5mg given x's 1. K 3.6 REPLEATED C 80MEQ POTASSIUM. CCU Addendum: 0545AM labs revealed Hct 28.6 - Dr. notified. MAG 1.8 REPLEATED C 2MG. Taking clears well. Pt is able to MAE. Course c/b UGIB - Hct decreased to 18 - multiple PRBC transfusions w/ stable Hct > 30. Denies nausea. BS <120.Plan: ?Transfer to floor. O2 sats 95-98%.Neuro: Pt is alert and oriented cooperative with care. significant improvement in spo2 & resp. Ace wrap remains to R leg.GI/GU: ABd round soft, + BS. No neural deficit noted.CV: Arrives from OR 1135hrs on Epi, neo drips. CI consistently > 2. BP stable - NBP 80-100s w/ MAP > 60. Low precordial lead voltage.Compared to the previous tracing of atrial ectopy is no longerrecorded. Cardiac enzymes not yet peaked - AM results: CK/MB/trop - 1243 (405)/173 (48)/3.55 (0.62).RESP: Lung fields: clear in apices, diminished bibasilarly. Interval left chest tube removal. Sinus rhythmRight bundle branch blockLow QRS voltage - clinical correlation is suggestedSince previous tracing of , sinus tachycardia absent There has been interval removal of a nasogastric tube and Swan-Ganz catheter. Unassisted systole 90s-100s, unassisted diastole 50s, unassisted MAP 65-79. SEMIUPRIGHT CHEST RADIOGRAPH: Cardiac and mediastinal silhouette is stable. PA-line intact via right groin - waveform dampened, softened hematoma, no oozing appreciated. AP SUPINE CHEST RADIOGRAPH: Heart size and mediastinal contours are within normal limits. became hypotensive - maintained MAP >60, but significant decrease noted in assisted systolic/diastolic pressures. A left-sided chest tube and two mediastinal drainage tubes are identified. The aorta is calcified. There has been interval removal of the Swan-Ganz catheter and mediastinal chest tubes. Small left pleural effusion. Systolic unloading , diastolic unloading . Status post chest tube removal. 1:2 hemodynamic results pending. The right internal jugular line position is unchanged. Sinus arrhythmia. Again seen is a right-sided cordis with tip overlying the SVC. Again seen is bilateral lower lobe atelectasis. Noprevious tracing available for comparison.TRACING #1 Denies nausea. Palpable radial pulses Initially, IABP 1:1 w/ assisted systole 80-96, BAEDP 49-62, and IABP MAP 68-81. IMPRESSION: 1) Mild congestive heart failure. developed discomfort in lower back accompanied by diaphoresis - EKG obtained; no changes per CCU team. PA-line waveform dampened despite intervention - Dr. attempted to wedge PA-line w/o results. Compared to the previous tracing tachycardia, right bundle-branchblock and low voltage persist.TRACING #2 Again seen is mild congestive heart failure. Interval removal of Swan-Ganz catheter and mediastinal chest tubes. FINDINGS: AP single view of the chest has been obtained with the patient in supine position. The left chest tube has been removed. Adequate UOP: 95-220cc/hr, -925cc thus far. There is small left pleural effusion. Heparin post-IABP on hold d/t UGIB. Mild congestive heart failure. Cardiac silhouette is upper limits of normal in size and stable. Sinus rhythm with probably sinus arrhythmia and atrial premature complexesRight bundle branch blockLow QRS voltage - clinical correlation is suggestedSince previous tracing of , atrial ectopy present Otherwise, stable appearing chest findings. There is pulmonary vascular engorgement, bilateral perihilar haziness, and bilateral septal thickening, not significantly changed allowing for technical differences between the studies. Sinus rhythm. No longer requiring pressors (received on Neo infusion). Sinus arrhythmiaConduction defect of RBBB typeLeft atrial abnormalityIncomplete right bundle branch blockInferior T wave changes are nonspecificRepolarization changes may be partly due to rhythmLow QRS voltages in precordial leadsSince previous tracing of , no significant change NGT intact - placement confirmed by CXR and auscultation. Repeat MVO2 obtained during episode of hypotension - 61%, C.O./C.I. Sinus tachycardia. Bibasilar atelectasis persists. IMPRESSION: Low positioned ETT, withdrawal by a few centimeters is recommended. | 28 | [
{
"category": "Echo",
"chartdate": "2134-02-02 00:00:00.000",
"description": "Report",
"row_id": 80391,
"text": "PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease. Left ventricular function.\nHeight: (in) 66\nWeight (lb): 185\nBSA (m2): 1.94 m2\nBP (mm Hg): 93/64\nHR (bpm): 100\nStatus: Inpatient\nDate/Time: at 11:52\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior\n- hypo; mid inferior - hypo; basal inferolateral - hypo; mid inferolateral -\nhypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets. Aortic valve not well\nseen. No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nThe left atrium is normal in size. There is mild symmetric left ventricular\nhypertrophy. The left ventricular cavity size is normal and systolic function\nis mildly impaired.. Resting regional wall motion abnormalities include\nthinned and akinetic/hypokinetic inferior and inferolateral segments. Right\nventricular chamber size and free wall motion are normal. The aortic valve\nleaflets are mildly thickened. The aortic valve is not well seen. There is no\naortic valve stenosis. No aortic regurgitation is seen. The mitral valve\nleaflets are mildly thickened. Trivial mitral regurgitation is seen. There is\na trivial/physiologic pericardial effusion.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-02-10 00:00:00.000",
"description": "Report",
"row_id": 1347670,
"text": "NEURO- PATIENT ALERT AND ORIENTED. MAE ON COMMAND. TRANSFERRED FROM BED TO CHAIR WITH ASSISTANCEX2 ,MANAGED WELL. OXYCODONE-ACETAMINOPHEN GIVEN FOR PAIN.\n\nRESP- ON NC 5L SPO2 92%-95%. LUNGS CLEAR TO COARSE,FEW CRACKLES EARLER,NOW DIMINISHED. NON PRODUCTIVE COUGH. ENCOURAGED DEEP BREATHING AND IS.\n\nCVS- NSR WITH OCCASSIONAL PVCS.HR-80-100. ELECTROLYTES REPLETED. WEANED PHENYLEPHRINE OFF,MAINTAINING SBP>90.MEDISTINAL TUBES REMOVED,PLEURAL ON SUCTION,MINIMAL TO MODERATE DRAINAGE.CXR DONE.PULSES DOPPERABLE BILATERALLY,LEFT DP WEAK DOPPLER000.\n\nGI/GU- TOLERATED PO INTAKE. BS PRESENT.FUROSEMIDE 20 MG IV GIVEN.RESPONED WELL.\n\nENDO- BS MAINTAINED AS SSRI.\n\nSOCIAL-FAMILY VISITING.\n\nA/P- LUNGS-CLEAR TO COARSE. ENCOURAGE PULMONARY REHAB.LABILE BP RESOLVED. MAINTAIN SBP(90-100).TO CLOSELY MONITOR AND REVIEW THE PARAMETERS. ENCOURAGE PO INTAKE. CONTINUE ICU INTERVENTIONS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-02-11 00:00:00.000",
"description": "Report",
"row_id": 1347671,
"text": "1900-0700\n\nNeuro: Pt awake, alert, oriented. Follows commands well. MAEs. Appropriate and cooperative. No neuro deficits noted.\n\nResp: Resp easy and regular, O2sat 92-95% on 5L NC. Encouraged to DBC/IS. Lungs clear bilaterally/diminished at the bases. Denies SOB. CT intact to pleurevac draining minimal amounts S/S fluid, no airleak noted.\n\nCV: NSR without ectopy. HR 70-80s, SBP remains >90. afebrile. Medicated for pain X1. + pulses to lower ext by doppler. Generalized edema noted. Skin warm/dry/intact. Chest dsg D+I. Wires intact/pacer wires intact. Ace wrap remains to R leg.\n\nGI/GU: ABd round soft, + BS. Taking clears well. No nausea/vomiting. Foley to BSD draining clear yellow urine, remains receiving lasix 20mg .\n\nEndo: Pt off insulin drip. BS <120.\n\nPlan: ?Transfer to floor. Supportive care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-02-09 00:00:00.000",
"description": "Report",
"row_id": 1347667,
"text": "CSRU NSG:\n\nNEURO: A&OX3, appropriate. +MAE equally. No neural deficit noted.\n\nCV: Arrives from OR 1135hrs on Epi, neo drips. Neo weaned off. Epinephrine titrated to current rate of 0.01mcg/kg/min per . CI consistently > 2. Initially AV asynch from OR, changed to a-pacing, now a- demand at 60bpm. Intrinsically SR w/PAC's/PVC's. LR boluses total 2.5L. HCT 37.3 before fluid boluses, repeat HCT pending. Magnesium 2GM IV given for frequent PVC's per with good result. K repleted per protocol, last K 4.4. K and Mg levels pending as of this writing. Radial pulses paslpable, faint pedal pulses per doppler only.\n\nPULM: Quickly weaned and extubated 1445 hrs per Fast Track protocol after reversal. LSCTAB, no SOB or dyspnea noted. Uses IS to 600cc. PaO2 67% on O2 4L via NC, O2 increased to 6L via NC.\n\nGU: Urine clr, dilute, output QS. CR 0.6.\n\nGI: Abdomen soft, NT, +BSX4Q.\n\nID: Afebrile, WBC 17.3.\n\nINTEG: Skin intact. Patient is able to make small position changes ad-lib. Complete bath given.\n\nENDO: Insulin drip per protocol. Regular insulin drip currently at 5U/hr.\n\nSOCIAL: Daughter is spokesperson - .\n\nASSESS: Epi drip for inotropy. Insulin drip for glucose control.\n\nPLAN: Titrate epi drip per order . Titrate insulin drip per protocol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-02-09 00:00:00.000",
"description": "Report",
"row_id": 1347668,
"text": "minimal change in hct after > 2 liters,low filling pressures w sbp dipping into the high 70's-low 80's esp. w movement & deep breathing. add'l fluid infusing & low dose neo started with resolution. excellent hemodynamics,epi off.insulin gtt titrated as indicated. significant improvement in spo2 & resp. effort after pain controlled w morphine.tol. po fluids well except for c/o sore throat. will advance to percocet as tolerated. family in,questions answered. see flow sheet.\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-02-10 00:00:00.000",
"description": "Report",
"row_id": 1347669,
"text": "Pt. alert and cooperative. C/O pain, mainly under left breast at chest tube insertion site. Improved after 2 percocets given. Pt. had fallen asleep for a couple of hours after meds.\nHemodynamics stable, although remains on .5mcq/kg of Neo. MAP's low 60's most of the night.\nBS clear bilat. Good inspiratory effort for spirocare. Inhaled volume ~600cc.\nExtr. warm except both feet cool below ankle line bilat. RLE edema > LLE.\nBilat pedal pulses +PT's by Doppler; unable to doppler DP's despite marked areas. Right SVG harvest site with noted erythema on medial lower leg. Leg rewrapped in ace bandage.\nChest tube drng. averaging 50cc/hr serosang.\nGood huo. Labs wnl. BS's Rx per SSRI protocol.\nAssessment: Neo for BP. Pt. has insulin requirements.\nPlan: Wean Neo to MAP> 60. Check BS's q6. Med. for pain prn. OOB to chair when de-lined. Continue pulm. toilet. Advance DAT.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-02-03 00:00:00.000",
"description": "Report",
"row_id": 1347661,
"text": "CCU NPN: 1900-0700\n\nS: \"My mouth is so dry - I won't ever be able to taste food again!\"\n\nO: See CareVue flowsheet for complete assessment details\n\nCV: HR 80s-90s, SR w/ freq. PACs and rare PVC. Continues to be hypotensive despite blood transfusion and IVFB from previous shift. SBP 80s-90s, MAP > 55 - discussed at length w/ Drs. - decision made to maintain MAP > 50 if pt. remains asymptomatic. Received 1L NS IVFB and transfused 2U PRBCs (repeat Hct at 2300: 28.8) w/ slight improvement in SBP/MAP. Metoprolol dose decreased - held this AM d/t marginal BP. Cortisol stim test completed. AM Hct (post 2U PRBC transfusion) pending. Right and left groin sites (post-sheath/IABP) D/I, no oozing nor hematoma noted. +Pulses - pedal pulses +1, confirmed by doppler. Cardiac enzymes peaked at 2300: CK/CK-MB: 750/58 (1404/).\n\nRESP: Lungs clear in apices, diminished bibasilarly. Denies SOB, DOE. O2 sat > 95% on 3L NC.\n\nGI/GU/ENDO: Abd. soft, non-tender, non-distended. BS active x4 quadrants. Remains NPO - continues to have soreness in throat (although NGT discontinued earlier in day) - relieved w/ ice chips. Denies nausea. No stool - +flatus. Post-EGD, remains on Protonix infusion at 8mg/hr. UOP 65-160cc/hr. I/O: +156cc , +275cc thus far. Insulin infusion titrated to BS <150 - pt. tolerating w/o hypoglycemia.\n\nNEURO/SOCIAL: Alert and oriented x3. Pleasant and cooperative - anxious for surgery. MAE, +CSM. Follows commands consistently. Asking appropriate questions re: plan of care. Family members visiting early in shift.\n\nA/P: Newly diagnosed 3VD - awaiting CABG. Surgical intervention postponed d/t UGIB - gastric ulcer cauterized per GI team . Hct continues to be unstable despite multiple PRBC transfusions - AM Hct pending - serial Hct. Marginal BP - minimal response to IVF - Cortisol stim test results pending. Continue to follow MAP w/ goal > 50 if pt. remains asymptomatic - radial a-line insertion ? NPO except for meds, ice chips - Cepacol lozenges for soreness in throat? Protonix infusion until further notice from GI team. Increase activity ? Hourly FS w/ insulin infusion. Emotional support and teaching to pt. and family. Awaiting further plans from team.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-02-03 00:00:00.000",
"description": "Report",
"row_id": 1347662,
"text": "Nursing Progress Note\n\nS: \"Do you think I can have some ice, I'm so thirsty.\"\n\nO: Please see flow sheet for objective data. Tele sinus 80's-90's with occ PCV's. SBP > 90. To be restarted on lopressor 12.5mg . Pt denies chest pain. plts down to 98,000.\n\nResp: Lungs diminished in bases with rales ^. O2 sats 95-98%.\n\nNeuro: Pt is alert and oriented cooperative with care. OOB to chair for several hrs during shift tolerated well.\n\nGU/GI: Diet advanced to clear liquids tolerated well. Denies n/v. Abd is nontender, soft with bowel sounds present. no BM today. Foley draining CYU. Urine output less than previous 24hrs. Na noted to be 150 this am. Free water intake ^'d. Given 500D5W with 40 MEQ's KCL over 5hrs followed by 1 liter of NS at 150/hr. Repeat labs pending. Protonix drip dc'd. To start dosing. Hct 33 this am then 30 repeat pending.\n\nEndo: Pt received on Insulin drip this am. Please see flow sheet for changes and bld sugars. Glyburide 2.5mg given x's 1. Insulin drip dc'd in pm.\n\nSocial: Daughters in to visit for most of the day. Spoke with medical doctors.\n\nA&P: 75 yo women with NSTEMI c/b UGI bleed 3VD awaiting CABG next week. Hct improving after bld overnight. cont to monitor hct. Cont with free water, IV fluids as per doctors . Check lytes later this pm.\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-02-04 00:00:00.000",
"description": "Report",
"row_id": 1347663,
"text": "CCU NPN\n\nS: \"I am scheduled for my surgery on Tuesday ...\"\n\nO: See CareVue flowsheet for complete assessment details\n\nCV: HR 70s-90s, SR w/ occ. PACs and respiratory variation. BP stable - NBP 80-100s w/ MAP > 60. Right and left groin sites benign - no oozing nor hematomas appreciated, +1 pedal pulses. ECHO results : EF 45%, decreased LV wall motion and mild LV hypertrophy. Hct remains stable - 2400 result: 30.0 - CCU team aware. Electrolytes repleted as needed - K+ 3.4 (repleted w/ 40meq KCl PO). HIT antibody result pending.\n\nRESP: Lungs clear in apices, diminished bibasilarly. Denies SOB, DOE. Continues on NC at 2L w/ O2 sats > 95%.\n\nGI/GU/ENDO: Abd. soft, non-tender, non-distended. BS active x4 quadrants. Tolerating clear liquids w/o difficulty. Protonix infusion changed to dosing. No stool, negative flatus. Continues to report mild soreness in throat relieved w/ Cepacol lozenges PRN. UOP 40-70cc/hr - continues on maintenance IVF (1/2 NS at 100cc/hr) for resolving hypovolemia. I/O: +2.9L , +275cc thus far. Received diabetic oral and 5U NPH insulin at 1700 - FS at 2300: 65 - Dr. aware. Pt. given 150cc cranberry juice w/ resultant FS: 118. NPH insulin order discontinued, sliding scale continues.\n\nNEURO: Alert and oriented x3. Pleasant and cooperative. Verbalized understanding of plan of care. MAE, +CSM. OOB to chair until 2100 - pt. tolerated well. No neuro deficits appreciated.\n\nA/P: NSTEMI w/ newly diagnosed 3VD - required IABP, pressor support - awaiting CABG . Course c/b UGIB - Hct decreased to 18 - multiple PRBC transfusions w/ stable Hct > 30. S/P EGD w/ cauterization of gastric ulcer . UOP improved w/ maintenance IVF - awaiting AM Na+ results. FS labile w/ PO and fixed doses of insulin - NPH dose discontinued, next dose of Glyburide in AM, FSq4h until stablizes. Advance diet as tolerated. AM labs, HIT antibody pending. Emotional support and teaching.\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-02-04 00:00:00.000",
"description": "Report",
"row_id": 1347664,
"text": "CCU Addendum: 0545\n\nAM labs revealed Hct 28.6 - Dr. notified. Awaiting plans from team re: PRBC transfusion. (Maintain Hct > 30 per GI recommendations?) Continue to monitor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-02-04 00:00:00.000",
"description": "Report",
"row_id": 1347665,
"text": "S:\"I FEEL GOOD TODAY.\" \"WHAT IS A ULCER.\"\n\nO:SEE CAREVUE FOR ASSESSMENT DETAILS\n\nCV:HR 70S-80S.NBP 90-110S. NSRHCT THIS AM 28.6 PT 1 UNIT PRBC TODAY. K 3.6 REPLEATED C 80MEQ POTASSIUM. MAG 1.8 REPLEATED C 2MG. HIT RESULT PENDING. CABG POSTPONED UNTIL NEXT WEEK BECAUSE OF GI BLEED.\n\nRESP:PT RECEIVING LASIX R/T PULMONARY EDEMA. O2 SAT ON RA >95%.\n\nGI: ABD. SOFT POSITIVE BS POSITIVE BM, BLACK TARRY GUIAC (+).DIABETIC DIET. GLUCOTROL RESTARTED TODAY. PT ALSO RECEIVING REG INSULIN AS NEEDED.\n\nGU: PT DIURESED TODAY (-) 1940CC SINCE MIDNIGHT.\n\nNEURO: PT AWAKE OX3. ABLE TO PIVOT WITHOUT DIFF TO CHAIR.\n\nA: NSTEMI C/ NEWLY DIAGNOSED 3VD-PT DID IABP,PRESSOR SUPPORT, AWAITING CABG .\n\nP: CONT. TO MONITOR HCT, CBC.\nCONT. TO MONITOR BP AND HR. CONT TO ASSESS FOR GI BLEEDING. CONT TO ADVANCE DIET AS TOLERATED TO DIABETIC DIET.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-02-09 00:00:00.000",
"description": "Report",
"row_id": 1347666,
"text": "Respiratory Care\nPt. extubated without incident, positive signs for airleak, gag, swallow, and cough. C/DB well able to clear secretions well. BS clear and equal Bilaterally.\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-02-02 00:00:00.000",
"description": "Report",
"row_id": 1347659,
"text": "(Continued)\nand cooperative. Dozing intermittently during night. MAE, +CSM. Follows commands and asking appropriate questions re: plan of care etc. Received Oxycodone 5mg PO (per NGT) for c/o general discomfort w/ adequate results. Family into visit upon arrival to CCU - oriented to unit. Daughter, (also health care proxy) updated on phone this AM.\n\nA/P: Presented to OSH after syncopal episodes x2. Initially R/O by cardiac enzymes and was scheduled for stress test which was positive w/ hypotension and ST depressions in anterior leads. Transferred to on Heparin, Integrilin, post-Plavix bolus for cath which revealed severe 3VD - 80% prox LAD, 100% prox (PTCA to OM1), and 100% RCA - IABP placed. C- consulted for CABG which is presently postponed as pt. developed UGIB. Tolerating IABP 1:2 w/ MAP > 60 - continue to wean w/ poss. discontinuation? Follow hemodynamics. Serial Hct - next Hct: 1000. Continue to cycle cardiac enzymes until peaked. Further IVFB for hypovolemia? GI consult this AM - poss. EGD? FSQID - insulin gtt for hyperglycemia? Provide emotional support and teaching to pt. and family. CABG in near future once GI bleeding resolves? Awaiting further plans from team.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-02-02 00:00:00.000",
"description": "Report",
"row_id": 1347660,
"text": "Nursing Progress Note\n\nS: When is this tube going to come out of my nose?\"\n\nO: Please see flow sheet for objective data. Tele sinus rhythm rate 90's 120's with occ bursts of SVT, asymptomatic. Lopressor started and titrated to 25mg . IABP dc'd by card fellow this pm. Tolerated well R groin is C&D with sm old hematoma. L groin is is C&D. distal pulses by doppler. L LE slightly cooler than R. No heparin d/t UGI bleed. Pt denies chest pain or shortness of breath.\n\nResp: Lungs diminshed throughout the bases. O2 sats 96-99%.\n\nNeuro: Pt is alert and oriented. Pt is able to MAE. Maintained on Bedrest post IABP pull.\n\nGU/GI: Pt remains NPO X meds and ice chips. Abd is slightly distended, non tender with bowel sounds present. Early this am pt with dark bldy drainage from NG tube. hct 31 after 4 units overnight. Down to 28 this pm. Pt to receive 2 additional units this pm. First unit is up. EGD done this pm by GI large ulcer noted which was cauterized. NG tube was pulled during the procedure. Pt to continue with Protonix drip at 8mg/hr.\n\nEndo: Pt started on Insulin drip for ^ blood sugars. Infusing at 4u/hr with bld sugars gradually coming down to <160.\n\nSocial: Three children in to visit. Have spoken with several MD's regarding possiblity of CABG and POC.\n\nA&P: 75 yo women with newly dx 3 VD needing CABG with significant hct drop to 19 and now known gastric ulcer limiting anticoagulation. cont with Protonix drip. Infuse bld per orders. Monitor hct closely overnight. ?? CABG sometime this week.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-02-02 00:00:00.000",
"description": "Report",
"row_id": 1347658,
"text": "CCU Admission Note: 2300-0700\n\nS: \"My throat is so sore - it hurts to swallow!\"\n\nO: See CareVue flowsheet for complete assessment details\n\nCV: HR 100s, ST w/ occasional PVCs - episode of AIVR and run of NSVT during which pt. asymptomatic - denies palpitations, lightheadedness etc. IABP (30cc) intact via left femoral artery - initially w/ minimal oozing at site - no further oozing nor hematoma appreciated, knee immobilizer intact. Left pulses dopplerable (PT/DP), warm to touch. PA-line intact via right groin - waveform dampened, softened hematoma, no oozing appreciated. Right DP absent, PT dopplerable, warm to touch. Unable to perform ABIs on pt. d/t equipment malfunction and peripheral claudication. Palpable radial pulses Initially, IABP 1:1 w/ assisted systole 80-96, BAEDP 49-62, and IABP MAP 68-81. No longer requiring pressors (received on Neo infusion). No signs of augmentation. Unassisted systole 90s-100s, unassisted diastole 50s, unassisted MAP 65-79. Systolic unloading , diastolic unloading . At 0315, pt. developed discomfort in lower back accompanied by diaphoresis - EKG obtained; no changes per CCU team. Shortly thereafter, pt. became hypotensive - maintained MAP >60, but significant decrease noted in assisted systolic/diastolic pressures. CCU team (including cardiology fellow, Dr. at bedside to evaluate. Decision made to wean IABP to 1:2 as BP improved after doing so. Tolerating 1:2 IABP setting w/ MAPs 80s. PAD 12-20 w/ tachycardia and anemia - adm. 500cc NS IVFB w/ slight improvement in PAD. PA-line waveform dampened despite intervention - Dr. attempted to wedge PA-line w/o results. MVO2 obtained on 1:1 early in shift - 60%, C.O./C.I.: 7.9/3.91. Repeat MVO2 obtained during episode of hypotension - 61%, C.O./C.I.: 5.5/2.72. 1:2 hemodynamic results pending. Heparin post-IABP on hold d/t UGIB. Transfused total of 4U PRBCs (4th presently infusing) - latest Hct: 26.5 - presumable UGIB - GI to consult , poss. EGD. Cardiac enzymes not yet peaked - AM results: CK/MB/trop - 1243 (405)/173 (48)/3.55 (0.62).\n\nRESP: Lung fields: clear in apices, diminished bibasilarly. No sx's of respiratory distress - denies SOB. O2 sat > 95% on 3L NC.\n\nGI/GU/ENDO: Abd. soft, slightly distended, non-tender. BS active x4 quadrants. NGT intact - placement confirmed by CXR and auscultation. NGT to LIS - dark red blood (grossly OB +) aspirated. Denies nausea. Primary complained of soreness in throat d/t NGT placement - temporary relief provided by ice chips. NPO except meds, ice chips. Received Protonix bolus followed by continuous Protonix infusion (8mg/hr). Foley placed upon arrival from cath lab - immediate UOP: 1250cc. Adequate UOP: 95-220cc/hr, -925cc thus far. Reports to be NIDDM at home, on oral meds but denies home blood glucose monitoring - FS at HS: 291 - received 4 units Humalog insulin (as pt. NPO) - AM FS continues to be elevated at 335.\n\nNEURO/SOCIAL: Alert and oriented x3, pleasant\n"
},
{
"category": "Radiology",
"chartdate": "2134-02-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 894756,
"text": " 7:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?infiltrate,edema\n Admitting Diagnosis: UNSTABLE ANGINA\\CARDIAC CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with IABP\n\n REASON FOR THIS EXAMINATION:\n ?infiltrate,edema\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 75-year-old with IABP. Question infiltrate and edema.\n\n COMPARISON: .\n\n SEMIUPRIGHT CHEST RADIOGRAPH: Cardiac and mediastinal silhouette is stable.\n The aorta is calcified. Again seen is mild congestive heart failure. A new\n left lower lobe opacity is seen. There is small left pleural effusion.\n\n There has been interval removal of a nasogastric tube and Swan-Ganz catheter.\n No intraaortic balloon pump is seen.\n\n IMPRESSION:\n\n 1. Mild congestive heart failure.\n\n 2. New left lower lobe opacity, which may represent pneumonia versus\n atelectasis. Small left pleural effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2134-02-02 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 894573,
"text": " 12:12 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: assess placement of balloon pump, NGT\n Admitting Diagnosis: UNSTABLE ANGINA\\CARDIAC CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with IABP\n REASON FOR THIS EXAMINATION:\n assess placement of balloon pump, NGT\n ______________________________________________________________________________\n FINAL REPORT\n No prior studies for comparison.\n\n AP SUPINE CHEST RADIOGRAPH: Heart size and mediastinal contours are within\n normal limits. Increased congestion of the pulmonary vasculature consistent\n with mild congestive heart failure. A nasogastric tube is seen with tip in\n the stomach. A Swan-Ganz catheter tip is seen in the main pulmonary artery.\n An intra-aortic balloon pump is not visualized on this film. There is no\n evidence of pneumothorax. Osseous structures are unremarkable.\n\n IMPRESSION:\n\n 1) Mild congestive heart failure.\n\n 2) Nasogastric tube in appropriate position. Swan-Ganz catheter in the main\n pulmonary artery. Intra-aortic balloon pump not seen.\n\n Findings were discussed with house officer.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2134-02-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 895783,
"text": " 9:38 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p CT d/c\n Admitting Diagnosis: UNSTABLE ANGINA\\CARDIAC CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman s/p CABG now with mediastinal chest tubes pulled\n\n REASON FOR THIS EXAMINATION:\n s/p CT d/c\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 75-year-old woman status post CABG. Status post chest tube\n removal.\n\n COMPARISON: .\n\n SUPINE AP PORTABLE CHEST: Patient remains rotated to the left. Midline skin\n staples, sternal wire sutures and mediastinal clips are manifestations of\n recent cardiac surgery. The right internal jugular line position is\n unchanged. The left chest tube has been removed. There is no interval\n mediastinal widening. Bibasilar atelectasis persists. No pneumothorax has\n developed.\n\n IMPRESSION:\n 1. Interval left chest tube removal. No pneumothorax identified.\n 2. Persistent bibasilar atelectasis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2134-02-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 895652,
"text": " 1:12 PM\n CHEST (PORTABLE AP) Clip # \n Reason: PTX\n Admitting Diagnosis: UNSTABLE ANGINA\\CARDIAC CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman s/p CABG now with mediastinal chest tubes pulled\n REASON FOR THIS EXAMINATION:\n PTX\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 75-year-old woman status post CABG now with mediastinal chest\n tubes pulled. Please evaluate for pneumothorax.\n\n FINDINGS: AP chest radiograph dated is compared with the\n previous AP chest radiograph dated .\n\n There has been interval removal of the Swan-Ganz catheter and mediastinal\n chest tubes. Again seen is a right-sided cordis with tip overlying the SVC.\n Left-sided chest tube is seen with the tip pointing towards the apex. Also\n seen are median sternotomy wires and midline surgical clips.\n\n There is no evidence of pneumothorax. Again seen is bilateral lower lobe\n atelectasis. The mediastinal and hilar contours appear stable.\n\n IMPRESSION: No evidence of pneumothorax. Interval removal of Swan-Ganz\n catheter and mediastinal chest tubes. Otherwise, stable appearing chest\n findings.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2134-02-08 00:00:00.000",
"description": "Report",
"row_id": 202579,
"text": "Sinus arrhythmia. Right bundle-branch block. Low precordial lead voltage.\nCompared to the previous tracing of atrial ectopy is no longer\nrecorded. Otherwise, no diagnostic interim change.\n\n"
},
{
"category": "ECG",
"chartdate": "2134-02-04 00:00:00.000",
"description": "Report",
"row_id": 202580,
"text": "Sinus rhythm with probably sinus arrhythmia and atrial premature complexes\nRight bundle branch block\nLow QRS voltage - clinical correlation is suggested\nSince previous tracing of , atrial ectopy present\n\n"
},
{
"category": "ECG",
"chartdate": "2134-02-03 00:00:00.000",
"description": "Report",
"row_id": 202581,
"text": "Sinus rhythm\nRight bundle branch block\nLow QRS voltage - clinical correlation is suggested\nSince previous tracing of , sinus tachycardia absent\n\n"
},
{
"category": "ECG",
"chartdate": "2134-02-09 00:00:00.000",
"description": "Report",
"row_id": 202577,
"text": "Sinus tachycardia\nDemand pacing; Interpretation is based on unpaced beats.\nLeft atrial abnormality\nRight bundle branch block\nInferior ST elevation - cannot rule out myocardial injury\nSince previous tracing of , rate is increased\n\n"
},
{
"category": "ECG",
"chartdate": "2134-02-09 00:00:00.000",
"description": "Report",
"row_id": 202578,
"text": "Sinus arrhythmia\nConduction defect of RBBB type\nLeft atrial abnormality\nIncomplete right bundle branch block\nInferior T wave changes are nonspecific\nRepolarization changes may be partly due to rhythm\nLow QRS voltages in precordial leads\nSince previous tracing of , no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2134-02-02 00:00:00.000",
"description": "Report",
"row_id": 202821,
"text": "Sinus rhythm. Compared to the previous tracing tachycardia, right bundle-branch\nblock and low voltage persist.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2134-02-02 00:00:00.000",
"description": "Report",
"row_id": 202822,
"text": "Sinus tachycardia. Right bundle-branch block patterning. Low normal voltage. No\nprevious tracing available for comparison.\nTRACING #1\n\n"
},
{
"category": "Radiology",
"chartdate": "2134-02-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 895470,
"text": " 12:02 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Pleural effusion, pulmonary edema, tamponade, pneumothorax\n Admitting Diagnosis: UNSTABLE ANGINA\\CARDIAC CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman s/p CABG\n REASON FOR THIS EXAMINATION:\n Pleural effusion, pulmonary edema, tamponade, pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest, AP portable single view.\n\n INDICATION: Status post bypass surgery, first postoperative film.\n\n FINDINGS: AP single view of the chest has been obtained with the patient in\n supine position. The patient is now intubated, the ETT terminating in the\n trachea, close to the bifurcation. Withdrawal by a few centimeters to assure\n stable position is recommended. Also the balloon cuff appears slightly\n overinflated as it bulges out the tracheal lumen. The heart size has not\n changed significantly in comparison with the previous examination of . A right internal jugular approach central venous sheath carries a\n Swan-Ganz catheter, the tip of which reaches the main pulmonary artery. A\n left-sided chest tube and two mediastinal drainage tubes are identified.\n There is no evidence of pneumothorax. Somewhat crowded vasculature exist on\n the lung bases related to relatively high positioned diaphragms, but the\n accessible pulmonary vasculature does not demonstrate any significant\n congestion and no alveolar edema is identified. The lateral pleural sinuses\n remain free.\n\n IMPRESSION: Low positioned ETT, withdrawal by a few centimeters is\n recommended. Otherwise, chest findings are satisfactory.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2134-02-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 894884,
"text": " 7:11 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess interval change\n Admitting Diagnosis: UNSTABLE ANGINA\\CARDIAC CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with ugib, fluid overload\n\n REASON FOR THIS EXAMINATION:\n assess interval change\n ______________________________________________________________________________\n FINAL REPORT\n Portable chest, , with indication of upper GI bleeding and\n fluid overload.\n\n COMPARISON: .\n\n Cardiac silhouette is upper limits of normal in size and stable. There is\n pulmonary vascular engorgement, bilateral perihilar haziness, and bilateral\n septal thickening, not significantly changed allowing for technical\n differences between the studies. Small pleural effusions and bilateral\n retrocardiac opacities are also noted.\n\n IMPRESSION: Persistent perihilar haziness and septal thickening, in keeping\n with pulmonary edema, likely due to fluid overload.\n\n\n"
}
] |
13,960 | 103,876 | A/P: 47 yo with COPD admitted with increasing respiratory disress now stable at baseline and transferred to floor. . # Respiratory distress- As the patient has severe disease and has a history of intubation and severe decompensation, the patient was felt to require MICU care but rapidly improved. The cause for her decompensation is likely a viral infection given her recent fatigue and shortness of breath coupled with her occasional rhinorrhea. Already r/o flu and r/o MI. (Of note, bronchial washing in OMR were logged incorrectly and are not from this patient) Will continue to treat for COPD - prednisone 40mg; plan back to prednisone 20mg over the next 3 days - completed 7 days Levofloxacin for COPD exacerbation - Ipratroprium, atrovent q6h prn - continue home pulm meds: montelukast, advair 500-50, tiotropium 18mcg daily - viral cultures negative - RISS while on steroids . # Tachycardia: Patient with chronic history of sinus tachycardia. Cause unclear. Fluid resuscitated. TFTs checked. - Continue dilt . # Osteoporosis: Patient with history of persistent fractures as a result of persistent steroid administration. - Continue Forteo as per outpatient regimen - Con't Vitamin D and calcium . # Hypertension- Currently normotensive, will continue on home regimen . # Leukocytosis- Infectious causes ruled out and afebrile. Likely steroids - Con't to monitor . # Abdominal discomfort: Likely constipation as improved with bowel movement and LFT unremarkable. - continue bowel regimen . # Anxiety: Continue outpatient medications. . # Sleep apnea: continued nightly CPAP. . # Pain control: Likely due to chronic fractures. Will continue oxycodone SR and IR for pain control as per outpatient regimen. . # FEN- diet, has elevated HCO3 due to chronic CO2 retention at baseline, monitor lytes. | Atrovent nebs given per with little effect noted/ Lungs dim bilat L>R. PALPABLE PULSES NOTED TO BILATERAL DORSALIS AND RADIALS.GI: ABD IS SOFT, NON-DISTENDED AND NON-TENDER TO PALPATION. This shift, RR 11-24, o2sat 97-99, LS clear upper diminished lower. Pt presented with ^ SOB and DOE x2-3wks, low grade temps, lightheadedness and CP. Pt has been afebrile.GI/GU: ABD is soft, +BS. PAIN AT THIS TIME NOT REQUIRING PRN BREAKTHROUGH DOSE.CV: S1 S2 AUSCULTATED. Sinus tachycardiaST-T wave configuartion suggests in part early repolarization pattern/normalvariant but clinical correlation is suggestedSince previous tracing of , no significant change BILATERAL CHEST EXPANSION NOTED.GI/GU: BOWEL SOUNDS PRESENT X4 QUADRANTS, ABDOMEN SOFT/NONTENDER/NONDISTENDED, DENIES N/V. Pt ?able c/o to floor. Scattered aortic calcifications are seen, however the aorta is within normal caliber and contour throughout its course. UNABLE TO MEASURE, BUT PT NOTED TO SATURATE DIAPER. FINDINGS: Allowing for apical lordotic projection, cardiomediastinal contours are within normal limits. Pt MAE ad lib, helpful with care although needs assist.CV: ST 100s-120s. Using 's independently, asking for Atrovent nebs as needed, received x1 this shift. Pt had one episode of chest-like pain, same as usual GI discomfort pt has. WET READ VERSION #1 MAlb TUE 1:02 AM No PE. NO SEIZURE ACTIVITY NOTED.PAIN: PT RECEIVING ATC FOR PAIN, STATES MIN. BBS CLEAR BILATERALLY DIMINISHED AT THE BASES. Pt has been afebrile.RESP: Pt was on 4L NC with sats mid 90s. LS coarse with ocas insp/exp wheezes. ABDOMEN SOFT/NONTENDER/NONDISTENDED. Voids in diaper, unable to measure amts but appears to be adequate. RR 15-20s.GI/GU: Abd is softly distended, +BS. Plat.exh valve in place. NO SEIZURE ACTIVITY NOTED.PAIN: PT'S PAIN IS CONTROLLED FOR THE MOST PART- REQUIRED ONE EXTRA DOSE OF OXYCONTIN THIS PM. ON HOME O2 AND CHRONIC STEROIDS. NOTED TO BE DIMINISHED TO BILATERAL BASES. SINUS TACH WITH NO ECTOPY NOTED. THANKS!THIS RN PRECEPTED BY , RN No c/o chest pain or SOB at this time.Cv: Hr 100-115 st, sbp 120s, 18 guage in place, pulses palpable in all four extremeties. PT PRESENTED TO ED W/INCREASED SOB AND DOE X2-3WKS. REGULAR DIABETIC DIET- TOLERATING WELL. The visualized parts of the liver, spleen, right kidney, adrenal glands, and pancreas are within normal limits. HAD EPISODE OF CHEST PAIN- EKG OBTAINED- MOST LIKELY INDIGESTION. IMPRESSION: Emphysema. (Over) 11:55 PM CTA CHEST W&W/O C &RECONS Clip # Reason: eval for PE Admitting Diagnosis: ASTHMA/COPD EXACERBATION Field of view: 36 Contrast: OPTIRAY Amt: 70 FINAL REPORT (Cont) IMPRESSION: 1. Biscodyl and senna given as ordered. Appears SOB w/ exertion. NO SEIZURE ACTIVITY, AFEBRILE.CV: S1 S2 PER AUSCULTATION. of PEs as D-dimer elevated. Pt hx is significant for: Emphysema, COPD, mitral valve prolapse, osteoperosis, urinary incontinence, ON prednisone taper, c-section , and benign tumor removed date. Emphysematous changes. Emphysematous changes. Pt c/o back pain secondary to osteoperosis, oxycodone standing and prn ordered.Resp: Pt was received on BiPAP, but was taken off this setting and put on 4L NC (which she is on @ home), o2 sats>95%, LS coarse to small wheezes posteriorly. Resp: Pt placed on our cpap machine (rental) with settings of 15/10 and 5lpm 02 bleed in. SBP 1TEENS TO 130'S. INH taken as ordered.GI/Gu: Regular diabetic diet, tolerating well. FSBG 112, no coverage per RISS.ID: Temp 97.9-98.5, WBC 16.3. PT NOTED TO GET SOB WITH ACTIVITY- SELF RESOLVES. PALPABLE DORSALIS AND RADIAL PULSES BILATERALLY. PT TRANSFERRED BACK TO BED WITH SUPERVISION ONLY. DROPLET PRECAUTIONS CEASED. Pt chose to just use her nasal 02 for the rest of the noc. LS coarse, diminished 2 bases. RECEIVING NEB TX AS ORDERED.GI/GU: BOWEL SOUNDS PRESENT X4 QUADRANTS, TOLERATING DIET. Pt freq declines nebs when offered. PALPABLE PULSES NOTED TO BILATERAL DORSALIS AND RADIALS. HR 1TEENS TO 120'S - THIS IS PT'S BASELINE. Resp. STRONG COUGH EFFORT- NON-PRODUCTIVE. Setting of 15/10 with 5 lpm 02 bleed and pt is comfortable. Pt uses MDIs independently. UNABLE TO MEASURE- APPEARS TO BE ADEQUATE IN AMOUNTS. NPN 7p-7aPt is a 47y/o with H/O COPD, emphysema, and asthma. BP 120s-150s/80s-90s. Palpable pulses bilaterally. Palpable pulses bilaterally. On home O2 and chronic steroids, off lung transplant list compression fractures. SINUS RHYTHM - NO ECTOPY NOTED. Attenuation of the upper lobe vasculature is suggestive of underlying emphysema. Maintanence fluids 1/2NS for 1L @ 75cc/hr. Pt requested to not use NIV last noc and instead use Bipap with full face mask per her home settings of 15/12/5 lpm 02 bled in. F/U with possible hyperthyroidism. VERAPAMIL DOSE ADJUSTED FROM 80MG TO 120MG FOR CURRENTLY PT UNABLE TO TOLERATE ANY TYPE OF ACTIVITY- HR INCREASES TO 150'S. U/O ample, pt incontinent of urine into a diaper. NO SIGNS OF SKIN BREAKDOWN AT THIS TIME.PAIN: PT RECEIVING 10MG ATC. AFEBRILE. AFEBRILE. SBP 130'S. BILATERAL CHEST EXPANSION NOTED. REPOSITIONS SELF IN BED W/MIN ASSIST. PRN ORDER FOR GI COCKTAIL OBTAINED IF RE-OCCURS. Appearing comfortable resp wise this shift. BS X 4 QUADRANTS. While in pt received Solumedrol, NS 1 L, 0.5 Ativan, zopinex, 1gm Magnesium, and was put on BiPAP.Pt takes medications at home: please see FHPPt has been intubated x 2 in the past; she is on 4 L NC @ homePt is in the MICU for closer monitoring given hx of past intubations, and is being ruled out for asthma, MI, and FLU.Neuro: pt is alert and oriented X 3, moves all extremeties, pupils pear 3mm brisk. INDICATION: Shortness of breath. Pt MAE ad lib, but does have back pain comp fractures-repositioning effective.RESP: Pt is on 5L NC with sats 96-99%. | 14 | [
{
"category": "ECG",
"chartdate": "2151-12-14 00:00:00.000",
"description": "Report",
"row_id": 131768,
"text": "Sinus tachycardia\nST-T wave configuartion suggests in part early repolarization pattern/normal\nvariant but clinical correlation is suggested\nSince previous tracing of , no significant change\n\n"
},
{
"category": "Radiology",
"chartdate": "2151-12-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 933712,
"text": " 12:46 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old woman with sob\n REASON FOR THIS EXAMINATION:\n r/o infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE SEMI-UPRIGHT CHEST, \n\n COMPARISON: radiograph.\n\n INDICATION: Shortness of breath.\n\n FINDINGS: Allowing for apical lordotic projection, cardiomediastinal contours\n are within normal limits. There are no focal areas of consolidation within\n the lungs, and no pleural effusions are identified on this single projection.\n Attenuation of the upper lobe vasculature is suggestive of underlying\n emphysema.\n\n IMPRESSION: Emphysema. No pneumonia.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2151-12-13 00:00:00.000",
"description": "CTA CHEST W&W/O C &RECONS",
"row_id": 933788,
"text": " 11:55 PM\n CTA CHEST W&W/O C &RECONS Clip # \n Reason: eval for PE\n Admitting Diagnosis: ASTHMA/COPD EXACERBATION\n Field of view: 36 Contrast: OPTIRAY Amt: 70\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old woman with COPD and increasing DOE in setting of chest pain\n REASON FOR THIS EXAMINATION:\n eval for PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MAlb TUE 1:21 AM\n No PE. Emphysematous changes. Multiple compression deformities of\n indeterminate age.\n WET READ VERSION #1 MAlb TUE 1:02 AM\n No PE. Emphysematous changes. Multiple compression deformities of\n indeterminate age.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 37-year-old woman with COPD and increasing dyspnea on exertion in\n the setting of chest pain. Evaluate for pulmonary embolism.\n\n COMPARISON: None.\n\n TECHNIQUE: Contiguous axial images were obtained from the thoracic inlet to\n the lung bases with multiplanar reformatted images.\n\n CONTRAST: 150 cc of IV Optiray contrast was administered due to the rapid\n rate of bolus injection required for this study.\n\n CTA OF THE CHEST: No filling defects or pulmonary emboli are identified\n within the pulmonary arteries to the level of the segmental branches.\n Scattered aortic calcifications are seen, however the aorta is within normal\n caliber and contour throughout its course.\n\n CT OF THE CHEST WITH IV CONTRAST: Soft tissue window images demonstrate no\n pathologically-enlarged mediastinal, hilar, or axillary lymphadenopathy. The\n heart and pericardium are normal in appearance. No pleural or pericardial\n effusions are seen. Lung window images demonstrate no pulmonary nodules or\n parenchymal consolidation. Scattered emphysematous changes are seen diffusely\n throughout the lungs.\n\n Limited images of the superior portion of the abdomen demonstrate a cyst with\n calcification within the superior pole of the left kidney. The visualized\n parts of the liver, spleen, right kidney, adrenal glands, and pancreas are\n within normal limits.\n\n BONE WINDOWS: Compression deformities are seen within several mid thoracic\n vertebral bodies, of indeterminate age.\n\n CT RECONSTRUCTIONS: Multiplanar reconstructions were essential in delineating\n the anatomy and pathology.\n (Over)\n\n 11:55 PM\n CTA CHEST W&W/O C &RECONS Clip # \n Reason: eval for PE\n Admitting Diagnosis: ASTHMA/COPD EXACERBATION\n Field of view: 36 Contrast: OPTIRAY Amt: 70\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n IMPRESSION:\n 1. No evidence of pulmonary embolism.\n 2. Extensive emphysematous changes are seen bilaterally.\n 3. Hypodensity within the superior pole of the left kidney with wall\n calcification likely represents a complex cyst.\n 4. Multiple compression farctures of the thoracic vertebrae.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2151-12-15 00:00:00.000",
"description": "Report",
"row_id": 1444433,
"text": "NURSING PROGRESS NOTES 0700-1900\nREPORT RECEIVED FROM NIGHT SHIFT. ALL ALARMS ARE FUNCTIONING PROPERLY AND PT'S ENVIRONMENT SECURED FOR SAFETY.\n\nNEURO: PT A&OX3 ABLE TO FOLLOW COMMANDS AND MAE X4. VERY INDEPENDENT IN PERSONAL CARE, REQUESTING ONLY MINIMAL ASSISTANCE. REPOSITIONS SELF IN BED W/MIN ASSIST. PERRLA 3MM/BRISK BILATERALLY. AFEBRILE. NO SEIZURE ACTIVITY NOTED.\n\nPAIN: PT RECEIVING ATC FOR PAIN, STATES MIN. PAIN AT THIS TIME NOT REQUIRING PRN BREAKTHROUGH DOSE.\n\nCV: S1 S2 AUSCULTATED. HR 1TEENS TO 120'S - THIS IS PT'S BASELINE. INCREASES TO 130'S W/ACTIVITY. SINUS RHYTHM - NO ECTOPY NOTED. SBP 130'S. PALPABLE PULSES NOTED TO BILATERAL DORSALIS AND RADIALS. VERAPAMIL DOSE ADJUSTED FROM 80MG TO 120MG FOR CURRENTLY PT UNABLE TO TOLERATE ANY TYPE OF ACTIVITY- HR INCREASES TO 150'S. GOAL IS FOR PATIENT TO EVENTUALLY BE ABLE TO TOLERATE STANDING OR SITTING IN A CHAIR- THUS VERAPAMIL DOSAGE INCREASED- ALSO NEED EVENTUAL INCREASE IN DILTIAZEM EVENTUALLY.\n\nRESP: O2 VIA NC 4-5L/MIN, SPO2 > OR = 95%. BBS COARSE THROUGHOUT, DIMINISHED AT THE BASES. PT NOTED TO BECOME SLIGHTLY TACHYPNIC W/ACTIVITY REQUIRING INCREASE IN O2 FROM 4L TO 5L, RECEIVING NEB TX AS ORDERED. BILATERAL CHEST EXPANSION NOTED.\n\nGI/GU: BOWEL SOUNDS PRESENT X4 QUADRANTS, ABDOMEN SOFT/NONTENDER/NONDISTENDED, DENIES N/V. PASSING FLATUS. TOLERATING A HOUSE DIABETIC DIET. INCONTINENT OF AMTS OF CLEAR YELLOW URINE. UNABLE TO MEASURE, HOWEVER NOTED TO SATURATE DIAPER - PT WEARS A DIAPER AT HOME AS BASELINE.\n\nINTEG: SKIN WARM AND DRY. NO SIGNS OF SKIN BREAKDOWN AT THIS TIME\n\nSOCIAL: NO CONTACT WITH NURSE FROM PT'S FAMILY TODAY. PT HAS TELEPHONE AT .\n\nPLAN: PT IS CALLED OUT TO THE FLOOR, AND IS AWAITING A BED. PLEASE SEE FLOW SHEET FOR ADDITIONAL INFORMATION. THANKS!\n\nTHIS RN PRECEPTED BY , RN\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2151-12-16 00:00:00.000",
"description": "Report",
"row_id": 1444434,
"text": "Nursing Progress note 1900-0700\n*Full Code\n\n*Access: 20g PIV\n\n*Allergies: Compazine(seizure & muscle spasms), Food Allergy: Nuts\n\nNeuro: A&O x3, MAE, moves self in bed, assists w/ turning, no complaints of pain this shift.\n\nCardiac: ST/NSR w/o ectopy, HR 97-122, SBP 124-133. Verapamil increased yesterday and working well to this point. Higher HR w/ exertion. Awaiting AM labs for Hct and electrolytes.\n\nResp: 4L NC to begin shift, later changed to BI-Pap for sleep which she does at home. Has own mask in room for bi-pap. Appears SOB w/ exertion. This shift, RR 11-24, o2sat 97-99, LS clear upper diminished lower. INH taken as ordered.\n\nGI/Gu: Regular diabetic diet, tolerating well. +BS, no stool again this shift, pt is concerned as she became impacted a few weeks ago. Biscodyl and senna given as ordered. Voids in diaper, unable to measure amts but appears to be adequate. Changed x2 thus far this shift. FSBG 112, no coverage per RISS.\n\nID: Temp 97.9-98.5, WBC 16.3. Cont flagyl.\n\nPsychosocial: no calls from fam overnight.\n\nDispo: cont to monitor resp status, pt is called out and awaiting a bed.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2151-12-16 00:00:00.000",
"description": "Report",
"row_id": 1444435,
"text": "Resp: Pt placed on our cpap machine (rental) with settings of 15/10 and 5lpm 02 bleed in. Pt has her own full face mask with our plat. valve in place. No distress noted @ this time and will continue to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2151-12-16 00:00:00.000",
"description": "Report",
"row_id": 1444436,
"text": "NURSING PROGRESS NOTE 0700-1900\nPT IS A 47 Y.O F W/HX OF COPD, EMPHYSEMA AND ASTHMA. ON HOME O2 AND CHRONIC STEROIDS. PT PRESENTED TO ED W/INCREASED SOB AND DOE X2-3WKS. IN , PT HAD INCREASED WOB REQUIRING CPAP WHIcH WAS QUICKLY WEANED TO 4L NC ONCE IN MICU. PT IS A FULL CODE.\n\nNEURO: A&O X3, ABLE TO FOLLOW COMMANDS, MAE X4. VERY INDEPENDENT WITH PERSONAL CARE, REQUESTS ONLY MINIMAL ASSISTANCE WITH CARE. NO SEIZURE ACTIVITY, AFEBRILE.\n\nCV: S1 S2 PER AUSCULTATION. HR LOW 100'S TO 120'S (THIS IS BASELINE), INCREASES TO 140'S WITH ACTIVITY. SINUS TACH WITH NO ECTOPY NOTED. SBP 1TEENS TO 130'S. PALPABLE DORSALIS AND RADIAL PULSES BILATERALLY. K THIS AM WAS 3.5, REPLETED WITH 40MEQ K PO.\n\nRESP: O2 4L VIA NC, PT NOTED TO BECOME SLIGHTLY TACHYPNEIC WITH ACTIVITY REQUIRING AN INCREASE IN O2 TO 5L FOR ACTIVITY. SPO2 > OR = 95%. BBS CLEAR BILATERALLY DIMINISHED AT THE BASES. CHEST RISE SYMMETRICAL. RECEIVING NEB TX AS ORDERED.\n\nGI/GU: BOWEL SOUNDS PRESENT X4 QUADRANTS, TOLERATING DIET. ABDOMEN SOFT/NONTENDER/NONDISTENDED. PT HAS NOT HAD A BM SINCE 2 DAYS PRIOR TO THIS HOSPITAL ADMISSION, MAG CITRATE GIVEN THIS AFTERNOON, AWAITING RESULT. INCONTINENT OF LGE AMTS OF CLEAR YELLOW URINE. UNABLE TO MEASURE, BUT PT NOTED TO SATURATE DIAPER. APPARENTLY PT WEARS A DIAPER AT HOME AND THIS IS BASELINE.\n\nINTEG: SKIN WARM/PINK/DRY. NO SIGNS OF SKIN BREAKDOWN AT THIS TIME.\n\nPAIN: PT RECEIVING 10MG ATC. OXY IR 5MG GIVEN FOR BREAKTHROUGH PAIN THIS AM FOR BACK PAIN R/T COMPRESSION FRACTURES.\n\nACTIVITY: PT OOB TO CHAIR TODAY WITH PT, ABLE TO TOLERATE FOR APPROX 2 HOURS. PT TRANSFERRED BACK TO BED WITH SUPERVISION ONLY. TOLERATED WELL.\n\nSOCIAL: PT HAS PHONE AT , NO CONTACT WITH NURSE FROM FAMILY THIS SHIFT.\n\nPLAN: PT IS CALLED OUT AND AWAITING A BED ON THE FLOOR\n\nPLEASE SEE FLOW SHEET FOR ADDITIONAL INFORMATION, THANKS!\n\nTHIS RN IS PRECEPTING WITH , RN\n"
},
{
"category": "Nursing/other",
"chartdate": "2151-12-13 00:00:00.000",
"description": "Report",
"row_id": 1444426,
"text": "npn micu west 0700-1900\nAllergy: compazine\nFood allergy: Nuts\n\nFull Code\n\n47 yo female admitted to the MICU today () at 1500 who came to ED w/ complaints of asthma exascerbation, increasing SOB times a few days and pt. had a low grade fever. Patient also complains of dizziness when standing up, chest pain since relieved by TUMS, and back pain from spinal compression secondary to osteoperosis. Pt hx is significant for: Emphysema, COPD, mitral valve prolapse, osteoperosis, urinary incontinence, ON prednisone taper, c-section , and benign tumor removed date. While in pt received Solumedrol, NS 1 L, 0.5 Ativan, zopinex, 1gm Magnesium, and was put on BiPAP.\n\nPt takes medications at home: please see FHP\n\nPt has been intubated x 2 in the past; she is on 4 L NC @ home\n\nPt is in the MICU for closer monitoring given hx of past intubations, and is being ruled out for asthma, MI, and FLU.\n\nNeuro: pt is alert and oriented X 3, moves all extremeties, pupils pear 3mm brisk. Pt c/o back pain secondary to osteoperosis, oxycodone standing and prn ordered.\n\nResp: Pt was received on BiPAP, but was taken off this setting and put on 4L NC (which she is on @ home), o2 sats>95%, LS coarse to small wheezes posteriorly. RR is regular, even, and comfortable 12-15 BPM. tracheal aspirate SENT, pt unable to expectorate sputum for gram stain. No c/o chest pain or SOB at this time.\n\nCv: Hr 100-115 st, sbp 120s, 18 guage in place, pulses palpable in all four extremeties. Blood sent for r/o MI, EKG NOT DONE - unable to obtain.\n\ngu/gi: pt is incontinent of urine and wears a pad at home, and is currently wearing a pad, straight catheter done for urine SENT, + BS.\nFULL Liquid Diet ordered.\n\nid: Low grade temp in ED, currently 98.6.\n\n: fsbs q 6hrs.\n\nsocial: pt lives with mother in same apartment building, pt has a 9 yo son who lives with her. Pt takes psych meds at home.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2151-12-14 00:00:00.000",
"description": "Report",
"row_id": 1444427,
"text": "NPN 7p-7a\nPt is a 47y/o with H/O COPD, emphysema, and asthma. On home O2 and chronic steroids, off lung transplant list compression fractures. Pt presented with ^ SOB and DOE x2-3wks, low grade temps, lightheadedness and CP. In pt had increased work of breathing requiring CPAP, which was quickly weaned to 4L NC once in MICU.\nOver night, pt had CTA for ? of PEs as D-dimer elevated. CT was negative, but pt has + labs for hyperthyroid and is being further worked up. Currently on droplet precautions to r/o Flu.\n\nNEURO: Pt has been alert and oriented x3, pleasant but occas anxious about care and tests being done. Emotional support provided. Pt MAE ad lib, but does have back pain comp fractures-repositioning effective.\n\nRESP: Pt is on 5L NC with sats 96-99%. LS coarse with ocas insp/exp wheezes. No cough or sputum. Pt is on bipap at night for sleep apnea which was tried briefly, but pt prefered NC. RR 15-27. Pt does become SOB when lying flat for long periods and while eating.\n\nCV: Pt has been tachy t/o shift, HR 1teens-120s. No ectopy. BP 1teens-140s/60s-70s. Palpable pulses bilaterally. Maintanence fluids 1/2NS for 1L @ 75cc/hr. Pt has been afebrile.\n\nGI/GU: ABD is soft, +BS. NO BM this shift. Pt is tolerating regular diet well, very and thirsty. Pt is incontinent of urine at baseline, she wears diaper and refusing a Foley catheter. U/O has been ample. U/A negative.\n\nSOCIAL: Pt has 9y/o son and both her and her son live with pt's mother. calls from family over night.\n\nPLAN: F/U with labs, cultures. F/U with possible hyperthyroidism. Provide emotional support. Pt ?able c/o to floor.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2151-12-14 00:00:00.000",
"description": "Report",
"row_id": 1444428,
"text": "RESP CARE: Pt presently on 5 lpm nasal cannula. Atrovent nebs given per with little effect noted/ Lungs dim bilat L>R. Pt requested to not use NIV last noc and instead use Bipap with full face mask per her home settings of 15/12/5 lpm 02 bled in. Pt placed on unit, but removed it about an hour later stating she had a bad dream and felt someone was pulling her mask off. 02 sats fell to 84% at this time. Pt chose to just use her nasal 02 for the rest of the noc. 02 sats acceptable SEE CAREVUE> Plan is to place pt on Bipap again tonight/nebs PRN. Pt uses MDIs independently.\n"
},
{
"category": "Nursing/other",
"chartdate": "2151-12-14 00:00:00.000",
"description": "Report",
"row_id": 1444429,
"text": "Resp. Care Note\nPt wearing O2 at 4-5L NP with sats 97%. Appearing comfortable resp wise this shift. Using 's independently, asking for Atrovent nebs as needed, received x1 this shift. Pt freq declines nebs when offered. Pt's family brought in her BIPAP mask from home. Full mask with plateau exhalation valve. Settings on BIPAP per last discharge summary 15/10. Cont to follow, pt called out to floors.\n"
},
{
"category": "Nursing/other",
"chartdate": "2151-12-14 00:00:00.000",
"description": "Report",
"row_id": 1444430,
"text": "NURSING PROGRESS NOTE 0700-1900\nREPORT RECEIVED FROM PM SHIFT. ALL ALARMS ON MONITOR ARE FUNCTIONING PROPERLY. PT'S ENVIRONMENT SECURED FOR SAFETY.\n\nNEURO: PT IS ALERT AND ORIENTED X 3. VERY INDEPENDENT- REFUSES MOST PERSONAL CARE AND PREFERS TO DO THINGS FOR HERSELF-(BATHING, REPOSITIONING- ALSO VERY PARICULAR REGARDING WHEN SHE TAKES HER MEDS). AFEBRILE. PERRLA, 3/BRISK. MAE X 4 WITHOUT DIFFICULTY. NO SEIZURE ACTIVITY NOTED.\n\nPAIN: PT'S PAIN IS CONTROLLED FOR THE MOST PART- REQUIRED ONE EXTRA DOSE OF OXYCONTIN THIS PM. PHYSICAL THERAPY IN TO EDUCATE ON HOW TO MOVE WITH COMPRESSION FRACTURES.\n\nRR: 4-5L O2 VIA NASAL CANNULA. BBS= ESSENTIALLY COARSE THROUGHOUT ALL LUNG FIELDS. NOTED TO BE DIMINISHED TO BILATERAL BASES. PT NOTED TO GET SOB WITH ACTIVITY- SELF RESOLVES. RECEIVING NEBULIZERS AS ORDERED. STRONG COUGH EFFORT- NON-PRODUCTIVE. BILATERAL CHEST EXPANSION NOTED. DROPLET PRECAUTIONS CEASED. SP02 > OR = TO 95%.\n\nCV: S1 AND S2 AS PER AUSCULTATION. HR 110-120'S AT BASELINE- INCREASES TO 130-140'S WITH STRENUOUS ACTIVITY. HAD EPISODE OF CHEST PAIN- EKG OBTAINED- MOST LIKELY INDIGESTION. PRN ORDER FOR GI COCKTAIL OBTAINED IF RE-OCCURS. SBP > OR = 90. PALPABLE PULSES NOTED TO BILATERAL DORSALIS AND RADIALS.\n\nGI: ABD IS SOFT, NON-DISTENDED AND NON-TENDER TO PALPATION. BS X 4 QUADRANTS. PASSING FLATUS. NO BM THIS SHIFT. REGULAR DIABETIC DIET- TOLERATING WELL. NO C/O N,V.\n\nGU: PT INCONTINENT OF URINE. WEARS DIAPER AT HOME. UNABLE TO MEASURE- APPEARS TO BE ADEQUATE IN AMOUNTS. CLEAR, YELLOW URINE NOTED.\n\nINTEG: NO SIGNS OF BREAKDOWN NOTED TO BACK OR BUTTOCKS.\n\nSOCIAL: MOM IN TO VISIT. ALL QUESTIONS ANSWERED. NO ISSUES.\n\nPLAN: CALLED OUT TO FLOOR AWAITING BED. PLEASE SEE FLOW SHEET AS NEEDED FOR ADDITIONAL INFORMATION. THANK YOU!\n"
},
{
"category": "Nursing/other",
"chartdate": "2151-12-15 00:00:00.000",
"description": "Report",
"row_id": 1444431,
"text": "Resp: Pt placed on bipap with her own full face mask. Plat.exh valve in place. Setting of 15/10 with 5 lpm 02 bleed and pt is comfortable. Will continue to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2151-12-15 00:00:00.000",
"description": "Report",
"row_id": 1444432,
"text": "NPN 7p-7a\nNeuro: Pt is alert and oriented. Pt had overall uneventful night, slept most of shift. Pt MAE ad lib, helpful with care although needs assist.\n\nCV: ST 100s-120s. No ectopy. BP 120s-150s/80s-90s. Palpable pulses bilaterally. Pt had one episode of chest-like pain, same as usual GI discomfort pt has. MD notified and ordered to give Maalox/benadryl/lidocaine cocktail with good effect. Pt has been afebrile.\n\nRESP: Pt was on 4L NC with sats mid 90s. Pt placed on usual bipap while sleeping, tolerates well. LS coarse, diminished 2 bases. No cough or sputum. RR 15-20s.\n\nGI/GU: Abd is softly distended, +BS. No BM this shift. Pt tolerating regular diet well. U/O ample, pt incontinent of urine into a diaper. pt offered bed pan several times but refused.\n\nPLAN: Pt c/o to floor, awaiting a bed. Continue O2 support. Encourage activity. F/U with am labs.\n\n\n"
}
] |
66,988 | 125,731 | Patient was admitted to ACS Surgery Service from the ED with the obvious peritonitis. He was taken from the ED directly to the operating room. The exploratory laparotomy, partial gastrectomy and J tube placement was performed. Patient tolerated the operation well. His blood pressure was supported with medications for a short period at a time. He was intubated. | Unchanged extent of mild right pleural effusion. Modest right ventricular conduction delay pattern.ST-T wave changes are primary and non-specific. Unchanged bilateral pleural effusions. Minimal pulmonary edema. ST-T wave changes are primary and non-specific.Since the previous tracing of the same date sinus tachycardic rate is slowerand right ventricular conduction delay pattern appears less prominent.TRACING #2 Stable bilateral pleural effusions and atelectasis. IMPRESSION: Small left pleural effusion with atelectasis. Moderate cardiomegaly, bilateral pleural effusions. Modest right ventricular conduction delay may be incompleteright bundle-branch block. However, a moderate retrocardiac atelectasis persists. The left internal jugular catheter is unchanged. There has been little interval change in moderate bilateral pleural effusions and associated atelectasis. The size of the cardiac silhouette is unchanged. FINDINGS: In comparison with the study of , the nasogastric tube has been removed. Non-specific ST-T wave flattening. Unchanged borderline size of the cardiac silhouette without overt pulmonary edema. IMPRESSION: AP chest compared to through 24: Bibasal consolidations, which worsened on the left and developed on the right since is stable since . IMPRESSION: No deep venous thrombosis involving the right or left lower extremity. ST-T wave changesremain primary and are non-specific. FINDINGS: As compared to the previous radiograph, there is no relevant change. FINDINGS: As compared to the previous radiograph, there is no relevant change. Left internal jugular line ends at the superior cavoatrial junction and nasogastric tube in the region of the pylorus. Bilateral parenchymal opacities that have not changed in extent. A left internal jugular catheter terminates in the lower SVC. SUPINE PORTABLE CHEST RADIOGRAPH: The lung volumes are low. Lung volumes are low, with linear opacity at the left lung base likely due to atelectasis and a small pleural effusion. FINDINGS: As compared to the previous radiograph, the monitoring and support devices are in unchanged position. The left lateral decubitus view shows mild-to-moderate air-fluid levels. Persisting left retrocardiac and right basal atelectasis. Sinus rhythm is at upper limits of normal rate. ST-T wave abnormalities. There are low lung volumes. RSR' pattern in lead V1 is no longer seen at a slowerrate. Left IJ catheter and NG tube remain in place. obstruction FINAL REPORT INDICATION: Resolving peritonitis, questionable obstruction. No newly appeared focal parenchymal opacities. Sinus tachycardia. Sinus tachycardia. Sinus tachycardia. Sinus tachycardia. Bibasilar opacities left greater than right are a combination of small bilateral pleural effusions and atelectasis, superimposed infection cannot be totally excluded. IMPRESSION: New endotracheal tube terminates 2.2 cm from the carina. IMPRESSION: Low lung volumes, with left basilar opacity, possibly representing atelectasis, thuogh developing pneumonia cannot be excluded. Since the previous tracing of no significant change.TRACING #3 Incomplete right bundle-branch block. The cardiomediastinal silhouette is stable. No evidence of newly appeared focal parenchymal opacities. An enteric tube loops within the stomach, extends distally and the tip is not visualized. Clinical correlation issuggested. Dislodged PEG tube. No pathological calcifications. ST-T wave abnormalities are improved. Respiratory distress. No pneumothorax. Cardiac size is top normal. The patient has been extubated. Indistinctness of pulmonary vessels suggests some overhydration. Median cutaneous clips. Since the previous tracing of the rate has decreased. Mild vascular congestion has improved. No newly appeared focal parenchymal opacities suggesting pneumonia. The upper lung zones are well aerated, though the lung volumes are low. Now aspirated. A nasogastric tube in correct position, with the tip projecting over the distal parts of the stomach. In the interval, the patient has been extubated and has received a nasogastric tube that shows a correct course. Pulmonary vascularity is normal. Pulmonary vascularity is normal. There is no pulmonary edema. BILATERAL LOWER EXTREMITY VENOUS ULTRASOUND: Grayscale and Doppler examination of the right and left common femoral, superficial femoral, and popliteal veins were performed and demonstrate normal compressibility, augmentability and respiratory variation in flow. Slightly improved ventilation at the left lung bases. SINGLE UPRIGHT VIEW OF THE CHEST AT 1425 HOURS: A new endotracheal tube terminates 2.2 cm from the carina. No intraluminal thrombus was identified. Cardiac silhouette remains within normal limits and there is no evidence of pulmonary vascular congestion. Heart size is normal. FINDINGS: A frontal and a left lateral decubitus view are provided. There is no new consolidation or pneumothorax. COMPARISON: None. COMPARISON: None. Since the previous tracing of findings as outlined are now present.TRACING #1 There is no other area of consolidation or right pleural effusion. The heart size is normal. Other monitoring and support devices are unchanged. FINDINGS: In comparison with the study of , there is persistent bibasilar opacification consistent with pleural effusion and compressive atelectasis. There is no pneumothorax. There is no pneumothorax. No evidence of pathological wall thickness. Baseline artifact. No prior examinations. There is no hilar or mediastinal enlargement. SINGLE SEMI-UPRIGHT VIEW OF THE CHEST AT 8:40 A.M.: The endotracheal tube terminates 4.3 cm from the carina. COMPARISON: No comparison available at the time of dictation. No previous tracingavailable for comparison. 12:46 PM PORTABLE ABDOMEN Clip # Reason: ? The endotracheal tube tip has been pulled back and now lies approximately 4 cm above the carina. An enteric tube extends below the diaphragm and terminates in the stomach. There is no evidence of pneumothorax. Aspiration. No evidence of free air. Early R waveprogression. There is opacity at the left base, which most likely represents atelectasis, though a developing pneumonia is difficult to exclude. | 17 | [
{
"category": "Radiology",
"chartdate": "2161-11-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1159995,
"text": " 3:34 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: ABDOMINAL PAIN;FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old man with peritonitis from peg-tube displacement s/p intubation for\n respiratory distress from aspiration of bile\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE PORTABLE RADIOGRAPH CHEST:\n\n REASON FOR EXAM: Peritonitis. Aspiration. Respiratory distress.\n\n Comparison is made with prior study performed a day earlier.\n\n The patient has been extubated. Left IJ catheter and NG tube remain in place.\n There are low lung volumes. Cardiac size is top normal. Bibasilar opacities\n left greater than right are a combination of small bilateral pleural effusions\n and atelectasis, superimposed infection cannot be totally excluded. Mild\n vascular congestion has improved.\n\n"
},
{
"category": "Radiology",
"chartdate": "2161-11-17 00:00:00.000",
"description": "BILAT LOWER EXT VEINS",
"row_id": 1159853,
"text": " 9:12 AM\n BILAT LOWER EXT VEINS Clip # \n Reason: H/O DVT, EVAL\n Admitting Diagnosis: ABDOMINAL PAIN;FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old man with h/o DVT\n REASON FOR THIS EXAMINATION:\n Evaluate for DVT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 30-year-old with history of DVT.\n\n No prior examinations.\n\n BILATERAL LOWER EXTREMITY VENOUS ULTRASOUND: Grayscale and Doppler\n examination of the right and left common femoral, superficial femoral, and\n popliteal veins were performed and demonstrate normal compressibility,\n augmentability and respiratory variation in flow. No intraluminal thrombus\n was identified.\n\n IMPRESSION: No deep venous thrombosis involving the right or left lower\n extremity.\n\n"
},
{
"category": "Radiology",
"chartdate": "2161-11-12 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1159095,
"text": " 8:06 AM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: ETT position? PTX?\n Admitting Diagnosis: ABDOMINAL PAIN;FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old man s/p intubation for ex-lap, new CVL\n REASON FOR THIS EXAMINATION:\n ETT position? PTX?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 30-year-old man status post ex lap, with new CVL and ETT.\n\n COMPARISON: None.\n\n SINGLE SEMI-UPRIGHT VIEW OF THE CHEST AT 8:40 A.M.: The endotracheal tube\n terminates 4.3 cm from the carina. An enteric tube extends below the\n diaphragm and terminates in the stomach. A left internal jugular catheter\n terminates in the lower SVC. Skin staples overlie the abdominal midline.\n\n Lung volumes are low, with linear opacity at the left lung base likely due to\n atelectasis and a small pleural effusion. There is no other area of\n consolidation or right pleural effusion. There is no pneumothorax. The heart\n size is normal. There is no hilar or mediastinal enlargement. Pulmonary\n vascularity is normal.\n\n IMPRESSION: Small left pleural effusion with atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2161-11-15 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1159616,
"text": " 12:46 PM\n PORTABLE ABDOMEN Clip # \n Reason: ? obstruction\n Admitting Diagnosis: ABDOMINAL PAIN;FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 yr old man with resolving peritonitis from dislodged peg\n REASON FOR THIS EXAMINATION:\n ? obstruction\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Resolving peritonitis, questionable obstruction.\n\n COMPARISON: No comparison available at the time of dictation.\n\n FINDINGS: A frontal and a left lateral decubitus view are provided. Median\n cutaneous clips. A nasogastric tube in correct position, with the tip\n projecting over the distal parts of the stomach. No evidence of free air. No\n pathological calcifications. There is no evidence of bowel or colonic\n distention. No evidence of pathological wall thickness. The left lateral\n decubitus view shows mild-to-moderate air-fluid levels.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2161-11-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1159585,
"text": " 6:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval lung fields\n Admitting Diagnosis: ABDOMINAL PAIN;FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old man with aspiration event & desat\n REASON FOR THIS EXAMINATION:\n eval lung fields\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Aspiration, desaturation.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is no relevant\n change. Persisting left retrocardiac and right basal atelectasis. Unchanged\n extent of mild right pleural effusion. The effusion on the left has slightly\n increased in extent. No evidence of newly appeared focal parenchymal\n opacities. In the interval, the patient has been extubated and has received a\n nasogastric tube that shows a correct course. There is no evidence of\n pneumothorax. The size of the cardiac silhouette is unchanged.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2161-11-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1159281,
"text": " 4:44 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: ABDOMINAL PAIN;FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old man with left base atelectasis/consolidation\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Left base atelectasis or consolidation, to assess for change.\n\n FINDINGS: In comparison with the study of , the nasogastric tube has\n been removed. There is increasing opacification at both bases, consistent\n with worsening pleural effusions and associated compressive atelectasis.\n Cardiac silhouette remains within normal limits and there is no evidence of\n pulmonary vascular congestion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2161-11-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1159668,
"text": " 4:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: ABDOMINAL PAIN;FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old man admitted for peritonitis from dislodged PEG tube, now s/p\n aspiration of vomit\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 4:51 AM, \n\n HISTORY: Peritonitis. Dislodged PEG tube. Now aspirated.\n\n IMPRESSION: AP chest compared to through 24:\n\n Bibasal consolidations, which worsened on the left and developed on the right\n since is stable since . Pulmonary vascular congestion\n and mediastinal venous engorgement have increased suggesting volume overload,\n accompanied by increasing small bilateral pleural effusions. Left internal\n jugular line ends at the superior cavoatrial junction and nasogastric tube in\n the region of the pylorus. No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2161-11-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1160179,
"text": " 4:07 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change in man w/ multiple aspirations\n Admitting Diagnosis: ABDOMINAL PAIN;FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old man with peritonitis from dislodged G tube, now s/p aspiration X 2\n in past 4 days\n REASON FOR THIS EXAMINATION:\n interval change in man w/ multiple aspirations\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Peritonitis, evaluation for interval change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is no relevant\n change. Moderate cardiomegaly, bilateral pleural effusions. Bilateral\n parenchymal opacities that have not changed in extent. Minimal pulmonary\n edema. No newly appeared focal parenchymal opacities suggesting pneumonia.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2161-11-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1159742,
"text": " 2:26 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Aspiration pneumonia?\n Admitting Diagnosis: ABDOMINAL PAIN;FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old man with tachypnea.\n REASON FOR THIS EXAMINATION:\n Aspiration pneumonia?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 30-year-old man with tachypnea.\n\n COMPARISON: Chest radiographs dating back to , most recently\n at 5 a.m.\n\n SINGLE UPRIGHT VIEW OF THE CHEST AT 1425 HOURS: A new endotracheal tube\n terminates 2.2 cm from the carina. An enteric tube loops within the stomach,\n extends distally and the tip is not visualized. The left internal jugular\n catheter is unchanged. Skin staples overlie the abdominal midline.\n\n There has been little interval change in moderate bilateral pleural effusions\n and associated atelectasis. There is no new consolidation or pneumothorax.\n The cardiomediastinal silhouette is stable. Pulmonary vascularity is normal.\n\n IMPRESSION: New endotracheal tube terminates 2.2 cm from the carina. Stable\n bilateral pleural effusions and atelectasis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2161-11-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1159066,
"text": " 12:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 29 year old man with fever, sepsis\n REASON FOR THIS EXAMINATION:\n please eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 29-year-old male with fever.\n\n COMPARISON: None.\n\n SUPINE PORTABLE CHEST RADIOGRAPH: The lung volumes are low. There is opacity\n at the left base, which most likely represents atelectasis, though a\n developing pneumonia is difficult to exclude. The upper lung zones are well\n aerated, though the lung volumes are low. There is no pneumothorax. Heart\n size is normal. There is no pulmonary edema. A nasogastric tube is seen\n passing into the stomach.\n\n IMPRESSION: Low lung volumes, with left basilar opacity, possibly\n representing atelectasis, thuogh developing pneumonia cannot be excluded.\n Radiographic follow-up is warranted.\n\n"
},
{
"category": "Radiology",
"chartdate": "2161-11-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1159817,
"text": " 4:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: progression of lung disease\n Admitting Diagnosis: ABDOMINAL PAIN;FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old man with aspiration\n REASON FOR THIS EXAMINATION:\n progression of lung disease\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Aspiration, to assess for change.\n\n FINDINGS: In comparison with the study of , there is persistent\n bibasilar opacification consistent with pleural effusion and compressive\n atelectasis. In the appropriate clinical setting, supervening pneumonia would\n have to be considered. Indistinctness of pulmonary vessels suggests some\n overhydration.\n\n The endotracheal tube tip has been pulled back and now lies approximately 4 cm\n above the carina. Other monitoring and support devices are unchanged.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2161-11-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1159454,
"text": " 4:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: progression of lung disease\n Admitting Diagnosis: ABDOMINAL PAIN;FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old man with resp insuffiency w/ SIRS\n REASON FOR THIS EXAMINATION:\n progression of lung disease\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Respiratory insufficiency, progression of disease.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the monitoring and support\n devices are in unchanged position. Slightly improved ventilation at the left\n lung bases. However, a moderate retrocardiac atelectasis persists. Unchanged\n bilateral pleural effusions. Unchanged borderline size of the cardiac\n silhouette without overt pulmonary edema. No newly appeared focal parenchymal\n opacities.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2161-11-19 00:00:00.000",
"description": "Report",
"row_id": 239204,
"text": "Sinus tachycardia. Modest right ventricular conduction delay pattern.\nST-T wave changes are primary and non-specific. Clinical correlation is\nsuggested. Since the previous tracing of no significant change.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2161-11-18 00:00:00.000",
"description": "Report",
"row_id": 239205,
"text": "Sinus tachycardia. Modest right ventricular conduction delay may be incomplete\nright bundle-branch block. ST-T wave changes are primary and non-specific.\nSince the previous tracing of the same date sinus tachycardic rate is slower\nand right ventricular conduction delay pattern appears less prominent.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2161-11-18 00:00:00.000",
"description": "Report",
"row_id": 239206,
"text": "Sinus tachycardia. Incomplete right bundle-branch block. ST-T wave changes\nremain primary and are non-specific. Since the previous tracing of \nfindings as outlined are now present.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2161-11-17 00:00:00.000",
"description": "Report",
"row_id": 239435,
"text": "Baseline artifact. Sinus rhythm is at upper limits of normal rate. Early R wave\nprogression. ST-T wave abnormalities. Since the previous tracing of \nthe rate has decreased. RSR' pattern in lead V1 is no longer seen at a slower\nrate. ST-T wave abnormalities are improved.\n\n"
},
{
"category": "ECG",
"chartdate": "2161-11-12 00:00:00.000",
"description": "Report",
"row_id": 239436,
"text": "Sinus tachycardia. Non-specific ST-T wave flattening. No previous tracing\navailable for comparison.\n\n"
}
] |
44,781 | 106,507 | The patient arrived to as transfer from OSH for a significantly sized intracerebral hemorrhage. On initial exam, he was following some commands after receiving 20gm Mannitol en route to hospital. He was emergently take to the OR for EVD placement after CT findings. His exam post drain did improve and MRI showed no obvious mass. CT showed with decrease in size of IVH and stable ICPs. CTA of head was done showed no AVM, however bleeding was likely due to arachnoid cyst. On , he was again taken to the OR for endoscopic cyst aspiration and Rickham catheter placement. Post-operatively he continue to improved markedly. On his examination on , he was found to have gross visual field deficits and ophthalmology was consulted. He was found to be blind with some light awareness bilaterally. This was thought to be secondary to vitreous hemorrhage of unclear origin. He was also able to see shadows towards the end of his hospital course. Ophthamology would like to see him on follow up. The patient was able to be extubated and was breathing well on his own and his diet was advanced to regular. He was eating and drinking without difficulty. He did have hyponatremia for several days for which he was placed on salt tablets and kept on a fluid restriction. On his sodium was improving and the salt tabs were decreased. They were decreased again on and his fluid restriction was liberalized. Since that time his sodium has normalized, without any recurrance of issue. Guardianship was pursued. The patient continued to have daily PT while waiting for guardianship. The papers were drawn up by the legal department, signed by Dr. , and given to the family on . Throughout the duration of his hospital stay, Mr worked daily with PT and was determined to be an appropriate rehab candidate. He was discharged to an appropriate facility on . | Intracerebral hemorrhage (ICH) Assessment: Pt sedated on propofol, moving all ext. Plan for cyst aspiration and MRI ; dilantin changed to Keppra; EVD for ICP monitor Cardiovascular: keep SBP<160, PO lopressor incr, nicardipine GTT restarted; hydralazine prn. Pneumococcal Vac Polyvalent 26. Pneumococcal Vac Polyvalent 26. found to have massive IVH, s/p Lt Burr hole W EVD placement , now s/p cyst aspiration Chief complaint: intraventricular hemorrhage PMHx: Asperger's Current medications: 1. found to have massive IVH, s/p Lt Burr hole W EVD placement , now s/p cyst aspiration Chief complaint: intraventricular hemorrhage PMHx: Asperger's Current medications: 1. Hypertension, benign Assessment: Nicardipine gtt weaned to off this am. Chlorhexidine Gluconate 0.12% Oral Rinse 7. Chlorhexidine Gluconate 0.12% Oral Rinse 7. Chlorhexidine Gluconate 0.12% Oral Rinse 7. Pneumococcal Vac Polyvalent 29. Vancomycin 24 Hour Events: started clonidine, HCTZ, DC'd. Pneumococcal Vac Polyvalent 15. Pneumococcal Vac Polyvalent 15. Pneumococcal Vac Polyvalent 15. Action: Nicardipine gtt started, Hydralazine po added. Metoprolol Tartrate 23. Nystatin Oral Suspension 28. Metoprolol Tartrate 24. Action: Nicardipine gtt for bp control goal 140-160 Propofol gtt for sedation and titrated Neuro signs q1hr. Hypertension, benign Assessment: Continues on Nicardipine IV drip to keep SBP<160 Action: Clonidine and Hydrochlorothiazide added with some effect on BP. Chlorhexidine Gluconate 0.12% Oral Rinse 9. Chlorhexidine Gluconate 0.12% Oral Rinse 7. Chlorhexidine Gluconate 0.12% Oral Rinse 7. Chlorhexidine Gluconate 0.12% Oral Rinse 7. Chlorhexidine Gluconate 0.12% Oral Rinse 7. Metoprolol Tartrate 23. Pneumococcal Vac Polyvalent 29. Nimodipine added. Pneumococcal Vac Polyvalent 26. Lidocaine 1% 19. Metoprolol Tartrate 24. Metoprolol Tartrate 17. Metoprolol Tartrate 17. Action: Niccardipine gtt titerated to keep bp < 159, hydralazine 10mg iv x 3 prn given. Nystatin Oral Suspension 28. Pneumococcal Vac Polyvalent 18. Pneumococcal Vac Polyvalent 18. Nystatin Oral Suspension 25. Propofol 24. Propofol 24. Nimodipine 24. Pneumococcal Vac Polyvalent 22. Pneumococcal Vac Polyvalent 22. Vancomycin 24 Hour Events: started clonidine, HCTZ, DC'd. Metoprolol Tartrate 22. Nicardipine gtt restarted. Nicardipine gtt restarted. Unchanged appearance of the known intraventricular hemorrhage and extension to subarachnoid space. Unchanged large suprasellar/pontine cyst and the position of the ventriculostomy draining tube. Unchanged intraventricular hemorrhage. Unchanged intraventricular hemorrhage. Unchanged intraventricular hemorrhage. Unchanged cystic dilatation of the lateral ventricles and the suprasellar cistern. Unchanged cystic dilatation of the lateral ventricles and the suprasellar cistern. Unchanged cystic dilatation of the lateral ventricles and the suprasellar cistern. FINDINGS: The left-sided central venous line ends at the upper SVC, unchanged. Unchanged L frontal extra-axial fluid collection. Hypertension, benign Assessment: Bp tonite ranging from 120s to 170s. The cystic structure within the lateral ventricles and the suprasellar region appear unchanged. Ventriculostomy catheter, hydrocephalus, and cystic mass involving the third ventricle appear unchanged. The extensive intraventricular hemorrhage is unchanged. Stable extent of intraventricular and trace subarachnoid hemorrhage. S/P endoscopic cyst aspiration and removal of EVD with placement of Rickam reservoir12/18 and wound revision REASON FOR THIS EXAMINATION: Post op study No contraindications for IV contrast PFI REPORT 1. Dilantin iv given q8hrs and level checked. Propofol gtt titrated Perla . Vap mouth care q4hrs. Propofol and nicardipine gtt titrated. Pneumococcal Vac Polyvalent 23. Nicardipine gtt infusijng and titrated. Pneumococcal Vac Polyvalent 18. head ct. .H/O respiratory failure, acute (not ARDS/) Assessment: Pt remains orally intubated. Plan for cyst aspiration and MRI ; dilantin changed to Keppra; EVD for ICP monitor Cardiovascular: keep SBP<160, PO lopressor incr, nicardipine GTT restarted; hydralazine prn. Nicardipine gtt restarted. Propofol gtt titrated for sedation. Propofol gtt titrated for sedation. Action: Nicardipine gtt started, Hydralazine po added. Chlorhexidine Gluconate 0.12% Oral Rinse 7. Chlorhexidine Gluconate 0.12% Oral Rinse 9. Intracerebral hemorrhage (ICH) Assessment: Left ventricular head in drain in place On propofol gtt and titrated for sedation Pupils react sluggishly size bilaterally. Intracerebral hemorrhage (ICH) Assessment: Pt sedated on propofol, moving all ext. Left ventricular catheter appears to terminate within the brain parenchyma as described on the accompanying head CT report. 9:26 AM CT HEAD W/O CONTRAST Clip # Reason: hydrocephalus, ventricular placement, ? A ventricular catheter entering from a left frontal approach appears to terminate within the left frontal lobe (2:13). Pneumococcal Vac Polyvalent 23. Scattered subarachnoid hemorrhage, stable. found to have massive IVH, s/p Lt Burr hole W EVD placement Neurologic: unclear source of bleed, possibly from cyst. Unchanged cystic dilatation of the lateral ventricles and suprasellar custern. NON-CONTRAST HEAD CT: Compared to prior exam from cystic structure within the lateral ventricles and suprasellar region is unchanged. Obstructive hydrocephalus, with dilatation of the left lateral ventricle and moderate on the right. FINDINGS: HEAD CT: There is an overall unchanged appearance of the massive intraventricular hemorrhage, left lateral ventricular more severe than right. There is a fluid-fluid level noted, in the anterior portions of the lateral ventricles. There is obstruction of the lateral ventricles bilaterally. Left frontal ventricular catheter appears to terminate in brain parenchyma as discussed on concurrent head CT. There is a small amount of subarachnoid hemorrhage in the sylvian fissures bilaterally. Left ventricular catheter appears to terminate within the brain parenchyma as described on the accompanying head CT report. Extensive intraventricular hemorrhage, with severe obstructive hydrocephalus, unchanged. | 136 | [
{
"category": "Nursing",
"chartdate": "2146-11-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 548420,
"text": "65M presented to OSH this am after complaining of headache\n this morning. Per reports from ED records, and parents (with whom\n he resides), he then went upstairs to the bathroom when a \"thump\"\n was heard. His mother went upstairs into the bathroom and found\n him on the floor, incontinent of urine and unresponsive. She then\n called 911, and was taken to OSH. Upon presentation to OSH, he\n was found to be hypertensive to 230/150, started on Nipride. His\n head was scanned and revealed a \"Massive Head Bleed, without\n midline shift\". He was then subsequently transferred to for\n definitive care and Neurosurgical evaluation. In the duration of\n transfer, per EMS noted, started decorticate posturing and they\n began infusion of 25 gm Mannitol IV.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Pt sedated on propofol, moving all ext. to pain. PERRL, however\n minimally responsive at beginning of the night and shown to Dr. .\n Vent drain at 15mm H20 at the tragus, draining bright red blood. ICP\n , drain oozing sanguinous drainage, shown to Dr. , reinforced.\n Remains intubated on CMV with normal ABGs.\n Action:\n Propofol stopped every few hours throughout the night for neuro exam.\n MRI done\n Response:\n When off sedation, pt opening eyes to voice, following all commands.\n Moving all ext. with weakness on right side. Denies pain. Results of\n MRI unknown.\n Plan:\n Continue to monitor neuro status, wean vent.\n"
},
{
"category": "Nursing",
"chartdate": "2146-11-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 548425,
"text": "Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Tmax 102.1\n Action:\n Tylenol given x 1, Dr. , no cultures done at that time.\n Room cooled, cool bath given\n Response:\n Pt\ns fever decreased t0 101.5\n Plan:\n Continue to monitor for temp spikes, culture when team decides, treat\n with tylenol\n Intracerebral hemorrhage (ICH)\n Assessment:\n Pt opening eyes to stimulation, sometimes voice. ICP 7-13 with vent\n drain at 10 above the tragus. Moves lower ext. to pain and a few times\n witnessed some spontaneous movement, however no movement from upper\n ext. Perrl, 5mm. Appearing sluggish at times, Dr. . Vent\n drain draining serosang, 5-10cc/hr.\n Action:\n Monitoring ICP by turning drain off to drainage bag Q 1hour, Q 1 hour\n neuro checks per Dr. \n Response:\n ICP varying slightly when turning off to drainage\n Plan:\n Continue to monitor neuro status Q 1hour, check ICP Q 1hour and\n drainage. MRI to be done on Thurs. as well as surgery\n Hypertension, benign\n Assessment:\n BP via a-line 140-150\ns systolic most of the night.\n Action:\n Nicardipine gtt titrated down over night, however rate increased this\n am due to rising systolic pressure above 160. Scheduled Lopressor given\n with fair effect\n Response:\n Pt responding well to Nicardipine gtt.\n Plan:\n ? need for increasing Lopressor TID, try to wean Nicardipine and\n maintain BP 140-160\ns systolic\n"
},
{
"category": "Nursing",
"chartdate": "2146-11-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 548466,
"text": "Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Tmax 102.7\n Action:\n Tylenol given x 2 overnight, Dr. , no cultures done at that\n time. Room cooled, cool bath given\n Response:\n Pt\ns fever decreased t0 101.3\n Plan:\n Continue to monitor for temp spikes, culture when team decides, treat\n with Tylenol\n Intracerebral hemorrhage (ICH)\n Assessment:\n Pt opening eyes to stimulation, sometimes voice. ICP 7-13 with vent\n drain at 10 above the tragus. Moves lower ext. to pain and a few times\n witnessed some spontaneous movement, however no movement from upper\n ext. Perrl, 5mm. Appearing sluggish at times, Dr. . Vent\n drain draining serosang, 5-10cc/hr.\n Action:\n Monitoring ICP by turning drain off to drainage bag Q 1hour, Q 1 hour\n neuro checks per Dr. \n Response:\n ICP varying slightly when turning off to drainage\n Plan:\n Continue to monitor neuro status Q 1hour, check ICP Q 1hour and\n drainage. MRI to be done on Thurs. as well as surgery\n Hypertension, benign\n Assessment:\n BP via a-line 140-150\ns systolic most of the night.\n Action:\n Nicardipine gtt titrated down over night, however rate increased this\n am due to rising systolic pressure above 160. Scheduled Lopressor given\n with fair effect\n Response:\n Pt responding well to Nicardipine gtt.\n Plan:\n ? need for increasing Lopressor TID, try to wean Nicardipine and\n maintain BP 140-160\ns systolic\n"
},
{
"category": "Respiratory ",
"chartdate": "2146-11-29 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 548427,
"text": "TITLE:\n Demographics\n Day of intubation: \n Day of mechanical ventilation: 6\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: OSH\n Reason: airway protection\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 23 cmH2O\n Cuff volume: mL /\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: PSV 5/5/.4\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: appears comf\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment: none noted\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Bedside Procedures: RSBI\n"
},
{
"category": "Respiratory ",
"chartdate": "2146-11-29 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 548452,
"text": "TITLE:\n Demographics\n Day of intubation: \n Day of mechanical ventilation: 6\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: OSH\n Reason: airway protection\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 23 cmH2O\n Cuff volume: mL /\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: PSV 5/5/.4\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: appears comf\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment: none noted\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Bedside Procedures: RSBI 50; abg with hyperoxia, resp alkalosis; occ\n apneic periods noted\n"
},
{
"category": "Nursing",
"chartdate": "2146-11-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 548559,
"text": "Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Tmax 103.0 orally.\n Action:\n Tylenol given x 1, cooling blanket applied with continuous temp\n monitoring. Pancultured.\n Response:\n Temp decreased following Tylenol to 101.6.\n Plan:\n Continue to monitor rectal temps, give Tylenol as needed\n Hypertension, benign\n Assessment:\n Systolic BP rising to 170\ns at the beginning of the shift. At that\n time, pt febrile and ICP rising to 22.\n Action:\n Dr. notified, as well as the NSURG resident. Nicardipine gtt\n restarted, Tylenol given for fever.\n Response:\n BP well controlled on gtt and systolic maintained at goal of 140-160.\n ICP decreasing after repositioning and BP control\n Plan:\n Continue to treat fevers with Tylenol, check ICP Q 1hour and notify\n resident if above 20 for more than a\n hour.\n"
},
{
"category": "Respiratory ",
"chartdate": "2146-11-30 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 548563,
"text": "Demographics\n Day of intubation: 7\n Day of mechanical ventilation: 7\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location: Outside hospital\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 7 mL / Air\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: RSBI completed on PS 5=50.\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n"
},
{
"category": "Respiratory ",
"chartdate": "2146-11-29 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 548523,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 6\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 23 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Physician ",
"chartdate": "2146-11-30 00:00:00.000",
"description": "Intensivist Note",
"row_id": 548597,
"text": "SICU\n HPI:\n 65M w/sudden onset HA on am of went into bathroom and fell to\n ground; parents found him to be unresponsive and taken to OSH; then\n txfr to \n Chief complaint:\n MASSIVE Central IPH(spont)\n PMHx:\n unknown\n Current medications:\n 24 Hour Events:\n PAN CULTURE - At 09:15 PM\n FEVER - 103.0\nF - 08:00 PM\n Post operative day:\n HD#7 POD#6 - Left burr hole with placement of ventriculostomy\n drain\n 24hr events: VitK, incr lopressor, CT head/C-spine, ETT repositioned;\n o/n temp 103, pancx/CXR; ICP 20-23 intermittently, neurosurg aware.\n Nicardipine gtt restarted.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 06:59 AM\n Vancomycin - 08:00 PM\n Meropenem - 06:00 AM\n Infusions:\n Nicardipine - 1.5 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 AM\n Metoprolol - 05:51 PM\n Hydralazine - 06:07 PM\n Other medications:\n Flowsheet Data as of 07:18 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 39.4\nC (103\n T current: 39\nC (102.2\n HR: 84 (79 - 104) bpm\n BP: 136/61(84) {129/56(82) - 176/76(109)} mmHg\n RR: 20 (20 - 21) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 66.6 kg (admission): 75 kg\n ICP: 7 (6 - 22) mmHg\n Total In:\n 2,167 mL\n 793 mL\n PO:\n Tube feeding:\n 1,149 mL\n 394 mL\n IV Fluid:\n 898 mL\n 369 mL\n Blood products:\n Total out:\n 3,008 mL\n 1,145 mL\n Urine:\n 2,830 mL\n 1,100 mL\n NG:\n Stool:\n Drains:\n 178 mL\n 45 mL\n Balance:\n -841 mL\n -352 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 390 (361 - 579) mL\n PS : 5 cmH2O\n RR (Spontaneous): 20\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 50\n PIP: 11 cmH2O\n SPO2: 100%\n ABG: ///24/\n Ve: 8.6 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Responds to: Verbal stimuli, Tactile stimuli, Noxious\n stimuli), Moves toes b/l on tactile stimulation. Moves arms b/l on\n noxious stimulation. opens eyes slightly with verbal.\n Labs / Radiology\n 164 K/uL\n 11.2 g/dL\n 177\n 0.6 mg/dL\n 24 mEq/L\n 3.7 mEq/L\n 17 mg/dL\n 104 mEq/L\n 137 mEq/L\n 31.1 %\n 7.9 K/uL\n [image002.jpg]\n 02:45 AM\n 03:22 AM\n 04:49 AM\n 02:11 AM\n 02:18 AM\n 02:02 AM\n 02:12 AM\n 09:23 PM\n 02:58 AM\n 04:00 AM\n WBC\n 11.5\n 8.8\n 5.3\n 7.6\n 7.9\n Hct\n 31.3\n 29.2\n 30.4\n 31.5\n 31.1\n Plt\n 69\n 164\n Creatinine\n 0.7\n 0.7\n 0.7\n 0.6\n TCO2\n 25\n 21\n 28\n 28\n Glucose\n 110\n 111\n 122\n 155\n 177\n Other labs: PT / PTT / INR:15.1/24.6/1.3, Lactic Acid:0.7 mmol/L,\n Albumin:3.8 g/dL, Ca:8.0 mg/dL, Mg:2.2 mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA), .H/O RESPIRATORY\n FAILURE, ACUTE (NOT ARDS/), PROBLEM - ENTER DESCRIPTION IN\n COMMENTS, INTRACEREBRAL HEMORRHAGE (ICH), HYPERTENSION, BENIGN\n Assessment and Plan: 65M w/ MASSIVE Central IPH(spont)\n Neurologic: Neuro checks Q: 2 hr, unclear source of bleed, possibly\n from cyst. Plan for cyst aspiration and MRI ; dilantin levels;\n EVD for ICP monitor\n Cardiovascular: keep SBP<160, PO lopressor incr, nicardipine GTT\n restarted; hydralazine prn. t/c adding 2nd PO \n Pulmonary: (Ventilator mode: CPAP + PS), intubated, on CPAP+PS 5/5 40%\n Gastrointestinal / Abdomen: DHT via mouth\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO\n Hematology: slight INR elevation, vitK given. decreased to 1.3\n Endocrine: RISS\n Infectious Disease: persistent fevers; on vanco/ for suspected\n sinusitis\n Lines / Tubes / Drains: Foley, OGT, ETT\n Wounds:\n Imaging:\n Fluids: KVO\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS)\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 02:25 AM 55 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 06:44 PM\n ICP Catheter - 06:44 PM\n 18 Gauge - 12:59 PM\n Multi Lumen - 06:00 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: DNR / DNI\n Disposition: ICU\n Total time spent: 34 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2146-11-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 548530,
"text": "Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Temp max 101.3, wbc 5.3\n Action:\n Tylenol 650 mg given, no change in antibiotics\n Response:\n Pt temp remains 101 range, cx still pending\n Plan:\n Cont to monitor temp curve , medciate with Tylenol, ? reculturing if pt\n spikes again\n Hypertension, benign\n Assessment:\n Systolic b/p in am above 165, hr 90-100\n Action:\n Pt given prn dosing of 10 mg iv hydralazine, lopressor dosing increased\n to 100mg tid\n Response:\n Systolic b/p 145-165 during day additional dosing of hydralazine given\n in afternoon, pt noted to have increasing systolic b/p with adl\ns and\n suctioning as expected, aline is patent waveform sharp\n Plan:\n Continue to monitor b/p / increasing lopressor to 125 or adding\n additional htn medication if does not maintain 140-160 systolic\n Intracerebral hemorrhage (ICH)\n Assessment:\n Pt flex withdraws both feet to painful stimuli, no response seen to\n stimulation applied to upper leg, no movement in bilat upper exts, pt\n will slightly open eyes with name calling, pupils brisk reactive at\n 4mm, continues off sedation medications, 5-12 cc output from vent\n drain.\n Action:\n Pt for head and c spine CT. started on keppra \n Response:\n No change in previous scan from , lg cyst in pontine and\n suprasellar cisterns with obstruction of lateral ventricles, also no\n evidence of fracture or subluxation in c-spine noted , please see\n report, also noted ett in low position\n Plan:\n Pt continues on q 2 neuro checks, scheduled for surgery on thursday for\n draining of cyst, ett moved out to 22, pt keppra dsoin to be inc to\n 1500mg and then phenytoin to be discontinued\n"
},
{
"category": "Physician ",
"chartdate": "2146-11-30 00:00:00.000",
"description": "Intensivist Note",
"row_id": 548617,
"text": "SICU\n HPI:\n 65M w/sudden onset HA on am of went into bathroom and fell to\n ground; parents found him to be unresponsive and taken to OSH; then\n txfr to \n Chief complaint:\n MASSIVE Central IPH(spont)\n PMHx:\n unknown\n Current medications:\n 24 Hour Events:\n PAN CULTURE - At 09:15 PM\n FEVER - 103.0\nF - 08:00 PM\n Post operative day:\n HD#7 POD#6 - Left burr hole with placement of ventriculostomy\n drain\n 24hr events: VitK, incr lopressor, CT head/C-spine, ETT repositioned;\n o/n temp 103, pancx/CXR; ICP 20-23 intermittently, neurosurg aware.\n Nicardipine gtt restarted.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 06:59 AM\n Vancomycin - 08:00 PM\n Meropenem - 06:00 AM\n Infusions:\n Nicardipine - 1.5 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 AM\n Metoprolol - 05:51 PM\n Hydralazine - 06:07 PM\n Other medications:\n Flowsheet Data as of 07:18 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 39.4\nC (103\n T current: 39\nC (102.2\n HR: 84 (79 - 104) bpm\n BP: 136/61(84) {129/56(82) - 176/76(109)} mmHg\n RR: 20 (20 - 21) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 66.6 kg (admission): 75 kg\n ICP: 7 (6 - 22) mmHg\n Total In:\n 2,167 mL\n 793 mL\n PO:\n Tube feeding:\n 1,149 mL\n 394 mL\n IV Fluid:\n 898 mL\n 369 mL\n Blood products:\n Total out:\n 3,008 mL\n 1,145 mL\n Urine:\n 2,830 mL\n 1,100 mL\n NG:\n Stool:\n Drains:\n 178 mL\n 45 mL\n Balance:\n -841 mL\n -352 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 390 (361 - 579) mL\n PS : 5 cmH2O\n RR (Spontaneous): 20\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 50\n PIP: 11 cmH2O\n SPO2: 100%\n ABG: ///24/\n Ve: 8.6 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Responds to: Verbal stimuli, Tactile stimuli, Noxious\n stimuli), Moves toes b/l on tactile stimulation. Moves arms b/l on\n noxious stimulation. opens eyes slightly with verbal.\n Labs / Radiology\n 164 K/uL\n 11.2 g/dL\n 177\n 0.6 mg/dL\n 24 mEq/L\n 3.7 mEq/L\n 17 mg/dL\n 104 mEq/L\n 137 mEq/L\n 31.1 %\n 7.9 K/uL\n [image002.jpg]\n 02:45 AM\n 03:22 AM\n 04:49 AM\n 02:11 AM\n 02:18 AM\n 02:02 AM\n 02:12 AM\n 09:23 PM\n 02:58 AM\n 04:00 AM\n WBC\n 11.5\n 8.8\n 5.3\n 7.6\n 7.9\n Hct\n 31.3\n 29.2\n 30.4\n 31.5\n 31.1\n Plt\n 69\n 164\n Creatinine\n 0.7\n 0.7\n 0.7\n 0.6\n TCO2\n 25\n 21\n 28\n 28\n Glucose\n 110\n 111\n 122\n 155\n 177\n Other labs: PT / PTT / INR:15.1/24.6/1.3, Lactic Acid:0.7 mmol/L,\n Albumin:3.8 g/dL, Ca:8.0 mg/dL, Mg:2.2 mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA), .H/O RESPIRATORY\n FAILURE, ACUTE (NOT ARDS/), PROBLEM - ENTER DESCRIPTION IN\n COMMENTS, INTRACEREBRAL HEMORRHAGE (ICH), HYPERTENSION, BENIGN\n Assessment and Plan: 65M w/ MASSIVE Central IPH(spont)\n Neurologic: Neuro checks Q: 2 hr, unclear source of bleed, possibly\n from cyst. Plan for cyst aspiration and MRI ; dilantin changed to\n Keppra; EVD for ICP monitor\n Cardiovascular: keep SBP<160, PO lopressor incr, nicardipine GTT\n restarted; hydralazine prn. Add amlodipine for better bp control, wean\n off nicard gtt as able\n Pulmonary: (Ventilator mode: CPAP + PS), intubated, on CPAP+PS 5/5 40%,\n no change. To OR tomorrow\n Gastrointestinal / Abdomen: DHT via mouth\n Nutrition: Tube feeding at goal, hold at midnight for OR\n Renal: Foley, Adequate UO, replace electrolytes\n Hematology: slight INR elevation, vitK given. decreased to 1.3\n Endocrine: RISS, one dose nph now, will hold when tube feeds off to\n avoid hypoglycemia\n Infectious Disease: persistent fevers; on vanco/ for suspected\n sinusitis, wbc normal\n Lines / Tubes / Drains: Foley, OGT, ETT\n Wounds: evd site ok\n Imaging: none\n Fluids: KVO\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS) , Respiratory Failure\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 02:25 AM 55 mL/hour\n Glycemic Control: NPH and SSI\n Lines: CVL\n Arterial Line - 06:44 PM\n ICP Catheter - 06:44 PM\n 18 Gauge - 12:59 PM\n Multi Lumen - 06:00 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Oral Care\n Comments:\n Communication: ICU consent signed Comments:\n Code status: DNR / DNI\n Disposition: ICU\n Total time spent: 34 minutes\n"
},
{
"category": "Respiratory ",
"chartdate": "2146-11-30 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 548637,
"text": "Airway\n Tube Type\n ETT:\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Assisted spontaneous breathing.\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Pt continues on PSV as charted.\n Plan\n Next 24-48 hours: Continue ventilating on current settings.\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n"
},
{
"category": "Respiratory ",
"chartdate": "2146-12-01 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 548702,
"text": "Demographics\n Day of mechanical ventilation: 8\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 23 cmH2O\n Cuff volume: mL /\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Ob CPAP/PS \n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Pending procedure /\n OR\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n MRI\n 0530\n Pre-op\n"
},
{
"category": "Nursing",
"chartdate": "2146-12-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 548705,
"text": "TITLE:\n Intracerebral hemorrhage (ICH)\n Assessment:\n temp 102 via continuous rectal probe monitor\n neuro checks q2h unchanged from prior shift\n pt scheduled for OR in am\n Action:\n md dr. and neurosurgical md notified of fever\n Tylenol given\n antibiotics added\n continue neuro checks q2h\n pre op ekg done and type and screen sent\n tube feeds put on hold at midnight\n Response:\n pt remains febrile\n neuro checks qh2\n pt npo\n Plan:\n MRI at 0530\n OR for cyst aspiration at 0730\n"
},
{
"category": "Physician ",
"chartdate": "2146-12-02 00:00:00.000",
"description": "Intensivist Note",
"row_id": 548877,
"text": "SICU\n HPI:\n 65M w/sudden onset HA on am of went into bathroom and fell to\n ground; parents found him to be unresponsive and taken to OSH; then\n txfr to . found to have massive IVH, s/p Lt Burr hole W EVD\n placement , now s/p cyst aspiration \n Chief complaint:\n intraventricular hemorrhage\n PMHx:\n Asperger's\n Current medications:\n 1. 2. 3. 20 mEq Potassium Chloride / 1000 mL NS 4. Acetaminophen 5.\n Amlodipine 6. Ampicillin\n 7. Bisacodyl 8. Calcium Gluconate 9. Chlorhexidine Gluconate 0.12% Oral\n Rinse 10. Docusate Sodium (Liquid)\n 11. Famotidine 12. HYDROmorphone (Dilaudid) 13. HYDROmorphone\n (Dilaudid) 14. Heparin 15. HydrALAzine\n 16. HydrALAzine 17. Insulin 18. Influenza Virus Vaccine 19.\n LeVETiracetam 20. Magnesium Sulfate\n 21. Meropenem 22. Metoprolol Tartrate 23. NiCARdipine 24. Nystatin Oral\n Suspension 25. Pneumococcal Vac Polyvalent\n 26. Potassium Chloride 27. Propofol 28. Senna 29. Sodium Chloride 0.9%\n Flush 30. Sodium Chloride 0.9% Flush\n 31. Vancomycin\n 24 Hour Events:\n OR SENT - At 08:13 AM\n ICP CATHETER - STOP 11:30 AM\n OR RECEIVED - At 11:37 AM\n PAN CULTURE - At 07:58 PM\n FEVER - 101.6\nF - 08:00 PM\n - organ bank called, will call back after surgery done and prognosis\n better known\n - to OR, EVD taken out, cyst aspirated, CT afterwards OK by report\n - social work working on getting court appointed guardian\n - started hydralazine\n Post operative day:\n POD#8 - Left burr hole with placement of ventriculostomy drain\n POD#1 - Endoscopic cysto ventriculostomy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Ampicillin - 06:00 AM\n Meropenem - 06:00 AM\n Infusions:\n Nicardipine - 3 mcg/Kg/min\n Other ICU medications:\n Metoprolol - 02:12 PM\n Famotidine (Pepcid) - 08:30 PM\n Hydromorphone (Dilaudid) - 02:30 AM\n Hydralazine - 04:33 AM\n Other medications:\n Flowsheet Data as of 06:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.7\nC (101.6\n T current: 38.4\nC (101.2\n HR: 85 (71 - 99) bpm\n BP: 131/52(78) {96/43(59) - 189/99(125)} mmHg\n RR: 18 (10 - 23) insp/min\n SPO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 66.6 kg (admission): 75 kg\n ICP: 5 (5 - 5) mmHg\n Total In:\n 4,783 mL\n 1,206 mL\n PO:\n Tube feeding:\n 170 mL\n 268 mL\n IV Fluid:\n 4,374 mL\n 878 mL\n Blood products:\n Total out:\n 2,899 mL\n 1,000 mL\n Urine:\n 2,480 mL\n 1,000 mL\n NG:\n Stool:\n Drains:\n 59 mL\n Balance:\n 1,884 mL\n 206 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 520 (471 - 636) mL\n PS : 5 cmH2O\n RR (Set): 12\n RR (Spontaneous): 14\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 41\n PIP: 11 cmH2O\n SPO2: 99%\n ABG: ///25/\n Ve: 7 L/min\n Physical Examination\n General Appearance: No acute distress, intubated\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: No(t) Moves all extremities, (RUE: No movement), (LUE: No\n movement), (RLE: No movement), (LLE: No movement), no spontaneous\n movement/withdrawal to pain in extremities; more awake and alert\n however, ?tracks with eyes\n Labs / Radiology\n 178 K/uL\n 11.0 g/dL\n 109 mg/dL\n 0.5 mg/dL\n 25 mEq/L\n 4.0 mEq/L\n 18 mg/dL\n 106 mEq/L\n 138 mEq/L\n 31.1 %\n 8.5 K/uL\n [image002.jpg]\n 02:11 AM\n 02:18 AM\n 02:02 AM\n 02:12 AM\n 09:23 PM\n 02:58 AM\n 04:00 AM\n 02:20 AM\n 11:46 AM\n 02:48 AM\n WBC\n 8.8\n 5.3\n 7.6\n 7.9\n 9.4\n 7.5\n 8.5\n Hct\n 29.2\n 30.4\n 31.5\n 31.1\n 32.5\n 30.9\n 31.1\n Plt\n 177\n 156\n 169\n 164\n 187\n 182\n 178\n Creatinine\n 0.7\n 0.7\n 0.6\n 0.7\n 0.6\n 0.5\n TCO2\n 28\n 28\n Glucose\n 111\n 122\n 155\n 177\n 103\n 116\n 109\n Other labs: PT / PTT / INR:15.5/24.9/1.4, Lactic Acid:0.7 mmol/L,\n Albumin:3.8 g/dL, Ca:8.0 mg/dL, Mg:2.3 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n IMPAIRED SKIN INTEGRITY, FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA,\n PYREXIA), .H/O RESPIRATORY FAILURE, ACUTE (NOT ARDS/), PROBLEM\n - ENTER DESCRIPTION IN COMMENTS, INTRACEREBRAL HEMORRHAGE (ICH),\n HYPERTENSION, BENIGN\n Assessment and Plan: 65 yo M with large IVH s/p Burr hole with EVD\n placement, now s/p cyst aspiration.\n Neurologic: Neuro checks Q: 2 hr, s/p cyst aspiration in OR , when\n extubating, extubate on precedex (severe autism/claustrophobia). Pt\n returned from OR with c-collar, ?c-spine cleared? organ bank notified\n of pt, awaiting prognosis/postop course. Much improved.\n Cardiovascular: Beta-blocker, keep SBP<140, on PO\n lopressor/amlodipine/hydralazine, wean nicardipine GTT as tolerated;\n hydralazine prn\n Pulmonary: Cont ETT, (Ventilator mode: CPAP + PS), intubated, on\n CPAP+PS, minimal settings, CXR clear. Extubate.\n Gastrointestinal / Abdomen: TF - advance to goal 70/hr, H2B\n Nutrition: Tube feeding after extubation.\n Renal: Foley, Adequate UO, follow UOP, no acute issues\n Hematology: HCt stable, starting Hep SQ today\n Endocrine: RISS, Follow FS, ?start NPH\n Infectious Disease: Check cultures, continues to be febrile but WBC\n wnl, cultures pending, on for suspected sinusitis, started\n Vanc/Amp for meningitis coverage\n Lines / Tubes / Drains: Foley, Dobhoff, ETT, A-line, central line\n Wounds: Wound oozing sero sang fluid, neuro evaluated and\n comfortable with situation.\n Imaging:\n Fluids: KVO\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS), (Respiratory distress: Failure)\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 03:36 PM 55 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 06:44 PM\n Multi Lumen - 06:00 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: DNR / DNI\n Disposition: ICU\n Total time spent: 31 minutes\n Patient is critically ill\n"
},
{
"category": "Nutrition",
"chartdate": "2146-12-01 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 548757,
"text": "Current Wt: 65.5kg\n Pertinent medications: Abx, Propofol gtt, Bisacodyl, colace,\n famotidine, senna, others noted\n Labs:\n Value\n Date\n Glucose\n 116 mg/dL\n 11:46 AM\n Glucose Finger Stick\n 156\n 10:00 PM\n BUN\n 18 mg/dL\n 11:46 AM\n Creatinine\n 0.6 mg/dL\n 11:46 AM\n Sodium\n 137 mEq/L\n 11:46 AM\n Potassium\n 4.1 mEq/L\n 11:46 AM\n Chloride\n 106 mEq/L\n 11:46 AM\n TCO2\n 23 mEq/L\n 11:46 AM\n PO2 (arterial)\n 187 mm Hg\n 02:12 AM\n PCO2 (arterial)\n 34 mm Hg\n 02:12 AM\n pH (arterial)\n 7.51 units\n 02:12 AM\n pH (urine)\n 5.0 units\n 09:23 PM\n CO2 (Calc) arterial\n 28 mEq/L\n 02:12 AM\n Albumin\n 3.8 g/dL\n 02:35 AM\n Calcium non-ionized\n 7.6 mg/dL\n 11:46 AM\n Phosphorus\n 3.7 mg/dL\n 11:46 AM\n Ionized Calcium\n 1.12 mmol/L\n 02:12 AM\n Magnesium\n 2.2 mg/dL\n 11:46 AM\n Current diet order / nutrition support: TF: off, was running Replete\n with Fiber @ 55cc/hr (1320kcal, 82g protein)\n GI:\n Assessment of Nutritional Status\n 65 y.o. M adm with massive ICH, underwent burr hole with\n ventriculostomy drain placement . Pt was weaned off sedation\n until today, when pt went back to OR for aspiration of cyst. Pt now\n remains intubated, and is sedated on propofol, which is running at a\n high rate and providing >900kcal/day. Current TF order is appropriate\n only in pt continues on propofol gtt. If sedation weaned off, rec\n increase goal TF rate to 75 cc/hr to better meet pt\ns kcal needs.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1) TF goal with propofol gtt running: Replete with fiber @ 55cc/hr.\n 2) If propofol weaned off, rec increase TF goal to Replete c/ Fiber @\n 75cc/hr (1800kcal, 112g protein).\n 3) Monitor progress and TF tolerance.\n Please page with ?\ns #\n"
},
{
"category": "Nursing",
"chartdate": "2146-12-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 548689,
"text": "TITLE:\n Intracerebral hemorrhage (ICH)\n Assessment:\n temp 102 via continuous rectal probe monitor\n neuro checks q2h unchanged from prior shift\n pt scheduled for OR in am\n Action:\n md dr. and neurosurgical md notified of fever\n Tylenol given\n antibiotics added\n continue neuro checks q2h\n pre op ekg done and type and screen sent\n tube feeds put on hold at midnight\n Response:\n pt remains febrile\n neuro checks qh2\n pt npo\n Plan:\n MRI at 0530\n OR for cyst aspiration at 0730\n"
},
{
"category": "Nursing",
"chartdate": "2146-12-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 548782,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Patient to OR for drainage of arachnoid cyst and reservoir placement\n Not following commands, no movement of extremeties\n Opening eyes to voice\n HTN to 150\n Action:\n Q1 neuro checks\n Propofol off\n Head Ct done\n Hydralazine,dilaudid, lopressor, norvasc\n Response:\n Bp remains elevated to 140\ns, awaiting further orders/interventions\n Plan:\n Cont q1 neuro checks\n DNR (DNI)\n SBP <140\n Await next 48 hours for improvement and reassess clinical status at\n that time\n SW- spoke with family and legal guardianship papers in\n front of chart with copy of birth certificate\n Impaired Skin Integrity\n Assessment:\n Red stage 1 non-blanchable area on buttocks after arrival from OR\n Action:\n Turned off buttocks\n Response:\n Redness continues\n Plan:\n Cont q2 turns\n Skin care\n"
},
{
"category": "Physician ",
"chartdate": "2146-12-02 00:00:00.000",
"description": "Intensivist Note",
"row_id": 548856,
"text": "SICU\n HPI:\n 65M w/sudden onset HA on am of went into bathroom and fell to\n ground; parents found him to be unresponsive and taken to OSH; then\n txfr to . found to have massive IVH, s/p Lt Burr hole W EVD\n placement , now s/p cyst aspiration \n Chief complaint:\n intraventricular hemorrhage\n PMHx:\n Asperger's\n Current medications:\n 1. 2. 3. 20 mEq Potassium Chloride / 1000 mL NS 4. Acetaminophen 5.\n Amlodipine 6. Ampicillin\n 7. Bisacodyl 8. Calcium Gluconate 9. Chlorhexidine Gluconate 0.12% Oral\n Rinse 10. Docusate Sodium (Liquid)\n 11. Famotidine 12. HYDROmorphone (Dilaudid) 13. HYDROmorphone\n (Dilaudid) 14. Heparin 15. HydrALAzine\n 16. HydrALAzine 17. Insulin 18. Influenza Virus Vaccine 19.\n LeVETiracetam 20. Magnesium Sulfate\n 21. Meropenem 22. Metoprolol Tartrate 23. NiCARdipine 24. Nystatin Oral\n Suspension 25. Pneumococcal Vac Polyvalent\n 26. Potassium Chloride 27. Propofol 28. Senna 29. Sodium Chloride 0.9%\n Flush 30. Sodium Chloride 0.9% Flush\n 31. Vancomycin\n 24 Hour Events:\n OR SENT - At 08:13 AM\n ICP CATHETER - STOP 11:30 AM\n OR RECEIVED - At 11:37 AM\n PAN CULTURE - At 07:58 PM\n FEVER - 101.6\nF - 08:00 PM\n - organ bank called, will call back after surgery done and prognosis\n better known\n - to OR, EVD taken out, cyst aspirated, CT afterwards OK by report\n - social work working on getting court appointed guardian\n - started hydralazine\n Post operative day:\n POD#8 - Left burr hole with placement of ventriculostomy drain\n POD#1 - Endoscopic cysto ventriculostomy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Ampicillin - 06:00 AM\n Meropenem - 06:00 AM\n Infusions:\n Nicardipine - 3 mcg/Kg/min\n Other ICU medications:\n Metoprolol - 02:12 PM\n Famotidine (Pepcid) - 08:30 PM\n Hydromorphone (Dilaudid) - 02:30 AM\n Hydralazine - 04:33 AM\n Other medications:\n Flowsheet Data as of 06:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.7\nC (101.6\n T current: 38.4\nC (101.2\n HR: 85 (71 - 99) bpm\n BP: 131/52(78) {96/43(59) - 189/99(125)} mmHg\n RR: 18 (10 - 23) insp/min\n SPO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 66.6 kg (admission): 75 kg\n ICP: 5 (5 - 5) mmHg\n Total In:\n 4,783 mL\n 1,206 mL\n PO:\n Tube feeding:\n 170 mL\n 268 mL\n IV Fluid:\n 4,374 mL\n 878 mL\n Blood products:\n Total out:\n 2,899 mL\n 1,000 mL\n Urine:\n 2,480 mL\n 1,000 mL\n NG:\n Stool:\n Drains:\n 59 mL\n Balance:\n 1,884 mL\n 206 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 520 (471 - 636) mL\n PS : 5 cmH2O\n RR (Set): 12\n RR (Spontaneous): 14\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 41\n PIP: 11 cmH2O\n SPO2: 99%\n ABG: ///25/\n Ve: 7 L/min\n Physical Examination\n General Appearance: No acute distress, intubated\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: No(t) Moves all extremities, (RUE: No movement), (LUE: No\n movement), (RLE: No movement), (LLE: No movement), no spontaneous\n movement/withdrawal to pain in extremities; more awake and alert\n however, ?tracks with eyes\n Labs / Radiology\n 178 K/uL\n 11.0 g/dL\n 109 mg/dL\n 0.5 mg/dL\n 25 mEq/L\n 4.0 mEq/L\n 18 mg/dL\n 106 mEq/L\n 138 mEq/L\n 31.1 %\n 8.5 K/uL\n [image002.jpg]\n 02:11 AM\n 02:18 AM\n 02:02 AM\n 02:12 AM\n 09:23 PM\n 02:58 AM\n 04:00 AM\n 02:20 AM\n 11:46 AM\n 02:48 AM\n WBC\n 8.8\n 5.3\n 7.6\n 7.9\n 9.4\n 7.5\n 8.5\n Hct\n 29.2\n 30.4\n 31.5\n 31.1\n 32.5\n 30.9\n 31.1\n Plt\n 177\n 156\n 169\n 164\n 187\n 182\n 178\n Creatinine\n 0.7\n 0.7\n 0.6\n 0.7\n 0.6\n 0.5\n TCO2\n 28\n 28\n Glucose\n 111\n 122\n 155\n 177\n 103\n 116\n 109\n Other labs: PT / PTT / INR:15.5/24.9/1.4, Lactic Acid:0.7 mmol/L,\n Albumin:3.8 g/dL, Ca:8.0 mg/dL, Mg:2.3 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n IMPAIRED SKIN INTEGRITY, FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA,\n PYREXIA), .H/O RESPIRATORY FAILURE, ACUTE (NOT ARDS/), PROBLEM\n - ENTER DESCRIPTION IN COMMENTS, INTRACEREBRAL HEMORRHAGE (ICH),\n HYPERTENSION, BENIGN\n Assessment and Plan: 65 yo M with large IVH s/p Burr hole with EVD\n placement, now s/p cyst aspiration.\n Neurologic: Neuro checks Q: 2 hr, s/p cyst aspiration in OR , when\n extubating, extubate on precedex (severe autism/claustrophobia). Pt\n returned from OR with c-collar, ?c-spine cleared? organ bank notified\n of pt, awaiting prognosis/postop course.\n Cardiovascular: Beta-blocker, keep SBP<140, on PO\n lopressor/amlodipine/hydralazine, wean nicardipine GTT as tolerated;\n hydralazine prn\n Pulmonary: Cont ETT, (Ventilator mode: CPAP + PS), intubated, on\n CPAP+PS, minimal settings, CXR clear\n Gastrointestinal / Abdomen: TF - advance to goal 70/hr, H2B\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO, follow UOP, no acute issues\n Hematology: HCt stable, starting Hep SQ today\n Endocrine: RISS, Follow FS, ?start NPH\n Infectious Disease: Check cultures, continues to be febrile but WBC\n wnl, cultures pending, on for suspected sinusitis, started\n Vanc/Amp for meningitis coverage\n Lines / Tubes / Drains: Foley, Dobhoff, ETT, A-line, central line\n Wounds: Wound oozing sero sang fluid, neuro evaluated, OK with it\n Imaging:\n Fluids: KVO\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS), (Respiratory distress: Failure)\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 03:36 PM 55 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 06:44 PM\n Multi Lumen - 06:00 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: DNR / DNI\n Disposition: ICU\n Total time spent: 31 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2146-11-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 548595,
"text": "Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Tmax 103.0 orally.\n Action:\n Tylenol given x 1, cooling blanket applied with continuous temp\n monitoring. Pancultured. Chest x-ray done\n Response:\n Temp decreased following Tylenol to 101.6.\n Plan:\n Continue to monitor rectal temps, give Tylenol as needed, follow up on\n cultures\n Hypertension, benign\n Assessment:\n Systolic BP rising to 170\ns at the beginning of the shift. At that\n time, pt febrile and ICP rising to 22.\n Action:\n Dr. notified, as well as the NSURG resident. Nicardipine gtt\n restarted, Tylenol given for fever.\n Response:\n BP well controlled on gtt and systolic maintained at goal of 140-160.\n ICP decreasing after repositioning and BP control\n Plan:\n Continue to treat fevers with Tylenol, check ICP Q 1hour and notify\n resident if above 20 for more than a\n hour.\n"
},
{
"category": "Nursing",
"chartdate": "2146-12-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 548762,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Respiratory ",
"chartdate": "2146-12-01 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 548775,
"text": "Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: pt weaned to CPAP this shift, tolerating well.\n Assessment of breathing comfort: No claim of dyspnea\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Respiratory Care Shift Procedures\n Traveled to and from CT, no complications.\n"
},
{
"category": "Nursing",
"chartdate": "2146-12-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 548851,
"text": "Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Tmax 101.6\n Action:\n Tylenol given, Dr. notified. Blood cultures done x 2\n Response:\n Pt mildly responding to Tylenol, temp decreased to 100.7\n Plan:\n Continue to monitor temp, follow up on pending cultures, give Tylenol\n as needed.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Pt opening eyes to voice and stimulation. Not moving any ext. until\n this am, pt slightly squeezing with left hand only. Ext. not responding\n to painful stimulation. Perrl, appear to be sluggish at times. Head\n incision oozing moderate amounts of rust colored drainage.\n Action:\n Head incision shown to Dr. , as well as SICU resident, dressing\n changed.\n Response:\n Drainage decreased throughout the night. Pt more responsive this am.\n Plan:\n Continue to monitor neuro status Q 1hour, monitor head incision for\n increased drainage\n Hypertension, benign\n Assessment:\n Systolic BP rising to 170\ns at times.\n Action:\n Nicardipine gtt started, Hydralazine po added.\n Response:\n Gtt increased this am to 2.5 mcgs/kg/min, pain med given with effect\n Plan:\n Continue to treat for ? pain, titrate Nicardipine to keep SBP < 140 per\n resident\n"
},
{
"category": "Respiratory ",
"chartdate": "2146-12-02 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 548827,
"text": "Demographics\n Day of mechanical ventilation: 9\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 23 cmH2O\n Cuff volume: mL /\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: AM RSBI-41\n Reason for continuing current ventilatory support: Cannot protect\n airway, Underlying illness not resolved\n"
},
{
"category": "Nursing",
"chartdate": "2146-11-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 547928,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Pt follows commands and moves all extremites off of Propofol. Pt\n clearly nodded head to questions. Pt was able to show 2 fingers with\n right hand. Pupils change from sluggish to brisk reactive equally\n CSF remains grossly bloody 8\n 20ml/hr. Vent drain remains 15cm above\n Tragus.ICP 4-14 and CPP 65-75\n Action:\n Propofol turned off q4hr for complete Neuro exam .Pt remains on\n Dilantin. Pt to have CTA this pm thus remains intubated ( on c-pap5\n with 5 IPS and on Propofol.\n Response:\n SBP and Map increase >160 when pt more awake. Nicardipine was required\n to be started for anticipation of turning off Propofol and extubating\n patient. Tolerating new vent settings\n Plan:\n Maintain SBP <160 with Nicardipine\n"
},
{
"category": "Nursing",
"chartdate": "2146-11-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 547801,
"text": "65yr old male was found unresponsive by his family after complaining of\n a headache. He was found to have son breathing by paramedics and\n had been incontinent of urine. Pt was intubated at and sent\n for Head CT which showed massive intracranial hemorrhage within the\n ventricles. He was transferred to and taken from the ER to the\n operating room for burr hole and ventriculostomy drain placement. He\n arrived to ICU on propofol gtt with cervical spine collar in place.\n Please refer to OR notes and admission data. Full report given to\n oncoming shift.\n"
},
{
"category": "Physician ",
"chartdate": "2146-11-24 00:00:00.000",
"description": "Physician Surgical Admission Note",
"row_id": 547803,
"text": "Chief Complaint: \"Massive Head Bleed\"\n HPI:\n 65M presented to OSH this am after complaining of headache\n this morning. Per reports from ED records, and parents(with whom\n he resides), he then went upstairs to the bathroom when a \"thump\"\n was heard. His mother went upstairs into the bathroom and found\n him on the floor, incontinent of urine and unresponsive. She then\n called 911, and was taken to OSH. Upon presentation to OSH, he\n was found to be hypertensive to 230/150, started on Nipride. His\n head was scanned and revealed a \"Massive Head Bleed, without\n midline shift\". He was then subsequently transferred to for\n definitive care and Neurosurgical evaluation. In the duration of\n transfer, per EMS noted, started decorticate posturing and they\n began infusion of 25 gm Mannitol IV.\n Post operative day:\n POD#0 - Left burr hole with placement of ventriculostomy drain\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Propofol - 70 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Past medical history:\n Family / Social history:\n PMHx: Unknown; however per mother; no HTN, cardiac history,\n cancer history, or any other major medical problems.\n : Unknown\n Medications prior to admission: Unknown; however per mother; does\n not take any regular anticoagulation medication.\n Social Hx: resides at home with parents.\n Family Hx: Non-contributory\n ROS: As above noted.\n Flowsheet Data as of 09:31 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.6\n Tcurrent: 38.1\nC (100.6\n HR: 82 (81 - 82) bpm\n BP: 114/62(79) {114/61(79) - 154/77(100)} mmHg\n RR: 12 (12 - 13) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n ICP: 12 (5 - 12) mmHg\n Total In:\n 901 mL\n PO:\n TF:\n IVF:\n 901 mL\n Blood products:\n Total out:\n 0 mL\n 2,216 mL\n Urine:\n 490 mL\n NG:\n Stool:\n Drains:\n 6 mL\n Balance:\n 0 mL\n -1,315 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 21 cmH2O\n Plateau: 19 cmH2O\n Compliance: 43.8 cmH2O/mL\n SpO2: 100%\n ABG: 7.46/32/269//0\n Ve: 6.8 L/min\n PaO2 / FiO2: 672\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: No(t) PERRL, Conjunctiva pale, NR pupil on the\n right\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition, Endotracheal\n tube\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Sedated, Paralyzed, Tone: Not assessed\n Labs / Radiology\n 120 mg/dL\n 4.3 mEq/L\n 102 mEq/L\n 136 mEq/L\n 38\n [image002.jpg]\n 05:42 PM\n 05:44 PM\n Hct\n 41\n 38\n TCO2\n 24\n 23\n Glucose\n 128\n 120\n Other labs: Lactic Acid:2.1 mmol/L\n Fluid analysis / Other labs: +corneals +swallowing , no posturing\n NR pupil on the right\n Assessment and Plan\n 65M w/sudden onset HA on am of went into bathroom and fell to\n ground; parents found him to be unresponsive and taken to OSH;then txfr\n to ; now s.p burr hole with evd placement\n Assessment And Plan:\n Neurologic: q1hr neuro checks, propofol, MRI head, EVD@ 15cm open\n Cardiovascular: keep SBP<140, hemodynamically stable thus far\n Pulmonary: intubated, weaning to CPAP\n Gastrointestinal: NPO for now, PPI\n Renal: follow UOP, foley in place, no acute issues\n Hematology: stable thus far, will continue to follow in the AM\n Infectious Disease: no acute issues thus far\n Endocrine: RISS\n Fluids: NS+20KCl@ 80cc/hr\n Electrolytes: will replete lytes aggressively\n Nutrition: NPO for now\n General:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 06:44 PM\n 18 Gauge - 06:46 PM\n 20 Gauge - 06:46 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 32 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2146-12-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 549170,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Inconsistent neurological exam this am with pt. being arousable to\n voice and wiggling left toes to command. Continued with large amounts\n of drainage from head incision.\n Action:\n Dr. in to assess pt and staples x3 placed on head\n incision. Head Ct done.\n Response:\n No further drainage from head incision. Preliminary CT results reveal\n hygroma. Post CT scan pt has been consistently following commands with\n left foot and sqeezing left hand. He is now verbal and denies pain. He\n was unable to say where he was or date. Pt. family states he is not\n very talkative at baseline.\n Plan:\n Continue to assess neurological status q2hrs.\n Hypertension, benign\n Assessment:\n Continues on Nicardipine IV drip to keep SBP<160\n Action:\n Clonidine and Hydrochlorothiazide added with some effect on BP.\n Nicardipine weaned down.\n Response:\n BP<160 maintained\n Plan:\n Wean Nicardipine to off as tolerated.\n"
},
{
"category": "Nursing",
"chartdate": "2146-12-05 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 549239,
"text": "HPI:\n 65M w/sudden onset HA on am of went into bathroom and fell to\n ground; parents found him to be unresponsive and taken to OSH; then\n txfr to . Found to have massive IVH, s/p Lt Burr hole W EVD\n placement . On he had external EVD removed, taken to OR for\n cyst aspiration and internal drainage placement.\n He was intubated . Nicardipine for BP control until \n with multiple po meds added to regime. He had an oral dobhoff placed\n orally d/t sinusitis and finished course of Merepenem on for it.\n He had been spiking fevers until -last pan cx and is on\n Vanco and Ampicillin for meningitis coverage.\n Head incision had been draining large amounts of serosang and clear\n drainage for a couple of days until 3 staples placed by Dr.\n on which stopped the drainage. Last CT scan done\n which showed a hygroma-final result pending.\n On there was a family meeting and he is DNR/DNI.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Improved neuro status. Pt has been inconsistently following commands\n and now more consistent. He is able to squeeze and let go with left\n hand and wiggle toes and right hand to command. Right weaker than left.\n Verbal and A/O x1\n\nhome\n Action:\n Neurological exam q2hrs.\n Response:\n Improved neuro status\n Plan:\n Update Neurosurgical service this pm to evaluate possible transfer to\n SDU.\n Hypertension, benign\n Assessment:\n Nicardipine gtt weaned to off this am.\n Action:\n Hydralazine, Lopressor, Nimodipine, Amlodipine, HCTZ, and Clonidine as\n ordered with good effect.\n Response:\n BP maintained <160sys\n Plan:\n Monitor BP and keep <160\n"
},
{
"category": "Physician ",
"chartdate": "2146-11-25 00:00:00.000",
"description": "Intensivist Note",
"row_id": 547887,
"text": "SICU\n HPI:\n 65M w/sudden onset HA on am of went into bathroom and fell to\n ground; parents found him to be unresponsive and taken to OSH;then txfr\n to \n Chief complaint:\n intraventricular hemorrhage\n PMHx:\n PMH/PSH: mother; denies any cardiac/respiratory/cancer\n Current medications:\n 1. 2. 20 mEq Potassium Chloride / 1000 mL NS 3. Acetaminophen 4.\n Bisacodyl 5. CefazoLIN 6. Chlorhexidine Gluconate 0.12% Oral Rinse\n 7. Docusate Sodium 8. HYDROmorphone (Dilaudid) 9. HydrALAzine 10.\n Insulin 11. Influenza Virus Vaccine\n 12. Pantoprazole 13. Phenytoin 14. Pneumococcal Vac Polyvalent 15.\n Propofol 16. Senna 17. Sodium Chloride 0.9% Flush\n 24 Hour Events:\n INTUBATION - At 06:25 PM\n recieved intubated from OR\n INVASIVE VENTILATION - START 06:25 PM\n OR RECEIVED - At 06:37 PM\n ARTERIAL LINE - START 06:44 PM\n MAGNETIC RESONANCE IMAGING - At 02:00 AM\n .\n EVENTS:\n : +Corneals/+swallowing, Pupils symmetric in size, Lt3mm MR, spont\n mvmt on LUE/LLE, no spont mvmt of Rt side. Taken to or for EVD\n placement with burr hole and returned, MRI obtained, improving neuro\n exam by the morning\n Post operative day:\n POD#1 - Left burr hole with placement of ventriculostomy drain\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 10:00 PM\n Infusions:\n Propofol - 50 mcg/Kg/min\n Other ICU medications:\n Dilantin - 12:30 AM\n Hydralazine - 05:16 AM\n Other medications:\n Flowsheet Data as of 06:07 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.2\nC (100.7\n T current: 37.4\nC (99.4\n HR: 81 (79 - 85) bpm\n BP: 146/69(97) {103/58(74) - 154/77(100)} mmHg\n RR: 22 (12 - 24) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n ICP: 12 (5 - 13) mmHg\n Total In:\n 1,252 mL\n 605 mL\n PO:\n Tube feeding:\n IV Fluid:\n 1,252 mL\n 605 mL\n Blood products:\n Total out:\n 2,391 mL\n 477 mL\n Urine:\n 665 mL\n 390 mL\n NG:\n Stool:\n Drains:\n 6 mL\n 87 mL\n Balance:\n -1,139 mL\n 128 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 65\n PIP: 22 cmH2O\n Plateau: 18 cmH2O\n Compliance: 48 cmH2O/mL\n SPO2: 100%\n ABG: 7.42/36/185/23/0\n Ve: 7.1 L/min\n PaO2 / FiO2: 463\n Physical Examination\n General Appearance: No acute distress, Well nourished\n HEENT: PERRL, EOMI (changed from previous exam)\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, No(t) Distended\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 2), Follows simple commands,\n (Responds to: Verbal stimuli, Tactile stimuli, Noxious stimuli), R\n sided weakness\n Labs / Radiology\n 185 K/uL\n 12.2 g/dL\n 147 mg/dL\n 1.0 mg/dL\n 23 mEq/L\n 3.8 mEq/L\n 17 mg/dL\n 109 mEq/L\n 140 mEq/L\n 33.2 %\n 10.6 K/uL\n [image002.jpg]\n 05:42 PM\n 05:44 PM\n 09:21 PM\n 04:00 AM\n 04:31 AM\n WBC\n 12.5\n 10.6\n Hct\n 41\n 38\n 33.6\n 33.2\n Plt\n 225\n 185\n Creatinine\n 1.0\n 1.0\n TCO2\n 24\n 23\n 24\n Glucose\n 128\n 120\n 131\n 150\n 147\n Other labs: PT / PTT / INR:15.5/24.9/1.4, Lactic Acid:1.1 mmol/L,\n Albumin:4.1 g/dL, Ca:8.5 mg/dL, Mg:2.4 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n INTRACEREBRAL HEMORRHAGE (ICH), HYPERTENSION, BENIGN\n Assessment and Plan: 65M w/sudden onset HA on am of went into\n bathroom and fell to ground; parents found him to be unresponsive and\n taken to OSH;then txfr to \n ; found to have massive Intraventricular hemorrhage, now s/p drainage\n and left burr hole placement, neuro exam significantly improved\n Neurologic: Neuro checks Q: 1 hr, Phenytoin - therapeutic, q1hr neuro\n checks, propofol, MRI head, EVD@ 15cm open\n Cardiovascular: keep SBP<140, hemodynamically stable thus far, without\n exogenous medication administration, start nicardipine for tight bp\n control during extubation\n Pulmonary: Cont ETT, (Ventilator mode: CPAP + PS), intubated, weaning\n to CPAP, extubate today if meets crtiteria\n Gastrointestinal / Abdomen: NPO for now, PPI\n Nutrition: NPO\n Renal: Foley, Adequate UO\n Hematology: Serial Hct, stable\n Endocrine: RISS, good bs control\n Infectious Disease: ancef for evd\n Lines / Tubes / Drains: Foley, NGT, ETT, Surgical drains (hemovac, JP),\n evd\n Wounds: Dry dressings\n Imaging: f/u MRI head today\n Fluids: NS, NS+20KCl@ 80cc/hr\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS), (Respiratory distress: Failure),\n Closed head injury\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 06:44 PM\n 18 Gauge - 06:46 PM\n 20 Gauge - 06:46 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 33 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2146-11-25 00:00:00.000",
"description": "Intensivist Note",
"row_id": 547888,
"text": "SICU\n HPI:\n 65M w/sudden onset HA on am of went into bathroom and fell to\n ground; parents found him to be unresponsive and taken to OSH;then txfr\n to \n Chief complaint:\n intraventricular hemorrhage\n PMHx:\n PMH/PSH: mother; denies any cardiac/respiratory/cancer\n Current medications:\n 1. 2. 20 mEq Potassium Chloride / 1000 mL NS 3. Acetaminophen 4.\n Bisacodyl 5. CefazoLIN 6. Chlorhexidine Gluconate 0.12% Oral Rinse\n 7. Docusate Sodium 8. HYDROmorphone (Dilaudid) 9. HydrALAzine 10.\n Insulin 11. Influenza Virus Vaccine\n 12. Pantoprazole 13. Phenytoin 14. Pneumococcal Vac Polyvalent 15.\n Propofol 16. Senna 17. Sodium Chloride 0.9% Flush\n 24 Hour Events:\n INTUBATION - At 06:25 PM\n recieved intubated from OR\n INVASIVE VENTILATION - START 06:25 PM\n OR RECEIVED - At 06:37 PM\n ARTERIAL LINE - START 06:44 PM\n MAGNETIC RESONANCE IMAGING - At 02:00 AM\n .\n EVENTS:\n : +Corneals/+swallowing, Pupils symmetric in size, Lt3mm MR, spont\n mvmt on LUE/LLE, no spont mvmt of Rt side. Taken to or for EVD\n placement with burr hole and returned, MRI obtained, improving neuro\n exam by the morning\n Post operative day:\n POD#1 - Left burr hole with placement of ventriculostomy drain\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 10:00 PM\n Infusions:\n Propofol - 50 mcg/Kg/min\n Other ICU medications:\n Dilantin - 12:30 AM\n Hydralazine - 05:16 AM\n Other medications:\n Flowsheet Data as of 06:07 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.2\nC (100.7\n T current: 37.4\nC (99.4\n HR: 81 (79 - 85) bpm\n BP: 146/69(97) {103/58(74) - 154/77(100)} mmHg\n RR: 22 (12 - 24) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n ICP: 12 (5 - 13) mmHg\n Total In:\n 1,252 mL\n 605 mL\n PO:\n Tube feeding:\n IV Fluid:\n 1,252 mL\n 605 mL\n Blood products:\n Total out:\n 2,391 mL\n 477 mL\n Urine:\n 665 mL\n 390 mL\n NG:\n Stool:\n Drains:\n 6 mL\n 87 mL\n Balance:\n -1,139 mL\n 128 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 65\n PIP: 22 cmH2O\n Plateau: 18 cmH2O\n Compliance: 48 cmH2O/mL\n SPO2: 100%\n ABG: 7.42/36/185/23/0\n Ve: 7.1 L/min\n PaO2 / FiO2: 463\n Physical Examination\n General Appearance: No acute distress, Well nourished\n HEENT: PERRL, EOMI (changed from previous exam)\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, No(t) Distended\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 2), Follows simple commands,\n (Responds to: Verbal stimuli, Tactile stimuli, Noxious stimuli), R\n sided weakness\n Labs / Radiology\n 185 K/uL\n 12.2 g/dL\n 147 mg/dL\n 1.0 mg/dL\n 23 mEq/L\n 3.8 mEq/L\n 17 mg/dL\n 109 mEq/L\n 140 mEq/L\n 33.2 %\n 10.6 K/uL\n [image002.jpg]\n 05:42 PM\n 05:44 PM\n 09:21 PM\n 04:00 AM\n 04:31 AM\n WBC\n 12.5\n 10.6\n Hct\n 41\n 38\n 33.6\n 33.2\n Plt\n 225\n 185\n Creatinine\n 1.0\n 1.0\n TCO2\n 24\n 23\n 24\n Glucose\n 128\n 120\n 131\n 150\n 147\n Other labs: PT / PTT / INR:15.5/24.9/1.4, Lactic Acid:1.1 mmol/L,\n Albumin:4.1 g/dL, Ca:8.5 mg/dL, Mg:2.4 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n INTRACEREBRAL HEMORRHAGE (ICH), HYPERTENSION, BENIGN\n Assessment and Plan: 65M w/sudden onset HA on am of went into\n bathroom and fell to ground; parents found him to be unresponsive and\n taken to OSH;then txfr to \n ; found to have massive Intraventricular hemorrhage, now s/p drainage\n and left burr hole placement, neuro exam significantly improved\n Neurologic: Neuro checks Q: 1 hr, Phenytoin - therapeutic, q1hr neuro\n checks, propofol, MRI head, EVD@ 15cm open\n Cardiovascular: keep SBP<140, hemodynamically stable thus far, without\n exogenous medication administration, start nicardipine for tight bp\n control during extubation\n Pulmonary: Cont ETT, (Ventilator mode: CPAP + PS), intubated, weaning\n to CPAP, extubate today if meets crtiteria\n Gastrointestinal / Abdomen: NPO for now, PPI\n Nutrition: NPO\n Renal: Foley, Adequate UO\n Hematology: Serial Hct, stable\n Endocrine: RISS, good bs control\n Infectious Disease: ancef for evd\n Lines / Tubes / Drains: Foley, NGT, ETT, Surgical drains (hemovac, JP),\n evd\n Wounds: Dry dressings\n Imaging: f/u MRI head today\n Fluids: NS, NS+20KCl@ 80cc/hr\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS), (Respiratory distress: Failure),\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 06:44 PM\n 18 Gauge - 06:46 PM\n 20 Gauge - 06:46 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 33 minutes\n Patient is critically ill\n"
},
{
"category": "Social Work",
"chartdate": "2146-11-25 00:00:00.000",
"description": "Social Work Progress Note",
"row_id": 547925,
"text": "Case referred by nursing to assist with the establishment of\n spokesperson for this 65 yr old single man who is admitted with a large\n head bleed. Pt intubated and sedated, Sister at the bedside.\n Sister expresses many concerns re: pt who she states is very\n claustrophobic and has no interpersonal skills. Sister is afraid that\n pt will be extremely frightened and agitated when he awakes. Spoke\n with pt\ns mother by phone as she is elderly and unable to be at the\n bedside\n Pt resides with his , never married and no children. Pt did not\n graduate from high school, has a very short work hx, and was dx by his\n mother as having . Per mother the patient was seen at\n Children\ns Hospital at the age of 14 and she was told everything was\n fine. Mother states she read about in the newspaper and\n states\nit explained everything about \n Sister requesting to be the pt\ns spokesperson and the person who will\n make medical decisions. Sister describes as elderly, unable to\n travel to the hospital, and is concerned that they will not be able to\n fully understand both the medical information or the implications of\n decisions should the pt be in crisis and require consents for\n procedures. Explained the hospital protocol re: legal next of to\n both sister and mother, mother wants to be informed about everything as\n well as to be the one who makes all decisions. In speaking with the\n mother I found her comprehension impaired by what seemed to be some\n hearing difficulties, mother did have some difficulty taking my contact\n information.\n Pt has never applied for social security, has no MA health or Medicare\n which will be problem should pt require rehab services upon medical\n clearance.\n Have spoken to the medical team and nursing with re: to my conversation\n with mother and sister encouraging that both be contact in case of an\n emergency and need for consent so that daughter can work with \n with re: to understanding medical information.\n Have arranged for a meeting with the mother and sister for \n at 11am to discuss planning for the pt. Mother was asked to\n bring pt\ns social security # in order to initiate applications for\n social security and MA Health. Pt may be in need of a guardian and\n this will be discussed further at the meeting.\n"
},
{
"category": "Physician ",
"chartdate": "2146-12-05 00:00:00.000",
"description": "Intensivist Note",
"row_id": 549226,
"text": "TITLE:\n SICU\n HPI:\n 65M w/sudden onset HA on am of went into bathroom and fell to\n ground; parents found him to be unresponsive and taken to OSH; then\n txfr to . found to have massive IVH, s/p Lt Burr hole W EVD\n placement now s/p cyst aspiration/internal drainage \n Chief complaint:\n none\n PMHx:\n Asperger's, otherwise unknown-per mother; denies any\n cardiac/respiratory/cancer\n : Unknown\n Current medications:\n Acetaminophen 4. Amlodipine 5. Ampicillin 6. Artificial Tears 7.\n Bisacodyl 8. Calcium Gluconate\n 9. CloniDINE 10. Docusate Sodium (Liquid) 11. Famotidine 12. Furosemide\n 13. HYDROmorphone (Dilaudid)\n 14. Heparin 15. HydrALAzine 16. HydrALAzine 17. Hydrochlorothiazide 18.\n Insulin 19. Influenza Virus Vaccine\n 20. LeVETiracetam 21. Magnesium Sulfate 22. Metoprolol Tartrate 23.\n Metoprolol Tartrate 24. Miconazole Powder 2% 25. Nimodipine 26.\n NiCARdipine 27. Nystatin Oral Suspension 28. Pneumococcal Vac\n Polyvalent 29. Potassium Chloride 30. Potassium Chloride 31. Senna 32.\n Sodium Chloride 0.9% Flush 33. Sodium Chloride 0.9% Flush\n 34. Vancomycin\n 24 Hour Events:\n started clonidine, HCTZ, DC'd. head CT repeated\n Post operative day:\n POD#11 - Left burr hole with placement of ventriculostomy drain\n POD#4 - Endoscopic cysto ventriculostomy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 11:18 PM\n Meropenem - 12:53 AM\n Ampicillin - 02:15 AM\n Infusions:\n Nicardipine - 0.5 mcg/Kg/min\n Other ICU medications:\n Hydralazine - 05:14 AM\n Furosemide (Lasix) - 05:38 AM\n Metoprolol - 06:14 AM\n Famotidine (Pepcid) - 08:26 PM\n Heparin Sodium (Prophylaxis) - 11:20 PM\n Other medications:\n Flowsheet Data as of 04:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.9\nC (100.3\n T current: 36.4\nC (97.5\n HR: 77 (70 - 108) bpm\n BP: 139/61(81) {121/52(74) - 167/70(94)} mmHg\n RR: 21 (15 - 24) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 69.6 kg (admission): 75 kg\n Total In:\n 3,966 mL\n 621 mL\n PO:\n Tube feeding:\n 1,472 mL\n 301 mL\n IV Fluid:\n 2,224 mL\n 320 mL\n Blood products:\n Total out:\n 4,910 mL\n 690 mL\n Urine:\n 4,910 mL\n 690 mL\n NG:\n Stool:\n Drains:\n Balance:\n -944 mL\n -69 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SPO2: 100%\n ABG: ///26/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Temperature: Warm)\n Right Extremities: (Edema: 1+), (Temperature: Warm)\n Skin: No(t) Rash: , No(t) Jaundice\n Neurologic: (Awake / Alert / Oriented: x 1), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 268 K/uL\n 10.2 g/dL\n 137 mg/dL\n 0.6 mg/dL\n 26 mEq/L\n 3.8 mEq/L\n 19 mg/dL\n 103 mEq/L\n 134 mEq/L\n 29.1 %\n 10.1 K/uL\n [image002.jpg]\n 02:58 AM\n 04:00 AM\n 02:20 AM\n 11:46 AM\n 02:48 AM\n 03:08 AM\n 12:00 PM\n 03:25 AM\n 05:30 PM\n 02:29 AM\n WBC\n 7.9\n 9.4\n 7.5\n 8.5\n 8.3\n 10.2\n 10.1\n Hct\n 31.1\n 32.5\n 30.9\n 31.1\n 28.9\n 28.2\n 29.1\n Plt\n 164\n 187\n 182\n 178\n 197\n 249\n 268\n Creatinine\n 0.6\n 0.7\n 0.6\n 0.5\n 0.5\n 0.6\n 0.6\n 0.6\n 0.6\n Glucose\n 155\n 177\n 103\n 116\n 109\n 111\n 119\n 119\n 167\n 137\n Other labs: PT / PTT / INR:15.5/24.9/1.4, Lactic Acid:0.7 mmol/L,\n Albumin:3.8 g/dL, Ca:8.0 mg/dL, Mg:2.3 mg/dL, PO4:3.0 mg/dL\n Imaging: CT head: no definite change in size of cyst, mild decr\n in size of frontal of L lateral ventricle, interval development of\n small subdural effusion along L frontoparietal convexity w mild incr\n midline shift. no new hemorrhage.\n Microbiology: UCx: neg\n Ucx: neg\n MRSA: NEG\n sputum: rare pan-S pseudomonas\n BCx: pending\n UCx: no growth\n 12/14,15,16 sputum: contaminated\n CSF: 2500 WBC, prot 156, glu 75 - NGTD\n MRSA: NG\n BCx: P\n Assessment and Plan\n IMPAIRED SKIN INTEGRITY, FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA,\n PYREXIA), .H/O RESPIRATORY FAILURE, ACUTE (NOT ARDS/), PROBLEM\n - ENTER DESCRIPTION IN COMMENTS, INTRACEREBRAL HEMORRHAGE (ICH),\n HYPERTENSION, BENIGN\n Assessment and Plan: 65M w/sudden onset HA on am of went into\n bathroom and fell to ground; parents found him to be unresponsive and\n taken to OSH; then txfr to . found to have massive IVH, s/p Lt\n Burr hole W EVD placement now s/p cyst aspiration/internal\n drainage \n Neurologic: s/p cyst aspiration in OR , q2hr neuro checks, more\n awake/alert. cont Keppra. cont Ccollar per NSurg - may be able to\n clear clinically soon. Neurosurg to do vp shunt at some point\n Cardiovascular: keep SBP<160, on PO\n lopressor/amlodipine/hydralazine/nimotop/clonidine/HCTZ, off\n nicardipine GTT\n Pulmonary: extubated, wean supplementary oxygen\n Gastrointestinal / Abdomen: TF - at goal 65/hr, H2B\n Nutrition: TF - advance to goal, swallow eval today\n Renal: follow UOP, foley in place, no acute issues\n Hematology: HCt stable\n Endocrine: NPH 15/15, RISS\n Infectious Disease: Vanc/Amp for empiric meningitis coverage\n Lines / Tubes / Drains: foley, Dobhoff orally, Aline, left subclavian\n TLC\n Wounds: head wound drainage improved, cont dry dsgs\n Imaging: none\n Fluids: KVO\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS), Respiratory Insufficiency\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale, NPH\n Lines:\n Arterial Line - 06:44 PM\n Multi Lumen - 06:00 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: DNR / DNI\n Disposition: Transfer to floor\n Total time spent: 33 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2146-12-05 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 549232,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Action:\n Response:\n Plan:\n Hypertension, benign\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2146-12-05 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 549237,
"text": "HPI:\n 65M w/sudden onset HA on am of went into bathroom and fell to\n ground; parents found him to be unresponsive and taken to OSH; then\n txfr to . found to have massive IVH, s/p Lt Burr hole W EVD\n placement now s/p cyst aspiration/internal drainage \n Intracerebral hemorrhage (ICH)\n Assessment:\n Action:\n Response:\n Plan:\n Hypertension, benign\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Respiratory ",
"chartdate": "2146-11-25 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 547846,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: Suctioned / None\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: RSBI=63\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Physician ",
"chartdate": "2146-11-25 00:00:00.000",
"description": "Intensivist Note",
"row_id": 547852,
"text": "SICU\n HPI:\n 65M w/sudden onset HA on am of went into bathroom and fell to\n ground; parents found him to be unresponsive and taken to OSH;then txfr\n to \n Chief complaint:\n intraventricular hemorrhage\n PMHx:\n PMH/PSH: mother; denies any cardiac/respiratory/cancer\n Current medications:\n 1. 2. 20 mEq Potassium Chloride / 1000 mL NS 3. Acetaminophen 4.\n Bisacodyl 5. CefazoLIN 6. Chlorhexidine Gluconate 0.12% Oral Rinse\n 7. Docusate Sodium 8. HYDROmorphone (Dilaudid) 9. HydrALAzine 10.\n Insulin 11. Influenza Virus Vaccine\n 12. Pantoprazole 13. Phenytoin 14. Pneumococcal Vac Polyvalent 15.\n Propofol 16. Senna 17. Sodium Chloride 0.9% Flush\n 24 Hour Events:\n INTUBATION - At 06:25 PM\n recieved intubated from OR\n INVASIVE VENTILATION - START 06:25 PM\n OR RECEIVED - At 06:37 PM\n ARTERIAL LINE - START 06:44 PM\n MAGNETIC RESONANCE IMAGING - At 02:00 AM\n .\n EVENTS:\n : +Corneals/+swallowing, Pupils symmetric in size, Lt3mm MR, spont\n mvmt on LUE/LLE, no spont mvmt of Rt side. Taken to or for EVD\n placement with burr hole and returned, MRI obtained, improving neuro\n exam by the morning\n Post operative day:\n POD#1 - Left burr hole with placement of ventriculostomy drain\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 10:00 PM\n Infusions:\n Propofol - 50 mcg/Kg/min\n Other ICU medications:\n Dilantin - 12:30 AM\n Hydralazine - 05:16 AM\n Other medications:\n Flowsheet Data as of 06:07 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.2\nC (100.7\n T current: 37.4\nC (99.4\n HR: 81 (79 - 85) bpm\n BP: 146/69(97) {103/58(74) - 154/77(100)} mmHg\n RR: 22 (12 - 24) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n ICP: 12 (5 - 13) mmHg\n Total In:\n 1,252 mL\n 605 mL\n PO:\n Tube feeding:\n IV Fluid:\n 1,252 mL\n 605 mL\n Blood products:\n Total out:\n 2,391 mL\n 477 mL\n Urine:\n 665 mL\n 390 mL\n NG:\n Stool:\n Drains:\n 6 mL\n 87 mL\n Balance:\n -1,139 mL\n 128 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 65\n PIP: 22 cmH2O\n Plateau: 18 cmH2O\n Compliance: 48 cmH2O/mL\n SPO2: 100%\n ABG: 7.42/36/185/23/0\n Ve: 7.1 L/min\n PaO2 / FiO2: 463\n Physical Examination\n General Appearance: No acute distress, Well nourished\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, No(t) Distended\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 2), Follows simple commands,\n (Responds to: Verbal stimuli, Tactile stimuli, Noxious stimuli), R\n sided weakness\n Labs / Radiology\n 185 K/uL\n 12.2 g/dL\n 147 mg/dL\n 1.0 mg/dL\n 23 mEq/L\n 3.8 mEq/L\n 17 mg/dL\n 109 mEq/L\n 140 mEq/L\n 33.2 %\n 10.6 K/uL\n [image002.jpg]\n 05:42 PM\n 05:44 PM\n 09:21 PM\n 04:00 AM\n 04:31 AM\n WBC\n 12.5\n 10.6\n Hct\n 41\n 38\n 33.6\n 33.2\n Plt\n 225\n 185\n Creatinine\n 1.0\n 1.0\n TCO2\n 24\n 23\n 24\n Glucose\n 128\n 120\n 131\n 150\n 147\n Other labs: PT / PTT / INR:15.5/24.9/1.4, Lactic Acid:1.1 mmol/L,\n Albumin:4.1 g/dL, Ca:8.5 mg/dL, Mg:2.4 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n INTRACEREBRAL HEMORRHAGE (ICH), HYPERTENSION, BENIGN\n Assessment and Plan: 65M w/sudden onset HA on am of went into\n bathroom and fell to ground; parents found him to be unresponsive and\n taken to OSH;then txfr to \n ; found to have massive Intraventricular hemorrhage, now s/p drainage\n and left b urr hole placement\n Neurologic: Neuro checks Q: 1 hr, Phenytoin - therapeutic, q1hr neuro\n checks, propofol, MRI head, EVD@ 15cm open\n Cardiovascular: keep SBP<140, hemodynamically stable thus far, without\n exogenous medication administration\n Pulmonary: Cont ETT, (Ventilator mode: CPAP + PS), intubated, weaning\n to CPAP\n Gastrointestinal / Abdomen: NPO for now, PPI\n Nutrition: NPO\n Renal: Foley, Adequate UO\n Hematology: Serial Hct\n Endocrine: RISS\n Infectious Disease: Check cultures\n Lines / Tubes / Drains: Foley, NGT, ETT, Surgical drains (hemovac, JP)\n Wounds: Dry dressings\n Imaging: f/u MRI head today\n Fluids: NS, NS+20KCl@ 80cc/hr\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS), (Respiratory distress: Failure),\n Closed head injury\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 06:44 PM\n 18 Gauge - 06:46 PM\n 20 Gauge - 06:46 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 32 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2146-11-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 547953,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Pt on propofol gtt for sedation. Pt arouses to verbal\n stimuli\n Action:\n Response:\n Plan:\n Ineffective Airway Maintenance\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2146-11-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 547960,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Pt on propofol gtt for sedation. Pt arouses to verbal stimuli when\n propofol is lowered. MAE, following simple commands. PERRL at 3-4\n with brisk response. Left ventricular drain continues to be open\n draining bloody drainage, ICP less than 20 and CPP 60-90s. Nicardipine\n gtt for SBP 140-160s. No seizure activity. To CTA this shift. \n J for c spine precautions due to unknown mechanism of\n injury.\n Action:\n Nicardipine gtt for SBP 140-160, Propofol gtt for sedation, dilantin\n prophylaxis, neuro checks q1h, logroll with turns\n Response:\n SBP 140-160s, sedated, when\n Plan:\n Continue to monitor, q1h neuro checks\n Ineffective Airway Maintenance\n Assessment:\n Remains orally intubated, on CPAP 5 PS 5 PEEP 40% FiO2, ABG WNL, LS\n clear, thick yellow secretions small amount x1, sats 100%\n Action:\n Continue to monitor\n Response:\n Adequate oxygenation\n Plan:\n Plan to extubate in the AM.\n"
},
{
"category": "Nursing",
"chartdate": "2146-11-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 548039,
"text": ".H/O respiratory failure, acute (not ARDS/)\n Assessment:\n Remains intubated. On cpap 40% 5/5\n Action:\n Vap mouth care q2hrs. abg q shift. Suctioned for thick white yellow\n sputum.\n Response:\n Tolerated cpap with 5/5\n Plan:\n ? extubate today.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Propofol gtt infusing for sedation, gtt off for neuro assessment. Moves\n upper extremities on the bed as well as lower extremities. Right side\n moves slower than left. Pupils equal and react to light. Left\n ventricular drain in place 15 above the tragus. Drain draining 5-20cc\n bloody drainage. Icp 10-12. j collar in place. Logroll white\n turning.\n Action:\n Nicardipine gtt for bp control goal 140-160\n Propofol gtt for sedation and titrated\n Neuro signs q1hr.\n Ventricular drain 15 above the tragus and output noted q1hr.\n Dilantin 100mg iv q8hrs\n j collar and collar care q6hrs.\n Response:\n Ativan and nicardipine gtt being weaned. Bp 140-160. ventricular drain\n patent and draining bloody drainage.\n Plan:\n Monitor neuro status closely.,\n"
},
{
"category": "Nursing",
"chartdate": "2146-11-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 547969,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Pt on propofol gtt for sedation. Pt arouses to verbal stimuli when\n propofol is lowered. MAE, following simple commands. PERRL at 3-4\n with brisk response. Left ventricular drain continues to be open\n draining bloody drainage, ICP less than 20 and CPP 60-90s. Nicardipine\n gtt for SBP 140-160s. No seizure activity. To CTA this shift. \n J for c spine precautions due to unknown mechanism of\n injury.\n Action:\n Nicardipine gtt for SBP 140-160, Propofol gtt for sedation, dilantin\n prophylaxis, neuro checks q1h, logroll with turns\n Response:\n SBP 140-160s, sedated, when\n Plan:\n Continue to monitor, q1h neuro checks\n Ineffective Airway Maintenance\n Assessment:\n Remains orally intubated, on CPAP 5 PS 5 PEEP 40% FiO2, ABG WNL, LS\n clear, thick yellow secretions small amount x1, sats 100%\n Action:\n Continue to monitor\n Response:\n Adequate oxygenation\n Plan:\n Plan to extubate in the AM.\n"
},
{
"category": "Physician ",
"chartdate": "2146-11-26 00:00:00.000",
"description": "Intensivist Note",
"row_id": 548048,
"text": "SICU\n HPI:\n 65M w/sudden onset HA on am of went into bathroom and fell to\n ground; parents found him to be unresponsive and taken to OSH;then txfr\n to . Found to have large central IPH\n Chief complaint:\n large central IPH\n PMHx:\n Unknown by family\n Current medications:\n 24 Hour Events:\n INTUBATION - At 06:25 PM\n recieved intubated from OR\n INVASIVE VENTILATION - START 06:25 PM\n OR RECEIVED - At 06:37 PM\n ARTERIAL LINE - START 06:44 PM\n ICP CATHETER - START 06:44 PM\n MAGNETIC RESONANCE IMAGING - At 02:00 AM\n Post operative day:\n POD#2 - Left burr hole with placement of ventriculostomy drain\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 09:32 PM\n Infusions:\n Nicardipine - 1 mcg/Kg/min\n Propofol - 30 mcg/Kg/min\n Other ICU medications:\n Hydralazine - 05:16 AM\n Pantoprazole (Protonix) - 11:17 PM\n Dilantin - 12:05 AM\n Other medications:\n Flowsheet Data as of 03:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.8\nC (100.1\n T current: 37.2\nC (98.9\n HR: 106 (79 - 106) bpm\n BP: 171/67(102) {107/54(74) - 171/73(105)} mmHg\n RR: 19 (12 - 22) insp/min\n SPO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n ICP: 12 (5 - 16) mmHg\n Total In:\n 2,710 mL\n 354 mL\n PO:\n Tube feeding:\n IV Fluid:\n 2,710 mL\n 354 mL\n Blood products:\n Total out:\n 2,507 mL\n 435 mL\n Urine:\n 2,228 mL\n 400 mL\n NG:\n Stool:\n Drains:\n 279 mL\n 35 mL\n Balance:\n 203 mL\n -81 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 433 (400 - 442) mL\n PS : 5 cmH2O\n RR (Set): 12\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 65\n PIP: 11 cmH2O\n Plateau: 18 cmH2O\n Compliance: 48 cmH2O/mL\n SPO2: 100%\n ABG: 7.43/37/187/23/1\n Ve: 7 L/min\n PaO2 / FiO2: 468\n Physical Examination\n General Appearance: intubated, sedated, C-\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: No(t) Moves all extremities, (RUE: Weakness), (LUE:\n Weakness), (RLE: Weakness), (LLE: Weakness), Sedated, intubated and\n sedated, seen moving all 4 ext weakly\n Labs / Radiology\n 185 K/uL\n 12.2 g/dL\n 127 mg/dL\n 1.0 mg/dL\n 23 mEq/L\n 3.8 mEq/L\n 17 mg/dL\n 109 mEq/L\n 140 mEq/L\n 33.2 %\n 10.6 K/uL\n [image002.jpg]\n 05:42 PM\n 05:44 PM\n 09:21 PM\n 04:00 AM\n 04:31 AM\n 01:31 PM\n 02:45 AM\n WBC\n 12.5\n 10.6\n Hct\n 41\n 38\n 33.6\n 33.2\n Plt\n 225\n 185\n Creatinine\n 1.0\n 1.0\n TCO2\n 24\n 23\n 24\n 25\n 25\n Glucose\n 128\n 120\n 131\n 150\n 147\n 127\n Other labs: PT / PTT / INR:15.5/24.9/1.4, Lactic Acid:1.0 mmol/L,\n Albumin:4.1 g/dL, Ca:8.5 mg/dL, Mg:2.4 mg/dL, PO4:3.9 mg/dL\n Imaging: : MR : IMPRESSION:\n 1. Extensive intraventricular hemorrhage involving all the ventricles\n as\n described above, predominantly in the acute stage with a small subacute\n component.\n 2. Obstructive hydrocephalus, with dilatation of the left lateral\n ventricle\n and moderate on the right.\n 2. While there is no obvious abnormal enhancement noted within the area\n of\n hemorrhage, small neoplastic or vascular causes within the ventricles\n cannot\n be excluded. Repeat evaluation can be considered after evacuation or\n resolution of the hematoma.\n 3. Subarachnoid hemorrhage, in both cerebral hemispheres.\n Given the presence of intraventricular and subarachnoid hemorrhage,\n patient\n needs further evaluation to exclude a vascular cause like an aneurysm\n by CT\n angiogram. The intracranial arteries are not adequately assessed on the\n present study. Displacement of the right internal carotid artery\n termination\n and the anterior cerebral arteries on both sides related to the\n enlarged\n ventricles is noted.\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS, INTRACEREBRAL HEMORRHAGE\n (ICH), HYPERTENSION, BENIGN\n Assessment and Plan: 65M p/w massive central IPH\n Neurologic: Neuro checks Q: 1 hr, ICP monitor, q1hr neuro checks,\n propofol gtt, dilantin, MRI head inconclusive re source of bleed, EVD@\n 15cm open; f/ read CTA head, f/u neurosx re plans, talk with\n neurosurg regarding ccollar clearance\n Cardiovascular: keep SBP140-160, cont nicardipine gtt to meet goals,\n lopressor scheduled for htn and tachycardia\n Pulmonary: (Ventilator mode: CPAP + PS), intubated, on CPAP 5/5; f/u\n with neurosurg re when it's okay to extubate\n Gastrointestinal / Abdomen: NGT in place, NPO for now\n Nutrition: NPO, tube feeds if stays intubated\n Renal: Foley, no active issues\n Hematology: stable HCT\n Endocrine: RISS\n Infectious Disease: cefazolin while EVD in place\n Lines / Tubes / Drains: Foley, NGT, ETT, EVD\n Wounds: evd site clean\n Imaging: none\n Fluids: NS, Potassium Chloride\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS), (Respiratory distress: Failure)\n ICU Care\n Nutrition: tube feeds if to stay intubated\n Glycemic Control:\n Lines: aline, evd, ngt, ett\n Arterial Line - 06:44 PM\n ICP Catheter - 06:44 PM\n 18 Gauge - 12:59 PM\n 20 Gauge - 08:35 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 12 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2146-11-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 548095,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Pt on propofol gtt for sedation.\n Pt arouses sluggishly and intermittently to verbal & tactile stimuli\n when propofol is decreased.\n MAE, following simple commands, shakes head no when asked if in pain\n PERRL at 3-4 with brisk response.\n Left ventricular drain continues to be open draining bloody drainage.\n ICP less than 20 and CPP 60-90s.\n Nicardipine gtt for SBP 140-160s.\n No seizure activity.\n J for c spine precautions due to unknown mechanism of\n injury.\n Action:\n Nicardipine gtt for SBP 140-160\n Propofol gtt for sedation\n dilantin prophylaxis, given 100mg extra dose for low dilantin level of\n 9.\n neuro checks q1h\n logroll with turns\n Response:\n SBP 140-160s\n Sedated and sluggish response when propofol off for neuro checks\n Remains in J for cspine precautions\n Plan:\n Continue to monitor\n q1h neuro checks\n Ineffective Airway Maintenance\n Assessment:\n Remains orally intubated\n Vent settings of CPAP 5 PS 5 PEEP 40% FiO2, vT >375\n LS clear, thick yellow/white/tan secretions small to moderate amounts\n sats 100%\n RR 16-20 breaths per minute\n Action:\n Continue mechanical ventilation\n ABGs as ordered\n Response:\n Adequate oxygenation\n Plan:\n Plan to extubate in the AM.\n"
},
{
"category": "Nursing",
"chartdate": "2146-11-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 548106,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Pt on propofol gtt for sedation.\n Pt arouses sluggishly and intermittently to verbal & tactile stimuli\n when propofol is decreased.\n MAE, following simple commands, shakes head no when asked if in pain\n PERRL at 3-4 with brisk response.\n Left ventricular drain continues to be open draining bloody drainage.\n ICP less than 20 and CPP 60-90s.\n Nicardipine gtt for SBP 140-160s.\n No seizure activity.\n J for c spine precautions due to unknown mechanism of\n injury.\n Action:\n Nicardipine gtt for SBP 140-160\n Propofol gtt for sedation\n dilantin prophylaxis, given 100mg extra dose for low dilantin level of\n 9.\n neuro checks q1h\n logroll with turns\n Response:\n SBP 140-160s\n Sedated and sluggish response when propofol off for neuro checks\n Remains in J for cspine precautions\n Plan:\n Continue to monitor\n q1h neuro checks\n Ineffective Airway Maintenance\n Assessment:\n Remains orally intubated\n Vent settings of CPAP 5 PS 5 PEEP 40% FiO2, vT >375\n LS clear, thick yellow/white/tan secretions small to moderate amounts\n sats 100%\n RR 16-20 breaths per minute\n Action:\n Continue mechanical ventilation\n ABGs as ordered\n Response:\n Adequate oxygenation\n Plan:\n Plan to extubate in the AM.\n"
},
{
"category": "Respiratory ",
"chartdate": "2146-11-27 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 548133,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 4\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Cannot manage\n secretions, Underlying illness not resolved\n Comments:\n Suctioning large amounts of thick sputum. A.M. cxr pending.. RSBI =\n 35.\n"
},
{
"category": "Physician ",
"chartdate": "2146-11-27 00:00:00.000",
"description": "Intensivist Note",
"row_id": 548173,
"text": "TITLE:\n SICU\n HPI:\n 65M w/sudden onset HA on am of went into bathroom and fell to\n ground; parents found him to be unresponsive and taken to OSH;then txfr\n to \n Chief complaint:\n lethargy\n PMHx:\n mother; denies any cardiac/respiratory/cancer\n : Unknonwn\n Current medications:\n 20 mEq Potassium Chloride / 1000 mL NS 3. Acetaminophen 4. Bisacodyl 5.\n CefazoLIN 6. Chlorhexidine Gluconate 0.12% Oral Rinse 7. Docusate\n Sodium (Liquid) 8. Famotidine 9. HYDROmorphone (Dilaudid) 10. Insulin\n 11. Influenza Virus Vaccine 12. Magnesium Sulfate 13. Metoprolol\n Tartrate 14. NiCARdipine 15. Phenytoin 16. Phenytoin 17. Pneumococcal\n Vac Polyvalent 18. Propofol 19. Senna 20. Sodium Chloride 0.9% Flush\n 24 Hour Events:\n FEVER - 101.2\nF - 04:00 AM\n incr beta blocker, extrabolus dilantin, drain temporarily occluded\n overnight\n Post operative day:\n POD#3 - Left burr hole with placement of ventriculostomy drain\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 04:50 AM\n Infusions:\n Nicardipine - 1.2 mcg/Kg/min\n Propofol - 30 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 09:53 PM\n Dilantin - 12:19 AM\n Other medications:\n Flowsheet Data as of 06:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.4\nC (101.2\n T current: 38.4\nC (101.2\n HR: 99 (83 - 111) bpm\n BP: 145/61(89) {131/56(81) - 176/71(106)} mmHg\n RR: 18 (16 - 21) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n ICP: 11 (5 - 17) mmHg\n Total In:\n 2,927 mL\n 705 mL\n PO:\n Tube feeding:\n IV Fluid:\n 2,777 mL\n 705 mL\n Blood products:\n Total out:\n 3,002 mL\n 579 mL\n Urine:\n 2,740 mL\n 500 mL\n NG:\n Stool:\n Drains:\n 262 mL\n 79 mL\n Balance:\n -75 mL\n 126 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 450 (412 - 671) mL\n PS : 5 cmH2O\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 35\n PIP: 11 cmH2O\n SPO2: 100%\n ABG: 7.45/29/196/25/-1\n Ve: 7.5 L/min\n PaO2 / FiO2: 490\n Physical Examination\n General Appearance: No acute distress, Well nourished\n HEENT: PERRL, pupils sluggish bilaterally\n Cardiovascular: (Rhythm: Regular), (Murmur: No(t) Systolic, No(t)\n Diastolic)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: 1+), (Temperature: Warm)\n Right Extremities: (Edema: 1+), (Temperature: Warm)\n Skin: No(t) Rash: , No(t) Jaundice\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities, Sedated, responds but quite sluggishly\n Labs / Radiology\n 228 K/uL\n 11.0 g/dL\n 110 mg/dL\n 0.7 mg/dL\n 25 mEq/L\n 3.9 mEq/L\n 11 mg/dL\n 109 mEq/L\n 140 mEq/L\n 31.3 %\n 11.5 K/uL\n [image002.jpg]\n 05:42 PM\n 05:44 PM\n 09:21 PM\n 04:00 AM\n 04:31 AM\n 01:31 PM\n 02:35 AM\n 02:45 AM\n 03:22 AM\n 04:49 AM\n WBC\n 12.5\n 10.6\n 10.6\n 11.5\n Hct\n 41\n 38\n 33.6\n 33.2\n 32.2\n 31.3\n Plt\n 28\n Creatinine\n 1.0\n 1.0\n 0.7\n 0.7\n TCO2\n 24\n 23\n 24\n 25\n 25\n 21\n Glucose\n 128\n 120\n 131\n 150\n 147\n 127\n 137\n 110\n Other labs: PT / PTT / INR:15.5/24.9/1.4, Lactic Acid:0.7 mmol/L,\n Albumin:3.8 g/dL, Ca:8.1 mg/dL, Mg:2.3 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n .H/O RESPIRATORY FAILURE, ACUTE (NOT ARDS/), PROBLEM - ENTER\n DESCRIPTION IN COMMENTS, INTRACEREBRAL HEMORRHAGE (ICH), HYPERTENSION,\n BENIGN\n Assessment and Plan: 65M w/sudden onset HA on am of went into\n bathroom and fell to ground; parents found him to be unresponsive and\n taken to OSH;then txfr to , found to have massive central IVH\n Neurologic: q2hr neuro checks, propofol, rebolus dilantin for low lvl,\n EVD@ 15cm open, needs tubing changed as poorly draining due to clots;\n Neurosurgery wants to wait to clear Cspine clinically. CTA continues\n to show massive hydrocephalus\n Cardiovascular: keep SBP<160,increase PO lopressor, wean nicardipine\n GTT\n Pulmonary: intubated, on CPAP 5/5; extubate , keep intubated for\n airway protection\n Gastrointestinal / Abdomen: NPO for now, H2B\n Nutrition: NPO for now, start tube feeds\n Renal: follow UOP, foley in place, no acute issues, kvo once tube feeds\n at goal, replace calcium\n Hematology: stable thus far, will continue to follow in the AM\n Endocrine: RISS\n Infectious Disease: wbc and fever, copious secretions but cxr very\n clear. Concerned for sinusitis with nasal tube in. Will send for sinus\n CT, if positive will treat for Hosp Acquired Sinusitis\n Lines / Tubes / Drains: foley, ETT, NGT, Aline, PIV\n Wounds: none\n Imaging: Sinus CT\n Fluids: NS+20KCl@ 80cc/hr, KVO once tube feeds at goal\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS) , Respiratory Failure\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 06:44 PM\n ICP Catheter - 06:44 PM\n 18 Gauge - 12:59 PM\n 20 Gauge - 08:51 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 12 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2146-11-27 00:00:00.000",
"description": "Intensivist Note",
"row_id": 548175,
"text": "TITLE:\n SICU\n HPI:\n 65M w/sudden onset HA on am of went into bathroom and fell to\n ground; parents found him to be unresponsive and taken to OSH;then txfr\n to \n Chief complaint:\n lethargy\n PMHx:\n mother; denies any cardiac/respiratory/cancer\n : Unknonwn\n Current medications:\n 20 mEq Potassium Chloride / 1000 mL NS 3. Acetaminophen 4. Bisacodyl 5.\n CefazoLIN 6. Chlorhexidine Gluconate 0.12% Oral Rinse 7. Docusate\n Sodium (Liquid) 8. Famotidine 9. HYDROmorphone (Dilaudid) 10. Insulin\n 11. Influenza Virus Vaccine 12. Magnesium Sulfate 13. Metoprolol\n Tartrate 14. NiCARdipine 15. Phenytoin 16. Phenytoin 17. Pneumococcal\n Vac Polyvalent 18. Propofol 19. Senna 20. Sodium Chloride 0.9% Flush\n 24 Hour Events:\n FEVER - 101.2\nF - 04:00 AM\n incr beta blocker, extrabolus dilantin, drain temporarily occluded\n overnight\n Post operative day:\n POD#3 - Left burr hole with placement of ventriculostomy drain\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 04:50 AM\n Infusions:\n Nicardipine - 1.2 mcg/Kg/min\n Propofol - 30 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 09:53 PM\n Dilantin - 12:19 AM\n Other medications:\n Flowsheet Data as of 06:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.4\nC (101.2\n T current: 38.4\nC (101.2\n HR: 99 (83 - 111) bpm\n BP: 145/61(89) {131/56(81) - 176/71(106)} mmHg\n RR: 18 (16 - 21) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n ICP: 11 (5 - 17) mmHg\n Total In:\n 2,927 mL\n 705 mL\n PO:\n Tube feeding:\n IV Fluid:\n 2,777 mL\n 705 mL\n Blood products:\n Total out:\n 3,002 mL\n 579 mL\n Urine:\n 2,740 mL\n 500 mL\n NG:\n Stool:\n Drains:\n 262 mL\n 79 mL\n Balance:\n -75 mL\n 126 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 450 (412 - 671) mL\n PS : 5 cmH2O\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 35\n PIP: 11 cmH2O\n SPO2: 100%\n ABG: 7.45/29/196/25/-1\n Ve: 7.5 L/min\n PaO2 / FiO2: 490\n Physical Examination\n General Appearance: No acute distress, Well nourished\n HEENT: PERRL, pupils sluggish bilaterally\n Cardiovascular: (Rhythm: Regular), (Murmur: No(t) Systolic, No(t)\n Diastolic)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: 1+), (Temperature: Warm)\n Right Extremities: (Edema: 1+), (Temperature: Warm)\n Skin: No(t) Rash: , No(t) Jaundice\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities, Sedated, responds but quite sluggishly\n Labs / Radiology\n 228 K/uL\n 11.0 g/dL\n 110 mg/dL\n 0.7 mg/dL\n 25 mEq/L\n 3.9 mEq/L\n 11 mg/dL\n 109 mEq/L\n 140 mEq/L\n 31.3 %\n 11.5 K/uL\n [image002.jpg]\n 05:42 PM\n 05:44 PM\n 09:21 PM\n 04:00 AM\n 04:31 AM\n 01:31 PM\n 02:35 AM\n 02:45 AM\n 03:22 AM\n 04:49 AM\n WBC\n 12.5\n 10.6\n 10.6\n 11.5\n Hct\n 41\n 38\n 33.6\n 33.2\n 32.2\n 31.3\n Plt\n 28\n Creatinine\n 1.0\n 1.0\n 0.7\n 0.7\n TCO2\n 24\n 23\n 24\n 25\n 25\n 21\n Glucose\n 128\n 120\n 131\n 150\n 147\n 127\n 137\n 110\n Other labs: PT / PTT / INR:15.5/24.9/1.4, Lactic Acid:0.7 mmol/L,\n Albumin:3.8 g/dL, Ca:8.1 mg/dL, Mg:2.3 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n .H/O RESPIRATORY FAILURE, ACUTE (NOT ARDS/), PROBLEM - ENTER\n DESCRIPTION IN COMMENTS, INTRACEREBRAL HEMORRHAGE (ICH), HYPERTENSION,\n BENIGN\n Assessment and Plan: 65M w/sudden onset HA on am of went into\n bathroom and fell to ground; parents found him to be unresponsive and\n taken to OSH;then txfr to , found to have massive central IVH\n Neurologic: q2hr neuro checks, propofol, rebolus dilantin for low lvl,\n EVD@ 15cm open, needs tubing changed as poorly draining due to clots;\n Neurosurgery wants to wait to clear C-spine clinically. CTA continues\n to show massive hydrocephalus\n Cardiovascular: keep SBP<160,increase PO lopressor, wean nicardipine\n GTT\n Pulmonary: intubated, on CPAP 5/5; keep intubated for airway protection\n Gastrointestinal / Abdomen: NPO for now, H2B\n Nutrition: NPO for now, start tube feeds\n Renal: follow UOP, foley in place, no acute issues, kvo once tube feeds\n at goal, replace calcium\n Hematology: stable thus far, will continue to follow in the AM\n Endocrine: RISS\n Infectious Disease: wbc and fever, copious secretions but cxr very\n clear. Concerned for sinusitis with nasal tube in. Will send for sinus\n CT, if positive will treat for Hosp Acquired Sinusitis\n Lines / Tubes / Drains: foley, ETT, NGT, Aline, PIV\n Wounds: none\n Imaging: Sinus CT\n Fluids: NS+20KCl@ 80cc/hr, KVO once tube feeds at goal\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS) , Respiratory Failure\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 06:44 PM\n ICP Catheter - 06:44 PM\n 18 Gauge - 12:59 PM\n 20 Gauge - 08:51 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 12 minutes\n"
},
{
"category": "Respiratory ",
"chartdate": "2146-11-27 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 548216,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 4\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments: rotated and secured. BS equal and bilat.\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Unassisted spontaneous breathing\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n CT\n 1000\n Bedside Procedures:\n Comments:\n 17:35\n"
},
{
"category": "Nursing",
"chartdate": "2146-11-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 548385,
"text": "Family meeting today with SW and NP from neurosurg team, Pt made\n dnr/dni, consent signed for surgery on Thursday. Subject of\n guardianship discussed with SW and family memebers present, see SW\n note. Family also spoke with sicu team fellow concerning possible trach\n and peg which family will discuss and come to a decision when time\n appropriate.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Temp m ax 102.4, previous sputum collected contaminated, other cx from\n still pending\n Action:\n New sputum cx sent by RT, pt has received 2 doses of Tylenol one pngt\n 2^nd dose PR, ice packs to groin and axillia, cefazolin dc\nd, no\n additional antibiotics started at this time\n Response:\n Last temp 102.2 oral, Tylenol dosing cont q 4 per prn\n Plan:\n Continue to monitor temp curve, ? reculturing if temp continues, check\n cx results.\n Intracerebral hemorrhage (ICH)\n Assessment:\n pt will slightly open eyes to name calling, ? if he is actually\n following commands to open eyes, perrla at 4mm, flexwithdraws with both\n feet , no other purposeful or non-purposeful movement noted,\n ventriculostomy patent draining 7-12 cc/hr of blood tinged fluid, some\n small blood clots noted in am but continues to drain well.\n Action:\n Ventriculostomy at 10mm at tragus, propofol off at 9am, pt has\n received no other sedation meds today\n Response:\n Pt neuro status has not changed through out shift, continues only to\n slightly open eyes to name calling , flexwithdraws feet and no other\n movement of exts noted, team is aware,\n Plan:\n Continue with propofol off, pt is scheduled for MRI tomorrow and\n subsequent surgery on Thursday to drain arachnoid cyst, continue to\n monitor neuro status, alert team of changes.\n Hypertension, benign\n Assessment:\n Pt remains on nicardipine gtt at 1.5 mcg, systolic b/p maintained\n 140-160, hr 90-100, no ectopy noted, slight increase in b/p to 170\n with suctioning and turning but fleeting response\n Action:\n Lopressor dosiong increased to 50 mg tid, nicardipine gtt remains at\n 1.5mcg\n Response:\n Unable to wean nicardipine gtt, ? further increasing lopressor and or\n adding ACE.\n Plan:\n Continue to maintain systolic b/p 140-160\n"
},
{
"category": "Physician ",
"chartdate": "2146-11-29 00:00:00.000",
"description": "Intensivist Note",
"row_id": 548489,
"text": "TITLE:\n SICU\n HPI:\n 65M w/sudden onset HA on am of went into bathroom and fell to\n ground; parents found him to be unresponsive and taken to OSH; then\n txfr to found to have extensive intraventricular hemorrhage, now\n thought to be ruptured cyst\n Chief complaint:\n persistently depressed mental status\n PMHx:\n Asperger's syndrome, otherwise unknown\n Current medications:\n 20 mEq Potassium Chloride / 1000 mL NS 3. Acetaminophen 4. Bisacodyl 5.\n Calcium Gluconate 6. Chlorhexidine Gluconate 0.12% Oral Rinse 7.\n Docusate Sodium (Liquid) 8. Famotidine 9. HYDROmorphone (Dilaudid)\n 10. HydrALAzine 11. Insulin 12. Influenza Virus Vaccine 13.\n LeVETiracetam 14. LeVETiracetam 15. Magnesium Sulfate 16. Metoprolol\n Tartrate 17. Meropenem 18. NiCARdipine 19. Nystatin Oral Suspension 20.\n Phenytoin (Suspension) 21. Pneumococcal Vac Polyvalent 22. Potassium\n Chloride 23. Propofol 24. Senna 25. Sodium Chloride 0.9% Flush 26.\n Vancomycin\n 24 Hour Events:\n FEVER - 102.7\nF - 04:00 AM\n family meeting - pt made DNR\n Post operative day:\n POD#5 - Left burr hole with placement of ventriculostomy drain\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 06:59 AM\n Meropenem - 05:00 AM\n Vancomycin - 08:30 AM\n Infusions:\n Other ICU medications:\n Hydralazine - 08:30 AM\n Other medications:\n Flowsheet Data as of 09:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 39.3\nC (102.7\n T current: 38.2\nC (100.8\n HR: 84 (81 - 101) bpm\n BP: 165/73(104) {135/55(82) - 165/73(104)} mmHg\n RR: 20 (12 - 24) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 66.6 kg (admission): 75 kg\n ICP: 6 (6 - 13) mmHg\n Total In:\n 3,947 mL\n 897 mL\n PO:\n Tube feeding:\n 509 mL\n 390 mL\n IV Fluid:\n 3,198 mL\n 447 mL\n Blood products:\n Total out:\n 3,790 mL\n 1,229 mL\n Urine:\n 3,620 mL\n 1,160 mL\n NG:\n Stool:\n Drains:\n 170 mL\n 69 mL\n Balance:\n 157 mL\n -282 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 577 (348 - 577) mL\n PS : 5 cmH2O\n RR (Set): 12\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 50\n PIP: 11 cmH2O\n SPO2: 100%\n ABG: 7.51/34/187/26/4\n Ve: 13.4 L/min\n PaO2 / FiO2: 468\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, sluggish\n Cardiovascular: (Rhythm: Regular), (Murmur: No(t) Systolic, No(t)\n Diastolic)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Skin: No(t) Rash: , No(t) Jaundice\n Neurologic: (Responds to: Noxious stimuli), Moves all extremities,\n Sedated\n Labs / Radiology\n 156 K/uL\n 10.6 g/dL\n 122 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 3.8 mEq/L\n 17 mg/dL\n 105 mEq/L\n 138 mEq/L\n 30.4 %\n 5.3 K/uL\n [image002.jpg]\n 04:31 AM\n 01:31 PM\n 02:35 AM\n 02:45 AM\n 03:22 AM\n 04:49 AM\n 02:11 AM\n 02:18 AM\n 02:02 AM\n 02:12 AM\n WBC\n 10.6\n 11.5\n 8.8\n 5.3\n Hct\n 32.2\n 31.3\n 29.2\n 30.4\n Plt\n 184\n 228\n 177\n 156\n Creatinine\n 0.7\n 0.7\n 0.7\n 0.7\n TCO2\n 24\n 25\n 25\n 21\n 28\n 28\n Glucose\n 147\n 127\n 137\n 110\n 111\n 122\n Other labs: PT / PTT / INR:16.8/25.9/1.5, Lactic Acid:0.7 mmol/L,\n Albumin:3.8 g/dL, Ca:8.2 mg/dL, Mg:2.3 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA), .H/O RESPIRATORY\n FAILURE, ACUTE (NOT ARDS/), PROBLEM - ENTER DESCRIPTION IN\n COMMENTS, INTRACEREBRAL HEMORRHAGE (ICH), HYPERTENSION, BENIGN\n Assessment and Plan: 65M w/sudden onset HA on am of went into\n bathroom and fell to ground; parents found him to be unresponsive and\n taken to OSH; then txfr to found to have extensive\n intraventricular hemorrhage, now thought to be ruptured cyst.\n Neurologic: Neuro exam unchanged. plan for OR on thursday with preop\n MRI. Off sedation. transition Dilantin to Keppra.\n Cardiovascular: SBP < 160 with lopressor, hydral PRN, titrate BB as\n necessary\n Pulmonary: intubated, no changes in requirements\n Gastrointestinal / Abdomen: TFs per , H2b\n Nutrition: TFs at goal\n Renal: no issues, adequate UOP\n Hematology: Hct stable, f/u INR\n Endocrine: RISS\n Infectious Disease: Vanc/ for sinusitis Tx; WBC trending down\n Lines / Tubes / Drains: foley, ETT, , , left subclavian\n TLC, PIV\n Wounds: C/D/I\n Imaging: CT Cspine\n Fluids: KVO\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 06:44 PM\n ICP Catheter - 06:44 PM\n 18 Gauge - 12:59 PM\n Multi Lumen - 06:00 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2146-11-29 00:00:00.000",
"description": "Intensivist Note",
"row_id": 548490,
"text": "TITLE:\n SICU\n HPI:\n 65M w/sudden onset HA on am of went into bathroom and fell to\n ground; parents found him to be unresponsive and taken to OSH; then\n txfr to found to have extensive intraventricular hemorrhage, now\n thought to be ruptured cyst\n Chief complaint:\n persistently depressed mental status\n PMHx:\n Asperger's syndrome, otherwise unknown\n Current medications:\n 20 mEq Potassium Chloride / 1000 mL NS 3. Acetaminophen 4. Bisacodyl 5.\n Calcium Gluconate 6. Chlorhexidine Gluconate 0.12% Oral Rinse 7.\n Docusate Sodium (Liquid) 8. Famotidine 9. HYDROmorphone (Dilaudid)\n 10. HydrALAzine 11. Insulin 12. Influenza Virus Vaccine 13.\n LeVETiracetam 14. LeVETiracetam 15. Magnesium Sulfate 16. Metoprolol\n Tartrate 17. Meropenem 18. NiCARdipine 19. Nystatin Oral Suspension 20.\n Phenytoin (Suspension) 21. Pneumococcal Vac Polyvalent 22. Potassium\n Chloride 23. Propofol 24. Senna 25. Sodium Chloride 0.9% Flush 26.\n Vancomycin\n 24 Hour Events:\n FEVER - 102.7\nF - 04:00 AM\n family meeting - pt made DNR\n Post operative day:\n POD#5 - Left burr hole with placement of ventriculostomy drain\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 06:59 AM\n Meropenem - 05:00 AM\n Vancomycin - 08:30 AM\n Infusions:\n Other ICU medications:\n Hydralazine - 08:30 AM\n Other medications:\n Flowsheet Data as of 09:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 39.3\nC (102.7\n T current: 38.2\nC (100.8\n HR: 84 (81 - 101) bpm\n BP: 165/73(104) {135/55(82) - 165/73(104)} mmHg\n RR: 20 (12 - 24) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 66.6 kg (admission): 75 kg\n ICP: 6 (6 - 13) mmHg\n Total In:\n 3,947 mL\n 897 mL\n PO:\n Tube feeding:\n 509 mL\n 390 mL\n IV Fluid:\n 3,198 mL\n 447 mL\n Blood products:\n Total out:\n 3,790 mL\n 1,229 mL\n Urine:\n 3,620 mL\n 1,160 mL\n NG:\n Stool:\n Drains:\n 170 mL\n 69 mL\n Balance:\n 157 mL\n -282 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 577 (348 - 577) mL\n PS : 5 cmH2O\n RR (Set): 12\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 50\n PIP: 11 cmH2O\n SPO2: 100%\n ABG: 7.51/34/187/26/4\n Ve: 13.4 L/min\n PaO2 / FiO2: 468\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, sluggish\n Cardiovascular: (Rhythm: Regular), (Murmur: No(t) Systolic, No(t)\n Diastolic)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Skin: No(t) Rash: , No(t) Jaundice\n Neurologic: (Responds to: Noxious stimuli), Moves all extremities,\n Sedated\n Labs / Radiology\n 156 K/uL\n 10.6 g/dL\n 122 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 3.8 mEq/L\n 17 mg/dL\n 105 mEq/L\n 138 mEq/L\n 30.4 %\n 5.3 K/uL\n [image002.jpg]\n 04:31 AM\n 01:31 PM\n 02:35 AM\n 02:45 AM\n 03:22 AM\n 04:49 AM\n 02:11 AM\n 02:18 AM\n 02:02 AM\n 02:12 AM\n WBC\n 10.6\n 11.5\n 8.8\n 5.3\n Hct\n 32.2\n 31.3\n 29.2\n 30.4\n Plt\n 184\n 228\n 177\n 156\n Creatinine\n 0.7\n 0.7\n 0.7\n 0.7\n TCO2\n 24\n 25\n 25\n 21\n 28\n 28\n Glucose\n 147\n 127\n 137\n 110\n 111\n 122\n Other labs: PT / PTT / INR:16.8/25.9/1.5, Lactic Acid:0.7 mmol/L,\n Albumin:3.8 g/dL, Ca:8.2 mg/dL, Mg:2.3 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA), .H/O RESPIRATORY\n FAILURE, ACUTE (NOT ARDS/), PROBLEM - ENTER DESCRIPTION IN\n COMMENTS, INTRACEREBRAL HEMORRHAGE (ICH), HYPERTENSION, BENIGN\n Assessment and Plan: 65M w/sudden onset HA on am of went into\n bathroom and fell to ground; parents found him to be unresponsive and\n taken to OSH; then txfr to found to have extensive\n intraventricular hemorrhage, now thought to be ruptured cyst.\n Neurologic: Neuro exam unchanged. plan for OR on thursday with preop\n MRI. Off sedation. transition Dilantin to Keppra.\n Cardiovascular: SBP < 160 with lopressor, hydral PRN, titrate BB as\n necessary\n Pulmonary: intubated, no changes in requirements\n Gastrointestinal / Abdomen: TFs per , H2b\n Nutrition: TFs at goal\n Renal: no issues, adequate UOP\n Hematology: Hct stable, f/u INR\n Endocrine: RISS\n Infectious Disease: Vanc/ for sinusitis Tx; WBC trending down\n Lines / Tubes / Drains: foley, ETT, , , left subclavian\n TLC, PIV\n Wounds: C/D/I\n Imaging: CT Cspine\n Fluids: KVO\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 06:44 PM\n ICP Catheter - 06:44 PM\n 18 Gauge - 12:59 PM\n Multi Lumen - 06:00 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n Total time spent:\n"
},
{
"category": "Social Work",
"chartdate": "2146-11-29 00:00:00.000",
"description": "Social Work Progress Note",
"row_id": 548491,
"text": "Family meeting held today with pt\ns mother & father, 2 sisters and pt\n brother in law. Purpose of the meeting was to further discuss the role\n of spokesperson for the pt, guardianship, health and social\n security. Family also here for a medical update from the neuro-surgery\n team. Pt remains incubated, not sedated and not awake.\n Parents understand the hospital definition of legal next of .\n Explained the level of involvement that pt requires from next of \n with re: to consents medical procedures, assisting with the initiation\n of MA Health, Medicare and social security. Explained pt\ns potential\n need for rehab upon medical clearance as well as future planning for pt\n that already is unable to provide for his own shelter, food or medical\n care. Family in agreement that they would like the pt to have a\n guardian outside of the family to take care of these issues as the\n family does not feel capable of establishing this type of repore with\n pt.\n Explained the role of office in assisting the family with\n application for MA Health. Family has the list of documents that are\n needed in order to apply and will work on obtaining them. Family also\n willing to assist with initiating pt\ns social security as pt is now\n turning 66. Pt has never applied for any entitlements or benefits.\n NP from neurosurgery sat with family to explain CT scan findings and\n proposal for plan of care. Family asked good questions when they\n needed more explanation or clarification, all in agreement that pt\n undergo recommended procedure scheduled for this Thursday.\n SICU Attending met with family with re: the day to day medical\n management of the pt\ns care. Issue of DNR was presented, family helped\n define pt\ns wishes re: quality of life. Family explains that they\n believe that pt has Aspergers Syndrome and go on to describe a very\n isolated person who would never be able to live in an institutional\n setting nor accept any hands on type of care or assistance with ADL\n Family reports that the pt walks around town all day long and feel that\n if he does not have that level of freedom and independence\nhe would go\n crazy\n"
},
{
"category": "Nutrition",
"chartdate": "2146-11-28 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 548352,
"text": "Current Wt: 64.3kg Adm wt: 75kg\n Pertinent medications: Abx, RISS, Senna, Colace, Famotidine, Bisacodyl,\n others noted\n Labs:\n Value\n Date\n Glucose\n 111 mg/dL\n 02:11 AM\n Glucose Finger Stick\n 237\n 10:00 AM\n BUN\n 13 mg/dL\n 02:11 AM\n Creatinine\n 0.7 mg/dL\n 02:11 AM\n Sodium\n 141 mEq/L\n 02:11 AM\n Potassium\n 3.9 mEq/L\n 02:11 AM\n Chloride\n 108 mEq/L\n 02:11 AM\n TCO2\n 26 mEq/L\n 02:11 AM\n PO2 (arterial)\n 109 mm Hg\n 02:18 AM\n PCO2 (arterial)\n 38 mm Hg\n 02:18 AM\n pH (arterial)\n 7.47 units\n 02:18 AM\n CO2 (Calc) arterial\n 28 mEq/L\n 02:18 AM\n Albumin\n 3.8 g/dL\n 02:35 AM\n Calcium non-ionized\n 8.2 mg/dL\n 02:11 AM\n Phosphorus\n 2.8 mg/dL\n 02:11 AM\n Ionized Calcium\n 1.17 mmol/L\n 02:18 AM\n Magnesium\n 2.2 mg/dL\n 02:11 AM\n Phenytoin (Dilantin)\n 9.8 ug/mL\n 02:11 AM\n WBC\n 8.8 K/uL\n 02:11 AM\n Hgb\n 10.7 g/dL\n 02:11 AM\n Hematocrit\n 29.2 %\n 02:11 AM\n Current diet order / nutrition support: TF order: Replete with Fiber @\n 55cc/hr (1320kcal, 82g protein)\n GI: +BS, abd soft\n Assessment of Nutritional Status\n 65 y.o. M adm with massive IVH, now s/p L burr hole with\n ventriculostomy drain placement. Pt remains intubated, with minimal\n reaction to verbal stimuli. Sedation has been off x2.5hrs; pt had been\n receiving propofol gtt, which provides 1.1kcal/mL. TF is at trophic\n rate via OGT, pt tolerating thus far. Currently-ordered TF goal rate\n will underfeed pt, thus rec increase TF goal rate.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1) Rec change TF goal rate to Replete with Fiber @ 75cc/hr\n (1800kcal, 112g protein).\n 2) Rec H20 flushes 50cc q4hrs. Adj as needed to maintain\n hydration.\n 3) Monitor BG with TF increase, will likely need more RISS\n coverage.\n Will follow progress/plan. Please page with ?\ns #\n"
},
{
"category": "Physician ",
"chartdate": "2146-12-05 00:00:00.000",
"description": "Intensivist Note",
"row_id": 549197,
"text": "TITLE:\n SICU\n HPI:\n 65M w/sudden onset HA on am of went into bathroom and fell to\n ground; parents found him to be unresponsive and taken to OSH; then\n txfr to . found to have massive IVH, s/p Lt Burr hole W EVD\n placement now s/p cyst aspiration/internal drainage \n Chief complaint:\n none\n PMHx:\n Asperger's, otherwise unknown-per mother; denies any\n cardiac/respiratory/cancer\n : Unknown\n Current medications:\n Acetaminophen 4. Amlodipine 5. Ampicillin 6. Artificial Tears 7.\n Bisacodyl 8. Calcium Gluconate\n 9. CloniDINE 10. Docusate Sodium (Liquid) 11. Famotidine 12. Furosemide\n 13. HYDROmorphone (Dilaudid)\n 14. Heparin 15. HydrALAzine 16. HydrALAzine 17. Hydrochlorothiazide 18.\n Insulin 19. Influenza Virus Vaccine\n 20. LeVETiracetam 21. Magnesium Sulfate 22. Metoprolol Tartrate 23.\n Metoprolol Tartrate 24. Miconazole Powder 2% 25. Nimodipine 26.\n NiCARdipine 27. Nystatin Oral Suspension 28. Pneumococcal Vac\n Polyvalent 29. Potassium Chloride 30. Potassium Chloride 31. Senna 32.\n Sodium Chloride 0.9% Flush 33. Sodium Chloride 0.9% Flush\n 34. Vancomycin\n 24 Hour Events:\n started clonidine, HCTZ, DC'd. head CT repeated\n Post operative day:\n POD#11 - Left burr hole with placement of ventriculostomy drain\n POD#4 - Endoscopic cysto ventriculostomy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 11:18 PM\n Meropenem - 12:53 AM\n Ampicillin - 02:15 AM\n Infusions:\n Nicardipine - 0.5 mcg/Kg/min\n Other ICU medications:\n Hydralazine - 05:14 AM\n Furosemide (Lasix) - 05:38 AM\n Metoprolol - 06:14 AM\n Famotidine (Pepcid) - 08:26 PM\n Heparin Sodium (Prophylaxis) - 11:20 PM\n Other medications:\n Flowsheet Data as of 04:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.9\nC (100.3\n T current: 36.4\nC (97.5\n HR: 77 (70 - 108) bpm\n BP: 139/61(81) {121/52(74) - 167/70(94)} mmHg\n RR: 21 (15 - 24) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 69.6 kg (admission): 75 kg\n Total In:\n 3,966 mL\n 621 mL\n PO:\n Tube feeding:\n 1,472 mL\n 301 mL\n IV Fluid:\n 2,224 mL\n 320 mL\n Blood products:\n Total out:\n 4,910 mL\n 690 mL\n Urine:\n 4,910 mL\n 690 mL\n NG:\n Stool:\n Drains:\n Balance:\n -944 mL\n -69 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SPO2: 100%\n ABG: ///26/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Temperature: Warm)\n Right Extremities: (Edema: 1+), (Temperature: Warm)\n Skin: No(t) Rash: , No(t) Jaundice\n Neurologic: (Awake / Alert / Oriented: x 1), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 268 K/uL\n 10.2 g/dL\n 137 mg/dL\n 0.6 mg/dL\n 26 mEq/L\n 3.8 mEq/L\n 19 mg/dL\n 103 mEq/L\n 134 mEq/L\n 29.1 %\n 10.1 K/uL\n [image002.jpg]\n 02:58 AM\n 04:00 AM\n 02:20 AM\n 11:46 AM\n 02:48 AM\n 03:08 AM\n 12:00 PM\n 03:25 AM\n 05:30 PM\n 02:29 AM\n WBC\n 7.9\n 9.4\n 7.5\n 8.5\n 8.3\n 10.2\n 10.1\n Hct\n 31.1\n 32.5\n 30.9\n 31.1\n 28.9\n 28.2\n 29.1\n Plt\n 164\n 187\n 182\n 178\n 197\n 249\n 268\n Creatinine\n 0.6\n 0.7\n 0.6\n 0.5\n 0.5\n 0.6\n 0.6\n 0.6\n 0.6\n Glucose\n 155\n 177\n 103\n 116\n 109\n 111\n 119\n 119\n 167\n 137\n Other labs: PT / PTT / INR:15.5/24.9/1.4, Lactic Acid:0.7 mmol/L,\n Albumin:3.8 g/dL, Ca:8.0 mg/dL, Mg:2.3 mg/dL, PO4:3.0 mg/dL\n Imaging: CT head: no definite change in size of cyst, mild decr\n in size of frontal of L lateral ventricle, interval development of\n small subdural effusion along L frontoparietal convexity w mild incr\n midline shift. no new hemorrhage.\n Microbiology: UCx: neg\n Ucx: neg\n MRSA: NEG\n sputum: rare pan-S pseudomonas\n BCx: pending\n UCx: no growth\n 12/14,15,16 sputum: contaminated\n CSF: 2500 WBC, prot 156, glu 75 - NGTD\n MRSA: NG\n BCx: P\n Assessment and Plan\n IMPAIRED SKIN INTEGRITY, FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA,\n PYREXIA), .H/O RESPIRATORY FAILURE, ACUTE (NOT ARDS/), PROBLEM\n - ENTER DESCRIPTION IN COMMENTS, INTRACEREBRAL HEMORRHAGE (ICH),\n HYPERTENSION, BENIGN\n Assessment and Plan: 65M w/sudden onset HA on am of went into\n bathroom and fell to ground; parents found him to be unresponsive and\n taken to OSH; then txfr to . found to have massive IVH, s/p Lt\n Burr hole W EVD placement now s/p cyst aspiration/internal\n drainage \n Neurologic: s/p cyst aspiration in OR , q2hr neuro checks, more\n awake/alert. cont Keppra. cont Ccollar per NSurg - may be able to\n clear clinically soon.\n Cardiovascular: keep SBP<160, on PO\n lopressor/amlodipine/hydralazine/nimotop/clonidine/HCTZ, wean\n nicardipine GTT\n Pulmonary: extubated, wean supplementary oxygen\n Gastrointestinal / Abdomen: TF - advance to goal 65/hr, H2B\n Nutrition: TF - advance to goal\n Renal: follow UOP, foley in place, no acute issues\n Hematology: HCt stable\n Endocrine: NPH 15/15, RISS\n Infectious Disease: Vanc/Amp for empiric meningitis coverage\n Lines / Tubes / Drains: foley, Dobhoff orally, Aline, left subclavian\n TLC\n Wounds: head wound drainage improved, cont dry dsgs\n Imaging: none\n Fluids: KVO\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale, NPH\n Lines:\n Arterial Line - 06:44 PM\n Multi Lumen - 06:00 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: DNR / DNI\n Disposition: Transfer to floor\n Total time spent: 33 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2146-12-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 549010,
"text": "Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Temp up to 101.5 axillary. Dr. aware and no cultures done.\n Action:\n Tylenol 650 mg given\n Response:\n Temp down to 98.1 axillary. After Tylenol. Pt able to follow commands\n better\n Plan:\n Monitor culture results from yesterday.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Pt intermittent with following commands. Will stick out tongue and\n occasionally wiggle toes. Once\n squeezed left hand to command. No spontaneous movement noted. Lower\n extremities respond to painful stimuli. Pupils are equal and reactive\n to light. Incisional dressing continues to ooze rust colored drainage.\n Pt seen by Dr. and dressing changed.\n Action:\n Titrate nicardipine for sbp less than 150. continue to monitor neuro\n status. Dr. and Dr. aware of neuro exam and drainage\n from head incision.\n Response:\n Neuro status waxes and wanes. Nicardipine currently at 2.5\n Plan:\n No change in treatment plan at this time.\n"
},
{
"category": "Nursing",
"chartdate": "2146-12-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 549012,
"text": "Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Temp up to 101.5 axillary. Dr. aware and no cultures done.\n Action:\n Tylenol 650 mg given\n Response:\n Temp down to 98.1 axillary. After Tylenol. Pt able to follow commands\n better\n Plan:\n Monitor culture results from yesterday.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Pt intermittent with following commands. Will stick out tongue and\n occasionally wiggle toes. Once\n squeezed left hand to command. No spontaneous movement noted. Lower\n extremities respond to painful stimuli. Pupils are equal and reactive\n to light. Incisional dressing continues to ooze rust colored drainage.\n Pt seen by Dr. and dressing changed.\n Action:\n Titrate nicardipine for sbp less than 150. continue to monitor neuro\n status. Dr. and Dr. aware of neuro exam and drainage\n from head incision.\n Response:\n Neuro status waxes and wanes. Nicardipine currently at 2.5\n Plan:\n No change in treatment plan at this time.\n s/p extubation\n D; pt extubated today and on 50% face tent. Pt with weak cough but\n improving during the night. Pt coughing and raising small amts of\n white sputum to back of throat and suctioned out of the back of throat\n with tonsil tipi Breath sounds are clear and diminished in the bases.\n A: encourage to cough and deep breath. Monitor respirtatory status.\n R: doing well extubated\n"
},
{
"category": "Nursing",
"chartdate": "2146-12-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 549089,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Inconsistent neurological exam. Pt will wiggle left toes at times to\n command. Non-verbal. Perl. No spontaneous movement noted. Head incision\n with large amounts of drainage, including lighter colored drainage this\n afternoon which saturated\n of pink pad. Febrile to 100.1.\n Action:\n Dr. and neurosur team called to evaluate. Dressing changed x2 and\n reinforced x1 for continued drainage. Tylenol given.\n Response:\n Continues to drain serosang drainage and at times lighter colored\n drainage. Neurological exam brighter with pt. nodding when afebrile.\n Plan:\n Neurological exam every 2hrs. Continue to monitor drainage and elevate\n head of bed >30degrees.\n Hypertension, benign\n Assessment:\n Hypertensive to 150\ns sys.\n Action:\n Hydralazine dosing increased. Nimodipine added. Nicardipine gtt.\n Response:\n Bp,150 sys with effective weaning of Nicardipine gtt.\n Plan:\n Wean Nicardipine to off.\n .H/O respiratory failure, acute (not ARDS/)\n Assessment:\n Desat to 89%\n Action:\n NT suctioned for thick white sputum. Pt requires frequent oral\n suctioning for pooling of secretions at back of throat. He has a very\n poor gag and very weak cough. Maintained in upright position as much as\n possible due to potential airway obstruction/snoring. O2 increased to\n 70%.\n Response:\n Sats 100%.\n Plan:\n Continue to carefully monitor resp status and prevent obstruction of\n airway with positioning. No nasal trumpet due to sinusitis.\n"
},
{
"category": "Physician ",
"chartdate": "2146-12-03 00:00:00.000",
"description": "Intensivist Note",
"row_id": 548973,
"text": "SICU\n HPI:\n HPI: 65M w/sudden onset HA on am of went into bathroom and fell\n to ground; parents found him to be unresponsive and taken to OSH; then\n txfr to . found to have massive IVH, s/p Lt Burr hole W EVD\n placement now s/p cyst aspiration \n Chief complaint:\n headache\n PMHx:\n PMH/PSH: , mother; denies any\n cardiac/respiratory/cancer\n Current medications:\n 1. 2. 3. Acetaminophen 4. Amlodipine 5. Ampicillin 6. Bisacodyl 7.\n Calcium Gluconate 8. Chlorhexidine Gluconate 0.12% Oral Rinse\n 9. Docusate Sodium (Liquid) 10. Famotidine 11. HYDROmorphone (Dilaudid)\n 12. Heparin 13. HydrALAzine\n 14. HydrALAzine 15. Insulin 16. Influenza Virus Vaccine 17.\n LeVETiracetam 18. Lidocaine 1% 19. Magnesium Sulfate\n 20. Meropenem 21. Metoprolol Tartrate 22. NiCARdipine 23. Nimodipine\n 24. Nystatin Oral Suspension\n 25. Pneumococcal Vac Polyvalent 26. Potassium Chloride 27. Propofol 28.\n Senna 29. Sodium Chloride 0.9% Flush\n 30. Sodium Chloride 0.9% Flush 31. Vancomycin\n 24 Hour Events:\n EXTUBATION - At 08:30 AM\n FEVER - 101.2\nF - 12:00 AM\n : +Corneals/+swallowing, Pupils symmetric in size, Lt3mm MR, spont\n mvmt on LUE/LLE, no spont mvmt of Rt side. Taken to or for EVD\n placement with burr hole and returned, MRI obtained, improving neuro\n exam by the morning\n : MRI done but unable to determine vascular cause of bleed, CTA\n Head done, prelim read below. remained intubated until neurosurg;\n nicardipine gtt\n : started lopressor PO, bolused dilantin\n : started Replete with fiber; pt with fevers/copious secretions,\n clear CXR and CT head/sinus with sinus changes and persistant\n hemorrhage but decrease in size of IVH - started vanco/ for\n suspected sinusitis, NGT->oral dobhoff, Sputum cx; dilantin bolused and\n dose increased; central line placed for access\n : family meeting held - DNR status; increased lopressor; added\n nystatin; plan for cyst aspiration with AM MRI Thursday as prelude, NSG\n no SQH at this time; following up on cultures - continuing to be\n febrile\n : VitK, incr lopressor, CT head/C-spine, ETT repositioned; o/n\n temp 103, pancx/CXR; ICP 20-23 intermittently, neurosurg aware.\n Nicardipine gtt restarted.\n : cont fevers, Vanc DC'd, started amlodipine, incr lopressor\n : organ bank called, will call back after surgery done and\n prognosis better known; to OR, EVD taken out, cyst aspirated, CT\n afterwards OK by report; social work working on getting court appointed\n guardian; started po hydralazine\n : pan cx'd for fever, extubated, SQH started, RISS improved,\n collar removed; added nimotop to come off nimodipine\n Post operative day:\n POD#9 - Left burr hole with placement of ventriculostomy drain\n POD#2 - Endoscopic cysto ventriculostomy\n : +Corneals/+swallowing, Pupils symmetric in size, Lt3mm MR, spont\n mvmt on LUE/LLE, no spont mvmt of Rt side. Taken to or for EVD\n placement with burr hole and returned, MRI obtained, improving neuro\n exam by the morning\n : MRI done but unable to determine vascular cause of bleed, CTA\n Head done, prelim read below. remained intubated until neurosurg;\n nicardipine gtt\n : started lopressor PO, bolused dilantin\n : started Replete with fiber; pt with fevers/copious secretions,\n clear CXR and CT head/sinus with sinus changes and persistant\n hemorrhage but decrease in size of IVH - started vanco/ for\n suspected sinusitis, NGT->oral dobhoff, Sputum cx; dilantin bolused and\n dose increased; central line placed for access\n : family meeting held - DNR status; increased lopressor; added\n nystatin; plan for cyst aspiration with AM MRI Thursday as prelude, NSG\n no SQH at this time; following up on cultures - continuing to be\n febrile\n : VitK, incr lopressor, CT head/C-spine, ETT repositioned; o/n\n temp 103, pancx/CXR; ICP 20-23 intermittently, neurosurg aware.\n Nicardipine gtt restarted.\n : cont fevers, Vanc DC'd, started amlodipine, incr lopressor\n : organ bank called, will call back after surgery done and\n prognosis better known; to OR, EVD taken out, cyst aspirated, CT\n afterwards OK by report; social work working on getting court appointed\n guardian; started po hydralazine\n : pan cx'd for fever, extubated, SQH started, RISS improved,\n collar removed; added nimotop to come off nimodipine\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 12:32 AM\n Meropenem - 12:32 AM\n Ampicillin - 02:18 AM\n Infusions:\n Nicardipine - 2 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 AM\n Hydralazine - 08:15 PM\n Heparin Sodium (Prophylaxis) - 12:32 AM\n Other medications:\n Flowsheet Data as of 05:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.4\nC (101.2\n T current: 36.7\nC (98.1\n HR: 92 (84 - 112) bpm\n BP: 150/54(82) {119/46(69) - 160/66(91)} mmHg\n RR: 25 (17 - 31) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 66.6 kg (admission): 75 kg\n Total In:\n 4,019 mL\n 860 mL\n PO:\n Tube feeding:\n 1,231 mL\n 272 mL\n IV Fluid:\n 2,472 mL\n 543 mL\n Blood products:\n Total out:\n 3,355 mL\n 435 mL\n Urine:\n 3,355 mL\n 435 mL\n NG:\n Stool:\n Drains:\n Balance:\n 664 mL\n 425 mL\n Respiratory support\n O2 Delivery Device: Face tent\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 515 (515 - 515) mL\n PS : 5 cmH2O\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 50%\n SPO2: 100%\n ABG: ///27/\n Ve: 8 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli, Tactile stimuli, Noxious stimuli), Moves\n all extremities\n Labs / Radiology\n 197 K/uL\n 10.4 g/dL\n 111 mg/dL\n 0.5 mg/dL\n 27 mEq/L\n 3.3 mEq/L\n 18 mg/dL\n 105 mEq/L\n 139 mEq/L\n 28.9 %\n 8.3 K/uL\n [image002.jpg]\n 02:18 AM\n 02:02 AM\n 02:12 AM\n 09:23 PM\n 02:58 AM\n 04:00 AM\n 02:20 AM\n 11:46 AM\n 02:48 AM\n 03:08 AM\n WBC\n 5.3\n 7.6\n 7.9\n 9.4\n 7.5\n 8.5\n 8.3\n Hct\n 30.4\n 31.5\n 31.1\n 32.5\n 30.9\n 31.1\n 28.9\n Plt\n 156\n 169\n 164\n 187\n 182\n 178\n 197\n Creatinine\n 0.7\n 0.6\n 0.7\n 0.6\n 0.5\n 0.5\n TCO2\n 28\n 28\n Glucose\n 122\n 155\n 177\n 103\n 116\n 109\n 111\n Other labs: PT / PTT / INR:15.5/24.9/1.4, Lactic Acid:0.7 mmol/L,\n Albumin:3.8 g/dL, Ca:8.0 mg/dL, Mg:2.5 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n IMPAIRED SKIN INTEGRITY, FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA,\n PYREXIA), .H/O RESPIRATORY FAILURE, ACUTE (NOT ARDS/), PROBLEM\n - ENTER DESCRIPTION IN COMMENTS, INTRACEREBRAL HEMORRHAGE (ICH),\n HYPERTENSION, BENIGN\n Assessment and Plan: 65M w/sudden onset HA on am of went into\n bathroom and fell to ground; parents found him to be unresponsive and\n taken to OSH; then txfr to . found to have massive IVH, s/p Lt\n Burr hole W EVD placement now s/p cyst aspiration \n Neurologic: Neuro checks Q: 2 hr, s/p cyst aspiration in OR , q2hr\n neuro checks\n Cardiovascular: Beta-blocker, keep SBP<140, on PO\n lopressor/amlodipine/hydralazine/nimotop, wean nicardipine GTT;\n hydralazine prn; dilaudid for pain\n Pulmonary: IS, extubated, wean supplementary oxygen\n Gastrointestinal / Abdomen: TF - advance to goal 70/hr, H2B\n Nutrition: Tube feeding, TF - advance to goal 70/hr, H2B\n Renal: Foley, Adequate UO\n Hematology: Serial Hct\n Endocrine: RISS\n Infectious Disease: Check cultures, continues to be febrile but WBC\n wnl, cultures pending, on for suspected sinusitis, started\n Vanc/Amp for meningitis coverage.\n Lines / Tubes / Drains: foley, Dobhoff, Aline, left subclavian TLC\n Wounds: Dry dressings\n Imaging: no imaging today\n Fluids: KVO\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS), (Respiratory distress:\n Insufficiency / Post-op)\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 04:43 PM 55 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 06:44 PM\n Multi Lumen - 06:00 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: DNR / DNI\n Disposition: ICU\n Total time spent: 32 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2146-12-04 00:00:00.000",
"description": "Intensivist Note",
"row_id": 549136,
"text": "SICU\n HPI:\n 65M w/sudden onset HA on am of went into bathroom and fell to\n ground; parents found him to be unresponsive and taken to OSH; then\n txfr to . found to have massive IVH, s/p Lt Burr hole W EVD\n placement now s/p cyst aspiration \n Chief complaint:\n massive IVH\n PMHx:\n Asperger's\n Current medications:\n 24 Hour Events:\n Post operative day:\n POD#10 - Left burr hole with placement of ventriculostomy drain\n POD#3 - Endoscopic cysto ventriculostomy\n 24hr events: NPH added 15/15, hydral incr for HTN. Meropenem to be D/C\n on sunday, sig drainage on head dressing neurosx aware\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 01:05 AM\n Vancomycin - 01:06 AM\n Ampicillin - 02:15 AM\n Infusions:\n Nicardipine - 1 mcg/Kg/min\n Other ICU medications:\n Hydralazine - 08:00 PM\n Famotidine (Pepcid) - 08:09 PM\n Heparin Sodium (Prophylaxis) - 12:38 AM\n Other medications:\n Flowsheet Data as of 05:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.3\nC (101\n T current: 37.7\nC (99.8\n HR: 91 (80 - 111) bpm\n BP: 147/65(90) {107/51(69) - 168/99(111)} mmHg\n RR: 26 (25 - 34) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 69.6 kg (admission): 75 kg\n Total In:\n 3,983 mL\n 779 mL\n PO:\n Tube feeding:\n 1,320 mL\n 281 mL\n IV Fluid:\n 2,438 mL\n 497 mL\n Blood products:\n Total out:\n 3,047 mL\n 620 mL\n Urine:\n 3,047 mL\n 620 mL\n NG:\n Stool:\n Drains:\n Balance:\n 936 mL\n 159 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SPO2: 100%\n ABG: ///28/\n Physical Examination\n General Appearance: tachypneic\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: drainage around cystectomy site\n Neurologic: (Responds to: Verbal stimuli, Tactile stimuli, Noxious\n stimuli), Moves all extremities, track w/ eyes on verbal stimuli. UE\n inconsistently withdrawal to noxious. LE withdrawal to noxious\n Labs / Radiology\n 249 K/uL\n 10.3 g/dL\n 119 mg/dL\n 0.6 mg/dL\n 28 mEq/L\n 3.6 mEq/L\n 19 mg/dL\n 105 mEq/L\n 139 mEq/L\n 28.2 %\n 10.2 K/uL\n [image002.jpg]\n 02:12 AM\n 09:23 PM\n 02:58 AM\n 04:00 AM\n 02:20 AM\n 11:46 AM\n 02:48 AM\n 03:08 AM\n 12:00 PM\n 03:25 AM\n WBC\n 7.6\n 7.9\n 9.4\n 7.5\n 8.5\n 8.3\n 10.2\n Hct\n 31.5\n 31.1\n 32.5\n 30.9\n 31.1\n 28.9\n 28.2\n Plt\n 169\n 164\n 187\n 182\n 178\n 197\n 249\n Creatinine\n 0.6\n 0.7\n 0.6\n 0.5\n 0.5\n 0.6\n 0.6\n TCO2\n 28\n Glucose\n 155\n 177\n 103\n 116\n 109\n 111\n 119\n 119\n Other labs: PT / PTT / INR:15.5/24.9/1.4, Lactic Acid:0.7 mmol/L,\n Albumin:3.8 g/dL, Ca:8.0 mg/dL, Mg:2.4 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n IMPAIRED SKIN INTEGRITY, FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA,\n PYREXIA), .H/O RESPIRATORY FAILURE, ACUTE (NOT ARDS/), PROBLEM\n - ENTER DESCRIPTION IN COMMENTS, INTRACEREBRAL HEMORRHAGE (ICH),\n HYPERTENSION, BENIGN\n Assessment and Plan: 65M found to have massive IVH, s/p Lt Burr hole W\n EVD placement now s/p cyst aspiration \n Neurologic: Neuro checks Q: 2 hr, s/p cyst aspiration in OR , f/u\n neurosurg re wound drainage Add clonidiner for BP and potential for\n anxiety.\n Cardiovascular: keep SBP<150, on PO\n lopressor/amlodipine/hydralazine/nimotop; requiring to be placed back\n on nicardipine gtt\n Pulmonary: supplementary oxygen\n Gastrointestinal / Abdomen: tube feeds\n Nutrition: Tube feeding, DHT orally\n Renal: Foley, Adequate UO; lyte repletion\n Hematology: stable\n Endocrine: RISS, NPH 15/15 - sugars improved on regimen\n Infectious Disease: for suspected sinusitis to end ; Vanc/Amp\n for meningitis coverage. f/u cxs\n Lines / Tubes / Drains: Foley, Dobhoff, Aline, left subclavian TLC\n Wounds: head would w/ sig drainage - f/u neurosurg; maintain head\n elevation\n Imaging:\n Fluids: KVO\n Consults: Neuro surgery\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 08:16 AM 55 mL/hour\n Glycemic Control: Regular insulin sliding scale, NPH\n Lines:\n Arterial Line - 06:44 PM\n Multi Lumen - 06:00 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition: ICU\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2146-12-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 549122,
"text": "Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Fever up to 101.0 skin warm to touch. Skin flushed.\n Action:\n Tylenol 650mg via tube fdg given. Tepid bath given. Temp in room\n lowered.\n Response:\n Temp down to 100.4. pt appears to be more awake once temp down.\n Plan:\n Monitor temps q4hrs and monitor culture results.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Pt intermittently follows commands by saying hi, squeezing left hand\n upon command and wiggling toes upon command. Head incision intact but\n draining pink- bloody-rust colored drainage. Perla.\n Action:\n Head of bed elevated to 45 degrees. Neuro signs q2hrs. monitor head\n drainage and document. Dr in to see drainage. Neuro team called\n andnotiified of drainage. Nicardipine gtt titrated to keep bp < 150.\n Response:\n Neuro status waxes and wanes, neuro and sicu team of head drainage.\n Plan:\n Monitor neuro status closely. Monitor head drainage closely.\n Hypertension, benign\n Assessment:\n Bp up to 160-170\ns. nicardpine gtt titrated. Lopressor and hydrailazine\n via tube given. Wgt up today.\n Action:\n Niccardipine gtt titerated to keep bp < 159, hydralazine 10mg iv x 3\n prn given. Lopressor 10mg iv given x1. hydralazine via tube increased\n to 75mg. lasix 20mg ivp x1 given.\n Response:\n Bp continules to be elevated despite prn antihypertensive. Nicardipine\n gtt continues. Diuressing nicely.\n Plan:\n Monitor bp closely.\n"
},
{
"category": "Nursing",
"chartdate": "2146-12-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 549212,
"text": "Hypertension, benign\n Assessment:\n Bp tonite ranging from 120\ns to 170\ns. goal rate < 160.\n Action:\n Nicardipine gtt remains at 0.5mcg/kg/min. lopresssor, hydralazine and\n clonidine given via tube. Bp checked. Q1hr.\n Response:\n Bp very labile.\n Plan:\n Wean nicardipine gtt off slowly. Continue with hydralazine, lopressor\n and clonidine via tube.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Perla, moves left arm and leg. No movement in right leg and arm. More\n awqke and answers some questions with one word answer .head incision\n intact and no drainage noted tonite. Nicardipine gtt for bp control.\n Action:\n Neuro signs q2hrs. head of bed elevated nimodipine q4hrs via tube.\n Response:\n Neuro status waxes and wanes but most of tonite more awake.\n Plan:\n Monitor neuro status.\n"
},
{
"category": "Radiology",
"chartdate": "2146-12-01 00:00:00.000",
"description": "CT STEREOTAXIS W/ CONTRAST",
"row_id": 1051935,
"text": " 8:21 AM\n CT STEREOTAXIS W/ CONTRAST Clip # \n Reason: pre-op for stx cyst/endoscopic cyst drainage\n Admitting Diagnosis: BLEED\n Contrast: OPTIRAY Amt: 90\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with cyst\n REASON FOR THIS EXAMINATION:\n pre-op for stx cyst/endoscopic cyst drainage\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 65-year-old male, with known intracranial hemorrhage, and also large\n cyst in the suprasellar and pontine region causing obstructing hydrocephalus.\n Now preop for stereotactic cyst drainage.\n\n TECHNIQUE: Contiguous helical MDCT images were obtained through the brain\n with IV contrast.\n\n COMPARISON: CT head without contrast on .\n\n FINDINGS:\n\n The study is limited by the overcasting artifacts by the surrounding metal\n stereotactic frame and hardware.\n\n There is no overall change compared to the study in . Again\n seen is a large cyst in the pontine and suprasellar cistern, with extension\n into the third ventricle. There is apparent obstruction to the lateral\n ventricles bilaterally. The extensive intraventricular hemorrhage is\n unchanged. The ventriculostomy drain is seen in unchanged position with its\n tip at the anterior of the left lateral ventricle and extending through\n the left frontal burr hole. There is presistent hydrocephalus.\n\n There is a mucus retention cyst on the medial wall of the left maxillary\n sinus, which was also visualized on the study. There is no new\n fracture identified.\n\n IMPRESSION:\n\n 1. Unchange of the massive intraventricular hemorrhage and hydrocephalus.\n\n 2. Unchanged large suprasellar/pontine cyst and the position of the\n ventriculostomy draining tube.\n\n\n\n (Over)\n\n 8:21 AM\n CT STEREOTAXIS W/ CONTRAST Clip # \n Reason: pre-op for stx cyst/endoscopic cyst drainage\n Admitting Diagnosis: BLEED\n Contrast: OPTIRAY Amt: 90\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-12-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1056277,
"text": " 11:52 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for aspiration, other acute process\n Admitting Diagnosis: BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with history of IPH, possible aspiration event this morning,\n then a fall today.\n REASON FOR THIS EXAMINATION:\n evaluate for aspiration, other acute process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of intraparenchymal hemorrhage and possible aspiration.\n\n COMPARISON: .\n\n SINGLE PORTABLE UPRIGHT CHEST RADIOGRAPH: There is no evidence of aspiration,\n consolidation, or pulmonary edema. There is no effusion or pneumothorax. A\n left subclavian catheter tip terminates over the mid SVC.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-12-14 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1054081,
"text": " 12:56 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Post op study\n Admitting Diagnosis: BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with persistant leaking scalp incision. S/P endoscopic cyst\n aspiration and removal of EVD with placement of Rickam reservoir12/18 and wound\n revision \n REASON FOR THIS EXAMINATION:\n Post op study\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): FBr WED 6:13 PM\n 1. Mild interval decrease in the left frontal subdural collection.\n\n 2. Unchanged intraventricular hemorrhage.\n\n 3. Unchanged cystic dilatation of the lateral ventricles and the suprasellar\n cistern.\n\n 4. New bifrontal and biventricular pneumocephalus is compatible with the\n recent operation.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 65-year-old man with endoscopic cyst aspiration and revision.\n Please evaluate interval change.\n\n Comparison is made to the prior study of .\n\n NON-CONTRAST HEAD CT: Patient is status post recent craniotomy with new\n bifrontal subdural and intraventricular pneumocephalus. The left convexity\n subdural is slightly smaller now measuring 8 mm compared to the prior study\n when it measured 11 mm. The appearance of the lateral ventricles including\n the left intraventricular hemorrhage and hemorrhage adjacent to the left\n ventriculostomy drain appear unchanged. The distal tip of ventriculostomy\n tube terminates in the prepontine cistern and is unchanged. The cystic\n structure within the lateral ventricles and the suprasellar region appear\n unchanged. No new focus of hemorrhage is identified. There has seen no\n interval change in the shift of midline structure.\n\n The visualized part of the paranasal sinuses do not demonstrate any mucosal\n thickening. Status post frontal burr hole placement.\n\n IMPRESSION:\n\n 1. Mild interval decrease in the left frontal subdural collection.\n\n 2. Unchanged intraventricular hemorrhage.\n\n 3. Unchanged cystic dilatation of the lateral ventricles and the suprasellar\n cistern.\n\n (Over)\n\n 12:56 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Post op study\n Admitting Diagnosis: BLEED\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 4. New bifrontal and biventricular pneumocephalus is compatible with the\n recent operation.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-12-06 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1052813,
"text": " 9:40 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Follow up head CT\n Admitting Diagnosis: BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with intraparenchymal hemorrhage\n REASON FOR THIS EXAMINATION:\n Follow up head CT\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ENYa TUE 4:07 PM\n 1. No significant interval change in size or appearance of the cystic\n dilatation of the suprasellar cistern.\n\n 2. Unchanged appearance of the known intraventricular hemorrhage and extension\n to subarachnoid space.\n\n 3. Unchanged location of the tip of the catheter.\n\n 4. Unchanged L frontal extra-axial fluid collection.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 65-year-old male, with known intracranial hemorrhage, assess for\n interval changes.\n\n TECHNIQUE: Contiguous helical MDCT images were acquired through the brain\n without contrast.\n\n COMPARISON: Series of non-contrast head CT study with the latest one dated on\n \n\n FINDINGS:\n\n Again seen is the marked cystic dilatation of the suprasellar cistern, now\n measuring 57 (AP) x 51 mm (TRV) compared to 65 x 51 mm, previously. This\n represents a slight interval decrease in size, allowing the differences in\n slice-selection and angulation, with continued clearing of the hemorrhage\n within. A drainage catheter has been inserted via a left frontal approach,\n with its tip terminating in the region of prepontine portion of the cyst,\n unchanged in position. There is essentially no change in size and appearance\n of the intraventricular hemorrhage, with the right-sided components more\n prominent than the left.\n\n There is unchanged hydrocephalus, but compared to the initial head CT study,\n there has been progressive reduction in dilatation of the temporal horns,\n bilaterally, representing a significant overall improvement. There is no\n evidence of transependymal migration of CSF. The newly-apparent left frontal\n subdural effusion is unchanged in size and appearance. There is a trace\n amount of subarachnoid hemorrhage in the Sylvian fissures, as before, with no\n evidence of new hemorrhage, and no acute infarction.\n\n IMPRESSION:\n (Over)\n\n 9:40 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Follow up head CT\n Admitting Diagnosis: BLEED\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 1. Slight interval decrease in the cystic dilatation of the suprasellar\n cistern, with no significant change of the overall size or appearance of the\n cyst. Its etiology remains obscure; however, such unusual cysts in this\n location, presenting with large associated hemorrhage, may be seen in the\n setting of \"pituitary apoplexy\" with occult underlying adenoma or other mass.\n\n 2. Unchanged position of the drainage catheter within the cyst.\n\n 3. Unchanged left frontal extra-axial collection, not likely related to\n ongoing intracranial hypotension (given that the pt has had ventriculostomy\n removed, and the lack of abrupt change in ventricular size and shape).\n\n Discussion with NPs associated with the primary Neurosurgery team confirms\n that the drainage catheter is not constantly connected to external drainage,\n thus making ongoing intracranial hypotension, accounting for the new subdural\n effusion, less likely. True subdural hygroma, related to trans-pial passage of\n the cyst- drainage cathether is not excluded.\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-12-19 00:00:00.000",
"description": "BILAT HIPS (AP,LAT & AP PELVIS)",
"row_id": 1055020,
"text": ", C. NSURG FA11 8:12 PM\n BILAT HIPS (AP,LAT & AP PELVIS) Clip # \n Reason: please eval for fracture; found on floor unwittnessed fall\n Admitting Diagnosis: BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with\n REASON FOR THIS EXAMINATION:\n please eval for fracture; found on floor unwittnessed fall\n ______________________________________________________________________________\n PFI REPORT\n No fracture and no dislocation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-12-14 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1054082,
"text": ", C. NSURG FA11 12:56 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Post op study\n Admitting Diagnosis: BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with persistant leaking scalp incision. S/P endoscopic cyst\n aspiration and removal of EVD with placement of Rickam reservoir12/18 and wound\n revision \n REASON FOR THIS EXAMINATION:\n Post op study\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n 1. Mild interval decrease in the left frontal subdural collection.\n\n 2. Unchanged intraventricular hemorrhage.\n\n 3. Unchanged cystic dilatation of the lateral ventricles and the suprasellar\n cistern.\n\n 4. New bifrontal and biventricular pneumocephalus is compatible with the\n recent operation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-12-19 00:00:00.000",
"description": "R SHOULDER 2-3 VIEWS NON TRAUMA RIGHT",
"row_id": 1055021,
"text": " 8:13 PM\n SHOULDER VIEWS NON TRAUMA RIGHT Clip # \n Reason: please evlaute for fracture, found on floor s/p unwittnessed\n Admitting Diagnosis: BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with\n REASON FOR THIS EXAMINATION:\n please evlaute for fracture, found on floor s/p unwittnessed fall\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JMGw 10:54 AM\n No fracture. No dislocation.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Unwitnessed fall, evaluate for fracture.\n\n FOUR RADIOGRAPHS OF THE RIGHT SHOULDER\n\n FINDINGS: No comparative studies are available. No fracture, dislocation is\n seen. There is mild degenerative change at the acromioclavicular joint. No\n degenerative changes are present at the glenohumeral joint. No sclerotic or\n lytic lesions are seen. No soft tissue calcifications or radiopaque foreign\n bodies are present. The partially visualized right lung is clear with the\n exception of a central venous line whose tip appears to terminate in the\n superior vena cava. Incidental note is made of a prominent tubercle of the\n humerus.\n\n IMPRESSION: No fracture. No dislocation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-12-19 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1054979,
"text": ", C. NSURG FA11 2:57 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: please eval for interval change/ found on floor unwittnessed\n Admitting Diagnosis: BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with\n REASON FOR THIS EXAMINATION:\n please eval for interval change/ found on floor unwittnessed fall. CT head to\n be performed first, followed by plain films of pelvis and shoulder\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n No evidence of hemorrhage or fracture. Ventriculostomy catheter,\n hydrocephalus, and cystic mass involving the third ventricle appear unchanged.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-12-19 00:00:00.000",
"description": "R UNILAT LOWER EXT VEINS RIGHT",
"row_id": 1054981,
"text": " 3:09 PM\n UNILAT LOWER EXT VEINS RIGHT Clip # \n Reason: eval for DVT / prolonged bedrest\n Admitting Diagnosis: BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with brain cyst\n REASON FOR THIS EXAMINATION:\n eval for DVT / prolonged bedrest\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 65-year-old man with brain cyst and prolonged bed rest, evaluate\n for DVT.\n\n COMPARISON: No previous exam for comparison.\n\n FINDINGS: scale, color and Doppler son of the right common\n femoral, superficial femoral, popliteal and tibial veins were performed. There\n is normal flow, compression and augmentation seen in all the vessels.\n\n -scale images with and without compression of the left common femoral,\n deep femoral and superficial femoral veins were performed. Normal compression\n is seen in all of these vessels. Color Doppler and pulse wave Doppler images\n of the left common femoral vein demonstrate normal flow.\n\n Note is made that Doppler images of the remainder of the left leg were not\n performed at the patient's request.\n\n IMPRESSION: No evidence of deep vein thrombosis in the right leg. No\n evidence of deep vein thrombosis in the left leg although the imaging was\n limited due to the patient's request.\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-12-26 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1056279,
"text": " 12:17 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: evalute for new hemorrhage, interval change in IPH\n Admitting Diagnosis: BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with IPH and cyst, s/p fall today\n REASON FOR THIS EXAMINATION:\n evalute for new hemorrhage, interval change in IPH\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of intraparenchymal hemorrhage and cysts, status post\n fall today. Evaluate for new hemorrhage.\n\n COMPARISON: .\n\n TECHNIQUE: Non-contrast head CT scan.\n\n FINDINGS: There is no new hemorrhage. Compared to prior study, there has\n been interval decrease in the amount intracranial air. Again demonstrated is\n a large suprasellar cystic structure extending to the third ventricle, not\n significantly changed compared to prior study. Left frontal shunt catheter is\n in unchanged position. The configuration of the ventricles, with enlargement\n of the lateral ventricles is not significantly changed from prior study. Left\n greater than right subdural collections are not significantly changed from\n prior study also. Visualized paranasal sinuses are normally aerated.\n\n IMPRESSION: No new hemorrhage. Slight decrease in amount of intracranial\n air. Otherwise, no significant change from prior.\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-12-04 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1052462,
"text": " 10:54 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: evaluate\n Admitting Diagnosis: BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with\n REASON FOR THIS EXAMINATION:\n evaluate\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): RSRc SUN 11:55 AM\n No significant change in size of cyst or intraventricular hemorrhage.\n Continued small subarachnoid hemorrhage in bilateral sylvian fissures.\n Decrease in degree of hemorrhage in cyst or third ventricle, and decreased\n pneumocephalus.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 65-year-old male with cyst drainage and intraventricular catheter.\n\n COMPARISON: Multiple prior head CTs, including and .\n\n TECHNIQUE: Axial imaging was performed from the cranial vertex to the foramen\n magnum without IV contrast.\n\n HEAD CT WITHOUT IV CONTRAST: There is overall no definite change in size of a\n large cyst in the suprasellar/pre-pontine cistern, with a drain tip from left\n frontal approach terminating within. The degree of hemorrhage in the lateral\n ventricles is not significantly changed. There is persistence of small amount\n of hemorrhage in the sylvian fissures bilaterally. There is apparent slight\n decrease in hemorrhage involving the cyst or third ventricle. There has been\n interval decrease in degree of pneumocephalus, with a tiny locule remaining in\n the left frontal region. The soft tissues and visualized paranasal sinuses\n are unremarkable.\n\n IMPRESSION:\n\n 1. No change in position of left frontal approach catheter terminating within\n a large cyst centered in the suprasellar/pre-pontine cistern.\n\n 2. No definite change in size of cyst.\n\n 3. Similar extensive hemorrhage within the lateral ventricles, and smaller\n subarachnoid hemorrhage in bilateral sylvian fissures.\n\n 4. Slight decrease in degree of hemorrhage within the cyst or third\n ventricle.\n\n NOTE ON ATTENDING REVIEW:\n\n There is mild decrease in the size of the frontal of the left lateral\n ventricle which measures 1.0cm in the AP dimension compared to the prior of\n 2.0cm. In addition, there is interval development of a small subdural effusion\n (Over)\n\n 10:54 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: evaluate\n Admitting Diagnosis: BLEED\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n along the left frontal and parietal convexity, 8-10 mm in transverse dimension\n with displacement of the cerebral parenchyma medially and mild increase in the\n rightward shift of the midline structures. This is concerning for development\n of intracranial hypotension. No ne whemorrhage.\n Close follow up as clinically indicated.\n D/w Dr. by Dr. on at 1.30pm.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-12-13 00:00:00.000",
"description": "CHEST (PRE-OP PA & LAT)",
"row_id": 1053869,
"text": " 2:40 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: BLEED\n Admitting Diagnosis: BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man s/p subarrachnoid cyst drainage\n REASON FOR THIS EXAMINATION:\n pre-op for wound revision\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: 65-year-old man status post subarachnoid cyst drainage.\n Pre-op for wound revision.\n\n TECHNIQUE: PA and lateral views of the chest are provided.\n\n COMPARISON: Multiple chest x-rays since are available for\n comparison.\n\n FINDINGS: The lungs are clear without pulmonary infiltrates or pulmonary\n nodules. No atelectases are noted. There is no evidence of pleural effusion.\n The cardiac silhouette is slightly enlarged and stable compared to prior x-\n rays. There is tortuosity of the thoracic aorta. A left subclavian line is\n present with tip in the upper aspect of the superior vena cava at the level of\n the azygos vein. There is no evidence of pneumothorax.\n\n IMPRESSION:\n 1. Left subclavian line. No pneumothorax. No acute cardiopulmonary process.\n\n 2. Cardiomegaly\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-12-04 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1052463,
"text": ", C. NSURG SICU-B 10:54 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: evaluate\n Admitting Diagnosis: BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with\n REASON FOR THIS EXAMINATION:\n evaluate\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n No significant change in size of cyst or intraventricular hemorrhage.\n Continued small subarachnoid hemorrhage in bilateral sylvian fissures.\n Decrease in degree of hemorrhage in cyst or third ventricle, and decreased\n pneumocephalus.\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-12-16 00:00:00.000",
"description": "CHEST (SINGLE VIEW)",
"row_id": 1054349,
"text": " 6:44 AM\n CHEST (SINGLE VIEW) Clip # \n Reason: Questioned aspiration\n Admitting Diagnosis: BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with acute desaturations and icreased sputum production.\n REASON FOR THIS EXAMINATION:\n Questioned aspiration\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JKSd 11:28 AM\n Lungs clear with no evidence of aspiration. Increase in heart size since\n prior study.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 65-year-old man with acute desaturations and increased sputum\n production. Question aspiration.\n\n COMPARISON: Multiple chest radiographs, most recent of .\n\n TECHNIQUE: Portable AP view of the chest.\n\n FINDINGS: The left-sided central venous line ends at the upper SVC,\n unchanged. The lungs appear clear bilaterally with no evidence of aspiration/\n pneumonia. There are no pleural effusions or pneumothorax. The heart size\n has increased since prior study. The mediastinal silhouette is stable.\n\n IMPRESSION:\n 1. Clear lungs with no evidence of aspiration.\n 2. Increase in heart size since prior study.\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-12-16 00:00:00.000",
"description": "CHEST (SINGLE VIEW)",
"row_id": 1054350,
"text": ", C. NSURG FA11 6:44 AM\n CHEST (SINGLE VIEW) Clip # \n Reason: Questioned aspiration\n Admitting Diagnosis: BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with acute desaturations and icreased sputum production.\n REASON FOR THIS EXAMINATION:\n Questioned aspiration\n ______________________________________________________________________________\n PFI REPORT\n Lungs clear with no evidence of aspiration. Increase in heart size since\n prior study.\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-12-08 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1053108,
"text": " 9:43 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: please evaluate for hydrocephalus\n Admitting Diagnosis: BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with cyst, IVH\n REASON FOR THIS EXAMINATION:\n please evaluate for hydrocephalus\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 12:06 PM\n 1. Interval increase in left extra-axial frontal collection, with local mass\n effect.\n\n 2. Stable extent of intraventricular and trace subarachnoid hemorrhage.\n\n 3. Stable size and configuration of the cystic dilatation in the suprasellar\n cistern.\n ______________________________________________________________________________\n FINAL REPORT\n HEAD CT WITHOUT INTRAVENOUS CONTRAST\n\n INDICATION: 65-year-old man with intraventricular hemorrhage, cyst. Evaluate\n for hydrocephalus.\n\n COMPARISON: Multiple prior studies, most recent dated .\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: Hypodense left extra-axial collection has increased in size,\n measuring now 13 mm in maximal thickness. There is increased local mass\n effect on subjacent sulci, but no significant change in configuration of\n midline structures. Intraventricular hemorrhage is minimally decreased,\n particularly in the right occipital . The size and configuration of the\n ventricles is unchanged compared to the most recent prior study. A cyst-\n like dilatation of the suprasellar cistern is also similar in size and\n configuration. Ventriculostomy tube remains present, terminating in the\n prepontine portion of the cyst. Trace subarachnoid hemorrhage in the posterior\n right frontal lobe is unchanged.\n\n Imaged paranasal sinuses are clear, with the exception of left maxillary\n retention cyst. Imaged osseous structures demonstrate burr hole in the left\n frontal bone.\n\n IMPRESSION:\n 1. Increased left frontal extra-axial hypodense collection with local mass\n effect on the subjacent sulci.\n\n 2. Similar or minimally decreased intraventricular hemorrhage.\n\n 3. Stable appearance of cystic dilatation of the suprasellar cistern.\n\n (Over)\n\n 9:43 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: please evaluate for hydrocephalus\n Admitting Diagnosis: BLEED\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Nursing",
"chartdate": "2146-12-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 548948,
"text": "Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Temp max 101.1, vanco level 7.1, continues on vanco, ampiciilln,\n meropenum , wbc 8.1, no growth with urine cx, previous blood cx\ns still\n pending\n Action:\n Vanco increased to tid, given Tylenol q 6 per \n Response:\n Pt continues to have temp of 100.6 axillary, started on vanco tid.\n Plan:\n Monitor temp curve, check cx results, continue with Tylenol q 6, check\n vanco trough tomorrow see orders\n Hypertension, benign\n Assessment:\n Systolic b/p > 150 at beginning of shift, NP pt range\n increased to <150, pt given am hypertensive meds and also extubated\n after which systolic b/p decreased and nicardipine gtt off then later\n in afternoon 1330 pt b/p increased to 160 range\n Action:\n Restarted on nicardipine gtt titrated up to 3mcg, given 1400\n hypertensives at 1330.\n Response:\n Systolic b/p continued to inc at 1630 and pt was given hydralzine 10\n mg iv per prn orders, current b/p 152, nicardipine gtt at 2mcg\n Plan:\n Continue with nicardipine gtt to maintain systoic b/p <150, pmedicate\n with prn hydralzine if needed\n Intracerebral hemorrhage (ICH)\n Assessment:\n Pt extubated at 830, pt alert thru day, inconsistently following\n commands, wiggles toes on left foot, will marginally stick out tongue,\n pupils 4mm and reactive , inconsistently nodding yes and no,\n inconsistently answering voice is garbled and low. Rust colored\n oozing from surgical site in head, drsg by \n Action:\n Np contact due to head drsg with from incisional site\n ( rust colored), NP cane and placed 3 additional stitches to\n site and new drsg . Neuro checks q 2, pt given emotional support\n and encouragement, reoriented to time and place and situation, updated\n sister on pt condition\n Response:\n Pt continues to inconsistently respond during neuro checks, no\n agitation noted, seems compliant and under no stress. No further\n from incisional site noted, pulsation present which is normal\n Plan:\n Continue with neuro checks q 2, cont with emotional support and\n encouragement\n .H/O respiratory failure, acute (not ARDS/)\n Assessment:\n Pt extubated at 830\n Action:\n Placed on 50% face tent,\n Response:\n Rr teens to 20, sats 99% ls clear, pt needs to be encouraged to DB&C\n Plan:\n Continue to monitor resp status, check abg\n"
},
{
"category": "Physician ",
"chartdate": "2146-12-04 00:00:00.000",
"description": "Intensivist Note",
"row_id": 549112,
"text": "SICU\n HPI:\n 65M w/sudden onset HA on am of went into bathroom and fell to\n ground; parents found him to be unresponsive and taken to OSH; then\n txfr to . found to have massive IVH, s/p Lt Burr hole W EVD\n placement now s/p cyst aspiration \n Chief complaint:\n massive IVH\n PMHx:\n Asperger's\n Current medications:\n 24 Hour Events:\n Post operative day:\n POD#10 - Left burr hole with placement of ventriculostomy drain\n POD#3 - Endoscopic cysto ventriculostomy\n 24hr events: NPH added 15/15, hydral incr for HTN. Meropenem to be D/C\n on sunday, sig drainage on head dressing neurosx aware\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 01:05 AM\n Vancomycin - 01:06 AM\n Ampicillin - 02:15 AM\n Infusions:\n Nicardipine - 1 mcg/Kg/min\n Other ICU medications:\n Hydralazine - 08:00 PM\n Famotidine (Pepcid) - 08:09 PM\n Heparin Sodium (Prophylaxis) - 12:38 AM\n Other medications:\n Flowsheet Data as of 05:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.3\nC (101\n T current: 37.7\nC (99.8\n HR: 91 (80 - 111) bpm\n BP: 147/65(90) {107/51(69) - 168/99(111)} mmHg\n RR: 26 (25 - 34) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 69.6 kg (admission): 75 kg\n Total In:\n 3,983 mL\n 779 mL\n PO:\n Tube feeding:\n 1,320 mL\n 281 mL\n IV Fluid:\n 2,438 mL\n 497 mL\n Blood products:\n Total out:\n 3,047 mL\n 620 mL\n Urine:\n 3,047 mL\n 620 mL\n NG:\n Stool:\n Drains:\n Balance:\n 936 mL\n 159 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SPO2: 100%\n ABG: ///28/\n Physical Examination\n General Appearance: tachypneic\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: drainage around cystectomy site\n Neurologic: (Responds to: Verbal stimuli, Tactile stimuli, Noxious\n stimuli), Moves all extremities, track w/ eyes on verbal stimuli. UE\n inconsistently withdrawal to noxious. LE withdrawal to noxious\n Labs / Radiology\n 249 K/uL\n 10.3 g/dL\n 119 mg/dL\n 0.6 mg/dL\n 28 mEq/L\n 3.6 mEq/L\n 19 mg/dL\n 105 mEq/L\n 139 mEq/L\n 28.2 %\n 10.2 K/uL\n [image002.jpg]\n 02:12 AM\n 09:23 PM\n 02:58 AM\n 04:00 AM\n 02:20 AM\n 11:46 AM\n 02:48 AM\n 03:08 AM\n 12:00 PM\n 03:25 AM\n WBC\n 7.6\n 7.9\n 9.4\n 7.5\n 8.5\n 8.3\n 10.2\n Hct\n 31.5\n 31.1\n 32.5\n 30.9\n 31.1\n 28.9\n 28.2\n Plt\n 169\n 164\n 187\n 182\n 178\n 197\n 249\n Creatinine\n 0.6\n 0.7\n 0.6\n 0.5\n 0.5\n 0.6\n 0.6\n TCO2\n 28\n Glucose\n 155\n 177\n 103\n 116\n 109\n 111\n 119\n 119\n Other labs: PT / PTT / INR:15.5/24.9/1.4, Lactic Acid:0.7 mmol/L,\n Albumin:3.8 g/dL, Ca:8.0 mg/dL, Mg:2.4 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n IMPAIRED SKIN INTEGRITY, FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA,\n PYREXIA), .H/O RESPIRATORY FAILURE, ACUTE (NOT ARDS/), PROBLEM\n - ENTER DESCRIPTION IN COMMENTS, INTRACEREBRAL HEMORRHAGE (ICH),\n HYPERTENSION, BENIGN\n Assessment and Plan: 65M found to have massive IVH, s/p Lt Burr hole W\n EVD placement now s/p cyst aspiration \n Neurologic: Neuro checks Q: 2 hr, s/p cyst aspiration in OR , f/u\n neurosurg re wound drainage\n Cardiovascular: keep SBP<150, on PO\n lopressor/amlodipine/hydralazine/nimotop; requiring to be placed back\n on nicardipine gtt\n Pulmonary: supplementary oxygen\n Gastrointestinal / Abdomen: tube feeds\n Nutrition: Tube feeding, DHT orally\n Renal: Foley, Adequate UO; lyte repletion\n Hematology: stable\n Endocrine: RISS, NPH 15/15 - sugars improved on regimen\n Infectious Disease: for suspected sinusitis to end ; Vanc/Amp\n for meningitis coverage. f/u cxs\n Lines / Tubes / Drains: Foley, Dobhoff, Aline, left subclavian TLC\n Wounds: head would w/ sig drainage - f/u neurosurg; maintain head\n elevation\n Imaging:\n Fluids: KVO\n Consults: Neuro surgery\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 08:16 AM 55 mL/hour\n Glycemic Control: Regular insulin sliding scale, NPH\n Lines:\n Arterial Line - 06:44 PM\n Multi Lumen - 06:00 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition: ICU\n Total time spent: 30 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2146-12-03 00:00:00.000",
"description": "Intensivist Note",
"row_id": 549032,
"text": "SICU\n HPI:\n HPI: 65M w/sudden onset HA on am of went into bathroom and fell\n to ground; parents found him to be unresponsive and taken to OSH; then\n txfr to . found to have massive IVH, s/p Lt Burr hole W EVD\n placement now s/p cyst aspiration \n Chief complaint:\n headache\n PMHx:\n PMH/PSH: , mother; denies any\n cardiac/respiratory/cancer\n Current medications:\n 1. 2. 3. Acetaminophen 4. Amlodipine 5. Ampicillin 6. Bisacodyl 7.\n Calcium Gluconate 8. Chlorhexidine Gluconate 0.12% Oral Rinse\n 9. Docusate Sodium (Liquid) 10. Famotidine 11. HYDROmorphone (Dilaudid)\n 12. Heparin 13. HydrALAzine\n 14. HydrALAzine 15. Insulin 16. Influenza Virus Vaccine 17.\n LeVETiracetam 18. Lidocaine 1% 19. Magnesium Sulfate\n 20. Meropenem 21. Metoprolol Tartrate 22. NiCARdipine 23. Nimodipine\n 24. Nystatin Oral Suspension\n 25. Pneumococcal Vac Polyvalent 26. Potassium Chloride 27. Propofol 28.\n Senna 29. Sodium Chloride 0.9% Flush\n 30. Sodium Chloride 0.9% Flush 31. Vancomycin\n 24 Hour Events:\n EXTUBATION - At 08:30 AM\n FEVER - 101.2\nF - 12:00 AM\n : +Corneals/+swallowing, Pupils symmetric in size, Lt3mm MR, spont\n mvmt on LUE/LLE, no spont mvmt of Rt side. Taken to or for EVD\n placement with burr hole and returned, MRI obtained, improving neuro\n exam by the morning\n : MRI done but unable to determine vascular cause of bleed, CTA\n Head done, prelim read below. remained intubated until neurosurg;\n nicardipine gtt\n : started lopressor PO, bolused dilantin\n : started Replete with fiber; pt with fevers/copious secretions,\n clear CXR and CT head/sinus with sinus changes and persistant\n hemorrhage but decrease in size of IVH - started vanco/ for\n suspected sinusitis, NGT->oral dobhoff, Sputum cx; dilantin bolused and\n dose increased; central line placed for access\n : family meeting held - DNR status; increased lopressor; added\n nystatin; plan for cyst aspiration with AM MRI Thursday as prelude, NSG\n no SQH at this time; following up on cultures - continuing to be\n febrile\n : VitK, incr lopressor, CT head/C-spine, ETT repositioned; o/n\n temp 103, pancx/CXR; ICP 20-23 intermittently, neurosurg aware.\n Nicardipine gtt restarted.\n : cont fevers, Vanc DC'd, started amlodipine, incr lopressor\n : organ bank called, will call back after surgery done and\n prognosis better known; to OR, EVD taken out, cyst aspirated, CT\n afterwards OK by report; social work working on getting court appointed\n guardian; started po hydralazine\n : pan cx'd for fever, extubated, SQH started, RISS improved,\n collar removed; added nimotop to come off nimodipine\n Post operative day:\n POD#9 - Left burr hole with placement of ventriculostomy drain\n POD#2 - Endoscopic cysto ventriculostomy\n : +Corneals/+swallowing, Pupils symmetric in size, Lt3mm MR, spont\n mvmt on LUE/LLE, no spont mvmt of Rt side. Taken to or for EVD\n placement with burr hole and returned, MRI obtained, improving neuro\n exam by the morning\n : MRI done but unable to determine vascular cause of bleed, CTA\n Head done, prelim read below. remained intubated until neurosurg;\n nicardipine gtt\n : started lopressor PO, bolused dilantin\n : started Replete with fiber; pt with fevers/copious secretions,\n clear CXR and CT head/sinus with sinus changes and persistant\n hemorrhage but decrease in size of IVH - started vanco/ for\n suspected sinusitis, NGT->oral dobhoff, Sputum cx; dilantin bolused and\n dose increased; central line placed for access\n : family meeting held - DNR status; increased lopressor; added\n nystatin; plan for cyst aspiration with AM MRI Thursday as prelude, NSG\n no SQH at this time; following up on cultures - continuing to be\n febrile\n : VitK, incr lopressor, CT head/C-spine, ETT repositioned; o/n\n temp 103, pancx/CXR; ICP 20-23 intermittently, neurosurg aware.\n Nicardipine gtt restarted.\n : cont fevers, Vanc DC'd, started amlodipine, incr lopressor\n : organ bank called, will call back after surgery done and\n prognosis better known; to OR, EVD taken out, cyst aspirated, CT\n afterwards OK by report; social work working on getting court appointed\n guardian; started po hydralazine\n : pan cx'd for fever, extubated, SQH started, RISS improved,\n collar removed; added nimotop to come off nimodipine\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 12:32 AM\n Meropenem - 12:32 AM\n Ampicillin - 02:18 AM\n Infusions:\n Nicardipine - 2 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 AM\n Hydralazine - 08:15 PM\n Heparin Sodium (Prophylaxis) - 12:32 AM\n Other medications:\n Flowsheet Data as of 05:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.4\nC (101.2\n T current: 36.7\nC (98.1\n HR: 92 (84 - 112) bpm\n BP: 150/54(82) {119/46(69) - 160/66(91)} mmHg\n RR: 25 (17 - 31) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 66.6 kg (admission): 75 kg\n Total In:\n 4,019 mL\n 860 mL\n PO:\n Tube feeding:\n 1,231 mL\n 272 mL\n IV Fluid:\n 2,472 mL\n 543 mL\n Blood products:\n Total out:\n 3,355 mL\n 435 mL\n Urine:\n 3,355 mL\n 435 mL\n NG:\n Stool:\n Drains:\n Balance:\n 664 mL\n 425 mL\n Respiratory support\n O2 Delivery Device: Face tent\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 515 (515 - 515) mL\n PS : 5 cmH2O\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 50%\n SPO2: 100%\n ABG: ///27/\n Ve: 8 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli, Tactile stimuli, Noxious stimuli), Moves\n all extremities\n Labs / Radiology\n 197 K/uL\n 10.4 g/dL\n 111 mg/dL\n 0.5 mg/dL\n 27 mEq/L\n 3.3 mEq/L\n 18 mg/dL\n 105 mEq/L\n 139 mEq/L\n 28.9 %\n 8.3 K/uL\n [image002.jpg]\n 02:18 AM\n 02:02 AM\n 02:12 AM\n 09:23 PM\n 02:58 AM\n 04:00 AM\n 02:20 AM\n 11:46 AM\n 02:48 AM\n 03:08 AM\n WBC\n 5.3\n 7.6\n 7.9\n 9.4\n 7.5\n 8.5\n 8.3\n Hct\n 30.4\n 31.5\n 31.1\n 32.5\n 30.9\n 31.1\n 28.9\n Plt\n 156\n 169\n 164\n 187\n 182\n 178\n 197\n Creatinine\n 0.7\n 0.6\n 0.7\n 0.6\n 0.5\n 0.5\n TCO2\n 28\n 28\n Glucose\n 122\n 155\n 177\n 103\n 116\n 109\n 111\n Other labs: PT / PTT / INR:15.5/24.9/1.4, Lactic Acid:0.7 mmol/L,\n Albumin:3.8 g/dL, Ca:8.0 mg/dL, Mg:2.5 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n IMPAIRED SKIN INTEGRITY, FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA,\n PYREXIA), .H/O RESPIRATORY FAILURE, ACUTE (NOT ARDS/), PROBLEM\n - ENTER DESCRIPTION IN COMMENTS, INTRACEREBRAL HEMORRHAGE (ICH),\n HYPERTENSION, BENIGN\n Assessment and Plan: 65M w/sudden onset HA on am of went into\n bathroom and fell to ground; parents found him to be unresponsive and\n taken to OSH; then txfr to . found to have massive IVH, s/p Lt\n Burr hole W EVD placement now s/p cyst aspiration \n Neurologic: Neuro checks Q: 2 hr, s/p cyst aspiration in OR , q2hr\n neuro checks\n Cardiovascular: Beta-blocker, keep SBP<140, on PO\n lopressor/amlodipine/hydralazine/nimotop, wean nicardipine GTT;\n hydralazine prn; dilaudid for pain. Added oral calcium channel\n blocker. Increase hydralazine.\n Pulmonary: IS, extubated, wean supplementary oxygen\n Gastrointestinal / Abdomen: TF - advance to goal 70/hr, H2B\n Nutrition: Tube feeding, TF - advance to goal 70/hr, H2B\n Renal: Foley, Adequate UO\n Hematology: Serial Hct\n Endocrine: RISS. Add Nph insulin.\n Infectious Disease: Check cultures, continues to be febrile but WBC\n wnl, cultures pending, on for suspected sinusitis, started\n Vanc/Amp for meningitis coverage.\n Lines / Tubes / Drains: foley, Dobhoff, Aline, left subclavian TLC\n Wounds: Dry dressings\n Imaging: no imaging today\n Fluids: KVO\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS), (Respiratory distress:\n Insufficiency / Post-op)\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 04:43 PM 55 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 06:44 PM\n Multi Lumen - 06:00 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: DNR / DNI\n Disposition: ICU\n Total time spent:\n Patient is critically ill\n"
},
{
"category": "Respiratory ",
"chartdate": "2146-11-25 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 547823,
"text": "Demographics\n Day of mechanical ventilation: 2\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Known difficult intubation: Yes\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: Suctioned / None\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n MRI\n 0200\n without incident\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Nutrition",
"chartdate": "2146-11-25 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 547942,
"text": "Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 177 cm (est)\n 75 kg\n 23.7\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 75.3\n 100%\n Diagnosis: bleed\n PMH : unknown\n Food allergies and intolerances: NKFA\n Pertinent medications: nicardipine, NS w/ KCl, RISS, IV abx,\n pantoprazole, others noted\n Labs:\n Value\n Date\n Glucose\n 127 mg/dL\n 01:31 PM\n Glucose Finger Stick\n 146\n 10:00 AM\n BUN\n 17 mg/dL\n 04:00 AM\n Creatinine\n 1.0 mg/dL\n 04:00 AM\n Sodium\n 140 mEq/L\n 04:00 AM\n Potassium\n 3.8 mEq/L\n 04:00 AM\n Chloride\n 109 mEq/L\n 04:00 AM\n TCO2\n 23 mEq/L\n 04:00 AM\n PO2 (arterial)\n 182 mm Hg\n 01:31 PM\n PCO2 (arterial)\n 37 mm Hg\n 01:31 PM\n pH (arterial)\n 7.43 units\n 01:31 PM\n CO2 (Calc) arterial\n 25 mEq/L\n 01:31 PM\n Albumin\n 4.1 g/dL\n 09:21 PM\n Calcium non-ionized\n 8.5 mg/dL\n 04:00 AM\n Phosphorus\n 3.9 mg/dL\n 04:00 AM\n Ionized Calcium\n 1.16 mmol/L\n 01:31 PM\n Magnesium\n 2.4 mg/dL\n 04:00 AM\n Phenytoin (Dilantin)\n 10.4 ug/mL\n 09:21 PM\n WBC\n 10.6 K/uL\n 04:00 AM\n Hgb\n 12.2 g/dL\n 04:00 AM\n Hematocrit\n 33.2 %\n 04:00 AM\n Current diet order / nutrition support: NPO\n GI: tender, +BS\n Assessment of Nutritional Status\n At risk for malnutrition\n Pt at risk due to: NPO / hypocaloric diet\n Estimated Nutritional Needs\n Calories: 1875-2100 ( 25-28 cal/kg)\n Protein: 90-113 (1.2-1.5 g/kg)\n Fluid: per team\n Estimation of previous intake: likely adequate\n Estimation of current intake: Inadequate\n Specifics: 65 year old male found unresponsive by family intubated at\n OSH and head CT showed massive ICh with ventricles, pt transferred to\n . Pt underwent burrhole and ventriculostomy drain placement on\n . Propofol stopped this am for extubation. Recommend initiating\n enteral nutrition if diet cannot be advanced in next 48-72 hours. TF\n recs below.\n Medical Nutrition Therapy Plan - Recommend the Following\n Recommend Replete with Fiber @ 15 ml/hr advance by 20 ml/hr q 6hrs to\n goal of 75 ml/hr (1800 kcals/ 112g pro)\n Check residuals q 4hrs hold if >150\n Monitor lytes and BS with start of TF\n Multivitamin / Mineral supplement: via TF\n Check chemistry 10 panel daily\n Will follow pls page with questions \n"
},
{
"category": "Nursing",
"chartdate": "2146-11-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 548230,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n On propofol gtt for sedation.\n Arouses sluggishly and intermittently to tactile stimuli when propofol\n is decreased. Localizes to pain w/ slight movement on bed. No eye\n opening. Does not follow commands.\n PERRLA at 3-4 with Sluggish response in Am returning to brisk by\n afternoon.\n Left ventricular drain continues to be open. Draining bloody drainage\n ~5-10ML hr. Clots present in drainage system\n ICP 11-13 and CPP 60-90s. Dilantin level 6.6 this am.\n No seizure activity noted.\n J collar in\n place.\n Action:\n Nicardipine gtt titrated to keep SBP 140-160. Propofol gtt titrated for\n sedation.\n Neuro checks changed to Q2 hr. Team notified re: .\n Dilantin bolus given.\n Response:\n SBP 140-160s\n Sedated and sluggish response when propofol off for neuro checks\n Remains in J for cspine precautions\n Plan:\n Continue to monitor\n q1h neuro checks\n Ineffective Airway Maintenance\n Assessment:\n Remains intubated. Comfortable on CPAP+PS 5/5 40%. Sats 100%\n LS scattered rhonci clears w/ suctioning.\n Suctioning copius thick yellow/ secretions.\n CXR clear\n Action:\n Suctioned as needed.\n Sinus ct done\n Response:\n LS cleared after suctioning .Sats remain 100%.\n Ct showed sinus wall thickening. Vanco/ meropenem ordered.\n Left subclavian TLC placed for access for multi gtt\n CXR taken to confirm placement.\n Plan:\n Continue pulm hygiene.\n Follow up CXR to confirm line placement.\n Start ABX as ordered.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n T-MAX 101.5.\n Action:\n Tylenol elixir 650mg given\n Team notified\n Response:\n Remains febrile 101.1\n Plan:\n Continue to monitor temp\n Tylenol as needed.\n BC once TLC placement confirmed.\n"
},
{
"category": "Physician ",
"chartdate": "2146-11-26 00:00:00.000",
"description": "Intensivist Note",
"row_id": 548004,
"text": "SICU\n HPI:\n 65M w/sudden onset HA on am of went into bathroom and fell to\n ground; parents found him to be unresponsive and taken to OSH;then txfr\n to . Found to have large central IPH\n Chief complaint:\n large central IPH\n PMHx:\n Unknown by family\n Current medications:\n 24 Hour Events:\n INTUBATION - At 06:25 PM\n recieved intubated from OR\n INVASIVE VENTILATION - START 06:25 PM\n OR RECEIVED - At 06:37 PM\n ARTERIAL LINE - START 06:44 PM\n ICP CATHETER - START 06:44 PM\n MAGNETIC RESONANCE IMAGING - At 02:00 AM\n Post operative day:\n POD#2 - Left burr hole with placement of ventriculostomy drain\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 09:32 PM\n Infusions:\n Nicardipine - 1 mcg/Kg/min\n Propofol - 30 mcg/Kg/min\n Other ICU medications:\n Hydralazine - 05:16 AM\n Pantoprazole (Protonix) - 11:17 PM\n Dilantin - 12:05 AM\n Other medications:\n Flowsheet Data as of 03:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.8\nC (100.1\n T current: 37.2\nC (98.9\n HR: 106 (79 - 106) bpm\n BP: 171/67(102) {107/54(74) - 171/73(105)} mmHg\n RR: 19 (12 - 22) insp/min\n SPO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n ICP: 12 (5 - 16) mmHg\n Total In:\n 2,710 mL\n 354 mL\n PO:\n Tube feeding:\n IV Fluid:\n 2,710 mL\n 354 mL\n Blood products:\n Total out:\n 2,507 mL\n 435 mL\n Urine:\n 2,228 mL\n 400 mL\n NG:\n Stool:\n Drains:\n 279 mL\n 35 mL\n Balance:\n 203 mL\n -81 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 433 (400 - 442) mL\n PS : 5 cmH2O\n RR (Set): 12\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 65\n PIP: 11 cmH2O\n Plateau: 18 cmH2O\n Compliance: 48 cmH2O/mL\n SPO2: 100%\n ABG: 7.43/37/187/23/1\n Ve: 7 L/min\n PaO2 / FiO2: 468\n Physical Examination\n General Appearance: intubated, sedated, C-\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: No(t) Moves all extremities, (RUE: Weakness), (LUE:\n Weakness), (RLE: Weakness), (LLE: Weakness), Sedated, intubated and\n sedated, seen moving all 4 ext weakly\n Labs / Radiology\n 185 K/uL\n 12.2 g/dL\n 127 mg/dL\n 1.0 mg/dL\n 23 mEq/L\n 3.8 mEq/L\n 17 mg/dL\n 109 mEq/L\n 140 mEq/L\n 33.2 %\n 10.6 K/uL\n [image002.jpg]\n 05:42 PM\n 05:44 PM\n 09:21 PM\n 04:00 AM\n 04:31 AM\n 01:31 PM\n 02:45 AM\n WBC\n 12.5\n 10.6\n Hct\n 41\n 38\n 33.6\n 33.2\n Plt\n 225\n 185\n Creatinine\n 1.0\n 1.0\n TCO2\n 24\n 23\n 24\n 25\n 25\n Glucose\n 128\n 120\n 131\n 150\n 147\n 127\n Other labs: PT / PTT / INR:15.5/24.9/1.4, Lactic Acid:1.0 mmol/L,\n Albumin:4.1 g/dL, Ca:8.5 mg/dL, Mg:2.4 mg/dL, PO4:3.9 mg/dL\n Imaging: : MR : IMPRESSION:\n 1. Extensive intraventricular hemorrhage involving all the ventricles\n as\n described above, predominantly in the acute stage with a small subacute\n component.\n 2. Obstructive hydrocephalus, with dilatation of the left lateral\n ventricle\n and moderate on the right.\n 2. While there is no obvious abnormal enhancement noted within the area\n of\n hemorrhage, small neoplastic or vascular causes within the ventricles\n cannot\n be excluded. Repeat evaluation can be considered after evacuation or\n resolution of the hematoma.\n 3. Subarachnoid hemorrhage, in both cerebral hemispheres.\n Given the presence of intraventricular and subarachnoid hemorrhage,\n patient\n needs further evaluation to exclude a vascular cause like an aneurysm\n by CT\n angiogram. The intracranial arteries are not adequately assessed on the\n present study. Displacement of the right internal carotid artery\n termination\n and the anterior cerebral arteries on both sides related to the\n enlarged\n ventricles is noted.\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS, INTRACEREBRAL HEMORRHAGE\n (ICH), HYPERTENSION, BENIGN\n Assessment and Plan: 65M p/w massive central IPH\n Neurologic: Neuro checks Q: 1 hr, ICP monitor, q1hr neuro checks,\n propofol gtt, dilantin, MRI head inconclusive re source of bleed, EVD@\n 15cm open; f/ read CTA head, f/u neurosx re plans\n Cardiovascular: keep SBP<150, cont nicardipine gtt to meet goals\n Pulmonary: (Ventilator mode: CPAP + PS), intubated, on CPAP 5/5; f/u\n with neurosurg re when it's okay to extubate\n Gastrointestinal / Abdomen: NGT in place, NPO for now\n Nutrition: NPO\n Renal: Foley, no active issues\n Hematology: stable HCT\n Endocrine: RISS\n Infectious Disease: no active issues. cefazolin while EVD in place\n Lines / Tubes / Drains: Foley, NGT, ETT, EVD\n Wounds:\n Imaging:\n Fluids: NS, Potassium Chloride\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS), (Respiratory distress: Failure)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 06:44 PM\n ICP Catheter - 06:44 PM\n 18 Gauge - 12:59 PM\n 20 Gauge - 08:35 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 34 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2146-11-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 548157,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Left ventricular head in drain in place\n On propofol gtt and titrated for sedation\n Pupils react sluggishly size bilaterally.\n Sluggishly moves extremties on the bed and to command. Dr aware and\n in to see pt.\n Icp 11-15 draining bloody driainage. Episode of icp increasing to 20 dr\n at the bedside. Drainage bloody. Drain system checked and pt\n turned. Icp down to 11-12.\n j collar in place.\n Action:\n Logroll while turning.\n Propofol and nicardipine gtt titrated.\n Dilantin iv given q8hrs and level checked.\n Neuro signs q1hrs.\n j collar in place.\n Response:\n Bp goal 140-160 propofol gtt and nicardipine gtt nfusing and\n titrated. Vent drain cont to drain bloody drainage\n Plan:\n Monitor neuro status closely. ? head ct.\n .H/O respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains orally intubated. O2sats 100%. Suctioned for thick yellow\n white sputum. Wbc 11.5 temp 101.2 resp rate 15-22.\n Action:\n Abg\ns done as ordered. Suctioned prn. Vap mouth care q4hrs. chest xray\n done and results pending.\n Response:\n stable\n Plan:\n Monitor resp status and ? extubate today.\n"
},
{
"category": "Physician ",
"chartdate": "2146-11-27 00:00:00.000",
"description": "Intensivist Note",
"row_id": 548159,
"text": "TITLE:\n SICU\n HPI:\n 65M w/sudden onset HA on am of went into bathroom and fell to\n ground; parents found him to be unresponsive and taken to OSH;then txfr\n to \n Chief complaint:\n lethargy\n PMHx:\n mother; denies any cardiac/respiratory/cancer\n : Unknonwn\n Current medications:\n 20 mEq Potassium Chloride / 1000 mL NS 3. Acetaminophen 4. Bisacodyl 5.\n CefazoLIN 6. Chlorhexidine Gluconate 0.12% Oral Rinse 7. Docusate\n Sodium (Liquid) 8. Famotidine 9. HYDROmorphone (Dilaudid) 10. Insulin\n 11. Influenza Virus Vaccine 12. Magnesium Sulfate 13. Metoprolol\n Tartrate 14. NiCARdipine 15. Phenytoin 16. Phenytoin 17. Pneumococcal\n Vac Polyvalent 18. Propofol 19. Senna 20. Sodium Chloride 0.9% Flush\n 24 Hour Events:\n FEVER - 101.2\nF - 04:00 AM\n incr beta blocker, extrabolus dilantin, drain temporarily occluded\n overnight\n Post operative day:\n POD#3 - Left burr hole with placement of ventriculostomy drain\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 04:50 AM\n Infusions:\n Nicardipine - 1.2 mcg/Kg/min\n Propofol - 30 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 09:53 PM\n Dilantin - 12:19 AM\n Other medications:\n Flowsheet Data as of 06:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.4\nC (101.2\n T current: 38.4\nC (101.2\n HR: 99 (83 - 111) bpm\n BP: 145/61(89) {131/56(81) - 176/71(106)} mmHg\n RR: 18 (16 - 21) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n ICP: 11 (5 - 17) mmHg\n Total In:\n 2,927 mL\n 705 mL\n PO:\n Tube feeding:\n IV Fluid:\n 2,777 mL\n 705 mL\n Blood products:\n Total out:\n 3,002 mL\n 579 mL\n Urine:\n 2,740 mL\n 500 mL\n NG:\n Stool:\n Drains:\n 262 mL\n 79 mL\n Balance:\n -75 mL\n 126 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 450 (412 - 671) mL\n PS : 5 cmH2O\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 35\n PIP: 11 cmH2O\n SPO2: 100%\n ABG: 7.45/29/196/25/-1\n Ve: 7.5 L/min\n PaO2 / FiO2: 490\n Physical Examination\n General Appearance: No acute distress, Well nourished\n HEENT: PERRL, pupils sluggish bilaterally\n Cardiovascular: (Rhythm: Regular), (Murmur: No(t) Systolic, No(t)\n Diastolic)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: 1+), (Temperature: Warm)\n Right Extremities: (Edema: 1+), (Temperature: Warm)\n Skin: No(t) Rash: , No(t) Jaundice\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities, Sedated, responds but quite sluggishly\n Labs / Radiology\n 228 K/uL\n 11.0 g/dL\n 110 mg/dL\n 0.7 mg/dL\n 25 mEq/L\n 3.9 mEq/L\n 11 mg/dL\n 109 mEq/L\n 140 mEq/L\n 31.3 %\n 11.5 K/uL\n [image002.jpg]\n 05:42 PM\n 05:44 PM\n 09:21 PM\n 04:00 AM\n 04:31 AM\n 01:31 PM\n 02:35 AM\n 02:45 AM\n 03:22 AM\n 04:49 AM\n WBC\n 12.5\n 10.6\n 10.6\n 11.5\n Hct\n 41\n 38\n 33.6\n 33.2\n 32.2\n 31.3\n Plt\n 28\n Creatinine\n 1.0\n 1.0\n 0.7\n 0.7\n TCO2\n 24\n 23\n 24\n 25\n 25\n 21\n Glucose\n 128\n 120\n 131\n 150\n 147\n 127\n 137\n 110\n Other labs: PT / PTT / INR:15.5/24.9/1.4, Lactic Acid:0.7 mmol/L,\n Albumin:3.8 g/dL, Ca:8.1 mg/dL, Mg:2.3 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n .H/O RESPIRATORY FAILURE, ACUTE (NOT ARDS/), PROBLEM - ENTER\n DESCRIPTION IN COMMENTS, INTRACEREBRAL HEMORRHAGE (ICH), HYPERTENSION,\n BENIGN\n Assessment and Plan: 65M w/sudden onset HA on am of went into\n bathroom and fell to ground; parents found him to be unresponsive and\n taken to OSH;then txfr to , found to have massive central IVH\n Neurologic: q1hr neuro checks, propofol, dilantin-f/u lvl, EVD@ 15cm\n open; extubate AM. Neurosurge wants to wait to clear Cspine\n clinically. CTA continues to show massive hydrocephalus\n Cardiovascular: keep SBP<160, PO lopressor, wean nicardipine GTT\n Pulmonary: intubated, on CPAP 5/5; extubate \n Gastrointestinal / Abdomen: NPO for now, H2B\n Nutrition: NPO for now\n Renal: follow UOP, foley in place, no acute issues\n Hematology: stable thus far, will continue to follow in the AM\n Endocrine: RISS\n Infectious Disease: no acute issues thus far\n Lines / Tubes / Drains: foley, ETT, NGT, Aline, PIV\n Wounds: none\n Imaging: none\n Fluids: NS+20KCl@ 80cc/hr, NPO\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 06:44 PM\n ICP Catheter - 06:44 PM\n 18 Gauge - 12:59 PM\n 20 Gauge - 08:51 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2146-11-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 548321,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Arouses sluggishly to voice and tacitle stimuli.\n Does not open eyes to command.\n Moves extremities very slowly and intermittently.\n Nicardipine gtt infusijng and titrated.\n Propofol gtt titrated\n Perla . Pupils #.\n Left ventricular drain intact and draining small amt of bloody\n drainage. Small tiny clots present in tubing. Neuro team aware.\n Action:\n Nicardi;ine gtt and propofol gtt.\n Goal of bp 140-160.\n Dilantin level 98. this and iv bolus of dilantin 500mg x1\n Dilantin po increased to 200mg q8hrs.\n Neuro signs q2hrs.\n Response:\n Neuro status sluggish. Bp 140-160 with titration of nicardipine gtt and\n propofol gtt.\n Plan:\n monitor neuro status closely and update family on condition.\n"
},
{
"category": "Physician ",
"chartdate": "2146-11-28 00:00:00.000",
"description": "Intensivist Note",
"row_id": 548329,
"text": "SICU\n HPI:\n DX: MASSIVE Central IPH(spont)\n Procedure(s): :Lt Burr Hole w/EVD placement\n HPI: 65M w/sudden onset HA on am of went into bathroom and fell\n to ground; parents found him to be unresponsive and taken to OSH; then\n txfr to \n .\n PMH/PSH: mother; denies any cardiac/respiratory/cancer\n .\n : Unknonwn\n .\n EVENTS:\n : +Corneals/+swallowing, Pupils symmetric in size, Lt3mm MR, spont\n mvmt on LUE/LLE, no spont mvmt of Rt side. Taken to or for EVD\n placement with burr hole and returned, MRI obtained, improving neuro\n exam by the morning\n : MRI done but unable to determine vascular cause of bleed, CTA\n Head done, prelim read below. remained intubated until neurosurg;\n nicardipine gtt\n : started lopressor PO, bolused dilantin\n : started Replete with fiber; pt with fevers/copious secretions,\n clear CXR and CT head/sinus with sinus changes and persistant\n hemorrhage but decrease in size of IVH - started vanco/ for\n suspected sinusitis, NGT->oral dobhoff, Sputum cx; dilantin bolused and\n dose increased; central line placed for access\n .\n MICRO:\n UCx: neg\n SpCx: pending\n .\n IMAGING:\n CT head : extensive hemorrhage involving entire ventricular\n system, with transependymal migration of CSF. Left ventriculostomy\n drain placed via frontal burr hole technique, with tip satisfactorily\n terminating in the frontal of the left lateral ventricle.\n CT head presentation: Hemorrhage centered at the level of the mid brain\n with large amount of blood seen within the lateral, third, and fourth\n ventricles with associated hydrocephalus. MRI is recommended.\n : MRI HEAD: 1. Extensive intraventricular hemorrhage involving all\n the ventricles as described above, predominantly in the acute stage\n with a small subacute component. 2. Obstructive hydrocephalus, with\n dilatation of the left lateral ventricle\n and moderate on the right. 2. While there is no obvious abnormal\n enhancement noted within the area of hemorrhage, small neoplastic or\n vascular causes within the ventricles cannot be excluded. Repeat\n evaluation can be considered after evacuation or resolution of the\n hematoma. 3. Subarachnoid hemorrhage, in both cerebral hemispheres.\n CTA HEAD: 1. No evidence of aneurysm, vasospasm or occlusive\n lesion. No evidence of contrast extravasation. 2. Persistent massive\n intraventricular hemorrhage. Severe hydrocephalus, L greater than R.\n Persistent Mass effect. No evidence of subarachnoid\n hemorrhage.\n CT head: Left ventricular catheter may terminate in the left\n frontal lobe and attention to positioning is recommended. Persistent\n ventricular and subarachnoid hemorrhage.\n CT sinuses: Interval increase in mucosal thickening of all\n paranasal sinuses compared to CT of including obstruction of\n the ostiomeatal units bilaterally. Extensive nasal secretions status\n post NG tube placement\n CXR: clear\n Chief complaint:\n PMHx:\n Current medications:\n 24 Hour Events:\n MULTI LUMEN - START 06:00 PM\n BLOOD CULTURED - At 08:24 PM\n peripheral and line\n NASAL SWAB - At 02:23 AM\n FEVER - 101.5\nF - 08:00 AM\n Post operative day:\n POD#4 - Left burr hole with placement of ventriculostomy drain\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 06:59 AM\n Meropenem - 08:31 AM\n Vancomycin - 08:57 AM\n Infusions:\n Nicardipine - 1.5 mcg/Kg/min\n Propofol - 20 mcg/Kg/min\n Other ICU medications:\n Dilantin - 04:26 AM\n Famotidine (Pepcid) - 08:00 AM\n Other medications:\n Flowsheet Data as of 09:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.8\nC (101.9\n T current: 38.8\nC (101.9\n HR: 105 (81 - 107) bpm\n BP: 151/61(92) {128/50(81) - 174/93(110)} mmHg\n RR: 20 (19 - 23) insp/min\n SPO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n ICP: 11 (5 - 14) mmHg\n Total In:\n 3,452 mL\n 1,756 mL\n PO:\n Tube feeding:\n 139 mL\n IV Fluid:\n 3,272 mL\n 1,557 mL\n Blood products:\n Total out:\n 3,042 mL\n 1,290 mL\n Urine:\n 2,845 mL\n 1,220 mL\n NG:\n Stool:\n Drains:\n 197 mL\n 70 mL\n Balance:\n 410 mL\n 466 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 407 (344 - 435) mL\n PS : 5 cmH2O\n RR (Spontaneous): 20\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 83\n PIP: 10 cmH2O\n SPO2: 100%\n ABG: 7.47/38/109/26/3\n Ve: 8.4 L/min\n PaO2 / FiO2: 273\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n No(t) Moves all extremities, (RUE: Weakness), (LUE: Weakness)\n Labs / Radiology\n 177 K/uL\n 10.7 g/dL\n 111 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 3.9 mEq/L\n 13 mg/dL\n 108 mEq/L\n 141 mEq/L\n 29.2 %\n 8.8 K/uL\n [image002.jpg]\n 09:21 PM\n 04:00 AM\n 04:31 AM\n 01:31 PM\n 02:35 AM\n 02:45 AM\n 03:22 AM\n 04:49 AM\n 02:11 AM\n 02:18 AM\n WBC\n 12.5\n 10.6\n 10.6\n 11.5\n 8.8\n Hct\n 33.6\n 33.2\n 32.2\n 31.3\n 29.2\n Plt\n 28\n 177\n Creatinine\n 1.0\n 1.0\n 0.7\n 0.7\n 0.7\n TCO2\n 24\n 25\n 25\n 21\n 28\n Glucose\n 131\n 150\n 147\n 127\n 137\n 110\n 111\n Other labs: PT / PTT / INR:15.4/25.6/1.4, Lactic Acid:0.7 mmol/L,\n Albumin:3.8 g/dL, Ca:8.2 mg/dL, Mg:2.2 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA), .H/O RESPIRATORY\n FAILURE, ACUTE (NOT ARDS/), PROBLEM - ENTER DESCRIPTION IN\n COMMENTS, INTRACEREBRAL HEMORRHAGE (ICH), HYPERTENSION, BENIGN\n Assessment and Plan:\n Neurologic: Neuro checks Q: 2 hr, ICP monitor, Ventriculostomy, evd at\n 15 cm\n Cardiovascular: nicardipine gtt, goal sbp < 160, increase scheduled\n lopressor to 50\n Pulmonary: Cont ETT, (Ventilator mode: CPAP + PS), cpap 5/5, not awake\n enough to extubate\n Gastrointestinal / Abdomen: bowel regimen\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO\n Hematology: Serial Hct, stable\n Endocrine: RISS\n Infectious Disease: Vanco/ for sinusitis, wbc decreasing after Abx\n started yesterday, oral nystatin, d/c cefazolin, resend sputum\n Lines / Tubes / Drains: Foley, ETT, cvl, EVD\n Wounds:\n Imaging:\n Fluids: KVO\n Consults: Neuro surgery, Neurology\n Billing Diagnosis: CVA, (Respiratory distress: Failure)\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 12:11 AM 15 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 06:44 PM\n ICP Catheter - 06:44 PM\n 18 Gauge - 12:59 PM\n Multi Lumen - 06:00 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2146-11-28 00:00:00.000",
"description": "Intensivist Note",
"row_id": 548330,
"text": "SICU\n HPI:\n DX: MASSIVE Central IPH(spont)\n Procedure(s): :Lt Burr Hole w/EVD placement\n HPI: 65M w/sudden onset HA on am of went into bathroom and fell\n to ground; parents found him to be unresponsive and taken to OSH; then\n txfr to \n .\n PMH/PSH: mother; denies any cardiac/respiratory/cancer\n .\n : Unknonwn\n .\n EVENTS:\n : +Corneals/+swallowing, Pupils symmetric in size, Lt3mm MR, spont\n mvmt on LUE/LLE, no spont mvmt of Rt side. Taken to or for EVD\n placement with burr hole and returned, MRI obtained, improving neuro\n exam by the morning\n : MRI done but unable to determine vascular cause of bleed, CTA\n Head done, prelim read below. remained intubated until neurosurg;\n nicardipine gtt\n : started lopressor PO, bolused dilantin\n : started Replete with fiber; pt with fevers/copious secretions,\n clear CXR and CT head/sinus with sinus changes and persistant\n hemorrhage but decrease in size of IVH - started vanco/ for\n suspected sinusitis, NGT->oral dobhoff, Sputum cx; dilantin bolused and\n dose increased; central line placed for access\n .\n MICRO:\n UCx: neg\n SpCx: pending\n .\n IMAGING:\n CT head : extensive hemorrhage involving entire ventricular\n system, with transependymal migration of CSF. Left ventriculostomy\n drain placed via frontal burr hole technique, with tip satisfactorily\n terminating in the frontal of the left lateral ventricle.\n CT head presentation: Hemorrhage centered at the level of the mid brain\n with large amount of blood seen within the lateral, third, and fourth\n ventricles with associated hydrocephalus. MRI is recommended.\n : MRI HEAD: 1. Extensive intraventricular hemorrhage involving all\n the ventricles as described above, predominantly in the acute stage\n with a small subacute component. 2. Obstructive hydrocephalus, with\n dilatation of the left lateral ventricle\n and moderate on the right. 2. While there is no obvious abnormal\n enhancement noted within the area of hemorrhage, small neoplastic or\n vascular causes within the ventricles cannot be excluded. Repeat\n evaluation can be considered after evacuation or resolution of the\n hematoma. 3. Subarachnoid hemorrhage, in both cerebral hemispheres.\n CTA HEAD: 1. No evidence of aneurysm, vasospasm or occlusive\n lesion. No evidence of contrast extravasation. 2. Persistent massive\n intraventricular hemorrhage. Severe hydrocephalus, L greater than R.\n Persistent Mass effect. No evidence of subarachnoid\n hemorrhage.\n CT head: Left ventricular catheter may terminate in the left\n frontal lobe and attention to positioning is recommended. Persistent\n ventricular and subarachnoid hemorrhage.\n CT sinuses: Interval increase in mucosal thickening of all\n paranasal sinuses compared to CT of including obstruction of\n the ostiomeatal units bilaterally. Extensive nasal secretions status\n post NG tube placement\n CXR: clear\n Chief complaint:\n PMHx:\n Current medications:\n 24 Hour Events:\n MULTI LUMEN - START 06:00 PM\n BLOOD CULTURED - At 08:24 PM\n peripheral and line\n NASAL SWAB - At 02:23 AM\n FEVER - 101.5\nF - 08:00 AM\n Post operative day:\n POD#4 - Left burr hole with placement of ventriculostomy drain\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 06:59 AM\n Meropenem - 08:31 AM\n Vancomycin - 08:57 AM\n Infusions:\n Nicardipine - 1.5 mcg/Kg/min\n Propofol - 20 mcg/Kg/min\n Other ICU medications:\n Dilantin - 04:26 AM\n Famotidine (Pepcid) - 08:00 AM\n Other medications:\n Flowsheet Data as of 09:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.8\nC (101.9\n T current: 38.8\nC (101.9\n HR: 105 (81 - 107) bpm\n BP: 151/61(92) {128/50(81) - 174/93(110)} mmHg\n RR: 20 (19 - 23) insp/min\n SPO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n ICP: 11 (5 - 14) mmHg\n Total In:\n 3,452 mL\n 1,756 mL\n PO:\n Tube feeding:\n 139 mL\n IV Fluid:\n 3,272 mL\n 1,557 mL\n Blood products:\n Total out:\n 3,042 mL\n 1,290 mL\n Urine:\n 2,845 mL\n 1,220 mL\n NG:\n Stool:\n Drains:\n 197 mL\n 70 mL\n Balance:\n 410 mL\n 466 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 407 (344 - 435) mL\n PS : 5 cmH2O\n RR (Spontaneous): 20\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 83\n PIP: 10 cmH2O\n SPO2: 100%\n ABG: 7.47/38/109/26/3\n Ve: 8.4 L/min\n PaO2 / FiO2: 273\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n No(t) Moves all extremities, (RUE: Weakness), (LUE: Weakness)\n Labs / Radiology\n 177 K/uL\n 10.7 g/dL\n 111 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 3.9 mEq/L\n 13 mg/dL\n 108 mEq/L\n 141 mEq/L\n 29.2 %\n 8.8 K/uL\n [image002.jpg]\n 09:21 PM\n 04:00 AM\n 04:31 AM\n 01:31 PM\n 02:35 AM\n 02:45 AM\n 03:22 AM\n 04:49 AM\n 02:11 AM\n 02:18 AM\n WBC\n 12.5\n 10.6\n 10.6\n 11.5\n 8.8\n Hct\n 33.6\n 33.2\n 32.2\n 31.3\n 29.2\n Plt\n 28\n 177\n Creatinine\n 1.0\n 1.0\n 0.7\n 0.7\n 0.7\n TCO2\n 24\n 25\n 25\n 21\n 28\n Glucose\n 131\n 150\n 147\n 127\n 137\n 110\n 111\n Other labs: PT / PTT / INR:15.4/25.6/1.4, Lactic Acid:0.7 mmol/L,\n Albumin:3.8 g/dL, Ca:8.2 mg/dL, Mg:2.2 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA), .H/O RESPIRATORY\n FAILURE, ACUTE (NOT ARDS/), PROBLEM - ENTER DESCRIPTION IN\n COMMENTS, INTRACEREBRAL HEMORRHAGE (ICH), HYPERTENSION, BENIGN\n Assessment and Plan:\n Neurologic: Neuro checks Q: 2 hr, ICP monitor, Ventriculostomy, evd at\n 15 cm\n Cardiovascular: nicardipine gtt, goal sbp < 160, increase scheduled\n lopressor to 50\n Pulmonary: Cont ETT, (Ventilator mode: CPAP + PS), cpap 5/5, not awake\n enough to extubate\n Gastrointestinal / Abdomen: bowel regimen\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO\n Hematology: Serial Hct, stable\n Endocrine: RISS\n Infectious Disease: Vanco/ for sinusitis, wbc decreasing after Abx\n started yesterday, oral nystatin, d/c cefazolin, resend sputum\n Lines / Tubes / Drains: Foley, ETT, cvl, EVD\n Wounds:\n Imaging:\n Fluids: KVO\n Consults: Neuro surgery, Neurology\n Billing Diagnosis: CVA, (Respiratory distress: Failure)\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 12:11 AM 15 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 06:44 PM\n ICP Catheter - 06:44 PM\n 18 Gauge - 12:59 PM\n Multi Lumen - 06:00 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n Patient is critically ill\n"
},
{
"category": "Respiratory ",
"chartdate": "2146-11-26 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 548077,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Unassisted spontaneous breathing\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Cannot protect\n airway\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n 16:11\n"
},
{
"category": "Nursing",
"chartdate": "2146-11-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 548221,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n On propofol gtt for sedation.\n Arouses sluggishly and intermittently to tactile stimuli when propofol\n is decreased. Localizes to pain w/ slight movement on bed. No eye\n opening. Does not follow commands.\n PERRLA at 3-4 with Sluggish response in Am returning to brisk by\n afternoon.\n Left ventricular drain continues to be open. Draining bloody drainage\n ~5-10ML hr. Clots present in drainage system\n ICP 11-13 and CPP 60-90s. Dilantin level 6.6 this am.\n No seizure activity noted.\n J collar in\n place.\n Action:\n Nicardipine gtt titrated to keep SBP 140-160. Propofol gtt titrated for\n sedation.\n Neuro checks changed to Q2 hr. Team notified re: .\n Dilantin bolus given.\n Response:\n SBP 140-160s\n Sedated and sluggish response when propofol off for neuro checks\n Remains in J for cspine precautions\n Plan:\n Continue to monitor\n q1h neuro checks\n Ineffective Airway Maintenance\n Assessment:\n Remains intubated. Comfortable on CPAP+PS 5/5 40%. Sats 100%\n LS scattered rhonci clears w/ suctioning.\n Suctioning copius thick yellow/ secretions.\n CXR clear\n Action:\n Suctioned as needed.\n Sinus ct done\n Response:\n LS cleared after suctioning .Sats remain 100%.\n Ct showed sinus wall thickening. Vanco/ meropenem ordered.\n Left subclavian TLC placed for access for multi gtt\n CXR taken to confirm placement.\n Plan:\n Continue pulm hygiene.\n Follow up CXR to confirm line placement.\n Start ABX as ordered.\n"
},
{
"category": "Respiratory ",
"chartdate": "2146-11-28 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 548290,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments: sputum specimen obtained and sent\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Cannot protect\n airway\n Respiratory Care Shift Procedures\n AM RSBI 83\n ABG Hyperoxia with slight respiratory alkalosis\n"
},
{
"category": "Respiratory ",
"chartdate": "2146-11-28 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 548399,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Tube Type\n Tracheostomy tube:\n Type: Perc Trach\n Manufacturer: Portex\n Size: 7.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 23 cmH2O\n Cuff volume: mL /\n Airway problems: Positional leak around cuff\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n Lung Sounds: Clear\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Assessment of breathing comfort: No claim of dyspnea)\n Dysynchrony assessment: Erratic exhaled Tidal Volumes, Frequent alarms\n Comments: pt with positional cuff leak and occasional erratic TV and\n alarms for leakage\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated; Comments: able to wean fiO2 from 70-60%\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Comments:\n"
},
{
"category": "Respiratory ",
"chartdate": "2146-11-28 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 548408,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Tube Type\n Tracheostomy tube:\n Type: Perc Trach\n Manufacturer: Portex\n Size: 7.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 23 cmH2O\n Cuff volume: mL /\n Airway problems: Positional leak around cuff\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n Lung Sounds: Clear\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Assessment of breathing comfort: No claim of dyspnea)\n Dysynchrony assessment: Erratic exhaled Tidal Volumes, Frequent alarms\n Comments: pt with positional cuff leak and occasional erratic TV and\n alarms for leakage\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated; Comments: able to wean fiO2 from 70-60%\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Comments:\n ------ Protected Section------\n Note was charted on incorrect pt.\n ------ Protected Section Error Entered By: , RRT\n on: 18:11 ------\n"
},
{
"category": "Respiratory ",
"chartdate": "2146-11-28 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 548409,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location: Outside hospital\n Reason:\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 23 cmH2O\n Cuff volume: mL /\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Comments:\n Pt maintained on PSV 5 peep 5 for airway protection. Plan is for MRI on\n Tuesday and OR on Thursday for cyst drainage.\n"
},
{
"category": "Nursing",
"chartdate": "2146-12-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 548817,
"text": "Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Tmax 101.6\n Action:\n Tylenol given, Dr. notified. Blood cultures done x 2\n Response:\n Pt mildly responding to Tylenol, temp decreased to 100.7\n Plan:\n Continue to monitor temp, follow up on pending cultures, give Tylenol\n as needed.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Pt opening eyes to voice and stimulation. Not moving any ext. until\n this am, pt slightly squeezing with left hand only. Ext. not responding\n to painful stimulation. Perrl, appear to be sluggish at times. Head\n incision oozing moderate amounts of rust colored drainage.\n Action:\n Head incision shown to Dr. , as well as SICU resident, dressing\n changed.\n Response:\n Drainage decreased throughout the night. Pt more responsive this am.\n Plan:\n Continue to monitor neuro status Q 1hour, monitor head incision for\n increased drainage\n Hypertension, benign\n Assessment:\n Systolic BP rising to 170\ns at times.\n Action:\n Nicardipine gtt started, Hydralazine po added.\n Response:\n Gtt increased this am to 2.5 mcgs/kg/min, pain med given with effect\n Plan:\n Continue to treat for ? pain, titrate Nicardipine to keep SBP < 140 per\n resident\n"
},
{
"category": "Social Work",
"chartdate": "2146-12-02 00:00:00.000",
"description": "Social Work Progress Note",
"row_id": 548917,
"text": "Spoke with legal department re: need for legal guardian for pt, forms\n have been received and are being completed by Neurosurgery. Family was\n able to locate pt\ns social security # and did go to obtain a birth\n certificate from the town . \ns office has been made\n aware that the documents have been secured in order to apply pt for MA\n Health. With these documents family may be able to represent pt at\n Social Security to initiate his benefits as he is pending his 66^th\n birthday, is now eligible for Medicare.\n Still unable to speak with pt secondary to his medical condition.\n"
},
{
"category": "Nursing",
"chartdate": "2146-11-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 548662,
"text": "Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Temp inc to 103, cx still pending\n Action:\n Cooling blanket placed on pt, Tylenol given, vanco dc\n Response:\n Pt temp inc to 103.5, cooling blanket taken off, pt given alcohol bath,\n groin and axillia cool packs placed, cx taken of csf showing wbc.\n Current temp 102.5\n Plan:\n Cont to monitor temp curve, ? change in antibiotics, continue with\n Tylenol\n Hypertension, benign\n Assessment:\n Pt abp maintained <160 with nicardipine gtt at 1.5,\n Action:\n Lopressor increased to 150 mg tid, amlodipine 10 mg ordered QD,\n Response:\n Nicardipine gtt off at 1430, systolic abp 140-160 thru out day,\n amlodipine had little effect on b/p\n Plan:\n Continue to monitor systolic b/p maintain <160,\n Intracerebral hemorrhage (ICH)\n Assessment:\n No change in neuro status, pt flex withdraws to stimulation to bilat\n feet, no movement of upper legs noted except in early am with NP exam\n left leg only, , no movement noted in upper exts, pupils reactive to\n light, pt does open eyes slightly in response to voice, icp drainage\n bloody with some clots noted, 4-16 cc output,\n Action:\n Csf cx done due to inc temps, q 2 hr neuro checks\n Response:\n ICP drain clotted off after csf drawn for cx which neuro np came and\n corrected and drain seems to be working with good waveform present,\n CSF cx + wbc,\n Plan:\n Pt still scheduled for surgery tomorrow to drain cyst, anesthia consent\n and surgery consent signed, pt needs EKG and ? type and screen done\n overnight, continue to monitor ICP drainage and report sign changes to\n neuro team\n"
},
{
"category": "Physician ",
"chartdate": "2146-12-01 00:00:00.000",
"description": "Intensivist Note",
"row_id": 548737,
"text": "SICU\n HPI:\n 65M w/sudden onset HA on am of went into bathroom and fell to\n ground; parents found him to be unresponsive and taken to OSH; then\n txfr to \n Chief complaint:\n MASSIVE Central IPH(spont)\n PMHx:\n unknown\n Current medications:\n 24 Hour Events:\n PAN CULTURE - At 09:15 PM\n FEVER - 103.0\nF - 08:00 PM\n Post operative day:\n HD#7 POD#6 - Left burr hole with placement of ventriculostomy\n drain\n 24hr events: VitK, incr lopressor, CT head/C-spine, ETT repositioned;\n o/n temp 103, pancx/CXR; ICP 20-23 intermittently, neurosurg aware.\n Nicardipine gtt restarted.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 06:59 AM\n Vancomycin - 08:00 PM\n Meropenem - 06:00 AM\n Infusions:\n Nicardipine - 1.5 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 AM\n Metoprolol - 05:51 PM\n Hydralazine - 06:07 PM\n Other medications:\n Flowsheet Data as of 07:18 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 39.4\nC (103\n T current: 39\nC (102.2\n HR: 84 (79 - 104) bpm\n BP: 136/61(84) {129/56(82) - 176/76(109)} mmHg\n RR: 20 (20 - 21) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 66.6 kg (admission): 75 kg\n ICP: 7 (6 - 22) mmHg\n Total In:\n 2,167 mL\n 793 mL\n PO:\n Tube feeding:\n 1,149 mL\n 394 mL\n IV Fluid:\n 898 mL\n 369 mL\n Blood products:\n Total out:\n 3,008 mL\n 1,145 mL\n Urine:\n 2,830 mL\n 1,100 mL\n NG:\n Stool:\n Drains:\n 178 mL\n 45 mL\n Balance:\n -841 mL\n -352 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 390 (361 - 579) mL\n PS : 5 cmH2O\n RR (Spontaneous): 20\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 50\n PIP: 11 cmH2O\n SPO2: 100%\n ABG: ///24/\n Ve: 8.6 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Responds to: Verbal stimuli, Tactile stimuli, Noxious\n stimuli), Moves toes b/l on tactile stimulation. Moves arms b/l on\n noxious stimulation. opens eyes slightly with verbal.\n Labs / Radiology\n 164 K/uL\n 11.2 g/dL\n 177\n 0.6 mg/dL\n 24 mEq/L\n 3.7 mEq/L\n 17 mg/dL\n 104 mEq/L\n 137 mEq/L\n 31.1 %\n 7.9 K/uL\n [image002.jpg]\n 02:45 AM\n 03:22 AM\n 04:49 AM\n 02:11 AM\n 02:18 AM\n 02:02 AM\n 02:12 AM\n 09:23 PM\n 02:58 AM\n 04:00 AM\n WBC\n 11.5\n 8.8\n 5.3\n 7.6\n 7.9\n Hct\n 31.3\n 29.2\n 30.4\n 31.5\n 31.1\n Plt\n 69\n 164\n Creatinine\n 0.7\n 0.7\n 0.7\n 0.6\n TCO2\n 25\n 21\n 28\n 28\n Glucose\n 110\n 111\n 122\n 155\n 177\n Other labs: PT / PTT / INR:15.1/24.6/1.3, Lactic Acid:0.7 mmol/L,\n Albumin:3.8 g/dL, Ca:8.0 mg/dL, Mg:2.2 mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA), .H/O RESPIRATORY\n FAILURE, ACUTE (NOT ARDS/), PROBLEM - ENTER DESCRIPTION IN\n COMMENTS, INTRACEREBRAL HEMORRHAGE (ICH), HYPERTENSION, BENIGN\n Assessment and Plan: 65M w/ MASSIVE Central IPH(spont)\n Neurologic: Neuro checks Q: 2 hr, unclear source of bleed, possibly\n from cyst. Plan for cyst aspiration and MRI ; dilantin changed to\n Keppra; EVD for ICP monitor\n Cardiovascular: keep SBP<160, PO lopressor incr, nicardipine GTT\n restarted; hydralazine prn. Add amlodipine for better bp control, wean\n off nicard gtt as able\n Pulmonary: (Ventilator mode: CPAP + PS), intubated, on CPAP+PS 5/5 40%,\n no change. To OR tomorrow\n Gastrointestinal / Abdomen: DHT via mouth\n Nutrition: Tube feeding at goal, hold at midnight for OR\n Renal: Foley, Adequate UO, replace electrolytes\n Hematology: slight INR elevation, vitK given. decreased to 1.3\n Endocrine: RISS, one dose nph now, will hold when tube feeds off to\n avoid hypoglycemia\n Infectious Disease: persistent fevers; on vanco/ for suspected\n sinusitis, wbc normal\n Lines / Tubes / Drains: Foley, OGT, ETT\n Wounds: evd site ok\n Imaging: none\n Fluids: KVO\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS) , Respiratory Failure\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 02:25 AM 55 mL/hour\n Glycemic Control: NPH and SSI\n Lines: CVL\n Arterial Line - 06:44 PM\n ICP Catheter - 06:44 PM\n 18 Gauge - 12:59 PM\n Multi Lumen - 06:00 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Oral Care\n Comments:\n Communication: ICU consent signed Comments:\n Code status: DNR / DNI\n Disposition: ICU\n Total time spent: 34 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2146-12-01 00:00:00.000",
"description": "Intensivist Note",
"row_id": 548739,
"text": "TITLE:\n SICU\n HPI:\n 65M w/sudden onset HA on am of went into bathroom and fell to\n ground; parents found him to be unresponsive and taken to OSH; then\n txfr to . found to have massive IVH, s/p Lt Burr hole W EVD\n placement \n Chief complaint:\n depressed mental status\n PMHx:\n , mother; denies any cardiac/respiratory/cancer\n .\n : Unknonwn\n Current medications:\n Acetaminophen 4. Amlodipine 5. Ampicillin 6. Bisacodyl\n 7. Calcium Gluconate 8. Chlorhexidine Gluconate 0.12% Oral Rinse 9.\n Docusate Sodium (Liquid) 10. Famotidine\n 11. HYDROmorphone (Dilaudid) 12. HydrALAzine 13. Insulin 14. Insulin\n 15. Influenza Virus Vaccine\n 16. LeVETiracetam 17. Magnesium Sulfate 18. Metoprolol Tartrate 19.\n Meropenem 20. NiCARdipine 21. Nystatin Oral Suspension\n 22. Pneumococcal Vac Polyvalent 23. Potassium Chloride 24. Propofol 25.\n Senna 26. Sodium Chloride 0.9% Flush\n 27. Vancomycin\n 24 Hour Events:\n EKG - At 09:00 PM\n MAGNETIC RESONANCE IMAGING - At 06:44 AM\n pre-op head\n FEVER - 103.4\nF - 03:00 PM\n pancultured, CSF sent, started Vanc/Amp. Nicardipine off, increased\n lopressor, started amlodipine\n Post operative day:\n POD#7 - Left burr hole with placement of ventriculostomy drain\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 12:12 AM\n Ampicillin - 05:13 AM\n Meropenem - 05:13 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:34 PM\n Hydralazine - 02:18 AM\n Hydromorphone (Dilaudid) - 04:16 AM\n Metoprolol - 05:13 AM\n Other medications:\n Flowsheet Data as of 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 39.7\nC (103.4\n T current: 38.2\nC (100.8\n HR: 72 (72 - 105) bpm\n BP: 160/72(103) {99/57(82) - 175/97(116)} mmHg\n RR: 12 (12 - 25) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 66.6 kg (admission): 75 kg\n ICP: 5 (2 - 14) mmHg\n Total In:\n 2,559 mL\n 765 mL\n PO:\n Tube feeding:\n 1,330 mL\n IV Fluid:\n 1,049 mL\n 675 mL\n Blood products:\n Total out:\n 2,698 mL\n 1,069 mL\n Urine:\n 2,550 mL\n 1,010 mL\n NG:\n Stool:\n Drains:\n 148 mL\n 59 mL\n Balance:\n -139 mL\n -304 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 386 (367 - 596) mL\n PS : 5 cmH2O\n RR (Spontaneous): 21\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 11 cmH2O\n SPO2: 100%\n ABG: ///25/\n Ve: 8.2 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: 1+), (Temperature: Warm)\n Right Extremities: (Edema: 1+), (Temperature: Warm)\n Skin: No(t) Rash: , No(t) Jaundice\n Neurologic: No(t) Follows simple commands, (Responds to: Noxious\n stimuli), Moves all extremities, Sedated\n Labs / Radiology\n 187 K/uL\n 11.5 g/dL\n 103 mg/dL\n 0.7 mg/dL\n 25 mEq/L\n 3.7 mEq/L\n 20 mg/dL\n 103 mEq/L\n 136 mEq/L\n 32.5 %\n 9.4 K/uL\n [image002.jpg]\n 03:22 AM\n 04:49 AM\n 02:11 AM\n 02:18 AM\n 02:02 AM\n 02:12 AM\n 09:23 PM\n 02:58 AM\n 04:00 AM\n 02:20 AM\n WBC\n 11.5\n 8.8\n 5.3\n 7.6\n 7.9\n 9.4\n Hct\n 31.3\n 29.2\n 30.4\n 31.5\n 31.1\n 32.5\n Plt\n 69\n 164\n 187\n Creatinine\n 0.7\n 0.7\n 0.7\n 0.6\n 0.7\n TCO2\n 21\n 28\n 28\n Glucose\n 110\n 111\n 122\n 155\n 177\n 103\n Other labs: PT / PTT / INR:15.0/25.0/1.3, Lactic Acid:0.7 mmol/L,\n Albumin:3.8 g/dL, Ca:8.4 mg/dL, Mg:2.3 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA), .H/O RESPIRATORY\n FAILURE, ACUTE (NOT ARDS/), PROBLEM - ENTER DESCRIPTION IN\n COMMENTS, INTRACEREBRAL HEMORRHAGE (ICH), HYPERTENSION, BENIGN\n Assessment and Plan: 65M w/sudden onset HA on am of went into\n bathroom and fell to ground; parents found him to be unresponsive and\n taken to OSH; then txfr to . found to have massive IVH, s/p Lt\n Burr hole W EVD placement \n Neurologic: unclear source of bleed, possibly from cyst. Plan for cyst\n aspiration and MRI , q2hr neuro checks, EVD@ 15cm open; when\n extubating, extubate on precedex (severe autism/claustrophobia).\n Neurosurge wants to wait to clear Cspine clinically. OR today for cyst\n aspiration.\n Cardiovascular: keep SBP<160, on PO lopressor/amlodipine, hydralazine\n prn\n Pulmonary: intubated, on CPAP+PS, minimal settings, CXR clear\n Gastrointestinal / Abdomen: TF - advanced to goal 70/hr, H2B\n Nutrition: TF on hold for OR\n Renal: follow UOP, foley in place, no acute issues\n Hematology: HCt stable\n Endocrine: RISS, follow FS, reeval for NPH after OR\n Infectious Disease: continues to be febrile but WBC wnl, cultures\n pending, on for suspected sinusitis., started Vanc/Amp for\n meningitis coverage.\n Lines / Tubes / Drains: foley, ETT, , , left subclavian\n TLC, PIV\n Wounds: C/D/I\n Imaging: MRI done\n Fluids: KVO\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 06:44 PM\n ICP Catheter - 06:44 PM\n Multi Lumen - 06:00 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: DNR / DNI\n Disposition: ICU\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2146-12-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 548815,
"text": "Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Tmax 101.6\n Action:\n Tylenol given, Dr. notified. Blood cultures done x 2\n Response:\n Pt mildly responding to Tylenol, temp decreased to 100.7\n Plan:\n Continue to monitor temp, follow up on pending cultures, give Tylenol\n as needed.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Action:\n Response:\n Plan:\n Hypertension, benign\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2146-12-01 00:00:00.000",
"description": "Intensivist Note",
"row_id": 548728,
"text": "TITLE:\n SICU\n HPI:\n 65M w/sudden onset HA on am of went into bathroom and fell to\n ground; parents found him to be unresponsive and taken to OSH; then\n txfr to . found to have massive IVH, s/p Lt Burr hole W EVD\n placement \n Chief complaint:\n depressed mental status\n PMHx:\n , mother; denies any cardiac/respiratory/cancer\n .\n : Unknonwn\n Current medications:\n Acetaminophen 4. Amlodipine 5. Ampicillin 6. Bisacodyl\n 7. Calcium Gluconate 8. Chlorhexidine Gluconate 0.12% Oral Rinse 9.\n Docusate Sodium (Liquid) 10. Famotidine\n 11. HYDROmorphone (Dilaudid) 12. HydrALAzine 13. Insulin 14. Insulin\n 15. Influenza Virus Vaccine\n 16. LeVETiracetam 17. Magnesium Sulfate 18. Metoprolol Tartrate 19.\n Meropenem 20. NiCARdipine 21. Nystatin Oral Suspension\n 22. Pneumococcal Vac Polyvalent 23. Potassium Chloride 24. Propofol 25.\n Senna 26. Sodium Chloride 0.9% Flush\n 27. Vancomycin\n 24 Hour Events:\n EKG - At 09:00 PM\n MAGNETIC RESONANCE IMAGING - At 06:44 AM\n pre-op head\n FEVER - 103.4\nF - 03:00 PM\n pancultured, CSF sent, started Vanc/Amp. Nicardipine off, increased\n lopressor, started amlodipine\n Post operative day:\n POD#7 - Left burr hole with placement of ventriculostomy drain\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 12:12 AM\n Ampicillin - 05:13 AM\n Meropenem - 05:13 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:34 PM\n Hydralazine - 02:18 AM\n Hydromorphone (Dilaudid) - 04:16 AM\n Metoprolol - 05:13 AM\n Other medications:\n Flowsheet Data as of 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 39.7\nC (103.4\n T current: 38.2\nC (100.8\n HR: 72 (72 - 105) bpm\n BP: 160/72(103) {99/57(82) - 175/97(116)} mmHg\n RR: 12 (12 - 25) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 66.6 kg (admission): 75 kg\n ICP: 5 (2 - 14) mmHg\n Total In:\n 2,559 mL\n 765 mL\n PO:\n Tube feeding:\n 1,330 mL\n IV Fluid:\n 1,049 mL\n 675 mL\n Blood products:\n Total out:\n 2,698 mL\n 1,069 mL\n Urine:\n 2,550 mL\n 1,010 mL\n NG:\n Stool:\n Drains:\n 148 mL\n 59 mL\n Balance:\n -139 mL\n -304 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 386 (367 - 596) mL\n PS : 5 cmH2O\n RR (Spontaneous): 21\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 11 cmH2O\n SPO2: 100%\n ABG: ///25/\n Ve: 8.2 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: 1+), (Temperature: Warm)\n Right Extremities: (Edema: 1+), (Temperature: Warm)\n Skin: No(t) Rash: , No(t) Jaundice\n Neurologic: No(t) Follows simple commands, (Responds to: Noxious\n stimuli), Moves all extremities, Sedated\n Labs / Radiology\n 187 K/uL\n 11.5 g/dL\n 103 mg/dL\n 0.7 mg/dL\n 25 mEq/L\n 3.7 mEq/L\n 20 mg/dL\n 103 mEq/L\n 136 mEq/L\n 32.5 %\n 9.4 K/uL\n [image002.jpg]\n 03:22 AM\n 04:49 AM\n 02:11 AM\n 02:18 AM\n 02:02 AM\n 02:12 AM\n 09:23 PM\n 02:58 AM\n 04:00 AM\n 02:20 AM\n WBC\n 11.5\n 8.8\n 5.3\n 7.6\n 7.9\n 9.4\n Hct\n 31.3\n 29.2\n 30.4\n 31.5\n 31.1\n 32.5\n Plt\n 69\n 164\n 187\n Creatinine\n 0.7\n 0.7\n 0.7\n 0.6\n 0.7\n TCO2\n 21\n 28\n 28\n Glucose\n 110\n 111\n 122\n 155\n 177\n 103\n Other labs: PT / PTT / INR:15.0/25.0/1.3, Lactic Acid:0.7 mmol/L,\n Albumin:3.8 g/dL, Ca:8.4 mg/dL, Mg:2.3 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA), .H/O RESPIRATORY\n FAILURE, ACUTE (NOT ARDS/), PROBLEM - ENTER DESCRIPTION IN\n COMMENTS, INTRACEREBRAL HEMORRHAGE (ICH), HYPERTENSION, BENIGN\n Assessment and Plan: 65M w/sudden onset HA on am of went into\n bathroom and fell to ground; parents found him to be unresponsive and\n taken to OSH; then txfr to . found to have massive IVH, s/p Lt\n Burr hole W EVD placement \n Neurologic: unclear source of bleed, possibly from cyst. Plan for cyst\n aspiration and MRI , q2hr neuro checks, EVD@ 15cm open; when\n extubating, extubate on precedex (severe autism/claustrophobia).\n Neurosurge wants to wait to clear Cspine clinically. OR today for cyst\n aspiration.\n Cardiovascular: keep SBP<160, on PO lopressor/amlodipine, hydralazine\n prn\n Pulmonary: intubated, on CPAP+PS, minimal settings, CXR clear\n Gastrointestinal / Abdomen: TF - advanced to goal 70/hr, H2B\n Nutrition: TF on hold for OR\n Renal: follow UOP, foley in place, no acute issues\n Hematology: HCt stable\n Endocrine: RISS, follow FS, reeval for NPH after OR\n Infectious Disease: continues to be febrile but WBC wnl, cultures\n pending, on for suspected sinusitis., started Vanc/Amp for\n meningitis coverage.\n Lines / Tubes / Drains: foley, ETT, , , left subclavian\n TLC, PIV\n Wounds: C/D/I\n Imaging: MRI done\n Fluids: KVO\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 06:44 PM\n ICP Catheter - 06:44 PM\n Multi Lumen - 06:00 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: DNR / DNI\n Disposition: ICU\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2146-11-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 547836,
"text": "65M presented to OSH this am after complaining of headache\n this morning. Per reports from ED records, and parents (with whom\n he resides), he then went upstairs to the bathroom when a \"thump\"\n was heard. His mother went upstairs into the bathroom and found\n him on the floor, incontinent of urine and unresponsive. She then\n called 911, and was taken to OSH. Upon presentation to OSH, he\n was found to be hypertensive to 230/150, started on Nipride. His\n head was scanned and revealed a \"Massive Head Bleed, without\n midline shift\". He was then subsequently transferred to for\n definitive care and Neurosurgical evaluation. In the duration of\n transfer, per EMS noted, started decorticate posturing and they\n began infusion of 25 gm Mannitol IV.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Pt sedated on propofol, moving all ext. to pain. PERRL, however\n minimally responsive at beginning of the night and shown to Dr. .\n Vent drain at 15mm H20 at the tragus, draining bright red blood. ICP\n , drain oozing sanguinous drainage, shown to Dr. , reinforced.\n Remains intubated on CMV with normal ABGs.\n Action:\n Propofol stopped every few hours throughout the night for neuro exam.\n MRI done\n Response:\n When off sedation, pt opening eyes to voice, following all commands.\n Moving all ext. with weakness on right side. Denies pain. Results of\n MRI unknown.\n Plan:\n Continue to monitor neuro status, wean vent.\n"
},
{
"category": "Nursing",
"chartdate": "2146-11-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 547832,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Respiratory ",
"chartdate": "2146-11-26 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 548025,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: OR\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n :\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Expectorated / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Cannot protect\n airway\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:Comfortable overnight on psv. RSBI = 48 this morning. Pt does\n have thick secretions, not strong cough.\n"
},
{
"category": "Nursing",
"chartdate": "2146-11-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 547944,
"text": " Problem - Description In Comments- Family Dynamics\n Assessment:\n ,Daughter in. Stated that the patient\ns elderly (80\ns)do\n not have a grasp of the seriousness of the patient\ns condition and do\n not seem to understand. However,the patient\ns insist making all\n decisions. also stated that her brother having a form of\n autism,has never had professional help.\n Action:\n Social Services( was called and met with .Plan\n for the patient\ns , and to meet Monday and set a\n plan in place for decisions and any professional help the patient may\n need in the future. SICU team to be made aware of the plan.\n Response:\n appeared pleased with the above plan\n Plan:\n Over the weekend both the patient\ns mother and Sister, to be\n called for any decisions\n"
},
{
"category": "Respiratory ",
"chartdate": "2146-11-25 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 547948,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n no complications\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Radiology",
"chartdate": "2146-12-08 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1053109,
"text": ", C. NSURG FA11 9:43 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: please evaluate for hydrocephalus\n Admitting Diagnosis: BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with cyst, IVH\n REASON FOR THIS EXAMINATION:\n please evaluate for hydrocephalus\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n 1. Interval increase in left extra-axial frontal collection, with local mass\n effect.\n\n 2. Stable extent of intraventricular and trace subarachnoid hemorrhage.\n\n 3. Stable size and configuration of the cystic dilatation in the suprasellar\n cistern.\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-12-01 00:00:00.000",
"description": "MR HEAD W/CNTRST&TUMOR VOLUMETRIC",
"row_id": 1051917,
"text": " 5:16 AM\n MR HEAD W/CNTRST&TUMOR VOLUMETRIC Clip # \n Reason: PLEASE DO MRI +/- GADOLIDIUM WITH 2.5MM CUTS ON FOR\n Admitting Diagnosis: BLEED\n Contrast: MAGNEVIST Amt: 14\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with CYST / BRAIN\n REASON FOR THIS EXAMINATION:\n MPRAGE Axial. PLEASE DO MRI +/- GADOLIDIUM WITH 2.5MM CUTS ON FOR\n STEREOTACTIC BIOPSY - PT WILL NEED THE STUDY COMPLETED AT 6AM ON \n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n MR BRAIN WITH CONTRAST .\n\n HISTORY: Intracranial cyst for stereotactic biopsy.\n\n Imaging was performed after administration of Magnevist intravenous contrast.\n Axial MP-RAGE imaging was performed along with axial, coronal, and sagittal\n short TR, short TE spin echo imaging. Comparison to a brain MR study of\n .\n\n FINDINGS: There has been a reduction in the volume of hemorrhage present\n within the bodies of the lateral ventricles. The large suprasellar cyst,\n previously identified, has enlarged dramatically in this interval. A left\n frontal ventricular catheter is again identified. No pre-contrast imaging was\n performed. It is unclear whether hyperintensity of the lateral ventricular\n margins represent enhancement or subacute hemorrhage.\n\n CONCLUSION: Dramatic enlargement of the suprasellar cyst since the brain MR\n of . Evolution of intraventricular hemorrhage.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-12-01 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1051954,
"text": " 9:35 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: OR CT\n Admitting Diagnosis: BLEED\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 65-year-old male patient, with a large suprasellar and prepontine\n cyst status post drainage.\n\n COMPARISON: CT done for stereotaxis guidance, on , just before the\n study.\n\n TECHNIQUE: Non-contrast CT of the head was performed in O.R., with 18 axial\n images of the head at 5-mm thickness available. Scout image not available.\n\n FINDINGS:\n\n There is a small amount of pneumocephalus in the left side, following the\n procedure. There is interval placement of ventricular drain, with the tip in\n the previously described suprasellar and prepontine cistern. Again visualized\n are dense areas in the cyst as well as in the adjacent portions of the\n ventricles as well as in the sulci and the tentorium cerebelli on both sides,\n representing intraventricular, subarachnoid and subdural hemorrhage\n respectively. The images do not cover the entire brain. There is some change\n in the shape of the previously described cyst, with the dense blood products,\n coursing more posteriorly than the prior study.\n\n IMPRESSION:\n 1. Status post drain placement in the previously noted large\n suprasellar/prepontine cyst, change in the shape of the cyst, and possible\n mild or no significant change in the overall size. Close f/u.\n\n 2. Extensive intraventricular, some amount of subarachnoid and subdural\n hemorrhage partially imaged and not significantly changed.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-12-19 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1054978,
"text": " 2:57 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: please eval for interval change/ found on floor unwittnessed\n Admitting Diagnosis: BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with\n REASON FOR THIS EXAMINATION:\n please eval for interval change/ found on floor unwittnessed fall. CT head to\n be performed first, followed by plain films of pelvis and shoulder\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DBH MON 4:55 PM\n No evidence of hemorrhage or fracture. Ventriculostomy catheter,\n hydrocephalus, and cystic mass involving the third ventricle appear unchanged.\n ______________________________________________________________________________\n FINAL REPORT\n CT HEAD WITHOUT CONTRAST, \n\n HISTORY: Found on the floor after unwitnessed fall.\n\n Contiguous axial images were obtained through the brain. No contrast was\n administered. Comparison to a head CT of .\n\n FINDINGS: There has been a decrease in the volume of intracranial air since\n the prior study. This airspace is now partially filled with extra-axial\n fluid. However, there is an increase in intraventricular air in the frontal\n horns of the lateral ventricles bilaterally. Again demonstrated is dramatic\n enlargement of the lateral ventricles as well as a cystic structure apparently\n within the third ventricle. A ventricular catheter remains in place. There\n is no evidence of hemorrhage. Other than the changes in the air distribution,\n there have been no significant changes since the prior study. No fractures\n are identified.\n\n CONCLUSION: Reduction in the volume of air, but slight increase in the volume\n of intraventricular air since the study of . No evidence of\n hemorrhage or fracture. Again identified is a large cyst involving the third\n ventricle, a ventriculostomy, and hydrocephalus.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-12-19 00:00:00.000",
"description": "R SHOULDER 2-3 VIEWS NON TRAUMA RIGHT",
"row_id": 1055022,
"text": ", C. NSURG FA11 8:13 PM\n SHOULDER VIEWS NON TRAUMA RIGHT Clip # \n Reason: please evlaute for fracture, found on floor s/p unwittnessed\n Admitting Diagnosis: BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with\n REASON FOR THIS EXAMINATION:\n please evlaute for fracture, found on floor s/p unwittnessed fall\n ______________________________________________________________________________\n PFI REPORT\n No fracture. No dislocation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-12-19 00:00:00.000",
"description": "BILAT HIPS (AP,LAT & AP PELVIS)",
"row_id": 1055019,
"text": " 8:12 PM\n BILAT HIPS (AP,LAT & AP PELVIS) Clip # \n Reason: please eval for fracture; found on floor unwittnessed fall\n Admitting Diagnosis: BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with\n REASON FOR THIS EXAMINATION:\n please eval for fracture; found on floor unwittnessed fall\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JMGw 10:48 AM\n No fracture and no dislocation.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Unwitnessed fall, evaluate for fracture.\n\n AP RADIOGRAPH OF THE PELVIS AND TWO VIEWS OF THE RIGHT AND LEFT HIPS EACH\n\n FINDINGS: No comparative radiographs are available. No fracture or\n dislocation is seen. No degenerative changes are present. The sacroiliac\n joints are normal in their appearance. No focal sclerotic or lytic lesions\n are seen. No pubic symphysis diastasis is present. No radiopaque foreign\n bodies or soft tissue calcifications are present.\n\n IMPRESSION: Normal pelvis and bilateral hip radiographs.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-11-27 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1051052,
"text": " 9:26 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: hydrocephalus, ventricular placement, ? change in ms\n Admitting Diagnosis: BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with\n REASON FOR THIS EXAMINATION:\n hydrocephalus, ventricular placement, ? change in ms\n contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DMFj SUN 11:34 AM\n Left ventricular catheter may terminate in the left frontal lobe and attention\n to positioning is recommended. Persistent ventricular and subarachnoid\n hemorrhage.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: CT of the head without contrast.\n\n HISTORY: 65-year-old male with hydrocephalus status post ventricular catheter\n placement. Assess change.\n\n COMPARISONS: , .\n\n TECHNIQUE: 5-mm axial contiguous images of the head were obtained.\n\n FINDINGS: Endotracheal and nasogastric tubes are partially visualized. A\n ventricular catheter entering from a left frontal approach appears to\n terminate within the left frontal lobe (2:13). The left lateral ventricle\n remains extremely dilated but not significantly changed compared to the\n examination two days prior. Large amount of blood within the lateral\n ventricles and the third ventricle is essentially unchanged. Scattered foci\n of subarachnoid hemorrhage throughout both cerebral hemispheres are unchanged.\n Thickening of the ethmoid, sphenoid, and maxillary sinuses of the mucosal\n surface is stable compared to the most recent exam.\n\n IMPRESSION:\n 1. Left ventricular catheter from frontal approach probably terminates within\n the left frontal lobe. No interval change in size of the left lateral\n ventricle. Attention to catheter positioning and drain output is recommended.\n 2. Unchanged ventricular hemorrhage.\n 3. Scattered subarachnoid hemorrhage, stable.\n\n Findings were discussed with Dr. at 11:35 am by Dr. on\n .\n\n\n Final Attending Comment: There is again concern for \"trapped third ventricle\"\n which appears slightly larger than the prior study with less hemorrhage in it.\n Alternatively, this could represent an arachnoid cyst with hemorrhage. Follow\n up MRI after resolution of hemorrhage is recommended\n (Over)\n\n 9:26 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: hydrocephalus, ventricular placement, ? change in ms\n Admitting Diagnosis: BLEED\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-11-27 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1051053,
"text": ", C. NSURG SICU-B 9:26 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: hydrocephalus, ventricular placement, ? change in ms\n Admitting Diagnosis: BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with\n REASON FOR THIS EXAMINATION:\n hydrocephalus, ventricular placement, ? change in ms\n contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Left ventricular catheter may terminate in the left frontal lobe and attention\n to positioning is recommended. Persistent ventricular and subarachnoid\n hemorrhage.\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-11-24 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1050621,
"text": " 5:22 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: S/P DRAIN\n Admitting Diagnosis: BLEED\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 7:59 PM\n As in prior study, extensive hemorrhage involving entire ventricular system,\n with transependymal migration of CSF. Left ventriculostomy drain placed via\n frontal burr hole technique, with tip satisfactorily terminating in the\n frontal of the left lateral ventricle.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 65 year old male with hemorrhage in midbrain and extensively\n involving ventricular system with hydrocephalus.\n\n COMPARISON: Non-contrast head CT two hours prior.\n\n TECHNIQUE: Limited axial imaging was performed through the ventricular\n system.\n\n HEAD CT WITHOUT IV CONTRAST: Limited axial imaging of the brain was\n performed. A left frontal approach ventriculostomy drain has been inserted\n via a burr hole, with the tip of the catheter terminating in the frontal \n of the left lateral ventricle. As in the comparison study from two hours\n prior, there is extensive filling of the ventricular system with hemorrhage.\n The midbrain and skull base are not imaged, and the cranial vertex is also not\n imaged. There is again periventricular low-density fluid consistent with\n transependymal migration of CSF. There is expected postoperative\n pneumocephalus.\n\n IMPRESSION:\n\n 1. Extensive hemorrhage persists in the ventricular system.\n\n 2. Satisfactory placement of left frontal approach ventriculostomy drain.\n\n 3. Limited study due to incomplete brain imaging.\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-11-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1051073,
"text": " 11:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: dobhoff tube placement\n Admitting Diagnosis: BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with large intracranial hemorrhage\n REASON FOR THIS EXAMINATION:\n dobhoff tube placement\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest, .\n\n HISTORY: 65-year-old man with large intracranial hemorrhage. Dobbhoff tube\n placement.\n\n FINDINGS: The tip of the Dobbhoff tube is just beyond the gastroesophageal\n junction. This could be advanced several centimeters for more optimal\n placement. There is an endotracheal tube. The visualized lung fields are\n clear. The lung apices have been cut off from the study.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-11-27 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1051134,
"text": " 6:01 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: s/p central line placement, ?PTX\n Admitting Diagnosis: BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with large intraparenchymal hemorrhage, s/p central line\n placement\n REASON FOR THIS EXAMINATION:\n s/p central line placement, ?PTX\n ______________________________________________________________________________\n WET READ: JXKc SUN 9:09 PM\n Left subclavian line terminates in the mid SVC. ET tube is 3 cm from carina.\n Dobhoff tube terminates in the region of the GE junction and should be\n advanced further. Lungs are clear without consolidation. There is no\n pleural effusion or pneumothorax. Findings were discussed with Dr. at 8\n p.m. -jkang\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Central line placement.\n\n COMPARISON: , 10:15.\n\n FINDINGS: As compared to the previous examination, a new central venous\n access line has been inserted. The line projects with its tip over the upper\n SVC, the course of the catheter is unremarkable. There is no evidence of\n pneumothorax or other complications. Unchanged position of the endotracheal\n tube and the Dobbhoff catheter, the Dobbhoff could be advanced by 5 cm.\n Unchanged aspect of the lung parenchyma, unchanged size of the cardiac\n silhouette.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-11-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1051022,
"text": " 4:36 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for interval change, planned extubation\n Admitting Diagnosis: BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man s/p intraventricular hemorrhage, intubated\n REASON FOR THIS EXAMINATION:\n assess for interval change, planned extubation\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest, .\n\n HISTORY: Evaluate for interval change. Extubation as planned.\n\n FINDINGS: Comparison is made with prior study from .\n\n Endotracheal tube and feeding tube are unchanged in position. Cardiac\n silhouette and mediastinum is within normal limits. There is no focal\n infiltrate, pleural effusion or signs of overt pulmonary edema.\n\n IMPRESSION: No signs of acute cardiopulmonary process.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-11-27 00:00:00.000",
"description": "CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST",
"row_id": 1051044,
"text": "CT of including obstruction of the ostiomeatal units bilaterally.\n Extensive nasal secretions status post NG tube placement. Left jugular\n catheter appears to terminate within the left frontal lobe as described on the\n accompanying head CT report Page: 3\n\n , M 65 () \n , C. NSURG SICU-B 8:42 AM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \n Reason: ?sinusitis\n Admitting Diagnosis: BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with massive IPH, with lots of secretions, NGT, clear CXR\n REASON FOR THIS EXAMINATION:\n ?sinusitis\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Interval increase in mucosal thickening of all paranasal sinuses compared to\n CT of including obstruction of the ostiomeatal units bilaterally.\n Extensive nasal secretions status post NG tube placement. Left ventricular\n catheter appears to terminate within the brain parenchyma as described on the\n accompanying head CT report.\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-11-27 00:00:00.000",
"description": "CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST",
"row_id": 1051043,
"text": " 8:42 AM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \n Reason: ?sinusitis\n Admitting Diagnosis: BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with massive IPH, with lots of secretions, NGT, clear CXR\n REASON FOR THIS EXAMINATION:\n ?sinusitis\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DMFj SUN 1:49 PM\n Interval increase in mucosal thickening of all paranasal sinuses compared to\n CT of including obstruction of the ostiomeatal units bilaterally.\n Extensive nasal secretions status post NG tube placement. Left ventricular\n catheter appears to terminate within the brain parenchyma as described on the\n accompanying head CT report.\n PFI VERSION #1 DMFj SUN 11:54 AM\n Interval increase in mucosal thickening of all paranasal sinuses compared to\n CT of including obstruction of the ostiomeatal units bilaterally.\n Extensive nasal secretions status post NG tube placement. Left jugular\n catheter appears to terminate within the left frontal lobe as described on the\n accompanying head CT report\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: CT of the facial bones.\n\n HISTORY: 65-year-old male with massive hemorrhage and loss of secretions.\n Assess for sinusitis.\n\n COMPARISONS: CT head .\n\n TECHNIQUE: MDCT axial images of the facial bones were acquired. Coronal and\n sagittal reformatted images were then obtained.\n\n FINDINGS: Mild mucosal thickening within the maxillary sinuses, sphenoid\n sinuses, frontal sinuses and ethmoid air cells has increased compared to the\n CT of . A left maxillary polyp versus a mucus retention cyst is\n additionally noted. No air-fluid levels are present. An NG tube is\n visualized coursing through the right naris. Significant secretions within\n the nasal cavity are evident. The ostiomeatal units are obstructed by mucosal\n secretions bilaterally. The nasal septum is midline. The cribriform plate is\n not pneumatized. Incidental note is again made of left frontal ventricular\n catheter terminating outside the inferior aspect of the left lateral ventricle\n within the brain parenchyma (400B:46).\n\n IMPRESSION: Panmucosal thickening within the paranasal sinuses, increased\n compared to the CT of . Obstruction of the ostiomeatal units\n bilaterally. Extensive nasal secretions. Left frontal ventricular catheter\n appears to terminate in brain parenchyma as discussed on concurrent head CT.\n\n Findings discussed with Dr. . at 11:35 am on by Dr. over\n the telephone.\n (Over)\n\n 8:42 AM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \n Reason: ?sinusitis\n Admitting Diagnosis: BLEED\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-12-16 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1054353,
"text": " 6:18 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: please assess interval change\n Admitting Diagnosis: BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with subarrachnoid cyst\n REASON FOR THIS EXAMINATION:\n please assess interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 65-year-old male with subarachnoid cyst. Evaluate for interval\n change.\n\n NON-CONTRAST HEAD CT: Compared to prior exam from cystic\n structure within the lateral ventricles and suprasellar region is unchanged.\n The degree of ventricular dilatation is stable. There is continued evolution\n of left intraventricular blood surrounding the ventriculostomy catheter. Since\n the last exam, there is decreased layering in the occipital of the left\n lateral ventricle. The degree of pneumocephalus within the ventricles is\n probably unchanged allowing for redistribution into the temporal horns.\n Bifrontal pneumocephalus is slightly decreased. No new hemorrhage is\n identified. The paranasal sinuses and mastoid air cells are normally aerated.\n Tip of left transfrontal ventriculostomy catheter terminates in the prepontine\n cistern, unchanged from .\n\n The -white matter differentiation is preserved. There is no evidence of\n major vascular territorial infarct.\n\n IMPRESSION:\n\n 1. Compared to , blood in the occipital of the left\n lateral ventricle is decreased in size. There is continued evolution of\n intraventricular blood surrounding the ventriculostomy catheter in the frontal\n of the left lateral ventricle. No new hemorrhage is identified.\n\n 2. Unchanged cystic dilatation of the lateral ventricles and suprasellar\n custern.\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-11-25 00:00:00.000",
"description": "CTA HEAD W&W/O C & RECONS",
"row_id": 1050801,
"text": " 2:41 PM\n CTA HEAD W&W/O C & RECONS Clip # \n Reason: evaluate origin of bleed\n Admitting Diagnosis: BLEED\n Contrast: OPTIRAY Amt: 80\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with sudden onset HA with large intraparenchymal hemmorrhage\n REASON FOR THIS EXAMINATION:\n evaluate origin of bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): ENYa FRI 5:59 PM\n 1. No evidence of aneurysm, vasospasm or occlusive lesion. No evidence of\n contrast extravasation.\n 2. Persistent massive intraventricular hemorrhage. Severe hydrocephalus, L\n greater than R. Persistent Mass effect. No evidence of subarachnoid\n hemorrhage.\n 3. Tip of ventrilucostomy draining catheter in the left lateral ventricle.\n Concern for non-draining in light of the severe hydrocephalus.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 65-year-old man, with sudden onset of headache and finding of large\n intracranial hemorrhage. Now assess for the origin of bleed.\n\n TECHNIQUE: Initially, contiguous axial MDCT images were obtained through the\n brain without contrast material. Subsequently, rapid helical axial MDCT was\n performed from the base of the skull to the vertex during infusion of IV\n contrast. The images were processed on a separate workstation with display of\n curved reformatted, volume-rendered, and maximum intensity projection\n reconstructed images.\n\n COMPARISON: CT head without contrast on and MR head with\n and without contrast on .\n\n FINDINGS:\n\n HEAD CT: There is an overall unchanged appearance of the massive\n intraventricular hemorrhage, left lateral ventricular more severe than right.\n There is persistent obstructive hydrocephalus with dilated lateral ventricular\n temporal horns, with persistent periventricular low-attenuation suggesting\n transependymal migration of CSF. There is continued marked and cystic-\n appearing dilatation of particularly, the 3rd ventricle. A left transfrontal\n ventriculostomy catheter, enters via left frontal burr hole, but its tip\n appears to abut, and may transgress, the lateral wall of the left lateral\n ventricle. There is persistent mass effect, with 14 mm rightward shift of\n normally-midline structures, and the basal cisterns remain efffaced. A small\n locus of blood in the midbrain is again seen. There is only scattered very\n scant foci of subarachnoid hemorrhage (better demonstrated on the MR FLAIR\n sequence). There is very small pneumocephalus in the non- dependent left\n frontal region, likely related to placement of the ventriculostomy.\n\n CRANIAL CTA: The carotid and vertebral arteries and their major branches are\n (Over)\n\n 2:41 PM\n CTA HEAD W&W/O C & RECONS Clip # \n Reason: evaluate origin of bleed\n Admitting Diagnosis: BLEED\n Contrast: OPTIRAY Amt: 80\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n patent without evidence of significant mural irregularity or flow-limiting\n stenosis. There is no focus of contrast-extravasation, either in the midbrain\n or along the lateral ventricular margins. The circle of is complete and\n its vessels are patent, with no evidence of vasospasm, stenosis or occlusive\n lesion. There is no aneurysm or evidence of AVM or other vascular abnormality.\n The distal cervical internal carotid arteries measure 4 mm in minimum\n diameter, bilaterally, at the skull base.\n\n IMPRESSION:\n 1. No evidence of aneurysm, arteriovenous malformation or other vascular\n abnormality as source of massive intraventricular hemorrhage. There is also no\n focal contrast extravasation to suggest a bleeding source or risk of continued\n hemorrhage.\n 2. Only scant subarachnoid hemorrhage, unchanged, with no evidence of\n cerebral vasospasm.\n 3. Extensive intraventricular hemorrhage, with severe obstructive\n hydrocephalus, unchanged.\n 4. Persistent dilatation of the left lateral ventricle, despite the\n ventriculostomy catheter, whose tip may abut or even transgress the lateral\n ventricular wall.\n 5. Persistent disproportionate and cystic-appearing dilatation of the 3rd\n ventricle (despite presence of lateral ventriculostomy) which may,\n effectively, be \"trapped.\"\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-11-25 00:00:00.000",
"description": "CTA HEAD W&W/O C & RECONS",
"row_id": 1050802,
"text": ", C. NSURG SICU-B 2:41 PM\n CTA HEAD W&W/O C & RECONS Clip # \n Reason: evaluate origin of bleed\n Admitting Diagnosis: BLEED\n Contrast: OPTIRAY Amt: 80\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with sudden onset HA with large intraparenchymal hemmorrhage\n REASON FOR THIS EXAMINATION:\n evaluate origin of bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n 1. No evidence of aneurysm, vasospasm or occlusive lesion. No evidence of\n contrast extravasation.\n 2. Persistent massive intraventricular hemorrhage. Severe hydrocephalus, L\n greater than R. Persistent Mass effect. No evidence of subarachnoid\n hemorrhage.\n 3. Tip of ventrilucostomy draining catheter in the left lateral ventricle.\n Concern for non-draining in light of the severe hydrocephalus.\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-11-25 00:00:00.000",
"description": "MR HEAD W & W/O CONTRAST",
"row_id": 1050665,
"text": " 1:10 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: please evaluate for tumors\n Admitting Diagnosis: BLEED\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with IVH\n REASON FOR THIS EXAMINATION:\n please evaluate for tumors\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: NPw FRI 12:50 PM\n extensive intraventricular hemorrhage and some subarachnoid hemorrhage;\n obstructive hydrocephalus; no significant change compared to CT on .\n No abnormal enhancement to suggest mass in the ventricles; however, small\n vascular or neoplastic lesions obscured by the hemorrhage cannot be evaluated\n on the present study- pt. needs follow up after resolution/ evacuation of the\n hematoma.\n Given the presence of IVH and SAH, further evaluation for vascular cause nneds\n to be performed with CTA Head.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 65-year-old male patient, with intraventricular hemorrhage, to\n evaluate for tumors.\n\n COMPARISON: CT of the head done on .\n\n TECHNIQUE: Multiplanar T1- and T2-weighted imaging of the head was performed\n without and with IV contrast.\n\n FINDINGS:\n\n There is extensive intraventricular hemorrhage, noted in the lateral\n ventricles and the third and the cerebral aqueduct and the fourth ventricle,\n the latter being better seen on the prior CT study done on . There is\n a fluid-fluid level noted, in the anterior portions of the lateral ventricles.\n The hemorrhage is more on the left lateral ventricle, with displacement of the\n septum pellucidum and the midline septum pellucidum to the right side by 1.0\n cm and not significantly changed. Some of the blood products are hyperintense\n on the T1- and the T2-weighted images, likely related to subacute stage.\n However, the hemorrhage is predominantly in the acute stage.\n\n No abnormal enhancement is noted in the areas of hemorrhage to suggest mass\n lesion. However, repeat evaluation after resolution of the hematoma or\n evacuation can be considered to assess for any small underlying lesions,\n vascular or neoplastic that may be obscured by the extensive hemorrhage. There\n is mild enhancement of the ependyma in the atria and the occipital horns,\n which may relate to mild inflammation, related to the hemorrhage. Evaluation\n for any restricted diffusion is limited given the presence of hemorrhage.\n There is displacement of the right supraclinoid internal carotid artery and\n the anterior cerebral arteries on both sides from the dilated ventricles.\n There is ventriculostomy catheter noted through the left frontal approach, the\n (Over)\n\n 1:10 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: please evaluate for tumors\n Admitting Diagnosis: BLEED\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n tip in the body of the ventricle, within the area of hemorrhage. There is also\n some increased signal in the cerebral sulci on the FLAIR sequence which may\n relate to subarachnoid hemorrhage in association with the intraventricular\n hemorrhage. There are areas of increased signal in the maxillary sinuses on\n both sides and ethmoid and sphenoid air cells, related to mild mucosal\n thickening along with small retention cyst vs. polyps.\n\n IMPRESSION:\n 1. Extensive intraventricular hemorrhage involving all the ventricles as\n described above, predominantly in the acute stage with a small subacute\n component.\n\n 2. Obstructive hydrocephalus, with dilatation of the left lateral ventricle\n and moderate on the right.\n\n 2. While there is no obvious abnormal enhancement noted within the area of\n hemorrhage, small neoplastic or vascular causes within the ventricles cannot\n be excluded. Repeat evaluation can be considered after evacuation or\n resolution of the hematoma.\n 3. Subarachnoid hemorrhage, in both cerebral hemispheres.\n\n Given the presence of intraventricular and subarachnoid hemorrhage, patient\n needs further evaluation to exclude a vascular cause like an aneurysm by CT\n angiogram. The intracranial arteries are not adequately assessed on the\n present study. Displacement of the right internal carotid artery termination\n and the anterior cerebral arteries on both sides related to the enlarged\n ventricles is noted.\n\n 4. Paranasal sinus disease as described above.\n\n D/w with , NP by Dr. on soon after dictation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-11-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1051151,
"text": " 8:24 PM\n CHEST (PORTABLE AP) Clip # \n Reason: placement of dobhoff tube\n Admitting Diagnosis: BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with large intraparenchymal hemorrhage\n REASON FOR THIS EXAMINATION:\n placement of dobhoff tube\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Followup.\n\n COMPARISON: , 6:22 p.m.\n\n FINDINGS: As compared to the previous examination, the Dobbhoff tube has been\n advanced and is now in correct position. Otherwise, the radiograph is\n unchanged.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-11-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1050588,
"text": " 3:41 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ? tube placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with ich\n REASON FOR THIS EXAMINATION:\n ? tube placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient is a 65-year-old male with intracranial hemorrhage,\n questionable for tube placement.\n\n EXAMINATION: Single supine chest radiograph.\n\n COMPARISONS: There are no prior studies available for comparison.\n\n FINDINGS: There is an endotracheal tube whose tip is approximately 2.4 cm\n above the level of the carina. There is a nasogastric tube that courses below\n the diaphragm and lies within the stomach. The stomach, however, remains\n moderately distended with gas. The lungs are clear. There is no evidence of\n congestive heart failure or pneumonia. There is no evidence of pleural\n effusions or pneumothorax. The cardiac and mediastinal contours are normal in\n appearance. The visualized osseous structures are unremarkable.\n\n IMPRESSION: Slightly low lying endotracheal tube, with tip 2.4 cm above the\n level of the carina.\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-11-24 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1050589,
"text": " 2:56 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with ich\n REASON FOR THIS EXAMINATION:\n ? bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 3:25 PM\n hemorrage centered in the region of the midbrain with a large amount of blood\n in the lateral, third and fourth ventricles with associated hydrocephalus.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 65-year-old male with question of intracerebral hemorrhage.\n Evaluate for bleed.\n\n TECHNIQUE: Contiguous axial images were obtained through the brain. No\n intravenous contrast was administered.\n\n COMPARISON: None.\n\n NON-CONTRAST HEAD CT: There is a large amount of acute hemorrhage centered at\n the level of the mid brain with blood filling the lateral, third, and fourth\n ventricles. Dilatation of the ventricles and transependymal migration of CSF\n is consistent with obstructive hydrocephalus. There is 8 mm rightward shift\n of normally midline structures. Grey-white matter differentiation\n remains preserved. Secretions in the nasopharynx may be related to NG tube.\n Ethmoidal, maxillary, and sphenoidal mucosal thickening is mild. The mastoid\n air cells remain normally aerated. The surrounding osseous structures are\n unremarkable. Note is made of prominent CSF space in the suprasellar cistern,\n which can be seen with marked obstructive hydrocephalus, but a suprasellar\n arachnoid cyst can have a similar appearance.\n\n IMPRESSION: Hemorrhage centered at the level of the mid brain with large\n amount of blood seen within the lateral, third, and fourth ventricles with\n associated hydrocephalus. MRI is recommended.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-11-24 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1050622,
"text": ", C. NSURG SICU-B 5:22 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: S/P DRAIN\n Admitting Diagnosis: BLEED\n ______________________________________________________________________________\n PFI REPORT\n As in prior study, extensive hemorrhage involving entire ventricular system,\n with transependymal migration of CSF. Left ventriculostomy drain placed via\n frontal burr hole technique, with tip satisfactorily terminating in the\n frontal of the left lateral ventricle.\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-11-29 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1051498,
"text": " 11:02 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Interval change of IPH.\n Admitting Diagnosis: BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with Massive Central IPH admitted . Intubated not\n following commands, no sedation.\n REASON FOR THIS EXAMINATION:\n Interval change of IPH.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT HEAD WITHOUT CONTRAST :\n\n HISTORY: Intracranial hemorrhage. Intubated and not following commands off\n sedation.\n\n Contiguous axial images were obtained through the brain. No contrast was\n administered. Comparison to a head CT of .\n\n FINDINGS: There have been no significant changes since the study of , . Again seen is a large cyst centered in the pontine and suprasellar\n cisterns extending superiorly to invaginate into the third ventricle. There\n is obstruction of the lateral ventricles bilaterally. A ventricular catheter\n is present in the left frontal . There is dilatation of the lateral\n ventricles, more severe on the left than right. Extensive intraventricular\n hemorrhage is present in the lateral ventricles with a smaller amount of\n hemorrhage either in the third ventricle or in the cyst inferior to the third.\n The aqueduct and fourth ventricle appear clear by CT standards. There is a\n small amount of subarachnoid hemorrhage in the sylvian fissures bilaterally.\n Overall, the appearance is stable since the earlier examination with no\n evidence of new hemorrhage and stable dilatation of the ventricular systems as\n well as the cyst described above.\n\n CONCLUSION: Stable appearance since . Larger cyst in the prepontine\n and suprasellar cisterns with hydrocephalus and a ventricular catheter in\n place.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-11-29 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 1051499,
"text": " 11:03 AM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: r/o fracture\n Admitting Diagnosis: BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with s/p fall\n REASON FOR THIS EXAMINATION:\n r/o fracture\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT CERVICAL SPINE WITHOUT CONTRAST \n\n HISTORY: Status post fall.\n\n Contiguous axial images were obtained through the cervical spine. No contrast\n was administered. No prior cervical spine imaging studies are available for\n comparison. Sagittal and coronal reformatted images were prepared.\n\n FINDINGS: There is no evidence of fracture or subluxation. There are mild\n degenerative changes at multiple levels with intervertebral osteophytes\n narrowing the spinal canal at C5-6 mildly and C6-7 moderately. There is\n insufficient intraspinal soft tissue contrast resolution to determine whether\n these make a contact with the spinal cord. An endotracheal tube is in place.\n Note that the scout view demonstrates this to be positioned quite close to the\n carina.\n\n A nasogastric tube also was in place.\n\n CONCLUSION: No evidence of fracture or subluxation. Low position of the\n endotracheal tube. These findings were discussed with Dr. at\n the time of interpretation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-11-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1051655,
"text": " 10:04 PM\n CHEST (PORTABLE AP) Clip # \n Reason: fever. r/o pneumonia.\n Admitting Diagnosis: BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with massive intraparencymal hemorhage\n REASON FOR THIS EXAMINATION:\n fever. r/o pneumonia.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Cerebral hemorrhage with fever.\n\n FINDINGS: In comparison with the study of , the Dobbhoff tube has now\n been extended into the body of the stomach. Endotracheal tube and left\n subclavian catheter remain in place.\n\n Specifically, no evidence of acute pneumonia. No vascular congestion or\n pleural effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-12-01 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1052050,
"text": " 2:42 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: please evaluate for size of cyst and any new hemorrhage**ple\n Admitting Diagnosis: BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with s/p cyst drainage\n REASON FOR THIS EXAMINATION:\n please evaluate for size of cyst and any new hemorrhage**please do within 4\n hours**\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION:\n\n 65-year-old male patient, with status post cyst drainage, for followup\n evaluation.\n This is a redictation of the report as the prior dictation was lost before\n transcription.\n\n COMPARISON:\n\n CT of the head done on in the OR.\n\n TECHNIQUE: Non-contrast CT of the head was performed.\n\n FINDINGS:\n\n There is a ventricular drain/reservoir catheter noted through the left frontal\n approach, with the tip in the region of the prepontine portion of the cyst.\n There is no significant change in the size of the cyst or the areas of\n intraventricular and subarachnoid hemorrhage compared to the study done few\n hours earlier. Small amount of pneumocephalus is noted. No new areas of\n hemorrhage are noted.\n\n IMPRESSION:\n\n 1. No significant change in the areas of intracranial hemorrhage, or the size\n of the cyst in the prepontine and suprasellar region.\n\n Close followup as clinically indicated.\n\n\n\n"
},
{
"category": "ECG",
"chartdate": "2147-01-04 00:00:00.000",
"description": "Report",
"row_id": 241348,
"text": "Sinus bradycardia. Normal tracing. Compared to the previous tracing\nof there is a change in the atrial morphology. The rate has slowed.\nOtherwise, no diagnostic interim change.\n\n"
},
{
"category": "ECG",
"chartdate": "2146-12-14 00:00:00.000",
"description": "Report",
"row_id": 241349,
"text": "Sinus rhythm. Normal tracing. Compared to the previous tracing of \nthe rate has slowed. Otherwise, no diagnostic interim change.\n\n"
},
{
"category": "ECG",
"chartdate": "2146-11-30 00:00:00.000",
"description": "Report",
"row_id": 241350,
"text": "Sinus rhythm\nNormal ECG\nNo previous tracing available for comparison\n\n"
}
] |
46,262 | 155,235 | # Hypotension/Pneumonia: Patient was admitted to the ICU with tachycardia, fever, and hypotension which was felt most likely from acute pneumonia given cough, pleuritis, and opacities on CXR. Pt was covered with Vancomycin/Levofloxacin due to her history of MRSA PNA. She was aggressively fluid resuscitated and supported with pressors with resolution of hypotension. Pt did not require ventilator support and later had significant autodiuresis of large volumes of urine and BP remained stable off pressors. She was called out to the floor with resolution of fevers. Additional infectious work up included multiple negative Urine & Blood Cx, an echo that did not show any vegetations, negative HIV viral load, negative Viral Influenza screen and negative Legionella Antigen. Leukocytosis continued to resolve on Linezolid with high dose Levofloxacin. Pt was continued on Linezolid for an 8 day course and pre-authorization was obtained for po Linezolid on discharge to sober house. Levofloxacin was transitioned to Moxifloxacin to complete the 8 day course due to insurance approval requirements. . # Abnomal LFTs: Pt reports intermittent RUQ pain and initial u/s showed small amount of ascites though not enough for paracentesis and LFTs revealed a mildly elevated transaminases with mild Alk Phos elevation. Hepatitis panel was sent and returned positive for Hep C Ab though Hep C VL was negative. Hep B studies revealed prior immunization and repeated RUQ u/s was performed prior to discharge which showed small periportal lymphadenopathy. These results were discussed with the patient and she was given an appointment to follow up with the liver clinic for further investigation. . # Narcotic addiction: Pt was continued on Methadone at confirmed clinic doses but had an epsiode of somnolence in the ICU thought due to multidrug interaction. There was concern raised for in hospital drug abuse though repeat urine drug screen returned positive for opiates (on Methadone) and barbituates (on Fioricet) without any unexplained positive substances on the screen. Given this concern, all visitors were screened prior to visits. After being transitioned to medical floor, pt was restarted on her home medication regimen including Clonidine, Clonazepam and Methadone with mild intermittent somnolence though no acute episodes of confusion. It was suggested that this regimen may be overmedicating her and pt felt that it was necessary to treat her anxiety and withdrawal. She was discharged with plan for PCP and clinic follow up but was not given any refills on these medications. . # Vulvovaginitis: Pt reported symptoms of vaginal itching/burning consistent with prior yeast infections. Symptoms were only somewhat relieved with fluconazole/miconazole cream. Pt endorsed some concern of possible exposure to an STI prior to admission and pelvic exam was performed on that was significant for vulvar irritation most likely c/ . Cervical swabs were sent for gonorrhea/chlamydia but were pending at the time of this dictation. We will follow up on the final results. Pt was discharged with a course of miconazole and acidophilus per her request. | Normal main PA. No Doppler evidence for PDAPERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - patient unable to cooperate.Conclusions:The left atrium is normal in size. There is no mitral valve prolapse.There is moderate pulmonary artery systolic hypertension. No MS.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Moderate PA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. PA AND LATERAL CHEST RADIOGRAPH: Cardiac, mediastinal and hilar contours are normal. No resting LVOT gradient.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level. The portal vein is patent and shows normal hepatopetal flow. PORTABLE SUPINE AP CHEST RADIOGRAPH: The tip of the right internal jugular catheter projects over the expected location of the upper SVC, unchanged from prior. Cardiomediastinal and hilar contours are normal. PATIENT/TEST INFORMATION:Indication: EndocarditisHeight: (in) 70Weight (lb): 145BSA (m2): 1.82 m2BP (mm Hg): 102/58HR (bpm): 115Status: InpatientDate/Time: at 11:23Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/globalsystolic function (LVEF >55%). Heart and mediastinum are within normal limits. Normal tricuspid valve supporting structures.No TS. Right IJ catheter terminates in the superior vena cava. Both lungs are clear with no focal consolidation, pleural effusion or pneumothorax. The mitral valve appears structurallynormal with trivial mitral regurgitation. The aortic valveleaflets (3) appear structurally normal with good leaflet excursion and noaortic stenosis or aortic regurgitation. The pancreas appears normal. Spleen appears normal and is not enlarged. Normal ascending aortadiameter.AORTIC VALVE: Normal aortic valve leaflets (3). No AR.MITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. No CBD dilatation is noted. Left ventricular wall thickness, cavitysize and regional/global systolic function are normal (LVEF 70%). Heart size normal. Rightventricular chamber size and free wall motion are normal. Left lung is clear. Normalmitral valve supporting structures. The liver is normal in echotexture and demonstrates no focal or diffuse lesions. Both kidneys are normal in size and shape with no evidence of calculi or hydronephrosis. There is nopericardial effusion.IMPRESSION: no vegetations seen, but suboptimal image qualityIf clinically suggested, the absence of a vegetation by 2D echocardiographydoes not exclude endocarditis. The left lung is clear. The left lung is clear. ST-T wave abnormalities areless marked.TRACING #2 Tip of the new right internal jugular line ends in the upper SVC. IMPRESSION: Improved aeration of the right lung with residual mild opacification. Standard position of right central line. No evidence of intrahepatic biliary radical dilatation noted. No pleural effusion. Within normal limits. There is no pulmonary edema, pleural effusions, or pneumothorax. No other remarkable abnormalities noted. No pneumothorax. COMPARISON: PA and lateral chest radiograph, . Minor ST-T wave abnormalities.Since the previous tracing the rate is slower. Sinus rhythm at upper limits of normal rate. Compared to the prior study from , there is marked improvement with decreased consolidation of the right upper and mid lung zones, although mild opacification remains. IMPRESSION: Small periportal nodes, subcentimeteric in short axis diameter. FINDINGS: There is trace ascites noted in Morison's pouch in the right upper quadrant. IMPRESSION: Trace ascites in Morison's pouch not amenable to ultrasound-guided paracentesis. 2:28 AM CHEST (PORTABLE AP) Clip # Reason: eval for acute CT process? No PS.Physiologic PR. COMPARISON: Chest radiograph from . No mass orvegetation on tricuspid valve. There is no mediastinal widening, pneumothorax, or pleural effusion. No evidence of ascites noted. There is not enough ascites to be amenable to ultrasound guided paracentesis. ST-T wave abnormalities. Sinus rhythm. LINE PLACEMENT; -76 BY SAME PHYSICIAN # Reason: line placement? Sinus tachycardia. The papid progression makes primary active tuberculosis very unlikely. COMPARISON: Previous ultrasound examination dated . IMPRESSION: 1. No AS. Sincethe previous tracing of the rate is faster.TRACING #1 The rapid progression of the right lung opacities are indicative of fulminant pneumonia. Ultrasound examination of the upper abdomen was performed. Early R wave progression. FINDINGS: Two views of the chest compared to the prior study from . Differential diagnosis includes Pneumococcus, Legionella, or Klebsiella. Another smaller node is also noted in the periportal region measuring 1.2 x 0.6 cm. 5:17 AM CHEST PORT. Rapidly progressive fulminant pneumonia involving the right upper lobe and probable superior segment of the right lower lobe. There is a periportal node measuring 2 x 0.8 cm in dimension. There is new heterogeneous opacification in the right mid and upper lung zones strongly suggestive of developing pneumonia. IMPRESSION: AP chest compared to , 2:41 a.m. 2. 11:06 AM US ABD LIMIT, SINGLE ORGAN Clip # Reason: Please evaluate for ascites Admitting Diagnosis: FEVER MEDICAL CONDITION: 36 year old woman with hepC, RUQ pain s/p ccy and abd distention REASON FOR THIS EXAMINATION: Please evaluate for ascites FINAL REPORT INDICATION: 36-year-old female with hepatitis C, right upper quadrant pain, status post cholecystectomy and abdominal distention, assess for ascites. Opacification of the right upper and mid lung zones has rapidly increased, now more confluent and severe. 2:33 PM ABDOMEN U.S. (COMPLETE STUDY) Clip # Reason: pls evaluate for biliary dilation Admitting Diagnosis: FEVER MEDICAL CONDITION: 36 year old woman with PMHx of hep C, s/p CCY, abn transaminases and intermittent severe epigastric pain REASON FOR THIS EXAMINATION: pls evaluate for biliary dilation FINAL REPORT CLINICAL INDICATION: 36-year-old woman with status post cholecystectomy and abnormal transaminases with intermittent severe epigastric pain. | 10 | [
{
"category": "Echo",
"chartdate": "2158-05-12 00:00:00.000",
"description": "Report",
"row_id": 63791,
"text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis\nHeight: (in) 70\nWeight (lb): 145\nBSA (m2): 1.82 m2\nBP (mm Hg): 102/58\nHR (bpm): 115\nStatus: Inpatient\nDate/Time: at 11:23\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. Normal\nmitral valve supporting structures. No MS.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. No mass or\nvegetation on tricuspid valve. Normal tricuspid valve supporting structures.\nNo TS. Moderate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR. Normal main PA. No Doppler evidence for PDA\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - patient unable to cooperate.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thickness, cavity\nsize and regional/global systolic function are normal (LVEF 70%). Right\nventricular chamber size and free wall motion are normal. The aortic valve\nleaflets (3) appear structurally normal with good leaflet excursion and no\naortic stenosis or aortic regurgitation. The mitral valve appears structurally\nnormal with trivial mitral regurgitation. There is no mitral valve prolapse.\nThere is moderate pulmonary artery systolic hypertension. There is no\npericardial effusion.\n\nIMPRESSION: no vegetations seen, but suboptimal image quality\n\nIf clinically suggested, the absence of a vegetation by 2D echocardiography\ndoes not exclude endocarditis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2158-05-12 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1185624,
"text": " 5:17 AM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: line placement?\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 36 year old woman with central ine placement\n REASON FOR THIS EXAMINATION:\n line placement?\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 5:25 A.M.\n\n HISTORY: 36-year-old woman with a central line placed.\n\n IMPRESSION: AP chest compared to , 2:41 a.m.\n\n Tip of the new right internal jugular line ends in the upper SVC. There is no\n mediastinal widening, pneumothorax, or pleural effusion. There is new\n heterogeneous opacification in the right mid and upper lung zones strongly\n suggestive of developing pneumonia. Left lung is clear. Heart size normal.\n No pleural effusion.\n\n Findings were discussed with the physician covering in the ICU at 10:15 a.m.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2158-05-14 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1185932,
"text": " 2:09 PM\n CHEST (PA & LAT) Clip # \n Reason: ?pleural effusion, change in pneumonia\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 36 year old woman with pneumonia, persistent fevers\n REASON FOR THIS EXAMINATION:\n ?pleural effusion, change in pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n CHEST TWO VIEWS, \n\n CLINICAL INFORMATION: Question pleural effusion, change in pneumonia.\n\n FINDINGS:\n\n Two views of the chest compared to the prior study from . Right IJ\n catheter terminates in the superior vena cava. Compared to the prior study\n from , there is marked improvement with decreased consolidation of\n the right upper and mid lung zones, although mild opacification remains. The\n left lung is clear. Heart and mediastinum are within normal limits.\n\n IMPRESSION:\n\n Improved aeration of the right lung with residual mild opacification.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2158-05-17 00:00:00.000",
"description": "ABDOMEN U.S. (COMPLETE STUDY)",
"row_id": 1186328,
"text": " 2:33 PM\n ABDOMEN U.S. (COMPLETE STUDY) Clip # \n Reason: pls evaluate for biliary dilation\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 36 year old woman with PMHx of hep C, s/p CCY, abn transaminases and\n intermittent severe epigastric pain\n REASON FOR THIS EXAMINATION:\n pls evaluate for biliary dilation\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: 36-year-old woman with status post cholecystectomy and\n abnormal transaminases with intermittent severe epigastric pain.\n\n Ultrasound examination of the upper abdomen was performed.\n\n COMPARISON: Previous ultrasound examination dated .\n\n The liver is normal in echotexture and demonstrates no focal or diffuse\n lesions. No evidence of intrahepatic biliary radical dilatation noted. No\n CBD dilatation is noted. The portal vein is patent and shows normal\n hepatopetal flow. There is a periportal node measuring 2 x 0.8 cm in\n dimension. Another smaller node is also noted in the periportal region\n measuring 1.2 x 0.6 cm. The pancreas appears normal. Both kidneys are normal\n in size and shape with no evidence of calculi or hydronephrosis. Spleen\n appears normal and is not enlarged. No evidence of ascites noted.\n\n IMPRESSION: Small periportal nodes, subcentimeteric in short axis diameter.\n No other remarkable abnormalities noted.\n\n"
},
{
"category": "Radiology",
"chartdate": "2158-05-12 00:00:00.000",
"description": "US ABD LIMIT, SINGLE ORGAN",
"row_id": 1185663,
"text": " 11:06 AM\n US ABD LIMIT, SINGLE ORGAN Clip # \n Reason: Please evaluate for ascites\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 36 year old woman with hepC, RUQ pain s/p ccy and abd distention\n REASON FOR THIS EXAMINATION:\n Please evaluate for ascites\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 36-year-old female with hepatitis C, right upper quadrant pain,\n status post cholecystectomy and abdominal distention, assess for ascites.\n\n FINDINGS:\n There is trace ascites noted in Morison's pouch in the right upper quadrant.\n There is not enough ascites to be amenable to ultrasound guided paracentesis.\n\n IMPRESSION:\n Trace ascites in Morison's pouch not amenable to ultrasound-guided\n paracentesis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2158-05-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1185633,
"text": " 8:00 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Evaluate for effusion, pneumonia\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 36 year old woman with cough and dyspnea\n REASON FOR THIS EXAMINATION:\n Evaluate for effusion, pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 36-year-old female with cough and dyspnea.\n\n COMPARISON: Chest radiograph from .\n\n PORTABLE SUPINE AP CHEST RADIOGRAPH: The tip of the right internal jugular\n catheter projects over the expected location of the upper SVC, unchanged from\n prior. Opacification of the right upper and mid lung zones has rapidly\n increased, now more confluent and severe. The rapid progression of the right\n lung opacities are indicative of fulminant pneumonia. Differential diagnosis\n includes Pneumococcus, Legionella, or Klebsiella. Alveolar hemorrhage\n secondary to infection is also possible, recommend correlation with clinical\n signs and symptoms. The papid progression makes primary active tuberculosis\n very unlikely. The left lung is clear. Cardiomediastinal and hilar contours\n are normal. There is no pulmonary edema, pleural effusions, or pneumothorax.\n\n IMPRESSION:\n 1. Rapidly progressive fulminant pneumonia involving the right upper lobe and\n probable superior segment of the right lower lobe.\n 2. Standard position of right central line. No pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2158-05-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1185608,
"text": " 2:28 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for acute CT process?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 36 year old woman with c/o high fever and rigors, not feeling well,\n REASON FOR THIS EXAMINATION:\n eval for acute CT process?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 36-year-old woman with complaint of high fever and rigors, not\n feeling well.\n\n COMPARISON: PA and lateral chest radiograph, .\n\n PA AND LATERAL CHEST RADIOGRAPH: Cardiac, mediastinal and hilar contours are\n normal. Both lungs are clear with no focal consolidation, pleural effusion or\n pneumothorax.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2158-05-12 00:00:00.000",
"description": "Report",
"row_id": 124445,
"text": "Sinus rhythm at upper limits of normal rate. Minor ST-T wave abnormalities.\nSince the previous tracing the rate is slower. ST-T wave abnormalities are\nless marked.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2158-05-12 00:00:00.000",
"description": "Report",
"row_id": 124446,
"text": "Sinus tachycardia. Early R wave progression. ST-T wave abnormalities. Since\nthe previous tracing of the rate is faster.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2158-05-07 00:00:00.000",
"description": "Report",
"row_id": 124447,
"text": "Sinus rhythm. Within normal limits.\n\n"
}
] |
5,488 | 115,727 | Admitted on and underwent AVR/ replacement of asc. and hemi-arch aorta with Dr. . Transferred to the CSRU in stable condition on insulin and propofol drips. Extubated that evening and off all drips on POD #1. Swan removed, and transferred to the floor to begin increasing his activity level. C/O bilat. hand paresthesias with significant edema which slightly improved on POD #2. Chest tubes, pacing wires and foley removed. Beta blockade titrated for better HR and BP management, and gentle diuresis continued. Went into AFib on POD #3, converted to SR on lopressor, and then had another eipsode. Lytes were repleted and converted to SR again. Remained in SR and was cleared for discharge to home with VNA services on POD #5. Pt. is to follow up as per discharge instructions. | Normal descending aorta diameter. Mild tomoderate (+) aortic regurgitation is seen. Normal regional LV systolic function. Physiologic mitral regurgitation is seen (within normallimits). There are simple atheroma in thedescending thoracic aorta. Moderately dilated ascending aorta. Stable postoperative appearance to the cardiomediastinal silhouette following AVR. Lownormal LVEF.LV WALL MOTION: basal anterior - normal; mid anterior - normal; basalanteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal;mid inferoseptal - normal; basal inferior - normal; mid inferior - normal;basal inferolateral - normal; mid inferolateral - normal; basal anterolateral- normal; mid anterolateral - normal; anterior apex - normal; septal apex -normal; inferior apex - normal; lateral apex - normal; apex - normal;RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic root diameter. Physiologic MR (withinnormal limits).TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: A TEE was performed in the location listed above. Simpleatheroma in descending aorta.AORTIC VALVE: Mildly thickened aortic valve leaflets. Mild bibasilar atelectasis. Theascending aorta is moderately dilated. B/P STABLE, NO GTT.RESP: LUNGS CLEAR WITH DIM BASES. IMPRESSION: PA and lateral chest compared to : Small bilateral pleural effusion probably unchanged since , no pneumothorax, following removal of pleural and midline drains. Mild to moderate(+) AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. There aretwo jets of trace aortic regurgitation - one appears valvular and the otherperivalvular. The leftventricular cavity size is normal. TURNS/REPOSITIONS SELF.CV: SR/ST, NO ECTOPY. ABD SOFT, HYPO BS.GU: FOLEY PATENT. The aortic valve leaflets are mildly thickened.There is commisural fusion of the left and right coronary cusps leading to afunctionally bicuspid aortic valve. labile bp on arrival with low filling pressures,brisk huo(intra op lasix),hypothermia but excellent hemodynamics/svo2 treated with volume,neo titration,warming & transient a pacing with effect. Right ventricular chamber size and free wall motion are normal. IMPRESSION: Resolution of bilateral pleural effusions. advanced to percocet,toradol started & continued on low dose precedex with better control. Normal LV cavity size. Trachea is midline. There is no pericardial effusion.POST-CPB Normal biventricular systolic function. Upper lungs clear. Cardiomediastinal contours are unchanged. PA and lateral radiographs of the chest demonstrate resolution of the previously seen bilateral pleural effusions. extremity warm with rapid refill,normal motion & pleth wave. C/O SINUS POSTNASAL DRIP THAT HAS BEEN ONGOING.GI: TOLERATING CLEAR LIQ/PILLS WITHOUT NAUSEA. The patient appears to be in sinus rhythm. able to extubate w/o incident after precedex started,calm & cooperative.sternal discomfort controlled only for short periods of time with iv morphine. Sinus rhythm. Regional left ventricular wall motion isnormal. TREATED WITH PERCOCET AND ELEVATION WITH ENCOURAGEMENT. Focalcalcifications in ascending aorta. Patchy bibasilar atelectatic changes are present as well as a probable small left pleural effusion. The patient was under general anesthesia throughout theprocedure. An endotracheal tube terminates just above the level of the clavicles, approximately 6-1/2 cm above the carina. The valve is well seated and displays normal leaflet function. Ascending aortic graft in situ. INDICATION: Status post aortic valve surgery. O2 AT 4LNC, SATS ADEQUATE. Lungs are clear. ADEQUATE HUO.ENDO: HUMULIN-R GTT, TITRATED PER CSRU PROTOCOL.PLAN: D/C SWAN, TXFR TO 2. Swan-Ganz catheter is in the right main pulmonary artery, nasogastric tube terminates in the stomach, and mediastinal drains are present. PATIENT/TEST INFORMATION:Indication: Intraoperative TEE for repair of ascending aortic aneurysmHeight: (in) 71Weight (lb): 215BSA (m2): 2.18 m2BP (mm Hg): 142/72HR (bpm): 74Status: InpatientDate/Time: at 10:39Test: TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2Dimages. Compared to the previous tracingof cardiac now atrial flutter. Delayed anterior precordial R wave progression.Non-diagnostic repolarization abnormalities. A small amount of pneumomediastinum is present tracking into the soft tissues of the lower neck. Aortic valve bioprosthesis insitu. Clinical correlation is suggested. IMPRESSION: Proximal location of endotracheal tube, which could be advanced several centimeters for standard positioning as communicated by telephone to Dr. on I certifyI was present in compliance with HCFA regulations. Atrial flutter with 2:1 block. a line removed & pt. Overall left ventricular systolic function is low normal (LVEF50-55%). Results were personallyreviewed with the MD caring for the patient.Conclusions:PRE-CPB No atrial septal defect is seen by 2D or color Doppler. breathing despite high dose propofol,reversed & propofol decreased but extremely agitated,thrashing,biting ett & only intermittently following commands.resedated & precedex ordered. No aortic stenosis. goal bp is 85-120 mm hg.shortly after weaning parameters met noted spont. Left axis deviation. Delayed precordial R wave progression.Compared to the previous tracing of there is now left axis deviation andthe rate has increased. There is no aortic valve stenosis. NO COUGH. hand. OOB > CHAIR. Cardiac and mediastinal contours appear slightly prominent, but are likely accentuated by technical factors of the exam as well as due to postoperative changes related to recent surgery. No TEE relatedcomplications. No newaortic pathology noted. The mitral valve leaflets aremildly thickened. able to participate in deep breathing,performing 1250 cc on spirometer.c/o severe parasthesias,tingling in rt. No AS. NO PACING NOTED. CSRU NPNNEURO: A/OX3, ANXIOUS AT TIMES. TCDB/IS TEACHING. 2:06 PM CHEST (PORTABLE AP) Clip # Reason: pleural effusion, tamponade, pulmonary edema, pneumothorax Admitting Diagnosis: ASCENDING AORTIC ANEURYSM\BENTAL PROCEDURE /SDA MEDICAL CONDITION: 51 year old man with AVR/ASC Aorta replacement REASON FOR THIS EXAMINATION: pleural effusion, tamponade, pulmonary edema, pneumothorax FINAL REPORT PORTABLE SUPINE CHEST DATED COMPARISON: . | 8 | [
{
"category": "Nursing/other",
"chartdate": "2131-07-24 00:00:00.000",
"description": "Report",
"row_id": 1334470,
"text": "labile bp on arrival with low filling pressures,brisk huo(intra op lasix),hypothermia but excellent hemodynamics/svo2 treated with volume,neo titration,warming & transient a pacing with effect. goal bp is 85-120 mm hg.shortly after weaning parameters met noted spont. breathing despite high dose propofol,reversed & propofol decreased but extremely agitated,thrashing,biting ett & only intermittently following commands.resedated & precedex ordered. able to extubate w/o incident after precedex started,calm & cooperative.sternal discomfort controlled only for short periods of time with iv morphine. advanced to percocet,toradol started & continued on low dose precedex with better control. able to participate in deep breathing,performing 1250 cc on spirometer.c/o severe parasthesias,tingling in rt. hand. extremity warm with rapid refill,normal motion & pleth wave. a line removed & pt. encouraged by me & to keep arm elevated but is reluctant to comply at times.cuff bp's correlate in both arms.glucoses in range using insulin gtt,see flow sheet.plan to deline,advance diet & activity &continue to control glucoses,probable 2 in a.m.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-07-25 00:00:00.000",
"description": "Report",
"row_id": 1334471,
"text": "CSRU NPN\nNEURO: A/OX3, ANXIOUS AT TIMES. C/O BUE \"HOT POKER DRAGGING DOWN THE NERVES.\" TREATED WITH PERCOCET AND ELEVATION WITH ENCOURAGEMENT. TURNS/REPOSITIONS SELF.\n\nCV: SR/ST, NO ECTOPY. NO PACING NOTED. B/P STABLE, NO GTT.\n\nRESP: LUNGS CLEAR WITH DIM BASES. O2 AT 4LNC, SATS ADEQUATE. NO COUGH. C/O SINUS POSTNASAL DRIP THAT HAS BEEN ONGOING.\n\nGI: TOLERATING CLEAR LIQ/PILLS WITHOUT NAUSEA. ABD SOFT, HYPO BS.\n\nGU: FOLEY PATENT. ADEQUATE HUO.\n\nENDO: HUMULIN-R GTT, TITRATED PER CSRU PROTOCOL.\n\nPLAN: D/C SWAN, TXFR TO 2. TCDB/IS TEACHING. INCREASE ACTIVITY. OOB > CHAIR.\n"
},
{
"category": "Echo",
"chartdate": "2131-07-24 00:00:00.000",
"description": "Report",
"row_id": 80855,
"text": "PATIENT/TEST INFORMATION:\nIndication: Intraoperative TEE for repair of ascending aortic aneurysm\nHeight: (in) 71\nWeight (lb): 215\nBSA (m2): 2.18 m2\nBP (mm Hg): 142/72\nHR (bpm): 74\nStatus: Inpatient\nDate/Time: at 10:39\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D\nimages. Normal LV cavity size. Normal regional LV systolic function. Low\nnormal LVEF.\n\nLV WALL MOTION: basal anterior - normal; mid anterior - normal; basal\nanteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal;\nmid inferoseptal - normal; basal inferior - normal; mid inferior - normal;\nbasal inferolateral - normal; mid inferolateral - normal; basal anterolateral\n- normal; mid anterolateral - normal; anterior apex - normal; septal apex -\nnormal; inferior apex - normal; lateral apex - normal; apex - normal;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter. Moderately dilated ascending aorta. Focal\ncalcifications in ascending aorta. Normal descending aorta diameter. Simple\natheroma in descending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets. No AS. Mild to moderate\n(+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Physiologic MR (within\nnormal limits).\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. No TEE related\ncomplications. The patient was under general anesthesia throughout the\nprocedure. The patient appears to be in sinus rhythm. Results were personally\nreviewed with the MD caring for the patient.\n\nConclusions:\nPRE-CPB No atrial septal defect is seen by 2D or color Doppler. The left\nventricular cavity size is normal. Regional left ventricular wall motion is\nnormal. Overall left ventricular systolic function is low normal (LVEF\n50-55%). Right ventricular chamber size and free wall motion are normal. The\nascending aorta is moderately dilated. There are simple atheroma in the\ndescending thoracic aorta. The aortic valve leaflets are mildly thickened.\nThere is commisural fusion of the left and right coronary cusps leading to a\nfunctionally bicuspid aortic valve. There is no aortic valve stenosis. Mild to\nmoderate (+) aortic regurgitation is seen. The mitral valve leaflets are\nmildly thickened. Physiologic mitral regurgitation is seen (within normal\nlimits). There is no pericardial effusion.\n\nPOST-CPB Normal biventricular systolic function. Aortic valve bioprosthesis in\nsitu. The valve is well seated and displays normal leaflet function. There are\ntwo jets of trace aortic regurgitation - one appears valvular and the other\nperivalvular. No aortic stenosis. Ascending aortic graft in situ. No new\naortic pathology noted.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2131-07-27 00:00:00.000",
"description": "Report",
"row_id": 201741,
"text": "Atrial flutter with 2:1 block. Delayed anterior precordial R wave progression.\nNon-diagnostic repolarization abnormalities. Compared to the previous tracing\nof cardiac now atrial flutter.\n\n"
},
{
"category": "ECG",
"chartdate": "2131-07-24 00:00:00.000",
"description": "Report",
"row_id": 201742,
"text": "Sinus rhythm. Left axis deviation. Delayed precordial R wave progression.\nCompared to the previous tracing of there is now left axis deviation and\nthe rate has increased. Clinical correlation is suggested.\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-07-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 916724,
"text": " 2:06 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pleural effusion, tamponade, pulmonary edema, pneumothorax\n Admitting Diagnosis: ASCENDING AORTIC ANEURYSM\\BENTAL PROCEDURE /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with AVR/ASC Aorta replacement\n REASON FOR THIS EXAMINATION:\n pleural effusion, tamponade, pulmonary edema, pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE SUPINE CHEST DATED \n\n COMPARISON: .\n\n INDICATION: Status post aortic valve surgery.\n\n An endotracheal tube terminates just above the level of the clavicles,\n approximately 6-1/2 cm above the carina. Swan-Ganz catheter is in the right\n main pulmonary artery, nasogastric tube terminates in the stomach, and\n mediastinal drains are present. Cardiac and mediastinal contours appear\n slightly prominent, but are likely accentuated by technical factors of the\n exam as well as due to postoperative changes related to recent surgery.\n Patchy bibasilar atelectatic changes are present as well as a probable small\n left pleural effusion. A small amount of pneumomediastinum is present\n tracking into the soft tissues of the lower neck.\n\n IMPRESSION:\n\n Proximal location of endotracheal tube, which could be advanced several\n centimeters for standard positioning as communicated by telephone to Dr. \n on \n\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-07-26 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 917094,
"text": " 3:42 PM\n CHEST (PA & LAT) Clip # \n Reason: r/o ptx s/p ct's removed\n Admitting Diagnosis: ASCENDING AORTIC ANEURYSM\\BENTAL PROCEDURE /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with\n REASON FOR THIS EXAMINATION:\n r/o ptx s/p ct's removed\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST ON \n\n HISTORY: Chest tubes removed, rule out pneumothorax.\n\n IMPRESSION: PA and lateral chest compared to :\n\n Small bilateral pleural effusion probably unchanged since , no\n pneumothorax, following removal of pleural and midline drains. Stable\n postoperative appearance to the cardiomediastinal silhouette following AVR.\n Mild bibasilar atelectasis. Upper lungs clear.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-07-28 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 917367,
"text": " 4:20 PM\n CHEST (PA & LAT) Clip # \n Reason: r/o inf., eff\n Admitting Diagnosis: ASCENDING AORTIC ANEURYSM\\BENTAL PROCEDURE /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with\n\n REASON FOR THIS EXAMINATION:\n r/o inf., eff\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Effusion.\n\n PA and lateral radiographs of the chest demonstrate resolution of the\n previously seen bilateral pleural effusions. Cardiomediastinal contours are\n unchanged. Lungs are clear. Trachea is midline.\n\n IMPRESSION:\n\n Resolution of bilateral pleural effusions.\n\n\n"
}
] |
8,076 | 141,464 | The patient was admitted to for cardiac catheterization, which showed normal ejection fraction, left ventricular end diastolic pressure of 19, diffusely diseased LAD with an 80% mid LAD lesion, 50% ostial left circumflex stenosis, 80% proximal OM-1 lesion, 70% mid OM-1 lesion, 90% proximal RCA lesion, and 99% mid RCA lesion. Patient was referred to Dr. for coronary artery bypass grafting. Patient was taken to the operating room on with Dr. for CABG x3. Underwent a LIMA to LAD, saphenous vein graft to PDA and OM. Please see operative note for further details. The patient was transported to the Intensive Care Unit in stable condition. Patient was weaned and extubated for mechanical ventilation. On his first postoperative night, patient began working with Physical Therapy on postoperative day #1. On postoperative day #2, the patient was noted to have some decrease in his oxygen saturation requiring up to 50% face tent, maintained adequate oxygen saturation. Due to his prior history of asbestos exposure and abnormal chest x-ray, Pulmonary consult was obtained. Per the Pulmonary Medicine team, it was felt that the patient's hypoxia was due to multiple factors including volume overload, atelectasis, as well as his prior asbestos exposure. They recommended starting the patient on albuterol and Atrovent nebulizers, encouraging coughing and deep breathing, chest physiotherapy, and diuresis. Patient began working with physical therapy, increasing his mobility, and patient was aggressively diuresed over the next couple of days with improvement in his oxygen saturation. Chest x-ray continued to lung volumes, however, by postoperative day #3, patient improved sufficiently and was stable to transfer from the Intensive Care Unit to the regular part of the hospital, where he continued receiving albuterol and Atrovent nebulizers, and aggressive chest pulmonary toilet. On postoperative day #4, the patient after having been ambulating with physical therapy, was able to ambulate 500 feet. On postoperative day #5, patient's oxygen had been weaned off and the patient had adequate oxygen saturation on room air anywhere from 90-94 without complaints of shortness of breath. Patient's chest x-ray on postoperative day #5 showed improved lung volumes, decreased atelectasis, and small bilateral pleural effusions. Patient's epicardial pacing wires were removed on postoperative day #5 without incident, and by postoperative day #6, the patient was cleared for discharge to home. | ct drainage minimal.neuro: reversals given/prop off. plan to extubate when more awake.gi/gu: absent bs. BS upper clear, lower=rales. lytes repleated.resp: lungs clear. SEMI-UPRIGHT AP CHEST: There is again evidence of prior CABG with median sternotomy wires and vascular clips. FINDINGS: There is interval removal of the ETT. Lungs clear in upper lobes, diminished in base bilat. TECHNIQUE: PA and lateral chest. FINDINGS: The heart size and mediastinal contours are within normal limits. Rule out pneumothorax. AP supine single view of the chest is compared to . Mild CHF. AP semi-upright single view of the chest is compared to . AP SEMI-UPRIGHT SINGLE VIEW OF THE CHEST is compared to . Small left pleural effusion. Pulmonary vascularity appears to be within normal limits. suctioned x1->no secreations. Noprevious tracing available for comparison. Patient is s/p median sternotomy and CABG. ct & jp drainage minimal. There is again note of low lung volumes. There is probably a small left pleural effusion. There is a small left pleural effusion. FINDINGS: The patient is status post CABG. +pp bilat. Cannot exclude bilateral small pleural effusions. ez intubation. arrived on neo & prop. There is again note of bilateral calcified pleural plaques. IMPRESSION: Small lung volume. HAS BS. PT UPDATE PT IS S/P CABG X3 ON . The cardiac, mediastinal and hilar contours are unchanged. The heart, mediastinal and hilar contours are unchanged. Sinus rhythm with borderline first degree A-V block. There is interval removal of left chest tube and left IJ central line. There is a left chest tube. og->lws. There are small bilateral pleural effusions and adjacent atelectasis. U/O ADEQUATE. IMPRESSION: 1. IMPRESSION: 1. Poor R wave progressionin leads VI-V4 consistent with old anteroseptal myocardial infarction. There is an NG tube extending beyond the limits of radiograph and postoperative changes status post median sternotomy and CABG. BS CLEAR, SL. There is again noted the bilateral retrocardiac patchy opacities that are unchanged when compared to the previous study. + periph pulses, no edema, extrems warm. There are again demonstrated bilateral calcified pleural plaques. CV: PT INTO AFIB 2230. Slightly improved appearance of left lower lobe atelectasis and small effusion. There are low lung volumes. IMPRESSION: 1) Interval extubation with marked decrease in lung volumes bilaterally. There is again note of prior CABG. Low lung volumes. 2) Bilateral retrocardiac opacities are unchanged when compared to the previous study. u/o 20-30/hr, lasix given.Skin-Sternun, mediastinum dsgs intact; RLE, D&I, ace re-wrapped. slow to wake. hr<60 & sbp<90 after reversals. arrouse to voice. There is a mediastinal tube. There is a mediastinal tube. CT pain limiting full expansion. Pleased w/ pt progress.A/PMonitor resp status. There is left lower lobe atelectasis and a small pleural effusion, which appears slightly improved compared to the prior study. There is a left-sided chest. post op note:s/p cabg x3. There is small left subcutaneous emphysema in the left axilla. RESP: PT SEEN BY PULMONARY TEAM YEST-?IF OXYGENATION AND SATS IN LOW 90'S ARE PT'S BASELINE. Increased bibasilar patchy atelectasis. Sinus rhythmBorderline first degree A-V blockSince previous tracing of , poor R wave progression not seen and notsuggestive of anteroseptal myocardial infarction The patient has prior CABG and median sternotomy. The pulmonary vasculature appears unremarkable. This may represent a calcified pleural plaque along the mediastinal pleura, or less likely a calcified node. FINDINGS: ET tube is located in the right main stem bronchus. A rounded focus of calcification is seen on the lateral view just anterior to the trachea, corresponding with a region of calcific density to the right of trachea on PA view. 3) Possible pleural effusion. abg's acceptable. Drained 22cc today.Access-RIJ central line d/c. PA AND LATERAL CHEST: There are improved lung volumes. There are bilateral calcified pleural plauqes seen in profile and en face. PT ON PO BID LOPRESSOR-WHICH HE HAD RECEIVED AT . There is subcutaneous emphysema. JP in R leg w/ serosang drainage - 10cc.Pt was seen by pulmonary today - on nebs q 6hr. IMPRESSION: Interval improved lung volumes with small bilateral pleural effusions and associated atelectasis. 2) There is a new atelectasis/consolidation in the left lower lobe. OOB> chair; inc spir, DB as able q1-2hr. There is a small amount of subcutaneous emphysema along the left chest wall. Again noted are the chronic changes of pleural plaques. Becomae a bit SOB when he ambulated.GI/GU: Abd soft, +BS, no BM. These tubes are in unchanged position. Comparison is made to prior chest x-ray of . On the lateral view, there is a suggestion of fullness of the infrahilar region. PT WITH 5LNP AND SATS 92-95. IMPROVED BREATHING MONITOR RESP STATUS CT removed @1500 w/o complication-site D&I, w/ increase comfort of pt. update given.plan: extubate when more awake. Very slow, but steady.CV: BP=100-120/50s, HR=80-90s, NSR no ectopy. AT CHANGE OF SHIFT ALINE SOMEWHAT POSITIONAL. med w/mso4 2mg ivx1.cardiac: nsr. uneventful or. Diureses well after lasix.Access: R rad a-line, 1PIV.Pain: Med x1 after ambulation for comfort w/ one tab percocet - effective.ID: Afebrile, Not on any antibx.Labs: FS=130-156 and covered w/ RISS.Plan: Monitor resp/cardiac/ neuro status. uop adequate.endo: insulin gtt started per protocol. IMPRESSION: Bilateral calcified pleural plaques are consistent with prior asbestos exposure. The ET tube tip located in the right main stem bronchus. There is increased patchy opacity in both lower lobes indicating atelectasis. There is right IJ central line with the tip in the cavoatrial junction. Fullness of infrahilar region on lateral view, possibly due to crowding of vessels related to low lung volumes. BP 110-120/50-60. Again noted are the chronic changes that include calcified pleural plaques. HCT 25. Right IJ central line with the tip in the right atrium. NEURO: PT IS A&O X3. no vea. 3. 3. The lung volume is small. 2. 2. A/P: DOING WELL. In the interval, there is marked decrease in the lung volumes. | 16 | [
{
"category": "Radiology",
"chartdate": "2104-03-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 822266,
"text": " 10:35 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o ptx\n Admitting Diagnosis: UNSTABLE ANGINA;TELEMETRY\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with CAD, SOB\n\n REASON FOR THIS EXAMINATION:\n r/o ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 75 year old male with coronary artery disease and shortness of\n breath. Rule out pneumothorax.\n\n AP semi-upright single view of the chest is compared to .\n\n FINDINGS: The patient is status post CABG. There is interval removal of left\n chest tube and left IJ central line. There is no evidence of pneumothorax.\n There is subcutaneous emphysema. The cardiac, mediastinal and hilar contours\n are unchanged. There is again noted the bilateral retrocardiac patchy\n opacities that are unchanged when compared to the previous study. There are\n low lung volumes.\n\n IMPRESSION: 1) There is no evidence of pneumothorax. 2) Bilateral retrocardiac\n opacities are unchanged when compared to the previous study.\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-03-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 822285,
"text": " 8:38 AM\n CHEST (PORTABLE AP) Clip # \n Reason: S/P cabg W/hypoxia-r/o PTX/effusion\n Admitting Diagnosis: UNSTABLE ANGINA;TELEMETRY\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with CAD, SOB\n /\n REASON FOR THIS EXAMINATION:\n S/P cabg W/hypoxia-r/o PTX/effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post CABG, shortness of breath, hypoxia.\n\n Comparison is made to prior chest x-ray of .\n\n SEMI-UPRIGHT AP CHEST: There is again evidence of prior CABG with median\n sternotomy wires and vascular clips. The heart, mediastinal and hilar\n contours are unchanged. There is no evidence of pneumothorax. There is again\n note of low lung volumes. There is left lower lobe atelectasis and a small\n pleural effusion, which appears slightly improved compared to the prior study.\n There is again note of bilateral calcified pleural plaques. There is a small\n amount of subcutaneous emphysema along the left chest wall.\n\n IMPRESSION:\n\n 1. Slightly improved appearance of left lower lobe atelectasis and small\n effusion.\n\n 2. Low lung volumes.\n\n 3. No other significant changes.\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-03-31 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 822545,
"text": " 4:05 PM\n CHEST (PA & LAT) Clip # \n Reason: s/p CABG w/hypoxia-r/o effusion/infiltrate\n Admitting Diagnosis: UNSTABLE ANGINA;TELEMETRY\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with\n\n REASON FOR THIS EXAMINATION:\n s/p CABG w/hypoxia-r/o effusion/infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post CABG with hypoxia.\n\n Comparison is made with prior chest x-ray on .\n\n PA AND LATERAL CHEST: There are improved lung volumes. There is again note\n of prior CABG. The pulmonary vascularity is unremarkable. There are small\n bilateral pleural effusions and adjacent atelectasis. There is no\n pneumothorax. There are again demonstrated bilateral calcified pleural\n plaques.\n\n IMPRESSION: Interval improved lung volumes with small bilateral pleural\n effusions and associated atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-03-24 00:00:00.000",
"description": "CHEST (PRE-OP PA & LAT)",
"row_id": 821945,
"text": " 9:01 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: UNSTABLE ANGINA;TELEMETRY\\CATH\n Admitting Diagnosis: UNSTABLE ANGINA;TELEMETRY\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with\n REASON FOR THIS EXAMINATION:\n r/o chf\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Preoperative for CABG.\n\n COMPARISON: None.\n\n TECHNIQUE: PA and lateral chest.\n\n FINDINGS: The heart size and mediastinal contours are within normal limits.\n The pulmonary vasculature appears unremarkable. There are bilateral calcified\n pleural plauqes seen in profile and en face. A rounded focus of calcification\n is seen on the lateral view just anterior to the trachea, corresponding with a\n region of calcific density to the right of trachea on PA view. This may\n represent a calcified pleural plaque along the mediastinal pleura, or less\n likely a calcified node. On the lateral view, there is a suggestion of\n fullness of the infrahilar region. No prior examinations are available for\n comparison. No pleural effusions and no pneumothorax. The surrounding\n osseous structures appear unremarkable.\n\n IMPRESSION: Bilateral calcified pleural plaques are consistent with prior\n asbestos exposure.\n\n Fullness of infrahilar region on lateral view, possibly due to crowding of\n vessels related to low lung volumes. Recommend repeat PA and lateral chest x-\n ray with improved inspiration for initial further evaluation of this region.\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-03-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 822133,
"text": " 2:36 PM\n CHEST (PORTABLE AP) Clip # \n Reason: post-op CABG\n Admitting Diagnosis: UNSTABLE ANGINA;TELEMETRY\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with CAD\n REASON FOR THIS EXAMINATION:\n post-op CABG\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post CABG.\n\n AP supine single view of the chest is compared to .\n\n FINDINGS: ET tube is located in the right main stem bronchus. There is a\n left-sided chest. There is a mediastinal tube. There is an NG tube extending\n beyond the limits of radiograph and postoperative changes status post median\n sternotomy and CABG. There is right IJ central line with the tip in the\n cavoatrial junction. There is no evidence of pneumothorax. Again noted are\n the chronic changes that include calcified pleural plaques. There is a small\n left pleural effusion.\n\n IMPRESSION:\n 1. The ET tube tip located in the right main stem bronchus. Recommend\n withdrawing the ET tube approximately 3.5 cm.\n 2. Mild CHF.\n 3. There is no evidence of pneumothorax.\n\n Findings were communicated to the service taking care of the patient at the\n time of the interpretation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-03-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 822178,
"text": " 1:32 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o PTX, infiltrate\n Admitting Diagnosis: UNSTABLE ANGINA;TELEMETRY\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with CAD, SOB\n\n REASON FOR THIS EXAMINATION:\n r/o PTX, infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 75 y/o male s/p CABG.\n\n AP SEMI-UPRIGHT SINGLE VIEW OF THE CHEST is compared to .\n\n FINDINGS: There is interval removal of the ETT. Right IJ central line with the\n tip in the right atrium. There is a left chest tube. There is a mediastinal\n tube. These tubes are in unchanged position. There is small left subcutaneous\n emphysema in the left axilla. Patient is s/p median sternotomy and CABG. In\n the interval, there is marked decrease in the lung volumes. There is also\n appearance of a new atelectasis or consolidation in the left lower lobe.\n Cannot exclude bilateral small pleural effusions. There is no evidence of\n pneumothorax. Pulmonary vascularity appears to be within normal limits. There\n is also interval removal of the NG tube. Again noted are the chronic changes\n of pleural plaques.\n\n IMPRESSION: 1) Interval extubation with marked decrease in lung volumes\n bilaterally. 2) There is a new atelectasis/consolidation in the left lower\n lobe. There is also increase in the small right atelectasis. 3) Possible\n pleural effusion.\n\n\n\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-03-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 822385,
"text": " 8:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess airway and lung parenchyma\n Admitting Diagnosis: UNSTABLE ANGINA;TELEMETRY\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with CAD, SOB\n /\n REASON FOR THIS EXAMINATION:\n assess airway and lung parenchyma\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 75 y/o male with CAD and SOB.\n\n COMMENTS: Portable AP radiograph of the chest was reviewed and compared to the\n previous study of yesterday.\n\n The lung volume is small. There is increased patchy opacity in both lower\n lobes indicating atelectasis. There is probably a small left pleural\n effusion. The previously identified subcutaneous emphysema in the chest wall\n has been improving. There is no evidence for pneumothorax. The patient has\n prior CABG and median sternotomy.\n\n IMPRESSION: Small lung volume. Increased bibasilar patchy atelectasis. Small\n left pleural effusion.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-03-28 00:00:00.000",
"description": "Report",
"row_id": 1369769,
"text": "NEURO ALERT ORIENTED NO DEFECITS NOTED\n\nC/V NSR ST NO ECT B/P STABLE PLP PULSES\n\nRESP NC 4-5L SATS 91-94% ABG MARGINAL WITH PO2 60 TEAM AWARE NO RESP DISTRESS NOTED WITH THIS ABG ? BASELINE ABG AT HOME SECONDARY TO ASBESTOSIS CXR FOR TODAY CREPITUS NOTED NP CXR DONE UNCHANGED DEEP BREATHING NONPRODUCTIVE COUGH\n\nGU/GI ABD SOFT ADEQUATE URINE OUT TOL PO WELL\n\nPLAN TRANSFER TO 2 TODAY CONTINUE TO EVAL RESP STATUS\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-03-28 00:00:00.000",
"description": "Report",
"row_id": 1369770,
"text": "FULL CODE Universal Precautions NKDA\n\n\nNeuro: AAox3, MAEx4, OOB to Chair x2 today and amb to end of nurses station only. Very slow, but steady.\n\nCV: BP=100-120/50s, HR=80-90s, NSR no ectopy. + periph pulses, no edema, extrems warm. On Lopressor 25mg po BID.\n\nResp: 5L N/P w/ 02 sat 90-95%. Strong cough, but not productive. Lungs clear in upper lobes, diminished in base bilat. RR=20-27. Becomae a bit SOB when he ambulated.\n\nGI/GU: Abd soft, +BS, no BM. Taking diet poorly as he doesn't care for the food. Foley w/ clear yellow urine - lasix changed to 20mg TID from . Diureses well after lasix.\n\nAccess: R rad a-line, 1PIV.\n\nPain: Med x1 after ambulation for comfort w/ one tab percocet - effective.\n\nID: Afebrile, Not on any antibx.\n\nLabs: FS=130-156 and covered w/ RISS.\n\nPlan: Monitor resp/cardiac/ neuro status. Tx orders/note written - awaiting bed to . Monitor I/Os, appetitie, comfort level.\n\nSocial: Wife and son in to visit today.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-03-28 00:00:00.000",
"description": "Report",
"row_id": 1369771,
"text": "JP in R leg w/ serosang drainage - 10cc.\n\nPt was seen by pulmonary today - on nebs q 6hr. Continues w/ strong cough, but still non-productive. Lungs at 10pm - crackles in bases.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-03-29 00:00:00.000",
"description": "Report",
"row_id": 1369772,
"text": "PT UPDATE\n PT IS S/P CABG X3 ON .\n\n NEURO: PT IS A&O X3. CALM AND COOPERATIVE.\n\n RESP: PT SEEN BY PULMONARY TEAM YEST-?IF OXYGENATION AND SATS IN LOW 90'S ARE PT'S BASELINE. BS CLEAR, SL. DECREASED IN BASES DURING NIGHT. PT WITH 5LNP AND SATS 92-95. NO C/O SOB. RECEIVED NEB RXMENT LATE EVENING AND WAS COMF DURING NIGHT. C/O PAIN WITH COUGHING-MED WITH RELIEF.\n\n CV: PT INTO AFIB 2230. GIVEN 5MG IV LOPRESSOR WHICH DID SLOW RATE DOWN TO LOW 100'S-GIVEN ANOTHER 5MG IV LOPRESSOR AT 0115 AND CONVERTED BACK TO SR. HAS REMAINED IN SR REMAINDER OF NIGHT HR 75-85. PT ON PO BID LOPRESSOR-WHICH HE HAD RECEIVED AT . AT CHANGE OF SHIFT ALINE SOMEWHAT POSITIONAL. BLDS DRAWN AND LINE FLUSHED WITH NO FURTHER DIFFICULTY. BP 110-120/50-60.\n\n GU: PT ON TID LASIX-WHICH HE RECEIVED AT 2400 WITH GOOD DIURESIS. HAVE NOT OBTAINED WEIGHT YET. U/O ADEQUATE.\n\n GI: NO STOOL. HAS BS.\n\n LAB: K 3.9 BEFORE DIURESIS-GIVEN 40 PO AND K 4.7 THIS AM. ALSO GIVEN 2 GM MG WHEN IN AFIB. HCT 25.\n\n OTHER: PT MED WITH PERCOCET FOR INCISIONAL PAIN WITH GOOD RELIEF. PT SLEPT WELL DURING NIGHT.\n\n A/P: DOING WELL. READY TO TRANSFER TO FLOOR WHEN BED AVAILABLE. CONT TO INCREASE ACTIVITY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-03-26 00:00:00.000",
"description": "Report",
"row_id": 1369766,
"text": "post op note:\n\ns/p cabg x3. uneventful or. ez intubation. arrived on neo & prop. ct drainage minimal.\n\nneuro: reversals given/prop off. slow to wake. arrouse to voice. follows commands. mae. able to lift head off bed. med w/mso4 2mg ivx1.\n\ncardiac: nsr. no vea. hr 60-80's. hr<60 & sbp<90 after reversals. neo/ntg titrated to keep map>60 & <90. all gtts currently off. epi wires attached. unable to sense or capture w/either a or v wires. polarity changed w/o effect. ct & jp drainage minimal. +pp bilat. lytes repleated.\n\nresp: lungs clear. remains vented on cpap 50%. suctioned x1->no secreations. abg's acceptable. plan to extubate when more awake.\n\ngi/gu: absent bs. og->lws. uop adequate.\n\nendo: insulin gtt started per protocol. see flow sheet.\n\nsocial: wife & son into visit. update given.\n\nplan: extubate when more awake. monitor hemodynamics/labs/ct & jp drainage/i&o. cont to fast track. ?transfer to 2 in am. pain management.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-03-27 00:00:00.000",
"description": "Report",
"row_id": 1369767,
"text": "NEURO ALERT ORIENTED MOVES ALL EXTREMETIES FOLLOWS COMMANDS NO DEFECITS NOTED\n\nC/V ST B/P STABLE OFF NEO SOME DECREASED TO 90S SYSTOLIC WITH MS MD AWARE NO LOPRESSOR TONOC GOOD PEDAL PULSES EPI WIRE INTACT NO TESTED DUE TO HIGH HR\n\nRESP INCREASED SOB WITH COARSE BS SOME WHEEZES HEARD TXS GIVEN X2 CHEST PT X2 WITH NT SUCTIONING X1 FOR SMALL TAN SECRETIONS REQUIRED FM WITH NC FOR MOISTURE OVERNOC OOB TO CHAIR TOL WELL NC 4L ONLY WITH SATS 91-93% IS WITH MUCH ENCOURAGMENT LOW VOLUMES FM BACK ON 60% WITH SATS RETURN TO 97% NO SOB BUT STATES VERY AWARE OF CHEST TUBE WITH BREATHING CXR DONE ATELECTASIS BILAT FREQ DEEP BREATHING AND COUGHING DONE NONPRODUCTIVE MD PATIENT\n\nGU/GI TOL PO WELL ADEQUATE URINE NO BM TODAY\n\nPAIN C/O PAIN AT CHEST TUBE SITE AND WITH DEEP BREATHING PERC WITH LITTLE EFFECT MS X2 WITH MINIMAL RELIEF OF PAIN MD NOTIFIED\n\nPLAN POSSIBLE CHEST TUBE REMOVAL TODAY ? IMPROVED BREATHING MONITOR RESP STATUS\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-03-27 00:00:00.000",
"description": "Report",
"row_id": 1369768,
"text": "CSRU Nursing Progress Note 7a-7p\n\nNeuro-\nA&Ox3, MAE, pivot to bed from chair (OOB x7h)w/ minimal 1 assist w/ PT. Pain controlled w/ percocet.\nResp-\n4lNC w/ sat 92-94%, attempt to wean to 3l=91%, returned to 4L. OOB> chair; inc spir, DB as able q1-2hr. CT pain limiting full expansion. CT removed @1500 w/o complication-site D&I, w/ increase comfort of pt. BS upper clear, lower=rales. Lasix 20 mg given @1800, to continue .\nCV-\nStable- BP 115-120/45-50, HR 90-109 SR- ST, Lopressor 25mg started @1800 tonight. u/o 20-30/hr, lasix given.\nSkin-\nSternun, mediastinum dsgs intact; RLE, D&I, ace re-wrapped. Drained 22cc today.\nAccess-\nRIJ central line d/c. DSD in place.\nSocial-\nFamily visiting short time today, updated. Pleased w/ pt progress.\nA/P\nMonitor resp status. Encourage DB, inc spir, u/o\nIncrease activity as tol.\n\n"
},
{
"category": "ECG",
"chartdate": "2104-03-26 00:00:00.000",
"description": "Report",
"row_id": 186107,
"text": "Sinus rhythm\nBorderline first degree A-V block\nSince previous tracing of , poor R wave progression not seen and not\nsuggestive of anteroseptal myocardial infarction\n\n"
},
{
"category": "ECG",
"chartdate": "2104-03-24 00:00:00.000",
"description": "Report",
"row_id": 186108,
"text": "Sinus rhythm with borderline first degree A-V block. Poor R wave progression\nin leads VI-V4 consistent with old anteroseptal myocardial infarction. No\nprevious tracing available for comparison.\n\n"
}
] |
64,350 | 199,224 | 51 yo M with HTN, HLD, CAD, alcoholism admitted with necrotizing pancreatitis, alcohol withdrawal and acute renal failure. The patient presented with severe, necrotizing pancreatitis to an outside hospital. He had a lipase> and CT imaging with a pancreatic phlegmon. This was felt due to alcohol abuse. He also was found to have non-obstructive gallstones and hypertriglyceridemia with levels >1000; both of which may have contributed to his pancreatitis. The patient was started on broad spectrum antibiotics and completed a 2 week course of Zosyn. While at the outside hospital, the patient received aggressive IV fluids and developed respiratory distress requiring intubation prior to transfer. After transfer, he slowly improved. He was successfully extubated and after a short course of post-pyloric -enteral feeding, the patient was advanced to clear liquids and then a regular diet without problems. was counselled extensive on the need for alcohol cessation and was started on crestor and niacin for triglyceride control. Consideration can be made as an outpatient for cholecystectomy as passed gallstone may have contributed to his presentation (though EtOH abuse seems to be the more likely, predominant cause of his symptoms, he does have gallstones confirmed on outside hospital ultrasound). His hospital course was complicated by alcohol withdrawal and delirium tremens requiring high doses of benzodiazepines. He ultimately improved and the withdrawal symptoms resolved. He had acute renal failure initially and this resolved with volume rescucitation. The patient had diarrhea throughout much of his hospitalization. Multiple stool studies were sent for C Diff and all were negative. This may be related to the pancreatitis. He was given anti-diarrheals as needed. The diarrhea improved on a regular diet towards the end of his hospitalization. The patient continued to have fever spikes to 100 throughout his hospitalization even after completing his antibiotic. He had no findings of a new acute infection and this seemed to be related to the pancreatitis. His fever curve trended down and he had no temperatures above 99 in the days prior to discharge. The patient had a sinus tachycardia to 100-120 for much of his hospitalization. This seemed most related to relative hypovolemia and anemia. He received volume rescucitation and 1 unit PRBC transfusion with improvement though he continues to have some asymptomatic tachycardia with exertion up to 120. The patient should have a repeat Hct measured at his follow-up appointment and may require further transfusion as an outpatient. Anemia. The patient has anemia of chronic disease and probable iron deficiency anemia. He was started on iron supplements. He received 1 unit of PRBC's. On discharge he was persistently anemic to 23. The patient should have a repeat Hct measured at his follow-up appointment and may require further transfusion as an outpatient. The patient has chronic HTN, HLD and continues on beta-blocker, ACEi and statin therapy. He was counselled extensively on the need for alcohol cessation. | Small bilateral pleural effusions, vascular engorgement and early edema. Tip placement within the small bowel was confirmed by injection of iodinated contrast. A nasoenteric tube is present -- it most likely extends into the duodenum. One NG and one enteric tube, as described. This area was marked for paracentesis. Small inferior Q waves of uncertain diagnostic significancebut possibly consistent with inferior myocardial infarction of indeterminateage. Intermittent fluoroscopy was used to evaluate the position of the - tube. An additional NG-type tube is present, tip overlying expected site of gastric fundus. Left hemidiaphragm is slightly elevated with a small left effusion and underlying patchy collapse and/or consolidation. REASON FOR THIS EXAMINATION: eval ETT placement, PICC placement, edema? FLUOROSCOPIC-GUIDED NASOENTERIC TUBE PLACEMENT. REASON FOR THIS EXAMINATION: is there a tappable pocket for relief of intra-abdominal pressures? EXAMINATION: Fluoroscopic guided nasointestinal tube placement. Atelectasis of right mid zone noted. Bibasilar atelectasis, large bilateral pleural effusions and what appears to be as vascular engorgement/mild edema are noted. Sinus tachycardia. Sinus tachycardia. The right internal jugular line tip is at the level of cavoatrial junction. Right PICC tip is at the cavoatrial junction or upper right antrum. Right PIC line ends in the upper right atrium just beyond the estimated location of the superior cavoatrial junction and the nasogastric tube passes below the diaphragm and out of view. NG tube tip is in the stomach. Check ET tube. Request for post-pyloric feeding tube. Densities in the right abdomen may represent residual contrast in the colon. The NG tube tip is in the stomach. REASON FOR THIS EXAMINATION: ET tube placement? Left lower lobe opacity is likely atelectasis. 4:48 AM CHEST (PORTABLE AP) Clip # Reason: ET tube placement? Interval improvement of patchy bibasilar opacities compared with . TECHNIQUE AND FINDINGS: Under direct fluoroscopic guidance, a - feeding tube was placed into the left naris into the fourth portion of the duodenum. LINE PLACEMENT Clip # Reason: eval ETT placement, PICC placement, edema? It is possible that that an ET tibe is present, but overlies upper thoracic structures and is therefore partially obscured. CHEST, SINGLE AP PORTABLE VIEW: Lordotic positioning. IMPRESSION: Moderate ascites, most significant in right lower quadrant. Small bilateral pleural effusions are better seen on prior CT from . Respiratory distress. A right-sided PICC line is present, tip near SVC/RA junction. A small amount of contrast was injected to verify the position of the tube. IMPRESSION: Successful placement of a post-pyloric feeding tube with its tip in the fourth portion of the duodenum. Diffuse non-specific ST-T wave changes most likely relatedto the rate. Local anesthesia of the left nostril was achieved using lidocaine jelly. Right lower lobe aeration has improved. Poor R wave progression. Low lung volumes persist. The nasointestinal tube was secured in place with a tape dressing. Portable AP chest radiograph was reviewed in comparison to outside CT abdomen obtained on . ET tube tip is 4.9 cm above the carina. ET tube is in standard placement. The upper-most portion of thoracic inlet is excluded from the film. The tube was advanced past the pylorus into the fourth portion of the duodenum at the duodeno-jejunal junction. The tube was secured to the patient's nostril with tape. COMPARISON: . There is a moderate amount of abdominal ascites, with the largest pocket in the right lower quadrant measuring up to 4.6 cm in depth. Non-specific ST segment changes. The catheter was then flushed with water. Difficult to identify ET tube. FINAL REPORT REASON FOR EXAMINATION: Evaluation of the patient with severe acute pancreatitis, intubated. COMPARISON: Outside CT abdomen from . IMPRESSION: Successful placement of post-pyloric nasointestinal tube into the fourth portion of the duodenum at the duodeno-jejunal junction with no immediate post-procedure complications. Mild vascular congestion has improved. IMPRESSION: 1. , M. MED 11:08 AM -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # Reason: please place post-pyloric feeding tube; please place post-am Admitting Diagnosis: ACUTE PANCREATITITIS Contrast: OPTIRAY Amt: MEDICAL CONDITION: 51 year old man with pancreatitis, pulled out PPFT today REASON FOR THIS EXAMINATION: please place post-pyloric feeding tube; please place post-ampulla if possible PFI REPORT PFI: Successful placement of post-pyloric nasointestinal tube into the fourth portion of the duodenum with no immediate post-procedure complications. 11:08 AM -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # Reason: please place post-pyloric feeding tube; please place post-am Admitting Diagnosis: ACUTE PANCREATITITIS Contrast: OPTIRAY Amt: MEDICAL CONDITION: 51 year old man with pancreatitis, pulled out PPFT today REASON FOR THIS EXAMINATION: please place post-pyloric feeding tube; please place post-ampulla if possible PROVISIONAL FINDINGS IMPRESSION (PFI): MON 12:06 PM PFI: Successful placement of post-pyloric nasointestinal tube into the fourth portion of the duodenum with no immediate post-procedure complications. | 10 | [
{
"category": "Radiology",
"chartdate": "2171-07-22 00:00:00.000",
"description": "NASO-INTESTINAL TUBE PLACEMENT (W/FLUORO)",
"row_id": 1197910,
"text": " 11:08 AM\n -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # \n Reason: please place post-pyloric feeding tube; please place post-am\n Admitting Diagnosis: ACUTE PANCREATITITIS\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with pancreatitis, pulled out PPFT today\n REASON FOR THIS EXAMINATION:\n please place post-pyloric feeding tube; please place post-ampulla if possible\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): MON 12:06 PM\n PFI: Successful placement of post-pyloric nasointestinal tube into the fourth\n portion of the duodenum with no immediate post-procedure complications.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 51-year-old man with pancreatitis, pulled out his post-pyloric\n feeding tube.\n\n COMPARISON: .\n\n FLUOROSCOPIC-GUIDED NASOENTERIC TUBE PLACEMENT. Local anesthesia of the left\n nostril was achieved using lidocaine jelly. An 8 French -\n feeding tube was advanced from the left naris into the stomach_. Intermittent\n fluoroscopy was used to evaluate the position of the - tube.\n The tube was advanced past the pylorus into the fourth portion of the duodenum\n at the duodeno-jejunal junction. A small amount of contrast was injected to\n verify the position of the tube. The catheter was then flushed with water.\n The tube was secured to the patient's nostril with tape. The patient\n tolerated the procedure well with no immediate post-procedure complications.\n\n IMPRESSION: Successful placement of post-pyloric nasointestinal tube into the\n fourth portion of the duodenum at the duodeno-jejunal junction with no\n immediate post-procedure complications.\n\n"
},
{
"category": "Radiology",
"chartdate": "2171-07-16 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1197082,
"text": " 11:18 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: eval ETT placement, PICC placement, edema?\n Admitting Diagnosis: ACUTE PANCREATITITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with severe acute EtOH pancreatitis intubated for DT's.\n REASON FOR THIS EXAMINATION:\n eval ETT placement, PICC placement, edema?\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient with severe acute\n pancreatitis, intubated.\n\n Portable AP chest radiograph was reviewed in comparison to outside CT abdomen\n obtained on .\n\n The ET tube tip is 5 cm above the carina. The right internal jugular line tip\n is at the level of cavoatrial junction. The NG tube tip is in the stomach.\n\n Bibasilar atelectasis, large bilateral pleural effusions and what appears to\n be as vascular engorgement/mild edema are noted.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2171-07-22 00:00:00.000",
"description": "NASO-INTESTINAL TUBE PLACEMENT (W/FLUORO)",
"row_id": 1197911,
"text": ", M. MED 11:08 AM\n -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # \n Reason: please place post-pyloric feeding tube; please place post-am\n Admitting Diagnosis: ACUTE PANCREATITITIS\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with pancreatitis, pulled out PPFT today\n REASON FOR THIS EXAMINATION:\n please place post-pyloric feeding tube; please place post-ampulla if possible\n ______________________________________________________________________________\n PFI REPORT\n PFI: Successful placement of post-pyloric nasointestinal tube into the fourth\n portion of the duodenum with no immediate post-procedure complications.\n\n"
},
{
"category": "Radiology",
"chartdate": "2171-07-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1197808,
"text": " 10:15 AM\n CHEST (PORTABLE AP) Clip # \n Reason: re-evaluate PPFT and NG tube placement - recently reposition\n Admitting Diagnosis: ACUTE PANCREATITITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with pancreatitis\n REASON FOR THIS EXAMINATION:\n re-evaluate PPFT and NG tube placement - recently repositioned\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pancreatitis, evaluate PPFT and NG tube placement.\n\n CHEST, SINGLE AP PORTABLE VIEW:\n\n Lordotic positioning. The upper-most portion of thoracic inlet is excluded\n from the film.\n\n On the current film, no ET tube is clearly visible. It is possible that that\n an ET tibe is present, but overlies upper thoracic structures and is therefore\n partially obscured. A nasoenteric tube is present -- it most likely extends\n into the duodenum. An additional NG-type tube is present, tip overlying\n expected site of gastric fundus. A right-sided PICC line is present, tip near\n SVC/RA junction.\n\n Densities in the right abdomen may represent residual contrast in the colon.\n Left hemidiaphragm is slightly elevated with a small left effusion and\n underlying patchy collapse and/or consolidation. Atelectasis of right mid\n zone noted.\n\n IMPRESSION:\n 1. Difficult to identify ET tube. Please see comment above.\n 2. One NG and one enteric tube, as described.\n 3. Interval improvement of patchy bibasilar opacities compared with .\n\n"
},
{
"category": "Radiology",
"chartdate": "2171-07-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1197487,
"text": " 4:48 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ET tube placement?\n Admitting Diagnosis: ACUTE PANCREATITITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with acute on chronic pancreatitis intubated for respiratory\n distress.\n REASON FOR THIS EXAMINATION:\n ET tube placement?\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 5:22 A.M. ON \n\n HISTORY: Chronic pancreatitis. Respiratory distress. Check ET tube.\n\n IMPRESSION: AP chest compared to :\n\n Lung volumes are lower, accounting for some of the increased opacification in\n both lungs, but there is also worsening bibasilar atelectasis. Small\n bilateral pleural effusions, vascular engorgement and early edema. Moderate\n cardiomegaly and mediastinal vascular engorgement have also increased. ET\n tube is in standard placement. Right PIC line ends in the upper right atrium\n just beyond the estimated location of the superior cavoatrial junction and the\n nasogastric tube passes below the diaphragm and out of view. No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2171-07-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1197282,
"text": " 4:16 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ett placement, interval change\n Admitting Diagnosis: ACUTE PANCREATITITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with resp failure, intubated\n REASON FOR THIS EXAMINATION:\n ett placement, interval change\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Intubated respiratory failure.\n\n Comparison is made with prior study .\n\n ET tube tip is 4.9 cm above the carina. NG tube tip is in the stomach. Low\n lung volumes persist. Right lower lobe aeration has improved. Mild vascular\n congestion has improved. Left lower lobe opacity is likely atelectasis.\n Small bilateral pleural effusions are better seen on prior CT from .\n Cardiomegaly is stable. Right PICC tip is at the cavoatrial junction or\n upper right antrum.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2171-07-19 00:00:00.000",
"description": "NASO-INTESTINAL TUBE PLACEMENT (W/FLUORO)",
"row_id": 1197547,
"text": " 11:34 AM\n -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # \n Reason: Please place post-pyloric feeding tube\n Admitting Diagnosis: ACUTE PANCREATITITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with pancreatitis and intubation for delerium tremens\n REASON FOR THIS EXAMINATION:\n Please place post-pyloric feeding tube\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: The patient is a 51-year-old male with pancreatitis. Request for\n post-pyloric feeding tube.\n\n EXAMINATION: Fluoroscopic guided nasointestinal tube placement.\n\n COMPARISONS: None available.\n\n TECHNIQUE AND FINDINGS: Under direct fluoroscopic guidance, a\n - feeding tube was placed into the left naris into the fourth\n portion of the duodenum. Tip placement within the small bowel was confirmed\n by injection of iodinated contrast. The nasointestinal tube was secured in\n place with a tape dressing. The patient tolerated the procedure well with no\n immediate post-procedural complications.\n\n IMPRESSION: Successful placement of a post-pyloric feeding tube with its tip\n in the fourth portion of the duodenum.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2171-07-17 00:00:00.000",
"description": "US ABD LIMIT, SINGLE ORGAN",
"row_id": 1197238,
"text": " 6:03 PM\n US ABD LIMIT, SINGLE ORGAN Clip # \n Reason: is there a tappable pocket for relief of intra-abdominal pre\n Admitting Diagnosis: ACUTE PANCREATITITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with necrotizing pancreatitis, ascites, and possible abdominal\n compartment syndrome (bladder pressure 24 mmHg).\n REASON FOR THIS EXAMINATION:\n is there a tappable pocket for relief of intra-abdominal pressures?\n ______________________________________________________________________________\n WET READ: MLHh WED 7:13 PM\n Moderate ascites, largest in RLQ.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 51-year-old male with necrotizing pancreatitis and ascites,\n evaluate for paracentesis.\n\n COMPARISON: Outside CT abdomen from .\n\n LIMITED ABDOMINAL ULTRASOUND: Representative images were obtained of all four\n quadrants of the abdomen, as well as midline. There is a moderate amount of\n abdominal ascites, with the largest pocket in the right lower quadrant\n measuring up to 4.6 cm in depth. This area was marked for paracentesis.\n\n IMPRESSION: Moderate ascites, most significant in right lower quadrant.\n\n"
},
{
"category": "ECG",
"chartdate": "2171-07-19 00:00:00.000",
"description": "Report",
"row_id": 249207,
"text": "Sinus tachycardia. Small inferior Q waves of uncertain diagnostic significance\nbut possibly consistent with inferior myocardial infarction of indeterminate\nage. Poor R wave progression. Non-specific ST segment changes. Compared to the\nprevious tracing of there is no interval change.\n\n"
},
{
"category": "ECG",
"chartdate": "2171-07-17 00:00:00.000",
"description": "Report",
"row_id": 249208,
"text": "Sinus tachycardia. Diffuse non-specific ST-T wave changes most likely related\nto the rate. No previous tracing available for comparison.\n\n"
}
] |
81,387 | 195,180 | #Anemia: was likely the cause of her dizziness and fatigue. Iron studies and MCV were consistent with iron deficiency likely chronic blood loss. Haptoglobin, LDH, Tbili, Dbili were normal and were not consistent with hemolysis. Lactate was normal and not consistent with bowel ischemia. In the MICU she was transfused 3 units of blood. Her hematocrit trended from 17-> 28.3->27.5. On transfer to the floor, vital signs were stable and she showed no signs of ongoing bleeding. Stool gauic was positive. . #. H/O DVT: Pt had DVT in after l first toe amputation. Had been on coumadin tx for anti-coagulation. INR on admission was 4 and was reversed to 2 with vitamin K. Patient has had 4 months of anti-coagulation and risks of further treatment outweigh the benefits. . #. DM: Her home metformin was held while inpatient but was restarted on discharge. She was given a diabetic diet and fingersticks were checked QID FS and she was given humalog insulin sliding scale . #. HYPONATREMIA: As low as 131, normalized over the admission. Was likely secondary to fluid administration. . #. COPD asthma: -continued on albuterol neb prn for asthma . #. HTN: At first , her home atenolol, diovan and HCTZ were held in the setting of hypotension and possible GI bleed. She was discharged on atenolol 25 mg once a day (prior dose was 50 mg po qD) and valsartan 80 mg po BID. Her hydrochlorothiazide was stopped. . #. HYPERLIPIDEMIA: She was continued on simvastatin 40 mg QD, fish oil. . #. ANXIETY/DEPRESSION: She was continued on home cymbalta 30 mg . | Lowinferolateral lead T wave amplitude. Low limb lead QRS voltage. Indeterminate axis. Findings are non-specific. Since theprevious tracing of ventricular ectopy is absent and precordiallead T wave changes appear decreased. | 1 | [
{
"category": "ECG",
"chartdate": "2175-09-25 00:00:00.000",
"description": "Report",
"row_id": 269111,
"text": "Sinus rhythm. Indeterminate axis. Low limb lead QRS voltage. Low\ninferolateral lead T wave amplitude. Findings are non-specific. Since the\nprevious tracing of ventricular ectopy is absent and precordial\nlead T wave changes appear decreased.\n\n"
}
] |
728 | 167,721 | Pt. was admitted on with sternal dehiscence. IV ABX were started and pt was kept NPO for preparation to OR the next day. On HD #2 he was brought to the operating room and underwent sternal rewiring. Please see op note. Pt. tolerated the procedure well, was extubated in the OR and was transferred to the CSRU in stable condition. POD #1 pt was recovering well after rewiring. He was not receiving any gtts and pre-op meds were started. Pt. cont. to need aggressive chest pt, nebs and O2 to remain adequate O2 stats. He therefore remained in the CSRU until POD #2. On this day he was transferred to the telemetry floor. His chest tubes were removed and ABX were cont. His pre-op culture (urine) was negative and the chest swab performed in the OR was negative as well. From POD # pt slowly improved. He cont. to need O2 via NC which was slowly weaned with aggressive pt, IS and nebs. Vanco was continued until day of discharge where it was stopped. Exam on POD #5 was unremarkable. Chest was stable, without clicks or drainage. Pt was discharged home with the appropriate follow-up. | FINDINGS: There has been interval rewiring of the previously seen displaced sternal wires. Displacement and rotation of sternotomy wires, consistent with sternal dehiscence. There is left basilar atelectasis. IMPRESSION: Interval rewiring. Status post removal of bilateral chest tubes. COMPARISON: Chest x-ray dated . The small right pleural effusion appears stable to decreased. Again, note is made of tortuous aorta. There is hazy opacification seen at the left lung base as well as a left pleural effusion which may be consistent with the recent postoperative status. RIJ . tolerated full liquids.GU: foley to gravity. cvp 5-12. afebrile. SBP > 94. palp DP/PT. ween off FT. if able monitor SAT. Sinus bradycardia. Tortuous aorta, bilateral pleural effusion and atelectasis. bs presentgu: minimal to marginal uop despite lasix po. TECHNIQUE: PA and lateral chest radiograph. perc x1 given.gi: tolerating clear liquids. Bs present. toiletP TCDP,CPT,IS. Sat >95.GI: ABD soft . need pulm. CHEST, PA AND LATERAL: The patient is status post median sternotomy and CABG. Cardiac, mediastinal, and hilar contours are stable. IMPRESSION: Interval increase in moderate left pleural effusion. PIV x2.Lungs: Clear upper lobes. Note is made of a metallic density rounded object along the left paratracheal region on the frontal view, noted to be within the soft tissues on the lateral view. coarse to diminished in Bases. Sinus rhythmInferior/lateral T wave changes are nonspecificSince previous tracing, further T wave changes noted, sinus bradycardia absent There are small bilateral pleural effusions and bibasilar atelectases as well as linear atelectases in both upper lobes. short burst of AF /afib not tolerated well. IMPRESSION: Status post CABG and sternal wire repair. COMPARISON: . csru updatecvs: hr ^80s-90s sbp up to 170, lopressor po given, hr to 60s and abp to 130s. COMPARISON: and . gave 1 percocet for splinting .CV: NSR 58-70's . PORTABLE UPRIGHT FRONTAL RADIOGRAPH. MAE.Pain : denied pain. Two of the sternotomy wires have become displaced and others have rotated compared to prior exam. Consolidation/atelectasis and effusion seen at the left lung base. FINDINGS: The patient is status post CABG with median sternotomy and sternal wire repair. ct draining minimal serosang fluids.neuro: ao x3 mae's with no deficit. Compared to theprevious tracing of electronic atrial pacing no longer evident. verbalized pain controlled. Sternal wires appear intact. Neuro: pt alert and oriented. referred to np , no treatments yetskin: all dressings cdi. Non-diagnostic repolarization abnormalities. Note is made of left lower lobe atelectasis and effusion, improving compared to the prior study. sacrum red/blanching. Osseous and soft tissue structures are stable. There has been interval increase in the left pleural effusion. broke on own. TCDP,CPT IS q3-4 . Note is made of small metallic structure in the left upper thorax. pedal pulses palpableresp: extubated in OR, requiring aggressive chest pt to improve sats. possible transfer to floor . The lungs are otherwise clear. This was present on prior studies. pt poor cough did bring up thick white sputum x1. no problems with swallowing. no BM. oob to chair . No displaced median sternotomy wires. There are chest tubes seen in the right mid lung as well as the basal portion of the left lung. position changes doneplan: aggressive pulmonary toilet, monitor hemodynamics. coughing out moderate amount of tan/blood tinged secretions, very thick to almost plugs. Bilateral chest tubes with no evidence of pneumothorax. no blood products required. output marginal 20-40. shifted to hiflow fio2 weaned down from 80%, sao2 maintained >95% PO2 up to >100. change from IV insulin to RISS. on high flow FT at 60% down to 40 at 0640. Staples are also seen overlying the arm. 2 in am No pneumothoraces (a tiny curvilinear density along the inferior aspect of the left third rib is not believed to represent a pneumothorax). No pneumothorax is identified. 3:35 PM CHEST (PA & LAT) Clip # Reason: s/p sternal rewire w/continued O2 requirement-r/o effusion Admitting Diagnosis: INCISION DRAINAGE MEDICAL CONDITION: 83 year old man s/p CABG REASON FOR THIS EXAMINATION: s/p sternal rewire w/continued O2 requirement-r/o effusion FINAL REPORT INDICATION: 83-year-old male with CABG. 10:05 AM CHEST (PORTABLE AP) Clip # Reason: assess fro chest tube location Admitting Diagnosis: INCISION DRAINAGE MEDICAL CONDITION: 83 year old man s/p cabg x4, now s/p sternal rewiring REASON FOR THIS EXAMINATION: assess fro chest tube location FINAL REPORT INDICATION: 83-year-old post CABG, assess chest tube. Lasix 20mg IV @ 0630.Endo: placed on insulin drip at 2unit most of night up to 3 at 0600 for FS of 31.Skin: Dsg D/I .. buttock red skin prep applied.A stable . three beat run and some couplets through night rare. 2:30 PM CHEST (PA & LAT) Clip # Reason: check for pneumothorax Admitting Diagnosis: INCISION DRAINAGE MEDICAL CONDITION: 83 year old man s/p cabg x4, now s/p sternal rewiring s/p chest tube removal REASON FOR THIS EXAMINATION: check for pneumothorax FINAL REPORT History of CABG with sternal re-wiring and chest tube removal. | 8 | [
{
"category": "Radiology",
"chartdate": "2154-03-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 863919,
"text": " 10:05 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess fro chest tube location\n Admitting Diagnosis: INCISION DRAINAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man s/p cabg x4, now s/p sternal rewiring\n\n REASON FOR THIS EXAMINATION:\n assess fro chest tube location\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 83-year-old post CABG, assess chest tube.\n\n PORTABLE UPRIGHT FRONTAL RADIOGRAPH.\n\n COMPARISON: and .\n\n FINDINGS:\n\n There has been interval rewiring of the previously seen displaced sternal\n wires. Staples are also seen overlying the arm. There are chest tubes seen\n in the right mid lung as well as the basal portion of the left lung. No\n pneumothorax is identified. There is hazy opacification seen at the left lung\n base as well as a left pleural effusion which may be consistent with the\n recent postoperative status. Note is made of a metallic density rounded\n object along the left paratracheal region on the frontal view, noted to be\n within the soft tissues on the lateral view. This was present on prior\n studies.\n\n IMPRESSION:\n\n Interval rewiring. No displaced median sternotomy wires. Bilateral chest\n tubes with no evidence of pneumothorax. Consolidation/atelectasis and\n effusion seen at the left lung base.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2154-03-27 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 864237,
"text": " 2:30 PM\n CHEST (PA & LAT) Clip # \n Reason: check for pneumothorax\n Admitting Diagnosis: INCISION DRAINAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man s/p cabg x4, now s/p sternal rewiring s/p chest tube removal\n REASON FOR THIS EXAMINATION:\n check for pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n History of CABG with sternal re-wiring and chest tube removal.\n\n Status post removal of bilateral chest tubes. No pneumothoraces (a tiny\n curvilinear density along the inferior aspect of the left third rib is not\n believed to represent a pneumothorax). Sternal wires appear intact. There\n are small bilateral pleural effusions and bibasilar atelectases as well as\n linear atelectases in both upper lobes.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2154-03-29 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 864523,
"text": " 3:35 PM\n CHEST (PA & LAT) Clip # \n Reason: s/p sternal rewire w/continued O2 requirement-r/o effusion\n Admitting Diagnosis: INCISION DRAINAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man s/p CABG\n REASON FOR THIS EXAMINATION:\n s/p sternal rewire w/continued O2 requirement-r/o effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 83-year-old male with CABG.\n\n TECHNIQUE: PA and lateral chest radiograph.\n\n COMPARISON: Chest x-ray dated .\n\n FINDINGS: The patient is status post CABG with median sternotomy and sternal\n wire repair. Again, note is made of tortuous aorta. Note is made of left\n lower lobe atelectasis and effusion, improving compared to the prior study.\n Note is made of small metallic structure in the left upper thorax.\n\n IMPRESSION: Status post CABG and sternal wire repair. Tortuous aorta,\n bilateral pleural effusion and atelectasis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2154-03-24 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 863785,
"text": " 1:32 AM\n CHEST (PA & LAT) Clip # \n Reason: Looking for fluid collection\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man s/p CABG and chest tube pull wound opened up\n\n REASON FOR THIS EXAMINATION:\n Looking for fluid collection\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 83-year-old man status post CABG and chest tube now with wound\n opened up.\n\n COMPARISON: .\n\n CHEST, PA AND LATERAL: The patient is status post median sternotomy and CABG.\n Two of the sternotomy wires have become displaced and others have\n rotated compared to prior exam. Cardiac, mediastinal, and hilar contours are\n stable. There has been interval increase in the left pleural effusion. There\n is left basilar atelectasis. The small right pleural effusion appears stable\n to decreased. The lungs are otherwise clear. Osseous and soft tissue\n structures are stable.\n\n IMPRESSION: Interval increase in moderate left pleural effusion. Displacement\n and rotation of sternotomy wires, consistent with sternal dehiscence.\n\n"
},
{
"category": "ECG",
"chartdate": "2154-03-25 00:00:00.000",
"description": "Report",
"row_id": 193164,
"text": "Sinus rhythm\nInferior/lateral T wave changes are nonspecific\nSince previous tracing, further T wave changes noted, sinus bradycardia absent\n\n"
},
{
"category": "ECG",
"chartdate": "2154-03-24 00:00:00.000",
"description": "Report",
"row_id": 193165,
"text": "Sinus bradycardia. Non-diagnostic repolarization abnormalities. Compared to the\nprevious tracing of electronic atrial pacing no longer evident.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-03-25 00:00:00.000",
"description": "Report",
"row_id": 1270461,
"text": "csru update\ncvs: hr ^80s-90s sbp up to 170, lopressor po given, hr to 60s and abp to 130s. no blood products required. cvp 5-12. afebrile. pedal pulses palpable\n\nresp: extubated in OR, requiring aggressive chest pt to improve sats. shifted to hiflow fio2 weaned down from 80%, sao2 maintained >95% PO2 up to >100. coughing out moderate amount of tan/blood tinged secretions, very thick to almost plugs. ct draining minimal serosang fluids.\n\nneuro: ao x3 mae's with no deficit. verbalized pain controlled. perc x1 given.\n\ngi: tolerating clear liquids. no problems with swallowing. bs present\n\ngu: minimal to marginal uop despite lasix po. referred to np , no treatments yet\n\nskin: all dressings cdi. sacrum red/blanching. position changes done\n\nplan: aggressive pulmonary toilet, monitor hemodynamics. 2 in am\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-03-26 00:00:00.000",
"description": "Report",
"row_id": 1270462,
"text": "Neuro: pt alert and oriented. MAE.\n\nPain : denied pain. gave 1 percocet for splinting .\n\nCV: NSR 58-70's . three beat run and some couplets through night rare. short burst of AF /afib not tolerated well. broke on own. SBP > 94. palp DP/PT. RIJ . PIV x2.\n\nLungs: Clear upper lobes. coarse to diminished in Bases. TCDP,CPT IS q3-4 . pt poor cough did bring up thick white sputum x1. on high flow FT at 60% down to 40 at 0640. Sat >95.\n\nGI: ABD soft . Bs present. no BM. tolerated full liquids.\n\nGU: foley to gravity. output marginal 20-40. Lasix 20mg IV @ 0630.\n\nEndo: placed on insulin drip at 2unit most of night up to 3 at 0600 for FS of 31.\n\nSkin: Dsg D/I .. buttock red skin prep applied.\n\nA stable . need pulm. toilet\nP TCDP,CPT,IS. ween off FT. if able monitor SAT. oob to chair . change from IV insulin to RISS. possible transfer to floor .\n"
}
] |
15,087 | 115,312 | This is a y/o female with influenza, rapid afib requiring BIPAP therapy now with comfort as main goal of care. Her respiratory distress was multifactorial including influenza, COPD, possible secondary bacterial pneumonia. Unable to wean off BiPAP for any extended period of time. Family meeting on decided to make the patient DNR/DNI no BiPAP, no blood draws, no finger sticks. No morphine drip, but morphine prn. The patient was made as comfortable as possible with ativan, morphine, nebs, and steroids prn. She passed away at 6 am on from hypoxic respiratory failure. | ABG'S JUST DRAWN AWAITING RESULTS.GU/GI: FOLEY CATH WITH SCANT AMT U/O. LS DIMINSHED, INSP/EXP WEEZES. Pt desaturating, tachypneic. PT IS A DNR/DNI. RECHECK LYTES THIS AM. AM BUN/creat 59/2.0(53/1.9).ID: Afebrile. IS A DNR/DNI. IF NO IMPROVEMENT OR WORSENS THEN WILL DISCUSS CMO. Pt rec'd scheduled neb txs. MOANING WITH AM ASSESSMENT. WHEN PLACED BACK ON BI-PAP, PT. NURSING MICU NOTE 7A-7PNEURO: PT ALERT, AT TIMES ABLE TO MAKE OUT SIMPLE WORDS LIKE YES, NO. Pt on CPAP/PS mask 10/+5 with FiO2 60& from ->MN. ANSWERING QUESTIONS APPROPRIATELY.CV: TACHYCARDIC TO 130'S. Receiving .63 unit dose Xopenex/unit dose Atrovent q4hrs. PRESENTLY BACK ON BI-PAP. ABG during this time 7.37/46/173. PT REMAINS DNR/DNI. MAEE, repeatedly removing O2 sat prob. Abdomen soft +BS no stool.GU: UO adequate via foley. HR 100-130 a-fib. IVF'S D/C'ED.NEURO: PT. Abd soft/distended with hypoactive bowel snds. LUNGS DIMINISHED THROUGHOUT.CV: HR 90-120'S , PT. RR 22-30 and irreg. WILL RECHECK K+ IN AM. NPO AS PT IS NOT RESPONSIVE.PLAN: SUPPORT RESP EFFORT AND MONITOR ABG'S. ASPIRATION.RENAL: ADEQUATE U/O'S. AFEBRILE. AFEBRILE. Brought to unit and placed on NIPPV. BP WITHIN NORMAL LIMITS. Since theprevious tracing of the ventricular response rate has slowed somewhat.Minimal increase in lateral ST-T wave abnormality is present and there isslightly more ST segment elevation seen over the anterior and mid-precordium. BP STABLE SEE CAREVUE FOR MOST UP TO DATE INFO.GI: ABD. Pt requiring niv for coarse rales, i and e clears with positive pressure. Pt given 500cc's NS bolus times one for elevated BUN/Cr which is thought to be related to being dry.Resp: Pt on and off bi-pap as needed today. CONT WITH NEBS, BIPAP WHEN NEEDED. , RRT BUN/Cr rising.ID: Pt 98.8 axillary today. Fluid balance for LOS +294ml. 1L NS GIVEN OVER 4HRS THIS AM.GI/GU: ABD SOFT, +BS, NO BM. Bilat wrist restaints in place.Resp: Droplet prec remain in effect. Plan to continue alternating NIV and Venti mask. O2 SAT'S IN LOW TO MID 90'S.CV: PT REMAINS IN AFIB WITH OCC PVC'S. ABD SOFT WITH HYPOACTIVE BOWEL SOUNDS. SOMEWHAT HOARSE.GI: ABSENT BS'S. PT. RESP: BS'S CLEAR POST NEBS THIS AM. Meanwhile cont to alternate CPAP mask and ventimask. BS's diminished with fine exp wheezes. BP 110/70-133/80. SpO2 remained high 90s. PT 2 DOSES XOPENEX INH ALONG WITH ATROVENT INH.CV: HR 90-110'S AFIB, SBP 110-130'S. Atrial fibrillation. GIVEN DILT 5MG IVP X1 WITH MIN. Atrial fibrillation with an average ventricular response, rate 101. AFIB WITH THE RATE RANGING 95-110.NEURO: PT ARRIVED WITH VERY LITTLE RESPONSE. AM WBC 6.8(11.3).Social: Dgtr called re pt's status X 1. Respiratory CarePt currently on NIV 505. RESPIRATORY CARE:Pt admitted from 11R w/ tachypnea and hypoxemia. O2 SATS ADEQUATE AS LONG AS PT. Since the previous tracing earlier this date nosignificant change.TRACING #2 Left bundle-branch blockwith left axis deviation. Left bundle-branch blockwith left axis deviation. PCO2 ON ARRIVAL 98. Vent standby. U/O APPROX. PER ATTENDING NOT GIVIN PR KAYEXALATE. pt on non-rebreather mask, SaO2=100%. Lung snds coarse, diminished @ bases, with intermit I/E wheezes throughout. PT INTERMITTENTLY FOLLOWING COMMANDS. NARRATIVE NOTE:PT WAS ADM TO MICU AT 0300. Sincethe previous tracing of ventricular rate is slower.TRACING #3 COPD EXACERBATION.NEURO: RESPONDS TO VOICE AND PAIN, MOANS OTHERWISE DOES NOT ANSWER QUESTIONS.RESP: VERY TACHYPNIC WHEN FIRST ARRIVED, RR IN THE 30-40'S PLACED ON MASK VENTILATION AND NOW IS IN 100% NON REBREATHER WITH SATS 96-98%. PT ANXIOUS WITH BIPAP.RESP: PT RECIEVED ON BIPAP, THIS AM NOT ABLE TO TOLERATE OFF BIPAP. Pt with productive cough, but unable to cough on command.CV: HR 112-124AFib with rare-occas PVC's. Placed on non-invasive positive pressure ventilation @ and 60%. AFTERNOON K+ 5.3, AM K+ 5.2. RESULTS. SAO2 93-98%. AT 1630 PT OFF BIPAP AND REMAINS OFF. LUNGS WITH SCATTERED INS/EXP WHEEZES AND DIM THROUGHOUT. Left bundle-branch block with left axis deviation. ABG'S DONE ON FACE MASK. CONTINUE WITH 100% NON-BREATHER MASK OR MASK VENTILATION. Atrial fibrillation with rapid ventricular responseLeft axis deviationLeft bundle branch blockSince previous tracing, no significant change BASELINE PT IS A&O.RESP: ARRIVED TACHYPNIC WITH RR 40'S PLACED ON CPAP 100% 5/10. BS w/ coarse crackles at bases, some scattered expiratory wheezes. MICU ADMIT NOTED Y/O FEMALE TRANSFERRED 11R WITH INCREASED RESP. BECAME LESS TACHY. Vt=340, RR=22-25, Ve= 6-7 liters. WBC 6.4 on levoquin.Endo: Blood sugar up to 199 at noon and sliding scale coverage needed. NURSING PROGRESS NOTE:NEURO: PT VERY LETHARGIC BUT WILL OPEN EYES AND IS ABLE SAY A FEW WORDS. SKIN COOL TO TOUCH.GI: PT IS NPO. Family say it is new. PLAN WAS TO GIVEN PT 24-48HRS WITH BIPAP WHEN NEED TO SEE IF PT IMPROVES. SOFT, +BS.GU: FOLEY IN PLACE, 20MG OF IV LASIX WAS GIVEN PT. AT NOON WAS ABLE TO COME OFF FOR ~45MIN. MICU NPN 11AM-7PM:Neuro: Pt awake with periods of restlessness. See resp flowsheet for specifics.Plan: continue current support & bronchodilator therapy ABG shows some improvement in respiratory acidosis, oxygenation baseline. Pt without access for po meds. K+ 5.2 this AM repeated this eve was down to 4.9. Respiratory TherapyPt continues on/off NIPPV +10PSV/+5PEEP, uncomfortable, but tolerating fairly well. AM labs include Na 146, K+ 5.2, Hct 37.2(41.5).GI: NPO. U/O DID IMPROVE WITH FLUID.ACCESS: PT HAS ONE PIV, #20 LEFT ARM.DISPO: BOTH PT'S DAUGHTER IN THIS AFTERNOON. Vt ~300s RR ~20s. C&R THICK TENACIOUS TAN SPUTUM. See flowsheet for further pt data. MORE AWAKE DURING THE AM HOURS. LUNG SOUNDS COARSE WITH CRACKLES AT THE BASES. Her lungs sound junky with stimulation and pt appears to be distressed with any activity off the mask vent.GI: NPO while needing mask ventillation. Just taken off bi-pap mask ventillation at 6PM. Will follow. WHEN LOWER ? ALL PO MEDS HAVE BEEN ON HOLD. Since the previous tracing of ventricularrate has increased.TRACING #1 RESPIRATORY CARE NOTEPt received from floors in acute respiratory distress d/t CHF. PT UNABLE TO COUGH ON COMMAND BUT WILL COUGH PROD AT TIMES. No coverage needed at 1800.Skin: Left hand all bruised which looks old today. | 17 | [
{
"category": "ECG",
"chartdate": "2134-03-16 00:00:00.000",
"description": "Report",
"row_id": 281530,
"text": "Atrial fibrillation with rapid ventricular response\nLeft axis deviation\nLeft bundle branch block\nSince previous tracing, no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2134-03-15 00:00:00.000",
"description": "Report",
"row_id": 281531,
"text": "Atrial fibrillation. Left bundle-branch block with left axis deviation. Since\nthe previous tracing of ventricular rate is slower.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2134-03-14 00:00:00.000",
"description": "Report",
"row_id": 281532,
"text": "Atrial fibrillation with rapid ventricular response. Left bundle-branch block\nwith left axis deviation. Since the previous tracing earlier this date no\nsignificant change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2134-03-14 00:00:00.000",
"description": "Report",
"row_id": 281533,
"text": "Atrial fibrillation with a rapid ventricular response. Left bundle-branch block\nwith left axis deviation. Since the previous tracing of ventricular\nrate has increased.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2134-03-17 00:00:00.000",
"description": "Report",
"row_id": 285061,
"text": "Atrial fibrillation with an average ventricular response, rate 101. Since the\nprevious tracing of the ventricular response rate has slowed somewhat.\nMinimal increase in lateral ST-T wave abnormality is present and there is\nslightly more ST segment elevation seen over the anterior and mid-precordium.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-03-15 00:00:00.000",
"description": "Report",
"row_id": 1458706,
"text": "MICU ADMIT NOTED\n Y/O FEMALE TRANSFERRED 11R WITH INCREASED RESP. DISTRESS, PT WAS BROUGHT TO ER FROM REHAB WITH INCREASED SOB ? COPD EXACERBATION.\n\nNEURO: RESPONDS TO VOICE AND PAIN, MOANS OTHERWISE DOES NOT ANSWER QUESTIONS.\n\nRESP: VERY TACHYPNIC WHEN FIRST ARRIVED, RR IN THE 30-40'S PLACED ON MASK VENTILATION AND NOW IS IN 100% NON REBREATHER WITH SATS 96-98%. LUNGS DIMINISHED THROUGHOUT.\n\nCV: HR 90-120'S , PT. DOES HAVE A PACEMAKER ON LEFT CHEST, BUT IS NOT CAPTURING. BP STABLE SEE CAREVUE FOR MOST UP TO DATE INFO.\n\nGI: ABD. SOFT, +BS.\n\nGU: FOLEY IN PLACE, 20MG OF IV LASIX WAS GIVEN PT. U/O APPROX. 450CC FROM LASIX.\n\nSOCIAL: FAMILY TO COME IN THIS AM.\n\nPLAN: PT. IS A DNR/DNI. CONTINUE WITH 100% NON-BREATHER MASK OR MASK VENTILATION.\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-03-15 00:00:00.000",
"description": "Report",
"row_id": 1458707,
"text": "RESPIRATORY CARE:\n\nPt admitted from 11R w/ tachypnea and hypoxemia. Placed on non-invasive positive pressure ventilation @ and 60%. Oxygenation improved, pt became more responsive- pulling off mask. BS's diminished with fine exp wheezes. pt on non-rebreather mask, SaO2=100%. Vent standby. See flowsheet for further pt data. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-03-17 00:00:00.000",
"description": "Report",
"row_id": 1458708,
"text": "NARRATIVE NOTE:\n\nPT WAS ADM TO MICU AT 0300. HAS BEEN IN HOSPITAL SINCE AND WAS IN MICU UNTIL WHEN SHE WAS TRANSFERED TO THE 11R.\n\nCV: B/P HAS RANGED FROM 104/47-136/56. AFIB WITH THE RATE RANGING 95-110.\n\nNEURO: PT ARRIVED WITH VERY LITTLE RESPONSE. NOT RESPONDING TO QUESTIONS AND NOT FOLLOWING COMMANDS. UNABLE TO DETERMINE PAIN LEVEL AS PT NOT ANSWERING QUESTIONS. PCO2 ON ARRIVAL 98. WHEN LOWER ? MORE ALERT. BASELINE PT IS A&O.\n\nRESP: ARRIVED TACHYPNIC WITH RR 40'S PLACED ON CPAP 100% 5/10. LUNGS WITH SCATTERED INS/EXP WHEEZES AND DIM THROUGHOUT. SAO2 93-98%. ABG'S JUST DRAWN AWAITING RESULTS.\n\nGU/GI: FOLEY CATH WITH SCANT AMT U/O. TEAM AWARE. NPO AS PT IS NOT RESPONSIVE.\n\nPLAN: SUPPORT RESP EFFORT AND MONITOR ABG'S. MONITOR LABS AND REPLENISH LYTES.\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-03-17 00:00:00.000",
"description": "Report",
"row_id": 1458709,
"text": "RESPIRATORY CARE NOTE\n\nPt received from floors in acute respiratory distress d/t CHF. Pt desaturating, tachypneic. Brought to unit and placed on NIPPV. Vt=340, RR=22-25, Ve= 6-7 liters. ABG shows some improvement in respiratory acidosis, oxygenation baseline.\n\n , RRT\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-03-17 00:00:00.000",
"description": "Report",
"row_id": 1458710,
"text": "Respiratory Therapy\n\nPt continues on/off NIPPV +10PSV/+5PEEP, uncomfortable, but tolerating fairly well. Vt ~300s RR ~20s. Receiving .63 unit dose Xopenex/unit dose Atrovent q4hrs. BS w/ coarse crackles at bases, some scattered expiratory wheezes. No current ABGs. SpO2 remained high 90s. See resp flowsheet for specifics.\n\nPlan: continue current support & bronchodilator therapy\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-03-17 00:00:00.000",
"description": "Report",
"row_id": 1458711,
"text": "NURSING MICU NOTE 7A-7P\n\nNEURO: PT ALERT, AT TIMES ABLE TO MAKE OUT SIMPLE WORDS LIKE YES, NO. PT INTERMITTENTLY FOLLOWING COMMANDS. PT ANXIOUS WITH BIPAP.\n\nRESP: PT RECIEVED ON BIPAP, THIS AM NOT ABLE TO TOLERATE OFF BIPAP. AT NOON WAS ABLE TO COME OFF FOR ~45MIN. AT 1630 PT OFF BIPAP AND REMAINS OFF. LS DIMINSHED, INSP/EXP WEEZES. PT 2 DOSES XOPENEX INH ALONG WITH ATROVENT INH.\n\nCV: HR 90-110'S AFIB, SBP 110-130'S. AFEBRILE. AFTERNOON K+ 5.3, AM K+ 5.2. PER ATTENDING NOT GIVIN PR KAYEXALATE. WILL RECHECK K+ IN AM. 1L NS GIVEN OVER 4HRS THIS AM.\n\nGI/GU: ABD SOFT, +BS, NO BM. PT NOT TAKING PO'S. FOLEY INTACT DRAINING YELLOW URINE, SCANT AMTS. U/O DID IMPROVE WITH FLUID.\n\nACCESS: PT HAS ONE PIV, #20 LEFT ARM.\n\nDISPO: BOTH PT'S DAUGHTER IN THIS AFTERNOON. HAD FAMILY MEETING. PLAN WAS TO GIVEN PT 24-48HRS WITH BIPAP WHEN NEED TO SEE IF PT IMPROVES. IF NO IMPROVEMENT OR WORSENS THEN WILL DISCUSS CMO. PT IS A DNR/DNI. CONT WITH NEBS, BIPAP WHEN NEEDED. RECHECK LYTES THIS AM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-03-18 00:00:00.000",
"description": "Report",
"row_id": 1458712,
"text": "Nursing Progress Note 1900-0700\nReview of Systems:\n\nNeuro: Pt dozing intermit overnight, otherwise restless and groaning. Will rarely answer question approp, but generally confused/disoriented. MAEE, repeatedly removing O2 sat prob. Bilat wrist restaints in place.\n\nResp: Droplet prec remain in effect. Pt on CPAP/PS mask 10/+5 with FiO2 60& from ->MN. ABG during this time 7.37/46/173. Otherwise pt on venti-mask 50%. RR 22-30 and irreg. O2 sat 95-100%. Lung snds coarse, diminished @ bases, with intermit I/E wheezes throughout. Pt rec'd scheduled neb txs. Pt with productive cough, but unable to cough on command.\n\nCV: HR 112-124AFib with rare-occas PVC's. BP 110/70-133/80. Pt without access for po meds. AM labs include Na 146, K+ 5.2, Hct 37.2(41.5).\n\nGI: NPO. Abd soft/distended with hypoactive bowel snds. No BM.\n\nGU: Urine light yellow/clear, draining @ 10-40ml/hr. Fluid balance for LOS +294ml. AM BUN/creat 59/2.0(53/1.9).\n\nID: Afebrile. AM WBC 6.8(11.3).\n\nSocial: Dgtr called re pt's status X 1. Pt remains DNI.\n\nPlan: Family to discuss plan of care with staff today. Meanwhile cont to alternate CPAP mask and ventimask.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-03-18 00:00:00.000",
"description": "Report",
"row_id": 1458713,
"text": "RESP: BS'S CLEAR POST NEBS THIS AM. C&R THICK TENACIOUS TAN SPUTUM. O2 SATS ADEQUATE AS LONG AS PT. KEPT HER MASK ON. PRESENTLY BACK ON BI-PAP. ABG'S DONE ON FACE MASK. PT. SOMEWHAT HOARSE.\nGI: ABSENT BS'S. TAKING SMALL AMT OF ICE-CHIPS WITH MIN. ASPIRATION.\nRENAL: ADEQUATE U/O'S. IVF'S D/C'ED.\nNEURO: PT. MOANING WITH AM ASSESSMENT. MORE AWAKE DURING THE AM HOURS. OPENING EYES AND SPEAKING CLEARLY. ANSWERING QUESTIONS APPROPRIATELY.\nCV: TACHYCARDIC TO 130'S. ALL PO MEDS HAVE BEEN ON HOLD. GIVEN DILT 5MG IVP X1 WITH MIN. RESULTS. WHEN PLACED BACK ON BI-PAP, PT. BECAME LESS TACHY. WILL NEED TO ADDRESS THIS SITUATION.\nSOCIAL: BOTH DAUGHTER HAVE SPOKEN WITH ME AND I'VE UPDATED THEM. BOTH PLAN TO VISIT THIS AFTERNOON.\nI\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-03-18 00:00:00.000",
"description": "Report",
"row_id": 1458714,
"text": "Respiratory Care\nPt currently on NIV 505. Pt requiring niv for coarse rales, i and e clears with positive pressure. Plan to continue alternating NIV and Venti mask.\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-03-18 00:00:00.000",
"description": "Report",
"row_id": 1458715,
"text": "MICU NPN 11AM-7PM:\nNeuro: Pt awake with periods of restlessness. Confused and moaning at times. Does not like to be moved. Wrist restraints on loosely when family not present in room to provide safety for all tubes/lines.\n\nCV: BP 110-150/50-60. HR 100-130 a-fib. Has order for dilt IV PRN but has not needed a dose so far. K+ 5.2 this AM repeated this eve was down to 4.9. Pt given 500cc's NS bolus times one for elevated BUN/Cr which is thought to be related to being dry.\n\nResp: Pt on and off bi-pap as needed today. She was off from 12 noon till 3PM then back on from 3PM to 6pM. Just taken off bi-pap mask ventillation at 6PM. Family visited with pt while it was on and feel it is uncomfortable and were asking if it can come off and for how long we need to keep it on. I told them that the plan was to use it PRN for the next 24hrs and readdress plan tomorrow. Her lungs sound junky with stimulation and pt appears to be distressed with any activity off the mask vent.\n\nGI: NPO while needing mask ventillation. Not able to take pills either due to somnolence. Abdomen soft +BS no stool.\n\nGU: UO adequate via foley. BUN/Cr rising.\n\nID: Pt 98.8 axillary today. WBC 6.4 on levoquin.\n\nEndo: Blood sugar up to 199 at noon and sliding scale coverage needed. No coverage needed at 1800.\n\nSkin: Left hand all bruised which looks old today. Family say it is new. Probably IV/Blood gas attempts.\n\nSocial: Two daughters in to visit today and are appropriately concerned but still seem hopeful for pt recovery.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-03-19 00:00:00.000",
"description": "Report",
"row_id": 1458716,
"text": "NURSING PROGRESS NOTE:\nNEURO: PT VERY LETHARGIC BUT WILL OPEN EYES AND IS ABLE SAY A FEW WORDS. PT MOVING ALL EXTREMETIES AND AT TIMES IS VERY RESTLESS IN THE BED.\n\nRESP: PT ON BIPAP X 2 DURING THE NIGHT. PT UNABLE TO COUGH ON COMMAND BUT WILL COUGH PROD AT TIMES. LUNG SOUNDS COARSE WITH CRACKLES AT THE BASES. O2 SAT'S IN LOW TO MID 90'S.\n\nCV: PT REMAINS IN AFIB WITH OCC PVC'S. BP WITHIN NORMAL LIMITS. AFEBRILE. SKIN COOL TO TOUCH.\n\nGI: PT IS NPO. ABD SOFT WITH HYPOACTIVE BOWEL SOUNDS. NO STOOL OVERNIGHT.\n\nGU: FOLEY CATH PATENT DRAINING SMALL AMT'S OF CLEAR URINE.\n\nSKIN: NO ISSUES, A FEW ECHYMOTIC AREAS BUT NO BREAKS.\n\nIV ACCESS: PT HAS ONE PERIPH IV IN RIGHT HAND.\n\nSOCIAL: HAVE NOT HEARD FROM FAMILY OVERNIGHT. PT REMAINS DNR/DNI.\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-03-19 00:00:00.000",
"description": "Report",
"row_id": 1458717,
"text": "NPN 0700-1900:\nNeuro: pt is alert, responding to verbal stimuli, confused, not following commands, denied any pain, at times agitated trying to remove Foley, O2 mask and IV, so she's kept restrained.\n\nResp: Breathing irregularly, on high flow O2 40%, to be changed to shovel mask, RR 24-33, SPO2 97-100%, LS coarse with wheezes, coughing but not able to expectorate.\n\nCV: A-Fib HR 98-124, on Diltiazem, BP 124-144/60-98, with a rt peripheral IV. received boluses of NS, on D51/2NS at 100 ml/hr, peripheral pulses difficult to palpate.\n\nGI/GU: started eating pudding and thickened soft diet, abdomen soft, BS hypoactive, with Foley cath drained clear yellowish u/o.\n\nInteg: with echymotic areas over hands but no skin breakdown, T max 97.7, on Droplet precaution due to flue, DNI/DNR.\n\nSocial: Family members visited in, had a meeting with Dr. , they don't want any more BiPAP on the pt, no bld draws, no needle sticks even for bld sugar monitoring, can take a small dose of Morphine if uncomfortable or gasping (but not Morphine drip), continue antibiotics.\n\n\n"
}
] |
5,957 | 125,434 | 1. CHF: Patient was admitted with bibasilar rales on lung examination with a loud diastolic murmur. She was initially evaluated in the Emergency Department with a CTA for a question of pulmonary embolus. The patient did not tolerate the dye load and had a creatinine that bumped to 2.2 and was acutely short of breath requiring a face mask. Given her loud murmur; an echocardiogram was performed on , which showed new deterioration of his LV systolic function with focal hypokinesis of the basal inferior lateral wall. Overall LV ejection fraction was over 55%. She had a mildly dilated ascending aorta with prosthetic aortic valve leaflets thickened, but not stenotic. There is a noted focal fluttering echo density on the left ventricular side of the leaflet consistent with valve tissue or vegetation. The patient was given gentle hydration on her first hospital day for her intolerance of the contrast during her CTA. She was noted to have an increasing short of breath, and was requiring high amounts of oxygen. She was placed on Lasix and nesiritide drip. The CCU was contact for transfer. On transfer to the MICU, the patient was maintained on the nesiritide and Lasix with a urine output that gradually increased. The etiology of her CHF was thought to be secondary to worsened aortic regurgitation with a possibly small contribution from her non-ST-elevation myocardial infarction, which eventually ruled in for. The patient was briefly maintained on the nitroglycerin drip for mean arterial pressures over 80% while in the CCU. During her brief stay in the CCU, the patient was eventually switched over to Lasix IV and chlorothiazide IV and had a good urine output. Her sats were noted to be stable in the 90s on liters of oxygen by nasal cannula, and the patient was transferred back to the floor on . Patient diuresed 2-3 liters on her first several days back on the floor and was eventually switched over to p.o. diuretic regimen with Lasix 20 q.a.m. and hydrochlorothiazide 25 q.d. The patient's urine output decreased slightly over the next several days, but she remains stable with good oxygen saturations and improving lung examination with a decreased jugular venous distention. 2. MI: The patient was admitted for a rule out MI and eventually ruled in with a peak CK of 339 and troponin of 0.91. The patient was maintained on aspirin and a beta blocker throughout her hospitalization. A cardiac catheterization was postponed given the patient's development of acute renal failure and CHF. It was decided toward the end of her hospitalization, to delay cardiac catheterization until the patient is out of the hospital. She remained stable throughout her hospitalization without nausea, which was considered to be her anginal equivalent. 3. Atrial fibrillation: The patient was in normal sinus rhythm until when she went into a brief episode of atrial fibrillation. The covering team started the patient on low dosed digoxin. The patient was maintained on digoxin and on beta blocker throughout the rest of her hospitalization, and self converted the following day into normal sinus rhythm and was noted to be in a normal rhythm throughout the remainder of hospitalization. 4. Renal: On admission to the hospital, the patient received a CTA for evaluation for pulmonary embolus. After receiving a small amount of contrast, the patient became acutely hypoxic and required a face mask, and it was noted that her creatinine jumped to 2.2 from her initial creatinine of 1.0. Patient was given IV fluids, and was noted to go into heart failure. Patient's renal function slowly resolved throughout the rest of her hospitalization, and her creatinine drifted down to 1.7. The patient was maintained on diuretics throughout her hospitalization, and was eventually switched over to p.o. The etiology of her acute renal failure was thought likely secondary to contrast-induced ATN versus congestive heart failure causing transient hypotension and decreased perfusion of her kidneys. 5. ID: The patient was noted to have Citrobacter in her urine on hospital day #4. She was placed on renally dosed levofloxacin and should receive a total of seven doses of levofloxacin. Her blood cultures were negative throughout her hospitalization, and the patient remained afebrile. 6. Heme: The patient had decreasing hematocrits throughout her hospitalization. She was initially placed on Heparin and Integrilin after she ruled in for a MI, but given hematuria and melanic stools, the Heparin and Integrilin were D/C'd. The patient received 2 units of packed red blood cells on transfer to the CCU for a hematocrit of 27.4. Throughout the rest of her hospitalization, the patient was noted to have no further blood loss, and her hematocrit was stable around 33. | lead location; T wavechanges are resolved; and the atrial premature complex is absent Normal sinus rhythmProbable old septal infarctLateral ST-T changes are nonspecificAtrial premature complexSince previous tracing, atrial premature complex is noted Moderate [2+]tricuspid regurgitation is seen. denied CP/diaphoresis/nausea at that time. There is mild regional left ventricular systolicdysfunction. 4) Mild intrahepatic biliary ductal dilatation. The ascending aorta is moderatelydilated. Mildto moderate (+) mitral regurgitation is seen. Compared to the previous tracing there isatrial fibrillation. Left ventricularhypertrophy. Sinus rhythmProbable old septal infarctSince previous tracing, atrial fibrillation and left ventricular hypertrophy byvoltage are absent; ST-T wave changes are improved Sinus rhythmSupraventricular extrasystolesProbable old septal infarctSince previous tracing, QS configuration in lead V2; atrial premature complexesare noted There is mild symmetric left ventricularhypertrophy with normal cavity size. There is moderate pulmonary artery systolichypertension. There ismoderate mitral annular calcification. ]LV WALL MOTION: The following resting regional left ventricular wall motionabnormalities are seen: basal inferolateral - hypokinetic; mid inferolateral -hypokinetic;AORTA: The aortic root is normal in diameter. There is moderate pulmonary artery systolichypertension.PULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve is not well seen.Physiologic (normal) pulmonic regurgitation is seen.PERICARDIUM: There is no pericardial effusion.GENERAL COMMENTS: Compared to the findings of the prior study, leftventricular systolic function has deteriorated. Sinus rhythmProbable old septal infarctSince previous tracing, atrial premature complex absent At least moderate (2+) aortic regurgitation is seen.The mitral valve leaflets and supporting structures are mildly thickened. There is a small right sided pleural effusion. A left pleural effusion is present.Conclusions:The left atrium is mildly dilated. There is a subcentimeter noncalcified pulmonary nodule in the right lung base. LS crackles 1/2 up.given SL NGT x1 with no relief. Sinus rhythmPoor R wave progression - probable old septal myocardial infarctionNonspecific T wave inversion in leads l, aVLSince last ECG, no significant change Moderate [2+] tricuspidregurgitation is seen. The thoracic aorta tapers to a normal caliber within the descending portion of the thoracic aorta and the abdominal aorta. Sinus rhythmProbable old septal infarctNonspecific lateral ST-T changes consider ischemiaSince previous tracing, ST-T wave changes noted There is no pericardial effusion.Compared to the findings of the prior study of , the severity of aorticregurgitation has increased and a fluttering echodensity is identified. Moderate (2+) aorticregurgitation is seen.MITRAL VALVE: The mitral valve leaflets are mildly thickened. Poor R wave progression - questionold septal myocardial infarction. 3) Subcentimeter noncalcified pulmonary nodule within the right lung base. CRACLKES PERSIST .FAIR APPETITE .SENSCKOT,DULCLAX SUPP ,PAST GAS ,MORE COMFORTABLE NO STOOL.NEG 1300 ,GOAL 1L NEG,LASIX GTT WEANED .A,OX3,ANXIOUS CONCERNING CATH CHF RESPONDING TO DIURESISFOLLOW HCTWEAN LASIX TO MAINTAIN 1L NEG . Mild to moderate (+) mitral regurgitation is seen.TRICUSPID VALVE: The tricuspid valve leaflets are normal. H/O cardiac surgery.Height: (in) 62Weight (lb): 127BSA (m2): 1.58 m2BP (mm Hg): 101/35HR (bpm): 65Status: InpatientDate/Time: at 11:51Test: Portable TTE(Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: The left atrium is mildly dilated.RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is mildly dilated.LEFT VENTRICLE: There is mild symmetric left ventricular hypertrophy withnormal cavity size. CT ABDOMEN WITH CONTRAST: There is mild intrahepatic biliary ductal dilatation with no evidence of intrahepatic biliary ductal dilatation. Pulmonary artery systolichypertension is now identified. The prostheticaortic valve leaflets are thickened but not stenotic. Sinus rhythmProbable old septal infarctSince last ECG, no significant change 5) Fibroid uterus. [Intrinsic left ventricular systolic function may be moredepressed given the severity of valvular regurgitation. Sinus rhythmR wave not seen in V2 previously that is now present probably representvariation in leadsSince last ECG, no significant change There is a subcentimeter low attenuation lesion within the right lobe of the liver likely representative of a simple hepatic cyst. tachypnic with little effort. BP STABLE .NO CO CP,SOB BUT DOE. There is mild regional left ventricularsystolic dysfunction with focal hypokinesis of the basal inferolateral wall.The remaining segments contract well and overall systolic function is normal. [Intrinsic left ventricular systolic function may be more depressed given theseverity of valvular regurgitation.] (Over) 8:03 PM CTA CHEST W&W/O C &RECONS; CTA ABD W&W/O C & RECONS Clip # CTA PELVIS W&W/O C & RECONS; CT 100CC NON IONIC CONTRAST Reason: cp, low bp, evaluate for aortic dissection Field of view: 35 Contrast: OPTIRAY Amt: 100 FINAL REPORT (Cont) CT RECONSTRUCTIONS: Images reformatted in the coronal plane demonstrate aneurysmal dilatation of the ascending portion of the thoracic aorta which tapers to a normal caliber within the descending portion of the thoracic aorta and the abdominal aorta. Aregional left ventricular wall motion is now seen. bowel regimen. The gallbladder, pancreas, and spleen are within normal limits. improvment with morphine.P: contin. no nausea/dizziness/diaphoresis.HR 60's SR. BP 103-118/50.LS crackles 1/3 up. lasix off.P: wean O2 as tol. dry cough.remains off lasix gtt. Sinus rhythmProbable old septal infarctNonspecific T wave inversion in leads l, aVLSince previous tracing, the T wave changes are improved in leads V5-6 Non-specific ST-T wave changes. Sinus rhythmSince previous tracing, QRS changes in lead V2 - ? There is focal dilatation of the ascending thoracic aorta which measures 4.3 cm in greatest dimension. There is mild thickening of the mitralvalve chordae. (+) BS.pt. HCT. may be ready to dangle at bedside today and possibly get OOB.A: improved symptoms. repleted with 20meq KCL IV. monitor u/o, lytes. given sl NGT and 1mg morphine. 2) Aortic valve prosthesis in place with focal aneurysmal dilatation of the ascending aorta which measures 4.3 cm in greatest dimension. Mg+ 2.3. The ascending aorta ismoderately dilated.AORTIC VALVE: A bioprosthetic aortic valve prosthesis is present. Cr 2.2bedpan x1 with no results. symptoms improved and pt. slept for ~ 4hours.access: one PIV.A: episode of worsening symptoms during eve, req. | 17 | [
{
"category": "Nursing/other",
"chartdate": "2123-09-01 00:00:00.000",
"description": "Report",
"row_id": 1340576,
"text": "CCU Progress Note:\n\nO- see flowsheet for all objective data.\n\ncv- Tele: SR no ectopy- HR 61-71- C/O one episode of nausea when feeling like moving her bowels this am- SBP 88- no diaphoresis- instructed to give Pt ntg sl with next episode if SBP > 80- no further c/o this shift- Hct 29.3 this am- K 4.8- Mg 2.6- B/P 94-117/29-62- MAP's 44- 72.\n\nresp- In 02 3L via NC- lung sounds with crackles 1/3 up bilaterally- resp even, non-labored- RR-16-22- Sp02 94-97%.\n\ngi- abd soft non-tender (+) bowel sounds- no stool today- PO intake fair- con't on 1500cc fld restriction.\n\ngu- foley draining yellow colored urine with sediment- U/A & C&S sent to lab- BUN 71 Crea 3 this am- repeat labs pending- con't on lasix gtt @ 24mg/hr- U/O 15-80cc/hr- I&O presently = at present- seen by renal team- diuril 250mg IV ordered in addition to lasix gtt- U/O trending up last few hrs.\n\nneuro- A&O X3- moving all extremities- pleasant & cooperative- follows command.\n\nA- S/P MI complicated by renal failure\n\nP- monitor vs, lung sounds, I&O, & labs- assess for further episodes of nausea/diaphoresis- give ntg sl & note effect- repeat labs due @ 2100- offer emotional support to Pt & family- keep them updated on plan of care.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-09-02 00:00:00.000",
"description": "Report",
"row_id": 1340577,
"text": "CCU NPN 1900-0700\nS: \" I feel its hard to breath \"\nO: afeb.\npt. developed increasing SOB after turning side to side with linen change. sats down to 92% on 3lnc. BP 125/40. HR 70's. EKG no change. pt. denied CP/diaphoresis/nausea at that time. appearing tired and slightly labored breathing pattern. LS crackles 1/2 up.\ngiven SL NGT x1 with no relief. given .5mg morphine with better relief. However, one hour later at 2100, pt. again c/o SOB, this time assoc. with mild nausea. no diaphoresis or CP. BP contin. 120's/40. given sl NGT and 1mg morphine. lasix gtt inc. to 30mg/hr. FIO2 inc. to NC 4l in addition to 100% face tent. symptoms improved and pt. fell asleep.\nHR down to 60's. BP 103-113/30's. O2 changed to 6lNC with sats 92-96%. pt. c/o face tent bothering her.\nK+ 4.0 given 20meq KCL\nGU: u/o 60-150cc/hr on 30mg lasix gtt. (-) 500 for . currently ~ 400cc neg. given 250mg diurel at 0400 per order.\nGI: tried on bedpan with no success. on colace.\nneuro: A/Ox3. pt. tachypnic with little effort. needs HOB at 30-45degrees. slept for ~ 4hours.\naccess: one PIV.\nA: episode of worsening symptoms during eve, req. inc. in FIO2 and inc. dose of lasix. improvment with morphine.\nP: contin. to try SL TNG / morphine for acute SOB episodes. follow u/o, sats, lytes. HCT. may need better access. both arms very bruised. very difficult venepunture.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-09-02 00:00:00.000",
"description": "Report",
"row_id": 1340578,
"text": "SR NO ECTOPY. BP STABLE .NO CO CP,SOB BUT DOE. HCT 27,NO TRANSFUSION TODAY .PICC PLACED .K REPLETED .\n\nSAT 90 TO 95 6LNP. CRACLKES PERSIST .\n\nFAIR APPETITE .SENSCKOT,DULCLAX SUPP ,PAST GAS ,MORE COMFORTABLE NO STOOL.\n\nNEG 1300 ,GOAL 1L NEG,LASIX GTT WEANED .\n\nA,OX3,ANXIOUS CONCERNING CATH CHF RESPONDING TO DIURESIS\n\nFOLLOW HCT\nWEAN LASIX TO MAINTAIN 1L NEG .\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-09-03 00:00:00.000",
"description": "Report",
"row_id": 1340579,
"text": "CCU NPN 1900-0700\nS: \" I feel better tonight \"\nO: pt. verbalizing improved symptoms tonight. no episodes of acute SOB although contin. with general slight DOE. no nausea/dizziness/diaphoresis.\nHR 60's SR. BP 103-118/50.\n\nLS crackles 1/3 up. Sats 94-97% on 6lnc. occas. dry cough.\n\nremains off lasix gtt. u/o 60-70cc/hr. (-) 2L for . currently ~ 300cc neg.\nK+ 3.9 in eve. repleted with 20meq KCL IV. Mg+ 2.3. Cr 2.2\n\nbedpan x1 with no results. abd flat, soft. (+) BS.\n\npt. able to pull self up to sitting position in bed. may be ready to dangle at bedside today and possibly get OOB.\n\nA: improved symptoms. lasix off.\nP: wean O2 as tol. monitor u/o, lytes. try to dangle. bowel regimen.\n"
},
{
"category": "Radiology",
"chartdate": "2123-08-28 00:00:00.000",
"description": "CT 100CC NON IONIC CONTRAST",
"row_id": 799929,
"text": " 8:03 PM\n CTA CHEST W&W/O C &RECONS; CTA ABD W&W/O C & RECONS Clip # \n CTA PELVIS W&W/O C & RECONS; CT 100CC NON IONIC CONTRAST\n Reason: cp, low bp, evaluate for aortic dissection\n Field of view: 35 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old woman with avr, cardiac perforation, s/p mi with stent placement,\n REASON FOR THIS EXAMINATION:\n cp, low bp, evaluate for aortic dissection\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: EKEK SUN 8:38 AM\n no dissection\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 88 year old female with aortic valve replacement and history of\n myocardial infarct with cardiac perforation and stent placement. Patient with\n chest pain and hypotension. Evaluate for aortic dissection.\n\n TECHNIQUE: CT imaging of the torso from the thoracic inlet to the level of the\n iliac bifurcation performed after the intravenous administration of 150 cc of\n Optiray. Nonionic contrast was used due to patient debility. Additional\n reformatted images in multiple planes were also obtained.\n\n CT CHEST WITH CONTRAST: There is no evidence of aortic dissection. There is\n focal dilatation of the ascending thoracic aorta which measures 4.3 cm in\n greatest dimension. There is an aortic valve prosthesis in place. The thoracic\n aorta tapers to a normal caliber within the descending portion of the thoracic\n aorta and the abdominal aorta. There is no evidence of mediastinal hematoma or\n pulmonary embolism. There is no evidence of pericardial effusion.\n\n There is a small right sided pleural effusion. There is atelectasis and/or\n scarring throughout both lungs. There is a subcentimeter noncalcified\n pulmonary nodule in the right lung base. There is no evidence of\n pneumothorax.\n\n CT ABDOMEN WITH CONTRAST: There is mild intrahepatic biliary ductal dilatation\n with no evidence of intrahepatic biliary ductal dilatation. The liver is\n normal in contour and attenuation with no evidence of hepatic mass. There is a\n subcentimeter low attenuation lesion within the right lobe of the liver likely\n representative of a simple hepatic cyst. The gallbladder, pancreas, and spleen\n are within normal limits. There are multiple simple cysts within both\n kidneys. Both kidneys enhance and excrete contrast promptly and symmetrically\n with no evidence of renal mass. There is no evidence of retroperitoneal lymph\n node pathologic enlargement. There is no abnormal dilatation or wall\n thickening within the visualized portions of large and small bowel. There are\n calcified fibroids identified within the visualized portion of this patient's\n post menopausal uterus.\n\n Bone windows show no suspicious lytic or sclerotic lesions.\n\n (Over)\n\n 8:03 PM\n CTA CHEST W&W/O C &RECONS; CTA ABD W&W/O C & RECONS Clip # \n CTA PELVIS W&W/O C & RECONS; CT 100CC NON IONIC CONTRAST\n Reason: cp, low bp, evaluate for aortic dissection\n Field of view: 35 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n CT RECONSTRUCTIONS: Images reformatted in the coronal plane demonstrate\n aneurysmal dilatation of the ascending portion of the thoracic aorta which\n tapers to a normal caliber within the descending portion of the thoracic aorta\n and the abdominal aorta. These reconstructed images demonstrate no evidence of\n aortic dissection.\n\n IMPRESSION:\n\n 1) No evidence of aortic dissection.\n 2) Aortic valve prosthesis in place with focal aneurysmal dilatation of the\n ascending aorta which measures 4.3 cm in greatest dimension.\n 3) Subcentimeter noncalcified pulmonary nodule within the right lung base.\n 4) Mild intrahepatic biliary ductal dilatation.\n 5) Fibroid uterus.\n\n"
},
{
"category": "Echo",
"chartdate": "2123-08-31 00:00:00.000",
"description": "Report",
"row_id": 103856,
"text": "PATIENT/TEST INFORMATION:\nIndication: Bioprosthetic aortic valve. H/O cardiac surgery.\nHeight: (in) 62\nWeight (lb): 127\nBSA (m2): 1.58 m2\nBP (mm Hg): 101/35\nHR (bpm): 65\nStatus: Inpatient\nDate/Time: at 11:51\nTest: Portable TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: The left atrium is mildly dilated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is mildly dilated.\n\nLEFT VENTRICLE: There is mild symmetric left ventricular hypertrophy with\nnormal cavity size. There is mild regional left ventricular systolic\ndysfunction. [Intrinsic left ventricular systolic function may be more\ndepressed given the severity of valvular regurgitation.]\n\nLV WALL MOTION: The following resting regional left ventricular wall motion\nabnormalities are seen: basal inferolateral - hypokinetic; mid inferolateral -\nhypokinetic;\n\nAORTA: The aortic root is normal in diameter. The ascending aorta is\nmoderately dilated.\n\nAORTIC VALVE: A bioprosthetic aortic valve prosthesis is present. The\nprosthetic aortic valve leaflets are thickened. Moderate (2+) aortic\nregurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is\nmoderate mitral annular calcification. There is mild thickening of the mitral\nvalve chordae. Mild to moderate (+) mitral regurgitation is seen.\n\nTRICUSPID VALVE: The tricuspid valve leaflets are normal. Moderate [2+]\ntricuspid regurgitation is seen. There is moderate pulmonary artery systolic\nhypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve is not well seen.\nPhysiologic (normal) pulmonic regurgitation is seen.\n\nPERICARDIUM: There is no pericardial effusion.\n\nGENERAL COMMENTS: Compared to the findings of the prior study, left\nventricular systolic function has deteriorated. Compared to the findings of\nthe prior study, the severity of aortic insufficiency has increased. Based on\n AHA endocarditis prophylaxis recommendations, the echo findings indicate\na high risk (prophylaxis strongly recommended). Clinical decisions regarding\nthe need for prophylaxis should be based on clinical and echocardiographic\ndata. The echocardiographic results were reviewed by telephone with the\nhouseofficer caring for the patient. A left pleural effusion is present.\n\nConclusions:\nThe left atrium is mildly dilated. There is mild symmetric left ventricular\nhypertrophy with normal cavity size. There is mild regional left ventricular\nsystolic dysfunction with focal hypokinesis of the basal inferolateral wall.\nThe remaining segments contract well and overall systolic function is normal.\n[Intrinsic left ventricular systolic function may be more depressed given the\nseverity of valvular regurgitation.] The ascending aorta is moderately\ndilated. A bioprosthetic aortic valve prosthesis is present. The prosthetic\naortic valve leaflets are thickened but not stenotic. A focal fluttering\nechodensity is seen on the LV side of the leaflet coaptation point c/w valve\ntissue (vs. vegetation). At least moderate (2+) aortic regurgitation is seen.\nThe mitral valve leaflets and supporting structures are mildly thickened. Mild\nto moderate (+) mitral regurgitation is seen. Moderate [2+] tricuspid\nregurgitation is seen. There is moderate pulmonary artery systolic\nhypertension. There is no pericardial effusion.\n\nCompared to the findings of the prior study of , the severity of aortic\nregurgitation has increased and a fluttering echodensity is identified. A\nregional left ventricular wall motion is now seen. Pulmonary artery systolic\nhypertension is now identified. The severity of mitral regurgitation has also\nincreased.\nThe constellation raises the suspicion for flail leaflet/vegetation migration\nleading to myocardial infarction.\n\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate a high risk (prophylaxis strongly recommended). Clinical decisions\nregarding the need for prophylaxis should be based on clinical and\nechocardiographic data.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2123-08-30 00:00:00.000",
"description": "Report",
"row_id": 297645,
"text": "Sinus rhythm\nProbable old septal infarct\nSince previous tracing, atrial premature complex absent\n\n"
},
{
"category": "ECG",
"chartdate": "2123-08-29 00:00:00.000",
"description": "Report",
"row_id": 297646,
"text": "Sinus rhythm\nSupraventricular extrasystoles\nProbable old septal infarct\nSince previous tracing, QS configuration in lead V2; atrial premature complexes\nare noted\n\n"
},
{
"category": "ECG",
"chartdate": "2123-08-29 00:00:00.000",
"description": "Report",
"row_id": 297647,
"text": "Sinus rhythm\nSince previous tracing, QRS changes in lead V2 - ? lead location; T wave\nchanges are resolved; and the atrial premature complex is absent\n\n"
},
{
"category": "ECG",
"chartdate": "2123-08-28 00:00:00.000",
"description": "Report",
"row_id": 297648,
"text": "Normal sinus rhythm\nProbable old septal infarct\nLateral ST-T changes are nonspecific\nAtrial premature complex\nSince previous tracing, atrial premature complex is noted\n\n"
},
{
"category": "ECG",
"chartdate": "2123-08-28 00:00:00.000",
"description": "Report",
"row_id": 297649,
"text": "Sinus rhythm\nProbable old septal infarct\nNonspecific T wave inversion in leads l, aVL\nSince previous tracing, the T wave changes are improved in leads V5-6\n\n"
},
{
"category": "ECG",
"chartdate": "2123-08-28 00:00:00.000",
"description": "Report",
"row_id": 297650,
"text": "Sinus rhythm\nProbable old septal infarct\nNonspecific lateral ST-T changes consider ischemia\nSince previous tracing, ST-T wave changes noted\n\n"
},
{
"category": "ECG",
"chartdate": "2123-09-06 00:00:00.000",
"description": "Report",
"row_id": 297640,
"text": "Sinus rhythm\nProbable old septal infarct\nSince previous tracing, atrial fibrillation and left ventricular hypertrophy by\nvoltage are absent; ST-T wave changes are improved\n\n"
},
{
"category": "ECG",
"chartdate": "2123-09-04 00:00:00.000",
"description": "Report",
"row_id": 297641,
"text": "Atrial fibrillation with a rapid ventricular response. Left ventricular\nhypertrophy. Non-specific ST-T wave changes. Poor R wave progression - question\nold septal myocardial infarction. Compared to the previous tracing there is\natrial fibrillation. Increased voltage and ST-T wave changes are present.\n\n"
},
{
"category": "ECG",
"chartdate": "2123-09-01 00:00:00.000",
"description": "Report",
"row_id": 297642,
"text": "Sinus rhythm\nPoor R wave progression - probable old septal myocardial infarction\nNonspecific T wave inversion in leads l, aVL\nSince last ECG, no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2123-08-31 00:00:00.000",
"description": "Report",
"row_id": 297643,
"text": "Sinus rhythm\nProbable old septal infarct\nSince last ECG, no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2123-08-31 00:00:00.000",
"description": "Report",
"row_id": 297644,
"text": "Sinus rhythm\nR wave not seen in V2 previously that is now present probably represent\nvariation in leads\nSince last ECG, no significant change\n\n"
}
] |
3,484 | 162,377 | 1. Subdural hematoma. 89 y/o M with h/o afib, CAD, hypercholesterolemia who presented s/p syncopal fall with new subdural hematoma. SDH was felt to be likely a consequence of the syncopal fall. Patient was initially admitted to ICU for close neurological monitoring and remained neurologically stable. C-spine was cleared. Head CT was repeated in 24 hours to assess for interval changes and SDH appearance was stable. Neurosurgery recommended to hold anticoagulation for 4 weeks and to keep platelets >100 for 7 days after the event. The patient may continue Aspirin. The follow up appointment with neurosurgery was arranged for the patient. He will follow up with neurosurgery in 3 months and will have CT head repeated prior to the appointment. 2. Syncope. Etiology of syncopal fall was not entirely clear. As part of work up for syncope, the patient was ruled out for MI with two sets of enzymes. Carotid US was done and showed <40% bilateral carotid artery stenosis. Echo was unrevealing. CT head was negative for acute pathology that would explain syncopal event. The etiology of his syncope was felt possibly to be due to orthostasis. The patient was orthostatic initially on the floor. Cosyntropin stim test was done to r/o adrenal insufficiency was normal. Tamsulosin was discontinued to eliminate this as a cause of the patient's syncopal fall. The patient was transfused one units of pRBCs and platelets and his orthostasis has resolved. The possibility that he was dehydrated from Lasix and/or poor po intake prior to admission was entertained to explain his orthostasis. Electrophysiology were consulted with the question of whether patient's slow a fib could have caused his syncope (patient with a fib with rate down to high 30's on telemetry at night) and whether he would be a candidate for a pacemaker. They felt that this was unlikely and that no further EP investigation was warranted. 3. Renal failure. Patient had mild elevation of creatinine on admission from his baseline Cr of around 2.0. Lasix was held and his Cr remained stable and was 1.7 at the time of discharge. 4. Atrial fibrillation. The patient has been in slow afib with HR down to high 30's when asleep. He was asymptomatic. Coumadin was held given new SDH. Digoxin level was checked on admission and was 0.5. Digoxin was held given his slow rate. EP did not think that his syncope was from cardiac cause and felt that a pacemaker was not necessary. They recommended Holter as an outpatient. Given patient's slow heart rate, his digoxin should not be restarted. If the patient starts having rapid atrial fibrillation, EP recommended metoprolol for rate control. 5. Thrombocytopenia. From and records appears to have baseline in low 100s. No obvious offensive medications. No splenomegaly on exam. Consider BM bx as outpatient given anemia and thrombocytopenia. 6. Hypercholesterolemia. The patient was continued on Statin. 7. HTN. The patient was not on any antihypertensive . His SBP were mostly within the normal range. If he needs to be started on a medication for BP control, would favor starting a beta-blocker as heart rate tolerates. 8. H/o CVA, remote. This was an incidental finding on CT head. The patient was continued on aspirin 81 mg. 9. CHF. The patient has a h/o systolic dysfunction and EF around 30%. Echocardiogram was repeated here as part of work up for syncope and showed EF 55% but mild LVH. Diuretics have been held during this hospital admission as the patent appeared euvolemic and because of slight increase in creatinine from baseline. The patient will need to be closely monitored for signs of decompensated CHF with daily weight. He needs to be on low Na diet. Lasix can be given on as needed basis. 10. Indirect bilirubinemia, mild. Work up showed no signs of intravascular hemolysis. This felt likely to be secondary to hematomas after the fall. 11. Anemia, macrocytic. Baseline HCT 36-38 from records. Patient had slow decreased in HCT of about 3 points from admission and remained hemodynamically stable. There was no evidence of hemolysis. Stool guaiacs were negative. Fe studies were not consistent with iron deficiency anemia. B12 level was low normal and the patient was started on B12 supplements. Reticulocyte index was low 2.1% (not adjusted). The patient is discharged on Epogen given his renal insufficiency. The patient received a total of 2 units of pRBCs today for orthostatic hypotension. UPEP and SPEP were checked and were normal. 12. BPH. Flomax was stopped to eliminate this as a cause of orthostatis. 13. DM. Glycemic control was initially maintained with Insulin sliding scale. The patient was then restarted on Avandia. His finger sticks were mostly in low 100's. 14. Secondary Hyperparathyroidism. Serum calcium was nornal but the patient did have an elevated Alk Phos and high PTH. His secondary hyperparathyroidism is possibly due to chronic renal insufficiency. The patient was started on Vitamin D supplements. | Mild(1+) mitral regurgitation is seen. Mild mitral annularcalcification. Mild to moderate (+) aorticregurgitation is seen. 3) Low attenuation in the left anterior temporal lobe, extending to the matter consistent with an infarction, probably remote. Moderate PA systolichypertension.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Resting bradycardic (HR<60bpm).Conclusions:The left atrium is moderately dilated. 2) Low attenuation regions in the left frontal and left anterior temporal lobes consisent with infarctions, age indeterminate. The right atrium is moderately dilated.There is mild symmetric left ventricular hypertrophy. The aorticroot is moderately dilated. Atrial fibrillation with a moderate ventricular response. There is moderate pulmonary artery systolichypertension. IMPRESSION: 1) Extra-axial isodense material present over the left frontal convexity consistent with a subdural hematoma. Left ventricular function. The aortic valve leaflets (3) are mildlythickened. Suboptimaltechnical quality, a focal LV wall motion abnormality cannot be fullyexcluded.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Moderately dilated aortic root. Mild tomoderate (+) AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. 2) Low attenuation in the left frontal lobe that may extend to the matter consistent with an infarction, age indeterminant. Coarse bilateral interstitial markings, which may be chronic in nature. There is less prominent calcification of the supraclinoid portions of both internal carotid arteries. There is a focal region of hypodensity involving and white matter in the left temporal lobe consistent with an infarction, probably remote. A small right-sided deep right frontal infarct is also noted, chronic in appearance. Mild (1+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets. Coarse bilateral interstitial markings. Syncope.Height: (in) 71Weight (lb): 200BSA (m2): 2.11 m2BP (mm Hg): 146/50HR (bpm): 75Status: InpatientDate/Time: at 10:18Test: Portable TTE (Complete)Doppler: Full doppler and color dopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Moderate LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.LEFT VENTRICLE: Mild symmetric LVH. There is straightening of the normal cervical lordosis. Straightening of the normal cervical lordosis. Straightening of the normal cervical lordosis. There is a second focal region of low attenuation present within the subcortical white matter with possible extension to the matter in the left frontal lobe (series 2, image 26), also suggestive of an infarction, age indeterminant. Non-specificinferolateral T wave changes. Degenerative disease of the anterior and posterior elements. The left ventricularcavity size is normal. COMMENT: Both studies show rather tortuous appearance of the cavernous portion of the left internal carotid artery, which is heavily calcified, and atherosclerotic in nature. Normal ascending aorta diameter.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). FINAL REPORT *ABNORMAL! The visualized portions of the paranasal sinuses are well aerated. TECHNIQUE: Non-contrast head CT scan. The aorta is calcified and tortuous. On Coumadin. The ICA to CCA ratio is 1.7. FINDINGS: Duplex evaluation was performed of both carotid arteries. COMMENT: There is atherosclerotic calfiication of the right vertebral artery, at the C7 level. +loc and pt. Overall left ventricular systolic function appearspreserved (ejection fraction ?55%) but views are suboptimal. Normal LV cavity size. Minimal plaques identified. There are degenerative changes of the posterior elements, notably with osseous fusion of the right facet joints at the C3/4 level. Atrial fibrillation/flutter. Note is made of calcification of the right vertebral artery. Emphysema. IMPRESSION: Minimal plaque with bilateral less than 40% carotid stenosis. bp stable. FINAL REPORT INDICATION: Syncope and fall. uop q.s. TECHNIQUE: Axial images of the head were obtained without contrast. IMPRESSION: Degenerative disease with no evidence of acute fracture. (Cont) FINDINGS: There are degenerative changes at multiple levels with anterior osteophytes and endplate sclerosis. to then to ew . pauses. IMPRESSION: 1. REASON: Syncope and AFib. Multilevel neural foraminal narrowing is observed, due to cervical spondylosis. Osseous and soft tissue structures are unremarkable. This is consistent with less than 40% stenosis. This is consistent with less than 40% stenosis. The hemorrhage is slightly hyperdense relative to the adjacent spinal fluid within cerebral sulci. thinks he hit his head. The mitral valve leaflets are mildly thickened. The vertebral body heights are maintained. There is antegrade flow in both vertebral arteries. FINDINGS: There is isodense material present along the left cerebral convexity overlying the region of the frontal lobe with a maximal diameter of 5 mm consistent with a subdural hematoma. TECHNIQUE: Axial images of the cervical spine were obtained without IV contrast. Emphysematous disease of the lung apices. Due to suboptimaltechnical quality, a focal wall motion abnormality cannot be fully excluded.Right ventricular chamber size and free wall motion are normal. denies a headache.plan: continue to monitor neuro signs q1h. Once again noted are chronic infarcts within the left middle cerebral artery territory, involving both the left temporal lobe and left frontal lobe. No AS. INDICATION: Syncope, fall, subdural hematoma on outside CT scan. Pt. No definite pleural effusions, however, the left costophrenic angle is not fully evaluated. c-collar still in place even though spine cleared.pt. The imaged portions of the lung apices demonstrate emphysematous disease. The ICA to CCA ratio is 1.5. room air o2 with good sats. Assess for change in the subdural hemorrhage. The basilar cisterns are patent. PATIENT/TEST INFORMATION:Indication: Aortic valve disease. No overt CHF or pulmonary consolidations. Status post fall. Cardiomegaly. On the left, peak systolic velocities are 114, 66, and 61 in the ICA, CCA, and ECA respectively. On the right, peak systolic velocities are 105, 71, and 53 in the ICA, CCA, and ECA respectively. Comparison with prior outside radiographs is recommended, if available. Washed with saline and wrapped in gauze. COMPARISON: None. Skin warm and dry left toes all with abrasions. ct of head confirmed 5mm subdural hematoma. ? FINDINGS: Comparison with the prior day's study discloses no increase in size or significant change in density of the relatively thin left frontal subdural hemorrhage. COMPARISON: None available. c-collar remains intact. in chronic afib and is on coumadin.cv/resp Afib in the 50's with occ. | 9 | [
{
"category": "Nursing/other",
"chartdate": "2132-07-15 00:00:00.000",
"description": "Report",
"row_id": 1307311,
"text": "89 year old male lives alone. states he fell yest morning in the bathroom after standing and feeling dizzy. +loc and pt. thinks he hit his head. Crawled to his bed and phoned his daughter. to then to ew . ct of head confirmed 5mm subdural hematoma. c-collar still in place even though spine cleared.\npt. in chronic afib and is on coumadin.\ncv/resp Afib in the 50's with occ. pauses. bp stable. room air o2 with good sats. lungs are clear.\ngi/gu c/o of being hungry then fell asleep. uop q.s. voiding in urinal without difficulty\ninteg. Skin warm and dry left toes all with abrasions. very painful. Washed with saline and wrapped in gauze. c-collar remains intact. Pt. denies a headache.\nplan: continue to monitor neuro signs q1h. Plan ?c/o to floor today??\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-07-15 00:00:00.000",
"description": "Report",
"row_id": 1307312,
"text": "See nursing transfer note.\n"
},
{
"category": "Echo",
"chartdate": "2132-07-15 00:00:00.000",
"description": "Report",
"row_id": 99096,
"text": "PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease. Atrial fibrillation/flutter. Left ventricular function. Syncope.\nHeight: (in) 71\nWeight (lb): 200\nBSA (m2): 2.11 m2\nBP (mm Hg): 146/50\nHR (bpm): 75\nStatus: Inpatient\nDate/Time: at 10:18\nTest: Portable TTE (Complete)\nDoppler: Full doppler and color doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Suboptimal\ntechnical quality, a focal LV wall motion abnormality cannot be fully\nexcluded.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Moderately dilated aortic root. Normal ascending aorta diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild to\nmoderate (+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate PA systolic\nhypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Resting bradycardic (HR<60bpm).\n\nConclusions:\nThe left atrium is moderately dilated. The right atrium is moderately dilated.\nThere is mild symmetric left ventricular hypertrophy. The left ventricular\ncavity size is normal. Overall left ventricular systolic function appears\npreserved (ejection fraction ?55%) but views are suboptimal. Due to suboptimal\ntechnical quality, a focal wall motion abnormality cannot be fully excluded.\nRight ventricular chamber size and free wall motion are normal. The aortic\nroot is moderately dilated. The aortic valve leaflets (3) are mildly\nthickened. There is no aortic valve stenosis. Mild to moderate (+) aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. Mild\n(1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic\nhypertension. There is no pericardial effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-07-15 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 869959,
"text": " 8:10 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for change in subdural hematoma\n Admitting Diagnosis: SUBDURAL HEMAROMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old man with afib on coumadin s/p syncopal fall now with new subdural\n hematoma\n REASON FOR THIS EXAMINATION:\n eval for change in subdural hematoma\n CONTRAINDICATIONS for IV CONTRAST:\n high creatinine\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Atrial fibrillation. On Coumadin. Status post fall. Assess for\n change in the subdural hemorrhage.\n\n TECHNIQUE: Non-contrast head CT scan.\n\n FINDINGS: Comparison with the prior day's study discloses no increase in size\n or significant change in density of the relatively thin left frontal subdural\n hemorrhage. The hemorrhage is slightly hyperdense relative to the adjacent\n spinal fluid within cerebral sulci. There are no other interval changes seen.\n Once again noted are chronic infarcts within the left middle cerebral artery\n territory, involving both the left temporal lobe and left frontal lobe. A\n small right-sided deep right frontal infarct is also noted, chronic in\n appearance.\n\n CONCLUSION: No significant interval change from previous day's study.\n\n COMMENT: Both studies show rather tortuous appearance of the cavernous\n portion of the left internal carotid artery, which is heavily calcified, and\n atherosclerotic in nature. There is less prominent calcification of the\n supraclinoid portions of both internal carotid arteries.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-07-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 869914,
"text": " 5:44 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess for infiltrate,effusion\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old man with syncope\n REASON FOR THIS EXAMINATION:\n please assess for infiltrate,effusion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 89-year-old man with syncope.\n\n The heart size is enlarged. The aorta is calcified and tortuous. Coarse\n bilateral interstitial markings. No definite pleural effusions, however, the\n left costophrenic angle is not fully evaluated. Osseous and soft tissue\n structures are unremarkable.\n\n IMPRESSION:\n\n 1. Cardiomegaly. No overt CHF or pulmonary consolidations.\n\n 2. Coarse bilateral interstitial markings, which may be chronic in nature.\n Comparison with prior outside radiographs is recommended, if available.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-07-14 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 869918,
"text": " 6:20 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: please assess for bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old man with syncope, fall, SDH on CT at OSH\n REASON FOR THIS EXAMINATION:\n please assess for bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JJMl MON 6:52 PM\n 1) Isodense, extraaxial material consistent with a right frontal subdural\n hematoma.\n 2) Low attenuation regions in the left frontal and left anterior temporal\n lobes consisent with infarctions, age indeterminate.\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n INDICATION: Syncope, fall, subdural hematoma on outside CT scan.\n\n COMPARISON: None available.\n\n TECHNIQUE: Axial images of the head were obtained without contrast.\n\n FINDINGS: There is isodense material present along the left cerebral\n convexity overlying the region of the frontal lobe with a maximal diameter of\n 5 mm consistent with a subdural hematoma. There is a focal region of\n hypodensity involving and white matter in the left temporal lobe\n consistent with an infarction, probably remote. There is a second focal\n region of low attenuation present within the subcortical white matter with\n possible extension to the matter in the left frontal lobe (series 2,\n image 26), also suggestive of an infarction, age indeterminant. The basilar\n cisterns are patent. There is no hydrocephalus. Note is made of calcification\n of the right vertebral artery. The visualized portions of the paranasal\n sinuses are well aerated. No displaced skull fracture is identified.\n\n IMPRESSION:\n 1) Extra-axial isodense material present over the left frontal convexity\n consistent with a subdural hematoma.\n 2) Low attenuation in the left frontal lobe that may extend to the \n matter consistent with an infarction, age indeterminant.\n 3) Low attenuation in the left anterior temporal lobe, extending to the \n matter consistent with an infarction, probably remote.\n\n If there is concern for acute infarction, further evaluation with MRI with DWI\n may be performed.\n\n The above was discussed with Dr. at the time of interpretation of the\n study.\n (Over)\n\n 6:20 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: please assess for bleed\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-07-14 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 869919,
"text": " 6:24 PM\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: please assess for fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old man with syncope, fall\n REASON FOR THIS EXAMINATION:\n please assess for fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JJMl MON 6:58 PM\n No evidence of acute fracture.\n Straightening of the normal cervical lordosis.\n Degenerative disease of the anterior and posterior elements.\n Emphysema.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Syncope and fall.\n\n COMPARISON: None.\n\n TECHNIQUE: Axial images of the cervical spine were obtained without IV\n contrast. Coronal and sagittal reformatted images were also obtained.\n\n FINDINGS: There are degenerative changes at multiple levels with anterior\n osteophytes and endplate sclerosis. There are degenerative changes of the\n posterior elements, notably with osseous fusion of the right facet joints at\n the C3/4 level. Multilevel neural foraminal narrowing is observed, due to\n cervical spondylosis. There is straightening of the normal cervical lordosis.\n The vertebral body heights are maintained. There is no prevertebral soft\n tissue swelling. The imaged portions of the lung apices demonstrate\n emphysematous disease.\n\n IMPRESSION: Degenerative disease with no evidence of acute fracture.\n Straightening of the normal cervical lordosis. Emphysematous disease of the\n lung apices.\n\n COMMENT: There is atherosclerotic calfiication of the right vertebral artery,\n at the C7 level.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-07-15 00:00:00.000",
"description": "CAROTID SERIES COMPLETE",
"row_id": 870020,
"text": " 2:48 PM\n CAROTID SERIES COMPLETE Clip # \n Reason: SYNCOPE\n Admitting Diagnosis: SUBDURAL HEMAROMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old man with afib, cad, syncope\n REASON FOR THIS EXAMINATION:\n r/o stenosis\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Carotid series complete.\n\n REASON: Syncope and AFib.\n\n FINDINGS: Duplex evaluation was performed of both carotid arteries. Minimal\n plaques identified.\n\n On the right, peak systolic velocities are 105, 71, and 53 in the ICA, CCA,\n and ECA respectively. The ICA to CCA ratio is 1.5. This is consistent with\n less than 40% stenosis.\n\n On the left, peak systolic velocities are 114, 66, and 61 in the ICA, CCA, and\n ECA respectively. The ICA to CCA ratio is 1.7. This is consistent with less\n than 40% stenosis.\n\n There is antegrade flow in both vertebral arteries.\n\n IMPRESSION: Minimal plaque with bilateral less than 40% carotid stenosis.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2132-07-14 00:00:00.000",
"description": "Report",
"row_id": 280317,
"text": "Atrial fibrillation with a moderate ventricular response. Non-specific\ninferolateral T wave changes. No previous tracing available for comparison.\n\n"
}
] |
79,400 | 182,082 | This patient was transferred from on and underwent CABGx3(LIMA->LAD, SVG->OM1, OM3). The cross clamp time was 51 minutes with a total bypass time of 62 minutes. He tolerated the procedure well and was transferred to the CVIVU in stable condition on Neo and Propofol. He was extubated on the post op night and had his chest tubes discontinued on POD 1. He was transferred to the floor on POD 1. His chest tubes and pacing wires were removed per protocol. The post chest tube removal chest XRAY revealed at PTX and Mr. was also symptomatic with low oxygen saturation. A chest tube was re-inserted into the right pleural space and was placed to suction with lung re-expansion. The chest tube was placed to water seal on POD# 5 without PTX. Chest tube was removed and CXR post removal resulted in a left sided small apical pneumothorax which was stable on multiple subsequent chest radiographs. The patient was discharged to home after review of these radiographs by Dr. with the understanding that Mr. should return in three days to repeat a chest radiograph. All follow-up appointments were advised. | Mitral valve disease.Status: InpatientDate/Time: at 13:09Test: TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Mild LA enlargement. No TEErelated complications.Conclusions:PRE-BYPASS: The left atrium is mildly dilated. Simple atheroma in ascending aorta.Normal descending aorta diameter. PATIENT/TEST INFORMATION:Indication: Coronary artery disease.Height: (in) 65Weight (lb): 200BSA (m2): 1.98 m2BP (mm Hg): 129/60HR (bpm): 57Status: InpatientDate/Time: at 11:02Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:LEFT ATRIUM: Mild LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Normal LV wall thickness. Physiologic TR.PERICARDIUM: No pericardial effusion.Conclusions:The left atrium is mildly dilated. Normal LV wall thickness and cavity size.LV WALL MOTION: basal anterior - normal; mid anterior - normal; basalanteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal;mid inferoseptal - normal; basal inferior - normal; mid inferior - normal;basal inferolateral - normal; mid inferolateral - normal; basal anterolateral- normal; mid anterolateral - normal; anterior apex - normal; septal apex -normal; inferior apex - normal; lateral apex - normal; apex - normal;RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal ascending aorta diameter. Coronary artery bypass graft (CABG) Assessment: Sr in the 90s, tmax 35.3, sbp supported with neo.5, sedated on 30 propofol, , ci 1.8,k 3.8, ica 1.09, minimal ct output ,adequate u/o. Mildly thickenedaortic valve leaflets (?#). Trivial mitral regurgitation is seen. Trivial mitral regurgitation is seen. There are simple atheroma in the ascending aorta.There are simple atheroma in the descending thoracic aorta. Trivial MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. No resting LVOT gradient.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). off by pass ef wnl, sr, neo and propofol Latest Vital Signs and I/O Non-invasive BP: S:93 D:51 Temperature: 98.3 Arterial BP: S:107 D:51 Respiratory rate: 20 insp/min Heart Rate: 86 bpm Heart rhythm: SR (Sinus Rhythm) O2 delivery device: Nasal cannula O2 saturation: 97% % O2 flow: 2 L/min FiO2 set: 24h total in: 1,752 mL 24h total out: 2,315 mL Pacer Data Temporary pacemaker type: Epicardial Wires Temporary pacemaker mode: Ventricular Demand Temporary pacemaker rate: 50 bpm Temporary atrial sensitivity: No Temporary ventricular sensitivity: Yes Temporary ventricular sensitivity threshold: 3 mV Temporary ventricular sensitivity setting: 1.5 mV Temporary ventricular stimulation threshold : 19 mA Temporary ventricular stimulation setting : 25 mA Temporary pacemaker wire condition: Attached-Pacer Temporary pacemaker wires atrial: 2 Temporary pacemaker wires ventricular: 2 Pertinent Lab Results: Sodium: 137 mEq/L 01:59 AM Potassium: 4.4 mEq/L 01:59 AM Chloride: 109 mEq/L 01:59 AM CO2: 24 mEq/L 01:59 AM BUN: 9 mg/dL 01:59 AM Creatinine: 0.8 mg/dL 01:59 AM Glucose: 116 mg/dL 01:59 AM Hematocrit: 31.0 % 01:59 AM Finger Stick Glucose: 113 02:00 PM Valuables / Signature Patient valuables: Other valuables: Clothes: Transferred with patient Wallet / Money: No money / wallet Cash / Credit cards sent home with: Jewelry: Transferred from: 795 Transferred to: 609 Date & time of Transfer: 06:00PM There is a right apical pneumothorax, faintly visualized. FINDINGS: There is again seen a right apical pneumothorax which appears unchanged from the prior study. Check for right-sided pneumothorax. IMPRESSION: New right apical pneumothorax of moderate size. In the interval, an endotracheal tube, a right central venous line and a right chest tube were removed. IMPRESSION: Stable appearances with unchanged right apical pneumothorax. There is sparing of the ascending aorta and the aortic arch. The right apical pneumothorax is unchanged. The right-sided chest tube appears to have been slightly withdrawn from the previous study. The distal end of right chest tube is unchanged. FINAL REPORT TYPE OF EXAMINATION: Chest AP portable single view. FINDINGS: There is a new moderate-sized right apical pneumothorax, which was not present on the chest x-ray on . Subcutaneous emphysema on the right chest wall is unchanged. The elevated right hemidiaphragm is unchanged. The right chest tube is unchanged. FINDINGS: Since the previous chest radiograph the right apical pneumothorax is unchanged and extends to between the third and fourth posterior ribs. 2-mm noncalcified nodule of the left upper lobe (series 4, image 39) and 6-mm noncalcified nodule of the right upper lobe are noted (series 4, image 64). There are small bilateral pleural effusions and a left retrocardiac opacity which is stable. FINDINGS: In comparison with the study of earlier in this date, there has been removal of the right chest tube with the development of a pneumothorax that extends to about the superior margin of the fourth posterior rib. Left-sided hemithorax with unchanged findings. There remains a right basilar chest tube. IMPRESSION: Right apical pneunothorax persistent, following chest tube placement. Mediastinal and right chest tubes are in place. There is a loculated pneumothorax seen adjacent to the right CP angle at the insertion site of the chest tube. The right pneumothorax is moderate, unchanged since . Diffuse calcification of the left anterior descending, circumflex, and right coronary artery is noted. PA AND LATERAL RADIOGRAPH OF THE CHEST: Cardiomediastinal silhouette and hilar contours are normal. IMPRESSION: Slight increase of right-sided apical pneumothorax. There is a right basilar chest tube. There is persistent right basilar pneumothorax. There is an unchanged right apical pneunothorax, stable. Please rule out pneumothorax. The small left pleural effusion and left basilar atelectasis are unchanged. The chest tube position appears unchanged. COMPARISON: Portable chest x-ray from . FINDINGS: AP single view of the chest was obtained with patient in sitting semi upright position. Evaluate pneumothorax. PORTABLE UPRIGHT RADIOGRAPH OF THE CHEST: Cardiomediastinal silhouette and hilar contours are normal. The right basilar chest tube is again visualized with tip and side port within the chest wall. Small area of opacification at the right base medially could represent a developing consolidation and atelectasis or merely crowding of pulmonary vessels. Continued low lung volumes with left basilar opacity consistent with atelectasis and effusion. Small left pleural effusion is unchanged. | 33 | [
{
"category": "Nursing",
"chartdate": "2176-09-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 691969,
"text": "Coronary artery bypass graft (CABG)\n Assessment:\n Sr in the 90s, tmax 35.3, sbp supported with neo.5, sedated on 30\n propofol, , ci 1.8,k 3.8, ica 1.09, minimal ct output ,adequate u/o.\n Action:\n Bair hugger on, sbp 100-120\ns. fluid infusing received 1000cc lr thus\n far, kcl/ca replaced. With stabilization family visited , update\n given.\n Response:\n Patient warming cxr/ekg comleted. Hemodynamics stabilzing\n Plan:\n Patient speaks Spanish, a little bit of English, interpreter as needed.\n Reverse/wean from vent as tolerated.\n .\n"
},
{
"category": "Respiratory ",
"chartdate": "2176-09-18 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 691959,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 1\n Ideal body weight: 72.6 None\n Ideal tidal volume: 290.4 / 435.6 / 580.8 mL/kg\n Airway\n Tube Type\n ETT:\n Position: 20 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed\n Respiratory Care Shift Procedures\n Pt received from OR placed on a/c vent plan to wean on fast track\n protocol.\n"
},
{
"category": "Nursing",
"chartdate": "2176-09-19 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 692069,
"text": "Coronary artery bypass graft (CABG)\n Assessment:\n Spanish speaking, speaks/understands little English\n Pupils irregular at baseline RN report\n R pupil smaller than L\n Both reactive\n SR-ST 90-110\n Awires not sensing. Vdemand backup\n PO Lopressor given in early am\n CTs with minimal sanguineous drainage\n Good urine output\n c/o incisional pain with cough\n Action:\n Pt MAE and followed commands\n Patient continues in ST 100.\n Lopressor given IV, po dose increased\n Patient on 2L NC with SAT in mid 90\n Percocet/ Toradol 15mg IV for pain\n Lasix given\n Response:\n HR in 90\ns NSR\n Pain relieved with Percocet and toradol\n Able to communicate with pt slightly\n Insulin SC per protocol, no coverage required.\n Taking po well.\n Plan:\n Pain management with Toradol Q6 percocet prn\n Transfer to 6 for cardiac rehab.\n Demographics\n Attending MD:\n R.\n Admit diagnosis:\n CAD;\n Code status:\n Full code\n Height:\n 69 Inch\n Admission weight:\n 89.1 kg\n Daily weight:\n 97 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: No Additional Precautions\n PMH:\n CV-PMH: Angina, Hypertension\n Additional history: reactive airway\n Surgery / Procedure and date: cabgx3 lima to lad, saph to om1,om3.\n xclzmp 51min, bypass 62min. easy intubation, uneventful or course labs\n wnl. opening pa pse 30-20/16.12 noon received vanco/cipro. off by pass\n ef wnl, sr, neo and propofol\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:93\n D:51\n Temperature:\n 98.3\n Arterial BP:\n S:107\n D:51\n Respiratory rate:\n 20 insp/min\n Heart Rate:\n 86 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 97% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 1,752 mL\n 24h total out:\n 2,315 mL\n Pacer Data\n Temporary pacemaker type:\n Epicardial Wires\n Temporary pacemaker mode:\n Ventricular Demand\n Temporary pacemaker rate:\n 50 bpm\n Temporary atrial sensitivity:\n No\n Temporary ventricular sensitivity:\n Yes\n Temporary ventricular sensitivity threshold:\n 3 mV\n Temporary ventricular sensitivity setting:\n 1.5 mV\n Temporary ventricular stimulation threshold :\n 19 mA\n Temporary ventricular stimulation setting :\n 25 mA\n Temporary pacemaker wire condition:\n Attached-Pacer\n Temporary pacemaker wires atrial:\n 2\n Temporary pacemaker wires ventricular:\n 2\n Pertinent Lab Results:\n Sodium:\n 137 mEq/L\n 01:59 AM\n Potassium:\n 4.4 mEq/L\n 01:59 AM\n Chloride:\n 109 mEq/L\n 01:59 AM\n CO2:\n 24 mEq/L\n 01:59 AM\n BUN:\n 9 mg/dL\n 01:59 AM\n Creatinine:\n 0.8 mg/dL\n 01:59 AM\n Glucose:\n 116 mg/dL\n 01:59 AM\n Hematocrit:\n 31.0 %\n 01:59 AM\n Finger Stick Glucose:\n 113\n 02:00 PM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: 795\n Transferred to: 609\n Date & time of Transfer: 06:00PM\n"
},
{
"category": "Nursing",
"chartdate": "2176-09-19 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 692051,
"text": "Coronary artery bypass graft (CABG)\n Assessment:\n Spanish speaking, speaks/understands little English\n Pupils irregular at baseline RN report\n R pupil smaller than L\n Both reactive\n SR-ST 90-110\n Awires not sensing. Vdemand backup\n PO Lopressor given in early am\n CTs with minimal sanguineous drainage\n Good urine output\n c/o incisional pain with cough\n Action:\n Pt MAE and followed commands\n Patient continues in ST 100.\n Lopressor given IV, po dose increased\n Patient on 2L NC with SAT in mid 90\n Percocet/ Toradol 15mg IV for pain\n Lasix given\n Response:\n Pain relieved with Percocet and toradol\n Able to communicate with pt slightly\n Insulin SC per protocol, no coverage required.\n Taking po well.\n Plan:\n Pain management with Toradol Q6 percocet prn\n Transfer to 6 for cardiac rehab.\n"
},
{
"category": "Nursing",
"chartdate": "2176-09-19 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 692052,
"text": "Coronary artery bypass graft (CABG)\n Assessment:\n Spanish speaking, speaks/understands little English\n Pupils irregular at baseline RN report\n R pupil smaller than L\n Both reactive\n SR-ST 90-110\n Awires not sensing. Vdemand backup\n PO Lopressor given in early am\n CTs with minimal sanguineous drainage\n Good urine output\n c/o incisional pain with cough\n Action:\n Pt MAE and followed commands\n Patient continues in ST 100.\n Lopressor given IV, po dose increased\n Patient on 2L NC with SAT in mid 90\n Percocet/ Toradol 15mg IV for pain\n Lasix given\n Response:\n HR in 90\ns NSR\n Pain relieved with Percocet and toradol\n Able to communicate with pt slightly\n Insulin SC per protocol, no coverage required.\n Taking po well.\n Plan:\n Pain management with Toradol Q6 percocet prn\n Transfer to 6 for cardiac rehab.\n"
},
{
"category": "Physician ",
"chartdate": "2176-09-19 00:00:00.000",
"description": "Intensivist Note",
"row_id": 692019,
"text": "CVICU\n HPI:\n POD 1\n 69M s/p CABGx3(LIMA->LAD, SVG->OM1, OM3) \n EF: 60% Wt.: 81 kgs Cr.:1.1 HgbA1c: 6.1\n Chief complaint:\n PMHx:\n HTN,hypercholesterolemia,BPH, reactive airway disease\n Current medications:\n Acetaminophen . Albumin 5% (25g / 500mL) . Aspirin EC\n . Calcium Gluconate . Dextrose 50% Docusate Sodium . Furosemide\n Insulin Ketorolac\n Magnesium Sulfate . Metoprolol Tartrate . Metoclopramide Milk of\n Magnesia\n Morphine Sulfate Oxycodone-Acetaminophen Pneumococcal Vac Polyvalent\n . Potassium Chloride\n . Ranitidine . Rosuvastatin Calcium Tamsulosin Vancomycin\n 24 Hour Events:\n INVASIVE VENTILATION - START 04:55 PM\n ARTERIAL LINE - START 04:59 PM\n CORDIS/INTRODUCER - START 05:00 PM\n PA CATHETER - START 05:01 PM\n EKG - At 06:09 PM\n INVASIVE VENTILATION - STOP 10:45 PM\n EXTUBATION - At 10:46 PM\n PA CATHETER - STOP 12:59 AM\n ARTERIAL LINE - STOP 06:33 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 07:30 PM\n Infusions:\n Other ICU medications:\n Insulin - Regular - 06:32 PM\n Ranitidine (Prophylaxis) - 08:00 PM\n Morphine Sulfate - 04:00 AM\n Metoprolol - 04:15 AM\n Other medications:\n Flowsheet Data as of 07:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.5\nC (99.5\n T current: 37.5\nC (99.5\n HR: 99 (79 - 123) bpm\n BP: 128/70(78) {128/62(78) - 131/70(79)} mmHg\n RR: 16 (9 - 26) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 97 kg (admission): 89.1 kg\n Height: 69 Inch\n CVP: 18 (9 - 18) mmHg\n PAP: (41 mmHg) / (29 mmHg)\n PCWP: 47 (47 - 47) mmHg\n CO/CI (Thermodilution): (6.63 L/min) / (3.2 L/min/m2)\n SVR: 929 dynes*sec/cm5\n PVR: -408 dynes*sec/cm5\n SV: 57 mL\n SVI: 28 mL/m2\n Total In:\n 8,676 mL\n 1,379 mL\n PO:\n 120 mL\n Tube feeding:\n IV Fluid:\n 8,086 mL\n 759 mL\n Blood products:\n 500 mL\n 500 mL\n Total out:\n 3,710 mL\n 555 mL\n Urine:\n 1,450 mL\n 435 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,966 mL\n 824 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PPS\n Vt (Set): 600 (600 - 600) mL\n PS : 10 cmH2O\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 0%\n PIP: 22 cmH2O\n Plateau: 21 cmH2O\n Compliance: 37.5 cmH2O/mL\n SPO2: 97%\n ABG: 7.37/41/95./24/-1\n Ve: 8.4 L/min\n PaO2 / FiO2: 240\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Trace)\n Right Extremities: (Edema: Trace)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), No(t) Follows simple\n commands, Moves all extremities\n Labs / Radiology\n 152 K/uL\n 10.5 g/dL\n 116 mg/dL\n 0.8 mg/dL\n 24 mEq/L\n 4.4 mEq/L\n 9 mg/dL\n 109 mEq/L\n 137 mEq/L\n 31.0 %\n 6.1 K/uL\n [image002.jpg]\n 04:41 PM\n 05:10 PM\n 07:39 PM\n 10:02 PM\n 10:07 PM\n 01:59 AM\n WBC\n 7.6\n 6.1\n Hct\n 33.7\n 34.2\n 31.0\n Plt\n 158\n 152\n Creatinine\n 0.7\n 0.8\n TCO2\n 25\n 25\n 25\n Glucose\n 130\n 98\n 116\n Other labs: PT / PTT / INR:14.7/35.5/1.3, Ca:7.8 mg/dL, Mg:1.9 mg/dL,\n PO4:4.0 mg/dL\n Assessment and Plan\n CORONARY ARTERY BYPASS GRAFT (CABG)\n Assessment and Plan: POD 1 69M s/p CABGx3(LIMA->LAD, SVG->OM1,\n OM3) . Did well overnight after volume resuscitation from OR.\n Neurologic: Neuro checks Q: 4 hr, Pain controlled, spanish speaking,\n reports being comfortable\n Cardiovascular: Aspirin, Beta-blocker, Statins\n Pulmonary: extubated O/N, clear CXR\n Gastrointestinal / Abdomen: no issues\n Nutrition: Regular diet\n Renal: Foley, keep until MN tonight for diuresis\n Hematology: stable anemia\n Endocrine: RISS\n Infectious Disease: periop vanco\n Lines / Tubes / Drains: d/c CT\n Wounds: Dry dressings\n Imaging: CXR today, clear CXR, no repeat\n Fluids: KVO\n Consults: CT surgery, P.T., O.T.\n Billing Diagnosis: Post-op hypotension\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Cordis/Introducer - 05:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 31 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2176-09-19 00:00:00.000",
"description": "Intensivist Note",
"row_id": 692021,
"text": "CVICU\n HPI:\n POD 1\n 69M s/p CABGx3(LIMA->LAD, SVG->OM1, OM3) \n EF: 60% Wt.: 81 kgs Cr.:1.1 HgbA1c: 6.1\n PMHx:\n HTN,hypercholesterolemia,BPH, reactive airway disease\n Current medications:\n Acetaminophen . Albumin 5% (25g / 500mL) . Aspirin EC\n . Calcium Gluconate . Dextrose 50% Docusate Sodium . Furosemide\n Insulin Ketorolac Magnesium Sulfate . Metoprolol Tartrate .\n Metoclopramide Milk of Magnesia Morphine Sulfate\n Oxycodone-Acetaminophen Pneumococcal Vac Polyvalent . Potassium\n Chloride\n . Ranitidine . Rosuvastatin Calcium Tamsulosin Vancomycin\n 24 Hour Events:\n INVASIVE VENTILATION - START 04:55 PM\n ARTERIAL LINE - START 04:59 PM\n CORDIS/INTRODUCER - START 05:00 PM\n PA CATHETER - START 05:01 PM\n EKG - At 06:09 PM\n INVASIVE VENTILATION - STOP 10:45 PM\n EXTUBATION - At 10:46 PM\n PA CATHETER - STOP 12:59 AM\n ARTERIAL LINE - STOP 06:33 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 07:30 PM\n Other ICU medications:\n Insulin - Regular - 06:32 PM\n Ranitidine (Prophylaxis) - 08:00 PM\n Morphine Sulfate - 04:00 AM\n Metoprolol - 04:15 AM\n Flowsheet Data as of 07:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.5\nC (99.5\n T current: 37.5\nC (99.5\n HR: 99 (79 - 123) bpm\n BP: 128/70(78) {128/62(78) - 131/70(79)} mmHg\n RR: 16 (9 - 26) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 97 kg (admission): 89.1 kg\n Height: 69 Inch\n CVP: 18 (9 - 18) mmHg\n PAP: (41 mmHg) / (29 mmHg)\n PCWP: 47 (47 - 47) mmHg\n CO/CI (Thermodilution): (6.63 L/min) / (3.2 L/min/m2)\n SVR: 929 dynes*sec/cm5\n PVR: -408 dynes*sec/cm5\n SV: 57 mL\n SVI: 28 mL/m2\n Total In:\n 8,676 mL\n 1,379 mL\n PO:\n 120 mL\n Tube feeding:\n IV Fluid:\n 8,086 mL\n 759 mL\n Blood products:\n 500 mL\n 500 mL\n Total out:\n 3,710 mL\n 555 mL\n Urine:\n 1,450 mL\n 435 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,966 mL\n 824 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PPS\n Vt (Set): 600 (600 - 600) mL\n PS : 10 cmH2O\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 0%\n PIP: 22 cmH2O\n Plateau: 21 cmH2O\n Compliance: 37.5 cmH2O/mL\n SPO2: 97%\n ABG: 7.37/41/95./24/-1\n Ve: 8.4 L/min\n PaO2 / FiO2: 240\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Trace)\n Right Extremities: (Edema: Trace)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), No(t) Follows simple\n commands, Moves all extremities\n Labs / Radiology\n 152 K/uL\n 10.5 g/dL\n 116 mg/dL\n 0.8 mg/dL\n 24 mEq/L\n 4.4 mEq/L\n 9 mg/dL\n 109 mEq/L\n 137 mEq/L\n 31.0 %\n 6.1 K/uL\n [image002.jpg]\n 04:41 PM\n 05:10 PM\n 07:39 PM\n 10:02 PM\n 10:07 PM\n 01:59 AM\n WBC\n 7.6\n 6.1\n Hct\n 33.7\n 34.2\n 31.0\n Plt\n 158\n 152\n Creatinine\n 0.7\n 0.8\n TCO2\n 25\n 25\n 25\n Glucose\n 130\n 98\n 116\n Other labs: PT / PTT / INR:14.7/35.5/1.3, Ca:7.8 mg/dL, Mg:1.9 mg/dL,\n PO4:4.0 mg/dL\n Assessment and Plan\n CORONARY ARTERY BYPASS GRAFT (CABG)\n Assessment and Plan: POD 1 69M s/p CABGx3(LIMA->LAD, SVG->OM1,\n OM3) . Did well overnight after volume resuscitation from OR.\n Neurologic: Neuro checks Q: 4 hr, Pain controlled, spanish speaking,\n reports being comfortable\n Cardiovascular: Aspirin, Beta-blocker, Statins\n Pulmonary: extubated O/N, clear CXR\n Gastrointestinal / Abdomen: no issues\n Nutrition: Regular diet\n Renal: Foley, keep until MN tonight for diuresis\n Hematology: stable anemia\n Endocrine: RISS\n Infectious Disease: periop vanco\n Lines / Tubes / Drains: d/c CT\n Wounds: Dry dressings\n Imaging: CXR today, clear CXR, no repeat\n Fluids: KVO\n Consults: CT surgery, P.T., O.T.\n Billing Diagnosis: Post-op hypotension post op resp insufficiency\n ICU Care\n Nutrition: ADAT\n Glycemic Control:\n Lines:\n Cordis/Introducer - 05:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer: H2 blocker\n VAP bundle:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 31 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2176-09-19 00:00:00.000",
"description": "ICU Note - CVI",
"row_id": 692023,
"text": "CVICU\n HPI:\n POD 1\n 69M s/p CABGx3(LIMA->LAD, SVG->OM1, OM3) \n EF: 60% Wt.: 81 kgs Cr.:1.1 HgbA1c: 6.1\n PMHx:HTN,hypercholesterolemia,BPH, ?reactive airway disease\n Chief complaint:\n PMHx:\n Current medications:\n Acetaminophen , Albumin 5% (25g / 500mL) , Aspirin EC , Calcium\n Gluconate , Dextrose 50% , Docusate Sodium, Furosemide , Insulin ,\n Ketorolac, Magnesium Sulfate , Metoprolol Tartrate , Metoclopramide ,\n Milk of Magnesia,\n Morphine Sulfate , Oxycodone-Acetaminophen , Pneumococcal Vac\n Polyvalent, Potassium Chloride,\n Ranitidine , Rosuvastatin Calcium , Sodium Chloride 0.9% Flush ,\n Tamsulosin , Vancomycin\n 24 Hour Events:\n INVASIVE VENTILATION - START 04:55 PM\n ARTERIAL LINE - START 04:59 PM\n CORDIS/INTRODUCER - START 05:00 PM\n PA CATHETER - START 05:01 PM\n EKG - At 06:09 PM\n INVASIVE VENTILATION - STOP 10:45 PM\n EXTUBATION - At 10:46 PM\n PA CATHETER - STOP 12:59 AM\n ARTERIAL LINE - STOP 06:33 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 07:30 PM\n Infusions:\n Other ICU medications:\n Insulin - Regular - 06:32 PM\n Ranitidine (Prophylaxis) - 08:00 PM\n Morphine Sulfate - 04:00 AM\n Metoprolol - 04:15 AM\n Other medications:\n Flowsheet Data as of 08:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.5\nC (99.5\n T current: 37.5\nC (99.5\n HR: 99 (79 - 123) bpm\n BP: 128/70(78) {128/62(78) - 131/70(79)} mmHg\n RR: 16 (9 - 26) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 97 kg (admission): 89.1 kg\n Height: 69 Inch\n CVP: 18 (9 - 18) mmHg\n PAP: (41 mmHg) / (29 mmHg)\n PCWP: 47 (47 - 47) mmHg\n CO/CI (Thermodilution): (6.63 L/min) / (3.2 L/min/m2)\n SVR: 784 dynes*sec/cm5\n PVR: -265 dynes*sec/cm5\n SV: 60 mL\n SVI: 29 mL/m2\n Total In:\n 8,676 mL\n 1,382 mL\n PO:\n 120 mL\n Tube feeding:\n IV Fluid:\n 8,086 mL\n 762 mL\n Blood products:\n 500 mL\n 500 mL\n Total out:\n 3,710 mL\n 555 mL\n Urine:\n 1,450 mL\n 435 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,966 mL\n 827 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 97%\n ABG: 7.37/41/95./24/-1\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 152 K/uL\n 10.5 g/dL\n 116 mg/dL\n 0.8 mg/dL\n 24 mEq/L\n 4.4 mEq/L\n 9 mg/dL\n 109 mEq/L\n 137 mEq/L\n 31.0 %\n 6.1 K/uL\n [image002.jpg]\n 04:41 PM\n 05:10 PM\n 07:39 PM\n 10:02 PM\n 10:07 PM\n 01:59 AM\n WBC\n 7.6\n 6.1\n Hct\n 33.7\n 34.2\n 31.0\n Plt\n 158\n 152\n Creatinine\n 0.7\n 0.8\n TCO2\n 25\n 25\n 25\n Glucose\n 130\n 98\n 116\n Other labs: PT / PTT / INR:14.7/35.5/1.3, Ca:7.8 mg/dL, Mg:1.9 mg/dL,\n PO4:4.0 mg/dL\n Imaging: CXR: Clear, all lines in good position\n Microbiology: neg\n Assessment and Plan\n CORONARY ARTERY BYPASS GRAFT (CABG)\n Assessment and Plan: Pt. doing very well post op. Will d/c ct and\n transfer to the floor. Lopressor and Lasix started. Cont. present\n care.\n Neurologic:\n Cardiovascular: Aspirin, Beta-blocker, Statins\n Pulmonary: IS\n Gastrointestinal / Abdomen:\n Nutrition: Advance diet as tolerated\n Renal: Foley, Adequate UO\n Hematology: Serial Hct\n Endocrine: RISS\n Infectious Disease: neg\n Lines / Tubes / Drains: Foley, Chest tube - pleural , Chest tube -\n mediastinal, Pacing , d/c ct today.\n Wounds: Dry dressings\n Imaging: CXR today\n Fluids:\n Consults: P.T.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Cordis/Introducer - 05:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: Transfer to floor\n"
},
{
"category": "Nursing",
"chartdate": "2176-09-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 692008,
"text": "Coronary artery bypass graft (CABG)\n Assessment:\n Received pt intubated sedated not yet reversed\n Spanish speaking, speaks/understands little English\n Pupils irregular at baseline RN report\n R pupil smaller than L\n Both reactive\n SR-ST ^120s with rare PVCs noted\n Set at back up V Demand RN report d/t As not appropriately sensing\n BP labile\n Neo/nitro titrated to keep SBP 90-120\n Filling pressures adequate\n CO 4\n CI 2\n AC 40% Vt 600 rate 14 and 5 PEEP\n ABG WNL\n LS clear, dim in bases\n Suctioned for nothing\n CTs with minimal sanguineous drainage\n L pleural not draining, even after turn\n HUO adequate\n Insulin gtt infusing per protocol\n Action:\n Pt given reversals\n HR down 60s\n Pt hypotensive 70s-80s\n Neo gtt started; fluid opened wide & pt flat in bed\n Polarity changed on A wires to attempt to A pace for BP\n augmentation\n Unable to A Pace, V demand with mA 25\n Slowly gave remaining 4cc of reversals\n Propofol turned off, pt woke followed commands\n Morphine IV given for pain relief\n Pt MAE and followed commands\n Weaned to PS 8/5\n Pt became increasingly agitated with ETT\n HR ^ 125 with SBP ^ 160s\n Morphine given\n Nitro gtt started\n Pt extubated without incident following ABG WNL\n 6L NC initially with sats >95%\n Toradol 30mg IV given for unresolved pain from morphine\n Pt remained ST >110\n Given additional fluid\n 5mg IV lopressor given x 3\n Hemodynamics unremarkable\n Response:\n + pain relief from Toradol, pt denying pain\n Able to communicate with pt slightly\n Neo gtt titrated for SBP <90 while sleeping\n Swan D/C\nd per without incident\n Insulin gtt titrated per CVICU protocol\n Plan:\n Albumin 5% ordered (waiting from pharmacy)\n Start PO lopressor following albumin\n Pain management with Toradol Q6\n Start Diuresis\n Pumonary toilet\n ^ diet and activity per pt\n Transfer to 6\n"
},
{
"category": "Nursing",
"chartdate": "2176-09-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 691988,
"text": "Coronary artery bypass graft (CABG)\n Assessment:\n Received pt intubated sedated not yet reversed\n Spanish speaking, speaks/understands little English\n Pupils irregular at baseline RN report\n R pupil smaller than L\n Both reactive\n SR-ST ^120s with rare PVCs noted\n Set at back up V Demand RN report d/t As not appropriately sensing\n BP labile\n Neo/nitro titrated to keep SBP 90-120\n Filling pressures adequate\n CO 4\n CI 2\n AC 40% Vt 600 rate 14 and 5 PEEP\n ABG WNL\n LS clear, dim in bases\n Suctioned for nothing\n CTs with minimal sanguineous drainage\n L pleural not draining, even after turn\n HUO adequate\n Insulin gtt infusing per protocol\n Action:\n Pt given reversals\n HR down 60s\n Pt hypotensive 70s-80s\n Neo gtt started; fluid opened wide & pt flat in bed\n Polarity changed on A wires to attempt to A pace for BP\n augmentation\n Unable to A Pace, V demand with mA 25\n Slowly gave remaining 4cc of reversals\n Propofol turned off, pt woke followed commands\n Morphine IV given for pain relief\n Pt MAE and followed commands\n Weaned to PS 8/5\n Pt became increasingly agitated with ETT\n HR ^ 125 with SBP ^ 160s\n Morphine given\n Nitro gtt started\n Pt extubated without incident following ABG WNL\n 6L NC initially with sats >95%\n Toradol 30mg IV given for unresolved pain from morphine\n Pt remained ST >110\n Given additional fluid\n 5mg IV lopressor given x 2\n Hemodynamics unremarkable\n Response:\n + pain relief from Toradol, pt denying pain\n Able to communicate with pt slightly\n Neo gtt restarted for SBP <90 while sleeping\n Swan D/C\nd per without incident\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2176-09-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 691996,
"text": "Coronary artery bypass graft (CABG)\n Assessment:\n Received pt intubated sedated not yet reversed\n Spanish speaking, speaks/understands little English\n Pupils irregular at baseline RN report\n R pupil smaller than L\n Both reactive\n SR-ST ^120s with rare PVCs noted\n Set at back up V Demand RN report d/t As not appropriately sensing\n BP labile\n Neo/nitro titrated to keep SBP 90-120\n Filling pressures adequate\n CO 4\n CI 2\n AC 40% Vt 600 rate 14 and 5 PEEP\n ABG WNL\n LS clear, dim in bases\n Suctioned for nothing\n CTs with minimal sanguineous drainage\n L pleural not draining, even after turn\n HUO adequate\n Insulin gtt infusing per protocol\n Action:\n Pt given reversals\n HR down 60s\n Pt hypotensive 70s-80s\n Neo gtt started; fluid opened wide & pt flat in bed\n Polarity changed on A wires to attempt to A pace for BP\n augmentation\n Unable to A Pace, V demand with mA 25\n Slowly gave remaining 4cc of reversals\n Propofol turned off, pt woke followed commands\n Morphine IV given for pain relief\n Pt MAE and followed commands\n Weaned to PS 8/5\n Pt became increasingly agitated with ETT\n HR ^ 125 with SBP ^ 160s\n Morphine given\n Nitro gtt started\n Pt extubated without incident following ABG WNL\n 6L NC initially with sats >95%\n Toradol 30mg IV given for unresolved pain from morphine\n Pt remained ST >110\n Given additional fluid\n 5mg IV lopressor given x 3\n Hemodynamics unremarkable\n Response:\n + pain relief from Toradol, pt denying pain\n Able to communicate with pt slightly\n Neo gtt titrated for SBP <90 while sleeping\n Swan D/C\nd per without incident\n Insulin gtt titrated per CVICU protocol\n Plan:\n Keep SBP >90\n Pain management with Toradol Q6\n Start PO lopressor\n Start Diuresis\n ^ diet and activity per pt\n Transfer to 6\n"
},
{
"category": "Nursing",
"chartdate": "2176-09-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 692005,
"text": "Coronary artery bypass graft (CABG)\n Assessment:\n Received pt intubated sedated not yet reversed\n Spanish speaking, speaks/understands little English\n Pupils irregular at baseline RN report\n R pupil smaller than L\n Both reactive\n SR-ST ^120s with rare PVCs noted\n Set at back up V Demand RN report d/t As not appropriately sensing\n BP labile\n Neo/nitro titrated to keep SBP 90-120\n Filling pressures adequate\n CO 4\n CI 2\n AC 40% Vt 600 rate 14 and 5 PEEP\n ABG WNL\n LS clear, dim in bases\n Suctioned for nothing\n CTs with minimal sanguineous drainage\n L pleural not draining, even after turn\n HUO adequate\n Insulin gtt infusing per protocol\n Action:\n Pt given reversals\n HR down 60s\n Pt hypotensive 70s-80s\n Neo gtt started; fluid opened wide & pt flat in bed\n Polarity changed on A wires to attempt to A pace for BP\n augmentation\n Unable to A Pace, V demand with mA 25\n Slowly gave remaining 4cc of reversals\n Propofol turned off, pt woke followed commands\n Morphine IV given for pain relief\n Pt MAE and followed commands\n Weaned to PS 8/5\n Pt became increasingly agitated with ETT\n HR ^ 125 with SBP ^ 160s\n Morphine given\n Nitro gtt started\n Pt extubated without incident following ABG WNL\n 6L NC initially with sats >95%\n Toradol 30mg IV given for unresolved pain from morphine\n Pt remained ST >110\n Given additional fluid\n 5mg IV lopressor given x 3\n Hemodynamics unremarkable\n Response:\n + pain relief from Toradol, pt denying pain\n Able to communicate with pt slightly\n Neo gtt titrated for SBP <90 while sleeping\n Swan D/C\nd per without incident\n Insulin gtt titrated per CVICU protocol\n Plan:\n Albumin 5% ordered (waiting from pharmacy)\n Start PO lopressor following albumin\n Pain management with Toradol Q6\n Start Diuresis\n Pumonary toilet\n ^ diet and activity per pt\n Transfer to 6\n"
},
{
"category": "Echo",
"chartdate": "2176-09-18 00:00:00.000",
"description": "Report",
"row_id": 89091,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Mitral valve disease.\nStatus: Inpatient\nDate/Time: at 13:09\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement. No spontaneous echo contrast or thrombus in\nthe body of the LAA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or pacing wire is\nseen in the RA. No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D\nimages. Normal LV wall thickness and cavity size.\n\nLV WALL MOTION: basal anterior - normal; mid anterior - normal; basal\nanteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal;\nmid inferoseptal - normal; basal inferior - normal; mid inferior - normal;\nbasal inferolateral - normal; mid inferolateral - normal; basal anterolateral\n- normal; mid anterolateral - normal; anterior apex - normal; septal apex -\nnormal; inferior apex - normal; lateral apex - normal; apex - normal;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal ascending aorta diameter. Simple atheroma in ascending aorta.\nNormal descending aorta diameter. Simple atheroma in descending aorta.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. Mildly thickened\naortic valve leaflets (?#). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The TEE probe was passed\nwith assistance from the anesthesioology staff using a laryngoscope. No TEE\nrelated complications.\n\nConclusions:\nPRE-BYPASS: The left atrium is mildly dilated. No spontaneous echo contrast or\nthrombus is seen in the body of the left atrium or left atrial appendage. No\natrial septal defect is seen by 2D or color Doppler. Left ventricular wall\nthicknesses and cavity size are normal. Right ventricular chamber size and\nfree wall motion are normal. There are simple atheroma in the ascending aorta.\nThere are simple atheroma in the descending thoracic aorta. The aortic valve\nleaflets (3) appear structurally normal with good leaflet excursion and no\naortic regurgitation. The aortic valve leaflets are mildly thickened . There\nis no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve\nleaflets are mildly thickened. Trivial mitral regurgitation is seen. There is\nno pericardial effusion.\n\nPOST-BYPASS: Patient is on no inotropic agents post-bypass. No changes from\npre-bypass findings. Left ventricular function is normal. The aorta appears to\nbe intact post decannulation. All findings communicated to surgical team.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2176-09-17 00:00:00.000",
"description": "Report",
"row_id": 89281,
"text": "PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease.\nHeight: (in) 65\nWeight (lb): 200\nBSA (m2): 1.98 m2\nBP (mm Hg): 129/60\nHR (bpm): 57\nStatus: Inpatient\nDate/Time: at 11:02\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Suboptimal\ntechnical quality, a focal LV wall motion abnormality cannot be fully\nexcluded. Overall normal LVEF (>55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Physiologic TR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity size is normal. Due to suboptimal\ntechnical quality, a focal wall motion abnormality cannot be fully excluded.\nOverall left ventricular systolic function is normal (LVEF>55%) with probably\nnormal regional function. Right ventricular chamber size and free wall motion\nare normal. The aortic valve leaflets (3) are mildly thickened. There is no\naortic valve stenosis. No aortic regurgitation is seen. The mitral valve\nleaflets are mildly thickened. Trivial mitral regurgitation is seen. The\ntricuspid valve leaflets are mildly thickened. There is no pericardial\neffusion.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2176-09-18 00:00:00.000",
"description": "Report",
"row_id": 232836,
"text": "Sinus rhythm. Consider prior inferior myocardial infarction. Extensive anterior\nST-T wave changes which may be due to myocardial ischemia. Compared to the\nprevious tracing of the heart rate is faster.\n\n"
},
{
"category": "ECG",
"chartdate": "2176-09-17 00:00:00.000",
"description": "Report",
"row_id": 232837,
"text": "Sinus rhythm. Short P-R interval. Consider inferior myocardial infarction,\nage undetermined. Precordial T wave abnormalities. No previous tracing\navailable for comparison. Clinical correlation is suggested.\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-09-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1093361,
"text": " 1:33 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: PTX**pls do at 1400\n Admitting Diagnosis: CAD;\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man s/p CABG\n REASON FOR THIS EXAMINATION:\n PTX**pls do at 1400\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 69-year-old man status post CABG, please assess for pneumothorax.\n\n TECHNIQUE: AP upright chest x-ray.\n\n COMPARISON: Portable chest x-ray from at 7:38 a.m.\n\n FINDINGS: Increased right apical pneumothorax. Otherwise, unchanged\n presentation of mild bibasilar atelectasis. The cardiomediastinal silhouette\n is normal.\n\n IMPRESSION: Slightly increased right pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-09-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1093163,
"text": " 9:55 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o ptx\n Admitting Diagnosis: CAD;\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man s/p cabg and ct removal\n REASON FOR THIS EXAMINATION:\n r/o ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 69-year-old male status post coronary artery bypass graft, status\n post chest tube removal. Please rule out pneumothorax.\n\n TECHNIQUE: Portable AP chest x-ray.\n\n COMPARISON: Portable chest x-ray from .\n\n FINDINGS: There is a new moderate-sized right apical pneumothorax, which was\n not present on the chest x-ray on . There is mild left basilar\n atelectasis. There is no pleural effusion. The mediastinum, hila and heart\n are unremarkable. In the interval, an endotracheal tube, a right central\n venous line and a right chest tube were removed.\n\n IMPRESSION: New right apical pneumothorax of moderate size.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-09-21 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1093494,
"text": " 11:12 AM\n CHEST (PA & LAT) Clip # \n Reason: evaluate ptx\n Admitting Diagnosis: CAD;\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with s/p cabg, CT inserted yesterday for ptx\n REASON FOR THIS EXAMINATION:\n evaluate ptx\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: PA and lateral chest, .\n\n HISTORY: Patient is status post CABG and placement of chest tube. Evaluate\n pneumothorax.\n\n FINDINGS: Comparison is made to previous study from at 11:45\n p.m.\n\n The right apical pneumothorax is unchanged. There is a loculated pneumothorax\n seen adjacent to the right CP angle at the insertion site of the chest tube.\n The chest tube position appears unchanged. There is persistent atelectasis at\n the lung bases with low lung volumes.\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-09-17 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 1092864,
"text": " 11:14 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: no contrast please page if ? - evaluate for aortic ca\n Admitting Diagnosis: CAD;\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with CAD\n REASON FOR THIS EXAMINATION:\n no contrast please page if ? - evaluate for aortic calcification\n CONTRAINDICATIONS for IV CONTRAST:\n previous load\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 69-year-old man with coronary artery disease. Please evaluate\n for aortic calcification.\n\n No comaprison is available.\n\n TECHNIQUE: Axial MDCT images of the chest were obtained with no contrast\n administration. Multiplanar reformatted images were then acquired.\n\n CT OF THE CHEST WITH NO CONTRAST: No central pathologically enlarged nodes\n are visualized. No pleural or pericardial effusion is noted. The heart size\n is normal. Diffuse calcification of the left anterior descending, circumflex,\n and right coronary artery is noted.\n\n There is calcification at the aortic root at the level of the sinus of\n Valsalva and within the descending aorta. There is sparing of the ascending\n aorta and the aortic arch.\n\n 2-mm noncalcified nodule of the left upper lobe (series 4, image 39) and 6-mm\n noncalcified nodule of the right upper lobe are noted (series 4, image 64). 2-\n mm calcified nodule of the left upper lobe is noted (series 4, image 67).\n Centrilobular emphysema of the upper lung zones is mild to moderate. Mild\n atelectatic changes are noted at the bases.\n\n The visualized portions of upper abdomen demonstrate calcified granuloma of\n the liver dome. The gallbladder and spleen appear unremarkable.\n Diverticulosis with no signs of diverticulitis is noted. There is a hazy\n appearance to the mesentery which is of undetermined significance.\n\n BONE WINDOWS: No concerning lytic or sclerotic lesions are identified. Severe\n degenerative changes of the thoracic spine are noted.\n\n IMPRESSION:\n 1. Calcification of the aortic root at the level of sinus of Valsalva and\n descending aorta with sparing of the ascending aorta and aortic root.\n 2. 6-mm pulmonary nodule within the right upper lobe for which a six-month\n followup is recommended given the presence of emphysema.\n 3. Hazy appearance to the mesentery, nonspecific should be correlated\n clinically with the presence of panniculitis.\n\n\n (Over)\n\n 11:14 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: no contrast please page if ? - evaluate for aortic ca\n Admitting Diagnosis: CAD;\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-09-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1093409,
"text": " 6:36 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: evaluate position of chest tube\n Admitting Diagnosis: CAD;\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with s/p cabg- CT inserted, repositioned since 1st film- please\n re-evaluate\n REASON FOR THIS EXAMINATION:\n evaluate position of chest tube\n ______________________________________________________________________________\n WET READ: SBNa FRI 7:14 PM\n Right CT side hole appears to be more superiorly positioned (chest tube\n slightly withdrawn from original postion). Otherwise, no significant change.\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n STUDY: AP chest, .\n\n HISTORY: Patient is status post CABG. Chest tube inserted. Please evaluate\n position.\n\n FINDINGS: Comparison is made to the previous study from , at\n 5:45 p.m.\n\n The right-sided chest tube appears to have been slightly withdrawn from the\n previous study. There is an unchanged right apical pneunothorax, stable.\n There are small bilateral pleural effusions and a left retrocardiac opacity\n which is stable.\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-09-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1093614,
"text": " 9:51 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate PTX\n Admitting Diagnosis: CAD;\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with s/p cabg, CT inserted for PTX\n REASON FOR THIS EXAMINATION:\n evaluate PTX\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest, .\n\n HISTORY: Pneumothorax.\n\n FINDINGS: Comparison is made to the previous study from .\n\n Today's study is technically limited; however, no pneumothorax is identified.\n There remains a right basilar chest tube. There are low lung volumes due to\n poor inspiratory effort. Bilateral pleural effusions are seen, which are\n small.\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-09-18 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1093076,
"text": " 4:40 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: postop film0 contact # if abnormal\n Admitting Diagnosis: CAD;\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man s/p cabg x3\n REASON FOR THIS EXAMINATION:\n postop film0 contact # if abnormal\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: S/P CABG.\n\n ET tube tip is 6 cm above the carina. There are low lung volumes. There is\n no evidence of CHF. Cardiac size is top normal. Sternal wires are aligned.\n Swan-Ganz catheter tip is in the main pulmonary artery. There is no\n pneumothorax or pleural effusion. NG tube tip is in the distal esophagus and\n should be advanced at least 10 cm for standard position. Mediastinal and\n right chest tubes are in place.\n\n Findings discussed with \n\n"
},
{
"category": "Radiology",
"chartdate": "2176-09-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1093397,
"text": " 5:31 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: PTX\n Admitting Diagnosis: CAD;\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man s/p right CT insertion\n REASON FOR THIS EXAMINATION:\n PTX\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n STUDY: AP chest .\n\n HISTORY: 69-year-old man status post right chest tube insertion. Evaluate\n for pneumothorax.\n\n FINDINGS: Comparison is made to previous study from .\n\n There is a right basilar chest tube. There is subcutaneous emphysema within\n the right chest wall. There is a right apical pneumothorax, faintly\n visualized. There is low lung volumes. There are small pleural effusions\n bilaterally. Median sternotomy wires are present.\n\n IMPRESSION:\n\n Right apical pneunothorax persistent, following chest tube placement.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-09-16 00:00:00.000",
"description": "CHEST (PRE-OP PA & LAT)",
"row_id": 1092772,
"text": " 9:42 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: CAD;\n Admitting Diagnosis: CAD;\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with CAD\n REASON FOR THIS EXAMINATION:\n ? infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Preoperative evaluation prior to CAD, CABG.\n\n COMPARISON: None.\n\n FRONTAL LATERAL VIEWS, CHEST: The lungs are clear without focal\n consolidation, pleural effusion or pneumothorax. Prominence of\n bronchovascular markings is noted and could reflect chronic vascular\n congestion. There is no overt pulmonary edema. Lung volumes are low causing\n elevation of the hemidiaphragms and bronchovascular crowding. The\n cardiomediastinal silhouette is exaggerated due to the elevated\n hemidiaphragms. Heart size is mildly enlarged. Hilar contours are\n unremarkable.\n\n There are degenerative changes of vertebral column.\n\n IMPRESSION: Low lung volumes. No focal consolidation seen.\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-09-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1093445,
"text": " 11:35 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Please eval for change in PTX and chest tube position. Ches\n Admitting Diagnosis: CAD;\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with persistent PTX s/p chest tube placement\n REASON FOR THIS EXAMINATION:\n Please eval for change in PTX and chest tube position. Chest tube pulled back\n at 1800. Please take film at 2200.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST .\n\n HISTORY: Please evaluate for change in pneumothorax and chest tube position.\n\n FINDINGS: There is again seen a right apical pneumothorax which appears\n unchanged from the prior study. There is markedly low lung volumes and\n bilateral pleural effusions, left side worse than right. The right basilar\n chest tube is again visualized with tip and side port within the chest wall.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-09-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1093241,
"text": " 4:33 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: check R ptx\n Admitting Diagnosis: CAD;\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man s/p cabg\n REASON FOR THIS EXAMINATION:\n check R ptx\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SP 6:35 PM\n PFI: Right-sided moderate pneumothorax has increased slightly. No other new\n abnormalities identified. Recommend further followup to decide if new chest\n tube is required. was paged.\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: Status post bypass surgery. Check for right-sided pneumothorax.\n\n FINDINGS: AP single view of the chest was obtained with patient in sitting\n semi upright position. Analysis is performed in direct comparison with the\n next preceding similar study obtained six hours earlier during the same date.\n The previously identified as moderate-sized described right-sided apical\n pneumothorax has developed after right-sided chest tube removal, persists and\n the apical width has actually increased slightly. There is no major\n atelectasis or new infiltrate in the partially collapsed right lung. No\n significant mediastinal shift has developed. Left-sided hemithorax with\n unchanged findings.\n\n IMPRESSION: Slight increase of right-sided apical pneumothorax. During the\n latest six hours examination interval. Replacement of chest tube could be\n guided by clinical indications. Consider repeat followup in an another six\n hours interval.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-09-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1093242,
"text": ", R. CSRU 4:33 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: check R ptx\n Admitting Diagnosis: CAD;\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man s/p cabg\n REASON FOR THIS EXAMINATION:\n check R ptx\n ______________________________________________________________________________\n PFI REPORT\n PFI: Right-sided moderate pneumothorax has increased slightly. No other new\n abnormalities identified. Recommend further followup to decide if new chest\n tube is required. was paged.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-09-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1093305,
"text": " 7:37 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess r ptx\n Admitting Diagnosis: CAD;\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man s/p cabg w/ptx after ct removal\n REASON FOR THIS EXAMINATION:\n assess r ptx\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of the patient after CABG and pneumothorax\n after chest tube removal.\n\n Portable AP chest radiograph was compared to .\n\n The right pneumothorax is moderate, unchanged since . Compared\n to the prior study, it appears to be slightly smaller. There is no left\n pneumothorax. The cardiomediastinal silhouette is stable and bibasilar\n opacities are consistent with unchanged atelectasis.\n\n Findings were discussed with nurse over the phone\n by Dr. approximately at 8:50 a.m. on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-09-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1093827,
"text": " 4:56 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval for PTX\n Admitting Diagnosis: CAD;\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with removal of right chest tube\n REASON FOR THIS EXAMINATION:\n eval for PTX\n ______________________________________________________________________________\n WET READ: RSRc MON 9:50 PM\n Chest tube removed; right apical PTX at level of 4th posterior rib. Low lung\n volumes, small left effusion. 9:20 p D/W Dr. \n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Right chest tube removal, to evaluate for pneumothorax.\n\n FINDINGS: In comparison with the study of earlier in this date, there has\n been removal of the right chest tube with the development of a pneumothorax\n that extends to about the superior margin of the fourth posterior rib.\n Continued low lung volumes with left basilar opacity consistent with\n atelectasis and effusion. Small area of opacification at the right base\n medially could represent a developing consolidation and atelectasis or merely\n crowding of pulmonary vessels.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-09-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1093723,
"text": " 9:40 AM\n CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: PTX ***please take at 10am \n Admitting Diagnosis: CAD;\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with right ptx placed on water seal\n REASON FOR THIS EXAMINATION:\n PTX ***please take at 10am \n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 69-year-old man with right pneumothorax, please evaluate interval\n change.\n\n Comparison is made to the prior study of .\n\n PORTABLE UPRIGHT RADIOGRAPH OF THE CHEST: Cardiomediastinal silhouette and\n hilar contours are normal. The small left pleural effusion and left basilar\n atelectasis are unchanged. There is persistent right basilar pneumothorax.\n The right chest tube is unchanged.\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-09-23 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1093802,
"text": " 2:55 PM\n CHEST (PA & LAT) Clip # \n Reason: pls eval for right PTX\n Admitting Diagnosis: CAD;\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with right chest tube to water seal\n REASON FOR THIS EXAMINATION:\n pls eval for right PTX\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 69-year-old man with right chest tube. Please evaluate\n pneumothorax.\n\n PA AND LATERAL RADIOGRAPH OF THE CHEST: Cardiomediastinal silhouette and\n hilar contours are normal. No pneumothorax is noted on the right side. The\n elevated right hemidiaphragm is unchanged. The distal end of right chest tube\n is unchanged. Small left pleural effusion is unchanged. Subcutaneous\n emphysema on the right chest wall is unchanged.\n\n IMPRESSION: No pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-09-24 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1093896,
"text": " 9:44 AM\n CHEST (PA & LAT) Clip # \n Reason: eval for interval chnage in right PTX\n Admitting Diagnosis: CAD;\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with right PTX\n REASON FOR THIS EXAMINATION:\n eval for interval chnage in right PTX\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest PA and lateral.\n\n REASON FOR EXAM: 69-year-old man with right-sided pneumothorax. Evaluate for\n interval change.\n\n FINDINGS: Since the previous chest radiograph the right apical pneumothorax\n is unchanged and extends to between the third and fourth posterior ribs. Low\n lung volumes are contributing to the appearances in the lung bases bilaterally\n with left lower lobe atelectasis with a stable small pleural effusion. The\n patient is status post CABG. The subcutaneous emphysema in the overlying\n chest wall is resolving.\n\n IMPRESSION:\n\n Stable appearances with unchanged right apical pneumothorax.\n\n"
}
] |
91,561 | 114,231 | 77F with dCHF, pulmonary hypertension and chronic lung disease that presented with dyspnea, hypotension, and altered mental status found to have Klebsiella UTI and . . ACTIVE ISSUES: # Hypotension: Pt presented with a low BP compared to her baseline of SBP 100 - 110, but this improved rapidly with IVF. It was felt that overdiuresis with her outpatient Lasix regimen may have contributed to her volume depletion, although there was also a likely infectious component, as the patient was ultimately diagnosed with a Klebsiella pneumoniae UTI . Throughout the hospitalization, the pt's BP continued to remain stable, with good urine output. A repeat ECHO during this admission did not show any evidence of new systolic heart failure. The patient's BP tolerated the restarting of her Lasix regimen without any difficulty. The pts SBPs on discharge was in high 90s, mentating at baseline. . # Dyspnea and Hypoxemia: At baseline, the patient carries a diagnosis of diastolic heart failure, pulmonary HTN, and COPD, on home oxygen of 4.5 liters with sats in the high 80s-low 90s. She was admitted with low oxygen saturation, requiring 5 liters of oxygen. This requirement improved only slightly during her hospitalization, ultimately at 4.5 liters (her home oxygen amount). CXR did not show any evidence of infiltrate, nor did she have symptoms or exam consistent with pneumonia. Although her BNP suggest possible heart failure, her exam and recent history of increased Lasix use did not support a diagnosis of CHF exacerbation. Furthermore, an ECHO done during this admission did not show any evidence of worsening diastolic heart failure or new systolic heart failure. Although CTA of her chest showed no evidence of PE, it did show findings consistent with severe pulmonary hypertension. Please see below regarding additional details on her pulmonary hypertension. She developed worsening shortness of breath and hypoxemia on with a chest xray that was consistent with acute on chronic diastolic congestive heart failure. She was diuresed with intravenous lasix however this was somewhat limited by acute renal failure. Ultimately, she was discharged on the Lasix 120mg . . # Acute Toxic Metabolic Encephalopathy: Pt presented with waxing and mental status. She was oriented x3 but showed poor attention. Per family has been confused for past month and seems improved to them now. A CT head was negative and an ABG showed she was not hypercarbic. The initial thought on admission to the ICU was that her delirium was likely due to either infection, effect of her medications, or a combination of both. She was started on broad-spectrum IV antibiotics on admission with Vancomycin and Zosyn, and her medications including Mirapex, Xanax, trazodone, and gabapentin were all held. By morning following admission, the patient's mental status had already improved significantly. She was re-started on her medications one at a time, and tolerated them well, with the exception of trazodone, which she now uses PRN sleep and Xanax which continues to be held now. Please see below for further details regarding her Xanax. Additionally, the patient's urine culture grew Klebsiella pneumoniae, and she was treated with ciprofloxacin to treat a complicated UTI. Her mental status has continued to be at baseline and stable since her admission. . # Chronic diastolic CHF: The patient presented with a low BP and elevated BNP to suggest an acute flare of her CHF. However, clinically she appeared volume depleted rather than volume overloaded. In speaking with her outpatient nurse as well as her daughters, the patient had been taking increased doses of her Lasix in an attempt to reduce the edema in her legs. However, given her right-sided heart failure, the patient is extremely volume sensitive, and the diuresis may have been exacerbating the situation, rather than alleviating her symptoms. Given her low BP's and poor mental status on admission, the Lasix was held over the next few days. The patient was then followed clinically with daily weight, I+O's, and physical exam. Once her BP and Cr stabilized, she was restarted on Lasix at a lower dose, and has since been titrated back up to 120 mg twice daily. A repeat ECHO on this admission confirmed evidence of right-sided heart failure in the setting of elevated pulmonary pressures. Of note, the patient's discharge weight from her last hospital admission approximately 2 weeks prior was in the range of 200 - 202 pounds. She then developed recurrent dyspnea and was found to have pulmonary edema, likey due to acute on chronic diastolic CHF. She was diuresed with IV lasix with good effect for her breathing but resultant renal failure. Her diuretics were then again held. Ultimately, these were restarted at Lasix 120BID. Her discharge wt was 208lbs. . # Pulmonary HTN: The patient had not carry a formal diagnosis of pulmonary hypertension, and her hypoxia has always been attributed to a presumed diagnosis of COPD given her extensive prior tobacco use. Previous ECHO did show elevated pressures, suggesting pulmonary hypertension. CTA on this admission did not show any evidence of PE, but was also consistent with with severe pulmonary hypertension. A repeat ECHO done during this admission also confirmed findings consistent with severe pulmonary hypertension. After her transfer from the ICU, the Pulm Consult service saw the patient, and felt that the patient likely had a multi-factorial etiology to her pulmonary hypertension. At Mixed connective tissue disease screen (, ESR, ACE, and RF levels) to initiate the work-up of pulmonary hypertension. She should follow-up with Pulmonary Clinic as an outpatient, where she will likely undergo additional studies, including full PFT's with spirometry, lung volumes, DLCO and bronchodilator challenge. Additional she will need a full sleep study and possibly a right heart cath. . # Klebsiella Pneumoniae Urinary Tract Infection: Pt with hx of urinary incontinence with chronic indwelling foley: The patient had her Foley catheter changed on admission. Her UA was positive for pyuria with 85 WBC's. She initially received broad spectrum coverage with Vancomycin and Zosyn in the ICU. Her final urine culture grew pan-sensitive Klebisella pneunomiae, and she was tailored to ciprofloxacin. She completed a total of a 10-day course of ciprofloxacin for complicated UTI on given the presence of a chronic Foley catheter. . # Anxiety: The patient takes standing Xanax as an outpatient. This medication was held during this admission due to the patient's mental status on admission. However, even after her mental status improved to baseline, this medication was held after conversation with the patient. It was discussed with the patient that benzodiazepenes in the elderly can have serious side effects, and that benzodiazepenes are not optimal for long-term management of anxiety given their potential for dependence and withdrawl. Pt expressed that she was not experiencing any symptoms of her anxiety off the medication, and would not require the Xanax. She will follow-up with her outpatient PCP to monitor her anxiety and to hold off on taking Xanax for now. . INACTIVE ISSUES: # h/o MRSA infection: The patient has a history of septic arthritis with MRSA, and has had hardware removed from her right knee recently. She is on chronic prophylactic oral antibiotics with Bactrim. Given her on admission to the hospital, and also that she received Vancomycin in the ER, her Bactrim was initially held. After her renal function stabilized, she was restarted on the Bactrim without any issues. . # GERD: The patient was asymptomatic during this admission and was kept on her home does of omeprazole. . # Hypothyroidism: The patient's recent TSH at outpt PCP visit was WNL. She was continued on her home dose of levothyroxine. . # Depression: The patient was continued on her outpatient regimen of sertraline, and she denied any depressed mood or suicidal ideation during this admission. . # Restless leg syndrome: Pt is on Mirapex and Neurontin as an outpatient for her RLS. However, given her mental status on admission, both of these medications were withheld for their possible sedating effect. After the patient's mental status improved with fluids and antibiotics, she was restarted on both of these medications and tolerated them without any side effects. . # Bilateral renal and Pelvic masses: These are known masses and have been stable on outside images. The patient will need to follow-up with her PCP to evaluate and monitor these masses. . # Diabetes Mellitus: diet controlled. has not required therapy and A1C's all below 6. patient had her fingersticks checked, but did not require any insulin. . TRANSITIONAL ISSUES # Code Status: Full Code Daughter is contact: Medications on Admission: Alprazolam 0.25 mg 1 to 2 tabs x daily prn anxiety Pramipexole 0.25 mg Oral Tablet take three tablets daily at bedtime Furosemide 120 mg TWICE DAILY Sertraline 100 mg Oral Tablet TAKE 2 TABLETS DAILY Oxycodone 5 mg TID prn (not needing often) Levothyroxine 75 mcg Oral Tablet TAKE ONE TABLET DAILY Gabapentin 300 mg Oral Capsule TAKE 1 CAPSULE DAILY AT BEDTIME Simvastatin 40 mg Oral Tablet take 1 tablet every evening Fluticasone (FLOVENT HFA) 110 mcg/INHALE 2 PUFFS BY MOUTH TWICE DAILY Ipratropium-Albuterol 3mL in nebulizer EVERY SIX HOURS AS NEEDED Omeprazole 20 mg 1 capsule once daily Trazodone 50 mg Oral Tablet 1 pill at nightime POTASSIUM CHLORIDE ORAL 40 meq every day Sulfamethoxazole-Trimethoprim 800-160 mg Oral Tablet TAKE 1 TABLET TWICE DAILY to take life ling for joint infection s/p replacement Multivitamin Oral Capsule 1 TABLET DAILY Aspirin 81 mg Oral Tablet Take 1 tablet daily. PROAIR HFA 90 MCG 2 puffs FOUR TIMES DAILY AS NEEDED FERROUS SULFATE 325 MG (65 MG IRON) TAB 1 tablet a day SENNA 8.6 MG TAB (SENNOSIDES) 1-2 tablets as needed for constipation CALCIUM CARBONATE W/VITAMIN D TABLET 600-200 PO one Discharge Medications: 1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 2. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for Constipation. 3. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours) as needed for shortness of breath/wheeze. 4. ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for shortness of breath/wheeze. 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. sertraline 50 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 7. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation (2 times a day). 10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 11. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 13. gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 14. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. pramipexole 0.25 mg Tablet Sig: Three (3) Tablet PO qhs (). 16. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 17. Outpatient Lab Work Please have a basic metabolic panel checked and faxed to the patients PCP , Phone: Fax: on Friday . 18. Oxygen Patient is on 4.5L with 02 sats 88% to 90% at baseline. 19. furosemide 40 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: for Extended Care - Discharge Diagnosis: Primary Diagnosis - Urinary Tract Infection - Acute Kidney Injury Secondary Diagnoses - Pulmonary Hypertension - Chronic Diastolic CHF Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted to the hospital with confusion, shortness of breath and low oxygen saturations. This was most likely due to a urinary tract infection. In this setting you were probably slightly dehydrated on admission. The medication Xanax has been stopped because it seems like it was making you confused. Please make sure to weigh yourself every day and call your doctor if your weight increases. Followup Instructions: Please have your labs checked and sent to Dr. on Phone: Fax: . Name: , A. Location: Address: , , Phone: When: Monday, , 9:40AM *Please discuss booking a Pulmonary appointment at with Dr. . | Probable right ventricular hypertrophy.Compared to the previous tracing of no change. Minimal aortic valvular calcification is seen. No MS. TrivialMR.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. 1.1cm right infrahilar node with right greater than left lower lobe peribronchovascular soft tissue thickening without discrete lesions. 1.1-cm right infrahilar node with right greater than left lower lobe peribronchovascular soft tissue thickening without discrete lesions. No MS. LV inflowpattern c/w impaired relaxation.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Abnormalsystolic septal motion/position consistent with RV pressure overload.AORTA: Normal diameter of aorta at the sinus, ascending and arch levels.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Abnormal systolic septal motion/position consistent with RVpressure overload.AORTA: Normal diameter of aorta at the sinus, ascending and arch levels.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Aorta and major branches are patent with normal 3-vessel arch and mild atherosclerotic calcification. There is severe pulmonaryartery systolic hypertension.Compared with the prior study (images reviewed) of , no change. No aortic regurgitation is seen.The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. Severe PA systolic hypertension.Conclusions:The left atrium is normal in size. The right ventricular cavity is markedly dilated with depressedfree wall contractility. Trace aorticregurgitation is seen. Ventricles and sulci are slightly prominent, compatible with age-appropriate atrophy. The aortic valve leaflets (3)are mildly thickened but aortic stenosis is not present. A 1.1-cm right infrahilar node is seen (3A:29) along with soft tissue thickening in a peribronchovascular distribution, the right greater than left lower lobes. Severe PA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: No PS.PERICARDIUM: No pericardial effusion.Conclusions:The left atrium is normal in size. The left ventricular inflow pattern suggests impaired relaxation.The tricuspid valve leaflets are mildly thickened. There is abnormal systolic septal motion/positionconsistent with right ventricular pressure overload. The right atrium is moderately dilated. Perihepatic and perisplenic ascites with trace pelvic free fluid is seen. (Hx last PA pressure 86 by echo).Height: (in) 64Weight (lb): 217BSA (m2): 2.03 m2BP (mm Hg): 111/65HR (bpm): 70Status: OutpatientDate/Time: at 12:06Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. The aorta is calcified. Normal interatrialseptum. Contrast: OPTIRAY Amt: 110 FINAL REPORT (Cont) ground glass opacity in the right upper lobe, non-specific, but could be infectious. Moderate [2+] tricuspidregurgitation is seen. The rightventricular cavity is markedly dilated with moderate global free wallhypokinesis. The IVC is dilated (>2.5cm)LEFT VENTRICLE: Normal LV wall thickness. Trace perihepatic and perisplenic ascites with trace pelvic free fluid. Mild tomoderate [+] TR. The left ventricular cavity isunusually small. The diameters of aorta atthe sinus, ascending and arch levels are normal. Trace perihepatic and perisplenic ascites with trace simple-appearing free pelvic fluid. Still present interstitial edema is mild. The aortic valve leaflets (3) are mildlythickened but aortic stenosis is not present. Small (Over) 3:16 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABD & PELVIS WITH CONTRASTClip # Reason: PE? Right axis deviation. The diameters of aorta at the sinus,ascending and arch levels are normal. 3:16 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABD & PELVIS WITH CONTRASTClip # Reason: PE? NoVSD.RIGHT VENTRICLE: Markedly dilated RV cavity. NoVSD.RIGHT VENTRICLE: Markedly dilated RV cavity. ONE VIEW OF THE CHEST: The lungs are low in volume and show mild bilateral lower lobe opacities. Trace AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. PATIENT/TEST INFORMATION:Indication: Pericardial effusion.Height: (in) 64Weight (lb): 200BSA (m2): 1.96 m2BP (mm Hg): 106/73HR (bpm): 75Status: OutpatientDate/Time: at 09:41Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. Left ventricular wallthicknesses are normal. There is abnormal systolic septal motion/position consistent withright ventricular pressure overload. CT OF THE PELVIS WITH CONTRAST: Imaging of the pelvis is limited by streak artifact from the right hip arthroplasty. FINDINGS: Single semi-erect AP portable view of the chest was obtained. There is severe pulmonary artery systolic hypertension.There is no pericardial effusion.IMPRESSION: Severe pulmonary hypertension with RV dilation/dysfunctionsecondary to chronic pressure overload. Normal regional LVsystolic function. Normal regional LVsystolic function. Contrast: OPTIRAY Amt: 110 FINAL REPORT (Cont) 2. (Over) 3:16 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABD & PELVIS WITH CONTRASTClip # Reason: PE? The left ventricular cavity is small. Normal interatrial septum.No ASD by 2D or color Doppler. Bilateral basal ganglia mineralization is noted. Regional left ventricular wall motion is normal. There is no mesenteric or retroperitoneal lymphadenopathy with the exception of a 1.2-cm portacaval node (3B:86). Moderate global RV free wallhypokinesis. TECHNIQUE: MDCT-acquired axial images were obtained through the chest prior to and in the arterial phase after the administration of intravenous, but not oral contrast. Regional leftventricular wall motion is normal. Portal veins appear patent. The renal veins appear patent bilaterally without evidence of malignant involvement. IMPRESSION: No acute intracranial process. Leftventricular wall thicknesses are normal. Small and large bowel are unremarkable with rounded area of fat in the transverse colon which could be ingested material or intramural (3B:98). Moderate[2+] TR. Thetricuspid valve leaflets are mildly thickened. Adrenal glands are unremarkable bilaterally. | 9 | [
{
"category": "Radiology",
"chartdate": "2113-08-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1198518,
"text": " 12:07 PM\n CHEST (PORTABLE AP) Clip # \n Reason: chf? pna?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with hypoxia and hypotension\n REASON FOR THIS EXAMINATION:\n chf? pna?\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: Chest, single semi-erect portable view.\n\n CLINICAL INFORMATION: 77-year-old female with history of hypoxia and\n hypotension.\n\n COMPARISON: None.\n\n FINDINGS:\n\n Single semi-erect AP portable view of the chest was obtained. There are\n relatively low lung volumes. The cardiac silhouette is enlarged. The aorta\n is calcified. Prominence of the central vasculature suggests pulmonary\n vascular engorgement. Bibasilar opacities are seen, which could relate to\n vascular congestion, but underlying infectious process is not excluded. No\n large pleural effusion or pneumothorax is seen. Severe degenerative changes\n are seen at the partially imaged shoulder joints.\n\n"
},
{
"category": "Radiology",
"chartdate": "2113-08-11 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1198522,
"text": " 12:28 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: bleed?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with altered ms change\n REASON FOR THIS EXAMINATION:\n bleed?\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: SHSf FRI 3:26 PM\n Motion limited examination without acute intracranial process. White matter\n hypodensities likely reflect small vessel ischemic disease.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Altered mental status, assess for interval change or bleed.\n\n TECHNIQUE: Contiguous axial images were obtained through the brain without\n intravenous contrast. Coronal and sagittal reformations were prepared.\n\n COMPARISONS: None available.\n\n FINDINGS: There is no acute intracranial hemorrhage, edema, mass effect, or\n major vascular territorial infarction. Examination is slightly limited by\n motion. Periventricular and subcortical white matter hypodensities, greater\n on the left, are likely reflective of chronic small vessel ischemic disease.\n Bilateral basal ganglia mineralization is noted. There is no shift of\n normally midline structures. Ventricles and sulci are slightly prominent,\n compatible with age-appropriate atrophy. There is no fracture. Imaged\n paranasal sinuses and mastoid air cells are clear.\n\n IMPRESSION: No acute intracranial process.\n\n"
},
{
"category": "Radiology",
"chartdate": "2113-08-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1199483,
"text": " 8:54 AM\n CHEST (PORTABLE AP) Clip # \n Reason: change in mental status, ? pneumonia\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with change in mental status, hypoxic, ? pneumonia\n REASON FOR THIS EXAMINATION:\n change in mental status, ? pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 77-year-old woman with change in mental status, hypoxia,\n question pneumonia.\n\n COMPARISON: CT of the torso from and a chest radiograph from\n .\n\n ONE VIEW OF THE CHEST:\n\n The lungs are low in volume and show mild bilateral lower lobe opacities. The\n hilar contours are prominent. No definite pleural effusion or pneumothorax is\n present. The cardiac silhouette is enlarged. The mediastinal silhouette is\n normal.\n\n IMPRESSION:\n\n Bilateral basilar opacities are concerning for pneumonia especially on the\n right.\n\n"
},
{
"category": "Radiology",
"chartdate": "2113-08-11 00:00:00.000",
"description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY",
"row_id": 1198553,
"text": " 3:16 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABD & PELVIS WITH CONTRASTClip # \n Reason: PE?\n Contrast: OPTIRAY Amt: 110\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with hypoxia\n REASON FOR THIS EXAMINATION:\n PE?\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: SHSf FRI 4:02 PM\n 1. No pulmonary embolism or acute aortic pathology\n 2. Prominent interstitial markings in the upper lobes likely reflect an\n element of chronic pulmonary disease, though comparisons with prior and\n history is recommended.\n 3. 6 mm right upper lobe nodule. Follow up in 6 months if high risk and 12\n months if low risk.\n 4. Enlarged PA and RA/RV suggests pulmonary hypertension with right heart\n failure.\n 5. 1.1cm right infrahilar node with right greater than left lower lobe\n peribronchovascular soft tissue thickening without discrete lesions. Could be\n inflammatory but given lack of priors malignancy must be considered. Follow up\n in 3 months is suggested.\n 6. Bilateral renal lesions with internal hyperdensity that may reflect\n enhancement, evaluation by MRI is recommended.\n 7. Heterogeneous liver with wedge-shaped areas of hyper and hypo enhancement,\n could be perfusional. Correlation with history and lab values is suggested.\n Can also be evaluated at time of MRI.\n 8. Trace perihepatic and perisplenic ascites with trace pelvic free fluid.\n 9. Bilateral adnexal cysts, 5.4cm on left. Given age and size of lesions\n should be evaluated by pelvic US.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hypoxia, assess for PE and abdominal bloating and discomfort.\n\n TECHNIQUE: MDCT-acquired axial images were obtained through the chest prior\n to and in the arterial phase after the administration of intravenous, but not\n oral contrast. Portal venous phase images were obtained from the lung bases\n to the pubic symphysis. Coronal, sagittal, and oblique reformations were\n prepared of the chest, and coronal and sagittal reformations were prepared of\n the abdomen and pelvis.\n\n CT OF THE CHEST WITH AND WITHOUT CONTRAST: Imaged thyroid gland demonstrates\n heterogeneous right thyroid lobe. There is no supraclavicular, axillary, or\n mediastinal adenopathy though scattered non-enlarged mediastinal nodes are\n seen. The pulmonary arteries, right atrium and ventricle are enlarged which\n suggests pulmonary hypertension and right heart failure. No pulmonary\n embolism or acute aortic pathology is identified. Bibasilar atelectasis is\n seen along with prominence of the interstitial markings in the bilateral right\n upper lobes which could reflect a chronic pulmonary disease process. Small\n (Over)\n\n 3:16 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABD & PELVIS WITH CONTRASTClip # \n Reason: PE?\n Contrast: OPTIRAY Amt: 110\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n ground glass opacity in the right upper lobe, non-specific, but could be\n infectious. Right upper lobe 6-mm nodule (3A:16) is seen. Trachea and central\n airways are patent to the segmental level. There is no pleural or pericardial\n effusion. Aorta and major branches are patent with normal 3-vessel arch and\n mild atherosclerotic calcification. Minimal aortic valvular calcification is\n seen. A 1.1-cm right infrahilar node is seen (3A:29) along with soft tissue\n thickening in a peribronchovascular distribution, the right greater than left\n lower lobes. This could be inflammatory in nature; however, given lack of\n priors for evaluation of stability, malignancy must also be considered.\n\n CT OF THE ABDOMEN WITH CONTRAST: The liver is heterogeneous in appearance\n with wedge-shaped areas of hyper- and hypo-enhancement of uncertain\n significance. There is no measurable focal lesion or intra- or extra-hepatic\n biliary ductal dilatation. Portal veins appear patent. The gallbladder is\n unremarkable. The pancreas and spleen are normal. Perihepatic and perisplenic\n ascites with trace pelvic free fluid is seen. Multiple hypodensities are seen\n in the kidneys bilaterally, many which are not definitely cystic.\n Additionally, in the upper pole of the right kidney, there is a 2.9 x 2.4-cm\n lesion with internal hyperdensity which could reflect enhancement though is\n not seen on non-contrast, concerning for neoplasm. In the upper pole of the\n left kidney (3B:93) is a 2.5 x 2.4-cm lesion with similar internal\n hyperenhancement, concerning for neoplastic process. The renal veins appear\n patent bilaterally without evidence of malignant involvement. Adrenal glands\n are unremarkable bilaterally. Small and large bowel are unremarkable with\n rounded area of fat in the transverse colon which could be ingested material\n or intramural (3B:98). There is no free air or free fluid in the abdomen.\n There is no mesenteric or retroperitoneal lymphadenopathy with the exception\n of a 1.2-cm portacaval node (3B:86). Aorta and major branches are patent with\n atherosclerotic disease noted.\n\n CT OF THE PELVIS WITH CONTRAST: Imaging of the pelvis is limited by streak\n artifact from the right hip arthroplasty. Bladder, uterus, and rectum are\n unremarkable with a Foley catheter in place decompressing the bladder and a\n focus of air likely reflecting post-Foley catheter placement. Bilateral\n adnexal cystic lesions are seen, larger on the left measuring 5.4 x 4.1 cm\n (3B:124) and measuring 2.1 x 1.9 cm on the right (3B:124). No pelvic or\n inguinal lymphadenopathy is seen.\n\n OSSEOUS STRUCTURES: There is no lytic or sclerotic lesion in the bones\n concerning for osseous malignant process with multilevel degenerative disease\n noted.\n\n IMPRESSION:\n\n 1. No pulmonary embolism or acute aortic pathology.\n\n (Over)\n\n 3:16 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABD & PELVIS WITH CONTRASTClip # \n Reason: PE?\n Contrast: OPTIRAY Amt: 110\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 2. Prominent interstitial markings in the upper lobes bilaterally likely\n reflect an element of chronic pulmonary disease though comparison with history\n and prior imaging is recommended. Small right upper lobe ground glass\n opacity, non-specific, but could be infectious.\n\n 3. 6-mm right upper lobe nodule. Followup in six months is recommended if\n high risk and 12 months if low risk.\n\n 4. Enlarged pulmonary arteries and right atrium/right ventricle suggests\n pulmonary hypertension with right heart failure.\n\n 5. 1.1-cm right infrahilar node with right greater than left lower lobe\n peribronchovascular soft tissue thickening without discrete lesions. This\n could be inflammatory in etiology; however, given the lack of priors,\n malignancy must also be considered, correlate with history of malignancy, and\n followup in three months is suggested.\n\n 6. Bilateral upper pole renal lesions with internal hyperdensity may reflect\n enhancement, and evaluation with MRI is recommended.\n\n 7. Heterogeneous liver with wedge-shaped areas of hyper- and\n hypo-enhancement, could be perfusional in etiology. Correlation with history\n and lab values is suggested. This can also be evaluated at the time of the\n MRI.\n\n 8. Trace perihepatic and perisplenic ascites with trace simple-appearing free\n pelvic fluid.\n\n 9. Bilateral adnexal cysts, 5.4 cm on the left and 2.1 cm on the right.\n Given age and size of the lesions, these should be evaluated by pelvic\n ultrasound.\n\n 10. Heterogenous right thyroid can be assessed on ultrasound if indicated.\n\n"
},
{
"category": "Radiology",
"chartdate": "2113-08-19 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1199675,
"text": " 12:22 PM\n CHEST (PA & LAT) Clip # \n Reason: r/o pneumonia, now s/p diuresis\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with worsened hypoxemia, r/o pneumonia.\n REASON FOR THIS EXAMINATION:\n r/o pneumonia, now s/p diuresis\n ______________________________________________________________________________\n WET READ: ENYa SAT 1:28 PM\n Interval increased size of a now globular cardiac silhouette, concerning for\n increased pericardial effusion. Persistent engorgement of pulmonary vessels,\n compatible with mild-to-moderate pulmonary congestion. No PTX.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Worsening hypoxia after diuresis.\n\n Portable AP radiograph of the chest was reviewed in comparison to and CT torso from .\n\n Since the prior chest radiograph there is significant improvement up to almost\n complete resolution of pulmonary edema. Severe cardiomegaly with prominence\n of the main pulmonary artery and right heart is re-demonstrated with still\n present bilateral pleural effusions. There is no evidence of pneumothorax.\n\n Still present interstitial edema is mild. Continued surveillance is\n recommended.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2113-08-21 00:00:00.000",
"description": "Report",
"row_id": 91368,
"text": "PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion.\nHeight: (in) 64\nWeight (lb): 200\nBSA (m2): 1.96 m2\nBP (mm Hg): 106/73\nHR (bpm): 75\nStatus: Outpatient\nDate/Time: at 09:41\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. Normal interatrial\nseptum. No ASD by 2D or color Doppler. The IVC is dilated (>2.5cm)\n\nLEFT VENTRICLE: Normal LV wall thickness. Small LV cavity. Normal regional LV\nsystolic function. Overall normal LVEF (>55%). No resting LVOT gradient. No\nVSD.\n\nRIGHT VENTRICLE: Markedly dilated RV cavity. Moderate global RV free wall\nhypokinesis. Abnormal systolic septal motion/position consistent with RV\npressure overload.\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. No MS. LV inflow\npattern c/w impaired relaxation.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No TS. Mild to\nmoderate [+] TR. Severe PA systolic hypertension.\n\nConclusions:\nThe left atrium is normal in size. The right atrium is moderately dilated. No\natrial septal defect is seen by 2D or color Doppler. Left ventricular wall\nthicknesses are normal. The left ventricular cavity is small. Regional left\nventricular wall motion is normal. Overall left ventricular systolic function\nis normal (LVEF>55%). There is no ventricular septal defect. The right\nventricular cavity is markedly dilated with moderate global free wall\nhypokinesis. There is abnormal systolic septal motion/position consistent with\nright ventricular pressure overload. The diameters of aorta at the sinus,\nascending and arch levels are normal. The aortic valve leaflets (3) are mildly\nthickened but aortic stenosis is not present. No aortic regurgitation is seen.\nThe mitral valve leaflets are mildly thickened. There is no mitral valve\nprolapse. The left ventricular inflow pattern suggests impaired relaxation.\nThe tricuspid valve leaflets are mildly thickened. There is severe pulmonary\nartery systolic hypertension.\n\nCompared with the prior study (images reviewed) of , no change.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2113-08-14 00:00:00.000",
"description": "Report",
"row_id": 91369,
"text": "PATIENT/TEST INFORMATION:\nIndication: Evaluate for right heart failure/pulmonary artery pressure. (Hx last PA pressure 86 by echo).\nHeight: (in) 64\nWeight (lb): 217\nBSA (m2): 2.03 m2\nBP (mm Hg): 111/65\nHR (bpm): 70\nStatus: Outpatient\nDate/Time: at 12:06\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal interatrial septum.\nNo ASD by 2D or color Doppler. Normal IVC diameter (>2.1cm) with <50% decrease\nwith sniff (estimated RA pressure (>=15 mmHg).\n\nLEFT VENTRICLE: Normal LV wall thickness. Small LV cavity. Normal regional LV\nsystolic function. Overall normal LVEF (>55%). No resting LVOT gradient. No\nVSD.\n\nRIGHT VENTRICLE: Markedly dilated RV cavity. RV function depressed. Abnormal\nsystolic septal motion/position consistent with RV pressure overload.\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. No MS. Trivial\nMR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No TS. Moderate\n[2+] TR. Severe PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: No PS.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is normal in size. No atrial septal defect is seen by 2D or\ncolor Doppler. The estimated right atrial pressure is at least 15 mmHg. Left\nventricular wall thicknesses are normal. The left ventricular cavity is\nunusually small. Regional left ventricular wall motion is normal. Overall left\nventricular systolic function is normal (LVEF>55%). There is no ventricular\nseptal defect. The right ventricular cavity is markedly dilated with depressed\nfree wall contractility. There is abnormal systolic septal motion/position\nconsistent with right ventricular pressure overload. The diameters of aorta at\nthe sinus, ascending and arch levels are normal. The aortic valve leaflets (3)\nare mildly thickened but aortic stenosis is not present. Trace aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. There\nis no mitral valve prolapse. Trivial mitral regurgitation is seen. The\ntricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid\nregurgitation is seen. There is severe pulmonary artery systolic hypertension.\nThere is no pericardial effusion.\n\nIMPRESSION: Severe pulmonary hypertension with RV dilation/dysfunction\nsecondary to chronic pressure overload.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2113-08-18 00:00:00.000",
"description": "Report",
"row_id": 248306,
"text": "Sinus rhythm. Rightward axis. Probable right ventricular hypertrophy.\nCompared to the previous tracing of no change.\n\n"
},
{
"category": "ECG",
"chartdate": "2113-08-11 00:00:00.000",
"description": "Report",
"row_id": 248307,
"text": "Sinus rhythm. Right axis deviation. Probable right ventricular hypertrophy.\nDiffuse ST-T wave abnormalities may be due to right ventricular hypertrophy but\ncannot rule out underying myocardial ischemia. No previous tracing available\nfor comparison.\nTRACING #1\n\n"
}
] |
19,805 | 182,193 | A/P: 84 YO F chronically ventilated via trach admitted for ventilator management after placed under general anesthesia for TE fistula repair. . Patient admitted after the placement of an esophageal stent. She was brought to the unit for post-procedure monitring as she is chronically vented. She did well overnight, and a post-procedure CT scan was performed. The CT scan was provided to the family as well as a CD copy of it. . She was afebrile with stable vital signs. She was discharged in the care of her daughter. | This is consistent with an intraosseous lipoma. Notes on CareWeb mentions placement of an esophageal stent and revision of tracheal stent. Developed tracheal/bronchial fistula. There is right frontal encephalomalacia with mineralization and ex vacuo degeneration, likely in the region of prior infarct. Had tracheal stent done . Note is made of a tracheostomy, as well as an esophageal stent. A tracheostomy tube is noted. Left preauricular and pinna soft tissue swelling (see separate report of the dedicated CT of neck soft tissues). The oropharynx was anesthetized with Cetacaine spray. Respiratory Care NotePt received on PSV 8/5 as noted. Tube placement preparatory to upper endoscopy. Final tip position is in the gastric lumen. Albuterol MDI's given as ordered. IMPRESSION: Placement of the esophagus prosthesis ? IMPRESSION: Intra-operative views of enteric stent placement. Within the right cervical region, there are asymmetric soft tissues, presumably related to asymmetric musculature related to positioning. One identifies now a metallic mesh indicating an esophageal prosthesis in the midline of the upper mediastinum reaching to the level of the carina. INDICATION: Known tracheal esophageal fistula, status post Y stent of trachea with questionable placement of stent - balloon. CXR done and Interventional Pulmonary contact. There is a mucosal retention cyst in the left sphenoid sinus. Position of tracheostomy cannula is unchanged. NPO except for meds. Ct of neck done. TECHNIQUE: Non-contrast head CT. There are fluid levels as well as opacification of the left mastoid air cells. G-tube used for stomach decompression and j-tube used for meds andfeeds. Fluid levels within the left mastoid air cells. Recieved fluid bolus for decreased BP. Seen by IP who did quick bronch and repositioned her trach tube further down into the stent. It was requested as a non- contrast study per the referring clinician. FINDINGS: AP single view of the chest has been obtained with patient in sitting upright position. Will cont to monitor resp status. There is mucosal thickening within the ethmoid and sphenoid sinus, which could be related to prior intubation. Getting all meds through her J-tube.Trach site oozing moderate amts serous fluid which is her baseline.Pt is afebrile with WBC 12. There is low attenuation in the region of the left basal ganglia, which could represent a prior lacunar infarct or prominent VR space. Suctioned for moderate amts thick bloody sputum via trach. Although this may be related to intubation or positioning, acute mastoiditis cannot be excluded. clinical correlation recommended. Resp Care Note, Pt is home ventilated occ goes onto t-collar. Pt had esopageal stent placed in GI suite under general anesthesia. The biapical consolidation with air bronchograms is stable from . Trach site oozing sm amt of serous drainage. CLINICAL HISTORY: Tracheoesophageal fistula. of placment of stent/balloon, think we can see balloon just inside pt's stoma REASON FOR THIS EXAMINATION: assess placement of trach stent/ballon, FINAL REPORT TYPE OF EXAMINATION: Chest AP portable single view. These views show ongoing placement of esophageal stents. TECHNIQUE: Intra-operative fluoroscopic images. S/P J-tube and s/p g-tube insertions. If pt c/o nausea or has episode of vomiting we need to put it to gravity drainage. Right frontal encephalomalacia. NOTE: The findings were communicated to Dr after the above cited procedure, by Dr . Note is made of soft tissue swelling in the preauricular area on the left, as well as thickening of the left pinna. The ventricles and sulci are prominent consistent with atrophy. It is possible that this corresponds to some pleural effusion layering in the posterior spaces. MDI'S given. There are vascular calcifications within the left vertebral and the cavernous segments of the internal carotid arteries. We will try tylenol. Services in place per pt's dgt. Tip of catheter was positioned and once satisfactory positioning of the tip of the catheter was confirmed using dilute contrast injection and injection of air for insufflation of the stomach, the catheter was secured at the left corner of the mouth with tape. The catheter was closed with an end cap. A 5 French Kumpe catheter - 0.035-inch angled tip glidewire combination was used to negotiate the oropharynx and esophagus. Respiratory Care NotePt received from home in Angiography. Swelling within the left preauricular region extending to the level of the hyoid bone, with thickening of the left pinna; cellulitis is a consideration. Pt taken to CT Scan for head and neck - results pending. On vent rested overnight on 14/5 for increased RR.Suctioned and instilled with saline for sml amts thick bldy secretions. Albuterol MDI given with improved aeration throughout. FINDINGS: There is soft tissue swelling in the left preauricular region extending down to the level of the hyoid bone. Now weaned down to home settings of . Pt placed on ventilator. Pt's dgt planning to f/u w/pt's ENT. There is a 2.2-cm fatty attenuation lucency within the left frontal bone at the vertex, with internal ossification or soft tissue. Would like to avoid foley if possible.ID: afebrileAccess: One peripheral IV in place.Social: Lives at home with daughter who is ER physician. Wearing diaper. Vital signs are stable.Neuro: Awake and , c/o pain in neck for which daughter would like to not give her narcotics due to pt sensitivity. Denies chest pain.Resp: On our vent on PSV 40% FIO2 5cm peep and 5PSV. Although these may be related to prior intubation or supine positioning, infection cannot be excluded. Balloon should be in the tracheal stent. Pt does get tube feeds usually. OPERATORS: , MD (staff, present and attending throughout the procedure) , MD (IR fellow) DESCRIPTION OF PROCEDURE: After appropriate informed consent was verified and appropriate timeout performed, the patient was positioned in supine fashion on a special procedure/angiography table. | 12 | [
{
"category": "Nursing/other",
"chartdate": "2195-11-13 00:00:00.000",
"description": "Report",
"row_id": 1522512,
"text": "Respiratory Care Note\nPt received on PSV 8/5 as noted. BS essentially clear, but diminished. Albuterol MDI given with improved aeration throughout. Pt suctioned for small amts thick, yellow secretions. Pt taken to CT Scan for head and neck - results pending. Pt discharged to home on home ventilator.\n"
},
{
"category": "Nursing/other",
"chartdate": "2195-11-12 00:00:00.000",
"description": "Report",
"row_id": 1522506,
"text": "MICU NPN Admission Note:\n84y.o. female with history aspiration PNA, tracheal/broncheal malacia and TE fistula who came from home today for esophageal stent placement, done under general anesthesia.\n\nPMH: CVA , left sided weakness, A-fib, Mild MR/TR, High cholesterol, thyroid CA s/o surgery and radiation, skin cancer, resp failure, frequent aspiration PNA requiring trach. Developed tracheal/bronchial fistula. Had tracheal stent done . S/P J-tube and s/p g-tube insertions. G-tube used for stomach decompression and j-tube used for meds andfeeds. Pt has 24hr caregiver at home and lives with her daughter who is EW physician. lifter OOB to chair daily.\n\nAllergies: Sulfa\n\nPt had insertion of esophageal stent done in GI unit under general anesthesia which she tolerated well. Arrived in MICU and oriented. Smiles and follows simple commands. Daughter present and plan for 24hr caregiven to sit with her through the night. Vital signs are stable.\n\nNeuro: Awake and , c/o pain in neck for which daughter would like to not give her narcotics due to pt sensitivity. We will try tylenol. Pt takes ambien for sleep 5mg at 8PM and 5mg at 11PM. MAE, follows simple commands.\n\nCV: BP 120-150's. Pt with history a-fib for which daughter says she responds well to sotolol 40 PO times one. Currently pt is in NSR 70-80. Denies chest pain.\n\nResp: On our vent on PSV 40% FIO2 5cm peep and 5PSV. with adequate sat 93%. Daughter noticed that trach tube looked a little high in the stoma and she could visualize the balloon which should have been lower in the trach. Balloon should be in the tracheal stent. Interventional pulmonology will be called to look at pt tonight and CXR done to look at placement of trach tube and balloon.\n\nGI: NPO for now pending what IP wants to do. Pt does get tube feeds usually. Passing dark brown OB positve stool.\n\nGU: Incontinent of urine, uses diapers. Would like to avoid foley if possible.\n\nID: afebrile\n\nAccess: One peripheral IV in place.\n\nSocial: Lives at home with daughter who is ER physician. 24hr caregiver.\n\nSkin: Several red areas on legs and arms.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2195-11-12 00:00:00.000",
"description": "Report",
"row_id": 1522507,
"text": "Respiratory Care Note\nPt received from home in Angiography. Pt is with a #8.0 portex and on vent at home. BS essentially clear, but slightly decreased throughout. Pt placed on ventilator. Pt had esopageal stent placed in GI suite under general anesthesia. Pt placed on PSV upon arrival to unit. Trach seems to be sitting higher in stoma than daughter remembers. CXR done and Interventional Pulmonary contact. to continue on PSV overnight.\n"
},
{
"category": "Nursing/other",
"chartdate": "2195-11-12 00:00:00.000",
"description": "Report",
"row_id": 1522508,
"text": "Brief Update to NPN:\nPt has had stable vital signs, dropped BP to 80 at times but daughter states she does this and comes right back up which she did. Seen by IP who did quick bronch and repositioned her trach tube further down into the stent. Pt resting on the vent on PSV 10 with 5cm peep for the night. Suctioned for moderate amts thick bloody sputum via trach. Albuterol MDI's given as ordered. Incontinent of urine in large amts. Passed a small amt loose brown stool. Plan is to watch pt overnight and send her home with her services which are all in place tomorrow.\n\nGastric tube is clamped. If pt c/o nausea or has episode of vomiting we need to put it to gravity drainage. Getting all meds through her J-tube.\n\nTrach site oozing moderate amts serous fluid which is her baseline.\n\nPt is afebrile with WBC 12. K+ 4.8. IVF NS at 100cc/hr.\n\nPt's PCA will be in at 2200 to stay the night with her per her daughter's request.\n\nPlan for discharge tomorrow if stable overnight.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2195-11-13 00:00:00.000",
"description": "Report",
"row_id": 1522509,
"text": "Nusring Assessment Note 2300-0700\nNEURO: Pt is chronic vent pt who does not verbalize, but can make needs known by nodding and answering \"Yes or No\" questions appropriately, pt moves all extremities weakly, but legs are much weaker than arms\n\nCV: Pt afebrile, vss, but pt has a very liabile BP at night per caregiver going from 60/20 to 154/74, pt completely asymptomatic during hypotensive episodes and will maintain baseline mental status, Skin is pale, warm, and dry, PP + & =, with +1 edema, Pt in SB/NSR without ectopy noted, Pt has #20 in right arm, with NS @ 100 cc/hour infusing well without problems, Pt did receive 250 cc NS bolus for low bp\n\nRESP: Pt is chronic Vented pt who had stent placed in GI suite and needed to have stent repositioned here in MICU, pt doing well at this time with no further migration of stent noted, lung sounds reveal coarse sounds throughout, pt on CPAP initially PS-10, but increased to 14 during the night, PEEP-5, Fio2-40% with sats 95-99%, pt suctioned for scant amount thick slightly bloody secretions, before pt had stent repositioned secretions were only tan in nature\n\nGI: Pt npo at this time, pt's G-tube placement confirmed via air bolus and is connect to drain bag, pt's J-tube placement confirmed via air bolus and was noted to have slight bilious drainage around site, new drain DSG was applied to J-tube site, Pt's bowel sounds are positive with soft abd\n\nGU: Pt is INC of large amounts urine qs\n\nPLAN:\n-Continue to monitor Resp status if pt has no further problems then she should be D/C'd home with services already in place\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2195-11-13 00:00:00.000",
"description": "Report",
"row_id": 1522510,
"text": "Resp Care Note, Pt is home ventilated occ goes onto t-collar. On vent rested overnight on 14/5 for increased RR.Suctioned and instilled with saline for sml amts thick bldy secretions. MDI'S given. Pt has nebs @ home through vent explained to family we don't do it that way.RSBI done on 0 peep/5 ips 58. Now weaned down to home settings of . Recieved fluid bolus for decreased BP. Will cont to monitor resp status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2195-11-13 00:00:00.000",
"description": "Report",
"row_id": 1522511,
"text": "MICU EAST NPN 0700-1500\n\nPlease see flowsheet for further details..\n\n. Pt's dgt in room w/pt all shift. VSS. T max 99.8 po. NPO except for meds. Inc of urine and stool. Wearing diaper. Skin intact. Trach site oozing sm amt of serous drainage. Suct x1 for sm amt brownish sputum. Ct of neck done. Pt's dgt planning to f/u w/pt's ENT. Plan for to home. Services in place per pt's dgt.\n"
},
{
"category": "Radiology",
"chartdate": "2195-11-12 00:00:00.000",
"description": "NASAL/OROGASTRC TUBE PLMT, PRO FEE ONLY",
"row_id": 940913,
"text": " 12:35 PM\n PERC G/J TUBE CHECK Clip # \n Reason: place guidewire through PEG retrograde up to proximal esopha\n Contrast: OPTIRAY Amt: 10\n ********************************* CPT Codes ********************************\n * NASAL/OROGASTRC TUBE PLMT, PRO *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n tracheoesophageal fistula\n REASON FOR THIS EXAMINATION:\n place guidewire through PEG retrograde up to proximal esophagus to facilate\n placing esophageal stent\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Fluoroscopically guided placement of 5 French orogastric tube.\n\n CLINICAL HISTORY: Tracheoesophageal fistula. Tube placement preparatory to\n upper endoscopy.\n\n INFORMED CONSENT: Procedural informed consent was obtained from the patient's\n daughter who was in attendance to the patient upon intake, signed witnessed\n informed consent, signature was obtained and placed in the medical\n record.\n\n OPERATORS: , MD (staff, present and attending throughout the\n procedure)\n\n , MD (IR fellow)\n\n DESCRIPTION OF PROCEDURE: After appropriate informed consent was verified and\n appropriate timeout performed, the patient was positioned in supine fashion on\n a special procedure/angiography table. The oropharynx was anesthetized with\n Cetacaine spray. A 5 French Kumpe catheter - 0.035-inch angled tip glidewire\n combination was used to negotiate the oropharynx and esophagus. Tip of\n catheter was positioned and once satisfactory positioning of the tip of the\n catheter was confirmed using dilute contrast injection and injection of air\n for insufflation of the stomach, the catheter was secured at the left corner\n of the mouth with tape. The catheter was closed with an end cap.\n\n NOTE: The findings were communicated to Dr after the above cited\n procedure, by Dr . The patient tolerated the procedure well. No\n immediate complications were encountered.\n\n IMPRESSION: Successful placement of 5 French orogastric tube. Final tip\n position is in the gastric lumen.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2195-11-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 940957,
"text": " 4:24 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess placement of trach stent/ballon,\n Admitting Diagnosis: TRACHEAL ESOPHAGEAL FISTULA\\STENT PLACEMENT ESOPHAGUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with known tracheoesophageal fistula s/p Y-stent of\n trachea with ? of placment of stent/balloon, think we can see balloon just\n inside pt's stoma\n REASON FOR THIS EXAMINATION:\n assess placement of trach stent/ballon,\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: Known tracheal esophageal fistula, status post Y stent of trachea\n with questionable placement of stent - balloon. Assess placement.\n\n FINDINGS: AP single view of the chest has been obtained with patient in\n sitting upright position. Comparison is made with a similar preceding study\n of . Position of tracheostomy cannula is unchanged. One\n identifies now a metallic mesh indicating an esophageal prosthesis in the\n midline of the upper mediastinum reaching to the level of the carina. There\n is no evidence of pneumothorax. The pulmonary vasculature has not changed in\n appearance, but there is a somewhat increased diffuse density overlying the\n mid portion of the left hemithorax. It is possible that this corresponds to\n some pleural effusion layering in the posterior spaces. The amount of pleural\n effusion blunting the left lateral pleural sinus has not changed\n significantly. No new parenchymal infiltrates can be identified.\n\n IMPRESSION: Placement of the esophagus prosthesis ? clinical correlation\n recommended. No evidence of new pneumonic infiltrates in comparison with\n previous study of .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2195-11-13 00:00:00.000",
"description": "CT NECK W/O CONTRAST (EG: PAROTIDS)",
"row_id": 941055,
"text": " 11:34 AM\n CT NECK W/O CONTRAST (EG: PAROTIDS) Clip # \n Reason: Evaluate left facial swellingDO NOT GIVE CONTRAST\n Admitting Diagnosis: TRACHEAL ESOPHAGEAL FISTULA\\STENT PLACEMENT ESOPHAGUS\n Field of view: 25\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with chronic trach/vent admitted for esophageal stent under\n general anesthesia with left facial swelling\n REASON FOR THIS EXAMINATION:\n Evaluate left facial swellingDO NOT GIVE CONTRAST\n CONTRAINDICATIONS for IV CONTRAST:\n renal failure\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Tracheostomy and esophageal stents, left facial swelling.\n\n TECHNIQUE: Non-contrast images through the neck. It was requested as a non-\n contrast study per the referring clinician.\n\n FINDINGS: There is soft tissue swelling in the left preauricular region\n extending down to the level of the hyoid bone. There is also marked\n thickening of the left pinna. The external auditory canal appears normal.\n There are fluid levels as well as opacification of the left mastoid air cells.\n Although these may be related to prior intubation or supine positioning,\n infection cannot be excluded. There are no discrete fluid collections.\n\n The visualized orbits and brain appear normal. The left middle ear is clear.\n Note is made of a tracheostomy, as well as an esophageal stent. The biapical\n consolidation with air bronchograms is stable from .\n\n Within the right cervical region, there are asymmetric soft tissues,\n presumably related to asymmetric musculature related to positioning. No\n discrete fluid collection is seen.\n\n IMPRESSION:\n 1. Swelling within the left preauricular region extending to the level of the\n hyoid bone, with thickening of the left pinna; cellulitis is a consideration.\n 2. Fluid levels within the left mastoid air cells. Although this may be\n related to intubation or positioning, acute mastoiditis cannot be excluded.\n\n Note that there is no apparent communication between these processes,\n involvement of the external auditory canal or the middle ear, to specifically\n suggest \"malignant\" otitis externa.\n\n COMMENT: These findings were discussed with Dr. at 3 p.m. on , .\n\n"
},
{
"category": "Radiology",
"chartdate": "2195-11-13 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 941056,
"text": " 11:35 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: evaluate left facial swellingPLEASE NO IV CONTRAST - PLEASE\n Admitting Diagnosis: TRACHEAL ESOPHAGEAL FISTULA\\STENT PLACEMENT ESOPHAGUS\n Field of view: 25\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with chronic trach/vent admitted for esophageal stent with\n left facial swelling\n REASON FOR THIS EXAMINATION:\n evaluate left facial swellingPLEASE NO IV CONTRAST - PLEASE DO ASAP AS PATIENT\n GOING TO BE DISCHARGED\n CONTRAINDICATIONS for IV CONTRAST:\n renal failure\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Chronic trache/vent admitted for esophageal stent, with left facial\n swelling.\n\n TECHNIQUE: Non-contrast head CT.\n\n COMPARISONS: None.\n\n FINDINGS: There is no shift of normally midline structures, acute hemorrhage,\n or evidence of an acute major vascular territorial infarct. There is right\n frontal encephalomalacia with mineralization and ex vacuo degeneration, likely\n in the region of prior infarct. There is low attenuation in the region of the\n left basal ganglia, which could represent a prior lacunar infarct or prominent\n VR space. The ventricles and sulci are prominent consistent with atrophy.\n There are vascular calcifications within the left vertebral and the cavernous\n segments of the internal carotid arteries. The -white matter\n differentiation is preserved. There are no acute fractures. There is mucosal\n thickening within the ethmoid and sphenoid sinus, which could be related to\n prior intubation. There is a mucosal retention cyst in the left sphenoid\n sinus. Note is made of soft tissue swelling in the preauricular area on the\n left, as well as thickening of the left pinna.\n\n There is a 2.2-cm fatty attenuation lucency within the left frontal bone at\n the vertex, with internal ossification or soft tissue. This is consistent\n with an intraosseous lipoma. There is also extremely dense in the frontal\n bone, superficially (?h/o Paget's disease).\n\n IMPRESSION: No intracranial hemorrhage or acute infarct. Right frontal\n encephalomalacia. Left preauricular and pinna soft tissue swelling (see\n separate report of the dedicated CT of neck soft tissues).\n\n"
},
{
"category": "Radiology",
"chartdate": "2195-11-12 00:00:00.000",
"description": "ERCP S/P DUODENAL/ENTERAL STENT PLACEMENT",
"row_id": 942274,
"text": " 9:18 AM\n ERCP S/P DUODENAL/ENTERAL STENT PLACEMENT Clip # \n Reason: tracheal stent placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with tracheo-esophageal fistula s/p tracheostomy and tracheal\n stent placementProcedure performed , req sent \n REASON FOR THIS EXAMINATION:\n tracheal stent placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 84-year-old woman with tracheo-esophageal fistula status post\n tracheostomy and stent placement. Notes on CareWeb mentions placement of an\n esophageal stent and revision of tracheal stent.\n\n TECHNIQUE: Intra-operative fluoroscopic images.\n\n FINDINGS: Six spot views are submitted for review from an enteric stent\n placement procedure. No radiologist was present during the procedure. These\n views show ongoing placement of esophageal stents. Stents are not appreciated\n within the airways on these views. A tracheostomy tube is noted.\n\n IMPRESSION: Intra-operative views of enteric stent placement.\n\n"
}
] |
6,378 | 122,006 | Mild (1+) mitral regurgitation isseen. +PP.GI: Abd soft +BS. Mild thickening of mitral valvechordae. Normal ascending aorta diameter. taking po fluids with restriction intact. Normalaortic arch diameter. There is a minimally increased gradientconsistent with trivial mitral stenosis. cough effort good. cough effort good. Lungs mostly clear with occ. nebs and pulm care, including oxygen. cough prod tan secretions mod amt. enc calories. CV stable. pp intact x 4. support for adl's and enc. Tmax 101. responsive to tylenol. C&DB and using IS well. The tricuspid valve leaflets are mildlythickened. Nursing Progress Note 7a-7pPt is A&Ox3, MAE with good strength. Extremities warm with +PP. ]TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Suboptimal technical quality, a focal LV wall motion abnormalitycannot be fully excluded.RIGHT VENTRICLE: Paradoxic septal motion consistent with prior cardiacsurgery.AORTA: Normal aortic root diameter. Tol pills whole. Lytes WNL.RESP: lung clear to dim at bases. bases.GU/GI: foley dc'd. There is moderate pulmonary artery systolic hypertension. ROM and assist with adl needed at this time. abd soft flat, denies nausea, bt active, stool x 3ACCESS: 2 piv intactPAIN: deniesSOCIAL: visitors this pm. Very articulate and knowledgeable about diagnosis.RESP: Arrived to unit on Non-rebreather. +flatus. per pt. cough prod. Sinus rhythm. pt. pt. pt. pt. pt. Denies pain.CV: low grade temp 99.4, HR 70-80's NSR with no ectopy SBP 110-120's. cont. setup for adl.CV: sinus rate 70-80, sys 110-120, no ectopy. noted above response to lasix. Mnimally increased gradient consistent with trivial MS. 1900-0700 NPNNEURO: intact pt. ph arm reviewed with pt. Modest low amplitude T waves in lead V2 are non-specific andprobably within normal limits. Mild [1+] TR.Moderate PA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor echo windows.Conclusions:The left atrium is normal in size. seems well supported by spouse.PLAN: pulm toilet, contact precautions, fluid restriction, increase activity as tol. PERRLA 3 and brisk. SBP 110-130. Mild (1+) MR.[Due to acoustic shadowing, the severity of MR may be significantlyUNDERestimated. 1900-0700 NPNNEURO: intact, parkinsons tremors but able to mobilize self with min. Thankyou request. wheezing. LS coarse. provide for pt safety. Hemodynamically stableResp: remains on 4 L NC with adeqaute oxygenation received nebs X2 for wheezes.GI: tolerating POs with out problems.GU: foley patent voiding adeqaute amounts of urine.Pt currently awaiting a floor bed. Able to expectorate mod amounts of thick white secretions.GI: tol diet well. lung fields coarse to clear after cough. Since the previous tracing of rightprecordial T wave amplitude has improved. mucous membranes dry. Ambulated with PT and tolerated it fair. Prominent Eustachian valve(normal variant).LEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function(LVEF>55%). A mitralvalve annuloplasty ring is present. Receiving PRN neb treatment and pt uses IS intermittently. O2 sat low to mid 90s on 2L NC. MAE. Answers questions appropriately follows commands. NPNN: alert oriented follows commands, moves all extremeties, OOB to chair .CV: tmax 101.7 orally, down with tylenol. provide safe environment for pt. Without O2, desaturates in to mid 80s, however pt denies difficulty breathing. mod to large amt tan secretions. Left ventricular wall thickness, cavitysize, and systolic function are normal (LVEF>55%). Portable home O2 is to be arranged for discharge. O2 at 2.5l/min via N/C. breath sounds with crackles bil. Productive cough self yankours thick white sputum.CARDIAC: Tmax 102 to be cultured again. Sl anxious. 1 small stool this am.GU: voiding in urinal adequate amounts.ENDO:blood sugars WNL.PLAN: awaiting transfer to floor PATIENT/TEST INFORMATION:Indication: Congestive heart failure.Height: (in) 67Weight (lb): 146BSA (m2): 1.77 m2BP (mm Hg): 122/55HR (bpm): 89Status: InpatientDate/Time: at 12:27Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:This study was compared to the report of the prior study (images notavailable) of .LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Has difficulty with fine motor tasks. states not needed at home.CV: sinus tach in pm to sinus in am rate 70-80. no ectopy noted. to participate actively in care. Pt verbalizes periods of rigidness related to his medications. Small stool. assist between bed to chair and participate with min. NURSING NOTE: REVIEW OF SYSTEMS:NEURO: AWAKE ALERT AND ORIENTED, PERRLA, MOVES ALL EXTREMITIES WELL, VERY TREMULOUSLY FROM PARKINSONS, TAKES OWN MEDICATION FROM HOME CURRENTLY ON BEDSIDE.C/V: NSR RATE IN THE 80-100 NO ECTOPY.RESP: O2 ON AT 4L NC, LUNG SOUNDS WITH EXPIRATORY WHEEZE ALBUTEROL TREATMENT GIVEN BY RESP. HR 60-70's. vd 100-200 cc amts. urine out drk amber min. O2 sats >96%. no rales noted in bases.GU/GI: abd soft nontender, foley amber qs. response to lasix at 1 hr 150 cc. tol po food and fluids with restriction wellSKIN: intactENDO: no sliding scale, bs 162 after meal.ACCESS: TLC in right shoulder all ports open. Will transfer to the floor, okay to go to semi-private with ID team approval. C/O abdominal pain. Cultured at 2AM in ED results PE. [Due to acoustic shadowing, the severity of mitral regurgitation may besignificantly UNDERestimated.] increase activity as tol. Ordered for a cardiac diet.GU: Foley intact draining 10-40cc/hr of clear yellow urine.PSYCH/SOCIAL: Extremely pleasant and cooperative. piv in left arm withgood return.PAIN: denies painSOCIAL: wife called to inquire. Please see flowsheets for all other information. O2 ON AT 96-99%.GU: VOIDING IN URINAL QS.GI: TAKING PO DIET WELL, BEDPAN X1 MODERATE AMOUNTS SOFT BROWN STOOLACCESS: 2 PIV LINE INTACT.SOCIAL: WIFE INTO VISIT AND UPDATED ON PLAN OF CARE.PLAN: TRANSFER TO FLOOR WHEN BED AVAILABLE. is well versed in his parkinson's disease. CVP 14 now RESP: pt on 4 liters nc, some scattered wheeze early in shift, now no distress 100% 4 liters decreased to 2 liters with sat drop to 80's return to 4 liters. tmax 102 responsive to tylenol.RESP: 4 liter nc for sats 97%. meds at bedside. Wife at bedside very supportive and helpful with care.INTEG: Skin CDI.PLAN: Monitor VS, RESP, I&O, Provide comfort and support. There isno pericardial effusion.Compared with the report of the prior study (tape unavailable for review) of, no diagnostic change. | 9 | [
{
"category": "Nursing/other",
"chartdate": "2197-12-26 00:00:00.000",
"description": "Report",
"row_id": 1346456,
"text": "Nursing Note--A Shift Arrival to Unit\nPlease see Carevue for complete assessment and specifics:\n\nPt arrived to unit from ED at 3:30pm.\n\nNEURO: A&OX3. PERRLA 3 and brisk. MAE. Has parkinsonian tremors all 4 ext. Has difficulty with fine motor tasks. Answers questions appropriately follows commands. Very articulate and knowledgeable about diagnosis.\n\nRESP: Arrived to unit on Non-rebreather. Changed to NC 4L sat 95%. LS coarse. Productive cough self yankours thick white sputum.\n\nCARDIAC: Tmax 102 to be cultured again. Cultured at 2AM in ED results PE. HR 60-70's. SBP 110-130. +PP.\n\nGI: Abd soft +BS. C/O abdominal pain. +flatus. Small stool. Tol pills whole. Ordered for a cardiac diet.\n\nGU: Foley intact draining 10-40cc/hr of clear yellow urine.\n\nPSYCH/SOCIAL: Extremely pleasant and cooperative. Sl anxious. Very knowledgeable about Parkinsons disease and anatomy. Wife at bedside very supportive and helpful with care.\n\nINTEG: Skin CDI.\n\nPLAN: Monitor VS, RESP, I&O, Provide comfort and support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-27 00:00:00.000",
"description": "Report",
"row_id": 1346457,
"text": "1900-0700 NPN\nNEURO: intact pt. is well versed in his parkinson's disease. ROM and assist with adl needed at this time. pt. states not needed at home.\n\nCV: sinus tach in pm to sinus in am rate 70-80. no ectopy noted. urine out drk amber min. response to lasix at 1 hr 150 cc. mucous membranes dry. pp intact x 4. Tmax 101. responsive to tylenol. CVP 14 now \n\nRESP: pt on 4 liters nc, some scattered wheeze early in shift, now no distress 100% 4 liters decreased to 2 liters with sat drop to 80's return to 4 liters. cough prod. mod to large amt tan secretions. cough effort good. lung fields coarse to clear after cough. no rales noted in bases.\n\nGU/GI: abd soft nontender, foley amber qs. noted above response to lasix. tol po food and fluids with restriction well\n\nSKIN: intact\n\nENDO: no sliding scale, bs 162 after meal.\n\nACCESS: TLC in right shoulder all ports open. piv in left arm withgood return.\n\nPAIN: denies pain\n\nSOCIAL: wife called to inquire. pt. seems well supported by spouse.\n\nPLAN: pulm toilet, contact precautions, fluid restriction, increase activity as tol. provide safe environment for pt. support for adl's and enc. pt. to participate actively in care. pt. meds at bedside. ph arm reviewed with pt.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-27 00:00:00.000",
"description": "Report",
"row_id": 1346458,
"text": "NPN\nN: alert oriented follows commands, moves all extremeties, OOB to chair .\nCV: tmax 101.7 orally, down with tylenol. Hemodynamically stable\nResp: remains on 4 L NC with adeqaute oxygenation received nebs X2 for wheezes.\nGI: tolerating POs with out problems.\nGU: foley patent voiding adeqaute amounts of urine.\nPt currently awaiting a floor bed. Please see flowsheets for all other information. Thankyou\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-28 00:00:00.000",
"description": "Report",
"row_id": 1346459,
"text": "1900-0700 NPN\nNEURO: intact, parkinsons tremors but able to mobilize self with min. assist between bed to chair and participate with min. setup for adl.\n\nCV: sinus rate 70-80, sys 110-120, no ectopy. taking po fluids with restriction intact. tmax 102 responsive to tylenol.\n\nRESP: 4 liter nc for sats 97%. room air sats 89%. cough prod tan secretions mod amt. cough effort good. breath sounds with crackles bil. bases.\n\nGU/GI: foley dc'd. per pt. request. vd 100-200 cc amts. abd soft flat, denies nausea, bt active, stool x 3\n\nACCESS: 2 piv intact\n\nPAIN: denies\n\nSOCIAL: visitors this pm. pt. interactive with staff\n\nPLAN: called out to floor bed with isolation for contact precautions. cont. nebs and pulm care, including oxygen. increase activity as tol. enc calories. provide for pt safety.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-28 00:00:00.000",
"description": "Report",
"row_id": 1346460,
"text": "NURSING NOTE: REVIEW OF SYSTEMS:\nNEURO: AWAKE ALERT AND ORIENTED, PERRLA, MOVES ALL EXTREMITIES WELL, VERY TREMULOUSLY FROM PARKINSONS, TAKES OWN MEDICATION FROM HOME CURRENTLY ON BEDSIDE.\nC/V: NSR RATE IN THE 80-100 NO ECTOPY.\nRESP: O2 ON AT 4L NC, LUNG SOUNDS WITH EXPIRATORY WHEEZE ALBUTEROL TREATMENT GIVEN BY RESP. O2 ON AT 96-99%.\nGU: VOIDING IN URINAL QS.\nGI: TAKING PO DIET WELL, BEDPAN X1 MODERATE AMOUNTS SOFT BROWN STOOL\nACCESS: 2 PIV LINE INTACT.\nSOCIAL: WIFE INTO VISIT AND UPDATED ON PLAN OF CARE.\nPLAN: TRANSFER TO FLOOR WHEN BED AVAILABLE.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-29 00:00:00.000",
"description": "Report",
"row_id": 1346461,
"text": "Neuro: Pt alert and oriented X3, generalized weakness due to Parkinson's. Denies pain.\nCV: low grade temp 99.4, HR 70-80's NSR with no ectopy SBP 110-120's. Extremities warm with +PP. Lytes WNL.\nRESP: lung clear to dim at bases. O2 at 2.5l/min via N/C. O2 sats >96%. C&DB and using IS well. Able to expectorate mod amounts of thick white secretions.\nGI: tol diet well. 1 small stool this am.\nGU: voiding in urinal adequate amounts.\nENDO:blood sugars WNL.\nPLAN: awaiting transfer to floor\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-29 00:00:00.000",
"description": "Report",
"row_id": 1346462,
"text": "Nursing Progress Note 7a-7p\n\nPt is A&Ox3, MAE with good strength. Ambulated with PT and tolerated it fair. Pt verbalizes periods of rigidness related to his medications. O2 sat low to mid 90s on 2L NC. Without O2, desaturates in to mid 80s, however pt denies difficulty breathing. Portable home O2 is to be arranged for discharge. Receiving PRN neb treatment and pt uses IS intermittently. Lungs mostly clear with occ. wheezing. CV stable. Will transfer to the floor, okay to go to semi-private with ID team approval.\n"
},
{
"category": "Echo",
"chartdate": "2197-12-27 00:00:00.000",
"description": "Report",
"row_id": 105110,
"text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure.\nHeight: (in) 67\nWeight (lb): 146\nBSA (m2): 1.77 m2\nBP (mm Hg): 122/55\nHR (bpm): 89\nStatus: Inpatient\nDate/Time: at 12:27\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the report of the prior study (images not\navailable) of .\n\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Prominent Eustachian valve\n(normal variant).\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function\n(LVEF>55%). Suboptimal technical quality, a focal LV wall motion abnormality\ncannot be fully excluded.\n\nRIGHT VENTRICLE: Paradoxic septal motion consistent with prior cardiac\nsurgery.\n\nAORTA: Normal aortic root diameter. Normal ascending aorta diameter. Normal\naortic arch diameter. No 2D or Doppler evidence of distal arch coarctation.\n\nMITRAL VALVE: Mitral valve annuloplasty ring. Mild thickening of mitral valve\nchordae. Mnimally increased gradient consistent with trivial MS. Mild (1+) MR.\n[Due to acoustic shadowing, the severity of MR may be significantly\nUNDERestimated.]\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR.\nModerate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thickness, cavity\nsize, and systolic function are normal (LVEF>55%). Due to suboptimal technical\nquality, a focal wall motion abnormality cannot be fully excluded. A mitral\nvalve annuloplasty ring is present. There is a minimally increased gradient\nconsistent with trivial mitral stenosis. Mild (1+) mitral regurgitation is\nseen. [Due to acoustic shadowing, the severity of mitral regurgitation may be\nsignificantly UNDERestimated.] The tricuspid valve leaflets are mildly\nthickened. There is moderate pulmonary artery systolic hypertension. There is\nno pericardial effusion.\n\nCompared with the report of the prior study (tape unavailable for review) of\n, no diagnostic change.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2197-12-25 00:00:00.000",
"description": "Report",
"row_id": 307904,
"text": "Sinus rhythm. Modest low amplitude T waves in lead V2 are non-specific and\nprobably within normal limits. Since the previous tracing of right\nprecordial T wave amplitude has improved.\n\n"
}
] |
|
15,784 | 128,195 | 80 yo male c/CAD, CHF, DM, CRF and cryptogenic cirrhosis who is admitted for obstructive pancreatitis and jaundice now s/p ERCP . RESOLVING SEPSIS - appears resolved, BP became stable with good CVP's. Pt was briefly placed on Zosyn, which was then d/c'd with continued stable BP and negative cultures. . GALLSTONE PANCREATITIS - s/p ERCP, and was able to tolerate PO diet without complaint. His enzymes continued to trend down. Pt was felt to be a high risk surgery for , no inpatient surgery was planned. This may be re-addressed as an outpatient. . CV: CORONARIES - pt has known CAD, with allergy to ASA (unclear if true allergy). benifit from repeat stress as an outpatient. PUMP - pt with known CHF, but continued to have stable O2 sats. He was restarted on his outpt diuretics. RATE - he was restarted on his outpatient Diltiazem for Afib, as well as Digoxin. He was temporarily placed on IV Heparin, but Coumadin was held b/o history of GIB, and well as fall history. Coumadin was held during previous admission, and his PCP's office was contact. It was agreed that we should continue holding his Coumadin, and this could be further evaluated as an outpatient. . DVT - it was noted by radiology that he may have a possible RUE dvt on his abdominal CT. Follow-up US confirmed nonocclusive thrombus. Given previously discussed risks, he was not treated with Coumadin. These risks were discussed with the patient and family. . ANEMIA - pt w/ h/o GIB, with only grade 1 varices. He was mildly guiac positive while on Heparin, and recieved 1U of PRBC's with Hct corrected to baseline. He should have f/u Hct checks. . DM - his prevous NPH regimen was held, and was covered with ISS. He should restart a lower NPH regimen as outpatient, and cover with ISS. . HTN - his ACEi was held, and he was placed back on Diltiazem for rate control. His BP remained stable without Lisinopril, so this was not restarted. consider change from Diltiazem to nonselective BB in the future. . LIVER - his liver lesion on CT was concerning for HCC, and his previous AFP was 37.5 on . Repeated was now 1892. He has a pacermaker, and could not get MRCP. Will d/w hepatology, and felt this AFP level was likely diagnostic. A 50lb weight loss makes this even more concerning. Discussed with IR and ordered another abd u/s. It was unclear how much the lesion was infiltrating tumor vs AVM, and given the location and description he was not a surgical candidate, or a candidiate for chemoembolization or RFA. He will f/u with Dr as an outpatient for medical therapy. As far as his cirrhosis goes he does not appear encephalopathic, and was continued on Lactulose. He was restarted on outpt diuretics. | FINDINGS: -scale and Doppler son of the right common femoral, superficial femoral, and popliteal veins were performed. There is upper zone redistribution on the semiupright film with vascular engorgement consistent with mild CHF. Systolic murmur. NPO STATUS MAINTAINED AFTER MN EXCEPT MEDS. 0700-1300 NPN: TRANSFER FROM MICU B/WEST TO /EAST VIA ALS, ACCOMPANIED BY RN W/O DIFFICULTY FOR ERCP ON . These findings are suggestive of a partial, nonocclusive thrombus which may be chronic or acute. AP SEMIUPRIGHT VIEW OF THE CHEST: There is interval placement of a right IJ line terminating in the distal SVC. Delayed abdomen and pelvis was obtained. FS=108-156. IMPRESSION: Findings suggestive of partial, nonocclusive thrombus in the right common femoral vein, which may be chronic or acute. CONCLUSION: Findings are consistent with cirrhosis and an arteriovenous fistula. PMH OF CHF. Dr do perform u/s. Dr do perform u/s. CXR with some congestion and pt with bilat. LACTATE TRENDING DOWN, 1.2 THIS AM. The main portal vein is patent with hepatopetal flow. Again seen within segment VI of the liver, is a 2.0 x 2.3 x 2.1 cm hypoechoic focus with a vascular rim, which is unchanged from prior study dated . Compared to the previous tracing of the rhythmis no longer ventricular paced and there is intrinsic A-V conduction. cortstim test sent. Coronal and sagittal reformatted images were obtained. IV ABX THERAPY. IS NOTED TO MAE'S AND SLURRED SPEECH IS FROM OLD CVA. SVO2 Catheter in RIJ. AM CXR SHOWED CONGESTION.CV- CHRONIC AFIB @ 90-130. FINAL REPORT INDICATION: Status post right IJ line placement. The liver has a coarsened echotexture consistent with cirrhosis. AP SUPINE PORTABLE CHEST X-RAY: Comparison is made to . COMPARISON: Radiograph dated . The superficial femoral, and popliteal veins demonstrate normal compressibility, color flow, waveforms, and augmentation. PMH OF CVA. 3) Coarsened echotexture of liver consistent with cirrhosis. RESP; PT. This is an arterio-portal fistula with refluxing contrast down the portal vein. There is a small pericardial effusion. Pt c/o N/V and abd.pain. MPR value (Over) 12:37 AM CTA ABD W&W/O C & RECONS; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST; 200CC NON IONIC CONTRAST SUPPLY Reason: ?gallstone pancreatitis ?thrombosis of PV ?other abnl Admitting Diagnosis: GALLSTONE PANCREATITIS Field of view: 45 Contrast: OPTIRAY Amt: 200 FINAL REPORT (REVISED) (Cont) grade V. IMPRESSION: 1) Mild Pancreatitis. LS clear bilateral upper lobes and crackles bibasilarly.GI: Abdomin nontender soft and flat. 2) Cholelithiasis, without evidence of acute cholecystitis. CVP=. elevated lipase and AP. FOLLOW UP LYTES/LACTATE/AMMONIA LEVEL. Diffuse non-specificST-T wave abnormalities. DIGOXIN TODAY. IMPRESSION: Gallstone in the distal common bile duct, which, by report, was successfully removed. PT DENIES SOB. On delayed imaging, there is persistent heterogeneous enhancement in segment VI. Thereis ST-T wave flattening. COOCYX REGION REMAINS SLIGHTLY REDDENED WITH NO BREAKDOWN NOTED. crackles.GU: pt with baseline cri-1.2-1.6. These are expanded with thrombus. AFEBRILE.GI/GU- ABD SOFT/NONDISTENDED. There is slight prominence of the vasculature, particularly in the perihilar region. 2) Stable appearance of lesion in segment VI of the liver, most consistent with an AVM. Extending from this region are finger-like projections that represent thrombosed portal vessel branches. CT OF THE PELVIS WITH ORAL, WITH INTRAVENOUS CONTRAST: Sigmoid diverticulosis without evidence of diverticulitis. Clinicalcorrelation is suggested. Chin obscures the lung apices. Evaluate for cholecystitis and ascites. Surgery consulting-possible ercp today. SLIGHT NAUSEA X1, VOMITED SM AMT AND TX W/ ANZEMET IN GI UNIT W/ GOOD EFFECTS. RECEIVED PT. DENIES ABD PAIN. Lactate trending down. PT became hypotensive in ER 70's systolic and transferred to MICUB for further care.Neuro:PT lethargic but easily arousable. Coronal and sagittal reformatted images confirm the axial findings. 2) Mild CHF. FOLLOWS COMMANDS.AMMONIA LEVEL=86, CONTINUES ON LACTULOSE TID.RESP- NO DISTRESS NOTED. PERRL. Calcifications and evidence of old infarct are seen within the spleen. 6) Splenic infarcts. Hepatic arteries, hepatic veins and portal veins are all patent. COMPARISON: No previous right lower extremity venous ultrasound. Normal color flow, waveforms, and augmentation demonstrated in the common femoral vein. HAS BEEN AFIB 80-120'S UNSUSTAINED. DFDkq no c/o pain at this timeCVS: Pt in afib w/RVR. A simple cyst is again appreciated within the lower pole of the right kidney. Left- sided biventricular pacemaker is seen in good position. IS TO RECEIVE I.V. Somewhat slurred speech(pt w/ h/o cva-unknown defecits) and pt states that speech is slurred at times. Slighty increased sedative effect r/t fentanyl, versed and propofol for procedure.N: Mentation intact on arrival, oriented x3 now with decreased lethargy, remains sleepy. REPORT: There is a seen moderate amount of ascites present. CONTINUE LACTULOSE TID. IMPRESSION: 1) Gallstones and sludge within the gallbladder, without evidence of acute cholecystitis. FROM 4 LAST HS WITH PT. Rule out mechanical obstruction. Continuing with lactulose tid. Admitting Diagnosis: GALLSTONE PANCREATITIS MEDICAL CONDITION: 79 yo man s/p R IJ central line REASON FOR THIS EXAMINATION: confirm placement. Pt oriented x3. LFT's elevated-see careview for details. The liver is small and cirrhotic consistent with cirrhosis. The right common femoral vein is not fully compressible. By report, the stone was removed and a sphincterotomy was performed. | 14 | [
{
"category": "Radiology",
"chartdate": "2116-04-13 00:00:00.000",
"description": "R UNILAT LOWER EXT VEINS RIGHT",
"row_id": 863128,
"text": " 3:40 PM\n UNILAT LOWER EXT VEINS RIGHT Clip # \n Reason: Please evaluate for DVT\n Admitting Diagnosis: GALLSTONE PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with cirrhosis amd liver mass, with evidence of R femoral DVT\n by CT\n REASON FOR THIS EXAMINATION:\n Please evaluate for DVT\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Cirrhosis and liver mass. Right femoral vein thrombus noted on CT\n scan of the abdomen and pelvis.\n\n COMPARISON: No previous right lower extremity venous ultrasound. CT of the\n abdomen and pelvis performed on is available for correlation.\n\n FINDINGS: -scale and Doppler son of the right common femoral,\n superficial femoral, and popliteal veins were performed. The right common\n femoral vein is not fully compressible. However, no intraluminal thrombus is\n identified on -scale imaging. Normal color flow, waveforms, and\n augmentation demonstrated in the common femoral vein. These findings are\n suggestive of a partial, nonocclusive thrombus which may be chronic or acute.\n The superficial femoral, and popliteal veins demonstrate normal\n compressibility, color flow, waveforms, and augmentation. No intraluminal\n thrombus is demonstrated in the superficial femoral and popliteal veins.\n\n IMPRESSION: Findings suggestive of partial, nonocclusive thrombus in the\n right common femoral vein, which may be chronic or acute.\n DFDkq\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-04-08 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 862575,
"text": " 8:48 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: ELEV LIPASE, AP, CIRRHOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with cirrhosis and altered mental status. elevated lipase\n and AP.\n REASON FOR THIS EXAMINATION:\n ?ascites\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 79-year-old man with cirrhosis and altered mental status, now\n with elevated lipase and alkaline phosphatase. Evaluate for cholecystitis and\n ascites.\n\n RIGHT UPPER QUADRANT ULTRASOUND: When compared with the prior study dated\n , there is no significant interval change. The gallbladder is\n normal in size, and is filled with sludge and stones. There is no\n pericholecystic fluid, and the gallbladder wall is not thickened. The common\n bile duct measures 4 mm.\n\n Again seen within segment VI of the liver, is a 2.0 x 2.3 x 2.1 cm hypoechoic\n focus with a vascular rim, which is unchanged from prior study dated\n . There is no significant abdominal ascites. The liver has a\n coarsened echotexture consistent with cirrhosis. The main portal vein is\n patent with hepatopetal flow. A simple cyst is again appreciated within the\n lower pole of the right kidney.\n\n IMPRESSION:\n 1) Gallstones and sludge within the gallbladder, without evidence of acute\n cholecystitis.\n 2) Stable appearance of lesion in segment VI of the liver, most consistent\n with an AVM.\n 3) Coarsened echotexture of liver consistent with cirrhosis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-04-08 00:00:00.000",
"description": "CHEST (SINGLE VIEW)",
"row_id": 862580,
"text": " 10:04 PM\n CHEST (SINGLE VIEW) Clip # \n Reason: ?PNA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with hx of liver dz who presents with N/V, fevers. crackles\n bilaterally.\n REASON FOR THIS EXAMINATION:\n ?PNA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 80-year-old man with history of liver disease, now with nausea,\n vomiting, fevers, and crackles bilaterally.\n\n AP SUPINE PORTABLE CHEST X-RAY: Comparison is made to . Chin\n obscures the lung apices. Cardiac silhouette is enlarged. There is slight\n prominence of the vasculature, particularly in the perihilar region. This\n could be due to supine technique or reflect mild CHF. There is no interstitial\n or alveolar edema. There are no focal consolidations or large effusions. Left-\n sided biventricular pacemaker is seen in good position.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-04-09 00:00:00.000",
"description": "ERCP S&I (74330)",
"row_id": 863281,
"text": " 11:17 PM\n ERCP S&I () Clip # \n Reason: R/O Mechanical obstruction\n Admitting Diagnosis: GALLSTONE PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with GS pancreatitis and Cholangitis.\n Exam performed , req sent \n REASON FOR THIS EXAMINATION:\n R/O Mechanical obstruction\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: An 80-year-old man with gallstone pancreatitis and cholangitis.\n Rule out mechanical obstruction.\n\n COMPARISON: None.\n\n ERCP: Six fluoroscopic images are presented for radiology interpretation. No\n radiologist was present during image acquisition. These images demonstrate an\n approximately 1-cm filling defect within the distal common bile duct,\n consisting of a stone. By report, the stone was removed and a sphincterotomy\n was performed.\n\n IMPRESSION: Gallstone in the distal common bile duct, which, by report, was\n successfully removed.\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-04-13 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 863113,
"text": " 3:40 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOP ABD/PEL LIMITED\n Reason: Please evaluate suspicious liver mass, and for portal vein i\n Admitting Diagnosis: GALLSTONE PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with cirrhosis and gallstones pancreatitis s/p ERCP, with\n suspicious mass in segment VI. Dr do perform u/s.\n REASON FOR THIS EXAMINATION:\n Please evaluate suspicious liver mass, and for portal vein involvement. Dr \n do perform u/s.\n ______________________________________________________________________________\n FINAL REPORT\n ULTRASOUND OF LIVER.\n\n INDICATION: Patient with a suspicious lesion in the right lobe of liver. For\n evaluation.\n\n TECHNIQUE: -scale, pulsed wave and color-flow Doppler analysis of the\n liver and its vasculature was performed.\n\n COMPARISON: Reference is made to previous ultrasound examinations going back\n over six months as well as CT examinations going back as far as .\n\n REPORT: There is a seen moderate amount of ascites present. The liver is\n small and cirrhotic consistent with cirrhosis. Within the right lobe of the\n liver corresponding to previous examinations, there is an intensely\n hypervascular lesion. This is associated with extensive turbulent flow and is\n most consistent with an arteriovenous or arterioportal malformation. Extending\n from this region are finger-like projections that represent thrombosed portal\n vessel branches. These are expanded with thrombus. Pulsed-wave and color-flow\n imaging of these portal vessels, however fails to reveal definite vascularity\n within them. The AV fistula measures approximately 2.3 x 2.7 cm.Review of\n previous imaging shows that the AV shunt was probably present in , but\n that the portal venous thrombosis is definitely new.\n\n The gallbladder contains extensive sludge. No intra- or extrahepatic biliary\n dilatation is identified. There is splenomegaly at 16 cm.\n\n CONCLUSION:\n\n Findings are consistent with cirrhosis and an arteriovenous fistula. No\n definite vascularized portal venous tumor thrombus is identified, and the\n peripheral RPV thrombus hence appears on imaging to be bland thrombus.\n However, although no focal hepatic mass is identified apart from the AV\n fistula, the patient's alpha fetoprotein is noted to be markedly elevated and\n the possibility of tumor thrombus cannot definitively be excluded. As the\n patient cannot get an MRI and there is no definable target for biopsy,\n consideration for a PET-CT study should be given.\n\n\n\n (Over)\n\n 3:40 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOP ABD/PEL LIMITED\n Reason: Please evaluate suspicious liver mass, and for portal vein i\n Admitting Diagnosis: GALLSTONE PANCREATITIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-04-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 862595,
"text": " 2:08 AM\n CHEST (PORTABLE AP) Clip # \n Reason: confirm placement.\n Admitting Diagnosis: GALLSTONE PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 yo man s/p R IJ central line\n REASON FOR THIS EXAMINATION:\n confirm placement.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post right IJ line placement.\n\n COMPARISON: Radiograph dated .\n\n AP SEMIUPRIGHT VIEW OF THE CHEST: There is interval placement of a right IJ\n line terminating in the distal SVC. No pneumothorax is identified. The\n cardiac size is stable. There is upper zone redistribution on the semiupright\n film with vascular engorgement consistent with mild CHF. No pleural effusion\n is identified. The dual-lead pacemaker device is unchanged.\n\n IMPRESSION:\n\n 1) Right IJ line in satisfactory position. No evidence of pneumothorax.\n 2) Mild CHF.\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-04-09 00:00:00.000",
"description": "CTA ABD W&W/O C & RECONS",
"row_id": 862589,
"text": " 12:37 AM\n CTA ABD W&W/O C & RECONS; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; 200CC NON IONIC CONTRAST SUPPLY\n Reason: ?gallstone pancreatitis ?thrombosis of PV ?other abnl\n Admitting Diagnosis: GALLSTONE PANCREATITIS\n Field of view: 45 Contrast: OPTIRAY Amt: 200\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with cryptogenic cirrhosis who presents wiht labs suggestive of\n gallstone pancreatitis.\n REASON FOR THIS EXAMINATION:\n ?gallstone pancreatitis ?thrombosis of PV ?other abnl\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION: 80-year-old man with cryptogenic cirrhosis and possible gallstone\n pancreatitis. Evaluate.\n\n TECHNIQUE: Multidetector imaging was obtained through the liver before and\n after the administration of 150 cc of intravenous Optiray. Delayed abdomen\n and pelvis was obtained. Coronal and sagittal reformatted images were\n obtained.\n\n CTA LIVER: Small pleural effusions are seen at both lung bases. There are\n diffuse coronary artery calcifications, evidence of prior coronary artery\n bypass graft. There is a small pericardial effusion. Multiple-phase imaging\n through the liver demonstrates a lesion in segment VI of the liver with early\n arterial enhancement and early washout, which was previously imaged on prior\n ultrasounds from and . The remainder of the liver\n enhances normally. Hepatic arteries, hepatic veins and portal veins are all\n patent. There is early arterial filling of the portal vein, with retrograde\n opacification of the splenic vein. The splenic vein is dilated. On delayed\n imaging, there is persistent heterogeneous enhancement in segment VI. The\n gallbladder is slightly distended with sludge and stones. The gallbladder wall\n is not thickened. The CBD is not significantly dilated. Calcifications and\n evidence of old infarct are seen within the spleen. There is diffuse soft\n tissue stranding surrounding the pancreas, without significant dilation of the\n pancreatic duct or focal fluid collections. Both adrenals are normal. There\n is a 3.5 x 2.8 cm simple cyst within the inferior pole of the right kidney.\n Within the ascending colon, at the level of the splenic flexure, there is a\n 5.5 cm segment of thickened colon with peripheral stranding consistent with\n diverticulitis. There is diffuse diverticulosis of the entire large bowel.\n There is no intra-abdominal free air.\n\n CT OF THE PELVIS WITH ORAL, WITH INTRAVENOUS CONTRAST: Sigmoid diverticulosis\n without evidence of diverticulitis. Distal ureters and prostate are normal.\n Foley catheter is seen within a collapsed bladder. There is no inguinal or\n pelvic lymphadenopathy. There is no free air and no free fluid.\n\n BONE WINDOWS: Degenerative changes are seen throughout the lower thoracic and\n lumbar spine. There are no lytic or sclerotic osseous abnormalities.\n\n Coronal and sagittal reformatted images confirm the axial findings. MPR value\n (Over)\n\n 12:37 AM\n CTA ABD W&W/O C & RECONS; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; 200CC NON IONIC CONTRAST SUPPLY\n Reason: ?gallstone pancreatitis ?thrombosis of PV ?other abnl\n Admitting Diagnosis: GALLSTONE PANCREATITIS\n Field of view: 45 Contrast: OPTIRAY Amt: 200\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n (Cont)\n grade V.\n\n IMPRESSION:\n 1) Mild Pancreatitis.\n\n 2) Cholelithiasis, without evidence of acute cholecystitis.\n\n 3) Extensive colonic diverticulosis. Pericolic fluid is most likely due to\n underlying liver disease.\n\n 4) Lesion in segment VI of liver which has been noted on prior ultrasounds\n from , and . This is an arterio-portal fistula\n with refluxing contrast down the portal vein. The findings are concerning for\n a mass in the liver causing this fistula. Because of this, an MRI is once\n again recommended to evaluate the vasculature and in particular, to exclude an\n underlying liver malignancy.\n\n\n 5) All intrahepatic arteries, veins and the portal vein are patent without\n intraluminal thrombus.\n\n 6) Splenic infarcts.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2116-04-08 00:00:00.000",
"description": "Report",
"row_id": 113578,
"text": "Atrial fibrillation with a rapid ventricular response. Diffuse non-specific\nST-T wave abnormalities. Compared to the previous tracing of the rhythm\nis no longer ventricular paced and there is intrinsic A-V conduction. Compared\nto the previous tracing of the voltage has diminished throughout. There\nis ST-T wave flattening. Otherwise, no diagnostic interim change. Clinical\ncorrelation is suggested.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-04-09 00:00:00.000",
"description": "Report",
"row_id": 1467776,
"text": "nursing note:\n80 yo male w/history of cad, chf, dm, cri, and cryptogenic cirrhosis admitted from osh with AMS and inc.LFT's. Pt c/o N/V and abd.pain. PT became hypotensive in ER 70's systolic and transferred to MICUB for further care.\n\nNeuro:PT lethargic but easily arousable. Somewhat slurred speech(pt w/ h/o cva-unknown defecits) and pt states that speech is slurred at times. MAE weakly. Pt oriented x3. Ammonia level 86 in er. Continuing with lactulose tid. no c/o pain at this time\n\nCVS: Pt in afib w/RVR. Dig level 0.6 this am. Aline inserted upon admission. BP stable-map maintained>65 thus far. HR range 90-125. CVP 8-10. LR infusing @ 150cc/hr x1L. Pt received 5L ivf in er. SVO2 Catheter in RIJ. Svo2 sent on admission. Per DR. pt is not septic protocol and does not need continuous svo2 monitoring. Lactate trending down. cortstim test sent. TRop 0.05 in ed-level sent this am with labs\n\nPulm: Pt on ra with o2sats 98-100%. Denies SOB. CXR with some congestion and pt with bilat. crackles.\n\nGU: pt with baseline cri-1.2-1.6. UO adequate so far but only 400ml out in ED.\n\nGI: Pt denies abd. pain at this time. Distended, soft abd with bowel sounds. LFT's elevated-see careview for details. Surgery consulting-possible ercp today. PT diabetic-on insulin at home. BS currently 100-130. Insulin gtt written for BS >120. Discussed with Dr. hold off insulin gtt for now and follow BS closely.\n\nSkin: intact.\n\nsocial: Significant for wife recently passing away 2weeks ago. Since then pt has been stayng with both daughter and son-alternating between the two.\n\nPlan: Continue to rehydrate gently, monitor pulm.status closely r/t chf, please have SW consult. Monitor FS closely-insulin gtt may be needed. Continue lactulose for encephalopathy.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-04-09 00:00:00.000",
"description": "Report",
"row_id": 1467777,
"text": "nursing update:\nSurgical resident in to see patient this am. updated on status. Plan for pt to have ercp today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-04-09 00:00:00.000",
"description": "Report",
"row_id": 1467780,
"text": "npn 7:30p-10:30p\n\n80 yo man w/ hx cirrhosis, s/p ERCP of this afternoon; tract cleared of stones confirmed w/ cholangiogram at ERCP:\n\nvss following; remains in a-fib, usually in low 100's, has occasional brief approx 6 sec increases to 120's, immediately returns to low 100's; is s/p extra IV Dig earlier today, now ordered for 0.125 IV QD;\n\nasymptomatic of bleeding this 3 hours; T 99.4 oral at 22:30.\n\npt being transferred back to MICU-B at 22:30 via ACLS ambulance; report called to RN/MICU-B. Pt was admitted to same unit last night.\n\nno labs ordered for this eve; next labs ordered for a.m.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-04-10 00:00:00.000",
"description": "Report",
"row_id": 1467781,
"text": "RECEIVED PT. FROM 4 LAST HS WITH PT. TOLERATING THIS WELL, WITHOUT INCIDENCE. PT. IS NOW A/A/O AND DENIES ANY PAIN OR DISCOMFORT AT THIS TIME. PT. HAD SUCCESSFULL ERCP YESTERDAY BUT HAS HAD A LOW GRADE TEMP SINCE PROCEDURE WITH TMAX 99.7 PT. IS NOTED TO MAE'S AND SLURRED SPEECH IS FROM OLD CVA. PT. HAS BEEN AFIB 80-120'S UNSUSTAINED. PT. IS TO RECEIVE I.V. DIGOXIN TODAY. CVP HAS BEEN AND VIA RIGHT A-LINE B/P HAS BEEN STABLE 90'S-120'S/40-60'S. PULSES ARE EASILY PALPABLE. AM LABS ARE PENDING. RESP; PT. HAD EXHIBITED BIBASILAR CRACKLES, BUT THESE HAVE SINCE CLEARED, WITH ALL LUNG SOUNDS CLEAR. PT. IS PRESENTLY SATING >97% ON ROOM AIR, WITH RESP RATE CONTROLLED. PT. HAS BEEN NPO SINCE PROCEDURE, WITH TEAM TO RE ADDRESS NUTRITION THIS AM. BOWEL SOUNDS ARE EASILY AUDIBLE IN ALL QUADRANTS WITH NO STOOL NOTED DURING THIS SHIFT. SUGARS HAVE NOT REQUIRED COVERAGE. FOLEY CATHETER REMAINS IN PLACE DRAINING >50CC/HR OF CLEAR YELLOW URINE. PT. COOCYX REGION REMAINS SLIGHTLY REDDENED WITH NO BREAKDOWN NOTED. PT. HAS BEEN ABLE TO REPOSITION HIMSELF AND SKIN CARE PROVIDED. PT. REMAINS A FULL CODE WITH PLANS TO MONITOR LABS CLOSELY FOR RESOLVING PANCREATITIS. PT. HAD EFFECTIVE ERCP YESTERDAY WITH REMOVAL OF SEVERAL GALL STONES. SON AND DAUGHTER HAVE CALLED ON PREVIOUS SHIFT. WIFE DIED TWO WEEKS AGO, HE CONTINUES TO MOURN AND BECOMES TEARY EYED FROM TIME TO TIME. CONTINUED SUPPORT PROVIDED.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-04-09 00:00:00.000",
"description": "Report",
"row_id": 1467778,
"text": "0700-1300 NPN:\n TRANSFER FROM MICU B/WEST TO /EAST VIA ALS, ACCOMPANIED BY RN W/O DIFFICULTY FOR ERCP ON . VERBAL REPORT GIVEN TO GI RN AND WHO WILL TAKE OVER CARE FOR THIS PT. BELONGINGS TRNASFER W/ PT AND GLASSES, CANE/WALKER HOME W/ SON).\n\nNEURO- ALERT AND ORIENTED, MAE. SLIGHT SLURRED SPEECH. PMH OF CVA. CONTINUES TO BE LETHARGIC, AROUSES TO VOICE/TOUCH. FOLLOWS COMMANDS.\nAMMONIA LEVEL=86, CONTINUES ON LACTULOSE TID.\n\nRESP- NO DISTRESS NOTED. 97-99% ON 1L N/C. LS=BIBAS CRACKLES. PT DENIES SOB. PMH OF CHF. AM CXR SHOWED CONGESTION.\n\nCV- CHRONIC AFIB @ 90-130. DIG LEVEL=0.6, IV DOSE 0.25MG GIVEN IN GI UNIT, PT MISSED AM PO DOSE. MAP ABOVE 65, APPROX 75-90. ORDER FOR LEVOPHED NEVER STARTED. CVP=. LACTATE TRENDING DOWN, 1.2 THIS AM. NO SEPTIC PROTOCOL AT THIS TIME. AFEBRILE.\n\nGI/GU- ABD SOFT/NONDISTENDED. PRESENT BS, NO BM. DENIES ABD PAIN. SLIGHT NAUSEA X1, VOMITED SM AMT AND TX W/ ANZEMET IN GI UNIT W/ GOOD EFFECTS. NPO STATUS MAINTAINED AFTER MN EXCEPT MEDS. FOLEY CATH D/S/P DRAINING ADEQ AMTS AMNER URINE 40-100CC/HR. CRI 1.2-1.6. INSULIN GTT CURRENTLY @ 2U/HR. FS=108-156.\n\n PT RESIDING W/ DAUGHTER AND SON ALTERNATING BETWEEN AT THIS TIME, PT WAS PREVIOUSLY INDEP LIVING W/ WIFE. WIFE PASSED AWAY 2 WEEKS. POSSIBLY WILL NEED SOCIAL SERVICES/CASE MANAGEMENT.\n\nPLAN- GI STAFF TO GIVE VERBAL REPORT TO R/T ERCP FINDINGS. MONITOR FLUID STATUS, NFB 4.7 LITERS POSITIVE. CONTINUE INSULIN GTT TO TITRATE FS 120. FOLLOW UP LYTES/LACTATE/AMMONIA LEVEL. CONTINUE LACTULOSE TID. IV ABX THERAPY. CONSULT SOCIAL WORK.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-04-09 00:00:00.000",
"description": "Report",
"row_id": 1467779,
"text": "Shift Summary\nArrived s/p ERCP w/ spincterotomy from GI suite as transfer from MICU-B. Baseline assessment with lethargy r/t PMH hepatic encephalopathy r/t cryptogenic cirrhosis and increased ammonia levels of 86. Slighty increased sedative effect r/t fentanyl, versed and propofol for procedure.\n\nN: Mentation intact on arrival, oriented x3 now with decreased lethargy, remains sleepy. Pt shaking d/t cold chills vs. rigors on arrival now virtually gone. PERRL. Equal bilateral strength, assissts with turning. PMH CVA with no residual.\n\nCV: Baseline afib w/ DDD pacemaker HR100-110 and no ectopy. AM dig level .6 R IJ presep cath with CVP 7-9. R radial aline BP 140s/60s. No edema. Systolic murmur. No c/o CP or discomfort. PIV cath x 2 R AC 18g and L AC 20g.\n\nR: No c/o SOB or on 1L O2 per NC. RR 16-20 with sats 100%. LS clear bilateral upper lobes and crackles bibasilarly.\n\nGI: Abdomin nontender soft and flat. BS + x4. Strict NPO.\n\nGU: Foley cath with good UOP 100-200cc/hr clear yellow.\n\nSkin: Stage one coccyx decub, OTA.\n\nRSSI coverage off insulin drip x4hours. FSG 126.\n\nDaughter home for the night, at bedside after procedure. Tearful with emotional support offered r/t recent unexpected death of mother 2wks ago and concern over continued ailing health of father.\n\n\n"
}
] |
19,267 | 117,996 | 80 year-old female with CAD, CHF, transferred from OSH for NSTEMI and CHF causing respiratory failure. The patient was transferred intubated and on a ventilator. Cardiac catheterization revealed severe 3-vessel disease. The patient's anatomy was not suitable for PCI and cardiac surgery declined due to poor targets. Echocardiogram revealed ischemic cardiomyopathy with worsened ejection fraction of %. The patient was not a candidate for IABP due to severe PVD involving the aortoiliac system. The patient's family was made aware of her poor prognosis. The patient was initially managed in the CCU with lasix gtt despite worsening creatinine. The patient did not improve after 24 hours and blood pressure was tenuous. The health care proxy and family were made aware of the poor prognosis. After discussion with the family, the goals of care were changed to comfort. The patient expired at 13:15. | rsbi deferred d/t hemodynamic status.gi: ogt clamped. FINAL REPORT ONE-VIEW CHEST DATED COMPARISON: One-view chest dated . Normal LV inflow pattern for age.TRICUSPID VALVE: Physiologic TR. Vascular engorgement and perihilar haziness are present consistent with mild CHF. Moderate (2+)mitral regurgitation is seen. vap ongoing.gi: ogt confirmed by cxr. There is mild global rightventricular free wall hypokinesis. wbc 19.1labs: bs 174 received 2 u humulog. FINAL REPORT PORTABLE CHEST OF . abd soft hypoactive bs. creat 1.7. course/crackles bilat 1/4^ cxr completed. Unchanged retrocardiac airspace opacity, likely atelectasis. bs course w exp wheezes and crackles noted. Trabeculated LV apex. 7:05 AM CHEST (PORTABLE AP) Clip # Reason: Evaluate for interval change. She has expiratory wheezes and some course BS. cxr showed chf. Heparin was shut off at 0930 and swan and venous sheath was pulled at 1215. Wedge 40 and pt received lasix iv. Overall left ventricular systolic function is severelydepressed with global hypokinesis and akinesis of the distal LV and apex.Right ventricular chamber size is normal. iv sites replaced. Once she is weaned and extubated she will not be reintubated.A: hypotensive/occasional aggitation/swan outP: PTT due 2130. borderline bp's/ team notifed. low dose dopamine trialed but hr > 100. currently map's 60-61 pad's 30-35, cvp 16-20 initial set of data co 3.5, ci 1.91, svr 823. mv sat 52. ck , mb 131, troponin 4. heparin gtt started @ 900u/hr initial ptt 91 heparin held ptt rechecked and heparin restarted. versed gtt started. abd soft distended. presented to osh on w sob. There is unchanged blunting of both costophrenic angles which may be secondary to small bilateral pleural effusions versus pleural thickening. pt was made dnr. Mildly thickened aortic valveleaflets.MITRAL VALVE: Mild mitral annular calcification. The retrocardiac airspace opacities is again demonstrated which likely represents atelectasis. INDICATION: Acute MI and abnormal breath sounds. ccu npn 7p-7as: pt intubated/mech ventcv/gu: remains in nsr w rare to occassional pvc's noted. pt intubated for hypoxia. Not on ABX.CV: Hr in 70s NSR with rare PVC. Preoperative assessment.Height: (in) 62Weight (lb): 160BSA (m2): 1.74 m2BP (mm Hg): 110/60HR (bpm): 84Status: InpatientDate/Time: at 19:16Test: Portable TTE (Focused views)Doppler: Limited Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:RIGHT ATRIUM/INTERATRIAL SEPTUM: The IVC is normal in diameter with <50%decrease during respiration (estimated RAP 11-15mmHg).LEFT VENTRICLE: Normal LV wall thicknesses and cavity size. am ptt 86.6 rate decreased to 700u/hr @ 0530.resp; mech vent # 7.5 @ 19 l. equal/bilat ant bs. Sinus rhythmLate R wave progression consider anteroseptal infarct - age undeterminedAnterolateral ST-T changes offer additional evidence of ischemiaGeneralized low QRS voltagesClinical correlation is suggested CCU NSG NOTE: ALT IN CV/RI MIO: For complete VS see CCU flow sheet. transfered to on to cath. Moderate (2+) MR. [Dueto acoustic shadowing, the severity of MR may be significantlyUNDERestimated.] lasix 160mg iv given w fair responce. Mild global RV free wall hypokinesis.AORTIC VALVE: ?# aortic valve leaflets. INDICATION: Acute MI. Nasogastric tube is demonstrated with distal tip excluded from view. Endotracheal tube and nasogastric tube are in standard position. PAPs 40-50s/23-28 with RA . fentanyl gtt added as pt having breakthrough agitation. Left ventricular function. # 7.5 @ 19 l equal bilat ant bs. initial ck's flat, but bumped to 1796, troponin 34. st depressions noted in inf leads. l groin c/d ft bilat wrm pulses dopller bilat + r brachial site c/d + rad pulsess noted. Plan to wean down ventilatory support. freq turning and skin care.id: afebrile wbc down to 12.0 temp max 98.2 no abx @ presentneuro: on initial rounds pt agitated, pulling at arms and restraints. She has diminished bowel sounds. Her last CO was 3.6/1.9/844. 7:55 PM CHEST (PORTABLE AP) Clip # Reason: Assess volume status. Unchanged small bilateral pleural effusions versus pleural thickening. She was suctioned for small to mod amts of thick tan sputum ~ Q3-4hr. Cardiac silhouette is within normal limits in size, and the aorta is calcified. 7:56 AM CHEST (PORTABLE AP) Clip # Reason: Assess for interval change. no stool noted con't on ppi.gu: poor u/o despite lasix gtt. pt moving all ext. biting on ett. , RRT Myocardial infarction. REASON FOR THIS EXAMINATION: Assess volume status. Within the right upper lobe, a new focal opacity has developed with associated slight elevation of the minor fissure. prn boluses of fentanyl. ccu npn 7p-7acv: remains in nsr w hr 68-74 no veanoted. R brachial cath site continues to ooze. Features suggesting mild CHF with no evidence for PTX or focal consolidation. fentanyl 25mcg bolus given w adequate sedation. received lasix, solumedrol adm to icu. A Swan-Ganz catheter is seen from the inferior approach, distal tip now overlying the main pulmonary artery outflow tract. FINDINGS: Single frontal radiograph of the chest labeled supine demonstrates an ET tube unchanged in position. FINAL REPORT PORTABLE CHEST ON AT 20:09. follow hct. for now she remains on current gtt's. follow i/o con't per nsg judgement. There is some mild blunting at the CP angles consistent with small pleural effusions and some distension of pulmonary vasculature, findings consistent with an element of fluid overload. | 12 | [
{
"category": "Radiology",
"chartdate": "2188-02-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 953119,
"text": " 7:05 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for interval change.\n Admitting Diagnosis: MYOCARDIAL INFARCTION\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with CAD with acute MI, CHF, intubated.\n REASON FOR THIS EXAMINATION:\n Evaluate for interval change.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST OF .\n\n COMPARISON: .\n\n INDICATION: Acute MI.\n\n Endotracheal tube and nasogastric tube are in standard position. Cardiac\n silhouette is mildly enlarged but stable in size. Vascular engorgement and\n perihilar haziness are present consistent with mild CHF. Within the right\n upper lobe, a new focal opacity has developed with associated slight elevation\n of the minor fissure. This is most likely due to an area of atelectasis but\n aspiration should also be considered in the appropriate clinical setting.\n Bibasilar retrocardiac opacities are likely due to atelectasis, and there are\n probable small pleural effusions.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2188-02-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 953047,
"text": " 7:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Assess for interval change.\n Admitting Diagnosis: MYOCARDIAL INFARCTION\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with CAD with acute MI, CHF, intubated.\n REASON FOR THIS EXAMINATION:\n Assess for interval change.\n ______________________________________________________________________________\n FINAL REPORT\n ONE-VIEW CHEST DATED \n\n COMPARISON: One-view chest dated .\n\n INDICATION: 80-year-old male with CAD and acute MI, CHF, intubated, evaluate\n for interval change.\n\n FINDINGS: Single frontal radiograph of the chest labeled supine demonstrates\n an ET tube unchanged in position. Nasogastric tube is demonstrated with\n distal tip excluded from view. A Swan-Ganz catheter is seen from the inferior\n approach, distal tip now overlying the main pulmonary artery outflow tract.\n There is unchanged blunting of both costophrenic angles which may be secondary\n to small bilateral pleural effusions versus pleural thickening. There is no\n evidence of pneumothorax. There is no pulmonary edema or free air. The\n retrocardiac airspace opacities is again demonstrated which likely represents\n atelectasis.\n\n IMPRESSION:\n 1. Unchanged retrocardiac airspace opacity, likely atelectasis.\n 2. Unchanged small bilateral pleural effusions versus pleural thickening.\n 3. Swan-Ganz catheter with distal tip overlying the main pulmonary artery\n outflow tract.\n\n"
},
{
"category": "Radiology",
"chartdate": "2188-02-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 953024,
"text": " 7:55 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Assess volume status.\n Admitting Diagnosis: MYOCARDIAL INFARCTION\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with CAD with acute MI, CHF, intubated.\n REASON FOR THIS EXAMINATION:\n Assess volume status.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST ON AT 20:09.\n\n INDICATION: Acute MI and abnormal breath sounds.\n\n FINDINGS:\n\n An ETT is seen with the tip 4.2 cm above the carina. A right central venous\n catheter courses from below and is seen extending through the cardiac\n silhouette with tip in the pulmonary outflow tract. An NGT is visualized with\n its tip in the expected location of the antrum. There is some mild blunting\n at the CP angles consistent with small pleural effusions and some distension\n of pulmonary vasculature, findings consistent with an element of fluid\n overload. No focal consolidation is visualized. Cardiac silhouette is within\n normal limits in size, and the aorta is calcified.\n\n Features suggesting mild CHF with no evidence for PTX or focal consolidation.\n Followup is recommended.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2188-02-23 00:00:00.000",
"description": "Report",
"row_id": 1516429,
"text": "Resp Care\nPt remains intubated on CMV, no vent changes. Plan to continue with current tx, wean in AM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2188-02-24 00:00:00.000",
"description": "Report",
"row_id": 1516430,
"text": "ccu npn 7p-7a\n\ncv: remains in nsr w hr 68-74 no veanoted. borderline bp's/ team notifed. sbp 80-90 w map's 55-60. con't on heparin @ 850u/hr. am ptt 86.6 rate decreased to 700u/hr @ 0530.\n\nresp; mech vent # 7.5 @ 19 l. equal/bilat ant bs. o2 sats 98-100%. current settings ac 40%,600x12,5 rate decreased from 14-12. am abg 7.40,40,90,0,26, 96%. suctioned for thick yellow secretions. bs course w exp wheezes and crackles noted. con't on mdi's. rsbi deferred d/t hemodynamic status.\n\ngi: ogt clamped. abd soft hypoactive bs. no stool noted con't on ppi.\n\ngu: poor u/o despite lasix gtt. lasix @ 10mg/hr u/o 20-25cc/hr los neg 625. creat this am 2.4\n\nskin: r groin c/d eccymotic. l groin c/d. arms w mild bruising likely d/t blood draws and iv's. coccyx slightly red but intact. freq turning and skin care.\n\nid: afebrile wbc down to 12.0 temp max 98.2 no abx @ present\n\nneuro: on initial rounds pt agitated, pulling at arms and restraints. biting on ett. attempting to talk around ett and picking up head off bed. attempted bolus of fentanyl but iv's leaking. iv sites replaced. fentanyl 25mcg bolus given w adequate sedation. pt will respond to voice and painfull stimuli. opens eyes. can follow commands but inconsistent. pupils 2mm brisk. mae. has breakthrough agitation esp when family present and she is aware of surrounds and family in room. fentanyl ^ 100mcg and versed currently @ 9mg. wrist restraints for safety.\n\nlabs: ptt this am 86.6 rate decreased to 700u/hr @ 0530\n bs 142,132 no coverage per ssi\n hct this am 25.8 team notifed.\n\nsocial; family present 2 bedside, but pt appears more agitated when they are there and she hears there voice. I have suggested to them that only two visitors come @ a time limiting their visits. family in solarium and one visitor staying w pt. the con't to ask appropriate questions and they are very appreciative.\n\np: con't talks and communication efforts w family regarding grave condition. support them as needed. follow i/o con't per nsg judgement.\n"
},
{
"category": "Nursing/other",
"chartdate": "2188-02-24 00:00:00.000",
"description": "Report",
"row_id": 1516431,
"text": "CCU NSG NOTE: DEATH NOTE\nO: PT had sedation shut off at 0730 with plans of starting propofol but she did not wake up. She was breathing and went to CPAP 5/5 and was breathing at a rate of with sats in the high 90s. At ~10am she dropped her heart rate and went into a ventricular escape rhythm with decreasing BP. All family members arrived and patient died at ~1305. Family appreciative of care given. Autopsy declined.\n"
},
{
"category": "Nursing/other",
"chartdate": "2188-02-23 00:00:00.000",
"description": "Report",
"row_id": 1516426,
"text": "ccu npn 7p-7a\n\ns: pt intubated/mech vent\n\ncv/gu: remains in nsr w rare to occassional pvc's noted. hr 84-86. sbp 84-99 w map's 58-65. occassional borerline map's 56-58. team aware, but plan at this point is to observe, no pressors yet for fear of worsening cad,^ hr. low dose dopamine trialed but hr > 100. currently map's 60-61 pad's 30-35, cvp 16-20 initial set of data co 3.5, ci 1.91, svr 823. mv sat 52. ck , mb 131, troponin 4. heparin gtt started @ 900u/hr initial ptt 91 heparin held ptt rechecked and heparin restarted. lasix 160mg iv given w fair responce. started on lasix gtt now gently titrated to 10mg. creat 1.7. 864cc. u/o 50-100cc/hr. current echo 10-20% + mr\n\nsocial: family spoke w medical team. based on pt current status and pt wished per hcp(daughter). pt was made dnr. family would like emphasis on comfort. for now she remains on current gtt's. the family would like to speak w attending this am and discuss further poc's/ pt outcomes. they ask many appropriate questions and are very involved w pt and her care. they are very receptive towards teaching and appreciate all input. family wishes no further invasive lines. they will further discuss use of pressors today w md's\n\nresp; pt remains mech vent. ac 40%,600x14,5. # 7.5 @ 19 l equal bilat ant bs. course/crackles bilat 1/4^ cxr completed. started on alb/atv mdi's suctioned for thick yellow secretions. minimal oral secretions noted. vap ongoing.\n\ngi: ogt confirmed by cxr. on lis draining bilious drainage. abd soft distended. + bs + flatus no stool con't on colace. senna if needed.\n\nskin: intact r groin ( swan site) w small ooz now stable. l groin c/d ft bilat wrm pulses dopller bilat + r brachial site c/d + rad pulsess noted. r hand warm\n\nneuro; awake and alert on admission. attempting to mouth words. versed gtt started. fentanyl gtt added as pt having breakthrough agitation. prn boluses of fentanyl. pt moving all ext. pupils 2mm brisk/equal. fentanyl @ 50mcg/hr and versed @ 7 mg/hr wrist restraints for safety.\n\nid: afebrile. ua obtained and sent. wbc 19.1\n\nlabs: bs 174 received 2 u humulog.\n k+ 4.7\n mag 2.4\n hct 29.8,29.2 md \n plt 287\n\na/p: 80 yr old female W pmh cad,chf,copd. presented to osh on w sob. cxr showed chf. pt intubated for hypoxia. received lasix, solumedrol adm to icu. initial ck's flat, but bumped to 1796, troponin 34. st depressions noted in inf leads. transfered to on to cath. 80% lm, 80% rca,lad and lcx noted. pt refused by ct d/t poor target sites. (pt has hx aortoiliac, iabp also deferred) pt also poor pci risk so plan is med tx best as possible. con't support and update family as needed. follow hct. am abg pending.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2188-02-23 00:00:00.000",
"description": "Report",
"row_id": 1516427,
"text": "RESPIRATORY CARE NOTE\n\nPatient received from cath lab at change of shift intubated and fully ventilated on AC settings. BLBS are somewhat coarse and diminished at bases. sxn for thick yellow secretions. ABG drawn at 0500 showed adequate ventilation and oxygenation. Plan to wean down ventilatory support.\n\n , RRT\n"
},
{
"category": "Nursing/other",
"chartdate": "2188-02-23 00:00:00.000",
"description": "Report",
"row_id": 1516428,
"text": "CCU NSG NOTE: ALT IN CV/RI MI\nO: For complete VS see CCU flow sheet. This 81y old woman with PMH of NIDDM, COPD, CAD went to OSH with SOB and was intubated. SHe RI for lg MI and was transfered to to cath lab . In lab she had severe LM dx and RCA dx. Lesion unable to be treated by surgery or intervention. Due to severe PVD cath done thru L brachial. Wedge 40 and pt received lasix iv. Transfered to CCU with groin swan in place for medical management. She was started on lasix and heparin gtts with versed and fentanyl for sedation. After consult with family pt DNR with no further line placement and no pressurs.\nID: Pt remains afebrile. WBC decreased to 13.6 (17.5). Not on ABX.\nCV: Hr in 70s NSR with rare PVC. BP ranging 75-93/30-40s with maps mostly in the low 50s. PAPs 40-50s/23-28 with RA . Her last CO was 3.6/1.9/844. Heparin was shut off at 0930 and swan and venous sheath was pulled at 1215. Heparin restarted at 1530 at 850u/hr. Groin is dry with no ooze but residual eccymosis. L groin site was dry and in tact with no ooze or hematoma. R brachial cath site continues to ooze. Dsg changed X 2. All pedal pulses and radial pulses dopplerable.\nRESP: Pts remains intubated on AC 14 X 600 5 PEEP 40% with sats 97-100%. She has expiratory wheezes and some course BS. She was suctioned for small to mod amts of thick tan sputum ~ Q3-4hr. She did very little overbreathing.\nRENAL: Pt conts on lasix gtt at 10mg/hr, but as filling pressures dropped, bp dropped and urine output dropped. U/O has ranged 0-45cc/hr. She is neg 180cc for the day and ~800cc LOS.\nGI: She was minimal brown flecked asp that is mildly G+. She started PPI today. She has diminished bowel sounds. No BM.\nENDO: finger sticks 119 and 139 and no SS reg insulin given.\nSKIN: Pt has areas of eccymosis on arm, but no breakdown on arms or pressure points.\nMS: PT remains sedated on midazalam 9mg/hr and fentanyl 75 mic/hr. She has been rouseable, but only inconsistently follows commands. She became aggitated twice, pulling at restraints and trying to grab tube and required bolus sedation.\nSOCIAL: family is united in goal of keeping their mother comfortable and knowing she would not like to be kept alive on ventilator, or in situation where she could not remain independent. The last daughter will be arriving tomorrow. The goal is for pt to recover as best she is able from MI, and to be as unloaded at possible to maximise her chances for success. Once she is weaned and extubated she will not be reintubated.\nA: hypotensive/occasional aggitation/swan out\nP: PTT due 2130. Continue to keep careful I & O. CONt with vap bundle and frequent mouth care. Support pt and family and ensure pt comfort.\n"
},
{
"category": "Echo",
"chartdate": "2188-02-22 00:00:00.000",
"description": "Report",
"row_id": 84065,
"text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure. Coronary artery disease. Left ventricular function. Myocardial infarction. Preoperative assessment.\nHeight: (in) 62\nWeight (lb): 160\nBSA (m2): 1.74 m2\nBP (mm Hg): 110/60\nHR (bpm): 84\nStatus: Inpatient\nDate/Time: at 19:16\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The IVC is normal in diameter with <50%\ndecrease during respiration (estimated RAP 11-15mmHg).\n\nLEFT VENTRICLE: Normal LV wall thicknesses and cavity size. No LV\nmass/thrombus. Trabeculated LV apex. Severely depressed LVEF. No resting LVOT\ngradient.\n\nRIGHT VENTRICLE: Normal RV chamber size. Mild global RV free wall hypokinesis.\n\nAORTIC VALVE: ?# aortic valve leaflets. Mildly thickened aortic valve\nleaflets.\n\nMITRAL VALVE: Mild mitral annular calcification. No MS. Moderate (2+) MR. [Due\nto acoustic shadowing, the severity of MR may be significantly\nUNDERestimated.] Normal LV inflow pattern for age.\n\nTRICUSPID VALVE: Physiologic TR. Indeterminate PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor parasternal views.\nSuboptimal image quality - ventilator. Emergency study performed by the\ncardiology fellow on call.\n\nConclusions:\nThe estimated right atrial pressure is 11-15mmHg. Left ventricular wall\nthicknesses and cavity size are normal. No masses or thrombi are seen in the\nleft ventricle. Overall left ventricular systolic function is severely\ndepressed with global hypokinesis and akinesis of the distal LV and apex.\nRight ventricular chamber size is normal. There is mild global right\nventricular free wall hypokinesis. The number of aortic valve leaflets cannot\nbe determined. The aortic valve leaflets are mildly thickened. Moderate (2+)\nmitral regurgitation is seen. [Due to acoustic shadowing, the severity of\nmitral regurgitation may be significantly UNDERestimated.] The pulmonary\nartery systolic pressure could not be determined. There is no pericardial\neffusion.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2188-02-23 00:00:00.000",
"description": "Report",
"row_id": 226461,
"text": "Sinus rhythm\nLate R wave progression consider anteroseptal infarct - age undetermined\nAnterolateral ST-T changes offer additional evidence of ischemia\nGeneralized low QRS voltages\nClinical correlation is suggested\n\n"
},
{
"category": "ECG",
"chartdate": "2188-02-24 00:00:00.000",
"description": "Report",
"row_id": 226462,
"text": "Technically difficult study\nSinus rhythm\nConsider old anteroseptal infarct\nLeft atrial abnormality\nInferior/lateral ST-T changes may be due to myocardial ischemia\nLow QRS voltages in limb leads\nSince pervious tracing, inferolateral ST-T wave abnormalities more marked\nClinical correlation is suggested\n\n"
}
] |
9,855 | 168,096 | This is an 83 yo woman with history of breast cancer, HTN, and high cholesterol, and DVTs on Coumadin who presents with headache x 48 hours and emesis. The patient was admitted to the neuro ICU with an intracranial hemorrhage. After 3 days she was transferred to the floor. . 1. Neurological: Intracranial hemorrhage: The neurological exam at admission was significant for a left homonomous hemianopsia and mild left leg weakness in an upper motor neuron pattern. No papilledema was seen on fundi exam. CT showed an intracerebral hemorrhage in the right parietal lobe with some surrounding edema. There is a question of two other hyperdensities in bilateral frontal lobes as well. Repeat head CT 6 hrs later is stable, without signs of enlargement, hydrocephalus, or shift. There was a question of whether the intracranial bleed was into a mass lesion. MRI of the head with and without gadolinium did not demonstrate a mass, but follow-up MRI in weeks was recommended to re-evaluate once hemorrhage has partially resorbed. Given the breakthrough of the hemorrhage into the ventricular system, the patient was monitored closely for signs of hydrocephalus. Neurosurgery was consulted and recommended no operative management. They recommended beginning a mannitol drip, for a few days only, and to start the patient on dilantin for seizure prophylaxis. Patient had been started on phenytoin for seizure prophylaxis, at a dose of 100 mg tid. Patient was sub therapeutic in dilantin level and did not have any seizures during this time. She also developed a rash to dilantin. Therefore, dilantin was discontinued. An EEG showed no epileptiform discharges but was remarkable for mild encephalopathy. Patient's left homonymous hemianopsia remained stable and the encephalopathy, noticeable by inattentiveness and sleepiness, slowly improved. . 2. Cardiovascular: While in the ICU, patient's elevated blood pressure was managed with labetalol gtt (goal <140). She was then weaned off the drip and started on atenolol 100 mg. She ruled out for MI. No events were noted per telemetry. Her blood pressure goal was <140 SBP. . 3. Hematology: a) The patient was on Coumadin for DVT. The supra therapeutic INR was decreased by multiple units of FFP and Vit-K. In the setting of history of hypercoagulability, and a new RLE DVT, an IVC filter was placed by vascular surgery, as Coumadin is contraindicated at this point. Given a positive family history for DVT and PE, a hypercoagulable workup should be considered. b) The patient was noted to have an increased WBC. She was seen by Hematology/Oncology for rule out CLL. Peripheral blood flow cytometry study revealed involvement by a CD5 positive, CD23 positive, CD20 (dim) B-cell lymphoproliferative disorder, immuonphenotypically consistent with chronic lymphocytic leukemia. There was no recommendation for treatment at the present time, however, WBC count will be followed as an outpatient. . 4. Pulmonary: Chest XR on admission demonstrated hilar fullness which was concerning for mass. A CT-chest showed no evidence for pulmonary or hilar masses. . 5. ID: The patient was febrile during the acute phase, and was found to have an elevated white count and a urinalysis suggesting a UTI. The patient had a foley catheter in place for the first 5 days of her hospital stay. The patient was treated with levofloxacin 500 mg QD. Also, due to the possibility of line infection, her left subclavian central line which was placed at the time of admission, was removed and the tip was sent for culture. Access was maintained through a peripheral IV in her right arm. . 6. Renal: The patient was noted to have a renal cyst on Chest-CT. The patient is known to have this cyst for 4 years which has not changed in size. Primary care doctor will repeat a MR abdomen with contrast in a few months. . 7. FEN: Patient was evaluated by Speech and Swallow after the acute phase, and her diet was advanced accordingly. She tolerated a cardiac diet. . 8. Disposition: PT/OT consult obtained, recommended short term rehabilitation. Placed at center. . 9. FULL CODE. HCP = (daughter) . | Please MRI head w and w/o gadolinium. HR 59-66.RESP: LS Clear and diminished. URINE CX PENDING.A-STABLE.P-CON'T WITH CURRENT PLAN. Right hilar fullness, which may indicate lymphadenopathy. TECHNIQUE: T1 sagittal images were obtained. TOL WELL.ENDO-SSRI. Comparison is made to a portable chest x-ray of , which described fullness of the right hilum. FINDINGS: This is a limited study with motion degraded T1 sagittal images obtained. mannitol iv q6hr. CX FROM LAST NOC PENDING.A-STABLE.P-CON'T WITH CURRENT PLAN. Note is made of small dependent bilateral pleural effusions. Note is made of post-radiation changes within the right lung anteriorly with minimal fibrosis subpleurally. iv dilantin given. repeat mri this am. C+DB ENC.GI-ABD SOFT, NT/ND. T1 axial and coronal images were obtained following gadolinium. Minor atelectatic changes are noted adjacent to the pleural effusions and in the inferior aspect of the lingula. IMPRESSION: Interval evolution of blood products in the intraaxial hematoma in the right temporoparietal region with unchanged surrounding edema. PULM HYGIENE. LABETOLOL GTT OFF. Noprevious tracing available for comparison.TRACING #1 Left anterior fascicular block. The trachea is deviated to the right. Finally, a punctate calcification is noted centrally in the right breast, most likely a benign finding. Mild cardiomegaly with left atrial dilatation indicating cardiac decompensation. NEURO CHECKS. NEURO CHECKS. SKIN W+D. SKIN W+D. FINDINGS: Again an area of intraparenchymal hemorrhage is identified in the right temporoparietal region with surrounding edema. Subtle chronic intraparenchymal blood products in the left frontal subcortical white matter. Assess patency. PT WITH FINE TREMOR INHANDS.CV-HR 60-70'S, NSR. Now for IVC filter. For IVC filter , h/o BL DVTs. perla #3 blilaterally. LS CTA. The right hilar contour appears full, which may indicate lymphadenopathy. A small area of the hemorrhage demonstrate T1 hyperintensity prior to gadolinium administration. iv dilantin and iv mannnitol given. dr. aware (sicu resident). focus hemodynmicsdata: alert and oriented x2. focus hemodynicsdata: neuro: alert and oriented x2. Sinus rhythm. Sinus rhythm. HCT STABLE. CXR with suspcision of hilar lympadenopathy. NARD NOTED. NARD NOTED. IMPRESSION: Stable size and appearance of dominant right intraparenchymal hemorrhage, with slight increased prominence of subarachnoid blood at the left vertex and adjacent to the falx. IMPRESSION: Acute right temporoparietal intraaxial hematoma without abnormal enhancement in this region or in other parts of the brain. There are dependent small bilateral pleural effusions present. NSG NOTESEE FLOWSHEET FOR SPECIFICS.NEURO-PT A+OX3. PERRL. PERRL. PROCEDURE. REASON FOR THIS EXAMINATION: evaluation of progression/resolution of bleed No contraindications for IV contrast FINAL REPORT INDICATION: Assess for change in hemorrhage. DFDkq FINDINGS: Comparison was made with the previous CT examination of . Again small areas of chronic blood products are seen in the left frontal white matter and in the left occipital region as well as in the left middle cerebellar peduncle. FINDINGS: AP UPRIGHT CHEST. There is hypodensity in the corona radiata of both cerebral hemispheres, and in the subinsular white matter on the left, as well as the left internal capsule, right internal capsule, as well as foci of calcification in both internal capsules. DR. New left subclavian catheter projects over the SVC. DENIES CARDIAC COMPLAINTS. complanins of dry nasal passage. The right common femoral vein is patent. PBOOTS ON. PBOOTS ON. The area of hemorrhage is identified in the right posterior temporoparietal region as seen on the CT of . IMPRESSION: Normal MRA of the head. LINE PLACEMENT Clip # Reason: Please eval for line placement/PTX. +PP. +PP. neruo is also aware mri not done.,cardiac: pt remains on labetolol for bp control and is currently on 2.0mg.min, goal of sbp less than 130.resp: breath sound remain clear and pt sat 100% on 3l nc.gi: pt remains npo and postive bowel sounds.gu: urine output remains adequate.labs: transfused with 1unit of ffp and repeat inr 1.1. hct 26.5 and Dr. aware and repeat drawn. ADAT IF NO IVC FILTER PLACEMENT. TOL WELL.COMFORT- PRN FOR C/O HIP ACHES.ENDO-SSRI. In the distal superficial femoral vein, echogenic thrombus is seen within the vein, and the vein is not compressible. Waxes and wanes confused and then will be a&ox3. tremors MD's aware. No contraindications for IV contrast FINAL REPORT CT WITH CONTRAST ON . Intraventricular hemorrhage is again noted, as are small foci of blood along the falx. IMPRESSION: Focal partially occlusive thrombus seen within the distal right superficial femoral vein. +BS. +BS. There is surrounding edema visualized with some mass effect on the left lateral ventricle. Mild changes of small vessel disease are again seen. nsg noteSEE FLOWSHEET FOR SPECIFICS.NEURO-PT MOSTLY ORIENTED X3. There is scoliosis in the thoracic spine. Susceptibility weighted images demonstrate a small area of chronic hemorrhage in the left frontal subcortical region. C+DB ENC. TECHNIQUE: T1 sagittal and FLAIR, T2 susceptibility, and diffusion axial images of the brain were acquired. FINDINGS: -scale and pulsed color Doppler images of the right common femoral, greater saphenous, superficial femoral, popliteal, and left common femoral veins were performed. IMPRESSION: 1. IMPRESSION: 1. IMPRESSION: 1. Hemorrhage is again seen as seen on the CT of in the right posterior temporoparietal region. Right bundle-branch block. LS CLEAR. The heart is mildly enlarged, and coronary artery calcifications are noted. multiple ecchymotic areas on arms from iv infiltration.respnnse: monitor closelly Again seen are several tiny foci of hemorrhage adjacent to the falx, unchanged from prior studies. | 19 | [
{
"category": "Radiology",
"chartdate": "2122-07-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 877175,
"text": " 6:23 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate, mass\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with hx of breast CA p/w ICH from OSH and elevated white\n count w/low grade fever.\n REASON FOR THIS EXAMINATION:\n eval for infiltrate, mass\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Breast cancer and intracranial hemorrhage. Fever.\n\n COMPARISON: No previous studies.\n\n FINDINGS: AP UPRIGHT CHEST. The heart is mildly enlarged. The trachea is\n deviated to the right. The right hilar contour appears full, which may\n indicate lymphadenopathy. Interstitial markings are minimally increased\n bilaterally, which may represent pulmonary vascular congestion, atypical\n infection, or an inflammatory process. Bilateral lymphangitic spread of tumor\n is less likely. Correlation with any existing outside prior studies is\n recommended. There is no pulmonary consolidation, pleural effusion or\n pneumothorax. There is scoliosis in the thoracic spine.\n\n IMPRESSION:\n 1. Right hilar fullness, which may indicate lymphadenopathy.\n 2. Minimally increased interstitial markings bilaterally, which may represent\n interstitial pulmonary edema, atypical pneumonia, or an inflammatory process.\n Correlation with any existing outside studies is recommended.\n\n DFDkq\n\n"
},
{
"category": "Radiology",
"chartdate": "2122-07-18 00:00:00.000",
"description": "MR HEAD W/O CONTRAST",
"row_id": 877202,
"text": " 2:26 AM\n MR HEAD W/O CONTRAST; -52 REDUCED SERVICES Clip # \n -59 DISTINCT PROCEDURAL SERVICE\n Reason: r/o metastatic disease. Please MRI head w and w/o gadolinium\n Admitting Diagnosis: ICH;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with h/o breat CA no w/ intracranial bleed\n REASON FOR THIS EXAMINATION:\n r/o metastatic disease. Please MRI head w and w/o gadolinium.\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: MRI BRAIN\n\n CLINICAL INFORMATION: The patient with intraparenchymal hemorrhage, for\n further evaluation.\n\n TECHNIQUE: T1 sagittal images were obtained. The patient was unable to\n continue and the examination could not be completed.\n\n FINDINGS: This is a limited study with motion degraded T1 sagittal images\n obtained. The area of hemorrhage is identified in the right posterior\n temporoparietal region as seen on the CT of .\n\n IMPRESSION: Limited study without diagnostic information. Hemorrhage is\n again seen as seen on the CT of in the right posterior temporoparietal\n region.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2122-07-20 00:00:00.000",
"description": "R UNILAT LOWER EXT VEINS RIGHT",
"row_id": 877480,
"text": " 8:13 PM\n UNILAT LOWER EXT VEINS RIGHT Clip # \n Reason: r/o clot in area of R femoral vein as potential cannulation\n Admitting Diagnosis: ICH;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with intracranial hemorrhage, stable. For IVC filter ,\n h/o BL DVTs.\n REASON FOR THIS EXAMINATION:\n r/o clot in area of R femoral vein as potential cannulation site for IVC filter\n placement tomorrow.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 83-year-old with a history of lower extremity venous thrombosis.\n Now for IVC filter. Assess patency.\n\n FINDINGS: -scale and pulsed color Doppler images of the right common\n femoral, greater saphenous, superficial femoral, popliteal, and left common\n femoral veins were performed. In the distal superficial femoral vein,\n echogenic thrombus is seen within the vein, and the vein is not compressible.\n A minimal amount of flow is seen in the distal superficial femoral vein. The\n remainder of the venous structures in the right leg appears normal with normal\n compressibility, color-flow, waveforms. The left common femoral vein is also\n normal in appearance.\n\n IMPRESSION: Focal partially occlusive thrombus seen within the distal right\n superficial femoral vein. The right common femoral vein is patent.\n\n"
},
{
"category": "Radiology",
"chartdate": "2122-07-21 00:00:00.000",
"description": "CT CHEST W/CONTRAST",
"row_id": 877539,
"text": " 10:12 AM\n CT CHEST W/CONTRAST; CT 150CC NONIONIC CONTRAST Clip # \n Reason: Any evidence of lung mass or lymphadenopathy?\n Admitting Diagnosis: ICH;TELEMETRY\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with intracranial hemorrhage, h/o breast ca. CXR with\n suspcision of hilar lympadenopathy.\n REASON FOR THIS EXAMINATION:\n Any evidence of lung mass or lymphadenopathy?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT WITH CONTRAST ON .\n\n INDICATION: Breast cancer. Suspicion of hilar lymphadenopathy on chest\n x-ray.\n\n Comparison is made to a portable chest x-ray of , which\n described fullness of the right hilum. There are no prior chest CT scans for\n comparison.\n\n Multidetector CT of the chest was performed following intravenous\n administration of 100 cc of Optiray. Images were presented for review in the\n axial plane at 5-mm and 2-mm collimation and in the coronal plane at 2-mm\n collimation.\n\n Soft tissue structures of the thorax demonstrate enlargement of the main and\n central pulmonary arteries, which likely accounts for the observed hilar\n prominence on recent chest x-ray. There are small, subcentimeter hilar nodes\n bilaterally, but there are no dominant lymph nodes in this area. Numerous\n mediastinal lymph nodes are also present, measuring less than 1 cm in greatest\n short axis dimension.\n\n There are dependent small bilateral pleural effusions present. The heart is\n mildly enlarged, and coronary artery calcifications are noted. There is no\n significant pericardial effusion. Note is made of small dependent bilateral\n pleural effusions.\n\n Within the imaged portion of the upper abdomen, there is a large cyst within\n the upper pole of the left kidney, which has a lobulated contour and contains\n peripheral calcifications. It measures up to 6.8 cm in diameter. Additional\n smaller cystic lesions are noted in both kidneys, some of which are too small\n to accurately characterize by CT. A subcentimeter enhancing lesion is seen in\n the periphery of the right lobe of the liver measuring less than 5 mm in\n diameter, and too small to characterize by CT.\n\n Assessment of the lungs is limited due to respiratory motion. Note is made of\n post-radiation changes within the right lung anteriorly with minimal fibrosis\n subpleurally. Minor atelectatic changes are noted adjacent to the pleural\n effusions and in the inferior aspect of the lingula. There are numerous\n smoothly thickened septal lines which are diffusely distributed but are more\n (Over)\n\n 10:12 AM\n CT CHEST W/CONTRAST; CT 150CC NONIONIC CONTRAST Clip # \n Reason: Any evidence of lung mass or lymphadenopathy?\n Admitting Diagnosis: ICH;TELEMETRY\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n prominent in the lower lung zones than the upper lung zones.\n\n CORONAL REFORMATION IMAGES: These images confirm the presence of septal\n thickening and mild radiation fibrosis as described above.\n\n Skeletal structures demonstrate scoliosis and degenerative changes within the\n spine. Finally, a punctate calcification is noted centrally in the right\n breast, most likely a benign finding.\n\n IMPRESSION:\n 1. No evidence of right hilar mass. Observed prominence of right hilum on\n recent portable chest x-ray was due to prominent hilar vascular structures.\n\n 2. Enlargement of main and central pulmonary arteries, suggesting the\n possibility of pulmonary arterial hypertension.\n\n 3. Bilateral smoothly thickened septal lines. In the setting of dependent\n pleural effusions, this is most likely due to interstitial edema from either\n congestive heart failure or fluid overload. However, if the diagnosis is in\n doubt clinically, followup limited HRCT could be performed after diuresis to\n fully exclude lymphangitic carcinomatosis.\n\n 4. Multiple renal cysts, with a dominant 6.8 cm diameter cyst in the upper\n pole of left kidney which contains peripheral calcifications. Ultrasound may\n be helpful to confirm cystic characteristics of the remaining lesions and to\n better evaluate this complex cyst. At that time, attention to the right lobe\n of the liver may be helpful to evaluate for a possible small peripheral\n hepatic lesion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2122-07-17 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 877181,
"text": " 8:07 PM\n CT HEAD W/O CONTRAST; -77 BY DIFFERENT PHYSICIAN # \n Reason: follow R tempo-parietal intraparenchymal bleed\n Admitting Diagnosis: ICH;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 yo F w/ intraparenchymal bleed\n REASON FOR THIS EXAMINATION:\n follow R tempo-parietal intraparenchymal bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 83-year-old with a history of breast cancer and intraparenchymal\n hemorrhage.\n\n CT OF THE BRAIN WITHOUT IV CONTRAST. Comparison is made to a study performed\n at 3:40 p.m. today.\n\n FINDINGS: There has been no significant change in the extent of the large\n right temporoparietal and occipital lobe intraparenchymal hemorrhage. This\n measures approximately 3.9 x 4.7 cm, which is essentially unchanged.\n Intraventricular hemorrhage is again noted, as are small foci of blood along\n the falx. No hydrocephalus or significant shift of midline structures is\n seen.\n\n IMPRESSION:\n\n No significant change in the extent of intracranial hemorrhage.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2122-07-18 00:00:00.000",
"description": "MR HEAD W & W/O CONTRAST",
"row_id": 877222,
"text": " 10:11 AM\n MR HEAD W & W/O CONTRAST; MR CONTRAST GADOLIN Clip # \n Reason: Please eval for change/new bleeding/edema/underlying patholo\n Admitting Diagnosis: ICH;TELEMETRY\n Contrast: MAGNEVIST Amt: 12CC\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with R temporo-parietal IPH.\n REASON FOR THIS EXAMINATION:\n Please eval for change/new bleeding/edema/underlying pathology.\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: MRI BRAIN.\n\n CLINICAL INFORMATION: Patient with intraparenchymal hemorrhage, for further\n evaluation.\n\n TECHNIQUE: T1 sagittal and axial and FLAIR T2 susceptibility and diffusion\n axial images of the brain were obtained before gadolinium. T1 axial and\n coronal images were obtained following gadolinium.\n\n FINDINGS: Comparison was made with the previous CT examination of .\n\n As seen on the CT, there is an acute intraparenchymal hemorrhage identified in\n the right temporoparietal region. A small area of the hemorrhage demonstrate\n T1 hyperintensity prior to gadolinium administration. There is surrounding\n edema visualized with some mass effect on the left lateral ventricle. There\n is no evidence of slow diffusion seen in the brain to indicate acute infarct.\n Following gadolinium administration, no evidence of abnormal enhancement is\n seen in the region of hematoma or in other parts of the brain. There is no\n evidence of midline shift or hydrocephalus identified. Fluid-fluid level\n within the occipital of the left lateral ventricle indicate\n intraventricular extension of the hemorrhage. There are mild changes of small\n vessel disease seen in the periventricular white matter. Susceptibility\n weighted images demonstrate a small area of chronic hemorrhage in the left\n frontal subcortical region. Otherwise, no other areas of chronic hemorrhage\n are identified.\n\n IMPRESSION: Acute right temporoparietal intraaxial hematoma without abnormal\n enhancement in this region or in other parts of the brain. Subtle chronic\n intraparenchymal blood products in the left frontal subcortical white matter.\n In absence of enhancement in the region of hematoma, no definite underlying\n lesion is identified. The differential diagnosis includes amyloid angiopathy\n versus underlying neoplasm. Further followup in six to eight weeks is\n recommended as clinically appropriate.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2122-07-18 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 877262,
"text": " 8:37 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Please eval for line placement/PTX.\n Admitting Diagnosis: ICH;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with IPH now s/p L subclavian line placement.\n REASON FOR THIS EXAMINATION:\n Please eval for line placement/PTX.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 2043 HOURS ON \n\n HISTORY: IPH. New left subclavian line placement.\n\n IMPRESSION: AP chest compared to :\n\n Mild pulmonary edema and progression of hilar vascular enlargement. Mild\n cardiomegaly with left atrial dilatation indicating cardiac decompensation.\n New left subclavian catheter projects over the SVC. No pneumothorax,\n mediastinal widening or substantial pleural effusion.\n\n\n DR. \n"
},
{
"category": "Radiology",
"chartdate": "2122-07-25 00:00:00.000",
"description": "MR HEAD W/O CONTRAST",
"row_id": 878052,
"text": " 3:47 PM\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: 83 year old woman with history of right occipitotemporoparie\n Admitting Diagnosis: ICH;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with see above\n REASON FOR THIS EXAMINATION:\n 83 year old woman with history of right occipitotemporoparietal hemorrhage of\n unknown etiology. is there any underlying mass?\n ______________________________________________________________________________\n FINAL REPORT\n MRI OF THE BRAIN AND MRA OF THE HEAD\n\n CLINICAL INFORMATION: Patient with brain hemorrhage, rule out underlying\n abnormality.\n\n TECHNIQUE: T1 sagittal and FLAIR, T2 susceptibility, and diffusion axial\n images of the brain were acquired. 3D time-of-flight MRA of the circle of\n was obtained. Comparison was made with the previous MRI study of\n .\n\n FINDINGS: Again an area of intraparenchymal hemorrhage is identified in the\n right temporoparietal region with surrounding edema. Since the previous\n study, there has been evolution in the blood products in this region. The\n size of hematoma has remained unchanged compared to the prior study. The\n surrounding edema has also not significantly changed. There is minimal mass\n effect on the left lateral ventricle. There is no midline shift seen. Again\n small areas of chronic blood products are seen in the left frontal white\n matter and in the left occipital region as well as in the left middle\n cerebellar peduncle. There is no evidence of slow diffusion to suggest acute\n infarct associated with the hemorrhage.\n\n IMPRESSION: Interval evolution of blood products in the intraaxial hematoma\n in the right temporoparietal region with unchanged surrounding edema. Given\n the other areas of chronic hemorrhages in the left frontal and left occipital\n regions and in the left middle cerebellar peduncle, the differential diagnosis\n includes amyloid angiopathy as well as cavernous angiomas as underlying\n abnormality. Followup gadolinium-enhanced images would be helpful for further\n evaluation. Mild changes of small vessel disease are again seen.\n\n MRA OF THE HEAD:\n\n The head MRA demonstrates normal flow signal within the arteries of anterior\n and posterior circulation.\n\n IMPRESSION: Normal MRA of the head.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2122-07-23 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 877788,
"text": " 9:19 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: evaluation of progression/resolution of bleed\n Admitting Diagnosis: ICH;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with ICH, bleeding into ventricles.\n REASON FOR THIS EXAMINATION:\n evaluation of progression/resolution of bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Assess for change in hemorrhage.\n\n COMPARISONS: .\n\n TECHNIQUE: Axial MDCT images of the brain without IV contrast.\n\n FINDINGS: There has been no appreciable change in size or surrounding edema\n of the large right temporoparietal intraparenchymal hemorrhage, with extension\n into the right lateral ventricle. Blood layering in the left occipital \n has been resorbed. Again seen are several tiny foci of hemorrhage adjacent to\n the falx, unchanged from prior studies. There is subarachnoid blood and\n isolated sulcus at the extreme left vertex, new from the prior study. There\n is no hydrocephalus or shift of normally midline structures.\n\n IMPRESSION: Stable size and appearance of dominant right intraparenchymal\n hemorrhage, with slight increased prominence of subarachnoid blood at the left\n vertex and adjacent to the falx.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2122-07-17 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 877146,
"text": " 3:27 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with confirmed ICH- intraparachyal with? underlying mets\n REASON FOR THIS EXAMINATION:\n eval bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ACKe FRI 3:52 PM\n LARGE BLEED WITH EDEMA IN RT PARIETO-OCCIPITAL LOBE. MASS EFFECT, BUT NO\n SHIFT OF MIDLINE STRUCTURES. SOME INTRAVENTRICULAR EXTENSION OF BLEED INTO\n OCCIPITAL HORNS.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Query intracranial hemorrhage as seen on outside studies.\n\n TECHNIQUE: Non-contrast head CT. No prior studies are available for\n comparison.\n\n FINDINGS: There is a large intraparenchymal hemorrhage arising from the right\n posterior temporal, parietal and occipital lobes, with surrounding edema and\n mass effect, although there is no appreciable shift of midline structures.\n Extension of the hemorrhage is seen into the lateral ventricles, with layering\n in the occipital horns; additionally, small foci of subarachnoid blood are\n seen in the sulci along the falx. There is no hydrocephalus. There is\n hypodensity in the corona radiata of both cerebral hemispheres, and in the\n subinsular white matter on the left, as well as the left internal capsule,\n right internal capsule, as well as foci of calcification in both internal\n capsules. The imaged sinuses are clear. Surrounding osseous structures are\n unremarkable.\n\n IMPRESSION:\n 1. Large intraparenchymal hemorrhage arising within the right cerebrum. This\n may be secondary to amyloid angiopathy, and underlying vascular malformation\n or mass. 2. Extension of hemorrhage into lateral ventricles and subarachnoid\n space.\n\n Preliminary findings were relayed to the ED Dashboard at approximately 4\n o'clock p.m., .\n\n\n"
},
{
"category": "ECG",
"chartdate": "2122-07-17 00:00:00.000",
"description": "Report",
"row_id": 211535,
"text": "Sinus rhythm. Compared to tracing #1 no significant diagnostic change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2122-07-17 00:00:00.000",
"description": "Report",
"row_id": 211536,
"text": "Sinus rhythm. Left anterior fascicular block. Right bundle-branch block. No\nprevious tracing available for comparison.\nTRACING #1\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-07-18 00:00:00.000",
"description": "Report",
"row_id": 1392236,
"text": "admission note\nD: pt is lethargic but opens eyes tovoice and follows commands. pupils are equal and reactive and normal strength in all extremities. pt is confused to place and time. pt denies any heacache and nausea is better. attempt to get mri but pt becames anxious and claustraphobic in scanner. trying to sit up and hyperventilating. dr. aware (sicu resident). pt reeval again in the am. neruo is also aware mri not done.,\ncardiac: pt remains on labetolol for bp control and is currently on 2.0mg.min, goal of sbp less than 130.\nresp: breath sound remain clear and pt sat 100% on 3l nc.\ngi: pt remains npo and postive bowel sounds.\ngu: urine output remains adequate.\nlabs: transfused with 1unit of ffp and repeat inr 1.1. hct 26.5 and Dr. aware and repeat drawn. hct 26 and no treatment at this time.\na: continue with neuro checks. repeat mri this am. titrate labetolol for bp control.\nr: labetolol effective in controlling bp. neuro pt is more awake this am. know date and hospital\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-07-18 00:00:00.000",
"description": "Report",
"row_id": 1392237,
"text": "Nursing Note--A Shift\nPlease see Carevue for complete assessment and specifics.\n\nNEURO: Intermittently opens eyes to loud voice. Often refuses to open her eyes. PERRLA 3 and brisk. Waxes and wanes confused and then will be a&ox3. Answers some questions appropriately. Needs lots of encouragement to answer questions and follow commands. TM, SS, no drift. MAE in bed. Strong grasps. Lifts and holds LE. tremors MD's aware. More interactive before MRI scan done at 10am. Given 1mg of Ativan for MRI and has been more lethargic and slow to respond.\n\nCARDIAC: afebrile. Labetalol gtt off at 12noon, restarted at 5pm for SBP above 140 and sustained. SBP is less than 140. HR 59-66.\n\nRESP: LS Clear and diminished. productive cough scant amts of thick white secretions. SAt 97-100% on 3L NC.\n\nGI: Abd soft +BS NPO except for icechips.\n\nGU: Foley changed draining clear yellow in the morning. Changed to light pink around 5pm UCX sent.\n\nINTEG: Eccymotic and erethematous areas on arms from previous IV sites. very sore to touch. Skin fragile. Very difficult stick.\n\nPSYCH/SOCIAL: Very large family very involved with her care. Patient more interactive and responsive with family present.\n\nOTHER: MRI done at 10am, initial read shows no Mets. Started on Mannitol. sitter for impulsive behavior more apparent overnight.\n\nPLAN: Wean from Labetalol gtt, Mannitol and Dilantin, monitor lytes, Hourly neuro checks, Provide extra reassurance.\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-07-20 00:00:00.000",
"description": "Report",
"row_id": 1392241,
"text": "NSG NOTE\nSEE FLOWSHEET FOR SPECIFICS.\n\nNEURO-PT A+OX3. PT CONFUSED AT TIMES WITH DATE, BUT EASILY REORIENTED. PERRL. FOLLOWS COMMANDS. MAE. NORMAL EQUAL STRENGTH. ON PO DILANTIN.\n\nCV-HR 60-70'S, NSR. SBP MAINTAINED <160 PER TEAM. ON PO ATENOLOL. DENIES CARDIAC COMPLAINTS. SKIN W+D. +PP. PBOOTS ON. ? IVC FILTER TO BE PLACED.\n\nRESP-O2 SAT 97% ON 2LNC. LS CTA. NARD NOTED. C+DB ENC.\n\nGI-ABD SOFT, NT/ND. +BS. +RF. NPO FOR ? PROCEDURE. NO N/V.\n\nGU-VOIDING VIA FOLEY ADEQ AMTS CL YELLOW URINE.\n\nACT-OOB TO CHAIR WITH 2 ASSIST X 2 HRS. TOL WELL.\n\nCOMFORT- PRN FOR C/O HIP ACHES.\n\nENDO-SSRI. NO COVERAGE NEEDED.\n\nID-TMAX 99.8. CX FROM LAST NOC PENDING.\n\nA-STABLE.\n\nP-CON'T WITH CURRENT PLAN. NEURO CHECKS. ? ADAT IF NO IVC FILTER PLACEMENT. ENC ACTIVITY. LIKELY TX TO FLOOR WHEN BED AVAIL.\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-07-20 00:00:00.000",
"description": "Report",
"row_id": 1392242,
"text": "focus hemodynmics\ndata: alert and oriented x2. at times forgetful to the year. moves all extremities on the bed.\n\nresp: o2 on at 3 liters np. o2sat 100% no difficulty breathing. complanins of dry nasal passage. breath sounds clear.\n\ncardiac: remains in nsr with no ectopy. on po atenolol. bp to be kept , 160.\n\ngI taking po's ok. no complaints of nausea. no stool tonite.\n\ngu: foley patent and draining yellow urine.\n\naction: to ultrasound tonite to check for clots in right leg. clot seen and ho aware. to have ivc filter placed tomorrow. family in to visit and aware of days events.\n\nrespnse: transfer to the .\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-07-19 00:00:00.000",
"description": "Report",
"row_id": 1392238,
"text": "focus hemoydnmics\ndata:\n neuro: alert when name being called. at times very sleepy and requires to call her a couple of times. during residents exam alert and oriented. very pleasant and full of good humor. moves all extremities on the bed. at times picks at her aline. sitter at the bedside for safety issues. perla #3 blilaterally. no headaches.\n\nresp: breath sounds clear. o2 on at 2liters via np. o2sats 100%\n\ncardiac: in nsr. on labetolol gtt for bp control. bp to be < 140.\n\ngI abd soft and audible bowel sounds. no stool. taking po's ok.\n\ngu: foley patent and draiing yellow urine.\n\naction: neuro signs q1hr and documented on assessment sheet. sitter at the bedside for safety issue. lobetolol gtt infusing to keep bp < 140. family in and update given. left subclavian line inserted by the resident with the attending present during line change. iv dilantin and iv mannnitol given. tol well. aline intact. multiple ecchymotic areas on arms from iv infiltration.\n\nrespnnse: monitor closelly\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-07-19 00:00:00.000",
"description": "Report",
"row_id": 1392239,
"text": "nsg note\nSEE FLOWSHEET FOR SPECIFICS.\n\nNEURO-PT MOSTLY ORIENTED X3. PT WITH FEW EPISODES SL CONFUSION, BUT EASILY REORIENTED. DOZING THROUGHOUT DAT. MAE. FOLLOWS COMMANDS. NORMAL, EQUAL STRENGTH. TONGUE MIDLINE. PERRL. DILANTIN AND MANNITOL CON'T. PT WITH FINE TREMOR INHANDS.\n\nCV-HR 60-70'S, NSR. LABETOLOL GTT OFF. SBP <140. PO HYDRALAZINE AND LOPRESSOR STARTED. SKIN W+D. +PP. PBOOTS ON. HCT STABLE. DENIES CARDIAC COMPLAINTS.\n\nRESP-O2 SAT 98% 3LNC. LS CLEAR. C+DB ENC. NARD NOTED. O2 SAT DOES DROP TO 80'S WHEN O2 OFF.\n\nGI-ABD SOFT, NT/ND. +BS. REMAINS ON COLACE. TOL SIPS. PT DID C/O NAUSEA THIA AM, ANZIMET GIVEN WITH + EFFECT.\n\nGU-VOIDING VIA FOLEY ADEQ AMTS SL BLOOD TINGED URINE.\n\nACT-STOOD AND PIVOT OOB TO CHAIR X 2 HRS WITH 2 ASSIST. TOL WELL.\n\nENDO-SSRI. NO COVERAGE NEEDED.\n\nID-TMAX 100.8. WILL MONITOR. URINE CX PENDING.\n\nA-STABLE.\n\nP-CON'T WITH CURRENT PLAN. NEURO CHECKS. KEEP SBP <140. FOLLOW TEMP. PULM HYGIENE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-07-20 00:00:00.000",
"description": "Report",
"row_id": 1392240,
"text": "focus hemodynics\ndata: neuro: alert and oriented x2. at times becomes confused to the year. moves all extremities on the bed and at times becomes restless in the bed and wishes to sit oob. perla #3 bilaterally. no conplains of headache or dizzness.\n\nresp: on o2 at 3 liters via np. no difficult in breathing. o2sats 100%.\n\ncardiac: remains in nsr. no ectopy seen. hydralazine 10mg iv prn given to keep bp < 140.\n\ngI abd soft and audible bowel sounds. no stool. passing small amt of flatus. taking po's ok. no nausea.\n\ngu: foley patent and draining pink-yellow urine.\n\naction: labs as ordered. mannitol iv q6hr. serum osmolarity done prior to giving mannitol. iv dilantin given. update to daughter. elevated to 40degrees.\nresponse: monitor closely.\n"
}
] |
46,355 | 130,978 | ASSESSMENT AND PLAN: 44 y/o with synovial sarcoma s/p resection and multiple drainage of seroma presents with LLQ / left groin pain and fever. . #. Sepsis: Febrile to 105 with mild hypotension despite 6L IVF recusitation suggestive of sepsis. Location of pain with large fluid collection makes the fluid collection the most likely source of infection. JP with suction in place. The presences of dacron graft in the area is worrisome for possible colonization of the foreign body. CXR without PNA. UA clean making them less likely as source of infection. No prodrome to suggest viral infection. He was continued on vanco and zosyn for broad coverage. Dopamine weaned. Levophed used briefly and weaned. Hemodynamically stable upon transfer. . # Left groin fluid collection s/p recection of synovial sarcoma. Followed by Gen and plastics while in the ICU. As above, most likely source of infection. Fluid collection grew 2+ GNRs. CT was done. It showed a large fluid collection tracking along the left iliopsoas muscle, through the left inguinal canal, possiboly the iliopsoas bursa as well as stable thrombosis. His drain was changed on . . # Cardiomyopathy: EF 35% on echo in . Given hypotension lasix, coreg, and spironolactone were held. Digoxin was continued. A digoxin level was low at 0.3. . #. Thrombosed left CFV and SFV. Unchanged from prior. Likely vascular surgery in this area. Avoided anticoagulation at this time given IR drainage / possible surgery | JP drain which had been placed in groin was felt to be clogged and after cultures, 4L IVF and one dose IV zosyn pt was sent to EW. JP drain which had been placed in groin was felt to be clogged and after cultures, 4L IVF and one dose IV zosyn pt was sent to EW. JP drain which had been placed in groin was felt to be clogged and after cultures, 4L IVF and one dose IV zosyn pt was sent to EW. IVF stopped as pt seemed to have Large jugular veins on AM assessment. I would emphasize and add the following points: 44M synovial sarcoma c/b recurrent fluid collection L groin p/w decreased JP output, fever and hypotension. Will get f/u CT in AM, vascular surgery eval and consideration of second drain by IR. IMPRESSION: (Over) 9:08 AM CT PELVIS W/CONTRAST Clip # Reason: assess pelvis, evaluate fluid collection after drainage Admitting Diagnosis: ABDOMINAL ABCESS Field of view: 39 Contrast: OPTIRAY Amt: 130 FINAL REPORT (Cont) 1. Thrombosed left CFV and SFV, similar to prior study. Please with questions No contraindications for IV contrast FINAL REPORT INDICATION: Synovial sarcoma, status post resection with sepsis, recurrent seroma despite presence of 12 French catheter, and severe left lower quadrant pain, status post exchange of drain on . Given a dose of Vanco and sent to MICU for further care. Given a dose of Vanco and sent to MICU for further care. Given a dose of Vanco and sent to MICU for further care. - Given hypotension hold lasix, coreg, spironolactone - minimize IVF if possible - Hold digoxin may need to d/c as outpatient b/c of the juntional bradycardia he has had here, which may have just been related to the levophed use . digoxin was held and dc/d. digoxin was held and dc/d. FEN: IVF prn for hypotension, NPO for IR procedure, lytes prn . FEN: IVF prn for hypotension, NPO for IR procedure, lytes prn . Thrombosed left CFV and SFV, similar to prior study. Thrombosed left CFV and SFV, similar to prior study. Levophed weaned this AM but BPs borderline in 90s systolic. Left groin dressing changed with small amt serous and serosanguinous drainage. Left groin dressing changed with small amt serous and serosanguinous drainage. Action: Attempted to wean off levophed gtt -> BP dropped to 80s systolic -> levophed gtt restarted. - Given hypotension hold lasix, coreg, spironolactone - minimize IVF if possible - continue dig . - Given hypotension hold lasix, coreg, spironolactone - minimize IVF if possible - continue dig . - Given hypotension hold lasix, coreg, spironolactone - minimize IVF if possible - continue dig . Action: Pt medicated with ms contin standing dose in am. Action: Pt medicated with ms contin standing dose in am. Back to floor with BP 120s and was able to wean levo down slightly. PTT 26.1 WBC 8.1, hgb 31.2 plt 214, 87% neut, 5.7% lymph. PTT 26.1 WBC 8.1, hgb 31.2 plt 214, 87% neut, 5.7% lymph. Response: Pt continues on vanco/zosyn. Response: Pt continues on vanco/zosyn. I would emphasize and add the following points: 44M synovial sarcoma c/b recurrent fluid collection L groin p/w decreased JP output, fever and hypotension. Response: BP 95-115 systolic with levophed gtt. Thrombosed left CFV and SFV. Thrombosed left CFV and SFV. Thrombosed left CFV and SFV. Thrombosed left CFV and SFV. F.u final CT read. F.u final CT read. F.u final CT read. He was discharged on Bactrim. He was discharged on Bactrim. Mild (1+) mitral regurgitation is seen. Mild (1+) mitral regurgitation is seen. Received pt on levophed at 0.04mcg/kg/min. Received pt on levophed at 0.04mcg/kg/min. JP drain which had been placed in groin was felt to be clogged and after cultures, 4L IVF and one dose IV zosyn pt was sent to EW. JP drain which had been placed in groin was felt to be clogged and after cultures, 4L IVF and one dose IV zosyn pt was sent to EW. JP drain which had been placed in groin was felt to be clogged and after cultures, 4L IVF and one dose IV zosyn pt was sent to EW. IVF stopped as pt seemed to have Large jugular veins on AM assessment. | 27 | [
{
"category": "ECG",
"chartdate": "2139-11-23 00:00:00.000",
"description": "Report",
"row_id": 131099,
"text": "Sinus bradycardia. T wave inversions in leads V1-V3 suggestive of anteroseptal\nmyocardial ischemia. T wave inversions are also noted in leads III and aVF\nsuggesting possible anterior myocardial ischemia. Compared to the previous\ntracing of the ST segment abnormalities are new. Clinical correlation\nis suggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2139-11-22 00:00:00.000",
"description": "Report",
"row_id": 131100,
"text": "Sinus tachycardia. Compared to the previous tracing of the rate has\nincreased.\n\n"
},
{
"category": "Nursing",
"chartdate": "2139-11-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 493099,
"text": "44 y/o with h/o left groin synovial sarcoma, cardomyopathy presents to\n with 1 day of Left groin pain, left lower abdominal pain and\n fever to 102 at home. He went to (Pt lives in\n ) where pt was febrile to 105 and he c/o severe left groin,\n abdominal and upper leg pain. Abdominal CT showed 14cm fluid\n collection. JP drain which had been placed in groin was felt to be\n clogged and after cultures, 4L IVF and one dose IV zosyn pt was sent to\n EW.\n Pt continued to c/o left groin pain. Given 8mg IV morphine en route to\n . BP dropped to 90\ns in EW. Pt given 2 more liters IVF and started\n on dopamine. Right port accessed in EW. Given a dose of Vanco and sent\n to MICU for further care.\n PMH: Synovial sarcoma s/p resection with arterial graft placed,\n s/p multiple surgeries for fluid accumulation in site, s/p JP insertion\n last month,Cardiomyopathy due to chemotherapy, last EF 50%, CHF,\n depression, anxiety, sinusitis, asthma, GERD\n Allergies: Latex/Tape.\n"
},
{
"category": "Nursing",
"chartdate": "2139-11-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 493100,
"text": "44 y/o with h/o left groin synovial sarcoma, cardomyopathy presents to\n with 1 day of Left groin pain, left lower abdominal pain and\n fever to 102 at home. He went to (Pt lives in\n ) where pt was febrile to 105 and he c/o severe left groin,\n abdominal and upper leg pain. Abdominal CT showed 14cm fluid\n collection. JP drain which had been placed in groin was felt to be\n clogged and after cultures, 4L IVF and one dose IV zosyn pt was sent to\n EW.\n Pt continued to c/o left groin pain. Given 8mg IV morphine en route to\n . BP dropped to 90\ns in EW. Pt given 2 more liters IVF and started\n on dopamine. Right port accessed in EW. Given a dose of Vanco and sent\n to MICU for further care.\n PMH: Synovial sarcoma s/p resection with arterial graft placed,\n s/p multiple surgeries for fluid accumulation in site, s/p JP insertion\n last month,Cardiomyopathy due to chemotherapy, last EF 50%, CHF,\n depression, anxiety, sinusitis, asthma, GERD\n Allergies: Latex/Tape.\n Wound infection\n Assessment:\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n Ineffective Coping\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2139-11-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 493152,
"text": "44 y/o with h/o left groin synovial sarcoma, cardomyopathy presents to\n with 1 day of Left groin pain, left lower abdominal pain and\n fever to 102 at home. He went to (Pt lives in\n ) where pt was febrile to 105 and he c/o severe left groin,\n abdominal and upper leg pain. Abdominal CT showed 14cm fluid\n collection. JP drain which had been placed in groin was felt to be\n clogged and after cultures, 4L IVF and one dose IV zosyn pt was sent to\n EW.\n Pt continued to c/o left groin pain. Given 8mg IV morphine en route to\n . BP dropped to 90\ns in EW. Pt given 2 more liters IVF and started\n on dopamine. Right port accessed in EW. Given a dose of Vanco and sent\n to MICU for further care.\n PMH: Synovial sarcoma s/p resection with arterial graft placed,\n s/p multiple surgeries for fluid accumulation in site, s/p JP insertion\n last month,Cardiomyopathy due to chemotherapy, last EF 50%, CHF,\n depression, anxiety, sinusitis, asthma, GERD\n Allergies: Latex/Tape.\n Wound infection\n Assessment:\n Pt with large fluid collection in left groin from synovial sarcoma.\n Drain was clogged and attempts to unclog drain at bedside were\n unsuccessful.( CT Team came up from CT to try guidewire and we used TPA\n unsuccessfully.) WBC 8.2 today. Temp 99 axillary. Two blood cultures\n sent today. One from Port and one peripheral. Culture also sent from\n abcess in groin.\n Action:\n Pt brought to CT for insertion of new drain at 1530. #12 drain\n inserted. We need to flush drain into pt with 10cc\ns NS Q4hr to keep it\n open.\n Response:\n Pt continues on vanco/zosyn. Continues to require levophed for low BP.\n UO is good via foley.\n Plan:\n Continue to follow vital signs, pt\ns temp and UO. Give antibiotics as\n ordered. Assist pt with ADL\ns as he is very tired and in need of\n support. Flush drain Q4hr as ordered. Follow-up with cultures.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt describes left groin pain. This pain radiates up to his left\n lower abdomen and down his left thigh. He has graft in left groin and\n also blood clot.\n Action:\n Pt given his normal dose of MS SR 30mg PO at 8AM and had needed small\n doses dilaudid 1mg IV PRN Q3-6hr.\n Response:\n Pt states relief after 1mg IV dilaudid is acceptable at 5/10. Pt\n medicated during CT procedure with fentanyl and versed IV.\n Plan:\n Continue to assess pain and administer meds as needed. Frequency of\n dilaudid switched to Q6hr.\n Ineffective Coping\n Assessment:\n Pt has history depression and is feeling poorly at this point. He is\n being followed by our social worker .\n Action:\n Seen by today. He did not feel well enough to talk. Pt asked for\n all visitors to check in with nurse and if he is sleeping to allow him\n to sleep.\n Response:\n Being followed by SW and visitors checked at desk. His family is aware\n of pt\ns request. His mother, father and sister visited and let him\n sleep until he needed to be awake to go to CT for drain insertion.\n Plan:\n Monitor pt\ns mood and administer meds as ordered. Continue to offer\n support and encourage pt to verbalize his concerns.\n Sepsis without organ dysfunction\n Assessment:\n Pt remains on pressors. Dopamine changed to levophed drip. Currently\n running at .1mcg/kg/min. IVF stopped as pt seemed to have Large jugular\n veins on AM assessment.\n Action:\n Pt has needed levophed for BP control. Will wean down as tolerated.\n Response:\n BP goal is MAP>65 UO remains excellent via foley.\n Plan:\n Titrate levophed as tolerated and follow pt\ns vital signs closely.\n Pt received 150mcg IV fentanyl and 2mg IV versed for insertion of new\n drain in left lower abdomen.\n"
},
{
"category": "Nursing",
"chartdate": "2139-11-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 493222,
"text": "44 y/o with h/o left groin synovial sarcoma, presented to with severe left groin and abdominal pain, and fever to\n 105. Abdominal CT showed 14cm fluid collection. JP drain which had been\n placed in groin was felt to be clogged and after cultures, 4L IVF and\n abx he was sent to . Following arrival to pt became\n hypotensive requiring IVF boluses and pressors. Attempts to unclog JP\n drain were unsuccessful and new drain placed under CT guidance on\n .\n PMH: Synovial sarcoma s/p resection with arterial graft placed,\n s/p multiple surgeries for fluid accumulation in site, s/p JP insertion\n last month,Cardiomyopathy due to chemotherapy, last EF 50%, CHF,\n depression, anxiety, sinusitis, asthma, GERD\n Sepsis without organ dysfunction\n Assessment:\n Pt 3,\ntired\n Remains on levophed gtt to maintain BP.\n Urine output >100cc/hr.\n 02 sats 95-98% on room air.\n Synovial drain w/ serous fluid out (see flowsheet for totals).\n Pt c/o pain in left groin/abdomen at start of shift.\n Action:\n Attempted to wean off levophed gtt -> BP dropped to 80\ns systolic ->\n levophed gtt restarted.\n Cont abx as ordered.\n Received PO morphine SR as ordered.\n Response:\n BP 95-115 systolic with levophed gtt.\n Temp 99.5 PO, synovial drain cont serous output.\n Urine output remains adequate.\n Resp status stable, remains on room air.\n Pt stated relief from pain following morphine dose.\n Plan:\n Cont to monitor pts BP and urine output, titrate pressors as indicated\n to maintain perfusion.\n Cont to monitor output from synovial drain, flush drain with NS as\n ordered.\n Cont to monitor pts pain level, medicate as needed.\n"
},
{
"category": "Nursing",
"chartdate": "2139-11-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 493223,
"text": "44 y/o with h/o left groin synovial sarcoma, presented to with severe left groin and abdominal pain, and fever to\n 105. Abdominal CT showed 14cm fluid collection. JP drain which had been\n placed in groin was felt to be clogged and after cultures, 4L IVF and\n abx he was sent to . Following arrival to pt became\n hypotensive requiring IVF boluses and pressors. Attempts to unclog JP\n drain were unsuccessful and new drain placed under CT guidance on\n .\n PMH: Synovial sarcoma s/p resection with arterial graft placed,\n s/p multiple surgeries for fluid accumulation in site, s/p JP insertion\n last month,Cardiomyopathy due to chemotherapy, last EF 50%, CHF,\n depression, anxiety, sinusitis, asthma, GERD\n Sepsis without organ dysfunction\n Assessment:\n Pt 3,\ntired\n Remains on levophed gtt to maintain BP.\n Urine output >100cc/hr.\n 02 sats 95-98% on room air.\n Synovial drain w/ serous fluid out (see flowsheet for totals).\n Pt c/o pain in left groin/abdomen at start of shift.\n Action:\n Attempted to wean off levophed gtt -> BP dropped to 80\ns systolic ->\n levophed gtt restarted.\n Cont abx as ordered.\n Received PO morphine SR and dilaudid IV prn as ordered for pain.\n Response:\n BP 95-115 systolic with levophed gtt.\n Temp 99.5 PO, synovial drain cont serous output.\n Urine output remains adequate.\n Resp status stable, remains on room air.\n Pt stated relief from pain following medication.\n Plan:\n Cont to monitor pts BP and urine output, titrate pressors as indicated\n to maintain perfusion.\n Cont to monitor output from synovial drain, flush drain with NS as\n ordered.\n Cont to monitor pts pain level, medicate as needed.\n"
},
{
"category": "Physician ",
"chartdate": "2139-11-24 00:00:00.000",
"description": "Physician Resident/Attending Progress Note - MICU",
"row_id": 493401,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED\n - CT Imaging attempt at bedside to unclog drain w alteplase didn\nt work\n - IR procedure to change catheter draining fluid collection in groin\n increased drain output\n - dopamine was switched to levophed\n - bradycardia appears related to levophed\n - levophed weaned off this AM at 8:15\n - had some nausea yesterday b/c didn\nt get home PPI, but nausea\n improved now that PPI given\n Allergies:\n Latex\n Rash;\n Adhesive Tape (Topical)\n red skin/paper\n Last dose of Antibiotics:\n Vancomycin - 07:30 PM\n Piperacillin/Tazobactam (Zosyn) - 11:59 PM\n Infusions:\n Norepinephrine - 0.04 mcg/Kg/min\n Other ICU medications:\n Hydromorphone (Dilaudid) - 03:24 AM\n Pantoprazole (Protonix) - 06:06 AM\n Heparin Sodium (Prophylaxis) - 06:06 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100.1\n Tcurrent: 37.4\nC (99.4\n HR: 51 (48 - 110) bpm\n BP: 101/48(61) {82/45(53) - 124/78(86)} mmHg\n RR: 15 (12 - 21) insp/min\n SpO2: 95%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 86.6 kg (admission): 89 kg\n Height: 68 Inch\n Total In:\n 7,736 mL\n 174 mL\n PO:\n TF:\n IVF:\n 1,616 mL\n 174 mL\n Blood products:\n Total out:\n 4,725 mL\n 900 mL\n Urine:\n 2,625 mL\n 710 mL\n NG:\n Stool:\n Drains:\n 700 mL\n 190 mL\n Balance:\n 3,011 mL\n -726 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 95%\n ABG: ///22/\n Physical Examination\n General Appearance: Thin, sleeping comfortably\n Eyes / Conjunctiva: Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic, mucus membranes slightly dry\n Lymphatic: Cervical WNL\n Cardiovascular: Rate 60s, Reg Rhythm, could not appreciate rub\n Peripheral Vascular: left PT 1+, left fem dopplerable\n Respiratory / Chest: clear bilaterally to auscultation\n Abdominal: Soft, Bowel sounds present, Tender: LLQ, TTP in LLQ> LUQ a\n little guarding on left but no rebound. No HSM. drain with\n serosangious fluid from LLQ\n Extremities: No edema in Right lower extremity: Absent, 2+ Left lower\n extremity edema In left groin; has skin flap approx 6cm with 3cm open\n wound draining serous fluid. mild erthyema and warmth. No pus\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Oriented: x3\n Labs / Radiology\n 187 K/uL\n 9.7 g/dL\n 112 mg/dL\n 0.8 mg/dL\n 22 mEq/L\n 3.6 mEq/L\n 6 mg/dL\n 108 mEq/L\n 139 mEq/L\n 28.7 %\n 7.2 K/uL\n [image002.jpg]\n 07:43 AM\n 03:27 AM\n WBC\n 9.5\n 7.2\n Hct\n 29.1\n 28.7\n Plt\n 192\n 187\n Cr\n 0.8\n 0.8\n Glucose\n 134\n 112\n Other labs: PT / PTT / INR:12.5/23.2/1.1, CK / CKMB / Troponin-T:150//,\n ALT / AST:18/15, Alk Phos / T Bili:99/0.3, Differential-Neuts:79.8 %,\n Lymph:12.1 %, Mono:6.3 %, Eos:1.7 %, LDH:154 IU/L, Ca++:8.5 mg/dL,\n Mg++:2.1 mg/dL, PO4:2.2 mg/dL\n CT:\n 1. Large fluid collection tracking along the left iliopsoas muscle,\n through\n the left inguinal canal, possiboly the iliopsoas bursa. Though this\n collection\n contains a pigtail catheter, the collection is larger in size compared\n to\n .\n 2. Asymmetric enlargement of the left lower extremity relative to the\n right,\n with subcutaneous, intermuscular, and muscular edema.\n 3. Thrombosis of left common femoral vein and superficial femoral\n veins,\n unchanged.\n Assessment and Plan\n ASSESSMENT AND PLAN: 44 y/o with synovial sarcoma s/p resection and\n multiple drainage of seroma presents with LLQ / left groin pain and\n fever.\n .\n #. Sepsis: Febrile to 100.1 with persisting mild hypotension despite\n aggressive fluid resuscitation yesterday. Has hx of cardiomyopathy, so\n fluid balance is tenuous. fluid collection is the source of infection;\n arterial and venous graft may also be infected. Drain changed by CT\n Imaging yesterday and currently draining well. Levophed weaned this AM\n but BPs borderline in 90s systolic. Serous fluid culture shows Gm\n Rods.\n - continue vanco and zosyn for broad coverage\n - monitor BPs and tolerate MAPs of 60 ; try to hold on IVFs due to\n cardiomyopathy\n - continue monitor UO for goal > 0.5cc/kg/hr\n so far urine output good\n - f/u blood and urine cult\n - do another blood culture today from Port and venipuncture\n bacteremic, need to pull Port\n - Per Surgery Recs (Dr. \n need to be aggressive in draining all\n of the seroma fluid; may need a CT tomorrow to evaluate for improvement\n and eval for loculation; may need to have CT Imaging place another\n drain in seroma tomorrow or the next day\n - F/U w Vascular recs\n small chance they may want to operate to\n remove graft and replace, though unlikely now because area infected\n # Left groin fluid collection s/p recection of synovial sarcoma.\n Followed by Gen and plastics. As above, most likely source of\n infection. Drain changed by IR and working well now\n - Appreciate Surgical recs\n - f/u plastics/vascular recs regarding flap reconstruction\n - wound care per \n - continue MScotin and dilaudid IV prn for breakthrough pain\n - increase frequency of pain meds\n .\n # Cardiomyopathy: EF 35% on echo in .\n - Given hypotension hold lasix, coreg, spironolactone\n - minimize IVF if possible\n - Hold digoxin\n may need to d/c as outpatient b/c of the juntional\n bradycardia he has had here, which may have just been related to the\n levophed use\n .\n #. Thrombosed left CFV and SFV. Unchanged from prior. be \n vascular surgery in this area.\n - Avoid anticoagulation at this time given possibility of further\n surgery or interventional procedure\n - discuss with surgery long term management / need for anticoagulation.\n - trend pulses\n .\n #.Anemia: Baseline low 30s. Hct has been stable here at 28.\n - T+S\n - trend HCT\n .\n #. GERD: EGD only with Irregular Z-line. Had some nausea\n yesterday when didn\nt get protonix, but improved now w PPI.\n - continue PPI\n .\n #. Depression/ anxiety:\n Pt understandably sad affect, frustrated mildly by medical situation\n but very pleasant.\n - continue celexa\n - hold ativan given hypotension\n - per patient, visitors to check in w nurse to see if he is sleeping\n before waking him up\n .\n # Asthma: stable. no home meds.\n - add nebs if symptomatic\n .\n .\n PPX:\n -DVT ppx: heparin subq\n -Bowel regimen: senna, colace\n -Pain management: MScontin, Dilaudid\n ICU Care\n Nutrition:\n Has been NPO but may eat today if Surgery plans no procedures\n Glycemic Control:\n Lines: PIV, central Port\n 18 Gauge - 06:13 AM\n Indwelling Port (PortaCath) - 06:14 AM\n Prophylaxis:\n DVT: heparin SC\n Stress ulcer: home PPI\n VAP:\n Comments:\n Communication: Comments: Father, . \n Code status: Full code\n Disposition: ICU\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 44M synovial sarcoma c/b recurrent fluid\n collection L groin p/w decreased JP output, fever and hypotension. IR\n drain placed, off pressors.\n Exam notable for Tm 102.7 BP 110/50 HR 94 RR 16 with sat 97 on RA. WD\n pale man, NAD. JVD 8cm. RRR s1s2. CTA B, few rales B bases. Soft +BS. L\n groin with post surgical changes, buldging soft mass / collection with\n mod LLQ pain. Drain site c/d/i. LLE edema 2+. Labs notable for WBC 7K,\n HCT 32, K+ 3.5, Cr 0.8. CXR with mild volume overload. CT as described\n above.\n Agree with plan to manage likely infected L groin fluid collection with\n suction drainage via new large bore drain while following up cx and\n continuing broad abx coverage. Will get f/u CT in AM, vascular surgery\n eval and consideration of second drain by IR. Will d/c port only if BCx\n are positive, check again today. Hold off on anticoag for LLE clot\n until vascular / IR procedures completed\n low embolic risk given\n absence communication with central circulation. Needs f/u with rad-onc\n once acute issues resolved. Continue dilaudid for pain control,\n surgical team following exam closely. For chronic systolic CHF, EF has\n risen on recent studies, appears euvolemic, hold digoxin for now and\n check level, esp given intermittent bradycardia with sedation / sleep.\n Above d/w Dr. in detail. Remainder of plan as outlined above.\n Total time: 35 min\n ------ Protected Section Addendum Entered By: , MD\n on: 04:19 PM ------\n"
},
{
"category": "Radiology",
"chartdate": "2139-11-26 00:00:00.000",
"description": "CT PELVIS W/CONTRAST",
"row_id": 1103900,
"text": " 1:16 PM\n CT PELVIS W/CONTRAST Clip # \n Reason: Dr. requests aggressive drainage of abd fluid collectio\n Admitting Diagnosis: ABDOMINAL ABCESS\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with PMHx of synovial sarcoma w/ sepsis and severe LLQ pain,\n s/p exchange of drain \n REASON FOR THIS EXAMINATION:\n Dr. requests aggressive drainage of abd fluid collections. Please \n with questions \n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Synovial sarcoma, status post resection with sepsis, recurrent\n seroma despite presence of 12 French catheter, and severe left lower quadrant\n pain, status post exchange of drain on . Dr. requests\n aggressive drainage of abdominal fluid collections with second catheter and\n aspiration of anterior, small presumably undrained collection in lower aspect\n of surgical bed.\n\n PROCEDURE: The risks and benefits of the procedure were explained to the\n patient and written informed consent was obtained. Specifically, two separate\n procedures were discussed with the patient including placement of a second\n catheter adjacent to the currently existing 12 French catheter in the larger\n portion of the seroma, and needle aspiration of a smaller collection located\n anteriorly in the lower surgical bed.\n\n The patient was placed supine on the CT table. A preprocedure timeout was\n performed using three patient identifiers. The skin of the left lower abdomen\n and upper thigh was prepped and draped in standard sterile fashion.\n Attention was first turned to aspiration of the smaller collection located\n inferiorly in the surgical bed, which measured approximately 2.8 cm. Local\n anesthesia was achieved via injection of 4 mL of 1% lidocaine. Under CT\n guidance, a 25-gauge needle was placed into the collection and its position\n confirmed. However, fluid could not be aspirated and therefore subsequent\n 18-gauge followed by 16-gauge needles were placed into the collection. There\n was brisk return of fluid with the 16-gauge needle, and 12 mL of clear serous\n fluid were aspirated and sent for Gram stain and culture with complete\n collapse of the collection.\n Following this, attention was turned to placement of a second catheter in the\n larger portion of the collection where the 12 French catheter currently\n resided. The skin of this region had been previously prepped and draped. A\n 60 mL of sterile saline was injected into the existing 12 French catheter in\n order to distend the collection and provide a safer footprint for placement of\n a second catheter. Under direct CT guidance, and after local anesthesia with\n 7 mL of 1% lidocaine, an 18-gauge needle was advanced into the\n collection. A 0.035 wire was advanced into the collection and its\n position confirmed. Subsequent dilation was performed with 6, 8, and 10\n French dilators. A 10 French catheter was advanced over the wire into\n the collection and the pigtail formed and locked. A quantity of fluid had\n expressed spontaneously from the collection during the procedure. In addition,\n (Over)\n\n 1:16 PM\n CT PELVIS W/CONTRAST Clip # \n Reason: Dr. requests aggressive drainage of abd fluid collectio\n Admitting Diagnosis: ABDOMINAL ABCESS\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 45 mL of blood-tinged serous fluid was aspirated from the catheter. An\n additional 10 mL was aspirated from the pre-existing 12 French catheter. Both\n catheters were placed to bulb suction. Followup CT scanning was performed\n showing partial collapse of the collection with satisfactory placement of both\n catheters. StatLock devices were used to secure both devices to the skin.\n The patient tolerated the procedure well without complications evident at the\n time of the procedure.\n\n There is left common femoral vein thrombus, as previously indicated,\n unchanged.\n\n The attending radiologist, Dr. , participated throughout both portions of\n the entire procedure.\n\n\n MODERATE SEDATION: Moderate sedation was provided by administering divided\n doses of Versed and fentanyl intravenously throughout the intraservice time of\n 60 minutes, during which time the patient's hemodynamic parameters were\n continuously monitored.\n\n IMPRESSION:\n 1. Successful CT-guided aspiration of small anterior subcutaneous collection,\n yielding 12 mL of serous fluid, which was sent for Gram stain and culture.\n\n 2. Successful CT-guided placement of a second, 10-French catheter adjacent to\n the existing 12 French catheter within a left lower quadrant seroma, as\n requested by the surgical team.\n\n 3. Unchanged left common femoral vein thrombus.\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-11-23 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 1103251,
"text": " 2:33 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: (w/PO and IV contrast) ?infection\n Field of view: 40 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with fever and JP drain tenderness\n REASON FOR THIS EXAMINATION:\n (w/PO and IV contrast) ?infection\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JXKc MON 3:44 AM\n 14 cm fluid collection tracking along left iliopsoas, through inguinal canal,\n larger in size compared to . A pigtail catheter is centered within the\n collection- correlate with output. Asymmetric enlargement of left leg\n compared to right leg, with inflammatory stranding/edema. Thrombosed left CFV\n and SFV, similar to prior study.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 44-year-old male with fever and JP drain tenderness.\n\n TECHNIQUE: MDCT axial images were obtained from the lung bases to the level\n of the mid thigh, following administration of intravenous and oral contrast.\n Coronal and sagittal reformations were obtained.\n\n COMPARISON: and .\n\n CT OF THE ABDOMEN WITH IV CONTRAST: Dependent atelectasis present within the\n visualized lung bases. No pleural effusion is evident. The visualized heart\n and pericardium are unremarkable. Gynecomastia is noted.\n\n A tiny hypodensity in the left lobe of the liver (2:24) is too small to\n characterize. Otherwise, the liver is unremarkable. The gallbladder, spleen,\n pancreas, adrenal glands, and kidneys are unremarkable.\n\n The stomach, small bowel, and large bowel are within normal limits. No free\n air or free fluid is identified.\n\n There is a large fluid collection, tracking anterior along the left iliopsoas\n muscle, with a pigtail catheter centered within the collection. This\n collection measures approximately 14 cm craniocaudal x 5.5 cm transverse x 6.6\n cm AP, and is larger in size compared to . This collection\n tracks through the left inguinal canal, and appears to track deep to the left\n common femoral artery and veins. This collection surrounds an arterial graft,\n which otherwise enhances normally. The collection also appears to extend to\n the skin anteriorly at site of a flap reconstruction.\n\n A second fluid collection is also noted laterally at the level of the left\n hip, which measures 2.8 cm transverse x 2.7 cm in AP x 3.1 cm craniocaudal,\n which is not significantly changed in size.\n\n Post-surgical changes are noted following resection of a sarcoma with a\n reconstruction flap noted within the left groin.\n (Over)\n\n 2:33 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: (w/PO and IV contrast) ?infection\n Field of view: 40 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n There is asymmetric enlargement of the left lower extremity relative to right,\n with subcutaneous, intermuscular, and muscular edema. Thrombosis is noted\n within the left common femoral vein, as well as left superficial femoral vein,\n which appear unchanged. The left external iliac vein appears surgically tied.\n\n CT OF PELVIS WITH IV CONTRAST: Urinary bladder contains a Foley catheter,\n with air seen in the bladder, likely related to instrumentation. Prostate and\n rectum are unremarkable.\n\n OSSEOUS STRUCTURES: No suspicious lytic or sclerotic lesions are identified.\n\n IMPRESSION:\n\n 1. Large fluid collection tracking along the left iliopsoas muscle, through\n the left inguinal canal, possiboly the iliopsoas bursa. Though this collection\n contains a pigtail catheter, the collection is larger in size compared to\n .\n\n 2. Asymmetric enlargement of the left lower extremity relative to the right,\n with subcutaneous, intermuscular, and muscular edema.\n\n 3. Thrombosis of left common femoral vein and superficial femoral veins,\n unchanged.\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-11-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1103252,
"text": " 3:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for PNA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with fever\n REASON FOR THIS EXAMINATION:\n eval for PNA\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 44-year-old male with fever, evaluate for pneumonia.\n\n COMPARISON: .\n\n SINGLE AP VIEW OF THE CHEST: A port overlies right chest wall, with the leads\n terminating within the cavoatrial junction. The heart is normal in size. The\n mediastinal and hilar contours are unremarkable. The lung volumes are low\n with accenuation of bronchovascular structures. However, there appears to be\n increased opacities in the lower lobes bilaterally, which could indicate an\n early consolidation. There is no pleural effusion or pneumothorax.\n\n IMPRESSION:\n Low lung volumes, with increased opacity in the lower lobes bilaterally.\n While this may be secondary to crowding from the low lung volumes, an early\n consolidation cannot be excluded.\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-11-25 00:00:00.000",
"description": "CT PELVIS W/CONTRAST",
"row_id": 1103659,
"text": " 9:08 AM\n CT PELVIS W/CONTRAST Clip # \n Reason: assess pelvis, evaluate fluid collection after drainage\n Admitting Diagnosis: ABDOMINAL ABCESS\n Field of view: 39 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with with L groin collection s/p rsxn of synovial sarcoma, s/p\n IR drainage ()\n REASON FOR THIS EXAMINATION:\n assess pelvis, evaluate fluid collection after drainage\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: IPf WED 2:10 PM\n Interval decrease in size in the fluid collection with pigtail in place.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 44-year-old man with left groin collection, status post resection of\n synovial sarcoma and status post IR drainage on . Assess pelvis and\n evaluate for fluid collection after drainage.\n\n TECHNIQUE: CT pelvis with IV contrast.\n\n COMPARISON: Compared to CT abdomen and pelvis .\n\n FINDINGS: The loops of large and small bowel appear normal. No free air, or\n free fluid is identified.\n\n The large fluid collection, tracking anteriorly along the left iliopsoas\n muscle with the pigtail catheter centered within the collection, shows\n interval decrease in size compared to prior study. This collection measures\n 11 (craniocaudal) x 5.2 x 4.4 cm. This collection tracks through the left\n inguinal canal, as described before, and surrounds an arterial graft which\n otherwise enhances normally. There is a separate small collection in the\n subcutaneous tissue anterior to the large fluid collection, which is not\n connected to the prior collection, and measures 2.9 x 2.9 cm (2:38), unchanged\n in size compared to prior study.\n\n Postsurgical changes are noted following resection of sarcoma with\n reconstruction flap within the left groin.\n\n Again seen is an asymmetric enlargement of the left extremity with fat\n stranding, and subcutaneous, intermuscular and muscular edema, as described\n above. Again seen is thrombosis of the left common femoral vein as well as\n left superficial femoral vein, which appear unchanged. The left external\n iliac vein appears surgically tied.\n\n There is an air bubble within the urinary bladder, likely from placement of\n Foley catheter. Prostate and rectum are unremarkable.\n\n OSSEOUS STRUCTURES: No suspicious lytic or sclerotic lesions are seen.\n\n IMPRESSION:\n (Over)\n\n 9:08 AM\n CT PELVIS W/CONTRAST Clip # \n Reason: assess pelvis, evaluate fluid collection after drainage\n Admitting Diagnosis: ABDOMINAL ABCESS\n Field of view: 39 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 1. Fluid collection tracking along the left iliopsoas muscle, through the\n left inguinal canal with pigtail catheter in place, and interval decrease in\n size compared to prior study.\n 2. Separate stable fluid collection anterior to the large fluid collection in\n the left inguinal area, measuring less than 3 cm, unchanged.\n 3. Symmetric enlargement of the left lower extremity relative to the right\n with subcutaneous, intermuscular and muscular edema, unchanged.\n 4. Deep venous thrombosis of left common femoral vein and superficial femoral\n vein, unchanged.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-11-23 00:00:00.000",
"description": "CT ABSCESS CATH CHANGE",
"row_id": 1103370,
"text": " 3:09 PM\n CT ABSCESS CATH CHANGE; CT CHANGE PERCUTANEOUS TUBE Clip # \n Reason: aspiration of fluid and placement of drains\n Admitting Diagnosis: ABDOMINAL ABCESS\n ********************************* CPT Codes ********************************\n * CT ABSCESS CATH CHANGE CT CHANGE PERCUTANEOUS TUBE *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with synovial sarcoma in L illopoas s/p resection, including\n dacron graft from illiac to common fem art with recurrent fluid collection.\n Presents with fever, rigors. Enlarging 14cm fluid collection (JP already in\n place from prior CT guided drainage.)\n REASON FOR THIS EXAMINATION:\n aspiration of fluid and placement of drains\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 44-year-old man with synovial sarcoma in the left iliopsoas\n status post resection. Dacron graft from the iliac to common femoral artery\n with recurrent fluid collection. The patient presents with fever and rigors.\n There is an enlarging 14 cm fluid collection with JP already in place where\n prior CT-guided insertion of the drainage.\n\n After risk, benefits, alternatives and procedure were explained to the\n patient, written informed consent was obtained. A preprocedure timeout was\n performed using three patient identifiers.\n\n Initial CT imaging shows noncollection in the left iliopsoas area with the\n drainage catheter inside.\n\n The site over the drainage in the left low abdomen was prepped and draped in\n usual sterile fashion. Local anesthesia was achieved with lidocaine 1%\n buffered solution. Moderate sedation was provided by administering divided\n doses of fentanyl and Versed throughout the total intraservice time of 15\n minutes during which patient's hemodynamic parameters were continuously\n monitored.\n\n The distal part of the 8-French catheter was cut off. Fluid started to drip\n from the distal end. Then the guidewire was inserted. It was seen in the\n collection in the fluoroscopy images. Over the guidewire a 10-French and\n 12-French dilators wire inserted and after that 12-French catheter was\n inserted. Following that a small amount of fluid was taken for the lab as\n requested. Following that 150 cc of clear yellow fluid was aspirated into the\n bag from the collection. The catheter was secured.\n\n The patient tolerated the procedure well. No immediate post-procedure\n complications were noted.\n\n The attending radiologist, Dr. was present and supervised the\n whole procedure.\n\n IMPRESSION: Successful CT-guided exchange of the catheter to the 12-French\n (Over)\n\n 3:09 PM\n CT ABSCESS CATH CHANGE; CT CHANGE PERCUTANEOUS TUBE Clip # \n Reason: aspiration of fluid and placement of drains\n Admitting Diagnosis: ABDOMINAL ABCESS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n catheter and a small amount of fluid was sent to the lab as requested.\n 150 cc of clear yellow fluid were drained into bag.\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-11-30 00:00:00.000",
"description": "CT PELVIS W/CONTRAST",
"row_id": 1104556,
"text": " 12:46 PM\n CT PELVIS W/CONTRAST Clip # \n Reason: please re-assess fluid collection\n Admitting Diagnosis: ABDOMINAL ABCESS\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man s/p IR drain for fluid collection\n REASON FOR THIS EXAMINATION:\n please re-assess fluid collection\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SBNa MON 2:27 PM\n PFI: No significant change from five days prior.\n ______________________________________________________________________________\n FINAL REPORT\n CT PELVIS\n\n COMPARISON: .\n\n HISTORY: Fluid collection, status post drain placement.\n\n TECHNIQUE: MDCT axially acquired images through the pelvis were obtained. IV\n contrast was administered. Coronal and sagittal reformats were performed.\n\n FINDINGS: Again identified is a large fluid collection tracking along the\n left anterior psoas muscle and into the left inguinal region. A pigtail\n catheter is centered within this fluid collection (2, 25). The fluid\n collection measures approximately 4.2 x 6.0 cm (2, 30), not significantly\n changed from most recent exam performed five days prior. A smaller fluid\n collection in the subcutaneous soft tissues at the post-surgical site (2, 34)\n is not significantly changed in size and now contains foci of air. A 1.8 x\n 2.6 cm fluid collection anterior to the left proximal femur (2, 42) is\n unchanged. Post-surgical changes in the left groin following resection of\n sarcoma with reconstruction flap are similar in appearance. Filling defect\n within the left common femoral vein with expansion of the lumen is unchanged,\n consistent with thrombus (2, 44). The prostate and bladder are unremarkable.\n A tiny focus of air within the bladder is likely due to recent\n instrumentation. The rectum, sigmoid colon are unremarkable.\n\n BONE WINDOWS: There are no suspicious lytic or sclerotic lesions identified.\n\n IMPRESSION:\n 1. Fluid collection tracking along the left iliopsoas muscle and extending\n into the left inguinal canal with pigtail catheter in place. No significant\n change when compared to most recent exam performed on .\n Smaller fluid collections in the subcutaneous soft tissue as well as anterior\n to the left proximal femur are unchanged.\n 2. No significant change in thrombosis of the left common femoral vein.\n\n\n\n\n (Over)\n\n 12:46 PM\n CT PELVIS W/CONTRAST Clip # \n Reason: please re-assess fluid collection\n Admitting Diagnosis: ABDOMINAL ABCESS\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-11-30 00:00:00.000",
"description": "CT PELVIS W/CONTRAST",
"row_id": 1104557,
"text": ", E. 5S 12:46 PM\n CT PELVIS W/CONTRAST Clip # \n Reason: please re-assess fluid collection\n Admitting Diagnosis: ABDOMINAL ABCESS\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man s/p IR drain for fluid collection\n REASON FOR THIS EXAMINATION:\n please re-assess fluid collection\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI: No significant change from five days prior.\n\n"
},
{
"category": "Nursing",
"chartdate": "2139-11-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 493002,
"text": "Admission at 0615am.\n 44 yo male pt with h/o seroma/sarcoma of Lt groin with past h/o\n multiple surgeries including resectin/ wound vac/ arteriole graft dc'\n drecently fom this hospital ,with JP drain in place .per pt JP was\n draining 20cc/day ,but since last 2-3 days ~ 300cc/day, presented to\n with fever ,severe pain in the groin, received 4mg dilaudid\n and 4lit fluid and iv zosyn from and 8mg iv morphine on the way\n to hospital transfered to ED ,where his Tmax 105F, received 2\n lit fluid ,dilaudid 1.5 mg dilaudid for pain,vanco 1gm,protonix ,zosyn\n x 2 doses.SBP dropped to 90's ,started with dopamine gtt,CT pelvis\n showed 14cm fluid collection . transfered to for further\n management.\n Neuro; alert and oriented x3,c/o pain in Lt groin ,dilaudid 1 mg\n for pain with better effect.\n CVS; HR 90\ns, SR.SBP 100-110\nS ,on dopamine 5mics/kg/min\n Resp: NC 2lit/min ,sats 100% .\n Gu/gi: abd soft, foley to gravity,UO adequate.\n Remains stable now.plan to drain pelvi fluid collection in IR today.\n"
},
{
"category": "Nursing",
"chartdate": "2139-11-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 493378,
"text": "44 y/o with h/o left groin synovial sarcoma, presented to with severe left groin and abdominal pain, and fever to\n 105. Abdominal CT showed 14cm fluid collection. JP drain which had been\n placed in groin was felt to be clogged and after cultures, 4L IVF and\n abx he was sent to . Following arrival to pt became\n hypotensive requiring IVF boluses and pressors. Attempts to unclog JP\n drain were unsuccessful and new drain placed under CT guidance on\n .\n PMH: Synovial sarcoma s/p resection with arterial graft placed,\n s/p multiple surgeries for fluid accumulation in site, s/p JP insertion\n last month,Cardiomyopathy due to chemotherapy, last EF 50%, CHF,\n depression, anxiety, sinusitis, asthma, GERD\n Sepsis without organ dysfunction\n Assessment:\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n Wound infection\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2139-11-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 493181,
"text": "44 y/o with h/o left groin synovial sarcoma, cardomyopathy presents to\n with 1 day of Left groin pain, left lower abdominal pain and\n fever to 102 at home. He went to (Pt lives in\n ) where pt was febrile to 105 and he c/o severe left groin,\n abdominal and upper leg pain. Abdominal CT showed 14cm fluid\n collection. JP drain which had been placed in groin was felt to be\n clogged and after cultures, 4L IVF and one dose IV zosyn pt was sent to\n EW.\n Pt continued to c/o left groin pain. Given 8mg IV morphine en route to\n . BP dropped to 90\ns in EW. Pt given 2 more liters IVF and started\n on dopamine. Right port accessed in EW. Given a dose of Vanco and sent\n to MICU for further care.\n PMH: Synovial sarcoma s/p resection with arterial graft placed,\n s/p multiple surgeries for fluid accumulation in site, s/p JP insertion\n last month,Cardiomyopathy due to chemotherapy, last EF 50%, CHF,\n depression, anxiety, sinusitis, asthma, GERD\n Allergies: Latex/Tape.\n Wound infection\n Assessment:\n Pt with large fluid collection in left groin from synovial sarcoma.\n Drain was clogged and attempts to unclog drain at bedside were\n unsuccessful.( CT Team came up from CT to try guidewire and we used TPA\n unsuccessfully.) WBC 8.2 today. Temp 99 axillary. Two blood cultures\n sent today. One from Port and one peripheral. Culture also sent from\n abcess in groin.\n Action:\n Pt brought to CT for insertion of new drain at 1530. #12 drain\n inserted. We need to flush drain into pt with 10cc\ns NS Q8hr to keep it\n open.\n Response:\n Pt continues on vanco/zosyn. Continues to require levophed for low BP.\n UO is good via foley.\n Plan:\n Continue to follow vital signs, pt\ns temp and UO. Give antibiotics as\n ordered. Assist pt with ADL\ns as he is very tired and in need of\n support. Flush drain Q8hr as ordered. Follow-up with cultures. Follow\n amt drainage from new pigtail.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt describes left groin pain. This pain radiates up to his left\n lower abdomen and down his left thigh. He has graft in left groin and\n also blood clot.\n Action:\n Pt given his normal dose of MS SR 30mg PO at 8AM and had needed small\n doses dilaudid 1mg IV PRN Q3-6hr.\n Response:\n Pt states relief after 1mg IV dilaudid is acceptable at 5/10. Pt\n medicated during CT procedure with fentanyl and versed IV. C/O nausea\n and vomited once due to pain.\n Plan:\n Continue to assess pain and administer meds as needed. Frequency of\n dilaudid switched to Q6hr.\n Ineffective Coping\n Assessment:\n Pt has history depression and is feeling poorly at this point. He is\n being followed by our social worker .\n Action:\n Seen by today. He did not feel well enough to talk. Pt asked for\n all visitors to check in with nurse and if he is sleeping to allow him\n to sleep.\n Response:\n Being followed by SW and visitors checked at desk. His family is aware\n of pt\ns request. His mother, father and sister visited and let him\n sleep until he needed to be awake to go to CT for drain insertion.\n Plan:\n Monitor pt\ns mood and administer meds as ordered. Continue to offer\n support and encourage pt to verbalize his concerns.\n Sepsis without organ dysfunction\n Assessment:\n Pt remains on pressors. Dopamine changed to levophed drip. Currently\n running at .1mcg/kg/min. IVF stopped as pt seemed to have Large jugular\n veins on AM assessment.\n Action:\n Pt has needed levophed for BP control. Will wean down as tolerated.\n Response:\n BP goal is MAP>65 UO remains excellent via foley.\n Plan:\n Titrate levophed as tolerated and follow pt\ns vital signs closely.\n Pt received 150mcg IV fentanyl and 2mg IV versed for insertion of new\n drain in left lower abdomen. Tolerated procedure well. Back to floor\n with BP 120\ns and was able to wean levo down slightly. Team has OK\n for him to eat a few crackers. Tolerating crackers and his N/V has\n improved.\n"
},
{
"category": "Physician ",
"chartdate": "2139-11-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 493335,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED\n - CT Imaging attempt at bedside to unclog drain w alteplase didn\nt work\n - IR procedure to change catheter draining fluid collection in groin\n increased drain output\n - dopamine was switched to levophed\n - bradycardia appears related to levophed\n - levophed weaned off this AM at 8:15\n - had some nausea yesterday b/c didn\nt get home PPI, but nausea\n improved now that PPI given\n Allergies:\n Latex\n Rash;\n Adhesive Tape (Topical)\n red skin/paper\n Last dose of Antibiotics:\n Vancomycin - 07:30 PM\n Piperacillin/Tazobactam (Zosyn) - 11:59 PM\n Infusions:\n Norepinephrine - 0.04 mcg/Kg/min\n Other ICU medications:\n Hydromorphone (Dilaudid) - 03:24 AM\n Pantoprazole (Protonix) - 06:06 AM\n Heparin Sodium (Prophylaxis) - 06:06 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100.1\n Tcurrent: 37.4\nC (99.4\n HR: 51 (48 - 110) bpm\n BP: 101/48(61) {82/45(53) - 124/78(86)} mmHg\n RR: 15 (12 - 21) insp/min\n SpO2: 95%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 86.6 kg (admission): 89 kg\n Height: 68 Inch\n Total In:\n 7,736 mL\n 174 mL\n PO:\n TF:\n IVF:\n 1,616 mL\n 174 mL\n Blood products:\n Total out:\n 4,725 mL\n 900 mL\n Urine:\n 2,625 mL\n 710 mL\n NG:\n Stool:\n Drains:\n 700 mL\n 190 mL\n Balance:\n 3,011 mL\n -726 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 95%\n ABG: ///22/\n Physical Examination\n General Appearance: Thin, sleeping comfortably\n Eyes / Conjunctiva: Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic, mucus membranes slightly dry\n Lymphatic: Cervical WNL\n Cardiovascular: Rate 60s, Reg Rhythm, could not appreciate rub\n Peripheral Vascular: left PT 1+, left fem dopplerable\n Respiratory / Chest: clear bilaterally to auscultation\n Abdominal: Soft, Bowel sounds present, Tender: LLQ, TTP in LLQ> LUQ a\n little guarding on left but no rebound. No HSM. drain with\n serosangious fluid from LLQ\n Extremities: No edema in Right lower extremity: Absent, 2+ Left lower\n extremity edema In left groin; has skin flap approx 6cm with 3cm open\n wound draining serous fluid. mild erthyema and warmth. No pus\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Oriented: x3\n Labs / Radiology\n 187 K/uL\n 9.7 g/dL\n 112 mg/dL\n 0.8 mg/dL\n 22 mEq/L\n 3.6 mEq/L\n 6 mg/dL\n 108 mEq/L\n 139 mEq/L\n 28.7 %\n 7.2 K/uL\n [image002.jpg]\n 07:43 AM\n 03:27 AM\n WBC\n 9.5\n 7.2\n Hct\n 29.1\n 28.7\n Plt\n 192\n 187\n Cr\n 0.8\n 0.8\n Glucose\n 134\n 112\n Other labs: PT / PTT / INR:12.5/23.2/1.1, CK / CKMB / Troponin-T:150//,\n ALT / AST:18/15, Alk Phos / T Bili:99/0.3, Differential-Neuts:79.8 %,\n Lymph:12.1 %, Mono:6.3 %, Eos:1.7 %, LDH:154 IU/L, Ca++:8.5 mg/dL,\n Mg++:2.1 mg/dL, PO4:2.2 mg/dL\n CT:\n 1. Large fluid collection tracking along the left iliopsoas muscle,\n through\n the left inguinal canal, possiboly the iliopsoas bursa. Though this\n collection\n contains a pigtail catheter, the collection is larger in size compared\n to\n .\n 2. Asymmetric enlargement of the left lower extremity relative to the\n right,\n with subcutaneous, intermuscular, and muscular edema.\n 3. Thrombosis of left common femoral vein and superficial femoral\n veins,\n unchanged.\n Assessment and Plan\n ASSESSMENT AND PLAN: 44 y/o with synovial sarcoma s/p resection and\n multiple drainage of seroma presents with LLQ / left groin pain and\n fever.\n .\n #. Sepsis: Febrile to 100.1 with persisting mild hypotension despite\n aggressive fluid resuscitation yesterday. Has hx of cardiomyopathy, so\n fluid balance is tenuous. fluid collection is the source of infection;\n arterial and venous graft may also be infected. Drain changed by CT\n Imaging yesterday and currently draining well. Levophed weaned this AM\n but BPs borderline in 90s systolic. Serous fluid culture shows Gm\n Rods.\n - continue vanco and zosyn for broad coverage\n - monitor BPs and tolerate MAPs of 60 ; try to hold on IVFs due to\n cardiomyopathy\n - continue monitor UO for goal > 0.5cc/kg/hr\n so far urine output good\n - f/u blood and urine cult\n - do another blood culture today from Port and venipuncture\n bacteremic, need to pull Port\n - Per Surgery Recs (Dr. \n need to be aggressive in draining all\n of the seroma fluid; may need a CT tomorrow to evaluate for improvement\n and eval for loculation; may need to have CT Imaging place another\n drain in seroma tomorrow or the next day\n - F/U w Vascular recs\n small chance they may want to operate to\n remove graft and replace, though unlikely now because area infected\n # Left groin fluid collection s/p recection of synovial sarcoma.\n Followed by Gen and plastics. As above, most likely source of\n infection. Drain changed by IR and working well now\n - Appreciate Surgical recs\n - f/u plastics/vascular recs regarding flap reconstruction\n - wound care per \n - continue MScotin and dilaudid IV prn for breakthrough pain\n - increase frequency of pain meds\n .\n # Cardiomyopathy: EF 35% on echo in .\n - Given hypotension hold lasix, coreg, spironolactone\n - minimize IVF if possible\n - Hold digoxin\n may need to d/c as outpatient b/c of the juntional\n bradycardia he has had here, which may have just been related to the\n levophed use\n .\n #. Thrombosed left CFV and SFV. Unchanged from prior. be \n vascular surgery in this area.\n - Avoid anticoagulation at this time given possibility of further\n surgery or interventional procedure\n - discuss with surgery long term management / need for anticoagulation.\n - trend pulses\n .\n #.Anemia: Baseline low 30s. Hct has been stable here at 28.\n - T+S\n - trend HCT\n .\n #. GERD: EGD only with Irregular Z-line. Had some nausea\n yesterday when didn\nt get protonix, but improved now w PPI.\n - continue PPI\n .\n #. Depression/ anxiety:\n Pt understandably sad affect, frustrated mildly by medical situation\n but very pleasant.\n - continue celexa\n - hold ativan given hypotension\n - per patient, visitors to check in w nurse to see if he is sleeping\n before waking him up\n .\n # Asthma: stable. no home meds.\n - add nebs if symptomatic\n .\n .\n PPX:\n -DVT ppx: heparin subq\n -Bowel regimen: senna, colace\n -Pain management: MScontin, Dilaudid\n ICU Care\n Nutrition:\n Has been NPO but may eat today if Surgery plans no procedures\n Glycemic Control:\n Lines: PIV, central Port\n 18 Gauge - 06:13 AM\n Indwelling Port (PortaCath) - 06:14 AM\n Prophylaxis:\n DVT: heparin SC\n Stress ulcer: home PPI\n VAP:\n Comments:\n Communication: Comments: Father, . \n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2139-11-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 493242,
"text": "44 y/o with h/o left groin synovial sarcoma, presented to with severe left groin and abdominal pain, and fever to\n 105. Abdominal CT showed 14cm fluid collection. JP drain which had been\n placed in groin was felt to be clogged and after cultures, 4L IVF and\n abx he was sent to . Following arrival to pt became\n hypotensive requiring IVF boluses and pressors. Attempts to unclog JP\n drain were unsuccessful and new drain placed under CT guidance on\n .\n PMH: Synovial sarcoma s/p resection with arterial graft placed,\n s/p multiple surgeries for fluid accumulation in site, s/p JP insertion\n last month,Cardiomyopathy due to chemotherapy, last EF 50%, CHF,\n depression, anxiety, sinusitis, asthma, GERD\n Sepsis without organ dysfunction\n Assessment:\n Pt 3,\ntired\n Remains on levophed gtt to maintain BP.\n Urine output >100cc/hr.\n 02 sats 95-98% on room air.\n Synovial drain w/ serous fluid out (see flowsheet for totals).\n Pt c/o pain in left groin/abdomen at start of shift.\n Action:\n Attempted to wean off levophed gtt -> BP dropped to 80\ns systolic ->\n levophed gtt restarted.\n Cont abx as ordered.\n Received PO morphine SR and dilaudid IV prn as ordered for pain.\n Response:\n BP 95-115 systolic with levophed gtt.\n Temp 99.5 PO, synovial drain cont serous output.\n Urine output remains adequate.\n Resp status stable, remains on room air.\n Pt stated relief from pain following medication.\n Plan:\n Cont to monitor pts BP and urine output, titrate pressors as indicated\n to maintain perfusion.\n Cont to monitor output from synovial drain, flush drain with NS as\n ordered.\n Cont to monitor pts pain level, medicate as needed.\n"
},
{
"category": "Nursing",
"chartdate": "2139-11-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 493144,
"text": "44 y/o with h/o left groin synovial sarcoma, cardomyopathy presents to\n with 1 day of Left groin pain, left lower abdominal pain and\n fever to 102 at home. He went to (Pt lives in\n ) where pt was febrile to 105 and he c/o severe left groin,\n abdominal and upper leg pain. Abdominal CT showed 14cm fluid\n collection. JP drain which had been placed in groin was felt to be\n clogged and after cultures, 4L IVF and one dose IV zosyn pt was sent to\n EW.\n Pt continued to c/o left groin pain. Given 8mg IV morphine en route to\n . BP dropped to 90\ns in EW. Pt given 2 more liters IVF and started\n on dopamine. Right port accessed in EW. Given a dose of Vanco and sent\n to MICU for further care.\n PMH: Synovial sarcoma s/p resection with arterial graft placed,\n s/p multiple surgeries for fluid accumulation in site, s/p JP insertion\n last month,Cardiomyopathy due to chemotherapy, last EF 50%, CHF,\n depression, anxiety, sinusitis, asthma, GERD\n Allergies: Latex/Tape.\n Wound infection\n Assessment:\n Pt with large fluid collection in left groin from synovial sarcoma.\n Drain was clogged and attempts to unclog drain at bedside were\n unsuccessful. Team came up from CT to try guidewire and we used TPA\n unsuccessfully. WBC 8.2 today. Temp 99 axillary. Two blood cultures\n sent today. One from Port and one peripheral.\n Action:\n Pt brought to CT for insertion of new drain at 1530.\n Response:\n Pt continues on vanco/zosyn.\n Plan:\n Continue to follow vital signs, pt\ns temp. Give antibiotics as ordered.\n Assist pt with ADL\ns as he is very tired and in need of support.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt describes left groin pain. This pain radiates up to his left\n lower abdomen and down his left thigh. He has graft in left groin and\n also blood clot.\n Action:\n Pt given his normal dose of MS SR 30mg PO at 8AM and had needed small\n doses dilaudid 1mg IV PRN.\n Response:\n Pt states relief after 1mg IV dilaudid is acceptable at 5/10. Pt\n medicated during CT procedure with fentanyl and versed IV.\n Plan:\n Continue to assess pain and administer meds as needed.\n Ineffective Coping\n Assessment:\n Pt has history depression and is feeling poorly at this point. He is\n being followed by our social worker .\n Action:\n Seen by today. He did not feel well enough to talk. Pt asked for\n all visitors to check in with nurse and if he is sleeping to allow him\n to sleep.\n Response:\n Being followed by SW and visitors checked at desk. His family is aware\n of pt\ns request. His mother, father and sister visited and let him\n sleep until he needed to be awake to go to CT for drain insertion.\n Plan:\n Monitor pt\ns mood and administer meds as ordered. Continue to offer\n support and encourage pt to verbalize his concerns.\n Sepsis without organ dysfunction\n Assessment:\n Pt remains on pressors. Dopamine changed to levophed drip. Currently\n running at .1mcg/kg/min. IVF stopped as pt seemed to have Large jugular\n veins on AM assessment.\n Action:\n Response:\n BP goal is MAP>65 UO remains excellent via foley.\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2139-11-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 493102,
"text": "44 y/o with h/o left groin synovial sarcoma, cardomyopathy presents to\n with 1 day of Left groin pain, left lower abdominal pain and\n fever to 102 at home. He went to (Pt lives in\n ) where pt was febrile to 105 and he c/o severe left groin,\n abdominal and upper leg pain. Abdominal CT showed 14cm fluid\n collection. JP drain which had been placed in groin was felt to be\n clogged and after cultures, 4L IVF and one dose IV zosyn pt was sent to\n EW.\n Pt continued to c/o left groin pain. Given 8mg IV morphine en route to\n . BP dropped to 90\ns in EW. Pt given 2 more liters IVF and started\n on dopamine. Right port accessed in EW. Given a dose of Vanco and sent\n to MICU for further care.\n PMH: Synovial sarcoma s/p resection with arterial graft placed,\n s/p multiple surgeries for fluid accumulation in site, s/p JP insertion\n last month,Cardiomyopathy due to chemotherapy, last EF 50%, CHF,\n depression, anxiety, sinusitis, asthma, GERD\n Allergies: Latex/Tape.\n Wound infection\n Assessment:\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n Ineffective Coping\n Assessment:\n Action:\n Response:\n Plan:\n Sepsis without organ dysfunction\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2139-11-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 493300,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED\n - CT Imaging attempt at bedside to unclog drain w alteplase didn\nt work\n - IR procedure to change catheter draining fluid collection in groin\n increased drain output\n - dopamine was switched to levophed\n - bradycardia appears related to levophed\n Allergies:\n Latex\n Rash;\n Adhesive Tape (Topical)\n red skin/paper\n Last dose of Antibiotics:\n Vancomycin - 07:30 PM\n Piperacillin/Tazobactam (Zosyn) - 11:59 PM\n Infusions:\n Norepinephrine - 0.04 mcg/Kg/min\n Other ICU medications:\n Hydromorphone (Dilaudid) - 03:24 AM\n Pantoprazole (Protonix) - 06:06 AM\n Heparin Sodium (Prophylaxis) - 06:06 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100.1\n Tcurrent: 37.4\nC (99.4\n HR: 51 (48 - 110) bpm\n BP: 101/48(61) {82/45(53) - 124/78(86)} mmHg\n RR: 15 (12 - 21) insp/min\n SpO2: 95%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 86.6 kg (admission): 89 kg\n Height: 68 Inch\n Total In:\n 7,736 mL\n 174 mL\n PO:\n TF:\n IVF:\n 1,616 mL\n 174 mL\n Blood products:\n Total out:\n 4,725 mL\n 900 mL\n Urine:\n 2,625 mL\n 710 mL\n NG:\n Stool:\n Drains:\n 700 mL\n 190 mL\n Balance:\n 3,011 mL\n -726 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 95%\n ABG: ///22/\n Physical Examination\n General Appearance: Thin\n Eyes / Conjunctiva: Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: Rate 60s, Reg Rhythm, ?Rub, JVP\n Peripheral Vascular: left PT 1+, left fem dopplerable\n Respiratory / Chest: clear bilaterally to auscultation\n Abdominal: Soft, Bowel sounds present, Tender: LLQ, TTP in LLQ> LUQ\n without rebound or guarding. No HSM. JP drain with 20cc of serosangious\n fluid in LLQ, without sign of infection\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: 2+, In left groin approx 6cm skin flap with 3cm open wound\n draining serous fluid. mild erthyema and warmth. No pus\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Oriented: x3\n Labs / Radiology\n 187 K/uL\n 9.7 g/dL\n 112 mg/dL\n 0.8 mg/dL\n 22 mEq/L\n 3.6 mEq/L\n 6 mg/dL\n 108 mEq/L\n 139 mEq/L\n 28.7 %\n 7.2 K/uL\n [image002.jpg]\n 07:43 AM\n 03:27 AM\n WBC\n 9.5\n 7.2\n Hct\n 29.1\n 28.7\n Plt\n 192\n 187\n Cr\n 0.8\n 0.8\n Glucose\n 134\n 112\n Other labs: PT / PTT / INR:12.5/23.2/1.1, CK / CKMB / Troponin-T:150//,\n ALT / AST:18/15, Alk Phos / T Bili:99/0.3, Differential-Neuts:79.8 %,\n Lymph:12.1 %, Mono:6.3 %, Eos:1.7 %, LDH:154 IU/L, Ca++:8.5 mg/dL,\n Mg++:2.1 mg/dL, PO4:2.2 mg/dL\n CT:\n 1. Large fluid collection tracking along the left iliopsoas muscle,\n through\n the left inguinal canal, possiboly the iliopsoas bursa. Though this\n collection\n contains a pigtail catheter, the collection is larger in size compared\n to\n .\n 2. Asymmetric enlargement of the left lower extremity relative to the\n right,\n with subcutaneous, intermuscular, and muscular edema.\n 3. Thrombosis of left common femoral vein and superficial femoral\n veins,\n unchanged.\n Assessment and Plan\n ASSESSMENT AND PLAN: 44 y/o with synovial sarcoma s/p resection and\n multiple drainage of seroma presents with LLQ / left groin pain and\n fever.\n .\n #. Sepsis: Febrile to 100.1 with persisting mild hypotension despite 6L\n IVF recussitation suggestive of sepsis w fluid collection the most\n likely source of infection. The presences of dacron graft in the area\n is worrisome for possible colonization of the foreign body. Drain\n changed by IR yesterday\n - continue vanco and zosyn for broad coverage\n - Wean dopamine for goal MAP > 65\n - IVF as needed for hypotenson. Given PVC on CXR and JVP at mandible\n minimize at this time.\n - monitor UO for goal > 0.5cc/kg/hr.\n - f/u blood and urince cult\n - survalience blood cult today\n # Left groin fluid collection s/p recection of synovial sarcoma.\n Followed by Gen and plastics. As above, most likely source of\n infection. Drain changed by IR\n - Appreciate Surgical recs\n - f/u plastic recs regarding flap reconstruction\n - wound care per \n - continue MScotin and dilaudid IV prn for breakthrough pain\n .\n # Cardiomyopathy: EF 35% on echo in .\n - Given hypotension hold lasix, coreg, spironolactone\n - minimize IVF if possible\n - continue dig\n .\n #. Thrombosed left CFV and SFV. Unchanged from prior. F.u final CT\n read. Likely vascular surgery in this area.\n - Avoid anticoagulation at this time given IR drainage / possible\n surgery\n - discuss with surgery long term management / need for anticoagulation.\n - trend pulses\n .\n #.Anemia: Baseline low 30s. Currently 28.6. Drop likely dilational\n given aggressive fluid recussitation.\n - T+S\n - trend HCT\n .\n #. GERD: EGD only with Irregular Z-line.\n - continue PPI\n .\n #. Depression/ anxiety: continue celexa\n - hold ativan given hypotension\n - per patient, visitors to check in w nurse to see if he is sleeping\n before waking him up\n .\n # Asthma: stable. no home meds.\n - add nebs if symptomatic\n .\n .\n PPX:\n -DVT ppx: heparin subq\n -Bowel regimen: senna, colace\n -Pain management: MScontin, Dilaudid\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines: PIV's\n 18 Gauge - 06:13 AM\n Indwelling Port (PortaCath) - 06:14 AM\n Prophylaxis:\n DVT: heparin SC\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments: Father, . \n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2139-11-23 00:00:00.000",
"description": "Physician Resident/Attending Admission Note - MICU",
"row_id": 493137,
"text": "Chief Complaint: Left groin / LLQ pain and fever\n HPI:\n 44 y/o with h/o left groin synovial sarcoma, cardomyopathy presents to\n with 1 day of Left groin pain and fever to 102 at home. He felt\n normal until this am when he developed rapidly worsenging Left\n groin/LLQ pain. The pain is described as a deep, dull ache which\n radiates down the left leg. He has decreased ROM and increased swelling\n in the left leg as well. He has a JP drain in place from last admission\n which was previously putting out 200-300cc daily which has decreased to\n 25cc daily over the last week. His wound vac was discontinued by Dr\n last THursday. This am after he was seen by VNA he developed Fever\n to 102 and rigors. He reports Nausea and vomitting x 2 in the ED,\n non-bloody. No diarrhea.\n .\n Mr. was initially diagnosed with synovial sarcoma in\n 3/. Biopsy on showed a malignant spindle cell\n neoplasm, intermediate grade, most consistent with synovial\n sarcoma, predominantly monophasic type. He completed\n neoadjuvant adriamycin/radiation followed by resection\n of left pelvic the synovial sarcoma on . The resection included\n excision of the left external iliac artery and vein with a 10-mm Dacron\n graft reconstruction extending from the proximal origin of the external\n iliac to the common femoral artery. He was\n re-hospitalized /09 with abdominal pain, nausea, and\n vomiting with fluid collection and concern for infection at the\n operative site. He was treated with vancomycin and Zosyn, and then\n discharged to home on ciprofloxacin and metronidazole. Mr was\n again admitted from for abd pain, fever, N/V and underwent\n US-guided drainage of left inguinal seroma () Left groin\n exploration and debridement of lymphocele and vacuum-assisted closure\n device placement (). He was discharged on Bactrim. He presented\n again on , undergoing an additional CT guided drainage and\n placement of JP drain with continued treatment with bactrim.\n .\n Review of systems is otherwise normal. No nightsweats. No myalgias.\n Mild sore throat this am. No SOB, cough, chest pain, palpatations, PND\n or orthopnea, dysuria or urinary frequency. No diarrhea or blood in\n stool.\n .\n In the emergency department at Tm 105. At he received zosyn\n 3.375 mg, ? vanco 1gm, 4mg dilaudid, 4L IVF. Enroute received 8mg IV\n morphine. On presentation to 102.7, HR 116, BP 104/62, RR 16, 97%\n RA. At he has received 2mg Dilaudid, vanco 1g, 2L IVF (for total of\n 6L), tylenol 500mg, zofran 2mg, and dopamine @ 5 for hypotension with\n SBP 90. CT abd/pelvis should enlarging left illiopsoas fluid collection\n with pigtail in place. CXR with mild PVC. EKG normal.\n Patient admitted from: ER\n Allergies:\n Latex\n Rash;\n Adhesive Tape (Topical)\n red skin/paper\n Last dose of Antibiotics:\n Infusions:\n Dopamine - 5 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Furosemide 40mg daily\n Lisinopril 5mg daily\n spironolactone 25mg daily\n acetaminophen 325mg 1-2tab PO q4h prn\n digoxin 125mcg PO daily\n Prochlorperazine 5mg tab PO q6h prn\n zolpidem 5mg tab PO HS\n lorazepam 0.5mg tab PO q8h\n gabapentin 300mg cap 2 cap PO HS\n citalopram 20mg 2 tab PO daily\n carvedilol 12.5mg tab PO BID\n docusate 100mg PO BID\n Bactrim 160-800mg tab tab PO BID\n Morphine sustained release 30mg PO q12h\n pantoprazole 40mg PO q12h\n Past medical history:\n Family history:\n Social History:\n cell neoplasm, intermediate grade, most consistent with synovial\n sarcoma, predominantly monophasic type. The immunohistochemical\n stain for EMA is positive, while actin, desmin, cytokeratin\n cocktail, MNF-116, CD34 and S100 were negative. He completed\n neoadjuvant adriamycin/radiation followed by resection\n of left pelvic the synovial sarcoma on . The resection included\n excision of the left external iliac artery and vein with a 10-mm Dacron\n graft reconstruction extending from the proximal origin of the external\n iliac to the common femoral artery\n 2. Cardiomyopathy - idiopathic, ?secondary to steroid abuse, EF\n previously 35%, improved to 55%\n 3. Depression/Anxiety\n 4. Gerd\n 5. Chronic sinusitis s/pt surgery with middle meatal antrostomy\n and anterior ethmoidectomy \n 6. Asthma - induced by exercise and cold weather\n 7. H/o MRSA folliculitis\n 8. Latent syphilis\n 9. HSV labialis\n maternal grandmother died of colon cancer in her 60s. CAD in his\n grandmother.\n Occupation: currently unemployed\n Drugs: distant meth use\n Tobacco: no\n Alcohol: no\n Other: lives with his parents in and is single.\n Review of systems:\n Constitutional: Fever\n Ear, Nose, Throat: sore throat x 1 day\n Cardiovascular: Tachycardia\n Nutritional Support: NPO\n Respiratory: Cough, after vomiting\n Gastrointestinal: Abdominal pain, Nausea, Emesis, vomitting x 2 in \n ED\n Musculoskeletal: left leg pain\n Heme / Lymph: Anemia\n Neurologic: Numbness / tingling, chronic decreased sensation in left\n leg\n Flowsheet Data as of 09:19 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 37.4\nC (99.4\n HR: 82 (82 - 101) bpm\n BP: 118/66(79) {108/64(74) - 118/66(79)} mmHg\n RR: 15 (15 - 20) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 89 kg (admission): 89 kg\n Height: 68 Inch\n Total In:\n 6,384 mL\n PO:\n TF:\n IVF:\n 384 mL\n Blood products:\n Total out:\n 0 mL\n 1,520 mL\n Urine:\n 120 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 4,864 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///25/\n Physical Examination\n General Appearance: Thin\n Eyes / Conjunctiva: Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (PMI Normal), (S1: Normal), Rub, JVP to mandible\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present), left PT 1+, left fem dopplerable\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Bowel sounds present, Tender: LLQ, TTP in LLQ> LUQ\n without rebound or guarding. No HSM. JP drain with 20cc of serosangious\n fluid in LLQ, without sign of infection\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: 2+, In left groin approx 6cm skin flap with 3cm open wound\n draining serous fluid. mild erthyema and warmth. No pus\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): x3, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 192 K/uL\n 10.0 g/dL\n 134 mg/dL\n 0.8 mg/dL\n 8 mg/dL\n 25 mEq/L\n 103 mEq/L\n 3.4 mEq/L\n 135 mEq/L\n 29.1 %\n 9.5 K/uL\n [image002.jpg]\n \n 2:33 A10/19/ 07:43 AM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 9.5\n Hct\n 29.1\n Plt\n 192\n Cr\n 0.8\n Glucose\n 134\n Other labs: PT / PTT / INR:13.2/24.1/1.1, CK / CKMB / Troponin-T:150//,\n Ca++:7.8 mg/dL, Mg++:1.6 mg/dL, PO4:2.1 mg/dL\n Fluid analysis / Other labs: labs\n VBG 7.43/43/28\n PT 10.3, INR 1.0. PTT 26.1\n WBC 8.1, hgb 31.2 plt 214, 87% neut, 5.7% lymph.\n lactic acid 0.9\n BUN14, Cr 1.07. Na 134, K 4, Cl98, HCO3 26\n Imaging: iliopsoas, through inguinal canal, larger in size compared to\n . A pigtail catheter is centered within the collection-\n correlate with output. Asymmetric enlargement of left leg compared to\n right leg, with inflammatory stranding/edema. Thrombosed left CFV and\n SFV, similar to prior study.\n .\n CXR: per me. : mild PVC, improved from previous imaging.\n .\n TEE: No atrial septal defect is seen by 2D or color Doppler.\n Overall left ventricular systolic function is moderately depressed\n (LVEF= 35 %). Right ventricular chamber size and free wall motion are\n normal. The aortic valve leaflets (3) are mildly thickened but aortic\n stenosis is not present. No aortic regurgitation is seen. Mild (1+)\n mitral regurgitation is seen. There is no pericardial effusion\n Microbiology: blood and urine pending\n ECG: EKG: Sinus tach at 100 bpm. NL axis. Nl intervals. TWI in III,\n flattenign in aVF, unchanged since . No st changes.\n Assessment and Plan\n ASSESSMENT AND PLAN: 44 y/o with synovial sarcoma s/p resection and\n multiple drainage of seroma presents with LLQ / left groin pain and\n fever.\n .\n #. Sepsis: Febrile to 105 with mild hypotension despite 6L IVF\n recussitation suggestive of sepsis. Location of pain with large fluid\n collection and JP in place makes the fluid collection the most likely\n source of infection. The presences of dacron graft in the area is\n worrisome for possible colonization of the foreign body. CXR without\n PNA. UA clean making them less likely as source of infection. No\n prodrome to suggest viral infection.\n - continue vanco and zosyn for broad coverage\n - Wean dopamine for goal MAP > 65\n - IVF as needed for hypotenson. Given PVC on CXR and JVP at mandible\n minimize at this time.\n - monitor UO for goal > 0.5cc/kg/hr.\n - f/u blood and urince cult\n - survalience blood cult today\n # Left groin fluid collection s/p recection of synovial sarcoma.\n Followed by Gen and plastics. As above, most likely source of\n infection.\n - Appreciate Surgical recs\n - Plan for IR guided drainage of fluid collection / drain placement\n - If collection loculated may need OR washout\n - f/u plastic recs regarding flap reconstruction\n - wound care per \n - follow up final read CT.\n - continue MScotin and dilaudid IV prn for breakthrough pain\n - check CK given asymmetric swelling and pain r/o compartment syndrome\n .\n # Cardiomyopathy: EF 35% on echo in .\n - Given hypotension hold lasix, coreg, spironolactone\n - minimize IVF if possible\n - continue dig\n .\n #. Thrombosed left CFV and SFV. Unchanged from prior. F.u final CT\n read. Likely vascular surgery in this area.\n - Avoid anticoagulation at this time given IR drainage / possible\n surgery\n - discuss with surgery long term management / need for anticoagulation.\n - trend pulses\n .\n #.Anemia: Baseline low 30s. Currently 28.6. Drop likely dilational\n given aggressive fluid recussitation.\n - T+S\n - trend HCT\n .\n #. GERD: EGD only with Irregular Z-line.\n - continue PPI\n .\n #. Depression/ anxiety: continue celexa\n - hold ativan given hypotension\n .\n # Asthma: stable. no home meds.\n - add nebs if symptomatic\n .\n .\n FEN: IVF prn for hypotension, NPO for IR procedure, lytes prn\n .\n PPX:\n -DVT ppx with heparin SC\n -Bowel regimen senna, colace\n -Pain management with MScontin, Dilaudid\n .\n ACCESS: PIV's\n .\n CODE STATUS: confirmed full\n .\n EMERGENCY CONTACT: Father, . \n .\n DISPOSITION: ICU\n ICU Care\n Nutrition:\n Comments: NPO for IR\n Glycemic Control:\n Lines:\n 18 Gauge - 06:13 AM\n Indwelling Port (PortaCath) - 06:14 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 44M synovial sarcoma c/b recurrent fluid\n collection L groin p/w decreased JP output, fever and hypotension.\n Exam notable for Tm 102.7 BP 110/50 HR 94 RR 16 with sat 97 on RA. WD\n pale man, NAD. JVD 8cm. RRR s1s2. CTA B, few rales B bases. Soft +BS. L\n groin with post surgical changes, buldging soft mass / collection with\n mod LLQ pain. No rrainage from pigtail site. LLE edema 2+. Labs notable\n for WBC 9K, HCT 29, K+ 3.5, Cr 1.0, lactate 1.5. CXR with mild volume\n overload. CT as described above.\n Agree with plan to manage likely infected L groin fluid collection with\n IR drainage via existing pigtail or new large bore drain, continue\n dilaudid for pain control, surgical team following exam closely. Will\n continue vanco / zosyn, hold IVF and wean dopa to off or transition to\n levophed for likely septic shock. UOP is excellent at this point,\n lactate <2. For chronic systolic CHF, EF has risen on recent studies,\n appears euvolemic, hold cardiac meds for now, esp given intermittent\n bradycardia with sedation / sleep. Remainder of plan as outlined above.\n Patient is critically ill\n Total time: 40 min\n ------ Protected Section Addendum Entered By: , MD\n on: 15:34 ------\n"
},
{
"category": "Physician ",
"chartdate": "2139-11-23 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 493044,
"text": "Chief Complaint: Left groin / LLQ pain and fever\n HPI:\n 44 y/o with h/o left groin synovial sarcoma, cardomyopathy presents to\n with 1 day of Left groin pain and fever to 102 at home. He felt\n normal until this am when he developed rapidly worsenging Left\n groin/LLQ pain. The pain is described as a deep, dull ache which\n radiates down the left leg. He has decreased ROM and increased swelling\n in the left leg as well. He has a JP drain in place from last admission\n which was previously putting out 200-300cc daily which has decreased to\n 25cc daily over the last week. His wound vac was discontinued by Dr\n last THursday. This am after he was seen by VNA he developed Fever\n to 102 and rigors. He reports Nausea and vomitting x 2 in the ED,\n non-bloody. No diarrhea.\n .\n Mr. was initially diagnosed with synovial sarcoma in\n 3/. Biopsy on showed a malignant spindle cell\n neoplasm, intermediate grade, most consistent with synovial\n sarcoma, predominantly monophasic type. He completed\n neoadjuvant adriamycin/radiation followed by resection\n of left pelvic the synovial sarcoma on . The resection included\n excision of the left external iliac artery and vein with a 10-mm Dacron\n graft reconstruction extending from the proximal origin of the external\n iliac to the common femoral artery. He was\n re-hospitalized /09 with abdominal pain, nausea, and\n vomiting with fluid collection and concern for infection at the\n operative site. He was treated with vancomycin and Zosyn, and then\n discharged to home on ciprofloxacin and metronidazole. Mr was\n again admitted from for abd pain, fever, N/V and underwent\n US-guided drainage of left inguinal seroma () Left groin\n exploration and debridement of lymphocele and vacuum-assisted closure\n device placement (). He was discharged on Bactrim. He presented\n again on , undergoing an additional CT guided drainage and\n placement of JP drain with continued treatment with bactrim.\n .\n Review of systems is otherwise normal. No nightsweats. No myalgias.\n Mild sore throat this am. No SOB, cough, chest pain, palpatations, PND\n or orthopnea, dysuria or urinary frequency. No diarrhea or blood in\n stool.\n .\n In the emergency department at Tm 105. At he received zosyn\n 3.375 mg, ? vanco 1gm, 4mg dilaudid, 4L IVF. Enroute received 8mg IV\n morphine. On presentation to 102.7, HR 116, BP 104/62, RR 16, 97%\n RA. At he has received 2mg Dilaudid, vanco 1g, 2L IVF (for total of\n 6L), tylenol 500mg, zofran 2mg, and dopamine @ 5 for hypotension with\n SBP 90. CT abd/pelvis should enlarging left illiopsoas fluid collection\n with pigtail in place. CXR with mild PVC. EKG normal.\n Patient admitted from: ER\n Allergies:\n Latex\n Rash;\n Adhesive Tape (Topical)\n red skin/paper\n Last dose of Antibiotics:\n Infusions:\n Dopamine - 5 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Furosemide 40mg daily\n Lisinopril 5mg daily\n spironolactone 25mg daily\n acetaminophen 325mg 1-2tab PO q4h prn\n digoxin 125mcg PO daily\n Prochlorperazine 5mg tab PO q6h prn\n zolpidem 5mg tab PO HS\n lorazepam 0.5mg tab PO q8h\n gabapentin 300mg cap 2 cap PO HS\n citalopram 20mg 2 tab PO daily\n carvedilol 12.5mg tab PO BID\n docusate 100mg PO BID\n Bactrim 160-800mg tab tab PO BID\n Morphine sustained release 30mg PO q12h\n pantoprazole 40mg PO q12h\n Past medical history:\n Family history:\n Social History:\n cell neoplasm, intermediate grade, most consistent with synovial\n sarcoma, predominantly monophasic type. The immunohistochemical\n stain for EMA is positive, while actin, desmin, cytokeratin\n cocktail, MNF-116, CD34 and S100 were negative. He completed\n neoadjuvant adriamycin/radiation followed by resection\n of left pelvic the synovial sarcoma on . The resection included\n excision of the left external iliac artery and vein with a 10-mm Dacron\n graft reconstruction extending from the proximal origin of the external\n iliac to the common femoral artery\n 2. Cardiomyopathy - idiopathic, ?secondary to steroid abuse, EF\n previously 35%, improved to 55%\n 3. Depression/Anxiety\n 4. Gerd\n 5. Chronic sinusitis s/pt surgery with middle meatal antrostomy\n and anterior ethmoidectomy \n 6. Asthma - induced by exercise and cold weather\n 7. H/o MRSA folliculitis\n 8. Latent syphilis\n 9. HSV labialis\n maternal grandmother died of colon cancer in her 60s. CAD in his\n grandmother.\n Occupation: currently unemployed\n Drugs: distant meth use\n Tobacco: no\n Alcohol: no\n Other: lives with his parents in and is single.\n Review of systems:\n Constitutional: Fever\n Ear, Nose, Throat: sore throat x 1 day\n Cardiovascular: Tachycardia\n Nutritional Support: NPO\n Respiratory: Cough, after vomiting\n Gastrointestinal: Abdominal pain, Nausea, Emesis, vomitting x 2 in \n ED\n Musculoskeletal: left leg pain\n Heme / Lymph: Anemia\n Neurologic: Numbness / tingling, chronic decreased sensation in left\n leg\n Flowsheet Data as of 09:19 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 37.4\nC (99.4\n HR: 82 (82 - 101) bpm\n BP: 118/66(79) {108/64(74) - 118/66(79)} mmHg\n RR: 15 (15 - 20) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 89 kg (admission): 89 kg\n Height: 68 Inch\n Total In:\n 6,384 mL\n PO:\n TF:\n IVF:\n 384 mL\n Blood products:\n Total out:\n 0 mL\n 1,520 mL\n Urine:\n 120 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 4,864 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///25/\n Physical Examination\n General Appearance: Thin\n Eyes / Conjunctiva: Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (PMI Normal), (S1: Normal), Rub, JVP to mandible\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present), left PT 1+, left fem dopplerable\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Bowel sounds present, Tender: LLQ, TTP in LLQ> LUQ\n without rebound or guarding. No HSM. JP drain with 20cc of serosangious\n fluid in LLQ, without sign of infection\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: 2+, In left groin approx 6cm skin flap with 3cm open wound\n draining serous fluid. mild erthyema and warmth. No pus\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): x3, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 192 K/uL\n 10.0 g/dL\n 134 mg/dL\n 0.8 mg/dL\n 8 mg/dL\n 25 mEq/L\n 103 mEq/L\n 3.4 mEq/L\n 135 mEq/L\n 29.1 %\n 9.5 K/uL\n [image002.jpg]\n \n 2:33 A10/19/ 07:43 AM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 9.5\n Hct\n 29.1\n Plt\n 192\n Cr\n 0.8\n Glucose\n 134\n Other labs: PT / PTT / INR:13.2/24.1/1.1, CK / CKMB / Troponin-T:150//,\n Ca++:7.8 mg/dL, Mg++:1.6 mg/dL, PO4:2.1 mg/dL\n Fluid analysis / Other labs: labs\n VBG 7.43/43/28\n PT 10.3, INR 1.0. PTT 26.1\n WBC 8.1, hgb 31.2 plt 214, 87% neut, 5.7% lymph.\n lactic acid 0.9\n BUN14, Cr 1.07. Na 134, K 4, Cl98, HCO3 26\n Imaging: iliopsoas, through inguinal canal, larger in size compared to\n . A pigtail catheter is centered within the collection-\n correlate with output. Asymmetric enlargement of left leg compared to\n right leg, with inflammatory stranding/edema. Thrombosed left CFV and\n SFV, similar to prior study.\n .\n CXR: per me. : mild PVC, improved from previous imaging.\n .\n TEE: No atrial septal defect is seen by 2D or color Doppler.\n Overall left ventricular systolic function is moderately depressed\n (LVEF= 35 %). Right ventricular chamber size and free wall motion are\n normal. The aortic valve leaflets (3) are mildly thickened but aortic\n stenosis is not present. No aortic regurgitation is seen. Mild (1+)\n mitral regurgitation is seen. There is no pericardial effusion\n Microbiology: blood and urine pending\n ECG: EKG: Sinus tach at 100 bpm. NL axis. Nl intervals. TWI in III,\n flattenign in aVF, unchanged since . No st changes.\n Assessment and Plan\n ASSESSMENT AND PLAN: 44 y/o with synovial sarcoma s/p resection and\n multiple drainage of seroma presents with LLQ / left groin pain and\n fever.\n .\n #. Sepsis: Febrile to 105 with mild hypotension despite 6L IVF\n recussitation suggestive of sepsis. Location of pain with large fluid\n collection and JP in place makes the fluid collection the most likely\n source of infection. The presences of dacron graft in the area is\n worrisome for possible colonization of the foreign body. CXR without\n PNA. UA clean making them less likely as source of infection. No\n prodrome to suggest viral infection.\n - continue vanco and zosyn for broad coverage\n - Wean dopamine for goal MAP > 65\n - IVF as needed for hypotenson. Given PVC on CXR and JVP at mandible\n minimize at this time.\n - monitor UO for goal > 0.5cc/kg/hr.\n - f/u blood and urince cult\n - survalience blood cult today\n # Left groin fluid collection s/p recection of synovial sarcoma.\n Followed by Gen and plastics. As above, most likely source of\n infection.\n - Appreciate Surgical recs\n - Plan for IR guided drainage of fluid collection / drain placement\n - If collection loculated may need OR washout\n - f/u plastic recs regarding flap reconstruction\n - wound care per \n - follow up final read CT.\n - continue MScotin and dilaudid IV prn for breakthrough pain\n - check CK given asymmetric swelling and pain r/o compartment syndrome\n .\n # Cardiomyopathy: EF 35% on echo in .\n - Given hypotension hold lasix, coreg, spironolactone\n - minimize IVF if possible\n - continue dig\n .\n #. Thrombosed left CFV and SFV. Unchanged from prior. F.u final CT\n read. Likely vascular surgery in this area.\n - Avoid anticoagulation at this time given IR drainage / possible\n surgery\n - discuss with surgery long term management / need for anticoagulation.\n - trend pulses\n .\n #.Anemia: Baseline low 30s. Currently 28.6. Drop likely dilational\n given aggressive fluid recussitation.\n - T+S\n - trend HCT\n .\n #. GERD: EGD only with Irregular Z-line.\n - continue PPI\n .\n #. Depression/ anxiety: continue celexa\n - hold ativan given hypotension\n .\n # Asthma: stable. no home meds.\n - add nebs if symptomatic\n .\n .\n FEN: IVF prn for hypotension, NPO for IR procedure, lytes prn\n .\n PPX:\n -DVT ppx with heparin SC\n -Bowel regimen senna, colace\n -Pain management with MScontin, Dilaudid\n .\n ACCESS: PIV's\n .\n CODE STATUS: confirmed full\n .\n EMERGENCY CONTACT: Father, . \n .\n DISPOSITION: ICU\n ICU Care\n Nutrition:\n Comments: NPO for IR\n Glycemic Control:\n Lines:\n 18 Gauge - 06:13 AM\n Indwelling Port (PortaCath) - 06:14 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2139-11-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 493389,
"text": "44 y/o with h/o left groin synovial sarcoma, presented to with severe left groin and abdominal pain, and fever to\n 105. Abdominal CT showed 14cm fluid collection. JP drain which had been\n placed in groin was felt to be clogged and after cultures, 4L IVF and\n abx he was sent to . Following arrival to pt became\n hypotensive requiring IVF boluses and pressors. Attempts to unclog JP\n drain were unsuccessful and new drain placed under CT guidance on\n .\n PMH: Synovial sarcoma s/p resection with arterial graft placed,\n s/p multiple surgeries for fluid accumulation in site, s/p JP insertion\n last month,Cardiomyopathy due to chemotherapy, last EF 50%, CHF,\n depression, anxiety, sinusitis, asthma, GERD\n Sepsis without organ dysfunction\n Assessment:\n Pt a&ox3, tired in am sleeping in am in naps. Received pt on levophed\n at 0.04mcg/kg/min. sbp in 100s. hr in 40s-60s sb/sr. u.o. remains\n >30cc/hr. 02 sats remain >95% on rm air. Lungs clear.\n Action:\n Levophed weaned off with sbp in 90s-80s while sleeping but map >60. pt\n was sleeping with arm bent lying on bp cuff. Pt woken up with sbp in\n 90s. digoxin was held and dc/\nd. after pt awake in afternoon sbp\n remained in 100s. hr 60s-100s sr/st while awake off levophed. Given iv\n vanco and zosyn. Bld cx sent from port o cath site.\n Response:\n Sbp remains stable in 100s off levophed. Hr improved 70s-100s sr/st. no\n ectopy. U.o. remains good.\n Plan:\n Continue to monitor bp, hr, u.o. continue iv abx, follow up with cx\n data.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o left groin/abd pain at 11:10am about 8 out of 0-10 pain scale.\n Action:\n Pt medicated with ms contin standing dose in am. Pt medicated with 1mg\n dilaudid iv with good effect with pain down to a 5. bp remained stable\n with sbp in 90s-100s. hr in 70s-100s.\n Response:\n Pain relieved with dilaudid for breakthrough pain.\n Plan:\n Continue standing dose of ms contin and dilaudid iv prn breakthrough\n pain.\n Wound infection\n Assessment:\n Synovial drain with serous fluid draining 770cc since mn.\n Action:\n Pigtail drainage bag removed by surgery team and switched to a JP drain\n at 15;15. dressings changed. Pigtail drain exit site clean with no\n drainage. Cleansed with\n strength hydrogen peroxide and ns and\n cleansed with ns with dsd over drain. Left groin dressing changed with\n small amt serous and serosanguinous drainage. Depth of wound 1cm,\n length approx. 2cm. bed of dressing pink. Continues on iv vanco and\n zosyn.\n Response:\n Left groin site with minimal drainage, left pigtail drain site cd&i. pt\n remains afebrile.\n Plan:\n Continue dressing changes per surgery. Monitor temp, continue iv abx.\n Access: right port o cath with double lumen patent. Heplock from\n outside hospital removed from left hand.\n"
},
{
"category": "Nursing",
"chartdate": "2139-11-24 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 493390,
"text": "44 y/o with h/o left groin synovial sarcoma, presented to with severe left groin and abdominal pain, and fever to\n 105. Abdominal CT showed 14cm fluid collection. JP drain which had been\n placed in groin was felt to be clogged and after cultures, 4L IVF and\n abx he was sent to . Following arrival to pt became\n hypotensive requiring IVF boluses and pressors. Attempts to unclog JP\n drain were unsuccessful and new drain placed under CT guidance on\n .\n PMH: Synovial sarcoma s/p resection with arterial graft placed,\n s/p multiple surgeries for fluid accumulation in site, s/p JP insertion\n last month,Cardiomyopathy due to chemotherapy, last EF 50%, CHF,\n depression, anxiety, sinusitis, asthma, GERD\n Sepsis without organ dysfunction\n Assessment:\n Pt a&ox3, tired in am sleeping in am in naps. Received pt on levophed\n at 0.04mcg/kg/min. sbp in 100s. hr in 40s-60s sb/sr. u.o. remains\n >30cc/hr. 02 sats remain >95% on rm air. Lungs clear.\n Action:\n Levophed weaned off with sbp in 90s-80s while sleeping but map >60. pt\n was sleeping with arm bent lying on bp cuff. Pt woken up with sbp in\n 90s. digoxin was held and dc/\nd. after pt awake in afternoon sbp\n remained in 100s. hr 60s-100s sr/st while awake off levophed. Given iv\n vanco and zosyn. Bld cx sent from port o cath site.\n Response:\n Sbp remains stable in 100s off levophed. Hr improved 70s-100s sr/st. no\n ectopy. U.o. remains good.\n Plan:\n Continue to monitor bp, hr, u.o. continue iv abx, follow up with cx\n data.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o left groin/abd pain at 11:10am about 8 out of 0-10 pain scale.\n Action:\n Pt medicated with ms contin standing dose in am. Pt medicated with 1mg\n dilaudid iv with good effect with pain down to a 5. bp remained stable\n with sbp in 90s-100s. hr in 70s-100s.\n Response:\n Pain relieved with dilaudid for breakthrough pain.\n Plan:\n Continue standing dose of ms contin and dilaudid iv prn breakthrough\n pain.\n Wound infection\n Assessment:\n Synovial drain with serous fluid draining 770cc since mn.\n Action:\n Pigtail drainage bag removed by surgery team and switched to a JP drain\n at 15;15. dressings changed. Pigtail drain exit site clean with no\n drainage. Cleansed with\n strength hydrogen peroxide and ns and\n cleansed with ns with dsd over drain. Left groin dressing changed with\n small amt serous and serosanguinous drainage. Depth of wound 1cm,\n length approx. 2cm. bed of dressing pink. Continues on iv vanco and\n zosyn.\n Response:\n Left groin site with minimal drainage, left pigtail drain site cd&i. pt\n remains afebrile.\n Plan:\n Continue dressing changes per surgery. Monitor temp, continue iv abx.\n Access: right port o cath with double lumen patent. Heplock from\n outside hospital removed from left hand.\n Demographics\n Attending MD:\n E.\n Admit diagnosis:\n ABDOMINAL ABCESS\n Code status:\n Full code\n Height:\n 68 Inch\n Admission weight:\n 89 kg\n Daily weight:\n 86.6 kg\n Allergies/Reactions:\n Latex\n Rash;\n Adhesive Tape (Topical)\n red skin/paper\n Precautions: Contact\n PMH:\n CV-PMH: CHF\n Additional history: pt with h/o seroma/sarcoma of L groin with mutiple\n surgeries ( resection,wound vac, artificial arteriole graft) with JP\n drain in place\n Surgery / Procedure and date: s/p resection,wound vac, artificial\n arterole graft ? date\n power port .\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:107\n D:61\n Temperature:\n 97.9\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 14 insp/min\n Heart Rate:\n 96 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 100% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 694 mL\n 24h total out:\n 1,982 mL\n Pertinent Lab Results:\n Sodium:\n 139 mEq/L\n 03:27 AM\n Potassium:\n 3.6 mEq/L\n 03:27 AM\n Chloride:\n 108 mEq/L\n 03:27 AM\n CO2:\n 22 mEq/L\n 03:27 AM\n BUN:\n 6 mg/dL\n 03:27 AM\n Creatinine:\n 0.8 mg/dL\n 03:27 AM\n Glucose:\n 112 mg/dL\n 03:27 AM\n Hematocrit:\n 28.7 %\n 03:27 AM\n Valuables / Signature\n Patient valuables: cell phone\n Other valuables:\n Clothes: sent with pt\n / Money:\n No money / \n Cash / Credit cards: none\n Jewelry: none\n Transferred from: 4 icu\n Transferred to: 5south\n Date & time of Transfer: 16;00\n"
}
] |
99,464 | 153,692 | 75 yo M with COPD, aortic dissection, recent spinal cord infarction, paraplegia, depression, admitted with altered mental status, somnolence, increased abdominal distension concerning for colonic pseudo-obstruction. After discussion with family and wife, a goals of care discussion revealed comfort measures only was appropriate (as of ). He was maintained on opioids for pain control and his colonic distention worsened. The patient expired on . . A death certificate was completed, an autopsy was declined by the family. The attending of record was notified. | Enlargement of the aortic knob and descending thoracic aortic contours likely relate to a known intramural hematoma, as seen on CT from . Pleural effusions and bibasilar atelectasis are better seen in prior CT. Comparison is made with CT, . COMPARISON: Outside hospital chest radiographs from . Marked distention of large bowel loops is unchanged. REASON FOR THIS EXAMINATION: {See Clinical Indication Field} No contraindications for IV contrast FINAL REPORT INDICATION: Desaturation with rhonchorous breath sounds. Chest radiograph from . Outside hospital CT abdomen from . 9:09 PM CHEST (PORTABLE AP) Clip # Reason: {See Clinical Indication Field} MEDICAL CONDITION: History: 75M with desats, rhoncorous breath sounds Clinical Question: PNA, other acute? FINDINGS: A single semi-erect portable radiograph of the chest was acquired. IMPRESSION: Distention of large bowel loops. Findings concerning for bibasilar aspiration pneumonitis and/or pneumonia. Small bilateral pleural effusions are better appreciated on the outside hospital CT from earlier today at 5:32 p.m. Bibasilar and right mid lung heterogeneous opacities are at least partially due to compressive atelectasis, although a concomitant bibasilar process such as aspiration pneumonitis or infection is thought likely. Evaluate for pneumonia or other acute process. there is air in the rectum. Bilateral small pleural effusions, as seen on CT from earlier today at 5:32 p.m. IMPRESSION: 1. Degenerative changes are in the lower lumbar spine. Concomitant atelectasis is also present at the bases. The heart size is normal. There is no pneumothorax. No evidence of obstruction. 12:25 PM PORTABLE ABDOMEN Clip # Reason: evaluate for obstruction or free air Admitting Diagnosis: ABDOMINAL DISTENTION;RESPIRATORY DISTRESS MEDICAL CONDITION: 75 year old man with abdominal distension, colonic pseudoobstruction REASON FOR THIS EXAMINATION: evaluate for obstruction or free air FINAL REPORT ABDOMEN REASON FOR EXAM: Abdominal distention, colonic pneudo-obstruction, assess for free air. 2. | 2 | [
{
"category": "Radiology",
"chartdate": "2146-04-09 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1231313,
"text": " 12:25 PM\n PORTABLE ABDOMEN Clip # \n Reason: evaluate for obstruction or free air\n Admitting Diagnosis: ABDOMINAL DISTENTION;RESPIRATORY DISTRESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with abdominal distension, colonic pseudoobstruction\n REASON FOR THIS EXAMINATION:\n evaluate for obstruction or free air\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMEN\n\n REASON FOR EXAM: Abdominal distention, colonic pneudo-obstruction, assess for\n free air.\n\n Comparison is made with CT, .\n\n Marked distention of large bowel loops is unchanged. there is air in the\n rectum. There is no evidence of free air or pathologic intra-abdominal\n calcifications. Degenerative changes are in the lower lumbar spine. Pleural\n effusions and bibasilar atelectasis are better seen in prior CT.\n\n IMPRESSION: Distention of large bowel loops. No evidence of obstruction.\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-04-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1231254,
"text": " 9:09 PM\n CHEST (PORTABLE AP) Clip # \n Reason: {See Clinical Indication Field}\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 75M with desats, rhoncorous breath sounds Clinical Question: PNA,\n other acute?\n REASON FOR THIS EXAMINATION:\n {See Clinical Indication Field}\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Desaturation with rhonchorous breath sounds. Evaluate for\n pneumonia or other acute process.\n\n COMPARISON: Outside hospital chest radiographs from . Outside\n hospital CT abdomen from . Chest radiograph from .\n\n FINDINGS: A single semi-erect portable radiograph of the chest was acquired.\n Small bilateral pleural effusions are better appreciated on the outside\n hospital CT from earlier today at 5:32 p.m. Bibasilar and right mid lung\n heterogeneous opacities are at least partially due to compressive atelectasis,\n although a concomitant bibasilar process such as aspiration pneumonitis or\n infection is thought likely. There is no pneumothorax. The heart size is\n normal. Enlargement of the aortic knob and descending thoracic aortic\n contours likely relate to a known intramural hematoma, as seen on CT from\n .\n\n IMPRESSION:\n\n 1. Findings concerning for bibasilar aspiration pneumonitis and/or pneumonia.\n Concomitant atelectasis is also present at the bases.\n\n 2. Bilateral small pleural effusions, as seen on CT from earlier today at\n 5:32 p.m.\n\n"
}
] |
77,271 | 148,746 | The patient is a 67 year old right handed woman with a history of atrial fibrillation not on Coumadin, hypertension, and hyperlipidemia who presented with a minute episode of word-finding difficulties with possible reported L facial droop, and then had another episode of expressive aphasia while in the ED. She was a Code Stroke in the ED, with blood pressure 210/120 on admission. CTA Head/Neck, CTP showed dense left MCA with perfusion imaging demonstrating ischemic tissue in the left MCA distribution, filling defect within the distal M1 segment of the left MCA compatible with acute clot, and no evidence for hemorrhage. MRI/MRA showed tiny areas of increased signal on diffusion images in the left frontal lobe and external capsule insular region, and no significant abnormalities on MRA of the head. TTE showed LVEF 50-55%, no PFO or ASD, mild global left ventricular hypokinesis, which may be partially explained by the markedly irregular rhythm, mild (1+) mitral regurgitation. Given that she had a mild aphasia and likely cardioembolic source of stroke, thrombolysis was not given. CEs: CK 75-59-56, TropT <0.01 x2, FLP Chol 194, TG 90, HDL 66, LDL 110, HgA1c 5.9%, TSH 2.4, CRP 7.9. She was started on a heparin gtt given the partial opacification of the M2 segment of L MCA suggesting intraarterial embolus. She was initially admitted to NeuroICU, but transferred to the Neurology floor when stable. She was continued on a heparin gtt for bridge to Coumadin 5 mg daily. Her ASA was discontinued. She was discharged on Lovenox 100 to finish the bridge to Coumadin, and her INR was 1.6 at the time of discharge. Her PCP, . , will follow her INR as an outpatient. Her blood pressure was initially allowed to auto-regulate, but her home doses of Atenolol 12.5 mg daily, Verapamil 240 daily, and HCTZ 25 daily were restarted at the time of discharge. She was continued on Simvastatin 80 daily. She will follow up with Dr. in Neurology as an outpatient. Her UA showed neg leuk, pos nitr, 3 WBC, many bacteria. Urine culture grew pan-sensitive E. coli, and she was started on Bactrim DS to complete a 5 day course. | BUBBLE STUDY.Height: (in) 62Weight (lb): 251BSA (m2): 2.11 m2BP (mm Hg): 141/73HR (bpm): 92Status: InpatientDate/Time: at 10:41Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: SalineTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Mild LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Transient ischemic attack (TIA) Assessment: Periodic word finding difficulties, otherwise neurologically intact Action: Q1 hour neuro checks, heparin gtt, Response: Neurologically waxes and wanes Plan: Cont neuro checks, await reliable family member to complete MRI checklist, hold antihypertensives, heparin gtt Atrial fibrillation (Afib) Assessment: In and out of afib Action: Heparin gtt, rule out for MI Response: Cont to be in and out of afib, no chest pain, Plan: 3^rd set of CPKs at 1000, restart heparin at 0630 at 1100units-check PTT in 6 hours, TTE Trace AR.MITRAL VALVE: Mild (1+) MR.TRICUSPID VALVE: Physiologic TR. Transient ischemic attack (TIA) Assessment: Periodic word finding difficulties, otherwise neurologically intact Action: Q1 hour neuro checks, heparin gtt, Response: Neurologically waxes and wanes Plan: Cont neuro checks, await reliable family member to complete MRI checklist, hold antihypertensives, heparin gtt Atrial fibrillation (Afib) Assessment: In and out of afib Action: Heparin gtt, rule out for MI Response: Plan: (Over) 8:01 PM CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # CT BRAIN PERFUSION Reason: TIA, SLURRED SPEECH, LT SIDED FACIAL DROOP Contrast: OPTIRAY Amt: 120 FINAL REPORT (Cont) Mild (1+) mitral regurgitation is seen. Mild global LV hypokinesis. Normal global and regional biventricularsystolic function. Pt remains NPO until after F/U MRI. Chief complaint: Stroke PMHx: HTN' Hyperlipidemia, afib not on anticoagulation without known contraindication; L total knee replaecment in ; obesity -anxiety, nephrectomy in for renal malignancy, OA, TAHSO CVA (Stroke, Cerebral infarction), Ischemic Assessment: Pt is neurologically intact, able to speak fluently and identify objects without difficulty, however reports that she feels only about 95% back to normal in this regard she feels it takes her a bit longer to find words, etc. Chief complaint: Stroke PMHx: HTN' Hyperlipidemia, afib not on anticoagulation without known contraindication; L total knee replaecment in ; obesity -anxiety, nephrectomy in for renal malignancy, OA, TAHSO CVA (Stroke, Cerebral infarction), Ischemic Assessment: Pt is neurologically intact, able to speak fluently and identify objects without difficulty, however reports that she feels only about 95% back to normal in this regard she feels it takes her a bit longer to find words, etc. Chief complaint: Stroke PMHx: HTN' Hyperlipidemia, afib not on anticoagulation without known contraindication; L total knee replaecment in ; obesity -anxiety, nephrectomy in for renal malignancy, OA, TAHSO CVA (Stroke, Cerebral infarction), Ischemic Assessment: Pt is neurologically intact, able to speak fluently and identify objects without difficulty, however reports that she feels only about 95% back to normal in this regard she feels it takes her a bit longer to find words, etc. The patient is left vertebral artery dominant. Filling defect within the distal M1 segment of the left MCA compatible with acute clot. CVA (Stroke, Cerebral infarction), Ischemic Assessment: Pt is neurologically intact, able to speak fluently and identify objects without difficulty, however reports that she feels only about 95% back to normal in this regard she feels it takes her a bit longer to find words, etc. Trace aortic regurgitationis seen. 8:01 PM CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # CT BRAIN PERFUSION Reason: TIA, SLURRED SPEECH, LT SIDED FACIAL DROOP Contrast: OPTIRAY Amt: 120 MEDICAL CONDITION: 67 year old woman with TIA like symptoms (slurred speach, left sided faical droop) now resolved REASON FOR THIS EXAMINATION: ? Demographics Attending MD: Admit diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK Code status: Height: 62 Inch Admission weight: 113.9 kg Daily weight: Allergies/Reactions: No Known Drug Allergies Precautions: PMH: CV-PMH: Arrhythmias, Hypertension Additional history: HTN, HLD, L knee replacement in , obesity, anxiety, nephrectomy in for renal malignancy Surgery / Procedure and date: Latest Vital Signs and I/O Non-invasive BP: S:156 D:87 Temperature: 98.6 Arterial BP: S: D: Respiratory rate: 20 insp/min Heart Rate: 89 bpm Heart rhythm: AF (Atrial Fibrillation) O2 delivery device: None O2 saturation: 95% % O2 flow: 2 L/min FiO2 set: 24h total in: 1,478 mL 24h total out: 2,375 mL Pertinent Lab Results: Sodium: 141 mEq/L 04:12 AM Potassium: 4.1 mEq/L 04:12 AM Chloride: 103 mEq/L 04:12 AM CO2: 28 mEq/L 04:12 AM BUN: 22 mg/dL 04:12 AM Creatinine: 1.0 mg/dL 04:12 AM Glucose: 133 mg/dL 04:12 AM Hematocrit: 35.7 % 04:12 AM Finger Stick Glucose: 110 04:00 PM Valuables / Signature Patient valuables: eye glasses with patient Other valuables: Clothes: Sent home with: Wallet / Money: No money / wallet Cash / Credit cards sent home with: Jewelry: Transferred from: SICU A Transferred to: 1117 Date & time of Transfer: @ | 11 | [
{
"category": "Radiology",
"chartdate": "2100-10-14 00:00:00.000",
"description": "CT BRAIN PERFUSION",
"row_id": 1044376,
"text": " 8:01 PM\n CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # \n CT BRAIN PERFUSION\n Reason: TIA, SLURRED SPEECH, LT SIDED FACIAL DROOP\n Contrast: OPTIRAY Amt: 120\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with TIA like symptoms (slurred speach, left sided faical\n droop) now resolved\n REASON FOR THIS EXAMINATION:\n ? hemmorage\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: CT of the head without contrast.\n\n HISTORY: 67-year-old female presenting with new-onset aphasia.\n\n COMPARISONS: None.\n\n TECHNIQUE: 5-mm axial contiguous images of the head were obtained.\n\n CT HEAD: There is no acute intracranial hemorrhage, shift of normally midline\n structures, hydrocephalus, or major apparent vascular territorial infarction.\n However, the left middle cerebral artery appears relatively hyperdense\n compared to the contralateral side. A sylvian dot sign may be evident as\n well. Mild low- attenuation area within the periventricular white matter is\n consistent with chronic small vessel disease. The visualized paranasal sinuses\n and mastoid air cells appear well aerated. Soft tissues and osseous structures\n are intact.\n\n CTA HEAD AND NECK: A filling defect is noted within the distal aspect of the\n left M1 segment. The patient is left vertebral artery dominant. The circle of\n is otherwise unremarkable without evidence of stenosis or aneurysm.\n\n CT PERFUSION: CT perfusion imaging demonstrates increased mean transit time\n and a decrease in blood flow with relatively preserved blood volume,\n confirming ischemic tissue (penumbra) within the left MCA territory.\n\n IMPRESSION: Dense left MCA with perfusion imaging demonstrating ischemic\n tissue in the left MCA distribution. Filling defect within the distal M1\n segment of the left MCA compatible with acute clot. No evidence for\n hemorrhage.\n\n Findings were discussed immediately with Drs. and of the\n neurology service at the time of interpretation by Dr. .\n\n\n\n (Over)\n\n 8:01 PM\n CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # \n CT BRAIN PERFUSION\n Reason: TIA, SLURRED SPEECH, LT SIDED FACIAL DROOP\n Contrast: OPTIRAY Amt: 120\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Echo",
"chartdate": "2100-10-15 00:00:00.000",
"description": "Report",
"row_id": 100842,
"text": "PATIENT/TEST INFORMATION:\nIndication: Cerebrovascular event/TIA. Atrial fibrillation. BUBBLE STUDY.\nHeight: (in) 62\nWeight (lb): 251\nBSA (m2): 2.11 m2\nBP (mm Hg): 141/73\nHR (bpm): 92\nStatus: Inpatient\nDate/Time: at 10:41\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: Saline\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. No ASD or PFO by 2D, color\nDoppler or saline contrast with maneuvers.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolic\nfunction (LVEF>55%). Suboptimal technical quality, a focal LV wall motion\nabnormality cannot be fully excluded. Mild global LV hypokinesis. No resting\nLVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Mild (1+) MR.\n\nTRICUSPID VALVE: Physiologic TR. Normal PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Contrast study was performed with 3 iv injections of 8 ccs\nof agitated normal saline, at rest, with cough and post-Valsalva maneuver. The\nrhythm appears to be atrial fibrillation.\n\nConclusions:\nThe left atrium is mildly dilated. No atrial septal defect or patent foramen\novale is seen by 2D, color Doppler or saline contrast with maneuvers. Left\nventricular wall thickness, cavity size, and global systolic function are\nnormal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion\nabnormality cannot be fully excluded. There appears to be mild global left\nventricular hypokinesis, which may be partially explained by the markedly\nirregular rhythm (LVEF = 50%). Right ventricular chamber size and free wall\nmotion are normal. The aortic valve leaflets (3) appear structurally normal\nwith good leaflet excursion and no aortic stenosis. Trace aortic regurgitation\nis seen. Mild (1+) mitral regurgitation is seen. The estimated pulmonary\nartery systolic pressure is normal. There is no pericardial effusion.\n\nIMPRESSION: No PFO or ASD seen. Normal global and regional biventricular\nsystolic function.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2100-10-14 00:00:00.000",
"description": "Report",
"row_id": 300415,
"text": "Atrial fibrillation with rapid ventricular response. No previous tracing\navailable for comparison.\n\n"
},
{
"category": "Nursing",
"chartdate": "2100-10-15 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 643704,
"text": "HPI:\n 67 yo lady acute onset of difficulty in word finding and ?L facial\n droop lasted for 15 min. In ED no deficit SBP > 200. When talking to a\n nurse she had another episode. CT shoed thrombus in L MCA Heparin gtt\n started, to be dose with coumadin today, MRI today. Now neurologically\n intact.\n Chief complaint:\n Stroke\n PMHx:\n HTN' Hyperlipidemia, afib not on anticoagulation without known\n contraindication; L total knee replaecment in ; obesity\n -anxiety, nephrectomy in for renal malignancy, OA, TAHSO\n CVA (Stroke, Cerebral infarction), Ischemic\n Assessment:\n Pt is neurologically intact, able to speak fluently and identify\n objects without difficulty, however reports that she feels only about\n 95% back to normal in this regard\n she feels it takes her a bit longer\n to find words, etc.\n Action:\n Q 2 hour neuro checks, bp allowed to auto-regulate, heparin gtt\n infusing.\n Response:\n Neurologically intact, except minor self reports word finding deficits.\n Plan:\n Start coumadin tonight, mri, transfer to floor\n Atrial fibrillation (Afib)\n Assessment:\n Afib, rate controlled to 80\ns-90\n Action:\n Atenolol given this morning, heparin gtt continues\n Response:\n Tolerating a-fib rhythm.\n Plan:\n Telemetry when transferred to the floor, first coumadin dose tonight,\n continue heparin until coumadin therapeutic.\n"
},
{
"category": "Nutrition",
"chartdate": "2100-10-15 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 643705,
"text": "Potential for nutrition risk. Patient being monitored. Current\n intervention if any, listed below:\n Comments:\n Ht: 62\n Wt: 113kg\n 67 y.o. F adm with partial occlusion of L MCA. Pt now with greatly\n improved mental and verbal ability. Pt remains NPO until after F/U\n MRI. Expect diet advancement after procedure. Will follow up with\n diet advancement and tolerance.\n Please page if ?\ns arise \n"
},
{
"category": "Nursing",
"chartdate": "2100-10-15 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 643701,
"text": "CVA (Stroke, Cerebral infarction), Ischemic\n Assessment:\n Pt is neurologically intact, able to speak fluently and identify\n objects without difficulty, however reports that she feels only about\n 95% back to normal in this regard\n she feels it takes her a bit longer\n to find words, etc.\n Action:\n Q 2 hour neuro checks, bp allowed to auto-regulate, heparin gtt\n infusing.\n Response:\n Neurologically intact, except minor self reports word finding deficits.\n Plan:\n Start coumadin tonight, mri, transfer to floor\n Atrial fibrillation (Afib)\n Assessment:\n Afib, rate controlled to 80\ns-90\n Action:\n Atenolol given this morning, heparin gtt continues\n Response:\n Tolerating a-fib rhythm.\n Plan:\n Telemetry when transferred to the floor, first coumadin dose tonight,\n continue heparin until coumadin therapeutic.\n"
},
{
"category": "Nursing",
"chartdate": "2100-10-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 643597,
"text": "Transient ischemic attack (TIA)\n Assessment:\n Periodic word finding difficulties, otherwise neurologically intact\n Action:\n Q1 hour neuro checks, heparin gtt,\n Response:\n Neurologically waxes and wanes\n Plan:\n Cont neuro checks, await reliable family member to complete MRI\n checklist, hold antihypertensives, heparin gtt\n Atrial fibrillation (Afib)\n Assessment:\n In and out of afib\n Action:\n Heparin gtt, rule out for MI\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2100-10-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 643628,
"text": "Transient ischemic attack (TIA)\n Assessment:\n Periodic word finding difficulties, otherwise neurologically intact\n Action:\n Q1 hour neuro checks, heparin gtt,\n Response:\n Neurologically waxes and wanes\n Plan:\n Cont neuro checks, await reliable family member to complete MRI\n checklist, hold antihypertensives, heparin gtt\n Atrial fibrillation (Afib)\n Assessment:\n In and out of afib\n Action:\n Heparin gtt, rule out for MI\n Response:\n Cont to be in and out of afib, no chest pain,\n Plan:\n 3^rd set of CPK\ns at 1000, restart heparin at 0630 at 1100units-check\n PTT in 6 hours, TTE\n"
},
{
"category": "Nursing",
"chartdate": "2100-10-15 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 643764,
"text": "HPI:\n 67 yo lady acute onset of difficulty in word finding and ?L facial\n droop lasted for 15 min. In ED no deficit SBP > 200. When talking to a\n nurse she had another episode. CT shoed thrombus in L MCA Heparin gtt\n started, to be dose with coumadin today, MRI today. Now neurologically\n intact.\n Chief complaint:\n Stroke\n PMHx:\n HTN' Hyperlipidemia, afib not on anticoagulation without known\n contraindication; L total knee replaecment in ; obesity\n -anxiety, nephrectomy in for renal malignancy, OA, TAHSO\n CVA (Stroke, Cerebral infarction), Ischemic\n Assessment:\n Pt is neurologically intact, able to speak fluently and identify\n objects without difficulty, however reports that she feels only about\n 95% back to normal in this regard\n she feels it takes her a bit longer\n to find words, etc.\n Action:\n Q 2 hour neuro checks, bp allowed to auto-regulate, heparin gtt\n infusing.\n Response:\n Neurologically intact, except minor self reports word finding deficits.\n Plan:\n Start coumadin tonight, mri, transfer to floor\n Atrial fibrillation (Afib)\n Assessment:\n Afib, rate controlled to 80\ns-90\n Action:\n Atenolol given this morning, heparin gtt continues\n Response:\n Tolerating a-fib rhythm.\n Plan:\n Telemetry when transferred to the floor, first coumadin dose tonight,\n continue heparin until coumadin therapeutic.\n"
},
{
"category": "Nursing",
"chartdate": "2100-10-15 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 643765,
"text": "HPI:\n 67 yo lady acute onset of difficulty in word finding and ?L facial\n droop lasted for 15 min. In ED no deficit SBP > 200. When talking to a\n nurse she had another episode. CT shoed thrombus in L MCA Heparin gtt\n started, to be dose with coumadin today, MRI today. Now neurologically\n intact.\n Chief complaint:\n Stroke\n PMHx:\n HTN' Hyperlipidemia, afib not on anticoagulation without known\n contraindication; L total knee replaecment in ; obesity\n -anxiety, nephrectomy in for renal malignancy, OA, TAHSO\n CVA (Stroke, Cerebral infarction), Ischemic\n Assessment:\n Pt is neurologically intact, able to speak fluently and identify\n objects without difficulty, however reports that she feels only about\n 95% back to normal in this regard\n she feels it takes her a bit longer\n to find words, etc.\n Action:\n Q 2 hour neuro checks, bp allowed to auto-regulate, heparin gtt\n infusing.\n Response:\n Neurologically intact, except minor self reports word finding deficits.\n Plan:\n Start coumadin tonight, mri, transfer to floor\n Atrial fibrillation (Afib)\n Assessment:\n Afib, rate controlled to 80\ns-90\n Action:\n Atenolol given this morning, heparin gtt continues\n Response:\n Tolerating a-fib rhythm.\n Plan:\n Telemetry when transferred to the floor, first coumadin dose tonight,\n continue heparin until coumadin therapeutic.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n Code status:\n Height:\n 62 Inch\n Admission weight:\n 113.9 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH: Arrhythmias, Hypertension\n Additional history: HTN, HLD, L knee replacement in , obesity,\n anxiety, nephrectomy in for renal malignancy\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:156\n D:87\n Temperature:\n 98.6\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 20 insp/min\n Heart Rate:\n 89 bpm\n Heart rhythm:\n AF (Atrial Fibrillation)\n O2 delivery device:\n None\n O2 saturation:\n 95% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 1,478 mL\n 24h total out:\n 2,375 mL\n Pertinent Lab Results:\n Sodium:\n 141 mEq/L\n 04:12 AM\n Potassium:\n 4.1 mEq/L\n 04:12 AM\n Chloride:\n 103 mEq/L\n 04:12 AM\n CO2:\n 28 mEq/L\n 04:12 AM\n BUN:\n 22 mg/dL\n 04:12 AM\n Creatinine:\n 1.0 mg/dL\n 04:12 AM\n Glucose:\n 133 mg/dL\n 04:12 AM\n Hematocrit:\n 35.7 %\n 04:12 AM\n Finger Stick Glucose:\n 110\n 04:00 PM\n Valuables / Signature\n Patient valuables: eye glasses with patient\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: SICU A\n Transferred to: 1117\n Date & time of Transfer: @ \n"
},
{
"category": "Physician ",
"chartdate": "2100-10-15 00:00:00.000",
"description": "Intensivist Note",
"row_id": 643661,
"text": "SICU\n HPI:\n 67 yo lady ac onset (7PM) with diff in word finding and ?L facial droop\n lasted for 15 min. In ED no deficit SBP > 200. When talking to a nurse\n she had another episode. CT shoed thrombus in L MCA\n Chief complaint:\n Stroke\n PMHx:\n HTN' Hyperlipidemia, afib not on anticoagulation without known\n contraindication; L total knee replaecment in ; obesity\n -anxiety, nephrectomy in for renal malignancy, OA, TAHSO\n Current medications:\n 1. 2. 1000 mL NS 3. Acetaminophen 4. Acetylcysteine 20% 5. Atenolol 6.\n Heparin 7. Insulin 8. Influenza Virus Vaccine\n 9. Nitroglycerin SL 10. Pantoprazole 11. Pneumococcal Vac Polyvalent\n 12. Simvastatin 13. Sodium Chloride 0.9% Flush\n 14. Verapamil SR\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,100 units/hour\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 08:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.6\nC (97.9\n T current: 36.6\nC (97.9\n HR: 92 (92 - 98) bpm\n BP: 151/78(92) {135/61(80) - 158/93(103)} mmHg\n RR: 19 (15 - 21) insp/min\n SPO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 568 mL\n PO:\n Tube feeding:\n IV Fluid:\n 568 mL\n Blood products:\n Total out:\n 0 mL\n 1,320 mL\n Urine:\n 1,320 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -752 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 95%\n ABG: ///28/\n Physical Examination\n General Appearance: No acute distress, Cachectic\n Cardiovascular: (Rhythm: Irregular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Labs / Radiology\n 313 K/uL\n 11.7 g/dL\n 133 mg/dL\n 1.0 mg/dL\n 28 mEq/L\n 4.1 mEq/L\n 22 mg/dL\n 103 mEq/L\n 141 mEq/L\n 35.7 %\n 7.5 K/uL\n [image002.jpg]\n 04:12 AM\n WBC\n 7.5\n Hct\n 35.7\n Plt\n 313\n Creatinine\n 1.0\n Troponin T\n <0.01\n Glucose\n 133\n Other labs: PT / PTT / INR:13.8/134.4/1.2, CK / CK-MB / Troponin\n T:59//<0.01, ALT / AST:19/14, Ca:8.9 mg/dL, Mg:2.0 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n TRANSIENT ISCHEMIC ATTACK (TIA), ATRIAL FIBRILLATION (AFIB)\n Assessment and Plan: 67 yo admitted yesterday for thrombus in L MCA\n Neurologic: Neuro checks Q: 2 hr, Pain controlled\n Cardiovascular: Beta-blocker, Statins, Permissive HTN let her SBP\n autoregulate up to 180, TTE, continue and increase the dose of Atenolo\n to avoid rebound tachyl, D/C Verapamil\n Pulmonary: Sattting well on RA, PT and OT consult\n Gastrointestinal / Abdomen: Bowel regimen\n Nutrition: NPO, After MRI advance diet\n Renal: Foley, Adequate UO, Monitor BUN and creatinine\n Hematology: Hct stable, Continue heparin drip goal 50-70\n Endocrine: RISS, Goal <150\n Infectious Disease: No issue\n Lines / Tubes / Drains: Foley, PIV\n Wounds: None\n Imaging: MRA of the head\n Fluids: NS, 75cc/h\n Consults: Neurology\n Billing Diagnosis: Other: Stroke\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 01:04 AM\n 20 Gauge - 01:05 AM\n Prophylaxis:\n DVT: Boots (Systemic anticoagulation: Heparin drip)\n Stress ulcer: H2 blocker\n VAP bundle: Mouth care, Daily wake up\n Comments:\n Communication: ICU consent signed Comments:\n Code status:\n Disposition: Transfer to floor\n Total time spent: 31 minutes\n"
}
] |
59,917 | 140,938 | This is an 80 year old male with a history of critical AS (peak velocity 5.2 m/s, peak gradient 106 mmHg, .8 cm2) presenting with acute onset of shortness of breath this morning consistent with CHF exacerbation. . # Shortness of breath: Likely secondary to congestive heart failure as patient has signs of fluid overload on imaging and physical exam as well as a BNP=7739. Patient required CPAP to maintain sats in ED, but was quickly weaned to room air after diuresis. He responded well to Lasix 40mg IV by putting out over 3.5 Liters of urine. PE was ruled out after a negative CTA. Pneumonia seemed less likely given the acuity of onset of shortness of breath without prodromal syptoms. Although he did have a WBC count of 17.2 on admission and an ill defined lingular opacity on CT, he never look clinically infected and only received one dose of vanco in the ED. His antibiotics were not continued in the CCU and he improved dramatically with diuresis alone. . # Aortic Stenosis: Patient has critical AS by Echo in , but has never had syncope, angina, or CHF in the past. CT surgery was consulted and the pre-surgical work-up for AVR was started. The patient had an elective cardiac cath which demonstrated no coronary artery disease. A carotid ultrasound showed less than 40% stenosis bilaterally. A pre-op CXR and Panorex were also obtained. Urine and blood cultures are negative to date. He was therefore cleared for AVR to be performed on . . # CORONARIES: He has no history of CAD or prior MI and CEs were negative on admission. However, he did need an elective pre-surgical cath prior to proceeding for AVR. He tolerated the procedure well, had a normal post cath check, and had clean coronaries so he will not need any further intervention on his coronary arteries during the AVR. . # Hypertension: Patient is on amlodipine 5mg/benazepril 20mg daily as well as triamterene 37.5mg/HCTZ 25mg daily at home. His blood pressure was running in the 90s to 110s throughout his hospital course secondary to the Lasix and all blood pressure meds were held. His home Lotrel was stopped and he was given lisinopril and metoprolol in addition to his home triamterene/HCTZ for blood pressure control at home. . # Hyperlipidemia: Continue home dose of simvastatin 40mg. . # Spinal stenosis: Continue home pain regimen of celebrex 200mg . . CODE: Full code . COMM: with patient, (wife)-> (home), (cell); - | TITLE: Chief Complaint: critical AS 24 Hour Events: - Pt underwent pre-AVR cath that demonstrated clean arteries, critical AS. TITLE: Chief Complaint: critical AS 24 Hour Events: - Pt underwent pre-AVR cath that demonstrated clean arteries, critical AS. TITLE: Chief Complaint: critical AS 24 Hour Events: - Pt underwent pre-AVR cath that demonstrated clean arteries, critical AS. TITLE: Chief Complaint: critical AS 24 Hour Events: - Pt underwent pre-AVR cath that demonstrated clean arteries, critical AS. TITLE: Chief Complaint: 24 Hour Events: - Pt underwent pre-AVR cath that demonstrated clean arteries, critical AS. TITLE: Chief Complaint: 24 Hour Events: - Pt underwent pre-AVR cath that demonstrated clean arteries, critical AS. Post cath checks +dopplerable pulses x4, R fem site cd+I. Post cath checks +dopplerable pulses x4, R fem site cd+I. Required CPAP to maintain sats in ED but was quickly weaned to nasal prongs after diuresing w/ lasix. Required CPAP to maintain sats in ED but was quickly weaned to nasal prongs after diuresing w/ lasix. DISPO: discharge today, with plan to return for AVR ICU Care Nutrition: Glycemic Control: Lines: 22 Gauge - 03:00 PM Prophylaxis: DVT: heparin SQ Stress ulcer: VAP: Comments: Communication: Comments: Code status: Full code Disposition: discharge today DISPO: discharge today, with plan to return for AVR ICU Care Nutrition: Glycemic Control: Lines: 22 Gauge - 03:00 PM Prophylaxis: DVT: heparin SQ Stress ulcer: VAP: Comments: Communication: Comments: Code status: Full code Disposition: discharge today Required CPAP to maintain sats in ED but was quickly weaned to nasal prongs after diuresing w/ lasix. Required CPAP to maintain sats in ED but was quickly weaned to nasal prongs after diuresing w/ lasix. Action: Weaned off 02, given 10mg ivp lasix Response: Plan: Aortic stenosis Assessment: Action: Response: Plan: . EXTREMITIES: 1+ edema bilaterally PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 1+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 1+ Labs / Radiology 1.1 mg/dL 4.4 mEq/L [image002.jpg] 2:33 A8/19/ 09:00 PM 10:20 P 1:20 P 11:50 P 1:20 A 7:20 P 1//11/006 1:23 P 1:20 P 11:20 P 4:20 P Cr 1.1 Other labs: ALT / AST:42/28, Alk Phos / T Bili:67/0.4, Amylase / Lipase:185/68, D-dimer:1411 ng/mL, Lactic Acid:2.0 mmol/L, Albumin:3.8 g/dL, LDH:284 IU/L Assessment and Plan This is an 80 year old male with a history of critical AS (peak velocity 5.2 m/s, peak gradient 106 mmHg, .8 cm2) presenting with acute onset of shortness of breath this morning consistent with CHF exacerbation. lung opacity seen, Temp 99.8 po. lung opacity seen, Temp 99.8 po. lung opacity seen, Temp 99.8 po. lung opacity seen, Temp 99.8 po. Plan: Cardiac cath, carotid US. Plan: Cardiac cath, carotid US. Plan: Cardiac cath, carotid US. Plan: Cardiac cath, carotid US. Aortic stenosis Assessment: Critical AS, peak velocity 5.2 m/s, peak gradient 106 mmHg, .8 cm2) Action: Response: Plan: . Aortic stenosis Assessment: Critical AS, peak velocity 5.2 m/s, peak gradient 106 mmHg, .8 cm2) Action: Response: Plan: . Aortic stenosis Assessment: Critical AS, peak velocity 5.2 m/s, peak gradient 106 mmHg, .8 cm2) Action: Response: Plan: . Aortic stenosis Assessment: Critical AS, peak velocity 5.2 m/s, peak gradient 106 mmHg, .8 cm2) Action: Response: Plan: . further diuresis. EKG showing ST changes that are consistent with LVH per team; CEs flat. EKG showing ST changes that are consistent with LVH per team; CEs flat. EKG showing ST changes that are consistent with LVH per team; CEs flat. Trace pedal edema; clonus in left leg > right leg. Trace pedal edema; clonus in left leg > right leg. Trace pedal edema; clonus in left leg > right leg. Aortic stenosis Assessment: New Dx of critical AS, peak velocity 5.2 m/s, peak gradient 106 mmHg, 0.8 cm. Aortic stenosis Assessment: New Dx of critical AS, peak velocity 5.2 m/s, peak gradient 106 mmHg, 0.8 cm. Continued to diurese to lasix given in the ED. Continued to diurese to lasix given in the ED. | 42 | [
{
"category": "Nursing",
"chartdate": "2108-08-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 590734,
"text": "80 year old man w/ pmh including AS & spinal stenosis, admitted to the\n ED from home after waking up with acute shortness of breath and\n diaphoresis. Placed on Cpap in the ED & given 40 meq IVP lasix. Also\n given Vanco in the ED to treat elevated WBC; BC & urine cultures sent\n from ED.\n : pre-op AVR work-up including dental panorex & cardiac cath with\n pre-cath hydration. Patient called out to 3.\n Aortic stenosis\n Assessment:\n s/p excellent diuresis on (4 liters out to 40 IV lasix) Lungs\n clear/diminished w/ trace pedal edema; clonus in left leg > right leg.\n Current pipe smoker. History of Aortic Stenosis; but no history of CHF.\n Afebrile. HR 70s-80s w/ some PAC\ns. BP 130\ns/50\ns. Sats > 95% on RA.\n Denies SOB. EKG changes c/w LVH.\n Action:\n v Continued to monitor I/O & daily weight, stands @ end of bed to\n use urinal pre-cath\n v Dental panorex obtained as part of pre-op work-up\n v Dermatology consulted to evaluate long-standing history of skin\n rash (not active at this time) on patient\ns back to see if it poses an\n infection risk to a potential sternal wound.\n v Given dose mucamyst & started infusion of D5\n NS @ 75 ml/hr\n for renal protection prior to cath.\n v To cath at 1330\n Response:\n v I/O even pre-cath, but LOS negative approximately 5 liters\n v O2 sats remains >95 % on RA.\n v Dental service to follow-up with patient this evening\n v Dermatology to see patient tomorrow when off bedrest to\n evaluate patient\ns back\n v Awaiting return from cath lab\n Plan:\n Continue to monitor hemodynamic & respiratory status. Smoking cessation\n counseling. Await recommendations from CSurg regarding scheduling of\n AVR, (potentially next Friday, although patient would like to go next\n Monday or Tuesday)- patient wishing to go home for a few days\n pre-operatively.\n Patient returned from cath at 15:30-\n o verbal report states no significant CAD seen, 200 IVF in, DTV\n via condom cath.\n o Right groin site C,D & I, pedal pulses by Doppler only.\n o Bedrest until 1900\n o\n NS at 75 ml/hr for 500 ml.\n o Plan: Patient wishing to go home this evening & wife\n uncomfortable managing patient at home before surgery; no clear plan\n for discharge at this time. 0.5 mg Ativan given at 1620 per patient\n request to relieve anxiety, effect pending.\n"
},
{
"category": "Nursing",
"chartdate": "2108-08-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 590731,
"text": "80 year old man w/ pmh including AS & spinal stenosis, admitted to the\n ED from home after waking up with acute shortness of breath and\n diaphoresis. Placed on Cpap in the ED & given 40 meq IVP lasix. Also\n given Vanco in the ED to treat elevated WBC; BC & urine cultures sent\n from ED.\n : pre-op AVR work-up including dental panorex & cardiac cath with\n pre-cath hydration. Patient called out to 3.\n Aortic stenosis\n Assessment:\n s/p excellent diuresis on (4 liters out to 40 IV lasix) Lungs\n clear/diminished w/ trace pedal edema; clonus in left leg > right leg.\n Current pipe smoker. History of Aortic Stenosis; but no history of CHF.\n Afebrile. HR 70s-80s w/ some PAC\ns. BP 130\ns/50\ns. Sats > 95% on RA.\n Denies SOB. EKG changes c/w LVH.\n Action:\n v Continued to monitor I/O & daily weight, stands @ end of bed to\n use urinal pre-cath\n v Dental panorex obtained as part of pre-op work-up\n v Given dose mucamyst & started infusion of D5\n NS @ 75 ml/hr\n for renal protection prior to cath.\n v To cath at 1330\n Response:\n v I/O even pre-cath, but LOS negative approximately 5 liters\n v O2 sats remains >95 % on RA.\n v Dental service to follow-up with patient this evening\n v Awaiting return from cath lab\n Plan:\n Continue to monitor hemodynamic & respiratory status. Smoking cessation\n counseling. Await recommendations from CSurg regarding scheduling of\n AVR- patient wishing to go home for a few days pre-operatively.\n Patient returned from cath at 15:30- verbal report states no\n significant CAD seen, 200 IVF in, DTV via condom cath. Right groin site\n C,D & I, pedal pulses by Doppler only. Bedrest x 3 hours, hemostasis at\n 1500. Patient wishing to go home immediately following completion of\n MD\ns notified.\n"
},
{
"category": "Nursing",
"chartdate": "2108-08-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 590740,
"text": "80 year old man w/ pmh including AS & spinal stenosis, admitted to the\n ED from home after waking up with acute shortness of breath and\n diaphoresis. Placed on Cpap in the ED & given 40 meq IVP lasix. Also\n given Vanco in the ED to treat elevated WBC; BC & urine cultures sent\n from ED.\n : pre-op AVR work-up including dental panorex & cardiac cath with\n pre-cath hydration. Patient called out to 3.\n Aortic stenosis\n Assessment:\n s/p excellent diuresis on (4 liters out to 40 IV lasix) Lungs\n clear/diminished w/ trace pedal edema; clonus in left leg > right leg.\n Current pipe smoker. History of Aortic Stenosis; but no history of CHF.\n Afebrile. HR 70s-80s w/ some PAC\ns. BP 130\ns/50\ns. Sats > 95% on RA.\n Denies SOB. EKG changes c/w LVH.\n Action:\n v Continued to monitor I/O & daily weight, stands @ end of bed to\n use urinal pre-cath. UA C&S sent.\n v Dental panorex obtained as part of pre-op work-up\n v Dermatology consulted to evaluate long-standing history of skin\n rash (not active at this time) on patient\ns back to see if it poses an\n infection risk to a potential sternal wound.\n v Given dose mucamyst & started infusion of D5\n NS @ 75 ml/hr\n for renal protection prior to cath.\n v To cath at 1330\n Response:\n v I/O even pre-cath, but LOS negative approximately 5 liters\n v O2 sats remains >95 % on RA.\n v Dental service to follow-up with patient this evening\n v Dermatology to see patient tomorrow when off bedrest to\n evaluate patient\ns back\n v Awaiting return from cath lab\n Plan:\n Continue to monitor hemodynamic & respiratory status. Smoking cessation\n counseling. Await recommendations from CSurg regarding scheduling of\n AVR, (potentially next Friday, although patient would like to go next\n Monday or Tuesday)- patient wishing to go home for a few days\n pre-operatively.\n Patient returned from cath at 15:30-\n o verbal report states no significant CAD seen, 200 IVF in, DTV\n via condom cath.\n o Right groin site C,D & I, pedal pulses by Doppler only.\n o Bedrest until 1900\n o\n NS at 75 ml/hr for 500 ml.\n o Plan: Patient wishing to go home this evening & wife\n uncomfortable managing patient at home before surgery; no clear plan\n for discharge at this time. 0.5 mg Ativan given at 1620 per patient\n request to relieve anxiety, effect pending.\n"
},
{
"category": "Nursing",
"chartdate": "2108-08-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 590742,
"text": "80 year old man w/ pmh including AS & spinal stenosis, admitted to the\n ED from home after waking up with acute shortness of breath and\n diaphoresis. Placed on Cpap in the ED & given 40 meq IVP lasix. Also\n given Vanco in the ED to treat elevated WBC; BC & urine cultures sent\n from ED.\n : pre-op AVR work-up including dental panorex, UA/C&S & cardiac\n cath with pre-cath hydration. Patient called out to 3.\n Aortic stenosis\n Assessment:\n s/p excellent diuresis on (4 liters out to 40 IV lasix) Lungs\n clear/diminished w/ trace pedal edema; clonus in left leg > right leg.\n Current pipe smoker. History of Aortic Stenosis; but no history of CHF.\n Afebrile. HR 70s-80s w/ some PAC\ns. BP 130\ns/50\ns. Sats > 95% on RA.\n Denies SOB. EKG changes c/w LVH.\n Action:\n v Continued to monitor I/O & daily weight, stands @ end of bed to\n use urinal pre-cath. UA C&S sent.\n v Dental panorex obtained as part of pre-op work-up\n v Dermatology consulted to evaluate long-standing history of skin\n rash (not active at this time) on patient\ns back to see if it poses an\n infection risk to a potential sternal wound.\n v Given dose mucamyst & started infusion of D5\n NS @ 75 ml/hr\n for renal protection prior to cath.\n v To cath at 1330\n Response:\n v I/O even pre-cath, but LOS negative approximately 5 liters\n v O2 sats remains >95 % on RA.\n v Dental service to follow-up with patient this evening\n v Dermatology to see patient tomorrow when off bedrest to\n evaluate patient\ns back\n v Awaiting return from cath lab\n Plan:\n Continue to monitor hemodynamic & respiratory status. Smoking cessation\n counseling. Await recommendations from CSurg regarding scheduling of\n AVR, (potentially next Friday, although patient would like to go next\n Monday or Tuesday)- patient wishing to go home for a few days\n pre-operatively.\n Patient returned from cath at 15:30-\n o Verbal report states no significant CAD seen, 200 IVF in,\n voided 300 ml condom cath at 1745.\n o Right groin site C,D & I, pedal pulses by Doppler only.\n o Bedrest until 1900\n o\n NS at 75 ml/hr for 500 ml.\n o Plan: Patient wishing to go home this evening & wife\n uncomfortable managing patient at home before surgery; no clear plan\n for discharge at this time. 0.5 mg Ativan given at 1620 per patient\n request to relieve anxiety, effective per patient.\n"
},
{
"category": "Nursing",
"chartdate": "2108-08-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 590800,
"text": "Pt is 80yo male Dx w/ critical AS (echo ) but has remained\n asymptomatic & is very active. Presenting with acute onset of\n shortness of breath consistent with CHF exacerbation. Likely secondary\n to congestive heart failure as patient was fluid overload on CXR.\n Required CPAP to maintain sats in ED but was quickly weaned to nasal\n prongs after diuresing w/ lasix. PE ruled out by CTA. Pneumonia\n unlikely but does have WBC 17.2, ? lung opacity seen, Temp 99.8 po.\n Blood/ urine cx pending.\n : Pt agrees to AVR surgery, preliminary time set for Tues .\n Underwent dental panorax & diag cath showing clean c\ns. To be d/c\n home today & return on Tues for surgery.\n Aortic stenosis\n Assessment:\n Pt w/ critical AS, peak velocity 5.2 m/s, peak gradient 106 mmHg, \n 0.8 cm. Post cath checks +dopplerable pulses x4, R fem site cd+I. Pt\n agreed to stay in hospital overnight.\n Action:\n Given post cath fluids, mycomyst dose #2. Offered prn Ativan for sleep.\n Response:\n Refused Ativan, slept well.\n Plan:\n Pt will be allowed to go home over weekend. Plan for AVR on tues .\n"
},
{
"category": "Physician ",
"chartdate": "2108-08-10 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 590803,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n Pt underwent pre-AVR cath and demonstrated clean arteries. No\n intervention needed. Pre-op studies completed. Cleared for CABG on\n . Plan to discharge on at noon with plans to return on \n at 6AM. Patient agrees with plan. Stable, no complaints. Post-cath\n check at 7:30pm was normal.\n Allergies:\n Atorvastatin\n myalgias;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.1\nC (98.8\n HR: 72 (72 - 98) bpm\n BP: 135/73(89) {106/32(60) - 150/99(107)} mmHg\n RR: 16 (13 - 30) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 64 kg (admission): 65.7 kg\n Height: 66 Inch\n Total In:\n 1,120 mL\n PO:\n TF:\n IVF:\n 1,120 mL\n Blood products:\n Total out:\n 2,000 mL\n 500 mL\n Urine:\n 2,000 mL\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n -880 mL\n -500 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: 7.45/42/128/26/5\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 199 K/uL\n 11.3 g/dL\n 100 mg/dL\n 0.8 mg/dL\n 26 mEq/L\n 4.2 mEq/L\n 20 mg/dL\n 107 mEq/L\n 139 mEq/L\n 34.1 %\n 9.0 K/uL\n [image002.jpg]\n 09:00 PM\n 06:00 AM\n 09:17 AM\n 02:39 PM\n 05:04 AM\n WBC\n 10.6\n 11.2\n 9.0\n Hct\n 31.9\n 34.4\n 34.1\n Plt\n \n Cr\n 1.1\n 0.9\n 0.8\n TCO2\n 30\n Glucose\n 110\n 100\n Other labs: ALT / AST:42/28, Alk Phos / T Bili:67/0.4, Amylase /\n Lipase:130/52, D-dimer:1411 ng/mL, Lactic Acid:2.0 mmol/L, Albumin:3.8\n g/dL, LDH:284 IU/L, Ca++:9.0 mg/dL, Mg++:2.4 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n PULMONARY EDEMA\n AORTIC STENOSIS\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 03:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2108-08-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 590799,
"text": "Pt is 80yo male Dx w/ critical AS (echo ) but has remained\n asymptomatic & is very active. Presenting with acute onset of\n shortness of breath consistent with CHF exacerbation. Likely secondary\n to congestive heart failure as patient was fluid overload on CXR.\n Required CPAP to maintain sats in ED but was quickly weaned to nasal\n prongs after diuresing w/ lasix. PE ruled out by CTA. Pneumonia\n unlikely but does have WBC 17.2, ? lung opacity seen, Temp 99.8 po.\n Blood/ urine cx pending.\n : Pt agrees to AVR surgery, preliminary time set for Tues .\n Underwent dental panorax & diag cath showing clean c\ns. To be d/c\n home today & return on Tues for surgery.\n Aortic stenosis\n Assessment:\n Pt w/ critical AS, peak velocity 5.2 m/s, peak gradient 106 mmHg, \n 0.8 cm. Post cath checks +dopplerable pulses x4, R fem site cd+I. Pt\n agreed to stay in hospital overnight.\n Action:\n Given post cath fluids, mycomyst dose #2. Offered prn Ativan for sleep.\n Response:\n Refused Ativan, slept well.\n Plan:\n Pt will be allowed to go home over weekend. Plan for AVR on tues .\n"
},
{
"category": "Physician ",
"chartdate": "2108-08-10 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 590809,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - Pt underwent pre-AVR cath that demonstrated clean arteries, critical\n AS.\n - Pre-op studies completed.\n - Cleared for CABG on .\n - Plan to discharge on at noon with plans to return on at\n 6AM.\n - Stable, no complaints.\n Allergies:\n Atorvastatin\n myalgias;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.1\nC (98.8\n HR: 72 (72 - 98) bpm\n BP: 135/73(89) {106/32(60) - 150/99(107)} mmHg\n RR: 16 (13 - 30) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 64 kg (admission): 65.7 kg\n Height: 66 Inch\n Total In:\n 1,120 mL\n PO:\n TF:\n IVF:\n 1,120 mL\n Blood products:\n Total out:\n 2,000 mL\n 500 mL\n Urine:\n 2,000 mL\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n -880 mL\n -500 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: 7.45/42/128/26/5\n Physical Examination\n Labs / Radiology\n 199 K/uL\n 11.3 g/dL\n 100 mg/dL\n 0.8 mg/dL\n 26 mEq/L\n 4.2 mEq/L\n 20 mg/dL\n 107 mEq/L\n 139 mEq/L\n 34.1 %\n 9.0 K/uL\n [image002.jpg]\n 09:00 PM\n 06:00 AM\n 09:17 AM\n 02:39 PM\n 05:04 AM\n WBC\n 10.6\n 11.2\n 9.0\n Hct\n 31.9\n 34.4\n 34.1\n Plt\n \n Cr\n 1.1\n 0.9\n 0.8\n TCO2\n 30\n Glucose\n 110\n 100\n Other labs: ALT / AST:42/28, Alk Phos / T Bili:67/0.4, Amylase /\n Lipase:130/52, D-dimer:1411 ng/mL, Lactic Acid:2.0 mmol/L, Albumin:3.8\n g/dL, LDH:284 IU/L, Ca++:9.0 mg/dL, Mg++:2.4 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n PULMONARY EDEMA\n CRITICAL AORTIC STENOSIS\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 03:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2108-08-10 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 590810,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - Pt underwent pre-AVR cath that demonstrated clean arteries, critical\n AS.\n - Pre-op studies completed.\n - Cleared for CABG on .\n - Plan to discharge on at noon with plans to return on at\n 6AM.\n - Stable, no complaints.\n Allergies:\n Atorvastatin\n myalgias;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.1\nC (98.8\n HR: 72 (72 - 98) bpm\n BP: 135/73(89) {106/32(60) - 150/99(107)} mmHg\n RR: 16 (13 - 30) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 64 kg (admission): 65.7 kg\n Height: 66 Inch\n Total In:\n 1,120 mL\n PO:\n TF:\n IVF:\n 1,120 mL\n Blood products:\n Total out:\n 2,000 mL\n 500 mL\n Urine:\n 2,000 mL\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n -880 mL\n -500 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: 7.45/42/128/26/5\n Physical Examination\n GENERAL: pleasant male in NAD, speaking in full sentences. Oriented x3.\n Mood, affect appropriate.\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no\n pallor or cyanosis of the oral mucosa. No xanthalesma.\n NECK: Supple with JVP to just below angle of mandible.\n CARDIAC: RRR, harsh systolic ejection murmur radiating to the carotids.\n No thrills, lifts.\n LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were\n unlabored, no accessory muscle use. Crackles way up from bases\n bilaterally, no wheezes or rhonchi.\n ABDOMEN: Soft, NTND. No HSM or tenderness.\n EXTREMITIES: 1+ edema bilaterally\n PULSES:\n Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 1+\n Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 1+\n Labs / Radiology\n 199 K/uL\n 11.3 g/dL\n 100 mg/dL\n 0.8 mg/dL\n 26 mEq/L\n 4.2 mEq/L\n 20 mg/dL\n 107 mEq/L\n 139 mEq/L\n 34.1 %\n 9.0 K/uL\n [image002.jpg]\n 09:00 PM\n 06:00 AM\n 09:17 AM\n 02:39 PM\n 05:04 AM\n WBC\n 10.6\n 11.2\n 9.0\n Hct\n 31.9\n 34.4\n 34.1\n Plt\n \n Cr\n 1.1\n 0.9\n 0.8\n TCO2\n 30\n Glucose\n 110\n 100\n Other labs: ALT / AST:42/28, Alk Phos / T Bili:67/0.4, Amylase /\n Lipase:130/52, D-dimer:1411 ng/mL, Lactic Acid:2.0 mmol/L, Albumin:3.8\n g/dL, LDH:284 IU/L, Ca++:9.0 mg/dL, Mg++:2.4 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n PULMONARY EDEMA\n CRITICAL AORTIC STENOSIS\n This is an 80 year old male with a history of critical AS (peak\n velocity 5.2 m/s, peak gradient 106 mmHg, .8 cm2) presenting with\n acute onset of shortness of breath this morning consistent with CHF\n exacerbation.\n .\n # Shortness of breath: Likely secondary to congestive heart failure as\n patient has signs of fluid overload on imaging and BNP=7739. Patient\n required CPAP to maintain sats in ED, but was quickly weaned to room\n air after diuresis. Differential includes flash pulmonary edema, PE,\n and pneumonia. PE has been ruled out after negative CTA. Pneumonia\n seems less likely given the acuity of onset of shortness of breath\n without prodromal syptoms. Although he does have an unexplained WBC\n count of 17.2 and an ill defined lingular opacity on CT, he does not\n look clinically infected. Regarding the cause, he does have severe\n aortic stenosis (albeit with a normal EF and adequate pulse pressure),\n so a small insult could throw him into failure. Ischemia is on the\n differential, but no CP or EKG changes. He does have evidence of\n infection that may have tipped him over.\n - Blood cultures and urine culture pending\n - f/u final read of chest CTA\n - Continue diuresis. Patient is Lasix naive and put out 3.5 Liters\n after single dose of Lasix 40mg IV.\n - Pt received one dose of vanco IV in the ED which was not continued\n after arrival to the CCU as patient does not look clinically infected.\n .\n # Aortic Stenosis: Patient has critical AS by Echo in , but has\n never had syncope, angina, or CHF in the past. Will consult CT surgery\n to begin work-up for potential AVR.\n - Elective cath today to r/o coronary disease prior to AVR, NPO after\n midnight.\n .\n # CORONARIES: He has no history of CAD or prior MI. He will need to\n have a cardiac cath tomorrow prior to proceeding for AVR.\n -CEs negative on admission\n -If there are no signs of CAD on cath, patient would most likely prefer\n to have percutaneous AVR.\n .\n # Hypertension: Patient is on amlodipine 5mg/benazepril 20mg daily as\n well as triamterene 37.5mg/HCTZ 25mg daily at home. His blood pressure\n has been running in the 90s to 110s since admission secondary to the\n Lasix and all blood pressure meds will be held. His BP will be\n monitored closely.\n .\n # Hyperlipidemia: Continue home dose of simvastatin 40mg.\n .\n # Spinal stenosis: Continue home pain regimen of celebrex 200mg .\n .\n FEN: Heart healthy/low sodium diet\n .\n ACCESS: PIV\n .\n PROPHYLAXIS:\n -DVT ppx with heparin SC\n -Bowel regimen with colace/senna\n .\n CODE: Full code\n .\n COMM: with patient, (wife)-> (home), \n (cell); -> \n .\n DISPO: CCU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 03:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2108-08-10 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 590811,
"text": "TITLE:\n Chief Complaint: critical AS\n 24 Hour Events:\n - Pt underwent pre-AVR cath that demonstrated clean arteries, critical\n AS.\n - Pre-op studies completed.\n - Cleared for surgery on .\n - Plan to discharge on at noon with plans to return on at\n 6AM.\n - Stable, no complaints.\n Allergies:\n Atorvastatin\n myalgias;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.1\nC (98.8\n HR: 72 (72 - 98) bpm\n BP: 135/73(89) {106/32(60) - 150/99(107)} mmHg\n RR: 16 (13 - 30) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 64 kg (admission): 65.7 kg\n Height: 66 Inch\n Total In:\n 1,120 mL\n PO:\n TF:\n IVF:\n 1,120 mL\n Blood products:\n Total out:\n 2,000 mL\n 500 mL\n Urine:\n 2,000 mL\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n -880 mL\n -500 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: 7.45/42/128/26/5\n Physical Examination\n GENERAL: pleasant male in NAD, speaking in full sentences. Oriented x3.\n Mood, affect appropriate.\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no\n pallor or cyanosis of the oral mucosa. No xanthalesma.\n NECK: Supple with JVP to just below angle of mandible.\n CARDIAC: RRR, harsh grade III systolic murmur heard best at RUS border\n radiating to the carotids. No thrills, lifts.\n LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were\n unlabored, no accessory muscle use. Minimal crackles at bases.\n ABDOMEN: Soft, NTND. No HSM or tenderness.\n EXTREMITIES: 1+ edema bilaterally\n PULSES:\n Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 1+\n Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 1+\n Labs / Radiology\n 199 K/uL\n 11.3 g/dL\n 100 mg/dL\n 0.8 mg/dL\n 26 mEq/L\n 4.2 mEq/L\n 20 mg/dL\n 107 mEq/L\n 139 mEq/L\n 34.1 %\n 9.0 K/uL\n [image002.jpg]\n 09:00 PM\n 06:00 AM\n 09:17 AM\n 02:39 PM\n 05:04 AM\n WBC\n 10.6\n 11.2\n 9.0\n Hct\n 31.9\n 34.4\n 34.1\n Plt\n \n Cr\n 1.1\n 0.9\n 0.8\n TCO2\n 30\n Glucose\n 110\n 100\n Other labs: ALT / AST:42/28, Alk Phos / T Bili:67/0.4, Amylase /\n Lipase:130/52, D-dimer:1411 ng/mL, Lactic Acid:2.0 mmol/L, Albumin:3.8\n g/dL, LDH:284 IU/L, Ca++:9.0 mg/dL, Mg++:2.4 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n PULMONARY EDEMA\n CRITICAL AORTIC STENOSIS\n This is an 80 year old male who presented with acute onset of shortness\n of breath consistent with CHF exacerbation, now s/p cardiac cath\n showing critical AS (peak velocity 5.2 m/s, peak gradient 106 mmHg, \n .8 cm2) and clean coronaries.\n .\n # Shortness of breath: Likely secondary to congestive heart failure as\n patient has signs of fluid overload on imaging and BNP=7739. Patient\n required CPAP to maintain sats in ED, but was quickly weaned to room\n air after diuresis. Differential includes flash pulmonary edema, PE,\n and pneumonia. PE has been ruled out after negative CTA. Pneumonia\n seems less likely given the acuity of onset of shortness of breath\n without pro-dromal symptoms. Although he does have an unexplained WBC\n count of 17.2 and an ill defined lingular opacity on CT, he does not\n look clinically infected. Regarding the cause, he does have severe\n aortic stenosis (albeit with a normal EF and adequate pulse pressure),\n so a small insult could throw him into failure. Ischemia is on the\n differential, but no CP or EKG changes.\n - Blood cultures and urine culture NGTD\n - chest CTA without PE\n - diuresed well and has been oxygenating well on RA\n - Pt received one dose of vanco IV in the ED which was not continued\n after arrival to the CCU as patient does not look clinically infected.\n .\n # Aortic Stenosis: Patient has critical AS by Echo in and\n confirmed with cardiac cath yesterday, but has never had syncope,\n angina, or CHF in the past. CT surgery to begin work-up for potential\n AVR.\n - Planned procedure on Tuesday\n .\n # CORONARIES: He has no history of CAD or prior MI.\n -CEs negative on admission\n - cath showing no flow limiting CAD, R dominant system, LMCA without\n obstructive disease LAD with mild luminal irregularities with a 20% mid\n vessel stenosis, LCX and RCA with mild luminal irregularities\n -If there are no signs of CAD on cath, patient would most likely prefer\n to have percutaneous AVR.\n .\n # Hypertension: Patient is on amlodipine 5mg/benazepril 20mg daily as\n well as triamterene 37.5mg/HCTZ 25mg daily at home. His blood pressure\n has been running in the 90s to 110s since admission secondary to the\n Lasix and all blood pressure meds will be held.\n - can restart home regimen\n .\n # Hyperlipidemia: Continue home dose of simvastatin 40mg.\n .\n # Spinal stenosis: Continue home pain regimen of celebrex 200mg .\n .\n FEN: Heart healthy/low sodium diet\n .\n ACCESS: PIV\n .\n PROPHYLAXIS:\n -DVT ppx with heparin SC\n -Bowel regimen with colace/senna\n .\n CODE: Full code\n .\n COMM: with patient, (wife)-> (home), \n (cell); -> \n .\n DISPO: discharge today, with plan to return for AVR\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 03:00 PM\n Prophylaxis:\n DVT: heparin SQ\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: discharge today\n"
},
{
"category": "Physician ",
"chartdate": "2108-08-10 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 590814,
"text": "TITLE:\n Chief Complaint: Acute onset shortness of breath\n HPI: Mr. is an 80 year-old man with a history of critical AS\n (peak velocity 5.2 m/s, peak gradient 106 mmHg, .8 cm2) presenting\n with acute onset shortness of breath this morning. He has never been\n short of breath in the past and actually leads quite an active\n lifestyle. His symptoms seem to have started on the morning of \n when he experienced 5 minutes of shortness of breath. This feeling\n quickly resolved and the patient felt well enough to play 18 holes of\n golf later that day. At baseline he is very active and he is able to\n log 20 miles per week on his stationary bicycle without any episodes of\n chest discomfort, palpitations, or lightheadedness. Later on the 18th\n the patient went out for dinner and ate a very salty meal of clams and\n stuffed shrimp. He also ate a pint of ice cream and biked for 6 miles\n on his stationary bike before going to bed. He slept well overnight on\n 1 pillow and got up to urinate over night. He then woke up at 8AM and\n felt extremely short of breath after brushing his teeth. It didn't\n effect him that much because he was still able to carry out his normal\n morning routine, although with difficulty. He was not able to do his\n morning exercises, however, and he tried to lay down and his shortness\n of breath did not resolve. Finally he went outside to get some fresh\n air with his dog and got diaphoretic and wheezy. His neighbor\n convinced him to call the ambulance to be brought in to the hospital.\n He specifically denies any fevers, chills, cough, change in bowel\n habits, dysuria, dizziness, lightheadedness, chest pain, or abdominal\n pain.\n An outpatient ETT-echo had been planned to assess his blood pressure\n response to exercise in anticipation of a possible back surgery for his\n spinal stenosis. He has had 2 back surgeries in the past for this\n condition, the last being 7-8 years ago. Of note, he received a\n Cortisone injection of his back 2 weeks ago. This pending surgery\n would be to address his chronic right leg pain which he feels has been\n limiting his activity. The plan was to proceed with the surgery unless\n he had an abnormally hypotensive response to exercise, then AVR would\n be considered. No AVR was planned because the patient has never\n experienced any lightheadedness, dizziness, presyncope, chest pain, or\n shortness of breath in the past.\n .\n Documentation of inital EMS vitals is not available. By report, en\n route to hospital he received 1 SL nitro and albuterol nebs after which\n he felt somewhat better. On arrival to the ED, the first set of\n documented vitals T 97.8, HR 120, RR 36, BP 163/91, O2 Sat 95% on 10 L\n O2. In the ED he desatted to the 80s on RA. Exam notable for poor air\n movement, tachycardia with SEM, and 2+ b/l pitting edema. EKG showed\n sinus tachycardia, and CXR was without evidence of infiltrate but did\n show volume overload. Labs notable for WBC 17.4 with 93% PMN as well\n as a D-Dimer of 1411. His oxygen requirement escalated and he required\n CPAP. He received 40 mg IV lasix and put out 300 cc of urine within 30\n minutes. He also received 1 g vancomycin. VS prior to transfer HR 108,\n BP 114/65, RR 17, 99% on CPAP, T 97.4.\n .\n En route to CCU patient underwent CTA which, per discussion with\n radiology resident, was negative for PE, infiltrate, volume overload,\n or other abnormalities apart from small bilaterally symmetric pleural\n effusions.\n .\n On arrival to the CCU the patient had diuresed a total of 1700cc and\n was satting well on 3L nasal cannula.\n .\n On review of systems, s/he denies any prior history of stroke, TIA,\n deep venous thrombosis, pulmonary embolism, bleeding at the time of\n surgery, myalgias, joint pains, cough, hemoptysis, black stools or red\n stools. He denies recent fevers, chills or rigors. He denies exertional\n buttock or calf pain. All of the other review of systems were\n negative.\n .\n Cardiac review of systems is notable for absence of chest pain, dyspnea\n on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,\n palpitations, syncope or presyncope.\n Allergies:\n Atorvastatin\n myalgias;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 09:00 PM\n Other medications:\n Home meds:\n amlodipine-benazepril 5 mg-20 mg daily\n celebrex 200 mg \n simvastatin unknown dose\n cialis PRN\n tetracycline 500 mg x 2 months\n triamterene-hctz 75 mg-50 mg tablet daily\n amoxicillin PRN as antibiotic prophylaxis\n ASA 81 mg daily\n glucosamine 1500 mg daily\n vitamin C 1 g daily\n potassium (OTC) 99 mg daily\n Past medical history:\n Family history:\n Social History:\n 1. CARDIAC RISK FACTORS: no Diabetes, + Dyslipidemia,+ Hypertension\n 2. CARDIAC HISTORY:\n - Aortic stenosis as above\n 3. OTHER PAST MEDICAL HISTORY:\n - Hypertension\n - Hypercholesterolemia\n - Mild carotid stenosis by ultrasound\n - GERD\n - Spinal stenosis with chronic right leg pain, s/p two operations and\n more recent steroid injections, considering operative treatment.\n - R thumb surgery\n Parents are deceased (father 48 years, cancer; mother - years,\n cancer). A daughter has multiple sclerosis.\n He has been married for 28 years. He spends -mid in \n where he is now a resident. He continues to smoke a pipe up to 5 times\n daily and drinks 2-3 glasses of wine/wk.\n Review of systems:\n Flowsheet Data as of 02:14 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.3\nC (99.1\n HR: 82 (82 - 105) bpm\n BP: 104/64(73) {90/49(59) - 116/72(83)} mmHg\n RR: 17 (17 - 22) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n Total In:\n 108 mL\n 22 mL\n PO:\n TF:\n IVF:\n 108 mL\n 22 mL\n Blood products:\n Total out:\n 4,190 mL\n 0 mL\n Urine:\n 3,790 mL\n NG:\n Stool:\n Drains:\n Balance:\n -4,083 mL\n 22 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 97%\n Physical Examination\n GENERAL: pleasant male in NAD, speaking in full sentences. Oriented x3.\n Mood, affect appropriate.\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no\n pallor or cyanosis of the oral mucosa. No xanthalesma.\n NECK: Supple with JVP to just below angle of mandible.\n CARDIAC: RRR, harsh systolic ejection murmur radiating to the carotids.\n No thrills, lifts.\n LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were\n unlabored, no accessory muscle use. Crackles way up from bases\n bilaterally, no wheezes or rhonchi.\n ABDOMEN: Soft, NTND. No HSM or tenderness.\n EXTREMITIES: 1+ edema bilaterally\n PULSES:\n Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 1+\n Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 1+\n Labs / Radiology\n 1.1 mg/dL\n 4.4 mEq/L\n [image002.jpg]\n \n 2:33 A8/19/ 09:00 PM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n Cr\n 1.1\n Other labs: ALT / AST:42/28, Alk Phos / T Bili:67/0.4, Amylase /\n Lipase:185/68, D-dimer:1411 ng/mL, Lactic Acid:2.0 mmol/L, Albumin:3.8\n g/dL, LDH:284 IU/L\n Assessment and Plan\n This is an 80 year old male with a history of critical AS (peak\n velocity 5.2 m/s, peak gradient 106 mmHg, .8 cm2) presenting with\n acute onset of shortness of breath this morning consistent with CHF\n exacerbation.\n .\n # Shortness of breath: Likely secondary to congestive heart failure as\n patient has signs of fluid overload on imaging and BNP=7739. Patient\n required CPAP to maintain sats in ED, but was quickly weaned to room\n air after diuresis. Differential includes flash pulmonary edema, PE,\n and pneumonia. PE has been ruled out after negative CTA. Pneumonia\n seems less likely given the acuity of onset of shortness of breath\n without prodromal syptoms. Although he does have an unexplained WBC\n count of 17.2 and an ill defined lingular opacity on CT, he does not\n look clinically infected. Regarding the cause, he does have severe\n aortic stenosis (albeit with a normal EF and adequate pulse pressure),\n so a small insult could throw him into failure. Ischemia is on the\n differential, but no CP or EKG changes. He does have evidence of\n infection that may have tipped him over.\n - Blood cultures and urine culture pending\n - f/u final read of chest CTA\n - Continue diuresis. Patient is Lasix naive and put out 3.5 Liters\n after single dose of Lasix 40mg IV.\n - Pt received one dose of vanco IV in the ED which was not continued\n after arrival to the CCU as patient does not look clinically infected.\n .\n # Aortic Stenosis: Patient has critical AS by Echo in , but has\n never had syncope, angina, or CHF in the past. Will consult CT surgery\n to begin work-up for potential AVR.\n - Elective cath today to r/o coronary disease prior to AVR, NPO after\n midnight.\n .\n # CORONARIES: He has no history of CAD or prior MI. He will need to\n have a cardiac cath tomorrow prior to proceeding for AVR.\n -CEs negative on admission\n -If there are no signs of CAD on cath, patient would most likely prefer\n to have percutaneous AVR.\n .\n # Hypertension: Patient is on amlodipine 5mg/benazepril 20mg daily as\n well as triamterene 37.5mg/HCTZ 25mg daily at home. His blood pressure\n has been running in the 90s to 110s since admission secondary to the\n Lasix and all blood pressure meds will be held. His BP will be\n monitored closely.\n .\n # Hyperlipidemia: Continue home dose of simvastatin 40mg.\n .\n # Spinal stenosis: Continue home pain regimen of celebrex 200mg .\n .\n FEN: Heart healthy/low sodium diet\n .\n ACCESS: PIV\n .\n PROPHYLAXIS:\n -DVT ppx with heparin SC\n -Bowel regimen with colace/senna\n .\n CODE: Full code\n .\n COMM: with patient, (wife)-> (home), \n (cell); -> \n .\n DISPO: CCU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 01:00 PM\n 18 Gauge - 01:00 PM\n Prophylaxis:\n DVT: heparin SC\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I would add the following remarks:\n History\n Nothing to add, ROS otherwise negative\n Physical Examination\n Nothing to add\n Medical Decision Making\n Nothing to add\n Total time spent on patient care: 90 minutes in addition to 60 minutes\n of direct discussion to keep patient from being discharged AMA\n ------ Protected Section Addendum Entered By: ,MD\n on: 08:57 ------\n"
},
{
"category": "Physician ",
"chartdate": "2108-08-10 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 590820,
"text": "TITLE:\n Chief Complaint: critical AS\n 24 Hour Events:\n - Pt underwent pre-AVR cath that demonstrated clean arteries, critical\n AS.\n - Pre-op studies completed.\n - Cleared for surgery on .\n - Plan to discharge on at noon with plans to return on at\n 6AM.\n - Stable, no complaints.\n Allergies:\n Atorvastatin\n myalgias;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.1\nC (98.8\n HR: 72 (72 - 98) bpm\n BP: 135/73(89) {106/32(60) - 150/99(107)} mmHg\n RR: 16 (13 - 30) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 64 kg (admission): 65.7 kg\n Height: 66 Inch\n Total In:\n 1,120 mL\n PO:\n TF:\n IVF:\n 1,120 mL\n Blood products:\n Total out:\n 2,000 mL\n 500 mL\n Urine:\n 2,000 mL\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n -880 mL\n -500 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: 7.45/42/128/26/5\n Physical Examination\n GENERAL: pleasant male in NAD, speaking in full sentences. Oriented x3.\n Mood, affect appropriate.\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no\n pallor or cyanosis of the oral mucosa. No xanthalesma.\n NECK: Supple with JVP to just below angle of mandible.\n CARDIAC: RRR, harsh grade III systolic murmur heard best at RUS border\n radiating to the carotids. No thrills, lifts.\n LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were\n unlabored, no accessory muscle use. Minimal crackles at bases.\n ABDOMEN: Soft, NTND. No HSM or tenderness.\n EXTREMITIES: 1+ edema bilaterally\n PULSES:\n Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 1+\n Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 1+\n Labs / Radiology\n 199 K/uL\n 11.3 g/dL\n 100 mg/dL\n 0.8 mg/dL\n 26 mEq/L\n 4.2 mEq/L\n 20 mg/dL\n 107 mEq/L\n 139 mEq/L\n 34.1 %\n 9.0 K/uL\n [image002.jpg]\n 09:00 PM\n 06:00 AM\n 09:17 AM\n 02:39 PM\n 05:04 AM\n WBC\n 10.6\n 11.2\n 9.0\n Hct\n 31.9\n 34.4\n 34.1\n Plt\n \n Cr\n 1.1\n 0.9\n 0.8\n TCO2\n 30\n Glucose\n 110\n 100\n Other labs: ALT / AST:42/28, Alk Phos / T Bili:67/0.4, Amylase /\n Lipase:130/52, D-dimer:1411 ng/mL, Lactic Acid:2.0 mmol/L, Albumin:3.8\n g/dL, LDH:284 IU/L, Ca++:9.0 mg/dL, Mg++:2.4 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n PULMONARY EDEMA\n CRITICAL AORTIC STENOSIS\n This is an 80 year old male who presented with acute onset of shortness\n of breath consistent with CHF exacerbation, now s/p cardiac cath\n showing critical AS (peak velocity 5.2 m/s, peak gradient 106 mmHg, \n .8 cm2) and clean coronaries.\n .\n # Shortness of breath: Likely secondary to congestive heart failure as\n patient has signs of fluid overload on imaging and BNP=7739. Patient\n required CPAP to maintain sats in ED, but was quickly weaned to room\n air after diuresis. Differential includes flash pulmonary edema, PE,\n and pneumonia. PE has been ruled out after negative CTA. Pneumonia\n seems less likely given the acuity of onset of shortness of breath\n without pro-dromal symptoms. Although he does have an unexplained WBC\n count of 17.2 and an ill defined lingular opacity on CT, he does not\n look clinically infected. Regarding the cause, he does have severe\n aortic stenosis (albeit with a normal EF and adequate pulse pressure),\n so a small insult could throw him into failure. Ischemia is on the\n differential, but no CP or EKG changes.\n - Blood cultures and urine culture NGTD\n - chest CTA without PE\n - diuresed well and has been oxygenating well on RA\n - Pt received one dose of vanco IV in the ED which was not continued\n after arrival to the CCU as patient does not look clinically infected.\n .\n # Aortic Stenosis: Patient has critical AS by Echo in and\n confirmed with cardiac cath yesterday, but has never had syncope,\n angina, or CHF in the past. CT surgery to begin work-up for potential\n AVR.\n - Planned procedure on Tuesday\n .\n # CORONARIES: He has no history of CAD or prior MI.\n -CEs negative on admission\n - cath showing no flow limiting CAD, R dominant system, LMCA without\n obstructive disease LAD with mild luminal irregularities with a 20% mid\n vessel stenosis, LCX and RCA with mild luminal irregularities\n -If there are no signs of CAD on cath, patient would most likely prefer\n to have percutaneous AVR.\n .\n # Hypertension: Patient is on amlodipine 5mg/benazepril 20mg daily as\n well as triamterene 37.5mg/HCTZ 25mg daily at home. His blood pressure\n has been running in the 90s to 110s since admission secondary to the\n Lasix and all blood pressure meds will be held.\n -stopped amlodipine/benazepril\n -metoprolol 25mg PO BID\n -add lisinopril 20mg PO daily\n .\n # Hyperlipidemia: Continue home dose of simvastatin 40mg.\n .\n # Spinal stenosis: Continue home pain regimen of celebrex 200mg .\n .\n FEN: Heart healthy/low sodium diet\n .\n ACCESS: PIV\n .\n PROPHYLAXIS:\n -DVT ppx with heparin SC\n -Bowel regimen with colace/senna\n .\n CODE: Full code\n .\n COMM: with patient, (wife)-> (home), \n (cell); -> \n .\n DISPO: discharge today, with plan to return for AVR\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 03:00 PM\n Prophylaxis:\n DVT: heparin SQ\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: discharge today\n"
},
{
"category": "Physician ",
"chartdate": "2108-08-10 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 590821,
"text": "TITLE:\n Chief Complaint: critical AS\n 24 Hour Events:\n - Pt underwent pre-AVR cath that demonstrated clean arteries, critical\n AS.\n - Pre-op studies completed.\n - Cleared for surgery on .\n - Plan to discharge on at noon with plans to return on at\n 6AM.\n - Stable, no complaints.\n Allergies:\n Atorvastatin\n myalgias;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.1\nC (98.8\n HR: 72 (72 - 98) bpm\n BP: 135/73(89) {106/32(60) - 150/99(107)} mmHg\n RR: 16 (13 - 30) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 64 kg (admission): 65.7 kg\n Height: 66 Inch\n Total In:\n 1,120 mL\n PO:\n TF:\n IVF:\n 1,120 mL\n Blood products:\n Total out:\n 2,000 mL\n 500 mL\n Urine:\n 2,000 mL\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n -880 mL\n -500 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: 7.45/42/128/26/5\n Physical Examination\n GENERAL: pleasant male in NAD, speaking in full sentences. Oriented x3.\n Mood, affect appropriate.\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no\n pallor or cyanosis of the oral mucosa. No xanthalesma.\n NECK: Supple with JVP to just below angle of mandible.\n CARDIAC: RRR, harsh grade III systolic murmur heard best at RUS border\n radiating to the carotids. No thrills, lifts.\n LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were\n unlabored, no accessory muscle use. Minimal crackles at bases.\n ABDOMEN: Soft, NTND. No HSM or tenderness.\n EXTREMITIES: 1+ edema bilaterally\n PULSES:\n Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 1+\n Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 1+\n Labs / Radiology\n 199 K/uL\n 11.3 g/dL\n 100 mg/dL\n 0.8 mg/dL\n 26 mEq/L\n 4.2 mEq/L\n 20 mg/dL\n 107 mEq/L\n 139 mEq/L\n 34.1 %\n 9.0 K/uL\n [image002.jpg]\n 09:00 PM\n 06:00 AM\n 09:17 AM\n 02:39 PM\n 05:04 AM\n WBC\n 10.6\n 11.2\n 9.0\n Hct\n 31.9\n 34.4\n 34.1\n Plt\n \n Cr\n 1.1\n 0.9\n 0.8\n TCO2\n 30\n Glucose\n 110\n 100\n Other labs: ALT / AST:42/28, Alk Phos / T Bili:67/0.4, Amylase /\n Lipase:130/52, D-dimer:1411 ng/mL, Lactic Acid:2.0 mmol/L, Albumin:3.8\n g/dL, LDH:284 IU/L, Ca++:9.0 mg/dL, Mg++:2.4 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n PULMONARY EDEMA\n CRITICAL AORTIC STENOSIS\n This is an 80 year old male who presented with acute onset of shortness\n of breath consistent with CHF exacerbation, now s/p cardiac cath\n showing critical AS (peak velocity 5.2 m/s, peak gradient 106 mmHg, \n .8 cm2) and clean coronaries.\n .\n # Shortness of breath: Likely secondary to congestive heart failure as\n patient has signs of fluid overload on imaging and BNP=7739. Patient\n required CPAP to maintain sats in ED, but was quickly weaned to room\n air after diuresis. Differential includes flash pulmonary edema, PE,\n and pneumonia. PE has been ruled out after negative CTA. Pneumonia\n seems less likely given the acuity of onset of shortness of breath\n without pro-dromal symptoms. Although he does have an unexplained WBC\n count of 17.2 and an ill defined lingular opacity on CT, he does not\n look clinically infected. Regarding the cause, he does have severe\n aortic stenosis (albeit with a normal EF and adequate pulse pressure),\n so a small insult could throw him into failure. Ischemia is on the\n differential, but no CP or EKG changes.\n - Blood cultures and urine culture NGTD\n - chest CTA without PE\n - diuresed well and has been oxygenating well on RA\n - Pt received one dose of vanco IV in the ED which was not continued\n after arrival to the CCU as patient does not look clinically infected.\n .\n # Aortic Stenosis: Patient has critical AS by Echo in and\n confirmed with cardiac cath yesterday, but has never had syncope,\n angina, or CHF in the past. CT surgery to begin work-up for potential\n AVR.\n - Planned procedure on Tuesday\n .\n # CORONARIES: He has no history of CAD or prior MI.\n -CEs negative on admission\n - cath showing no flow limiting CAD, R dominant system, LMCA without\n obstructive disease LAD with mild luminal irregularities with a 20% mid\n vessel stenosis, LCX and RCA with mild luminal irregularities\n -If there are no signs of CAD on cath, patient would most likely prefer\n to have percutaneous AVR.\n .\n # Hypertension: Patient is on amlodipine 5mg/benazepril 20mg daily as\n well as triamterene 37.5mg/HCTZ 25mg daily at home. His blood pressure\n has been running in the 90s to 110s since admission secondary to the\n Lasix and all blood pressure meds will be held.\n - can restart home regimen\n .\n # Hyperlipidemia: Continue home dose of simvastatin 40mg.\n .\n # Spinal stenosis: Continue home pain regimen of celebrex 200mg .\n .\n FEN: Heart healthy/low sodium diet\n .\n ACCESS: PIV\n .\n PROPHYLAXIS:\n -DVT ppx with heparin SC\n -Bowel regimen with colace/senna\n .\n CODE: Full code\n .\n COMM: with patient, (wife)-> (home), \n (cell); -> \n .\n DISPO: discharge today, with plan to return for AVR\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 03:00 PM\n Prophylaxis:\n DVT: heparin SQ\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: discharge today\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I would add the following remarks:\n History\n nothing to add\n Physical Examination\n nothing to add\n Medical Decision Making\n nothing to add,\n discharge home today, start beta blocker\n Total time spent on patient care: 50 minutes.\n"
},
{
"category": "Physician ",
"chartdate": "2108-08-10 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 590828,
"text": "TITLE:\n Chief Complaint: critical AS\n 24 Hour Events:\n - Pt underwent pre-AVR cath that demonstrated clean arteries, critical\n AS.\n - Pre-op studies completed.\n - Cleared for surgery on .\n - Plan to discharge on at noon with plans to return on at\n 6AM.\n - Stable, no complaints.\n Allergies:\n Atorvastatin\n myalgias;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.1\nC (98.8\n HR: 72 (72 - 98) bpm\n BP: 135/73(89) {106/32(60) - 150/99(107)} mmHg\n RR: 16 (13 - 30) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 64 kg (admission): 65.7 kg\n Height: 66 Inch\n Total In:\n 1,120 mL\n PO:\n TF:\n IVF:\n 1,120 mL\n Blood products:\n Total out:\n 2,000 mL\n 500 mL\n Urine:\n 2,000 mL\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n -880 mL\n -500 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: 7.45/42/128/26/5\n Physical Examination\n GENERAL: pleasant male in NAD, speaking in full sentences. Oriented x3.\n Mood, affect appropriate.\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no\n pallor or cyanosis of the oral mucosa. No xanthalesma.\n NECK: Supple with JVP to just below angle of mandible.\n CARDIAC: RRR, harsh grade III systolic murmur heard best at RUS border\n radiating to the carotids. No thrills, lifts.\n LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were\n unlabored, no accessory muscle use. Minimal crackles at bases.\n ABDOMEN: Soft, NTND. No HSM or tenderness.\n EXTREMITIES: 1+ edema bilaterally\n PULSES:\n Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 1+\n Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 1+\n Labs / Radiology\n 199 K/uL\n 11.3 g/dL\n 100 mg/dL\n 0.8 mg/dL\n 26 mEq/L\n 4.2 mEq/L\n 20 mg/dL\n 107 mEq/L\n 139 mEq/L\n 34.1 %\n 9.0 K/uL\n [image002.jpg]\n 09:00 PM\n 06:00 AM\n 09:17 AM\n 02:39 PM\n 05:04 AM\n WBC\n 10.6\n 11.2\n 9.0\n Hct\n 31.9\n 34.4\n 34.1\n Plt\n \n Cr\n 1.1\n 0.9\n 0.8\n TCO2\n 30\n Glucose\n 110\n 100\n Other labs: ALT / AST:42/28, Alk Phos / T Bili:67/0.4, Amylase /\n Lipase:130/52, D-dimer:1411 ng/mL, Lactic Acid:2.0 mmol/L, Albumin:3.8\n g/dL, LDH:284 IU/L, Ca++:9.0 mg/dL, Mg++:2.4 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n PULMONARY EDEMA\n CRITICAL AORTIC STENOSIS\n This is an 80 year old male who presented with acute onset of shortness\n of breath consistent with CHF exacerbation, now s/p cardiac cath\n showing critical AS (peak velocity 5.2 m/s, peak gradient 106 mmHg, \n .8 cm2) and clean coronaries.\n .\n # Shortness of breath: Likely secondary to congestive heart failure as\n patient has signs of fluid overload on imaging and BNP=7739. Patient\n required CPAP to maintain sats in ED, but was quickly weaned to room\n air after diuresis. Differential includes flash pulmonary edema, PE,\n and pneumonia. PE has been ruled out after negative CTA. Pneumonia\n seems less likely given the acuity of onset of shortness of breath\n without pro-dromal symptoms. Although he does have an unexplained WBC\n count of 17.2 and an ill defined lingular opacity on CT, he does not\n look clinically infected. Regarding the cause, he does have severe\n aortic stenosis (albeit with a normal EF and adequate pulse pressure),\n so a small insult could throw him into failure. Ischemia is on the\n differential, but no CP or EKG changes.\n - Blood cultures and urine culture NGTD\n - chest CTA without PE\n - diuresed well and has been oxygenating well on RA\n - Pt received one dose of vanco IV in the ED which was not continued\n after arrival to the CCU as patient does not look clinically infected.\n .\n # Aortic Stenosis: Patient has critical AS by Echo in and\n confirmed with cardiac cath yesterday, but has never had syncope,\n angina, or CHF in the past. CT surgery to begin work-up for potential\n AVR.\n -Carotid U/S and CXR (PA/Lateral)- scheduled for today before\n discharge.\n - Planned procedure on Tuesday\n .\n # CORONARIES: He has no history of CAD or prior MI.\n -CEs negative on admission\n - cath showing no flow limiting CAD, R dominant system, LMCA without\n obstructive disease LAD with mild luminal irregularities with a 20% mid\n vessel stenosis, LCX and RCA with mild luminal irregularities\n -If there are no signs of CAD on cath, patient would most likely prefer\n to have percutaneous AVR.\n .\n # Hypertension: Patient is on amlodipine 5mg/benazepril 20mg daily as\n well as triamterene 37.5mg/HCTZ 25mg daily at home. His blood pressure\n has been running in the 90s to 110s since admission secondary to the\n Lasix and all blood pressure meds will be held.\n -stopped amlodipine/benazepril\n -metoprolol 25mg PO BID\n -add lisinopril 20mg PO daily\n .\n # Hyperlipidemia: Continue home dose of simvastatin 40mg.\n .\n # Spinal stenosis: Continue home pain regimen of celebrex 200mg .\n .\n FEN: Heart healthy/low sodium diet\n .\n ACCESS: PIV\n .\n PROPHYLAXIS:\n -DVT ppx with heparin SC\n -Bowel regimen with colace/senna\n .\n CODE: Full code\n .\n COMM: with patient, (wife)-> (home), \n (cell); -> \n .\n DISPO: discharge today, with plan to return for AVR\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 03:00 PM\n Prophylaxis:\n DVT: heparin SQ\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: discharge today\n"
},
{
"category": "Rehab Services",
"chartdate": "2108-08-10 00:00:00.000",
"description": "Physical Therapy Evaluation Note",
"row_id": 590832,
"text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: AS / 424.1\n Reason of referral: Eval & treat\n History of Present Illness / Subjective Complaint: 80 yo M with known\n AS presents with acute SOB c/w critical AS. Cardiac cath neg for CAD,\n now plan is to undergo AVR on .\n Past Medical / Surgical History: AS, HTN, Groves dx,\n hypercholesterolemia, carotid stenosis, GERD, spinal stenosis s/p\n surgery, scoliosis\n Medications: aspirin, lorazepam, heparin, lisinopril, metoprolol\n Radiology: chest CT - Moderate bilateral pleural effusion and\n bibasilar atelectasis.\n Labs:\n 34.1\n 11.3\n 199\n 9.0\n [image002.jpg]\n Other labs:\n Activity Orders: Activity as tolerated\n Social / Occupational History: lives with wife\n Environment: lives in multi-level home with flight of stairs to\n bedroom\n Prior Functional Status / Activity Level: I pta, no DME. Active per\n family\n Objective Test\n Arousal / Attention / Cognition / Communication: A&O x3,\n pleasant/cooperative\n Hemodynamic Response\n Aerobic Capacity\n HR\n BP\n RR\n O[2 ]sat\n HR\n BP\n RR\n O[2] sat\n RPE\n Supine\n /\n Rest\n 71\n 137/75\n 96% on RA\n Sit\n /\n Activity\n 76\n 130/67\n 95% on RA\n Stand\n /\n Recovery\n /\n Total distance walked: 200'\n Minutes:\n Pulmonary Status: non-labored breathing, no cough noted\n Integumentary / Vascular: skin intact, tele\n Sensory Integrity: B LE's intact to light touch\n Pain / Limiting Symptoms: denies pain\n Posture: mild kyphosis\n Range of Motion\n Muscle Performance\n B LE's WNL\n age-appropriate t/o\n Motor Function: no abnormal movement patterns\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: steady functional gait, min c/o fatigue\n Rolling:\n T\n\n\n\n\n\n Supine /\n Sidelying to Sit:\n T\n\n\n\n\n\n Transfer:\n T\n\n\n\n\n\n Sit to Stand:\n T\n\n\n\n\n\n Ambulation:\n T\n\n\n\n\n Stairs:\n\n\n\n\n\n Balance: S sitting, S/CG static/dynamic standing balance. No gross LOB\n with mobility\n Education / Communication: Reviewed PT and d/c planning.\n Communicated with nsg re: status\n Intervention:\n Other:\n Diagnosis:\n 1.\n Impaired functional mobility\n 2.\n Impaired endurance\n 3.\n Impaired balance\n Clinical impression / Prognosis: 80 yo M with AS p/w above impairments\n a/w cardiovascular pump dysfunction. He is at overall independent\n level and appears to be at his baseline level. He is safe for d/c home\n when medically appropriate, no further acute PT needs at this time.\n Will follow-up post-op AVR.\n Goals\n Time frame: Met on eval\n 1.\n Independent with all mobility\n 2.\n Ambulate >/= 200' with stable HDR\n 3.\n No LOB with mobility\n 4.\n 5.\n 6.\n Anticipated Discharge: Home without PT\n Treatment :\n Frequency / Duration: d/c\n d/c acute PT\n T Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n"
},
{
"category": "Nursing",
"chartdate": "2108-08-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 590664,
"text": "80 year old man w/ pmh including AS & spinal stenosis, admitted to the\n ED from home after waking up with acute shortness of breath and\n diaphoresis. Placed on Cpap in the ED & given 40 mg IVP lasix. Also\n given Vanco in the ED to treat elevated WBC; BC & urine cultures sent\n from ED.\n : Arrived CCU in no acute distress on venti- mask, quickly\n transitioned to NC only. Continued to diurese to lasix given in the ED.\n Remains afebrile, no further antibiotics.\n"
},
{
"category": "Physician ",
"chartdate": "2108-08-09 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 590665,
"text": "TITLE:\n Chief Complaint: Acute onset shortness of breath\n HPI: Mr. is an 80 year-old man with a history of critical AS\n (peak velocity 5.2 m/s, peak gradient 106 mmHg, .8 cm2) presenting\n with acute onset shortness of breath this morning. He has never been\n short of breath in the past and actually leads quite an active\n lifestyle. His symptoms seem to have started on the morning of \n when he experienced 5 minutes of shortness of breath. This feeling\n quickly resolved and the patient felt well enough to play 18 holes of\n golf later that day. At baseline he is very active and he is able to\n log 20 miles per week on his stationary bicycle without any episodes of\n chest discomfort, palpitations, or lightheadedness. Later on the 18th\n the patient went out for dinner and ate a very salty meal of clams and\n stuffed shrimp. He also ate a pint of ice cream and biked for 6 miles\n on his stationary bike before going to bed. He slept well overnight on\n 1 pillow and got up to urinate over night. He then woke up at 8AM and\n felt extremely short of breath after brushing his teeth. It didn't\n effect him that much because he was still able to carry out his normal\n morning routine, although with difficulty. He was not able to do his\n morning exercises, however, and he tried to lay down and his shortness\n of breath did not resolve. Finally he went outside to get some fresh\n air with his dog and got diaphoretic and wheezy. His neighbor\n convinced him to call the ambulance to be brought in to the hospital.\n He specifically denies any fevers, chills, cough, change in bowel\n habits, dysuria, dizziness, lightheadedness, chest pain, or abdominal\n pain.\n An outpatient ETT-echo had been planned to assess his blood pressure\n response to exercise in anticipation of a possible back surgery for his\n spinal stenosis. He has had 2 back surgeries in the past for this\n condition, the last being 7-8 years ago. Of note, he received a\n Cortisone injection of his back 2 weeks ago. This pending surgery\n would be to address his chronic right leg pain which he feels has been\n limiting his activity. The plan was to proceed with the surgery unless\n he had an abnormally hypotensive response to exercise, then AVR would\n be considered. No AVR was planned because the patient has never\n experienced any lightheadedness, dizziness, presyncope, chest pain, or\n shortness of breath in the past.\n .\n Documentation of inital EMS vitals is not available. By report, en\n route to hospital he received 1 SL nitro and albuterol nebs after which\n he felt somewhat better. On arrival to the ED, the first set of\n documented vitals T 97.8, HR 120, RR 36, BP 163/91, O2 Sat 95% on 10 L\n O2. In the ED he desatted to the 80s on RA. Exam notable for poor air\n movement, tachycardia with SEM, and 2+ b/l pitting edema. EKG showed\n sinus tachycardia, and CXR was without evidence of infiltrate but did\n show volume overload. Labs notable for WBC 17.4 with 93% PMN as well\n as a D-Dimer of 1411. His oxygen requirement escalated and he required\n CPAP. He received 40 mg IV lasix and put out 300 cc of urine within 30\n minutes. He also received 1 g vancomycin. VS prior to transfer HR 108,\n BP 114/65, RR 17, 99% on CPAP, T 97.4.\n .\n En route to CCU patient underwent CTA which, per discussion with\n radiology resident, was negative for PE, infiltrate, volume overload,\n or other abnormalities apart from small bilaterally symmetric pleural\n effusions.\n .\n On arrival to the CCU the patient had diuresed a total of 1700cc and\n was satting well on 3L nasal cannula.\n .\n On review of systems, s/he denies any prior history of stroke, TIA,\n deep venous thrombosis, pulmonary embolism, bleeding at the time of\n surgery, myalgias, joint pains, cough, hemoptysis, black stools or red\n stools. He denies recent fevers, chills or rigors. He denies exertional\n buttock or calf pain. All of the other review of systems were\n negative.\n .\n Cardiac review of systems is notable for absence of chest pain, dyspnea\n on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,\n palpitations, syncope or presyncope.\n Allergies:\n Atorvastatin\n myalgias;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 09:00 PM\n Other medications:\n Home meds:\n amlodipine-benazepril 5 mg-20 mg daily\n celebrex 200 mg \n simvastatin unknown dose\n cialis PRN\n tetracycline 500 mg x 2 months\n triamterene-hctz 75 mg-50 mg tablet daily\n amoxicillin PRN as antibiotic prophylaxis\n ASA 81 mg daily\n glucosamine 1500 mg daily\n vitamin C 1 g daily\n potassium (OTC) 99 mg daily\n Past medical history:\n Family history:\n Social History:\n 1. CARDIAC RISK FACTORS: no Diabetes, + Dyslipidemia,+ Hypertension\n 2. CARDIAC HISTORY:\n - Aortic stenosis as above\n 3. OTHER PAST MEDICAL HISTORY:\n - Hypertension\n - Hypercholesterolemia\n - Mild carotid stenosis by ultrasound\n - GERD\n - Spinal stenosis with chronic right leg pain, s/p two operations and\n more recent steroid injections, considering operative treatment.\n - R thumb surgery\n Parents are deceased (father 48 years, cancer; mother - years,\n cancer). A daughter has multiple sclerosis.\n He has been married for 28 years. He spends -mid in \n where he is now a resident. He continues to smoke a pipe up to 5 times\n daily and drinks 2-3 glasses of wine/wk.\n Review of systems:\n Flowsheet Data as of 02:14 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.3\nC (99.1\n HR: 82 (82 - 105) bpm\n BP: 104/64(73) {90/49(59) - 116/72(83)} mmHg\n RR: 17 (17 - 22) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n Total In:\n 108 mL\n 22 mL\n PO:\n TF:\n IVF:\n 108 mL\n 22 mL\n Blood products:\n Total out:\n 4,190 mL\n 0 mL\n Urine:\n 3,790 mL\n NG:\n Stool:\n Drains:\n Balance:\n -4,083 mL\n 22 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 97%\n Physical Examination\n GENERAL: pleasant male in NAD, speaking in full sentences. Oriented x3.\n Mood, affect appropriate.\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no\n pallor or cyanosis of the oral mucosa. No xanthalesma.\n NECK: Supple with JVP to just below angle of mandible.\n CARDIAC: RRR, harsh systolic ejection murmur radiating to the carotids.\n No thrills, lifts.\n LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were\n unlabored, no accessory muscle use. Crackles way up from bases\n bilaterally, no wheezes or rhonchi.\n ABDOMEN: Soft, NTND. No HSM or tenderness.\n EXTREMITIES: 1+ edema bilaterally\n PULSES:\n Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 1+\n Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 1+\n Labs / Radiology\n 1.1 mg/dL\n 4.4 mEq/L\n [image002.jpg]\n \n 2:33 A8/19/ 09:00 PM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n Cr\n 1.1\n Other labs: ALT / AST:42/28, Alk Phos / T Bili:67/0.4, Amylase /\n Lipase:185/68, D-dimer:1411 ng/mL, Lactic Acid:2.0 mmol/L, Albumin:3.8\n g/dL, LDH:284 IU/L\n Assessment and Plan\n This is an 80 year old male with a history of critical AS (peak\n velocity 5.2 m/s, peak gradient 106 mmHg, .8 cm2) presenting with\n acute onset of shortness of breath this morning consistent with CHF\n exacerbation.\n .\n # Shortness of breath: Likely secondary to congestive heart failure as\n patient has signs of fluid overload on imaging and BNP=7739. Patient\n required CPAP to maintain sats in ED, but was quickly weaned to room\n air after diuresis. Differential includes flash pulmonary edema, PE,\n and pneumonia. PE has been ruled out after negative CTA. Pneumonia\n seems less likely given the acuity of onset of shortness of breath\n without prodromal syptoms. Although he does have an unexplained WBC\n count of 17.2 and an ill defined lingular opacity on CT, he does not\n look clinically infected. Regarding the cause, he does have severe\n aortic stenosis (albeit with a normal EF and adequate pulse pressure),\n so a small insult could throw him into failure. Ischemia is on the\n differential, but no CP or EKG changes. He does have evidence of\n infection that may have tipped him over.\n - Blood cultures and urine culture pending\n - f/u final read of chest CTA\n - Continue diuresis. Patient is Lasix naive and put out 3.5 Liters\n after single dose of Lasix 40mg IV.\n - Pt received one dose of vanco IV in the ED which was not continued\n after arrival to the CCU as patient does not look clinically infected.\n .\n # Aortic Stenosis: Patient has critical AS by Echo in , but has\n never had syncope, angina, or CHF in the past. Will consult CT surgery\n to begin work-up for potential AVR.\n - Elective cath tomorrow to r/o coronary disease prior to AVR, NPO\n after midnight.\n .\n # CORONARIES: He has no history of CAD or prior MI. He will need to\n have a cardiac cath tomorrow prior to proceeding for AVR.\n -CEs negative on admission\n -If there are no signs of CAD on cath, patient would most likely prefer\n to have percutaneous AVR.\n .\n # Hypertension: Patient is on amlodipine 5mg/benazepril 20mg daily as\n well as triamterene 37.5mg/HCTZ 25mg daily at home. His blood pressure\n has been running in the 90s to 110s since admission secondary to the\n Lasix and all blood pressure meds will be held. His BP will be\n monitored closely.\n .\n # Hyperlipidemia: Continue home dose of simvastatin 40mg.\n .\n # Spinal stenosis: Continue home pain regimen of celebrex 200mg .\n .\n FEN: Heart healthy/low sodium diet\n .\n ACCESS: PIV\n .\n PROPHYLAXIS:\n -DVT ppx with heparin SC\n -Bowel regimen with colace/senna\n .\n CODE: Full code\n .\n COMM: with patient, (wife)-> (home), \n (cell); -> \n .\n DISPO: CCU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 01:00 PM\n 18 Gauge - 01:00 PM\n Prophylaxis:\n DVT: heparin SC\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2108-08-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 590751,
"text": "80 year old man w/ pmh including AS & spinal stenosis, admitted to the\n ED from home after waking up with acute shortness of breath and\n diaphoresis. Placed on Cpap in the ED & given 40 meq IVP lasix. Also\n given Vanco in the ED to treat elevated WBC; BC & urine cultures sent\n from ED.\n : pre-op AVR work-up including dental panorex, UA/C&S & cardiac\n cath with pre-cath hydration. Patient called out to 3.\n Aortic stenosis\n Assessment:\n s/p excellent diuresis on (4 liters out to 40 IV lasix) Lungs\n clear/diminished w/ trace pedal edema; clonus in left leg > right leg.\n Current pipe smoker. History of Aortic Stenosis; but no history of CHF.\n Afebrile. HR 70s-80s w/ some PAC\ns. BP 130\ns/50\ns. Sats > 95% on RA.\n Denies SOB. EKG changes c/w LVH.\n Action:\n v Continued to monitor I/O & daily weight, stands @ end of bed to\n use urinal pre-cath. UA C&S sent.\n v Dental panorex obtained as part of pre-op work-up\n v Dermatology consulted to evaluate long-standing history of skin\n rash (not active at this time) on patient\ns back to see if it poses an\n infection risk to a potential sternal wound.\n v Given dose mucamyst & started infusion of D5\n NS @ 75 ml/hr\n for renal protection prior to cath.\n v To cath at 1330\n Response:\n v I/O even pre-cath, but LOS negative approximately 5 liters\n v O2 sats remains >95 % on RA.\n v Dental service to follow-up with patient this evening\n v Dermatology to see patient tomorrow when off bedrest to\n evaluate patient\ns back\n v Awaiting return from cath lab\n Plan:\n Continue to monitor hemodynamic & respiratory status. Smoking cessation\n counseling. Await recommendations from CSurg regarding scheduling of\n AVR, (potentially next Friday, although patient would like to go next\n Monday or Tuesday)- patient wishing to go home for a few days\n pre-operatively.\n Patient returned from cath at 15:30-\n o Verbal report states no significant CAD seen, 200 IVF in,\n voided 300 ml condom cath at 1745; 200 into urinal 1830\n o Right groin site C,D & I, pedal pulses by Doppler only.\n o Bedrest until 1900\n o\n NS at 75 ml/hr for 500 ml.\n o Plan: Patient wishing to go home this evening & wife\n uncomfortable managing patient at home before surgery; no clear plan\n for discharge at this time. 0.5 mg Ativan given at 1620 per patient\n request to relieve anxiety, effective per patient.\n"
},
{
"category": "Nursing",
"chartdate": "2108-08-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 590752,
"text": "80 year old man w/ pmh including AS & spinal stenosis, admitted to the\n ED from home after waking up with acute shortness of breath and\n diaphoresis. Placed on Cpap in the ED & given 40 meq IVP lasix. Also\n given Vanco in the ED to treat elevated WBC; BC & urine cultures sent\n from ED.\n : pre-op AVR work-up including dental panorex, UA/C&S & cardiac\n cath with pre-cath hydration. Patient called out to 3.\n Aortic stenosis\n Assessment:\n s/p excellent diuresis on (4 liters out to 40 IV lasix) Lungs\n clear/diminished w/ trace pedal edema; clonus in left leg > right leg.\n Current pipe smoker. History of Aortic Stenosis; but no history of CHF.\n Afebrile. HR 70s-80s w/ some PAC\ns. BP 130\ns/50\ns. Sats > 95% on RA.\n Denies SOB. EKG changes c/w LVH.\n Action:\n v Continued to monitor I/O & daily weight, stands @ end of bed to\n use urinal pre-cath. UA C&S sent.\n v Dental panorex obtained as part of pre-op work-up\n v Dermatology consulted to evaluate long-standing history of skin\n rash (not active at this time) on patient\ns back to see if it poses an\n infection risk to a potential sternal wound.\n v Given dose mucamyst & started infusion of D5\n NS @ 75 ml/hr\n for renal protection prior to cath.\n v To cath at 1330\n Response:\n v I/O even pre-cath, but LOS negative approximately 5 liters\n v O2 sats remains >95 % on RA.\n v Dental service to follow-up with patient this evening\n v Dermatology to see patient tomorrow when off bedrest to\n evaluate patient\ns back\n v Awaiting return from cath lab\n Plan:\n Continue to monitor hemodynamic & respiratory status. Smoking cessation\n counseling. Await recommendations from CSurg regarding scheduling of\n AVR, (potentially next Friday, although patient would like to go next\n Monday or Tuesday)- patient wishing to go home for a few days\n pre-operatively.\n Patient returned from cath at 15:30-\n o Verbal report states no significant CAD seen, 200 IVF in,\n voided 300 ml condom cath at 1745; 200 into urinal 1830\n o Right groin site C,D & I, pedal pulses by Doppler only.\n o Bedrest until 1900\n o\n NS at 75 ml/hr for 500 ml.\n o Plan: Patient wishing to go home this evening & wife\n uncomfortable managing patient at home before surgery; no clear plan\n for discharge at this time. 0.5 mg Ativan given at 1620 per patient\n request to relieve anxiety, effective per patient.\n"
},
{
"category": "Nursing",
"chartdate": "2108-08-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 590836,
"text": "Pt discharged at in the company of his wife and daughter after\n pre-op carotid US, CXR completed. Pt ; OOB ambulating ad lib and\n tolerating well. Discharge plan reviewed with pt and family including\n medication list, activity restrictions, warning signs, and daily\n weights. Plan is for pt to return on Tuesday, at 0600 for\n AVR. Pt/family understand plan and are in agreement.\n"
},
{
"category": "Physician ",
"chartdate": "2108-08-09 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 590708,
"text": "TITLE:\n Chief Complaint: Acute onset shortness of breath\n HPI: Mr. is an 80 year-old man with a history of critical AS\n (peak velocity 5.2 m/s, peak gradient 106 mmHg, .8 cm2) presenting\n with acute onset shortness of breath this morning. He has never been\n short of breath in the past and actually leads quite an active\n lifestyle. His symptoms seem to have started on the morning of \n when he experienced 5 minutes of shortness of breath. This feeling\n quickly resolved and the patient felt well enough to play 18 holes of\n golf later that day. At baseline he is very active and he is able to\n log 20 miles per week on his stationary bicycle without any episodes of\n chest discomfort, palpitations, or lightheadedness. Later on the 18th\n the patient went out for dinner and ate a very salty meal of clams and\n stuffed shrimp. He also ate a pint of ice cream and biked for 6 miles\n on his stationary bike before going to bed. He slept well overnight on\n 1 pillow and got up to urinate over night. He then woke up at 8AM and\n felt extremely short of breath after brushing his teeth. It didn't\n effect him that much because he was still able to carry out his normal\n morning routine, although with difficulty. He was not able to do his\n morning exercises, however, and he tried to lay down and his shortness\n of breath did not resolve. Finally he went outside to get some fresh\n air with his dog and got diaphoretic and wheezy. His neighbor\n convinced him to call the ambulance to be brought in to the hospital.\n He specifically denies any fevers, chills, cough, change in bowel\n habits, dysuria, dizziness, lightheadedness, chest pain, or abdominal\n pain.\n An outpatient ETT-echo had been planned to assess his blood pressure\n response to exercise in anticipation of a possible back surgery for his\n spinal stenosis. He has had 2 back surgeries in the past for this\n condition, the last being 7-8 years ago. Of note, he received a\n Cortisone injection of his back 2 weeks ago. This pending surgery\n would be to address his chronic right leg pain which he feels has been\n limiting his activity. The plan was to proceed with the surgery unless\n he had an abnormally hypotensive response to exercise, then AVR would\n be considered. No AVR was planned because the patient has never\n experienced any lightheadedness, dizziness, presyncope, chest pain, or\n shortness of breath in the past.\n .\n Documentation of inital EMS vitals is not available. By report, en\n route to hospital he received 1 SL nitro and albuterol nebs after which\n he felt somewhat better. On arrival to the ED, the first set of\n documented vitals T 97.8, HR 120, RR 36, BP 163/91, O2 Sat 95% on 10 L\n O2. In the ED he desatted to the 80s on RA. Exam notable for poor air\n movement, tachycardia with SEM, and 2+ b/l pitting edema. EKG showed\n sinus tachycardia, and CXR was without evidence of infiltrate but did\n show volume overload. Labs notable for WBC 17.4 with 93% PMN as well\n as a D-Dimer of 1411. His oxygen requirement escalated and he required\n CPAP. He received 40 mg IV lasix and put out 300 cc of urine within 30\n minutes. He also received 1 g vancomycin. VS prior to transfer HR 108,\n BP 114/65, RR 17, 99% on CPAP, T 97.4.\n .\n En route to CCU patient underwent CTA which, per discussion with\n radiology resident, was negative for PE, infiltrate, volume overload,\n or other abnormalities apart from small bilaterally symmetric pleural\n effusions.\n .\n On arrival to the CCU the patient had diuresed a total of 1700cc and\n was satting well on 3L nasal cannula.\n .\n On review of systems, s/he denies any prior history of stroke, TIA,\n deep venous thrombosis, pulmonary embolism, bleeding at the time of\n surgery, myalgias, joint pains, cough, hemoptysis, black stools or red\n stools. He denies recent fevers, chills or rigors. He denies exertional\n buttock or calf pain. All of the other review of systems were\n negative.\n .\n Cardiac review of systems is notable for absence of chest pain, dyspnea\n on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,\n palpitations, syncope or presyncope.\n Allergies:\n Atorvastatin\n myalgias;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 09:00 PM\n Other medications:\n Home meds:\n amlodipine-benazepril 5 mg-20 mg daily\n celebrex 200 mg \n simvastatin unknown dose\n cialis PRN\n tetracycline 500 mg x 2 months\n triamterene-hctz 75 mg-50 mg tablet daily\n amoxicillin PRN as antibiotic prophylaxis\n ASA 81 mg daily\n glucosamine 1500 mg daily\n vitamin C 1 g daily\n potassium (OTC) 99 mg daily\n Past medical history:\n Family history:\n Social History:\n 1. CARDIAC RISK FACTORS: no Diabetes, + Dyslipidemia,+ Hypertension\n 2. CARDIAC HISTORY:\n - Aortic stenosis as above\n 3. OTHER PAST MEDICAL HISTORY:\n - Hypertension\n - Hypercholesterolemia\n - Mild carotid stenosis by ultrasound\n - GERD\n - Spinal stenosis with chronic right leg pain, s/p two operations and\n more recent steroid injections, considering operative treatment.\n - R thumb surgery\n Parents are deceased (father 48 years, cancer; mother - years,\n cancer). A daughter has multiple sclerosis.\n He has been married for 28 years. He spends -mid in \n where he is now a resident. He continues to smoke a pipe up to 5 times\n daily and drinks 2-3 glasses of wine/wk.\n Review of systems:\n Flowsheet Data as of 02:14 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.3\nC (99.1\n HR: 82 (82 - 105) bpm\n BP: 104/64(73) {90/49(59) - 116/72(83)} mmHg\n RR: 17 (17 - 22) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n Total In:\n 108 mL\n 22 mL\n PO:\n TF:\n IVF:\n 108 mL\n 22 mL\n Blood products:\n Total out:\n 4,190 mL\n 0 mL\n Urine:\n 3,790 mL\n NG:\n Stool:\n Drains:\n Balance:\n -4,083 mL\n 22 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 97%\n Physical Examination\n GENERAL: pleasant male in NAD, speaking in full sentences. Oriented x3.\n Mood, affect appropriate.\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no\n pallor or cyanosis of the oral mucosa. No xanthalesma.\n NECK: Supple with JVP to just below angle of mandible.\n CARDIAC: RRR, harsh systolic ejection murmur radiating to the carotids.\n No thrills, lifts.\n LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were\n unlabored, no accessory muscle use. Crackles way up from bases\n bilaterally, no wheezes or rhonchi.\n ABDOMEN: Soft, NTND. No HSM or tenderness.\n EXTREMITIES: 1+ edema bilaterally\n PULSES:\n Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 1+\n Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 1+\n Labs / Radiology\n 1.1 mg/dL\n 4.4 mEq/L\n [image002.jpg]\n \n 2:33 A8/19/ 09:00 PM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n Cr\n 1.1\n Other labs: ALT / AST:42/28, Alk Phos / T Bili:67/0.4, Amylase /\n Lipase:185/68, D-dimer:1411 ng/mL, Lactic Acid:2.0 mmol/L, Albumin:3.8\n g/dL, LDH:284 IU/L\n Assessment and Plan\n This is an 80 year old male with a history of critical AS (peak\n velocity 5.2 m/s, peak gradient 106 mmHg, .8 cm2) presenting with\n acute onset of shortness of breath this morning consistent with CHF\n exacerbation.\n .\n # Shortness of breath: Likely secondary to congestive heart failure as\n patient has signs of fluid overload on imaging and BNP=7739. Patient\n required CPAP to maintain sats in ED, but was quickly weaned to room\n air after diuresis. Differential includes flash pulmonary edema, PE,\n and pneumonia. PE has been ruled out after negative CTA. Pneumonia\n seems less likely given the acuity of onset of shortness of breath\n without prodromal syptoms. Although he does have an unexplained WBC\n count of 17.2 and an ill defined lingular opacity on CT, he does not\n look clinically infected. Regarding the cause, he does have severe\n aortic stenosis (albeit with a normal EF and adequate pulse pressure),\n so a small insult could throw him into failure. Ischemia is on the\n differential, but no CP or EKG changes. He does have evidence of\n infection that may have tipped him over.\n - Blood cultures and urine culture pending\n - f/u final read of chest CTA\n - Continue diuresis. Patient is Lasix naive and put out 3.5 Liters\n after single dose of Lasix 40mg IV.\n - Pt received one dose of vanco IV in the ED which was not continued\n after arrival to the CCU as patient does not look clinically infected.\n .\n # Aortic Stenosis: Patient has critical AS by Echo in , but has\n never had syncope, angina, or CHF in the past. Will consult CT surgery\n to begin work-up for potential AVR.\n - Elective cath today to r/o coronary disease prior to AVR, NPO after\n midnight.\n .\n # CORONARIES: He has no history of CAD or prior MI. He will need to\n have a cardiac cath tomorrow prior to proceeding for AVR.\n -CEs negative on admission\n -If there are no signs of CAD on cath, patient would most likely prefer\n to have percutaneous AVR.\n .\n # Hypertension: Patient is on amlodipine 5mg/benazepril 20mg daily as\n well as triamterene 37.5mg/HCTZ 25mg daily at home. His blood pressure\n has been running in the 90s to 110s since admission secondary to the\n Lasix and all blood pressure meds will be held. His BP will be\n monitored closely.\n .\n # Hyperlipidemia: Continue home dose of simvastatin 40mg.\n .\n # Spinal stenosis: Continue home pain regimen of celebrex 200mg .\n .\n FEN: Heart healthy/low sodium diet\n .\n ACCESS: PIV\n .\n PROPHYLAXIS:\n -DVT ppx with heparin SC\n -Bowel regimen with colace/senna\n .\n CODE: Full code\n .\n COMM: with patient, (wife)-> (home), \n (cell); -> \n .\n DISPO: CCU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 01:00 PM\n 18 Gauge - 01:00 PM\n Prophylaxis:\n DVT: heparin SC\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2108-08-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 590722,
"text": "80 year old man w/ pmh including AS & spinal stenosis, admitted to the\n ED from home after waking up with acute shortness of breath and\n diaphoresis. Placed on Cpap in the ED & given 40 meq IVP lasix. Also\n given Vanco in the ED to treat elevated WBC; BC & urine cultures sent\n from ED.\n : pre-op AVR work-up including dental panorex & cardiac cath with\n pre-cath hydration. Potential call-out from cath lab to F3.\n Aortic stenosis\n Assessment:\n s/p excellent diuresis on (4 liters out to 40 IV lasix) Lungs\n clear/diminished w/ trace pedal edema; clonus in left leg > right leg.\n Current pipe smoker. History of Aortic Stenosis; but no history of CHF.\n Afebrile. HR 70s-80s w/ some PAC\ns. BP 130\ns/50\ns. Sats > 95% on RA.\n Denies SOB. EKG changes c/w LVH.\n Action:\n v Continued to monitor I/O & daily weight, stands @ end of bed to\n use urinal pre-cath\n v Dental panorex obtained as part of pre-op work-up\n v Given dose mucamyst & started infusion of D5\n NS @ 75 ml/hr\n for renal protection prior to cath.\n v To cath at 1330\n Response:\n v I/O even pre-cath, but LOS negative approximately 5 liters\n v O2 sats remains >95 % on RA.\n v Dental service to follow-up with patient this evening\n v Awaiting return from cath lab\n Plan:\n Continue to monitor hemodynamic & respiratory status. Smoking cessation\n counseling. Await recommendations from CSurg regarding scheduling of\n AVR- patient wishing to go home for a few days pre-operatively.\n"
},
{
"category": "Nursing",
"chartdate": "2108-08-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 590777,
"text": "Pt is 80yo male Dx w/ critical AS (echo ) but has remained\n asymptomatic & is very active. Presenting with acute onset of\n shortness of breath consistent with CHF exacerbation. Likely secondary\n to congestive heart failure as patient was fluid overload on CXR.\n Required CPAP to maintain sats in ED but was quickly weaned to nasal\n prongs after diuresing w/ lasix. PE ruled out by CTA. Pneumonia\n unlikely but does have WBC 17.2, ? lung opacity seen, Temp 99.8 po.\n Blood/ urine cx pending.\n : Pt agrees to AVR surgery, preliminary time set for Tues .\n Underwent dental panorax & diag cath showing clean c\ns. To be d/c\n home today & return on Tues for surgery.\n"
},
{
"category": "Nursing",
"chartdate": "2108-08-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 590778,
"text": "Pt is 80yo male Dx w/ critical AS (echo ) but has remained\n asymptomatic & is very active. Presenting with acute onset of\n shortness of breath consistent with CHF exacerbation. Likely secondary\n to congestive heart failure as patient was fluid overload on CXR.\n Required CPAP to maintain sats in ED but was quickly weaned to nasal\n prongs after diuresing w/ lasix. PE ruled out by CTA. Pneumonia\n unlikely but does have WBC 17.2, ? lung opacity seen, Temp 99.8 po.\n Blood/ urine cx pending.\n : Pt agrees to AVR surgery, preliminary time set for Tues .\n Underwent dental panorax & diag cath showing clean c\ns. To be d/c\n home today & return on Tues for surgery.\n Aortic stenosis\n Assessment:\n New Dx of critical AS, peak velocity 5.2 m/s, peak gradient 106 mmHg,\n 0.8 cm.\n Action:\n Cardiac consulted. Cath fellow spoke w/ pt & family about\n undergoing a diagnostic cath & carotid US as a preliminary to prob AVR.\n Response:\n Pt agreed to procedures, made NPO p mn.\n Plan:\n Cardiac cath, carotid US. Cardiac to meet w/ pt & family regarding\n AVR.\n"
},
{
"category": "Nursing",
"chartdate": "2108-08-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 590758,
"text": "80 year old man w/ pmh including AS & spinal stenosis, admitted to the\n ED from home after waking up with acute shortness of breath and\n diaphoresis. Placed on Cpap in the ED & given 40 meq IVP lasix. Also\n given Vanco in the ED to treat elevated WBC; BC & urine cultures sent\n from ED.\n : pre-op AVR work-up including dental panorex, UA/C&S & cardiac\n cath with pre-cath hydration. Patient called out to 3.\n Aortic stenosis\n Assessment:\n s/p excellent diuresis on (4 liters out to 40 IV lasix) Lungs\n clear/diminished w/ trace pedal edema; clonus in left leg > right leg.\n Current pipe smoker. History of Aortic Stenosis; but no history of CHF.\n Afebrile. HR 70s-80s w/ some PAC\ns. BP 130\ns/50\ns. Sats > 95% on RA.\n Denies SOB. EKG changes c/w LVH.\n Action:\n v Continued to monitor I/O & daily weight, stands @ end of bed to\n use urinal pre-cath. UA C&S sent.\n v Dental panorex obtained as part of pre-op work-up\n v Dermatology consulted to evaluate long-standing history of skin\n rash (not active at this time) on patient\ns back to see if it poses an\n infection risk to a potential sternal wound.\n v Given dose mucamyst & started infusion of D5\n NS @ 75 ml/hr\n for renal protection prior to cath.\n v To cath at 1330\n Response:\n v I/O even pre-cath, but LOS negative approximately 5 liters\n v O2 sats remains >95 % on RA.\n v Dental service to follow-up with patient this evening\n v Dermatology to see patient tomorrow when off bedrest to\n evaluate patient\ns back\n v Awaiting return from cath lab\n Plan:\n Continue to monitor hemodynamic & respiratory status. Smoking cessation\n counseling. Await recommendations from CSurg regarding scheduling of\n AVR, (potentially next Friday, although patient would like to go next\n Monday or Tuesday)- patient wishing to go home for a few days\n pre-operatively.\n Patient returned from cath at 15:30-\n o Verbal report states no significant CAD seen, 200 IVF in,\n voided 300 ml condom cath at 1745; 200 into urinal 1830\n o Right groin site C,D & I, pedal pulses by Doppler only.\n o Bedrest until 1900\n o\n NS at 75 ml/hr for 500 ml.\n o Plan: Patient wishing to go home this evening & wife\n uncomfortable managing patient at home before surgery; no clear plan\n for discharge at this time. 0.5 mg Ativan given at 1620 per patient\n request to relieve anxiety, effective per patient.\n o Dr. discussing staying overnight with patient\n"
},
{
"category": "Nursing",
"chartdate": "2108-08-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 590671,
"text": "Pt is an 80yo male with PMH of critical AS (peak velocity 5.2 m/s, peak\n gradient 106 mmHg, .8 cm2) presenting with acute onset of shortness\n of breath this morning. Likely secondary to congestive heart failure\n as patient had signs of fluid overload on CXR and BNP=7739. Pt required\n CPAP to maintain sats in ED, but was quickly weaned to room air after\n diuresing w/ lasix. PE ruled out by CTA. Pneumonia seems\n .\n"
},
{
"category": "Nursing",
"chartdate": "2108-08-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 590672,
"text": "Pt is an 80yo male with PMH of critical AS (peak velocity 5.2 m/s, peak\n gradient 106 mmHg, .8 cm2) presenting with acute onset of shortness\n of breath this morning. Likely secondary to congestive heart failure\n as patient had signs of fluid overload on CXR. Required CPAP to\n maintain sats in ED but was quickly weaned to room air after diuresing\n w/ lasix. PE ruled out by CTA. Pneumonia unlikely but does have ^WBC\n 17.2, Temp 99.8 po. Blood/ urine cx pending.\n Pulmonary edema\n Assessment:\n Received on 3L nc, sats >98%, no c/o sob. Lung sounds w/ faint\n bibasilar crackles.\n Action:\n Weaned off 02, given 10mg ivp lasix\n Response:\n Plan:\n Aortic stenosis\n Assessment:\n Action:\n Response:\n Plan:\n .\n"
},
{
"category": "Nursing",
"chartdate": "2108-08-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 590673,
"text": "Pt is an 80yo male with PMH of critical AS (peak velocity 5.2 m/s, peak\n gradient 106 mmHg, .8 cm2) presenting with acute onset of shortness\n of breath this morning. Likely secondary to congestive heart failure\n as patient had signs of fluid overload on CXR. Required CPAP to\n maintain sats in ED but was quickly weaned to room air after diuresing\n w/ lasix. PE ruled out by CTA. Pneumonia unlikely but does have ^WBC\n 17.2, ? lung opacity seen. Temp 99.8 po. Blood/ urine cx pending.\n Pulmonary edema\n Assessment:\n Received on 3L nc, sats >98%, no c/o sob. Lung sounds w/ faint\n bibasilar crackles.\n Action:\n Weaned off 02, given 10mg ivp lasix.\n Response:\n Maintained sats>95% ra, no sob, rate 14-20. Diuresed approx 450cc\n overnight.\n Plan:\n Repeat CTA\n Aortic stenosis\n Assessment:\n Action:\n Response:\n Plan:\n .\n"
},
{
"category": "Nursing",
"chartdate": "2108-08-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 590674,
"text": "Pt is an 80yo male with PMH of critical AS, HTN presenting with acute\n onset of shortness of breath this morning. Likely secondary to\n congestive heart failure as patient had signs of fluid overload on CXR.\n Required CPAP to maintain sats in ED but was quickly weaned to room air\n after diuresing w/ lasix. PE ruled out by CTA. Pneumonia unlikely but\n does have WBC 17.2, ? lung opacity seen. Temp 99.8 po. Blood/ urine cx\n pending.\n Pulmonary edema\n Assessment:\n Received on 3L nc, sats >98%, no c/o sob. Lung sounds w/ faint\n bibasilar crackles.\n Action:\n Weaned off 02, given additional 10mg ivp lasix.\n Response:\n Maintained sats>95% ra, no sob, rate 14-20. Diuresed approx 450cc.\n Plan:\n Morning CXR, final report on CTA.\n Aortic stenosis\n Assessment:\n Critical AS, peak velocity 5.2 m/s, peak gradient 106 mmHg, .8 cm2)\n Action:\n Response:\n Plan:\n .\n"
},
{
"category": "Nursing",
"chartdate": "2108-08-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 590675,
"text": "Pt is an 80yo male with PMH of critical AS but has never had syncope,\n angina, or CHF in the past. Likely secondary to congestive heart\n failure as patient had signs of fluid overload on CXR. Required CPAP to\n maintain sats in ED but was quickly weaned to room air after diuresing\n w/ lasix. PE ruled out by CTA. Pneumonia unlikely but does have WBC\n 17.2, ? lung opacity seen. Temp 99.8 po. Blood/ urine cx pending.\n Pulmonary edema\n Assessment:\n Received on 3L nc, sats >98%, no c/o sob. Lung sounds w/ faint\n bibasilar crackles.\n Action:\n Weaned off 02, given additional 10mg ivp lasix.\n Response:\n Maintained sats>95% ra, no sob, rate 14-20. Diuresed approx 450cc.\n Plan:\n Morning CXR, final report on CTA.\n Aortic stenosis\n Assessment:\n Critical AS, peak velocity 5.2 m/s, peak gradient 106 mmHg, .8 cm2)\n Action:\n Response:\n Plan:\n .\n"
},
{
"category": "Nursing",
"chartdate": "2108-08-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 590840,
"text": "Pt discharged at 1500 in the company of his wife and daughter after\n pre-op carotid US, CXR completed. Pt ; OOB ambulating ad lib and\n tolerating well. Discharge plan reviewed with pt and family including\n medication list, activity restrictions, warning signs, and daily\n weights. Plan is for pt to return on Tuesday, at 0600 for\n AVR. Pt/family understand plan and are in agreement.\n"
},
{
"category": "Nursing",
"chartdate": "2108-08-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 590652,
"text": "80 year old man admitted to the ED from home after waking up with acute\n shortness of breath and diaphoresis. Placed on Cpap in the ED & given\n 40 meq IVP lasix. Also given Vanco in the ED to treat elevated WBC; BC\n & urine cultures sent from ED.\n : Arrived CCU in no acute distress on venti- mask, quickly\n transitioned to NC only. Continued to diurese to lasix given in the ED.\n Remains afebrile.\n Pulmonary edema\n Assessment:\n Arrived CCU pain-free, wearing a venti-mask from the ED (after spending\n 1 hour on Cpap & diuresing 500 cc to IV lasix dose). Lungs\n clear/diminished in upper apices, with fine bibasilar crackles. Trace\n pedal edema; clonus in left leg > right leg. Current pipe smoker.\n History of Aortic Stenosis; but no history of CHF. Per CCU team, likely\n patient\ns first episode of flash pulmonary edema. Afebrile. HR\n 90\ns-100, with PAC\ns. BP 90-115/50\ns. Sats > 95%.\n Action:\n Continued to monitor I/O. Foley maintained for accurate I/O. Admission\n weight. EKG obtained. Transitioned to 3 L NC soon after arrival as\n patient pulling off mask to speak & answer questions from team. No\n further antibiotics given (1 x dose vanco only) for elevated wbc in ED\n (17.2).\n Response:\n I/O even. Diuresed well to lasix (lasix na\nve). EKG showing ST changes\n that are consistent with LVH per team; CE\ns flat. O2 sats > 95 % on 3 L\n NC. Patient initially requesting removal of Foley catheter, but is now\n napping, and foley remains in place for accurate I/O- team states may\n remove Foley according to patient wishes.\n Plan:\n Continue to monitor hemodynamic & respiratory status. Wean O2 as\n tolerated. ? further diuresis overnight ? cath this admission to\n further evaluate AS. Smoking cessation counseling. Continue to monitor\n for worsening EKG changes or chest pain. Remove foley prn.\n"
},
{
"category": "Nursing",
"chartdate": "2108-08-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 590649,
"text": "80 year old man admitted to the ED from home after waking up with acute\n shortness of breath and diaphoresis. Placed on Cpap in the ED & given\n 40 meq IVP lasix. Also given Vanco in the ED to treat elevated WBC; BC\n & urine cultures sent from ED.\n : Arrived CCU in no acute distress on venti- mask, quickly\n transitioned to NC only. Continued to diurese to lasix given in the ED.\n Remains afebrile.\n Pulmonary edema\n Assessment:\n Arrived CCU pain-free, wearing a venti-mask from the ED (after spending\n 1 hour on Cpap & diuresing 500 cc to IV lasix dose). Lungs\n clear/diminished in upper apices, with fine bibasilar crackles. Trace\n pedal edema; clonus in left leg > right leg. Current pipe smoker.\n History of Aortic Stenosis; but no history of CHF. Per CCU team, likely\n patient\ns first episode of flash pulmonary edema. Afebrile. HR\n 90\ns-100, with PAC\ns. BP 90-115/50\ns. Sats > 95%.\n Action:\n Continued to monitor I/O. Foley maintained for accurate I/O. Admission\n weight. EKG obtained. Transitioned to 3 L NC soon after arrival as\n patient pulling off mask to speak & answer questions from team.\n Response:\n I/O even. Diuresed well to lasix (lasix na\nve). EKG showing ST changes\n that are consistent with LVH per team; CE\ns flat. O2 sats > 95 % on 3 L\n NC. Patient initially requesting removal of Foley catheter, but is now\n napping, and foley remains in place for accurate I/O- team states may\n remove Foley according to patient wishes.\n Plan:\n Continue to monitor hemodynamic & respiratory status. Wean O2 as\n tolerated. ? further diuresis. ? cath this admission to further\n evaluate AS. Smoking cessation counseling. Continue to monitor for\n worsening EKG changes or chest pain. Remove foley prn.\n"
},
{
"category": "Nursing",
"chartdate": "2108-08-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 590656,
"text": "80 year old man w/ pmh including AS & spinal stenosis, admitted to the\n ED from home after waking up with acute shortness of breath and\n diaphoresis. Placed on Cpap in the ED & given 40 meq IVP lasix. Also\n given Vanco in the ED to treat elevated WBC; BC & urine cultures sent\n from ED.\n : Arrived CCU in no acute distress on venti- mask, quickly\n transitioned to NC only. Continued to diurese to lasix given in the ED.\n Remains afebrile, no further antibiotics.\n Pulmonary edema\n Assessment:\n Arrived CCU pain-free, wearing a venti-mask from the ED (after spending\n 1 hour on Cpap & diuresing 500 cc to IV lasix dose). Lungs\n clear/diminished in upper apices, with fine bibasilar crackles. Trace\n pedal edema; clonus in left leg > right leg. Current pipe smoker.\n History of Aortic Stenosis; but no history of CHF. Per CCU team, likely\n patient\ns first episode of flash pulmonary edema. Afebrile. HR\n 90\ns-100, with PAC\ns. BP 90-115/50\ns. Sats > 95%.\n Action:\n Continued to monitor I/O. Foley maintained for accurate I/O. Admission\n weight. EKG obtained. Transitioned to 3 L NC soon after arrival as\n patient pulling off mask to speak & answer questions from team. No\n further antibiotics given (1 x dose vanco only) for elevated WBC in ED\n (17.2).\n Response:\n I/O grossly negative LOS. Diuresed well to lasix (lasix na\nve). EKG\n showing ST changes that are consistent with LVH per team; CE\ns flat. O2\n sats > 95 % on 2 L NC. Patient initially requesting removal of Foley\n catheter, but is now napping, and foley remains in place for accurate\n I/O- team states may remove Foley according to patient wishes.\n Plan:\n Continue to monitor hemodynamic & respiratory status. Wean O2 as\n tolerated. ? further diuresis overnight ? cath this admission to\n further evaluate AS. Smoking cessation counseling. Continue to monitor\n for worsening EKG changes or chest pain. Remove foley prn.\n"
},
{
"category": "Nursing",
"chartdate": "2108-08-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 590693,
"text": "Pt is 80yo male Dx w/ critical AS (echo ) but has remained\n asymptomatic & is very active. Presenting with acute onset of\n shortness of breath consistent with CHF exacerbation. Likely secondary\n to congestive heart failure as patient was fluid overload on CXR.\n Required CPAP to maintain sats in ED but was quickly weaned to nasal\n prongs after diuresing w/ lasix. PE ruled out by CTA. Pneumonia\n unlikely but does have WBC 17.2, ? lung opacity seen, Temp 99.8 po.\n Blood/ urine cx pending.\n Pulmonary edema\n Assessment:\n Received on 3L nc, sats >98%, no c/o sob. Lung sounds w/ faint\n bibasilar crackles.\n Action:\n Weaned off 02, given additional 10mg ivp lasix.\n Response:\n Maintained sats>95% ra, no sob, rate 14-20. Diuresed approx 800cc.\n Plan:\n Morning CXR, final report due on CTA.\n Aortic stenosis\n Assessment:\n New Dx of critical AS, peak velocity 5.2 m/s, peak gradient 106 mmHg,\n 0.8 cm.\n Action:\n Cardiac consulted. Cath fellow spoke w/ pt & family about\n undergoing a diagnostic cath & carotid US as a preliminary to prob AVR.\n Response:\n Pt agreed to procedures, made NPO p mn.\n Plan:\n Cardiac cath, carotid US. Cardiac to meet w/ pt & family regarding\n AVR.\n .\n"
},
{
"category": "Nursing",
"chartdate": "2108-08-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 590694,
"text": "Pt is 80yo male Dx w/ critical AS (echo ) but has remained\n asymptomatic & is very active. Presenting with acute onset of\n shortness of breath consistent with CHF exacerbation. Likely secondary\n to congestive heart failure as patient was fluid overload on CXR.\n Required CPAP to maintain sats in ED but was quickly weaned to nasal\n prongs after diuresing w/ lasix. PE ruled out by CTA. Pneumonia\n unlikely but does have WBC 17.2, ? lung opacity seen, Temp 99.8 po.\n Blood/ urine cx pending.\n Pulmonary edema\n Assessment:\n Received on 3L nc, sats >98%, no c/o sob. Lung sounds w/ faint\n bibasilar crackles.\n Action:\n Weaned off 02, given additional 10mg ivp lasix.\n Response:\n Maintained sats>95% ra, no sob, rate 14-20. Diuresed approx 800cc.\n Plan:\n Morning CXR, final report due on CTA.\n Aortic stenosis\n Assessment:\n New Dx of critical AS, peak velocity 5.2 m/s, peak gradient 106 mmHg,\n 0.8 cm.\n Action:\n Cardiac consulted. Cath fellow spoke w/ pt & family about\n undergoing a diagnostic cath & carotid US as a preliminary to prob AVR.\n Response:\n Pt agreed to procedures, made NPO p mn.\n Plan:\n Cardiac cath, carotid US. Cardiac to meet w/ pt & family regarding\n AVR.\n .\n"
},
{
"category": "Nursing",
"chartdate": "2108-08-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 590677,
"text": "Pt is an 80yo male with PMH of critical AS but has remained\n asymptomatic or CHF in the past. Presenting with acute onset of\n shortness of breath this morning consistent with CHF exacerbation.\n Likely secondary to congestive heart failure as patient had signs of\n fluid overload on CXR. Required CPAP to maintain sats in ED but was\n quickly weaned to room air after diuresing w/ lasix. PE ruled out by\n CTA. Pneumonia unlikely but does have WBC 17.2, ? lung opacity seen.\n Temp 99.8 po. Blood/ urine cx pending.\n Pulmonary edema\n Assessment:\n Received on 3L nc, sats >98%, no c/o sob. Lung sounds w/ faint\n bibasilar crackles.\n Action:\n Weaned off 02, given additional 10mg ivp lasix.\n Response:\n Maintained sats>95% ra, no sob, rate 14-20. Diuresed approx 450cc.\n Plan:\n Morning CXR, final report on CTA.\n Aortic stenosis\n Assessment:\n Critical AS, peak velocity 5.2 m/s, peak gradient 106 mmHg, .8 cm2)\n Action:\n Response:\n Plan:\n .\n"
},
{
"category": "Nursing",
"chartdate": "2108-08-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 590680,
"text": "Pt is 80yo male Dx w/ critical AS (echo ) but has remained\n asymptomatic & is very active. Presenting with acute onset of\n shortness of breath consistent with CHF exacerbation. Likely secondary\n to congestive heart failure as patient was fluid overload on CXR.\n Required CPAP to maintain sats in ED but was quickly weaned to nasal\n prongs after diuresing w/ lasix. PE ruled out by CTA. Pneumonia\n unlikely but does have WBC 17.2, ? lung opacity seen, Temp 99.8 po.\n Blood/ urine cx pending.\n Pulmonary edema\n Assessment:\n Received on 3L nc, sats >98%, no c/o sob. Lung sounds w/ faint\n bibasilar crackles.\n Action:\n Weaned off 02, given additional 10mg ivp lasix.\n Response:\n Maintained sats>95% ra, no sob, rate 14-20. Diuresed approx 450cc.\n Plan:\n Morning CXR, final report due on CTA.\n Aortic stenosis\n Assessment:\n Critical AS, peak velocity 5.2 m/s, peak gradient 106 mmHg, 0.8\n cm2)\n Action:\n Cardiac consulted. Cath fellow spoke w/ pt & family about\n undergoing a diagnostic cath & carotid US as a preliminary to prob AVR.\n Response:\n Pt agreed to procedures, made NPO p mn.\n Plan:\n Cardiac cath, carotid US. Cardiac to meet w/ pt & family regarding\n AVR.\n .\n"
},
{
"category": "Nursing",
"chartdate": "2108-08-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 590681,
"text": "Pt is 80yo male Dx w/ critical AS (echo ) but has remained\n asymptomatic & is very active. Presenting with acute onset of\n shortness of breath consistent with CHF exacerbation. Likely secondary\n to congestive heart failure as patient was fluid overload on CXR.\n Required CPAP to maintain sats in ED but was quickly weaned to nasal\n prongs after diuresing w/ lasix. PE ruled out by CTA. Pneumonia\n unlikely but does have WBC 17.2, ? lung opacity seen, Temp 99.8 po.\n Blood/ urine cx pending.\n Pulmonary edema\n Assessment:\n Received on 3L nc, sats >98%, no c/o sob. Lung sounds w/ faint\n bibasilar crackles.\n Action:\n Weaned off 02, given additional 10mg ivp lasix.\n Response:\n Maintained sats>95% ra, no sob, rate 14-20. Diuresed approx 800cc.\n Plan:\n Morning CXR, final report due on CTA.\n Aortic stenosis\n Assessment:\n Critical AS, peak velocity 5.2 m/s, peak gradient 106 mmHg, 0.8\n cm2)\n Action:\n Cardiac consulted. Cath fellow spoke w/ pt & family about\n undergoing a diagnostic cath & carotid US as a preliminary to prob AVR.\n Response:\n Pt agreed to procedures, made NPO p mn.\n Plan:\n Cardiac cath, carotid US. Cardiac to meet w/ pt & family regarding\n AVR.\n .\n"
},
{
"category": "Nursing",
"chartdate": "2108-08-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 590678,
"text": "Pt is an 80yo male with PMH of critical AS but has remained\n asymptomatic or CHF in the past. Presenting with acute onset of\n shortness of breath this morning consistent with CHF exacerbation.\n Likely secondary to congestive heart failure as patient had signs of\n fluid overload on CXR. Required CPAP to maintain sats in ED but was\n quickly weaned to room air after diuresing w/ lasix. PE ruled out by\n CTA. Pneumonia unlikely but does have WBC 17.2, ? lung opacity seen.\n Temp 99.8 po. Blood/ urine cx pending.\n Pulmonary edema\n Assessment:\n Received on 3L nc, sats >98%, no c/o sob. Lung sounds w/ faint\n bibasilar crackles.\n Action:\n Weaned off 02, given additional 10mg ivp lasix.\n Response:\n Maintained sats>95% ra, no sob, rate 14-20. Diuresed approx 450cc.\n Plan:\n Morning CXR, final report on CTA.\n Aortic stenosis\n Assessment:\n Critical AS, peak velocity 5.2 m/s, peak gradient 106 mmHg, .8 cm2)\n Action:\n Response:\n Plan:\n .\n"
},
{
"category": "ECG",
"chartdate": "2108-08-08 00:00:00.000",
"description": "Report",
"row_id": 303737,
"text": "Sinus rhythm. Compared to the previous tracing there is no diagnostic change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2108-08-08 00:00:00.000",
"description": "Report",
"row_id": 303738,
"text": "Sinus tachycardia. Non-diagnostic repolarization abnormalities. Compared to the\nprevious tracing of the heart rate is increased, now with\nnon-diagnostic repolarization abnormalities.\nTRACING #1\n\n"
}
] |
65,176 | 173,812 | # Abdominal pain: The patient presented with abdominal pain. The patient was found to have a pancreatic cyst, SMV thrombus, ascites and diffuse bowel thickening. The pancreatic cyst was seen on prior images and felt to be unchanged in appearance. The SMV thrombus appeared chronic in nature. He was started on anticoagulation that will need to be continued for at least 6 months. This should be followed by the vascular surgeons. The ascites had a diagnostic tap which showed a leukocytosis. He was broadly covered with vancomycin and zosyn for secondary peritonitis. No bacteria grew on cultures. He had a total of 2 weeks of this course. The patient also had diffuse bowel thickening that was of unknown etiology but concerning for edema vs inschemia. He had a low lactates so edema more likely. The patient had a CTAP on which showed partial small bowel obstruction vs ileus and gas in the bowel suggestive of a microperforation. Surgery was contact and the patient was kept on intermittent low suction and remained NPO. He received another 2 weeks of antibiotics with ciprofloxacin and metronidazole. After he finishes his course of antibiotics he will need another imaging study to evaluate for ascites. If he does have ascites he will need a paracentesis with cell count and differential. The patient passed speech and swallow and was fed with PO food. His pain was controlled with IV morphine and tylenol. At the time of discharge the patient had no evidence of abdominal pain and was not requiring analgesics. . # GIB: On , Mr. developed coffee-ground emesis, abdominal pain, Hct drop (30.8 to 24.6) and hypotension to SBPs in the 60s, and was transferred to the MICU. He received 3 units of pRBCs in response to Hct drop with appropriate response. He was seen by GI and the general surgery service, and CT scan of the abdomen was obtained showing retroperitoneal bleed. Anticoagulation for SMV thrombosis was held, and the patient's abdominal pain improved steadily over 48 hours, at which time his family felt that he was back to his baseline and abdominal distension (appreciated on transfer) had resolved. NGT placed to suction showed no further evidence of UGIB, so endoscopy was deferred. The patient was initially placed on low-dose phenylephrine to maintain SBP > 75, but this was weaned within 48 hours. SBPs remained low (upper 70s-90s) but this was consistent with patient's recent baseline and small size. He was observed in the unit for an additional 24 hours, during which time Hct and BPs remained stable, and he was called out to the floor. There were no more GIB episodes since then. His hct has been stable during the rest of his hospital stay. . # Humeral fracture: The patient was noted to have left arm pain after he got a new PICC line in the MICU. A x-ray of the LUE was done, which showed left humeral fracture. It was unclear what caused the fracture. The suspicion is that the fracture occured when he was down in the radiology department to get PICC line. Patient was seen by orthopedics, who recommended a repeat shoulder film. After all the imaging was obtained, orthopedics recommende...... . # Nutrition: The patient presented with a very low albumin level suggesting very poor nutrition status. The patient was started on TPN and remained NPO. As his abdominal pain improved he was started on slow tube feeds which he tolerated well. The patient passed a speech and swallow evaluated and ate PO food and the NGT was discontinued. He will need to continue TPN for the next month. He should also consider a PEG tube as his prior nutrition was inadequate. . # Acute renal failure: The patient has a baseline of 0.4-0.5. His creatinine peaked at 1.2. The most likely etiology was thought to be secondary to ATN secondary to nephrotoxic . IVF failure to return Cr to baseline. He had medications renally dosed and nephrotoxins were avoided. . # Anemia: The patient has a baseline Hct of 35. He was guaiac and NG lavage negative on admission. He required multiple transfusions for Hct under 21. He showed some anemia of chronic disease/iron deficiency anemia. No evidence of hemolysis and B12, folate normal. Will need iron supplementation as an outpatient. Patient had GIB and RP hematoma on anticoagulation on , and anticoagulation was stopped. Patient was transferred to MICU and required 3u pRBC transfusion. His hct has been stable during the rest of his hospital stay. . # Respiratory failure: The patient was intubated for respiratory failure. The patient had a LLL infiltrate on CXR. He was treated with vancomycin and zosyn for HAP/VAP. The patient was extubated and quickly weaned to room air with normal oxygen saturation. . # SMV occlusion: This appears to be chronic given the number of collaterals. He will need to be maintained on anticoagulation for 6 months per vascular surgery. He was on a lovenox bridge to warfarin with a goal INR of . . # Seizure disorder: The patient was started on fosphenytoin and phenobarbital. His levels were adjusted. He had daily episodes of "absence seizures". He will need close follow up as an outpatient. outpatient Neurology Openheimer (). . # Hypotension: The patient has a baseline systolic blood pressure in the 80s. The patient remained near his baseline as an inpatient. . MICU Course . # Hypoxemia: The patient was transferred to MICU with tachypnea and hypoxia on . He was initially started on BiPap and did well for several hours, even weaning off of the BiPap. Unfortunately, the patient became increasingly hypoxemic and required intubation on . Imaging at that time was consistent with multilobar pneumonia with sputum growing MRSA. The patient completed an 8 day course of vancomycin, cefepime, and flagyl on . . Pleural effusions were also noted on imaging, likely due to fluid resuscitation for hypotension in the setting of albumin of 2.3, so the patient was aggressively diuresed with lasix boluses. . Prior to extubation, the patient was made DNR/DNI after long discussion with family. After optimization, the patient was extubated on to face mask and nasal cannula. Oxygen requirement thought due to pulmonary edema, mucous plugging and secretions, also restrictive with low lung volumes in setting of ascites. . During the patient's last several days in the MICU, he had improvement in O2 requirement with continued gentle diuresis. . The patient was started on standing lasix 40mg PO BID. . # Yeast bacteremia: The patient was noted to have low grade fevers. On , a urine culture regurned with > 100k yeast. On , a blood culture returned that was also growing yeast We suspected possible urogenital source with hematogenous spread. Heart rate and blood pressure currently at baseline. Normal WBC count, lactate. . The patient was initially started on micafungin while speciation and identification were finalized. The infectious disease service was consulted and followed the patient. The yeast was speciated as albicans that was fluconazole sensitive. On the day of discharge the patient was started on fluconazole and micafungin was discontinued. He should have LFTs monitored every three days while on fluconazole for a total course of 14 days. . The patient's lines and foley catheter were replaced during this time. A new PICC line was placed on . . The patient had daily surveillance blood cultures that did not show evidence of any further fungemia. . Dilated fundoscopic exam on neg for apparent chororetinal lesions with signif corneal scarring. Recommend repeat DFE in 2 weeks of if patient having ANY procedure requiring general anesthesia. On lacrilub gtts. . #Fevers: The patient had daily low grade febrile episodes despite broad spectrum antibiotics. Completed treatment for pulmonary infection with 8 day course of vancomycin, cefepime, flagyl. SBP possible but 3 taps have not been c/w SBP. PE considered but no evidence on CTA. CT read as possible liver abscess but repeat RUQ ultrasound read as more consistent with infarct. C. Diff has been negative. The low grade fevers were then though to be due to positive urine and blood culture growing yeast. Repeat cultures of blood, urine ngtd. . # Tachycardia: The patient had persistent tachycardia into the 110s that was likely hyperdynamic in setting of fever and infection. Volume status appeared grossly euvolemic; pt mentating at baseline and maintaining urine output. Echo with evidence of depressed cardiac fxn, ? tachycardia induced cardiomyopathy. The patient's baseline HR has been consistently 100-115 bpm. . It should also be noted that the patient's baseline systolic blood pressure is between 80-100 mmHg. We were obtaining blood pressures via a thigh cuff as this more likely represented his true blood pressure. . # Anemia/bleed: Pt with retroperitoneal bleed and CT evidence of hemorrhage into bowel wall, also gastric varices c/b GIB earlier in admission. He was transfused 1 unit pRBCs with appropriate bump and has remained stable since. . His hematocrits were trended daily and stools were guaiac negative. . He was continued on PO pantoprazole and iron supplementation. . # Liver lesion. The patient had a Noted on abdominal CT with concern for possible ischemia/infarction vs abscess. Abdominal U/S not consistent with abscess. . # Left humeral fx: Likely d/t trauma sustained during radiology. Patient briefly received morphine for pain control and also continued to receive lidoderm patches for comfort. No lab draws were conducted on the left arm. There was no indication for surgical intervention. . # SMV thrombus: The initial plan for the SMV thrombus was for anticoagulation x 6 months, but in the setting of recent GI and RP bleed all anticoagulants were discontinued. . The patient was restarted on heparin SQ for DVT prophylaxis. . # Seizure disorder: No recent reports of seizures. The patient was maintained on his home doses of phenobarbitol and fosphenytoin. Drug levels were checked frequently and were in the therapeutic window. . # Cerebral palsy: Stable mental status. Interactive with family but nonverbal at baseline. . FEN: continue tube feeds while fully transitioning to PO diet cleared for nectar thick liquids, pureed solids; needs 1:1 observation (mother may need to feed). OK to try crushed meds, but may not take reliably. . | # Anemia/bleed: Hct stable. CHEST, AP: Bilateral perihilar opacities and moderate interstitial edema persist. There is a stable left retroperitoneal hemorrhage which now appears more organized. Normal WBC count, lactate. Progressing left lower lobe atelectasis with sparse air bronchograms. centralized bowel loops, consistent with ascites. At least moderate mitral regurgitation. unchanged pancreatic atrophy and calcification c/w chronic pancreatitis. Noaortic regurgitation is seen. and pt seems to be at baseline mental status Cardiovascular: - HR and BP holding stable Pulmonary: - Respiratory failure: now extubated, requiring aggresive pulm toilet, chest PT and suctioning due to secretion - Diuresis since traits of CHF on CXR and tenuous respiratory status. Chlorhexidine Gluconate 0.12% Oral Rinse 7. Chlorhexidine Gluconate 0.12% Oral Rinse 7. Chlorhexidine Gluconate 0.12% Oral Rinse 7. - CTA revealed SMV occlusion, venous stasis--->On hep gtt. - CTA revealed SMV occlusion, venous stasis--->On hep gtt. - CTA revealed SMV occlusion, venous stasis--->On hep gtt. - Stop heparin, Coumadin - Start Lovenox # Hypoalbuminemia: Noted on arrival, with similar etiology to coagulopathy. - Stop heparin, Coumadin - Start Lovenox # Hypoalbuminemia: Noted on arrival, with similar etiology to coagulopathy. While in SICU: Thrombosis found in SMV. While in SICU: Thrombosis found in SMV. - Stop heparin, Coumadin - Start Lovenox as above # Hypoalbuminemia: Noted on arrival, with similar etiology to coagulopathy. -S/P Transfusion 2UPRBC for Hct of 26 on , Stable 29-31---Hct 27 on On hep gtt for SMV occlusion (goal 60-80) -coumadin started on (3) Endocrine: - RISS with adequate BG control. On hep gtt for SMV occlusion (goal 60-80) -coumadin started on , inc 5 today, last INR 1.4 Endocrine: - RISS with adequate BG control. - Stop heparin, Coumadin - Start Lovenox as above # Hypoalbuminemia: Noted on arrival, with similar etiology to coagulopathy. + scrotal edema. Piperacillin-Tazobactam 19. Piperacillin-Tazobactam 19. CTA with LLL and RLL PNA and atelectasis, and effusions. Tachypnea/tachycardia/ grimacing resolved w fentanyl Hct 29 after first unit prbc. Vancomycin/Zosyn administered MD order. Vancomycin/Zosyn administered MD order. CTA w/SMV occlusion. .H/O abdominal pain (including abdominal tenderness) Assessment: tmax 99.9, hr/bp stable. FEN: NG tube likely in duodenum, bolus IVF prn, TPN; continue tube feeds today PROPHYLAXIS: pneumoboots, IV PPI ACCESS: PICC, PIV, A-line in right brachial artery CODE: Do not resuscitate. FEN: NG tube likely in duodenum, bolus IVF prn, TPN; continue tube feeds today PROPHYLAXIS: pneumoboots, IV PPI ACCESS: PICC, PIV, A-line in right brachial artery CODE: Do not resuscitate. FEN: NG tube likely in duodenum, bolus IVF prn, TPN; continue tube feeds today PROPHYLAXIS: pneumoboots, IV PPI ACCESS: PICC, PIV, D/C A-line in right brachial artery CODE: Do not resuscitate. FEN: NG tube likely in duodenum, bolus IVF prn, TPN; continue tube feeds today PROPHYLAXIS: pneumoboots, IV PPI ACCESS: PICC, PIV, D/C A-line in right brachial artery CODE: Do not resuscitate. On CT, a SMV thrombus was noted and heparin was started on . On CT, a SMV thrombus was noted and heparin was started on . On CT, a SMV thrombus was noted and heparin was started on . Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding) Assessment: Pt had slight HCT drop this am => 24.8. Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding) Assessment: Pt had slight HCT drop this am => 24.8. OGT to intermittent suction, clamped after meds given. Pt on levophed drip for hypotension. Pt on levophed drip for hypotension. Anemia/bleed: -h/o rp bleed, varices so follow hct trend closely -hct down 2 points but sig positive fluid balance - Guaiac stools SMV thrombus: Seizure disorder: -no sz activity No - Continue phenobarbitol and phenytoin Cerebral palsy: Remainder of plan as outlined in resident note. CXR w/ some pulm edema noted. Respiratory failure, acute (not ARDS/) Assessment: Action: SBT this AM, 40mg IV lasix Response: Plan: Fracture, other Assessment: Action: Response: Plan: Response: Pts temp down after Tylenol. Monitor the filter, if it becomes saturate he drops is o2 sat( close communication with RT) Patient is on vanco and cefepime iv. Monitor the filter, if it becomes saturate he drops is o2 sat( close communication with RT) Patient is on vanco and cefepime iv. On CT, a SMV thrombus was noted and heparin was started on . FEN: NG tube likely in duodenum, bolus IVF prn, TPN; continue tube feeds today PROPHYLAXIS: pneumoboots, IV PPI ACCESS: PICC, PIV, D/C A-line in right brachial artery CODE: Do not resuscitate. On CT, a SMV thrombus was noted and heparin was started on . On CT, a SMV thrombus was noted and heparin was started on . Anemia/bleed: -h/o rp bleed, varices so follow hct trend closely -hct down 2 points but sig positive fluid balance - Guaiac stools SMV thrombus: Seizure disorder: -no sz activity No - Continue phenobarbitol and phenytoin Cerebral palsy: Remainder of plan as outlined in resident note. - NPO for now given GI bleeding - holding TPN for now for blood tx and boluses - restart TPN when stable - continue to follow albumin levels; remains hypoalbuminemic . - NPO for now given GI bleeding - holding TPN for now for blood tx and boluses - restart TPN when stable - continue to follow albumin levels; remains hypoalbuminemic . Again identified is thrombosis of the right portal vein branches with some minimal peripheral flow identified in the proximal right portal vein. Calcifications are identified in the pancreatic head, and there is a 2.3 x 1.6 x 4.9 cm rim- enhancing fluid collection in the region of the pancreatic head, likely representing pseudocyst. FEN: NG tube likely in duodenum, bolus IVF prn, TPN; continue tube feeds today PROPHYLAXIS: pneumoboots, IV PPI ACCESS: PICC, PIV, D/C A-line in right brachial artery CODE: Do not resuscitate/Do not re-intubate. FEN: NG tube likely in duodenum, bolus IVF prn, TPN; continue tube feeds today PROPHYLAXIS: pneumoboots, IV PPI ACCESS: PICC, PIV, D/C A-line in right brachial artery CODE: Do not resuscitate/Do not re-intubate. PREVIOUSLY DESCRIBED BOWEL WALL HEMATOMA AT DESCENDING- SIGMOID JUNCTION, IMPROVED. Stable left retroperitoneal bleed and interval resolution of hemorrhage seen between the rectum and bladder. hazy opacity over left hemithorax probably posteriorly layering pleural effusion, with atelectasis obscuring left hemidiaphragm. Approximately 1.7 x 1.7 x 4.6 cm rim-enhancing lesion in the pancreatic head is unchanged and likely represents a pseudocyst. REASON FOR THIS EXAMINATION: evaluate colonic dilation FINAL REPORT HISTORY: colonic distension with rectal tube SUPINE ABDOMEN: There is marked dilation of large bowel, with sigmoid colon measuring up to 9.8 cm, overall unchanged when compared to prior study. | 390 | [
{
"category": "Radiology",
"chartdate": "2115-04-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1131287,
"text": " 2:34 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Interval change?\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with bacteremia, recently extubated \n REASON FOR THIS EXAMINATION:\n Interval change?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Bacteremia with recent extubation.\n\n FINDINGS: In comparison with the study of , the left subclavian catheter\n has been removed. There are continued low lung volumes with evidence of\n severe pulmonary edema. Poor definition of the hemidiaphragms could reflect\n pleural effusion and atelectasis at the bases.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-03-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1130604,
"text": " 4:59 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Confirm placement of NGT tip\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with NGT slipped out and replaced\n REASON FOR THIS EXAMINATION:\n Confirm placement of NGT tip\n ______________________________________________________________________________\n WET READ: 6:55 PM\n NGT ends in the second portion of the duodenum. little change.\n centralized bowel loops, consistent with ascites.\n WET READ VERSION #1 6:54 PM\n NGT ends in the second portion of the duodenum. little change.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: NG tube placement.\n\n FINDINGS: In comparison with the earlier study of this date, the nasogastric\n tube tip now lies within the second portion of the duodenum. Little overall\n change in the appearance of the heart and lungs.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-04-03 00:00:00.000",
"description": "VIDEO OROPHARYNGEAL SWALLOW",
"row_id": 1131413,
"text": " 2:58 PM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: assess for aspiration\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with pneumonia\n REASON FOR THIS EXAMINATION:\n assess for aspiration\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 35-year-old man with pneumonia, assess for aspiration.\n\n VIDEO OROPHARYNGEAL SWALLOWING FLUOROSCOPY: Oropharyngeal swallow fluoroscopy\n was performed in conjunction with the speech and swallow division. This is a\n limited study with nectar and thick consistencies of barium only used. No\n aspiration or penetration was noted for nectar or thick consistencies.\n\n IMPRESSION: Limited study with no aspiration or penetration for thick and\n nectar consistencies. For additional details, please see OMR speech and\n swallow division note.\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-03-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1130643,
"text": " 2:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Interval change?\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with cerebral palsy, recent PNA, intubated\n REASON FOR THIS EXAMINATION:\n Interval change?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 35-year-old male with cerebral palsy, multifocal pneumonia.\n\n COMPARISON: .\n\n CHEST, AP: Bilateral perihilar opacities and moderate interstitial edema\n persist. Mild cardiomegaly and bilateral effusions, moderate on the left and\n small on the right, are unchanged. Endotracheal tube again terminates near\n the thoracic inlet. Nasogastric tube courses into the stomach and beyond the\n film. There is no pneumothorax.\n\n IMPRESSION: ETT at thoracic inlet, please advance. Continued multifocal\n pneumonia and edema.\n\n Dr. was notified on at 11:15 a.m.\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-04-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1131140,
"text": " 2:36 AM\n CHEST (PORTABLE AP) Clip # \n Reason: edema, infiltrate\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with shortness of breath\n REASON FOR THIS EXAMINATION:\n edema, infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Shortness of breath, pulmonary edema.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the pre-existing signs of\n severe pulmonary edema have further increased. There is no additional\n atelectasis of the right mid and basal parts of the lung as well as of the\n retrocardiac lung zones. Lung volumes are still very low. Unchanged position\n of the monitoring and support devices.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-04-05 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1131781,
"text": " 8:35 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: please check PICC tip 34 cm right basilic\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with new line placement\n REASON FOR THIS EXAMINATION:\n please check PICC tip 34 cm right basilic\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: New PICC line placement.\n\n COMPARISON: .\n\n FINDINGS: The PICC line projects with its tip in the superior SVC. No\n evidence of complications, notably no pneumothorax.\n\n Otherwise, unchanged radiograph.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-03-31 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1130940,
"text": " 9:20 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: pls evaluate for interval change\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with hypoxia with PNA and fluid overload, now s/p extubation\n REASON FOR THIS EXAMINATION:\n pls evaluate for interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 9:42 A.M., \n\n HISTORY: Hypoxia, pneumonia, fluid overload. Extubated.\n\n IMPRESSION: AP chest compared to , 2:24 a.m.:\n\n There has been no appreciable change following removal of the endotracheal\n tube, except for worsening of the left perihilar component of moderately\n severe pulmonary edema. Lung volumes are low, but unchanged.\n Moderate-to-large left and small-to-moderate right pleural effusions are\n stable. Heart size is normal. Left subclavian line ends at the superior\n cavoatrial junction and nasogastric tube in the region of the proximal\n duodenum. No pneumothorax.\n\n Displacement of the left humeral fracture has progressed over the past several\n days.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-04-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1131462,
"text": " 3:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Interval change?\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with cerebral palsy, recently extubated, still with crackles on\n lungs exam\n REASON FOR THIS EXAMINATION:\n Interval change?\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Cerebral palsy, recently extubated, evaluation of interval\n change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is no relevant\n change. Unchanged small lung volumes, unchanged extensive bilateral\n parenchymal opacities that combine to increase in interstitial structures,\n increased vascular diameters and a moderately increased cardiac silhouette\n suggests pulmonary edema rather than pneumonia. No evidence of new focal\n parenchymal opacities. The presence of small pleural effusions cannot be\n excluded.\n\n\n"
},
{
"category": "Physician ",
"chartdate": "2115-04-04 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 632862,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 35 yo man with CP, respiratory failure. has been doing well.\n Continued diuresis.\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Fluconazole - 01:56 AM\n Micafungin - 06:00 PM\n Infusions:\n Other ICU medications:\n Other medications:\n SSI\n lidocaine patch\n FeSO4\n pancrease\n phenobarb\n prevacid\n dilantin\n micafungin\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 12:29 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.8\nC (100.1\n Tcurrent: 37.8\nC (100.1\n HR: 115 (108 - 128) bpm\n BP: 93/66(72) {85/11(35) - 101/69(76)} mmHg\n RR: 34 (18 - 36) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 1,440 mL\n 833 mL\n PO:\n TF:\n 1,200 mL\n 490 mL\n IVF:\n 240 mL\n 123 mL\n Blood products:\n Total out:\n 1,960 mL\n 160 mL\n Urine:\n 1,960 mL\n 160 mL\n NG:\n Stool:\n Drains:\n Balance:\n -520 mL\n 673 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///30/\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace\n Skin: Not assessed\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Not assessed, No(t) Oriented (to): , Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 9.3 g/dL\n 149 K/uL\n 157 mg/dL\n 0.5 mg/dL\n 30 mEq/L\n 3.9 mEq/L\n 25 mg/dL\n 102 mEq/L\n 139 mEq/L\n 27.7 %\n 7.0 K/uL\n [image002.jpg]\n 09:03 AM\n 03:28 AM\n 08:25 AM\n 03:08 PM\n 06:23 AM\n 06:29 AM\n 05:37 PM\n 06:16 AM\n 03:52 PM\n 05:10 AM\n WBC\n 7.3\n 8.1\n 6.7\n 7.0\n Hct\n 27.9\n 26.5\n 26.6\n 27.7\n Plt\n 137\n 147\n 146\n 149\n Cr\n 0.6\n 0.6\n 0.5\n 0.6\n 0.5\n 0.6\n 0.5\n TCO2\n 28\n 28\n 30\n Glucose\n 148\n 105\n 159\n 145\n 65\n 123\n 157\n Other labs: PT / PTT / INR:15.0/24.2/1.3, CK / CKMB /\n Troponin-T:8//0.01, ALT / AST:18/32, Alk Phos / T Bili:178/0.3, Amylase\n / Lipase:/11, Differential-Neuts:86.9 %, Lymph:8.0 %, Mono:3.6 %,\n Eos:1.3 %, Lactic Acid:1.6 mmol/L, Albumin:2.5 g/dL, LDH:314 IU/L,\n Ca++:7.9 mg/dL, Mg++:2.3 mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n ALTERATION IN NUTRITION\n TACHYCARDIA, OTHER\n ANEMIA, ACUTE, SECONDARY TO BLOOD LOSS (HEMORRHAGE, BLEEDING)\n FRACTURE, OTHER\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/): Much improved today:\n Heart failure with valvular disease: continue diuresis as he still has\n significant edema.\n Can restart s/q heparin\n Seizure disorder\n can consider removing NGTube if eating adequately.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 04:42 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition :ICU\n Total time spent: 35 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2115-04-03 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 632629,
"text": "Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - STOP 12:25 PM\n PARACENTESIS - At 04:00 PM\n TRANSTHORACIC ECHO - At 04:51 PM\n PICC LINE - STOP 08:30 PM\n dual lumen\n - ID consult: Change fluconazole to micafungin.\n - Ophthalmology consult: difficult exam, no apparent chororetinal\n lesions. Corneal Scarring. Recommend repeat dilated fundoscopic exam if\n patient having ANY procedure requiring general anesthesia. Otherwise,\n repeat DFE in 2 weeks. Recommend lacrilub drops.\n - diagnostic paracentesis : sanguinous fluid aspirated, albumin\n 1.1, protein 2.3, glucose 121, LDH 160, WBC 300, RBC , diff\n PENDING\n - right EJ peripheral line placed\n - 40 Lasix in AM and in PM; still positive\n - video swallow study \n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Fluconazole - 01:56 AM\n Micafungin - 06:00 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:20 AM\n Furosemide (Lasix) - 06:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 37.2\nC (98.9\n HR: 116 (101 - 118) bpm\n BP: 101/66(73) {81/45(39) - 101/71(79)} mmHg\n RR: 30 (23 - 41) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 1,976 mL\n 443 mL\n PO:\n 200 mL\n TF:\n 1,206 mL\n 369 mL\n IVF:\n 451 mL\n 74 mL\n Blood products:\n Total out:\n 1,700 mL\n 160 mL\n Urine:\n 1,700 mL\n 160 mL\n NG:\n Stool:\n Drains:\n Balance:\n 276 mL\n 284 mL\n Respiratory support\n SpO2: 100%\n Physical Examination\n Labs / Radiology\n 146 K/uL\n 8.9 g/dL\n 145 mg/dL\n 0.6 mg/dL\n 26 mEq/L\n 3.5 mEq/L\n 28 mg/dL\n 107 mEq/L\n 145 mEq/L\n 26.6 %\n 6.7 K/uL\n [image002.jpg]\n 02:46 AM\n 03:02 AM\n 09:03 AM\n 03:28 AM\n 08:25 AM\n 03:08 PM\n 06:23 AM\n 06:29 AM\n 05:37 PM\n 06:16 AM\n WBC\n 7.1\n 7.3\n 8.1\n 6.7\n Hct\n 28.5\n 27.9\n 26.5\n 26.6\n Plt\n 142\n 137\n 147\n 146\n Cr\n 0.6\n 0.6\n 0.6\n 0.5\n 0.6\n TCO2\n 30\n 28\n 28\n 30\n Glucose\n 145\n 148\n 105\n 159\n 145\n Other labs: PT / PTT / INR:14.1/25.1/1.2,\n Peritoneal fluid: 300WBC, 19 PMN, 41L, 40mono, 89000RBC\n Micro:\n - catheter tip: pending\n -yeast urine/blood cx speciation: pending\n TTE:\n IMPRESSION: Moderately thickened and deformed aortic valve leaflets\n with moderate to severe stenosis. At least moderate mitral\n regurgitation. Small echodensity in the left atrium adjacent to the\n anterior leaflet of the mitral valve (clip ) which appears consistent\n with artifact from mitral annular and valvular calcification; however,\n a small vegetation cannot be excluded. Mild global biventricular\n hypokinesis.\n If clinically suggested, the absence of a vegetation by 2D\n echocardiography does not exclude endocarditis.\n Compared with the prior study (images reviewed) of , the\n findings are similar.\n Assessment and Plan\n 35 yo M with PMH of CP, seizure disorder, GIB, pancreatic cyst s/p\n drainage in , admitted with abdominal pain with complicated course\n now with fever, hypoxemia, blood culture growing yeast.\n .\n # Hypoxemia: Patient transferred to MICU with tachypnea and hypoxia\n on and intubated on . Imaging findings consistent with\n multilobar pneumonia with sputum growing MRSA, complted 8 day course of\n vanc, cefepime, and flagyl on . Pleural effusions also noted on\n imaging, likely due to fluid resuscitation for hypotension in the\n setting of albumin of 2.3, so have been diuresing with lasix boluses.\n Extubated on . The current respiratory distress is likely due\n to mucous plugging, secretions with rhonchorous breath sounds on exam.\n Pulmonary edema may also be contributing.\n - suction and light chest PT\n - continue gentle diuresis with lasix 40mg IV boluses to go even to\n -500cc negative\n - follow ABGs\n - morphine for grunting/resp distress x 1 to see if helpful\n - will discuss non-invasive pressure ventilation if necessary with\n family\n .\n # Yeast bacteremia: Patient continues to have fevers, now with\n positive urine and blood cultures growing yeast. Possible urogenital\n source with hematogenous spread. Heart rate and blood pressure\n currently at baseline. Normal WBC count, lactate.\n - follow fever curve\n - daily blood cultures\n - follow speciation and sensitivity\n - continue micafungin IV\n - f/u ID recs\n - follow LFT, EKG\n - f/u PICC tip culture\n - f/u aspergillus, beta glucan\n .\n #Fevers: Patient daily low grade febrile episodes despite broad\n spectrum antibiotics. Completed treatment for pulmonary infection with\n 8 day course of vancomycin, cefepime, flagyl. SBP possible but 3 taps\n have not been c/w SBP. PE considered but no evidence on CTA. CT read\n as possible liver abscess but repeat RUQ ultrasound read as more\n consistent with infarct. C. Diff has been negative. Overnight\n positive urine and blood culture growing yeast.\n - treatment for yeast bloodstream infection as above\n -\n # Tachycardia: Likely hyperdynamic in setting of fever, infection.\n Volume status appears grossly euvolemic; pt mentating at baseline and\n maintaining urine output. Echo with evidence of depressed cardiac fxn,\n ? tachycardia induced cardiomyopathy\n - Tylenol prn fever\n - Antimicrobial agents as above\n .\n # Anemia/bleed: Hct stable. Pt with RP bleed and CT evidence of\n hemorrhage into bowel wall, also gastric varices c/b GIB earlier in\n admission. Transfused 1 unit pRBCs with appropriate bump and has\n remained stable since.\n - Trend Hct\n - Guaiac stools\n - Active T&S\n - change pantoprazole to PO\n - Continue iron supplement\n # Liver lesion. Noted on abdominal CT. Possible ischemia/infarction vs\n abscess. Abdominal U/S not consistent with abscess.\n .\n # Left humeral fx: Likely d/t trauma sustained during radiology.\n - No surgical indication at this time\n - Pain control with lidoderm patch and morphine prn\n .\n # SMV thrombus: Plan for anticoagulation x 6 months but held in setting\n of recent GI and RP bleed.\n - Continue heparin SQ\n .\n # Seizure disorder: No recent reports of seizures. Caution as certain\n antibiotics may lower seizure threshold.\n - Continue phenobarbitol and phenytoin, but transition to PO route\n - check drug levels\n .\n # Cerebral palsy: Stable mental status. Interactive with family but\n nonverbal at baseline.\n - speech and swallow evaluation\n .\n FEN: continue tube feeds today\n PROPHYLAXIS: pneumoboots, PO PPI\n ACCESS: PICC, A-line in right brachial artery\n CODE: Do not resuscitate/Do not re-intubate. No CPR or defibrillation.\n Will clarify role for BIPAP/CPAP.\n ICU Care\n Nutrition:\n Vivonex (Full) - 09:49 AM 50 mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 07:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Radiology",
"chartdate": "2115-03-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1130796,
"text": " 5:57 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ET tube\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man intubated, ET tube repositioned\n REASON FOR THIS EXAMINATION:\n ET tube\n ______________________________________________________________________________\n WET READ: JKSd FRI 9:29 PM\n ETT now 3.5 cm above carina. otherwise, little change from prior.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n COMPARISON: Study of earlier the same date.\n\n INDICATION: Endotracheal tube repositioning.\n\n FINDINGS: Endotracheal tube tip now terminates 3.5 cm above the carina.\n Appearance of the chest is otherwise not appreciably changed since the recent\n study of earlier the same date.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-03-24 00:00:00.000",
"description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY",
"row_id": 1129888,
"text": " 3:39 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: eval for PE\n Admitting Diagnosis: ABDOMINAL PAIN\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with sudden onset of hypoxia, tachypnea, and fever yesterday;\n known SMV clot\n REASON FOR THIS EXAMINATION:\n eval for PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CTA CHEST AND CT ABDOMEN AND PELVIS WITH CONTRAST\n\n INDICATION: 35-year-old man with sudden onset of hypoxia, tachypnea and fever\n since yesterday. Known SMV clot, evaluate for PE.\n\n COMPARISON STUDY: CT torso from and chest x-ray from .\n\n TECHNIQUE: MDCT of the chest, abdomen and pelvis was performed following the\n uneventful administration of nonionic intravenous contrast. Coronal, sagittal\n and multiple oblique reformatted images were reviewed per PE protocol.\n\n FINDINGS:\n\n CHEST: The endotracheal tube is in satisfactory position. An NG tube\n terminates within the stomach. The ascending aorta is mildly ectatic at 3.8\n cm. The descending aorta is normal in caliber. A left-sided PICC line\n terminates in the SVC. There are no enlarged axillary, mediastinal or hilar\n lymph nodes.\n\n There is new patchy multifocal airspace consolidation, particularly within the\n left upper lobe and medial segment right middle lobe consistent with\n pneumonia. There are increased moderate bilateral pleural effusions with\n compressive atelectasis.\n\n There is no pulmonary embolism within the main, lobar or segmental pulmonary\n arteries.\n\n ABDOMEN: There is new ill-defined area of hypoattenuation within segment V of\n the liver measuring 2.8 x 3.5 cm. This may represent a developing abscess.\n There is stable marked ascites. The patient is status post cholecystectomy.\n The spleen, pancreas and adrenal glands are unremarkable. The kidneys have\n symmetric nephrograms. There is a 1.2 cm low attenuating lesion within the\n mid pole right kidney, incompletely assessed on this contrast-enhanced study.\n There is no evidence of small-bowel obstruction. There is stable thickening\n of the sigmoid colon and rectal wall. There is continued dilation of the\n colon. There is a stable left retroperitoneal hemorrhage which now appears\n more organized.\n\n (Over)\n\n 3:39 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: eval for PE\n Admitting Diagnosis: ABDOMINAL PAIN\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Bone windows show degenerative change and scoliosis without focal suspicious\n lesion.\n\n IMPRESSION:\n\n 1. New bilateral patchy pneumonia, particularly within the left upper lobe\n and right middle lobe.\n\n 2. New ill-defined 2.8 x 3 cm hypoattenuating lesion in segment V of the\n liver. This may be secondary to a developing abscess. Follow-up ultrasound\n is recommended in 3 days.\n\n 3. Persistent sigmoid and rectal thickening with stable marked abdominal and\n pelvic ascites.\n\n 4. Stable left retroperitoneal bleed, more organized.\n\n 5. Increased moderate bilateral pleural effusions.\n\n Findings were discussed with ordering physician, . at the time of\n dictation.\n\n\n AKDLa\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-03-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1129256,
"text": " 9:47 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for infiltrate/free air\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with increased O2 requirement, ileus\n REASON FOR THIS EXAMINATION:\n evaluate for infiltrate/free air\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Increased O2 requirement, evaluation for pneumonia.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is increased density\n in the perihilar areas and increased perihilar haze. Progressing left lower\n lobe atelectasis with sparse air bronchograms.\n\n The bilaterality of the opacities as well as slight peribronchial cuffing and\n increase in diameter of the pulmonary vessels suggests central pulmonary edema\n rather than pneumonia. No evidence of pleural effusions, the lung volumes are\n low.\n\n Newly inserted left PICC line, the tip projects over the mid-to-low SVC. The\n prepositioned right PICC line has been removed in the interval.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-04-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1131027,
"text": " 1:58 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with hypoxia with PNA and fluid overload, now s/p extubation\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 2:40 A.M. ON \n\n HISTORY: Hypoxia, pneumonia and fluid overload. Extubated.\n\n IMPRESSION: AP chest compared to :\n\n Severe pulmonary edema, low lung volumes, moderate left pleural effusion, all\n unchanged since . Heart size top normal, stable. Left PIC line low\n in the SVC. Nasogastric tube ends in the distal duodenum, but intestinal\n distention is noted throughout the GI tract in the upper abdomen.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-03-11 00:00:00.000",
"description": "ABDOMEN (SUPINE & ERECT)",
"row_id": 1127996,
"text": " 5:53 PM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: please do lat/decub as well. eval for change in colonic dil\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with known SBO, known micro perf and adb distension\n REASON FOR THIS EXAMINATION:\n please do lat/decub as well. eval for change in colonic dilation, free air.\n ______________________________________________________________________________\n WET READ: AJy MON 10:05 PM\n dilated colon, likely sigmoid, similar in appearance to one day prior. large\n AFL on lateral decub. no free air. no pneumatosis.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Abdominal distention.\n\n COMPARISON: \n\n SUPINE AND LATERAL DECUBITUS ABDOMEN:\n\n Compared to the prior study there is slight improvement of large bowel\n dilatation with sigmoid colon measuring up to 9 cm. Air fluid level is seen\n in lateral decubitus likely in a loop of large bowel. There is no free\n intraperitoneal air or pneumatosis. A nasogastric tube is seen in appropriate\n position.\n\n IMPRESSION: Slightly improvement of marked sigmoid dilatation. No free\n intraperitoneal air.\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-03-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1130277,
"text": " 2:54 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with CP, pneumonia, intubated\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 2:55 A.M. ON \n\n HISTORY: Chest pain and pneumonia.\n\n IMPRESSION: AP chest compared to and 13:\n\n There has been no interval change since in dense bilateral\n consolidation in the lower lung on the right and mid and lower lung on the\n left, shown by the intervening torso CT as bilateral lower lobe atelectasis\n and probable left upper lobe pneumonia. Moderate left pleural effusion is\n slightly larger today. Small-to-moderate right pleural effusion probably\n unchanged. Heart size top normal. Pulmonary vascularity is engorged, but\n this may be a function of supine positioning rather than cardiac dysfunction.\n ET tube, left PIC line, and nasogastric tube in standard placements\n respectively. No pneumothorax.\n\n Fracture of proximal left humerus substantially distracted, and not clearly\n present before .\n\n Dr. was paged.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-03-31 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1130915,
"text": " 2:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with hypoxia, intubated\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 2:24 A.M. ON \n\n HISTORY: 35-year-old man with hypoxia.\n\n IMPRESSION: AP chest compared to :\n\n Widespread moderately severe pulmonary edema, bilateral pleural effusions,\n moderate to large on the left, moderate on the right are unchanged. ET tube\n and left subclavian line are in standard placements and a nasogastric tube\n ends in the region of proximal duodenum. No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-03-17 00:00:00.000",
"description": "P ABDOMEN (SUPINE & ERECT) PORT",
"row_id": 1128844,
"text": " 3:54 PM\n ABDOMEN (SUPINE & ERECT) PORT Clip # \n Reason: r/o obstruction\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with h/o obstruction, now back on tube feeds with firm abdomen\n REASON FOR THIS EXAMINATION:\n r/o obstruction\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: History of prior obstructions, now feeding.\n\n ABDOMEN:\n\n The distribution of gas in the abdomen is unremarkable with gas seen\n throughout the large and small bowel indicating the absence of obstruction.\n None of the loops appear dilated.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-04-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1131660,
"text": " 9:08 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with shortness of breath,\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 09:48 A.M., \n\n HISTORY: Shortness of breath, question interval change.\n\n IMPRESSION: AP chest compared to through :\n\n Pulmonary edema has cleared from the periphery of the lungs. Central\n consolidation persists. Whether this is pneumonia or pulmonary edema is\n radiographically indeterminate. Small bilateral pleural effusions are\n presumed. Heart size is normal. Mediastinal vascular engorgement persists.\n No pneumothorax. Nasogastric tube ends in the third portion of the duodenum.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-03-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1128226,
"text": " 10:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate NGT and for signs of aspiration/pneumonia\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with NGT and hypotension, had order on floor but may not have\n been completed and is not online\n REASON FOR THIS EXAMINATION:\n evaluate NGT and for signs of aspiration/pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Nasogastric tube and hypertension.\n\n Portable AP chest radiograph was compared to .\n\n The NG tube has been advanced with its tip currently now in post-pyloric\n location. The right PICC line tip is at the level of low SVC.\n Cardiomediastinal silhouette is stable. Lung volumes are low, but lungs are\n essentially clear. There is extensive degree of small bowel distention but\n significantly improved since the prior study. Please correlate with abdominal\n imaging and clinical findings.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-03-27 00:00:00.000",
"description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT",
"row_id": 1130309,
"text": " 8:17 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # \n Reason: eval for interval change of possible liver abscess\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with recent RUQ ultrasound showing 2.8 x 3cm abscess in segment\n 5\n REASON FOR THIS EXAMINATION:\n eval for interval change of possible liver abscess\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): KKgc WED 11:23 AM\n PFI:\n 1. No focal liver lesions or abscesses identified in the study. The\n hypoenhancing lesion seen in the CT of could represent infarct\n secondary to compromised blood flow through the right portal vein.\n 2. Ascites and right pleural effusion.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 35-year-old man with possible liver abscess, to assess for\n interval change.\n\n COMPARISON: CT torso, .\n\n FINDINGS: Liver has a normal echotexture without evidence of focal liver\n lesions. The hypoenhancing lesion, seen in the prior CT scan, is not\n visualized in the ultrasound study. This likely represents an infarct of the\n liver, secondary to compromised blood supply through the right portal vein.\n There is no intrahepatic or extrahepatic biliary dilatation. Patient is\n status post cholecystectomy.\n Common duct measures 5 mm.\n\n A moderate amount of right pleural effusion and ascites are seen.\n\n IMPRESSION:\n 1. No son correlate corresponding to the hypoenhancing lesion seen on\n prior CT of is seen. Lesion seen on CT could represent an infarct\n secondary to compromised blood supply through the right portal vein, which\n appears nearly occluded.\n 2. Right pleural effusion and ascites.\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-03-27 00:00:00.000",
"description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT",
"row_id": 1130310,
"text": ", R. MED MICU 8:17 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # \n Reason: eval for interval change of possible liver abscess\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with recent RUQ ultrasound showing 2.8 x 3cm abscess in segment\n 5\n REASON FOR THIS EXAMINATION:\n eval for interval change of possible liver abscess\n ______________________________________________________________________________\n PFI REPORT\n PFI:\n 1. No focal liver lesions or abscesses identified in the study. The\n hypoenhancing lesion seen in the CT of could represent infarct\n secondary to compromised blood flow through the right portal vein.\n 2. Ascites and right pleural effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-03-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1130109,
"text": " 2:47 AM\n CHEST (PORTABLE AP) Clip # \n Reason: intubated\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with respiratory distress, intubated\n REASON FOR THIS EXAMINATION:\n intubated\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Respiratory distress.\n\n FINDINGS: In comparison with the study of , the monitoring and support\n devices remain in place. Little overall change in the diffuse bilateral\n pulmonary opacifications with air bronchograms, reflecting pneumonia,\n pulmonary edema, or both. The opacification along the left lateral chest wall\n is consistent with pleural fluid.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-03-13 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 1128299,
"text": " 5:26 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: re-evaluate abd and pelvix for signs of infection, microferp\n Admitting Diagnosis: ABDOMINAL PAIN\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with hx of SMV thrombus, large bowel obstruction, worsening\n belly distention and new hypotension\n REASON FOR THIS EXAMINATION:\n re-evaluate abd and pelvix for signs of infection, microferp, worsening clots,\n etc\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: AJy WED 10:36 PM\n small left effusion unchanged. tiny right effusion. bibasilar atelectasis.\n Increased ascites, slightly high density (30 ) suggesting component of\n hemoperitoneum. unchanged pancreatic atrophy and calcification c/w chronic\n pancreatitis. unchanged occlusion of the superior smv with extensive\n collaterals and reconstitution of patent portal vein. colon less distended,\n rectal tube in place. however, colonic wall thickening has increased. in the\n rectum and distal sigmoid, this may reflect decerased distention. however, in\n the descending colon and prox sigmoid, there is marked wall thickening and\n edema c/w colitis, as well as a region of relative and mass-like\n thickening at the descending-sigmoid junction that suggests intramural\n hemorrhage. also new from prior study there is a large heterogeneous high\n density collection ectending from the left RP space and disecting into the\n pelvis anterior to the rectum and anteriorly displacing the bladder. this is\n c/w retroperitoneal hematoma, which may be extending from colonic mural\n bleeding? while no extraluminal oral contrast is seen, there are small foci of\n air seen anteriorly just deep to/within the rectus sheath. these are in a\n similar location to extraluminal air seen on the 14th. (2:63). these are of\n unclear etiology or significance, but GI perforation cannot be exlcuded.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: History of SMV occlusion and large bowel obstruction,\n with worsening abdominal distention and new hypotension.\n\n TECHNIQUE: MDCT of the abdomen and pelvis was performed following the\n uneventful administration of nonionic intravenous contrast and oral contrast.\n Comparison exam is dated .\n\n FINDINGS: Limited images of the lung bases demonstrate small left pleural\n effusion, unchanged and trace right pleural fluid. There is bibasilar\n atelectasis, left greater than right.\n\n A feeding tube is seen terminating in the third portion of the duodenum.\n Compared to the prior exam, there is increased abdominal ascites, which is\n slightly hyperdense, measuring 30 Hounsfield units in some areas. There has\n been interval development of marked colonic wall thickening involving the\n ascending colon, descending colon, sigmoid and rectum. The transverse colon\n appears relatively spared. There is an area of mass-like hyperdense\n thickening of the descending/transverse colon junction (2:63). Additionally,\n (Over)\n\n 5:26 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: re-evaluate abd and pelvix for signs of infection, microferp\n Admitting Diagnosis: ABDOMINAL PAIN\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n is seen tracking along the descending colonic wall, likely\n representing hemorrhage. Compared to the prior exam, there is decreased\n distention of the rectum and sigmoid colon. A rectal tube is now in place.\n There is a new hyperdense left retroperitoneal collection extending from just\n inferior to the left kidney into the pelvis, interposed between the rectum and\n bladder and displacing the bladder anteriorly and inferiorly. There are a few\n foci of gas in the left rectus muscle. Additionally, there is a focus of gas\n which appears to be intraperitoneal (2:62), that was not clearly present on\n the prior exam. It is not clear whether this is extraluminal or not. There\n is no contrast extravasation. There are prominent small bowel loops with\n diffuse distention, but no evidence of transition point. The small bowel is\n non-thickened. Again noted are numerous venous collaterals related to known\n SMV occlusion. The portal vein again reconstitutes and is patent, as is the\n splenic vein.\n\n The pancreas is atrophic with multiple calcifications in the region of the\n head, consistent with chronic pancreatitis. The gallbladder is surgically\n absent. There is a right renal cyst. The left kidney, adrenal glands and\n spleen are unremarkable.\n\n PELVIS: The bladder contains a Foley catheter with contrast and foci of gas.\n There are no pathologically enlarged lymph nodes. There is diffuse mild\n anasarca.\n\n Bone windows demonstrate scoliosis and degenerative changes of the spine.\n There are no focal suspicious lesions.\n\n IMPRESSION:\n\n 1. Interval development of marked colonic thickening involving the ascending\n colon, descending colon, sigmoid and rectum, concerning for colitis,\n possiblby on the basis of venous obstruction. There is hyperdense mass-like\n thickening at the junction of the descending colon and transverse colon, which\n is new from the prior exam and consistent with hemorrhage. is\n also seen along the descending colonic wall, also likely representing\n hemorrhage. There is a focus of gas which appears to be within the peritoneal\n cavity (2:62), not present on the prior study. This is not clearly\n extraluminal and no oral contrast extravasation is seen, although perforation\n cannot be fully excluded.\n\n 2. Interval development of a large left retroperitoneal hematoma extending in\n the pelvis.\n\n 3. Prominent small bowel distention diffusely, consistent with ileus.\n\n (Over)\n\n 5:26 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: re-evaluate abd and pelvix for signs of infection, microferp\n Admitting Diagnosis: ABDOMINAL PAIN\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 4. Increased abdominal ascites, slightly hyperdense, suggesting a component\n of hemoperitoneum.\n\n 5. Numerous collateral vessels related to known SMV occlusion. This appears\n stable from the prior exam, and the portal vein is patent and reconstituted.\n\n These findings were discussed with the surgery resident, Dr. by the on-\n call radiology resident at 10:00 p.m. on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-03-30 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1130827,
"text": " 3:25 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with respiratory failure; intubated\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST \n\n COMPARISON: One day earlier.\n\n INDICATION: Respiratory failure.\n\n FINDINGS: Indwelling devices are unchanged in position, and cardiomediastinal\n contours are similar to prior study. Widespread alveolar opacities presumably\n representing pulmonary edema appear similar to the recent study as well as\n moderate to large layering pleural effusions.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-03-10 00:00:00.000",
"description": "ABDOMEN (SUPINE ONLY)",
"row_id": 1127790,
"text": " 11:37 AM\n ABDOMEN (SUPINE ONLY) Clip # \n Reason: Please evaluate colonic distention\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man w/ SMV thrombus with abdominal distension with imaging\n concerning for microperf and partial obstruction\n REASON FOR THIS EXAMINATION:\n Please evaluate colonic distention\n ______________________________________________________________________________\n FINAL REPORT\n SUPINE ABDOMEN VIEW \n\n COMPARISON: .\n\n INDICATION: Colonic distention and abdominal distention.\n\n FINDINGS: There has been apparent placement of a rectal tube (recommend\n clinical correlation with recent procedural history). There has been decrease\n in degree of distention of a prominent loop of bowel in the lower mid abdomen,\n likely representing sigmoid colon, with decrease in maximal diameter from\n about 10 cm to 8.6 cm in transverse width. Other air- filled loops of small\n and large bowel appear relatively similar to the recent radiograph. By\n report, there is clinical concern for perforation. Either an upright or left\n lateral decubitus abdominal radiograph would be recommended to evaluate for\n free intraperitoneal air. Alternatively, a CT could be performed.\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-03-09 00:00:00.000",
"description": "ABDOMEN (SUPINE ONLY)",
"row_id": 1127689,
"text": " 11:15 AM\n ABDOMEN (SUPINE ONLY) Clip # \n Reason: assess for interval change in colonic dilitation\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with abnormal KUB, colonic dilitation\n REASON FOR THIS EXAMINATION:\n assess for interval change in colonic dilitation\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMEN\n\n HISTORY: Colonic dilatation.\n\n Two supine views. Comparison with . There is interval increase in\n caliber of the dilated segment of colon in the lower abdomen and pelvis.\n Prominent air-filled loops of bowel are scattered throughout the abdomen.\n There is a relative paucity of gas in the region of the rectum. Soft tissues\n are unremarkable. There is a lumbar scoliosis convex to the right with\n accompanying degenerative arthritic change. Surgical clips are projected in\n the region of the gallbladder fossa.\n\n IMPRESSION: Interval increase in gaseous distension of a segment of colon in\n the lower abdomen. Appearance is nonspecific, but distal colonic obstruction\n cannot be excluded and further evaluation by CT should be considered.\n\n\n"
},
{
"category": "Physician ",
"chartdate": "2115-02-21 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 625471,
"text": "24 Hour Events:\n No events overnight. Pt w/ SBP in 60s-80s. Remains intubated.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Tobramycin - 12:15 PM\n Vancomycin - 08:30 PM\n Piperacillin/Tazobactam (Zosyn) - 12:10 AM\n Infusions:\n Other ICU medications:\n Fentanyl - 09:30 AM\n Pantoprazole (Protonix) - 09:00 PM\n Dilantin - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 38\nC (100.4\n HR: 71 (49 - 94) bpm\n BP: 70/48(54) {62/44(49) - 108/81(88)} mmHg\n RR: 29 (16 - 41) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 29.3 kg (admission): 32.3 kg\n Height: 55 Inch\n CVP: 14 (9 - 17)mmHg\n Total In:\n 3,597 mL\n 820 mL\n PO:\n TF:\n 85 mL\n IVF:\n 2,433 mL\n 350 mL\n Blood products:\n Total out:\n 2,620 mL\n 717 mL\n Urine:\n 1,770 mL\n 467 mL\n NG:\n 350 mL\n Stool:\n Drains:\n Balance:\n 977 mL\n 103 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 300 (300 - 300) mL\n Vt (Spontaneous): 264 (147 - 322) mL\n PS : 8 cmH2O\n RR (Set): 14\n RR (Spontaneous): 28\n PEEP: 0 cmH2O\n FiO2: 50%\n RSBI: 186\n PIP: 8 cmH2O\n Plateau: 17 cmH2O\n SpO2: 100%\n ABG: ///29/\n NIF: -21 cmH2O\n Ve: 6.2 L/min\n Physical Examination\n Gen: Intubated, sedated\n Resp: tacchypneic, clear anteriorly\n Cards: rrr no m/r/g\n Abd: soft, nt/nd, no guarding\n Ext: Contracted, WWP, no c/c/e\n Labs / Radiology\n 122 K/uL\n 8.0 g/dL\n 118 mg/dL\n 1.0 mg/dL\n 29 mEq/L\n 5.5 mEq/L\n 15 mg/dL\n 109 mEq/L\n 140 mEq/L\n 24.8 %\n 6.5 K/uL\n [image002.jpg]\n 02:40 PM\n 02:29 AM\n 04:00 PM\n 01:32 AM\n 03:31 AM\n 01:00 AM\n 08:19 AM\n 04:27 PM\n 10:27 PM\n 04:15 AM\n WBC\n 9.4\n 10.1\n 7.6\n 6.5\n Hct\n 30.9\n 29.2\n 28.6\n 27.1\n 24.1\n 25.6\n 17\n 24.8\n Plt\n 107\n 110\n 109\n 122\n Cr\n 0.5\n 0.4\n 0.4\n 0.4\n 0.5\n 0.7\n 0.8\n 1.0\n TropT\n <0.01\n TCO2\n 36\n Glucose\n 137\n 141\n 104\n 106\n 98\n 132\n 109\n 118\n Other labs: PT / PTT / INR:17.0/29.2/1.5, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:, Alk Phos / T Bili:80/0.3,\n Amylase Lipase:62/19, Lactic Acid:0.9 mmol/L, Albumin:2.5 g/dL,\n LDH:158 IU/L, Ca++:8.1 mg/dL, Mg++:2.8 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n # Abdominal pain: Patient with finding of SMV thrombus with collaterals\n indicative of a chronic process. Surgery and Vascular involved,\n suspect to low flow state in setting of chronic pancreatitis. No\n e/o malignancy at this point. Patient started on heparin gtt. Also\n with diffuse bowel edema concerning for bowel ischemia / congestion.\n No e/o localized infection overlying inflammation at this point (though\n s/p paracentesis x 2, both with > 1000 WBC). Given compromised bowel\n wall, at high risk for translocation of bacteria.\n - Continue Vanc / Zosyn (14 day total course)\n - Follow-up cultures\n - Transition to Lovenox (30 mg per Pharmacy given decreased renal\n function; if improves increase to 40 mg )\n - Vascular recs / Surgery recs\n - Resend C.diff if new leukocytosis, febrile\n - GI recommendations\n - Started on Tube feeds overnight\n .\n # Respiratory failure: Treating for HAP/VAP with\n Vanc/Zosyn/Tobramycin. ID said no to Amikacin. With LLL infiltrate on\n CXR (persistent) but new since admission. Afebrile the night prior to\n transfer but with continued heavy secretions. No appreciable changes\n in ventilator settings. Following VBGs given too contracted for ABG.\n Family endorses heavy secretions at baseline.\n - Scopolamine patch (Cyproheptadine at home)\n - Goal fluid balance of even\n - VAP (Cefepime / Vanc) x 14 days total\n - Check NIF in AM (to assess for nueromuscular component)\n - Trial pressure support\n # Fever: Intermittent since admission on , . Could be \n ischemia; other possible sources of infection include pulmonary with\n some infiltrate on his CXR but he is without a leukocytosis. Does have\n prominent secretions per primary Surgical team.\n - Continue Vanc/Zosyn for HAP/VAP (14 days total)\n - Stop Tobramycin\n - Follow-up Micro\n - Culture if febrile\n - UA\n # Hypotension: Per family, patient's baseline BP high 70s - low 80s.\n Per nursing, also newly bradycardic and hypotensive (SBP 70s) overnight\n on . Could be vagal tone with ET/CVL but also consider\n infectious process. Previously responded to Albumin and 500cc bolus\n LR. Echo (final pending) Ef=55% and no focal wall motion\n abnormalities.\n - Monitor fluid balance\n - Goal SBP 80\n # SMV Occlusion: SMV occulsion with plan for 6 months anticoagulation\n per Vascular recommendation. Started on Heparin gtt for\n anticoagulation PTT 60-80, as well as daily Coumadin with Goal INR\n . Also noted to have diarrhea during stay (C.diff negative) thought\n to be lack of absorption due to bowel wall edema.\n - Per discussion with Vascular, no reason to not use Lovenox\n - Per discussion with pharmacy, will dose 30 mg SC BID (consider 40 mg\n if Cr improves)\n # Anemia: Unclear source for acute on chronic anemia (baseline 35) but\n now on anticoagulation. NG lavage / guaiac negative . Could\n consider some dilutional component, but likely does not explain\n complete loss\n - T&C x 2U PRBC\n - Monitor q8H Hct until stable\n - Continue to monitor stool guaiac\n # Renal insufficiency: Increased Cr to 0.7 from 0.4-0.5. Could be \n hypovolemia, infection (with Foley) vs medication reaction with AIN.\n - UA, Ulytes, UEos\n # Thrombocytopenia: New . With prior hospitalization, could\n consider new exposure to heparin with HIT. Other medications include\n antibiotics and Leviteracitam.\n - Stop heparin\n - Start Lovenox\n - Stop Keppra\n # Coagulopathy: Noted on admission; consider malnutrition vs\n malabsorption vs intrinsic liver disease.\n - Stop heparin, Coumadin\n - Start Lovenox \n # Hypoalbuminemia: Noted on arrival, with similar etiology to\n coagulopathy.\n - Restart TF; support nutrition as able\n - Discuss trophic TF with Surgery\n # Cerebral Palsy: Not ambulatory at baseline; also with h/o chronic,\n intermittent diarrhea; chronic pancreatitis. Could be an undiagnosed\n syndrome.\n - Seizure meds as below\n - Discuss with outpatient Neurology\n - Pancreatic enzymes as diet advances\n # Seizure disorder: Family describes them as 'drop seizures' with\n sudden head slumps. On Dilantin / Phenobarbital as outpatient.\n Patient transitioned to Keppra while inpatient.\n - Discuss restarting Dilantin / Phenobarbital safely with pharmacy\n - Touch base with outpatient Neurology Openheimer ()\n FEN Euvolemic to hypovolemic / replete PRN / NPO given bowel edema but\n planning on advancing soon\n PPX:\n - PPI\n - Chlorehexadine gluconate\n - Pneumoboots\n - Systemically anticoagulated\n ACCESS: L-Subclavian CL (); R PIV\n Communication: & \n CODE: FULL\n Dispo: ICU pending clinical improvement\n ICU Care\n Nutrition:\n TPN w/ Lipids - 06:02 PM 46 mL/hour\n Ensure (Full) - 12:00 AM 20 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 03:15 AM\n 20 Gauge - 12:17 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2115-02-21 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 625481,
"text": "24 Hour Events:\n No events overnight. Pt w/ SBP in 60s-80s. Remains intubated. Appears\n comfortable.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Tobramycin - 12:15 PM\n Vancomycin - 08:30 PM\n Piperacillin/Tazobactam (Zosyn) - 12:10 AM\n Infusions:\n Other ICU medications:\n Fentanyl - 09:30 AM\n Pantoprazole (Protonix) - 09:00 PM\n Dilantin - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 38\nC (100.4\n HR: 71 (49 - 94) bpm\n BP: 70/48(54) {62/44(49) - 108/81(88)} mmHg\n RR: 29 (16 - 41) insp/min\n SpO2: 100% on PS FiO2 50%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 29.3 kg (admission): 32.3 kg\n Height: 55 Inch\n CVP: 14 (9 - 17)mmHg\n Total In:\n 3,597 mL\n 820 mL\n PO:\n TF:\n 85 mL\n IVF:\n 2,433 mL\n 350 mL\n Blood products:\n Total out:\n 2,620 mL\n 717 mL\n Urine:\n 1,770 mL\n 467 mL\n NG:\n 350 mL\n Stool:\n Drains:\n Balance:\n 977 mL\n 103 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 300 (300 - 300) mL\n Vt (Spontaneous): 264 (147 - 322) mL\n PS : 8 cmH2O\n RR (Set): 14\n RR (Spontaneous): 28\n PEEP: 0 cmH2O\n FiO2: 50%\n RSBI: 186\n PIP: 8 cmH2O\n Plateau: 17 cmH2O\n SpO2: 100%\n ABG: ///29/\n NIF: -21 cmH2O\n Ve: 6.2 L/min\n Physical Examination\n Gen: Intubated, sedated\n Resp: tacchypneic, clear anteriorly\n Cards: rrr no m/r/g\n Abd: soft, nt/nd, no guarding\n Ext: Contracted, WWP, no c/c/e\n Labs / Radiology\n 122 K/uL\n 8.0 g/dL\n 118 mg/dL\n 1.0 mg/dL\n 29 mEq/L\n 5.5 mEq/L\n 15 mg/dL\n 109 mEq/L\n 140 mEq/L\n 24.8 %\n 6.5 K/uL\n [image002.jpg]\n 02:40 PM\n 02:29 AM\n 04:00 PM\n 01:32 AM\n 03:31 AM\n 01:00 AM\n 08:19 AM\n 04:27 PM\n 10:27 PM\n 04:15 AM\n WBC\n 9.4\n 10.1\n 7.6\n 6.5\n Hct\n 30.9\n 29.2\n 28.6\n 27.1\n 24.1\n 25.6\n 17\n 24.8\n Plt\n 107\n 110\n 109\n 122\n Cr\n 0.5\n 0.4\n 0.4\n 0.4\n 0.5\n 0.7\n 0.8\n 1.0\n TropT\n <0.01\n TCO2\n 36\n Glucose\n 137\n 141\n 104\n 106\n 98\n 132\n 109\n 118\n Other labs: PT / PTT / INR:17.0/29.2/1.5, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:, Alk Phos / T Bili:80/0.3,\n Amylase Lipase:62/19, Lactic Acid:0.9 mmol/L, Albumin:2.5 g/dL,\n LDH:158 IU/L, Ca++:8.1 mg/dL, Mg++:2.8 mg/dL, PO4:3.5 mg/dL\n \n 06:00a\n _______________________________________________________________________\n Source: Line-cvl; Vancomycin @ Trough\n Other Blood Chemistry:\n Vanco: 72.3\n \n 07:53a\n _______________________________________________________________________\n pH\n 7.37\n pCO2\n 45\n pO2\n 43\n HCO3\n 27\n BaseXS\n 0\n Assessment and Plan\n 34M cerebral palsy initially p/w concern for abdominal infection now\n reintubated for respiratory failure.\n # Renal insufficiency: with Cr at 1.0 from baseline 0.3-0.4. Likely\n multifactorial with series of renal insults including hypovolemia\n followed by infection (with Foley) and then medications (including ABX)\n with possible AIN. CVP 10-15. Unwell week prior to admission, likely\n poor PO intake.\n - UA, Ulytes, UEos\n - holding vanc and tobra\n - consider renal consult\n - give another 500cc NS\n # Abdominal pain: Patient with finding of SMV thrombus with collaterals\n indicative of a chronic process. Surgery and Vascular involved,\n suspect to low flow state in setting of chronic pancreatitis. No\n e/o malignancy at this point. Patient started on heparin gtt. Also with\n diffuse bowel edema concerning for bowel ischemia / congestion. No e/o\n localized infection overlying inflammation at this point (though s/p\n paracentesis x 2, both with > 1000 WBC). Given compromised bowel wall,\n at high risk for translocation of bacteria.\n - Continue Zosyn (14 day total course)\n - D/C vanc given high levels\n - Continue Lovenox (30 mg per Pharmacy given decreased renal\n function; if improves increase to 40 mg )\n - Vascular recs / Surgery recs\n - Follow-up cultures\n - Send repeat C.diff given fevers\n - GI recommendations\n - Hold tube feeds (started overnight) for extubation\n - Cont TPN across the day, order for tomorrow but hope to wean if can\n - Start pancreatic enzymes\n - f/u with re: potential syndrome\n - check celiac disease labs\n # Respiratory failure: Treating for HAP/VAP with\n Vanc/Zosyn/Tobramycin. ID said no to Amikacin. With LLL infiltrate on\n CXR (persistent) but new since admission. Afebrile the night prior to\n transfer but with continued heavy secretions. No appreciable changes\n in ventilator settings. Following VBGs given too contracted for ABG.\n Family endorses heavy secretions at baseline. NIF today showing\n significant component of NM contribution.\n - Scopolamine patch (Cyproheptadine at home)\n - Goal fluid balance of even\n - d/c vanc and tobra\n - continue Cefepime x 14 days total\n - Trial pressure support today and ? extubation\n # Fever: Intermittent since admission on , . Could be \n ischemia; other possible sources of infection include pulmonary with\n some infiltrate on his CXR but he is without a leukocytosis. Does have\n prominent secretions per primary Surgical team.\n - Antibiotics as above (cont Zosyn, stopping Vanc and Tobra)\n - Follow-up Micro\n - Culture if febrile\n - UA\n # Hypotension: Per family, patient's baseline BP high 70s - low 80s.\n Per nursing, also newly bradycardic and hypotensive (SBP 70s) overnight\n on . Could be vagal tone with ET/CVL but also consider\n infectious process. Previously responded to Albumin and 500cc bolus\n LR. Echo (final pending) Ef=55% and no focal wall motion\n abnormalities.\n - Monitor fluid balance; goal even\n - Goal SBP 80, MAP ~60s\n - if bolus use 250-500cc\n # SMV Occlusion: SMV occulsion with plan for 6 months anticoagulation\n per Vascular recommendation. Started on Heparin gtt for\n anticoagulation PTT 60-80, as well as daily Coumadin with Goal INR ,\n now holding coumadin. Also noted to have diarrhea during stay (C.diff\n negative) thought to be lack of absorption due to bowel wall edema.\n - continue low dose Lovenox (discussed with vascular) at 30 qd\n - check Factor Xa level after 3^rd dose\n - Per discussion with pharmacy, will dose 30 mg SC BID (consider 40 mg\n if Cr improves)\n - trend PLT (increased today, but some concern for HIT)\n - send HIT antibody\n - if tolerates tube feeds may restart Coumadin in next few days\n # Anemia: Unclear source for acute on chronic anemia (baseline 35) but\n now on anticoagulation. NG lavage / guaiac negative . Could\n consider some dilutional component, but likely does not explain\n complete loss. No blood yet given.\n - T&C x 2U PRBC; transfuse to 21 unless e/o ischemia/bleeding\n - Monitor Hct now that stable\n - Continue to monitor stool guaiac\n # Thrombocytopenia: New . With prior hospitalization, could\n consider new exposure to heparin with HIT. Other medications include\n antibiotics and Leviteracitam.\n - Stop heparin\n - Start Lovenox\n - Stop Keppra\n - check HIT antibodies as above\n # Coagulopathy: Noted on admission; consider malnutrition vs\n malabsorption vs intrinsic liver disease.\n - Stop heparin, Coumadin\n - Start Lovenox as above\n # Hypoalbuminemia: Noted on arrival, with similar etiology to\n coagulopathy.\n - Restart TF; support nutrition as able\n - Discuss trophic TF with Surgery\n # Cerebral Palsy: Not ambulatory at baseline; also with h/o chronic,\n intermittent diarrhea; chronic pancreatitis. Could be an undiagnosed\n syndrome. Phenobarb level within therapeutic range on admission.\n - Seizure meds as below\n - Discuss with outpatient Neurology\n - Pancreatic enzymes as diet advances\n - check free dilantin level and free phenobarb levels\n # Seizure disorder: Family describes them as 'drop seizures' with\n sudden head slumps. On Dilantin / Phenobarbital as outpatient. Patient\n transitioned to Keppra while inpatient.\n - Discuss restarting Dilantin / Phenobarbital safely with pharmacy\n - Touch base with outpatient Neurology Openheimer ()\n - switch to phosphenitoin\n # FEN Euvolemic to hypovolemic / replete PRN / continue TPN for now /\n start tube feeds later today\n # PPX:\n - PPI\n - Chlorehexadine gluconate\n - Pneumoboots\n - Systemically anticoagulated\n # ACCESS: L-Subclavian CL (); R PIV\n # Communication: & (Parents) \n # CODE: FULL\n # Dispo: ICU pending clinical improvement\n ICU Care\n Nutrition:\n TPN w/ Lipids - 06:02 PM 46 mL/hour\n Ensure (Full) - 12:00 AM 20 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 03:15 AM\n 20 Gauge - 12:17 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2115-02-22 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 625597,
"text": "24 Hour Events:\n - extubated yest AM, tolerated well with moderate cough; on humidified\n face mask and then nasal canula 3 L at night\n - received 2 500 cc NS boluses during day\n - Cr continued to rise to 1.2; UO good at about 60-100cc/hr\n - TPN and TFs both continued\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Tobramycin - 12:15 PM\n Vancomycin - 08:30 PM\n Piperacillin/Tazobactam (Zosyn) - 07:14 AM\n Infusions:\n Other ICU medications:\n Fosphenytoin - 10:16 AM\n Pantoprazole (Protonix) - 08:07 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.4\nC (97.5\n HR: 94 (64 - 98) bpm\n BP: 101/62(72) {78/35(51) - 101/76(81)} mmHg\n RR: 19 (19 - 32) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 29.3 kg (admission): 32.3 kg\n Height: 55 Inch\n CVP: 10 (6 - 18)mmHg\n Total In:\n 3,394 mL\n 711 mL\n PO:\n TF:\n 257 mL\n 157 mL\n IVF:\n 1,810 mL\n 200 mL\n Blood products:\n Total out:\n 3,517 mL\n 602 mL\n Urine:\n 1,567 mL\n 552 mL\n NG:\n 300 mL\n Stool:\n Drains:\n Balance:\n -123 mL\n 109 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: Standby\n FiO2: 70%\n SpO2: 99%\n ABG: ///25/\n Physical Examination\n Gen:\n Labs / Radiology\n 129 K/uL\n 7.4 g/dL\n 143 mg/dL\n 1.2 mg/dL\n 25 mEq/L\n 4.3 mEq/L\n 16 mg/dL\n 119 mEq/L\n 149 mEq/L\n 24.1 %\n 5.4 K/uL\n [image002.jpg]\n 04:00 PM\n 01:32 AM\n 03:31 AM\n 01:00 AM\n 08:19 AM\n 04:27 PM\n 10:27 PM\n 04:15 AM\n 02:49 PM\n 03:57 AM\n WBC\n 10.1\n 7.6\n 6.5\n 5.4\n Hct\n 28.6\n 27.1\n 24.1\n 25.6\n 17\n 24.8\n 24.9\n 24.1\n Plt\n 110\n 109\n 122\n 129\n Cr\n 0.4\n 0.4\n 0.5\n 0.7\n 0.8\n 1.0\n 1.2\n 1.2\n TropT\n <0.01\n TCO2\n 36\n Glucose\n 104\n 106\n 98\n 132\n 109\n 118\n 94\n 143\n Other labs: PT / PTT / INR:17.0/29.2/1.5, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:, Alk Phos / T Bili:77/0.2,\n Amylase / Lipase:62/19, Lactic Acid:0.9 mmol/L, Albumin:2.4 g/dL,\n LDH:162 IU/L, Ca++:8.3 mg/dL, Mg++:2.7 mg/dL, PO4:4.5 mg/dL\n Assessment and Plan\n )\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 03:12 PM 25 mL/hour\n TPN w/ Lipids - 05:11 PM 46 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 03:15 AM\n 20 Gauge - 12:17 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2115-02-22 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 625605,
"text": "24 Hour Events:\n - extubated yest AM, tolerated well with moderate cough; on humidified\n face mask and then nasal canula 3 L at night\n - received 2 500 cc NS boluses during day\n - Cr continued to rise to 1.2; UO good at about 60-100cc/hr\n - TPN and TFs both continued\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Tobramycin - 12:15 PM\n Vancomycin - 08:30 PM\n Piperacillin/Tazobactam (Zosyn) - 07:14 AM\n Infusions:\n Other ICU medications:\n Fosphenytoin - 10:16 AM\n Pantoprazole (Protonix) - 08:07 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.4\nC (97.5\n HR: 94 (64 - 98) bpm\n BP: 101/62(72) {78/35(51) - 101/76(81)} mmHg\n RR: 19 (19 - 32) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 29.3 kg (admission): 32.3 kg\n Height: 55 Inch\n CVP: 10 (6 - 18)mmHg\n Total In:\n 3,394 mL\n 711 mL\n PO:\n TF:\n 257 mL\n 157 mL\n IVF:\n 1,810 mL\n 200 mL\n Blood products:\n Total out:\n 3,517 mL\n 602 mL\n Urine:\n 1,567 mL\n 552 mL\n NG:\n 300 mL\n Stool:\n Drains:\n Balance:\n -123 mL\n 109 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: Standby\n FiO2: 70%\n SpO2: 99%\n ABG: ///25/\n Physical Examination\n Gen: NAD\n Pulm: CTAB anteriorly\n CV: RRR, 2/6 systolic murmur heard in all fields\n Abd: soft, ND, did not push away hand while palpating\n Extremities: pulses intact, contracted, at baseline\n Neuro: alert, nonverbal,\n Labs / Radiology\n 129 K/uL\n 7.4 g/dL\n 143 mg/dL\n 1.2 mg/dL\n 25 mEq/L\n 4.3 mEq/L\n 16 mg/dL\n 119 mEq/L\n 149 mEq/L\n 24.1 %\n 5.4 K/uL\n [image002.jpg]\n 04:00 PM\n 01:32 AM\n 03:31 AM\n 01:00 AM\n 08:19 AM\n 04:27 PM\n 10:27 PM\n 04:15 AM\n 02:49 PM\n 03:57 AM\n WBC\n 10.1\n 7.6\n 6.5\n 5.4\n Hct\n 28.6\n 27.1\n 24.1\n 25.6\n 17\n 24.8\n 24.9\n 24.1\n Plt\n 110\n 109\n 122\n 129\n Cr\n 0.4\n 0.4\n 0.5\n 0.7\n 0.8\n 1.0\n 1.2\n 1.2\n TropT\n <0.01\n TCO2\n 36\n Glucose\n 104\n 106\n 98\n 132\n 109\n 118\n 94\n 143\n Other labs: PT / PTT / INR:17.0/29.2/1.5, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:, Alk Phos / T Bili:77/0.2,\n Amylase / Lipase:62/19, Lactic Acid:0.9 mmol/L, Albumin:2.4 g/dL,\n LDH:162 IU/L, Ca++:8.3 mg/dL, Mg++:2.7 mg/dL, PO4:4.5 mg/dL\n Assessment and Plan\n 34M cerebral palsy initially p/w concern for abdominal infection now\n reintubated for respiratory failure.\n # Renal insufficiency: with Cr at 1.2 from baseline 0.3-0.4. Likely\n multifactorial with series of renal insults including hypovolemia\n followed by infection (with Foley) and then medications (including ABX)\n with possible ATN/AIN. CVP 10-15. Unwell week prior to admission,\n likely poor PO intake.\n -Urine lytes consistent w/ ATN\n - holding vanc and tobra\n - consider renal consult\n - give another 500cc NS\n # Abdominal pain: Patient with finding of SMV thrombus with collaterals\n indicative of a chronic process. Surgery and Vascular involved,\n suspect to low flow state in setting of chronic pancreatitis. No\n e/o malignancy at this point. Patient started on heparin gtt. Also with\n diffuse bowel edema concerning for bowel ischemia / congestion. No e/o\n localized infection overlying inflammation at this point (though s/p\n paracentesis x 2, both with > 1000 WBC). Given compromised bowel wall,\n at high risk for translocation of bacteria.\n - Continue Zosyn (14 day total course)\n - D/C vanc given high levels\n - Continue Lovenox (30 mg QD per Pharmacy)\n - Start on Coumadin 5mg PO tonight\n - Vascular recs / Surgery recs\n - Follow-up cultures\n - Send repeat C.diff given fevers\n - GI recommendations\n - Hold tube feeds (started overnight) for extubation\n - Cont TPN and tube feeds\n start weaning TPN once INR starts to\n elevate (would indicate gut absorption)\n - Continue pancreatic enzymes\n - f/u with re: potential syndrome\n - F/U celiac disease labs\n # Respiratory failure: Treating for HAP/VAP with\n Vanc/Zosyn/Tobramycin. ID said no to Amikacin. With LLL infiltrate on\n CXR (persistent) but new since admission. Afebrile the night prior to\n transfer but with continued heavy secretions. No appreciable changes\n in ventilator settings. Following VBGs given too contracted for ABG.\n Family endorses heavy secretions at baseline. NIF today showing\n significant component of NM contribution.\n - Scopolamine patch (Cyproheptadine at home)\n - Goal fluid balance of even\n - d/c vanc and tobra\n - continue Cefepime x 14 days total\n - consider starting chest PT\n # Hypernatremia: Sodium is 149. Approximately 1.3L free water\n defecit.\n - increase free water flushes today by giving 200 q6h via NG\n - check PM lytes\n # Fever: Intermittent since admission on , . Could be \n ischemia; other possible sources of infection include pulmonary with\n some infiltrate on his CXR but he is without a leukocytosis. Does have\n prominent secretions per primary Surgical team.\n - Antibiotics as above (cont Zosyn, stopping Vanc and Tobra)\n - Follow-up Micro\n - Culture if febrile\n - UA\n # Hypotension: Per family, patient's baseline BP high 70s - low 80s.\n Per nursing, also newly bradycardic and hypotensive (SBP 70s) overnight\n on . Could be vagal tone with ET/CVL but also consider\n infectious process. Previously responded to Albumin and 500cc bolus\n LR. Echo (final pending) Ef=55% and no focal wall motion\n abnormalities.\n - Monitor fluid balance; goal even\n - Goal SBP 80, MAP ~60s\n - if bolus use 250-500cc\n # SMV Occlusion: SMV occulsion with plan for 6 months anticoagulation\n per Vascular recommendation. Started on Heparin gtt for\n anticoagulation PTT 60-80, as well as daily Coumadin with Goal INR ,\n now holding coumadin. Also noted to have diarrhea during stay (C.diff\n negative) thought to be lack of absorption due to bowel wall edema.\n - continue low dose Lovenox (discussed with vascular) at 30 qd\n - check Factor Xa level after 3^rd dose\n - Start Coumadin\n - trend PLT (increased today, but some concern for HIT)\n - send HIT antibody\n - if tolerates tube feeds may restart Coumadin in next few days\n # Anemia: Unclear source for acute on chronic anemia (baseline 35) but\n now on anticoagulation. NG lavage / guaiac negative . Could\n consider some dilutional component, but likely does not explain\n complete loss. No blood yet given.\n - T&C x 2U PRBC; transfuse to 21 unless e/o ischemia/bleeding\n - Monitor Hct now that stable\n - Continue to monitor stool guaiac\n # Thrombocytopenia: New . With prior hospitalization, could\n consider new exposure to heparin with HIT. Other medications include\n antibiotics and Leviteracitam.\n - Stop heparin\n - Start Lovenox\n - Stop Keppra\n - check HIT antibodies as above\n # Coagulopathy: Noted on admission; consider malnutrition vs\n malabsorption vs intrinsic liver disease.\n - Stop heparin, Coumadin\n - Start Lovenox as above\n # Hypoalbuminemia: Noted on arrival, with similar etiology to\n coagulopathy.\n - Restart TF; support nutrition as able\n - Discuss trophic TF with Surgery\n # Cerebral Palsy: Not ambulatory at baseline; also with h/o chronic,\n intermittent diarrhea; chronic pancreatitis. Could be an undiagnosed\n syndrome. Phenobarb level within therapeutic range on admission.\n - Seizure meds as below\n - Discuss with outpatient Neurology\n - Pancreatic enzymes as diet advances\n - check free dilantin level and free phenobarb levels\n # Seizure disorder: Family describes them as 'drop seizures' with\n sudden head slumps. On Dilantin / Phenobarbital as outpatient. Keppra\n DC\nd. Started on fosphenytoin and phenobarb and levels are currently\n reasonable.\n - Continue Fosphenytoin / Phenobarbital\n - Touch base with outpatient Neurology Openheimer ()\n # FEN Euvolemic to hypovolemic / replete PRN / continue TPN for now /\n start tube feeds later today\n # PPX:\n - PPI\n - Chlorehexadine gluconate\n - Pneumoboots\n - Systemically anticoagulated\n # ACCESS: L-Subclavian CL (); R PIV\n # Communication: & (Parents) \n # CODE: FULL\n # Dispo: call out to floor today\n"
},
{
"category": "Physician ",
"chartdate": "2115-04-01 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 632284,
"text": "Chief Complaint: - Extubated in AM with plan to NOT reintubate\n - Had some coughing and desat to upper 80s post-extubation, as well as\n fever; recultured and gave dose of 40 mg IV lasix, which seemed to help\n - TF held given risk of aspiration\n - Hypotensive to SBPs in 70s in PM after diuresing ~800 cc to Lasix; no\n intervention and BPs improved to 90s.\n - Overnight while sleeping MAP dropped to 55 and SBP to < 70, so got\n 250 cc bolus\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 09:15 AM\n BLOOD CULTURED - At 01:50 PM\n URINE CULTURE - At 01:50 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 06:00 PM\n Vancomycin - 08:00 PM\n Cefipime - 10:00 PM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 01:50 PM\n Pantoprazole (Protonix) - 08:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.2\nC (100.8\n Tcurrent: 36.2\nC (97.1\n HR: 107 (100 - 130) bpm\n BP: 91/70(79) {72/52(60) - 95/77(84)} mmHg\n RR: 21 (16 - 41) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 721 mL\n 746 mL\n PO:\n TF:\n 321 mL\n 297 mL\n IVF:\n 260 mL\n 329 mL\n Blood products:\n Total out:\n 1,780 mL\n 200 mL\n Urine:\n 1,780 mL\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,059 mL\n 547 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: PSV/SBT\n Vt (Spontaneous): 369 (369 - 369) mL\n PS : 8 cmH2O\n RR (Spontaneous): 27\n PEEP: 0 cmH2O\n FiO2: 50%\n SpO2: 94%\n ABG: 7.49/36/89./29/4\n Ve: 9.4 L/min\n PaO2 / FiO2: 178\n Physical Examination\n Gen: Thin, opening eyes but no clear orientation to voice; grunting\n this morning and appears uncomfortable\n HEENT: Sclera anicteric, eyes sunken, MMM, audible secretions\n Neck: Supple\n Lungs: Intubated, coarse BS bilaterally with diffuse ronchi\n CV: S1, S2 regular rhythm, increased rate\n Abdomen: Soft, BS+, distended, no facial grimacing to palpation\n GU: foley catheter in place\n Ext: Warm, cachectic, BLE contractures, + DP pulses\n Labs / Radiology\n 137 K/uL\n 9.1 g/dL\n 148 mg/dL\n 0.6 mg/dL\n 29 mEq/L\n 3.2 mEq/L\n 20 mg/dL\n 103 mEq/L\n 138 mEq/L\n 27.9 %\n 7.3 K/uL\n [image002.jpg]\n 02:18 PM\n 02:33 PM\n 05:01 AM\n 02:23 PM\n 03:50 AM\n 04:15 PM\n 02:46 AM\n 03:02 AM\n 09:03 AM\n 03:28 AM\n WBC\n 10.7\n 8.7\n 7.1\n 7.3\n Hct\n 30.4\n 30.2\n 28.5\n 27.9\n Plt\n 37\n Cr\n 0.6\n 0.7\n 0.6\n 0.6\n 0.6\n 0.6\n 0.6\n TCO2\n 27\n 30\n 28\n Glucose\n 118\n 116\n 85\n 139\n 150\n 145\n 148\n Other labs: PT / PTT / INR:16.6/26.3/1.5, CK / CKMB /\n Troponin-T:8//0.01, ALT / AST:17/19, Alk Phos / T Bili:106/0.6, Amylase\n / Lipase:/11, Differential-Neuts:86.5 %, Lymph:6.6 %, Mono:5.9 %,\n Eos:0.9 %, Lactic Acid:1.6 mmol/L, Albumin:2.4 g/dL, LDH:383 IU/L,\n Ca++:7.7 mg/dL, Mg++:2.1 mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n 35 yo M with PMH of CP, seizure disorder, GIB, pancreatic cyst s/p\n drainage in , admitted with abdominal pain with complicated course,\n now with new fever, tachypnea, and hypoxia.\n .\n # Respiratory failure: Patient transferred to MICU with tachypnea and\n hypoxia on and intubated on . Given his new fever,\n respiratory deterioration, and imaging findings consistent with\n multilobar pneumonia he was started on vancomycin, cefepime and flagyl\n (concern for aspiration given recently started tube feeds). Sputum\n growing MRSA. Pleural effusions also noted on imaging, likely due to\n fluid resuscitation for hypotension in the setting of albumin of 2.3,\n so over the past 24 hours have been diuresing with lasix boluses. PE\n considered but CTA negative. Few apneic episodes two nights ago may\n be secondary to aggressive diuresis. Extubated yesterday; has had a\n few low O2 sats.\n - Completed 8-day course of vanc, cefepime, metronidazole\n - continue with daily RSBI and SBT as tolerated, likely will extubate\n today\n - follow ABGs\n - electrolytes with repletion while on Lasix\n - f/u blood cultures\n - morphine for grunting/resp distress x 1 to see if helpful\n .\n # Fever/sepsis: Pt febrile with tachycardia and tachypnea; meets\n definition of sepsis with most likely source being pulmonary (MRSA).\n With ascites, SBP is also possible although he is now s/p 3 taps which\n have not been c/w SBP. Urinalysis and culture from with staph spp\n but repeat appears clean with NGTD. MS with no obvious\n nuchal rigidity although exam limited by pt cooperation. Again, PE\n could cause similar sx of fever and respiratory distress but none seen\n on CTA. Continues febrile daily. No further episodes of AMS. CT read as\n possible liver abscess but repeat RUQ ultrasound read as more\n consistent with infarct. C. Diff has been negative. Continues to have\n fever to 101 on overnight but normal white count, lactate normal.\n - Off Abx as above.\n - Goal CVP 8-12 but no measurements available currently\n will bolus\n for tachycardia, UOP < 30cc/h, goal MAP >60, CvO2 >70\n - Pressors for MAP > 55-60, off vasopressors\n - Monitor mental status\n - Consider paracentesis if continues febrile and no other source (would\n likely need to be done by IR)\n .\n #Hypotension. MAP goal > 60. No further episodes of AMS since starting\n pressors on . Not on vasopressors.\n # Tachycardia: Likely hyperdynamic in setting of fever, infection.\n Volume status appears grossly euvolemic; pt mentating at and\n maintaining urine output. Echo with evidence of depressed cardiac fxn,\n ? tachycardia induced cardiomyopathy\n - Tylenol prn fever\n - Abx as above\n - Fluid boluses prn, though patient with heart rate 110s;\n appears hypervolemic\n # Anemia/bleed: Hct stable. Pt with RP bleed and CT evidence of\n hemorrhage into bowel wall, also gastric varices c/b GIB earlier in\n admission. Transfused 1 unit pRBCs with appropriate bump and has\n remained stable since.\n - Trend Hct\n - Guaiac stools\n - Active T&S\n - continue pantoprazole 40mg IV bid\n - Continue iron supplement\n # Liver lesion. Noted on abdominal CT. Possible ischemia/infarction vs\n abscess. Abdominal U/S not consistent with abscess.\n # Left humeral fx: Likely d/t trauma sustained during radiology.\n - No surgical indication at this time\n - Pain control with lidoderm patch and morphine prn\n .\n # SMV thrombus: Plan for anticoagulation x 6 months but held in setting\n of recent GI and RP bleed.\n - Continue heparin SQ\n .\n # Seizure disorder: No recent reports of seizures. Caution as certain\n antibiotics may lower seizure threshold.\n - Continue phenobarbitol and phenytoin\n - drug levels stable as of \n .\n # Cerebral palsy: Stable mental status. Interactive with family but\n nonverbal at .\n .\n FEN: NG tube likely in duodenum, bolus IVF prn, TPN; continue tube\n feeds today\n PROPHYLAXIS: pneumoboots, IV PPI\n ACCESS: PICC, PIV, D/C A-line in right brachial artery\n CODE: Do not resuscitate/Do not re-intubate. No CPR or defibrillation.\n Will clarify role for BIPAP/CPAP.\n ICU Care\n Nutrition:\n Vivonex (Full) - 02:00 AM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 11:14 AM\n Arterial Line - 11:10 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2115-04-03 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 632624,
"text": "Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - STOP 12:25 PM\n PARACENTESIS - At 04:00 PM\n TRANSTHORACIC ECHO - At 04:51 PM\n PICC LINE - STOP 08:30 PM\n dual lumen\n - ID consult: Change fluconazole to micafungin.\n - Ophthalmology consult: difficult exam, no apparent chororetinal\n lesions. Corneal Scarring. Recommend repeat dilated fundoscopic exam if\n patient having ANY procedure requiring general anesthesia. Otherwise,\n repeat DFE in 2 weeks. Recommend lacrilub drops.\n - TTE: EF 35-40%. Moderately thickened and deformed AV leaflets with\n moderate to severe AS. moderate MR. in the \n to the anterior leaflet of the MV which appears c/w artifact\n from mitral annular and valvular calcification; however, a small\n vegetation cannot be excluded. Mild global biventricular hypokinesis.\n Compared with the prior study , the findings are similar.\n - diagnostic paracentesis : sanguinous fluid aspirated, albumin\n 1.1, protein 2.3, glucose 121, LDH 160, WBC 300, RBC , diff\n PENDING\n - right EJ peripheral line placed\n - 40 Lasix in AM and in PM; still positive\n - video swallow study \n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Fluconazole - 01:56 AM\n Micafungin - 06:00 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:20 AM\n Furosemide (Lasix) - 06:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 37.2\nC (98.9\n HR: 116 (101 - 118) bpm\n BP: 101/66(73) {81/45(39) - 101/71(79)} mmHg\n RR: 30 (23 - 41) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 1,976 mL\n 443 mL\n PO:\n 200 mL\n TF:\n 1,206 mL\n 369 mL\n IVF:\n 451 mL\n 74 mL\n Blood products:\n Total out:\n 1,700 mL\n 160 mL\n Urine:\n 1,700 mL\n 160 mL\n NG:\n Stool:\n Drains:\n Balance:\n 276 mL\n 284 mL\n Respiratory support\n SpO2: 100%\n ABG: ///26/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 146 K/uL\n 8.9 g/dL\n 145 mg/dL\n 0.6 mg/dL\n 26 mEq/L\n 3.5 mEq/L\n 28 mg/dL\n 107 mEq/L\n 145 mEq/L\n 26.6 %\n 6.7 K/uL\n [image002.jpg]\n 02:46 AM\n 03:02 AM\n 09:03 AM\n 03:28 AM\n 08:25 AM\n 03:08 PM\n 06:23 AM\n 06:29 AM\n 05:37 PM\n 06:16 AM\n WBC\n 7.1\n 7.3\n 8.1\n 6.7\n Hct\n 28.5\n 27.9\n 26.5\n 26.6\n Plt\n 142\n 137\n 147\n 146\n Cr\n 0.6\n 0.6\n 0.6\n 0.5\n 0.6\n TCO2\n 30\n 28\n 28\n 30\n Glucose\n 145\n 148\n 105\n 159\n 145\n Other labs: PT / PTT / INR:14.1/25.1/1.2,\n TTE:\n IMPRESSION: Moderately thickened and deformed aortic valve leaflets\n with moderate to severe stenosis. At least moderate mitral\n regurgitation. Small in the left atrium adjacent to the\n anterior leaflet of the mitral valve (clip ) which appears consistent\n with artifact from mitral annular and valvular calcification; however,\n a small vegetation cannot be excluded. Mild global biventricular\n hypokinesis.\n If clinically suggested, the absence of a vegetation by 2D\n echocardiography does not exclude endocarditis.\n Compared with the prior study (images reviewed) of , the\n findings are similar.\n Assessment and Plan\n ICU Care\n Nutrition:\n Vivonex (Full) - 09:49 AM 50 mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 07:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Nutrition",
"chartdate": "2115-04-04 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 632865,
"text": "Subjective\n Per mother-has not had anything since diet advanced-\nDoing well\n Objective\n Pertinent medications: noted\n Labs:\n Value\n Date\n Glucose\n 157 mg/dL\n 05:10 AM\n Glucose Finger Stick\n 135\n 10:00 AM\n BUN\n 25 mg/dL\n 05:10 AM\n Creatinine\n 0.5 mg/dL\n 05:10 AM\n Sodium\n 139 mEq/L\n 05:10 AM\n Potassium\n 3.9 mEq/L\n 05:10 AM\n Chloride\n 102 mEq/L\n 05:10 AM\n TCO2\n 30 mEq/L\n 05:10 AM\n Calcium non-ionized\n 7.9 mg/dL\n 05:10 AM\n Phosphorus\n 2.4 mg/dL\n 05:10 AM\n Magnesium\n 2.3 mg/dL\n 05:10 AM\n ALT\n 18 IU/L\n 05:10 AM\n Alkaline Phosphate\n 178 IU/L\n 05:10 AM\n AST\n 32 IU/L\n 05:10 AM\n Total Bilirubin\n 0.3 mg/dL\n 05:10 AM\n WBC\n 7.0 K/uL\n 05:10 AM\n Hgb\n 9.3 g/dL\n 05:10 AM\n Hematocrit\n 27.7 %\n 05:10 AM\n Current diet order / nutrition support: Soft dysphagia, nectar liquids\n Vivonex @ 50mL/hr (1200 kcals/46 gr protein)\n GI: Abd: soft/nbs\n Assessment of Nutritional Status\n Specifics:\n Patient extubated . Tube feeds continue @ goal, meeting 100%\n estimated nutrition needs. Patient had swallow eval yesterday and was\n cleared for pureed solids and nectar liquids. Please note above order\n does not reflect SLP recommendations. Patient has yet to receive meal\n tray- one ordered for patient. Mother to attempt to feed once\n received. 2 packets neutraphos ordered for low Phos.\n Medical Nutrition Therapy Plan - Recommend the Following\n Continue on full tube feeds\n Change diet rx to pureed solids and nectar liquids (done in\n POE- needs co-sign)\n 1:1 supervision w/ feeds\n Lyte and glucose management as you are\n As po intake improves can discuss weaning tube feeds\n Following #\n 12:49 PM\n"
},
{
"category": "Echo",
"chartdate": "2115-04-02 00:00:00.000",
"description": "Report",
"row_id": 90468,
"text": "PATIENT/TEST INFORMATION:\nIndication: ?Endocarditis.\nHeight: (in) 60\nWeight (lb): 80\nBSA (m2): 1.27 m2\nBP (mm Hg): 98/66\nHR (bpm): 74\nStatus: Inpatient\nDate/Time: at 15:55\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nRIGHT VENTRICLE: Normal RV chamber size. Mild global RV free wall hypokinesis.\n\nAORTA: Focal calcifications in aortic root.\n\nAORTIC VALVE: ?# aortic valve leaflets. Moderately thickened aortic valve\nleaflets. No masses or vegetations on aortic valve, but cannot be fully\nexcluded due to suboptimal image quality. Moderate AS (area 1.0-1.2cm2) No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Mild thickening of mitral valve chordae. Moderate (2+)\nMR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. No mass or vegetation on\ntricuspid valve. No TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.\n\nConclusions:\nRight ventricular chamber size is normal. with mild global free wall\nhypokinesis. The number of aortic valve leaflets cannot be determined. The\naortic valve leaflets are moderately thickened. No masses or vegetations are\nseen on the aortic valve, but cannot be fully excluded due to suboptimal image\nquality. There is moderate aortic valve stenosis (valve area 1.0-1.2cm2). No\naortic regurgitation is seen. The mitral valve leaflets are mildly thickened.\nThere is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen.\n\nIMPRESSION: Moderately thickened and deformed aortic valve leaflets with\nmoderate to severe stenosis. At least moderate mitral regurgitation. Small\nechodensity in the left atrium adjacent to the anterior leaflet of the mitral\nvalve (clip ) which appears consistent with artifact from mitral annular and\nvalvular calcification; however, a small vegetation cannot be excluded. Mild\nglobal biventricular hypokinesis.\nIf clinically suggested, the absence of a vegetation by 2D echocardiography\ndoes not exclude endocarditis.\n\nCompared with the prior study (images reviewed) of , the findings are\nsimilar.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2115-03-25 00:00:00.000",
"description": "Report",
"row_id": 90469,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 60\nWeight (lb): 80\nBSA (m2): 1.27 m2\nBP (mm Hg): 103/62\nHR (bpm): 128\nStatus: Inpatient\nDate/Time: at 12:10\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal interatrial septum. No\nASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Normal\nregional LV systolic function. Mild-moderate global left ventricular\nhypokinesis. No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTIC VALVE: ?# aortic valve leaflets. Moderate AS (area 1.0-1.2cm2)\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Mild thickening of mitral valve chordae. No MS. Moderate (2+)\nMR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. No TS. Mild [1+] TR. Mild PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: No PS.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Resting\ntachycardia (HR>100bpm).\n\nConclusions:\nThe left atrium is normal in size. No atrial septal defect is seen by 2D or\ncolor Doppler. Left ventricular wall thicknesses are normal. The left\nventricular cavity size is normal. Regional left ventricular wall motion is\nnormal. There is mild to moderate global left ventricular hypokinesis\nsuggested(LVEF = 45 %). There is no ventricular septal defect. Right\nventricular chamber size and free wall motion are normal. The number of aortic\nvalve leaflets cannot be determined. There is moderate aortic valve stenosis\n(valve area 1.0-1.2cm2). The mitral valve leaflets are mildly thickened.\nModerate (2+) mitral regurgitation is seen. There is mild pulmonary artery\nsystolic hypertension. There is no pericardial effusion.\n\nCompared with the prior study (images reviewed) of , the patient is\nmore tachycardic. The LV systolic function now appears depressed. The aortic\nvalve gradient appears similar. If indicated, a TEE would better clarify the\nbasis and severity of the aortic stenosis (as well as global LV systolic\nfunction).\n\n\n"
},
{
"category": "Echo",
"chartdate": "2115-02-19 00:00:00.000",
"description": "Report",
"row_id": 90470,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 60\nWeight (lb): 80\nBSA (m2): 1.27 m2\nBP (mm Hg): 78/61\nHR (bpm): 83\nStatus: Inpatient\nDate/Time: at 16:09\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTIC VALVE: ?# aortic valve leaflets. Moderately thickened aortic valve\nleaflets. Significant AS is present (not quantified) No AR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality - body habitus.\n\nConclusions:\nTechnically limited study; Overall left ventricular systolic function is\nnormal (LVEF>55%). Right ventricular chamber size and free wall motion are\nnormal. The number of aortic valve leaflets cannot be determined. The aortic\nvalve leaflets are moderately thickened. At least mild to moderate aortic\nstenosis is present (but cannot be fully quantified). No aortic regurgitation\nis seen. There is no pericardial effusion.\n\n\n"
},
{
"category": "Nursing",
"chartdate": "2115-02-22 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 625636,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt failed extubation earlier on this week and required\n reintubation on Monday night.\n Successfully extubated yesterday on Thurs \n O2 sats high 90\ns on 2L nc. Pt has a strong cough when\n stimulated and requires assistance to clear secretions from back of\n throat\n Requires diligent mouth care\n Making adequate amts of urine at this time\n Action:\n Chest PT done Q2hrs\n Assisted OOB to chair\n IV zosyn for PNA\n Response:\n Afebrile at this time\n Responding to pulmonary toilet\n Plan:\n Cont pulmonary toilet\n OOB daily\n SMV thrombosis\n Assessment:\n TF at goal via NGT supplementing with TPN for now until\n bowel absorption improves\n Passing lge amts of watery bile appearing stool-remains on\n pancreatic enzymes with flexiseal in place\n Flexiseal does leak this morning trouble shooting flexiseal\n found formed stool sitting at end of flexiseal\npatency improved once\n reinserted\n Na climbing (d/t loose stool)\n Action:\n Frequent skin care to buttocks with clear critic aid barrier\n cream-positioned off buttocks as much as possible\n Coumadin ordered for tonight\n Free water bolus added to TF 200cc Q6hr\n Response:\n Buttocks becoming pink d/t leakage from flexiseal\n Daily INR in response to PO coumadin will be indicator of\n bowel absorption\n Plan:\n Cont TF and TPN\n Coumadin/lovenox for thromosis\n Family updated by Dr. and aware of plans to transfer patient out\n to floor.\n"
},
{
"category": "Physician ",
"chartdate": "2115-02-18 00:00:00.000",
"description": "Intensivist Note",
"row_id": 625015,
"text": "SICU\n HPI:\n 35M with Cerebral palsy,presented with abdominal pain and distention to\n an OSH this am where CT scan was performed and reported as diffused\n bowel edema,gastric varices, ascites, pancreatic cyst. No association\n with nausea,vomitting, diarrhea, hematemesis, hematochezia, no GU\n symptoms. No jaundice , no fevers. No weight loss, no NSAIDs, ASA use.\n Pt recieved Unasyn at the OSH and was transferred to \n Chief complaint:\n respiratory distress, peritonitis, SMV occlusion\n PMHx:\n Cerebral Palsy (Patient non verbal baseline), Seizure d/o, Chronic\n anemia (transfusion x2)\n Current medications:\n Acetaminophen 4. Albuterol 0.083% Neb Soln 5. Calcium Gluconate 6.\n Dextrose 50% 7. Fentanyl Citrate\n 8. Furosemide 9. Furosemide 10. Glucagon 11. Heparin 12. Heparin Flush\n (10 units/ml) 13. 14. Insulin\n 15. LeVETiracetam 16. Magnesium Sulfate 17. MetRONIDAZOLE (FLagyl) 18.\n Midazolam 19. Pantoprazole\n 20. Piperacillin-Tazobactam\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 06:03 PM\n EXTUBATION - At 06:19 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:00 PM\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Metronidazole - 03:53 AM\n Infusions:\n Heparin Sodium - 700 units/hour\n Other ICU medications:\n Furosemide (Lasix) - 09:44 PM\n Fentanyl - 02:20 AM\n Other medications:\n Flowsheet Data as of 04:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.7\nC (99.9\n T current: 36.9\nC (98.5\n HR: 95 (75 - 110) bpm\n BP: 80/56(73) {80/52(62) - 125/81(90)} mmHg\n RR: 26 (9 - 48) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 38 kg (admission): 32.3 kg\n Height: 55 Inch\n CVP: 185 (1 - 238) mmHg\n Total In:\n 2,607 mL\n 431 mL\n PO:\n Tube feeding:\n IV Fluid:\n 1,471 mL\n 244 mL\n Blood products:\n Total out:\n 2,816 mL\n 1,380 mL\n Urine:\n 1,816 mL\n 730 mL\n NG:\n 250 mL\n Stool:\n Drains:\n Balance:\n -209 mL\n -949 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, Aerosol-cool\n Ventilator mode: CPAP/PSV\n Vt (Set): 350 (350 - 350) mL\n Vt (Spontaneous): 321 (293 - 555) mL\n PS : 5 cmH2O\n RR (Set): 10\n RR (Spontaneous): 17\n PEEP: 0 cmH2O\n FiO2: 70%\n RSBI: 93\n PIP: 16 cmH2O\n SPO2: 98%\n ABG: ///29/\n Ve: 5.4 L/min\n Physical Examination\n General Appearance: No acute distress\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric)\n Abdominal: No(t) Soft, softer than previously\n Neurologic: (Responds to: Tactile stimuli), No(t) Moves all\n extremities, (RUE: No(t) Weakness), (LUE: No(t) Weakness), (RLE: No\n movement), (LLE: No movement)\n Labs / Radiology\n 107 K/uL\n 10.0 g/dL\n 141 mg/dL\n 0.4 mg/dL\n 29 mEq/L\n 3.1 mEq/L\n 12 mg/dL\n 104 mEq/L\n 138 mEq/L\n 29.2 %\n 9.4 K/uL\n [image002.jpg]\n 03:35 AM\n 12:11 PM\n 04:42 PM\n 03:27 AM\n 02:48 AM\n 06:09 AM\n 03:11 PM\n 04:05 AM\n 02:40 PM\n 02:29 AM\n WBC\n 9.3\n 9.3\n 10.6\n 8.7\n 9.4\n Hct\n 28.3\n 27.1\n 26.2\n 29.1\n 31.6\n 32.9\n 30.9\n 29.2\n Plt\n 39\n 107\n Creatinine\n 0.4\n 0.5\n 0.5\n 0.4\n 0.5\n 0.5\n 0.5\n 0.4\n TCO2\n 25\n Glucose\n 112\n 90\n 74\n 134\n 80\n 118\n 137\n 141\n Other labs: PT / PTT / INR:15.0/90.1/1.3, ALT / AST:, Alk-Phos / T\n bili:83/0.3, Amylase / Lipase:52/, Lactic Acid:1.6 mmol/L, Albumin:2.5\n g/dL, LDH:158 IU/L, Ca:8.2 mg/dL, Mg:1.9 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n Assessment and Plan: 35M with CP, peritonitis and ascites, chronic\n pancreatitis, most likely ascites and peritonitis SMV occlusion\n Neurologic:\n - Cerebral palsy with mental status at baseline.\n - Pre-existing seizure disorder -> Keppra 20 .\n - Pain seems to be well controlled. and pt seems to be at\n baseline mental status\n Cardiovascular:\n - HR and BP holding stable\n Pulmonary:\n - Respiratory failure: now extubated, requiring aggresive pulm\n toilet, chest PT and suctioning due to secretion\n - Diuresis since traits of CHF on CXR and tenuous respiratory\n status.\n Gastrointestinal / Abdomen:\n - SMV and partial vein thrombosis. Both seems to be chronic\n processes considering the large amount of collaterals. However, there\n is massive venous engorgement and bowel edema. Started on heparin drip\n with aPTT at goal..\n o On empiric ABX for peritonitis.\n o Diarrhea: likely due to lack of absorption d/t bowel wall\n edema.\n - Chronic inactive pancreatitis.\n - Stable parenchymal changes\n - Clamp NG tube.\n Nutrition:\n o TPN; no refeeding syndrome.\n o Unclear status of PO/TF intake\n Renal:\n o Being diuresed with the goal of -0.5-1L/24hrs.\n o Hypokalemia\n Hematology:\n - On systemic anticoagulation with the goal og aPTT of\n 60-80sec. Start on coumadin.\n - Stable anemia now.\n Endocrine:\n - RISS with adequate BG control.\n Infectious Disease:\n - Abdominal peritonitis - on empiric coverage with vanc/flagyl/zosyn.\n DC flagyl .Keep vancomycin and zosyn for four more days.\n --Awaiting cultures to identify causitive organism -> so far negative.\n -- WBC 9.4, afebrile\n Consults: General surgery, Vascular surgery\n ICU Care\n Nutrition:\n TPN without Lipids - 04:00 PM 45 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 03:15 AM\n 20 Gauge - 12:17 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin drip)\n Stress ulcer: PPI\n VAP bundle: (+)\n Communication\n Code status: FULL\n Disposition: SICU\n Total time spent: 33 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2115-02-18 00:00:00.000",
"description": "Intensivist Note",
"row_id": 625016,
"text": "SICU\n HPI:\n 35M with Cerebral palsy,presented with abdominal pain and distention to\n an OSH this am where CT scan was performed and reported as diffused\n bowel edema,gastric varices, ascites, pancreatic cyst. No association\n with nausea,vomitting, diarrhea, hematemesis, hematochezia, no GU\n symptoms. No jaundice , no fevers. No weight loss, no NSAIDs, ASA use.\n Pt recieved Unasyn at the OSH and was transferred to \n Chief complaint:\n respiratory distress, peritonitis, SMV occlusion\n PMHx:\n Cerebral Palsy (Patient non verbal baseline), Seizure d/o, Chronic\n anemia (transfusion x2)\n Current medications:\n Acetaminophen 4. Albuterol 0.083% Neb Soln 5. Calcium Gluconate 6.\n Dextrose 50% 7. Fentanyl Citrate\n 8. Furosemide 9. Furosemide 10. Glucagon 11. Heparin 12. Heparin Flush\n (10 units/ml) 13. 14. Insulin\n 15. LeVETiracetam 16. Magnesium Sulfate 17. MetRONIDAZOLE (FLagyl) 18.\n Midazolam 19. Pantoprazole\n 20. Piperacillin-Tazobactam\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 06:03 PM\n EXTUBATION - At 06:19 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:00 PM\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Metronidazole - 03:53 AM\n Infusions:\n Heparin Sodium - 700 units/hour\n Other ICU medications:\n Furosemide (Lasix) - 09:44 PM\n Fentanyl - 02:20 AM\n Other medications:\n Flowsheet Data as of 04:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.7\nC (99.9\n T current: 36.9\nC (98.5\n HR: 95 (75 - 110) bpm\n BP: 80/56(73) {80/52(62) - 125/81(90)} mmHg\n RR: 26 (9 - 48) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 38 kg (admission): 32.3 kg\n Height: 55 Inch\n CVP: 185 (1 - 238) mmHg\n Total In:\n 2,607 mL\n 431 mL\n PO:\n Tube feeding:\n IV Fluid:\n 1,471 mL\n 244 mL\n Blood products:\n Total out:\n 2,816 mL\n 1,380 mL\n Urine:\n 1,816 mL\n 730 mL\n NG:\n 250 mL\n Stool:\n Drains:\n Balance:\n -209 mL\n -949 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, Aerosol-cool\n Ventilator mode: CPAP/PSV\n Vt (Set): 350 (350 - 350) mL\n Vt (Spontaneous): 321 (293 - 555) mL\n PS : 5 cmH2O\n RR (Set): 10\n RR (Spontaneous): 17\n PEEP: 0 cmH2O\n FiO2: 70%\n RSBI: 93\n PIP: 16 cmH2O\n SPO2: 98%\n ABG: ///29/\n Ve: 5.4 L/min\n Physical Examination\n General Appearance: No acute distress\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric)\n Abdominal: No(t) Soft, softer than previously\n Neurologic: (Responds to: Tactile stimuli), No(t) Moves all\n extremities, (RUE: No(t) Weakness), (LUE: No(t) Weakness), (RLE: No\n movement), (LLE: No movement)\n Labs / Radiology\n 107 K/uL\n 10.0 g/dL\n 141 mg/dL\n 0.4 mg/dL\n 29 mEq/L\n 3.1 mEq/L\n 12 mg/dL\n 104 mEq/L\n 138 mEq/L\n 29.2 %\n 9.4 K/uL\n [image002.jpg]\n 03:35 AM\n 12:11 PM\n 04:42 PM\n 03:27 AM\n 02:48 AM\n 06:09 AM\n 03:11 PM\n 04:05 AM\n 02:40 PM\n 02:29 AM\n WBC\n 9.3\n 9.3\n 10.6\n 8.7\n 9.4\n Hct\n 28.3\n 27.1\n 26.2\n 29.1\n 31.6\n 32.9\n 30.9\n 29.2\n Plt\n 39\n 107\n Creatinine\n 0.4\n 0.5\n 0.5\n 0.4\n 0.5\n 0.5\n 0.5\n 0.4\n TCO2\n 25\n Glucose\n 112\n 90\n 74\n 134\n 80\n 118\n 137\n 141\n Other labs: PT / PTT / INR:15.0/90.1/1.3, ALT / AST:, Alk-Phos / T\n bili:83/0.3, Amylase / Lipase:52/, Lactic Acid:1.6 mmol/L, Albumin:2.5\n g/dL, LDH:158 IU/L, Ca:8.2 mg/dL, Mg:1.9 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n Assessment and Plan: 35M with CP, peritonitis and ascites, chronic\n pancreatitis, most likely ascites and peritonitis SMV occlusion\n Neurologic:\n - Cerebral palsy with mental status at baseline.\n - Pre-existing seizure disorder -> Keppra 20 .\n - Pain seems to be well controlled. and pt seems to be at\n baseline mental status\n Cardiovascular:\n - HR and BP holding stable\n Pulmonary:\n - Respiratory failure: now extubated, requiring aggresive pulm\n toilet, chest PT and suctioning due to secretion\n - Diuresis since traits of CHF on CXR and tenuous respiratory\n status.\n Gastrointestinal / Abdomen:\n - SMV and partial vein thrombosis. Both seems to be chronic\n processes considering the large amount of collaterals. However, there\n is massive venous engorgement and bowel edema. Started on heparin drip\n with aPTT at goal..\n o On empiric ABX for peritonitis.\n o Diarrhea: likely due to lack of absorption d/t bowel wall\n edema.\n - Chronic inactive pancreatitis.\n - Stable parenchymal liver changes\n - Clamp NG tube.\n Nutrition:\n o TPN; no refeeding syndrome.\n o Unclear status of PO/TF intake\n Renal:\n o Being diuresed with the goal of -0.5-1L/24hrs.\n o Hypokalemia\n Hematology:\n - On systemic anticoagulation with the goal og aPTT of\n 60-80sec. Start on coumadin.\n - Stable anemia now.\n Endocrine:\n - RISS with adequate BG control.\n Infectious Disease:\n - Abdominal peritonitis - on empiric coverage with vanc/flagyl/zosyn.\n DC flagyl .Keep vancomycin and zosyn for four more days.\n --Awaiting cultures to identify causitive organism -> so far negative.\n -- WBC 9.4, afebrile\n Consults: General surgery, Vascular surgery\n ICU Care\n Nutrition:\n TPN without Lipids - 04:00 PM 45 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 03:15 AM\n 20 Gauge - 12:17 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin drip)\n Stress ulcer: PPI\n VAP bundle:\n Communication\n Code status: FULL\n Disposition: SICU\n Total time spent: 33 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2115-02-19 00:00:00.000",
"description": "Intensivist Note",
"row_id": 625175,
"text": "SICU\n HPI: 35M with Cerebral palsy, presented with abdominal pain and\n distention to an OSH this am where CT scan was performed and reported\n as diffused bowel edema,gastric varices, ascites, pancreatic cyst. No\n association with nausea,vomitting, diarrhea, hematemesis, hematochezia,\n no GU symptoms. No jaundice , no fevers. No weight loss, no NSAIDs, ASA\n use. Pt recieved Unasyn at the OSH and was transferred to .\n Chief complaint: respiratory distress, peritonitis, SMV occlusion\n PMHx: Cerebral Palsy (Patient non verbal baseline), Seizure d/o,\n Chronic anemia (transfusion x2)\n .\n PSH:\n Lap cholecystectomy\n Pancreatic cyst drainage (last year, )\n Current medications:\n . Acetaminophen 4. Albuterol 0.083% Neb Soln 5. Calcium Gluconate 6.\n Chlorhexidine Gluconate 0.12% Oral Rinse\n 7. Dextrose 50% 8. Fentanyl Citrate 9. Furosemide 10. Furosemide 11.\n Glucagon 12. Heparin 13. Heparin Flush (10 units/ml)\n 14. 15. Insulin 16. LeVETiracetam 17. Magnesium Sulfate 18. Midazolam\n 19. Pantoprazole 20. Phenylephrine\n 21. Piperacillin-Tazobactam 22. Potassium Chloride 23. Propofol 24.\n Sodium Chloride 0.9% Flush 25. Vancomycin\n 26. Warfarin\n 24 Hour Events:\n INTUBATION - At 10:31 PM\n INVASIVE VENTILATION - START 10:32 PM\n FEVER - 101.6\nF - 12:00 AM\n : Lasix given again, reintubated overnight for inability to clear\n secretions, desaturation, tachypnea. Tm 101.6, pan-cultured\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 03:53 AM\n Vancomycin - 08:34 PM\n Piperacillin/Tazobactam (Zosyn) - 12:30 AM\n Infusions:\n Heparin Sodium - 950 units/hour\n Propofol - 15 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:35 PM\n Furosemide (Lasix) - 09:53 PM\n Fentanyl - 02:00 AM\n Other medications:\n Flowsheet Data as of 04:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.7\nC (101.6\n T current: 38.7\nC (101.6\n HR: 103 (81 - 113) bpm\n BP: 80/59(64) {74/51(58) - 104/80(84)} mmHg\n RR: 27 (17 - 40) insp/min\n SPO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 38 kg (admission): 32.3 kg\n Height: 55 Inch\n CVP: 7 (2 - 183) mmHg\n Total In:\n 2,434 mL\n 374 mL\n PO:\n Tube feeding:\n IV Fluid:\n 1,538 mL\n 155 mL\n Blood products:\n Total out:\n 4,535 mL\n 640 mL\n Urine:\n 2,925 mL\n 640 mL\n NG:\n 710 mL\n Stool:\n Drains:\n Balance:\n -2,101 mL\n -266 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 300 (300 - 480) mL\n RR (Set): 26\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 60%\n RSBI Deferred: Agitated\n PIP: 20 cmH2O\n SPO2: 100%\n ABG: 7.50/45/74/34/9\n Ve: 7.5 L/min\n PaO2 / FiO2: 123\n Physical Examination\n General Appearance: No acute distress, Cachectic\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric)\n Abdominal: Distended, Tender:\n Left Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present),\n (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present),\n (Pulse - Posterior tibial: Present)\n Skin: No(t) Rash:\n Neurologic: (Responds to: Noxious stimuli), Moves all extremities,\n Sedated\n Labs / Radiology\n 110 K/uL\n 9.7 g/dL\n 104 mg/dL\n 0.4 mg/dL\n 34 mEq/L\n 3.7 mEq/L\n 9 mg/dL\n 99 mEq/L\n 136 mEq/L\n 28.6 %\n 10.1 K/uL\n [image002.jpg]\n 03:27 AM\n 02:48 AM\n 06:09 AM\n 03:11 PM\n 04:05 AM\n 02:40 PM\n 02:29 AM\n 04:00 PM\n 01:32 AM\n 03:31 AM\n WBC\n 9.3\n 10.6\n 8.7\n 9.4\n 10.1\n Hct\n 26.2\n 29.1\n 31.6\n 32.9\n 30.9\n 29.2\n 28.6\n Plt\n 177\n 179\n 139\n 107\n 110\n Creatinine\n 0.5\n 0.4\n 0.5\n 0.5\n 0.5\n 0.4\n 0.4\n TCO2\n 25\n 36\n Glucose\n 74\n 134\n 80\n 118\n 137\n 141\n 104\n Other labs: PT / PTT / INR:15.5/51.1/1.4, ALT / AST:, Alk-Phos / T\n bili:83/0.3, Amylase / Lipase:52/, Lactic Acid:1.6 mmol/L, Albumin:2.5\n g/dL, LDH:158 IU/L, Ca:8.2 mg/dL, Mg:2.3 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), .H/O ABDOMINAL PAIN\n (INCLUDING ABDOMINAL TENDERNESS)\n Assessment and Plan: ASSESSMENT: 35M with CP, chronic pancreatitis,\n transudative ascites and peritonitis likely SMV occlusion, now on\n hep gtt, intubated due to secretions\n Neurologic:\n - Pre-existing seizure disorder -> Keppra 20 .\n - Pain seems to be well controlled.\n - Baseline mental status\n -\n Cardiovascular:\n - HR and BP holding stable\n Pulmonary:\n - Respiratory failure: now reintubated, requiring aggresive pulmonary\n toilet, chest PT and suctioning due to secretions, probable pneumonia\n - Lasix for pulmonary edema with good effect.\n Gastrointestinal / Abdomen:\n - On empiric ABX for peritonitis. Work up for ascities on-going. F/U Cx\n --CTA revealed SMV occlusion, venous stasis--->On hep gtt\n -- Diarrhea: likely due to lack of absorption d/t bowel wall edema,\n Flagyl d/c'd, C diff negative\n -- Pantoprazole for GI proph\n Nutrition:\n - TPN\n Renal:\n --stable urine output, lasix \n --Hypokalemia, monitoring and getting repleted\n Hematology:\n - Slowly worsening anemia secondary to dilution, inflammation, and\n pre-existing chronic anemia.\n - Elevated INR & PTT secondary to the nutritional depletion.\n -S/P Transfusion 2UPRBC for Hct of 26 on , Stable 29-31 on \n On hep gtt for SMV occlusion (goal 60-80)\n -coumadin started on (5)\n Endocrine:\n - RISS with adequate BG control.\n ID:\n - Abdominal peritonitis - on empiric coverage with vanc/zosyn\n - F/u cultures\n T/L/D: PIV, Foley, Left sub clav ()\n Wounds: none\n Imaging: CTA abdomen\n Fluids: KVO\n Consults: General surgery, GI\n Billing Diagnosis: PERITONITIS, Respitratory failure\n Prophylaxis:\n DVT: Boots, hep gtt\n Stress ulcer: PPI\n VAP bundle: +\n Comments: Consent done\n Communication:\n Code status:FULL\n Disposition:SICU\n Time spent: 35\n Billing Diagnosis:\n"
},
{
"category": "Physician ",
"chartdate": "2115-02-19 00:00:00.000",
"description": "Intensivist Note",
"row_id": 625178,
"text": "SICU\n HPI: 35M with Cerebral palsy, presented with abdominal pain and\n distention to an OSH this am where CT scan was performed and reported\n as diffused bowel edema,gastric varices, ascites, pancreatic cyst. No\n association with nausea,vomitting, diarrhea, hematemesis, hematochezia,\n no GU symptoms. No jaundice , no fevers. No weight loss, no NSAIDs, ASA\n use. Pt recieved Unasyn at the OSH and was transferred to .\n Chief complaint: respiratory distress, peritonitis, SMV occlusion\n PMHx: Cerebral Palsy (Patient non verbal baseline), Seizure d/o,\n Chronic anemia (transfusion x2)\n .\n PSH:\n Lap cholecystectomy\n Pancreatic cyst drainage (last year, )\n Current medications:\n . Acetaminophen 4. Albuterol 0.083% Neb Soln 5. Calcium Gluconate 6.\n Chlorhexidine Gluconate 0.12% Oral Rinse\n 7. Dextrose 50% 8. Fentanyl Citrate 9. Furosemide 10. Furosemide 11.\n Glucagon 12. Heparin 13. Heparin Flush (10 units/ml)\n 14. 15. Insulin 16. LeVETiracetam 17. Magnesium Sulfate 18. Midazolam\n 19. Pantoprazole 20. Phenylephrine\n 21. Piperacillin-Tazobactam 22. Potassium Chloride 23. Propofol 24.\n Sodium Chloride 0.9% Flush 25. Vancomycin\n 26. Warfarin\n 24 Hour Events:\n INTUBATION - At 10:31 PM\n INVASIVE VENTILATION - START 10:32 PM\n FEVER - 101.6\nF - 12:00 AM\n : Lasix given again, reintubated overnight for inability to clear\n secretions, desaturation, tachypnea. Tm 101.6, pan-cultured\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 03:53 AM\n Vancomycin - 08:34 PM\n Piperacillin/Tazobactam (Zosyn) - 12:30 AM\n Infusions:\n Heparin Sodium - 950 units/hour\n Propofol - 15 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:35 PM\n Furosemide (Lasix) - 09:53 PM\n Fentanyl - 02:00 AM\n Other medications:\n Flowsheet Data as of 04:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.7\nC (101.6\n T current: 38.7\nC (101.6\n HR: 103 (81 - 113) bpm\n BP: 80/59(64) {74/51(58) - 104/80(84)} mmHg\n RR: 27 (17 - 40) insp/min\n SPO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 38 kg (admission): 32.3 kg\n Height: 55 Inch\n CVP: 7 (2 - 183) mmHg\n Total In:\n 2,434 mL\n 374 mL\n PO:\n Tube feeding:\n IV Fluid:\n 1,538 mL\n 155 mL\n Blood products:\n Total out:\n 4,535 mL\n 640 mL\n Urine:\n 2,925 mL\n 640 mL\n NG:\n 710 mL\n Stool:\n Drains:\n Balance:\n -2,101 mL\n -266 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 300 (300 - 480) mL\n RR (Set): 26\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 60%\n RSBI Deferred: Agitated\n PIP: 20 cmH2O\n SPO2: 100%\n ABG: 7.50/45/74/34/9\n Ve: 7.5 L/min\n PaO2 / FiO2: 123\n Physical Examination\n General Appearance: No acute distress, Cachectic\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric)\n Abdominal: Distended, Tender:\n Left Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present),\n (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present),\n (Pulse - Posterior tibial: Present)\n Skin: No(t) Rash:\n Neurologic: (Responds to: Noxious stimuli), Moves all extremities,\n Sedated\n Labs / Radiology\n 110 K/uL\n 9.7 g/dL\n 104 mg/dL\n 0.4 mg/dL\n 34 mEq/L\n 3.7 mEq/L\n 9 mg/dL\n 99 mEq/L\n 136 mEq/L\n 28.6 %\n 10.1 K/uL\n [image002.jpg]\n 03:27 AM\n 02:48 AM\n 06:09 AM\n 03:11 PM\n 04:05 AM\n 02:40 PM\n 02:29 AM\n 04:00 PM\n 01:32 AM\n 03:31 AM\n WBC\n 9.3\n 10.6\n 8.7\n 9.4\n 10.1\n Hct\n 26.2\n 29.1\n 31.6\n 32.9\n 30.9\n 29.2\n 28.6\n Plt\n 177\n 179\n 139\n 107\n 110\n Creatinine\n 0.5\n 0.4\n 0.5\n 0.5\n 0.5\n 0.4\n 0.4\n TCO2\n 25\n 36\n Glucose\n 74\n 134\n 80\n 118\n 137\n 141\n 104\n Other labs: PT / PTT / INR:15.5/51.1/1.4, ALT / AST:, Alk-Phos / T\n bili:83/0.3, Amylase / Lipase:52/, Lactic Acid:1.6 mmol/L, Albumin:2.5\n g/dL, LDH:158 IU/L, Ca:8.2 mg/dL, Mg:2.3 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), .H/O ABDOMINAL PAIN\n (INCLUDING ABDOMINAL TENDERNESS)\n Assessment and Plan: 35M with CP, chronic pancreatitis, transudative\n ascites and peritonitis likely SMV occlusion, now on hep gtt,\n intubated due to evolving pneumonia\n Neurologic:\n - Pre-existing seizure disorder -> Keppra 20 .\n - Pain seems to be well controlled.\n - Baseline mental status prior to intubation\n - - Will change from propofol to midazolam for sedation.\n Cardiovascular:\n - HR and BP holding stable, mild hypotension responsive to decrease in\n propofol\n - Will obtain TTE if continue hypotension and lactic acidosis.\n Pulmonary:\n - Respiratory failure: now reintubated, requiring aggresive pulmonary\n toilet, chest PT and suctioning due to secretions, probable pneumonia\n --Will change ventilator setting to SIMV\n --Will send sputum/mini BAL\n --will place a-line for monitoring blood gases\n - Lasix for pulmonary edema with good effect on prior to\n intubation; will monitor for pulmonary edema\n - Amikacin added after cultures obtained for HAP with high suscpicion\n for drug resistance given lengthy hospital stay.\n Gastrointestinal / Abdomen:\n - On empiric ABX for peritonitis. Work up for ascities on-going. F/U Cx\n --CTA revealed SMV occlusion, venous stasis--->On hep gtt\n -- Diarrhea: likely due to lack of absorption d/t bowel wall edema,\n Flagyl d/c'd , C diff negative\n -- Pantoprazole for GI proph\n Nutrition:\n - TPN\n Renal:\n --stable urine output and creatinine, lasix x2 doses (10mg)\n --Hypokalemia, monitoring and getting repleted\n --KVO\nd, but receiving about 70cc/h with additional medications. Will\n continue current care and hold off on additional Lasix given\n hypotension overnight. Will monitor closely for signs of hypovolemia.\n Will obtain lactate.\n --multifactorial metabolic alkalosis.\n Hematology:\n - Stable anemia secondary to dilution, inflammation, and pre-existing\n chronic anemia.\n - Elevated INR & PTT secondary to the nutritional depletion.\n On hep gtt for SMV occlusion (goal 60-80)\n -coumadin started on (5)\n Endocrine:\n - RISS with adequate BG control.\n ID:\n --HAP, will add Amikacin\n --Abdominal peritonitis - on empiric coverage with vanc/zosyn\n --F/u cultures\n T/L/D: PIV, Foley, Left sub clav ()\n Wounds: none\n Imaging: CXR\n Fluids: KVO\n Consults: General surgery, GI\n Billing Diagnosis: PERITONITIS, Respitratory failure\n Prophylaxis:\n DVT: Boots, hep gtt\n Stress ulcer: PPI\n VAP bundle: +\n Comments: Consent done\n Communication:\n Code status:FULL\n Disposition:SICU\n Time spent: 35\n Billing Diagnosis:\n"
},
{
"category": "Consult",
"chartdate": "2115-02-14 00:00:00.000",
"description": "GI Consult Progress Note",
"row_id": 624471,
"text": "TITLE: GI Consult Progress Note\n Consult requested by: Dr \n Chief Complaint: abdominal pain, fever, ascites\n 24 Hour Events:\n - transfer to SICU\n - Intubation for respiratory failure.\n - febrile to 101 while on antibiotics\n - diagnostic tap was performed results see:\n Ascites : WBC: (P 55% L 0 M 17), Mesothe: 2 Macroph: 26\n Lipase 216, Amylase: 141, Albumin: <1.0, Glu 88, protein 1.2, LDH 116\n SAAG = or > 1.1; AFTP 1.2; cultures are pending, thus far no growth.\n MULTI LUMEN - START 03:15 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 03:00 AM\n Vancomycin - 08:30 AM\n Piperacillin/Tazobactam (Zosyn) - 08:30 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:30 AM\n Famotidine (Pepcid) - 09:29 AM\n Fentanyl - 10:00 AM\n Other medications:\n Changes to medical and family history:\n none\n Review of systems is unchanged from admission except as noted below\n Review of systems: none\n Flowsheet Data as of 10:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.4\nC (101.1\n Tcurrent: 38.4\nC (101.1\n HR: 113 (107 - 116) bpm\n BP: 93/71(76) {80/45(64) - 111/76(80)} mmHg\n RR: 23 (19 - 33) insp/min\n SpO2: 98%\n Heart rhythm:: ST (Sinus Tachycardia)\n Wgt (current): 35.4 kg (admission): 71 kg\n CVP: 308 (8 - 308)mmHg\n Mixed Venous O2% Sat: 73 - 73\n Total In:\n 7,165 mL\n PO:\n TF:\n IVF:\n 1,665 mL\n Blood products:\n Total out:\n 0 mL\n 682 mL\n Urine:\n 232 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 6,483 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PPS\n Vt (Set): 0 (0 - 400) mL\n PS : 12 cmH2O\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 20 cmH2O\n Plateau: 16 cmH2O\n SpO2: 98%\n ABG: ///24/\n Ve: 8 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 226 K/uL\n 9.1 g/dL\n 112 mg/dL\n 0.4 mg/dL\n 24 mEq/L\n 3.1 mEq/L\n 13 mg/dL\n 116 mEq/L\n 144 mEq/L\n 28.3 %\n 9.3 K/uL\n [image002.jpg]\n 03:35 AM\n WBC\n 9.3\n Hct\n 28.3\n Plt\n 226\n Cr\n 0.4\n Glucose\n 112\n Other labs: PT / PTT / INR:16.7/89.2/1.5, ALT / AST:, Alk Phos / T\n Bili:103/0.2, Amylase / Lipase:52/, Lactic Acid:1.2 mmol/L, Ca++:6.7\n mg/dL, Mg++:2.1 mg/dL, PO4:1.5 mg/dL\n Assessment and Plan\n 35 yom with CP, non-verbal, p/w abdominal pain, fever, on CT noted to\n have ascites and diffused bowel edema.\n 1. bowel edema/ascites: Patient was intubated for respiratory\n failure. Ascites fluid notable for SAAG =>1.1 and AFTP is 1.2\n suggestive of liver pathology. However, given frank signs of infection\n with polys greater than , patient like has secondary peritonitis\n from ischemic bowel.\n - suggest Cefepime/flagyl/vanco for abx\n - f/u ascites cultures\n - consider IV albumin 1.5g/kg today then 1g/kg on day 3\n (treatment for SBP, though patient is likely having secondary\n peritonitis from polymycrobial infection edema of bowel/ ? bowel\n perforation / ischemic bowel)\n - will perform flex-sig this PM to eval viability of the bowel\n - agree with family meeting and address goals of care\n - consider repeat tap in 72 hours if clinical improves\n - if performing therapeutic tap, would recommend IV albumin\n 25% 6-8g per Liter of fluid removed (if total volume removed is > 3L.\n .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n"
},
{
"category": "Physician ",
"chartdate": "2115-02-19 00:00:00.000",
"description": "Intensivist Note",
"row_id": 625257,
"text": "SICU\n HPI: 35M with Cerebral palsy, presented with abdominal pain and\n distention to an OSH this am where CT scan was performed and reported\n as diffused bowel edema,gastric varices, ascites, pancreatic cyst. No\n association with nausea,vomitting, diarrhea, hematemesis, hematochezia,\n no GU symptoms. No jaundice , no fevers. No weight loss, no NSAIDs, ASA\n use. Pt recieved Unasyn at the OSH and was transferred to .\n Chief complaint: respiratory distress, peritonitis, SMV occlusion\n PMHx: Cerebral Palsy (Patient non verbal baseline), Seizure d/o,\n Chronic anemia (transfusion x2)\n .\n PSH:\n Lap cholecystectomy\n Pancreatic cyst drainage (last year, )\n Current medications:\n . Acetaminophen 4. Albuterol 0.083% Neb Soln 5. Calcium Gluconate 6.\n Chlorhexidine Gluconate 0.12% Oral Rinse\n 7. Dextrose 50% 8. Fentanyl Citrate 9. Furosemide 10. Furosemide 11.\n Glucagon 12. Heparin 13. Heparin Flush (10 units/ml)\n 14. 15. Insulin 16. LeVETiracetam 17. Magnesium Sulfate 18. Midazolam\n 19. Pantoprazole 20. Phenylephrine\n 21. Piperacillin-Tazobactam 22. Potassium Chloride 23. Propofol 24.\n Sodium Chloride 0.9% Flush 25. Vancomycin\n 26. Warfarin\n 24 Hour Events:\n INTUBATION - At 10:31 PM\n INVASIVE VENTILATION - START 10:32 PM\n FEVER - 101.6\nF - 12:00 AM\n : Lasix given again, reintubated overnight for inability to clear\n secretions, desaturation, tachypnea. Tm 101.6, pan-cultured\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 03:53 AM\n Vancomycin - 08:34 PM\n Piperacillin/Tazobactam (Zosyn) - 12:30 AM\n Infusions:\n Heparin Sodium - 950 units/hour\n Propofol - 15 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:35 PM\n Furosemide (Lasix) - 09:53 PM\n Fentanyl - 02:00 AM\n Other medications:\n Flowsheet Data as of 04:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.7\nC (101.6\n T current: 38.7\nC (101.6\n HR: 103 (81 - 113) bpm\n BP: 80/59(64) {74/51(58) - 104/80(84)} mmHg\n RR: 27 (17 - 40) insp/min\n SPO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 38 kg (admission): 32.3 kg\n Height: 55 Inch\n CVP: 7 (2 - 183) mmHg\n Total In:\n 2,434 mL\n 374 mL\n PO:\n Tube feeding:\n IV Fluid:\n 1,538 mL\n 155 mL\n Blood products:\n Total out:\n 4,535 mL\n 640 mL\n Urine:\n 2,925 mL\n 640 mL\n NG:\n 710 mL\n Stool:\n Drains:\n Balance:\n -2,101 mL\n -266 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 300 (300 - 480) mL\n RR (Set): 26\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 60%\n RSBI Deferred: Agitated\n PIP: 20 cmH2O\n SPO2: 100%\n ABG: 7.50/45/74/34/9\n Ve: 7.5 L/min\n PaO2 / FiO2: 123\n Physical Examination\n General Appearance: No acute distress, Cachectic\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric)\n Abdominal: Distended, Tender:\n Left Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present),\n (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present),\n (Pulse - Posterior tibial: Present)\n Skin: No(t) Rash:\n Neurologic: (Responds to: Noxious stimuli), Moves all extremities,\n Sedated\n Labs / Radiology\n 110 K/uL\n 9.7 g/dL\n 104 mg/dL\n 0.4 mg/dL\n 34 mEq/L\n 3.7 mEq/L\n 9 mg/dL\n 99 mEq/L\n 136 mEq/L\n 28.6 %\n 10.1 K/uL\n [image002.jpg]\n 03:27 AM\n 02:48 AM\n 06:09 AM\n 03:11 PM\n 04:05 AM\n 02:40 PM\n 02:29 AM\n 04:00 PM\n 01:32 AM\n 03:31 AM\n WBC\n 9.3\n 10.6\n 8.7\n 9.4\n 10.1\n Hct\n 26.2\n 29.1\n 31.6\n 32.9\n 30.9\n 29.2\n 28.6\n Plt\n 177\n 179\n 139\n 107\n 110\n Creatinine\n 0.5\n 0.4\n 0.5\n 0.5\n 0.5\n 0.4\n 0.4\n TCO2\n 25\n 36\n Glucose\n 74\n 134\n 80\n 118\n 137\n 141\n 104\n Other labs: PT / PTT / INR:15.5/51.1/1.4, ALT / AST:, Alk-Phos / T\n bili:83/0.3, Amylase / Lipase:52/, Lactic Acid:1.6 mmol/L, Albumin:2.5\n g/dL, LDH:158 IU/L, Ca:8.2 mg/dL, Mg:2.3 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), .H/O ABDOMINAL PAIN\n (INCLUDING ABDOMINAL TENDERNESS)\n Assessment and Plan: 35M with CP, chronic pancreatitis, transudative\n ascites and peritonitis likely SMV occlusion, now on hep gtt,\n intubated due to evolving pneumonia\n Neurologic:\n - Pre-existing seizure disorder -> Keppra 20 .\n - Pain seems to be well controlled.\n - Baseline mental status prior to intubation\n - - Will change from propofol to midazolam for sedation.\n Cardiovascular:\n - HR and BP holding stable, mild hypotension responsive to decrease in\n propofol\n - Will obtain TTE if continue hypotension and lactic acidosis.\n Pulmonary:\n - Respiratory failure: now reintubated, requiring aggresive pulmonary\n toilet, chest PT and suctioning due to secretions, probable pneumonia\n --Will change ventilator setting to SIMV\n --Will send sputum/mini BAL\n --will place a-line for monitoring blood gases\n - Lasix for pulmonary edema with good effect on prior to\n intubation; will monitor for pulmonary edema\n - Amikacin added after cultures obtained for HAP with high suscpicion\n for drug resistance given lengthy hospital stay.\n Gastrointestinal / Abdomen:\n - On empiric ABX for peritonitis. Work up for ascities on-going. F/U Cx\n --CTA revealed SMV occlusion, venous stasis--->On hep gtt\n -- Diarrhea: likely due to lack of absorption d/t bowel wall edema,\n Flagyl d/c'd , C diff negative\n -- Pantoprazole for GI proph\n Nutrition:\n - TPN\n Renal:\n --stable urine output and creatinine, lasix x2 doses (10mg)\n --Hypokalemia, monitoring and getting repleted\n --KVO\nd, but receiving about 70cc/h with additional medications. Will\n continue current care and hold off on additional Lasix given\n hypotension overnight. Will monitor closely for signs of hypovolemia.\n Will obtain lactate.\n --multifactorial metabolic alkalosis.\n Hematology:\n - Stable anemia secondary to dilution, inflammation, and pre-existing\n chronic anemia.\n - Elevated INR & PTT secondary to the nutritional depletion.\n On hep gtt for SMV occlusion (goal 60-80)\n -coumadin started on (5)\n Endocrine:\n - RISS with adequate BG control.\n ID:\n --HAP, will add Amikacin\n --Abdominal peritonitis - on empiric coverage with vanc/zosyn\n --F/u cultures\n T/L/D: PIV, Foley, Left sub clav ()\n Wounds: none\n Imaging: CXR\n Fluids: KVO\n Consults: General surgery, GI\n Billing Diagnosis: PERITONITIS, Respitratory failure\n Prophylaxis:\n DVT: Boots, hep gtt\n Stress ulcer: PPI\n VAP bundle: +\n Comments: Consent done\n Communication:\n Code status:FULL\n Disposition:SICU\n Time spent: 34 minutes\n Billing Diagnosis:\n"
},
{
"category": "Physician ",
"chartdate": "2115-02-14 00:00:00.000",
"description": "Intensivist Note",
"row_id": 624433,
"text": "SICU\n HPI:\n 35 yo M with Cerebral palsy,presented with abdominal pain and\n distention to an OSH this am where CT scan was performed and reported\n as diffused bowel edema,gastric varices, ascites, pancreatic cyst. No\n association with nausea, vomitting, diarrhea, hematemesis,\n hematochezia, no GU symptoms. No jaundice , no fevers. No weight loss,\n no NSAIDs, ASA use. Pt recieved Unasyn at the OSH and was transferred\n to .\n He had a history of GI bleed in , unclear source, recieved blood\n transfusion (). Last EGD and colonscopy were done in , wnl\n according to mother. Pancreatic cyst was aspirated in 6/.\n Laprascopic cholecystectomy done in .\n Chief complaint:\n Sepsis\n PMHx:\n Cerebral Palsy,\n Seizure disorder\n Chronic anemia (transfusion x2)\n .PSH:\n Lap cholecystectomy\n Pancreatic cyst drainage (last year, )\n Current medications:\n 1. 2. 1000 mL LR 3. Albuterol 0.083% Neb Soln 4. Fentanyl Citrate 5.\n MetRONIDAZOLE (FLagyl) 6. Midazolam\n 7. Pantoprazole 8. Piperacillin-Tazobactam 9. Piperacillin-Tazobactam\n 10. Sodium Chloride 0.9% Flush\n 11. Vancomycin 12. Vancomycin\n 24 Hour Events:\n MULTI LUMEN - START 03:15 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 01:21 AM\n Metronidazole - 03:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 04:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.2\nC (98.9\n T current: 37.2\nC (98.9\n HR: 112 (107 - 115) bpm\n BP: 86/67(71) {80/45(64) - 111/76(80)} mmHg\n RR: 22 (19 - 33) insp/min\n SPO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n CVP: 19 (19 - 19) mmHg\n Mixed Venous O2% sat: 73 - 73\n Total In:\n 6,061 mL\n PO:\n Tube feeding:\n IV Fluid:\n 561 mL\n Blood products:\n Total out:\n 0 mL\n 560 mL\n Urine:\n 110 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 5,501 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 22\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 30 cmH2O\n SPO2: 98%\n ABG: ////\n Ve: 9.8 L/min\n Physical Examination\n General Appearance: Cachectic\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), Sinus tachycardia\n Respiratory / Chest: (Breath Sounds: CTA bilateral : bilteral)\n Abdominal: Distended, Tender: , +peritoneal sign. +\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Neurologic: No(t) Follows simple commands, (Responds to: Tactile\n stimuli), Moves all extremities\n Labs / Radiology\n 226 K/uL\n 9.1 g/dL\n 28.3 %\n 9.3 K/uL\n [image002.jpg]\n 03:35 AM\n WBC\n 9.3\n Hct\n 28.3\n Plt\n 226\n Other labs: Lactic Acid:1.2 mmol/L\n Assessment and Plan\n Assessment and Plan: 35 yo M with cerebral palsy, with abdominal pain\n and ascites, CT scan noted findings consistent with shock bowel/low\n flow state. No vascular occlusion. No perforation, no free air. No\n obstruction\n Neurologic:\n --Intubated and sedated PRN Midazolem\n --Patient non verbal baseline\n --Move all extremities\n --Pain controlled w/ Fentanyl PRN\n Cardiovascular:\n HD stable basline BP 80'S\n Sinus tachycardia\n Pulmonary:\n - Intubated for respiratory distress\n Gastrointestinal / Abdomen:\n --abdomenal exam c/w peritonitis, Bowel thickening, no free air\n --s/p paracenthesis: amylase 141, LDH116, WBC , RBC 1250 C/W\n peritonitis\n Nutrition: NPO\n Renal:\n --Foley, --AUOP\n --Creatinine 0.5\n Hematology:\n -- Hct 34.6\n Endocrine: RISS\n Infectious Disease:\n --Afebrile, WBC 8, paracenthesis c/ w infected ascitis\n --Continue Vancomyci/Zosyn/Flagyl\n --F/up Cx\n Lines / Tubes / Drains: ETT, Foley, PIV X2, Left Sub clav. need\n Aline\n Wounds:\n Imaging:\n Fluids: LR, 75cc/h\n Consults: General surgery\n Billing Diagnosis: (Respiratory distress: Failure), Sepsis, (Shock:\n Septic)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 22 Gauge - 12:46 AM\n Multi Lumen - 03:15 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Respiratory ",
"chartdate": "2115-02-14 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 624434,
"text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 1\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: ED\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: pt remains orally intubated on full mechanical support;\n arrived to ICU from ER, continues on A/C ventilation w/ PIP/Pplat =\n 19/16. Vt decreased for ARDSnet protocol.\n Assessment of breathing comfort: No claim of dyspnea\n Trigger work assessment: Not triggering\n Plan\n Next 24-48 hours: Utilize ARDSnet protocol\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n"
},
{
"category": "Nursing",
"chartdate": "2115-02-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 624449,
"text": "35 year old male patient with Hx of Cerebral Palsy, seizure disorder,\n and chronic anemia presented to an OSH am with abdominal\n discomfort and distension. CT scan showing diffuse bowel edema,\n gastric varices, ascites, pancreatic cyst. Transferred to for\n further work up. Consulted by surgery, given 51/2 liters of fluid in\n the ED, intubated in the ED due to O2 Sats dropping wth no clear\n etiology.\n .H/O abdominal pain (including abdominal tenderness)\n Assessment:\n Patient is non verbal at baseline, does not walk.\n Intubated, coughing, LS coarse at times.\n Abdomen firm distended\n No bowel sounds\n NGT with scant bilious drainage in tubing.\n Foley with low urine output\n Tachycardic\n Action:\n TLCL placed\n Chest x-ray done\n TLCL pulled back slightly post x-ray\n IV ABX started\n Electrolytes treated\n Suctioned for thick white sputum\n Repositioned frequently due to cachectic appearance and many\n areas\n ARDS Net protocol for ventilator settings as his chest x-ray\n is concerning.\n Fentanyl for pain control x2\n Response:\n Does not appear to be in worsening pain\n Currently ~ 6 liter positive fluid balance\n CVP ~10\n Lactic acid 1.2\n WBC 9.3\n Plan:\n Continue to monitor\n ? aline if possible, radial arteries ultrasound showed\n vessel too small to cannulate.\n Parents with patient. Continue patient and family support.\n"
},
{
"category": "Nutrition",
"chartdate": "2115-02-15 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 624609,
"text": "Subjective\n spoke to mother, patient is a poor eater, usually eats meals, likes\n Ensure plus and pudding. Weight been stable for years at 70 pounds.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 140 cm\n 32.3 kg\n 36.4 kg ( 12:00 AM)\n Up due to fluid\n 16.5\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 43.7 kg\n 74%\n ~70lb(32kg)\n 100%\n Diagnosis: ABDOMINAL PAIN\n PMHx:\n Cerebral Palsy,\n Seizure disorder\n Chronic anemia (transfusion x2)\n Lap cholecystectomy\n Pancreatic cyst drainage (last year, )\n Food allergies and intolerances: none\n Pertinent medications: IV Fluid, ABx, RISS, others noted\n Labs:\n Value\n Date\n Glucose\n 74 mg/dL\n 03:27 AM\n Glucose Finger Stick\n 95\n 10:00 AM\n BUN\n 13 mg/dL\n 03:27 AM\n Creatinine\n 0.5 mg/dL\n 03:27 AM\n Sodium\n 144 mEq/L\n 03:27 AM\n Potassium\n 3.3 mEq/L\n 03:27 AM\n Chloride\n 115 mEq/L\n 03:27 AM\n TCO2\n 25 mEq/L\n 03:27 AM\n PO2 (venous)\n 42 mm Hg\n 08:08 AM\n PCO2 (venous)\n 42 mm Hg\n 08:08 AM\n pH (venous)\n 7.34 units\n 08:08 AM\n pH (urine)\n 5.0 units\n 04:42 PM\n CO2 (Calc) venous\n 24 mEq/L\n 08:08 AM\n Albumin\n 2.1 g/dL\n 04:42 PM\n Calcium non-ionized\n 7.7 mg/dL\n 03:27 AM\n Phosphorus\n 2.2 mg/dL\n 03:27 AM\n Ionized Calcium\n 1.08 mmol/L\n 03:51 AM\n Magnesium\n 2.2 mg/dL\n 03:27 AM\n ALT\n 12 IU/L\n 04:42 PM\n Alkaline Phosphate\n 91 IU/L\n 04:42 PM\n AST\n 18 IU/L\n 04:42 PM\n Amylase\n 52 IU/L\n 03:35 AM\n Total Bilirubin\n 0.1 mg/dL\n 04:42 PM\n Phenytoin (Dilantin)\n 4.9 ug/mL\n 03:27 AM\n WBC\n 9.3 K/uL\n 03:27 AM\n Hgb\n 8.2 g/dL\n 03:27 AM\n Hematocrit\n 26.2 %\n 03:27 AM\n Current diet order / nutrition support: Day /Starter TPN (providing\n 800 Kcal) For Date: \n GI:\n Assessment of Nutritional Status\n Malnourished\n Patient at risk due to: chronic poor po intake, NPO, chronic illness,\n low % body wt\n Estimated Nutritional Needs\n Calories: (BEE x or / 30-40 cal/kg)\n Protein: 48-58 (1.5-1.8 g/kg)\n Fluid: per team\n Calculations based on: Admit weight\n Estimation of previous intake: Inadequate\n Estimation of current intake: Inadequate\n Specifics:\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement:\n TPN recommendations:\n Check chemistry 10 panel daily\n Start regular insulin sliding scale if serum glucose greater\n than 150 mg/dL\n Decrease IV Fluid once TPN starts\n Other: \n Comments:\n 35 year old male with Cerebral palsy, presented with abdominal pain and\n distention to outside hospital on where CT scan was performed and\n reported as diffused bowel edema, gastric varices, ascites, pancreatic\n cyst. Patient recieved Unasyn at the transferred to for continue\n care.\n"
},
{
"category": "Nutrition",
"chartdate": "2115-02-15 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 624613,
"text": "Subjective\n Spoke to mother, patient is a poor eater, usually eats meals, likes\n Ensure plus and pudding. Weight been stable for years at 70 pounds.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 140 cm\n 32.3 kg\n 36.4 kg ( 12:00 AM)\n Up due to fluid\n 16.5\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 43.7 kg\n 74%\n ~70lb(32kg)\n 100%\n Diagnosis: ABDOMINAL PAIN\n PMHx:\n Cerebral Palsy,\n Seizure disorder\n Chronic anemia (transfusion x2)\n Lap cholecystectomy\n Pancreatic cyst drainage (last year, )\n Food allergies and intolerances: none\n Pertinent medications: IV Fluid, ABx, RISS, others noted\n Labs:\n Value\n Date\n Glucose\n 74 mg/dL\n 03:27 AM\n Glucose Finger Stick\n 95\n 10:00 AM\n BUN\n 13 mg/dL\n 03:27 AM\n Creatinine\n 0.5 mg/dL\n 03:27 AM\n Sodium\n 144 mEq/L\n 03:27 AM\n Potassium\n 3.3 mEq/L\n 03:27 AM\n Chloride\n 115 mEq/L\n 03:27 AM\n TCO2\n 25 mEq/L\n 03:27 AM\n PO2 (venous)\n 42 mm Hg\n 08:08 AM\n PCO2 (venous)\n 42 mm Hg\n 08:08 AM\n pH (venous)\n 7.34 units\n 08:08 AM\n pH (urine)\n 5.0 units\n 04:42 PM\n CO2 (Calc) venous\n 24 mEq/L\n 08:08 AM\n Albumin\n 2.1 g/dL\n 04:42 PM\n Calcium non-ionized\n 7.7 mg/dL\n 03:27 AM\n Phosphorus\n 2.2 mg/dL\n 03:27 AM\n Ionized Calcium\n 1.08 mmol/L\n 03:51 AM\n Magnesium\n 2.2 mg/dL\n 03:27 AM\n ALT\n 12 IU/L\n 04:42 PM\n Alkaline Phosphate\n 91 IU/L\n 04:42 PM\n AST\n 18 IU/L\n 04:42 PM\n Amylase\n 52 IU/L\n 03:35 AM\n Total Bilirubin\n 0.1 mg/dL\n 04:42 PM\n Phenytoin (Dilantin)\n 4.9 ug/mL\n 03:27 AM\n WBC\n 9.3 K/uL\n 03:27 AM\n Hgb\n 8.2 g/dL\n 03:27 AM\n Hematocrit\n 26.2 %\n 03:27 AM\n Current diet order / nutrition support: Day /Starter TPN (providing\n 800 Kcal) For Date: \n GI: distended\n Assessment of Nutritional Status\n Malnourished\n Patient at risk due to: chronic poor po intake, NPO, low % body wt\n Estimated Nutritional Needs\n Calories: (BEE x or / 30-40 cal/kg)\n Protein: 48-58 (1.5-1.8 g/kg)\n Fluid: per team\n Calculations based on: Admit weight\n Estimation of previous intake: Inadequate\n Estimation of current intake: Inadequate\n Specifics:\n 35 year old male with cerebral palsy transferred to for continue\n care of peritonitis and possible ischemic bowel. GI and surgery\n involved regarding plan of care, etiology of current illness remains\n unclear at this time, ischemic unlikely given lactate trending down.\n Patient is malnourished per admission wt; agree with initiating TPN as\n temporary nutrition support. Noted Day 1 TPN ordered, not impropriate\n given it provides excess kcal/protein, patient at risk for high\n dextrose infusion rate.\n Medical Nutrition Therapy Plan - Recommend the Following\n Consider discontinue day 1 TPN\n Can give Premixed PPN tonight instead (1L, 50g dextrose/45g\n protein)\n If concerns about amount of Cl in Premixed PPN ( 39meq),\n then run Dextrose 5% IV Fluid instead\n Multivitamin / Mineral supplement: in TPN\n Please check trig\n Provided trig is <400 , goal TPN will be 1.1L(200g\n dextrose/50g protein/22g fat) to provide 1100kcal/day\n TPN recommendations:\n Check chemistry 10 panel daily\n Start regular insulin sliding scale if serum glucose greater\n than 150 mg/dL\n Decrease IV Fluid once TPN starts\n Above recommendation discussed with MD, MD to consider!\n Other: \n"
},
{
"category": "Respiratory ",
"chartdate": "2115-02-15 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 624614,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 43.7 None\n Ideal tidal volume: 174.8 / 262.2 / 349.6 mL/kg\n Airway\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 24 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Crackles\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Small\n Comments: sputum sample sent\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment PSV 12 peep 5 and 50%\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n"
},
{
"category": "Nursing",
"chartdate": "2115-02-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 624616,
"text": "35M with Cerebral palsy,presented with abdominal pain and distention to\n an OSH this am where CT scan was performed and reported as diffused\n bowel edema,gastric varices, ascites, pancreatic cyst. No association\n with nausea,vomitting, diarrhea, hematemesis, hematochezia, no GU\n symptoms. No jaundice , no fevers. No weight loss, no NSAIDs, ASA use.\n Pt recieved Unasyn at the OSH and was transferred to .\n .H/O abdominal pain (including abdominal tenderness)\n Assessment:\n Patient\ns belly remains firm and distended\n +bowel sounds with frequent bowel movement, all guiac negative\n Stool sent for cdif\n ON CPCP , no vent changes today\n Urine output marginal all day, dropping to 11cc @ 1700\n Blood pressur around 85-95\n Action:\n TPN on old until tomorrow\n IV fluid changed to d51/2@75\n Bladder pressure 15\n ?Angio tomorrow to evaluate bowel/liver circulation\n Family\nmom/dad aunts and uncles very supportive and at bedside\n Medicated once for pain,\n Response:\n Continues with abd. Distention\n Improving in that lactate down and wbc not increasing\n Unclear for etiology for peritonitis.\n Plan:\n NPO\n NGT to LCWS\n ?Angio in am\n Give fluid as needed\n Call with changes.\n"
},
{
"category": "Respiratory ",
"chartdate": "2115-02-14 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 624517,
"text": "TITLE:\n Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Respiratory ",
"chartdate": "2115-02-16 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 624785,
"text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 3\n Ideal body weight: 43.7 None\n Ideal tidal volume: 174.8 / 262.2 / 349.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: Outside hospital\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 24 cmH2O\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Underlying illness not resolved\n"
},
{
"category": "Nursing",
"chartdate": "2115-02-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 624956,
"text": ".H/O abdominal pain (including abdominal tenderness)\n Assessment:\n Abd distended, soft\n Hypoactive BS\n Copious green liquid stool via flexiseal\n NGT to LCWS for bilious fld\n TPN continues\n Heparin gtt at 850 units/hr restarted at 1730 on day shift\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2115-02-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 624833,
"text": "HPI: 35M with Cerebral palsy,presented with abdominal pain and\n distention to an OSH this am where CT scan was performed and reported\n as diffused bowel edema,gastric varices, ascites, pancreatic cyst. No\n association with nausea,vomitting, diarrhea, hematemesis, hematochezia,\n no GU symptoms. No jaundice , no fevers. No weight loss, no NSAIDs, ASA\n use. Pt recieved Unasyn at the OSH and was transferred to .\n He had a history of GI bleed in , unclear source, recieved\n transfusion (). Last EGD and colonoscopy were done in\n , wnl according to mother. Pancreatic cyst was aspirated in\n 6/. Laprascopic cholecystectomy done in .\n Chief complaint: respiratory distress, peritonitis, SMV occlusion\n PMHx: Cerebral Palsy (Patient non verbal baseline), Seizure d/o,\n chronic anemia (transfusion x2)\n .H/O abdominal pain (including abdominal tenderness)\n Assessment:\n Received intubated on CPAP. POX: 96-100%.\n Arouses to voice. PERRLA. MAE. Positive gag/cough.\n C/O pain.\n T-Max: 101.5. NSR, no ectopy. SBP: 80-90\ns/70\n LS: Clear throughout. Suction for small amount of thick\n white sputum.\n NGT: to CLW suction. ABD: Distended. +BSX4, soft, no\n tenderness. Flexi-seal intact with copious amounts of brown/green\n liquid stool.\n CAT scan with question of a SMV.\n Action:\n Medicated with 12.5mg IVP Fentanyl with good effect.\n 325mg Tylenol with good effect for fever.\n Conitnues on Vancomycin/Flagyl/\n LUQ paracentesis site with no hematoma/bleeding. Dressing\n CDI. . Flexi-seal remains intact. . C-Diff and O+P from still\n pending.\n Heparin drip initiated at 1150 units per hour for a SMV\n thrombosis. Concerns regarding dosing discussed with MD .\n Continues on TPN.\n Supportive care provided to patient and family.\n Response:\n ABD: Distended. +BSX4, soft, no tenderness. Flexi-seal\n intact with copious amounts of brown/green liquid stool.\n Appears to have good pain relief with Fentanyl.\n Continues on Heparin drip with no evidence of bleeding.\n Plan:\n Aggressive pulmonary hygiene.\n Pain management PRN.\n Closely follow abdominal exam.\n Continues on a Heparin drip with goal PTT between 60-100.\n"
},
{
"category": "Physician ",
"chartdate": "2115-02-17 00:00:00.000",
"description": "Intensivist Note",
"row_id": 624853,
"text": "SICU\n HPI:\n 35M with Cerebral palsy,presented with abdominal pain and distention to\n an OSH this am where CT scan was performed and reported as diffused\n bowel edema,gastric varices, ascites, pancreatic cyst. No association\n with nausea,vomitting, diarrhea, hematemesis, hematochezia, no GU\n symptoms. No jaundice , no fevers. No weight loss, no NSAIDs, ASA use.\n Pt recieved Unasyn at the OSH and was transferred to .\n He had a history of GI bleed in , unclear source, recieved\n blood transfusion (). Last EGD and colonscopy were done in\n , wnl according to mother. Pancreatic cyst was aspirated in\n 6/. Laprascopic cholecystectomy done in .\n Chief complaint:\n respiratory distress, peritonitis, SMV occlusion\n PMHx:\n Cerebral Palsy (Patient non verbal baseline), Seizure d/o, Chronic\n anemia (transfusion x2)\n Current medications:\n Acetaminophen 4. Albumin 25% (12.5g / 50mL) 5. Albuterol 0.083% Neb\n Soln 6. Calcium Gluconate\n 7. Dextrose 50% 8. Fentanyl Citrate 9. Furosemide 10. Glucagon 11.\n Heparin 12. Heparin Flush (10 units/ml)\n 13. 14. Insulin 15. LeVETiracetam 16. Magnesium Sulfate 17.\n MetRONIDAZOLE (FLagyl) 18. Midazolam\n 19. Pantoprazole 20. Piperacillin-Tazobactam 21. Potassium Chloride 22.\n Sodium Chloride 0.9% Flush\n 23. Vancomycin\n 24 Hour Events:\n PARACENTESIS - At 09:45 AM\n STOOL CULTURE - At 10:55 AM\n spec sent for cdiff and o+p.\n FEVER - 101.5\nF - 08:00 PM\n : Peritoneal fluid sent (3L tapped). 25% albumin resolved\n tachycardia. CTA w/SMV occlusion. Hypokalemia aggressively treated. Hep\n gtt started\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:00 PM\n Piperacillin/Tazobactam (Zosyn) - 12:30 AM\n Metronidazole - 04:04 AM\n Infusions:\n Heparin Sodium - 1,150 units/hour\n Other ICU medications:\n Furosemide (Lasix) - 06:21 AM\n Fentanyl - 10:15 AM\n Pantoprazole (Protonix) - 08:56 PM\n Other medications:\n Flowsheet Data as of 04:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.6\nC (101.5\n T current: 37.6\nC (99.6\n HR: 87 (70 - 107) bpm\n BP: 97/62(80) {86/62(71) - 106/87(98)} mmHg\n RR: 26 (14 - 30) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 38 kg (admission): 32.3 kg\n Height: 55 Inch\n CVP: 10 (8 - 17) mmHg\n Total In:\n 3,945 mL\n 415 mL\n PO:\n Tube feeding:\n IV Fluid:\n 2,152 mL\n 235 mL\n Blood products:\n 732 mL\n Total out:\n 5,850 mL\n 100 mL\n Urine:\n 3,050 mL\n 100 mL\n NG:\n 300 mL\n Stool:\n Drains:\n 2,500 mL\n Balance:\n -1,905 mL\n 315 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 300 (300 - 300) mL\n Vt (Spontaneous): 444 (293 - 444) mL\n PS : 15 cmH2O\n RR (Set): 22\n RR (Spontaneous): 28\n PEEP: 10 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10\n PIP: 25 cmH2O\n SPO2: 99%\n ABG: 7.41/38/84./25/0\n Ve: 11.4 L/min\n PaO2 / FiO2: 140\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: Diminished: bibasilar)\n Abdominal: Distended\n Neurologic: Follows simple commands, Moves all extremities\n Labs / Radiology\n 179 K/uL\n 9.3 g/dL\n 80 mg/dL\n 0.5 mg/dL\n 25 mEq/L\n 3.7 mEq/L\n 7 mg/dL\n 108 mEq/L\n 141 mEq/L\n 31.6 %\n 10.6 K/uL\n [image002.jpg]\n 03:35 AM\n 12:11 PM\n 04:42 PM\n 03:27 AM\n 02:48 AM\n 06:09 AM\n 03:11 PM\n WBC\n 9.3\n 9.3\n 10.6\n Hct\n 28.3\n 27.1\n 26.2\n 29.1\n 31.6\n Plt\n \n Creatinine\n 0.4\n 0.5\n 0.5\n 0.4\n 0.5\n TCO2\n 25\n Glucose\n 112\n 90\n 74\n 134\n 80\n Other labs: PT / PTT / INR:16.0/36.0/1.4, ALT / AST:, Alk-Phos / T\n bili:66/0.1, Amylase / Lipase:52/, Lactic Acid:1.6 mmol/L, Albumin:2.5\n g/dL, LDH:142 IU/L, Ca:8.3 mg/dL, Mg:1.8 mg/dL, PO4:2.2 mg/dL\n Imaging: CT abd Pelvis: Simple global ascites, 6mm aortic diam\n IVC slit diam, Diffuse small bowel dilatation with mildly thickened\n folds. Diffuse moderate edema of the colon with a thickened wall.\n Distened rectum with thickened wall and stools. 4.5 x 2.3 x 1.4 cm\n pancreatic cyst with a veritical orientation in head of pancreas.\n surgical cholecystectomy, Extensive thrombus in porta hepatis. SMV SMA\n celiac patent,chr right PV thrombosis. No perf, no free air. No\n obstruction!\n CT: SMV occlusion with diffuse bowel wall edema & thickening c/w\n congestion/venous ischemia, possible shock bowel. Venous engorgement\n throughout. Sequelae of chronic pancreatitis, possible pseudocyst.\n Diffusely abnormal hepatic parenchyma. Partially occlusive right portal\n vein thrombus. Small b/l pleural effusions, increased from the prior\n exam. Ground-glass and nodular opacities @ bases suggesting infection.\n Microbiology: Peritoneal Fluid: NG\n MRSA P\n Assessment and Plan\n .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n Assessment and Plan: 35M with CP, peritonitis and ascites, chronic\n pancreatitis, Hepatitis B, most likely ascites and peritonitis SMV\n occlusion.\n Neurologic:\n - Intubated and sedated PRN Midazolam.\n - Pre-existing seizure disorder -> Keppra 20 .\n - Pain seems to be well controlled.\n Cardiovascular: - Tachycardic secondary to volume depletion and SIRS\n response. Otherwise stable, resolved with albumin.\n Pulmonary:\n - Respiratory failure resolved on. Assess for possible extubation.\n Gastrointestinal / Abdomen:\n - On empiric ABX for peritonitis. Work up for ascities on-going.\n - CTA revealed SMV occlusion, venous stasis--->On hep gtt.\n Nutrition: TPN; electrolytes stable (no re-feeding syndrome observed)\n Renal/FeNa:\n - Hypokalemia, monitoring. Rechecking lytes.\n Hematology:\n - Slowly worsening anemia secondary to dilution, inflammation, and\n pre-existing chronic anemia.\n - S/P Transfusion 2UPRBC for Hct of 26 on , Stable 29-31 on \n - On hep gtt for SMV occlusion (goal 60-80).\n Endocrine: RISS with adequate BG\n Infectious Disease:\n - Check cultures, - Abdominal peritonits - on empiric coverage with\n vanc/Flagyl/zosyn. Still febrile.\n Lines / Tubes / Drains: PIV, Foley, Left sub clav ()\n Fluids: D5 1/2 NS 75CC/H\n Consults: General surgery, GI\n Billing Diagnosis: Other: PERITONITIS, Respitratory failure\n ICU Care\n Nutrition:\n TPN without Lipids - 04:07 PM 41. mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 03:15 AM\n 20 Gauge - 12:17 PM\n Prophylaxis:\n DVT: Boots (Systemic anticoagulation: Heparin drip)\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2115-02-17 00:00:00.000",
"description": "Intensivist Note",
"row_id": 624857,
"text": "SICU\n HPI:\n 35M with Cerebral palsy,presented with abdominal pain and distention to\n an OSH this am where CT scan was performed and reported as diffused\n bowel edema,gastric varices, ascites, pancreatic cyst. No association\n with nausea,vomitting, diarrhea, hematemesis, hematochezia, no GU\n symptoms. No jaundice , no fevers. No weight loss, no NSAIDs, ASA use.\n Pt recieved Unasyn at the OSH and was transferred to .\n He had a history of GI bleed in , unclear source, recieved\n blood transfusion (). Last EGD and colonscopy were done in\n , wnl according to mother. Pancreatic cyst was aspirated in\n 6/. Laprascopic cholecystectomy done in .\n Chief complaint:\n respiratory distress, peritonitis, SMV occlusion\n PMHx:\n Cerebral Palsy (Patient non verbal baseline), Seizure d/o, Chronic\n anemia (transfusion x2)\n Current medications:\n Acetaminophen 4. Albumin 25% (12.5g / 50mL) 5. Albuterol 0.083% Neb\n Soln 6. Calcium Gluconate\n 7. Dextrose 50% 8. Fentanyl Citrate 9. Furosemide 10. Glucagon 11.\n Heparin 12. Heparin Flush (10 units/ml)\n 13. 14. Insulin 15. LeVETiracetam 16. Magnesium Sulfate 17.\n MetRONIDAZOLE (FLagyl) 18. Midazolam\n 19. Pantoprazole 20. Piperacillin-Tazobactam 21. Potassium Chloride 22.\n Sodium Chloride 0.9% Flush\n 23. Vancomycin\n 24 Hour Events:\n PARACENTESIS - At 09:45 AM\n STOOL CULTURE - At 10:55 AM\n spec sent for cdiff and o+p.\n FEVER - 101.5\nF - 08:00 PM\n : Peritoneal fluid sent (3L tapped). 25% albumin resolved\n tachycardia. CTA w/SMV occlusion. Hypokalemia aggressively treated. Hep\n gtt started\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:00 PM\n Piperacillin/Tazobactam (Zosyn) - 12:30 AM\n Metronidazole - 04:04 AM\n Infusions:\n Heparin Sodium - 1,150 units/hour\n Other ICU medications:\n Furosemide (Lasix) - 06:21 AM\n Fentanyl - 10:15 AM\n Pantoprazole (Protonix) - 08:56 PM\n Other medications:\n Flowsheet Data as of 04:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.6\nC (101.5\n T current: 37.6\nC (99.6\n HR: 87 (70 - 107) bpm\n BP: 97/62(80) {86/62(71) - 106/87(98)} mmHg\n RR: 26 (14 - 30) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 38 kg (admission): 32.3 kg\n Height: 55 Inch\n CVP: 10 (8 - 17) mmHg\n Total In:\n 3,945 mL\n 415 mL\n PO:\n Tube feeding:\n IV Fluid:\n 2,152 mL\n 235 mL\n Blood products:\n 732 mL\n Total out:\n 5,850 mL\n 100 mL\n Urine:\n 3,050 mL\n 100 mL\n NG:\n 300 mL\n Stool:\n Drains:\n 2,500 mL\n Balance:\n -1,905 mL\n 315 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 300 (300 - 300) mL\n Vt (Spontaneous): 444 (293 - 444) mL\n PS : 15 cmH2O\n RR (Set): 22\n RR (Spontaneous): 28\n PEEP: 10 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10\n PIP: 25 cmH2O\n SPO2: 99%\n ABG: 7.41/38/84./25/0\n Ve: 11.4 L/min\n PaO2 / FiO2: 140\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: Diminished: bibasilar)\n Abdominal: Distended\n Neurologic: Follows simple commands, Moves all extremities\n Labs / Radiology\n 179 K/uL\n 9.3 g/dL\n 80 mg/dL\n 0.5 mg/dL\n 25 mEq/L\n 3.7 mEq/L\n 7 mg/dL\n 108 mEq/L\n 141 mEq/L\n 31.6 %\n 10.6 K/uL\n [image002.jpg]\n 03:35 AM\n 12:11 PM\n 04:42 PM\n 03:27 AM\n 02:48 AM\n 06:09 AM\n 03:11 PM\n WBC\n 9.3\n 9.3\n 10.6\n Hct\n 28.3\n 27.1\n 26.2\n 29.1\n 31.6\n Plt\n \n Creatinine\n 0.4\n 0.5\n 0.5\n 0.4\n 0.5\n TCO2\n 25\n Glucose\n 112\n 90\n 74\n 134\n 80\n Other labs: PT / PTT / INR:16.0/36.0/1.4, ALT / AST:, Alk-Phos / T\n bili:66/0.1, Amylase / Lipase:52/, Lactic Acid:1.6 mmol/L, Albumin:2.5\n g/dL, LDH:142 IU/L, Ca:8.3 mg/dL, Mg:1.8 mg/dL, PO4:2.2 mg/dL\n Imaging: CT abd Pelvis: Simple global ascites, 6mm aortic diam\n IVC slit diam, Diffuse small bowel dilatation with mildly thickened\n folds. Diffuse moderate edema of the colon with a thickened wall.\n Distened rectum with thickened wall and stools. 4.5 x 2.3 x 1.4 cm\n pancreatic cyst with a veritical orientation in head of pancreas.\n surgical cholecystectomy, Extensive thrombus in porta hepatis. SMV SMA\n celiac patent,chr right PV thrombosis. No perf, no free air. No\n obstruction!\n CT: SMV occlusion with diffuse bowel wall edema & thickening c/w\n congestion/venous ischemia, possible shock bowel. Venous engorgement\n throughout. Sequelae of chronic pancreatitis, possible pseudocyst.\n Diffusely abnormal hepatic parenchyma. Partially occlusive right portal\n vein thrombus. Small b/l pleural effusions, increased from the prior\n exam. Ground-glass and nodular opacities @ bases suggesting infection.\n Microbiology: Peritoneal Fluid: NG\n MRSA P\n Assessment and Plan\n .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n Assessment and Plan: 35M with CP, peritonitis and ascites, chronic\n pancreatitis, Hepatitis B, most likely ascites and peritonitis SMV\n occlusion.\n Neurologic:\n - Intubated and sedated PRN Midazolam.\n - Pre-existing seizure disorder -> Keppra 20 .\n - Pain seems to be well controlled.\n Cardiovascular:\n - Tachycardic secondary to volume depletion and SIRS response.\n Otherwise stable, resolved with albumin.\n Pulmonary:\n - Respiratory failure resolved on. Assess for possible\n extubation.\n - Ground glass opacities\n possible evolving pneumonia. High\n respiratory demand.\n Gastrointestinal / Abdomen:\n - On empiric ABX for peritonitis. Work up for ascities on-going.\n - CTA revealed SMV occlusion, venous stasis--->On hep gtt. We will try\n to get official CT to established the mechanism of SMV\n thrombosis.\n - Unclear reason for diffused parenchymal changes in liver.\n - Immunized for hepatitis B.\n Nutrition:\n - TPN; electrolytes stable (no re-feeding syndrome observed)\n Renal/FeNa:\n - Hypokalemia, monitoring. Rechecking lytes.\n - Difficult Foley placement yesterday.\n Hematology:\n - Slowly worsening anemia secondary to dilution, inflammation, and\n pre-existing chronic anemia.\n - S/P Transfusion 2UPRBC for Hct of 26 on , Stable 29-31 on \n - On hep gtt for SMV occlusion (goal 60-80).\n Endocrine:\n - RISS with adequate BG\n Infectious Disease:\n - No growth on cultures to date. On empiric coverage for peritonitis\n and pneumonia. Still febrile.\n Lines / Tubes / Drains: PIV, Foley, Left sub clav ()\n Fluids: TPN\n Consults: General surgery, GI\n Billing Diagnosis: Other: PERITONITIS, Respiratory failure\n ICU Care\n Nutrition:\n TPN without Lipids - 04:07 PM 41. mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 03:15 AM\n 20 Gauge - 12:17 PM\n Prophylaxis:\n DVT: Boots (Systemic anticoagulation: Heparin drip)\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2115-02-17 00:00:00.000",
"description": "Intensivist Note",
"row_id": 624862,
"text": "SICU\n HPI:\n 35M with Cerebral palsy,presented with abdominal pain and distention to\n an OSH this am where CT scan was performed and reported as diffused\n bowel edema,gastric varices, ascites, pancreatic cyst. No association\n with nausea,vomitting, diarrhea, hematemesis, hematochezia, no GU\n symptoms. No jaundice , no fevers. No weight loss, no NSAIDs, ASA use.\n Pt recieved Unasyn at the OSH and was transferred to .\n He had a history of GI bleed in , unclear source, recieved\n blood transfusion (). Last EGD and colonscopy were done in\n , wnl according to mother. Pancreatic cyst was aspirated in\n 6/. Laprascopic cholecystectomy done in .\n Chief complaint:\n respiratory distress, peritonitis, SMV occlusion\n PMHx:\n Cerebral Palsy (Patient non verbal baseline), Seizure d/o, Chronic\n anemia (transfusion x2)\n Current medications:\n Acetaminophen 4. Albumin 25% (12.5g / 50mL) 5. Albuterol 0.083% Neb\n Soln 6. Calcium Gluconate\n 7. Dextrose 50% 8. Fentanyl Citrate 9. Furosemide 10. Glucagon 11.\n Heparin 12. Heparin Flush (10 units/ml)\n 13. 14. Insulin 15. LeVETiracetam 16. Magnesium Sulfate 17.\n MetRONIDAZOLE (FLagyl) 18. Midazolam\n 19. Pantoprazole 20. Piperacillin-Tazobactam 21. Potassium Chloride 22.\n Sodium Chloride 0.9% Flush\n 23. Vancomycin\n 24 Hour Events:\n PARACENTESIS - At 09:45 AM\n STOOL CULTURE - At 10:55 AM\n spec sent for cdiff and o+p.\n FEVER - 101.5\nF - 08:00 PM\n : Peritoneal fluid sent (3L tapped). 25% albumin resolved\n tachycardia. CTA w/SMV occlusion. Hypokalemia aggressively treated. Hep\n gtt started\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:00 PM\n Piperacillin/Tazobactam (Zosyn) - 12:30 AM\n Metronidazole - 04:04 AM\n Infusions:\n Heparin Sodium - 1,150 units/hour\n Other ICU medications:\n Furosemide (Lasix) - 06:21 AM\n Fentanyl - 10:15 AM\n Pantoprazole (Protonix) - 08:56 PM\n Other medications:\n Flowsheet Data as of 04:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.6\nC (101.5\n T current: 37.6\nC (99.6\n HR: 87 (70 - 107) bpm\n BP: 97/62(80) {86/62(71) - 106/87(98)} mmHg\n RR: 26 (14 - 30) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 38 kg (admission): 32.3 kg\n Height: 55 Inch\n CVP: 10 (8 - 17) mmHg\n Total In:\n 3,945 mL\n 415 mL\n PO:\n Tube feeding:\n IV Fluid:\n 2,152 mL\n 235 mL\n Blood products:\n 732 mL\n Total out:\n 5,850 mL\n 100 mL\n Urine:\n 3,050 mL\n 100 mL\n NG:\n 300 mL\n Stool:\n Drains:\n 2,500 mL\n Balance:\n -1,905 mL\n 315 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 300 (300 - 300) mL\n Vt (Spontaneous): 444 (293 - 444) mL\n PS : 15 cmH2O\n RR (Set): 22\n RR (Spontaneous): 28\n PEEP: 10 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10\n PIP: 25 cmH2O\n SPO2: 99%\n ABG: 7.41/38/84./25/0\n Ve: 11.4 L/min\n PaO2 / FiO2: 140\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: Diminished: bibasilar)\n Abdominal: Distended\n Neurologic: Follows simple commands, Moves all extremities\n Labs / Radiology\n 179 K/uL\n 9.3 g/dL\n 80 mg/dL\n 0.5 mg/dL\n 25 mEq/L\n 3.7 mEq/L\n 7 mg/dL\n 108 mEq/L\n 141 mEq/L\n 31.6 %\n 10.6 K/uL\n [image002.jpg]\n 03:35 AM\n 12:11 PM\n 04:42 PM\n 03:27 AM\n 02:48 AM\n 06:09 AM\n 03:11 PM\n WBC\n 9.3\n 9.3\n 10.6\n Hct\n 28.3\n 27.1\n 26.2\n 29.1\n 31.6\n Plt\n \n Creatinine\n 0.4\n 0.5\n 0.5\n 0.4\n 0.5\n TCO2\n 25\n Glucose\n 112\n 90\n 74\n 134\n 80\n Other labs: PT / PTT / INR:16.0/36.0/1.4, ALT / AST:, Alk-Phos / T\n bili:66/0.1, Amylase / Lipase:52/, Lactic Acid:1.6 mmol/L, Albumin:2.5\n g/dL, LDH:142 IU/L, Ca:8.3 mg/dL, Mg:1.8 mg/dL, PO4:2.2 mg/dL\n Imaging: CT abd Pelvis: Simple global ascites, 6mm aortic diam\n IVC slit diam, Diffuse small bowel dilatation with mildly thickened\n folds. Diffuse moderate edema of the colon with a thickened wall.\n Distened rectum with thickened wall and stools. 4.5 x 2.3 x 1.4 cm\n pancreatic cyst with a veritical orientation in head of pancreas.\n surgical cholecystectomy, Extensive thrombus in porta hepatis. SMV SMA\n celiac patent,chr right PV thrombosis. No perf, no free air. No\n obstruction!\n CT: SMV occlusion with diffuse bowel wall edema & thickening c/w\n congestion/venous ischemia, possible shock bowel. Venous engorgement\n throughout. Sequelae of chronic pancreatitis, possible pseudocyst.\n Diffusely abnormal hepatic parenchyma. Partially occlusive right portal\n vein thrombus. Small b/l pleural effusions, increased from the prior\n exam. Ground-glass and nodular opacities @ bases suggesting infection.\n Microbiology: Peritoneal Fluid: NG\n MRSA P\n Assessment and Plan\n .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n Assessment and Plan: 35M with CP, peritonitis and ascites, chronic\n pancreatitis, Hepatitis B, most likely ascites and peritonitis SMV\n occlusion.\n Neurologic:\n - Intubated and sedated PRN Midazolam.\n - Pre-existing seizure disorder -> Keppra 20 .\n - Pain seems to be well controlled.\n Cardiovascular:\n - Tachycardic secondary to volume depletion and SIRS response.\n Otherwise stable, resolved with albumin.\n Pulmonary:\n - Respiratory failure resolved on. Assess for possible\n extubation.\n - Ground glass opacities\n possible evolving pneumonia. High\n respiratory demand.\n Gastrointestinal / Abdomen:\n - On empiric ABX for peritonitis. Work up for ascities on-going.\n - CTA revealed SMV occlusion, venous stasis--->On hep gtt. We will try\n to get official CT to establish the mechanism of SMV\n thrombosis.\n - Unclear reason for diffused parenchymal changes in liver. Immunized\n for hepatitis B.\n - Ascites secondary to venous engorgement and low serum albumin levels.\n - Chronic pancreatitis with pseudocysts (?)\n Nutrition:\n - TPN; electrolytes stable (no re-feeding syndrome observed)\n Renal/FeNa:\n - Hypokalemia, monitoring. Rechecking lytes.\n - Difficult Foley placement yesterday.\n Hematology:\n - Slowly worsening anemia secondary to dilution, inflammation, and\n pre-existing chronic anemia.\n - S/P Transfusion 2UPRBC for Hct of 26 on , Stable 29-31 on \n - On hep gtt for SMV occlusion (goal 60-80).\n Endocrine:\n - RISS with adequate BG\n Infectious Disease:\n - No growth on cultures to date. On empiric coverage for peritonitis\n and pneumonia. Still febrile.\n Lines / Tubes / Drains: PIV, Foley, Left sub clav ()\n Fluids: TPN\n Consults: General surgery, GI\n Billing Diagnosis: Other: PERITONITIS, Respiratory failure\n ICU Care\n Nutrition:\n TPN without Lipids - 04:07 PM 41. mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 03:15 AM\n 20 Gauge - 12:17 PM\n Prophylaxis:\n DVT: Boots (Systemic anticoagulation: Heparin drip)\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2115-02-17 00:00:00.000",
"description": "Intensivist Note",
"row_id": 624864,
"text": "SICU\n HPI:\n 35M with Cerebral palsy,presented with abdominal pain and distention to\n an OSH this am where CT scan was performed and reported as diffused\n bowel edema,gastric varices, ascites, pancreatic cyst. No association\n with nausea,vomitting, diarrhea, hematemesis, hematochezia, no GU\n symptoms. No jaundice , no fevers. No weight loss, no NSAIDs, ASA use.\n Pt recieved Unasyn at the OSH and was transferred to .\n He had a history of GI bleed in , unclear source, recieved\n blood transfusion (). Last EGD and colonscopy were done in\n , wnl according to mother. Pancreatic cyst was aspirated in\n 6/. Laprascopic cholecystectomy done in .\n Chief complaint:\n respiratory distress, peritonitis, SMV occlusion\n PMHx:\n Cerebral Palsy (Patient non verbal baseline), Seizure d/o, Chronic\n anemia (transfusion x2)\n Current medications:\n Acetaminophen 4. Albumin 25% (12.5g / 50mL) 5. Albuterol 0.083% Neb\n Soln 6. Calcium Gluconate\n 7. Dextrose 50% 8. Fentanyl Citrate 9. Furosemide 10. Glucagon 11.\n Heparin 12. Heparin Flush (10 units/ml)\n 13. 14. Insulin 15. LeVETiracetam 16. Magnesium Sulfate 17.\n MetRONIDAZOLE (FLagyl) 18. Midazolam\n 19. Pantoprazole 20. Piperacillin-Tazobactam 21. Potassium Chloride 22.\n Sodium Chloride 0.9% Flush\n 23. Vancomycin\n 24 Hour Events:\n PARACENTESIS - At 09:45 AM\n STOOL CULTURE - At 10:55 AM\n spec sent for cdiff and o+p.\n FEVER - 101.5\nF - 08:00 PM\n : Peritoneal fluid sent (3L tapped). 25% albumin resolved\n tachycardia. CTA w/SMV occlusion. Hypokalemia aggressively treated. Hep\n gtt started\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:00 PM\n Piperacillin/Tazobactam (Zosyn) - 12:30 AM\n Metronidazole - 04:04 AM\n Infusions:\n Heparin Sodium - 1,150 units/hour\n Other ICU medications:\n Furosemide (Lasix) - 06:21 AM\n Fentanyl - 10:15 AM\n Pantoprazole (Protonix) - 08:56 PM\n Other medications:\n Flowsheet Data as of 04:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.6\nC (101.5\n T current: 37.6\nC (99.6\n HR: 87 (70 - 107) bpm\n BP: 97/62(80) {86/62(71) - 106/87(98)} mmHg\n RR: 26 (14 - 30) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 38 kg (admission): 32.3 kg\n Height: 55 Inch\n CVP: 10 (8 - 17) mmHg\n Total In:\n 3,945 mL\n 415 mL\n PO:\n Tube feeding:\n IV Fluid:\n 2,152 mL\n 235 mL\n Blood products:\n 732 mL\n Total out:\n 5,850 mL\n 100 mL\n Urine:\n 3,050 mL\n 100 mL\n NG:\n 300 mL\n Stool:\n Drains:\n 2,500 mL\n Balance:\n -1,905 mL\n 315 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 300 (300 - 300) mL\n Vt (Spontaneous): 444 (293 - 444) mL\n PS : 15 cmH2O\n RR (Set): 22\n RR (Spontaneous): 28\n PEEP: 10 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10\n PIP: 25 cmH2O\n SPO2: 99%\n ABG: 7.41/38/84./25/0\n Ve: 11.4 L/min\n PaO2 / FiO2: 140\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: Diminished: bibasilar)\n Abdominal: Distended\n Neurologic: Follows simple commands, Moves all extremities\n Labs / Radiology\n 179 K/uL\n 9.3 g/dL\n 80 mg/dL\n 0.5 mg/dL\n 25 mEq/L\n 3.7 mEq/L\n 7 mg/dL\n 108 mEq/L\n 141 mEq/L\n 31.6 %\n 10.6 K/uL\n [image002.jpg]\n 03:35 AM\n 12:11 PM\n 04:42 PM\n 03:27 AM\n 02:48 AM\n 06:09 AM\n 03:11 PM\n WBC\n 9.3\n 9.3\n 10.6\n Hct\n 28.3\n 27.1\n 26.2\n 29.1\n 31.6\n Plt\n \n Creatinine\n 0.4\n 0.5\n 0.5\n 0.4\n 0.5\n TCO2\n 25\n Glucose\n 112\n 90\n 74\n 134\n 80\n Other labs: PT / PTT / INR:16.0/36.0/1.4, ALT / AST:, Alk-Phos / T\n bili:66/0.1, Amylase / Lipase:52/, Lactic Acid:1.6 mmol/L, Albumin:2.5\n g/dL, LDH:142 IU/L, Ca:8.3 mg/dL, Mg:1.8 mg/dL, PO4:2.2 mg/dL\n Imaging: CT abd Pelvis: Simple global ascites, 6mm aortic diam\n IVC slit diam, Diffuse small bowel dilatation with mildly thickened\n folds. Diffuse moderate edema of the colon with a thickened wall.\n Distened rectum with thickened wall and stools. 4.5 x 2.3 x 1.4 cm\n pancreatic cyst with a veritical orientation in head of pancreas.\n surgical cholecystectomy, Extensive thrombus in porta hepatis. SMV SMA\n celiac patent,chr right PV thrombosis. No perf, no free air. No\n obstruction!\n CT: SMV occlusion with diffuse bowel wall edema & thickening c/w\n congestion/venous ischemia, possible shock bowel. Venous engorgement\n throughout. Sequelae of chronic pancreatitis, possible pseudocyst.\n Diffusely abnormal hepatic parenchyma. Partially occlusive right portal\n vein thrombus. Small b/l pleural effusions, increased from the prior\n exam. Ground-glass and nodular opacities @ bases suggesting infection.\n Microbiology: Peritoneal Fluid: NG\n MRSA P\n Assessment and Plan\n .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n Assessment and Plan: 35M with CP, peritonitis and ascites, chronic\n pancreatitis, Hepatitis B, most likely ascites and peritonitis SMV\n occlusion.\n Neurologic:\n - Intubated and sedated PRN Midazolam.\n - Pre-existing seizure disorder -> Keppra 20 .\n - Pain seems to be well controlled.\n Cardiovascular:\n - Tachycardic secondary to volume depletion and SIRS response.\n Otherwise stable, resolved with albumin.\n Pulmonary:\n - Respiratory failure resolved on. Assess for possible\n extubation.\n - Ground glass opacities\n possible evolving pneumonia. High\n respiratory demand.\n Gastrointestinal / Abdomen:\n - On empiric ABX for peritonitis. Work up for ascities on-going.\n - CTA revealed SMV occlusion, venous stasis--->On hep gtt. We will try\n to get official CT to establish the mechanism of SMV\n thrombosis.\n - Unclear reason for diffused parenchymal changes in liver. Immunized\n for hepatitis B.\n - Ascites secondary to venous engorgement and low serum albumin levels.\n - Chronic pancreatitis with pseudocysts (?)\n Nutrition:\n - TPN; electrolytes stable (no re-feeding syndrome observed)\n Renal/FeNa:\n - Hypokalemia, monitoring. Rechecking lytes.\n - Difficult Foley placement yesterday.\n Hematology:\n - Slowly worsening anemia secondary to dilution, inflammation, and\n pre-existing chronic anemia.\n - S/P Transfusion 2UPRBC for Hct of 26 on , Stable 29-31 on \n - On hep gtt for SMV occlusion (goal 60-80).\n Endocrine:\n - RISS with adequate BG\n Infectious Disease:\n - No growth on cultures to date. On empiric coverage for peritonitis\n and pneumonia. Still febrile.\n Lines / Tubes / Drains: PIV, Foley, Left sub clav ()\n Fluids: TPN\n Consults: General surgery, GI\n Billing Diagnosis: Other: PERITONITIS, Respiratory failure\n ICU Care\n Nutrition:\n TPN without Lipids - 04:07 PM 41. mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 03:15 AM\n 20 Gauge - 12:17 PM\n Prophylaxis:\n DVT: Boots (Systemic anticoagulation: Heparin drip)\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2115-02-20 00:00:00.000",
"description": "Intensivist Note",
"row_id": 625348,
"text": "SICU\n HPI:\n 35M with Cerebral palsy, presented with abdominal pain and distention\n to an OSH this am where CT scan was performed and reported as diffused\n bowel edema, gastric varices, ascites, pancreatic cyst. No association\n with nausea, vomitting, diarrhea, hematemesis, hematochezia, no GU\n symptoms. No jaundice, no fevers. No weight loss, no NSAIDs, ASA use.\n Pt recieved Unasyn at the OSH and was transferred to .\n Chief complaint:\n respiratory distress, peritonitis, SMV occlusion\n PMHx:\n Cerebral Palsy (Patient non verbal baseline), Seizure d/o, Chronic\n anemia (transfusion x2)\n .\n PSH:\n Lap cholecystectomy\n Pancreatic cyst drainage (last year, )\n Current medications:\n 1. 2. 3. Acetaminophen 4. Albumin 5% (12.5g / 250mL) 5. Albuterol\n 0.083% Neb Soln 6. Calcium Gluconate 7. Chlorhexidine Gluconate 0.12%\n Oral Rinse 8. Dextrose 50% 9. Fentanyl Citrate 10. Glucagon 11. Heparin\n 12. Heparin Flush (10 units/ml) 13. Insulin 14. LeVETiracetam 15.\n Magnesium Sulfate 16. Midazolam 17. Pantoprazole 18. Phenylephrine 19.\n Piperacillin-Tazobactam 20. Potassium Chloride 21. Sodium Chloride 0.9%\n Flush 22. Sodium Chloride 0.9% Flush 23. Tobramycin 24. Vancomycin 25.\n Warfarin\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 03:20 PM\n : Episode of hypotension to low 70's recieved a bolus of albumin w/\n good response. Vancomycine increased to 1250\". Started on tobramycin\n presumed to have pneumonia\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 03:53 AM\n Tobramycin - 12:04 PM\n Vancomycin - 08:26 PM\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium - 08:19 AM\n Midazolam (Versed) - 11:07 AM\n Pantoprazole (Protonix) - 08:00 PM\n Other medications:\n Flowsheet Data as of 04:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.9\nC (100.3\n T current: 36.5\nC (97.7\n HR: 93 (75 - 99) bpm\n BP: 93/68(74) {71/47(59) - 119/86(89)} mmHg\n RR: 22 (17 - 31) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 37.1 kg (admission): 32.3 kg\n Height: 55 Inch\n CVP: 8 (5 - 14) mmHg\n Total In:\n 2,674 mL\n 319 mL\n PO:\n Tube feeding:\n IV Fluid:\n 1,281 mL\n 121 mL\n Blood products:\n 250 mL\n Total out:\n 2,745 mL\n 420 mL\n Urine:\n 2,095 mL\n 420 mL\n NG:\n 350 mL\n Stool:\n Drains:\n Balance:\n -71 mL\n -101 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: SIMV/PSV/AutoFlow\n Vt (Set): 300 (300 - 300) mL\n Vt (Spontaneous): 341 (291 - 341) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 8\n PEEP: 8 cmH2O\n FiO2: 50%\n PIP: 22 cmH2O\n Plateau: 17 cmH2O\n SPO2: 99%\n ABG: ///30/\n Ve: 8.8 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: Crackles : Bilateral)\n Abdominal: Soft, Distended\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Neurologic: Follows simple commands, Moves all extremities, alert\n Labs / Radiology\n 109 K/uL\n 8.9 g/dL\n 98 mg/dL\n 0.5 mg/dL\n 30 mEq/L\n 4.3 mEq/L\n 9 mg/dL\n 104 mEq/L\n 142 mEq/L\n 27.1 %\n 7.6 K/uL\n [image002.jpg]\n 02:48 AM\n 06:09 AM\n 03:11 PM\n 04:05 AM\n 02:40 PM\n 02:29 AM\n 04:00 PM\n 01:32 AM\n 03:31 AM\n 01:00 AM\n WBC\n 10.6\n 8.7\n 9.4\n 10.1\n 7.6\n Hct\n 29.1\n 31.6\n 32.9\n 30.9\n 29.2\n 28.6\n 27.1\n Plt\n 179\n 139\n 107\n 110\n 109\n Creatinine\n 0.4\n 0.5\n 0.5\n 0.5\n 0.4\n 0.4\n 0.4\n 0.5\n TCO2\n 25\n 36\n Glucose\n 134\n 80\n 118\n 137\n 141\n 104\n 106\n 98\n Other labs: PT / PTT / INR:15.8/129.8/1.4, ALT / AST:, Alk-Phos /\n T bili:80/0.3, Amylase / Lipase:62/19, Lactic Acid:0.9 mmol/L,\n Albumin:2.5 g/dL, LDH:158 IU/L, Ca:8.2 mg/dL, Mg:3.0 mg/dL, PO4:3.8\n mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), .H/O ABDOMINAL PAIN\n (INCLUDING ABDOMINAL TENDERNESS)\n Assessment and Plan: 35M with CP, chronic pancreatitis, transudative\n ascites and peritonitis likely SMV occlusion, now on hep gtt.\n Neurologic:\n - Pre-existing seizure disorder -> Keppra 20 .\n - Pain seems to be well controlled.\n - Baseline mental status\n -Intubated off sedation\n Cardiovascular:\n --Episodes of asym brady to 40s; hypotensive, given albumin and LR;\n now stable, continue to monitor\n --ECHO: EF 55% f/up final read\n Pulmonary:\n - Respiratory failure: now reintubated, requiring aggresive pulm\n toilet, chest PT and suctioning due to secretions\n --Wean the vent as tolerated\n --F/up sputum Cx\n Gastrointestinal / Abdomen:\n - On empiric ABX for peritonitis. Work up for ascities on-going. F/U\n Cx\n --CTA revealed SMV occlusion, venous stasis--->On hep gtt\n -- Diarrhea: likely due to lack of absorption d/t bowel wall edema,\n improving today, Flagyl d/c'd, C diff negative\n -- Pantoprazole for GI proph\n --NGT lavage to eval bleeding source given HCT drop\n Nutrition: TPN\n Renal:\n --stable urine output, lasix \n --Hypokalemia, resolved\n --Patient on tobramycin and vancomycin monitor Renal function closely\n Hematology:\n - Slowly worsening anemia secondary to dilution, inflammation, and\n pre-existing chronic anemia\n - Hct 27.1\n 24.1 on gastric lavage to eval bleeding source,\n CT/CTA to eval abdominal bleeding for HCT <20\n -S/P Transfusion 2UPRBC for Hct of 26 on ,\n - Elevated INR & PTT secondary to the nutritional depletion.\n On hep gtt for SMV occlusion (goal 60-80)\n -coumadin started on , inc 5 today, last INR 1.4\n Endocrine:\n - RISS with adequate BG control.\n Infectious Disease:\n - Abdominal peritonitis - on empiric coverage with vanc/zosyn and\n tobramycin to cover pseudomonas pneumonia\n - F/u cultures\n - suspected pneumonia and at risk MDR HAP added tobramycin, f/u AM\n trough level (goal less than 1)\n Lines / Tubes / Drains: ETT, PIV, Foley, Left sub clav ()\n Wounds:\n Imaging: CXR today\n Fluids: KVO\n Consults: General surgery\n Billing Diagnosis: (Respiratory distress: Failure)\n ICU Care\n Nutrition:\n TPN w/ Lipids - 06:08 PM 46 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 03:15 AM\n 20 Gauge - 12:17 PM\n Prophylaxis:\n DVT: Boots (Systemic anticoagulation: Heparin drip)\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2115-02-18 00:00:00.000",
"description": "Intensivist Note",
"row_id": 624955,
"text": "SICU\n HPI:\n 35M with Cerebral palsy,presented with abdominal pain and distention to\n an OSH this am where CT scan was performed and reported as diffused\n bowel edema,gastric varices, ascites, pancreatic cyst. No association\n with nausea,vomitting, diarrhea, hematemesis, hematochezia, no GU\n symptoms. No jaundice , no fevers. No weight loss, no NSAIDs, ASA use.\n Pt recieved Unasyn at the OSH and was transferred to \n Chief complaint:\n respiratory distress, peritonitis, SMV occlusion\n PMHx:\n Cerebral Palsy (Patient non verbal baseline), Seizure d/o, Chronic\n anemia (transfusion x2)\n Current medications:\n Acetaminophen 4. Albuterol 0.083% Neb Soln 5. Calcium Gluconate 6.\n Dextrose 50% 7. Fentanyl Citrate\n 8. Furosemide 9. Furosemide 10. Glucagon 11. Heparin 12. Heparin Flush\n (10 units/ml) 13. 14. Insulin\n 15. LeVETiracetam 16. Magnesium Sulfate 17. MetRONIDAZOLE (FLagyl) 18.\n Midazolam 19. Pantoprazole\n 20. Piperacillin-Tazobactam\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 06:03 PM\n EXTUBATION - At 06:19 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:00 PM\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Metronidazole - 03:53 AM\n Infusions:\n Heparin Sodium - 700 units/hour\n Other ICU medications:\n Furosemide (Lasix) - 09:44 PM\n Fentanyl - 02:20 AM\n Other medications:\n Flowsheet Data as of 04:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.7\nC (99.9\n T current: 36.9\nC (98.5\n HR: 95 (75 - 110) bpm\n BP: 80/56(73) {80/52(62) - 125/81(90)} mmHg\n RR: 26 (9 - 48) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 38 kg (admission): 32.3 kg\n Height: 55 Inch\n CVP: 185 (1 - 238) mmHg\n Total In:\n 2,607 mL\n 431 mL\n PO:\n Tube feeding:\n IV Fluid:\n 1,471 mL\n 244 mL\n Blood products:\n Total out:\n 2,816 mL\n 1,380 mL\n Urine:\n 1,816 mL\n 730 mL\n NG:\n 250 mL\n Stool:\n Drains:\n Balance:\n -209 mL\n -949 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, Aerosol-cool\n Ventilator mode: CPAP/PSV\n Vt (Set): 350 (350 - 350) mL\n Vt (Spontaneous): 321 (293 - 555) mL\n PS : 5 cmH2O\n RR (Set): 10\n RR (Spontaneous): 17\n PEEP: 0 cmH2O\n FiO2: 70%\n RSBI: 93\n PIP: 16 cmH2O\n SPO2: 98%\n ABG: ///29/\n Ve: 5.4 L/min\n Physical Examination\n General Appearance: No acute distress\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric)\n Abdominal: No(t) Soft, softer than previously\n Neurologic: (Responds to: Tactile stimuli), No(t) Moves all\n extremities, (RUE: No(t) Weakness), (LUE: No(t) Weakness), (RLE: No\n movement), (LLE: No movement)\n Labs / Radiology\n 107 K/uL\n 10.0 g/dL\n 141 mg/dL\n 0.4 mg/dL\n 29 mEq/L\n 3.1 mEq/L\n 12 mg/dL\n 104 mEq/L\n 138 mEq/L\n 29.2 %\n 9.4 K/uL\n [image002.jpg]\n 03:35 AM\n 12:11 PM\n 04:42 PM\n 03:27 AM\n 02:48 AM\n 06:09 AM\n 03:11 PM\n 04:05 AM\n 02:40 PM\n 02:29 AM\n WBC\n 9.3\n 9.3\n 10.6\n 8.7\n 9.4\n Hct\n 28.3\n 27.1\n 26.2\n 29.1\n 31.6\n 32.9\n 30.9\n 29.2\n Plt\n 39\n 107\n Creatinine\n 0.4\n 0.5\n 0.5\n 0.4\n 0.5\n 0.5\n 0.5\n 0.4\n TCO2\n 25\n Glucose\n 112\n 90\n 74\n 134\n 80\n 118\n 137\n 141\n Other labs: PT / PTT / INR:15.0/90.1/1.3, ALT / AST:, Alk-Phos / T\n bili:83/0.3, Amylase / Lipase:52/, Lactic Acid:1.6 mmol/L, Albumin:2.5\n g/dL, LDH:158 IU/L, Ca:8.2 mg/dL, Mg:1.9 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n Assessment and Plan: 35M with CP, peritonitis and ascites, chronic\n pancreatitis, most likely ascites and peritonitis SMV occlusion\n Neurologic: - Pre-existing seizure disorder -> Keppra 20 .\n - Pain seems to be well controlled. and pt seems to be at baseline\n mental status\n Cardiovascular: HR and BP holding stable\n Pulmonary: - Respiratory failure: now extubated, requiring aggresive\n pulm toilet, chest PT and suctioning due to secretions\n - CXR looked vol overload, gave 5mg then 10mg of lasix for diuresis\n Gastrointestinal / Abdomen: - On empiric ABX for peritonitis. Work up\n for ascities on-going.F/U Cx\n --CTA revealed SMV occlusion, venous stasis--->On hep gtt\n -- Diarrhea: likely due to lack of absorption d/t bowel wall edema\n -- Pantoprazole for GI proph\n Nutrition: tpn\n Renal: - stable urine output, had lasix x5mg and then x10mg for fluid\n overload, over night\n --Hypokalemia, monitoring and getting repleted\n Hematology: - On hep gtt for SMV occlusion (goal 60-80)\n -S/P Transfusion 2UPRBC for Hct of 26 on , now stable,\n Endocrine: - RISS with adequate BG control.\n Infectious Disease: - Abdominal peritonitis - on empiric coverage with\n vanc/Flagyl/zosyn.\n --Awaiting cultures to identify causitive organism.\n -- WBC 9.4, afebrile\n Lines / Tubes / Drains:\n Wounds:\n Imaging:\n Fluids:\n Consults: General surgery, Vascular surgery\n Billing Diagnosis:\n ICU Care\n Nutrition:\n TPN without Lipids - 04:00 PM 45 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 03:15 AM\n 20 Gauge - 12:17 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin drip)\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n Total time spent: 33 minutes\n"
},
{
"category": "Nutrition",
"chartdate": "2115-02-21 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 625496,
"text": "Subjective\n Patient remains intubated\n Objective\n Pertinent medications: noted\n Labs:\n Value\n Date\n Glucose\n 118 mg/dL\n 04:15 AM\n Glucose Finger Stick\n 149\n 10:00 AM\n BUN\n 15 mg/dL\n 04:15 AM\n Creatinine\n 1.0 mg/dL\n 04:15 AM\n Sodium\n 140 mEq/L\n 04:15 AM\n Potassium\n 5.5 mEq/L\n 04:15 AM\n Chloride\n 109 mEq/L\n 04:15 AM\n TCO2\n 29 mEq/L\n 04:15 AM\n pH (urine)\n 6.5 units\n 04:15 AM\n Calcium non-ionized\n 8.1 mg/dL\n 04:15 AM\n Phosphorus\n 3.5 mg/dL\n 04:15 AM\n Magnesium\n 2.8 mg/dL\n 04:15 AM\n WBC\n 6.5 K/uL\n 04:15 AM\n Hgb\n 8.0 g/dL\n 04:15 AM\n Hematocrit\n 24.8 %\n 04:15 AM\n Current diet order / nutrition support: Tube feed: Ensure @ 40mL/hr\n (1017 kcals/35 gr protein)-on hold\n TPN 3/10-1100mL(150 dextrose/50 protein/22 fat) 930 kcals\n GI: Abd: soft/nbs/liquid stool\n Assessment of Nutritional Status\n Specifics:\n Tube feeds initiated p/ surgery ok\nd. Per discussion w/ RN, patient\n was tolerating @ 20mL/hr without residuals until feeds were turned off\n for probable extubation. TPN still infusing for nutrition. High and K\n and Mg noted- would hold TPN given large amounts of K in TPN. Will\n also need to change tube feed to renal formula until lytes return to\n normal\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: Will need multivitamin\n daily- 5mL liquid via NGT\n Would stop TPN now\n When resuming feeds, please change Rx to Novasource Renal @\n 25mL/hr (1200 kcals/44.4 gr protein)\n Will monitor lytes for ability to change to more standard\n formula\n Residual checks q4 hr, hold if over 150mL\n Glucose management as you are\n Following #\n"
},
{
"category": "Nursing",
"chartdate": "2115-02-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 624507,
"text": ".H/O abdominal pain (including abdominal tenderness)\n Assessment:\n Patient is non verbal at baseline, does not walk.\n Intubated. CPAP. LSCTA.\n Abdomen firm distended\n Positive bowel sounds.\n Stooling, soft green tinged. Guiac negative. CDiff sent.\n NGT with scant clear drainage in tubing.\n Foley with low urine output\n Tachycardic\n SBP 80\ns-90\n Tmax 101.1\n Action:\n Triple antibiotic therapy.\n Electrolytes monitored.\n Repositioned frequently due to cachectic appearance and many\n areas\n Continue ARDS Net protocol for ventilator settings as his\n chest x-ray is concerning.\n Fentanyl PRN with turning and repositioning.\n Response:\n Does not appear to be in worsening pain\n Currently ~ 6 liter positive fluid balance\n CVP ~15-16\n Lactic acid from 1.2 to currently 0.7\n HCT 27.1\n Urine Cult negative.\n PO2 116.\n Plan:\n Continue to monitor.\n Parents with patient. Continue patient and family support.\n"
},
{
"category": "Nursing",
"chartdate": "2115-02-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 624509,
"text": "GI Assessment and Plan :\n 35 yom with CP, non-verbal, p/w abdominal pain, fever, on CT noted to\n have ascites and diffused bowel edema.\n 1. bowel edema/ascites: Patient was intubated for respiratory\n failure. Ascites fluid notable for SAAG =>1.1 and AFTP is 1.2\n suggestive of liver pathology. However, given frank signs of infection\n with polys greater than , patient like has secondary peritonitis\n from ischemic bowel.\n - suggest Cefepime/flagyl/vanco for abx\n - f/u ascites cultures\n - consider IV albumin 1.5g/kg today then 1g/kg on day 3\n (treatment for SBP, though patient is likely having secondary\n peritonitis from polymycrobial infection edema of bowel/ ? bowel\n perforation / ischemic bowel)\n - will perform flex-sig this PM to eval viability of the bowel\n - agree with family meeting and address goals of care\n - consider repeat tap in 72 hours if clinical improves\n - if performing therapeutic tap, would recommend IV albumin\n 25% 6-8g per Liter of fluid removed (if total volume removed is > 3L.\n .H/O abdominal pain (including abdominal tenderness)\n Assessment:\n Patient is non verbal at baseline, does not walk.\n Intubated. CPAP. LSCTA.\n Abdomen firm distended\n Positive bowel sounds.\n Stooling, soft green tinged. Guiac negative. CDiff sent.\n NGT with scant clear drainage in tubing.\n Foley with low urine output\n Tachycardic\n SBP 80\ns-90\n Tmax 101.1\n Action:\n Triple antibiotic therapy.\n Electrolytes monitored.\n Repositioned frequently due to cachectic appearance and many\n areas\n Continue ARDS Net protocol for ventilator settings as his\n chest x-ray is concerning.\n Fentanyl PRN with turning and repositioning.\n Response:\n Does not appear to be in worsening pain\n Currently ~ 6 liter positive fluid balance\n CVP ~15-16\n Lactic acid from 1.2 to currently 0.7\n HCT 27.1\n Urine Cult negative.\n PO2 116.\n Plan:\n Continue to monitor.\n Parents with patient. Continue patient and family support.\n"
},
{
"category": "Respiratory ",
"chartdate": "2115-02-19 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 625216,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 43.7 None\n Ideal tidal volume: 174.8 / 262.2 / 349.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: Wean to PSV as tol\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Cannot protect airway, Cannot manage secretions,\n Underlying illness not resolved\n"
},
{
"category": "Nutrition",
"chartdate": "2115-02-20 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 625344,
"text": "Subjective: patient intubated.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 140 cm\n 32.3 kg\n 32.8 kg ( 01:00 AM)\n 16.5\n Pertinent medications: Heparin drip, ABx, Protonix, warfarin, others\n noted\n Labs:\n Value\n Date\n Glucose\n 132 mg/dL\n 08:19 AM\n Glucose Finger Stick\n 147\n 04:00 AM\n BUN\n 11 mg/dL\n 08:19 AM\n Creatinine\n 0.7 mg/dL\n 08:19 AM\n Sodium\n 141 mEq/L\n 08:19 AM\n Potassium\n 4.3 mEq/L\n 08:19 AM\n Chloride\n 106 mEq/L\n 08:19 AM\n TCO2\n 30 mEq/L\n 08:19 AM\n PO2 (arterial)\n 74 mm Hg\n 01:32 AM\n PO2 (venous)\n 42 mm Hg\n 08:08 AM\n PCO2 (arterial)\n 45 mm Hg\n 01:32 AM\n PCO2 (venous)\n 42 mm Hg\n 08:08 AM\n pH (arterial)\n 7.50 units\n 01:32 AM\n pH (venous)\n 7.37 units\n 08:31 AM\n pH (urine)\n 6.5 units\n 01:13 AM\n CO2 (Calc) arterial\n 36 mEq/L\n 01:32 AM\n CO2 (Calc) venous\n 24 mEq/L\n 08:08 AM\n Albumin\n 2.5 g/dL\n 03:11 PM\n Calcium non-ionized\n 7.9 mg/dL\n 08:19 AM\n Phosphorus\n 4.2 mg/dL\n 08:19 AM\n Ionized Calcium\n 1.18 mmol/L\n 08:31 AM\n Magnesium\n 2.8 mg/dL\n 08:19 AM\n ALT\n 10 IU/L\n 01:00 AM\n Alkaline Phosphate\n 80 IU/L\n 01:00 AM\n AST\n 18 IU/L\n 01:00 AM\n Amylase\n 62 IU/L\n 01:00 AM\n Total Bilirubin\n 0.3 mg/dL\n 03:31 AM\n Triglyceride\n 61 mg/dL\n 02:29 AM\n Phenytoin (Dilantin)\n 4.9 ug/mL\n 03:27 AM\n WBC\n 7.6 K/uL\n 01:00 AM\n Hgb\n 8.9 g/dL\n 01:00 AM\n Hematocrit\n 24.1 %\n 08:19 AM\n Current diet order / nutrition support: Diet: NPO\n TPN: 1100mL (150g dextrose/ 50g amino acid/ 22g lipid) = 930kcals\n GI: abd soft, distended, hypoactive bowel sounds, large amt of liquid\n green stool\n Assessment of Nutritional Status\n 35 y.o. Male with CP, transudative ascites and peritonitis likely \n SMV occlusion, now on heparin drip. Patient is intubated due to\n inability to handle own secretions. TPN is running for nutrition as he\n would likely not tolerate tube feeds at this time. Current TPN does\n not meet needs; the dextrose should be advanced tomorrow to 200g.\n Medical Nutrition Therapy Plan - Recommend the Following\n Recommend advance to goal TPN tomorrow (): 1100mL (200g\n dextrose/ 50g amino acid/ 22fat) = 1100kcals.\n Continue to monitor lytes, blood sugar and hydration.\n Following - #\n"
},
{
"category": "Consult",
"chartdate": "2115-02-15 00:00:00.000",
"description": "Physician Consult Progress Note",
"row_id": 624567,
"text": "TITLE: GI consult progress note\n Consult requested by: Dr. \n Chief Complaint: peritonitis, abdominal distention, ascites\n 24 Hour Events:\n Had several BM yesterday.\n HBsAg: Pnd\n HBs-Ab: Pnd\n HBc-Ab: Pnd\n HAV-Ab: Pnd\n IgM-HBc: Pnd\n HCV-Ab: Pnd\n FEVER - 101.1\nF - 08:00 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 04:30 AM\n Piperacillin/Tazobactam (Zosyn) - 07:59 AM\n Vancomycin - 08:00 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 09:29 AM\n Pantoprazole (Protonix) - 08:00 PM\n Fentanyl - 06:34 AM\n Other medications:\n Changes to medical and family history:\n none\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.8\nC (100.1\n Tcurrent: 36.3\nC (97.4\n HR: 105 (97 - 117) bpm\n BP: 87/66(78) {80/59(65) - 97/78(83)} mmHg\n RR: 21 (20 - 32) insp/min\n SpO2: 100%\n Heart rhythm:: ST (Sinus Tachycardia)\n Wgt (current): 36.4 kg (admission): 71 kg\n CVP: 10 (10 - 18)mmHg\n Total In:\n 8,837 mL\n 1,325 mL\n PO:\n TF:\n IVF:\n 3,287 mL\n 1,325 mL\n Blood products:\n 50 mL\n Total out:\n 959 mL\n 355 mL\n Urine:\n 509 mL\n 355 mL\n NG:\n Stool:\n Drains:\n Balance:\n 7,878 mL\n 970 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 0 (0 - 0) mL\n Vt (Spontaneous): 320 (258 - 320) mL\n PS : 12 cmH2O\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 69\n PIP: 7 cmH2O\n SpO2: 100%\n ABG: ///25/\n Ve: 6.6 L/min\n Physical Examination\n HEENT: NCAT, thin, not following commands\n CVS: tachy, nl s1s2, systolic murmur , no r/g\n Pulm: ctab, no w/r/c, intubated\n ABD: no BS, distended, tender to percussion and palpation\n Ext: contracted, thin\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 177 K/uL\n 8.2 g/dL\n 74 mg/dL\n 0.5 mg/dL\n 25 mEq/L\n 3.3 mEq/L\n 13 mg/dL\n 115 mEq/L\n 144 mEq/L\n 26.2 %\n 9.3 K/uL\n [image002.jpg]\n 03:35 AM\n 12:11 PM\n 04:42 PM\n 03:27 AM\n WBC\n 9.3\n 9.3\n Hct\n 28.3\n 27.1\n 26.2\n Plt\n 226\n 177\n Cr\n 0.4\n 0.5\n 0.5\n Glucose\n 112\n 90\n 74\n Other labs: PT / PTT / INR:16.9/45.5/1.5, ALT / AST:, Alk Phos / T\n Bili:91/0.1, Amylase / Lipase:52/, Lactic Acid:0.5 mmol/L, Albumin:2.1\n g/dL, LDH:142 IU/L, Ca++:7.7 mg/dL, Mg++:2.2 mg/dL, PO4:2.2 mg/dL\n Assessment and Plan\n .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n 35 yom with cerebral palsy, non-verbal, present with peritonitis,\n ascites of unknown etiology, and ischemic bowel. \\\n - question etiology of the liver disease, f/u serologies\n - consider RUQ US for eval of hepatobiliary structures.\n - having BMs, continue to clinical monitor and consider reassess with\n CT in 48 hours to eval bowel\n - cont current antibiotics\n - continue monitor patient, if clinically worsen will readdress need to\n scope, will fold off for now\n - will follow with you\n"
},
{
"category": "Nursing",
"chartdate": "2115-02-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 625106,
"text": "HPI: 35M with Cerebral palsy,presented with abdominal pain and\n distention to an OSH this am where CT scan was performed and reported\n as diffused bowel edema,gastric varices, ascites, pancreatic cyst. No\n association with nausea,vomitting, diarrhea, hematemesis, hematochezia,\n no GU symptoms. No jaundice , no fevers. No weight loss, no NSAIDs, ASA\n use. Pt recieved Unasyn at the OSH and was transferred to .\n He had a history of GI bleed in , unclear source, recieved\n transfusion (). Last EGD and colonoscopy were done in\n , wnl according to mother. Pancreatic cyst was aspirated in\n 6/. Laprascopic cholecystectomy done in .\n Chief complaint: respiratory distress, peritonitis, SMV occlusion\n PMHx: Cerebral Palsy (Patient non verbal baseline), Seizure d/o,\n chronic anemia (transfusion x2)\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received extubated on 5L NC, POX: 94-97%, RR: 17-32. LS:\n Rhoncherous. Impaired gag and cough.\n Patient unable to follow commands for coughing, deep\n breathing, or to expectorate secretions.\n 2200 patient oxygenation saturation decreased to the low\n 80\n Action:\n Chest PT every 1-2 hours.\n Suctioned for copious amounts of thick tinged oral\n secretions.\n Patient placed on high flow aerosol mask and then a NRB\n without improvement. POX: Remained in the mid-high 80\ns. RR: 30-40\n 10mg IVP Lasix given.\n MD notified of respiratory status and present during\n all interventions. Patient was intubated due to poor oxygenation and\n tachypnea.\n Sedated on Propofol for comfort.\n MD spoke with parents regarding need for\n re-intubation.\n Response:\n Good diuresis with IVP Lasix.\n Plan:\n .H/O abdominal pain (including abdominal tenderness)\n Assessment:\n T-max: 101.6.\n Abdomen SD, +BSx4,S,tender.\n L-nare NGT with residual of 100cc of bilious/brown\n drainage.\n Flexi-seal with brown liquid stool.\n Continues on a Heparin drip for SMV thrombosis.\n Patient appearing to grimace in pain.\n Action:\n Patient pancultured and 325mg Tylenol given.\n Heparin drip adjusted per Heparin sliding scale. Goal PTT is\n between 60-100.\n Remains NPO except for medications. At 1800 NGT residual\n greater than 100cc-placed to CLW with bilious/brown drainage.\n Vancomycin/Zosyn administered MD order.\n IVP Fentanyl given with good pain relief.\n Response:\n Plan:\n Continue to follow fever curve and WBC\n Adjust Heparin drip per Heparin sliding scale. Goal PTT:\n 60-100.\n Provide supportive care to patient and family.\n Social work consult.\n"
},
{
"category": "Nursing",
"chartdate": "2115-02-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 625107,
"text": "HPI: 35M with Cerebral palsy,presented with abdominal pain and\n distention to an OSH this am where CT scan was performed and reported\n as diffused bowel edema,gastric varices, ascites, pancreatic cyst. No\n association with nausea,vomitting, diarrhea, hematemesis, hematochezia,\n no GU symptoms. No jaundice , no fevers. No weight loss, no NSAIDs, ASA\n use. Pt recieved Unasyn at the OSH and was transferred to .\n He had a history of GI bleed in , unclear source, recieved\n transfusion (). Last EGD and colonoscopy were done in\n , wnl according to mother. Pancreatic cyst was aspirated in\n 6/. Laprascopic cholecystectomy done in .\n Chief complaint: respiratory distress, peritonitis, SMV occlusion\n PMHx: Cerebral Palsy (Patient non verbal baseline), Seizure d/o,\n chronic anemia (transfusion x2)\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received extubated on 5L NC, POX: 94-97%, RR: 17-32. LS:\n Rhoncherous. Impaired gag and cough.\n Patient unable to follow commands for coughing, deep\n breathing, or to expectorate secretions.\n 2200 patient oxygenation saturation decreased to the low\n 80\n Action:\n Chest PT every 1-2 hours.\n Suctioned for copious amounts of thick tinged oral\n secretions.\n Patient placed on high flow aerosol mask and then a NRB\n without improvement. POX: Remained in the mid-high 80\ns. RR: 30-40\n 10mg IVP Lasix given.\n MD notified of respiratory status and present during\n all interventions. Patient was intubated due to poor oxygenation and\n tachypnea.\n Sedated on Propofol for comfort.\n MD spoke with parents regarding need for\n re-intubation.\n Response:\n Good diuresis with IVP Lasix.\n Plan:\n .H/O abdominal pain (including abdominal tenderness)\n Assessment:\n T-max: 101.6.\n Abdomen SD, +BSx4,S,tender.\n L-nare NGT with residual of 100cc of bilious/brown\n drainage.\n Flexi-seal with brown liquid stool.\n Continues on a Heparin drip for SMV thrombosis.\n Patient appearing to grimace in pain.\n Action:\n Patient pan-cultured and 325mg Tylenol given.\n Heparin drip adjusted per Heparin sliding scale. Goal PTT is\n between 60-80.\n Remains NPO except for medications. At 1800 NGT residual\n greater than 100cc-placed to CLW with bilious/brown drainage.\n Vancomycin/Zosyn administered MD order.\n IVP Fentanyl given with good pain relief.\n Response:\n Plan:\n Continue to follow fever curve and WBC\n Adjust Heparin drip per Heparin sliding scale. Goal PTT:\n 60-80.\n Provide supportive care to patient and family.\n Social work consult.\n"
},
{
"category": "Respiratory ",
"chartdate": "2115-02-19 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 625108,
"text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 2\n Ideal body weight: 43.7 None\n Ideal tidal volume: 174.8 / 262.2 / 349.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: ICU\n Reason: Re-intubation\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 24 cmH2O\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Secretions\n Sputum color / consistency: Tinged / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Frequent desaturation episodes\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n"
},
{
"category": "Nursing",
"chartdate": "2115-02-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 625402,
"text": "Hypotension (not Shock) and Bradycardia\n Assessment:\n Hypotensive to SBP 60\ns x 2 episodes today\n Bradycardic to 40\ns, HR baseline 80\ns-90\ns prior to today\n Concerning to have bradycardia and hypotension in setting of\n possible hypovolemia with no beta blockers given this admission\n Action:\n LR 500 cc bolus\ns x2\n EKG done\n Electrolytes sent\n HCT 25.6 (24.1)\n \n Transferred to MICU service\n No S+S of active bleeding\n Response:\n HR and BP improved\n Plan:\n Continue to closely monitor vitals\n Follow up on pending labs and cultures\n ? Neurologic component? Seizure activity? Pt\ns mother does\n not believe he is seizing. MICU team discussing.\n .H/O abdominal pain (including abdominal tenderness)\n Assessment:\n Abdomen softly distended\n + bs\n NGT to LCWS with bilious drainage\n Flexi seal with decreased liquid stool output, ~ 50 cc\n this shift with also some leakage around tube at rectum\n Action:\n NPO\n NGT\n Fentanyl x1 this shift for discomfort with turning\n Response:\n Stooling has decreased\n Abdomen remains softly distended\n Plan:\n Continue to monitor\n Continue NPO\n Follow up with primary team regarding when trophic tube\n feeds would be appropriate.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n O2 Sats ~100% on SIMV\n ETT suction for minimal blood tinged sputum\n Action:\n Vent changed to CPAP + PS\n VAP protocol\n Repositioned frequently\n HOB > 30 degrees\n Response:\n Initially had periods of apnea on CPAP, placed back on SIMV,\n then placed back on CPAP with good success so far\n Plan:\n Continue to wean vent as tolerated\n SBT in AM\n"
},
{
"category": "Physician ",
"chartdate": "2115-02-20 00:00:00.000",
"description": "MICU Resident Transfer Accept Note",
"row_id": 625414,
"text": "TITLE: MICU RESIDENT TRANSFER ACCEPT NOTE\n Chief complaint: Abdominal pain, distention\n Reason for MICU admission: Respiratory failure, sepsis\n History of Present Illness (Per review of medical record)\n 35 yo M with cerebral palsy who initially presented with\n abdominal pain and distention to an OSH. CT scan was performed and was\n reported as diffuse bowel edema, gastric varices, ascites and a\n pancreatic cyst. He reportedly had no associated nausea, vomiting,\n diarrhea, hematemesis, hematochezia, jaundice, fevers or dysuria. Also\n reported no recent weight loss, no NSAIDs or ASA use. In ED, his\n initial vitals temp 98.0 HR 100 BP 83/59 RR 20. He then received Unasyn\n at the OSH. Foley placed, recieved IVF and was transferred to .\n Patient was non-verbal, in distress.\n Per family, patient had multiple admissions prior for constipation,\n with a recent drainage of a pancreatic cyst this past year in . He has a bowel movement everyday except on the day of\n presentation to the OSH. He tolerated PO and was at his baseline the\n night of his presentation. His abdomen was distended and painful to\n palpation according to his mother, which is why she brought her son to\n the OSH.\n Upon transferred to and admitted to the SICU team given\n concern for an acute surgical abdomen. Diagnostic paracentesis ()\n with WBC (no growth so thought to be inflammatory state),\n Lipase 216, Amylase 141. He was started on Vanco/Zosyn/Flagyl for\n suspected peritonitis and ischemic bowel with translocation. He was\n then intubated (in the ED) for respiratory failure. A left\n subclavian line was placed on . He was then given Phenytoin but\n this was transitioned to Keppra the same day. On Vitamin K 1mg was\n infused. TPN started . He was continued on maintenance IVF\n with intermittent bolus but on was given Lasix. On he was\n started on Heparin gtt for SMV thrombus. Did have diarrhea, but\n improving over the course of admission. with 3L therapeutic /\n diagnostic paracentesis (negative culture to date, WBC 1390).\n Concerning his respiratory status, he was extubated (s/p 4 days of\n mechanical ventilation) and re-intubated given increased secretions\n and concern that he was unable to protect his airway. On Warfarin\n was started and Flagyl was discontinued. On Tobramycin was added\n for suspected untreated infection given lower blood pressures. Upon\n transfer there is no positive culture data. Patient has been febrile >\n 100.5 on and but without leukocytosis. Also with\n persisent tachycardia > 100 bpm except for and . CTA Abdomen /\n pelvis with SMV thrombus, Vascular surgery consulted and thought it was\n likely a chronic issue given degree of collaterals and probably due to\n chronic pancreatic inflammation with associated vascular congestion and\n slowing.\n Given no acute surgical issues, patient was transferred to the Medical\n ICU team on . Upon initial evaluation, family at bedside\n confirms that he felt unwell for about one week prior to admission. He\n is nonverbal at baseline, but will push your hand away if you push his\n abdomen and he's in pain. Otherwise, no localizing symptoms.\n Past Medical History\n Cerebral Palsy\n Seizure disorder\n Chronic anemia - Hct 35\n GIB in \n h/o liver cyst drainage (, )\n H/o Laproscopic cholecystectomy\n H/o pancreatic cyst drainage with chronic pancreatitis\n Medications (Upon admission)\n Miralax prn\n Phenobarbital 32.4 mg TAB am, 1PM\n Dilantin (Extended caps) 75mg in am 100mg in pm\n Ferrous Fumarate 324 mg Tabs daily\n MVI daily\n Cyproheptadine HCL 4mg tabs 0.5 tab in AM, 0.5 tabs in PM\n Prilosec 20mg daily\n Celexa 20mg daily\n Zovirax 5% oint (acyclovir) q2hr while awake x 4 days prn cold sore\n vitamine D 400 Unit Caps\n Medications (Upon transfer to MICU service)\n Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN low oxygen sats\n Piperacillin-Tazobactam 4.5 g IV Q8H\n Midazolam 0.5-1 mg IV Q4H:PRN comfort of ETT\n Fentanyl Citrate 12.5-100 mcg IV Q2H:PRN pain\n Pantoprazole 40 mg IV Q12H\n Magnesium Sulfate IV Sliding Scale\n Calcium Gluconate IV Sliding Scale\n LeVETiracetam 1000 mg IV Q12H\n Insulin SC (per Insulin Flowsheet) Sliding Scale\n Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol\n Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol\n Acetaminophen 325 mg PO/NG Q6H:PRN fever, pain\n Potassium Chloride IV Sliding Scale\n Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL \n Tobramycin 220 mg IV Q24H\n Vancomycin 1250 mg IV Q 12H\n Heparin IV Sliding Scale\n Warfarin 5 mg PO/NG DAILY16\n Allergies: NKDA\n Family History\n NC, Maternal grandmother had DM, paternal grandfather had HTN, parents\n healthy.\n Social History\n Lives at home with family, goes to school 5 days a week, no recent\n travels, no smoke/drink/IVDU.\n Physical Exam:\n 98.3, 79, 100/70, 22, 100% SIMV , 12, TV 300, 50% CVP 13\n Gen: Thin, no apparent distress but slight tearing in left eye; alert\n HEENT: Sclera anicteric, eyes sunken, MMM, ET in place\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally anteriorly, no wheezes, rales,\n ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, flat, patient pushes hand away with palpation in\n LUQ/LLQ, bowel sounds present, no guarding, unable to assess rebound\n tenderness\n GU: Foley in place\n Ext: warm, very thin, cannot palpate radial pulses or DP b/l, no\n cyanosis or edema\n \n 08:19a\n _______________________________________________________________________\n Source: Line-tlcl\n 141\n [image002.gif]\n 106\n [image002.gif]\n 11\n [image004.gif]\n 132\n AGap=9\n [image005.gif]\n 4.3\n [image002.gif]\n 30\n [image002.gif]\n 0.7\n [image007.gif]\n Comments:\n Glucose: If Fasting, 70-100 Normal, >125 Provisional Diabetes\n CK: 29\n MB: Notdone\n Trop-T: <0.01\n Comments:\n CK(CPK): New Reference Interval As Of ;Upper Limit (97.5th %Ile)\n Varies With Ancestry And Gender (Male/Female);Whites 322/201 Blacks\n 801/414 Asians 641/313\n cTropnT: Ctropnt > 0.10 Ng/Ml Suggests Acute Mi\n Ca: 7.9 Mg: 2.8 P: 4.2\n Source: Line-tlcl\n [image007.gif]\n [image004.gif]\n [image008.gif]\n [image004.gif]\n 24.1\n [image007.gif]\n Imaging:\n CT Scan (OSH):\n Massive ascites and diffuse mesenteric edema. Diffused small bowel\n dilatation with mildly thickened folds. Diffused moderate edema of the\n colon with a thickened nodular wall., Distened rectum with thickened\n wall. 4.5 x 2.3 x 1.4 cm pancreatic cyst with a veritical orientation.\n S/P cholecystectomy, Moderate dextroconvex thoracolumbar scoliosis. B/L\n lower lobe subsegmental atelectasis, small pleural effusion. Focal\n areas of abnormal attnuation/enhancement in the liver.\n CTA ABD/PELVIS W&W/O C & RECONS Study Date of \n 1. Diffusely abnormal gastrointestinal tract with mucosal\n hyperenhancement and wall thickening. Given the finding of SMV\n occlusion, findings are highly concerning for venous\n congestion/ischemia. An element of shock bowel could also be a\n possibility. There is occlusion of the SMV at the level of the portal\n confluence. More inferiorly, the SMV is patent, as is the IMV, and\n distal branches appear patent. Numerous venous collateral branches are\n seen in the upper abdomen and in the region of SMV occlusion.\n 2. Hyperenhancement of the adrenal glands and narrowed distal aorta,\n iliac and femoral vessels, suggesting hypovolemia/shock. Correlate\n clinically.\n 3. Sequelae of chronic pancreatitis with a rim-enhancing fluid\n collection in the region of the pancreatic head, likely representing\n pseudocyst. This may be the etiology of SMV thrombosis.\n 4. Diffusely abnormal hepatic parenchyma, consistent with the history\n of hepatitis. Partially occlusive right portal vein thrombus.\n 5. Small bilateral pleural effusions, increased from the prior exam.\n Ground- glass and nodular opacities at the lung bases suggesting\n infection.\n CHEST (PORTABLE AP) Study Date of \n In comparison with the study of , the monitoring and support\n devices are unchanged except that the nasogastric tip points away from\n the esophagogastric junction. The opacification at the left base is not\n appreciated, though this could merely represent shift in the appearance\n of the pleural effusion on a relatively image. Patchy\n opacification at the left base is worrisome for supervening pneumonia.\n Portable TTE (Focused views) Done \n Technically limited study; Overall left ventricular systolic function\n is normal (LVEF>55%). Right ventricular chamber size and free wall\n motion are normal. The number of aortic valve leaflets cannot be\n determined. The aortic valve leaflets are moderately thickened. At\n least mild to moderate aortic stenosis is present (but cannot be fully\n quantified). No aortic regurgitation is seen. There is no pericardial\n effusion.\n Impression\n 35 yo M with PMH of CP, seizure disorder, GIB, pancreatic cyst s/p\n drainage in , admitted with one week of abdominal discomfort, found\n to have SMV thrombus indicative of an acute on chronic process with\n diffuse bowel edema concerning for ischemia.\n PLAN\n # Abdominal pain: Patient with finding of SMV thrombus with collaterals\n indicative of a chronic process. Surgery and Vascular involved,\n suspect to low flow state in setting of chronic pancreatitis. No\n e/o malignancy at this point. Patient started on heparin gtt. Also\n with diffuse bowel edema concerning for bowel ischemia / congestion.\n No e/o localized infection overlying inflammation at this point (though\n s/p paracentesis x 2, both with > 1000 WBC). Given compromised bowel\n wall, at high risk for translocation of bacteria.\n - Continue Vanc / Zosyn (14 day total course)\n - Follow-up cultures\n - Transition to Lovenox (30 mg per Pharmacy given decreased renal\n function; if improves increase to 40 mg )\n - Vascular recs / Surgery recs\n - Resend C.diff if new leukocytosis, febrile\n - GI recommendations\n - Discuss NPO duration with surgery / GI\n - Once PO advanced; start Pancreatic enyzyme replacement\n # Respiratory failure: Treating for HAP/VAP with\n Vanc/Zosyn/Tobramycin. ID said no to Amikacin. With LLL infiltrate on\n CXR (persistent) but new since admission. Afebrile the night prior to\n transfer but with continued heavy secretions. No appreciable changes\n in ventilator settings. Following VBGs given too contracted for ABG.\n Family endorses heavy secretions at baseline.\n - Scopolamine patch (Cyproheptadine at home)\n - Goal fluid balance of even\n - VAP (Cefepime / Vanc) x 14 days total\n - Check NIF in AM (to assess for nueromuscular component)\n - Trial pressure support\n # Fever: Intermittent since admission on , . Could be \n ischemia; other possible sources of infection include pulmonary with\n some infiltrate on his CXR but he is without a leukocytosis. Does have\n prominent secretions per primary Surgical team.\n - Continue Vanc/Zosyn for HAP/VAP (14 days total)\n - Stop Tobramycin\n - Follow-up Micro\n - Culture if febrile\n - UA\n # Hypotension: Per family, patient's baseline BP high 70s - low 80s.\n Per nursing, also newly bradycardic and hypotensive (SBP 70s) overnight\n on . Could be vagal tone with ET/CVL but also consider\n infectious process. Previously responded to Albumin and 500cc bolus\n LR. Echo (final pending) Ef=55% and no focal wall motion\n abnormalities.\n - Monitor fluid balance\n - Goal SBP 80\n # SMV Occlusion: SMV occulsion with plan for 6 months anticoagulation\n per Vascular recommendation. Started on Heparin gtt for\n anticoagulation PTT 60-80, as well as daily Coumadin with Goal INR\n . Also noted to have diarrhea during stay (C.diff negative) thought\n to be lack of absorption due to bowel wall edema.\n - Per discussion with Vascular, no reason to not use Lovenox\n - Per discussion with pharmacy, will dose 30 mg SC BID (consider 40 mg\n if Cr improves)\n # Anemia: Unclear source for acute on chronic anemia (baseline 35) but\n now on anticoagulation. NG lavage / guaiac negative . Could\n consider some dilutional component, but likely does not explain\n complete loss\n - T&C x 2U PRBC\n - Monitor q8H Hct until stable\n - Continue to monitor stool guaiac\n # Renal insufficiency: Increased Cr to 0.7 from 0.4-0.5. Could be \n hypovolemia, infection (with Foley) vs medication reaction with AIN.\n - UA, Ulytes, UEos\n # Thrombocytopenia: New . With prior hospitalization, could\n consider new exposure to heparin with HIT. Other medications include\n antibiotics and Leviteracitam.\n - Stop heparin\n - Start Lovenox\n - Stop Keppra\n # Coagulopathy: Noted on admission; consider malnutrition vs\n malabsorption vs intrinsic liver disease.\n - Stop heparin, Coumadin\n - Start Lovenox \n # Hypoalbuminemia: Noted on arrival, with similar etiology to\n coagulopathy.\n - Restart TF; support nutrition as able\n - Discuss trophic TF with Surgery\n # Cerebral Palsy: Not ambulatory at baseline; also with h/o chronic,\n intermittent diarrhea; chronic pancreatitis. Could be an undiagnosed\n syndrome.\n - Seizure meds as below\n - Discuss with outpatient Neurology\n - Pancreatic enzymes as diet advances\n # Seizure disorder: Family describes them as 'drop seizures' with\n sudden head slumps. On Dilantin / Phenobarbital as outpatient.\n Patient transitioned to Keppra while inpatient.\n - Discuss restarting Dilantin / Phenobarbital safely with pharmacy\n - Touch base with outpatient Neurology Openheimer ()\n FEN Euvolemic to hypovolemic / replete PRN / NPO given bowel edema but\n planning on advancing soon\n PPX:\n - PPI\n - Chlorehexadine gluconate\n - Pneumoboots\n - Systemically anticoagulated\n ACCESS: L-Subclavian CL (); R PIV\n Communication: & \n CODE: FULL\n Dispo: ICU pending clinical improvement\n"
},
{
"category": "Physician ",
"chartdate": "2115-02-15 00:00:00.000",
"description": "Intensivist Note",
"row_id": 624569,
"text": "SICU\n HPI:\n 35M with Cerebral palsy,presented with abdominal pain and distention to\n an OSH this am where CT scan was performed and reported as diffused\n bowel edema,gastric varices, ascites, pancreatic cyst. No association\n with nausea,vomitting, diarrhea, hematemesis, hematochezia, no GU\n symptoms. No jaundice , no fevers. No weight loss, no NSAIDs, ASA use.\n Pt recieved Unasyn at the OSH and was transferred to .\n Chief complaint:\n respiratory distress, peritonitis, possible ischemic bowel\n PMHx:\n Cerebral Palsey (Patient non verbal baseline), Seizure d/o, Chronic\n anemia (transfusion x2)\n Current medications:\n 1000 mL LR 4. Acetaminophen 5. Albuterol 0.083% Neb Soln 6. Albumin 25%\n (12.5g / 50mL)\n 7. Calcium Gluconate 8. Dextrose 50% 9. Fentanyl Citrate 10. Glucagon\n 11. Heparin Flush (10 units/ml)\n 12. 13. Insulin 14. LeVETiracetam 15. Magnesium Sulfate 16.\n MetRONIDAZOLE (FLagyl) 17. Midazolam\n 18. Pantoprazole 19. Piperacillin-Tazobactam 20.\n Piperacillin-Tazobactam 21. Potassium Chloride 22. Sodium Chloride 0.9%\n Flush\n 23. Vancomycin\n 24 Hour Events:\n FEVER - 101.1\nF - 08:00 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 12:37 AM\n Metronidazole - 04:30 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 09:29 AM\n Pantoprazole (Protonix) - 08:00 PM\n Fentanyl - 03:00 AM\n Other medications:\n Flowsheet Data as of 04:46 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.4\nC (101.1\n T current: 37.1\nC (98.8\n HR: 108 (97 - 117) bpm\n BP: 92/69(75) {80/59(65) - 97/78(83)} mmHg\n RR: 29 (20 - 29) insp/min\n SPO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 35.4 kg (admission): 71 kg\n CVP: 12 (8 - 18) mmHg\n Total In:\n 8,837 mL\n 559 mL\n PO:\n Tube feeding:\n IV Fluid:\n 3,287 mL\n 559 mL\n Blood products:\n 50 mL\n Total out:\n 959 mL\n 195 mL\n Urine:\n 509 mL\n 195 mL\n NG:\n Stool:\n Drains:\n Balance:\n 7,878 mL\n 364 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 0 (0 - 300) mL\n Vt (Spontaneous): 320 (258 - 320) mL\n PS : 12 cmH2O\n RR (Set): 22\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 69\n PIP: 7 cmH2O\n SPO2: 99%\n ABG: ///25/\n Ve: 6.6 L/min\n Physical Examination\n General Appearance: Cachectic\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Distended, Peritoneal sign\n Labs / Radiology\n 177 K/uL\n 8.2 g/dL\n 74 mg/dL\n 0.5 mg/dL\n 25 mEq/L\n 3.3 mEq/L\n 13 mg/dL\n 115 mEq/L\n 144 mEq/L\n 26.2 %\n 9.3 K/uL\n [image002.jpg]\n 03:35 AM\n 12:11 PM\n 04:42 PM\n 03:27 AM\n WBC\n 9.3\n 9.3\n Hct\n 28.3\n 27.1\n 26.2\n Plt\n 226\n 177\n Creatinine\n 0.4\n 0.5\n 0.5\n Glucose\n 112\n 90\n 74\n Other labs: PT / PTT / INR:16.9/45.5/1.5, ALT / AST:, Alk-Phos / T\n bili:91/0.1, Amylase / Lipase:52/, Lactic Acid:0.7 mmol/L, Albumin:2.1\n g/dL, LDH:142 IU/L, Ca:7.7 mg/dL, Mg:2.2 mg/dL, PO4:2.2 mg/dL\n Assessment and Plan\n .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n Assessment and Plan: 35M with CP, peritonitis and ascites. Continuing\n work to detemrine etiology of SBP and monitor for ischemic colitis.\n Neurologic: Neurologic:\n --Intubated and sedated PRN Midazolam\n --Hx of Seizure disorder: switched from home dilantin to keppra while\n in ICU\n --Moves all extremities\n Cardiovascular: -- baseline SBP 80'S\n --Tachycardia O/N likely due to volume depletion and SBP, albumin\n given, Hr's decreased to ~100's\n Pulmonary: AM chest XRAY shows LLL PNA tx with vanco + zosyn , f/u\n sputum culture\n Gastrointestinal / Abdomen: --portal vein thrombosis\n SBP\n peritonitis w/ ascites, on antibiotic prophylaxis with vanc, zosyn,\n flagyl , f/u cultures, lactate decreasing\n -- C. Diff tests pending\n -- GI consult yesterday felt it was not prudent to scope at this time\n given risks of perforation\n -- F/U LFTs and Hepatitis serologies to identify cause of ascities\n -- Ischemic bowel seems unlikely at this time as lactate has remained\n low\n Nutrition: NPO, consider TPN\n Renal: --AUOP\n -- stable Cr\n Hematology: --Hct 34.6->28.3->26.2, most likely dilutional\n --elevated INR, PTT: likely secondary to nutritional depletion,\n trending down, continue vitamin K\n Endocrine: --RISS for glycemic control\n Infectious Disease: -- Abd Peritonits and infected ascities: On empiric\n coverage with vanc/flagyl/zosyn. Awaiting cultures to identify\n causitive organism.\n Lines / Tubes / Drains: PIV, Foley, Left sub clav ()\n Wounds:\n Imaging:\n Fluids:\n Consults: General surgery, GI\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 12:46 AM\n Multi Lumen - 03:15 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n Total time spent: 33 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2115-02-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 624769,
"text": ".H/O abdominal pain (including abdominal tenderness)\n Assessment:\n Tmax 100.7. hr 70\ns, sinus. sbp 80-100\ns. skin w+d.\n remains vented on cpap. Rested on mmv after fent dose d/t apnea. Now\n back on cpap. Ls cta. O2 sat 100%. Sm amt thick white sputum. Lg amt\n oral secretions.\n abd firm distended. +bs. Lg amt loose stool. Ngt to lws with bilious\n drg. Npo.\n foley with adeq amts cl yellow urine.\n k+ 2.3\n Action:\n rested on mmv after fent. No other vent changes,\n paracentesis done at bedside. 2.5 liters removed. Flexiseal placed.\n Cta abd done. Stool sent for cdiff and o+p.\n foley noted to be out. New foley placed with difficulty. Needed coude\n cath.\n lytes being repleted. On tpn.\n Response:\n tol cpap. Tol pareacentesis. Abd soft immed post paracentesis, although\n becoming firmer as shift progresses. Team aware. Leaking lg amt\n ascities from tap site.\n Plan:\n con\nt with current plan. Monitor for changes. Assess pain. Monitor abd.\n follow temp. con\nt to replete lytes. f/u cx and ct. support.\n"
},
{
"category": "Physician ",
"chartdate": "2115-02-20 00:00:00.000",
"description": "Intensivist Note",
"row_id": 625331,
"text": "SICU\n HPI:\n 35M with Cerebral palsy, presented with abdominal pain and distention\n to an OSH this am where CT scan was performed and reported as diffused\n bowel edema, gastric varices, ascites, pancreatic cyst. No association\n with nausea, vomitting, diarrhea, hematemesis, hematochezia, no GU\n symptoms. No jaundice, no fevers. No weight loss, no NSAIDs, ASA use.\n Pt recieved Unasyn at the OSH and was transferred to .\n Chief complaint:\n respiratory distress, peritonitis, SMV occlusion\n PMHx:\n Cerebral Palsy (Patient non verbal baseline), Seizure d/o, Chronic\n anemia (transfusion x2)\n .\n PSH:\n Lap cholecystectomy\n Pancreatic cyst drainage (last year, )\n Current medications:\n 1. 2. 3. Acetaminophen 4. Albumin 5% (12.5g / 250mL) 5. Albuterol\n 0.083% Neb Soln 6. Calcium Gluconate 7. Chlorhexidine Gluconate 0.12%\n Oral Rinse 8. Dextrose 50% 9. Fentanyl Citrate 10. Glucagon 11. Heparin\n 12. Heparin Flush (10 units/ml) 13. Insulin 14. LeVETiracetam 15.\n Magnesium Sulfate 16. Midazolam 17. Pantoprazole 18. Phenylephrine 19.\n Piperacillin-Tazobactam 20. Potassium Chloride 21. Sodium Chloride 0.9%\n Flush 22. Sodium Chloride 0.9% Flush 23. Tobramycin 24. Vancomycin 25.\n Warfarin\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 03:20 PM\n : Episode of hypotension to low 70's recieved a bolus of albumin w/\n good response. Vancomycine increased to 1250\". Started on tobramycin\n presumed to have pneumonia\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 03:53 AM\n Tobramycin - 12:04 PM\n Vancomycin - 08:26 PM\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium - 08:19 AM\n Midazolam (Versed) - 11:07 AM\n Pantoprazole (Protonix) - 08:00 PM\n Other medications:\n Flowsheet Data as of 04:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.9\nC (100.3\n T current: 36.5\nC (97.7\n HR: 93 (75 - 99) bpm\n BP: 93/68(74) {71/47(59) - 119/86(89)} mmHg\n RR: 22 (17 - 31) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 37.1 kg (admission): 32.3 kg\n Height: 55 Inch\n CVP: 8 (5 - 14) mmHg\n Total In:\n 2,674 mL\n 319 mL\n PO:\n Tube feeding:\n IV Fluid:\n 1,281 mL\n 121 mL\n Blood products:\n 250 mL\n Total out:\n 2,745 mL\n 420 mL\n Urine:\n 2,095 mL\n 420 mL\n NG:\n 350 mL\n Stool:\n Drains:\n Balance:\n -71 mL\n -101 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: SIMV/PSV/AutoFlow\n Vt (Set): 300 (300 - 300) mL\n Vt (Spontaneous): 341 (291 - 341) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 8\n PEEP: 8 cmH2O\n FiO2: 50%\n PIP: 22 cmH2O\n Plateau: 17 cmH2O\n SPO2: 99%\n ABG: ///30/\n Ve: 8.8 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: Crackles : Bilateral)\n Abdominal: Soft, Distended\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Neurologic: Follows simple commands, Moves all extremities, alert\n Labs / Radiology\n 109 K/uL\n 8.9 g/dL\n 98 mg/dL\n 0.5 mg/dL\n 30 mEq/L\n 4.3 mEq/L\n 9 mg/dL\n 104 mEq/L\n 142 mEq/L\n 27.1 %\n 7.6 K/uL\n [image002.jpg]\n 02:48 AM\n 06:09 AM\n 03:11 PM\n 04:05 AM\n 02:40 PM\n 02:29 AM\n 04:00 PM\n 01:32 AM\n 03:31 AM\n 01:00 AM\n WBC\n 10.6\n 8.7\n 9.4\n 10.1\n 7.6\n Hct\n 29.1\n 31.6\n 32.9\n 30.9\n 29.2\n 28.6\n 27.1\n Plt\n 179\n 139\n 107\n 110\n 109\n Creatinine\n 0.4\n 0.5\n 0.5\n 0.5\n 0.4\n 0.4\n 0.4\n 0.5\n TCO2\n 25\n 36\n Glucose\n 134\n 80\n 118\n 137\n 141\n 104\n 106\n 98\n Other labs: PT / PTT / INR:15.8/129.8/1.4, ALT / AST:, Alk-Phos /\n T bili:80/0.3, Amylase / Lipase:62/19, Lactic Acid:0.9 mmol/L,\n Albumin:2.5 g/dL, LDH:158 IU/L, Ca:8.2 mg/dL, Mg:3.0 mg/dL, PO4:3.8\n mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), .H/O ABDOMINAL PAIN\n (INCLUDING ABDOMINAL TENDERNESS)\n Assessment and Plan: 35M with CP, chronic pancreatitis, transudative\n ascites and peritonitis likely SMV occlusion, now on hep gtt.\n Neurologic:\n - Pre-existing seizure disorder -> Keppra 20 .\n - Pain seems to be well controlled.\n - Baseline mental status\n -Intubated off sedation\n Cardiovascular:\n - HR and BP holding stable\n --ECHO: EF 55% f/up final read\n Pulmonary:\n - Respiratory failure: now reintubated, requiring aggresive pulm\n toilet, chest PT and suctioning due to secretions\n --Wean the vent as tolerated\n --F/up sputum Cx\n Gastrointestinal / Abdomen:\n - On empiric ABX for peritonitis. Work up for ascities on-going. F/U\n Cx\n --CTA revealed SMV occlusion, venous stasis--->On hep gtt\n -- Diarrhea: likely due to lack of absorption d/t bowel wall edema,\n Flagyl d/c'd, C diff negative\n -- Pantoprazole for GI proph\n --NGT output tinged w/ blood, hct stable\n Nutrition: TPN\n Renal:\n --stable urine output, lasix \n --Hypokalemia, monitoring and getting repleted\n --Patient on tobramycin and vancomycin monitor Renal function closely\n Hematology:\n - Slowly worsening anemia secondary to dilution, inflammation, and\n pre-existing chronic anemia.\n - Elevated INR & PTT secondary to the nutritional depletion.\n -S/P Transfusion 2UPRBC for Hct of 26 on , Stable 29-31---Hct 27\n on \n On hep gtt for SMV occlusion (goal 60-80)\n -coumadin started on (3)\n Endocrine:\n - RISS with adequate BG control.\n Infectious Disease:\n - Abdominal peritonitis - on empiric coverage with vanc/zosyn and\n tobramycine to covert pseudomonas pnemonia\n - F/u cultures\n - suspected pneumonia and at risk MDR HAP added tobramycin, f/u AM\n trough level (goal less than 1)\n Lines / Tubes / Drains: ETT, PIV, Foley, Left sub clav ()\n Wounds:\n Imaging: CXR today\n Fluids: KVO\n Consults: General surgery\n Billing Diagnosis: (Respiratory distress: Failure)\n ICU Care\n Nutrition:\n TPN w/ Lipids - 06:08 PM 46 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 03:15 AM\n 20 Gauge - 12:17 PM\n Prophylaxis:\n DVT: Boots (Systemic anticoagulation: Heparin drip)\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Respiratory ",
"chartdate": "2115-02-16 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 624652,
"text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 3\n Ideal body weight: 43.7 None\n Ideal tidal volume: 174.8 / 262.2 / 349.6 mL/kg\n Airway\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 24 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Copious\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Underlying illness not resolved\n"
},
{
"category": "Nursing",
"chartdate": "2115-02-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 625102,
"text": "HPI: 35M with Cerebral palsy,presented with abdominal pain and\n distention to an OSH this am where CT scan was performed and reported\n as diffused bowel edema,gastric varices, ascites, pancreatic cyst. No\n association with nausea,vomitting, diarrhea, hematemesis, hematochezia,\n no GU symptoms. No jaundice , no fevers. No weight loss, no NSAIDs, ASA\n use. Pt recieved Unasyn at the OSH and was transferred to .\n He had a history of GI bleed in , unclear source, recieved\n transfusion (). Last EGD and colonoscopy were done in\n , wnl according to mother. Pancreatic cyst was aspirated in\n 6/. Laprascopic cholecystectomy done in .\n Chief complaint: respiratory distress, peritonitis, SMV occlusion\n PMHx: Cerebral Palsy (Patient non verbal baseline), Seizure d/o,\n chronic anemia (transfusion x2)\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received extubated on 5L NC, POX:\n Action:\n Response:\n Plan:\n .H/O abdominal pain (including abdominal tenderness)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2115-02-20 00:00:00.000",
"description": "MICU Attending Accept Note",
"row_id": 625397,
"text": "MICU ATTENDING TRANSFER NOTE\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n Resident admission note by Dr. of todays\ns date, including\n the assessment and plan. I would emphasize and add the following\n points: 35M CP, seizures admitted to SICU with diffuse bowel edema,\n peritonitis, varicies - w/u notable for SMV thrombosis, started on\n anticoagulation, treated with broad antibiotic coverage. Initially\n intubated in the ED, extubated for one day but reintubated for\n secretions and respiratory distress.\n Exam notable for Tm BP 100/70 HR 74 RR with 99 sat on SIMV. Hypoteloric\n man, thin, NAD. LSC CVL. CTA B. RRR s1s2. Soft +BS. No edema / cord /\n rash. Labs notable for WBC 7K, HCT 24, K+ 4.3, Cr 0.7, PTT 90. CXR with\n patchy LLL pneumonia.\n Agree with plan to manage ongoing respiratory failure with transition\n to low level PSV with close monitoring, check muscle forces, treat\n pneumonia with vanco / zosyn, and add scopalomine patch for secretions.\n For SMV thrombosis - likely chronic / triggered by pancreatitis,\n continue heparin / warfarin (likely poorly absorbed given slow bump in\n INR), will add pancreatic enzyme when starting POs and work to\n transition off TPN using trophic feeds and serial LFTs / lipase. For\n pneumonia / fevers - pancx, continue vanco / zosyn x14d, stop tobra.\n For non-oliguric ARF with elevation in creatinine, RD meds, optimize\n hemodynamics, check lytes / eos / sed. Thrombocytopenia - check HIT\n (continue heparin for now), monitor, may need to change\n anticoagulation. For anemia, guiac stools, BBS. For seizures - will\n transition back to home regimen and wean keppra to off and d/w outpt\n neurologist. Remainder of plan as outlined above.\n Patient is critically ill\n Total time: 50 min\n"
},
{
"category": "Physician ",
"chartdate": "2115-02-21 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 625464,
"text": "24 Hour Events:\n No events overnight. Pt w/ SBP in 60s-80s. Remains intubated.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Tobramycin - 12:15 PM\n Vancomycin - 08:30 PM\n Piperacillin/Tazobactam (Zosyn) - 12:10 AM\n Infusions:\n Other ICU medications:\n Fentanyl - 09:30 AM\n Pantoprazole (Protonix) - 09:00 PM\n Dilantin - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 38\nC (100.4\n HR: 71 (49 - 94) bpm\n BP: 70/48(54) {62/44(49) - 108/81(88)} mmHg\n RR: 29 (16 - 41) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 29.3 kg (admission): 32.3 kg\n Height: 55 Inch\n CVP: 14 (9 - 17)mmHg\n Total In:\n 3,597 mL\n 820 mL\n PO:\n TF:\n 85 mL\n IVF:\n 2,433 mL\n 350 mL\n Blood products:\n Total out:\n 2,620 mL\n 717 mL\n Urine:\n 1,770 mL\n 467 mL\n NG:\n 350 mL\n Stool:\n Drains:\n Balance:\n 977 mL\n 103 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 300 (300 - 300) mL\n Vt (Spontaneous): 264 (147 - 322) mL\n PS : 8 cmH2O\n RR (Set): 14\n RR (Spontaneous): 28\n PEEP: 0 cmH2O\n FiO2: 50%\n RSBI: 186\n PIP: 8 cmH2O\n Plateau: 17 cmH2O\n SpO2: 100%\n ABG: ///29/\n NIF: -21 cmH2O\n Ve: 6.2 L/min\n Physical Examination\n Gen:\n Resp:\n Cards:\n Abd:\n Ext:\n Neuro:\n Labs / Radiology\n 122 K/uL\n 8.0 g/dL\n 118 mg/dL\n 1.0 mg/dL\n 29 mEq/L\n 5.5 mEq/L\n 15 mg/dL\n 109 mEq/L\n 140 mEq/L\n 24.8 %\n 6.5 K/uL\n [image002.jpg]\n 02:40 PM\n 02:29 AM\n 04:00 PM\n 01:32 AM\n 03:31 AM\n 01:00 AM\n 08:19 AM\n 04:27 PM\n 10:27 PM\n 04:15 AM\n WBC\n 9.4\n 10.1\n 7.6\n 6.5\n Hct\n 30.9\n 29.2\n 28.6\n 27.1\n 24.1\n 25.6\n 17\n 24.8\n Plt\n 107\n 110\n 109\n 122\n Cr\n 0.5\n 0.4\n 0.4\n 0.4\n 0.5\n 0.7\n 0.8\n 1.0\n TropT\n <0.01\n TCO2\n 36\n Glucose\n 137\n 141\n 104\n 106\n 98\n 132\n 109\n 118\n Other labs: PT / PTT / INR:17.0/29.2/1.5, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:, Alk Phos / T Bili:80/0.3,\n Amylase / Lipase:62/19, Lactic Acid:0.9 mmol/L, Albumin:2.5 g/dL,\n LDH:158 IU/L, Ca++:8.1 mg/dL, Mg++:2.8 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n TPN w/ Lipids - 06:02 PM 46 mL/hour\n Ensure (Full) - 12:00 AM 20 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 03:15 AM\n 20 Gauge - 12:17 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2115-02-21 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 625465,
"text": "24 Hour Events:\n No events overnight. Pt w/ SBP in 60s-80s. Remains intubated.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Tobramycin - 12:15 PM\n Vancomycin - 08:30 PM\n Piperacillin/Tazobactam (Zosyn) - 12:10 AM\n Infusions:\n Other ICU medications:\n Fentanyl - 09:30 AM\n Pantoprazole (Protonix) - 09:00 PM\n Dilantin - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 38\nC (100.4\n HR: 71 (49 - 94) bpm\n BP: 70/48(54) {62/44(49) - 108/81(88)} mmHg\n RR: 29 (16 - 41) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 29.3 kg (admission): 32.3 kg\n Height: 55 Inch\n CVP: 14 (9 - 17)mmHg\n Total In:\n 3,597 mL\n 820 mL\n PO:\n TF:\n 85 mL\n IVF:\n 2,433 mL\n 350 mL\n Blood products:\n Total out:\n 2,620 mL\n 717 mL\n Urine:\n 1,770 mL\n 467 mL\n NG:\n 350 mL\n Stool:\n Drains:\n Balance:\n 977 mL\n 103 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 300 (300 - 300) mL\n Vt (Spontaneous): 264 (147 - 322) mL\n PS : 8 cmH2O\n RR (Set): 14\n RR (Spontaneous): 28\n PEEP: 0 cmH2O\n FiO2: 50%\n RSBI: 186\n PIP: 8 cmH2O\n Plateau: 17 cmH2O\n SpO2: 100%\n ABG: ///29/\n NIF: -21 cmH2O\n Ve: 6.2 L/min\n Physical Examination\n Gen:\n Resp:\n Cards:\n Abd:\n Ext:\n Neuro:\n Labs / Radiology\n 122 K/uL\n 8.0 g/dL\n 118 mg/dL\n 1.0 mg/dL\n 29 mEq/L\n 5.5 mEq/L\n 15 mg/dL\n 109 mEq/L\n 140 mEq/L\n 24.8 %\n 6.5 K/uL\n [image002.jpg]\n 02:40 PM\n 02:29 AM\n 04:00 PM\n 01:32 AM\n 03:31 AM\n 01:00 AM\n 08:19 AM\n 04:27 PM\n 10:27 PM\n 04:15 AM\n WBC\n 9.4\n 10.1\n 7.6\n 6.5\n Hct\n 30.9\n 29.2\n 28.6\n 27.1\n 24.1\n 25.6\n 17\n 24.8\n Plt\n 107\n 110\n 109\n 122\n Cr\n 0.5\n 0.4\n 0.4\n 0.4\n 0.5\n 0.7\n 0.8\n 1.0\n TropT\n <0.01\n TCO2\n 36\n Glucose\n 137\n 141\n 104\n 106\n 98\n 132\n 109\n 118\n Other labs: PT / PTT / INR:17.0/29.2/1.5, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:, Alk Phos / T Bili:80/0.3,\n Amylase / Lipase:62/19, Lactic Acid:0.9 mmol/L, Albumin:2.5 g/dL,\n LDH:158 IU/L, Ca++:8.1 mg/dL, Mg++:2.8 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n # Abdominal pain: Patient with finding of SMV thrombus with collaterals\n indicative of a chronic process. Surgery and Vascular involved,\n suspect to low flow state in setting of chronic pancreatitis. No\n e/o malignancy at this point. Patient started on heparin gtt. Also\n with diffuse bowel edema concerning for bowel ischemia / congestion.\n No e/o localized infection overlying inflammation at this point (though\n s/p paracentesis x 2, both with > 1000 WBC). Given compromised bowel\n wall, at high risk for translocation of bacteria.\n - Continue Vanc / Zosyn (14 day total course)\n - Follow-up cultures\n - Transition to Lovenox (30 mg per Pharmacy given decreased renal\n function; if improves increase to 40 mg )\n - Vascular recs / Surgery recs\n - Resend C.diff if new leukocytosis, febrile\n - GI recommendations\n - Started on Tube feeds overnight\n .\n # Respiratory failure: Treating for HAP/VAP with\n Vanc/Zosyn/Tobramycin. ID said no to Amikacin. With LLL infiltrate on\n CXR (persistent) but new since admission. Afebrile the night prior to\n transfer but with continued heavy secretions. No appreciable changes\n in ventilator settings. Following VBGs given too contracted for ABG.\n Family endorses heavy secretions at baseline.\n - Scopolamine patch (Cyproheptadine at home)\n - Goal fluid balance of even\n - VAP (Cefepime / Vanc) x 14 days total\n - Check NIF in AM (to assess for nueromuscular component)\n - Trial pressure support\n # Fever: Intermittent since admission on , . Could be \n ischemia; other possible sources of infection include pulmonary with\n some infiltrate on his CXR but he is without a leukocytosis. Does have\n prominent secretions per primary Surgical team.\n - Continue Vanc/Zosyn for HAP/VAP (14 days total)\n - Stop Tobramycin\n - Follow-up Micro\n - Culture if febrile\n - UA\n # Hypotension: Per family, patient's baseline BP high 70s - low 80s.\n Per nursing, also newly bradycardic and hypotensive (SBP 70s) overnight\n on . Could be vagal tone with ET/CVL but also consider\n infectious process. Previously responded to Albumin and 500cc bolus\n LR. Echo (final pending) Ef=55% and no focal wall motion\n abnormalities.\n - Monitor fluid balance\n - Goal SBP 80\n # SMV Occlusion: SMV occulsion with plan for 6 months anticoagulation\n per Vascular recommendation. Started on Heparin gtt for\n anticoagulation PTT 60-80, as well as daily Coumadin with Goal INR\n . Also noted to have diarrhea during stay (C.diff negative) thought\n to be lack of absorption due to bowel wall edema.\n - Per discussion with Vascular, no reason to not use Lovenox\n - Per discussion with pharmacy, will dose 30 mg SC BID (consider 40 mg\n if Cr improves)\n # Anemia: Unclear source for acute on chronic anemia (baseline 35) but\n now on anticoagulation. NG lavage / guaiac negative . Could\n consider some dilutional component, but likely does not explain\n complete loss\n - T&C x 2U PRBC\n - Monitor q8H Hct until stable\n - Continue to monitor stool guaiac\n # Renal insufficiency: Increased Cr to 0.7 from 0.4-0.5. Could be \n hypovolemia, infection (with Foley) vs medication reaction with AIN.\n - UA, Ulytes, UEos\n # Thrombocytopenia: New . With prior hospitalization, could\n consider new exposure to heparin with HIT. Other medications include\n antibiotics and Leviteracitam.\n - Stop heparin\n - Start Lovenox\n - Stop Keppra\n # Coagulopathy: Noted on admission; consider malnutrition vs\n malabsorption vs intrinsic liver disease.\n - Stop heparin, Coumadin\n - Start Lovenox \n # Hypoalbuminemia: Noted on arrival, with similar etiology to\n coagulopathy.\n - Restart TF; support nutrition as able\n - Discuss trophic TF with Surgery\n # Cerebral Palsy: Not ambulatory at baseline; also with h/o chronic,\n intermittent diarrhea; chronic pancreatitis. Could be an undiagnosed\n syndrome.\n - Seizure meds as below\n - Discuss with outpatient Neurology\n - Pancreatic enzymes as diet advances\n # Seizure disorder: Family describes them as 'drop seizures' with\n sudden head slumps. On Dilantin / Phenobarbital as outpatient.\n Patient transitioned to Keppra while inpatient.\n - Discuss restarting Dilantin / Phenobarbital safely with pharmacy\n - Touch base with outpatient Neurology Openheimer ()\n FEN Euvolemic to hypovolemic / replete PRN / NPO given bowel edema but\n planning on advancing soon\n PPX:\n - PPI\n - Chlorehexadine gluconate\n - Pneumoboots\n - Systemically anticoagulated\n ACCESS: L-Subclavian CL (); R PIV\n Communication: & \n CODE: FULL\n Dispo: ICU pending clinical improvement\n ICU Care\n Nutrition:\n TPN w/ Lipids - 06:02 PM 46 mL/hour\n Ensure (Full) - 12:00 AM 20 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 03:15 AM\n 20 Gauge - 12:17 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2115-02-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 625542,
"text": "Hypotension (not Shock)\n Assessment:\n Patient\ns SBP 70\ns-80\ns, MAP down to low 50\ns x 1,\n u/o down to 17 cc/hr, Creat up to 1 this am.\n Action:\n Given 250 cc fluid bolus for hypotension and 500 cc fluid bolus for low\n u/o x 2\n Repeat lytes sent\n Response:\n Urine output increased to 50-100 cc/hr,\n Creat up to 1.2 this evening (MICU team made aware)\n Plan:\n Fluid bolus as needed for Map < 60 and low u/o\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient intubated on CPAP 0/8, RR 20\ns-40\ns (patient breathes fast\n normally per mother). 50% fiO2 sating 99-100%.\n Suctioned for moderate amount of thick white secretions down ET tube,\n copious amounts of oral secretions.\n Action:\n SBT done,\n VBG sent (pH 7.37, pCo2- 40)\n Extubated, put on 70% face tent\n TF\ns held for extubation.\n Weaned to 50% fiO2 on face tent\n Response:\n Patient couging, appears to be choking on secretions at times, able to\n cough and swallow secretions.\n Sating 94-100% on 50% fiO2 on face tent\n Plan:\n Continue to monitor.\n .H/O abdominal pain (including abdominal tenderness)\n Assessment:\n Abdomen is soft and slightly distended.\n Does not appear to be painful to palpation,\n On tube feeds at 20 cc/hr at start of shift with minimal residuals.\n Action:\n TF\ns turned off prior to extubation for a few hours,\n NG to suction.\n TPN paused for potassium content (K 5.5 this am)\n CDiff specimen sent\n TF\ns resumed later in afternoon.\n Response:\n Continues to have liquid green/brown stool output from flexicele\n Plan:\n Continue to monitor.\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n Potassium 5.5 this am.\n Action:\n Given kayexelate (however unsure how much was absorbed because NG to\n suction prior to extubation) ,\n TPN paused due to high K+ content\n Response:\n Evening potassium\n 4.9 (given second dose of kayexelate in afternoon),\n evening TPN restarted as well.\n Plan:\n Continue to monitor, follow up lytes.\n"
},
{
"category": "Nursing",
"chartdate": "2115-02-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 625547,
"text": "Hypotension (not Shock) and Bradycardia\n Assessment:\n Repeat episode of hypotension with SBP in lower 60\n Bradycardic to 40\ns during hypotensive episode\n Action:\n NS 250cc bolus x2.\n Heparin gtts discontinued at 2100.\n Response:\n HR and BP improved to baseline.\n Plan:\n Continue to closely monitor vitals.\n Commence lovenox regimen in am.\n Maintain map>60.\n .H/O abdominal pain (including abdominal tenderness)\n Assessment:\n Abdomen soft slightly distended.\n Bowel sounds active.\n NGT initially draining small amount of bile to LCWS.\n Flexi seal with decreased liquid stool output.\n TPN continued.\n Action:\n Started tube feeds at 10cc/h at midnight via NGT.\n Flexiseal cuff deflated, removed and replaced.\n Fentanyl 12.5mg x1 this shift for discomfort with turning.\n Response:\n Immediately passed 200cc green liquid stool when flexiseal\n reinserted.\n Abdomen remains softly distended.\n Tolerating tube feed at this time.\n Plan:\n Continue to monitor\n Increase tube feed by 10cc Q6hours as tolerated, goal 40cc/h.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on cpap ventilation.\n Shortly after pt and family settled for night, pt presented with\n extended periods of apnea.\n Copious thick oral secretions.\n Action:\n Scopolomine patch applied as ordered to diminish oral secretions.\n Vent changed to mmv overnight.\n ETT suction for minimal tan sputum.\n Repositioned frequently.\n HOB > 30 degrees.\n VAP protocol maintained.\n CXR this am.\n Response:\n Breath sounds clear after suction.\n O2 sats 98-100% consistently.\n Continues to require frequent clearance of copious oral secretions.\n Plan:\n Wean vent back to cpap as tolerated.\n Follow up on CXR.\n Continue frequent pulmonary toilet.\n"
},
{
"category": "Respiratory ",
"chartdate": "2115-02-16 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 624758,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 43.7 None\n Ideal tidal volume: 174.8 / 262.2 / 349.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n :\n Cuff Management:\n Vol/Press:\n Cuff pressure: 24 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Plan\n Next 24-48 hours: Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n CT\n 14:00\n"
},
{
"category": "Nursing",
"chartdate": "2115-02-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 624760,
"text": ".H/O abdominal pain (including abdominal tenderness)\n Assessment:\n Tmax 100.7. hr 70\ns. sbp 80-100\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2115-02-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 624765,
"text": ".H/O abdominal pain (including abdominal tenderness)\n Assessment:\n Tmax 100.7. hr 70\ns, sinus. sbp 80-100\ns. skin w+d.\n remains vented on cpap. Rested on mmv after fent dose d/t apnea. Now\n back on cpap, 10 peep 12, ips. Ls cta. O2 sat 100%. Sm amt thick white\n sputum. Lg amt oral secretions.\n abd firm distended. +bs. Lg amt loose stool. Ngt to lws with bilious\n drg. Npo.\n foley with adeq amts cl yellow urine.\n k+ 2.3\n Action:\n rested on mmv after fent. No other vent changes,\n paracentesis done at bedside. 2.5 liters removed. Flexiseal placed.\n Cta abd done. Stool sent for cdiff and o+p.\n foley noted to be out. New foley placed with difficulty. Needed coude\n cath.\n lytes being repleted. On tpn.\n Response:\n tol cpap. Tol pareacentesis. Abd soft immed post paracentesis, although\n becoming firmer as shift progresses. Team aware. Leaking lg amt\n ascities from tap site.\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2115-02-22 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 625637,
"text": "HPI:\n 35M with Cerebral palsy, presented with abdominal pain and distention\n to an OSH this am where CT scan was performed and reported as diffused\n bowel edema, gastric varices, ascites, pancreatic cyst. No association\n with nausea, vomitting, diarrhea, hematemesis, hematochezia, no GU\n symptoms. No jaundice, no fevers. No weight loss, no NSAIDs, ASA use.\n Pt was transferred to for further care on .\n Chief complaint:\n respiratory distress, peritonitis, SMV occlusion\n PMHx:\n Cerebral Palsy (Patient non verbal baseline), Seizure d/o, Chronic\n anemia (transfusion x2)\n .\n While in SICU:\n Thrombosis found in SMV. Pt started on heparin drip briefly and was\n then discontinued and treated with coumadin and lovenox. Received ~4\n doses of coumadin with no bump in INR probably related to poor bowel\n absorption. Pt also has chronic pancreatitis so was given TPN for\n nutrition and started on pancreatic enzymes. Pt failed extubation\n earlier on this week d/t poor cough/gag and copious secretions and was\n re-intubated ~24hrs after extubation. Remained intubated for another\n few days and was extubated on Thurs . On zosyn for PNA. Throughout\n course of ICU has had some hypotension which responds to small IVF\n bolus of 250cc no bolus since yesterday. Pt\ns baseline SBP high 70\n -90 with MAP 60\n Respiratory failure, acute (not ARDS/)\n Assessment:\n O2 sats high 90\ns on 2L nc. Pt has a strong cough when\n stimulated and requires assistance to clear secretions from back of\n throat\n Requires diligent mouth care\n Making adequate amts of urine at this time\n Action:\n Chest PT done Q2hrs\n Assisted OOB to chair\n IV zosyn for PNA\n Response:\n Afebrile at this time\n Responding to pulmonary toilet\n Plan:\n Cont pulmonary toilet\n OOB daily\n SMV thrombosis\n Assessment:\n TF at goal via NGT supplementing with TPN for now until\n bowel absorption improves\n Passing lge amts of watery bile appearing stool-remains on\n pancreatic enzymes with flexiseal in place\n Flexiseal does leak this morning trouble shooting flexiseal\n found formed stool sitting at end of flexiseal\npatency improved once\n reinserted\n Na climbing (d/t loose stool)\n Action:\n Frequent skin care to buttocks with clear critic aid barrier\n cream-positioned off buttocks as much as possible\n Coumadin ordered for tonight\n Free water bolus added to TF 200cc Q6hr\n Response:\n Buttocks becoming pink d/t leakage from flexiseal\n Daily INR in response to PO coumadin will be indicator of\n bowel absorption\n Plan:\n Cont TF and TPN\n Coumadin/lovenox for thromosis\n Family updated by Dr. and aware of plans to transfer patient out\n to floor.\n"
},
{
"category": "Nursing",
"chartdate": "2115-02-22 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 625643,
"text": "HPI:\n 35M with Cerebral palsy, presented with abdominal pain and distention\n to an OSH this am where CT scan was performed and reported as diffused\n bowel edema, gastric varices, ascites, pancreatic cyst. No association\n with nausea, vomitting, diarrhea, hematemesis, hematochezia, no GU\n symptoms. No jaundice, no fevers. No weight loss, no NSAIDs, ASA use.\n Pt was transferred to for further care on .\n Chief complaint:\n respiratory distress, peritonitis, SMV occlusion\n PMHx:\n Cerebral Palsy (Patient non verbal baseline), Seizure d/o, Chronic\n anemia (transfusion x2)\n .\n While in SICU:\n Thrombosis found in SMV. Pt started on heparin drip briefly and was\n then discontinued and treated with coumadin and lovenox. Received ~4\n doses of coumadin with no bump in INR probably related to poor bowel\n absorption. Pt also has chronic pancreatitis so was given TPN for\n nutrition and started on pancreatic enzymes. Pt failed extubation\n earlier on this week d/t poor cough/gag and copious secretions and was\n re-intubated ~24hrs after extubation. Remained intubated for another\n few days and was extubated on Thurs . On zosyn for PNA. Throughout\n course of ICU has had some hypotension which responds to small IVF\n bolus of 250cc no bolus since yesterday. Pt\ns baseline SBP high 70\n -90 with MAP 60\n Respiratory failure, acute (not ARDS/)\n Assessment:\n O2 sats high 90\ns on 2L nc. Pt has a strong cough when\n stimulated and requires assistance to clear secretions from back of\n throat\n Requires diligent mouth care\n Making adequate amts of urine at this time\n Action:\n Chest PT done Q2hrs\n Assisted OOB to chair\n IV zosyn for PNA\n Response:\n Afebrile at this time\n Responding to pulmonary toilet\n Plan:\n Cont pulmonary toilet\n OOB daily\n SMV thrombosis\n Assessment:\n TF at goal via NGT supplementing with TPN for now until\n bowel absorption improves\n Passing lge amts of watery bile appearing stool-remains on\n pancreatic enzymes with flexiseal in place\n Flexiseal does leak this morning trouble shooting flexiseal\n found formed stool sitting at end of flexiseal\npatency improved once\n reinserted\n Na climbing (d/t loose stool)\n This afternoon pt pulled NGT out about 4 inches. NGT pushed\n easily back in place\n Action:\n Frequent skin care to buttocks with clear critic aid barrier\n cream-positioned off buttocks as much as possible\n Coumadin ordered for tonight\n Free water bolus added to TF 200cc Q6hr\n CXR done to confirm NGT placement after pt pulled and\n dislodged\n Response:\n Buttocks becoming pink d/t leakage from flexiseal\n Daily INR in response to PO coumadin will be indicator of\n bowel absorption\n Flexiseal removed this afternoon d/t not draining and\n leaking around again. Flushed without any effect and when removed had\n mucous clogging tip.\n Plan:\n Cont TF and TPN\n Coumadin/lovenox for thromosis\n Family updated by Dr. and aware of plans to transfer patient out\n to floor.\n"
},
{
"category": "Nursing",
"chartdate": "2115-02-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 625644,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n O2 sats high 90\ns on 2L nc. Pt has a strong cough when\n stimulated and requires assistance to clear secretions from back of\n throat\n Requires diligent mouth care\n Making adequate amts of urine at this time\n Action:\n Chest PT done Q2hrs\n Assisted OOB to chair\n IV zosyn for PNA\n Response:\n Afebrile at this time\n Responding to pulmonary toilet\n Plan:\n Cont pulmonary toilet\n OOB daily\n SMV thrombosis\n Assessment:\n TF at goal via NGT supplementing with TPN for now until\n bowel absorption improves\n Passing lge amts of watery bile appearing stool-remains on\n pancreatic enzymes with flexiseal in place\n Flexiseal does leak this morning trouble shooting flexiseal\n found formed stool sitting at end of flexiseal\npatency improved once\n reinserted\n Na climbing (d/t loose stool)\n This afternoon pt pulled NGT out about 4 inches. NGT pushed\n easily back in place\n SBP more stable today with SBP>78 and MAP>60\n Action:\n Frequent skin care to buttocks with clear critic aid barrier\n cream-positioned off buttocks as much as possible\n Coumadin ordered for tonight\n Free water bolus added to TF 200cc Q6hr\n CXR done to confirm NGT placement after pt pulled and\n dislodged\n Response:\n Buttocks becoming pink d/t leakage from flexiseal\n Daily INR in response to PO coumadin will be indicator of\n bowel absorption\n Flexiseal removed this afternoon d/t not draining and\n leaking around again. Flushed without any effect and when removed had\n mucous clogging tip.\n Plan:\n Cont TF and TPN\n Coumadin/lovenox for thromosis\n Family updated by Dr. and aware of plans to transfer pt out to\n floor. At bedside for most of shift. Did go home to shower and returned\n this afternoon.\n"
},
{
"category": "Physician ",
"chartdate": "2115-02-16 00:00:00.000",
"description": "Intensivist Note",
"row_id": 624649,
"text": "SICU\n HPI:\n 35M with Cerebral palsy, presented with abdominal pain and distention\n to an OSH this am where CT scan was performed and reported as diffused\n bowel edema,gastric varices, ascites, pancreatic cyst. No association\n with nausea, vomitting, diarrhea, hematemesis, hematochezia, no GU\n symptoms. No jaundice, no fevers. No weight loss, no NSAIDs, ASA use.\n Pt received Unasyn at the OSH and was transferred to .\n He had a history of GI bleed in , unclear source, received\n transfusion (). Last EGD and colonoscopy were done in\n , wnl according to mother. Pancreatic cyst was aspirated in\n 6/. Laprascopic cholecystectomy done in .\n .\n Chief complaint:\n respiratory distress, peritonitis, possible ischemic bowel\n PMHx:\n Cerebral Palsey (Patient non verbal baseline), Seizure d/o, Chronic\n anemia (transfusion x2)\n .\n PSH:\n Lap cholecystectomy\n Pancreatic cyst drainage (last year, )\n Current medications:\n 1. 2. 3. Acetaminophen 4. Albuterol 0.083% Neb Soln 5. Calcium\n Gluconate 6. Dextrose 50% 7. Fentanyl Citrate 8. Glucagon 9. Heparin\n Flush (10 units/ml) 10. 11. Insulin 12. LeVETiracetam 13. Magnesium\n Sulfate 14. MetRONIDAZOLE (FLagyl) 15. Midazolam 16. Pantoprazole 17.\n Phytonadione 18. Piperacillin-Tazobactam 19. Potassium Chloride 20.\n Sodium Phosphate 21. Sodium Chloride 0.9% Flush 22. Vancomycin\n 24 Hour Events:\n SPUTUM CULTURE - At 12:50 PM\n : Transfused 2UPRBC for Hct of 26\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:04 PM\n Metronidazole - 08:55 PM\n Piperacillin/Tazobactam (Zosyn) - 11:54 PM\n Infusions:\n Other ICU medications:\n Fentanyl - 06:12 PM\n Pantoprazole (Protonix) - 08:56 PM\n Other medications:\n Flowsheet Data as of 04:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.7\nC (99.9\n T current: 37.7\nC (99.9\n HR: 93 (92 - 111) bpm\n BP: 97/74(79) {84/61(65) - 106/77(83)} mmHg\n RR: 26 (17 - 43) insp/min\n SPO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 36.4 kg (admission): 32.3 kg\n Height: 55 Inch\n CVP: 14 (9 - 18) mmHg\n Bladder pressure: 15 (15 - 15) mmHg\n Total In:\n 3,733 mL\n 958 mL\n PO:\n Tube feeding:\n IV Fluid:\n 3,691 mL\n 333 mL\n products:\n 447 mL\n Total out:\n 917 mL\n 155 mL\n Urine:\n 917 mL\n 155 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,816 mL\n 803 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 285 (283 - 318) mL\n PS : 12 cmH2O\n RR (Spontaneous): 30\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 18 cmH2O\n SPO2: 95%\n ABG: ///24/\n Ve: 6.5 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Distended, Tender: , Atonic peritonitis\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Neurologic: Follows simple commands, Moves all extremities\n Labs / Radiology\n 179 K/uL\n 9.3 g/dL\n 134 mg/dL\n 0.4 mg/dL\n 24 mEq/L\n 2.7 mEq/L\n 10 mg/dL\n 115 mEq/L\n 142 mEq/L\n 29.1 %\n 10.6 K/uL\n [image002.jpg]\n 03:35 AM\n 12:11 PM\n 04:42 PM\n 03:27 AM\n 02:48 AM\n WBC\n 9.3\n 9.3\n 10.6\n Hct\n 28.3\n 27.1\n 26.2\n 29.1\n Plt\n \n Creatinine\n 0.4\n 0.5\n 0.5\n 0.4\n Glucose\n 112\n 90\n 74\n 134\n Other labs: PT / PTT / INR:16.0/36.0/1.4, ALT / AST:, Alk-Phos / T\n bili:66/0.1, Amylase / Lipase:52/, Lactic Acid:0.5 mmol/L, Albumin:2.1\n g/dL, LDH:142 IU/L, Ca:7.0 mg/dL, Mg:2.0 mg/dL, PO4:1.7 mg/dL\n Assessment and Plan\n .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n Assessment and Plan: 35M with CP, peritonitis and ascites. Continuing\n work to detemrine etiology of SBP and monitor for ischemic colitis\n Neurologic:\n - Intubated and sedated PRN Midazolam\n - Pre-existing seizure disorder -> Keppra 20 .\n - Pain seems to be well controlled.\n Cardiovascular:\n - Tachycardic secondary to volume depletion and SIRS response.\n Otherwise stable.\n Pulmonary:\n - Respiratory failure resolved on minimal settings. Possible extubation\n in am.\n Gastrointestinal / Abdomen:\n - Peritonitis seems to be under control. On empirici ABX. Work up for\n ascities on-going.\n Pericentesis in am\n --CTA of the abd to evaluate mesenteric artery and vein flow.\n Nutrition: TPN\n Renal:\n - stable\n Hematology:\n - Slowly worsening anemia secondary to dilution, inflammation, and\n pre-existing chronic anemia.\n - Elevated INR & PTT secondary to the nutritional depletion.\n -S/P Transfusion 2UPRBC for Hct of 26 \n Endocrine: RISS\n Infectious Disease:\n - Abdominal peritonits - on empiric coverage with vanc/Flagyl/zosyn.\n Awaiting cultures to identify causitive organism.\n Lines / Tubes / Drains: PIV, Foley, Left sub clav ()\n Wounds:\n Imaging:\n Fluids: KVO\n Consults: General surgery, GI\n Billing Diagnosis: Sepsis, Peritonitis\n ICU Care\n Nutrition:\n TPN without Lipids - 11:00 PM 41. mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 22 Gauge - 12:46 AM\n Multi Lumen - 03:15 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2115-02-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 624827,
"text": ".H/O abdominal pain (including abdominal tenderness)\n Assessment:\n Tmax 100.7. hr 70\ns, sinus. sbp 80-100\ns. skin w+d.\n remains vented on cpap. Rested on mmv after fent dose d/t apnea. Now\n back on cpap. Ls cta. O2 sat 100%. Sm amt thick white sputum. Lg amt\n oral secretions.\n abd firm distended. +bs. Lg amt loose stool. Ngt to lws with bilious\n drg. Npo.\n foley with adeq amts cl yellow urine.\n k+ 2.3\n Action:\n rested on mmv after fent. No other vent changes,\n paracentesis done at bedside. 2.5 liters removed. Flexiseal placed.\n Cta abd done. Stool sent for cdiff and o+p.\n foley noted to be out. New foley placed with difficulty. Needed coude\n cath.\n lytes being repleted. On tpn.\n Response:\n tol cpap. Tol pareacentesis. Abd soft immed post paracentesis, although\n becoming firmer as shift progresses. Team aware. Leaking lg amt\n ascities from tap site.\n Plan:\n con\nt with current plan. Monitor for changes. Assess pain. Monitor abd.\n follow temp. con\nt to replete lytes. f/u cx and ct. support.\n"
},
{
"category": "Social Work",
"chartdate": "2115-02-18 00:00:00.000",
"description": "Social Work Progress Note",
"row_id": 625022,
"text": "Outreach visit to parents of this 36 yr old patient who is disabled\n with cerebral palsy. Pt was admitted last week to work up abdominal\n pain. Pt is non-verbal, lives with parents who provide 24 hr's of care\n and supervision. Pt seen sitting up in bedside chair, in no apparent\n distress. Pt extubated yesterday. Parent's are happy with the care that\n the patient is receiving. Parents taking turns staying overnight with\n pt. Parents are coping well with this hospitalization. Provided parking\n stickers for family.\n"
},
{
"category": "Nursing",
"chartdate": "2115-02-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 625536,
"text": "Hypotension (not Shock)\n Assessment:\n Patient\ns SBP 70\ns-80\ns, MAP down to low 50\ns x 1,\n u/o down to 17 cc/hr, Creat up to 1 this am.\n Action:\n Given 250 cc fluid bolus for hypotension and 500 cc fluid bolus for low\n u/o\n Repeat lytes sent\n Response:\n Urine output increased to 50-100 cc/hr,\n Creat up to 1.2 this evening (MICU team made aware)\n Plan:\n Fluid bolus as needed for Map < 60 and low u/o\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient intubated on CPAP 0/8, RR 20\ns-40\ns (patient breathes fast\n normally per mother). 50% fiO2 sating 99-100%.\n Suctioned for moderate amount of thick white secretions down ET tube,\n copious amounts of oral secretions.\n Action:\n SBT done,\n VBG sent (pH 7.37, pCo2- 40)\n Extubated, put on 70% face tent\n TF\ns held for extubation.\n Weaned to 50% fiO2 on face tent\n Response:\n Patient couging, appears to be choking on secretions at times, able to\n cough and swallow secretions.\n Sating 94-100% on 50% fiO2 on face tent\n Plan:\n Continue to monitor.\n .H/O abdominal pain (including abdominal tenderness)\n Assessment:\n Abdomen is soft and slightly distended.\n Does not appear to be in pain to palpation,\n On tube feeds at 20 cc/hr at start of shift with minimal residuals.\n Action:\n TF\ns turned off prior to extubation for a few hours,\n NG to suction.\n TPN paused for potassium content (K 5.5 this am)\n CDiff specimen sent\n Response:\n Continues to have liquid green/brown stool output from flexicele\n Plan:\n Continue to monitor.\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n Potassium 5.5 this am.\n Action:\n Given kayexelate (however unsure how much was absorbed because NG to\n suction prior to extubation) ,\n TPN paused due to high K+ content\n Response:\n Evening potassium\n 4.9\n Plan:\n Restart TPN with this evenings dose\n"
},
{
"category": "Nursing",
"chartdate": "2115-02-22 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 625631,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2115-02-18 00:00:00.000",
"description": "Intensivist Note",
"row_id": 625006,
"text": "SICU\n HPI:\n 35M with Cerebral palsy,presented with abdominal pain and distention to\n an OSH this am where CT scan was performed and reported as diffused\n bowel edema,gastric varices, ascites, pancreatic cyst. No association\n with nausea,vomitting, diarrhea, hematemesis, hematochezia, no GU\n symptoms. No jaundice , no fevers. No weight loss, no NSAIDs, ASA use.\n Pt recieved Unasyn at the OSH and was transferred to \n Chief complaint:\n respiratory distress, peritonitis, SMV occlusion\n PMHx:\n Cerebral Palsy (Patient non verbal baseline), Seizure d/o, Chronic\n anemia (transfusion x2)\n Current medications:\n Acetaminophen 4. Albuterol 0.083% Neb Soln 5. Calcium Gluconate 6.\n Dextrose 50% 7. Fentanyl Citrate\n 8. Furosemide 9. Furosemide 10. Glucagon 11. Heparin 12. Heparin Flush\n (10 units/ml) 13. 14. Insulin\n 15. LeVETiracetam 16. Magnesium Sulfate 17. MetRONIDAZOLE (FLagyl) 18.\n Midazolam 19. Pantoprazole\n 20. Piperacillin-Tazobactam\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 06:03 PM\n EXTUBATION - At 06:19 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:00 PM\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Metronidazole - 03:53 AM\n Infusions:\n Heparin Sodium - 700 units/hour\n Other ICU medications:\n Furosemide (Lasix) - 09:44 PM\n Fentanyl - 02:20 AM\n Other medications:\n Flowsheet Data as of 04:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.7\nC (99.9\n T current: 36.9\nC (98.5\n HR: 95 (75 - 110) bpm\n BP: 80/56(73) {80/52(62) - 125/81(90)} mmHg\n RR: 26 (9 - 48) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 38 kg (admission): 32.3 kg\n Height: 55 Inch\n CVP: 185 (1 - 238) mmHg\n Total In:\n 2,607 mL\n 431 mL\n PO:\n Tube feeding:\n IV Fluid:\n 1,471 mL\n 244 mL\n Blood products:\n Total out:\n 2,816 mL\n 1,380 mL\n Urine:\n 1,816 mL\n 730 mL\n NG:\n 250 mL\n Stool:\n Drains:\n Balance:\n -209 mL\n -949 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, Aerosol-cool\n Ventilator mode: CPAP/PSV\n Vt (Set): 350 (350 - 350) mL\n Vt (Spontaneous): 321 (293 - 555) mL\n PS : 5 cmH2O\n RR (Set): 10\n RR (Spontaneous): 17\n PEEP: 0 cmH2O\n FiO2: 70%\n RSBI: 93\n PIP: 16 cmH2O\n SPO2: 98%\n ABG: ///29/\n Ve: 5.4 L/min\n Physical Examination\n General Appearance: No acute distress\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric)\n Abdominal: No(t) Soft, softer than previously\n Neurologic: (Responds to: Tactile stimuli), No(t) Moves all\n extremities, (RUE: No(t) Weakness), (LUE: No(t) Weakness), (RLE: No\n movement), (LLE: No movement)\n Labs / Radiology\n 107 K/uL\n 10.0 g/dL\n 141 mg/dL\n 0.4 mg/dL\n 29 mEq/L\n 3.1 mEq/L\n 12 mg/dL\n 104 mEq/L\n 138 mEq/L\n 29.2 %\n 9.4 K/uL\n [image002.jpg]\n 03:35 AM\n 12:11 PM\n 04:42 PM\n 03:27 AM\n 02:48 AM\n 06:09 AM\n 03:11 PM\n 04:05 AM\n 02:40 PM\n 02:29 AM\n WBC\n 9.3\n 9.3\n 10.6\n 8.7\n 9.4\n Hct\n 28.3\n 27.1\n 26.2\n 29.1\n 31.6\n 32.9\n 30.9\n 29.2\n Plt\n 39\n 107\n Creatinine\n 0.4\n 0.5\n 0.5\n 0.4\n 0.5\n 0.5\n 0.5\n 0.4\n TCO2\n 25\n Glucose\n 112\n 90\n 74\n 134\n 80\n 118\n 137\n 141\n Other labs: PT / PTT / INR:15.0/90.1/1.3, ALT / AST:, Alk-Phos / T\n bili:83/0.3, Amylase / Lipase:52/, Lactic Acid:1.6 mmol/L, Albumin:2.5\n g/dL, LDH:158 IU/L, Ca:8.2 mg/dL, Mg:1.9 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n Assessment and Plan: 35M with CP, peritonitis and ascites, chronic\n pancreatitis, most likely ascites and peritonitis SMV occlusion\n Neurologic:\n - Cerebral palsy with mental status at baseline.\n - Pre-existing seizure disorder -> Keppra 20 .\n - Pain seems to be well controlled. and pt seems to be at\n baseline mental status\n Cardiovascular:\n - HR and BP holding stable\n Pulmonary:\n - Respiratory failure: now extubated, requiring aggresive pulm\n toilet, chest PT and suctioning due to secretion\n - CXR looked vol overload, gave 5mg then 10mg of lasix for\n diuresis\n Gastrointestinal / Abdomen:\n - SMV and partial vein thrombosis. Both seems to be chronic\n processes considering the large amount of collaterals. However, there\n is massive venous engorgement and bowel edema. Start on heparin drip.\n o On empiric ABX for peritonitis.\n o Diarrhea: likely due to lack of absorption d/t bowel wall\n edema\n Nutrition:\n o TPN\n Renal:\n - Being diuresed with the goal of -0.5-1L/24hrs.\n - Hypokalemia\n Hematology:\n - On systemic anticoagulation with the goal og aPTT of\n 60-80sec\n - Stable anemia now.\n Endocrine:\n - RISS with adequate BG control.\n Infectious Disease:\n - Abdominal peritonitis - on empiric coverage with vanc/Flagyl/zosyn.\n --Awaiting cultures to identify causitive organism.\n -- WBC 9.4, afebrile\n Lines / Tubes / Drains:\n Consults: General surgery, Vascular surgery\n ICU Care\n Nutrition:\n TPN without Lipids - 04:00 PM 45 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 03:15 AM\n 20 Gauge - 12:17 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin drip)\n Stress ulcer: PPI\n VAP bundle: (+)\n Communication\n Code status: FULL\n Disposition: SICU\n Total time spent: 33 minutes\n"
},
{
"category": "Nutrition",
"chartdate": "2115-02-18 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 625007,
"text": "Subjective: Unable to speak with patient. RN, patient is\n tolerating TPN well and abd exam is much improved from yesterday.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 140 cm\n 32.3 kg\n 38 kg ( 12:00 AM)\n 16.5\n Pertinent medications: Heparin drip, lasix, ABx, Protonix, RISS.\n repletions (potassium, magnesium), others noted\n Labs:\n Value\n Date\n Glucose\n 141 mg/dL\n 02:29 AM\n Glucose Finger Stick\n 150\n 10:00 AM\n BUN\n 12 mg/dL\n 02:29 AM\n Creatinine\n 0.4 mg/dL\n 02:29 AM\n Sodium\n 138 mEq/L\n 02:29 AM\n Potassium\n 3.1 mEq/L\n 02:29 AM\n Chloride\n 104 mEq/L\n 02:29 AM\n TCO2\n 29 mEq/L\n 02:29 AM\n PO2 (arterial)\n 84. mm Hg\n 06:09 AM\n PO2 (venous)\n 42 mm Hg\n 08:08 AM\n PCO2 (arterial)\n 38 mm Hg\n 06:09 AM\n PCO2 (venous)\n 42 mm Hg\n 08:08 AM\n pH (arterial)\n 7.41 units\n 06:09 AM\n pH (venous)\n 7.33 units\n 06:11 AM\n pH (urine)\n 5.0 units\n 04:42 PM\n CO2 (Calc) arterial\n 25 mEq/L\n 06:09 AM\n CO2 (Calc) venous\n 24 mEq/L\n 08:08 AM\n Albumin\n 2.5 g/dL\n 03:11 PM\n Calcium non-ionized\n 8.2 mg/dL\n 02:29 AM\n Phosphorus\n 3.5 mg/dL\n 02:29 AM\n Ionized Calcium\n 1.07 mmol/L\n 06:11 AM\n Magnesium\n 1.9 mg/dL\n 02:29 AM\n ALT\n 7 IU/L\n 02:29 AM\n Alkaline Phosphate\n 83 IU/L\n 02:29 AM\n AST\n 15 IU/L\n 02:29 AM\n Amylase\n 52 IU/L\n 03:35 AM\n Total Bilirubin\n 0.3 mg/dL\n 02:29 AM\n Phenytoin (Dilantin)\n 4.9 ug/mL\n 03:27 AM\n WBC\n 9.4 K/uL\n 02:29 AM\n Hgb\n 10.0 g/dL\n 02:29 AM\n Hematocrit\n 29.2 %\n 02:29 AM\n Current diet order / nutrition support: Diet: NPO\n TPN: 1.1L (150g dextrose/ 50g amino acid) = 710kcals\n GI: abd distended, soft, hypoactive bowel sounds, NGT to low continuous\n wall suction with 250mL out \n Assessment of Nutritional Status\n 35 y.o. Male with CP, adm with peritonitis and ascites, most likely\n ascites and peritonitis SMV occlusion, now on heparin drip.\n Patient was started on TPN due to malnourished state and inability\n to use gut for nutrition. TPN is advancing slowly to goal, with\n potassium and magnesium repletions given outside bag and also amount In\n bag increased. Goal TPN will likely be reached tomorrow. Patient\n abdomen exam is much improved, so patient may be able to try either\n diet advancement to clear liquids or trophic tube feeds within the next\n few days.\n Medical Nutrition Therapy Plan - Recommend the Following\n Continue with advancement to goal TPN of 1.1L (200g\n dextrose/ 50g amino acid/ 22g lipid) = 1100kcals.\n Montior blood sugars, lytes and fluid status.\n Recommend diet advancement to clear liquids or start of\n trophic tube feeds when medically cleared.\n Will follow - #\n"
},
{
"category": "Nursing",
"chartdate": "2115-02-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 625528,
"text": "Hypotension (not Shock)\n Assessment:\n Patient\ns SBP 70\ns-80\ns, MAP down to low 50\ns x 1,\n u/o down to 17 cc/hr, Creat up to 1 this am.\n Action:\n Given 250 cc fluid bolus for hypotension and 500 cc fluid bolus for low\n u/o\n Repeat lytes sent\n Response:\n Urine output increased to 50-100 cc/hr,\n Creat up to 1.2 this evening (MICU team made aware)\n Plan:\n Fluid bolus as needed for Map < 60 and low u/o\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient intubated on CPAP 0/8, RR 20\ns-40\ns (patient breathes fast\n normally per mother). 50% fiO2 sating 99-100%.\n Suctioned for moderate amount of thick white secretions down ET tube,\n copious amounts of oral secretions.\n Action:\n SBT done,\n VBG sent (pH 7.37, pCo2- 40)\n Extubated, put on 70% face tent\n TF\ns held for extubation.\n Weaned to 50% fiO2 on face tent\n Response:\n Patient couging, appears to be choking on secretions at times, able to\n cough and swallow secretions.\n Sating 94-100% on 50% fiO2 on face tent\n Plan:\n Continue to monitor.\n .H/O abdominal pain (including abdominal tenderness)\n Assessment:\n Abdomen is soft and slightly distended.\n Does not appear to be in pain to palpation,\n On tube feeds at 20 cc/hr at start of shift with minimal residuals.\n Action:\n TF\ns turned off prior to extubation for a few hours,\n NG to suction.\n TPN paused for potassium content (K 5.5 this am)\n CDiff specimen sent\n Response:\n Continues to have liquid green/brown stool output from flexicele\n Plan:\n Continue to monitor.\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n Potassium 5.5 this am.\n Action:\n Given kayexelate (however unsure how much was absorbed because NG to\n suction prior to extubation) ,\n TPN paused due to high K+ content\n Response:\n Evening potassium\n 4.9\n Plan:\n Restart TPN with this evenings dose\n"
},
{
"category": "Physician ",
"chartdate": "2115-02-20 00:00:00.000",
"description": "Intensivist Note",
"row_id": 625274,
"text": "SICU\n HPI:\n 35M with Cerebral palsy, presented with abdominal pain and distention\n to an OSH this am where CT scan was performed and reported as diffused\n bowel edema, gastric varices, ascites, pancreatic cyst. No association\n with nausea, vomitting, diarrhea, hematemesis, hematochezia, no GU\n symptoms. No jaundice, no fevers. No weight loss, no NSAIDs, ASA use.\n Pt recieved Unasyn at the OSH and was transferred to .\n Chief complaint:\n respiratory distress, peritonitis, SMV occlusion\n PMHx:\n Cerebral Palsy (Patient non verbal baseline), Seizure d/o, Chronic\n anemia (transfusion x2)\n .\n PSH:\n Lap cholecystectomy\n Pancreatic cyst drainage (last year, )\n Current medications:\n 1. 2. 3. Acetaminophen 4. Albumin 5% (12.5g / 250mL) 5. Albuterol\n 0.083% Neb Soln 6. Calcium Gluconate 7. Chlorhexidine Gluconate 0.12%\n Oral Rinse 8. Dextrose 50% 9. Fentanyl Citrate 10. Glucagon 11. Heparin\n 12. Heparin Flush (10 units/ml) 13. Insulin 14. LeVETiracetam 15.\n Magnesium Sulfate 16. Midazolam 17. Pantoprazole 18. Phenylephrine 19.\n Piperacillin-Tazobactam 20. Potassium Chloride 21. Sodium Chloride 0.9%\n Flush 22. Sodium Chloride 0.9% Flush 23. Tobramycin 24. Vancomycin 25.\n Warfarin\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 03:20 PM\n : Episode of hypotension to low 70's recieved a bolus of albumin w/\n good response. Vancomycine increased to 1250\". Started on tobramycin\n presumed to have pneumonia\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 03:53 AM\n Tobramycin - 12:04 PM\n Vancomycin - 08:26 PM\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium - 08:19 AM\n Midazolam (Versed) - 11:07 AM\n Pantoprazole (Protonix) - 08:00 PM\n Other medications:\n Flowsheet Data as of 04:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.9\nC (100.3\n T current: 36.5\nC (97.7\n HR: 93 (75 - 99) bpm\n BP: 93/68(74) {71/47(59) - 119/86(89)} mmHg\n RR: 22 (17 - 31) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 37.1 kg (admission): 32.3 kg\n Height: 55 Inch\n CVP: 8 (5 - 14) mmHg\n Total In:\n 2,674 mL\n 319 mL\n PO:\n Tube feeding:\n IV Fluid:\n 1,281 mL\n 121 mL\n Blood products:\n 250 mL\n Total out:\n 2,745 mL\n 420 mL\n Urine:\n 2,095 mL\n 420 mL\n NG:\n 350 mL\n Stool:\n Drains:\n Balance:\n -71 mL\n -101 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: SIMV/PSV/AutoFlow\n Vt (Set): 300 (300 - 300) mL\n Vt (Spontaneous): 341 (291 - 341) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 8\n PEEP: 8 cmH2O\n FiO2: 50%\n PIP: 22 cmH2O\n Plateau: 17 cmH2O\n SPO2: 99%\n ABG: ///30/\n Ve: 8.8 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: Crackles : Bilateral)\n Abdominal: Soft, Distended\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Neurologic: Follows simple commands, Moves all extremities, alert\n Labs / Radiology\n 109 K/uL\n 8.9 g/dL\n 98 mg/dL\n 0.5 mg/dL\n 30 mEq/L\n 4.3 mEq/L\n 9 mg/dL\n 104 mEq/L\n 142 mEq/L\n 27.1 %\n 7.6 K/uL\n [image002.jpg]\n 02:48 AM\n 06:09 AM\n 03:11 PM\n 04:05 AM\n 02:40 PM\n 02:29 AM\n 04:00 PM\n 01:32 AM\n 03:31 AM\n 01:00 AM\n WBC\n 10.6\n 8.7\n 9.4\n 10.1\n 7.6\n Hct\n 29.1\n 31.6\n 32.9\n 30.9\n 29.2\n 28.6\n 27.1\n Plt\n 179\n 139\n 107\n 110\n 109\n Creatinine\n 0.4\n 0.5\n 0.5\n 0.5\n 0.4\n 0.4\n 0.4\n 0.5\n TCO2\n 25\n 36\n Glucose\n 134\n 80\n 118\n 137\n 141\n 104\n 106\n 98\n Other labs: PT / PTT / INR:15.8/129.8/1.4, ALT / AST:, Alk-Phos /\n T bili:80/0.3, Amylase / Lipase:62/19, Lactic Acid:0.9 mmol/L,\n Albumin:2.5 g/dL, LDH:158 IU/L, Ca:8.2 mg/dL, Mg:3.0 mg/dL, PO4:3.8\n mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), .H/O ABDOMINAL PAIN\n (INCLUDING ABDOMINAL TENDERNESS)\n Assessment and Plan: 35M with CP, chronic pancreatitis, transudative\n ascites and peritonitis likely SMV occlusion, now on hep gtt.\n Neurologic:\n - Pre-existing seizure disorder -> Keppra 20 .\n - Pain seems to be well controlled.\n - Baseline mental status\n -Intubated off sedation\n Cardiovascular:\n - HR and BP holding stable\n --ECHO: EF 55% f/up final read\n Pulmonary:\n - Respiratory failure: now reintubated, requiring aggresive pulm\n toilet, chest PT and suctioning due to secretions\n --Wean the vent as tolerated\n --F/up sputum Cx\n Gastrointestinal / Abdomen:\n - On empiric ABX for peritonitis. Work up for ascities on-going. F/U\n Cx\n --CTA revealed SMV occlusion, venous stasis--->On hep gtt\n -- Diarrhea: likely due to lack of absorption d/t bowel wall edema,\n Flagyl d/c'd, C diff negative\n -- Pantoprazole for GI proph\n --NGT output tinged w/ blood, hct stable\n Nutrition: TPN\n Renal:\n --stable urine output, lasix \n --Hypokalemia, monitoring and getting repleted\n --Patient on tobramycin and vancomycin monitor Renal function closely\n Hematology:\n - Slowly worsening anemia secondary to dilution, inflammation, and\n pre-existing chronic anemia.\n - Elevated INR & PTT secondary to the nutritional depletion.\n -S/P Transfusion 2UPRBC for Hct of 26 on , Stable 29-31---Hct 27\n on \n On hep gtt for SMV occlusion (goal 60-80)\n -coumadin started on (3)\n Endocrine:\n - RISS with adequate BG control.\n Infectious Disease:\n - Abdominal peritonitis - on empiric coverage with vanc/zosyn and\n tobramycine to covert pseudomonas pnemonia\n - F/u cultures\n - suspected pneumonia and at risk MDR HAP added tobramycin, f/u AM\n trough level (goal less than 1)\n Lines / Tubes / Drains: ETT, PIV, Foley, Left sub clav ()\n Wounds:\n Imaging: CXR today\n Fluids: KVO\n Consults: General surgery\n Billing Diagnosis: (Respiratory distress: Failure)\n ICU Care\n Nutrition:\n TPN w/ Lipids - 06:08 PM 46 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 03:15 AM\n 20 Gauge - 12:17 PM\n Prophylaxis:\n DVT: Boots (Systemic anticoagulation: Heparin drip)\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Respiratory ",
"chartdate": "2115-02-20 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 625275,
"text": "Demographics\n Day of mechanical ventilation: 3\n Ideal body weight: 43.7 None\n Ideal tidal volume: 174.8 / 262.2 / 349.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Copious\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: pt remains orally\n intubated/mechanically ventilated; no vent changes made overnoc;\n continues on SIMV/PSV per team, w/ spontaneous Vt ~200cc, overbreathing\n set vent rate of 12 up to mid 20s, Ve 6-8L/M. SpO2 99%.\n Assessment of breathing comfort: No claim of dyspnea\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n"
},
{
"category": "Nursing",
"chartdate": "2115-02-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 625433,
"text": "Hypotension (not Shock) and Bradycardia\n Assessment:\n Repeat episode of hypotension with SBP in lower 60\n Bradycardic to 40\ns during hypotensive episode\n Action:\n NS 250cc bolus x1.\n Heparin gtts discontinued at 2100.\n Response:\n HR and BP improved to baseline.\n Plan:\n Continue to closely monitor vitals.\n Commence lovenox regimen in am.\n .H/O abdominal pain (including abdominal tenderness)\n Assessment:\n Abdomen soft slightly distended.\n Bowel sounds active.\n NGT initially draining small amount of bile to LCWS.\n Flexi seal with decreased liquid stool output.\n TPN continued.\n Action:\n Started tube feeds at 10cc/h at midnight via NGT.\n Flexiseal cuff deflated, removed and replaced.\n Fentanyl 12.5mg x1 this shift for discomfort with turning.\n Response:\n Immediately passed 200cc green liquid stool when flexiseal\n reinserted.\n Abdomen remains softly distended.\n Tolerating tube feed at this time.\n Plan:\n Continue to monitor\n Increase tube feed by 10cc Q6hours as tolerated, goal 40cc/h.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on cpap ventilation.\n Shortly after pt and family settled for night, pt presented with\n extended periods of apnea.\n Copious thick oral secretions.\n Action:\n Scopolomine patch applied as ordered to diminish oral secretions.\n Vent changed to mmv overnight.\n ETT suction for minimal tan sputum.\n Repositioned frequently.\n HOB > 30 degrees.\n VAP protocol maintained.\n CXR this am.\n Response:\n Breath sounds clear after suction.\n O2 sats 98-100% consistently.\n Continues to require frequent clearance of copious oral secretions.\n Plan:\n Wean vent back to cpap as tolerated.\n Follow up on CXR.\n Continue frequent pulmonary toilet.\n"
},
{
"category": "Physician ",
"chartdate": "2115-02-22 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 625598,
"text": "24 Hour Events:\n - extubated yest AM, tolerated well with moderate cough; on humidified\n face mask and then nasal canula 3 L at night\n - received 2 500 cc NS boluses during day\n - Cr continued to rise to 1.2; UO good at about 60-100cc/hr\n - TPN and TFs both continued\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Tobramycin - 12:15 PM\n Vancomycin - 08:30 PM\n Piperacillin/Tazobactam (Zosyn) - 07:14 AM\n Infusions:\n Other ICU medications:\n Fosphenytoin - 10:16 AM\n Pantoprazole (Protonix) - 08:07 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.4\nC (97.5\n HR: 94 (64 - 98) bpm\n BP: 101/62(72) {78/35(51) - 101/76(81)} mmHg\n RR: 19 (19 - 32) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 29.3 kg (admission): 32.3 kg\n Height: 55 Inch\n CVP: 10 (6 - 18)mmHg\n Total In:\n 3,394 mL\n 711 mL\n PO:\n TF:\n 257 mL\n 157 mL\n IVF:\n 1,810 mL\n 200 mL\n Blood products:\n Total out:\n 3,517 mL\n 602 mL\n Urine:\n 1,567 mL\n 552 mL\n NG:\n 300 mL\n Stool:\n Drains:\n Balance:\n -123 mL\n 109 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: Standby\n FiO2: 70%\n SpO2: 99%\n ABG: ///25/\n Physical Examination\n Gen:\n Labs / Radiology\n 129 K/uL\n 7.4 g/dL\n 143 mg/dL\n 1.2 mg/dL\n 25 mEq/L\n 4.3 mEq/L\n 16 mg/dL\n 119 mEq/L\n 149 mEq/L\n 24.1 %\n 5.4 K/uL\n [image002.jpg]\n 04:00 PM\n 01:32 AM\n 03:31 AM\n 01:00 AM\n 08:19 AM\n 04:27 PM\n 10:27 PM\n 04:15 AM\n 02:49 PM\n 03:57 AM\n WBC\n 10.1\n 7.6\n 6.5\n 5.4\n Hct\n 28.6\n 27.1\n 24.1\n 25.6\n 17\n 24.8\n 24.9\n 24.1\n Plt\n 110\n 109\n 122\n 129\n Cr\n 0.4\n 0.4\n 0.5\n 0.7\n 0.8\n 1.0\n 1.2\n 1.2\n TropT\n <0.01\n TCO2\n 36\n Glucose\n 104\n 106\n 98\n 132\n 109\n 118\n 94\n 143\n Other labs: PT / PTT / INR:17.0/29.2/1.5, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:, Alk Phos / T Bili:77/0.2,\n Amylase / Lipase:62/19, Lactic Acid:0.9 mmol/L, Albumin:2.4 g/dL,\n LDH:162 IU/L, Ca++:8.3 mg/dL, Mg++:2.7 mg/dL, PO4:4.5 mg/dL\n Assessment and Plan\n 34M cerebral palsy initially p/w concern for abdominal infection now\n reintubated for respiratory failure.\n # Renal insufficiency: with Cr at 1.2 from baseline 0.3-0.4. Likely\n multifactorial with series of renal insults including hypovolemia\n followed by infection (with Foley) and then medications (including ABX)\n with possible AIN. CVP 10-15. Unwell week prior to admission, likely\n poor PO intake.\n -Urine lytes consistent w/ ATN\n - holding vanc and tobra\n - consider renal consult\n - give another 500cc NS\n # Abdominal pain: Patient with finding of SMV thrombus with collaterals\n indicative of a chronic process. Surgery and Vascular involved,\n suspect to low flow state in setting of chronic pancreatitis. No\n e/o malignancy at this point. Patient started on heparin gtt. Also with\n diffuse bowel edema concerning for bowel ischemia / congestion. No e/o\n localized infection overlying inflammation at this point (though s/p\n paracentesis x 2, both with > 1000 WBC). Given compromised bowel wall,\n at high risk for translocation of bacteria.\n - Continue Zosyn (14 day total course)\n - D/C vanc given high levels\n - Continue Lovenox (30 mg per Pharmacy given decreased renal\n function; if improves increase to 40 mg )\n - Vascular recs / Surgery recs\n - Follow-up cultures\n - Send repeat C.diff given fevers\n - GI recommendations\n - Hold tube feeds (started overnight) for extubation\n - Cont TPN across the day, order for tomorrow but hope to wean if can\n - Start pancreatic enzymes\n - f/u with re: potential syndrome\n - check celiac disease labs\n # Respiratory failure: Treating for HAP/VAP with\n Vanc/Zosyn/Tobramycin. ID said no to Amikacin. With LLL infiltrate on\n CXR (persistent) but new since admission. Afebrile the night prior to\n transfer but with continued heavy secretions. No appreciable changes\n in ventilator settings. Following VBGs given too contracted for ABG.\n Family endorses heavy secretions at baseline. NIF today showing\n significant component of NM contribution.\n - Scopolamine patch (Cyproheptadine at home)\n - Goal fluid balance of even\n - d/c vanc and tobra\n - continue Cefepime x 14 days total\n # Fever: Intermittent since admission on , . Could be \n ischemia; other possible sources of infection include pulmonary with\n some infiltrate on his CXR but he is without a leukocytosis. Does have\n prominent secretions per primary Surgical team.\n - Antibiotics as above (cont Zosyn, stopping Vanc and Tobra)\n - Follow-up Micro\n - Culture if febrile\n - UA\n # Hypotension: Per family, patient's baseline BP high 70s - low 80s.\n Per nursing, also newly bradycardic and hypotensive (SBP 70s) overnight\n on . Could be vagal tone with ET/CVL but also consider\n infectious process. Previously responded to Albumin and 500cc bolus\n LR. Echo (final pending) Ef=55% and no focal wall motion\n abnormalities.\n - Monitor fluid balance; goal even\n - Goal SBP 80, MAP ~60s\n - if bolus use 250-500cc\n # SMV Occlusion: SMV occulsion with plan for 6 months anticoagulation\n per Vascular recommendation. Started on Heparin gtt for\n anticoagulation PTT 60-80, as well as daily Coumadin with Goal INR ,\n now holding coumadin. Also noted to have diarrhea during stay (C.diff\n negative) thought to be lack of absorption due to bowel wall edema.\n - continue low dose Lovenox (discussed with vascular) at 30 qd\n - check Factor Xa level after 3^rd dose\n - Per discussion with pharmacy, will dose 30 mg SC BID (consider 40 mg\n if Cr improves)\n - trend PLT (increased today, but some concern for HIT)\n - send HIT antibody\n - if tolerates tube feeds may restart Coumadin in next few days\n # Anemia: Unclear source for acute on chronic anemia (baseline 35) but\n now on anticoagulation. NG lavage / guaiac negative . Could\n consider some dilutional component, but likely does not explain\n complete loss. No blood yet given.\n - T&C x 2U PRBC; transfuse to 21 unless e/o ischemia/bleeding\n - Monitor Hct now that stable\n - Continue to monitor stool guaiac\n # Thrombocytopenia: New . With prior hospitalization, could\n consider new exposure to heparin with HIT. Other medications include\n antibiotics and Leviteracitam.\n - Stop heparin\n - Start Lovenox\n - Stop Keppra\n - check HIT antibodies as above\n # Coagulopathy: Noted on admission; consider malnutrition vs\n malabsorption vs intrinsic liver disease.\n - Stop heparin, Coumadin\n - Start Lovenox as above\n # Hypoalbuminemia: Noted on arrival, with similar etiology to\n coagulopathy.\n - Restart TF; support nutrition as able\n - Discuss trophic TF with Surgery\n # Cerebral Palsy: Not ambulatory at baseline; also with h/o chronic,\n intermittent diarrhea; chronic pancreatitis. Could be an undiagnosed\n syndrome. Phenobarb level within therapeutic range on admission.\n - Seizure meds as below\n - Discuss with outpatient Neurology\n - Pancreatic enzymes as diet advances\n - check free dilantin level and free phenobarb levels\n # Seizure disorder: Family describes them as 'drop seizures' with\n sudden head slumps. On Dilantin / Phenobarbital as outpatient. Patient\n transitioned to Keppra while inpatient.\n - Discuss restarting Dilantin / Phenobarbital safely with pharmacy\n - Touch base with outpatient Neurology Openheimer ()\n - switch to phosphenitoin\n # FEN Euvolemic to hypovolemic / replete PRN / continue TPN for now /\n start tube feeds later today\n # PPX:\n - PPI\n - Chlorehexadine gluconate\n - Pneumoboots\n - Systemically anticoagulated\n # ACCESS: L-Subclavian CL (); R PIV\n # Communication: & (Parents) \n # CODE: FULL\n # Dispo: ICU pending clinical improvement\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 03:12 PM 25 mL/hour\n TPN w/ Lipids - 05:11 PM 46 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 03:15 AM\n 20 Gauge - 12:17 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2115-02-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 625432,
"text": "Hypotension (not Shock) and Bradycardia\n Assessment:\n Repeat episode of hypotensive with SBP in upper 60\n Bradycardic to 40\ns during hypotensive episode\n Action:\n NS 250cc bolus x1.\n Heparin gtts discontinued at 2100.\n Response:\n HR and BP improved to baseline.\n Plan:\n Continue to closely monitor vitals.\n Commence lovenox regimen in am.\n .H/O abdominal pain (including abdominal tenderness)\n Assessment:\n Abdomen soft slightly distended.\n Bowel sounds active.\n NGT initially draining small amount of bile to LCWS.\n Flexi seal with decreased liquid stool output.\n TPN continued.\n Action:\n Started tube feeds at 10cc/h at midnight via NGT.\n Flexiseal cuff deflated, removed and replaced.\n Fentanyl 12.5mg x1 this shift for discomfort with turning.\n Response:\n Immediately passed 200cc green liquid stool when flexiseal\n reinserted.\n Abdomen remains softly distended.\n Tolerating tube feed at this time.\n Plan:\n Continue to monitor\n Increase tube feed by 10cc Q6hours as tolerated, goal 40cc/h.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on cpap ventilation.\n Shortly after pt and family settled for night, pt presented with\n extended periods of apnea.\n Copious thick oral secretions.\n Action:\n Scopolomine patch applied as ordered to diminish oral secretions.\n Vent changed to mmv overnight.\n ETT suction for minimal tan sputum.\n Repositioned frequently.\n HOB > 30 degrees.\n VAP protocol maintained.\n CXR this am.\n Response:\n Breath sounds clear after suction.\n O2 sats 98-100% consistently.\n Continues to require frequent clearance of copious oral secretions.\n Plan:\n Wean vent back to cpap as tolerated.\n Follow up on CXR.\n Continue frequent pulmonary toilet.\n"
},
{
"category": "Nursing",
"chartdate": "2115-02-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 625499,
"text": "Hypotension (not Shock)\n Assessment:\n Patient\ns SBP 70\ns-80\ns, MAP down to low 50\ns x 1,\n u/o down to 17 cc/hr\n Action:\n Given 250 cc fluid bolus for hypotension and 500 cc\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O abdominal pain (including abdominal tenderness)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nutrition",
"chartdate": "2115-02-21 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 625500,
"text": "Subjective\n Patient remains intubated\n Objective\n Pertinent medications: noted\n Labs:\n Value\n Date\n Glucose\n 118 mg/dL\n 04:15 AM\n Glucose Finger Stick\n 149\n 10:00 AM\n BUN\n 15 mg/dL\n 04:15 AM\n Creatinine\n 1.0 mg/dL\n 04:15 AM\n Sodium\n 140 mEq/L\n 04:15 AM\n Potassium\n 5.5 mEq/L\n 04:15 AM\n Chloride\n 109 mEq/L\n 04:15 AM\n TCO2\n 29 mEq/L\n 04:15 AM\n pH (urine)\n 6.5 units\n 04:15 AM\n Calcium non-ionized\n 8.1 mg/dL\n 04:15 AM\n Phosphorus\n 3.5 mg/dL\n 04:15 AM\n Magnesium\n 2.8 mg/dL\n 04:15 AM\n WBC\n 6.5 K/uL\n 04:15 AM\n Hgb\n 8.0 g/dL\n 04:15 AM\n Hematocrit\n 24.8 %\n 04:15 AM\n Current diet order / nutrition support: Tube feed: Ensure @ 40mL/hr\n (1017 kcals/35 gr protein)-on hold\n TPN 3/10-1100mL(150 dextrose/50 protein/22 fat) 930 kcals\n GI: Abd: soft/nbs/liquid stool\n Assessment of Nutritional Status\n Specifics:\n Tube feeds initiated p/ surgery ok\nd. Per discussion w/ RN, patient\n was tolerating @ 20mL/hr without residuals until feeds were turned off\n for probable extubation. TPN still infusing for nutrition. High and K\n and Mg noted- would hold TPN given large amounts of K in TPN. Will\n also need to change tube feed to renal formula until lytes return to\n normal\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: Will need multivitamin\n daily- 5mL liquid via NGT\n Would stop TPN now\n When resuming feeds, please change Rx to Novasource Renal @\n 25mL/hr (1200 kcals/44.4 gr protein)\n Will monitor lytes for ability to change to more standard\n formula\n Residual checks q4 hr, hold if over 150mL\n Glucose management as you are\n Following #\n ------ Protected Section ------\n Per discussion w/ team, plan to not resume tube feeds p/ extubation and\n continue w/ TPN due to bowel edema. TPN recommendations entered for\n goal TPN 1.1L(200 dextrose/50 gr protein/22 fat) to provide 1100\n kcals. K decreased significantly in TPN.\n ------ Protected Section Addendum Entered By: , RD, \n on: 12:43 PM ------\n"
},
{
"category": "Respiratory ",
"chartdate": "2115-02-21 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 625512,
"text": "Demographics\n Day of intubation: \n Ideal body weight: 43.7 None\n Ideal tidal volume: 174.8 / 262.2 / 349.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 26 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Pt received intubated and on SBT 8/0 as noted. PS weaned to 5cm and pt\n tolerated well with good follow up ABG. Subglottic suctioning done\n prior to extubation. Pt has a positive cuff leak test. Pt extubated to\n cool aerosol without incident.\n"
},
{
"category": "Nursing",
"chartdate": "2115-02-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 625502,
"text": "Hypotension (not Shock)\n Assessment:\n Patient\ns SBP 70\ns-80\ns, MAP down to low 50\ns x 1,\n u/o down to 17 cc/hr, Creat up to 1 this am.\n Action:\n Given 250 cc fluid bolus for hypotension and 500 cc fluid bolus for low\n u/o\n Repeat lytes sent\n Response:\n Plan:\n Fluid bolus as needed for Map < 60 and low u/o\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient intubated on CPAP 0/8, RR 20\ns-40\ns (patient breathes fast\n normally per mother). 50% fiO2 sating 99-100%.\n Suctioned for moderate amount of thick white secretions down ET tube,\n copious amounts of oral secretions.\n Action:\n SBT done,\n VBG sent (pH 7.37, pCo2- 40)\n Extubated, put on 70% face tent\n TF\ns held for extubation.\n Response:\n Patient couging, appears to be choking on secretions at times, able to\n cough and swallow secretions.\n Sating 94-100%.\n Plan:\n Continue to monitor.\n .H/O abdominal pain (including abdominal tenderness)\n Assessment:\n Abdomen is soft and slightly distended.\n Does not appear to be in pain to palpation,\n On tube feeds at 20 cc/hr at start of shift with minimal residuals.\n Action:\n TF\ns turned off prior to extubation for a few hours,\n NG to suction.\n TPN paused for potassium content (K 5.5 this am)\n Response:\n Plan:\n Continue to monitor.\n"
},
{
"category": "Nursing",
"chartdate": "2115-02-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 625504,
"text": "Hypotension (not Shock)\n Assessment:\n Patient\ns SBP 70\ns-80\ns, MAP down to low 50\ns x 1,\n u/o down to 17 cc/hr, Creat up to 1 this am.\n Action:\n Given 250 cc fluid bolus for hypotension and 500 cc fluid bolus for low\n u/o\n Repeat lytes sent\n Response:\n Plan:\n Fluid bolus as needed for Map < 60 and low u/o\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient intubated on CPAP 0/8, RR 20\ns-40\ns (patient breathes fast\n normally per mother). 50% fiO2 sating 99-100%.\n Suctioned for moderate amount of thick white secretions down ET tube,\n copious amounts of oral secretions.\n Action:\n SBT done,\n VBG sent (pH 7.37, pCo2- 40)\n Extubated, put on 70% face tent\n TF\ns held for extubation.\n Response:\n Patient couging, appears to be choking on secretions at times, able to\n cough and swallow secretions.\n Sating 94-100%.\n Plan:\n Continue to monitor.\n .H/O abdominal pain (including abdominal tenderness)\n Assessment:\n Abdomen is soft and slightly distended.\n Does not appear to be in pain to palpation,\n On tube feeds at 20 cc/hr at start of shift with minimal residuals.\n Action:\n TF\ns turned off prior to extubation for a few hours,\n NG to suction.\n TPN paused for potassium content (K 5.5 this am)\n Response:\n Continues to have liquid green/brown stool output from flexicele\n Plan:\n Continue to monitor.\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n Potassium 5.5 this am.\n Action:\n Given kayexelate,\n TPN paused due to high K+ content\n Response:\n Evening potassium -\n Plan:\n Restart TPN with this evenings dose\n"
},
{
"category": "Nursing",
"chartdate": "2115-02-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 625563,
"text": "H/O abdominal pain (including abdominal tenderness)\n Assessment:\n Abdomen soft slightly distended.\n Bowel sounds active.\n NGT with tube feed infusing.\n Flexi seal in place, draining green liquid stool but leaking around\n also.\n TPN continued.\n Action:\n Increased tube feeds to 20cc/h due to low gastric residual.\n Flexiseal cuff deflated and reinglated.\n Response:\n Continues to pass green liquid stool through and around\n flexiseal.\n Abdomen remains softly distended.\n Tolerating tube feed at this time.\n Plan:\n Continue to monitor\n Increase tube feed to goal of 25cc/h if tolerated.\n Probably dc tpn today.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on humidified face tent which he persistently removed.\n Copious thick oral secretions.\n Action:\n O2 delivery changed to nasal prongs 3l.\n Oral cavity suctioned for thick blood tinged mucous.\n Repositioned frequently.\n HOB > 30 degrees.\n Response:\n Breath sounds clear.\n O2 sats 98-100% consistently.\n Continues to require frequent clearance of copious oral secretions,\n though pt resistant to oral care.\n Plan:\n Continue to monitor respiratory status closely.\n Continue frequent pulmonary toilet.\n"
},
{
"category": "Physician ",
"chartdate": "2115-02-22 00:00:00.000",
"description": "Physician Resident/Attending Progress Note - MICU",
"row_id": 625668,
"text": "24 Hour Events:\n - extubated yest AM, tolerated well with moderate cough; on humidified\n face mask and then nasal canula 3 L at night\n - received 2 500 cc NS boluses during day\n - Cr continued to rise to 1.2; UO good at about 60-100cc/hr\n - TPN and TFs both continued\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Tobramycin - 12:15 PM\n Vancomycin - 08:30 PM\n Piperacillin/Tazobactam (Zosyn) - 07:14 AM\n Infusions:\n Other ICU medications:\n Fosphenytoin - 10:16 AM\n Pantoprazole (Protonix) - 08:07 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.4\nC (97.5\n HR: 94 (64 - 98) bpm\n BP: 101/62(72) {78/35(51) - 101/76(81)} mmHg\n RR: 19 (19 - 32) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 29.3 kg (admission): 32.3 kg\n Height: 55 Inch\n CVP: 10 (6 - 18)mmHg\n Total In:\n 3,394 mL\n 711 mL\n PO:\n TF:\n 257 mL\n 157 mL\n IVF:\n 1,810 mL\n 200 mL\n Blood products:\n Total out:\n 3,517 mL\n 602 mL\n Urine:\n 1,567 mL\n 552 mL\n NG:\n 300 mL\n Stool:\n Drains:\n Balance:\n -123 mL\n 109 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: Standby\n FiO2: 70%\n SpO2: 99%\n ABG: ///25/\n Physical Examination\n Gen: NAD\n Pulm: CTAB anteriorly\n CV: RRR, 2/6 systolic murmur heard in all fields\n Abd: soft, ND, did not push away hand while palpating\n Extremities: pulses intact, contracted, at baseline\n Neuro: alert, nonverbal,\n Labs / Radiology\n 129 K/uL\n 7.4 g/dL\n 143 mg/dL\n 1.2 mg/dL\n 25 mEq/L\n 4.3 mEq/L\n 16 mg/dL\n 119 mEq/L\n 149 mEq/L\n 24.1 %\n 5.4 K/uL\n [image002.jpg]\n 04:00 PM\n 01:32 AM\n 03:31 AM\n 01:00 AM\n 08:19 AM\n 04:27 PM\n 10:27 PM\n 04:15 AM\n 02:49 PM\n 03:57 AM\n WBC\n 10.1\n 7.6\n 6.5\n 5.4\n Hct\n 28.6\n 27.1\n 24.1\n 25.6\n 17\n 24.8\n 24.9\n 24.1\n Plt\n 110\n 109\n 122\n 129\n Cr\n 0.4\n 0.4\n 0.5\n 0.7\n 0.8\n 1.0\n 1.2\n 1.2\n TropT\n <0.01\n TCO2\n 36\n Glucose\n 104\n 106\n 98\n 132\n 109\n 118\n 94\n 143\n Other labs: PT / PTT / INR:17.0/29.2/1.5, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:, Alk Phos / T Bili:77/0.2,\n Amylase / Lipase:62/19, Lactic Acid:0.9 mmol/L, Albumin:2.4 g/dL,\n LDH:162 IU/L, Ca++:8.3 mg/dL, Mg++:2.7 mg/dL, PO4:4.5 mg/dL\n Assessment and Plan\n 34M cerebral palsy initially p/w concern for abdominal infection now\n reintubated for respiratory failure.\n # Renal insufficiency: with Cr at 1.2 from baseline 0.3-0.4. Likely\n multifactorial with series of renal insults including hypovolemia\n followed by infection (with Foley) and then medications (including ABX)\n with possible ATN/AIN. CVP 10-15. Unwell week prior to admission,\n likely poor PO intake.\n -Urine lytes consistent w/ ATN\n - holding vanc and tobra\n - consider renal consult\n - give another 500cc NS\n # Abdominal pain: Patient with finding of SMV thrombus with collaterals\n indicative of a chronic process. Surgery and Vascular involved,\n suspect to low flow state in setting of chronic pancreatitis. No\n e/o malignancy at this point. Patient started on heparin gtt. Also with\n diffuse bowel edema concerning for bowel ischemia / congestion. No e/o\n localized infection overlying inflammation at this point (though s/p\n paracentesis x 2, both with > 1000 WBC). Given compromised bowel wall,\n at high risk for translocation of bacteria.\n - Continue Zosyn (14 day total course)\n - D/C vanc given high levels\n - Continue Lovenox (30 mg QD per Pharmacy)\n - Start on Coumadin 5mg PO tonight\n - Vascular recs / Surgery recs\n - Follow-up cultures\n - Send repeat C.diff given fevers\n - GI recommendations\n - Hold tube feeds (started overnight) for extubation\n - Cont TPN and tube feeds\n start weaning TPN once INR starts to\n elevate (would indicate gut absorption)\n - Continue pancreatic enzymes\n - f/u with re: potential syndrome\n - F/U celiac disease labs\n # Respiratory failure: Treating for HAP/VAP with\n Vanc/Zosyn/Tobramycin. ID said no to Amikacin. With LLL infiltrate on\n CXR (persistent) but new since admission. Afebrile the night prior to\n transfer but with continued heavy secretions. No appreciable changes\n in ventilator settings. Following VBGs given too contracted for ABG.\n Family endorses heavy secretions at baseline. NIF today showing\n significant component of NM contribution.\n - Scopolamine patch (Cyproheptadine at home)\n - Goal fluid balance of even\n - d/c vanc and tobra\n - continue Cefepime x 14 days total\n - consider starting chest PT\n # Hypernatremia: Sodium is 149. Approximately 1.3L free water\n defecit.\n - increase free water flushes today by giving 200 q6h via NG\n - check PM lytes\n # Fever: Intermittent since admission on , . Could be \n ischemia; other possible sources of infection include pulmonary with\n some infiltrate on his CXR but he is without a leukocytosis. Does have\n prominent secretions per primary Surgical team.\n - Antibiotics as above (cont Zosyn, stopping Vanc and Tobra)\n - Follow-up Micro\n - Culture if febrile\n - UA\n # Hypotension: Per family, patient's baseline BP high 70s - low 80s.\n Per nursing, also newly bradycardic and hypotensive (SBP 70s) overnight\n on . Could be vagal tone with ET/CVL but also consider\n infectious process. Previously responded to Albumin and 500cc bolus\n LR. Echo (final pending) Ef=55% and no focal wall motion\n abnormalities.\n - Monitor fluid balance; goal even\n - Goal SBP 80, MAP ~60s\n - if bolus use 250-500cc\n # SMV Occlusion: SMV occulsion with plan for 6 months anticoagulation\n per Vascular recommendation. Started on Heparin gtt for\n anticoagulation PTT 60-80, as well as daily Coumadin with Goal INR ,\n now holding coumadin. Also noted to have diarrhea during stay (C.diff\n negative) thought to be lack of absorption due to bowel wall edema.\n - continue low dose Lovenox (discussed with vascular) at 30 qd\n - check Factor Xa level after 3^rd dose\n - Start Coumadin\n - trend PLT (increased today, but some concern for HIT)\n - send HIT antibody\n - if tolerates tube feeds may restart Coumadin in next few days\n # Anemia: Unclear source for acute on chronic anemia (baseline 35) but\n now on anticoagulation. NG lavage / guaiac negative . Could\n consider some dilutional component, but likely does not explain\n complete loss. No blood yet given.\n - T&C x 2U PRBC; transfuse to 21 unless e/o ischemia/bleeding\n - Monitor Hct now that stable\n - Continue to monitor stool guaiac\n # Thrombocytopenia: New . With prior hospitalization, could\n consider new exposure to heparin with HIT. Other medications include\n antibiotics and Leviteracitam.\n - Stop heparin\n - Start Lovenox\n - Stop Keppra\n - check HIT antibodies as above\n # Coagulopathy: Noted on admission; consider malnutrition vs\n malabsorption vs intrinsic liver disease.\n - Stop heparin, Coumadin\n - Start Lovenox as above\n # Hypoalbuminemia: Noted on arrival, with similar etiology to\n coagulopathy.\n - Restart TF; support nutrition as able\n - Discuss trophic TF with Surgery\n # Cerebral Palsy: Not ambulatory at baseline; also with h/o chronic,\n intermittent diarrhea; chronic pancreatitis. Could be an undiagnosed\n syndrome. Phenobarb level within therapeutic range on admission.\n - Seizure meds as below\n - Discuss with outpatient Neurology\n - Pancreatic enzymes as diet advances\n - check free dilantin level and free phenobarb levels\n # Seizure disorder: Family describes them as 'drop seizures' with\n sudden head slumps. On Dilantin / Phenobarbital as outpatient. Keppra\n DC\nd. Started on fosphenytoin and phenobarb and levels are currently\n reasonable.\n - Continue Fosphenytoin / Phenobarbital\n - Touch base with outpatient Neurology Openheimer ()\n # FEN Euvolemic to hypovolemic / replete PRN / continue TPN for now /\n start tube feeds later today\n # PPX:\n - PPI\n - Chlorehexadine gluconate\n - Pneumoboots\n - Systemically anticoagulated\n # ACCESS: L-Subclavian CL (); R PIV\n # Communication: & (Parents) \n # CODE: FULL\n # Dispo: call out to floor today\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 35M CP, seizures admitted to SICU with\n diffuse bowel edema, peritonitis, varicies - w/u notable for SMV\n thrombosis, started on anticoagulation, treated with broad antibiotic\n coverage. Initially intubated in the ED, extubated for one day but\n reintubated for secretions and respiratory distress. Extubated without\n complication yesterday, renal failure stable overnight s/p NS 500x2.\n Exam notable for Tm 98.2 BP 80/60 HR 74-90 RR 28 with sat 100 on 2LNC.\n Small hypoteloric man, NAD. Coarse BS B. RRR s1s2. Softer, +BS. No\n edema. Labs notable for WBC 5K, HCT 24, Na 149, K+ 4.3, Cr 1.2, vanco\n 43. No new imaging.\n Agree with plan to manage resolving respiratory failure with CPT,\n PT/OOB, scopalomine patch and pneumonia rx with zosyn and vanco to\n level. For SMV thrombosis - continue lovenox 30qd and continue bridge\n to coumadin, will add pancreatic enzyme and work to transition off TPN\n using tube feeds and serial LFTs / lipase; will also check anti-TTG ab\n to r/o celiac dz and will finish 14 day total abx course for\n peritonitis bowel edema and translocation. For pneumonia / fevers -\n pancx, continue zosyn x14d, vanco to level. For ARF with elevation in\n creatinine, RD meds, optimize hemodynamics\n etiology likely a\n combination of vanco (level >70), tobra, contrast, low flow /\n hypovolemia; will hydrate and continue med rx of hyperkalemia, check\n lytes \n hold TPN given high K content in his formulation.\n Hypernatremia - FWB 200 q6h, check PM lytes. Thrombocytopenia - stable.\n For seizures - will transition back to home regimen and follow drug\n levels. Care d/w family in detail at bedside. Remainder of plan as\n outlined above.\n Total time: 35 min\n ------ Protected Section Addendum Entered By: , MD\n on: 06:49 PM ------\n"
},
{
"category": "Nursing",
"chartdate": "2115-02-22 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 625651,
"text": "HPI:\n 35M with Cerebral palsy, presented with abdominal pain and distention\n to an OSH this am where CT scan was performed and reported as diffused\n bowel edema, gastric varices, ascites, pancreatic cyst. No association\n with nausea, vomitting, diarrhea, hematemesis, hematochezia, no GU\n symptoms. No jaundice, no fevers. No weight loss, no NSAIDs, ASA use.\n Pt was transferred to for further care on .\n Chief complaint:\n respiratory distress, peritonitis, SMV occlusion\n PMHx:\n Cerebral Palsy (Patient non verbal baseline), Seizure d/o, Chronic\n anemia (transfusion x2)\n .\n While in SICU:\n Thrombosis found in SMV. Pt started on heparin drip briefly and was\n then discontinued and treated with coumadin and lovenox. Received ~4\n doses of coumadin with no bump in INR probably related to poor bowel\n absorption. Pt also has chronic pancreatitis so was given TPN for\n nutrition and started on pancreatic enzymes. Pt failed extubation\n earlier on this week d/t poor cough/gag and copious secretions and was\n re-intubated ~24hrs after extubation. Remained intubated for another\n few days and was extubated on Thurs . On zosyn for PNA. Throughout\n course of ICU has had some hypotension which responds to small IVF\n bolus of 250cc no bolus since yesterday. Pt\ns baseline SBP high 70\n -90 with MAP 60\n Respiratory failure, acute (not ARDS/)\n Assessment:\n O2 sats high 90\ns on 2L nc. Pt has a strong cough when\n stimulated and requires assistance to clear secretions from back of\n throat\n Requires diligent mouth care\n Making adequate amts of urine at this time\n Action:\n Chest PT done Q2hrs\n Assisted OOB to chair\n IV zosyn for PNA\n Response:\n Afebrile at this time\n Responding to pulmonary toilet\n Plan:\n Cont pulmonary toilet\n OOB daily\n SMV thrombosis\n Assessment:\n TF at goal via NGT supplementing with TPN for now until\n bowel absorption improves\n Passing lge amts of watery bile appearing stool-remains on\n pancreatic enzymes with flexiseal in place\n Flexiseal does leak this morning trouble shooting flexiseal\n found formed stool sitting at end of flexiseal\npatency improved once\n reinserted\n Na climbing (d/t loose stool)\n This afternoon pt pulled NGT out about 4 inches. NGT pushed\n easily back in place\n Action:\n Frequent skin care to buttocks with clear critic aid barrier\n cream-positioned off buttocks as much as possible\n Coumadin ordered for tonight\n Free water bolus added to TF 200cc Q6hr\n CXR done to confirm NGT placement after pt pulled and\n dislodged\n Response:\n Buttocks becoming pink d/t leakage from flexiseal\n Daily INR in response to PO coumadin will be indicator of\n bowel absorption\n Flexiseal removed this afternoon d/t not draining and\n leaking around again. Flushed without any effect and when removed had\n mucous clogging tip.\n Plan:\n Cont TF and TPN\n Coumadin/lovenox for thromosis\n Family updated by Dr. and aware of plans to transfer patient out\n to floor.\n Demographics\n Attending MD:\n F.\n Admit diagnosis:\n ABDOMINAL PAIN\n Code status:\n Height:\n 55 Inch\n Admission weight:\n 32.3 kg\n Daily weight:\n 29.3 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH:\n Additional history: Cerebral Palsy, Seizure disorder, chronic anemia,\n GIB in , hx of \"abdominal issues\" that have resolved with\n conservative management.\n PSH: Lap Chole, Pancreatic cyst drainage\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:91\n D:63\n Temperature:\n 99.6\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 28 insp/min\n Heart Rate:\n 99 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 96% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 70% %\n 24h total in:\n 2,034 mL\n 24h total out:\n 1,162 mL\n Pertinent Lab Results:\n Sodium:\n 149 mEq/L\n 03:57 AM\n Potassium:\n 4.3 mEq/L\n 03:57 AM\n Chloride:\n 119 mEq/L\n 03:57 AM\n CO2:\n 25 mEq/L\n 03:57 AM\n BUN:\n 16 mg/dL\n 03:57 AM\n Creatinine:\n 1.2 mg/dL\n 03:57 AM\n Glucose:\n 143 mg/dL\n 03:57 AM\n Hematocrit:\n 24.1 %\n 03:57 AM\n Finger Stick Glucose:\n 135\n 04:00 PM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: SICU B 676\n Transferred to: CC-715\n Date & time of Transfer: \n"
},
{
"category": "Nursing",
"chartdate": "2115-02-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 625295,
"text": "HPI:\n 35M with Cerebral palsy, presented with abdominal pain and distention\n to an OSH where CT scan was performed and reported as diffuse bowel\n edema, gastric varices, ascites, pancreatic cyst. No association with\n nausea, vomiting, diarrhea, hematemesis, hematochezia, no GU symptoms.\n No jaundice, no fevers. No weight loss, no NSAIDs, ASA use. Pt recieved\n Unasyn at the OSH and was transferred to .\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains ventilated on simv at 50%, rate 12, 8 peep and 10 PS.\n Bs with rhonchi, congested cough\n Sats 98-100\n Action:\n Turned q 2\n 3 hrs\n Sx several times via ETT for copious thick bloody secretions\n Sputum sent for c+s\n oral secretions also copious, blood tinged\n Response:\n BS less rhonchorous\n Fewer secretions this am\n Plan:\n ? begin weaning from vent\n Continue thorough pulmonary toileting\n .H/O abdominal pain (including abdominal tenderness)\n Assessment:\n Abdomen remains distended but soft, with hypoactive bowel sounds. No\n obvious signs of pain\n Heparin at 1100 units/hr, PTT 129.\n Sputum and oral secretions bloody\n Flexiseal in place, draining large amts green liquid stool\n Action:\n Heparin off x 2 hrs, resumed at 850 units /hour\n Response:\n Sputum and oral secretions less bloody\n Plan:\n Check PTT and hct at 10 am.\n"
},
{
"category": "Respiratory ",
"chartdate": "2115-02-20 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 625396,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 43.7 None\n Ideal tidal volume: 174.8 / 262.2 / 349.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Dysynchrony assessment: Frequent alarms (Low min. ventilation)\n Comments: Patient had several episodes of short burst of apnea after\n high RR during cpap/ps mode. Changed to imv for a few hours and then\n back to cpap mode. Doing better this pm in cpap mode.\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Cannot protect airway, Cannot manage secretions\n"
},
{
"category": "Physician ",
"chartdate": "2115-02-20 00:00:00.000",
"description": "Intensivist Note",
"row_id": 625392,
"text": "SICU\n HPI:\n 35M with Cerebral palsy, presented with abdominal pain and distention\n to an OSH this am where CT scan was performed and reported as diffused\n bowel edema, gastric varices, ascites, pancreatic cyst. No association\n with nausea, vomitting, diarrhea, hematemesis, hematochezia, no GU\n symptoms. No jaundice, no fevers. No weight loss, no NSAIDs, ASA use.\n Pt recieved Unasyn at the OSH and was transferred to .\n Chief complaint:\n respiratory distress, peritonitis, SMV occlusion\n PMHx:\n Cerebral Palsy (Patient non verbal baseline), Seizure d/o, Chronic\n anemia (transfusion x2)\n .\n PSH:\n Lap cholecystectomy\n Pancreatic cyst drainage (last year, )\n Current medications:\n 1. 2. 3. Acetaminophen 4. Albumin 5% (12.5g / 250mL) 5. Albuterol\n 0.083% Neb Soln 6. Calcium Gluconate 7. Chlorhexidine Gluconate 0.12%\n Oral Rinse 8. Dextrose 50% 9. Fentanyl Citrate 10. Glucagon 11. Heparin\n 12. Heparin Flush (10 units/ml) 13. Insulin 14. LeVETiracetam 15.\n Magnesium Sulfate 16. Midazolam 17. Pantoprazole 18. Phenylephrine 19.\n Piperacillin-Tazobactam 20. Potassium Chloride 21. Sodium Chloride 0.9%\n Flush 22. Sodium Chloride 0.9% Flush 23. Tobramycin 24. Vancomycin 25.\n Warfarin\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 03:20 PM\n : Episode of hypotension to low 70's recieved a bolus of albumin w/\n good response. Vancomycine increased to 1250\". Started on tobramycin\n presumed to have pneumonia\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 03:53 AM\n Tobramycin - 12:04 PM\n Vancomycin - 08:26 PM\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium - 08:19 AM\n Midazolam (Versed) - 11:07 AM\n Pantoprazole (Protonix) - 08:00 PM\n Other medications:\n Flowsheet Data as of 04:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.9\nC (100.3\n T current: 36.5\nC (97.7\n HR: 93 (75 - 99) bpm\n BP: 93/68(74) {71/47(59) - 119/86(89)} mmHg\n RR: 22 (17 - 31) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 37.1 kg (admission): 32.3 kg\n Height: 55 Inch\n CVP: 8 (5 - 14) mmHg\n Total In:\n 2,674 mL\n 319 mL\n PO:\n Tube feeding:\n IV Fluid:\n 1,281 mL\n 121 mL\n Blood products:\n 250 mL\n Total out:\n 2,745 mL\n 420 mL\n Urine:\n 2,095 mL\n 420 mL\n NG:\n 350 mL\n Stool:\n Drains:\n Balance:\n -71 mL\n -101 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: SIMV/PSV/AutoFlow\n Vt (Set): 300 (300 - 300) mL\n Vt (Spontaneous): 341 (291 - 341) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 8\n PEEP: 8 cmH2O\n FiO2: 50%\n PIP: 22 cmH2O\n Plateau: 17 cmH2O\n SPO2: 99%\n ABG: ///30/\n Ve: 8.8 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: Crackles : Bilateral)\n Abdominal: Soft, Distended\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Neurologic: Follows simple commands, Moves all extremities, alert\n Labs / Radiology\n 109 K/uL\n 8.9 g/dL\n 98 mg/dL\n 0.5 mg/dL\n 30 mEq/L\n 4.3 mEq/L\n 9 mg/dL\n 104 mEq/L\n 142 mEq/L\n 27.1 %\n 7.6 K/uL\n [image002.jpg]\n 02:48 AM\n 06:09 AM\n 03:11 PM\n 04:05 AM\n 02:40 PM\n 02:29 AM\n 04:00 PM\n 01:32 AM\n 03:31 AM\n 01:00 AM\n WBC\n 10.6\n 8.7\n 9.4\n 10.1\n 7.6\n Hct\n 29.1\n 31.6\n 32.9\n 30.9\n 29.2\n 28.6\n 27.1\n Plt\n 179\n 139\n 107\n 110\n 109\n Creatinine\n 0.4\n 0.5\n 0.5\n 0.5\n 0.4\n 0.4\n 0.4\n 0.5\n TCO2\n 25\n 36\n Glucose\n 134\n 80\n 118\n 137\n 141\n 104\n 106\n 98\n Other labs: PT / PTT / INR:15.8/129.8/1.4, ALT / AST:, Alk-Phos /\n T bili:80/0.3, Amylase / Lipase:62/19, Lactic Acid:0.9 mmol/L,\n Albumin:2.5 g/dL, LDH:158 IU/L, Ca:8.2 mg/dL, Mg:3.0 mg/dL, PO4:3.8\n mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), .H/O ABDOMINAL PAIN\n (INCLUDING ABDOMINAL TENDERNESS)\n Assessment and Plan: 35M with CP, chronic pancreatitis, transudative\n ascites and peritonitis likely SMV occlusion, now on hep gtt.\n Neurologic:\n - Pre-existing seizure disorder -> Keppra 20 .\n - Pain seems to be well controlled.\n - Baseline mental status\n -Intubated off sedation\n Cardiovascular:\n --Episodes of asym brady to 40s; hypotensive, given albumin and LR;\n now stable, continue to monitor\n --ECHO: EF 55% f/up final read\n Pulmonary:\n - Respiratory failure: now reintubated, requiring aggresive pulm\n toilet, chest PT and suctioning due to secretions\n --Wean the vent as tolerated\n --F/up sputum Cx\n Gastrointestinal / Abdomen:\n - On empiric ABX for peritonitis. Work up for ascities on-going. F/U\n Cx\n --CTA revealed SMV occlusion, venous stasis--->On hep gtt\n -- Diarrhea: likely due to lack of absorption d/t bowel wall edema,\n improving today, Flagyl d/c'd, C diff negative\n -- Pantoprazole for GI proph\n --NGT lavage to eval bleeding source given HCT drop\n Nutrition: TPN\n Renal:\n --stable urine output, lasix \n --Hypokalemia, resolved\n --Patient on tobramycin and vancomycin monitor Renal function closely\n Hematology:\n - Slowly worsening anemia secondary to dilution, inflammation, and\n pre-existing chronic anemia\n - Hct 27.1\n 24.1 on gastric lavage to eval bleeding source,\n CT/CTA to eval abdominal bleeding for HCT <20\n -S/P Transfusion 2UPRBC for Hct of 26 on ,\n - Elevated INR & PTT secondary to the nutritional depletion.\n On hep gtt for SMV occlusion (goal 60-80)\n -coumadin started on , inc 5 today, last INR 1.4\n Endocrine:\n - RISS with adequate BG control.\n Infectious Disease:\n - Abdominal peritonitis - on empiric coverage with vanc/zosyn and\n tobramycin to cover pseudomonas pneumonia\n - F/u cultures\n - suspected pneumonia and at risk MDR HAP added tobramycin, f/u AM\n trough level (goal less than 1)\n Lines / Tubes / Drains: ETT, PIV, Foley, Left sub clav ()\n Wounds:\n Imaging: CXR today\n Fluids: KVO\n Consults: General surgery\n Billing Diagnosis: (Respiratory distress: Failure)\n ICU Care\n Nutrition:\n TPN w/ Lipids - 06:08 PM 46 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 03:15 AM\n 20 Gauge - 12:17 PM\n Prophylaxis:\n DVT: Boots (Systemic anticoagulation: Heparin drip)\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 32 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2115-02-21 00:00:00.000",
"description": "Physician Resident/Attending Progress Note - MICU",
"row_id": 625525,
"text": "24 Hour Events:\n No events overnight. Pt w/ SBP in 60s-80s. Remains intubated. Appears\n comfortable.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Tobramycin - 12:15 PM\n Vancomycin - 08:30 PM\n Piperacillin/Tazobactam (Zosyn) - 12:10 AM\n Infusions:\n Other ICU medications:\n Fentanyl - 09:30 AM\n Pantoprazole (Protonix) - 09:00 PM\n Dilantin - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 38\nC (100.4\n HR: 71 (49 - 94) bpm\n BP: 70/48(54) {62/44(49) - 108/81(88)} mmHg\n RR: 29 (16 - 41) insp/min\n SpO2: 100% on PS FiO2 50%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 29.3 kg (admission): 32.3 kg\n Height: 55 Inch\n CVP: 14 (9 - 17)mmHg\n Total In:\n 3,597 mL\n 820 mL\n PO:\n TF:\n 85 mL\n IVF:\n 2,433 mL\n 350 mL\n Blood products:\n Total out:\n 2,620 mL\n 717 mL\n Urine:\n 1,770 mL\n 467 mL\n NG:\n 350 mL\n Stool:\n Drains:\n Balance:\n 977 mL\n 103 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 300 (300 - 300) mL\n Vt (Spontaneous): 264 (147 - 322) mL\n PS : 8 cmH2O\n RR (Set): 14\n RR (Spontaneous): 28\n PEEP: 0 cmH2O\n FiO2: 50%\n RSBI: 186\n PIP: 8 cmH2O\n Plateau: 17 cmH2O\n SpO2: 100%\n ABG: ///29/\n NIF: -21 cmH2O\n Ve: 6.2 L/min\n Physical Examination\n Gen: Intubated, sedated\n Resp: tacchypneic, clear anteriorly\n Cards: rrr no m/r/g\n Abd: soft, nt/nd, no guarding\n Ext: Contracted, WWP, no c/c/e\n Labs / Radiology\n 122 K/uL\n 8.0 g/dL\n 118 mg/dL\n 1.0 mg/dL\n 29 mEq/L\n 5.5 mEq/L\n 15 mg/dL\n 109 mEq/L\n 140 mEq/L\n 24.8 %\n 6.5 K/uL\n [image002.jpg]\n 02:40 PM\n 02:29 AM\n 04:00 PM\n 01:32 AM\n 03:31 AM\n 01:00 AM\n 08:19 AM\n 04:27 PM\n 10:27 PM\n 04:15 AM\n WBC\n 9.4\n 10.1\n 7.6\n 6.5\n Hct\n 30.9\n 29.2\n 28.6\n 27.1\n 24.1\n 25.6\n 17\n 24.8\n Plt\n 107\n 110\n 109\n 122\n Cr\n 0.5\n 0.4\n 0.4\n 0.4\n 0.5\n 0.7\n 0.8\n 1.0\n TropT\n <0.01\n TCO2\n 36\n Glucose\n 137\n 141\n 104\n 106\n 98\n 132\n 109\n 118\n Other labs: PT / PTT / INR:17.0/29.2/1.5, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:, Alk Phos / T Bili:80/0.3,\n Amylase Lipase:62/19, Lactic Acid:0.9 mmol/L, Albumin:2.5 g/dL,\n LDH:158 IU/L, Ca++:8.1 mg/dL, Mg++:2.8 mg/dL, PO4:3.5 mg/dL\n \n 06:00a\n _______________________________________________________________________\n Source: Line-cvl; Vancomycin @ Trough\n Other Blood Chemistry:\n Vanco: 72.3\n \n 07:53a\n _______________________________________________________________________\n pH\n 7.37\n pCO2\n 45\n pO2\n 43\n HCO3\n 27\n BaseXS\n 0\n Assessment and Plan\n 34M cerebral palsy initially p/w concern for abdominal infection now\n reintubated for respiratory failure.\n # Renal insufficiency: with Cr at 1.0 from baseline 0.3-0.4. Likely\n multifactorial with series of renal insults including hypovolemia\n followed by infection (with Foley) and then medications (including ABX)\n with possible AIN. CVP 10-15. Unwell week prior to admission, likely\n poor PO intake.\n - UA, Ulytes, UEos\n - holding vanc and tobra\n - consider renal consult\n - give another 500cc NS\n # Abdominal pain: Patient with finding of SMV thrombus with collaterals\n indicative of a chronic process. Surgery and Vascular involved,\n suspect to low flow state in setting of chronic pancreatitis. No\n e/o malignancy at this point. Patient started on heparin gtt. Also with\n diffuse bowel edema concerning for bowel ischemia / congestion. No e/o\n localized infection overlying inflammation at this point (though s/p\n paracentesis x 2, both with > 1000 WBC). Given compromised bowel wall,\n at high risk for translocation of bacteria.\n - Continue Zosyn (14 day total course)\n - D/C vanc given high levels\n - Continue Lovenox (30 mg per Pharmacy given decreased renal\n function; if improves increase to 40 mg )\n - Vascular recs / Surgery recs\n - Follow-up cultures\n - Send repeat C.diff given fevers\n - GI recommendations\n - Hold tube feeds (started overnight) for extubation\n - Cont TPN across the day, order for tomorrow but hope to wean if can\n - Start pancreatic enzymes\n - f/u with re: potential syndrome\n - check celiac disease labs\n # Respiratory failure: Treating for HAP/VAP with\n Vanc/Zosyn/Tobramycin. ID said no to Amikacin. With LLL infiltrate on\n CXR (persistent) but new since admission. Afebrile the night prior to\n transfer but with continued heavy secretions. No appreciable changes\n in ventilator settings. Following VBGs given too contracted for ABG.\n Family endorses heavy secretions at baseline. NIF today showing\n significant component of NM contribution.\n - Scopolamine patch (Cyproheptadine at home)\n - Goal fluid balance of even\n - d/c vanc and tobra\n - continue Cefepime x 14 days total\n - Trial pressure support today and ? extubation\n # Fever: Intermittent since admission on , . Could be \n ischemia; other possible sources of infection include pulmonary with\n some infiltrate on his CXR but he is without a leukocytosis. Does have\n prominent secretions per primary Surgical team.\n - Antibiotics as above (cont Zosyn, stopping Vanc and Tobra)\n - Follow-up Micro\n - Culture if febrile\n - UA\n # Hypotension: Per family, patient's baseline BP high 70s - low 80s.\n Per nursing, also newly bradycardic and hypotensive (SBP 70s) overnight\n on . Could be vagal tone with ET/CVL but also consider\n infectious process. Previously responded to Albumin and 500cc bolus\n LR. Echo (final pending) Ef=55% and no focal wall motion\n abnormalities.\n - Monitor fluid balance; goal even\n - Goal SBP 80, MAP ~60s\n - if bolus use 250-500cc\n # SMV Occlusion: SMV occulsion with plan for 6 months anticoagulation\n per Vascular recommendation. Started on Heparin gtt for\n anticoagulation PTT 60-80, as well as daily Coumadin with Goal INR ,\n now holding coumadin. Also noted to have diarrhea during stay (C.diff\n negative) thought to be lack of absorption due to bowel wall edema.\n - continue low dose Lovenox (discussed with vascular) at 30 qd\n - check Factor Xa level after 3^rd dose\n - Per discussion with pharmacy, will dose 30 mg SC BID (consider 40 mg\n if Cr improves)\n - trend PLT (increased today, but some concern for HIT)\n - send HIT antibody\n - if tolerates tube feeds may restart Coumadin in next few days\n # Anemia: Unclear source for acute on chronic anemia (baseline 35) but\n now on anticoagulation. NG lavage / guaiac negative . Could\n consider some dilutional component, but likely does not explain\n complete loss. No blood yet given.\n - T&C x 2U PRBC; transfuse to 21 unless e/o ischemia/bleeding\n - Monitor Hct now that stable\n - Continue to monitor stool guaiac\n # Thrombocytopenia: New . With prior hospitalization, could\n consider new exposure to heparin with HIT. Other medications include\n antibiotics and Leviteracitam.\n - Stop heparin\n - Start Lovenox\n - Stop Keppra\n - check HIT antibodies as above\n # Coagulopathy: Noted on admission; consider malnutrition vs\n malabsorption vs intrinsic liver disease.\n - Stop heparin, Coumadin\n - Start Lovenox as above\n # Hypoalbuminemia: Noted on arrival, with similar etiology to\n coagulopathy.\n - Restart TF; support nutrition as able\n - Discuss trophic TF with Surgery\n # Cerebral Palsy: Not ambulatory at baseline; also with h/o chronic,\n intermittent diarrhea; chronic pancreatitis. Could be an undiagnosed\n syndrome. Phenobarb level within therapeutic range on admission.\n - Seizure meds as below\n - Discuss with outpatient Neurology\n - Pancreatic enzymes as diet advances\n - check free dilantin level and free phenobarb levels\n # Seizure disorder: Family describes them as 'drop seizures' with\n sudden head slumps. On Dilantin / Phenobarbital as outpatient. Patient\n transitioned to Keppra while inpatient.\n - Discuss restarting Dilantin / Phenobarbital safely with pharmacy\n - Touch base with outpatient Neurology Openheimer ()\n - switch to phosphenitoin\n # FEN Euvolemic to hypovolemic / replete PRN / continue TPN for now /\n start tube feeds later today\n # PPX:\n - PPI\n - Chlorehexadine gluconate\n - Pneumoboots\n - Systemically anticoagulated\n # ACCESS: L-Subclavian CL (); R PIV\n # Communication: & (Parents) \n # CODE: FULL\n # Dispo: ICU pending clinical improvement\n ICU Care\n Nutrition:\n TPN w/ Lipids - 06:02 PM 46 mL/hour\n Ensure (Full) - 12:00 AM 20 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 03:15 AM\n 20 Gauge - 12:17 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 35M CP, seizures admitted to SICU with\n diffuse bowel edema, peritonitis, varicies - w/u notable for SMV\n thrombosis, started on anticoagulation, treated with broad antibiotic\n coverage. Initially intubated in the ED, extubated for one day but\n reintubated for secretions and respiratory distress. Progressive renal\n failure with elevated vanco level. Changed from heparin to lovenox.\n Exam notable for Tm 100.7 BP 90/50 HR 74 RR 28 with sat 100 on PSV 8/5\n v7.37/45 NIF -21. Small hypoteloric man, mild distress on vent. Coarse\n BS B. RRR s1s2. Firm, +BS. No edema. Labs notable for WBC 6K, HCT 24,\n K+ 5.5, Cr 1.0, vanco 70. CXR with patchy LL pneumonia.\n Agree with plan to manage ongoing respiratory failure with SBT and\n trial of extubation, follow muscle forces, continue scopalomine patch\n and pneumonia rx with zosyn and vanco to level. For SMV thrombosis -\n continue lovenox 30qd and continue bridge to coumadin, will add\n pancreatic enzyme when starting POs and work to transition off TPN\n using trophic feeds and serial LFTs / lipase; will alos check anti-TTG\n ab to r/o celiac dz. For pneumonia / fevers - pancx, continue zosyn\n x14d, vanco to level. For ARF with elevation in creatinine, RD meds,\n optimize hemodynamics\n give 500cc NS now, check lytes / eos / sed -\n etiology may well be combination of vanco (level >70) and tobra,\n contrast, low flow / hypovolemia; will hydrate now and continue med rx\n of hyperkalemia, check lytes \n hold TPN given high K content in his\n formulation. Thrombocytopenia - improving, check HIT, monitor, may need\n to change anticoagulation if +. For anemia, guiac stools, BBS. For\n seizures - will transition back to home regimen and follow drug levels.\n Care d/w family in detail at bedside. Remainder of plan as outlined\n above.\n ADDENDUM\n Patient successfully extubated at 1130, UOP increased with\n IVF; continue to monitor with plan as above.\n Patient is critically ill\n Total time: 50 min\n ------ Protected Section Addendum Entered By: , MD\n on: 04:10 PM ------\n"
},
{
"category": "Respiratory ",
"chartdate": "2115-02-15 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 624548,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 20 cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments/Plan\n Remains intubated, vent supported. No changes made overnight. See\n Flowsheet for further pt data. Will follow.\n 05:50\n"
},
{
"category": "Nursing",
"chartdate": "2115-02-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 624745,
"text": ".H/O abdominal pain (including abdominal tenderness)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2115-02-15 00:00:00.000",
"description": "Intensivist Note",
"row_id": 624540,
"text": "SICU\n HPI:\n 35M with Cerebral palsy,presented with abdominal pain and distention to\n an OSH this am where CT scan was performed and reported as diffused\n bowel edema,gastric varices, ascites, pancreatic cyst. No association\n with nausea,vomitting, diarrhea, hematemesis, hematochezia, no GU\n symptoms. No jaundice , no fevers. No weight loss, no NSAIDs, ASA use.\n Pt recieved Unasyn at the OSH and was transferred to .\n Chief complaint:\n respiratory distress, peritonitis, possible ischemic bowel\n PMHx:\n Cerebral Palsey (Patient non verbal baseline), Seizure d/o, Chronic\n anemia (transfusion x2)\n Current medications:\n 1000 mL LR 4. Acetaminophen 5. Albuterol 0.083% Neb Soln 6. Albumin 25%\n (12.5g / 50mL)\n 7. Calcium Gluconate 8. Dextrose 50% 9. Fentanyl Citrate 10. Glucagon\n 11. Heparin Flush (10 units/ml)\n 12. 13. Insulin 14. LeVETiracetam 15. Magnesium Sulfate 16.\n MetRONIDAZOLE (FLagyl) 17. Midazolam\n 18. Pantoprazole 19. Piperacillin-Tazobactam 20.\n Piperacillin-Tazobactam 21. Potassium Chloride 22. Sodium Chloride 0.9%\n Flush\n 23. Vancomycin\n 24 Hour Events:\n FEVER - 101.1\nF - 08:00 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 12:37 AM\n Metronidazole - 04:30 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 09:29 AM\n Pantoprazole (Protonix) - 08:00 PM\n Fentanyl - 03:00 AM\n Other medications:\n Flowsheet Data as of 04:46 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.4\nC (101.1\n T current: 37.1\nC (98.8\n HR: 108 (97 - 117) bpm\n BP: 92/69(75) {80/59(65) - 97/78(83)} mmHg\n RR: 29 (20 - 29) insp/min\n SPO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 35.4 kg (admission): 71 kg\n CVP: 12 (8 - 18) mmHg\n Total In:\n 8,837 mL\n 559 mL\n PO:\n Tube feeding:\n IV Fluid:\n 3,287 mL\n 559 mL\n Blood products:\n 50 mL\n Total out:\n 959 mL\n 195 mL\n Urine:\n 509 mL\n 195 mL\n NG:\n Stool:\n Drains:\n Balance:\n 7,878 mL\n 364 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 0 (0 - 300) mL\n Vt (Spontaneous): 320 (258 - 320) mL\n PS : 12 cmH2O\n RR (Set): 22\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 69\n PIP: 7 cmH2O\n SPO2: 99%\n ABG: ///25/\n Ve: 6.6 L/min\n Physical Examination\n General Appearance: Cachectic\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Distended, Peritoneal sign\n Labs / Radiology\n 177 K/uL\n 8.2 g/dL\n 74 mg/dL\n 0.5 mg/dL\n 25 mEq/L\n 3.3 mEq/L\n 13 mg/dL\n 115 mEq/L\n 144 mEq/L\n 26.2 %\n 9.3 K/uL\n [image002.jpg]\n 03:35 AM\n 12:11 PM\n 04:42 PM\n 03:27 AM\n WBC\n 9.3\n 9.3\n Hct\n 28.3\n 27.1\n 26.2\n Plt\n 226\n 177\n Creatinine\n 0.4\n 0.5\n 0.5\n Glucose\n 112\n 90\n 74\n Other labs: PT / PTT / INR:16.9/45.5/1.5, ALT / AST:, Alk-Phos / T\n bili:91/0.1, Amylase / Lipase:52/, Lactic Acid:0.7 mmol/L, Albumin:2.1\n g/dL, LDH:142 IU/L, Ca:7.7 mg/dL, Mg:2.2 mg/dL, PO4:2.2 mg/dL\n Assessment and Plan\n .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n Assessment and Plan: 35M with CP, peritonitis and ascites. Continuing\n work to detemrine etiology of SBP and monitor for ischemic colitis.\n Neurologic: Neurologic:\n --Intubated and sedated PRN Midazolam\n --Hx of Seizure disorder: switched from home dilantin to keppra while\n in ICU\n --Moves all extremities\n Cardiovascular: -- baseline SBP 80'S\n --Tachycardia O/N likely due to volume depletion and SBP, albumin\n given, Hr's decreased to ~100's\n Pulmonary: -Respiratory Failure and Possible : Pt on Low PIP and TV\n for likely , wean as tolerated, will f/u AM chest XRAY\n Gastrointestinal / Abdomen: --peritonitis, Bowel thickening, no free\n air, lactate decreasing on antibiotic prophylaxis, f/u AM mixed venous\n gas and lactate\n -- C. Diff tests pending\n -- GI consult yesterday felt it was not prudent to scope at this time\n given risks of perforation\n -- LFTs and Hepatitis serologies sent to identify cause of ascities\n -- Ischemic bowel seems unlikely at this time as lactate has remained\n low\n Nutrition: NPO\n Renal: --AUOP\n -- stable Cr\n Hematology: --Hct 34.6->28.3->26.2, most likely dilutional\n --elevated INR, PTT: likely secondary to nutritional depletion, will\n hold vit K for now d/t concerns for ?ischemic bowel\n Endocrine: --RISS for glycemic control\n Infectious Disease: -- Abd Peritonits and infected ascities: On empiric\n coverage with vanc/gent/zosyn. Awaiting cultures to identify causitive\n organism.\n Lines / Tubes / Drains: PIV, Foley, Left sub clav ()\n Wounds:\n Imaging:\n Fluids:\n Consults: General surgery, GI\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 12:46 AM\n Multi Lumen - 03:15 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n Total time spent: 33 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2115-02-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 624543,
"text": ".H/O abdominal pain (including abdominal tenderness)\n Assessment:\n Patient is non verbal and non ambulatory at baseline.\n Intubated, coughing, LS clear upper, diminished bases\n Abdomen firm distended\n Hyperactive sounds\n Stooling loose, paste type stool, black\n NGT with scant amount of clear drainage in tubing.\n Foley with clear yellow urine ~ 30 cc\ns/hr low urine output\n Tachycardia has improved from yesterday \n Action:\n IV ABX as ordered\n Electrolytes treated\n Repositioned frequently due to cachectic appearance and many\n areas\n Breathing well on CPAP + PS.\n Fentanyl for pain control\n Response:\n Does not appear to be in worsening pain\n Currently ~ 6 liter positive fluid balance\n CVP ~10\n Lactic acid 1.2\n WBC 9.3\n Plan:\n Continue to monitor\n ? aline if possible, radial arteries ultrasound showed\n vessel too small to cannulate.\n Parents with patient. Continue patient and family support.\n"
},
{
"category": "ECG",
"chartdate": "2115-04-04 00:00:00.000",
"description": "Report",
"row_id": 232173,
"text": "Moderate baseline artifact. Compared to tracing #1 no diagnostic interval\nchange.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2115-04-03 00:00:00.000",
"description": "Report",
"row_id": 232174,
"text": "Sinus tachycardia at a rate of 126. Low voltage in the standard leads.\nQ wave in leads V1-V2. Non-specific ST segment change in leads V4-V6.\nConsider left atrial abnormality. Left ventricular hypertrophy. Non-specific\nST-T wave changes. Compared to the previous tracing of no diagnostic\ninterval change, although the standard lead voltage has decreased further.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2115-04-02 00:00:00.000",
"description": "Report",
"row_id": 232175,
"text": "Sinus tachycardia. Borderline low limb lead voltage. Left atrial abnormality.\nDelayed precordial R wave transition. Left ventricular hypertrophy. Compared to\nthe previous tracing of the rate has slowed. There is variation in the\nprecordial lead placement without diagnostic interim change.\n\n"
},
{
"category": "Physician ",
"chartdate": "2115-02-16 00:00:00.000",
"description": "Intensivist Note",
"row_id": 624726,
"text": "SICU\n HPI:\n 35M with Cerebral palsy, presented with abdominal pain and distention\n to an OSH this am where CT scan was performed and reported as diffused\n bowel edema,gastric varices, ascites, pancreatic cyst. No association\n with nausea, vomitting, diarrhea, hematemesis, hematochezia, no GU\n symptoms. No jaundice, no fevers. No weight loss, no NSAIDs, ASA use.\n Pt received Unasyn at the OSH and was transferred to .\n He had a history of GI bleed in , unclear source, received\n transfusion (). Last EGD and colonoscopy were done in\n , wnl according to mother. Pancreatic cyst was aspirated in\n 6/. Laprascopic cholecystectomy done in .\n .\n Chief complaint:\n respiratory distress, peritonitis, possible ischemic bowel\n PMHx:\n Cerebral Palsey (Patient non verbal baseline), Seizure d/o, Chronic\n anemia (transfusion x2)\n .\n PSH:\n Lap cholecystectomy\n Pancreatic cyst drainage (last year, )\n Current medications:\n 1. 2. 3. Acetaminophen 4. Albuterol 0.083% Neb Soln 5. Calcium\n Gluconate 6. Dextrose 50% 7. Fentanyl Citrate 8. Glucagon 9. Heparin\n Flush (10 units/ml) 10. 11. Insulin 12. LeVETiracetam 13. Magnesium\n Sulfate 14. MetRONIDAZOLE (FLagyl) 15. Midazolam 16. Pantoprazole 17.\n Phytonadione 18. Piperacillin-Tazobactam 19. Potassium Chloride 20.\n Sodium Phosphate 21. Sodium Chloride 0.9% Flush 22. Vancomycin\n 24 Hour Events:\n SPUTUM CULTURE - At 12:50 PM\n : Transfused 2UPRBC for Hct of 26\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:04 PM\n Metronidazole - 08:55 PM\n Piperacillin/Tazobactam (Zosyn) - 11:54 PM\n Infusions:\n Other ICU medications:\n Fentanyl - 06:12 PM\n Pantoprazole (Protonix) - 08:56 PM\n Other medications:\n Flowsheet Data as of 04:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.7\nC (99.9\n T current: 37.7\nC (99.9\n HR: 93 (92 - 111) bpm\n BP: 97/74(79) {84/61(65) - 106/77(83)} mmHg\n RR: 26 (17 - 43) insp/min\n SPO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 36.4 kg (admission): 32.3 kg\n Height: 55 Inch\n CVP: 14 (9 - 18) mmHg\n Bladder pressure: 15 (15 - 15) mmHg\n Total In:\n 3,733 mL\n 958 mL\n PO:\n Tube feeding:\n IV Fluid:\n 3,691 mL\n 333 mL\n products:\n 447 mL\n Total out:\n 917 mL\n 155 mL\n Urine:\n 917 mL\n 155 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,816 mL\n 803 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 285 (283 - 318) mL\n PS : 12 cmH2O\n RR (Spontaneous): 30\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 18 cmH2O\n SPO2: 95%\n ABG: ///24/\n Ve: 6.5 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Distended, Tender: , Atonic peritonitis\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Neurologic: Follows simple commands, Moves all extremities\n Labs / Radiology\n 179 K/uL\n 9.3 g/dL\n 134 mg/dL\n 0.4 mg/dL\n 24 mEq/L\n 2.7 mEq/L\n 10 mg/dL\n 115 mEq/L\n 142 mEq/L\n 29.1 %\n 10.6 K/uL\n [image002.jpg]\n 03:35 AM\n 12:11 PM\n 04:42 PM\n 03:27 AM\n 02:48 AM\n WBC\n 9.3\n 9.3\n 10.6\n Hct\n 28.3\n 27.1\n 26.2\n 29.1\n Plt\n \n Creatinine\n 0.4\n 0.5\n 0.5\n 0.4\n Glucose\n 112\n 90\n 74\n 134\n Other labs: PT / PTT / INR:16.0/36.0/1.4, ALT / AST:, Alk-Phos / T\n bili:66/0.1, Amylase / Lipase:52/, Lactic Acid:0.5 mmol/L, Albumin:2.1\n g/dL, LDH:142 IU/L, Ca:7.0 mg/dL, Mg:2.0 mg/dL, PO4:1.7 mg/dL\n Assessment and Plan\n .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n Assessment and Plan: 35M with CP, peritonitis and ascites. Continuing\n work to detemrine etiology of SBP and monitor for ischemic colitis\n Neurologic:\n - Intubated and sedated PRN Midazolam\n - Pre-existing seizure disorder -> Keppra 20 .\n - Pain seems to be well controlled.\n Cardiovascular:\n - Tachycardic secondary to volume depletion and SIRS response.\n Otherwise stable.\n Pulmonary:\n - Respiratory failure resolved on minimal settings.\n - Pneumonia on ABX\n Gastrointestinal / Abdomen:\n - Peritonitis seems to be under control. On empiric ABX. Work up for\n ascities on-going.\n - Pericentesis in am\n - CTA of the abd to evaluate mesenteric artery and vein flow.\n Nutrition:\n - TPN\n Renal:\n - stable\n Hematology:\n - Slowly worsening anemia secondary to dilution, inflammation, and\n pre-existing chronic anemia.\n - Elevated INR & PTT secondary to the nutritional depletion.\n - S/P Transfusion 2UPRBC for Hct of 26 \n Endocrine:\n RISS with adequate BG control\n Infectious Disease:\n - Abdominal peritonits - on empiric coverage with vanc/Flagyl/zosyn.\n Awaiting cultures to identify causitive organism.\n Lines / Tubes / Drains: PIV, Foley, Left sub clav ()\n Wounds:\n Imaging:\n Fluids: KVO\n Consults: General surgery, GI\n Billing Diagnosis: Sepsis, Peritonitis\n ICU Care\n Nutrition:\n TPN without Lipids - 11:00 PM 41. mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 22 Gauge - 12:46 AM\n Multi Lumen - 03:15 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2115-02-18 00:00:00.000",
"description": "Intensivist Note",
"row_id": 625076,
"text": "SICU\n HPI:\n 35M with Cerebral palsy,presented with abdominal pain and distention to\n an OSH this am where CT scan was performed and reported as diffused\n bowel edema,gastric varices, ascites, pancreatic cyst. No association\n with nausea,vomitting, diarrhea, hematemesis, hematochezia, no GU\n symptoms. No jaundice , no fevers. No weight loss, no NSAIDs, ASA use.\n Pt recieved Unasyn at the OSH and was transferred to \n Chief complaint:\n respiratory distress, peritonitis, SMV occlusion\n PMHx:\n Cerebral Palsy (Patient non verbal baseline), Seizure d/o, Chronic\n anemia (transfusion x2)\n Current medications:\n Acetaminophen 4. Albuterol 0.083% Neb Soln 5. Calcium Gluconate 6.\n Dextrose 50% 7. Fentanyl Citrate\n 8. Furosemide 9. Furosemide 10. Glucagon 11. Heparin 12. Heparin Flush\n (10 units/ml) 13. 14. Insulin\n 15. LeVETiracetam 16. Magnesium Sulfate 17. MetRONIDAZOLE (FLagyl) 18.\n Midazolam 19. Pantoprazole\n 20. Piperacillin-Tazobactam\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 06:03 PM\n EXTUBATION - At 06:19 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:00 PM\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Metronidazole - 03:53 AM\n Infusions:\n Heparin Sodium - 700 units/hour\n Other ICU medications:\n Furosemide (Lasix) - 09:44 PM\n Fentanyl - 02:20 AM\n Other medications:\n Flowsheet Data as of 04:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.7\nC (99.9\n T current: 36.9\nC (98.5\n HR: 95 (75 - 110) bpm\n BP: 80/56(73) {80/52(62) - 125/81(90)} mmHg\n RR: 26 (9 - 48) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 38 kg (admission): 32.3 kg\n Height: 55 Inch\n CVP: 185 (1 - 238) mmHg\n Total In:\n 2,607 mL\n 431 mL\n PO:\n Tube feeding:\n IV Fluid:\n 1,471 mL\n 244 mL\n Blood products:\n Total out:\n 2,816 mL\n 1,380 mL\n Urine:\n 1,816 mL\n 730 mL\n NG:\n 250 mL\n Stool:\n Drains:\n Balance:\n -209 mL\n -949 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, Aerosol-cool\n Ventilator mode: CPAP/PSV\n Vt (Set): 350 (350 - 350) mL\n Vt (Spontaneous): 321 (293 - 555) mL\n PS : 5 cmH2O\n RR (Set): 10\n RR (Spontaneous): 17\n PEEP: 0 cmH2O\n FiO2: 70%\n RSBI: 93\n PIP: 16 cmH2O\n SPO2: 98%\n ABG: ///29/\n Ve: 5.4 L/min\n Physical Examination\n General Appearance: No acute distress\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric)\n Abdominal: No(t) Soft, softer than previously\n Neurologic: (Responds to: Tactile stimuli), No(t) Moves all\n extremities, (RUE: No(t) Weakness), (LUE: No(t) Weakness), (RLE: No\n movement), (LLE: No movement)\n Labs / Radiology\n 107 K/uL\n 10.0 g/dL\n 141 mg/dL\n 0.4 mg/dL\n 29 mEq/L\n 3.1 mEq/L\n 12 mg/dL\n 104 mEq/L\n 138 mEq/L\n 29.2 %\n 9.4 K/uL\n [image002.jpg]\n 03:35 AM\n 12:11 PM\n 04:42 PM\n 03:27 AM\n 02:48 AM\n 06:09 AM\n 03:11 PM\n 04:05 AM\n 02:40 PM\n 02:29 AM\n WBC\n 9.3\n 9.3\n 10.6\n 8.7\n 9.4\n Hct\n 28.3\n 27.1\n 26.2\n 29.1\n 31.6\n 32.9\n 30.9\n 29.2\n Plt\n 39\n 107\n Creatinine\n 0.4\n 0.5\n 0.5\n 0.4\n 0.5\n 0.5\n 0.5\n 0.4\n TCO2\n 25\n Glucose\n 112\n 90\n 74\n 134\n 80\n 118\n 137\n 141\n Other labs: PT / PTT / INR:15.0/90.1/1.3, ALT / AST:, Alk-Phos / T\n bili:83/0.3, Amylase / Lipase:52/, Lactic Acid:1.6 mmol/L, Albumin:2.5\n g/dL, LDH:158 IU/L, Ca:8.2 mg/dL, Mg:1.9 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n Assessment and Plan: 35M with CP, peritonitis and ascites, chronic\n pancreatitis, most likely ascites and peritonitis SMV occlusion\n Neurologic:\n - Cerebral palsy with mental status at baseline.\n - Pre-existing seizure disorder -> Keppra 20 .\n - Pain seems to be well controlled. and pt seems to be at\n baseline mental status\n Cardiovascular:\n - HR and BP holding stable\n Pulmonary:\n - Respiratory failure: now extubated, requiring aggresive pulm\n toilet, chest PT and suctioning due to secretion\n - Diuresis since traits of CHF on CXR and tenuous respiratory\n status.\n Gastrointestinal / Abdomen:\n - SMV and partial vein thrombosis. Both seems to be chronic\n processes considering the large amount of collaterals. However, there\n is massive venous engorgement and bowel edema. Started on heparin drip\n with aPTT at goal..\n o On empiric ABX for peritonitis.\n o Diarrhea: likely due to lack of absorption d/t bowel wall\n edema.\n - Chronic inactive pancreatitis.\n - Stable parenchymal liver changes\n - Clamp NG tube.\n Nutrition:\n o TPN; no refeeding syndrome.\n o Unclear status of PO/TF intake\n Renal:\n o Being diuresed with the goal of -0.5-1L/24hrs.\n o Hypokalemia\n Hematology:\n - On systemic anticoagulation with the goal og aPTT of\n 60-80sec. Start on coumadin.\n - Stable anemia now.\n Endocrine:\n - RISS with adequate BG control.\n Infectious Disease:\n - Abdominal peritonitis - on empiric coverage with vanc/flagyl/zosyn.\n DC flagyl .Keep vancomycin and zosyn for four more days.\n --Awaiting cultures to identify causitive organism -> so far negative.\n -- WBC 9.4, afebrile\n Consults: General surgery, Vascular surgery\n ICU Care\n Nutrition:\n TPN without Lipids - 04:00 PM 45 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 03:15 AM\n 20 Gauge - 12:17 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin drip)\n Stress ulcer: PPI\n VAP bundle:\n Communication\n Code status: FULL\n Disposition: SICU\n Total time spent: 35 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2115-02-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 624700,
"text": "TITLE:\n .H/O abdominal pain (including abdominal tenderness)\n Assessment:\n Resp-Intubated on cpap 50% -bbs rhonchorous -> clear but dim at\n bases. POX flux low to mid 90\n Neuro- withdraws to pain, opens eyes to voice, moves upper extremeties\n spontaneously, bilat lower extremeties contracted. Grimacing w\n turn/reposition early a.m.\n Cv- sbp low 90\ns (baseline bp 80\ns) Nsr\n 4 beat run VT (self limiting)\n serum K+ 2.7 at time\n Gi-Abd firm distended, + bowel sounds, incontinent of liq green\n stool.Ngt to lws w thick pale yellow bilious drainage.\n Gu- marginal to qs Uop cloudy yellow urine w sediment.\n Skin- intact, buttocks pink, scrotum grossly edematous taut\n Heme/ID- tmax 99.3 on triple antibx coverage-zosyn, vanco,flagyl.\n Stable Hct 27 no active gi bldg noted\n Action:\n Vap bundle and freq(q 1-2h )subglottal suct for copious oral\n secretions.\n Lavage and suct for mod to copious amts thick white secretions.\n BBS w crackles at bases early am after suct w desat to 89-91%-> peep\n to 10cm w O2 sat incr to 95%. ABG sent. Am labs sent serumCa+,K+ and\n phos low-> repleting, repeat hct w am labs done betwn first and second\n uprbc\n Pcxr done w desat- Per Dr \nworsening pneumonia\n (antibx- flagly,vanco & zosyn).Lasix 20mg iv x1 @ 0630 after repeat\n serum K+ checked -4.0 .\n Med w fentanyl 25mcg for grimacing and tachypneic/tachycardic w\n turn/reposition\n Turn/reposition q2-3h, incont stool x 2 for small to mod amts of green\n liq stool.double guard barrier cream to buttocks and scrotum\n Response:\n Diuresing w lasix. O2 sats> 95% on peep 10cm.\n Tachypnea/tachycardia/ grimacing resolved w fentanyl\n Hct 29 after first unit prbc.\n No further VT noted after K+ repletion.\n Plan:\n Cont aggressive pulm hygiene and VAP bundle\n Recheck serum K+ w diuresis, replete lytes per slid scale.\n Abd CT scan today .Cont to look for source of abd process.\n Check with team re: TPN orders for \n Check pending culture results. ? recheck urine for culture _ cloudy w\n sediment.\n"
},
{
"category": "Physician ",
"chartdate": "2115-02-17 00:00:00.000",
"description": "Intensivist Note",
"row_id": 624809,
"text": "SICU\n HPI:\n 35M with Cerebral palsy,presented with abdominal pain and distention to\n an OSH this am where CT scan was performed and reported as diffused\n bowel edema,gastric varices, ascites, pancreatic cyst. No association\n with nausea,vomitting, diarrhea, hematemesis, hematochezia, no GU\n symptoms. No jaundice , no fevers. No weight loss, no NSAIDs, ASA use.\n Pt recieved Unasyn at the OSH and was transferred to .\n He had a history of GI bleed in , unclear source, recieved\n blood transfusion (). Last EGD and colonscopy were done in\n , wnl according to mother. Pancreatic cyst was aspirated in\n 6/. Laprascopic cholecystectomy done in .\n Chief complaint:\n respiratory distress, peritonitis, SMV occlusion\n PMHx:\n Cerebral Palsy (Patient non verbal baseline), Seizure d/o, Chronic\n anemia (transfusion x2)\n Current medications:\n Acetaminophen 4. Albumin 25% (12.5g / 50mL) 5. Albuterol 0.083% Neb\n Soln 6. Calcium Gluconate\n 7. Dextrose 50% 8. Fentanyl Citrate 9. Furosemide 10. Glucagon 11.\n Heparin 12. Heparin Flush (10 units/ml)\n 13. 14. Insulin 15. LeVETiracetam 16. Magnesium Sulfate 17.\n MetRONIDAZOLE (FLagyl) 18. Midazolam\n 19. Pantoprazole 20. Piperacillin-Tazobactam 21. Potassium Chloride 22.\n Sodium Chloride 0.9% Flush\n 23. Vancomycin\n 24 Hour Events:\n PARACENTESIS - At 09:45 AM\n STOOL CULTURE - At 10:55 AM\n spec sent for cdiff and o+p.\n FEVER - 101.5\nF - 08:00 PM\n : Peritoneal fluid sent (3L tapped). 25% albumin resolved\n tachycardia. CTA w/SMV occlusion. Hypokalemia aggressively treated. Hep\n gtt started\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:00 PM\n Piperacillin/Tazobactam (Zosyn) - 12:30 AM\n Metronidazole - 04:04 AM\n Infusions:\n Heparin Sodium - 1,150 units/hour\n Other ICU medications:\n Furosemide (Lasix) - 06:21 AM\n Fentanyl - 10:15 AM\n Pantoprazole (Protonix) - 08:56 PM\n Other medications:\n Flowsheet Data as of 04:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.6\nC (101.5\n T current: 37.6\nC (99.6\n HR: 87 (70 - 107) bpm\n BP: 97/62(80) {86/62(71) - 106/87(98)} mmHg\n RR: 26 (14 - 30) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 38 kg (admission): 32.3 kg\n Height: 55 Inch\n CVP: 10 (8 - 17) mmHg\n Total In:\n 3,945 mL\n 415 mL\n PO:\n Tube feeding:\n IV Fluid:\n 2,152 mL\n 235 mL\n Blood products:\n 732 mL\n Total out:\n 5,850 mL\n 100 mL\n Urine:\n 3,050 mL\n 100 mL\n NG:\n 300 mL\n Stool:\n Drains:\n 2,500 mL\n Balance:\n -1,905 mL\n 315 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 300 (300 - 300) mL\n Vt (Spontaneous): 444 (293 - 444) mL\n PS : 15 cmH2O\n RR (Set): 22\n RR (Spontaneous): 28\n PEEP: 10 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10\n PIP: 25 cmH2O\n SPO2: 99%\n ABG: 7.41/38/84./25/0\n Ve: 11.4 L/min\n PaO2 / FiO2: 140\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: Diminished: bibasilar)\n Abdominal: Distended\n Neurologic: Follows simple commands, Moves all extremities\n Labs / Radiology\n 179 K/uL\n 9.3 g/dL\n 80 mg/dL\n 0.5 mg/dL\n 25 mEq/L\n 3.7 mEq/L\n 7 mg/dL\n 108 mEq/L\n 141 mEq/L\n 31.6 %\n 10.6 K/uL\n [image002.jpg]\n 03:35 AM\n 12:11 PM\n 04:42 PM\n 03:27 AM\n 02:48 AM\n 06:09 AM\n 03:11 PM\n WBC\n 9.3\n 9.3\n 10.6\n Hct\n 28.3\n 27.1\n 26.2\n 29.1\n 31.6\n Plt\n \n Creatinine\n 0.4\n 0.5\n 0.5\n 0.4\n 0.5\n TCO2\n 25\n Glucose\n 112\n 90\n 74\n 134\n 80\n Other labs: PT / PTT / INR:16.0/36.0/1.4, ALT / AST:, Alk-Phos / T\n bili:66/0.1, Amylase / Lipase:52/, Lactic Acid:1.6 mmol/L, Albumin:2.5\n g/dL, LDH:142 IU/L, Ca:8.3 mg/dL, Mg:1.8 mg/dL, PO4:2.2 mg/dL\n Imaging: CT abd Pelvis: Simple global ascites, 6mm aortic diam\n IVC slit diam, Diffuse small bowel dilatation with mildly thickened\n folds. Diffuse moderate edema of the colon with a thickened wall.\n Distened rectum with thickened wall and stools. 4.5 x 2.3 x 1.4 cm\n pancreatic cyst with a veritical orientation in head of pancreas.\n surgical cholecystectomy, Extensive thrombus in porta hepatis. SMV SMA\n celiac patent,chr right PV thrombosis. No perf, no free air. No\n obstruction!\n CT: SMV occlusion with diffuse bowel wall edema & thickening c/w\n congestion/venous ischemia, possible shock bowel. Venous engorgement\n throughout. Sequelae of chronic pancreatitis, possible pseudocyst.\n Diffusely abnormal hepatic parenchyma. Partially occlusive right portal\n vein thrombus. Small b/l pleural effusions, increased from the prior\n exam. Ground-glass and nodular opacities @ bases suggesting infection.\n Microbiology: Peritoneal Fluid: NG\n MRSA P\n Assessment and Plan\n .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n Assessment and Plan: 35M with CP, peritonitis and ascites, chronic\n pancreatitis, Hepatitis B, most likely ascites and peritonitis SMV\n occlusion.\n Neurologic: - Intubated and sedated PRN Midazolam\n - Pre-existing seizure disorder -> Keppra 20 .\n - Pain seems to be well controlled.\n Cardiovascular: - Tachycardic secondary to volume depletion and SIRS\n response. Otherwise stable, resolved with albumin.\n Pulmonary: - Respiratory failure resolved on minimal settings. Possible\n extubation tomrow.\n Gastrointestinal / Abdomen: - On empiric ABX for peritonitis. Work up\n for ascities on-going. + Hepatitis B\n --f/u Cx\n --CTA revealed SMV occlusion, venous stasis--->On hep gtt\n Nutrition: TPN\n Renal: - stable urine output\n --Hypokalemia, monitoring\n Hematology: - Slowly worsening anemia secondary to dilution,\n inflammation, and pre-existing chronic anemia.\n - Elevated INR & PTT secondary to the nutritional depletion.\n -S/P Transfusion 2UPRBC for Hct of 26 on , Stable 29-31 on \n On hep gtt for SMV occlusion (goal 60-80)\n Endocrine: RISS\n Infectious Disease: Check cultures, - Abdominal peritonits - on empiric\n coverage with vanc/Flagyl/zosyn. --Awaiting cultures to identify\n causitive organism.\n --temp 101.5 \n Lines / Tubes / Drains: PIV, Foley, Left sub clav ()\n Wounds:\n Imaging:\n Fluids: D5 1/2 NS 75CC/H\n Consults: General surgery, GI\n Billing Diagnosis: Other: PERITONITIS, Respitratory failure\n ICU Care\n Nutrition:\n TPN without Lipids - 04:07 PM 41. mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 03:15 AM\n 20 Gauge - 12:17 PM\n Prophylaxis:\n DVT: Boots (Systemic anticoagulation: Heparin drip)\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Respiratory ",
"chartdate": "2115-02-17 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 624913,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 4\n Ideal body weight: 43.7 None\n Ideal tidal volume: 174.8 / 262.2 / 349.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n :\n Cuff pressure: 25 cmH2O\n :\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: White /\n Sputum source/amount: Suctioned / Small\n Comments: lg amt oral secretions\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Cannot manage\n secretions, weaning\n"
},
{
"category": "Physician ",
"chartdate": "2115-02-16 00:00:00.000",
"description": "Intensivist Note",
"row_id": 624711,
"text": "SICU\n HPI:\n 35M with Cerebral palsy, presented with abdominal pain and distention\n to an OSH this am where CT scan was performed and reported as diffused\n bowel edema,gastric varices, ascites, pancreatic cyst. No association\n with nausea, vomitting, diarrhea, hematemesis, hematochezia, no GU\n symptoms. No jaundice, no fevers. No weight loss, no NSAIDs, ASA use.\n Pt received Unasyn at the OSH and was transferred to .\n He had a history of GI bleed in , unclear source, received\n transfusion (). Last EGD and colonoscopy were done in\n , wnl according to mother. Pancreatic cyst was aspirated in\n 6/. Laprascopic cholecystectomy done in .\n .\n Chief complaint:\n respiratory distress, peritonitis, possible ischemic bowel\n PMHx:\n Cerebral Palsey (Patient non verbal baseline), Seizure d/o, Chronic\n anemia (transfusion x2)\n .\n PSH:\n Lap cholecystectomy\n Pancreatic cyst drainage (last year, )\n Current medications:\n 1. 2. 3. Acetaminophen 4. Albuterol 0.083% Neb Soln 5. Calcium\n Gluconate 6. Dextrose 50% 7. Fentanyl Citrate 8. Glucagon 9. Heparin\n Flush (10 units/ml) 10. 11. Insulin 12. LeVETiracetam 13. Magnesium\n Sulfate 14. MetRONIDAZOLE (FLagyl) 15. Midazolam 16. Pantoprazole 17.\n Phytonadione 18. Piperacillin-Tazobactam 19. Potassium Chloride 20.\n Sodium Phosphate 21. Sodium Chloride 0.9% Flush 22. Vancomycin\n 24 Hour Events:\n SPUTUM CULTURE - At 12:50 PM\n : Transfused 2UPRBC for Hct of 26\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:04 PM\n Metronidazole - 08:55 PM\n Piperacillin/Tazobactam (Zosyn) - 11:54 PM\n Infusions:\n Other ICU medications:\n Fentanyl - 06:12 PM\n Pantoprazole (Protonix) - 08:56 PM\n Other medications:\n Flowsheet Data as of 04:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.7\nC (99.9\n T current: 37.7\nC (99.9\n HR: 93 (92 - 111) bpm\n BP: 97/74(79) {84/61(65) - 106/77(83)} mmHg\n RR: 26 (17 - 43) insp/min\n SPO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 36.4 kg (admission): 32.3 kg\n Height: 55 Inch\n CVP: 14 (9 - 18) mmHg\n Bladder pressure: 15 (15 - 15) mmHg\n Total In:\n 3,733 mL\n 958 mL\n PO:\n Tube feeding:\n IV Fluid:\n 3,691 mL\n 333 mL\n products:\n 447 mL\n Total out:\n 917 mL\n 155 mL\n Urine:\n 917 mL\n 155 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,816 mL\n 803 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 285 (283 - 318) mL\n PS : 12 cmH2O\n RR (Spontaneous): 30\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 18 cmH2O\n SPO2: 95%\n ABG: ///24/\n Ve: 6.5 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Distended, Tender: , Atonic peritonitis\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Neurologic: Follows simple commands, Moves all extremities\n Labs / Radiology\n 179 K/uL\n 9.3 g/dL\n 134 mg/dL\n 0.4 mg/dL\n 24 mEq/L\n 2.7 mEq/L\n 10 mg/dL\n 115 mEq/L\n 142 mEq/L\n 29.1 %\n 10.6 K/uL\n [image002.jpg]\n 03:35 AM\n 12:11 PM\n 04:42 PM\n 03:27 AM\n 02:48 AM\n WBC\n 9.3\n 9.3\n 10.6\n Hct\n 28.3\n 27.1\n 26.2\n 29.1\n Plt\n \n Creatinine\n 0.4\n 0.5\n 0.5\n 0.4\n Glucose\n 112\n 90\n 74\n 134\n Other labs: PT / PTT / INR:16.0/36.0/1.4, ALT / AST:, Alk-Phos / T\n bili:66/0.1, Amylase / Lipase:52/, Lactic Acid:0.5 mmol/L, Albumin:2.1\n g/dL, LDH:142 IU/L, Ca:7.0 mg/dL, Mg:2.0 mg/dL, PO4:1.7 mg/dL\n Assessment and Plan\n .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n Assessment and Plan: 35M with CP, peritonitis and ascites. Continuing\n work to detemrine etiology of SBP and monitor for ischemic colitis\n Neurologic:\n - Intubated and sedated PRN Midazolam\n - Pre-existing seizure disorder -> Keppra 20 .\n - Pain seems to be well controlled.\n Cardiovascular:\n - Tachycardic secondary to volume depletion and SIRS response.\n Otherwise stable.\n Pulmonary:\n - Respiratory failure resolved on minimal settings.\n - Pneumonia on ABX\n Gastrointestinal / Abdomen:\n - Peritonitis seems to be under control. On empiric ABX. Work up for\n ascities on-going.\n - Pericentesis in am\n - CTA of the abd to evaluate mesenteric artery and vein flow.\n Nutrition:\n - TPN\n Renal:\n - stable\n Hematology:\n - Slowly worsening anemia secondary to dilution, inflammation, and\n pre-existing chronic anemia.\n - Elevated INR & PTT secondary to the nutritional depletion.\n - S/P Transfusion 2UPRBC for Hct of 26 \n Endocrine:\n RISS with adequate BG control\n Infectious Disease:\n - Abdominal peritonits - on empiric coverage with vanc/Flagyl/zosyn.\n Awaiting cultures to identify causitive organism.\n Lines / Tubes / Drains: PIV, Foley, Left sub clav ()\n Wounds:\n Imaging:\n Fluids: KVO\n Consults: General surgery, GI\n Billing Diagnosis: Sepsis, Peritonitis\n ICU Care\n Nutrition:\n TPN without Lipids - 11:00 PM 41. mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 22 Gauge - 12:46 AM\n Multi Lumen - 03:15 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2115-02-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 624963,
"text": ".H/O abdominal pain (including abdominal tenderness)\n Assessment:\n Abd distended, soft\n Hypoactive BS\n Copious green liquid stool via flexiseal\n NGT to LCWS for bilious fld\n TPN continues\n Heparin gtt at 850 units/hr restarted at 1730 on day shift\n for SMV thrombosis\n Action:\n NGT/stool output monitored, recorded q 4 hr\n Fentanyl for abd tenderness to palpation/facial grimacing,\n 25-50mcg IVP\n Heparin gtt titrated per PTT draws/written scale per SICU\n IV Abx\n vanco, flagyl, zosyn\nas ordered\n Response:\n PTT WNL for pt goal 60-80 at 2330, but elevated with AM\n labs\n rate cut by 250units/hr\n Plan:\n PTT to be re-checked at 0530\n Closely monitor abd distension, labs, drain outputs\n Cont heparin gtt per protocol\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt received recently extubated, ~1815\n On facemask cool aerosol with O2 sats 85-89%, RR 40-50s,\n audible insp/exp wheeze, rhonchi through out all lung fields\n Pt with minimal cough, unable to fully raise secretions\n dependent on RN for yankaur suctioning as pt unable to follow commands\n Pt (+) ~10L on LOS\n Action:\n Pt sat upright, 90 degrees with reverse Tburg for minimizing\n pressure on diaphragm from distended abd\n Given albuterol nebulizer treatment\n Bilat chest PT q 1 hr, then q2 as pt stabilized resp status\n Pt placed on high flow concentrated mask 95%\n Frequent suctioning as pt with weak cough and unable to\n follow commands to cough/deep breathe\n Lasix given 5mg x1, and 10mg x1\n O2 weaned from 95% high flow to cool aerosol face tent, to\n 3L NC with O2 sats 95-100%\n CXR done with AM rounds\n Response:\n Pt diuresing ~1L from lasix boluses, and ~800cc (-) for\n midnoc\n LS clear, occasional wheeze/rhonchi clearing with pt\n coughing\n Plan:\n Cont to monitor resp status closely\n F/u on CXR\n OOB to chair, frequent pulm toileting\n"
},
{
"category": "Nursing",
"chartdate": "2115-02-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 624894,
"text": ".H/O abdominal pain (including abdominal tenderness)\n Assessment:\n tmax 99.9, hr/bp stable. Skin w+d. +pp. on heparin gtt. O2 sat 97%.\n Vented on cpap. Ls cta. Sm amt thick white sputum. Abd softly\n distended. +bs. Con\nt with lg amt liq brown stool. Voiding via foley.\n u/o trending down and amber in color. + scrotal edema.\n Action:\n on heparin gtt. Ptt followed and gtt adjusted accordingly. Vent weaned\n to cpap, 50%, . flexiseal in place. on abx. Team aware of low u/o.\n npo on tpn.\n Response:\n tol vent thus far. Rr wnl. Spont tv adeq.\n Plan:\n con\nt with current plan. Monitor for changes. Assess pain. Follow coags\n and lytes. Heparin gtt. Monitor u/o closely.\n"
},
{
"category": "Nursing",
"chartdate": "2115-02-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 625058,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Extubated last evening\n Lung sounds rhoncherous\n Patient does not follow commands for coughing, deep\n breathing, or to expectorate sputum\n Patient does not like suctioning or mouth care, very\n difficult to clear secretions\n Impaired gag and cough\n Action:\n Frequent chest PT\n Oral suctioning frequently\n Lasix x1\n Response:\n Fluid balance MN\n 1700 negative 2 liters\n Remains 6 liters positive length of stay\n O2 Sats 93-100 % on 4 liters O2 via nasal canula\n OOB to chair for ~ 3 hours today\n Plan:\n Continue pulmonary toilet\n Continue to monitor fluid status\n Patient and family support\n .H/O abdominal pain (including abdominal tenderness)\n Assessment:\n Abdomen softly distended\n Produced 300 cc\ns liquid brown stool this shift\n Heparin gtt continues for SMA thrombosis\n Patient uncomfortable at times\n Action:\n Heparin drip adjusted based on sub therapeutic PTT\n NPO\n NGT clamping trial started @ 1300, 4 hour residual was 10\n cc\n Coumadin ordered tonight, first dose\n OOB to chair\n Flagyl discontinued\n Vanco and Zosyn continue\n Fentanyl for pain control\n Flexiseal for fecal contamination\n Response:\n Afebrile\n Low blood pressure, near baseline with SBP in low 80\n Pain seems well controlled with Fentanyl, family in\n agreement\n Plan:\n Remain NPO\n ? Starting tube feeds ?\n Continue patient and family support\n"
},
{
"category": "Nursing",
"chartdate": "2115-02-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 625244,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Alert. Purposeful mvt.\n Tmax 100.3.\n Remains intubated on SIMV 50% O2.\n Copious thick, bld tinged oral secretions. Scant from ETT.\n Additional antibiotic initiated for presumed pneumonia.\n Action:\n Pulmonary toileting.\n VAP protocol.\n OOB to chair.\n Mixed venous O2\n Antibiotics as ordered.\n Response:\n Pt O2 SATs 95-100%.\n LS clear in upper lobes, diminished in lower.\n Plan:\n Continue to provide pulmonary toileting.\n ABGs if warranted.\n Antibiotics.\n Chest xray in am.\n Mini BAL when BP able to tolerated sedation.\n"
},
{
"category": "Physician ",
"chartdate": "2115-02-19 00:00:00.000",
"description": "Intensivist Note",
"row_id": 625121,
"text": "SICU\n HPI:\n Chief complaint:\n PMHx:\n Current medications:\n 24 Hour Events:\n INTUBATION - At 10:31 PM\n INVASIVE VENTILATION - START 10:32 PM\n FEVER - 101.6\nF - 12:00 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 03:53 AM\n Vancomycin - 08:34 PM\n Piperacillin/Tazobactam (Zosyn) - 12:30 AM\n Infusions:\n Heparin Sodium - 950 units/hour\n Propofol - 15 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:35 PM\n Furosemide (Lasix) - 09:53 PM\n Fentanyl - 02:00 AM\n Other medications:\n Flowsheet Data as of 04:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.7\nC (101.6\n T current: 38.7\nC (101.6\n HR: 103 (81 - 113) bpm\n BP: 80/59(64) {74/51(58) - 104/80(84)} mmHg\n RR: 27 (17 - 40) insp/min\n SPO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 38 kg (admission): 32.3 kg\n Height: 55 Inch\n CVP: 7 (2 - 183) mmHg\n Total In:\n 2,434 mL\n 374 mL\n PO:\n Tube feeding:\n IV Fluid:\n 1,538 mL\n 155 mL\n Blood products:\n Total out:\n 4,535 mL\n 640 mL\n Urine:\n 2,925 mL\n 640 mL\n NG:\n 710 mL\n Stool:\n Drains:\n Balance:\n -2,101 mL\n -266 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 300 (300 - 480) mL\n RR (Set): 26\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 60%\n RSBI Deferred: Agitated\n PIP: 20 cmH2O\n SPO2: 100%\n ABG: 7.50/45/74/34/9\n Ve: 7.5 L/min\n PaO2 / FiO2: 123\n Physical Examination\n General Appearance: No acute distress, Cachectic\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric)\n Abdominal: Distended, Tender:\n Left Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present),\n (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present),\n (Pulse - Posterior tibial: Present)\n Skin: No(t) Rash:\n Neurologic: (Responds to: Noxious stimuli), Moves all extremities,\n Sedated\n Labs / Radiology\n 110 K/uL\n 9.7 g/dL\n 104 mg/dL\n 0.4 mg/dL\n 34 mEq/L\n 3.7 mEq/L\n 9 mg/dL\n 99 mEq/L\n 136 mEq/L\n 28.6 %\n 10.1 K/uL\n [image002.jpg]\n 03:27 AM\n 02:48 AM\n 06:09 AM\n 03:11 PM\n 04:05 AM\n 02:40 PM\n 02:29 AM\n 04:00 PM\n 01:32 AM\n 03:31 AM\n WBC\n 9.3\n 10.6\n 8.7\n 9.4\n 10.1\n Hct\n 26.2\n 29.1\n 31.6\n 32.9\n 30.9\n 29.2\n 28.6\n Plt\n 177\n 179\n 139\n 107\n 110\n Creatinine\n 0.5\n 0.4\n 0.5\n 0.5\n 0.5\n 0.4\n 0.4\n TCO2\n 25\n 36\n Glucose\n 74\n 134\n 80\n 118\n 137\n 141\n 104\n Other labs: PT / PTT / INR:15.5/51.1/1.4, ALT / AST:, Alk-Phos / T\n bili:83/0.3, Amylase / Lipase:52/, Lactic Acid:1.6 mmol/L, Albumin:2.5\n g/dL, LDH:158 IU/L, Ca:8.2 mg/dL, Mg:2.3 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), .H/O ABDOMINAL PAIN\n (INCLUDING ABDOMINAL TENDERNESS)\n Assessment and Plan: ASSESSMENT: 35M with CP, chronic pancreatitis,\n transudative ascites and peritonitis likely SMV occlusion, now on\n hep gtt, intubated due to secretions\n Neurologic:\n - Pre-existing seizure disorder -> Keppra 20 .\n - Pain seems to be well controlled.\n - Baseline mental status\n Cardiovascular:\n - HR and BP holding stable\n Pulmonary:\n - Respiratory failure: now reintubated, requiring aggresive pulm\n toilet, chest PT and suctioning due to secretions\n - Lasix for pulmonary edema with good effect.\n Gastrointestinal / Abdomen:\n - On empiric ABX for peritonitis. Work up for ascities on-going. F/U Cx\n --CTA revealed SMV occlusion, venous stasis--->On hep gtt\n -- Diarrhea: likely due to lack of absorption d/t bowel wall edema,\n Flagyl d/c'd, C diff negative\n -- Pantoprazole for GI proph\n Nutrition:\n - TPN\n Renal:\n --stable urine output, lasix \n --Hypokalemia, monitoring and getting repleted\n Hematology:\n - Slowly worsening anemia secondary to dilution, inflammation, and\n pre-existing chronic anemia.\n - Elevated INR & PTT secondary to the nutritional depletion.\n -S/P Transfusion 2UPRBC for Hct of 26 on , Stable 29-31 on \n On hep gtt for SMV occlusion (goal 60-80)\n -coumadin started on (5)\n Endocrine:\n - RISS with adequate BG control.\n ID:\n - Abdominal peritonitis - on empiric coverage with vanc/zosyn\n - F/u cultures\n T/L/D: PIV, Foley, Left sub clav ()\n Wounds: none\n Imaging: CTA abdomen\n Fluids: KVO\n Consults: General surgery, GI\n Billing Diagnosis: PERITONITIS, Respitratory failure\n Prophylaxis:\n DVT: Boots, hep gtt\n Stress ulcer: PPI\n VAP bundle: +\n Comments: Consent done\n Communication:\n Code status:FULL\n Disposition:SICU\n Time spent: 35\n Billing Diagnosis:\n"
},
{
"category": "Nursing",
"chartdate": "2115-02-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 625123,
"text": "HPI: 35M with Cerebral palsy,presented with abdominal pain and\n distention to an OSH this am where CT scan was performed and reported\n as diffused bowel edema,gastric varices, ascites, pancreatic cyst. No\n association with nausea,vomitting, diarrhea, hematemesis, hematochezia,\n no GU symptoms. No jaundice , no fevers. No weight loss, no NSAIDs, ASA\n use. Pt recieved Unasyn at the OSH and was transferred to .\n He had a history of GI bleed in , unclear source, recieved\n transfusion (). Last EGD and colonoscopy were done in\n , wnl according to mother. Pancreatic cyst was aspirated in\n 6/. Laprascopic cholecystectomy done in .\n Chief complaint: respiratory distress, peritonitis, SMV occlusion\n PMHx: Cerebral Palsy (Patient non verbal baseline), Seizure d/o,\n chronic anemia (transfusion x2)\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received extubated on 5L NC, POX: 94-97%, RR: 17-32. LS:\n Rhoncherous. Impaired gag and cough.\n Patient unable to follow commands for coughing, deep\n breathing, or to expectorate secretions.\n 2200 patient oxygenation saturation decreased to the low\n 80\n Action:\n Chest PT every 1-2 hours.\n Suctioned for copious amounts of thick tinged oral\n secretions.\n Patient placed on high flow aerosol mask and then a NRB\n without improvement. POX: Remained in the mid-high 80\ns. RR: 30-40\n 10mg IVP Lasix given.\n MD notified of respiratory status and present during\n all interventions. Patient was intubated due to poor oxygenation and\n tachypnea.\n Sedated on Propofol for comfort.\n MD spoke with parents regarding need for\n re-intubation.\n Response:\n Good diuresis with IVP Lasix.\n Plan:\n .H/O abdominal pain (including abdominal tenderness)\n Assessment:\n T-max: 101.6.\n Abdomen SD, +BSx4,S,tender.\n L-nare NGT with residual of 100cc of bilious/brown\n drainage.\n Flexi-seal with brown liquid stool.\n Continues on a Heparin drip for SMV thrombosis.\n Patient appearing to grimace in pain.\n Action:\n Patient pan-cultured and 325mg Tylenol given.\n Heparin drip adjusted per Heparin sliding scale. Goal PTT is\n between 60-80.\n Remains NPO except for medications. At 1800 NGT residual\n greater than 100cc-placed to CLW with bilious/brown drainage.\n Vancomycin/Zosyn administered MD order.\n IVP Fentanyl given with good pain relief.\n Response:\n Plan:\n Continue to follow fever curve and WBC\n Adjust Heparin drip per Heparin sliding scale. Goal PTT:\n 60-80.\n Provide supportive care to patient and family.\n Social work consult.\n"
},
{
"category": "Nursing",
"chartdate": "2115-02-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 625124,
"text": "HPI: 35M with Cerebral palsy,presented with abdominal pain and\n distention to an OSH this am where CT scan was performed and reported\n as diffused bowel edema,gastric varices, ascites, pancreatic cyst. No\n association with nausea,vomitting, diarrhea, hematemesis, hematochezia,\n no GU symptoms. No jaundice , no fevers. No weight loss, no NSAIDs, ASA\n use. Pt recieved Unasyn at the OSH and was transferred to .\n He had a history of GI bleed in , unclear source, recieved\n transfusion (). Last EGD and colonoscopy were done in\n , wnl according to mother. Pancreatic cyst was aspirated in\n 6/. Laprascopic cholecystectomy done in .\n Chief complaint: respiratory distress, peritonitis, SMV occlusion\n PMHx: Cerebral Palsy (Patient non verbal baseline), Seizure d/o,\n chronic anemia (transfusion x2)\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received extubated on 5L NC, POX: 94-97%, RR: 17-32. LS:\n Rhoncherous. Impaired gag and cough.\n Patient unable to follow commands for coughing, deep\n breathing, or to expectorate secretions.\n 2200 patient oxygenation saturation decreased to the low\n 80\n Action:\n Chest PT every 1-2 hours.\n Suctioned for copious amounts of thick tinged oral\n secretions.\n Patient placed on high flow aerosol mask and then a NRB\n without improvement. POX: Remained in the mid-high 80\ns. RR: 30-40\n 10mg IVP Lasix given.\n MD notified of respiratory status and present during\n all interventions. Patient was intubated due to poor oxygenation and\n tachypnea.\n Sedated on Propofol for comfort.\n MD spoke with parents regarding need for\n re-intubation.\n Response:\n Good diuresis with IVP Lasix.\n LS: R+LUL clear, diminished bibasilar.\n Plan:\n Continue to closely monitor respiratory status.\n Aggressive pulmonary hygiene.\n .H/O abdominal pain (including abdominal tenderness)\n Assessment:\n T-max: 101.6.\n Abdomen SD, +BSx4,S,tender.\n L-nare NGT with residual of 100cc of bilious/brown\n drainage.\n Flexi-seal with brown liquid stool.\n Continues on a Heparin drip for SMV thrombosis.\n Patient appearing to grimace in pain.\n Action:\n Patient pan-cultured and 325mg Tylenol given.\n Heparin drip adjusted per Heparin sliding scale. Goal PTT is\n between 60-80.\n Remains NPO except for medications. At 1800 NGT residual\n greater than 100cc-placed to CLW with bilious/brown drainage.\n Vancomycin/Zosyn administered MD order.\n IVP Fentanyl given with good pain relief.\n Response:\n Abdominal exam remains unchanged.\n PTT at 2300 sub-therapeutic. Rate increased to 950 units per\n hour. Next PTT due at 0700 on .\n Plan:\n Continue to follow fever curve and WBC\n Continue to monitor abdominal exam for distention.\n Adjust Heparin drip per Heparin sliding scale. Goal PTT:\n 60-80.\n Provide supportive care to patient and family.\n Social work consult.\n"
},
{
"category": "Nursing",
"chartdate": "2115-02-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 624553,
"text": ".H/O abdominal pain (including abdominal tenderness)\n Assessment:\n Patient is non verbal and non ambulatory at baseline.\n Intubated, coughing, LS clear upper, diminished bases\n Abdomen firm distended\n Hyperactive bowel sounds\n Stooling loose, paste type stool, green / black quiac\n negative\n NGT with scant amount of clear drainage in tubing.\n Foley with clear yellow urine ~ 30 cc\ns/hr low urine output\n Tachycardia has improved from yesterday \n Action:\n IV ABX as ordered\n Electrolytes treated\n Repositioned frequently due to cachectic appearance and many\n areas\n Breathing well on CPAP + PS.\n Fentanyl for pain control\n Response:\n Does not appear to be in worsening pain\n Currently ~ 8 liters positive fluid balance length of stay,\n ~ 400 cc\ns + MN - 0600\n CVP ~12\n WBC 9.3\n HCT 26.2 (27.1), INR 1.5 (unchanged)\n Plan:\n Continue to monitor\n ? aline if possible, radial arteries ultrasound showed\n vessel too small to cannulate.\n Parents with patient. Continue patient and family support.\n ? wean ventilator even further to extubated in settings of\n concerning chest x-ray\n"
},
{
"category": "ECG",
"chartdate": "2115-03-24 00:00:00.000",
"description": "Report",
"row_id": 228715,
"text": "Sinus tachycardia. Compared to the previous tracing no change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2115-03-23 00:00:00.000",
"description": "Report",
"row_id": 228716,
"text": "Sinus tachycardia. Compared to previous tracing of no change.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2115-03-13 00:00:00.000",
"description": "Report",
"row_id": 228717,
"text": "Sinus tachycardia. Otherwise, tracing is without diagnostic abnormality.\n\n"
},
{
"category": "ECG",
"chartdate": "2115-03-07 00:00:00.000",
"description": "Report",
"row_id": 228718,
"text": "Sinus tachycardia. Normal tracing. Compared to the previous tracing there is\nno significant change.\n\n"
},
{
"category": "ECG",
"chartdate": "2115-02-20 00:00:00.000",
"description": "Report",
"row_id": 228719,
"text": "Sinus rhythm. Normal tracing. No previous tracing available for comparison.\n\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 631354,
"text": "TITLE:\n 35M with cerebral palsy, non verbal. Admitted in with acute\n abdomen, peritonitis, and chronic pancreatitis. Found to have SMV\n thrombus, anticoagulated which resulted in retoperitoneal hemorrhage.\n Was on floor when he was re-admitted with progressive hypoxemia and\n then subsequently intubated. CTA with LLL and RLL PNA and atelectasis,\n and effusions.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lung sounds with diffuse and scattered rhonci, accepted pt on MMV: TV\n 300X12 / Pressure support 12 / peep 8/ Fio2 40%. Temp to 101.1,\n suctioned for tan to clear secretions. AM ABG 7.45 / 33 / 125. 02 sat\n >96%\n Action:\n Pt weaned to CPAP with pressure support, Pt given 1x dose lasix 40 mg,\n pt turned and repositioned q 2 hours, suctioned q 2 hours and prn.\n Repeat ABG 7.42 / 40 / 107. Antibiotic coverage with vanco, cefepime,\n and flagyl\n Response:\n Pt lung sounds clear through lung fields, diminished at bases, copious\n urine output from lasix 1 xFever down to 98.8\n Plan:\n Continue to wean MV as tolerated, continue to monitor ABGs, 02 sat,\n Continue to monitor repiratory status, Tylenol for fever, pulmonary\n toilet, Follow up Cultures, antibiotics as ordered.\n Tachycardia, Other\n Assessment:\n Heart rate 103\n 125, bp 85\n 100s / 50\n 60s Maps 61- 79\n Action:\n Attempted to titrate levophed to 0.04\n Response:\n Sbp down to 70s with maps 57, Levophed titrated back up to 0.05. As\n shift progressed able to wean levophed back to 0.04, currently bp 84/60\n with Map 70\n Plan:\n Continue to attempt to wean levophed as tolerated, monitor both NBP\n with Aline readings for correlation, Team felt during rounds that\n tachycardia is chronic, continue to monitor\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 631496,
"text": "35M with cerebral palsy, non verbal. Admitted in with acute\n abdomen, peritonitis, and chronic pancreatitis. Found to have SMV\n thrombus, anticoagulated which resulted in retoperitoneal hemorrhage.\n Was on floor when he was re-admitted with progressive hypoxemia and\n then subsequently intubated. CTA with LLL and RLL PNA and atelectasis,\n and effusions.\n Code Status: DNR, already intubated.\n EVENTS: Stable overnight, tolerating CPAP+PS\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lungs with scattered rhonchi all fields---clears with suctioning,\n ETtube suctioned for mod. Amts thick yellow tinged sputum, oral suction\n for large amts of thick white sputum, remains resistant to oral care\n and to oral suctioning, RR=19-30, no vent changes overnight, current\n vent settings include CPAP+PS 330-40% with Peep= 8. MV= , TV-\n 300-350, Sats= 92-96%, ABG= 7.40-45-100\n Action:\n Aggressive pulmonary toileting, no diuretics overnight, Sats and ABG\n monitored, no vent changes\n Response:\n Tolerating CPAP+PS, Continues to require freq. ETtube suctioning for\n mod. Amt sputum\n Plan:\n Continue aggressive pulmonary toileting, ? need for further diuresis,\n Continue to wean vent as tolerated, probably not ready for extubation\n due to large amt of sputum being suctioned from ETtube and orally.\n Alteration in Nutrition\n Assessment:\n Abd softly distended with positive bowel sounds all quads, positive\n flatus, Flexiseal draining loose green stool, NGtube placement\n confirmed by auscultation, tolerating FS Vivonex feedings without any\n residuals, abd is less distended tonight than previous nights,\n fingersticks WNL---being covered with sliding scale insulin, TPN\n infusing at 45 ml/hr via left AC PICC\n Action:\n Vivonex feedings increased to 50ml/hr, residuals checked Q 4hr, TPN\n infusing as ordered, fingersticks monitored and covered with sliding\n scale\n Response:\n Tolerating tube feedings, Abd less distended\n Plan:\n Increase tube feedings to goal as tolerated, d/c TPN when tube feedings\n at goal, continue to monitor residuals Q4hr along with freq. abd.\n Assessments.\n Seizure, without status epilepticus\n Assessment:\n , , opens eyes and tracks, follows all simple commands within\n his baseline abilities,moving all extremities purposely, bilat soft\n wrist restraints to prevent pt from pulling at line and tubes, resting\n in naps, IV Fentanyl infusing at 30 mcgs/hr and IV versed infusing at 1\n mg/hr, no seizure activity noted.\n Action:\n Freq. neuro and safety checks, anticonvulsant meds as ordered\n Response:\n Baseline neuro status, no evidence of seizure activity\n Plan:\n Continue freq. safety and neuro checks, ? of weaning versed and\n fentanyl to off and using bolus dosing of fentanyl for pain due to\n fractured arm.\n Tachycardia, Other\n Assessment:\n HR= 109-122 ST with no ectopy noted, low grade temps with Tmax= 100.3,\n right brachial Aline still dampens but when it has a good waveform then\n it correlates well with NBP, BP= 79-98/50\ns, received pt on IV Levophed\n infusing at 0.03 mcgs/kg/min but MAP\ns continuously down to 50\ns so\n Levophed titrated up and currently at 0.08 mcgs/kg/min with MAP\ns >65,\n antibx as ordered, WBC= 6.5, lactate= 0.9\n Action:\n Levophed titrated up due to hypotension , Tylenol x 1 for low grade\n temp\n Response:\n Still requiring levophed to maintain MAP\ns > 65, Tachycardia continues\n and appears unrelated to Levophed rate or to temps----? If tachycardia\n is pt\ns baseline HR\n Plan:\n Continue to attempt to wean levophed while maintaining MAP\ns > 65,\n continue antibx, monitor temps and culture results.\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 631058,
"text": "35 yo man who has been in hospital some time, with cerebral palsy, non\n verbal. admitted in with acute abdomen, peritonitis, chronic\n pancreatitits. Found to have SMV thrombus, anticoagulated, then\n developed retoperitoneal hemorrhage. Was on floor readmitted with\n progressive hypoxemia, intubated. Had CT with ? of liver abscess.\n CTA with LLL and RLL PNA and atelectasis, and effusions.\n Code Status: DNR but can be intubated .\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Patient has known RP on admission, which is resolving ( noted on ABD\n CT). His abdomen is large and firm, NG to low intermittent wall\n suction. Yesterday evening HCT 23.8\n Action:\n Blood ordered and started at 2100.\n Response:\n HCT 27\n Plan:\n Next HCT is do this evening.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n I received the patient on MMV 40% 10 PEEP,\n Action:\n Response:\n Plan:\n Fracture, other\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Social Work",
"chartdate": "2115-03-27 00:00:00.000",
"description": "Social Work Progress Note",
"row_id": 631349,
"text": "Social Work:\n SW met with pt\ns mother at bedside in MICU. Her husband and\n brother-in-law also present for part of meeting. Discussed sleeping\n arrangements for mother as she continues to spend nights in the\n hospital. She states she obtained the key for the 7^th floor sleep\n room today and plans to sleep there tonight for the first time. Last\n night, she slept in an unlocked consult room in the 6^th floor ICU\n family waiting room. Discussed possibility of obtaining a cot for her\n as well, to put in the 6^th floor waiting room, but she plans to stick\n with the 7^th floor sleep room tonight to see how that goes. Will\n continue to check in with her to ensure she feels as comfortable as\n possible with these arrangements during pt\ns prolonged hospital stay.\n Will also continue to provide parking stickers. Discussed with RN\n Manager. Please page with any questions or concerns.\n , LICSW, #\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 631246,
"text": "35M with cerebral palsy, non verbal. Admitted in with acute\n abdomen, peritonitis, and chronic pancreatitis. Found to have SMV\n thrombus, anticoagulated which resulted in retoperitoneal hemorrhage.\n Was on floor when he was re-admitted with progressive hypoxemia and\n then subsequently intubated. CTA with LLL and RLL PNA and atelectasis,\n and effusions.\n Code Status: DNR, already intubated.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lungs clear bilat to bases, occasional scattered rhonchi but clears\n with coughing, strong prod. Cough of thick yellow sputum, ETtube\n suctioned for mod amts thick yellow sputum, oral suctioned for copious\n amts thick white sputum, RR= 21-31, Current vent settings include: MMV\n mode 300-40%-12 with Peep= 10, Good ABG: 7.45-33-125, Sats 96-100%\n Action:\n Aggressive pulmonary toileting, diuresed with 40 mg. IV Lasix, Sats and\n ABG\ns monitored\n Response:\n Good diuresis from lasix\n Plan:\n Attempt to wean vent to CPAP+PS today, continue aggressive pulmonary\n toileting\n Tachycardia, Other\n Assessment:\n HR= 106-120 ST with no ectopy noted, HR in 100-110 range when sleeping\n and 110-120\ns while awake, Tmax = 100.0 (po), right brachial aline\n dampens but when it has a good waveform it correlates to NBP, BP=\n 94-115/70-80\ns, MAP\ns= 70\ns, received pt on 0.2 mcgs/kg/min of IV\n Levophed, Levophed weaned slowly during the night and currently at\n 0.08mcgs/kg/min, Tylenol x 1 for temp\n Action:\n Levophed gtt weaned down to maintain MAP\ns >65\n Response:\n Tachycardia unchanged, Tolerating slow wean of levophed\n Plan:\n Attempt to wean levophed to off, Tylenol and cultures for temps\n Alteration in Nutrition\n Assessment:\n Abd slightly firm and distended, positive hypoactive bowel sounds in\n all quads, positive flatus, NGtube placement confirmed by auscultation,\n Tolerating FS Vivonex at 20ml/hr with no residuals, Flexiseal in place\n and draining small amts liquid green stool, TPN infusing at 45 ml/hr as\n ordered via PICC, fingersticks 100-220---being covered with sliding\n scale.\n Action:\n Residuals checked Q4hr, vivonex increased to 20ml/hr overnight, TPN\n maintained as ordered\n Response:\n Abd remains distended with positive bowel sounds, tolerating Tube\n feedings with no residuals\n Plan:\n Increased tube feedings to goal as tolerated, once tolerating tube\n feedings then d/c TPN, continue to monitor fingersticks and cover via\n sliding scale.\n Seizure, without status epilepticus\n Assessment:\n Resting in naps, when awake will track with eyes, moves all extremities\n on command, PEARL, no evidence of seizures noted, fosphenytoin and\n phenobarb as ordered, bilat soft wrist restraints to prevent pt from\n pulling at lines and tubes, remains on IV Versed at 1 mg/hr and IV\n Fentanyl at 30 mcgs/hr\n Action:\n Freq neuro and freq. safety checks, anticonvulsant meds as ordered,\n gentle sedation\n Response:\n Stable Neuro status, appears to be at baseline for mental status,\n Plan:\n Wean off sedation as tolerated, continue freq. neuro checks, monitor\n drug levels\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 631247,
"text": "35M with cerebral palsy, non verbal. Admitted in with acute\n abdomen, peritonitis, and chronic pancreatitis. Found to have SMV\n thrombus, anticoagulated which resulted in retoperitoneal hemorrhage.\n Was on floor when he was re-admitted with progressive hypoxemia and\n then subsequently intubated. CTA with LLL and RLL PNA and atelectasis,\n and effusions.\n Code Status: DNR, already intubated.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lungs clear bilat to bases, occasional scattered rhonchi but clears\n with coughing, strong prod. Cough of thick yellow sputum, ETtube\n suctioned for mod amts thick yellow sputum, oral suctioned for copious\n amts thick white sputum, RR= 21-31, Current vent settings include: MMV\n mode 300-40%-12 with Peep= 10, Good ABG: 7.45-33-125, Sats 96-100%\n Action:\n Aggressive pulmonary toileting, diuresed with 40 mg. IV Lasix, Sats and\n ABG\ns monitored\n Response:\n Good diuresis from lasix\n Plan:\n Attempt to wean vent to CPAP+PS today, continue aggressive pulmonary\n toileting\n Tachycardia, Other\n Assessment:\n HR= 106-120 ST with no ectopy noted, HR in 100-110 range when sleeping\n and 110-120\ns while awake, Tmax = 100.0 (po), right brachial aline\n dampens but when it has a good waveform it correlates to NBP, BP=\n 94-115/70-80\ns, MAP\ns= 70\ns, received pt on 0.2 mcgs/kg/min of IV\n Levophed, Levophed weaned slowly during the night and currently at\n 0.08mcgs/kg/min, Tylenol x 1 for temp\n Action:\n Levophed gtt weaned down to maintain MAP\ns >65\n Response:\n Tachycardia unchanged, Tolerating slow wean of levophed\n Plan:\n Attempt to wean levophed to off, Tylenol and cultures for temps\n Alteration in Nutrition\n Assessment:\n Abd slightly firm and distended, positive hypoactive bowel sounds in\n all quads, positive flatus, NGtube placement confirmed by auscultation,\n Tolerating FS Vivonex at 20ml/hr with no residuals, Flexiseal in place\n and draining small amts liquid green stool, TPN infusing at 45 ml/hr as\n ordered via PICC, fingersticks 100-220---being covered with sliding\n scale.\n Action:\n Residuals checked Q4hr, vivonex increased to 20ml/hr overnight, TPN\n maintained as ordered\n Response:\n Abd remains distended with positive bowel sounds, tolerating Tube\n feedings with no residuals\n Plan:\n Increased tube feedings to goal as tolerated, once tolerating tube\n feedings then d/c TPN, continue to monitor fingersticks and cover via\n sliding scale.\n Seizure, without status epilepticus\n Assessment:\n Resting in naps, when awake will track with eyes, moves all extremities\n on command, PEARL, no evidence of seizures noted, fosphenytoin and\n phenobarb as ordered, bilat soft wrist restraints to prevent pt from\n pulling at lines and tubes, remains on IV Versed at 1 mg/hr and IV\n Fentanyl at 30 mcgs/hr\n Action:\n Freq neuro and freq. safety checks, anticonvulsant meds as ordered,\n gentle sedation\n Response:\n Stable Neuro status, appears to be at baseline for mental status,\n Plan:\n Wean off sedation as tolerated, continue freq. neuro checks, monitor\n drug levels\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 631627,
"text": "35M with cerebral palsy, non verbal. Admitted in with acute\n abdomen, peritonitis, and chronic pancreatitis. Found to have SMV\n thrombus, anticoagulated which resulted in retoperitoneal hemorrhage.\n Was on floor when he was re-admitted with progressive hypoxemia and\n then subsequently intubated. CTA with LLL and RLL PNA and atelectasis,\n and effusions.\n Code Status: DNR, already intubated.\n Shift Events:\n Dr met with family and discussed possibility that pt may need to\n be trached if he cannot tolerate being off Ventilatory support.\n Discussed possibility that pt may not be able to return to baseline and\n the possibility that pt may need long term rehab for support with\n Ventilatory support. Family became visibly upset with possibility pt\n may not be able to return home or return to previous level of\n functioning. Once Dr left room Father would not engage Mother at\n all and was visibly angry stating he did not want to talk about it.\n Then led into an outburst yelling at Wife stating he has known for a\n long time that his son is going to\n and he is\nsick of the games\n these Doctors [and] is sick of people sticking and prodding his\n son, just let him go\n. When asked what her understanding was Mother\n stated she understands that.\n he might need a tube in his throat once\n they take the tube out and that he may not return back to what he once\n was\n. Social work came to see family.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Accepted pt on CPAP with pressure support titrated down to 10 from 12,\n and peep 8, 0800 ABG 7.44 / 38 / 100. lung sounds rhoncorous and\n diminsed at bases. Copious amounts of tan thick sputum suctioned from\n ETT, clear to white secretions suctioned orally.\n Action:\n PEEP weaned to 5, pt turned and suctioned q 2 hours and prn, frequent\n ABGs. Pt given Lasix 1x 40 mg IV.\n Response:\n Lung sounds less rhoncorous, pt continues to need frequent suctioning.\n At 1200 during turning pt became increasingly tachypneic during\n turning, pt began to desat to low 80s, pt immediately turned back and\n appeared cyanotic appearing and in distress. Suctioning through ETT\n once again found copious amounts of tan colored sputum. Pt quickly\n returned to 02 sat 96%\n Plan:\n Continue to attempt to wean on CPAP/pressure support/peep as tolerated,\n monitor ABGs, Lung sounds, Antibiotics as ordered\n Seizure, without status epilepticus\n Assessment:\n Pt currently without any s/s seizure activity, currently on\n Phenobarbital and Fosfenytoin IV Pupils , Pt sleeps with eyes\n open but will track when awake, responds to some simple commands and at\n times will be seen making an effort to assist with turns with right\n hand and turning his body. Otherwise pt at baseline neurologically.\n Action:\n Frequent neuro checks, discussed with team if there is any need for\n possible laboratory monitoring for fosphenytoin and Phenobarbital\n levels.\n Response:\n Pt remains at baseline Neurologically, HO states he will order levels\n for am, pt remains safe\n Plan:\n Continue to monitor neurological status, follow up with drug levels in\n the am, provide for pt safety and comfort.\n Tachycardia, Other\n Assessment:\n Pt heart rate remains >100 up to 135, accepted pt this am on levophed\n 0.08 bp 101/71 71/51 to 107/50\n Action:\n Levophed titrated down from 0.08 to off at 1445\n Response:\n Bp 71/51\n 107/50 Map 58 - 71 through course of shift. BP 93/68 with\n Map 77 at 1530\n Plan:\n Continue to monitor hemodynamic status,\n"
},
{
"category": "Physician ",
"chartdate": "2115-03-29 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 631777,
"text": "Chief Complaint:\n 24 Hour Events:\n afds\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 10:02 AM\n Metronidazole - 05:34 PM\n Vancomycin - 07:55 PM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 12:10 PM\n Fosphenytoin - 11:54 PM\n Midazolam (Versed) - 05:53 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 37.3\nC (99.2\n HR: 111 (111 - 141) bpm\n BP: 102/89(95) {71/51(60) - 107/93(96)} mmHg\n RR: 23 (23 - 35) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 2,638 mL\n 586 mL\n PO:\n TF:\n 1,180 mL\n 385 mL\n IVF:\n 800 mL\n 101 mL\n Blood products:\n Total out:\n 2,325 mL\n 330 mL\n Urine:\n 2,325 mL\n 330 mL\n NG:\n Stool:\n Drains:\n Balance:\n 313 mL\n 256 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 328 (177 - 355) mL\n PS : 10 cmH2O\n RR (Spontaneous): 38\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 121\n PIP: 16 cmH2O\n SpO2: 95%\n ABG: 7.49/34/82./26/2\n Ve: 11.3 L/min\n PaO2 / FiO2: 207\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 216 K/uL\n 9.9 g/dL\n 116 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 4.2 mEq/L\n 29 mg/dL\n 105 mEq/L\n 138 mEq/L\n 30.4 %\n 10.7 K/uL\n [image002.jpg]\n 03:52 AM\n 11:49 AM\n 01:56 PM\n 02:25 AM\n 02:42 AM\n 07:36 AM\n 09:06 AM\n 02:18 PM\n 02:33 PM\n 05:01 AM\n WBC\n 6.5\n 10.7\n Hct\n 28.1\n 30.4\n Plt\n 171\n 216\n Cr\n 0.6\n 0.6\n 0.6\n 0.7\n TCO2\n 24\n 27\n 29\n 27\n 25\n 27\n Glucose\n 153\n 136\n 118\n 116\n Other labs: PT / PTT / INR:15.5/27.2/1.4, CK / CKMB /\n Troponin-T:8//0.01, ALT / AST:17/19, Alk Phos / T Bili:106/0.6, Amylase\n / Lipase:/11, Differential-Neuts:86.5 %, Lymph:6.6 %, Mono:5.9 %,\n Eos:0.9 %, Lactic Acid:1.1 mmol/L, Albumin:2.4 g/dL, LDH:383 IU/L,\n Ca++:7.6 mg/dL, Mg++:1.8 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n ALTERATION IN NUTRITION\n TACHYCARDIA, OTHER\n ANEMIA, ACUTE, SECONDARY TO BLOOD LOSS (HEMORRHAGE, BLEEDING)\n FRACTURE, OTHER\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Vivonex (Full) - 06:45 AM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 11:14 AM\n Arterial Line - 11:10 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2115-03-29 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 631779,
"text": "Chief Complaint:\n 24 Hour Events:\n - Pressure support 10, PEEP 5 overnight; initially off fent/versed, but\n then agitated so got versed\n - A-line no longer drawing well\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 10:02 AM\n Metronidazole - 05:34 PM\n Vancomycin - 07:55 PM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 12:10 PM\n Fosphenytoin - 11:54 PM\n Midazolam (Versed) - 05:53 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 37.3\nC (99.2\n HR: 111 (111 - 141) bpm\n BP: 102/89(95) {71/51(60) - 107/93(96)} mmHg\n RR: 23 (23 - 35) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 2,638 mL\n 586 mL\n PO:\n TF:\n 1,180 mL\n 385 mL\n IVF:\n 800 mL\n 101 mL\n Blood products:\n Total out:\n 2,325 mL\n 330 mL\n Urine:\n 2,325 mL\n 330 mL\n NG:\n Stool:\n Drains:\n Balance:\n 313 mL\n 256 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 328 (177 - 355) mL\n PS : 10 cmH2O\n RR (Spontaneous): 38\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 121\n PIP: 16 cmH2O\n SpO2: 95%\n ABG: 7.49/34/82./26/2\n Ve: 11.3 L/min\n PaO2 / FiO2: 207\n Physical Examination\n Labs / Radiology\n 216 K/uL\n 9.9 g/dL\n 116 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 4.2 mEq/L\n 29 mg/dL\n 105 mEq/L\n 138 mEq/L\n 30.4 %\n 10.7 K/uL\n [image002.jpg]\n 03:52 AM\n 11:49 AM\n 01:56 PM\n 02:25 AM\n 02:42 AM\n 07:36 AM\n 09:06 AM\n 02:18 PM\n 02:33 PM\n 05:01 AM\n WBC\n 6.5\n 10.7\n Hct\n 28.1\n 30.4\n Plt\n 171\n 216\n Cr\n 0.6\n 0.6\n 0.6\n 0.7\n TCO2\n 24\n 27\n 29\n 27\n 25\n 27\n Glucose\n 153\n 136\n 118\n 116\n Other labs: PT / PTT / INR:15.5/27.2/1.4, CK / CKMB /\n Troponin-T:8//0.01, ALT / AST:17/19, Alk Phos / T Bili:106/0.6, Amylase\n / Lipase:/11, Differential-Neuts:86.5 %, Lymph:6.6 %, Mono:5.9 %,\n Eos:0.9 %, Lactic Acid:1.1 mmol/L, Albumin:2.4 g/dL, LDH:383 IU/L,\n Ca++:7.6 mg/dL, Mg++:1.8 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n 35 yo M with PMH of CP, seizure disorder, GIB, pancreatic cyst s/p\n drainage in , admitted with abdominal pain with complicated course,\n now with new fever, tachypnea, and hypoxia.\n .\n # Respiratory failure: Patient transferred to MICU with tachypnea and\n hypoxia on and intubated on . Given his new fever,\n respiratory deterioration, and imaging findings consistent with\n multilobar pneumonia he was started on vancomycin, cefepime and flagyl\n (concern for aspiration given recently started tube feeds). Sputum\n growing MRSA. Pleural effusions also noted on imaging, likely due to\n fluid resuscitation for hypotension in the setting of albumin of 2.3,\n so over the past 24 hours have been diuresing with lasix boluses. PE\n considered but CTA negative.\n - continue antibiotic coverage for HAP/aspiration PNA with vanc,\n cefepime, metronidazole x total 8 days (Day 1 = )\n - continue with daily RSBI and SBT as tolerated, attempt to wean to\n PSV; reduced PEEP from 8 to 5 this morning without problems\n - ABG later today\n - gentle diuresis with IV lasix boluses to goal net negative 500cc\n - electrolytes with repletion while on Lasix\n - f/u blood cultures\n .\n # Fever/sepsis: Pt febrile with tachycardia and tachypnea; meets\n definition of sepsis with most likely source being pulmonary (MRSA).\n With ascites, SBP is also possible although he is now s/p 3 taps which\n have not been c/w SBP. Urinalysis and culture from with staph spp\n but repeat appears clean with NGTD. MS with no obvious\n nuchal rigidity although exam limited by pt cooperation. Again, PE\n could cause similar sx of fever and respiratory distress but none seen\n on CTA. Continues febrile daily. No further episodes of AMS. CT read as\n possible liver abscess but repeat RUQ ultrasound read as more\n consistent with infarct. C. Diff has been negative. Continues to have\n fever to 101 on overnight but normal white count, lactate normal.\n - Broad abx as above with good gram positive, gram neg, and anaerobic\n coverage. Consider adding additional coverage for double gram negative\n coverage if WBC does not continue trending down.\n - Goal CVP 8-12 but no measurements available currently\n will bolus\n for tachycardia, UOP < 30cc/h, goal MAP >60, CvO2 >70\n - Pressors for MAP > 60, wean levophed as tolerated (may be easier once\n extubated and off sedation)\n - Monitor mental status\n - Consider paracentesis if continues febrile and no other source (would\n likely need to be done by IR)\n .\n #Hypotension. Continues to wean from levophed\n currently at 0.06.\n pressures run low and currently sedated which may contribute.\n MAP goal > 60. No further episodes of AMS since starting pressors on\n .\n # Tachycardia: Likely hyperdynamic in setting of fever, infection.\n Volume status appears grossly euvolemic; pt mentating at and\n maintaining urine output. Echo with evidence of depressed cardiac fxn,\n ? tachycardia induced cardiomyopathy\n - Tylenol prn fever\n - Abx as above\n - Fluid boluses prn, though patient with heart rate 110s;\n appears hypervolemic\n # Anemia/bleed: Hct stable. Pt with RP bleed and CT evidence of\n hemorrhage into bowel wall, also gastric varices c/b GIB earlier in\n admission. Transfused 1 unit pRBCs with appropriate bump and has\n remained stable since.\n - Trend Hct\n - Guaiac stools\n - Active T&S\n - continue pantoprazole 40mg IV bid\n - Continue iron supplement\n # Liver lesion. Noted on abdominal CT. Possible ischemia/infarction vs\n abscess. Abdominal U/S not consistent with abscess.\n # Left humeral fx: Likely d/t trauma sustained during radiology.\n - No surgical indication at this time\n - Pain control with lidoderm patch and morphine prn\n .\n # SMV thrombus: Plan for anticoagulation x 6 months but held in setting\n of recent GI and RP bleed.\n - Continue heparin SQ\n .\n # Seizure disorder: No recent reports of seizures. Caution as certain\n antibiotics may lower seizure threshold.\n - Continue phenobarbitol and phenytoin\n - drug levels stable as of \n .\n # Cerebral palsy: Stable mental status. Interactive with family but\n nonverbal at .\n .\n FEN: NG tube likely in duodenum, bolus IVF prn, TPN; continue tube\n feeds today\n PROPHYLAXIS: pneumoboots, IV PPI\n ACCESS: PICC, PIV, A-line in right brachial artery\n CODE: Do not resuscitate. Ok to intubate or use pressors. No CPR or\n defibrillation\n ICU Care\n Nutrition:\n Vivonex (Full) - 06:45 AM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 11:14 AM\n Arterial Line - 11:10 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2115-03-29 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 631780,
"text": "Chief Complaint:\n 24 Hour Events:\n - Pressure support 10, PEEP 5 overnight; initially off fent/versed, but\n then agitated so got versed\n - A-line no longer drawing well\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 10:02 AM\n Metronidazole - 05:34 PM\n Vancomycin - 07:55 PM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 12:10 PM\n Fosphenytoin - 11:54 PM\n Midazolam (Versed) - 05:53 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 37.3\nC (99.2\n HR: 111 (111 - 141) bpm\n BP: 102/89(95) {71/51(60) - 107/93(96)} mmHg\n RR: 23 (23 - 35) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 2,638 mL\n 586 mL\n PO:\n TF:\n 1,180 mL\n 385 mL\n IVF:\n 800 mL\n 101 mL\n Blood products:\n Total out:\n 2,325 mL\n 330 mL\n Urine:\n 2,325 mL\n 330 mL\n NG:\n Stool:\n Drains:\n Balance:\n 313 mL\n 256 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 328 (177 - 355) mL\n PS : 10 cmH2O\n RR (Spontaneous): 38\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 121\n PIP: 16 cmH2O\n SpO2: 95%\n ABG: 7.49/34/82./26/2\n Ve: 11.3 L/min\n PaO2 / FiO2: 207\n Physical Examination\n Gen: Thin, opening eyes but no clear orientation to voice\n HEENT: Sclera anicteric, eyes sunken, MMM, audible secretions\n Neck: Supple, thin, EJs prominent and hyperdynamic, no LAD\n Lungs: Intubated, coarse BS bilaterally with diffuse ronchi\n CV: S1, S2 regular rhythm, increased rate\n Abdomen: Soft, BS+, distended, no facial grimacing to palpation\n GU: foley catheter in place\n Ext: Warm, cachectic, BLE contractures, + DP pulses\n Labs / Radiology\n 216 K/uL\n 9.9 g/dL\n 116 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 4.2 mEq/L\n 29 mg/dL\n 105 mEq/L\n 138 mEq/L\n 30.4 %\n 10.7 K/uL\n [image002.jpg]\n 03:52 AM\n 11:49 AM\n 01:56 PM\n 02:25 AM\n 02:42 AM\n 07:36 AM\n 09:06 AM\n 02:18 PM\n 02:33 PM\n 05:01 AM\n WBC\n 6.5\n 10.7\n Hct\n 28.1\n 30.4\n Plt\n 171\n 216\n Cr\n 0.6\n 0.6\n 0.6\n 0.7\n TCO2\n 24\n 27\n 29\n 27\n 25\n 27\n Glucose\n 153\n 136\n 118\n 116\n Other labs: PT / PTT / INR:15.5/27.2/1.4\n Ca++:7.6 mg/dL, Mg++:1.8 mg/dL, PO4:2.3 mg/dL\n phenytoin: 12.4 phenobarb: 13.4\n Assessment and Plan\n 35 yo M with PMH of CP, seizure disorder, GIB, pancreatic cyst s/p\n drainage in , admitted with abdominal pain with complicated course,\n now with new fever, tachypnea, and hypoxia.\n .\n # Respiratory failure: Patient transferred to MICU with tachypnea and\n hypoxia on and intubated on . Given his new fever,\n respiratory deterioration, and imaging findings consistent with\n multilobar pneumonia he was started on vancomycin, cefepime and flagyl\n (concern for aspiration given recently started tube feeds). Sputum\n growing MRSA. Pleural effusions also noted on imaging, likely due to\n fluid resuscitation for hypotension in the setting of albumin of 2.3,\n so over the past 24 hours have been diuresing with lasix boluses. PE\n considered but CTA negative.\n - continue antibiotic coverage for HAP/aspiration PNA with vanc,\n cefepime, metronidazole x total 8 days (Day 1 = )\n - continue with daily RSBI and SBT as tolerated, attempt to wean to\n PSV; reduced PEEP from 8 to 5 this morning without problems\n - ABG later today\n - gentle diuresis with IV lasix boluses to goal net negative 500cc\n - electrolytes with repletion while on Lasix\n - f/u blood cultures\n .\n # Fever/sepsis: Pt febrile with tachycardia and tachypnea; meets\n definition of sepsis with most likely source being pulmonary (MRSA).\n With ascites, SBP is also possible although he is now s/p 3 taps which\n have not been c/w SBP. Urinalysis and culture from with staph spp\n but repeat appears clean with NGTD. MS with no obvious\n nuchal rigidity although exam limited by pt cooperation. Again, PE\n could cause similar sx of fever and respiratory distress but none seen\n on CTA. Continues febrile daily. No further episodes of AMS. CT read as\n possible liver abscess but repeat RUQ ultrasound read as more\n consistent with infarct. C. Diff has been negative. Continues to have\n fever to 101 on overnight but normal white count, lactate normal.\n - Broad abx as above with good gram positive, gram neg, and anaerobic\n coverage. Consider adding additional coverage for double gram negative\n coverage if WBC does not continue trending down.\n - Goal CVP 8-12 but no measurements available currently\n will bolus\n for tachycardia, UOP < 30cc/h, goal MAP >60, CvO2 >70\n - Pressors for MAP > 55-60, wean levophed as tolerated (may be easier\n once extubated and off sedation)\n - Monitor mental status\n - Consider paracentesis if continues febrile and no other source (would\n likely need to be done by IR)\n .\n #Hypotension. Continues to wean from levophed\n currently at 0.06.\n pressures run low and currently sedated which may contribute.\n MAP goal > 60. No further episodes of AMS since starting pressors on\n .\n # Tachycardia: Likely hyperdynamic in setting of fever, infection.\n Volume status appears grossly euvolemic; pt mentating at and\n maintaining urine output. Echo with evidence of depressed cardiac fxn,\n ? tachycardia induced cardiomyopathy\n - Tylenol prn fever\n - Abx as above\n - Fluid boluses prn, though patient with heart rate 110s;\n appears hypervolemic\n # Anemia/bleed: Hct stable. Pt with RP bleed and CT evidence of\n hemorrhage into bowel wall, also gastric varices c/b GIB earlier in\n admission. Transfused 1 unit pRBCs with appropriate bump and has\n remained stable since.\n - Trend Hct\n - Guaiac stools\n - Active T&S\n - continue pantoprazole 40mg IV bid\n - Continue iron supplement\n # Liver lesion. Noted on abdominal CT. Possible ischemia/infarction vs\n abscess. Abdominal U/S not consistent with abscess.\n # Left humeral fx: Likely d/t trauma sustained during radiology.\n - No surgical indication at this time\n - Pain control with lidoderm patch and morphine prn\n .\n # SMV thrombus: Plan for anticoagulation x 6 months but held in setting\n of recent GI and RP bleed.\n - Continue heparin SQ\n .\n # Seizure disorder: No recent reports of seizures. Caution as certain\n antibiotics may lower seizure threshold.\n - Continue phenobarbitol and phenytoin\n - drug levels stable as of \n .\n # Cerebral palsy: Stable mental status. Interactive with family but\n nonverbal at .\n .\n FEN: NG tube likely in duodenum, bolus IVF prn, TPN; continue tube\n feeds today\n PROPHYLAXIS: pneumoboots, IV PPI\n ACCESS: PICC, PIV, A-line in right brachial artery\n CODE: Do not resuscitate. Ok to intubate or use pressors. No CPR or\n defibrillation\n ICU Care\n Nutrition:\n Vivonex (Full) - 06:45 AM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 11:14 AM\n Arterial Line - 11:10 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Respiratory ",
"chartdate": "2115-03-27 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 631249,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 4\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 20 cm at teeth\n Route: Oral\n Type: Standard\n Size: 6.5mm\n Cuff Management:\n /Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n"
},
{
"category": "Physician ",
"chartdate": "2115-03-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 631298,
"text": "Chief Complaint:\n 24 Hour Events:\n PAN CULTURE - At 04:00 PM\n FEVER - 101.1\nF - 04:00 PM\n - During the day had increased levophed requirement to maintain MAP >65\n (lactate nml) but then O/N able to wean down (from 0.2 to 0.08)\n - Got 40IV lasix overnight as discussed yesterday\n Has done well per family\n no further episodes of AMS since starting\n pressors and receiving 1 unit blood.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Cefipime - 11:00 PM\n Metronidazole - 01:22 AM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Fentanyl (Concentrate) - 30 mcg/hour\n Norepinephrine - 0.06 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 PM\n Fosphenytoin - 11:59 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.4\nC (101.1\n Tcurrent: 37.5\nC (99.5\n HR: 115 (102 - 131) bpm\n BP: 99/48(73) {88/48(62) - 118/83(90)} mmHg\n RR: 29 (16 - 34) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 2,206 mL\n 658 mL\n PO:\n TF:\n 65 mL\n 132 mL\n IVF:\n 1,166 mL\n 221 mL\n Blood products:\n Total out:\n 2,545 mL\n 1,150 mL\n Urine:\n 1,895 mL\n 1,150 mL\n NG:\n 150 mL\n Stool:\n Drains:\n Balance:\n -339 mL\n -492 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: MMV/PSV/AutoFlow\n Vt (Set): 300 (300 - 300) mL\n Vt (Spontaneous): 312 (312 - 402) mL\n PS : 12 cmH2O\n RR (Set): 12\n RR (Spontaneous): 27\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 141\n PIP: 21 cmH2O\n Plateau: 22 cmH2O\n Compliance: 23.4 cmH2O/mL\n SpO2: 95%\n ABG: 7.45/33/125/24/0\n Ve: 9.6 L/min\n PaO2 / FiO2: 313\n Physical Examination\n Gen: Thin, appears sedated/comfortable at rest, opening eyes but no\n clear orientation to voice\n HEENT: Sclera anicteric, eyes sunken, MMM, audible secretions\n Neck: Supple, thin, EJs prominent and hyperdynamic, no LAD\n Lungs: Intubated, coarse BS bilaterally with diffuse ronchi, wet\n congestion L > R\n CV: Regular but tachycardic, normal S1 + S2, unable to appreciate any\n murmurs, rubs, gallops\n Abdomen: Soft, BS+, distended, pt appears uncomfortable on palpations\n GU: Condom cath in place\n Ext: Warm, cachectic, BLE contractures, + DP pulses, no cyanosis or\n edema\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 206 K/uL\n 9.5 g/dL\n 99 mg/dL\n 0.6 mg/dL\n 24 mEq/L\n 3.7 mEq/L\n 26 mg/dL\n 107 mEq/L\n 140 mEq/L\n 28.9 %\n 8.1 K/uL\n [image002.jpg]\n 01:30 PM\n 06:52 PM\n 07:01 PM\n 02:03 AM\n 02:19 AM\n 03:29 PM\n 03:46 PM\n 06:28 PM\n 03:24 AM\n 03:52 AM\n WBC\n 10.1\n 8.1\n Hct\n 23.8\n 23.1\n 27.2\n 27.5\n 28.9\n Plt\n 195\n 206\n Cr\n 0.7\n 0.6\n TCO2\n 28\n 27\n 23\n 22\n 24\n Glucose\n 157\n 99\n Other labs:\n PT / PTT / INR:15.6/25.5/1.4\n Ca++:7.9 mg/dL, Mg++:1.8 mg/dL, PO4:3.4 mg/dL\n Micro:\n : Sputum with no microorganisms on gram stain, S. aureus on\n culture (prelim)\n : Sputum with no microorganisms on gram stain, GNR on culture\n (prelim)\n : All blood, urine cx pending or no growth\n Assessment and Plan\n 35 yo M with PMH of CP, seizure disorder, GIB, pancreatic cyst s/p\n drainage in , admitted with abdominal pain with complicated course,\n now with new fever, tachypnea, and hypoxia.\n .\n # Respiratory failure: Hypoxic with ABG on floor c/w respiratory\n alkalosis in setting of tachypnea. Given constellation of new fever,\n tachypnea, and significant hypoxia, as well as new opacities on CXR,\n concern for pneumonia - HAP v. aspiration (tube feeds restarted\n yesterday); less likely VAP as was extubated several weeks prior. \n also with a component of pleural effusion to opacities; recent TTE with\n nl EF but labs notable for low albumin. PE is also a concern as pt is\n bedbound; has not had pneumoboots on and just restarted heparin SQ\n yesterday for DVT ppx. Intubated in setting of declining resp\n status/PNA. CTA yesterday with final read pending, but shows\n infusions/infiltrates b/l. No PE noted.\n - Serial ABG, recheck lactate (most recent ABG with mild resp\n alkalosis)\n - Continue broad antibiotic coverage for HAP/aspiration PNA with vanc,\n cefepime, metronidazole.\n - f/u sputum cx, f/u blood cultures\n - consider nasopharyngeal swab for viral\n - sputum sample with staph aureus, GNR (no sensitivities yet)\n - attempt weaning to PSV again if continues stable\n - Consider additional Lasix for crackles on exam\n - electrolytes with repletion while on Lasix\n .\n # Fever/sepsis: Pt febrile with tachycardia and tachypnea; meets\n definition of sepsis with most likely source being pulmonary. With\n ascites, SBP is also possible although he is now s/p 3 taps which have\n not been c/w SBP. U/A appears clean. MS with no obvious\n nuchal rigidity although exam limited by pt cooperation. Again, PE\n could cause similar sx of fever and respiratory distress but none seen\n on prelim CTA. Continues febrile daily. No further episodes of AMS.\n - F/u blood and urine cx, sputum cx, C. diff (urine with staph\n spp, UA dirty and UCx pending)\n - Repeat abdominal US today to evaluate for change in liver lesion (?\n Abscess)\n - Broad abx as above with good gram positive, gram neg, and anaerobic\n coverage\n - Goal CVP 8-12 but no measurements available currently\n will bolus\n for tachycardia, UOP < 30cc/h, goal MAP >65, CvO2 >70\n - Pressors for MAP > 65, wean levophed as tolerated\n - Monitor mental status\n - Consider paracentesis if continues febrile and no other source (would\n likely need to be done by IR, but will F/U US report today)\n #Hypotension. Continues to wean from levophed\n currently at 0.06.\n pressures run low. No further episodes of AMS since starting\n pressors on .\n # Tachycardia: Likely hyperdynamic in setting of fever, infection.\n Volume status appears grossly euvolemic; pt mentating at and\n maintaining urine output. Echo with evidence of depressed cardiac fxn,\n ? tachycardia induced cardiomyopathy\n - Tylenol prn fever\n - Abx as above\n - Fluid boluses prn, though patient with heart rate 110s;\n appears hypervolemic\n # Anemia/bleed: Hct stable. Pt with RP bleed and CT evidence of\n hemorrhage into bowel wall, also gastric varices c/b GIB earlier in\n admission. Transfused 1 unit pRBCs with appropriate bump and has\n remained stable.\n - Trend Hct\n - Guaiac stools\n - Active T&S\n - continue pantoprazole 40mg IV bid\n - Continue iron supplement\n # Liver lesion. Noted on abdominal CT. Possible abscess.\n - Abdominal U/S tomorrow to eval for interval change\n - Discuss possible drainage with IR (? CT guided?)\n # Left humeral fx: Likely d/t trauma sustained during radiology.\n - No surgical indication at this time\n - Pain control with lidoderm patch and morphine prn\n .\n # SMV thrombus: Plan for anticoagulation x 6 months but held in setting\n of recent GI and RP bleed.\n - Continue heparin SQ\n .\n # Seizure disorder: No recent reports of seizures. Caution as certain\n antibiotics may lower seizure threshold.\n - Continue phenobarbitol and phenytoin\n - will check drug levels tomorrow\n .\n # Cerebral palsy: Stable mental status. Interactive with family but\n nonverbal at .\n .\n FEN: NG tube likely in duodenum, bolus IVF, TPN; start tube feeds today\n PROPHYLAXIS: pneumoboots, IV PPI\n ACCESS: PICC, PIV, A-line in right brachial artery\n CODE: Do not resuscitate. Ok to intubate or use pressors. No CPR or\n defibrillation\n ICU Care\n Nutrition:\n Vivonex (Full) - 05:30 PM 20 mL/hour\n TPN w/ Lipids - 06:00 PM 45 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 11:14 AM\n 20 Gauge - 11:42 AM\n Arterial Line - 11:10 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 631308,
"text": "TITLE:\n 35M with cerebral palsy, non verbal. Admitted in with acute\n abdomen, peritonitis, and chronic pancreatitis. Found to have SMV\n thrombus, anticoagulated which resulted in retoperitoneal hemorrhage.\n Was on floor when he was re-admitted with progressive hypoxemia and\n then subsequently intubated. CTA with LLL and RLL PNA and atelectasis,\n and effusions.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 631704,
"text": "Tachycardia, Other\n Assessment:\n Received pt in NSR, HR 120-130. Remained off levophed for BP 80-90\n with Map >60; TF at goal\n Action:\n Weaned off fent/versed; given Tylenol 650mg for LGT; Tf remained at\n goal\n Response:\n Pt appears to have NAD; remained tachycardic at baseline of 120\ns even\n while sleeping\n Plan:\n Continue present treatment plan/monitoring.\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 631706,
"text": "Tachycardia, Other\n Assessment:\n Received pt in NSR, HR 120-130. Remained off levophed for BP 80-90\n with Map >60; TF at goal\n Action:\n Weaned off fent/versed; given Tylenol 650mg for LGT; Tf remained at\n goal\n Response:\n Pt appears to have NAD; remained tachycardic at baseline of 120\ns even\n while sleeping\n Plan:\n Continue present treatment plan/monitoring.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Orally intubated; PSV 40/5PEEP/10 Vt 240-450, RR 20-30\ns clear after\n suctioning\n Action:\n Suctioning for small amts thick white/yellow secretions.\n Response:\n Stable resp status\n Plan:\n Anticipate for further discussion re: ?trach. Continue to\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 631709,
"text": "35M with cerebral palsy, non verbal. Admitted in with acute\n abdomen, peritonitis, and chronic pancreatitis. Found to have SMV\n thrombus, anticoagulated which resulted in retoperitoneal hemorrhage.\n Was on floor when he was re-admitted with progressive hypoxemia and\n then subsequently intubated. CTA with LLL and RLL PNA and atelectasis,\n and effusions.\n Tachycardia, Other\n Assessment:\n Received pt in NSR, HR 120-130. Remained off levophed for BP 80-90\n with Map >60; TF at goal\n Action:\n Weaned off fent/versed; given Tylenol 650mg for LGT; Tf remained at\n goal\n Response:\n Pt appears to have NAD; remained tachycardic at baseline of 120\ns even\n while sleeping\n Plan:\n Continue present treatment plan/monitoring.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Orally intubated; PSV 40/5PEEP/10 Vt 240-450, RR 20-30\ns clear after\n suctioning\n Action:\n Suctioning for small amts thick white/yellow secretions.\n Response:\n Stable resp status\n Plan:\n Anticipate for further discussion re: ?trach. Continue to\n"
},
{
"category": "Physician ",
"chartdate": "2115-03-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 631332,
"text": "Chief Complaint:\n 24 Hour Events:\n PAN CULTURE - At 04:00 PM\n FEVER - 101.1\nF - 04:00 PM\n - During the day had increased levophed requirement to maintain MAP >65\n (lactate nml) but then O/N able to wean down (from 0.2 to 0.08)\n - Got 40IV lasix overnight as discussed yesterday\n Has done well per family\n no further episodes of AMS since starting\n pressors and receiving 1 unit blood.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Cefipime - 11:00 PM\n Metronidazole - 01:22 AM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Fentanyl (Concentrate) - 30 mcg/hour\n Norepinephrine - 0.06 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 PM\n Fosphenytoin - 11:59 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.4\nC (101.1\n Tcurrent: 37.5\nC (99.5\n HR: 115 (102 - 131) bpm\n BP: 99/48(73) {88/48(62) - 118/83(90)} mmHg\n RR: 29 (16 - 34) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 2,206 mL\n 658 mL\n PO:\n TF:\n 65 mL\n 132 mL\n IVF:\n 1,166 mL\n 221 mL\n Blood products:\n Total out:\n 2,545 mL\n 1,150 mL\n Urine:\n 1,895 mL\n 1,150 mL\n NG:\n 150 mL\n Stool:\n Drains:\n Balance:\n -339 mL\n -492 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: MMV/PSV/AutoFlow\n Vt (Set): 300 (300 - 300) mL\n Vt (Spontaneous): 312 (312 - 402) mL\n PS : 12 cmH2O\n RR (Set): 12\n RR (Spontaneous): 27\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 141\n PIP: 21 cmH2O\n Plateau: 22 cmH2O\n Compliance: 23.4 cmH2O/mL\n SpO2: 95%\n ABG: 7.45/33/125/24/0\n Ve: 9.6 L/min\n PaO2 / FiO2: 313\n Physical Examination\n Gen: Thin, appears sedated/comfortable at rest, opening eyes but no\n clear orientation to voice\n HEENT: Sclera anicteric, eyes sunken, MMM, audible secretions\n Neck: Supple, thin, EJs prominent and hyperdynamic, no LAD\n Lungs: Intubated, coarse BS bilaterally with diffuse ronchi, wet\n congestion L > R\n CV: Regular but tachycardic, normal S1 + S2, unable to appreciate any\n murmurs, rubs, gallops\n Abdomen: Soft, BS+, distended, pt appears uncomfortable on palpations\n GU: foley catheter in place\n Ext: Warm, cachectic, BLE contractures, + DP pulses, no cyanosis or\n edema\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 206 K/uL\n 9.5 g/dL\n 99 mg/dL\n 0.6 mg/dL\n 24 mEq/L\n 3.7 mEq/L\n 26 mg/dL\n 107 mEq/L\n 140 mEq/L\n 28.9 %\n 8.1 K/uL\n [image002.jpg]\n 01:30 PM\n 06:52 PM\n 07:01 PM\n 02:03 AM\n 02:19 AM\n 03:29 PM\n 03:46 PM\n 06:28 PM\n 03:24 AM\n 03:52 AM\n WBC\n 10.1\n 8.1\n Hct\n 23.8\n 23.1\n 27.2\n 27.5\n 28.9\n Plt\n 195\n 206\n Cr\n 0.7\n 0.6\n TCO2\n 28\n 27\n 23\n 22\n 24\n Glucose\n 157\n 99\n Other labs:\n PT / PTT / INR:15.6/25.5/1.4\n Ca++:7.9 mg/dL, Mg++:1.8 mg/dL, PO4:3.4 mg/dL\n Micro:\n : Sputum with no microorganisms on gram stain, S. aureus on\n culture (prelim)\n : Sputum with no microorganisms on gram stain, GNR on culture\n (prelim)\n : All blood, urine cx pending or no growth\n Assessment and Plan\n 35 yo M with PMH of CP, seizure disorder, GIB, pancreatic cyst s/p\n drainage in , admitted with abdominal pain with complicated course,\n now with new fever, tachypnea, and hypoxia.\n .\n # Respiratory failure: Hypoxic with ABG on floor c/w respiratory\n alkalosis in setting of tachypnea. Given constellation of new fever,\n tachypnea, and significant hypoxia, as well as new opacities on CXR,\n concern for pneumonia - HAP v. aspiration (tube feeds restarted\n yesterday); less likely VAP as was extubated several weeks prior. \n also with a component of pleural effusion to opacities; recent TTE with\n nl EF but labs notable for low albumin. PE is also a concern as pt is\n bedbound; has not had pneumoboots on and just restarted heparin SQ\n yesterday for DVT ppx. Intubated in setting of declining resp\n status/PNA. CTA yesterday with final read pending, but shows\n infusions/infiltrates b/l. No PE noted.\n - Serial ABG, recheck lactate (most recent ABG with mild resp\n alkalosis)\n - Continue broad antibiotic coverage for HAP/aspiration PNA with vanc,\n cefepime, metronidazole x total 8 days (Day 1 = )\n - f/u sputum cx, f/u blood cultures\n - consider nasopharyngeal swab for viral\n - sputum sample with staph aureus, GNR (no sensitivities yet)\n - attempt weaning to PSV again if continues stable\n - Consider additional Lasix for crackles on exam; 40mg IV x 1\n - electrolytes with repletion while on Lasix\n .\n # Fever/sepsis: Pt febrile with tachycardia and tachypnea; meets\n definition of sepsis with most likely source being pulmonary. With\n ascites, SBP is also possible although he is now s/p 3 taps which have\n not been c/w SBP. U/A appears clean. MS with no obvious\n nuchal rigidity although exam limited by pt cooperation. Again, PE\n could cause similar sx of fever and respiratory distress but none seen\n on prelim CTA. Continues febrile daily. No further episodes of AMS.\n - F/u blood and urine cx, sputum cx, C. diff (urine with staph\n spp, UA dirty and UCx pending)\n - Repeat abdominal US today to evaluate for change in liver lesion (?\n Abscess)\n - Broad abx as above with good gram positive, gram neg, and anaerobic\n coverage\n - Goal CVP 8-12 but no measurements available currently\n will bolus\n for tachycardia, UOP < 30cc/h, goal MAP >65, CvO2 >70\n - Pressors for MAP > 65, wean levophed as tolerated\n - Monitor mental status\n - Consider paracentesis if continues febrile and no other source (would\n likely need to be done by IR, but will F/U US report today)\n #Hypotension. Continues to wean from levophed\n currently at 0.06.\n pressures run low. No further episodes of AMS since starting\n pressors on .\n # Tachycardia: Likely hyperdynamic in setting of fever, infection.\n Volume status appears grossly euvolemic; pt mentating at and\n maintaining urine output. Echo with evidence of depressed cardiac fxn,\n ? tachycardia induced cardiomyopathy\n - Tylenol prn fever\n - Abx as above\n - Fluid boluses prn, though patient with heart rate 110s;\n appears hypervolemic\n # Anemia/bleed: Hct stable. Pt with RP bleed and CT evidence of\n hemorrhage into bowel wall, also gastric varices c/b GIB earlier in\n admission. Transfused 1 unit pRBCs with appropriate bump and has\n remained stable.\n - Trend Hct\n - Guaiac stools\n - Active T&S\n - continue pantoprazole 40mg IV bid\n - Continue iron supplement\n # Liver lesion. Noted on abdominal CT. Possible abscess.\n - Abdominal U/S tomorrow to eval for interval change\n - Discuss possible drainage with IR (? CT guided?)\n # Left humeral fx: Likely d/t trauma sustained during radiology.\n - No surgical indication at this time\n - Pain control with lidoderm patch and morphine prn\n .\n # SMV thrombus: Plan for anticoagulation x 6 months but held in setting\n of recent GI and RP bleed.\n - Continue heparin SQ\n .\n # Seizure disorder: No recent reports of seizures. Caution as certain\n antibiotics may lower seizure threshold.\n - Continue phenobarbitol and phenytoin\n - will check drug levels tomorrow\n .\n # Cerebral palsy: Stable mental status. Interactive with family but\n nonverbal at .\n .\n FEN: NG tube likely in duodenum, bolus IVF prn, TPN; continue tube\n feeds today\n PROPHYLAXIS: pneumoboots, IV PPI\n ACCESS: PICC, PIV, A-line in right brachial artery\n CODE: Do not resuscitate. Ok to intubate or use pressors. No CPR or\n defibrillation\n ICU Care\n Nutrition:\n Vivonex (Full) - 05:30 PM 30 mL/hour\n TPN w/ Lipids - 06:00 PM 45 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 11:14 AM\n 20 Gauge - 11:42 AM\n Arterial Line - 11:10 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2115-03-27 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 631333,
"text": "Chief Complaint: Respiratory failure.\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 35 yo man with CP, respiratory failure, sepsis from aspiration.\n Levophed increased overnight and then weaned down. Diuresed overnight.\n 24 Hour Events:\n PAN CULTURE - At 04:00 PM\n FEVER - 101.1\nF - 04:00 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Cefipime - 11:00 PM\n Metronidazole - 01:22 AM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Fentanyl (Concentrate) - 30 mcg/hour\n Norepinephrine - 0.04 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 PM\n Fosphenytoin - 11:59 PM\n Other medications:\n SSI\n phosphenytoin\n phenobarb\n lidocaine\n FeSO4\n pancrealipase\n chlorhex\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.4\nC (101.1\n Tcurrent: 38.1\nC (100.6\n HR: 123 (102 - 132) bpm\n BP: 85/64(73) {79/61(70) - 115/87(97)} mmHg\n RR: 27 (16 - 34) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 2,206 mL\n 1,116 mL\n PO:\n TF:\n 65 mL\n 175 mL\n IVF:\n 1,166 mL\n 336 mL\n Blood products:\n Total out:\n 2,545 mL\n 1,310 mL\n Urine:\n 1,895 mL\n 1,310 mL\n NG:\n 150 mL\n Stool:\n Drains:\n Balance:\n -339 mL\n -194 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 300 (300 - 300) mL\n Vt (Spontaneous): 351 (312 - 402) mL\n PS : 12 cmH2O\n RR (Set): 12\n RR (Spontaneous): 24\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 141\n PIP: 20 cmH2O\n Plateau: 22 cmH2O\n Compliance: 23.4 cmH2O/mL\n SpO2: 96%\n ABG: 7.45/33/125/24/0\n Ve: 7.7 L/min\n PaO2 / FiO2: 313\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Diminished), (Left DP pulse:\n Diminished)\n Respiratory / Chest: (Breath Sounds: Crackles : b/l)\n Abdominal: Soft, Non-tender, Distended\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace\n Skin: Warm\n Neurologic: Attentive, No(t) Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed, eyes open, not\n interactive\n Labs / Radiology\n 9.5 g/dL\n 206 K/uL\n 99 mg/dL\n 0.6 mg/dL\n 24 mEq/L\n 3.7 mEq/L\n 26 mg/dL\n 107 mEq/L\n 140 mEq/L\n 28.9 %\n 8.1 K/uL\n [image002.jpg]\n 01:30 PM\n 06:52 PM\n 07:01 PM\n 02:03 AM\n 02:19 AM\n 03:29 PM\n 03:46 PM\n 06:28 PM\n 03:24 AM\n 03:52 AM\n WBC\n 10.1\n 8.1\n Hct\n 23.8\n 23.1\n 27.2\n 27.5\n 28.9\n Plt\n 195\n 206\n Cr\n 0.7\n 0.6\n TCO2\n 28\n 27\n 23\n 22\n 24\n Glucose\n 157\n 99\n Other labs: PT / PTT / INR:15.6/25.5/1.4, CK / CKMB /\n Troponin-T:8//0.01, ALT / AST:17/19, Alk Phos / T Bili:106/0.6, Amylase\n / Lipase:/11, Differential-Neuts:86.5 %, Lymph:6.6 %, Mono:5.9 %,\n Eos:0.9 %, Lactic Acid:1.1 mmol/L, Albumin:2.4 g/dL, LDH:383 IU/L,\n Ca++:7.9 mg/dL, Mg++:1.8 mg/dL, PO4:3.4 mg/dL\n Microbiology: Sputum Cx: with staph\n Sputum Cx: GNRs\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/): Improved respiratory\n status. Continue to wean as tolerated.\n HAP: continue 8 day course of vanco/cefepime/flagyl\n fluid overload: continue diuresis with lasix. goal 500cc negative\n fevers: abd u/s without evidence of abscess.\n SEIZURE, WITHOUT STATUS EPILEPTICUS: no further seizures\n ANEMIA, ACUTE, SECONDARY TO BLOOD LOSS (HEMORRHAGE, BLEEDING)\n FRACTURE, OTHER: left humeral\n will try and meet family today to discuss overall progress\n ICU Care\n Nutrition:\n TPN w/ Lipids - 06:00 PM 45 mL/hour\n Comments: advance TFs as tolerated\n Glycemic Control:\n Lines:\n PICC Line - 11:14 AM\n 20 Gauge - 11:42 AM\n Arterial Line - 11:10 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition :ICU\n Total time spent: 40 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2115-03-28 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 631619,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 35 yo with CP, apiration PNA, continued ventilator requirement.\n 24 Hour Events:\n ULTRASOUND - At 09:53 AM\n FEVER - 101.1\nF - 08:00 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:42 PM\n Metronidazole - 09:01 AM\n Cefipime - 10:02 AM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Fentanyl (Concentrate) - 30 mcg/hour\n Norepinephrine - 0.06 mcg/Kg/min\n Other ICU medications:\n Furosemide (Lasix) - 12:48 PM\n Pantoprazole (Protonix) - 08:42 PM\n Other medications:\n SSI\n phosphenytoin\n phenobarb\n lidocaine patch\n FeSO4\n pancrealipase\n protonix\n chlorhexidine\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38\nC (100.4\n Tcurrent: 37.6\nC (99.7\n HR: 126 (108 - 130) bpm\n BP: 85/63(73) {74/54(63) - 101/77(86)} mmHg\n RR: 35 (19 - 35) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 2,938 mL\n 1,373 mL\n PO:\n TF:\n 710 mL\n 396 mL\n IVF:\n 938 mL\n 369 mL\n Blood products:\n Total out:\n 3,620 mL\n 570 mL\n Urine:\n 3,120 mL\n 570 mL\n NG:\n Stool:\n 500 mL\n Drains:\n Balance:\n -682 mL\n 803 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 328 (328 - 445) mL\n PS : 10 cmH2O\n RR (Spontaneous): 30\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 145\n PIP: 16 cmH2O\n SpO2: 95%\n ABG: 7.44/36/86./25/0\n Ve: 10.4 L/min\n PaO2 / FiO2: 218\n Physical Examination\n General Appearance: No acute distress\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Rhonchorous: b/l)\n Abdominal: Soft, Non-tender, Distended\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+\n Skin: Not assessed\n Neurologic: Attentive, No(t) Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 9.1 g/dL\n 171 K/uL\n 136 mg/dL\n 0.6 mg/dL\n 25 mEq/L\n 3.8 mEq/L\n 29 mg/dL\n 105 mEq/L\n 139 mEq/L\n 28.1 %\n 6.5 K/uL\n [image002.jpg]\n 03:46 PM\n 06:28 PM\n 03:24 AM\n 03:52 AM\n 11:49 AM\n 01:56 PM\n 02:25 AM\n 02:42 AM\n 07:36 AM\n 09:06 AM\n WBC\n 8.1\n 6.5\n Hct\n 28.9\n 28.1\n Plt\n 206\n 171\n Cr\n 0.6\n 0.6\n 0.6\n TCO2\n 23\n 22\n 24\n 27\n 29\n 27\n 25\n Glucose\n 99\n 153\n 136\n Other labs: PT / PTT / INR:16.1/28.6/1.4, CK / CKMB /\n Troponin-T:8//0.01, ALT / AST:17/19, Alk Phos / T Bili:106/0.6, Amylase\n / Lipase:/11, Differential-Neuts:86.5 %, Lymph:6.6 %, Mono:5.9 %,\n Eos:0.9 %, Lactic Acid:1.2 mmol/L, Albumin:2.4 g/dL, LDH:383 IU/L,\n Ca++:7.7 mg/dL, Mg++:1.8 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n ALTERATION IN NUTRITION\n TACHYCARDIA, OTHER\n ANEMIA, ACUTE, SECONDARY TO BLOOD LOSS (HEMORRHAGE, BLEEDING)\n FRACTURE, OTHER\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/): Aspiration PNA.\n Continue broad spectrum antibiotics - sputum with more than one\n organism. Day \n - Continue to diurese for volume overload - aim\n net out 500 cc\n septic shock: wean pressors as tolerated. On sedation which is likely\n dropping his BP a bit. On only low dose levophed\n Fevers: no clear source, WBC trending down, and overall doing well, so\n will follow for now.\n Anemia: hct stable\n SMV thrombosis\n retroperitoneal hemorrhage\n ICU Care\n Nutrition: Now off TPN, tolerating TFs at full rate\n Glycemic Control:\n Lines:\n PICC Line - 11:14 AM\n 20 Gauge - 11:42 AM\n Arterial Line - 11:10 PM\n Prophylaxis:\n DVT: s/q hep\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition :ICU\n Total time spent: 40 minutes\n Patient is critically ill\n ------ Protected Section ------\n Spoke with Mr. \ns mother, father, and uncle. Explained to them\n that Mr. has been very ill, in the hospital for 6 weeks.\n There is a significant chance that he will not be able to come off the\n vent, and will be reintubated after extubation. In this case he would\n require tracheostomy and prolonged ventilator weaning. Given his\n underlying illness with cerebral palsy his chances of returning to the\n quality of life that he had before this illness very poor, but not\n inconceivable. Given this they might want to think about whether or\n not they would want a tracheostomy for him, with the knowledge that\n this would mean a prolonged ventilator wean at a rehab facility with\n uncertainty about his chances for recovery. They said that they would\n think about it.\n ------ Protected Section Addendum Entered By: , MD\n on: 15:12 ------\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 631622,
"text": "35M with cerebral palsy, non verbal. Admitted in with acute\n abdomen, peritonitis, and chronic pancreatitis. Found to have SMV\n thrombus, anticoagulated which resulted in retoperitoneal hemorrhage.\n Was on floor when he was re-admitted with progressive hypoxemia and\n then subsequently intubated. CTA with LLL and RLL PNA and atelectasis,\n and effusions.\n Code Status: DNR, already intubated.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Accepted pt on CPAP with pressure support titrated down to 10 from 12,\n and peep 8, 0800 ABG 7.44 / 38 / 100. lung sounds rhoncorous and\n diminsed at bases. Copious amounts of tan thick sputum suctioned from\n ETT, clear to white secretions suctioned orally.\n Action:\n PEEP weaned to 5, pt turned and suctioned q 2 hours and prn, frequent\n ABGs. Pt given Lasix 1x 40 mg IV.\n Response:\n Lung sounds less rhoncorous, pt continues to need frequent suctioning.\n At 1200 during turning pt became increasingly tachypneic during\n turning, pt began to desat to low 80s, pt immediately turned back and\n appeared cyanotic appearing and in distress. Suctioning through ETT\n once again found copious amounts of tan colored sputum. Pt quickly\n returned to 02 sat 96%\n Plan:\n Continue to attempt to wean on CPAP/pressure support/peep as tolerated,\n monitor ABGs, Lung sounds, Antibiotics as ordered\n Seizure, without status epilepticus\n Assessment:\n Pt currently without any s/s seizure activity, currently on\n Phenobarbital and Fosfenytoin IV Pupils , Pt sleeps with eyes\n open but will track when awake, responds to some simple commands and at\n times will be seen making an effort to assist with turns with right\n hand and turning his body. Otherwise pt at baseline neurologically.\n Action:\n Frequent neuro checks, discussed with team if there is any need for\n possible laboratory monitoring for fosphenytoin and Phenobarbital\n levels.\n Response:\n Pt remains at baseline Neurologically, HO states he will order levels\n for am, pt remains safe\n Plan:\n Continue to monitor neurological status, follow up with drug levels in\n the am, provide for pt safety and comfort.\n Tachycardia, Other\n Assessment:\n Pt heart rate remains >100 up to 135, accepted pt this am on levophed\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 631897,
"text": "35 yo M with PMH of CP, seizure disorder, GIB, pancreatic cyst s/p\n drainage in , admitted with abdominal pain with complicated course,\n now with new fever, tachypnea, and hypoxia.\n Code Status: Full Code.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n I received the patient on CPAP/PS 40% 5/10 with o2 sat 96%. With\n activity his HR will increase to the\n Action:\n Response:\n Plan:\n Fracture, other\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 631404,
"text": "TITLE:\n 35M with cerebral palsy, non verbal. Admitted in with acute\n abdomen, peritonitis, and chronic pancreatitis. Found to have SMV\n thrombus, anticoagulated which resulted in retoperitoneal hemorrhage.\n Was on floor when he was re-admitted with progressive hypoxemia and\n then subsequently intubated. CTA with LLL and RLL PNA and atelectasis,\n and effusions.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lung sounds with diffuse and scattered rhonci, accepted pt on MMV: TV\n 300X12 / Pressure support 12 / peep 8/ Fio2 40%. Temp to 101.1,\n suctioned for tan to clear secretions. AM ABG 7.45 / 33 / 125. 02 sat\n >96%\n Action:\n Pt weaned to CPAP with pressure support, Pt given 1x dose lasix 40 mg,\n pt turned and repositioned q 2 hours, suctioned q 2 hours and prn.\n Repeat ABG 7.42 / 40 / 107. Antibiotic coverage with vanco, cefepime,\n and flagyl\n Response:\n Pt lung sounds clear through lung fields, diminished at bases, copious\n urine output from lasix 1 xFever down to 98.8\n Plan:\n Continue to wean MV as tolerated, continue to monitor ABGs, 02 sat,\n Continue to monitor repiratory status, Tylenol for fever, pulmonary\n toilet, Follow up Cultures, antibiotics as ordered.\n Tachycardia, Other\n Assessment:\n Heart rate 103\n 125, bp 85\n 100s / 50\n 60s Maps 61- 79\n Action:\n Attempted to titrate levophed\n Response:\n Sbp down to 70s with maps 57, Levophed titrated back up to 0.05. As\n shift progressed able to wean levophed back to 0.04, bp to 84/60 with\n Map 70. At 1800 levophed weaned down to 0.03 with bp to 80\n 90 / 60s\n map of 74.\n Plan:\n Continue to attempt to wean levophed as tolerated, monitor both NBP\n with Aline readings for correlation, Team felt during rounds that\n tachycardia is chronic, continue to monitor\n"
},
{
"category": "Respiratory ",
"chartdate": "2115-03-29 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 631880,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 6\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location: icu\n Reason:\n reintubation\n Tube Type\n ETT:\n Position: 20 cm at teeth\n Route: Oral\n Type: Standard\n Size: 6.5mm\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Crackles\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thin\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing,\n Tachypneic (RR> 35 b/min)\n Assessment of breathing comfort: No response (sleeping / sedated)\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Cannot manage secretions\n :\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 631894,
"text": "35 yo M with PMH of CP, seizure disorder, GIB, pancreatic cyst s/p\n drainage in , admitted with abdominal pain with complicated course,\n now with new fever, tachypnea, and hypoxia.\n Code Status: Full Code.\n"
},
{
"category": "Physician ",
"chartdate": "2115-03-29 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 631904,
"text": "Chief Complaint: respiratory failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 35 yo man with cerebral palsy. Weaned off pressors and peep weaned\n down. Weaned off sedation.\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 10:02 AM\n Vancomycin - 07:55 PM\n Metronidazole - 10:41 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 12:10 PM\n Fosphenytoin - 11:54 PM\n Midazolam (Versed) - 05:53 AM\n Other medications:\n SSI\n phosphenytoin\n phenobarb\n lidocaine\n FeSO4\n pancrealipase\n protonix\n chlorhexidine\n levophed\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 37.2\nC (98.9\n HR: 117 (111 - 141) bpm\n BP: 96/71(82) {77/55(65) - 107/93(96)} mmHg\n RR: 33 (21 - 34) insp/min\n SpO2: 92%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 2,638 mL\n 960 mL\n PO:\n TF:\n 1,180 mL\n 577 mL\n IVF:\n 800 mL\n 282 mL\n Blood products:\n Total out:\n 2,325 mL\n 505 mL\n Urine:\n 2,325 mL\n 505 mL\n NG:\n Stool:\n Drains:\n Balance:\n 313 mL\n 455 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 324 (177 - 355) mL\n PS : 10 cmH2O\n RR (Spontaneous): 36\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 121\n PIP: 16 cmH2O\n SpO2: 92%\n ABG: 7.49/34/82./26/2\n Ve: 11.5 L/min\n PaO2 / FiO2: 207\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Non-tender, Distended, firm\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace\n Musculoskeletal: Unable to stand\n Skin: Warm\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Not assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 9.9 g/dL\n 216 K/uL\n 116 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 4.2 mEq/L\n 29 mg/dL\n 105 mEq/L\n 138 mEq/L\n 30.4 %\n 10.7 K/uL\n [image002.jpg]\n 03:52 AM\n 11:49 AM\n 01:56 PM\n 02:25 AM\n 02:42 AM\n 07:36 AM\n 09:06 AM\n 02:18 PM\n 02:33 PM\n 05:01 AM\n WBC\n 6.5\n 10.7\n Hct\n 28.1\n 30.4\n Plt\n 171\n 216\n Cr\n 0.6\n 0.6\n 0.6\n 0.7\n TCO2\n 24\n 27\n 29\n 27\n 25\n 27\n Glucose\n 153\n 136\n 118\n 116\n Other labs: PT / PTT / INR:15.5/27.2/1.4, CK / CKMB /\n Troponin-T:8//0.01, ALT / AST:17/19, Alk Phos / T Bili:106/0.6, Amylase\n / Lipase:/11, Differential-Neuts:86.5 %, Lymph:6.6 %, Mono:5.9 %,\n Eos:0.9 %, Lactic Acid:1.1 mmol/L, Albumin:2.4 g/dL, LDH:383 IU/L,\n Ca++:7.6 mg/dL, Mg++:1.8 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n ALTERATION IN NUTRITION\n TACHYCARDIA, OTHER\n ANEMIA, ACUTE, SECONDARY TO BLOOD LOSS (HEMORRHAGE, BLEEDING)\n FRACTURE, OTHER\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/): Wean PSV to .\n Pulmonary edema: continue lasix diuresis\n HAP: Continue antibiotics for 8 days.\n Will remove a-line\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 11:14 AM\n Arterial Line - 11:10 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition :ICU\n Total time spent: 40 minutes\n ------ Protected Section ------\n Spoke with patient\ns mother, father, uncles and aunt. Explained to\n them that he is close to a trial of extubation, but there is a\n significant chance that he would not be able to protect airway and is\n at risk for reintubation. In this case he would need a tracheostomy\n for continued vent weaning. However given his prolonged illess (6\n weeks in hospital), and his chronic debilitation, his chances of\n recovery and getting home and back to his previous quality of life are\n at best poor. Given this situation the family has elected to not\n reintubate if we extubate him. If he fails, they will make him CMO and\n not choose further aggressive care.\n ------ Protected Section Addendum Entered By: , MD\n on: 18:05 ------\n"
},
{
"category": "Respiratory ",
"chartdate": "2115-03-28 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 631475,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 20 cm at teeth\n Route: Oral\n Type: Standard\n Size: 6.5mm\n Cuff Management:\n Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Rhonchi\n Comments:\n SecretionSputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n"
},
{
"category": "Physician ",
"chartdate": "2115-03-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 631559,
"text": "Chief Complaint:\n 24 Hour Events:\n ULTRASOUND - At 09:53 AM\n FEVER - 101.1\nF - 08:00 AM\n :\n - Diuresed with lasix - negative 760 for day.\n - continues on levophed (0.08 this AM)\n - no overnight events\n - continuing to wean PSV; will attempt SBT this morning.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 11:00 AM\n Vancomycin - 08:42 PM\n Metronidazole - 01:51 AM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Fentanyl (Concentrate) - 30 mcg/hour\n Norepinephrine - 0.08 mcg/Kg/min\n Other ICU medications:\n Furosemide (Lasix) - 12:48 PM\n Pantoprazole (Protonix) - 08:42 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.4\nC (101.1\n Tcurrent: 37.9\nC (100.2\n HR: 118 (108 - 132) bpm\n BP: 85/62(72) {74/54(63) - 103/77(87)} mmHg\n RR: 27 (19 - 32) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 2,938 mL\n 973 mL\n PO:\n TF:\n 710 mL\n 345 mL\n IVF:\n 938 mL\n 200 mL\n Blood products:\n Total out:\n 3,620 mL\n 510 mL\n Urine:\n 3,120 mL\n 510 mL\n NG:\n Stool:\n 500 mL\n Drains:\n Balance:\n -682 mL\n 463 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 300 (300 - 300) mL\n Vt (Spontaneous): 445 (330 - 445) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 19\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 145\n PIP: 21 cmH2O\n SpO2: 96%\n ABG: 7.40/45/99./25/1 (TV325, FiO240, rate21, peep 8)\n Ve: 7 L/min\n PaO2 / FiO2: 250\n Physical Examination\n Gen: Thin, opening eyes but no clear orientation to voice\n HEENT: Sclera anicteric, eyes sunken, MMM, audible secretions\n Neck: Supple, thin, EJs prominent and hyperdynamic, no LAD\n Lungs: Intubated, coarse BS bilaterally with diffuse ronchi\n CV: S1, S2 regular rhythm, increased rate\n Abdomen: Soft, BS+, distended, no facial grimacing to palpation\n GU: foley catheter in place\n Ext: Warm, cachectic, BLE contractures, + DP pulses\n Labs / Radiology\n 171 K/uL\n 9.1 g/dL\n 136 mg/dL\n 0.6 mg/dL\n 25 mEq/L\n 3.8 mEq/L\n 29 mg/dL\n 105 mEq/L\n 139 mEq/L\n 28.1 %\n 6.5 K/uL\n [image002.jpg]\n 02:19 AM\n 03:29 PM\n 03:46 PM\n 06:28 PM\n 03:24 AM\n 03:52 AM\n 11:49 AM\n 01:56 PM\n 02:25 AM\n 02:42 AM\n WBC\n 8.1\n 6.5\n Hct\n 27.5\n 28.9\n 28.1\n Plt\n 206\n 171\n Cr\n 0.6\n 0.6\n 0.6\n TCO2\n 27\n 23\n 22\n 24\n 27\n 29\n Glucose\n 99\n 153\n 136\n Other labs: PT / PTT / INR:16.1/28.6/1.4,\n Ca++:7.7 mg/dL, Mg++:1.8 mg/dL, PO4:3.2 mg/dL\n Lactate: 0.9\n RUQ U/S:\n 1. No son correlate corresponding to the hypoenhancing lesion\n seen on prior CT of is seen. Lesion seen on CT could\n represent an infarct secondary to compromised blood supply through the\n right portal vein, which appears nearly occluded.\n 2. Right pleural effusion and ascites.\n Sputum growing MRSA () and rare gram negative rods ()\n Assessment and Plan\n 35 yo M with PMH of CP, seizure disorder, GIB, pancreatic cyst s/p\n drainage in , admitted with abdominal pain with complicated course,\n now with new fever, tachypnea, and hypoxia.\n .\n # Respiratory failure: Patient transferred to MICU with tachypnea and\n hypoxia on and intubated on . Given his new fever,\n respiratory deterioration, and imaging findings consistent with\n multilobar pneumonia he was started on vancomycin, cefepime and flagyl\n (concern for aspiration given recently started tube feeds). Sputum\n growing MRSA. Pleural effusions also noted on imaging, likely due to\n fluid resuscitation for hypotension in the setting of albumin of 2.3,\n so over the past 24 hours have been diuresing with lasix boluses. PE\n considered but CTA negative.\n - continue antibiotic coverage for HAP/aspiration PNA with vanc,\n cefepime, metronidazole x total 8 days (Day 1 = )\n - continue with daily RSBI and SBT as tolerated, attempt to wean to PSV\n will reduce PEEP from 8 to 5\n - gentle diuresis with IV lasix boluses to goal net negative 500cc\n - electrolytes with repletion while on Lasix\n - f/u blood cultures\n .\n # Fever/sepsis: Pt febrile with tachycardia and tachypnea; meets\n definition of sepsis with most likely source being pulmonary. With\n ascites, SBP is also possible although he is now s/p 3 taps which have\n not been c/w SBP. Urinalysis and culture from with staph spp but\n repeat appears clean with NGTD. MS with no obvious nuchal\n rigidity although exam limited by pt cooperation. Again, PE could\n cause similar sx of fever and respiratory distress but none seen on\n CTA. Continues febrile daily. No further episodes of AMS. CT read as\n possible liver abscess but repeat RUQ ultrasound read as more\n consistent with infarct. C. Diff has been negative. Continues to have\n fever to 101 but normal white count, lactate normal.\n - Broad abx as above with good gram positive, gram neg, and anaerobic\n coverage\n - Goal CVP 8-12 but no measurements available currently\n will bolus\n for tachycardia, UOP < 30cc/h, goal MAP >60, CvO2 >70\n - Pressors for MAP > 60, wean levophed as tolerated\n - Monitor mental status\n - Consider paracentesis if continues febrile and no other source (would\n likely need to be done by IR,\n .\n #Hypotension. Continues to wean from levophed\n currently at 0.06.\n pressures run low. No further episodes of AMS since starting\n pressors on .\n # Tachycardia: Likely hyperdynamic in setting of fever, infection.\n Volume status appears grossly euvolemic; pt mentating at and\n maintaining urine output. Echo with evidence of depressed cardiac fxn,\n ? tachycardia induced cardiomyopathy\n - Tylenol prn fever\n - Abx as above\n - Fluid boluses prn, though patient with heart rate 110s;\n appears hypervolemic\n # Anemia/bleed: Hct stable. Pt with RP bleed and CT evidence of\n hemorrhage into bowel wall, also gastric varices c/b GIB earlier in\n admission. Transfused 1 unit pRBCs with appropriate bump and has\n remained stable.\n - Trend Hct\n - Guaiac stools\n - Active T&S\n - continue pantoprazole 40mg IV bid\n - Continue iron supplement\n # Liver lesion. Noted on abdominal CT. Possible abscess.\n - Abdominal U/S tomorrow to eval for interval change\n - Discuss possible drainage with IR (? CT guided?)\n # Left humeral fx: Likely d/t trauma sustained during radiology.\n - No surgical indication at this time\n - Pain control with lidoderm patch and morphine prn\n .\n # SMV thrombus: Plan for anticoagulation x 6 months but held in setting\n of recent GI and RP bleed.\n - Continue heparin SQ\n .\n # Seizure disorder: No recent reports of seizures. Caution as certain\n antibiotics may lower seizure threshold.\n - Continue phenobarbitol and phenytoin\n - will check drug levels tomorrow\n .\n # Cerebral palsy: Stable mental status. Interactive with family but\n nonverbal at .\n .\n FEN: NG tube likely in duodenum, bolus IVF prn, TPN; continue tube\n feeds today\n PROPHYLAXIS: pneumoboots, IV PPI\n ACCESS: PICC, PIV, A-line in right brachial artery\n CODE: Do not resuscitate. Ok to intubate or use pressors. No CPR or\n defibrillation\n ICU Care\n Nutrition:\n TPN w/ Lipids - 06:14 PM 45 mL/hour\n Vivonex (Full) - 03:32 AM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 11:14 AM\n 20 Gauge - 11:42 AM\n Arterial Line - 11:10 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 631609,
"text": "35M with cerebral palsy, non verbal. Admitted in with acute\n abdomen, peritonitis, and chronic pancreatitis. Found to have SMV\n thrombus, anticoagulated which resulted in retoperitoneal hemorrhage.\n Was on floor when he was re-admitted with progressive hypoxemia and\n then subsequently intubated. CTA with LLL and RLL PNA and atelectasis,\n and effusions.\n Code Status: DNR, already intubated.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Accepted pt on CPAP with pressure support titrated down to 10 from 12,\n and peep 8,\n Action:\n Response:\n Plan:\n Seizure, without status epilepticus\n Assessment:\n Action:\n Response:\n Plan:\n Tachycardia, Other\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 631959,
"text": "35 yo M with PMH of CP, seizure disorder, GIB, pancreatic cyst s/p\n drainage in , admitted with abdominal pain with complicated course,\n now with new fever, tachypnea, and hypoxia.\n Code Status: Full Code.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt on CPAP/PS 40% 5/10 with o2 sat 94-98%. HR to the 120\ns RR in\n the 40\ns with activity.. his CXR is positive for a multilobar\n pneumonia and also has effusion noted. Pt has had low grade temp in\n the 99-100 range, tmax this shift 100.3. He is not sedated and coughing\n clear sputum for the ET, family meeting on previous shift r/t plan of\n care after extubation.\n Action:\n Cont on vanco/cefepime/ flagyl, Blood and urine cx sent, tylenol x1 for\n persistent low grade temp and pain relief. Lasix 20mg IV x1 for net neg\n FB goal. Suctioned q4hrs for mod amt clear-> white sputum\n Response:\n Tmax as above, temp down to 99 following Tylenol, LS clear bilat w/\n dim bases, HR/RR cont to increase with activity. Uop increased with\n lasix. Pt with liquid stool ? secondary to abx, Cdiff spec sent on prev\n shift.\n Plan:\n Con\nt abx, diuretics and plan is to extubate when appropriate. Per the\n family meeting pt will not be reintubated.\n Fracture, other\n Assessment:\n Patient left arm is fractured. Facial grimace and increase in HR/RR\n with any activity\n Action:\n Turning pt to right side and supine only. Morphine prn and lidocaine\n for pain control.\n Response:\n Pt appeared more comfortable with R sided and supine positioning only\n and L arm supported on pillow. Pt was able to sleep ~4hrs.\n Plan:\n Cont to gently reposition patient, morphine prn for pain\n"
},
{
"category": "Physician ",
"chartdate": "2115-03-30 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 631992,
"text": "Chief Complaint:\n 24 Hour Events:\n - continues w/ temp to 100.6 O/N with slightly elevated WBC this AM\n sent blood/urine cx, beta glucan, aspergillus, consider d/c picc\n - lasix 40 and 20IV boluses to goal net negative 1L/24 hours\n - Tolerating pressure support trial well; PEEP at 5 with PSV 10\n - ET tube advanced\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 10:41 AM\n Cefipime - 10:00 PM\n Vancomycin - 02:00 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 10:30 AM\n Pantoprazole (Protonix) - 08:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.1\nC (100.6\n Tcurrent: 37.8\nC (100.1\n HR: 117 (114 - 125) bpm\n BP: 91/66(77) {84/63(73) - 104/76(87)} mmHg\n RR: 25 (19 - 34) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 1,966 mL\n 608 mL\n PO:\n TF:\n 1,201 mL\n 331 mL\n IVF:\n 665 mL\n 278 mL\n Blood products:\n Total out:\n 2,675 mL\n 460 mL\n Urine:\n 2,075 mL\n 460 mL\n NG:\n Stool:\n Drains:\n Balance:\n -709 mL\n 148 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 309 (309 - 381) mL\n PS : 10 cmH2O\n RR (Spontaneous): 26\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 125\n PIP: 16 cmH2O\n SpO2: 97%\n ABG: ///24/\n Ve: 9.3 L/min\n Physical Examination\n Labs / Radiology\n 189 K/uL\n 9.9 g/dL\n 139 mg/dL\n 0.6 mg/dL\n 24 mEq/L\n 3.8 mEq/L\n 27 mg/dL\n 105 mEq/L\n 138 mEq/L\n 30.2 %\n 8.7 K/uL\n [image002.jpg]\n 01:56 PM\n 02:25 AM\n 02:42 AM\n 07:36 AM\n 09:06 AM\n 02:18 PM\n 02:33 PM\n 05:01 AM\n 02:23 PM\n 03:50 AM\n WBC\n 6.5\n 10.7\n 8.7\n Hct\n 28.1\n 30.4\n 30.2\n Plt\n 171\n 216\n 189\n Cr\n 0.6\n 0.6\n 0.6\n 0.7\n 0.6\n 0.6\n TCO2\n 29\n 27\n 25\n 27\n Glucose\n 153\n 136\n 118\n 116\n 85\n 139\n Other labs: PT / PTT / INR:15.7/27.6/1.4\n Ca++:7.4 mg/dL, Mg++:2.6 mg/dL, PO4:2.0 mg/dL\n Lactate: 1.8\n UA: mod LE, pos nitr, few bact, 298 WBC\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 11:14 AM\n Arterial Line - 11:10 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2115-03-30 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 631994,
"text": "Chief Complaint:\n 24 Hour Events:\n - continues w/ temp to 100.6 O/N with slightly elevated WBC this AM\n sent blood/urine cx, beta glucan, aspergillus, consider d/c picc\n - lasix 40 and 20IV boluses to net negative 700cc\n - Tolerating pressure support trial well; PEEP at 5 with PSV 10\n - ET tube advanced\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 10:41 AM\n Cefipime - 10:00 PM\n Vancomycin - 02:00 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 10:30 AM\n Pantoprazole (Protonix) - 08:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.1\nC (100.6\n Tcurrent: 37.8\nC (100.1\n HR: 117 (114 - 125) bpm\n BP: 91/66(77) {84/63(73) - 104/76(87)} mmHg\n RR: 25 (19 - 34) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 1,966 mL\n 608 mL\n PO:\n TF:\n 1,201 mL\n 331 mL\n IVF:\n 665 mL\n 278 mL\n Blood products:\n Total out:\n 2,675 mL\n 460 mL\n Urine:\n 2,075 mL\n 460 mL\n NG:\n Stool:\n Drains:\n Balance:\n -709 mL\n 148 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 309 (309 - 381) mL\n PS : 10 cmH2O\n RR (Spontaneous): 26\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 125\n PIP: 16 cmH2O\n SpO2: 97%\n ABG: ///24/\n Ve: 9.3 L/min\n Physical Examination\n Labs / Radiology\n 189 K/uL\n 9.9 g/dL\n 139 mg/dL\n 0.6 mg/dL\n 24 mEq/L\n 3.8 mEq/L\n 27 mg/dL\n 105 mEq/L\n 138 mEq/L\n 30.2 %\n 8.7 K/uL\n [image002.jpg]\n 01:56 PM\n 02:25 AM\n 02:42 AM\n 07:36 AM\n 09:06 AM\n 02:18 PM\n 02:33 PM\n 05:01 AM\n 02:23 PM\n 03:50 AM\n WBC\n 6.5\n 10.7\n 8.7\n Hct\n 28.1\n 30.4\n 30.2\n Plt\n 171\n 216\n 189\n Cr\n 0.6\n 0.6\n 0.6\n 0.7\n 0.6\n 0.6\n TCO2\n 29\n 27\n 25\n 27\n Glucose\n 153\n 136\n 118\n 116\n 85\n 139\n Other labs: PT / PTT / INR:15.7/27.6/1.4\n Ca++:7.4 mg/dL, Mg++:2.6 mg/dL, PO4:2.0 mg/dL\n Lactate: 1.8\n UA: mod LE, pos nitr, few bact, 298 WBC\n Assessment and Plan\n35 yo M with PMH of CP, seizure disorder, GIB, pancreatic cyst s/p\n drainage in , admitted with abdominal pain with complicated course,\n now with new fever, tachypnea, and hypoxia.\n .\n # Respiratory failure: Patient transferred to MICU with tachypnea and\n hypoxia on and intubated on . Given his new fever,\n respiratory deterioration, and imaging findings consistent with\n multilobar pneumonia he was started on vancomycin, cefepime and flagyl\n (concern for aspiration given recently started tube feeds). Sputum\n growing MRSA. Pleural effusions also noted on imaging, likely due to\n fluid resuscitation for hypotension in the setting of albumin of 2.3,\n so over the past 24 hours have been diuresing with lasix boluses. PE\n considered but CTA negative.\n - continue antibiotic coverage for HAP/aspiration PNA with vanc,\n cefepime, metronidazole x total 8 days (Day 1 = )\n - continue with daily RSBI and SBT as tolerated, attempt to wean to\n PSV; reduced PEEP from 8 to 5 this morning without problems\n - ABG later today\n - gentle diuresis with IV lasix boluses to goal net negative 500cc\n - electrolytes with repletion while on Lasix\n - f/u blood cultures\n .\n # Fever/sepsis: Pt febrile with tachycardia and tachypnea; meets\n definition of sepsis with most likely source being pulmonary (MRSA).\n With ascites, SBP is also possible although he is now s/p 3 taps which\n have not been c/w SBP. Urinalysis and culture from with staph spp\n but repeat appears clean with NGTD. MS with no obvious\n nuchal rigidity although exam limited by pt cooperation. Again, PE\n could cause similar sx of fever and respiratory distress but none seen\n on CTA. Continues febrile daily. No further episodes of AMS. CT read as\n possible liver abscess but repeat RUQ ultrasound read as more\n consistent with infarct. C. Diff has been negative. Continues to have\n fever to 101 on overnight but normal white count, lactate normal.\n - Broad abx as above with good gram positive, gram neg, and anaerobic\n coverage. Consider adding additional coverage for double gram negative\n coverage if WBC does not continue trending down.\n - f/u beta glucan, aspergillus galactomannan\n - consider D/C picc line\n - Goal CVP 8-12 but no measurements available currently\n will bolus\n for tachycardia, UOP < 30cc/h, goal MAP >60, CvO2 >70\n - Pressors for MAP > 55-60, off vasopressors\n - Monitor mental status\n - Consider paracentesis if continues febrile and no other source (would\n likely need to be done by IR)\n .\n #Hypotension. Continues to wean from levophed\n currently at 0.06.\n pressures run low and currently sedated which may contribute.\n MAP goal > 60. No further episodes of AMS since starting pressors on\n .\n # Tachycardia: Likely hyperdynamic in setting of fever, infection.\n Volume status appears grossly euvolemic; pt mentating at and\n maintaining urine output. Echo with evidence of depressed cardiac fxn,\n ? tachycardia induced cardiomyopathy\n - Tylenol prn fever\n - Abx as above\n - Fluid boluses prn, though patient with heart rate 110s;\n appears hypervolemic\n # Anemia/bleed: Hct stable. Pt with RP bleed and CT evidence of\n hemorrhage into bowel wall, also gastric varices c/b GIB earlier in\n admission. Transfused 1 unit pRBCs with appropriate bump and has\n remained stable since.\n - Trend Hct\n - Guaiac stools\n - Active T&S\n - continue pantoprazole 40mg IV bid\n - Continue iron supplement\n # Liver lesion. Noted on abdominal CT. Possible ischemia/infarction vs\n abscess. Abdominal U/S not consistent with abscess.\n # Left humeral fx: Likely d/t trauma sustained during radiology.\n - No surgical indication at this time\n - Pain control with lidoderm patch and morphine prn\n .\n # SMV thrombus: Plan for anticoagulation x 6 months but held in setting\n of recent GI and RP bleed.\n - Continue heparin SQ\n .\n # Seizure disorder: No recent reports of seizures. Caution as certain\n antibiotics may lower seizure threshold.\n - Continue phenobarbitol and phenytoin\n - drug levels stable as of \n .\n # Cerebral palsy: Stable mental status. Interactive with family but\n nonverbal at .\n .\n FEN: NG tube likely in duodenum, bolus IVF prn, TPN; continue tube\n feeds today\n PROPHYLAXIS: pneumoboots, IV PPI\n ACCESS: PICC, PIV, D/C A-line in right brachial artery\n CODE: Do not resuscitate. Ok to intubate or use pressors. No CPR or\n defibrillation\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 11:14 AM\n Arterial Line - 11:10 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2115-03-30 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 631995,
"text": "Chief Complaint:\n 35 yo man who has been in hospital some time, with cerebral palsy, non\n verbal. admitted with acute abdomen, peritonitis, chronic\n pancreatitits. found to have SMV thrombus, anticoagulated, then\n developed retoperitoneal hemorrhage. Was on floor readmitted with\n progressive hypoxemia, intubated. Had CT with ? of liver abscess.\n CTA with LLL and RLL PNA and atelectasis, and effusions.\n 24 Hour Events:\n - continues w/ temp to 100.6 O/N with slightly elevated WBC this AM\n sent blood/urine cx, beta glucan, aspergillus, consider d/c picc\n - lasix 40 and 20IV boluses to net negative 700cc\n - Tolerating pressure support trial well; PEEP at 5 with PSV 10\n - ET tube advanced\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 10:41 AM\n Cefipime - 10:00 PM\n Vancomycin - 02:00 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 10:30 AM\n Pantoprazole (Protonix) - 08:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.1\nC (100.6\n Tcurrent: 37.8\nC (100.1\n HR: 117 (114 - 125) bpm\n BP: 91/66(77) {84/63(73) - 104/76(87)} mmHg\n RR: 25 (19 - 34) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 1,966 mL\n 608 mL\n PO:\n TF:\n 1,201 mL\n 331 mL\n IVF:\n 665 mL\n 278 mL\n Blood products:\n Total out:\n 2,675 mL\n 460 mL\n Urine:\n 2,075 mL\n 460 mL\n NG:\n Stool:\n Drains:\n Balance:\n -709 mL\n 148 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 309 (309 - 381) mL\n PS : 10 cmH2O\n RR (Spontaneous): 26\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 125\n PIP: 16 cmH2O\n SpO2: 97%\n ABG: ///24/\n Ve: 9.3 L/min\n Physical Examination\n Labs / Radiology\n 189 K/uL\n 9.9 g/dL\n 139 mg/dL\n 0.6 mg/dL\n 24 mEq/L\n 3.8 mEq/L\n 27 mg/dL\n 105 mEq/L\n 138 mEq/L\n 30.2 %\n 8.7 K/uL\n [image002.jpg]\n 01:56 PM\n 02:25 AM\n 02:42 AM\n 07:36 AM\n 09:06 AM\n 02:18 PM\n 02:33 PM\n 05:01 AM\n 02:23 PM\n 03:50 AM\n WBC\n 6.5\n 10.7\n 8.7\n Hct\n 28.1\n 30.4\n 30.2\n Plt\n 171\n 216\n 189\n Cr\n 0.6\n 0.6\n 0.6\n 0.7\n 0.6\n 0.6\n TCO2\n 29\n 27\n 25\n 27\n Glucose\n 153\n 136\n 118\n 116\n 85\n 139\n Other labs: PT / PTT / INR:15.7/27.6/1.4\n Ca++:7.4 mg/dL, Mg++:2.6 mg/dL, PO4:2.0 mg/dL\n Lactate: 1.8\n UA: mod LE, pos nitr, few bact, 298 WBC\n Assessment and Plan\n35 yo M with PMH of CP, seizure disorder, GIB, pancreatic cyst s/p\n drainage in , admitted with abdominal pain with complicated course,\n now with new fever, tachypnea, and hypoxia.\n .\n # Respiratory failure: Patient transferred to MICU with tachypnea and\n hypoxia on and intubated on . Given his new fever,\n respiratory deterioration, and imaging findings consistent with\n multilobar pneumonia he was started on vancomycin, cefepime and flagyl\n (concern for aspiration given recently started tube feeds). Sputum\n growing MRSA. Pleural effusions also noted on imaging, likely due to\n fluid resuscitation for hypotension in the setting of albumin of 2.3,\n so over the past 24 hours have been diuresing with lasix boluses. PE\n considered but CTA negative.\n - continue antibiotic coverage for HAP/aspiration PNA with vanc,\n cefepime, metronidazole x total 8 days (Day 1 = )\n - continue with daily RSBI and SBT as tolerated, attempt to wean to\n PSV; reduced PEEP from 8 to 5 this morning without problems\n - ABG later today\n - gentle diuresis with IV lasix boluses to goal net negative 500cc\n - electrolytes with repletion while on Lasix\n - f/u blood cultures\n .\n # Fever/sepsis: Pt febrile with tachycardia and tachypnea; meets\n definition of sepsis with most likely source being pulmonary (MRSA).\n With ascites, SBP is also possible although he is now s/p 3 taps which\n have not been c/w SBP. Urinalysis and culture from with staph spp\n but repeat appears clean with NGTD. MS with no obvious\n nuchal rigidity although exam limited by pt cooperation. Again, PE\n could cause similar sx of fever and respiratory distress but none seen\n on CTA. Continues febrile daily. No further episodes of AMS. CT read as\n possible liver abscess but repeat RUQ ultrasound read as more\n consistent with infarct. C. Diff has been negative. Continues to have\n fever to 101 on overnight but normal white count, lactate normal.\n - Broad abx as above with good gram positive, gram neg, and anaerobic\n coverage. Consider adding additional coverage for double gram negative\n coverage if WBC does not continue trending down.\n - f/u beta glucan, aspergillus galactomannan\n - consider D/C picc line\n - Goal CVP 8-12 but no measurements available currently\n will bolus\n for tachycardia, UOP < 30cc/h, goal MAP >60, CvO2 >70\n - Pressors for MAP > 55-60, off vasopressors\n - Monitor mental status\n - Consider paracentesis if continues febrile and no other source (would\n likely need to be done by IR)\n .\n #Hypotension. Continues to wean from levophed\n currently at 0.06.\n pressures run low and currently sedated which may contribute.\n MAP goal > 60. No further episodes of AMS since starting pressors on\n .\n # Tachycardia: Likely hyperdynamic in setting of fever, infection.\n Volume status appears grossly euvolemic; pt mentating at and\n maintaining urine output. Echo with evidence of depressed cardiac fxn,\n ? tachycardia induced cardiomyopathy\n - Tylenol prn fever\n - Abx as above\n - Fluid boluses prn, though patient with heart rate 110s;\n appears hypervolemic\n # Anemia/bleed: Hct stable. Pt with RP bleed and CT evidence of\n hemorrhage into bowel wall, also gastric varices c/b GIB earlier in\n admission. Transfused 1 unit pRBCs with appropriate bump and has\n remained stable since.\n - Trend Hct\n - Guaiac stools\n - Active T&S\n - continue pantoprazole 40mg IV bid\n - Continue iron supplement\n # Liver lesion. Noted on abdominal CT. Possible ischemia/infarction vs\n abscess. Abdominal U/S not consistent with abscess.\n # Left humeral fx: Likely d/t trauma sustained during radiology.\n - No surgical indication at this time\n - Pain control with lidoderm patch and morphine prn\n .\n # SMV thrombus: Plan for anticoagulation x 6 months but held in setting\n of recent GI and RP bleed.\n - Continue heparin SQ\n .\n # Seizure disorder: No recent reports of seizures. Caution as certain\n antibiotics may lower seizure threshold.\n - Continue phenobarbitol and phenytoin\n - drug levels stable as of \n .\n # Cerebral palsy: Stable mental status. Interactive with family but\n nonverbal at .\n .\n FEN: NG tube likely in duodenum, bolus IVF prn, TPN; continue tube\n feeds today\n PROPHYLAXIS: pneumoboots, IV PPI\n ACCESS: PICC, PIV, D/C A-line in right brachial artery\n CODE: Do not resuscitate. Ok to intubate or use pressors. No CPR or\n defibrillation\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 11:14 AM\n Arterial Line - 11:10 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2115-03-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 631564,
"text": "Chief Complaint:\n 24 Hour Events:\n ULTRASOUND - At 09:53 AM\n FEVER - 101.1\nF - 08:00 AM\n :\n - Diuresed with lasix - negative 760 for day.\n - continues on levophed (0.08 this AM)\n - no overnight events\n - continuing to wean PSV; will attempt SBT this morning.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 11:00 AM\n Vancomycin - 08:42 PM\n Metronidazole - 01:51 AM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Fentanyl (Concentrate) - 30 mcg/hour\n Norepinephrine - 0.08 mcg/Kg/min\n Other ICU medications:\n Furosemide (Lasix) - 12:48 PM\n Pantoprazole (Protonix) - 08:42 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.4\nC (101.1\n Tcurrent: 37.9\nC (100.2\n HR: 118 (108 - 132) bpm\n BP: 85/62(72) {74/54(63) - 103/77(87)} mmHg\n RR: 27 (19 - 32) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 2,938 mL\n 973 mL\n PO:\n TF:\n 710 mL\n 345 mL\n IVF:\n 938 mL\n 200 mL\n Blood products:\n Total out:\n 3,620 mL\n 510 mL\n Urine:\n 3,120 mL\n 510 mL\n NG:\n Stool:\n 500 mL\n Drains:\n Balance:\n -682 mL\n 463 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 300 (300 - 300) mL\n Vt (Spontaneous): 445 (330 - 445) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 19\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 145\n PIP: 21 cmH2O\n SpO2: 96%\n ABG: 7.40/45/99./25/1 (TV325, FiO240, rate21, peep 8)\n Ve: 7 L/min\n PaO2 / FiO2: 250\n Physical Examination\n Gen: Thin, opening eyes but no clear orientation to voice\n HEENT: Sclera anicteric, eyes sunken, MMM, audible secretions\n Neck: Supple, thin, EJs prominent and hyperdynamic, no LAD\n Lungs: Intubated, coarse BS bilaterally with diffuse ronchi\n CV: S1, S2 regular rhythm, increased rate\n Abdomen: Soft, BS+, distended, no facial grimacing to palpation\n GU: foley catheter in place\n Ext: Warm, cachectic, BLE contractures, + DP pulses\n Labs / Radiology\n 171 K/uL\n 9.1 g/dL\n 136 mg/dL\n 0.6 mg/dL\n 25 mEq/L\n 3.8 mEq/L\n 29 mg/dL\n 105 mEq/L\n 139 mEq/L\n 28.1 %\n 6.5 K/uL\n [image002.jpg]\n 02:19 AM\n 03:29 PM\n 03:46 PM\n 06:28 PM\n 03:24 AM\n 03:52 AM\n 11:49 AM\n 01:56 PM\n 02:25 AM\n 02:42 AM\n WBC\n 8.1\n 6.5\n Hct\n 27.5\n 28.9\n 28.1\n Plt\n 206\n 171\n Cr\n 0.6\n 0.6\n 0.6\n TCO2\n 27\n 23\n 22\n 24\n 27\n 29\n Glucose\n 99\n 153\n 136\n Other labs: PT / PTT / INR:16.1/28.6/1.4,\n Ca++:7.7 mg/dL, Mg++:1.8 mg/dL, PO4:3.2 mg/dL\n Lactate: 0.9\n RUQ U/S:\n 1. No son correlate corresponding to the hypoenhancing lesion\n seen on prior CT of is seen. Lesion seen on CT could\n represent an infarct secondary to compromised blood supply through the\n right portal vein, which appears nearly occluded.\n 2. Right pleural effusion and ascites.\n Sputum growing MRSA () and rare gram negative rods ()\n Assessment and Plan\n 35 yo M with PMH of CP, seizure disorder, GIB, pancreatic cyst s/p\n drainage in , admitted with abdominal pain with complicated course,\n now with new fever, tachypnea, and hypoxia.\n .\n # Respiratory failure: Patient transferred to MICU with tachypnea and\n hypoxia on and intubated on . Given his new fever,\n respiratory deterioration, and imaging findings consistent with\n multilobar pneumonia he was started on vancomycin, cefepime and flagyl\n (concern for aspiration given recently started tube feeds). Sputum\n growing MRSA. Pleural effusions also noted on imaging, likely due to\n fluid resuscitation for hypotension in the setting of albumin of 2.3,\n so over the past 24 hours have been diuresing with lasix boluses. PE\n considered but CTA negative.\n - continue antibiotic coverage for HAP/aspiration PNA with vanc,\n cefepime, metronidazole x total 8 days (Day 1 = )\n - continue with daily RSBI and SBT as tolerated, attempt to wean to\n PSV; reduced PEEP from 8 to 5 this morning without problems\n - ABG later today\n - gentle diuresis with IV lasix boluses to goal net negative 500cc\n - electrolytes with repletion while on Lasix\n - f/u blood cultures\n .\n # Fever/sepsis: Pt febrile with tachycardia and tachypnea; meets\n definition of sepsis with most likely source being pulmonary (MRSA).\n With ascites, SBP is also possible although he is now s/p 3 taps which\n have not been c/w SBP. Urinalysis and culture from with staph spp\n but repeat appears clean with NGTD. MS with no obvious\n nuchal rigidity although exam limited by pt cooperation. Again, PE\n could cause similar sx of fever and respiratory distress but none seen\n on CTA. Continues febrile daily. No further episodes of AMS. CT read as\n possible liver abscess but repeat RUQ ultrasound read as more\n consistent with infarct. C. Diff has been negative. Continues to have\n fever to 101 on overnight but normal white count, lactate normal.\n - Broad abx as above with good gram positive, gram neg, and anaerobic\n coverage. Consider adding additional coverage for double gram negative\n coverage if WBC does not continue trending down.\n - Goal CVP 8-12 but no measurements available currently\n will bolus\n for tachycardia, UOP < 30cc/h, goal MAP >60, CvO2 >70\n - Pressors for MAP > 60, wean levophed as tolerated (may be easier once\n extubated and off sedation)\n - Monitor mental status\n - Consider paracentesis if continues febrile and no other source (would\n likely need to be done by IR)\n .\n #Hypotension. Continues to wean from levophed\n currently at 0.06.\n pressures run low and currently sedated which may contribute.\n MAP goal > 60. No further episodes of AMS since starting pressors on\n .\n # Tachycardia: Likely hyperdynamic in setting of fever, infection.\n Volume status appears grossly euvolemic; pt mentating at and\n maintaining urine output. Echo with evidence of depressed cardiac fxn,\n ? tachycardia induced cardiomyopathy\n - Tylenol prn fever\n - Abx as above\n - Fluid boluses prn, though patient with heart rate 110s;\n appears hypervolemic\n # Anemia/bleed: Hct stable. Pt with RP bleed and CT evidence of\n hemorrhage into bowel wall, also gastric varices c/b GIB earlier in\n admission. Transfused 1 unit pRBCs with appropriate bump and has\n remained stable since.\n - Trend Hct\n - Guaiac stools\n - Active T&S\n - continue pantoprazole 40mg IV bid\n - Continue iron supplement\n # Liver lesion. Noted on abdominal CT. Possible ischemia/infarction vs\n abscess. Abdominal U/S not consistent with abscess.\n # Left humeral fx: Likely d/t trauma sustained during radiology.\n - No surgical indication at this time\n - Pain control with lidoderm patch and morphine prn\n .\n # SMV thrombus: Plan for anticoagulation x 6 months but held in setting\n of recent GI and RP bleed.\n - Continue heparin SQ\n .\n # Seizure disorder: No recent reports of seizures. Caution as certain\n antibiotics may lower seizure threshold.\n - Continue phenobarbitol and phenytoin\n - drug levels stable as of \n .\n # Cerebral palsy: Stable mental status. Interactive with family but\n nonverbal at .\n .\n FEN: NG tube likely in duodenum, bolus IVF prn, TPN; continue tube\n feeds today\n PROPHYLAXIS: pneumoboots, IV PPI\n ACCESS: PICC, PIV, A-line in right brachial artery\n CODE: Do not resuscitate. Ok to intubate or use pressors. No CPR or\n defibrillation\n ICU Care\n Nutrition:\n TPN w/ Lipids - 06:14 PM 45 mL/hour\n Vivonex (Full) - 03:32 AM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 11:14 AM\n 20 Gauge - 11:42 AM\n Arterial Line - 11:10 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2115-03-28 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 631565,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 35 yo with CP, apiration PNA, continued ventilator requirement.\n 24 Hour Events:\n ULTRASOUND - At 09:53 AM\n FEVER - 101.1\nF - 08:00 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:42 PM\n Metronidazole - 09:01 AM\n Cefipime - 10:02 AM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Fentanyl (Concentrate) - 30 mcg/hour\n Norepinephrine - 0.06 mcg/Kg/min\n Other ICU medications:\n Furosemide (Lasix) - 12:48 PM\n Pantoprazole (Protonix) - 08:42 PM\n Other medications:\n SSI\n phosphenytoin\n phenobarb\n lidocaine patch\n FeSO4\n pancrealipase\n protonix\n chlorhexidine\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38\nC (100.4\n Tcurrent: 37.6\nC (99.7\n HR: 126 (108 - 130) bpm\n BP: 85/63(73) {74/54(63) - 101/77(86)} mmHg\n RR: 35 (19 - 35) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 2,938 mL\n 1,373 mL\n PO:\n TF:\n 710 mL\n 396 mL\n IVF:\n 938 mL\n 369 mL\n Blood products:\n Total out:\n 3,620 mL\n 570 mL\n Urine:\n 3,120 mL\n 570 mL\n NG:\n Stool:\n 500 mL\n Drains:\n Balance:\n -682 mL\n 803 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 328 (328 - 445) mL\n PS : 10 cmH2O\n RR (Spontaneous): 30\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 145\n PIP: 16 cmH2O\n SpO2: 95%\n ABG: 7.44/36/86./25/0\n Ve: 10.4 L/min\n PaO2 / FiO2: 218\n Physical Examination\n General Appearance: No acute distress\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Rhonchorous: b/l)\n Abdominal: Soft, Non-tender, Distended\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+\n Skin: Not assessed\n Neurologic: Attentive, No(t) Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 9.1 g/dL\n 171 K/uL\n 136 mg/dL\n 0.6 mg/dL\n 25 mEq/L\n 3.8 mEq/L\n 29 mg/dL\n 105 mEq/L\n 139 mEq/L\n 28.1 %\n 6.5 K/uL\n [image002.jpg]\n 03:46 PM\n 06:28 PM\n 03:24 AM\n 03:52 AM\n 11:49 AM\n 01:56 PM\n 02:25 AM\n 02:42 AM\n 07:36 AM\n 09:06 AM\n WBC\n 8.1\n 6.5\n Hct\n 28.9\n 28.1\n Plt\n 206\n 171\n Cr\n 0.6\n 0.6\n 0.6\n TCO2\n 23\n 22\n 24\n 27\n 29\n 27\n 25\n Glucose\n 99\n 153\n 136\n Other labs: PT / PTT / INR:16.1/28.6/1.4, CK / CKMB /\n Troponin-T:8//0.01, ALT / AST:17/19, Alk Phos / T Bili:106/0.6, Amylase\n / Lipase:/11, Differential-Neuts:86.5 %, Lymph:6.6 %, Mono:5.9 %,\n Eos:0.9 %, Lactic Acid:1.2 mmol/L, Albumin:2.4 g/dL, LDH:383 IU/L,\n Ca++:7.7 mg/dL, Mg++:1.8 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n ALTERATION IN NUTRITION\n TACHYCARDIA, OTHER\n ANEMIA, ACUTE, SECONDARY TO BLOOD LOSS (HEMORRHAGE, BLEEDING)\n FRACTURE, OTHER\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/): Aspiration PNA.\n Continue broad spectrum antibiotics - sputum with more than one\n organism. Day \n - Continue to diurese for volume overload - aim\n net out 500 cc\n septic shock: wean pressors as tolerated. On sedation which is likely\n dropping his BP a bit. On only low dose levophed\n Fevers: no clear source, WBC trending down, and overall doing well, so\n will follow for now.\n Anemia: hct stable\n SMV thrombosis\n retroperitoneal hemorrhage\n ICU Care\n Nutrition: Now off TPN, tolerating TFs at full rate\n Glycemic Control:\n Lines:\n PICC Line - 11:14 AM\n 20 Gauge - 11:42 AM\n Arterial Line - 11:10 PM\n Prophylaxis:\n DVT: s/q hep\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition :ICU\n Total time spent: 40 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2115-03-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 631568,
"text": "Chief Complaint:\n 24 Hour Events:\n ULTRASOUND - At 09:53 AM\n FEVER - 101.1\nF - 08:00 AM\n :\n - Diuresed with lasix - negative 760 for day.\n - continues on levophed (0.08 this AM)\n - no overnight events\n - continuing to wean PSV; will attempt SBT this morning.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 11:00 AM\n Vancomycin - 08:42 PM\n Metronidazole - 01:51 AM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Fentanyl (Concentrate) - 30 mcg/hour\n Norepinephrine - 0.08 mcg/Kg/min\n Other ICU medications:\n Furosemide (Lasix) - 12:48 PM\n Pantoprazole (Protonix) - 08:42 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.4\nC (101.1\n Tcurrent: 37.9\nC (100.2\n HR: 118 (108 - 132) bpm\n BP: 85/62(72) {74/54(63) - 103/77(87)} mmHg\n RR: 27 (19 - 32) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 2,938 mL\n 973 mL\n PO:\n TF:\n 710 mL\n 345 mL\n IVF:\n 938 mL\n 200 mL\n Blood products:\n Total out:\n 3,620 mL\n 510 mL\n Urine:\n 3,120 mL\n 510 mL\n NG:\n Stool:\n 500 mL\n Drains:\n Balance:\n -682 mL\n 463 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 300 (300 - 300) mL\n Vt (Spontaneous): 445 (330 - 445) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 19\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 145\n PIP: 21 cmH2O\n SpO2: 96%\n ABG: 7.40/45/99./25/1 (TV325, FiO240, rate21, peep 8)\n Ve: 7 L/min\n PaO2 / FiO2: 250\n Physical Examination\n Gen: Thin, opening eyes but no clear orientation to voice\n HEENT: Sclera anicteric, eyes sunken, MMM, audible secretions\n Neck: Supple, thin, EJs prominent and hyperdynamic, no LAD\n Lungs: Intubated, coarse BS bilaterally with diffuse ronchi\n CV: S1, S2 regular rhythm, increased rate\n Abdomen: Soft, BS+, distended, no facial grimacing to palpation\n GU: foley catheter in place\n Ext: Warm, cachectic, BLE contractures, + DP pulses\n Labs / Radiology\n 171 K/uL\n 9.1 g/dL\n 136 mg/dL\n 0.6 mg/dL\n 25 mEq/L\n 3.8 mEq/L\n 29 mg/dL\n 105 mEq/L\n 139 mEq/L\n 28.1 %\n 6.5 K/uL\n [image002.jpg]\n 02:19 AM\n 03:29 PM\n 03:46 PM\n 06:28 PM\n 03:24 AM\n 03:52 AM\n 11:49 AM\n 01:56 PM\n 02:25 AM\n 02:42 AM\n WBC\n 8.1\n 6.5\n Hct\n 27.5\n 28.9\n 28.1\n Plt\n 206\n 171\n Cr\n 0.6\n 0.6\n 0.6\n TCO2\n 27\n 23\n 22\n 24\n 27\n 29\n Glucose\n 99\n 153\n 136\n Other labs: PT / PTT / INR:16.1/28.6/1.4,\n Ca++:7.7 mg/dL, Mg++:1.8 mg/dL, PO4:3.2 mg/dL\n Lactate: 0.9\n RUQ U/S:\n 1. No son correlate corresponding to the hypoenhancing lesion\n seen on prior CT of is seen. Lesion seen on CT could\n represent an infarct secondary to compromised blood supply through the\n right portal vein, which appears nearly occluded.\n 2. Right pleural effusion and ascites.\n Sputum growing MRSA () and rare gram negative rods ()\n Assessment and Plan\n 35 yo M with PMH of CP, seizure disorder, GIB, pancreatic cyst s/p\n drainage in , admitted with abdominal pain with complicated course,\n now with new fever, tachypnea, and hypoxia.\n .\n # Respiratory failure: Patient transferred to MICU with tachypnea and\n hypoxia on and intubated on . Given his new fever,\n respiratory deterioration, and imaging findings consistent with\n multilobar pneumonia he was started on vancomycin, cefepime and flagyl\n (concern for aspiration given recently started tube feeds). Sputum\n growing MRSA. Pleural effusions also noted on imaging, likely due to\n fluid resuscitation for hypotension in the setting of albumin of 2.3,\n so over the past 24 hours have been diuresing with lasix boluses. PE\n considered but CTA negative.\n - continue antibiotic coverage for HAP/aspiration PNA with vanc,\n cefepime, metronidazole x total 8 days (Day 1 = )\n - continue with daily RSBI and SBT as tolerated, attempt to wean to\n PSV; reduced PEEP from 8 to 5 this morning without problems\n - ABG later today\n - gentle diuresis with IV lasix boluses to goal net negative 500cc\n - electrolytes with repletion while on Lasix\n - f/u blood cultures\n .\n # Fever/sepsis: Pt febrile with tachycardia and tachypnea; meets\n definition of sepsis with most likely source being pulmonary (MRSA).\n With ascites, SBP is also possible although he is now s/p 3 taps which\n have not been c/w SBP. Urinalysis and culture from with staph spp\n but repeat appears clean with NGTD. MS with no obvious\n nuchal rigidity although exam limited by pt cooperation. Again, PE\n could cause similar sx of fever and respiratory distress but none seen\n on CTA. Continues febrile daily. No further episodes of AMS. CT read as\n possible liver abscess but repeat RUQ ultrasound read as more\n consistent with infarct. C. Diff has been negative. Continues to have\n fever to 101 on overnight but normal white count, lactate normal.\n - Broad abx as above with good gram positive, gram neg, and anaerobic\n coverage. Consider adding additional coverage for double gram negative\n coverage if WBC does not continue trending down.\n - Goal CVP 8-12 but no measurements available currently\n will bolus\n for tachycardia, UOP < 30cc/h, goal MAP >60, CvO2 >70\n - Pressors for MAP > 60, wean levophed as tolerated (may be easier once\n extubated and off sedation)\n - Monitor mental status\n - Consider paracentesis if continues febrile and no other source (would\n likely need to be done by IR)\n .\n #Hypotension. Continues to wean from levophed\n currently at 0.06.\n pressures run low and currently sedated which may contribute.\n MAP goal > 60. No further episodes of AMS since starting pressors on\n .\n # Tachycardia: Likely hyperdynamic in setting of fever, infection.\n Volume status appears grossly euvolemic; pt mentating at and\n maintaining urine output. Echo with evidence of depressed cardiac fxn,\n ? tachycardia induced cardiomyopathy\n - Tylenol prn fever\n - Abx as above\n - Fluid boluses prn, though patient with heart rate 110s;\n appears hypervolemic\n # Anemia/bleed: Hct stable. Pt with RP bleed and CT evidence of\n hemorrhage into bowel wall, also gastric varices c/b GIB earlier in\n admission. Transfused 1 unit pRBCs with appropriate bump and has\n remained stable since.\n - Trend Hct\n - Guaiac stools\n - Active T&S\n - continue pantoprazole 40mg IV bid\n - Continue iron supplement\n # Liver lesion. Noted on abdominal CT. Possible ischemia/infarction vs\n abscess. Abdominal U/S not consistent with abscess.\n # Left humeral fx: Likely d/t trauma sustained during radiology.\n - No surgical indication at this time\n - Pain control with lidoderm patch and morphine prn\n .\n # SMV thrombus: Plan for anticoagulation x 6 months but held in setting\n of recent GI and RP bleed.\n - Continue heparin SQ\n .\n # Seizure disorder: No recent reports of seizures. Caution as certain\n antibiotics may lower seizure threshold.\n - Continue phenobarbitol and phenytoin\n - drug levels stable as of \n .\n # Cerebral palsy: Stable mental status. Interactive with family but\n nonverbal at .\n .\n FEN: NG tube likely in duodenum, bolus IVF prn, TPN; continue tube\n feeds today\n PROPHYLAXIS: pneumoboots, IV PPI\n ACCESS: PICC, PIV, A-line in right brachial artery\n CODE: Do not resuscitate. Ok to intubate or use pressors. No CPR or\n defibrillation\n ICU Care\n Nutrition:\n TPN w/ Lipids - 06:14 PM 45 mL/hour\n Vivonex (Full) - 03:32 AM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 11:14 AM\n 20 Gauge - 11:42 AM\n Arterial Line - 11:10 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Nutrition",
"chartdate": "2115-03-28 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 631571,
"text": "Subjective\n Patient remains intubated\n Objective\n Pertinent medications: iron, pancrealipase, RISS, protonix, abx,\n anti-seizure meds, others noted\n Labs:\n Value\n Date\n Glucose\n 136 mg/dL\n 02:25 AM\n Glucose Finger Stick\n 194\n 10:00 AM\n BUN\n 29 mg/dL\n 02:25 AM\n Creatinine\n 0.6 mg/dL\n 02:25 AM\n Sodium\n 139 mEq/L\n 02:25 AM\n Potassium\n 3.8 mEq/L\n 02:25 AM\n Chloride\n 105 mEq/L\n 02:25 AM\n TCO2\n 25 mEq/L\n 02:25 AM\n PO2 (arterial)\n 86. mm Hg\n 09:06 AM\n PCO2 (arterial)\n 36 mm Hg\n 09:06 AM\n pH (arterial)\n 7.44 units\n 09:06 AM\n CO2 (Calc) arterial\n 25 mEq/L\n 09:06 AM\n Albumin\n 2.4 g/dL\n 02:03 AM\n Calcium non-ionized\n 7.7 mg/dL\n 02:25 AM\n Phosphorus\n 3.2 mg/dL\n 02:25 AM\n Ionized Calcium\n 1.04 mmol/L\n 07:36 AM\n Magnesium\n 1.8 mg/dL\n 02:25 AM\n WBC\n 6.5 K/uL\n 02:25 AM\n Hgb\n 9.1 g/dL\n 02:25 AM\n Hematocrit\n 28.1 %\n 02:25 AM\n Current diet order / nutrition support: Tube feeds: Vivonex @ 50mL/hr\n (1200 kcals/46 gr protein)\n TPN rx () 1100mL (200 dextrose/50 protein/22 fat) 1100 kcals\n GI: Abd: soft/distended/+liquid green stool\n Assessment of Nutritional Status\n Specifics:\n 35 year old male w/ CP, long hospital course- remains intubated on\n pressor support. Patient has been receiving TPN as main source of\n nutrition given multiple failed tube feed trials. Tube feed formula\n changed to elemental formula on and have since advanced to goal w/\n good tolerance up to this point. Can therefore discontinue TPN and\n continue w/ tube feeds for full nutrition. Low ionized Ca. Elevated\n FSBG- likely d/t TPN and tube feeds infusing @ goal.\n Medical Nutrition Therapy Plan - Recommend the Following\n Stop TPN\n Continue tube feeds @ goal\n Replete Ca++\n glucose management as you are\n Following #\n 10:59\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 632090,
"text": "35 yo M with PMH of CP, seizure disorder, GIB, pancreatic cyst s/p\n drainage in , admitted with abdominal pain with complicated course,\n now with new fever, tachypnea, and hypoxia.\n Code Status: DNR, per family meeting will NOT re-intubate after\n extubation.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on CPAP+PS 40%/, RR teens with sats >95%. Lung sounds\n clear w./dim bases Pt off sedation, not following commands however\n withdraws to pain. On final day of IV abx but cont to have LG fever.\n TMAx this shift 100.5 Foley changed on prev shift r/t persistent low\n grade temps. Being duiresed w/ lasix to optimize resp status for\n possible extubation this am. Was short of FB goal at the start of this\n shift. PM lytes showed K+ 3.3,\n Action:\n Additional 80mg IV lasix at start of this shift. K+ repleted with 60\n meq KCL. Tylenol for temp, morphine x2 for pain. Tube Feeding on hold\n at 2am foe possible extubation today.\n Response:\n 02 sat remains >95%, good UOP from lasix w/ FB net neg ~1L at midnight.\n AM lytes pending. Temp at 2am\n Plan:\n Plan to extubate today, replete lytes as needed, continue pulmonary\n toilet. Per family meeting will NOT re-intubate after extubation.\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 631748,
"text": "35M with cerebral palsy, non verbal. Admitted in with acute\n abdomen, peritonitis, and chronic pancreatitis. Found to have SMV\n thrombus, anticoagulated which resulted in retoperitoneal hemorrhage.\n Was on floor when he was re-admitted with progressive hypoxemia and\n then subsequently intubated. CTA with LLL and RLL PNA and atelectasis,\n and effusions. Family meeting where plan of care was discussed;\n social worker called to assist in supporting parents who were visible\n torn in decision making process. (see note). Pt is a DNR at present.\n Tachycardia, Other\n Assessment:\n Received pt in NSR, HR 120-130. Remained off levophed for BP 80-90\n with Map >60; TF at goal\n Action:\n Weaned off fent/versed; given Tylenol 650mg for LGT; Tf remained at\n goal\n Response:\n Pt appears to have some agitation/anxiety r/t incontinence and need for\n suctioning- med with 1mg versed x2 with good effect.; remained\n tachycardic at baseline of 120\ns even while sleeping\n Plan:\n Continue present treatment plan/monitoring. IVP fent/versed prn.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Orally intubated; PSV 40/5PEEP/10 Vt 240-450, RR 20-30\ns clear after\n suctioning\n Action:\n Suctioning for small to moderate amts thick white/yellow secretions\n every 3 hrs\n Response:\n Stable resp status; dependent on vent support\n Plan:\n Anticipate for further discussion re: ?trach. Continue to support\n parents during decision process. Broad spectrum antibx for pna. Wean\n as tolerated.\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 632070,
"text": "35 yo M with PMH of CP, seizure disorder, GIB, pancreatic cyst s/p\n drainage in , admitted with abdominal pain with complicated course,\n now with new fever, tachypnea, and hypoxia.\n Code Status: DNR, per family meeting will NOT re-intubate after\n extubation.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on CPAP+PS 40%/, RR teens with sats >95%. Lung sounds\n clear to rhonchorous. Pt off sedation, not following commands however\n withdraws to pain.\n Action:\n RSBI this AM, 40mg IV lasix given for fluid overload with goal fluid\n balance 1L negative at MN. Suctioned for small amounts of thin, blood\n tinged secretions.\n Response:\n RSBI this AM 92, SBT performed and tolerated 8/0 for 2 hours. Good\n response to IV lasix however still not near fluid goal. PM lytes sent\n at 1600.\n Plan:\n Plan to extubate tomorrow, replete lytes as needed, may require\n additional lasix dose to reach fluid balance, continue pulmonary\n toilet. Per family meeting will NOT re-intubate after extubation.\n Foley changed this afternoon due to persistent fevers.\n"
},
{
"category": "Respiratory ",
"chartdate": "2115-03-31 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 632193,
"text": ":Pt extubated after improving rsbis and spontaneous breathing trial.\n Tolerating extubation, requiring O2 and oral suctioning prn. Per family\n pt not to be reintubated.\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 630605,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient arrived from floor tachypneic, tachycardic and mildly hypoxic\n on 15L NRB. LS clear throughout, diminished on R side. Patient using\n accessory muscles to breathe.\n Action:\n Non-invasive ventilation initiated. 500cc NS bolus administered for\n tachycardia x2. VBG sent, unable to obtain ABG.\n Response:\n Plan:\n"
},
{
"category": "Respiratory ",
"chartdate": "2115-03-29 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 631736,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 6\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 6.5mm\n :\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: Tan /\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Tachypneic (RR> 35 b/min)\n Assessment of breathing comfort: Pt acknowledges dyspnea\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 631952,
"text": "35 yo M with PMH of CP, seizure disorder, GIB, pancreatic cyst s/p\n drainage in , admitted with abdominal pain with complicated course,\n now with new fever, tachypnea, and hypoxia.\n Code Status: Full Code.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt on CPAP/PS 40% 5/10 with o2 sat 94-98%. HR to the 120\ns RR in\n the 40\ns with activity.. his CXR is positive for a multilobar\n pneumonia and also has effusion noted. Pt has had low grade temp in\n the 99-100 range, tmax this shift 100.3. He is not sedated and coughing\n clear sputum for the ET, family meeting on previous shift r/t plan of\n care after extubation.\n Action:\n Cont on vanco/cefepime/ flagyl, Blood and urine cx sent, tylenol x1 for\n persistent low grade temp and pain relief. Lasix 20mg IV x1 for net neg\n FB goal. Suctioned q4hrs for mod amt clear-> white sputum\n Response:\n Tmax as above, temp down to 99 following Tylenol, LS clear bilat w/\n dim bases, HR/RR cont to increase with activity. Uop increased with\n lasix. Pt with liquid stool ? secondary to abx, Cdiff spec sent on prev\n shift.\n Plan:\n Con\nt abx, diuretics and plan is to extubated when appropriate. Per the\n family meeting pt will not be reintubated.\n Fracture, other\n Assessment:\n Patient left arm is fractured. Facial grimace and increase in HR/RR\n with any activity\n Action:\n Turning pt to right side and supine only. Tylenol and lidocaine for\n pain control.\n Response:\n Pt appeared more comfortable with R sided and supine positioning only\n and L arm supported on pillow. Pt was able to sleep ~4hrs.\n Plan:\n Cont to gently reposition patient, Tylenol for pain, ? need for\n stronger pain med.\n"
},
{
"category": "Respiratory ",
"chartdate": "2115-03-24 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 630819,
"text": "Day of mechanical ventilation: 1\n Known difficult intubation: No\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 6.5mm\n Lung sounds\n RLL Lung Sounds: Crackles\n RUL Lung Sounds: Crackles\n LUL Lung Sounds: Crackles\n LLL Lung Sounds: Crackles\n Secretions\n Sputum color / consistency: Tan / Frothy\n Sputum source/amount: Suctioned / Small\n Comments:\n 35 yr male with cerebral palsy, presents with abdominal pain and\n probable aspiration PNA. Intubated for hypoxic respiratory failure. CT\n reveals PNA, pleural effusions, ascites. Wean FiO2 as tolerated.\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 630825,
"text": "35 yo M with PMH of CP, seizure disorder, GIB, pancreatic cyst s/p\n drainage in , admitted with abdominal pain with complicated course,\n now with new fever, tachypnea, and hypoxia.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt from TSICU with 02 sats 88\n 90 on 100% FIO2 peep 8, pt\n tachypneic to 45, Heart rate to 130\n 140slung sounds rales and\n crackles heard throughout lung fields, Versed at 3mg/hr, low grade temp\n to\n Action:\n Pt bolused with 0.5 mg versed, fentanyl added for 25 mcg/hr, lasix 40\n mg iv given\n Response:\n Vs at 1900 heart rate 117, 02 sat 95% after peep increased to 8, and\n Fio2 weaned to 60, respirations 25 - 27\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 630829,
"text": "35 yo M with PMH of CP, seizure disorder, GIB, pancreatic cyst s/p\n drainage in , admitted with abdominal pain with complicated course,\n now with new fever, tachypnea, and hypoxia.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt from TSICU with 02 sats 88\n 90 on 100% FIO2 peep 8, pt\n tachypneic to 45, Heart rate to 130\n 140slung sounds rales and\n crackles heard throughout lung fields, Versed at 3mg/hr, low grade temp\n to\n Action:\n Pt bolused with 0.5 mg versed, fentanyl added for 25 mcg/hr, lasix 40\n mg iv given\n Response:\n Vs at 1900 heart rate 117, 02 sat 95% after peep increased to 8, and\n Fio2 weaned to 60, respirations 25 - 27\n Plan:\n Continue to monitor respiratory status, labs, wean ventilation as\n tolerated, turn and mouth care q 2 hours and prn.\n"
},
{
"category": "Physician ",
"chartdate": "2115-03-23 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 630590,
"text": "TITLE:\n Chief Complaint: Fever, hypoxia, tachypnea\n HPI: (per Medicine team and most recent transfer accept note): This is\n a 35 y/o M, with a hx of cerebral palsy, seizure disorder, nonverbal at\n . He was initially admitted to an OSH on with abdominal\n pain and distention. CT scan showed diffuse bowel edema, gastric\n varices, ascites and a pancreatic cyst. He was transferred here to the\n SICU team for further management of an acute abdomen. He had a\n diagnostic paracentesis on with WBC , but no growth so thought\n to be inflammatory state. He was started on Vanco/Zosyn/Flagyl for\n suspected peritonitis and ischemic bowel with translocation. On CT, a\n SMV thrombus was noted and heparin was started on . His thrombus was\n likely chronic and secondary to chronic pancreatic inflammation. He was\n transitioned to coumadin. He was then intubated for respiratory\n failure. He was extubated but was then reintubated likely secondary\n to fluid overload. He had had difficultly weaning off the ventilator\n and was transferred to the MICU team for further management. He was\n extubated successfully and then transferred to the floor for further\n management of his abdominal pain. He was changed from heparin to\n lovenox for bridging and coumadin. He started TPN. He did tolerated POs\n for a few days but has intermittent large bowel obstructions and then\n remade NPO. GI has been consulted for a possible PEG tube. He completed\n a 14 d course of vanco and was continued on cipro/flagyl for his\n initial peritonitis.\n .\n He was again transferred to the MICU for hypotension and coffee ground\n emesis. The patient had been on the floor being treated for\n intermittent small and large bowel obstructions when blood was found in\n his NGT. Several hours later, he was found to have coffee ground\n emesis. Lovenox and coumadin were discontinued at that time and vitamin\n K was given. On , he went for CT abdomen showing colonic wall\n thickening with RP hematoma and microperforation. He was hypotensive\n requiring pressors. The RP bleed was in the setting of anticoagulation\n on for SMV thrombus and anticoagulation was held. Cipro/flagyl for\n colitis/microperforation was stopped, and vanco was discontinued after\n blood cultures were finalized.\n .\n Pt was transferred back to the floor, and his Hct has remained stable.\n However, he has continued to have low grade fevers in the 100s and\n tachycardia to the 120s. ID work-up of this included a paracentesis on\n which was not c/w SBP (one dose of ceftriaxone given) and a\n negative CT torso on . He was found to have a left humeral\n fracture. Pt appeared to be clinically improving yesterday, and his NG\n tube feeds were restarted. However, at 4 AM, he spiked a fever to\n 101.9. He had increased work of breathing and at 8am had recorded\n tachypnea with RR in the 40s, O2 sats 84% on 2L ( high 90s on\n 2L), tachycardia to 140s ( 120s for past few days), and SBP\n high 80s-low 90s ( low 90s-100s). He was increased to 6L NC\n without improvement so was started on a 100% NRB with ABG 7.52/34/64.\n CXR showed new left lower lobe infiltrate. Portable abdomen without\n dilated bowel loops. VS at time of MICU floor evaluation were: T 99,\n BP 88/66, P 134, RR 32, O2sat 100% on NRB. Pt was started on broad\n antibiotic coverage for HAP/aspiration PNA with vancomycin, cefepime,\n and metronidazole and transferred to the MICU. Access with\n double-lumen PICC and 22g PIV.\n .\n In the unit, mother reports that pt's mental status is at .\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 11:22 AM\n Cefipime - 12:37 PM\n Other medications (on transfer):\n Vancomycin 750 mg IV Q 12H\n CefePIME 2 g IV Q12H\n MetRONIDAZOLE (FLagyl) 500 mg IV Q8H\n Lansoprazole Oral Disintegrating Tab 30mg PO/NG DAILY\n Pancrelipase 5000 2 CAP PO TID\n PHENObarbital 30 mg IV Q12H\n Fosphenytoin 100 mg PE IV Q8H\n Ferrous Sulfate 300 mg PO/NG DAILY\n Insulin SC SS\n Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol\n Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol\n Heparin 5000 UNIT SC TID\n Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheezing, SOB\n Lidocaine 5% Patch 1 PTCH TD DAILY\n Morphine Sulfate 2-4 mg IV Q4H:PRN Pain\n Acetaminophen 650 mg PO/NG Q6H:PRN pain/fever\n Miconazole 2% Cream 1 Appl TP \n Sarna Lotion 1 Appl TP QID:PRN itch\n Hydrocortisone Cream 1% 1 Appl TP QID:PRN itch\n Past medical history:\n Family history:\n Social History:\n Cerebral Palsy\n Seizure disorder\n Chronic anemia - Hct 35\n GIB in \n h/o liver cyst drainage (, )\n H/o Laproscopic cholecystectomy\n H/o pancreatic cyst drainage with chronic pancreatitis\n Per OMR, maternal grandmother had DM, paternal grandfather had HTN,\n parents healthy.\n Per OMR, lives at home with family, goes to school 5 days a week, no\n recent travels, no smoke/drink/IVDU.\n Review of systems:\n Unable to obtain.\n Flowsheet Data as of 01:02 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 37.9\nC (100.3\n HR: 133 (123 - 133) bpm\n BP: 87/73(76) {87/71(76) - 90/73(76)} mmHg\n RR: 53 (38 - 53) insp/min\n SpO2: 86%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 292 mL\n PO:\n TF:\n IVF:\n 215 mL\n Blood products:\n Total out:\n 0 mL\n 130 mL\n Urine:\n 130 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 162 mL\n Respiratory\n O2 Delivery Device: Non-rebreather\n SpO2: 86%\n Physical Examination\n VS: T 100.3, BP 90/71, P 123, RR 38, O2sat 91% on 100% NRB\n Gen: Thin, alert but appears uncomfortable, tachypneic with increased\n wob, use of accessory respiratory muscles\n HEENT: Sclera anicteric, eyes sunken, MMM, on NRB mask\n Neck: Supple, thin, EJs prominent and hyperdynamic, no LAD\n Lungs: Bronchial BS at L>R base, upper airways clearer; no wheezes,\n rhonchi, or rales\n CV: Regular but tachycardic, normal S1 + S2, unable to appreciate any\n murmurs, rubs, gallops\n Abdomen: Soft, BS+, distended, pt appears uncomfortable on palpations\n GU: Condom cath in place\n Ext: Warm, cachectic, BLE contractures, + DP pulses, no cyanosis or\n edema\n Neuro: Alert, nonverbal, tracking gaze, moving upper extremities\n purposefully\n Labs / Radiology\n 180\n 9.4\n 123\n 0.6\n 27\n 28\n 105\n 4.9\n 141\n 28.3\n 7.2\n [image002.jpg]\n Bcx pending, Ucx pending\n Portable CXR: L PICC line and NGT tips in place. Diffuse\n airspace opacities at lung bases: fluid overload + atelectasis. L\n retrocardiac opacity and likely left sided pleural effusion. Overall\n unchanged. Also fracture of L proximal humerus at surgical neck.\n Portable abdominal x-ray: Air & stool seen throughout colon;\n unchanged. No free intraabdominal air. Appearance unchanged from prior.\n CT torso:\n 1. Interval resolution of small bowel dilatation, and near interval\n resolution of high density thickening of the descending colon.\n Persistent sigmoid and rectal thickening. Increased abdominal and\n pelvic ascites with some layering high density posteriorly. Stable left\n retroperitoneal bleed and interval resolution of hemorrhage seen\n between the rectum and bladder.\n 2. Small bilateral pleural effusions, increased from the prior exam.\n 3. Stable occlusion of the SMV, with numerous collaterals.\n 4. Dilatation of the ascending aorta and marked calcification of the\n aortic valve for the patient's age. This finding could indicate a\n bicuspid valve.\n Portable TTE:\n Technically limited study; Overall left ventricular systolic function\n is normal (LVEF>55%). Right ventricular chamber size and free wall\n motion are normal. The number of aortic valve leaflets cannot be\n determined. The aortic valve leaflets are moderately thickened. At\n least mild to moderate aortic stenosis is present (but cannot be fully\n quantified). No aortic regurgitation is seen. There is no pericardial\n effusion.\n Assessment and Plan\n 35 yo M with PMH of CP, seizure disorder, GIB, pancreatic cyst s/p\n drainage in , admitted with abdominal pain with complicated course,\n now with new fever, tachypnea, and hypoxia.\n .\n # Respiratory failure: Hypoxic with ABG on floor c/w respiratory\n alkalosis in setting of tachypnea. Given constellation of new fever,\n tachypnea, and significant hypoxia, as well as new opacities on CXR,\n concern for pneumonia - HAP v. aspiration (tube feeds restarted\n yesterday); less likely VAP as was extubated several weeks prior. \n also with a component of pleural effusion to opacities; recent TTE with\n nl EF but labs notable for low albumin. PE is also a concern as pt is\n bedbound; has not had pneumoboots on and just restarted heparin SQ\n yesterday for DVT ppx.\n - NRB for now but may need PPV for support; will check ABG now.\n Ultimately, utility of NIPPV will likely be limited if pneumonia is his\n underlying issue and may need intubation; ok per mother.\n - Continue broad antibiotic coverage for HAP/aspiration PNA with vanc,\n cefepime, metronidazole. Currently not double covering for pseudomonas.\n - Check sputum cx, urine legionella Ag, f/u blood cultures\n - Check EKG for evidence of right heart strain\n - Consider CTA to r/o PE\n .\n # Fever/sepsis: Pt febrile with tachycardia and tachypnea; meets\n definition of sepsis with most likely source being pulmonary. With\n ascites, SBP is also possible although he is now s/p 3 taps which have\n not been c/w SBP. U/A appears clean. MS with no obvious\n nuchal rigidity although exam limited by pt cooperation. Again, PE\n could cause similar sx of fever and respiratory distress.\n - F/u blood and urine cx, sputum cx, urine legionella, C. diff\n - Consider paracentesis\n - Broad abx as above with good gram positive, gram neg, and anaerobic\n coverage\n - Goal CVP 8-12 but no measurements available currently\n will bolus\n for tachycardia, UOP >30cc/h, goal MAP >65, CvO2 >70\n - Pressors not currently indicated; does have PICC in place for central\n access\n - Monitor mental status\n - Check lactate, CvO2\n # Tachycardia: Likely hyperdynamic in setting of fever, infection.\n Volume status appears grossly euvolemic; pt mentating at and\n maintaining urine output. Ddx PE.\n - Tylenol prn fever\n - Abx as above\n - Fluid boluses prn\n # Anemia/bleed: Hct stable. Pt with RP bleed and CT evidence of\n hemorrhage into bowel wall, also gastric varices c/b GIB earlier in\n admission.\n - Trend Hct\n - Guaiac stools\n - Active T&S\n - Switch to pantoprazole 40mg IV bid\n - Continue iron supplement\n # Left humeral fx: Likely d/t trauma sustained during radiology.\n - No surgical indication at this time\n - Pain control with lidoderm patch and morphine prn\n .\n # SMV thrombus: Plan for anticoagulation x 6 months but held in setting\n of recent GI and RP bleed.\n - Continue heparin SQ\n .\n # Seizure disorder: No recent reports of seizures. Caution as certain\n antibiotics may lower seizure threshold.\n - Continue phenobarbitol and phenytoin\n .\n # Cerebral pasy: Stable mental status. Interactive with family but\n nonverbal at .\n ICU Care\n Nutrition: NPO, hold tube feeds\n TPN w/ Lipids - 11:21 AM 45. mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 11:14 AM\n 22 Gauge - 11:15 AM\n Prophylaxis:\n DVT: SQ heparin\n Stress ulcer: IV PPI \n Communication: With family, especially mother\n status: Do not resuscitate, ok to intubate and use pressors. Goals\n of care is to return home\n Disposition: ICU pending clinical improvement.\n"
},
{
"category": "Physician ",
"chartdate": "2115-03-23 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 630603,
"text": "TITLE:\n Chief Complaint: Fever, hypoxia, tachypnea\n HPI: (per Medicine team and most recent transfer accept note): This is\n a 35 y/o M, with a hx of cerebral palsy, seizure disorder, nonverbal at\n . He was initially admitted to an OSH on with abdominal\n pain and distention. CT scan showed diffuse bowel edema, gastric\n varices, ascites and a pancreatic cyst. He was transferred here to the\n SICU team for further management of an acute abdomen. He had a\n diagnostic paracentesis on with WBC , but no growth so thought\n to be inflammatory state. He was started on Vanco/Zosyn/Flagyl for\n suspected peritonitis and ischemic bowel with translocation. On CT, a\n SMV thrombus was noted and heparin was started on . His thrombus was\n likely chronic and secondary to chronic pancreatic inflammation. He was\n transitioned to coumadin. He was then intubated for respiratory\n failure. He was extubated but was then reintubated likely secondary\n to fluid overload. He had had difficultly weaning off the ventilator\n and was transferred to the MICU team for further management. He was\n extubated successfully and then transferred to the floor for further\n management of his abdominal pain. He was changed from heparin to\n lovenox for bridging and coumadin. He started TPN. He did tolerated POs\n for a few days but has intermittent large bowel obstructions and then\n remade NPO. GI has been consulted for a possible PEG tube. He completed\n a 14 d course of vanco and was continued on cipro/flagyl for his\n initial peritonitis.\n .\n He was again transferred to the MICU for hypotension and coffee ground\n emesis. The patient had been on the floor being treated for\n intermittent small and large bowel obstructions when blood was found in\n his NGT. Several hours later, he was found to have coffee ground\n emesis. Lovenox and coumadin were discontinued at that time and vitamin\n K was given. On , he went for CT abdomen showing colonic wall\n thickening with RP hematoma and microperforation. He was hypotensive\n requiring pressors. The RP bleed was in the setting of anticoagulation\n on for SMV thrombus and anticoagulation was held. Cipro/flagyl for\n colitis/microperforation was stopped, and vanco was discontinued after\n blood cultures were finalized.\n .\n Pt was transferred back to the floor, and his Hct has remained stable.\n However, he has continued to have low grade fevers in the 100s and\n tachycardia to the 120s. ID work-up of this included a paracentesis on\n which was not c/w SBP (one dose of ceftriaxone given) and a\n negative CT torso on . He was found to have a left humeral\n fracture. Pt appeared to be clinically improving yesterday, and his NG\n tube feeds were restarted. However, at 4 AM, he spiked a fever to\n 101.9. He had increased work of breathing and at 8am had recorded\n tachypnea with RR in the 40s, O2 sats 84% on 2L ( high 90s on\n 2L), tachycardia to 140s ( 120s for past few days), and SBP\n high 80s-low 90s ( low 90s-100s). He was increased to 6L NC\n without improvement so was started on a 100% NRB with ABG 7.52/34/64.\n CXR showed new left lower lobe infiltrate. Portable abdomen without\n dilated bowel loops. VS at time of MICU floor evaluation were: T 99,\n BP 88/66, P 134, RR 32, O2sat 100% on NRB. Pt was started on broad\n antibiotic coverage for HAP/aspiration PNA with vancomycin, cefepime,\n and metronidazole and transferred to the MICU. Access with\n double-lumen PICC and 22g PIV.\n .\n In the unit, mother reports that pt's mental status is at .\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 11:22 AM\n Cefipime - 12:37 PM\n Other medications (on transfer):\n Vancomycin 750 mg IV Q 12H\n CefePIME 2 g IV Q12H\n MetRONIDAZOLE (FLagyl) 500 mg IV Q8H\n Lansoprazole Oral Disintegrating Tab 30mg PO/NG DAILY\n Pancrelipase 5000 2 CAP PO TID\n PHENObarbital 30 mg IV Q12H\n Fosphenytoin 100 mg PE IV Q8H\n Ferrous Sulfate 300 mg PO/NG DAILY\n Insulin SC SS\n Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol\n Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol\n Heparin 5000 UNIT SC TID\n Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheezing, SOB\n Lidocaine 5% Patch 1 PTCH TD DAILY\n Morphine Sulfate 2-4 mg IV Q4H:PRN Pain\n Acetaminophen 650 mg PO/NG Q6H:PRN pain/fever\n Miconazole 2% Cream 1 Appl TP \n Sarna Lotion 1 Appl TP QID:PRN itch\n Hydrocortisone Cream 1% 1 Appl TP QID:PRN itch\n Past medical history:\n Family history:\n Social History:\n Cerebral Palsy\n Seizure disorder\n Chronic anemia - Hct 35\n GIB in \n h/o liver cyst drainage (, )\n H/o Laproscopic cholecystectomy\n H/o pancreatic cyst drainage with chronic pancreatitis\n Per OMR, maternal grandmother had DM, paternal grandfather had HTN,\n parents healthy.\n Per OMR, lives at home with family, goes to school 5 days a week, no\n recent travels, no smoke/drink/IVDU.\n Review of systems:\n Unable to obtain.\n Flowsheet Data as of 01:02 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 37.9\nC (100.3\n HR: 133 (123 - 133) bpm\n BP: 87/73(76) {87/71(76) - 90/73(76)} mmHg\n RR: 53 (38 - 53) insp/min\n SpO2: 86%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 292 mL\n PO:\n TF:\n IVF:\n 215 mL\n Blood products:\n Total out:\n 0 mL\n 130 mL\n Urine:\n 130 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 162 mL\n Respiratory\n O2 Delivery Device: Non-rebreather\n SpO2: 86%\n Physical Examination\n VS: T 100.3, BP 90/71, P 123, RR 38, O2sat 91% on 100% NRB\n Gen: Thin, alert but appears uncomfortable, tachypneic with increased\n wob, use of accessory respiratory muscles\n HEENT: Sclera anicteric, eyes sunken, MMM, on NRB mask\n Neck: Supple, thin, EJs prominent and hyperdynamic, no LAD\n Lungs: Bronchial BS at L>R base, upper airways clearer; no wheezes,\n rhonchi, or rales\n CV: Regular but tachycardic, normal S1 + S2, unable to appreciate any\n murmurs, rubs, gallops\n Abdomen: Soft, BS+, distended, pt appears uncomfortable on palpations\n GU: Condom cath in place\n Ext: Warm, cachectic, BLE contractures, + DP pulses, no cyanosis or\n edema\n Neuro: Alert, nonverbal, tracking gaze, moving upper extremities\n purposefully\n Labs / Radiology\n 180\n 9.4\n 123\n 0.6\n 27\n 28\n 105\n 4.9\n 141\n 28.3\n 7.2\n [image002.jpg]\n Bcx pending, Ucx pending\n Portable CXR: L PICC line and NGT tips in place. Diffuse\n airspace opacities at lung bases: fluid overload + atelectasis. L\n retrocardiac opacity and likely left sided pleural effusion. Overall\n unchanged. Also fracture of L proximal humerus at surgical neck.\n Portable abdominal x-ray: Air & stool seen throughout colon;\n unchanged. No free intraabdominal air. Appearance unchanged from prior.\n CT torso:\n 1. Interval resolution of small bowel dilatation, and near interval\n resolution of high density thickening of the descending colon.\n Persistent sigmoid and rectal thickening. Increased abdominal and\n pelvic ascites with some layering high density posteriorly. Stable left\n retroperitoneal bleed and interval resolution of hemorrhage seen\n between the rectum and bladder.\n 2. Small bilateral pleural effusions, increased from the prior exam.\n 3. Stable occlusion of the SMV, with numerous collaterals.\n 4. Dilatation of the ascending aorta and marked calcification of the\n aortic valve for the patient's age. This finding could indicate a\n bicuspid valve.\n Portable TTE:\n Technically limited study; Overall left ventricular systolic function\n is normal (LVEF>55%). Right ventricular chamber size and free wall\n motion are normal. The number of aortic valve leaflets cannot be\n determined. The aortic valve leaflets are moderately thickened. At\n least mild to moderate aortic stenosis is present (but cannot be fully\n quantified). No aortic regurgitation is seen. There is no pericardial\n effusion.\n Assessment and Plan\n 35 yo M with PMH of CP, seizure disorder, GIB, pancreatic cyst s/p\n drainage in , admitted with abdominal pain with complicated course,\n now with new fever, tachypnea, and hypoxia.\n .\n # Respiratory failure: Hypoxic with ABG on floor c/w respiratory\n alkalosis in setting of tachypnea. Given constellation of new fever,\n tachypnea, and significant hypoxia, as well as new opacities on CXR,\n concern for pneumonia - HAP v. aspiration (tube feeds restarted\n yesterday); less likely VAP as was extubated several weeks prior. \n also with a component of pleural effusion to opacities; recent TTE with\n nl EF but labs notable for low albumin. PE is also a concern as pt is\n bedbound; has not had pneumoboots on and just restarted heparin SQ\n yesterday for DVT ppx.\n - NRB for now but may need PPV for support; will check ABG now.\n Ultimately, utility of NIPPV will likely be limited if pneumonia is his\n underlying issue and may need intubation; ok per mother.\n - Continue broad antibiotic coverage for HAP/aspiration PNA with vanc,\n cefepime, metronidazole. Currently not double covering for pseudomonas.\n - Check sputum cx, urine legionella Ag, f/u blood cultures\n - Check EKG for evidence of right heart strain\n - Consider CTA to r/o PE\n .\n # Fever/sepsis: Pt febrile with tachycardia and tachypnea; meets\n definition of sepsis with most likely source being pulmonary. With\n ascites, SBP is also possible although he is now s/p 3 taps which have\n not been c/w SBP. U/A appears clean. MS with no obvious\n nuchal rigidity although exam limited by pt cooperation. Again, PE\n could cause similar sx of fever and respiratory distress.\n - F/u blood and urine cx, sputum cx, urine legionella, C. diff\n - Consider paracentesis\n - Broad abx as above with good gram positive, gram neg, and anaerobic\n coverage\n - Goal CVP 8-12 but no measurements available currently\n will bolus\n for tachycardia, UOP >30cc/h, goal MAP >65, CvO2 >70\n - Pressors not currently indicated; does have PICC in place for central\n access\n - Monitor mental status\n - Check lactate, CvO2\n # Tachycardia: Likely hyperdynamic in setting of fever, infection.\n Volume status appears grossly euvolemic; pt mentating at and\n maintaining urine output. Ddx PE.\n - Tylenol prn fever\n - Abx as above\n - Fluid boluses prn\n # Anemia/bleed: Hct stable. Pt with RP bleed and CT evidence of\n hemorrhage into bowel wall, also gastric varices c/b GIB earlier in\n admission.\n - Trend Hct\n - Guaiac stools\n - Active T&S\n - Switch to pantoprazole 40mg IV bid\n - Continue iron supplement\n # Left humeral fx: Likely d/t trauma sustained during radiology.\n - No surgical indication at this time\n - Pain control with lidoderm patch and morphine prn\n .\n # SMV thrombus: Plan for anticoagulation x 6 months but held in setting\n of recent GI and RP bleed.\n - Continue heparin SQ\n .\n # Seizure disorder: No recent reports of seizures. Caution as certain\n antibiotics may lower seizure threshold.\n - Continue phenobarbitol and phenytoin\n .\n # Cerebral pasy: Stable mental status. Interactive with family but\n nonverbal at .\n ICU Care\n Nutrition: NPO, hold tube feeds\n TPN w/ Lipids - 11:21 AM 45. mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 11:14 AM\n 22 Gauge - 11:15 AM\n Prophylaxis:\n DVT: SQ heparin\n Stress ulcer: IV PPI \n Communication: With family, especially mother\n status: Do not resuscitate, ok to intubate and use pressors. Goals\n of care is to return home\n Disposition: ICU pending clinical improvement.\n ------ Protected Section ------\n Chart reviewed, patient examined, case discussed in detail with the\n house officer team. I was present for all key aspects of care delivery\n and my thoughts are reflected in Dr. \ns note above. In addition,\n I would add/emphasize:\n 35M with h/o cerebral palsy (nonverbal at ), seizure disorder\n with long, complex hospitalization detail above including three ICU\n stays and multiple intubations represents to the ICU from the floor\n where he was found to be increasingly hypoxemic and tachycardic 130s\n since early this morning. At the time of MICU evaluation on the floor\n he was requiring a NRB for adequate oxygenation. His blood pressure is\n at the low end of his usual range (high 80s systolic).\n On exam:\n Tcurrent: 37.9\nC (100.3\n HR: 133 (123 - 133) bpm\n BP: 87/73(76) {87/71(76) - 90/73(76)} mmHg\n RR: 33\n SpO2: 96% NRB\n Awake, alert but nonverbal mask ventilation in place\n Lungs\n clear anteriorly\n CV\n tachy , 2/6 SEM\n Abd\n soft NT BS+\n WBC 7.2, Hct 28.3, creat 0.6\n CXR Left mid-lower lung field haziness\n Hypoxemic respiratory failure:\n -hypoxemia with respiratory alkalosis\n -fever (though no leukocytosis), infiltrate, tachypnea make pneumonia\n likely etiology\n -HAP vs. aspiration\n given clear left sided more likely HAP\n -broad abx coverage for HAP\n -mask ventilation has been initiated but no clearly rapidly reversible\n cause identified so likely will require intubation. Follow clinical\n course, abg, signs of tiring closely. If any worsen or failure to\n improve by late afternoon would electively intubate to facilitate\n optimal care\n -scx, gs, bx\n Tachycardia\n -fever and SIRS\n -fluid boluses as likely intravascularly dry\n -currently maintaining bp within pt\ns usual range, no signs of\n perfusion issues at present, lactate not elevated.\n Anemia/bleed:\n -h/o rp bleed, varices so follow hct trend closely\n - Guaiac stools\n SMV thrombus:\n Seizure disorder:\n -no sz activity No\n - Continue phenobarbitol and phenytoin\n Cerebral palsy:\n Remainder of plan as noted above.\n Pt is critically ill. Time spent on care: 50minutes.\n ------ Protected Section Addendum Entered By: , MD\n on: 15:40 ------\n"
},
{
"category": "Nutrition",
"chartdate": "2115-03-25 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 630938,
"text": "Subjective\n Intub/sedated\n Objective\n Pertinent medications: PHENObarbital, Fosphenytoin, Ferrous Sulfate,\n Pancrelipase , Heparin, ABX, RISS, Fentanyl Citrate, Midazolam, others\n noted\n Labs:\n Value\n Date\n Glucose\n 141 mg/dL\n 02:57 AM\n Glucose Finger Stick\n 174\n 10:00 AM\n BUN\n 23 mg/dL\n 02:57 AM\n Creatinine\n 0.6 mg/dL\n 02:57 AM\n Sodium\n 138 mEq/L\n 02:57 AM\n Potassium\n 4.1 mEq/L\n 02:57 AM\n Chloride\n 106 mEq/L\n 02:57 AM\n TCO2\n 26 mEq/L\n 02:57 AM\n PO2 (arterial)\n 105 mm Hg\n 12:25 PM\n PO2 (venous)\n 102 mm Hg\n 02:04 PM\n PCO2 (arterial)\n 45 mm Hg\n 12:25 PM\n PCO2 (venous)\n 47 mm Hg\n 02:04 PM\n pH (arterial)\n 7.38 units\n 12:25 PM\n pH (venous)\n 7.33 units\n 02:04 PM\n pH (urine)\n 5.0 units\n 05:08 AM\n CO2 (Calc) arterial\n 28 mEq/L\n 12:25 PM\n CO2 (Calc) venous\n 26 mEq/L\n 02:04 PM\n Albumin\n 2.6 g/dL\n 01:45 AM\n Calcium non-ionized\n 7.8 mg/dL\n 02:57 AM\n Phosphorus\n 3.5 mg/dL\n 02:57 AM\n Magnesium\n 2.0 mg/dL\n 02:57 AM\n ALT\n 29 IU/L\n 01:45 AM\n Alkaline Phosphate\n 105 IU/L\n 01:45 AM\n AST\n 31 IU/L\n 01:45 AM\n Total Bilirubin\n 0.5 mg/dL\n 01:45 AM\n Phenytoin (Dilantin)\n 9.7 ug/mL\n 02:57 AM\n WBC\n 5.8 K/uL\n 02:57 AM\n Hgb\n 8.3 g/dL\n 02:57 AM\n Hematocrit\n 24.7 %\n 02:57 AM\n Current diet order / nutrition support: Goal TPN 1.1L (200g\n dextose/50protein/22g fat)\n GI: Abd: distended, firm, poor bowel sounds, positive ascites\n Assessment of Nutritional Status\n 35 year old man with prolonged hospital course readmitted to MICU due\n to tachy/hypoxia, intubated yesterday. CT showed pneumonia and\n atelectasis, possible liver abscess on liver, may need IR drainage.\n Patient on TPN for full nutrition support, tolerating without issue,\n current TPN providing 1100kcal/50g protein, meeting 100% of patient\n estimated needs.\n Noted abdomen remains distended, team consider NG to suction, if ever\n plan to restart tube feed, consider change tube feed to elemental\n formula.\n Medical Nutrition Therapy Plan - Recommend the Following\n TPN recommendations: goal as ordered ( daily recommendation\n to be entered in POE)\n Check chemistry 10 panel daily\n Continue regular insulin sliding scale if serum glucose\n greater than 150 mg/dL\n Once ready to start tube feed: trial Vivonex TEN 10ml/hr adv\n as tol to goal 50ml/hr (1200kcal/46g protein)\n Other: \n 01:51 PM\n"
},
{
"category": "Physician ",
"chartdate": "2115-03-23 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 630587,
"text": "TITLE:\n Chief Complaint: Fever, hypoxia, tachypnea\n HPI: (per Medicine team and most recent transfer accept note): This is\n a 35 y/o M, with a hx of cerebral palsy, seizure disorder, nonverbal at\n . He was initially admitted to an OSH on with abdominal\n pain and distention. CT scan showed diffuse bowel edema, gastric\n varices, ascites and a pancreatic cyst. He was transferred here to the\n SICU team for further management of an acute abdomen. He had a\n diagnostic paracentesis on with WBC , but no growth so thought\n to be inflammatory state. He was started on Vanco/Zosyn/Flagyl for\n suspected peritonitis and ischemic bowel with translocation. On CT, a\n SMV thrombus was noted and heparin was started on . His thrombus was\n likely chronic and secondary to chronic pancreatic inflammation. He was\n transitioned to coumadin. He was then intubated for respiratory\n failure. He was extubated but was then reintubated likely secondary\n to fluid overload. He had had difficultly weaning off the ventilator\n and was transferred to the MICU team for further management. He was\n extubated successfully and then transferred to the floor for futher\n management of his abdominal pain. He was changed from heparin to\n lovenox for bridging and coumadin. He started TPN. He did tolerated POs\n for a few days but has intermittent large bowel obstuctions and then\n remade NPO. GI has been consulted for a possible PEG tube. He completed\n a 14 d course of vanco and was continued on cipro/flagyl for his\n initial peritonitis.\n .\n He was again transferred to the MICU for hypotension and coffee ground\n emesis. The patient had been on the floor being treated for\n intermittent small and large bowel obstructions when blood was found in\n his NGT. Several hours later, he was found to have coffee ground\n emesis. Lovenox and coumadin were discontinued at that time and vitamin\n K was given. On , he went for CT abdomen showing colonic wall\n thickening with RP hematoma and microperforation. He was hypotensive\n requiring pressors. The RP bleed was in the setting of anticoagulation\n on for SMV thrombus and anticoagulation was held. Cipro/flagyl for\n colitis/microperforation was stopped, and vanco was discontinued after\n blood cultures were finalized.\n .\n Pt was transferred back to the floor, and his Hct has remained stable.\n However, he has continued to have low grade fevers in the 100s and\n tachycardia to the 120s. ID work-up of this included a paracentesis on\n which was not c/w SBP (one dose of ceftriaxone given) and a\n negative CT torso on . He was found to have a left humeral\n fracture. Pt appeared to be clinically improving yesterday, and his NG\n tube feeds were restarted. However, at 4 AM, he spiked a fever to\n 101.9. He had increased work of breathing and at 8am had recorded\n tachypnea with RR in the 40s, O2 sats 84% on 2L ( high 90s on\n 2L), tachycadria to 140s ( 120s for past few days), and SBP\n high 80s-low 90s ( low 90s-100s). He was increased to 6L NC\n without improvement so was started on a 100% NRB with ABG 7.52/34/64.\n CXR showed new left lower lobe infiltrate. Portable abdomen without\n dilated bowel loops. VS at time of MICU floor evaluation were: T 99,\n BP 88/66, P 134, RR 32, O2sat 100% on NRB. Pt was started on broad\n antibiotic coverage for HCAP/aspiration PNA with vancomycin, cefepime,\n and metronidazole and transferred to the MICU. Access with\n double-lumen PICC and 22g PIV.\n .\n In the unit, mother reports that pt's mental status is at .\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 11:22 AM\n Cefipime - 12:37 PM\n Other medications (on transfer):\n Vancomycin 750 mg IV Q 12H\n CefePIME 2 g IV Q12H\n MetRONIDAZOLE (FLagyl) 500 mg IV Q8H\n Lansoprazole Oral Disintegrating Tab 30mg PO/NG DAILY\n Pancrelipase 5000 2 CAP PO TID\n PHENObarbital 30 mg IV Q12H\n Fosphenytoin 100 mg PE IV Q8H\n Ferrous Sulfate 300 mg PO/NG DAILY\n Insulin SC SS\n Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol\n Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol\n Heparin 5000 UNIT SC TID\n Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheezing, SOB\n Lidocaine 5% Patch 1 PTCH TD DAILY\n Morphine Sulfate 2-4 mg IV Q4H:PRN Pain\n Acetaminophen 650 mg PO/NG Q6H:PRN pain/fever\n Miconazole 2% Cream 1 Appl TP \n Sarna Lotion 1 Appl TP QID:PRN itch\n Hydrocortisone Cream 1% 1 Appl TP QID:PRN itch\n Past medical history:\n Family history:\n Social History:\n Cerebral Palsy\n Seizure disorder\n Chronic anemia - Hct 35\n GIB in \n h/o liver cyst drainage (, )\n H/o Laproscopic cholecystectomy\n H/o pancreatic cyst drainage with chronic pancreatitis\n Per OMR, maternal grandmother had DM, paternal grandfather had HTN,\n parents healthy.\n Per OMR, lives at home with family, goes to school 5 days a week, no\n recent travels, no smoke/drink/IVDU.\n Review of systems:\n Unable to obtain.\n Flowsheet Data as of 01:02 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 37.9\nC (100.3\n HR: 133 (123 - 133) bpm\n BP: 87/73(76) {87/71(76) - 90/73(76)} mmHg\n RR: 53 (38 - 53) insp/min\n SpO2: 86%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 292 mL\n PO:\n TF:\n IVF:\n 215 mL\n Blood products:\n Total out:\n 0 mL\n 130 mL\n Urine:\n 130 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 162 mL\n Respiratory\n O2 Delivery Device: Non-rebreather\n SpO2: 86%\n Physical Examination\n VS: T 100.3, BP 90/71, P 123, RR 38, O2sat 91% on 100% NRB\n Gen: Thin, alert but appears uncomfortable, tachypneic with increased\n wob, use of accessory respiratory muscles\n HEENT: Sclera anicteric, eyes sunken, MMM, on NRB mask\n Neck: Supple, thin, EJs prominent and hyperdynamic, no LAD\n Lungs: Bronchial BS at L>R base, upper airways clearer; no wheezes,\n rhonchi, or rales\n CV: Regular but tachycardic, normal S1 + S2, unable to appreciate any\n murmurs, rubs, gallops\n Abdomen: Soft, BS+, distended, pt appears uncomfortable on palpations\n GU: Condom cath in place\n Ext: Warm, cachectic, BLE contractures, + DP pulses, no cyanosis or\n edema\n Neuro: Alert, nonverbal, tracking gaze, moving upper extremities\n purposefully\n Labs / Radiology\n 180\n 9.4\n 123\n 0.6\n 27\n 28\n 105\n 4.9\n 141\n 28.3\n 7.2\n [image002.jpg]\n Assessment and Plan\n 35 yo M with PMH of CP, seizure disorder, GIB, pancreatic cyst s/p\n drainage in , admitted with abdominal pain with complicated course,\n now with new fever, tachypnea, and hypoxia.\n .\n # Respiratory failure: Hypoxic with ABG on floor c/w respiratory\n alkalosis in setting of tachypnea. Given constellation of new fever,\n tachypnea, and significant hypoxia, as well as new opacities on CXR,\n concern for pneumonia - HAP v. aspiration (tube feeds restarted\n yesterday); less likely VAP as was extubated several weeks prior.\n Likely also with a component of pleural effusion to opacities; recent\n TTE with nl EF but labs notable for low albumin. PE is also a concern\n as pt is bedbound; has not had pneumoboots on and just restarted\n heparin SQ yesterday for DVT ppx.\n - NRB for respiratory support for now but may need NIPPV for support if\n tachypnea persists; will check ABG now. Ultimately, NIPPV may be\n limited by secretions or mental status and may need intubation; ok per\n mother.\n - Broad antibiotic coverage for HAP/aspiration PNA with vanc, cefepime,\n metronidazole\n - Check sputum cx, urine legionella Ag, f/u blood cultures\n - Goal fluid balance even\n - Check EKG for evidence of right heart strain\n - Consider CTA to r/o PE\n .\n # Fever/sepsis: Pt febrile with tachycardia and tachypnea; meets\n definition of sepsis with most likely source being pulmonary. With\n ascites, SBP is also possible although he is now s/p 3 taps which have\n not been c/w SBP. U/A appears clean. MS with no obvious\n nuchal rigidity although exam limited by pt cooperation. Again, PE\n could cause similar sx of fever and respiratory distress.\n - F/u blood and urine cx, sputum cx, urine legionella, C. diff\n - Consider paracentesis\n - Broad abx as above with good gram positive, gram neg, and anaerobic\n coverage\n - Maintain CVP 8-12, MAP >65, CvO2 >70, UOP >30 cc/h\n - Monitor mental status\n - Check lactate\n .\n # Tachycardia: Likely hyperdynamic in setting of fever, infection.\n Volume status appears grossly euvolemic; pt mentating at and\n maintaining urine output. Ddx PE.\n - Tylenol prn fever\n - Abx as above\n - Fluid boluses prn\n .\n # Anemia/bleed: Hct stable. Pt with RP bleed and CT evidence of\n hemorrhage into bowel wall, also gastric varices c/b GIB earlier in\n admission.\n - Trend Hct\n - Guaiac stools\n - Active T&S\n - Continue lansoprazole 30mg daily\n - Continue iron supplement\n .\n # Left humeral fx: Likely d/t trauma sustained during radiology.\n - No surgical indication at this time\n - Pain control with lidoderm patch and morphine\n .\n # SMV thrombus: Plan for anticoagulation x 6 months but held in setting\n of recent GI and RP bleed.\n - Continue heparin SQ\n .\n # Seizure disorder: No recent reports of seizures. Caution as certain\n antibiotics may lower seizure threshold.\n - Continue phenobarbitol and phenytoin\n .\n # Cerebral pasy: Stable mental status. Interactive with family but\n nonverbal at .\n .\n # FEN: NPO, hold tube feeds, TPN\n # Access: R 22g PIV, L PICC\n # Ppx: PPI , SQ heparin\n # Communication: With family, especially mother.\n # Code: Do not resuscitate, ok to intubate and use pressors. Goals of\n care is to return home.\n # Dispo: ICU pending clinical improvement.\n ICU Care\n Nutrition:\n TPN w/ Lipids - 11:21 AM 45. mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 11:14 AM\n 22 Gauge - 11:15 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 630660,
"text": "Pt was transferred back to the floor, and his Hct has remained stable.\n However, he has continued to have low grade fevers in the 100s and\n tachycardia to the 120s. ID work-up of this included a paracentesis on\n which was not c/w SBP (one dose of ceftriaxone given) and a\n negative CT torso on . He was found to have a left humeral\n fracture. Pt appeared to be clinically improving yesterday, and his NG\n tube feeds were restarted. However, at 4 AM, he spiked a fever to\n 101.9. He had increased work of breathing and at 8am had recorded\n tachypnea with RR in the 40s, O2 sats 84% on 2L (baseline high 90s on\n 2L), tachycardia to 140s (baseline 120s for past few days), and SBP\n high 80s-low 90s (baseline low 90s-100s). He was increased to 6L NC\n without improvement so was started on a 100% NRB with ABG 7.52/34/64.\n CXR showed new left lower lobe infiltrate. Portable abdomen without\n dilated bowel loops. VS at time of MICU floor evaluation were: T 99,\n BP 88/66, P 134, RR 32, O2sat 100% on NRB. Pt was started on broad\n antibiotic coverage for HAP/aspiration PNA with vancomycin, cefepime,\n and metronidazole and transferred to the MICU. Access with\n double-lumen PICC and 22g PIV.\n .\n In the unit, mother reports that pt's mental status is at baseline\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 630662,
"text": "Pt was transferred back to the floor, and his Hct has remained stable.\n However, he has continued to have low grade fevers in the 100s and\n tachycardia to the 120s. ID work-up of this included a paracentesis on\n which was not c/w SBP (one dose of ceftriaxone given) and a\n negative CT torso on . He was found to have a left humeral\n fracture. Pt appeared to be clinically improving yesterday, and his NG\n tube feeds were restarted. However, at 4 AM, he spiked a fever to\n 101.9. He had increased work of breathing and at 8am had recorded\n tachypnea with RR in the 40s, O2 sats 84% on 2L (baseline high 90s on\n 2L), tachycardia to 140s (baseline 120s for past few days), and SBP\n high 80s-low 90s (baseline low 90s-100s). He was increased to 6L NC\n without improvement so was started on a 100% NRB with ABG 7.52/34/64.\n CXR showed new left lower lobe infiltrate. Portable abdomen without\n dilated bowel loops. VS at time of MICU floor evaluation were: T 99,\n BP 88/66, P 134, RR 32, O2sat 100% on NRB. Pt was started on broad\n antibiotic coverage for HAP/aspiration PNA with vancomycin, cefepime,\n and metronidazole and transferred to the MICU. Access with\n double-lumen PICC and 22g PIV.\n .\n In the unit, mother reports that pt's mental status is at baseline\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Respiratory ",
"chartdate": "2115-03-30 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 631949,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 7\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 6.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: RSBI-125, on 8/0 while pt was awake\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Underlying illness not resolved\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 630996,
"text": "35 yo man who has been in hospital some time, with cerebral palsy, non\n verbal. admitted in with acute abdomen, peritonitis, chronic\n pancreatitits. Found to have SMV thrombus, anticoagulated, then\n developed retoperitoneal hemorrhage. Was on floor readmitted with\n progressive hypoxemia, intubated. Had CT with ? of liver abscess.\n CTA with LLL and RLL PNA and atelectasis, and effusions.\n UPDATE:\n Abdomen firm/distended. Pt w/ h/o ascites. CT showing some ascites,\n but more bowel gas. Monitor abdomen. NGT to Low Intermittent sxn.\n Plan for U/S of abdomen/Liver (Liver nodule- ?liver abcess vs lesion)\n on .\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Pt had slight HCT drop this am => 24.8.\n Action:\n HCT rechecked. Monitored for s/s of bleeding. Given Pantoprazole and\n ferrous sulfate.\n Response:\n HCT now 23.8. ICU team aware.\n Plan:\n Trend HCT, guaic stools, Pt w/ an active T&S (outdates ).\n Tachycardia, Other\n Assessment:\n HR 100s-120s, ST, no ectopy. SBP 80s-100s/60s-70s, ABP\n 80s-90s/50s-60s. Temp max 102.3 orally. Pt grimaces to pain w/\n turning and repositioning- pt w/ Lt UE fx (not in sling as pt not\n tolerating) Assumed pt on 30mcg of fent and 1mg of versed.\n Action:\n Given 650mg Po tyelenol, given 0.5mg versed x 1.\n Response:\n Temp now 100.6 orally. HR cont in the 100s-120s, ST. ABP in the\n 70s-80s following versed , .\n Plan:\n Monitor temp curve, f/u on cultures, tyelenol prn, cautiously\n prn.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Assumed on CMV 40%/20/300/10+. LS clear to rhonchorous throughout.\n Deep sxn\nd for small to moderate thick/yellow secretions. RR 20s at\n rest and 40s-50s w/ stimulation/repositioning and turning.\n Action:\n Sputum cx sent, antibiotics given. Place on PS 18/10+/40%.\n Response:\n ABG7.38/45/105/28 , O2 sats 95s-100%. RR 20s. LSCTA to b/l apices,\n diminished to b/l bases.\n Plan:\n Cont to wean vent as able, cont antibiotics\n ------ Protected Section ------\n AT approx 1800, pt became unresponsive, BP in the 70s/30s, HR 100-110,\n ST. Period of apnea for approx 10-15 seconds. RT placed pt on AC.\n Currently back on PS of 18/40%/10+- RR in the 20s, O2 sats of 100%.\n Fent and versed gtts turned off. ICU team notified. ? seizure\n activity. Given a 500cc NS and started on levophed gtt.\n Currently @ 0.08mcg. HCT being drawn. BP now in the low 80s w/ maps\n in the 70s, HR in the 1-teens.\n ------ Protected Section Addendum Entered By: , RN\n on: 18:51 ------\n"
},
{
"category": "Physician ",
"chartdate": "2115-03-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 630727,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n PICC LINE - START 11:14 AM\n dual lumen\n Patient maintained on CPAP during the day with stable ABG, weaned FIO2\n from 100 to 60%, then transitioned for 2hr period to high flow\n facemask, but then increasing RR so put back on CPAP 60%\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 01:12 PM\n Cefipime - 11:22 PM\n Metronidazole - 02:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 09:03 PM\n Other medications:\n Changes to medical and family history:\n Unchanged\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Unable to obtain\n Flowsheet Data as of 06:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 37.1\nC (98.8\n HR: 123 (118 - 133) bpm\n BP: 87/64(67) {80/57(63) - 101/79(82)} mmHg\n RR: 32 (14 - 53) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 2,604 mL\n 1,234 mL\n PO:\n TF:\n IVF:\n 2,025 mL\n 919 mL\n Blood products:\n Total out:\n 590 mL\n 1,150 mL\n Urine:\n 590 mL\n 450 mL\n NG:\n 700 mL\n Stool:\n Drains:\n Balance:\n 2,014 mL\n 84 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n Ventilator mode: Standby\n Vt (Spontaneous): 687 (320 - 710) mL\n PS : 18 cmH2O\n RR (Set): 35\n RR (Spontaneous): 25\n PEEP: 4 cmH2O\n FiO2: 100%\n PIP: 23 cmH2O\n SpO2: 96%\n ABG: ///28/\n Ve: 13 L/min\n Physical Examination\n Gen: Thin, alert but appears uncomfortable, tachypneic with increased\n wob, use of accessory respiratory muscles\n HEENT: Sclera anicteric, eyes sunken, MMM, on NRB mask\n Neck: Supple, thin, EJs prominent and hyperdynamic, no LAD\n Lungs: Bronchial BS at L>R base, upper airways clearer; no wheezes,\n rhonchi, or rales\n CV: Regular but tachycardic, normal S1 + S2, unable to appreciate any\n murmurs, rubs, gallops\n Abdomen: Soft, BS+, distended, pt appears uncomfortable on palpations\n GU: Condom cath in place\n Ext: Warm, cachectic, BLE contractures, + DP pulses, no cyanosis or\n edema\n Neuro: Alert, nonverbal, tracking gaze, moving upper extremities\n purposefully\n Labs / Radiology\n 168 K/uL\n 8.8 g/dL\n 133 mg/dL\n 0.6 mg/dL\n 28 mEq/L\n 4.4 mEq/L\n 24 mg/dL\n 107 mEq/L\n 141 mEq/L\n 26.3 %\n 6.8 K/uL\n [image002.jpg]\n 03:16 PM\n 03:47 PM\n 01:45 AM\n WBC\n 6.8\n Hct\n 29\n 26.3\n Plt\n 168\n Cr\n 0.6\n 0.6\n Glucose\n 118\n 133\n Other labs: Lactic Acid:0.8 mmol/L, Ca++:7.6 mg/dL, Mg++:2.1 mg/dL,\n PO4:3.4 mg/dL\n Assessment and Plan\n 35 yo M with PMH of CP, seizure disorder, GIB, pancreatic cyst s/p\n drainage in , admitted with abdominal pain with complicated course,\n now with new fever, tachypnea, and hypoxia.\n .\n # Respiratory failure: Hypoxic with ABG on floor c/w respiratory\n alkalosis in setting of tachypnea. Given constellation of new fever,\n tachypnea, and significant hypoxia, as well as new opacities on CXR,\n concern for pneumonia - HAP v. aspiration (tube feeds restarted\n yesterday); less likely VAP as was extubated several weeks prior. \n also with a component of pleural effusion to opacities; recent TTE with\n nl EF but labs notable for low albumin. PE is also a concern as pt is\n bedbound; has not had pneumoboots on and just restarted heparin SQ\n yesterday for DVT ppx.\n - Patient continues on CPAP. Ultimately, utility of NIPPV will likely\n be limited if pneumonia is his underlying issue and may need\n intubation; ok per mother.\n - Continue broad antibiotic coverage for HAP/aspiration PNA with vanc,\n cefepime, metronidazole. Currently not double covering for pseudomonas.\n - f/u sputum cx, f/u blood cultures\n .\n # Fever/sepsis: Pt febrile with tachycardia and tachypnea; meets\n definition of sepsis with most likely source being pulmonary. With\n ascites, SBP is also possible although he is now s/p 3 taps which have\n not been c/w SBP. U/A appears clean. MS with no obvious\n nuchal rigidity although exam limited by pt cooperation. Again, PE\n could cause similar sx of fever and respiratory distress.\n - F/u blood and urine cx, sputum cx, C. diff\n - Consider paracentesis\n - Broad abx as above with good gram positive, gram neg, and anaerobic\n coverage\n - Goal CVP 8-12 but no measurements available currently\n will bolus\n for tachycardia, UOP < 30cc/h, goal MAP >65, CvO2 >70\n - Pressors not currently indicated; does have PICC in place for central\n access\n - Monitor mental status\n # Tachycardia: Likely hyperdynamic in setting of fever, infection.\n Volume status appears grossly euvolemic; pt mentating at and\n maintaining urine output. Ddx PE.\n - Tylenol prn fever\n - Abx as above\n - Fluid boluses prn\n # Anemia/bleed: Hct stable. Pt with RP bleed and CT evidence of\n hemorrhage into bowel wall, also gastric varices c/b GIB earlier in\n admission.\n - Trend Hct\n - Guaiac stools\n - Active T&S\n - continue pantoprazole 40mg IV bid\n - Continue iron supplement\n # Left humeral fx: Likely d/t trauma sustained during radiology.\n - No surgical indication at this time\n - Pain control with lidoderm patch and morphine prn\n .\n # SMV thrombus: Plan for anticoagulation x 6 months but held in setting\n of recent GI and RP bleed.\n - Continue heparin SQ\n .\n # Seizure disorder: No recent reports of seizures. Caution as certain\n antibiotics may lower seizure threshold.\n - Continue phenobarbitol and phenytoin\n .\n # Cerebral pasy: Stable mental status. Interactive with family but\n nonverbal at .\n ICU Care\n Nutrition: NPO, hold tube feeds\n TPN w/ Lipids - 11:21 AM 45. mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 11:14 AM\n 22 Gauge - 11:15 AM\n Prophylaxis:\n DVT: SQ heparin\n Stress ulcer: IV PPI \n Communication: With family, especially mother\n status: Do not resuscitate, ok to intubate and use pressors. Goals\n of care is to return home\n Disposition: ICU pending clinical improvement.\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 630780,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 630781,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient tachpneic and restless. Grunting, labored breathing. Sats low\n 90\ns on non-invasive ventilation. Tachycardic. SBP 80\ns (baseline).\n Action:\n 500cc NS bolus administered for tachycardia. VBG sent. Patient\n intubated at 1100 for respiratory distress. CXR obtained.\n Response:\n Patient Tachypneic\n Plan:\n Continue to watch respiratory status closely. Wean non-invasive\n ventilation as tolerated. Follow VBGs.\n"
},
{
"category": "Nursing",
"chartdate": "2115-04-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 632234,
"text": "35 yo M with PMH of CP, seizure disorder, GIB, pancreatic cyst s/p\n drainage in , admitted with abdominal pain with complicated course,\n now with new fever, tachypnea, and hypoxia.\n Code Status: DNR/DNI\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on 02 4l via n/c 02 sats 94-98%. LS rhonchi throughout.\n Strong cough, though pt unable to expectorate secretions. Medicated\n with 40mg lasix on previous shift to optimize resp status. Pt b/p\n dropped to the 70\ns while asleep UOP decreased to 20ml/hr concentrated\n urine.\n Action:\n NT suctioned x2 for sm-mod amt clear thin secretions. 02 weaned to 3l\n n/c w/ no change in 02 sat. 250ml n/s IV bolus r/t hypotension.\n Response:\n 02 sat remains as above, L/S still with rhonchi throughout though\n notably improved. b/p improved intoi the 80\ns/60\ns following fluid\n bolus. Am K+ 3.2, repleted with 60meq KCL P04 2.4, repleted w/ 2\n packets, neutral phos.\n Plan:\n Wean O2 as tolerated while maintaining good sats, encourage coughing,\n pulmonary toilet. Monitor lytes replete as needed.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n T max 100 axillary. Abx course finished . blood/urine cx sent on\n prev shift.\n Action:\n Tylenol PRN x1\n Response:\n Pt\ns temp down after Tylenol. 97.1 this am.\n Plan:\n Monitor temp curve, follow up culture data, Tylenol PRN.\n"
},
{
"category": "Physician ",
"chartdate": "2115-03-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 630905,
"text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 09:10 AM\n ARTERIAL LINE - START 11:10 PM\n - Patient maintained on CPAP during the day with stable ABG, weaned\n FIO2 from 100 to 60%, then transitioned for 2hr period to high flow\n facemask, but then increasing RR so put back on CPAP 60%\n - Required intubation for airway management.\n CT-Torso:\n Chest - There are increased moderate bilateral pleural effusions. ETT\n is in satisfactory position. NGT terminates in stomach. Ascending aorta\n is ectatic. A left sided PICC line terminates in the SVC. There are no\n enlarged axillary/mediastinal/hilar lymph nodes. There is new\n development of patchy pna particularly in LUL and anterior basal\n segment of RLL. There is atelectasis. There is no PE.\n Abd - There is new ill defined hypoattenuation of segment 5 of the\n liver measuring 2.8cm x 3 cm that may represent developing abscess.\n Stable marked ascites. No evidence of SBO. There is stable thickening\n of the sigmoid colon and rectal wall. There is a stable left RP\n hemorrhage that now appears more organized.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:19 PM\n Cefipime - 10:20 PM\n Metronidazole - 02:20 AM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Fentanyl (Concentrate) - 30 mcg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:13 AM\n Heparin Sodium (Prophylaxis) - 08:13 AM\n Morphine Sulfate - 10:26 AM\n Fentanyl - 05:51 PM\n Midazolam (Versed) - 04:24 AM\n Other medications:\n Changes to medical and family history:\n Unchanged\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Unable to obtain\n Flowsheet Data as of 07:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 38.2\nC (100.7\n HR: 128 (111 - 136) bpm\n BP: 78/57(66) {78/57(66) - 95/66(250)} mmHg\n RR: 34 (23 - 45) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 4,407 mL\n 186 mL\n PO:\n 900 mL\n TF:\n IVF:\n 2,524 mL\n 186 mL\n Blood products:\n Total out:\n 2,500 mL\n 600 mL\n Urine:\n 1,800 mL\n 600 mL\n NG:\n 700 mL\n Stool:\n Drains:\n Balance:\n 1,907 mL\n -414 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 300 (260 - 300) mL\n Vt (Spontaneous): 280 (280 - 280) mL\n PS : 18 cmH2O\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 22 cmH2O\n Plateau: 12 cmH2O\n SpO2: 96%\n ABG: 7.40/45/147/26/2\n Ve: 9.1 L/min\n PaO2 / FiO2: 367\n Physical Examination\n Gen: Thin, appears sedated/comfortable at rest, opening eyes but no\n clear orientation to voice\n HEENT: Sclera anicteric, eyes sunken, MMM\n Neck: Supple, thin, EJs prominent and hyperdynamic, no LAD\n Lungs: Intubated, coarse BS bilaterally with soft ronchi\n CV: Regular but tachycardic, normal S1 + S2, unable to appreciate any\n murmurs, rubs, gallops\n Abdomen: Soft, BS+, distended, pt appears uncomfortable on palpations\n GU: Condom cath in place\n Ext: Warm, cachectic, BLE contractures, + DP pulses, no cyanosis or\n edema\n Labs / Radiology\n 142 K/uL\n 8.3 g/dL\n 141 mg/dL\n 0.6 mg/dL\n 26 mEq/L\n 4.1 mEq/L\n 23 mg/dL\n 106 mEq/L\n 138 mEq/L\n 24.7 %\n 5.8 K/uL\n [image002.jpg]\n 03:16 PM\n 03:47 PM\n 01:45 AM\n 12:28 AM\n 02:57 AM\n 03:14 AM\n 05:21 AM\n WBC\n 6.8\n 5.8\n Hct\n 29\n 26.3\n 24.7\n Plt\n 168\n 142\n Cr\n 0.6\n 0.6\n 0.6\n TropT\n 0.01\n TCO2\n 27\n 30\n 29\n Glucose\n 118\n 133\n 141\n Other labs:\n PT / PTT / INR:14.1/34.6/1.2,\n CK / CKMB / Troponin-T:8//0.01,\n ALT / AST:29/31, Alk Phos / T Bili:105/0.5, Amylase / Lipase:/11,\n Lactic Acid:1.0 mmol/L,\n Albumin:2.6 g/dL,\n LDH:415 IU/L,\n Ca++:7.8 mg/dL, Mg++:2.0 mg/dL, PO4:3.5 mg/dL\n CTA chest, CT pelvis/abdomen\n (OFFICIAL READ PENDING)\n Sputum \n poor sample\n Assessment and Plan\n 35 yo M with PMH of CP, seizure disorder, GIB, pancreatic cyst s/p\n drainage in , admitted with abdominal pain with complicated course,\n now with new fever, tachypnea, and hypoxia.\n .\n # Respiratory failure: Hypoxic with ABG on floor c/w respiratory\n alkalosis in setting of tachypnea. Given constellation of new fever,\n tachypnea, and significant hypoxia, as well as new opacities on CXR,\n concern for pneumonia - HAP v. aspiration (tube feeds restarted\n yesterday); less likely VAP as was extubated several weeks prior. \n also with a component of pleural effusion to opacities; recent TTE with\n nl EF but labs notable for low albumin. PE is also a concern as pt is\n bedbound; has not had pneumoboots on and just restarted heparin SQ\n yesterday for DVT ppx. Intubated in setting of declining resp\n status/PNA. CTA yesterday with final read pending, but shows\n infusions/infiltrates b/l. No PE on prelim read.\n - Serial ABG, recheck lactate\n - Continue broad antibiotic coverage for HAP/aspiration PNA with vanc,\n cefepime, metronidazole.\n - f/u sputum cx, f/u blood cultures\n - consider nasopharyngeal swab for viral\n - Repeat sputum sample\n - attempt weaning to PSV\n .\n # Fever/sepsis: Pt febrile with tachycardia and tachypnea; meets\n definition of sepsis with most likely source being pulmonary. With\n ascites, SBP is also possible although he is now s/p 3 taps which have\n not been c/w SBP. U/A appears clean. MS with no obvious\n nuchal rigidity although exam limited by pt cooperation. Again, PE\n could cause similar sx of fever and respiratory distress but none seen\n on prelim CTA.\n - F/u blood and urine cx, sputum cx, C. diff (urine with staph\n spp, UA dirty and UCx pending)\n - Consider abdominal u/s and paracentesis\n - Broad abx as above with good gram positive, gram neg, and anaerobic\n coverage\n - Goal CVP 8-12 but no measurements available currently\n will bolus\n for tachycardia, UOP < 30cc/h, goal MAP >65, CvO2 >70\n - Pressors not currently indicated; does have PICC in place for central\n access\n - Monitor mental status\n # Tachycardia: Likely hyperdynamic in setting of fever, infection.\n Volume status appears grossly euvolemic; pt mentating at and\n maintaining urine output. Ddx PE.\n - Tylenol prn fever\n - Abx as above\n - Fluid boluses prn\n - CT to evaluate for PE\n # Anemia/bleed: Hct stable. Pt with RP bleed and CT evidence of\n hemorrhage into bowel wall, also gastric varices c/b GIB earlier in\n admission.\n - Trend Hct\n - Guaiac stools\n - Active T&S\n - continue pantoprazole 40mg IV bid\n - Continue iron supplement\n # Liver lesion. Noted on abdominal CT. Possible abscess.\n - Await final CT report\n - Discuss possible drainage with IR (? CT guided?)\n # Left humeral fx: Likely d/t trauma sustained during radiology.\n - No surgical indication at this time\n - Pain control with lidoderm patch and morphine prn\n .\n # SMV thrombus: Plan for anticoagulation x 6 months but held in setting\n of recent GI and RP bleed.\n - Continue heparin SQ\n .\n # Seizure disorder: No recent reports of seizures. Caution as certain\n antibiotics may lower seizure threshold.\n - Continue phenobarbitol and phenytoin\n .\n # Cerebral pasy: Stable mental status. Interactive with family but\n nonverbal at .\n .\n FEN: NG tube in stomach, bolus IVF, TPN\n ACCESS: PICC, PIV, A-line\n CODE: Do not resuscitate. Ok to intubate or use pressors. No CPR or\n defibrillation\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 11:14 AM\n 20 Gauge - 11:42 AM\n Arterial Line - 11:10 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2115-03-25 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 630906,
"text": "Chief Complaint: respiratory failure\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 35 yo man who has been in hospital some time, with cerebral palsy, non\n verbal. admitted with acute abdomen, peritonitis, chronic\n pancreatitits. found to have SMV thrombus, anticoagulated, then\n developed retoperitoneal hemorrhage. Was on floor readmitted with\n progressive hypoxemia, intubated. Had CT with ? of liver abscess.\n CTA with LLL and RLL PNA and atelectasis, and effusions.\n 24 Hour Events:\n EKG - At 09:10 AM\n ARTERIAL LINE - START 11:10 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 10:20 PM\n Metronidazole - 02:20 AM\n Vancomycin - 09:12 AM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Fentanyl (Concentrate) - 30 mcg/hour\n Other ICU medications:\n Morphine Sulfate - 10:26 AM\n Fentanyl - 05:51 PM\n Midazolam (Versed) - 04:24 AM\n Other medications:\n SSI\n phosphenytoin\n phenobarb\n FeSO4\n tylenol\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 37.7\nC (99.9\n HR: 124 (111 - 136) bpm\n BP: 96/69(81) {77/55(64) - 96/69(250)} mmHg\n RR: 27 (23 - 45) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 4,407 mL\n 487 mL\n PO:\n 900 mL\n TF:\n IVF:\n 2,524 mL\n 487 mL\n Blood products:\n Total out:\n 2,500 mL\n 600 mL\n Urine:\n 1,800 mL\n 600 mL\n NG:\n 700 mL\n Stool:\n Drains:\n Balance:\n 1,907 mL\n -113 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 300 (260 - 300) mL\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 16 cmH2O\n Plateau: 12 cmH2O\n SpO2: 97%\n ABG: 7.40/45/147/26/2\n Ve: 8.6 L/min\n PaO2 / FiO2: 367\n Physical Examination:\n Awake, not following commands:\n lungs rhoncherous\n CV: reg\n Abd: distended, firm, poor BS.\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 8.3 g/dL\n 142 K/uL\n 141 mg/dL\n 0.6 mg/dL\n 26 mEq/L\n 4.1 mEq/L\n 23 mg/dL\n 106 mEq/L\n 138 mEq/L\n 24.7 %\n 5.8 K/uL\n [image002.jpg]\n 03:16 PM\n 03:47 PM\n 01:45 AM\n 12:28 AM\n 02:57 AM\n 03:14 AM\n 05:21 AM\n WBC\n 6.8\n 5.8\n Hct\n 29\n 26.3\n 24.7\n Plt\n 168\n 142\n Cr\n 0.6\n 0.6\n 0.6\n TropT\n 0.01\n TCO2\n 27\n 30\n 29\n Glucose\n 118\n 133\n 141\n Other labs: PT / PTT / INR:14.1/34.6/1.2, CK / CKMB /\n Troponin-T:8//0.01, ALT / AST:29/31, Alk Phos / T Bili:105/0.5, Amylase\n / Lipase:/11, Lactic Acid:1.0 mmol/L, Albumin:2.6 g/dL, LDH:415 IU/L,\n Ca++:7.8 mg/dL, Mg++:2.0 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/): Severe LUL PNA -\n continue vanco/cefepime. Check sputum cx.\n Abdominal distension: has some ascites on exam, but looks more to be\n significant bowel distension. Will try NGT to suction.\n tachycardia: slightly hyperdynamic in the setting of infection.\n Liver lesion: Will await for final abdominal CT read.\n TACHYCARDIA, OTHER\n ANEMIA, ACUTE, SECONDARY TO BLOOD LOSS (HEMORRHAGE, BLEEDING)\n FRACTURE, OTHER: left humerus not tolerating sling.\n SMV thrombosis: not candidate for anticoagulation.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 11:14 AM\n 20 Gauge - 11:42 AM\n Arterial Line - 11:10 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition :ICU\n Total time spent: 40 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2115-03-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 631085,
"text": "Chief Complaint:\n 24 Hour Events:\n TRANS ESOPHAGEAL ECHO - At 10:30 AM\n TRANSTHORACIC ECHO - At 11:03 AM\n FEVER - 102.3\nF - 12:00 PM\n - Weaned to PS - F/U ABG 7.38/45/105/28/0\n - Spiked to 102.3, but already pan-cultured, on Abx\n - Final CT report recommends F/U US to evaluate liver lesion (?abscess)\n in 3 days (ordered)\n - Pt noted to be apneic (RR 2 at one pt, usually overbreathes vent) and\n change MS (not opening eyes or grimacing as usual), with SBP in 70s.\n Unclear precipitant, seizure vs post-ictal vs acute bleed. Started\n levophed with improved SBPs to 90s-100s, and improved MS quickly. Hct\n 23.1; ordered for 1 unit pRBC with repeat Hct post-transfusion.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Cefipime - 10:00 PM\n Metronidazole - 02:02 AM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Fentanyl (Concentrate) - 30 mcg/hour\n Norepinephrine - 0.07 mcg/Kg/min\n Other ICU medications:\n Midazolam (Versed) - 11:46 AM\n Heparin Sodium (Prophylaxis) - 01:44 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:29 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 39.1\nC (102.3\n Tcurrent: 37.7\nC (99.9\n HR: 106 (100 - 131) bpm\n BP: 96/73(83) {74/56(64) - 108/76(89)} mmHg\n RR: 25 (15 - 39) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,247 mL\n 331 mL\n PO:\n TF:\n IVF:\n 1,752 mL\n 271 mL\n Blood products:\n 375 mL\n Total out:\n 1,275 mL\n 990 mL\n Urine:\n 1,275 mL\n 340 mL\n NG:\n 150 mL\n Stool:\n Drains:\n Balance:\n 972 mL\n -659 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: MMV/PSV/AutoFlow\n Vt (Set): 300 (300 - 300) mL\n Vt (Spontaneous): 399 (345 - 445) mL\n PS : 18 cmH2O\n RR (Set): 12\n RR (Spontaneous): 19\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 28 cmH2O\n Plateau: 20 cmH2O\n Compliance: 31.3 cmH2O/mL\n SpO2: 98%\n ABG: 7.44/38/102/23/1\n Ve: 6.8 L/min\n PaO2 / FiO2: 255\n Physical Examination\n Gen: Thin, appears sedated/comfortable at rest, opening eyes but no\n clear orientation to voice\n HEENT: Sclera anicteric, eyes sunken, MMM\n Neck: Supple, thin, EJs prominent and hyperdynamic, no LAD\n Lungs: Intubated, coarse BS bilaterally with soft ronchi\n CV: Regular but tachycardic, normal S1 + S2, unable to appreciate any\n murmurs, rubs, gallops\n Abdomen: Soft, BS+, distended, pt appears uncomfortable on palpations\n GU: Condom cath in place\n Ext: Warm, cachectic, BLE contractures, + DP pulses, no cyanosis or\n edema\n Labs / Radiology\n 195 K/uL\n 8.9 g/dL\n 157 mg/dL\n 0.7 mg/dL\n 23 mEq/L\n 4.0 mEq/L\n 23 mg/dL\n 107 mEq/L\n 138 mEq/L\n 27.2 %\n 10.1 K/uL\n [image002.jpg]\n 12:28 AM\n 02:57 AM\n 03:14 AM\n 05:21 AM\n 12:25 PM\n 01:30 PM\n 06:52 PM\n 07:01 PM\n 02:03 AM\n 02:19 AM\n WBC\n 5.8\n 10.1\n Hct\n 24.7\n 23.8\n 23.1\n 27.2\n Plt\n 142\n 195\n Cr\n 0.6\n 0.7\n TCO2\n 27\n 30\n 29\n 28\n 28\n 27\n Glucose\n 141\n 157\n Other labs: PT / PTT / INR:15.0/31.5/1.3,\n CK / CKMB / Troponin-T:8//0.01,\n ALT / AST:17/19, Alk Phos / T Bili:106/0.6, Amylase / Lipase:/11,\n Lactic Acid:0.8 mmol/L, Albumin:2.4 g/dL, LDH:383 IU/L, Ca++:7.6 mg/dL,\n Mg++:2.0 mg/dL, PO4:2.8 mg/dL\n Micro:\n - Sputum: NGTD\n - Blood cx: NGTD\n TTE ()\n The left atrium is normal in size. No atrial septal defect is seen by\n 2D or color Doppler. Left ventricular wall thicknesses are normal. The\n left ventricular cavity size is normal. Regional left ventricular wall\n motion is normal. There is mild to moderate global left ventricular\n hypokinesis suggested(LVEF = 45 %). There is no ventricular septal\n defect. Right ventricular chamber size and free wall motion are normal.\n The number of aortic valve leaflets cannot be determined. There is\n moderate aortic valve stenosis (valve area 1.0-1.2cm2). The mitral\n valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation\n is seen. There is mild pulmonary artery systolic hypertension. There is\n no pericardial effusion.\n..Compared with the prior study (images\n reviewed) of , the patient is more tachycardic. The LV systolic\n function now appears depressed. The aortic valve gradient appears\n similar. If indicated, a TEE would better clarify the basis and\n severity of the aortic stenosis (as well as global LV systolic\n function).\n .\n CTA ()\n 1. New bilateral patchy pneumonia, particularly within the left upper\n lobe\n and right middle lobe.\n 2. New ill-defined 2.8 x 3 cm hypoattenuating lesion in segment V of\n the\n liver. This may be secondary to a developing abscess. Follow-up\n ultrasound\n is recommended in 3 days.\n 3. Persistent sigmoid and rectal thickening with stable marked\n abdominal and\n pelvic ascites.\n 4. Stable left retroperitoneal bleed, more organized.\n 5. Increased moderate bilateral pleural effusions.\n Assessment and Plan\n TACHYCARDIA, OTHER\n ANEMIA, ACUTE, SECONDARY TO BLOOD LOSS (HEMORRHAGE, BLEEDING)\n FRACTURE, OTHER\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n 35 yo M with PMH of CP, seizure disorder, GIB, pancreatic cyst s/p\n drainage in , admitted with abdominal pain with complicated course,\n now with new fever, tachypnea, and hypoxia.\n .\n # Respiratory failure: Hypoxic with ABG on floor c/w respiratory\n alkalosis in setting of tachypnea. Given constellation of new fever,\n tachypnea, and significant hypoxia, as well as new opacities on CXR,\n concern for pneumonia - HAP v. aspiration (tube feeds restarted\n yesterday); less likely VAP as was extubated several weeks prior. \n also with a component of pleural effusion to opacities; recent TTE with\n nl EF but labs notable for low albumin. PE is also a concern as pt is\n bedbound; has not had pneumoboots on and just restarted heparin SQ\n yesterday for DVT ppx. Intubated in setting of declining resp\n status/PNA. CTA yesterday with final read pending, but shows\n infusions/infiltrates b/l. No PE on prelim read.\n - Serial ABG, recheck lactate\n - Continue broad antibiotic coverage for HAP/aspiration PNA with vanc,\n cefepime, metronidazole.\n - f/u sputum cx, f/u blood cultures\n - consider nasopharyngeal swab for viral\n - Repeat sputum sample\n - attempt weaning to PSV\n .\n # Fever/sepsis: Pt febrile with tachycardia and tachypnea; meets\n definition of sepsis with most likely source being pulmonary. With\n ascites, SBP is also possible although he is now s/p 3 taps which have\n not been c/w SBP. U/A appears clean. MS with no obvious\n nuchal rigidity although exam limited by pt cooperation. Again, PE\n could cause similar sx of fever and respiratory distress but none seen\n on prelim CTA.\n - F/u blood and urine cx, sputum cx, C. diff (urine with staph\n spp, UA dirty and UCx pending)\n - Consider abdominal u/s and paracentesis\n - Broad abx as above with good gram positive, gram neg, and anaerobic\n coverage\n - Goal CVP 8-12 but no measurements available currently\n will bolus\n for tachycardia, UOP < 30cc/h, goal MAP >65, CvO2 >70\n - Pressors not currently indicated; does have PICC in place for central\n access\n - Monitor mental status\n # Tachycardia: Likely hyperdynamic in setting of fever, infection.\n Volume status appears grossly euvolemic; pt mentating at and\n maintaining urine output. Echo with evidence of depressed cardiac fxn,\n ? tachycardia induced cardiomyopathy\n - Tylenol prn fever\n - Abx as above\n - Fluid boluses prn\n # Anemia/bleed: Hct stable. Pt with RP bleed and CT evidence of\n hemorrhage into bowel wall, also gastric varices c/b GIB earlier in\n admission.\n - Trend Hct\n - Guaiac stools\n - Active T&S\n - continue pantoprazole 40mg IV bid\n - Continue iron supplement\n # Liver lesion. Noted on abdominal CT. Possible abscess.\n - Abdominal U/S tomorrow\n - Discuss possible drainage with IR (? CT guided?)\n # Left humeral fx: Likely d/t trauma sustained during radiology.\n - No surgical indication at this time\n - Pain control with lidoderm patch and morphine prn\n .\n # SMV thrombus: Plan for anticoagulation x 6 months but held in setting\n of recent GI and RP bleed.\n - Continue heparin SQ\n .\n # Seizure disorder: No recent reports of seizures. Caution as certain\n antibiotics may lower seizure threshold.\n - Continue phenobarbitol and phenytoin\n .\n # Cerebral palsy: Stable mental status. Interactive with family but\n nonverbal at .\n .\n FEN: NG tube in stomach, bolus IVF, TPN\n PROPHYLAXIS: pneumoboots, IV PPI\n ACCESS: PICC, PIV, A-line\n CODE: Do not resuscitate. Ok to intubate or use pressors. No CPR or\n defibrillation\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 11:14 AM\n 20 Gauge - 11:42 AM\n Arterial Line - 11:10 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2115-03-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 631088,
"text": "Chief Complaint:\n 24 Hour Events:\n TRANS ESOPHAGEAL ECHO - At 10:30 AM\n TRANSTHORACIC ECHO - At 11:03 AM\n FEVER - 102.3\nF - 12:00 PM\n 35 yo man who has been in hospital some time, with cerebral palsy, non\n verbal. admitted with acute abdomen, peritonitis, chronic\n pancreatitits. found to have SMV thrombus, anticoagulated, then\n developed retoperitoneal hemorrhage. Was on floor readmitted with\n progressive hypoxemia, intubated. Had CT with ? of liver abscess.\n CTA with LLL and RLL PNA and atelectasis, and effusions.\n - Weaned to PS - F/U ABG 7.38/45/105/28/0\n - Spiked to 102.3, but already pan-cultured, on Abx\n - Final CT report recommends F/U US to evaluate liver lesion (?abscess)\n in 3 days (ordered)\n - Pt noted to be apneic (RR 2 at one pt, usually overbreathes vent) and\n change MS (not opening eyes or grimacing as usual), with SBP in 70s.\n Unclear precipitant, seizure vs post-ictal vs acute bleed. Started\n levophed with improved SBPs to 90s-100s, and improved MS quickly. Hct\n 23.1; ordered for 1 unit pRBC with repeat Hct post-transfusion.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Cefipime - 10:00 PM\n Metronidazole - 02:02 AM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Fentanyl (Concentrate) - 30 mcg/hour\n Norepinephrine - 0.07 mcg/Kg/min\n Other ICU medications:\n Midazolam (Versed) - 11:46 AM\n Heparin Sodium (Prophylaxis) - 01:44 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:29 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 39.1\nC (102.3\n Tcurrent: 37.7\nC (99.9\n HR: 106 (100 - 131) bpm\n BP: 96/73(83) {74/56(64) - 108/76(89)} mmHg\n RR: 25 (15 - 39) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,247 mL\n 331 mL\n PO:\n TF:\n IVF:\n 1,752 mL\n 271 mL\n Blood products:\n 375 mL\n Total out:\n 1,275 mL\n 990 mL\n Urine:\n 1,275 mL\n 340 mL\n NG:\n 150 mL\n Stool:\n Drains:\n Balance:\n 972 mL\n -659 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: MMV/PSV/AutoFlow\n Vt (Set): 300 (300 - 300) mL\n Vt (Spontaneous): 399 (345 - 445) mL\n PS : 18 cmH2O\n RR (Set): 12\n RR (Spontaneous): 19\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 28 cmH2O\n Plateau: 20 cmH2O\n Compliance: 31.3 cmH2O/mL\n SpO2: 98%\n ABG: 7.44/38/102/23/1\n Ve: 6.8 L/min\n PaO2 / FiO2: 255\n Physical Examination\n Gen: Thin, appears sedated/comfortable at rest, opening eyes but no\n clear orientation to voice\n HEENT: Sclera anicteric, eyes sunken, MMM\n Neck: Supple, thin, EJs prominent and hyperdynamic, no LAD\n Lungs: Intubated, coarse BS bilaterally with soft ronchi\n CV: Regular but tachycardic, normal S1 + S2, unable to appreciate any\n murmurs, rubs, gallops\n Abdomen: Soft, BS+, distended, pt appears uncomfortable on palpations\n GU: Condom cath in place\n Ext: Warm, cachectic, BLE contractures, + DP pulses, no cyanosis or\n edema\n Labs / Radiology\n 195 K/uL\n 8.9 g/dL\n 157 mg/dL\n 0.7 mg/dL\n 23 mEq/L\n 4.0 mEq/L\n 23 mg/dL\n 107 mEq/L\n 138 mEq/L\n 27.2 %\n 10.1 K/uL\n [image002.jpg]\n 12:28 AM\n 02:57 AM\n 03:14 AM\n 05:21 AM\n 12:25 PM\n 01:30 PM\n 06:52 PM\n 07:01 PM\n 02:03 AM\n 02:19 AM\n WBC\n 5.8\n 10.1\n Hct\n 24.7\n 23.8\n 23.1\n 27.2\n Plt\n 142\n 195\n Cr\n 0.6\n 0.7\n TCO2\n 27\n 30\n 29\n 28\n 28\n 27\n Glucose\n 141\n 157\n Other labs: PT / PTT / INR:15.0/31.5/1.3,\n CK / CKMB / Troponin-T:8//0.01,\n ALT / AST:17/19, Alk Phos / T Bili:106/0.6, Amylase / Lipase:/11,\n Lactic Acid:0.8 mmol/L, Albumin:2.4 g/dL, LDH:383 IU/L, Ca++:7.6 mg/dL,\n Mg++:2.0 mg/dL, PO4:2.8 mg/dL\n Micro:\n - Sputum: NGTD\n - Blood cx: NGTD\n TTE ()\n The left atrium is normal in size. No atrial septal defect is seen by\n 2D or color Doppler. Left ventricular wall thicknesses are normal. The\n left ventricular cavity size is normal. Regional left ventricular wall\n motion is normal. There is mild to moderate global left ventricular\n hypokinesis suggested(LVEF = 45 %). There is no ventricular septal\n defect. Right ventricular chamber size and free wall motion are normal.\n The number of aortic valve leaflets cannot be determined. There is\n moderate aortic valve stenosis (valve area 1.0-1.2cm2). The mitral\n valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation\n is seen. There is mild pulmonary artery systolic hypertension. There is\n no pericardial effusion.\n..Compared with the prior study (images\n reviewed) of , the patient is more tachycardic. The LV systolic\n function now appears depressed. The aortic valve gradient appears\n similar. If indicated, a TEE would better clarify the basis and\n severity of the aortic stenosis (as well as global LV systolic\n function).\n .\n CTA ()\n 1. New bilateral patchy pneumonia, particularly within the left upper\n lobe\n and right middle lobe.\n 2. New ill-defined 2.8 x 3 cm hypoattenuating lesion in segment V of\n the\n liver. This may be secondary to a developing abscess. Follow-up\n ultrasound\n is recommended in 3 days.\n 3. Persistent sigmoid and rectal thickening with stable marked\n abdominal and\n pelvic ascites.\n 4. Stable left retroperitoneal bleed, more organized.\n 5. Increased moderate bilateral pleural effusions.\n Assessment and Plan\n TACHYCARDIA, OTHER\n ANEMIA, ACUTE, SECONDARY TO BLOOD LOSS (HEMORRHAGE, BLEEDING)\n FRACTURE, OTHER\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n 35 yo M with PMH of CP, seizure disorder, GIB, pancreatic cyst s/p\n drainage in , admitted with abdominal pain with complicated course,\n now with new fever, tachypnea, and hypoxia.\n .\n # Respiratory failure: Hypoxic with ABG on floor c/w respiratory\n alkalosis in setting of tachypnea. Given constellation of new fever,\n tachypnea, and significant hypoxia, as well as new opacities on CXR,\n concern for pneumonia - HAP v. aspiration (tube feeds restarted\n yesterday); less likely VAP as was extubated several weeks prior. \n also with a component of pleural effusion to opacities; recent TTE with\n nl EF but labs notable for low albumin. PE is also a concern as pt is\n bedbound; has not had pneumoboots on and just restarted heparin SQ\n yesterday for DVT ppx. Intubated in setting of declining resp\n status/PNA. CTA yesterday with final read pending, but shows\n infusions/infiltrates b/l. No PE on prelim read.\n - Serial ABG, recheck lactate\n - Continue broad antibiotic coverage for HAP/aspiration PNA with vanc,\n cefepime, metronidazole.\n - f/u sputum cx, f/u blood cultures\n - consider nasopharyngeal swab for viral\n - Repeat sputum sample\n - attempt weaning to PSV\n .\n # Fever/sepsis: Pt febrile with tachycardia and tachypnea; meets\n definition of sepsis with most likely source being pulmonary. With\n ascites, SBP is also possible although he is now s/p 3 taps which have\n not been c/w SBP. U/A appears clean. MS with no obvious\n nuchal rigidity although exam limited by pt cooperation. Again, PE\n could cause similar sx of fever and respiratory distress but none seen\n on prelim CTA.\n - F/u blood and urine cx, sputum cx, C. diff (urine with staph\n spp, UA dirty and UCx pending)\n - Consider abdominal u/s and paracentesis\n - Broad abx as above with good gram positive, gram neg, and anaerobic\n coverage\n - Goal CVP 8-12 but no measurements available currently\n will bolus\n for tachycardia, UOP < 30cc/h, goal MAP >65, CvO2 >70\n - Pressors not currently indicated; does have PICC in place for central\n access\n - Monitor mental status\n # Tachycardia: Likely hyperdynamic in setting of fever, infection.\n Volume status appears grossly euvolemic; pt mentating at and\n maintaining urine output. Echo with evidence of depressed cardiac fxn,\n ? tachycardia induced cardiomyopathy\n - Tylenol prn fever\n - Abx as above\n - Fluid boluses prn\n # Anemia/bleed: Hct stable. Pt with RP bleed and CT evidence of\n hemorrhage into bowel wall, also gastric varices c/b GIB earlier in\n admission.\n - Trend Hct\n - Guaiac stools\n - Active T&S\n - continue pantoprazole 40mg IV bid\n - Continue iron supplement\n # Liver lesion. Noted on abdominal CT. Possible abscess.\n - Abdominal U/S tomorrow\n - Discuss possible drainage with IR (? CT guided?)\n # Left humeral fx: Likely d/t trauma sustained during radiology.\n - No surgical indication at this time\n - Pain control with lidoderm patch and morphine prn\n .\n # SMV thrombus: Plan for anticoagulation x 6 months but held in setting\n of recent GI and RP bleed.\n - Continue heparin SQ\n .\n # Seizure disorder: No recent reports of seizures. Caution as certain\n antibiotics may lower seizure threshold.\n - Continue phenobarbitol and phenytoin\n .\n # Cerebral palsy: Stable mental status. Interactive with family but\n nonverbal at .\n .\n FEN: NG tube in stomach, bolus IVF, TPN\n PROPHYLAXIS: pneumoboots, IV PPI\n ACCESS: PICC, PIV, A-line\n CODE: Do not resuscitate. Ok to intubate or use pressors. No CPR or\n defibrillation\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 11:14 AM\n 20 Gauge - 11:42 AM\n Arterial Line - 11:10 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 631206,
"text": "35M with cerebral palsy, non verbal. Admitted in with acute\n abdomen, peritonitis, and chronic pancreatitis. Found to have SMV\n thrombus, anticoagulated which resulted in retoperitoneal hemorrhage.\n Was on floor when he was re-admitted with progressive hypoxemia and\n then subsequently intubated. CTA with LLL and RLL PNA and atelectasis,\n and effusions.\n Code Status: DNR, already intubated.\n Tachycardia, Other\n Assessment:\n Pt sinus tach most of shift ranging 100-130s, rare PVCs. Febrile to\n 101.1. Pt on levophed drip for hypotension.\n Action:\n Tachycardia likely related to levophed and/or fever. Pt pan-cultured\n and medicated with Tylenol for fever and fan placed in room for\n comfort. Levophed drip titrated up.\n Response:\n Pt\ns HR trending down as temp trending down. No change in HR as\n levophed drip titrated up. Multiple cultures pending.\n Plan:\n Continue to monitor heart rate and rhythm, positive correlation between\n HR and temp, consider switching to other pressor if HR affected.\n Follow up culture data.\n Respiratory failure, acute (not ARDS/)Anemia, acute, secondary to\n blood loss (Hemorrhage, Bleeding)\n Assessment:\n Received pt on CMV 40%/300*12/+10, RR 20s, STV 400s , MV . Lung\n sounds clear throughout. Copious oral secretions. Pt refusing mouth\n care most times. CXR revealing PNA and pulmonary edema. GPCs in\n sputum.\n Action:\n Pt initially suctioned for small amounts of thick, tan secretions,\n later in shift secretions increasing to thin, yellow. Afternoon ABG\n 7.50/29/100. PEEP decreased to 8. Pt on multiple IV ABX for PNA,\n ordered for 40mg IV lasix however unable to give due to low BP.\n Response:\n Continues to mobilize secretions, especially after turns. ABG post\n vent change pending. HO aware Lasix dose held.\n Plan:\n Follow up ABG 7.41/34/92, continue pulmonary toilet and IV ABX, wean\n vent as tolerated by pt, give lasix for pulmonary edema when able.\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Pt received one unit PRBC overnight for low HCT. No obvious signs of\n bleeding noted.\n Action:\n Appropriate response to unit received overnight, HCT checked this\n evening.\n Response:\n HCT 27.3 to 27.5.\n Plan:\n Continue to monitor for active signs of bleeding, next HCT with AM\n labs. Transfusion goal >21. Pt has active clot in blood bank,\n outdates tomorrow at MN.\n Alteration in Nutrition\n Assessment:\n Pt with distended abdomen, firm but improving over last few days. OGT\n to intermittent suction, clamped after meds given. Draining small\n amounts of bilious fluid. NGT placement checked via CXR. TPN infusing\n via PICC line.\n Action:\n TF reattempted this evening given low residuals. Started at 1630 at\n 10cc/hr.\n Response:\n TF residuals to be checked frequently.\n Plan:\n Continue to assess TF residuals, advance as tolerated.\n Pt has left arm fracture from PICC insertion, appears to be in no\n discomfort on fentanyl drip.\n"
},
{
"category": "Physician ",
"chartdate": "2115-03-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 630736,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n PICC LINE - START 11:14 AM\n dual lumen\n Patient maintained on CPAP during the day with stable ABG, weaned FIO2\n from 100 to 60%, then transitioned for 2hr period to high flow\n facemask, but then increasing RR so put back on CPAP 60%\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 01:12 PM\n Cefipime - 11:22 PM\n Metronidazole - 02:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 09:03 PM\n Other medications:\n Changes to medical and family history:\n Unchanged\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Unable to obtain\n Flowsheet Data as of 06:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 37.1\nC (98.8\n HR: 123 (118 - 133) bpm\n BP: 87/64(67) {80/57(63) - 101/79(82)} mmHg\n RR: 32 (14 - 53) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 2,604 mL\n 1,234 mL\n PO:\n TF:\n IVF:\n 2,025 mL\n 919 mL\n Blood products:\n Total out:\n 590 mL\n 1,150 mL\n Urine:\n 590 mL\n 450 mL\n NG:\n 700 mL\n Stool:\n Drains:\n Balance:\n 2,014 mL\n 84 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n Ventilator mode: Standby\n Vt (Spontaneous): 687 (320 - 710) mL\n PS : 18 cmH2O\n RR (Set): 35\n RR (Spontaneous): 25\n PEEP: 4 cmH2O\n FiO2: 100%\n PIP: 23 cmH2O\n SpO2: 96%\n ABG: ///28/\n Ve: 13 L/min\n Physical Examination\n Gen: Thin, alert but appears uncomfortable, tachypneic with increased\n wob, use of accessory respiratory muscles\n HEENT: Sclera anicteric, eyes sunken, MMM, on NRB mask\n Neck: Supple, thin, EJs prominent and hyperdynamic, no LAD\n Lungs: Bronchial BS at L>R base, upper airways clearer; no wheezes,\n rhonchi, or rales\n CV: Regular but tachycardic, normal S1 + S2, unable to appreciate any\n murmurs, rubs, gallops\n Abdomen: Soft, BS+, distended, pt appears uncomfortable on palpations\n GU: Condom cath in place\n Ext: Warm, cachectic, BLE contractures, + DP pulses, no cyanosis or\n edema\n Neuro: Alert, nonverbal, tracking gaze, moving upper extremities\n purposefully\n Labs / Radiology\n 168 K/uL\n 8.8 g/dL\n 133 mg/dL\n 0.6 mg/dL\n 28 mEq/L\n 4.4 mEq/L\n 24 mg/dL\n 107 mEq/L\n 141 mEq/L\n 26.3 %\n 6.8 K/uL\n [image002.jpg]\n 03:16 PM\n 03:47 PM\n 01:45 AM\n WBC\n 6.8\n Hct\n 29\n 26.3\n Plt\n 168\n Cr\n 0.6\n 0.6\n Glucose\n 118\n 133\n Other labs: Lactic Acid:0.8 mmol/L, Ca++:7.6 mg/dL, Mg++:2.1 mg/dL,\n PO4:3.4 mg/dL\n Assessment and Plan\n 35 yo M with PMH of CP, seizure disorder, GIB, pancreatic cyst s/p\n drainage in , admitted with abdominal pain with complicated course,\n now with new fever, tachypnea, and hypoxia.\n .\n # Respiratory failure: Hypoxic with ABG on floor c/w respiratory\n alkalosis in setting of tachypnea. Given constellation of new fever,\n tachypnea, and significant hypoxia, as well as new opacities on CXR,\n concern for pneumonia - HAP v. aspiration (tube feeds restarted\n yesterday); less likely VAP as was extubated several weeks prior. \n also with a component of pleural effusion to opacities; recent TTE with\n nl EF but labs notable for low albumin. PE is also a concern as pt is\n bedbound; has not had pneumoboots on and just restarted heparin SQ\n yesterday for DVT ppx.\n - Patient continues on CPAP. Ultimately, utility of NIPPV will likely\n be limited if pneumonia is his underlying issue and may need\n intubation; ok per mother.\n - serial ABG\n - Continue broad antibiotic coverage for HAP/aspiration PNA with vanc,\n cefepime, metronidazole.\n - f/u sputum cx, f/u blood cultures\n - CT chest to evaluate for PE\n .\n # Fever/sepsis: Pt febrile with tachycardia and tachypnea; meets\n definition of sepsis with most likely source being pulmonary. With\n ascites, SBP is also possible although he is now s/p 3 taps which have\n not been c/w SBP. U/A appears clean. MS with no obvious\n nuchal rigidity although exam limited by pt cooperation. Again, PE\n could cause similar sx of fever and respiratory distress.\n - F/u blood and urine cx, sputum cx, C. diff\n - Consider abdominal u/s and paracentesis\n - Broad abx as above with good gram positive, gram neg, and anaerobic\n coverage\n - Goal CVP 8-12 but no measurements available currently\n will bolus\n for tachycardia, UOP < 30cc/h, goal MAP >65, CvO2 >70\n - Pressors not currently indicated; does have PICC in place for central\n access\n - Monitor mental status\n # Tachycardia: Likely hyperdynamic in setting of fever, infection.\n Volume status appears grossly euvolemic; pt mentating at and\n maintaining urine output. Ddx PE.\n - Tylenol prn fever\n - Abx as above\n - Fluid boluses prn\n - CT to evaluate for PE\n # Anemia/bleed: Hct stable. Pt with RP bleed and CT evidence of\n hemorrhage into bowel wall, also gastric varices c/b GIB earlier in\n admission.\n - Trend Hct\n - Guaiac stools\n - Active T&S\n - continue pantoprazole 40mg IV bid\n - Continue iron supplement\n # Left humeral fx: Likely d/t trauma sustained during radiology.\n - No surgical indication at this time\n - Pain control with lidoderm patch and morphine prn\n .\n # SMV thrombus: Plan for anticoagulation x 6 months but held in setting\n of recent GI and RP bleed.\n - Continue heparin SQ\n .\n # Seizure disorder: No recent reports of seizures. Caution as certain\n antibiotics may lower seizure threshold.\n - Continue phenobarbitol and phenytoin\n .\n # Cerebral pasy: Stable mental status. Interactive with family but\n nonverbal at .\n .\n .\n ICU Care\n Nutrition: NPO, hold tube feeds\n TPN w/ Lipids - 11:21 AM 45. mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 11:14 AM\n 22 Gauge - 11:15 AM\n Prophylaxis:\n DVT: SQ heparin\n Stress ulcer: IV PPI \n Communication: With family, especially mother\n status: Do not resuscitate, ok to intubate and use pressors. Goals\n of care is to return home\n Disposition: ICU pending clinical improvement.\n"
},
{
"category": "Physician ",
"chartdate": "2115-03-24 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 630737,
"text": "TITLE:\n Chief Complaint: hypoxemic respiratory failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n PICC LINE - START 11:14 AM\n dual lumen\n EKG - At 12:48 PM\n STOOL CULTURE - At 04:47 PM\nOn and off mask ventilation\n History obtained from Medical records\n Patient unable to provide history: CP - nonverbal at \n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 11:22 PM\n Metronidazole - 02:00 AM\n Vancomycin - 08:32 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:13 AM\n Heparin Sodium (Prophylaxis) - 08:13 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 36.3\nC (97.4\n HR: 134 (118 - 134) bpm\n BP: 97/63(140) {80/57(63) - 101/79(140)} mmHg\n RR: 34 (14 - 55) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 2,604 mL\n 1,592 mL\n PO:\n TF:\n IVF:\n 2,025 mL\n 1,196 mL\n Blood products:\n Total out:\n 590 mL\n 1,185 mL\n Urine:\n 590 mL\n 485 mL\n NG:\n 700 mL\n Stool:\n Drains:\n Balance:\n 2,014 mL\n 407 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n Ventilator mode: Standby\n Vt (Spontaneous): 687 (320 - 710) mL\n PS : 18 cmH2O\n RR (Set): 35\n RR (Spontaneous): 25\n PEEP: 4 cmH2O\n FiO2: 100%\n PIP: 23 cmH2O\n SpO2: 94%\n ABG: ///28/\n Ve: 13 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 8.8 g/dL\n 168 K/uL\n 133 mg/dL\n 0.6 mg/dL\n 28 mEq/L\n 4.4 mEq/L\n 24 mg/dL\n 107 mEq/L\n 141 mEq/L\n 26.3 %\n 6.8 K/uL\n [image002.jpg]\n 03:16 PM\n 03:47 PM\n 01:45 AM\n WBC\n 6.8\n Hct\n 29\n 26.3\n Plt\n 168\n Cr\n 0.6\n 0.6\n Glucose\n 118\n 133\n Other labs: ALT / AST:29/31, Alk Phos / T Bili:105/0.5, Amylase /\n Lipase:/11, Lactic Acid:0.8 mmol/L, Albumin:2.6 g/dL, LDH:415 IU/L,\n Ca++:7.6 mg/dL, Mg++:2.1 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n Hypoxemic respiratory failure:\n -hypoxemia with respiratory alkalosis\n -waxing and resp status. able to take off mask ventilation but\n now back on this morning\n -cxr worsening - now b/l diffuse process across all lung fields\n -CT chest to better characterize process\n -afebrile, wbc remains wnl though did have fever preceding 24hrs\n -leading dx HAP vs. aspiration PNA though other processes remain\n possible\n -broad abx coverage for HAP\n Tachycardia\n -persistent despite resolution of fever and IVF boluses\n -cont to fluid bolus\n -currently maintaining bp within pt\ns usual range, no signs of\n perfusion issues at present, lactate not elevated.\n Anemia/bleed:\n -h/o rp bleed, varices so follow hct trend closely\n -hct down 2 points but sig positive fluid balance\n - Guaiac stools\n SMV thrombus:\n Seizure disorder:\n -no sz activity No\n - Continue phenobarbitol and phenytoin\n Cerebral palsy:\n Remainder of plan as outlined in resident note.\n Above discussed with patient's mother during .\n Pt is critically ill. Time spent on care: 50minutes.\n ICU Care\n Nutrition:\n TPN w/ Lipids - 06:36 PM 45. mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 11:14 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition :\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2115-03-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 630739,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n PICC LINE - START 11:14 AM\n dual lumen\n Patient maintained on CPAP during the day with stable ABG, weaned FIO2\n from 100 to 60%, then transitioned for 2hr period to high flow\n facemask, but then increasing RR so put back on CPAP 60%\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 01:12 PM\n Cefipime - 11:22 PM\n Metronidazole - 02:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 09:03 PM\n Other medications:\n Changes to medical and family history:\n Unchanged\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Unable to obtain\n Flowsheet Data as of 06:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 37.1\nC (98.8\n HR: 123 (118 - 133) bpm\n BP: 87/64(67) {80/57(63) - 101/79(82)} mmHg\n RR: 32 (14 - 53) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 2,604 mL\n 1,234 mL\n PO:\n TF:\n IVF:\n 2,025 mL\n 919 mL\n Blood products:\n Total out:\n 590 mL\n 1,150 mL\n Urine:\n 590 mL\n 450 mL\n NG:\n 700 mL\n Stool:\n Drains:\n Balance:\n 2,014 mL\n 84 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n Ventilator mode: Standby\n Vt (Spontaneous): 687 (320 - 710) mL\n PS : 18 cmH2O\n RR (Set): 35\n RR (Spontaneous): 25\n PEEP: 4 cmH2O\n FiO2: 100%\n PIP: 23 cmH2O\n SpO2: 96%\n ABG: ///28/\n Ve: 13 L/min\n Physical Examination\n Gen: Thin, alert but appears uncomfortable, tachypneic with increased\n wob, use of accessory respiratory muscles\n HEENT: Sclera anicteric, eyes sunken, MMM, on NRB mask\n Neck: Supple, thin, EJs prominent and hyperdynamic, no LAD\n Lungs: Bronchial BS at L>R base, upper airways clearer; no wheezes,\n rhonchi, or rales\n CV: Regular but tachycardic, normal S1 + S2, unable to appreciate any\n murmurs, rubs, gallops\n Abdomen: Soft, BS+, distended, pt appears uncomfortable on palpations\n GU: Condom cath in place\n Ext: Warm, cachectic, BLE contractures, + DP pulses, no cyanosis or\n edema\n Neuro: Alert, nonverbal, tracking gaze, moving upper extremities\n purposefully\n Labs / Radiology\n 168 K/uL\n 8.8 g/dL\n 133 mg/dL\n 0.6 mg/dL\n 28 mEq/L\n 4.4 mEq/L\n 24 mg/dL\n 107 mEq/L\n 141 mEq/L\n 26.3 %\n 6.8 K/uL\n [image002.jpg]\n 03:16 PM\n 03:47 PM\n 01:45 AM\n WBC\n 6.8\n Hct\n 29\n 26.3\n Plt\n 168\n Cr\n 0.6\n 0.6\n Glucose\n 118\n 133\n Other labs: Lactic Acid:0.8 mmol/L, Ca++:7.6 mg/dL, Mg++:2.1 mg/dL,\n PO4:3.4 mg/dL\n Assessment and Plan\n 35 yo M with PMH of CP, seizure disorder, GIB, pancreatic cyst s/p\n drainage in , admitted with abdominal pain with complicated course,\n now with new fever, tachypnea, and hypoxia.\n .\n # Respiratory failure: Hypoxic with ABG on floor c/w respiratory\n alkalosis in setting of tachypnea. Given constellation of new fever,\n tachypnea, and significant hypoxia, as well as new opacities on CXR,\n concern for pneumonia - HAP v. aspiration (tube feeds restarted\n yesterday); less likely VAP as was extubated several weeks prior. \n also with a component of pleural effusion to opacities; recent TTE with\n nl EF but labs notable for low albumin. PE is also a concern as pt is\n bedbound; has not had pneumoboots on and just restarted heparin SQ\n yesterday for DVT ppx.\n - Patient continues on CPAP. Ultimately, utility of NIPPV will likely\n be limited if pneumonia is his underlying issue and may need\n intubation; ok per mother.\n - serial ABG, recheck lactate\n - Continue broad antibiotic coverage for HAP/aspiration PNA with vanc,\n cefepime, metronidazole.\n - f/u sputum cx, f/u blood cultures\n - CT chest to evaluate for PE\n - consider A-line\n - consider nasopharyngeal swab for viral\n .\n # Fever/sepsis: Pt febrile with tachycardia and tachypnea; meets\n definition of sepsis with most likely source being pulmonary. With\n ascites, SBP is also possible although he is now s/p 3 taps which have\n not been c/w SBP. U/A appears clean. MS with no obvious\n nuchal rigidity although exam limited by pt cooperation. Again, PE\n could cause similar sx of fever and respiratory distress.\n - F/u blood and urine cx, sputum cx, C. diff\n - Consider abdominal u/s and paracentesis\n - Broad abx as above with good gram positive, gram neg, and anaerobic\n coverage\n - Goal CVP 8-12 but no measurements available currently\n will bolus\n for tachycardia, UOP < 30cc/h, goal MAP >65, CvO2 >70\n - Pressors not currently indicated; does have PICC in place for central\n access\n - Monitor mental status\n # Tachycardia: Likely hyperdynamic in setting of fever, infection.\n Volume status appears grossly euvolemic; pt mentating at and\n maintaining urine output. Ddx PE.\n - Tylenol prn fever\n - Abx as above\n - Fluid boluses prn\n - CT to evaluate for PE\n # Anemia/bleed: Hct stable. Pt with RP bleed and CT evidence of\n hemorrhage into bowel wall, also gastric varices c/b GIB earlier in\n admission.\n - Trend Hct\n - Guaiac stools\n - Active T&S\n - continue pantoprazole 40mg IV bid\n - Continue iron supplement\n # Left humeral fx: Likely d/t trauma sustained during radiology.\n - No surgical indication at this time\n - Pain control with lidoderm patch and morphine prn\n .\n # SMV thrombus: Plan for anticoagulation x 6 months but held in setting\n of recent GI and RP bleed.\n - Continue heparin SQ\n .\n # Seizure disorder: No recent reports of seizures. Caution as certain\n antibiotics may lower seizure threshold.\n - Continue phenobarbitol and phenytoin\n .\n # Cerebral pasy: Stable mental status. Interactive with family but\n nonverbal at .\n .\n FEN: NG tube post-pylorus will need to reposition, bolus IVF, continue\n TF\n ACCESS: PICC, PIV\n CODE: Do not resuscitate. Ok to intubate or use pressors. No CPR or\n defibrillation\n ICU Care\n Nutrition: NPO, hold tube feeds\n TPN w/ Lipids - 11:21 AM 45. mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 11:14 AM\n 22 Gauge - 11:15 AM\n Prophylaxis:\n DVT: SQ heparin\n Stress ulcer: IV PPI \n Communication: With family, especially mother\n status: Do not resuscitate, ok to intubate and use pressors. Goals\n of care is to return home\n Disposition: ICU pending clinical improvement.\n"
},
{
"category": "Physician ",
"chartdate": "2115-03-31 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 632155,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n -goal at least 1 liter negative today. Received multiple doses of\n lasix with moderate diuresis.\n -patient is not to be reintubated after extubation.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 06:00 PM\n Vancomycin - 08:00 PM\n Cefipime - 10:00 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 PM\n Other medications:\n Changes to medical and family history:\n Unchanged.\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n No Changes\n Flowsheet Data as of 06:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.1\nC (100.5\n Tcurrent: 37.2\nC (98.9\n HR: 112 (105 - 129) bpm\n BP: 80/61(69) {77/59(67) - 102/73(86)} mmHg\n RR: 24 (17 - 28) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 2,429 mL\n 462 mL\n PO:\n TF:\n 1,199 mL\n 301 mL\n IVF:\n 1,010 mL\n 60 mL\n Blood products:\n Total out:\n 3,580 mL\n 385 mL\n Urine:\n 3,320 mL\n 385 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,151 mL\n 77 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 303 (224 - 375) mL\n PS : 10 cmH2O\n RR (Spontaneous): 24\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 109\n PIP: 16 cmH2O\n SpO2: 96%\n ABG: 7.44/43/106/26/4\n Ve: 7.4 L/min\n PaO2 / FiO2: 265\n Physical Examination\n Gen: Thin, opening eyes but no clear orientation to voice\n HEENT: Sclera anicteric, eyes sunken, MMM, audible secretions\n Neck: Supple\n Lungs: Intubated, coarse BS bilaterally with diffuse ronchi\n CV: S1, S2 regular rhythm, increased rate\n Abdomen: Soft, BS+, distended, no facial grimacing to palpation\n GU: foley catheter in place\n Ext: Warm, cachectic, BLE contractures, + DP pulses\n Labs / Radiology\n 142 K/uL\n 9.5 g/dL\n 145 mg/dL\n 0.6 mg/dL\n 26 mEq/L\n 3.8 mEq/L\n 24 mg/dL\n 102 mEq/L\n 136 mEq/L\n 28.5 %\n 7.1 K/uL\n [image002.jpg]\n 07:36 AM\n 09:06 AM\n 02:18 PM\n 02:33 PM\n 05:01 AM\n 02:23 PM\n 03:50 AM\n 04:15 PM\n 02:46 AM\n 03:02 AM\n WBC\n 10.7\n 8.7\n 7.1\n Hct\n 30.4\n 30.2\n 28.5\n Plt\n \n Cr\n 0.6\n 0.7\n 0.6\n 0.6\n 0.6\n 0.6\n TCO2\n 27\n 25\n 27\n 30\n Glucose\n 118\n 116\n 85\n 139\n 150\n 145\n Other labs: PT / PTT / INR:15.9/27.4/1.4, CK / CKMB /\n Troponin-T:8//0.01, ALT / AST:17/19, Alk Phos / T Bili:106/0.6, Amylase\n / Lipase:/11, Differential-Neuts:86.5 %, Lymph:6.6 %, Mono:5.9 %,\n Eos:0.9 %, Lactic Acid:1.6 mmol/L, Albumin:2.4 g/dL, LDH:383 IU/L,\n Ca++:7.4 mg/dL, Mg++:2.1 mg/dL, PO4:2.2 mg/dL\n Assessment and Plan\n 35 yo M with PMH of CP, seizure disorder, GIB, pancreatic cyst s/p\n drainage in , admitted with abdominal pain with complicated course,\n now with new fever, tachypnea, and hypoxia.\n .\n # Respiratory failure: Patient transferred to MICU with tachypnea and\n hypoxia on and intubated on . Given his new fever,\n respiratory deterioration, and imaging findings consistent with\n multilobar pneumonia he was started on vancomycin, cefepime and flagyl\n (concern for aspiration given recently started tube feeds). Sputum\n growing MRSA. Pleural effusions also noted on imaging, likely due to\n fluid resuscitation for hypotension in the setting of albumin of 2.3,\n so over the past 24 hours have been diuresing with lasix boluses. PE\n considered but CTA negative. Few apneic episodes overnight may be\n secondary to aggressive diuresis.\n - discontinue antibiotic coverage for HAP/aspiration PNA with vanc,\n cefepime, metronidazole as patient has completed total 8 days (Day 1 =\n )\n - continue with daily RSBI and SBT as tolerated, likely will extubate\n today\n - follow ABGs\n - optimize for extubation\n - electrolytes with repletion while on Lasix\n - f/u blood cultures\n .\n # Fever/sepsis: Pt febrile with tachycardia and tachypnea; meets\n definition of sepsis with most likely source being pulmonary (MRSA).\n With ascites, SBP is also possible although he is now s/p 3 taps which\n have not been c/w SBP. Urinalysis and culture from with staph spp\n but repeat appears clean with NGTD. MS with no obvious\n nuchal rigidity although exam limited by pt cooperation. Again, PE\n could cause similar sx of fever and respiratory distress but none seen\n on CTA. Continues febrile daily. No further episodes of AMS. CT read as\n possible liver abscess but repeat RUQ ultrasound read as more\n consistent with infarct. C. Diff has been negative. Continues to have\n fever to 101 on overnight but normal white count, lactate normal.\n - Broad abx as above with good gram positive, gram neg, and anaerobic\n coverage. Today is last day of 8-day course.\n - Goal CVP 8-12 but no measurements available currently\n will bolus\n for tachycardia, UOP < 30cc/h, goal MAP >60, CvO2 >70\n - Pressors for MAP > 55-60, off vasopressors\n - Monitor mental status\n - Consider paracentesis if continues febrile and no other source (would\n likely need to be done by IR)\n .\n #Hypotension. MAP goal > 60. No further episodes of AMS since starting\n pressors on . Not on vasopressors.\n # Tachycardia: Likely hyperdynamic in setting of fever, infection.\n Volume status appears grossly euvolemic; pt mentating at and\n maintaining urine output. Echo with evidence of depressed cardiac fxn,\n ? tachycardia induced cardiomyopathy\n - Tylenol prn fever\n - Abx as above\n - Fluid boluses prn, though patient with heart rate 110s;\n appears hypervolemic\n # Anemia/bleed: Hct stable. Pt with RP bleed and CT evidence of\n hemorrhage into bowel wall, also gastric varices c/b GIB earlier in\n admission. Transfused 1 unit pRBCs with appropriate bump and has\n remained stable since.\n - Trend Hct\n - Guaiac stools\n - Active T&S\n - continue pantoprazole 40mg IV bid\n - Continue iron supplement\n # Liver lesion. Noted on abdominal CT. Possible ischemia/infarction vs\n abscess. Abdominal U/S not consistent with abscess.\n # Left humeral fx: Likely d/t trauma sustained during radiology.\n - No surgical indication at this time\n - Pain control with lidoderm patch and morphine prn\n .\n # SMV thrombus: Plan for anticoagulation x 6 months but held in setting\n of recent GI and RP bleed.\n - Continue heparin SQ\n .\n # Seizure disorder: No recent reports of seizures. Caution as certain\n antibiotics may lower seizure threshold.\n - Continue phenobarbitol and phenytoin\n - drug levels stable as of \n .\n # Cerebral palsy: Stable mental status. Interactive with family but\n nonverbal at .\n .\n FEN: NG tube likely in duodenum, bolus IVF prn, TPN; continue tube\n feeds today\n PROPHYLAXIS: pneumoboots, IV PPI\n ACCESS: PICC, PIV, D/C A-line in right brachial artery\n CODE: Do not resuscitate/Do not re-intubate. No CPR or defibrillation.\n ICU Care\n Nutrition:\n Vivonex (Full) - 06:25 AM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 11:14 AM\n Arterial Line - 11:10 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2115-03-31 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 632156,
"text": "Chief Complaint: Respiratory Failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 1.1L negative\n 24 Hour Events:\n History obtained from Medical records, icu team\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 06:00 PM\n Vancomycin - 08:00 PM\n Cefipime - 10:00 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Other medications:\n per ICU resident note\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fever\n Ear, Nose, Throat: OG / NG tube\n Cardiovascular: Tachycardia\n Respiratory: mechanical ventilation\n Pain: No pain / appears comfortable\n Flowsheet Data as of 09:18 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.1\nC (100.5\n Tcurrent: 37.5\nC (99.5\n HR: 120 (105 - 129) bpm\n BP: 94/75(72) {78/44(59) - 151/95(114)} mmHg\n RR: 27 (15 - 27) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 2,429 mL\n 562 mL\n PO:\n TF:\n 1,199 mL\n 321 mL\n IVF:\n 1,010 mL\n 101 mL\n Blood products:\n Total out:\n 3,580 mL\n 495 mL\n Urine:\n 3,320 mL\n 495 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,151 mL\n 67 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PSV/SBT\n Vt (Spontaneous): 369 (224 - 375) mL\n PS : 8 cmH2O\n RR (Spontaneous): 27\n PEEP: 0 cmH2O\n FiO2: 40%\n RSBI: 109\n PIP: 16 cmH2O\n SpO2: 99%\n ABG: 7.49/36/89./26/4\n Ve: 9.4 L/min\n PaO2 / FiO2: 223\n Physical Examination\n General Appearance: No acute distress\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Warm\n Neurologic: Attentive, No(t) Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 9.5 g/dL\n 142 K/uL\n 145 mg/dL\n 0.6 mg/dL\n 26 mEq/L\n 3.8 mEq/L\n 24 mg/dL\n 102 mEq/L\n 136 mEq/L\n 28.5 %\n 7.1 K/uL\n [image002.jpg]\n 09:06 AM\n 02:18 PM\n 02:33 PM\n 05:01 AM\n 02:23 PM\n 03:50 AM\n 04:15 PM\n 02:46 AM\n 03:02 AM\n 09:03 AM\n WBC\n 10.7\n 8.7\n 7.1\n Hct\n 30.4\n 30.2\n 28.5\n Plt\n \n Cr\n 0.6\n 0.7\n 0.6\n 0.6\n 0.6\n 0.6\n TCO2\n 25\n 27\n 30\n 28\n Glucose\n 118\n 116\n 85\n 139\n 150\n 145\n Other labs: PT / PTT / INR:15.9/27.4/1.4, CK / CKMB /\n Troponin-T:8//0.01, ALT / AST:17/19, Alk Phos / T Bili:106/0.6, Amylase\n / Lipase:/11, Differential-Neuts:86.5 %, Lymph:6.6 %, Mono:5.9 %,\n Eos:0.9 %, Lactic Acid:1.6 mmol/L, Albumin:2.4 g/dL, LDH:383 IU/L,\n Ca++:7.4 mg/dL, Mg++:2.1 mg/dL, PO4:2.2 mg/dL\n Imaging: CXR: improved but not resolved bilateral infiltrates\n Assessment and Plan\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n ALTERATION IN NUTRITION\n TACHYCARDIA, OTHER\n ANEMIA, ACUTE, SECONDARY TO BLOOD LOSS (HEMORRHAGE, BLEEDING)\n FRACTURE, OTHER\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n 35 yo man with cerebral palsy with recurrent respiratory failure due to\n pneumonia and volume overload\n Respiratory Failure: Doing well this AM on SBT, able to be negative\n overnight. Will aim to extubate this AM.\n Fevers: Still with some low grade fevers. Abx xourse completed today.\n Remainder of issue per ICU team\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 11:14 AM\n Arterial Line - 11:10 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition :ICU\n Total time spent: 31 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2115-03-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 630881,
"text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 09:10 AM\n ARTERIAL LINE - START 11:10 PM\n - Patient maintained on CPAP during the day with stable ABG, weaned\n FIO2 from 100 to 60%, then transitioned for 2hr period to high flow\n facemask, but then increasing RR so put back on CPAP 60%\n - Required intubation for airway management.\n CT-Torso:\n Chest - There are increased moderate bilateral pleural effusions. ETT\n is in satisfactory position. NGT terminates in stomach. Ascending aorta\n is ectatic. A left sided PICC line terminates in the SVC. There are no\n enlarged axillary/mediastinal/hilar lymph nodes. There is new\n development of patchy pna particularly in LUL and anterior basal\n segment of RLL. There is atelectasis. There is no PE.\n Abd - There is new ill defined hypoattenuation of segment 5 of the\n liver measuring 2.8cm x 3 cm that may represent developing abscess.\n Stable marked ascites. No evidence of SBO. There is stable thickening\n of the sigmoid colon and rectal wall. There is a stable left RP\n hemorrhage that now appears more organized.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:19 PM\n Cefipime - 10:20 PM\n Metronidazole - 02:20 AM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Fentanyl (Concentrate) - 30 mcg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:13 AM\n Heparin Sodium (Prophylaxis) - 08:13 AM\n Morphine Sulfate - 10:26 AM\n Fentanyl - 05:51 PM\n Midazolam (Versed) - 04:24 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 38.2\nC (100.7\n HR: 128 (111 - 136) bpm\n BP: 78/57(66) {78/57(66) - 95/66(250)} mmHg\n RR: 34 (23 - 45) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 4,407 mL\n 186 mL\n PO:\n 900 mL\n TF:\n IVF:\n 2,524 mL\n 186 mL\n Blood products:\n Total out:\n 2,500 mL\n 600 mL\n Urine:\n 1,800 mL\n 600 mL\n NG:\n 700 mL\n Stool:\n Drains:\n Balance:\n 1,907 mL\n -414 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 300 (260 - 300) mL\n Vt (Spontaneous): 280 (280 - 280) mL\n PS : 18 cmH2O\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 22 cmH2O\n Plateau: 12 cmH2O\n SpO2: 96%\n ABG: 7.40/45/147/26/2\n Ve: 9.1 L/min\n PaO2 / FiO2: 367\n Physical Examination\n Labs / Radiology\n 142 K/uL\n 8.3 g/dL\n 141 mg/dL\n 0.6 mg/dL\n 26 mEq/L\n 4.1 mEq/L\n 23 mg/dL\n 106 mEq/L\n 138 mEq/L\n 24.7 %\n 5.8 K/uL\n [image002.jpg]\n 03:16 PM\n 03:47 PM\n 01:45 AM\n 12:28 AM\n 02:57 AM\n 03:14 AM\n 05:21 AM\n WBC\n 6.8\n 5.8\n Hct\n 29\n 26.3\n 24.7\n Plt\n 168\n 142\n Cr\n 0.6\n 0.6\n 0.6\n TropT\n 0.01\n TCO2\n 27\n 30\n 29\n Glucose\n 118\n 133\n 141\n Other labs: PT / PTT / INR:14.1/34.6/1.2, CK / CKMB /\n Troponin-T:8//0.01, ALT / AST:29/31, Alk Phos / T Bili:105/0.5, Amylase\n / Lipase:/11, Lactic Acid:1.0 mmol/L, Albumin:2.6 g/dL, LDH:415 IU/L,\n Ca++:7.8 mg/dL, Mg++:2.0 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 11:14 AM\n 20 Gauge - 11:42 AM\n Arterial Line - 11:10 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2115-03-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 630886,
"text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 09:10 AM\n ARTERIAL LINE - START 11:10 PM\n - Patient maintained on CPAP during the day with stable ABG, weaned\n FIO2 from 100 to 60%, then transitioned for 2hr period to high flow\n facemask, but then increasing RR so put back on CPAP 60%\n - Required intubation for airway management.\n CT-Torso:\n Chest - There are increased moderate bilateral pleural effusions. ETT\n is in satisfactory position. NGT terminates in stomach. Ascending aorta\n is ectatic. A left sided PICC line terminates in the SVC. There are no\n enlarged axillary/mediastinal/hilar lymph nodes. There is new\n development of patchy pna particularly in LUL and anterior basal\n segment of RLL. There is atelectasis. There is no PE.\n Abd - There is new ill defined hypoattenuation of segment 5 of the\n liver measuring 2.8cm x 3 cm that may represent developing abscess.\n Stable marked ascites. No evidence of SBO. There is stable thickening\n of the sigmoid colon and rectal wall. There is a stable left RP\n hemorrhage that now appears more organized.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:19 PM\n Cefipime - 10:20 PM\n Metronidazole - 02:20 AM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Fentanyl (Concentrate) - 30 mcg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:13 AM\n Heparin Sodium (Prophylaxis) - 08:13 AM\n Morphine Sulfate - 10:26 AM\n Fentanyl - 05:51 PM\n Midazolam (Versed) - 04:24 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 38.2\nC (100.7\n HR: 128 (111 - 136) bpm\n BP: 78/57(66) {78/57(66) - 95/66(250)} mmHg\n RR: 34 (23 - 45) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 4,407 mL\n 186 mL\n PO:\n 900 mL\n TF:\n IVF:\n 2,524 mL\n 186 mL\n Blood products:\n Total out:\n 2,500 mL\n 600 mL\n Urine:\n 1,800 mL\n 600 mL\n NG:\n 700 mL\n Stool:\n Drains:\n Balance:\n 1,907 mL\n -414 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 300 (260 - 300) mL\n Vt (Spontaneous): 280 (280 - 280) mL\n PS : 18 cmH2O\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 22 cmH2O\n Plateau: 12 cmH2O\n SpO2: 96%\n ABG: 7.40/45/147/26/2\n Ve: 9.1 L/min\n PaO2 / FiO2: 367\n Physical Examination\n Labs / Radiology\n 142 K/uL\n 8.3 g/dL\n 141 mg/dL\n 0.6 mg/dL\n 26 mEq/L\n 4.1 mEq/L\n 23 mg/dL\n 106 mEq/L\n 138 mEq/L\n 24.7 %\n 5.8 K/uL\n [image002.jpg]\n 03:16 PM\n 03:47 PM\n 01:45 AM\n 12:28 AM\n 02:57 AM\n 03:14 AM\n 05:21 AM\n WBC\n 6.8\n 5.8\n Hct\n 29\n 26.3\n 24.7\n Plt\n 168\n 142\n Cr\n 0.6\n 0.6\n 0.6\n TropT\n 0.01\n TCO2\n 27\n 30\n 29\n Glucose\n 118\n 133\n 141\n Other labs:\n PT / PTT / INR:14.1/34.6/1.2,\n CK / CKMB / Troponin-T:8//0.01,\n ALT / AST:29/31, Alk Phos / T Bili:105/0.5, Amylase / Lipase:/11,\n Lactic Acid:1.0 mmol/L,\n Albumin:2.6 g/dL,\n LDH:415 IU/L,\n Ca++:7.8 mg/dL, Mg++:2.0 mg/dL, PO4:3.5 mg/dL\n CTA chest, CT pelvis/abdomen\n (OFFICIAL READ PENDING)\n Sputum \n poor sample\n Assessment and Plan\n 35 yo M with PMH of CP, seizure disorder, GIB, pancreatic cyst s/p\n drainage in , admitted with abdominal pain with complicated course,\n now with new fever, tachypnea, and hypoxia.\n .\n # Respiratory failure: Hypoxic with ABG on floor c/w respiratory\n alkalosis in setting of tachypnea. Given constellation of new fever,\n tachypnea, and significant hypoxia, as well as new opacities on CXR,\n concern for pneumonia - HAP v. aspiration (tube feeds restarted\n yesterday); less likely VAP as was extubated several weeks prior. \n also with a component of pleural effusion to opacities; recent TTE with\n nl EF but labs notable for low albumin. PE is also a concern as pt is\n bedbound; has not had pneumoboots on and just restarted heparin SQ\n yesterday for DVT ppx. Intubated in setting of declining resp\n status/PNA. CTA yesterday with final read pending, but shows\n infusions/infiltrates b/l. No PE on prelim read.\n - Serial ABG, recheck lactate\n - Continue broad antibiotic coverage for HAP/aspiration PNA with vanc,\n cefepime, metronidazole.\n - f/u sputum cx, f/u blood cultures\n - consider nasopharyngeal swab for viral\n - Repeat sputum sample\n .\n # Fever/sepsis: Pt febrile with tachycardia and tachypnea; meets\n definition of sepsis with most likely source being pulmonary. With\n ascites, SBP is also possible although he is now s/p 3 taps which have\n not been c/w SBP. U/A appears clean. MS with no obvious\n nuchal rigidity although exam limited by pt cooperation. Again, PE\n could cause similar sx of fever and respiratory distress but none seen\n on prelim CTA.\n - F/u blood and urine cx, sputum cx, C. diff (urine with staph\n spp, UA dirty and UCx pending)\n - Consider abdominal u/s and paracentesis\n - Broad abx as above with good gram positive, gram neg, and anaerobic\n coverage\n - Goal CVP 8-12 but no measurements available currently\n will bolus\n for tachycardia, UOP < 30cc/h, goal MAP >65, CvO2 >70\n - Pressors not currently indicated; does have PICC in place for central\n access\n - Monitor mental status\n # Tachycardia: Likely hyperdynamic in setting of fever, infection.\n Volume status appears grossly euvolemic; pt mentating at and\n maintaining urine output. Ddx PE.\n - Tylenol prn fever\n - Abx as above\n - Fluid boluses prn\n - CT to evaluate for PE\n # Anemia/bleed: Hct stable. Pt with RP bleed and CT evidence of\n hemorrhage into bowel wall, also gastric varices c/b GIB earlier in\n admission.\n - Trend Hct\n - Guaiac stools\n - Active T&S\n - continue pantoprazole 40mg IV bid\n - Continue iron supplement\n # Liver lesion. Noted on abdominal CT. Possible abscess.\n - Await final CT report\n - Discuss drainage with IR\n # Left humeral fx: Likely d/t trauma sustained during radiology.\n - No surgical indication at this time\n - Pain control with lidoderm patch and morphine prn\n .\n # SMV thrombus: Plan for anticoagulation x 6 months but held in setting\n of recent GI and RP bleed.\n - Continue heparin SQ\n .\n # Seizure disorder: No recent reports of seizures. Caution as certain\n antibiotics may lower seizure threshold.\n - Continue phenobarbitol and phenytoin\n .\n # Cerebral pasy: Stable mental status. Interactive with family but\n nonverbal at .\n .\n FEN: NG tube post-pylorus will need to reposition, bolus IVF, continue\n TF\n ACCESS: PICC, PIV, A-line\n CODE: Do not resuscitate. Ok to intubate or use pressors. No CPR or\n defibrillation\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 11:14 AM\n 20 Gauge - 11:42 AM\n Arterial Line - 11:10 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2115-03-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 630887,
"text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 09:10 AM\n ARTERIAL LINE - START 11:10 PM\n - Patient maintained on CPAP during the day with stable ABG, weaned\n FIO2 from 100 to 60%, then transitioned for 2hr period to high flow\n facemask, but then increasing RR so put back on CPAP 60%\n - Required intubation for airway management.\n CT-Torso:\n Chest - There are increased moderate bilateral pleural effusions. ETT\n is in satisfactory position. NGT terminates in stomach. Ascending aorta\n is ectatic. A left sided PICC line terminates in the SVC. There are no\n enlarged axillary/mediastinal/hilar lymph nodes. There is new\n development of patchy pna particularly in LUL and anterior basal\n segment of RLL. There is atelectasis. There is no PE.\n Abd - There is new ill defined hypoattenuation of segment 5 of the\n liver measuring 2.8cm x 3 cm that may represent developing abscess.\n Stable marked ascites. No evidence of SBO. There is stable thickening\n of the sigmoid colon and rectal wall. There is a stable left RP\n hemorrhage that now appears more organized.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:19 PM\n Cefipime - 10:20 PM\n Metronidazole - 02:20 AM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Fentanyl (Concentrate) - 30 mcg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:13 AM\n Heparin Sodium (Prophylaxis) - 08:13 AM\n Morphine Sulfate - 10:26 AM\n Fentanyl - 05:51 PM\n Midazolam (Versed) - 04:24 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 38.2\nC (100.7\n HR: 128 (111 - 136) bpm\n BP: 78/57(66) {78/57(66) - 95/66(250)} mmHg\n RR: 34 (23 - 45) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 4,407 mL\n 186 mL\n PO:\n 900 mL\n TF:\n IVF:\n 2,524 mL\n 186 mL\n Blood products:\n Total out:\n 2,500 mL\n 600 mL\n Urine:\n 1,800 mL\n 600 mL\n NG:\n 700 mL\n Stool:\n Drains:\n Balance:\n 1,907 mL\n -414 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 300 (260 - 300) mL\n Vt (Spontaneous): 280 (280 - 280) mL\n PS : 18 cmH2O\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 22 cmH2O\n Plateau: 12 cmH2O\n SpO2: 96%\n ABG: 7.40/45/147/26/2\n Ve: 9.1 L/min\n PaO2 / FiO2: 367\n Physical Examination\n Gen: Thin, alert but appears uncomfortable, tachypneic with increased\n wob, use of accessory respiratory muscles\n HEENT: Sclera anicteric, eyes sunken, MMM, on NRB mask\n Neck: Supple, thin, EJs prominent and hyperdynamic, no LAD\n Lungs: Intubated.\n CV: Regular but tachycardic, normal S1 + S2, unable to appreciate any\n murmurs, rubs, gallops\n Abdomen: Soft, BS+, distended, pt appears uncomfortable on palpations\n GU: Condom cath in place\n Ext: Warm, cachectic, BLE contractures, + DP pulses, no cyanosis or\n edema\n Neuro: Alert, nonverbal, tracking gaze, moving upper extremities\n purposefully\n Labs / Radiology\n 142 K/uL\n 8.3 g/dL\n 141 mg/dL\n 0.6 mg/dL\n 26 mEq/L\n 4.1 mEq/L\n 23 mg/dL\n 106 mEq/L\n 138 mEq/L\n 24.7 %\n 5.8 K/uL\n [image002.jpg]\n 03:16 PM\n 03:47 PM\n 01:45 AM\n 12:28 AM\n 02:57 AM\n 03:14 AM\n 05:21 AM\n WBC\n 6.8\n 5.8\n Hct\n 29\n 26.3\n 24.7\n Plt\n 168\n 142\n Cr\n 0.6\n 0.6\n 0.6\n TropT\n 0.01\n TCO2\n 27\n 30\n 29\n Glucose\n 118\n 133\n 141\n Other labs:\n PT / PTT / INR:14.1/34.6/1.2,\n CK / CKMB / Troponin-T:8//0.01,\n ALT / AST:29/31, Alk Phos / T Bili:105/0.5, Amylase / Lipase:/11,\n Lactic Acid:1.0 mmol/L,\n Albumin:2.6 g/dL,\n LDH:415 IU/L,\n Ca++:7.8 mg/dL, Mg++:2.0 mg/dL, PO4:3.5 mg/dL\n CTA chest, CT pelvis/abdomen\n (OFFICIAL READ PENDING)\n Sputum \n poor sample\n Assessment and Plan\n 35 yo M with PMH of CP, seizure disorder, GIB, pancreatic cyst s/p\n drainage in , admitted with abdominal pain with complicated course,\n now with new fever, tachypnea, and hypoxia.\n .\n # Respiratory failure: Hypoxic with ABG on floor c/w respiratory\n alkalosis in setting of tachypnea. Given constellation of new fever,\n tachypnea, and significant hypoxia, as well as new opacities on CXR,\n concern for pneumonia - HAP v. aspiration (tube feeds restarted\n yesterday); less likely VAP as was extubated several weeks prior. \n also with a component of pleural effusion to opacities; recent TTE with\n nl EF but labs notable for low albumin. PE is also a concern as pt is\n bedbound; has not had pneumoboots on and just restarted heparin SQ\n yesterday for DVT ppx. Intubated in setting of declining resp\n status/PNA. CTA yesterday with final read pending, but shows\n infusions/infiltrates b/l. No PE on prelim read.\n - Serial ABG, recheck lactate\n - Continue broad antibiotic coverage for HAP/aspiration PNA with vanc,\n cefepime, metronidazole.\n - f/u sputum cx, f/u blood cultures\n - consider nasopharyngeal swab for viral\n - Repeat sputum sample\n .\n # Fever/sepsis: Pt febrile with tachycardia and tachypnea; meets\n definition of sepsis with most likely source being pulmonary. With\n ascites, SBP is also possible although he is now s/p 3 taps which have\n not been c/w SBP. U/A appears clean. MS with no obvious\n nuchal rigidity although exam limited by pt cooperation. Again, PE\n could cause similar sx of fever and respiratory distress but none seen\n on prelim CTA.\n - F/u blood and urine cx, sputum cx, C. diff (urine with staph\n spp, UA dirty and UCx pending)\n - Consider abdominal u/s and paracentesis\n - Broad abx as above with good gram positive, gram neg, and anaerobic\n coverage\n - Goal CVP 8-12 but no measurements available currently\n will bolus\n for tachycardia, UOP < 30cc/h, goal MAP >65, CvO2 >70\n - Pressors not currently indicated; does have PICC in place for central\n access\n - Monitor mental status\n # Tachycardia: Likely hyperdynamic in setting of fever, infection.\n Volume status appears grossly euvolemic; pt mentating at and\n maintaining urine output. Ddx PE.\n - Tylenol prn fever\n - Abx as above\n - Fluid boluses prn\n - CT to evaluate for PE\n # Anemia/bleed: Hct stable. Pt with RP bleed and CT evidence of\n hemorrhage into bowel wall, also gastric varices c/b GIB earlier in\n admission.\n - Trend Hct\n - Guaiac stools\n - Active T&S\n - continue pantoprazole 40mg IV bid\n - Continue iron supplement\n # Liver lesion. Noted on abdominal CT. Possible abscess.\n - Await final CT report\n - Discuss drainage with IR\n # Left humeral fx: Likely d/t trauma sustained during radiology.\n - No surgical indication at this time\n - Pain control with lidoderm patch and morphine prn\n .\n # SMV thrombus: Plan for anticoagulation x 6 months but held in setting\n of recent GI and RP bleed.\n - Continue heparin SQ\n .\n # Seizure disorder: No recent reports of seizures. Caution as certain\n antibiotics may lower seizure threshold.\n - Continue phenobarbitol and phenytoin\n .\n # Cerebral pasy: Stable mental status. Interactive with family but\n nonverbal at .\n .\n FEN: NG tube post-pylorus will need to reposition, bolus IVF, continue\n TF\n ACCESS: PICC, PIV, A-line\n CODE: Do not resuscitate. Ok to intubate or use pressors. No CPR or\n defibrillation\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 11:14 AM\n 20 Gauge - 11:42 AM\n Arterial Line - 11:10 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2115-03-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 630888,
"text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 09:10 AM\n ARTERIAL LINE - START 11:10 PM\n - Patient maintained on CPAP during the day with stable ABG, weaned\n FIO2 from 100 to 60%, then transitioned for 2hr period to high flow\n facemask, but then increasing RR so put back on CPAP 60%\n - Required intubation for airway management.\n CT-Torso:\n Chest - There are increased moderate bilateral pleural effusions. ETT\n is in satisfactory position. NGT terminates in stomach. Ascending aorta\n is ectatic. A left sided PICC line terminates in the SVC. There are no\n enlarged axillary/mediastinal/hilar lymph nodes. There is new\n development of patchy pna particularly in LUL and anterior basal\n segment of RLL. There is atelectasis. There is no PE.\n Abd - There is new ill defined hypoattenuation of segment 5 of the\n liver measuring 2.8cm x 3 cm that may represent developing abscess.\n Stable marked ascites. No evidence of SBO. There is stable thickening\n of the sigmoid colon and rectal wall. There is a stable left RP\n hemorrhage that now appears more organized.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:19 PM\n Cefipime - 10:20 PM\n Metronidazole - 02:20 AM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Fentanyl (Concentrate) - 30 mcg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:13 AM\n Heparin Sodium (Prophylaxis) - 08:13 AM\n Morphine Sulfate - 10:26 AM\n Fentanyl - 05:51 PM\n Midazolam (Versed) - 04:24 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 38.2\nC (100.7\n HR: 128 (111 - 136) bpm\n BP: 78/57(66) {78/57(66) - 95/66(250)} mmHg\n RR: 34 (23 - 45) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 4,407 mL\n 186 mL\n PO:\n 900 mL\n TF:\n IVF:\n 2,524 mL\n 186 mL\n Blood products:\n Total out:\n 2,500 mL\n 600 mL\n Urine:\n 1,800 mL\n 600 mL\n NG:\n 700 mL\n Stool:\n Drains:\n Balance:\n 1,907 mL\n -414 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 300 (260 - 300) mL\n Vt (Spontaneous): 280 (280 - 280) mL\n PS : 18 cmH2O\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 22 cmH2O\n Plateau: 12 cmH2O\n SpO2: 96%\n ABG: 7.40/45/147/26/2\n Ve: 9.1 L/min\n PaO2 / FiO2: 367\n Physical Examination\n Gen: Thin, appears sedated/comfortable at rest, opening eyes but no\n clear orientation to voice\n HEENT: Sclera anicteric, eyes sunken, MMM\n Neck: Supple, thin, EJs prominent and hyperdynamic, no LAD\n Lungs: Intubated, coarse BS bilaterally with soft ronchi\n CV: Regular but tachycardic, normal S1 + S2, unable to appreciate any\n murmurs, rubs, gallops\n Abdomen: Soft, BS+, distended, pt appears uncomfortable on palpations\n GU: Condom cath in place\n Ext: Warm, cachectic, BLE contractures, + DP pulses, no cyanosis or\n edema\n Labs / Radiology\n 142 K/uL\n 8.3 g/dL\n 141 mg/dL\n 0.6 mg/dL\n 26 mEq/L\n 4.1 mEq/L\n 23 mg/dL\n 106 mEq/L\n 138 mEq/L\n 24.7 %\n 5.8 K/uL\n [image002.jpg]\n 03:16 PM\n 03:47 PM\n 01:45 AM\n 12:28 AM\n 02:57 AM\n 03:14 AM\n 05:21 AM\n WBC\n 6.8\n 5.8\n Hct\n 29\n 26.3\n 24.7\n Plt\n 168\n 142\n Cr\n 0.6\n 0.6\n 0.6\n TropT\n 0.01\n TCO2\n 27\n 30\n 29\n Glucose\n 118\n 133\n 141\n Other labs:\n PT / PTT / INR:14.1/34.6/1.2,\n CK / CKMB / Troponin-T:8//0.01,\n ALT / AST:29/31, Alk Phos / T Bili:105/0.5, Amylase / Lipase:/11,\n Lactic Acid:1.0 mmol/L,\n Albumin:2.6 g/dL,\n LDH:415 IU/L,\n Ca++:7.8 mg/dL, Mg++:2.0 mg/dL, PO4:3.5 mg/dL\n CTA chest, CT pelvis/abdomen\n (OFFICIAL READ PENDING)\n Sputum \n poor sample\n Assessment and Plan\n 35 yo M with PMH of CP, seizure disorder, GIB, pancreatic cyst s/p\n drainage in , admitted with abdominal pain with complicated course,\n now with new fever, tachypnea, and hypoxia.\n .\n # Respiratory failure: Hypoxic with ABG on floor c/w respiratory\n alkalosis in setting of tachypnea. Given constellation of new fever,\n tachypnea, and significant hypoxia, as well as new opacities on CXR,\n concern for pneumonia - HAP v. aspiration (tube feeds restarted\n yesterday); less likely VAP as was extubated several weeks prior. \n also with a component of pleural effusion to opacities; recent TTE with\n nl EF but labs notable for low albumin. PE is also a concern as pt is\n bedbound; has not had pneumoboots on and just restarted heparin SQ\n yesterday for DVT ppx. Intubated in setting of declining resp\n status/PNA. CTA yesterday with final read pending, but shows\n infusions/infiltrates b/l. No PE on prelim read.\n - Serial ABG, recheck lactate\n - Continue broad antibiotic coverage for HAP/aspiration PNA with vanc,\n cefepime, metronidazole.\n - f/u sputum cx, f/u blood cultures\n - consider nasopharyngeal swab for viral\n - Repeat sputum sample\n .\n # Fever/sepsis: Pt febrile with tachycardia and tachypnea; meets\n definition of sepsis with most likely source being pulmonary. With\n ascites, SBP is also possible although he is now s/p 3 taps which have\n not been c/w SBP. U/A appears clean. MS with no obvious\n nuchal rigidity although exam limited by pt cooperation. Again, PE\n could cause similar sx of fever and respiratory distress but none seen\n on prelim CTA.\n - F/u blood and urine cx, sputum cx, C. diff (urine with staph\n spp, UA dirty and UCx pending)\n - Consider abdominal u/s and paracentesis\n - Broad abx as above with good gram positive, gram neg, and anaerobic\n coverage\n - Goal CVP 8-12 but no measurements available currently\n will bolus\n for tachycardia, UOP < 30cc/h, goal MAP >65, CvO2 >70\n - Pressors not currently indicated; does have PICC in place for central\n access\n - Monitor mental status\n # Tachycardia: Likely hyperdynamic in setting of fever, infection.\n Volume status appears grossly euvolemic; pt mentating at and\n maintaining urine output. Ddx PE.\n - Tylenol prn fever\n - Abx as above\n - Fluid boluses prn\n - CT to evaluate for PE\n # Anemia/bleed: Hct stable. Pt with RP bleed and CT evidence of\n hemorrhage into bowel wall, also gastric varices c/b GIB earlier in\n admission.\n - Trend Hct\n - Guaiac stools\n - Active T&S\n - continue pantoprazole 40mg IV bid\n - Continue iron supplement\n # Liver lesion. Noted on abdominal CT. Possible abscess.\n - Await final CT report\n - Discuss drainage with IR\n # Left humeral fx: Likely d/t trauma sustained during radiology.\n - No surgical indication at this time\n - Pain control with lidoderm patch and morphine prn\n .\n # SMV thrombus: Plan for anticoagulation x 6 months but held in setting\n of recent GI and RP bleed.\n - Continue heparin SQ\n .\n # Seizure disorder: No recent reports of seizures. Caution as certain\n antibiotics may lower seizure threshold.\n - Continue phenobarbitol and phenytoin\n .\n # Cerebral pasy: Stable mental status. Interactive with family but\n nonverbal at .\n .\n FEN: NG tube post-pylorus will need to reposition, bolus IVF, continue\n TF\n ACCESS: PICC, PIV, A-line\n CODE: Do not resuscitate. Ok to intubate or use pressors. No CPR or\n defibrillation\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 11:14 AM\n 20 Gauge - 11:42 AM\n Arterial Line - 11:10 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2115-03-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 631076,
"text": "Chief Complaint:\n 24 Hour Events:\n TRANS ESOPHAGEAL ECHO - At 10:30 AM\n TRANSTHORACIC ECHO - At 11:03 AM\n FEVER - 102.3\nF - 12:00 PM\n - Weaned to PS - F/U ABG 7.38/45/105/28/0\n - Spiked to 102.3, but already pan-cultured, on Abx\n - Final CT report recommends F/U US to evaluate liver lesion (?abscess)\n in 3 days (ordered)\n - Pt noted to be apneic (RR 2 at one pt, usually overbreathes vent) and\n change MS (not opening eyes or grimacing as usual), with SBP in 70s.\n Unclear precipitant, seizure vs post-ictal vs acute bleed. Started\n levophed with improved SBPs to 90s-100s, and improved MS quickly. Hct\n 23.1; ordered for 1 unit pRBC with repeat Hct post-transfusion.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Cefipime - 10:00 PM\n Metronidazole - 02:02 AM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Fentanyl (Concentrate) - 30 mcg/hour\n Norepinephrine - 0.07 mcg/Kg/min\n Other ICU medications:\n Midazolam (Versed) - 11:46 AM\n Heparin Sodium (Prophylaxis) - 01:44 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:29 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 39.1\nC (102.3\n Tcurrent: 37.7\nC (99.9\n HR: 106 (100 - 131) bpm\n BP: 96/73(83) {74/56(64) - 108/76(89)} mmHg\n RR: 25 (15 - 39) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,247 mL\n 331 mL\n PO:\n TF:\n IVF:\n 1,752 mL\n 271 mL\n Blood products:\n 375 mL\n Total out:\n 1,275 mL\n 990 mL\n Urine:\n 1,275 mL\n 340 mL\n NG:\n 150 mL\n Stool:\n Drains:\n Balance:\n 972 mL\n -659 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: MMV/PSV/AutoFlow\n Vt (Set): 300 (300 - 300) mL\n Vt (Spontaneous): 399 (345 - 445) mL\n PS : 18 cmH2O\n RR (Set): 12\n RR (Spontaneous): 19\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 28 cmH2O\n Plateau: 20 cmH2O\n Compliance: 31.3 cmH2O/mL\n SpO2: 98%\n ABG: 7.44/38/102/23/1\n Ve: 6.8 L/min\n PaO2 / FiO2: 255\n Physical Examination\n Labs / Radiology\n 195 K/uL\n 8.9 g/dL\n 157 mg/dL\n 0.7 mg/dL\n 23 mEq/L\n 4.0 mEq/L\n 23 mg/dL\n 107 mEq/L\n 138 mEq/L\n 27.2 %\n 10.1 K/uL\n [image002.jpg]\n 12:28 AM\n 02:57 AM\n 03:14 AM\n 05:21 AM\n 12:25 PM\n 01:30 PM\n 06:52 PM\n 07:01 PM\n 02:03 AM\n 02:19 AM\n WBC\n 5.8\n 10.1\n Hct\n 24.7\n 23.8\n 23.1\n 27.2\n Plt\n 142\n 195\n Cr\n 0.6\n 0.7\n TCO2\n 27\n 30\n 29\n 28\n 28\n 27\n Glucose\n 141\n 157\n Other labs: PT / PTT / INR:15.0/31.5/1.3,\n CK / CKMB / Troponin-T:8//0.01,\n ALT / AST:17/19, Alk Phos / T Bili:106/0.6, Amylase / Lipase:/11,\n Lactic Acid:0.8 mmol/L, Albumin:2.4 g/dL, LDH:383 IU/L, Ca++:7.6 mg/dL,\n Mg++:2.0 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n TACHYCARDIA, OTHER\n ANEMIA, ACUTE, SECONDARY TO BLOOD LOSS (HEMORRHAGE, BLEEDING)\n FRACTURE, OTHER\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 11:14 AM\n 20 Gauge - 11:42 AM\n Arterial Line - 11:10 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 630716,
"text": "Pt was transferred back to the floor, and his Hct has remained stable.\n However, he has continued to have low grade fevers in the 100s and\n tachycardia to the 120s. ID work-up of this included a paracentesis on\n which was not c/w SBP (one dose of ceftriaxone given) and a\n negative CT torso on . He was found to have a left humeral\n fracture. Pt appeared to be clinically improving yesterday, and his NG\n tube feeds were restarted. However, at 4 AM, he spiked a fever to\n 101.9. He had increased work of breathing and at 8am had recorded\n tachypnea with RR in the 40s, O2 sats 84% on 2L (baseline high 90s on\n 2L), tachycardia to 140s (baseline 120s for past few days), and SBP\n high 80s-low 90s (baseline low 90s-100s). He was increased to 6L NC\n without improvement so was started on a 100% NRB with ABG 7.52/34/64.\n CXR showed new left lower lobe infiltrate. Portable abdomen without\n dilated bowel loops. VS at time of MICU floor evaluation were: T 99,\n BP 88/66, P 134, RR 32, O2sat 100% on NRB. Pt was started on broad\n antibiotic coverage for HAP/aspiration PNA with vancomycin, cefepime,\n and metronidazole and transferred to the MICU. Access with\n double-lumen PICC and 22g PIV.\n .\n In the unit, mother reports that pt's mental status is at baseline\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient alert moving all extremities as shift progresses with\n purposeful movement, lung diminished all fields, heart rate sinus\n tachycardia 120-130\ns systolic b/p 80-90\ns over 60\ns abd distended +\n bowel sounds Foley patent draining clear yellow urine remains NPO\n Action:\n Patient b/p dropped to high 70\ns over 60\ns. Trial humidified face mask\n for 2 hours off CPAP bolused with 1000 cc of normal saline\n Response:\n Patient had little response to fluid boluses tolerated 2 hour trial.\n Plan:\n Continue to try to wean off CPAP provide comfort and support as needed\n notify MICU of any changes Per Micu only trial every 6 hours\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 630975,
"text": "35 yo man who has been in hospital some time, with cerebral palsy, non\n verbal. admitted in with acute abdomen, peritonitis, chronic\n pancreatitits. Found to have SMV thrombus, anticoagulated, then\n developed retoperitoneal hemorrhage. Was on floor readmitted with\n progressive hypoxemia, intubated. Had CT with ? of liver abscess.\n CTA with LLL and RLL PNA and atelectasis, and effusions.\n UPDATE:\n Abdomen firm/distended. Pt w/ h/o ascites. CT showing some ascites,\n but more bowel gas. Monitor abdomen. NGT to Low Intermittent sxn.\n Plan for U/S of abdomen/Liver (Liver nodule- ?liver abcess vs lesion)\n on .\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Pt had slight HCT drop this am => 24.8.\n Action:\n HCT rechecked. Monitored for s/s of bleeding. Given Pantoprazole and\n ferrous sulfate.\n Response:\n HCT now 23.8. ICU team aware.\n Plan:\n Trend HCT, guaic stools, Pt w/ an active T&S (outdates ).\n Tachycardia, Other\n Assessment:\n HR 100s-120s, ST, no ectopy. SBP 80s-100s/60s-70s, ABP\n 80s-90s/50s-60s. Temp max 102.3 orally. Pt grimaces to pain w/\n turning and repositioning- pt w/ Lt UE fx (not in sling as pt not\n tolerating) Assumed pt on 30mcg of fent and 1mg of versed.\n Action:\n Given 650mg Po tyelenol, given 0.5mg versed x 1.\n Response:\n Temp now 100.6 orally. HR cont in the 100s-120s, ST. ABP in the\n 70s-80s following versed , .\n Plan:\n Monitor temp curve, f/u on cultures, tyelenol prn, cautiously\n prn.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Assumed on CMV 40%/20/300/10+. LS clear to rhonchorous throughout.\n Deep sxn\nd for small to moderate thick/yellow secretions. RR 20s at\n rest and 40s-50s w/ stimulation/repositioning and turning.\n Action:\n Sputum cx sent, antibiotics given. Place on PS 18/10+/40%.\n Response:\n ABG7.38/45/105/28 , O2 sats 95s-100%. RR 20s. LSCTA to b/l apices,\n diminished to b/l bases.\n Plan:\n Cont to wean vent as able, cont antibiotics\n"
},
{
"category": "Physician ",
"chartdate": "2115-03-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 631082,
"text": "Chief Complaint:\n 24 Hour Events:\n TRANS ESOPHAGEAL ECHO - At 10:30 AM\n TRANSTHORACIC ECHO - At 11:03 AM\n FEVER - 102.3\nF - 12:00 PM\n - Weaned to PS - F/U ABG 7.38/45/105/28/0\n - Spiked to 102.3, but already pan-cultured, on Abx\n - Final CT report recommends F/U US to evaluate liver lesion (?abscess)\n in 3 days (ordered)\n - Pt noted to be apneic (RR 2 at one pt, usually overbreathes vent) and\n change MS (not opening eyes or grimacing as usual), with SBP in 70s.\n Unclear precipitant, seizure vs post-ictal vs acute bleed. Started\n levophed with improved SBPs to 90s-100s, and improved MS quickly. Hct\n 23.1; ordered for 1 unit pRBC with repeat Hct post-transfusion.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Cefipime - 10:00 PM\n Metronidazole - 02:02 AM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Fentanyl (Concentrate) - 30 mcg/hour\n Norepinephrine - 0.07 mcg/Kg/min\n Other ICU medications:\n Midazolam (Versed) - 11:46 AM\n Heparin Sodium (Prophylaxis) - 01:44 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:29 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 39.1\nC (102.3\n Tcurrent: 37.7\nC (99.9\n HR: 106 (100 - 131) bpm\n BP: 96/73(83) {74/56(64) - 108/76(89)} mmHg\n RR: 25 (15 - 39) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,247 mL\n 331 mL\n PO:\n TF:\n IVF:\n 1,752 mL\n 271 mL\n Blood products:\n 375 mL\n Total out:\n 1,275 mL\n 990 mL\n Urine:\n 1,275 mL\n 340 mL\n NG:\n 150 mL\n Stool:\n Drains:\n Balance:\n 972 mL\n -659 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: MMV/PSV/AutoFlow\n Vt (Set): 300 (300 - 300) mL\n Vt (Spontaneous): 399 (345 - 445) mL\n PS : 18 cmH2O\n RR (Set): 12\n RR (Spontaneous): 19\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 28 cmH2O\n Plateau: 20 cmH2O\n Compliance: 31.3 cmH2O/mL\n SpO2: 98%\n ABG: 7.44/38/102/23/1\n Ve: 6.8 L/min\n PaO2 / FiO2: 255\n Physical Examination\n Labs / Radiology\n 195 K/uL\n 8.9 g/dL\n 157 mg/dL\n 0.7 mg/dL\n 23 mEq/L\n 4.0 mEq/L\n 23 mg/dL\n 107 mEq/L\n 138 mEq/L\n 27.2 %\n 10.1 K/uL\n [image002.jpg]\n 12:28 AM\n 02:57 AM\n 03:14 AM\n 05:21 AM\n 12:25 PM\n 01:30 PM\n 06:52 PM\n 07:01 PM\n 02:03 AM\n 02:19 AM\n WBC\n 5.8\n 10.1\n Hct\n 24.7\n 23.8\n 23.1\n 27.2\n Plt\n 142\n 195\n Cr\n 0.6\n 0.7\n TCO2\n 27\n 30\n 29\n 28\n 28\n 27\n Glucose\n 141\n 157\n Other labs: PT / PTT / INR:15.0/31.5/1.3,\n CK / CKMB / Troponin-T:8//0.01,\n ALT / AST:17/19, Alk Phos / T Bili:106/0.6, Amylase / Lipase:/11,\n Lactic Acid:0.8 mmol/L, Albumin:2.4 g/dL, LDH:383 IU/L, Ca++:7.6 mg/dL,\n Mg++:2.0 mg/dL, PO4:2.8 mg/dL\n Micro:\n - Sputum: NGTD\n - Blood cx: NGTD\n TTE ()\n The left atrium is normal in size. No atrial septal defect is seen by\n 2D or color Doppler. Left ventricular wall thicknesses are normal. The\n left ventricular cavity size is normal. Regional left ventricular wall\n motion is normal. There is mild to moderate global left ventricular\n hypokinesis suggested(LVEF = 45 %). There is no ventricular septal\n defect. Right ventricular chamber size and free wall motion are normal.\n The number of aortic valve leaflets cannot be determined. There is\n moderate aortic valve stenosis (valve area 1.0-1.2cm2). The mitral\n valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation\n is seen. There is mild pulmonary artery systolic hypertension. There is\n no pericardial effusion.\n..Compared with the prior study (images\n reviewed) of , the patient is more tachycardic. The LV systolic\n function now appears depressed. The aortic valve gradient appears\n similar. If indicated, a TEE would better clarify the basis and\n severity of the aortic stenosis (as well as global LV systolic\n function).\n .\n CTA ()\n 1. New bilateral patchy pneumonia, particularly within the left upper\n lobe\n and right middle lobe.\n 2. New ill-defined 2.8 x 3 cm hypoattenuating lesion in segment V of\n the\n liver. This may be secondary to a developing abscess. Follow-up\n ultrasound\n is recommended in 3 days.\n 3. Persistent sigmoid and rectal thickening with stable marked\n abdominal and\n pelvic ascites.\n 4. Stable left retroperitoneal bleed, more organized.\n 5. Increased moderate bilateral pleural effusions.\n Assessment and Plan\n TACHYCARDIA, OTHER\n ANEMIA, ACUTE, SECONDARY TO BLOOD LOSS (HEMORRHAGE, BLEEDING)\n FRACTURE, OTHER\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n 35 yo M with PMH of CP, seizure disorder, GIB, pancreatic cyst s/p\n drainage in , admitted with abdominal pain with complicated course,\n now with new fever, tachypnea, and hypoxia.\n .\n # Respiratory failure: Hypoxic with ABG on floor c/w respiratory\n alkalosis in setting of tachypnea. Given constellation of new fever,\n tachypnea, and significant hypoxia, as well as new opacities on CXR,\n concern for pneumonia - HAP v. aspiration (tube feeds restarted\n yesterday); less likely VAP as was extubated several weeks prior. \n also with a component of pleural effusion to opacities; recent TTE with\n nl EF but labs notable for low albumin. PE is also a concern as pt is\n bedbound; has not had pneumoboots on and just restarted heparin SQ\n yesterday for DVT ppx. Intubated in setting of declining resp\n status/PNA. CTA yesterday with final read pending, but shows\n infusions/infiltrates b/l. No PE on prelim read.\n - Serial ABG, recheck lactate\n - Continue broad antibiotic coverage for HAP/aspiration PNA with vanc,\n cefepime, metronidazole.\n - f/u sputum cx, f/u blood cultures\n - consider nasopharyngeal swab for viral\n - Repeat sputum sample\n - attempt weaning to PSV\n .\n # Fever/sepsis: Pt febrile with tachycardia and tachypnea; meets\n definition of sepsis with most likely source being pulmonary. With\n ascites, SBP is also possible although he is now s/p 3 taps which have\n not been c/w SBP. U/A appears clean. MS with no obvious\n nuchal rigidity although exam limited by pt cooperation. Again, PE\n could cause similar sx of fever and respiratory distress but none seen\n on prelim CTA.\n - F/u blood and urine cx, sputum cx, C. diff (urine with staph\n spp, UA dirty and UCx pending)\n - Consider abdominal u/s and paracentesis\n - Broad abx as above with good gram positive, gram neg, and anaerobic\n coverage\n - Goal CVP 8-12 but no measurements available currently\n will bolus\n for tachycardia, UOP < 30cc/h, goal MAP >65, CvO2 >70\n - Pressors not currently indicated; does have PICC in place for central\n access\n - Monitor mental status\n # Tachycardia: Likely hyperdynamic in setting of fever, infection.\n Volume status appears grossly euvolemic; pt mentating at and\n maintaining urine output. Echo with evidence of depressed cardiac fxn,\n ? tachycardia induced cardiomyopathy\n - Tylenol prn fever\n - Abx as above\n - Fluid boluses prn\n # Anemia/bleed: Hct stable. Pt with RP bleed and CT evidence of\n hemorrhage into bowel wall, also gastric varices c/b GIB earlier in\n admission.\n - Trend Hct\n - Guaiac stools\n - Active T&S\n - continue pantoprazole 40mg IV bid\n - Continue iron supplement\n # Liver lesion. Noted on abdominal CT. Possible abscess.\n - Abdominal U/S tomorrow\n - Discuss possible drainage with IR (? CT guided?)\n # Left humeral fx: Likely d/t trauma sustained during radiology.\n - No surgical indication at this time\n - Pain control with lidoderm patch and morphine prn\n .\n # SMV thrombus: Plan for anticoagulation x 6 months but held in setting\n of recent GI and RP bleed.\n - Continue heparin SQ\n .\n # Seizure disorder: No recent reports of seizures. Caution as certain\n antibiotics may lower seizure threshold.\n - Continue phenobarbitol and phenytoin\n .\n # Cerebral palsy: Stable mental status. Interactive with family but\n nonverbal at .\n .\n FEN: NG tube in stomach, bolus IVF, TPN\n PROPHYLAXIS: pneumoboots, IV PPI\n ACCESS: PICC, PIV, A-line\n CODE: Do not resuscitate. Ok to intubate or use pressors. No CPR or\n defibrillation\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 11:14 AM\n 20 Gauge - 11:42 AM\n Arterial Line - 11:10 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 631191,
"text": "35M with cerebral palsy, non verbal. Admitted in with acute\n abdomen, peritonitis, and chronic pancreatitis. Found to have SMV\n thrombus, anticoagulated which resulted in retoperitoneal hemorrhage.\n Was on floor when he was re-admitted with progressive hypoxemia and\n then subsequently intubated. CTA with LLL and RLL PNA and atelectasis,\n and effusions.\n Code Status: DNR, already intubated.\n Tachycardia, Other\n Assessment:\n Pt sinus tach most of shift ranging 100-130s, rare PVCs. Febrile to\n 101.1. Pt on levophed drip for hypotension.\n Action:\n Tachycardia likely related to levophed and/or fever. Pt pan-cultured\n and medicated with Tylenol for fever and fan placed in room for\n comfort. Levophed drip titrated up.\n Response:\n Pt\ns HR trending down as temp trending down. No change in HR as\n levophed drip titrated up. Multiple cultures pending.\n Plan:\n Continue to monitor heart rate and rhythm, positive correlation between\n HR and temp, consider switching to other pressor if HR affected.\n Follow up culture data.\n Respiratory failure, acute (not ARDS/)Anemia, acute, secondary to\n blood loss (Hemorrhage, Bleeding)\n Assessment:\n Received pt on CMV 40%/300*12/+10, RR 20s, STV 400s , MV . Lung\n sounds clear throughout. Copious oral secretions. Pt refusing mouth\n care most times. CXR revealing PNA and pulmonary edema.\n Action:\n Pt initially suctioned for small amounts of thick, tan secretions,\n later in shift secretions increasing to thin, yellow. Afternoon ABG\n 7.50/29/100. PEEP decreased to 8. Pt on multiple IV ABX for PNA,\n ordered for 40mg IV lasix however unable to give due to low BP.\n Response:\n Continues to mobilize secretions, especially after turns. ABG post\n vent change pending. HO aware Lasix dose held.\n Plan:\n Follow up ABG, continue pulmonary toilet and IV ABX, wean vent as\n tolerated by pt, give lasix for pulmonary edema when able.\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Pt received one unit PRBC overnight for\n Action:\n Response:\n Plan:\n"
},
{
"category": "Respiratory ",
"chartdate": "2115-03-25 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 630869,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: ICU\n Reason: Re-intubation; Comments: respiratory failure\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 6.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: / scant white\n Ventilation Assessment\n Level of breathing assistance: full support\n Visual assessment of breathing pattern: Normal quiet breathing\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Underlying illness not resolved\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 630872,
"text": "35 yo M with PMH of CP, seizure disorder, GIB, pancreatic cyst s/p\n drainage in , admitted with abdominal pain with complicated course,\n now with new fever, tachypnea, and hypoxia.\n Events: intubated yesterday\n A line placed right brachial. 20G PIV right next to the a line\n Code Status: DNR But can be intubated.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n I received the patient intubated and off sedation 2/2 blood pressure in\n the 70\ns by the cuff. RR 35 o2 sat 85-88%, heart rate 120\ns. Vent\n Settings CMV 60%/300/20/10. CXR was positive for fluid overload, and\n question of PNA. Lasix 40mg Iv was given on the previous shift.\n Action:\n Called the Intern\n Change the cuff the his right leg\n Respiratory called.\n Suctioned for a large amount of pink sputum.\n Monitored temps.\n Response:\n The right leg cuff pressure was up to the 90\ns with a map of\n 65.\n ICU team placed a right brachial a line ( which is right next\n to a 20G PIV). The wave form is damp, but the blood pressure is lower\n than the cuff pressure. But the A line has good return.\n Respiratory changed the filter in the circuit.\n After his o2 sat was 95% for one hour. ABG 7.42/40/110/0/27.\n Temp max 100.0 oral.\n Re-started his sedation fent 30mcg and the versed 1mg. With\n good effect noted.\n Plan:\n Follow cuff pressure.\n Keep map at 60-65.\n Monitor the filter, if it becomes saturate he drops is o2 sat(\n close communication with RT)\n Patient is on vanco and cefepime iv.\n Fio2 down to 40%.\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n On admission the patient was positive for a RP bleed with a CT which\n showed bleeding into the bowel. He also has gastric varices which was\n c/b GI bleed in his early admission.\n Action:\n HCT the morning\n Response:\n Was 26.3 now down to 24.7\n Plan:\n ICU team is aware no new orders at this time\n Fracture, other\n Assessment:\n Picc line placed on at that time he sustained a left arm fracture.\n His arm is not in a sling. He has a positive radial pulse noted. Full\n sensation and he is able to move the hand. Good cap refill noted.\n Action:\n Monitored for changes\n He is on a fent gtt\n Arm is elevated on a pillow.\n No turns to the left side.\n Response:\n With activity pain noted.\n Plan:\n Monitor left arm.\n 06:33\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 631063,
"text": "35 yo man who has been in hospital some time, with cerebral palsy, non\n verbal. admitted in with acute abdomen, peritonitis, chronic\n pancreatitits. Found to have SMV thrombus, anticoagulated, then\n developed retoperitoneal hemorrhage. Was on floor readmitted with\n progressive hypoxemia, intubated. Had CT with ? of liver abscess.\n CTA with LLL and RLL PNA and atelectasis, and effusions.\n Code Status: DNR but can be intubated .\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Patient has known RP on admission, which is resolving ( noted on ABD\n CT). His abdomen is large and firm, NG to low intermittent wall\n suction. Yesterday evening HCT 23.8\n Action:\n Blood ordered and started at 2100.\n Response:\n HCT 27\n Plan:\n Next HCT is do this evening.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n I received the patient on MMV 40% /18 with peep 10. O2 sat 98% RR with\n agitation is 40\ns to 50\ns. When he is calm his RR is 24. MV 700. I\n received him with lung sounds course and ronchi. A large amount of\n clear thick oral secretion noted.\n Action:\n No periods of Apnea noted.\n Suctioned for thick tan secretions noted. Suctioned every \n hours.\n Suctioned and performed VAP oral hygiene.\n Response:\n His lung sounds are clear upper lobes and diminished lower\n lobes.\n He still has a large amount of oral secretions. His tongue has\n a coat noted.\n Plan:\n Monitor for periods of apnea.\n Suction every 3 hours.\n Please get an order for nystatin.\n Fracture, other\n Assessment:\n Patient sustained a fracture of his left arm during PICC Line\n placement. Positive CSM noted to the left hand.\n Action:\n Elevated his arm on a pillow.\n He is able to lift and hold that arm when he is agitated.\n He is on Fent Gtt.\n Response:\n Good pain control noted.\n Plan:\n Cont with pain control.\n 06:52\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 631183,
"text": "35M with cerebral palsy, non verbal. Admitted in with acute\n abdomen, peritonitis, and chronic pancreatitis. Found to have SMV\n thrombus, anticoagulated which resulted in retoperitoneal hemorrhage.\n Was on floor when he was re-admitted with progressive hypoxemia and\n then subsequently intubated. CTA with LLL and RLL PNA and atelectasis,\n and effusions.\n Code Status: DNR, already intubated.\n Tachycardia, Other\n Assessment:\n Pt sinus tach most of shift ranging 100-130s, rare PVCs.\n Action:\n Response:\n Plan:\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 631431,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n Seizure, without status epilepticus\n Assessment:\n Action:\n Response:\n Plan:\n Tachycardia, Other\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 631432,
"text": "35M with cerebral palsy, non verbal. Admitted in with acute\n abdomen, peritonitis, and chronic pancreatitis. Found to have SMV\n thrombus, anticoagulated which resulted in retoperitoneal hemorrhage.\n Was on floor when he was re-admitted with progressive hypoxemia and\n then subsequently intubated. CTA with LLL and RLL PNA and atelectasis,\n and effusions.\n Code Status: DNR, already intubated.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n Seizure, without status epilepticus\n Assessment:\n Action:\n Response:\n Plan:\n Tachycardia, Other\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Respiratory ",
"chartdate": "2115-03-27 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 631363,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 4\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 6.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Underlying illness not resolved\n \\\n"
},
{
"category": "Nursing",
"chartdate": "2115-04-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 632596,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on 5 LNC, 40% face tent. Lungs clear/ diminished bases\n bilat. Strong dry non- productive cough. Sats 98-99% . marginal U/O\n condom cath.\n Action:\n 40 mg IV lasix given early afternoon, good diuresis. Minimal U/O\n trending down this am. U/o this am. MD notified.\n Response:\n Remains on FT+NC.\n Plan:\n Continue monitoring.\n"
},
{
"category": "Nursing",
"chartdate": "2115-04-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 632597,
"text": "35 yo man with cerebral palsy, recurrent aspiration. FUO. Blood cx\n from with yeast. Continues with thick secretions and significant\n oxygen requirement.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on 5 LNC, 40% face tent. Lungs clear/ diminished bases\n bilat. Strong dry non- productive cough. Sats 98-99% . marginal U/O\n condom cath.\n Action:\n 40 mg IV lasix given early afternoon, good diuresis. Minimal U/O\n trending down this am. U/o this am. MD notified.\n Response:\n Remains on FT+NC.\n Plan:\n Continue monitoring.\n"
},
{
"category": "Nursing",
"chartdate": "2115-04-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 632598,
"text": "Code Status: DNR/DNI.\n 35 yo man with cerebral palsy, recurrent aspiration. FUO. Blood cx\n from with yeast. Continues with thick secretions and significant\n oxygen requirement.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on 5 LNC, 40% face tent. Lungs clear/ diminished bases\n bilat. Strong dry non- productive cough. Sats 98-99% . marginal U/O\n condom cath. Patient has finished a course of IV AXB pneumonia.\n He is positive for MRSA in his sputum. HR 100-110. SBP 90\n Action:\n 40 mg IV lasix given early afternoon, good diuresis. Minimal U/O\n trending down this am. U/o this am. MD notified.\n Response:\n Remains on FT+NC.\n Plan:\n Continue monitoring.\n"
},
{
"category": "Nursing",
"chartdate": "2115-04-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 632729,
"text": "35 yo M with PMH of CP, seizure disorder, GIB, pancreatic cyst s/p\n drainage in , admitted with abdominal pain with complicated course\n now with fever, hypoxemia, blood culture growing yeast.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt on 70% face tent with additional 02 5L via n/c. LS clear bilat\n w/ dim bases. 02 sat 98-100%CXR w/ some pulm edema noted. 40mg lasix at\n the end of previous shift. 600ml UOP early in this shift r/t am lasix.\n With some ? of asp pna playing a part in increased 02 requirements. K+\n 3.5, Mg 1.8\n Action:\n 40mg IV lasix this pm, face tent weaned to 35%. Video swallow done to\n assess for aspiration. K+ and Mg repleted.\n Response:\n 02 sat rmains in the mid-high 90%\ns, UOP 500ml from pm lasix. Video\n swallow results show no aspiration of puree/ nectar thick liquids, pt\n diet advanced. Repeat K+ 4.6, Mg 2.8. P04 this pm 1.9, repleted w/\n 2pkts neutral phos.\n Plan:\n Monitor for uop goal is 500\n 750 ml negative.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Pt noted to have low grade fever to 100.3 ax, PICC line removed\n yesterday and only access R EJ #20ga.\n Action:\n Tylenol x1, PIV placed in L arm, EJ d/c\nd. cont on micafungin for +\n yeast in blood.\n Response:\n Temp down to 99 this pm.\n Plan:\n , monitor fever curve, monitor labs, Tylenol PRN, Surveillance cultures\n in am.\n"
},
{
"category": "Nursing",
"chartdate": "2115-04-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 632794,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt on 35% face tent with additional 02 5L via n/c. LS clear bilat\n w/ dim bases. 02 sat 98-100%. Pt with a strong productive cough. For\n pt is negative 500cc for the day.\n Action:\n Pt switched to only 4L NC, CXR obtained this AM\n Response:\n SpO2 continue to remain above 95%. Lung sounds clear in upper lobes\n with diminished breath sounds at the bases. Currently pt is positive\n 150cc.\n Plan:\n Monitor for uop goal is 500\n 750 ml negative. Titrate O2 as allowed.\n Follow up on AM CXR\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Pt noted to have low grade fever to 100.1 ax,\n Action:\n Tylenol x1,\n Response:\n Temp currently 99.3 PO, BC sent this AM with CBC/ Diff.\n Plan:\n ,monitor fever curve, monitor labs, Tylenol PRN, Surveillance cultures.\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 632052,
"text": "35 yo M with PMH of CP, seizure disorder, GIB, pancreatic cyst s/p\n drainage in , admitted with abdominal pain with complicated course,\n now with new fever, tachypnea, and hypoxia.\n Code Status: DNR, per family meeting will NOT re-intubate after\n extubation.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on CPAP+PS 40%/, RR teens with sats >95%. Lung sounds\n clear to rhonchorous. Pt off sedation, not following commands however\n withdraws to pain.\n Action:\n RSBI this AM, 40mg IV lasix given for fluid overload with goal fluid\n balance 1L negative at MN. Suctioned for small amounts of thin, blood\n tinged secretions.\n Response:\n RSBI this AM 92, SBT performed and tolerated 8/0 for 2 hours. Good\n response to IV lasix however still not near fluid goal. PM lytes sent\n at 1600.\n Plan:\n Plan to extubate tomorrow, replete lytes as needed, may require\n additional lasix dose to reach fluid balance, continue pulmonary\n toilet. Per family meeting will NOT re-intubate after extubation.\n"
},
{
"category": "Nursing",
"chartdate": "2115-04-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 632599,
"text": "Code Status: DNR/DNI.\n 35 yo man with cerebral palsy, recurrent aspiration. FUO. Blood cx\n from with yeast. Continues with thick secretions and significant\n oxygen requirement.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on 5 LNC, 40% face tent. Lungs clear/ diminished bases\n bilat. Strong dry non- productive cough. Sats 98-99% . marginal U/O\n condom cath. Patient has finished a course of IV AXB pneumonia.\n He is positive for MRSA in his sputum. HR 100-110. SBP 90\n Action:\n 40 mg IV lasix given early afternoon, good diuresis. Minimal U/O\n trending down this am. U/o this am. MD notified.\n Response:\n Remains on FT+NC. Low U/O\n Plan:\n Continue monitoring fever, hypoxia. Wean O2 as tolerated , maintain\n O2sat >92%, encourage coughing, pulmonary toilet. Monitor lytes and\n replete PRN.\n"
},
{
"category": "Nursing",
"chartdate": "2115-04-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 632721,
"text": "35 yo M with PMH of CP, seizure disorder, GIB, pancreatic cyst s/p\n drainage in , admitted with abdominal pain with complicated course\n now with fever, hypoxemia, blood culture growing yeast.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt on 70% face tent with additional 02 5L via n/c. LS clear bilat\n w/ dim bases. CXR w/ some pulm edema noted. 40mg lasix at the end of\n previous shift. With Als some ? of asp pna playing a part in increased\n 02 requirements.\n Action:\n 40mg IV lasix this pm\n Response:\n Pt noted to have only put out 420 ml and is 320 ml positive reason for\n 1800 additional lasix\n Condom cath placed\n Pt responded well to chest pt, able to cough up and swallows sputum\n Plan:\n Monitor for uop goal is ml negative\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Pt noted to have low grade fever to 100.1 oral, blood cultures from\n PICC\n Action:\n Arterial line pulled, new EJ placed right , orders for PICC to be\n removed, IV team aware, blood cultures redrawn, urine cultures redrawn,\n peritoneal fluid tapped from right lower quadand sent for cultures\n Tylenol given for fever,\n Speech and swallow eval\n pt to go for video swallow in am\n Medications changed from iv to po\n fluconazole iv changed to micoungin\n iv\n WBC 8.1 up from 7.3 previous day\n Response:\n Pt remains with intermittent fever to 100.1, team aware.\n Plan:\n Follow up cultures, monitor fever curve, monitor labs, wbc\n"
},
{
"category": "Respiratory ",
"chartdate": "2115-03-30 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 632049,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 7\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location: ICU\n Reason: Re-intubation\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 6.5mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thin\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: continue with\n diuresis and pulm.hygiene, optimize and plan for extubation \n :\n"
},
{
"category": "Physician ",
"chartdate": "2115-03-31 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 632119,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n -goal at least 1 liter negative today. Received multiple doses of\n lasix with moderate diuresis.\n -patient is not to be reintubated after extubation.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 06:00 PM\n Vancomycin - 08:00 PM\n Cefipime - 10:00 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 PM\n Other medications:\n Changes to medical and family history:\n Unchanged.\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n No Changes\n Flowsheet Data as of 06:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.1\nC (100.5\n Tcurrent: 37.2\nC (98.9\n HR: 112 (105 - 129) bpm\n BP: 80/61(69) {77/59(67) - 102/73(86)} mmHg\n RR: 24 (17 - 28) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 2,429 mL\n 462 mL\n PO:\n TF:\n 1,199 mL\n 301 mL\n IVF:\n 1,010 mL\n 60 mL\n Blood products:\n Total out:\n 3,580 mL\n 385 mL\n Urine:\n 3,320 mL\n 385 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,151 mL\n 77 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 303 (224 - 375) mL\n PS : 10 cmH2O\n RR (Spontaneous): 24\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 109\n PIP: 16 cmH2O\n SpO2: 96%\n ABG: 7.44/43/106/26/4\n Ve: 7.4 L/min\n PaO2 / FiO2: 265\n Physical Examination\n Gen: Thin, opening eyes but no clear orientation to voice\n HEENT: Sclera anicteric, eyes sunken, MMM, audible secretions\n Neck: Supple\n Lungs: Intubated, coarse BS bilaterally with diffuse ronchi\n CV: S1, S2 regular rhythm, increased rate\n Abdomen: Soft, BS+, distended, no facial grimacing to palpation\n GU: foley catheter in place\n Ext: Warm, cachectic, BLE contractures, + DP pulses\n Labs / Radiology\n 142 K/uL\n 9.5 g/dL\n 145 mg/dL\n 0.6 mg/dL\n 26 mEq/L\n 3.8 mEq/L\n 24 mg/dL\n 102 mEq/L\n 136 mEq/L\n 28.5 %\n 7.1 K/uL\n [image002.jpg]\n 07:36 AM\n 09:06 AM\n 02:18 PM\n 02:33 PM\n 05:01 AM\n 02:23 PM\n 03:50 AM\n 04:15 PM\n 02:46 AM\n 03:02 AM\n WBC\n 10.7\n 8.7\n 7.1\n Hct\n 30.4\n 30.2\n 28.5\n Plt\n \n Cr\n 0.6\n 0.7\n 0.6\n 0.6\n 0.6\n 0.6\n TCO2\n 27\n 25\n 27\n 30\n Glucose\n 118\n 116\n 85\n 139\n 150\n 145\n Other labs: PT / PTT / INR:15.9/27.4/1.4, CK / CKMB /\n Troponin-T:8//0.01, ALT / AST:17/19, Alk Phos / T Bili:106/0.6, Amylase\n / Lipase:/11, Differential-Neuts:86.5 %, Lymph:6.6 %, Mono:5.9 %,\n Eos:0.9 %, Lactic Acid:1.6 mmol/L, Albumin:2.4 g/dL, LDH:383 IU/L,\n Ca++:7.4 mg/dL, Mg++:2.1 mg/dL, PO4:2.2 mg/dL\n Assessment and Plan\n 35 yo M with PMH of CP, seizure disorder, GIB, pancreatic cyst s/p\n drainage in , admitted with abdominal pain with complicated course,\n now with new fever, tachypnea, and hypoxia.\n .\n # Respiratory failure: Patient transferred to MICU with tachypnea and\n hypoxia on and intubated on . Given his new fever,\n respiratory deterioration, and imaging findings consistent with\n multilobar pneumonia he was started on vancomycin, cefepime and flagyl\n (concern for aspiration given recently started tube feeds). Sputum\n growing MRSA. Pleural effusions also noted on imaging, likely due to\n fluid resuscitation for hypotension in the setting of albumin of 2.3,\n so over the past 24 hours have been diuresing with lasix boluses. PE\n considered but CTA negative.\n - discontinue antibiotic coverage for HAP/aspiration PNA with vanc,\n cefepime, metronidazole as patient has completed total 8 days (Day 1 =\n )\n - continue with daily RSBI and SBT as tolerated, likely will extubate\n today\n - follow ABGs\n - optimize for extubation\n - electrolytes with repletion while on Lasix\n - f/u blood cultures\n .\n # Fever/sepsis: Pt febrile with tachycardia and tachypnea; meets\n definition of sepsis with most likely source being pulmonary (MRSA).\n With ascites, SBP is also possible although he is now s/p 3 taps which\n have not been c/w SBP. Urinalysis and culture from with staph spp\n but repeat appears clean with NGTD. MS with no obvious\n nuchal rigidity although exam limited by pt cooperation. Again, PE\n could cause similar sx of fever and respiratory distress but none seen\n on CTA. Continues febrile daily. No further episodes of AMS. CT read as\n possible liver abscess but repeat RUQ ultrasound read as more\n consistent with infarct. C. Diff has been negative. Continues to have\n fever to 101 on overnight but normal white count, lactate normal.\n - Broad abx as above with good gram positive, gram neg, and anaerobic\n coverage. Consider adding additional coverage for double gram negative\n coverage if WBC does not continue trending down.\n - Goal CVP 8-12 but no measurements available currently\n will bolus\n for tachycardia, UOP < 30cc/h, goal MAP >60, CvO2 >70\n - Pressors for MAP > 55-60, off vasopressors\n - Monitor mental status\n - Consider paracentesis if continues febrile and no other source (would\n likely need to be done by IR)\n .\n #Hypotension. MAP goal > 60. No further episodes of AMS since starting\n pressors on . Not on vasopressors.\n # Tachycardia: Likely hyperdynamic in setting of fever, infection.\n Volume status appears grossly euvolemic; pt mentating at and\n maintaining urine output. Echo with evidence of depressed cardiac fxn,\n ? tachycardia induced cardiomyopathy\n - Tylenol prn fever\n - Abx as above\n - Fluid boluses prn, though patient with heart rate 110s;\n appears hypervolemic\n # Anemia/bleed: Hct stable. Pt with RP bleed and CT evidence of\n hemorrhage into bowel wall, also gastric varices c/b GIB earlier in\n admission. Transfused 1 unit pRBCs with appropriate bump and has\n remained stable since.\n - Trend Hct\n - Guaiac stools\n - Active T&S\n - continue pantoprazole 40mg IV bid\n - Continue iron supplement\n # Liver lesion. Noted on abdominal CT. Possible ischemia/infarction vs\n abscess. Abdominal U/S not consistent with abscess.\n # Left humeral fx: Likely d/t trauma sustained during radiology.\n - No surgical indication at this time\n - Pain control with lidoderm patch and morphine prn\n .\n # SMV thrombus: Plan for anticoagulation x 6 months but held in setting\n of recent GI and RP bleed.\n - Continue heparin SQ\n .\n # Seizure disorder: No recent reports of seizures. Caution as certain\n antibiotics may lower seizure threshold.\n - Continue phenobarbitol and phenytoin\n - drug levels stable as of \n .\n # Cerebral palsy: Stable mental status. Interactive with family but\n nonverbal at .\n .\n FEN: NG tube likely in duodenum, bolus IVF prn, TPN; continue tube\n feeds today\n PROPHYLAXIS: pneumoboots, IV PPI\n ACCESS: PICC, PIV, D/C A-line in right brachial artery\n CODE: Do not resuscitate/Do not re-intubate. No CPR or defibrillation\n ICU Care\n Nutrition:\n Vivonex (Full) - 06:25 AM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 11:14 AM\n Arterial Line - 11:10 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 631913,
"text": "35 yo M with PMH of CP, seizure disorder, GIB, pancreatic cyst s/p\n drainage in , admitted with abdominal pain with complicated course,\n now with new fever, tachypnea, and hypoxia.\n Code Status: Full Code.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n I received the patient on CPAP/PS 40% 5/10 with o2 sat 96%. With\n activity his HR will increase to the 120\n with activity. O2 sat 96%\n with RR 20\ns and with agitation or activity his RR will increase up to\n 40\ns and 50\ns. his CXR is positive for a multilobar pneumonia, she\n grew MRSA from sputum and also has effusion noted. temp max 100.6 oral.\n CXR this morning did show that the ET needed to be advanced. Patient\n has copious amounts of clear oral secretions noted. He is not sedated\n and coughing clear sputum for the ET,\n Action:\n He is on vanco/cefepime/flagyl\n Lasix 40mg iv was given.\n Tylenol given for temps.\n Oral care done every houres,\n Suctioned the ET every 2-3 hours.\n Evening labs obtained.\n Response:\n Patient did have good results with the lasix.\n He continues with low grade temps.\n Tylenol last given at 1730 via the NG.\n He continues to have a large amount of oral secretions.\n Phos and potassium was given PO.\n Plan:\n Family meeting today regarding extubation or trach. The Family wants\n him to be extubated when he is ready. But they do not want him trached.\n They feel he will loose what quality of life he had at home.\n Fracture, other\n Assessment:\n Patient left arm is fractured. He can move the hand, and when he is\n agitated he will reach for the ET.\n Action:\n When turning the patient I put him on his right side and back\n to supine position.\n Positioned his arm up on a pillow when he is on his right side.\n Tylenol given to help with the pain.\n Response:\n Unable to give the patients pain a number score. But I did note\n less facial grimace. And decrease in anxiety.\n Plan:\n Position patient for comfort.\n Give Tylenol.\n 18:50\n"
},
{
"category": "Nursing",
"chartdate": "2115-04-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 632782,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt on 35% face tent with additional 02 5L via n/c. LS clear bilat\n w/ dim bases. 02 sat 98-100%. Pt with a strong productive cough. For\n pt is negative 500cc for the day.\n Action:\n Pt switched to only 4L NC, CXR obtained this AM\n Response:\n SpO2 continue to remain above 95%. Lung sounds clear in upper lobes\n with diminished breath sounds at the bases. Currently pt is positive\n 150cc.\n Plan:\n Monitor for uop goal is 500\n 750 ml negative. Titrate O2 as allowed.\n Follow up on AM CXR\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Pt noted to have low grade fever to 100.1 ax,\n Action:\n Tylenol x1,\n Response:\n Temp currently 99.3 PO, BC sent this AM with CBC/ Diff.\n Plan:\n ,monitor fever curve, monitor labs, Tylenol PRN, Surveillance cultures.\n"
},
{
"category": "Physician ",
"chartdate": "2115-03-30 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 632013,
"text": "Chief Complaint: Respiratory Failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Completed 2 hr SBT sucessfully on 8/0 this AM\n 24 Hour Events:\n RSBI 93 this AM.\n History obtained from Medical records, icu team\n Patient unable to provide history: Encephalopathy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 02:00 AM\n Cefipime - 10:00 AM\n Metronidazole - 10:00 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Other medications:\n per ICU resident note\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fever\n Respiratory: mechanical ventilation\n Flowsheet Data as of 11:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.1\nC (100.6\n Tcurrent: 37.1\nC (98.8\n HR: 114 (114 - 125) bpm\n BP: 84/61(71) {83/60(70) - 104/75(87)} mmHg\n RR: 20 (19 - 34) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 1,966 mL\n 1,112 mL\n PO:\n TF:\n 1,201 mL\n 552 mL\n IVF:\n 665 mL\n 520 mL\n Blood products:\n Total out:\n 2,675 mL\n 580 mL\n Urine:\n 2,075 mL\n 580 mL\n NG:\n Stool:\n Drains:\n Balance:\n -709 mL\n 532 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 224 (224 - 381) mL\n PS : 10 cmH2O\n RR (Spontaneous): 23\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 93\n PIP: 15 cmH2O\n SpO2: 95%\n ABG: ///24/\n Ve: 6.9 L/min\n Physical Examination\n General Appearance: No acute distress\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Warm\n Neurologic: Attentive, No(t) Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed, more awake today\n Labs / Radiology\n 9.9 g/dL\n 189 K/uL\n 139 mg/dL\n 0.6 mg/dL\n 24 mEq/L\n 3.8 mEq/L\n 27 mg/dL\n 105 mEq/L\n 138 mEq/L\n 30.2 %\n 8.7 K/uL\n [image002.jpg]\n 01:56 PM\n 02:25 AM\n 02:42 AM\n 07:36 AM\n 09:06 AM\n 02:18 PM\n 02:33 PM\n 05:01 AM\n 02:23 PM\n 03:50 AM\n WBC\n 6.5\n 10.7\n 8.7\n Hct\n 28.1\n 30.4\n 30.2\n Plt\n 171\n 216\n 189\n Cr\n 0.6\n 0.6\n 0.6\n 0.7\n 0.6\n 0.6\n TCO2\n 29\n 27\n 25\n 27\n Glucose\n 153\n 136\n 118\n 116\n 85\n 139\n Other labs: PT / PTT / INR:15.7/27.6/1.4, CK / CKMB /\n Troponin-T:8//0.01, ALT / AST:17/19, Alk Phos / T Bili:106/0.6, Amylase\n / Lipase:/11, Differential-Neuts:86.5 %, Lymph:6.6 %, Mono:5.9 %,\n Eos:0.9 %, Lactic Acid:1.8 mmol/L, Albumin:2.4 g/dL, LDH:383 IU/L,\n Ca++:7.4 mg/dL, Mg++:2.6 mg/dL, PO4:2.0 mg/dL\n Assessment and Plan\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n ALTERATION IN NUTRITION\n TACHYCARDIA, OTHER\n ANEMIA, ACUTE, SECONDARY TO BLOOD LOSS (HEMORRHAGE, BLEEDING)\n FRACTURE, OTHER\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n 35 yo man with cerebral palsy with recurrent respiratory failure due to\n pneumonia and volume overload\n Respiratory Failure: RSBI good and passed SBT this AM. Cont\n vanc/cefepime Flagyl - tomorrow is last day. His CXR has not\n improved. Given that we will not plan to reintubate, we will plan to\n diurese aggressively today (goal 1L neg given his size) and aim for\n extubation tomorrow.\n Fevers: Cont abx - repeat CXRs of of PICC\n Remainder of issue per ICU team\n ICU Care\n Nutrition:\n Vivonex (Full) - 06:25 AM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 11:14 AM\n Arterial Line - 11:10 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition :ICU\n Total time spent: 32 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2115-03-30 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 632015,
"text": "Chief Complaint:\n 35 yo man who has been in hospital some time, with cerebral palsy, non\n verbal. admitted with acute abdomen, peritonitis, chronic\n pancreatitits. found to have SMV thrombus, anticoagulated, then\n developed retoperitoneal hemorrhage. Was on floor readmitted with\n progressive hypoxemia, intubated. Had CT with ? of liver abscess.\n CTA with LLL and RLL PNA and atelectasis, and effusions.\n 24 Hour Events:\n - continues w/ temp to 100.6 O/N with slightly elevated WBC this AM\n sent blood/urine cx, beta glucan, aspergillus, consider d/c picc\n - lasix 40 and 20IV boluses to net negative 700cc\n - Tolerating pressure support trial well; PEEP at 5 with PSV 10\n - ET tube advanced\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 10:41 AM\n Cefipime - 10:00 PM\n Vancomycin - 02:00 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 10:30 AM\n Pantoprazole (Protonix) - 08:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.1\nC (100.6\n Tcurrent: 37.8\nC (100.1\n HR: 117 (114 - 125) bpm\n BP: 91/66(77) {84/63(73) - 104/76(87)} mmHg\n RR: 25 (19 - 34) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 1,966 mL\n 608 mL\n PO:\n TF:\n 1,201 mL\n 331 mL\n IVF:\n 665 mL\n 278 mL\n Blood products:\n Total out:\n 2,675 mL\n 460 mL\n Urine:\n 2,075 mL\n 460 mL\n NG:\n Stool:\n Drains:\n Balance:\n -709 mL\n 148 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 309 (309 - 381) mL\n PS : 10 cmH2O\n RR (Spontaneous): 26\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 125\n PIP: 16 cmH2O\n SpO2: 97%\n ABG: ///24/\n Ve: 9.3 L/min\n Physical Examination\n Labs / Radiology\n 189 K/uL\n 9.9 g/dL\n 139 mg/dL\n 0.6 mg/dL\n 24 mEq/L\n 3.8 mEq/L\n 27 mg/dL\n 105 mEq/L\n 138 mEq/L\n 30.2 %\n 8.7 K/uL\n [image002.jpg]\n 01:56 PM\n 02:25 AM\n 02:42 AM\n 07:36 AM\n 09:06 AM\n 02:18 PM\n 02:33 PM\n 05:01 AM\n 02:23 PM\n 03:50 AM\n WBC\n 6.5\n 10.7\n 8.7\n Hct\n 28.1\n 30.4\n 30.2\n Plt\n 171\n 216\n 189\n Cr\n 0.6\n 0.6\n 0.6\n 0.7\n 0.6\n 0.6\n TCO2\n 29\n 27\n 25\n 27\n Glucose\n 153\n 136\n 118\n 116\n 85\n 139\n Other labs: PT / PTT / INR:15.7/27.6/1.4\n Ca++:7.4 mg/dL, Mg++:2.6 mg/dL, PO4:2.0 mg/dL\n Lactate: 1.8\n UA: mod LE, pos nitr, few bact, 298 WBC\n Assessment and Plan\n35 yo M with PMH of CP, seizure disorder, GIB, pancreatic cyst s/p\n drainage in , admitted with abdominal pain with complicated course,\n now with new fever, tachypnea, and hypoxia.\n .\n # Respiratory failure: Patient transferred to MICU with tachypnea and\n hypoxia on and intubated on . Given his new fever,\n respiratory deterioration, and imaging findings consistent with\n multilobar pneumonia he was started on vancomycin, cefepime and flagyl\n (concern for aspiration given recently started tube feeds). Sputum\n growing MRSA. Pleural effusions also noted on imaging, likely due to\n fluid resuscitation for hypotension in the setting of albumin of 2.3,\n so over the past 24 hours have been diuresing with lasix boluses. PE\n considered but CTA negative.\n - continue antibiotic coverage for HAP/aspiration PNA with vanc,\n cefepime, metronidazole x total 8 days (Day 1 = )\n - continue with daily RSBI and SBT as tolerated, attempt to wean to\n PSV; reduced PEEP from 8 to 5 this morning without problems\n - likely extubation tomorrow with optimization today\n - ABG later today\n - gentle diuresis with IV lasix boluses to goal net negative 1000cc\n - electrolytes with repletion while on Lasix\n - f/u blood cultures\n .\n # Fever/sepsis: Pt febrile with tachycardia and tachypnea; meets\n definition of sepsis with most likely source being pulmonary (MRSA).\n With ascites, SBP is also possible although he is now s/p 3 taps which\n have not been c/w SBP. Urinalysis and culture from with staph spp\n but repeat appears clean with NGTD. MS with no obvious\n nuchal rigidity although exam limited by pt cooperation. Again, PE\n could cause similar sx of fever and respiratory distress but none seen\n on CTA. Continues febrile daily. No further episodes of AMS. CT read as\n possible liver abscess but repeat RUQ ultrasound read as more\n consistent with infarct. C. Diff has been negative. Continues to have\n fever to 101 on overnight but normal white count, lactate normal.\n - Broad abx as above with good gram positive, gram neg, and anaerobic\n coverage. Consider adding additional coverage for double gram negative\n coverage if WBC does not continue trending down.\n - f/u beta glucan, aspergillus galactomannan\n - consider D/C picc line\n - Goal CVP 8-12 but no measurements available currently\n will bolus\n for tachycardia, UOP < 30cc/h, goal MAP >60, CvO2 >70\n - Pressors for MAP > 55-60, off vasopressors\n - Monitor mental status\n - Consider paracentesis if continues febrile and no other source (would\n likely need to be done by IR)\n - change foley today, follow up on culture data\n .\n #Hypotension. Off Vasopressors. pressures run low and\n currently sedated which may contribute. MAP goal > 60. No further\n episodes of AMS since starting pressors on .\n # Tachycardia: Likely hyperdynamic in setting of fever, infection.\n Volume status appears grossly euvolemic; pt mentating at and\n maintaining urine output. Echo with evidence of depressed cardiac fxn,\n ? tachycardia induced cardiomyopathy\n - Tylenol prn fever\n - Abx as above\n - Fluid boluses prn, though patient with heart rate 110s;\n appears hypervolemic\n # Anemia/bleed: Hct stable. Pt with RP bleed and CT evidence of\n hemorrhage into bowel wall, also gastric varices c/b GIB earlier in\n admission. Transfused 1 unit pRBCs with appropriate bump and has\n remained stable since.\n - Trend Hct\n - Guaiac stools\n - Active T&S\n - continue pantoprazole 40mg IV bid\n - Continue iron supplement\n # Liver lesion. Noted on abdominal CT. Possible ischemia/infarction vs\n abscess. Abdominal U/S not consistent with abscess.\n # Left humeral fx: Likely d/t trauma sustained during radiology.\n - No surgical indication at this time\n - Pain control with lidoderm patch and morphine prn\n .\n # SMV thrombus: Plan for anticoagulation x 6 months but held in setting\n of recent GI and RP bleed.\n - Continue heparin SQ\n .\n # Seizure disorder: No recent reports of seizures. Caution as certain\n antibiotics may lower seizure threshold.\n - Continue phenobarbitol and phenytoin\n - drug levels stable as of \n .\n # Cerebral palsy: Stable mental status. Interactive with family but\n nonverbal at .\n .\n FEN: NG tube likely in duodenum, bolus IVF prn, TPN; continue tube\n feeds today\n PROPHYLAXIS: pneumoboots, IV PPI\n ACCESS: PICC, PIV, D/C A-line in right brachial artery\n CODE: Do not resuscitate. Ok to intubate or use pressors. No CPR or\n defibrillation\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 11:14 AM\n Arterial Line - 11:10 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 632027,
"text": "35 yo M with PMH of CP, seizure disorder, GIB, pancreatic cyst s/p\n drainage in , admitted with abdominal pain with complicated course,\n now with new fever, tachypnea, and hypoxia.\n Code Status: DNR, per family meeting will NOT re-intubate after\n extubation.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n SBT this AM, 40mg IV lasix\n Response:\n Plan:\n Fracture, other\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Respiratory ",
"chartdate": "2115-03-31 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 632106,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 8\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 6.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thin\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Supra-sternal retractions\n Assessment of breathing comfort: No response (sleeping / sedated)\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: RSBI-109 (on 8/0)\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 632208,
"text": "35 yo M with PMH of CP, seizure disorder, GIB, pancreatic cyst s/p\n drainage in , admitted with abdominal pain with complicated course,\n now with new fever, tachypnea, and hypoxia.\n Code Status: DNR/DNI\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on CPAP+PS, RR in 20s with sats >95%, breathing appearing\n even and unlabored, lung sounds clear to diminished in bases.\n Action:\n AM RSBI in 90s, pt placed on SBT.\n Response:\n Tolerated SBT for 2 hours then extubated to humidified face tent. Sats\n dropping to high 80s approx 2 hours after extubation, FiO2 increased\n and placed on additional 4L NC with some effect. HO in to assess and\n ordered for 40mg lasix IVP. Good response from lasix, diuresed 600ccs,\n sats to mid then high 90s. Pt able to cough up secretions to back of\n throat, needs to be suctioned by RN/RT with yankaeur.\n Plan:\n Wean O2 as tolerated while maintaining good sats, encourage coughing,\n pulmonary toilet.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Pt spiked temp to 100.8. Tachy to 130s\n Action:\n Blood and urine cultures sent, received one dose PRN Tylenol.\n Response:\n Pt\ns temp down after Tylenol.\n Plan:\n Monitor temp curve, follow up culture data.\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 630972,
"text": "35 yo man who has been in hospital some time, with cerebral palsy, non\n verbal. admitted with acute abdomen, peritonitis, chronic\n pancreatitits. found to have SMV thrombus, anticoagulated, then\n developed retoperitoneal hemorrhage. Was on floor readmitted with\n progressive hypoxemia, intubated. Had CT with ? of liver abscess.\n CTA with LLL and RLL PNA and atelectasis, and effusions.\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n HCT 24.8.\n Action:\n HCT rechecked @ 1400. Monitored for s/s of bleeding. Given\n Pantoprazole and ferrous sulfate.\n Response:\n HCT now 23.8.\n Plan:\n Trend HCT, guaic stools\n Tachycardia, Other\n Assessment:\n HR 100s-120s, ST, no ectopy. SBP 80s-100s/60s-70s, ABP\n 80s-90s/50s-60s. Temp max 102.3 orally. Pt grimaces to pain w/\n turning and repositioning- pt w/ Lt UE fx.\n Action:\n Given 650mg Po tyelenol, given 0.5mg versed bolus x 1.\n Response:\n Temp now 100.6 orally. HR cont in the 100s-120s, ST.\n Plan:\n Monitor temp curve, f/u on cultures, tyelenol prn.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Assumed on CMV 40%/20/300/10+. LS clear to rhonchorous throughout.\n Deep sxn\nd for small to moderate thick/yellow secretions. RR 20s at\n rest and 40s-50s w/ stimulation/repositioning and turning.\n Action:\n Sputum cx sent, antibiotics given. Place on PS 18/10+/40%.\n Response:\n ABG , O2 sats 95s-100%. RR 20s. LSCTA.\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 632098,
"text": "35 yo M with PMH of CP, seizure disorder, GIB, pancreatic cyst s/p\n drainage in , admitted with abdominal pain with complicated course,\n now with new fever, tachypnea, and hypoxia.\n Code Status: DNR, per family meeting will NOT re-intubate after\n extubation.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on CPAP+PS 40%/, RR teens with sats >95%. Lung sounds\n clear w./dim bases Pt off sedation, not following commands however\n withdraws to pain. On final day of IV abx but cont to have LG fever.\n TMAx this shift 100.5. Foley changed on previous shift r/t persistent\n low grade temps. Being duiresed w/ lasix to optimize resp status for\n possible extubation this am. Was short of FB goal at the start of this\n shift. PM lytes showed K+ 3.3,\n Action:\n Additional 80mg IV lasix at start of this shift. K+ repleted with 60\n meq KCL. Tylenol for temp, morphine x2 for pain. Tube Feeding on hold\n at 2am foe possible extubation today.\n Response:\n 02 sat remains >95%, good UOP from lasix w/ FB net neg ~1L at\n midnight. AM lytes pending. Temp 98.9 at 4am RSBI this am 117 repeat\n K+ 3.8 this am.\n Plan:\n ?Plan to extubate today r/t RSBI of 117. Monitor/replete lytes as\n needed, continue pulmonary toilet. Per family meeting will NOT\n re-intubate after extubation.\n"
},
{
"category": "Rehab Services",
"chartdate": "2115-04-02 00:00:00.000",
"description": "Repeat Bedside Swallowing Evaluation",
"row_id": 632501,
"text": "TITLE:\n REPEAT BEDSIDE SWALLOWING EVALUATION\n HISTORY\n Thank you for reconsulting on this 35 year old man with long hospital\n stay, initially admitted on with abdominal pain, distention. At\n OSH found to have diffuse bowel edema, gastric varices, ascites, and\n pancreatic cyst on CT abd/pelvis. This admission has included\n intubation , , and . hospital course\n complicated by hypoxemia, multilobar PNA with sputum growing MRSA,\n yeast bacteremia with possible urogenital source, persistent fevers.\n With regard to feeding/nutritional history during this admission, was\n given TPN starting to . Has had tube feeds intermittently\n since , frequently held due to GI issues. RN notes, currently\n tolerating NGT feedings. GI was consulted, however pt not PEG\n candidate at this time due to ascites and other issues. RN, pt\n with significant secretions, though able to cough/swallow, especially\n in setting of humidified O2 via facemask.\n We met the pt on at which time he was inappropriate for PO intake\n due to GI issues. Eventually performed initial evaluation on \n with mother's assistance. He appeared safe for his baseline diet of\n pureed solids and nectar thick liquids and was recommended to maintain\n this diet during admission. However, PO status changed to NPO on \n and has not had PO intake since that time.\n mother, sister, and father present at bedside today. Report\n baseline diet of puree solids with occasional \"treats\" of ground and\n soft solids (e.g., Twinkies, PB + J ) which pt is able to take\n isolated bites of. mother reports using thick-it in drinks,\n though denies using enough to create \"nectar thick\" - she feels she\n uses a \"full spoon in the glass.\" Mother notes frequent\n coughing/choking at home, especially with liquids by cup.\n Past Medical History\n Cerebral Palsy\n cholecystectomy\n h/o pancreatic cyst drainage (last year, )\n h/o anemia (transfusion x2)\n EVALUATION:\n The examination was performed while the patient was seated upright in\n the chair, fed by mother.\n Cognition, language, speech, voice:\n Awake, alert, and attentive to mother. Becomes distressed/frowning\n when I palpate his throat. Consistently opens mouth for spoon,\n ?follows command to swallow. Non verbal with no vocalizations at all\n during my evaluation.\n Teeth: intact from what I can see - mother reports x per year\n dental trips, poor oral hygiene at home due to poor patient compliance\n Secretions: stringy secretions near corners of lips, but WNL on tongue\n from what I can see. Cannot evaluation posterior oropharynx.\n ORAL MOTOR EXAM:\n Did not test\n SWALLOWING ASSESSMENT:\n Pt offered pureed solids and nectar thick liquids by tspn only. For\n each bite, opens mouth and actively allows spoon in. Mother has to tip\n spoon up to extract bolus. Pt has munch-chew pattern with puree\n followed by delayed swallow. More timely with nectar thick liquids,\n without chewing. Pt had no throat clearing, coughing, choking during\n or after PO intake. We had removed O2 facemask and placed it lower on\n abd to allow mother into oral cavity with spoon - over the course of\n the evaluation, had gradual desaturation to 90% which could be related\n to poor oxygenation vs. silent aspiration. O2 sats returned to 100%\n with ceasing PO and returning O2 facemask.\n SUMMARY / IMPRESSION:\n Pt presents without overt s/sx of limited consistencies assessed today\n (pureed solids/nectar thick liquids), however with gradual decline in\n O2 sats concerning for possible silent aspiration in setting of\n Cerebral Palsy. Would recommend attempting videoswallow study with\n pt's mother present for PO feeding to obtain objective information\n regarding PO intake, at least in limited quantities. mother\n reports was not participatory in barium swallow study in the past.\n mother unavailable tomorrow morning, as she's going to MD appt.\n Will schedule for 3pm at a time when mother can join us. If her\n schedule becomes delayed, we will post- to Thursday, as cannot go\n later in the day Weds.\n The Functional Oral Intake Scale (FOIS) rating is deferred pending\n videoswallow results.\n RECOMMENDATIONS:\n 1. Maintain NPO pending video\n 2. Videoswallow study to be attempted with mother present at 3:00pm on\n or Thurs if mother unavailable.\n 3. Q4 oral care as able. Encourage humidified shovel mask since pt not\n likely to be cooperative with oral care\n These recommendations were shared with the patient, nurse and medical\n team.\n ____________________________________\n - M.S., CCC-SLP\n Pager # \n Face time: 14:15-14:45\n Total time: 60 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 630837,
"text": "35 yo M with PMH of CP, seizure disorder, GIB, pancreatic cyst s/p\n drainage in , admitted with abdominal pain with complicated course,\n now with new fever, tachypnea, and hypoxia.\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 630838,
"text": "35 yo M with PMH of CP, seizure disorder, GIB, pancreatic cyst s/p\n drainage in , admitted with abdominal pain with complicated course,\n now with new fever, tachypnea, and hypoxia.\n Events: intubated yesterday\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 632201,
"text": "35 yo M with PMH of CP, seizure disorder, GIB, pancreatic cyst s/p\n drainage in , admitted with abdominal pain with complicated course,\n now with new fever, tachypnea, and hypoxia.\n Code Status: DNR/DNI\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on CPAP+PS, RR in 20s with sats >95%, breathing appearing\n even and unlabored, lung sounds clear to diminished in bases.\n Action:\n AM RSBI in 90s, pt placed on SBT.\n Response:\n Tolerated SBT for 2 hours then extubated to humidified face tent. Sats\n dropping to high 80s approx 2 hours after extubation, FiO2 increased\n and placed on additional 4L NC with some effect. HO in to assess and\n ordered for 40mg lasix IVP. Good response from lasix, diuresed 600ccs,\n sats to mid then high 90s. Pt able to cough up secretions to back of\n throat, needs to be suctioned by RN/RT with yankaeur.\n Plan:\n Wean O2 as tolerated while maintaining good sats, encourage coughing,\n pulmonary toilet.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Pt spiked temp to 100.8. Tachy to 130s\n Action:\n Blood and urine cultures sent, received one dose PRN Tylenol.\n Response:\n Pt\ns temp down after Tylenol.\n Plan:\n Monitor temp curve, follow up culture data.\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 630849,
"text": "35 yo M with PMH of CP, seizure disorder, GIB, pancreatic cyst s/p\n drainage in , admitted with abdominal pain with complicated course,\n now with new fever, tachypnea, and hypoxia.\n Events: intubated yesterday\n A line placed right brachial. 20G PIV right next to the a line\n Code Status: DNR But can be intubated.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n I received the patient intubated and off sedation 2/2 blood pressure in\n the 70\ns by the cuff. RR 35 o2 sat 85-88%, heart rate 120\ns. Vent\n Settings CMV 60%/300/20/10. CXR was positive for fluid overload, and\n question of PNA. Lasix 40mg Iv was given on the previous shift.\n Action:\n Called the Intern\n Change the cuff the his right leg\n Respiratory called.\n Suctioned for a large amount of pink sputum.\n Response:\n The right leg cuff pressure was up to the 90\ns with a map of\n 65.\n ICU team placed a right brachial a line( which is right next to\n a 20G PIV). The wave form is damp, but the blood pressure is lower than\n the cuff pressure. But the A line has good return.\n Respiratory changed the filter in the circuit.\n After he o2 sat was 95% for one hour. ABG were\n Plan:\n Tachycardia, Other\n Assessment:\n Action:\n Response:\n Plan:\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Action:\n Response:\n Plan:\n Fracture, other\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 630850,
"text": "35 yo M with PMH of CP, seizure disorder, GIB, pancreatic cyst s/p\n drainage in , admitted with abdominal pain with complicated course,\n now with new fever, tachypnea, and hypoxia.\n Events: intubated yesterday\n A line placed right brachial. 20G PIV right next to the a line\n Code Status: DNR But can be intubated.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n I received the patient intubated and off sedation 2/2 blood pressure in\n the 70\ns by the cuff. RR 35 o2 sat 85-88%, heart rate 120\ns. Vent\n Settings CMV 60%/300/20/10. CXR was positive for fluid overload, and\n question of PNA. Lasix 40mg Iv was given on the previous shift.\n Action:\n Called the Intern\n Change the cuff the his right leg\n Respiratory called.\n Suctioned for a large amount of pink sputum.\n Monitored temps.\n Response:\n The right leg cuff pressure was up to the 90\ns with a map of\n 65.\n ICU team placed a right brachial a line ( which is right next\n to a 20G PIV). The wave form is damp, but the blood pressure is lower\n than the cuff pressure. But the A line has good return.\n Respiratory changed the filter in the circuit.\n After his o2 sat was 95% for one hour. ABG 7.42/40/110/0/27.\n Temp max 100.0 oral.\n Plan:\n Follow cuff pressure.\n Keep map at 60-65.\n Monitor the filter, if it becomes saturate he drops is o2 sat(\n close communication with RT)\n Patient is on vanco and cefepime iv.\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n On admission the patient was positive for a RP bleed with a CT which\n showed bleeding into the bowel. He also has gastric varices which was\n c/b GI bleed in his early admission.\n Action:\n HCT the morning\n Response:\n Was 26.3 now down to 24.7\n Plan:\n ICU team is aware no new orders at this time\n Fracture, other\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 630851,
"text": "35 yo M with PMH of CP, seizure disorder, GIB, pancreatic cyst s/p\n drainage in , admitted with abdominal pain with complicated course,\n now with new fever, tachypnea, and hypoxia.\n Events: intubated yesterday\n A line placed right brachial. 20G PIV right next to the a line\n Code Status: DNR But can be intubated.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n I received the patient intubated and off sedation 2/2 blood pressure in\n the 70\ns by the cuff. RR 35 o2 sat 85-88%, heart rate 120\ns. Vent\n Settings CMV 60%/300/20/10. CXR was positive for fluid overload, and\n question of PNA. Lasix 40mg Iv was given on the previous shift.\n Action:\n Called the Intern\n Change the cuff the his right leg\n Respiratory called.\n Suctioned for a large amount of pink sputum.\n Monitored temps.\n Response:\n The right leg cuff pressure was up to the 90\ns with a map of\n 65.\n ICU team placed a right brachial a line ( which is right next\n to a 20G PIV). The wave form is damp, but the blood pressure is lower\n than the cuff pressure. But the A line has good return.\n Respiratory changed the filter in the circuit.\n After his o2 sat was 95% for one hour. ABG 7.42/40/110/0/27.\n Temp max 100.0 oral.\n Re-started his sedation fent 30mcg and the versed 1mg. With\n good effect noted.\n Plan:\n Follow cuff pressure.\n Keep map at 60-65.\n Monitor the filter, if it becomes saturate he drops is o2 sat(\n close communication with RT)\n Patient is on vanco and cefepime iv.\n Fio2 down to 40%.\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n On admission the patient was positive for a RP bleed with a CT which\n showed bleeding into the bowel. He also has gastric varices which was\n c/b GI bleed in his early admission.\n Action:\n HCT the morning\n Response:\n Was 26.3 now down to 24.7\n Plan:\n ICU team is aware no new orders at this time\n Fracture, other\n Assessment:\n Picc line placed on at that time he sustained a left arm fracture.\n His arm is not in a sling. He has a positive radial pulse noted. Full\n sensation and he is able to move the hand. Good cap refill noted.\n Action:\n Monitored for changes\n He is on a fent gtt\n Arm is elevated on a pillow.\n No turns to the left side.\n Response:\n With activity pain noted.\n Plan:\n Monitor left arm.\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 630961,
"text": "35 yo man who has been in hospital some time, with cerebral palsy, non\n verbal. admitted with acute abdomen, peritonitis, chronic\n pancreatitits. found to have SMV thrombus, anticoagulated, then\n developed retoperitoneal hemorrhage. Was on floor readmitted with\n progressive hypoxemia, intubated. Had CT with ? of liver abscess.\n CTA with LLL and RLL PNA and atelectasis, and effusions.\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n HCT 24.8.\n Action:\n HCT rechecked @ 1400. Monitored for s/s of bleeding. Given\n Pantoprazole and ferrous sulfate.\n Response:\n HCT now 23.8.\n Plan:\n Monitor HCT, guaic stools.\n Tachycardia, Other\n Assessment:\n HR 100s-120s, ST, no ectopy. SBP 80s-100s/60s-70s, ABP\n 80s-90s/50s-60s. Temp max 102.3 orally. Pt grimaces to pain w/\n turning and repositioning- pt w/ Lt UE fx.\n Action:\n Given 650mg Po tyelenol, given 0.5mg versed bolus x 1.\n Response:\n Temp now 100.6 orally. HR cont in the 100s-120s, ST.\n Plan:\n Monitor temp curve, f/u on cultures, tyelenol prn.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Assumed on CMV 40%/20/300/10+. LS clear to rhonchorous throughout.\n Deep sxn\nd for small to moderate thick/yellow secretions. RR 20s at\n rest and 40s-50s w/ stimulation/repositioning and turning.\n Action:\n Sputum cx sent, antibiotics given. Place\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 630965,
"text": "35 yo man who has been in hospital some time, with cerebral palsy, non\n verbal. admitted with acute abdomen, peritonitis, chronic\n pancreatitits. found to have SMV thrombus, anticoagulated, then\n developed retoperitoneal hemorrhage. Was on floor readmitted with\n progressive hypoxemia, intubated. Had CT with ? of liver abscess.\n CTA with LLL and RLL PNA and atelectasis, and effusions.\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n HCT 24.8.\n Action:\n HCT rechecked @ 1400. Monitored for s/s of bleeding. Given\n Pantoprazole and ferrous sulfate.\n Response:\n HCT now 23.8.\n Plan:\n Monitor HCT, guaic stools.\n Tachycardia, Other\n Assessment:\n HR 100s-120s, ST, no ectopy. SBP 80s-100s/60s-70s, ABP\n 80s-90s/50s-60s. Temp max 102.3 orally. Pt grimaces to pain w/\n turning and repositioning- pt w/ Lt UE fx.\n Action:\n Given 650mg Po tyelenol, given 0.5mg versed bolus x 1.\n Response:\n Temp now 100.6 orally. HR cont in the 100s-120s, ST.\n Plan:\n Monitor temp curve, f/u on cultures, tyelenol prn.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Assumed on CMV 40%/20/300/10+. LS clear to rhonchorous throughout.\n Deep sxn\nd for small to moderate thick/yellow secretions. RR 20s at\n rest and 40s-50s w/ stimulation/repositioning and turning.\n Action:\n Sputum cx sent, antibiotics given. Place on PS 18/10+/40%.\n Response:\n ABG , O2 sats 95s-100%. RR 20s. LSCTA.\n Plan:\n"
},
{
"category": "Respiratory ",
"chartdate": "2115-03-25 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 630967,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 20 cm at teeth\n Route: Oral\n Type: Standard\n Size: 6.5mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Pt on the vent changes made tol well. See respiratory page of meta\n vision for more information.\n"
},
{
"category": "Social Work",
"chartdate": "2115-03-25 00:00:00.000",
"description": "Social Work Progress Note",
"row_id": 630964,
"text": "Social Work:\n SW met with pt\ns mother at bedside in MICU as he was just transferred\n to this unit last night. Mother states she slept in an empty consult\n room in the 6^th floor family waiting room and was comfortable there\n last night. Informed her of 7^th floor ICU family sleep room, but she\n denied interest in this, stating she would prefer to stay on the 6^th\n floor again. Also informed her of access to showers at Be Well across\n the street if she wishes to use these, but she states she plans to go\n home tomorrow to shower, attend to responsibilities there, and rest a\n bit before returning to the hospital to be with pt. Provided parking\n stickers. Discussed pt\ns prolonged hospitalization with multiple ICU\n admissions and how difficult this has been. Mo speaks of feeling\n well-supported by husband and family, however, and though tearful and\n expressing some weariness, she seems to be coping well given difficult\n circumstances. Informed her of ongoing availability of SW for added\n support as needed and provided SW contact info. Discussed with RN.\n Please page with any questions or concerns.\n , LICSW, #\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 631043,
"text": "35 yo man who has been in hospital some time, with cerebral palsy, non\n verbal. admitted in with acute abdomen, peritonitis, chronic\n pancreatitits. Found to have SMV thrombus, anticoagulated, then\n developed retoperitoneal hemorrhage. Was on floor readmitted with\n progressive hypoxemia, intubated. Had CT with ? of liver abscess.\n CTA with LLL and RLL PNA and atelectasis, and effusions.\n Code Status: DNR but can be intubated .\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Fracture, other\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Respiratory ",
"chartdate": "2115-03-26 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 631161,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Tube Type\n ETT:\n Position: 20 cm at teeth\n Route: Oral\n Type: Standard\n Size: 6.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Pt on the vent changes made tol well. See respiratory page of meta\n vision for more information.\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 630957,
"text": "35 yo man who has been in hospital some time, with cerebral palsy, non\n verbal. admitted with acute abdomen, peritonitis, chronic\n pancreatitits. found to have SMV thrombus, anticoagulated, then\n developed retoperitoneal hemorrhage. Was on floor readmitted with\n progressive hypoxemia, intubated. Had CT with ? of liver abscess.\n CTA with LLL and RLL PNA and atelectasis, and effusions.\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Action:\n Response:\n Plan:\n Tachycardia, Other\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2115-03-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 631284,
"text": "Chief Complaint:\n 24 Hour Events:\n PAN CULTURE - At 04:00 PM\n FEVER - 101.1\nF - 04:00 PM\n - During the day had increased levophed requirement to maintain MAP >65\n (lactate nml) but then O/N able to wean down (from 0.2 to 0.08)\n - Got 40IV lasix overnight as discussed yesterday\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Cefipime - 11:00 PM\n Metronidazole - 01:22 AM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Fentanyl (Concentrate) - 30 mcg/hour\n Norepinephrine - 0.06 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 PM\n Fosphenytoin - 11:59 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.4\nC (101.1\n Tcurrent: 37.5\nC (99.5\n HR: 115 (102 - 131) bpm\n BP: 99/48(73) {88/48(62) - 118/83(90)} mmHg\n RR: 29 (16 - 34) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 2,206 mL\n 658 mL\n PO:\n TF:\n 65 mL\n 132 mL\n IVF:\n 1,166 mL\n 221 mL\n Blood products:\n Total out:\n 2,545 mL\n 1,150 mL\n Urine:\n 1,895 mL\n 1,150 mL\n NG:\n 150 mL\n Stool:\n Drains:\n Balance:\n -339 mL\n -492 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: MMV/PSV/AutoFlow\n Vt (Set): 300 (300 - 300) mL\n Vt (Spontaneous): 312 (312 - 402) mL\n PS : 12 cmH2O\n RR (Set): 12\n RR (Spontaneous): 27\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 141\n PIP: 21 cmH2O\n Plateau: 22 cmH2O\n Compliance: 23.4 cmH2O/mL\n SpO2: 95%\n ABG: 7.45/33/125/24/0\n Ve: 9.6 L/min\n PaO2 / FiO2: 313\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 206 K/uL\n 9.5 g/dL\n 99 mg/dL\n 0.6 mg/dL\n 24 mEq/L\n 3.7 mEq/L\n 26 mg/dL\n 107 mEq/L\n 140 mEq/L\n 28.9 %\n 8.1 K/uL\n [image002.jpg]\n 01:30 PM\n 06:52 PM\n 07:01 PM\n 02:03 AM\n 02:19 AM\n 03:29 PM\n 03:46 PM\n 06:28 PM\n 03:24 AM\n 03:52 AM\n WBC\n 10.1\n 8.1\n Hct\n 23.8\n 23.1\n 27.2\n 27.5\n 28.9\n Plt\n 195\n 206\n Cr\n 0.7\n 0.6\n TCO2\n 28\n 27\n 23\n 22\n 24\n Glucose\n 157\n 99\n Other labs:\n PT / PTT / INR:15.6/25.5/1.4\n Ca++:7.9 mg/dL, Mg++:1.8 mg/dL, PO4:3.4 mg/dL\n Micro:\n : Sputum with no microorganisms on gram stain, S. aureus on\n culture (prelim)\n : Sputum with no microorganisms on gram stain, GNR on culture\n (prelim)\n : All blood, urine cx pending or no growth\n Assessment and Plan\n ICU Care\n Nutrition:\n Vivonex (Full) - 05:30 PM 20 mL/hour\n TPN w/ Lipids - 06:00 PM 45 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 11:14 AM\n 20 Gauge - 11:42 AM\n Arterial Line - 11:10 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2115-03-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 631288,
"text": "Chief Complaint:\n 24 Hour Events:\n PAN CULTURE - At 04:00 PM\n FEVER - 101.1\nF - 04:00 PM\n - During the day had increased levophed requirement to maintain MAP >65\n (lactate nml) but then O/N able to wean down (from 0.2 to 0.08)\n - Got 40IV lasix overnight as discussed yesterday\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Cefipime - 11:00 PM\n Metronidazole - 01:22 AM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Fentanyl (Concentrate) - 30 mcg/hour\n Norepinephrine - 0.06 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 PM\n Fosphenytoin - 11:59 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.4\nC (101.1\n Tcurrent: 37.5\nC (99.5\n HR: 115 (102 - 131) bpm\n BP: 99/48(73) {88/48(62) - 118/83(90)} mmHg\n RR: 29 (16 - 34) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 2,206 mL\n 658 mL\n PO:\n TF:\n 65 mL\n 132 mL\n IVF:\n 1,166 mL\n 221 mL\n Blood products:\n Total out:\n 2,545 mL\n 1,150 mL\n Urine:\n 1,895 mL\n 1,150 mL\n NG:\n 150 mL\n Stool:\n Drains:\n Balance:\n -339 mL\n -492 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: MMV/PSV/AutoFlow\n Vt (Set): 300 (300 - 300) mL\n Vt (Spontaneous): 312 (312 - 402) mL\n PS : 12 cmH2O\n RR (Set): 12\n RR (Spontaneous): 27\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 141\n PIP: 21 cmH2O\n Plateau: 22 cmH2O\n Compliance: 23.4 cmH2O/mL\n SpO2: 95%\n ABG: 7.45/33/125/24/0\n Ve: 9.6 L/min\n PaO2 / FiO2: 313\n Physical Examination\n Gen: Thin, appears sedated/comfortable at rest, opening eyes but no\n clear orientation to voice\n HEENT: Sclera anicteric, eyes sunken, MMM\n Neck: Supple, thin, EJs prominent and hyperdynamic, no LAD\n Lungs: Intubated, coarse BS bilaterally with soft ronchi\n CV: Regular but tachycardic, normal S1 + S2, unable to appreciate any\n murmurs, rubs, gallops\n Abdomen: Soft, BS+, distended, pt appears uncomfortable on palpations\n GU: Condom cath in place\n Ext: Warm, cachectic, BLE contractures, + DP pulses, no cyanosis or\n edema\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 206 K/uL\n 9.5 g/dL\n 99 mg/dL\n 0.6 mg/dL\n 24 mEq/L\n 3.7 mEq/L\n 26 mg/dL\n 107 mEq/L\n 140 mEq/L\n 28.9 %\n 8.1 K/uL\n [image002.jpg]\n 01:30 PM\n 06:52 PM\n 07:01 PM\n 02:03 AM\n 02:19 AM\n 03:29 PM\n 03:46 PM\n 06:28 PM\n 03:24 AM\n 03:52 AM\n WBC\n 10.1\n 8.1\n Hct\n 23.8\n 23.1\n 27.2\n 27.5\n 28.9\n Plt\n 195\n 206\n Cr\n 0.7\n 0.6\n TCO2\n 28\n 27\n 23\n 22\n 24\n Glucose\n 157\n 99\n Other labs:\n PT / PTT / INR:15.6/25.5/1.4\n Ca++:7.9 mg/dL, Mg++:1.8 mg/dL, PO4:3.4 mg/dL\n Micro:\n : Sputum with no microorganisms on gram stain, S. aureus on\n culture (prelim)\n : Sputum with no microorganisms on gram stain, GNR on culture\n (prelim)\n : All blood, urine cx pending or no growth\n Assessment and Plan\n ICU Care\n Nutrition:\n Vivonex (Full) - 05:30 PM 20 mL/hour\n TPN w/ Lipids - 06:00 PM 45 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 11:14 AM\n 20 Gauge - 11:42 AM\n Arterial Line - 11:10 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2115-03-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 631292,
"text": "Chief Complaint:\n 24 Hour Events:\n PAN CULTURE - At 04:00 PM\n FEVER - 101.1\nF - 04:00 PM\n - During the day had increased levophed requirement to maintain MAP >65\n (lactate nml) but then O/N able to wean down (from 0.2 to 0.08)\n - Got 40IV lasix overnight as discussed yesterday\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Cefipime - 11:00 PM\n Metronidazole - 01:22 AM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Fentanyl (Concentrate) - 30 mcg/hour\n Norepinephrine - 0.06 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 PM\n Fosphenytoin - 11:59 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.4\nC (101.1\n Tcurrent: 37.5\nC (99.5\n HR: 115 (102 - 131) bpm\n BP: 99/48(73) {88/48(62) - 118/83(90)} mmHg\n RR: 29 (16 - 34) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 2,206 mL\n 658 mL\n PO:\n TF:\n 65 mL\n 132 mL\n IVF:\n 1,166 mL\n 221 mL\n Blood products:\n Total out:\n 2,545 mL\n 1,150 mL\n Urine:\n 1,895 mL\n 1,150 mL\n NG:\n 150 mL\n Stool:\n Drains:\n Balance:\n -339 mL\n -492 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: MMV/PSV/AutoFlow\n Vt (Set): 300 (300 - 300) mL\n Vt (Spontaneous): 312 (312 - 402) mL\n PS : 12 cmH2O\n RR (Set): 12\n RR (Spontaneous): 27\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 141\n PIP: 21 cmH2O\n Plateau: 22 cmH2O\n Compliance: 23.4 cmH2O/mL\n SpO2: 95%\n ABG: 7.45/33/125/24/0\n Ve: 9.6 L/min\n PaO2 / FiO2: 313\n Physical Examination\n Gen: Thin, appears sedated/comfortable at rest, opening eyes but no\n clear orientation to voice\n HEENT: Sclera anicteric, eyes sunken, MMM\n Neck: Supple, thin, EJs prominent and hyperdynamic, no LAD\n Lungs: Intubated, coarse BS bilaterally with soft ronchi\n CV: Regular but tachycardic, normal S1 + S2, unable to appreciate any\n murmurs, rubs, gallops\n Abdomen: Soft, BS+, distended, pt appears uncomfortable on palpations\n GU: Condom cath in place\n Ext: Warm, cachectic, BLE contractures, + DP pulses, no cyanosis or\n edema\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 206 K/uL\n 9.5 g/dL\n 99 mg/dL\n 0.6 mg/dL\n 24 mEq/L\n 3.7 mEq/L\n 26 mg/dL\n 107 mEq/L\n 140 mEq/L\n 28.9 %\n 8.1 K/uL\n [image002.jpg]\n 01:30 PM\n 06:52 PM\n 07:01 PM\n 02:03 AM\n 02:19 AM\n 03:29 PM\n 03:46 PM\n 06:28 PM\n 03:24 AM\n 03:52 AM\n WBC\n 10.1\n 8.1\n Hct\n 23.8\n 23.1\n 27.2\n 27.5\n 28.9\n Plt\n 195\n 206\n Cr\n 0.7\n 0.6\n TCO2\n 28\n 27\n 23\n 22\n 24\n Glucose\n 157\n 99\n Other labs:\n PT / PTT / INR:15.6/25.5/1.4\n Ca++:7.9 mg/dL, Mg++:1.8 mg/dL, PO4:3.4 mg/dL\n Micro:\n : Sputum with no microorganisms on gram stain, S. aureus on\n culture (prelim)\n : Sputum with no microorganisms on gram stain, GNR on culture\n (prelim)\n : All blood, urine cx pending or no growth\n Assessment and Plan\n 35 yo M with PMH of CP, seizure disorder, GIB, pancreatic cyst s/p\n drainage in , admitted with abdominal pain with complicated course,\n now with new fever, tachypnea, and hypoxia.\n .\n # Respiratory failure: Hypoxic with ABG on floor c/w respiratory\n alkalosis in setting of tachypnea. Given constellation of new fever,\n tachypnea, and significant hypoxia, as well as new opacities on CXR,\n concern for pneumonia - HAP v. aspiration (tube feeds restarted\n yesterday); less likely VAP as was extubated several weeks prior. \n also with a component of pleural effusion to opacities; recent TTE with\n nl EF but labs notable for low albumin. PE is also a concern as pt is\n bedbound; has not had pneumoboots on and just restarted heparin SQ\n yesterday for DVT ppx. Intubated in setting of declining resp\n status/PNA. CTA yesterday with final read pending, but shows\n infusions/infiltrates b/l. No PE on prelim read.\n - Serial ABG, recheck lactate\n - Continue broad antibiotic coverage for HAP/aspiration PNA with vanc,\n cefepime, metronidazole.\n - f/u sputum cx, f/u blood cultures\n - consider nasopharyngeal swab for viral\n - sputum sample with staph aureus (no sensitivities yet)\n - attempt weaning to PSV\n .\n # Fever/sepsis: Pt febrile with tachycardia and tachypnea; meets\n definition of sepsis with most likely source being pulmonary. With\n ascites, SBP is also possible although he is now s/p 3 taps which have\n not been c/w SBP. U/A appears clean. MS with no obvious\n nuchal rigidity although exam limited by pt cooperation. Again, PE\n could cause similar sx of fever and respiratory distress but none seen\n on prelim CTA.\n - F/u blood and urine cx, sputum cx, C. diff (urine with staph\n spp, UA dirty and UCx pending)\n - Consider abdominal u/s and paracentesis\n - Broad abx as above with good gram positive, gram neg, and anaerobic\n coverage\n - Goal CVP 8-12 but no measurements available currently\n will bolus\n for tachycardia, UOP < 30cc/h, goal MAP >65, CvO2 >70\n - Pressors for MAP > 65, wean levophed\n - Monitor mental status\n # Tachycardia: Likely hyperdynamic in setting of fever, infection.\n Volume status appears grossly euvolemic; pt mentating at and\n maintaining urine output. Echo with evidence of depressed cardiac fxn,\n ? tachycardia induced cardiomyopathy\n - Tylenol prn fever\n - Abx as above\n - Fluid boluses prn, though patient with heart rate 110s;\n appears hypervolemic\n # Anemia/bleed: Hct stable. Pt with RP bleed and CT evidence of\n hemorrhage into bowel wall, also gastric varices c/b GIB earlier in\n admission. Transfused 1 unit pRBCs yesterday with appropriate bump\n - Trend Hct\n - Guaiac stools\n - Active T&S\n - continue pantoprazole 40mg IV bid\n - Continue iron supplement\n # Liver lesion. Noted on abdominal CT. Possible abscess.\n - Abdominal U/S tomorrow to eval for interval change\n - Discuss possible drainage with IR (? CT guided?)\n # Left humeral fx: Likely d/t trauma sustained during radiology.\n - No surgical indication at this time\n - Pain control with lidoderm patch and morphine prn\n .\n # SMV thrombus: Plan for anticoagulation x 6 months but held in setting\n of recent GI and RP bleed.\n - Continue heparin SQ\n .\n # Seizure disorder: No recent reports of seizures. Caution as certain\n antibiotics may lower seizure threshold.\n - Continue phenobarbitol and phenytoin\n - will check drug levels tomorrow\n .\n # Cerebral palsy: Stable mental status. Interactive with family but\n nonverbal at .\n .\n FEN: NG tube likely in duodenum, bolus IVF, TPN; start tube feeds today\n PROPHYLAXIS: pneumoboots, IV PPI\n ACCESS: PICC, PIV, A-line in right brachial artery\n CODE: Do not resuscitate. Ok to intubate or use pressors. No CPR or\n defibrillation\n ICU Care\n Nutrition:\n Vivonex (Full) - 05:30 PM 20 mL/hour\n TPN w/ Lipids - 06:00 PM 45 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 11:14 AM\n 20 Gauge - 11:42 AM\n Arterial Line - 11:10 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2115-03-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 631294,
"text": "Chief Complaint:\n 24 Hour Events:\n PAN CULTURE - At 04:00 PM\n FEVER - 101.1\nF - 04:00 PM\n - During the day had increased levophed requirement to maintain MAP >65\n (lactate nml) but then O/N able to wean down (from 0.2 to 0.08)\n - Got 40IV lasix overnight as discussed yesterday\n Has done well per family\n no further episodes of AMS since starting\n pressors and receiving 1 unit blood.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Cefipime - 11:00 PM\n Metronidazole - 01:22 AM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Fentanyl (Concentrate) - 30 mcg/hour\n Norepinephrine - 0.06 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 PM\n Fosphenytoin - 11:59 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.4\nC (101.1\n Tcurrent: 37.5\nC (99.5\n HR: 115 (102 - 131) bpm\n BP: 99/48(73) {88/48(62) - 118/83(90)} mmHg\n RR: 29 (16 - 34) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 2,206 mL\n 658 mL\n PO:\n TF:\n 65 mL\n 132 mL\n IVF:\n 1,166 mL\n 221 mL\n Blood products:\n Total out:\n 2,545 mL\n 1,150 mL\n Urine:\n 1,895 mL\n 1,150 mL\n NG:\n 150 mL\n Stool:\n Drains:\n Balance:\n -339 mL\n -492 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: MMV/PSV/AutoFlow\n Vt (Set): 300 (300 - 300) mL\n Vt (Spontaneous): 312 (312 - 402) mL\n PS : 12 cmH2O\n RR (Set): 12\n RR (Spontaneous): 27\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 141\n PIP: 21 cmH2O\n Plateau: 22 cmH2O\n Compliance: 23.4 cmH2O/mL\n SpO2: 95%\n ABG: 7.45/33/125/24/0\n Ve: 9.6 L/min\n PaO2 / FiO2: 313\n Physical Examination\n Gen: Thin, appears sedated/comfortable at rest, opening eyes but no\n clear orientation to voice\n HEENT: Sclera anicteric, eyes sunken, MMM\n Neck: Supple, thin, EJs prominent and hyperdynamic, no LAD\n Lungs: Intubated, coarse BS bilaterally with soft ronchi\n CV: Regular but tachycardic, normal S1 + S2, unable to appreciate any\n murmurs, rubs, gallops\n Abdomen: Soft, BS+, distended, pt appears uncomfortable on palpations\n GU: Condom cath in place\n Ext: Warm, cachectic, BLE contractures, + DP pulses, no cyanosis or\n edema\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 206 K/uL\n 9.5 g/dL\n 99 mg/dL\n 0.6 mg/dL\n 24 mEq/L\n 3.7 mEq/L\n 26 mg/dL\n 107 mEq/L\n 140 mEq/L\n 28.9 %\n 8.1 K/uL\n [image002.jpg]\n 01:30 PM\n 06:52 PM\n 07:01 PM\n 02:03 AM\n 02:19 AM\n 03:29 PM\n 03:46 PM\n 06:28 PM\n 03:24 AM\n 03:52 AM\n WBC\n 10.1\n 8.1\n Hct\n 23.8\n 23.1\n 27.2\n 27.5\n 28.9\n Plt\n 195\n 206\n Cr\n 0.7\n 0.6\n TCO2\n 28\n 27\n 23\n 22\n 24\n Glucose\n 157\n 99\n Other labs:\n PT / PTT / INR:15.6/25.5/1.4\n Ca++:7.9 mg/dL, Mg++:1.8 mg/dL, PO4:3.4 mg/dL\n Micro:\n : Sputum with no microorganisms on gram stain, S. aureus on\n culture (prelim)\n : Sputum with no microorganisms on gram stain, GNR on culture\n (prelim)\n : All blood, urine cx pending or no growth\n Assessment and Plan\n 35 yo M with PMH of CP, seizure disorder, GIB, pancreatic cyst s/p\n drainage in , admitted with abdominal pain with complicated course,\n now with new fever, tachypnea, and hypoxia.\n .\n # Respiratory failure: Hypoxic with ABG on floor c/w respiratory\n alkalosis in setting of tachypnea. Given constellation of new fever,\n tachypnea, and significant hypoxia, as well as new opacities on CXR,\n concern for pneumonia - HAP v. aspiration (tube feeds restarted\n yesterday); less likely VAP as was extubated several weeks prior. \n also with a component of pleural effusion to opacities; recent TTE with\n nl EF but labs notable for low albumin. PE is also a concern as pt is\n bedbound; has not had pneumoboots on and just restarted heparin SQ\n yesterday for DVT ppx. Intubated in setting of declining resp\n status/PNA. CTA yesterday with final read pending, but shows\n infusions/infiltrates b/l. No PE noted.\n - Serial ABG, recheck lactate (most recent ABG with mild resp\n alkalosis)\n - Continue broad antibiotic coverage for HAP/aspiration PNA with vanc,\n cefepime, metronidazole.\n - f/u sputum cx, f/u blood cultures\n - consider nasopharyngeal swab for viral\n - sputum sample with staph aureus, GNR (no sensitivities yet)\n - attempt weaning to PSV again if continues stable\n .\n # Fever/sepsis: Pt febrile with tachycardia and tachypnea; meets\n definition of sepsis with most likely source being pulmonary. With\n ascites, SBP is also possible although he is now s/p 3 taps which have\n not been c/w SBP. U/A appears clean. MS with no obvious\n nuchal rigidity although exam limited by pt cooperation. Again, PE\n could cause similar sx of fever and respiratory distress but none seen\n on prelim CTA. Continues febrile daily. No further episodes of AMS.\n - F/u blood and urine cx, sputum cx, C. diff (urine with staph\n spp, UA dirty and UCx pending)\n - Repeat abdominal US today to evaluate for change in liver lesion (?\n Abscess)\n - Broad abx as above with good gram positive, gram neg, and anaerobic\n coverage\n - Goal CVP 8-12 but no measurements available currently\n will bolus\n for tachycardia, UOP < 30cc/h, goal MAP >65, CvO2 >70\n - Pressors for MAP > 65, wean levophed as tolerated\n - Monitor mental status\n - Consider paracentesis if continues febrile and no other source (would\n likely need to be done by IR, but will F/U US report today)\n #Hypotension. Continues to wean from levophed\n currently at 0.06.\n pressures run low. No further episodes of AMS since starting\n pressors on .\n # Tachycardia: Likely hyperdynamic in setting of fever, infection.\n Volume status appears grossly euvolemic; pt mentating at and\n maintaining urine output. Echo with evidence of depressed cardiac fxn,\n ? tachycardia induced cardiomyopathy\n - Tylenol prn fever\n - Abx as above\n - Fluid boluses prn, though patient with heart rate 110s;\n appears hypervolemic\n # Anemia/bleed: Hct stable. Pt with RP bleed and CT evidence of\n hemorrhage into bowel wall, also gastric varices c/b GIB earlier in\n admission. Transfused 1 unit pRBCs with appropriate bump and has\n remained stable.\n - Trend Hct\n - Guaiac stools\n - Active T&S\n - continue pantoprazole 40mg IV bid\n - Continue iron supplement\n # Liver lesion. Noted on abdominal CT. Possible abscess.\n - Abdominal U/S tomorrow to eval for interval change\n - Discuss possible drainage with IR (? CT guided?)\n # Left humeral fx: Likely d/t trauma sustained during radiology.\n - No surgical indication at this time\n - Pain control with lidoderm patch and morphine prn\n .\n # SMV thrombus: Plan for anticoagulation x 6 months but held in setting\n of recent GI and RP bleed.\n - Continue heparin SQ\n .\n # Seizure disorder: No recent reports of seizures. Caution as certain\n antibiotics may lower seizure threshold.\n - Continue phenobarbitol and phenytoin\n - will check drug levels tomorrow\n .\n # Cerebral palsy: Stable mental status. Interactive with family but\n nonverbal at .\n .\n FEN: NG tube likely in duodenum, bolus IVF, TPN; start tube feeds today\n PROPHYLAXIS: pneumoboots, IV PPI\n ACCESS: PICC, PIV, A-line in right brachial artery\n CODE: Do not resuscitate. Ok to intubate or use pressors. No CPR or\n defibrillation\n ICU Care\n Nutrition:\n Vivonex (Full) - 05:30 PM 20 mL/hour\n TPN w/ Lipids - 06:00 PM 45 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 11:14 AM\n 20 Gauge - 11:42 AM\n Arterial Line - 11:10 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2115-03-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 631296,
"text": "Chief Complaint:\n 24 Hour Events:\n PAN CULTURE - At 04:00 PM\n FEVER - 101.1\nF - 04:00 PM\n - During the day had increased levophed requirement to maintain MAP >65\n (lactate nml) but then O/N able to wean down (from 0.2 to 0.08)\n - Got 40IV lasix overnight as discussed yesterday\n Has done well per family\n no further episodes of AMS since starting\n pressors and receiving 1 unit blood.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Cefipime - 11:00 PM\n Metronidazole - 01:22 AM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Fentanyl (Concentrate) - 30 mcg/hour\n Norepinephrine - 0.06 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 PM\n Fosphenytoin - 11:59 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.4\nC (101.1\n Tcurrent: 37.5\nC (99.5\n HR: 115 (102 - 131) bpm\n BP: 99/48(73) {88/48(62) - 118/83(90)} mmHg\n RR: 29 (16 - 34) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 2,206 mL\n 658 mL\n PO:\n TF:\n 65 mL\n 132 mL\n IVF:\n 1,166 mL\n 221 mL\n Blood products:\n Total out:\n 2,545 mL\n 1,150 mL\n Urine:\n 1,895 mL\n 1,150 mL\n NG:\n 150 mL\n Stool:\n Drains:\n Balance:\n -339 mL\n -492 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: MMV/PSV/AutoFlow\n Vt (Set): 300 (300 - 300) mL\n Vt (Spontaneous): 312 (312 - 402) mL\n PS : 12 cmH2O\n RR (Set): 12\n RR (Spontaneous): 27\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 141\n PIP: 21 cmH2O\n Plateau: 22 cmH2O\n Compliance: 23.4 cmH2O/mL\n SpO2: 95%\n ABG: 7.45/33/125/24/0\n Ve: 9.6 L/min\n PaO2 / FiO2: 313\n Physical Examination\n Gen: Thin, appears sedated/comfortable at rest, opening eyes but no\n clear orientation to voice\n HEENT: Sclera anicteric, eyes sunken, MMM, audible secretions\n Neck: Supple, thin, EJs prominent and hyperdynamic, no LAD\n Lungs: Intubated, coarse BS bilaterally with diffuse ronchi, wet\n congestion L > R\n CV: Regular but tachycardic, normal S1 + S2, unable to appreciate any\n murmurs, rubs, gallops\n Abdomen: Soft, BS+, distended, pt appears uncomfortable on palpations\n GU: Condom cath in place\n Ext: Warm, cachectic, BLE contractures, + DP pulses, no cyanosis or\n edema\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 206 K/uL\n 9.5 g/dL\n 99 mg/dL\n 0.6 mg/dL\n 24 mEq/L\n 3.7 mEq/L\n 26 mg/dL\n 107 mEq/L\n 140 mEq/L\n 28.9 %\n 8.1 K/uL\n [image002.jpg]\n 01:30 PM\n 06:52 PM\n 07:01 PM\n 02:03 AM\n 02:19 AM\n 03:29 PM\n 03:46 PM\n 06:28 PM\n 03:24 AM\n 03:52 AM\n WBC\n 10.1\n 8.1\n Hct\n 23.8\n 23.1\n 27.2\n 27.5\n 28.9\n Plt\n 195\n 206\n Cr\n 0.7\n 0.6\n TCO2\n 28\n 27\n 23\n 22\n 24\n Glucose\n 157\n 99\n Other labs:\n PT / PTT / INR:15.6/25.5/1.4\n Ca++:7.9 mg/dL, Mg++:1.8 mg/dL, PO4:3.4 mg/dL\n Micro:\n : Sputum with no microorganisms on gram stain, S. aureus on\n culture (prelim)\n : Sputum with no microorganisms on gram stain, GNR on culture\n (prelim)\n : All blood, urine cx pending or no growth\n Assessment and Plan\n 35 yo M with PMH of CP, seizure disorder, GIB, pancreatic cyst s/p\n drainage in , admitted with abdominal pain with complicated course,\n now with new fever, tachypnea, and hypoxia.\n .\n # Respiratory failure: Hypoxic with ABG on floor c/w respiratory\n alkalosis in setting of tachypnea. Given constellation of new fever,\n tachypnea, and significant hypoxia, as well as new opacities on CXR,\n concern for pneumonia - HAP v. aspiration (tube feeds restarted\n yesterday); less likely VAP as was extubated several weeks prior. \n also with a component of pleural effusion to opacities; recent TTE with\n nl EF but labs notable for low albumin. PE is also a concern as pt is\n bedbound; has not had pneumoboots on and just restarted heparin SQ\n yesterday for DVT ppx. Intubated in setting of declining resp\n status/PNA. CTA yesterday with final read pending, but shows\n infusions/infiltrates b/l. No PE noted.\n - Serial ABG, recheck lactate (most recent ABG with mild resp\n alkalosis)\n - Continue broad antibiotic coverage for HAP/aspiration PNA with vanc,\n cefepime, metronidazole.\n - f/u sputum cx, f/u blood cultures\n - consider nasopharyngeal swab for viral\n - sputum sample with staph aureus, GNR (no sensitivities yet)\n - attempt weaning to PSV again if continues stable\n .\n # Fever/sepsis: Pt febrile with tachycardia and tachypnea; meets\n definition of sepsis with most likely source being pulmonary. With\n ascites, SBP is also possible although he is now s/p 3 taps which have\n not been c/w SBP. U/A appears clean. MS with no obvious\n nuchal rigidity although exam limited by pt cooperation. Again, PE\n could cause similar sx of fever and respiratory distress but none seen\n on prelim CTA. Continues febrile daily. No further episodes of AMS.\n - F/u blood and urine cx, sputum cx, C. diff (urine with staph\n spp, UA dirty and UCx pending)\n - Repeat abdominal US today to evaluate for change in liver lesion (?\n Abscess)\n - Broad abx as above with good gram positive, gram neg, and anaerobic\n coverage\n - Goal CVP 8-12 but no measurements available currently\n will bolus\n for tachycardia, UOP < 30cc/h, goal MAP >65, CvO2 >70\n - Pressors for MAP > 65, wean levophed as tolerated\n - Monitor mental status\n - Consider paracentesis if continues febrile and no other source (would\n likely need to be done by IR, but will F/U US report today)\n #Hypotension. Continues to wean from levophed\n currently at 0.06.\n pressures run low. No further episodes of AMS since starting\n pressors on .\n # Tachycardia: Likely hyperdynamic in setting of fever, infection.\n Volume status appears grossly euvolemic; pt mentating at and\n maintaining urine output. Echo with evidence of depressed cardiac fxn,\n ? tachycardia induced cardiomyopathy\n - Tylenol prn fever\n - Abx as above\n - Fluid boluses prn, though patient with heart rate 110s;\n appears hypervolemic\n # Anemia/bleed: Hct stable. Pt with RP bleed and CT evidence of\n hemorrhage into bowel wall, also gastric varices c/b GIB earlier in\n admission. Transfused 1 unit pRBCs with appropriate bump and has\n remained stable.\n - Trend Hct\n - Guaiac stools\n - Active T&S\n - continue pantoprazole 40mg IV bid\n - Continue iron supplement\n # Liver lesion. Noted on abdominal CT. Possible abscess.\n - Abdominal U/S tomorrow to eval for interval change\n - Discuss possible drainage with IR (? CT guided?)\n # Left humeral fx: Likely d/t trauma sustained during radiology.\n - No surgical indication at this time\n - Pain control with lidoderm patch and morphine prn\n .\n # SMV thrombus: Plan for anticoagulation x 6 months but held in setting\n of recent GI and RP bleed.\n - Continue heparin SQ\n .\n # Seizure disorder: No recent reports of seizures. Caution as certain\n antibiotics may lower seizure threshold.\n - Continue phenobarbitol and phenytoin\n - will check drug levels tomorrow\n .\n # Cerebral palsy: Stable mental status. Interactive with family but\n nonverbal at .\n .\n FEN: NG tube likely in duodenum, bolus IVF, TPN; start tube feeds today\n PROPHYLAXIS: pneumoboots, IV PPI\n ACCESS: PICC, PIV, A-line in right brachial artery\n CODE: Do not resuscitate. Ok to intubate or use pressors. No CPR or\n defibrillation\n ICU Care\n Nutrition:\n Vivonex (Full) - 05:30 PM 20 mL/hour\n TPN w/ Lipids - 06:00 PM 45 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 11:14 AM\n 20 Gauge - 11:42 AM\n Arterial Line - 11:10 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Rehab Services",
"chartdate": "2115-04-03 00:00:00.000",
"description": "Video Swallow Study",
"row_id": 632692,
"text": "TITLE:\n OROPHARYNGEAL VIDEOFLUOROSCOPIC SWALLOWING EVALUATION\n EVALUATION:\n A limited oral and pharyngeal swallowing videofluoroscopy was performed\n today in collaboration with Radiology. Nectar-thick liquid and pureed\n consistency barium, were administered. Of note, pt had poor\n cooperation with today's evaluation, limited volumes were assessed and\n positioning was suboptimal. Best available results follow:\n ORAL PHASE:\n Pt presents with poor bolus cohesion/formation with anterior spill and\n residue in lateral suclci. Anterior to posterior tongue transit was\n remarkable for tongue pumping and piecemeal deglutition. Moderate oral\n cavity residue remained after the swallow and cues to perform repeat\n swallows were only mildly effective. There was no documentation of\n premature spillover to the pharynx prior to the swallow.\n PHARYNGEAL PHASE:\n Pharyngeal phase was initiated in a timely manner. At the height of\n the swallow, velar elevation, hyolaryngeal excursion, laryngeal valve\n closure, and epiglottic deflection were all grossly within functional\n limits. Bolus propulsion mildly reduced. UES opening WFL. Pt\n presented with mild residue on lateral wall which was suggestive of\n ?pharyngocele, but could not be evaluated more fully in the A-P view\n due to positioning and cooperation. There was also mild-moderate\n residue in the valleculae due to oral deficits and pooling of\n secretions mixed with barium in the pyriform sinuses. All residue\n improved but was not eliminated with follow up dry swallows.\n ANTERIOR TO POSTERIOR POSITION:\n Could not test due to pt positioning and cooperation.\n ASPIRATION/PENETRATION:\n There was no documentation of laryngeal penetration or aspiration on\n today's limited study.\n SUMMARY:\n participated in a limited videoswallow study, aided by\n his mother to maximize results obtained. During today's evaluation, he\n presents with a moderate oropharyngeal dysphagia which is likely\n consistent with his baseline functioning at home. There was no overt\n laryngeal penetration or aspiration during today's limited exam. He\n does, however, remain at risk for intermittent aspiration across\n consistencies due to his poor bolus control, however this risk appears\n to be no greater with foods/liquids than it is with saliva alone. As\n such, it appears reasonable for to return to a diet of pureed\n solids and nectar thick liquids at this time. He'll require max assist\n with PO intake and volume/safety of intake likely to be best if\n supervised by his mother, a familiar caregiver. She has repeatedly\n demonsrated safe feeding techniques with her son during this admission.\n If presents again with clinical signs of aspiration PNA, it can\n be presumed that in larger volumes, PO poses an increased risk to him\n than in the small volumes observed today. If this occurs, I would\n recommend Palliative Care consult to assist with discussion of goals of\n care. We would be happy to participate in team/family discussion as\n needed in this scenario.\n With regard to NGT - would recommend leaving it in place until \n demonstrates he can take adequate volume of intake PO to maintain\n nutrition and hydration. Nutrition f/u to maximize PO intake on his\n modified diet is recommended. Mother would benefit from education\n regarding opptions for oral supplements at home as well. If pt unable\n to demonstrate adequate oral intake to prevent\n dehydration/malnutrition, would again encourage Palliative Care consult\n prior to re-consideration of PEG or other longer term non-oral\n nutrition to ensure goals of care are reasonable given pt's baseline\n disease.\n RECOMMENDATIONS:\n 1. PO diet: pureed solids, nectar thick liquids\n 2. PO meds: can be attempted crushed in puree, though IV likely to be\n more reliable given pt's cooperation\n 3. Attempt oral care Q4, assuming he will not always allow. Oral care\n also encouraged prior to PO intake to reduce risk for aspiration of\n oral bacterias.\n 4. Strict aspiration precautions, max assist with PO intake -\n preferably by familiar family member when possible.\n 5. Nutrition f/u to ensure adequate oral intake, provide\n recommendations for home for mother\n 6. If pt presents with aspiration PNA again or is unable to obtain\n adequate oral intake, please consult Palliative Care.\n 7. Please contact us by page or reconsult if we can be of further\n assistance.\n These recommendations were shared with the patient, the nurse and the\n medical team.\n ___________________________________\n -, MS, CCC-SLP\n Pager # \n Face time: 3:00-3:45\n Total time: 90 minutes\n"
},
{
"category": "Respiratory ",
"chartdate": "2115-03-26 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 631029,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 20 cm at teeth\n Route: Oral\n Type: Standard\n Size: 6.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Scant\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Cannot protect\n airway, Underlying illness not resolved\n"
},
{
"category": "Physician ",
"chartdate": "2115-03-26 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 631135,
"text": "Chief Complaint: respiratory failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 35 yo man with CP, with prolonged hospitalization for peritonitis,\n sepsis, respiratory failure, SMV thrombosis, course c/b retroperitonial\n hemorrhage. Had episode of decreased alertness and apnea yesterday\n evening which has now resolved.\n 24 Hour Events:\n TRANS ESOPHAGEAL ECHO - At 10:30 AM\n TRANSTHORACIC ECHO - At 11:03 AM\n FEVER - 102.3\nF - 12:00 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Cefipime - 10:00 PM\n Metronidazole - 10:00 AM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Fentanyl (Concentrate) - 30 mcg/hour\n Norepinephrine - 0.07 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 01:44 PM\n Pantoprazole (Protonix) - 08:00 AM\n Other medications:\n phenobarbital\n cefepime\n lidocaine patch\n flagyl\n vanco\n protonix\n chlorhexidine\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 12:16 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 39.1\nC (102.3\n Tcurrent: 36.8\nC (98.2\n HR: 121 (100 - 131) bpm\n BP: 92/66(77) {74/57(64) - 108/76(89)} mmHg\n RR: 28 (15 - 39) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 2,247 mL\n 592 mL\n PO:\n TF:\n IVF:\n 1,752 mL\n 502 mL\n Blood products:\n 375 mL\n Total out:\n 1,275 mL\n 1,180 mL\n Urine:\n 1,275 mL\n 530 mL\n NG:\n 150 mL\n Stool:\n Drains:\n Balance:\n 972 mL\n -588 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: MMV/PSV/AutoFlow\n Vt (Set): 300 (300 - 300) mL\n Vt (Spontaneous): 399 (345 - 445) mL\n PS : 18 cmH2O\n RR (Set): 12\n RR (Spontaneous): 33\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 28 cmH2O\n Plateau: 20 cmH2O\n Compliance: 30 cmH2O/mL\n SpO2: 97%\n ABG: 7.44/38/102/23/1\n Ve: 11.7 L/min\n PaO2 / FiO2: 255\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Warm\n Neurologic: Responds to: Verbal stimuli, Movement: Not assessed, Tone:\n Not assessed, makes eye contact to voice\n / Radiology\n 8.9 g/dL\n 195 K/uL\n 157 mg/dL\n 0.7 mg/dL\n 23 mEq/L\n 4.0 mEq/L\n 23 mg/dL\n 107 mEq/L\n 138 mEq/L\n 27.2 %\n 10.1 K/uL\n [image002.jpg]\n 12:28 AM\n 02:57 AM\n 03:14 AM\n 05:21 AM\n 12:25 PM\n 01:30 PM\n 06:52 PM\n 07:01 PM\n 02:03 AM\n 02:19 AM\n WBC\n 5.8\n 10.1\n Hct\n 24.7\n 23.8\n 23.1\n 27.2\n Plt\n 142\n 195\n Cr\n 0.6\n 0.7\n TCO2\n 27\n 30\n 29\n 28\n 28\n 27\n Glucose\n 141\n 157\n Other : PT / PTT / INR:15.0/31.5/1.3, CK / CKMB /\n Troponin-T:8//0.01, ALT / AST:17/19, Alk Phos / T Bili:106/0.6, Amylase\n / Lipase:/11, Differential-Neuts:86.5 %, Lymph:6.6 %, Mono:5.9 %,\n Eos:0.9 %, Lactic Acid:0.8 mmol/L, Albumin:2.4 g/dL, LDH:383 IU/L,\n Ca++:7.6 mg/dL, Mg++:2.0 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n Respiratory failure: Aspiration PNA wth GPCs in sputum. Also with\n evidence of volume overload. Will try and diurese.\n PNA: continue broad spectrum antibiotics.\n HOTN: will target MAP of 65, and wean down levophed.\n Anemia: appropriate Hct bump with transfusion\n liver abscess: repeat ultrasound tomorrow\n seizure yesterday. Dilantin level corrected is therapeutic.\n continue TPN. Start low dose TFs.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 11:14 AM\n 20 Gauge - 11:42 AM\n Arterial Line - 11:10 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition :ICU\n Total time spent: 40 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2115-03-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 631136,
"text": "Chief Complaint:\n 24 Hour Events:\n TRANS ESOPHAGEAL ECHO - At 10:30 AM\n TRANSTHORACIC ECHO - At 11:03 AM\n FEVER - 102.3\nF - 12:00 PM\n 35 yo man who has been in hospital some time, with cerebral palsy, non\n verbal. admitted with acute abdomen, peritonitis, chronic\n pancreatitits. found to have SMV thrombus, anticoagulated, then\n developed retoperitoneal hemorrhage. Was on floor readmitted with\n progressive hypoxemia, intubated. Had CT with ? of liver abscess.\n CTA with LLL and RLL PNA and atelectasis, and effusions.\n - Weaned to PS - F/U ABG 7.38/45/105/28/0\n - Spiked to 102.3, but already pan-cultured, on Abx\n - Final CT report recommends F/U US to evaluate liver lesion (?abscess)\n in 3 days (ordered)\n - Pt noted to be apneic (RR 2 at one pt, usually overbreathes vent) and\n change MS (not opening eyes or grimacing as usual), with SBP in 70s.\n Unclear precipitant, seizure vs post-ictal vs acute bleed. Started\n levophed with improved SBPs to 90s-100s, and improved MS quickly. Hct\n 23.1; ordered for 1 unit pRBC with repeat Hct post-transfusion.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Cefipime - 10:00 PM\n Metronidazole - 02:02 AM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Fentanyl (Concentrate) - 30 mcg/hour\n Norepinephrine - 0.07 mcg/Kg/min\n Other ICU medications:\n Midazolam (Versed) - 11:46 AM\n Heparin Sodium (Prophylaxis) - 01:44 PM\n Other medications:\n Changes to medical and family history:\n Unchanged\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Unable to obtain\n Flowsheet Data as of 07:29 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 39.1\nC (102.3\n Tcurrent: 37.7\nC (99.9\n HR: 106 (100 - 131) bpm\n BP: 96/73(83) {74/56(64) - 108/76(89)} mmHg\n RR: 25 (15 - 39) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,247 mL\n 331 mL\n PO:\n TF:\n IVF:\n 1,752 mL\n 271 mL\n Blood products:\n 375 mL\n Total out:\n 1,275 mL\n 990 mL\n Urine:\n 1,275 mL\n 340 mL\n NG:\n 150 mL\n Stool:\n Drains:\n Balance:\n 972 mL\n -659 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: MMV/PSV/AutoFlow\n Vt (Set): 300 (300 - 300) mL\n Vt (Spontaneous): 399 (345 - 445) mL\n PS : 18 cmH2O\n RR (Set): 12\n RR (Spontaneous): 19\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 28 cmH2O\n Plateau: 20 cmH2O\n Compliance: 31.3 cmH2O/mL\n SpO2: 98%\n ABG: 7.44/38/102/23/1\n Ve: 6.8 L/min\n PaO2 / FiO2: 255\n Physical Examination\n Gen: Thin, appears sedated/comfortable at rest, opening eyes but no\n clear orientation to voice\n HEENT: Sclera anicteric, eyes sunken, MMM\n Neck: Supple, thin, EJs prominent and hyperdynamic, no LAD\n Lungs: Intubated, coarse BS bilaterally with soft ronchi\n CV: Regular but tachycardic, normal S1 + S2, unable to appreciate any\n murmurs, rubs, gallops\n Abdomen: Soft, BS+, distended, pt appears uncomfortable on palpations\n GU: Condom cath in place\n Ext: Warm, cachectic, BLE contractures, + DP pulses, no cyanosis or\n edema\n / Radiology\n 195 K/uL\n 8.9 g/dL\n 157 mg/dL\n 0.7 mg/dL\n 23 mEq/L\n 4.0 mEq/L\n 23 mg/dL\n 107 mEq/L\n 138 mEq/L\n 27.2 %\n 10.1 K/uL\n [image002.jpg]\n 12:28 AM\n 02:57 AM\n 03:14 AM\n 05:21 AM\n 12:25 PM\n 01:30 PM\n 06:52 PM\n 07:01 PM\n 02:03 AM\n 02:19 AM\n WBC\n 5.8\n 10.1\n Hct\n 24.7\n 23.8\n 23.1\n 27.2\n Plt\n 142\n 195\n Cr\n 0.6\n 0.7\n TCO2\n 27\n 30\n 29\n 28\n 28\n 27\n Glucose\n 141\n 157\n Other : PT / PTT / INR:15.0/31.5/1.3,\n CK / CKMB / Troponin-T:8//0.01,\n ALT / AST:17/19, Alk Phos / T Bili:106/0.6, Amylase / Lipase:/11,\n Lactic Acid:0.8 mmol/L, Albumin:2.4 g/dL, LDH:383 IU/L, Ca++:7.6 mg/dL,\n Mg++:2.0 mg/dL, PO4:2.8 mg/dL\n Micro:\n - Sputum: NGTD\n - Blood cx: NGTD\n TTE ()\n The left atrium is normal in size. No atrial septal defect is seen by\n 2D or color Doppler. Left ventricular wall thicknesses are normal. The\n left ventricular cavity size is normal. Regional left ventricular wall\n motion is normal. There is mild to moderate global left ventricular\n hypokinesis suggested(LVEF = 45 %). There is no ventricular septal\n defect. Right ventricular chamber size and free wall motion are normal.\n The number of aortic valve leaflets cannot be determined. There is\n moderate aortic valve stenosis (valve area 1.0-1.2cm2). The mitral\n valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation\n is seen. There is mild pulmonary artery systolic hypertension. There is\n no pericardial effusion.\n..Compared with the prior study (images\n reviewed) of , the patient is more tachycardic. The LV systolic\n function now appears depressed. The aortic valve gradient appears\n similar. If indicated, a TEE would better clarify the basis and\n severity of the aortic stenosis (as well as global LV systolic\n function).\n .\n CTA ()\n 1. New bilateral patchy pneumonia, particularly within the left upper\n lobe\n and right middle lobe.\n 2. New ill-defined 2.8 x 3 cm hypoattenuating lesion in segment V of\n the\n liver. This may be secondary to a developing abscess. Follow-up\n ultrasound\n is recommended in 3 days.\n 3. Persistent sigmoid and rectal thickening with stable marked\n abdominal and\n pelvic ascites.\n 4. Stable left retroperitoneal bleed, more organized.\n 5. Increased moderate bilateral pleural effusions.\n Assessment and Plan\n TACHYCARDIA, OTHER\n ANEMIA, ACUTE, SECONDARY TO BLOOD LOSS (HEMORRHAGE, BLEEDING)\n FRACTURE, OTHER\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n 35 yo M with PMH of CP, seizure disorder, GIB, pancreatic cyst s/p\n drainage in , admitted with abdominal pain with complicated course,\n now with new fever, tachypnea, and hypoxia.\n .\n # Respiratory failure: Hypoxic with ABG on floor c/w respiratory\n alkalosis in setting of tachypnea. Given constellation of new fever,\n tachypnea, and significant hypoxia, as well as new opacities on CXR,\n concern for pneumonia - HAP v. aspiration (tube feeds restarted\n yesterday); less likely VAP as was extubated several weeks prior. \n also with a component of pleural effusion to opacities; recent TTE with\n nl EF but notable for low albumin. PE is also a concern as pt is\n bedbound; has not had pneumoboots on and just restarted heparin SQ\n yesterday for DVT ppx. Intubated in setting of declining resp\n status/PNA. CTA yesterday with final read pending, but shows\n infusions/infiltrates b/l. No PE on prelim read.\n - Serial ABG, recheck lactate\n - Continue broad antibiotic coverage for HAP/aspiration PNA with vanc,\n cefepime, metronidazole.\n - f/u sputum cx, f/u blood cultures\n - consider nasopharyngeal swab for viral\n - sputum sample with staph aureus (no sensitivities yet)\n - attempt weaning to PSV\n .\n # Fever/sepsis: Pt febrile with tachycardia and tachypnea; meets\n definition of sepsis with most likely source being pulmonary. With\n ascites, SBP is also possible although he is now s/p 3 taps which have\n not been c/w SBP. U/A appears clean. MS with no obvious\n nuchal rigidity although exam limited by pt cooperation. Again, PE\n could cause similar sx of fever and respiratory distress but none seen\n on prelim CTA.\n - F/u blood and urine cx, sputum cx, C. diff (urine with staph\n spp, UA dirty and UCx pending)\n - Consider abdominal u/s and paracentesis\n - Broad abx as above with good gram positive, gram neg, and anaerobic\n coverage\n - Goal CVP 8-12 but no measurements available currently\n will bolus\n for tachycardia, UOP < 30cc/h, goal MAP >65, CvO2 >70\n - Pressors for MAP > 65, wean levophed\n - Monitor mental status\n # Tachycardia: Likely hyperdynamic in setting of fever, infection.\n Volume status appears grossly euvolemic; pt mentating at and\n maintaining urine output. Echo with evidence of depressed cardiac fxn,\n ? tachycardia induced cardiomyopathy\n - Tylenol prn fever\n - Abx as above\n - Fluid boluses prn, though patient with heart rate 110s;\n appears hypervolemic\n # Anemia/bleed: Hct stable. Pt with RP bleed and CT evidence of\n hemorrhage into bowel wall, also gastric varices c/b GIB earlier in\n admission. Transfused 1 unit pRBCs yesterday with appropriate bump\n - Trend Hct\n - Guaiac stools\n - Active T&S\n - continue pantoprazole 40mg IV bid\n - Continue iron supplement\n # Liver lesion. Noted on abdominal CT. Possible abscess.\n - Abdominal U/S tomorrow to eval for interval change\n - Discuss possible drainage with IR (? CT guided?)\n # Left humeral fx: Likely d/t trauma sustained during radiology.\n - No surgical indication at this time\n - Pain control with lidoderm patch and morphine prn\n .\n # SMV thrombus: Plan for anticoagulation x 6 months but held in setting\n of recent GI and RP bleed.\n - Continue heparin SQ\n .\n # Seizure disorder: No recent reports of seizures. Caution as certain\n antibiotics may lower seizure threshold.\n - Continue phenobarbitol and phenytoin\n - will check drug levels tomorrow\n .\n # Cerebral palsy: Stable mental status. Interactive with family but\n nonverbal at .\n .\n FEN: NG tube likely in duodenum, bolus IVF, TPN; start tube feeds today\n PROPHYLAXIS: pneumoboots, IV PPI\n ACCESS: PICC, PIV, A-line in right brachial artery\n CODE: Do not resuscitate. Ok to intubate or use pressors. No CPR or\n defibrillation\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 11:14 AM\n 20 Gauge - 11:42 AM\n Arterial Line - 11:10 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 631225,
"text": "35M with cerebral palsy, non verbal. Admitted in with acute\n abdomen, peritonitis, and chronic pancreatitis. Found to have SMV\n thrombus, anticoagulated which resulted in retoperitoneal hemorrhage.\n Was on floor when he was re-admitted with progressive hypoxemia and\n then subsequently intubated. CTA with LLL and RLL PNA and atelectasis,\n and effusions.\n Code Status: DNR, already intubated.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Tachycardia, Other\n Assessment:\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n Seizure, without status epilepticus\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 631227,
"text": "35M with cerebral palsy, non verbal. Admitted in with acute\n abdomen, peritonitis, and chronic pancreatitis. Found to have SMV\n thrombus, anticoagulated which resulted in retoperitoneal hemorrhage.\n Was on floor when he was re-admitted with progressive hypoxemia and\n then subsequently intubated. CTA with LLL and RLL PNA and atelectasis,\n and effusions.\n Code Status: DNR, already intubated.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lungs clear bilat to bases, occasional scattered rhonchi but clears\n with coughing, strong prod. Cough of thick yellow sputum, ETtube\n suctioned for mod amts thick yellow sputum, oral suctioned for copious\n amts thick white sputum, RR= 21-31, Current vent settings include: MMV\n mode 300-40%-12 with Peep= 10,\n Action:\n Aggressive pulmonary toileting, diuresed with 40 mg. IV Lasix\n Response:\n Good diuresis from lasix\n Plan:\n Tachycardia, Other\n Assessment:\n HR= 106-120 ST with no ectopy noted, HR in 100-110 range when sleeping\n and 110-120\ns while awake, Tmax = 100.0 (po), right brachial aline\n dampens but when it has a good waveform it correlates to NBP, BP=\n 94-115/70-80\ns, MAP\ns= 70\ns, received pt on 0.2 mcgs/kg/min of IV\n Levophed, Levophed weaned slowly during the night\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Abd slightly firm and distended, positive hypoactive bowel sounds in\n all quads, positive flatus, NGtube placement confirmed by auscultation,\n Tolerating FS Vivonex at 20ml/hr with no residuals, Flexiseal in place\n and draining small amts liquid green stool, TPN infusing at 45 ml/hr as\n ordered via PICC,\n Action:\n Response:\n Plan:\n Seizure, without status epilepticus\n Assessment:\n Resting in naps, when awake will track with eyes, moves all extremities\n on command, PEARL, no evidence of seizures noted, fosphenytoin and\n phenobarb as ordered, bilat soft wrist restraints to prevent pt from\n pulling at lines and tubes, remains on IV Versed at 1 mg/hr and IV\n Fentanyl at 30 mcgs/hr\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2115-03-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 631539,
"text": "Chief Complaint:\n 24 Hour Events:\n ULTRASOUND - At 09:53 AM\n FEVER - 101.1\nF - 08:00 AM\n :\n - Diuresed with lasix - negative 760 for day.\n - continues on levophed (0.08 this AM)\n - no overnight events\n - continuing to wean PSV; will attempt SBT this morning.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 11:00 AM\n Vancomycin - 08:42 PM\n Metronidazole - 01:51 AM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Fentanyl (Concentrate) - 30 mcg/hour\n Norepinephrine - 0.08 mcg/Kg/min\n Other ICU medications:\n Furosemide (Lasix) - 12:48 PM\n Pantoprazole (Protonix) - 08:42 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.4\nC (101.1\n Tcurrent: 37.9\nC (100.2\n HR: 118 (108 - 132) bpm\n BP: 85/62(72) {74/54(63) - 103/77(87)} mmHg\n RR: 27 (19 - 32) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 2,938 mL\n 973 mL\n PO:\n TF:\n 710 mL\n 345 mL\n IVF:\n 938 mL\n 200 mL\n Blood products:\n Total out:\n 3,620 mL\n 510 mL\n Urine:\n 3,120 mL\n 510 mL\n NG:\n Stool:\n 500 mL\n Drains:\n Balance:\n -682 mL\n 463 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 300 (300 - 300) mL\n Vt (Spontaneous): 445 (330 - 445) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 19\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 145\n PIP: 21 cmH2O\n SpO2: 96%\n ABG: 7.40/45/99./25/1 (TV325, FiO240, rate21, peep 8)\n Ve: 7 L/min\n PaO2 / FiO2: 250\n Physical Examination\n Gen: Thin, opening eyes but no clear orientation to voice\n HEENT: Sclera anicteric, eyes sunken, MMM, audible secretions\n Neck: Supple, thin, EJs prominent and hyperdynamic, no LAD\n Lungs: Intubated, coarse BS bilaterally with diffuse ronchi\n CV: S1, S2 regular rhythm, increased rate\n Abdomen: Soft, BS+, distended,\n GU: foley catheter in place\n Ext: Warm, cachectic, BLE contractures, + DP pulses\n Labs / Radiology\n 171 K/uL\n 9.1 g/dL\n 136 mg/dL\n 0.6 mg/dL\n 25 mEq/L\n 3.8 mEq/L\n 29 mg/dL\n 105 mEq/L\n 139 mEq/L\n 28.1 %\n 6.5 K/uL\n [image002.jpg]\n 02:19 AM\n 03:29 PM\n 03:46 PM\n 06:28 PM\n 03:24 AM\n 03:52 AM\n 11:49 AM\n 01:56 PM\n 02:25 AM\n 02:42 AM\n WBC\n 8.1\n 6.5\n Hct\n 27.5\n 28.9\n 28.1\n Plt\n 206\n 171\n Cr\n 0.6\n 0.6\n 0.6\n TCO2\n 27\n 23\n 22\n 24\n 27\n 29\n Glucose\n 99\n 153\n 136\n Other labs: PT / PTT / INR:16.1/28.6/1.4,\n Ca++:7.7 mg/dL, Mg++:1.8 mg/dL, PO4:3.2 mg/dL\n Lactate: 0.9\n RUQ U/S:\n 1. No son correlate corresponding to the hypoenhancing lesion\n seen on\n prior CT of is seen. Lesion seen on CT could represent an\n infarct\n secondary to compromised blood supply through the right portal vein,\n which\n appears nearly occluded.\n 2. Right pleural effusion and ascites.\n Assessment and Plan\n 35 yo M with PMH of CP, seizure disorder, GIB, pancreatic cyst s/p\n drainage in , admitted with abdominal pain with complicated course,\n now with new fever, tachypnea, and hypoxia.\n .\n # Respiratory failure: Patient transferred to MICU with tachypnea and\n hypoxia on and intubated on . Given his new fever,\n respiratory deterioration, and imaging findings consistent with\n multilobar pneumonia he was started on vancomycin, cefepime and flagyl\n (concern for aspiration given recently started tube feeds). Pleural\n effusions also noted on imaging, likely due to fluid resuscitation for\n hypotension in the setting of albumin of 2.3, so over the past 24 hours\n have been diuresing with lasix boluses. PE considered but CTA\n negative. Patient has been inbutated for 5 days,\n - Serial ABG, recheck lactate (most recent ABG with mild resp\n alkalosis)\n - Continue broad antibiotic coverage for HAP/aspiration PNA with vanc,\n cefepime, metronidazole x total 8 days (Day 1 = )\n - f/u sputum cx, f/u blood cultures\n - consider nasopharyngeal swab for viral\n - sputum sample with staph aureus, GNR (no sensitivities yet)\n - attempt weaning to PSV again if continues stable\n - Consider additional Lasix for crackles on exam; 40mg IV x 1\n - electrolytes with repletion while on Lasix\n .\n # Fever/sepsis: Pt febrile with tachycardia and tachypnea; meets\n definition of sepsis with most likely source being pulmonary. With\n ascites, SBP is also possible although he is now s/p 3 taps which have\n not been c/w SBP. U/A appears clean. MS with no obvious\n nuchal rigidity although exam limited by pt cooperation. Again, PE\n could cause similar sx of fever and respiratory distress but none seen\n on prelim CTA. Continues febrile daily. No further episodes of AMS.\n - F/u blood and urine cx, sputum cx, C. diff (urine with staph\n spp, UA dirty and UCx pending)\n - Repeat abdominal US today to evaluate for change in liver lesion (?\n Abscess)\n - Broad abx as above with good gram positive, gram neg, and anaerobic\n coverage\n - Goal CVP 8-12 but no measurements available currently\n will bolus\n for tachycardia, UOP < 30cc/h, goal MAP >65, CvO2 >70\n - Pressors for MAP > 65, wean levophed as tolerated\n - Monitor mental status\n - Consider paracentesis if continues febrile and no other source (would\n likely need to be done by IR, but will F/U US report today)\n #Hypotension. Continues to wean from levophed\n currently at 0.06.\n pressures run low. No further episodes of AMS since starting\n pressors on .\n # Tachycardia: Likely hyperdynamic in setting of fever, infection.\n Volume status appears grossly euvolemic; pt mentating at and\n maintaining urine output. Echo with evidence of depressed cardiac fxn,\n ? tachycardia induced cardiomyopathy\n - Tylenol prn fever\n - Abx as above\n - Fluid boluses prn, though patient with heart rate 110s;\n appears hypervolemic\n # Anemia/bleed: Hct stable. Pt with RP bleed and CT evidence of\n hemorrhage into bowel wall, also gastric varices c/b GIB earlier in\n admission. Transfused 1 unit pRBCs with appropriate bump and has\n remained stable.\n - Trend Hct\n - Guaiac stools\n - Active T&S\n - continue pantoprazole 40mg IV bid\n - Continue iron supplement\n # Liver lesion. Noted on abdominal CT. Possible abscess.\n - Abdominal U/S tomorrow to eval for interval change\n - Discuss possible drainage with IR (? CT guided?)\n # Left humeral fx: Likely d/t trauma sustained during radiology.\n - No surgical indication at this time\n - Pain control with lidoderm patch and morphine prn\n .\n # SMV thrombus: Plan for anticoagulation x 6 months but held in setting\n of recent GI and RP bleed.\n - Continue heparin SQ\n .\n # Seizure disorder: No recent reports of seizures. Caution as certain\n antibiotics may lower seizure threshold.\n - Continue phenobarbitol and phenytoin\n - will check drug levels tomorrow\n .\n # Cerebral palsy: Stable mental status. Interactive with family but\n nonverbal at .\n .\n FEN: NG tube likely in duodenum, bolus IVF prn, TPN; continue tube\n feeds today\n PROPHYLAXIS: pneumoboots, IV PPI\n ACCESS: PICC, PIV, A-line in right brachial artery\n CODE: Do not resuscitate. Ok to intubate or use pressors. No CPR or\n defibrillation\n ICU Care\n Nutrition:\n TPN w/ Lipids - 06:14 PM 45 mL/hour\n Vivonex (Full) - 03:32 AM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 11:14 AM\n 20 Gauge - 11:42 AM\n Arterial Line - 11:10 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Respiratory ",
"chartdate": "2115-03-28 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 631664,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Tube Type\n ETT:\n Position: 20 cm at teeth\n Route: Oral\n Type: Standard\n Size: 6.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Invasive ventilation assessment: PSV 10 peep 5 and 40%\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Underlying illness not resolved\n"
},
{
"category": "Physician ",
"chartdate": "2115-03-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 631547,
"text": "Chief Complaint:\n 24 Hour Events:\n ULTRASOUND - At 09:53 AM\n FEVER - 101.1\nF - 08:00 AM\n :\n - Diuresed with lasix - negative 760 for day.\n - continues on levophed (0.08 this AM)\n - no overnight events\n - continuing to wean PSV; will attempt SBT this morning.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 11:00 AM\n Vancomycin - 08:42 PM\n Metronidazole - 01:51 AM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Fentanyl (Concentrate) - 30 mcg/hour\n Norepinephrine - 0.08 mcg/Kg/min\n Other ICU medications:\n Furosemide (Lasix) - 12:48 PM\n Pantoprazole (Protonix) - 08:42 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.4\nC (101.1\n Tcurrent: 37.9\nC (100.2\n HR: 118 (108 - 132) bpm\n BP: 85/62(72) {74/54(63) - 103/77(87)} mmHg\n RR: 27 (19 - 32) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 2,938 mL\n 973 mL\n PO:\n TF:\n 710 mL\n 345 mL\n IVF:\n 938 mL\n 200 mL\n Blood products:\n Total out:\n 3,620 mL\n 510 mL\n Urine:\n 3,120 mL\n 510 mL\n NG:\n Stool:\n 500 mL\n Drains:\n Balance:\n -682 mL\n 463 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 300 (300 - 300) mL\n Vt (Spontaneous): 445 (330 - 445) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 19\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 145\n PIP: 21 cmH2O\n SpO2: 96%\n ABG: 7.40/45/99./25/1 (TV325, FiO240, rate21, peep 8)\n Ve: 7 L/min\n PaO2 / FiO2: 250\n Physical Examination\n Gen: Thin, opening eyes but no clear orientation to voice\n HEENT: Sclera anicteric, eyes sunken, MMM, audible secretions\n Neck: Supple, thin, EJs prominent and hyperdynamic, no LAD\n Lungs: Intubated, coarse BS bilaterally with diffuse ronchi\n CV: S1, S2 regular rhythm, increased rate\n Abdomen: Soft, BS+, distended,\n GU: foley catheter in place\n Ext: Warm, cachectic, BLE contractures, + DP pulses\n Labs / Radiology\n 171 K/uL\n 9.1 g/dL\n 136 mg/dL\n 0.6 mg/dL\n 25 mEq/L\n 3.8 mEq/L\n 29 mg/dL\n 105 mEq/L\n 139 mEq/L\n 28.1 %\n 6.5 K/uL\n [image002.jpg]\n 02:19 AM\n 03:29 PM\n 03:46 PM\n 06:28 PM\n 03:24 AM\n 03:52 AM\n 11:49 AM\n 01:56 PM\n 02:25 AM\n 02:42 AM\n WBC\n 8.1\n 6.5\n Hct\n 27.5\n 28.9\n 28.1\n Plt\n 206\n 171\n Cr\n 0.6\n 0.6\n 0.6\n TCO2\n 27\n 23\n 22\n 24\n 27\n 29\n Glucose\n 99\n 153\n 136\n Other labs: PT / PTT / INR:16.1/28.6/1.4,\n Ca++:7.7 mg/dL, Mg++:1.8 mg/dL, PO4:3.2 mg/dL\n Lactate: 0.9\n RUQ U/S:\n 1. No son correlate corresponding to the hypoenhancing lesion\n seen on\n prior CT of is seen. Lesion seen on CT could represent an\n infarct\n secondary to compromised blood supply through the right portal vein,\n which\n appears nearly occluded.\n 2. Right pleural effusion and ascites.\n Sputum growing MRSA () and rare gram negative rods ()\n Assessment and Plan\n 35 yo M with PMH of CP, seizure disorder, GIB, pancreatic cyst s/p\n drainage in , admitted with abdominal pain with complicated course,\n now with new fever, tachypnea, and hypoxia.\n .\n # Respiratory failure: Patient transferred to MICU with tachypnea and\n hypoxia on and intubated on . Given his new fever,\n respiratory deterioration, and imaging findings consistent with\n multilobar pneumonia he was started on vancomycin, cefepime and flagyl\n (concern for aspiration given recently started tube feeds). Sputum\n growing MRSA. Pleural effusions also noted on imaging, likely due to\n fluid resuscitation for hypotension in the setting of albumin of 2.3,\n so over the past 24 hours have been diuresing with lasix boluses. PE\n considered but CTA negative.\n - continue antibiotic coverage for HAP/aspiration PNA with vanc,\n cefepime, metronidazole x total 8 days (Day 1 = )\n - continue with daily RSBI and SBT as tolerated, attempt to wean to PSV\n will reduce PEEP from 8 to 5\n - gentle diuresis with IV lasix boluses to goal net negative 500cc\n - electrolytes with repletion while on Lasix\n - f/u blood cultures\n .\n # Fever/sepsis: Pt febrile with tachycardia and tachypnea; meets\n definition of sepsis with most likely source being pulmonary. With\n ascites, SBP is also possible although he is now s/p 3 taps which have\n not been c/w SBP. Urinalysis and culture from with staph spp but\n repeat appears clean with NGTD. MS with no obvious nuchal\n rigidity although exam limited by pt cooperation. Again, PE could\n cause similar sx of fever and respiratory distress but none seen on\n CTA. Continues febrile daily. No further episodes of AMS. CT read as\n possible liver abscess but repeat RUQ ultrasound read as more\n consistent with infarct. C. Diff has been negative. Continues to have\n fever to 101 but normal white count, lactate normal.\n - Broad abx as above with good gram positive, gram neg, and anaerobic\n coverage\n - Goal CVP 8-12 but no measurements available currently\n will bolus\n for tachycardia, UOP < 30cc/h, goal MAP >60, CvO2 >70\n - Pressors for MAP > 60, wean levophed as tolerated\n - Monitor mental status\n - Consider paracentesis if continues febrile and no other source (would\n likely need to be done by IR,\n .\n #Hypotension. Continues to wean from levophed\n currently at 0.06.\n pressures run low. No further episodes of AMS since starting\n pressors on .\n # Tachycardia: Likely hyperdynamic in setting of fever, infection.\n Volume status appears grossly euvolemic; pt mentating at and\n maintaining urine output. Echo with evidence of depressed cardiac fxn,\n ? tachycardia induced cardiomyopathy\n - Tylenol prn fever\n - Abx as above\n - Fluid boluses prn, though patient with heart rate 110s;\n appears hypervolemic\n # Anemia/bleed: Hct stable. Pt with RP bleed and CT evidence of\n hemorrhage into bowel wall, also gastric varices c/b GIB earlier in\n admission. Transfused 1 unit pRBCs with appropriate bump and has\n remained stable.\n - Trend Hct\n - Guaiac stools\n - Active T&S\n - continue pantoprazole 40mg IV bid\n - Continue iron supplement\n # Liver lesion. Noted on abdominal CT. Possible abscess.\n - Abdominal U/S tomorrow to eval for interval change\n - Discuss possible drainage with IR (? CT guided?)\n # Left humeral fx: Likely d/t trauma sustained during radiology.\n - No surgical indication at this time\n - Pain control with lidoderm patch and morphine prn\n .\n # SMV thrombus: Plan for anticoagulation x 6 months but held in setting\n of recent GI and RP bleed.\n - Continue heparin SQ\n .\n # Seizure disorder: No recent reports of seizures. Caution as certain\n antibiotics may lower seizure threshold.\n - Continue phenobarbitol and phenytoin\n - will check drug levels tomorrow\n .\n # Cerebral palsy: Stable mental status. Interactive with family but\n nonverbal at .\n .\n FEN: NG tube likely in duodenum, bolus IVF prn, TPN; continue tube\n feeds today\n PROPHYLAXIS: pneumoboots, IV PPI\n ACCESS: PICC, PIV, A-line in right brachial artery\n CODE: Do not resuscitate. Ok to intubate or use pressors. No CPR or\n defibrillation\n ICU Care\n Nutrition:\n TPN w/ Lipids - 06:14 PM 45 mL/hour\n Vivonex (Full) - 03:32 AM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 11:14 AM\n 20 Gauge - 11:42 AM\n Arterial Line - 11:10 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 631662,
"text": "35M with cerebral palsy, non verbal. Admitted in with acute\n abdomen, peritonitis, and chronic pancreatitis. Found to have SMV\n thrombus, anticoagulated which resulted in retoperitoneal hemorrhage.\n Was on floor when he was re-admitted with progressive hypoxemia and\n then subsequently intubated. CTA with LLL and RLL PNA and atelectasis,\n and effusions.\n Code Status: DNR, already intubated.\n Shift Events:\n Dr met with family and discussed possibility that pt may need to\n be trached if he cannot tolerate being off Ventilatory support.\n Discussed possibility that pt may not be able to return to baseline and\n the possibility that pt may need long term rehab for support with\n Ventilatory support. Family became visibly upset with possibility pt\n may not be able to return home or return to previous level of\n functioning. Once Dr left room Father would not engage Mother at\n all and was visibly angry stating he did not want to talk about it.\n Then led into an outburst yelling at Wife stating he has known for a\n long time that his son is going to\n and he is\nsick of the games\n these Doctors [and] is sick of people sticking and prodding his\n son, just let him go\n. When asked what her understanding was Mother\n stated she understands that.\n he might need a tube in his throat once\n they take the tube out and that he may not return back to what he once\n was\n. Social work came to see family.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Accepted pt on CPAP with pressure support titrated down to 10 from 12,\n and peep 8, 0800 ABG 7.44 / 38 / 100. lung sounds rhoncorous and\n diminsed at bases. Copious amounts of tan thick sputum suctioned from\n ETT, clear to white secretions suctioned orally.\n Action:\n PEEP weaned to 5, pt turned and suctioned q 2 hours and prn, frequent\n ABGs. Pt given Lasix 1x 40 mg IV.\n Response:\n Lung sounds less rhoncorous, pt continues to need frequent suctioning.\n At 1200 during turning pt became increasingly tachypneic during\n turning, pt began to desat to low 80s, pt immediately turned back and\n appeared cyanotic appearing and in distress. Suctioning through ETT\n once again found copious amounts of tan colored sputum. Pt quickly\n returned to 02 sat 96%\n Plan:\n Continue to attempt to wean on CPAP/pressure support/peep as tolerated,\n monitor ABGs, Lung sounds, Antibiotics as ordered\n Seizure, without status epilepticus\n Assessment:\n Pt currently without any s/s seizure activity, currently on\n Phenobarbital and Fosfenytoin IV Pupils , Pt sleeps with eyes\n open but will track when awake, responds to some simple commands and at\n times will be seen making an effort to assist with turns with right\n hand and turning his body. Otherwise pt at baseline neurologically.\n Action:\n Frequent neuro checks, discussed with team if there is any need for\n possible laboratory monitoring for fosphenytoin and Phenobarbital\n levels.\n Response:\n Pt remains at baseline Neurologically, HO states he will order levels\n for am, pt remains safe\n Plan:\n Continue to monitor neurological status, follow up with drug levels in\n the am, provide for pt safety and comfort.\n Tachycardia, Other\n Assessment:\n Pt heart rate remains >100 up to 135, accepted pt this am on levophed\n 0.08 bp 101/71\n Action:\n Levophed titrated down from 0.08 to off at 1445\n Response:\n Bp 71/51\n 107/50 Map 58 - 71 through course of shift. BP 93/68 with\n Map 77 at 1530\n Plan:\n Continue to monitor hemodynamic status, Levophed if needed\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 631454,
"text": "35M with cerebral palsy, non verbal. Admitted in with acute\n abdomen, peritonitis, and chronic pancreatitis. Found to have SMV\n thrombus, anticoagulated which resulted in retoperitoneal hemorrhage.\n Was on floor when he was re-admitted with progressive hypoxemia and\n then subsequently intubated. CTA with LLL and RLL PNA and atelectasis,\n and effusions.\n Code Status: DNR, already intubated.\n EVENTS: Stable overnight, tolerating CPAP+PS\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lungs with scattered rhonchi all fields---clears with suctioning,\n ETtube suctioned for mod. Amts thick yellow tinged sputum, oral suction\n for large amts of thick white sputum, remains resistant to oral care\n and to oral suctioning, RR=19-30, no vent changes overnight, current\n vent settings include CPAP+PS 330-40% with Peep= 8. MV= , TV-\n 300-350, Sats= 92-96%, ABG= 7.40-45-100\n Action:\n Aggressive pulmonary toileting, no diuretics overnight, Sats and ABG\n monitored, no vent changes\n Response:\n Tolerating CPAP+PS, Continues to require freq. ETtube suctioning for\n mod. Amt sputum\n Plan:\n Continue aggressive pulmonary toileting, ? need for further diuresis,\n Continue to wean vent as tolerated, probably not ready for extubation\n due to large amt of sputum being suctioned from ETtube and orally.\n Alteration in Nutrition\n Assessment:\n Abd softly distended with positive bowel sounds all quads, positive\n flatus, Flexiseal draining loose green stool, NGtube placement\n confirmed by auscultation, tolerating FS Vivonex feedings without any\n residuals, abd is less distended tonight than previous nights,\n fingersticks WNL---being covered with sliding scale insulin, TPN\n infusing at 45 ml/hr via left AC PICC\n Action:\n Vivonex feedings increased to 50ml/hr, residuals checked Q 4hr, TPN\n infusing as ordered, fingersticks monitored and covered with sliding\n scale\n Response:\n Tolerating tube feedings, Abd less distended\n Plan:\n Increase tube feedings to goal as tolerated, d/c TPN when tube feedings\n at goal, continue to monitor residuals Q4hr along with freq. abd.\n Assessments.\n Seizure, without status epilepticus\n Assessment:\n , , opens eyes and tracks, follows all simple commands within\n his baseline abilities,moving all extremities purposely, bilat soft\n wrist restraints to prevent pt from pulling at line and tubes, resting\n in naps, IV Fentanyl infusing at 30 mcgs/hr and IV versed infusing at 1\n mg/hr, no seizure activity noted.\n Action:\n Freq. neuro and safety checks, anticonvulsant meds as ordered\n Response:\n Baseline neuro status, no evidence of seizure activity\n Plan:\n Continue freq. safety and neuro checks, ? of weaning versed and\n fentanyl to off and using bolus dosing of fentanyl for pain due to\n fractured arm.\n Tachycardia, Other\n Assessment:\n HR= 109-122 ST with no ectopy noted, low grade temps with Tmax= 100.3,\n right brachial Aline still dampens but when it has a good waveform then\n it correlates well with NBP, BP= 79-98/50\ns, received pt on IV Levophed\n infusing at 0.03 mcgs/kg/min but MAP\ns continuously down to 50\ns so\n Levophed titrated up and currently at 0.08 mcgs/kg/min with MAP\ns >65,\n antibx as ordered, WBC= 6.5, lactate= 0.9\n Action:\n Levophed titrated up due to hypotension , Tylenol x 1 for low grade\n temp\n Response:\n Still requiring levophed to maintain MAP\ns > 65, Tachycardia continues\n and appears unrelated to Levophed rate or to temps----? If tachycardia\n is pt\ns baseline HR\n Plan:\n Continue to attempt to wean levophed while maintaining MAP\ns > 65,\n continue antibx, monitor temps and culture results.\n"
},
{
"category": "Physician ",
"chartdate": "2115-03-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 631532,
"text": "Chief Complaint:\n 24 Hour Events:\n ULTRASOUND - At 09:53 AM\n FEVER - 101.1\nF - 08:00 AM\n :\n - Diuresed with lasix - negative 760 for day.\n - continues on levophed (0.08 this AM)\n - no overnight events\n - continuing to wean PSV; will attempt SBT this morning.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 11:00 AM\n Vancomycin - 08:42 PM\n Metronidazole - 01:51 AM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Fentanyl (Concentrate) - 30 mcg/hour\n Norepinephrine - 0.08 mcg/Kg/min\n Other ICU medications:\n Furosemide (Lasix) - 12:48 PM\n Pantoprazole (Protonix) - 08:42 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.4\nC (101.1\n Tcurrent: 37.9\nC (100.2\n HR: 118 (108 - 132) bpm\n BP: 85/62(72) {74/54(63) - 103/77(87)} mmHg\n RR: 27 (19 - 32) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 2,938 mL\n 973 mL\n PO:\n TF:\n 710 mL\n 345 mL\n IVF:\n 938 mL\n 200 mL\n Blood products:\n Total out:\n 3,620 mL\n 510 mL\n Urine:\n 3,120 mL\n 510 mL\n NG:\n Stool:\n 500 mL\n Drains:\n Balance:\n -682 mL\n 463 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 300 (300 - 300) mL\n Vt (Spontaneous): 445 (330 - 445) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 19\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 145\n PIP: 21 cmH2O\n SpO2: 96%\n ABG: 7.40/45/99./25/1\n Ve: 7 L/min\n PaO2 / FiO2: 250\n Physical Examination\n Labs / Radiology\n 171 K/uL\n 9.1 g/dL\n 136 mg/dL\n 0.6 mg/dL\n 25 mEq/L\n 3.8 mEq/L\n 29 mg/dL\n 105 mEq/L\n 139 mEq/L\n 28.1 %\n 6.5 K/uL\n [image002.jpg]\n 02:19 AM\n 03:29 PM\n 03:46 PM\n 06:28 PM\n 03:24 AM\n 03:52 AM\n 11:49 AM\n 01:56 PM\n 02:25 AM\n 02:42 AM\n WBC\n 8.1\n 6.5\n Hct\n 27.5\n 28.9\n 28.1\n Plt\n 206\n 171\n Cr\n 0.6\n 0.6\n 0.6\n TCO2\n 27\n 23\n 22\n 24\n 27\n 29\n Glucose\n 99\n 153\n 136\n Other labs: PT / PTT / INR:16.1/28.6/1.4,\n Ca++:7.7 mg/dL, Mg++:1.8 mg/dL, PO4:3.2 mg/dL\n Lactate: 0.9\n Assessment and Plan\n ICU Care\n Nutrition:\n TPN w/ Lipids - 06:14 PM 45 mL/hour\n Vivonex (Full) - 03:32 AM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 11:14 AM\n 20 Gauge - 11:42 AM\n Arterial Line - 11:10 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2115-04-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 632343,
"text": "35 yo M with PMH of CP, seizure disorder, GIB, pancreatic cyst s/p\n drainage in , admitted with abdominal pain with complicated course,\n now with new fever, tachypnea, and hypoxia.\n Code Status: DNR/DNI(will discuss noninv\n Respiratory failure, acute (not ARDS/)\n Assessment:\n I received the patient with a HR 140\ns, RR 40-45, and o2 sat\n 86-88% on NC. Lung sounds were ronchi bilaterally. He was coughing but\n unable to clear his secretions. CXR was positive for mild fluid\n overload. Patient has finished a course of IV AXB pneumonia. He is\n positive for MRSA in his sputum. Temp max 99.6 oral.\n Action:\n Morphine 1mg iv given.\n Humidified face tent placed at 100%.\n Continued with the 4L NC.\n Nasal and oral suctioned done,\n Gentle chest PT.\n Lasix 20mg ordered at 1500(gentle diuresis).\n Response:\n He did appear more comfortable after the morphine and\n suctioning.\n He was able to cough up his secretions and swallow them the\n humidification.\n O2 sat 98-100%.\n When I did chest PT. He did drop his sats back down to the\n 87-88%. He did recover over 20 minutes.\n Now he is on 4L NC and 40% face tent. And he is able to\n maintain his o2 sat of 98% w/ RR 25-30..\n Plan:\n The patients were ordered to be drawn at 1500, and ICU team\n wanted the ordered the lasix at1500.\n Please obtain PM lytes.\n Continue with the humidification and nasal prongs.\n The goal is 250 to 500 negative for the day.\n Fracture, other\n Assessment:\n Patient sustained a left fracture of his arm.\n Action:\n Morphine.\n Response:\n Good effect noted.\n Plan:\n Turn the patient on the right side and his back for comfort.\n Morphine or Tylenol depending on the severity of the pain.\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 631451,
"text": "35M with cerebral palsy, non verbal. Admitted in with acute\n abdomen, peritonitis, and chronic pancreatitis. Found to have SMV\n thrombus, anticoagulated which resulted in retoperitoneal hemorrhage.\n Was on floor when he was re-admitted with progressive hypoxemia and\n then subsequently intubated. CTA with LLL and RLL PNA and atelectasis,\n and effusions.\n Code Status: DNR, already intubated.\n EVENTS: Stable overnight, tolerating CPAP+PS\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lungs with scattered rhonchi all fields---clears with suctioning,\n ETtube suctioned for mod. Amts thick yellow tinged sputum, oral suction\n for large amts of thick white sputum, remains resistant to oral care\n and to oral suctioning, RR+\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n Seizure, without status epilepticus\n Assessment:\n Action:\n Response:\n Plan:\n Tachycardia, Other\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Social Work",
"chartdate": "2115-03-28 00:00:00.000",
"description": "Social Work Progress Note",
"row_id": 631650,
"text": "Social Work:\n Met at some length with pt\ns mother and her brother-in-law in ICU\n family waiting room after a brief meeting with mother and father\n together at bedside in MICU. They had been having a difficult, tense\n conversation on the heels of meeting with MICU team to discuss plan of\n care, and father declined interest in moving the conversation away from\n the bedside at that moment, preferring to stay with pt alone and not\n talk further. Mother and her brother-in-law subsequently speak with SW\n about the decision they are faced with around plan of care and code\n status in anticipation of pt\ns possible extubation. Brother-in-law\n steps into what he acknowledges feels like a\nmediator\n role in the\n family and shares his sense for what his brother (pt\ns father) is\n experiencing now and how this differs from what pt\ns mother is\n experiencing. Pt\ns mother speaks of how she wants to maintain hope for\n pt\ns recovery and recognizes how she will look for hopeful signs and\n let them lead her in her decision-making process. She clarifies that\n she is pt\ns HCP and that\nabout 90%\nof the decision-making process\n rests with her, with her husband ultimately deferring to her, usually.\n Husband (pt\ns father) is described as less optimistic and more\n frustrated by the course of pt\nup and down\n hospitalization and\n perhaps fears that a trach might only prolong pt\ns suffering without\n realistic hope for recovery. Pt\ns mother speaks of how much she wants\n pt home, and she wonders how long he might need to be in rehab if he\n does have a trach put in. SW discussed with MICU attending and relayed\n that mother would benefit from additional conversation with team about\n what this procedure entails, the function of a trach, how long he might\n need to be in rehab, and pt\ns prognosis with or without it. Also\n provided reflective listening and supportive counseling for mother and\n her brother-in-law. continue to follow for ongoing emotional\n support throughout pt\ns hospitalization. Please page as needed.\n , LICSW, #\n"
},
{
"category": "Physician ",
"chartdate": "2115-03-29 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 631830,
"text": "Chief Complaint:\n 24 Hour Events:\n - Pressure support 10, PEEP 5 overnight; initially off fent/versed, but\n then agitated so got versed\n - A-line no longer drawing well/no longer with accurate tracing\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 10:02 AM\n Metronidazole - 05:34 PM\n Vancomycin - 07:55 PM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 12:10 PM\n Fosphenytoin - 11:54 PM\n Midazolam (Versed) - 05:53 AM\n Other medications:\n Changes to medical and family history:\n No changes\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Unchanged\n Flowsheet Data as of 07:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 37.3\nC (99.2\n HR: 111 (111 - 141) bpm\n BP: 102/89(95) {71/51(60) - 107/93(96)} mmHg\n RR: 23 (23 - 35) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 2,638 mL\n 586 mL\n PO:\n TF:\n 1,180 mL\n 385 mL\n IVF:\n 800 mL\n 101 mL\n Blood products:\n Total out:\n 2,325 mL\n 330 mL\n Urine:\n 2,325 mL\n 330 mL\n NG:\n Stool:\n Drains:\n Balance:\n 313 mL\n 256 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 328 (177 - 355) mL\n PS : 10 cmH2O\n RR (Spontaneous): 38\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 121\n PIP: 16 cmH2O\n SpO2: 95%\n ABG: 7.49/34/82./26/2\n Ve: 11.3 L/min\n PaO2 / FiO2: 207\n Physical Examination\n Gen: Thin, opening eyes but no clear orientation to voice\n HEENT: Sclera anicteric, eyes sunken, MMM, audible secretions\n Neck: Supple, thin, EJs prominent and hyperdynamic, no LAD\n Lungs: Intubated, coarse BS bilaterally with diffuse ronchi\n CV: S1, S2 regular rhythm, increased rate\n Abdomen: Soft, BS+, distended, no facial grimacing to palpation\n GU: foley catheter in place\n Ext: Warm, cachectic, BLE contractures, + DP pulses\n Labs / Radiology\n 216 K/uL\n 9.9 g/dL\n 116 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 4.2 mEq/L\n 29 mg/dL\n 105 mEq/L\n 138 mEq/L\n 30.4 %\n 10.7 K/uL\n [image002.jpg]\n 03:52 AM\n 11:49 AM\n 01:56 PM\n 02:25 AM\n 02:42 AM\n 07:36 AM\n 09:06 AM\n 02:18 PM\n 02:33 PM\n 05:01 AM\n WBC\n 6.5\n 10.7\n Hct\n 28.1\n 30.4\n Plt\n 171\n 216\n Cr\n 0.6\n 0.6\n 0.6\n 0.7\n TCO2\n 24\n 27\n 29\n 27\n 25\n 27\n Glucose\n 153\n 136\n 118\n 116\n Other labs: PT / PTT / INR:15.5/27.2/1.4\n Ca++:7.6 mg/dL, Mg++:1.8 mg/dL, PO4:2.3 mg/dL\n phenytoin: 12.4 phenobarb: 13.4\n Assessment and Plan\n 35 yo M with PMH of CP, seizure disorder, GIB, pancreatic cyst s/p\n drainage in , admitted with abdominal pain with complicated course,\n now with new fever, tachypnea, and hypoxia.\n .\n # Respiratory failure: Patient transferred to MICU with tachypnea and\n hypoxia on and intubated on . Given his new fever,\n respiratory deterioration, and imaging findings consistent with\n multilobar pneumonia he was started on vancomycin, cefepime and flagyl\n (concern for aspiration given recently started tube feeds). Sputum\n growing MRSA. Pleural effusions also noted on imaging, likely due to\n fluid resuscitation for hypotension in the setting of albumin of 2.3,\n so over the past 24 hours have been diuresing with lasix boluses. PE\n considered but CTA negative.\n - continue antibiotic coverage for HAP/aspiration PNA with vanc,\n cefepime, metronidazole x total 8 days (Day 1 = )\n - continue with daily RSBI and SBT as tolerated, attempt to wean to\n PSV; reduced PEEP from 8 to 5 this morning without problems\n - ABG later today\n - gentle diuresis with IV lasix boluses to goal net negative 500cc\n - electrolytes with repletion while on Lasix\n - f/u blood cultures\n .\n # Fever/sepsis: Pt febrile with tachycardia and tachypnea; meets\n definition of sepsis with most likely source being pulmonary (MRSA).\n With ascites, SBP is also possible although he is now s/p 3 taps which\n have not been c/w SBP. Urinalysis and culture from with staph spp\n but repeat appears clean with NGTD. MS with no obvious\n nuchal rigidity although exam limited by pt cooperation. Again, PE\n could cause similar sx of fever and respiratory distress but none seen\n on CTA. Continues febrile daily. No further episodes of AMS. CT read as\n possible liver abscess but repeat RUQ ultrasound read as more\n consistent with infarct. C. Diff has been negative. Continues to have\n fever to 101 on overnight but normal white count, lactate normal.\n - Broad abx as above with good gram positive, gram neg, and anaerobic\n coverage. Consider adding additional coverage for double gram negative\n coverage if WBC does not continue trending down.\n - Goal CVP 8-12 but no measurements available currently\n will bolus\n for tachycardia, UOP < 30cc/h, goal MAP >60, CvO2 >70\n - Pressors for MAP > 55-60, off vasopressors\n - Monitor mental status\n - Consider paracentesis if continues febrile and no other source (would\n likely need to be done by IR)\n .\n #Hypotension. Continues to wean from levophed\n currently at 0.06.\n pressures run low and currently sedated which may contribute.\n MAP goal > 60. No further episodes of AMS since starting pressors on\n .\n # Tachycardia: Likely hyperdynamic in setting of fever, infection.\n Volume status appears grossly euvolemic; pt mentating at and\n maintaining urine output. Echo with evidence of depressed cardiac fxn,\n ? tachycardia induced cardiomyopathy\n - Tylenol prn fever\n - Abx as above\n - Fluid boluses prn, though patient with heart rate 110s;\n appears hypervolemic\n # Anemia/bleed: Hct stable. Pt with RP bleed and CT evidence of\n hemorrhage into bowel wall, also gastric varices c/b GIB earlier in\n admission. Transfused 1 unit pRBCs with appropriate bump and has\n remained stable since.\n - Trend Hct\n - Guaiac stools\n - Active T&S\n - continue pantoprazole 40mg IV bid\n - Continue iron supplement\n # Liver lesion. Noted on abdominal CT. Possible ischemia/infarction vs\n abscess. Abdominal U/S not consistent with abscess.\n # Left humeral fx: Likely d/t trauma sustained during radiology.\n - No surgical indication at this time\n - Pain control with lidoderm patch and morphine prn\n .\n # SMV thrombus: Plan for anticoagulation x 6 months but held in setting\n of recent GI and RP bleed.\n - Continue heparin SQ\n .\n # Seizure disorder: No recent reports of seizures. Caution as certain\n antibiotics may lower seizure threshold.\n - Continue phenobarbitol and phenytoin\n - drug levels stable as of \n .\n # Cerebral palsy: Stable mental status. Interactive with family but\n nonverbal at .\n .\n FEN: NG tube likely in duodenum, bolus IVF prn, TPN; continue tube\n feeds today\n PROPHYLAXIS: pneumoboots, IV PPI\n ACCESS: PICC, PIV, D/C A-line in right brachial artery\n CODE: Do not resuscitate. Ok to intubate or use pressors. No CPR or\n defibrillation\n ICU Care\n Nutrition:\n Vivonex (Full) - 06:45 AM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 11:14 AM\n Arterial Line - 11:10 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2115-03-29 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 631831,
"text": "Chief Complaint: respiratory failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 35 yo man with cerebral palsy. Weaned off pressors and peep weaned\n down. Weaned off sedation.\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 10:02 AM\n Vancomycin - 07:55 PM\n Metronidazole - 10:41 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 12:10 PM\n Fosphenytoin - 11:54 PM\n Midazolam (Versed) - 05:53 AM\n Other medications:\n SSI\n phosphenytoin\n phenobarb\n lidocaine\n FeSO4\n pancrealipase\n protonix\n chlorhexidine\n levophed\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 37.2\nC (98.9\n HR: 117 (111 - 141) bpm\n BP: 96/71(82) {77/55(65) - 107/93(96)} mmHg\n RR: 33 (21 - 34) insp/min\n SpO2: 92%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 2,638 mL\n 960 mL\n PO:\n TF:\n 1,180 mL\n 577 mL\n IVF:\n 800 mL\n 282 mL\n Blood products:\n Total out:\n 2,325 mL\n 505 mL\n Urine:\n 2,325 mL\n 505 mL\n NG:\n Stool:\n Drains:\n Balance:\n 313 mL\n 455 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 324 (177 - 355) mL\n PS : 10 cmH2O\n RR (Spontaneous): 36\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 121\n PIP: 16 cmH2O\n SpO2: 92%\n ABG: 7.49/34/82./26/2\n Ve: 11.5 L/min\n PaO2 / FiO2: 207\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Non-tender, Distended, firm\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace\n Musculoskeletal: Unable to stand\n Skin: Warm\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Not assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 9.9 g/dL\n 216 K/uL\n 116 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 4.2 mEq/L\n 29 mg/dL\n 105 mEq/L\n 138 mEq/L\n 30.4 %\n 10.7 K/uL\n [image002.jpg]\n 03:52 AM\n 11:49 AM\n 01:56 PM\n 02:25 AM\n 02:42 AM\n 07:36 AM\n 09:06 AM\n 02:18 PM\n 02:33 PM\n 05:01 AM\n WBC\n 6.5\n 10.7\n Hct\n 28.1\n 30.4\n Plt\n 171\n 216\n Cr\n 0.6\n 0.6\n 0.6\n 0.7\n TCO2\n 24\n 27\n 29\n 27\n 25\n 27\n Glucose\n 153\n 136\n 118\n 116\n Other labs: PT / PTT / INR:15.5/27.2/1.4, CK / CKMB /\n Troponin-T:8//0.01, ALT / AST:17/19, Alk Phos / T Bili:106/0.6, Amylase\n / Lipase:/11, Differential-Neuts:86.5 %, Lymph:6.6 %, Mono:5.9 %,\n Eos:0.9 %, Lactic Acid:1.1 mmol/L, Albumin:2.4 g/dL, LDH:383 IU/L,\n Ca++:7.6 mg/dL, Mg++:1.8 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n ALTERATION IN NUTRITION\n TACHYCARDIA, OTHER\n ANEMIA, ACUTE, SECONDARY TO BLOOD LOSS (HEMORRHAGE, BLEEDING)\n FRACTURE, OTHER\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/): Wean PSV to .\n Pulmonary edema: continue lasix diuresis\n HAP: Continue antibiotics for 8 days.\n Will remove a-line\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 11:14 AM\n Arterial Line - 11:10 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition :ICU\n Total time spent: 40 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2115-04-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 632336,
"text": "35 yo M with PMH of CP, seizure disorder, GIB, pancreatic cyst s/p\n drainage in , admitted with abdominal pain with complicated course,\n now with new fever, tachypnea, and hypoxia\n"
},
{
"category": "Physician ",
"chartdate": "2115-03-13 00:00:00.000",
"description": "Physician Resident/Attending Admission Note - MICU",
"row_id": 628657,
"text": "Chief Complaint: hypotension/GI bleed\n HPI:\n 35 y/o M, known to MICU team from previously stay, with a hx of\n cerebral palsy, seizure disorder, anemia and a GI bleed in the past is\n transferred to the MICU for hypotension and coffee ground emesis. The\n patient has been on the floor being treated for intermittent small and\n large bowel obstructions when last night at around 1 am, his nurse\n noted about a teaspoon of blood in his NGT. The nightfloat intern was\n called to the bedside and a NG lavage was done and clear. A stat Hct\n was at his baseline of 30. He BP was in the 80s and HR in 100s at his\n baseline. Several hours later, he was found to have coffee ground\n emesis. Lovenox and coumadin were discontinued at that time. Vitamin\n K was given. This morning, his hct was 27 and his BP had dropped to a\n low of 68/doppler. HR remained in the low 100s. He was receiving a NS\n bolus and 1u PRBCs. He has a PICC for access. He had no further\n episodes of coffee grounds and had a mildly tender abdomen without\n rebound or guarding. His mother notes that he had been his usual self\n the last few days; playing in bed, interactive. But starting last\n night, he was more somnulent and less interactive. His last fever was\n several days ago, but he has been having intermittent fevers since\n admission.\n .\n In terms of his current hospitalization, he was initially admitted on\n with abdominal pain and distention to an OSH. CT scan was\n performed and was reported as diffuse bowel edema, gastric varices,\n ascites and a pancreatic cyst. He was transferred for further\n management to the SICU team for concerns of an acute abdomen. He had a\n diagnostic paracentesis on with WBC , but no growth so thought\n to be inflammatory state. He was started on Vanco/Zosyn/Flagyl for\n suspected peritonitis and ischemic bowel with translocation. On CT, a\n SMV thrombus was noted and heparin was started on . His thrombus\n was likely chronic and secondary to chronic pancreatic inflammation.\n He was transitioned to coumadin. He was then intubated for\n respiratory failure. He was extubated but was then reintubated\n likely secondary to fluid overload. When had had difficultly weaning\n off the ventilator, he was transferred to the MICU team for further\n management. He was extubated successfully and then transferred to the\n floor for futher management of his abdominal pain. He was changed from\n heparin to lovenox for bridging and coumadin. He started TPN. He did\n tolerated POs for a few days but has intermittent large bowel\n obstuctions and then remade NPO. GI has been consulted for a possible\n PEG tube. He completed a 14 d course of vanco and was continued on\n cipro/flagyl for his initial peritonitis.\n .\n On arrival to the floor, he is awake and alert and in no distress. He\n remains hypotensive with SBPs in the 70s. He winces during the\n abdominal exam. His mother is at the bedside.\n Patient admitted from: \n History obtained from Family / Medical records\n Patient unable to provide history: non-verbal\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Past Medical History:\n Cerebral Palsy\n Seizure disorder\n Chronic anemia - Hct 35\n GIB in \n h/o liver cyst drainage (, )\n H/o Laproscopic cholecystectomy\n H/o pancreatic cyst drainage with chronic pancreatitis\n .\n Medications (Upon admission):\n Miralax prn\n Phenobarbital 32.4 mg TAB am, 1PM\n Dilantin (Extended caps) 75mg in am 100mg in pm\n Ferrous Fumarate 324 mg Tabs daily\n MVI daily\n Cyproheptadine HCL 4mg tabs 0.5 tab in AM, 0.5 tabs in PM\n Prilosec 20mg daily\n Celexa 20mg daily\n Zovirax 5% oint (acyclovir) q2hr while awake x 4 days prn cold sore\n vitamine D 400 Unit Caps\n .\n Medications (Upon transfer to MICU service):\n Phytonadione 5 mg IV ONCE \n Pantoprazole 40 mg IV Q12H @ 0147 View\n Acetylcysteine 20% 600 mg PO/NG x4\n Ciprofloxacin 400 mg IV Q12H\n MetRONIDAZOLE (FLagyl) 500 mg IV Q8H\n Hydrocortisone Cream 1% 1 Appl TP QID:PRN\n Sarna Lotion 1 Appl TP QID:PRN\n Acetaminophen 650 mg PO/NG Q6H:PRN\n PHENObarbital 30 mg IV Q12H\n Fosphenytoin 100 mg PE IV Q8H\n Morphine Sulfate 2-4 mg IV Q4H:PRN\n Ferrous Sulfate 325 mg PO/NG DAILY\n Pancrelipase 4500 2 CAP PO TID\n Miconazole 2% Cream 1 Appl TP \n Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN\n Glucagon 1 mg IM Q15MIN:PRN\n Dextrose 50% 12.5 gm IV PRN\n Insulin Sliding Scale\n NC, Maternal grandmother had DM, paternal grandfather had HTN, parents\n healthy.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Lives at home with family, goes to school 5 days a week, no\n recent travels, no smoke/drink/IVDU.\n Review of systems:\n Constitutional: Fatigue, Fever, Weight loss\n Ear, Nose, Throat: OG / NG tube\n Gastrointestinal: Abdominal pain, Nausea, Emesis, Diarrhea\n Genitourinary: incontinence\n Integumentary (skin): itch\n Heme / Lymph: Anemia\n Neurologic: Seizure\n Flowsheet Data as of 10:54 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 35.6\nC (96\n Tcurrent: 35.6\nC (96\n HR: 109 (101 - 112) bpm\n BP: 83/64(69) {66/49(53) - 83/64(69)} mmHg\n RR: 26 (24 - 28) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n SpO2: 100%\n Physical Examination\n General Appearance: Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: NG tube\n Lymphatic: Cervical WNL, Supraclavicular WNL, Cervical adenopathy\n Cardiovascular: (S1: Normal), (S2: Normal, No(t) Distant)\n Peripheral Vascular: (Right radial pulse: Diminished), (Left radial\n pulse: Diminished), (Right DP pulse: Diminished), (Left DP pulse:\n Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Bowel sounds present, Distended, Tender: winces with diffuse\n palpation; mild guarding, no rebound\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Musculoskeletal: Unable to stand\n Skin: Warm\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n [image002.jpg]\n Other labs: Lactic Acid:\n 2.4 mmol/L\n Fluid analysis / Other labs: wbc 6.6, hct 27.6 from baseline 30-31, plt\n 212\n inr 1.9\n na 134, k 3.6, cl 102, hco3 28, bun 24, inr 1.0 (baseline)\n alt 10, ast 17, alk phos 128, t bili 0.2\n ca 7.2, mg 2.1, phos 3.2, alb 2.4\n tsh 2.9\n phenobarb 12.6, dilantin 9.0 ()\n Imaging: Imaging:\n portable abdomen -\n per HO, dilated loops of bowel; generally unchanged from yesterday\n .\n portable abdomen -\n IMPRESSION: Unchanged marked colonic/sigmoid dilation.\n .\n upright abdomen -\n IMPRESSION: Slightly improvement of marked sigmoid dilatation. No free\n intraperitoneal air.\n .\n CT abd/pelvis -\n (wet read) Pleural effusions decreased compared to prior study. NG tube\n noted within stomach. No evidence of SBO. Dilated fluid filled rectum\n and sigmoid with rectal tube in place may reflect ileus. No free air.\n No loculated fluid collections. Redemonstration of SMV thrombosis with\n collateral flow to a patent main portal vein, unchanged. Portal vein\n branches are difficult to evaluate. Major mesenteric arteries are\n widely patent. Low attenuation hepatic parenchyma may represent edema\n or fatty infiltration. Previously\n noted likely small pancraetic pseudocyst no longer identified, though\n calcifications in panc head and pancreatic atrophy again suggest prior\n pancreatitis.\n .\n RUQ Ultrasound -\n IMPRESSION: Small ascites. Again noted probable pseudocyst in the\n midline and collateral vessels related to the SMV thrombosis.\n .\n Renal US -\n IMPRESSION: 1. Small size and echogenic appearance of the kidneys\n consistent with chronic, diffuse parenchymal disease. No\n hydronephrosis. 2. Ascites.\n .\n CT Head -\n IMPRESSION: Exam limited due to motion. No evidence of hemorrhage or\n shift.\n .\n Echo -\n Technically limited study; Overall left ventricular systolic function\n is normal (LVEF>55%). Right ventricular chamber size and free wall\n motion are normal. The number of aortic valve leaflets cannot be\n determined. The aortic valve leaflets are moderately thickened. At\n least mild to moderate aortic stenosis is present (but cannot be fully\n quantified). No aortic regurgitation is seen. There is no pericardial\n effusion.\n .\n ** No EGDs or colonoscopies in our system.\n Microbiology: , peritoneal fluid - no growth\n , , blood cultures - no growth\n , , stool - no growth for c.diff, ovas, parasites\n sputum - rare yeast, sputum - no growth\n urine - no growth, urine - yeast\n ECG: EKG: NSR, no signs of ischemia, poor baseline; unchanged from\n prior\n Assessment and Plan\n Assessment and Plan:\n 35 y/o M with hx of cerebral palsy, seizure disorder, chronic\n pancreatitis and known gastric varices who is transferred with coffee\n ground emesis and hypotension.\n .\n # GI bleed: has blood in NGT and then coffee ground emesis worrisome\n for new upper GI bleed. Hct of not reflect active, ongoing\n bleed. Getting IVFs and 1u PRBCs now. Has known gastric varices which\n could be the cause of the bleed.\n - GI consulted and aware of patient, likely need EGD today\n - NPO, NGT in place, will check placement and then keep to LIS\n - PICC for access, try for PIVs\n - protonix 40 mg IV BID\n - complete 1u PRBC transfusion\n - 64hr Hcts, transfuse for hct <27 or active bleeding\n - check lactate\n - surgery following along\n .\n # Hypotension: baseline SBPs in the 80s, but has low BP to 68/doppler\n today. Is likely secondary to GI bleed and hypovolemia, although could\n be a sign of new early infection, PE, cardiogenic shock or adrenal\n insufficiency. These etiologies are less likely, though. He has\n remains afebrile and has no localizing infectious symptoms, although is\n difficult to interview. Has known SMV clot and has been slightly\n subtherpeutic on his coumadin, so may have other clots and is at risk\n of PE but is not hypoxic or with leg swelling. No hx of cardiac\n problems or signs of pulm edema suggesting cardiac failure. And he has\n not been on chronic steroids.\n - fluid resuccitation with IVF boluses and 1u PRBCs for now\n - levofed pressors if needed with SBP goal > 75, MAP >55\n - blood, urine cultures, c.diff\n - continue cipro and flagyl for peritonitis treatment\n - broaden abx by adding vanco for potential line infection, although\n PICC line looks uninfected on exam\n - would be missing VRE coverage and if clinically worsening, consider\n broadening by adding dapto\n - CT scan to evaluate for RP bleed\n - CXR to look for pneumonia\n - KUB to look for obstruction or new obstruction\n - EKG and CEs to rule out cardiac cause\n .\n # Abdominal Pain: was initial presentation and thought to be due to\n peritonitis from microperforations and translocation. Has had chronic\n abdominal pain this admission with intermittent large bowel\n obstructions and chronically dilated loops of bowel. Is passing gas\n and stooling. Did have recent rectal tube for decompression, but fell\n out two nights ago. Also has signs of chronic pancreatitis and an SMV\n as discussed below. Pain could be from multiple etiologies.\n - serial abdominal exams\n - f/u final read of KUB, appears stable per HO read\n - abd pain seems at baseline\n - consider repeat CT abdomen to look for possible new microperf or\n abscess as source of infection, but just had CT two days ago that was\n stable and without obvious source\n - continue pancreatic enzyme repletion\n - hold anticoagulation for thrombus as below\n - morphine PRN\n - surgery following along\n .\n # Peritonitis: although no positive cultures, was presumed to have\n peritonitis on admission and cause of initial presentation.\n - continue cipro/flagyl as above\n - course of cipro/flagyl to complete 2 week course; consider ID consult\n if infectious workup positive\n .\n # SMV Thrombus: has a chronic SMV thrombus with good collaterals. Was\n on lovenox for briding of subtherapeutic INR and on coumadin.\n Reimaging several days ago showed stable clot without progression.\n Vascular surgery was following along and plan was for 6 months of\n anticoagulation and reevaluation at that time.\n - hold lovenox and coumadin in setting of GI bleed\n - no need to reverse with FFP at this time\n - consider risks/benefits of long term anticoagulation and consider\n holding based on EGD findings and extent of bleed\n .\n # Anemia: has new baseline anemia around 30 from 35, and fe studies\n suggest iron deficiency.\n - continue fe supplementation after GI workup complete\n - transfuse for hct <27 in setting of bleed\n .\n # Nutrition: has been receiving TPN and GI had been consulted for a PEG\n tube for long term feeding, although wanted to wait for abx course to\n be completed and repeat para if fluid was present to confirm resolution\n of possible peritonitis. Did tolerated POs for a few days on the floor\n prior to his most recent large bowel obstruction.\n - NPO for now given GI bleeding\n - holding TPN for now for blood tx and boluses\n - restart TPN when stable\n - continue to follow albumin levels; remains hypoalbuminemic\n .\n # Seizure Disorder: is stable, no reports of recent seizures.\n - continue phenobarbitol and phenytoin\n .\n # Cerebral Palsy: stable, is interactive with family although\n non-verbal. Continue to monitor mental status.\n .\n # FEN: on TPN, holding for access issues today, but will consider based\n on clinical course today; NPO; replete electrolytes as needed.\n # Access: PICC, attempt at PIV\n # PPx: PPI , holding anticoagulation, pneumoboots\n # Communication: with family, mom in particular\n # Code: full, confirmed with family\n # Dispo: ICU for now\n .\n .\n , MD\n PGY 2\n pager \n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 35M CP, seizures, GIB, chronic pancreatitis,\n SMV thrombosis on coumadin / lovenox p/w hypotension and possible UGIB.\n Recent events include intermittent bowel obstruction / PO intolerance.\n This AM, CG emesis, NGL neg / guiac neg, SBP dropped from 80 (baseline)\n to 60. HCT 30 to 24 despite 1 unit PRBCs.\n Exam notable for Tm BP 76/55 HR 110 RR 18 with sat 99 on RA. Pale,\n uncomfortable appearing man. JVD flat. CTA B. RRR s1s2 3/6SM. Tense\n +BS, no rebound. No edema. Labs notable for WBC 6K, HCT 24, INR 1.9, K+\n 3.4, Cr 1.0, lactate 2.4. KUB with multiple dilated loops of bowel.\n Agree with plan to manage hypotension with likely blood loss anemia\n with transfusion to maintain HCT >25, GI eval, PPI IV, octreotide, BBS,\n PIV if possible. Will support BP with blood products, IVF and levophed\n if needed to maintain SBP>80 / MAP >55. Needs abd CT now to look for RB\n bleed or clear transition point, though bowel sounds and + stool\n suggest he is not totally obstructed. Leading concern is for RP bleed\n in the setting of anticoagulation, which is now on hold. Will broaden\n abx coverage for possible nosocomial sepsis given PIC with addition of\n vanco, pan cx; fever may be related to transfusion. Remainder of plan\n as outlined above.\n Patient is critically ill\n Total time: 50 min\n ------ Protected Section Addendum Entered By: , MD\n on: 04:55 PM ------\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 628747,
"text": "Retroperitoneal bleed (RP bleed), spontaneous\n Assessment:\n Repeat hct 25.5 after 1 unit prbc. Hypotensive to a map in the 40\n (Initially goal was map >55 per micu team) Abdomen is softly\n distended, hyperactive bowel sounds. Bladder pressure 12- 14.\n Abdomen appears tender to deep palpation, particularly lower right\n quadrant. NGT clamped. Flexiseal in place, draining dark green liquid\n stool.\n Action:\n 1 liter NS bolus given, 2 units PRBC given. Started on Neo with goal\n to keep sbp >75\n Response:\n Hct improved to 30.4 and subsequently 32.3. sbp improved to 80\ns - 90\n with map 50\ns-60\ns. . Urine output adequate, mentating at baseline\n level.\n Plan:\n titrate neo to keep sbp >75, monitor hct, monitor bladder pressures,\n serial abdominal exams.\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 630679,
"text": "Pt was transferred back to the floor, and his Hct has remained stable.\n However, he has continued to have low grade fevers in the 100s and\n tachycardia to the 120s. ID work-up of this included a paracentesis on\n which was not c/w SBP (one dose of ceftriaxone given) and a\n negative CT torso on . He was found to have a left humeral\n fracture. Pt appeared to be clinically improving yesterday, and his NG\n tube feeds were restarted. However, at 4 AM, he spiked a fever to\n 101.9. He had increased work of breathing and at 8am had recorded\n tachypnea with RR in the 40s, O2 sats 84% on 2L (baseline high 90s on\n 2L), tachycardia to 140s (baseline 120s for past few days), and SBP\n high 80s-low 90s (baseline low 90s-100s). He was increased to 6L NC\n without improvement so was started on a 100% NRB with ABG 7.52/34/64.\n CXR showed new left lower lobe infiltrate. Portable abdomen without\n dilated bowel loops. VS at time of MICU floor evaluation were: T 99,\n BP 88/66, P 134, RR 32, O2sat 100% on NRB. Pt was started on broad\n antibiotic coverage for HAP/aspiration PNA with vancomycin, cefepime,\n and metronidazole and transferred to the MICU. Access with\n double-lumen PICC and 22g PIV.\n .\n In the unit, mother reports that pt's mental status is at baseline\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient alert moving all extremities as shift progresses with\n purposeful movement, lung diminished all fields, heart rate sinus\n tachycardia 120-130\ns systolic b/p 80-90\ns over 60\ns abd distended +\n bowel sounds Foley patent draining clear yellow urine remains NPO\n Action:\n Patient b/p dropped to high 70\ns over 60\ns trial humidified face mask\n for 2 hours off CPAP bolused with 750 cc of normal saline\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 630680,
"text": "Pt was transferred back to the floor, and his Hct has remained stable.\n However, he has continued to have low grade fevers in the 100s and\n tachycardia to the 120s. ID work-up of this included a paracentesis on\n which was not c/w SBP (one dose of ceftriaxone given) and a\n negative CT torso on . He was found to have a left humeral\n fracture. Pt appeared to be clinically improving yesterday, and his NG\n tube feeds were restarted. However, at 4 AM, he spiked a fever to\n 101.9. He had increased work of breathing and at 8am had recorded\n tachypnea with RR in the 40s, O2 sats 84% on 2L (baseline high 90s on\n 2L), tachycardia to 140s (baseline 120s for past few days), and SBP\n high 80s-low 90s (baseline low 90s-100s). He was increased to 6L NC\n without improvement so was started on a 100% NRB with ABG 7.52/34/64.\n CXR showed new left lower lobe infiltrate. Portable abdomen without\n dilated bowel loops. VS at time of MICU floor evaluation were: T 99,\n BP 88/66, P 134, RR 32, O2sat 100% on NRB. Pt was started on broad\n antibiotic coverage for HAP/aspiration PNA with vancomycin, cefepime,\n and metronidazole and transferred to the MICU. Access with\n double-lumen PICC and 22g PIV.\n .\n In the unit, mother reports that pt's mental status is at baseline\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient alert moving all extremities as shift progresses with\n purposeful movement, lung diminished all fields, heart rate sinus\n tachycardia 120-130\ns systolic b/p 80-90\ns over 60\ns abd distended +\n bowel sounds Foley patent draining clear yellow urine remains NPO\n Action:\n Patient b/p dropped to high 70\ns over 60\ns. Trial humidified face mask\n for 2 hours off CPAP bolused with 750 cc of normal saline\n Response:\n Patient had little response to fluid boluses tolerated 2 hour trial.\n Plan:\n Continue to try to wean off CPAP provide comfort and support as needed\n notify MICU of any changes\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 628853,
"text": "Retroperitoneal bleed (RP bleed), spontaneous\n Assessment:\n Last Hct 33.4.\n SBP remains >75, MAP remains >55\n Abdomen softly distended- tender to deep palpation,\n otherwise appears comfortable\n U/O >36 cc/hr\n Action\n NGT to LIWS with bilious drainage\n Neo weaned to off\n Response:\n u/o WNL\n BP\ns WNL\n HCT stable\n Plan:\n q8 HCT- next due 20\n SBP>75, MAP>55\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 630790,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient tachpneic and restless. Grunting, labored breathing. Sats low\n 90\ns on non-invasive ventilation. Tachycardic. SBP 80\ns (baseline).\n Action:\n 500cc NS bolus administered for tachycardia. VBG sent. Patient\n intubated at 1100 for respiratory distress. CXR obtained. VAP bundle.\n Response:\n Patient remains tachypneic in 30\ns. Midazolam drip initiated.\n Suctioned for thin/frothy, tan secretions. Sputum cx to be sent.\n Plan:\n Pulmonary hygiene. Follow VBG\ns. Place a-line. Follow up w/ pending\n sputum cx. Follow CXRs.\n"
},
{
"category": "Physician ",
"chartdate": "2115-03-24 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 630798,
"text": "TITLE:\n Chief Complaint: hypoxemic respiratory failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n PICC LINE - START 11:14 AM\n dual lumen\n EKG - At 12:48 PM\n STOOL CULTURE - At 04:47 PM\nOn and off mask ventilation\n History obtained from Medical records\n Patient unable to provide history: CP - nonverbal at baseline\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 11:22 PM\n Metronidazole - 02:00 AM\n Vancomycin - 08:32 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:13 AM\n Heparin Sodium (Prophylaxis) - 08:13 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 36.3\nC (97.4\n HR: 134 (118 - 134) bpm\n BP: 97/63(140) {80/57(63) - 101/79(140)} mmHg\n RR: 34 (14 - 55) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 2,604 mL\n 1,592 mL\n PO:\n TF:\n IVF:\n 2,025 mL\n 1,196 mL\n Blood products:\n Total out:\n 590 mL\n 1,185 mL\n Urine:\n 590 mL\n 485 mL\n NG:\n 700 mL\n Stool:\n Drains:\n Balance:\n 2,014 mL\n 407 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n Ventilator mode: Standby\n Vt (Spontaneous): 687 (320 - 710) mL\n PS : 18 cmH2O\n RR (Set): 35\n RR (Spontaneous): 25\n PEEP: 4 cmH2O\n FiO2: 100%\n PIP: 23 cmH2O\n SpO2: 94%\n ABG: ///28/\n Ve: 13 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 8.8 g/dL\n 168 K/uL\n 133 mg/dL\n 0.6 mg/dL\n 28 mEq/L\n 4.4 mEq/L\n 24 mg/dL\n 107 mEq/L\n 141 mEq/L\n 26.3 %\n 6.8 K/uL\n [image002.jpg]\n 03:16 PM\n 03:47 PM\n 01:45 AM\n WBC\n 6.8\n Hct\n 29\n 26.3\n Plt\n 168\n Cr\n 0.6\n 0.6\n Glucose\n 118\n 133\n Other labs: ALT / AST:29/31, Alk Phos / T Bili:105/0.5, Amylase /\n Lipase:/11, Lactic Acid:0.8 mmol/L, Albumin:2.6 g/dL, LDH:415 IU/L,\n Ca++:7.6 mg/dL, Mg++:2.1 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n Hypoxemic respiratory failure:\n -hypoxemia with respiratory alkalosis\n -waxing and resp status. able to take off mask ventilation but\n now back on this morning\n -cxr worsening - now b/l diffuse process across all lung fields\n -CT chest to better characterize process\n -afebrile, wbc remains wnl though did have fever preceding 24hrs\n -leading dx HAP vs. aspiration PNA though other processes remain\n possible\n -broad abx coverage for HAP\n Tachycardia\n -persistent despite resolution of fever and IVF boluses\n -cont to fluid bolus\n -currently maintaining bp within pt\ns usual range, no signs of\n perfusion issues at present, lactate not elevated.\n Anemia/bleed:\n -h/o rp bleed, varices so follow hct trend closely\n -hct down 2 points but sig positive fluid balance\n - Guaiac stools\n SMV thrombus:\n Seizure disorder:\n -no sz activity No\n - Continue phenobarbitol and phenytoin\n Cerebral palsy:\n Remainder of plan as outlined in resident note.\n Above discussed with patient's mother during .\n Pt is critically ill. Time spent on care: 50minutes.\n ICU Care\n Nutrition:\n TPN w/ Lipids - 06:36 PM 45. mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 11:14 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition :\n Total time spent:\n ------ Protected Section ------\n I did not document his examination in the note above. It was as\n follows:\n Exam:\n Awake, alert. Mom says pt is more interactive today -- at his baseline\n interactivity this morning\n Supine in bed. Mask ventilation.\n Lungs\n bronchial breath sounds b/l greater on left\n CV\n tachy 2/6 SEM\n Abd - soft NTND BS+\n ------ Protected Section Addendum Entered By: , MD\n on: 17:09 ------\n"
},
{
"category": "Physician ",
"chartdate": "2115-03-15 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 628962,
"text": "Chief Complaint:\n 24 Hour Events:\n - episode of hypotension 70/40 MAP 54. Bolus 500cc with\n limited improvement so Phenylephrine restarted.\n - Per family, feeling better, improved since yesterday\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 07:55 PM\n Ciprofloxacin - 12:22 AM\n Metronidazole - 01:23 AM\n Infusions:\n Phenylephrine - 0.5 mcg/Kg/min\n Other ICU medications:\n Fosphenytoin - 04:53 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:46 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.8\nC (98.3\n HR: 100 (86 - 113) bpm\n BP: 73/52(57) {71/43(49) - 87/67(72)} mmHg\n RR: 24 (21 - 32) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 37 kg (admission): 120 kg\n Total In:\n 3,285 mL\n 733 mL\n PO:\n TF:\n IVF:\n 3,013 mL\n 730 mL\n Blood products:\n Total out:\n 3,520 mL\n 1,560 mL\n Urine:\n 2,720 mL\n 760 mL\n NG:\n 100 mL\n 300 mL\n Stool:\n Drains:\n Balance:\n -235 mL\n -827 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///25/\n Physical Examination\n Labs / Radiology\n 155 K/uL\n 11.2 g/dL\n 106 mg/dL\n 0.9 mg/dL\n 25 mEq/L\n 3.3 mEq/L\n 13 mg/dL\n 109 mEq/L\n 140 mEq/L\n 32.6 %\n 6.1 K/uL\n [image002.jpg]\n 10:16 AM\n 12:30 PM\n 07:32 PM\n 12:20 AM\n 03:48 AM\n 05:08 AM\n 11:16 AM\n 01:15 PM\n 08:15 PM\n 01:50 AM\n WBC\n 7.2\n 6.1\n 6.1\n Hct\n 24.6\n 25.5\n 30.4\n 32.3\n 33.4\n 32.3\n 32.6\n Plt\n 197\n 143\n 155\n Cr\n 0.7\n 0.7\n 0.8\n 0.9\n TropT\n <0.01\n Glucose\n 300\n 100\n 95\n 106\n Other labs: PT / PTT / INR:13.9/24.7/1.2, CK / CKMB /\n Troponin-T:16//<0.01, ALT / AST:, Alk Phos / T Bili:99/0.6, Lactic\n Acid:1.2 mmol/L, Ca++:7.7 mg/dL, Mg++:3.0 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 10:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2115-03-15 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 628963,
"text": "Chief Complaint:\n 24 Hour Events:\n - episode of hypotension 70/40 MAP 54. Bolus 500cc with\n limited improvement so Phenylephrine restarted.\n - Per family, feeling better, improved since yesterday\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 07:55 PM\n Ciprofloxacin - 12:22 AM\n Metronidazole - 01:23 AM\n Infusions:\n Phenylephrine - 0.5 mcg/Kg/min\n Other ICU medications:\n Fosphenytoin - 04:53 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:46 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.8\nC (98.3\n HR: 100 (86 - 113) bpm\n BP: 73/52(57) {71/43(49) - 87/67(72)} mmHg\n RR: 24 (21 - 32) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 37 kg (admission): 120 kg\n Total In:\n 3,285 mL\n 733 mL\n PO:\n TF:\n IVF:\n 3,013 mL\n 730 mL\n Blood products:\n Total out:\n 3,520 mL\n 1,560 mL\n Urine:\n 2,720 mL\n 760 mL\n NG:\n 100 mL\n 300 mL\n Stool:\n Drains:\n Balance:\n -235 mL\n -827 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///25/\n Physical Examination\n General: Awake in bed, orients to voice, shakes head in response to\n some Qs, appears generally comfortable\n HEENT: JVP at clavicle, NGT draining ~bilious fluid\n CV: RRR, 2/6 systolic ejection murmur\n Lungs: Shallow resp. but seem CTA bilaterally\n Abdomen: Distended, somewhat firm but does not seem overly TTP, +NABS\n Extremities: Contracted/frail, but good skin integrity, warm/WP\n Labs / Radiology\n 155 K/uL\n 11.2 g/dL\n 106 mg/dL\n 0.9 mg/dL\n 25 mEq/L\n 3.3 mEq/L\n 13 mg/dL\n 109 mEq/L\n 140 mEq/L\n 32.6 %\n 6.1 K/uL\n [image002.jpg]\n 10:16 AM\n 12:30 PM\n 07:32 PM\n 12:20 AM\n 03:48 AM\n 05:08 AM\n 11:16 AM\n 01:15 PM\n 08:15 PM\n 01:50 AM\n WBC\n 7.2\n 6.1\n 6.1\n Hct\n 24.6\n 25.5\n 30.4\n 32.3\n 33.4\n 32.3\n 32.6\n Plt\n 197\n 143\n 155\n Cr\n 0.7\n 0.7\n 0.8\n 0.9\n TropT\n <0.01\n Glucose\n 300\n 100\n 95\n 106\n Other labs: PT / PTT / INR:13.9/24.7/1.2, CK / CKMB /\n Troponin-T:16//<0.01, ALT / AST:, Alk Phos / T Bili:99/0.6, Lactic\n Acid:1.2 mmol/L, Ca++:7.7 mg/dL, Mg++:3.0 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 10:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2115-03-15 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 628966,
"text": "Chief Complaint:\n 24 Hour Events:\n - episode of hypotension 70/40 MAP 54. Bolus 500cc with\n limited improvement so Phenylephrine restarted.\n - Per family, feeling better, improved since yesterday\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 07:55 PM\n Ciprofloxacin - 12:22 AM\n Metronidazole - 01:23 AM\n Infusions:\n Phenylephrine - 0.5 mcg/Kg/min\n Other ICU medications:\n Fosphenytoin - 04:53 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:46 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.8\nC (98.3\n HR: 100 (86 - 113) bpm\n BP: 73/52(57) {71/43(49) - 87/67(72)} mmHg\n RR: 24 (21 - 32) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 37 kg (admission): 120 kg\n Total In:\n 3,285 mL\n 733 mL\n PO:\n TF:\n IVF:\n 3,013 mL\n 730 mL\n Blood products:\n Total out:\n 3,520 mL\n 1,560 mL\n Urine:\n 2,720 mL\n 760 mL\n NG:\n 100 mL\n 300 mL\n Stool:\n Drains:\n Balance:\n -235 mL\n -827 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///25/\n Physical Examination\n General: Awake in bed, orients to voice, shakes head in response to\n some Qs, appears generally comfortable\n HEENT: JVP at clavicle, NGT draining ~bilious fluid\n CV: RRR, 2/6 systolic ejection murmur\n Lungs: Shallow resp. but seem CTA bilaterally\n Abdomen: Distended, somewhat firm but does not seem overly TTP, +NABS\n Extremities: Contracted/frail, but good skin integrity, warm/WP\n Labs / Radiology\n 155 K/uL\n 11.2 g/dL\n 106 mg/dL\n 0.9 mg/dL\n 25 mEq/L\n 3.3 mEq/L\n 13 mg/dL\n 109 mEq/L\n 140 mEq/L\n 32.6 %\n 6.1 K/uL\n [image002.jpg]\n 10:16 AM\n 12:30 PM\n 07:32 PM\n 12:20 AM\n 03:48 AM\n 05:08 AM\n 11:16 AM\n 01:15 PM\n 08:15 PM\n 01:50 AM\n WBC\n 7.2\n 6.1\n 6.1\n Hct\n 24.6\n 25.5\n 30.4\n 32.3\n 33.4\n 32.3\n 32.6\n Plt\n 197\n 143\n 155\n Cr\n 0.7\n 0.7\n 0.8\n 0.9\n TropT\n <0.01\n Glucose\n 300\n 100\n 95\n 106\n Other labs: PT / PTT / INR:13.9/24.7/1.2, CK / CKMB /\n Troponin-T:16//<0.01, ALT / AST:, Alk Phos / T Bili:99/0.6, Lactic\n Acid:1.2 mmol/L, Ca++:7.7 mg/dL, Mg++:3.0 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n 35 y/o M with hx of cerebral palsy, seizure disorder, chronic\n pancreatitis and known gastric varices who is transferred with coffee\n ground emesis and hypotension.\n .\n # Hypotension: Most likely secondary to GI bleed or RP bleed in the\n setting of anticoagulation for SMV clot. Baseline SBPs in the 80s,\n today s/p fluid resuscitation and pressure support with pressures\n closer to baseline with good UOP. Still on low-dose phenylephrine.\n - attempt to wean off pressors with goal MAP > 55, SBP > 75\n - continue with IVF, bolus to UOP >50cc/hr\n - transfuse for HCT <25\n - continue vanc, cipro and flagyl for peritonitis treatment pending\n culture data (at least 48 H negative)\n - would be missing VRE coverage and if clinically worsening, consider\n broadening by adding dapto\n .\n # GI bleed: Patient with know gastric varices with blood in NGT and\n coffee ground emesis concerning for GI bleed while on Coumadin with\n imaging concerning for GI and / or RP bleed. Patient with improving HCT\n s/p transfusion without evidence of active bleeding.\n - NPO, NGT in place draining bilious fluid to suction\n - coordinate care with GI and surgery\n - PICC for access, try for PIVs\n - protonix 40 mg IV BID\n - trend HCT and transfuse for HCT <25\n - hold anticoagulation for now\n ..\n # Peritonitis: although no positive cultures, was presumed to have\n peritonitis on admission and cause of initial presentation.\n - continue Abx as above\n - serial abdominal exams\n .\n # SMV Thrombus: has a chronic SMV thrombus with good collaterals. Was\n on lovenox for briding of subtherapeutic INR and on coumadin.\n Reimaging several days ago showed stable clot without progression.\n Vascular surgery was following along and plan was for 6 months of\n anticoagulation and reevaluation at that time.\n - hold lovenox and coumadin in setting of GI bleed\n - consider risks/benefits of long term anticoagulation and consider\n holding based on EGD findings and extent of bleed\n .\n # Anemia: has new baseline anemia around 30 from 35, and fe studies\n suggest iron deficiency.\n - continue fe supplementation after GI workup complete\n - transfuse for hct <25 in setting of bleed\n .\n # Nutrition: Had been receiving TPN and GI had been consulted for a PEG\n tube for long term feeding, although wanted to wait for abx course to\n be completed and repeat para if fluid was present to confirm resolution\n of possible peritonitis. Did tolerated POs for a few days on the floor\n prior to his most recent large bowel obstruction.\n - NPO for now given GI bleeding\n - TPN ordered, but patient not receiving as no dedicated line\n - continue to follow albumin levels; remains hypoalbuminemic\n .\n # Seizure Disorder: is stable, no reports of recent seizures.\n - continue phenobarbitol and phenytoin\n .\n # Cerebral Palsy: stable, is interactive with family although\n non-verbal. Continue to monitor mental status.\n .\n # FEN: on TPN, holding for access issues today, but will consider based\n on clinical course today; NPO; replete electrolytes as needed.\n # Access: PICC, attempt at PIV\n # PPx: PPI , holding anticoagulation, pneumoboots\n # Communication: with family, mom in particular\n # Code: full, confirmed with family\n # Dispo: ICU for now\n could likely be called out if stable BP off of\n pressors\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 10:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2115-03-14 00:00:00.000",
"description": "Physician Resident/Attending Progress Note - MICU",
"row_id": 628837,
"text": "Chief Complaint:\n 24 Hour Events:\n PICC LINE - START 10:00 AM\n - Went for CT abdomen per GI recs. Prelim read shows colonic wall\n thickening with ? bleed, ? RP hematoma, ? microperforation. Plan to\n hold off on EGD unless evidence of active bleed.\n - Hypotensive overnight. On neo for pressure support -> improved UOP.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 07:55 PM\n Ciprofloxacin - 11:21 PM\n Metronidazole - 12:30 AM\n Infusions:\n Phenylephrine - 0.5 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 07:55 PM\n Fosphenytoin - 12:22 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.8\nC (100\n Tcurrent: 36.8\nC (98.3\n HR: 101 (88 - 119) bpm\n BP: 76/53(59) {66/42(48) - 100/73(78)} mmHg\n RR: 30 (13 - 32) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Bladder pressure: 12 (12 - 14) mmHg\n Total In:\n 8,127 mL\n 832 mL\n PO:\n TF:\n IVF:\n 5,767 mL\n 832 mL\n Blood products:\n 1,400 mL\n Total out:\n 915 mL\n 1,870 mL\n Urine:\n 915 mL\n 1,170 mL\n NG:\n Stool:\n Drains:\n Balance:\n 7,212 mL\n -1,038 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 94%\n ABG: ///27/\n Physical Examination\n General: Awake in bed, orients to voice, shakes head in response to\n some Qs, appears generally comfortable\n HEENT: JVP at clavicle\n CV: RRR, 2/6 systolic ejection murmur\n Lungs: Shallow resp. but seem CTA bilaterally\n Abdomen: Distended\n Labs / Radiology\n 143 K/uL\n 11.3 g/dL\n 100 mg/dL\n 0.7 mg/dL\n 27 mEq/L\n 2.9 mEq/L\n 13 mg/dL\n 106 mEq/L\n 140 mEq/L\n 32.3 %\n 6.1 K/uL\n [image002.jpg]\n 10:16 AM\n 12:30 PM\n 07:32 PM\n 12:20 AM\n 03:48 AM\n 05:08 AM\n WBC\n 7.2\n 6.1\n Hct\n 24.6\n 25.5\n 30.4\n 32.3\n Plt\n 197\n 143\n Cr\n 0.7\n 0.7\n TropT\n <0.01\n Glucose\n 300\n 100\n Other labs: PT / PTT / INR:16.5/29.3/1.5, CK / CKMB /\n Troponin-T:16//<0.01, ALT / AST:, Alk Phos / T Bili:99/0.6, Lactic\n Acid:1.2 mmol/L, Ca++:6.2 mg/dL, Mg++:1.5 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n 35 y/o M with hx of cerebral palsy, seizure disorder, chronic\n pancreatitis and known gastric varices who is transferred with coffee\n ground emesis and hypotension.\n .\n # Hypotension: Most likely secondary to GI bleed or RP bleed in the\n setting of anticoagulation for SMV clot. Baseline SBPs in the 80s,\n today s/p fluid resuscitation and pressure support with pressures\n closer to baseline with good UOP.\n - wean off pressors with goal MAP >60\n - continue with IVF, bolus to OUP >50cc/hr\n - transfuse for HCT <27\n - continue vanc, cipro and flagyl for peritonitis treatment pending\n culture data and final read of CT\n - would be missing VRE coverage and if clinically worsening, consider\n broadening by adding dapto\n .\n # GI bleed: Patient with know gastric varices with blood in NGT and\n coffee ground emesis concerning for GI bleed while on Coumadin with\n imaging concerning for GI and / or RP bleed. Patient with improving HCT\n s/p transfusion without evidence of active bleeding.\n - NPO, NGT in place\n - coordinate care with GI and surgery\n - PICC for access, try for PIVs\n - protonix 40 mg IV BID\n - trend HCT and transfuse for HCT <27\n - hold Coumadin for now\n ..\n # Peritonitis: although no positive cultures, was presumed to have\n peritonitis on admission and cause of initial presentation.\n - continue cipro/flagyl as above\n - serial abdominal exams\n - F/U final imaging read\n .\n # SMV Thrombus: has a chronic SMV thrombus with good collaterals. Was\n on lovenox for briding of subtherapeutic INR and on coumadin.\n Reimaging several days ago showed stable clot without progression.\n Vascular surgery was following along and plan was for 6 months of\n anticoagulation and reevaluation at that time.\n - hold lovenox and coumadin in setting of GI bleed\n - consider risks/benefits of long term anticoagulation and consider\n holding based on EGD findings and extent of bleed\n .\n # Anemia: has new baseline anemia around 30 from 35, and fe studies\n suggest iron deficiency.\n - continue fe supplementation after GI workup complete\n - transfuse for hct <25 in setting of bleed\n .\n # Nutrition: has been receiving TPN and GI had been consulted for a PEG\n tube for long term feeding, although wanted to wait for abx course to\n be completed and repeat para if fluid was present to confirm resolution\n of possible peritonitis. Did tolerated POs for a few days on the floor\n prior to his most recent large bowel obstruction.\n - NPO for now given GI bleeding\n - holding TPN for now for blood tx and boluses\n - restart TPN when stable\n - continue to follow albumin levels; remains hypoalbuminemic\n .\n # Seizure Disorder: is stable, no reports of recent seizures.\n - continue phenobarbitol and phenytoin\n .\n # Cerebral Palsy: stable, is interactive with family although\n non-verbal. Continue to monitor mental status.\n .\n # FEN: on TPN, holding for access issues today, but will consider based\n on clinical course today; NPO; replete electrolytes as needed.\n # Access: PICC, attempt at PIV\n # PPx: PPI , holding anticoagulation, pneumoboots\n # Communication: with family, mom in particular\n # Code: full, confirmed with family\n # Dispo: ICU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 10:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 35M CP, seizures, GIB, chronic pancreatitis,\n SMV thrombosis on coumadin / lovenox p/w hypotension and blood loss\n anemia. CT c/w RP bleed, bowel edema - final read pending.\n Exam notable for Tm 100.0 BP 75/50 HR 100 RR 18 with sat 99 on RA.\n Comfortable appearing. JVD flat. CTA B. RRR s1s2 3/6SM. Tense +BS, no\n rebound. No edema. Labs notable for WBC 6K, HCT 32, INR 1.5, K+ 2.9,\n Cr 0.7, lactate 1.2. CT as above.\n Agree with plan to manage hypotension / blood loss anemia / RP bleed\n with transfusion to maintain HCT >25, check q8h, BBS, PIV if possible.\n Will support BP with blood products, IVF and will try to wean neo for\n SBP>75 / MAP >55 / UOP >50cc/h. ARF improved with volume. Will hold, AC\n for SMV thrombosis, and will check NGT residuals, and initiate trophic\n feeding. For nutritional support, will restart TPN today and d/w\n nutrition and surgery teams. Will continue broad abx coverage for\n possible nosocomial sepsis, f/u pan cx\n if cx neg at 48h will likely\n d/c. For seizures, check drug levels and continue phenobarb and\n fosphenytoin. Remainder of plan as outlined above.\n Patient is critically ill\n Total time: 35 min\n ------ Protected Section Addendum Entered By: , MD\n on: 03:19 PM ------\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 629048,
"text": "Sepsis without organ dysfunction\n Assessment:\n Patient alert to voice and to mother this am\n Purposeful with arms, as will try to pull out lines\n Belly less distended\n Will check blood pressures on thigh, as more of a\ntrue\n pressure for\n patient\n Action:\n To IR for new PICC\n Old PICC out, tip sent for culture\n Tube feeds begun at 10 cc hr.\n Neo weaned to off with parameters of M>55 and SBP>75\n Will d/c foley and use either diaper or condom cath\n Cipro and flagyl dc/d\n Vanco given today as level 15\n Response:\n Tolerating above changes well\n Remains with flexiseal in, loose bilious stool\n Plan:\n Continue to gear patient\ns care to leaving ICU\n Tolerating todays changes well\n Will call MICU with any changes.\n"
},
{
"category": "Physician ",
"chartdate": "2115-03-16 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 629120,
"text": "Chief Complaint: PICC exchanged. Patient remains hypotensive but\n asymptomatic, leg blood pressures measured, and slightly higher with\n SBP low 80s. Foley changed out given yeast in URINE. Patient called\n out to floor.\n 24 Hour Events:\n PICC LINE - STOP 05:25 PM\n PICC LINE - START 05:40 PM\n left antecub.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 12:22 AM\n Metronidazole - 07:58 AM\n Vancomycin - 09:08 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 37.3\nC (99.2\n HR: 100 (88 - 111) bpm\n BP: 87/52(60) {79/42(53) - 95/70(73)} mmHg\n RR: 18 (16 - 30) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 36.5 kg (admission): 32.3 kg\n Height: 55 Inch\n Total In:\n 1,547 mL\n 253 mL\n PO:\n TF:\n 104 mL\n 120 mL\n IVF:\n 1,440 mL\n 133 mL\n Blood products:\n Total out:\n 3,190 mL\n 500 mL\n Urine:\n 1,590 mL\n NG:\n 600 mL\n Stool:\n 500 mL\n 500 mL\n Drains:\n Balance:\n -1,643 mL\n -247 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///22/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 132 K/uL\n 11.0 g/dL\n 112 mg/dL\n 0.8 mg/dL\n 22 mEq/L\n 4.2 mEq/L\n 12 mg/dL\n 112 mEq/L\n 141 mEq/L\n 31.6 %\n 5.9 K/uL\n [image002.jpg]\n 12:30 PM\n 07:32 PM\n 12:20 AM\n 03:48 AM\n 05:08 AM\n 11:16 AM\n 01:15 PM\n 08:15 PM\n 01:50 AM\n 02:30 AM\n WBC\n 7.2\n 6.1\n 6.1\n 5.9\n Hct\n 24.6\n 25.5\n 30.4\n 32.3\n 33.4\n 32.3\n 32.6\n 31.6\n Plt\n 197\n 143\n 155\n 132\n Cr\n 0.7\n 0.7\n 0.8\n 0.9\n 0.8\n Glucose\n 300\n 100\n 95\n 106\n 112\n Other labs: PT / PTT / INR:13.9/24.7/1.2, CK / CKMB /\n Troponin-T:16//<0.01, ALT / AST:, Alk Phos / T Bili:99/0.6,\n Differential-Neuts:75.4 %, Lymph:15.7 %, Mono:7.6 %, Eos:1.2 %, Lactic\n Acid:1.2 mmol/L, Ca++:7.7 mg/dL, Mg++:2.7 mg/dL, PO4:3.0 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n RETROPERITONEAL BLEED (RP BLEED), SPONTANEOUS\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 05:40 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2115-03-16 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 629122,
"text": "Chief Complaint: PICC exchanged. Patient remains hypotensive but\n asymptomatic, leg blood pressures measured, and slightly higher with\n SBP low 80s. Foley changed out given yeast in URINE. Patient called\n out to floor.\n 24 Hour Events:\n PICC LINE - STOP 05:25 PM\n PICC LINE - START 05:40 PM\n left antecub.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 12:22 AM\n Metronidazole - 07:58 AM\n Vancomycin - 09:08 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n None\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Mild abdominal discomfort\n Flowsheet Data as of 06:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 37.3\nC (99.2\n HR: 100 (88 - 111) bpm\n BP: 87/52(60) {79/42(53) - 95/70(73)} mmHg\n RR: 18 (16 - 30) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 36.5 kg (admission): 32.3 kg\n Height: 55 Inch\n Total In:\n 1,547 mL\n 253 mL\n PO:\n TF:\n 104 mL\n 120 mL\n IVF:\n 1,440 mL\n 133 mL\n Blood products:\n Total out:\n 3,190 mL\n 500 mL\n Urine:\n 1,590 mL\n NG:\n 600 mL\n Stool:\n 500 mL\n 500 mL\n Drains:\n Balance:\n -1,643 mL\n -247 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///22/\n Physical Examination\n General: Awake in bed, orients to voice, shakes head in response to\n some Qs, appears generally comfortable\n HEENT: JVP at clavicle, NGT draining ~bilious fluid\n CV: RRR, 2/6 systolic ejection murmur\n Lungs: Shallow resp. but seem CTA bilaterally\n Abdomen: Distended, somewhat firm but does not seem overly TTP, +NABS\n Extremities: Contracted/frail, but good skin integrity, warm/WP\n Labs / Radiology\n 132 K/uL\n 11.0 g/dL\n 112 mg/dL\n 0.8 mg/dL\n 22 mEq/L\n 4.2 mEq/L\n 12 mg/dL\n 112 mEq/L\n 141 mEq/L\n 31.6 %\n 5.9 K/uL\n [image002.jpg]\n 12:30 PM\n 07:32 PM\n 12:20 AM\n 03:48 AM\n 05:08 AM\n 11:16 AM\n 01:15 PM\n 08:15 PM\n 01:50 AM\n 02:30 AM\n WBC\n 7.2\n 6.1\n 6.1\n 5.9\n Hct\n 24.6\n 25.5\n 30.4\n 32.3\n 33.4\n 32.3\n 32.6\n 31.6\n Plt\n 197\n 143\n 155\n 132\n Cr\n 0.7\n 0.7\n 0.8\n 0.9\n 0.8\n Glucose\n 300\n 100\n 95\n 106\n 112\n Other labs: PT / PTT / INR:13.9/24.7/1.2, CK / CKMB /\n Troponin-T:16//<0.01, ALT / AST:, Alk Phos / T Bili:99/0.6,\n Differential-Neuts:75.4 %, Lymph:15.7 %, Mono:7.6 %, Eos:1.2 %, Lactic\n Acid:1.2 mmol/L, Ca++:7.7 mg/dL, Mg++:2.7 mg/dL, PO4:3.0 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n RETROPERITONEAL BLEED (RP BLEED), SPONTANEOUS\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n 35 y/o M with hx of cerebral palsy, seizure disorder, chronic\n pancreatitis and known gastric varices who is transferred with coffee\n ground emesis and hypotension.\n .\n # Hypotension: Most likely secondary to GI bleed or RP bleed in the\n setting of anticoagulation for SMV clot. Although patient had reported\n coffee ground emesis on the floor, most likely source of hypotension\n may have been RP bleed given CT findings. Now off pressors since\n yesterday afternoon, and leg pressures have been stable with SBPs in\n the 70s and 80s.\n - Continue bp cuff on thighs for more accurate read\n - goal MAP > 55, SBP > 75\n - continue with IVF, bolus to UOP >30cc/hr\n - transfuse for HCT <25\n - Cipro flagyl D/cd yesterday given that cx data was negative x 48\n hours. Given history of instrumentation, will continue Vanco until\n cultures finalize\n - would be missing VRE coverage and if clinically worsening, consider\n broadening by adding dapto\n .\n # GI bleed: Patient with know gastric varices with blood in NGT and\n coffee ground emesis concerning for GI bleed while on Coumadin with\n imaging concerning for GI and / or RP bleed. Patient with improving HCT\n s/p transfusion without evidence of active bleeding. Now Hct and HD\n stable with Tfts running.\n - NPO, NGT in place draining bilious fluid to suction\n - Continue protonix 40 mg IV BID\n - trend HCT and transfuse for HCT <25\n - hold anticoagulation for now, but may consider lovenox again in the\n next 24-48 hours\n ..\n # Peritonitis: although no positive cultures, was presumed to have\n peritonitis on admission and cause of initial presentation.\n - continue Abx as above\n - serial abdominal exams, currently improving\n .\n # SMV Thrombus: has a chronic SMV thrombus with good collaterals. Was\n on lovenox for bridging of subtherapeutic INR and on coumadin.\n Reimaging several days ago showed stable clot without progression.\n Vascular surgery was following along and plan was for 6 months of\n anticoagulation and reevaluation at that time.\n - hold lovenox and coumadin in setting of GI bleed\n - consider risks/benefits of long term anticoagulation and consider\n holding based on EGD findings and extent of bleed\n .\n # Anemia: has new baseline anemia around 30 from 35, and fe studies\n suggest iron deficiency. Also with RP bleed (see above)\n - continue fe supplementation after GI workup complete\n - transfuse for hct <25 in setting of bleed\n .\n # Nutrition: Had been receiving TPN and GI had been consulted for a PEG\n tube for long term feeding, although wanted to wait for abx course to\n be completed and repeat para if fluid was present to confirm resolution\n of possible peritonitis. Did tolerate POs for a few days on the floor\n prior to his most recent large bowel obstruction.\n - start tube feeds with pancreatic enzyme replacement (tube currently\n in duodenum)\n - Hold TPN for now as patient appears to be tolerating TFs well\n - continue to follow albumin levels; remains hypoalbuminemic\n .\n # Seizure Disorder: is stable, no reports of recent seizures.\n - continue phenobarbitol and phenytoin\n .\n # Yeast in urine\n - Change foley\n .\n # Cerebral Palsy: stable, is interactive with family although\n non-verbal. Continue to monitor mental status.\n .\n # FEN: on TPN, holding for access issues, starting TFs; replete\n electrolytes as needed.\n # Access: PICC, attempt at PIV\n # PPx: PPI , holding anticoagulation, pneumoboots\n # Communication: with family, mom in particular\n # Code: full, confirmed with family\n # Dispo: CALLED OUT\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 05:40 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 629037,
"text": "Sepsis without organ dysfunction\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 629038,
"text": "Sepsis without organ dysfunction\n Assessment:\n Patient alert to voice and to mother this am\n Purposeful with arms, as will try to pull out lines\n Belly less distended\n Will check blood pressures on thigh, as more of a\ntrue\n pressure for\n patient\n Action:\n To IR for new PICC\n Old PICC out, tip sent for culture\n Tube feeds begun at 10 cc hr.\n Neo weaned to off with parameters of M>55 and SBP>75\n Will d/c foley and use either diaper or condom cath\n Cipro and flagyl dc/d\n Vanco given today as level 15\n Response:\n Tolerating above changes well\n Remains with flexiseal in, loose bilious stool\n Plan:\n Continue to gear patient\ns care to leaving ICU\n Tolerating todays changes well\n Will call MICU with any changes.\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 629097,
"text": "Hypotension (not Shock)\n Assessment:\n Neuro status intact and unchanged from baseline. Tmax ~99.\n Left PICC site painful on palpation/movement of arm. Treated with\n Tylenol 650mg x 1.\n Non-invasive BP cuff on thigh. SBP > 75 throughout entire\n shift off pressors. Current BP in 90s (MAP ~60). Pulses palpable. No\n edema.\n 4L NC with sat > 95%. Lungs clear in upper airways.\n Diminished in bases. No cough present.\n Abdomen softly distended. Non-tender on palpation.\n Advanced tube feeding q 4 hours by 5cc/hr as ordered. Tolerating\n well. No residuals. Flexiseal in place draining liquid green stool.\n Foley catheter dc\n MD due to high yeast count. No\n incontinence system in place. Incontinent in bedding (small to medium\n amount) at this time.\n Skin intact. Buttocks reddened from leaking flexiseal.\n Barrier and antifungal creams applied after cleaning. Turn and\n position q 2 hours and PRN.\n Mother at bedside. Emotional support provided. Enjoys\n assisting nurse with care of patient.\n Plan:\n Continue to monitor BP, F&E status (secondary to diarrhea). Transfer\n to floor today ().\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 630629,
"text": "Patient is a 35 year old male w/ complicated medical history as well as\n hospital stay. Please see physician note for detailed hospital\n course. Admit from CC7 this a.m. for respiratory distress.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient arrived from floor tachypneic, tachycardic and mildly hypoxic\n on 15L NRB. LS clear throughout, diminished on R side. Patient using\n accessory muscles to breathe.\n Action:\n Non-invasive ventilation initiated. 500cc NS bolus administered for\n tachycardia x2. VBG sent, unable to obtain ABG.\n Response:\n RR 20-30, less labored. Patient currently sleeping. Sats 98-100%. VBG\n WNL.\n Plan:\n Continue to watch respiratory status closely. Wean non-invasive\n ventilation as tolerated. Follow VBGs.\n"
},
{
"category": "Respiratory ",
"chartdate": "2115-03-24 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 630699,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: unknown\n Tube Type\n Airway problems:\n Comments: On NIPPV mask with alternating HF Humidity.\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment: Tolerated well; Comments: On\n NIPPV, same settings as chrted.\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue present care. Using Sats & VBG.\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n"
},
{
"category": "Physician ",
"chartdate": "2115-03-13 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 628630,
"text": "Chief Complaint: hypotension/GI bleed\n HPI:\n 35 y/o M, known to MICU team from previously stay, with a hx of\n cerebral palsy, seizure disorder, anemia and a GI bleed in the past is\n transferred to the MICU for hypotension and coffee ground emesis. The\n patient has been on the floor being treated for intermittent small and\n large bowel obstructions when last night at around 1 am, his nurse\n noted about a teaspoon of blood in his NGT. The nightfloat intern was\n called to the bedside and a NG lavage was done and clear. A stat Hct\n was at his baseline of 30. He BP was in the 80s and HR in 100s at his\n baseline. Several hours later, he was found to have coffee ground\n emesis. Lovenox and coumadin were discontinued at that time. Vitamin\n K was given. This morning, his hct was 27 and his BP had dropped to a\n low of 68/doppler. HR remained in the low 100s. He was receiving a NS\n bolus and 1u PRBCs. He has a PICC for access. He had no further\n episodes of coffee grounds and had a mildly tender abdomen without\n rebound or guarding. His mother notes that he had been his usual self\n the last few days; playing in bed, interactive. But starting last\n night, he was more somnulent and less interactive. His last fever was\n several days ago, but he has been having intermittent fevers since\n admission.\n .\n In terms of his current hospitalization, he was initially admitted on\n with abdominal pain and distention to an OSH. CT scan was\n performed and was reported as diffuse bowel edema, gastric varices,\n ascites and a pancreatic cyst. He was transferred for further\n management to the SICU team for concerns of an acute abdomen. He had a\n diagnostic paracentesis on with WBC , but no growth so thought\n to be inflammatory state. He was started on Vanco/Zosyn/Flagyl for\n suspected peritonitis and ischemic bowel with translocation. On CT, a\n SMV thrombus was noted and heparin was started on . His thrombus\n was likely chronic and secondary to chronic pancreatic inflammation.\n He was transitioned to coumadin. He was then intubated for\n respiratory failure. He was extubated but was then reintubated\n likely secondary to fluid overload. When had had difficultly weaning\n off the ventilator, he was transferred to the MICU team for further\n management. He was extubated successfully and then transferred to the\n floor for futher management of his abdominal pain. He was changed from\n heparin to lovenox for bridging and coumadin. He started TPN. He did\n tolerated POs for a few days but has intermittent large bowel\n obstuctions and then remade NPO. GI has been consulted for a possible\n PEG tube. He completed a 14 d course of vanco and was continued on\n cipro/flagyl for his initial peritonitis.\n .\n On arrival to the floor, he is awake and alert and in no distress. He\n remains hypotensive with SBPs in the 70s. He winces during the\n abdominal exam. His mother is at the bedside.\n Patient admitted from: \n History obtained from Family / Medical records\n Patient unable to provide history: non-verbal\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Past Medical History:\n Cerebral Palsy\n Seizure disorder\n Chronic anemia - Hct 35\n GIB in \n h/o liver cyst drainage (, )\n H/o Laproscopic cholecystectomy\n H/o pancreatic cyst drainage with chronic pancreatitis\n .\n Medications (Upon admission):\n Miralax prn\n Phenobarbital 32.4 mg TAB am, 1PM\n Dilantin (Extended caps) 75mg in am 100mg in pm\n Ferrous Fumarate 324 mg Tabs daily\n MVI daily\n Cyproheptadine HCL 4mg tabs 0.5 tab in AM, 0.5 tabs in PM\n Prilosec 20mg daily\n Celexa 20mg daily\n Zovirax 5% oint (acyclovir) q2hr while awake x 4 days prn cold sore\n vitamine D 400 Unit Caps\n .\n Medications (Upon transfer to MICU service):\n Phytonadione 5 mg IV ONCE \n Pantoprazole 40 mg IV Q12H @ 0147 View\n Acetylcysteine 20% 600 mg PO/NG x4\n Ciprofloxacin 400 mg IV Q12H\n MetRONIDAZOLE (FLagyl) 500 mg IV Q8H\n Hydrocortisone Cream 1% 1 Appl TP QID:PRN\n Sarna Lotion 1 Appl TP QID:PRN\n Acetaminophen 650 mg PO/NG Q6H:PRN\n PHENObarbital 30 mg IV Q12H\n Fosphenytoin 100 mg PE IV Q8H\n Morphine Sulfate 2-4 mg IV Q4H:PRN\n Ferrous Sulfate 325 mg PO/NG DAILY\n Pancrelipase 4500 2 CAP PO TID\n Miconazole 2% Cream 1 Appl TP \n Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN\n Glucagon 1 mg IM Q15MIN:PRN\n Dextrose 50% 12.5 gm IV PRN\n Insulin Sliding Scale\n NC, Maternal grandmother had DM, paternal grandfather had HTN, parents\n healthy.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Lives at home with family, goes to school 5 days a week, no\n recent travels, no smoke/drink/IVDU.\n Review of systems:\n Constitutional: Fatigue, Fever, Weight loss\n Ear, Nose, Throat: OG / NG tube\n Gastrointestinal: Abdominal pain, Nausea, Emesis, Diarrhea\n Genitourinary: incontinence\n Integumentary (skin): itch\n Heme / Lymph: Anemia\n Neurologic: Seizure\n Flowsheet Data as of 10:54 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 35.6\nC (96\n Tcurrent: 35.6\nC (96\n HR: 109 (101 - 112) bpm\n BP: 83/64(69) {66/49(53) - 83/64(69)} mmHg\n RR: 26 (24 - 28) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n SpO2: 100%\n Physical Examination\n General Appearance: Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: NG tube\n Lymphatic: Cervical WNL, Supraclavicular WNL, Cervical adenopathy\n Cardiovascular: (S1: Normal), (S2: Normal, No(t) Distant)\n Peripheral Vascular: (Right radial pulse: Diminished), (Left radial\n pulse: Diminished), (Right DP pulse: Diminished), (Left DP pulse:\n Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Bowel sounds present, Distended, Tender: winces with diffuse\n palpation; mild guarding, no rebound\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Musculoskeletal: Unable to stand\n Skin: Warm\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n [image002.jpg]\n Other labs: Lactic Acid:\n 2.4 mmol/L\n Fluid analysis / Other labs: wbc 6.6, hct 27.6 from baseline 30-31, plt\n 212\n inr 1.9\n na 134, k 3.6, cl 102, hco3 28, bun 24, inr 1.0 (baseline)\n alt 10, ast 17, alk phos 128, t bili 0.2\n ca 7.2, mg 2.1, phos 3.2, alb 2.4\n tsh 2.9\n phenobarb 12.6, dilantin 9.0 ()\n Imaging: Imaging:\n portable abdomen -\n per HO, dilated loops of bowel; generally unchanged from yesterday\n .\n portable abdomen -\n IMPRESSION: Unchanged marked colonic/sigmoid dilation.\n .\n upright abdomen -\n IMPRESSION: Slightly improvement of marked sigmoid dilatation. No free\n intraperitoneal air.\n .\n CT abd/pelvis -\n (wet read) Pleural effusions decreased compared to prior study. NG tube\n noted within stomach. No evidence of SBO. Dilated fluid filled rectum\n and sigmoid with rectal tube in place may reflect ileus. No free air.\n No loculated fluid collections. Redemonstration of SMV thrombosis with\n collateral flow to a patent main portal vein, unchanged. Portal vein\n branches are difficult to evaluate. Major mesenteric arteries are\n widely patent. Low attenuation hepatic parenchyma may represent edema\n or fatty infiltration. Previously\n noted likely small pancraetic pseudocyst no longer identified, though\n calcifications in panc head and pancreatic atrophy again suggest prior\n pancreatitis.\n .\n RUQ Ultrasound -\n IMPRESSION: Small ascites. Again noted probable pseudocyst in the\n midline and collateral vessels related to the SMV thrombosis.\n .\n Renal US -\n IMPRESSION: 1. Small size and echogenic appearance of the kidneys\n consistent with chronic, diffuse parenchymal disease. No\n hydronephrosis. 2. Ascites.\n .\n CT Head -\n IMPRESSION: Exam limited due to motion. No evidence of hemorrhage or\n shift.\n .\n Echo -\n Technically limited study; Overall left ventricular systolic function\n is normal (LVEF>55%). Right ventricular chamber size and free wall\n motion are normal. The number of aortic valve leaflets cannot be\n determined. The aortic valve leaflets are moderately thickened. At\n least mild to moderate aortic stenosis is present (but cannot be fully\n quantified). No aortic regurgitation is seen. There is no pericardial\n effusion.\n .\n ** No EGDs or colonoscopies in our system.\n Microbiology: , peritoneal fluid - no growth\n , , blood cultures - no growth\n , , stool - no growth for c.diff, ovas, parasites\n sputum - rare yeast, sputum - no growth\n urine - no growth, urine - yeast\n ECG: EKG: NSR, no signs of ischemia, poor baseline; unchanged from\n prior\n Assessment and Plan\n Assessment and Plan:\n 35 y/o M with hx of cerebral palsy, seizure disorder, chronic\n pancreatitis and known gastric varices who is transferred with coffee\n ground emesis and hypotension.\n .\n # GI bleed: has blood in NGT and then coffee ground emesis worrisome\n for new upper GI bleed. Hct of not reflect active, ongoing\n bleed. Getting IVFs and 1u PRBCs now. Has known gastric varices which\n could be the cause of the bleed.\n - GI consulted and aware of patient, likely need EGD today\n - NPO, NGT in place, will check placement and then keep to LIS\n - PICC for access, try for PIVs\n - protonix 40 mg IV BID\n - complete 1u PRBC transfusion\n - 64hr Hcts, transfuse for hct <27 or active bleeding\n - check lactate\n - surgery following along\n .\n # Hypotension: baseline SBPs in the 80s, but has low BP to 68/doppler\n today. Is likely secondary to GI bleed and hypovolemia, although could\n be a sign of new early infection, PE, cardiogenic shock or adrenal\n insufficiency. These etiologies are less likely, though. He has\n remains afebrile and has no localizing infectious symptoms, although is\n difficult to interview. Has known SMV clot and has been slightly\n subtherpeutic on his coumadin, so may have other clots and is at risk\n of PE but is not hypoxic or with leg swelling. No hx of cardiac\n problems or signs of pulm edema suggesting cardiac failure. And he has\n not been on chronic steroids.\n - fluid resuccitation with IVF boluses and 1u PRBCs for now\n - levofed pressors if needed with SBP goal > 75, MAP >55\n - blood, urine cultures, c.diff\n - continue cipro and flagyl for peritonitis treatment\n - broaden abx by adding vanco for potential line infection, although\n PICC line looks uninfected on exam\n - would be missing VRE coverage and if clinically worsening, consider\n broadening by adding dapto\n - CT scan to evaluate for RP bleed\n - CXR to look for pneumonia\n - KUB to look for obstruction or new obstruction\n - EKG and CEs to rule out cardiac cause\n .\n # Abdominal Pain: was initial presentation and thought to be due to\n peritonitis from microperforations and translocation. Has had chronic\n abdominal pain this admission with intermittent large bowel\n obstructions and chronically dilated loops of bowel. Is passing gas\n and stooling. Did have recent rectal tube for decompression, but fell\n out two nights ago. Also has signs of chronic pancreatitis and an SMV\n as discussed below. Pain could be from multiple etiologies.\n - serial abdominal exams\n - f/u final read of KUB, appears stable per HO read\n - abd pain seems at baseline\n - consider repeat CT abdomen to look for possible new microperf or\n abscess as source of infection, but just had CT two days ago that was\n stable and without obvious source\n - continue pancreatic enzyme repletion\n - hold anticoagulation for thrombus as below\n - morphine PRN\n - surgery following along\n .\n # Peritonitis: although no positive cultures, was presumed to have\n peritonitis on admission and cause of initial presentation.\n - continue cipro/flagyl as above\n - course of cipro/flagyl to complete 2 week course; consider ID consult\n if infectious workup positive\n .\n # SMV Thrombus: has a chronic SMV thrombus with good collaterals. Was\n on lovenox for briding of subtherapeutic INR and on coumadin.\n Reimaging several days ago showed stable clot without progression.\n Vascular surgery was following along and plan was for 6 months of\n anticoagulation and reevaluation at that time.\n - hold lovenox and coumadin in setting of GI bleed\n - no need to reverse with FFP at this time\n - consider risks/benefits of long term anticoagulation and consider\n holding based on EGD findings and extent of bleed\n .\n # Anemia: has new baseline anemia around 30 from 35, and fe studies\n suggest iron deficiency.\n - continue fe supplementation after GI workup complete\n - transfuse for hct <27 in setting of bleed\n .\n # Nutrition: has been receiving TPN and GI had been consulted for a PEG\n tube for long term feeding, although wanted to wait for abx course to\n be completed and repeat para if fluid was present to confirm resolution\n of possible peritonitis. Did tolerated POs for a few days on the floor\n prior to his most recent large bowel obstruction.\n - NPO for now given GI bleeding\n - holding TPN for now for blood tx and boluses\n - restart TPN when stable\n - continue to follow albumin levels; remains hypoalbuminemic\n .\n # Seizure Disorder: is stable, no reports of recent seizures.\n - continue phenobarbitol and phenytoin\n .\n # Cerebral Palsy: stable, is interactive with family although\n non-verbal. Continue to monitor mental status.\n .\n # FEN: on TPN, holding for access issues today, but will consider based\n on clinical course today; NPO; replete electrolytes as needed.\n # Access: PICC, attempt at PIV\n # PPx: PPI , holding anticoagulation, pneumoboots\n # Communication: with family, mom in particular\n # Code: full, confirmed with family\n # Dispo: ICU for now\n .\n .\n , MD\n PGY 2\n pager \n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2115-03-13 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 628587,
"text": "Chief Complaint: hypotension/GI bleed\n HPI:\n 35 y/o M, known to MICU team from previously stay, with a hx of\n cerebral palsy, seizure disorder, anemia and a GI bleed in the past is\n transferred to the MICU for hypotension and coffee ground emesis. The\n patient has been on the floor being treated for intermittent small and\n large bowel obstructions when last night at around 1 am, his nurse\n noted about a teaspoon of blood in his NGT. The nightfloat intern was\n called to the bedside and a NG lavage was done and clear. A stat Hct\n was at his baseline of 30. He BP was in the 80s and HR in 100s at his\n baseline. Several hours later, he was found to have coffee ground\n emesis. Lovenox and coumadin were discontinued at that time. Vitamin\n K was given. This morning, his hct was 27 and his BP had dropped to a\n low of 68/doppler. HR remained in the low 100s. He was receiving a NS\n bolus and 1u PRBCs. He has a PICC for access. He had no further\n episodes of coffee grounds and had a mildly tender abdomen without\n rebound or guarding. His mother notes that he had been his usual self\n the last few days; playing in bed, interactive. But starting last\n night, he was more somnulent and less interactive. His last fever was\n several days ago, but he has been having intermittent fevers since\n admission.\n .\n In terms of his current hospitalization, he was initially admitted on\n with abdominal pain and distention to an OSH. CT scan was\n performed and was reported as diffuse bowel edema, gastric varices,\n ascites and a pancreatic cyst. He was transferred for further\n management to the SICU team for concerns of an acute abdomen. He had a\n diagnostic paracentesis on with WBC , but no growth so thought\n to be inflammatory state. He was started on Vanco/Zosyn/Flagyl for\n suspected peritonitis and ischemic bowel with translocation. On CT, a\n SMV thrombus was noted and heparin was started on . His thrombus\n was likely chronic and secondary to chronic pancreatic inflammation.\n He was transitioned to coumadin. He was then intubated for\n respiratory failure. He was extubated but was then reintubated\n likely secondary to fluid overload. When had had difficultly weaning\n off the ventilator, he was transferred to the MICU team for further\n management. He was extubated successfully and then transferred to the\n floor for futher management of his abdominal pain. He was changed from\n heparin to lovenox for bridging and coumadin. He started TPN. He did\n tolerated POs for a few days but has intermittent large bowel\n obstuctions and then remade NPO. GI has been consulted for a possible\n PEG tube. He completed a 14 d course of vanco and was continued on\n cipro/flagyl for his initial peritonitis.\n .\n On arrival to the floor, he is awake and alert and in no distress. He\n remains hypotensive with SBPs in the 70s. He winces during the\n abdominal exam. His mother is at the bedside.\n Patient admitted from: \n History obtained from Family / Medical records\n Patient unable to provide history: non-verbal\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Past Medical History:\n Cerebral Palsy\n Seizure disorder\n Chronic anemia - Hct 35\n GIB in \n h/o liver cyst drainage (, )\n H/o Laproscopic cholecystectomy\n H/o pancreatic cyst drainage with chronic pancreatitis\n .\n Medications (Upon admission):\n Miralax prn\n Phenobarbital 32.4 mg TAB am, 1PM\n Dilantin (Extended caps) 75mg in am 100mg in pm\n Ferrous Fumarate 324 mg Tabs daily\n MVI daily\n Cyproheptadine HCL 4mg tabs 0.5 tab in AM, 0.5 tabs in PM\n Prilosec 20mg daily\n Celexa 20mg daily\n Zovirax 5% oint (acyclovir) q2hr while awake x 4 days prn cold sore\n vitamine D 400 Unit Caps\n .\n Medications (Upon transfer to MICU service):\n Phytonadione 5 mg IV ONCE \n Pantoprazole 40 mg IV Q12H @ 0147 View\n Acetylcysteine 20% 600 mg PO/NG x4\n Ciprofloxacin 400 mg IV Q12H\n MetRONIDAZOLE (FLagyl) 500 mg IV Q8H\n Hydrocortisone Cream 1% 1 Appl TP QID:PRN\n Sarna Lotion 1 Appl TP QID:PRN\n Acetaminophen 650 mg PO/NG Q6H:PRN\n PHENObarbital 30 mg IV Q12H\n Fosphenytoin 100 mg PE IV Q8H\n Morphine Sulfate 2-4 mg IV Q4H:PRN\n Ferrous Sulfate 325 mg PO/NG DAILY\n Pancrelipase 4500 2 CAP PO TID\n Miconazole 2% Cream 1 Appl TP \n Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN\n Glucagon 1 mg IM Q15MIN:PRN\n Dextrose 50% 12.5 gm IV PRN\n Insulin Sliding Scale\n NC, Maternal grandmother had DM, paternal grandfather had HTN, parents\n healthy.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Lives at home with family, goes to school 5 days a week, no\n recent travels, no smoke/drink/IVDU.\n Review of systems:\n Constitutional: Fatigue, Fever, Weight loss\n Ear, Nose, Throat: OG / NG tube\n Gastrointestinal: Abdominal pain, Nausea, Emesis, Diarrhea\n Genitourinary: incontinence\n Integumentary (skin): itch\n Heme / Lymph: Anemia\n Neurologic: Seizure\n Flowsheet Data as of 10:54 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 35.6\nC (96\n Tcurrent: 35.6\nC (96\n HR: 109 (101 - 112) bpm\n BP: 83/64(69) {66/49(53) - 83/64(69)} mmHg\n RR: 26 (24 - 28) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n SpO2: 100%\n Physical Examination\n General Appearance: Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: NG tube\n Lymphatic: Cervical WNL, Supraclavicular WNL, Cervical adenopathy\n Cardiovascular: (S1: Normal), (S2: Normal, No(t) Distant)\n Peripheral Vascular: (Right radial pulse: Diminished), (Left radial\n pulse: Diminished), (Right DP pulse: Diminished), (Left DP pulse:\n Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Bowel sounds present, Distended, Tender: winces with diffuse\n palpation; mild guarding, no rebound\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Musculoskeletal: Unable to stand\n Skin: Warm\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n [image002.jpg]\n Other labs: Lactic Acid:2.4 mmol/L\n Fluid analysis / Other labs: wbc 6.6, hct 27.6 from baseline 30-31, plt\n 212\n inr 1.9\n na 134, k 3.6, cl 102, hco3 28, bun 24, inr 1.0 (baseline)\n alt 10, ast 17, alk phos 128, t bili 0.2\n ca 7.2, mg 2.1, phos 3.2, alb 2.4\n tsh 2.9\n phenobarb 12.6, dilantin 9.0 ()\n Imaging: Imaging:\n portable abdomen -\n per HO, dilated loops of bowel; generally unchanged from yesterday\n .\n portable abdomen -\n IMPRESSION: Unchanged marked colonic/sigmoid dilation.\n .\n upright abdomen -\n IMPRESSION: Slightly improvement of marked sigmoid dilatation. No free\n intraperitoneal air.\n .\n CT abd/pelvis -\n (wet read) Pleural effusions decreased compared to prior study. NG tube\n noted within stomach. No evidence of SBO. Dilated fluid filled rectum\n and sigmoid with rectal tube in place may reflect ileus. No free air.\n No loculated fluid collections. Redemonstration of SMV thrombosis with\n collateral flow to a patent main portal vein, unchanged. Portal vein\n branches are difficult to evaluate. Major mesenteric arteries are\n widely patent. Low attenuation hepatic parenchyma may represent edema\n or fatty infiltration. Previously\n noted likely small pancraetic pseudocyst no longer identified, though\n calcifications in panc head and pancreatic atrophy again suggest prior\n pancreatitis.\n .\n RUQ Ultrasound -\n IMPRESSION: Small ascites. Again noted probable pseudocyst in the\n midline and collateral vessels related to the SMV thrombosis.\n .\n Renal US -\n IMPRESSION: 1. Small size and echogenic appearance of the kidneys\n consistent with chronic, diffuse parenchymal disease. No\n hydronephrosis. 2. Ascites.\n .\n CT Head -\n IMPRESSION: Exam limited due to motion. No evidence of hemorrhage or\n shift.\n .\n Echo -\n Technically limited study; Overall left ventricular systolic function\n is normal (LVEF>55%). Right ventricular chamber size and free wall\n motion are normal. The number of aortic valve leaflets cannot be\n determined. The aortic valve leaflets are moderately thickened. At\n least mild to moderate aortic stenosis is present (but cannot be fully\n quantified). No aortic regurgitation is seen. There is no pericardial\n effusion.\n .\n ** No EGDs or colonoscopies in our system.\n Microbiology: , peritoneal fluid - no growth\n , , blood cultures - no growth\n , , stool - no growth for c.diff, ovas, parasites\n sputum - rare yeast, sputum - no growth\n urine - no growth, urine - yeast\n ECG: EKG: NSR, no signs of ischemia, poor baseline; unchanged from\n prior\n Assessment and Plan\n Assessment and Plan:\n 35 y/o M with hx of cerebral palsy, seizure disorder, chronic\n pancreatitis and known gastric varices who is transferred with coffee\n ground emesis and hypotension.\n .\n # GI bleed: has blood in NGT and then coffee ground emesis worrisome\n for new upper GI bleed. Hct of not reflect active, ongoing\n bleed. Getting IVFs and 1u PRBCs now. Has known gastric varices which\n could be the cause of the bleed.\n - GI consulted and aware of patient, likely need EGD today\n - NPO, NGT in place, will check placement and then keep to LIS\n - PICC for access, try for PIVs\n - protonix 40 mg IV BID\n - complete 1u PRBC transfusion\n - q4hr Hcts, transfuse for hct <27 or active bleeding\n - check lactate\n - surgery following along\n .\n # Hypotension: baseline SBPs in the 80s, but has low BP to 68/doppler\n today. Is likely secondary to GI bleed and hypovolemia, although could\n be a sign of new early infection, PE, cardiogenic shock or adrenal\n insufficiency. These etiologies are less likely, though. He has\n remains afebrile and has no localizing infectious symptoms, although is\n difficult to interview. Has known SMV clot and has been slightly\n subtherpeutic on his coumadin, so may have other clots and is at risk\n of PE but is not hypoxic or with leg swelling. No hx of cardiac\n problems or signs of pulm edema suggesting cardiac failure. And he has\n not been on chronic steroids.\n - fluid resuccitation with IVF boluses and 1u PRBCs for now\n - levofed pressors if needed with SBP goal > 75, MAP >55\n - blood, urine cultures, c.diff\n - continue cipro and flagyl for peritonitis treatment\n - broaden abx by adding vanco for potential line infection, although\n PICC line looks uninfected on exam\n - would be missing VRE coverage and if clinically worsening, consider\n broadening by adding dapto\n - CXR to look for pneumonia\n - KUB to look for obstruction or new obstruction\n - EKG and CEs to rule out cardiac cause\n .\n # Abdominal Pain: was initial presentation and thought to be due to\n peritonitis from microperforations and translocation. Has had chronic\n abdominal pain this admission with intermittent large bowel\n obstructions and chronically dilated loops of bowel. Is passing gas\n and stooling. Did have recent rectal tube for decompression, but fell\n out two nights ago. Also has signs of chronic pancreatitis and an SMV\n as discussed below. Pain could be from multiple etiologies.\n - serial abdominal exams\n - f/u final read of KUB, appears stable per HO read\n - abd pain seems at baseline\n - consider repeat CT abdomen to look for possible new microperf or\n abscess as source of infection, but just had CT two days ago that was\n stable and without obvious source\n - continue pancreatic enzyme repletion\n - hold anticoagulation for thrombus as below\n - morphine PRN\n - surgery following along\n .\n # Peritonitis: although no positive cultures, was presumed to have\n peritonitis on admission and cause of initial presentation.\n - continue cipro/flagyl as above\n - course of cipro/flagyl to complete 2 week course from ___ per floor\n team; consider ID consult if infectious workup positive\n .\n # SMV Thrombus: has a chronic SMV thrombus with good collaterals. Was\n on lovenox for briding of subtherapeutic INR and on coumadin.\n Reimaging several days ago showed stable clot without progression.\n Vascular surgery was following along and plan was for 6 months of\n anticoagulation and reevaluation at that time.\n - hold lovenox and coumadin in setting of GI bleed\n - consider risks/benefits of long term anticoagulation and consider\n holding based on EGD findings and extent of bleed\n .\n # Anemia: has new baseline anemia around 30 from 35, and fe studies\n suggest iron deficiency.\n - continue fe supplementation after GI workup complete\n - transfuse for hct <27 in setting of bleed\n .\n # Nutrition: has been receiving TPN and GI had been consulted for a PEG\n tube for long term feeding, although wanted to wait for abx course to\n be completed and repeat para if fluid was present to confirm resolution\n of possible peritonitis. Did tolerated POs for a few days on the floor\n prior to his most recent large bowel obstruction.\n - NPO for now given GI bleeding\n - holding TPN for now for blood tx and boluses\n - restart TPN when stable\n - continue to follow albumin levels; remains hypoalbuminemic\n .\n # Seizure Disorder: is stable, no reports of recent seizures.\n - continue phenobarbitol and phenytoin\n .\n # Cerebral Palsy: stable, is interactive with family although\n non-verbal. Continue to monitor mental status.\n .\n # FEN: on TPN, holding for access issues today, but will consider based\n on clinical course today; NPO; replete electrolytes as needed.\n # Access: PICC, attempt at PIV\n # PPx: PPI , holding anticoagulation, pneumoboots\n # Communication: with family, mom in particular\n # Code: full, confirmed with family\n # Dispo: ICU for now\n .\n .\n , MD\n PGY 2\n pager \n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 628711,
"text": "Retroperitoneal bleed (RP bleed), spontaneous\n Assessment:\n Repeat hct 25.5 after 1 unit prbc. Hypotensive to 70\ns/40, initially\n tolerating map >55, though map dipping to 40\ns. Abdomen is softly\n distended, hyperactive bowel sounds. Bladder pressure 14. Abdomen\n appears tender to deep palpation, particularly lower right quadrant.\n NGT clamped. Flexiseal in place, draining dark green liquid stool.\n Action:\n 1 liter NS bolus given, 2 units PRBC given. Started on Neo with goal\n to keep sbp >75\n Response:\n Hct improved to 30.4, sbp improved to 90\ns. Urine output adequate,\n mentating at baseline level.\n Plan:\n titrate neo to keep sbp >75, monitor hct, monitor bladder pressures\n"
},
{
"category": "Physician ",
"chartdate": "2115-03-14 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 628811,
"text": "Chief Complaint:\n 24 Hour Events:\n PICC LINE - START 10:00 AM\n - Went for CT abdomen per GI recs. Prelim read shows colonic wall\n thickening with ? bleed, ? RP hematoma, ? microperforation. Plan to\n hold off on EGD unless evidence of active bleed.\n - Hypotensive overnight. On neo for pressure support -> improved UOP.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 07:55 PM\n Ciprofloxacin - 11:21 PM\n Metronidazole - 12:30 AM\n Infusions:\n Phenylephrine - 0.5 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 07:55 PM\n Fosphenytoin - 12:22 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.8\nC (100\n Tcurrent: 36.8\nC (98.3\n HR: 101 (88 - 119) bpm\n BP: 76/53(59) {66/42(48) - 100/73(78)} mmHg\n RR: 30 (13 - 32) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Bladder pressure: 12 (12 - 14) mmHg\n Total In:\n 8,127 mL\n 832 mL\n PO:\n TF:\n IVF:\n 5,767 mL\n 832 mL\n Blood products:\n 1,400 mL\n Total out:\n 915 mL\n 1,870 mL\n Urine:\n 915 mL\n 1,170 mL\n NG:\n Stool:\n Drains:\n Balance:\n 7,212 mL\n -1,038 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 94%\n ABG: ///27/\n Physical Examination\n General: Awake in bed, orients to voice, shakes head in response to\n some Qs, appears generally comfortable\n HEENT: JVP at clavicle\n CV: RRR, 2/6 systolic ejection murmur\n Lungs: Shallow resp. but seem CTA bilaterally\n Abdomen: Distended\n Labs / Radiology\n 143 K/uL\n 11.3 g/dL\n 100 mg/dL\n 0.7 mg/dL\n 27 mEq/L\n 2.9 mEq/L\n 13 mg/dL\n 106 mEq/L\n 140 mEq/L\n 32.3 %\n 6.1 K/uL\n [image002.jpg]\n 10:16 AM\n 12:30 PM\n 07:32 PM\n 12:20 AM\n 03:48 AM\n 05:08 AM\n WBC\n 7.2\n 6.1\n Hct\n 24.6\n 25.5\n 30.4\n 32.3\n Plt\n 197\n 143\n Cr\n 0.7\n 0.7\n TropT\n <0.01\n Glucose\n 300\n 100\n Other labs: PT / PTT / INR:16.5/29.3/1.5, CK / CKMB /\n Troponin-T:16//<0.01, ALT / AST:, Alk Phos / T Bili:99/0.6, Lactic\n Acid:1.2 mmol/L, Ca++:6.2 mg/dL, Mg++:1.5 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n 35 y/o M with hx of cerebral palsy, seizure disorder, chronic\n pancreatitis and known gastric varices who is transferred with coffee\n ground emesis and hypotension.\n .\n # Hypotension: Most likely secondary to GI bleed or RP bleed in the\n setting of anticoagulation for SMV clot. Baseline SBPs in the 80s,\n today s/p fluid resuscitation and pressure support with pressures\n closer to baseline with good UOP.\n - wean off pressors with goal MAP >60\n - continue with IVF, bolus to OUP >50cc/hr\n - transfuse for HCT <27\n - continue vanc, cipro and flagyl for peritonitis treatment pending\n culture data and final read of CT\n - would be missing VRE coverage and if clinically worsening, consider\n broadening by adding dapto\n .\n # GI bleed: Patient with know gastric varices with blood in NGT and\n coffee ground emesis concerning for GI bleed while on Coumadin with\n imaging concerning for GI and / or RP bleed. Patient with improving HCT\n s/p transfusion without evidence of active bleeding.\n - NPO, NGT in place\n - coordinate care with GI and surgery\n - PICC for access, try for PIVs\n - protonix 40 mg IV BID\n - trend HCT and transfuse for HCT <27\n - hold Coumadin for now\n ..\n # Peritonitis: although no positive cultures, was presumed to have\n peritonitis on admission and cause of initial presentation.\n - continue cipro/flagyl as above\n - serial abdominal exams\n - F/U final imaging read\n .\n # SMV Thrombus: has a chronic SMV thrombus with good collaterals. Was\n on lovenox for briding of subtherapeutic INR and on coumadin.\n Reimaging several days ago showed stable clot without progression.\n Vascular surgery was following along and plan was for 6 months of\n anticoagulation and reevaluation at that time.\n - hold lovenox and coumadin in setting of GI bleed\n - consider risks/benefits of long term anticoagulation and consider\n holding based on EGD findings and extent of bleed\n .\n # Anemia: has new baseline anemia around 30 from 35, and fe studies\n suggest iron deficiency.\n - continue fe supplementation after GI workup complete\n - transfuse for hct <25 in setting of bleed\n .\n # Nutrition: has been receiving TPN and GI had been consulted for a PEG\n tube for long term feeding, although wanted to wait for abx course to\n be completed and repeat para if fluid was present to confirm resolution\n of possible peritonitis. Did tolerated POs for a few days on the floor\n prior to his most recent large bowel obstruction.\n - NPO for now given GI bleeding\n - holding TPN for now for blood tx and boluses\n - restart TPN when stable\n - continue to follow albumin levels; remains hypoalbuminemic\n .\n # Seizure Disorder: is stable, no reports of recent seizures.\n - continue phenobarbitol and phenytoin\n .\n # Cerebral Palsy: stable, is interactive with family although\n non-verbal. Continue to monitor mental status.\n .\n # FEN: on TPN, holding for access issues today, but will consider based\n on clinical course today; NPO; replete electrolytes as needed.\n # Access: PICC, attempt at PIV\n # PPx: PPI , holding anticoagulation, pneumoboots\n # Communication: with family, mom in particular\n # Code: full, confirmed with family\n # Dispo: ICU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 10:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2115-03-14 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 628804,
"text": "Chief Complaint:\n 24 Hour Events:\n PICC LINE - START 10:00 AM\n - Went for CT abdomen per GI recs. Prelim read shows colonic wall\n thickening with ? bleed, ? RP hematoma, ? microperforation. Plan to\n hold off on EGD unless evidence of active bleed.\n - Hypotensive overnight. On neo for pressure support -> improved UOP.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 07:55 PM\n Ciprofloxacin - 11:21 PM\n Metronidazole - 12:30 AM\n Infusions:\n Phenylephrine - 0.5 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 07:55 PM\n Fosphenytoin - 12:22 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.8\nC (100\n Tcurrent: 36.8\nC (98.3\n HR: 101 (88 - 119) bpm\n BP: 76/53(59) {66/42(48) - 100/73(78)} mmHg\n RR: 30 (13 - 32) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Bladder pressure: 12 (12 - 14) mmHg\n Total In:\n 8,127 mL\n 832 mL\n PO:\n TF:\n IVF:\n 5,767 mL\n 832 mL\n Blood products:\n 1,400 mL\n Total out:\n 915 mL\n 1,870 mL\n Urine:\n 915 mL\n 1,170 mL\n NG:\n Stool:\n Drains:\n Balance:\n 7,212 mL\n -1,038 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 94%\n ABG: ///27/\n Physical Examination\n General: Awake in bed, orients to voice, shakes head in response to\n some Qs, appears generally comfortable\n HEENT: appears ~euvolemic\n CV: RRR, 2/6 systolic ejection murmur\n Lungs: Shallow resp. but seem CTA bilaterally\n Abdomen: Distended\n Labs / Radiology\n 143 K/uL\n 11.3 g/dL\n 100 mg/dL\n 0.7 mg/dL\n 27 mEq/L\n 2.9 mEq/L\n 13 mg/dL\n 106 mEq/L\n 140 mEq/L\n 32.3 %\n 6.1 K/uL\n [image002.jpg]\n 10:16 AM\n 12:30 PM\n 07:32 PM\n 12:20 AM\n 03:48 AM\n 05:08 AM\n WBC\n 7.2\n 6.1\n Hct\n 24.6\n 25.5\n 30.4\n 32.3\n Plt\n 197\n 143\n Cr\n 0.7\n 0.7\n TropT\n <0.01\n Glucose\n 300\n 100\n Other labs: PT / PTT / INR:16.5/29.3/1.5, CK / CKMB /\n Troponin-T:16//<0.01, ALT / AST:, Alk Phos / T Bili:99/0.6, Lactic\n Acid:1.2 mmol/L, Ca++:6.2 mg/dL, Mg++:1.5 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n 35 y/o M with hx of cerebral palsy, seizure disorder, chronic\n pancreatitis and known gastric varices who is transferred with coffee\n ground emesis and hypotension.\n .\n # GI bleed: has blood in NGT and then coffee ground emesis worrisome\n for new upper GI bleed. Hct of not reflect active, ongoing\n bleed. Getting IVFs and 1u PRBCs now. Has known gastric varices which\n could be the cause of the bleed.\n - GI consulted and aware of patient, likely need EGD today\n - NPO, NGT in place, will check placement and then keep to LIS\n - PICC for access, try for PIVs\n - protonix 40 mg IV BID\n - complete 1u PRBC transfusion\n - q4hr Hcts, transfuse for hct <27 or active bleeding\n - check lactate\n - surgery following along\n .\n # Hypotension: baseline SBPs in the 80s, but has low BP to 68/doppler\n today. Is likely secondary to GI bleed and hypovolemia, although could\n be a sign of new early infection, PE, cardiogenic shock or adrenal\n insufficiency. These etiologies are less likely, though. He has\n remains afebrile and has no localizing infectious symptoms, although is\n difficult to interview. Has known SMV clot and has been slightly\n subtherpeutic on his coumadin, so may have other clots and is at risk\n of PE but is not hypoxic or with leg swelling. No hx of cardiac\n problems or signs of pulm edema suggesting cardiac failure. And he has\n not been on chronic steroids.\n - fluid resuccitation with IVF boluses and 1u PRBCs for now\n - levofed pressors if needed with SBP goal > 75, MAP >55\n - blood, urine cultures, c.diff\n - continue cipro and flagyl for peritonitis treatment\n - broaden abx by adding vanco for potential line infection, although\n PICC line looks uninfected on exam\n - would be missing VRE coverage and if clinically worsening, consider\n broadening by adding dapto\n - CXR to look for pneumonia\n - KUB to look for obstruction or new obstruction\n - EKG and CEs to rule out cardiac cause\n .\n # Abdominal Pain: was initial presentation and thought to be due to\n peritonitis from microperforations and translocation. Has had chronic\n abdominal pain this admission with intermittent large bowel\n obstructions and chronically dilated loops of bowel. Is passing gas\n and stooling. Did have recent rectal tube for decompression, but fell\n out two nights ago. Also has signs of chronic pancreatitis and an SMV\n as discussed below. Pain could be from multiple etiologies.\n - serial abdominal exams\n - f/u final read of KUB, appears stable per HO read\n - abd pain seems at baseline\n - repeat CT abdomen to look for possible new microperf or abscess as\n source of infection, but just had CT two days ago that was stable and\n without obvious source\n - continue pancreatic enzyme repletion\n - hold anticoagulation for thrombus as below\n - morphine PRN\n - surgery following along\n .\n # Peritonitis: although no positive cultures, was presumed to have\n peritonitis on admission and cause of initial presentation.\n - continue cipro/flagyl as above\n - course of cipro/flagyl to complete 2 week course from ___ per floor\n team; consider ID consult if infectious workup positive\n .\n # SMV Thrombus: has a chronic SMV thrombus with good collaterals. Was\n on lovenox for briding of subtherapeutic INR and on coumadin.\n Reimaging several days ago showed stable clot without progression.\n Vascular surgery was following along and plan was for 6 months of\n anticoagulation and reevaluation at that time.\n - hold lovenox and coumadin in setting of GI bleed\n - consider risks/benefits of long term anticoagulation and consider\n holding based on EGD findings and extent of bleed\n .\n # Anemia: has new baseline anemia around 30 from 35, and fe studies\n suggest iron deficiency.\n - continue fe supplementation after GI workup complete\n - transfuse for hct <25 in setting of bleed\n .\n # Nutrition: has been receiving TPN and GI had been consulted for a PEG\n tube for long term feeding, although wanted to wait for abx course to\n be completed and repeat para if fluid was present to confirm resolution\n of possible peritonitis. Did tolerated POs for a few days on the floor\n prior to his most recent large bowel obstruction.\n - NPO for now given GI bleeding\n - holding TPN for now for blood tx and boluses\n - restart TPN when stable\n - continue to follow albumin levels; remains hypoalbuminemic\n .\n # Seizure Disorder: is stable, no reports of recent seizures.\n - continue phenobarbitol and phenytoin\n .\n # Cerebral Palsy: stable, is interactive with family although\n non-verbal. Continue to monitor mental status.\n .\n # FEN: on TPN, holding for access issues today, but will consider based\n on clinical course today; NPO; replete electrolytes as needed.\n # Access: PICC, attempt at PIV\n # PPx: PPI , holding anticoagulation, pneumoboots\n # Communication: with family, mom in particular\n # Code: full, confirmed with family\n # Dispo: ICU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 10:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2115-03-14 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 628806,
"text": "Chief Complaint:\n 24 Hour Events:\n PICC LINE - START 10:00 AM\n - Went for CT abdomen per GI recs. Prelim read shows colonic wall\n thickening with ? bleed, ? RP hematoma, ? microperforation. Plan to\n hold off on EGD unless evidence of active bleed.\n - Hypotensive overnight. On neo for pressure support -> improved UOP.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 07:55 PM\n Ciprofloxacin - 11:21 PM\n Metronidazole - 12:30 AM\n Infusions:\n Phenylephrine - 0.5 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 07:55 PM\n Fosphenytoin - 12:22 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.8\nC (100\n Tcurrent: 36.8\nC (98.3\n HR: 101 (88 - 119) bpm\n BP: 76/53(59) {66/42(48) - 100/73(78)} mmHg\n RR: 30 (13 - 32) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Bladder pressure: 12 (12 - 14) mmHg\n Total In:\n 8,127 mL\n 832 mL\n PO:\n TF:\n IVF:\n 5,767 mL\n 832 mL\n Blood products:\n 1,400 mL\n Total out:\n 915 mL\n 1,870 mL\n Urine:\n 915 mL\n 1,170 mL\n NG:\n Stool:\n Drains:\n Balance:\n 7,212 mL\n -1,038 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 94%\n ABG: ///27/\n Physical Examination\n General: Awake in bed, orients to voice, shakes head in response to\n some Qs, appears generally comfortable\n HEENT: JVP at clavicle\n CV: RRR, 2/6 systolic ejection murmur\n Lungs: Shallow resp. but seem CTA bilaterally\n Abdomen: Distended\n Labs / Radiology\n 143 K/uL\n 11.3 g/dL\n 100 mg/dL\n 0.7 mg/dL\n 27 mEq/L\n 2.9 mEq/L\n 13 mg/dL\n 106 mEq/L\n 140 mEq/L\n 32.3 %\n 6.1 K/uL\n [image002.jpg]\n 10:16 AM\n 12:30 PM\n 07:32 PM\n 12:20 AM\n 03:48 AM\n 05:08 AM\n WBC\n 7.2\n 6.1\n Hct\n 24.6\n 25.5\n 30.4\n 32.3\n Plt\n 197\n 143\n Cr\n 0.7\n 0.7\n TropT\n <0.01\n Glucose\n 300\n 100\n Other labs: PT / PTT / INR:16.5/29.3/1.5, CK / CKMB /\n Troponin-T:16//<0.01, ALT / AST:, Alk Phos / T Bili:99/0.6, Lactic\n Acid:1.2 mmol/L, Ca++:6.2 mg/dL, Mg++:1.5 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n 35 y/o M with hx of cerebral palsy, seizure disorder, chronic\n pancreatitis and known gastric varices who is transferred with coffee\n ground emesis and hypotension.\n .\n # Hypotension: Most likely secondary to GI bleed or RP bleed in the\n setting of anticoagulation for SMV clot. Baseline SBPs in the 80s,\n today s/p fluid resuscitation and pressure support with pressures\n closer to baseline with good UOP.\n - wean off pressors with goal MAP >60\n - continue with IVF, bolus to OUP >50cc/hr\n - transfuse for HCT <27\n - continue vanc, cipro and flagyl for peritonitis treatment pending\n culture data and final read of CT\n - would be missing VRE coverage and if clinically worsening, consider\n broadening by adding dapto\n .\n # GI bleed: Patient with know gastric varices with blood in NGT and\n coffee ground emesis concerning for GI bleed while on Coumadin with\n imaging concerning for GI and / or RP bleed. Patient with improving HCT\n s/p transfusion without evidence of active bleeding.\n - NPO, NGT in place\n - coordinate care with GI and surgery\n - PICC for access, try for PIVs\n - protonix 40 mg IV BID\n - trend HCT and transfuse for HCT <27\n - hold Coumadin for now\n ..\n # Peritonitis: although no positive cultures, was presumed to have\n peritonitis on admission and cause of initial presentation.\n - continue cipro/flagyl as above\n - course of cipro/flagyl to complete 2 week course from ___ per floor\n team; consider ID consult if infectious workup positive\n .\n # SMV Thrombus: has a chronic SMV thrombus with good collaterals. Was\n on lovenox for briding of subtherapeutic INR and on coumadin.\n Reimaging several days ago showed stable clot without progression.\n Vascular surgery was following along and plan was for 6 months of\n anticoagulation and reevaluation at that time.\n - hold lovenox and coumadin in setting of GI bleed\n - consider risks/benefits of long term anticoagulation and consider\n holding based on EGD findings and extent of bleed\n .\n # Anemia: has new baseline anemia around 30 from 35, and fe studies\n suggest iron deficiency.\n - continue fe supplementation after GI workup complete\n - transfuse for hct <25 in setting of bleed\n .\n # Nutrition: has been receiving TPN and GI had been consulted for a PEG\n tube for long term feeding, although wanted to wait for abx course to\n be completed and repeat para if fluid was present to confirm resolution\n of possible peritonitis. Did tolerated POs for a few days on the floor\n prior to his most recent large bowel obstruction.\n - NPO for now given GI bleeding\n - holding TPN for now for blood tx and boluses\n - restart TPN when stable\n - continue to follow albumin levels; remains hypoalbuminemic\n .\n # Seizure Disorder: is stable, no reports of recent seizures.\n - continue phenobarbitol and phenytoin\n .\n # Cerebral Palsy: stable, is interactive with family although\n non-verbal. Continue to monitor mental status.\n .\n # FEN: on TPN, holding for access issues today, but will consider based\n on clinical course today; NPO; replete electrolytes as needed.\n # Access: PICC, attempt at PIV\n # PPx: PPI , holding anticoagulation, pneumoboots\n # Communication: with family, mom in particular\n # Code: full, confirmed with family\n # Dispo: ICU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 10:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nutrition",
"chartdate": "2115-03-14 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 628818,
"text": "Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 140cm\n 32.3 kg\n 16.5\n Pertinent medications: Neosynephrine drip, repletions (potassium,\n magnesium), ABx, sodium bicarb, RISS, protonix, ferrous sulfate, others\n noted\n Labs:\n Value\n Date\n Glucose\n 100 mg/dL\n 05:08 AM\n Glucose Finger Stick\n 114\n 10:00 AM\n BUN\n 13 mg/dL\n 05:08 AM\n Creatinine\n 0.7 mg/dL\n 05:08 AM\n Sodium\n 140 mEq/L\n 05:08 AM\n Potassium\n 2.9 mEq/L\n 05:08 AM\n Chloride\n 106 mEq/L\n 05:08 AM\n TCO2\n 27 mEq/L\n 05:08 AM\n pH (urine)\n 6.5 units\n 10:16 AM\n Calcium non-ionized\n 6.2 mg/dL\n 05:08 AM\n Phosphorus\n 2.3 mg/dL\n 05:08 AM\n Magnesium\n 1.5 mg/dL\n 05:08 AM\n ALT\n 8 IU/L\n 03:48 AM\n Alkaline Phosphate\n 99 IU/L\n 03:48 AM\n AST\n 18 IU/L\n 03:48 AM\n Total Bilirubin\n 0.6 mg/dL\n 03:48 AM\n WBC\n 6.1 K/uL\n 03:48 AM\n Hgb\n 11.3 g/dL\n 03:48 AM\n Hematocrit\n 32.3 %\n 03:48 AM\n Current diet order / nutrition support: TPN: off .\n TPN Order 3:30: 1.1L (200g dextrose/ 50g amino acid/ 22g fat) =\n 1100kcals.\n GI: abd soft/distended, NGT to low intermittent suction\n Assessment of Nutritional Status\n 35 y/o M with hx of cerebral palsy, seizure disorder, chronic\n pancreatitis and known gastric varices who is now transferred with\n coffee ground emesis and hypotension. Patient has been receiving TPN\n at goal, which provides 34kcals/kg and 1.5g protein/kg, meeting 100% of\n estimated needs. TPN was turned off yesterday, as patient needed\n additional IV medicines after transfer to ICU and did not have a port\n free for TPN. Per discussion with RN, a port will free up and TPN will\n be restarted tonight. Recommend continue with TPN at previous goal.\n Will continue to follow progress and tolerance.\n #\n 12:18\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 628689,
"text": "Sepsis without organ dysfunction\n Assessment:\n Mentally retarded male received from CC7 for hypotension and\n decrease in HCT (by approx 3 points). NS bolus infusing, as well as\n PRBCs at that time.\n Alert, eyes open spontaneously, does not follow commands.\n Localizes pain. Temp increased from 96 to 99 during this shift. Pan\n cultured.\n Hypotensive entire shift. Per MICU team, MAP goal >=55 (as\n long as patient making urine and mentating well). Received 3 units NS\n today and 2 units PRBC. 3 units crossmatched as well. HR ST, rate\n 100-120.\n O2 sat 99% on room air. Lungs clear bilaterally. No\n cough.\n Abdomen distended, drum-like on percussion, tender on\n palpation. OGT placed and in good position per x-ray. Scant amount of\n bilious drainage. Clamped at this time.\n Foley catheter placed today. Draining clear yellow urine.\n 9 WBCs on UA. Urine output 60-80cc/hr.\n Skin intact.\n Right AC PICC patent and aspirates well.\n CT of abdomen with oral and IV contrast completed. Awaiting\n results.\n Plan:\n CBC at 1900 post PRBC infusion.\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 628694,
"text": "Sepsis without organ dysfunction\n Assessment:\n Mentally retarded male received from CC7 for hypotension and\n decrease in HCT (by approx 3 points). NS bolus infusing, as well as\n PRBCs at that time.\n Alert, eyes open spontaneously, does not follow commands.\n Localizes pain. Temp increased from 96 to 99 during this shift. Pan\n cultured.\n Hypotensive entire shift. Per MICU team, MAP goal >=55 (as\n long as patient making urine and mentating well). Received 3 units NS\n today and 2 units PRBC. 3 units crossmatched as well. HR ST, rate\n 100-120.\n O2 sat 99% on room air. Lungs clear bilaterally. No\n cough.\n Abdomen distended, drum-like on percussion, tender on\n palpation. OGT placed and in good position per x-ray. Scant amount of\n bilious drainage. Clamped at this time.\n Foley catheter placed today. Draining clear yellow urine.\n 9 WBCs on UA. Urine output 60-80cc/hr.\n Skin intact.\n Right AC PICC patent and aspirates well.\n CT of abdomen with oral and IV contrast completed. Awaiting\n results.\n Plan:\n CBC at 1900 post PRBC infusion. Keep MAP >= 55. Turn and position q\n 2hr and PRN. Continue to assess abdomen for further distention. NGT\n to suction if needed.\n"
},
{
"category": "Physician ",
"chartdate": "2115-03-14 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 628782,
"text": "Chief Complaint:\n 24 Hour Events:\n PICC LINE - START 10:00 AM\n - Went for CT abdomen per GI recs. Prelim read shows colonic wall\n thickening with ? bleed, ? RP hematoma, ? microperforation. Plan to\n hold off on EGD unless evidence of active bleed.\n - Hypotensive overnight. On neo for pressure support -> improved UOP.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 07:55 PM\n Ciprofloxacin - 11:21 PM\n Metronidazole - 12:30 AM\n Infusions:\n Phenylephrine - 0.5 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 07:55 PM\n Fosphenytoin - 12:22 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.8\nC (100\n Tcurrent: 36.8\nC (98.3\n HR: 101 (88 - 119) bpm\n BP: 76/53(59) {66/42(48) - 100/73(78)} mmHg\n RR: 30 (13 - 32) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Bladder pressure: 12 (12 - 14) mmHg\n Total In:\n 8,127 mL\n 832 mL\n PO:\n TF:\n IVF:\n 5,767 mL\n 832 mL\n Blood products:\n 1,400 mL\n Total out:\n 915 mL\n 1,870 mL\n Urine:\n 915 mL\n 1,170 mL\n NG:\n Stool:\n Drains:\n Balance:\n 7,212 mL\n -1,038 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 94%\n ABG: ///27/\n Physical Examination\n Labs / Radiology\n 143 K/uL\n 11.3 g/dL\n 100 mg/dL\n 0.7 mg/dL\n 27 mEq/L\n 2.9 mEq/L\n 13 mg/dL\n 106 mEq/L\n 140 mEq/L\n 32.3 %\n 6.1 K/uL\n [image002.jpg]\n 10:16 AM\n 12:30 PM\n 07:32 PM\n 12:20 AM\n 03:48 AM\n 05:08 AM\n WBC\n 7.2\n 6.1\n Hct\n 24.6\n 25.5\n 30.4\n 32.3\n Plt\n 197\n 143\n Cr\n 0.7\n 0.7\n TropT\n <0.01\n Glucose\n 300\n 100\n Other labs: PT / PTT / INR:16.5/29.3/1.5, CK / CKMB /\n Troponin-T:16//<0.01, ALT / AST:, Alk Phos / T Bili:99/0.6, Lactic\n Acid:1.2 mmol/L, Ca++:6.2 mg/dL, Mg++:1.5 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n 35 y/o M with hx of cerebral palsy, seizure disorder, chronic\n pancreatitis and known gastric varices who is transferred with coffee\n ground emesis and hypotension.\n .\n # GI bleed: has blood in NGT and then coffee ground emesis worrisome\n for new upper GI bleed. Hct of not reflect active, ongoing\n bleed. Getting IVFs and 1u PRBCs now. Has known gastric varices which\n could be the cause of the bleed.\n - GI consulted and aware of patient, likely need EGD today\n - NPO, NGT in place, will check placement and then keep to LIS\n - PICC for access, try for PIVs\n - protonix 40 mg IV BID\n - complete 1u PRBC transfusion\n - q4hr Hcts, transfuse for hct <27 or active bleeding\n - check lactate\n - surgery following along\n .\n # Hypotension: baseline SBPs in the 80s, but has low BP to 68/doppler\n today. Is likely secondary to GI bleed and hypovolemia, although could\n be a sign of new early infection, PE, cardiogenic shock or adrenal\n insufficiency. These etiologies are less likely, though. He has\n remains afebrile and has no localizing infectious symptoms, although is\n difficult to interview. Has known SMV clot and has been slightly\n subtherpeutic on his coumadin, so may have other clots and is at risk\n of PE but is not hypoxic or with leg swelling. No hx of cardiac\n problems or signs of pulm edema suggesting cardiac failure. And he has\n not been on chronic steroids.\n - fluid resuccitation with IVF boluses and 1u PRBCs for now\n - levofed pressors if needed with SBP goal > 75, MAP >55\n - blood, urine cultures, c.diff\n - continue cipro and flagyl for peritonitis treatment\n - broaden abx by adding vanco for potential line infection, although\n PICC line looks uninfected on exam\n - would be missing VRE coverage and if clinically worsening, consider\n broadening by adding dapto\n - CXR to look for pneumonia\n - KUB to look for obstruction or new obstruction\n - EKG and CEs to rule out cardiac cause\n .\n # Abdominal Pain: was initial presentation and thought to be due to\n peritonitis from microperforations and translocation. Has had chronic\n abdominal pain this admission with intermittent large bowel\n obstructions and chronically dilated loops of bowel. Is passing gas\n and stooling. Did have recent rectal tube for decompression, but fell\n out two nights ago. Also has signs of chronic pancreatitis and an SMV\n as discussed below. Pain could be from multiple etiologies.\n - serial abdominal exams\n - f/u final read of KUB, appears stable per HO read\n - abd pain seems at baseline\n - repeat CT abdomen to look for possible new microperf or abscess as\n source of infection, but just had CT two days ago that was stable and\n without obvious source\n - continue pancreatic enzyme repletion\n - hold anticoagulation for thrombus as below\n - morphine PRN\n - surgery following along\n .\n # Peritonitis: although no positive cultures, was presumed to have\n peritonitis on admission and cause of initial presentation.\n - continue cipro/flagyl as above\n - course of cipro/flagyl to complete 2 week course from ___ per floor\n team; consider ID consult if infectious workup positive\n .\n # SMV Thrombus: has a chronic SMV thrombus with good collaterals. Was\n on lovenox for briding of subtherapeutic INR and on coumadin.\n Reimaging several days ago showed stable clot without progression.\n Vascular surgery was following along and plan was for 6 months of\n anticoagulation and reevaluation at that time.\n - hold lovenox and coumadin in setting of GI bleed\n - consider risks/benefits of long term anticoagulation and consider\n holding based on EGD findings and extent of bleed\n .\n # Anemia: has new baseline anemia around 30 from 35, and fe studies\n suggest iron deficiency.\n - continue fe supplementation after GI workup complete\n - transfuse for hct <25 in setting of bleed\n .\n # Nutrition: has been receiving TPN and GI had been consulted for a PEG\n tube for long term feeding, although wanted to wait for abx course to\n be completed and repeat para if fluid was present to confirm resolution\n of possible peritonitis. Did tolerated POs for a few days on the floor\n prior to his most recent large bowel obstruction.\n - NPO for now given GI bleeding\n - holding TPN for now for blood tx and boluses\n - restart TPN when stable\n - continue to follow albumin levels; remains hypoalbuminemic\n .\n # Seizure Disorder: is stable, no reports of recent seizures.\n - continue phenobarbitol and phenytoin\n .\n # Cerebral Palsy: stable, is interactive with family although\n non-verbal. Continue to monitor mental status.\n .\n # FEN: on TPN, holding for access issues today, but will consider based\n on clinical course today; NPO; replete electrolytes as needed.\n # Access: PICC, attempt at PIV\n # PPx: PPI , holding anticoagulation, pneumoboots\n # Communication: with family, mom in particular\n # Code: full, confirmed with family\n # Dispo: ICU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 10:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 628925,
"text": "Retroperitoneal bleed (RP bleed), spontaneous\n Assessment:\n Abdomen softly distended, more soft and slightly less distended than\n previous evening. Hyperactive bowel sounds, some tenderness noted on\n deep palpation. Hct stable at 32. Sbp dipping to low seventies and\n map to low 50\ns. (goal sbp >75, map >55). Urine output adequate.\n Action:\n Fluid bolused 500cc\ns normal saline with little response. Neo gtt\n re-started.\n Response:\n Sbp improved to low 80\ns, map >55.\n Plan:\n Continue to monitor hct, wean neo as tolerated.\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 628910,
"text": "Retroperitoneal bleed (RP bleed), spontaneous\n Assessment:\n Abdomen softly distended, more soft than previous evening. Hyperactive\n bowel sounds, some tenderness noted on deep palpation. Hct stable at\n 32. Sbp dipping to low seventies and map to low 50\ns. (goal sbp >75,\n map >55). Urine output adequate.\n Action:\n Fluid bolused 500cc\ns normal saline with little response. Neo gtt\n re-started.\n Response:\n Sbp improved to low 80\ns, map >55.\n Plan:\n Continue to monitor hct, wean neo as tolerated.\n"
},
{
"category": "Physician ",
"chartdate": "2115-03-15 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 628998,
"text": "Chief Complaint:\n 24 Hour Events:\n - episode of hypotension 70/40 MAP 54. Bolus 500cc with\n limited improvement so Phenylephrine restarted.\n - Per family, feeling better, improved since yesterday\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 07:55 PM\n Ciprofloxacin - 12:22 AM\n Metronidazole - 01:23 AM\n Infusions:\n Phenylephrine - 0.5 mcg/Kg/min\n Other ICU medications:\n Fosphenytoin - 04:53 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:46 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.8\nC (98.3\n HR: 100 (86 - 113) bpm\n BP: 73/52(57) {71/43(49) - 87/67(72)} mmHg\n RR: 24 (21 - 32) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 37 kg (admission): 120 kg\n Total In:\n 3,285 mL\n 733 mL\n PO:\n TF:\n IVF:\n 3,013 mL\n 730 mL\n Blood products:\n Total out:\n 3,520 mL\n 1,560 mL\n Urine:\n 2,720 mL\n 760 mL\n NG:\n 100 mL\n 300 mL\n Stool:\n Drains:\n Balance:\n -235 mL\n -827 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///25/\n Physical Examination\n General: Awake in bed, orients to voice, shakes head in response to\n some Qs, appears generally comfortable\n HEENT: JVP at clavicle, NGT draining ~bilious fluid\n CV: RRR, 2/6 systolic ejection murmur\n Lungs: Shallow resp. but seem CTA bilaterally\n Abdomen: Distended, somewhat firm but does not seem overly TTP, +NABS\n Extremities: Contracted/frail, but good skin integrity, warm/WP\n Labs / Radiology\n 155 K/uL\n 11.2 g/dL\n 106 mg/dL\n 0.9 mg/dL\n 25 mEq/L\n 3.3 mEq/L\n 13 mg/dL\n 109 mEq/L\n 140 mEq/L\n 32.6 %\n 6.1 K/uL\n [image002.jpg]\n 10:16 AM\n 12:30 PM\n 07:32 PM\n 12:20 AM\n 03:48 AM\n 05:08 AM\n 11:16 AM\n 01:15 PM\n 08:15 PM\n 01:50 AM\n WBC\n 7.2\n 6.1\n 6.1\n Hct\n 24.6\n 25.5\n 30.4\n 32.3\n 33.4\n 32.3\n 32.6\n Plt\n 197\n 143\n 155\n Cr\n 0.7\n 0.7\n 0.8\n 0.9\n TropT\n <0.01\n Glucose\n 300\n 100\n 95\n 106\n Other labs: PT / PTT / INR:13.9/24.7/1.2, CK / CKMB /\n Troponin-T:16//<0.01, ALT / AST:, Alk Phos / T Bili:99/0.6, Lactic\n Acid:1.2 mmol/L, Ca++:7.7 mg/dL, Mg++:3.0 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n 35 y/o M with hx of cerebral palsy, seizure disorder, chronic\n pancreatitis and known gastric varices who is transferred with coffee\n ground emesis and hypotension.\n .\n # Hypotension: Most likely secondary to GI bleed or RP bleed in the\n setting of anticoagulation for SMV clot. Baseline SBPs in the 80s,\n today s/p fluid resuscitation and pressure support with pressures\n closer to baseline with good UOP. Still on low-dose phenylephrine.\n - attempt to wean off pressors with goal MAP > 55, SBP > 75\n - continue with IVF, bolus to UOP >50cc/hr\n - transfuse for HCT <25\n - continue vanc, cipro and flagyl for peritonitis treatment pending\n culture data (at least 48 H negative)\n - would be missing VRE coverage and if clinically worsening, consider\n broadening by adding dapto\n .\n # GI bleed: Patient with know gastric varices with blood in NGT and\n coffee ground emesis concerning for GI bleed while on Coumadin with\n imaging concerning for GI and / or RP bleed. Patient with improving HCT\n s/p transfusion without evidence of active bleeding.\n - NPO, NGT in place draining bilious fluid to suction\n - coordinate care with GI and surgery\n - PICC for access, try for PIVs\n - protonix 40 mg IV BID\n - trend HCT and transfuse for HCT <25\n - hold anticoagulation for now\n ..\n # Peritonitis: although no positive cultures, was presumed to have\n peritonitis on admission and cause of initial presentation.\n - continue Abx as above\n - serial abdominal exams\n .\n # SMV Thrombus: has a chronic SMV thrombus with good collaterals. Was\n on lovenox for briding of subtherapeutic INR and on coumadin.\n Reimaging several days ago showed stable clot without progression.\n Vascular surgery was following along and plan was for 6 months of\n anticoagulation and reevaluation at that time.\n - hold lovenox and coumadin in setting of GI bleed\n - consider risks/benefits of long term anticoagulation and consider\n holding based on EGD findings and extent of bleed\n .\n # Anemia: has new baseline anemia around 30 from 35, and fe studies\n suggest iron deficiency.\n - continue fe supplementation after GI workup complete\n - transfuse for hct <25 in setting of bleed\n .\n # Nutrition: Had been receiving TPN and GI had been consulted for a PEG\n tube for long term feeding, although wanted to wait for abx course to\n be completed and repeat para if fluid was present to confirm resolution\n of possible peritonitis. Did tolerated POs for a few days on the floor\n prior to his most recent large bowel obstruction.\n - NPO for now given GI bleeding\n - TPN ordered, but patient not receiving as no dedicated line\n - continue to follow albumin levels; remains hypoalbuminemic\n .\n # Seizure Disorder: is stable, no reports of recent seizures.\n - continue phenobarbitol and phenytoin\n .\n # Cerebral Palsy: stable, is interactive with family although\n non-verbal. Continue to monitor mental status.\n .\n # FEN: on TPN, holding for access issues today, but will consider based\n on clinical course today; NPO; replete electrolytes as needed.\n # Access: PICC, attempt at PIV\n # PPx: PPI , holding anticoagulation, pneumoboots\n # Communication: with family, mom in particular\n # Code: full, confirmed with family\n # Dispo: ICU for now\n could likely be called out if stable BP off of\n pressors\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 10:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nutrition",
"chartdate": "2115-03-15 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 629024,
"text": "Subjective: Tube feeds have been started at 10mL/hr via PPFT.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 140 cm\n 32.3 kg\n 37 kg ( 12:00 AM)\n 16.5\n Pertinent medications: RISS, Protonix, Pancrelipase 4500, ABx, others\n noted\n Labs:\n Value\n Date\n Glucose\n 106 mg/dL\n 01:50 AM\n Glucose Finger Stick\n 130\n 10:00 AM\n BUN\n 13 mg/dL\n 01:50 AM\n Creatinine\n 0.9 mg/dL\n 01:50 AM\n Sodium\n 140 mEq/L\n 01:50 AM\n Potassium\n 3.3 mEq/L\n 01:50 AM\n Chloride\n 109 mEq/L\n 01:50 AM\n TCO2\n 25 mEq/L\n 01:50 AM\n pH (venous)\n 7.37 units\n 02:06 AM\n pH (urine)\n 6.5 units\n 10:16 AM\n Calcium non-ionized\n 7.7 mg/dL\n 01:50 AM\n Phosphorus\n 2.7 mg/dL\n 01:50 AM\n Ionized Calcium\n 1.12 mmol/L\n 02:06 AM\n Magnesium\n 3.0 mg/dL\n 01:50 AM\n ALT\n 8 IU/L\n 03:48 AM\n Alkaline Phosphate\n 99 IU/L\n 03:48 AM\n AST\n 18 IU/L\n 03:48 AM\n Total Bilirubin\n 0.6 mg/dL\n 03:48 AM\n Phenytoin (Dilantin)\n 6.8 ug/mL\n 05:08 AM\n WBC\n 6.1 K/uL\n 01:50 AM\n Hgb\n 11.2 g/dL\n 01:50 AM\n Hematocrit\n 32.6 %\n 01:50 AM\n Current diet order / nutrition support: Diet: NPO\n Tube Feeds: Impact with Fiber @ 15mL/hr\n GI: abd soft, distended, hypoactive bowel sounds, post pyloric feeding\n tube in place\n Assessment of Nutritional Status\n Patient\ns TPN had to be turned off due to lack of free central line. A\n ppft was placed and team has now started trophic tube feeds. Recommend\n changing tube feed goal to full strength Fibersource @ 40mL/hr to meet\n 100% of estimated needs. Monitor tolerance with abd exam, as\n residuals can\nt be checked with a ppft.\n Following - #\n 15:33\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-16 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 629176,
"text": "Hypotension (not Shock)\n Assessment/Action:\n Neuro status intact and unchanged from baseline\n Low grade febrile, 99-100\n Non-invasive BP cuff on thigh.\n Goal SBP > 75, Pt running ~85-95 SBP\n 4L NC weaned to RA with sat > 95%\n Lungs clear in upper airways, clear to diminished in bases\n Abdomen soft-softly distended\n Non-tender on palpation\n Advanced tube feeding q 4 hours by 5cc/hr as ordered to goal\n rate 40cc/h, TF residuals<5cc\n Flexiseal in place draining liquid green stool\n Foley catheter discontinued overnoc, using diapers (pt\n baseline when at home per mother)\n Buttocks reddened from leaking flexiseal/incontinence\n Barrier and antifungal creams applied after cleaning, pt\n turned and positioned q 2 hours and PRN\n OOB to chair via lift, pt tolerating well\n Plan:\n Continue to monitor BP, nutritional status (2/t diarrhea)\n Transfer to floor today ()\n Demographics\n Attending MD:\n F.\n Admit diagnosis:\n ABDOMINAL PAIN\n Code status:\n Height:\n 55 Inch\n Admission weight:\n 32.3 kg\n Daily weight:\n 36.5 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: Anemia\n CV-PMH:\n Additional history: cerebal palsy, seizure disorder, chronic anemia,\n GIB ', choleycystectomy, pancreatic cyst drainage.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:93\n D:57\n Temperature:\n 99.2\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 25 insp/min\n Heart Rate:\n 91 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 94% %\n O2 flow:\n 3 L/min\n FiO2 set:\n 24h total in:\n 834 mL\n 24h total out:\n 500 mL\n Pertinent Lab Results:\n Sodium:\n 141 mEq/L\n 02:30 AM\n Potassium:\n 4.2 mEq/L\n 02:30 AM\n Chloride:\n 112 mEq/L\n 02:30 AM\n CO2:\n 22 mEq/L\n 02:30 AM\n BUN:\n 12 mg/dL\n 02:30 AM\n Creatinine:\n 0.8 mg/dL\n 02:30 AM\n Glucose:\n 112 mg/dL\n 02:30 AM\n Hematocrit:\n 31.6 %\n 02:30 AM\n Finger Stick Glucose:\n 126\n 10:00 PM\n Valuables / Signature\n Patient valuables: 2 bags clothing\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: SICU A\n Transferred to: CC7\n Date & time of Transfer: \n"
},
{
"category": "Physician ",
"chartdate": "2115-03-15 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 629000,
"text": "Chief Complaint:\n 24 Hour Events:\n - episode of hypotension 70/40 MAP 54. Bolus 500cc with\n limited improvement so Phenylephrine restarted.\n - Per family, feeling better, improved since yesterday\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 07:55 PM\n Ciprofloxacin - 12:22 AM\n Metronidazole - 01:23 AM\n Infusions:\n Phenylephrine - 0.5 mcg/Kg/min\n Other ICU medications:\n Fosphenytoin - 04:53 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:46 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.8\nC (98.3\n HR: 100 (86 - 113) bpm\n BP: 73/52(57) {71/43(49) - 87/67(72)} mmHg\n RR: 24 (21 - 32) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 37 kg (admission): 120 kg\n Total In:\n 3,285 mL\n 733 mL\n PO:\n TF:\n IVF:\n 3,013 mL\n 730 mL\n Blood products:\n Total out:\n 3,520 mL\n 1,560 mL\n Urine:\n 2,720 mL\n 760 mL\n NG:\n 100 mL\n 300 mL\n Stool:\n Drains:\n Balance:\n -235 mL\n -827 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///25/\n Physical Examination\n General: Awake in bed, orients to voice, shakes head in response to\n some Qs, appears generally comfortable\n HEENT: JVP at clavicle, NGT draining ~bilious fluid\n CV: RRR, 2/6 systolic ejection murmur\n Lungs: Shallow resp. but seem CTA bilaterally\n Abdomen: Distended, somewhat firm but does not seem overly TTP, +NABS\n Extremities: Contracted/frail, but good skin integrity, warm/WP\n Labs / Radiology\n 155 K/uL\n 11.2 g/dL\n 106 mg/dL\n 0.9 mg/dL\n 25 mEq/L\n 3.3 mEq/L\n 13 mg/dL\n 109 mEq/L\n 140 mEq/L\n 32.6 %\n 6.1 K/uL\n [image002.jpg]\n 10:16 AM\n 12:30 PM\n 07:32 PM\n 12:20 AM\n 03:48 AM\n 05:08 AM\n 11:16 AM\n 01:15 PM\n 08:15 PM\n 01:50 AM\n WBC\n 7.2\n 6.1\n 6.1\n Hct\n 24.6\n 25.5\n 30.4\n 32.3\n 33.4\n 32.3\n 32.6\n Plt\n 197\n 143\n 155\n Cr\n 0.7\n 0.7\n 0.8\n 0.9\n TropT\n <0.01\n Glucose\n 300\n 100\n 95\n 106\n Other labs: PT / PTT / INR:13.9/24.7/1.2, CK / CKMB /\n Troponin-T:16//<0.01, ALT / AST:, Alk Phos / T Bili:99/0.6, Lactic\n Acid:1.2 mmol/L, Ca++:7.7 mg/dL, Mg++:3.0 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n 35 y/o M with hx of cerebral palsy, seizure disorder, chronic\n pancreatitis and known gastric varices who is transferred with coffee\n ground emesis and hypotension.\n .\n # Hypotension: Most likely secondary to GI bleed or RP bleed in the\n setting of anticoagulation for SMV clot. Baseline SBPs in the 80s,\n today s/p fluid resuscitation and pressure support with pressures\n closer to baseline with good UOP. Still on low-dose phenylephrine.\n - try placing bp cuff on thighs for more accurate read\n - attempt to wean off pressors with goal MAP > 55, SBP > 75\n - continue with IVF, bolus to UOP >50cc/hr\n - transfuse for HCT <25\n - continue vanc, cipro and flagyl for peritonitis treatment pending\n culture data (however had been on cipro , then restarted );\n stop cipro/flagyl when negative cultures X48 hrs, maintain vanco until\n PICC line replaced\n - would be missing VRE coverage and if clinically worsening, consider\n broadening by adding dapto\n .\n # GI bleed: Patient with know gastric varices with blood in NGT and\n coffee ground emesis concerning for GI bleed while on Coumadin with\n imaging concerning for GI and / or RP bleed. Patient with improving HCT\n s/p transfusion without evidence of active bleeding.\n - NPO, NGT in place draining bilious fluid to suction\n - coordinate care with GI and surgery\n - PICC for access (no access for PIVs)\n - protonix 40 mg IV BID\n - trend HCT and transfuse for HCT <25\n - hold anticoagulation for now\n ..\n # Peritonitis: although no positive cultures, was presumed to have\n peritonitis on admission and cause of initial presentation.\n - continue Abx as above\n - serial abdominal exams, currently improving\n .\n # SMV Thrombus: has a chronic SMV thrombus with good collaterals. Was\n on lovenox for briding of subtherapeutic INR and on coumadin.\n Reimaging several days ago showed stable clot without progression.\n Vascular surgery was following along and plan was for 6 months of\n anticoagulation and reevaluation at that time.\n - hold lovenox and coumadin in setting of GI bleed\n - consider risks/benefits of long term anticoagulation and consider\n holding based on EGD findings and extent of bleed\n .\n # Anemia: has new baseline anemia around 30 from 35, and fe studies\n suggest iron deficiency. Also with RP bleed (see above)\n - continue fe supplementation after GI workup complete\n - transfuse for hct <25 in setting of bleed\n .\n # Nutrition: Had been receiving TPN and GI had been consulted for a PEG\n tube for long term feeding, although wanted to wait for abx course to\n be completed and repeat para if fluid was present to confirm resolution\n of possible peritonitis. Did tolerate POs for a few days on the floor\n prior to his most recent large bowel obstruction.\n - start tube feeds with pancreatic enzyme replacement (tube currently\n in duodenum)\n - TPN ordered, but patient not receiving as no dedicated line\n - continue to follow albumin levels; remains hypoalbuminemic\n .\n # Seizure Disorder: is stable, no reports of recent seizures.\n - continue phenobarbitol and phenytoin\n .\n # Yeast in urine\n - Change foley\n .\n # Cerebral Palsy: stable, is interactive with family although\n non-verbal. Continue to monitor mental status.\n .\n # FEN: on TPN, holding for access issues, starting TFs; replete\n electrolytes as needed.\n # Access: PICC, attempt at PIV\n # PPx: PPI , holding anticoagulation, pneumoboots\n # Communication: with family, mom in particular\n # Code: full, confirmed with family\n # Dispo: ICU for now\n could likely be called out if stable BP off of\n pressors\n"
},
{
"category": "Physician ",
"chartdate": "2115-03-15 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 629001,
"text": "Chief Complaint:\n 24 Hour Events:\n - episode of hypotension 70/40 MAP 54. Bolus 500cc with\n limited improvement so Phenylephrine restarted.\n - Per family, feeling better, improved since yesterday\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 07:55 PM\n Ciprofloxacin - 12:22 AM\n Metronidazole - 01:23 AM\n Infusions:\n Phenylephrine - 0.5 mcg/Kg/min\n Other ICU medications:\n Fosphenytoin - 04:53 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:46 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.8\nC (98.3\n HR: 100 (86 - 113) bpm\n BP: 73/52(57) {71/43(49) - 87/67(72)} mmHg\n RR: 24 (21 - 32) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 37 kg (admission): 120 kg\n Total In:\n 3,285 mL\n 733 mL\n PO:\n TF:\n IVF:\n 3,013 mL\n 730 mL\n Blood products:\n Total out:\n 3,520 mL\n 1,560 mL\n Urine:\n 2,720 mL\n 760 mL\n NG:\n 100 mL\n 300 mL\n Stool:\n Drains:\n Balance:\n -235 mL\n -827 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///25/\n Physical Examination\n General: Awake in bed, orients to voice, shakes head in response to\n some Qs, appears generally comfortable\n HEENT: JVP at clavicle, NGT draining ~bilious fluid\n CV: RRR, 2/6 systolic ejection murmur\n Lungs: Shallow resp. but seem CTA bilaterally\n Abdomen: Distended, somewhat firm but does not seem overly TTP, +NABS\n Extremities: Contracted/frail, but good skin integrity, warm/WP\n Labs / Radiology\n 155 K/uL\n 11.2 g/dL\n 106 mg/dL\n 0.9 mg/dL\n 25 mEq/L\n 3.3 mEq/L\n 13 mg/dL\n 109 mEq/L\n 140 mEq/L\n 32.6 %\n 6.1 K/uL\n [image002.jpg]\n 10:16 AM\n 12:30 PM\n 07:32 PM\n 12:20 AM\n 03:48 AM\n 05:08 AM\n 11:16 AM\n 01:15 PM\n 08:15 PM\n 01:50 AM\n WBC\n 7.2\n 6.1\n 6.1\n Hct\n 24.6\n 25.5\n 30.4\n 32.3\n 33.4\n 32.3\n 32.6\n Plt\n 197\n 143\n 155\n Cr\n 0.7\n 0.7\n 0.8\n 0.9\n TropT\n <0.01\n Glucose\n 300\n 100\n 95\n 106\n Other labs: PT / PTT / INR:13.9/24.7/1.2, CK / CKMB /\n Troponin-T:16//<0.01, ALT / AST:, Alk Phos / T Bili:99/0.6, Lactic\n Acid:1.2 mmol/L, Ca++:7.7 mg/dL, Mg++:3.0 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n 35 y/o M with hx of cerebral palsy, seizure disorder, chronic\n pancreatitis and known gastric varices who is transferred with coffee\n ground emesis and hypotension.\n .\n # Hypotension: Most likely secondary to GI bleed or RP bleed in the\n setting of anticoagulation for SMV clot. Baseline SBPs in the 80s,\n today s/p fluid resuscitation and pressure support with pressures\n closer to baseline with good UOP. Still on low-dose phenylephrine.\n - try placing bp cuff on thighs for more accurate read\n - attempt to wean off pressors with goal MAP > 55, SBP > 75\n - continue with IVF, bolus to UOP >50cc/hr\n - transfuse for HCT <25\n - continue vanc, cipro and flagyl for peritonitis treatment pending\n culture data (however had been on cipro , then restarted );\n stop cipro/flagyl when negative cultures X48 hrs, maintain vanco until\n PICC line replaced\n - would be missing VRE coverage and if clinically worsening, consider\n broadening by adding dapto\n .\n # GI bleed: Patient with know gastric varices with blood in NGT and\n coffee ground emesis concerning for GI bleed while on Coumadin with\n imaging concerning for GI and / or RP bleed. Patient with improving HCT\n s/p transfusion without evidence of active bleeding.\n - NPO, NGT in place draining bilious fluid to suction\n - coordinate care with GI and surgery\n - PICC for access (no access for PIVs)\n - protonix 40 mg IV BID\n - trend HCT and transfuse for HCT <25\n - hold anticoagulation for now\n ..\n # Peritonitis: although no positive cultures, was presumed to have\n peritonitis on admission and cause of initial presentation.\n - continue Abx as above\n - serial abdominal exams, currently improving\n .\n # SMV Thrombus: has a chronic SMV thrombus with good collaterals. Was\n on lovenox for briding of subtherapeutic INR and on coumadin.\n Reimaging several days ago showed stable clot without progression.\n Vascular surgery was following along and plan was for 6 months of\n anticoagulation and reevaluation at that time.\n - hold lovenox and coumadin in setting of GI bleed\n - consider risks/benefits of long term anticoagulation and consider\n holding based on EGD findings and extent of bleed\n .\n # Anemia: has new baseline anemia around 30 from 35, and fe studies\n suggest iron deficiency. Also with RP bleed (see above)\n - continue fe supplementation after GI workup complete\n - transfuse for hct <25 in setting of bleed\n .\n # Nutrition: Had been receiving TPN and GI had been consulted for a PEG\n tube for long term feeding, although wanted to wait for abx course to\n be completed and repeat para if fluid was present to confirm resolution\n of possible peritonitis. Did tolerate POs for a few days on the floor\n prior to his most recent large bowel obstruction.\n - start tube feeds with pancreatic enzyme replacement (tube currently\n in duodenum)\n - TPN ordered, but patient not receiving as no dedicated line\n - continue to follow albumin levels; remains hypoalbuminemic\n .\n # Seizure Disorder: is stable, no reports of recent seizures.\n - continue phenobarbitol and phenytoin\n .\n # Yeast in urine\n - Change foley\n .\n # Cerebral Palsy: stable, is interactive with family although\n non-verbal. Continue to monitor mental status.\n .\n # FEN: on TPN, holding for access issues, starting TFs; replete\n electrolytes as needed.\n # Access: PICC, attempt at PIV\n # PPx: PPI , holding anticoagulation, pneumoboots\n # Communication: with family, mom in particular\n # Code: full, confirmed with family\n # Dispo: ICU for now\n could likely be called out if stable BP off of\n pressors\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 629081,
"text": "Hypotension (not Shock)\n Assessment:\n Neuro status intact and unchanged from baseline. Tmax ~99.\n Left PICC site painful on palpation/movement of arm. Treated with\n Tylenol 650mg x 1.\n Non-invasive BP cuff on thigh. SBP > 75 throughout entire\n shift off pressors. Current BP in 90s (MAP ~60). Pulses palpable. No\n edema.\n 4L NC with sat > 95%. Lungs clear in upper airways.\n Diminished in bases. No cough present.\n Abdomen softly distended. Non-tender on palpation.\n Advanced tube feeding q 4 hours by 5cc/hr as ordered. Tolerating\n well. No residuals. Flexiseal in place draining liquid green stool.\n Foley catheter dc\n MD due to high yeast count. No\n incontinence system in place. Incontinent in bedding (small amount) at\n this time.\n Skin intact. Buttocks reddened from leaking flexiseal.\n Barrier and antifungal creams applied after cleaning. Turn and\n position q 2 hours and PRN.\n Mother at bedside. Emotional support provided. Enjoys\n assisting nurse with care of patient.\n Plan:\n Continue to monitor BP, F&E status (secondary to diarrhea). Transfer\n to floor today ().\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-16 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 629169,
"text": "Hypotension (not Shock)\n Assessment/Action:\n Neuro status intact and unchanged from baseline\n Low grade febrile, 99-100\n Non-invasive BP cuff on thigh. SBP > 75 throughout entire\n shift off pressors >24hrs\n Current BP in 90s (MAP ~60)\n 4L NC weaned to RA with sat > 95%\n Lungs clear in upper airways, clear to diminished in bases\n Abdomen soft-softly distended\n Non-tender on palpation\n Advanced tube feeding q 4 hours by 5cc/hr as ordered to goal\n rate 40cc/h, TF residuals<5cc\n Flexiseal in place draining liquid green stool\n Foley catheter discontinued overnoc, using diapers (pt\n baseline when at home per mother)\n Buttocks reddened from leaking flexiseal/incontinence\n Barrier and antifungal creams applied after cleaning, pt\n turned and positioned q 2 hours and PRN\n OOB to chair via lift, pt tolerating well\n Plan:\n Continue to monitor BP, nutritional status (2/t diarrhea)\n Transfer to floor today ()\n"
},
{
"category": "Physician ",
"chartdate": "2115-03-16 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 629157,
"text": "Chief Complaint: PICC exchanged. Patient remains hypotensive but\n asymptomatic, leg blood pressures measured, and slightly higher with\n SBP low 80s. Foley changed out given yeast in URINE. Patient called\n out to floor.\n 24 Hour Events:\n PICC LINE - STOP 05:25 PM\n PICC LINE - START 05:40 PM\n left antecub.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 12:22 AM\n Metronidazole - 07:58 AM\n Vancomycin - 09:08 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n None\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Mild abdominal discomfort\n Flowsheet Data as of 06:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 37.3\nC (99.2\n HR: 100 (88 - 111) bpm\n BP: 87/52(60) {79/42(53) - 95/70(73)} mmHg\n RR: 18 (16 - 30) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 36.5 kg (admission): 32.3 kg\n Height: 55 Inch\n Total In:\n 1,547 mL\n 253 mL\n PO:\n TF:\n 104 mL\n 120 mL\n IVF:\n 1,440 mL\n 133 mL\n Blood products:\n Total out:\n 3,190 mL\n 500 mL\n Urine:\n 1,590 mL\n NG:\n 600 mL\n Stool:\n 500 mL\n 500 mL\n Drains:\n Balance:\n -1,643 mL\n -247 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///22/\n Physical Examination\n General: Awake in bed, orients to voice, shakes head in response to\n some Qs, appears generally comfortable\n HEENT: JVP at clavicle, NGT draining ~bilious fluid\n CV: RRR, 2/6 systolic ejection murmur\n Lungs: Shallow resp. but seem CTA bilaterally\n Abdomen: Distended, somewhat firm but does not seem overly TTP, +NABS\n Extremities: Contracted/frail, but good skin integrity, warm/WP\n Labs / Radiology\n 132 K/uL\n 11.0 g/dL\n 112 mg/dL\n 0.8 mg/dL\n 22 mEq/L\n 4.2 mEq/L\n 12 mg/dL\n 112 mEq/L\n 141 mEq/L\n 31.6 %\n 5.9 K/uL\n [image002.jpg]\n 12:30 PM\n 07:32 PM\n 12:20 AM\n 03:48 AM\n 05:08 AM\n 11:16 AM\n 01:15 PM\n 08:15 PM\n 01:50 AM\n 02:30 AM\n WBC\n 7.2\n 6.1\n 6.1\n 5.9\n Hct\n 24.6\n 25.5\n 30.4\n 32.3\n 33.4\n 32.3\n 32.6\n 31.6\n Plt\n 197\n 143\n 155\n 132\n Cr\n 0.7\n 0.7\n 0.8\n 0.9\n 0.8\n Glucose\n 300\n 100\n 95\n 106\n 112\n Other labs: PT / PTT / INR:13.9/24.7/1.2, CK / CKMB /\n Troponin-T:16//<0.01, ALT / AST:, Alk Phos / T Bili:99/0.6,\n Differential-Neuts:75.4 %, Lymph:15.7 %, Mono:7.6 %, Eos:1.2 %, Lactic\n Acid:1.2 mmol/L, Ca++:7.7 mg/dL, Mg++:2.7 mg/dL, PO4:3.0 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n RETROPERITONEAL BLEED (RP BLEED), SPONTANEOUS\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n 35 y/o M with hx of cerebral palsy, seizure disorder, chronic\n pancreatitis and known gastric varices who is transferred with coffee\n ground emesis and hypotension.\n .\n # Hypotension: Most likely secondary to GI bleed or RP bleed in the\n setting of anticoagulation for SMV clot. Although patient had reported\n coffee ground emesis on the floor, most likely source of hypotension\n may have been RP bleed given CT findings. Now off pressors since\n yesterday afternoon, and leg pressures have been stable with SBPs in\n the 70s and 80s.\n - Continue bp cuff on thighs for more accurate read\n - goal MAP > 55, SBP > 75\n - continue with IVF, bolus to UOP >30cc/hr\n - transfuse for HCT <25\n - Cipro flagyl D/cd yesterday given that cx data was negative x 48\n hours. Given history of instrumentation, will continue Vanco until\n cultures finalize\n - would be missing VRE coverage and if clinically worsening, consider\n broadening by adding dapto\n .\n # GI bleed: Patient with know gastric varices with blood in NGT and\n coffee ground emesis concerning for GI bleed while on Coumadin with\n imaging concerning for GI and / or RP bleed. Patient with improving HCT\n s/p transfusion without evidence of active bleeding. Now Hct and HD\n stable with Tfts running.\n - NPO, NGT in place draining bilious fluid to suction\n - Continue protonix 40 mg IV BID\n - trend HCT and transfuse for HCT <25\n - hold anticoagulation for now, but may consider lovenox again in the\n next 24-48 hours\n ..\n # Peritonitis: although no positive cultures, was presumed to have\n peritonitis on admission and cause of initial presentation.\n - continue Abx as above\n - serial abdominal exams, currently improving\n .\n # SMV Thrombus: has a chronic SMV thrombus with good collaterals. Was\n on lovenox for bridging of subtherapeutic INR and on coumadin.\n Reimaging several days ago showed stable clot without progression.\n Vascular surgery was following along and plan was for 6 months of\n anticoagulation and reevaluation at that time.\n - hold lovenox and coumadin in setting of GI bleed\n - consider risks/benefits of long term anticoagulation and consider\n holding based on EGD findings and extent of bleed\n .\n # Anemia: has new baseline anemia around 30 from 35, and fe studies\n suggest iron deficiency. Also with RP bleed (see above)\n - continue fe supplementation after GI workup complete\n - transfuse for hct <25 in setting of bleed\n .\n # Nutrition: Had been receiving TPN and GI had been consulted for a PEG\n tube for long term feeding, although wanted to wait for abx course to\n be completed and repeat para if fluid was present to confirm resolution\n of possible peritonitis. Did tolerate POs for a few days on the floor\n prior to his most recent large bowel obstruction.\n - start tube feeds with pancreatic enzyme replacement (tube currently\n in duodenum)\n - Hold TPN for now as patient appears to be tolerating TFs well\n - continue to follow albumin levels; remains hypoalbuminemic\n .\n # Seizure Disorder: is stable, no reports of recent seizures.\n - continue phenobarbitol and phenytoin\n .\n # Yeast in urine\n - Change foley\n .\n # Cerebral Palsy: stable, is interactive with family although\n non-verbal. Continue to monitor mental status.\n .\n # FEN: on TPN, holding for access issues, starting TFs; replete\n electrolytes as needed.\n # Access: PICC, attempt at PIV\n # PPx: PPI , holding anticoagulation, pneumoboots\n # Communication: with family, mom in particular\n # Code: full, confirmed with family\n # Dispo: CALLED OUT\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 05:40 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2115-03-16 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 629158,
"text": "Chief Complaint: PICC exchanged. Patient remains hypotensive but\n asymptomatic, leg blood pressures measured, and slightly higher with\n SBP low 80s. Foley changed out given yeast in URINE. Patient called\n out to floor.\n 24 Hour Events:\n PICC LINE - STOP 05:25 PM\n PICC LINE - START 05:40 PM\n left antecub.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 12:22 AM\n Metronidazole - 07:58 AM\n Vancomycin - 09:08 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n None\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Mild abdominal discomfort\n Flowsheet Data as of 06:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 37.3\nC (99.2\n HR: 100 (88 - 111) bpm\n BP: 87/52(60) {79/42(53) - 95/70(73)} mmHg\n RR: 18 (16 - 30) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 36.5 kg (admission): 32.3 kg\n Height: 55 Inch\n Total In:\n 1,547 mL\n 253 mL\n PO:\n TF:\n 104 mL\n 120 mL\n IVF:\n 1,440 mL\n 133 mL\n Blood products:\n Total out:\n 3,190 mL\n 500 mL\n Urine:\n 1,590 mL\n NG:\n 600 mL\n Stool:\n 500 mL\n 500 mL\n Drains:\n Balance:\n -1,643 mL\n -247 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///22/\n Physical Examination\n General: Awake in bed, orients to voice, shakes head in response to\n some Qs, appears generally comfortable\n HEENT: JVP at clavicle, NGT draining ~bilious fluid\n CV: RRR, 2/6 systolic ejection murmur\n Lungs: Shallow resp. but seem CTA bilaterally\n Abdomen: Distended, somewhat firm but does not seem overly TTP, +NABS\n Extremities: Contracted/frail, but good skin integrity, warm/WP\n Labs / Radiology\n 132 K/uL\n 11.0 g/dL\n 112 mg/dL\n 0.8 mg/dL\n 22 mEq/L\n 4.2 mEq/L\n 12 mg/dL\n 112 mEq/L\n 141 mEq/L\n 31.6 %\n 5.9 K/uL\n [image002.jpg]\n 12:30 PM\n 07:32 PM\n 12:20 AM\n 03:48 AM\n 05:08 AM\n 11:16 AM\n 01:15 PM\n 08:15 PM\n 01:50 AM\n 02:30 AM\n WBC\n 7.2\n 6.1\n 6.1\n 5.9\n Hct\n 24.6\n 25.5\n 30.4\n 32.3\n 33.4\n 32.3\n 32.6\n 31.6\n Plt\n 197\n 143\n 155\n 132\n Cr\n 0.7\n 0.7\n 0.8\n 0.9\n 0.8\n Glucose\n 300\n 100\n 95\n 106\n 112\n Other labs: PT / PTT / INR:13.9/24.7/1.2, CK / CKMB /\n Troponin-T:16//<0.01, ALT / AST:, Alk Phos / T Bili:99/0.6,\n Differential-Neuts:75.4 %, Lymph:15.7 %, Mono:7.6 %, Eos:1.2 %, Lactic\n Acid:1.2 mmol/L, Ca++:7.7 mg/dL, Mg++:2.7 mg/dL, PO4:3.0 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n RETROPERITONEAL BLEED (RP BLEED), SPONTANEOUS\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n 35 y/o M with hx of cerebral palsy, seizure disorder, chronic\n pancreatitis and known gastric varices who is transferred with coffee\n ground emesis and hypotension.\n .\n # Hypotension: Most likely secondary to RP bleed in the setting of\n anticoagulation for SMV clot. Off pressors since am , no\n transfusions since .\n - Continue bp cuff on thighs for more accurate read\n - goal MAP > 55, SBP > 75\n - continue with IVF, bolus to UOP >30cc/hr\n - transfuse for HCT <25\n - Cipro flagyl D/cd yesterday given that cx data was negative x 48\n hours. Given history of instrumentation, will continue Vanco until\n cultures finalize\n - would be missing VRE coverage and if clinically worsening, consider\n broadening by adding dapto\n .\n # GI bleed: Patient with know gastric varices with blood in NGT and\n coffee ground emesis concerning for GI bleed while on Coumadin with\n imaging concerning for GI and / or RP bleed. Patient with improving HCT\n s/p transfusion without evidence of active bleeding. Now Hct and HD\n stable with Tfts running.\n - NPO, NGT in place draining bilious fluid to suction\n - Change IV protonix to lansoprazole per NGT\n - trend HCT and transfuse for HCT <25\n - hold anticoagulation for now\n - Revisit anticoagulation issue at a later time (perhaps d/w liver)\n .\n # SMV Thrombus: has a chronic SMV thrombus with good collaterals. Was\n on lovenox for bridging of subtherapeutic INR and on coumadin.\n Reimaging several days ago showed stable clot without progression.\n Vascular surgery was following along and plan was for 6 months of\n anticoagulation and reevaluation at that time.\n - hold lovenox and coumadin in setting of GI bleed\n - consider risks/benefits of long term anticoagulation and consider\n holding based on EGD findings and extent of bleed\n .\n # Anemia: has new baseline anemia around 30 from 35, and fe studies\n suggest iron deficiency. Also with RP bleed (see above)\n - continue fe supplementation after GI workup complete\n - transfuse for hct <25 in setting of bleed\n .\n # Nutrition: Had been receiving TPN and GI had been consulted for a PEG\n tube for long term feeding, although wanted to wait for abx course to\n be completed and repeat para if fluid was present to confirm resolution\n of possible peritonitis. Did tolerate POs for a few days on the floor\n prior to his most recent large bowel obstruction.\n - start tube feeds with pancreatic enzyme replacement (tube currently\n in duodenum)\n - Hold TPN for now as patient appears to be tolerating TFs well\n - continue to follow albumin levels; remains hypoalbuminemic\n .\n # Seizure Disorder: is stable, no reports of recent seizures.\n - continue phenobarbitol and phenytoin\n .\n # Yeast in urine\n - Change foley\n .\n # Cerebral Palsy: stable, is interactive with family although\n non-verbal. Continue to monitor mental status.\n .\n # FEN: on TPN, holding for access issues, starting TFs; replete\n electrolytes as needed.\n # Access: PICC, attempt at PIV\n # PPx: PPI , holding anticoagulation, pneumoboots\n # Communication: with family, mom in particular\n # Code: full, confirmed with family\n # Dispo: CALLED OUT\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 05:40 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2115-03-16 00:00:00.000",
"description": "Physician Resident/Attending Progress Note - MICU",
"row_id": 629163,
"text": "Chief Complaint: PICC exchanged. Patient remains hypotensive but\n asymptomatic, leg blood pressures measured, and slightly higher with\n SBP low 80s. Foley changed out given yeast in URINE. Patient called\n out to floor.\n 24 Hour Events:\n PICC LINE - STOP 05:25 PM\n PICC LINE - START 05:40 PM\n left antecub.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 12:22 AM\n Metronidazole - 07:58 AM\n Vancomycin - 09:08 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n None\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Mild abdominal discomfort\n Flowsheet Data as of 06:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 37.3\nC (99.2\n HR: 100 (88 - 111) bpm\n BP: 87/52(60) {79/42(53) - 95/70(73)} mmHg\n RR: 18 (16 - 30) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 36.5 kg (admission): 32.3 kg\n Height: 55 Inch\n Total In:\n 1,547 mL\n 253 mL\n PO:\n TF:\n 104 mL\n 120 mL\n IVF:\n 1,440 mL\n 133 mL\n Blood products:\n Total out:\n 3,190 mL\n 500 mL\n Urine:\n 1,590 mL\n NG:\n 600 mL\n Stool:\n 500 mL\n 500 mL\n Drains:\n Balance:\n -1,643 mL\n -247 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///22/\n Physical Examination\n General: Awake in bed, orients to voice, shakes head in response to\n some Qs, appears generally comfortable\n HEENT: JVP at clavicle, NGT draining ~bilious fluid\n CV: RRR, 2/6 systolic ejection murmur\n Lungs: Shallow resp. but seem CTA bilaterally\n Abdomen: Distended, somewhat firm but does not seem overly TTP, +NABS\n Extremities: Contracted/frail, but good skin integrity, warm/WP\n Labs / Radiology\n 132 K/uL\n 11.0 g/dL\n 112 mg/dL\n 0.8 mg/dL\n 22 mEq/L\n 4.2 mEq/L\n 12 mg/dL\n 112 mEq/L\n 141 mEq/L\n 31.6 %\n 5.9 K/uL\n [image002.jpg]\n 12:30 PM\n 07:32 PM\n 12:20 AM\n 03:48 AM\n 05:08 AM\n 11:16 AM\n 01:15 PM\n 08:15 PM\n 01:50 AM\n 02:30 AM\n WBC\n 7.2\n 6.1\n 6.1\n 5.9\n Hct\n 24.6\n 25.5\n 30.4\n 32.3\n 33.4\n 32.3\n 32.6\n 31.6\n Plt\n 197\n 143\n 155\n 132\n Cr\n 0.7\n 0.7\n 0.8\n 0.9\n 0.8\n Glucose\n 300\n 100\n 95\n 106\n 112\n Other labs: PT / PTT / INR:13.9/24.7/1.2, CK / CKMB /\n Troponin-T:16//<0.01, ALT / AST:, Alk Phos / T Bili:99/0.6,\n Differential-Neuts:75.4 %, Lymph:15.7 %, Mono:7.6 %, Eos:1.2 %, Lactic\n Acid:1.2 mmol/L, Ca++:7.7 mg/dL, Mg++:2.7 mg/dL, PO4:3.0 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n RETROPERITONEAL BLEED (RP BLEED), SPONTANEOUS\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n 35 y/o M with hx of cerebral palsy, seizure disorder, chronic\n pancreatitis and known gastric varices who is transferred with coffee\n ground emesis and hypotension.\n .\n # Hypotension: Most likely secondary to RP bleed in the setting of\n anticoagulation for SMV clot. Off pressors since am , no\n transfusions since .\n - Continue bp cuff on thighs for more accurate read\n - goal MAP > 55, SBP > 75\n - continue with IVF, bolus to UOP >30cc/hr\n - transfuse for HCT <25\n - Cipro flagyl D/cd yesterday given that cx data was negative x 48\n hours. Given history of instrumentation, will continue Vanco until\n cultures finalize\n - would be missing VRE coverage and if clinically worsening, consider\n broadening by adding dapto\n .\n # GI bleed: Patient with know gastric varices with blood in NGT and\n coffee ground emesis concerning for GI bleed while on Coumadin with\n imaging concerning for GI and / or RP bleed. Patient with improving HCT\n s/p transfusion without evidence of active bleeding. Now Hct and HD\n stable with Tfts running.\n - NPO, NGT in place draining bilious fluid to suction\n - Change IV protonix to lansoprazole per NGT\n - trend HCT and transfuse for HCT <25\n - hold anticoagulation for now\n - Revisit anticoagulation issue at a later time (perhaps d/w liver)\n .\n # SMV Thrombus: has a chronic SMV thrombus with good collaterals. Was\n on lovenox for bridging of subtherapeutic INR and on coumadin.\n Reimaging several days ago showed stable clot without progression.\n Vascular surgery was following along and plan was for 6 months of\n anticoagulation and reevaluation at that time.\n - hold lovenox and coumadin in setting of GI bleed\n - consider risks/benefits of long term anticoagulation and consider\n holding based on EGD findings and extent of bleed\n .\n # Anemia: has new baseline anemia around 30 from 35, and fe studies\n suggest iron deficiency. Also with RP bleed (see above)\n - continue fe supplementation after GI workup complete\n - transfuse for hct <25 in setting of bleed\n .\n # Nutrition: Had been receiving TPN and GI had been consulted for a PEG\n tube for long term feeding, although wanted to wait for abx course to\n be completed and repeat para if fluid was present to confirm resolution\n of possible peritonitis. Did tolerate POs for a few days on the floor\n prior to his most recent large bowel obstruction.\n - start tube feeds with pancreatic enzyme replacement (tube currently\n in duodenum)\n - Hold TPN for now as patient appears to be tolerating TFs well\n - continue to follow albumin levels; remains hypoalbuminemic\n .\n # Seizure Disorder: is stable, no reports of recent seizures.\n - continue phenobarbitol and phenytoin\n .\n # Yeast in urine\n - Change foley\n .\n # Cerebral Palsy: stable, is interactive with family although\n non-verbal. Continue to monitor mental status.\n .\n # FEN: on TPN, holding for access issues, starting TFs; replete\n electrolytes as needed.\n # Access: PICC, attempt at PIV\n # PPx: PPI , holding anticoagulation, pneumoboots\n # Communication: with family, mom in particular\n # Code: full, confirmed with family\n # Dispo: CALLED OUT\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 05:40 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points:\n events\n PICC line changed over wire yesterday due to concern for infection. Tip\n pending.\n BP more acceptable after changing to LE cuff.\n Foley removed.\n Tm 99.4 87/44 107 94% on RA.\n I/O.5/3.1 over 24h.\n Acc to pt's mother pt is at his baseline mental status. Med histories\n unchanged, ROS unobtainable.\n Appears comfortable, anxious with exam. Lungs CTA with shallow breaths.\n Abd soft, NDNT. No edema. No rashes. Contracted.\n PICC tip pending. CDiff neg , .\n Blood Cx .\n Readmitted to ICU for hypotension, GI bleed, received 4 PRBC tx on\n , attributed to RP bleed in setting of lovenox and coumadin for SMV\n thrombus as well as gastric varices. Remains off anticoagulation. No\n further bleeding and hct stable.\n Safe for transfer to med floor. Important to be aware of chronic\n hypotension and set parameters accordingly.\n ------ Protected Section Addendum Entered By: , MD\n on: 13:45 ------\n"
},
{
"category": "Physician ",
"chartdate": "2115-03-15 00:00:00.000",
"description": "Physician Resident/Attending Progress Note - MICU",
"row_id": 629066,
"text": "Chief Complaint:\n 24 Hour Events:\n - episode of hypotension 70/40 MAP 54. Bolus 500cc with\n limited improvement so Phenylephrine restarted.\n - Per family, feeling better, improved since yesterday\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 07:55 PM\n Ciprofloxacin - 12:22 AM\n Metronidazole - 01:23 AM\n Infusions:\n Phenylephrine - 0.5 mcg/Kg/min\n Other ICU medications:\n Fosphenytoin - 04:53 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:46 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.8\nC (98.3\n HR: 100 (86 - 113) bpm\n BP: 73/52(57) {71/43(49) - 87/67(72)} mmHg\n RR: 24 (21 - 32) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 37 kg (admission): 120 kg\n Total In:\n 3,285 mL\n 733 mL\n PO:\n TF:\n IVF:\n 3,013 mL\n 730 mL\n Blood products:\n Total out:\n 3,520 mL\n 1,560 mL\n Urine:\n 2,720 mL\n 760 mL\n NG:\n 100 mL\n 300 mL\n Stool:\n Drains:\n Balance:\n -235 mL\n -827 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///25/\n Physical Examination\n General: Awake in bed, orients to voice, shakes head in response to\n some Qs, appears generally comfortable\n HEENT: JVP at clavicle, NGT draining ~bilious fluid\n CV: RRR, 2/6 systolic ejection murmur\n Lungs: Shallow resp. but seem CTA bilaterally\n Abdomen: Distended, somewhat firm but does not seem overly TTP, +NABS\n Extremities: Contracted/frail, but good skin integrity, warm/WP\n Labs / Radiology\n 155 K/uL\n 11.2 g/dL\n 106 mg/dL\n 0.9 mg/dL\n 25 mEq/L\n 3.3 mEq/L\n 13 mg/dL\n 109 mEq/L\n 140 mEq/L\n 32.6 %\n 6.1 K/uL\n [image002.jpg]\n 10:16 AM\n 12:30 PM\n 07:32 PM\n 12:20 AM\n 03:48 AM\n 05:08 AM\n 11:16 AM\n 01:15 PM\n 08:15 PM\n 01:50 AM\n WBC\n 7.2\n 6.1\n 6.1\n Hct\n 24.6\n 25.5\n 30.4\n 32.3\n 33.4\n 32.3\n 32.6\n Plt\n 197\n 143\n 155\n Cr\n 0.7\n 0.7\n 0.8\n 0.9\n TropT\n <0.01\n Glucose\n 300\n 100\n 95\n 106\n Other labs: PT / PTT / INR:13.9/24.7/1.2, CK / CKMB /\n Troponin-T:16//<0.01, ALT / AST:, Alk Phos / T Bili:99/0.6, Lactic\n Acid:1.2 mmol/L, Ca++:7.7 mg/dL, Mg++:3.0 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n 35 y/o M with hx of cerebral palsy, seizure disorder, chronic\n pancreatitis and known gastric varices who is transferred with coffee\n ground emesis and hypotension.\n .\n # Hypotension: Most likely secondary to GI bleed or RP bleed in the\n setting of anticoagulation for SMV clot. Baseline SBPs in the 80s,\n today s/p fluid resuscitation and pressure support with pressures\n closer to baseline with good UOP. Still on low-dose phenylephrine.\n - try placing bp cuff on thighs for more accurate read\n - attempt to wean off pressors with goal MAP > 55, SBP > 75\n - continue with IVF, bolus to UOP >50cc/hr\n - transfuse for HCT <25\n - continue vanc, cipro and flagyl for peritonitis treatment pending\n culture data (however had been on cipro , then restarted );\n stop cipro/flagyl when negative cultures X48 hrs, maintain vanco until\n PICC line replaced\n - would be missing VRE coverage and if clinically worsening, consider\n broadening by adding dapto\n .\n # GI bleed: Patient with know gastric varices with blood in NGT and\n coffee ground emesis concerning for GI bleed while on Coumadin with\n imaging concerning for GI and / or RP bleed. Patient with improving HCT\n s/p transfusion without evidence of active bleeding.\n - NPO, NGT in place draining bilious fluid to suction\n - coordinate care with GI and surgery\n - PICC for access (no access for PIVs)\n - protonix 40 mg IV BID\n - trend HCT and transfuse for HCT <25\n - hold anticoagulation for now\n ..\n # Peritonitis: although no positive cultures, was presumed to have\n peritonitis on admission and cause of initial presentation.\n - continue Abx as above\n - serial abdominal exams, currently improving\n .\n # SMV Thrombus: has a chronic SMV thrombus with good collaterals. Was\n on lovenox for briding of subtherapeutic INR and on coumadin.\n Reimaging several days ago showed stable clot without progression.\n Vascular surgery was following along and plan was for 6 months of\n anticoagulation and reevaluation at that time.\n - hold lovenox and coumadin in setting of GI bleed\n - consider risks/benefits of long term anticoagulation and consider\n holding based on EGD findings and extent of bleed\n .\n # Anemia: has new baseline anemia around 30 from 35, and fe studies\n suggest iron deficiency. Also with RP bleed (see above)\n - continue fe supplementation after GI workup complete\n - transfuse for hct <25 in setting of bleed\n .\n # Nutrition: Had been receiving TPN and GI had been consulted for a PEG\n tube for long term feeding, although wanted to wait for abx course to\n be completed and repeat para if fluid was present to confirm resolution\n of possible peritonitis. Did tolerate POs for a few days on the floor\n prior to his most recent large bowel obstruction.\n - start tube feeds with pancreatic enzyme replacement (tube currently\n in duodenum)\n - TPN ordered, but patient not receiving as no dedicated line\n - continue to follow albumin levels; remains hypoalbuminemic\n .\n # Seizure Disorder: is stable, no reports of recent seizures.\n - continue phenobarbitol and phenytoin\n .\n # Yeast in urine\n - Change foley\n .\n # Cerebral Palsy: stable, is interactive with family although\n non-verbal. Continue to monitor mental status.\n .\n # FEN: on TPN, holding for access issues, starting TFs; replete\n electrolytes as needed.\n # Access: PICC, attempt at PIV\n # PPx: PPI , holding anticoagulation, pneumoboots\n # Communication: with family, mom in particular\n # Code: full, confirmed with family\n # Dispo: ICU for now\n could likely be called out if stable BP off of\n pressors\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 35M CP, seizures, GIB, chronic pancreatitis,\n SMV thrombosis on coumadin / lovenox p/w hypotension and blood loss\n anemia. CT c/w RP bleed, bowel edema. HCT has stabilized following RP\n bleed, but was hypotensive overnight.\n Exam notable for Tm 99.2 BP 75/57 HR 100 RR 18 with sat 99 on RA.\n Comfortable appearing. JVD flat. CTA B. RRR s1s2 3/6SM. Tense +BS, no\n rebound. No edema. Labs notable for WBC 6K, HCT 32, INR 1.5, K+ 2.9,\n Cr 0.7, lactate 1.2. CT as above.\n Agree with plan to manage hypotension / blood loss anemia / RP bleed\n with transfusion to maintain HCT >25, check CBC QD, maintain BBS. Will\n check NBP in BLEs, goal SBP>75 / MAP >55 / UOP >50cc/h, ARF improved\n with volume and UOP excellent\n can likely stop vasopressors. Will stop\n abx x vanco until PICC changed and tip cultured. Will hold AC for SMV\n thrombosis - timing of reinitiation depends upon stability of HCT / RP\n bleed. For nutritional support, will check NGT residuals, and initiate\n trophic feeding in addition to pancreatic repletion will restart TPN\n today. For seizures, check drug levels and continue phenobarb and\n fosphenytoin. Remainder of plan as outlined above.\n Patient is critically ill\n Total time: 35 min\n ------ Protected Section Addendum Entered By: , MD\n on: 08:06 PM ------\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-16 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 629149,
"text": "Hypotension (not Shock)\n Assessment/Action:\n Neuro status intact and unchanged from baseline\n Low grade febrile, 99-100\n Non-invasive BP cuff on thigh. SBP > 75 throughout entire\n shift off pressors >24hrs\n Current BP in 90s (MAP ~60)\n 4L NC weaned to 2L with sat > 95%\n Lungs clear in upper airways, clear to diminished in bases\n Abdomen soft-softly distended\n Non-tender on palpation\n Advanced tube feeding q 4 hours by 5cc/hr as ordered, TF\n residuals<5cc\n Flexiseal in place draining liquid green stool.\n Foley catheter discontinued overnoc, using diapers (pt\n baseline when at home per mother)\n Buttocks reddened from leaking flexiseal/incontinence\n Barrier and antifungal creams applied after cleaning, pt\n turned and positioned q 2 hours and PRN\n Mother at bedside. Emotional support provided. Enjoys\n assisting nurse with care of patient.\n Plan:\n Continue to monitor BP, nutritional status (secondary to\n diarrhea)\n Transfer to floor today ()\n"
},
{
"category": "Radiology",
"chartdate": "2115-02-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1125376,
"text": " 2:57 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval NGT\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with CP s/p pulling NGT\n REASON FOR THIS EXAMINATION:\n eval NGT\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n COMPARISON: .\n\n INDICATION: Status post pulling of nasogastric tube.\n\n FINDINGS: Nasogastric tube has slightly changed in position. It continues to\n coil in the upper stomach but distal tip is now directed back towards the GE\n junction. A moderate degree of gastric distension has also developed.\n Assessment of the lungs is limited by respiratory motion, but there has been\n apparent worsening of left retrocardiac opacity. Blurring of pulmonary\n vessels related to motion artifact limits assessment of the cardiovascular\n status of the patient.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-02-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1124794,
"text": " 10:25 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Confirm ETT position, assess for interval change\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with copious secrections, resp failure requiring reintubation\n REASON FOR THIS EXAMINATION:\n Confirm ETT position, assess for interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Copious secretions, to confirm ET tube placement.\n\n FINDINGS: In comparison with earlier study of this date, there has been\n placement of an endotracheal tube with its tip approximately 3.6 cm above the\n carina. Nasogastric tube is coiled within the upper stomach with the tip\n possibly above the esophagogastric junction. Left central catheter tip is in\n the lower SVC.\n\n There is some mild indistinctness of pulmonary vessels consistent with\n elevated pulmonary venous pressure. Atelectatic changes are seen in both\n lower lungs, substantially worse on the left. Hazy opacification with\n obliteration of the hemidiaphragms suggest layering left pleural effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-02-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1124640,
"text": " 4:54 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with CP, peritonitis and ascites, and Hepatitis B, intubated\n and sedated\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 4:57 A.M. \n\n HISTORY: 35-year-old man with peritonitis and ascites.\n\n IMPRESSION: AP chest compared to :\n\n Small bilateral pleural effusions have increased. Heart is normal in size but\n mediastinal vasculature is more engorged, suggesting elevated central venous\n pressure or volume, reflected in mild vascular engorgement of the pulmonary\n vessels. Infrahilar atelectasis in both lower lobes has worsened appreciably\n since following tracheal extubation. Left subclavian line ends at the\n superior cavoatrial junction and a nasogastric tube in the stomach.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-03-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1126720,
"text": " 3:00 PM\n CHEST (PORTABLE AP) Clip # \n Reason: NGT placement\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with new NGT placement. Pleave eval for placement.\n REASON FOR THIS EXAMINATION:\n NGT placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Nasogastric tube placement, evaluation.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the patient has received a\n new nasogastric tube. The tip of the tube projects over the mid-to-lower\n parts of the duodenum. The course of the tube is unremarkable.\n\n No evidence of complications, notably no pneumothorax. The pre-existing\n parenchymal opacities has markedly decreased. On the right, the pre-existing\n opacity is barely visible. Also, markedly improved in the extent of the\n retrocardiac atelectasis.\n\n Unchanged position of the right PICC line.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-02-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1124441,
"text": " 6:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval interval change, Sat trending down\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35M with CP, peritonitis and ascites. Continuing work to detemrine etiology of\n SBP and monitor for ischemic colitis.\n REASON FOR THIS EXAMINATION:\n eval interval change, Sat trending down\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: History of peritonitis, ascites, colitis. Hypoxia.\n\n FINDINGS: A single semi-upright radiograph of the chest was obtained and\n compared to prior exam dated . Endotracheal tube, left\n subclavian catheter and nasogastric tube are in stable and satisfactory\n position. There is minimal central hilar density, not significantly changed\n and there are stable layering pleural effusions. Lung volumes are low. There\n is wall thickening of the left transverse colon as seen on the prior CT dated\n . Surgical clips are seen in the right upper quadrant.\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-02-25 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1125744,
"text": " 6:14 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ?bleed, intracranial pathology\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with seizure, on anticoag, ?bleed\n REASON FOR THIS EXAMINATION:\n ?bleed, intracranial pathology\n CONTRAINDICATIONS for IV CONTRAST:\n ?bleed, renal failure\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SBNa MON 7:20 PM\n 1. Exam limited due to motion. No definite evidence of acute hemorrhage or\n shift.\n 2. Sinusitis.\n ______________________________________________________________________________\n FINAL REPORT\n CT HEAD WITHOUT CONTRAST.\n\n COMPARISON: None.\n\n HISTORY: On anticoagulation with seizure. Evaluate for bleed.\n\n TECHNIQUE: MDCT axially acquired images through the brain were obtained. No\n IV contrast was administered.\n\n FINDINGS: Exam is somewhat limited due to patient motion. Within this\n limitation, there is no evidence of infarction, hemorrhage or shift of\n normally midline structures. The ventricles and sulci are normal in\n appearance. There is no evidence of hydrocephalus. The basilar cisterns are\n preserved. There is normal -white matter differentiation. The visualized\n paranasal sinuses demonstrate aerosolized secretions and mucosal thickening of\n the bilateral maxillary sinuses. There is non-pneumatization of the bilateral\n mastoid air cells. In addition, the frontal sinuses are not pneumatized. An\n retention cyst is identified within the sphenoid sinus. There is no evidence\n of acute fracture.\n\n IMPRESSION:\n Exam limited due to motion. No evidence of hemorrhage or shift.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-02-25 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1125745,
"text": ", R. MED CC7A 6:14 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ?bleed, intracranial pathology\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with seizure, on anticoag, ?bleed\n REASON FOR THIS EXAMINATION:\n ?bleed, intracranial pathology\n CONTRAINDICATIONS for IV CONTRAST:\n ?bleed, renal failure\n ______________________________________________________________________________\n PFI REPORT\n 1. Exam limited due to motion. No definite evidence of acute hemorrhage or\n shift.\n 2. Sinusitis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-02-25 00:00:00.000",
"description": "PICC W/O PORT",
"row_id": 1125632,
"text": " 8:19 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: picc placement\n Admitting Diagnosis: ABDOMINAL PAIN\n ********************************* CPT Codes ********************************\n * PICC W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with failed bedside picc, needs TPN\n REASON FOR THIS EXAMINATION:\n picc placement\n ______________________________________________________________________________\n FINAL REPORT\n PICC LINE PLACEMENT:\n\n INDICATION: IV access needed for antibiotics TPN.\n\n The procedure was explained to the patient. A timeout was performed.\n\n RADIOLOGIST: Drs. and were present. Dr. the\n attending interventional radiologist was present and supervising throughout.\n\n TECHNIQUE: Using sterile technique and local anesthesia, the right basilic\n vein was punctured under direct ultrasound guidance using a micropuncture set.\n Hard copies of ultrasound images were obtained before and immediately after\n establishing intravenous access. A peel-away sheath was then placed over a\n guidewire and a double lumen PICC line measuring 33 cm in length was then\n placed through the peel-away sheath with its tip positioned in the SVC under\n fluoroscopic guidance. Position of the catheter was confirmed by a\n fluoroscopic spot film of the chest.\n\n The peel-away sheath and guidewire were then removed. The catheter was secured\n to the skin, flushed, and a sterile dressing applied.\n\n The patient tolerated the procedure well. There were no immediate\n complications.\n\n IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided 5 French\n double lumen PICC line placement via the right basilic venous approach. Final\n internal length is 33 cm, with the tip positioned in SVC. The line is ready to\n use.\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-02-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1124025,
"text": " 11:55 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ?ARDS, pneumonia, pneumothorax\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with hypoxia\n REASON FOR THIS EXAMINATION:\n ?ARDS, pneumonia, pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Hypoxia.\n\n FINDINGS: In comparison with the study of earlier in this date, there are\n continued low lung volumes. There is an area of increasing opacification\n primarily involving the left lung centrally. Although this could represent\n asymmetric pulmonary edema, which is more common on the right, the possibility\n of aspiration must be seriously considered. This is especially so since there\n has been interval placement of an endotracheal tube, with its tip\n approximately 2.7 cm above the carina.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-02-16 00:00:00.000",
"description": "CTA ABD W&W/O C & RECONS",
"row_id": 1124492,
"text": " 2:16 PM\n CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # \n Reason: Eval mesenteric flow arterial and venous. Ct scan 2 days ago\n Admitting Diagnosis: ABDOMINAL PAIN\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35M with CP, peritonitis and ascites. Continuing work to detemrine etiology of\n SBP and monitor for ischemic colitis.\n REASON FOR THIS EXAMINATION:\n Eval mesenteric flow arterial and venous. Ct scan 2 days ago concerning for\n ischemic bowel. Re-eval\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AKPe SAT 8:48 PM\n PFI:\n 1. Diffusely abnormal gastrointestinal tract with mucosal hyperenhancement and\n wall thickening. Given the finding of SMV occlusion, findings are highly\n concerning for congestion/venous ischemia. An element of shock bowel could\n also be a possibility.\n 2. Hyperenhancement of the adrenal glands and narrowed distal aorta, iliac and\n femoral vessels, suggesting hypovolemia.\n 3. Sequelae of chronic pancreatitis with a rim-enhancing fluid collection in\n the region of the pancreatic head, likely representing pseudocyst. This may\n be the etiology of SMV thrombosis.\n 4. Diffusely abnormal hepatic parenchyma, consistent with the history of\n hepatitis. Partially occlusive right portal vein thrombus.\n 5. Small bilateral pleural effusions, increased from the prior exam.\n Ground-glass and nodular opacities at the lung bases suggesting infection.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: History of cerebral palsy with peritonitis, ascites and\n bowel wall thickening seen on prior exam.\n\n TECHNIQUE: MDCT of the abdomen and pelvis was performed prior to and\n following the uneventful administration of nonionic intravenous contrast.\n Images were obtained in arterial and portal venous phases. Sagittal and\n coronal reconstructed images were reviewed. Comparison is made to prior CT\n performed at an outside institution dated .\n\n FINDINGS:\n\n Limited images of the lung bases demonstrate small bilateral pleural\n effusions, increased from the prior exam, and dependent atelectasis.\n Additional nondependent areas of ground glass and nodular density are\n identified at the lung bases, concerning for infection.\n\n Again noted is diffuse thickening of the majority of the gastrointestinal\n tract including the small and large bowel (most notably within the transverse\n and sigmoid colon). There is persistent diffuse hyperenhancement of the\n gastric, small bowel, and colonic mucosa. Overall, findings are very similar\n in appearance to the prior study. There is diffuse mesenteric stranding and\n small ascites, which is stable. There is increased soft tissue edema from the\n (Over)\n\n 2:16 PM\n CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # \n Reason: Eval mesenteric flow arterial and venous. Ct scan 2 days ago\n Admitting Diagnosis: ABDOMINAL PAIN\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n prior study. Again identified is thrombosis of the right portal vein branches\n with some minimal peripheral flow identified in the proximal right portal\n vein. The left portal vein and branches, and main portal vein are patent.\n There is occlusion of the SMV at the level of the portal confluence. More\n inferiorly, the SMV is patent, as is the IMV, and distal branches appear\n patent. Numerous venous collateral branches are seen in the upper abdomen and\n in the region of SMV occlusion.\n\n The aorta is small in caliber, especially distally, as are the iliac and\n common femoral arteries. All major aortic branches are patent. The adrenal\n glands are hyperenhancing, but otherwise unremarkable. The liver is low\n density on pre-contrast images, consistent with fatty infiltration, and there\n is heterogeneous hepatic enhancement consistent with the history of hepatitis.\n There are no obvious focal liver lesions. The gallbladder is surgically\n absent. There is a right midpole renal cyst. Otherwise, the kidneys are\n unremarkable, as is the spleen. The pancreas is markedly atrophic and there\n is pancreatic ductal dilatation measuring up to 6 mm. Calcifications are\n identified in the pancreatic head, and there is a 2.3 x 1.6 x 4.9 cm rim-\n enhancing fluid collection in the region of the pancreatic head, likely\n representing pseudocyst. Subcentimeter retroperitoneal lymph nodes are\n identified.\n\n The bladder is decompressed with a Foley catheter. Again, there is marked\n bowel wall thickening in the pelvis, especially involving the colon. There is\n moderate ascites. There are no pathologically enlarged pelvic lymph nodes.\n\n Bone windows demonstrate diffuse osteopenia, without focal suspicious lesion.\n\n IMPRESSION:\n\n 1. Diffusely abnormal gastrointestinal tract with mucosal hyperenhancement\n and wall thickening. Given the finding of SMV occlusion, findings are highly\n concerning for venous congestion/ischemia. An element of shock bowel could\n also be a possibility.\n\n 2. Hyperenhancement of the adrenal glands and narrowed distal aorta, iliac\n and femoral vessels, suggesting hypovolemia/shock. Correlate clinically.\n\n 3. Sequelae of chronic pancreatitis with a rim-enhancing fluid collection in\n the region of the pancreatic head, likely representing pseudocyst. This may\n be the etiology of SMV thrombosis.\n\n 4. Diffusely abnormal hepatic parenchyma, consistent with the history of\n hepatitis. Partially occlusive right portal vein thrombus.\n\n (Over)\n\n 2:16 PM\n CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # \n Reason: Eval mesenteric flow arterial and venous. Ct scan 2 days ago\n Admitting Diagnosis: ABDOMINAL PAIN\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 5. Small bilateral pleural effusions, increased from the prior exam. Ground-\n glass and nodular opacities at the lung bases suggesting infection.\n\n Findings were discussed with Dr. at 7:17 p.m. on .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-02-16 00:00:00.000",
"description": "CTA ABD W&W/O C & RECONS",
"row_id": 1124493,
"text": ", B. SICU-B 2:16 PM\n CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # \n Reason: Eval mesenteric flow arterial and venous. Ct scan 2 days ago\n Admitting Diagnosis: ABDOMINAL PAIN\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35M with CP, peritonitis and ascites. Continuing work to detemrine etiology of\n SBP and monitor for ischemic colitis.\n REASON FOR THIS EXAMINATION:\n Eval mesenteric flow arterial and venous. Ct scan 2 days ago concerning for\n ischemic bowel. Re-eval\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI:\n 1. Diffusely abnormal gastrointestinal tract with mucosal hyperenhancement and\n wall thickening. Given the finding of SMV occlusion, findings are highly\n concerning for congestion/venous ischemia. An element of shock bowel could\n also be a possibility.\n 2. Hyperenhancement of the adrenal glands and narrowed distal aorta, iliac and\n femoral vessels, suggesting hypovolemia.\n 3. Sequelae of chronic pancreatitis with a rim-enhancing fluid collection in\n the region of the pancreatic head, likely representing pseudocyst. This may\n be the etiology of SMV thrombosis.\n 4. Diffusely abnormal hepatic parenchyma, consistent with the history of\n hepatitis. Partially occlusive right portal vein thrombus.\n 5. Small bilateral pleural effusions, increased from the prior exam.\n Ground-glass and nodular opacities at the lung bases suggesting infection.\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-02-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1125727,
"text": " 3:57 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for consolidation\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with fevers, eval for consolidation\n REASON FOR THIS EXAMINATION:\n eval for consolidation\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 4:03 P.M. ON \n\n HISTORY: Fever, evaluate for consolidation.\n\n IMPRESSION: AP chest compared to through 12:\n\n Widespread pulmonary consolidation, severe on the left, moderate on the right\n has progressed since . This could be edema, particularly since small\n left pleural effusion has increased, and although heart size is normal,\n mediastinal veins are engorged. Nasogastric tube passes into the duodenum and\n out of view. Large and small bowel are both substantially distended with gas.\n Right subclavian line or PIC line ends at the superior cavoatrial junction.\n No pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-02-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1124970,
"text": " 4:32 AM\n CHEST (PORTABLE AP) Clip # \n Reason: volume status\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with CP and pancreatic cyst\n REASON FOR THIS EXAMINATION:\n volume status\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Chest pain and pancreatic cyst, to evaluate volume status.\n\n FINDINGS: In comparison with the study of , the monitoring and support\n devices are unchanged except that the nasogastric tip points away from the\n esophagogastric junction. The opacification at the left base is not\n appreciated, though this could merely represent shift in the appearance of the\n pleural effusion on a relatively image. Patchy opacification at the\n left base is worrisome for supervening pneumonia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-02-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1125116,
"text": " 4:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for tube placement\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with intubation\n REASON FOR THIS EXAMINATION:\n eval for tube placement\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Reassess ET tube.\n\n Comparison is made with prior study performed a day earlier.\n\n The ET tube tip is 2.7 cm above the carina. There are low lung volumes.\n Cardiomediastinal contours are normal. NG tube tip is in the stomach. Left\n subclavian catheter tip is in the lower SVC. There is no pneumothorax or\n pleural effusion. Bibasilar opacities left greater than right have improved.\n There is scoliosis.\n\n Surgical clips project in the right upper quadrant.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-02-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1125929,
"text": " 6:01 PM\n CHEST (PORTABLE AP) Clip # \n Reason: NGT placement\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with NGT readjustment. Please eval for proper positioning\n REASON FOR THIS EXAMINATION:\n NGT placement\n ______________________________________________________________________________\n WET READ: SBNa TUE 7:14 PM\n NGT coiled in stomach and slightly increased diffuse opacity on the right.\n Otherwise, no significant change.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 6:24 P.M., .\n\n HISTORY: NG tube readjusted.\n\n IMPRESSION: AP chest compared to :\n\n Nasogastric tube is looped in a non-distended stomach, but distension of the\n colon persists. Lung volumes remain very low. Moderate pulmonary edema has\n worsened, with increasing pleural effusion, at least moderate size on the left\n and persistent left basal consolidation, probably collapsed. Right subclavian\n line ends low in the SVC. No pneumothorax.\n\n\n"
},
{
"category": "Physician ",
"chartdate": "2115-04-01 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 632297,
"text": "Chief Complaint: Respiratory Failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Extubated yesterday\n Diuresed further due to ongoing hypoxemia with improvement --> 250cc\n bolus given back overnight due to MAPs in the 50s.\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 09:15 AM\n BLOOD CULTURED - At 01:50 PM\n URINE CULTURE - At 01:50 PM\n History obtained from Medical records, icu team\n Patient unable to provide history: Encephalopathy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 06:00 PM\n Vancomycin - 08:00 PM\n Cefipime - 10:00 PM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 01:50 PM\n Pantoprazole (Protonix) - 08:00 PM\n Morphine Sulfate - 08:00 AM\n Other medications:\n per ICU resident note\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fever\n Cardiovascular: Tachycardia\n Respiratory: Tachypnea\n Pain: Minimal\n Flowsheet Data as of 09:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.2\nC (100.8\n Tcurrent: 37.6\nC (99.6\n HR: 132 (100 - 134) bpm\n BP: 115/83(97) {72/52(60) - 115/83(97)} mmHg\n RR: 45 (16 - 45) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 721 mL\n 861 mL\n PO:\n TF:\n 321 mL\n 383 mL\n IVF:\n 260 mL\n 358 mL\n Blood products:\n Total out:\n 1,780 mL\n 280 mL\n Urine:\n 1,780 mL\n 280 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,059 mL\n 581 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: 7.42/42/72/29/2\n PaO2 / FiO2: 144\n Physical Examination\n General Appearance: Moderate resp distress\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous: loud throughout)\n Abdominal: Soft, Non-tender\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Warm\n Neurologic: Attentive, No(t) Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 9.1 g/dL\n 137 K/uL\n 148 mg/dL\n 0.6 mg/dL\n 29 mEq/L\n 3.2 mEq/L\n 20 mg/dL\n 103 mEq/L\n 138 mEq/L\n 27.9 %\n 7.3 K/uL\n [image002.jpg]\n 02:33 PM\n 05:01 AM\n 02:23 PM\n 03:50 AM\n 04:15 PM\n 02:46 AM\n 03:02 AM\n 09:03 AM\n 03:28 AM\n 08:25 AM\n WBC\n 10.7\n 8.7\n 7.1\n 7.3\n Hct\n 30.4\n 30.2\n 28.5\n 27.9\n Plt\n 37\n Cr\n 0.7\n 0.6\n 0.6\n 0.6\n 0.6\n 0.6\n TCO2\n 27\n 30\n 28\n 28\n Glucose\n 116\n 85\n 139\n 150\n 145\n 148\n Other labs: PT / PTT / INR:16.6/26.3/1.5, CK / CKMB /\n Troponin-T:8//0.01, ALT / AST:17/19, Alk Phos / T Bili:106/0.6, Amylase\n / Lipase:/11, Differential-Neuts:86.5 %, Lymph:6.6 %, Mono:5.9 %,\n Eos:0.9 %, Lactic Acid:1.6 mmol/L, Albumin:2.4 g/dL, LDH:383 IU/L,\n Ca++:7.7 mg/dL, Mg++:2.1 mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n ALTERATION IN NUTRITION\n TACHYCARDIA, OTHER\n ANEMIA, ACUTE, SECONDARY TO BLOOD LOSS (HEMORRHAGE, BLEEDING)\n FRACTURE, OTHER\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n 35 yo man with cerebral palsy with recurrent respiratory failure due to\n pneumonia and volume overload\n Respiratory Failure: Extubated but still requiring a large amount of\n oxygen and using accessory muscles to breath. Will hold off on further\n diuresis for the moment given worry about concreting secretions.\n Gentle chest PT.\n Fevers: Low grade fevers. Has completed abx course.\n Remainder of issues per ICU team\n ICU Care\n Nutrition:\n Vivonex (Full) - 02:00 AM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 11:14 AM\n Arterial Line - 11:10 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition :ICU\n Total time spent: 31 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2115-04-01 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 632298,
"text": "Chief Complaint: - Extubated in AM with plan to NOT reintubate\n - Had some coughing and desat to upper 80s post-extubation, as well as\n fever; recultured and gave dose of 40 mg IV lasix, which seemed to help\n - TF held given risk of aspiration\n - Hypotensive to SBPs in 70s in PM after diuresing ~800 cc to Lasix; no\n intervention and BPs improved to 90s.\n - Overnight while sleeping MAP dropped to 55 and SBP to < 70, so got\n 250 cc bolus\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 09:15 AM\n BLOOD CULTURED - At 01:50 PM\n URINE CULTURE - At 01:50 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 06:00 PM\n Vancomycin - 08:00 PM\n Cefipime - 10:00 PM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 01:50 PM\n Pantoprazole (Protonix) - 08:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.2\nC (100.8\n Tcurrent: 36.2\nC (97.1\n HR: 107 (100 - 130) bpm\n BP: 91/70(79) {72/52(60) - 95/77(84)} mmHg\n RR: 21 (16 - 41) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 721 mL\n 746 mL\n PO:\n TF:\n 321 mL\n 297 mL\n IVF:\n 260 mL\n 329 mL\n Blood products:\n Total out:\n 1,780 mL\n 200 mL\n Urine:\n 1,780 mL\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,059 mL\n 547 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: PSV/SBT\n Vt (Spontaneous): 369 (369 - 369) mL\n PS : 8 cmH2O\n RR (Spontaneous): 27\n PEEP: 0 cmH2O\n FiO2: 50%\n SpO2: 94%\n ABG: 7.49/36/89./29/4\n Ve: 9.4 L/min\n PaO2 / FiO2: 178\n Physical Examination\n Gen: Thin, opening eyes but no clear orientation to voice; grunting\n this morning and appears uncomfortable\n HEENT: Sclera anicteric, eyes sunken, MMM, audible secretions\n Neck: Supple\n Lungs: Intubated, coarse BS bilaterally with diffuse ronchi\n CV: S1, S2 regular rhythm, increased rate\n Abdomen: Soft, BS+, distended, no facial grimacing to palpation\n GU: foley catheter in place\n Ext: Warm, cachectic, BLE contractures, + DP pulses\n Labs / Radiology\n 137 K/uL\n 9.1 g/dL\n 148 mg/dL\n 0.6 mg/dL\n 29 mEq/L\n 3.2 mEq/L\n 20 mg/dL\n 103 mEq/L\n 138 mEq/L\n 27.9 %\n 7.3 K/uL\n [image002.jpg]\n 02:18 PM\n 02:33 PM\n 05:01 AM\n 02:23 PM\n 03:50 AM\n 04:15 PM\n 02:46 AM\n 03:02 AM\n 09:03 AM\n 03:28 AM\n WBC\n 10.7\n 8.7\n 7.1\n 7.3\n Hct\n 30.4\n 30.2\n 28.5\n 27.9\n Plt\n 37\n Cr\n 0.6\n 0.7\n 0.6\n 0.6\n 0.6\n 0.6\n 0.6\n TCO2\n 27\n 30\n 28\n Glucose\n 118\n 116\n 85\n 139\n 150\n 145\n 148\n Other labs: PT / PTT / INR:16.6/26.3/1.5, CK / CKMB /\n Troponin-T:8//0.01, ALT / AST:17/19, Alk Phos / T Bili:106/0.6, Amylase\n / Lipase:/11, Differential-Neuts:86.5 %, Lymph:6.6 %, Mono:5.9 %,\n Eos:0.9 %, Lactic Acid:1.6 mmol/L, Albumin:2.4 g/dL, LDH:383 IU/L,\n Ca++:7.7 mg/dL, Mg++:2.1 mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n 35 yo M with PMH of CP, seizure disorder, GIB, pancreatic cyst s/p\n drainage in , admitted with abdominal pain with complicated course,\n now with new fever, tachypnea, and hypoxia.\n .\n # Respiratory failure: Patient transferred to MICU with tachypnea and\n hypoxia on and intubated on . Given his new fever,\n respiratory deterioration, and imaging findings consistent with\n multilobar pneumonia he was started on vancomycin, cefepime and flagyl\n (concern for aspiration given recently started tube feeds). Sputum\n growing MRSA. Pleural effusions also noted on imaging, likely due to\n fluid resuscitation for hypotension in the setting of albumin of 2.3,\n so over the past 24 hours have been diuresing with lasix boluses. PE\n considered but CTA negative. Few apneic episodes two nights ago may\n be secondary to aggressive diuresis. Extubated on . The\n current respiratory distress is likely due to mucous plugging,\n secretions with rhonchorous breath sounds on exam. Pulmonary edema may\n also be contributing.\n - Completed 8-day course of vanc, cefepime, metronidazole\n - suction and light chest PT\n - consider gentle diuresis although difficult given low BP\n - follow ABGs\n - f/u blood cultures\n - morphine for grunting/resp distress x 1 to see if helpful\n - will discuss non-invasive pressure ventilation if necessary with\n family\n .\n # Fever/sepsis: Pt febrile with tachycardia and tachypnea; meets\n definition of sepsis with most likely source being pulmonary (MRSA).\n With ascites, SBP is also possible although he is now s/p 3 taps which\n have not been c/w SBP. Urinalysis and culture from with staph spp\n but repeat appears clean with NGTD. MS with no obvious\n nuchal rigidity although exam limited by pt cooperation. Again, PE\n could cause similar sx of fever and respiratory distress but none seen\n on CTA. Continues febrile daily. No further episodes of AMS. CT read as\n possible liver abscess but repeat RUQ ultrasound read as more\n consistent with infarct. C. Diff has been negative. Continues to have\n fever to 101 on overnight but normal white count, lactate normal.\n - Off Abx as above.\n - Goal CVP 8-12 but no measurements available currently\n will bolus\n for tachycardia, UOP < 30cc/h, goal MAP >60, CvO2 >70\n - Pressors for MAP > 55-60, off vasopressors\n - Monitor mental status\n - Consider paracentesis if continues febrile and no other source (would\n likely need to be done by IR)\n .\n #Hypotension. MAP goal > 60. No further episodes of AMS since starting\n pressors on . Not on vasopressors.\n # Tachycardia: Likely hyperdynamic in setting of fever, infection.\n Volume status appears grossly euvolemic; pt mentating at and\n maintaining urine output. Echo with evidence of depressed cardiac fxn,\n ? tachycardia induced cardiomyopathy\n - Tylenol prn fever\n - Abx as above\n - Fluid boluses prn, though patient with heart rate 110s;\n appears hypervolemic\n # Anemia/bleed: Hct stable. Pt with RP bleed and CT evidence of\n hemorrhage into bowel wall, also gastric varices c/b GIB earlier in\n admission. Transfused 1 unit pRBCs with appropriate bump and has\n remained stable since.\n - Trend Hct\n - Guaiac stools\n - Active T&S\n - continue pantoprazole 40mg IV bid\n - Continue iron supplement\n # Liver lesion. Noted on abdominal CT. Possible ischemia/infarction vs\n abscess. Abdominal U/S not consistent with abscess.\n # Left humeral fx: Likely d/t trauma sustained during radiology.\n - No surgical indication at this time\n - Pain control with lidoderm patch and morphine prn\n .\n # SMV thrombus: Plan for anticoagulation x 6 months but held in setting\n of recent GI and RP bleed.\n - Continue heparin SQ\n .\n # Seizure disorder: No recent reports of seizures. Caution as certain\n antibiotics may lower seizure threshold.\n - Continue phenobarbitol and phenytoin\n - drug levels stable as of \n .\n # Cerebral palsy: Stable mental status. Interactive with family but\n nonverbal at .\n .\n FEN: NG tube likely in duodenum, bolus IVF prn, TPN; continue tube\n feeds today\n PROPHYLAXIS: pneumoboots, IV PPI\n ACCESS: PICC, PIV, D/C A-line in right brachial artery\n CODE: Do not resuscitate/Do not re-intubate. No CPR or defibrillation.\n Will clarify role for BIPAP/CPAP.\n ICU Care\n Nutrition:\n Vivonex (Full) - 02:00 AM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 11:14 AM\n Arterial Line - 11:10 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2115-04-01 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 632280,
"text": "Chief Complaint: - Extubated in AM with plan to NOT reintubate\n - Had some coughing and desat to upper 80s post-extubation, as well as\n fever; recultured and gave dose of 40 mg IV lasix, which seemed to help\n - TF held given risk of aspiration\n - Hypotensive to SBPs in 70s in PM after diuresing ~800 cc to Lasix; no\n intervention and BPs improved to 90s.\n - Overnight while sleeping MAP dropped to 55 and SBP to < 70, so got\n 250 cc bolus\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 09:15 AM\n BLOOD CULTURED - At 01:50 PM\n URINE CULTURE - At 01:50 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 06:00 PM\n Vancomycin - 08:00 PM\n Cefipime - 10:00 PM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 01:50 PM\n Pantoprazole (Protonix) - 08:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.2\nC (100.8\n Tcurrent: 36.2\nC (97.1\n HR: 107 (100 - 130) bpm\n BP: 91/70(79) {72/52(60) - 95/77(84)} mmHg\n RR: 21 (16 - 41) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 721 mL\n 746 mL\n PO:\n TF:\n 321 mL\n 297 mL\n IVF:\n 260 mL\n 329 mL\n Blood products:\n Total out:\n 1,780 mL\n 200 mL\n Urine:\n 1,780 mL\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,059 mL\n 547 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: PSV/SBT\n Vt (Spontaneous): 369 (369 - 369) mL\n PS : 8 cmH2O\n RR (Spontaneous): 27\n PEEP: 0 cmH2O\n FiO2: 50%\n SpO2: 94%\n ABG: 7.49/36/89./29/4\n Ve: 9.4 L/min\n PaO2 / FiO2: 178\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 137 K/uL\n 9.1 g/dL\n 148 mg/dL\n 0.6 mg/dL\n 29 mEq/L\n 3.2 mEq/L\n 20 mg/dL\n 103 mEq/L\n 138 mEq/L\n 27.9 %\n 7.3 K/uL\n [image002.jpg]\n 02:18 PM\n 02:33 PM\n 05:01 AM\n 02:23 PM\n 03:50 AM\n 04:15 PM\n 02:46 AM\n 03:02 AM\n 09:03 AM\n 03:28 AM\n WBC\n 10.7\n 8.7\n 7.1\n 7.3\n Hct\n 30.4\n 30.2\n 28.5\n 27.9\n Plt\n 37\n Cr\n 0.6\n 0.7\n 0.6\n 0.6\n 0.6\n 0.6\n 0.6\n TCO2\n 27\n 30\n 28\n Glucose\n 118\n 116\n 85\n 139\n 150\n 145\n 148\n Other labs: PT / PTT / INR:16.6/26.3/1.5, CK / CKMB /\n Troponin-T:8//0.01, ALT / AST:17/19, Alk Phos / T Bili:106/0.6, Amylase\n / Lipase:/11, Differential-Neuts:86.5 %, Lymph:6.6 %, Mono:5.9 %,\n Eos:0.9 %, Lactic Acid:1.6 mmol/L, Albumin:2.4 g/dL, LDH:383 IU/L,\n Ca++:7.7 mg/dL, Mg++:2.1 mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n ALTERATION IN NUTRITION\n TACHYCARDIA, OTHER\n ANEMIA, ACUTE, SECONDARY TO BLOOD LOSS (HEMORRHAGE, BLEEDING)\n FRACTURE, OTHER\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Vivonex (Full) - 02:00 AM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 11:14 AM\n Arterial Line - 11:10 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2115-04-01 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 632282,
"text": "Chief Complaint: - Extubated in AM with plan to NOT reintubate\n - Had some coughing and desat to upper 80s post-extubation, as well as\n fever; recultured and gave dose of 40 mg IV lasix, which seemed to help\n - TF held given risk of aspiration\n - Hypotensive to SBPs in 70s in PM after diuresing ~800 cc to Lasix; no\n intervention and BPs improved to 90s.\n - Overnight while sleeping MAP dropped to 55 and SBP to < 70, so got\n 250 cc bolus\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 09:15 AM\n BLOOD CULTURED - At 01:50 PM\n URINE CULTURE - At 01:50 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 06:00 PM\n Vancomycin - 08:00 PM\n Cefipime - 10:00 PM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 01:50 PM\n Pantoprazole (Protonix) - 08:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.2\nC (100.8\n Tcurrent: 36.2\nC (97.1\n HR: 107 (100 - 130) bpm\n BP: 91/70(79) {72/52(60) - 95/77(84)} mmHg\n RR: 21 (16 - 41) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 721 mL\n 746 mL\n PO:\n TF:\n 321 mL\n 297 mL\n IVF:\n 260 mL\n 329 mL\n Blood products:\n Total out:\n 1,780 mL\n 200 mL\n Urine:\n 1,780 mL\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,059 mL\n 547 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: PSV/SBT\n Vt (Spontaneous): 369 (369 - 369) mL\n PS : 8 cmH2O\n RR (Spontaneous): 27\n PEEP: 0 cmH2O\n FiO2: 50%\n SpO2: 94%\n ABG: 7.49/36/89./29/4\n Ve: 9.4 L/min\n PaO2 / FiO2: 178\n Physical Examination\n Labs / Radiology\n 137 K/uL\n 9.1 g/dL\n 148 mg/dL\n 0.6 mg/dL\n 29 mEq/L\n 3.2 mEq/L\n 20 mg/dL\n 103 mEq/L\n 138 mEq/L\n 27.9 %\n 7.3 K/uL\n [image002.jpg]\n 02:18 PM\n 02:33 PM\n 05:01 AM\n 02:23 PM\n 03:50 AM\n 04:15 PM\n 02:46 AM\n 03:02 AM\n 09:03 AM\n 03:28 AM\n WBC\n 10.7\n 8.7\n 7.1\n 7.3\n Hct\n 30.4\n 30.2\n 28.5\n 27.9\n Plt\n 37\n Cr\n 0.6\n 0.7\n 0.6\n 0.6\n 0.6\n 0.6\n 0.6\n TCO2\n 27\n 30\n 28\n Glucose\n 118\n 116\n 85\n 139\n 150\n 145\n 148\n Other labs: PT / PTT / INR:16.6/26.3/1.5, CK / CKMB /\n Troponin-T:8//0.01, ALT / AST:17/19, Alk Phos / T Bili:106/0.6, Amylase\n / Lipase:/11, Differential-Neuts:86.5 %, Lymph:6.6 %, Mono:5.9 %,\n Eos:0.9 %, Lactic Acid:1.6 mmol/L, Albumin:2.4 g/dL, LDH:383 IU/L,\n Ca++:7.7 mg/dL, Mg++:2.1 mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n 35 yo M with PMH of CP, seizure disorder, GIB, pancreatic cyst s/p\n drainage in , admitted with abdominal pain with complicated course,\n now with new fever, tachypnea, and hypoxia.\n .\n # Respiratory failure: Patient transferred to MICU with tachypnea and\n hypoxia on and intubated on . Given his new fever,\n respiratory deterioration, and imaging findings consistent with\n multilobar pneumonia he was started on vancomycin, cefepime and flagyl\n (concern for aspiration given recently started tube feeds). Sputum\n growing MRSA. Pleural effusions also noted on imaging, likely due to\n fluid resuscitation for hypotension in the setting of albumin of 2.3,\n so over the past 24 hours have been diuresing with lasix boluses. PE\n considered but CTA negative. Few apneic episodes two nights ago may\n be secondary to aggressive diuresis. Extubated yesterday; has had a\n few low O2 sats.\n - Completed 8-day course of vanc, cefepime, metronidazole\n - continue with daily RSBI and SBT as tolerated, likely will extubate\n today\n - follow ABGs\n - electrolytes with repletion while on Lasix\n - f/u blood cultures\n - morphine for grunting/resp distress x 1 to see if helpful\n .\n # Fever/sepsis: Pt febrile with tachycardia and tachypnea; meets\n definition of sepsis with most likely source being pulmonary (MRSA).\n With ascites, SBP is also possible although he is now s/p 3 taps which\n have not been c/w SBP. Urinalysis and culture from with staph spp\n but repeat appears clean with NGTD. MS with no obvious\n nuchal rigidity although exam limited by pt cooperation. Again, PE\n could cause similar sx of fever and respiratory distress but none seen\n on CTA. Continues febrile daily. No further episodes of AMS. CT read as\n possible liver abscess but repeat RUQ ultrasound read as more\n consistent with infarct. C. Diff has been negative. Continues to have\n fever to 101 on overnight but normal white count, lactate normal.\n - Off Abx as above.\n - Goal CVP 8-12 but no measurements available currently\n will bolus\n for tachycardia, UOP < 30cc/h, goal MAP >60, CvO2 >70\n - Pressors for MAP > 55-60, off vasopressors\n - Monitor mental status\n - Consider paracentesis if continues febrile and no other source (would\n likely need to be done by IR)\n .\n #Hypotension. MAP goal > 60. No further episodes of AMS since starting\n pressors on . Not on vasopressors.\n # Tachycardia: Likely hyperdynamic in setting of fever, infection.\n Volume status appears grossly euvolemic; pt mentating at and\n maintaining urine output. Echo with evidence of depressed cardiac fxn,\n ? tachycardia induced cardiomyopathy\n - Tylenol prn fever\n - Abx as above\n - Fluid boluses prn, though patient with heart rate 110s;\n appears hypervolemic\n # Anemia/bleed: Hct stable. Pt with RP bleed and CT evidence of\n hemorrhage into bowel wall, also gastric varices c/b GIB earlier in\n admission. Transfused 1 unit pRBCs with appropriate bump and has\n remained stable since.\n - Trend Hct\n - Guaiac stools\n - Active T&S\n - continue pantoprazole 40mg IV bid\n - Continue iron supplement\n # Liver lesion. Noted on abdominal CT. Possible ischemia/infarction vs\n abscess. Abdominal U/S not consistent with abscess.\n # Left humeral fx: Likely d/t trauma sustained during radiology.\n - No surgical indication at this time\n - Pain control with lidoderm patch and morphine prn\n .\n # SMV thrombus: Plan for anticoagulation x 6 months but held in setting\n of recent GI and RP bleed.\n - Continue heparin SQ\n .\n # Seizure disorder: No recent reports of seizures. Caution as certain\n antibiotics may lower seizure threshold.\n - Continue phenobarbitol and phenytoin\n - drug levels stable as of \n .\n # Cerebral palsy: Stable mental status. Interactive with family but\n nonverbal at .\n .\n FEN: NG tube likely in duodenum, bolus IVF prn, TPN; continue tube\n feeds today\n PROPHYLAXIS: pneumoboots, IV PPI\n ACCESS: PICC, PIV, D/C A-line in right brachial artery\n CODE: Do not resuscitate/Do not re-intubate. No CPR or defibrillation.\n Will clarify role for BIPAP/CPAP.\n ICU Care\n Nutrition:\n Vivonex (Full) - 02:00 AM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 11:14 AM\n Arterial Line - 11:10 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2115-04-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 632376,
"text": "35 yo M with PMH of CP, seizure disorder, GIB, pancreatic cyst s/p\n drainage in , admitted with abdominal pain with complicated course,\n now with new fever, tachypnea, and hypoxia.\n Code Status: DNR/DNI(will discuss noninvasive ventilation if it is\n needed.)\n Respiratory failure, acute (not ARDS/)\n Assessment:\n I received the patient with a HR 140\ns, RR 40-45, and o2 sat\n 86-88% on NC. Lung sounds were ronchi bilaterally. He was coughing but\n unable to clear his secretions. CXR was positive for mild fluid\n overload. Patient has finished a course of IV AXB pneumonia. He is\n positive for MRSA in his sputum. Temp max 99.6 oral.\n Action:\n Morphine 1mg iv given.\n Humidified face tent placed at 100%.\n Continued with the 4L NC.\n Nasal and oral suctioned done,\n Gentle chest PT.\n Lasix 20mg ordered at 1500(gentle diuresis).\n Response:\n He did appear more comfortable after the morphine and\n suctioning.\n He was able to cough up his secretions and swallow them the\n humidification.\n O2 sat 98-100%.\n When I did chest PT. He did drop his sats back down to the\n 87-88%. He did recover over 20 minutes.\n Now he is on 4L NC and 40% face tent. And he is able to\n maintain his o2 sat of 98% w/ RR 25-30..\n Plan:\n The patients were ordered to be drawn at 1500, and ICU team\n wanted the ordered the lasix at1500.\n Please obtain PM lytes.\n Continue with the humidification and nasal prongs.\n The goal is 250 to 500 negative for the day.\n Fracture, other\n Assessment:\n Patient sustained a left fracture of his arm.\n Action:\n Morphine.\n Response:\n Good effect noted.\n Plan:\n Turn the patient on the right side and his back for comfort.\n Morphine or Tylenol depending on the severity of the pain.\n 19:11\n"
},
{
"category": "Physician ",
"chartdate": "2115-04-02 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 632439,
"text": "Chief Complaint:\n 24 Hour Events:\n - Blood CX () growing yeast\n - Urine CX () growing >100K yeast\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 06:00 PM\n Vancomycin - 08:00 PM\n Cefipime - 10:00 PM\n Fluconazole - 01:56 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:46 PM\n Furosemide (Lasix) - 11:08 PM\n Morphine Sulfate - 12:24 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 37.7\nC (99.8\n HR: 116 (112 - 134) bpm\n BP: 83/63(72) {76/53(62) - 115/83(97)} mmHg\n RR: 39 (24 - 47) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 2,616 mL\n 548 mL\n PO:\n TF:\n 1,896 mL\n 332 mL\n IVF:\n 600 mL\n 216 mL\n Blood products:\n Total out:\n 930 mL\n 740 mL\n Urine:\n 930 mL\n 740 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,686 mL\n -192 mL\n Respiratory support\n O2 Delivery Device: Face tent 15L 70% FiO2\n SpO2: 97%\n ABG: 7.44/43/128/25/5\n Physical Examination\n Gen: Thin, opening eyes but no clear orientation to voice; grunting\n this morning and appears uncomfortable\n HEENT: Sclera anicteric, eyes sunken, MMM, audible secretions\n Neck: Supple\n Lungs: Intubated, coarse BS bilaterally with diffuse ronchi\n CV: S1, S2 regular rhythm, increased rate\n Abdomen: Soft, BS+, distended, no facial grimacing to palpation\n GU: foley catheter in place\n Ext: Warm, cachectic, BLE contractures, + DP pulses\n Labs / Radiology\n 137 K/uL\n 9.1 g/dL\n 105 mg/dL\n 0.6 mg/dL\n 25 mEq/L\n 4.8 mEq/L\n 23 mg/dL\n 107 mEq/L\n 142 mEq/L\n 27.9 %\n 7.3 K/uL\n [image002.jpg]\n 02:23 PM\n 03:50 AM\n 04:15 PM\n 02:46 AM\n 03:02 AM\n 09:03 AM\n 03:28 AM\n 08:25 AM\n 03:08 PM\n 06:29 AM\n WBC\n 8.7\n 7.1\n 7.3\n Hct\n 30.2\n 28.5\n 27.9\n Plt\n 189\n 142\n 137\n Cr\n 0.6\n 0.6\n 0.6\n 0.6\n 0.6\n 0.6\n TCO2\n 30\n 28\n 28\n 30\n Glucose\n 85\n 139\n 150\n 145\n 148\n 105\n NO labs this AM\n - Blood CX () growing yeast\n - Urine CX () growing >100K yeast, growing ~9000 yeast\n Assessment and Plan\n 35 yo M with PMH of CP, seizure disorder, GIB, pancreatic cyst s/p\n drainage in , admitted with abdominal pain with complicated course\n now with fever, hypoxemia, blood culture growing yeast.\n .\n # Hypoxemia: Patient transferred to MICU with tachypnea and hypoxia\n on and intubated on . Imaging findings consistent with\n multilobar pneumonia with sputum growing MRSA, complted 8 day course of\n vanc, cefepime, and flagyl on . Pleural effusions also noted on\n imaging, likely due to fluid resuscitation for hypotension in the\n setting of albumin of 2.3, so have been diuresing with lasix boluses.\n Extubated on . The current respiratory distress is likely due\n to mucous plugging, secretions with rhonchorous breath sounds on exam.\n Pulmonary edema may also be contributing.\n - suction and light chest PT\n - continue gentle diuresis with lasix 40mg IV boluses to goal -500cc\n - change pantoprazole from IV to PO to limit amount of IVF\n - follow ABGs\n - f/u blood cultures\n - morphine for grunting/resp distress x 1 to see if helpful\n - will discuss non-invasive pressure ventilation if necessary with\n family\n .\n # Yeast bacteremia: Patient continues to have fevers, now with\n positive urine and blood cultures growing yeast. Possible urogenital\n source with hematogenous spread. Heart rate and blood pressure\n currently at baseline. Normal WBC count, lactate.\n - daily blood cultures\n - TTE\n - pull PICC line and attempt peripheral access or if unable central\n line for temporary access\n - start fluconazole 200 IV (6mg/kg)\n - foley catheter changed overnight\n - ophthalmologic evaluation\n - check LFT, EKG\n - f/u aspergillus, beta glucan\n .\n #Fevers: Patient daily low grade febrile episodes despite broad\n spectrum antibiotics. Completed treatment for pulmonary infection with\n 8 day course of vancomycin, cefepime, flagyl. SBP possible but 3 taps\n have not been c/w SBP. PE considered but no evidence on CTA. CT read\n as possible liver abscess but repeat RUQ ultrasound read as more\n consistent with infarct. C. Diff has been negative. Overnight\n positive urine and blood culture growing yeast.\n - treatment for yeast bloodstream infection as above\n -\n # Tachycardia: Likely hyperdynamic in setting of fever, infection.\n Volume status appears grossly euvolemic; pt mentating at baseline and\n maintaining urine output. Echo with evidence of depressed cardiac fxn,\n ? tachycardia induced cardiomyopathy\n - Tylenol prn fever\n - Antimicrobial agents as above\n .\n # Anemia/bleed: Hct stable. Pt with RP bleed and CT evidence of\n hemorrhage into bowel wall, also gastric varices c/b GIB earlier in\n admission. Transfused 1 unit pRBCs with appropriate bump and has\n remained stable since.\n - Trend Hct\n - Guaiac stools\n - Active T&S\n - change pantoprazole to PO\n - Continue iron supplement\n # Liver lesion. Noted on abdominal CT. Possible ischemia/infarction vs\n abscess. Abdominal U/S not consistent with abscess.\n .\n # Left humeral fx: Likely d/t trauma sustained during radiology.\n - No surgical indication at this time\n - Pain control with lidoderm patch and morphine prn\n .\n # SMV thrombus: Plan for anticoagulation x 6 months but held in setting\n of recent GI and RP bleed.\n - Continue heparin SQ\n .\n # Seizure disorder: No recent reports of seizures. Caution as certain\n antibiotics may lower seizure threshold.\n - Continue phenobarbitol and phenytoin\n - drug levels stable as of , continue to monitor\n .\n # Cerebral palsy: Stable mental status. Interactive with family but\n nonverbal at baseline.\n .\n FEN: continue tube feeds today\n PROPHYLAXIS: pneumoboots, PO PPI\n ACCESS: PICC, A-line in right brachial artery\n CODE: Do not resuscitate/Do not re-intubate. No CPR or defibrillation.\n Will clarify role for BIPAP/CPAP.\n ICU Care\n Nutrition:\n Vivonex (Full) - 10:05 AM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 11:14 AM\n Arterial Line - 11:10 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2115-04-02 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 632442,
"text": "Chief Complaint:\n 24 Hour Events:\n - Blood CX () growing yeast\n - Urine CX () growing >100K yeast\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 06:00 PM\n Vancomycin - 08:00 PM\n Cefipime - 10:00 PM\n Fluconazole - 01:56 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:46 PM\n Furosemide (Lasix) - 11:08 PM\n Morphine Sulfate - 12:24 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 37.7\nC (99.8\n HR: 116 (112 - 134) bpm\n BP: 83/63(72) {76/53(62) - 115/83(97)} mmHg\n RR: 39 (24 - 47) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 2,616 mL\n 548 mL\n PO:\n TF:\n 1,896 mL\n 332 mL\n IVF:\n 600 mL\n 216 mL\n Blood products:\n Total out:\n 930 mL\n 740 mL\n Urine:\n 930 mL\n 740 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,686 mL\n -192 mL\n Respiratory support\n O2 Delivery Device: Face tent 15L 70% FiO2\n SpO2: 97%\n ABG: 7.44/43/128/25/5\n Physical Examination\n Gen: Thin, opening eyes but no clear orientation to voice; grunting\n this morning and appears uncomfortable\n HEENT: Sclera anicteric, eyes sunken, MMM, audible secretions\n Neck: Supple\n Lungs: Intubated, coarse BS bilaterally with diffuse ronchi\n CV: S1, S2 regular rhythm, increased rate\n Abdomen: Soft, BS+, distended, no facial grimacing to palpation\n GU: foley catheter in place\n Ext: Warm, cachectic, BLE contractures, + DP pulses\n Labs / Radiology\n 137 K/uL\n 9.1 g/dL\n 105 mg/dL\n 0.6 mg/dL\n 25 mEq/L\n 4.8 mEq/L\n 23 mg/dL\n 107 mEq/L\n 142 mEq/L\n 27.9 %\n 7.3 K/uL\n [image002.jpg]\n 02:23 PM\n 03:50 AM\n 04:15 PM\n 02:46 AM\n 03:02 AM\n 09:03 AM\n 03:28 AM\n 08:25 AM\n 03:08 PM\n 06:29 AM\n WBC\n 8.7\n 7.1\n 7.3\n Hct\n 30.2\n 28.5\n 27.9\n Plt\n 189\n 142\n 137\n Cr\n 0.6\n 0.6\n 0.6\n 0.6\n 0.6\n 0.6\n TCO2\n 30\n 28\n 28\n 30\n Glucose\n 85\n 139\n 150\n 145\n 148\n 105\n NO labs this AM\n - Blood CX () growing yeast\n - Urine CX () growing >100K yeast, growing ~9000 yeast\n Assessment and Plan\n 35 yo M with PMH of CP, seizure disorder, GIB, pancreatic cyst s/p\n drainage in , admitted with abdominal pain with complicated course\n now with fever, hypoxemia, blood culture growing yeast.\n .\n # Hypoxemia: Patient transferred to MICU with tachypnea and hypoxia\n on and intubated on . Imaging findings consistent with\n multilobar pneumonia with sputum growing MRSA, complted 8 day course of\n vanc, cefepime, and flagyl on . Pleural effusions also noted on\n imaging, likely due to fluid resuscitation for hypotension in the\n setting of albumin of 2.3, so have been diuresing with lasix boluses.\n Extubated on . The current respiratory distress is likely due\n to mucous plugging, secretions with rhonchorous breath sounds on exam.\n Pulmonary edema may also be contributing.\n - suction and light chest PT\n - continue gentle diuresis with lasix 40mg IV boluses to goal -500cc\n - change pantoprazole from IV to PO to limit amount of IVF\n - follow ABGs\n - f/u blood cultures\n - morphine for grunting/resp distress x 1 to see if helpful\n - will discuss non-invasive pressure ventilation if necessary with\n family\n .\n # Yeast bacteremia: Patient continues to have fevers, now with\n positive urine and blood cultures growing yeast. Possible urogenital\n source with hematogenous spread. Heart rate and blood pressure\n currently at baseline. Normal WBC count, lactate.\n - daily blood cultures\n - TTE\n - pull picc line pending obtainment of new temporary central/peripheral\n access\n - start fluconazole 200 IV (6mg/kg)\n - foley catheter changed overnight\n - ophthalmologic evaluation\n - check LFT, EKG\n - f/u aspergillus, beta glucan\n .\n #Fevers: Patient daily low grade febrile episodes despite broad\n spectrum antibiotics. Completed treatment for pulmonary infection with\n 8 day course of vancomycin, cefepime, flagyl. SBP possible but 3 taps\n have not been c/w SBP. PE considered but no evidence on CTA. CT read\n as possible liver abscess but repeat RUQ ultrasound read as more\n consistent with infarct. C. Diff has been negative. Overnight\n positive urine and blood culture growing yeast.\n - treatment for yeast bloodstream infection as above\n -\n # Tachycardia: Likely hyperdynamic in setting of fever, infection.\n Volume status appears grossly euvolemic; pt mentating at baseline and\n maintaining urine output. Echo with evidence of depressed cardiac fxn,\n ? tachycardia induced cardiomyopathy\n - Tylenol prn fever\n - Antimicrobial agents as above\n .\n # Anemia/bleed: Hct stable. Pt with RP bleed and CT evidence of\n hemorrhage into bowel wall, also gastric varices c/b GIB earlier in\n admission. Transfused 1 unit pRBCs with appropriate bump and has\n remained stable since.\n - Trend Hct\n - Guaiac stools\n - Active T&S\n - change pantoprazole to PO\n - Continue iron supplement\n # Liver lesion. Noted on abdominal CT. Possible ischemia/infarction vs\n abscess. Abdominal U/S not consistent with abscess.\n .\n # Left humeral fx: Likely d/t trauma sustained during radiology.\n - No surgical indication at this time\n - Pain control with lidoderm patch and morphine prn\n .\n # SMV thrombus: Plan for anticoagulation x 6 months but held in setting\n of recent GI and RP bleed.\n - Continue heparin SQ\n .\n # Seizure disorder: No recent reports of seizures. Caution as certain\n antibiotics may lower seizure threshold.\n - Continue phenobarbitol and phenytoin\n - drug levels stable as of , continue to monitor\n .\n # Cerebral palsy: Stable mental status. Interactive with family but\n nonverbal at baseline.\n .\n FEN: continue tube feeds today\n PROPHYLAXIS: pneumoboots, PO PPI\n ACCESS: PICC, A-line in right brachial artery\n CODE: Do not resuscitate/Do not re-intubate. No CPR or defibrillation.\n Will clarify role for BIPAP/CPAP.\n ICU Care\n Nutrition:\n Vivonex (Full) - 10:05 AM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 11:14 AM\n Arterial Line - 11:10 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2115-04-02 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 632443,
"text": "Chief Complaint:\n 24 Hour Events:\n - Blood CX () growing yeast\n - Urine CX () growing >100K yeast\n - IV team evaluated\n no peripheral access, needs central line\n -\n Received pt on 5 LNC, 40% face tent. Lungs clear diminished at bases.\n Strong productive cough for thick white secretions. Sats 87-88% at\n beginning of shift. RR consistently mid 40\n 40 mg IV lasix given, 2 mg morphine given. FiO2 increased to 100%\n 500 cc response to lasix but remains + for day. 02 weaned to 70% AM\n ABG 7.44/43/128 RR continues to be elevated to mid 30\n Gentle CPT as tolerated. Wean O2, gentle diuresis.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 06:00 PM\n Vancomycin - 08:00 PM\n Cefipime - 10:00 PM\n Fluconazole - 01:56 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:46 PM\n Furosemide (Lasix) - 11:08 PM\n Morphine Sulfate - 12:24 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 37.7\nC (99.8\n HR: 116 (112 - 134) bpm\n BP: 83/63(72) {76/53(62) - 115/83(97)} mmHg\n RR: 39 (24 - 47) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 2,616 mL\n 548 mL\n PO:\n TF:\n 1,896 mL\n 332 mL\n IVF:\n 600 mL\n 216 mL\n Blood products:\n Total out:\n 930 mL\n 740 mL\n Urine:\n 930 mL\n 740 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,686 mL\n -192 mL\n Respiratory support\n O2 Delivery Device: Face tent 15L 70% FiO2\n SpO2: 97%\n ABG: 7.44/43/128/25/5\n Physical Examination\n Gen: Thin, opening eyes but no clear orientation to voice; grunting\n this morning and appears uncomfortable\n HEENT: Sclera anicteric, eyes sunken, MMM, audible secretions\n Neck: Supple\n Lungs: Intubated, coarse BS bilaterally with diffuse ronchi\n CV: S1, S2 regular rhythm, increased rate\n Abdomen: Soft, BS+, distended, no facial grimacing to palpation\n GU: foley catheter in place\n Ext: Warm, cachectic, BLE contractures, + DP pulses\n Labs / Radiology\n 137 K/uL\n 9.1 g/dL\n 105 mg/dL\n 0.6 mg/dL\n 25 mEq/L\n 4.8 mEq/L\n 23 mg/dL\n 107 mEq/L\n 142 mEq/L\n 27.9 %\n 7.3 K/uL\n [image002.jpg]\n 02:23 PM\n 03:50 AM\n 04:15 PM\n 02:46 AM\n 03:02 AM\n 09:03 AM\n 03:28 AM\n 08:25 AM\n 03:08 PM\n 06:29 AM\n WBC\n 8.7\n 7.1\n 7.3\n Hct\n 30.2\n 28.5\n 27.9\n Plt\n 189\n 142\n 137\n Cr\n 0.6\n 0.6\n 0.6\n 0.6\n 0.6\n 0.6\n TCO2\n 30\n 28\n 28\n 30\n Glucose\n 85\n 139\n 150\n 145\n 148\n 105\n NO labs this AM\n - Blood CX () growing yeast\n - Urine CX () growing >100K yeast, growing ~9000 yeast\n Assessment and Plan\n 35 yo M with PMH of CP, seizure disorder, GIB, pancreatic cyst s/p\n drainage in , admitted with abdominal pain with complicated course\n now with fever, hypoxemia, blood culture growing yeast.\n .\n # Hypoxemia: Patient transferred to MICU with tachypnea and hypoxia\n on and intubated on . Imaging findings consistent with\n multilobar pneumonia with sputum growing MRSA, complted 8 day course of\n vanc, cefepime, and flagyl on . Pleural effusions also noted on\n imaging, likely due to fluid resuscitation for hypotension in the\n setting of albumin of 2.3, so have been diuresing with lasix boluses.\n Extubated on . The current respiratory distress is likely due\n to mucous plugging, secretions with rhonchorous breath sounds on exam.\n Pulmonary edema may also be contributing.\n - suction and light chest PT\n - continue gentle diuresis with lasix 40mg IV boluses to goal -500cc\n - change pantoprazole from IV to PO to limit amount of IVF\n - follow ABGs\n - f/u blood cultures\n - morphine for grunting/resp distress x 1 to see if helpful\n - will discuss non-invasive pressure ventilation if necessary with\n family\n .\n # Yeast bacteremia: Patient continues to have fevers, now with\n positive urine and blood cultures growing yeast. Possible urogenital\n source with hematogenous spread. Heart rate and blood pressure\n currently at baseline. Normal WBC count, lactate.\n - daily blood cultures\n - TTE\n - pull picc line and arterial line pending obtainment of new central\n access\n - start fluconazole 200 IV (6mg/kg)\n - foley catheter changed overnight\n - ophthalmologic evaluation\n - check LFT, EKG\n - f/u aspergillus, beta glucan\n .\n #Fevers: Patient daily low grade febrile episodes despite broad\n spectrum antibiotics. Completed treatment for pulmonary infection with\n 8 day course of vancomycin, cefepime, flagyl. SBP possible but 3 taps\n have not been c/w SBP. PE considered but no evidence on CTA. CT read\n as possible liver abscess but repeat RUQ ultrasound read as more\n consistent with infarct. C. Diff has been negative. Overnight\n positive urine and blood culture growing yeast.\n - treatment for yeast bloodstream infection as above\n -\n # Tachycardia: Likely hyperdynamic in setting of fever, infection.\n Volume status appears grossly euvolemic; pt mentating at baseline and\n maintaining urine output. Echo with evidence of depressed cardiac fxn,\n ? tachycardia induced cardiomyopathy\n - Tylenol prn fever\n - Antimicrobial agents as above\n .\n # Anemia/bleed: Hct stable. Pt with RP bleed and CT evidence of\n hemorrhage into bowel wall, also gastric varices c/b GIB earlier in\n admission. Transfused 1 unit pRBCs with appropriate bump and has\n remained stable since.\n - Trend Hct\n - Guaiac stools\n - Active T&S\n - change pantoprazole to PO\n - Continue iron supplement\n # Liver lesion. Noted on abdominal CT. Possible ischemia/infarction vs\n abscess. Abdominal U/S not consistent with abscess.\n .\n # Left humeral fx: Likely d/t trauma sustained during radiology.\n - No surgical indication at this time\n - Pain control with lidoderm patch and morphine prn\n .\n # SMV thrombus: Plan for anticoagulation x 6 months but held in setting\n of recent GI and RP bleed.\n - Continue heparin SQ\n .\n # Seizure disorder: No recent reports of seizures. Caution as certain\n antibiotics may lower seizure threshold.\n - Continue phenobarbitol and phenytoin\n - drug levels stable as of , continue to monitor\n .\n # Cerebral palsy: Stable mental status. Interactive with family but\n nonverbal at baseline.\n .\n FEN: continue tube feeds today\n PROPHYLAXIS: pneumoboots, PO PPI\n ACCESS: PICC, A-line in right brachial artery\n CODE: Do not resuscitate/Do not re-intubate. No CPR or defibrillation.\n Will clarify role for BIPAP/CPAP.\n ICU Care\n Nutrition:\n Vivonex (Full) - 10:05 AM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 11:14 AM\n Arterial Line - 11:10 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2115-04-02 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 632467,
"text": "Chief Complaint:\n 24 Hour Events:\n - Blood CX () growing yeast\n - Urine CX () growing >100K yeast\n - IV team evaluated\n no peripheral access, needs central line\n -\n Received pt on 5 LNC, 40% face tent. Lungs clear diminished at bases.\n Strong productive cough for thick white secretions. Sats 87-88% at\n beginning of shift. RR consistently mid 40\n 40 mg IV lasix given, 2 mg morphine given. FiO2 increased to 100%\n 500 cc response to lasix but remains + for day. 02 weaned to 70% AM\n ABG 7.44/43/128 RR continues to be elevated to mid 30\n Gentle CPT as tolerated. Wean O2, gentle diuresis.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 06:00 PM\n Vancomycin - 08:00 PM\n Cefipime - 10:00 PM\n Fluconazole - 01:56 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:46 PM\n Furosemide (Lasix) - 11:08 PM\n Morphine Sulfate - 12:24 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 37.7\nC (99.8\n HR: 116 (112 - 134) bpm\n BP: 83/63(72) {76/53(62) - 115/83(97)} mmHg\n RR: 39 (24 - 47) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 2,616 mL\n 548 mL\n PO:\n TF:\n 1,896 mL\n 332 mL\n IVF:\n 600 mL\n 216 mL\n Blood products:\n Total out:\n 930 mL\n 740 mL\n Urine:\n 930 mL\n 740 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,686 mL\n -192 mL\n Respiratory support\n O2 Delivery Device: Face tent 15L 70% FiO2\n SpO2: 97%\n ABG: 7.44/43/128/25/5\n Physical Examination\n Gen: Thin, opening eyes but no clear orientation to voice; grunting\n this morning and appears uncomfortable\n HEENT: Sclera anicteric, eyes sunken, MMM, audible secretions\n Neck: Supple\n Lungs: Intubated, coarse BS bilaterally with diffuse ronchi\n CV: S1, S2 regular rhythm, increased rate\n Abdomen: Soft, BS+, distended, no facial grimacing to palpation\n GU: foley catheter in place\n Ext: Warm, cachectic, BLE contractures, + DP pulses\n Labs / Radiology\n 137 K/uL\n 9.1 g/dL\n 105 mg/dL\n 0.6 mg/dL\n 25 mEq/L\n 4.8 mEq/L\n 23 mg/dL\n 107 mEq/L\n 142 mEq/L\n 27.9 %\n 7.3 K/uL\n [image002.jpg]\n 02:23 PM\n 03:50 AM\n 04:15 PM\n 02:46 AM\n 03:02 AM\n 09:03 AM\n 03:28 AM\n 08:25 AM\n 03:08 PM\n 06:29 AM\n WBC\n 8.7\n 7.1\n 7.3\n Hct\n 30.2\n 28.5\n 27.9\n Plt\n 189\n 142\n 137\n Cr\n 0.6\n 0.6\n 0.6\n 0.6\n 0.6\n 0.6\n TCO2\n 30\n 28\n 28\n 30\n Glucose\n 85\n 139\n 150\n 145\n 148\n 105\n NO labs this AM\n - Blood CX () growing yeast\n - Urine CX () growing >100K yeast, growing ~9000 yeast\n Assessment and Plan\n 35 yo M with PMH of CP, seizure disorder, GIB, pancreatic cyst s/p\n drainage in , admitted with abdominal pain with complicated course\n now with fever, hypoxemia, blood culture growing yeast.\n .\n # Hypoxemia: Patient transferred to MICU with tachypnea and hypoxia\n on and intubated on . Imaging findings consistent with\n multilobar pneumonia with sputum growing MRSA, complted 8 day course of\n vanc, cefepime, and flagyl on . Pleural effusions also noted on\n imaging, likely due to fluid resuscitation for hypotension in the\n setting of albumin of 2.3, so have been diuresing with lasix boluses.\n Extubated on . The current respiratory distress is likely due\n to mucous plugging, secretions with rhonchorous breath sounds on exam.\n Pulmonary edema may also be contributing.\n - suction and light chest PT\n - continue gentle diuresis with lasix 40mg IV boluses to goal -500cc\n - change pantoprazole from IV to PO to limit amount of IVF\n - follow ABGs\n - f/u blood cultures\n - morphine for grunting/resp distress x 1 to see if helpful\n - will discuss non-invasive pressure ventilation if necessary with\n family\n .\n # Yeast bacteremia: Patient continues to have fevers, now with\n positive urine and blood cultures growing yeast. Possible urogenital\n source with hematogenous spread. Heart rate and blood pressure\n currently at baseline. Normal WBC count, lactate.\n - daily blood cultures\n - TTE\n - pull picc line and arterial line pending obtainment of new central\n access\n - d/c fluconazone for micafungin pending speciation\n - foley catheter changed overnight\n may be able to transition to\n condom catheter\n - ophthalmologic evaluation\n - check LFT, EKG\n - f/u aspergillus, beta glucan\n .\n #Fevers: Patient daily low grade febrile episodes despite broad\n spectrum antibiotics. Completed treatment for pulmonary infection with\n 8 day course of vancomycin, cefepime, flagyl. SBP possible but 3 taps\n have not been c/w SBP. PE considered but no evidence on CTA. CT read\n as possible liver abscess but repeat RUQ ultrasound read as more\n consistent with infarct. C. Diff has been negative. Overnight\n positive urine and blood culture growing yeast.\n - treatment for yeast bloodstream infection as above\n -\n # Tachycardia: Likely hyperdynamic in setting of fever, infection.\n Volume status appears grossly euvolemic; pt mentating at baseline and\n maintaining urine output. Echo with evidence of depressed cardiac fxn,\n ? tachycardia induced cardiomyopathy\n - Tylenol prn fever\n - Antimicrobial agents as above\n .\n # Anemia/bleed: Hct stable. Pt with RP bleed and CT evidence of\n hemorrhage into bowel wall, also gastric varices c/b GIB earlier in\n admission. Transfused 1 unit pRBCs with appropriate bump and has\n remained stable since.\n - Trend Hct\n - Guaiac stools\n - Active T&S\n - change pantoprazole to PO\n - Continue iron supplement\n # Liver lesion. Noted on abdominal CT. Possible ischemia/infarction vs\n abscess. Abdominal U/S not consistent with abscess.\n .\n # Left humeral fx: Likely d/t trauma sustained during radiology.\n - No surgical indication at this time\n - Pain control with lidoderm patch and morphine prn\n .\n # SMV thrombus: Plan for anticoagulation x 6 months but held in setting\n of recent GI and RP bleed.\n - Continue heparin SQ\n .\n # Seizure disorder: No recent reports of seizures. Caution as certain\n antibiotics may lower seizure threshold.\n - Continue phenobarbitol and phenytoin, but transition to PO route\n - drug levels stable as of , continue to monitor\n .\n # Cerebral palsy: Stable mental status. Interactive with family but\n nonverbal at baseline.\n - speech and swallow evaluation\n .\n FEN: continue tube feeds today\n PROPHYLAXIS: pneumoboots, PO PPI\n ACCESS: PICC, A-line in right brachial artery\n CODE: Do not resuscitate/Do not re-intubate. No CPR or defibrillation.\n Will clarify role for BIPAP/CPAP.\n ICU Care\n Nutrition:\n Vivonex (Full) - 10:05 AM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 11:14 AM\n Arterial Line - 11:10 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2115-04-02 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 632468,
"text": "Chief Complaint: respiratory failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 35 yo man with cerebral palsy, recurrent aspiration, prolonged\n aspiration. Blood cx from with yeast.\n Has contiued thick secretions and significant oxygen requirement.\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 06:00 PM\n Vancomycin - 08:00 PM\n Cefipime - 10:00 PM\n Fluconazole - 01:56 AM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 12:24 AM\n Pantoprazole (Protonix) - 08:20 AM\n Furosemide (Lasix) - 08:20 AM\n Other medications:\n SSI\n miconazole\n phosphenytoin\n lidocaine\n patch\n FeSO4\n pancrealipase\n protonix\n fluconazole\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 37.9\nC (100.3\n HR: 111 (111 - 130) bpm\n BP: 87/64(75) {76/53(62) - 100/72(84)} mmHg\n RR: 30 (24 - 47) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 2,616 mL\n 810 mL\n PO:\n TF:\n 1,896 mL\n 500 mL\n IVF:\n 600 mL\n 310 mL\n Blood products:\n Total out:\n 930 mL\n 880 mL\n Urine:\n 930 mL\n 880 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,686 mL\n -70 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, Face tent\n SpO2: 98%\n ABG: 7.44/43/128/28/5\n PaO2 / FiO2: 183\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Diminished), (Left radial\n pulse: Diminished), (Right DP pulse: Not assessed), (Left DP pulse: Not\n assessed)\n Respiratory / Chest: (Breath Sounds: Rhonchorous: b/l)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace\n Musculoskeletal: Unable to stand\n Skin: Warm\n Neurologic: Attentive, No(t) Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 8.9 g/dL\n 147 K/uL\n 159 mg/dL\n 0.5 mg/dL\n 28 mEq/L\n 3.9 mEq/L\n 28 mg/dL\n 107 mEq/L\n 143 mEq/L\n 26.5 %\n 8.1 K/uL\n [image002.jpg]\n 03:50 AM\n 04:15 PM\n 02:46 AM\n 03:02 AM\n 09:03 AM\n 03:28 AM\n 08:25 AM\n 03:08 PM\n 06:23 AM\n 06:29 AM\n WBC\n 8.7\n 7.1\n 7.3\n 8.1\n Hct\n 30.2\n 28.5\n 27.9\n 26.5\n Plt\n 189\n 142\n 137\n 147\n Cr\n 0.6\n 0.6\n 0.6\n 0.6\n 0.6\n 0.5\n TCO2\n 30\n 28\n 28\n 30\n Glucose\n 139\n 150\n 145\n 148\n 105\n 159\n Other labs: PT / PTT / INR:15.7/24.4/1.4, CK / CKMB /\n Troponin-T:8//0.01, ALT / AST:, Alk Phos / T Bili:150/0.3, Amylase\n / Lipase:/11, Differential-Neuts:86.5 %, Lymph:6.6 %, Mono:5.9 %,\n Eos:0.9 %, Lactic Acid:1.6 mmol/L, Albumin:2.5 g/dL, LDH:314 IU/L,\n Ca++:7.3 mg/dL, Mg++:1.8 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n Respiratory distress/hypoxemia: still with evidence of pumonary edema\n and poor secretion clearance.\n - Continue pulmonary toilette and diuresis\n Yeast bacteremia from PIC line: Will need lines removed. On\n micafungin. Will attempt to place peripheral IV through U/S.\n seizure disorder: make meds PO.\n Can get S+S eval.\n ICU Care\n Nutrition:\n Vivonex (Full) - 10:05 AM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 11:14 AM\n Arterial Line - 11:10 PM\n Prophylaxis:\n DVT:\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2115-04-03 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 632662,
"text": "Chief Complaint: respiratory failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 35 yo man with cerebral palsy, respiratory failure, aspiration PNA.\n Had PIC line removed yesterday. EJ placed.\n 24 Hour Events:\n ARTERIAL LINE - STOP 12:25 PM\n PARACENTESIS - At 04:00 PM\n TRANSTHORACIC ECHO - At 04:51 PM\n PICC LINE - STOP 08:30 PM\n dual lumen\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Fluconazole - 01:56 AM\n Micafungin - 06:00 PM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 06:00 AM\n Other medications:\n SSI\n lidocaine patch\n FeSO4\n pancrease\n phenobarb\n prevacid\n dilantin\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.9\nC (100.2\n Tcurrent: 37.9\nC (100.2\n HR: 117 (99 - 118) bpm\n BP: 91/61(67) {84/45(56) - 101/70(87)} mmHg\n RR: 25 (21 - 37) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 1,976 mL\n 681 mL\n PO:\n 200 mL\n TF:\n 1,206 mL\n 568 mL\n IVF:\n 451 mL\n 114 mL\n Blood products:\n Total out:\n 1,700 mL\n 920 mL\n Urine:\n 1,700 mL\n 920 mL\n NG:\n Stool:\n Drains:\n Balance:\n 276 mL\n -239 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, Face tent\n SpO2: 100%\n ABG: ///30/\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Diminished: diminished at bases)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Warm\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 8.9 g/dL\n 146 K/uL\n 65 mg/dL\n 0.5 mg/dL\n 30 mEq/L\n 3.7 mEq/L\n 27 mg/dL\n 106 mEq/L\n 143 mEq/L\n 26.6 %\n 6.7 K/uL\n [image002.jpg]\n 02:46 AM\n 03:02 AM\n 09:03 AM\n 03:28 AM\n 08:25 AM\n 03:08 PM\n 06:23 AM\n 06:29 AM\n 05:37 PM\n 06:16 AM\n WBC\n 7.1\n 7.3\n 8.1\n 6.7\n Hct\n 28.5\n 27.9\n 26.5\n 26.6\n Plt\n 142\n 137\n 147\n 146\n Cr\n 0.6\n 0.6\n 0.6\n 0.5\n 0.6\n 0.5\n TCO2\n 30\n 28\n 28\n 30\n Glucose\n 145\n 148\n 105\n 159\n 145\n 65\n Other labs: PT / PTT / INR:14.1/25.1/1.2, CK / CKMB /\n Troponin-T:8//0.01, ALT / AST:13/27, Alk Phos / T Bili:156/0.2, Amylase\n / Lipase:/11, Differential-Neuts:84.2 %, Lymph:10.2 %, Mono:4.1 %,\n Eos:1.3 %, Lactic Acid:1.6 mmol/L, Albumin:2.5 g/dL, LDH:314 IU/L,\n Ca++:7.7 mg/dL, Mg++:1.8 mg/dL, PO4:2.7 mg/dL\n Fluid analysis / Other labs: peritoneal fluid: 300 WBC, 19% neutraphils\n Microbiology: cath tip cx: pending\n Assessment and Plan\n Acute on chronic systolic hear failure with valvular disease: continue\n diuresis for pulmonary edema.\n fungemia: follow-up cx have been negative. continue micafungin.\n follow up on PIC tip culture.\n Fever curve: slighly improved. Paracentesis with no evidence of SBP.\n To get S+S study today.\n seizure disorder: on phenobarb and dilantin\n ICU Care\n Nutrition:\n Vivonex (Full) - 09:48 AM 50 mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 07:00 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2115-04-03 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 632663,
"text": "Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - STOP 12:25 PM\n PARACENTESIS - At 04:00 PM\n TRANSTHORACIC ECHO - At 04:51 PM\n PICC LINE - STOP 08:30 PM\n dual lumen\n - ID consult: Change fluconazole to micafungin.\n - Ophthalmology consult: difficult exam, no apparent chororetinal\n lesions. Corneal Scarring. Recommend repeat dilated fundoscopic exam if\n patient having ANY procedure requiring general anesthesia. Otherwise,\n repeat DFE in 2 weeks. Recommend lacrilub drops.\n - diagnostic paracentesis : sanguinous fluid aspirated, albumin\n 1.1, protein 2.3, glucose 121, LDH 160, WBC 300, RBC , diff\n PENDING\n - right EJ peripheral line placed\n - 40 Lasix in AM and in PM; still positive\n - video swallow study \n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Fluconazole - 01:56 AM\n Micafungin - 06:00 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:20 AM\n Furosemide (Lasix) - 06:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 37.2\nC (98.9\n HR: 116 (101 - 118) bpm\n BP: 101/66(73) {81/45(39) - 101/71(79)} mmHg\n RR: 30 (23 - 41) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 1,976 mL\n 443 mL\n PO:\n 200 mL\n TF:\n 1,206 mL\n 369 mL\n IVF:\n 451 mL\n 74 mL\n Blood products:\n Total out:\n 1,700 mL\n 160 mL\n Urine:\n 1,700 mL\n 160 mL\n NG:\n Stool:\n Drains:\n Balance:\n 276 mL\n 284 mL\n Respiratory support\n SpO2: 100%\n Physical Examination\n Labs / Radiology\n 146 K/uL\n 8.9 g/dL\n 145 mg/dL\n 0.6 mg/dL\n 26 mEq/L\n 3.5 mEq/L\n 28 mg/dL\n 107 mEq/L\n 145 mEq/L\n 26.6 %\n 6.7 K/uL\n [image002.jpg]\n 02:46 AM\n 03:02 AM\n 09:03 AM\n 03:28 AM\n 08:25 AM\n 03:08 PM\n 06:23 AM\n 06:29 AM\n 05:37 PM\n 06:16 AM\n WBC\n 7.1\n 7.3\n 8.1\n 6.7\n Hct\n 28.5\n 27.9\n 26.5\n 26.6\n Plt\n 142\n 137\n 147\n 146\n Cr\n 0.6\n 0.6\n 0.6\n 0.5\n 0.6\n TCO2\n 30\n 28\n 28\n 30\n Glucose\n 145\n 148\n 105\n 159\n 145\n Other labs: PT / PTT / INR:14.1/25.1/1.2,\n Peritoneal fluid: 300WBC, 19 PMN, 41L, 40mono, 89000RBC\n Micro:\n - catheter tip: pending\n -yeast urine/blood cx speciation: pending\n TTE:\n IMPRESSION: Moderately thickened and deformed aortic valve leaflets\n with moderate to severe stenosis. At least moderate mitral\n regurgitation. Small echodensity in the left atrium adjacent to the\n anterior leaflet of the mitral valve (clip ) which appears consistent\n with artifact from mitral annular and valvular calcification; however,\n a small vegetation cannot be excluded. Mild global biventricular\n hypokinesis.\n If clinically suggested, the absence of a vegetation by 2D\n echocardiography does not exclude endocarditis.\n Compared with the prior study (images reviewed) of , the\n findings are similar.\n Assessment and Plan\n 35 yo M with PMH of CP, seizure disorder, GIB, pancreatic cyst s/p\n drainage in , admitted with abdominal pain with complicated course\n now with fever, hypoxemia, blood culture growing yeast.\n .\n # Hypoxemia: Patient transferred to MICU with tachypnea and hypoxia\n on and intubated on . Imaging findings consistent with\n multilobar pneumonia with sputum growing MRSA, complted 8 day course of\n vanc, cefepime, and flagyl on . Pleural effusions also noted on\n imaging, likely due to fluid resuscitation for hypotension in the\n setting of albumin of 2.3, so have been diuresing with lasix boluses.\n Extubated on . The current respiratory distress is likely due\n to mucous plugging, secretions with rhonchorous breath sounds on exam.\n Pulmonary edema may also be contributing.\n - suction and light chest PT\n - continue gentle diuresis with lasix 40mg IV boluses to go even to\n -500cc negative\n - follow ABGs\n - morphine for grunting/resp distress x 1 to see if helpful\n - will discuss non-invasive pressure ventilation if necessary with\n family\n .\n # Yeast bacteremia: Patient continues to have fevers, now with\n positive urine and blood cultures growing yeast. Possible urogenital\n source with hematogenous spread. Heart rate and blood pressure\n currently at baseline. Normal WBC count, lactate.\n - follow fever curve\n - daily blood cultures\n - follow speciation and sensitivity\n - continue micafungin IV\n - f/u ID recs\n - follow LFT, EKG\n - f/u PICC tip culture\n - f/u aspergillus, beta glucan\n .\n #Fevers: Patient daily low grade febrile episodes despite broad\n spectrum antibiotics. Completed treatment for pulmonary infection with\n 8 day course of vancomycin, cefepime, flagyl. SBP possible but 3 taps\n have not been c/w SBP. PE considered but no evidence on CTA. CT read\n as possible liver abscess but repeat RUQ ultrasound read as more\n consistent with infarct. C. Diff has been negative. Overnight\n positive urine and blood culture growing yeast.\n - treatment for yeast bloodstream infection as above\n -\n # Tachycardia: Likely hyperdynamic in setting of fever, infection.\n Volume status appears grossly euvolemic; pt mentating at baseline and\n maintaining urine output. Echo with evidence of depressed cardiac fxn,\n ? tachycardia induced cardiomyopathy\n - Tylenol prn fever\n - Antimicrobial agents as above\n .\n # Anemia/bleed: Hct stable. Pt with RP bleed and CT evidence of\n hemorrhage into bowel wall, also gastric varices c/b GIB earlier in\n admission. Transfused 1 unit pRBCs with appropriate bump and has\n remained stable since.\n - Trend Hct\n - Guaiac stools\n - Active T&S\n - change pantoprazole to PO\n - Continue iron supplement\n # Liver lesion. Noted on abdominal CT. Possible ischemia/infarction vs\n abscess. Abdominal U/S not consistent with abscess.\n .\n # Left humeral fx: Likely d/t trauma sustained during radiology.\n - No surgical indication at this time\n - Pain control with lidoderm patch and morphine prn\n .\n # SMV thrombus: Plan for anticoagulation x 6 months but held in setting\n of recent GI and RP bleed.\n - Continue heparin SQ\n .\n # Seizure disorder: No recent reports of seizures. Caution as certain\n antibiotics may lower seizure threshold.\n - Continue phenobarbitol and phenytoin, but transition to PO route\n - check drug levels\n .\n # Cerebral palsy: Stable mental status. Interactive with family but\n nonverbal at baseline.\n - speech and swallow evaluation\n .\n FEN: continue tube feeds today\n PROPHYLAXIS: pneumoboots, PO PPI\n ACCESS: PICC, A-line in right brachial artery\n CODE: Do not resuscitate/Do not re-intubate. No CPR or defibrillation.\n Will clarify role for BIPAP/CPAP.\n ICU Care\n Nutrition:\n Vivonex (Full) - 09:49 AM 50 mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 07:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2115-04-03 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 632665,
"text": "Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - STOP 12:25 PM\n PARACENTESIS - At 04:00 PM\n TRANSTHORACIC ECHO - At 04:51 PM\n PICC LINE - STOP 08:30 PM\n dual lumen\n - ID consult: Change fluconazole to micafungin.\n - Ophthalmology consult: difficult exam, no apparent chororetinal\n lesions. Corneal Scarring. Recommend repeat dilated fundoscopic exam if\n patient having ANY procedure requiring general anesthesia. Otherwise,\n repeat DFE in 2 weeks. Recommend lacrilub drops.\n - diagnostic paracentesis : sanguinous fluid aspirated, albumin\n 1.1, protein 2.3, glucose 121, LDH 160, WBC 300, RBC , diff\n PENDING\n - right EJ peripheral line placed\n - 40 Lasix in AM and in PM; still positive\n - video swallow study \n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Fluconazole - 01:56 AM\n Micafungin - 06:00 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:20 AM\n Furosemide (Lasix) - 06:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 37.2\nC (98.9\n HR: 116 (101 - 118) bpm\n BP: 101/66(73) {81/45(39) - 101/71(79)} mmHg\n RR: 30 (23 - 41) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 1,976 mL\n 443 mL\n PO:\n 200 mL\n TF:\n 1,206 mL\n 369 mL\n IVF:\n 451 mL\n 74 mL\n Blood products:\n Total out:\n 1,700 mL\n 160 mL\n Urine:\n 1,700 mL\n 160 mL\n NG:\n Stool:\n Drains:\n Balance:\n 276 mL\n 284 mL\n Respiratory support\n SpO2: 100%\n Physical Examination\n Labs / Radiology\n 146 K/uL\n 8.9 g/dL\n 145 mg/dL\n 0.6 mg/dL\n 26 mEq/L\n 3.5 mEq/L\n 28 mg/dL\n 107 mEq/L\n 145 mEq/L\n 26.6 %\n 6.7 K/uL\n [image002.jpg]\n 02:46 AM\n 03:02 AM\n 09:03 AM\n 03:28 AM\n 08:25 AM\n 03:08 PM\n 06:23 AM\n 06:29 AM\n 05:37 PM\n 06:16 AM\n WBC\n 7.1\n 7.3\n 8.1\n 6.7\n Hct\n 28.5\n 27.9\n 26.5\n 26.6\n Plt\n 142\n 137\n 147\n 146\n Cr\n 0.6\n 0.6\n 0.6\n 0.5\n 0.6\n TCO2\n 30\n 28\n 28\n 30\n Glucose\n 145\n 148\n 105\n 159\n 145\n Other labs: PT / PTT / INR:14.1/25.1/1.2,\n Peritoneal fluid: 300WBC, 19 PMN, 41L, 40mono, 89000RBC\n Micro:\n - catheter tip: pending\n -yeast urine/blood cx speciation: pending\n TTE:\n IMPRESSION: Moderately thickened and deformed aortic valve leaflets\n with moderate to severe stenosis. At least moderate mitral\n regurgitation. Small echodensity in the left atrium adjacent to the\n anterior leaflet of the mitral valve (clip ) which appears consistent\n with artifact from mitral annular and valvular calcification; however,\n a small vegetation cannot be excluded. Mild global biventricular\n hypokinesis.\n If clinically suggested, the absence of a vegetation by 2D\n echocardiography does not exclude endocarditis.\n Compared with the prior study (images reviewed) of , the\n findings are similar.\n Assessment and Plan\n 35 yo M with PMH of CP, seizure disorder, GIB, pancreatic cyst s/p\n drainage in , admitted with abdominal pain with complicated course\n now with fever, hypoxemia, blood culture growing yeast.\n .\n # Hypoxemia: Patient transferred to MICU with tachypnea and hypoxia\n on and intubated on . Imaging findings consistent with\n multilobar pneumonia with sputum growing MRSA, complted 8 day course of\n vanc, cefepime, and flagyl on . Pleural effusions also noted on\n imaging, likely due to fluid resuscitation for hypotension in the\n setting of albumin of 2.3, so have been diuresing with lasix boluses.\n Extubated on . The current respiratory distress is likely due\n to mucous plugging, secretions with rhonchorous breath sounds on exam.\n Pulmonary edema may also be contributing.\n - suction and light chest PT\n - continue gentle diuresis with lasix 40mg IV boluses to go even to\n -500cc negative\n - follow ABGs\n - morphine for grunting/resp distress x 1 to see if helpful\n - will discuss non-invasive pressure ventilation if necessary with\n family\n .\n # Yeast bacteremia: Patient continues to have fevers, now with\n positive urine and blood cultures growing yeast. Possible urogenital\n source with hematogenous spread. Heart rate and blood pressure\n currently at baseline. Normal WBC count, lactate.\n - follow fever curve\n - daily blood cultures\n - follow speciation and sensitivity\n - continue micafungin IV\n - f/u ID recs\n - follow LFT, EKG\n - f/u PICC tip culture\n - f/u aspergillus, beta glucan\n .\n #Fevers: Patient daily low grade febrile episodes despite broad\n spectrum antibiotics. Completed treatment for pulmonary infection with\n 8 day course of vancomycin, cefepime, flagyl. SBP possible but 3 taps\n have not been c/w SBP. PE considered but no evidence on CTA. CT read\n as possible liver abscess but repeat RUQ ultrasound read as more\n consistent with infarct. C. Diff has been negative. Overnight\n positive urine and blood culture growing yeast.\n - treatment for yeast bloodstream infection as above\n -\n # Tachycardia: Likely hyperdynamic in setting of fever, infection.\n Volume status appears grossly euvolemic; pt mentating at baseline and\n maintaining urine output. Echo with evidence of depressed cardiac fxn,\n ? tachycardia induced cardiomyopathy\n - Tylenol prn fever\n - Antimicrobial agents as above\n .\n # Anemia/bleed: Hct stable. Pt with RP bleed and CT evidence of\n hemorrhage into bowel wall, also gastric varices c/b GIB earlier in\n admission. Transfused 1 unit pRBCs with appropriate bump and has\n remained stable since.\n - Trend Hct\n - Guaiac stools\n - Active T&S\n - change pantoprazole to PO\n - Continue iron supplement\n # Liver lesion. Noted on abdominal CT. Possible ischemia/infarction vs\n abscess. Abdominal U/S not consistent with abscess.\n .\n # Left humeral fx: Likely d/t trauma sustained during radiology.\n - No surgical indication at this time\n - Pain control with lidoderm patch and morphine prn\n .\n # SMV thrombus: Plan for anticoagulation x 6 months but held in setting\n of recent GI and RP bleed.\n - Continue heparin SQ\n .\n # Seizure disorder: No recent reports of seizures. Caution as certain\n antibiotics may lower seizure threshold.\n - Continue phenobarbitol and phenytoin, but transition to PO route\n - check drug levels\n .\n # Cerebral palsy: Stable mental status. Interactive with family but\n nonverbal at baseline.\n - speech and swallow evaluation\n .\n FEN: continue tube feeds today\n PROPHYLAXIS: pneumoboots, PO PPI\n ACCESS: PICC, A-line in right brachial artery\n CODE: Do not resuscitate/Do not re-intubate. No CPR or defibrillation.\n Will clarify role for BIPAP/CPAP.\n ICU Care\n Nutrition:\n Vivonex (Full) - 09:49 AM 50 mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 07:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2115-04-02 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 632420,
"text": "Chief Complaint:\n 24 Hour Events:\n - Blood CX () growing yeast\n - Urine CX () growing >100K yeast\n - started on floconazole 6mg/kg (talk to ID in AM as may prefer\n micafungin), changed foley catheter, getting daily blood CX, will need\n to pull PICC line,probably needs echo, probably needs ophtho consult,\n check LFT/EKG in AM\n - IV nurse could not get peripheral access (consider EJ vs. PICC)\n - PICC now difficulty flushing and drawing labs off of\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 06:00 PM\n Vancomycin - 08:00 PM\n Cefipime - 10:00 PM\n Fluconazole - 01:56 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:46 PM\n Furosemide (Lasix) - 11:08 PM\n Morphine Sulfate - 12:24 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 37.7\nC (99.8\n HR: 116 (112 - 134) bpm\n BP: 83/63(72) {76/53(62) - 115/83(97)} mmHg\n RR: 39 (24 - 47) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 2,616 mL\n 548 mL\n PO:\n TF:\n 1,896 mL\n 332 mL\n IVF:\n 600 mL\n 216 mL\n Blood products:\n Total out:\n 930 mL\n 740 mL\n Urine:\n 930 mL\n 740 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,686 mL\n -192 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, Face tent\n SpO2: 97%\n ABG: 7.44/43/128/25/5\n PaO2 / FiO2: 183\n Physical Examination\n Labs / Radiology\n 137 K/uL\n 9.1 g/dL\n 105 mg/dL\n 0.6 mg/dL\n 25 mEq/L\n 4.8 mEq/L\n 23 mg/dL\n 107 mEq/L\n 142 mEq/L\n 27.9 %\n 7.3 K/uL\n [image002.jpg]\n 02:23 PM\n 03:50 AM\n 04:15 PM\n 02:46 AM\n 03:02 AM\n 09:03 AM\n 03:28 AM\n 08:25 AM\n 03:08 PM\n 06:29 AM\n WBC\n 8.7\n 7.1\n 7.3\n Hct\n 30.2\n 28.5\n 27.9\n Plt\n 189\n 142\n 137\n Cr\n 0.6\n 0.6\n 0.6\n 0.6\n 0.6\n 0.6\n TCO2\n 30\n 28\n 28\n 30\n Glucose\n 85\n 139\n 150\n 145\n 148\n 105\n NO labs this AM\n Assessment and Plan\n ICU Care\n Nutrition:\n Vivonex (Full) - 10:05 AM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 11:14 AM\n Arterial Line - 11:10 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2115-04-02 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 632421,
"text": "Chief Complaint:\n 24 Hour Events:\n - Blood CX () growing yeast\n - Urine CX () growing >100K yeast\n - started on floconazole 6mg/kg (talk to ID in AM as may prefer\n micafungin), changed foley catheter, getting daily blood CX, will need\n to pull PICC line,probably needs echo, probably needs ophtho consult,\n check LFT/EKG in AM\n - IV nurse could not get peripheral access (consider EJ vs. PICC)\n - PICC now difficulty flushing and drawing labs off of\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 06:00 PM\n Vancomycin - 08:00 PM\n Cefipime - 10:00 PM\n Fluconazole - 01:56 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:46 PM\n Furosemide (Lasix) - 11:08 PM\n Morphine Sulfate - 12:24 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 37.7\nC (99.8\n HR: 116 (112 - 134) bpm\n BP: 83/63(72) {76/53(62) - 115/83(97)} mmHg\n RR: 39 (24 - 47) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 2,616 mL\n 548 mL\n PO:\n TF:\n 1,896 mL\n 332 mL\n IVF:\n 600 mL\n 216 mL\n Blood products:\n Total out:\n 930 mL\n 740 mL\n Urine:\n 930 mL\n 740 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,686 mL\n -192 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, Face tent\n SpO2: 97%\n ABG: 7.44/43/128/25/5\n PaO2 / FiO2: 183\n Physical Examination\n Labs / Radiology\n 137 K/uL\n 9.1 g/dL\n 105 mg/dL\n 0.6 mg/dL\n 25 mEq/L\n 4.8 mEq/L\n 23 mg/dL\n 107 mEq/L\n 142 mEq/L\n 27.9 %\n 7.3 K/uL\n [image002.jpg]\n 02:23 PM\n 03:50 AM\n 04:15 PM\n 02:46 AM\n 03:02 AM\n 09:03 AM\n 03:28 AM\n 08:25 AM\n 03:08 PM\n 06:29 AM\n WBC\n 8.7\n 7.1\n 7.3\n Hct\n 30.2\n 28.5\n 27.9\n Plt\n 189\n 142\n 137\n Cr\n 0.6\n 0.6\n 0.6\n 0.6\n 0.6\n 0.6\n TCO2\n 30\n 28\n 28\n 30\n Glucose\n 85\n 139\n 150\n 145\n 148\n 105\n NO labs this AM\n Assessment and Plan\n 35 yo M with PMH of CP, seizure disorder, GIB, pancreatic cyst s/p\n drainage in , admitted with abdominal pain with complicated course,\n now with new fever, tachypnea, and hypoxia.\n .\n # Respiratory failure: Patient transferred to MICU with tachypnea and\n hypoxia on and intubated on . Given his new fever,\n respiratory deterioration, and imaging findings consistent with\n multilobar pneumonia he was started on vancomycin, cefepime and flagyl\n (concern for aspiration given recently started tube feeds). Sputum\n growing MRSA. Pleural effusions also noted on imaging, likely due to\n fluid resuscitation for hypotension in the setting of albumin of 2.3,\n so over the past 24 hours have been diuresing with lasix boluses. PE\n considered but CTA negative. Few apneic episodes two nights ago may\n be secondary to aggressive diuresis. Extubated on . The\n current respiratory distress is likely due to mucous plugging,\n secretions with rhonchorous breath sounds on exam. Pulmonary edema may\n also be contributing.\n - Completed 8-day course of vanc, cefepime, metronidazole\n - suction and light chest PT\n - consider gentle diuresis although difficult given low BP\n - follow ABGs\n - f/u blood cultures\n - morphine for grunting/resp distress x 1 to see if helpful\n - will discuss non-invasive pressure ventilation if necessary with\n family\n .\n # Fever/sepsis: Pt febrile with tachycardia and tachypnea; meets\n definition of sepsis with most likely source being pulmonary (MRSA).\n With ascites, SBP is also possible although he is now s/p 3 taps which\n have not been c/w SBP. Urinalysis and culture from with staph spp\n but repeat appears clean with NGTD. MS with no obvious\n nuchal rigidity although exam limited by pt cooperation. Again, PE\n could cause similar sx of fever and respiratory distress but none seen\n on CTA. Continues febrile daily. No further episodes of AMS. CT read as\n possible liver abscess but repeat RUQ ultrasound read as more\n consistent with infarct. C. Diff has been negative. Continues to have\n fever to 101 on overnight but normal white count, lactate normal.\n - Off Abx as above.\n - Goal CVP 8-12 but no measurements available currently\n will bolus\n for tachycardia, UOP < 30cc/h, goal MAP >60, CvO2 >70\n - Pressors for MAP > 55-60, off vasopressors\n - Monitor mental status\n - Consider paracentesis if continues febrile and no other source (would\n likely need to be done by IR)\n .\n #Hypotension. MAP goal > 60. No further episodes of AMS since starting\n pressors on . Not on vasopressors.\n # Tachycardia: Likely hyperdynamic in setting of fever, infection.\n Volume status appears grossly euvolemic; pt mentating at and\n maintaining urine output. Echo with evidence of depressed cardiac fxn,\n ? tachycardia induced cardiomyopathy\n - Tylenol prn fever\n - Abx as above\n - Fluid boluses prn, though patient with heart rate 110s;\n appears hypervolemic\n # Anemia/bleed: Hct stable. Pt with RP bleed and CT evidence of\n hemorrhage into bowel wall, also gastric varices c/b GIB earlier in\n admission. Transfused 1 unit pRBCs with appropriate bump and has\n remained stable since.\n - Trend Hct\n - Guaiac stools\n - Active T&S\n - continue pantoprazole 40mg IV bid\n - Continue iron supplement\n # Liver lesion. Noted on abdominal CT. Possible ischemia/infarction vs\n abscess. Abdominal U/S not consistent with abscess.\n # Left humeral fx: Likely d/t trauma sustained during radiology.\n - No surgical indication at this time\n - Pain control with lidoderm patch and morphine prn\n .\n # SMV thrombus: Plan for anticoagulation x 6 months but held in setting\n of recent GI and RP bleed.\n - Continue heparin SQ\n .\n # Seizure disorder: No recent reports of seizures. Caution as certain\n antibiotics may lower seizure threshold.\n - Continue phenobarbitol and phenytoin\n - drug levels stable as of \n .\n # Cerebral palsy: Stable mental status. Interactive with family but\n nonverbal at .\n .\n FEN: NG tube likely in duodenum, bolus IVF prn, TPN; continue tube\n feeds today\n PROPHYLAXIS: pneumoboots, IV PPI\n ACCESS: PICC, PIV, D/C A-line in right brachial artery\n CODE: Do not resuscitate/Do not re-intubate. No CPR or defibrillation.\n Will clarify role for BIPAP/CPAP.\n ICU Care\n Nutrition:\n Vivonex (Full) - 10:05 AM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 11:14 AM\n Arterial Line - 11:10 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2115-04-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 632422,
"text": "Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n T max 100.8, Single blood culture from + for budding yeast.\n Action:\n Fluconazole IV given, Foley changed. IV team in to evaluate for PIV\n Response:\n No Peripheral access per IV team, will need new central line placement\n today\n Plan:\n D/C arterial line & PICC line once new central access is obtained.\n Needs additional set of BC from PICC, follow temp curve. EKG this AM,\n Echo this AM\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on 5 LNC, 40% face tent. Lungs clear diminished at bases.\n Strong productive cough for thick white secretions. Sats 87-88% at\n beginning of shift. RR consistently mid 40\n Action:\n 40 mg IV lasix given, 2 mg morphine given. FiO2 increased to 100%\n Response:\n 500 cc response to lasix but remains + for day. 02 weaned to 70% AM\n ABG 7.44/43/128 RR continues to be elevated to mid 30\n Plan:\n Gentle CPT as tolerated. Wean O2, gentle diuresis.\n"
},
{
"category": "Nursing",
"chartdate": "2115-04-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 632615,
"text": "Code Status: DNR/DNI.\n 35 yo man with cerebral palsy, recurrent aspiration. FUO. Blood cx\n from with yeast. Continues with thick secretions and significant\n oxygen requirement.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Low grade T. Received pt on 5 LNC, 40% face tent. Lungs clear/\n diminished bases bilat. Strong dry non- productive cough. Sats 98-99%\n . Marginal U/O\n condom cath. Patient has finished a course of IV AXB\n pneumonia. He is positive for MRSA in his sputum. HR 100-110. SBP\n 90\n Action:\n 40 mg IV lasix given early afternoon, good diuresis. Minimal U/O\n trending down this am. U/o this am. MD notified.\n Response:\n Remains on FT+NC. Low U/O\n Plan:\n Continue monitoring fever, hypoxia. Wean O2 as tolerated , maintain\n O2sat >92%, encourage coughing, pulmonary toilet. Monitor lytes and\n replete PRN. Lasix 40mg IV given 0600hr.\n"
},
{
"category": "Nursing",
"chartdate": "2115-04-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 632553,
"text": "35 yo M with PMH of CP, seizure disorder, GIB, pancreatic cyst s/p\n drainage in , admitted with abdominal pain with complicated course\n now with fever, hypoxemia, blood culture growing yeast.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Accepted pt with crackles heard through lung fields, 02 sat > 96\n through shift, no apparent respiratory distress, 4 liters nasal cannula\n with humidified 02 15 liters face shield. Neuro checks at baseline.\n Action:\n 40 mg iv lasix in am\n Foley catheter DC\n Gentle chest pt done\n Response:\n Pt noted to have only put out 420 ml and is 320 ml positive reason for\n 1800 additional lasix\n Condom cath placed\n Pt responded well to chest pt, able to cough up and swallows sputum\n Plan:\n Monitor for uop goal is ml negative\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Pt noted to have low grade fever to 100.1 oral, blood cultures from\n PICC\n Action:\n Arterial line pulled, new EJ placed right , orders for PICC to be\n removed, IV team aware, blood cultures redrawn, urine cultures redrawn,\n peritoneal fluid tapped from right lower quadand sent for cultures\n Tylenol given for fever,\n Speech and swallow eval\n pt to go for video swallow in am\n Medications changed from iv to po\n fluconazole iv changed to micoungin\n iv\n WBC 8.1 up from 7.3 previous day\n Response:\n Pt remains with intermittent fever to 100.1, team aware.\n Plan:\n Follow up cultures, monitor fever curve, monitor labs, wbc\n"
},
{
"category": "Physician ",
"chartdate": "2115-04-04 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 632861,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - ID: Cont micafungin. Favor TTE.\n - Bcx: presumptive C. albicans\n - Lasix 40 in AM -> -80cc. Lasix 40 in PM -> -900. Net negative 500 for\n day.\n - Very limited swallowing study but no aspiration; cleared for nectar\n thick liquids, pureed solids; needs 1:1 observation (mother may need to\n feed). OK to try crushed meds, but may not take reliably\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Fluconazole - 01:56 AM\n Micafungin - 06:00 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.9\nC (100.2\n Tcurrent: 37.4\nC (99.4\n HR: 109 (99 - 128) bpm\n BP: 91/56(65) {85/11(35) - 101/70(87)} mmHg\n RR: 29 (18 - 36) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 1,440 mL\n 577 mL\n PO:\n TF:\n 1,200 mL\n 389 mL\n IVF:\n 240 mL\n 78 mL\n Blood products:\n Total out:\n 1,960 mL\n 160 mL\n Urine:\n 1,960 mL\n 160 mL\n NG:\n Stool:\n Drains:\n Balance:\n -520 mL\n 417 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 97%\n ABG: ///30/\n Physical Examination\n Gen: Thin, opening eyes but no clear orientation to voice; appears\n comfortable\n HEENT: Sclera anicteric, eyes sunken, MM dry\n Neck: Supple\n Lungs: coarse BS bilaterally with diffuse ronchi\n CV: S1, S2 regular rhythm, increased rate, II/VI systolic ejection\n murmur at base\n Abdomen: Soft, BS+, distended, no facial grimacing to palpation\n GU: condom catheter in place\n Ext: Warm, cachectic, BLE contractures, + DP pulses\n Labs / Radiology\n 149 K/uL\n 9.3 g/dL\n 157 mg/dL\n 0.5 mg/dL\n 30 mEq/L\n 3.9 mEq/L\n 25 mg/dL\n 102 mEq/L\n 139 mEq/L\n 27.7 %\n 7.0 K/uL\n [image002.jpg]\n 09:03 AM\n 03:28 AM\n 08:25 AM\n 03:08 PM\n 06:23 AM\n 06:29 AM\n 05:37 PM\n 06:16 AM\n 03:52 PM\n 05:10 AM\n WBC\n 7.3\n 8.1\n 6.7\n 7.0\n Hct\n 27.9\n 26.5\n 26.6\n 27.7\n Plt\n 137\n 147\n 146\n 149\n Cr\n 0.6\n 0.6\n 0.5\n 0.6\n 0.5\n 0.6\n 0.5\n TCO2\n 28\n 28\n 30\n Glucose\n 148\n 105\n 159\n 145\n 65\n 123\n 157\n Other labs: PT / PTT / INR:15.0/24.2/1.3, CK / CKMB /\n Troponin-T:8//0.01, ALT / AST:18/32, Alk Phos / T Bili:178/0.3, Amylase\n / Lipase:/11, Differential-Neuts:86.9 %, Lymph:8.0 %, Mono:3.6 %,\n Eos:1.3 %, Lactic Acid:1.6 mmol/L, Albumin:2.5 g/dL, LDH:314 IU/L,\n Ca++:7.9 mg/dL, Mg++:2.3 mg/dL, PO4:2.4 mg/dL\n Aspergillus, beta-glucan - pending\n ESR 55\n CRP 140\n Phenobarb 17.9, Phenytoin 11.5\n blood cx pending\n cath tip cx pending\n blood cx pending (includes fungal)\n ascites fluid cx\n pending\n urine cx - ngtd\n blood cx\n \n urine cx - yeast\n CXR - In comparison with the study of , the left subclavian\n catheter has been removed. There are continued low lung volumes with\n evidence of severe pulmonary edema. Poor definition of the\n hemidiaphragms could reflect pleural effusion and atelectasis at the\n bases.\n CXR\n pending\n video swallow\n pending\n Assessment and Plan\n 35 yo M with PMH of CP, seizure disorder, GIB, pancreatic cyst s/p\n drainage in , admitted with abdominal pain with complicated course\n now with fever, hypoxemia, blood culture growing yeast.\n .\n # Hypoxemia: Patient transferred to MICU with tachypnea and hypoxia\n on and intubated on . Imaging findings consistent with\n multilobar pneumonia with sputum growing MRSA, complted 8 day course of\n vanc, cefepime, and flagyl on . Pleural effusions also noted on\n imaging, likely due to fluid resuscitation for hypotension in the\n setting of albumin of 2.3, so have been diuresing with lasix boluses.\n Extubated on . The current respiratory distress is likely due\n to mucous plugging, secretions with rhonchorous breath sounds on exam.\n Pulmonary edema may also be contributing.\n - suction and light chest PT as tolerated\n - continue gentle diuresis with lasix 40mg IV for TBB -500ml today\n - follow ABGs\n - morphine for grunting/resp distress as needed\n - will discuss non-invasive pressure ventilation if necessary with\n family\n .\n # Yeast bacteremia: Patient continues to have low grade fevers, now\n with positive blood cultures growing yeast. Possible urogenital source\n with hematogenous spread. Heart rate and blood pressure currently at\n baseline. Normal WBC count, lactate.\n - follow fever curve\n - lines removed and replaced\n - daily blood cultures\n - follow speciation and sensitivity\n - continue micafungin IV per ID day 1 = \n - f/u ID recs\n - follow LFT, EKG while on micafungin\n - f/u PICC tip culture\n - f/u aspergillus, beta glucan\n .\n #Fevers: Patient daily low grade febrile episodes despite broad\n spectrum antibiotics. Completed treatment for pulmonary infection with\n 8 day course of vancomycin, cefepime, flagyl. SBP possible but 3 taps\n have not been c/w SBP. PE considered but no evidence on CTA. CT read\n as possible liver abscess but repeat RUQ ultrasound read as more\n consistent with infarct. C. Diff has been negative. Overnight\n positive urine and blood culture growing yeast. Repeat cultures of\n blood, urine ngtd.\n - treatment for yeast bloodstream infection as above\n -\n # Tachycardia: Likely hyperdynamic in setting of fever, infection.\n Volume status appears grossly euvolemic; pt mentating at baseline and\n maintaining urine output. Echo with evidence of depressed cardiac fxn,\n ? tachycardia induced cardiomyopathy\n - Tylenol prn fever\n - Antimicrobial agents as above\n .\n # Anemia/bleed: Hct stable. Pt with RP bleed and CT evidence of\n hemorrhage into bowel wall, also gastric varices c/b GIB earlier in\n admission. Transfused 1 unit pRBCs with appropriate bump and has\n remained stable since.\n - Trend Hct qd\n - Guaiac stools\n - Active T&S\n - PO pantoprazole\n - Continue iron supplement\n # Liver lesion. Noted on abdominal CT. Possible ischemia/infarction vs\n abscess. Abdominal U/S not consistent with abscess.\n .\n # Left humeral fx: Likely d/t trauma sustained during radiology.\n - No surgical indication at this time\n - Pain control with lidoderm patch and morphine prn\n .\n # SMV thrombus: Plan for anticoagulation x 6 months but held in setting\n of recent GI and RP bleed.\n - Continue heparin SQ\n .\n # Seizure disorder: No recent reports of seizures. Caution as certain\n antibiotics may lower seizure threshold.\n - Continue phenobarbitol and phenytoin, but transition to PO route\n - Drug levels wnl on \n .\n # Cerebral palsy: Stable mental status. Interactive with family but\n nonverbal at baseline.\n - speech and swallow evaluation: advance diet\n .\n # Case Management\n likely d/c to rehab tomorrow.\n .\n FEN: continue tube feeds today; cleared for nectar thick liquids,\n pureed solids; needs 1:1 observation (mother may need to feed). OK to\n try crushed meds, but may not take reliably\n PROPHYLAXIS: pneumoboots, PO PPI, restart SC heparin\n ACCESS: PIV\n CODE: DNR/DNI. No CPR or defibrillation. Will clarify role for\n BIPAP/CPAP.\n ICU Care\n Nutrition:\n Vivonex (Full) - 09:48 AM 50 mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 04:42 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Case Management ",
"chartdate": "2115-04-04 00:00:00.000",
"description": "Discharge Planning Note",
"row_id": 632880,
"text": "Discharge Planning\n Case discussed w/ team, plan is rehab, MD pt ready. CM met w/ pt\n parents at bedside, reviewed their discussion w/ previous case manager\n concerning referral to LTAC level of care\n of . Parents\n verbalized their agreement with this referral. CM educated on referral\n process, need for BC auth and bed availability. liaison called\n to make aware that pt is ready, she will update this afternoon. Cm will\n follow.\n"
},
{
"category": "Physician ",
"chartdate": "2115-04-04 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 632822,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - ID: Cont micafungin. Favor TTE.\n - Bcx: presumptive C. albicans\n - Lasix 40 in AM -> -80cc. Lasix 40 in PM -> -900. Net negative 500 for\n day.\n - Very limited swallowing study but no aspiration; cleared for nectar\n thick liquids, pureed solids; needs 1:1 observation (mother may need to\n feed). OK to try crushed meds, but may not take reliably\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Fluconazole - 01:56 AM\n Micafungin - 06:00 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.9\nC (100.2\n Tcurrent: 37.4\nC (99.4\n HR: 109 (99 - 128) bpm\n BP: 91/56(65) {85/11(35) - 101/70(87)} mmHg\n RR: 29 (18 - 36) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 1,440 mL\n 577 mL\n PO:\n TF:\n 1,200 mL\n 389 mL\n IVF:\n 240 mL\n 78 mL\n Blood products:\n Total out:\n 1,960 mL\n 160 mL\n Urine:\n 1,960 mL\n 160 mL\n NG:\n Stool:\n Drains:\n Balance:\n -520 mL\n 417 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 97%\n ABG: ///30/\n Physical Examination\n Gen: Thin, opening eyes but no clear orientation to voice; appears\n comfortable\n HEENT: Sclera anicteric, eyes sunken, MM dry\n Neck: Supple\n Lungs: coarse BS bilaterally with diffuse ronchi\n CV: S1, S2 regular rhythm, increased rate, II/VI systolic ejection\n murmur at base\n Abdomen: Soft, BS+, distended, no facial grimacing to palpation\n GU: condom catheter in place\n Ext: Warm, cachectic, BLE contractures, + DP pulses\n Labs / Radiology\n 149 K/uL\n 9.3 g/dL\n 157 mg/dL\n 0.5 mg/dL\n 30 mEq/L\n 3.9 mEq/L\n 25 mg/dL\n 102 mEq/L\n 139 mEq/L\n 27.7 %\n 7.0 K/uL\n [image002.jpg]\n 09:03 AM\n 03:28 AM\n 08:25 AM\n 03:08 PM\n 06:23 AM\n 06:29 AM\n 05:37 PM\n 06:16 AM\n 03:52 PM\n 05:10 AM\n WBC\n 7.3\n 8.1\n 6.7\n 7.0\n Hct\n 27.9\n 26.5\n 26.6\n 27.7\n Plt\n 137\n 147\n 146\n 149\n Cr\n 0.6\n 0.6\n 0.5\n 0.6\n 0.5\n 0.6\n 0.5\n TCO2\n 28\n 28\n 30\n Glucose\n 148\n 105\n 159\n 145\n 65\n 123\n 157\n Other labs: PT / PTT / INR:15.0/24.2/1.3, CK / CKMB /\n Troponin-T:8//0.01, ALT / AST:18/32, Alk Phos / T Bili:178/0.3, Amylase\n / Lipase:/11, Differential-Neuts:86.9 %, Lymph:8.0 %, Mono:3.6 %,\n Eos:1.3 %, Lactic Acid:1.6 mmol/L, Albumin:2.5 g/dL, LDH:314 IU/L,\n Ca++:7.9 mg/dL, Mg++:2.3 mg/dL, PO4:2.4 mg/dL\n Aspergillus, beta-glucan - pending\n ESR 55\n CRP 140\n Phenobarb 17.9, Phenytoin 11.5\n blood cx pending\n cath tip cx pending\n blood cx pending (includes fungal)\n ascites fluid cx\n pending\n urine cx - ngtd\n blood cx\n \n urine cx - yeast\n CXR - In comparison with the study of , the left subclavian\n catheter has been removed. There are continued low lung volumes with\n evidence of severe pulmonary edema. Poor definition of the\n hemidiaphragms could reflect pleural effusion and atelectasis at the\n bases.\n CXR\n pending\n video swallow\n pending\n Assessment and Plan\n 35 yo M with PMH of CP, seizure disorder, GIB, pancreatic cyst s/p\n drainage in , admitted with abdominal pain with complicated course\n now with fever, hypoxemia, blood culture growing yeast.\n .\n # Hypoxemia: Patient transferred to MICU with tachypnea and hypoxia\n on and intubated on . Imaging findings consistent with\n multilobar pneumonia with sputum growing MRSA, complted 8 day course of\n vanc, cefepime, and flagyl on . Pleural effusions also noted on\n imaging, likely due to fluid resuscitation for hypotension in the\n setting of albumin of 2.3, so have been diuresing with lasix boluses.\n Extubated on . The current respiratory distress is likely due\n to mucous plugging, secretions with rhonchorous breath sounds on exam.\n Pulmonary edema may also be contributing.\n - suction and light chest PT as tolerated\n - continue gentle diuresis with lasix 40mg IV boluses to go even as\n patient appears slightly dry on exam\n - follow ABGs\n - morphine for grunting/resp distress as needed\n - will discuss non-invasive pressure ventilation if necessary with\n family\n .\n # Yeast bacteremia: Patient continues to have low grade fevers, now\n with positive blood cultures growing yeast. Possible urogenital source\n with hematogenous spread. Heart rate and blood pressure currently at\n baseline. Normal WBC count, lactate.\n - follow fever curve\n - lines removed and replaced\n - daily blood cultures\n - follow speciation and sensitivity\n - continue micafungin IV per ID day 1 = \n - f/u ID recs\n - follow LFT, EKG\n - f/u PICC tip culture\n - f/u aspergillus, beta glucan\n .\n #Fevers: Patient daily low grade febrile episodes despite broad\n spectrum antibiotics. Completed treatment for pulmonary infection with\n 8 day course of vancomycin, cefepime, flagyl. SBP possible but 3 taps\n have not been c/w SBP. PE considered but no evidence on CTA. CT read\n as possible liver abscess but repeat RUQ ultrasound read as more\n consistent with infarct. C. Diff has been negative. Overnight\n positive urine and blood culture growing yeast. Repeat cultures of\n blood, urine ngtd.\n - treatment for yeast bloodstream infection as above\n -\n # Tachycardia: Likely hyperdynamic in setting of fever, infection.\n Volume status appears grossly euvolemic; pt mentating at baseline and\n maintaining urine output. Echo with evidence of depressed cardiac fxn,\n ? tachycardia induced cardiomyopathy\n - Tylenol prn fever\n - Antimicrobial agents as above\n .\n # Anemia/bleed: Hct stable. Pt with RP bleed and CT evidence of\n hemorrhage into bowel wall, also gastric varices c/b GIB earlier in\n admission. Transfused 1 unit pRBCs with appropriate bump and has\n remained stable since.\n - Trend Hct qd\n - Guaiac stools\n - Active T&S\n - PO pantoprazole\n - Continue iron supplement\n # Liver lesion. Noted on abdominal CT. Possible ischemia/infarction vs\n abscess. Abdominal U/S not consistent with abscess.\n .\n # Left humeral fx: Likely d/t trauma sustained during radiology.\n - No surgical indication at this time\n - Pain control with lidoderm patch and morphine prn\n .\n # SMV thrombus: Plan for anticoagulation x 6 months but held in setting\n of recent GI and RP bleed.\n - Continue heparin SQ???\n .\n # Seizure disorder: No recent reports of seizures. Caution as certain\n antibiotics may lower seizure threshold.\n - Continue phenobarbitol and phenytoin, but transition to PO route\n - Drug levels wnl on \n .\n # Cerebral palsy: Stable mental status. Interactive with family but\n nonverbal at baseline.\n - speech and swallow evaluation: advance diet\n .\n FEN: continue tube feeds today; cleared for nectar thick liquids,\n pureed solids; needs 1:1 observation (mother may need to feed). OK to\n try crushed meds, but may not take reliably\n PROPHYLAXIS: pneumoboots, PO PPI\n ACCESS: PIV\n CODE: Do not resuscitate/Do not re-intubate. No CPR or defibrillation.\n Will clarify role for BIPAP/CPAP.\n ICU Care\n Nutrition:\n Vivonex (Full) - 09:48 AM 50 mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 04:42 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Radiology",
"chartdate": "2115-03-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1129863,
"text": " 11:24 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: evaluate tube placement, NG tube positioning\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with respiratory distress now intubated\n REASON FOR THIS EXAMINATION:\n evaluate tube placement, NG tube positioning\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST.\n\n HISTORY: Evaluate placement of a nasogastric tube.\n\n FINDINGS: Comparison is made to previous study from 47 minutes earlier.\n\n The tip of the nasogastric tube is just beyond the gastroesophageal junction,\n similar to prior positioning. There is an endotracheal tube whose distal tip\n is 3.7 cm above the carina, appropriately sited. The left-sided central line\n has its distal tip at the cavoatrial junction. There is again noted diffuse\n airspace opacities, particularly in the perihilar regions. There is left-\n sided pleural effusion and low lung volumes which are stable. No\n pneumothoraces are present.\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-03-11 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 1127989,
"text": " 5:32 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: eval for acute process with po and iv contrast\n Admitting Diagnosis: ABDOMINAL PAIN\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with known micro perf, SBO, colonic dilation and increased abd\n distension today\n REASON FOR THIS EXAMINATION:\n eval for acute process with po and iv contrast\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: AJy TUE 12:12 AM\n Pleural effusions decreased compared to prior study. NG tube noted within\n stomach. No evidence of SBO. Dilated fluid filled rectum and sigmoid with\n rectal tube in place may reflect ileus. No free air. No loculated fluid\n collections. Redemonstration of SMV thrombosis with collateral flow to a\n patent main portal vein, unchanged. Portal vein branches are difficult to\n evaluate. Major mesenteric arteries are widely patent. Low attenuation\n hepatic parenchyma may represent edema or fatty infiltration. Previously\n noted likely small pancraetic pseudocyst no longer identified, though\n calcifications in panc head and pancreatic atrophy again suggest prior\n pancreatitis.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 35-year-old man with known microperforation, small-bowel\n obstruction and colonic dilatation. Increased abdominal distention.\n\n TECHNIQUE: CT imaging of the abdomen and pelvis was performed following the\n administration of oral and intravenous contrast. Multiplanar reconstructions\n were generated.\n\n COMPARISON: Comparison is made to prior CT performed .\n\n FINDINGS:\n\n CT ABDOMEN:\n\n Small bilateral basal pleural effusions have decreased in size in comparison\n to the prior CT. There has also been partial resolution of atelectasis and\n consolidation in the basilar segments of both lower lobes. A nasogastric tube\n is in situ with tip in the gastric body. There is moderate gaseous distention\n of the stomach. There is marked distention of the sigmoid colon with gas and\n debris, although mural thickening is less prominent than on CT performed\n . A rectal catheter is in situ. The remainder of the colon is less\n distended than the sigmoid colon, but also contains fluid and gas throughout.\n No discrete transition point is identified within the large bowel. The small\n bowel is not significantly dilated. No free fluid or gas is seen within the\n abdomen or pelvis.\n\n The patient is status post cholecystectomy. No focal parenchymal abnormality\n is identified in the liver. The pancreas is atrophic in appearance as on\n (Over)\n\n 5:32 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: eval for acute process with po and iv contrast\n Admitting Diagnosis: ABDOMINAL PAIN\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n prior scan. Calcifications are again identified at the pancreatic head. A\n 1.7 cm x 1.4 cm cystic lesion at the pancreatic head seen on the prior CT is\n again identified, but is of higher attenuation than on the previous scan. A\n cortical cyst at the mid pole of the right kidney measuring 1.4 cm x 1.2 cm is\n unchanged from prior study. No other focal renal lesion is seen. The adrenal\n glands and spleen are normal in appearance. A small amount of free fluid is\n seen in the abdomen and pelvis, which has decreased in comparison to the prior\n CT scan. Small bowel dilatation is less prominent than on the prior scan.\n\n There is occlusion of the superior mesenteric vein at the level of the\n pancreas (series 2, image 28), but the proximal portion of the vein remains\n patent. Extensive collateral vessels are again identified in the perigastric\n area. The portal vein and left and right portal branches are patent.\n\n CT PELVIS:\n\n No pelvic lymphadenopathy is seen. The urinary bladder appears unremarkable,\n but is pushed anteriorly by the distended rectum and sigmoid colon. Marked\n degenerative changes are seen in the thoracolumbar spine with scoliosis convex\n to right.\n\n IMPRESSION:\n 1. Marked distention of the rectum and sigmoid colon with gas and fluid. The\n distention is more marked than on the prior scan , but the degree of\n mural thickening in the sigmoid colon has decreased in comparison to CT\n . A catheter is in situ within the lumen of the distatl sigmoid\n colon. Mild distention with gas and fluid in the remainder of the colon.\n 2. No free intraperitoneal gas is seen. Ascites has decreased in volume in\n comparison to the prior CT.\n 3. Occlusive thrombus is again identified in the distal portion of the\n superior mesenteric vein. The portal vein remains patent.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-03-19 00:00:00.000",
"description": "L WRIST(3 + VIEWS) LEFT",
"row_id": 1129173,
"text": " 3:27 PM\n WRIST(3 + VIEWS) LEFT; FOREARM (AP & LAT) LEFT Clip # \n HAND (AP, LAT & OBLIQUE) LEFT\n Reason: left hand, wrist, arm and shoulder fracture\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with cerebral palsy now with LUE pain\n REASON FOR THIS EXAMINATION:\n left hand, wrist, arm and shoulder fracture\n ______________________________________________________________________________\n FINAL REPORT\n LEFT WRIST\n\n CLINICAL HISTORY: Trauma and pain.\n\n AP and lateral films of the wrist and a somewhat motion limited AP film of the\n forearm were obtained. On the somewhat oblique lateral film there is a\n vertical lucency projected at the anterior aspect of the radius which is\n probably artifactual. No fracture is seen on the AP view. The carpal bones\n are normally aligned.\n\n IMPRESSION: The study is somewhat technically limited. No definite fracture\n is seen. If the patient's symptoms persist, a repeat view might be of use.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-03-15 00:00:00.000",
"description": "EXCH PERPHERAL W/O PORT",
"row_id": 1128649,
"text": " 3:28 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: evaluate and place new Picc on L arm if possible\n Admitting Diagnosis: ABDOMINAL PAIN\n ********************************* CPT Codes ********************************\n * EXCH PERPHERAL W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with new hypotension and picc; would like to change to a new\n picc\n REASON FOR THIS EXAMINATION:\n evaluate and place new Picc on L arm if possible\n ______________________________________________________________________________\n FINAL REPORT\n PICC LINE PLACEMENT\n\n INDICATION: IV access needed for IV access and fluids.\n\n The procedure was explained to the patient. A timeout was performed.\n\n RADIOLOGIST: Dr. performed the procedure. Dr. , the\n attending radiologist who was present and supervising throughout.\n\n TECHNIQUE: Using sterile technique and local anesthesia, the left brachial\n vein was punctured under direct ultrasound guidance using a micropuncture set.\n Hard copies of ultrasound images were obtained before and immediately after\n establishing intravenous access. A peel-away sheath was then placed over a\n guidewire and a double-lumen PICC line measuring 36 cm in length was then\n placed through the peel-away sheath with its tip positioned in the SVC under\n fluoroscopic guidance. Position of the catheter was confirmed by a\n fluoroscopic spot film of the chest.\n\n The peel-away sheath and guidewire were then removed. The catheter was\n secured to the skin, flushed, and a sterile dressing applied.\n\n The patient tolerated the procedure well. There were no immediate\n complications.\n\n IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided 5 French\n double-lumen PICC line placement via the left brachial venous approach. Final\n internal length is 36 cm, with the tip positioned in SVC. The line is ready\n to use.\n\n After placing the left-sided PICC line, the right PICC line, which is thought\n to be infected, was removed and the tip sent for culture and sensitivities.\n Sterile dressings applied.\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-03-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1129943,
"text": " 3:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with pneumonia, bilateral pleural effusions, intubated\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pneumonia and effusions.\n\n FINDINGS: In comparison with the study of , there has been some decrease\n in the diffuse bilateral pulmonary opacifications with air bronchograms.\n Again, this could reflect improving pneumonia or decreasing vascular\n congestion.\n\n The tip of the nasogastric tube now appears to be within the second portion of\n the duodenum.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-03-17 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1128876,
"text": " 10:07 PM\n PORTABLE ABDOMEN Clip # \n Reason: interval change of abdominal distension, r/o free air.\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with improving SBO and known dilated colon, with continued\n abdominal distension. Please evaluate for changes in abdominal distension.\n REASON FOR THIS EXAMINATION:\n interval change of abdominal distension, r/o free air.\n ______________________________________________________________________________\n WET READ: AJy MON 12:11 AM\n stable radiograph with scttered bowel gas and prominent pelvic colonic loops,\n likely sigmoid. no free air.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Improving SBO, known dilated colon. Abdominal distention.\n\n SUPINE & UPRIHT ABDOMEN:\n Slightly improvement of diameter of prominent loops of large bowel measuring\n up to 6.4 cm and previously measured up to 11 cm. There is no free\n intraperitoneal air or pneumatosis.\n\n IMPRESSION: Slightly improvement of mildly dilated loops of large bowel. No\n free intraperitoneal air.\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-02-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1124040,
"text": " 3:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p L sub clavian check the position please\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 yo M with cerebral palsy, with abdominal pain and ascites, CT scan noted\n findings consistent with shock bowel/low flow state. No vascular occlusion. No\n perforation, no free air. Noobstruction\n REASON FOR THIS EXAMINATION:\n s/p L sub clavian check the position please\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: For left subclavian catheter.\n\n FINDINGS: In comparison with the study of , there has been placement of a\n left subclavian catheter that extends to about the level of the cavoatrial\n junction. The opacification in the left hemithorax is increasing and there is\n increasing prominence of pulmonary markings on the right as well. The\n findings are suggestive of increased pulmonary venous pressure with possible\n supervening pneumonia on the left. The left hemidiaphragm is not well seen,\n suggesting some layering effusion on this side.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-02-24 00:00:00.000",
"description": "CT PELVIS W/CONTRAST",
"row_id": 1125573,
"text": " 5:12 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: NO PO contrast, in addition to pelvis CT, eval for SBO\n Admitting Diagnosis: ABDOMINAL PAIN\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with cerebral palsy, known SMV thrombus, bowel edema has\n worsening abd pain, distension\n REASON FOR THIS EXAMINATION:\n NO PO contrast, in addition to pelvis CT, eval for SBO\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Cerebral palsy, known SMV thrombosis, worsening abdominal pain and\n distention. Concern for small-bowel obstruction.\n\n COMPARISON: CT of the abdomen and pelvis , and CT of the abdomen\n from an outside institution .\n\n TECHNIQUE: CT of the abdomen and pelvis was performed following intravenous\n contrast administration. No oral contrast could be administered due to\n patient's inability to tolerate p.o. contrast. Coronal and sagittal\n reconstructions were performed.\n\n FINDINGS:\n\n LOWER THORAX: Moderate-sized left and small right pleural effusions and\n compressive bibasilar atelectasis, unchanged.\n\n ABDOMEN:\n\n Nasogastric tube is again seen, currently, the tip is in the gastric antrum.\n The liver, spleen, adrenals are within normal limits. 10-mm cyst in the right\n mid kidney is again noted. There is no hydronephrosis.\n\n Again seen is marked atrophy of the pancreas as well as several coarse\n calcifications in the pancreatic head. Approximately 1.7 x 1.7 x 4.6 cm\n rim-enhancing lesion in the pancreatic head is unchanged and likely represents\n a pseudocyst. There is no pancreatic ductal dilatation.\n\n The patient is status post cholecystectomy and several surgical clips are seen\n in the gallbladder fossa. There is no intrahepatic or extrahepatic biliary\n ductal dilatation.\n\n Again seen is SMV occlusion just inferior to the level of the pancreas.\n Extensive superior mesenteric venous collaterals are again seen adjacent to\n the pylorus of the stomach and drain into the main portal vein. Large\n collateral from the spleen coursing anterior to the stomach is noted. The\n splenic vein drains into the superior mesenteric vein as the SMV connects with\n the numerous SMV collaterals. The portal veins are patent.\n\n Moderate amount of abdominal and pelvic ascites is not significantly changed.\n (Over)\n\n 5:12 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: NO PO contrast, in addition to pelvis CT, eval for SBO\n Admitting Diagnosis: ABDOMINAL PAIN\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n There is no hematocrit level to suggest hemorrhagic acites.\n\n Few prominent loops of fluid-filled small bowel are seen in the right lower\n abdomen measuring up to 2.5 cm in greatest diameter. Otherwise, the small\n bowel is within normal limits. There is air and fluid throughout the colon.\n Again seen is marked wall thickening of the rectum and sigmoid colon, slightly\n decreased since the previous study. There is a small focus of gas anterior to\n the sigmoid colon (best seen on series 2: images 61 and 62). This may\n represent an unusual appearance of a diverticulum or a small focus of\n extraluminal gas. Scattered descending colonic diverticula are noted.\n\n PELVIS:\n\n Foley catheter likely accounts for the intravesicular air. No pelvic masses\n or lymphadenopathy.\n\n BONES: Scoliosis, and probable coxa valga is again noted.\n\n IMPRESSION:\n\n 1. Mildly dilated loop of small bowel in the right lower quadrant without\n focal transition point, suggestive of ileus. No bowel obstruction.\n\n 2. Marked wall thickening of the rectum and sigmoid colon, decreased since\n previous studies. Findings are nonspecific and may be infectious, ischemic or\n inflammatory in etiology.\n\n 3. Small focus of gas anterior to the sigmoid colon may represent an unusual\n appearance of a diverticulum or a small focus of extraluminal gas.\n\n Findings were discussed with Dr. on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-03-24 00:00:00.000",
"description": "BY SAME PHYSICIAN",
"row_id": 1129861,
"text": " 10:39 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: eval for NGT placement, was pulled back after noted to be po\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with NGT in place, post pyloric on previous imaging\n REASON FOR THIS EXAMINATION:\n eval for NGT placement, was pulled back after noted to be post-pyloric\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest, .\n\n HISTORY: Patient with nasogastric tube placement, was pulled back.\n\n FINDINGS: Comparison is made to prior study from five hours earlier.\n\n FINDINGS: The tip of the nasogastric tube and side port has been pulled back\n to just beyond the gastroesophageal junction. There is an unchanged left-\n sided PICC line with distal lead tip at the cavoatrial junction. There is\n again noted diffuse airspace opacities as well as a left retrocardiac opacity\n and low lung volumes which are stable.\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-03-20 00:00:00.000",
"description": "CT PELVIS W/CONTRAST",
"row_id": 1129359,
"text": " 6:43 PM\n CT PELVIS W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT CHEST W/CONTRAST\n Reason: interval development\n Admitting Diagnosis: ABDOMINAL PAIN\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with h/o bowel edema, partial SBO, large bowel dilatation,\n gastric varices, ascites, SMV thrombosis, GIB, RP bleed, now with worsening abd\n distention and tenderness, hct drop, fever.\n REASON FOR THIS EXAMINATION:\n interval development\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MBue WED 10:17 PM\n ECTASIA OF ASCENDING AORTA. INCREASE IN B/L SMALL PLEURAL EFFUSIONS AND\n ADJACENT ATELECTASIS. INTERVAL INCREASE IN INTRAPERITONEAL FLUID MEASURING\n 20HU, MOST LIKELY ASCITES RELATED TO SMV THROMBOSIS. SMALL AMOUNT OF HIGHER\n ATTENUATION FLUID LAYERING POST IN PELVIS, SMALL AMOUNT OF HEMORRHAGE CANNOT\n BE EXCLUDED. LEFT RETROPERITONEAL HEMATOMA ADJACENT TO LEFT PSOAS\n MUSCLE UNCHANGED. PREVIOUSLY DESCRIBED BOWEL WALL HEMATOMA AT DESCENDING-\n SIGMOID JUNCTION, IMPROVED. IMPROVEMENT IN SMALL BOWEL DILATION. PERISTANT\n THICKEING ON SIGMOID AND DESCENDING COLON, COULD REFLECT COLITIS SECONDARY TO\n SMV THROMBOSIS.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: History of cerebral palsy with SMV occlusion, partial\n small-bowel obstruction, colonic and retroperitoneal hemorrhage with worsening\n abdominal distention, tenderness, hematocrit drop and fever.\n\n TECHNIQUE: MDCT of the chest, abdomen and pelvis was performed following the\n uneventful administration of nonionic intravenous contrast and oral contrast.\n Comparison exam is dated .\n\n FINDINGS:\n\n CHEST: There are small bilateral pleural effusions, increased from the prior\n exam. There are calcifications of the aortic valve, and the ascending aorta\n is ectatic, measuring 3.9 cm. The descending aorta is normal in caliber. A\n right-sided venous catheter terminates in the SVC. There are no\n pathologically enlarged thoracic lymph nodes.\n\n Lung windows demonstrate compressive atelectasis. There are no focal nodules\n or masses. The central airways are patent.\n\n ABDOMEN: The liver, spleen, left kidney, adrenal glands are unremarkable.\n The gallbladder is surgically absent. There is a stable right renal\n hypodensity. Again noted is atrophy of the pancreas with calcifications in\n the head, consistent with chronic pancreatitis. A feeding tube terminates in\n the duodenum.\n\n Compared to the prior exam, there has been interval resolution of small bowel\n (Over)\n\n 6:43 PM\n CT PELVIS W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT CHEST W/CONTRAST\n Reason: interval development\n Admitting Diagnosis: ABDOMINAL PAIN\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n dilatation. Colonic wall thickening has also improved, with minimal residual\n thickening in the descending colon in the area of prior hemorrhage. There is\n increased abdominal ascites. Again noted is occlusion of the superior\n mesenteric vein, with numerous collaterals. The portal veins are patent.\n Left retroperitoneal hemorrhage is stable.\n\n PELVIS: Previously seen hemorrhage interposed between the rectum and bladder\n is resolved. There is increased pelvic ascites with some layering high\n density posteriorly. There is stable rectal and sigmoid thickening. There\n are no pathologically enlarged lymph nodes.\n\n Bone windows demonstrate degenerative changes and scoliosis, without focal\n suspicious lesion.\n\n IMPRESSION:\n\n 1. Interval resolution of small bowel dilatation, and near interval\n resolution of high density thickening of the descending colon. Persistent\n sigmoid and rectal thickening. Increased abdominal and pelvic ascites with\n some layering high density posteriorly. Stable left retroperitoneal bleed and\n interval resolution of hemorrhage seen between the rectum and bladder.\n\n 2. Small bilateral pleural effusions, increased from the prior exam.\n\n 3. Stable occlusion of the SMV, with numerous collaterals.\n\n 4. Dilatation of the ascending aorta and marked calcification of the aortic\n valve for the patient's age. This finding could indicate a bicuspid valve.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-03-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1129896,
"text": " 5:00 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: NGT placement\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man self discontinued NGT, s/p replacement.\n REASON FOR THIS EXAMINATION:\n NGT placement\n ______________________________________________________________________________\n WET READ: MBue SUN 8:41 PM\n SLIGHT INTERVAL WORSENING OF DIFFUSE B/L AIRSPACE OPACITIES WITH AIR\n BRONCHOGRAMS. ET TUBE STABLE. NGT TERMINATES IN DISTAL STOMACH.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: NG tube replacement.\n\n FINDINGS: In comparison with the earlier study of this date, the tip of the\n nasogastric tube extends well into the antral region. Continued bilateral\n diffuse airspace opacifications with air bronchograms. This could reflect\n pulmonary vascular congestion, widespread pneumonia, or even ARDS depending on\n the clinical presentation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-02-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1125400,
"text": " 6:51 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: placement of NGT\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with NGT moved, please eval placement\n REASON FOR THIS EXAMINATION:\n placement of NGT\n ______________________________________________________________________________\n WET READ: AGLc SAT 4:00 AM\n NGT in stomach. hazy opacity over left hemithorax probably posteriorly\n layering pleural effusion, with atelectasis obscuring left hemidiaphragm.\n dense retrocardiac opacity persists.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 35-year-old, moved nasogastric tube.\n\n COMPARISON: at 15:52.\n\n FINDINGS:\n\n Semi-erect portable frontal radiograph of the chest demonstrates mild\n advancement of the nasogastric tube, which is in satisfactory position with\n the tip in the antrum. Left subclavian central venous catheter with the tip\n at the cavoatrial junction, unchanged. Retrocardiac opacity is unchanged,\n likely atelectasis. There is mild pulmonary interstitial edema. No\n pneumothorax. Normal cardiomediastinal silhouette.\n\n IMPRESSION:\n\n Advancement of the nasogastric tube, which is in satisfactory position.\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-02-15 00:00:00.000",
"description": "P ABDOMEN (SUPINE & ERECT) PORT",
"row_id": 1124267,
"text": ", B. SICU-B 9:07 AM\n ABDOMEN (SUPINE & ERECT) PORT Clip # \n Reason: free air\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with CP, SBP, bowel wall thickening\n REASON FOR THIS EXAMINATION:\n free air\n ______________________________________________________________________________\n PFI REPORT\n No evidence of gross free air.\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-02-24 00:00:00.000",
"description": "P ABDOMEN (SUPINE ONLY) PORT",
"row_id": 1125527,
"text": " 10:15 AM\n ABDOMEN (SUPINE ONLY) PORT Clip # \n Reason: please evaluate for acute process\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with hx of peritonitis with worsen abdominal pain and\n distention\n REASON FOR THIS EXAMINATION:\n please evaluate for acute process\n ______________________________________________________________________________\n WET READ: DLrc SUN 1:17 PM\n Findings concerning for small bowel obstruction with dilated loops of small\n bowel measuring up to 3.3cm. CT can be obtained for further delineation as\n clinically indicated.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE ABDOMEN ON AT 10:48\n\n INDICATION: Abdominal pain and distention.\n\n FINDINGS:\n\n Distended loops of small bowel are visualized close to 3 cm in diameter. One\n loop along the left flank may be descending colon with air in it. The right\n flank has been cut off from view and I do not see the hemidiaphragms.\n Therefore evaluation for free air is limited. There is no ptosis. The\n thoracic spine shows a complex scoliosis including a rotary component and a\n component that is convex to the right.\n\n IMPRESSION: Findings consistent with at least a partial small-bowel\n obstruction. Followup imaging and/or CT can be obtained.\n\n A preliminary report suggesting concern for small-bowel obstruction was\n directly communicated to Dr. at 1:10 p.m. on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-02-15 00:00:00.000",
"description": "P ABDOMEN (SUPINE & ERECT) PORT",
"row_id": 1124266,
"text": " 9:07 AM\n ABDOMEN (SUPINE & ERECT) PORT Clip # \n Reason: free air\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with CP, SBP, bowel wall thickening\n REASON FOR THIS EXAMINATION:\n free air\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): LLTc FRI 1:09 PM\n No evidence of gross free air.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Wall thickening on CT examination, question of free air.\n\n COMPARISON: CT available from . Chest radiograph from .\n\n FRONTAL RADIOGRAPHS OF THE ABDOMEN: Imaging was performed with patient in\n supine and left lateral decubitus positions. There is relative paucity of\n bowel gas within the abdomen. A small segment of nondistended large bowel is\n seen. No free air is demonstrated on left lateral decubitus, although the\n most dependent portion is excluded from the study. Lumbar scoliosis is\n present. There is no acute fracture or dislocation. Included views of the\n chest are unremarkable.\n\n IMPRESSION: No evidence of free air. There is a relative paucity of bowel\n gas on this study; distended loops of fluid-containing small bowel cannot be\n excluded.\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-03-06 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 1127218,
"text": " 1:29 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: ?ascites, pseudocyst\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with abdominal distension, history of secondary peritonitis\n REASON FOR THIS EXAMINATION:\n ?ascites, pseudocyst\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: History of SMV occlusion, question ascites and\n pseudocyst.\n\n TECHNIQUE: Limited ultrasound of the midline and four quadrants was\n performed. Comparison is made to CT exams performed and , .\n\n FINDINGS: There is a small amount of ascites. Numerous collateral vessels\n are identified in the midline as seen on prior CT scan. There is an avascular\n anechoic structure at the midline, measuring approximately 1.5 cm in\n transverse dimension, correlating with presumed pseudocyst seen on CT. The\n pancreas is not well visualized.\n\n IMPRESSION: Small ascites. Again noted probable pseudocyst in the midline\n and collateral vessels related to the SMV thrombosis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-03-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1129755,
"text": " 8:25 AM\n CHEST (PORTABLE AP) Clip # \n Reason: infiltrate\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n FINAL ADDENDUM\n ADDENDUM: Please note that the shoulder fracture is unchanged from\n radiographs of the left shoulder from , not \"\" as\n written above.\n\n\n\n\n\n 8:25 AM\n CHEST (PORTABLE AP) Clip # \n Reason: infiltrate\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with complicated bowel pathology including SMV thrombus, bowel\n edema, RP bleed etc now is tachypneic and has hypoxia, fever\n REASON FOR THIS EXAMINATION:\n infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 35-year-old man with complicated bowel pathology including SMV\n thrombus and bowel edema. Now with hypoxia.\n\n FINDINGS: Comparison is made to prior study from .\n\n There is a left-sided PICC line with the distal tip in the cavoatrial\n junction. There is a nasogastric tube whose tip and sideport are beyond the\n GE junction and stable. There is again seen diffuse airspace opacities,\n particularly of the lung bases which was likely due to a combination of fluid\n overload as well as atelectasis. There is a left retrocardiac opacity and\n likely left-sided pleural effusion. Overall, the findings are unchanged.\n There is also a fracture involving the left proximal humerus at the surgical\n neck. This is unchanged from the shoulder radiographs from .\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-03-23 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1129757,
"text": " 8:42 AM\n PORTABLE ABDOMEN Clip # \n Reason: interval change\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with complicated bowel pathology, now with fever, hypoxia, pain\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n\n STUDY: Portable abdomen .\n\n HISTORY: 35-year-old man with complicated bowel pathology, now with fever and\n hypoxia.\n\n FINDINGS: Comparison is made to previous study from .\n\n There is a nasogastric tube with distal tip and side port beyond the\n gastroesophageal junction. There is air and stool seen throughout the colon\n and small bowel which is unchanged from previous. No free intra-abdominal air\n is identified. Overall appearance is unchanged from prior.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-03-19 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1129090,
"text": " 10:09 AM\n PORTABLE ABDOMEN Clip # \n Reason: interval development\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with abd distention\n REASON FOR THIS EXAMINATION:\n interval development\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Abdominal distention.\n\n COMPARISON: Multiple priors including most recent .\n\n AP PORTABLE ABDOMEN: Persistent dilation of large bowel loops, now measuring\n up to 8.4 cm in diameter, likely sigmoid colon. No free intraperitoneal air\n is noted in this supine study. Nasogastric tube is seen in appropriate\n position.\n\n IMPRESSION: Large bowel dilation. No free intraperitoneal air is seen in\n this supine radiograph.\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-03-13 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1128210,
"text": " 8:12 AM\n PORTABLE ABDOMEN Clip # \n Reason: BOWEL OBSTRUCTION AND NGT PLACEMENT\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with NGT in place, now with vomiting, NGT not drawing back\n REASON FOR THIS EXAMINATION:\n bowel obstruction\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Vomiting.\n\n COMPARISON: Multiple priors including .\n\n SUPINE AND UPRIGHT ABDOMEN:\n\n Unchanged marked dilation of large bowel with sigmoid colon measuring up to 10\n cm in diameter, may represent chronic air swallowing pattern. There is no\n free intraperitoneal air or pneumatosis. Surgical clips are seen in the right\n upper quadrant. Nasogastric tube is seen in appropriate position.\n\n IMPRESSION: Unchanged marked large bowel dilation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-03-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1130459,
"text": " 2:59 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with pneumonia; intubated\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n COMPARISON: .\n\n INDICATION: Pneumonia. Intubated.\n\n FINDINGS: Endotracheal tube has been withdrawn slightly, now terminating\n about 5 cm above the carina. Other indwelling devices are unchanged in\n position, and cardiomediastinal contours are stable in appearance. Layering\n large bilateral pleural effusions appear increased compared to the previous\n study, and partially obscure pre-existing areas of perihilar consolidation.\n Additionally, note is made of apparent ascites and anasarca.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-02-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1124543,
"text": " 4:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with CP, peritonitis and ascites, and Hepatitis B, intubated\n and sedated\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n CLINICAL INFORMATION: Chest pain.\n\n COMPARISON STUDY: at 06:14 hours.\n\n FINDINGS:\n\n Endotracheal tube terminates at the thoracic inlet. Left subclavian catheter\n terminates at the superior vena cava. Nasogastric tube is coiled within the\n fundus of the stomach with the tip at the gastroesophageal junction. This\n should be advanced somewhat.\n\n There is minimal atelectasis at the right lung base. There is eventration of\n the left hemidiaphragm with mild atelectasis. Upper lung zones are clear.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-03-07 00:00:00.000",
"description": "ABDOMEN (SUPINE ONLY)",
"row_id": 1127407,
"text": " 1:09 PM\n ABDOMEN (SUPINE ONLY) Clip # \n Reason: eval for SBO\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with known partial SBO with more abd distension\n REASON FOR THIS EXAMINATION:\n eval for SBO\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: History of small bowel obstruction with more abdominal distention.\n\n COMPARISON: .\n\n SUPINE ABDOMEN:\n\n There are multiple dilated loops of large and small bowel, mostly are loops of\n colon, measuring up to 8.4 cm. There is no free intraperitoneal air or\n pneumatosis. The thoracic spine demonstrates a complex scoliosis, unchanged.\n\n IMPRESSION: Multiple dilated loops of large and small bowel, more prominent\n is colonic dilation. Findings are concerning for large bowel obstruction.\n\n These findings were reported to Dr. on the time of reporting.\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-03-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1129835,
"text": " 5:52 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for interval change\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with possible pneumonia\n REASON FOR THIS EXAMINATION:\n please evaluate for interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST.\n\n HISTORY: 35-year-old male with possible pneumonia, please evaluate for\n interval change.\n\n FINDINGS: Comparison is made to previous study from .\n\n The nasogastric tube and left-sided PICC line are unchanged in position. There\n are markedly low lung volumes and there are diffuse airspace opacities\n bilaterally, left side worse than right. There is also a left retrocardiac\n opacity and left-sided pleural effusion. These findings are unchanged.\n\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-03-12 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1128040,
"text": " 6:57 AM\n PORTABLE ABDOMEN Clip # \n Reason: evaluate colonic dilation\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with cerebral palsy, improving abdominal microperf and partial\n small bowel obstruction. Has significant colonic distension with rectal tube\n which fell out. Evaluate with serial KUB to r/o worsening colonic dilation.\n REASON FOR THIS EXAMINATION:\n evaluate colonic dilation\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: colonic distension with rectal tube\n\n SUPINE ABDOMEN:\n There is marked dilation of large bowel, with sigmoid colon measuring up to\n 9.8 cm, overall unchanged when compared to prior study. There is no free\n intraperitoneal air or pneumatosis. Surgical clips are seen in the right\n upper quadrant. The bladder is filled with contrast. The rectal tube is not\n seen on today's study.\n\n IMPRESSION:\n Unchanged marked colonic/sigmoid dilation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-03-20 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1129226,
"text": " 4:00 AM\n PORTABLE ABDOMEN Clip # \n Reason: evaluate for interval change of colonic distension, r/o free\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with gastric varicies and complicated medical history, h/o SBO\n which was improving, also with colonic distension now with increased abdominal\n distension, new PO2 requirement. Please evaluate for evaluate for interval\n change of colonic distension, r/o free air, r/o sbo\n REASON FOR THIS EXAMINATION:\n evaluate for interval change of colonic distension, r/o free air, r/o sbo\n ______________________________________________________________________________\n WET READ: AJy WED 5:09 AM\n no signficant interval change. scattered air in small and large bowel with\n prominent sigmoid measuring up to 8.2 cm. no pneumatosis or supine evidence\n of free air.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Abdominal distention.\n\n COMPARISON: Multiple priors including the most recent radiograph from , .\n\n SUPINE ABDOMEN:\n\n Bowel gas pattern is unchanged when compared to prior study. Persistent\n prominent loops of large bowel, with sigmoid colon measuring 8.2 cm in\n diameter. No free intraperitoneal air in this supine radiograph.\n\n IMPRESSION: Unchanged large bowel dilation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-02-26 00:00:00.000",
"description": "RENAL U.S.",
"row_id": 1125887,
"text": " 2:26 PM\n RENAL U.S. Clip # \n Reason: cause of ARF\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with worsening renal failure, please eval for obstruction or\n renal abnormality\n REASON FOR THIS EXAMINATION:\n cause of ARF\n ______________________________________________________________________________\n FINAL REPORT\n RENAL ULTRASOUND, \n\n INDICATION: Worsening renal failure.\n\n COMPARISON: CT.\n\n FINDINGS: The right kidney measures 9.4 cm. The left kidney measures 7.8 cm.\n A simple cyst in the interpolar right kidney measures 1.1 x 1.0 x 1.0 cm.\n Both kidneys demonstrate mildly echogenic parenchyma, but there is no solid\n mass, stone, or hydronephrosis. Pre-void bladder is partially distended,\n unremarkable in appearance. Incidental note is made of ascites in the lower\n pelvis.\n\n IMPRESSION:\n 1. Small size and echogenic appearance of the kidneys consistent with\n chronic, diffuse parenchymal disease. No hydronephrosis.\n 2. Ascites.\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-02-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1124233,
"text": " 4:39 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 yo M with cerebral palsy, with abdominal pain and ascites, CT scan noted\n findings consistent with shock bowel/low flow state. No vascular occlusion. No\n perforation, no free air. Noobstruction\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 35-year-old male with cerebral palsy and shock bowel, question\n interval change.\n\n COMPARISON: Chest radiograph from .\n\n SINGLE FRONTAL CHEST PREOP:\n\n Lungs are low in volume but show interval improvement in mild pulmonary edema.\n An ET tube, NG tube and left subclavian catheter all terminate appropriately,\n unchanged. The left lower lobe consolidation with associated left pleural\n effusion likely represents pneumonia.\n\n IMPRESSION:\n\n Left lower lobe pneumonia with moderate associated effusion. Improving\n pulmonary edema.\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-03-20 00:00:00.000",
"description": "L SHOULDER 2-3 VIEWS NON TRAUMA LEFT",
"row_id": 1129367,
"text": " 7:09 PM\n SHOULDER VIEWS NON TRAUMA LEFT Clip # \n Reason: surgery requests axillary view shoulder film and true(er) AP\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with complicated hospital course with numerous GI issues now\n has left humeral fx\n REASON FOR THIS EXAMINATION:\n surgery requests axillary view shoulder film and true(er) AP shoulder view to\n make sure this is not dislocated\n ______________________________________________________________________________\n WET READ: MBue WED 9:51 PM\n fracture in the region of the surgical neck of the humerus with medial\n displacement of the shaft relative to the humeral head. possible mild anterior\n subluxation of humeral head without evidence of dislocation.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Man with complicated hospital course and left humeral fracture.\n\n COMPARISON: None available.\n\n THREE VIEWS OF THE LEFT SHOULDER:\n There is a fracture through the surgical neck of the humerus with slight\n medial displacement of the distal fragment. No dislocations or subluxations\n are noted. The visible lungs are clear.\n\n IMPRESSION:\n Fracture through the surgical neck of the humerus.\n\n These findings were communicated to Dr. via telephone on 11:50 a.m. on\n and the change from the preliminary report was conveyed as well.\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-03-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1127990,
"text": " 5:44 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval NGT placement\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with ngt placement\n REASON FOR THIS EXAMINATION:\n eval NGT placement\n ______________________________________________________________________________\n WET READ: AJy MON 10:15 PM\n NGT extends to stomach with sideholes in the region of the GE jxn and should\n be advanced for optimal positioning. low lung volumes withou focal\n consolidation, effuision or ptx. right PICC to SVC. prom bowel loops with\n dilated sigmoid colon as on KUB.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: NG tube placement.\n\n FINDINGS: In comparison with study of , there has been placement of\n nasogastric tube that extends to the upper stomach, though the side hole is in\n the region of the esophagogastric junction. The tube should be pushed forward\n several cm for optimal positioning.\n\n The lung volumes are even lower than on the previous study. There is mild\n prominence of the pulmonary markings, especially on the left. This could\n reflect asymmetric pulmonary edema, though this condition usually\n preferentially affects the right side. The possibility of a developing\n consolidation at the left base must be considered.\n\n There is generalized dilatation of loops of large and small bowel, consistent\n with adynamic ileus.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-03-19 00:00:00.000",
"description": "L HUMERUS (AP & LAT) LEFT",
"row_id": 1129172,
"text": " 3:27 PM\n HUMERUS (AP & LAT) LEFT; SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA LEFTClip # \n Reason: fracture\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with cerebral palsy now with LUE pain\n REASON FOR THIS EXAMINATION:\n fracture\n ______________________________________________________________________________\n WET READ: RHB TUE 6:54 PM\n mildly displaced fracture surgical neck left humerus\n ______________________________________________________________________________\n FINAL REPORT\n LEFT HUMERUS\n\n CLINICAL HISTORY: Fracture.\n\n AP, oblique and scapular Y views of the left humerus were obtained.\n\n There is a fracture in the region of the surgical neck of the humerus with\n medial displacement of the shaft relative to the humeral head. A catheter\n likely a PICC line, is noted.\n\n IMPRESSION:\n There is a mildly displaced fracture in the region of the surgical neck of the\n left humerus.\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-02-13 00:00:00.000",
"description": "CHEST (SINGLE VIEW)",
"row_id": 1123972,
"text": " 3:06 PM\n CHEST (SINGLE VIEW) Clip # \n Reason: r/o PNA, free air\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with hx abd dist, course breath sounds\n REASON FOR THIS EXAMINATION:\n r/o PNA, free air\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 35-year-old male with abdominal distension and coarse breath\n sounds.\n\n There are no prior examinations for comparison.\n\n FINDINGS: Single AP radiograph of the chest was obtained. The patient is\n rotated. There are low lung volumes. The lungs are clear without\n consolidation or edema. There are no pleural effusions or pneumothorax. The\n cardiomediastinal silhouette is unremarkable.\n\n A nasogastric tube is seen coiled in the stomach. Multiple small bowel loops\n are dilated up to 4.6 cm, with visible wall thickening (\"thumbprint sign\").\n Surgical clips are noted in the right upper quadrant.\n\n There is lumbar dextroscoliosis, which may be positional. The soft tissues\n are normal.\n\n IMPRESSION:\n 1. Low lung volumes. No focal consolidation.\n 2. Small bowel wall thickening and dilation, better evaluated on the outside\n hospital CT.\n\n"
}
] |
81,685 | 139,844 | The patient was admitted to the ICU after having been intubated and sedated. He was not opening his eyes and was not following commands upon admission. He was however, able to move all 4 extremities to noxious stimuli. On he had a CTA showing no aneurysm or AVM. There was complete right ICA occulsion but there was collateral flow. On there was a question of a self-resolving focal seizure in the LUE so keppra was started. He underwent craniotomy for evacuation of hematoma on . The patient was able to move his extremities spontaneously and started to follow commands with the LUE post-operatively. He was also able to open his eyes. The patient was able to tolerate some time on trach mask but still required the ventilator at night. On the patient had been on the trach mask for over 24 hours. He was tracking with his eyes and moving his LUE and lowers spontaneously and the RUE had slight withdrawal. On the patient had a stat head CT due to a period of unresponsiveness. The scan was unchanged and the patient's exam improved subsequently. He had blood and urine cultures drawn for continued fevers. On , he was found to have lower extremity DVT and IVC filter was placed by interventional radiology on . Subsequent to that, he was started on a heparin infusion without bolus, with goal PTT of 50-70. Also on , he was taken to interventional radiology again to have PICC line placed for continued access. During his hospitalization, he had hyponatremia, which was treated with salt tablets and a fluid restriction. On the patient had a fall on the floor. He had a stat head CT which was unchanged. He was also scanned for any traumatic injuries. All of the imaging was unremarkable. He was seen and evaluated by physical and occupational therapy who determined he would be a candidate for rehab. The patient was more awake and attentive to examiner on the day of discharge although it was still difficult to have him follow commands. His pupils were equal and reactive to light. He was moving spontaneously with the right upper and both lowers. The left upper moved slightly. He was evaluated by the speech therapist and he was unable to tolerate a passimuir valve. Therefore his will go to rehab with a trach mask. He was discharged to an appropriate facility on . | Pt in NARD on aerosol; though tachypneic at times 2 to temp. given hydral and Lopressor as needed for underlying hypertenstion. Action: lopressor given Q8 as ordered, iv Hydralazine given x1 for SBP>160 Response: Patients SBP kept within goal of 100-160 Plan: Continue to monitor. IV fent prn for agitation/pain, continue with standing dose of ativan. Treat agitation and hypertension as needed. Hydralazine PRN and scheduled Metoprolol PRN Ativan d/cd per team and IV Kepra changed to po RUE duplex completed at BS Tylenol po ordered ATC. PSH: unknown Allergies: NKA Neurologic: Neuro checks Q: 2 hr, # IPH q2h neuro checks, sz ppx: keppra , minimize sedating medicines, D/C ativan. PSH: unknown Allergies: NKA Neurologic: Neuro checks Q: 2 hr, # IPH q2h neuro checks, sz ppx: keppra , minimize sedating medicines, D/C ativan. Hypertension, benign Assessment: - goal sbp < 160 - hypertensive to sbp 150s-160s Action: - started on 20mg IV Hydralazine q6h - on PO lopressor 37.5mg PO TID Response: - bp decreased to sbp 120s-130s Plan: - continue to assess/treat hypertension with goal sbp < 160 Intracerebral hemorrhage (ICH) Assessment: - pt alert, tracking movement around the room, does not follow commands - moves L side spontaneously/purposefully, has baseline tremors of LUE - withdraws/postures R upper to nail bed stimuli - no response to nail bed pressure from RLE, this is a new finding - ? Dilantin level sub-therapeutic. - Will need PICC or CVL today as pt with poor peripheral venous access. - Given hydralazine and lopressor prn to keep SBP < 160. Intracerebral hemorrhage (ICH) Assessment: Pt opens eyes spont, not to command. Action: Given hydralazine and lopressor prn. Intracerebral hemorrhage (ICH) Assessment: Neuro exam unchanged. Intracerebral hemorrhage (ICH) Assessment: Neuro exam unchanged. Nutrition: - on TF, w/ Vit/folate/Thiamine supplement Renal: Foley, Adequate UO, - mixed alkalosis - hyponatremia - to monitor w/ q12hr labs, limit free water Hematology: - Stable anemia - Thrombocytopenia, most likely c/w EtOH-induced. Stable appearance of subfalcine herniation and left uncal herniation. An additional focus of hemorrhage within the right inferior frontal lobe with associated edema is unchanged. Unchanged size of left parietotemporal intraparenchymal hemorrhage with increased surrounding vasogenic edema and associated slightly increased rightward subfalcine herniation. Stable right inferior frontal lobe hemorrhage. FINDINGS: There has been an interval left temporal craniotomy, with evacuation of a large parietotemporal intraparenchymal hemorrhage. FINDINGS: Overall appearance of the chest is not substantially changed except for a subtle hazy opacity that has developed in the left infrahilar region, partially obscuring the left heart border. Rightward subfalcine herniation and left uncal herniation, improved. There are mild coronary calcifications and atherosclerotic disease of the thoracic aorta. There is an old right clavicular deformity. Hypertension, benign Assessment: -NIBP: 160s/60-70s with agitation. Hypertension, benign Assessment: -NIBP: 160s/60-70s with agitation. given hydral and Lopressor as needed for underlying hypertenstion. given hydral and Lopressor as needed for underlying hypertenstion. given hydral and Lopressor as needed for underlying hyptertension. given hydral and Lopressor as needed for underlying hyptertension. Treat agitation and hypertension as needed. Able to withdraw with rest of extremities to nail bed pressure. Right IJ placed by anesthesia staff intraop. Patient appeared to betiring out on trach mask. Patient appeared to betiring out on trach mask. Response: -Current temp: 101.0 Plan: -Continue to follow fever curve. -Continue IVP Ativan/Fentany/Lopressor PRN and Hydralazine. CTH: continued evolution of parenchymal hemorrhage and edema, Stable appearance of subfalcine herniation and left uncal herniation, Evolution of right inferior frontal lobe intraparenchymal hemorrhage RUE: pending CXR: no acute process Microbiology: MRSA screen neg Sputum: flora bcx: PND ucx: No growth ucx: No growth bcx: PND : MRSA neg stool/cdiff: pending BCx: pending UCx: pending sputum: o/p contamination Assessment and Plan RESPIRATORY FAILURE, ACUTE (NOT ARDS/), FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN), HYPERTENSION, BENIGN, INTRACEREBRAL HEMORRHAGE (ICH), SEIZURE, WITHOUT STATUS EPILEPTICUS, .H/O SEIZURE, WITHOUT STATUS EPILEPTICUS, ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES) Assessment and Plan: 53M with L large IPH with R frontal contracoup IPH Neurologic: q2h neuro checks, sz ppx: keppra , minimize sedating medicines, ativan given 1mg x2 when patient was diaphoretic, unclear if this represented withdrawl or simple agitation, but some improvement noted Cardiovascular: goal SBP < 160; lopressor + prn hydralazine; in and out of bigeminy with electrolytes normal, keep K>4 and Mg>2 Pulmonary: trach mask, tachypnic at times with respiratory alkalosis Gastrointestinal / Abdomen: tube feeds to goal via NGT Nutrition: MVI, Nutren 2.0 TF, minimize free water Renal: Cr stable; hyponatremia, keep fluid < 1L. If consistentely high start Nicardapine ggts Pulmonary: intubated, sedated, currently CPAP. FINAL REPORT INDICATION: Parenchymal hemmorrhage post evacuation with new mental status chnages. Dilantin level sub-therapeutic. If consistentely high start Nicardapine ggts Pulmonary: intubated, sedated, wean vent as tolerated, currently CPAP. Pneumocephalus has resolved. FINDINGS: The patient is status post left partial craniotomy. Intracerebral hemorrhage (ICH) Assessment: Neuro exam unchanged. Chlorhexidine Gluconate 0.12% Oral Rinse 8. Chlorhexidine Gluconate 0.12% Oral Rinse 8. Metoprolol Tartrate 17. Metoprolol Tartrate 17. Action: Given hydralazine and lopressor prn. 7 mm rightward shift of normally midline structures, left subfalcine and uncal herniation are similar to . IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided double lumen PICC line placement via the right brachial venous approach. FINAL REPORT STUDY: Bilateral lower extremity veins ultrasound. RIGHT LOWER EXTREMITY VENOUS ULTRASOUND: Single Doppler image of the right common femoral vein was obtained, with a normal waveform. FINAL REPORT HISTORY: Known intracranial hemorrhage. The right superficial femoral vein is expanded with echogenic thrombus within and lack of compression demonstrated. There is a right-sided central venous catheter whose tip terminates at the cavoatrial junction. FINDINGS: Grayscale, color and pulse Doppler son was performed on the bilateral common femoral, superficial femoral and popliteal veins. IMPRESSION: Short-segment thrombus within the right superficial femoral vein which is occlusive. There is an infrarenal IVC filter. EXAMINATION: Supine portable abdominal radiograph. There is calcification of the coronary vasculature. The IVC filter and the sheath were then pulled back under the fluoroscope guidance and the IVUS guidance till the tip was located right below the right and left renal veins. | 146 | [
{
"category": "Nursing",
"chartdate": "2140-05-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 564742,
"text": "Hypertension, benign\n Assessment:\n SBP > 140 at times while patient agitated up to 160\ns, up to 150\ns at\n rest at times.\n Action:\n Given prn orders of fent for pain/ agitation.\n Given prn doses of Hydralazine IV and lopressor IV.\n Standing order of lopressor po increased.\n Response:\n SBP < 140 most of shift. > 140 at times.\n Plan:\n Continue to monitor. Treat agitation and hypertension as needed.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Patient s/p craniotomy post op day 1. Patient is able to spontaneously\n open eyes, however not to command. Patient is unable to follow\n commands. Localizes/ lifts and holds with left arm. Able to withdraw\n with rest of extremities to nail bed pressure. Decreased sensation in\n right arm. Pupils are and briskly reactive to light. Aggitated at\n times. Swelling on left side of head and around left eye noted.\n Action:\n Q 2 hour neuro checks.\n Dr. in to assess facial swelling.\n Keep HOB at least 15 degrees\n Turned and repositioned for comfort, fent prn pain, iv ativan.\n Response:\n Patient able to relax after fent and ativan boluses.\n Neuro status unchanged.\n Plan:\n Continue to monitor.\n Trach mask?\n Keep SBP < 140\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Patient febrile up to 103.8.\n Action:\n Dr. notified, no cultures at this time (patient was cultured\n during day)\n Temp in patients room turned down.\n ice packs put under patients arms and behind neck.\n Response:\n temp down to 101. 7 after 1 hour.\n Plan:\n continue to monitor, follow up cultures?\n"
},
{
"category": "Physician ",
"chartdate": "2140-05-06 00:00:00.000",
"description": "Intensivist Note",
"row_id": 565071,
"text": "SICU\n HPI:\n 53M with known EtOH abuse found in home down by social worker on ,\n taken to OSH where patient was combative though moving all 4\n extremities. Patient was intubated and found to have large IPH, was\n subsequently transferred to , with initial labs: plt 40, ethanol\n 71, lactate 3.3, glucose 217.\n Chief complaint:\n PMHx:\n PMH: EtOH abuse, seizure disorder (epilepsy), schizophrenia\n .\n PSH: unknown\n Current medications:\n Acetaminophen, Bisacodyl, Calcium Gluconate, CeftazIDIME, Docusate\n Sodium (Liquid), Fentanyl Citrate, FoLIC Acid, Heparin, HydrALAzine,\n Insulin, LeVETiracetam, Lorazepam, Magnesium Sulfate, Metoprolol\n Tartrate, Multivitamins W/minerals, Ondansetron, Phenytoin\n (Suspension), Potassium Phosphate, Ranitidine, Senna, Thiamine,\n Vancomycin\n 24 Hour Events:\n : Tolerated TCM x 24 hrs. TF restarted on nutren 2.0 - rechecked\n with nutrition, protein intake deemed adequate. Febrile x 1 to 101.5F\n - no repeat cultures done. Pending cultures are all no growth to date.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 05:00 PM\n Infusions:\n Other ICU medications:\n Metoprolol - 01:14 PM\n Heparin Sodium (Prophylaxis) - 02:00 PM\n Other medications:\n Flowsheet Data as of 05:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.8\nC (101.8\n T current: 37.7\nC (99.8\n HR: 80 (72 - 107) bpm\n BP: 107/68(88) {107/52(75) - 164/99(112)} mmHg\n RR: 26 (18 - 33) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 73.4 kg (admission): 70 kg\n Total In:\n 2,521 mL\n 237 mL\n PO:\n Tube feeding:\n 726 mL\n 140 mL\n IV Fluid:\n 1,375 mL\n 97 mL\n Blood products:\n Total out:\n 1,870 mL\n 420 mL\n Urine:\n 1,870 mL\n 420 mL\n NG:\n Stool:\n Drains:\n Balance:\n 651 mL\n -183 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool, Trach mask\n SPO2: 100%\n ABG: ///26/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : , Rhonchorous : )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Responds to: Verbal stimuli, Tactile stimuli, Noxious\n stimuli), Moves all extremities\n Labs / Radiology\n 336 K/uL\n 9.1 g/dL\n 118 mg/dL\n 0.4 mg/dL\n 26 mEq/L\n 3.6 mEq/L\n 12 mg/dL\n 97 mEq/L\n 129 mEq/L\n 26.3 %\n 7.9 K/uL\n [image002.jpg]\n 02:20 AM\n 10:00 AM\n 05:00 PM\n 12:27 AM\n 02:57 AM\n 08:30 PM\n 03:08 AM\n 03:21 AM\n 02:14 AM\n 03:10 AM\n WBC\n 5.0\n 6.7\n 7.2\n 7.9\n Hct\n 27.1\n 27.4\n 27.1\n 26.3\n Plt\n 140\n 186\n 236\n 336\n Creatinine\n 0.6\n 0.5\n 0.4\n 0.4\n TCO2\n 30\n 31\n 25\n 25\n Glucose\n 152\n 142\n 94\n 93\n 118\n 118\n Other labs: PT / PTT / INR:12.1/32.6/1.0, CK / CK-MB / Troponin\n T:247//, ALT / AST:53/32, Alk-Phos / T bili:68/0.4, Fibrinogen:487\n mg/dL, Albumin:3.2 g/dL, LDH:329 IU/L, Ca:8.2 mg/dL, Mg:2.0 mg/dL,\n PO4:2.1 mg/dL\n Microbiology: MRSA screen neg\n Sputum: flora\n bcx: PND\n ucx: No growth\n ucx: No growth\n bcx: PND\n : MRSA neg\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), FEVER (HYPERTHERMIA,\n PYREXIA, NOT FEVER OF UNKNOWN ORIGIN), HYPERTENSION, BENIGN,\n INTRACEREBRAL HEMORRHAGE (ICH), SEIZURE, WITHOUT STATUS EPILEPTICUS,\n .H/O SEIZURE, WITHOUT STATUS EPILEPTICUS, ALCOHOL WITHDRAWAL (INCLUDING\n DELIRIUM TREMENS, DTS, SEIZURES)\n Assessment and Plan: 53M with L large IPH with R frontal contracoup IPH\n Neurologic: Neuro checks Q: 2 hr, # IPH - q1h neuro checks, sz ppx:\n keppra , minimize sedating medicines, decrease Ativan (HD6) to 0.5-1\n Q8H prn iv due to history of heavy EtOH use and to continue slow\n weaning of benzos.\n Cardiovascular: goal SBP < 160; lopressor increased + prn hydralazine\n Pulmonary: respiratory failure s/p trach, on trach mask x 24 hrs w/o\n signs of fatigue although with copious secretions. Continue to monitor.\n Gastrointestinal / Abdomen: s/p PEG, tube feeds to goal\n Nutrition: MVI, Nutren 2.0 TF, to minimize free water given\n hyponatremia\n Renal: creatinine stable; hyponatremia most likely secondary to SIADH\n given CNS pathology, to further restrict free water.\n Hematology: stable anemia\n Endocrine: RISS\n Infectious Disease: Check cultures, WBC normal, off antibiotics.\n Continues to spike, suspect central fever, cultures NGTD, reculture\n q3-4 days if continue to be intermittently febrile\n Lines / Tubes / Drains: G-tube, Trach, PIV, right a-line.\n Consider placing PICC line when consistently afebrile.\n Wounds: Dry dressings\n Imaging: CT scan head today\n Fluids: KVO\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid), (Respiratory\n distress: Failure)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 04:00 PM\n Multi Lumen - 09:15 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2140-05-03 00:00:00.000",
"description": "Intensivist Note",
"row_id": 564625,
"text": "SICU\n HPI:\n 53yo male with known EtOH abuse found in home down by social worker on\n , taken to OSH where patient was combative though moving all 4\n extremities. Patient was intubated and found to have large IPH, was\n subsequently transferred to , with initial labs: plt 40, ethanol\n 71, lactate 3.3, glucose 217.\n Chief complaint:\n L large subacute IPH with R frontal contracoup IPH\n PMHx:\n EtOH abuse, seizure disorder (epilepsy), schizophrenia\n Current medications:\n Acetaminophen, Bisacodyl, Calcium Gluconate, CeftazIDIME, Chlorhexidine\n Gluconate 0.12% Oral Rinse, Docusate Sodium (Liquid), Fentanyl Citrate,\n FoLIC Acid, Heparin, HydrALAzine, Insulin, Influenza Virus Vaccine,\n LeVETiracetam, Lorazepam, Magnesium Sulfate, Metoprolol Tartrate,\n Multivitamins W/minerals, Ondansetron, Phenytoin (Suspension),\n Potassium Phosphate, Ranitidine, Senna, Thiamine, Vancomycin\n 24 Hour Events:\n OR SENT - At 06:36 PM\n MULTI LUMEN - START 09:15 PM\n placed in OR. \n Allergies:\n Last dose of Antibiotics:\n Vancomycin - 08:11 AM\n Ceftazidime - 04:00 AM\n Infusions:\n Other ICU medications:\n Dilantin - 06:16 AM\n Lorazepam (Ativan) - 02:00 AM\n Fentanyl - 04:45 AM\n Other medications:\n Flowsheet Data as of 05:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.1\nC (100.6\n T current: 38.1\nC (100.6\n HR: 84 (61 - 105) bpm\n BP: 129/59(80) {97/54(68) - 154/78(106)} mmHg\n RR: 18 (12 - 33) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 5 (2 - 7) mmHg\n Total In:\n 3,570 mL\n 509 mL\n PO:\n Tube feeding:\n 284 mL\n IV Fluid:\n 2,996 mL\n 509 mL\n Blood products:\n 200 mL\n Total out:\n 2,240 mL\n 660 mL\n Urine:\n 2,240 mL\n 660 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,330 mL\n -151 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 801 (482 - 801) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 12\n PEEP: 5 cmH2O\n FiO2: 30%\n RSBI: 44\n PIP: 10 cmH2O\n SPO2: 97%\n ABG: 7.51/37/129/28/6\n Ve: 9.2 L/min\n PaO2 / FiO2: 430\n Physical Examination\n General Appearance: No acute distress, Well nourished\n HEENT: PERRL, no purposeful movement of eyes\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: LEFT base), (Sternum: Stable )\n Abdominal: Soft, Non-tender, Distended\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: No(t) Moves all extremities, (RUE: No movement), (LUE:\n Weakness), (RLE: No movement), (LLE: Weakness), Sedated. Now opens\n eyes.\n Labs / Radiology\n 140 K/uL\n 9.4 g/dL\n 94 mg/dL\n 0.6 mg/dL\n 28 mEq/L\n 3.6 mEq/L\n 10 mg/dL\n 100 mEq/L\n 136 mEq/L\n 27.1 %\n 5.0 K/uL\n [image002.jpg]\n 01:40 AM\n 01:47 AM\n 04:26 PM\n 01:50 AM\n 02:12 AM\n 02:20 AM\n 10:00 AM\n 05:00 PM\n 12:27 AM\n 02:57 AM\n WBC\n 6.8\n 9.2\n 6.5\n 5.0\n Hct\n 31.4\n 29.9\n 29.0\n 27.1\n Plt\n 122\n 107\n 91\n 86\n 140\n Creatinine\n 0.5\n 0.5\n 0.5\n 0.6\n TCO2\n 28\n 30\n 31\n Glucose\n 105\n 135\n 118\n 152\n 142\n 94\n Other labs: PT / PTT / INR:11.7/27.8/1.0, CK / CK-MB / Troponin\n T:247//, ALT / AST:53/32, Alk-Phos / T bili:68/0.4, Fibrinogen:487\n mg/dL, Albumin:3.5 g/dL, LDH:329 IU/L, Ca:8.0 mg/dL, Mg:2.4 mg/dL,\n PO4:3.1 mg/dL\n Imaging: CXR: Endotracheal tube 7.5 cm from the carina\n CTH: Large left parietotemporal intraparenchymal hemorrhage with\n associated mass effect including 5 mm rightward shift of the normally\n midline structures and subfalcine herniation; intraparenchymal\n hemorrhage in the right inferior frontal lobe; Scattered areas of\n subarachnoid hemorrhage bilaterally; Maxillary and ethmoidal sinus\n disease.\n CT CAP: pending\n CTA head: No aneurysm or sign of vascular malformation. Complete R\n ICA occlusion. Intracranial vessels largely reconstituted via\n collaterals\n MRI c-spine (wet): degenerative changes worst at c5/6,\n moderate-severe cervical spinal stenosis, ?soft tissue or LF injury @\n C5-7 w/ mild edema\n CT T/L spine (wet): no t-spine injury, marked fatty infiltration\n of liver.\n CXR: mild atelectasis\n CTH: Unchanged size of left parietotemporal intraparenchymal\n hemorrhage, slightly increased rightward subfalcine herniation,\n unchanged size of right frontal intraparenchymal hematoma\n CXR: Left basal opacity is unchanged and might be consistent with\n aspiration/pneumonia\n AXR: pending\n CTH: pending\n CXR: pending\n Microbiology: MRSA screen: pending\n : Sputum: GSTAIN: 25PMN and G+R\n : bcx #1\n : bcx #2\n : ucx no growth\n Assessment and Plan\n HYPERTENSION, BENIGN, INTRACEREBRAL HEMORRHAGE (ICH), SEIZURE, WITHOUT\n STATUS EPILEPTICUS, .H/O SEIZURE, WITHOUT STATUS EPILEPTICUS, ALCOHOL\n WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES)\n Assessment and Plan: 53M with L large subacute IPH with R frontal\n contracoup IPH\n Neurologic: IPH, q1h neuro checks, sz ppx: dilantin tid, keppra added\n due to concern for ongoing seizure, minimize sedating medicines, Ativan\n 0.5-1 Q4H iv due to history of heavy EtOH use\n Cardiovascular: goal SBP < 140; lopressor + prn hydralazine,\n nicardipine gtt if needed\n Pulmonary: intubated, sedated, wean vent as tolerated, currently CPAP.\n Daily RSBI, plan for trach \n Gastrointestinal / Abdomen: mild hypertransaminemia, hx chronic EtOH,\n distended abdomen\n Nutrition: TF on hold due to post-op and distended abdomen,\n Vit/folate/Thiamine supplement\n Renal: mixed alkalosis, hyponatremia, restrict free water to < 1L/day\n Hematology: stable anemia, thrombocytopenia, goal PLT > 100K\n Endocrine: tight glucose control RISS\n Infectious Disease: started on vanc/ceftaz for fever, re-evaluate\n need daily\n Lines / Tubes / Drains: ETT, R A-line, L 20g PIV hand (), RIJ TLC\n Wounds: craniotomy\n Imaging:\n Fluids: NS + 20KCL @ 80/hr\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 04:00 PM\n 20 Gauge - 08:58 PM\n Multi Lumen - 09:15 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2140-05-03 00:00:00.000",
"description": "Intensivist Note",
"row_id": 564626,
"text": "SICU\n HPI:\n 53yo male with known EtOH abuse found in home down by social worker on\n , taken to OSH where patient was combative though moving all 4\n extremities. Patient was intubated and found to have large IPH, was\n subsequently transferred to , with initial labs: plt 40, ethanol\n 71, lactate 3.3, glucose 217.\n Chief complaint:\n L large subacute IPH with R frontal contracoup IPH\n PMHx:\n EtOH abuse, seizure disorder (epilepsy), schizophrenia\n Current medications:\n Acetaminophen, Bisacodyl, Calcium Gluconate, CeftazIDIME, Chlorhexidine\n Gluconate 0.12% Oral Rinse, Docusate Sodium (Liquid), Fentanyl Citrate,\n FoLIC Acid, Heparin, HydrALAzine, Insulin, Influenza Virus Vaccine,\n LeVETiracetam, Lorazepam, Magnesium Sulfate, Metoprolol Tartrate,\n Multivitamins W/minerals, Ondansetron, Phenytoin (Suspension),\n Potassium Phosphate, Ranitidine, Senna, Thiamine, Vancomycin\n 24 Hour Events:\n OR SENT - At 06:36 PM\n MULTI LUMEN - START 09:15 PM\n placed in OR. \n Allergies:\n Last dose of Antibiotics:\n Vancomycin - 08:11 AM\n Ceftazidime - 04:00 AM\n Infusions:\n Other ICU medications:\n Dilantin - 06:16 AM\n Lorazepam (Ativan) - 02:00 AM\n Fentanyl - 04:45 AM\n Other medications:\n Flowsheet Data as of 05:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.1\nC (100.6\n T current: 38.1\nC (100.6\n HR: 84 (61 - 105) bpm\n BP: 129/59(80) {97/54(68) - 154/78(106)} mmHg\n RR: 18 (12 - 33) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 5 (2 - 7) mmHg\n Total In:\n 3,570 mL\n 509 mL\n PO:\n Tube feeding:\n 284 mL\n IV Fluid:\n 2,996 mL\n 509 mL\n Blood products:\n 200 mL\n Total out:\n 2,240 mL\n 660 mL\n Urine:\n 2,240 mL\n 660 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,330 mL\n -151 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 801 (482 - 801) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 12\n PEEP: 5 cmH2O\n FiO2: 30%\n RSBI: 44\n PIP: 10 cmH2O\n SPO2: 97%\n ABG: 7.51/37/129/28/6\n Ve: 9.2 L/min\n PaO2 / FiO2: 430\n Physical Examination\n General Appearance: No acute distress, Well nourished\n HEENT: PERRL, no purposeful movement of eyes\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: LEFT base), (Sternum: Stable )\n Abdominal: Soft, Non-tender, Distended\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: No(t) Moves all extremities, (RUE: No movement), (LUE:\n Weakness), (RLE: No movement), (LLE: Weakness), Sedated. Now opens\n eyes.\n Labs / Radiology\n 140 K/uL\n 9.4 g/dL\n 94 mg/dL\n 0.6 mg/dL\n 28 mEq/L\n 3.6 mEq/L\n 10 mg/dL\n 100 mEq/L\n 136 mEq/L\n 27.1 %\n 5.0 K/uL\n [image002.jpg]\n 01:40 AM\n 01:47 AM\n 04:26 PM\n 01:50 AM\n 02:12 AM\n 02:20 AM\n 10:00 AM\n 05:00 PM\n 12:27 AM\n 02:57 AM\n WBC\n 6.8\n 9.2\n 6.5\n 5.0\n Hct\n 31.4\n 29.9\n 29.0\n 27.1\n Plt\n 122\n 107\n 91\n 86\n 140\n Creatinine\n 0.5\n 0.5\n 0.5\n 0.6\n TCO2\n 28\n 30\n 31\n Glucose\n 105\n 135\n 118\n 152\n 142\n 94\n Other labs: PT / PTT / INR:11.7/27.8/1.0, CK / CK-MB / Troponin\n T:247//, ALT / AST:53/32, Alk-Phos / T bili:68/0.4, Fibrinogen:487\n mg/dL, Albumin:3.5 g/dL, LDH:329 IU/L, Ca:8.0 mg/dL, Mg:2.4 mg/dL,\n PO4:3.1 mg/dL\n Imaging: CXR: Endotracheal tube 7.5 cm from the carina\n CTH: Large left parietotemporal intraparenchymal hemorrhage with\n associated mass effect including 5 mm rightward shift of the normally\n midline structures and subfalcine herniation; intraparenchymal\n hemorrhage in the right inferior frontal lobe; Scattered areas of\n subarachnoid hemorrhage bilaterally; Maxillary and ethmoidal sinus\n disease.\n CT CAP: pending\n CTA head: No aneurysm or sign of vascular malformation. Complete R\n ICA occlusion. Intracranial vessels largely reconstituted via\n collaterals\n MRI c-spine (wet): degenerative changes worst at c5/6,\n moderate-severe cervical spinal stenosis, ?soft tissue or LF injury @\n C5-7 w/ mild edema\n CT T/L spine (wet): no t-spine injury, marked fatty infiltration\n of liver.\n CXR: mild atelectasis\n CTH: Unchanged size of left parietotemporal intraparenchymal\n hemorrhage, slightly increased rightward subfalcine herniation,\n unchanged size of right frontal intraparenchymal hematoma\n CXR: Left basal opacity is unchanged and might be consistent with\n aspiration/pneumonia\n AXR: pending\n CTH: pending\n CXR: pending\n Microbiology: MRSA screen: pending\n : Sputum: GSTAIN: 25PMN and G+R\n : bcx #1\n : bcx #2\n : ucx no growth\n Assessment and Plan\n HYPERTENSION, BENIGN, INTRACEREBRAL HEMORRHAGE (ICH), SEIZURE, WITHOUT\n STATUS EPILEPTICUS, .H/O SEIZURE, WITHOUT STATUS EPILEPTICUS, ALCOHOL\n WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES)\n Assessment and Plan: 53M with L large subacute IPH with R frontal\n contracoup IPH\n Neurologic: IPH, q1h neuro checks, sz ppx: dilantin tid, keppra added\n due to concern for ongoing seizure, minimize sedating medicines, Ativan\n 0.5-1 Q4H iv due to history of heavy EtOH use\n Cardiovascular: goal SBP < 140; lopressor + prn hydralazine,\n nicardipine gtt if needed\n Pulmonary: intubated, sedated, wean vent as tolerated, currently CPAP.\n Daily RSBI, plan for trach \n Gastrointestinal / Abdomen: mild hypertransaminemia, hx chronic EtOH,\n distended abdomen\n Nutrition: TF on hold due to post-op and distended abdomen,\n Vit/folate/Thiamine supplement\n Renal: mixed alkalosis, hyponatremia, restrict free water to < 1L/day\n Hematology: stable anemia, thrombocytopenia, goal PLT > 100K\n Endocrine: tight glucose control RISS\n Infectious Disease: started on vanc/ceftaz for fever, re-evaluate\n need daily\n Lines / Tubes / Drains: ETT, R A-line, L 20g PIV hand (), RIJ TLC\n Wounds: craniotomy\n Imaging:\n Fluids: NS + 20KCL @ 80/hr\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 04:00 PM\n 20 Gauge - 08:58 PM\n Multi Lumen - 09:15 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n Total time spent:\n ------ Protected Section ------\n Time spent 31 min.\n ------ Protected Section Addendum Entered By: , MD\n on: 08:00 ------\n"
},
{
"category": "General",
"chartdate": "2140-05-03 00:00:00.000",
"description": "Generic Note",
"row_id": 564642,
"text": "TITLE:\n Rehab Services. PT Consult received and appreciated. Communicated with\n RN RE Pt Status. Pt has orders for bedrest and is currently unable to\n participate in PT MS. Please call with questions or reconsult with\n changes. Will f/u later this week.\n"
},
{
"category": "Nursing",
"chartdate": "2140-05-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 565147,
"text": "53M with known EtOH abuse found in home down by social worker on ,\n taken to OSH where patient was combative though moving all 4\n extremities. Patient was intubated and found to have large IPH w/ right\n frontal contracoup IPH. HE was subsequently transferred to , with\n initial labs: plt 40, ethanol 71, lactate 3.3, glucose 217.\n PMH: EtOH abuse, seizure disorder (epilepsy), schizophrenia.\n PSH: unknown\n Allergies: NKA\n Intracerebral hemorrhage (ICH)\n Assessment:\n Pt alert, not consistently tracking w/ eyes. Pupils 2-3mm\n PERRL\n Neuro checks Q2hrs. SZ precautions. Head CT from this am\n pending\n Baseline tremor to left upper extremity. Lifts and holds\n left extremities\n Right sided extremtities only moving on bed and withdrawing\n to painful stimuli\n Left heal w/ crani site. Sutures OTA, no drainage or signs\n of infection\n Goal Systolic <160. SR/ST 70-100\ns w/ occasional Vent\n Bigeminy\n Tolerating Trach mask 35% over 24hrs now.\n Temp 100-101.5. Last Cx\nd .\n RUE swollen\n Right Nare NGT w/ Nutren 2.o at goal 40cc/hr. Sodium 129.\n Action:\n Neuro checks Q2hrs. Hydralazine PRN and scheduled Metoprolol\n PRN Ativan d/c\nd per team and IV Kepra changed to po\n RUE duplex completed at BS\n Team aware of Bigeminy. K-3.6. Given 40meq IV KCL per team\n Tylenol po ordered ATC. No cultures to be done today.\n Poor PIV access. Right IJ remains but d/c is being\n considered\n GT flushes decreased to restrict free water d/t NA level\n Soft limb restraints d/t purposeful movement to pull at\n lines w/ LUE\n Response:\n No change in Neuro\n Hydralazine x1 w/ good response. SR/ST 70-100\ns No further\n Bigeminy\n Awaiting official read of Duplex but per tech looks negative\n Remains w/ temps\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2140-05-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 564433,
"text": "Intracerebral hemorrhage (ICH\n Assessment:\n Patient , open eyes spontaneously, does not obey commands.\n Moves left ue/le spontaneously. Some withdraw noted to right ue, to\n painful stimuli. Withdraws to stimuli right le.\n Action:\n Monitor neuro checks Q2.\n Response:\n No change in neuro status.\n Plan:\n Will continue to monitor neuro checks Q1. No plan for intervention at\n this time.\n Seizure, without status epilepticus\n Assessment:\n No seizure activity noted overnight.\n Action:\n Monitor for seizure activity, iv dilantin given as ordered. Patient\n levels low, dr aware will need bolus dose.\n Response:\n No change in status.\n Plan:\n Will continue to monitor and treat accordingly\n Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Patient agitated at times, attempts to pull out ett, hr becomes\n elevated. Occasional tremors noted.\n Action:\n iv Ativan 0.5mgs given Q4 as ordered,\n Response:\n patient lightly sedated, appears comfortable, less agitated\n Plan:\n will continue to monitor and treat accordingly\n Hypertension, benign\n Assessment:\n Patient hypertensive above goal of SBP < 160 a couple of times during\n shift.\n Action:\n lopressor given Q8 as ordered, iv Hydralazine given x1 for SBP>160\n Response:\n Patient\ns SBP kept within goal of 100-160\n Plan:\n Continue to monitor.\n Tube feed held at 4am, for ? extubation today.\n"
},
{
"category": "Nursing",
"chartdate": "2140-05-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 564881,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Patient continues to localize with left arm only. Able to withdraw to\n nailbed pressure with lower extremities and right arm. Pupils are \n and briskly reactive to light. Patient does not follow any commands.\n Appears to be tracking at times.\n SBP < 140 most of shift. > 140 at times mostly with agitation.\n Action:\n continued with q 2 hour neuro exams.\n given IV fent and ativan for agitation.\n given hydral and Lopressor as needed for underlying hypertenstion.\n Response:\n neuro exam unchanged.\n Plan:\n continue to monitor. Step down?\n Hypertension, benign\n Assessment:\n Patient\ns BP is labile. Ranging from 100-160\ns at times. SBP > 140\n with agitation mostly.\n Action:\n given prn fent and ativan for agitation.\n given hydral and Lopressor as needed for underlying hyptertension.\n Dr. aware of labile BP.\n Response:\n SBP < 140 most of night.\n Plan:\n continue to monitor. Prn antihypertensives/ prn pain meds for\n aggiation.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient on trach mask at 35 % sating 99-100% RR 30\ns- 40\ns at start of\n shift. Patient appeared comfortable until about midnight patient was\n breathing faster- RR 40\ns, with thick white secretions, patient able to\n expectorate own secretions but inadequately at times. Patient appeared\n to be\ntiring out\n on trach mask.\n Action:\n Patient deep suctioned x 3 for moderate amount of thick white\n secretions.\n Patient put back on CPAP 5/5 fi02 40% during night to rest.\n Response:\n Patient appeared more comfortable RR 20\ns-30\ns sating 99-100%.\n Plan:\n put back on trach mask in am. Continue to monitor, suction as needed.\n"
},
{
"category": "Nursing",
"chartdate": "2140-05-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 565000,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt with inability to protect airway, trached. Productive, strong\n cough.\n Action:\n On trach mask trial since 0700 today.\n Response:\n Tolerating well at present, no sings/symptoms of resp distress.\n Plan:\n Maintain on trach mask as long as tolerated.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Pt s/p evacuation of ICH. Moving left upper limb well and with\n purpose, moving left leg around more in bed. Right side weak/flaccid\n at times. Opens eyes spontaneously, seems to track at times today.\n Not following any commands. Occasional rhythmic twitching to left side\n noted.\n Action:\n Medicated with fentanyl, Lopressor, Ativan and Hydralazine for periods\n of twitching and associated hypertension.\n Response:\n Pt settled afterwards.\n Plan:\n Continue to monitor Q2 neuro exam, medicate as needed.\n"
},
{
"category": "Nursing",
"chartdate": "2140-05-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 565146,
"text": "53M with known EtOH abuse found in home down by social worker on ,\n taken to OSH where patient was combative though moving all 4\n extremities. Patient was intubated and found to have large IPH w/ right\n frontal contracoup IPH. HE was subsequently transferred to , with\n initial labs: plt 40, ethanol 71, lactate 3.3, glucose 217.\n PMH: EtOH abuse, seizure disorder (epilepsy), schizophrenia.\n PSH: unknown\n Allergies: NKA\n Intracerebral hemorrhage (ICH)\n Assessment:\n Pt alert, not consistently tracking w/ eyes. Pupils 2-3mm\n PERRL\n Neuro checks Q2hrs. SZ precautions. Head CT from this am\n pending\n Baseline tremor to left upper extremity. Lifts and holds\n left extremities\n Right sided extremtities only moving on bed and withdrawing\n to painful stimuli\n Left heal w/ crani site. Sutures OTA, no drainage or signs\n of infection\n Goal Systolic <160\n Tolerating Trach mask 35% over 24hrs now.\n Temp 100-101.5. Last Cx\nd .\n RUE swollen\n Right Nare NGT w/ Nutren 2.o at goal 40cc/hr. Sodium 129.\n Action:\n Neuro checks Q2hrs. Hydralazine PRN and scheduled Metoprolol\n PRN Ativan d/c\nd per team and IV Kepra changed to po\n RUE duplex completed at BS\n Tylenol po ordered ATC. No cultures to be done today.\n Poor PIV access. Right IJ remains but d/c is being\n considered\n GT flushes decreased to restrict free water d/t NA level\n Soft limb restraints d/t purposeful movement to pull at\n lines w/ LUE\n Response:\n No change in Neuro\n Hydralazine x1 w/ good response\n Awaiting official read of Duplex but per tech looks negative\n Remains w/ temps\n Plan:\n"
},
{
"category": "Respiratory ",
"chartdate": "2140-05-07 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 565201,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Cuffed, Inner Cannula, Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 20 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Expectorated / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt cont trached on cool mist aerosol. Lung sounds ess clear\n after suct th yellow sput. Pt in NARD on aerosol; though tachypneic at\n times 2\n to temp. Cont cool mist aerosol/pulm toilet as required.\n"
},
{
"category": "Nursing",
"chartdate": "2140-05-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 565357,
"text": "Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n T-max 101.7 overnight. . WBC 10.0.\n Action:\n Tylenol and motrin around the clock. Pan cultured for urine, sputum\n and blood (via central line). C. Diff spec. sent.\n Response:\n Temp. down to 100.1. culture results pending.\n Plan:\n Continue Tylenol and motrin around the clock, monitor temperature and\n wbc.\n Seizure, without status epilepticus\n Assessment:\n Pt noted to have significant tremors in the left upper extremity, and\n bilateral lower extremities lasting several minutes. Pt remained alert\n and tracking during the episode. Tremors ceased briefly, then returned\n x\ns 2. Pt reportedly has a history of tremors in his left arm at\n baseline (per brother) ? seizure vs. rigors.\n Action:\n Sicu h.o. notified and at the bedside to eval. Neurosurgery n.p.\n notified. 0.5 mg iv Ativan given.\n Response:\n Tremors resolved, unclear if a result of Ativan as they were beginning\n to resolve as Ativan was being administered.\n Plan:\n Continue to monitor, eeg today.\n"
},
{
"category": "Nursing",
"chartdate": "2140-05-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 564608,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Patient returned from OR s/p left sided craniotomy. Patient able to\n open eyes spontaneously, fairly alert most of night. Able to localize\n with left arm and moves lower extremities on bed. Withdraws/ flexes\n with right arm to nail bed pressure. Pupils are equal and briskly\n reactive to light. Patient agitated and restless frequently throughout\n night. SBP 100-140, occasionally > 140 when agitated.\n Action:\n q 1 hour neuro checks.\n turned and repositioned frequently for comfort.\n IV fent prn for agitation/pain, continue with standing dose of ativan.\n Response:\n Patient awake most of night.\n SBP kept 100-140.\n no change in neuro change.\n Plan:\n continue to monitor, q 1 hour neuro checks until am, trach and peg\n today? Discuss restarting tube feeds in am.\n"
},
{
"category": "Rehab Services",
"chartdate": "2140-05-05 00:00:00.000",
"description": "Physical Therapy Evaluation Note",
"row_id": 564984,
"text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: IPH / 431\n Reason of referral: Eval & treat\n History of Present Illness / Subjective Complaint: 53 yo M found down\n at home on , combative at OSH and moving all 4 extremeties,\n intubated and found to have large left temoro-parietal intraparenchymal\n hemmorhage with with R frontal contrcoup transferred to on\n and underwent craniotomy for evacuation on . Underwent trach\n on and weaned to trach mask by .\n Past Medical / Surgical History: Etoh abuse, seizure disorder,\n schizophrenia\n Medications: hydralazine, fentanyl, heparin, tylenol, metoprolol,\n lorazepam\n Radiology: head CT - Post-surgical changes are again demonstrated\n following evacuation of a left temporoparietal intraparenchymal\n hemorrhage with continued evolution of parenchymal hemorrhage and\n edema, evolution of right inferior frontal lobe intraparenchymal\n hemorrhage without evidence of new parenchymal hemorrhage detected.\n Labs:\n 27.1\n 9.5\n 236\n 7.2\n [image002.jpg]\n Other labs:\n pO2 155\n Activity Orders: OOB with assist\n Social / Occupational History: lives alone, social worker checks in on\n him once/week\n Living Environment: unknown\n Prior Functional Status / Activity Level: unknown, presumed I pta\n Objective Test\n Arousal / Attention / Cognition / Communication: arousable but opens\n eyes minimally, not tracking visually but gaze is not fixed. Following\n 0% of commands.\n Hemodynamic Response\n Aerobic Capacity\n HR\n BP\n RR\n O[2 ]sat\n HR\n BP\n RR\n O[2] sat\n RPE\n Supine\n /\n Rest\n 82\n 136/64\n 100% on TM\n Sit\n /\n Activity\n 96\n 164/86\n 99% on TM\n Stand\n /\n Recovery\n 91\n 152/67\n 100% on TM\n Total distance walked: 0\n Minutes:\n Pulmonary Status: course breath sounds bilaterally, strong productive\n cough of thick yellow sputum. On 40% FIO2 via trach mask.\n Integumentary / Vascular: L parietal incision with dressing intact,\n trach with trach mask, right radial a-line, R IJ central line, foley,\n rectal tube, tele\n Sensory Integrity: unable to assess\n Pain / Limiting Symptoms: patient unable to relate pain\n Posture: mildly kyphotic in sitting\n Range of Motion\n Muscle Performance\n B LE's grossly WNL\n unable to assess\n Motor Function: 3+ spasticity RUE/LE, 1+ tone noted RUE/LE. Moving\n LUE/LE purposefully, RLE occasionally spontaneous movements.\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: patient total assist for all mobility, not actively\n participating\n Rolling:\n\n\n\n\n\n\n Supine /\n Sidelying to Sit:\n\n\n\n\n\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n\n\n\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Balance: max A static sitting at edge of bed, strong pushing with LUE\n toward the right. No other postural/balance reactions noted.\n Education / Communication: Patient unable to participate in education\n cognitive status. Communicated with nsg re: status\n Intervention:\n Other:\n Diagnosis:\n 1.\n Impaired functional mobility\n 2.\n Impaired sitting balance\n 3.\n Impaired endurance\n 4.\n Impaired cognition\n Clinical impression / Prognosis: 53 yo M s/p IPH p/w above impairments\n a/w non-progressive CNS disorder. He is currently not tracking or\n following any commands at this time, however is demonstrating increased\n level of alertness since extubation. He is significantly below his\n baseline, and prognosis is guarded at this time given his cognitive\n status, however given his age and plof he has potential to make\n progress. Recommend rehab at this time, and patient will continue to\n benefit from daily PT to re-assess and progress as able.\n Goals\n Time frame: 1 week\n 1.\n Max A with bed mobility/transfers\n 2.\n Maintain static sitting with mod A\n 3.\n Tolerate OOB >/= 2 hours/day\n 4.\n Follows >25% of simple commands\n 5.\n 6.\n Anticipated Discharge: Rehab\n Treatment Plan:\n Frequency / Duration: 3-5x/wk\n bed mobility, transfers, balance, strengthening, endurance, education,\n d/c planning\n Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n"
},
{
"category": "Physician ",
"chartdate": "2140-05-03 00:00:00.000",
"description": "Intensivist Note",
"row_id": 564593,
"text": "SICU\n HPI:\n 53yo male with known EtOH abuse found in home down by social worker on\n , taken to OSH where patient was combative though moving all 4\n extremities. Patient was intubated and found to have large IPH, was\n subsequently transferred to , with initial labs: plt 40, ethanol\n 71, lactate 3.3, glucose 217.\n Chief complaint:\n L large subacute IPH with R frontal contracoup IPH\n PMHx:\n EtOH abuse, seizure disorder (epilepsy), schizophrenia\n Current medications:\n Acetaminophen, Bisacodyl, Calcium Gluconate, CeftazIDIME, Chlorhexidine\n Gluconate 0.12% Oral Rinse, Docusate Sodium (Liquid), Fentanyl Citrate,\n FoLIC Acid, Heparin, HydrALAzine, Insulin, Influenza Virus Vaccine,\n LeVETiracetam, Lorazepam, Magnesium Sulfate, Metoprolol Tartrate,\n Multivitamins W/minerals, Ondansetron, Phenytoin (Suspension),\n Potassium Phosphate, Ranitidine, Senna, Thiamine, Vancomycin\n 24 Hour Events:\n OR SENT - At 06:36 PM\n MULTI LUMEN - START 09:15 PM\n placed in OR. \n Allergies:\n Last dose of Antibiotics:\n Vancomycin - 08:11 AM\n Ceftazidime - 04:00 AM\n Infusions:\n Other ICU medications:\n Dilantin - 06:16 AM\n Lorazepam (Ativan) - 02:00 AM\n Fentanyl - 04:45 AM\n Other medications:\n Flowsheet Data as of 05:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.1\nC (100.6\n T current: 38.1\nC (100.6\n HR: 84 (61 - 105) bpm\n BP: 129/59(80) {97/54(68) - 154/78(106)} mmHg\n RR: 18 (12 - 33) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 5 (2 - 7) mmHg\n Total In:\n 3,570 mL\n 509 mL\n PO:\n Tube feeding:\n 284 mL\n IV Fluid:\n 2,996 mL\n 509 mL\n Blood products:\n 200 mL\n Total out:\n 2,240 mL\n 660 mL\n Urine:\n 2,240 mL\n 660 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,330 mL\n -151 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 801 (482 - 801) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 12\n PEEP: 5 cmH2O\n FiO2: 30%\n RSBI: 44\n PIP: 10 cmH2O\n SPO2: 97%\n ABG: 7.51/37/129/28/6\n Ve: 9.2 L/min\n PaO2 / FiO2: 430\n Physical Examination\n General Appearance: No acute distress, Well nourished\n HEENT: PERRL, no purposeful movement of eyes\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: LEFT base), (Sternum: Stable )\n Abdominal: Soft, Non-tender, Distended\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: No(t) Moves all extremities, (RUE: No movement), (LUE:\n Weakness), (RLE: No movement), (LLE: Weakness), Sedated\n Labs / Radiology\n 140 K/uL\n 9.4 g/dL\n 94 mg/dL\n 0.6 mg/dL\n 28 mEq/L\n 3.6 mEq/L\n 10 mg/dL\n 100 mEq/L\n 136 mEq/L\n 27.1 %\n 5.0 K/uL\n [image002.jpg]\n 01:40 AM\n 01:47 AM\n 04:26 PM\n 01:50 AM\n 02:12 AM\n 02:20 AM\n 10:00 AM\n 05:00 PM\n 12:27 AM\n 02:57 AM\n WBC\n 6.8\n 9.2\n 6.5\n 5.0\n Hct\n 31.4\n 29.9\n 29.0\n 27.1\n Plt\n 122\n 107\n 91\n 86\n 140\n Creatinine\n 0.5\n 0.5\n 0.5\n 0.6\n TCO2\n 28\n 30\n 31\n Glucose\n 105\n 135\n 118\n 152\n 142\n 94\n Other labs: PT / PTT / INR:11.7/27.8/1.0, CK / CK-MB / Troponin\n T:247//, ALT / AST:53/32, Alk-Phos / T bili:68/0.4, Fibrinogen:487\n mg/dL, Albumin:3.5 g/dL, LDH:329 IU/L, Ca:8.0 mg/dL, Mg:2.4 mg/dL,\n PO4:3.1 mg/dL\n Imaging: CXR: Endotracheal tube 7.5 cm from the carina\n CTH: Large left parietotemporal intraparenchymal hemorrhage with\n associated mass effect including 5 mm rightward shift of the normally\n midline structures and subfalcine herniation; intraparenchymal\n hemorrhage in the right inferior frontal lobe; Scattered areas of\n subarachnoid hemorrhage bilaterally; Maxillary and ethmoidal sinus\n disease.\n CT CAP: pending\n CTA head: No aneurysm or sign of vascular malformation. Complete R\n ICA occlusion. Intracranial vessels largely reconstituted via\n collaterals\n MRI c-spine (wet): degenerative changes worst at c5/6,\n moderate-severe cervical spinal stenosis, ?soft tissue or LF injury @\n C5-7 w/ mild edema\n CT T/L spine (wet): no t-spine injury, marked fatty infiltration\n of liver.\n CXR: mild atelectasis\n CTH: Unchanged size of left parietotemporal intraparenchymal\n hemorrhage, slightly increased rightward subfalcine herniation,\n unchanged size of right frontal intraparenchymal hematoma\n CXR: Left basal opacity is unchanged and might be consistent with\n aspiration/pneumonia\n AXR: pending\n CTH: pending\n CXR: pending\n Microbiology: MRSA screen: pending\n : Sputum: GSTAIN: 25PMN and G+R\n : bcx #1\n : bcx #2\n : ucx no growth\n Assessment and Plan\n HYPERTENSION, BENIGN, INTRACEREBRAL HEMORRHAGE (ICH), SEIZURE, WITHOUT\n STATUS EPILEPTICUS, .H/O SEIZURE, WITHOUT STATUS EPILEPTICUS, ALCOHOL\n WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES)\n Assessment and Plan: 53M with L large subacute IPH with R frontal\n contracoup IPH\n Neurologic: IPH, q1h neuro checks, sz ppx: dilantin tid, keppra added\n due to concern for ongoing seizure, minimize sedating medicines, Ativan\n 0.5-1 Q4H iv due to history of heavy EtOH use\n Cardiovascular: goal SBP < 140; lopressor + prn hydralazine,\n nicardipine gtt if needed\n Pulmonary: intubated, sedated, wean vent as tolerated, currently CPAP.\n Daily RSBI, plan for trach \n Gastrointestinal / Abdomen: mild hypertransaminemia, hx chronic EtOH,\n distended abdomen\n Nutrition: TF on hold due to post-op and distended abdomen,\n Vit/folate/Thiamine supplement\n Renal: mixed alkalosis, hyponatremia, restrict free water to < 1L/day\n Hematology: stable anemia, thrombocytopenia, goal PLT > 100K\n Endocrine: tight glucose control RISS\n Infectious Disease: started on vanc/ceftaz for fever, re-evaluate\n need daily\n Lines / Tubes / Drains: ETT, R A-line, L 20g PIV hand (), RIJ TLC\n Wounds: craniotomy\n Imaging:\n Fluids: NS + 20KCL @ 80/hr\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 04:00 PM\n 20 Gauge - 08:58 PM\n Multi Lumen - 09:15 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2140-05-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 565145,
"text": "53M with known EtOH abuse found in home down by social worker on ,\n taken to OSH where patient was combative though moving all 4\n extremities. Patient was intubated and found to have large IPH w/ right\n frontal contracoup IPH. HE was subsequently transferred to , with\n initial labs: plt 40, ethanol 71, lactate 3.3, glucose 217.\n PMH: EtOH abuse, seizure disorder (epilepsy), schizophrenia.\n PSH: unknown\n Allergies: NKA\n Intracerebral hemorrhage (ICH)\n Assessment:\n Pt alert, not consistently tracking w/ eyes. Pupils 2-3mm\n PERRL\n Neuro checks Q2hrs. SZ precautions. Head CT from this am\n pending\n Baseline tremor to left upper extremity. Lifts and holds\n left extremities\n Right sided extremtities only moving on bed and withdrawing\n to painful stimuli\n Goal Systolic <160\n Tolerating Trach mask 35% over 24hrs now.\n Temp 100-101.5. Last Cx\nd .\n RUE swollen\n Right Nare NGT w/ Nutren 2.o at goal 40cc/hr. Sodium 129.\n Action:\n Neuro checks Q2hrs. Hydralazine PRN and scheduled Metoprolol\n PRN Ativan d/c\nd per team and IV Kepra changed to po\n RUE duplex completed at BS\n Tylenol po ordered ATC. No cultures to be done today.\n Poor PIV access. Right IJ remains but d/c is being\n considered\n GT flushes decreased to restrict free water d/t NA level\n Soft limb restraints d/t purposeful movement to pull at\n lines w/ LUE\n Response:\n No change in Neuro\n Hydralazine x1 w/ good response\n Awaiting official read of Duplex but per tech looks negative\n Remains w/ temps\n Plan:\n"
},
{
"category": "Respiratory ",
"chartdate": "2140-05-08 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 565347,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Cuffed, Inner Cannula, Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 20 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Expectorated / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt cont trached on cool mist aerosol. Lung sounds ess clear\n after spont exp th yellow sput. Pt in NARD on aerosol. Cont cool mist\n aerosol/pulm toilet as required.\n"
},
{
"category": "Nursing",
"chartdate": "2140-05-08 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 565442,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n - pt alert, tracking movement around the room, does not follow\n commands\n - moves L side spontaneously/purposefully, has baseline\n tremors of LUE\n - withdraws/postures R upper to nail bed stimuli\n - no response to nail bed pressure from RLE, this is a new\n finding\n - ? seizure activity overnight but pt was alert and tracking\n movements at this time, given 0.5 ativan\n Action:\n - Neurosurg evaluated pt this am\n - Q2h neuro assessments\n Response:\n - not concerned about decreased movement of RLE\n - CT from yesterday shows no new findings\n Plan:\n - continue q2h neuro assessments\n - monitor for seizure activity\n - transfer pt to neuro stepdown\n Hypertension, benign\n Assessment:\n - goal sbp < 160\n - hypertensive to sbp 150s-160s\n Action:\n - started on 20mg IV Hydralazine q6h\n - on PO lopressor 37.5mg PO TID\n Response:\n - bp decreased to sbp 120s-130s\n Plan:\n - continue to assess/treat hypertension with goal sbp < 160\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n - Tmax overnight was 101.7\n - R hand is swollen, ultrasound has been done and negative for\n clots in RUE\n Action:\n - pt was pan cultured again last night\n - on ibuprofen and Tylenol around the clock\n Response:\n - Temp currently is 100.1\n - ? origin of fever\n Plan:\n - Ultrasound of lower extremities to be done today for rule\n out ? LE DVT\n - Continue to monitor temperature\n Respiratory failure, acute (not ARDS/)\n Assessment:\n - pt is trached on trach mask 10L with 35% FIO2\n Action:\n - frequent turning/repositioning\n Response:\n - strong cough, expectorates moderate amts of whitish/yellow\n secretions\n Plan:\n - continue to assess respiratory status\n Ineffective Coping\n Assessment:\n Action:\n Response:\n Plan:\n Pt has an NG tube and is receiving tube feeds at goal. Needs PEG per\n Dr. .\n"
},
{
"category": "Nursing",
"chartdate": "2140-05-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 565058,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt is on Trach mask since yesterday morning, tolerated well, large am\n of secretion, good cough\n Action:\n Suction prn, pt is able to cough out sputum, needs suction from trach\n prn.nebs per order\n Response:\n O2 sat 99 -100%.secretion is loose, good cough.\n Plan:\n Cont monitoring, pulm hygiene, support to pt.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Patient s/p evacuation hemetoma.\n Action:\n Neuro checks q2h, SBP <140, hydralazine x1 for SBP >140.\n Response:\n Unchanged neuro status, SBP maintained <140.\n Plan:\n Neuro checks q2h, for Ct head this morning.\n"
},
{
"category": "Physician ",
"chartdate": "2140-05-06 00:00:00.000",
"description": "Intensivist Note",
"row_id": 565133,
"text": "SICU\n HPI:\n 53M with known EtOH abuse found in home down by social worker on ,\n taken to OSH where patient was combative though moving all 4\n extremities. Patient was intubated and found to have large IPH, was\n subsequently transferred to , with initial labs: plt 40, ethanol\n 71, lactate 3.3, glucose 217.\n Chief complaint:\n PMHx:\n PMH: EtOH abuse, seizure disorder (epilepsy), schizophrenia\n .\n PSH: unknown\n Current medications:\n Acetaminophen, Bisacodyl, Calcium Gluconate, CeftazIDIME, Docusate\n Sodium (Liquid), Fentanyl Citrate, FoLIC Acid, Heparin, HydrALAzine,\n Insulin, LeVETiracetam, Lorazepam, Magnesium Sulfate, Metoprolol\n Tartrate, Multivitamins W/minerals, Ondansetron, Phenytoin\n (Suspension), Potassium Phosphate, Ranitidine, Senna, Thiamine,\n Vancomycin\n 24 Hour Events:\n : Tolerated TCM x 24 hrs. TF restarted on nutren 2.0 - rechecked\n with nutrition, protein intake deemed adequate. Febrile x 1 to 101.5F\n - no repeat cultures done. Pending cultures are all no growth to date.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 05:00 PM\n Infusions:\n Other ICU medications:\n Metoprolol - 01:14 PM\n Heparin Sodium (Prophylaxis) - 02:00 PM\n Other medications:\n Flowsheet Data as of 05:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.8\nC (101.8\n T current: 37.7\nC (99.8\n HR: 80 (72 - 107) bpm\n BP: 107/68(88) {107/52(75) - 164/99(112)} mmHg\n RR: 26 (18 - 33) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 73.4 kg (admission): 70 kg\n Total In:\n 2,521 mL\n 237 mL\n PO:\n Tube feeding:\n 726 mL\n 140 mL\n IV Fluid:\n 1,375 mL\n 97 mL\n Blood products:\n Total out:\n 1,870 mL\n 420 mL\n Urine:\n 1,870 mL\n 420 mL\n NG:\n Stool:\n Drains:\n Balance:\n 651 mL\n -183 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool, Trach mask\n SPO2: 100%\n ABG: ///26/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : , Rhonchorous : )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Responds to: Verbal stimuli, Tactile stimuli, Noxious\n stimuli), Moves all extremities\n Labs / Radiology\n 336 K/uL\n 9.1 g/dL\n 118 mg/dL\n 0.4 mg/dL\n 26 mEq/L\n 3.6 mEq/L\n 12 mg/dL\n 97 mEq/L\n 129 mEq/L\n 26.3 %\n 7.9 K/uL\n [image002.jpg]\n 02:20 AM\n 10:00 AM\n 05:00 PM\n 12:27 AM\n 02:57 AM\n 08:30 PM\n 03:08 AM\n 03:21 AM\n 02:14 AM\n 03:10 AM\n WBC\n 5.0\n 6.7\n 7.2\n 7.9\n Hct\n 27.1\n 27.4\n 27.1\n 26.3\n Plt\n 140\n 186\n 236\n 336\n Creatinine\n 0.6\n 0.5\n 0.4\n 0.4\n TCO2\n 30\n 31\n 25\n 25\n Glucose\n 152\n 142\n 94\n 93\n 118\n 118\n Other labs: PT / PTT / INR:12.1/32.6/1.0, CK / CK-MB / Troponin\n T:247//, ALT / AST:53/32, Alk-Phos / T bili:68/0.4, Fibrinogen:487\n mg/dL, Albumin:3.2 g/dL, LDH:329 IU/L, Ca:8.2 mg/dL, Mg:2.0 mg/dL,\n PO4:2.1 mg/dL\n Microbiology: MRSA screen neg\n Sputum: flora\n bcx: PND\n ucx: No growth\n ucx: No growth\n bcx: PND\n : MRSA neg\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), FEVER (HYPERTHERMIA,\n PYREXIA, NOT FEVER OF UNKNOWN ORIGIN), HYPERTENSION, BENIGN,\n INTRACEREBRAL HEMORRHAGE (ICH), SEIZURE, WITHOUT STATUS EPILEPTICUS,\n .H/O SEIZURE, WITHOUT STATUS EPILEPTICUS, ALCOHOL WITHDRAWAL (INCLUDING\n DELIRIUM TREMENS, DTS, SEIZURES)\n Assessment and Plan: 53M with L large IPH with R frontal contracoup IPH\n Neurologic: Neuro checks Q: 2 hr, # IPH\n q2h neuro checks, sz ppx:\n keppra , minimize sedating medicines, D/C ativan. Review repeat\n head CT .\n Cardiovascular: goal SBP < 160; lopressor increased + prn hydralazine\n Pulmonary: respiratory failure s/p trach, on trach mask x 24 hrs w/o\n signs of fatigue although with copious secretions. Continue to\n monitor. RUE duplex to r/o DVT (RUE swelling)\n Gastrointestinal / Abdomen:, tube feeds at goal per NGT\n Nutrition: MVI, Nutren 2.0 TF at goal\n Renal: creatinine stable; hyponatremia most likely secondary to SIADH\n given CNS pathology, to further restrict free water.\n Hematology: stable anemia\n Endocrine: RISS\n Infectious Disease: Check cultures, WBC normal, off antibiotics.\n Continues to spike, suspect central fever, cultures NGTD, reculture\n q3-4 days if continue to be intermittently febrile. RUE duplex and c.\n dif for fever source. Consider d/c CVL.\n Lines / Tubes / Drains: G-tube, Trach, PIV, right a-line, NGT\n Consider placing PICC line when consistently afebrile.\n Wounds: Dry dressings\n Imaging: CT scan head today\n Fluids: KVO\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid), (Respiratory\n distress: Failure)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 04:00 PM\n Multi Lumen - 09:15 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition:Neuro step down\n Total time spent:\n"
},
{
"category": "Rehab Services",
"chartdate": "2140-05-06 00:00:00.000",
"description": "Physical Therapy Progress Note",
"row_id": 565139,
"text": "Subjective:\n Objective:\n Follow up PT visit to address goals of: . Patient seen today\n for balance training\n Updated medical status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Rolling:\n\n\n\n\n\n Supine/\n Sidelying to Sit:\n\n\n\n\n\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n\n\n\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Aerobic Activity Response:\n Position\n HR\n BP\n RR\n O[2] sat\n RPE\n Rest\n Supine\n 100\n 142/64\n 99% TM\n Activity\n Sit\n 123\n /\n Recovery\n Supine\n 102\n 125/60\n 99% 35% TM\n Total distance walked:\n Minutes:\n Gait:\n Balance: Pt required total A x 2 to achieve sitting at EOB, once\n upright pt required Max A to maintain. Pt demonstrated no postural or\n protective reactions with LOB.\n Education / Communication: Pt status discussed with RN\n Other: No visual tracking\n Pt has L lateral gaze bias\n Pt activly moving L UE with purpose, reaching for face and holding on\n to bed linens.\n Assessment: 53 yo m s/p craniotomy for IPH s/p fall. Pt continues to be\n functioning well below baseline. He demonstrates significant decreased\n levels of attention, and alertness. Pt will require rehab upon d/c in\n order to optimize functional return\n Anticipated Discharge: Rehab\n Plan: cont POC\n"
},
{
"category": "Nursing",
"chartdate": "2140-05-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 565142,
"text": "53M with known EtOH abuse found in home down by social worker on ,\n taken to OSH where patient was combative though moving all 4\n extremities. Patient was intubated and found to have large IPH w/ right\n frontal contracoup IPH. HE was subsequently transferred to , with\n initial labs: plt 40, ethanol 71, lactate 3.3, glucose 217.\n PMH: EtOH abuse, seizure disorder (epilepsy), schizophrenia.\n PSH: unknown\n Allergies: NKA\n Neurologic: Neuro checks Q: 2 hr, # IPH\n q2h neuro checks, sz ppx:\n keppra , minimize sedating medicines, D/C ativan. Review repeat\n head CT .\n Cardiovascular: goal SBP < 160; lopressor increased + prn hydralazine\n Pulmonary: respiratory failure s/p trach, on trach mask x 24 hrs w/o\n signs of fatigue although with copious secretions. Continue to\n monitor. RUE duplex to r/o DVT (RUE swelling)\n Gastrointestinal / Abdomen:, tube feeds at goal per NGT\n Nutrition: MVI, Nutren 2.0 TF at goal\n Renal: creatinine stable; hyponatremia most likely secondary to SIADH\n given CNS pathology, to further restrict free water.\n Hematology: stable anemia\n Endocrine: RISS\n Infectious Disease: Check cultures, WBC normal, off antibiotics.\n Continues to spike, suspect central fever, cultures NGTD, reculture\n q3-4 days if continue to be intermittently febrile. RUE duplex and c.\n dif for fever source. Consider d/c CVL.\n Lines / Tubes / Drains: G-tube, Trach, PIV, right a-line, NGT\n Consider placing PICC line when consistently afebrile.\n Wounds: Dry dressings\n Imaging: CT scan head today\n"
},
{
"category": "Nursing",
"chartdate": "2140-05-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 565143,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2140-05-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 565144,
"text": "53M with known EtOH abuse found in home down by social worker on ,\n taken to OSH where patient was combative though moving all 4\n extremities. Patient was intubated and found to have large IPH w/ right\n frontal contracoup IPH. HE was subsequently transferred to , with\n initial labs: plt 40, ethanol 71, lactate 3.3, glucose 217.\n PMH: EtOH abuse, seizure disorder (epilepsy), schizophrenia.\n PSH: unknown\n Allergies: NKA\n Neurologic: Neuro checks Q: 2 hr, # IPH\n q2h neuro checks, sz ppx:\n keppra , minimize sedating medicines, D/C ativan. Review repeat\n head CT .\n Cardiovascular: goal SBP < 160; lopressor increased + prn hydralazine\n Pulmonary: respiratory failure s/p trach, on trach mask x 24 hrs w/o\n signs of fatigue although with copious secretions. Continue to\n monitor. RUE duplex to r/o DVT (RUE swelling)\n Gastrointestinal / Abdomen:, tube feeds at goal per NGT\n Nutrition: MVI, Nutren 2.0 TF at goal\n Renal: creatinine stable; hyponatremia most likely secondary to SIADH\n given CNS pathology, to further restrict free water.\n Hematology: stable anemia\n Endocrine: RISS\n Infectious Disease: Check cultures, WBC normal, off antibiotics.\n Continues to spike, suspect central fever, cultures NGTD, reculture\n q3-4 days if continue to be intermittently febrile. RUE duplex and c.\n dif for fever source. Consider d/c CVL.\n Lines / Tubes / Drains: G-tube, Trach, PIV, right a-line, NGT\n Consider placing PICC line when consistently afebrile.\n Wounds: Dry dressings\n Imaging: CT scan head today\n Intracerebral hemorrhage (ICH)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2140-05-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 565140,
"text": "Assessment and Plan: 53M with L large IPH with R frontal contracoup IPH\n Neurologic: Neuro checks Q: 2 hr, # IPH\n q2h neuro checks, sz ppx:\n keppra , minimize sedating medicines, D/C ativan. Review repeat\n head CT .\n Cardiovascular: goal SBP < 160; lopressor increased + prn hydralazine\n Pulmonary: respiratory failure s/p trach, on trach mask x 24 hrs w/o\n signs of fatigue although with copious secretions. Continue to\n monitor. RUE duplex to r/o DVT (RUE swelling)\n Gastrointestinal / Abdomen:, tube feeds at goal per NGT\n Nutrition: MVI, Nutren 2.0 TF at goal\n Renal: creatinine stable; hyponatremia most likely secondary to SIADH\n given CNS pathology, to further restrict free water.\n Hematology: stable anemia\n Endocrine: RISS\n Infectious Disease: Check cultures, WBC normal, off antibiotics.\n Continues to spike, suspect central fever, cultures NGTD, reculture\n q3-4 days if continue to be intermittently febrile. RUE duplex and c.\n dif for fever source. Consider d/c CVL.\n Lines / Tubes / Drains: G-tube, Trach, PIV, right a-line, NGT\n Consider placing PICC line when consistently afebrile.\n Wounds: Dry dressings\n Imaging: CT scan head today\n"
},
{
"category": "Nursing",
"chartdate": "2140-05-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 565189,
"text": "53M with known EtOH abuse found in home down by social worker on ,\n taken to OSH where patient was combative though moving all 4\n extremities. Patient was intubated and found to have large IPH w/ right\n frontal contracoup IPH. HE was subsequently transferred to , with\n initial labs: plt 40, ethanol 71, lactate 3.3, glucose 217.\n PMH: EtOH abuse, seizure disorder (epilepsy), schizophrenia.\n PSH: unknown\n Allergies: NKA\n Intracerebral hemorrhage (ICH)\n Assessment:\n Pt alert, not consistently tracking w/ eyes. Pupils 2-3mm\n PERRL\n Neuro checks Q2hrs. SZ precautions. Head CT from this am\n pending\n Baseline tremor to left upper extremity. Lifts and holds\n left extremities\n Right sided extremtities only moving on bed and withdrawing\n to painful stimuli\n Left heal w/ crani site. Sutures OTA, no drainage or signs\n of infection\n Goal Systolic <160. SR/ST 70-100\ns w/ occasional Vent\n Bigeminy\n Tolerating Trach mask 35% over 24hrs now.\n Temp 100-101.5. Last Cx\nd .\n RUE swollen\n Right Nare NGT w/ Nutren 2.o at goal 40cc/hr. Sodium 129.\n Action:\n Neuro checks Q2hrs. Hydralazine PRN and scheduled Metoprolol\n PRN Ativan d/c\nd per team and IV Kepra changed to po\n RUE duplex completed at BS\n Team aware of Bigeminy. K-3.6. Given 40meq IV KCL/MG 2gm per\n team\n Tylenol po ordered ATC. No cultures to be done today.\n Poor PIV access. Right IJ remains but d/c is being\n considered\n GT flushes decreased to restrict free water d/t NA level\n Soft limb restraints d/t purposeful movement to pull at\n lines w/ LUE\n Response:\n No change in Neuro\n Hydralazine x2/ Metoprolol x2 d/t SBP >160 w/ more\n Bigeminy. EKG w/o change\n Awaiting official read of Duplex but per tech looks negative\n Spiked temp to 102.2. Pan Cx completed\n NA- 130. To receive IV NaPHos\n Plan:\n Cont Q2hr Neuro\n Keep SBP <160\n Morning labs along w/ c.diff specimen\n Transfer to 11 this evening.\n"
},
{
"category": "Physician ",
"chartdate": "2140-05-07 00:00:00.000",
"description": "Intensivist Note",
"row_id": 565253,
"text": "SICU\n HPI:\n 53M with known EtOH abuse found in home down by social worker on ,\n taken to OSH where patient was combative though moving all 4\n extremities. Patient was intubated and found to have large IPH, was\n subsequently transferred to , with initial labs: plt 40, ethanol\n 71, lactate 3.3, glucose 217\n Chief complaint:\n L large subacute IPH with R frontal contracoup IPH\n PMHx:\n EtOH abuse, seizure disorder (epilepsy), schizophrenia\n Current medications:\n Acetaminophen (Liquid), Albuterol, Bisacodyl, Calcium Gluconate,\n Docusate Sodium (Liquid), Erythromycin 0.5% Ophth Oint, Fentanyl\n Citrate, Heparin, HydrALAzine, Insulin, Influenza Virus, LeVETiracetam,\n Lorazepam, Magnesium Sulfate, Metoprolol Tartrate, Metoprolol Tartrate,\n Multivitamins W/minerals, Ondansetron, Potassium Phosphate, Potassium\n Chloride, Ranitidine, Senna, Sodium Chloride, Sodium Phosphate\n 24 Hour Events:\n FEVER - 102.2\nF - 10:00 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 02:07 PM\n Lorazepam (Ativan) - 08:14 PM\n Metoprolol - 10:10 PM\n Hydralazine - 11:14 PM\n Fentanyl - 04:49 AM\n Other medications:\n Flowsheet Data as of 06:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 39\nC (102.2\n T current: 38.1\nC (100.6\n HR: 110 (69 - 110) bpm\n BP: 150/68(93) {110/54(70) - 167/115(118)} mmHg\n RR: 25 (21 - 38) insp/min\n SPO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 73.4 kg (admission): 70 kg\n Total In:\n 1,736 mL\n 624 mL\n PO:\n Tube feeding:\n 962 mL\n 251 mL\n IV Fluid:\n 670 mL\n 313 mL\n Blood products:\n Total out:\n 1,750 mL\n 455 mL\n Urine:\n 1,750 mL\n 455 mL\n NG:\n Stool:\n Drains:\n Balance:\n -14 mL\n 169 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool, Trach mask\n Ventilator mode: Standby\n FiO2: 35%\n SPO2: 99%\n ABG: 7.50/29/196/24/0\n PaO2 / FiO2: 560\n Physical Examination\n General Appearance: No acute distress, Well nourished\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : ), (Sternum: Stable ), tachypnic\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: spontaneous movement of LLE, LUE, occasional RLE movement\n Labs / Radiology\n 432 K/uL\n 8.8 g/dL\n 138 mg/dL\n 0.5 mg/dL\n 24 mEq/L\n 3.7 mEq/L\n 15 mg/dL\n 97 mEq/L\n 128 mEq/L\n 25.6 %\n 8.3 K/uL\n [image002.jpg]\n 12:27 AM\n 02:57 AM\n 08:30 PM\n 03:08 AM\n 03:21 AM\n 02:14 AM\n 03:10 AM\n 04:16 PM\n 07:54 PM\n 03:44 AM\n WBC\n 5.0\n 6.7\n 7.2\n 7.9\n 8.3\n Hct\n 27.1\n 27.4\n 27.1\n 26.3\n 25.6\n Plt\n 140\n 186\n 236\n 336\n 432\n Creatinine\n 0.6\n 0.5\n 0.4\n 0.4\n 0.4\n 0.5\n TCO2\n 31\n 25\n 25\n 23\n Glucose\n 94\n 93\n 118\n 118\n 121\n 138\n Other labs: PT / PTT / INR:12.1/32.6/1.0, CK / CK-MB / Troponin\n T:247//, ALT / AST:53/32, Alk-Phos / T bili:68/0.4, Fibrinogen:487\n mg/dL, Lactic Acid:0.5 mmol/L, Albumin:3.2 g/dL, LDH:329 IU/L, Ca:8.2\n mg/dL, Mg:2.3 mg/dL, PO4:3.6 mg/dL\n Imaging: CT T/L spine (wet): no t-spine injury, marked fatty\n infiltration of liver.\n CXR: mild atelectasis\n CTH: Unchanged size of left parietotemporal intraparenchymal\n hemorrhage, slightly increased rightward subfalcine herniation,\n unchanged size of right frontal intraparenchymal hematoma\n CXR: Left basal opacity is unchanged and might be consistent with\n aspiration/pneumonia\n CXR: no new airspace disease, NGT in stomach\n CT head: Improvement in subfalcine and uncal herniation s/p\n intraparenchymal hemorrhage evacuation. No areas of new hemorrhage.\n CTH: continued evolution of parenchymal hemorrhage and edema,\n Stable appearance of subfalcine herniation and left uncal herniation,\n Evolution of right inferior frontal lobe intraparenchymal hemorrhage\n RUE: pending\n CXR: no acute process\n Microbiology: MRSA screen neg\n Sputum: flora\n bcx: PND\n ucx: No growth\n ucx: No growth\n bcx: PND\n : MRSA neg\n stool/cdiff: pending\n BCx: pending\n UCx: pending\n sputum: o/p contamination\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), FEVER (HYPERTHERMIA,\n PYREXIA, NOT FEVER OF UNKNOWN ORIGIN), HYPERTENSION, BENIGN,\n INTRACEREBRAL HEMORRHAGE (ICH), SEIZURE, WITHOUT STATUS EPILEPTICUS,\n .H/O SEIZURE, WITHOUT STATUS EPILEPTICUS, ALCOHOL WITHDRAWAL (INCLUDING\n DELIRIUM TREMENS, DTS, SEIZURES)\n Assessment and Plan: 53M with L large IPH with R frontal contracoup IPH\n Neurologic: q2h neuro checks, sz ppx: keppra , minimize sedating\n medicines, ativan given 1mg x2 when patient was diaphoretic, unclear if\n this represented withdrawl or simple agitation, but some improvement\n noted\n Cardiovascular: goal SBP < 160; lopressor + prn hydralazine; in and out\n of bigeminy with electrolytes normal, keep K>4 and Mg>2\n Pulmonary: trach mask, tachypnic at times with respiratory alkalosis\n Gastrointestinal / Abdomen: tube feeds to goal via NGT\n Nutrition: MVI, Nutren 2.0 TF, minimize free water\n Renal: Cr stable; hyponatremia, keep fluid < 1L.. Add salt tabs for\n hyponatrenia\n Hematology: trending down slowly\n Endocrine: tight glucose control RISS\n Infectious Disease: WBC normal, off antibiotics, Last cultured ,\n cultures NGTD, reculture q48h if febrile, receiving scheduled tylenol,\n ibuprofen added with improved temperatures\n Lines / Tubes / Drains: trach, R A-line, RIJ TLC. To consider PICC when\n afebrile\n Wounds: craniotomy\n Imaging:C XR OK\n Fluids: KVO,\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS)\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 01:30 AM 40 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 04:00 PM\n Multi Lumen - 09:15 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2140-05-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 565329,
"text": "Seizure, without status epilepticus\n Assessment:\n - Pt alert, tracking movements with eyes, pupils equal and\n reactive\n - Not following commands\n - Moves L side spontaneously, has baseline tremors on L arm\n - Withdraws RL to tactile stimuli, and slightly\n withdraws/postures RU to nail bed pressure\n - Rhand is swollen, ultrasound of RUE done yesterday\n - While down in US (for r/o lower extremity DVTs) pts upper\n and lower extremities began shacking more vigorously than at any point\n during the day. Pt was unresponsive, and would not open eyes, when\n eyes manually opened pt did not look at me, his gaze was upward and to\n the right.\n Action:\n - Ultrasound not completed, pt monitored and brought back to\n SICU\n - Emergent head CT done to see if there was any additional\n bleeding\n - Given 0.5 ativan\n Response:\n - SICU resident and Neurosurg in to evaluate pt status\n - Neurosurg reports no changes in CT scan\n - Pt appeared to be post-ictal after ? seizure activity,\n unresponsive, not opening eyes or spontaneously moving extremities\n Plan:\n - continue to assess neuro status q2h\n - continue to assess for ? seizure activity\n - ultrasound of lower extremities to be scheduled for tomorrow\n - ? EEG\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n - pt febrile to 101.1 max\n Action:\n - Tylenol and ibuprofen doses around the clock\n Response:\n - temp remains 100-101\n Plan:\n - continue to administer Tylenol and ibuprofen\n - continue to assess temperatures\n - ? source of infection\n Hypertension, benign\n Assessment:\n - pt hypertensive to sbp 170s at times throughout the day\n - goal sbp <160\n Action:\n - 5mg IV lopressor\n - 20mg IV Hydralazine\n - PO \n Response:\n - good response from antihypertensives, pts bp resumed to 130s\n Plan:\n - continue to monitor sbp with goal < 160\n - treat hypertension with Hydralazine or lopressor IV\n"
},
{
"category": "Nursing",
"chartdate": "2140-05-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 565330,
"text": "Seizure, without status epilepticus\n Assessment:\n - Pt alert, tracking movements with eyes, pupils equal and\n reactive\n - Not following commands\n - Moves L side spontaneously, has baseline tremors on L arm\n - Withdraws RL to tactile stimuli, and slightly\n withdraws/postures RU to nail bed pressure\n - Rhand is swollen, ultrasound of RUE done yesterday\n - While down in US (for r/o lower extremity DVTs) pts upper\n and lower extremities began shacking more vigorously than at any point\n during the day. Pt was unresponsive, and would not open eyes, when\n eyes manually opened pt did not look at me, his gaze was upward and to\n the right.\n Action:\n - Ultrasound not completed, pt monitored and brought back to\n SICU\n - Emergent head CT done to see if there was any additional\n bleeding\n - Given 0.5 ativan\n Response:\n - SICU resident and Neurosurg in to evaluate pt status\n - Neurosurg reports no changes in CT scan\n - Pt appeared to be post-ictal after ? seizure activity,\n unresponsive, not opening eyes or spontaneously moving extremities\n Plan:\n - continue to assess neuro status q2h\n - continue to assess for ? seizure activity\n - ultrasound of lower extremities to be scheduled for tomorrow\n - ? EEG\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n - pt febrile to 101.1 max\n Action:\n - Tylenol and ibuprofen doses around the clock\n Response:\n - temp remains 100-101\n Plan:\n - continue to administer Tylenol and ibuprofen\n - continue to assess temperatures\n - ? source of infection\n Hypertension, benign\n Assessment:\n - pt hypertensive to sbp 170s at times throughout the day\n - goal sbp <160\n Action:\n - 5mg IV lopressor\n - 20mg IV Hydralazine\n - PO \n Response:\n - good response from antihypertensives, pts bp resumed to 130s\n Plan:\n - continue to monitor sbp with goal < 160\n - treat hypertension with Hydralazine or lopressor IV\n"
},
{
"category": "Nursing",
"chartdate": "2140-05-08 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 565410,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n - pt alert, tracking movement around the room, does not follow\n commands\n - moves L side spontaneously/purposefully, has baseline\n tremors of LUE\n - withdraws/postures R upper to nail bed stimuli\n - no response to nail bed pressure from RLE, this is a new\n finding\n - ? seizure activity overnight but pt was alert and tracking\n movements at this time, given 0.5 ativan\n Action:\n - Neurosurg evaluated pt this am\n - Q2h neuro assessments\n Response:\n - not concerned about decreased movement of RLE\n - CT from yesterday shows no new findings\n Plan:\n - continue q2h neuro assessments\n - monitor for seizure activity\n - transfer pt to neuro stepdown\n Hypertension, benign\n Assessment:\n - goal sbp < 160\n - hypertensive to sbp 150s-160s\n Action:\n - started on 20mg IV Hydralazine q6h\n - on PO lopressor 37.5mg PO TID\n Response:\n - bp decreased to sbp 120s-130s\n Plan:\n - continue to assess/treat hypertension with goal sbp < 160\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n - Tmax overnight was 101.7\n - R hand is swollen, ultrasound has been done and negative for\n clots in RUE\n Action:\n - pt was pan cultured again last night\n - on ibuprofen and Tylenol around the clock\n Response:\n - Temp currently is 100.1\n - ? origin of fever\n Plan:\n - Ultrasound of lower extremities to be done today for rule\n out ? LE DVT\n - Continue to monitor temperature\n Respiratory failure, acute (not ARDS/)\n Assessment:\n - pt is trached on trach mask 10L with 35% FIO2\n Action:\n - frequent turning/repositioning\n Response:\n - strong cough, expectorates moderate amts of whitish/yellow\n secretions\n Plan:\n - continue to assess respiratory status\n Pt has an NG tube and is receiving tube feeds at goal. Needs PEG per\n Dr. .\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 564144,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Patient , open eyes spontansously, does not obey commands.\n Moves left ue/le spontaneously. No movement noted to right ue, only\n gross upper movement to painful stimuli. Withdraws to stimuli right le.\n Action:\n Monitor neuro checks Q1..\n Response:\n No change in neuro status.\n Plan:\n Will continue to monitor neuro checks Q1. No plan for intervention at\n this time.\n Seizure, without status epilepticus\n Assessment:\n No seizure activity noted overnight.\n Action:\n Monitor for seizure activity, iv dilantin given as ordered.\n Response:\n No change in status.\n Plan:\n Will continue to monitor and treat accordingly\n Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n patient agitated at times, attempts to pull out ett, hr becomes\n elevated. Occasional tremors noted.\n Action:\n iv Ativan 0.5mgs given Q4 as ordered, iv fentanyl 25mcgs given prn as\n needed.\n Response:\n patient lightly sedated, appears comfortable, less agitated\n Plan:\n will continue to monitor and treat accordingly\n"
},
{
"category": "Physician ",
"chartdate": "2140-05-08 00:00:00.000",
"description": "Intensivist Note",
"row_id": 565395,
"text": "SICU\n HPI:\n 53M with known EtOH abuse found in home down by social worker on ,\n taken to OSH where patient was combative though moving all 4\n extremities. Patient was intubated and found to have large IPH, was\n subsequently transferred to , with initial labs: plt 40, ethanol\n 71, lactate 3.3, glucose 217.\n Chief complaint:\n L large subacute IPH with R frontal contracoup IPH\n PMHx:\n EtOH abuse, seizure disorder (epilepsy), schizophrenia\n Current medications:\n Acetaminophen (Liquid), Albuterol, Bisacodyl, Calcium Gluconate,\n Docusate Sodium (Liquid), Erythromycin 0.5% Ophth Oint, Fentanyl\n Citrate, Heparin, HydrALAzine, Insulin, Influenza Virus, LeVETiracetam,\n Lorazepam, Magnesium Sulfate, Metoprolol Tartrate, Metoprolol Tartrate,\n Multivitamins W/minerals, Ondansetron, Potassium Phosphate, Potassium\n Chloride, Ranitidine, Senna, Sodium Chloride, Sodium Phosphate\n 24 Hour Events:\n PAN CULTURE - At 12:00 AM\n FEVER - 101.7\nF - 12:00 AM\n Salt tabs started for hyponatremia, Keppra increased to 1500\", ?seizure\n activity in U/S with ?post-ictal state in ICU, CT head showed little\n change, given ativan x 2 overnight, pancultured for 101.7\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Metoprolol - 09:00 AM\n Hydralazine - 06:33 PM\n Heparin Sodium (Prophylaxis) - 10:20 PM\n Other medications:\n Flowsheet Data as of 06:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.7\nC (101.7\n T current: 37.8\nC (100.1\n HR: 90 (63 - 114) bpm\n BP: 143/68(94) {100/53(68) - 166/76(105)} mmHg\n RR: 30 (17 - 32) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 71.3 kg (admission): 70 kg\n Total In:\n 1,901 mL\n 533 mL\n PO:\n Tube feeding:\n 960 mL\n 275 mL\n IV Fluid:\n 550 mL\n 138 mL\n Blood products:\n Total out:\n 1,980 mL\n 535 mL\n Urine:\n 1,980 mL\n 535 mL\n NG:\n Stool:\n Drains:\n Balance:\n -79 mL\n -2 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool, Trach mask\n SPO2: 99%\n ABG: ///26/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Neurologic: Tracks with eyes, but does not follow commands\n Labs / Radiology\n 499 K/uL\n 9.1 g/dL\n 123 mg/dL\n 0.6 mg/dL\n 26 mEq/L\n 4.2 mEq/L\n 16 mg/dL\n 96 mEq/L\n 129 mEq/L\n 25.0 %\n 10.0 K/uL\n [image002.jpg]\n 02:57 AM\n 08:30 PM\n 03:08 AM\n 03:21 AM\n 02:14 AM\n 03:10 AM\n 04:16 PM\n 07:54 PM\n 03:44 AM\n 02:09 AM\n WBC\n 5.0\n 6.7\n 7.2\n 7.9\n 8.3\n 10.0\n Hct\n 27.1\n 27.4\n 27.1\n 26.3\n 25.6\n 25.0\n Plt\n 140\n 186\n 236\n \n Creatinine\n 0.6\n 0.5\n 0.4\n 0.4\n 0.4\n 0.5\n 0.6\n TCO2\n 25\n 25\n 23\n Glucose\n 94\n 93\n 118\n 118\n 121\n 138\n 123\n Other labs: PT / PTT / INR:12.1/32.6/1.0, CK / CK-MB / Troponin\n T:247//, ALT / AST:53/32, Alk-Phos / T bili:68/0.4, Fibrinogen:487\n mg/dL, Lactic Acid:0.5 mmol/L, Albumin:3.2 g/dL, LDH:329 IU/L, Ca:8.8\n mg/dL, Mg:2.2 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), FEVER (HYPERTHERMIA,\n PYREXIA, NOT FEVER OF UNKNOWN ORIGIN), HYPERTENSION, BENIGN,\n INTRACEREBRAL HEMORRHAGE (ICH), SEIZURE, WITHOUT STATUS EPILEPTICUS,\n .H/O SEIZURE, WITHOUT STATUS EPILEPTICUS, ALCOHOL WITHDRAWAL (INCLUDING\n DELIRIUM TREMENS, DTS, SEIZURES)\n Assessment and Plan: ASSESSMENT/PLAN: 53M with L large IPH with R\n frontal contracoup IPH\n Neuro: q2h neuro checks, sz ppx: keppra , patient became\n unresponsive after seizure-like activity, was given ativan x 2,\n returned to baseline of tracking, repeat head CT showed little change,\n EEG ordered\n CV: goal SBP < 160; lopressor + prn hydralazine\n Pulm: trach mask\n GI: tube feeds to goal via NGT\n FEN: MVI, Nutren 2.0 TF, minimize free water, hyponatremia improving,\n salt tabs 1g tid started. Will increase salt\n Renal: Cr stable\n Heme: Hct 25\n Endo: tight glucose control RISS\n ID: WBC normal, off antibiotics, Last cultured , cultures NGTD,\n reculture q48h if febrile, receiving tylenol and ibuprofen\n T/L/D: trach, R A-line, PICC when afebrile\n Wounds: craniotomy\n Imaging: LE Duplex\n Fluids: KVO\n Prophylaxis: H2B, Boots, SQH\n Consults: neurosurgery \n Disposition: floor\n Code: full\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 06:15 AM 40 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 04:00 PM\n Multi Lumen - 09:15 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: SICU\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2140-05-08 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 565401,
"text": "Hypertension, benign\n Assessment:\n - goal sbp < 160\n - hypertensive to 150s-160s\n Action:\n - given 20mg hydralazine\n -\n Response:\n - bp decreased to sbp ____\n -\n Plan:\n - continue to assess/treat hypertension with goal sbp < 160\n -\n Intracerebral hemorrhage (ICH)\n Assessment:\n Action:\n Response:\n Plan:\n Seizure, without status epilepticus\n Assessment:\n Action:\n Response:\n Plan:\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2140-05-08 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 565414,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n - pt alert, tracking movement around the room, does not follow\n commands\n - moves L side spontaneously/purposefully, has baseline\n tremors of LUE\n - withdraws/postures R upper to nail bed stimuli\n - no response to nail bed pressure from RLE, this is a new\n finding\n - ? seizure activity overnight but pt was alert and tracking\n movements at this time, given 0.5 ativan\n Action:\n - Neurosurg evaluated pt this am\n - Q2h neuro assessments\n Response:\n - not concerned about decreased movement of RLE\n - CT from yesterday shows no new findings\n Plan:\n - continue q2h neuro assessments\n - monitor for seizure activity\n - transfer pt to neuro stepdown\n Hypertension, benign\n Assessment:\n - goal sbp < 160\n - hypertensive to sbp 150s-160s\n Action:\n - started on 20mg IV Hydralazine q6h\n - on PO lopressor 37.5mg PO TID\n Response:\n - bp decreased to sbp 120s-130s\n Plan:\n - continue to assess/treat hypertension with goal sbp < 160\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n - Tmax overnight was 101.7\n - R hand is swollen, ultrasound has been done and negative for\n clots in RUE\n Action:\n - pt was pan cultured again last night\n - on ibuprofen and Tylenol around the clock\n Response:\n - Temp currently is 100.1\n - ? origin of fever\n Plan:\n - Ultrasound of lower extremities to be done today for rule\n out ? LE DVT\n - Continue to monitor temperature\n Respiratory failure, acute (not ARDS/)\n Assessment:\n - pt is trached on trach mask 10L with 35% FIO2\n Action:\n - frequent turning/repositioning\n Response:\n - strong cough, expectorates moderate amts of whitish/yellow\n secretions\n Plan:\n - continue to assess respiratory status\n Ineffective Coping\n Assessment:\n Action:\n Response:\n Plan:\n Pt has an NG tube and is receiving tube feeds at goal. Needs PEG per\n Dr. .\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 563908,
"text": "HPI:53M apparently found down (?in bed) and intoxicated, brought to OSH\n apparently moving all 4 extremities, combative. Intubated, head CT\n showed large left temporal hemorrhage, pt transported to\n Ed for further evaluation/treatment.\n CT:large left temporal 8 x 4 cm subacute hemorrhage with right\n frontal small IPH -contracoup. no mass effect or sift.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Patient admitted to SICU off propofol, moving all extremities to\n nailbed pressure. Purposefully lifting left arm. Pupils 2 equal and\n reactive to light and brisk. Unable to follow commands. Appeared to\n be having a focal seizure involving mostly left arm and left leg.\n Action:\n 2 mg IV ativan given, prop gtt started, q 1 hour neuro checks\n instituted. CIWA scale initiated. Keep SBP 100-140 per Dr. .\n Response:\n Neuro status unchanged, Seizure activity stopped after IV ativan and\n prop initiated. SBP 100\ns-130\n Plan:\n No plans to go to OR per Dr. not an acute bleed. Wean off\n sedation, plan to extubated in am?\n Seizure, without status epilepticus\n Assessment:\n Patient arrived to SICU having what appeared to be a focal seizure\n affected left arm mostly. SICU resident and neuro PA present\n during seizure activity.\n Action:\n Neuro informed. Given 2 mg IV ativan, prop gtt started, CIWA scale\n initiated\n Response:\n No more focal seizure activity noted.\n Plan:\n Continue with seizure precautions, contact neuro if seizure\n activity occurs.\n"
},
{
"category": "Respiratory ",
"chartdate": "2140-04-29 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 563966,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 25 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: White / Thin\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: pt has been stable on 8 ps 5 PEEP CPAP overnight. plan to\n extubate when pt becomes awake and alert.\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n"
},
{
"category": "Physician ",
"chartdate": "2140-04-29 00:00:00.000",
"description": "Intensivist Note",
"row_id": 564031,
"text": "SICU\n HPI:\n 53M known EtOH found in home down by social worker, taken to OSH where\n patient was combative moving all 4 extremities, patient was intubated\n and found to have, transfer to , plt 40, ethanol 71, lactate 3.3,\n glucose 217\n Chief complaint:\n L large subacute IPH with R frontal contracoup IPH\n PMHx:\n EtOH abuse, siezure disorder, schizophrenia\n Current medications:\n Acetaminophen, Bisacodyl, Chlorhexidine Gluconate 0.12% Oral Rinse,\n Folic Acid/Multivitamin/Thiamine-1000mL NS, HydrALAzine, Insulin,\n Influenza Virus Vaccine, Lorazepam, Ondansetron, Pantoprazole,\n Phenytoin, Propofol, Thiamine\n 24 Hour Events:\n INTUBATION - At 04:35 PM\n INVASIVE VENTILATION - START 04:35 PM\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Propofol - 25 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 06:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.8\nC (100\n T current: 37.5\nC (99.5\n HR: 89 (81 - 97) bpm\n BP: 146/71(97) {119/61(81) - 158/80(109)} mmHg\n RR: 14 (12 - 18) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,044 mL\n 707 mL\n PO:\n Tube feeding:\n IV Fluid:\n 924 mL\n 587 mL\n Blood products:\n Total out:\n 1,165 mL\n 625 mL\n Urine:\n 565 mL\n 625 mL\n NG:\n Stool:\n Drains:\n Balance:\n -121 mL\n 82 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 656 (519 - 656) mL\n PS : 8 cmH2O\n RR (Set): 12\n RR (Spontaneous): 13\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 49\n PIP: 14 cmH2O\n Plateau: 12 cmH2O\n SPO2: 99%\n ABG: 7.48/42/188/31/7\n Ve: 6.3 L/min\n PaO2 / FiO2: 470\n Physical Examination\n General Appearance: No acute distress, Well nourished\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Neurologic: (Responds to: Noxious stimuli), No(t) Moves all\n extremities, (RUE: Weakness), (RLE: Weakness), Sedated\n Labs / Radiology\n 92 K/uL\n 10.5 g/dL\n 101 mg/dL\n 0.7 mg/dL\n 31 mEq/L\n 3.5 mEq/L\n 13 mg/dL\n 99 mEq/L\n 137 mEq/L\n 30.2 %\n 4.6 K/uL\n [image002.jpg]\n 05:27 PM\n 06:43 PM\n 08:17 PM\n 02:07 AM\n 02:24 AM\n WBC\n 4.4\n 4.6\n Hct\n 30.4\n 30.2\n Plt\n 115\n 92\n Creatinine\n 0.6\n 0.7\n TCO2\n 33\n 30\n 32\n Glucose\n 94\n 101\n Other labs: PT / PTT / INR:12.5/31.8/1.1, CK / CK-MB / Troponin\n T:247//, ALT / AST:126/162, Alk-Phos / T bili:55/0.8, Fibrinogen:156\n mg/dL, Albumin:3.6 g/dL, LDH:329 IU/L, Ca:8.4 mg/dL, Mg:2.1 mg/dL,\n PO4:2.7 mg/dL\n Imaging: CXR: Endotracheal tube 7.5 cm from the carina\n CTH: Large left parietotemporal intraparenchymal hemorrhage with\n associated mass effect including 5 mm rightward shift of the normally\n midline structures and subfalcine herniation; intraparenchymal\n hemorrhage in the right inferior frontal lobe; Scattered areas of\n subarachnoid hemorrhage bilaterally; Maxillary and ethmoidal sinus\n disease.\n CT CAP: pending\n CTA head: No aneurysm or sign of vascular malformation. Complete R\n ICA occlusion. Intracranial vessels largely reconstituted via\n collaterals\n Microbiology: MRSA screen: pending\n Assessment and Plan\n INTRACEREBRAL HEMORRHAGE (ICH), SEIZURE, WITHOUT STATUS EPILEPTICUS,\n .H/O SEIZURE, WITHOUT STATUS EPILEPTICUS, ALCOHOL WITHDRAWAL (INCLUDING\n DELIRIUM TREMENS, DTS, SEIZURES)\n Assessment and Plan: 53M with L large subacute IPH with R frontal\n contracoup IPH\n Neurologic: q1h neuro checks, dilantin load + 100 tid, acetaminophen\n for all fevers, try to d/c propofol. Add narcotics. Ativan for EtOH\n withdrawal\n start empirically 0.5-1 mg q 4 hrs. Re-start home meds\n (serequal, etc.). Clear c-spine and TLS\n will need CT of TLS, c-spine\n and MRI of C-spine.\n Cardiovascular: goal SBP < 160; prn hydralazine. Start b-blocker po and\n prn IV.\n Pulmonary: intubated, sedated, wean vent as tolerated, currently CPAP.\n Patient may not be able to get extubated due to poor mental status\n Gastrointestinal / Abdomen: transaminitis, chronic EtOH.\n Nutrition: Start TF today. Thiamine/folate/ MVI\n Renal: No issues\n Hematology: Stable anemia. Thrombocytopenia, m/p EtOH-related. goal PLT\n > 100\n Endocrine: tight glucose control. Keep < 150. RISS\n Infectious Disease: no issues\n Lines / Tubes / Drains: ETT, R A-line, L 20g PIV hand (), R 18g\n hand + L 20g wrist from OSH\n Wounds: none\n Imaging: CT head performed this AM, follow up read\n Fluids: NS + KCL @ 80/hr after banana pack finishes\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS)\n ICU Care\n Nutrition: Start TF\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 04:42 PM\n 20 Gauge - 04:44 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n change to H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 32 min\n"
},
{
"category": "Nursing",
"chartdate": "2140-05-08 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 565407,
"text": "Hypertension, benign\n Assessment:\n - goal sbp < 160\n - hypertensive to sbp 150s-160s\n Action:\n - started on 20mg IV Hydralazine q6h\n - on PO lopressor 37.5mg PO TID\n Response:\n - bp decreased to sbp 120s-130s\n Plan:\n - continue to assess/treat hypertension with goal sbp < 160\n Intracerebral hemorrhage (ICH)\n Assessment:\n - pt alert, tracking movement around the room, does not follow\n commands\n - moves L side spontaneously/purposefully, has baseline\n tremors of LUE\n - withdraws/postures R upper to nail bed stimuli\n - no response to nail bed pressure from RLE, this is a new\n finding\n - ? seizure activity overnight but pt was alert and tracking\n movements at this time, given 0.5 ativan\n Action:\n - Neurosurg evaluated pt this am\n - Q2h neuro assessments\n Response:\n - not concerned about decreased movement of RLE\n - CT from yesterday shows no new findings\n Plan:\n - continue q2h neuro assessments\n - monitor for seizure activity\n - transfer pt to neuro stepdown\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n -\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Needs peg\n"
},
{
"category": "Nursing",
"chartdate": "2140-05-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 564690,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Pt opens eyes spont, not to command. Not following any commands,\n minimal movement to RUE noted. Withdraws and occ. Localizes. PERRLA 3mm\n and brisk. Crani site intact, DSD. SBP maintained <140. Strong cough,\n gagging and bucking vent at times. Purposeful w/LUE towards ETT.\n Dilantin level sub-therapeutic.\n Action:\n Fentanyl/Ativan for discomfort, PRN anti-hypertensives, frequent neuro\n checks, pt. trached @ bedside today. Dilantin bolus 500mg IV given, due\n for 8pm level.\n Response:\n Neuro status unchanged, trach done w/o incident at bedside, well\n tolerated.\n Plan:\n Neuro checks, head CT this evening, post trach CXR, follow labs, resp.\n care, vent wean as tolerated, CIWA scale as pt wakes.\n"
},
{
"category": "Nursing",
"chartdate": "2140-05-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 564401,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Pt slightly improving. Requiring less sedation to tolerate\n ETT. Neurologically continues to move left side purposefully but not on\n command. Minimal movement on right side sometimes postures with RUE,\n withdraws on RLE. Opening eyes more spontaneously but also not on\n command, very strong with Left side and localizes and goes for ETT with\n LUE\n Abd remains softly distended with hyperactive bowel sounds\n +BS\n Requires suctioning every couple hours for what is now thick\n yellow sputum, has a strong cough/gag but does not follow commands\n Afebrile today\n Action:\n Had discussion with family re: possible plan for Trach/Peg\n Neuro checks changed to Q2hrs\n SICU resident performed rectal exam\n Receiving vanco/ceftaz for +sputum culture\n Response:\n Pt\ns Brother who is HCP understands reason and procedure of\n trach/peg and agrees to consent when time is appropriate\n Multiple Lge BM this afternoon\n Plan:\n Discuss plan to trach/peg with Dr. tomorrow\n Pt\ns brother planning to bring Mom in on Tuesday to visit\n Neuro checks Q2hrs\n Pulmonary toilet and cont iv anbx for +sputum\n"
},
{
"category": "Physician ",
"chartdate": "2140-05-04 00:00:00.000",
"description": "Intensivist Note",
"row_id": 564772,
"text": "SICU\n HPI:\n 53M with known EtOH abuse found in home down by social worker on ,\n taken to OSH where patient was combative though moving all 4\n extremities. Patient was intubated and found to have large IPH, was\n subsequently transferred to , with initial labs: plt 40, ethanol\n 71, lactate 3.3, glucose 217.\n Chief complaint:\n L large subacute IPH with R frontal contracoup IPH\n PMHx:\n EtOH abuse, seizure disorder (epilepsy), schizophrenia\n Current medications:\n Acetaminophen (Liquid). Bisacodyl. Docusate Sodium (Liquid).\n Erythromycin 0.5% Ophth Oint. Fentanyl Citrate. FoLIC Acid. Heparin.\n HydrALAzine. Insulin. LeVETiracetam. Lorazepam. Magnesium Sulfate.\n Metoprolol Tartrate. Multivitamins W/minerals. Ondansetron. Phenytoin.\n Propofol. Ranitidine. Senna. Thiamine.\n 24 Hour Events:\n BLOOD CULTURED - At 01:04 PM\n URINE CULTURE - At 01:04 PM\n FEVER - 103.8\nF - 04:00 AM\n febrile to 103.8, pancultured, Abx stopped, trach at bedside, no PEG\n dilated bowel, repeat CT shows improved herniation and no new\n hemorrhage\n Allergies:\n Last dose of Antibiotics:\n Vancomycin - 08:11 AM\n Ceftazidime - 04:00 AM\n Cefazolin - 05:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:19 PM\n Hydralazine - 02:13 AM\n Metoprolol - 03:15 AM\n Lorazepam (Ativan) - 06:08 AM\n Fentanyl - 06:08 AM\n Other medications:\n Flowsheet Data as of 07:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 39.9\nC (103.8\n T current: 38.7\nC (101.7\n HR: 81 (70 - 108) bpm\n BP: 146/75(99) {121/53(72) - 167/97(123)} mmHg\n RR: 26 (12 - 26) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 70.9 kg (admission): 70 kg\n CVP: 8 (3 - 11) mmHg\n Total In:\n 3,240 mL\n 914 mL\n PO:\n Tube feeding:\n IV Fluid:\n 3,060 mL\n 854 mL\n Blood products:\n Total out:\n 1,860 mL\n 790 mL\n Urine:\n 1,860 mL\n 790 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,380 mL\n 124 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 450 (450 - 500) mL\n Vt (Spontaneous): 1,064 (384 - 1,064) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 15\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 83\n PIP: 11 cmH2O\n SPO2: 100%\n ABG: 7.48/32/155/26/1\n Ve: 9.8 L/min\n PaO2 / FiO2: 388\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-tender, Distended\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Responds to: Noxious stimuli), Sedated\n Labs / Radiology\n 186 K/uL\n 9.5 g/dL\n 93 mg/dL\n 0.5 mg/dL\n 26 mEq/L\n 3.8 mEq/L\n 11 mg/dL\n 101 mEq/L\n 133 mEq/L\n 27.4 %\n 6.7 K/uL\n [image002.jpg]\n 01:50 AM\n 02:12 AM\n 02:20 AM\n 10:00 AM\n 05:00 PM\n 12:27 AM\n 02:57 AM\n 08:30 PM\n 03:08 AM\n 03:21 AM\n WBC\n 9.2\n 6.5\n 5.0\n 6.7\n Hct\n 29.9\n 29.0\n 27.1\n 27.4\n Plt\n 91\n 86\n 140\n 186\n Creatinine\n 0.5\n 0.5\n 0.6\n 0.5\n TCO2\n 30\n 31\n 25\n 25\n Glucose\n 135\n 118\n 152\n 142\n 94\n 93\n Other labs: PT / PTT / INR:12.5/29.6/1.1, CK / CK-MB / Troponin\n T:247//, ALT / AST:53/32, Alk-Phos / T bili:68/0.4, Fibrinogen:487\n mg/dL, Albumin:3.4 g/dL, LDH:329 IU/L, Ca:8.2 mg/dL, Mg:2.1 mg/dL,\n PO4:2.3 mg/dL\n Assessment and Plan\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN),\n HYPERTENSION, BENIGN, INTRACEREBRAL HEMORRHAGE (ICH), SEIZURE, WITHOUT\n STATUS EPILEPTICUS, .H/O SEIZURE, WITHOUT STATUS EPILEPTICUS, ALCOHOL\n WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES)\n Assessment and Plan: ASSESSMENT/PLAN: 53M with L large IPH with R\n frontal contracoup IPH\n Neuro: IPH, q1h neuro checks, sz ppx: dilantin tid, keppra ,\n minimize sedating medicines, Ativan 0.5-1 Q4H iv due to history of\n heavy EtOH use.\n CV: goal SBP < 160; lopressor increased + prn hydralazine\n Pulm: s/p bedside trach\n GI: PEG aborted distended abdomen, ?start Tube feeds today via NGT\n FEN: ?start tube feeds via NGT, Vit/folate/Thiamine supplement\n Renal: creatinine stable\n Heme: stable anemia\n Endo: tight glucose control RISS\n ID: off antibiotics, fever to 103.8, pancultured, CXR showed no\n consolidations, f/u cultures\n T/L/D: trach, R A-line, PIV, RIJ TLC\n Wounds: craniotomy\n Imaging: none\n Fluids: NS + 20KCL @ 80/hr\n Prophylaxis: H2B, Boots, SQH\n Consults: neurosurgery\n Disposition: SICU\n Code: full\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 04:00 PM\n 20 Gauge - 08:58 PM\n Multi Lumen - 09:15 PM\n Prophylaxis:\n DVT: H2B\n Stress ulcer: SQH, venodynes\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: SICU\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2140-05-04 00:00:00.000",
"description": "Intensivist Note",
"row_id": 564781,
"text": "SICU\n HPI:\n 53M with known EtOH abuse found in home down by social worker on ,\n taken to OSH where patient was combative though moving all 4\n extremities. Patient was intubated and found to have large IPH, was\n subsequently transferred to , with initial labs: plt 40, ethanol\n 71, lactate 3.3, glucose 217.\n Chief complaint:\n L large subacute IPH with R frontal contracoup IPH\n PMHx:\n EtOH abuse, seizure disorder (epilepsy), schizophrenia\n Current medications:\n Acetaminophen (Liquid). Bisacodyl. Docusate Sodium (Liquid).\n Erythromycin 0.5% Ophth Oint. Fentanyl Citrate. FoLIC Acid. Heparin.\n HydrALAzine. Insulin. LeVETiracetam. Lorazepam. Magnesium Sulfate.\n Metoprolol Tartrate. Multivitamins W/minerals. Ondansetron. Phenytoin.\n Propofol. Ranitidine. Senna. Thiamine.\n 24 Hour Events:\n BLOOD CULTURED - At 01:04 PM\n URINE CULTURE - At 01:04 PM\n FEVER - 103.8\nF - 04:00 AM\n febrile to 103.8, pancultured, Abx stopped, trach at bedside, no PEG\n dilated bowel, repeat CT shows improved herniation and no new\n hemorrhage\n Allergies:\n Last dose of Antibiotics:\n Vancomycin - 08:11 AM\n Ceftazidime - 04:00 AM\n Cefazolin - 05:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:19 PM\n Hydralazine - 02:13 AM\n Metoprolol - 03:15 AM\n Lorazepam (Ativan) - 06:08 AM\n Fentanyl - 06:08 AM\n Other medications:\n Flowsheet Data as of 07:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 39.9\nC (103.8\n T current: 38.7\nC (101.7\n HR: 81 (70 - 108) bpm\n BP: 146/75(99) {121/53(72) - 167/97(123)} mmHg\n RR: 26 (12 - 26) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 70.9 kg (admission): 70 kg\n CVP: 8 (3 - 11) mmHg\n Total In:\n 3,240 mL\n 914 mL\n PO:\n Tube feeding:\n IV Fluid:\n 3,060 mL\n 854 mL\n Blood products:\n Total out:\n 1,860 mL\n 790 mL\n Urine:\n 1,860 mL\n 790 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,380 mL\n 124 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 450 (450 - 500) mL\n Vt (Spontaneous): 1,064 (384 - 1,064) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 15\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 83\n PIP: 11 cmH2O\n SPO2: 100%\n ABG: 7.48/32/155/26/1\n Ve: 9.8 L/min\n PaO2 / FiO2: 388\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-tender, Distended\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Responds to: Noxious stimuli), Sedated\n Labs / Radiology\n 186 K/uL\n 9.5 g/dL\n 93 mg/dL\n 0.5 mg/dL\n 26 mEq/L\n 3.8 mEq/L\n 11 mg/dL\n 101 mEq/L\n 133 mEq/L\n 27.4 %\n 6.7 K/uL\n [image002.jpg]\n 01:50 AM\n 02:12 AM\n 02:20 AM\n 10:00 AM\n 05:00 PM\n 12:27 AM\n 02:57 AM\n 08:30 PM\n 03:08 AM\n 03:21 AM\n WBC\n 9.2\n 6.5\n 5.0\n 6.7\n Hct\n 29.9\n 29.0\n 27.1\n 27.4\n Plt\n 91\n 86\n 140\n 186\n Creatinine\n 0.5\n 0.5\n 0.6\n 0.5\n TCO2\n 30\n 31\n 25\n 25\n Glucose\n 135\n 118\n 152\n 142\n 94\n 93\n Other labs: PT / PTT / INR:12.5/29.6/1.1, CK / CK-MB / Troponin\n T:247//, ALT / AST:53/32, Alk-Phos / T bili:68/0.4, Fibrinogen:487\n mg/dL, Albumin:3.4 g/dL, LDH:329 IU/L, Ca:8.2 mg/dL, Mg:2.1 mg/dL,\n PO4:2.3 mg/dL\n Assessment and Plan\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN),\n HYPERTENSION, BENIGN, INTRACEREBRAL HEMORRHAGE (ICH), SEIZURE, WITHOUT\n STATUS EPILEPTICUS, .H/O SEIZURE, WITHOUT STATUS EPILEPTICUS, ALCOHOL\n WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES)\n Assessment and Plan: ASSESSMENT/PLAN: 53M with L large IPH with R\n frontal contracoup IPH\n Neuro: IPH, q1h neuro checks, sz ppx: dilantin tid, keppra ,\n minimize sedating medicines, Ativan 0.5-1 Q4H iv due to history of\n heavy EtOH use.\n CV: goal SBP < 160; lopressor increased + prn hydralazine\n Pulm: s/p bedside trach trach today.\n GI: PEG aborted distended abdomen, ?start Tube feeds today via NGT\n FEN: ?start tube feeds via NGT, Vit/folate/Thiamine supplement\n Renal: creatinine stable\n Heme: stable anemia\n Endo: tight glucose control RISS\n ID: off antibiotics, fever to 103.8, pancultured, CXR showed no\n consolidations, f/u cultures. Probably central fever\n T/L/D: trach, R A-line, PIV, RIJ TLC\n Wounds: craniotomy\n Imaging: none\n Fluids:D5 NS + 20KCL @ 80/hr\n Prophylaxis: H2B, Boots, SQH\n Consults: neurosurgery\n Disposition: SICU\n Code: full\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 04:00 PM\n 20 Gauge - 08:58 PM\n Multi Lumen - 09:15 PM\n Prophylaxis:\n DVT: H2B\n Stress ulcer: SQH, venodynes\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: SICU\n Total time spent: 31 min\n"
},
{
"category": "Social Work",
"chartdate": "2140-05-04 00:00:00.000",
"description": "Social Work Admission Note",
"row_id": 564792,
"text": "Family Information\n Next of : Brother \n Health Care Proxy appointed: \n Guardian appointed:\n \n Family Spokesperson designated: \n Communication or visitation restriction: NA\n Patient Information:\n Previous living situation:\n Previous level of functioning: Independent\n Previous or other hospital admissions: NA\n Past psychiatric history: schizophrenia\n Past addictions history: current ETOH\n Employment status: Disabled\n Legal involvement: unknown\n Mandated Reporting Information:\n Additional Information:\n Patient / Family Assessment:\n Spoke with pt's brother at the time of admission, met yesterday\n with pt's brother and his mother who is here from . Per famility pt\n is adopted. Pt carries a dx of schizophrenia and epilepsy and receives\n his care at the in . Pt also has a past and\n current has of heavy ETOH use. Pt lives alone in an apartment and has\n a companion dog that has been trained to alert people when pt is having\n a seizure. Per pt's mother the dog also helps with pt's\n hallucinations. Mother explains that is the pt feels that there is\n someone following him he looks to the dog. Per mother pt states that\n if the dog is calm then he knows he is hallucinating, if the dog is\n barking pt gets concerned. Mother states that the pt has recently been\n to her home for an 8 day stay, pt is able to respect mother\ns rules\n about no alcohol in the house. Per mother pt \"hides his DT's\" but she\n is aware of his tremors, mother reports that with in a day or two he is\n fine and she enjoys his company. Mother cannot have pt living with her\n as it is \"too much\" but the pt is well supervised by the mother who is\n also the payee of his social security check. Pt has a social worker\n through the VA but per family their has been no consistent person in\n this role with the pt due to high turnover rates at the VA. Pt is a\n social security recipient who also has Medicare and MA health.\n Clergy Contact:\n Communication with Team:\n Plan / Follow up: Will follow pt for medical progress , provide support\n to family and intervene as appropriate.\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 564250,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Neuro exam unchanged. Right side moves on bed, Left side\n localizes but not on command. PERRLA, Does not follow any commands\n +gag/cough\n SBP elevated\n Bronchospastic after suctioning\n Abd softly distended with hyperactive bowel sounds\n Action:\n Hourly neuro checks\n Hydralazine given x1 with good effect\n Administered ativan .5mg Q4hrs when tachy/hypertensive given\n fent with good effect for comfort of ETT\n Dulcolax suppository administered\n TF at goal\n Kept intubated d/t poor neuro exam\n Brother in to visit and spoke with SICU team on rounds\n SICU team and NSURG team cleared C-spine based on\n yesterday\ns MRI results\n Response:\n Neuro exam stable\n Comfortably sedated on fent/ativan\n Effect from suppository pending\n Plan:\n Repeat with PO biscacodyl if no effect from suppository\n Re-eval for extubation in am\n"
},
{
"category": "Respiratory ",
"chartdate": "2140-04-30 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 564256,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Cannot protect\n airway, Underlying illness not resolved\n Comments:\n Remains on minimal PSV, not able to extubate due to mental status.\n"
},
{
"category": "Respiratory ",
"chartdate": "2140-05-02 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 564449,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 25 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Remain on minimal PSV.\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Maintain PEEP at current level and reduce FiO2 as tolerated; Comments:\n RSBI done ~ 40.\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Cannot protect airway\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 564124,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Patient intubated and sedated on propofol this am. Off prop patient is\n able to open eyes to painful stimulus. Localizes with left arm, and\n moves left leg and right leg, no movement noted on right arm. Pupils\n are 3-2mm and brisk, equally reactive to light. Patient does not\n follow any commands. Patient continues to wear J collar and on\n logroll precautions. SBP 100-160, above 160 at times. Breathing tidal\n volumes on 400-500 on CPAP 5/5.\n Action:\n - CT of head\n - MRI and CT of spine to rule out any spinal fractures.\n - Continue with q 1 hour neuro checks.\n - Propofol shut off. Standing dose of ativan ordered.\n - Given hydralazine and lopressor prn to keep SBP < 160.\n - Given fentanyl prn for agitation as well.\n Response:\n -possible soft tissue/ muscle swelling of spine per radiology report.\n -off propofol patient is agitated at times, trying to sit up and\n reaching for ET tube with left hand.\n -continues on CPAP 5/5 sating 100%, tidal volumes of 400-500 rate of\n 15-22.\n Plan:\n Continue to monitor, keep immobilizers on, close supervision. No plan\n for OR, extubated if patient is able to follow commands ?\n Hypertension, benign\n Assessment:\n Patient hypertensive above goal of SBP < 160 a couple of times during\n shift.\n Action:\n Given hydralazine and lopressor prn.\n Agitation treated with ativan and fentanyl.\n Response:\n Patient\ns SBP kept within goal of 100-160 throughout day.\n Plan:\n Continue to monitor.\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 564249,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Neuro exam unchanged. Right side moves on bed, Left side\n localizes but not on command. PERRLA, Does not follow any commands\n +gag/cough\n SBP elevated\n Bronchospastic after suctioning\n Abd softly distended with hyperactive bowel sounds\n Action:\n Hourly neuro checks\n Hydralazine given x1 with good effect\n Administered ativan .5mg Q4hrs when tachy/hypertensive given\n fent with good effect for comfort of ETT\n Dulcolax suppository administered\n TF at goal\n Kept intubated d/t poor neuro exam\n Brother in to visit and spoke with SICU team on rounds\n Response:\n Neuro exam stable\n Comfortably sedated on fent/ativan\n Effect from suppository pending\n Plan:\n Repeat with PO biscacodyl if no effect from suppository\n Re-eval for extubation in am\n"
},
{
"category": "Respiratory ",
"chartdate": "2140-05-01 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 564308,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 4\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 25 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Scant\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Remain orally intubated on minimal PSV.\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: RSBI done ~62./ Gag & cough present.\n Seems more awake with occ bouts of agitation.\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Underlying illness not resolved; Comments: ? elective extubation if he\n appears to follow commands.\n"
},
{
"category": "Physician ",
"chartdate": "2140-04-30 00:00:00.000",
"description": "Intensivist Note",
"row_id": 564211,
"text": "SICU\n HPI:\n HPI: 53M known EtOH found in home down by social worker, taken to OSH\n where patient was combative moving all 4 extremities, patient was\n intubated and found to have, transfer to , plt 40, ethanol 71,\n lactate 3.3, glucose 217\n .\n PMH: EtOH abuse, seizure disorder (epilepsy), schizophrenia\n .\n PSH: unknown\n .\n Meds: Acetaminophen, Bisacodyl, Chlorhexidine Gluconate 0.12% Oral\n Rinse, Folic Acid/Multivitamin/Thiamine-1000mL NS, HydrALAzine,\n Insulin, Influenza Virus Vaccine, Lorazepam, Ondansetron, Pantoprazole,\n Phenytoin, Propofol, Thiamine\n .\n : unknown, per mother noncompliant with prescribed medications.\n ALLERGIES:\n .\n 24 HOUR EVENTS:\n platlet transfusion\n .\n MICRO:\n MRSA screen: pending\n .\n Imaging/Diagnostics:\n CXR: Endotracheal tube 7.5 cm from the carina\n CTH: Large left parietotemporal intraparenchymal hemorrhage with\n associated mass effect including 5 mm rightward shift of the normally\n midline structures and subfalcine herniation; intraparenchymal\n hemorrhage in the right inferior frontal lobe; Scattered areas of\n subarachnoid hemorrhage bilaterally; Maxillary and ethmoidal sinus\n disease.\n CT CAP: pending\n CTA head: No aneurysm or sign of vascular malformation. Complete R\n ICA occlusion. Intracranial vessels largely reconstituted via\n collaterals\n MRI c-spine (wet): degenerative changes worst at c5/6,\n moderate-severe cervical spinal stenosis, ?soft tissue or LF injury @\n C5-7 w/ mild edema\n CT T/L spine (wet): no t-spine injury, marked fatty infiltration\n of liver.\n Chief complaint:\n PMHx:\n Current medications:\n 24 Hour Events:\n MAGNETIC RESONANCE IMAGING - At 12:00 PM\n FEVER - 101.4\nF - 06:45 PM\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Hydralazine - 03:22 PM\n Metoprolol - 04:00 PM\n Lorazepam (Ativan) - 02:00 AM\n Fentanyl - 02:05 AM\n Other medications:\n Flowsheet Data as of 05:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.6\nC (101.4\n T current: 37.9\nC (100.3\n HR: 80 (67 - 100) bpm\n BP: 145/73(98) {108/62(83) - 169/87(111)} mmHg\n RR: 12 (12 - 21) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,573 mL\n 259 mL\n PO:\n Tube feeding:\n 131 mL\n 165 mL\n IV Fluid:\n 1,815 mL\n 3 mL\n Blood products:\n 287 mL\n Total out:\n 1,943 mL\n 520 mL\n Urine:\n 1,943 mL\n 520 mL\n NG:\n Stool:\n Drains:\n Balance:\n 630 mL\n -261 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 485 (433 - 550) mL\n PS : 5 cmH2O\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 44\n PIP: 11 cmH2O\n SPO2: 98%\n ABG: 7.52/33/162/30/4\n Ve: 8.8 L/min\n PaO2 / FiO2: 405\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Murmur: Systolic)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, moderately distended and tympanitic , Non-tender\n Left Extremities: (Edema: Trace), (Temperature: Warm)\n Right Extremities: (Edema: 1+), (Temperature: Warm)\n Neurologic: Not following commands, Moves all extremities, poor mental\n status\n Labs / Radiology\n 122 K/uL\n 10.8 g/dL\n 105 mg/dL\n 0.5 mg/dL\n 30 mEq/L\n 3.2 mEq/L\n 10 mg/dL\n 99 mEq/L\n 136 mEq/L\n 31.4 %\n 6.8 K/uL\n [image002.jpg]\n 05:27 PM\n 06:43 PM\n 08:17 PM\n 02:07 AM\n 02:24 AM\n 10:00 AM\n 03:57 PM\n 09:06 PM\n 01:40 AM\n 01:47 AM\n WBC\n 4.4\n 4.6\n 6.8\n Hct\n 30.4\n 30.2\n 31.4\n Plt\n 115\n 92\n 78\n 115\n 122\n Creatinine\n 0.6\n 0.7\n 0.5\n TCO2\n 33\n 30\n 32\n 28\n 28\n Glucose\n 94\n 101\n 93\n 105\n Other labs: PT / PTT / INR:12.2/31.0/1.0, CK / CK-MB / Troponin\n T:247//, ALT / AST:91/89, Alk-Phos / T bili:63/0.7, Fibrinogen:303\n mg/dL, Albumin:3.6 g/dL, LDH:329 IU/L, Ca:8.3 mg/dL, Mg:1.9 mg/dL,\n PO4:2.0 mg/dL\n Assessment and Plan\n HYPERTENSION, BENIGN, INTRACEREBRAL HEMORRHAGE (ICH), SEIZURE, WITHOUT\n STATUS EPILEPTICUS, .H/O SEIZURE, WITHOUT STATUS EPILEPTICUS, ALCOHOL\n WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES)\n Assessment and Plan:\n Neurologic: Neuro checks Q: 1 hr, q1h neuro checks, dilantin load + 100\n tid, acetaminophen for all fevers, wean off propofol to eval neur exam,\n Ativan 0.5-1 Q4H iv.\n Re-start home meds (serequal, etc.). MRI of C-spine without ligamentous\n injury, cleared by neurosurg? ? D/C collar\n Cardiovascular: goal SBP < 160; prn hydralazine PRN, Lopressor standing\n and PRN\n Pulmonary: Cont ETT, (Ventilator mode: CPAP + PS), mental status\n necessitatiing intubation\n Gastrointestinal / Abdomen: OGT Begin bowel regimen\n Nutrition: Tube feeding, fibersource\n Renal: Foley, Adequate UO, Monitor Cr\n Hematology: Monitor HCT, keep platelets > 100\n Endocrine: RISS\n Infectious Disease: monitor temp\n Lines / Tubes / Drains: Foley, OGT, ETT. Consideration of trach / PEG\n Wounds:\n Imaging:\n Fluids: D5NS, 80/hr\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS), (Respiratory distress: Failure)\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 03:00 PM 40 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 04:42 PM\n 20 Gauge - 08:58 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n"
},
{
"category": "Respiratory ",
"chartdate": "2140-05-01 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 564395,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 4\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Invasive ventilation assessment:\n Trigger work assessment: Abnormal trigger efforts (efforts during\n inspiratory)\n Dysynchrony assessment: Vigorous inspiratory efforts, Possible air\n trapping, Erratic exhaled Tidal Volumes, Frequent alarms (High rate,\n High min. ventilation)\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts\n Comments:\n Pt intermittently quite agitated requiring frequent adjustments in\n sedation. Issue of trach/PEG will be addressed tomorrow. Continue on\n CSV, as tolerated.\n"
},
{
"category": "Physician ",
"chartdate": "2140-05-02 00:00:00.000",
"description": "Intensivist Note",
"row_id": 564443,
"text": "SICU\n HPI:\n 53yo male with known EtOH abuse found in home down by social worker on\n , taken to OSH where patient was combative though moving all 4\n extremities. Patient was intubated and found to have large IPH, was\n subsequently transferred to , with initial labs: plt 40, ethanol\n 71, lactate 3.3, glucose 217.\n Chief complaint:\n PMHx:\n PMH: EtOH abuse, seizure disorder (epilepsy), schizophrenia\n .\n PSH: unknown\n Current medications:\n Acetaminophen, Bisacodyl, Chlorhexidine Gluconate 0.12% Oral Rinse,\n Folic Acid/Multivitamin/Thiamine-1000mL NS, HydrALAzine, Insulin,\n Influenza Virus Vaccine, Lorazepam, Ondansetron, Pantoprazole,\n Phenytoin, Propofol, Thiamine\n 24 Hour Events:\n : passing loose BM, digital exam- no obstruction, distended abdomen\n on exam, frequent flatus. Mental status improved with more frequent\n spontaneous awakening, +cough +gag, remains on CPAP, though not\n following commands.\n Allergies:\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Ceftazidime - 09:14 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 01:01 PM\n Fentanyl - 10:00 PM\n Dilantin - 10:00 PM\n Hydralazine - 11:00 PM\n Lorazepam (Ativan) - 05:45 AM\n Other medications:\n Flowsheet Data as of 06:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.1\nC (100.6\n T current: 37.7\nC (99.8\n HR: 82 (60 - 108) bpm\n BP: 132/65(87) {112/58(80) - 166/106(119)} mmHg\n RR: 23 (15 - 30) insp/min\n SPO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 2,487 mL\n 499 mL\n PO:\n Tube feeding:\n 1,437 mL\n 239 mL\n IV Fluid:\n 840 mL\n 260 mL\n Blood products:\n Total out:\n 1,780 mL\n 510 mL\n Urine:\n 1,780 mL\n 510 mL\n NG:\n Stool:\n Drains:\n Balance:\n 707 mL\n -11 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 530 (390 - 552) mL\n PS : 5 cmH2O\n RR (Spontaneous): 20\n PEEP: 5 cmH2O\n FiO2: 30%\n RSBI: 40\n PIP: 11 cmH2O\n SPO2: 97%\n ABG: 7.51/36/241/29/6\n Ve: 10.3 L/min\n PaO2 / FiO2: 803\n Physical Examination\n General Appearance: intubated\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : , Diminished: at bases)\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Neurologic: (Responds to: Tactile stimuli, Noxious stimuli), Moves all\n extremities\n Labs / Radiology\n 86 K/uL\n 10.1 g/dL\n 118 mg/dL\n 0.5 mg/dL\n 29 mEq/L\n 3.1 mEq/L\n 10 mg/dL\n 96 mEq/L\n 131 mEq/L\n 29.0 %\n 6.5 K/uL\n [image002.jpg]\n 02:24 AM\n 10:00 AM\n 03:57 PM\n 09:06 PM\n 01:40 AM\n 01:47 AM\n 04:26 PM\n 01:50 AM\n 02:12 AM\n 02:20 AM\n WBC\n 6.8\n 9.2\n 6.5\n Hct\n 31.4\n 29.9\n 29.0\n Plt\n 78\n 115\n 122\n 107\n 91\n 86\n Creatinine\n 0.5\n 0.5\n 0.5\n TCO2\n 32\n 28\n 28\n 30\n Glucose\n 93\n 105\n 135\n 118\n Other labs: PT / PTT / INR:11.0/31.0/0.9, CK / CK-MB / Troponin\n T:247//, ALT / AST:53/32, Alk-Phos / T bili:68/0.4, Fibrinogen:487\n mg/dL, Albumin:3.5 g/dL, LDH:329 IU/L, Ca:8.6 mg/dL, Mg:1.9 mg/dL,\n PO4:2.0 mg/dL\n Assessment and Plan\n HYPERTENSION, BENIGN, INTRACEREBRAL HEMORRHAGE (ICH), SEIZURE, WITHOUT\n STATUS EPILEPTICUS, .H/O SEIZURE, WITHOUT STATUS EPILEPTICUS, ALCOHOL\n WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES)\n Assessment and Plan: 53yo male with L large subacute IPH with R frontal\n contracoup IPH\n Neurologic: #IPH w/o evidence of aneurysmal bleed\n - q1h neuro checks\n - sz ppx: dilantin tid, supplement per level\n - analgesic: acetaminophen for all fevers\n - EtOH abuse: on Ativan 0.5-1 Q4H iv.\n - Re-start psych meds - to check with primary provider : doses if\n known\n Cardiovascular: - goal SBP < 160; on standing lopressor with prn\n hydralazine and lopressor boluses, and nicardipine gtt if needed.\n Pulmonary: - intubated, sedated, wean vent as tolerated, currently\n CPAP. Daily RSBI, to attempt extubation .\n Gastrointestinal / Abdomen: - transaminitis, chronic EtOH\n - distended abdomen, +flatus, frequent watery BM - to monitor, may need\n enema.\n Nutrition: - on TF, w/ Vit/folate/Thiamine supplement\n Renal: Foley, Adequate UO, - mixed alkalosis\n - hyponatremia - to monitor w/ q12hr labs, limit free water\n Hematology: - Stable anemia\n - Thrombocytopenia, most likely c/w EtOH-induced. goal PLT ~ 100K\n Endocrine: RISS\n Infectious Disease: started on vanc/ceftaz for fever, f/u cultures\n Lines / Tubes / Drains: Foley, OGT, ETT, arterial line, PIV.\n - Will need PICC or CVL today as pt with poor peripheral venous access.\n Wounds:\n Imaging:\n Fluids: D5 1/2 NS, Potassium Chloride\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid), (Respiratory\n distress: Insufficiency / Post-op), Other: intraparenchymal hemorrhage\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 04:00 PM\n 20 Gauge - 08:58 PM\n 22 Gauge - 09:13 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n Patient is critically ill\n"
},
{
"category": "Radiology",
"chartdate": "2140-05-02 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1069252,
"text": ", M. NSURG SICU-A 8:11 PM\n CT HEAD W/O CONTRAST; -77 BY DIFFERENT PHYSICIAN # \n Reason: S/P CRANI. FOR EVACUATION.\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man s/p crani for evacuation\n REASON FOR THIS EXAMINATION:\n please eval for hemorrhage\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Post-surgical changes, following evacuation of left temporoparietal\n intraparenchymal hemorrhage, with small amount of residual hemorrhage seen.\n Rightward subfalcine herniation and left uncal herniation are minimally\n improved.\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-05-02 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1069253,
"text": " 8:46 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: line placement\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with new line placement\n REASON FOR THIS EXAMINATION:\n line placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: IJ placement.\n\n FINDINGS: In comparison with earlier study of this date, there has been\n placement of a right IJ catheter that extends to the mid portion of the SVC.\n Little change other than slightly better lung volumes.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-04-28 00:00:00.000",
"description": "CTA HEAD W&W/O C & RECONS",
"row_id": 1068612,
"text": " 1:53 PM\n CTA HEAD W&W/O C & RECONS Clip # \n Reason: 53 year old man with large L IPH, r/o vascular abnl\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with large L IPH, r/o vascular abnl\n REASON FOR THIS EXAMINATION:\n 53 year old man with large L IPH, r/o vascular abnl\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 2:39 PM\n No aneurysm or sign of vascular malformation.\n\n Complete R ICA occlusion. Intracranial vessels largely reconstituted via\n collateral flow.\n\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Large left intraparenchymal hemorrhage. Please evaluate for\n vascular abnormality.\n\n COMPARISON: Head CT from at 13:41 hours.\n\n TECHNIQUE: Contrast-enhanced CT angiography of the circle of was\n performed. Multiplanar reformatted images, including volume-rendered images\n were obtained and reviewed.\n\n CTA HEAD: There is no sign of aneurysm, or other vascular malformation. The\n distal right internal carotid artery is completely occluded, likely at its\n origin, which is only partially visualized. There is no flow seen within The\n right ICA to its junction with the circle of , where intracranial\n vessels on the right are recanalized, likely due to collateral flow from large\n anterior communicating artery, and also partially from ophthalmic collaterals.\n\n There is mild atherosclerotic narrowing in the left carotid siphon. Otherwise,\n the intracranial carotid and vertebral arteries and their major branches are\n normal in appearance, without additional stenosis, or occlusion.\n\n Large left intraparenchymal hemorrhage, and smaller right frontal\n intraparenchymal hemorrhage are better demonstrated on concurrently performed\n non-contrast CT of the head, reported separately under clip number .\n Ventricles and sulci are grossly unchanged in size and configuration.\n\n IMPRESSION:\n 1. No evidence of aneurysm or other vascular malformation.\n 2. Complete right ICA occlusion, likely at the origin.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-04-29 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1068700,
"text": " 7:24 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: 53 year old man with L IPH, please compare with prior\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with L IPH, please compare with prior\n REASON FOR THIS EXAMINATION:\n 53 year old man with L IPH, please compare with prior\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AJy FRI 10:10 AM\n PFI: The size and appearance of the large parietotemporal intraparenchymal\n hemorrhage and the smaller right inferior frontal intraparenchymal hemorrhage,\n as well as subarachnoid blood is unchanged. There is slightly increased edema\n and resultant mass effect, with now 8 mm of midline shift, and subfalcine\n herniation.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53-year-old male with left parietotemporal IPH.\n\n NON-CONTRAST HEAD CT: There is unchanged appearance of the large\n heterogeneously hyperdense intraparenchymal hemorrhage within the left\n parietotemporal lobe. There is slight increase in surrounding edema, with\n increased mass effect and increased subfalcine herniation. Shift of midline\n structures is increased from approximately 6 mm to 8 mm on today's study.\n There is no change in the appearance of the ventricles, with persistent mass\n effect upon the left lateral ventricle, but no enlargement or entrapment of\n the contralateral lateral ventricle. There is no evidence for uncal\n herniation. There is additional blood seen in the subarachnoid space of the\n left frontal and parietal lobes, and a second focus of intraparenchymal blood\n located in the inferior right frontal lobe. These are also unchanged in\n extent and appearance.\n\n There is no acute vascular territorial infarction. Accounting for underlying\n edema and hemorrhage, the -white differentiation is preserved. Minimal\n fluid is in the paranasal sinus is unchanged. Mastoid air cells remain\n pneumatized and clear. Osseous structures are again unremarkable.\n\n IMPRESSION:\n 1. Unchanged size and appearance of large left parietotemporal\n intraparenchymal hemorrhage, with slightly increased edema and associated mass\n effect, including 8-mm subfalcine herniation.\n 2. Unchanged additional focus of intraparenchymal hemorrhage in the right\n inferior temporal lobe and scattered bilateral subarachnoid blood.\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-04-29 00:00:00.000",
"description": "CT L-SPINE W/O CONTRAST",
"row_id": 1068775,
"text": " 11:41 AM\n CT L-SPINE W/O CONTRAST Clip # \n Reason: r/o fracture\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man +ETOH found down at home, intubated\n REASON FOR THIS EXAMINATION:\n r/o fracture\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DSsd FRI 1:40 PM\n No fx or malalignment.\n Multilevel deg. change.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53-year-old male found down at home, with alcohol intoxication.\n Now intubated. Please evaluate for fracture.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast CT of the lumbar spine, with multiplanar\n reformations.\n\n FINDINGS: There is no fracture or acute lumbar spine malalignment. Vertebral\n body heights are well maintained. There is diffuse degenerative disc space\n narrowing, and endplate sclerosis at multiple levels, most severe at L1/2 and\n L4/5. Multilevel facet and uncovertebral osteophytes, as well as small\n anterior osteophytes are noted, with calcified diffuse disc bulge also present\n at L2-3, resulting in mild bilateral foraminal narrowing. Visualized outline\n of the thecal sac appears intact, but please note that CT is unable to provide\n intrathecal detail comparable to MRI.\n\n Incidental note is made of atherosclerotic calcification of the distal\n abdominal aorta and bifurcation. Partially visualized portions of the liver\n redemonstrate diffusely decreased attenuation, consistent with fatty liver.\n\n IMPRESSION:\n 1. No fracture or lumbar spine malalignment.\n 2. Multilevel degenerative change as detailed above.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-05-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1069147,
"text": " 10:42 AM\n CHEST (PORTABLE AP) Clip # \n Reason: OGT placement\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man to be restarted on TF\n REASON FOR THIS EXAMINATION:\n OGT placement\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of OG tube placement.\n\n Portable AP chest radiograph was compared to .\n\n The ET tube tip is 5 cm above the carina. The NG tube tip is in the stomach.\n Left basal opacity is unchanged and might be consistent with\n aspiration/pneumonia. Lungs are otherwise clear. Continued dilatation of the\n colon is noted. The transverse colon being dilated up to 5.5 cm and the right\n ascending colon up to 6 cm, progressed since the prior study.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-05-03 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1069444,
"text": " 6:13 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval interval change\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man s/p IPH evacuation\n REASON FOR THIS EXAMINATION:\n eval interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JRCi 8:51 PM\n PFI: Improvement in subfalcine and uncal herniation status post\n intraparenchymal hemorrhage evacuation. No areas of new hemorrhage.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: CT head without contrast.\n\n INDICATION: Status post intraparenchymal hemorrhage evacuation. Evaluate for\n change.\n\n COMPARISON: CT head without contrast .\n\n FINDINGS: Post-surgical changes of a left temporal craniotomy with evacuation\n of a large left parietotemporal intraparenchymal hemorrhage are again\n demonstrated. Pocket of air within the intraparenchymal post-surgical bed\n demonstrates mild decrease from prior study. Continued evolution of left\n parietotemporal intraparenchymal hemorrhage continues with large region of\n vasogenic edema again demonstrated. Right frontal intraparenchymal hemorrhage\n is also evolving without increase in size or regions of new intraparenchymal\n hemorrhage demonstrated. Continued improvement of midline shift noted with\n currently 6 mm of shift of the septum pellucidum, previously 8 mm. Continued\n mass effect upon the ipsilateral lateral ventricle with considerable mass\n effect upon the left frontal demonstrated. No considerable change in\n size of the right lateral ventricle demonstrated. Overall pneumocephalus in\n the bifrontal extra-axial spaces has improved yet remains. Posterior fossa\n remains within normal limits without evidence of tonsillar herniation.\n\n There is complete opacification of partially visualized left maxillary sinus\n with mild opacification of the ethmoid air cells and small fluid level in the\n sphenoid sinus on the left. Mastoid air cells remain clear. Lobulated\n mucosal thickening in the left frontal sinus also demonstrated.\n\n There is overall increased effacement of sulci in the right cerebral\n hemisphere near the apex suggesting increased edema. Complete effacement of\n sulci on the left again demonstrated.\n\n IMPRESSION:\n\n 1. Post-surgical changes are again demonstrated following evacuation of a\n left temporoparietal intraparenchymal hemorrhage with continued evolution of\n parenchymal hemorrhage and edema.\n\n (Over)\n\n 6:13 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval interval change\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 2. Continued improvement of subfalcine herniation and left uncal herniation\n but persitent to a lesser degree.\n\n 3. Evolution of right inferior frontal lobe intraparenchymal hemorrhage\n without evidence of new parenchymal hemorrhage detected.\n\n 4. Continued significant cerebral edema.\n\n 5. Sinus opacification.\n\n Close follow up as clinically indicated.\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-05-03 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1069445,
"text": ", M. NSURG SICU-A 6:13 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval interval change\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man s/p IPH evacuation\n REASON FOR THIS EXAMINATION:\n eval interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI: Improvement in subfalcine and uncal herniation status post\n intraparenchymal hemorrhage evacuation. No areas of new hemorrhage.\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-05-06 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1069913,
"text": " 5:23 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval interval change\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with left intraparenchymal hemorrhage s/p evacuation\n REASON FOR THIS EXAMINATION:\n eval interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT HEAD WITHOUT CONTRAST\n\n COMPARISON: .\n\n HISTORY: 53-year-old male with left intraparenchymal hemorrhage status post\n evacuation, evaluate for interval change.\n\n TECHNIQUE: MDCT axially acquired images of the brain were obtained. No IV\n contrast was administered.\n\n FINDINGS: Post-surgical changes in the left temporal craniotomy with\n evacuation of large left parietotemporal intraparenchymal hemorrhage are again\n demonstrated. A pocket of air within the post-surgical bed slightly decreased\n when compared to prior exam. Continued evolution of left parietotemporal\n intracranial hemorrhage is identified with surrounding vasogenic edema. Right\n frontal intraparenchymal hemorrhage is also evolving without increased in size\n or regions of new hemorrhage identified. There is a shift of normally midline\n structures by approximately 6 mm, similar in appearance. Continued mass\n effect upon the ipsilateral lateral ventricle is unchanged. There has been\n interval decrease in bifrontal pneumocephalus.\n\n There is mucosal opacification of the left maxillary sinus, unchanged. Mild\n mucosal opacification of the ethmoid and sphenoid sinuses is also identified.\n The mastoid air cells are clear.\n\n Effacement of the adjacent sulci within the left cerebral hemisphere is\n unchanged. Mild effacement of the right cerebral hemisphere is also\n identified, similar in appearance.\n\n IMPRESSION:\n 1. Post-surgical changes following evacuation of left temporoparietal\n intraparenchymal hemorrhage with continued evolution of parenchymal hemorrhage\n and edema.\n 2. Stable appearance of subfalcine herniation and left uncal herniation.\n 3. Evolution of right inferior frontal lobe intraparenchymal hemorrhage\n without evidence of new hemorrhage identified.\n 4. Sinus opacification, unchanged.\n (Over)\n\n 5:23 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval interval change\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-05-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1070102,
"text": " 6:22 PM\n CHEST (PORTABLE AP) Clip # \n Reason: etiology of fevers\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with fevers\n REASON FOR THIS EXAMINATION:\n etiology of fevers\n ______________________________________________________________________________\n WET READ: PXDb FRI 6:41 PM\n No acute cardiopulmonary process. ET tube, NG tube, right IJ catheter\n unchanged. ( )\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST\n\n COMPARISON: .\n\n INDICATION: Fever.\n\n FINDINGS: Overall appearance of the chest is not substantially changed except\n for a subtle hazy opacity that has developed in the left infrahilar region,\n partially obscuring the left heart border. Attention to this area on a\n short-term followup radiograph is suggested to exclude the possibility of\n developing infectious pneumonia at this site.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-04-29 00:00:00.000",
"description": "MR CERVICAL SPINE W/O CONTRAST",
"row_id": 1068772,
"text": " 11:28 AM\n MR CERVICAL SPINE W/O CONTRAST Clip # \n Reason: R/O ligamentous injury\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with head trauma\n REASON FOR THIS EXAMINATION:\n R/O ligamentous injury\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DSsd FRI 1:36 PM\n No cord signal abnormality. Degenerative changes worst at C5/6, where there\n is moderate-several spinal stenosis.\n\n Mild edema around posterior elements from C5-C7 may reflect muscle/soft tissue\n injury, or ligamentum flavum injury.\n\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION: Head trauma. ? ligamentous injury.\n\n COMPARISON: CT of the cervical spine from obtained at \n Hospital. Comparison also made to head CT from .\n\n TECHNIQUE: Multiplanar T1- and T2-weighted imaging of the cervical spine.\n\n FINDINGS: There is no sign of acute fracture or cervical spine malalignment.\n There is slight degenerative retrolisthesis of C5 on C6. Degenerative disc\n space narrowing is present from C4-5 through C6/7. There is no cord or cauda\n signal abnormality. There is no abnormal signal in the prevertebral soft\n tissues. Slightly increased STIR signal is noted about the posterior elements\n from C5 through C7, could suggest a small amount of soft tissue injury, but\n there is no sign of injury to the ligamentum flavum in this region.\n\n Disc osteophyte complexes at multiple levels cause mild to moderate central\n canal stenosis at C4/5, mild-moderate central canal stenosis at C5/6, and mild\n central canal stenosis at C6/7. There is also mild-moderate bilateral\n foraminal narrowing at C5/6, left greater than right.\n\n Incidental note is made of mild atrophy of the cerebellar folia.\n\n IMPRESSION:\n 1. No evidence of ligamentous injury in the cervical spine.\n\n 2. Multilevel degenerative change as detailed above, most severe at C5/6. No\n sign of cord signal abnormality.\n\n (Over)\n\n 11:28 AM\n MR CERVICAL SPINE W/O CONTRAST Clip # \n Reason: R/O ligamentous injury\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-05-06 00:00:00.000",
"description": "UNILAT UP EXT VEINS US",
"row_id": 1069948,
"text": " 9:12 AM\n UNILAT UP EXT VEINS US Clip # \n Reason: RUE SWELLING EVAL FOR DVT\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with RUQ swelling\n REASON FOR THIS EXAMINATION:\n R/O DVT\n ______________________________________________________________________________\n FINAL REPORT\n UNILATERAL UPPER EXTREMITY VEINS VENOUS ULTRASOUND\n\n INDICATION: 55-year-old man with right upper extremity swelling.\n\n COMPARISON: None available.\n\n RIGHT UPPER EXTREMITY VENOUS ULTRASOUND: scale and color Doppler\n son images were obtained that demonstrate bilateral subclavian veins\n have wall-to-wall flow with expected variability. The right internal jugular,\n subclavian, axillary and both brachials demonstrate compressibility and wall-\n to-wall flow. The cephalic vein demonstrates wall-to-wall flow with\n augmentation.\n\n IMPRESSION: No DVT of the right upper extremity.\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-04-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1068667,
"text": " 7:51 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ETT placement\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with ETT\n REASON FOR THIS EXAMINATION:\n ETT placement\n ______________________________________________________________________________\n WET READ: 9:03 PM\n ETT remains 7.5 cm above the carina and could be advanced 4 cm for optimal\n position. No change from the prior study.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: ET tube placement.\n\n FINDINGS: In comparison with the earlier study of this date, the endotracheal\n tube tip lies approximately 7.5 cm above the carina. It could be pushed\n forward about 3-4 cm for optimal position. Little change in the appearance of\n the heart and lungs.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-05-02 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1069170,
"text": " 12:21 PM\n PORTABLE ABDOMEN Clip # \n Reason: extent, cause of ileus, transition point\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with ileus\n REASON FOR THIS EXAMINATION:\n extent, cause of ileus, transition point\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient is a 53-year-old male with ileus. Please evaluate for\n extent or cause of ileus, and transition point.\n\n EXAMINATION: Single supine portable abdominal radiograph.\n\n COMPARISON: Comparison to CT torso from .\n\n FINDINGS: There are mild gaseously distended loops of large and small bowel\n with large bowel measuring up to 6.0 cm and small bowel measuring up to 3.3 cm\n located throughout the entire abdomen extending through with air in the rectum\n compatible with patient's known diagnosis of ileus. No definitive transition\n point. The soft tissues are unremarkable. The visualized osseous structures\n are normal.\n\n IMPRESSION: Mild gaseous distention of loops of small and large bowel\n spanning entire abdomen extending through to the rectum compatible with ileus.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-04-29 00:00:00.000",
"description": "CT T-SPINE W/O CONTRAST",
"row_id": 1068774,
"text": " 11:41 AM\n CT T-SPINE W/O CONTRAST Clip # \n Reason: r/o fracture s/p fall\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man +ETOH found down at home, intubated\n REASON FOR THIS EXAMINATION:\n r/o fracture s/p fall\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DSsd FRI 1:38 PM\n No fracture or T-spine malalignment.\n\n Marked fatty infiltration of the liver.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Found down at home with alcohol intoxication. Now intubated.\n Please evaluate for fracture status post fall.\n\n COMPARISON: None available.\n\n TECHNIQUE: Non-contrast CT of the thoracic spine with multiplanar\n reformations.\n\n FINDINGS: There is no fracture or acute malalignment in the thoracic spine.\n Vertebral body and intervertebral disc space heights are well preserved. Mild\n facet arthropathy is noted at multiple levels, without significant foraminal\n stenosis.\n\n Visualized outline of the thecal sac appears intact, but please note that CT\n is unable to provide intrathecal detail comparable to MRI. Incidental note is\n made of nasogastric tube, which reaches the stomach. Endotracheal tube is in\n place in appropriate position.\n\n There is marked diffuse decreased attenuation throughout the visualized\n portions of the liver, most consistent with fatty infiltration of the liver.\n\n IMPRESSION:\n 1. No fracture or thoracic spine malalignment.\n 2. Fatty liver.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-05-02 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1069134,
"text": " 9:05 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Interval change - increase in IPH, shift\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with L IPH\n REASON FOR THIS EXAMINATION:\n Interval change - increase in IPH, shift\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SPfc MON 2:39 PM\n The foci of IPH, including at the right frontal and left temperoparietal are\n stable in size but show signs of evolution and layerying. There is no new\n bleeds. There is increase in the surround vasogenic edema about these\n hemorrhages with resultant increase in midline shift.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Previously documented left intraparenchymal hemorrhage, please\n assess for interval change.\n\n COMPARISON: Comparison is made to multiple previous CT studies of the head,\n spanning from to .\n\n TECHNIQUE: Contiguous, axial CT images were acquired of the head in the\n absence of intravenous contrast:\n\n FINDINGS:\n An 8.0 x 3.7cm hyperdense intraparenchymal hemorrhage within the left\n temporoparietal lobe is similar in size though shows notable increase in\n surrounding vasogenic edema. The appearance of the hemorrhage indicates\n continued evolution from the previous studies. There is a subfalcine, right\n shift of the normal midline anatomy of ~10mm, slightly increased since the\n study. There is persistent mass effect upon the left lateral ventricle,\n without evidence of entrapment of the contralateral lateral ventricle. There\n is no uncal herniation. The second focus of intraparenchymal hemorrhage in\n the inferior right frontal lobe (2:15), is minimally changed in size since the\n most recent study, though also shows increased surrounding vasogenic edema.\n\n There is no acute vascular territorial infarction. A moderate amount of fluid\n in the paranasal sinuses, most prominently at the left maxillary sinus is\n unchanged. The mastoid air cells remain pneumatized and clear. Osseous and\n extracranial soft tissue structures are unremarkable.\n\n IMPRESSION:\n 1. Unchanged size of left parietotemporal intraparenchymal hemorrhage with\n increased surrounding vasogenic edema and associated slightly increased\n rightward subfalcine herniation.\n 2. Unchanged size of right frontal intraparenchymal hematoma with increasing\n surrounding vasogenic edema, and no new hemorrhage.\n (Over)\n\n 9:05 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Interval change - increase in IPH, shift\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-05-02 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1069135,
"text": ", M. NSURG SICU-A 9:05 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Interval change - increase in IPH, shift\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with L IPH\n REASON FOR THIS EXAMINATION:\n Interval change - increase in IPH, shift\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n The foci of IPH, including at the right frontal and left temperoparietal are\n stable in size but show signs of evolution and layerying. There is no new\n bleeds. There is increase in the surround vasogenic edema about these\n hemorrhages with resultant increase in midline shift.\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-04-29 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1068701,
"text": ", M. NSURG SICU-A 7:24 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: 53 year old man with L IPH, please compare with prior\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with L IPH, please compare with prior\n REASON FOR THIS EXAMINATION:\n 53 year old man with L IPH, please compare with prior\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI: The size and appearance of the large parietotemporal intraparenchymal\n hemorrhage and the smaller right inferior frontal intraparenchymal hemorrhage,\n as well as subarachnoid blood is unchanged. There is slightly increased edema\n and resultant mass effect, with now 8 mm of midline shift, and subfalcine\n herniation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-04-28 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1068601,
"text": " 1:12 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: please eval for bleed / shift\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with SAH and IPH on osh films\n REASON FOR THIS EXAMINATION:\n please eval for bleed / shift\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 2:14 PM\n Large 7.6 x 3.3 cm acute and subacute hemorrhage in the left parietotemporal\n temporal hemorrhage with surrounding edema. Associated effacement of the\n sulci, 5 mm shift of normally midline sturctures with subfalcine herniation\n and effacement of left lateral ventricle. No entrapment of right lateral\n ventricle. No transtentorial herniation. Second 1.1 x 1.5 cm focus of acute\n hemorrhage in the right inferior frontal lobe. Scattered foci of subarachnoid\n hemorrhage in the left frontal and parietal and right temporal lobes.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53-year-old male with SAH and ICH on outside hospital films.\n Evaluate for bleed and shift.\n\n COMPARISON: No prior study available for comparison.\n\n TECHNIQUE: Contiguous axial images were obtained through the brain. No\n contrast administered. Coronal and sagittal reformats were displayed.\n\n FINDINGS: There is a large mixed density intraparenchymal blood collection in\n the left parietotemporal lobe measuring 7.6 x 3.3 cm in axial dimensions and\n consistent with acute hemorrhage. This lesion demonstrates surrounding edema.\n There is a 5-mm rightward shift of normally midline structures and subfalcine\n herniation. There is diffuse effacement of the sulci in the left cerebral\n hemisphere and the left lateral ventricle. There is no entrapment of the\n right lateral ventricle or uncal herniation. There is a second focus of acute\n hemorrhage in the right inferior frontal lobe measuring 1.1 x 1.5 cm. In\n addition, there are scattered foci of subarachnoid hemorrhage in the right\n temporal and left frontal and parietal lobes.\n\n There is no major vascular territory infarction. Mucosal thickening in the\n left maxillary and ethmoidal sinuses is noted. There is a mucous retention\n cyst in the right maxillary sinus. No osseous abnormality is detected.\n\n IMPRESSION:\n 1. Large left parietotemporal intraparenchymal hemorrhage with associated\n mass effect including 5 mm rightward shift of the normally midline structures\n and subfalcine herniation.\n\n 2. Focus of intraparenchymal hemorrhage in the right inferior frontal lobe.\n\n 3. Scattered areas of subarachnoid hemorrhage bilaterally.\n\n 4. Maxillary and ethmoidal sinus disease.\n (Over)\n\n 1:12 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: please eval for bleed / shift\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-04-28 00:00:00.000",
"description": "CT CHEST W/CONTRAST",
"row_id": 1068602,
"text": " 1:13 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: please eval for solid organ injury, fractures- chest, abd, p\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with SAH and IPH on osh films s/p fall\n REASON FOR THIS EXAMINATION:\n please eval for solid organ injury, fractures- chest, abd, pelvis\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 2:34 PM\n No acute intrathoracic, abdominal or pelvic abnl. Fatty liver. Old right and\n left rib fractures and b/l clavicular deformity.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53-year-old male with subarachnoid hemorrhage and\n intraparenchymal hemorrhage at outside hospital, status post fall. Evaluate\n for solid organ injury or fracture in the chest, abdomen, and pelvis.\n\n COMPARISON: Chest radiograph from earlier the same day.\n\n TECHNIQUE: MDCT-acquired axial images through the chest, abdomen, and pelvis\n were obtained after administration of 130 cc of Optiray intravenous contrast.\n Coronal and sagittal reformations were displayed and essential in delineating\n the anatomy and pathology.\n\n CT CHEST WITH IV CONTRAST: There is a tiny 2-mm nodule in the left lower lobe\n (2:41). The lungs are otherwise clear without consolidation, pneumothorax, or\n pleural effusion. An endotracheal tube terminates 6 cm from the carina.\n The heart and pericardium are normal without pericardial effusion. There are\n mild coronary calcifications and atherosclerotic disease of the thoracic\n aorta. There is no axillary, mediastinal, or hilar lymphadenopathy. Deformity\n of the bilateral clavicles is noted, likely related to old trauma.\n\n CT ABDOMEN WITH IV CONTRAST: There is diffuse fatty infiltration of the\n liver. The gallbladder, pancreas, spleen, adrenal glands, and intra-abdominal\n loops of bowel are normal. An NG tube terminates in the stomach. The kidneys\n enhance and excrete contrast symmetrically without evidence of hydronephrosis.\n There is a tiny 4 mm interpolar hypodensity in the left kidney which is too\n small to characterize, but likely a cyst. There is no mesenteric or\n retroperitoneal lymphadenopathy. No free air or fluid is identified in the\n abdomen.\n\n CT PELVIS WITH IV CONTRAST: The bladder is collapsed around a Foley catheter.\n The prostate, seminal vesicles, sigmoid colon, and rectum are normal. No\n pelvic or inguinal lymphadenopathy is identified. There is no free fluid in\n the pelvis.\n\n BONE WINDOWS: No suspicious lytic or sclerotic osseous lesion is identified.\n Degenerative changes of the lumbar spine are noted.\n\n IMPRESSION:\n (Over)\n\n 1:13 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: please eval for solid organ injury, fractures- chest, abd, p\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 1. No evidence of acute intrathoracic, intra-abdominal, or pelvic injury.\n\n 2. 2-mm nodule in the left lower lobe. According to the Society\n criteria, if the patient is at low risk for malignancy, no further followup is\n needed. If the patient is at high risk for malignancy, CT followup in 12\n months is recommended, and if unchanged at that time, no additional followup\n is recommended.\n\n 3. Probable remote bilateral clavicular fractures and right and left rib\n fractures.\n\n 4. Fatty infiltration of the liver.\n\n 5. 4-mm hypodensity in the left renal cortex which is too small to\n characterize, but likely a simple cyst.\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-05-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1069439,
"text": " 5:34 PM\n CHEST (PORTABLE AP) Clip # \n Reason: NGT placement\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with head bleed with new trach/NGT\n REASON FOR THIS EXAMINATION:\n NGT placement\n ______________________________________________________________________________\n WET READ: JRCi 6:37 PM\n Limited portable study. New tracheostomy tube overlies the tracheal air\n column in expected position. Right IJ CVL is unchanged in configuration. No\n new airspace process detected. Colonic dilation continues with NGT within\n normal limits.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of endotracheal tube placement.\n\n Portable AP chest radiograph was compared to .\n\n The ET tube tip is 7 cm above the carina. The right internal jugular line tip\n is in mid SVC. Cardiomediastinal silhouette is stable. No change in left\n basal opacity most likely consistent with atelectasis (possible aspiration) is\n demonstrated. Note is made of significant interval increase in large bowel\n dilatation with transverse colon being now up to 6 cm in diameter and the\n ascending colon up to 8 cm in diameter. Please correlate clinically with\n further imaging of the abdomen if necessary.\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-04-30 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1068958,
"text": " 4:56 PM\n CHEST (PORTABLE AP) Clip # \n Reason: High T 102, eval for asperation\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53M known EtOH found in home down by social worker, taken to OSH where patient\n was combative moving all 4 extremities, patient was intubated and found to\n have, transfer to , plt 40, ethanol 71, lactate 3.3, glucose 217\n REASON FOR THIS EXAMINATION:\n High T 102, eval for asperation\n ______________________________________________________________________________\n WET READ: JXKc SAT 5:42 PM\n ET tube 4 cm from carina. NG tube in stomach. Minimal left basilar\n atelectasis. Lungs otherwise clear. No evidence of pneumothorax. Old\n clavicle fracture deformities. -jkang\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n CLINICAL INFORMATION:. Found down. Question aspiration.\n\n FINDINGS:\n\n Comparison is made to the prior study from . Endotracheal tube\n terminates 4.2 cm above the carina. Cardiomediastinum otherwise normal.\n Nasogastric tube terminates in the stomach. There is mild atelectasis at both\n lung bases. Remainder of the lungs are clear. No frank infiltrate to suggest\n aspiration at this time. There is an old right clavicular deformity.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-05-02 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1069251,
"text": " 8:11 PM\n CT HEAD W/O CONTRAST; -77 BY DIFFERENT PHYSICIAN # \n Reason: S/P CRANI. FOR EVACUATION.\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man s/p crani for evacuation\n REASON FOR THIS EXAMINATION:\n please eval for hemorrhage\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JXKc MON 9:47 PM\n Post-surgical changes, following evacuation of left temporoparietal\n intraparenchymal hemorrhage, with small amount of residual hemorrhage seen.\n Rightward subfalcine herniation and left uncal herniation are minimally\n improved.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 53-year-old male status post craniotomy for evacuation, evaluate for\n hemorrhage.\n\n COMPARISON: at 9:00 a.m.\n\n TECHNIQUE: Contiguous axial images of the head were obtained without IV\n contrast.\n\n FINDINGS: There has been an interval left temporal craniotomy, with\n evacuation of a large parietotemporal intraparenchymal hemorrhage. There is\n foci of air within the surgical bed and post-operative pneumocephalus\n overlying the frontal lobes bilaterally. A small amount of residual hemorrhage\n is present within the left posterior temporal lobe and left parietal lobe.\n Associated vasogenic edema is similar. An additional focus of hemorrhage\n within the right inferior frontal lobe with associated edema is unchanged.\n There continues to be mass effect on the left lateral ventricle, and rightward\n subfalcine herniation of approximately 8 mm, improved from prior study. There\n is slight effacement of the left cerebral hemispheric sulci and gyri, likely\n related to the mass effect. Additionally, a left uncal herniation is\n unchanged.\n\n No new foci of hemorrhage identified. The caliber of the ventricular system\n appears similar. Visualized paranasal sinuses reveal air- fluid level in the\n left maxillary sinus, and mucoscal thickening of the sphenoid and ethmoidal\n sinuses. Mastoid air cells are normally aerated.\n\n IMPRESSION:\n 1. Post-surgical changes following evacuation of left temporoparietal\n intraparenchymal hemorrhage, with a small amount of residual hemorrhage and\n continued vasogenic edema.\n 2. Rightward subfalcine herniation and left uncal herniation, improved.\n 3. Stable right inferior frontal lobe hemorrhage.\n\n (Over)\n\n 8:11 PM\n CT HEAD W/O CONTRAST; -77 BY DIFFERENT PHYSICIAN # \n Reason: S/P CRANI. FOR EVACUATION.\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-04-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1068599,
"text": " 1:10 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ett tube placement?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with head bleed, intubated, transferred\n REASON FOR THIS EXAMINATION:\n ett tube placement?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53-year-old male with intracranial bleed, intubated and\n transferred. Assess ETT placement.\n\n COMPARISON: No prior study available for comparison.\n\n SINGLE SUPINE AP VIEW OF THE CHEST: The endotracheal tube terminates\n approximately 7.5 cm from the carina. The lungs are clear without focal\n consolidation, pneumothorax or pleural effusion. The heart size is normal.\n There is tortuosity of the thoracic aorta. There is bilateral clavicular\n deformity which may be related to prior trauma. An NG tube is noted projecting\n out of the field of view in the left upper abdomen.\n\n IMPRESSION: Endotracheal tube 7.5 cm from the carina. Consider\n repositioning.\n\n"
},
{
"category": "Physician ",
"chartdate": "2140-05-05 00:00:00.000",
"description": "Intensivist Note",
"row_id": 564897,
"text": "SICU\n HPI:\n Date HD 8 POD3 crani for evacuation\n .\n Abx: none\n .\n AC: SQH\n .\n CC: .\n HPI: 53M with known EtOH abuse found in home down by social worker on\n , taken to OSH where patient was combative though moving all 4\n extremities. Patient was intubated and found to have large IPH, was\n subsequently transferred to , with initial labs: plt 40, ethanol\n 71, lactate 3.3, glucose 217.\n .\n PMH: EtOH abuse, seizure disorder (epilepsy), schizophrenia\n .\n PSH: unknown\n .\n Meds: Acetaminophen, Bisacodyl, Calcium Gluconate, CeftazIDIME,\n Chlorhexidine Gluconate 0.12% Oral Rinse, Docusate Sodium (Liquid),\n Fentanyl Citrate, FoLIC Acid, Heparin, HydrALAzine, Insulin, Influenza\n Virus Vaccine, LeVETiracetam, Lorazepam, Magnesium Sulfate, Metoprolol\n Tartrate, Multivitamins W/minerals, Ondansetron, Phenytoin\n (Suspension), Potassium Phosphate, Ranitidine, Senna, Thiamine,\n Vancomycin\n .\n : unknown, per mother noncompliant with prescribed medications.\n ALLERGIES: NKDA\n .\n 24 HOUR EVENTS:\n : platelet transfusion\n : Spiked 102--> Pancx, sputum w/ 25+ PMN w/ GPR, started on Vanc\n and ceftaz. MRI c-spine cleared, collar d/c'ed.\n : passing loose BM, digital exam- no obstruction, distended abdomen\n on exam, frequent flatus. Mental status improved with more frequent\n spontaneous awakening, +cough +gag, remains on CPAP, though not\n following commands\n : repeat CT showed increased midline shift, went to OR for\n evacuation of LEFT IPH. Right IJ placed by anesthesia staff intraop.\n : febrile to 103.8, pancultured, Abx stopped, trach at bedside, no\n PEG dilated bowel, repeat CT shows improved herniation and no new\n hemorrhage\n : tolerated trach mask through the day, brief period of ventilation\n over night for tachypnea\n .\n MICRO:\n Sputum: flora\n bcx: PND\n ucx: No growth\n ucx: NG\n bcx: PND\n .\n Imaging/Diagnostics:\n CXR: Endotracheal tube 7.5 cm from the carina\n CTH: Large left parietotemporal intraparenchymal hemorrhage with\n associated mass effect including 5 mm rightward shift of the normally\n midline structures and subfalcine herniation; intraparenchymal\n hemorrhage in the right inferior frontal lobe; Scattered areas of\n subarachnoid hemorrhage bilaterally; Maxillary and ethmoidal sinus\n disease.\n CT CAP: pending\n CTA head: No aneurysm or sign of vascular malformation. Complete R\n ICA occlusion. Intracranial vessels largely reconstituted via\n collaterals\n MRI c-spine (wet): degenerative changes worst at c5/6,\n moderate-severe cervical spinal stenosis, ?soft tissue or LF injury @\n C5-7 w/ mild edema\n CT T/L spine (wet): no t-spine injury, marked fatty infiltration\n of liver.\n CXR: mild atelectasis\n CTH: Unchanged size of left parietotemporal intraparenchymal\n hemorrhage, slightly increased rightward subfalcine herniation,\n unchanged size of right frontal intraparenchymal hematoma\n CXR: Left basal opacity is unchanged and might be consistent with\n aspiration/pneumonia\n CXR: no new airspace disease, NGT in stomach\n CT head: Improvement in subfalcine and uncal herniation s/p\n intraparenchymal hemorrhage evacuation. No areas of new hemorrhage.\n 24 Hour Events:\n FEVER - 102.0\nF - 04:00 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:11 AM\n Ceftazidime - 04:00 AM\n Cefazolin - 05:00 PM\n Infusions:\n Other ICU medications:\n Metoprolol - 12:24 PM\n Dilantin - 10:00 PM\n Lorazepam (Ativan) - 12:07 AM\n Hydralazine - 12:30 AM\n Fentanyl - 04:42 AM\n Other medications:\n Flowsheet Data as of 06:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.9\nC (102\n T current: 38.9\nC (102\n HR: 84 (66 - 97) bpm\n BP: 98/58(71) {98/58(71) - 162/75(101)} mmHg\n RR: 24 (20 - 35) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 73.4 kg (admission): 70 kg\n Total In:\n 2,807 mL\n 969 mL\n PO:\n Tube feeding:\n 111 mL\n 200 mL\n IV Fluid:\n 2,396 mL\n 649 mL\n Blood products:\n Total out:\n 1,965 mL\n 560 mL\n Urine:\n 1,965 mL\n 560 mL\n NG:\n Stool:\n Drains:\n Balance:\n 842 mL\n 411 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 412 (383 - 449) mL\n PS : 5 cmH2O\n RR (Spontaneous): 27\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 63\n PIP: 11 cmH2O\n SPO2: 99%\n ABG: ///26/\n Ve: 11.7 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Abdominal: Soft, Non-tender\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Neurologic: (Awake / Alert / Oriented: x 1), Moves all extremities\n Labs / Radiology\n 236 K/uL\n 9.5 g/dL\n 118 mg/dL\n 0.4 mg/dL\n 26 mEq/L\n 3.7 mEq/L\n 12 mg/dL\n 101 mEq/L\n 133 mEq/L\n 27.1 %\n 7.2 K/uL\n [image002.jpg]\n 02:12 AM\n 02:20 AM\n 10:00 AM\n 05:00 PM\n 12:27 AM\n 02:57 AM\n 08:30 PM\n 03:08 AM\n 03:21 AM\n 02:14 AM\n WBC\n 6.5\n 5.0\n 6.7\n 7.2\n Hct\n 29.0\n 27.1\n 27.4\n 27.1\n Plt\n 86\n 140\n 186\n 236\n Creatinine\n 0.5\n 0.6\n 0.5\n 0.4\n TCO2\n 30\n 31\n 25\n 25\n Glucose\n 118\n 152\n 142\n 94\n 93\n 118\n Other labs: PT / PTT / INR:12.6/31.3/1.1, CK / CK-MB / Troponin\n T:247//, ALT / AST:53/32, Alk-Phos / T bili:68/0.4, Fibrinogen:487\n mg/dL, Albumin:3.2 g/dL, LDH:329 IU/L, Ca:8.3 mg/dL, Mg:2.1 mg/dL,\n PO4:2.1 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), FEVER (HYPERTHERMIA,\n PYREXIA, NOT FEVER OF UNKNOWN ORIGIN), HYPERTENSION, BENIGN,\n INTRACEREBRAL HEMORRHAGE (ICH), SEIZURE, WITHOUT STATUS EPILEPTICUS,\n .H/O SEIZURE, WITHOUT STATUS EPILEPTICUS, ALCOHOL WITHDRAWAL (INCLUDING\n DELIRIUM TREMENS, DTS, SEIZURES)\n Assessment and Plan: ASSESSMENT/PLAN: 53M with L large IPH with R\n frontal contracoup IPH\n Neuro: IPH, q1h neuro checks, sz ppx: dilantin tid, keppra ,\n minimize sedating medicines, decrease Ativan (HD6) to 0.5-1 Q8H prn iv\n due to history of heavy EtOH use.\n CV: goal SBP < 160; lopressor increased + prn hydralazine\n Pulm: trach mask\n GI: tube feeds to goal\n FEN: Vit/folate/Thiamine supplement\n Renal: creatinine stable\n Heme: stable anemia\n Endo: tight glucose control RISS\n ID: off antibiotics, continues to spike, f/u cultures\n T/L/D: trach, R A-line, PIV, RIJ TLC\n Wounds: craniotomy\n Imaging: none\n Fluids: D5NS + 20KCL @ 80/hr (changed from NS+20KCL)\n Prophylaxis: H2B, Boots, SQH\n Consults: neurosurgery\n Disposition: SICU, consider floor if tolerating trach mask\n Code: full\n PCP: : tel fax \n Billing Diagnosis:\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 05:50 AM 40 mL/hour\n Lines:\n Arterial Line - 04:00 PM\n Multi Lumen - 09:15 PM\n Total time spent:\n"
},
{
"category": "Respiratory ",
"chartdate": "2140-05-04 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 564734,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 7\n Airway\n Known difficult intubation: No\n Tracheostomy tube:\n Type: Cuffed\n Manufacturer: Portex\n Size: 8.0mm\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Bloody / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Frequently sigh breathing\n Assessment of breathing comfort:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n"
},
{
"category": "Nursing",
"chartdate": "2140-05-08 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 565463,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n - pt alert, tracking movement around the room, does not follow\n commands\n - moves L side spontaneously/purposefully, has baseline\n tremors of LUE\n - withdraws/postures R upper to nail bed stimuli\n - no response to nail bed pressure from RLE, this is a new\n finding\n - ? seizure activity overnight but pt was alert and tracking\n movements at this time, given 0.5 ativan\n Action:\n - Neurosurg evaluated pt this am\n - Q2h neuro assessments\n - EEG done today\n Response:\n - not concerned about decreased movement of RLE\n - CT from yesterday shows no new findings\n - EEG did not show any seizure activity per EEG technician\n Plan:\n - continue q2h neuro assessments\n - monitor for seizure activity\n - transfer pt to neuro stepdown\n Hypertension, benign\n Assessment:\n - goal sbp < 160\n - hypertensive to sbp 150s-160s\n Action:\n - started on 20mg IV Hydralazine q6h\n - on PO lopressor 37.5mg PO TID\n Response:\n - bp decreased to sbp 120s-130s\n Plan:\n - continue to assess/treat hypertension with goal sbp < 160\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n - Tmax overnight was 101.7\n - R hand is swollen, ultrasound has been done and negative for\n clots in RUE\n Action:\n - pt was pan cultured again last night\n - on ibuprofen and Tylenol around the clock\n - Ultrasound of lower extremities to be done today for rule\n out ? LE DVT\n Response:\n - Temp currently is 101.9\n - ? origin of fever\n - Ultrasound of lower extremities showed blood clot in RLE,\n above knee MD aware\n Plan:\n - Continue to monitor temperature and continue\n Tylenol/ibuprofen administration\n - Need to place IVC filter tonight or tomorrow morning per\n Neurosurg\n Respiratory failure, acute (not ARDS/)\n Assessment:\n - pt is trached on trach mask 10L with 35% FIO2\n Action:\n - frequent turning/repositioning\n Response:\n - strong cough, expectorates moderate amts of whitish/yellow\n secretions\n Plan:\n - continue to assess respiratory status\n Ineffective Coping\n Assessment:\n - pts brother visited today\n - voiced concerns about pts status/chance of recovery\n Action:\n - listened and provided emotional support\n Response:\n - Brother would like to have a family meeting with someone\n from neurosurg who can explain pts condition and chances of recovering\n more indepth\n - Brother has previously spoken with and would\n like her to also be at this meeting\n Plan:\n - coordinate family meeting if possible Monday to discuss pts\n status/chances and extent of recovery with neurosurg and \n . And notify pts brother of time and place of meeting.\n Pt has an NG tube and is receiving tube feeds at goal. Needs PEG per\n Dr. .\n"
},
{
"category": "Nursing",
"chartdate": "2140-05-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 565464,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n - pt alert, tracking movement around the room, does not follow\n commands\n - moves L side spontaneously/purposefully, has baseline\n tremors of LUE\n - withdraws/postures R upper to nail bed stimuli\n - no response to nail bed pressure from RLE, this is a new\n finding\n - ? seizure activity overnight but pt was alert and tracking\n movements at this time, given 0.5 ativan\n Action:\n - Neurosurg evaluated pt this am\n - Q2h neuro assessments\n - EEG done today\n Response:\n - not concerned about decreased movement of RLE\n - CT from yesterday shows no new findings\n - EEG did not show any seizure activity per EEG technician\n Plan:\n - continue q2h neuro assessments\n - monitor for seizure activity\n - transfer pt to neuro stepdown\n Hypertension, benign\n Assessment:\n - goal sbp < 160\n - hypertensive to sbp 150s-160s\n Action:\n - started on 20mg IV Hydralazine q6h\n - on PO lopressor 37.5mg PO TID\n Response:\n - bp decreased to sbp 120s-130s\n Plan:\n - continue to assess/treat hypertension with goal sbp < 160\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n - Tmax overnight was 101.7\n - R hand is swollen, ultrasound has been done and negative for\n clots in RUE\n Action:\n - pt was pan cultured again last night\n - on ibuprofen and Tylenol around the clock\n - Ultrasound of lower extremities to be done today for rule\n out ? LE DVT\n Response:\n - Temp currently is 101.9\n - ? origin of fever\n - Ultrasound of lower extremities showed blood clot in RLE,\n above knee MD aware\n Plan:\n - Continue to monitor temperature and continue\n Tylenol/ibuprofen administration\n - Need to place IVC filter tonight or tomorrow morning per\n Neurosurg\n Respiratory failure, acute (not ARDS/)\n Assessment:\n - pt is trached on trach mask 10L with 35% FIO2\n Action:\n - frequent turning/repositioning\n Response:\n - strong cough, expectorates moderate amts of whitish/yellow\n secretions\n Plan:\n - continue to assess respiratory status\n Ineffective Coping\n Assessment:\n - pts brother visited today\n - voiced concerns about pts status/chance of recovery\n Action:\n - listened and provided emotional support\n Response:\n - Brother would like to have a family meeting with someone\n from neurosurg who can explain pts condition and chances of recovering\n more indepth\n - Brother has previously spoken with and would\n like her to also be at this meeting\n Plan:\n - coordinate family meeting if possible Monday to discuss pts\n status/chances and extent of recovery with neurosurg and \n (social worker). And notify pts brother of time and place of\n meeting.\n Pt has an NG tube and is receiving tube feeds at goal. Needs PEG per\n Dr. .\n"
},
{
"category": "Nursing",
"chartdate": "2140-05-08 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 565465,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n - pt alert, tracking movement around the room, does not follow\n commands\n - moves L side spontaneously/purposefully, has baseline\n tremors of LUE\n - withdraws/postures R upper to nail bed stimuli\n - no response to nail bed pressure from RLE, this is a new\n finding\n - ? seizure activity overnight but pt was alert and tracking\n movements at this time, given 0.5 ativan\n Action:\n - Neurosurg evaluated pt this am\n - Q2h neuro assessments\n - EEG done today\n Response:\n - not concerned about decreased movement of RLE\n - CT from yesterday shows no new findings\n - EEG did not show any seizure activity per EEG technician\n Plan:\n - continue q2h neuro assessments\n - monitor for seizure activity\n - transfer pt to neuro stepdown\n Hypertension, benign\n Assessment:\n - goal sbp < 160\n - hypertensive to sbp 150s-160s\n Action:\n - started on 20mg IV Hydralazine q6h\n - on PO lopressor 37.5mg PO TID\n Response:\n - bp decreased to sbp 120s-130s\n Plan:\n - continue to assess/treat hypertension with goal sbp < 160\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n - Tmax overnight was 101.7\n - R hand is swollen, ultrasound has been done and negative for\n clots in RUE\n Action:\n - pt was pan cultured again last night\n - on ibuprofen and Tylenol around the clock\n - Ultrasound of lower extremities to be done today for rule\n out ? LE DVT\n Response:\n - Temp currently is 101.9\n - ? origin of fever\n - Ultrasound of lower extremities showed blood clot in RLE,\n above knee MD aware\n Plan:\n - Continue to monitor temperature and continue\n Tylenol/ibuprofen administration\n - Need to place IVC filter tonight or tomorrow morning per\n Neurosurg\n Respiratory failure, acute (not ARDS/)\n Assessment:\n - pt is trached on trach mask 10L with 35% FIO2\n Action:\n - frequent turning/repositioning\n Response:\n - strong cough, expectorates moderate amts of whitish/yellow\n secretions\n Plan:\n - continue to assess respiratory status\n Ineffective Coping\n Assessment:\n - pts brother visited today\n - voiced concerns about pts status/chance of recovery\n Action:\n - listened and provided emotional support\n Response:\n - Brother would like to have a family meeting with someone\n from neurosurg who can explain pts condition and chances of recovering\n more indepth\n - Brother has previously spoken with and would\n like her to also be at this meeting\n Plan:\n - coordinate family meeting if possible Monday to discuss pts\n status/chances and extent of recovery with neurosurg and \n . And notify pts brother of time and place of meeting.\n Pt has an NG tube and is receiving tube feeds at goal. Needs PEG per\n Dr. .\n"
},
{
"category": "Nursing",
"chartdate": "2140-05-08 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 565471,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n - pt alert, tracking movement around the room, does not follow\n commands\n - moves L side spontaneously/purposefully, has baseline\n tremors of LUE\n - withdraws/postures R upper to nail bed stimuli\n - no response to nail bed pressure from RLE, this is a new\n finding\n - ? seizure activity overnight but pt was alert and tracking\n movements at this time, given 0.5 ativan\n Action:\n - Neurosurg evaluated pt this am\n - Q2h neuro assessments\n - EEG done today\n Response:\n - not concerned about decreased movement of RLE\n - CT from yesterday shows no new findings\n - EEG did not show any seizure activity per EEG technician\n Plan:\n - continue q2h neuro assessments\n - monitor for seizure activity\n - transfer pt to neuro stepdown\n Hypertension, benign\n Assessment:\n - goal sbp < 160\n - hypertensive to sbp 150s-160s\n Action:\n - started on 20mg IV Hydralazine q6h\n - on PO lopressor 37.5mg PO TID\n Response:\n - bp decreased to sbp 120s-130s\n Plan:\n - continue to assess/treat hypertension with goal sbp < 160\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n - Tmax overnight was 101.7\n - R hand is swollen, ultrasound has been done and negative for\n clots in RUE\n Action:\n - pt was pan cultured again last night\n - on ibuprofen and Tylenol around the clock\n - Ultrasound of lower extremities to be done today for rule\n out ? LE DVT\n Response:\n - Temp currently is 101.9\n - ? origin of fever\n - Ultrasound of lower extremities showed blood clot in RLE,\n above knee MD aware\n Plan:\n - Continue to monitor temperature and continue\n Tylenol/ibuprofen administration\n - Need to place IVC filter tonight or tomorrow morning per\n Neurosurg\n Respiratory failure, acute (not ARDS/)\n Assessment:\n - pt is trached on trach mask 10L with 35% FIO2\n Action:\n - frequent turning/repositioning\n Response:\n - strong cough, expectorates moderate amts of whitish/yellow\n secretions\n Plan:\n - continue to assess respiratory status\n Ineffective Coping\n Assessment:\n - pts brother visited today\n - voiced concerns about pts status/chance of recovery\n Action:\n - listened and provided emotional support\n Response:\n - Brother would like to have a family meeting with someone\n from neurosurg who can explain pts condition and chances of recovering\n more indepth\n - Brother has previously spoken with and would\n like her to also be at this meeting\n Plan:\n - coordinate family meeting if possible Monday to discuss pts\n status/chances and extent of recovery with neurosurg and \n (social worker). And notify pts brother of time and place of\n meeting.\n Pt has an NG tube and is receiving tube feeds at goal. Needs PEG per\n Dr. .\n Demographics\n Attending MD:\n M.\n Admit diagnosis:\n INTRACRANIAL HEMORRHAGE\n Code status:\n Full code\n Height:\n Admission weight:\n 70 kg\n Daily weight:\n 71.3 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: COPD, ETOH, Seizures\n CV-PMH:\n Additional history:\n schizophrenic, noncompliant with meds.\n nonsustained ventricular tachycardia\n abnormal LFT\n pulmonary nodule\n lumbar disc disease\n *** , Hospital, case manager, \n Surgery / Procedure and date: crani for evac lt sdh, trached\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:138\n D:76\n Temperature:\n 100.1\n Arterial BP:\n S:154\n D:72\n Respiratory rate:\n 21 insp/min\n Heart Rate:\n 89 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Aerosol-cool\n O2 saturation:\n 98% %\n O2 flow:\n 8 L/min\n FiO2 set:\n 35% %\n 24h total in:\n 1,696 mL\n 24h total out:\n 2,055 mL\n Pertinent Lab Results:\n Sodium:\n 129 mEq/L\n 02:09 AM\n Potassium:\n 4.2 mEq/L\n 02:09 AM\n Chloride:\n 96 mEq/L\n 02:09 AM\n CO2:\n 26 mEq/L\n 02:09 AM\n BUN:\n 16 mg/dL\n 02:09 AM\n Creatinine:\n 0.6 mg/dL\n 02:09 AM\n Glucose:\n 123 mg/dL\n 02:09 AM\n Hematocrit:\n 25.0 %\n 02:09 AM\n Finger Stick Glucose:\n 140\n 10:00 PM\n Valuables / Signature\n Patient valuables: None\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: sicu\n Transferred to: 11 stepdown\n Date & time of Transfer: 12:00 AM\n"
},
{
"category": "Nursing",
"chartdate": "2140-05-08 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 565456,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n - pt alert, tracking movement around the room, does not follow\n commands\n - moves L side spontaneously/purposefully, has baseline\n tremors of LUE\n - withdraws/postures R upper to nail bed stimuli\n - no response to nail bed pressure from RLE, this is a new\n finding\n - ? seizure activity overnight but pt was alert and tracking\n movements at this time, given 0.5 ativan\n Action:\n - Neurosurg evaluated pt this am\n - Q2h neuro assessments\n - EEG done today\n Response:\n - not concerned about decreased movement of RLE\n - CT from yesterday shows no new findings\n - EEG did not show any seizure activity per EEG technician\n Plan:\n - continue q2h neuro assessments\n - monitor for seizure activity\n - transfer pt to neuro stepdown\n Hypertension, benign\n Assessment:\n - goal sbp < 160\n - hypertensive to sbp 150s-160s\n Action:\n - started on 20mg IV Hydralazine q6h\n - on PO lopressor 37.5mg PO TID\n Response:\n - bp decreased to sbp 120s-130s\n Plan:\n - continue to assess/treat hypertension with goal sbp < 160\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n - Tmax overnight was 101.7\n - R hand is swollen, ultrasound has been done and negative for\n clots in RUE\n Action:\n - pt was pan cultured again last night\n - on ibuprofen and Tylenol around the clock\n - Ultrasound of lower extremities to be done today for rule\n out ? LE DVT\n Response:\n - Temp currently is 101.9\n - ? origin of fever\n - Ultrasound of lower extremities showed blood clot in RLE,\n above knee MD aware\n Plan:\n - Continue to monitor temperature and continue\n Tylenol/ibuprofen administration\n - Need to place IVC filter tonight or tomorrow morning per\n Neurosurg\n Respiratory failure, acute (not ARDS/)\n Assessment:\n - pt is trached on trach mask 10L with 35% FIO2\n Action:\n - frequent turning/repositioning\n Response:\n - strong cough, expectorates moderate amts of whitish/yellow\n secretions\n Plan:\n - continue to assess respiratory status\n Ineffective Coping\n Assessment:\n - pts brother visited today\n - voiced concerns about pts status/chance of recovery\n Action:\n - listened and provided emotional support\n Response:\n - Brother would like to have a family meeting with someone\n from neurosurg who can explain pts condition and chances of recovering\n more indepth\n - Brother has previously spoken with and would\n like her to also be at this meeting\n Plan:\n - coordinate family meeting if possible Monday to discuss pts\n status/chances and extent of recovery with neurosurg and \n . And notify pts brother of time and place of meeting.\n Pt has an NG tube and is receiving tube feeds at goal. Needs PEG per\n Dr. .\n"
},
{
"category": "Nursing",
"chartdate": "2140-05-08 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 565453,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n - pt alert, tracking movement around the room, does not follow\n commands\n - moves L side spontaneously/purposefully, has baseline\n tremors of LUE\n - withdraws/postures R upper to nail bed stimuli\n - no response to nail bed pressure from RLE, this is a new\n finding\n - ? seizure activity overnight but pt was alert and tracking\n movements at this time, given 0.5 ativan\n Action:\n - Neurosurg evaluated pt this am\n - Q2h neuro assessments\n - EEG done today\n Response:\n - not concerned about decreased movement of RLE\n - CT from yesterday shows no new findings\n - EEG did not show any seizure activity per EEG technician\n Plan:\n - continue q2h neuro assessments\n - monitor for seizure activity\n - transfer pt to neuro stepdown\n Hypertension, benign\n Assessment:\n - goal sbp < 160\n - hypertensive to sbp 150s-160s\n Action:\n - started on 20mg IV Hydralazine q6h\n - on PO lopressor 37.5mg PO TID\n Response:\n - bp decreased to sbp 120s-130s\n Plan:\n - continue to assess/treat hypertension with goal sbp < 160\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n - Tmax overnight was 101.7\n - R hand is swollen, ultrasound has been done and negative for\n clots in RUE\n Action:\n - pt was pan cultured again last night\n - on ibuprofen and Tylenol around the clock\n - Ultrasound of lower extremities to be done today for rule\n out ? LE DVT\n Response:\n - Temp currently is 101.9\n - ? origin of fever\n - Ultrasound of lower extremities showed blood clot in RLE,\n above knee MD aware\n Plan:\n - Continue to monitor temperature and continue\n Tylenol/ibuprofen administration\n - Need to place IVC filter tonight or tomorrow morning per\n Neurosurg\n Respiratory failure, acute (not ARDS/)\n Assessment:\n - pt is trached on trach mask 10L with 35% FIO2\n Action:\n - frequent turning/repositioning\n Response:\n - strong cough, expectorates moderate amts of whitish/yellow\n secretions\n Plan:\n - continue to assess respiratory status\n Ineffective Coping\n Assessment:\n - pts brother visited today\n -\n Action:\n Response:\n Plan:\n Pt has an NG tube and is receiving tube feeds at goal. Needs PEG per\n Dr. .\n"
},
{
"category": "Nursing",
"chartdate": "2140-05-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 564724,
"text": "Hypertension, benign\n Assessment:\n SBP > 140 at times while patient agitated up to 160\ns, up to 150\ns at\n rest at times.\n Action:\n Given prn orders of fent for pain/ agitation.\n Given prn doses of Hydralazine IV and lopressor IV.\n Standing order of lopressor po increased.\n Response:\n SBP < 140 most of shift. > 140 at times.\n Plan:\n Continue to monitor. Treat agitation and hypertension as needed.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Patient s/p craniotomy post op day 1. Patient is able to spontaneously\n open eyes, however not to command. Patient is unable to follow\n commands. Localizes/ lifts and holds with left arm. Able to withdraw\n with rest of extremities to nail bed pressure. Decreased sensation in\n right arm. Pupils are and briskly reactive to light. Aggitated at\n times. Swelling on left side of head and around left eye noted.\n Action:\n Q 2 hour neuro checks.\n Dr. in to assess facial swelling.\n Keep HOB at least 15 degrees\n Turned and repositioned for comfort, fent prn pain, iv ativan.\n Response:\n Patient able to relax after fent and ativan boluses.\n Neuro status unchanged.\n Plan:\n Continue to monitor.\n Trach mask?\n Keep SBP < 140\n"
},
{
"category": "Nursing",
"chartdate": "2140-05-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 564809,
"text": "HPI:\n 53M with known EtOH abuse found in home down by social worker on ,\n taken to OSH where patient was combative though moving all 4\n extremities. Patient was intubated and found to have large IPH, was\n subsequently transferred to , with initial labs: plt 40, ethanol\n 71, lactate 3.3, glucose 217.\n Chief complaint:\n L large subacute IPH with R frontal contracoup IPH.\n Events:\n - Tolerating 35% trach collar.\n Hypertension, benign\n Assessment:\n -NIBP: 160\ns/60-70\ns with agitation.\n Action:\n -Medicated with IVP Ativan/Fentanyl for agitation-pain.\n -Medicated with IVP Lopressor as well as Hydralazine.\n Response:\n -Patient resting comfortably.\n -NIBP: 120-130\ns/67-75.\n Plan:\n -Continue to follow hemodynamics. Goal SBP<140.\n -Continue IVP Ativan/Fentany/Lopressor PRN and Hydralazine.\n Intracerebral hemorrhage (ICH)\n Assessment:\n -POD #1 for craniotomy.\n -Spontaneously eyes opening spontaneously.\n -Patient does not follow verbal commands.\n -PERRL, 3mm bilat/brisk.\n -Withdraws all extremities to noxious stimuli.\n -MAE except for RUE.\n -L craniotomy staples CDI and OTA. L-facial-peri-orbital edema.\n Action:\n -Q 2 hour Neuro checks.\n -Repositioned with back rub Q 2 for comfort.\n -Medicate PRN for agitation and pain.\n Response:\n -Neuro exam remains unchanged.\n Plan:\n -Q 2 hour Neuro checks.\n -Medicate PRN for agitation and pain.\n -Goal SBP less than 140.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n -T-max: 102.0\n Action:\n -650mg PR Tylenol given.\n -Cool compresses/ice packs applied to forehead/under arms and groin.\n -MD notified-no cultures at this time.\n Response:\n -Current temp: 101.0\n Plan:\n -Continue to follow fever curve.\n -Cultures and Tylenol PRN.\n"
},
{
"category": "Respiratory ",
"chartdate": "2140-05-04 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 564823,
"text": "Airway\n Tube Type\n Tracheostomy tube:\n Type: Cuffed, Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Expectorated / Small\n Ventilation Assessment\n Visual assessment of breathing pattern: Pt placed on 35% trach collar\n today at 10:30am. Pt tolerating wean well.\n Plan\n Next 24-48 hours: Continue with trach collar as tolerated; rest over\n night if indicated.\n"
},
{
"category": "Respiratory ",
"chartdate": "2140-05-03 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 564712,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 6\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Cuffed, Inner Cannula, Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Periodic SBT's for conditioning, Adjust Min. ventilation to control pH\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Cannot protect airway, Cannot manage secretions, Underlying illness not\n resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n CT\n 1800\n none\n Bedside Procedures:\n Bronchoscopy (1630)\n Bedside tracheostomy (1630)\n Comments:\n"
},
{
"category": "Respiratory ",
"chartdate": "2140-05-05 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 564871,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 8\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tracheostomy tube:\n Type: Cuffed\n Manufacturer: Portex\n Size: 8.0mm\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: RR in the high 30s at times on\n trach mask. Pt back on vent d/t fatigue at 1:00 AM\n Assessment of breathing comfort:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: wean to TM in morning\n Respiratory Care Shift Procedures\n"
},
{
"category": "Nursing",
"chartdate": "2140-05-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 564807,
"text": "HPI:\n 53M with known EtOH abuse found in home down by social worker on ,\n taken to OSH where patient was combative though moving all 4\n extremities. Patient was intubated and found to have large IPH, was\n subsequently transferred to , with initial labs: plt 40, ethanol\n 71, lactate 3.3, glucose 217.\n Chief complaint:\n L large subacute IPH with R frontal contracoup IPH.\n Hypertension, benign\n Assessment:\n -NIBP: 160\ns/60-70\ns with agitation.\n Action:\n -Medicated with IVP Ativan/Fentanyl for agitation-pain.\n -Medicated with IVP Lopressor as well as Hydralazine.\n Response:\n -Patient resting comfortably.\n -NIBP: 120-130\ns/67-75.\n Plan:\n -Continue to follow hemodynamics. Goal SBP<140.\n -Continue IVP Ativan/Fentany/Lopressor PRN and Hydralazine.\n Intracerebral hemorrhage (ICH)\n Assessment:\n -POD #1 for craniotomy.\n -Spontaneously opening eyes\n Action:\n Response:\n Plan:\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2140-05-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 564868,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Patient continues to localize with left arm only. Able to withdraw to\n nailbed pressure with lower extremities and right arm. Pupils are \n and briskly reactive to light. Patient does not follow any commands.\n Appears to be tracking at times.\n SBP < 140 most of shift. > 140 at times mostly with agitation.\n Action:\n continued with q 2 hour neuro exams.\n given IV fent and ativan for agitation.\n given hydral and Lopressor as needed for underlying hypertenstion.\n Response:\n neuro exam unchanged.\n Plan:\n continue to monitor. Step down?\n Hypertension, benign\n Assessment:\n Patient\ns BP is labile. Ranging from 100-160\ns at times. SBP > 140\n with agitation mostly.\n Action:\n given prn fent and ativan for agitation.\n given hydral and Lopressor as needed for underlying hyptertension.\n Dr. aware of labile BP.\n Response:\n SBP < 140 most of night.\n Plan:\n continue to monitor. Prn antihypertensives/ prn pain meds for\n aggiation.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient on trach mask at 35 % sating 99-100% RR 30\ns- 40\ns at start of\n shift. Patient appeared comfortable until about midnight patient was\n breathing faster- RR 40\ns, with thick white secretions, patient able to\n expectorate own secretions but inadequately at times. Patient appeared\n to be\ntiring out\n on trach mask.\n Action:\n Patient deep suctioned x 3 for moderate amount of thick white\n secretions.\n Patient put back on CPAP 5/5 fi02 40% during night to rest.\n Response:\n Patient appeared more comfortable RR 20\ns-30\ns sating 99-100%.\n Plan:\n put back on trach mask in am- blood gas. Continue to monitor, suction\n as needed.\n"
},
{
"category": "Nursing",
"chartdate": "2140-05-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 564805,
"text": "HPI:\n 53M with known EtOH abuse found in home down by social worker on ,\n taken to OSH where patient was combative though moving all 4\n extremities. Patient was intubated and found to have large IPH, was\n subsequently transferred to , with initial labs: plt 40, ethanol\n 71, lactate 3.3, glucose 217.\n Chief complaint:\n L large subacute IPH with R frontal contracoup IPH.\n Hypertension, benign\n Assessment:\n Action:\n Response:\n Plan:\n Intracerebral hemorrhage (ICH)\n Assessment:\n Action:\n Response:\n Plan:\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nutrition",
"chartdate": "2140-05-05 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 564962,
"text": "Objective\n Pertinent medications: RISS, Senna, Colace, Raniditine, Mvit with\n minerals, heparin, others noted\n Labs:\n Value\n Date\n Glucose\n 118 mg/dL\n 02:14 AM\n Glucose Finger Stick\n 168\n 10:00 AM\n BUN\n 12 mg/dL\n 02:14 AM\n Creatinine\n 0.4 mg/dL\n 02:14 AM\n Sodium\n 133 mEq/L\n 02:14 AM\n Potassium\n 3.7 mEq/L\n 02:14 AM\n Chloride\n 101 mEq/L\n 02:14 AM\n TCO2\n 26 mEq/L\n 02:14 AM\n PO2 (arterial)\n 155 mm Hg\n 03:21 AM\n PCO2 (arterial)\n 32 mm Hg\n 03:21 AM\n pH (arterial)\n 7.48 units\n 03:21 AM\n pH (urine)\n 8.0 units\n 05:01 PM\n CO2 (Calc) arterial\n 25 mEq/L\n 03:21 AM\n Albumin\n 3.2 g/dL\n 02:14 AM\n Calcium non-ionized\n 8.3 mg/dL\n 02:14 AM\n Phosphorus\n 2.1 mg/dL\n 02:14 AM\n Ionized Calcium\n 1.12 mmol/L\n 01:47 AM\n Magnesium\n 2.1 mg/dL\n 02:14 AM\n ALT\n 53 IU/L\n 02:12 AM\n Alkaline Phosphate\n 68 IU/L\n 02:12 AM\n AST\n 32 IU/L\n 02:12 AM\n Total Bilirubin\n 0.4 mg/dL\n 02:12 AM\n Phenytoin (Dilantin)\n 6.8 ug/mL\n 02:14 AM\n WBC\n 7.2 K/uL\n 02:14 AM\n Hgb\n 9.5 g/dL\n 02:14 AM\n Hematocrit\n 27.1 %\n 02:14 AM\n Current diet order / nutrition support: TF: Nutren 2.0 @ 40cc/hr\n (1920kcal, 77g protein)\n GI: abd soft, + BS\n Assessment of Nutritional Status\n Pt now s/p Left craniotomy and tracheotomy . Pt\ns TF were\n restarted via NGT last night, and are now up to goal. Pt tolerating TF\n well, meeting 100% estimated needs at 27kcals/kg and 1.1g protein/kg.\n Noted Low Na and low phos. There is no plan for PEG placement at this\n time due to dilated bowel.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1) Cont with TF at goal via NGT.\n 2) Monitor lytes, replete as needed.\n Following, please page with ?\ns #\n"
},
{
"category": "Respiratory ",
"chartdate": "2140-05-06 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 565047,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Cuffed, Inner Cannula, Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 20 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Expectorated / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt cont trached on cool mist aerosol. Lung sounds ess clear\n after suct th tan sput. Pt in NARD on aerosol; mech vent not required\n overnoc. Cont cool mist aerosol/pulm toilet as required.\n"
},
{
"category": "Nursing",
"chartdate": "2140-05-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 564864,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Patient continues to localize with left arm only. Able to withdraw to\n nailbed pressure with lower extremities and right arm. Pupils are \n and briskly reactive to light. Patient does not follow any commands.\n Appears to be tracking at times.\n SBP < 140 most of shift. > 140 at times mostly with agitation.\n Action:\n continued with q 2 hour neuro exams.\n given IV fent and ativan for agitation.\n given hydral and Lopressor as needed for underlying hypertenstion.\n Response:\n neuro exam unchanged.\n Plan:\n continue to monitor. Step down?\n Hypertension, benign\n Assessment:\n Patient\ns BP is labile. Ranging from 100-160\ns at times. SBP > 140\n with agitation mostly.\n Action:\n given prn fent and ativan for agitation.\n given hydral and Lopressor as needed for underlying hyptertension.\n Dr. aware of labile BP.\n Response:\n SBP < 140 most of night.\n Plan:\n continue to monitor. Prn antihypertensives/ prn pain meds for\n aggiation.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient on trach mask at 35 % sating 99-100% RR 30\ns- 40\ns at start of\n shift. Patient appeared comfortable until about midnight patient was\n breathing faster- RR 40\ns, with thick white secretions, patient able to\n expectorate own secretions but inadequately at times. Patient appeared\n to be\ntiring out\n on trach mask.\n Action:\n Patient deep suctioned x 3 for moderate amount of thick white\n secretions.\n Patient put back on CPAP 5/5 fi02 40% during night to rest.\n Response:\n Patient appeared more comfortable RR 20\ns-30\ns sating 99-100%.\n Plan:\n put back on trach mask in am- blood gas. Continue to monitor, suction\n as needed.\n"
},
{
"category": "Physician ",
"chartdate": "2140-05-05 00:00:00.000",
"description": "Intensivist Note",
"row_id": 564926,
"text": "SICU\n HPI:\n Date HD 8 POD3 crani for evacuation\n .\n Abx: none\n .\n AC: SQH\n .\n CC: .\n HPI: 53M with known EtOH abuse found in home down by social worker on\n , taken to OSH where patient was combative though moving all 4\n extremities. Patient was intubated and found to have large IPH, was\n subsequently transferred to , with initial labs: plt 40, ethanol\n 71, lactate 3.3, glucose 217.\n .\n PMH: EtOH abuse, seizure disorder (epilepsy), schizophrenia\n .\n PSH: unknown\n .\n Meds: Acetaminophen, Bisacodyl, Calcium Gluconate, CeftazIDIME,\n Chlorhexidine Gluconate 0.12% Oral Rinse, Docusate Sodium (Liquid),\n Fentanyl Citrate, FoLIC Acid, Heparin, HydrALAzine, Insulin, Influenza\n Virus Vaccine, LeVETiracetam, Lorazepam, Magnesium Sulfate, Metoprolol\n Tartrate, Multivitamins W/minerals, Ondansetron, Phenytoin\n (Suspension), Potassium Phosphate, Ranitidine, Senna, Thiamine,\n Vancomycin\n .\n : unknown, per mother noncompliant with prescribed medications.\n ALLERGIES: NKDA\n .\n 24 HOUR EVENTS:\n : platelet transfusion\n : Spiked 102--> Pancx, sputum w/ 25+ PMN w/ GPR, started on Vanc\n and ceftaz. MRI c-spine cleared, collar d/c'ed.\n : passing loose BM, digital exam- no obstruction, distended abdomen\n on exam, frequent flatus. Mental status improved with more frequent\n spontaneous awakening, +cough +gag, remains on CPAP, though not\n following commands\n : repeat CT showed increased midline shift, went to OR for\n evacuation of LEFT IPH. Right IJ placed by anesthesia staff intraop.\n : febrile to 103.8, pancultured, Abx stopped, trach at bedside, no\n PEG dilated bowel, repeat CT shows improved herniation and no new\n hemorrhage\n : tolerated trach mask through the day, brief period of ventilation\n over night for tachypnea\n .\n MICRO:\n Sputum: flora\n bcx: PND\n ucx: No growth\n ucx: NG\n bcx: PND\n .\n Imaging/Diagnostics:\n CXR: Endotracheal tube 7.5 cm from the carina\n CTH: Large left parietotemporal intraparenchymal hemorrhage with\n associated mass effect including 5 mm rightward shift of the normally\n midline structures and subfalcine herniation; intraparenchymal\n hemorrhage in the right inferior frontal lobe; Scattered areas of\n subarachnoid hemorrhage bilaterally; Maxillary and ethmoidal sinus\n disease.\n CT CAP: pending\n CTA head: No aneurysm or sign of vascular malformation. Complete R\n ICA occlusion. Intracranial vessels largely reconstituted via\n collaterals\n MRI c-spine (wet): degenerative changes worst at c5/6,\n moderate-severe cervical spinal stenosis, ?soft tissue or LF injury @\n C5-7 w/ mild edema\n CT T/L spine (wet): no t-spine injury, marked fatty infiltration\n of liver.\n CXR: mild atelectasis\n CTH: Unchanged size of left parietotemporal intraparenchymal\n hemorrhage, slightly increased rightward subfalcine herniation,\n unchanged size of right frontal intraparenchymal hematoma\n CXR: Left basal opacity is unchanged and might be consistent with\n aspiration/pneumonia\n CXR: no new airspace disease, NGT in stomach\n CT head: Improvement in subfalcine and uncal herniation s/p\n intraparenchymal hemorrhage evacuation. No areas of new hemorrhage.\n 24 Hour Events:\n FEVER - 102.0\nF - 04:00 AM\n Back on CPAP for 4 hr at night.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:11 AM\n Ceftazidime - 04:00 AM\n Cefazolin - 05:00 PM\n Infusions:\n Other ICU medications:\n Metoprolol - 12:24 PM\n Dilantin - 10:00 PM\n Lorazepam (Ativan) - 12:07 AM\n Hydralazine - 12:30 AM\n Fentanyl - 04:42 AM\n Other medications:\n Flowsheet Data as of 06:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.9\nC (102\n T current: 38.9\nC (102\n HR: 84 (66 - 97) bpm\n BP: 98/58(71) {98/58(71) - 162/75(101)} mmHg\n RR: 24 (20 - 35) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 73.4 kg (admission): 70 kg\n Total In:\n 2,807 mL\n 969 mL\n PO:\n Tube feeding:\n 111 mL\n 200 mL\n IV Fluid:\n 2,396 mL\n 649 mL\n Blood products:\n Total out:\n 1,965 mL\n 560 mL\n Urine:\n 1,965 mL\n 560 mL\n NG:\n Stool:\n Drains:\n Balance:\n 842 mL\n 411 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 412 (383 - 449) mL\n PS : 5 cmH2O\n RR (Spontaneous): 27\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 63\n PIP: 11 cmH2O\n SPO2: 99%\n ABG: ///26/\n Ve: 11.7 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Abdominal: Soft, Non-tender\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Neurologic: (Awake / Alert / Oriented: x 1), Moves all extremities\n Labs / Radiology\n 236 K/uL\n 9.5 g/dL\n 118 mg/dL\n 0.4 mg/dL\n 26 mEq/L\n 3.7 mEq/L\n 12 mg/dL\n 101 mEq/L\n 133 mEq/L\n 27.1 %\n 7.2 K/uL\n [image002.jpg]\n 02:12 AM\n 02:20 AM\n 10:00 AM\n 05:00 PM\n 12:27 AM\n 02:57 AM\n 08:30 PM\n 03:08 AM\n 03:21 AM\n 02:14 AM\n WBC\n 6.5\n 5.0\n 6.7\n 7.2\n Hct\n 29.0\n 27.1\n 27.4\n 27.1\n Plt\n 86\n 140\n 186\n 236\n Creatinine\n 0.5\n 0.6\n 0.5\n 0.4\n TCO2\n 30\n 31\n 25\n 25\n Glucose\n 118\n 152\n 142\n 94\n 93\n 118\n Other labs: PT / PTT / INR:12.6/31.3/1.1, CK / CK-MB / Troponin\n T:247//, ALT / AST:53/32, Alk-Phos / T bili:68/0.4, Fibrinogen:487\n mg/dL, Albumin:3.2 g/dL, LDH:329 IU/L, Ca:8.3 mg/dL, Mg:2.1 mg/dL,\n PO4:2.1 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), FEVER (HYPERTHERMIA,\n PYREXIA, NOT FEVER OF UNKNOWN ORIGIN), HYPERTENSION, BENIGN,\n INTRACEREBRAL HEMORRHAGE (ICH), SEIZURE, WITHOUT STATUS EPILEPTICUS,\n .H/O SEIZURE, WITHOUT STATUS EPILEPTICUS, ALCOHOL WITHDRAWAL (INCLUDING\n DELIRIUM TREMENS, DTS, SEIZURES)\n Assessment and Plan: ASSESSMENT/PLAN: 53M with L large IPH with R\n frontal contracoup IPH\n Neuro: IPH, q1h neuro checks, sz ppx: dilantin tid, keppra ,\n minimize sedating medicines, decrease Ativan (HD6) to 0.5-1 Q8H prn iv\n due to history of heavy EtOH use.\n CV: goal SBP < 160; lopressor increased + prn hydralazine\n Pulm: trach mask\n GI: tube feeds to goal Consider adding protein to Nutren renal\n FEN: Vit supplement\n Renal: creatinine stable\n Heme: stable anemia\n Endo: tight glucose control RISS\n ID: off antibiotics, continues to spike, f/u cultures\n T/L/D: trach, R A-line, PIV, RIJ TLC\n Wounds: craniotomy OK\n Imaging: none\n Fluids: D5NS + 20KCL @ 80/hr (changed from NS+20KCL). D/C IV fluids\n Prophylaxis: H2B, Boots, SQH\n Consults: neurosurgery\n Disposition: SICU, consider floor if tolerating trach mask\n Code: full\n PCP: : tel fax \n Billing Diagnosis:\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 05:50 AM 40 mL/hour\n Lines:\n Arterial Line - 04:00 PM\n Multi Lumen - 09:15 PM\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2140-05-05 00:00:00.000",
"description": "Intensivist Note",
"row_id": 564927,
"text": "SICU\n HPI:\n Date HD 8 POD3 crani for evacuation\n .\n Abx: none\n .\n AC: SQH\n .\n CC: .\n HPI: 53M with known EtOH abuse found in home down by social worker on\n , taken to OSH where patient was combative though moving all 4\n extremities. Patient was intubated and found to have large IPH, was\n subsequently transferred to , with initial labs: plt 40, ethanol\n 71, lactate 3.3, glucose 217.\n .\n PMH: EtOH abuse, seizure disorder (epilepsy), schizophrenia\n .\n PSH: unknown\n .\n Meds: Acetaminophen, Bisacodyl, Calcium Gluconate, CeftazIDIME,\n Chlorhexidine Gluconate 0.12% Oral Rinse, Docusate Sodium (Liquid),\n Fentanyl Citrate, FoLIC Acid, Heparin, HydrALAzine, Insulin, Influenza\n Virus Vaccine, LeVETiracetam, Lorazepam, Magnesium Sulfate, Metoprolol\n Tartrate, Multivitamins W/minerals, Ondansetron, Phenytoin\n (Suspension), Potassium Phosphate, Ranitidine, Senna, Thiamine,\n Vancomycin\n .\n : unknown, per mother noncompliant with prescribed medications.\n ALLERGIES: NKDA\n .\n 24 HOUR EVENTS:\n : platelet transfusion\n : Spiked 102--> Pancx, sputum w/ 25+ PMN w/ GPR, started on Vanc\n and ceftaz. MRI c-spine cleared, collar d/c'ed.\n : passing loose BM, digital exam- no obstruction, distended abdomen\n on exam, frequent flatus. Mental status improved with more frequent\n spontaneous awakening, +cough +gag, remains on CPAP, though not\n following commands\n : repeat CT showed increased midline shift, went to OR for\n evacuation of LEFT IPH. Right IJ placed by anesthesia staff intraop.\n : febrile to 103.8, pancultured, Abx stopped, trach at bedside, no\n PEG dilated bowel, repeat CT shows improved herniation and no new\n hemorrhage\n : tolerated trach mask through the day, brief period of ventilation\n over night for tachypnea\n .\n MICRO:\n Sputum: flora\n bcx: PND\n ucx: No growth\n ucx: NG\n bcx: PND\n .\n Imaging/Diagnostics:\n CXR: Endotracheal tube 7.5 cm from the carina\n CTH: Large left parietotemporal intraparenchymal hemorrhage with\n associated mass effect including 5 mm rightward shift of the normally\n midline structures and subfalcine herniation; intraparenchymal\n hemorrhage in the right inferior frontal lobe; Scattered areas of\n subarachnoid hemorrhage bilaterally; Maxillary and ethmoidal sinus\n disease.\n CT CAP: pending\n CTA head: No aneurysm or sign of vascular malformation. Complete R\n ICA occlusion. Intracranial vessels largely reconstituted via\n collaterals\n MRI c-spine (wet): degenerative changes worst at c5/6,\n moderate-severe cervical spinal stenosis, ?soft tissue or LF injury @\n C5-7 w/ mild edema\n CT T/L spine (wet): no t-spine injury, marked fatty infiltration\n of liver.\n CXR: mild atelectasis\n CTH: Unchanged size of left parietotemporal intraparenchymal\n hemorrhage, slightly increased rightward subfalcine herniation,\n unchanged size of right frontal intraparenchymal hematoma\n CXR: Left basal opacity is unchanged and might be consistent with\n aspiration/pneumonia\n CXR: no new airspace disease, NGT in stomach\n CT head: Improvement in subfalcine and uncal herniation s/p\n intraparenchymal hemorrhage evacuation. No areas of new hemorrhage.\n 24 Hour Events:\n FEVER - 102.0\nF - 04:00 AM\n Back on CPAP for 4 hr at night.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:11 AM\n Ceftazidime - 04:00 AM\n Cefazolin - 05:00 PM\n Infusions:\n Other ICU medications:\n Metoprolol - 12:24 PM\n Dilantin - 10:00 PM\n Lorazepam (Ativan) - 12:07 AM\n Hydralazine - 12:30 AM\n Fentanyl - 04:42 AM\n Other medications:\n Flowsheet Data as of 06:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.9\nC (102\n T current: 38.9\nC (102\n HR: 84 (66 - 97) bpm\n BP: 98/58(71) {98/58(71) - 162/75(101)} mmHg\n RR: 24 (20 - 35) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 73.4 kg (admission): 70 kg\n Total In:\n 2,807 mL\n 969 mL\n PO:\n Tube feeding:\n 111 mL\n 200 mL\n IV Fluid:\n 2,396 mL\n 649 mL\n Blood products:\n Total out:\n 1,965 mL\n 560 mL\n Urine:\n 1,965 mL\n 560 mL\n NG:\n Stool:\n Drains:\n Balance:\n 842 mL\n 411 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 412 (383 - 449) mL\n PS : 5 cmH2O\n RR (Spontaneous): 27\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 63\n PIP: 11 cmH2O\n SPO2: 99%\n ABG: ///26/\n Ve: 11.7 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Abdominal: Soft, Non-tender\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Neurologic: (Awake / Alert / Oriented: x 1), Moves all extremities\n Labs / Radiology\n 236 K/uL\n 9.5 g/dL\n 118 mg/dL\n 0.4 mg/dL\n 26 mEq/L\n 3.7 mEq/L\n 12 mg/dL\n 101 mEq/L\n 133 mEq/L\n 27.1 %\n 7.2 K/uL\n [image002.jpg]\n 02:12 AM\n 02:20 AM\n 10:00 AM\n 05:00 PM\n 12:27 AM\n 02:57 AM\n 08:30 PM\n 03:08 AM\n 03:21 AM\n 02:14 AM\n WBC\n 6.5\n 5.0\n 6.7\n 7.2\n Hct\n 29.0\n 27.1\n 27.4\n 27.1\n Plt\n 86\n 140\n 186\n 236\n Creatinine\n 0.5\n 0.6\n 0.5\n 0.4\n TCO2\n 30\n 31\n 25\n 25\n Glucose\n 118\n 152\n 142\n 94\n 93\n 118\n Other labs: PT / PTT / INR:12.6/31.3/1.1, CK / CK-MB / Troponin\n T:247//, ALT / AST:53/32, Alk-Phos / T bili:68/0.4, Fibrinogen:487\n mg/dL, Albumin:3.2 g/dL, LDH:329 IU/L, Ca:8.3 mg/dL, Mg:2.1 mg/dL,\n PO4:2.1 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), FEVER (HYPERTHERMIA,\n PYREXIA, NOT FEVER OF UNKNOWN ORIGIN), HYPERTENSION, BENIGN,\n INTRACEREBRAL HEMORRHAGE (ICH), SEIZURE, WITHOUT STATUS EPILEPTICUS,\n .H/O SEIZURE, WITHOUT STATUS EPILEPTICUS, ALCOHOL WITHDRAWAL (INCLUDING\n DELIRIUM TREMENS, DTS, SEIZURES)\n Assessment and Plan: ASSESSMENT/PLAN: 53M with L large IPH with R\n frontal contracoup IPH\n Neuro: IPH, q1h neuro checks, sz ppx: dilantin tid, keppra ,\n minimize sedating medicines, decrease Ativan (HD6) to 0.5-1 Q8H prn iv\n due to history of heavy EtOH use.\n CV: goal SBP < 160; lopressor increased + prn hydralazine\n Pulm: trach mask\n GI: tube feeds to goal Consider adding protein to Nutren renal\n FEN: Vit supplement\n Renal: creatinine stable\n Heme: stable anemia\n Endo: tight glucose control RISS\n ID: off antibiotics, continues to spike, f/u cultures\n T/L/D: trach, R A-line, PIV, RIJ TLC\n Wounds: craniotomy OK\n Imaging: none\n Fluids: D5NS + 20KCL @ 80/hr (changed from NS+20KCL). D/C IV fluids\n Prophylaxis: H2B, Boots, SQH\n Consults: neurosurgery\n Disposition: SICU, consider floor if tolerating trach mask\n Code: full\n PCP: : tel fax \n Billing Diagnosis:\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 05:50 AM 40 mL/hour\n Lines:\n Arterial Line - 04:00 PM\n Multi Lumen - 09:15 PM\n Total time spent:\n ------ Protected Section ------\n Time spent- 31 min\n ------ Protected Section Addendum Entered By: , MD\n on: 08:25 ------\n"
},
{
"category": "Nursing",
"chartdate": "2140-05-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 565097,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt is on Trach mask since yesterday morning, tolerated well, large am\n of secretion, good cough\n Action:\n Suction prn, pt is able to cough out sputum, needs suction from trach\n prn.nebs per order\n Response:\n O2 sat 99 -100%.secretion is loose, good cough.\n Plan:\n Cont monitoring, pulm hygiene, support to pt.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Patient s/p evacuation hemetoma.\n Action:\n Neuro checks q2h, SBP <140, hydralazine x1 for SBP >140.\n Response:\n Unchanged neuro status, SBP maintained <140.\n Plan:\n Neuro checks q2h, for Ct head this morning.\n"
},
{
"category": "Physician ",
"chartdate": "2140-05-06 00:00:00.000",
"description": "Intensivist Note",
"row_id": 565104,
"text": "SICU\n HPI:\n 53M with known EtOH abuse found in home down by social worker on ,\n taken to OSH where patient was combative though moving all 4\n extremities. Patient was intubated and found to have large IPH, was\n subsequently transferred to , with initial labs: plt 40, ethanol\n 71, lactate 3.3, glucose 217.\n Chief complaint:\n PMHx:\n PMH: EtOH abuse, seizure disorder (epilepsy), schizophrenia\n .\n PSH: unknown\n Current medications:\n Acetaminophen, Bisacodyl, Calcium Gluconate, CeftazIDIME, Docusate\n Sodium (Liquid), Fentanyl Citrate, FoLIC Acid, Heparin, HydrALAzine,\n Insulin, LeVETiracetam, Lorazepam, Magnesium Sulfate, Metoprolol\n Tartrate, Multivitamins W/minerals, Ondansetron, Phenytoin\n (Suspension), Potassium Phosphate, Ranitidine, Senna, Thiamine,\n Vancomycin\n 24 Hour Events:\n : Tolerated TCM x 24 hrs. TF restarted on nutren 2.0 - rechecked\n with nutrition, protein intake deemed adequate. Febrile x 1 to 101.5F\n - no repeat cultures done. Pending cultures are all no growth to date.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 05:00 PM\n Infusions:\n Other ICU medications:\n Metoprolol - 01:14 PM\n Heparin Sodium (Prophylaxis) - 02:00 PM\n Other medications:\n Flowsheet Data as of 05:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.8\nC (101.8\n T current: 37.7\nC (99.8\n HR: 80 (72 - 107) bpm\n BP: 107/68(88) {107/52(75) - 164/99(112)} mmHg\n RR: 26 (18 - 33) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 73.4 kg (admission): 70 kg\n Total In:\n 2,521 mL\n 237 mL\n PO:\n Tube feeding:\n 726 mL\n 140 mL\n IV Fluid:\n 1,375 mL\n 97 mL\n Blood products:\n Total out:\n 1,870 mL\n 420 mL\n Urine:\n 1,870 mL\n 420 mL\n NG:\n Stool:\n Drains:\n Balance:\n 651 mL\n -183 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool, Trach mask\n SPO2: 100%\n ABG: ///26/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : , Rhonchorous : )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Responds to: Verbal stimuli, Tactile stimuli, Noxious\n stimuli), Moves all extremities\n Labs / Radiology\n 336 K/uL\n 9.1 g/dL\n 118 mg/dL\n 0.4 mg/dL\n 26 mEq/L\n 3.6 mEq/L\n 12 mg/dL\n 97 mEq/L\n 129 mEq/L\n 26.3 %\n 7.9 K/uL\n [image002.jpg]\n 02:20 AM\n 10:00 AM\n 05:00 PM\n 12:27 AM\n 02:57 AM\n 08:30 PM\n 03:08 AM\n 03:21 AM\n 02:14 AM\n 03:10 AM\n WBC\n 5.0\n 6.7\n 7.2\n 7.9\n Hct\n 27.1\n 27.4\n 27.1\n 26.3\n Plt\n 140\n 186\n 236\n 336\n Creatinine\n 0.6\n 0.5\n 0.4\n 0.4\n TCO2\n 30\n 31\n 25\n 25\n Glucose\n 152\n 142\n 94\n 93\n 118\n 118\n Other labs: PT / PTT / INR:12.1/32.6/1.0, CK / CK-MB / Troponin\n T:247//, ALT / AST:53/32, Alk-Phos / T bili:68/0.4, Fibrinogen:487\n mg/dL, Albumin:3.2 g/dL, LDH:329 IU/L, Ca:8.2 mg/dL, Mg:2.0 mg/dL,\n PO4:2.1 mg/dL\n Microbiology: MRSA screen neg\n Sputum: flora\n bcx: PND\n ucx: No growth\n ucx: No growth\n bcx: PND\n : MRSA neg\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), FEVER (HYPERTHERMIA,\n PYREXIA, NOT FEVER OF UNKNOWN ORIGIN), HYPERTENSION, BENIGN,\n INTRACEREBRAL HEMORRHAGE (ICH), SEIZURE, WITHOUT STATUS EPILEPTICUS,\n .H/O SEIZURE, WITHOUT STATUS EPILEPTICUS, ALCOHOL WITHDRAWAL (INCLUDING\n DELIRIUM TREMENS, DTS, SEIZURES)\n Assessment and Plan: 53M with L large IPH with R frontal contracoup IPH\n Neurologic: Neuro checks Q: 2 hr, # IPH\n q2h neuro checks, sz ppx:\n keppra , minimize sedating medicines, D/C ativan. Review repeat\n head CT .\n Cardiovascular: goal SBP < 160; lopressor increased + prn hydralazine\n Pulmonary: respiratory failure s/p trach, on trach mask x 24 hrs w/o\n signs of fatigue although with copious secretions. Continue to\n monitor. RUE duplex to r/o DVT (RUE swelling)\n Gastrointestinal / Abdomen:, tube feeds at goal per NGT\n Nutrition: MVI, Nutren 2.0 TF at goal\n Renal: creatinine stable; hyponatremia most likely secondary to SIADH\n given CNS pathology, to further restrict free water.\n Hematology: stable anemia\n Endocrine: RISS\n Infectious Disease: Check cultures, WBC normal, off antibiotics.\n Continues to spike, suspect central fever, cultures NGTD, reculture\n q3-4 days if continue to be intermittently febrile. RUE duplex and c.\n dif for fever source. Consider d/c CVL.\n Lines / Tubes / Drains: G-tube, Trach, PIV, right a-line, NGT\n Consider placing PICC line when consistently afebrile.\n Wounds: Dry dressings\n Imaging: CT scan head today\n Fluids: KVO\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid), (Respiratory\n distress: Failure)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 04:00 PM\n Multi Lumen - 09:15 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition:Neuro step down\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2140-05-07 00:00:00.000",
"description": "Intensivist Note",
"row_id": 565223,
"text": "SICU\n HPI:\n 53M with known EtOH abuse found in home down by social worker on ,\n taken to OSH where patient was combative though moving all 4\n extremities. Patient was intubated and found to have large IPH, was\n subsequently transferred to , with initial labs: plt 40, ethanol\n 71, lactate 3.3, glucose 217\n Chief complaint:\n L large subacute IPH with R frontal contracoup IPH\n PMHx:\n EtOH abuse, seizure disorder (epilepsy), schizophrenia\n Current medications:\n Acetaminophen (Liquid), Albuterol, Bisacodyl, Calcium Gluconate,\n Docusate Sodium (Liquid), Erythromycin 0.5% Ophth Oint, Fentanyl\n Citrate, Heparin, HydrALAzine, Insulin, Influenza Virus, LeVETiracetam,\n Lorazepam, Magnesium Sulfate, Metoprolol Tartrate, Metoprolol Tartrate,\n Multivitamins W/minerals, Ondansetron, Potassium Phosphate, Potassium\n Chloride, Ranitidine, Senna, Sodium Chloride, Sodium Phosphate\n 24 Hour Events:\n FEVER - 102.2\nF - 10:00 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 02:07 PM\n Lorazepam (Ativan) - 08:14 PM\n Metoprolol - 10:10 PM\n Hydralazine - 11:14 PM\n Fentanyl - 04:49 AM\n Other medications:\n Flowsheet Data as of 06:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 39\nC (102.2\n T current: 38.1\nC (100.6\n HR: 110 (69 - 110) bpm\n BP: 150/68(93) {110/54(70) - 167/115(118)} mmHg\n RR: 25 (21 - 38) insp/min\n SPO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 73.4 kg (admission): 70 kg\n Total In:\n 1,736 mL\n 624 mL\n PO:\n Tube feeding:\n 962 mL\n 251 mL\n IV Fluid:\n 670 mL\n 313 mL\n Blood products:\n Total out:\n 1,750 mL\n 455 mL\n Urine:\n 1,750 mL\n 455 mL\n NG:\n Stool:\n Drains:\n Balance:\n -14 mL\n 169 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool, Trach mask\n Ventilator mode: Standby\n FiO2: 35%\n SPO2: 99%\n ABG: 7.50/29/196/24/0\n PaO2 / FiO2: 560\n Physical Examination\n General Appearance: No acute distress, Well nourished\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : ), (Sternum: Stable ), tachypnic\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: spontaneous movement of LLE, LUE, occasional RLE movement\n Labs / Radiology\n 432 K/uL\n 8.8 g/dL\n 138 mg/dL\n 0.5 mg/dL\n 24 mEq/L\n 3.7 mEq/L\n 15 mg/dL\n 97 mEq/L\n 128 mEq/L\n 25.6 %\n 8.3 K/uL\n [image002.jpg]\n 12:27 AM\n 02:57 AM\n 08:30 PM\n 03:08 AM\n 03:21 AM\n 02:14 AM\n 03:10 AM\n 04:16 PM\n 07:54 PM\n 03:44 AM\n WBC\n 5.0\n 6.7\n 7.2\n 7.9\n 8.3\n Hct\n 27.1\n 27.4\n 27.1\n 26.3\n 25.6\n Plt\n 140\n 186\n 236\n 336\n 432\n Creatinine\n 0.6\n 0.5\n 0.4\n 0.4\n 0.4\n 0.5\n TCO2\n 31\n 25\n 25\n 23\n Glucose\n 94\n 93\n 118\n 118\n 121\n 138\n Other labs: PT / PTT / INR:12.1/32.6/1.0, CK / CK-MB / Troponin\n T:247//, ALT / AST:53/32, Alk-Phos / T bili:68/0.4, Fibrinogen:487\n mg/dL, Lactic Acid:0.5 mmol/L, Albumin:3.2 g/dL, LDH:329 IU/L, Ca:8.2\n mg/dL, Mg:2.3 mg/dL, PO4:3.6 mg/dL\n Imaging: CT T/L spine (wet): no t-spine injury, marked fatty\n infiltration of liver.\n CXR: mild atelectasis\n CTH: Unchanged size of left parietotemporal intraparenchymal\n hemorrhage, slightly increased rightward subfalcine herniation,\n unchanged size of right frontal intraparenchymal hematoma\n CXR: Left basal opacity is unchanged and might be consistent with\n aspiration/pneumonia\n CXR: no new airspace disease, NGT in stomach\n CT head: Improvement in subfalcine and uncal herniation s/p\n intraparenchymal hemorrhage evacuation. No areas of new hemorrhage.\n CTH: continued evolution of parenchymal hemorrhage and edema,\n Stable appearance of subfalcine herniation and left uncal herniation,\n Evolution of right inferior frontal lobe intraparenchymal hemorrhage\n RUE: pending\n CXR: no acute process\n Microbiology: MRSA screen neg\n Sputum: flora\n bcx: PND\n ucx: No growth\n ucx: No growth\n bcx: PND\n : MRSA neg\n stool/cdiff: pending\n BCx: pending\n UCx: pending\n sputum: o/p contamination\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), FEVER (HYPERTHERMIA,\n PYREXIA, NOT FEVER OF UNKNOWN ORIGIN), HYPERTENSION, BENIGN,\n INTRACEREBRAL HEMORRHAGE (ICH), SEIZURE, WITHOUT STATUS EPILEPTICUS,\n .H/O SEIZURE, WITHOUT STATUS EPILEPTICUS, ALCOHOL WITHDRAWAL (INCLUDING\n DELIRIUM TREMENS, DTS, SEIZURES)\n Assessment and Plan: 53M with L large IPH with R frontal contracoup IPH\n Neurologic: q2h neuro checks, sz ppx: keppra , minimize sedating\n medicines, ativan given 1mg x2 when patient was diaphoretic, unclear if\n this represented withdrawl or simple agitation, but some improvement\n noted\n Cardiovascular: goal SBP < 160; lopressor + prn hydralazine; in and out\n of bigeminy with electrolytes normal, keep K>4 and Mg>2\n Pulmonary: trach mask, tachypnic at times with respiratory alkalosis\n Gastrointestinal / Abdomen: tube feeds to goal via NGT\n Nutrition: MVI, Nutren 2.0 TF, minimize free water\n Renal: Cr stable; hyponatremia, keep fluid < 1L.\n Hematology: trending down slowly\n Endocrine: tight glucose control RISS\n Infectious Disease: WBC normal, off antibiotics, Last cultured ,\n cultures NGTD, reculture q48h if febrile, receiving scheduled tylenol,\n ibuprofen added with improved temperatures\n Lines / Tubes / Drains: trach, R A-line, RIJ TLC. To consider PICC when\n afebrile\n Wounds: craniotomy\n Imaging:\n Fluids: KVO,\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS)\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 01:30 AM 40 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 04:00 PM\n Multi Lumen - 09:15 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2140-05-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 565237,
"text": "TITLE:\n Intracerebral hemorrhage (ICH)\n Assessment:\n Pserl brisk , does not follow any commands, tracking. Minimal movement\n of rue/rle, withdraw to nailbed pressure on rt. Lt side lifts and hold\n w purposeful movement (attempts to pull at ngt) soft restraints in\n place. Remains on trach collar w adeq sats, coughing and raising\n copious amts thick pale yellow secretions. Tachypneic to rr 40\ns & htn\n sbp > 160\ns ? ativan withdrawal. Sdu transfer on hold overnight\n per HO\n Action:\n Hydralazine 40 iv x 2 and prn Lopressor in addition to sched dose for\n htn. Ativan 1mg iv x2 and fent 100mcg\n Response:\n Tachypnea and htn resolving w above interventions.\n Plan:\n Cont to monitor neuro q2h. C/O to neuro sdu if vss.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Tmax 102.2, w persistent elevation despite atc Tylenol. cultures\n pending from 1600\n Action:\n Ibuprofen 400mg per ngt given\n Response:\n Defervesced to 100.6 w ibuprofen.\n Plan:\n Check for culture results.continue atc Tylenol and prn ibuprofen as\n ordered prn.\n"
},
{
"category": "Physician ",
"chartdate": "2140-05-08 00:00:00.000",
"description": "Intensivist Note",
"row_id": 565375,
"text": "SICU\n HPI:\n 53M with known EtOH abuse found in home down by social worker on ,\n taken to OSH where patient was combative though moving all 4\n extremities. Patient was intubated and found to have large IPH, was\n subsequently transferred to , with initial labs: plt 40, ethanol\n 71, lactate 3.3, glucose 217.\n Chief complaint:\n L large subacute IPH with R frontal contracoup IPH\n PMHx:\n EtOH abuse, seizure disorder (epilepsy), schizophrenia\n Current medications:\n Acetaminophen (Liquid), Albuterol, Bisacodyl, Calcium Gluconate,\n Docusate Sodium (Liquid), Erythromycin 0.5% Ophth Oint, Fentanyl\n Citrate, Heparin, HydrALAzine, Insulin, Influenza Virus, LeVETiracetam,\n Lorazepam, Magnesium Sulfate, Metoprolol Tartrate, Metoprolol Tartrate,\n Multivitamins W/minerals, Ondansetron, Potassium Phosphate, Potassium\n Chloride, Ranitidine, Senna, Sodium Chloride, Sodium Phosphate\n 24 Hour Events:\n PAN CULTURE - At 12:00 AM\n FEVER - 101.7\nF - 12:00 AM\n Salt tabs started for hyponatremia, Keppra increased to 1500\", ?seizure\n activity in U/S with ?post-ictal state in ICU, CT head showed little\n change, given ativan x 2 overnight, pancultured for 101.7\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Metoprolol - 09:00 AM\n Hydralazine - 06:33 PM\n Heparin Sodium (Prophylaxis) - 10:20 PM\n Other medications:\n Flowsheet Data as of 06:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.7\nC (101.7\n T current: 37.8\nC (100.1\n HR: 90 (63 - 114) bpm\n BP: 143/68(94) {100/53(68) - 166/76(105)} mmHg\n RR: 30 (17 - 32) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 71.3 kg (admission): 70 kg\n Total In:\n 1,901 mL\n 533 mL\n PO:\n Tube feeding:\n 960 mL\n 275 mL\n IV Fluid:\n 550 mL\n 138 mL\n Blood products:\n Total out:\n 1,980 mL\n 535 mL\n Urine:\n 1,980 mL\n 535 mL\n NG:\n Stool:\n Drains:\n Balance:\n -79 mL\n -2 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool, Trach mask\n SPO2: 99%\n ABG: ///26/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Neurologic: Tracks with eyes, but does not follow commands\n Labs / Radiology\n 499 K/uL\n 9.1 g/dL\n 123 mg/dL\n 0.6 mg/dL\n 26 mEq/L\n 4.2 mEq/L\n 16 mg/dL\n 96 mEq/L\n 129 mEq/L\n 25.0 %\n 10.0 K/uL\n [image002.jpg]\n 02:57 AM\n 08:30 PM\n 03:08 AM\n 03:21 AM\n 02:14 AM\n 03:10 AM\n 04:16 PM\n 07:54 PM\n 03:44 AM\n 02:09 AM\n WBC\n 5.0\n 6.7\n 7.2\n 7.9\n 8.3\n 10.0\n Hct\n 27.1\n 27.4\n 27.1\n 26.3\n 25.6\n 25.0\n Plt\n 140\n 186\n 236\n \n Creatinine\n 0.6\n 0.5\n 0.4\n 0.4\n 0.4\n 0.5\n 0.6\n TCO2\n 25\n 25\n 23\n Glucose\n 94\n 93\n 118\n 118\n 121\n 138\n 123\n Other labs: PT / PTT / INR:12.1/32.6/1.0, CK / CK-MB / Troponin\n T:247//, ALT / AST:53/32, Alk-Phos / T bili:68/0.4, Fibrinogen:487\n mg/dL, Lactic Acid:0.5 mmol/L, Albumin:3.2 g/dL, LDH:329 IU/L, Ca:8.8\n mg/dL, Mg:2.2 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), FEVER (HYPERTHERMIA,\n PYREXIA, NOT FEVER OF UNKNOWN ORIGIN), HYPERTENSION, BENIGN,\n INTRACEREBRAL HEMORRHAGE (ICH), SEIZURE, WITHOUT STATUS EPILEPTICUS,\n .H/O SEIZURE, WITHOUT STATUS EPILEPTICUS, ALCOHOL WITHDRAWAL (INCLUDING\n DELIRIUM TREMENS, DTS, SEIZURES)\n Assessment and Plan: ASSESSMENT/PLAN: 53M with L large IPH with R\n frontal contracoup IPH\n Neuro: q2h neuro checks, sz ppx: keppra , patient became\n unresponsive after seizure-like activity, was given ativan x 2,\n returned to baseline of tracking, repeat head CT showed little change,\n EEG ordered\n CV: goal SBP < 160; lopressor + prn hydralazine\n Pulm: trach mask\n GI: tube feeds to goal via NGT\n FEN: MVI, Nutren 2.0 TF, minimize free water, hyponatremia improving,\n salt tabs 1g tid started\n Renal: Cr stable\n Heme: Hct 25\n Endo: tight glucose control RISS\n ID: WBC normal, off antibiotics, Last cultured , cultures NGTD,\n reculture q48h if febrile, receiving tylenol and ibuprofen\n T/L/D: trach, R A-line, PICC when afebrile\n Wounds: craniotomy\n Imaging: LE Duplex\n Fluids: KVO\n Prophylaxis: H2B, Boots, SQH\n Consults: neurosurgery \n Disposition: SICU\n Code: full\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 06:15 AM 40 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 04:00 PM\n Multi Lumen - 09:15 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: SICU\n Total time spent:\n"
},
{
"category": "Respiratory ",
"chartdate": "2140-04-29 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 564111,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 25 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Clear / Thin\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: remain on minimal PSV.\n taken for Head CT/ MRI & CT neck-> ?possible soft tissue/ muscle\n swelling.\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Maintain PEEP at current level and reduce FiO2 as tolerated; Comments:\n remain intubated for airway protection.\n ?extubation if Pt able to follow commands.\n Reason for continuing current ventilatory support: Sedated / Paralyzed\n"
},
{
"category": "Physician ",
"chartdate": "2140-04-30 00:00:00.000",
"description": "Intensivist Note",
"row_id": 564176,
"text": "SICU\n HPI:\n HPI: 53M known EtOH found in home down by social worker, taken to OSH\n where patient was combative moving all 4 extremities, patient was\n intubated and found to have, transfer to , plt 40, ethanol 71,\n lactate 3.3, glucose 217\n .\n PMH: EtOH abuse, seizure disorder (epilepsy), schizophrenia\n .\n PSH: unknown\n .\n Meds: Acetaminophen, Bisacodyl, Chlorhexidine Gluconate 0.12% Oral\n Rinse, Folic Acid/Multivitamin/Thiamine-1000mL NS, HydrALAzine,\n Insulin, Influenza Virus Vaccine, Lorazepam, Ondansetron, Pantoprazole,\n Phenytoin, Propofol, Thiamine\n .\n : unknown, per mother noncompliant with prescribed medications.\n ALLERGIES:\n .\n 24 HOUR EVENTS:\n platlet transfusion\n .\n MICRO:\n MRSA screen: pending\n .\n Imaging/Diagnostics:\n CXR: Endotracheal tube 7.5 cm from the carina\n CTH: Large left parietotemporal intraparenchymal hemorrhage with\n associated mass effect including 5 mm rightward shift of the normally\n midline structures and subfalcine herniation; intraparenchymal\n hemorrhage in the right inferior frontal lobe; Scattered areas of\n subarachnoid hemorrhage bilaterally; Maxillary and ethmoidal sinus\n disease.\n CT CAP: pending\n CTA head: No aneurysm or sign of vascular malformation. Complete R\n ICA occlusion. Intracranial vessels largely reconstituted via\n collaterals\n MRI c-spine (wet): degenerative changes worst at c5/6,\n moderate-severe cervical spinal stenosis, ?soft tissue or LF injury @\n C5-7 w/ mild edema\n CT T/L spine (wet): no t-spine injury, marked fatty infiltration\n of liver.\n Chief complaint:\n PMHx:\n Current medications:\n 24 Hour Events:\n MAGNETIC RESONANCE IMAGING - At 12:00 PM\n FEVER - 101.4\nF - 06:45 PM\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Hydralazine - 03:22 PM\n Metoprolol - 04:00 PM\n Lorazepam (Ativan) - 02:00 AM\n Fentanyl - 02:05 AM\n Other medications:\n Flowsheet Data as of 05:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.6\nC (101.4\n T current: 37.9\nC (100.3\n HR: 80 (67 - 100) bpm\n BP: 145/73(98) {108/62(83) - 169/87(111)} mmHg\n RR: 12 (12 - 21) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,573 mL\n 259 mL\n PO:\n Tube feeding:\n 131 mL\n 165 mL\n IV Fluid:\n 1,815 mL\n 3 mL\n Blood products:\n 287 mL\n Total out:\n 1,943 mL\n 520 mL\n Urine:\n 1,943 mL\n 520 mL\n NG:\n Stool:\n Drains:\n Balance:\n 630 mL\n -261 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 485 (433 - 550) mL\n PS : 5 cmH2O\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 44\n PIP: 11 cmH2O\n SPO2: 98%\n ABG: 7.52/33/162/30/4\n Ve: 8.8 L/min\n PaO2 / FiO2: 405\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Murmur: Systolic)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Trace), (Temperature: Warm)\n Right Extremities: (Edema: 1+), (Temperature: Warm)\n Neurologic: No(t) Follows simple commands, Moves all extremities, poor\n mental status\n Labs / Radiology\n 122 K/uL\n 10.8 g/dL\n 105 mg/dL\n 0.5 mg/dL\n 30 mEq/L\n 3.2 mEq/L\n 10 mg/dL\n 99 mEq/L\n 136 mEq/L\n 31.4 %\n 6.8 K/uL\n [image002.jpg]\n 05:27 PM\n 06:43 PM\n 08:17 PM\n 02:07 AM\n 02:24 AM\n 10:00 AM\n 03:57 PM\n 09:06 PM\n 01:40 AM\n 01:47 AM\n WBC\n 4.4\n 4.6\n 6.8\n Hct\n 30.4\n 30.2\n 31.4\n Plt\n 115\n 92\n 78\n 115\n 122\n Creatinine\n 0.6\n 0.7\n 0.5\n TCO2\n 33\n 30\n 32\n 28\n 28\n Glucose\n 94\n 101\n 93\n 105\n Other labs: PT / PTT / INR:12.2/31.0/1.0, CK / CK-MB / Troponin\n T:247//, ALT / AST:91/89, Alk-Phos / T bili:63/0.7, Fibrinogen:303\n mg/dL, Albumin:3.6 g/dL, LDH:329 IU/L, Ca:8.3 mg/dL, Mg:1.9 mg/dL,\n PO4:2.0 mg/dL\n Assessment and Plan\n HYPERTENSION, BENIGN, INTRACEREBRAL HEMORRHAGE (ICH), SEIZURE, WITHOUT\n STATUS EPILEPTICUS, .H/O SEIZURE, WITHOUT STATUS EPILEPTICUS, ALCOHOL\n WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES)\n Assessment and Plan:\n Neurologic: Neuro checks Q: 1 hr, q1h neuro checks, dilantin load + 100\n tid, acetaminophen for all fevers, wean off propofol to eval neur exam,\n Ativan 0.5-1 Q4H iv.\n Re-start home meds (serequal, etc.). MRI of C-spine without ligamentous\n injury, cleared by neurosurg?\n Cardiovascular: goal SBP < 160; prn hydralazine PRN, Lopressor standing\n and PRN\n Pulmonary: Cont ETT, (Ventilator mode: CPAP + PS), mental status\n necessitatiing intubation\n Gastrointestinal / Abdomen: OGT\n Nutrition: Tube feeding, fibersource\n Renal: Foley, Adequate UO, Monitor Cr\n Hematology: Monitor HCT, keep platelets > 100\n Endocrine: RISS\n Infectious Disease: monitor temp\n Lines / Tubes / Drains: Foley, OGT, ETT\n Wounds:\n Imaging:\n Fluids: D5NS, 80/hr\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS), (Respiratory distress: Failure)\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 03:00 PM 40 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 04:42 PM\n 20 Gauge - 08:58 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 563935,
"text": "Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Ciwa scale 4-8.\n Action:\n Monitor ciwa scale and treat accordingly\n Response:\n No change\n Plan:\n Will continue to monitor and treat accordingly.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Patient , not open eyes, does not obey commands. Moves left\n ue/le spontaneously. No movement noted to right ue, only gross upper\n movement to painful stimuli. Withdraws to stimuli right le.\n Action:\n Monitor neuro checks Q1. Stopped sedation to fully assess neuro status.\n Response:\n No change in neuro status.\n Plan:\n Will continue to monitor neuro checks Q1. No plan for intervention at\n this time.\n Seizure, without status epilepticus\n Assessment:\n No seizure activity noted overnight.\n Action:\n Monitor for seizure activity, iv dilantin given as ordered.\n Response:\n No change in status.\n Plan:\n Will continue to monitor and treat accordingly\n"
},
{
"category": "Nursing",
"chartdate": "2140-05-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 564372,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Pt slightly improving. Requiring less sedation to tolerate\n ETT. Neurologically continues to move left side purposefully but not on\n command. Minimal movement on right side sometimes postures with RUE,\n withdraws on RLE. Opening eyes more spontaneously but also not on\n command, very strong with Left side and localizes and goes for ETT with\n LUE\n Abd remains softly distended with hyperactive bowel sounds\n +BS\n Requires suctioning every couple hours for what is now thick\n yellow sputum, has a strong cough/gag but does not follow commands\n Afebrile today\n Action:\n Had discussion with family re: possible plan for Trach/Peg\n Neuro checks changed to Q2hrs\n SICU resident performed rectal exam\n Receiving vanco/ceftaz for +sputum culture\n Response:\n Pt\ns Brother who is HCP understands reason and procedure of\n trach/peg and agrees to consent when time is appropriate\n Lge BM this afternoon\n Plan:\n Discuss plan to trach/peg with Dr. tomorrow\n Pt\ns brother planning to bring Mom in on Tuesday to visit\n Neuro checks Q2hrs\n"
},
{
"category": "Nursing",
"chartdate": "2140-05-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 564528,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2140-05-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 564530,
"text": "SICU\n HPI:\n 53yo male with known EtOH abuse found in home down by social worker on\n , taken to OSH where patient was combative though moving all 4\n extremities. Patient was intubated and found to have large IPH, was\n subsequently transferred to , with initial labs: plt 40, ethanol\n 71, lactate 3.3, glucose 217.\n Chief complaint:\n PMHx:\n PMH: EtOH abuse, seizure disorder (epilepsy), schizophrenia\n .\n Intracerebral hemorrhage (ICH)\n Assessment:\n Patient continues to be intubated, on CPAP 5/5\n Poor gag, lots of secretions\n No abg ordered this shift.\n Neuro continues to have left sided neglect\n Right sided movement upper and lower purposefully\n Left arm sometimes extension/withdrawal\n Left arm tremors noted this pm\n Head ct done this am.\n Poor IV access\n Action:\n Trach/peg likely in future\n Ativan for tremors, resolved.\n Keppra added for seizure control\n NPO for possible OR this evening to evacuate small area\n Brother , he is willing to act as spokesperson-\n arranged meeting w/brother and\n \ns mother for tomorrow.\n Unable to place bedside PICC\n Response:\n Stable.\n Awaiting OR\n Plan:\n PICC in iR\n OR as scheduled\n Continue w/q 2 hrs neuro assessment\n Ativan as needed for seizures\n Call neurosurg/ICU team with any changes.\n"
},
{
"category": "Respiratory ",
"chartdate": "2140-05-03 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 564587,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 6\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 25 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Invasive ventilation assessment:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Periodic SBT's for conditioning; Comments: ? trach and peg\n Reason for continuing current ventilatory support:\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 563974,
"text": "Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Ciwa scale 4-8.\n Action:\n Monitor ciwa scale and treat accordingly\n Response:\n No change\n Plan:\n Will continue to monitor and treat accordingly.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Patient , not open eyes, does not obey commands. Moves left\n ue/le spontaneously. No movement noted to right ue, only gross upper\n movement to painful stimuli. Withdraws to stimuli right le.\n Action:\n Monitor neuro checks Q1. Stopped sedation to fully assess neuro status.\n Response:\n No change in neuro status.\n Plan:\n Will continue to monitor neuro checks Q1. No plan for intervention at\n this time.\n Seizure, without status epilepticus\n Assessment:\n No seizure activity noted overnight.\n Action:\n Monitor for seizure activity, iv dilantin given as ordered.\n Response:\n No change in status.\n Plan:\n Will continue to monitor and treat accordingly\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 564095,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Patient intubated and sedated on propofol this am. Off prop patient is\n able to open eyes to painful stimulus. Localizes with left arm, and\n moves left leg and right leg, no movement noted on right arm. Pupils\n are 3-2mm and brisk, equally reactive to light. Patient does not\n follow any commands. Patient continues to wear J collar and on\n logroll precautions. SBP 100-160, above 160 at times. Breathing tidal\n volumes on 400-500 on CPAP 5/5.\n Action:\n - CT of head\n - MRI and CT of spine to rule out any spinal fractures.\n - Continue with q 1 hour neuro checks.\n - Propofol shut off. Standing dose of ativan ordered.\n - Given hydralazine and lopressor prn to keep SBP < 160.\n - Given fentanyl prn for agitation as well.\n Response:\n -possible soft tissue/ muscle swelling of spine per radiology report.\n -off propofol patient is agitated at times, trying to sit up and\n reaching for ET tube with left hand.\n -continues on CPAP 5/5 sating 100%, tidal volumes of 400-500 rate of\n 15-22.\n Plan:\n Continue to monitor, keep immobilizers on, close supervision. No plan\n for OR, extubated if patient is able to follow commands ?\n Hypertension, benign\n Assessment:\n Patient hypertensive above goal of SBP < 160 a couple of times during\n shift.\n Action:\n Given hydralazine and lopressor prn.\n Agitation treated with ativan and fentanyl.\n Response:\n Patient\ns SBP kept within goal of 100-160 throughout day.\n Plan:\n Continue to monitor.\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 564088,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Patient intubated and sedated on propofol this am. Off prop patient is\n able to open eyes to painful stimulus. Localizes with left arm, and\n moves left leg and right leg, no movement noted on right arm. Pupils\n are 3-2mm and brisk, equally reactive to light. Patient does not\n follow any commands. Patient continues to wear J collar and on\n logroll precautions. SBP 100-160, above 160 at times. Breathing tidal\n volumes on 400-500 on CPAP 5/5.\n Action:\n - CT of head\n - MRI and CT of spine to rule out any spinal fractures.\n - Continue with q 1 hour neuro checks.\n - Propofol shut off. Standing dose of ativan ordered.\n - Given hydralazine and lopressor prn to keep SBP < 160.\n - Given fentanyl prn for agitation as well.\n Response:\n -possible soft tissue/ muscle swelling of spine per radiology report.\n -off propofol patient is agitated at times, trying to sit up and\n reaching for ET tube with left hand.\n -continues on CPAP 5/5 sating 100%, tidal volumes of 400-500 rate of\n 15-22.\n Plan:\n Continue to monitor, keep immobilizers on, close supervision. No plan\n for OR, extubated if patient is able to follow commands ?\n Hypertension, benign\n Assessment:\n Patient hypertensive above goal of SBP < 160 a couple of times during\n shift.\n Action:\n Given hydralazine and lopressor prn.\n Agitation treated with ativan and fentanyl.\n Response:\n Patient\ns SBP keep within goal of 100-160 throughout day.\n Plan:\n Continue to monitor.\n"
},
{
"category": "Respiratory ",
"chartdate": "2140-04-30 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 564163,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 25 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: RSBI 44, pt changed to ET tube holder (). no\n increased response over the past 12 hrs will ocntinue to be monitered,\n pt does have gag reflex and spontatneous cough as well as air leak\n around tube (noted when checking cuff pressure.\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Underlying illness not resolved\n"
},
{
"category": "Nutrition",
"chartdate": "2140-04-29 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 564079,
"text": "Subjective\n intubated\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 175 cm\n 70 kg\n 22.7\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 72.6\n 96%\n Diagnosis: ICH\n PMH :\n Food allergies and intolerances: NKFA\n Pertinent medications: NS with KCl (20 mEq), dilantin, thiamine,\n multivitamin with minerals, folic acid, others noted\n Labs:\n Value\n Date\n Glucose\n 93 mg/dL\n 10:00 AM\n Glucose Finger Stick\n 109\n 10:00 PM\n BUN\n 13 mg/dL\n 02:07 AM\n Creatinine\n 0.7 mg/dL\n 02:07 AM\n Sodium\n 137 mEq/L\n 02:07 AM\n Potassium\n 3.5 mEq/L\n 02:07 AM\n Chloride\n 99 mEq/L\n 02:07 AM\n TCO2\n 31 mEq/L\n 02:07 AM\n PO2 (arterial)\n 187 mm Hg\n 10:00 AM\n PCO2 (arterial)\n 34 mm Hg\n 10:00 AM\n pH (arterial)\n 7.51 units\n 10:00 AM\n CO2 (Calc) arterial\n 28 mEq/L\n 10:00 AM\n Albumin\n 3.6 g/dL\n 02:07 AM\n Calcium non-ionized\n 8.4 mg/dL\n 02:07 AM\n Phosphorus\n 2.7 mg/dL\n 02:07 AM\n Ionized Calcium\n 1.16 mmol/L\n 02:24 AM\n Magnesium\n 2.1 mg/dL\n 02:07 AM\n ALT\n 126 IU/L\n 02:07 AM\n Alkaline Phosphate\n 55 IU/L\n 02:07 AM\n AST\n 162 IU/L\n 02:07 AM\n Total Bilirubin\n 0.8 mg/dL\n 02:07 AM\n Phenytoin (Dilantin)\n 11.9 ug/mL\n 02:07 AM\n WBC\n 4.6 K/uL\n 02:07 AM\n Hgb\n 10.5 g/dL\n 02:07 AM\n Hematocrit\n 30.2 %\n 02:07 AM\n Current diet order / nutrition support: Tubefeeding: Start After\n 12:01AM; Replete with fiber Full strength;\n Starting rate: 10 ml/hr; Advance rate by 10 ml q4h Goal rate: 50 ml/hr\n Residual Check: q4h Hold feeding for residual >= : 100 ml\n Flush w/ 30 ml water q4h\n GI: soft, +bowel sounds\n Assessment of Nutritional Status\n At risk for malnutrition\n Pt at risk due to: NPO / hypocaloric diet\n Estimated Nutritional Needs\n Calories: 1750-2100 (BEE x or / 25-30 cal/kg)\n Protein: 70-84 (1-1.2 g/kg)\n Fluid: per team\n Estimation of previous intake: Adequate\n Estimation of current intake: Inadequate\n Specifics:\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: via TF\n At risk for refeeding syndrome (monitor K / PO4 / Magnesium and repeat\n as needed):\n Check chemistry 10 panel daily\n Start regular insulin sliding scale if serum glucose >150 mg/dL\n Comments:\n"
},
{
"category": "Nutrition",
"chartdate": "2140-04-29 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 564080,
"text": "Subjective\n intubated\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 175 cm\n 70 kg\n 22.7\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 72.6\n 96%\n Diagnosis: ICH\n PMH : EtOH abuse, siezure disorder, schizophrenia\n Food allergies and intolerances: NKFA\n Pertinent medications: NS with KCl (20 mEq), dilantin, thiamine,\n multivitamin with minerals, folic acid, others noted\n Labs:\n Value\n Date\n Glucose\n 93 mg/dL\n 10:00 AM\n Glucose Finger Stick\n 109\n 10:00 PM\n BUN\n 13 mg/dL\n 02:07 AM\n Creatinine\n 0.7 mg/dL\n 02:07 AM\n Sodium\n 137 mEq/L\n 02:07 AM\n Potassium\n 3.5 mEq/L\n 02:07 AM\n Chloride\n 99 mEq/L\n 02:07 AM\n TCO2\n 31 mEq/L\n 02:07 AM\n PO2 (arterial)\n 187 mm Hg\n 10:00 AM\n PCO2 (arterial)\n 34 mm Hg\n 10:00 AM\n pH (arterial)\n 7.51 units\n 10:00 AM\n CO2 (Calc) arterial\n 28 mEq/L\n 10:00 AM\n Albumin\n 3.6 g/dL\n 02:07 AM\n Calcium non-ionized\n 8.4 mg/dL\n 02:07 AM\n Phosphorus\n 2.7 mg/dL\n 02:07 AM\n Ionized Calcium\n 1.16 mmol/L\n 02:24 AM\n Magnesium\n 2.1 mg/dL\n 02:07 AM\n ALT\n 126 IU/L\n 02:07 AM\n Alkaline Phosphate\n 55 IU/L\n 02:07 AM\n AST\n 162 IU/L\n 02:07 AM\n Total Bilirubin\n 0.8 mg/dL\n 02:07 AM\n Phenytoin (Dilantin)\n 11.9 ug/mL\n 02:07 AM\n WBC\n 4.6 K/uL\n 02:07 AM\n Hgb\n 10.5 g/dL\n 02:07 AM\n Hematocrit\n 30.2 %\n 02:07 AM\n Current diet order / nutrition support: Tubefeeding: Start After\n 12:01AM; Replete with fiber Full strength;\n Starting rate: 10 ml/hr; Advance rate by 10 ml q4h Goal rate: 50 ml/hr\n Residual Check: q4h Hold feeding for residual >= : 100 ml\n Flush w/ 30 ml water q4h\n GI: soft, +bowel sounds\n Assessment of Nutritional Status\n At risk for malnutrition\n Pt at risk due to: NPO / hypocaloric diet, etoh abuse\n Estimated Nutritional Needs\n Calories: 1750-2100 (BEE x or / 25-30 cal/kg)\n Protein: 70-84 (1-1.2 g/kg)\n Fluid: per team\n Estimation of previous intake: likely adequate\n Estimation of current intake: Inadequate\n Specifics: 53 year old male found down and intoxicated brought to\n outside hospital intubated, head CT showed left temporal hemorrhage\n transferred to . TF ordered, current TF running at 10 ml/hr via\n OGT. TF order provides 1200 kcals/ 74 g pro which underfeeds pt.\n Recommend changing TF to Fibersource HN @ 60 ml/hr to provide 1728\n kcals/ 76 g pro.\n Medical Nutrition Therapy Plan - Recommend the Following\n Tubefeeding Recommendations:\n Change TF to Fibersource HN @ 20 ml/hr advance to goal of 60\n ml/hr (1728 kcals/ 76 g pro)\n Check residuals q 4-6 hours hold if >150cc\n Multivitamin / Mineral supplement: via TF\n At risk for refeeding syndrome (monitor K / PO4 / Magnesium and repeat\n as needed):\n Check chemistry 10 panel daily\n Start regular insulin sliding scale if serum glucose >150 mg/dL\n Will continue to follow page with questions\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 564145,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Patient , open eyes spontansously, does not obey commands.\n Moves left ue/le spontaneously. No movement noted to right ue, only\n gross upper movement to painful stimuli. Withdraws to stimuli right le.\n Action:\n Monitor neuro checks Q1..\n Response:\n No change in neuro status.\n Plan:\n Will continue to monitor neuro checks Q1. No plan for intervention at\n this time.\n Seizure, without status epilepticus\n Assessment:\n No seizure activity noted overnight.\n Action:\n Monitor for seizure activity, iv dilantin given as ordered.\n Response:\n No change in status.\n Plan:\n Will continue to monitor and treat accordingly\n Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n patient agitated at times, attempts to pull out ett, hr becomes\n elevated. Occasional tremors noted.\n Action:\n iv Ativan 0.5mgs given Q4 as ordered, iv fentanyl 25mcgs given prn as\n needed.\n Response:\n patient lightly sedated, appears comfortable, less agitated\n Plan:\n will continue to monitor and treat accordingly\n Hypertension, benign\n Assessment:\n Patient hypertensive above goal of SBP < 160 a couple of times during\n shift.\n Action:\n Given hydralazine and lopressor prn.\n Agitation treated with ativan and fentanyl.\n Response:\n Patient\ns SBP kept within goal of 100-160 throughout day.\n Plan:\n Continue to monitor.\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 564272,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Neuro exam unchanged. Right side moves on bed, Left side\n localizes but not on command. PERRLA, Does not follow any commands\n +gag/cough\n SBP elevated\n Bronchospastic after suctioning\n Abd softly distended with hyperactive bowel sounds\n Tmax 102\n Action:\n Hourly neuro checks\n Hydralazine given x1 with good effect\n Administered ativan .5mg Q4hrs when tachy/hypertensive given\n fent with good effect for comfort of ETT\n Dulcolax suppository administered\n TF at goal\n Kept intubated d/t poor neuro exam\n Brother in to visit and spoke with SICU team on rounds\n SICU team and NSURG team cleared C-spine based on\n yesterday\ns MRI results\n Pan cultured, CXR, Tylenol given\n Response:\n Neuro exam stable\n Comfortably sedated on fent/ativan\n Effect from suppository pending\n Plan:\n Repeat with PO biscacodyl if no effect from suppository\n Re-eval for extubation in am\n Lge loose BM\n"
},
{
"category": "Physician ",
"chartdate": "2140-05-01 00:00:00.000",
"description": "Intensivist Note",
"row_id": 564343,
"text": "SICU\n HPI:\n 53M known EtOH found in home down by social worker, taken to OSH where\n patient was combative moving all 4 extremities, patient was intubated\n and found to have, transfer to , plt 40, ethanol 71, lactate 3.3,\n glucose 217\n Chief complaint:\n L large subacute IPH with R frontal contracoup IPH\n PMHx:\n EtOH abuse, seizure disorder (epilepsy), schizophrenia\n Current medications:\n 1. 20 mEq Potassium Chloride / 1000 mL NS 2. Acetaminophen 3. Bisacodyl\n 4. Calcium Gluconate 5. CeftazIDIME\n 6. CeftazIDIME 7. Chlorhexidine Gluconate 0.12% Oral Rinse 8. Fentanyl\n Citrate 9. FoLIC Acid 10. HydrALAzine\n 11. Insulin 12. Influenza Virus Vaccine 13. Lorazepam 14. Magnesium\n Sulfate 15. Metoprolol Tartrate\n 16. Metoprolol Tartrate 17. Metoprolol Tartrate 18. Multivitamins\n W/minerals 19. Neutra-Phos 20. Neutra-Phos\n 21. Ondansetron 22. Phenytoin 23. Potassium Chloride 24. Potassium\n Chloride 25. Propofol 26. Ranitidine\n 27. Thiamine 28. Vancomycin\n 24 Hour Events:\n PAN CULTURE - At 05:15 PM\n FEVER - 102.0\nF - 04:00 PM\n : Spiked 102--> Pancx, started on Vanc and Ciftazid\n Allergies:\n Last dose of Antibiotics:\n Vancomycin - 09:02 PM\n Ceftazidime - 10:47 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 AM\n Hydralazine - 12:15 PM\n Fentanyl - 02:33 AM\n Lorazepam (Ativan) - 02:33 AM\n Other medications:\n Flowsheet Data as of 04:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.9\nC (102\n T current: 37.9\nC (100.3\n HR: 68 (68 - 121) bpm\n BP: 129/63(84) {110/63(84) - 176/91(119)} mmHg\n RR: 19 (14 - 27) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,859 mL\n 287 mL\n PO:\n Tube feeding:\n 1,104 mL\n 246 mL\n IV Fluid:\n 1,376 mL\n 41 mL\n Blood products:\n Total out:\n 1,825 mL\n 180 mL\n Urine:\n 1,825 mL\n 180 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,034 mL\n 107 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 550 (474 - 716) mL\n PS : 5 cmH2O\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 62\n PIP: 11 cmH2O\n SPO2: 100%\n ABG: ///30/\n Ve: 11.9 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: Crackles : Bilateral)\n Abdominal: Soft, Non-tender, Distended with some tympany. About the\n same as yesterday.\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: No(t) Moves all extremities, (RUE: Weakness), (RLE:\n Weakness), move left extrimities unporposfully, poor MS\n / Radiology\n 91 K/uL\n 10.5 g/dL\n 135 mg/dL\n 0.5 mg/dL\n 30 mEq/L\n 3.0 mEq/L\n 11 mg/dL\n 98 mEq/L\n 133 mEq/L\n 29.9 %\n 9.2 K/uL\n [image002.jpg]\n 08:17 PM\n 02:07 AM\n 02:24 AM\n 10:00 AM\n 03:57 PM\n 09:06 PM\n 01:40 AM\n 01:47 AM\n 04:26 PM\n 01:50 AM\n WBC\n 4.6\n 6.8\n 9.2\n Hct\n 30.2\n 31.4\n 29.9\n Plt\n 92\n 78\n 115\n 122\n 107\n 91\n Creatinine\n 0.7\n 0.5\n 0.5\n TCO2\n 30\n 32\n 28\n 28\n Glucose\n 101\n 93\n 105\n 135\n Other : PT / PTT / INR:11.5/27.6/1.0, CK / CK-MB / Troponin\n T:247//, ALT / AST:65/51, Alk-Phos / T bili:64/0.6, Fibrinogen:487\n mg/dL, Albumin:3.4 g/dL, LDH:329 IU/L, Ca:8.5 mg/dL, Mg:1.8 mg/dL,\n PO4:1.9 mg/dL\n Assessment and Plan\n HYPERTENSION, BENIGN, INTRACEREBRAL HEMORRHAGE (ICH), SEIZURE, WITHOUT\n STATUS EPILEPTICUS, .H/O SEIZURE, WITHOUT STATUS EPILEPTICUS, ALCOHOL\n WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES)\n Assessment and Plan: 53M with L large subacute IPH with R frontal\n contracoup IPH\n Neurologic: Neuro checks Q: 1 hr, q1h neuro checks, dilantin load + 100\n tid, acetaminophen for all fevers, wean off propofol to eval neur exam,\n Ativan 0.5-1 Q4H iv. Check Alb level\n Re-start home meds (serequal, etc.). Clear c-spine collar d/ced\n Cardiovascular: goal SBP < 160; prn hydralazine PRN, Lopressor standing\n and PRN. If consistentely high start Nicardapine ggts\n Pulmonary: intubated, sedated, currently CPAP. Consider trach\n Gastrointestinal / Abdomen: transaminitis improving, chronic EtOH, abd\n distended and patient high flatus most likely due to TF. Check for\n impaction\n Nutrition: Tube feeding, at goal , fibersource\n Renal: Foley, Adequate UO, Creat stable\n Hematology: Monitor Cr, Keep plat>100\n Endocrine: RISS, Goal BS<150\n Infectious Disease: Febrile 102,WBC 9.9. Pancx overnight sputum Gram\n stain G+R and 25>PMN we will fellow up Cx. Started on Vanco and Ceftaz\n Lines / Tubes / Drains: Foley, OGT, ETT. Consideration of trach / PEG\n Wounds: None\n Imaging:\n Fluids: KVO,\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid), (Respiratory\n distress: Failure)\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 08:00 PM 60 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 04:00 PM\n 18 Gauge - 04:42 PM\n 20 Gauge - 08:58 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Respiratory ",
"chartdate": "2140-05-02 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 564518,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 25 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Periodic SBT's for conditioning, Tracheostomy planned\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Intolerant of weaning attempts, Cannot protect airway, Cannot manage\n secretions, Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n CT\n 0900\n"
},
{
"category": "Nutrition",
"chartdate": "2140-05-02 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 564490,
"text": "Objective\n Current Wt: 71kg\n Pertinent medications: D5 1/2NS +KCl @ 60cc/hr, KPhos repletion, RISS,\n Abx, Thiamine, Ranitidine, Mvit with Minerals, folic acid, ativan,\n others noted\n Labs:\n Value\n Date\n Glucose\n 152\n 10:00 AM\n Glucose Finger Stick\n 163\n 04:00 PM\n BUN\n 10 mg/dL\n 02:12 AM\n Creatinine\n 0.5 mg/dL\n 02:12 AM\n Sodium\n 131 mEq/L\n 02:12 AM\n Potassium\n 3.1 mEq/L\n 02:12 AM\n Chloride\n 96 mEq/L\n 02:12 AM\n TCO2\n 29 mEq/L\n 02:12 AM\n PO2 (arterial)\n 241 mm Hg\n 02:20 AM\n PCO2 (arterial)\n 36 mm Hg\n 02:20 AM\n pH (arterial)\n 7.51 units\n 02:20 AM\n pH (urine)\n 8.0 units\n 05:01 PM\n CO2 (Calc) arterial\n 30 mEq/L\n 02:20 AM\n Albumin\n 3.5 g/dL\n 02:12 AM\n Calcium non-ionized\n 8.6 mg/dL\n 02:12 AM\n Phosphorus\n 2.0 mg/dL\n 02:12 AM\n Ionized Calcium\n 1.12 mmol/L\n 01:47 AM\n Magnesium\n 1.9 mg/dL\n 02:12 AM\n ALT\n 53 IU/L\n 02:12 AM\n Alkaline Phosphate\n 68 IU/L\n 02:12 AM\n AST\n 32 IU/L\n 02:12 AM\n Total Bilirubin\n 0.4 mg/dL\n 02:12 AM\n Phenytoin (Dilantin)\n 8.6 ug/mL\n 02:12 AM\n Current diet order / nutrition support: TF: Fibersource @ 60cc/hr\n (1728kcal, 76g protein)\n GI: Abd distended, + copious amt of flatus, + loose watery stool\n Assessment of Nutritional Status\n 53 y.o. M adm with L large subacute IPH with R frontal contracoup IPH.\n Pt remains intubated with poor neuro exam. Pt is receiving TF via OGT,\n which is meeting 100% of estimated needs, but is causing some GI\n problems (flatus, abd distension, watery stool). Would recommend trial\n of fiber-free TF formula, which may help with copious amts of flatus.\n This fiber-free formula is also more concentrated than current TF\n formula, thus may help corrent hyponatremia.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1) Rec change TF goal to Nutren 2.0 @ 40cc/hr (1920kcal, 77g\n protein).\n 2) Monitor tolerance with abd exam, stool output and residual\n checks q4hrs.\n 3) Monitor lytes and BG.\n Following, please page with any ?\ns #\n"
},
{
"category": "Nursing",
"chartdate": "2140-05-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 564573,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Patient returned from OR s/p left sided craniotomy. Patient woken up\n and able to open eyes, fairly alert most of night. Able to localize\n with left arm and moves lower extremities on bed. Withdraws/ flexes\n with right arm to nail bed pressure. Pupils are equal and briskly\n reactive to light. Patient agitated and restless frequently throughout\n night. SBP 100-140, occasionally > 140 when agitated.\n Action:\n q 1 hour neuro checks.\n turned and repositioned frequently for comfort.\n IV fent prn for agitation/pain, continue with standing dose of ativan.\n Response:\n Patient awake most of night.\n SBP kept 100-140.\n no change in neuro change.\n Plan:\n continue to monitor, q 1 hour neuro checks until am, trach and peg\n tomorrow? Discuss restarting tube feeds in am.\n"
},
{
"category": "Physician ",
"chartdate": "2140-05-02 00:00:00.000",
"description": "Intensivist Note",
"row_id": 564470,
"text": "SICU\n HPI:\n 53yo male with known EtOH abuse found in home down by social worker on\n , taken to OSH where patient was combative though moving all 4\n extremities. Patient was intubated and found to have large IPH, was\n subsequently transferred to , with initial labs: plt 40, ethanol\n 71, lactate 3.3, glucose 217.\n Chief complaint:\n PMHx:\n PMH: EtOH abuse, seizure disorder (epilepsy), schizophrenia\n .\n PSH: unknown\n Current medications:\n Acetaminophen, Bisacodyl, Chlorhexidine Gluconate 0.12% Oral Rinse,\n Folic Acid/Multivitamin/Thiamine-1000mL NS, HydrALAzine, Insulin,\n Influenza Virus Vaccine, Lorazepam, Ondansetron, Pantoprazole,\n Phenytoin, Propofol, Thiamine\n 24 Hour Events:\n : passing loose BM, digital exam- no obstruction, distended abdomen\n on exam, frequent flatus. Mental status improved with more frequent\n spontaneous awakening, +cough +gag, remains on CPAP, though not\n following commands.\n Allergies:\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Ceftazidime - 09:14 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 01:01 PM\n Fentanyl - 10:00 PM\n Dilantin - 10:00 PM\n Hydralazine - 11:00 PM\n Lorazepam (Ativan) - 05:45 AM\n Other medications:\n Flowsheet Data as of 06:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.1\nC (100.6\n T current: 37.7\nC (99.8\n HR: 82 (60 - 108) bpm\n BP: 132/65(87) {112/58(80) - 166/106(119)} mmHg\n RR: 23 (15 - 30) insp/min\n SPO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 2,487 mL\n 499 mL\n PO:\n Tube feeding:\n 1,437 mL\n 239 mL\n IV Fluid:\n 840 mL\n 260 mL\n Blood products:\n Total out:\n 1,780 mL\n 510 mL\n Urine:\n 1,780 mL\n 510 mL\n NG:\n Stool:\n Drains:\n Balance:\n 707 mL\n -11 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 530 (390 - 552) mL\n PS : 5 cmH2O\n RR (Spontaneous): 20\n PEEP: 5 cmH2O\n FiO2: 30%\n RSBI: 40\n PIP: 11 cmH2O\n SPO2: 97%\n ABG: 7.51/36/241/29/6\n Ve: 10.3 L/min\n PaO2 / FiO2: 803\n Physical Examination\n General Appearance: intubated\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : , Diminished: at bases)\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Neurologic: (Responds to: Tactile stimuli, Noxious stimuli), Moves all\n extremities no eye opening\n Labs / Radiology\n 86 K/uL\n 10.1 g/dL\n 118 mg/dL\n 0.5 mg/dL\n 29 mEq/L\n 3.1 mEq/L\n 10 mg/dL\n 96 mEq/L\n 131 mEq/L\n 29.0 %\n 6.5 K/uL\n [image002.jpg]\n 02:24 AM\n 10:00 AM\n 03:57 PM\n 09:06 PM\n 01:40 AM\n 01:47 AM\n 04:26 PM\n 01:50 AM\n 02:12 AM\n 02:20 AM\n WBC\n 6.8\n 9.2\n 6.5\n Hct\n 31.4\n 29.9\n 29.0\n Plt\n 78\n 115\n 122\n 107\n 91\n 86\n Creatinine\n 0.5\n 0.5\n 0.5\n TCO2\n 32\n 28\n 28\n 30\n Glucose\n 93\n 105\n 135\n 118\n Other labs: PT / PTT / INR:11.0/31.0/0.9, CK / CK-MB / Troponin\n T:247//, ALT / AST:53/32, Alk-Phos / T bili:68/0.4, Fibrinogen:487\n mg/dL, Albumin:3.5 g/dL, LDH:329 IU/L, Ca:8.6 mg/dL, Mg:1.9 mg/dL,\n PO4:2.0 mg/dL\n Assessment and Plan\n HYPERTENSION, BENIGN, INTRACEREBRAL HEMORRHAGE (ICH), SEIZURE, WITHOUT\n STATUS EPILEPTICUS, .H/O SEIZURE, WITHOUT STATUS EPILEPTICUS, ALCOHOL\n WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES)\n Assessment and Plan: 53yo male with L large subacute IPH with R frontal\n contracoup IPH\n Neurologic: #IPH w/o evidence of aneurysmal bleed\n - q2h neuro checks\n - sz ppx: dilantin tid, supplement per level\n - analgesic: acetaminophen for all fevers\n - EtOH abuse: on Ativan 0.5-1 Q4H iv.\n - Re-start psych meds - to check with primary provider : doses if\n known\n Cardiovascular: - goal SBP < 160; on standing lopressor with prn\n hydralazine and lopressor boluses, and nicardipine gtt if needed.\n Pulmonary: - intubated, sedated, wean vent as tolerated, currently\n CPAP. Daily RSBI, to attempt extubation .only if MS improves.\n Consider trach\n Gastrointestinal / Abdomen: - transaminitis, chronic EtOH\n - distended abdomen, +flatus, frequent watery BM - to monitor, may need\n enema.\n Nutrition: - on TF, w/ Vit/folate/Thiamine supplement\n Renal: Foley, Adequate UO, - mixed alkalosis\n - hyponatremia - to monitor w/ q12hr labs, limit free water\n Hematology: - Stable anemia\n - Thrombocytopenia, most likely c/w EtOH-induced. goal PLT ~ 100K\n Endocrine: RISS\n Infectious Disease: started on vanc/ceftaz for fever, f/u cultures\n Lines / Tubes / Drains: Foley, OGT, ETT, arterial line, PIV.\n - Will need PICC or CVL today as pt with poor peripheral venous access.\n Wounds:\n Imaging: Head CT today.\n Fluids: D5 1/2 NS, Potassium Chloride\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid), (Respiratory\n distress: Insufficiency / Post-op), Other: intraparenchymal hemorrhage\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 04:00 PM\n 20 Gauge - 08:58 PM\n 22 Gauge - 09:13 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2140-05-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 564681,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Pt opens eyes spont, not to command. Not following any commands,\n minimal movement to RUE noted. Withdraws and occ. Localizes. PERRLA 3mm\n and brisk. Crani site intact, DSD. SBP maintained <140. Strong cough,\n gagging and bucking vent at times. Purposeful w/LUE towards ETT.\n Dilantin level sub-therapeutic.\n Action:\n Fentanyl/Ativan for discomfort, PRN anti-hypertensives, frequent neuro\n checks, pt. trached @ bedside today. Dilantin bolus 500mg IV given, due\n for 8pm level.\n Response:\n Neuro status unchanged, trach done w/o incident at bedside, well\n tolerated.\n Plan:\n Neuro checks, head CT this evening, post trach CXR, follow labs, resp.\n care, vent wean as tolerated, CIWA scale as pt wakes.\n"
},
{
"category": "Physician ",
"chartdate": "2140-04-29 00:00:00.000",
"description": "Intensivist Note",
"row_id": 563996,
"text": "SICU\n HPI:\n 53M known EtOH found in home down by social worker, taken to OSH where\n patient was combative moving all 4 extremities, patient was intubated\n and found to have, transfer to , plt 40, ethanol 71, lactate 3.3,\n glucose 217\n Chief complaint:\n L large subacute IPH with R frontal contracoup IPH\n PMHx:\n EtOH abuse, siezure disorder, schizophrenia\n Current medications:\n Acetaminophen, Bisacodyl, Chlorhexidine Gluconate 0.12% Oral Rinse,\n Folic Acid/Multivitamin/Thiamine-1000mL NS, HydrALAzine, Insulin,\n Influenza Virus Vaccine, Lorazepam, Ondansetron, Pantoprazole,\n Phenytoin, Propofol, Thiamine\n 24 Hour Events:\n INTUBATION - At 04:35 PM\n INVASIVE VENTILATION - START 04:35 PM\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Propofol - 25 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 06:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.8\nC (100\n T current: 37.5\nC (99.5\n HR: 89 (81 - 97) bpm\n BP: 146/71(97) {119/61(81) - 158/80(109)} mmHg\n RR: 14 (12 - 18) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,044 mL\n 707 mL\n PO:\n Tube feeding:\n IV Fluid:\n 924 mL\n 587 mL\n Blood products:\n Total out:\n 1,165 mL\n 625 mL\n Urine:\n 565 mL\n 625 mL\n NG:\n Stool:\n Drains:\n Balance:\n -121 mL\n 82 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 656 (519 - 656) mL\n PS : 8 cmH2O\n RR (Set): 12\n RR (Spontaneous): 13\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 49\n PIP: 14 cmH2O\n Plateau: 12 cmH2O\n SPO2: 99%\n ABG: 7.48/42/188/31/7\n Ve: 6.3 L/min\n PaO2 / FiO2: 470\n Physical Examination\n General Appearance: No acute distress, Well nourished\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Neurologic: (Responds to: Noxious stimuli), No(t) Moves all\n extremities, (RUE: Weakness), (RLE: Weakness), Sedated\n Labs / Radiology\n 92 K/uL\n 10.5 g/dL\n 101 mg/dL\n 0.7 mg/dL\n 31 mEq/L\n 3.5 mEq/L\n 13 mg/dL\n 99 mEq/L\n 137 mEq/L\n 30.2 %\n 4.6 K/uL\n [image002.jpg]\n 05:27 PM\n 06:43 PM\n 08:17 PM\n 02:07 AM\n 02:24 AM\n WBC\n 4.4\n 4.6\n Hct\n 30.4\n 30.2\n Plt\n 115\n 92\n Creatinine\n 0.6\n 0.7\n TCO2\n 33\n 30\n 32\n Glucose\n 94\n 101\n Other labs: PT / PTT / INR:12.5/31.8/1.1, CK / CK-MB / Troponin\n T:247//, ALT / AST:126/162, Alk-Phos / T bili:55/0.8, Fibrinogen:156\n mg/dL, Albumin:3.6 g/dL, LDH:329 IU/L, Ca:8.4 mg/dL, Mg:2.1 mg/dL,\n PO4:2.7 mg/dL\n Imaging: CXR: Endotracheal tube 7.5 cm from the carina\n CTH: Large left parietotemporal intraparenchymal hemorrhage with\n associated mass effect including 5 mm rightward shift of the normally\n midline structures and subfalcine herniation; intraparenchymal\n hemorrhage in the right inferior frontal lobe; Scattered areas of\n subarachnoid hemorrhage bilaterally; Maxillary and ethmoidal sinus\n disease.\n CT CAP: pending\n CTA head: No aneurysm or sign of vascular malformation. Complete R\n ICA occlusion. Intracranial vessels largely reconstituted via\n collaterals\n Microbiology: MRSA screen: pending\n Assessment and Plan\n INTRACEREBRAL HEMORRHAGE (ICH), SEIZURE, WITHOUT STATUS EPILEPTICUS,\n .H/O SEIZURE, WITHOUT STATUS EPILEPTICUS, ALCOHOL WITHDRAWAL (INCLUDING\n DELIRIUM TREMENS, DTS, SEIZURES)\n Assessment and Plan: 53M with L large subacute IPH with R frontal\n contracoup IPH\n Neurologic: q1h neuro checks, dilantin load + 100 tid, acetaminophen\n for all fevers, propofol for comfort on vent\n Cardiovascular: goal SBP < 160; prn hydralazine\n Pulmonary: intubated, sedated, wean vent as tolerated, currently CPAP\n Gastrointestinal / Abdomen: transaminitis, chronic EtOH\n Nutrition: NPO\n Renal: met alkalosis, ? contraction\n Hematology: goal plts > 100\n Endocrine: tight glucose control RISS\n Infectious Disease: no issues\n Lines / Tubes / Drains: ETT, R A-line, L 20g PIV hand (), R 18g\n hand + L 20g wrist from OSH\n Wounds: none\n Imaging: CT head performed this AM, follow up read\n Fluids: NS + KCL @ 80/hr after banana pack finishes\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 04:42 PM\n 20 Gauge - 04:44 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2140-05-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 564291,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Patient , open eyes spontaneously, does not obey commands.\n Moves left ue/le spontaneously. No movement noted to right ue, only\n gross upper movement to painful stimuli. Withdraws to stimuli right le.\n Action:\n Monitor neuro checks Q1..\n Response:\n No change in neuro status.\n Plan:\n Will continue to monitor neuro checks Q1. No plan for intervention at\n this time.\n Seizure, without status epilepticus\n Assessment:\n No seizure activity noted overnight.\n Action:\n Monitor for seizure activity, iv dilantin given as ordered. Patient\n levels low, dr aware will need bolus dose.\n Response:\n No change in status.\n Plan:\n Will continue to monitor and treat accordingly\n Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Patient agitated at times, attempts to pull out ett, hr becomes\n elevated. Occasional tremors noted.\n Action:\n iv Ativan 0.5mgs given Q4 as ordered, iv Fentanyl 25mcgs Q4-6 hrly\n Response:\n patient lightly sedated, appears comfortable, less agitated\n Plan:\n will continue to monitor and treat accordingly\n Hypertension, benign\n Assessment:\n Patient hypertensive above goal of SBP < 160 a couple of times during\n shift.\n Action:\n lopressor given Q8 as ordered\n Response:\n Patient\ns SBP kept within goal of 100-160\n Plan:\n Continue to monitor.\n"
},
{
"category": "Physician ",
"chartdate": "2140-05-01 00:00:00.000",
"description": "Intensivist Note",
"row_id": 564292,
"text": "SICU\n HPI:\n 53M known EtOH found in home down by social worker, taken to OSH where\n patient was combative moving all 4 extremities, patient was intubated\n and found to have, transfer to , plt 40, ethanol 71, lactate 3.3,\n glucose 217\n Chief complaint:\n L large subacute IPH with R frontal contracoup IPH\n PMHx:\n EtOH abuse, seizure disorder (epilepsy), schizophrenia\n Current medications:\n 1. 20 mEq Potassium Chloride / 1000 mL NS 2. Acetaminophen 3. Bisacodyl\n 4. Calcium Gluconate 5. CeftazIDIME\n 6. CeftazIDIME 7. Chlorhexidine Gluconate 0.12% Oral Rinse 8. Fentanyl\n Citrate 9. FoLIC Acid 10. HydrALAzine\n 11. Insulin 12. Influenza Virus Vaccine 13. Lorazepam 14. Magnesium\n Sulfate 15. Metoprolol Tartrate\n 16. Metoprolol Tartrate 17. Metoprolol Tartrate 18. Multivitamins\n W/minerals 19. Neutra-Phos 20. Neutra-Phos\n 21. Ondansetron 22. Phenytoin 23. Potassium Chloride 24. Potassium\n Chloride 25. Propofol 26. Ranitidine\n 27. Thiamine 28. Vancomycin\n 24 Hour Events:\n PAN CULTURE - At 05:15 PM\n FEVER - 102.0\nF - 04:00 PM\n : Spiked 102--> Pancx, started on Vanc and Ciftazid\n Allergies:\n Last dose of Antibiotics:\n Vancomycin - 09:02 PM\n Ceftazidime - 10:47 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 AM\n Hydralazine - 12:15 PM\n Fentanyl - 02:33 AM\n Lorazepam (Ativan) - 02:33 AM\n Other medications:\n Flowsheet Data as of 04:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.9\nC (102\n T current: 37.9\nC (100.3\n HR: 68 (68 - 121) bpm\n BP: 129/63(84) {110/63(84) - 176/91(119)} mmHg\n RR: 19 (14 - 27) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,859 mL\n 287 mL\n PO:\n Tube feeding:\n 1,104 mL\n 246 mL\n IV Fluid:\n 1,376 mL\n 41 mL\n Blood products:\n Total out:\n 1,825 mL\n 180 mL\n Urine:\n 1,825 mL\n 180 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,034 mL\n 107 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 550 (474 - 716) mL\n PS : 5 cmH2O\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 62\n PIP: 11 cmH2O\n SPO2: 100%\n ABG: ///30/\n Ve: 11.9 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: Crackles : Bilateral)\n Abdominal: Soft, Non-tender, Distended\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: No(t) Moves all extremities, (RUE: Weakness), (RLE:\n Weakness), move left extrimities unporposfully, poor MS\n / Radiology\n 91 K/uL\n 10.5 g/dL\n 135 mg/dL\n 0.5 mg/dL\n 30 mEq/L\n 3.0 mEq/L\n 11 mg/dL\n 98 mEq/L\n 133 mEq/L\n 29.9 %\n 9.2 K/uL\n [image002.jpg]\n 08:17 PM\n 02:07 AM\n 02:24 AM\n 10:00 AM\n 03:57 PM\n 09:06 PM\n 01:40 AM\n 01:47 AM\n 04:26 PM\n 01:50 AM\n WBC\n 4.6\n 6.8\n 9.2\n Hct\n 30.2\n 31.4\n 29.9\n Plt\n 92\n 78\n 115\n 122\n 107\n 91\n Creatinine\n 0.7\n 0.5\n 0.5\n TCO2\n 30\n 32\n 28\n 28\n Glucose\n 101\n 93\n 105\n 135\n Other : PT / PTT / INR:11.5/27.6/1.0, CK / CK-MB / Troponin\n T:247//, ALT / AST:65/51, Alk-Phos / T bili:64/0.6, Fibrinogen:487\n mg/dL, Albumin:3.4 g/dL, LDH:329 IU/L, Ca:8.5 mg/dL, Mg:1.8 mg/dL,\n PO4:1.9 mg/dL\n Assessment and Plan\n HYPERTENSION, BENIGN, INTRACEREBRAL HEMORRHAGE (ICH), SEIZURE, WITHOUT\n STATUS EPILEPTICUS, .H/O SEIZURE, WITHOUT STATUS EPILEPTICUS, ALCOHOL\n WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES)\n Assessment and Plan: 53M with L large subacute IPH with R frontal\n contracoup IPH\n Neurologic: Neuro checks Q: 1 hr, q1h neuro checks, dilantin load + 100\n tid, acetaminophen for all fevers, wean off propofol to eval neur exam,\n Ativan 0.5-1 Q4H iv. Check Alb level\n Re-start home meds (serequal, etc.). Clear c-spine collar d/ced\n Cardiovascular: goal SBP < 160; prn hydralazine PRN, Lopressor standing\n and PRN. If consistentely high start Nicardapine ggts\n Pulmonary: intubated, sedated, wean vent as tolerated, currently CPAP.\n Gastrointestinal / Abdomen: transaminitis improvine, chronic EtOH, abd\n distended and patient high flatus most likely due to TF\n Nutrition: Tube feeding, at goal , fibersource\n Renal: Foley, Adequate UO, Creat stable\n Hematology: Monitor Cr, Keep plat>100\n Endocrine: RISS, Goal BS<150\n Infectious Disease: Febrile 102,WBC 9.9. Pancx overnight sputum Gram\n stain G+R and 25>PMN we will fellow up Cx. Started on Vancomy and\n Ceftazid\n Lines / Tubes / Drains: Foley, OGT, ETT. Consideration of trach / PEG\n Wounds: None\n Imaging:\n Fluids: KVO,\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid), (Respiratory\n distress: Failure)\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 08:00 PM 60 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 04:00 PM\n 18 Gauge - 04:42 PM\n 20 Gauge - 08:58 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Radiology",
"chartdate": "2140-05-11 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1070874,
"text": " 12:14 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: please evaluate for ICH; s/p fall; found on face\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with know ICH\n REASON FOR THIS EXAMINATION:\n please evaluate for ICH; s/p fall; found on face\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SPfc WED 6:29 PM\n 1. Continuing evolution of left parietotemporal parenchymal hemorrhage as\n well as right frontal intraparenchymal hemorrhage. There are no new foci of\n hemorrhage.\n\n 2. Paranasal sinus opacification, unchanged from the most recent study,\n though progressed since the study of .\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: No intracranial hemorrhage after a fall.\n\n COMPARISON: Comparison is made to numerous previous CT scans of the head,\n spanning from to .\n\n TECHNIQUE: Contiguous, axial CT images were acquired through the brain in the\n absence of intravenous contrast. Coronal and sagittal reformatted images were\n also reviewed.\n\n FINDINGS:\n There continues to be evolution of the intraparenchymal blood and edema\n subjacent to the left frontal craniotomy. There is no new intracranial\n hemorrhage. Pneumocephalus has resolved. Right frontal lobe hemorrhage is\n now improved and minimally apparent. Layering within the sulci of the left\n frontal lobe, markedly decreased since presentation is subarachnoid\n hemorrhage. Right shift of normal midline anatomy persists, now 6mm,\n previously 7 mm. Subgaleal hematoma at the site of the craniotomy is\n unchanged. Opacity at the left mastoid air cells persists, possibly sequela\n of intubation. The right mastoid air cells are normally aerated. Visualized\n paranasal sinuses are notable for near total opacification of the left\n maxillary sinus as well as the left frontal sinus extending into the\n frontoethmoidal recess. This finding is unchanged since most recent study,\n though worse since the initial comparison study.\n\n IMPRESSION:\n 1. Continued evolution of left temporoparietal as well as right frontal\n parenchymal hematomas. There are no new foci of hemorrhage.\n 2. Paranasal sinus opacification, unchanged from the most recent study,\n though worse since the study of .\n (Over)\n\n 12:14 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: please evaluate for ICH; s/p fall; found on face\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-05-11 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1070875,
"text": ", M. NSURG FA11 12:14 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: please evaluate for ICH; s/p fall; found on face\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with know ICH\n REASON FOR THIS EXAMINATION:\n please evaluate for ICH; s/p fall; found on face\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n 1. Continuing evolution of left parietotemporal parenchymal hemorrhage as\n well as right frontal intraparenchymal hemorrhage. There are no new foci of\n hemorrhage.\n\n 2. Paranasal sinus opacification, unchanged from the most recent study,\n though progressed since the study of .\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-05-07 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1070249,
"text": " 5:42 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for intraparenchymal bleed\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with IPH s/p evacuation with new mental status changes\n REASON FOR THIS EXAMINATION:\n eval for intraparenchymal bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DXAe SAT 7:00 PM\n Little change since .\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Parenchymal hemmorrhage post evacuation with new mental status\n chnages.\n\n COMPARISON: .\n\n TECHNIQUE: Non-contrast axial imaging was obtained from the skull vertex to\n the skull base.\n\n FINDINGS: There is evolution of hemorrhage in the left frontal craniotomy bed\n with decreasing air in the post-surgical bed. Large vasogenic edema adjacent\n to the hemorrhage with moderate mass effect on the ipsilateral left frontal\n is similar to . Right inferior frontal lobe hemorrhage is similar\n to . There is stable minimal right frontal subarachnoid hemorrhage. 7\n mm rightward shift of normally midline structures, left subfalcine and uncal\n herniation are similar to . Bilateral pneumocephalus has slightly\n decreased since . Opacification of the left frontal sinus, the sphenoid\n sinus, bilateral ethmoids and left maxillary sinuses are similar to .\n The mastoid air cells are clear.\n\n IMPRESSION:\n\n 1. Evolution of left parietoemporal parenchymal hemorrhage with large edema\n and subfalcine as well as uncal herniation that is similar to .\n\n 2. Evolution of right inferior frontal lobe hemorrhage .\n\n 3. Diffuse paranasal sinus opacification is unchanged since .\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-05-12 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1071151,
"text": " 4:03 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: please evaluate for intracranial hemorrhage; now therapuetic\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with known ICH s/p evacuation; being anticoagulated for DVT.\n REASON FOR THIS EXAMINATION:\n please evaluate for intracranial hemorrhage; now therapuetic on heparin gtt.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 53-year-old male with known intracranial hemorrhage status post\n evacuation being anticoagulated for DVT. Assess for intracranial hemorrhage.\n\n COMPARISONS: Multiple priors, most recent .\n\n TECHNIQUE: Non-contrast MDCT axial images of the head were acquired.\n\n FINDINGS: The patient is status post left partial craniotomy. A subgaleal\n hematoma adjacent to the craniotomy site is probably unchanged. Evolution of\n hemorrhage within the left temporoparietal and right frontal lobe continues.\n Small areas of increased density, particularly within the left parietal lobe\n are unchanged. No new areas of hemorrhage are evident. Persistent sulcal\n effacement involving the entire left cerebral hemisphere is stable. There is\n shift of normally midline structures to the right of approximately 5 mm\n (previously 6 mm). There is no hydrocephalus. Near-complete opacification of\n the left maxillary sinus is unchanged. Complete opacification of the left\n frontal sinus, also remains stable. Small areas of mucosal thickening are\n evident within the posterior ethmoid sinuses and the sphenoid sinus. Partial\n opacification of the left mastoid air cell is evident. Small amount of soft\n tissue density is present within the left external auditory canal, probably\n unchanged.\n\n IMPRESSION:\n 1. No new acute intracranial hemorrhage.\n 2. Continued evolution of left temporoparietal and right frontal parenchymal\n hemorrhage.\n 3. Paranasal sinus and left mastoid air cell opacification, unchanged.\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-05-10 00:00:00.000",
"description": "PICC W/O PORT",
"row_id": 1070737,
"text": " 4:08 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: please place PICC; IV RN unable thread at bedside\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ********************************* CPT Codes ********************************\n * PICC W/O PORT -79 UNRELATED PROCEDURE/SERVICE DURI *\n * FLUORO GUID PLCT/REPLCT/REMOVE US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with .\n REASON FOR THIS EXAMINATION:\n please place PICC; IV RN unable thread at bedside\n ______________________________________________________________________________\n FINAL REPORT\n PICC LINE PLACEMENT\n\n INDICATION: Intracranial hemorrhage and DVT. Needs IV access.\n\n The procedure was explained to the patient. A timeout was performed.\n\n RADIOLOGISTS: Drs. , , and performed the procedure. Dr.\n , the Attending Radiologist, was present and supervised the entire\n procedure.\n\n TECHNIQUE: Using sterile technique and local anesthesia, the right brachial\n vein was punctured under direct ultrasound guidance using a micropuncture set.\n Hard copies of ultrasound images were obtained before and immediately after\n establishing intravenous access. A peel-away sheath was then placed over a\n guidewire and a double lumen PICC line measuring 32 cm in length was then\n placed through the peel-away sheath with its tip positioned in the SVC under\n fluoroscopic guidance. Position of the catheter was confirmed by a\n fluoroscopic spot film of the chest.\n\n The peel-away sheath and guidewire were then removed. The catheter was\n secured to the skin, flushed, and a sterile dressing applied.\n\n The patient tolerated the procedure well. There were no immediate\n complications.\n\n IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided double lumen\n PICC line placement via the right brachial venous approach. Final internal\n length is 32 cm, with the tip positioned in SVC. The line is ready to use.\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-05-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1071022,
"text": " 7:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o PNA\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with new PEG spikes fever\n REASON FOR THIS EXAMINATION:\n r/o PNA\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 11:29 AM\n No acute intrathoracic process.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE AP CHEST\n\n INDICATION: New gastrostomy tube and fever, evaluate for pneumonia.\n\n FINDINGS: Comparison is made with prior radiograph from . The\n lines and support devices are in the expected location. The lungs are clear\n without evidence of pneumonia or CHF. The cardiomediastinal silhouette is\n normal. There has been interval placement of a gastrostomy tube. The bowel\n is more distended in the interim with interposition of bowel between the liver\n and the anterior abdominal wall. The IVC filters are unchanged. The bones\n are unremarkable.\n\n IMPRESSION: No acute intrathoracic process. Interval increase in bowel\n distention.\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-05-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1071023,
"text": ", M. NSURG FA11 7:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o PNA\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with new PEG spikes fever\n REASON FOR THIS EXAMINATION:\n r/o PNA\n ______________________________________________________________________________\n PFI REPORT\n No acute intrathoracic process.\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-05-12 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1071024,
"text": " 7:14 AM\n PORTABLE ABDOMEN Clip # \n Reason: New PEG\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with new PEG spikes fever\n REASON FOR THIS EXAMINATION:\n New PEG\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient is a 53-year-old male, new PEG in place. Now spiking\n fevers. Evaluate new PEG.\n\n EXAMINATION: Supine portable abdominal radiograph.\n\n COMPARISONS: Comparison to abdominal radiographs from and CT torso\n from .\n\n FINDINGS: Since prior abdominal radiograph, there has been interval placement\n of an IVC filter, and a PEG tube with balloon seen projecting over the gastric\n antrum. Of note, there are extensive gaseously distended loops of both large\n and small bowel extending through to the rectum compatible with ileus. Limited\n examination for the evaluation of free air on this single portable supine\n radiograph. Visualized soft tissues are unremarkable. Visualized osseous\n structures are stable.\n\n IMPRESSION: Gaseously distended loops of both large and small bowel\n compatible with ileus. PEG tube with balloon projecting over gastric antrum.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-05-09 00:00:00.000",
"description": "INTERUP IVC",
"row_id": 1070479,
"text": " 11:50 AM\n IVC GRAM/FILTER Clip # \n Reason: IVC filter placement\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n Contrast: OPTIRAY Amt: 35\n ********************************* CPT Codes ********************************\n * INTERUP IVC PERC PLCMT IVC FILTER *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with intracranial hemorrhage now w/ R LE DVT\n REASON FOR THIS EXAMINATION:\n IVC filter placement\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JXXb MON 3:26 PM\n PFI: Placement of G2 retrievable infrarenal IVC filter. The filter can be\n retrieved at any time as needed.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: The patient is a 53-year-old man with intracranial\n hemorrhage, now developed right lower extremity DVT. A request was made to\n place an IVC filter.\n\n OPERATORS: Dr. and Dr. , the attending radiologist\n who was present and supervised during whole procedure.\n\n PROCEDURE: IVC filter placement.\n\n ANESTHESIA: IV fentanyl and local lidocaine was used.\n\n PROCEDURE AND FINDING: After risks and benefits of the procedure as well as\n anesthesia were explained, informed consent was obtained. The patient was\n brought to the angiography suite and placed supine on the imaging table. Both\n groins were prepared and draped in the usual sterile fashion. The right\n common femoral vein was accessed with a micropuncture needle under ultrasound\n guidance. A 0.018 wire was then placed through the needle into the right\n common femoral vein. A small incision was cut over the needle and the needle\n was removed and replaced with a 4.5 French micropuncture sheath. The wire and\n the inner stiffener of the sheath was removed. A 0.035 straight wire\n was then placed through the sheath into the right common femoral vein and was\n advanced upward into the inferior vena cava. The sheath was then removed and\n replaced with a 9 French sheath. The left common femoral vein was accessed in\n the same way. An IVUS probe was then placed through the sheath at the left\n groin and was advanced upward over the wire into the IVC at the level\n of the lower edges of the right and left renal veins. A 5 French Omni Flush\n catheter was then placed over the wire at the right groin sheath and\n was placed at the bifurcation of the lower IVC. IVC venograms through the\n Omni Flush sheath demonstrated no clots in IVC or any anatomic variance in the\n IVC. The location of the right and left renal veins were confirmed at the\n lower L1 body. The wire was then placed into the Omni Flush catheter\n and the Omni Flush catheter was then removed. The sheath at right groin was\n then removed and replaced with the sheath from a G2 IVC filter set. The\n sheath was advanced upward with its tip passing the renal veins under\n (Over)\n\n 11:50 AM\n IVC GRAM/FILTER Clip # \n Reason: IVC filter placement\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n Contrast: OPTIRAY Amt: 35\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n fluoroscopic guidance and IVUS guidance. The wire and the inner stiffener of\n the sheath were both removed. The IVC filter was then placed into the sheath\n and pushed forward till the tip of the filter lined up with the tip of the\n sheath. The IVC filter and the sheath were then pulled back under the\n fluoroscope guidance and the IVUS guidance till the tip was located right\n below the right and left renal veins. The filter was deployed by _____ the\n filter. The final position of the IVC filter was confirmed by fluoroscopic\n and spot image and it was placed infrarenally. All sheaths and IVUS probe\n were removed. Hemostasis was achieved at both groins by manual compression. A\n sterile dressing was applied.\n\n The patient tolerated the procedure well and there were no immediate\n complications.\n\n IMPRESSION: Placement of G2 retrievable IVC filter infrarenally with the\n possibility to retrieve the filter at any time if indicated.\n\n\n\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-05-09 00:00:00.000",
"description": "INTERUP IVC",
"row_id": 1070480,
"text": ", M. NSURG FA11 11:50 AM\n IVC GRAM/FILTER Clip # \n Reason: IVC filter placement\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n Contrast: OPTIRAY Amt: 35\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with intracranial hemorrhage now w/ R LE DVT\n REASON FOR THIS EXAMINATION:\n IVC filter placement\n ______________________________________________________________________________\n PFI REPORT\n PFI: Placement of G2 retrievable infrarenal IVC filter. The filter can be\n retrieved at any time as needed.\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-05-08 00:00:00.000",
"description": "BILAT LOWER EXT VEINS",
"row_id": 1070342,
"text": ", M. NSURG SICU-A 2:05 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: LE swelling, please eval for DVT\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with L intra-parenchymal cerebral hemorrhage\n REASON FOR THIS EXAMINATION:\n LE swelling, please eval for DVT\n ______________________________________________________________________________\n PFI REPORT\n DVT in the right superficial femoral vein which is occlusive.\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-05-11 00:00:00.000",
"description": "R HIP UNILAT MIN 2 VIEWS RIGHT",
"row_id": 1070880,
"text": " 12:53 PM\n HIP UNILAT MIN 2 VIEWS RIGHT Clip # \n Reason: please evaluate for fracture.\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with s/p fall\n REASON FOR THIS EXAMINATION:\n please evaluate for fracture.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Right hip two views .\n\n HISTORY: 53-year-old man status post fall. Evaluate for fracture.\n\n FINDINGS: There is no signs for acute fractures or dislocations. Joint\n spaces are preserved. Sacroiliac joints are unremarkable. There are some\n degenerative changes seen of lower lumbar spine. Foley catheter is\n visualized.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-05-11 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 1070876,
"text": " 12:15 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: please evaluate for fracture; s/p fall\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with know ICH\n REASON FOR THIS EXAMINATION:\n please evaluate for fracture; s/p fall\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JMGw WED 4:55 PM\n No acute fractures. Likely old clavicular trauma. Slight thickening of\n bladder wall may be due to chronic placement of Foley.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Known intracranial hemorrhage. Evaluate for fracture status post\n fall.\n\n COMPARISON: CT torso, .\n\n TECHNIQUE: Contiguous helical imaging was performed from the thoracic inlet\n through the pubic symphysis without administration of intravenous or oral\n contrast. Sagittal and coronal reformatted images were prepared.\n\n CT CHEST WITHOUT ORAL OR IV CONTRAST: Patient is intubated with an\n endotracheal tube tip terminating approximately 4.5 cm from the carina. A\n nasogastric tube courses through the esophagus and enters into the stomach.\n There is a right-sided central venous catheter whose tip terminates at the\n cavoatrial junction. There is bibasilar atelectasis. No pleural effusions\n are seen. In the upper portion of the left lower lobe (2:24) is a slight area\n of patchy opacity, which may represent a focus of inflammation or infection.\n The airways remain patent to the subsegmental levels bilaterally. No\n pneumothorax. There is calcification of the coronary vasculature. The aorta\n at the aortic arch measures 4.2 cm, unchanged from prior examination. There\n is no significant axillary, hilar, or mediastinal adenopathy.\n\n CT ABDOMEN WITH CONTRAST: Lack of IV contrast limits full evaluation of the\n solid intra-abdominal organs. No free air and no free fluid is seen. Compared\n to the prior study, there is decreased diffuse fatty infiltration of the\n liver. The spleen, adrenals, pancreas, and gallbladder appear normal. There\n is minimal atherosclerotic calcification of the abdominal aorta. There is an\n infrarenal IVC filter. There is no significant retroperitoneal or mesenteric\n adenopathy. Stomach contains a nasogastric tube. The abdominal loops of\n small bowel appear normal.\n\n CT PELVIS WITH CONTRAST: Pelvic loops of large bowel demonstrate mild\n diverticular disease without evidence for diverticulitis. The pelvic loops of\n small bowel appear normal. There is a Foley in a decompressed bladder\n containing air in the nondependent portion. The bladder wall appears mildly\n thickened, which may be due to the presence of a chronic indwelling Foley\n catheter. No free air or no free fluid. No pelvic or inguinal adenopathy is\n (Over)\n\n 12:15 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: please evaluate for fracture; s/p fall\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n present.\n\n BONE WINDOWS: There is deformity of the right and left clavicles, which\n appears related to old chronic fractures. There are no acute fractures\n identified. There are extensive degenerative changes particularly of the\n lower lumbar spine with intervertebral disc space narrowing and bridging\n osteophyte formation. No suspicious sclerotic or lytic lesions were seen.\n\n IMPRESSION:\n 1. No acute bony fracture identified. Deformity of bilateral clavicles is\n likely related to old trauma.\n 2. Improved fatty infiltration of the liver parenchyma.\n 3. Slight thickening of the bladder wall, which may be due to the presence of\n a chronic indwelling Foley catheter.\n 4. Diverticulosis without diverticulitis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-05-11 00:00:00.000",
"description": "CT PELVIS W/O CONTRAST",
"row_id": 1070877,
"text": ", M. NSURG FA11 12:15 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: please evaluate for fracture; s/p fall\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with know ICH\n REASON FOR THIS EXAMINATION:\n please evaluate for fracture; s/p fall\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n No acute fractures. Likely old clavicular trauma. Slight thickening of\n bladder wall may be due to chronic placement of Foley.\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-05-07 00:00:00.000",
"description": "BILAT LOWER EXT VEINS",
"row_id": 1070233,
"text": " 2:49 PM\n BILAT LOWER EXT VEINS; FEE ADJUSTED IN SPECIFIC SITUATION Clip # \n Reason: PT WITH FEVER, PLEASE DO DVT\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with fevers\n REASON FOR THIS EXAMINATION:\n please r/o DVT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53-year-old with fevers. Rule out DVT.\n\n No prior examinations.\n\n RIGHT LOWER EXTREMITY VENOUS ULTRASOUND: Single Doppler image of the right\n common femoral vein was obtained, with a normal waveform. Subsequently the\n patient proceeded to have multiple seizures and the exam was aborted, to be\n completed the following day. These findings were discussed with Dr. \n by , , at the time of the exam.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-05-07 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1070250,
"text": ", M. NSURG SICU-A 5:42 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for intraparenchymal bleed\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with IPH s/p evacuation with new mental status changes\n REASON FOR THIS EXAMINATION:\n eval for intraparenchymal bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Little change since .\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-05-08 00:00:00.000",
"description": "BILAT LOWER EXT VEINS",
"row_id": 1070341,
"text": " 2:05 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: LE swelling, please eval for DVT\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with L intra-parenchymal cerebral hemorrhage\n REASON FOR THIS EXAMINATION:\n LE swelling, please eval for DVT\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JRCi SUN 2:56 PM\n DVT in the right superficial femoral vein which is occlusive.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Bilateral lower extremity veins ultrasound.\n\n INDICATION: Left intraparenchymal cerebral hemorrhage and lower extremity\n swelling on the left.\n\n FINDINGS: Grayscale, color and pulse Doppler son was performed on the\n bilateral common femoral, superficial femoral and popliteal veins. The right\n superficial femoral vein is expanded with echogenic thrombus within and lack\n of compression demonstrated. The remaining mention veins are patent with\n normal flow, compression and waveforms.\n\n IMPRESSION: Short-segment thrombus within the right superficial femoral vein\n which is occlusive.\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-05-11 00:00:00.000",
"description": "R SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA RIGHT",
"row_id": 1070879,
"text": " 12:53 PM\n SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA RIGHT Clip # \n Reason: please evlaute for fracture\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with s/p fall\n REASON FOR THIS EXAMINATION:\n please evlaute for fracture\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Right shoulder three views .\n\n HISTORY: 53-year-old man status post fall, evaluate for fracture.\n\n FINDINGS: There is an old healed fracture involving the mid shaft of the\n right clavicle. Degenerative changes of the AC joint is visualized. There\n are no signs for acute fractures or dislocations. The patient has a PICC line\n with the distal tip in the mid SVC. The visualized right lung apex is clear.\n\n IMPRESSION:\n\n No signs for acute bony injury.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2140-05-11 00:00:00.000",
"description": "Report",
"row_id": 243653,
"text": "Sinus rhythm\nLow limb voltage\nNormal ECG\nSince previous tracing of , the heart rate is slower\n\n"
},
{
"category": "ECG",
"chartdate": "2140-04-28 00:00:00.000",
"description": "Report",
"row_id": 243654,
"text": "Sinus tachycardia. Low limb lead voltage. No previous tracing available for\ncomparison.\n\n"
}
] |
22,176 | 127,887 | The patient was admitted on and had a occipital craniotomy for excision of metastatic tumor. Postoperatively the patient's vital signs were stable. She was afebrile awake, alert, oriented x 3, smile was symmetric with no drift.Visual field exam showed a right inferior quadrantanopia . Her incision was clean, dry and intact. She remained afebrile. She was tolerating a regular diet. She will be discharged to home with follow up in the brain tumor clinic on . Staples will be removed at that time and she will be weaned down to 2 mg p.o. b.i.d. of her steroids. | TECHNIQUE: Axial contrast enhanced T1 weighted scans were obtained with a Wand protocol. 7:39 AM MR HEAD W/ CONTRAST Clip # Reason: PRE-OP FOR WAND PROTOCOL PLACEMENT OF MARKERS. MR HEAD W/CONTRAST: There is a heterogeneously enhancing mass in the left occipital lobe, which contacts and anteriorly displaces the left ventricular atrium. COMPARISON is made to previous MR examination of /03. SURGERY @ 9:30AM FINAL REPORT INDICATION: Operative planning . IMPRESSION: Study for stereotatic localization of a left occipital and parietal lobe mass. Cystic or necrotic appearing components of this mass may have increased slightly in size since the previous study. SURGERY / Contrast: MAGNEVIST Amt: 15 MEDICAL CONDITION: 44 year old woman with brain tumor REASON FOR THIS EXAMINATION: PRE-OP FOR WAND PROTOCOL PLACEMENT OF MARKERS. No other areas of abnormal enhancement are identified within the intracranial space. | 1 | [
{
"category": "Radiology",
"chartdate": "2185-04-20 00:00:00.000",
"description": "MR HEAD W/ CONTRAST",
"row_id": 784319,
"text": " 7:39 AM\n MR HEAD W/ CONTRAST Clip # \n Reason: PRE-OP FOR WAND PROTOCOL PLACEMENT OF MARKERS. SURGERY /\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman with brain tumor\n REASON FOR THIS EXAMINATION:\n PRE-OP FOR WAND PROTOCOL PLACEMENT OF MARKERS. SURGERY @ 9:30AM\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: Operative planning .\n\n TECHNIQUE: Axial contrast enhanced T1 weighted scans were obtained with a\n Wand protocol.\n\n COMPARISON is made to previous MR examination of /03.\n\n MR HEAD W/CONTRAST: There is a heterogeneously enhancing mass in the left\n occipital lobe, which contacts and anteriorly displaces the left ventricular\n atrium. Cystic or necrotic appearing components of this mass may have\n increased slightly in size since the previous study.\n\n The ventricles are not dilated. No other areas of abnormal enhancement are\n identified within the intracranial space.\n\n IMPRESSION: Study for stereotatic localization of a left occipital and\n parietal lobe mass.\n\n\n\n"
}
] |
32,665 | 194,834 | She was admitted preoperatively for IV heparin as she stopped her coumadin for surgery. She underwent PFTs, and then was taken to the operating room on where she underwent an AVR, please see OR report for details. In summary she had AVR with #23 Epic pericardial valve. She tolerated the operation well and was transferred to the ICU in stable condition. She did well in the immediate post-operative period, her anesthesia was reversed she was weaned from the ventilator and extubated the night of surgery. She was given 48 hours of vanocmycin as she was in the hospital preoperatively. She was transferred to the floor on POD #2. She was restarted on coumadin for atrial fibrillation. She remained in the ICU for aggressive pulmonary toilet and was transferred to the floors on POD... She developed sternal drainage associated with minimal erythema without fever or white count, antibiotics were initiated. The drainage dissipated after one day, she remained without fever or elevated white count. She was ready for discharge to rehab on POD7. | Mild (1+) mitralregurgitation is seen. EKG done. Normalregional LV systolic function. PALPABLE PULSES BILAT.RESP: LS CL DIM BASES. Mild mitral annularcalcification. + ppresp: Ls clear with dim bases. Mild (1+) MR.TRICUSPID VALVE: Physiologic TR.PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.GENERAL COMMENTS: A TEE was performed in the location listed above. Stable left moderate pleural effusion. Fluid boluses admin. + pp.resp: LS with exp wheezing bil and dim bases bil. hct stable. hct stable. Mild cardiomegaly is again noted. Normal aortic arch diameter. Non-specific ST-T wave changes.Compared to the previous tracing of the lateral downsloping ST segmenthas resolved.TRACING #1 pt started on lopressor PO this am - tolerated well. LYTES REPLETED PRN. The left atrial appendage emptying velocity isdepressed (<0.2m/s). CT's dc'd this am -> CXR donegi/gu: pt with + hypoactive bs. tolerating clears/soft solids. Pt reversed. There are simple atheroma in theaortic arch. Moderately dilated ascending aorta. tolerating clears. Right ventricular chamber is mildly enlarged and free wall motion isnormal.4. Bibasilar atelectasis are again noted, grossly unchanged. pH normal. FICK CI >2.2 SVO2 >68. Prop weaned off. POST EXTUBATION ABG WNL. Wean nitro keeping sbp <120. continues on alb nebs and advair MDI'sgi/gu: pt with + BS. SEE CAREVUE FOR FILLING PRESSURES. Mild spontaneous echo contrast in the LAA. PERRLA. PERRLA. s/p AVR tissue valve today. Moderately thickened aortic valveleaflets. Aorta is intact post decannulation4. WHZS WITH EXERTION.GU/GI: FOLEY TO GRAVITY. Will monitor ficks. Pacer turned down again, underlying afib 70s. Mild spontaneous echo contrast isseen in the body of the left atrium. Trace AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. PALPABLE PULSES BILAT. Biventricular function is preserved.3. Normal LV cavity size. (-)AIRLEAK.GU/GI: FOLEY TO GRAVITY WITH MARGINAL HUO. REASON FOR THIS EXAMINATION: r/o PTX/Effusion FINAL REPORT HISTORY: Status post AVR. CI by fick > 3.0 this am. 7P-7A NPN:ROS:NEURO: SLOW TO WAKE. Depressed LAAemptying velocity (<0.2m/s) No thrombus in the LAA.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. Fluid boluses for low filling pressures. Atrial fibrillation. Atrial fibrillation. Persistent moderate left pleural effusion is unchanged. TMAX AT TIME OF NOTE 100.4. pt given alb nebs and restarted on advair MDI this am. Simple atheroma in aortic arch.Mildly dilated descending aorta. UO adequate. Currenty titrating up. Mild spontaneous echo contrast is presentin the left atrial appendage. IMPRESSION: 1. The ascending aorta is moderately dilated. The descending thoracic aorta is mildly dilated. Intact sternal sutures are seen. Atrial fibrillation with controlled ventricular response. abg wnl. Fluid resuscitation. The left ventricular cavitysize is normal. UNDERLYING CHRONIC AFIB WITH PVCS. The left atrium is moderately dilated. HOH. HOH. Focal calcifications inaortic root. Slight increase of the small right pleural effusion. Therhythm appears to be atrial fibrillation. Maintain ci>2. CXR done, reviewed by np . Diffuse non-specific ST-T wave changes. Focal calcifications inascending aorta. PA line dc'd and introducer left intact. DIMINISHED HUO, 10MG IV LASIX ADMINISTERED WITH (+)DIURESIS. Mild spontaneous echo contrast in thebody of the LA. The following HR the insulin gtt was dc'd -> per protocol. PA CATHETER IN PLACE. Nitro started for hypertension, sbp >120. CI>2 by fick. ABD OBESE (+)BS. Neo weaned off quickly. Normal RV systolic function.AORTA: Normal aortic diameter at the sinus level. RARE PVCS NOTED. Nitro decreased. Once awake pt can wean to extubate. MAE and able to follow commands.CV: pt remains in afib, HR 70's. FINDINGS: In comparison with the study of , there is now an endotracheal tube in place with its tip approximately 5.7 cm above the carina. Monitor and cables swapped out. Breath sounds equal throughout. IMPRESSION: Standard appearance following cardiac surgery. COMPARISON: and . Poor R wave progression. Severe AS (AoVA <0.8cm2). Regional left ventricular wall motion is normal. MAE and able to follow commands.CV: pt remains in afib, with occasional PVC's. (see flowsheet). No underlying rhythm after valve replacement intra-op.Received on neo and prop. A small bilateral pleural effusion cannot be excluded. nursing addPropfol remains off. FINDINGS: There is slight increase in the right pleural effusion which is small. Left ventricular wall thicknesses are normal. 7P-7A NPNROS:NEURO: A/OX3. Delayed precordialR wave transition. Does open eyes and move all extremeties weakly on command. The patient was extubated in the meantime interval with removal of the NG tube and mediastinal drains. BP improved after the fluid bolus. The moderate cardiomegaly is stable. PATIENT/TEST INFORMATION:Indication: Intra-op TEE for AVR, and MVRHeight: (in) 65Weight (lb): 204BSA (m2): 2.00 m2BP (mm Hg): 124/72HR (bpm): 54Status: InpatientDate/Time: at 12:04Test: TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:LEFT ATRIUM: Moderate LA enlargement. NP aware. PULMONARY TOILETING. No ASD by 2D orcolor Doppler.LEFT VENTRICLE: Normal LV wall thickness. SVO2 60-70s. MR is still mild5. Pt needs inhalers & glaucoma drops reordered. Svo2 60-70's. 2A/2V EPICARDIAL WIRES, PACER OFF; INAPPROPRIATLEY SPIKING. Pt still very lethargic. The Swan-Ganz catheter tip terminates at the level of the main pulmonary artery. Portable AP chest radiograph compared to . pt slightly hypotensive this afternoon, SBP in the mid 80's (see flowsheet) -> pt given fluid bolus and captopril dc'd. nitro gtt weaned to off after PO meds. Otherwise no diagnostic interimchange. The mitral valve leaflets are mildly thickened. PT STILL LETHARGIC. Hct >30. 14-2300 nsg updateneuro: pt alert and orienated x3. 2. pt intially on nitro gtt for bp control. CLINICAL INFORMATION: CHF. MR did not increase despite provocative maneuvers suchas volume loading, phenylephrine drip and trendelenburg position.POST-BYPASS: For the post-bypass study, the patient was receiving vasoactiveinfusions including phenylephrine and is being paced1. No c/o pain when asked. I certifyI was present in compliance with HCFA regulations. LS WET WHEEZES, 20MG IV LASIX ADMINISTERED & NEBS PER RT. Overall leftventricular systolic function is normal (LVEF>55%).3. Received warm. CT TO 20CM SUCTION WITH SEROUSANGUINOUS DRAINAGE. | 14 | [
{
"category": "Radiology",
"chartdate": "2145-04-20 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1005199,
"text": " 1:21 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: r/o PTX/Effusion\n Admitting Diagnosis: AORTIC STENOSIS\\AORTIC AND MITRAL VALVE REPLACEMENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with AS s/p AVR. Please page at with\n abnormalities.\n REASON FOR THIS EXAMINATION:\n r/o PTX/Effusion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post AVR.\n\n FINDINGS: In comparison with the study of , there is now an endotracheal\n tube in place with its tip approximately 5.7 cm above the carina. Intact\n sternal sutures are seen. Right IJ Swan-Ganz catheter tip lies in the\n proximal right pulmonary artery. Nasogastric tube extends to the upper\n stomach. Atelectatic changes are seen at the left base.\n\n IMPRESSION: Standard appearance following cardiac surgery.\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-04-18 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1004906,
"text": " 4:05 PM\n CHEST (PA & LAT) Clip # \n Reason: CHF, effusion\n Admitting Diagnosis: AORTIC STENOSIS\\AORTIC AND MITRAL VALVE REPLACEMENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with AS / MR\n REASON FOR THIS EXAMINATION:\n CHF, effusion\n ______________________________________________________________________________\n FINAL REPORT\n CHEST TWO VIEWS, at 15:05.\n\n CLINICAL INFORMATION: CHF.\n\n FINDINGS:\n\n Two views of the chest are obtained without comparison studies. The lungs are\n clear. The cardiomediastinal silhouette is unremarkable. The bones are\n osteopenic. There are degenerative changes in the thoracic spine and about\n the shoulders.\n\n IMPRESSION:\n\n No active disease in the chest.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-04-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1005641,
"text": " 10:46 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval pleural effusions\n Admitting Diagnosis: AORTIC STENOSIS\\AORTIC AND MITRAL VALVE REPLACEMENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman s/p AVR\n REASON FOR THIS EXAMINATION:\n eval pleural effusions\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest portable AP on .\n\n COMPARISON: and .\n\n HISTORY: 84-year-old woman status post AVR, evaluate for pleural effusion.\n\n FINDINGS: There is slight increase in the right pleural effusion which is\n small. Persistent moderate left pleural effusion is unchanged. Mild\n cardiomegaly is again noted. No pulmonary edema. Status post cardiothoracic\n surgery with median sternotomy wires with no complications.\n\n IMPRESSION:\n 1. Stable left moderate pleural effusion.\n 2. Slight increase of the small right pleural effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-04-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1005314,
"text": " 9:43 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval ptx s/p CT d/c\n Admitting Diagnosis: AORTIC STENOSIS\\AORTIC AND MITRAL VALVE REPLACEMENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman s/p AVR\n REASON FOR THIS EXAMINATION:\n eval ptx s/p CT d/c\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of a patient after aortic valve replacement.\n\n Portable AP chest radiograph compared to .\n\n The patient was extubated in the meantime interval with removal of the NG tube\n and mediastinal drains. The Swan-Ganz catheter tip terminates at the level of\n the main pulmonary artery. The moderate cardiomegaly is stable. Bibasilar\n atelectasis are again noted, grossly unchanged. A small bilateral pleural\n effusion cannot be excluded. There is no evidence of pneumothorax. The\n patient is not radiologically evident cardiac failure.\n\n"
},
{
"category": "Echo",
"chartdate": "2145-04-20 00:00:00.000",
"description": "Report",
"row_id": 85837,
"text": "PATIENT/TEST INFORMATION:\nIndication: Intra-op TEE for AVR, and MVR\nHeight: (in) 65\nWeight (lb): 204\nBSA (m2): 2.00 m2\nBP (mm Hg): 124/72\nHR (bpm): 54\nStatus: Inpatient\nDate/Time: at 12:04\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Moderate LA enlargement. Mild spontaneous echo contrast in the\nbody of the LA. Mild spontaneous echo contrast in the LAA. Depressed LAA\nemptying velocity (<0.2m/s) No thrombus in the LAA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. No ASD by 2D or\ncolor Doppler.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Normal\nregional LV systolic function. Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic function.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root. Moderately dilated ascending aorta. Focal calcifications in\nascending aorta. Normal aortic arch diameter. Simple atheroma in aortic arch.\nMildly dilated descending aorta. Complex (>4mm) atheroma in the descending\nthoracic aorta.\n\nAORTIC VALVE: Three aortic valve leaflets. Moderately thickened aortic valve\nleaflets. Severe AS (AoVA <0.8cm2). Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. No MS. Mild (1+) MR.\n\nTRICUSPID VALVE: Physiologic TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was under\ngeneral anesthesia throughout the procedure. No TEE related complications. The\nrhythm appears to be atrial fibrillation. See Conclusions for post-bypass data\nThe post-bypass study was performed while the patient was receiving vasoactive\ninfusions (see Conclusions for listing of medications).\n\nConclusions:\nPRE-BYPASS:\n1. The left atrium is moderately dilated. Mild spontaneous echo contrast is\nseen in the body of the left atrium. Mild spontaneous echo contrast is present\nin the left atrial appendage. The left atrial appendage emptying velocity is\ndepressed (<0.2m/s). No thrombus is seen in the left atrial appendage. No\natrial septal defect is seen by 2D or color Doppler.\n2. Left ventricular wall thicknesses are normal. The left ventricular cavity\nsize is normal. Regional left ventricular wall motion is normal. Overall left\nventricular systolic function is normal (LVEF>55%).\n3. Right ventricular chamber is mildly enlarged and free wall motion is\nnormal.\n4. The ascending aorta is moderately dilated. There are simple atheroma in the\naortic arch. The descending thoracic aorta is mildly dilated. There are\ncomplex (>4mm) atheroma in the descending thoracic aorta.\n5. There are three aortic valve leaflets. The aortic valve leaflets are\nmoderately thickened. There is severe aortic valve stenosis (area <0.8cm2).\nTrace aortic regurgitation is seen.\n6. The mitral valve leaflets are mildly thickened. Mild (1+) mitral\nregurgitation is seen. MR did not increase despite provocative maneuvers such\nas volume loading, phenylephrine drip and trendelenburg position.\n\nPOST-BYPASS: For the post-bypass study, the patient was receiving vasoactive\ninfusions including phenylephrine and is being paced\n1. A well-seated bioprosthetic valve is seen in the aortic position with\nnormal leaflet motion and gradients (mean gradient = 15 mmHg). No aortic\nregurgitation is seen.\n2. Biventricular function is preserved.\n3. Aorta is intact post decannulation\n4. MR is still mild\n5. Other findings are unchanged\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-04-21 00:00:00.000",
"description": "Report",
"row_id": 1675236,
"text": "7am-14 update\nneuro: pt alert and orientated. MAE and able to follow commands.\n\nCV: pt remains in afib, with occasional PVC's. HR 80-90's. pt intially on nitro gtt for bp control. goal SBP -> keep SBP < 120 per team. pt started on lopressor PO this am - tolerated well. pt also started on captopril this am. nitro gtt weaned to off after PO meds. (see flowsheet). Svo2 60-70's. CI by fick > 3.0 this am. PA line dc'd and introducer left intact. hct stable. + pp.\n\nresp: LS with exp wheezing bil and dim bases bil. pt initally on 70% face tent -> pt weaned to 4 L NC. o2 sats 92-98%. pt given alb nebs and restarted on advair MDI this am. using IS to 500. CT's dc'd this am -> CXR done\n\ngi/gu: pt with + hypoactive bs. tolerating clears. taking pills without difficulty. foley draining clear yellow urine. UO adequate. started on lasix this am -> diuresing well\n\nendo: pt continues on insulin gtt. insulin gtt tirated per protocol\n\nacivity: OOB to chair with 2 assist\n\nskin: coccyx pink although no breakdown noted. Sternum covered with DSD.\n\nplan: pulm toliet, pain control, keep SBP < 120, advance diet and activity as tolerated, monitor lyte, antibiotics, skin care\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-04-21 00:00:00.000",
"description": "Report",
"row_id": 1675237,
"text": "14-2300 nsg update\nneuro: pt alert and orienated x3. MAE and able to follow commands.\n\nCV: pt remains in afib, HR 70's. pt slightly hypotensive this afternoon, SBP in the mid 80's (see flowsheet) -> pt given fluid bolus and captopril dc'd. BP improved after the fluid bolus. hct stable. + pp\n\nresp: Ls clear with dim bases. pt continues on 4 L nc, o2 sats 92-96%. continues on alb nebs and advair MDI's\n\ngi/gu: pt with + BS. tolerating clears/soft solids. foley draining clear yellow urine. UO adequate -> continues on lasix\n\nendo: insulin gtt dc'd this evening. pt given 30 units Lantus SC x 1 (per protocol). 1 hr later the pt was given 8 units reg insulin SC per protocol. The following HR the insulin gtt was dc'd -> per protocol. see flowhseet\n\nsocial: daughter into visit this evening\n\nplan: monitor HR and BP, monitor lytes, advance diet and acitivty as tolerated, MDI's, antiobiotics, pulm toliet, pain control\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-04-22 00:00:00.000",
"description": "Report",
"row_id": 1675238,
"text": "7P-7A NPN\n\nROS:\n\n\nNEURO: A/OX3. PLEASANT & COOPERATIVE. HOH. PERRLA. MAE, CONSISTENTLY FOLLOWS COMMANDS. PICKING AT LINES & O2 TUBING. PO PERCOCET FOR INCISIONAL PAIN WITH COUGHING.\n\nCV: CHRONIC AFIB 80S. RARE PVCS NOTED. LYTES REPLETED PRN. 2A/2V EPICARDIAL WIRES, PACER OFF; INAPPROPRIATLEY SPIKING. PALPABLE PULSES BILAT.\n\nRESP: LS CL DIM BASES. WET CONGESTED NON-PRODUCTIVE COUGH. 70% FACE TENT 02SAT >94%. WHZS WITH EXERTION.\n\nGU/GI: FOLEY TO GRAVITY. DIMINISHED HUO, 10MG IV LASIX ADMINISTERED WITH (+)DIURESIS. ABD OBESE (+)BS. SWALLOWING WITHOUT DIFFICULTY.\n\nENDO: GLUCOSE COVERAGE PER RISS PROTOCOL.\n\nPLAN: TRANSFER TO 6.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-04-20 00:00:00.000",
"description": "Report",
"row_id": 1675233,
"text": "Nursing 7a-7p\n84yr old w/hx of severe AS found in when pt presented to osh w/sob and near syncopal episode. s/p AVR tissue valve today. No underlying rhythm after valve replacement intra-op.\n\nReceived on neo and prop. Neo weaned off quickly. AV async paced, no underlying when received post-op. Pacer box battery replaced. When pacing turned down later hr 40s ?afib vs junctional w/SBP in the 60s. Fluid boluses for low filling pressures. Nitro started for hypertension, sbp >120. Currenty titrating up. Hct >30. SVO2 60-70s. First box did not monitor CCO, despite recal, \"cable test failed\". Monitor and cables swapped out. Cont to not monitor CCO, again \"cable test failed\". NP aware. Will monitor ficks. CI>2 by fick. Min sang drainage from 2 mediastinal CTs. CXR done, reviewed by np . Unable to obtain EKG d/t no underlying. Placed on simv 100% 5/5. abg wnl. Weaned to 50% fio2. Received warm. Pt reversed. Prop weaned off. Currently waiting for pt to waken. Daughter, , into visit w/pt. Dtr updated on pt's status, icu guidelines were given to her by this RN.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-04-20 00:00:00.000",
"description": "Report",
"row_id": 1675234,
"text": "nursing add\nPropfol remains off. Pt still very lethargic. Does open eyes and move all extremeties weakly on command. Does not lift head off pillow. No c/o pain when asked. ETT 6cm up from carina NP - ok to leave as is for now, ETT to be advanced if pt does not extubate tonight per team. pH normal. Sat 99-100%. Breath sounds equal throughout. Pacer turned down again, underlying afib 70s. EKG done. After 10min of allowing underlying rhythm sbp and svo2/CI decreased. Fluid boluses admin. Nitro decreased. pt vpaced at higher rate. bp increased when on rate and ci/svo2 increased after fluid. Per pt's daughter: pt is primary care giver of her husband who has dementia. Pt does have children as family support.\n\nPlan: Awaiting pt to wake/become more alert. Once awake pt can wean to extubate. Fluid resuscitation. Maintain ci>2. Monitor response to underlying rhythm. Wean nitro keeping sbp <120. Pt needs inhalers & glaucoma drops reordered. ?Social work consult.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-04-21 00:00:00.000",
"description": "Report",
"row_id": 1675235,
"text": "7P-7A NPN:\n\nROS:\n\nNEURO: SLOW TO WAKE. PT STILL LETHARGIC. A/OX3. PERRLA. MAE; CONSISTENTLY FOLLOWS COMMANDS. HOH. TMAX AT TIME OF NOTE 100.4. IV MORPHINE FOR PAIN.\n\nCV: VPACED MOST OF NOC. UNDERLYING CHRONIC AFIB WITH PVCS. PA CATHETER IN PLACE. LOW FILLING PRESSURES WITH NO RESPONSE TO FLUID. SEE CAREVUE FOR FILLING PRESSURES. FICK CI >2.2 SVO2 >68. PALPABLE PULSES BILAT. NTG GTT GOAL SBP <120.\n\nRESP: EXTUBATED @ 0400 TO 50% FACE TENT; 02SAT 94% ^TO 70% FACE TENT. POST EXTUBATION ABG WNL. LS WET WHEEZES, 20MG IV LASIX ADMINISTERED & NEBS PER RT. CT TO 20CM SUCTION WITH SEROUSANGUINOUS DRAINAGE. (-)AIRLEAK.\n\nGU/GI: FOLEY TO GRAVITY WITH MARGINAL HUO. ABD OBESE (-)BS.\n\nSEE CAREVUE FOR SKIN ASSESSMENT.\n\nENDO: GLUCOSE COVERAGE PER POST-OP PROTOCOL.\n\nPLAN: MONITOR HEMODYNAMICS. PULMONARY TOILETING.\n"
},
{
"category": "ECG",
"chartdate": "2145-04-28 00:00:00.000",
"description": "Report",
"row_id": 214256,
"text": "Atrial fibrillation. Poor R wave progression. Non-specific ST-T wave changes.\nCompared to the previous tracing of the lateral downsloping ST segment\nhas resolved.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2145-04-20 00:00:00.000",
"description": "Report",
"row_id": 214257,
"text": "Atrial fibrillation with controlled ventricular response. Delayed precordial\nR wave transition. Compared to the previous tracing of there are more\nprominent inferolateral ST segment changes. Otherwise no diagnostic interim\nchange.\n\n"
},
{
"category": "ECG",
"chartdate": "2145-04-18 00:00:00.000",
"description": "Report",
"row_id": 214258,
"text": "Atrial fibrillation. Diffuse non-specific ST-T wave changes. Compared to the\nprevious tracing there is no significant change.\n\n"
}
] |
4,761 | 167,578 | Respiratory: Infant was initially in room air upon admission and developed some grunting and retractions shortly after admission to the Neonatal Intensive Care Unit and was placed on CPAP, 5 cm of water, requiring 21 percent FI02. Infant remained on CPAP until day of life two. Infant transitioned to room air on day of life two and has remained in room air throughout this hospitalization with respiratory rate of 40 to 60. Infant has not had any apnea or bradycardia this hospitalization. Infant is not being treated with methylxanthine. | Isvoiding well and stooled lge mec. Will recheck in am.CLincially stable off abx.COntinue as at present. NPN 0700-1900RESP: Remains in RA, LS C/=, mild IC/SCR. Lytes drawn w/last cares.G/D: Temp stable nested in servo isolette. Lytes in good range.Bili in 11 range under phtoorx. Plan to obtain electrolytestomorrow morning.DEV: Temps stable, weaning servo control isolette. O2 saturations 93-99%.Mild SC retractions noted during cares. RN provided update. O: Infant remains under double phototherapy. LS clear/=,mild SC/IC retractions present. Am lytes 144/4.5/110/23/18. Tocheck bili on AM (along with lytes). NICU Fellow PNNo spells, mild desats. Lytes and bili in am . O: Infant remains on TF's of 140cc/k/d of SSC24. Updated atbedside. Am bili 11.3/0.3. STill req gavage.Bili in 11 range. Cont to advance feedsas tol.G&D: Temp stable nested in servo isolette. NPN 7A-7P#2 LS = clear, RR 50-70's, mild retractions. Cont to support and upate.Bili: Conts under single phototx. Spells not problem.Wt 2215 down 20. Bili this a.m.was 12.0/0.3. NICU Fellow PNNo spells. Mild sc retractions noted. Abd benign, noloops, +BS. , M.D. Ag stable 27.5cm.Dstick 86. in Resp. Plan: Continue tomonitor respiratory status.3. No spells.A: Appropriate for GAP: Continue to support developmental needs.#5 Alt. RR 30's-60's with mild SC retractions. Dstick 74. NPN 0700-2. Eye shiledsin place. Enteral feedingscurrently at 45cc/kg/d BM20/SC20, given via gavage q4hrs andincreased 15cc/kg/d as tolerated. O: Infant remains in low heat isolette under doublephototherapy with stable temp. 0700- NPN1 Infant with Potential SepsisSEPSIS: 48 r/o complete. D10 2,1 infusing viaPIV. Con't tosupport.#6 Remains under double photo with eye and genitalprotection in place. Continue phototherapy, lytes and bili in am . Mild RDS, still completing abx rule out for sepsis. Fontanels aresoft and flat. Will followFamily meeing held yesterday.COntinue as at present. NeonatologyDoing well. NeonatologyDOing well. Updated at the bedside by this RN. Took bottle this am. Rec'ingBM/SCF20 currently at 115cc/k/d, all ng over 30 min (thoughsucks on pacifier well, not interested in bottling). No spellsWeight 2280PE: Gen: Awake, MAE, pink and in NADHEENT: AFOF, soft, scalp edema and bruising of forehead. Stable off CPAP. 24bili level drawn. Neuro nopn-focal and age appropriate. Temp. Move to isolette this PM. in Resp. Cor nl s1s2 w/o mutmrus. IVF conception, EDC . TF 80 cc/k/d. Skin w/o leisosn. Breath sounds, resp rate, and WOBdecreased to wnl after that. bili=7.2/0.2/7.4. RR 30-60s with mild sc/ic retrx. tone wnl. RR 30's-70's with mild IC/SC retractions. MAE AFF. Updated. jaundiced, bili this am 11.5/.3. P:cont. P:cont. P:cont. On TF of80cc/k/day. Wt. Sm. Afebrile. Pt. Pt. Pt. Pt. Pt. Pt. in RA, RR 40-60, LS clear and equal, SC and ITCretractions present. Desat X 1 with shallow breathing.A: Appropriate for GAP: Continue to support developmental needs. Improved resp. TF at 80 cc/k/d. Infant isedematous. A/g . A: Cx pending P: Antibx as ordered. Follow D/S and daily wts. NeonatologyOn CPAP. Will start feeds when stable off cpap. Lytes in good range.Tempo sl elevated this am. TBILI 7.6 A: Bili level wnl P: Monitor NPO at present. 24 lytes sentA: Stable NPO P: Accurate I/Os . NeonatologyDoing well. Monitor for s/s ofinfection2. In RA. Appears to be environmental.Jaundiced with bili in 7 range.On abx for 48 h r/o. well perfused, jaundiced. Temp wnl underradiant warmer. Temp and VS WNL. to support nutritionalneeds.4remains swaddled in air isolette, temp stable, a/a withcares, settles well in between, fonts soft/flat, bringshands to mouth. Infant has remained in RA with sats 95-98. status.#3FEN. NSR. Placed undersingle phototherapy with eyeshields in place. mec stool X 1. A PIV was placed and infant is receiving D 10W at 80cc/k/d. Monitor D/S4. Nobradys. BS clear. alert,irritable with cares, settles between cares. Comfortable apeparing.Wt 2280 down 5. Abd. Abd. 1. One desats to 78 noted, associated with shallow breathing. Beginning feeds. Well-perfused with brisk cap refill x4 extrem. Advance feeds as able and encourage stooling.#6 Alt. Care 20 Q 4 hrs. Will continue adavnacing feed volume as tolerated and keep TF at 80 cc/k/d.Bili in range. Continue phototherapy, check bili inb am , M.D. are independent intemp taking and diaper change. Monitor weight progression.DEVELOPMENTO: Temp stable in air mode isolette. Resp rate, Breathsounds, and WOB are at baseline. Breath sounds, resprate, and WOB are at baseline. Transferredto open crib and maintaing temp well. P: Cont to supportdevelopment.#5 O: Both in to visit. Wgt: 2.480k ^30g A:Stable, tolerating feeds. Swaddled after bililights turned off and isolette weaned slightly. Weaned off isolette P Monitor5. Temp WNL in open crib A: Stable/Appropriate P: Monitor. Wgt:2.355k ^75g A: Stable,tolerating feeds P: Encourage PO feeds when awake andalert. Abd exam benign. Well-perfused with brisk cap refill x4 extrem.No spells A: Stable CV/RESP status P: Monitor anddocument spells.3. PARENTING O: in to visit. Mom has appt with LCtomorrow. Awakensbefore feeding is due. She has not yet voided but has had a large mec stool.P: As per NICU protocol and infant needs. P: Cont tomonitor.#4 O: Maintaining temp in oac. BP 64/31 (43).Wt 2450 (+65) on TFI 140 cc/kg/day SC/BM24, tolerating well orally and by gavage. Ampi and gent were given.CV: BP means are wnl. Stool x2 thus far quaic -. BP 62/34 (44).Wt 2480 (+30) on TFI 140 cc/kg/day BM/SC24, tolerating well orally and by gavage. Receiving 58cc BM 24/SCC24 q4PO/NG. Updated regardinginfant's status and plan of care. Abd soft, active bowel sounds, voiding and stooling. D/C phototherapy, check rebound bili in AM. BP 72/38 (56).Wt 2385 (+30) on TFI 140 cc/kg/day SC24/BM24, tolerating well. P- Cont to assess for respneeds.#3-O/A- TF=140cc/kg/d of BM/SC24 via po/pg. NPN 0700-1500#2 O: Infant remains in RA. Advance feeds astolerated.4. Neonatology - NNP PRogress Note is active with good tone. Abd benign. P: Cont to monitor.#3 O: TF= 140cc/kg/d. RR 40-60s with mild SCretrx noted. She is appropriate and active.F/N: Infant is currently NPO on 80cc/k/d of IVF infusing via a PIV. P- Cont to assess for Resp needs.#3-O/A- TF=140cc/kg/d of BM/SC24 via po/pg. | 57 | [
{
"category": "Nursing/other",
"chartdate": "2200-09-28 00:00:00.000",
"description": "Report",
"row_id": 1743080,
"text": "Respiratory Care Note\nThis 33 wga twin was placed on +5 prong CPAP today for grunting, retractions and desat's to the low 80's requiring BBO2. FiO2 21-25%. BS clear. RR 50-70's. Grunting stopped once on CPAP.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-10-02 00:00:00.000",
"description": "Report",
"row_id": 1743105,
"text": "NPN 7p-7a\n\n\nResp: Infant remains in RA. Ls clr/=. RR 40-60's. No spells\nor desats so far this shift. Mild sc retractions noted. Cont\nto monitor.\n\nFen: Wt 2.215kg (-15gms). Conts on tf 120cc/kg. Ivf of d10w\n2:1 at 20cc/kg via piv. Enteral feeds at 100cc/kgof sc/bm20.\nIncreasing 15cc/kg at 04&16. Tol feeds well. no spits.\nMinimal aspirates. Abd soft. Mec stool x2. Ag stable 27.5cm.\nDstick 86. Am lytes 144/4.5/110/23/18. Cont to advance feeds\nas tol.\n\nG&D: Temp stable nested in servo isolette. Alert and active\nwith cares. Settles well in prone position. Loves pacifier.\nCont to support developmental milestones.\n\nParenting: Mom in this evening for visit. Updated at\nbedside. Cont to support and upate.\n\nBili: Conts under single phototx. Am bili 11.3/0.3.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-10-02 00:00:00.000",
"description": "Report",
"row_id": 1743106,
"text": "Neonatology\nDoing well. REmains in RA. Spells not problem.\n\nWt 2215 down 20. Tolereating feeds at 100 out of TF 120 cc/k/d. Abdomen benign. WIll increase TF to 140 cc/ cc/k/d and advance feeds as tolerated. Lytes in good range.\n\nBili in 11 range under phtoorx. Will follow\n\nFamily meeing held yesterday.\n\nCOntinue as at present.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-10-02 00:00:00.000",
"description": "Report",
"row_id": 1743107,
"text": "NICU Fellow PN\nNo spells, mild desats. Working up on feeds\nWeight 2215 (down 20g)\nPE: Asleep on abdomen, breathing comfortably, in NAD\nHEENT: AFOF, OP clear, ng in place, MMM\nChest: Clear BS bilaterally, no distress\nCV: RRR, no murmur, cap refill brisk\nAbd: Soft, NT, ND, normal BS\nExt: \nPlan: 4 day-old 33 weeker, stable on room air. Increase fluids to 140 cc/kg/day. Will be almost to full feeds with BM/SC 20 tonight. Will advance cal tomorrow. Lab holiday tomorrow, continue bili lights for bili 11.3 today. Family meeting yesterday; parents fully updated. Declined Hep B vaccine so will readdress this closer to d/\n , M.D.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-10-02 00:00:00.000",
"description": "Report",
"row_id": 1743108,
"text": "NPN 7A-7P\n\n\n#2 LS = clear, RR 50-70's, mild retractions. Saturations\n>96%. No desat's or brady's. Con't to monitor.\n\n#3 TF increased to 140cc/k/d of enteral/IV fluids. Rec'ing\nBM/SCF20 currently at 115cc/k/d, all ng over 30 min (though\nsucks on pacifier well, not interested in bottling). Is\nvoiding well and stooled lge mec. Abdomen is soft but full,\nminimal residuals. Plan to increase enteral feeds by\n15cc/k/d at 4A-4P as tolerated. PIV infusing D10\nw/lytes, titrating as enterals increase. Con't to monitor\nfeed toleration.\n\n#4 Maintaining temp in air-control isolette, very alert,\nvigorously sucks on pacifier but gets disinterested to\nbottle. Will con't to attempt feeds. Also has small linear\nhealing excoriation at septum of nares which is intact.\n\n#5 Mom discharged today, dad in to visit. Family Meeting\nheld yesterday, and parents stated that they have no\nquestions at this time. Mom a bit but will visit when\nable. Will call with re: when she will be visiting. Con't to\nsupport.\n\n#6 Remains under double photo with eye and genital\nprotection in place. TF now at 140cc/k/d, is stooling,\nincreasing enteral feeds. Active, has resolving bruising. To\ncheck bili on AM (along with lytes).\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-10-03 00:00:00.000",
"description": "Report",
"row_id": 1743114,
"text": "NPN 0700-1900\n\n#2 Alt. in Resp. Function\nO: In RA wih sats 95-100. Breath sounds are clear and =. RR 30's-60's with mild SC retractions. No spells.\nA: Doing well in RA\nP: Continue observation and monitoring of resp. function. Document any spells.\n\n#3 Alt. in Nutrition\nO: TF=140cc/kg=54cc BM/Sp.Care 20, Q 4 hrs. Abd. is round, soft with + BS, no loops. Small aspirates, no spits. Voiding and stooling. PO fed X 3. Took 25-52cc by bottle. Latched on at breast and sucked intermittently ~ 5 min. Gavage fed remainder.\nA: Tolerating feeds well thus far, beginning to PO feed\nP: Continue with present feeding plan. Observe for feeding tolerance and follow daily wt. Encourage POs as able. Advance to 24cals tonight.\n\n#4 Alt. in Development\nO: Maintaining temp in low air isolette, nested with boundaries in place. Positioned changed Q 4 hrs. Starting to wake for some feeds. Alert and active with cares. Took one full bottle today. No spells.\nA: Appropriate for GA\nP: Continue to support developmental needs.\n\n#5 Alt. in Parenting\nO: Parents here from 1200-1800. Updated and questions answered. Reviewed temp taking and both parents able to take temps w/o difficulty. Discussed car seat screening, hearing screening, State screens, CPR class and possible transfer to SCN to be closer to home. Mom put infant to breast and Dad gave a bottle for the first time.\nA: Involved, parents, learning to care for twin daughters\nP: informed and support. Continue teaching.\n\n#6 Hyperbilirubinemia\nO: Double phototherapy in progress with eyes covered. Color is less jaundiced. Infant on full feeds and passing stool.\nA: Decreasing bili\nP: Continue with phototherapy and check bili in AM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-10-04 00:00:00.000",
"description": "Report",
"row_id": 1743115,
"text": "Nursing Progress Note\n\n\n#2. O: Infant remains in RA with O2 sats >95%. RR 40's-60's.\nBreath sounds are clear and equal Mild SC retractions noted.\nNo spells thus far. A: No spells. P: Continue to monitor\nresp status.\n\n#3. O: Infant remains on TF's of 140cc/k/d of SSC24. PO \nvolume x1. No spits, no aspirates. Abd soft and round with\nactive bowel sounsd. No loops. Voiding qs. Med mec x2. WGt\nis up 25gms to 2280gms. A: Tolerating feeds. P: Continue to\nencourage po feeds as tolerated.\n\n#4. O: Infant remains in low heat isolette under double\nphototherapy with stable temp. She is alert and active with\ncares. MAEW. A: AGA. P: Continue to assess and support\ndevelopmental needs.\n\n#5. No contact from this shift.\n\n#6. O: Infant remains under double phototherapy. Eye shileds\nin place. A :Hyperbili. P: Continue to monitor.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-10-01 00:00:00.000",
"description": "Report",
"row_id": 1743103,
"text": "Social Work\n\n\nMet with mother yesterday while visiting babies, and also later in the day in her room.\nShe is a 40 year old G2P0-1, married woman living with her husband in . This was an IVF pregnancy, complicated with need for admission at 22 weeks gestation, then placed on limited bedrest, admitted here on . Now following delivery at 33 weeks gestation of twins. Mother talked about emotional fluctuations she has felt over the past day, and how unusual this is for her. We talked about issues involved in fertility treatment, then problems during the pregnancy and most recent admission. Talked about hormonal changes and stress of being separated from babies, wanting to be more involved in their care. Normalized situation for this mom and encouraged verbalization of her feelings. Her husband is presently out of work, and has been very involved during this pregnancy, she was working in a biotech company until placed on bedrest for the past two months. Mother identified some friends who will be avilable for support, and will also have assistance of her mother who lives on .\nMother very pleasant and engaging, needs support as she adjusts to preterm delivery and demands of parenting twins.\nWill plan to follow, support and provide resource information as needed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-10-01 00:00:00.000",
"description": "Report",
"row_id": 1743104,
"text": "NPN 0700-\n\n\n2. RES: Infant is in RA, RR 30-50's. O2 saturations 93-99%.\nMild SC retractions noted during cares. No episodes of apnea\nor bradycardia thus far during this shift. Plan: Continue to\nmonitor respiratory status.\n\n3. FEN: TF currently at 120cc/kg/d. IVF of D10W 2NaCl and 1\nKCl infusing through PIV at 50cc/kg/d. Enteral feeds at\n70cc/kg/d, increasing by 15cc/kg/d . Abd benign, no\nloops, +BS. No stool thus far this shift. No spits, no\naspirates. AG stable at 27cm. DS 83. U.O. for the past eight\nhours= 3.8cc/kg/hr. Plan: Continue to increase enteral\nfluids er order and monitor FEN.\n\n4. G&D: Infant is nested in a servo isolette with stable\ntemperatures. Alert and active during cares. Fontanels are\nsoft and flat. Loves to suck on pacifier. MAE. Plan:\nContintue to monitor G&D.\n\n5. PAR: Parents in to visit today. Asking appropriate\nquestions. Updated at the bedside by this RN. Family meeting\ntoday at 1330. Plan: Continue to keep parents updated.\n\n6.BILI: Infant remains slightly jaundiced. Bili this a.m.\nwas 12.0/0.3. Infant is under double phototherapy with eye\nshields in place. Bilirubin and electrolyte levels to be\ndrawn tomorrow morning. Plan: Continue to monitor for\nevidence of hyperbilirubinemia.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-30 00:00:00.000",
"description": "Report",
"row_id": 1743100,
"text": "NICU Fellow PN\nStarted on phototherapy for bili 11.5 overnight. Transitioned to room air. No spells\nWeight 2280\nPE: Gen: Awake, MAE, pink and in NAD\nHEENT: AFOF, soft, scalp edema and bruising of forehead. OP clear, nares patent, MMM\nChest: Good aeration, clear BS, mild retractions, no flaring\nCV: RRR, no murmur, cap refill 2 seconds\nAbd: Soft, full, normal BS, NT\nExt: , \nPlan: 33 week twin now on dol 2. Mild RDS, still completing abx rule out for sepsis. Plan to start feeds today at 40 cc/kg and advqance 15 . Increase TF to 100 cc/kg/day. Lytes and bili in am . Continue phototherapy, d/c abx in am if cx remain negative. Will update parents today.\n , M.D.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-10-01 00:00:00.000",
"description": "Report",
"row_id": 1743101,
"text": "NPN 0700-1900\n\n\nRESP: Remains in RA, LS C/=, mild IC/SCR. Not on caffeine,\nno spells/desats thus far this shift.\n\nFEN: Tolerating working up on feeds well, no spits or\naspirates. Abdomen soft/full, good bs, no loops, girth\nstable. Voiding, no stool thus far. D10 2,1 infusing via\nPIV. D/S stable. Lytes drawn w/last cares.\n\nG/D: Temp stable nested in servo isolette. A&A w/cares,\nstarting to wake for feeds, sleeps well in between. Sucks on\npacifier for comfort.\n\nPARENTS: Both parents in to visit, updated by this RN,\nasking appropriate questions. Dad held . Family meeting\nplanned for Wed () @ 1330.\n\nBILI: Received infant under single phototherapy, eye shields\nin place. Increased to double phototherapy due to increase\nin bili level.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-10-01 00:00:00.000",
"description": "Report",
"row_id": 1743102,
"text": "NICU Fellow PN\nNo spells. Changed to double phototherapy\nWeight 2235 (down 45g)\nGen: Quiet, lying on abdomen, in NAD\nHEENT: Bili mask on, AFOF, soft, MMM\nChest: Min intercostal retractions, clear BS\nCV: RRR, no murmur, cap refill 3 sec\nAbd: Soft, NT, Nd, normal BS\nExt: \nPlan: Advance TF to 120 cc/kg/day, increasing feeds 15 . My increase by 20 if she tolerates this. Continue phototherapy, lytes and bili in am . Family meeting today at 130pm\n , M.D.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-30 00:00:00.000",
"description": "Report",
"row_id": 1743094,
"text": "0700- NPN\n\n1 Infant with Potential Sepsis\n\nSEPSIS: 48 r/o complete. No evidence of sepsis at this time.\n\nRESP: Remains in RA with RR 30s-60s, sats >94%. LS clear/=,\nmild SC/IC retractions present. No bradys or desats at this\ntime.\n\nFEN: TF increased to 100cc/kg/d. IVFs D10w with 2NaCl+1KCl\ninfusing via PIV at 55cc/kg/d at this time. Enteral feedings\ncurrently at 45cc/kg/d BM20/SC20, given via gavage q4hrs and\nincreased 15cc/kg/d as tolerated. No spits, min asp.\nAbdomen soft, full, no loops, active BS. Voiding, no stool\nat this time. Dstick 74. Plan to obtain electrolytes\ntomorrow morning.\n\nDEV: Temps stable, weaning servo control isolette. Infant is\nnested with sheepskin. MAE, fontanels soft and flat. Alert\nand active with cares, sleeping between cares. Brings hands\nto midline, sucks on pacifier for comfort. AGA.\n\nPARENTING: Mom visited at 1230 today, following infant's\ncares. RN provided update. Mom was and expressed that\nshe is feeling sad and worried about having her infants'\nborn prematurely and in the NICU. She also expressed that\nshe is concerned about her low milk supply. This RN provided\nMom support and encouragement and SW met with her briefly as\nwell. Lactation consult spoke with her about pumping. Mom\nappears and appropriately concerned. Hepatitis B\nVaccine information sheet provided.\n\nBILI: Continues under single photothx; most recent bilirubin\nlevel 11.5/0.3, plan to recheck tomorrow morning.\n\nREVISIONS TO PATHWAY:\n\n 1 Infant with Potential Sepsis; resolved\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-30 00:00:00.000",
"description": "Report",
"row_id": 1743095,
"text": "0700- NPN\nCORRECTION TO RESP NOTE ABOVE: Infant has had 2 desaturations thus far this shift, both down to the 70% range. See flowsheet for details.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-30 00:00:00.000",
"description": "Report",
"row_id": 1743096,
"text": "NICU Lactation Note-\nMet with Mom to discuss pumping for her 3 day old ~33 week twins. Mom asked questions about how much milk she should be pumping, how often to pump, how \"high\" to turn up the vaccum on the pump, etc. Questions were answered and general use of the pump was reviewed. Also demonstarted use of the vacuum setting use the SMB pump as an example. Pamphlets on Pumping and Storage and Transport of breastmilk were given to her. Encouraged her ask any further questions and ask for assistance when it is time to put her babaies to breast.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-30 00:00:00.000",
"description": "Report",
"row_id": 1743097,
"text": "Social Work\nMet mother at the bedside today, she was , stating that she had anticipated that she would be feeling stronger, expressing concern about managing care of twins. Will plan to see her later today, assess supports and adjustment to preterm delivery.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-30 00:00:00.000",
"description": "Report",
"row_id": 1743098,
"text": "NICU Fellow PN\nNote correction: Antibiotics discontinued, as cx neg at 48 hrs of life today at 0100.\n \n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-30 00:00:00.000",
"description": "Report",
"row_id": 1743099,
"text": "NICU Fellow PN\nNote correction: Antibiotics discontinued, as cx neg at 48 hrs of life today at 0100.\n \n"
},
{
"category": "Nursing/other",
"chartdate": "2200-10-03 00:00:00.000",
"description": "Report",
"row_id": 1743111,
"text": "Neonatology\nDOing well. REmains in RA. No spells. Comfortable appearing.\nNo murmur\n\nWt 2255 up 40. Tolerating feeds at 115 out of TF 140 cc/k/d. Abdomen benign. Took bottle this am. STill req gavage.\n\nBili in 11 range. Continues under photorx. Will recheck in am.\n\nCLincially stable off abx.\n\nCOntinue as at present.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-10-03 00:00:00.000",
"description": "Report",
"row_id": 1743112,
"text": "Neonatology\nWill increase to 24 cal.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-10-03 00:00:00.000",
"description": "Report",
"row_id": 1743113,
"text": "NICU Fellow PN\nTook all of one feed by mouth. No A/B in last 24 hrs\nWeight 2255 (up 40g)\nHEENT: AFOF, soft, OP clear\nChest: Clear BS bilat, no distress\nCV: RRR, no murmur, cap refill brisk\nAbd: Soft, NT, ND, no masses, normal BS\nExt: \nPlan: 5 day-old 33 weeker working on po feeds. No apnea. Up to full volume, will increase to 24 cal/oz today. Continue phototherapy, check bili inb am \n , M.D.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-10-03 00:00:00.000",
"description": "Report",
"row_id": 1743109,
"text": "PCA 1900-0700\n\n\n2\nRA, RR30-70, O2 SATs 96-100%, lung sounds cl=, mild sc\nretractions, no spells, no desats. P:cont. to monitor.\n\n3\nBW 2300g, CW 2255g ^40g, TF 140cc/kg/d, feeds increased from\n115cc/kg/d to 130cc/kg/d, needs 50cc q4h of sc20, infant\nbottled 20cc and 30cc with good coordination, full gavages\nover 40 minutes, no spits, abd soft, bs+, no loops, ag\n25.5-26.5, max asp 4.6cc, voiding qs urine output 198 in 24\nhours, small mec stool. P:cont. to support nutritional\nneeds.\n\n4\nremains swaddled in air isolette, temp stable, a/a with\ncares, settles well in between, fonts soft/flat, brings\nhands to mouth. P:cont. to support growth and development.\n\n5\nno known contact thus far this shift.\n\n6\nremains under double photo tx, with eye shields.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-10-03 00:00:00.000",
"description": "Report",
"row_id": 1743110,
"text": "NPN 7p-7a\n\n\nADD: I have examined infant and agree with above note\nwritten by PCA. Infant ivf at 10cc/kg of d10w\n2:1. Enteral feeds increasing 15/cckg as ordered.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-30 00:00:00.000",
"description": "Report",
"row_id": 1743089,
"text": "NPN 1900-0700\n\n\n#1Potential sepsis. Pt. well perfused, jaundiced. BP 56/31,\nMAP 39. BC negative at 48 hrs, antibiotics d/ced. Plan to\nmonitor for signs of sepsis.\n\n#2Resp. Pt. in RA, RR 40-60, LS clear and equal, SC and ITC\nretractions present. Sat 95 and above, no noted desats. No\nbradys. Plan to continue to monitor resp. status.\n\n#3FEN. Wt. 2280 gms, down 5 gms. BW 2300 gms. On TF of\n80cc/k/day. Currently receiving D10 with lytes via PIV at\n35cc/k/day. Enteral feeds of BM/SC20 increased to 45cc/k/day\nat 0430. Pt. has had no spits, minimal aspirates. Abd. soft,\nactive BS, no noted loops, stable girth. No stool overnight.\nUrine output 2cc/k/hr last 12 hrs, 1.8cc/k/hr yesterday.\nDstick 64. Plan to continue to advance enteral feeds as\ntolerated.\n\n#4G/D. Pt. received on open warmer with servo control, now\nin isolette with servo control. Temp. stable. Pt. alert,\nirritable with cares, settles between cares. MAE AFF. Takes\npacifier occasionally. Continue to support dev. needs.\n\n#5Parenting. Both parents here for evening cares, updated at\nbedside, asking appropriate questions. Mom held . Plan\nto continue to support and update parents.\n\n#6Bili. Pt. jaundiced, bili this am 11.5/.3. Placed under\nsingle phototherapy with eyeshields in place. Plan to\ncontinue phototherapy.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-30 00:00:00.000",
"description": "Report",
"row_id": 1743090,
"text": "Neonatology\nTF to be increased to 100 cc/k/d.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-30 00:00:00.000",
"description": "Report",
"row_id": 1743091,
"text": "Neonatology\nTF to be increased to 100 cc/k/d.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-30 00:00:00.000",
"description": "Report",
"row_id": 1743092,
"text": "Neonatology\nDoing well. Stable off CPAP. Comfortable apeparing.\n\nWt 2280 down 5. TF at 80 cc/k/d. Feeds at 45 cc/k/d being tolerated. Will continue adavnacing feed volume as tolerated and keep TF at 80 cc/k/d.\n\nBili in range. WIll follow.\n\nTemp stable in isollette.\n\nFamily meeting to be arranged.\n\nContinue as at present.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-30 00:00:00.000",
"description": "Report",
"row_id": 1743093,
"text": "0700- NPN\nCORRECTION TO RESP NOTE ABOVE: Infant has had 2 desaturations thus far this shift, both down to the 70% range. See flowsheet for details.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-29 00:00:00.000",
"description": "Report",
"row_id": 1743086,
"text": "Case Managment\n File reviewed. Please , RN Case Manager at for assistance with discharge issues.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-29 00:00:00.000",
"description": "Report",
"row_id": 1743087,
"text": "Respiratory Care Note\nBaby Girl I was taken off CPAP this am. In RA. BS clear. Has had one desat since off CPAP. Appears comfortable with no increased WOB.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-29 00:00:00.000",
"description": "Report",
"row_id": 1743088,
"text": "NPN 0700-1900\n\n#1 Possible Sepsis\nO: Infant active and alert with good tone and color. Temp and VS WNL. IV Ampicillin given Q 12 hrs as ordered. Improved resp. status.\nA: No s/s sepsis\nP: D/C antibiotics after 48 hrs if BC remain neg.\n\n#2 Alt. in Resp. Function\nO: CPAP D/C'd at 1130. Infant has remained in RA with sats 95-98. RR 30's-70's with mild IC/SC retractions. Breath sounds are clear. One desats to 78 noted, associated with shallow breathing. Mild stim. to recover.\nA: Doing well in RA off CPAP\nP: Continue close observation and monitoring for any resp. issues. Document any spells.\n\n#3 Alt. in Nutrition\nO: TF=80cc/kg. Feeds started at 1600. PIV D10/2NaCl+1KCl at 50cc/kg=4.7cc/hr and feeds at 30cc/kg=12cc BM/Sp. Care 20 Q 4 hrs. Abd. is large and round, but soft with +BS, no loops. Girth 28-30 cm. Voiding QS, small mec. stool X 1.\nA: Beginning feeds\nP: Close observation and monitoring for feeding tolerance. Follow D/S and daily wts. Increase feeds by 15cc/kg as tolerated.\n\n#4 Alt. in Parenting\nO: Mom up at 1200. Updated. Infant had just been taken off CPAP so mom did not hold her. She stroked her and spoke softly to her. Stated she would be back at 1600 for infant's cares, but did not come up.\nA: Involved mom, post C/S\nP: Keep informed and support.\n\n#5 Hyperbilirubinemia\nO: 24 hr. bili=7.2/0.2/7.4. Sm. mec stool X 1. Beginning feeds. Color increasing jaundice. Some bruising noted on labia.\nA: Potential for hyperbilrubinemia\nP: Check bili in AM. Advance feeds as able and encourage stooling.\n\n#6 Alt. in Development\nO: Maintaining temp on servo open warmer, nested in sheepskin with boundaries in place. Irritable at times, but settles with pacifier and containment. Desat X 1 with shallow breathing.\nA: Appropriate for GA\nP: Continue to support developmental needs. Move to isolette this PM.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-28 00:00:00.000",
"description": "Report",
"row_id": 1743081,
"text": "NICU Nursing Progress Note\n\nRESP:\nO: Over the course of the first few hrs of the shift, infant\nwas noted to have increasing grunting, retractions, and\ndesats into the low 80's requiring BBO2 to resolve, despite\nbeing placed prone. Prong CPAP inititated and infant placed\nin 5cms in room air. Breath sounds, resp rate, and WOB\ndecreased to wnl after that. No apnea or bradycardia\nobserved so far this shift. Infant tolerating prongs well\nand resting.\nA: TTN vs mild RDS.\nP: Support adequate ventilation.\n\nSEPSIS\nO: Remains on ampi and genta for 48 hr course awaiting blood\ncultures which are negative so far. Infant active with good\ntone and stable VS.\nA: No evidence of compromise.\nP: Monitor and assess.\n\nNUTRITION\nO: Remains NPO. PIV infusing D10W at 80cc/kg/day. Infant is\nedematous. Voiding with each diaper change but unable to\naccurately measure due to large amount of meconium in\ndiaper.\nA: NPO until resp status evens out.\nP: Check serum lytes at 24 hrs of life and adjust IV fluid\naccordingly.\n\nDEVELOPMENT\nO: Temp stable on heated warmer. tone wnl. Fontanelles wnl.\nSucking on pacifier.\nA: Appropriate behavior.\nP: Support development.\n\nPARENTING\nO: Mom called for update and progress report given. Dad and\ngrandparents in to visit and pictures taken. Dad updated at\nbedside.\nA: Involved parents.\nP: Support and keep informed.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-29 00:00:00.000",
"description": "Report",
"row_id": 1743082,
"text": "6 Hyperbilirubinemia\n\nREVISIONS TO PATHWAY:\n\n 6 Hyperbilirubinemia; added\n Start date: \n\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-29 00:00:00.000",
"description": "Report",
"row_id": 1743083,
"text": "1. Rule out sepsis O: Rec'd antibx as ordered. Afebrile.\n A: Cx pending P: Antibx as ordered. Monitor for s/s of\ninfection\n2. CV/RESP O: Remains on NCPAP +5 at 21% Fio2 with sats\nmid to hi 90s. BBS clear and equal with good air entry and\nexchange. RR 30-60s with mild sc/ic retrx. HRR without\naudible murmur. NSR. Pink. BP with MAP >50s. Well-per\nfused with brisk cap refill x4 extrem. No spells A:\nStable on CPAP P: Monitor and document any spells\n3. FEN O: TF=80cc/kg/day. Awaiting new IV bag of D10 with\nNacl and KCL. PIV on rt. hand soft and pink. D/S 72.\nVoiding and passing mec with diaper changes. 24 lytes sent\nA: Stable NPO P: Accurate I/Os . Monitor D/S\n4. G&D O: Active and alert. Lusty cry, soothed with\npacifier.Resting comfortably between cares. Temp wnl under\nradiant warmer. A: Appropriate P: Comfort measures.\nDecrease noxious stim.\n5. PARENTING O: Mom called and updated. Dad visited\nbriefly. Well-informed about current plan of care for\ninfants. A: Loving, concerned parents P: Support and keep\nupdated. Encourage to ask questions and to participate in\ncare\n6. HYPERBILI O: Pink with mild underlying jaundice. 24\nbili level drawn. TBILI 7.6 A: Bili level wnl P: Monitor\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-29 00:00:00.000",
"description": "Report",
"row_id": 1743084,
"text": "Respiratory Care\nBaby remains on cpap 5 21%.RR 30-60's.BS clear throughout.No spells,stable night.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-29 00:00:00.000",
"description": "Report",
"row_id": 1743085,
"text": "Neonatology\nOn CPAP. Comfortable apeparing this am. No murmur. Will triall off CPAP.\n\nWt 2285 down 15. TF 80 cc/k/d. NPO at present. Will start feeds when stable off cpap. Lytes in good range.\n\nTempo sl elevated this am. Appears to be environmental.\n\nJaundiced with bili in 7 range.\n\nOn abx for 48 h r/o. Will dc today.\n\nActive alert on exam. Skin w/o leisosn. Cor nl s1s2 w/o mutmrus. Abdomen benign. Moving all 4. Skin w/o lesions. Neuro nopn-focal and age appropriate.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-28 00:00:00.000",
"description": "Report",
"row_id": 1743077,
"text": "NICU Attending Admission Note\n\nID: 33 week twin A delivered by C section pre term due to PPROM and presenting parts of this twin.\n\nMother is 40 y.o G2 SAb1, P now 2. IVF conception, EDC . PNS: A+, Ab-, RPRNR, RI, HepBSAg-, GBS unknown. Pregnancy uncomplicated until PPROM of this twin on = 33 1/7 weeks gestation. Admitted for observation at that time, started on antibiotics on . No beta b/c > 32 weeks. Known breech/breech lie. On speculum exam tonight, fetal parts of presenting twin noted, therefore decision to deliver by C section. Mother always afebrile.\n\nThis twin emerged with spontaneous cry, required CPAP and routine care in DR, + marked retractions in DR, apgars 8 and 9, transferred to NICU for further evaluation and management of prematurity.\n\nAdmission PEx: See flow sheet for V.S. Weight 2300 gm, (75%), L 43 cm (25-50%), HC 31 cm (50%), overall nondysmorphic with general appearance c/w known gestational age. AFSOF, + RR bilaterally, palate intact, + mild to moderate retractions, but O2 sat 100% in RA, BS quite clear, very slightly diminished, RRR without murmur, 2+ peripheral pulses including femorals, abd benign without HSM or masses, normal female external genitalia for gestational age, + bruised labia majora, normal back and ext except slight edema of legs, skin pink and well perfused, normal tone, strength, responsivity.\n\n\nA/P: 33 week gestation, AGA twin A delivered 4 days post PROM of this twin, cervical dilation with presenting parts prompted C section delivery. No fever. Now with improving respiratory distress, ddx includes surfactant deficiency, retained fetal lung fluid, can not r/o sepsis/pneumoina with perinatal risk factor of prolongued ROM.\n\n- Monitor, supplemental O2 as needed, may need CPAP.\n- NPO for now, D10W at 80 cc/kg/d, monitor lytes, glucose and bili while NPO, treat as indicated\n-CBC and blood cx, amp and gent pending lab results and clinical course\nI spoke with parents in OR, will continue to update/support, contaqct PMD when name identified.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-28 00:00:00.000",
"description": "Report",
"row_id": 1743078,
"text": "NPN Admit to the NICU\n\nBaby girl is Twin #1, 33 4/7 weeks G/A delivered to a 40 yo Mom for and presenting parts of this twin visible upon exam in L & D. (See Dr. note for details.) A/g . Infant received facial CPAP in the OR and was brought to the NICU for further management.\n\nResp: Infant was grunting intermittently but improved quickly w/ some BBO2. She is still tachypneic but grunting only once in a while and is satting 99-100% in RA.\n\nSepsis: A CBC and bc were drawn and sent. She is currently receiving antibx.\n\nCV: No murmur audible. Bp means 35-36. She is on IVF.\n\nF/N: D/s was 54. A PIV was placed and infant is receiving D 10W at 80cc/k/d. Abd is benign w/ + bs. No void yet.\n\nParents: Dad was in to visit and updated.\n\nP: As per NICU protocol and infant's needs. Keep parents informed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-28 00:00:00.000",
"description": "Report",
"row_id": 1743079,
"text": "NPN addendum:\n\nResp: Infant has remained in RA throughout the night. She is still tachypneic at times but has not had any more GFR and has not desatted.\n\nSepsis: Infant vital signs are stable and she is in RA. She is active and alert. Ampi and gent were given.\n\nCV: BP means are wnl. No murmur audible.\n\nParents: Mom visited w/ Dad on her way to the post partum floor from L & D.\n\nG/d: Infant is nestled on a sheepskin on an open warmer on servo. She is warm but servo is weaning. She is appropriate and active.\n\nF/N: Infant is currently NPO on 80cc/k/d of IVF infusing via a PIV. F/u d/s was 102. She has not yet voided but has had a large mec stool.\n\nP: As per NICU protocol and infant needs.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-10-08 00:00:00.000",
"description": "Report",
"row_id": 1743131,
"text": "2. CV/RESP O: Pink, on room air. BBS clear and equal\nwith good air entry and exchange. RR 40-60s with mild SC\nretrx noted. HRR without audible murmur. NSR. HR\n130-160s. Well-perfused with brisk cap refill x4 extrem.\nNo spells A: Stable CV/RESP status P: Monitor and\ndocument spells.\n3. FEN O: TF=140cc/kg/day. Receiving 58cc BM 24/SCC24 q4\nPO/NG. Breastfed x1, but uninterested. Nippled well at\n12a, taking 50cc. Abdomen soft, girth stable at 28.5 cm.\nAssessment unremarkable. Voiding and stooling with diaper\nchanges. No emesis or aspirates. Wgt: 2.480k ^30g A:\nStable, tolerating feeds. Stable feeder and grower P:\nEncourage to PO feed when awake and alert. Monitor for\nfeeding intolerance.\n4.G&D O: Active and alert. Awakens before feeding is due.\nSucks pacifier eagerly. Temp WNL in open crib A: Stable/\nAppropriate P: Monitor. Comfort measures.\n5. PARENTING O: in to visit. Mom breasted\ninfants. did not consent for Hep B vaccine.\nPreferred to be followed up by pediatrician. Updated. A:\n, concerned P: Support and update.\nEncourage to ask questions and to participate in care,\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-10-08 00:00:00.000",
"description": "Report",
"row_id": 1743132,
"text": "Nursing Transfer Note\n\n\n#2-O/A- Received infant in RA. Infant remains in RA. No\nresp distress. P- Cont to assess for Resp needs.\n#3-O/A- TF=140cc/kg/d of BM/SC24 via po/pg. Abd exam\nbenign. Voiding and stooling. Tol feeds. P- Cont to\nassess for FEN needs.\n#4-O/A- cont to be awake and active with cluster cares\nq4hrs. Sleeps well between cares. Temp stable in open\ncrib, swaddled. Sucks on pacifier. P- Cont to assess for\nG&D needs.\n#5-O/A- No parental contact so far this shift. \nsigned consent for transfer to Hosp. last night\nbefore going home. P- Cont to enc parental calls and\nvisits.\nSee flowsheet for further details.\nReport called to nurse .\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-10-08 00:00:00.000",
"description": "Report",
"row_id": 1743133,
"text": "Neonatology Attending\nDOL 10 / CGA 35 weeks\n\n remains in room air with no distress and no cardiorespiratory events.\n\nNo murmur today. BP 62/34 (44).\n\nWt 2480 (+30) on TFI 140 cc/kg/day BM/SC24, tolerating well orally and by gavage. Voiding and stooling.\n\nTemp stable in open crib.\n\nA&P\n33-4/7 week GA with feeding immaturity\n- have declined HB immunization\n transfer to today (D/W Dr. \n"
},
{
"category": "Nursing/other",
"chartdate": "2200-10-05 00:00:00.000",
"description": "Report",
"row_id": 1743118,
"text": "2. CV/RESP O: Remains on room air with sats mid to hi\n90s. BBS cl and equal with good aeration. RR 30-60s with\nmild SC retrx. HRR without audible murmur. NSR. Pink. HR\n\n140-160s. Well-perfused. No spells A: Stable CV/RESP\nstatus P: Monitor and document\n3. FEN O: TF=140cc/kg/day. Taking 55 cc SCC 24 q4 per\nNG/PO. Nippled well at 8pm feeding. Abdomen remains soft,\ngirth stable at 28.5 cm. Assessment benign. Voiding and\nstooling with diaper changes. Wgt:2.355k ^75g A: Stable,\ntolerating feeds P: Encourage PO feeds when awake and\nalert. Monitor for feeding intolerance. Advance feeds as\ntolerated.\n4. G&D O: is active and alert with cares. Awakens\nbefore feeding is due. Sucks pacifier eagerly. Transferred\nto open crib and maintaing temp well. Small dry scab on\nnasal septum intact. No redness or bleeding noted. A:\nAppropriate. Weaned off isolette P Monitor\n5. PARENTING O: No social contact thus far this shift P:\nSupport and update. Encourage to ask questions and to\nparticipate in care.\n6. HYPERBILI O: Pink with mild underlying jaundice. Bili\nlevel to be drawn this am A: Rebound bili level pending\nthis am P: Monitor am lab result.\n\n\n\n\n\n\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-10-05 00:00:00.000",
"description": "Report",
"row_id": 1743120,
"text": "Neonatology Attending Progress\n\nNow day of life 7, CA 4/7 weeks.\nCardiorespiratory status stable in RA, RR 40-50.\nHR 140-160 BP 66/48 55\nNo apnea and bradycardia.\n\nWt. 2355gm up 75gm on 140cc/kg/d of MM24 or SSC24\nPO feedings are slowly improving - still getting half by gavage.\nNormal urine and stool output.\n\nBili - 8.2/0.3 yesterday - rebound 7.0\n\nAssessment/plan:\nVery nice gradual progress continues.\nWill continue with current support as po feeding skills improve.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-10-05 00:00:00.000",
"description": "Report",
"row_id": 1743121,
"text": "Neonatology - NNP PRogress Note\n\n is active with good tone. AFOF. She is pink, well perfused, no murmur auscultated. She is comfortable in room air. Breath sounds clear and equal. She is tolerating full volume po/pg feeds. Abd soft, active bowel sounds, voiding and stooling. Stable temp in open crib. Please refer to neonatology attending note for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-10-06 00:00:00.000",
"description": "Report",
"row_id": 1743122,
"text": "NPN\n\n\n#2 Resp-Remains in RA w/o2 sats 95-100%. BS clear.RR= 40-60.\n#3 F/N- Abd soft,+bs, no loops. Tolerating feeds of SC24\ncals w/sm spits. Minimlal asps.Voiding+ stooling in adeq\namts.Wt up 30gms.TF= 140cc/kg/day.\n#4 Dev-Alert+ active w/cares.Temp stable swaddled in open\ncrib.\n#5 - No contact yet tonight.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-10-06 00:00:00.000",
"description": "Report",
"row_id": 1743123,
"text": "Neonatology NP Note\nPE\nswaddled in open crib\nAFOF\nmild subcostal retractions in room air, lungs clear/=\nRRR, no murmur, pink/ruddy/ mildly jaundiced, in room air, well perfused\nabdomen soft, nontender and nondistended, active bowel sounds\nactive with good tone\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-10-06 00:00:00.000",
"description": "Report",
"row_id": 1743124,
"text": "Neonatology Attending\nDOL 8\n\n remains in room air with no distress and no cardiorespiratory events.\n\nNo murmur. BP 72/38 (56).\n\nWt 2385 (+30) on TFI 140 cc/kg/day SC24/BM24, tolerating well. Feeds orally and by gavage, with small volumes taken on oral feeding attempts. Voiding and stooling.\n\nTemp stable in open crib.\n\nA&P\n33-4/7 week GA twin with feeding immaturity\n-Continue to await maturation of oral feeding skills\n-Given excellent weight gain, will continue with current caloric supplementation\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-10-06 00:00:00.000",
"description": "Report",
"row_id": 1743125,
"text": "NPN 0700-1500\n\n\n#2 O: Infant remains in RA. RR 40's-70's with mild\nretractions. LS clear and =. No spells as yet this shift. A:\nStable in RA. P: Cont to monitor.\n\n#3 O: TF= 140cc/kg/d. Infant taking 56cc's of special care/\nBM24 via po/pg feeds q 4h. Attempted to BF at 1200; latching\non with sucking noted. Abdomen benign; voiding and stooling.\nNo spits, minimal aspirates. A: Tolerating feeds. P: Cont to\nmonitor.\n\n#4 O: Maintaining temp in oac. Awake and alert with cares;\nsleeping well between. Brings hands to face for comfort and\nsucking on fingers for comfort. A: AGA. P: Cont to support\ndevelopment.\n\n#5 O: Both in to visit. Asking appropriate\nquestions. Independent with cares. Mom breastfeeding and dad\nholding after. A: Involved. P: Cont to support and update.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-10-06 00:00:00.000",
"description": "Report",
"row_id": 1743126,
"text": "Lactation Progress Note\nMet with mom today to discuss supply issues. Baby was at 33 4/7 weeks, corrected to 34 5/7 weeks. Mom reports only getting 30cc per pumping if that. Reviewed pumping handout and stressed the importance of pumping 8-12 times per day. Recommended that mom keep a diary to see actual progress. Reviewed moist heat and gentle massage, kangaroo care, relaxation, mother's milk tea, and pumping after kangaroo care and at the baby's bedside. Mom reports that baby went to breast and sucked well but it was not observed. Discussed the possibility of using reglan after she increases pumping and diary is reviewed. Will followup .\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-10-07 00:00:00.000",
"description": "Report",
"row_id": 1743127,
"text": "NPN 7p-7a\n\n\nResp: Infant remains In RA. Ls clr/=. RR 40-60's. Mild sc\nretractions noted. NO spells or desats so far this shift.\nCont to monitor.\n\nFen: WT 2.450kg (+65gms). Conts on tf 140cc/kg of sc/bm 24.\nAlt po/pg. Po'ed x1 thus far 40cc gavaged remainder. No\nspits thus far. Abd soft. Active bs. Voiding with each\ndiaper change. Stool x2 thus far quaic -. Ag 27cm. Cont to\nencourage po feeds.\n\nG&D: Temp stable swaddled in open crib. Alert and active\nwith cares. Waking for feeds. Well coordinated with feeds,\nbut tires easily. Cont to support developmental milestones.\n\nParenting: No contact with so far this shift.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-10-07 00:00:00.000",
"description": "Report",
"row_id": 1743128,
"text": "Neonatal NP-Exam\n\nSee Dr. note for details and plan of care as discussed in rounds this am.\n\nAFOF. Breath sounds clear and equal. Nl S1S2, no audible murmur. Pink and well perfused. Abd benign, no HSM. Infant active with exam.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-10-07 00:00:00.000",
"description": "Report",
"row_id": 1743129,
"text": "Neonatology Attending\nDOL 9 / CGA 34-6/7\n\nIn room air with no distress and no bradycardias.\n\nMurmur noted intermittently. BP 64/31 (43).\n\nWt 2450 (+65) on TFI 140 cc/kg/day SC/BM24, tolerating well orally and by gavage. Abd benign. Voiding and stooling normally.\n\nTemp stable in open crib.\n\nA&P\n33-4/7 twin with feeding immaturity\n-Hepatitis once consent obtained\n-Will assess murmur clinically for now\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-10-07 00:00:00.000",
"description": "Report",
"row_id": 1743130,
"text": "Nursing Progress Note\n\n\n#2-O/A- Received infant in RA. Infant remains in RA. No\nresp distress. No A's or B's. P- Cont to assess for resp\nneeds.\n#3-O/A- TF=140cc/kg/d of BM/SC24 via po/pg. Abd exam\nbenign. Voiding and stooling. Tol feeds. P- Cont to\nassess for FEN needs.\n#4-O/A- cont to be awake and active with cluster cares\nq4hrs. Sleeps well between cares. Temp stable in open\ncrib. P- Cont to assess for G&D needs.\n#5-O/ Mom called with updates given. Mom plans to visit\nthis eve. P- Cont to enc parental calls and visits.\nSee flowsheet for further details.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-10-05 00:00:00.000",
"description": "Report",
"row_id": 1743119,
"text": "NICU Nursing Progress Note\n\nRESP\nO: Remains in room air witih O2 sats >95. Resp rate, Breath\nsounds, and WOB are at baseline. No apnea or bradycardia\nobserved so far this shift.\nA: No evidence of compromise.\nP: Monitor and assess.\n\nHYPERBILI\nO: Slightly jaundiced. At full feeds and stooling well.\nBilirubin did not rebound after lights d/c'd yesterday.\nA: Resolved hyperbili of prematurity.\nP: D/C problem and assess cliniacally.\n\nNUTRITION\nO: Infant po fed entire volume required for 2 feeds in a\nrow. Indwelling feeding tube in place and will gavge infant\nat next feed and Mom will attempt BF. Abd exam benign.\nVoiding and passing green stool.\nA: No evidence of intolerance to feeds. Advancing po.\n\nDEVELOPMENT\nO: Temp stable in open crib. Active and alert with feeds.\nSleeps between. Sucks on pacifier. Tone wnl.\nA: Appropriate behavior.\nP: Support development.\n\nPARENTING\nO: Mom and Dad and other family members in to visit today.\nMom has been pumping about every 3 hrs and brought in 6\npartially filled volufeeds (15-45cc each) that she had\npumped over the past 24 hrs. Mom states she is interested in\ncombining breast and bottle feeding. Mom has appt with LC\ntomorrow. Discussed potential transfer to Hosp\nfor level 2 care and interested. Mom would like an\nopportunity to tour the nursery there tomorrow before any\ntransfer arrangements are made.\nA: Involved . Mom able to provide about daily BM\nsupply for twins with present pumping schedule.\nP: Support and keep informed.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-10-04 00:00:00.000",
"description": "Report",
"row_id": 1743116,
"text": "Newborn Med Attending\n\nDOL#6. Cont in RA, no spells, AF flat, clear BS, no murmur, abd soft, MAE. WT=2280 up 25, on 140 cc/kg/d BM24 PO/PG. Bili=8.2, on phototherapy.\nA/P: Growing infant working up on PO feeds. D/C phototherapy, check rebound bili in AM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-10-04 00:00:00.000",
"description": "Report",
"row_id": 1743117,
"text": "NICU Nursing Progress Note\n\nRESP\nO: Remains in room air with O2 sats >95. Breath sounds, resp\nrate, and WOB are at baseline. No apnea or bradycardia\nobserved so far this shift.\nA: No evidence of compromise.\nP: Monitor and assess.\n\nHYPERBILI\nO: Double phototherapy turned off at 1130 today. Infant is\nslightly jaundiced. Feeding and stooling well at 6 days of\nlife.\nA: Resolving hyperbilirubinemia\nP: Check serum bili in a.m.\n\nNUTRITION\nO: Remains on 140cc/kg of 24BM/SC every 4 hrs. Infant\nbeginning to po feed once or twice a day. Took entire volume\nrequired once this morning by bottle and BF fair for Mom at\nsubsequent feed. Abd exam benign. Voiding and passing large\namount of green stool.\nA: Beginning to po feed.\nP: Advance po as tol. Monitor weight progression.\n\nDEVELOPMENT\nO: Temp stable in air mode isolette. Swaddled after bili\nlights turned off and isolette weaned slightly. Active and\nalert with cares. Tone wnl. Sleeps between feeds. Sucking on\npacifier.\nA: Appropriate behavior.\nP: Support development\n\nPARENTING\nO: Mom and Dad in for 1200 and 1600 feeds. Updated regarding\ninfant's status and plan of care. are independent in\ntemp taking and diaper change. Transfer infants well between\nthemselves handling them with ease. Mom states her goal for\nfeeding is to combine breast and bottle feeds and utilize\nformula as needed to supplement. Mom is pumping about 6\ntimes daily. Mom put infant to breast for 1200 feed and\nhandles infant well recognizing her signals and positioning\ninfant well in football hold.\nA: Involved . Regularly visiting.\nP: Support and keep informed.\n\n\n"
}
] |
29,991 | 109,430 | ASSESSMENT/PLAN: 32 man with no past medical history who presents with septic shock. . # Sepsis / Septic shock: Presents with leukoctyosis, tachycardia and hypotension along with evidence of end-organ injury (acute renal failure) and mild lactic acidosis. There is no clear source of infection, though the oropharynx appears a possible source; CT neck did not show any drainable collection or abscess. Central line was placed and he received IV fluids and brief pressor support. Cortisol testing demonstrated an intact adrenal axis. His ICU course was complicated by an episode of wide complex tachycardia which was felt to likely represent atrial tachycardia with bypass tract. ID consultation was obtained. Although the etiology of his sepsis-like syndrome was initially unclear despite extensive evaluation, he was treated empirically with broad-spectrum antibiotics for possible bacterial source. Laboratory testing failed to confirm a specific viral pathogen; HIV antibody and HIV viral load tests returned negative, and influenza testing also returned negative as well. He improved clinically. Throat culture from eventually returned positive for sparse growth of Group A beta-hemolytic strep. He was discharged on with a presumptive diagnosis of GABHS pharyngitis complicated by sepsis, with instructions to continue antibiotics and follow up with Dr in . He was also discharged with a prescription for acyclovir in the setting of newly-developed herpes labialis. | PERRL.Resp: LS-clear. Mg 1.7, repleted.Resp: LS-clear. A right IJ central line terminates in the distal SVC in a satisfactory location. Mg 1.9, repleted w/ 2g MgSo4.GI: abd soft nontender. BP 86-102/48-61. Denies CP.ID: Temp 98.8-102.2 PO. CVP 10-14, SVo2 81-85. temp upon arrival 102.0 po. +BS. +BS. Access includes right presept cath and PIV x 3. Denied SOB.CV: NSR/ST, no ectopy noted. No cough.Neuro: Alert, ox3. Levoquin d/c'd.GI/GU: Abd-soft. Right IJ line in a satisfactory location in the distal SVC. all ext str/=PERRLS.Resp: arrived on 02 2l n/c, now on RA, 02 sat 97-100%, LS clear bilat.CVS: NSR/ST HR 80's-110's, CVP 10-14, SVO2 81-85. SvO2 81-87. Known right-sided aortic arch. Known right-sided aortic arch. IMPRESSION: 1. IMPRESSION: 1. HR 97-121. Right aortic arch. HR 75-97. Otherwise, nochange. +BS x 4quads. Output 100-450cc/hr.Skin: Intact. Continues on ceftriaxone and clinda. pt medicated w/ tylenol 1G po. Normal size of the cardiac silhouette, no pleural effusion. BP 97-117/52-77. The remainder of the study appears unchanged compared to the prior. Baseline artifact. PERRL. DP's palpable. DP's palpable. Central venous access line in place. too low FINAL REPORT INDICATION: Followup. The cardiac silhouette is within normal limits for size. SvO2 77-85. Tachy. Sinus rhythm with atrial premature beats. Continues on antibiotics.GI/GU: Abd-soft. SvO2 85-87. MICU Nursing progress note 0700-1900CV: NSR, no noted ectopy. The visualized portion of the right kidney has normal appearance. Taking PO well. C/o ST.No significant voice change, no difficulty swallowing. The gallbladder has normal appearance with no stones. IMPRESSION: No acute pulmonary process. while in pt became hypotensive, tachycardic and febrile to 101.9. code sepsis initiated, Presep cath placed, labs, abx done per protocol. B/P 90's-110's/ 60's since off levophed. The right IJ distal tip projects at the expected location of the cavoatrial junction. The tip of the right-sided central venous access line is located in the distal superior vena cava. The size of the cardiac silhouette is within normal range. Continues to be off Levophed. able to wean levophed off after 2nd L of IVF.Allergies: PCNCode Stauts: FULL CODEROS:Neuro: A/Ox3 follows commands, pleasant cooperative. Foley-yellow/clear. O2 sats 97-99% RA. O2 sats 95-100% RA. As compared to the previous radiograph, there is no relevant change. FINDINGS: As compared to the previous examination, there is no relevant radiographic change. Borderline leftatrial abnormality. c/o to floor. Denies N/V. Denies CP. ABD US and neck CT done in ED. WBC 20.3. No BM. FINDINGS: The lungs are clear. FINDINGS: The lungs are clear. The pancreas has normal appearance in the head and body. Lungs clear throughout.GI: BS x 4, no stool documented since admission. Hypotensive to 80's after 2 liters. The liver has normal hepatopetal flow. The common bile duct is not dilated and measures 2 mm. Complains of sore throat, pain acceptable level per pt.ID: Temp 97.4 PO. Since theprevious tracing of atrial premature beats are new. UO 100-300cc/hr.Skin: Intact.ID: Tmax 99.8, given PRN tylenol x 1 0500, continues on multiple ABX for sepsis, ? 3. No acute cardiopulmonary process. Note that there is a right-sided aortic arch, displacing the trachea to the left. COMPARISON: . COMPARISON: . ? Given total of 2L NS in bolus' for low BP. Peripheral pulses present. The liver demonstrates increased echogenicity with no focal lesion. MAE. MAE. The heart is not enlarged. 2. 2. Denies SOB, difficulty breathing.GI: BS x 4, no stool this shift. RR 14-21. 9:21 PM CHEST PORT. pt given IVF x 5L, started on levophed at 0.1mcg/kg/min and transferred to the MICU for further management.Upon arrival to MICU pt b/p stable, levophed weaned to 0.06mcg/kg/min, additional 2L IVF given as b/p would dip when att to wean levophed. F/u on micro results. IMPRESSION: The distal tip of right IJ line projects at the expected location of the cavoatrial junction. 8:32 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: please eval R IJ placement, ? IMPRESSION: No abscess or fluid collection in the neck. Foley d/c'd- due to void by 2300. Pt complaining of moderate throat pain (not new) however refusing pain medication.CV: Hemodynamically stable, HR NSR 80-90 with no ectopy noted, NBP 90-110s/40-60, MAPs >55. No focal consolidation is noted. Normal gallbladder with no evidence of cholecystitis or cholelithiasis. No BM for shift. Monitor lytes. There is no pleural effusion. Given tylenol 650mg w/ good effect. No effusion or pneumothorax is evident. No signs of cholecystitis is noted. No pneumothorax or pleural effusion is detected. Follows commands. Follows commands. taking pills/ thin liq PO. No ascites is visualized. Initially with mild RUQ pain, now resolved. K+ 3.5, repleted w/ 40meq KCL po. For example, the large node in the right jugulodigastric area measures 2.3 x 1 cm. The mediastinum is unremarkable. The visualized osseous structures are unremarkable. Calm and cooperative. Calm and cooperative. FINDINGS: No abscess or fluid collection is noted within the neck. 12:09 AM CT NECK W/CONTRAST (EG:PAROTIDS) Clip # Reason: SORE THROAT Admitting Diagnosis: SEPSIS Contrast: OPTIRAY Amt: 90 MEDICAL CONDITION: yo M, otherwise healthy, w/1 day of cough, fever, ST, malaise. Pancreatic tail is not visualized. MICU Nursing Progress Note 1900-0700Code: FullAllergies: PCNNeuro: Pt A&O x 3, cooperative with nursing care, able to reposition self in bed, pt complaining of mild throat pain, however per pt is tolerable.CV: Hemodynamically stable, HR 60-80 NSR with no ectopy noted, NBP 90-110/50-60, CVP ~ 10, SvO2 monitor d/c'd.Resp: RR teens to 20s with sats >96% on RA. | 13 | [
{
"category": "Radiology",
"chartdate": "2183-03-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1005819,
"text": " 8:32 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: please eval R IJ placement, ? too low\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old man with 10 beat run v tach, has CVL\n REASON FOR THIS EXAMINATION:\n please eval R IJ placement, ? too low\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Followup.\n\n COMPARISON: , 3:40 a.m.\n\n FINDINGS: As compared to the previous examination, there is no relevant\n radiographic change. The tip of the right-sided central venous access line is\n located in the distal superior vena cava. Known right-sided aortic arch. The\n size of the cardiac silhouette is within normal range. No pneumothorax, no\n parenchymal opacities suggestive of pneumonia, no pleural effusions.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2183-03-06 00:00:00.000",
"description": "DISTINCT PROCEDURAL SERVICE",
"row_id": 1005556,
"text": " 9:21 PM\n CHEST PORT. LINE PLACEMENT; -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: eval line placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old man with New line\n REASON FOR THIS EXAMINATION:\n eval line placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 32-year-old man with new line placement.\n\n Comparison is made to the prior radiograph performed two hours ago.\n\n The right IJ distal tip projects at the expected location of the cavoatrial\n junction. No pneumothorax or pleural effusion is detected. No focal\n consolidation is noted. The remainder of the study appears unchanged compared\n to the prior.\n\n IMPRESSION: The distal tip of right IJ line projects at the expected location\n of the cavoatrial junction.\n\n"
},
{
"category": "Radiology",
"chartdate": "2183-03-06 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 1005552,
"text": " 8:00 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: EVAL FOR GALLSTONES,RUQ PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old man with RUQ pain, hypotension and fever\n REASON FOR THIS EXAMINATION:\n eval for gallstones\n ______________________________________________________________________________\n WET READ: 9:57 PM\n\n fatty liver. no gallstones or signs of cholecystitis.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 32-year-old man with right upper quadrant pain, hypertension and\n fever.\n\n No comparison is available.\n\n The liver demonstrates increased echogenicity with no focal lesion. The liver\n has normal hepatopetal flow. Apparent hypodensity in the gallbladder fossa\n most likely represents focal fatty sparing. The gallbladder has normal\n appearance with no stones. No signs of cholecystitis is noted. No son\n sign was present. The common bile duct is not dilated and measures 2\n mm. The pancreas has normal appearance in the head and body. Pancreatic tail\n is not visualized. The visualized portion of the right kidney has normal\n appearance. No hydronephrosis or mass is noted in the right kidney. No\n ascites is visualized.\n\n IMPRESSION:\n\n 1. Increased liver echogenicity is mostly consistent with the fatty liver,\n however, other liver disease and more advanced liver disease including\n cirrhosis/fibrosis cannot be excluded.\n 2. Normal gallbladder with no evidence of cholecystitis or cholelithiasis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2183-03-06 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1005548,
"text": " 6:45 PM\n CHEST (PA & LAT) Clip # \n Reason: cough and fever\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old man with\n REASON FOR THIS EXAMINATION:\n cough and fever\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST, AT 18:44 HOURS\n\n HISTORY: Cough and fever.\n\n COMPARISON: .\n\n FINDINGS: The lungs are clear. The mediastinum is unremarkable. The cardiac\n silhouette is within normal limits for size. No effusion or pneumothorax is\n evident. The visualized osseous structures are unremarkable.\n\n IMPRESSION: No acute pulmonary process.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2183-03-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1005728,
"text": " 2:54 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for infiltrate\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 yo M with sepsis\n REASON FOR THIS EXAMINATION:\n please eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Followup.\n\n COMPARISON: .\n\n As compared to the previous radiograph, there is no relevant change. Known\n right-sided aortic arch. Central venous access line in place. Normal size of\n the cardiac silhouette, no pleural effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2183-03-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1005575,
"text": " 3:25 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for infiltrates, effusions\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old man with hypotension, myalgias\n REASON FOR THIS EXAMINATION:\n evaluate for infiltrates, effusions\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest portable AP on .\n\n COMPARISON: Multiple previous chest radiographs that goes to \n and a CT neck on .\n\n HISTORY: 32-year-old man with hypotension, myalgia, evaluate for infiltrate\n and effusions.\n\n FINDINGS: The lungs are clear. A right IJ central line terminates in the\n distal SVC in a satisfactory location. The heart is not enlarged. There is\n no pleural effusion. Note that there is a right-sided aortic arch, displacing\n the trachea to the left.\n\n IMPRESSION:\n 1. No acute cardiopulmonary process.\n 2. Right IJ line in a satisfactory location in the distal SVC.\n 3. Right aortic arch.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2183-03-07 00:00:00.000",
"description": "CT NECK W/CONTRAST (EG:PAROTIDS)",
"row_id": 1005570,
"text": " 12:09 AM\n CT NECK W/CONTRAST (EG:PAROTIDS) Clip # \n Reason: SORE THROAT\n Admitting Diagnosis: SEPSIS\n Contrast: OPTIRAY Amt: 90\n ______________________________________________________________________________\n MEDICAL CONDITION:\n yo M, otherwise healthy, w/1 day of cough, fever, ST, malaise. Hypotensive to\n 80's after 2 liters. Tachy. Initially with mild RUQ pain, now resolved. C/o\n ST.No significant voice change, no difficulty swallowing.\n REASON FOR THIS EXAMINATION:\n please eval for RPA\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 32-year-old male with cough, fever, and hypotension.\n\n No comparison is available.\n\n TECHNIQUE: Axial MDCT images of the neck were obtained after administration\n of 90 cc of Optiray intravenously.\n\n FINDINGS: No abscess or fluid collection is noted within the neck. Multiple\n pathologically enlarged nodes are noted in the jugulodigastric regions\n bilaterally. For example, the large node in the right jugulodigastric area\n measures 2.3 x 1 cm. The one on the left side measures 1.6 x 1.3 cm. The\n nodes noted in other stations of the neck are not pathologically enlarged.\n Mucosal thickening of both maxillary sinuses is noted.\n\n IMPRESSION: No abscess or fluid collection in the neck.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2183-03-07 00:00:00.000",
"description": "Report",
"row_id": 1649306,
"text": "MICU Nursing progress note 0700-1900\n\u0013Neuro: Alert, ox3. Calm and cooperative. Follows commands. MAE. Moves independently in bed. PERRL.\n\nResp: LS-clear. RR 15-20. O2 sats 95-100% RA. SvO2 85-87. Denied SOB.\n\nCV: NSR/ST, no ectopy noted. HR 97-121. BP 86-102/48-61. CVP 6-15. Given total of 2L NS in bolus' for low BP. DP's palpable. Continues to be off Levophed. Denies CP.\n\nID: Temp 98.8-102.2 PO. Given tylenol 650mg w/ good effect. WBC 20.3. +5L LOS. Continues on ceftriaxone and clinda. Levoquin d/c'd.\n\nGI/GU: Abd-soft. +BS. No BM for shift. Taking some food PO. Denies N/V. Foley-yellow/clear. Output 100-200cc/hr.\n\nSkin: Intact.\n\nSocial: Wife in to visit most of day. Other family members visited periodically.\n\nPlan: Monitor BP (MAPs >60). Monitor temp curve. Monitor lytes. Support patient/family. F/u on micro results.\n"
},
{
"category": "Nursing/other",
"chartdate": "2183-03-08 00:00:00.000",
"description": "Report",
"row_id": 1649307,
"text": "MICU Nursing Progress Note 1900-0700\n\nCode: Full\nAllergies: PCN\n\nUneventful shift...\n\nNeuro: Pt oriented x 3, sleeping in naps. Pleasant and cooperative with nursing care, able to reposition self in bed. Pt complaining of moderate throat pain (not new) however refusing pain medication.\n\nCV: Hemodynamically stable, HR NSR 80-90 with no ectopy noted, NBP 90-110s/40-60, MAPs >55. SvO2 77-85. Peripheral pulses present. Access includes right presept cath and PIV x 3. HCT down slightly, team aware.\n\nResp: RR in teens with sats >95% on RA, lungs clear in all fields, cough/gag intact. Denies SOB, difficulty breathing.\nGI: BS x 4, no stool this shift. Tolerating diet well.\n\nGU: Foley patent and draining clear, light yellow urine. UO 100-300cc/hr.\n\nSkin: Intact.\n\nID: Tmax 99.8, given PRN tylenol x 1 0500, continues on multiple ABX for sepsis, ? source.\n\nSocial: Wife stayed till pt fell asleep, will be in today.\n\nPlan:\nmonitor BP, fluids as needed\nmonitor temp curve, ABX as ordered\nif stable c/o to floor\nroutine ICU care and monitoring\nsupport to pt and family\n"
},
{
"category": "Nursing/other",
"chartdate": "2183-03-08 00:00:00.000",
"description": "Report",
"row_id": 1649308,
"text": "MICU Nursing progress note 0700-1900\nCV: NSR, no noted ectopy. HR 75-97. BP 97-117/52-77. SvO2 81-87. DP's palpable. Denies CP. Mg 1.7, repleted.\n\nResp: LS-clear. RR 14-21. O2 sats 97-99% RA. No cough.\n\nNeuro: Alert, ox3. Follows commands. Calm and cooperative. MAE. PERRL. Moving self in bed. Complains of sore throat, pain acceptable level per pt.\n\nID: Temp 97.4 PO. Continues on antibiotics.\n\nGI/GU: Abd-soft. +BS. No BM. Taking PO well. Foley d/c'd- due to void by 2300. Output 100-450cc/hr.\n\nSkin: Intact. Moving self frequently in bed.\n\nSocial: Wife in to visit.\n\nPlan: Monitor BP, temp curve. Continue antibiotics. ? c/o to floor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2183-03-09 00:00:00.000",
"description": "Report",
"row_id": 1649309,
"text": "MICU Nursing Progress Note 1900-0700\n\nCode: Full\nAllergies: PCN\n\nNeuro: Pt A&O x 3, cooperative with nursing care, able to reposition self in bed, pt complaining of mild throat pain, however per pt is tolerable.\n\nCV: Hemodynamically stable, HR 60-80 NSR with no ectopy noted, NBP 90-110/50-60, CVP ~ 10, SvO2 monitor d/c'd.\n\nResp: RR teens to 20s with sats >96% on RA. Lungs clear throughout.\n\nGI: BS x 4, no stool documented since admission. Tolerating diet well, good appetite.\n\nGU: Voiding adequate amounts clear, light yellow urine. Will replete AM lytes as needed.\n\nSocial: Wife in to visit last night, will be in this morning.\n\nPlan:\nmonitor BP\ncall out to floor\nroutine ICU care and monitoring\nsupport to pt and family\n"
},
{
"category": "Nursing/other",
"chartdate": "2183-03-07 00:00:00.000",
"description": "Report",
"row_id": 1649305,
"text": "MICU admission note 0000-0700\npt is a 32yo male w/ PMH of arrythmias who presented to the ED w/ N/V, SOB, cough, sore throat, HA, fever, rigors, and RUQ pain x 24hrs. ABD US and neck CT done in ED. while in pt became hypotensive, tachycardic and febrile to 101.9. code sepsis initiated, Presep cath placed, labs, abx done per protocol. pt given IVF x 5L, started on levophed at 0.1mcg/kg/min and transferred to the MICU for further management.\n\nUpon arrival to MICU pt b/p stable, levophed weaned to 0.06mcg/kg/min, additional 2L IVF given as b/p would dip when att to wean levophed. CVP 10-14, SVo2 81-85. temp upon arrival 102.0 po. pt medicated w/ tylenol 1G po. able to wean levophed off after 2nd L of IVF.\n\nAllergies: PCN\n\nCode Stauts: FULL CODE\n\nROS:\n\nNeuro: A/Ox3 follows commands, pleasant cooperative. all ext str/=\nPERRLS.\n\nResp: arrived on 02 2l n/c, now on RA, 02 sat 97-100%, LS clear bilat.\n\nCVS: NSR/ST HR 80's-110's, CVP 10-14, SVO2 81-85. B/P 90's-110's/ 60's since off levophed. K+ 3.5, repleted w/ 40meq KCL po. Mg 1.9, repleted w/ 2g MgSo4.\n\nGI: abd soft nontender. +BS x 4quads. taking pills/ thin liq PO. tol well, no N/V since arrival to the MICU.\n\nGU: foley cath intact draining clear yellow urine. UOP 200-400ml/hr.\n\nID: will cont IV abx started in ED, WBC 20.3. temp 100.8 after tylenol.\n\nsocial: wife arrived in MICU w/ pt, updated r/t pt cond and POC.\n\nPlan:\ncont ICU care, monitoring\ncont IV abx as ordered.\nFB for hypotension.\ncardiac echo today.\nsupport pt and family.\n"
},
{
"category": "ECG",
"chartdate": "2183-03-06 00:00:00.000",
"description": "Report",
"row_id": 152086,
"text": "Baseline artifact. Sinus rhythm with atrial premature beats. Borderline left\natrial abnormality. Q waves in leads II, III, aVF and early R wave progression\nmay raise the possibility of posteroseptal accessory pathway. Since the\nprevious tracing of atrial premature beats are new. Otherwise, no\nchange.\n\n"
}
] |
4,622 | 148,015 | He was then taken to the computerized tomography scanner where he underwent a head cervical spine, chest and abdominal computerized tomography scans. The head computerized tomography scan showed a large left subdural hemorrhage with midline shift as well as a left interparenchymal bleed and clear ungual herniation. The computerized tomography scan of his neck was read as normal. Computerized tomography scan of his chest showed a small right pneumothorax and air in his mediastinal. The computerized tomography scan of the abdomen and pelvis was negative. Neurosurgery was called to consult and Dr. , after reviewing the films discussed with the family the poor prognosis and likely unsurvivability of his injury. The family was clear in that the patient did not want aggressive resuscitation. He was made Do-Not-Resuscitate until the family was able to arrive at the hospital at which point the wide open fluids were stopped and the ventilator was turned off. It was determined prior to the families arrival that a right chest tube was not something the patient would have wanted. It should be noted that in the Trauma Bay the patient received Mannitol as well as Ceftriaxone and Vancomycin for his open skull fracture. The patient passed away at 5:19 AM on . His chief cause of death was respiratory failure and the immediate cause was subdural hematoma. The family was notified and the medical examiner was notified. The medical examiner chose to accept the case. , M.D. Dictated By: MEDQUIST36 D: 06:41 T: 06:55 JOB#: | Right-sided pneumothorax and pneumomedistinum. There is accompanying uncal herniation. FINDINGS: There is a large, acute left cerebral convexity subdural hematoma within an area of low density that could represent unclotted blood. The aorta is calcified. There is dependent atelectasis seen in the dependent portion of the lungs bilaterally. There is fluid in the bilateral maxillary sinuses (left greater than right). Sagittal and coronal reconstructions were performed. There is an NG tube in the esophagus. There is subarchnoid blood in the bilateral temporal parietal regions. TECHNIQUE: Noncontrast head CT. Likely a tentorial herniation. There is dependent atelectasis of the right lung and pneumomediastinum. Bilateral anterior pneumothoraces (right greater than left) and a moderate amount of air in the mediastinum and the neck. Subarachnoid hemorrhage. There is a moderate anterior pneumothorax bilaterally (right greater than left). Pneumomediastinum. Subfalcine herniation. There is an ET tube in the trachea. AP SINGLE VIEW OF THE CHEST: There is a right-sided pneumothorax. There is presumed hemorrhage in the bilateral maxillary sinuses, sphenoid sinus and ethmoid cells. There is a large polyp or retention cyst in the right maxillary sinus. Epidural with bupivicaine. Large left subdural hematoma. Supported w/numberous fluid boluses for hypotension (see flow record for these details). The aorta is calcified, but intact. There are multiple small retroperitoneal and mesenteric lymph nodes that do not meet CT criteria for pathology. Multiple contusions. There are small inguinal and small pelvic wall lymph nodes that do not meet CT criteria for pathology. Multiple foci of subarchnoid blood and multiple parenchymal contusions. Pt has mulitple allergies and preop meds. Large acute left subdural and left frontal intraparenchymal hemorrhages. CT OF THE CHEST WITH IV CONTRAST: There are small axillary and mediastinal lymph nodes that do not meet CT criteria for pathology. Large left frontal parenchimal hematoma. These findings are causing 1.2-cm right shift in the normally midline structures with compression of the lateral ventricles. Midline incision with DSD. Admitted from the EW via CT. There is near complete opacification of the left maxillary sinus with fluid. Made DNR/DNI. They are depressed fractures in the occipital, parietal and temporal bones. WET READ VERSION #1 FINAL REPORT INDICATION: Trauma. Skin intact except for incisions. There are multipleparenchymal contusions in the temporal lobes and frontal lobes. FINDINGS: The vertebral body heights are preserved. JP site on LUchest, swelling noted and MD aware. There is extensive subcutaneous emphysema in the neck. There is extensive subcutaneous emphysema in the neck. Abd soft distended with absent BS. Pt on gent, flagyl and vanco. FINAL REPORT INDICATION: Trauma. CT OF THE PELVIS WITH IV CONTRAST: There are multiple diverticula in the sigmoid colon without evidence of diverticulitis. CT placement stopped. There is a moderate amount of air in the neck and behind the right scapula. There is a possibiity of injury of the intratemporal bone structures including the facial nerve. The visualized outline of the thecal sac is unremarkable. Fractures of the right temporal bone (at least two). Fractures of the right temporal bone. emphysema. Large amount of air in the soft tissues in the neck and in the mediastinum. There is probable blood in the external auditory canal. No definite fracture of the c-spine. Upon admission Left radial A line place. The heart and great vessels are within normal limits. A large scalp hematoma in the right parietal occipital region. Initially HTN tx w/hydrolazine and labetalol ivp. There is no free fluid in the abdomen. Nonionic IV contrast was used due to patient's condition. This is best seen in series 2 image 13 and extends superiorly in the posterior fossa beyond the limits of this radiograph (please see report of the head CT). There is fracture of the right portion of the occipital bone. There is blood in the auditory canal. There is probably fluid around the ET tube in the portions of the trachea above the balloon. SIMV/600/10/ ps5 peep5. There is fluid in the mastoid air cells. There is also a large, left frontal intraparenchymal hemorrhage which mesures 1.8 x 3.0-cm. CT OF THE ABDOMEN WITH IV CONTRAST ONLY: The NG tube tip is in the stomach. ACCIDENTLYENTER UNDER THIS PT NEOB notified. 9:13 PM CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # Reason: T FINAL ADDENDUM On a few axial sections, there is a question of a tiny dorsally situated hematoma, possibly extra- or subdural, at the level of C5. The NG tube is in the stomach. There is no free air in the abdomen. MAEs with equal stregnth. There is no obvious hematoma in the chest. There is no free air in the pelvis. ET tube is located approximately 1.5 cm from the carina. Fractures of the right occipital bone. There is no free fluid in the pelvis. There is air in the vicinity of the skull base, which is probably tracking up from the neck emphysema of the soft tissues. The liver, gallbladder, kidneys, spleen, pancreas, adrenal glands, small and large bowel are within normal limits. Th suprasellar cistern is not visualized which likely represents brain edema filling this space.. Afebrile, skin W/D with palpable pedal pulses and good cap refill. There is a moderate amount of air in the mediastinum in the pericardium. There are no evident lung contusions. Large amount of subcut. Dressings changed. Multiple depressed skull fractures, the largest depression is of 1.1-cm. | 7 | [
{
"category": "Radiology",
"chartdate": "2175-03-14 00:00:00.000",
"description": "TRAUMA #2 (AP CXR & PELVIS PORT)",
"row_id": 819947,
"text": " 9:10 PM\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \n Reason: TR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with\n REASON FOR THIS EXAMINATION:\n TR\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Trauma.\n\n AP SINGLE VIEW OF THE CHEST:\n\n There is a right-sided pneumothorax. There is also air in the mediastinum. No\n evidence of pulmonary contusion. There are no pleural effusions. ET tube is\n located approximately 1.5 cm from the carina. Recommend pulling the ET tube at\n least 2 cm. The NG tube is in the stomach. There are no rib fractures. There\n is extensive subcutaneous emphysema in the neck.\n\n AP SINGLE VIEW OF THE PELVIS:\n\n There is no definite evidence of fracture or dislocation. The pubic symphysis\n and SI joints are normal. Hip joints are in appropriate location.\n\n IMPRESSION:\n\n 1. Right-sided pneumothorax and pneumomedistinum. Recommend CT scan of the\n chest for further evaluation. There is extensive subcutaneous emphysema in\n the neck.\n\n 2. No evidence of pelvic fracture.\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-03-14 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 819948,
"text": " 9:12 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: \n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with\n REASON FOR THIS EXAMINATION:\n \n contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: FKh WED 1:05 AM\n Multiple skull fractures, including the skull base. Large left subdural\n hematoma. Large left frontal parenchimal hematoma. Multiple contusions.\n Subarachnoid hemorrhage.\n Large shift of the midline structures. Likely a tentorial herniation.\n Subfalcine herniation.\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n CLINICAL INDICATION: Trauma, patient fell down stairs.\n\n COMPARISON: None.\n\n TECHNIQUE: Noncontrast head CT.\n\n FINDINGS: There is a large, acute left cerebral convexity subdural hematoma\n within an area of low density that could represent unclotted blood. This\n hematoma measures 1.5-cm in the widest diameter. There is also a large, left\n frontal intraparenchymal hemorrhage which mesures 1.8 x 3.0-cm. There is\n subarchnoid blood in the bilateral temporal parietal regions. These findings\n are causing 1.2-cm right shift in the normally midline structures with\n compression of the lateral ventricles. There is accompanying uncal\n herniation. Th suprasellar cistern is not visualized which likely represents\n brain edema filling this space.. There are multipleparenchymal contusions in\n the temporal lobes and frontal lobes.\n\n There are multiple skull fractures. They are depressed fractures in the\n occipital, parietal and temporal bones. The occipital fracture extends to the\n skull base and extends into the foramen magnum. There is a transverse\n fracture through the right temporal bone causing blood in the right mastoid\n air cells. There is probable blood in the external auditory canal. If better\n evaluation is necessary, recommend dedicated views of the temporal bones.\n There is near complete opacification of the left maxillary sinus with fluid.\n There is also a small amount of fluid in the right maxillary sinus. There is\n also fluid in the sphenoid and ethmoid cells. However, no definite fracture\n in the orbit or paranasal sinuses was identified. If clinically indicated,\n recommend dedicated views of the facial bones. There is a large polyp or\n retention cyst in the right maxillary sinus. There is no intraorbital\n hematoma. The left lens is smaller than the right. Correlate this patient's\n surgical history. A large scalp hematoma in the right parietal occipital\n region. There are staples in that area.\n\n IMPRESSION:\n 1. Large acute left subdural and left frontal intraparenchymal hemorrhages.\n (Over)\n\n 9:12 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: \n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n (Cont)\n This is causing significant shift of the normally midline structure and\n probable transtentorial herniation.\n\n 2. Multiple foci of subarchnoid blood and multiple parenchymal contusions.\n\n 3. Multiple depressed skull fractures, the largest depression is of 1.1-cm.\n\n 4. Fractures of the right temporal bone (at least two). There is fluid in\n the mastoid air cells. There is a possibiity of injury of the intratemporal\n bone structures including the facial nerve.\n\n 5. There is presumed hemorrhage in the bilateral maxillary sinuses, sphenoid\n sinus and ethmoid cells. However, no definite fracture of the paranasal\n sinuses were identified. If clinically indicated, CT of the facial bones can\n be performed for further evaluation.\n 6. There is air in the vicinity of the skull base, which is probably tracking\n up from the neck emphysema of the soft tissues.\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-03-14 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 819949,
"text": " 9:13 PM\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: T\n ______________________________________________________________________________\n FINAL ADDENDUM\n On a few axial sections, there is a question of a tiny dorsally situated\n hematoma, possibly extra- or subdural, at the level of C5. Further evaluation\n by MR might be helpful, in this regard.\n\n\n 9:13 PM\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n -59 DISTINCT PROCEDURAL SERVICE\n Reason: T\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with\n REASON FOR THIS EXAMINATION:\n T\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: FKh WED 1:07 AM\n Skull base fracures (right temporal bone), right occipital bone.\n Anteriorlisthisis of c4 over c5. No definite fracture of the c-spine.\n Large amount of subcut. emphysema.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Trauma.\n\n COMPARISON: No comparisons are available.\n\n TECHNIQUE: Axially acquired contiguous images of the cervical spine were\n obtained. Sagittal and coronal reconstructions were performed.\n\n FINDINGS: The vertebral body heights are preserved. There are degenerative\n changes of the cervical spine including disc space narrowing more prominent at\n C4/C5, C5/C6 and C6/C7. There is grade 1 anterolisthesis of C4 over C5. There\n is no definite evidence of fracture of the cervical spine. There is a large\n amount of air in the neck. There is air in the prevertebral soft tissues,\n which limits the evaluation for soft tissue swelling. CT does not provide any\n intrathecal detail. The visualized outline of the thecal sac is unremarkable.\n There is an ET tube in the trachea. There is probably fluid around the ET\n tube in the portions of the trachea above the balloon. There is no evidence\n of hyoid bone fracture. There is no definite evidence of tracheal injury in\n this study. However it cannot be excluded. There is an NG tube in the\n esophagus. There is no visible injury of the esophagus; however an injury to\n the esophagus also cannot be excluded.\n\n There is fracture of the right portion of the occipital bone. This is best\n seen in series 2 image 13 and extends superiorly in the posterior fossa beyond\n the limits of this radiograph (please see report of the head CT). There is\n fluid in the right mastoid air cells and there is at least 2 fractures of the\n temporal bone (when the study was read in conjunction with the head CT. These\n fractures can be better evaluated if indicated with dedicated CT of the\n temporal bone. There is blood in the auditory canal. There is fluid in the\n bilateral maxillary sinuses (left greater than right). There is dependent\n atelectasis of the right lung and pneumomediastinum. Please refer to the CT of\n the chest for further information.\n\n IMPRESSION:\n\n 1. Fractures of the right temporal bone.\n\n (Over)\n\n 9:13 PM\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n -59 DISTINCT PROCEDURAL SERVICE\n Reason: T\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 2. Fractures of the right occipital bone.\n\n 3. There is no definite evidence of fracture of the cervical spine. There is\n grade 1 anterolisthesis of C4 over C5. Although this could be accounted to\n degenerative changes, clinical correlation is recommended and if tenderness of\n the cervical spine, recommend an MRI of the cervical spine to rule out\n ligamentous injury.\n\n 4. Large amount of air in the soft tissues in the neck and in the\n mediastinum. Although no definite evidence of tracheal or esophageal injury\n is present in this study, they cannot be ruled out in this study.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-03-14 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 819950,
"text": " 9:14 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CTA CHEST W&W/O C &RECONS\n Reason: T\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with\n REASON FOR THIS EXAMINATION:\n T\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: FKh WED 2:05 AM\n Bilateral pneumothoraces.\n Pneumomediastinum.\n no obvious injury to the trach or esphagus. However it cannot be r/o.\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Trauma.\n\n TECHNIQUE: CT of the chest, abdomen and pelvis was performed with IV contrast\n only.\n\n Nonionic IV contrast was used due to patient's condition.\n\n CT OF THE CHEST WITH IV CONTRAST:\n\n There are small axillary and mediastinal lymph nodes that do not meet CT\n criteria for pathology. The aorta is calcified, but intact. The heart and\n great vessels are within normal limits. There is no pericardial effusion.\n There is a moderate amount of air in the mediastinum in the pericardium. There\n is a moderate amount of air in the neck and behind the right scapula. There is\n a moderate anterior pneumothorax bilaterally (right greater than left). There\n is dependent atelectasis seen in the dependent portion of the lungs\n bilaterally. There are no evident lung contusions. No obvious tracheal\n injury is demonstrated. There is no obvious hematoma in the chest.\n\n CT OF THE ABDOMEN WITH IV CONTRAST ONLY: The NG tube tip is in the stomach.\n The stomach contains a moderate amount of food and air. The liver,\n gallbladder, kidneys, spleen, pancreas, adrenal glands, small and large bowel\n are within normal limits. There is no free fluid in the abdomen. There is no\n free air in the abdomen. There is no significant abdominal lymphadenopathy.\n There are multiple small retroperitoneal and mesenteric lymph nodes that do\n not meet CT criteria for pathology. The aorta is calcified.\n\n CT OF THE PELVIS WITH IV CONTRAST: There are multiple diverticula in the\n sigmoid colon without evidence of diverticulitis. The rectum, urinary\n bladder, and seminal vesicles are unremarkable. The prostate is enlarged.\n There is a Foley catheter within the urinary bladder with a small amount of\n air in the urinary bladder. There is no free fluid in the pelvis. There is\n no free air in the pelvis. There are small inguinal and small pelvic wall\n lymph nodes that do not meet CT criteria for pathology.\n (Over)\n\n 9:14 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CTA CHEST W&W/O C &RECONS\n Reason: T\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n BONE WINDOWS: There are no obvious thoracic, pelvic or vertebral fractures.\n\n MULTIPLANAR RECONTRUCTIONS: Were used for the interpretation of this study.\n\n IMPRESSION:\n\n 1. Bilateral anterior pneumothoraces (right greater than left) and a moderate\n amount of air in the mediastinum and the neck. The origin for the air is most\n likely from the lung injury. However, cannot rule out esophageal or tracheal\n injury.\n\n 2. No significant intra-abdominal injury.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-03-15 00:00:00.000",
"description": "Report",
"row_id": 1321841,
"text": "NPN -0700\n\n Pt admitted to unit from PACU. Pt has long history of GERD and had a gastroesophagectomy with J-tube placement in the past. Pt cont to aspirate TFs and had subsequent gastric surgeries without sucess. Developed COPD from repeated lung infections. Pt also has significant medical hx, listed in admit note, including chronic pain and depression. Admitted to OSH on from PMD office for questionable valium or klonpin OD vs benzo withdrawl from an overdose earlier that week.\n Pt had long OR course and combined with significant pulm disease, DOE at baseline, and was kept intubated overnight.\n\n Pt has mulitple allergies and preop meds. See admit sheet.\n\n REVIEW OF SYSTEMS\n\n Pt on propofol at 30mcg/kg/min and fentanyl gtt @ 50 mcg/hr. Epidural with bupivicaine. Pt was easily arousable and FCs on arrival. MAEs with equal stregnth. Able to nod yes/no to questions but does not attempt to mouth words. Pt c/o pain and and epidural increased from 4 to 8cc/h. Site intact with no swelling or leaking. Pt remained easily arousable and restless at times. Very drowsy when aroused.\n\nRESP-Remains vented with no setting changes. SIMV/600/10/ ps5 peep5. ABGs WNL. Lungs coarse with no secretions when sx'd.\n\n Pt arrived with aline and TLC. ST in low 100s and SBP fluctuates between 80s-110s. Lopressor held due to low BP. Pt received 1000cc LR bolus x 2 for hypotension and low UO. Afebrile, skin W/D with palpable pedal pulses and good cap refill. Skin intact except for incisions. JP site on LUchest, swelling noted and MD aware. Lytes repleted.\n\nGI/ Pt has gastric tube on right to gravity with 350cc bilious drainage. Jtube on left also to gravity with few cc drainage. Dressings changed. Both flushed. Abd soft distended with absent BS. Midline incision with DSD. Foley patent with clear yellow urine.\n\n Pt on gent, flagyl and vanco. Vanco listed under allergies in two spots on chart and reconfirmed with Dr that it was okay to give. Pt WBCs from 23 to 37 this am. Afebrile.\n\nNo contact from family\n\nPlan to extubated in am?!\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-03-15 00:00:00.000",
"description": "Report",
"row_id": 1321842,
"text": "THIS NOTE WAS FOR ANOTHER PT. ACCIDENTLYENTER UNDER THIS PT\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-03-15 00:00:00.000",
"description": "Report",
"row_id": 1321843,
"text": "Admitted from the EW via CT. This is a 75yo male who fell down the steps at home and recieved a occipital skull fx w/diffuse ICB. Transfered into bed, connected to monitors and vent. See flow record for details. Upon admission Left radial A line place. Initially HTN tx w/hydrolazine and labetalol ivp. Set up for chest tube done, team spoke w/wife who did not want any further invasive tx done. CT placement stopped. Wife wished to support him untill family could arrive but did not want CPR performed should his heart stop. Supported w/numberous fluid boluses for hypotension (see flow record for these details). Made DNR/DNI. Son and daughter here at 0200. Priest here at 0300, recieved sac of sick. Fluids stopped and vent weaned to just 21% Fio2 per families request. At 0515 no palpable pulse, monitor asystole, and no spontanious breaths. Family at bedside, support provided to family. NEOB notified. ME accepted case.\n\nFamily did not want personal belongings (clothes thrown away).\n\nBody transported to \n"
}
] |
98,999 | 120,075 | On HD 1 the patient was taken to the OR for an exploratory laparotomy and patch for a perforated duodenal ulcer. She was hypotensive and developed atrial fibrillation during the case and was started on Levophed. On POD 1, her hypotension and atrial fibrillation continued and her Levophed was changed to Neo-Synephrine; a Diltiazem drip was started as well. Her heart rate responded appropriately to the calcium channel blocker. Of note she failed a vent wean on POD 2, a Lasix drip was started in attempt to diurese to aid in ventilation. On POD 3, the Lasix drip was continued and she was started on acetazolamide for metabolic alkalosis. The Neo-Synephrine was weaned off as she was hemodynamically stable. She was extubated. On POD 4 narcotics were discontinued and the Lasix drip was changed to oral Lasix with adequate diuresis. She was transferred to the regular nursing unit. She was transferred to the floor on and was stable from a respiratory standpoint on 4L O2 via nasal prongs. However, she had a possible aspiration event on with a brief desaturation to the 60s. O2 sats stabilized with 60% O2 via shovel mask and she was transferred to the SICU for continued care. Her respiratory status improved and she was transferred back to the regular floor. While on the floor she was noted with marginal nutritional intake; calorie counts were initiated and were calculated at lower than required amounts. Nutritional supplements were added to her diet and her diet has improved but stills bears watching. Her Foley catheter remains in place after a failed voiding trial; while at rehab and once ore ambulatory another voiding trial should be attempted. She was again noted with a desaturation episode on hospital day 10 and was given a Mucomyst treatment as she was having difficulty coughing up sputum that was previously noted as thick; she did require nasal tracheal suctioning with improvement in her respiratory status. A CXR was done as well which showed in comparison with study of lower lung volumes, continued prominence of the cardiac silhouette with bilateral pleural effusions and bibasilar atelectatic change, more prominent on the left, with no acute pneumonia, vascular congestion, or pneumothorax. She was continued on her nebs. She was evaluated by Physical therapy and is being recommended for rehab after her acute hospital stay. | B/l pleural effusions, ascites, anasarca. Sinus tachycardia with baseline artifact and atrial premature depolarizations.Diffuse non-diagnostic repolarization abnormalities. The pancreas is atrophis. CT ABDOMEN WITH IV CONTRAST: Small bilateral pleural effusions with simple fluid attenuation and associated compressive atelectasis. Sinus rhythm with atrial premature beats. Hiatal hernia. Tortuosity of the thoracic aorta is noted, but the mediastinal silhouette is otherwise unremarkable. Atherosclerotic calcification of the aorta is again noted. Gallbladder is normal with pericholecystic fluid likely secondary to ascites. Lucency in the midline lower chest is compatible with hiatal hernia. Right IJ catheter tip is low, is in the right atrium. Pneumoperitoneum is less conspicuous than before. HISTORY: O2 desat, short of breath. Diffuse non-specific ST-T wave abnormalities.Compared to the previous tracing of heart rate is decreased.Precordial voltage is lower. UPRIGHT AP VIEW OF THE CHEST: Lung volumes are low. Large hiatal hernia is noted. Poor R wave progression. Bibasilar opacities and blunting of the costophrenic sulci persists. Site of bowel perforation is most likely sigmoid colon. The patient has been extubated. Lowprecordial voltage. Multiple small hypodensities are again noted in the bilateral kidneys. Known intraperitoneal fre air not well assessed on the current study. ET tube is low only 1.8 cm above the carina, to be withdrawn couple of centimeters to a standard position. Findings are compatible with perforated duodenal ulcer which is concordant with the operative findings. Coronal and sagittal reformats were displayed. Free air in the abdomen with free fluid and peritoneal enhancement compatible with peritonitis. Multiple small hypodensities are again noted in the liver, unchanged from prior. Mild-to-moderate cardiomegaly is acentuated by the low lung volumes. ADDENDUM: Upon further review, a mucosal defect is noted in the duodenum on series 300b, image 27 with a dense pill seen outside the lumen of the duodenum as well as fluid. A right internal jugular catheter remains in place. worsening colitis. worsening colitis. worsening colitis. There is diffuse thickening of the transverse colon, similar to what was seen on the prior CT, compatible with colitis. 9:04 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # Reason: ? Large hiatal hernia. Intraperitoneal free air identified on abdominal CT is not well appreciated on the current exam and may be due to positioning. Persistent colitis. The site of bowel perforation is not clearly defined though there is a perisigmoid collection seen on series 2, images 65-70 which is a likely candidate for perforation. FINDINGS: In comparison with study of , there are lower lung volumes. Small bilateral pleural effusions, lower lobe compressive atelectasis, increased from prior. IMPRESSION: No significant change post-extubation. Hilar contours and pulmonary vasculature are normal. There is small amount of ascites and anasarca. TECHNIQUE: MDCT-acquired axial images were obtained through the abdomen and pelvis after administration of 130 cc IV Optiray contrast. Right central catheter remains in place. please IV only REASON FOR THIS EXAMINATION: ? Spleen and bilateral adrenal glands are normal. NG tube tip is in the stomach. Kidneys enhance and excrete contrast symmetrically without evidence of hydronephrosis or hydroureter. There is free fluid tracking into the pelvis. One view. There is a large volume of free intraperitoneal gas, the largest pocket residing in the upper abdomen anterior to the liver. No acute intrathoracic abnormality. Bibasilar opacities are a combination of pleural effusion and atelectasis, left greater than right, increased from prior. IMPRESSION: 1. IMPRESSION: 1. Multilevel degenerative changes in the thoracolumbar spine. Continued prominence of the cardiac silhouette with bilateral pleural effusions and bibasilar atelectatic change, more prominent on the left. No appreciable pleural effusion or pneumothorax. COMPARISON: . COMPARISON: . Comparison with the previous study of . CT PELVIS: The urinary bladder, uterus, adnexa and rectum are unremarkable. No intra- or extra-hepatic biliary ductal dilatation. BONE WINDOWS: No suspicious lytic or sclerotic osseous lesions are (Over) 9:04 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # Reason: ? Suggest clinical correlation and repeat tracing. Otherwise, there isno major change. Mediastinal structures are unchanged. Enhancement of the peritoneum along the upper abdomen along the liver and spleen raises concern for peritonitis. Pre-op evaluation. 3:09 AM CHEST (PORTABLE AP) Clip # Reason: Eval post op film Admitting Diagnosis: PERFORATED DIVERTICULUM MEDICAL CONDITION: 88 year old woman s/p perf'd DU REASON FOR THIS EXAMINATION: Eval post op film FINAL REPORT SINGLE AP PORTABLE VIEW OF THE CHEST REASON FOR EXAM: Status post perf DU There are low lung volumes. Heart size is stable. 4. 3. pt will not tolerate po contrast. Field of view: 40 Contrast: OPTIRAY Amt: FINAL REPORT (Cont) identified. | 7 | [
{
"category": "Radiology",
"chartdate": "2199-09-10 00:00:00.000",
"description": "CHEST (SINGLE VIEW)",
"row_id": 1148334,
"text": " 4:37 PM\n CHEST (SINGLE VIEW) Clip # \n Reason: r/o pneumonia or other processes\n Admitting Diagnosis: PERFORATED DIVERTICULUM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old woman with desaturation episode and thick green mucous plug upon NT\n suctioning.\n REASON FOR THIS EXAMINATION:\n r/o pneumonia or other processes\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Desaturation with possible mucus plug or pneumonia.\n\n FINDINGS: In comparison with study of , there are lower lung volumes.\n Continued prominence of the cardiac silhouette with bilateral pleural\n effusions and bibasilar atelectatic change, more prominent on the left. No\n acute pneumonia, vascular congestion, or pneumothorax. Right central catheter\n remains in place.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2199-09-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1146992,
"text": " 3:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval post op film\n Admitting Diagnosis: PERFORATED DIVERTICULUM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old woman s/p perf'd DU\n REASON FOR THIS EXAMINATION:\n Eval post op film\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Status post perf DU\n\n There are low lung volumes. Bibasilar opacities are a combination of pleural\n effusion and atelectasis, left greater than right, increased from prior.\n Mild-to-moderate cardiomegaly is acentuated by the low lung volumes. ET tube\n is low only 1.8 cm above the carina, to be withdrawn couple of centimeters to\n a standard position. NG tube tip is in the stomach. Right IJ catheter tip is\n low, is in the right atrium.\n\n Pneumoperitoneum is less conspicuous than before.\n\n"
},
{
"category": "Radiology",
"chartdate": "2199-08-31 00:00:00.000",
"description": "P CHEST (PRE-OP AP ONLY) PORT",
"row_id": 1146968,
"text": " 10:45 PM\n CHEST (PRE-OP AP ONLY) PORT Clip # \n Reason: pre-op\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old woman with diverticulosis and free air.\n REASON FOR THIS EXAMINATION:\n pre-op\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 88-year-old female with diverticulosis and free air. Pre-op\n evaluation.\n\n COMPARISON: .\n\n UPRIGHT AP VIEW OF THE CHEST: Lung volumes are low. No focal consolidation.\n No appreciable pleural effusion or pneumothorax. Heart size is stable.\n Tortuosity of the thoracic aorta is noted, but the mediastinal silhouette is\n otherwise unremarkable. Hilar contours and pulmonary vasculature are normal.\n Lucency in the midline lower chest is compatible with hiatal hernia.\n Intraperitoneal free air identified on abdominal CT is not well appreciated on\n the current exam and may be due to positioning.\n\n IMPRESSION:\n 1. No acute intrathoracic abnormality. Known intraperitoneal fre air not well\n assessed on the current study.\n 2. Hiatal hernia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2199-09-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1147912,
"text": " 10:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: PERFORATED DIVERTICULUM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old woman with desats/SOB\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST X-RAY.\n\n HISTORY: O2 desat, short of breath.\n\n One view. Comparison with the previous study of . Bibasilar opacities\n and blunting of the costophrenic sulci persists. Mediastinal structures are\n unchanged. The patient has been extubated. A right internal jugular catheter\n remains in place.\n\n IMPRESSION: No significant change post-extubation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2199-08-31 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 1146961,
"text": " 9:04 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: ? worsening colitis.\n Field of view: 40 Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old woman with hx of radiation colitis w/ frequent diarrhea now w/\n worsening abd pain. pt will not tolerate po contrast. please IV only\n REASON FOR THIS EXAMINATION:\n ? worsening colitis.\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: EAGg SAT 9:42 PM\n Free air in the central upper abd concerning for perforation. B/l pleural\n effusions, ascites, anasarca.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 88-year-old female with history of radiation colitis, presents\n with frequent diarrhea and worsening abdominal pain.\n\n COMPARISON: .\n\n TECHNIQUE: MDCT-acquired axial images were obtained through the abdomen and\n pelvis after administration of 130 cc IV Optiray contrast. Coronal and\n sagittal reformats were displayed.\n\n CT ABDOMEN WITH IV CONTRAST: Small bilateral pleural effusions with simple\n fluid attenuation and associated compressive atelectasis. Large hiatal hernia\n is noted.\n\n There is a large volume of free intraperitoneal gas, the largest pocket\n residing in the upper abdomen anterior to the liver. The site of bowel\n perforation is not clearly defined though there is a perisigmoid collection\n seen on series 2, images 65-70 which is a likely candidate for perforation.\n There is diffuse thickening of the transverse colon, similar to what was seen\n on the prior CT, compatible with colitis. Enhancement of the peritoneum along\n the upper abdomen along the liver and spleen raises concern for peritonitis.\n There is small amount of ascites and anasarca.\n\n Multiple small hypodensities are again noted in the liver, unchanged from\n prior. No intra- or extra-hepatic biliary ductal dilatation. Gallbladder is\n normal with pericholecystic fluid likely secondary to ascites. The pancreas\n is atrophis. Spleen and bilateral adrenal glands are normal. Kidneys enhance\n and excrete contrast symmetrically without evidence of hydronephrosis or\n hydroureter. Multiple small hypodensities are again noted in the bilateral\n kidneys. No retroperitoneal or mesenteric lymphadenopathy meeting CT criteria\n for pathologic enlargement. Atherosclerotic calcification of the aorta is\n again noted.\n\n CT PELVIS: The urinary bladder, uterus, adnexa and rectum are unremarkable.\n There is free fluid tracking into the pelvis.\n\n BONE WINDOWS: No suspicious lytic or sclerotic osseous lesions are\n (Over)\n\n 9:04 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: ? worsening colitis.\n Field of view: 40 Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n identified. Multilevel degenerative changes in the thoracolumbar spine.\n\n IMPRESSION:\n\n 1. Free air in the abdomen with free fluid and peritoneal enhancement\n compatible with peritonitis. Site of bowel perforation is most likely sigmoid\n colon.\n\n 2. Persistent colitis.\n\n 3. Small bilateral pleural effusions, lower lobe compressive atelectasis,\n increased from prior.\n\n 4. Large hiatal hernia.\n\n Findings discussed with Dr. at 9:30 p.m. and Dr. at\n 10:00 p.m. on .\n\n ADDENDUM: Upon further review, a mucosal defect is noted in the duodenum on\n series 300b, image 27 with a dense pill seen outside the lumen of the duodenum\n as well as fluid. Findings are compatible with perforated duodenal ulcer which\n is concordant with the operative findings.\n\n"
},
{
"category": "ECG",
"chartdate": "2199-09-01 00:00:00.000",
"description": "Report",
"row_id": 194443,
"text": "Sinus rhythm with atrial premature beats. Poor R wave progression. Low\nprecordial voltage. Diffuse non-specific ST-T wave abnormalities.\nCompared to the previous tracing of heart rate is decreased.\nPrecordial voltage is lower. Suggest clinical correlation and repeat tracing.\n\n"
},
{
"category": "ECG",
"chartdate": "2199-08-31 00:00:00.000",
"description": "Report",
"row_id": 194444,
"text": "Sinus tachycardia with baseline artifact and atrial premature depolarizations.\nDiffuse non-diagnostic repolarization abnormalities. Compared to the previous\ntracing of heart rate is significantly increased. Otherwise, there is\nno major change.\n\n"
}
] |
18,241 | 126,220 | She was taken to the operating room on where she underwent a replacement of her ascending & hemiarch aorta with a #28 gelweave graft. Please see opeartive report for surgical details. She was transferred to the ICU in critical but stable condition for invasive monitoring. She was extubated and weaned from her vasoactive drips by POD #1. She was ready for transfer to the floor on POD #2. Her chest tubes and epicardial pacing wires were removed per protocol. Beta blockers and diuretics were initiated and she was gently diuresed towards her pre-op weight. A HIT panel was sent given her thrombocytopenia, but was negative. And her platelet count improved. She continued to improve post-operatively and worked with physical therapy for strength and mobility. She was ready for discharge on post-op day 7 with VNA and the appropriate follow-up appointments. | DSG WITH SLIGHT SANGUINOUS DRAINAGE NOTED. Mild (1+) aortic regurgitation is seen. Sternal and mediastinal dressings cdi. Sternal and mediastinal dressings cdi. Status post median sternotomy. Resp. ligs. Small right apical pneumothorax. Left pleural fluid now appears to be at least partially loculated. A small apical right pneumothorax is identified. BS DIMINISHED BIBASILAR. Monitor hct, lytes. Trace/mild AI. care note - Intubated pt. Small right pleural effusion. There is a persistent small right apical pneumothorax. Turns self. BS present. Bilateral chest tubes and the mediastinal tube is identified. Mild to moderate (+) mitralregurgitation is seen. bs clear bilat. Mild (1+) AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. CT DRAINAGE MIN. Sinus rhythm at upper limits of normal rate. K repleted. K repleted. Bilateral small layering pleural effusions are evident. There are simple atheroma in thedescending thoracic aorta. S/p replacement of acending aortaneuro- pt a+o x2, follows commands, mae's, perrla. Minimal serosanguinous drainage. Trace/mild MR.Proximal end of tube graft well-seen on ascending aorta. good UO.Endoc: RISSPlan: Transfer to floor. Descending aortaintact. Afebrile. KVO. +BS. A right chest tube has been removed. Pt. Good UO. Follows commands.Resp: LCTA diminished bases. IMPRESSION: 1. transffered from OR to CSRU. asc. asc. asc. Small layering bilateral pleural effusions. mod. Thedescending thoracic aorta is mildly dilated. Foley cath. Foley cath. NEURO: REVERSED AND AWOKE CALM , PERL, MAE, FOLLOWS COMMANDS. There is a persistent left pleural effusion, essentially unchanged in size. Monitor lytes and hct. oob->chair w 1 minimal assist. An endotracheal tube and nasogastric tube and Swan-Ganz catheter have been withdrawn. Good coughCV: SR w/o ectopy HR 80's. A right internal jugular sheath remains in place. cuff coorelated well. min amt s/s drainage from ct's, wound sited w/ psd intact min amt old staining. CT to wall suction. Dkin intact. Mild to moderate (+)MR.TRICUSPID VALVE: Mild to moderate [+] TR.PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: A TEE was performed in the location listed above. CLEAR UPPER. Themitral valve leaflets are mildly thickened. Mildly dilated descending aorta.Simple atheroma in descending aorta.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). The nasogastric tube is identified with its tip terminating near the gastric antrum. Pulses palpable. Pulses palpable. AS PER ORDERS. Mediastinal structures are probably unchanged. The thoracic aorta and mediastinum are unchanged when compared with a prior study of . MAE. Perl 3mm brisk.CV: SR w/o ectopy. w good refill,unable to obtain finger sats as before. w good refill,unable to obtain finger sats as before. s/p replacement of ascending aortaO: CARDIAC: SR 90'S-60'S WITH ISOLATED RARE PVC NOTED. IMPRESSION: Persistent small right pneumothorax post chest tube removal. 3. Trauma line intact. Postop film. LACTATE 2.5 DR. COMPARISON: Preop film from . lopressor started for climbing bp w effect,pacer in aai mode.huo consistently low,lasix started w great diuresis. PATIENT/TEST INFORMATION:Indication: Aortic aneurysm.Status: InpatientDate/Time: at 10:57Test: TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.LEFT VENTRICLE: Normal LV wall thicknesses and cavity size.LV WALL MOTION: basal anterior - normal; mid anterior - normal; basalanteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal;mid inferoseptal - normal; basal inferior - normal; mid inferior - normal;basal inferolateral - normal; mid inferolateral - normal; basal anterolateral- normal; mid anterolateral - normal; anterior apex - normal; septal apex -normal; inferior apex - normal; lateral apex - normal; apex - normal;RIGHT VENTRICLE: RV not well seen.AORTA: Markedly dilated ascending aorta. There is now a left pleural effusion which appears to be at least partially loculated and increased density is present in the retrocardiac area consistent with atelectasis or consolidation. amt thin sero sang. Speech clear. Speech clear. dng dumped from ct's when standing,otherwise minimal dng.oob->chair w 2 minimal assists,transfers well. Theascending aorta is markedly dilated. 2. One portable view. A and V wires intact. The patient is status post median sternotomy. Bulging contour of the left mediastinum likely representing the postoperative aorta. intubated with # 7 OET, 18 at the lip, placed on the vent at this time. see flow sheet. HR 80's. RIGHT SC DISSECTION REPAIRED + PALP RADIAL RIGHT PULSE AS WELL AS RIGHT ULNAR PULSE. Postoperative mediastinum is significant for a left mediastinal bulging contour, likely representing the postoperative aorta. HCT 34-28.5 TO BE REPEATED. The side port is below the level of the diaphragm. SVO2 70- TO AS LOW AS 52 PRESENTLY 60'S. Increased retrocardiac density, consistent with atelectasis or consolidation. There is no pericardial effusion.Post- CPB: Preserved biventricular systolic fxn. AWARE. Nursing Note:Neuro: AAO x3. This finding was discussed with . The patient was under generalanesthesia throughout the procedure.Conclusions:Pre-CPB: Left ventricular wall thicknesses and cavity size are normal. GOAL TO KEEP SBP 100-120. wires & ct's dc'd w/o incident. No AS. Good cough.GI/GU: Abdomen soft, flat. GI: C/O NAUSEA X 1 RECEIVED 5MG IV REGLAN X1. Skin intact. Sense and pace appropriately. CI 1.2 UPON ARRIVAL FROM OR RECEIVED 6 L LR TO KEEP CI>2. I certifyI was present in compliance with HCFA regulations. The residual along the left lower costal pleural surface may be loculated. Comparison with the previous study done . Perl 3mm brisk. Ademand at 60. The abnormal contour of the right hemidiaphragm is comparable to the preoperative appearance probably due to eventration, not to be mistaken for pleural effusion. Pulmonary hygiene. Pulmonary hygiene. Endotracheal tube is approximately 3.4 cm from the tip of the carina. Low limb lead voltage.Non-specific ST-T wave abnormalities. Assess for pneumothorax. CALCIUM 2 GM REPLACED X1. SBP REQUIRED NEO OUT OF OR NEO DC'D SHORTLY AFTER ARRIVAL. BP 90/50's. TOLERATED CPAP 5/5 WELL, NEURO STATUS- RESEDATE IF NEEDED, I+O, LABS. K REPLACED 20 MEQ X2. fick 4.5, svo2 mid to high 60's. bs clear in upper lobes and diminished in bases, weak productive cough. IMPRESSION: AP chest compared to and 4: Small left pleural effusion has decreased since . | 15 | [
{
"category": "Echo",
"chartdate": "2171-12-06 00:00:00.000",
"description": "Report",
"row_id": 81907,
"text": "PATIENT/TEST INFORMATION:\nIndication: Aortic aneurysm.\nStatus: Inpatient\nDate/Time: at 10:57\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.\n\nLEFT VENTRICLE: Normal LV wall thicknesses and cavity size.\n\nLV WALL MOTION: basal anterior - normal; mid anterior - normal; basal\nanteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal;\nmid inferoseptal - normal; basal inferior - normal; mid inferior - normal;\nbasal inferolateral - normal; mid inferolateral - normal; basal anterolateral\n- normal; mid anterolateral - normal; anterior apex - normal; septal apex -\nnormal; inferior apex - normal; lateral apex - normal; apex - normal;\n\nRIGHT VENTRICLE: RV not well seen.\n\nAORTA: Markedly dilated ascending aorta. Mildly dilated descending aorta.\nSimple atheroma in descending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild to moderate (+)\nMR.\n\nTRICUSPID VALVE: Mild to moderate [+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. No TEE related\ncomplications. The TEE probe was passed with assistance from the\nanesthesioology staff using a laryngoscope. The patient was under general\nanesthesia throughout the procedure.\n\nConclusions:\nPre-CPB: Left ventricular wall thicknesses and cavity size are normal. The\nascending aorta is markedly dilated. The sino-tubular junction is intact. The\ndescending thoracic aorta is mildly dilated. There are simple atheroma in the\ndescending thoracic aorta. The aortic valve leaflets (3) are mildly thickened.\nThere is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The\nmitral valve leaflets are mildly thickened. Mild to moderate (+) mitral\nregurgitation is seen. There is no pericardial effusion.\n\nPost- CPB: Preserved biventricular systolic fxn. Trace/mild AI. Trace/mild MR.\nProximal end of tube graft well-seen on ascending aorta. Descending aorta\nintact.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2171-12-06 00:00:00.000",
"description": "Report",
"row_id": 207975,
"text": "Sinus rhythm at upper limits of normal rate. Low limb lead voltage.\nNon-specific ST-T wave abnormalities. Since the previous tracing of \nST-T wave abnormalities are new.\n\n"
},
{
"category": "Radiology",
"chartdate": "2171-12-06 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 938298,
"text": " 2:11 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: postop film\n Admitting Diagnosis: AAA\\AORTIC VALVE REPLACEMENT;ASCENDING AORTIC REPLACEMENT;AORTIC ARCH REPLACEMENT;DHCA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman s/p repl. asc. /hemiarch aorta\n REASON FOR THIS EXAMINATION:\n postop film\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 73-year-old woman status post replaced ascending/hemiarch of the\n aorta. Postop film.\n\n COMPARISON: Preop film from .\n\n FINDINGS: Portable radiograph of the chest. Endotracheal tube is\n approximately 3.4 cm from the tip of the carina. The nasogastric tube is\n identified with its tip terminating near the gastric antrum. The side port is\n below the level of the diaphragm. Bilateral chest tubes and the mediastinal\n tube is identified. Right-sided internal jugular pulmonary artery catheter is\n seen with its tip terminating in the right main pulmonary artery.\n\n Postoperative mediastinum is significant for a left mediastinal bulging\n contour, likely representing the postoperative aorta. A small apical right\n pneumothorax is identified. Bilateral small layering pleural effusions are\n evident.\n\n IMPRESSION:\n 1. Small right apical pneumothorax. This finding was discussed with \n .\n 2. Small layering bilateral pleural effusions.\n 3. Bulging contour of the left mediastinum likely representing the\n postoperative aorta.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2171-12-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 938547,
"text": " 7:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for fluid collections/consolidations and pneumothorax\n Admitting Diagnosis: AAA\\AORTIC VALVE REPLACEMENT;ASCENDING AORTIC REPLACEMENT;AORTIC ARCH REPLACEMENT;DHCA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman s/p repl. asc. /hemiarch aorta s/p removal of chest and\n mediastinal tubes\n REASON FOR THIS EXAMINATION:\n assess for fluid collections/consolidations and pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 7:30 a.m. \n\n HISTORY: Status post arch replacement. Assess fluid collections in the\n chest.\n\n IMPRESSION: AP chest compared to and 4:\n\n Small left pleural effusion has decreased since . The residual\n along the left lower costal pleural surface may be loculated. Atelectasis at\n the base of the left lung which increased from to is\n stable. The lungs are otherwise clear. Heart is partially obscured by\n pleural abnormality, and appears slightly larger today than on , but\n still normal. The abnormal contour of the right hemidiaphragm is comparable\n to the preoperative appearance probably due to eventration, not to be mistaken\n for pleural effusion. No central venous catheter is noted. No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2171-12-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 938507,
"text": " 6:27 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Assess for pneumothorax and fluid collections\n Admitting Diagnosis: AAA\\AORTIC VALVE REPLACEMENT;ASCENDING AORTIC REPLACEMENT;AORTIC ARCH REPLACEMENT;DHCA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman s/p repl. asc. /hemiarch aorta s/p removal of chest and\n mediastinal tubes\n REASON FOR THIS EXAMINATION:\n Assess for pneumothorax and fluid collections\n ______________________________________________________________________________\n FINAL REPORT\n CHEST\n\n HISTORY: Removal of tubes. Assess for pneumothorax.\n\n One portable view. Comparison with the previous study done . A right\n chest tube has been removed. There is a persistent small right apical\n pneumothorax. There is now a left pleural effusion which appears to be at\n least partially loculated and increased density is present in the retrocardiac\n area consistent with atelectasis or consolidation. The patient is status post\n median sternotomy. Mediastinal structures are probably unchanged. An\n endotracheal tube and nasogastric tube and Swan-Ganz catheter have been\n withdrawn. A right internal jugular sheath remains in place.\n\n IMPRESSION: Persistent small right pneumothorax post chest tube removal.\n Left pleural fluid now appears to be at least partially loculated. Increased\n retrocardiac density, consistent with atelectasis or consolidation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2171-12-11 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 938927,
"text": " 2:57 PM\n CHEST (PA & LAT) Clip # \n Reason: pleural effusion\n Admitting Diagnosis: AAA\\AORTIC VALVE REPLACEMENT;ASCENDING AORTIC REPLACEMENT;AORTIC ARCH REPLACEMENT;DHCA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman s/p replacement of ascending and hemiarch aorta\n REASON FOR THIS EXAMINATION:\n pleural effusion\n ______________________________________________________________________________\n FINAL REPORT\n CHEST TWO VIEWS, PA AND LATERAL\n\n History of replacement of ascending and hemiarch aorta.\n\n Status post median sternotomy. Heart size is within normal limits and there\n is no evidence for CHF. The thoracic aorta and mediastinum are unchanged when\n compared with a prior study of . There is a persistent left\n pleural effusion, essentially unchanged in size. No pneumothorax. Small\n right pleural effusion.\n\n IMPRESSION: No significant abnormalities since the prior study of . Specifically the pleural effusions, left greater than right, are not\n significantly changed and there is no evidence for CHF, pulmonary edema, or\n change in width of the mediastinum.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-12-09 00:00:00.000",
"description": "Report",
"row_id": 1502262,
"text": "Nursing Note:\nNeuro: AAO x3. Moves all extremeties. Speech clear. Perl 3mm brisk.\n\nCV: SR w/o ectopy. HR 80's. MAP 60's. Afebrile. Pulses palpable. Dkin intact. Sternal and mediastinal dressings cdi. Trauma line intact. K repleted. HCT 24.3\n\nResp: LCTA Sats 96% on 2lnc. No c/o SOB. Good cough.\n\nGI/GU: Abdomen soft, flat. BS present. No c/o n/v. Foley cath. Good UO. Clear, yellow urine.\n\nEndoc: RISS\n\nPain: Percocet with relief\n\nPlan: Transfer to floor. Monitor hct, lytes. OOB to chair and ambulate. Pulmonary hygiene. Pain management.\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-12-07 00:00:00.000",
"description": "Report",
"row_id": 1502256,
"text": "S/p replacement of acending aorta\nneuro- pt a+o x2, follows commands, mae's, perrla. restless while intubated, on min amt propofol on and off per sbp, turned self and moved ett above cords necessitating extubation. tol well.\n\nresp- vented on simv/ps overnight, spo2's ~98-100%, post extubation abg w/ adeq oxygenation/ventillation. bs clear in upper lobes and diminished in bases, weak productive cough. spo2 on 70% ft ~97%. rr 16-20.\n\ncvs- sbp low most of the night 90's, cvp-2, pa- 16/7, ci 1.9,received 500cc ns bolus w/ gd results. fick 4.5, svo2 mid to high 60's. on ntg gtt .25mcg/kg/min during immed post extubation period. a/v epicardial wires sensing and capturing approp. min amt s/s drainage from ct's, wound sited w/ psd intact min amt old staining. strong pedal and r radial pulses.\n\ngi- abd soft/distended, hypoactive bs, no flatus, no c/o nausea\n\nuo- cyu via foley ~30-60cc/hr.\n\nendo- reg insulin gtt titrated per guidelines.\n\nskin- mediastinal dsg intact, l femoral dsg d+i, backside intact no reddened areas.\n\nsocial- no family contact overnight.\n\na: tol extubation well, improved hemodynamics post extubation.\n\np: monitor hemodynamics per routine, follow bs per protocol, enc c+db,\n monitor labs as ordered.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-12-07 00:00:00.000",
"description": "Report",
"row_id": 1502257,
"text": "hands warm bilat. w good refill,unable to obtain finger sats as before.\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-12-07 00:00:00.000",
"description": "Report",
"row_id": 1502258,
"text": "hands warm bilat. w good refill,unable to obtain finger sats as before.\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-12-07 00:00:00.000",
"description": "Report",
"row_id": 1502259,
"text": "initially confused to person & place,restless & climbing thru siderails,impulsively sitting up,removing o2 etc.reoriented easily,swan removed(stable hemodynamics). a line repeatedly redressed for bleeding(active hand) & finally removed d/t poor trace. cuff coorelated well. lopressor started for climbing bp w effect,pacer in aai mode.huo consistently low,lasix started w great diuresis. bs clear bilat. o2 off w spo2 consistently > 97%. mod. amt thin sero sang. dng dumped from ct's when standing,otherwise minimal dng.oob->chair w 2 minimal assists,transfers well. recieved dentures from family,at bedisde. see flow sheet.\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-12-08 00:00:00.000",
"description": "Report",
"row_id": 1502260,
"text": "Nursing Progress Note:\nNeuro: Opens eyes to voice. Perl 3mm brisk. Speech clear. Oriented to person and place. MAE. Turns self. Follows commands.\n\nResp: LCTA diminished bases. Sats 96% on 3lnc. Good cough\n\nCV: SR w/o ectopy HR 80's. BP 90/50's. TLC to rt IJ. KVO. Pulses palpable. Skin intact. Sternal and mediastinal dressings cdi. A and V wires intact. Sense and pace appropriately. Ademand at 60. K repleted. CT to wall suction. Minimal serosanguinous drainage. No airleak noted.\n\nGI/Gu: Abdomen soft, flat. +BS. Foley cath. good UO.\n\nEndoc: RISS\n\nPlan: Transfer to floor. Monitor lytes and hct. Pulmonary hygiene. Increase activity.\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-12-08 00:00:00.000",
"description": "Report",
"row_id": 1502261,
"text": "wires & ct's dc'd w/o incident. oob->chair w 1 minimal assist. poor appetite but tol. ligs. glucoses managed per csru scale.c/o sternal pain with procedures(wires,tubes) but well controlled w 1 tylenol & 1 percocet.iv team unable to obtain perip. access x many tries. team to change to multilumen when able. plan floor transfer when bed available.\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-12-06 00:00:00.000",
"description": "Report",
"row_id": 1502254,
"text": "Resp. care note - Intubated pt. transffered from OR to CSRU. Pt. intubated with # 7 OET, 18 at the lip, placed on the vent at this time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-12-06 00:00:00.000",
"description": "Report",
"row_id": 1502255,
"text": "s/p replacement of ascending aorta\nO: CARDIAC: SR 90'S-60'S WITH ISOLATED RARE PVC NOTED. SBP REQUIRED NEO OUT OF OR NEO DC'D SHORTLY AFTER ARRIVAL. NTG REQIURED AND PRESENTLY AT .5 MCQ TO KEEP MAP <90 . GOAL TO KEEP SBP 100-120. CT DRAINAGE MIN. DSG WITH SLIGHT SANGUINOUS DRAINAGE NOTED. FEET WARM AND DRY. HANDS COOL TO TOUCH BILATERALLY. RIGHT SC DISSECTION REPAIRED + PALP RADIAL RIGHT PULSE AS WELL AS RIGHT ULNAR PULSE. PT DENIES NUMBNESS AND OR TINGLING GOOD CAPILLARY REFILL. SVO2 70- TO AS LOW AS 52 PRESENTLY 60'S. CI 1.2 UPON ARRIVAL FROM OR RECEIVED 6 L LR TO KEEP CI>2. PAD'S TEENS. CVP 3-13. HCT 34-28.5 TO BE REPEATED. RECIEVED 50 MG PROTAMINE PER ORDER OF DR. . K REPLACED 20 MEQ X2. CALCIUM 2 GM REPLACED X1. LACTATE 2.5 DR. AWARE.\n RESP: PRESENTLY CPAP 5/5 HOWEVER DUE TO TIME OF NIGHT DR. HAS OPTED TO REST OVERNIGHT ON A RATE AND HAVE PT READY TO EXTUBATE IN AM ON ROUNDS. NO CHEST TUBE LEAK NOTED. BS DIMINISHED BIBASILAR. CLEAR UPPER. O2 SAT DIFFICULT TO OBTAIN, PRESENTLY 100.\n NEURO: REVERSED AND AWOKE CALM , PERL, MAE, FOLLOWS COMMANDS.\n GI: C/O NAUSEA X 1 RECEIVED 5MG IV REGLAN X1. ABD SOFT NONTENDER,ABSENT BOWEL SOUNDS.\n GU:AUTODIURESED 3150\n ENDO: INSULIN GTT AT 5 UNITS/HR\n PAIN: RECIEVED 2 MG MORPHINE SC X 1 AND IV X1.\n ID: RECIEVED KEFZOL 2 GM AT \n SOCIAL: DAUGHTERS INTO VISIT AND UPDATED, DAUGHTER WILL BE THE SPOKESPERSON.\nA: DIFFICULT TO KEEP CI >2 , FICK SLIGHTLY HIGHER.\nP: MONITOR COMFORT, HR AND RYTHYM, SBP-WEAN NTG AS TOLERATED TO KEEP MAP<90-SBP100-120, CI, SVO2,PAD,S,CVP, CT DRAINAGE , DSGS, RESP STATUS-REMAIN INTUBATED OVERNIGHT HAVE READY TO EXTUBATE ON AM ROUNDS. TOLERATED CPAP 5/5 WELL, NEURO STATUS- RESEDATE IF NEEDED, I+O, LABS. AS PER ORDERS.\n"
}
] |
91,669 | 195,384 | SUMMARY Ms. had a long course. Initially admitted with hypoNA and hypoK, she went on to develop severe fluid overload requiring intubation and CRRT as well as a UTI and presumptive PNA treated with broad spectrum antibiotics. Her fluid overload was complicated by SVT that prompted initiation of selective beta blockade and a cardiac evaluation (negative nuclear stress). She went on to tolerate aggressive diuresis and was discharged By Problem # Hyponatremia to Cirrhotic hemodynamics, fluid overload Hypotension, Shock with septic physiology On admission, Na+ was 120 and she was asymptomatic. Initially treated with fluid restriction with little success, then with Tolvaptan 15mg then 30mg with increases of mEq per day, plateauing at 126. On She was hypotensive to the 90's with orthostasis. She was transferred to the surgery team and SICU on for dyspnea and hemodynamic management. her respiratory status declined to the point of requiring intubation (see respiratory failure). She required the support of 2 pressors. Despite no clear source of her septic response, with supportive care and antibiotic treatment, the patient's hemodynamics and respirtory systems stabilized. On , Ceftriaxone, vanco, and flagyl due to her hypotension and worsening leukocytosis. On fluc was started. There was not a clear source of the patient's hypotension and leukocytosis. On , antibiotics were stopped. The patient was then transferred back to the floor in stable condition. # Respiratory Failure fluid overload Hepatic Hydrothorax Oliguric renal failure On admission she was short of breath, but saturating well 95-98% on room air. She became breathless with 5-7 word sentences. A paracentesis removed one liter of fluid on , without much resolution of symptoms, an ultrasounds on found insufficient ascites to tap. Thoracetesis on , removed 900cc of pleural transudative fluid. CXR on for SOB found pulmonary edema with sats 90-92%. After albumin/lasix/albuterol sats improved to 94-96% on 3L NC and creatinine rose to 1.4. Her saturations were at 90-92% sitting, and on standing her sats dropped to 85%. She was transferred to the ICU where she required intubation and CRRT. On , the patient failed BiPAP and was intubated. Bronch on showed minimal secretions. As more fluid was removed and her hypotension improved, the patient was weaned to PS from CMV. On , the patient was extubated. On , the patient tolerated being 2.6L negative on CVVHD along with BP support on pressors. The patient tolerated having 2L removed daily. By , the CVVHD was running even. On , CVVHD was stopped the patient's urine output slowly increased. Upon return to the floor, she tolerated aggressive diuresis with midodrine for BP support. # Atrial Fibrillation Patent Forament Ovale Normal EF, Normal Nuclear Stress On SICU admission, the patient had a stable blood pressure. On , the patient went into atrial fibrillation with a rapid response. Cardiology was consulted and recommended continued diuresis and to add metoprolol 12.5 PO BID for rate control. On an echo cardiogram (TTE and TEE) was performed which showed normal systolic function and a PFO. Cardiac enzymes were negative x 3. The patient went into intermittent A. fib. On , the patient was started on low dose dopamine with no cardiovascular or renal response. On , Neo-synephrine was started and the lopressor was d/c'ed. Vasporessin was also started for hypotension. Due to presumed sepsis, the Neo-synephrine was transitioned to levophed. Pressors were weaned over the next few days. The patient received intermittent IV and PO lopressor for bouts of A. fib. On the floor, she was maintained on 12.5 mg Metop tartrate TID. A nuclear stress was negative, save for persantine induced symptoms. Cardiology recommends continuing beta blockade through her # Hypokalemia She was repleted with KCl and her potassium corrected and was stable for the remainder of the admission. # Cirrhosis, likely from NASH (T2DM, hx of obesity, htn, dyslipidemia) The patient was continued on tube feeds (isosource 1.5). She was continued on lactulose and ursodiol, gastric varices, and ascites. # T2DM The patient is on an regular insulin SS for her DMII. In the ICU, on , an insulin gtt was started to improved glucose control. The insulin gtt was weaned and the patient was started on NPH and sliding scale which she tolerated well. # UTI The patient was on ciprofloxacin for a klebsiella UTI. The patient was then started on daily ciprofloxacin for SBP prophylaxis. | Questionable minimal right apical pneumothorax is seen, please correlate with the site of bronchoscopy. FINDINGS: As compared to the previous radiograph, the nasogastric tube has been removed. Unchanged moderate right pleural effusion with basal areas of atelectasis. The pre-existing parenchymal opacities and the relatively extensive right-sided pleural effusion are unchanged. IMPRESSION: Mild-to-moderate right pleural effusion. FINDINGS: Since the radiograph dated , the patient has developed a mild-to-moderate right pleural effusion. FINDINGS: In comparison with the earlier study of this date, there has been a placement of a left IJ catheter that appears to extend into the brachiocephalic vein. Right internal jugular line tip is at the level of lower SVC. FINDINGS: In comparison with the earlier study of this date, there has been placement of a left subclavian catheter that extends to the mid portion of the SVC. Bilateral patchy parenchymal opacities, which may represent multifocal pneumonia, and appear unchanged. FINDINGS: Contrast is seen passing out of the Dobbhoff tube and into the distal duodenum and proximal jejunum. Several calcified lymph nodes are seen within the aortopulmonary window, stable. FINDINGS: Right moderate pleural effusion and left small pleural effusion are unchanged in appearance when compared to study. Bilateral right more than left pleural effusion is unchanged. Assess for pleural effusions. IMPRESSION: Post-pyloric location of Dobbhoff tube confirmed with oral contrast. The right pleural effusion appears mildly diminished when compared to study. FINAL REPORT INDICATION: Confirmation of post-pyloric positioning of Dobbhoff tube. Right pleural effusion with associated atelectasis. Right plerual effusion and associated atelectasis. Right lower lobe opacities are a combination of pleural effusion and atelectasis. The right internal jugular catheter is at low SVC. FINDINGS: Moderate right-sided pleural effusion with associated compressive atelectasis. Bilateral pleural effusions obliterating diaphragmatic contours as before. Unchanged moderate bilateral pleural effusions, right more than left are noted. The previously described left subclavian approach central venous line, right internal jugular double-lumen line, and ETT in unchanged position. Hilar, mediastinal and cardiac silhouettes appear stable. Cardiac size is obscured by pleural effusions. ET tube, right internal jugular and left subclavian lines and a nasogastric tube are in standard placements. Small-to-moderate right pleural effusion is unchanged. Moderate amount of intra-abdominal ascites. The right subclavian line is in the low SVC. The hilar, mediastinal and cardiac silhouettes appear stable. Bilateral pulmonary edema, unchanged. Incidental note is made of a circumaortic left renal vein. There is equivocal narrowing of the origin of the celiac artery. FINDINGS: The lateral edge of the right hemithorax is not imaged. The ET tube is less than one cm from the carina. The patient was extubated in the meantime interval. Bilateral pulmonary edema is present. The ET tube is less than a centimeter from the carina. The portal vein and hepatic veins are patent. FINDINGS: In comparison with the study of , there are continued bilateral pleural effusions, more prominent on the right with basilar atelectasis. The visualized pericardium is normal. Indeterminate PA systolic pressure.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: The patient appears to be in sinus rhythm. Normal ascending aortadiameter. Mild (1+) mitral regurgitation is seen. Tissue Doppler imaging suggests a normal leftventricular filling pressure (PCWP<12mmHg). No AS.MITRAL VALVE: Normal mitral valve leaflets. No PS.Physiologic PR.PERICARDIUM: No pericardial effusion.Conclusions:The left atrium is mildly dilated. No PS.Physiologic PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor apical views.Conclusions:The left atrium is mildly dilated. The mitral valve appearsstructurally normal with trivial mitral regurgitation. Preserved rightventricular systolic function. The aorticvalve leaflets (3) are mildly thickened but aortic stenosis is not present.The mitral valve leaflets are structurally normal. Left ventricular function.Height: (in) 64Weight (lb): 172BSA (m2): 1.84 m2BP (mm Hg): 93/32HR (bpm): 75Status: InpatientDate/Time: at 16:03Test: Portable TTE (Focused views)Doppler: Limited Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:LEFT ATRIUM: Mild LA enlargement.LEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolicfunction (LVEF>55%). Mild (1+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Right ventricular function. Since the previous tracing of irregulartachycardia has replaced sinus rhythm and right axis deviation is now present.TRACING #1 A small amount of contrast injection revealed opacification of distal duodenum. PFO is present.LEFT VENTRICLE: Overall normal LVEF (>55%).RIGHT VENTRICLE: Normal RV chamber size and free wall motion.TRICUSPID VALVE: Mild PA systolic hypertension.GENERAL COMMENTS: Suboptimal image quality - poor apical views.Conclusions:A patent foramen ovale is present (right to left echo contrast shunting atrest within 3 beats of RA/RV opacification). No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Cardiomediastinal silhouette and widespread opacities are unchanged including right lower lobe consolidation and bilateral pleural effusion, at least moderate on the right and small on the left. Continued moderate right pleural effusion. Since the previous tracing of irregular tachy-arrhythmia is now absent and intraventricular conduction delayhas decreased and is without right axis deviation.TRACING #2 Small left and moderate right pleural effusions are unchanged. FINAL REPORT HISTORY: Hemachromatosis with shortness of breath. Bilateral small-to-moderate pleural effusions with associated compressive atelectasis, stable. Bilateral small-to-moderate pleural effusions are unchanged. Pulmonary edema stable. There is interval progression of multifocal opacities but slight improvement in the right pleural effusion. Small right pleural effusion is probably unchanged; however, minimally enlarged. Bibasilar opacity consistent with atelectasis and/or pneumonia are grossly unchanged. Hilar, mediastinal, and cardiac silhouettes are stable. Right IJ tip is positioned in mid to low SVC. Previously described suprahilar pulmonary edema appears mildly improved. Right hemidiaphragm is obscured likely due to compressive atelectasis. Findings c/w cirrhosis. Findings compatible with cirrhosis. PFI REPORT Post-pyloric location of Dobbhoff tube confirmed with oral contrast. Left pleural effusion is most likely present. Cardiomediastinal contours are unchanged. The cardiomediastinal silhouette is unchanged. An enteric tube is in nondistended stomach. Cardiac size is top normal. Cardiac size is top normal. Compared to the previous tracingof no change. FINAL REPORT SINGLE AP PORTABLE VIEW OF THE CHEST REASON FOR EXAM: Status post thoracentesis, assess for pneumothorax. Interval improvement of mild pulmonary edema. Cardiomediastinal silhouette is unchanged. | 62 | [
{
"category": "Radiology",
"chartdate": "2167-08-04 00:00:00.000",
"description": "RENAL U.S.",
"row_id": 1149321,
"text": " 3:31 PM\n RENAL U.S. Clip # \n Reason: eval for anatomic abn anatomy, hydronephrosis\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with persitent oliguria despite adequate resuscitation.\n REASON FOR THIS EXAMINATION:\n eval for anatomic abn anatomy, hydronephrosis\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 60-year-old female with persistent oliguria despite adequate\n resuscitation, evaluate for hydronephrosis.\n\n COMPARISON: Abdominal ultrasound .\n\n RENAL ULTRASOUND: The left kidney measures 10.4 cm, and the right kidney\n measures 10.5 cm. There is no evidence of stones, mass, or hydronephrosis.\n The bladder is collapsed.\n\n IMPRESSION: No hydronephrosis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-07-31 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1148727,
"text": " 8:48 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval pleural effusions\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old female with hemachromatosis c/b cirrhosis, that presented with\n hyponatremia and hypokalemia\n REASON FOR THIS EXAMINATION:\n eval pleural effusions\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient with hyponatremia and\n hypokalemia with history of hemachromatosis and cirrhosis.\n\n Portable AP chest radiograph was compared to prior study obtained on , at 5:48 p.m.\n\n Current study demonstrates no significant interval change in the right pleural\n effusion, right basal opacity and some degree of pulmonary edema. Note is\n made that the right basal consolidation appears to be slightly worsened again.\n As previously suggested it might demonstrate developing infection.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-07-23 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1147720,
"text": " 7:02 PM\n CHEST (PA & LAT) Clip # \n Reason: Please evaluate for liver transplant work-up\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with cirrhosis secondary to hemochromatosis being evaluated\n for pretransplant work-up\n REASON FOR THIS EXAMINATION:\n Please evaluate for liver transplant work-up\n ______________________________________________________________________________\n WET READ: 11:35 PM\n Right pleural effusion and right base atelectasis. Possible mild fluid\n overload.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Cirrhosis secondary to hemachromatosis. Pre-transplant\n radiograph.\n\n FINDINGS: Since the radiograph dated , the patient has developed a\n mild-to-moderate right pleural effusion. Perihilar vascular prominence,\n septal lines and upper lobe venous diversion are a new finding consistent with\n interstitial pulmonary edema. The cardiac size is normal.\n\n IMPRESSION:\n Mild-to-moderate right pleural effusion. Acute interstitial pulmonary edema.\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-07-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1148456,
"text": " 12:04 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for lung re-expansion, pneumothorax\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with hepatic hydrothorax, s/p drainage, air aspirated durring\n thoracentesis\n REASON FOR THIS EXAMINATION:\n evaluate for lung re-expansion, pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient with history of hepatic hydrothorax, status post\n thoracentesis. This study is obtained to assess for pneumothorax.\n\n COMPARISONS: Chest x-ray from .\n\n FINDINGS:\n\n This study is limited due to motion artifact.\n\n No pneumothorax is visualized. The right pleural effusion appears mildly\n diminished when compared to study. Pulmonary edema noted on\n prior exam appears improved, keeping in mind technical limitations of the\n current study. No focal consolidation is identified. Several calcified lymph\n nodes are seen within the aortopulmonary window, stable. The hilar and\n mediastinal silhouettes appear unchanged. Heart is not enlarged without\n pericardial effusions.\n\n Bony structures appear unremarkable.\n\n\n IMPRESSION:\n\n 1. No evidence of pneumothorax.\n\n 2. Right pleural effusion has slightly diminished in size when compared to\n study and pulmonary edema has improved.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-07-31 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1148770,
"text": " 12:33 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Please evaluate for appropriate DHT placement\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with h/o cirrhosis, req DHT, please eval for appropriate\n post-pyloric placement.\n REASON FOR THIS EXAMINATION:\n Please evaluate for appropriate DHT placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: History of cirrhosis, evaluation for appropriate post-pyloric\n placement of Dobbhoff catheter.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is no relevant\n change. The newly inserted Dobbhoff catheter projects with its tip in the\n post-pyloric region. The pre-existing parenchymal opacities and the\n relatively extensive right-sided pleural effusion are unchanged. Unchanged\n size of the cardiac silhouette. No evidence of complications.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-08-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1151118,
"text": " 4:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for change\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with hepatohydrothorax\n REASON FOR THIS EXAMINATION:\n please eval for change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Hepatohydrothorax. Evaluation for interval change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the nasogastric tube has\n been removed. The other monitoring and support devices are in unchanged\n position. Unchanged moderate right pleural effusion with basal areas of\n atelectasis.\n\n On the left, the pre-existing retrocardiac atelectasis has minimally increased\n in extent. Otherwise, there are no relevant changes. Unchanged size of the\n cardiac silhouette.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-08-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1149510,
"text": " 4:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for any thoracic abnormailities.\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman in ICU with hemochromatosis and liver failure.\n REASON FOR THIS EXAMINATION:\n Please eval for any thoracic abnormailities.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of the patient with hemochromatosis and\n liver failure.\n\n Portable AP chest radiograph was compared to .\n\n The ET tube tip is relatively low, 2.2 cm above the carina although note is\n made that patient's neck is in flexion. The Dobbhoff tube and the NG tube are\n passing below the diaphragm with the tips not included in field of view.\n Right internal jugular central venous line tip is at the cavoatrial junctions\n of proximal right atrium. Cardiomediastinal silhouette is stable. Widespread\n parenchymal opacities appear to be slightly worsened in the interim.\n Bilateral right more than left pleural effusion is unchanged.\n\n The central venous line tip is at the level of mid SVC. No pneumothorax is\n present.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-07-27 00:00:00.000",
"description": "P US ABD LIMIT, SINGLE ORGAN PORT",
"row_id": 1148184,
"text": ", J. MED FA10 3:09 PM\n US ABD LIMIT, SINGLE ORGAN PORT Clip # \n Reason: Please perform tap in the morning of . Please tap to d\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with hemachromatosis cirrhosis with increased abdominal girth\n REASON FOR THIS EXAMINATION:\n Please perform tap in the morning of . Please tap to dry.\n ______________________________________________________________________________\n PFI REPORT\n Insufficient ascites (280 cc) for therapeutic paracentesis; therefore not\n performed.\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-07-31 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1148810,
"text": " 3:15 PM\n PORTABLE ABDOMEN; -77 BY DIFFERENT PHYSICIAN # \n Reason: Please confirm post-pyloric positioning of DHT.\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with DHT placed, high risk for aspiration. Will administer\n gastrograffin to confirm placement.\n REASON FOR THIS EXAMINATION:\n Please confirm post-pyloric positioning of DHT.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SHSf FRI 5:13 PM\n Post-pyloric location of Dobbhoff tube confirmed with oral contrast.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Confirmation of post-pyloric positioning of Dobbhoff tube.\n\n COMPARISONS: Abdominal radiograph from at 13:41.\n\n TECHNIQUE: Portable abdominal radiograph following instillation of\n Gastrografin in the patient's Dobbhoff tube.\n\n FINDINGS: Contrast is seen passing out of the Dobbhoff tube and into the\n distal duodenum and proximal jejunum. Again are noted bilateral pleural\n effusions, right greater than left. Bowel gas pattern is normal.\n\n IMPRESSION: Post-pyloric location of Dobbhoff tube confirmed with oral\n contrast.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-08-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1150249,
"text": " 4:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for worsening pleural effusion\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with ESLD, with resp failure and pleural effusion, please\n eval for worsening pleural effusion\n REASON FOR THIS EXAMINATION:\n Please eval for worsening pleural effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient with ESLD with respiratory failure. Assess for pleural\n effusions.\n\n COMPARISONS: Chest x-ray from .\n\n FINDINGS:\n\n Right moderate pleural effusion and left small pleural effusion are unchanged\n in appearance when compared to study. Bilateral patchy parenchymal\n opacities, which may represent multifocal pneumonia, and appear unchanged.\n Mild pulmonary vascular congestion is seen. No pneumothorax is present.\n Hilar, mediastinal and cardiac silhouettes are unchanged.\n\n Bony structures appear unremarkable.\n\n ET tube is approximately 1.2 cm from the carina. Left subclavian line tip\n projects over mid SVC. Enteric tube is in nondistended stomach.\n\n IMPRESSION:\n\n 1. Moderate right pleural effusion and small left pleural effusion are stable\n in appearance.\n\n 2. Bilateral patchy pulmonary opacities, which may represent multifocal\n pneumonia, are stable.\n\n 3. ET tube is approximately 1.2 cm from the carina. Withdrawal by several\n centimeters is advised.\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-08-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1151283,
"text": " 2:49 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate intrapulmonary process for change\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with hepatohydrothorax\n REASON FOR THIS EXAMINATION:\n evaluate intrapulmonary process for change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of a patient with hepatohydrothorax.\n\n Portable AP chest radiograph was compared to .\n\n Right internal jugular line tip is at the level of lower SVC.\n Cardiomediastinal silhouette is stable. There is no change in pulmonary edema\n and bilateral right more than left at least moderate pleural effusion.\n\n The left subclavian line tip is at the superior SVC.\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-07-31 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1148780,
"text": " 1:17 PM\n PORTABLE ABDOMEN Clip # \n Reason: eval Dobhoff position\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old female with hemachromatosis c/b cirrhosis, that presented with\n hyponatremia and hypokalemia\n REASON FOR THIS EXAMINATION:\n eval Dobhoff position\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 60-year-old female with hemachromatosis complicated by cirrhosis,\n presenting with hyponatremia and hypokalemia. Here to assess Dobbhoff tube\n position.\n\n COMPARISON: CTA abdomen/pelvis of .\n\n PORTABLE SUPINE ABDOMINAL RADIOGRAPH: A Dobbhoff tube is seen coursing into\n the stomach, with tip terminating in the left mid abdomen, probably within the\n duodenojejunal junction, however, given that the patient's stomach has lateral\n extent on prior CT, the tube could also be coiled within the stomach. Bowel\n gas pattern is unremarkable; gas is noted in the rectum.\n\n Findings were discussed over the phone with at 2:30 p.m. If\n necessary to confirm exact position, tube check with injection of contrast\n material may be performed portably.\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-08-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1149617,
"text": " 3:46 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: ? PTX, underlying pulmonary process\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with PNA, s/p bronchoscopy\n REASON FOR THIS EXAMINATION:\n ? PTX, underlying pulmonary process\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of a patient with pneumonia after\n bronchoscopy.\n\n Portable AP chest radiograph was compared to prior study obtained the same day\n earlier.\n\n Questionable minimal right apical pneumothorax is seen, please correlate with\n the site of bronchoscopy. Widespread parenchymal opacities again\n redemonstrated, unchanged as well as there is no change in the position of\n multiple supporting devices.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-08-05 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1149447,
"text": " 2:19 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: placement of IJ line. ?lung injury.\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman s/p L IJ triple lumen central line placement.\n REASON FOR THIS EXAMINATION:\n placement of IJ line. ?lung injury.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Left IJ placement.\n\n FINDINGS: In comparison with the earlier study of this date, there has been a\n placement of a left IJ catheter that appears to extend into the\n brachiocephalic vein. Dobhoff tube extends at least to the mid body of the\n stomach, where it crosses the lower border of the image. Little change in the\n diffuse bilateral pulmonary opacifications.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-08-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1149468,
"text": " 4:38 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: please eval placement, thank you\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with new L sc cvl\n REASON FOR THIS EXAMINATION:\n please eval placement, thank you\n ______________________________________________________________________________\n WET READ: ENYa WED 10:15 PM\n New L subclavian CVL terminate at the mid SVC. Other supportive lines and\n tubes unchanged in position. Unchanged bilateral patchy opacities. Small\n bilateral pleural effusions.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: New central catheter.\n\n FINDINGS: In comparison with the earlier study of this date, there has been\n placement of a left subclavian catheter that extends to the mid portion of the\n SVC. The left IJ line has been removed. The other monitoring and support\n devices remain in place and there is continued diffuse bilateral pulmonary\n opacities with bilateral pleural effusions.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-08-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1149692,
"text": " 3:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: 60 year old woman with PNA, s/p bronchoscopy, compare with p\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with PNA, s/p bronchoscopy\n REASON FOR THIS EXAMINATION:\n 60 year old woman with PNA, s/p bronchoscopy, compare with prior\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Pneumonia, recent bronchoscopy.\n\n FINDINGS: Comparison to serial radiographs dating back to and most\n recently . The positions of the endotracheal tube tip, right internal\n jugular and left subclavian catheters and two nasogastric tubes are\n satisfactory. No pneumothorax is shown. There is worsened obliteration of the\n left medial hemidiaphragm and retrocardiac density and right lower lobe\n density since . Upper lobe venous diversion and a moderately large\n right pleural effusion are unchanged since .\n\n IMPRESSION:\n Worsening bilateral lower lobe opacities since , left and right lower\n lobe pneumonia are suspected.\n Stable mild to moderate right pleural effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-08-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1148991,
"text": " 1:43 AM\n CHEST (PORTABLE AP) Clip # \n Reason: effusions\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with liver failure, B pleural effusions\n REASON FOR THIS EXAMINATION:\n effusions\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Liver failure and bilateral pleural effusions.\n Followup.\n\n Portable AP chest radiograph was compared to obtained at 07:55\n a.m.\n\n There is no significant interval change in the right at least moderate pleural\n effusion, bibasal consolidations, and pleural plaques. The patient was\n extubated in the meantime interval. No appreciable evidence of failure is\n present. There is no evidence of pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-08-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1150406,
"text": " 4:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval interval film\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with difficulty weaning vent\n REASON FOR THIS EXAMINATION:\n Please eval interval film\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 4:19 A.M, \n\n HISTORY: Difficulty weaning from the ventilator.\n\n IMPRESSION: AP chest compared to through 24:\n\n Increase in moderate right and small-to-moderate left pleural effusion and\n caliber of suprahilar vessels suggests that increasing pulmonary opacification\n at least relative to is due to pulmonary edema. The heart is normal\n size. Concurrent noncardiac edema or lower lobe pneumonia cannot be excluded.\n\n There is no pneumothorax. ET tube, right internal jugular and left subclavian\n lines and a nasogastric tube are in standard placements.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-08-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1149356,
"text": " 8:23 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Please eval ETT placement\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with ESRD, intubated for resp failure, please eval for ETT\n placement\n REASON FOR THIS EXAMINATION:\n Please eval ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient with respiratory failure. Assess ET tube placement.\n\n COMPARISONS: Chest x-ray from .\n\n FINDINGS:\n\n The lateral aspect of the left hemithorax is not imaged.\n\n The ET tube is less than 1 cm from the carina, repositioning by 4cm is\n advised.\n The right internal jugular catheter is at low SVC. NG tube is within the\n nondistended stomach, its terminal tip is out of field of view.\n\n Bilateral heterogeneous opacities are worse when compared to \n radiograph, which can be attributed to worsening pulmonary edema. Right\n moderate pleural effusion is increased in size. No left pleural effusion is\n present. Hilar, mediastinal and cardiac silhouettes appear stable. No\n pneumothorax is seen.\n\n\n IMPRESSION:\n\n 1. The ET tube is less than 1 cm from the carina, withdrawal by 4 cm is\n advised. The finding discussed with critical care team at 12:15 pm .\n\n 2. Worsening pulmonary edema.\n\n 3. Right moderate pleural effusion, increased in size.\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-08-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1149488,
"text": " 9:12 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Please eval interval\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with hypotensive episode\n REASON FOR THIS EXAMINATION:\n Please eval interval\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Hypotensive episode, to assess for change.\n\n FINDINGS: In comparison with earlier study of this date, there is little\n change. Numerous monitoring and support devices remain in place, as do\n bilateral pulmonary opacifications. No evidence of acute pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-08-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1149859,
"text": " 4:43 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval interval film\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with ventilator dependence\n REASON FOR THIS EXAMINATION:\n Eval interval film\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Ventilator dependency.\n\n Comparison was made with prior study .\n\n Moderate to large right pleural effusion has improved with increased adjacent\n atelectasis. Cardiac size is obscured by pleural effusions. Small left\n pleural effusion has increased. Lines and tubes remain in place in standard\n position. Bibasilar opacities have worsened, could be worsening atelectasis\n or worsening pneumonia. Vascular congestion has also minimally worsened.\n There is no pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-08-04 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1149280,
"text": " 12:12 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: Eval post-line film\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with hypotension, new line\n REASON FOR THIS EXAMINATION:\n Eval post-line film\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hypertension.\n\n COMPARISON: at 3 a.m.\n\n AP UPRIGHT RADIOGRAPH OF THE CHEST: There is a new right IJ line with the tip\n terminating at the cavoatrial junction without evidence of pneumothorax or\n mediastinal widening. Moderate pulmonary edema has improved with multifocal\n consolidations worst in the left lung particularly the LUL. Unchanged moderate\n bilateral pleural effusions, right more than left are noted. No other short\n term changes.\n\n IMPRESSION:\n 1. Worsening left lung consolidations with interval improved pulmonary edema.\n\n 2. Right IJ terminating at cavoatrial junction.\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-08-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1149079,
"text": " 3:52 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval status of pleural effusion\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with pleural effusions\n REASON FOR THIS EXAMINATION:\n Eval status of pleural effusion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pleural effusion, to evaluate for status.\n\n FINDINGS: In comparison with the study of , there are continued bilateral\n pleural effusions, more prominent on the right with basilar atelectasis.\n However, there is probable increasing areas of multifocal opacification,\n suggesting the possibility of superimposed pneumonia. Central catheter\n remains in place.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-08-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1151000,
"text": " 4:27 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval interval film\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with ESLD, respiratory distress\n REASON FOR THIS EXAMINATION:\n Eval interval film\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: End-stage liver disease with respiratory distress.\n\n FINDINGS: In comparison with the study of , the monitoring and support\n devices remain in place. Continued evidence of elevated pulmonary venous\n pressure with bilateral layering pleural effusions, more prominent on the\n right, with associated compressive atelectasis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-08-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1150903,
"text": " 4:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for vol overload\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with ESLD, recently extubated, please eval for vol overload\n REASON FOR THIS EXAMINATION:\n Please eval for vol overload\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: End-stage liver disease, to assess for volume overload.\n\n FINDINGS: In comparison with the study of , there is little overall\n change. Monitoring and support devices remain in place. Continued evidence\n of elevated pulmonary venous pressure with bilateral pleural effusions, much\n more prominent on the right, with associated compressive atelectasis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-08-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1150328,
"text": " 2:17 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: check Dobhoff placement\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with Dobhoff replacement\n REASON FOR THIS EXAMINATION:\n check Dobhoff placement\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: A 60-year-old female patient with Dobbhoff replacement, check\n position.\n\n FINDINGS: AP single view of the chest has been obtained with patient in\n supine position and comparison is made with the next previous similar study\n obtained 10 hours earlier during the same day. The previously described left\n subclavian approach central venous line, right internal jugular double-lumen\n line, and ETT in unchanged position. Again, as described before, the ETT\n terminates unusually close to the bifurcation and recommendation for some\n withdrawal is reiterated. No pneumothorax has developed. Bilateral pleural\n effusions obliterating diaphragmatic contours as before. There are two lines\n passing through the esophagus and both reaching well into the stomach. The\n most distal portion of lines are outside the image field. Thus no significant\n interval change can be identified.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-08-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1149217,
"text": " 2:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for worsening effusion\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with ESLD, with resp distress/effusion, pelease eval for\n worsening effusion\n REASON FOR THIS EXAMINATION:\n Please eval for worsening effusion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: End-stage liver disease with respiratory distress and effusion.\n\n FINDINGS: In comparison with the study of , the patient and respiratory\n motion greatly degrade the image. Diffuse bilateral pulmonary opacifications\n are again seen consistent with areas of pneumonia superimposed on vascular\n congestion with overlying pleural effusions, especially on the right.\n Bibasilar atelectatic changes are noted. Central catheter remains in place.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-08-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1149384,
"text": " 3:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval interval film\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with respiratory distress, pulmonary effusions\n REASON FOR THIS EXAMINATION:\n Eval interval film\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: The patient with respiratory failure and pleural effusion.\n\n COMPARISONS: Chest x-ray from .\n\n FINDINGS:\n\n The lateral edge of the right hemithorax is not imaged.\n\n Bilateral heterogeneous opacities persist, consistent with multifocal\n pneumonia. Moderate right pleural effusion is increased in size. Left\n hemidiaphragm is obscured, likely due to new left lower lobe atelectasis.\n Bilateral pulmonary edema is present. The hilar, mediastinal and cardiac\n silhouettes appear stable. No pneumothorax is seen.\n\n\n The ET tube is less than a centimeter from the carina. The right subclavian\n line is in the low SVC. The NG tube is seen within the stomach.\n\n\n IMPRESSION:\n\n 1. The ET tube is less than one cm from the carina. The finding discussed\n with critical care team at 12:15 pm .\n\n 2. Persistent bilateral pneumonia.\n\n 3. Moderate right pleural effusion, increased in size.\n\n 4. New left lower lobe atelectasis.\n\n 5. Bilateral pulmonary edema, unchanged.\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-08-05 00:00:00.000",
"description": "NASO-INTESTINAL TUBE PLACEMENT (W/FLUORO)",
"row_id": 1149425,
"text": " 11:09 AM\n -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # \n Reason: please eval for post-pyloric DHT placement\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with ESLD, please eval place post-pyloric DHT placement\n REASON FOR THIS EXAMINATION:\n please eval for post-pyloric DHT placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 60-year-old female with end-stage liver disease, please evaluate\n placement of post-pyloric Dobbhoff tube.\n\n COMPARISON: Portable abdomen from .\n\n FINDINGS: The patient presented to the fluoroscopic suite without a tube in\n place. An 8-gauge - tube was advanced under fluoroscopic\n guidance into a post-pyloric position with its tip in the fourth portion of\n the duodenum. The placement of the tip was confirmed with injection of\n water-soluble contrast.\n\n IMPRESSION: Placement of - feeding tube into a post-pyloric\n position.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-08-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1150734,
"text": " 4:28 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval interval film\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with worsening respiratory status\n REASON FOR THIS EXAMINATION:\n Eval interval film\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Worsening respiratory status, to compare with prior study.\n\n FINDINGS: In comparison with the study of , there is little overall\n change. Monitoring and support devices remain in place. Continued elevation\n of pulmonary venous pressure with bilateral pleural effusions, worse on the\n right, and associated compressive atelectasis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-07-23 00:00:00.000",
"description": "CTA ABD W&W/O C & RECONS",
"row_id": 1147714,
"text": " 6:03 PM\n CTA ABD W&W/O C & RECONS Clip # \n Reason: Please perform multiphasic liver scan for liver transplant w\n Admitting Diagnosis: HYPONATREMIA\n Field of view: 42 Contrast: OPTIRAY Amt: 200\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old female with cirrhosis secondary to hemochromatosis undergoing liver\n transplant workup\n REASON FOR THIS EXAMINATION:\n Please perform multiphasic liver scan for liver transplant workup. Patient\n being premedicated with Mucomyst.\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 11:23 PM\n 1. No arterially enhancing liver lesion.\n 2. Findings consistent with cirrhosis including ascites, nodular liver,\n varices.\n 3. Patent vasculature.\n 4. Right plerual effusion and associated atelectasis.\n ______________________________________________________________________________\n FINAL REPORT\n CTA ABDOMEN AND PELVIS\n\n INDICATION: 60-year-old female with cirrhosis secondary to hemachromatosis,\n undergoing liver transplant workup.\n\n COMPARISON: MR abdomen, .\n\n TECHNIQUE: Axial images were acquired on MDCT from the lung bases to the\n pelvis in multiple phases of intravenous contrast enhancement. Coronal and\n sagittal reconstructions were performed and reviewed. Liver volumes and\n spleen volumes were calculated.\n\n FINDINGS:\n\n Moderate right-sided pleural effusion with associated compressive atelectasis.\n No pulmonary nodules seen at the lung bases. The visualized pericardium is\n normal.\n\n Moderate amount of intra-abdominal ascites. The liver is markedly irregular\n in outline. The right lobe is atrophic, with relative hypertrophy of the left\n lobe. The enhancement pattern is diffusely heterogenous, making\n identification of discrete lesions difficult. No convincing evidence of an\n arterially enhancing lesion seen. No biliary duct dilatation. The\n gallbladder is contracted. The portal vein and hepatic veins are patent.\n Numerous varices of the gastroesophageal junction and spleen. The estimated\n liver volume is 1616cm3. The spleen is normal in size and enhances\n homogenously. The estimated splenic volume is 514.5cm3. Both kidneys, both\n adrenal glands and pancreas are unremarkable in appearance. No\n intra-abdominal lymphadenopathy is seen.\n\n Incidental note is made of a circumaortic left renal vein. There is an\n (Over)\n\n 6:03 PM\n CTA ABD W&W/O C & RECONS Clip # \n Reason: Please perform multiphasic liver scan for liver transplant w\n Admitting Diagnosis: HYPONATREMIA\n Field of view: 42 Contrast: OPTIRAY Amt: 200\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n accessory renal artery on the right side. There is equivocal narrowing of the\n origin of the celiac artery. This may be artifact related to respiratory\n motion.\n\n OSSEOUS STRUCTURES: Degenerative changes in the thoracolumbar spine.\n\n IMPRESSION:\n 1. Findings consistent with cirrhosis with ascites, nodular heterogenous\n liver and multiple varices.\n 2. No discrete arterially enhancing liver lesions seen.\n 3. Possible stenosis at the celiac artery origin.\n 4. Right pleural effusion with associated atelectasis.\n 5. Estimated liver volume 1616cm3, estimated splenic volume 514.5cm3.\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-08-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1152499,
"text": " 9:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for Dobhoff placement.\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with cirrhosis and Dobhoff tube.\n REASON FOR THIS EXAMINATION:\n Please evaluate for Dobhoff placement.\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Assess Dobbhoff tube.\n\n Comparison is made with prior study .\n\n A catheter probably a Dobbhoff tube projects near the back of the mouth or the\n hypopharynx is only partially visualized at the top of the film. Cardiac size\n is top normal. Small-to-moderate right pleural effusion is unchanged.\n Opacities in the left lower lobe have improved. Mild fluid overload is\n present. Right lower lobe opacities are a combination of pleural effusion and\n atelectasis. There are no new lung abnormalities.\n\n Findings were discussed with Dr. at the time of the interpretation of\n the study.\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-08-26 00:00:00.000",
"description": "NASO-INTESTINAL TUBE PLACEMENT (W/FLUORO)",
"row_id": 1152527,
"text": " 11:33 AM\n -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # \n Reason: Please assess for post-pyloric Dobhoff placement.\n Admitting Diagnosis: HYPONATREMIA\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with cirrhosis and volume overload and Dobhoff in place.\n REASON FOR THIS EXAMINATION:\n Please assess for post-pyloric Dobhoff placement.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): YGd WED 2:30 PM\n Uncomplicated placement of a post-pyloric feeding tube.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 60-year-old female with cirrhosis and volume overload and\n Dobbhoff in place, here for post-pyloric placement.\n\n NASOINTESTINAL TUBE PLACEMENT: Patient presented with a Dobbhoff tube with 2\n cm of distal tip in the nostril with remainder of the tube in external\n position. This was removed. Following oral administration of Hurricaine\n Spray and lidocaine gel to the right nostril, a feeding tube was advanced\n through the oropharynx into the esophagus and stomach. Under subsequent\n fluoroscopic guidance, the tube was advanced through the first, second, and\n third portions of duodenum up to the ligament of Treitz. A small amount of\n contrast injection revealed opacification of distal duodenum. There is no\n evidence of leak or other complications. Patient tolerated procedure well\n without immediate complications. Incidental note is made of moderate lumbar\n spondylosis on captured image.\n\n IMPRESSION: Uncomplicated placement of a post-pyloric feeding tube.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-08-26 00:00:00.000",
"description": "NASO-INTESTINAL TUBE PLACEMENT (W/FLUORO)",
"row_id": 1152528,
"text": ", J. MED FA10 11:33 AM\n -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # \n Reason: Please assess for post-pyloric Dobhoff placement.\n Admitting Diagnosis: HYPONATREMIA\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with cirrhosis and volume overload and Dobhoff in place.\n REASON FOR THIS EXAMINATION:\n Please assess for post-pyloric Dobhoff placement.\n ______________________________________________________________________________\n PFI REPORT\n Uncomplicated placement of a post-pyloric feeding tube.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-08-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1151222,
"text": " 3:20 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: please assess Dobhoff placement\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with Dobhoff placed\n REASON FOR THIS EXAMINATION:\n please assess Dobhoff placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Dobbhoff tube placement, assess position.\n\n COMPARISON: .\n\n AP SEMI-UPRIGHT BEDSIDE RADIOGRAPH OF THE CHEST: There has been interval\n placement of a Dobbhoff tube with its tip projecting up to the pyloric end of\n the stomach. A right IJ catheter extending to the cavoatrial junction.\n\n There are no other short-term time interval changes with a large right pleural\n effusion, right bibasilar atelectasis and mild volume overload. A left\n subclavian catheter is extending into the upper mid SVC.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-08-20 00:00:00.000",
"description": "CARDIAC PERFUSION PERSANTINE",
"row_id": 1151533,
"text": "CARDIAC PERFUSION PERSANTINE Clip # \n Reason: LIVER FAILURE, RESOLVING FLUID OVERLOAD, PRE TRANSPLANT WORKUP, ?REVERSIBLE DEFECT\n ______________________________________________________________________________\n FINAL REPORT\n\n RADIOPHARMACEUTICAL DATA:\n 11.0 mCi Tc-m Sestamibi Rest ();\n 30.9 mCi Tc-99m Sestamibi Stress ();\n HISTORY: 60 year old DM2 woman with liver failure who was referred from the\n inpatient floor for an evaluation of shortness of breath prior to liver\n transplant surgery.\n\n SUMMARY FROM THE EXERCISE LAB:\n\n Dipyridamole was infused intravenously for 4 minutes at a dose of 0.142\n mg/kg/min. Patient complained of nausea, chest tightness and shortness of\n breath at 3 minutes into the infusion. Symptoms resolved with administration of\n IV Aminophylline at 1.5 minutes post Persantine infusion. No significant ST\n segment changes noted with the infusion; however, this was in the setting of\n development of LBBB during the infusion which returned back to baseline by the\n end of recovery period.\n\n IMAGING METHOD:\n\n Resting perfusion images were obtained with Tc-m sestamibi. Tracer was\n injected approximately 45 minutes prior to obtaining the resting images.\n\n Following resting images and two minutes following intravenous dipyridamole,\n approximately three times the resting dose of Tc-m sestamibi was administered\n intravenously. Stress images were obtained approximately 30 minutes following\n tracer injection.\n\n Imaging protocol: Gated SPECT.\n\n INTERPRETATION:\n\n The image quality is somewhat degraded by soft tissue attenuation.\n\n Left ventricular cavity size is normal with a LV EDV of 73 ml.\n\n Rest and stress perfusion images reveal uniform tracer uptake throughout the\n left ventricular myocardium.\n\n Gated images reveal normal wall motion.\n\n The visually apparent left ventricular ejection fraction is 70%.\n\n There are no prior studies available for comparison.\n\n IMPRESSION:\n\n No myocardial perfusion defects. No wall motion abnormalities. LVEF of 70%.\n (Over)\n\n CARDIAC PERFUSION PERSANTINE Clip # \n Reason: LIVER FAILURE, RESOLVING FLUID OVERLOAD, PRE TRANSPLANT WORKUP, ?REVERSIBLE DEFECT\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n\n , M.D.\n , M.D. Approved: FRI 4:08 PM\n West \n\n\n\n RADLINE ; A radiology consult service.\n To hear preliminary results, prior to transcription, call the\n Radiology Listen Line .\n"
},
{
"category": "Echo",
"chartdate": "2167-08-05 00:00:00.000",
"description": "Report",
"row_id": 99002,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Right ventricular function. Shortness of breath.\nBP (mm Hg): 94/45\nHR (bpm): 75\nStatus: Inpatient\nDate/Time: at 23:15\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\ndrips: neosynephrine at 4 mcg/kg/min, levophed at 0.02 mcg/kg/min\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Normal regional LV\nsystolic function. Hyperdynamic LVEF >75%. TDI E/e' < 8, suggesting normal\nPCWP (<12mmHg).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTIC VALVE: ?# aortic valve leaflets. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nTRICUSPID VALVE: No TR. Indeterminate PA systolic pressure.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: The patient appears to be in sinus rhythm. Emergency study.\nEchocardiographic results were reviewed with the houseofficer caring for the\npatient.\n\nConclusions:\nLeft ventricular wall thicknesses and cavity size are normal. Regional left\nventricular wall motion is normal. Left ventricular systolic function is\nhyperdynamic (EF>75%). Tissue Doppler imaging suggests a normal left\nventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and\nfree wall motion are normal. The number of aortic valve leaflets cannot be\ndetermined. No aortic regurgitation is seen. The mitral valve appears\nstructurally normal with trivial mitral regurgitation. The pulmonary artery\nsystolic pressure could not be determined. There is no pericardial effusion.\n\nIMIMPRESSION: Hyperdynamic left ventricular function. Preserved right\nventricular systolic function.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2167-07-31 00:00:00.000",
"description": "Report",
"row_id": 99003,
"text": "PATIENT/TEST INFORMATION:\nIndication: Pulmonary hypertension.\nHeight: (in) 61\nWeight (lb): 161\nBSA (m2): 1.72 m2\nBP (mm Hg): 89/47\nHR (bpm): 94\nStatus: Inpatient\nDate/Time: at 11:45\nTest: TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: Saline\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Dynamic interatrial septum. PFO is present.\n\nLEFT VENTRICLE: Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nTRICUSPID VALVE: Mild PA systolic hypertension.\n\nGENERAL COMMENTS: Suboptimal image quality - poor apical views.\n\nConclusions:\nA patent foramen ovale is present (right to left echo contrast shunting at\nrest within 3 beats of RA/RV opacification). Overall left ventricular systolic\nfunction is normal (LVEF>55%). Right ventricular chamber size and free wall\nmotion are normal. There is mild pulmonary artery systolic hypertension.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2167-08-05 00:00:00.000",
"description": "Report",
"row_id": 98964,
"text": "PATIENT/TEST INFORMATION:\nIndication: Hypotension. Atrial fibrillation. Left ventricular function.\nHeight: (in) 64\nWeight (lb): 172\nBSA (m2): 1.84 m2\nBP (mm Hg): 93/32\nHR (bpm): 75\nStatus: Inpatient\nDate/Time: at 16:03\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolic\nfunction (LVEF>55%). Suboptimal technical quality, a focal LV wall motion\nabnormality cannot be fully excluded. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter. Normal descending aorta diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.\n\nMITRAL VALVE: Normal mitral valve leaflets. No MVP. Calcified tips of\npapillary muscles. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Borderline\nPA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor apical views.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thickness, cavity\nsize, and global systolic function are normal (LVEF>55%). Due to suboptimal\ntechnical quality, a focal wall motion abnormality cannot be fully excluded.\nRight ventricular chamber size and free wall motion are normal. The aortic\nvalve leaflets (3) are mildly thickened but aortic stenosis is not present.\nThe mitral valve leaflets are structurally normal. There is no mitral valve\nprolapse. Mild (1+) mitral regurgitation is seen. There is borderline\npulmonary artery systolic hypertension. There is no pericardial effusion.\n\nIMPRESSION: Normal biventricular cavity sizes with preserved global\nbiventricular systolic function. Mild mitral regurgitation with normal valve\nmorphology.\n\nCLINICAL IMPLICATIONS:\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate prophylaxis is NOT recommended. Clinical decisions regarding the need\nfor prophylaxis should be based on clinical and echocardiographic data.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2167-07-24 00:00:00.000",
"description": "Report",
"row_id": 98965,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. History of hemachromatosis. Pre liver transplant evaluation\nHeight: (in) 61\nWeight (lb): 157\nBSA (m2): 1.71 m2\nBP (mm Hg): 129/67\nHR (bpm): 97\nStatus: Inpatient\nDate/Time: at 11:00\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nAscites.\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal IVC diameter (<2.1cm) with <35%\ndecrease during respiration (estimated RA pressure indeterminate).\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels. No 2D\nor Doppler evidence of distal arch coarctation.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild to moderate (+)\nMR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Borderline PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is mildly dilated. The right atrial pressure is indeterminate.\nLeft ventricular wall thickness, cavity size and regional/global systolic\nfunction are normal (LVEF >55%). Right ventricular chamber size and free wall\nmotion are normal. The diameters of aorta at the sinus, ascending and arch\nlevels are normal. The aortic valve leaflets (3) are mildly thickened but\naortic stenosis is not present. No aortic regurgitation is seen. The mitral\nvalve leaflets are mildly thickened. Mild to moderate (+) mitral\nregurgitation is seen. There is borderline pulmonary artery systolic\nhypertension. There is no pericardial effusion.\n\nIMPRESSION: Normal biventricular systolic function. Mild to moderate mitral\nregurgitation.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2167-08-16 00:00:00.000",
"description": "Report",
"row_id": 280067,
"text": "Sinus rhythm. Consider prior anterior wall myocardial infarction. Low limb\nand lateral precordial lead QRS voltage is non-specific. Since the previous\ntracing of no significant change.\n\n"
},
{
"category": "ECG",
"chartdate": "2167-08-12 00:00:00.000",
"description": "Report",
"row_id": 280068,
"text": "Sinus rhythm. Consider prior anterior myocardial infarction. Low limb lead\nQRS voltage is non-specific. Since the previous tracing of the same date no\nsignificant change.\n\n"
},
{
"category": "ECG",
"chartdate": "2167-08-12 00:00:00.000",
"description": "Report",
"row_id": 280069,
"text": "Baseline artifact. Sinus rhythm. Low limb QRS voltage. Consider prior anterior\nwall myocardial infarction. Compared to the previous tracing of the\nfindings are similar.\n\n"
},
{
"category": "ECG",
"chartdate": "2167-08-09 00:00:00.000",
"description": "Report",
"row_id": 280070,
"text": "Baseline artifact. Sinus rhythm. Low limb lead QRS voltage. Consider prior\nanterior myocardial infarction. Since the previous tracing of probably\nno significant change.\n\n"
},
{
"category": "ECG",
"chartdate": "2167-08-08 00:00:00.000",
"description": "Report",
"row_id": 280071,
"text": "Sinus rhythm with baseline artifact. Low QRS voltage in the limb leads.\nAnteroseptal myocardial infarction of indeterminate age. Compared to the\nprevious tracing of left bundle-branch block is no longer present.\n\n"
},
{
"category": "ECG",
"chartdate": "2167-08-05 00:00:00.000",
"description": "Report",
"row_id": 280072,
"text": "Marked baseline artiact in the standard leads. Normal sinus rhythm. Left\nbundle-branch block with a QRS duration of 130 milliseconds. Low voltage in\nthe standard leads. Compared to the previous tracing of no diagnostic\ninterval change.\n\n"
},
{
"category": "ECG",
"chartdate": "2167-08-04 00:00:00.000",
"description": "Report",
"row_id": 280073,
"text": "Sinus rhythm. Consider left atrial abnormality. Left bundle-branch block. Since\nthe previous tracing of same date complete left bundle-branch block has\nreplaced incomplete left bundle-branch block.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2167-08-01 00:00:00.000",
"description": "Report",
"row_id": 280290,
"text": "Irregular rhythm of uncertain mechanism but may be atrial fibrillation with\nrapid ventricular response - baseline artifact makes assessment difficult.\nIntraventricular conduction delay with right axis deviation may be atypical\nleft bundle-branch block/possible left posterior fascicular block. ST-T wave\nabnormalities may be due to intraventricular conduction delay. Clinical\ncorrelation is suggested. Since the previous tracing of irregular\ntachycardia has replaced sinus rhythm and right axis deviation is now present.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2167-07-30 00:00:00.000",
"description": "Report",
"row_id": 280291,
"text": "Sinus rhythm. Left bundle-branch block. Compared to the previous tracing\nof no change.\n\n"
},
{
"category": "ECG",
"chartdate": "2167-07-30 00:00:00.000",
"description": "Report",
"row_id": 280292,
"text": "Baseline artifact. Sinus rhythm. Left bundle-branch block. Since the previous\ntracing of no significant change.\n\n"
},
{
"category": "ECG",
"chartdate": "2167-07-21 00:00:00.000",
"description": "Report",
"row_id": 280293,
"text": "Sinus rhythm. Left bundle-branch block. No previous tracing available for\ncomparison.\n\n"
},
{
"category": "ECG",
"chartdate": "2167-08-04 00:00:00.000",
"description": "Report",
"row_id": 280289,
"text": "Sinus rhythm. Probable incomplete left bundle-branch block. Consider prior\nanterior wall myocardial infarction. Since the previous tracing of \nirregular tachy-arrhythmia is now absent and intraventricular conduction delay\nhas decreased and is without right axis deviation.\nTRACING #2\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-07-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1148514,
"text": " 6:42 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Rule out pneumothorax, evaluate worsening pleural effusion\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman s/p right thoracentisis with worsening SOB\n REASON FOR THIS EXAMINATION:\n Rule out pneumothorax, evaluate worsening pleural effusion\n ______________________________________________________________________________\n WET READ: SBNa WED 7:19 PM\n Slight interval increase in right pleural effusion. Pulmonary edema stable.\n Bibasilar atelectasis. No ptx.\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Status post thoracentesis, assess for pneumothorax.\n\n Comparison is made with prior study performed six hours earlier.\n\n There is no pneumothorax. Mild-to-moderate pulmonary edema is stable.\n Cardiomediastinal contours are unchanged. Cardiac size is top normal. Small\n right pleural effusion is probably unchanged; however, minimally enlarged.\n Right lower lobe atelectasis has increased. There are multiple calcified\n lymph nodes in the mediastinum and hilum bilaterally.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-08-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1150562,
"text": " 4:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for infiltrate/worsening effusion\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with ESLD, on ventilator w/ difficulty weaning. Please eval\n for infiltrate/effusion\n REASON FOR THIS EXAMINATION:\n Please eval for infiltrate/worsening effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Respiratory failure.\n\n COMPARISONS: Chest x-ray from .\n\n FINDINGS:\n\n Heart size is normal. Bilateral small-to-moderate pleural effusions are\n unchanged. Right hemidiaphragm is obscured likely due to compressive\n atelectasis. Previously described suprahilar pulmonary edema appears mildly\n improved. No pneumothorax is seen. Hilar, mediastinal, and cardiac\n silhouettes are stable.\n\n ET tube is approximately 2.5 cm from the carina. Left subclavian line tip\n projects over mid SVC. Right IJ tip is positioned in mid to low SVC. An\n enteric tube is in nondistended stomach.\n\n IMPRESSION:\n\n 1. Interval improvement of mild pulmonary edema.\n\n 2. Bilateral small-to-moderate pleural effusions with associated compressive\n atelectasis, stable.\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-07-27 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1148210,
"text": " 5:48 PM\n CHEST (PA & LAT) Clip # \n Reason: Evaluate for pleural effusion\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with hemachromatosis, with SOB\n REASON FOR THIS EXAMINATION:\n Evaluate for pleural effusion\n ______________________________________________________________________________\n WET READ: SBNa MON 7:57 PM\n Persistant mild-to-moderate right pleural effusion with interstitial pulmonary\n edema.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Hemachromatosis with shortness of breath.\n\n FINDINGS: In comparison with the study of , there is little overall\n change. There is prominence of indistinct pulmonary markings consistent with\n interstitial pulmonary edema. Continued moderate right pleural effusion. No\n definite acute focal pneumonia.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-07-31 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1148811,
"text": ", R. SICU-B 3:15 PM\n PORTABLE ABDOMEN; -77 BY DIFFERENT PHYSICIAN # \n Reason: Please confirm post-pyloric positioning of DHT.\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with DHT placed, high risk for aspiration. Will administer\n gastrograffin to confirm placement.\n REASON FOR THIS EXAMINATION:\n Please confirm post-pyloric positioning of DHT.\n ______________________________________________________________________________\n PFI REPORT\n Post-pyloric location of Dobbhoff tube confirmed with oral contrast.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-07-27 00:00:00.000",
"description": "P US ABD LIMIT, SINGLE ORGAN PORT",
"row_id": 1148183,
"text": " 3:09 PM\n US ABD LIMIT, SINGLE ORGAN PORT Clip # \n Reason: Please perform tap in the morning of . Please tap to d\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with hemachromatosis cirrhosis with increased abdominal girth\n REASON FOR THIS EXAMINATION:\n Please perform tap in the morning of . Please tap to dry.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): RSRc MON 4:11 PM\n Insufficient ascites (280 cc) for therapeutic paracentesis; therefore not\n performed.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 60-year-old female with hemachromatosis, referred for therapeutic\n paracentesis.\n\n COMPARISON: Abdominal CT, and MR abdomen, .\n\n FOUR QUADRANT ABDOMINAL ULTRASOUND: A scan of each quadrant was performed to\n evaluate for the degree of ascites. In the right upper quadrant, the greatest\n pocket of ascites measures 8.9 x 5.1 x 11.1 cm, predicting 280 cc of fluid.\n Other quadrants demonstrate only trace ascites.\n\n IMPRESSION: therapeutic paracentesis not performed given small amount of\n ascites.\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-07-22 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 1147427,
"text": " 12:15 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOP ABD/PEL LIMITED\n Reason: Eval acute process\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with cirrhosis and new elevated tbili\n REASON FOR THIS EXAMINATION:\n Eval acute process\n ______________________________________________________________________________\n WET READ: EAGg WED 3:57 AM\n Limited study due to pt inability to breathhold. Findings c/w cirrhosis.\n Ascites. Antegrade flow is not definitely detected in the main portal vein and\n adequate waveforms could not be obtained raising possiblity of portal vein\n thrombosis versus reversal/slow flow. Consider formal evaluation with complete\n liver doppler during regular hours. No intra- or extrahepatic biliary\n dilatation.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 60-year-old female with cirrhosis and elevated total bilirubin.\n Evaluate for acute process.\n\n COMPARISON: and MR .\n\n RIGHT UPPER QUADRANT ULTRASOUND: The liver is nodular, shrunken and\n echogenic, compatible with stated diagnosis of cirrhosis. No intra- or extra-\n hepatic biliary ductal dilatation and the common bile duct measures 4 mm.\n Large ascites. The gallbladder is contracted with wall thickening and small\n amount of pericholecystic fluid, which is likely secondary to liver disease.\n\n Evaluation of flow in the main portal vein is limited by patient's inability\n to comply with the exam. However, flow could not definitely be identified\n within the main portal vein. Possible reversal of flow is noted in the left\n portal vein.\n\n IMPRESSION:\n\n 1. Findings compatible with cirrhosis.\n\n 2. No intra- or extra-hepatic biliary ductal dilatation.\n\n 3. Although evaluation is limited by patient's inability to breath-hold, flow\n could not definitely be detected in the main portal vein and there is possible\n reversal of flow in the left portal vein. Dedicated liver Doppler is\n recommended during normal business hours to further evaluate for portal vein\n thrombosis.\n\n (Over)\n\n 12:15 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOP ABD/PEL LIMITED\n Reason: Eval acute process\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-07-30 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1148646,
"text": " 5:25 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval pleural effusions\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old female with hemachromatosis c/b cirrhosis, that presented with\n hyponatremia and hypokalemia\n REASON FOR THIS EXAMINATION:\n eval pleural effusions\n ______________________________________________________________________________\n WET READ: 6:14 PM\n Interval increase in right moderate pleural effusion. No significant change in\n pulm edema.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Hyponatremia and hypokalemia in a patient with\n hemochromatosis and cirrhosis.\n\n Portable AP chest radiograph was compared to obtained at 6:55\n p.m.\n\n The cardiomediastinal silhouette is unchanged. There is slight interval\n improvement in pulmonary edema with significant interstitial pulmonary nodules\n involving the lungs. There is slight interval increase in right pleural\n effusion. Left pleural effusion is most likely present. There is no evidence\n of pneumothorax.\n\n Right basal opacity is most likely secondary to effusion and represents\n atelectasis, but developing infection in that area cannot be entirely excluded\n and should be closely followed on the subsequent radiographs.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-08-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1148892,
"text": " 7:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for PNA/infiltrate\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with ESLD, with resp insufficiency, please eval for\n PNA/infiltrate\n REASON FOR THIS EXAMINATION:\n please eval for PNA/infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Insufficiency in a patient with end-stage liver\n disease.\n\n Portable AP chest radiograph was compared to prior study obtained on , .\n\n The feeding tube tip is in the distal duodenum/proximal jejunum.\n Cardiomediastinal silhouette and widespread opacities are unchanged including\n right lower lobe consolidation and bilateral pleural effusion, at least\n moderate on the right and small on the left.\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-08-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1149962,
"text": " 6:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for change from prior, thanks\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman intubated\n REASON FOR THIS EXAMINATION:\n please eval for change from prior, thanks\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Intubated patient.\n\n Comparison is made with prior study performed a day earlier.\n\n Cardiac size is top normal. Small left and moderate right pleural effusions\n are unchanged. Bibasilar opacity consistent with atelectasis and/or pneumonia\n are grossly unchanged. The component of pulmonary edema is continuously\n improving. There are no new lung abnormalities. Lines and tubes remain in\n place in standard position.\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-08-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1149029,
"text": " 1:50 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Eval line placement\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with IJ placement, thoracentesis\n REASON FOR THIS EXAMINATION:\n Eval line placement\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Internal jugular line placement.\n\n Portable AP chest radiograph was compared to .\n\n The right internal jugular line tip is at the cavoatrial junction.\n Cardiomediastinal silhouette is unchanged. There is interval progression of\n multifocal opacities but slight improvement in the right pleural effusion.\n Cardiomegaly is unchanged.\n\n\n"
}
] |
55,992 | 141,696 | 79 y/o F PMH significant for metastatic intra-abdominal GIST tumor, anemia, dCHF (last EF 55% 12/11) presents with lethargy, SOB and weakness x3 days found with HCT of 16.7. . #ACUTE ON CHRONIC ANEMIA/acute blood loss - presented with H/H 4.7/16.7. More recent baseline values were HCT of 28-30 as recently as suggesting acute change. MCV was chronically >100. Anemia w/u including b12/folate/fe studies checked in wnl. Hemoperitoneum noted on abd CT presumably from metastatic GIST. Stool was guiaic negative so unlikely intra-intestinal bleeding. Pt with Afib but not on coumadin, INR wnl on presentation. Her hemolysis labs were negative. IR and surgery evaluated the pt and noted no acute intervention needed to be taken. She was transfused a total of 3U PRBCs with good effect. She was restarted on aspirin therapy. Oncology team's plan is to stop sutent and start pt on sorefenib as an outpatient. . #SHORTNESS OF BREATH - pt reported 3 days of increasing DOE on admission with oxygen saturation in the high 90s on 2L NC. This was felt to be due to acute severe anemia. Her SOB improved after blood transfusions. Her EKG was significant for new TWI on ECG and slightly deeper 1mm ST dep in lateral leads which was felt to be due to demand ischemia in the setting of her acute anemia. Her cardiac enzymes were negative times three. . # GIST: Patient with hx of GIST s/p incomplete resection in and omental resections in 3/. Intermittently treated with gleevac now on low dose sutent. The sutent was initially held on admission. Heme/onc was consulted for further recommendations an decided to stop sutent and start pt on sorafenib after discharge. | There is a small right and trace left pleural effusion. FINDINGS: The included portions of the lung bases demonstrate mild dependent atelectatic changes. Soft tissue mass appears to involve the gallbladder which is not distinctly visualized. Multilobulated soft tissue masses consistent with known GIST recurrence with increased omental nodularity. Multilobulated soft tissue masses consistent with known GIST recurrence with increased omental nodularity. A small hiatal hernia is present. Multiple areas of nodular soft tissue along the omentum appear slightly increased from the prior examination. Cardiac and mediastinal silhouettes are stable with the cardiac silhouette mild-to-moderately enlarged. Multiple hepatic lesions appear unchanged. Compared to the previous tracingof ventricular response rate is slower. There is mild pulmonary vascular congestion. The higher density material is present along the lesser sac and along the gallbladder fossa, likely indicating the region of origin of hemorrhage near known soft tissue mass. The higher density material is present along the lesser sac and along the gallbladder fossa, likely indicating the region of origin of hemorrhage near known soft tissue mass. Compared to the previous tracing of atrialfibrillation remains present but now is slightly slower. FINAL REPORT (Cont) development of an adrenal lesion would be difficult to exclude. Stable liver lesions. Stable liver lesions. A 2 mm right middle lobe pulmonary nodule (2:2) is unchanged. The denser areas of fluid are along the lesser sac and the region of the gallbladder fossa, likely indicating origin of hemorrhage in this region. The borders are ill-defined in the presence of background fluid; however, the largest component measures approximately 12.6 x 11.9 cm, previously 12.2 x 12.2 cm on a similar image. Delayed R wave progression. IMPRESSION: Mild pulmonary vascular congestion. Atrial fibrillation. Heterogeneous fluid compatible with hemoperitoneum appears increased from the prior examination. FINDINGS: Frontal and lateral views of the chest were obtained. Within the abdomen and pelvis, again noted is a multilobulated mixed soft tissue and cystic lesion which abuts the stomach and appears to involve the gallbladder. Interval increase in heterogeneous intra-abdominal fluid, consistent with hemoperitoneum. Interval increase in heterogeneous intra-abdominal fluid, consistent with hemoperitoneum. Borderline low voltage in the limb leads.Non-specific inferolateral ST-T wave changes. The kidneys appear unchanged with several hypodensities, too small to characterize. Degenerative changes are seen along the spine. Poor R wave progression. There are multilevel degenerative changes including mild anterolisthesis of L3 on L4; however, no concerning osseous lesion is identified. A 4.1 x 2.0 cm lesion in the anterior midline (2:16) previously measured 3.1 x 1.3 cm. For instance, a soft tissue nodularity along the left anterior abdominal wall measuring 6.8 x 2.6 cm (2:23), previously measured 5.6 x 2.6 cm on a similar image. Distal loops of large bowel and rectum are normal in size and caliber. COMPARISON: Multiple prior examinations, most recent CT dated . FINAL REPORT INDICATION: Known recurrence of GIST tumor with new anemia concerning for hemoperitoneum. MEDICAL CONDITION: History: 79F with DOE and fatigue REASON FOR THIS EXAMINATION: pna? Other hypodense lesions concerning for metastases appear similar including a 7-mm lesion in segment VI (2:34) as well as a 1.9-cm lesion in segment V (2:25) and 2.0 and 0.4 cm lesions in segment VII. Otherwise, nointerval change. A 3.4-cm simple cyst in the left lobe is unchanged. Non-specific T wave inverionsin leads V4-V6. effusion? effusion? Pulmonary nodules documented on CT from are better appreciated on that study. Coronal and sagittal reformations were prepared. The bladder appears grossly unremarkable. No contraindications for IV contrast FINAL REPORT EXAM: Chest frontal and lateral views. The spleen, pancreas, and right adrenal gland appear grossly unremarkable. IMPRESSION: 1. Along the left adrenal gland, there is new hypodensity which measures 14 Hounsfield units and likely represents layering fluid, though (Over) 3:23 PM CT ABD & PELVIS WITH CONTRAST Clip # Reason: is she bleeding into your abdomen? Atrial fibrillation with a controlled ventricular response rate of 77 beats perminute. TECHNIQUE: Multidetector helical CT scan of the abdomen and pelvis was obtained after the administration of 100 cc IV Visipaque contrast. 2:51 PM CHEST (PA & LAT) Clip # Reason: pna? Cardiomegaly. COMPARISON: . 3:23 PM CT ABD & PELVIS WITH CONTRAST Clip # Reason: is she bleeding into your abdomen? Fluid tracking into the pelvis is also increased in volume on this examination. 2. 2. MEDICAL CONDITION: History: 79F with hx of GI tumor with new anemia and last ct concerning for blood in abd REASON FOR THIS EXAMINATION: is she bleeding into your abdomen? No contraindications for IV contrast WET READ: OXZa SUN 5:21 PM 1. | 4 | [
{
"category": "Radiology",
"chartdate": "2154-04-14 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1234237,
"text": " 2:51 PM\n CHEST (PA & LAT) Clip # \n Reason: pna? effusion?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 79F with DOE and fatigue\n REASON FOR THIS EXAMINATION:\n pna? effusion?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: Chest frontal and lateral views.\n\n CLINICAL INFORMATION: 79-year-old female with history of dyspnea on exertion\n and fatigue.\n\n COMPARISON: .\n\n FINDINGS: Frontal and lateral views of the chest were obtained. Cardiac and\n mediastinal silhouettes are stable with the cardiac silhouette\n mild-to-moderately enlarged. There is mild pulmonary vascular congestion. No\n pleural effusion or pneumothorax is seen. Degenerative changes are seen along\n the spine.\n\n IMPRESSION: Mild pulmonary vascular congestion. Cardiomegaly. Pulmonary\n nodules documented on CT from are better appreciated on that study.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2154-04-14 00:00:00.000",
"description": "CT ABD & PELVIS WITH CONTRAST",
"row_id": 1234242,
"text": " 3:23 PM\n CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: is she bleeding into your abdomen?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 79F with hx of GI tumor with new anemia and last ct concerning for\n blood in abd\n REASON FOR THIS EXAMINATION:\n is she bleeding into your abdomen?\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: OXZa SUN 5:21 PM\n 1. Interval increase in heterogeneous intra-abdominal fluid, consistent with\n hemoperitoneum. The higher density material is present along the lesser sac\n and along the gallbladder fossa, likely indicating the region of origin of\n hemorrhage near known soft tissue mass.\n 2. Multilobulated soft tissue masses consistent with known GIST recurrence\n with increased omental nodularity. Stable liver lesions.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Known recurrence of GIST tumor with new anemia concerning for\n hemoperitoneum.\n\n TECHNIQUE: Multidetector helical CT scan of the abdomen and pelvis was\n obtained after the administration of 100 cc IV Visipaque contrast. Coronal\n and sagittal reformations were prepared.\n\n COMPARISON: Multiple prior examinations, most recent CT dated .\n\n FINDINGS: The included portions of the lung bases demonstrate mild dependent\n atelectatic changes. There is a small right and trace left pleural effusion.\n A 2 mm right middle lobe pulmonary nodule (2:2) is unchanged. A small hiatal\n hernia is present.\n\n Within the abdomen and pelvis, again noted is a multilobulated mixed soft\n tissue and cystic lesion which abuts the stomach and appears to involve the\n gallbladder. The borders are ill-defined in the presence of background fluid;\n however, the largest component measures approximately 12.6 x 11.9 cm,\n previously 12.2 x 12.2 cm on a similar image. Heterogeneous fluid compatible\n with hemoperitoneum appears increased from the prior examination. The denser\n areas of fluid are along the lesser sac and the region of the gallbladder\n fossa, likely indicating origin of hemorrhage in this region. Fluid tracking\n into the pelvis is also increased in volume on this examination.\n\n Multiple hepatic lesions appear unchanged. A 3.4-cm simple cyst in the left\n lobe is unchanged. Other hypodense lesions concerning for metastases appear\n similar including a 7-mm lesion in segment VI (2:34) as well as a 1.9-cm\n lesion in segment V (2:25) and 2.0 and 0.4 cm lesions in segment VII.\n\n Soft tissue mass appears to involve the gallbladder which is not distinctly\n visualized. The spleen, pancreas, and right adrenal gland appear grossly\n unremarkable. Along the left adrenal gland, there is new hypodensity which\n measures 14 Hounsfield units and likely represents layering fluid, though\n (Over)\n\n 3:23 PM\n CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: is she bleeding into your abdomen?\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n development of an adrenal lesion would be difficult to exclude. The kidneys\n appear unchanged with several hypodensities, too small to characterize.\n\n Multiple areas of nodular soft tissue along the omentum appear slightly\n increased from the prior examination. For instance, a soft tissue nodularity\n along the left anterior abdominal wall measuring 6.8 x 2.6 cm (2:23),\n previously measured 5.6 x 2.6 cm on a similar image. A 4.1 x 2.0 cm lesion in\n the anterior midline (2:16) previously measured 3.1 x 1.3 cm.\n\n The bladder appears grossly unremarkable. No lymphadenopathy is identified.\n Distal loops of large bowel and rectum are normal in size and caliber. No\n evidence of bowel obstruction is seen.\n\n There are multilevel degenerative changes including mild anterolisthesis of L3\n on L4; however, no concerning osseous lesion is identified.\n\n IMPRESSION:\n 1. Interval increase in heterogeneous intra-abdominal fluid, consistent with\n hemoperitoneum. The higher density material is present along the lesser sac\n and along the gallbladder fossa, likely indicating the region of origin of\n hemorrhage near known soft tissue mass.\n 2. Multilobulated soft tissue masses consistent with known GIST recurrence\n with increased omental nodularity. Stable liver lesions.\n\n"
},
{
"category": "ECG",
"chartdate": "2154-04-14 00:00:00.000",
"description": "Report",
"row_id": 117404,
"text": "Atrial fibrillation with a controlled ventricular response rate of 77 beats per\nminute. Delayed R wave progression. Borderline low voltage in the limb leads.\nNon-specific inferolateral ST-T wave changes. Compared to the previous tracing\nof ventricular response rate is slower.\n\n"
},
{
"category": "ECG",
"chartdate": "2154-04-14 00:00:00.000",
"description": "Report",
"row_id": 117405,
"text": "Atrial fibrillation. Poor R wave progression. Non-specific T wave inverions\nin leads V4-V6. Compared to the previous tracing of atrial\nfibrillation remains present but now is slightly slower. Otherwise, no\ninterval change.\n\n"
}
] |
5,771 | 127,184 | 78 M with ESRD on hemodialysis was admitted with high grade SBO seen on CT. CT showed dilated loops of small bowel measuring up to 4.4 cm. Moderate ascites was noted. Two transition points were seen in the mid abdomen involving the proximal and distal jejunum best seen on (2:49) likely secondary to multiple adhesions in this area. An NG tube was placed with 500 cc of feculent material suction out. IV recussitation was administered. Blood cultures were sent. He was taken to the OR by Dr. who performed an exploratory lap with lysis of adhesions and reduction of internal volvulus for small bowel obstruction. He was given FFP for an inr of 2.3 (on coumadin for afib)and coumadin was held. Of note, he has a pacemaker. Please refer to Dr. operative note. Per OR note, the fascial incision was opened down to the pubic symphysis and almost to the xiphoid process. We took down some internal adhesions to the anterior abdominal wall. In doing this,a large serosal tear occurred which was repaired with a series of sutures. A large portion of the small bowel appeared gangrenous. The bowel was de-torsed. There was concern for the viability of the bowel and a second laparotomy was planned. He was temporarily closed. On , he was taken back to the OR where the bowel appeared viable and he was closed. Postop, he was sent to the SICU for management. He was kept NPO with an NG tube in place. CXR demonstrated a left lower lobe retrocardiac opacity was new. He continued on IV antibiotics. He was transferred out of the SICU on**** IV Cefepime,Flagyl and Vanco were administered from thru . WBC had been 13.6 on admission. This decreased to 5.5 by . Blood cultures were negative and an MRSA screen was also negative. TPN was started on postop day 4 ()as he remained NPO for bowel rest and because he was sleepy. By , he was passing flatus and stool. The NG was removed. He continued to be lethargic. Speech and swallow evaluated on recommending the following: PO diet of thin liquids and soft solids. Select ONLY moist soft foods. Please cut food into small, manageable pieces. Pills whole or crushed with puree. 1:1 assistance with POs. Give POs only when most awake and alert. Maintain aspiration precautions. Q8 oral care. Diet was slowly advanced. TPN continued. PO intake was fair. KCAL counts were ordered and started on to determine if TPN could be weaned off. Hemodialysis was continued via the LUE AVG. Until, when his graft clotted and dialysis could not be performed. He was also noted to be tachypnic in afib. CXR demonstrated fluid overload. A temporary right groin line was placed and he was dialyzed for 3 liters. Afib converted to sinus rhythm. Of note, cardiac/antihypertensives were held when npo. Hematocrit was noted to have slowly trended down to 23. One unit of PRBC was administered and epogen was increased at dialysis. On , a LUE AVG thrombectomy was performed by Dr. . There was a thrill/bruit and radial pulse. Of note, the preop cxr demonstrated improvement in left basilar opacity with minimal bibasilar atelectasis and small right pleural effusion. The left subclavian line was noted. On , hemodialysis was performed via the graft with good flows and 2.5 liters were removed. The temporary right groin dialysis line was removed without incident. PT evaluated and recommended rehab. He was screened by Rehab in and was accepted there. Most of home meds were held during this hospital course. At time of discharge, amiodarone and lopressor 12.5 , asa, coumadin 4mg qd, cinacalcet and zantac were resume. Hydralazine and nifedipine were held. These should be re-instituted as tolerated. Fosrenal should be resumed when dietary intake improved. | GI: Mesenteric volvulus s/p ex-lap, reduction, enterotomy. GI: Mesenteric volvulus s/p ex-lap, reduction, enterotomy. Heme: Taking coumadin for afib, INR 2.2 Keep INR < 2. Heme: Taking coumadin for afib, INR 2.2 Keep INR < 2. KVO Renal: ESRD on HD (MWF). Renal: ESRD on HD (MWF). Renal: ESRD on HD (MWF). Pulm: Intubated. Pulm: Intubated. Endocrine: DM. KVO, bolus prn to resuscitate. OR in Am for second look Nutrition: NPO Renal: Foley, ESRD on HD (MWF). OR in Am for second look Nutrition: NPO Renal: Foley, ESRD on HD (MWF). Plan: NGT to LCS, pain control, cont with TPN. M w/ ESRD, adm with a high grade bowel obstruction & mesenteric volvulus, now s/p ex-lap, reduction of volvulus, enterotomy repair . ID: Vanco, cefepime, flagyl. ID: Vanco, cefepime, flagyl. Neurologic: H/o CVA, dilaudid prn pain. f/u AM vanco level Lines / Tubes / Drains: aline, L subclavian TLC, NGT, JP x 2 wall sxn Wounds: abd Imaging: Fluids: Consults: , I Billing Diagnosis: ICU Care Nutrition: TPN without Lipids - 06:06 PM 44 mL/hour Glycemic Control: Lines: Arterial Line - 05:30 PM Multi Lumen - 05:30 PM Prophylaxis: DVT: Stress ulcer: VAP bundle: Comments: Communication: Comments: Code status: Full code Disposition: Total time spent: Small bowel obstruction (Intestinal obstruction, SBO, including intussusception, adhesions) Assessment: Pt is s/p ex lap with open abdomen 2 JPs within abd dsg draining large amts s/s Pt is sedated on propofol Hypotensive with MAP<60 Hypothermic Pt is anuric, is a HD pt. NGT to LCWS w/ scant blilious drng. Grimace and VS return to baseline. Abd incision C&D , OTA w/ staples. .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway Clearance, Cough) Assessment: Weaned and extubated at 1200. .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway Clearance, Cough) Assessment: Weaned and extubated at 1200. Marked generalized non-specific inferolateralrepolarization change persists, as does left ventricular hypertrophy.TRACING #2 previously controlled w/ intermittent Dilaudid IVP. Endocrine: DM. KVO Renal: ESRD on HD (MWF). L fistula used. L fistula used. Plan: NGT to LCS, pain control, cont with TPN. Neurologic: H/o CVA, dilaudid prn pain. Response: Slowing down of NGT and JP drainage. Maintenance target: 3 and overbreathing ventilator Order date: @ 1651 13. Left ventricular hypertrophy with secondaryrepolarization changes. f/u AM vanco level Lines / Tubes / Drains: aline, L subclavian TLC, NGT, JP x 2 wall sxn Wounds: abd Imaging: Fluids: Consults: , I Billing Diagnosis: ICU Care Nutrition: TPN without Lipids - 06:06 PM 44 mL/hour Glycemic Control: Lines: Arterial Line - 05:30 PM Multi Lumen - 05:30 PM Prophylaxis: DVT: Stress ulcer: VAP bundle: Comments: Communication: Comments: Code status: Full code Disposition: Floor Total time spent: SICU HPI: 78 M with high grade SBO, s/p ex-lap, reduction of SB volvulus, enterotomy repair ; abd closure on Chief complaint: abd pain PMHx: DM, ESRD on dialysis, HTN, renal cancer, prostate cancer, h/o SBO, h/o CVA, a fib/a flutter Current medications: IV access: Temporary central access (ICU) Location: Left Subclavian, Date inserted: Order date: @ 1651 8. NGT to LCWS w/ scant blilious drng. NGT to LCWS w/ scant blilious drng. NGT to LCWS w/ scant blilious drng. Grimace and VS return to baseline. Slightly hypertensive post-op. Abd incision C&D , OTA w/ staples. Abd incision C&D , OTA w/ staples. Abd incision C&D , OTA w/ staples. Loops of sigmoid colon are decompressed. COMPARISON: Supine and erect abdomen radiographs, . previously controlled w/ intermittent Dilaudid IVP. previously controlled w/ intermittent Dilaudid IVP. previously controlled w/ intermittent Dilaudid IVP. Right transvenous pacemaker leads terminate in standard position in the right atrium and right ventricle. Right pacemaker leads terminate in standard position in the right atrium and right ventricle. dilated loops of small bowel, stable since Ab/pelvis CT earlier today. Improvement in left basilar opacity with minimal bibasilar atelectasis. obstructive BS pattern FINAL REPORT ABDOMINAL RADIOGRAPH PERFORMED ON . Minimal uo via foley catheter. New right lower lobe opacities likely atelectasis. Abd softly distended. Abd softly distended. Abd softly distended. PA & LATERAL CHEST: Cardiomediastinal contours including marked tortuosity of the descending aorta are stable. Now with abdominal distention, obstruction and evaluate for obstruction. There is atherosclerotic calcification of the abdominal aorta, which is tortuous but unchanged. Hypodense material is once again noted in the large bowel, likely representing residual barium from prior CT. There are decompressed loops of small and large bowel distal to the second transition point. Response: Minimal uo. Pleural plaques are again noted. Small bilateral pleural effusions and new fluid overload. Moderate ascites. possible mild volume overload. EXAMINATION: Supine abdominal radiograph. FINDINGS: Supine and upright views of the abdomen as well as left lateral decubitus views were provided. Cont pulm toilet. | 44 | [
{
"category": "Physician ",
"chartdate": "2173-07-02 00:00:00.000",
"description": "Intensivist Note",
"row_id": 381951,
"text": "SICU\n HPI:\n 78M w/ ESRD, mesenteric volvulus s/p ex-lap, reduction of volvulus,\n enterotomy repair\n Chief complaint:\n volvulus\n PMHx:\n PMH: DM, ESRD on dialysis, HTN, renal cancer, prostate cancer, h/o SBO,\n h/o CVA, a fib/a flutter\n PSH: pacemaker, cataracts, R. nephrectomy ', b/l orchiectomy ', LOA\n ', ORIF R. bimalleolar ankle fracture ', creation L. AV graft ',\n Repair of left arm AV graft pseudoaneurysm ', Left forearm loop\n arteriovenous graft thrombectomy, venography, and venoplasty with\n coronary dilators ', revision AV graft ', Thrombectomy and balloon\n angioplasty of venous outflow stenosis x 2 in '.\n Current medications:\n 1. IV access: Temporary central access (ICU) Location: Left Subclavian,\n Date inserted: Order date: @ 1651 8. Magnesium Sulfate\n IV Sliding Scale Order date: @ 1651\n 2. IV access: Temporary central access (ICU) Location: Left Subclavian,\n Date inserted: Order date: @ 1651 9. MetRONIDAZOLE\n (FLagyl) 500 mg IV Q12H Order date: @ 1651\n 3. 1000 mL NS\n Continuous at 10 ml/hr\n KVO Order date: @ 1741 10. Pantoprazole 40 mg IV Q24H Order\n date: @ 1651\n 4. Calcium Gluconate IV Sliding Scale Order date: @ 1651 11.\n Propofol 5-20 mcg/kg/min IV DRIP TITRATE TO sedation Order date: \n @ 1651\n 5. CefePIME 500 mg IV Q24H Order date: @ 1651 12. Sodium\n Chloride 0.9% Flush 10 mL IV PRN line flush\n Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and\n PRN. Order date: @ 1651\n 6. Fentanyl Citrate 25-100 mcg IV Q6H:PRN Sedation\n Give doses every 5 min until sedated. Maintenance target: 3 and\n overbreathing ventilator Order date: @ 1651 13. Sodium Chloride\n 0.9% Flush 10 mL IV PRN line flush\n Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and\n PRN. Order date: @ 1651\n 7. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 1651 14. Vancomycin 1000 mg IV\n HD PROTOCOL\n ID Approval will be required for this order in 38 hours. Order date:\n @ 1651\n 24 Hour Events:\n INVASIVE VENTILATION - START 05:08 PM\n OR RECEIVED - At 05:30 PM\n ARTERIAL LINE - START 05:30 PM\n from OR\n MULTI LUMEN - START 05:30 PM\n MULTI LUMEN - START 06:07 PM\n EKG - At 06:17 PM\n MULTI LUMEN - STOP 03:30 AM\n Post operative day:\n POD#2 - ex lap\n Allergies:\n Cozaar (Oral) (Losartan Potassium)\n pt developed so\n Last dose of Antibiotics:\n Cefipime - 03:30 PM\n Vancomycin - 03:54 PM\n Metronidazole - 10:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 05:30 AM\n Fentanyl - 04:52 PM\n Pantoprazole (Protonix) - 10:00 PM\n Other medications:\n Flowsheet Data as of 03:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.2\nC (99\n T current: 36.3\nC (97.4\n HR: 60 (60 - 71) bpm\n BP: 152/40(72) {131/31(53) - 178/48(83)} mmHg\n RR: 16 (5 - 26) insp/min\n SPO2: 100%\n Heart rhythm: AV Paced\n Wgt (current): 72 kg (admission): 68.5 kg\n Height: 66 Inch\n CVP: 15 (5 - 15) mmHg\n Total In:\n 4,233 mL\n 169 mL\n PO:\n Tube feeding:\n IV Fluid:\n 2,988 mL\n 33 mL\n Blood products:\n 993 mL\n Total out:\n 1,537 mL\n 5 mL\n Urine:\n 72 mL\n 5 mL\n NG:\n 1,100 mL\n Stool:\n Drains:\n 350 mL\n Balance:\n 2,696 mL\n 164 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 383 (309 - 383) mL\n PS : 10 cmH2O\n RR (Set): 16\n RR (Spontaneous): 24\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 23 cmH2O\n Plateau: 16 cmH2O\n Compliance: 45.5 cmH2O/mL\n SPO2: 100%\n ABG: 7.47/31/169/23/0\n Ve: 8.6 L/min\n PaO2 / FiO2: 338\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: LLL), (Sternum: Stable )\n Abdominal: Soft, Non-tender, No(t) Bowel sounds present, Distended\n Left Extremities: (Edema: 1+)\n Right Extremities: (Edema: 1+)\n Neurologic: Moves all extremities\n Labs / Radiology\n 119 K/uL\n 9.3 g/dL\n 173 mg/dL\n 7.7 mg/dL\n 23 mEq/L\n 4.8 mEq/L\n 79 mg/dL\n 104 mEq/L\n 141 mEq/L\n 29.3 %\n 7.7 K/uL\n [image002.jpg]\n 05:35 PM\n 05:43 PM\n 09:39 PM\n 09:46 PM\n 04:46 AM\n 04:58 AM\n 05:16 PM\n 05:39 PM\n 11:15 PM\n WBC\n 6.4\n 6.4\n 6.3\n 5.5\n 7.7\n Hct\n 33.3\n 31.2\n 28.5\n 25.8\n 29.3\n Plt\n 149\n 147\n 123\n 100\n 119\n Creatinine\n 7.4\n 7.5\n 7.4\n 7.6\n 7.7\n TCO2\n 22\n 22\n 28\n 23\n Glucose\n 27\n 173\n Other labs: PT / PTT / INR:23.2/37.9/2.2, ALT / AST:, Alk-Phos / T\n bili:49/0.4, Fibrinogen:439 mg/dL, Lactic Acid:3.2 mmol/L, Albumin:2.5\n g/dL, LDH:165 IU/L, Ca:9.0 mg/dL, Mg:2.6 mg/dL, PO4:7.8 mg/dL\n Assessment and Plan\n .H/O AIRWAY, INABILITY TO PROTECT (RISK FOR ASPIRATION, ALTERED GAG,\n AIRWAY CLEARANCE, COUGH), PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN),\n RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD), SMALL BOWEL\n OBSTRUCTION (INTESTINAL OBSTRUCTION, SBO, INCLUDING INTUSSUSCEPTION,\n ADHESIONS)\n Assessment and Plan: 78M w/ ESRD, mesenteric volvulus s/p ex-lap,\n reduction of volvulus, enterotomy repair\n .\n Neuro: Intubated. H/o CVA. Fent, prop for sedation/comfort.\n .\n CVS: HD stable, h/o Afib/flutter with pacer (A/V). No pressors curr.\n .\n Pulm: Intubated. CPAP. Will try to extubate after dialysis.\n .\n GI: Mesenteric volvulus s/p ex-lap, reduction, enterotomy. NPO w/\n NGT. TPN @ 40\n .\n FEN: ESRD. KVO,. Fluid pos 10 L over LOS.\n .\n Renal: ESRD on HD (MWF). dialysis today. Cr 7.7. AV fistula L forearm.\n .\n Heme: Taking coumadin for afib, INR 2.2 Keep INR < 2. FFP as needed.\n .\n Endo: DM. RISS\n .\n ID: Vanco, cefepime, flagyl. wbc 6.3 -> 7.7\n TLD: aline, L subclavian TLC, NGT, ETT, JP x 2 wall sxn\n Wounds: midline abd\n Imaging: none today\n Prophylaxis: PPI, boots\n Consults: , I\n Code: Full\n Disposition: SICU\n ICU Care\n Nutrition:\n TPN without Lipids - 05:52 PM 41 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 05:30 PM\n Multi Lumen - 05:30 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2173-07-03 00:00:00.000",
"description": "Intensivist Note",
"row_id": 382037,
"text": "SICU\n HPI:\n 78 M with high grade SBO, s/p ex-lap, reduction of SB volvulus,\n enterotomy repair ; abd closure on \n Chief complaint:\n abd pain\n PMHx:\n DM, ESRD on dialysis, HTN, renal cancer, prostate cancer, h/o SBO, h/o\n CVA, a fib/a flutter\n Current medications:\n IV access: Temporary central access (ICU) Location: Left Subclavian,\n Date inserted: Order date: @ 1651 8. Insulin SC (per\n Insulin Flowsheet)\n Sliding Scale Order date: @ 1651\n 2. IV access: Temporary central access (ICU) Location: Left Subclavian,\n Date inserted: Order date: @ 1651 9. Magnesium Sulfate\n IV Sliding Scale Order date: @ 1651\n 3. 1000 mL NS\n Continuous at 10 ml/hr\n KVO Order date: @ 1741 10. MetRONIDAZOLE (FLagyl) 500 mg IV Q12H\n Order date: @ 1651\n 4. Calcium Gluconate IV Sliding Scale Order date: @ 1651 11.\n Pantoprazole 40 mg IV Q24H Order date: @ 1651\n 5. CefePIME 500 mg IV Q24H Order date: @ 1651 12. Sodium\n Chloride 0.9% Flush 10 mL IV PRN line flush\n Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and\n PRN. Order date: @ 1651\n 6. Fentanyl Citrate 25-100 mcg IV Q6H:PRN Sedation\n Give doses every 5 min until sedated. Maintenance target: 3 and\n overbreathing ventilator Order date: @ 1651 13. Sodium Chloride\n 0.9% Flush 10 mL IV PRN line flush\n Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and\n PRN. Order date: @ 1651\n 7. HYDROmorphone (Dilaudid) 0.25-0.5 mg IV Q4H:PRN pain Order date:\n @ 1755 14. Vancomycin 1000 mg IV HD PROTOCOL\n ID Approval will be required for this order in 12 hours.\n Need to dose per level Order date: @ 0809\n 24 Hour Events:\n EXTUBATION - At 02:00 PM\n INVASIVE VENTILATION - STOP 02:00 PM\n extubated\n Post operative day:\n POD#3 - ex lap\n Allergies:\n Cozaar (Oral) (Losartan Potassium)\n pt developed so\n Last dose of Antibiotics:\n Vancomycin - 03:54 PM\n Cefipime - 02:00 PM\n Metronidazole - 04:00 AM\n Infusions:\n Other ICU medications:\n Fentanyl - 11:03 AM\n Pantoprazole (Protonix) - 08:00 PM\n Hydromorphone (Dilaudid) - 12:00 AM\n Other medications:\n Flowsheet Data as of 05:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.1\nC (98.7\n T current: 36.2\nC (97.2\n HR: 83 (60 - 87) bpm\n BP: 128/29(55) {128/29(55) - 194/68(86)} mmHg\n RR: 17 (0 - 26) insp/min\n SPO2: 100%\n Heart rhythm: V Paced\n Wgt (current): 72 kg (admission): 68.5 kg\n Height: 66 Inch\n CVP: 2 (2 - 7) mmHg\n Total In:\n 1,406 mL\n 411 mL\n PO:\n Tube feeding:\n IV Fluid:\n 400 mL\n 158 mL\n Blood products:\n Total out:\n 2,680 mL\n 20 mL\n Urine:\n 30 mL\n 20 mL\n NG:\n 350 mL\n Stool:\n Drains:\n Balance:\n -1,274 mL\n 391 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: Standby\n Vt (Spontaneous): 398 (398 - 461) mL\n PS : 5 cmH2O\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 30\n PIP: 11 cmH2O\n SPO2: 100%\n ABG: 7.31/40/144/28/-5\n Ve: 8.1 L/min\n PaO2 / FiO2: 360\n Physical Examination\n General Appearance: No acute distress\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Bowel sounds present, Tender: around abd incision\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 104 K/uL\n 8.1 g/dL\n 180 mg/dL\n 5.0 mg/dL\n 28 mEq/L\n 3.6 mEq/L\n 47 mg/dL\n 103 mEq/L\n 141 mEq/L\n 25.9 %\n 5.5 K/uL\n [image002.jpg]\n 09:46 PM\n 04:46 AM\n 04:58 AM\n 05:16 PM\n 05:39 PM\n 11:15 PM\n 03:12 AM\n 03:32 AM\n 09:48 AM\n 03:00 AM\n WBC\n 6.3\n 5.5\n 7.7\n 6.7\n 5.5\n Hct\n 28.5\n 25.8\n 29.3\n 28.1\n 25.9\n Plt\n 123\n 100\n 119\n 123\n 104\n Creatinine\n 7.4\n 7.6\n 7.7\n 8.2\n 5.0\n TCO2\n 22\n 28\n 23\n 24\n 21\n Glucose\n 158\n 127\n 173\n 165\n 180\n Other labs: PT / PTT / INR:19.6/36.1/1.8, ALT / AST:14/23, Alk-Phos / T\n bili:55/0.3, Fibrinogen:439 mg/dL, Lactic Acid:3.2 mmol/L, Albumin:2.4\n g/dL, LDH:184 IU/L, Ca:8.8 mg/dL, Mg:2.4 mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n .H/O AIRWAY, INABILITY TO PROTECT (RISK FOR ASPIRATION, ALTERED GAG,\n AIRWAY CLEARANCE, COUGH), PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN),\n RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD), SMALL BOWEL\n OBSTRUCTION (INTESTINAL OBSTRUCTION, SBO, INCLUDING INTUSSUSCEPTION,\n ADHESIONS)\n Assessment and Plan: 78M w/ ESRD, mesenteric volvulus s/p ex-lap,\n reduction of volvulus, enterotomy repair. Extubated yesterday.\n Neurologic: H/o CVA, dilaudid prn pain.\n Cardiovascular: HD stable, h/o Afib/flutter with pacer (A/V). No\n pressors curr.\n Pulmonary: stable on NC, extubated yesterday.\n Gastrointestinal / Abdomen: Mesenteric volvulus s/p ex-lap, reduction,\n enterotomy. NPO w/\n NGT. TPN.\n Nutrition: ESRD. KVO\n Renal: ESRD on HD (MWF). dialysis yesterday. AV fistula L forearm\n Hematology: Taking coumadin for afib at home, daily INR, Keep INR < 2,\n coumadin held for now per surgical team as pt is post op abd surgery.\n Endocrine: DM. RISS\n Infectious Disease: Vanco, cefepime, flagyl for ischemic bowel. f/u AM\n vanco level\n Lines / Tubes / Drains: aline, L subclavian TLC, NGT, JP x 2 wall sxn\n Wounds: abd\n Imaging:\n Fluids:\n Consults: , I\n Billing Diagnosis:\n ICU Care\n Nutrition:\n TPN without Lipids - 06:06 PM 44 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 05:30 PM\n Multi Lumen - 05:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2173-07-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 382044,
"text": "78 M with high grade SBO, s/p ex-lap, reduction of SB volvulus,\n enterotomy repair ; abd closure on \n Chief complaint:\n abd pain\n PMHx:\n DM, ESRD on dialysis, HTN, renal cancer, prostate cancer, h/o SBO, h/o\n CVA, a fib/a flutter\n Small bowel obstruction (Intestinal obstruction, SBO, including\n intussusception, adhesions)\n Assessment:\n Patient\ns abdomen is softly distended, hypoactive BS, NGT to wall\n suction with bilious output.\n Action:\n NGT to LCS with bilious drainage, post op dressing still intact & dry.\n Response:\n NGT drain trending down, still bilious, hypoactive BS. patient on TPN\n Plan:\n NGT to LCS, pain control, cont with TPN.\n Pain control (acute pain, chronic pain)\n Assessment:\n Patient c/o pain with activities, deep breath and cough and turning\n moving.\n Action:\n Medicated with pain med before activities, encouraged deep breath and\n cough.\n Response:\n pain well controlled with pain med, able to deep breath and cough after\n pain med.\n Plan:\n Assess and treat pain, dilaudid is effective for him.\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Patient with h/o ESRD on HD.\n Action:\n Had HD yesterday, 2.3 L removed.\n Response:\n Very minimal UO, BUN & creat still elevated.\n Plan:\n HD per renal team, Vancomycin per HD protocol\n"
},
{
"category": "Nutrition",
"chartdate": "2173-07-01 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 381856,
"text": "Subjective: Per patient\ns wife, patient is a very picky eater. He\n will eat his meals and then is very sedentary for most of the day.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 168 cm\n 68.5 kg\n 72 kg ( 01:00 AM)\n 24.3\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 64.4 kg\n 106%\n unknown\n Diagnosis: Bowel Obstruction\n PMH : DM, ESRD on HD 3x/wk, renal cancer, prostate cancer, h/o SBO,\n CVA, afib/flutter, pacemaker, R nephrectomy ', b/l orchiectomy, LOA\n ', ORIF ankle fracture, Left arm AV graft pseudoaneurysm ', left\n forearm loop arteriovenous graft thrombectomy, venography and\n venoplasty with ocronary dilators ', revision of AV graft ',\n thrombectomy and balloon angioplasty of venous outflow stenosis x2 in\n '\n Food allergies and intolerances: no known food allergies\n Pertinent medications: Propofol, NaCl 0.9% @ 100cc/hr,\n Labs:\n Value\n Date\n Glucose\n 158 mg/dL\n 04:46 AM\n Glucose Finger Stick\n 123\n 10:00 AM\n BUN\n 60 mg/dL\n 04:46 AM\n Creatinine\n 7.4 mg/dL\n 04:46 AM\n Sodium\n 140 mEq/L\n 04:46 AM\n Potassium\n 4.4 mEq/L\n 04:46 AM\n Chloride\n 103 mEq/L\n 04:46 AM\n TCO2\n 23 mEq/L\n 04:46 AM\n PO2 (arterial)\n 213 mm Hg\n 04:58 AM\n PCO2 (arterial)\n 36 mm Hg\n 04:58 AM\n pH (arterial)\n 7.48 units\n 04:58 AM\n CO2 (Calc) arterial\n 28 mEq/L\n 04:58 AM\n Calcium non-ionized\n 9.0 mg/dL\n 04:46 AM\n Phosphorus\n 6.1 mg/dL\n 04:46 AM\n Ionized Calcium\n 1.08 mmol/L\n 09:46 PM\n Magnesium\n 2.4 mg/dL\n 04:46 AM\n ALT\n 11 IU/L\n 04:46 AM\n Alkaline Phosphate\n 46 IU/L\n 04:46 AM\n AST\n 20 IU/L\n 04:46 AM\n Total Bilirubin\n 0.3 mg/dL\n 04:46 AM\n WBC\n 6.3 K/uL\n 04:46 AM\n Hgb\n 9.0 g/dL\n 04:46 AM\n Hematocrit\n 28.5 %\n 04:46 AM\n Current diet order / nutrition support: Diet: NPO\n TPN: Day 1 standard.\n GI: abd open, absent bowel sounds\n Assessment of Nutritional Status\n At risk for malnutrition\n Pt at risk due to: extensive bowel surgery, ESRD on HD, possible\n prolonged dependence on TPN\n Estimated Nutritional Needs\n Calories: 1645- ( 24-28 cal/kg)\n Protein: 69-89 (1-1.3 g/kg)\n Fluid: per team\n Estimation of previous intake: Possibly Adequate\n Estimation of current intake: Inadequate\n Specifics:\n 78 y.o. M w/ ESRD, adm with a high grade bowel obstruction & mesenteric\n volvulus, now s/p ex-lap, reduction of volvulus, enterotomy repair\n . Abd left open, and plan is to return to OR today for possible\n further SBR. Patient is intubated and sedated on propofol, which\n provides 1.1 kcal/mL. Agree with start of TPN today to prevent\n nutritional decline, given likely prolonged NPO. Will provide TPN\n recommendations below\n recommend not adding lipid to TPN until\n propofol drip is off.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1) If Day 1 standard TPN tolerated today, advance to Day 2\n standard tomorrow .\n 2) Check triglycerides, if <400, ok to add lipid to TPN.\n 3) Recommend TPN goal of 1500mL (290dextrose/ 70amino acid/\n 45fat) = 1716kcals.\n 4) Monitor lytes and BG with start of TPN.\n Following\n please page with questions. #\n"
},
{
"category": "Respiratory ",
"chartdate": "2173-06-30 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 381767,
"text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 1\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Pt received from OR intubated and placed AC as noted. BS are\n equal upon arrival.\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Plan\n Next 24-48 hours: Plan to remain intubated and mechanically ventilated\n overnight.\n Reason for continuing current ventilatory support: Pending procedure /\n OR; Comments: Plan to go back to OR tomorrow.\n"
},
{
"category": "Physician ",
"chartdate": "2173-07-01 00:00:00.000",
"description": "Intensivist Note",
"row_id": 381839,
"text": "SICU\n HPI:\n 78 M with high grade SBO, s/p ex-lap, reduction of SB volvulus,\n enterotomy repair \n Chief complaint:\n SBO, obstipation\n PMHx:\n PMH: DM, ESRD on dialysis, HTN, renal cancer, prostate cancer, h/o SBO,\n h/o CVA, a fib/a flutter\n PSH: pacemaker, cataracts, R. nephrectomy ', b/l orchiectomy ', LOA\n ', ORIF R. bimalleolar ankle fracture ', creation L. AV graft ',\n Repair of left arm AV graft pseudoaneurysm ', Left forearm loop\n arteriovenous graft thrombectomy, venography, and venoplasty with\n coronary dilators ', revision AV graft ', Thrombectomy and balloon\n angioplasty of venous outflow stenosis x 2 in '.\n Current medications:\n Insulin SC (per Insulin Flowsheet) Sliding Scale\n 1000 mL NS Continuous at 100 ml/hr\n Magnesium Sulfate IV Sliding Scale\n MetRONIDAZOLE (FLagyl) 500 mg IV Q12H\n Norepinephrine 0.03-0.25 mcg/kg/min IV DRIP TITRATE TO keep sbp > 120\n Calcium Gluconate IV Sliding Scale\n Pantoprazole 40 mg IV Q24H\n CefePIME 500 mg IV Q24H\n Propofol 5-20 mcg/kg/min IV DRIP TITRATE TO sedation\n Fentanyl Citrate 25-100 mcg IV Q6H:PRN Sedation\n Heparin 5000 UNIT SC TID\n Vancomycin 1000 mg IV HD PROTOCOL\n 24 Hour Events:\n INVASIVE VENTILATION - START 05:08 PM\n OR RECEIVED - At 05:30 PM\n ARTERIAL LINE - START 05:30 PM\n from OR\n MULTI LUMEN - START 05:30 PM\n MULTI LUMEN - START 06:07 PM\n EKG - At 06:17 PM\n : High grade obstruction, NGT w/ feculent material. OR for sb\n decompression, enterotomy. L subclavian, R groin TLC placed. Renal cs\n for ? CVVH. 6L IVF in ED; 2u FFP, 1.5L in OR. s/p 3u FFP o/n for INR\n >2. Attempted change of R groin TLC to dialysis cath, coiled, removed.\n Re-attempt access in AM.\n Post operative day:\n POD#1 - ex lap\n Allergies:\n Cozaar (Oral) (Losartan Potassium)\n pt developed so\n Last dose of Antibiotics:\n Cefipime - 08:25 PM\n Metronidazole - 09:44 PM\n Infusions:\n Norepinephrine - 0.04 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 PM\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Fentanyl - 11:23 PM\n Other medications:\n Flowsheet Data as of 05:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.4\nC (99.4\n T current: 37.4\nC (99.4\n HR: 60 (60 - 64) bpm\n BP: 156/44(77) {101/35(56) - 182/54(100)} mmHg\n RR: 20 (10 - 20) insp/min\n SPO2: 100%\n Heart rhythm: AV Paced\n CVP: 10 (5 - 13) mmHg\n Total In:\n 10,783 mL\n 1,177 mL\n PO:\n Tube feeding:\n IV Fluid:\n 9,976 mL\n 464 mL\n Blood products:\n 807 mL\n 713 mL\n Total out:\n 1,300 mL\n 10 mL\n Urine:\n 10 mL\n NG:\n 750 mL\n Stool:\n Drains:\n 250 mL\n Balance:\n 9,483 mL\n 1,167 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 20 cmH2O\n Plateau: 16 cmH2O\n Compliance: 45.5 cmH2O/mL\n SPO2: 100%\n ABG: 7.42/33/186/23/-1\n Ve: 7.9 L/min\n PaO2 / FiO2: 372\n Physical Examination\n General Appearance: No acute distress, Well nourished, Cachectic,\n Intubated\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular), (Murmur: Systolic)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : ), (Sternum:\n Stable )\n Abdominal: Soft, Non-distended, Tender:\n Left Extremities: (Edema: Trace), (Temperature: Cool), (Pulse -\n Dorsalis pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Right Extremities: (Edema: Trace), (Temperature: Cool), (Pulse -\n Dorsalis pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Skin: open abdomen\n Neurologic: (Awake / Alert / Oriented: x 1), Sedated, Chemically\n paralyzed\n Labs / Radiology\n 147 K/uL\n 10.2 g/dL\n 179 mg/dL\n 7.5 mg/dL\n 23 mEq/L\n 4.4 mEq/L\n 56 mg/dL\n 103 mEq/L\n 139 mEq/L\n 31.2 %\n 6.4 K/uL\n [image002.jpg]\n 05:35 PM\n 05:43 PM\n 09:39 PM\n 09:46 PM\n WBC\n 6.4\n 6.4\n Hct\n 33.3\n 31.2\n Plt\n 149\n 147\n Creatinine\n 7.4\n 7.5\n TCO2\n 22\n 22\n Glucose\n 240\n 179\n Other labs: PT / PTT / INR:20.0/35.7/1.8, ALT / AST:, Alk-Phos / T\n bili:45/0.3, Lactic Acid:3.2 mmol/L, LDH:159 IU/L, Ca:8.4 mg/dL, Mg:1.7\n mg/dL, PO4:6.2 mg/dL\n Assessment and Plan\n SMALL BOWEL OBSTRUCTION (INTESTINAL OBSTRUCTION, SBO, INCLUDING\n INTUSSUSCEPTION, ADHESIONS)\n Assessment and Plan: 78M w/ ESRD, mesenteric volvulus s/p ex-lap,\n reduction of volvulus, enterotomy repair\n Neurologic: Intubated. H/o CVA. Fent, prop for sedation/comfort.\n Cardiovascular: h/o Afib/flutter with pacer (A/V). On levo for MAP > 60\n Pulmonary: Cont ETT, (Ventilator mode: CMV), Intubated.Keep intubated\n until second look operation.\n Gastrointestinal / Abdomen: Mesenteric volvulus s/p ex-lap, reduction,\n enterotomy. NPO w/ NGT. OR in Am for second look\n Nutrition: NPO\n Renal: Foley, ESRD on HD (MWF). Renal cs for ? CVVH. Pre-renal. Cr\n 8.7>7.5\n Hematology: Taking coumadin for afib, INR 2.3. Keep INR < 2. FFP as\n needed.\n Endocrine: RISS\n Infectious Disease: Vanco, cefepime, flagyl. wbc 13\n Lines / Tubes / Drains: aline, L subclavian TLC, R fem TLC, NGT, ETT,\n JP x 2 wall sxn\n Wounds: Open abdomen with drain to suction\n Imaging:\n Fluids: ESRD. Will need CVVH, but not at this poijnt. NS @ 100, bolus\n prn to resuscitate\n Consults: Transplant, Nephrology\n Billing Diagnosis: (Shock: Unspecified), Other: High grade bowel\n obstruction\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 05:30 PM\n Multi Lumen - 06:07 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 33 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2173-07-02 00:00:00.000",
"description": "Intensivist Note",
"row_id": 381913,
"text": "SICU\n HPI:\n 78M w/ ESRD, mesenteric volvulus s/p ex-lap, reduction of volvulus,\n enterotomy repair\n Chief complaint:\n volvulus\n PMHx:\n PMH: DM, ESRD on dialysis, HTN, renal cancer, prostate cancer, h/o SBO,\n h/o CVA, a fib/a flutter\n PSH: pacemaker, cataracts, R. nephrectomy ', b/l orchiectomy ', LOA\n ', ORIF R. bimalleolar ankle fracture ', creation L. AV graft ',\n Repair of left arm AV graft pseudoaneurysm ', Left forearm loop\n arteriovenous graft thrombectomy, venography, and venoplasty with\n coronary dilators ', revision AV graft ', Thrombectomy and balloon\n angioplasty of venous outflow stenosis x 2 in '.\n Current medications:\n 1. IV access: Temporary central access (ICU) Location: Left Subclavian,\n Date inserted: Order date: @ 1651 8. Magnesium Sulfate\n IV Sliding Scale Order date: @ 1651\n 2. IV access: Temporary central access (ICU) Location: Left Subclavian,\n Date inserted: Order date: @ 1651 9. MetRONIDAZOLE\n (FLagyl) 500 mg IV Q12H Order date: @ 1651\n 3. 1000 mL NS\n Continuous at 10 ml/hr\n KVO Order date: @ 1741 10. Pantoprazole 40 mg IV Q24H Order\n date: @ 1651\n 4. Calcium Gluconate IV Sliding Scale Order date: @ 1651 11.\n Propofol 5-20 mcg/kg/min IV DRIP TITRATE TO sedation Order date: \n @ 1651\n 5. CefePIME 500 mg IV Q24H Order date: @ 1651 12. Sodium\n Chloride 0.9% Flush 10 mL IV PRN line flush\n Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and\n PRN. Order date: @ 1651\n 6. Fentanyl Citrate 25-100 mcg IV Q6H:PRN Sedation\n Give doses every 5 min until sedated. Maintenance target: 3 and\n overbreathing ventilator Order date: @ 1651 13. Sodium Chloride\n 0.9% Flush 10 mL IV PRN line flush\n Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and\n PRN. Order date: @ 1651\n 7. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 1651 14. Vancomycin 1000 mg IV\n HD PROTOCOL\n ID Approval will be required for this order in 38 hours. Order date:\n @ 1651\n 24 Hour Events:\n INVASIVE VENTILATION - START 05:08 PM\n OR RECEIVED - At 05:30 PM\n ARTERIAL LINE - START 05:30 PM\n from OR\n MULTI LUMEN - START 05:30 PM\n MULTI LUMEN - START 06:07 PM\n EKG - At 06:17 PM\n MULTI LUMEN - STOP 03:30 AM\n Post operative day:\n POD#2 - ex lap\n Allergies:\n Cozaar (Oral) (Losartan Potassium)\n pt developed so\n Last dose of Antibiotics:\n Cefipime - 03:30 PM\n Vancomycin - 03:54 PM\n Metronidazole - 10:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 05:30 AM\n Fentanyl - 04:52 PM\n Pantoprazole (Protonix) - 10:00 PM\n Other medications:\n Flowsheet Data as of 03:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.2\nC (99\n T current: 36.3\nC (97.4\n HR: 60 (60 - 71) bpm\n BP: 152/40(72) {131/31(53) - 178/48(83)} mmHg\n RR: 16 (5 - 26) insp/min\n SPO2: 100%\n Heart rhythm: AV Paced\n Wgt (current): 72 kg (admission): 68.5 kg\n Height: 66 Inch\n CVP: 15 (5 - 15) mmHg\n Total In:\n 4,233 mL\n 169 mL\n PO:\n Tube feeding:\n IV Fluid:\n 2,988 mL\n 33 mL\n Blood products:\n 993 mL\n Total out:\n 1,537 mL\n 5 mL\n Urine:\n 72 mL\n 5 mL\n NG:\n 1,100 mL\n Stool:\n Drains:\n 350 mL\n Balance:\n 2,696 mL\n 164 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 383 (309 - 383) mL\n PS : 10 cmH2O\n RR (Set): 16\n RR (Spontaneous): 24\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 23 cmH2O\n Plateau: 16 cmH2O\n Compliance: 45.5 cmH2O/mL\n SPO2: 100%\n ABG: 7.47/31/169/23/0\n Ve: 8.6 L/min\n PaO2 / FiO2: 338\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: LLL), (Sternum: Stable )\n Abdominal: Soft, Non-tender, No(t) Bowel sounds present, Distended\n Left Extremities: (Edema: 1+)\n Right Extremities: (Edema: 1+)\n Neurologic: Moves all extremities\n Labs / Radiology\n 119 K/uL\n 9.3 g/dL\n 173 mg/dL\n 7.7 mg/dL\n 23 mEq/L\n 4.8 mEq/L\n 79 mg/dL\n 104 mEq/L\n 141 mEq/L\n 29.3 %\n 7.7 K/uL\n [image002.jpg]\n 05:35 PM\n 05:43 PM\n 09:39 PM\n 09:46 PM\n 04:46 AM\n 04:58 AM\n 05:16 PM\n 05:39 PM\n 11:15 PM\n WBC\n 6.4\n 6.4\n 6.3\n 5.5\n 7.7\n Hct\n 33.3\n 31.2\n 28.5\n 25.8\n 29.3\n Plt\n 149\n 147\n 123\n 100\n 119\n Creatinine\n 7.4\n 7.5\n 7.4\n 7.6\n 7.7\n TCO2\n 22\n 22\n 28\n 23\n Glucose\n 27\n 173\n Other labs: PT / PTT / INR:23.2/37.9/2.2, ALT / AST:, Alk-Phos / T\n bili:49/0.4, Fibrinogen:439 mg/dL, Lactic Acid:3.2 mmol/L, Albumin:2.5\n g/dL, LDH:165 IU/L, Ca:9.0 mg/dL, Mg:2.6 mg/dL, PO4:7.8 mg/dL\n Assessment and Plan\n .H/O AIRWAY, INABILITY TO PROTECT (RISK FOR ASPIRATION, ALTERED GAG,\n AIRWAY CLEARANCE, COUGH), PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN),\n RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD), SMALL BOWEL\n OBSTRUCTION (INTESTINAL OBSTRUCTION, SBO, INCLUDING INTUSSUSCEPTION,\n ADHESIONS)\n Assessment and Plan: 78M w/ ESRD, mesenteric volvulus s/p ex-lap,\n reduction of volvulus, enterotomy repair\n .\n Neuro: Intubated. H/o CVA. Fent, prop for sedation/comfort.\n .\n CVS: HD stable, h/o Afib/flutter with pacer (A/V). No pressors curr.\n .\n Pulm: Intubated. CPAP.\n .\n GI: Mesenteric volvulus s/p ex-lap, reduction, enterotomy. NPO w/\n NGT. TPN @ 40\n .\n FEN: ESRD. KVO, bolus prn to resuscitate. Fluid pos 10 L over LOS.\n .\n Renal: ESRD on HD (MWF). dialysis today. Cr 7.7. AV fistula L forearm.\n .\n Heme: Taking coumadin for afib, INR 2.2 Keep INR < 2. FFP as needed.\n .\n Endo: DM. RISS\n .\n ID: Vanco, cefepime, flagyl. wbc 6.3 -> 7.7\n TLD: aline, L subclavian TLC, NGT, ETT, JP x 2 wall sxn\n Wounds: midline abd\n Imaging: none today\n Prophylaxis: PPI, boots\n Consults: , I\n Code: Full\n Disposition: SICU\n ICU Care\n Nutrition:\n TPN without Lipids - 05:52 PM 41 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 05:30 PM\n Multi Lumen - 05:30 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 37 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2173-07-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 381932,
"text": "78M w/ ESRD, mesenteric volvulus s/p ex-lap, reduction of volvulus,\n enterotomy repair\n .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Patient remains intubated on ventilator cpap/ps mode no sedations on,\n propofol off from 6pm yesterday. Not waking up much, just opening eyes\n to pain and stimuli, not moving any extremities to stimulation or pain.\n Weak cough.\n Action:\n SICU MD notified, TOF checked 0-1 twitches noted, patient received 15mg\n of vacuronium in the OR and not reversed, OFF all sedation, neuro\n checks q2h. LS clear, o2 sat 99-100%\n Response:\n PERL, opening eyes to painful stimuli and to voice, started moving all\n extremities slowly, not very strong, patient nods appropriately.\n Plan:\n Cont to monitor, pulm hygiene.\n Small bowel obstruction (Intestinal obstruction, SBO, including\n intussusception, adhesions)\n Assessment:\n Patient s/p Exp lap bowel resection, NGT with bilious drainage,\n moderate amt. Bowel sounds absent. Patient on TPN, abd softly\n distended, dressing intact & dry.\n Action:\n NGT to LCS with bilious out put.\n Response:\n NG out put moderate, post op dressing intact & dry.\n Plan:\n Cont to monitor, cont with TPN.\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Patient with h/o End stage renal failure on HD, Had HD on last\n Saturday.\n Action:\n Anuric, with elevated Bun and creat, team aware.\n Response:\n BUN : 85 Creat 8.2 with am lab.\n Plan:\n ? HD toady, pt is hemodynamically stable.\n"
},
{
"category": "Physician ",
"chartdate": "2173-07-01 00:00:00.000",
"description": "Intensivist Note",
"row_id": 381804,
"text": "SICU\n HPI:\n 78 M with high grade SBO, s/p ex-lap, reduction of SB volvulus,\n enterotomy repair \n Chief complaint:\n SBO, obstipation\n PMHx:\n PMH: DM, ESRD on dialysis, HTN, renal cancer, prostate cancer, h/o SBO,\n h/o CVA, a fib/a flutter\n PSH: pacemaker, cataracts, R. nephrectomy ', b/l orchiectomy ', LOA\n ', ORIF R. bimalleolar ankle fracture ', creation L. AV graft ',\n Repair of left arm AV graft pseudoaneurysm ', Left forearm loop\n arteriovenous graft thrombectomy, venography, and venoplasty with\n coronary dilators ', revision AV graft ', Thrombectomy and balloon\n angioplasty of venous outflow stenosis x 2 in '.\n Current medications:\n Insulin SC (per Insulin Flowsheet) Sliding Scale\n 1000 mL NS Continuous at 100 ml/hr\n Magnesium Sulfate IV Sliding Scale\n MetRONIDAZOLE (FLagyl) 500 mg IV Q12H\n Norepinephrine 0.03-0.25 mcg/kg/min IV DRIP TITRATE TO keep sbp > 120\n Calcium Gluconate IV Sliding Scale\n Pantoprazole 40 mg IV Q24H\n CefePIME 500 mg IV Q24H\n Propofol 5-20 mcg/kg/min IV DRIP TITRATE TO sedation\n Fentanyl Citrate 25-100 mcg IV Q6H:PRN Sedation\n Heparin 5000 UNIT SC TID\n Vancomycin 1000 mg IV HD PROTOCOL\n 24 Hour Events:\n INVASIVE VENTILATION - START 05:08 PM\n OR RECEIVED - At 05:30 PM\n ARTERIAL LINE - START 05:30 PM\n from OR\n MULTI LUMEN - START 05:30 PM\n MULTI LUMEN - START 06:07 PM\n EKG - At 06:17 PM\n : High grade obstruction, NGT w/ feculent material. OR for sb\n decompression, enterotomy. L subclavian, R groin TLC placed. Renal cs\n for ? CVVH. 6L IVF in ED; 2u FFP, 1.5L in OR. s/p 3u FFP o/n for INR\n >2. Attempted change of R groin TLC to dialysis cath, coiled, removed.\n Re-attempt access in AM.\n Post operative day:\n POD#1 - ex lap\n Allergies:\n Cozaar (Oral) (Losartan Potassium)\n pt developed so\n Last dose of Antibiotics:\n Cefipime - 08:25 PM\n Metronidazole - 09:44 PM\n Infusions:\n Norepinephrine - 0.04 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 PM\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Fentanyl - 11:23 PM\n Other medications:\n Flowsheet Data as of 05:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.4\nC (99.4\n T current: 37.4\nC (99.4\n HR: 60 (60 - 64) bpm\n BP: 156/44(77) {101/35(56) - 182/54(100)} mmHg\n RR: 20 (10 - 20) insp/min\n SPO2: 100%\n Heart rhythm: AV Paced\n CVP: 10 (5 - 13) mmHg\n Total In:\n 10,783 mL\n 1,177 mL\n PO:\n Tube feeding:\n IV Fluid:\n 9,976 mL\n 464 mL\n Blood products:\n 807 mL\n 713 mL\n Total out:\n 1,300 mL\n 10 mL\n Urine:\n 10 mL\n NG:\n 750 mL\n Stool:\n Drains:\n 250 mL\n Balance:\n 9,483 mL\n 1,167 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 20 cmH2O\n Plateau: 16 cmH2O\n Compliance: 45.5 cmH2O/mL\n SPO2: 100%\n ABG: 7.42/33/186/23/-1\n Ve: 7.9 L/min\n PaO2 / FiO2: 372\n Physical Examination\n General Appearance: No acute distress, Well nourished, Cachectic,\n Intubated\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular), (Murmur: Systolic)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : ), (Sternum:\n Stable )\n Abdominal: Soft, Non-distended, Tender:\n Left Extremities: (Edema: Trace), (Temperature: Cool), (Pulse -\n Dorsalis pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Right Extremities: (Edema: Trace), (Temperature: Cool), (Pulse -\n Dorsalis pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Skin: open abdomen\n Neurologic: (Awake / Alert / Oriented: x 1), Sedated, Chemically\n paralyzed\n Labs / Radiology\n 147 K/uL\n 10.2 g/dL\n 179 mg/dL\n 7.5 mg/dL\n 23 mEq/L\n 4.4 mEq/L\n 56 mg/dL\n 103 mEq/L\n 139 mEq/L\n 31.2 %\n 6.4 K/uL\n [image002.jpg]\n 05:35 PM\n 05:43 PM\n 09:39 PM\n 09:46 PM\n WBC\n 6.4\n 6.4\n Hct\n 33.3\n 31.2\n Plt\n 149\n 147\n Creatinine\n 7.4\n 7.5\n TCO2\n 22\n 22\n Glucose\n 240\n 179\n Other labs: PT / PTT / INR:20.0/35.7/1.8, ALT / AST:, Alk-Phos / T\n bili:45/0.3, Lactic Acid:3.2 mmol/L, LDH:159 IU/L, Ca:8.4 mg/dL, Mg:1.7\n mg/dL, PO4:6.2 mg/dL\n Assessment and Plan\n SMALL BOWEL OBSTRUCTION (INTESTINAL OBSTRUCTION, SBO, INCLUDING\n INTUSSUSCEPTION, ADHESIONS)\n Assessment and Plan: 78M w/ ESRD, mesenteric volvulus s/p ex-lap,\n reduction of volvulus, enterotomy repair\n Neurologic: Intubated. H/o CVA. Fent, prop for sedation/comfort.\n Cardiovascular: h/o Afib/flutter with pacer (A/V). On levo for MAP > 60\n Pulmonary: Cont ETT, (Ventilator mode: CMV), Intubated.\n Gastrointestinal / Abdomen: Mesenteric volvulus s/p ex-lap, reduction,\n enterotomy. NPO w/ NGT. OR in Am for second look\n Nutrition: NPO\n Renal: Foley, ESRD on HD (MWF). Renal cs for ? CVVH. Pre-renal. Cr\n 8.7>7.5\n Hematology: Taking coumadin for afib, INR 2.3. Keep INR < 2. FFP as\n needed.\n Endocrine: RISS\n Infectious Disease: Vanco, cefepime, flagyl. wbc 13\n Lines / Tubes / Drains: aline, L subclavian TLC, R fem TLC, NGT, ETT,\n JP x 2 wall sxn\n Wounds: Open abdomen with drain to suction\n Imaging:\n Fluids: ESRD. Will need CVVH. NS @ 100, bolus prn to resuscitate\n Consults: Transplant, Nephrology\n Billing Diagnosis: (Shock: Unspecified), Other: High grade bowel\n obstruction\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 05:30 PM\n Multi Lumen - 06:07 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 40 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2173-07-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 381809,
"text": "Small bowel obstruction (Intestinal obstruction, SBO, including\n intussusception, adhesions)\n Assessment:\n Pt is s/p ex lap with open abdomen\n 2 JP\ns within abd dsg draining large amts s/s\n Pt is sedated on propofol\n Hypotensive with MAP<60\n Hypothermic\n Pt is anuric, is a HD pt.\n Pt is ventilated with good abg\ns on 50%\n INR 2.2\n Ng draining large amts dark bloody\n Action:\n Fluid bolus 1500cc total\n Levophed begun, at 0.04 mcg/kg/min\n 3 u FFP to correct INR\n Attempt to change femoral line to a Quinton over a wire, unable to\n thread Quinton\n Labs q 6 hrs\n Response:\n Temporary increase in bp after fluid boluses.\n Good response to levophed with MAP 70-80\n INR 1.8\n Magnesium and calcium relpleted\n HCT stable\n Plan:\n Place Quinton at new site later this am.\n Check labs q 6 hr, treat electrolystes, INR as needed. Monitor HCT.\n For OR later today to reassess bowel, ? close abdomen\n Maintain sedation\n"
},
{
"category": "Nursing",
"chartdate": "2173-07-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 381928,
"text": "78M w/ ESRD, mesenteric volvulus s/p ex-lap, reduction of volvulus,\n enterotomy repair\n .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Patient remains intubated on ventilator cpap/ps mode no sedations on,\n propofol off from 6pm yesterday. Not waking up much, just opening eyes\n to pain and stimuli, not moving any extremities to stimulation or pain.\n Weak cough.\n Action:\n SICU MD notified, TOF checked 0-1 twitches noted, patient received 15mg\n of vacuronium in the OR and not reversed, OFF all sedation, neuro\n checks q2h. LS clear, o2 sat 99-100%\n Response:\n PERL, opening eyes to painful stimuli and to voice, started moving LE\n with commands, upper extremities not moving still, patient nods\n appropriately.\n Plan:\n Cont to monitor, pulm hygiene.\n Small bowel obstruction (Intestinal obstruction, SBO, including\n intussusception, adhesions)\n Assessment:\n Patient s/p Exp lap bowel resection, NGT with bilious drainage,\n moderate amt. Bowel sounds absent. Patient on TPN, abd softly\n distended, dressing intact & dry.\n Action:\n NGT to LCS with bilious out put.\n Response:\n NG out put moderate, post op dressing intact & dry.\n Plan:\n Cont to monitor, cont with TPN.\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Patient with h/o End stage renal failure on HD, Had HD on last\n Saturday.\n Action:\n Anuric, with elevated Bun and creat, team aware.\n Response:\n BUN : Craet 8.3 with am lab.\n Plan:\n ? HD toady, pt is hemodynamically stable.\n"
},
{
"category": "Nursing",
"chartdate": "2173-07-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 381929,
"text": "78M w/ ESRD, mesenteric volvulus s/p ex-lap, reduction of volvulus,\n enterotomy repair\n .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Patient remains intubated on ventilator cpap/ps mode no sedations on,\n propofol off from 6pm yesterday. Not waking up much, just opening eyes\n to pain and stimuli, not moving any extremities to stimulation or pain.\n Weak cough.\n Action:\n SICU MD notified, TOF checked 0-1 twitches noted, patient received 15mg\n of vacuronium in the OR and not reversed, OFF all sedation, neuro\n checks q2h. LS clear, o2 sat 99-100%\n Response:\n PERL, opening eyes to painful stimuli and to voice, started moving LE\n with commands, upper extremities not moving still, patient nods\n appropriately.\n Plan:\n Cont to monitor, pulm hygiene.\n Small bowel obstruction (Intestinal obstruction, SBO, including\n intussusception, adhesions)\n Assessment:\n Patient s/p Exp lap bowel resection, NGT with bilious drainage,\n moderate amt. Bowel sounds absent. Patient on TPN, abd softly\n distended, dressing intact & dry.\n Action:\n NGT to LCS with bilious out put.\n Response:\n NG out put moderate, post op dressing intact & dry.\n Plan:\n Cont to monitor, cont with TPN.\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Patient with h/o End stage renal failure on HD, Had HD on last\n Saturday.\n Action:\n Anuric, with elevated Bun and creat, team aware.\n Response:\n BUN : 85 Creat 8.2 with am lab.\n Plan:\n ? HD toady, pt is hemodynamically stable.\n"
},
{
"category": "Nursing",
"chartdate": "2173-07-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 381907,
"text": ".H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n patient remains intubated on ventilator cpap/ps mode no sedations on,\n propofol off from 6pm yesterday. Not waking up much, just opening eyes\n to pain and stimuli, not moving any extremities to stimulation or pain.\n Weak cough.\n Action:\n SICU MD notified, TOF checked 0-1 twiches noted, patient received\n 15mg of vacuronium in the OR and not reversed, OFF all sedation, neuro\n checks q2h. LS clear, o2 sat 99-100%\n Response:\n PERL, opening eyes to painful stimuli, not moving any extremities\n still. LS clear.\n Plan:\n Cont to monitor, pulm hygiene.\n Small bowel obstruction (Intestinal obstruction, SBO, including\n intussusception, adhesions)\n Assessment:\n Patient s/p Exp lap bowel resection, NGT with bilious drainage,\n moderate amt. Bowel sounds absent.\n Action:\n Response:\n Plan:\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2173-07-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 381909,
"text": ".H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n patient remains intubated on ventilator cpap/ps mode no sedations on,\n propofol off from 6pm yesterday. Not waking up much, just opening eyes\n to pain and stimuli, not moving any extremities to stimulation or pain.\n Weak cough.\n Action:\n SICU MD notified, TOF checked 0-1 twiches noted, patient received\n 15mg of vacuronium in the OR and not reversed, OFF all sedation, neuro\n checks q2h. LS clear, o2 sat 99-100%\n Response:\n PERL, opening eyes to painful stimuli and to voice, started moving LE\n with commands, upper extremities not moving still, patient nods\n appropriately.\n Plan:\n Cont to monitor, pulm hygiene.\n Small bowel obstruction (Intestinal obstruction, SBO, including\n intussusception, adhesions)\n Assessment:\n Patient s/p Exp lap bowel resection, NGT with bilious drainage,\n moderate amt. Bowel sounds absent. Patient on TPN, abd softly\n distended, dressing intact & dry.\n Action:\n NGT to LCS with bilious out put.\n Response:\n NG out put moderate\n Plan:\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2173-07-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 382023,
"text": "Small bowel obstruction (Intestinal obstruction, SBO, including\n intussusception, adhesions)\n Assessment:\n Patient\ns abdomen is softly distended, hypoactive BS, NGT to wall\n suction with bilious output.\n Action:\n NGT to LCS with bilious drainage, post op dressing still intact & dry.\n Response:\n NGT drain trending down, still bilious, hypoactive BS.\n Plan:\n NGT to LCS, pain control, cont with TPN.\n Pain control (acute pain, chronic pain)\n Assessment:\n Patient c/o pain with activities, deep breath and cough and turning\n moving.\n Action:\n Medicated with pain med before activities, encouraged deep breath and\n cough.\n Response:\n pain well controlled with pain med, able to deep breath and cough after\n pain med.\n Plan:\n Assess and treat pain, dilaudid is effective for him.\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Patient with h/o ESRD on HD.\n Action:\n Had HD yesterday, 2.3 L removed.\n Response:\n Very minimal UO, BUN & creat still elevated.\n Plan:\n HD per renal team\n"
},
{
"category": "Nursing",
"chartdate": "2173-07-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 382010,
"text": "Small bowel obstruction (Intestinal obstruction, SBO, including\n intussusception, adhesions)\n Assessment:\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2173-07-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 382011,
"text": "Small bowel obstruction (Intestinal obstruction, SBO, including\n intussusception, adhesions)\n Assessment:\n Pateint\ns abdomen is softly distended, hypoactive BS, NGT to wall\n suction with bilious output.\n Action:\n NGT to LCS with bilious drainage, post op dressing still intact & dry.\n Response:\n NGT drain trending down , still bilious, hypoactive BS.\n Plan:\n NGT to LCS, pain control, cont with TPN.\n Pain control (acute pain, chronic pain)\n Assessment:\n Patient c/o pain with activities, deep breath and cough and turning\n moving.\n Action:\n medicated with pain med before activities, encouraged deep breath and\n cough.\n Response:\n pain well controlled with pain med\n Plan:\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2173-07-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 382118,
"text": "Small bowel obstruction (Intestinal obstruction, SBO, including\n intussusception, adhesions)\n Assessment:\n Afebrile. Abd softly distended. Tender w/ turning and activity. BS\n absent. NGT to LCWS w/ scant blilious drng. Abd incision C&D , OTA w/\n staples. Hct 26 this a.m. (no tx). WBC wnl.\n Action:\n Remains NPO except ice chips(O.K.\nd by Dr and swabs. OOB to\n chair w/ assist. I.S. instructed and done. TPN nutrition.\n Response:\n Stable G.I. status w/ expected level of discomfort. Incision healing.\n Tolerated sitting in chair well but transfers are weak. Lungs remain\n congested but oxygenating well on 3L NC O2.\n Plan:\n Cont to monitor abd status. Ice chips in moderation only. Keep NGT\n for now. Cont pulm toilet. Needs P.T. for strengthening. Transfering\n to floor this afternoon.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt A&O, sl lethargic. Incisional pain # mostly w/ movement/turning\n or coughing ; none when not moving. previously controlled w/\n intermittent Dilaudid IVP.\n Action:\n Dilaudid PCA started this a.m. Dose 0.25mg, 6 min lockout, 2.5mg /HR\n max.\n Response:\n Pt has used 1mg Dilaudid since PCA started.\n Plan:\n Cont to assess comfort and LOC on PCA.\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Last HD . 2300ml reportedly removed. Congested upper airway, as\n above.\n Action:\n No HD today. Minimal, clear yellow UO via foley(pt\ns baseline).\n Response:\n BUN/Creat 85/8.2 to 47/5 today.\n Plan:\n Next HD Mon. . Cont pulm toilet.\n ------ Protected Section------\n See Transfer note #1\n ------ Protected Section Error Entered By: , RN on:\n 17:16 ------\n"
},
{
"category": "ECG",
"chartdate": "2173-06-30 00:00:00.000",
"description": "Report",
"row_id": 105571,
"text": "Normal sinus rhythm, rate 77. Left ventricular hypertrophy. Left axis\ndeviation. Possible anteroseptal myocardial infarction of indeterminate age.\nMarked anterolateral and also inferior and lateral repolarization changes\nconsistent with left ventricular hypertrophy and/or ischemia. Compared to the\nprevious tracing of atrial pacing is no longer evident, ventricular\nrate has increased, inferior repolarization changes are new and lateral\nrepolarization changes are much more pronounced.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2173-07-07 00:00:00.000",
"description": "Report",
"row_id": 105567,
"text": "Possible sinus tachycardia with atrial ectopic beats. Ventricular ectopy.\nLeft ventricular hypertrophy with associated ST-T wave changes, although\nischemia or myocardial infarction cannot be excluded. Since the previous\ntracing atrial pacing is no longer present.\n\n"
},
{
"category": "ECG",
"chartdate": "2173-07-03 00:00:00.000",
"description": "Report",
"row_id": 105568,
"text": "Atrially paced rhythm. Left ventricular hypertrophy with secondary\nrepolarization changes. Compared to the previous tracing of \natrially paced rhythm is new.\n\n"
},
{
"category": "ECG",
"chartdate": "2173-07-01 00:00:00.000",
"description": "Report",
"row_id": 105569,
"text": "Supraventricular rhythm with P wave atypical for sinus. Borderline voltage for\nleft ventricular hypertrophy. ST-T wave abnormalities. Since the previous\ntracing of the QRS voltage is less prominent. Ventricular pacing\nartifact is no longer seen. The axis is more inferior. The Q-T interval is\nshorter. Clinical correlation is suggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2173-06-30 00:00:00.000",
"description": "Report",
"row_id": 105570,
"text": "Compared to the previous tracing atrial pacing at a rate of 60 with probable\nfirst degree A-V block has returned. There is also likely ventricular pacing\nwith ventricular fusion beats. Marked generalized non-specific inferolateral\nrepolarization change persists, as does left ventricular hypertrophy.\nTRACING #2\n\n"
},
{
"category": "Respiratory ",
"chartdate": "2173-07-01 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 381880,
"text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 2\n Ideal body weight: 64.4 None\n Ideal tidal volume: 257.6 / 386.4 / 515.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Clear / Thin\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Pt received on AC as noted. Pt taken to OR this afternoon for\n closure of abdomen.\n Assessment of breathing comfort: No claim of dyspnea\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Plan to continue on current settings at this time.\n Reason for continuing current ventilatory support: Plan to wean as\n tolerated toward extubation once pt has awakened from sedations.\n"
},
{
"category": "Respiratory ",
"chartdate": "2173-07-02 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 381992,
"text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 0\n Ideal body weight: 64.4 None\n Ideal tidal volume: 257.6 / 386.4 / 515.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Clear / Thin\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Pt received intubated and on PSV 10/5 as noted. PS weaned to 5. Pt\n tolerated well. RSBI was 30 with a VT 525 and RR 16. Subglottic\n suctioning done prior to extubation. Pt has a positive cuff leak test.\n Pt extubated at 2pm to cool aerosol without incident. Pt desatted to\n 82% at 3:45p and was subsequently placed on HiFlo O2\n sats improved to\n 96-97%.\n"
},
{
"category": "Nursing",
"chartdate": "2173-07-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 381875,
"text": "Pain control (acute pain, chronic pain)\n Assessment:\n Pt sedated on propofol at 25mcg/kg/min. Appears to have pain with\n turning as HR increases and BP increases. Given fentanyl 50 mcg approx\n every 2 hrs. Grimace and VS return to baseline. Pt nodded head in the\n affirmative when asked if he was having pain.\n Action:\n Medicated with fentanyl for pain control\n Response:\n Return to baseline BP and facial grimace stopped.\n Plan:\n Con\nt to monitor for pain, medicate, assess relief.\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Plan was initially to place dialysis cath at bedside today. Pt\ns INR\n elevated and corrected with FFP however, ICU team and Renal decided to\n abort these plans with hopes of pt being able to have HD tomorrow as he\n has been off of pressors for >12 hrs and is not symptomatic of fluid\n overload. Minimal uo via foley catheter. CR 6.0 Good bruit and thrill\n in L arm fistula.\n Action:\n No dialysis today. Pt\ns last dialysis was on Monday.\n Response:\n Minimal uo. BUN 6\n Plan:\n Plan is to reassess pt\ns fluid and electrolyte status overnight so\n that decision can be made when to dialyze. Con\nt to monitor pt\ns urine\n output.\n Small bowel obstruction (Intestinal obstruction, SBO, including\n intussusception, adhesions)\n Assessment:\n NG drainage has slowed down compared to overnight production. So far\n today it has drained ~250 cc. No stool. Bowel sounds are absent. Abd\n remains open and covered with tegaderm from OR yesterday. Pt sent to OR\n today at 1400 to re-explore abd with plans to close abd. Pt is to get\n Jejunostomy feeding tube while in OR. JP\ns to LCS draining ~ 300 cc\n of serosanguinous drainage prior to being sent to OR. Pt to start TPN\n tonight.\n Action:\n NGT and JP\ns are hooked up to LCS. Drainage from both sources are less\n than what was recorded overnight.\n Response:\n Slowing down of NGT and JP drainage.\n Plan:\n Con\nt to monitor and assess NGT and JP ouptut\n"
},
{
"category": "Nursing",
"chartdate": "2173-07-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 381971,
"text": "Pain control (acute pain, chronic pain)\n Assessment:\n Pt mouthing\npain\n while intubated. Pointed to stomach. Given 50 mcg iv\n fentanyl x2 without relief. Pain med changed to dilaudid .5mg iv. This\n worked well for pt for ~3 hrs when he was medicated again with .5mg.\n Pain is incisional and deep.\n Action:\n Medicated with dilaudid .5mg ~ every 3 hrs\n Response:\n Good relief of abdominal pain with dilaudid\n Plan:\n Con\nt to assess for pain, medicate, assess relief. Change frequency of\n dilaudid from 6 hrs to every 2-3 hrs.\n Small bowel obstruction (Intestinal obstruction, SBO, including\n intussusception, adhesions)\n Assessment:\n BS are very hypoactive. NGT draining much less bilious drainage than\n yesterday. No stool. Remains on TPN @41 cc hr.\n Action:\n NGT remains on LCS\n Response:\n NG drainage has been ~20-30 cc hr of bilious drainage.\n Plan:\n Con\nt To assess for abd pain, distention or increase in bilious\n drainage.\n .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Weaned and extubated at 1200. Doing well on 50% face tent . Spont resp\n 16-22. Weak but productive cough. SaO2 on face tent is >97%. Lungs are\n clear in all fields. Sputum prior to extubation had been clear->clear\n white.\n Action:\n Extubated and placed on face tent .\n Response:\n Good SaO2, weak productive cough. Lungs are clear with anterior\n auscultation bilaterally.\n Plan:\n Con\nt pulm toilet. Encourage use of IS, coughing and deep breathing.\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Dialysis , HD done today without incident. L fistula used. Good thrill\n and bruit. Hemostasis on fistula site.\n Action:\n 3 hr HD run by dialysis RN\n Response:\n Removed 2.3 KG\n Plan:\n Con\nt dialysis regime. Check lytes later today.\n Wife in to visit. She is elated that her husband is extubated. She has\n been updated by this RN.\n"
},
{
"category": "Nursing",
"chartdate": "2173-07-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 381985,
"text": "Pain control (acute pain, chronic pain)\n Assessment:\n Pt mouthing\npain\n while intubated. Pointed to stomach. Given 50 mcg iv\n fentanyl x2 without relief. Pain med changed to dilaudid .5mg iv. This\n worked well for pt for ~3 hrs when he was medicated again with .5mg.\n Pain is incisional and deep.\n Action:\n Medicated with dilaudid .5mg ~ every 3 hrs\n Response:\n Good relief of abdominal pain with dilaudid\n Plan:\n Con\nt to assess for pain, medicate, assess relief. Change frequency of\n dilaudid from 6 hrs to every 2-3 hrs.\n Small bowel obstruction (Intestinal obstruction, SBO, including\n intussusception, adhesions)\n Assessment:\n BS are very hypoactive. NGT draining much less bilious drainage than\n yesterday. No stool. Remains on TPN @41 cc hr.\n Action:\n NGT remains on LCS\n Response:\n NG drainage has been ~20-30 cc hr of bilious drainage.\n Plan:\n Con\nt To assess for abd pain, distention or increase in bilious\n drainage.\n .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Weaned and extubated at 1200. Doing well on 50% face tent . Spont resp\n 16-22. Weak but productive cough. SaO2 on face tent is >97%. Lungs are\n clear in all fields. Sputum prior to extubation had been clear->clear\n white.\n Action:\n Extubated and placed on face tent .\n Response:\n Good SaO2, weak productive cough. Lungs are clear with anterior\n auscultation bilaterally.\n Plan:\n Con\nt pulm toilet. Encourage use of IS, coughing and deep breathing.\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Dialysis , HD done today without incident. L fistula used. Good thrill\n and bruit. Hemostasis on fistula site.\n Action:\n 3 hr HD run by dialysis RN\n Response:\n Removed 2.3 KG\n Plan:\n Con\nt dialysis regime. Check lytes later today.\n Wife in to visit. She is elated that her husband is extubated. She has\n been updated by this RN.\n At ~1600, pt\ns SaO2 decreased to 82 with good pleth. Very weak cough\n but productive. NTS for moderate amts of thin white sputum (same that\n was suctioned out of ett when pt intubated.) Pt placed on Hi-Flow at\n 95% and now lowered to 60%.\n NGT output has increased drainage since 3pm. Still bilious.\n"
},
{
"category": "Physician ",
"chartdate": "2173-07-03 00:00:00.000",
"description": "Intensivist Note",
"row_id": 382061,
"text": "SICU\n HPI:\n 78 M with high grade SBO, s/p ex-lap, reduction of SB volvulus,\n enterotomy repair ; abd closure on \n Chief complaint:\n abd pain\n PMHx:\n DM, ESRD on dialysis, HTN, renal cancer, prostate cancer, h/o SBO, h/o\n CVA, a fib/a flutter\n Current medications:\n IV access: Temporary central access (ICU) Location: Left Subclavian,\n Date inserted: Order date: @ 1651 8. Insulin SC (per\n Insulin Flowsheet)\n Sliding Scale Order date: @ 1651\n 2. IV access: Temporary central access (ICU) Location: Left Subclavian,\n Date inserted: Order date: @ 1651 9. Magnesium Sulfate\n IV Sliding Scale Order date: @ 1651\n 3. 1000 mL NS\n Continuous at 10 ml/hr\n KVO Order date: @ 1741 10. MetRONIDAZOLE (FLagyl) 500 mg IV Q12H\n Order date: @ 1651\n 4. Calcium Gluconate IV Sliding Scale Order date: @ 1651 11.\n Pantoprazole 40 mg IV Q24H Order date: @ 1651\n 5. CefePIME 500 mg IV Q24H Order date: @ 1651 12. Sodium\n Chloride 0.9% Flush 10 mL IV PRN line flush\n Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and\n PRN. Order date: @ 1651\n 6. Fentanyl Citrate 25-100 mcg IV Q6H:PRN Sedation\n Give doses every 5 min until sedated. Maintenance target: 3 and\n overbreathing ventilator Order date: @ 1651 13. Sodium Chloride\n 0.9% Flush 10 mL IV PRN line flush\n Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and\n PRN. Order date: @ 1651\n 7. HYDROmorphone (Dilaudid) 0.25-0.5 mg IV Q4H:PRN pain Order date:\n @ 1755 14. Vancomycin 1000 mg IV HD PROTOCOL\n ID Approval will be required for this order in 12 hours.\n Need to dose per level Order date: @ 0809\n 24 Hour Events:\n EXTUBATION - At 02:00 PM\n INVASIVE VENTILATION - STOP 02:00 PM\n extubated\n Post operative day:\n POD#3 - ex lap\n Allergies:\n Cozaar (Oral) (Losartan Potassium)\n pt developed so\n Last dose of Antibiotics:\n Vancomycin - 03:54 PM\n Cefipime - 02:00 PM\n Metronidazole - 04:00 AM\n Infusions:\n Other ICU medications:\n Fentanyl - 11:03 AM\n Pantoprazole (Protonix) - 08:00 PM\n Hydromorphone (Dilaudid) - 12:00 AM\n Other medications:\n Flowsheet Data as of 05:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.1\nC (98.7\n T current: 36.2\nC (97.2\n HR: 83 (60 - 87) bpm\n BP: 128/29(55) {128/29(55) - 194/68(86)} mmHg\n RR: 17 (0 - 26) insp/min\n SPO2: 100%\n Heart rhythm: V Paced\n Wgt (current): 72 kg (admission): 68.5 kg\n Height: 66 Inch\n CVP: 2 (2 - 7) mmHg\n Total In:\n 1,406 mL\n 411 mL\n PO:\n Tube feeding:\n IV Fluid:\n 400 mL\n 158 mL\n Blood products:\n Total out:\n 2,680 mL\n 20 mL\n Urine:\n 30 mL\n 20 mL\n NG:\n 350 mL\n Stool:\n Drains:\n Balance:\n -1,274 mL\n 391 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: Standby\n Vt (Spontaneous): 398 (398 - 461) mL\n PS : 5 cmH2O\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 30\n PIP: 11 cmH2O\n SPO2: 100%\n ABG: 7.31/40/144/28/-5\n Ve: 8.1 L/min\n PaO2 / FiO2: 360\n Physical Examination\n General Appearance: No acute distress\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Bowel sounds present, Tender: around abd incision\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 104 K/uL\n 8.1 g/dL\n 180 mg/dL\n 5.0 mg/dL\n 28 mEq/L\n 3.6 mEq/L\n 47 mg/dL\n 103 mEq/L\n 141 mEq/L\n 25.9 %\n 5.5 K/uL\n [image002.jpg]\n 09:46 PM\n 04:46 AM\n 04:58 AM\n 05:16 PM\n 05:39 PM\n 11:15 PM\n 03:12 AM\n 03:32 AM\n 09:48 AM\n 03:00 AM\n WBC\n 6.3\n 5.5\n 7.7\n 6.7\n 5.5\n Hct\n 28.5\n 25.8\n 29.3\n 28.1\n 25.9\n Plt\n 123\n 100\n 119\n 123\n 104\n Creatinine\n 7.4\n 7.6\n 7.7\n 8.2\n 5.0\n TCO2\n 22\n 28\n 23\n 24\n 21\n Glucose\n 158\n 127\n 173\n 165\n 180\n Other labs: PT / PTT / INR:19.6/36.1/1.8, ALT / AST:14/23, Alk-Phos / T\n bili:55/0.3, Fibrinogen:439 mg/dL, Lactic Acid:3.2 mmol/L, Albumin:2.4\n g/dL, LDH:184 IU/L, Ca:8.8 mg/dL, Mg:2.4 mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n .H/O AIRWAY, INABILITY TO PROTECT (RISK FOR ASPIRATION, ALTERED GAG,\n AIRWAY CLEARANCE, COUGH), PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN),\n RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD), SMALL BOWEL\n OBSTRUCTION (INTESTINAL OBSTRUCTION, SBO, INCLUDING INTUSSUSCEPTION,\n ADHESIONS)\n Assessment and Plan: 78M w/ ESRD, mesenteric volvulus s/p ex-lap,\n reduction of volvulus, enterotomy repair. Extubated yesterday.\n Neurologic: H/o CVA, dilaudid prn pain. Change to PCA\n Cardiovascular: HD stable, h/o Afib/flutter with pacer (A/V). No\n pressors curr. Pacer looks erratic. EP to see.\n Pulmonary: stable on NC, extubated yesterday.\n Gastrointestinal / Abdomen: Mesenteric volvulus s/p ex-lap, reduction,\n enterotomy. NPO w/\n NGT. TPN.\n Nutrition: ESRD. KVO\n Renal: ESRD on HD (MWF). dialysis yesterday. AV fistula L forearm\n Hematology: Taking coumadin for afib at home, daily INR, Keep INR < 2,\n coumadin held for now per surgical team as pt is post op abd surgery.\n Endocrine: DM. RISS\n Infectious Disease: Vanco, cefepime, flagyl for ischemic bowel. f/u AM\n vanco level\n Lines / Tubes / Drains: aline, L subclavian TLC, NGT, JP x 2 wall sxn\n Wounds: abd\n Imaging:\n Fluids:\n Consults: , I\n Billing Diagnosis:\n ICU Care\n Nutrition:\n TPN without Lipids - 06:06 PM 44 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 05:30 PM\n Multi Lumen - 05:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: Floor\n Total time spent:\n"
},
{
"category": "Respiratory ",
"chartdate": "2173-07-01 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 381794,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Comments: Stable on current vent settings. Pt. is returning to o.r.\n later today.\n"
},
{
"category": "Nursing",
"chartdate": "2173-07-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 381887,
"text": "Pain control (acute pain, chronic pain)\n Assessment:\n Pt sedated on propofol at 25mcg/kg/min. Appears to have pain with\n turning as HR increases and BP increases. Given fentanyl 50 mcg approx\n every 2 hrs. Grimace and VS return to baseline. Pt nodded head in the\n affirmative when asked if he was having pain.\n Action:\n Medicated with fentanyl for pain control\n Response:\n Return to baseline BP and facial grimace stopped.\n Plan:\n Con\nt to monitor for pain, medicate, assess relief.\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Plan was initially to place dialysis cath at bedside today. Pt\ns INR\n elevated and corrected with FFP however, ICU team and Renal decided to\n abort these plans with hopes of pt being able to have HD tomorrow as he\n has been off of pressors for >12 hrs and is not symptomatic of fluid\n overload. Minimal uo via foley catheter. CR 6.0 Good bruit and thrill\n in L arm fistula.\n Action:\n No dialysis today. Pt\ns last dialysis was on Monday.\n Response:\n Minimal uo. BUN 6\n Plan:\n Plan is to reassess pt\ns fluid and electrolyte status overnight so\n that decision can be made when to dialyze. Con\nt to monitor pt\ns urine\n output.\n Small bowel obstruction (Intestinal obstruction, SBO, including\n intussusception, adhesions)\n Assessment:\n NG drainage has slowed down compared to overnight production. So far\n today it has drained ~250 cc. No stool. Bowel sounds are absent. Abd\n remains open and covered with tegaderm from OR yesterday. Pt sent to OR\n today at 1400 to re-explore abd with plans to close abd. Pt is to get\n Jejunostomy feeding tube while in OR. JP\ns to LCS draining ~ 300 cc\n of serosanguinous drainage prior to being sent to OR. Pt to start TPN\n tonight.\n Action:\n NGT and JP\ns are hooked up to LCS. Drainage from both sources are less\n than what was recorded overnight.\n Response:\n Slowing down of NGT and JP drainage.\n Plan:\n Con\nt to monitor and assess NGT and JP ouptut\n Returned from OR at 1600 s/p ex-lap and abdominal closure. JP\ns d/ced\n , abd closed. Tolerated well. No feeding jejunostomy tube placed. TPN\n started. Slightly hypertensive post-op. Given 100 mcg fentanyl upon\n return.\n This RN phoned pt\ns wife, on her cell phone. She did not answer\n but this RN left a message that her husband was back in his room ,\n tolerated procedure well and we will attempt to wean pt from\n respirator as tolerated.\n"
},
{
"category": "Nursing",
"chartdate": "2173-06-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 381783,
"text": "CC: nausea, vomiting\nHPI: 78 M presents with 24 hours of nausea, multiple bouts of\nemesis, and abdominal pain. Has thrown up non-stop overnight.\nReports not passing gas today but has had loose stool. Denies\nfevers, chills, or any urinary sypmtoms.\nPMH: DM, ESRD on dialysis, HTN, renal cancer, prostate cancer,\nh/o SBO, h/o CVA, a fib/a flutter\nPSH: pacemaker, cataracts, R. nephrectomy ', b/l orchiectomy\n', LOA ', ORIF R. bimalleolar ankle fracture ', creation L.\nAV graft ', Repair of left arm AV graft pseudoaneurysm ',\nLeft forearm loop arteriovenous graft thrombectomy, venography,\nand venoplasty with coronary dilators ', revision AV graft ',\nThrombectomy and balloon angioplasty of venous outflow stenosis x\n2 in '.\n: coumadin , amiodarone 100', cinacalcet 30', hydralazine\n25\"', metoprolol 25\", nifedipine 30', ranitidine 150\",\nsimvastatin 20', ASA 81, januvia 25\", fosrenol 1000\"'\n Small bowel obstruction (Intestinal obstruction, SBO, including\n intussusception, adhesions)\n Assessment:\n - Received at 1730 from OR post op ex lap today \n - Mechanically ventilated, sedated on propofol at 50mcg/kg/min\n - Required neo and levo throughout OR procedure, but have been\n stopped en-route to SICU\n - Paralyzed in OR, not reversed therefore not moving\n extremities or coughing\n - Pupils 3mm equal non-reactive at this time (pt has also had\n cataract surgery in past)\n - Sbp 170s slowly decreasing over the next hour\n - Sbp decreased to map < 60\n - Currently V paced, pt has a DDIR pacemaker\n - Abdomen is open, two towels and transparent dressing. 2 JPs\n to low wall suction\n - NG to low cont suction\n Action:\n - given 500cc bolus LR at 1900 for hypotension\n - ECG done on arrival\n - Labs sent\n - Continued propofol gtt\n - Chest xray done\n Response:\n - placement of CVL confirmed on chest xray\n - bp responded well to 500cc bolus\n - Lg amts of NG output\n dark bloody\n Plan:\n - R femoral triple lumen to be changed over wire for\n hemodialysis catheter\n - ? possible need for CVVH at some point\n - Continue to monitor bp for hypotension\n - Continue JPs to med wall suction and NG to low cont suction\n - Return to OR tomorrow for evaluation of bowel, possible\n resection, and closure\n - Recheck labs q6h\n"
},
{
"category": "Nursing",
"chartdate": "2173-07-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 382115,
"text": "Small bowel obstruction (Intestinal obstruction, SBO, including\n intussusception, adhesions)\n Assessment:\n Afebrile. Abd softly distended. Tender w/ turning and activity. BS\n absent. NGT to LCWS w/ scant blilious drng. Abd incision C&D , OTA w/\n staples. Hct 26 this a.m. (no tx). WBC wnl.\n Action:\n Remains NPO except ice chips(O.K.\nd by Dr and swabs. OOB to\n chair w/ assist. I.S. instructed and done. TPN nutrition.\n Response:\n Stable G.I. status w/ expected level of discomfort. Incision healing.\n Tolerated sitting in chair well but transfers are weak. Lungs remain\n congested but oxygenating well on 3L NC O2.\n Plan:\n Cont to monitor abd status. Ice chips in moderation only. Keep NGT\n for now. Cont pulm toilet. Needs P.T. for strengthening. Transfering\n to floor this afternoon.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt A&O, sl lethargic. Incisional pain # mostly w/ movement/turning\n or coughing ; none when not moving. previously controlled w/\n intermittent Dilaudid IVP.\n Action:\n Dilaudid PCA started this a.m. Dose 0.25mg, 6 min lockout, 2.5mg /HR\n max.\n Response:\n Pt has used 1mg Dilaudid since PCA started.\n Plan:\n Cont to assess comfort and LOC on PCA.\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Last HD . 2300ml reportedly removed. Congested upper airway, as\n above.\n Action:\n No HD today. Minimal, clear yellow UO via foley(pt\ns baseline).\n Response:\n BUN/Creat 85/8.2 to 47/5 today.\n Plan:\n Next HD Mon. . Cont pulm toilet.\n"
},
{
"category": "Nursing",
"chartdate": "2173-07-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 382116,
"text": "Small bowel obstruction (Intestinal obstruction, SBO, including\n intussusception, adhesions)\n Assessment:\n Afebrile. Abd softly distended. Tender w/ turning and activity. BS\n absent. NGT to LCWS w/ scant blilious drng. Abd incision C&D , OTA w/\n staples. Hct 26 this a.m. (no tx). WBC wnl.\n Action:\n Remains NPO except ice chips(O.K.\nd by Dr and swabs. OOB to\n chair w/ assist. I.S. instructed and done. TPN nutrition.\n Response:\n Stable G.I. status w/ expected level of discomfort. Incision healing.\n Tolerated sitting in chair well but transfers are weak. Lungs remain\n congested but oxygenating well on 3L NC O2.\n Plan:\n Cont to monitor abd status. Ice chips in moderation only. Keep NGT\n for now. Cont pulm toilet. Needs P.T. for strengthening. Transfering\n to floor this afternoon.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt A&O, sl lethargic. Incisional pain # mostly w/ movement/turning\n or coughing ; none when not moving. previously controlled w/\n intermittent Dilaudid IVP.\n Action:\n Dilaudid PCA started this a.m. Dose 0.25mg, 6 min lockout, 2.5mg /HR\n max.\n Response:\n Pt has used 1mg Dilaudid since PCA started.\n Plan:\n Cont to assess comfort and LOC on PCA.\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Last HD . 2300ml reportedly removed. Congested upper airway, as\n above.\n Action:\n No HD today. Minimal, clear yellow UO via foley(pt\ns baseline).\n Response:\n BUN/Creat 85/8.2 to 47/5 today.\n Plan:\n Next HD Mon. . Cont pulm toilet.\n"
},
{
"category": "Nursing",
"chartdate": "2173-07-03 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 382117,
"text": "Small bowel obstruction (Intestinal obstruction, SBO, including\n intussusception, adhesions)\n Assessment:\n Afebrile. Abd softly distended. Tender w/ turning and activity. BS\n absent. NGT to LCWS w/ scant blilious drng. Abd incision C&D , OTA w/\n staples. Hct 26 this a.m. (no tx). WBC wnl.\n Action:\n Remains NPO except ice chips(O.K.\nd by Dr and swabs. OOB to\n chair w/ assist. I.S. instructed and done. TPN nutrition.\n Response:\n Stable G.I. status w/ expected level of discomfort. Incision healing.\n Tolerated sitting in chair well but transfers are weak. Lungs remain\n congested but oxygenating well on 3L NC O2.\n Plan:\n Cont to monitor abd status. Ice chips in moderation only. Keep NGT\n for now. Cont pulm toilet. Needs P.T. for strengthening. Transfering\n to floor this afternoon.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt A&O, sl lethargic. Incisional pain # mostly w/ movement/turning\n or coughing ; none when not moving. previously controlled w/\n intermittent Dilaudid IVP.\n Action:\n Dilaudid PCA started this a.m. Dose 0.25mg, 6 min lockout, 2.5mg /HR\n max.\n Response:\n Pt has used 1mg Dilaudid since PCA started.\n Plan:\n Cont to assess comfort and LOC on PCA.\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Last HD . 2300ml reportedly removed. Congested upper airway, as\n above.\n Action:\n No HD today. Minimal, clear yellow UO via foley(pt\ns baseline).\n Response:\n BUN/Creat 85/8.2 to 47/5 today.\n Plan:\n Next HD Mon. . Cont pulm toilet.\n"
},
{
"category": "Radiology",
"chartdate": "2173-07-12 00:00:00.000",
"description": "CHEST (PRE-OP PA & LAT)",
"row_id": 1090608,
"text": " 8:42 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: OBSTRUCTION\n Admitting Diagnosis: OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with esrd on HD s/p ex lap, reduction of SB volvulus,\n enterotomy repair now preop for avf thrombectomy \n REASON FOR THIS EXAMINATION:\n assess for infiltrate, effusion, pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 78-year-old man with end-stage renal disease on hemodialysis, status\n post exploratory laparotomy with reduction of a small bowel volvulus with\n enterotomy repair, , now with preop for AV fistula thrombectomy.\n Evaluate for infiltrate, effusion or pulmonary edema.\n\n PA AND LATERAL CHEST RADIOGRAPH.\n\n COMPARISON: Chest radiograph, .\n\n FINDINGS: A pacer device overlies the right hemithorax with two pacer leads,\n one in the region of the right atrium and the other in the region of the right\n ventricle, unchanged. Cardiomegaly is stable. There is atherosclerotic\n calcification of the abdominal aorta, which is tortuous but unchanged. Minimal\n retrocardiac opacity has improved with minimal atelectasis at the left base. A\n small right effusion is stable, with improved pulmonary edema. A left-sided\n central line is in unchanged position.\n\n IMPRESSION:\n 1. Small right pleural effusions, stable. Stable cardiomegaly.\n 2. Improved pulmonary edema.\n 3. Improvement in left basilar opacity with minimal bibasilar atelectasis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2173-06-30 00:00:00.000",
"description": "ACUTE ABD SERIES (2-3 VIEWS OF ABD & SGL CHEST VIEW)",
"row_id": 1088570,
"text": " 8:05 AM\n ACUTE ABD SERIES ( VIEWS OF ABD & SGL CHEST VIEW) Clip # \n Reason: ? obstructive BS pattern\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with abdominal pain ? obstruction\n REASON FOR THIS EXAMINATION:\n ? obstructive BS pattern\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMINAL RADIOGRAPH PERFORMED ON .\n\n Comparison is made with a CT abdomen and pelvis performed approximately 40\n minutes earlier.\n\n CLINICAL HISTORY: Abdominal pain, assess for obstruction.\n\n FINDINGS: Supine and upright views of the abdomen as well as left lateral\n decubitus views were provided. Dilated small bowel loops containing air-fluid\n levels are seen concerning for high-grade small-bowel obstruction. Hyperdense\n material in the large bowel may represent residual barium from prior CT. Clips\n are noted in the right hemi-abdomen. There is no free air on left lateral\n decubitus view. Pacer leads are seen in the right heart.\n\n Vascular calcifications are noted in the pelvis. A right femoral venous\n catheter is in place.\n\n IMPRESSION: Findings concerning for high-grade small-bowel obstruction.\n Please refer to CT performed 30 minutes prior for further details.\n\n SESHa\n\n"
},
{
"category": "Radiology",
"chartdate": "2173-06-30 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1088691,
"text": " 6:30 PM\n CHEST PORT. LINE PLACEMENT; -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: rule out PTX\n Admitting Diagnosis: OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with new L subclavian tlc\n REASON FOR THIS EXAMINATION:\n rule out PTX\n ______________________________________________________________________________\n WET READ: JMGw WED 9:43 PM\n left central line in bracheocephalic vein, not yet into SVC. no pneumothorax.\n ETT 6.8cm from , need repositioning. dilated loops of small bowel,\n stable since Ab/pelvis CT earlier today.\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST:\n\n REASON FOR EXAM: New left subclavian catheter\n\n Left subclavian catheter tip is in the left brachiocephalic vein. There is no\n pneumothorax.\n ET tube tip is 6.8 cm above the . The aorta is tortuous. Moderate\n cardiomegaly is stable. Left lower lobe retrocardiac opacity is new, likely\n atelectasis. Extensive pleural plaques are again noted. Right pacemaker\n leads terminate in standard position in the right atrium and right ventricle.\n NG tube tip is in the stomach. Dilated bowel loops are again noted. Stable\n since early in the morning.\n\n"
},
{
"category": "Radiology",
"chartdate": "2173-06-30 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 1088564,
"text": " 7:31 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: ?OBSTRUCTION, PRIOR ABD SURGERY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with prior abd surgery, now with abd distention ? obstrucion\n REASON FOR THIS EXAMINATION:\n ? obstruction\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DLrc WED 11:32 AM\n High grade small bowel obstruction with dilated loops of small bowel up to\n 4.4cm with associated ascites. Two transition points seen in the mid abdomen\n involving proximal and distal jejenum (2:49) likely secondary to large\n adhesions in this area.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient is a 78-year-old male with prior abdominal surgery. Now\n with abdominal distention, obstruction and evaluate for obstruction.\n\n EXAMINATION: CT of the abdomen and pelvis with oral and intravenous contrast.\n\n COMPARISONS: Comparison to CTA of the abdomen from .\n\n TECHNIQUE: Helically acquired axial images were obtained from the lung bases\n to the pubic symphysis after administration of oral and 130 cc of Optiray\n intravenous contrast. Optiray intravenous contrast was hand injected through\n a central femoral venous catheter. Sagittal and coronal reformations were\n obtained.\n\n FINDINGS:\n\n CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST:\n\n There is minimal bilateral dependent atelectasis. The lung bases are\n otherwise clear with no focal pulmonary parenchymal opacities, pleural\n effusions, or pulmonary nodules. The patient is status post dual-lead\n pacemaker device with leads in stable position.\n\n There is a moderate amount of ascites scattered throughout the abdomen with\n perihepatic, and perisplenic fluid, and fluid centered about the mesenteric\n root. There is a small amount of pelvic free fluid.\n\n There are dilated loops of small bowel measuring up to 4.4 cm with an initial\n transition point best seen on (2:50) involving a loop of proximal jejunum, and\n a secondary more distal transition point seen involving a loop of distal\n jejunum also in the region of the mid abdomen best seen on (2:45). This is\n likely secondary to adhesions in this region. There are decompressed loops of\n small and large bowel distal to the second transition point. The overall\n findings described above are most compatible with a high-grade small-bowel\n obstruction secondary to adhesions within the mid abdomen.\n\n The liver, gallbladder, spleen, pancreas, and both adrenal glands are\n (Over)\n\n 7:31 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: ?OBSTRUCTION, PRIOR ABD SURGERY\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n unremarkable. The patient is status post right nephrectomy. There is an\n atrophic in appearance left kidney with multiple low-attenuation lesions\n scattered throughout the kidney that is compatible with patient's known\n history of medical renal disease on hemodialysis. No concerning renal masses\n are seen within the atrophic left native kidney. No mesenteric or\n retroperitoneal lymphadenopathy is identified. There is extensive\n atherosclerotic disease involving the abdominal aorta and all of its major\n branches.\n\n No bowel wall thickening or pneumatosis is identified. No evidence of free\n air.\n\n CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: There is sigmoid diverticulosis\n without evidence of diverticulitis. Note is made of retained high contrast\n fecal matter within the rectum and sigmoid colon. Loops of sigmoid colon are\n decompressed. The bladder, prostate, and seminal vesicles are unremarkable.\n There is a small amount of pelvic free fluid. There is no pelvic or inguinal\n lymphadenopathy. Note is made of a right-sided central venous catheter with\n tip terminating within the right common iliac vein.\n\n BONE WINDOWS: There are multilevel degenerative changes with a vacuum\n phenomenon noted at the level of L5-S1. No suspicious lytic or sclerotic\n lesions are identified.\n\n IMPRESSION: High-grade small-bowel obstruction with dilated loops of small\n bowel measuring up to 4.4 cm. Moderate ascites. Two transition points seen\n in the mid abdomen involving the proximal and distal jejunum best seen on\n (2:49) likely secondary to multiple adhesions in this area.\n\n"
},
{
"category": "Radiology",
"chartdate": "2173-06-30 00:00:00.000",
"description": "FOLLOW-UP,REQUEST BY RAD.",
"row_id": 1088647,
"text": " 1:48 PM\n CHEST (PORTABLE AP); FOLLOW-UP,REQUEST BY RAD. Clip # \n Reason: please eval for overload\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with SBO and increasing work of breathing\n REASON FOR THIS EXAMINATION:\n please eval for overload\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 78-year-old male with small bowel obstruction and increasing work of\n breathing.\n\n A supine portable AP chest radiograph is compared to same day examination\n performed at 8 a.m. There is enlargement of the cardiac silhouette compared\n to the earlier examination. However, the pulmonary vascularity remains\n normal. There are no pleural effusions or pneumothoraces.\n\n IMPRESSION: Increasing size of cardiac silhouette which may suggest mild\n volume overload or patient positioning.\n\n"
},
{
"category": "Radiology",
"chartdate": "2173-07-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1088917,
"text": " 4:11 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval changes, ETT\n Admitting Diagnosis: OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with ESRD, mesenteric volvulus s/p ex-lap, reduction of\n volvulus, enterotomy repair\n REASON FOR THIS EXAMINATION:\n interval changes, ETT\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of the patient with mesenteric volvulus and\n volvulus reduction.\n\n Portable AP chest radiograph was compared to prior study from .\n\n The ET tube tip is approximately 6 cm above the . The NG tube tip is in\n the stomach. There is interval worsening of the left lower lobe atelectasis\n currently with complete opacification of the left retrocardiac opacity. There\n is unchanged normal appearance of the right lung and most of the left upper\n lobe with minimal areas of opacity seen in that area representing known\n calcified pleural plaques. There is no pleural effusion or pneumothorax.\n\n IMPRESSION: Interval progression of left lower lobe atelectasis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2173-07-01 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1088856,
"text": " 3:55 PM\n PORTABLE ABDOMEN Clip # \n Reason: SPONGE COUNT\n Admitting Diagnosis: OBSTRUCTION\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient is a 78-year-old man with small bowel obstruction who\n underwent open abdomen with sponge and suction followed by OR procedure.\n Evaluate for sponge count per surgery protocol.\n\n COMPARISON: Supine and erect abdomen radiographs, .\n\n EXAMINATION: Supine abdominal radiograph.\n\n FINDINGS: No radiographic evidence of foreign body noted on supine abdominal\n radiograph; however, a small portion of the left flank is not included in the\n field of view. Hypodense material is once again noted in the large bowel,\n likely representing residual barium from prior CT. Clips are noted in the\n right hemi-abdomen. Staples are noted extending from the left upper quadrant\n to below the pubic symphysis. Mildly dilated small bowel loops are noted.\n Vascular calcifications are noted in the pelvis.\n\n IMPRESSION: No radiographic evidence of foreign body including sponge is\n noted in the abdomen.\n\n\n\n\n\n\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2173-07-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1089854,
"text": " 7:31 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for acute cardiopulmonary process\n Admitting Diagnosis: OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with shortness of breath\n REASON FOR THIS EXAMINATION:\n Please eval for acute cardiopulmonary process\n ______________________________________________________________________________\n WET READ: AJy WED 10:48 PM\n Lung volumes low. New density in the right perihilar/infrahilar region\n concerning for infectious process. unchanged cardiomegally. small bilateral\n effusions. possible mild volume overload. note is made that the left\n subclavian line projects to the left of midline, though it has followed a more\n traditional course on prior studies.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Shortness of breath.\n\n Comparison is made to prior study from .\n\n Mild to severe cardiomegaly is unchanged. Low lung volumes. Retrocardiac\n opacity has improved with mildly improved atelectasis. Bilateral pleural\n effusions are small. Right transvenous pacemaker leads terminate in standard\n position in the right atrium and right ventricle. The left supraclavicular\n catheter remains in place. There is new fluid overload and right infrahilar\n opacity that could be due to atelectasis. Surgical clips project in the right\n abdomen. Pleural plaques are again noted.\n\n IMPRESSION:\n 1. Small bilateral pleural effusions and new fluid overload.\n\n 2. Improved left lower lobe atelectasis. New right lower lobe opacities\n likely atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2173-06-30 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1088569,
"text": " 8:04 AM\n CHEST (PA & LAT) Clip # \n Reason: ? free air or abdominal process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with abdominal pain\n REASON FOR THIS EXAMINATION:\n ? free air or abdominal process\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 70-year-old male with abdominal pain. Assess for free air.\n\n COMPARISONS: CT and chest radiograph .\n\n PA & LATERAL CHEST: Cardiomediastinal contours including marked tortuosity of\n the descending aorta are stable. A dual lead pacemaker projects over the right\n mid chest as before. Leads are unchanged in position. Blunting of the left\n costophrenic angle, likely a combination of scarring and epicardial fat pad is\n evident. Otherwise, the lungs are clear. Scattered pleural plaques, many of\n which are calcified, are better delineated on the CT of . There is no\n free intra-abdominal air. Surgical clips project over the right upper\n quadrant of the abdomen.\n\n IMPRESSION:\n\n 1) No acute cardiopulmonary process.\n\n 2) No free air.\n\n 3) Evidence of previous asbestos exposure.\n\n"
}
] |
84,938 | 121,430 | 45yoW h/o HTN, DM, CKD, depression p/w status epilepticus in the setting of hypoglycemia and no prior history of seizures. # Seizures - The patient initially presented with recurrent generalized convulsions as well as subsequent lipsmacking concerning the possibility of nonconvulsive status epilepticus. The patient was thought to be initially hypoglycemic at home after taking insulin without eating. She was monitored on LTM cvEEG for four days without evidence of epileptiform discharges or further seizures. Her EEG showed an encephalopathic pattern. She was initially given a fosphenytoin load and continued on fosphenytoin for seizure prevention. She began transition to Keppra due to sedative effect of dilantin on with plan to double Keppra on and stop Dilantin at that timepoint. # Stupor/Coma from Cerebral Leukoencephalopathy - Her MRI (noncontrast) revealed extensive/diffuse subcortical white matter FLAIR hyperintensities suggesting a demyelinating process, toxic-metabolic encephalopathy, or extrapontine myelinolysis. Her Na at the OSH was normal between two admissions, making EPM from rapid hyponatremia correction unlikely. Methylprednisolone (1 gram daily) was started to reduce the cerebral edema, and her level of consciousness gradually improved however patient's family reported as of that patient was still not entirely at baseline. As of recent at home she would get out of bed and dress herself but often not leave her home, would be depressed and could not feed herself. Prednisone was tapered. # Acute Kidney Injury superimposed on Chronic Kidney Disease - Prior to admission, the patient had intermittently required hemodialysis but most recently was told that dialysis probably would not be necessary. Aggressive diuresis with Furosemide was initially attempted but was not successful in maintaining her renal clearance. Renal was consulted and patient received dialysis on . A tunnelled HD line was placed and later removed in the setting of improved GFR and increased urine output. Patient may have to initiate dialysis in the future as an outpatient and should follow-up with renal. # Diabetes - Her sugars were labile on methylprednisolone, was consulted to offer assistance in glycemic management. An insulin sliding scale and long acting were initiated. | Abnormal diastolic septalmotion/position consistent with RV volume overload.AORTA: Normal aortic diameter at the sinus level. Catheter tip was confirmed under fluoroscopy to be in the lower SVC. Inner cannula and nitinol wires were removed. FINDINGS: In comparison with the study of , the endotracheal tube has been removed. There is mildpulmonary artery systolic hypertension. Major intracranial flow voids are preserved. IMPRESSION: Removal of right internal jugular tunneled hemodialysis catheter. No PS.Physiologic PR.PERICARDIUM: Very small pericardial effusion.Conclusions:The left atrium is mildly dilated. The uterus grossly appears within normal limits. There is abnormal diastolic septal motion/positionconsistent with right ventricular volume overload. Mildly dilated rightventricular cavity with preserved regional and global systolic functino. Right lower lobe consolidation has slightly progressed, with complete silhouetting of the right hemidiaphragm. The right ventricular cavity is mildly dilated [Intrinsic rightventricular systolic function is likely more depressed given the severity oftricuspid regurgitation.] intracerebral process accounting for unresponsiveness CONTRAINDICATIONS for IV CONTRAST: Cr 2.2 Yes to Choyke questions. TECHNIQUE: Multiplanar, multisequence MRI of the head was obtained per acute seizure protocol.Contrast was not adminstered because of low GFR. CHEST, AP: Endotracheal tube has been placed, with tip at the carina. Mild PA systolichypertension.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. There is a very small pericardialeffusion.IMPRESSION: Mildly thickened tricuspid leaflets with moderate to severetricuspid regurgitation. An ANESTHESIA: Moderate sedation was provided. After additional anesthesia, a small was made in the skin. Mildsymmetric left ventricular hypertrophy with preserved global and regionalsystolic function.CLINICAL IMPLICATIONS:Based on AHA endocarditis prophylaxis recommendations, the echo findingsindicate prophylaxis is NOT recommended. PATIENT/TEST INFORMATION:Indication: Evaluate for tricuspid regurgitationHeight: (in) 66Weight (lb): 187BSA (m2): 1.95 m2BP (mm Hg): 159/75HR (bpm): 66Status: InpatientDate/Time: at 14:09Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Mild LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. GCS 5T in absence of ongoing sedation. The peel-away sheath was removed while the catheter was pushed into the right atrium. Central tunneled line placement requested for hemodialysis. A 0.018 nitinol wire was advanced into the superior vena cava. A sterile dressing was applied. IMPRESSION: AP chest compared to and 18: From its original position at the carina, it appears that the endotracheal tube has been withdrawn more than 8 cm, now ending at least 5 cm above the sternal notch and 9.5 cm above the carina. Sutures were removed, and the catheter was removed with gentle traction in its entirety, maintaining pressure at the venotomy site. A 0.035 J wire was advanced into the right atrium. Cannot assess RA pressure.LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/globalsystolic function (LVEF>55%). Endotracheal tube at carina. Moderate pulmonary edema. Progressive right lower lobe consolidation, likely aspiration, though superinfection cannot be excluded. No resting LVOT gradient.RIGHT VENTRICLE: Mildly dilated RV cavity. Left jugular line ends at the junction of the brachiocephalic veins. The wire and inner cannula were removed and the catheter was passed through the peel-away sheath. Less likely related to mild hypoglycemia as per clinical history. Grossly, the liver, spleen, adrenal glands and pancreas appear within normal limits. REASON FOR THIS EXAMINATION: please remove tunneled HD line FINAL REPORT PROCEDURE: Removal of right internal jugular hemodialysis catheter: . Abdominal and pelvic ascites and widespread anasarca. Right pleural effusion is most likely present. The right-sided tunneled hemodialysis catheter was prepped and draped in usual sterile fashion. The mitral valve appears structurally normalwith trivial mitral regurgitation. A 0.018 wire was advanced through the needle into the IVC. Mild mucosal thickening is seen in bilateral maxillary sinuses. No AR.MITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. There is new discoid atelectasis in the right mid lung. IMPRESSION: Uncomplicated ultrasound and fluoroscopy-guided placement of a 5 French 43 cm double-lumen PICC via the left brachial vein, and with its tip in the lower SVC. Minimally increasing atelectasis at the right lung base. Imaging appearances are nonspecific and the differentials include but are not limited to PRES, toxic metabolic encephalopathy, Osmotic demyelination syndrome, hypoxia. The patient ismechanically ventilated. Mild interstitial pulmonary edema is unchanged. There is generalized anasarca. AP radiograph of the chest was reviewed in comparison to . FINAL REPORT CHEST RADIOGRAPH INDICATION: Diabetes, intubation, new signs of effusion. Hickman catheter tip is at the level of right atrium. Moderate pulmonary edema is present, minimally improved from prior examination. The right neck was prepped and draped in usual sterile fashion. Intubated for airway protection. Intubated for airway protection. Intubated for airway protection. Intubated for airway protection. Evaluate for acute hematoma. Normal ascending aortadiameter.AORTIC VALVE: Normal aortic valve leaflets (3). Under aseptic conditions and son guidance, a micropuncture needle was placed in the left brachial vein. Unchanged moderate cardiomegaly. REASON FOR THIS EXAMINATION: Please evaluate tubes, lines and draines, as well as new signs of effusion, opacification, edema. Persistent interstitial edema. This was (Over) 2:59 PM TUNNELED DIALYSIS LINE PLACEME Clip # Reason: please eval and place a central tunnel line for Hemodialysis Admitting Diagnosis: SEIZURE Type of Port: None FINAL REPORT (Cont) confirmed with fluoroscopy demonstrating the catheter tip in the right atrium. | 15 | [
{
"category": "Radiology",
"chartdate": "2160-02-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1233004,
"text": " 6:25 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval placement NGT\n Admitting Diagnosis: SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45F w DM2, HTN, CKD xfer from OSH w recurrent seizures, persistent AMS of\n unknown etiology. Afebrile. Intubated for airway protection. Now improving w\n GCS 11T w waxing/ mental status.\n REASON FOR THIS EXAMINATION:\n eval placement NGT\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: NG tube placement.\n\n AP radiograph of the chest was reviewed in comparison to .\n\n ET tube tip is 5.5 cm above the carina. The NG tube tip is in the stomach.\n Hickman catheter tip is at the level of right atrium. Heart size and\n mediastinum are unchanged. Mild interstitial pulmonary edema is unchanged.\n Right pleural effusion is most likely present. Right lower lobe opacities\n might reflect area of infection. Overall improving since .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2160-02-27 00:00:00.000",
"description": "CT ABD & PELVIS W/O CONTRAST",
"row_id": 1233734,
"text": " 12:11 PM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: r/o acute bleed\n Admitting Diagnosis: SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 y/o woman with history of poorly controlled DM2, HTN, CKD and depression who\n initially presented comatose following a prolonged seizure from unknown\n etiology now transfered from neurology to medicine on steroids for acute\n disseminated encephalomyelitis now with Hct drop for unknown reason\n REASON FOR THIS EXAMINATION:\n r/o acute bleed\n CONTRAINDICATIONS for IV CONTRAST:\n \n ______________________________________________________________________________\n FINAL REPORT\n STUDY: CT of the abdomen and pelvis without contrast.\n\n INDICATION: 45-year-old female with history of poorly controlled diabetes,\n hypertension, renal insufficiency, presented in comatose condition following\n prolonged seizures from unknown etiology. The patient has history of acute\n disseminated encephalomyelitis and presents with acute hematocrit drop.\n Evaluate for acute hematoma.\n\n COMPARISON: None.\n\n TECHNIQUE: MDCT images of the abdomen and pelvis were obtained from the level\n of the lung bases to the proximal femurs without administration of IV or\n enteric contrast. Multiplanar reconstructions were performed and reviewed.\n\n DOSE REPORT: Total exam DLP: 809.53 mGy-cm.\n\n FINDINGS:\n\n LUNG BASES: There are plate-like atelectases involving the right lower lobe.\n Patchy atelectasis is also seen in the left lower lobe. Small pleural\n effusions are seen bilaterally.\n\n In the abdomen, evaluation of the solid visceral organs and bowel is limited\n due to lack of IV and enteric contrast. Grossly, the liver, spleen, adrenal\n glands and pancreas appear within normal limits. There is no intra- or\n extra-hepatic biliary ductal dilatation.\n\n Focal abnormalities are seen in the kidneys. There is no obvious upper\n abdominal lymphadenopathy.\n\n There is widespread ascites in the abdomen and in the pelvis. There is\n generalized anasarca.\n\n There is no retroperitoneal or pelvic lymphadenopathy. The urinary bladder is\n collapsed with Foley in place. The uterus grossly appears within normal\n limits.\n\n (Over)\n\n 12:11 PM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: r/o acute bleed\n Admitting Diagnosis: SEIZURE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Bridging osseous densities between six and seventh, eighth and ninth ribs on\n the right. There are no acute fractures seen. There are no suspicious\n osteolytic or osteoblastic lesions.\n\n IMPRESSION: No evidence of intra-abdominal or pelvic hematoma.\n\n Abdominal and pelvic ascites and widespread anasarca.\n\n Evaluation of solid visceral organs and bowel is limited due to lack of IV and\n enteric contrast.\n\n"
},
{
"category": "Radiology",
"chartdate": "2160-02-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1232705,
"text": " 7:47 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with DM2, HTN, CKD xfer from OSH w recurrent seizures of\n unknown etiology. Afebrile. Intubated for airway protection. GCS 5T in\n absence of ongoing sedation. On acyclovir for possible viral encephalitis.\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Outside hospital, recurrent seizures. Evaluation for interval\n change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is no relevant\n change. The monitoring and support devices are constant. There are minimally\n increased lung volumes, potentially reflecting improved ventilation or\n increased respiratory pressure. No newly appeared parenchymal opacities. No\n pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2160-02-18 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1232432,
"text": " 10:57 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: line placement, fluid overload in a renal pt\n Admitting Diagnosis: SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman 45F w DM2, HTN, CKD xfer from OSH w recurrent seizures of\n unknown etiology. Intubated for airway protection.\n REASON FOR THIS EXAMINATION:\n line placement, fluid overload in a renal pt\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST ON AT 10:40 A.M.\n\n HISTORY: Recurrent seizures. Intubated for airway protection. Fluid\n overload in renal failure.\n\n IMPRESSION: AP chest compared to and 18:\n\n From its original position at the carina, it appears that the endotracheal\n tube has been withdrawn more than 8 cm, now ending at least 5 cm above the\n sternal notch and 9.5 cm above the carina. It should be advanced 6 cm for\n secured seating. Previous small right pleural effusion, azygous distention\n and predominantly right-sided pulmonary edema have improved. The residual\n abnormality in the right lung could represent early aspiration pneumonia and\n should be followed. Left jugular line ends at the junction of the\n brachiocephalic veins. Moderate cardiomegaly, improved. Nasogastric tube\n passes into the stomach and out of view.\n\n Dr. was paged twice 12:50 and 1:15 with no response. Dr nd I\n discussed the findings and their clinical significance over the telephone at\n 1:30PM.\n\n"
},
{
"category": "Radiology",
"chartdate": "2160-02-24 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1233351,
"text": " 5:18 PM\n CHEST (PA & LAT) Clip # \n Reason: Compare ? infiltrate ? effusion ? chf\n Admitting Diagnosis: SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with diabetes renal failure fluid overload? infiltrate.\n recently extubated now on the floor\n REASON FOR THIS EXAMINATION:\n Compare ? infiltrate ? effusion ? chf\n ______________________________________________________________________________\n WET READ: EHAb SUN 7:07 PM\n Interval extubation. Low lung volumes. Persistent interstitial edema.\n Discussed with Dr. by phone at 7:05 p.m. on .\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Diabetic renal failure, to assess for fluid overload.\n\n FINDINGS:\n\n In comparison with the study of , the endotracheal tube has been removed.\n Little overall change in the appearance of the heart and lungs.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2160-02-29 00:00:00.000",
"description": "REMOVE TUNNELED CENTRAL W/O PORT",
"row_id": 1234053,
"text": " 4:37 PM\n DIALYSIS REMOVE Clip # \n Reason: please remove tunneled HD line\n Admitting Diagnosis: SEIZURE\n ********************************* CPT Codes ********************************\n * REMOVE TUNNELED CENTRAL W/O PO -58 SERVIC BY SAME MD DURING POST OP *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with CKD, stage 4. Nephrology has stated no longer a need for\n dialysis.\n REASON FOR THIS EXAMINATION:\n please remove tunneled HD line\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Removal of right internal jugular hemodialysis catheter: .\n\n INDICATION: 45 year-old woman with chronic kidney disease stage 4. Nephrology\n states that the catheter is no longer needed for dialysis.\n\n RADIOLOGISTS: Dr. (resident) and Dr. \n (fellow). Dr. was the supervising physician.\n\n TECHNIQUE/FINDINGS:\n\n Informed verbal consent was obtained. The right-sided tunneled hemodialysis\n catheter was prepped and draped in usual sterile fashion. Sutures were\n removed, and the catheter was removed with gentle traction in its entirety,\n maintaining pressure at the venotomy site. Manual pressure was maintained at\n the right venotomy site of the internal jugular access for five minutes. Good\n hemostasis was achieved. A sterile dressing was applied. There were no\n immediate complications.\n\n IMPRESSION:\n\n Removal of right internal jugular tunneled hemodialysis catheter.\n\n"
},
{
"category": "Radiology",
"chartdate": "2160-02-24 00:00:00.000",
"description": "MR NEURO SCOUTS ONLY, NO CHARGE",
"row_id": 1233346,
"text": " 4:12 PM\n MR ONLY, NO CHARGE Clip # \n Reason: reassess FLAIR hyperintensities, other pathology\n Admitting Diagnosis: SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with DM2, CKD, HTN p/w several seizures, likely in setting of\n hypoglycemia, then coma\n REASON FOR THIS EXAMINATION:\n reassess FLAIR hyperintensities, other pathology\n CONTRAINDICATIONS for IV CONTRAST:\n renal failure\n\n Yes to Choyke questions.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 45-year-old woman with diabetes, hypertension and end-stage renal\n disease. Complaining of seizures.\n\n COMPARISON: MRI from .\n\n TECHNIQUE: Images of the brain were obtained without contrast.\n\n FINDINGS:\n\n The study is very limited and not diagnostic. Only scout imaging were\n obtained. Patient refused to continue the study despite all efforts from the\n MRI technician's team.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2160-02-17 00:00:00.000",
"description": "MR HEAD W/O CONTRAST",
"row_id": 1232337,
"text": " 2:44 PM\n MR HEAD W/O CONTRAST Clip # \n Reason: ? intracerebral process accounting for unresponsiveness\n Admitting Diagnosis: SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with HTN ,DM with hypoglycemia-induced seizure found down at\n home with unclear period of unresponsiveness\n REASON FOR THIS EXAMINATION:\n ? intracerebral process accounting for unresponsiveness\n CONTRAINDICATIONS for IV CONTRAST:\n Cr 2.2\n\n Yes to Choyke questions.\n ______________________________________________________________________________\n WET READ: YGd MON 1:23 AM\n Striking bilateral diffuse white matter FLAIR signal abnormalities involving\n the supratentorial and infratentorial brain, including the midbrain, with high\n signals on diffusion without definite ADC correlate. Ddx include toxic-\n metabolic syndromes or ischemic anoxic injury although not classic HIE. Less\n likely related to mild hypoglycemia as per clinical history. Also no h/o\n electrolyte abn to extrapontine myelinolysis. Findings too extensive for\n classic PRES. Further correlation to clinical hx needed, and short term f/u\n may be helpful. - x \n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 45-year-old woman with hypertension, diabetes, and\n hyperglycemia-induced seizures.\n\n COMPARISON: Outside hospital CT head .\n\n TECHNIQUE: Multiplanar, multisequence MRI of the head was obtained per acute\n seizure protocol.Contrast was not adminstered because of low GFR.\n\n FINDINGS: There are extensive T2/FLAIR confluent hyperintensities involving\n bilateral white matter in both the supratentorial and infratentorial brain.\n There are few foci of increased signal on the DWI images, with no definite ADC\n correlate in bilateral frontoparietal lobes at the vertex. There is relative\n sparing of the matter. Ventricles and sulci appear age appropriate.\n Major intracranial flow voids are preserved. Visualized orbits and mastoid\n air cells are unremarkable. Mild mucosal thickening is seen in bilateral\n maxillary sinuses.\n\n IMPRESSION: Extensive confluent bilateral diffuse white matter signal\n abnormalities as described above. Imaging appearances are nonspecific and the\n differentials include but are not limited to PRES, toxic metabolic\n encephalopathy, Osmotic demyelination syndrome, hypoxia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2160-02-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1232566,
"text": " 7:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate tubes, lines and draines, as well as new sig\n Admitting Diagnosis: SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with DM2, HTN and HLD presents with tonic-clonic seizures,\n now intubated, off sedation, with continued depressed mental status.\n REASON FOR THIS EXAMINATION:\n Please evaluate tubes, lines and draines, as well as new signs of effusion,\n opacification, edema.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Diabetes, intubation, new signs of effusion.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is no relevant\n change. The monitoring and support devices are constant. Minimally\n increasing atelectasis at the right lung base. Unchanged moderate\n cardiomegaly. No changes in the left lung.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2160-02-28 00:00:00.000",
"description": "PICC W/O PORT",
"row_id": 1233918,
"text": " 5:13 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: eval and place PICC line\n Admitting Diagnosis: SEIZURE\n ********************************* CPT Codes ********************************\n * PICC W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with admission for seizures, MS changes, acute renal failure\n with difficult access. Tunnelled HD line in place\n REASON FOR THIS EXAMINATION:\n eval and place PICC line\n ______________________________________________________________________________\n FINAL REPORT\n PICC PLACEMENT\n\n INDICATION: 45-year-old woman with seizures, mental status change, acute\n renal failure, with difficult access.\n\n OPERATORS: Dr. (fellow) and Dr. (attending\n physician). Dr. was present during the key moments of the procedure.\n\n CONTRAST: None.\n\n SEDATION: None.\n\n PROCEDURE AND FINDINGS: Procedure explained to the patient. A timeout was\n performed as per protocol.\n\n Under aseptic conditions and son guidance, a micropuncture needle was\n placed in the left brachial vein. Son images were obtained prior to\n and following needle placement. A 0.018 wire was advanced through the needle\n into the IVC. After making a small skin incision, needle was exchanged for a\n peel-away sheath. After appropriate measurements and removal of the inner\n cannula, a 5 French 43 cm double-lumen PICC was placed over the wire. Sheath\n was peeled away. Wire was removed. Catheter tip was confirmed under\n fluoroscopy to be in the lower SVC. Ports were aspirated and flushed out.\n Catheter was secured by StatLock. Site was dressed in a sterile manner.\n Patient tolerated the procedure well. No immediate post-procedure\n complications.\n\n IMPRESSION: Uncomplicated ultrasound and fluoroscopy-guided placement of a 5\n French 43 cm double-lumen PICC via the left brachial vein, and with its tip in\n the lower SVC. It is ready for use.\n\n"
},
{
"category": "Echo",
"chartdate": "2160-02-18 00:00:00.000",
"description": "Report",
"row_id": 105126,
"text": "PATIENT/TEST INFORMATION:\nIndication: Evaluate for tricuspid regurgitation\nHeight: (in) 66\nWeight (lb): 187\nBSA (m2): 1.95 m2\nBP (mm Hg): 159/75\nHR (bpm): 66\nStatus: Inpatient\nDate/Time: at 14:09\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. The patient is\nmechanically ventilated. Cannot assess RA pressure.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global\nsystolic function (LVEF>55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. [Intrinsic RV systolic function\nlikely more depressed given the severity of TR]. Abnormal diastolic septal\nmotion/position consistent with RV volume overload.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No mass or\nvegetation on tricuspid valve. Moderate to severe [3+] TR. Mild PA systolic\nhypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: Very small pericardial effusion.\n\nConclusions:\nThe left atrium is mildly dilated. There is mild symmetric left ventricular\nhypertrophy with normal cavity size and regional/global systolic function\n(LVEF>55%). The right ventricular cavity is mildly dilated [Intrinsic right\nventricular systolic function is likely more depressed given the severity of\ntricuspid regurgitation.] There is abnormal diastolic septal motion/position\nconsistent with right ventricular volume overload. The aortic valve leaflets\n(3) appear structurally normal with good leaflet excursion and no aortic\nstenosis or aortic regurgitation. The mitral valve appears structurally normal\nwith trivial mitral regurgitation. There is no mitral valve prolapse. The\ntricuspid valve leaflets are mildly thickened. No discrete vegetations are\nseen. Moderate to severe [3+] tricuspid regurgitation is seen. There is mild\npulmonary artery systolic hypertension. There is a very small pericardial\neffusion.\n\nIMPRESSION: Mildly thickened tricuspid leaflets with moderate to severe\ntricuspid regurgitation. Pulmonary artery hypertension. Mildly dilated right\nventricular cavity with preserved regional and global systolic functino. Mild\nsymmetric left ventricular hypertrophy with preserved global and regional\nsystolic function.\n\nCLINICAL IMPLICATIONS:\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate prophylaxis is NOT recommended. Clinical decisions regarding the need\nfor prophylaxis should be based on clinical and echocardiographic data.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2160-02-20 00:00:00.000",
"description": "TUNNELED W/O PORT",
"row_id": 1232771,
"text": " 2:59 PM\n TUNNELED DIALYSIS LINE PLACEME Clip # \n Reason: please eval and place a central tunnel line for Hemodialysis\n Admitting Diagnosis: SEIZURE\n Type of Port: None\n ********************************* CPT Codes ********************************\n * TUNNELED W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with 45F w DM2, HTN, CKD xfer from OSH w recurrent seizures\n of unknown etiology.\n REASON FOR THIS EXAMINATION:\n please eval and place a central tunnel line for Hemodialysis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient with history of diabetes, hypertension, recurrent\n seizures and chronic kidney failure. Central tunneled line placement\n requested for hemodialysis.\n\n RADIOLOGISTS: Dr. (fellow), Tamuna Chadashvili (resident)\n performed the procedure, which was supervised by Dr. .\n\n An ANESTHESIA: Moderate sedation was provided. Local anesthesia was also\n delivered by 1% lidocaine into the dermis and 1% lidocaine with epinephrine\n into the subcutaneous tissues.\n\n PROCEDURE:\n Possible risks, benefits and complications of the procedure were explained to\n the healthcare proxy, daughter. Subsequently informed consent was\n obtained over the phone, which was witnessed. The patient was transported to\n the angiography suite and placed in the supine position on the imaging table.\n The right neck was prepped and draped in usual sterile fashion. A\n preprocedure huddle and timeout was performed per protocol.\n\n After anesthetizing the skin and subcutaneous tissues, a micropuncture needle\n was inserted into the right internal jugular vein under ultrasound guidance.\n Hard copy ultrasound images were saved for reference. A 0.018 nitinol wire\n was advanced into the superior vena cava. After additional anesthesia, a\n small was made in the skin. Micropuncture needle was exchanged with\n micropuncture sheath. Inner cannula and nitinol wires were removed. A 0.035\n J wire was advanced into the right atrium. Appropriate measurements were made\n for skin incision four fingerbreadths below the venotomy site. The wire was\n then advanced into the IVC.\n\n After additional local anesthesia 1 cm skin incision was made at the origin of\n the subcutaneous tunnel. A 10-French tunneled catheter was passed from the\n incision to the venotomy site with the aid of metal tunneling device.\n Venotomy tract was dilated with 3 and 9 French dilators. A peel-away sheath\n was placed over the wire. The wire and inner cannula were removed and the\n catheter was passed through the peel-away sheath. The peel-away sheath was\n removed while the catheter was pushed into the right atrium. This was\n (Over)\n\n 2:59 PM\n TUNNELED DIALYSIS LINE PLACEME Clip # \n Reason: please eval and place a central tunnel line for Hemodialysis\n Admitting Diagnosis: SEIZURE\n Type of Port: None\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n confirmed with fluoroscopy demonstrating the catheter tip in the right atrium.\n Both lumens withdrew blood and flushed easily. The catheter was secured with\n 4.0 silk sutures. The venotomy site was closed with statlock stitch. Dry\n sterile dressings were applied. No immediate post-procedure complications\n were noted. The patient tolerated the procedure well.\n\n IMPRESSION:\n\n Successful placement of tunneled access catheter through the right internal\n jugular vein approach. The tip is located in the right atrium and the\n catheter is ready for use.\n\n"
},
{
"category": "Radiology",
"chartdate": "2160-02-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1232282,
"text": " 5:12 AM\n CHEST (PORTABLE AP) Clip # \n Reason: {See Clinical Indication Field}\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 45F with s/p intubation for status epilepticusClinical Question: ?tube\n placement\n REASON FOR THIS EXAMINATION:\n {See Clinical Indication Field}\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 45-year-old female post-intubation for status epilepticus,\n evaluate tube placement.\n\n COMPARISON: Outside hospital radiograph from at 20:41.\n\n CHEST, AP: Endotracheal tube has been placed, with tip at the carina. A\n nasogastric tube coils in the stomach. Moderate pulmonary edema is present,\n minimally improved from prior examination. There is new discoid atelectasis\n in the right mid lung. Right lower lobe consolidation has slightly\n progressed, with complete silhouetting of the right hemidiaphragm. The left\n lung is clear. No significant pneumothorax.\n\n IMPRESSION:\n 1. Endotracheal tube at carina. This was called to Dr. on at\n 6:22 a.m., at which point the ETT had already been retracted.\n 2. Moderate pulmonary edema.\n 3. Progressive right lower lobe consolidation, likely aspiration, though\n superinfection cannot be excluded.\n\n"
},
{
"category": "ECG",
"chartdate": "2160-02-27 00:00:00.000",
"description": "Report",
"row_id": 304528,
"text": "Sinus rhythm. Wandering baseline and baseline artifact. Diffuse low voltage.\nCompared to the previous tracing of the rate has increased. The\nQ-T interval has normalized. Otherwise, no diagnostic interim change.\n\n"
},
{
"category": "ECG",
"chartdate": "2160-02-17 00:00:00.000",
"description": "Report",
"row_id": 304529,
"text": "Sinus rhythm. Prolonged Q-T interval. Non-specific lateral ST-T wave\nabnormalities. No previous tracing available for comparison.\n\n"
}
] |
17,065 | 104,633 | Admitted on and esmolol drip used for tight BP control. Evaluated for possible surgery or stent grafting. CT scanning repeated as well as esophageal evaluation done. Determined not to be a surgical candidate by Dr. . UTI and oral diagnosed and treated with abx. Also diagnosed with mass effect of aneurysm on esophagus as well as aging motility. IV BP meds titrated to oral meds with goal SBP 120's.To follow up with Dr. (GI)to monitor dysphagia. Cleared for discharge to rehab on . | Sinus rhythmAtrial premature complexesOtherwise probably normal ECGSince previous tracing of , atrial ectopy present and T wave changesdecreased ^ in size of previously stable thoracic aneurysm. 12:26 PM CTA CHEST W&W/O C &RECONS; CTA ABD W&W/O C & RECONS Clip # CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST Reason: MMS service to above CTA with attn. + edema noted to lower ext. + pulses to lower ext-easily palpable. The celiac, and superior and inferior mesenteric arteries are supplied by the true lumen which is well opacified. Asymptomatic with hypotension. Palpable DP's bilat.Resp: BS clear, diminished at bases. There are several hypoattenuating (Over) 12:26 PM CTA CHEST W&W/O C &RECONS; CTA ABD W&W/O C & RECONS Clip # CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST Reason: MMS service to above CTA with attn. ^ in aortic dissection on esmolol confusion hemodynamically stableP: follow bp/hr titrate to maintain sbp 100-120 reorient as needed The sigmoid and rectum are within normal limits. The aorta is ectatic. Transferred to for further management.ID: Low grade temp. Stomach, small and large bowel are within normal limits. Remains receiving lopressor po. Distal pulses palpable.Resp: O2 decreased to 2lnp with sats in the upper 90's. PIV intact to LLA.GI/GU: Abd soft + BS, no BM. Plan is for EGD .GU: u/o ~20cc/hr.Endo: SSRI per order.Comfort/Activity: Denies pain. HCT:26.4. Lungs clear and diminished at the bases. Esmolol gtt off. Denies any SOB or difficulty.CV: NSR with ventricular ectopy-4 beat run VT, occasional unifocal PVC. Although there is motion artifact limiting evaluation of the upper abdomen, the pancreas, spleen, and adrenal glands appear normal. Restart esmolol drip as needed. Nitro drip restarted and titrated as needed. The false lumen ends in the proximal right common iliac artery. using esmolol and hydralazine.neuro ;aoo to person and place,perla mae to command, asking appropriate questions,c/o of claustraphobia during ct scan.pt has had intermittent periods of confusion in ccu but appears to be appropriate at this time.pain; has fentanyl patch and received ms ir 15 mgs at 9am prior to transfer to csru denies pain at this time.cvs; tmax 98.2 po nsr 75-85 with iso pvc's bp 160-17/33 on 225 mgs/hr of esmolol and intermittent hydralazine. Some compression of the true lumen at the same level. please see admit note for full details.travelled for torso ct results pending.goal sbp changed from 130-<110. CCU NPN/CSRU BORDER80yo who presented to out lying hospital s/p syncope/fall. bs covered on riss.skin; ecchymotic on arms from blood sticks coccyx intact.soc; family called and will visit later today.a/p continue to maintain systolic bp less than 110offer emotional support to pt and family. INR:1.4. Coronary artery calcifications are noted. Lungs with diminished aeration in bases otherwise clear. The left common iliac is supplied by the true lumen entirely. to Admitting Diagnosis: TYPE B AORTIC DISSECTION Field of view: 36 Contrast: OPTIRAY Amt: 150 FINAL REPORT (Cont) foci bilaterally in the kidneys, the larger ones over a cm, which can be characterized as cysts and are unchanged since the prior MR study. Addendum 3-7pSBP labile, increasing to 140s. Monitor BP w/ increased lopressor dose. Compression boots on hold until ultrasound to R/O DVT. Has periods of confusion and mild agitation. No c/o sobGI: Down for Barium swallow. There is some narrowing of the true lumen at the diaphragmatic inlet, as low as 2.3 x 0.6 cm in axial dimensions. There is bibasilar atelectasis and tiny right effusion, but otherwise the lungs are clear. BP currently stable , below 110. Pedal pulses strong and palpable.RESP: LS clear ant and dim. EGD . 7a-3pneuro: AAOx3, follows commands, moving all extremitesresp: on 2 l np this am, bs+ all lobes & clear, diminished to bases, pt with sm amt bleeding from L nare, nasal prongs dc'd & room air sat stable @ 94-95, non-productive cough, no resp distress notedgi: npo for barrium swollow today, no N/V or stool, may resume diet after test, thin liquids & ground solids, pills may be given whole with purees(per swollow eval )gu: foley patent, clear yellow urine, uo 20-30 cc/hr, no tx NPcv: hr nsr, no ectopy, sbp 100-140, continues on iv ntg @ 0.25-1.0 mic/kg/min, po lopressor, ntg gtt off for short while when pt oob to chair, back on due to sbp 140other: wife called & updated on pt's condition, pt oob to chair with 2 assists, sbp done sitting & standing( sbp 111 sitting, sbp 100 standing, ntg gtt off for both), no c/o painplan: barrium swollow @ 1530 today, increase po lopressor after barrium swollow today, wean ntg to off keeping sbp =/< 120, tx to floor if pt off iv ntg Afebrile. Captopril started. Concern is that the aorta has enlarged. SBP decreasing to 100s. O2 sat 92-97%, pt placed on 2L NC with good effect. First dose at 0200, .Urine amt. Medicated with MsO4 PO for pain. CT at OSH revealed ? There is a type B dissection, as noted previously with the false lumen beginning shortly after the takeoff of the left subclavian artery, about 2 cm more distally. OOB to chair w/ 1 assist and use of walker.A: Attempting ntg gtt wean w/ increase in lopressor.P: NPO after MN for EGD . | 11 | [
{
"category": "ECG",
"chartdate": "2165-06-23 00:00:00.000",
"description": "Report",
"row_id": 171691,
"text": "Sinus rhythm\nAtrial premature complexes\nOtherwise probably normal ECG\nSince previous tracing of , atrial ectopy present and T wave changes\ndecreased\n\n"
},
{
"category": "Radiology",
"chartdate": "2165-06-24 00:00:00.000",
"description": "CT 150CC NONIONIC CONTRAST",
"row_id": 911960,
"text": " 12:26 PM\n CTA CHEST W&W/O C &RECONS; CTA ABD W&W/O C & RECONS Clip # \n CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST\n Reason: MMS service to above CTA with attn. to \n Admitting Diagnosis: TYPE B AORTIC DISSECTION\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with\n REASON FOR THIS EXAMINATION:\n MMS service to above CTA with attn. to \n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 80-year-old man with known type B aortic dissection, who\n presented to an outside hospital with dysphasia. Concern is that the aorta\n has enlarged.\n\n COMPARISONS: . That was an MR of the torso. More recent\n studies are not available.\n\n TECHNIQUE: Axial CT images of the chest, abdomen, and pelvis were obtained in\n the arterial phase of intravenous contrast administration.\n\n CT OF THE CHEST WITH IV CONTRAST: There is no axillary, hilar, or mediastinal\n lymphadenopathy. Coronary artery calcifications are noted. There is a type B\n dissection, as noted previously with the false lumen beginning shortly after\n the takeoff of the left subclavian artery, about 2 cm more distally. The\n aorta is ectatic. At the level of the passage into the abdomen at the\n diaphragmatic hiatus the aorta is overall slightly larger, measuring 6.4 x 4.4\n cm in axial dimensions, compared to 3.6 x 4.9 cm previously. There is some\n narrowing of the true lumen at the diaphragmatic inlet, as low as 2.3 x 0.6 cm\n in axial dimensions. At all levels, there are few calcifications along the\n outer wall of the aorta. The celiac, and superior and inferior mesenteric\n arteries are supplied by the true lumen which is well opacified. The left\n common iliac is supplied by the true lumen entirely. As noted on the prior\n MR, the dissection extends into the proximal right external iliac artery,\n where it appears that the distal arterial distribution for the right leg is\n supplied by the true lumen. The false lumen ends in the proximal right common\n iliac artery. The internal iliac artery on the right is also supplied by the\n true lumen. At the site of the gastroesophageal junction, the axial\n dimensions of the aorta are somewhat larger than before, mostly because of\n expansion of the false lumen since the prior study. At this level, it\n measures 4.3 x 5.4 cm in axial dimensions (series 8, image 86) compared to 3.7\n x 3.2 cm previously.\n\n There is bibasilar atelectasis and tiny right effusion, but otherwise the\n lungs are clear.\n\n CT OF THE ABDOMEN WITH IV CONTRAST: There is contrast in the gallbladder,\n probably from a recent CT. The liver appears normal. Although there is\n motion artifact limiting evaluation of the upper abdomen, the pancreas,\n spleen, and adrenal glands appear normal. There are several hypoattenuating\n (Over)\n\n 12:26 PM\n CTA CHEST W&W/O C &RECONS; CTA ABD W&W/O C & RECONS Clip # \n CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST\n Reason: MMS service to above CTA with attn. to \n Admitting Diagnosis: TYPE B AORTIC DISSECTION\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n foci bilaterally in the kidneys, the larger ones over a cm, which can be\n characterized as cysts and are unchanged since the prior MR study. A few\n subcentimeter bilateral hypoattenuating foci, however, are too small to\n characterize. There is no mesenteric or retroperitoneal lymphadenopathy or\n free air or fluid. Stomach, small and large bowel are within normal limits.\n\n CT OF THE PELVIS WITH IV CONTRAST: There is a Foley catheter in the bladder,\n and a large right diverticulum, which could be due to prior obstruction. The\n prostate and seminal vesicles are unremarkable. The sigmoid and rectum are\n within normal limits. There is a trace free fluid only, but no pelvic or\n mesenteric lymphadenopathy.\n\n BONE WINDOWS: There is very extensive involvement of sclerotic metastatic\n disease, attributed to the history of prostate cancer throughout the\n visualized skeleton.\n\n IMPRESSION:\n 1. Type B aortic dissection extending from the ascending aorta and\n terminating in the right external iliac artery. Its overall structure is\n similar to , but particularly near the diaphragmatic hiatus,\n the overall size of the aorta is somewhat larger, particularly because of\n increased size of the false lumen.\n 2. Some compression of the true lumen at the same level.\n 3. Large bladder diverticulum.\n 4. Very extensive sclerotic metastases.\n\n The findings were discussed with shortly after the study.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-06-26 00:00:00.000",
"description": "Report",
"row_id": 1485718,
"text": "Neuro: alert and oriented x 3, mae, following commands correctly, denies pain only reported that with supper did have a \"upset stomach\" but reported no pain.\n\nCardiac: nsr with occ pvc's did get one time mag for ectopy which helped, want to keep sbp less then 120 has been for most of the shift now slowly climbiing up into 120 range-did have antihypertensives d/c'd yesterday due to orthostatic hypotension, palpible pedial pulses, +3 edema in upper limb extremities, skin warm dry and intact, is afebrile.\n\nResp: on 2 liters nc satting at 96%, lungs are dim in bases bilat.\n\n\nGi/Gu: tolerating po's, abd is soft round and nontender, good bowel sounds, on csru riss, making 20-25/hr of lyte yellow u/o.\n\nPlan: Monitor bp's and ortho bps when oob to chair later today, ? restarting antihypertensives if bp continues to rise, monitor blood sugars and tx as needed, increase activity as tolerates.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-06-26 00:00:00.000",
"description": "Report",
"row_id": 1485719,
"text": "7a-3p\nneuro: AAOx3, follows commands, moving all extremites\n\nresp: on 2 l np this am, bs+ all lobes & clear, diminished to bases, pt with sm amt bleeding from L nare, nasal prongs dc'd & room air sat stable @ 94-95, non-productive cough, no resp distress noted\n\ngi: npo for barrium swollow today, no N/V or stool, may resume diet after test, thin liquids & ground solids, pills may be given whole with purees(per swollow eval )\n\ngu: foley patent, clear yellow urine, uo 20-30 cc/hr, no tx NP\n\ncv: hr nsr, no ectopy, sbp 100-140, continues on iv ntg @ 0.25-1.0 mic/kg/min, po lopressor, ntg gtt off for short while when pt oob to chair, back on due to sbp 140\n\nother: wife called & updated on pt's condition, pt oob to chair with 2 assists, sbp done sitting & standing( sbp 111 sitting, sbp 100 standing, ntg gtt off for both), no c/o pain\n\nplan: barrium swollow @ 1530 today, increase po lopressor after barrium swollow today, wean ntg to off keeping sbp =/< 120, tx to floor if pt off iv ntg\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-06-26 00:00:00.000",
"description": "Report",
"row_id": 1485720,
"text": "CSRU NPN 1500-1900\n\nNeuro: Alert and oriented x 3. Hands shaky bilat.\n\nCV: Received increased dose of 25mg lopressor at 1700. Ntg currently off for SBP in 90's. Palpable DP's bilat.\n\nResp: BS clear, diminished at bases. RA O2 sats 92% or greater. No c/o sob\n\nGI: Down for Barium swallow. Tolerated procedure well. Currently eating dinner without difficulty. Plan is for EGD .\n\nGU: u/o ~20cc/hr.\n\nEndo: SSRI per order.\n\nComfort/Activity: Denies pain. OOB to chair w/ 1 assist and use of walker.\n\nA: Attempting ntg gtt wean w/ increase in lopressor.\n\nP: NPO after MN for EGD . Monitor BP w/ increased lopressor dose. ? transfer to 2 tonight if BP acceptable. EGD .\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-06-24 00:00:00.000",
"description": "Report",
"row_id": 1485715,
"text": "Addendum 3-7p\nSBP labile, increasing to 140s. PA aware, hydralazine order increased, esmolol gtt increased to 300mcg/kg/min per PA . Captopril started. SBP decreasing to 100s. See carevue for details.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-06-25 00:00:00.000",
"description": "Report",
"row_id": 1485716,
"text": "Narrative Note\nNEURO: Awake, alert, oriented x's 2, PERRLA, Confused and restless throughout the night. Medicated with MsO4 PO for pain. Able to move side to side by himself in bed.\n\nCARDIAC: HR 70-80, NSR, PVC's frequent. Repleated with Magnesium times two. Second dose of Mag given after 6 beat run of Vtach. MD is aware. BP currently stable , below 110. Esmolol gtt off. Episode of Hypotension at 0530, unrelated to run of Vtach. Drop in BP seen after PO morphine, 15mg and Hydralazine 20mg IVP at 0400. Fluid Bolus, 500cc NS given with good results. Asymptomatic with hypotension. CA low at 6.0. Awaiting Vasc consult for surgical prognosis. Pedal pulses strong and palpable.\n\nRESP: LS clear ant and dim. at the bases. O2 sats WNL.\n\nGI/GU: Foley cath draining dark, foul smelling urine. Pos. for UTI, started on Levaquin QD, 500mg IVPB. First dose at 0200, .\nUrine amt. decreased, will monitor after U/O following fluid bolus.\n\nSOCIAL: Family has not RN this eve.\n\nPLAN: Mobilize, monitor BP, check pedal pulses. Restart esmolol drip as needed. Await vasc consult for surgical decision.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-06-25 00:00:00.000",
"description": "Report",
"row_id": 1485717,
"text": "nursing note (7a-7p):\n\nneuro: a&ox3 most of the time, can ask some odd questions ? d/t neuro status, MAE's, extremely weak on feet, wife visited & states that patient she has been helping w/his balance/gait for the last 3 weeks or so, she has picked him off the floor 3 times d/t syncopal episodes, wife notes tremors/shaking in hands/arms/face for last few months\n\nresp: UL clear, LL diminished, on 2l/nc w/sats>96%, rr wnl\n\ncv: known aortic aneurysm dissection goal to keep sbp < 110, however, all bp meds dc'd d/t ortho bp (lying flat 99/41, sitting 81/31, standing 65/30), sbp low most of day team wants to see where bp normalizes keep them updated, lytes NOT repleted team aware\n\ngu/gi: passed swallowing test today diet ground solids w/thin liquids, unsuccessful barium swallowing test d/t orthos in IR, multiple issues w/eating which may be resulting in weight loss, ? possible AO aneurysm pressing against GE junction to stomach causing patient not to eat, thrush noted, pills can be given whole w/purees, CA+ meds, possible neuro, foley +UTI receiving levofloxin, +BS w/no BM\n\n\nendo: no coverage needed not DM/not surgical running 80 to 90's\n\nplan/goal: monitor sbp, increase activity as tolerated, monitor neuro status along w/diet\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-06-24 00:00:00.000",
"description": "Report",
"row_id": 1485713,
"text": "CCU NPN/CSRU BORDER\n80yo who presented to out lying hospital s/p syncope/fall. CT at OSH revealed ? ^ in size of previously stable thoracic aneurysm. Transferred to for further management.\nID: Low grade temp. Urine sent for cx due to foul odor.\nCV: Hr 70-80's sr with occ pac. Bp 100-130's on esmolol at 200mcg/kg/min. No c/o cp. Distal pulses palpable.\nResp: O2 decreased to 2lnp with sats in the upper 90's. Lungs with diminished aeration in bases otherwise clear. No sputum/cough.\nGI/GU: Able to take meds, not crushed, with thickened apple juice. No aspiration noted. Other than meds pt is npo until after swallow test for his dysphagia. He has been incontinent multiple times. Urine was sent appeared to be cloudy.\nMS: He is alert and oriented most of the time to person place and year. Has periods of confusion and mild agitation. Stating that we are \"beating around the \"...that he has say and his family does not. Has gotten oob x 1 and found attempting to get oob many times. Reinforced to him that he must stay in bed for his safety. Side rails ^ x 4 with bed alarms off. Slept in small naps.\nA: ? ^ in aortic dissection on esmolol\n confusion\n hemodynamically stable\nP: follow bp/hr titrate to maintain sbp 100-120\n reorient as needed\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-06-24 00:00:00.000",
"description": "Report",
"row_id": 1485714,
"text": "npn 1015-1500;\n\n80 yr old gentleman transferred from ccu-csru for poss intervention and bp control for type b ao aneurysm. please see admit note for full details.\ntravelled for torso ct results pending.\ngoal sbp changed from 130-<110. using esmolol and hydralazine.\n\nneuro ;aoo to person and place,perla mae to command, asking appropriate questions,c/o of claustraphobia during ct scan.pt has had intermittent periods of confusion in ccu but appears to be appropriate at this time.\n\npain; has fentanyl patch and received ms ir 15 mgs at 9am prior to transfer to csru denies pain at this time.\n\ncvs; tmax 98.2 po nsr 75-85 with iso pvc's bp 160-17/33 on 225 mgs/hr of esmolol and intermittent hydralazine. goal bp less than 110 per md.\n\ngu passing mod amounts of cloudy yellow urine via foley c+s sent in ccu.\n\ngi; belly soft pos bs npo 2nd to sp/sw pt has 1 mth history of dysphasia.but is able to swallow pills whole in applesauce. bs covered on riss.\n\nskin; ecchymotic on arms from blood sticks coccyx intact.\n\nsoc; family called and will visit later today.\n\na/p continue to maintain systolic bp less than 110\noffer emotional support to pt and family.\n\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-06-27 00:00:00.000",
"description": "Report",
"row_id": 1485721,
"text": "1900-0700\n\nNeuro: Pt awake, confused for periods of the night becoming agitated and attempting to climb OOB. Pt did not require any meds for confusion-became cooperative and calm. Speech clear. Oriented X2. Follows commands well. MAEs well with equal strength. Pupils equal and reactive. No seizure activity noted.\n\nResp: Pt resp easy and regular. O2 sat 92-97%, pt placed on 2L NC with good effect. RR 22-26. Lungs clear and diminished at the bases. No cough noted. Denies any SOB or difficulty.\n\nCV: NSR with ventricular ectopy-4 beat run VT, occasional unifocal PVC. HR 80s. Remains receiving lopressor po. SBP labile 90-150, goal to keep SBP < 120. Nitro drip restarted and titrated as needed. HO aware, no further meds ordered at time. Transfer to floor postponed at this time. Afebrile. Denies pain. + pulses to lower ext-easily palpable. + edema noted to lower ext. Compression boots on hold until ultrasound to R/O DVT. HCT:26.4. INR:1.4. PIV intact to LLA.\n\nGI/GU: Abd soft + BS, no BM. NPO after midnight for EGD today. Pills crushed without difficulty swallowing. Foley to BDS draining yellow urine, approx 17-287cc/hr.\n\nEndo: RISS\n\nPlan: EGD today, Transfer to floor if BP stablizes.\n"
}
] |
729 | 115,616 | for enterococcal and Serratia bacteremia, multiple deep venous thromboses, severe malnutrition, improving pancreatic pseudocyst, ongoing ischemic colitis, paroxysmal atrial fibrillation, and depression. The patient was transferred to Sanai on at which time she continued to undergo total parenteral nutrition and had fair po intake. She remained afebrile while on Ampicillin for her bacteremia. Over the course of her rehabilitation stay she was noted to have increasing abdominal distention, lower quadrant pain bilaterally and KUB demonstrating persistent ileus. On the day of admission she was noted to be tachycardic in the 120s and irregularly irregular with a systolic blood pressure in the 110s, hematocrit was noted to be 22.9. She received intravenous fluids, Protonix, vitamin K for an INR of 2.6 and was transferred back to the for further evaluation. In the Emergency Department she was afebrile at 99, 100/56, 126, 97%, guaiac positive stool. Nasogastric lavage was positive for small amount of dried blood, received Vancomycin, Levaquin and Flagyl and was transferred to the Intensive Care Unit for further care. PHYSICAL EXAMINATION: Vital signs 99, 110, 108/60, 20, 97% on room air. General, she was awake, alert and oriented times three. HEENT pupils are equal, round and reactive to light and accommodation. Extraocular movements intact. Anicteric. Oral mucosa dry. Neck supple. No lymphadenopathy. Lungs clear to auscultation bilaterally. Cor tachycardic, but regular. Normal S1 and S2. Abdomen soft, mildly distended, nontender, positive bowel sounds. Stool guaiac negative in the Emergency Department. Extremities 2+, anasarca, warm, 2+ dorsalis pedis pulses and radial pulses bilaterally. Neurological Cranial nerves II through XII are intact, 4 out of 5 muscle strength in all four extremities. LABORATORY: White blood cell count 18.1, hematocrit 25, platelets 377, 74 neutrophils, 4 bands, 14 lymphocytes, INR 2.0, arterial blood gas 7.52/39/95 with a lactate of 1.1. Chest x-ray with low lung volumes and no signs of congestive heart failure or pneumonia. KUB with air filled loops of bowel consistent with an ileus. HOSPITAL COURSE: In the Emergency Department the patient received a CTA to rule out pulmonary embolism or aortic enteric fistula or ischemic colitis. The results of this was negative. The patient was admitted to the Intensive Care Unit for further management. She received blood transfusions for her anemia and continued to receive vitamin K for her elevated INR. She was maintained on Vancomycin, Levaquin and Flagyl and infectious disease was consulted. The patient then went into rapid atrial fibrillation with a heart rate in the 150s, blood pressure 110/50. She was started on an Esmolol drip due to her recent hypotension. During this her blood pressure decreased to 47 systolic and the drip was discontinued. Heart rate was maintained in the 90s. She tolerated the low blood pressure well. While in the Intensive Care Unit her PICC line was discontinued and a central line was placed. Blood cultures were performed. GI was consulted for ongoing bleeding and the patient had gastroscopy demonstrating only a hiatal hernia that was reduced with a scope. Sigmoidoscopy to 30 cm revealed the luminary with a possible stricture from old ischemic colitis versus a large diverticulum, status post surgical change. On hospital day number three the patient again went into rapid atrial fibrillation with a blood pressure decreased to 87/44 that responded with normal saline boluses. Also had a short run of supraventricular tachycardia. Right groin ultrasound and right upper extremity ultrasound revealed no evidence of deep venous thrombosis. The patient's blood cultures grew gram positive and gram negative organisms. Later that day the patient went to radiology for gastric graph to better characterize the nature of her stricture. The procedure was complicated by bradycardia to 37 likely a vasa vagal event. The patient then went into supraventricular tachycardia in the 160s, which lasted for less then one minute and spontaneously resolved. On hospital day number four the patient continued to have melanotic stools. She remained tachycardic in the 110s. She also grew out VRE in her blood cultures and was started on Linezolid. A transthoracic echocardiogram was performed on hospital day number five, which demonstrated a large vegetation on the posterior mitral leaflet, normal ejection fraction, 1+ mitral regurgitation. This was highly consistent with endocarditis likely VRE endocarditis given her positive blood cultures. The patient then proceeded to go back into atrial flutter with heart rate in the 160s, blood pressure again decreased to the 80s. The patient complained of a sore chest for several minutes, which resolved after she was treated with Diltiazem. A long discussion with the patient and her family resulted in the patient expressing that she did not wish to have any intensive treatment, but for her to have ventilation, but does not want ventilation or CPR performed if she became worse. Also she did not wish to have a painful procedures performed and would prefer leaning toward comfort care. This was a reasonable decision as the patient continued to have ongoing gastrointestinal bleeding, rapid atrial fibrillation that was difficult to control as well as new enterococcal endocarditis. The patient was transferred to the floor for additional management. On the floor she became minimally responsive. Discussions with the family was then readdressed and the patient's family wished to make the patient CMO. They felt this best represented her wishes. She was made comfort care only. Palliative care was consulted. The patient then passed on hospital day number eight. | Again noted is diffuse subcutaneous edema. There is moderatepulmonary artery systolic hypertension.Conclusions:1. IMPRESSION: There is a short stricture involving the mid sigmoid colon. There has been interval placement of a right-sided IJ CVC with its distal tip located within the inferior right atrium. Mild (1+) mitral regurgitationis seen.TRICUSPID VALVE: Mild tricuspid [1+] regurgitation is seen. IMPRESSION: 1) Bilateral lower lobe infiltrate/atelectasis (right greater than left). At this point there is a narrowing with a short strictured segment of sigmoid. An NG tube is seen with tip in the stomach but proximal port in the esophagus. There is evidence of bilateral lower lobe atelectasis/infiltrate with possible effusions which is unchanged in comparison to the prior exam. Again noted is an IVC filter within the superior vena cava. IMPRESSION: 1) Interval placement of a right-sided IJ CVC with its distal tip within the inferior right atrium. There are residual bilateral pleural effusions, right slightly greater than left. RIGHT LOWER EXTREMITY DOPPLER: scale and Doppler son of the right common femoral, superficial femoral, and popliteal veins were performed. The large bowel loop slightly distends. The central line catheter is low within the right atrium. Regional left ventricular wall motion isnormal.RIGHT VENTRICLE: Right ventricular chamber size and free wall motion arenormal.AORTA: The aortic root is normal in diameter.AORTIC VALVE: The aortic valve leaflets (3) are mildly thickened.MITRAL VALVE: The mitral valve leaflets are mildly thickened. There are bilateral pleural effusions layering. Probable atrial flutterPoor R wave progression - probable normal variantLow QRS voltages in limb leadsNonspecific ST-T wave changesSince previous tracing of the samed date: sinus tachycardia absent There is a nasogastric tube with its distal tip overlying the proximal stomach. A large hiatus hernia is noted. Bilateral pleural effusions. Also noted is interval development of a focal consolidation of the right lower lobe with air bronchograms noted within. Interval improvement of bilateral pleural effusion. There is diffuse demineralization of the osseous structures. There are bilateral pleural effusions. There is moderate pulmonary artery systolic hypertension. Mild (1+) mitralregurgitation is seen.4. Note is made of a right PICC with tip overlying the mid SVC. The contrast passed proximal to the stricture and demonstrated multiple diverticula within the dilated proximal colon. RIGHT UPPER EXTREMITY DOPPLER: scale and Doppler son of the right subclavian vein, right axillary vein, right basilic vein, and right brachial vein were obtained. There is a right-sided PICC line in position with its distal tip located within the mid SVC. Dilated bowel on the right has features of large and small bowel but is likely small intestine. There is a right sided PICC line in position with its distal tip located within the mid SVC. COMPARISON: CT ABDOMEN WITH IV CONTRAST: There is interval improvement of previously noted bilateral pleural effusions. 2) Nasogastric tube in position with its distal tip overlying the proximal stomach. There is bilateral lower lobe infiltrate/atelectasis which is slightly worse when compared with the prior exam. B/P decreased @ 0400- Dr. notified. GI consulted today, colonoscopy deferred at this time d/t stricture in colon.GU - U/O 30-95cc/hr. RIJ TLC pulled back approx. pt with gross anasarca noted. Cont with generalized edema +3 pitting in LE. Started on LIS and 1.5 L of guiac positive bilious secretions removed. 0500-0600: Pt had sm amt of liquidy melena noted new rectal bag applied. Cont with HR 120's-130's Aflutter occ in 140's, BP 90's-low 100's. hypoactive BS ausc. Cont to have hypoactive BS and sm amts of melana. Pt remains NPO, NG on LIS, cont to have bilious secretions from gut, > than yesterday. fine rales ausc @ b/l bases. Baseline artifactAtrial flutter with uncontrolled ventricular response2:1 A-V blockNonspecific ST-T wave changesSince previous tracing of the same date: sinus tachycardia absent Last HCT 36.5, cont to follow. Diltiazem 5mg x 2 IV with resulting HR in 120's-130's Aflutter. Pt's B/P decreased to 84 systolic- Dr. notified- 1L NSS bolus ordered and adm at this time. + VRE, +GNR bacteremia. Lg fld-like sac on R groin-HO aware.ID- Max temp 99.2, cont IVAB. pt did convert to nsr at 0400 and rate had been controlled with out futher rx.Resp: on 4 liter via nc, abg's done in the ew were on the 4 liters,7.52/39/95/33. Con't of care 2200-2400: pt turned back reddened without breakdown. Also repleted w/ 4 gm of Mag sulfate today. PERRLA, bsk. npn 7p-7a(see careview flowsheet)neuro: a/o x3 most of the time; occasionally needs gentle re-orient of place and time; verbalizes needs; non-specific groaning at times;c-v: resting hrt-rate mostly in mid 120's; a coupl times went up to 150s, but spontaneosly resolved with/in a few minutes; EKG obtained, covering resident assesssed; pt w/out new complaints during these episodes; continues to receive abx for endocarditis; continues to have 3+ generalized edema, though appears to be less than 24 hrs ago; weeping serous fluid through scattered tiny skin tears; b/p remains stable this shift, systolic down to mid 90's when has brief episodes of tachycardia to approx 150, otherwise sustolic mostly in 110's; 10p Ht 31, MD aware;resp: continues to have adeq O2 sats of 96-97% on 4 l nc O2; RR 16-24, non-labored; lungs clear upper, diminished lower;g-i: abd dist, firm, hypoactive bwl sounds; very small amt black non-formed stool via fecal incont bag; ngt to low wall sxn, draining very small amts greenish bilious return; remains on q6 hr FS w/ RISS; infreuently needs small amt riss coverage;g-u: voiding via patent foley;skin: hygiene care received, -lotion applied to dry skin areas, prominences;disposition: continue MICU care/management 1) continue to observe closely for s/s hemorrhage (serial Hcts) 2) frquent turning with skin care 3) re-orient 4) observe for for decompensation w/ ST episodes rate >130's 5) check a.m. labs | 30 | [
{
"category": "Radiology",
"chartdate": "2129-12-13 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 779416,
"text": " 6:29 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION\n Reason: Pt with h/o ischemic colitis, AAA repair, please assess for\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman s/p AAA repair p/w bacteremia, elevated alkphos, ggt.\n Enterococcal bacteremia, likely from sigmoid ischemia, but would like to r/o\n infected pancreatic cyst.\n REASON FOR THIS EXAMINATION:\n Pt with h/o ischemic colitis, AAA repair, please assess for ischemia, fistula,\n abscess.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: S/P AAA repair. Elevated GGT and Alkphos.\n\n TECHNIQUE: Helically acquired axial images were obtained from the lung bases\n to the pubic symphysis. 150 cc Optiray was used secondary to patient's\n debilitis.\n\n COMPARISON: \n\n CT ABDOMEN WITH IV CONTRAST: There is interval improvement of previously noted\n bilateral pleural effusions. There are residual bilateral pleural effusions,\n right slightly greater than left. Also noted is interval development of a\n focal consolidation of the right lower lobe with air bronchograms noted\n within. Again noted is diffuse subcutaneous edema.\n\n The liver appears unremarkable, without evidence of intra or extra-hepatic\n biliary ductal dilatation. Again noted high attenuation material within the\n gallbladder, most likely representing gallstones. Also noted is a small amount\n of ascites surrounding the liver as well as the spleen. The spleen appears\n unremarkable. A large hiatus hernia is noted. Again noted is a cystic\n structure within the tail of the pancreas, not significantly changed in size\n when compared with the prior study which measured 5.0 x 4.9 cm. There is no\n significant enhancement noted. Again noted is an IVC filter within the\n superior vena cava. The patient is s/p repair of AAA. There is no\n significantly dilated small bowel loops. The large bowel loop slightly\n distends. There has been interval improvement of previously reported distal\n sigmoid wall thickening, with minimal residual inflammatory change noted in\n the surrounding fat. There is no evidence of obstruction.\n\n The kidneys excrete contrast bilaterally and symmetrically.\n\n CT PELVIS WITH IV CONTRAST: Again noted is a right sided fluid collection in\n the groin, currently measuring 5.1 x 4.1 cm, slightly increased in size when\n compared to the prior study which measured 4.0 x 3.6 cm. There is some free\n fluid noted in the pelvis which is stable from the prior exam. A Foley\n catheter is again noted within the bladder and there is mild wall thickening\n of the urinary bladder.\n\n (Over)\n\n 6:29 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION\n Reason: Pt with h/o ischemic colitis, AAA repair, please assess for\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Bone windows demonstrate no evidence of suspicious lytic or blastic lesions.\n\n IMPRESSION:\n\n 1. Interval improvement of bilateral pleural effusion.\n 2. Interval development of a right lower lobe focal consolidation, infectious\n etiology should be considered.\n 3. There is no significant change in size of the large pancreatic tail cyst,\n without enhancement.\n 4. There is a small amount of ascites surrounding the liver and the spleen.\n Small amount of free fluid is noted in the pelvis.\n 5. Significant improvement of the distal sigmoid wall thickening, with\n residual inflammatory change noted in the distal sigmoid.\n 6. Cholelithiasis without evidence of cholecystitis.\n 7. Mild wall thickening of the urinary bladder.\n\n"
},
{
"category": "Radiology",
"chartdate": "2129-12-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 779501,
"text": " 6:19 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ?Central line placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with ?PNA, +B.C., hypotension, s/p R IJ placement\n REASON FOR THIS EXAMINATION:\n ?Central line placement\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP bedside chest radiograph.\n\n INDICATION: 63 year old female with pneumonia and hypotension status post\n right IJ line placement. Check line placement.\n\n FINDINGS: Comparison is made to a prior study performed on the same day.\n\n There has been interval placement of a right-sided IJ CVC with its distal tip\n located within the inferior right atrium. There is a right-sided PICC line in\n position with its distal tip located within the mid SVC. There is no evidence\n of pneumothorax. There is a nasogastric tube in position with its distal tip\n overlying the mid stomach. The proximal opening of this nasogastric tube\n overlies the gastroesophageal junction. The heart and mediastinal contours\n are stable when compared to the prior exam. There is evidence of bilateral\n lower lobe atelectasis/infiltrate with possible effusions which is unchanged\n in comparison to the prior exam. The soft tissues and osseous structures are\n unremarkable.\n\n IMPRESSION:\n\n 1) Interval placement of a right-sided IJ CVC with its distal tip within the\n inferior right atrium. This cvc should be adjusted. No evidence of\n pneumothorax.\n\n 2) Nasogastric tube in position with its distal tip overlying the mid stomach.\n The proximal opening of this nasogastric tube overlies the gastroesophageal\n junction. This tube should be advanced.\n\n 3) Otherwise, stable exam when compared to a similar exam of the same day.\n\n"
},
{
"category": "Radiology",
"chartdate": "2129-12-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 779481,
"text": " 1:25 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for CHF, PNA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with ?PNA, +B.C., CHF on P.E.\n REASON FOR THIS EXAMINATION:\n eval for CHF, PNA\n ______________________________________________________________________________\n FINAL REPORT\n AP BEDSIDE CHEST RADIOGRAPH\n\n INDICATION: 63 year old female with pneumonia and positive blood cultures.\n Evaluate for CHF or pneumonia.\n\n FINDINGS: Comparison is made to a prior radiograph from .\n\n The heart size and mediastinal contours are stable. There is a right sided\n PICC line in position with its distal tip located within the mid SVC. There\n is a nasogastric tube with its distal tip overlying the proximal stomach. The\n proximal opening of this nasogastric tube is located within the esophagus.\n There is bilateral lower lobe infiltrate/atelectasis which is slightly worse\n when compared with the prior exam. This infiltrate/atelectasis is most\n prominent within the right lung base. The pulmonary vascularity is normal.\n There is no pneumothorax. There are no large pleural effusions. The soft\n tissues and osseous structures are unremarkable.\n\n IMPRESSION: 1) Bilateral lower lobe infiltrate/atelectasis (right greater than\n left). This finding is slightly worse when compared to the prior days study.\n\n 2) Nasogastric tube in position with its distal tip overlying the proximal\n stomach. The proximal opening of this nasogastric tube is located within the\n esophagus and this nasogastric tube should be advanced.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2129-12-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 779566,
"text": " 10:45 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?PNA, ? line place,emt\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with ?PNA, +B.C., hypotension, s/p R IJ placement\n\n REASON FOR THIS EXAMINATION:\n ?PNA, ? line place,emt\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: ? pneumonia, hypertension.\n\n FINDINGS: Single view of the chest from . The NG tube tip is just\n below the diaphragm. The side port is within the lower chest. There are\n bilateral pleural effusions. There is persistent opacification in the left\n retrocardiac region, as well as the right lung base. Additionally, there is\n diffuse increased interstitial opacities bilaterally. No pneumothorax is\n seen. This may represent superimposed congestive heart failure. The central\n line catheter is low within the right atrium.\n\n IMPRESSION:\n\n 1. NG tube and PA catheter are not in satisfactory positions.\n\n 2. Bilateral pleural effusions. Bibasilar areas of consolidation. This may\n represent aspiration or pneumonia.\n\n 3. There has been increased interstitial markings, which may represent\n superimposed CHF.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2129-12-15 00:00:00.000",
"description": "COLON (GASTROGRAF)",
"row_id": 779568,
"text": " 2:09 PM\n COLON (GASTROGRAF) Clip # \n Reason: Please define anatomy of sigmoid colon.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with GI bleed, bacteremia, stricture found at ~25cm on\n colonoscopy\n REASON FOR THIS EXAMINATION:\n Please define anatomy of sigmoid colon.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: GI bleed. Stricture found at approximately 25 cm on colonoscopy.\n\n A limited single contrast barium enema was performed using ionic contrast. The\n study was stopped when the patient had bradycardia.\n\n FINDINGS: Contrast was introduced per rectum and flowed freely into the\n distal sigmoid colon. At this point there is a narrowing with a short\n strictured segment of sigmoid. The contrast extended beyond the narrowing\n into the more proximal sigmoid. At this point the patient experienced\n bradycardia and the rectal catheter was removed and the patient evacuated the\n barium from the distal sigmoid and rectum. Additional images in the AP\n projection were obtained demonstrating multiple diverticula within the\n descending colon. Note is made of air filled loops of small bowel.\n\n IMPRESSION: There is a short stricture involving the mid sigmoid colon. The\n contrast passed proximal to the stricture and demonstrated multiple\n diverticula within the dilated proximal colon. This stricture may be due to\n chronic inflammation from diverticulitis, fibrotic change as a result of\n ischemia or neoplasm.\n\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2129-12-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 779655,
"text": " 9:45 AM\n CHEST (PORTABLE AP) Clip # \n Reason: follow PNA, CHF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with ?PNA, +B.C., hypotension, s/p R IJ placement\n\n REASON FOR THIS EXAMINATION:\n follow PNA, CHF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: ? of pneumonia s/p central line placement.\n\n FINDINGS: Single frontal view of the chest with comparison to . The NG\n tube is in the stomach. The side port is above the gastroesophageal junction\n as before. The right internal jugular approach central line catheter tip is\n likely just beyond the junction of the superior vena cava and right atrium.\n There are bilateral pleural effusions layering. Additionally, there are patchy\n areas of opacification bilaterally. There is additional increased perihilar\n haziness and vascular indistinctness which may represent superimposed\n congestive heart failure.\n\n IMPRESSION: 1) Compared with the prior study, there has been interval\n worsening patchy areas of opacification particularly in the perihilar region.\n This may represent worsening congestive heart failure. Superimposed infectious\n process cannot be excluded on this chest radiograph. 2) There are bilateral\n layering pleural effusions not significantly changed. 3) The NG tube remains\n high as before.\n\n"
},
{
"category": "Radiology",
"chartdate": "2129-12-16 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 779656,
"text": " 9:45 AM\n PORTABLE ABDOMEN Clip # \n Reason: follow ileus\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with bacteremia, PNA, ileus on admission. Still with\n persistent abd fullness\n REASON FOR THIS EXAMINATION:\n follow ileus\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Persistent abdominal distension.\n\n There are multiple mild to moderately gas-distended loops of small bowel with\n gas present in the colon, essentially unchanged since the prior study of\n . No undue distension of the cecum. SAn IVC filter is present at the\n L2/3 level and there are surgical clips in the mid and left abdomen.\n\n IMPRESSION: No significant change since prior study of . Persistent\n gas-distended loops of small bowel with gas in the colon, consistent with\n ileus, but correlate clinically.\n\n"
},
{
"category": "Radiology",
"chartdate": "2129-12-14 00:00:00.000",
"description": "P UNILAT UP EXT VEINS US PORT",
"row_id": 779517,
"text": " 9:02 PM\n UNILAT UP EXT VEINS US PORT Clip # \n Reason: ?DVT R arm\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with GI bleed, h/o DVT, PICC line recently pulled, h/o\n clotted IJs\n REASON FOR THIS EXAMINATION:\n ?DVT R arm\n ______________________________________________________________________________\n WET READ: ZLb WED 11:48 PM\n neg\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Right arm swelling.\n\n RIGHT UPPER EXTREMITY DOPPLER: scale and Doppler son of the right\n subclavian vein, right axillary vein, right basilic vein, and right brachial\n vein were obtained. Normal flow, augmentation, compressibility, and wave\n forms are demonstrated. Intraluminal thrombus is not identified.\n\n IMPRESSION: No evidence of DVT.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2129-12-14 00:00:00.000",
"description": "RP UNILAT LOWER EXT VEINS RIGHT PORT",
"row_id": 779518,
"text": " 9:03 PM\n UNILAT LOWER EXT VEINS RIGHT PORT Clip # \n Reason: ?DVT R groin\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with GI bleed, h/o DVT, groin mass\n REASON FOR THIS EXAMINATION:\n ?DVT R groin\n ______________________________________________________________________________\n WET READ: ZLb WED 11:48 PM\n no dvt\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Right groin mass.\n\n RIGHT LOWER EXTREMITY DOPPLER: scale and Doppler son of the right\n common femoral, superficial femoral, and popliteal veins were performed.\n Normal flow, augmentation, compressibility, and wave forms are demonstrated.\n Intraluminal thrombus is not identified. There is a large hematoma noted in\n the right groin.\n\n IMPRESSION: No evidence of DVT.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2129-12-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 779398,
"text": " 2:34 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Pt with fever, elevated wbc, please assess\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman see above.\n REASON FOR THIS EXAMINATION:\n Pt with fever, elevated wbc, please assess\n ______________________________________________________________________________\n FINAL REPORT\n Portable chest radiograph from at 1545.\n\n INDICATION: Fever elevated white count.\n\n Comparison is made to .\n\n FINDINGS: The lung volumes are low. There is bibasilar atelectasis, likely\n related to the low volumes. The heart size is normal. There may be a small\n left sided pleural effusion. There are no consolidations with air bronchograms\n to suggest pneumonia. Note is made of a right PICC with tip overlying the mid\n SVC. There is no pneumothorax. An NG tube is seen with tip in the stomach but\n proximal port in the esophagus.\n\n IMPRESSION: 1. Low lung volumes likely relates to basilar atelectasis versus\n crowding. 2. No definite pneumonia. 3. No CHF.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2129-12-13 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 779399,
"text": " 2:34 PM\n PORTABLE ABDOMEN Clip # \n Reason: Pt with fever, elevated wbc, h/o ischemic colitis, please r/\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman see above.\n REASON FOR THIS EXAMINATION:\n Pt with fever, elevated wbc, h/o ischemic colitis, please r/o free air,\n obstruction.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Portable chest radiograph from at 15:45.\n\n INDICATION: Fever and elevated white count.\n\n FINDINGS: There are multiple dilated loops of bowel. Dilated bowel on the\n right has features of large and small bowel but is likely small intestine. Air\n is seen within the rectum. Multiple surgical clips are seen along the left\n paraspinal region. There is no free air or pneumatosis. A metallic cage\n device that appears to be an IVC filter is seen overlying the spine. There is\n diffuse demineralization of the osseous structures.\n\n IMPRESSION:\n\n Air-filled dilated loops of bowel. Most is small intestine but some is likely\n also colon. This is a nonspecific pattern. There is no obvious obstruction.\n There is no obvious wall thickening on the radiograph though this does not\n exclude ischemic colitis.\n\n"
},
{
"category": "Echo",
"chartdate": "2129-12-16 00:00:00.000",
"description": "Report",
"row_id": 74064,
"text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis.\nHeight: (in) 65\nWeight (lb): 134\nBSA (m2): 1.67 m2\nBP (mm Hg): 111/58\nHR (bpm): 114\nStatus: Inpatient\nDate/Time: at 12:15\nTest: Portable TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is normal in size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.\n\nLEFT VENTRICLE: Left ventricular wall thickness, cavity size, and systolic\nfunction are normal (LVEF>55%). Regional left ventricular wall motion is\nnormal.\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTA: The aortic root is normal in diameter.\n\nAORTIC VALVE: The aortic valve leaflets (3) are mildly thickened.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is a\nmoderate-sized vegetation on the mitral valve. Mild (1+) mitral regurgitation\nis seen.\n\nTRICUSPID VALVE: Mild tricuspid [1+] regurgitation is seen. There is moderate\npulmonary artery systolic hypertension.\n\nConclusions:\n1. Left ventricular wall thickness, cavity size, and systolic function are\nnormal (LVEF>55%). Regional left ventricular wall motion is normal.\n2. The aortic valve leaflets (3) are mildly thickened.\n3. The mitral valve leaflets are mildly thickened. There is a moderate-sized\nvegetation on the posterior leaflet of the mitral valve. Mild (1+) mitral\nregurgitation is seen.\n4. There is moderate pulmonary artery systolic hypertension.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2129-12-17 00:00:00.000",
"description": "Report",
"row_id": 170177,
"text": "Atrial flutter with rapid ventricular response\nLow QRS voltages in limb leads\nNonspecific ST-T wave changes\nSince previous tracing of the same date: ventricular rate slower\n\n"
},
{
"category": "ECG",
"chartdate": "2129-12-17 00:00:00.000",
"description": "Report",
"row_id": 170178,
"text": "Probable atrial flutter\nPoor R wave progression - probable normal variant\nLow QRS voltages in limb leads\nNonspecific ST-T wave changes\nSince previous tracing of the samed date: sinus tachycardia absent\n\n"
},
{
"category": "ECG",
"chartdate": "2129-12-17 00:00:00.000",
"description": "Report",
"row_id": 170179,
"text": "Sinus tachycardia\nAtrial premature complexes\nLow QRS voltages in limb leads\nModest nonspecific ST-T wave changes\nSince previous tracing of : correct lead placement\n\n"
},
{
"category": "ECG",
"chartdate": "2129-12-16 00:00:00.000",
"description": "Report",
"row_id": 170406,
"text": "Probable sinus tachycardia\n*** arm lead reversal ***\nLow limb lead voltage\nNonspecific ST-T wave changes\nSince previous tracing of the same date: arm leads reversed and rate faster\n\n"
},
{
"category": "ECG",
"chartdate": "2129-12-16 00:00:00.000",
"description": "Report",
"row_id": 170407,
"text": "Sinus tachycardia. Since the previous tracing of the rhythm is clearly\nsinus and the rate has slowed. No other changes have occurred.\n\n"
},
{
"category": "ECG",
"chartdate": "2129-12-13 00:00:00.000",
"description": "Report",
"row_id": 170408,
"text": "Baseline artifact\nAtrial flutter with uncontrolled ventricular response\n2:1 A-V block\nNonspecific ST-T wave changes\nSince previous tracing of the same date: sinus tachycardia absent\n\n"
},
{
"category": "ECG",
"chartdate": "2129-12-13 00:00:00.000",
"description": "Report",
"row_id": 170409,
"text": "Sinus tachycardia\nLateral ST-T changes are nonspecific - clinical correlation is suggested\nSince previous tracing of : ST-T wave abnormalities decreased\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-12-16 00:00:00.000",
"description": "Report",
"row_id": 1270470,
"text": "7p-7a addendum:\n\nlabs: 05:00 hct 33.8, up from 8 hr previous of 31.6.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-12-16 00:00:00.000",
"description": "Report",
"row_id": 1270471,
"text": "MICU nursing progress note 7A-7P\nNeuro - , pt was confused to place this AM. Reoriented, pt has been appropriate. Anxious, all care explained to decrease anxiety. Pt gets more anxious with any turning or bedside care, c/o pain with any movement. Moves arms, assists with turning.\n\nCV - BP 113-124/50-72. MAPs 75-85. HR 110's initially increasing to 130 ST by afternoon, occ PVC's. Short burst HR 140's. CVP 5-9. Fluid bolus 500cc x 2 for ? dehydration. Cont with generalized edema +3 pitting in LE. Pt had TTE which showed endocarditis on mitral valve. Pt to cont current antibx regime. Hct stable at 34. Recheck Hct 2100 with Vanco level.\n\nResp - Lungs essentially clear in upper lobes, occ coarse but clear with expectoration of thick pale yellow secretions. Diminished at bases. Sats high 90's. RR teens - low 20's.\n\nGI - Abd firm, distended. +BS. NGT to LCS, draining dark green bile~60cc this shift. NPO. Pt on TPN. Rectal bag intact, no new stool in bag. GI consulted today, colonoscopy deferred at this time d/t stricture in colon.\n\nGU - U/O 30-95cc/hr. clear yellow urine.\n\nID - T max 100. + VRE, +GNR bacteremia. Endocarditis. On multiple antibx.\n\nSocial - Family in to visit, spoke with Dr . All questions answered.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-12-17 00:00:00.000",
"description": "Report",
"row_id": 1270472,
"text": "npn 7p-7a\n\n(see careview flowsheet)\n\nneuro: a/o x3 most of the time; occasionally needs gentle re-orient of place and time; verbalizes needs; non-specific groaning at times;\n\nc-v: resting hrt-rate mostly in mid 120's; a coupl times went up to 150s, but spontaneosly resolved with/in a few minutes; EKG obtained, covering resident assesssed; pt w/out new complaints during these episodes; continues to receive abx for endocarditis; continues to have 3+ generalized edema, though appears to be less than 24 hrs ago; weeping serous fluid through scattered tiny skin tears;\n b/p remains stable this shift, systolic down to mid 90's when has brief episodes of tachycardia to approx 150, otherwise sustolic mostly in 110's;\n 10p Ht 31, MD aware;\n\nresp: continues to have adeq O2 sats of 96-97% on 4 l nc O2; RR 16-24, non-labored; lungs clear upper, diminished lower;\n\ng-i: abd dist, firm, hypoactive bwl sounds; very small amt black non-formed stool via fecal incont bag; ngt to low wall sxn, draining very small amts greenish bilious return;\n remains on q6 hr FS w/ RISS; infreuently needs small amt riss coverage;\n\ng-u: voiding via patent foley;\n\nskin: hygiene care received, -lotion applied to dry skin areas, prominences;\n\ndisposition: continue MICU care/management\n 1) continue to observe closely for s/s hemorrhage (serial Hcts)\n 2) frquent turning with skin care\n 3) re-orient\n 4) observe for for decompensation w/ ST episodes rate >130's\n 5) check a.m. labs\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-12-17 00:00:00.000",
"description": "Report",
"row_id": 1270473,
"text": "MICU nursing progress note 7A-7P\n Pt HR ST 100's-120's this morning with BP 100's/40's.Converted to Aflutter (EKG done)rate 160's with correlating drop in BP to 84/40. Pt denied CP/SOB but did admit to family she had heartburn. 2nd EKG showed no ischemia and heartburn self resolved. Diltiazem 5mg x 2 IV with resulting HR in 120's-130's Aflutter. BP remained in 90's. NS bolus 500cc x 2 kept BP in 90's-100, occ down to mid 80's. NS at 125/hr x 1 liter going now. Cont with HR 120's-130's Aflutter occ in 140's, BP 90's-low 100's. Digoxin .5mg IV at 1700, HR has stayed in 120's. Pt due for dig .125 at 2300 and in AM for dig load. Dr discussed code status with pt who does not want to be resuscitated, and called pt's daughter , Health Care Proxy, and decision made to make pt DNR/DNI.\n\nNeuro - Pt is more lethargic today than yesterday, and increasingly weaker this afternoon. Has been A&O all day but now with periods of confusion and calling out. Can move arms but very weak. Sleeping all day. denies pain and is refusing pain med when offered.\n\nCV - As above. Hcts have been stable. Last Hct 30.7. Hct drawn 1700 pending. +3 edema bilat LE and bilat hands, upper arms. Generalized weeping edema requiring frequent linen changes.\n\nResp - Lungs are clear upper lobes, diminished at bases. RR mid 20's. Sats high 90's this AM but pt breathing pattern has become more agonal this afternoon with RR 25-26, Sats down to 88% on 4L, now 92% on 5L NC.\n\nGI - Abd unchanged, firm, distended, hypoactive BS. Rectal bag in place with trace black foul smelling liquid stool. NGT to LCS draining dark green bile. On TPN, FSBS per RISS.\n\nGU - U/O 30-80cc/hr. clear yellow urine. Pt is ~1500cc + today.\n\nID - T max 100. Pt on multiple antibx for VRE, GNR bacteremia, endocarditis.\n\nSkin - Skin tear on right hand covered with DSD is weeping requiring dressing changed QS. Skin is very fragile and eccymotic.\n\nSocial - Family in to visit. Pt is now DNR/DNI per pt and family discussion with Dr .\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-12-15 00:00:00.000",
"description": "Report",
"row_id": 1270468,
"text": "PMICU Nursing Progress Note 7a-7p\nEvents;\n\nPt taken to radiology today for gastrografin enema and imaging of sigmoid. While in radiology, pt appeared to vagal, her HR dropped to 30's for 20 seconds. Procedure was stopped, pt's HR then went to SVTs to 170's..for 2 min. Ho notified and Pt was returned to MICU. Pt VS then returned to baseline during transport to MICU. Stable since return to MICU.\n\nNeuro- AXOX3, answers questions appropriately and follows commands. Occasionally confused when first awakes, returns to baseline with re-orientation. MAE, very weak. Requires a lot of emotional support. PT states that she is \"afraid of dying\".\n\nCV- Hemodynamically stable except for event listed above. HR 110's to 20's, NSR, no ectopy noted. Corrected Ca 8, plan to add more to TPN.\nHCT remains stable at 33, cont to check q 8 hrs. CVP 4-5.\n\nResp- Cont on 4 L NC, sats 96%. Bilateral pleural effusions and consolidation on R base per chest xray. Expectorates green sputum w/ a lot of encouragement, weak cough. Sputum sample sent. Cont w/ pulm toilet.\n\n Pt remains NPO, NG on LIS, cont to have bilious secretions from gut, > than yesterday. Cont to have hypoactive BS and sm amts of melana. Rectal bag in place to protect skin. TPN for nutritional purposes being delivered. Started on SSI, please check BG q 6. Awaiting GI consult.\n\nGU- Improved U/O/hr since yesterday; 40 cc/hr. Yellow, clr, foley patent.\n\nSkin- Placed on first step air mattress, requires q 2 hr turns. Skin extremely fragile, weeping from tears on arms and legs.\n\nID- Afebrile. + for Enterococcus per lab, ID consulted. Also found to have VRE, contact precautions now in place.\n\nPlan - Cont supportive medical care.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-12-16 00:00:00.000",
"description": "Report",
"row_id": 1270469,
"text": "npn 7p-7a:\n\n(see careview flowsheet)\n\nneuro: a/o x3; verbalized resistance to being turned, verbalized \"it hurts me\"; attempted to comfort pt and explain why it was important to turn her and give her skin care;\n\nc-v: heart rate sinus, mostly in 110's at rest, was briefly up to 131 after turning and hygiene cares, returned to 113-115 shortly after; continues to have 3+ generalized edema; 22:30 hct 31.6, MD notified, was 33 previous, and 31.6 earlier in the day; no new orders obtained;\n\nresp: O2 sat 98% on l n.c.; respirations without extra effort, though mildy elevated with cares; lungs with good air movement; clear upper bil, dim lower bases;\n\ng-i: hct as addressed above; continues to receive pantoprazole ; abd remains firm w/ hypoactive bowel sounds; rectal incont bag intact, leaks at times, peri-care received; bag not changed since is new rectal bag; stool black, liquid, foul;\n\ng-u: urine output adequate via patent foley; clear yellow;\n\nskin: generalized redness, very fragile; skin barrier cream applied to back and peri-area;\n\nsocial: asked if husband had to wear \"yellow gown\" when he visits;\nno phone-calls from family overnight;\n\nlabs: a.m. labs pending; need to obtain greet-top tube to send lactate level\n\nacess: left IJ line flushed 10pm, 5am, unable to draw from; all ports patent Rt tpl cvl;\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-12-14 00:00:00.000",
"description": "Report",
"row_id": 1270463,
"text": "nursing admission note 2300-0700\n\nthis is a 63 yo female that was admitted from the ew from rehab facility . Had sx on for a triple a repair and up until then was a very active woman. pt developed post op complications dvt, retroperitoneal bleed, afib, ischemic bowel and PE. Had a green field fitler placed in. Was admitted to in with bacteremia, pancreatic cyst and Gi bleed. She was dx with the aaa, last year and decided to have the sx. had severe malnutrition and anasarca and bilateral p effusions, was placed on tpn and lovenox as well as coumadin for her dvt and pe.\n\nPMH other than the other stated above:\nhiatal hernia, reflux, c diff, smoker for 30 yrs and quit 15 yrs ago.\nhypothyroidism\n\nNeuro: pt awake, alert and oriented x3, pearl, good movement and good strenth in all extremeities.\n\nCVs: arrived to micu with vs wnl hr in the 109-teen, at 2330 went into a raf rate 150-160, asymptmatic. team was at bedside, decided to rx with esmolol. after 12 cc of esmolol, pt's bp dropped from 113 to 47.\nbrevibloc immediately stopped, pt's hr was controlled and after a fluid bolus bp is at present 98/50. pt did convert to nsr at 0400 and rate had been controlled with out futher rx.\n\nResp: on 4 liter via nc, abg's done in the ew were on the 4 liters,\n7.52/39/95/33. bs ess clear, on admission faint crackles heard in left base other wise clear. pt using yankar to sxn mouth, is expectorating yellow, whitish thick secretions, pt states that she does this.\n\nGI/GU: foley to cd, clear to amber colored urine, 40 cc per hr.\nabd firm and ditended with anasarca, hypoactive bs noted, did have a liquid melana stool. team aware. pt was given two units of prbc in the ew, third one up at 0530.\n\nHeme: labs drawn this am, before packed cells. pending. 0200 crit 26\nsee carevue for values.\n\nF/E: afebrile, pan cx in the ew did receive a dose of vanco in the ew and will be on vanco in the micu and received a dose of levofloxacin in the micu awaiting ID approval. as well a flagyl\n\nSkin: multiple bruising and skin is dry. mucus membranes are dry.\narms are swollen.\n\nsocial: daughter no calls over night.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-12-14 00:00:00.000",
"description": "Report",
"row_id": 1270464,
"text": "PMICU Nursing Progress Note 7a-7p\nEvents - PT cont to melana and lg volumes of guiac positive bile per NG (LIS). GI consulted and pt scoped this evening, no obvious bleeding in upper GI tract, ?signs of stricture in sigmoid-difficult to assess even w/ scope since pt had lg amts of melana in bowel. PT also has a R side colon lesion-?need for Ca workup.\n\nReview of Sytems\n\n PT lethargic but consistently able to answer all questions appropriately. Complaints of pn when care delivered, otherwise dosing intermittently over coarse of day. PT expressed fear of dying and displayed a depressed affect, brightens when family members present. a lot of emotional support. Hosp chaplain came by to pray w/ Pt today per her request. PERRLA, bsk. MAE, very weak. Supportive family.\n\nResp- Currently on 5 L NC, increased from 2 L over coarse of day since pt sats were drifting down. Needs alot of encouragement to cough and deep breath, cough very weak. Sats presently 96%. LS coarse throughout. Chest ray pending.\n\nCV- HR 110's-120's, ST, no ectopy. Bp btw 84-110's/40's. Recieved 1x 250 NS bolus for hypotension. Currently being repleted w/ 40 meq of KCL @ 100 cc/hr through EG. Also repleted w/ 4 gm of Mag sulfate today. Please transduce CVP tonight.\n\nGI- Abd firm and distended, very tender this am. Started on LIS and 1.5 L of guiac positive bilious secretions removed. HO aware. As stated above pt had both an endoscopy and colonscopy. PT is NPO. Cont to have lg amts of melana, plan to rescope tomorrow. Cont on TPN. Last HCT 36.5, cont to follow. NG placement by GI team, tip sets in esophagus-per team can be used for suctioning but do not attempt to infuse anything through.\n\nGU- >20 cc/hr, yellow, clr. HO notified.\n\nAccess- New line RIJ placed under ultra sound today at bedside today, plan to save one port for TPN, tranduce a second port for CVP. HO will dc PICC once placement is confirmed, please send tip for cx.\n\nSkin- Rash like red patchy skin, very dry. Skin very fragile and tears easily-first step bed ordered. Lg fld-like sac on R groin-HO aware.\n\nID- Max temp 99.2, cont IVAB. One set of bld cx sent today from PICC line. Unable to attain second set since pt's skin is so fragile, unable to apply tourniquet w/out tearing. Follow up on all cx and lab results w/ team.\n\nPlan- Cont to offer both supportive medical care and emotional support to pt and family. Code staus addressed w/ family today by intern, currently pt is a full code.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-12-15 00:00:00.000",
"description": "Report",
"row_id": 1270465,
"text": "Received pt from previous RN: pt in standard bed with HOB elevated 30 degrees. Main events upon initial assessment. Dr. at BS ordered 500cc fld bolus for low urine output. RUA PICC line d/c'd and tip sent for culture. Bld cultures sent from new RIJ TLC. RIJ TLC pulled back approx. 1\" by Dr. o.k to use for infusions. TPN started via brown port of /hr.\nReveiw of Systems:\n pt lethargic, opens eyes spont. with positive focus and tracking. pt oriented x 3 with generalized weakness noted. MAE spont. weak cough and gag noted. PERRL @ 3mm. pt denies pain at this time.\nCV- ST noted on monitor without ectopy noted. B/P stable via cuff pressure. RIJ TLC intact. CVP monitoring started. CVP @ 5-6mmhg. pulses present bilat. pt with gross anasarca noted. afebrile.\n pt on 4L 02 via NC with 02sat @ 95-97%. Lungs clear in upper airways. fine rales ausc @ b/l bases. resp 1818- 24/min. pt does not appear in distress. weak cough without sputum noted.\nGI- NGT intact to intermittent suction for large amt's of bilious drainage. placement verified. Abd large distended yet soft. hypoactive BS ausc. pt NPO. no stool or flatus noted.\nGU- Foley intact draining min amt of amber urine.\n RN\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-12-15 00:00:00.000",
"description": "Report",
"row_id": 1270466,
"text": "Con't of care 2200-2400: pt turned back reddened without breakdown. LUE weeping serous drainage from old skin tear. ultrasound performed- 7 cm hematoma noted in R femoral area. negative findings of RUE. Pt's B/P decreased to 84 systolic- Dr. notified- 1L NSS bolus ordered and adm at this time. Hct sent and results notified to Dr. no orders given. Rectal bag applied for protection. RN\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-12-15 00:00:00.000",
"description": "Report",
"row_id": 1270467,
"text": "Con't of care 0100-0400: Hct sent @ 0200. B/P decreased @ 0400- Dr. notified. 1 L NSS ordered and infusing at this time. 0500-0600: Pt had sm amt of liquidy melena noted new rectal bag applied. sacrum red without breakdown. VSS.\n"
}
] |
2,584 | 184,733 | 1. Respiratory status - She was intubated soon after admission to the NICU. Her endotracheal tube was originally taped at the nine centimeter mark. On x-ray, the tip of the tube was at the carina so it was pulled back to the 8.0 centimeter mark. She received one dose of Surfactant. She was on ventilator settings of PIP of 25, PEEP 5, rate 30, I time 0.35 and she quickly weaned to room air after her first dose of Surfactant. Her arterial blood gases was pH 7.31, pCO2 42, pO2 50, bicarbonate 22 and base deficit -5. Her chest x-ray was consistent with hyaline membrane disease. 2. Cardiovascular - She did receive one normal saline bolus of 10 cc/kilogram for a blood pressure mean of 34 with improvement into the 40s. 3. Fluid, electrolyte and nutrition - Her admission dextrostix was 71. She was NPO with a nasogastric tube to continuous low suction. She had an intravenous peripherally of D10W at 80 cc/kilogram/day. She did void in the delivery room. 4. Gastrointestinal status - Meconium was milked out in the delivery room as described above. 5. Hematology status - Her hematocrit at the time of admission was 41.8 and platelet count was 313,000. 6. Infectious disease status - At the time of admission, her white blood cell count was 14.8, differential was 43 polys and 3 bands. She was started on Ampicillin 150 cc/kilogram q 12 hours, Gentamicin 3 mg/kilogram q 24 hours and Kefzol 25 mg/kilogram q 12 hours. Blood cultures were sent prior to the beginning of antibiotics. 7. Neurology - No issues. 8. Psychosocial- The parents both present in the delivery room and are very anxious about her transfer to . A State Newborn Screen was sent prior to transfer. The infant is discharged in guarded condition. She is transferred to Surgical Service on 7 North. She has received no immunizations. | Dr. reevaluating.NPO with IV D10W at 80 cc/kg/dDS 71CBC, BC sentAmp/Gent and Kefzol givenVit K and erythro givenPKU sentNo immunizations givenParents updated and consent to transferCH transport team called. Intubated with a 3.0 ETT taped initially at 9.0. Over time, segments of bowel have changed color dusky, seen by Dr. .Admitted to NICU with rectal temp 96.5. Initial vent settings: IMV, 25/5-30, RA with ABG: 7.31/42/50/22/-4. Neosporin/Bacitracin ointment placed around abdominal opening and Gauze applied as per Dr. . Heart rate 138 onadmission, now 192, but suspect temp elevated on warmer.Baby care meds given. NICU Nursing Progress NoteAttended delivery of this 34 5/7wk infant with gastroschoesis. Pulses in lower extremities wnl.TCH transport team here, report given, and consent for transport obtained. Stomach decompressed with ngt. Respiratory TherapyAddendum: ETT pulled back to 8.0cm, not 8.5cm as mentioned above. Respiratory Therapy36+ weeker born this morning with gastroschiscs. Dr. present and manipulated bowel partly into abdomen and rest into bag. CH NICU updated on statusInfant has been named CXR revealed ETT at , ETT was pulled back to 8.5. Consulted with Dr. in . Placed on oximeter, CR monitor, and heated warmer.BP mean 26 on right leg, bolus of NS given. AFI EFW grams. Presented with increasing oligo and dilated stomach protruding through defect. Concern for increasing oligohydramnios prompted repeat C/S this am. Infant transported to TCH by their team at 1210. Dr. milked out meconium through anus and placed 4 cm ventral wall defect silo bag. BP now 38-42 mean on right arm. 8.5cc surfactant given via ETT at 1100. Some evidence of bowel compromise, with some dusky areas. PXU done. Pink in color with BBO2 in the DR. to the NICU and intubated for respiratory distress. RR weaned to 25. Given brief facial CPAP. PIV started on left hand and Ampi, Genta, and Kefzol first doses given after CBC, diff and Blood cultures drawn and sent to lab. Infant with mild GFR. Plan to transfer to TCH later this morning. Large gastroschisis with dilated proximal stomach to sigmoid colon involved, pink, no thickening, anus patent. Cap refill brisk. Dr (CH surgeon) present at delivery. Apgars . Upward tension applied on bowel contents in bag. Transported to NICU with BBO2, silo elevated to prevent compression.Exam Premature female with grunting and retracting, gastroschisis elevated in silo bag.T 96.5->98.3 P 138 R 42 BP 55/21 mean 30 O2 sat 93% RA, 100% BBO2Wt 2120 grams Lt HCAF soft, flat, nondysmorphic, intact palate, RR not done, poor aeration, + retractions, gastroschisis as described above in elevated silo, soft abd, no masses (except ring of silo), 3 vessel cord, normal female genitalia, patent anus, no sacral dimple, no hip click, active, 3 sec capillary refill, normal tone for ageA: 34 week female with RDS, gastroschisis, R/O sepsisP: Stabilize and transfer to CH NICU for surgical management.Hospital Course:Intubated orally by with 3.0 ETT taped at 9 cm mark.Placed on vent with settings 21%/25/5/30 IT 0.35 O2 sats >95%Given survanta 4 cc/kg (8.5 cc) at 11 amCXR ETT low (at carina)->pulled back 1 cm to 8 cm mark, lungs with good inflation (9+ ribs)ABG 7.31/42/50/22/-4 (rate decreased to 25)NS bolus x 1 BP 53/23 mean 34ngt placed to continuous suctionSilo kept elevated. Warming lights and warm water gloves applied and infant's temp warmed to 98.3 over 30 mins. Neonatology Attending2120 gram 34 week female born to a 22 yo G2 P1->2 Portuguese femalePNS: O+/Ab-/RPR NR/R nonimmune/HBsAg-/GBS unknownPregnancy c/b gastroschisis and oligohydramnios. | 4 | [
{
"category": "Nursing/other",
"chartdate": "2105-02-07 00:00:00.000",
"description": "Report",
"row_id": 1713843,
"text": "Neonatology Attending\n\n2120 gram 34 week female born to a 22 yo G2 P1->2 Portuguese female\nPNS: O+/Ab-/RPR NR/R nonimmune/HBsAg-/GBS unknown\nPregnancy c/b gastroschisis and oligohydramnios. Consulted with Dr. in . Presented with increasing oligo and dilated stomach protruding through defect. AFI EFW grams. Concern for increasing oligohydramnios prompted repeat C/S this am. Vigorous female. Dr (CH surgeon) present at delivery. Large gastroschisis with dilated proximal stomach to sigmoid colon involved, pink, no thickening, anus patent. Stomach decompressed with ngt. Dr. milked out meconium through anus and placed 4 cm ventral wall defect silo bag. Infant with mild GFR. Given brief facial CPAP. Apgars . Transported to NICU with BBO2, silo elevated to prevent compression.\n\nExam Premature female with grunting and retracting, gastroschisis elevated in silo bag.\nT 96.5->98.3 P 138 R 42 BP 55/21 mean 30 O2 sat 93% RA, 100% BBO2\nWt 2120 grams Lt HC\nAF soft, flat, nondysmorphic, intact palate, RR not done, poor aeration, + retractions, gastroschisis as described above in elevated silo, soft abd, no masses (except ring of silo), 3 vessel cord, normal female genitalia, patent anus, no sacral dimple, no hip click, active, 3 sec capillary refill, normal tone for age\n\nA: 34 week female with RDS, gastroschisis, R/O sepsis\n\nP: Stabilize and transfer to CH NICU for surgical management.\n\nHospital Course:\n\nIntubated orally by with 3.0 ETT taped at 9 cm mark.\nPlaced on vent with settings 21%/25/5/30 IT 0.35 O2 sats >95%\nGiven survanta 4 cc/kg (8.5 cc) at 11 am\nCXR ETT low (at carina)->pulled back 1 cm to 8 cm mark, lungs with good inflation (9+ ribs)\nABG 7.31/42/50/22/-4 (rate decreased to 25)\nNS bolus x 1 BP 53/23 mean 34\nngt placed to continuous suction\nSilo kept elevated. Some evidence of bowel compromise, with some dusky areas. Dr. reevaluating.\nNPO with IV D10W at 80 cc/kg/d\nDS 71\nCBC, BC sent\nAmp/Gent and Kefzol given\nVit K and erythro given\nPKU sent\nNo immunizations given\nParents updated and consent to transfer\nCH transport team called. CH NICU updated on status\nInfant has been named \n\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-02-07 00:00:00.000",
"description": "Report",
"row_id": 1713844,
"text": "Respiratory Therapy\n36+ weeker born this morning with gastroschiscs. Pink in color with BBO2 in the DR. to the NICU and intubated for respiratory distress. Intubated with a 3.0 ETT taped initially at 9.0. CXR revealed ETT at , ETT was pulled back to 8.5. Initial vent settings: IMV, 25/5-30, RA with ABG: 7.31/42/50/22/-4. RR weaned to 25. 8.5cc surfactant given via ETT at 1100. Plan to transfer to TCH later this morning.\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-02-07 00:00:00.000",
"description": "Report",
"row_id": 1713845,
"text": "Respiratory Therapy\nAddendum:\n ETT pulled back to 8.0cm, not 8.5cm as mentioned above.\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-02-07 00:00:00.000",
"description": "Report",
"row_id": 1713846,
"text": "NICU Nursing Progress Note\n\nAttended delivery of this 34 5/7wk infant with gastroschoesis. Dr. present and manipulated bowel partly into abdomen and rest into bag. Upward tension applied on bowel contents in bag. Over time, segments of bowel have changed color dusky, seen by Dr. .\nAdmitted to NICU with rectal temp 96.5. Warming lights and warm water gloves applied and infant's temp warmed to 98.3 over 30 mins. Placed on oximeter, CR monitor, and heated warmer.\n\nBP mean 26 on right leg, bolus of NS given. BP now 38-42 mean on right arm. Cap refill brisk. Heart rate 138 onadmission, now 192, but suspect temp elevated on warmer.\n\nBaby care meds given. PIV started on left hand and Ampi, Genta, and Kefzol first doses given after CBC, diff and Blood cultures drawn and sent to lab. PXU done. Neosporin/Bacitracin ointment placed around abdominal opening and Gauze applied as per Dr. . Pulses in lower extremities wnl.\n\nTCH transport team here, report given, and consent for transport obtained. Infant transported to TCH by their team at 1210.\n"
}
] |
26,678 | 152,705 | The patient was seen by Cardiothoracic Surgery and accepted for coronary artery bypass grafting. However, on postoperative day one, the patient proceeded to have a gastrointestinal bleed, passing bright red blood per rectum. The Gastrointestinal Service was consulted. The patient was electively intubated for airway protection, and an esophagogastroduodenoscopy was done following intubation. The esophagogastroduodenoscopy showed esophagus, - tear, friable congestion, erythema of the stomach body, compatible with gastritis. Also friability and erythema in the anterior bulb and posterior bulb, compatible with duodenitis. Following the esophagogastroduodenoscopy, the coronary artery bypass grafting was delayed secondary to the - tear which was felt by the Gastrointestinal team would have significant bleeding with full heparinization. On hospital day four, the patient's spiked temperatures to 103. He was fully cultured at that time. Sputum cultures done at that time were positive for gram-negative rods. The patient was begun on cefepime, ciprofloxacin, vancomycin, and Flagyl. A chest x-ray also confirmed pneumonia at that time. The patient remained fully mechanically ventilated. Over the next several days, the patient remained in the Coronary Care Unit. He was hemodynamically stable. He was recatheterized on . That catheterization showed a stable left main dissection. On , it was felt that the patient was hemodynamically stable and ready to go to the operating room for coronary artery bypass grafting, despite the need for full heparinization and the risk of gastrointestinal bleed. This was fully explained to both the family and his family, and he agreed to proceed with the operation. Therefore, on , the patient was brought to the operating room. Please see the Operative Note for full details. At that time, he underwent a redo coronary artery bypass graft with a left internal mammary artery to the left anterior descending artery, a saphenous vein graft to the posterior descending artery, and a saphenous vein graft to the obtuse marginal. He tolerated the operation and was transferred from the operating room to the Cardiothoracic Intensive Care Unit. The patient remained hemodynamically stable throughout the day of his surgery. Given his multiple comorbidities, the patient remained sedated overnight. On the morning of postoperative day one, the patient's sedation was discontinued, and he was allowed to slowly awaken and weaned. Over the course of the day, the patient was weaned to pressure support ventilation which he tolerated well with adequate blood gases. He remained hemodynamically stable throughout that period. However, he continued to be neurologically unresponsive, not following commands. Although, his eyes at that time were open. Over the next several days, the patient remained hemodynamically stable. He remained intubated and ventilated with pressure support ventilation. Neurologically, he slowly became more interactive and began to follow commands; first by blinking his eyes, then with the ability to move his extremities at care giver's request. Each day, pressure support was progressively weaned. On postoperative day five, the patient was successfully extubated. He remained in the Intensive Care Unit for the next several days, where he received vigorous pulmonary toilet and gained back strength neurologically. On postoperative day seven, it was felt that the patient was stable and strong enough to be transferred to the floor where he would undergo continued postoperative care and cardiac rehabilitation. The patient remained on the floor for three additional days; where, with the help of the nursing staff and Physical Therapy he continued to gain strength and coordination. On postoperative day 10, it was felt that the patient would be stable and ready for transfer to a rehabilitation facility. | Await resp cx results.GI: Abd soft with hypoactive BS. The right IJ line has its tip in the mid SVC. PORTABLE CHEST: There is a new right IJ line with tip in the superior vena cava. Lopressor d/c. A right IJ catheter tip is in the mid-SVC. A single calcified granuloma is noted in the right upper lobe. IMPRESSION: Decreasing congestive failure. Note is made of a rounded calcific density in the right apex consistent with old healed granulomatous disease. U/O decreasing, d/t poor perfusing, is responding to NS bolus. IV Abx ordered, sepsis? Remains intubated, vent settings AC-%-PEEP 5. Incisions CDI. Foley patent, draining cl. Mild congestive failure with pleural effusions. L and R C/D/I, no bruit, no . HR 60s-80s.Pulm: LS-coarse BS, improved with suctioning. C/D/I. There is mild congestive failure. IMPRESSION: There is moderate right-sided pleural effusion and small-to-moderate left- sided pleural effusion. TOL LIQUIDS WELL. Cont sedation.Maintain NPO status. The right-sided pleural effusion is decreased. There is hazy opacity at both bases (left greater than right) consistent with pleural effusion probably associated with atelectatic changes. Decreasing right-sided pleural effusion and increasing left-sided pleural effusion. There is a calcified granuloma in the right apex. A-line inserted into L radial, L fem cordis d/c. DENIES NAUSEA. There is a new endotracheal tube with tip 1-1/2 cm above the carina. Previously identified calcified granuloma in the right upper lobe is again visualized. Resp. CCU NPN 7A-3PS/P MI, PTCA PDA, dissection LAD, GI bleedNeuro: Pt. PRESSURE DRSG , D/I. Old R cath site with ecchymosis, no . NGT PLACED BEFORE SCOPE AND GASTRIC SECTETIONS CLEAR. suctioned freq. PULSES DOPPLERABLE. PULSES DOPPLERABLE. PULSES DOPPLERABLE. Bilateral DP/Pt dopplerable. CXR DONE. + LE edema. Lytes replaced. FOLOW RIGHT AND PULSES. IABP SITE D/I, PRESSURE DRSG . Cont's on reglan. CCU NSG PROGRESS NOTE-IABP.O:CV=IABP--R FEM. Suctioned for scant amt secretions. Lungs clear upper lobes, crackles noted @ bases. id: afebrile, vanco q18. CO/CI-3.7/2.19. pp via dopp. 1:2-126/80/108. BP stable (see CareVue). dng. Pt denies nausea. SBP 160'S WHEN AGITATED, 100'S WHEN SEDATED. attempt extubation . FOLLOW PULSES & R FEM SITE. AWAITING NEW PUMP.ABD SOFT, BSP. Position confirmed & sucralfate given as ordered. decreased u/o this a.m.A: sedation d/c'dswan d/c'dantecub peripherals d/c'dcordis d/c'dleft triple lumen placedmediastinal tubes placed to H2O sealtransfused 1 unit PRBClasix 20 mgR: neuro remains flat ? POS BS. MAG AND CA WNL. hydralazine & lopressor started for htn,ntg off. VBG SENT. WILL HOLD ON FENTENYL FOR NOW. & coarse at times that clears w suctioning.plan removal of med. Adeq ci. Repeat HCt 29.9.26Pulm: o2 3L NC spo2 high 90s. cpap w ips 8->12 w rr < 30 & spont. + BS. Hold sedation. diuresis from lasix. BP stable. NO NGT AFTER SCOPE B/C OF TEAR. HR LOWER AFTER IV LOPRESSOR. upper ext. LEFT STILL WITH TLC. CSRU UPDATENEURO: PERL. ?EGD if bleeding occurs. PT. PT. SAfety precautions; Haldol/ativan for agitation. PERRL.CV: HR 80's NSR, occasional PAC's, rare PVC's. Pedal pulses diff.to palpate.Pulm:Remains on vent settings of CMV-12/700/40%/peep5.LS clear, diminished to bilat bases. LE cool, pulses audible with DP. Post cath fluid off. Abd soft with normoactive BSs. RESP RATE WNL. BS+hypo. L drsg D&I. On 3l/nC.Denies SOB.O2 100%GI/GU:Pt has remained NPO.abd soft.BS+. AM dose of Lopressor HELD d/t low HR/BP. bs diminished bibasilar. USE OF NTG STILL TO TX HYPERTENSION ? GI: Residual 170cc, tf held. Follows commands.MAE.CV:SR W/rare PVC. Orders rec'd for TPN. Opens eyes to verbal stim unable to focus.Facial grimace w suctioning.Cv status: sr w occ pvc noted.Bp stable on no drips.Circ adeq distal pulses weak palp bilat.Resp status: rr^ and sats dwn at 2300. opens eyes to voice/stimuli.PERL.CV:SR w/rare PVC. r/t preop sedation requirements. Moderately hypertensive post suctioning, 150s to 160s. resp. Sxn freq. ct dc'd. Skin: Fragile, edema.A: ?if altered neuro status d/t long course of preop midaz or periop neuro event. O2 Sat >98%.GI/GU:Abd.soft. Renal: Wt down .8 (3.9>preop). MAG,CA REPLACED FOR LOW VALUES. BS clear, little sputum. BUN/Cr up slightly with diuresis. Pt w/o OGT or NGT. rashID:Con't on ATB.Afebrile.Plan:Maintain comfort/sedation ? F/C c/lt.y output wnl.ID:Afebrile. Ext cool/pale.Pulm:Remains on vent. Pulses weakly palpable distal. GI: TF at goal with low residual. AND ABLE TO PULL TITAL VOL. PULSES BY DOPPLER. Left D/I with DSD. CCU NPN77YO ADM WITH ACUTE MI > CATH LAB WITH PDA OCCLUSION UNABLE TO PTCA. "O: For complete VS see CCU flow sheet.ID: Pt afebrile.CV: Pt has been hemodynamically stable today depite GI bleeding. RR 12-20.GI: Abd soft with hypoactive BS. EKG done this am per res order.GI/GU: Pt NPO ABD flat/soft, no BS present. + Generalzied edema noted.Pulm: Intubated. Mild (1+) mitralregurgitation is seen. W TURNING & HOYERING OOB.+ WITHDRAWAL BILAT. age - possible acute/recentP-R interval 0.160Since previous tracing , precordial T wave slight less prominent appears well sedated and synchronous with vent support. Right ventricular chamber size and free wall motion arenormal. BUN 21 Creat 1.7. Lopressor dc'd. Overall left ventricular systolic functionis mildly depressed.LV WALL MOTION: The following resting regional left ventricular wall motionabnormalities are seen: basal inferolateral - dyskinetic; mid inferolateral -dyskinetic; basal anterolateral - hypokinetic; mid anterolateral -hypokinetic;RIGHT VENTRICLE: Right ventricular chamber size and free wall motion arenormal.AORTA: The aortic root is mildly dilated.AORTIC VALVE: The aortic valve leaflets appear structurally normal with goodleaflet excursion. Repeat ABG not drawn; CCU team (Dr. aware.Gi: Npo. Suction Q1-2hr small-moderate amts of thick white. IV lopressor held for SBP < 100. ADVANCING TF'S AS TOLERATED W MIN. Pt on IV protonix as mentioned above. MD aware.FSBS WNL. Dopperable pulses. Follow VS. ?Cardiac Cath today.NPO. BP 97-119/53-63. Sinus rhythm*** arm lead reversal - only aVF, V1 - V6 analyzed ***Probable inferior infarct - posterior myocardial infarctSince previous tracing, AV block no longer presentST segment more isoelectric - also evidenece of posterior myocardial infarctevolved*********Suggest repeat tracing given lead reversal********* Abdomen soft, non distended, hypoactive BS. PS decreased to 10and pt tol well with adequate ABG (See CareVue). Sinus rhythmLow limb leads voltagePrior inferoposterior myocardial infarctionT wave changes are nonspecificSince previous tracing , sinus bradycardia absent and Q-T intervaldecreased | 68 | [
{
"category": "Radiology",
"chartdate": "2187-07-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 765056,
"text": " 3:36 PM\n CHEST (PORTABLE AP) Clip # \n Reason: 77 year old with CAD, s/p RIJ placement; please eval\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with CAD, ETOH\n REASON FOR THIS EXAMINATION:\n 77 year old with CAD, s/p RIJ placement; please eval\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Right IJ placement.\n\n COMPARISON: .\n\n PORTABLE CHEST: There is a new right IJ line with tip in the superior vena\n cava. There is a new endotracheal tube with tip 1-1/2 cm above the carina. .\n This is a reverse lordotic film and the left lower lateral chest is off the\n film. No focal infiltrate is identified. There is no pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2187-07-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 765094,
"text": " 11:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for evidence of pna/pneumothorax\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with CAD, ETOH\n\n REASON FOR THIS EXAMINATION:\n evaluate for evidence of pna/pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Coronary artery disease and alcohol abuse\n\n COMPARISON: \n\n CHEST, SINGLE VIEW: The cardiac, mediastinal and hilar contours are\n unremarkable other than a minimally unfolded aorta. The lungs are grossly\n clear with the exception of the unchanged right upper lobe granuloma. No\n infiltrates or effusions. The soft tissue and osseous structures are\n unremarkable. An endotracheal tube is tip is approximately 2 cm above the\n carina. A right IJ catheter tip is in the mid-SVC. No pneumothorax\n identified.\n\n IMPRESSION:\n 1) No evidence of CHF or pneumonia.\n 2) Endotracheal tube tip approximately 2 cm above the carina. This could be\n withdrawn slightly.\n\n"
},
{
"category": "Radiology",
"chartdate": "2187-07-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 765944,
"text": " 12:47 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p Right chest tube removal\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with CAD now with fever of unknown etiology. Please\n assess for any infitrates.\n REASON FOR THIS EXAMINATION:\n s/p Right chest tube removal\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Fever of unknown etiology.\n\n A single view of the chest is compared to a previous study performed\n yesterday.\n\n The ET tube, left subclavian line and chest tube are appropriately positioned.\n The cardiomediastinal contours are not significantly changed. There are\n sternal wires and clips overlying the cardiac silhouette consistent with\n previous CABG. There is decreasing prominence of the bronchopulmonary\n markings suggesting improved failure. The right-sided pleural effusion is\n decreased. The left-sided pleural effusion is slightly increased with\n increased atelectatic changes. There is a small left apical pneumothorax\n (5%).\n\n IMPRESSION:\n\n Decreasing congestive failure.\n\n Decreasing right-sided pleural effusion and increasing left-sided pleural\n effusion.\n\n Small (5%) left apical pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2187-07-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 765178,
"text": " 10:04 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o infiltrate/pneumonia\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with CAD now with fever of unknown etiology. Please assess\n for any infitrates.\n REASON FOR THIS EXAMINATION:\n r/o infiltrate/pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 77 year old man with fever and coronary artery disease, evaluate\n for pneumonia.\n\n FINDINGS: An AP supine chest radiograph of is compared to prior\n portable AP chest radiograph of . The left costophrenic angle is not\n visualized. There is a faint opacity in the right lower lobe which could\n represent early pneumonia or aspiration. Follow up chest x-rays would be\n useful to evaluate this or to correlate clinically. Previously identified\n calcified granuloma in the right upper lobe is again visualized. There is no\n pneumothorax. The ETT is in good position. The right IJ line has its tip in\n the mid SVC. The heart size is within normal limits. There is slight\n unfolding of the aorta.\n\n IMPRESSION: Possible early aspiration or pneumonia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2187-07-11 00:00:00.000",
"description": "P CHEST (SINGLE VIEW) PORT",
"row_id": 765852,
"text": " 1:42 PM\n CHEST (SINGLE VIEW) PORT Clip # \n Reason: s/p triple lumen placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with\n REASON FOR THIS EXAMINATION:\n s/p triple lumen placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: CVL placement.\n\n A single view of the chest is compared to a previous study dated .\n\n The ET tube, Swan-Ganz catheter and left subclavian line are appropriately\n positioned. There is no pneumothorax. There is bilateral chest tubes. There\n is bilateral hazy opacities at both bases suggesting pleural effusion and\n atelectatic changes. The heart is stable in size. There is mild congestive\n failure. There is a calcified granuloma in the right apex.\n\n IMPRESSION:\n\n No pneumothorax.\n\n Appropriately positioned left subclavian line.\n\n Mild congestive failure with pleural effusions.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2187-06-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 764886,
"text": " 12:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p cardiac arrest,CV line placement, acute MI\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with\n REASON FOR THIS EXAMINATION:\n s/p cardiac arrest,CV line placement, acute MI\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post cardiac arrest and central venous line placement.\n\n CHEST, SINGLE VIEW: The cardiac, mediastinal and hilar contours are\n unremarkable other than minimally unfolded aorta and status post sternotomy. A\n single calcified granuloma is noted in the right upper lobe. The lungs are\n otherwise clear. No central venous line is detected. The soft tissue and\n osseous structures are unremarkable.\n\n IMPRESSION:\n 1. No evidence of CHF.\n 2. Calcified granuloma in the right upper lobe.\n 3. Central venous line not visualized. No evidence of pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2187-07-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 766021,
"text": " 9:42 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p chest tube removal\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with CAD now with fever of unknown etiology. Please\n assess for any infitrates.\n REASON FOR THIS EXAMINATION:\n s/p chest tube removal\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Fever.\n\n PORTABLE CHEST: Comparison is made to previous films from .\n\n The ET tube and NG tube are appropriately positioned. The cardiomediastinal\n contours are stable. There is hazy opacity at both bases (left greater than\n right) consistent with pleural effusion probably associated with atelectatic\n changes. There is worsening congestive failure.\n\n IMPRESSION: Worsening CHF with bilateral pleural effusion (left greater than\n right).\n\n"
},
{
"category": "Radiology",
"chartdate": "2187-07-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 765597,
"text": " 12:46 PM\n CHEST (PORTABLE AP) Clip # \n Reason: 77 year old s.p change of RIJ over wire\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with CAD now with fever of unknown etiology. Please assess\n for any infitrates.\n REASON FOR THIS EXAMINATION:\n 77 year old s.p change of RIJ over wire\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Fever of unknown etiology. Status post change of right IJ over\n wire. Reference exam .\n\n FINDINGS: There is a right IJ line with tip in the superior vena cava,\n higher than typical for a central line. There continues to be hazy opacity in\n the right lower lung that might represent a layering effusion. Small focal\n area of consolidation in the right lower lobe cannot be totally excluded. The\n ET tube and sternal wires are unchanged.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2187-07-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 765646,
"text": " 12:35 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for pna\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with CAD now with fever of unknown etiology. Please\n assess for any infitrates.\n REASON FOR THIS EXAMINATION:\n evaluate for pna\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Fever of unknown origin.\n\n Single view of the chest is compared to a previous study dated . The ET tube and right IJ line are unchanged in position. The\n cardiomediastinal contours are stable. There is a bilateral hazy opacity\n involving both lung bases. The upper lung zones are clear. There is no\n pneumothorax. The osseous structures are unremarkable.\n\n Note is made of a rounded calcific density in the right apex consistent with\n old healed granulomatous disease.\n\n IMPRESSION:\n There is moderate right-sided pleural effusion and small-to-moderate left-\n sided pleural effusion.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-07-02 00:00:00.000",
"description": "Report",
"row_id": 1611183,
"text": "CCU NPN 7A-7P\nNeuro: Pt. aroused to voice at times, inconsistently follows commands. Pupils equal, reactive to light, can become agitated with turning. Cont. on versed at 4mg/hr, fentanyl gtt turned off d/t BP.\n\nCV: ABP 90s-110s/mid 40s-60s with MAP mid 60s-70s, HR 60s-70s. Receiving lopressor 5mg IV Q6 hrs. A-line inserted into L radial, L fem cordis d/c. L and R C/D/I, no bruit, no . R and L DP/PT pulses weak but palpable, extremities warm. TLC in L IJ, . This afternoon BP down to 70s systolically with MAP in the mid 50s, HR low 50s. D/c fentanyl, no response. Gave 500cc NS with response, ABP now 95-108/48-54. Lopressor d/c. IV Abx ordered, sepsis? K 3.6, 40mEq IV KCl infusing.\n\nPulm: LS CTA BL. Suctioned several times for thick yellow sputum via ET tube and orally. Remains intubated, vent settings AC-%-PEEP 5. Most recent ABG 7.33/31/120/17.\n\nGI/GU: Remains NPO, no emesis, no BM this shift. Foley patent, draining clear yellow urine. U/O decreasing, d/t poor perfusing, is responding to NS bolus. IVF-D5 infusing at 75cc/hr.\n\nID: WBC 7.2, Tmax 101.6R. Blood cultures, urine culture, sputum culture sent. Vanco 1gm Q 24 and cefepime 2gm Q 12 ordered, waiting for pharmacy to approve.\n\nHeme: Hct this AM 33.1, rechecked this afternoon, stable at 32. No need to transfuse at this time. Plt 57, HIT negative.\n\nSocial: Family updated by RN and MD, several family members in to see pt. througout day.\n\nPlan: CT deferred, plan was to go to cath lab but unsure now d/t temp. Cont. emotional support for family, monitor BP, start pressors if necessary. Monitor temps, cultures, IV Abx.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-07-03 00:00:00.000",
"description": "Report",
"row_id": 1611184,
"text": "CCU Nursing Progress Note 7p-7a:\n\nNeuro: Sedated with fentanyl 50mcg and versed 4mg IV. Pt's sedation requirements increased overnight. Pt was awake reaching for ETT and raising legs off bed. Pt conts to open eyes spontaneously and following commands inconsistently.\nPer Res. maintain pt's comfort on fentanyl and versed gtts as pt awaits surgery.\nBilateral wrist restraints in place.\n\nCV: SB to 49 overnight with stable BP, Res. aware. BP marginal at start of shift 90's/40's with maps of 60-62. Pt rec'd NS 500cc bolus and IVF rate increased to 100cc/hr. HR improved to 60's SR with rare PVC's and BP 120's/60's.\nKCL repletion completed am K+ 4.3. HCT 33.0 Mg 2.4. Ca 6.3 albumin added on to am labs to check for ca correction prior to repleting.\n C/D/I. Palpable pulses bilaterally.\n\nPULM: Mechanically ventilated on AC (vent setting changed at 6:30am due to am ABG 7.31/32/112/-9.) Current settings AC 700x12 40%. Await ABG on these settings. Pt overbreathing the vent prior to adequate sedation.\nLS clear to coarse. ETT sxn'd for thick yellow sputum in copious amts requiring lavage. Await resp cx results.\n\nGI: Abd soft with hypoactive BS. Pt conts on protonix gtt at 8mg. No signs of bleeding noted. No stool this shift.\nMaintaining NPO status.\n\nGU: Foley cath patent draining cyu +7213 LOS +577 since mn.\nBUN 28 Creat 1.6\n\nID: T max 98.8 rectally. Pt rec'd first doses of vanco and cefepime IV . Cont to follow temp curve and await all culture results.\n\nSKIN: Heels red.\nMany ecchymotic areas over arms and legs.\n\nLINES: RIJ TLC and L radial a-line.\n\nSOCIAL: Pt's daughter phoned last evening for an update.\n\nDISPO: Full Code.\n\n\nA: bradycardic\n +response to fluid bolus for BP.\n NPO. Increasing co2.\n Improved u/o.\n Increased sedation requirments.\n\n\nP: Follow temp curve. Surgery on hold due to temp spike . Await all cx results. Cont IVF at 100cc/hr. Follow HR and BP. Cont sedation.\nMaintain NPO status. Follow u/o. Cont skin care. Provide support to pt and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-07-03 00:00:00.000",
"description": "Report",
"row_id": 1611185,
"text": "CCU NPN 7A-3P\nAddendum:\n\nBP 80s/40s with MAP in low 50s. 500cc NS bolus given with good effect. BP now 104/54 with MAP of 73.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-07-03 00:00:00.000",
"description": "Report",
"row_id": 1611186,
"text": "CCU NPN 7A-3P\nS/P MI, PTCA PDA, dissection LAD, GI bleed\n\nNeuro: Pt. sedated, fentanyl @25mcg, versed @4mg. Inconsistently follows commands, opens eyes with movement and suctioning. Soft wrist restrains on.\n\nCV: L radial A-line, . ABP 140s-160s sytolically this AM, lopressor 5mg IV Q6hr ordered, ABP now 90s-100s/40s-50s. HR 60s-80s.\n\nPulm: LS-coarse BS, improved with suctioning. Vent settings AC-%-PEEP 5. Most recent ABG 7.33/31/129/17. Suctioned mod amt thick yellow sputum for ET and orally. CXR done, showed possible developing pneumonia or aspiration in right lower lobe.\n\nGI/GU: Hypoactive bowel sounds, no emesis/BM this shift. Continues to be NPO, no NG/OG tube at this time d/ - tear. Foley patent, draining cl. yellow urine. U/O 45-150cc/hr. Creat 1.6 from 1.8 yesterday.\n\nID: Tmax 103.2R, tylenol given. Sputum culture negative, urine and blood cultures pending, pna? Continues on vanco/cefepime.\n\nLabs: Ca 6.3, 2gm calcium gluconate given. Phos 2.6, 30mmol K-phos infusing. Hct 33, stable. Plt 71, increased from 57 yesterday.\n\nSocial: Family came to visit for an hour, updated by RN. Spent time with minister, Catholic priest to come and see pt.\n\nPlan: Pt. was going to go to cath lab tomorrow if afebrile but is spiking temps, ?pna. Continue Abx, support family, monitor BP-lopressor may need to be decreased.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-07-15 00:00:00.000",
"description": "Report",
"row_id": 1611219,
"text": "EXTUBATED & OGT REMOVED AFTER TOLERATING CPAP W 5 IPS W/O INCIDENT. MILDLY CONFUSED ABOUT DATES & TIME BUT KNOWS HE IS IN THE HOSP. & RECOGNIZES FAMILY MEMBERS.OOB->CHAIR W TRANSFER BELT. ABLE TO STAND & SUPPORT WEIGHT FOR BRIEF PERIODS.P.T. RECONSULTED.C/O HUNGER,TOL. ICE CHIPS WELL FOR NOW.BS CONGESTED BUT CLEAR W COUGHING.STRONG PRODUCTIVE COUGH. RAISES BUT SWALLOWS.SPO2 > 94% ON NASAL PRONGS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-07-15 00:00:00.000",
"description": "Report",
"row_id": 1611220,
"text": "Resp. Care Note\nPt extubated today after good ABG on PSV 5 peep 5 and 40%. Post-ext. ABG on 50% face tent 7.42/36/122/24.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-07-16 00:00:00.000",
"description": "Report",
"row_id": 1611221,
"text": "CSRU UPDATE:\nNEURO: ALERT.ORIENTED X2. COOPERATIVE TO CARE. MILDLY CONFUSED AT TMES. SPEECH CLEAR. PERL\n\nCV: VSS AS PER FLOWSHEET. NO ISSUES. CONT ON LOPRESSOR AND HYDRALAZINE.\n\nRESP: LUNGS ESSENTIALLY CLEAR. STRONG COUGH, RARELY PRODUCTIVE THICK WHITE SPUTUM. O2 4L N/C W/ O2 SATS > 94%. DENIES ANY DYPSNEA. RR REG AND NON-LABORED.\n\nGI: ABD FLAT, SOFT W/ BSP. DENIES NAUSEA. TOL LIQUIDS WELL. C/O HUNGER \" I'LL HAVE EGGS AND TOAST IN THE MORNING\". FIB IN PLACE W/ MIN LIQUID STOOL.\n\nGU: QS AMT YELLOW URINE VIA FOLEY.\n\nSKIN: WARM/PINK AND FRAGILE. DRY,HEALING SKIN TEARS AT OLD MEDIASTINAL TUBE SITE. REMAINS ON AIR MATTRESS.\n\nASSESS: STABLE POST EXTUBATION PM.\n\nPLAN: ? 2 TRANSFER TODAY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-07-16 00:00:00.000",
"description": "Report",
"row_id": 1611222,
"text": "CV: NSR, no ectopy. Afebrile. BP stable. AM hydralazine held due to SBP 100-110's.\nPULM: Switching between NC only and NC and face tent. Strong cough, able to raise tan thick sputum. Lungs clear.\nNERUO: When woke pt this morning, confused about place, situation, and time. Pt reoriented and has not been confused since. Requiring much reinforcement and explanation of limits (not able to get out of chair on own, leaving O2 on, etc) but does comply after told. No c/o pain. Able to lift and hold limbs, but not fine movement of hands.\nGU: Foley, marginal UOP. Pt almost to dry weight, not edematous. Team aware.\nGI: Ate 2 bites of breakfast and half a at lunch. FIB , with scant amts thin, brown stool draining.\nSKIN: OOB to chair with PT, almost a total lift though. Incisions CDI. Air mattress on bed.\nPLAN: Will keep pt in ICU another day minimum due to weak, inability to move well. Pulm toilet, encourage po intake.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-07-16 00:00:00.000",
"description": "Report",
"row_id": 1611223,
"text": "SHIFT UPDATE 3-7PM\nREPORT RECEIVED FROM DAY NURSE. PT. OOB TO CHAIR TOLERATING TILL AFTER DINNER THEN PLACED BACK TO BED WITH MAX ASSIST OF 2 PEOPLE, PT. VERY WEAK ON KNEES. 1800PM DOSE OF HYDRALAZINE HELD D/T LOW B/P, PT. ON INCREASED DOSE OF LOPRESSOR GIVEN EARLIER. TOLERATING PO'S, DOES NEED ASSISTANCE WITH FEEDING, DRINKING WITHOUT PROBLEMS. PT. CONT. TO BE STABLE AND WILL PLAN ON TRANSFERING TO 2 IN AM. URINE OUTPUT ADEQUATE, ON ROUNDS DISCUSSED WITH CT TEAM AND WILL ACCEPT U/O OF 20CC/HR, ENCOURAGE PO'S.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-07-01 00:00:00.000",
"description": "Report",
"row_id": 1611180,
"text": "CCU NPN 0700-1900\nS/O:\n\nCV: PT CONT WITH RUNS VT. K CL 40 MEQ GIVEN IV X1 FOR K 3.8. MAG AND CA WNL. HR LOWER AFTER IV LOPRESSOR. SBP 160'S WHEN AGITATED, 100'S WHEN SEDATED. IABP SITE D/I, PRESSURE DRSG . PULSES DOPPLERABLE. ASA GIVEN PR.\n\nRESP: PT ELECTIVELY INTUBATED AT 1030. REC'D SUCCS AND ETOMIDATE PLUS FENT 100 MCG. TOL WELL. CXR DONE. NO ABG B/C NO A-LINE, SATS HIGH 90'S. VBG SENT. SUCTIONED X3 FOR THICK LIGHT YELLOW SPUTUM. PERIPHERAL IV ATTEMPTS FAILED AND TLC PLACED BY HO'S.\n\nID: TEMP LOW GRADE PER RECTUM. NO ABX.\n\nGI: PT SCOPED AND DIFFUSE GASTRITIS, DUODENITIS, - TEAR AND BARRETTS ESOPHAGITIS FOUND, NO ACTIVE BLEED. REC'D 1U PRBC THIS AM, REPEAT HCT 31. NO STOOL OR VOMITING. NGT PLACED BEFORE SCOPE AND GASTRIC SECTETIONS CLEAR. NO NGT AFTER SCOPE B/C OF TEAR. WILL GIVE ALL MEDS IV. PLT INC AT NOON. NEW CLOT TO BLOOD BANK.\n\nGU: FOLEY DRAINING CLEAR URINE, UVOLEMIC FOR TODAY.\n\nSEDATION: PT COMBATIVE AND BELLIGERENT IN AM BEFORE INTUBATION. STARTED ON VERSED GTT AFTER INTUBATION AT 4MG/HR WITH GOOD SEDATION. WILL HOLD ON FENTENYL FOR NOW. PT TO PAIN AT PRESENT BUT COMFORTABLE.\n\nSOCIAL: FAMILY IN AND CONSENTED TO ANESTHESIA AND TLC. UPSET TO SEE PT WITH SO MANY TUBES, UNDERSTAND THAT PT'S OUTCOME BE DIFFICULT.\n\nA/P: FOR SURGERY TOMORROW, HIBICLENS SCRUB TONIGHT. NPO, NO NGT. FOLLOW HCT TONIGHT. CONT WITH SEDATION, ADD FENT IF NEEDED. FOLLOW LYTES.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-07-01 00:00:00.000",
"description": "Report",
"row_id": 1611181,
"text": "resp note:pt intubated per order this AM placed on ac/600/12/50% peep 5 and tolerating well.b/s diminished bilat with sx for small amounts thick pale/yellow secretions.abg's available in carevue,will re-assess as needed and wean as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-07-02 00:00:00.000",
"description": "Report",
"row_id": 1611182,
"text": "CCU Nursing Progress Note 1900-0700\n\nS/O:\nNeuro: Remains sedated on Versed 4mg/hr and Fentanyl 50mcg/hr. Opens eyes and grimaces with turning, Perrl. +gag/cough. No commands, + localizes.\n\nCv: Hr 60-70s NSR with occasional PVCs. SBP 89-119, Map> 60. Lopressor increased to 5mg Q6. Dopplerable pedal pulses. Old R cath site with ecchymosis, no . No .\n\nPulm: Orally intubated, mechanically ventilated. Vent settings: Ac rate 12 fio2 50% Tv 600 Peep 5. No spontaneous breathing noted. Lungs clear upper lobes, crackles noted @ bases. Spo2 > 96%. No acute respiratory distress.\n\nGi: NPO, Abdomen soft, nondistended. + BS. No N/V/D. No BM. No evidence of GI bleed. AM HCT `33.1\n\nGu: foley draining clear yellow urine. UOP decreased to 20-30cc/hr. Cr 1.8 Lasix 20mg IV x 1 with good response. (see Carevue for I/O)\n\nLines: RIJ TLC and L Fem Introducer.\n\nSkin: Skin grossly ; no breakdown noted on sacrum or buttocks.\n\nA/P: CABG Surgery scheduled for today was Canceled by Cardiothoracic - tear. ?Plan for OR tomorrow. Clot tube sent to blood bank last pm. Continue to monitor hemodynamics, labs, need for sedation.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-07-11 00:00:00.000",
"description": "Report",
"row_id": 1611207,
"text": "Update\nO:Neuro: pt opens eyes to verbal stim however no movment spont or to command yet. Perl at 2-3mm brisk.\n\nCv status: sr w occ pvc,bp well controlled w ntg at 5 mcg/kg/m. Adeq ci. Repletion x1 w hespan 500cc for low fp's and diminishing uop.Chest tubes x4 2 mediast and 2 pl w sm amts serousy drng.\nDistal pulses + w doppler x4.\n\nResp status: Vented on simv tv 700 rr 10 fio2 50% w peep 10. pip's mid 20's to 30. Lavage and suctioned for mod amt thick tan secretions. This am more spont breathing over vent total rr 20-22.Plan wean when more fully awake.As noted ct's x4 w sm serousy drng. Air leak via mediast ct's none noted via pleurals.\n\nGi status: ogt to lws w sm amts bilious drng. Position confirmed & sucralfate given as ordered. Abd soft,flat, no active bowel snds.\n\nGu status: huo qs cl yellow urine.\nEndocrine: glucoses stable.\n\nHeme/Id: hct stable, Id-on vancomycin 500mg q18h.\nIntegumentary: Generally skin fragile w mult skin tears,scattered petechial hemorrhages noted on thighs,arms and back, stage 1 pressure sores bilat heels and occiput.\nA/P: Hemodynamically Stable postop cab. Still somewhat sedated despite propofol off since 2130 and no further narcotics given overnight. Ventilator wean when more fully awake. Therapeutic mattress and\n? tf's to maximize nutritional status.\n Follow labs and rx per ho.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-07-11 00:00:00.000",
"description": "Report",
"row_id": 1611208,
"text": "Neuro\nD: pt remains off all sedation, given small propofol bolus for line change. (+)hiccups, opens eyes, not tracking, not following commands, (+) corneal reflex, (+) cough, (+) gag. Breath sounds course before suctioning requiring lavage for thick tan sputum. B/P stable with transient increase with stimulation. decreased u/o this a.m.\nA: sedation d/c'd\nswan d/c'd\nantecub peripherals d/c'd\ncordis d/c'd\nleft triple lumen placed\nmediastinal tubes placed to H2O seal\ntransfused 1 unit PRBC\nlasix 20 mg\nR: neuro remains flat ? due to long standing sedation, line d/c's requiring increased pressure (INR 1.1). transfusion given without incidence and gd. diuresis from lasix.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-07-11 00:00:00.000",
"description": "Report",
"row_id": 1611209,
"text": "opens eyes to voice but not tracking w eyes.grimaces to tactile stimuli i.e. turning,suctioning. upper ext. movement noted w above but no lower ext. activity elicited. + gag,cough,corneals. tol. cpap w ips 8->12 w rr < 30 & spont. tv > 420 cc. suctioned freq. for thick white material.breath sounds decreased bilat. & coarse at times that clears w suctioning.plan removal of med. ct tonight.pleurals still draining mod. amts thin sero-sang. dng. skin as described previously,thin,tears easily w multiple eccymotic areas. heels red bilat. waffles & 1st step mattress ordered. unavailable at this time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-07-11 00:00:00.000",
"description": "Report",
"row_id": 1611210,
"text": "hydralazine & lopressor started for htn,ntg off. atc carafate & pantoprazole started for recent gastritis,- tear per endoscopy pre-op. ? tf's to be started soon.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-06-30 00:00:00.000",
"description": "Report",
"row_id": 1611178,
"text": "CCU NPN 0700-1900\nS/O: \"DOES ANYONE OUT THERE HAVE A CIGARETTE FOR ME?\"\n\nCV: HR LOWER AFTER LOPRESSOR INC TO 25 MG. SBP 100'S-130'S. HR SR WITH FREQ RUNS VT. CALCIUM 2 AMPS GIVEN IV X1. IABP PULLED AT 1415, TOL WELL. PRESSURE DRSG , D/I. PULSES DOPPLERABLE. FEET COOL AND PALE, ABI'S WNL WHEN IABP IN. LEFT STILL WITH TLC. HEP OFF ALL DAY. PLT TO 64, RECHECKED AT 1700 ALONG WITH HIT PROFILE. CK'S FALLING. NO CHEST PAIN/SOB. 1/2 NS AT 75CC/HR.\n\nRESP; SATS HIGH 90'S ON 3LNP. LUNGS AT BASES, NO RALES. PT LYING FLAT IN BED.\n\nID: AFEB.\n\nGI: NO SIGNS OF GIB, HCT RECHECKED AT 1700. PT SIPPING ICE WATER, STILL NPO TODAY PER GI TEAM. POS BS. PROTONIX CONT AT 8MG/HR.\n\nGU: FOLEY DRAINING CLEAR URINE.\n\nMS: RESTLESS AND TAKING OFF EKG LEADS AND TRYING TO SIT UP THIS AM, CALMER NOW BUT STILL MOVES IN BED AS HE WISHES. CAN SIT UP MORE AT , 6 H AFTER IABP PULL. CIWA SCALE 1-2 ONLY. PT STATES WISH TO GO HOME AND HAVE A CIGARETTE. A/O BUT FORGETS DETAILS OF HOSPITALIZATION AT TIMES.\n\nA/P: ? ON MONDAY, CT WANTS SCOPE FIRST. FOLOW RIGHT AND PULSES. SAFETY PRECAUTIONS. FOLLOW LABS SENT THIS EVENING, REPLETE LYTES AS NECESSARY TO MINIMIZE ECTOPY. GIVE VALIUM PO IF PT BECOMES MORE RESTLESS OR AGITATED.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-07-14 00:00:00.000",
"description": "Report",
"row_id": 1611217,
"text": "CSRU NPN\n\nNeuro: Very alert. Following commands. MAE but weakly. Legs appear weaker than arms. Moving lips in an attempt to communicate. PERRL.\n\nCV: HR 80's NSR, occasional PAC's, rare PVC's. Lytes replaced. BP stable. Lopressor and hydralazine cont's. + LE edema. Weight down slightly from yesterday. Hct 35.2.\n\nResp: CPAP 5/5 initially with tidal volumes 400-600's, RR mid to high 20's. ABG w/ resp alkalosis, O2 sats 96% or greater. RR noted to be consistently in mid to upper 20's so IPS increased to 10 with decrease in RR. Suctioned for scant amt secretions. Strong cough. Per team, no plans for extubation today.\n\nGI/GU: TF restarted at 0930 at 40cc/hr. Residual at 1200 90cc. MD aware-per his suggestion, rate increased to 60cc/hr. Will recheck residual at 1400. Abd soft, hyperactive BS. Pt denies nausea. Cont's on reglan. FIB with liq, dk brown stool. u/o adequate. BUN/Cr 44/1.7.\n\nEndo: Glucose stable.\n\nID: Afebrile. WBC 11.7.\n\nSkin: to back/buttocks/heels. Chair cushion obtained. Total lift to chair w/ 3 assist-tolerating sitting well.\n\nComfort: Pt without complaints of discomfort. Will hold on sedation/narcotics d/t mental status finally clearing.\n\nSocial: Son in visiting. Explained plan of care, seemed to understand. He had no questions at this time.\n\nA: Hemodynamically stable. Increased IPS to help decrease RR. High residuals w/ tube feeds. Diuresing ok. More awake.\n\nP: Cont to monitor neuro status. Hold sedation. Ventilatory support. ? attempt extubation . Monitor tube feeds residuals and abd exam closely. OOB to chair QD as tolerates.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-07-01 00:00:00.000",
"description": "Report",
"row_id": 1611179,
"text": "Nursing Progress Note 1900-0700\n\nS/O \"I'm getting out of here!\"\n\nNeuro: Pt calm and quiet, AO x3, and following commands until 0200 then climbing oob, pulling @ ekg leads, and swearing @ staff. Pt confused and belligerant. AO x person only; pt forgets why he's in hospital and that he needs surger. bilateral soft wrist restraints and posey vest in place with little effect. Haldol and Ativan given and pt now sleeping. Safety precautions in place.\n\n-CV: Denies cp/sob. Hr 70-80s NSR with frequent runs of NSVT (6-10 beats). Serum mg level 1.9 - 2 gm Mgso4 ivpb as ordered. Discussed antiarrhymic drips with CCU team and was declined @ present non-sustained v-tach. Lopressor dose increased to 25mg TID. BP stable (see CareVue). R pressure drsg , , no bleeding. L TLC changed over wire to Introducer, transparent drsg . Bilateral DP/Pt dopplerable. No edema noted. Earlier Hct 26.5- 1 unit rbc transfused. Repeat HCt 29.9.\n\n26Pulm: o2 3L NC spo2 high 90s. Lung clear. Productive cough with scant secretions.\n\nGi: No S/S of GI bleeding. Remains NPO per GI service except meds. Abdomen soft, nondistended, nontender with +BS. No stool this shift. Denies n/v/d.\n\nGu: foley patent, draining clear yellow urine.\n\nID: Afebrile.\n\nA/P?: Monitor HR and ectopy. Replete electrolytes as needed. Monitor HCT, s/s of GI bleed. ?EGD if bleeding occurs. SAfety precautions; Haldol/ativan for agitation. ?Plan for CABG surgery on Monday.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-07-10 00:00:00.000",
"description": "Report",
"row_id": 1611203,
"text": "pt 7p-7a assessment and interventions\nnuero--eyes open w/ stim and occ spont does not track.very weak gen ext mvt w/draw to pain.versedand fent gtts not titrated per cardiac dr vent control and for cabg.lethargic.perrla brisk.no s/s of pain\nresp--ac12/700/40%/peep5.no distress scattered fine rhonchii a+p to clear.ets sm thin white.no resp distress sats >95%.resp rate spont no higher than at rest.\nc/v--heart tones distant.s1s2.afebrile.bp wnl 100's-120's systolic.ntg off for all shift.+pulses +1-2x4 ext.ext slighty cool to touch.+ edema general.\ngi---no access, no bm.+bs x4 normoactive.no n/v\ngu--good u/o clear yellow,no diuretics\nsurgery--- on hold at this time r/t no gi consult in to see pt to pass for am sx per anesthesia request.dr and dr managing consults and organizing care both state to have spoken w/ anesthesia on gi consult and that gi will see pt in am for ok for sx note r/t incraesed anticoagulants. all pre op from nursing completed.labs sent,total bath w/ hebiclense complete head to toe.pre op sheet complete to date.\niv----r ij cvc line tpn quick bag ordered by dr at 0100.and started to infuse over 24hr.\nskin-- no breakdown\nplan---to proceed w/ cabg pre-procedure plan.maintain hemodynamics and oxygenation.\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-07-10 00:00:00.000",
"description": "Report",
"row_id": 1611204,
"text": "surgery team present for cabg lines being established per anesthesia.anesthesia states pt is low risk for gib and for scheduled sx.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-07-10 00:00:00.000",
"description": "Report",
"row_id": 1611205,
"text": "s/p cabg x3\narrived on 30 mcq of propofol-iv ntg started upon arrival, 100 ml pleural drainage, 15 ml mediastinal output.\no: cardiac: a paced @ 92 underlying rythym 50's sb, isolated pvc noted, sbp requiring ntg 3 mcq until 2200 increased to 5 mcq , ci>3, pads 20, cvp 11-14, hct upon arrival 23.8 recieved 2 upc and repeat 32. k 20 meq iv x 2, medistinal ct draining minimal sanguinous drainage, pleural ct draining serosang-serous drainage. pp via dopp. feet and hands warm to touch.\n resp: remains intubated , abg per flow, o2 sats >98% on 50%, bs diminished bibasilar. sx x1. not over breathing rate of 10 at present.\n neuro: 2100 reversed and propofol 50mcq turned off , pt not responsive or moving extremities @ this point.perl + brisk.\n GI: ogt to lcs draining green bilious, + placement, absent bowel sounds.\n gu: excellent diuresis post 40 mg iv lasix given in or.\n id: afebrile, vanco q18.\n endo: 4units sliding scale x 1.\n social: have not spoken to any family members.\n skin: heels reddened, positioned on pillow,\na: awaiting mae, becoming hypertensive off propofol requiring ^ntg, good ci, mediastinal ct leak, to remain intubated ,\np: monitor comfort, hr and rythym, sbp-wean ntg as tolerated, ct drainage-leak, resp status, neuro status, i+o, labs, as per orders.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-07-11 00:00:00.000",
"description": "Report",
"row_id": 1611206,
"text": "Resp Care: Pt continues intubated and on ventilatory support with simv 700x10/fio2 .5/+10 peep/psv 5 with good abg; BS essentially clear, sxn thick tan/clear secretions, see carevue for details.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-07-15 00:00:00.000",
"description": "Report",
"row_id": 1611218,
"text": "CSRU UPDATE\nNEURO: PERL. ALERT , DOZING IN NAPS. MAE WEAKLY IN BED. ONLY ABLE TO WIGGLE TOES. LFTS OFF BED. FOLLOWS COMMANDS. NODS TO SOME QUESTION, ATTEMPTS TO MOUTH WORDS.\n\nCV: VSS AS PER FLOWSHEET. RARE PAC/PVC. CONT ON LOPRESSOR AND HYDRALAZINE. NO ISSUES.\n\nRESP: REMAINS INTUBATED, VENT CPAP W/ +5 PEEP AND IPS INCREASED LAST PM TO 10CM FOR RR 28-32. SX FOR MOD AMT PALE YELLOW SECRETIONS. STRONG COUGH. LUNGS ESSENTIALLY CLEAR W/ OCCAS SCAT RHONCHI.\n\nGU: UOP QS VIA FOLEY.LASIX AS ORDERED W/ MOD EFFECT LAST PM.\n\n\nGI: TOL TUBE FEEDS AT 20CC/HR. PRESENTLY OFF R/T TUBE FEEDING PUMP FAILURE. AWAITING NEW PUMP.ABD SOFT, BSP. MIN LIQUID BROWN STOOL IN FIB.\n\nSKIN: FRAGILE SKIN. PT ON AIR MATTRESS. MULT DRY HEALING SKIN TEARS NOTED AT OLD CHEST TUBE SITE.\n\nASSESS: STABLE PM, THOUGH REQUIRED INCREASE IN IPS.\n\nPLAN: WEAN IPS AS TOL. INCREASE TUBE FEEDS AS TOL. CONT SUPPORTIVE CARE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-06-29 00:00:00.000",
"description": "Report",
"row_id": 1611174,
"text": "CCU NSG PROGRESS NOTE-IABP.\nO:CV=IABP--R FEM. SITE OOZE @ SITE-WO PRESSURE DSG @ PRESENT. PULSES DOPPLERABLE. FEET PALE & COOL. LEG IMMOBILIZER INPLACE. #'S 1:1-105/160/76/108. 1:2-126/80/108. SYST UNLOADING 19-21 W DIASTOLIC UNLOADING . CO/CI-3.7/2.19. GOOD AUGMENTATION W APPROPRIATE WAVEFORM. HEPARIN @ 750U/HR-STARTED @ 0400 WO BOLUS & INTEGRILLIN @ 2MCG/KG/MIN.\nA:APPROPRIATELY FUNCTIONING IABP.\nP:CONTIN IABP TILL . FOLLOW PULSES & R FEM SITE. CK PTT-@ APPROX 0800. SUPPORT AS INDICATED.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-06-29 00:00:00.000",
"description": "Report",
"row_id": 1611175,
"text": "7p-7a Nursing Note\nStatus:Full Code\nNKDA\nCP S/P Cath--ballooned PDA,failed stent\nSEE Admission Note\nNeuro:A&OX3. Calm/pleasant/cooperative. Follows commands.MAE.\n\nCV:SR W/rare PVC. HR 80-85.Denies any CP. Pedal pulses dopplerable. Bilat feet cool/pale. Rt. groin oozing.No hematoma noted. Heparin at 750U/hr and integrelin @2mcg/kg/min.AM labs PND.C.O-3.7/C.I.2.19.\n\nResp:LS clear. On 3l/nC.Denies SOB.O2 100%\n\nGI/GU:Pt has remained NPO.abd soft.BS+. Condom cath intact. No UOP. Pt denies the urge to void.\n\nAccess:PIVX1 to Rt.AC. Mult.lumen cath to Lt. groin. IABP/PA to Rt.groin.\nPlan:CABG today. Monitor labs.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-06-29 00:00:00.000",
"description": "Report",
"row_id": 1611176,
"text": "CCU NSG NOTE: R/I MI/L Main dissection/IABP/GIB\nS: \" My back is a little sore, but that chest pressure is gone.\"\nO: For complete VS see CCU flow sheet.\nID: Pt afebrile.\nCV: Pt has been hemodynamically stable today depite GI bleeding. Integrelin was shut off at 11am and heparin was shut off at noon with PTT 126. Heparin has not been restarted. Pt remains chest pain free on IABP. HR 70-low 100s NSR, ST. He has occasional PVCs and pacs. He has excellent augmentation and is unloading points. Augmented diastole ranges 120-160, with assisted systole 80-120s and BAEDP 60-88 and maps 70-120s. PAP 20s on low teens despite fluid and blood. C/O this afternoon was 4.9/2.9. He continues to received D51/2NS at 150/hr which was stopped during blood and will end with the liter that is up.\nIABP in R groin has small ooze which has been decreasing with heparin off. Triple lumen in L groin is dry. Feet are cool and pale, but sensation normal. All pulses dopplerable. CKs are decreasing to 1361/204. If GIB resolves pt will have surgury on Monday for repair of L-main dissection.\nGI: Pt vomited ~125cc coffee grounds at 8am. He felt better but then had 250cc maroon stool with clots out at 11a. He had ng tube dropped and was lavaged, but unable to clear. He was connected in intermittent suction and has put out 290cc of maroon blood. He has 2 more stools and vomited another 500cc last at 4:30. He has put out a total of ~1640cc of dark blood and clots. He has received 3 units PRBCs, last in at 6pm with crit due 8pm. Crit on admission was 37, down to 29 with lates 32. He will be started on pantoprazole drip when loading dose is in. GI was consulted, but is very reluctant to scope him. He would require intubation were he to be scoped.\nRESP: Pt sating 98-100% on 3L NP. His blood gas on that was 175/ 37/ 7.36.-3. His BS are decreased at the bases, but otherwise clear.\nRENAL: Foley inserted but with GIB urine output has dropped to 5-15cc/hr. Pt is now ~2300cc positive for the day.\nCOMFORT/MS: Pt has remained alert and oriented with no deficits per CIWA scale. He has received no valium and has remained without symptoms. He initally c/o of mild mid-sternal chest ache, which has since resolved. He now has minor back and muscle ache for which he has received MSO4 with fair relief. Frequent position changes also help. He may need IV med to help with sleep later.\nFAMILY: Wife and adult children in to visit. They have been called by physicians and are up to date with the days occurances.\nA: CKs decreasing/no pain/GIB\nP: Continue CIWA scale and medicate if necessary. Continue MSO4 if needed. Keep careful I & O. D/C IVF after this liter. Check crit at 8p. Monitor for change.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-07-08 00:00:00.000",
"description": "Report",
"row_id": 1611199,
"text": "addenduem to above\nPt. was not given 5 mg IV Lopressor at 0600, had received 5mg IV at 2100 and 0200, next dose due at 0800.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-07-08 00:00:00.000",
"description": "Report",
"row_id": 1611200,
"text": "7a-7p Nursing Note\n\nNeuro:Pt remains sedated on Fentanyl 25mcg/hr and Versed 4mg/hr. No spont. mvmt. opens eyes to voice/stimuli.PERL.\n\nCV:SR w/rare PVC. HR 70-80. SBP 90-120. AM dose of Lopressor HELD d/t low HR/BP. L drsg D&I. Pedal pulses diff.to palpate.\n\nPulm:Remains on vent settings of CMV-12/700/40%/peep5.LS clear, diminished to bilat bases. Sxn small amts thick lt.yellow sputum. O2 Sat >98%.\n\nGI/GU:Abd.soft. BS+hypo.No BM. Orders rec'd for TPN. F/C patent w/c/lt.yellow UOP WNL.\n\nID:Con't on Cipro for gm(-)rods in sputum and UTI. Afebrile. On oral nystatin for thrush.\n\nAccess:Mult lumen to Rt.IJ.Changed over wire today.\n\nPlan:Awaiting CT . Poss.Tomorrow. Con't to monitor HR/BP in response to lopressor.Maintain sedation/comfort.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-06-30 00:00:00.000",
"description": "Report",
"row_id": 1611177,
"text": "NSG NOTE\n\nCV: DENIES CP/SOB AT THIS TIME. HYPERTENSIVE ON EVES WITH MAP'S 118. HOUSES STAFF AWARE. RECEIVED LOPRESSOR 12.5MG WITH LITTLE TO NO EFFECT. ? D/T ANXIETY. MS04 GIVEN WITH LITTLE EFFECT. ATIVAN 1 MG GIVEN. PT SLEPT IN LONG NAP'S. IMPROVED BP,HOWEVER PT PICKING AT LINES,PULLING OFF 02 WHILE AWAKE. ADDITIONAL LOPRESSOR 12.5 MG GIVEN. HR 70-80. NSR. HAD INCREASING RUNS OF VT 4-8 BEATS OVERNOC. MAG,CA REPLACED FOR LOW VALUES. SEE FLOW . LESS ECTOPY NOTED AFTER REPLACMENT. IABP 1:1 WITH SYSTOLIC UNLOAD 11-29,DIASTOLIC UNLOAD 1-5. PAD'S .\n\nRESP: DENIES SOB. O2 @ 3L. 02 SATS 97-98%.\n BS CL/DIMINISHED.\n\nLABS: HCT (POST 3 UNITS PRBC) 35. REPEAT AT MN 31.6\n K+ 4.7\n CA 6.7 RECEIVED 2 AMPS CA GLUCONATE\n MG 1.4 RECEIVED 2 AMPS MAG SULFATE.\n HCT @ MN DOWN TO 31.6 HOUSE STAFF NOTIFIED.\n\nGI: NGT TO LIS DRAINING SMALL AMT'S OF DK BLD. NO STOOL THIS SHITF. + BS. TOL SIPS OF CL LIQS. REMAINS ON PROTONIX CON'T GTT AT8MG/HR.\n\nGU: U/O SLUGGLISH,BUT HAS PICKED UP NOW TO 90CC/HR.\n\nID: 98.5\n\nIVF: NS 150CC/HR\n\nNEURO: CIWA SCALE INITIATED. PT HAS REMAINED A&O X2. PLEASANT AND FOLLOWS COMMANDS. MAE. WOULD REFRAIN FROM GIVEN ATIVAN TO PT AS HE BECAME RESTLESS, PICKING AT BED SHEET,NGT AND GROIN SITES.\n\nSKIN: R GROIN SM OOZ. STABLE AT PRESENT. L GROIN C&D. PULSES BY DOPPLER. FT PALE AND COOL .\n\nA: INCREASING ECTOPY LIKELY RELATED TO LYTES\n\nP: SURGERY SCHEDULED FOR MONDAY D/T RECENT GI BLEED\n FOLLOW LYTES\n DO NOT GIVE ATIVAN\n AM HCT,CK\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-07-09 00:00:00.000",
"description": "Report",
"row_id": 1611201,
"text": "CCU NPN\n77YO ADM WITH ACUTE MI > CATH LAB WITH PDA OCCLUSION UNABLE TO PTCA. CATH C/B LM DISSECTION AWAITING CABG.\nID: AFEBRILE, REMAINS ON CIPRO IV.\nCV: VERY LABILE BP RANGING 80-170'S, STARTED IVNTG WITH ELEVATED BP (AFTER REC'ING EXTRA SEDATION) BUT IVNTG AFTER PT WITH VERSED 2MG AND FENT 25MCG. HR 50-70'S SB/SR WITH OCC/RARE PVC. REMAINS D/I.\nRESP: REMAINS ORALLY INTUBATED WITH NO VENT CHANGES MADE. SATS HIGH 90'S. SUCTIONED FREQUENTLY FOR SM-MOD AMTS OF WHITE THIN SECRETIONS. LUNGS CLEAR AFTER BEING SUCTIONED.\nGI/GU: NO EVIDENCE OF FURTHER GI BLEEDING. FOLEY DRNG ADEQUATE AMTS OF URINE.\nMS: PT UNRESPONSIVE TO PAINFUL STIMULI. DOES NOT MOVE EXTREMS. PUPILS ARE EQUAL AND REACTIVE, HE DOES OPEN THEM AT TIMES WHEN MOVING FROM SIDE TO SIDE. DECREASED VERSED TO 3MG AT 8PM, BY 6AM WITH TURNING PT CHOKING AND GAGGING ON ETT, THEREFORE WITH TOTAL OF VERSED 2MG AND FENT 25MCG WITH RELIEF OF GAGGING BUT DECREASE IN BP.\nSKIN: NOTED THAT FINGER TIPS OF L HAND BLUE/PURPLE. TEAM AWARE. UNKNOWN CAUSE, RADIAL PULSE PRESENT.\nA: AWAITS CABG\n UNRESPONSIVE\n LABILE BP\nP: ? USE OF NTG STILL TO TX HYPERTENSION\n ? PROPOFOL INSTEAD OF VERSED/FENT TO ADEQUATELY ASSESS MS\n CONT TO ASSESS L HAND\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-07-09 00:00:00.000",
"description": "Report",
"row_id": 1611202,
"text": "CCU Progress Note:\n\nS- intubated & sedated.\n\nO- see flowsheet for all objective data.\n\ncv- Tele: SB-SR occ PVC's- HR 51-70- B/P 97/58-151/68- hemodynamically stable- L d & i- NPO after midnight for CABG in AM- T&C done- U/A sent.\n\nneuro- sedated for vent control- on fentanyl gtt @ 25 mcq/hr & versed 3mg/hr- no spontaneous movement noted- opens eyes to painful stimuli-\nPupils = & sluggishly react to light.\n\nresp- con't on vent CMV12/700/40%/PEEP 5- lung sounds diminished @ the bases, otherwise clear- suctioned small amt white colored mucous.\n\ngi- abd. soft (+) bowel sounds- TPN infusing @ 41cc/hr- no evidence of any GI bleeding.\n\nid- afebrile- T 96.7-97.3 PO.\n\ngu- UO qs- foley draining clear yellow urine.\n\nA- Pre-op for surgery in am.\n\nP- Con't to monitor vs, i&o, lung sounds, & labs- monitor response to lopressor- maintain sedation/comfort- 2% CHG scrub from chin to toes for 10 min. this evening for surgery in am.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-07-13 00:00:00.000",
"description": "Report",
"row_id": 1611214,
"text": "CSRU Progress Note\nS/O: Neuro: Eyes open, blinks to command. Withdraws feet to pain. No movement of arms. No sedation.\n CV: HR 85, Bp 115/60 on hydralazine and lopressor.\n Resp: CPAP with IPS8/5, 40% with good ABG, Vt 400s, RR 25. Strong cough, freq suction for sticky tan sputum. Hypersensitive gag, regurg tf several times but did not aspirate.\n Renal: Wt down 3+kg, lytes repleted. BUN/Cr up to 40/1.9 (35/1.7).\n Heme: Hct 37.\n ID: T99, WBC 11.8, postop vanco.\n GI: TF at goal with low residual. Protonix.\n Endo: No insulin.\n Skin: Fragile, edema.\nA: ?if altered neuro status d/t long course of preop midaz or periop neuro event. BUN/Cr up slightly with diuresis. Hypersensitive gag puts pt at risk for aspiration.\nP: CT scan today. Increase lopressor. Cont pulm toilet. No extubation until neuro status determined. Trach and PEG if no extubation soon.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-07-13 00:00:00.000",
"description": "Report",
"row_id": 1611215,
"text": "altered cardiac status:\no: cardiac: sr 80's with pvc's, k 3.5 recieved 40 meq kcl iv, po lopressor increased to 50 mg with next dose, continues to recieve iv hydralazine 10 mg q6. sbp 120's-100. ct dc'd. pacing wires dc'd,jp dc'd. pp palp. afebrile feels warmer than temp taken.\n resp: continues on cpap 5/5 with tv 400's with rr teens. sx for a small amount of white sputum x2. bs diminished bibasilar. o2 sats >95%.\n neuro: perl, following commands, this am could weakly squeeze with his left hand and move his right toes,as day progressed can squeeze weakly with both hands, still no movement from left leg.\n gi: tf residual >120 therefore tf held, 0900 vomited 100ml. 1030 vomited again and ngt to lcs. tf restarted @ 1700, recieved 5 mg reglan iv x2. +bowel sounds, mod amount of liquid brown stool,fib applied.\n gu: good uo.\n skin: skin tears with tegaderm. coccyx not red until up in chair less red after being in bed.\n endo: no sliding scale insulin.\n social: family into visit and updated.\nA: vomited x2. cpap5/5. slowly able to follow commands. appears to understand.\nP: monitor comfort, hr and rythym, sbp, temp , resp status, neuro status, i+O, labs, as per orders.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-07-14 00:00:00.000",
"description": "Report",
"row_id": 1611216,
"text": "CSRU Progress Note\nS/O: Neuro: Much more awake, moving hands off bed, nods to questions. Wiggles toes.\n CV: Stable on hydralazine and lopressor.\n Resp: RR up to 40s, IPS increased to 10 with RR low 20s and Vt 500s. BS clear, little sputum.\n Renal: Wt down .8 (3.9>preop). K repleted. BUN/Cr 44/1.7 (40/1.9). Lasix 20 pogt with UO 30-100/hr.\n Heme: Hct 35.6.\n ID: T99, wbc 11.\n GI: Residual 170cc, tf held. Small amt loose brown G+ stool. On reglan.\n Endo: No insulin required.\n Skin: Skin tears.\nA: Neuro status improving. ?high residual.\nP: ?extubate. Cont gi assessment.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-07-07 00:00:00.000",
"description": "Report",
"row_id": 1611197,
"text": "7a-7p Nursing Note\nNeuro:Sedated on Fentanyl 25mcg/hr and Versed 4mg/hr.Opens eyes to stimuli and at times verbal stimulation. No spont. mvmt. Positive cough and gag.\n\nCV:SR on monitor w/rare PVC. HR 65-80. BP 115-130. Increased w/stimulation. Lt site D&I w/dry sterile dressing. Bilat. pedal pulses difficult to palpate. Ext cool/pale.\n\nPulm:Remains on vent. No changes this shift.O2 sat 96-100%. LS course throughout sxn mod. amts thick secretions\n\nGI/GU:Abd soft. BS+hypo. Remains NPO. No BM. F/C c/lt.y output wnl.\n\nID:Afebrile. WBC wnl. con't on Cipro.\n\nPlan:start nutrition\n maintain comfort\n ? plan for CT \n"
},
{
"category": "Nursing/other",
"chartdate": "2187-07-08 00:00:00.000",
"description": "Report",
"row_id": 1611198,
"text": "ccu npn 7p-7a\nS: Orally intubated and sedated\n\nO: Please see carevue for VS and objective data\n\nCVS: Hemodynamically stable with increased HR/BP noted. HR 60-80's NSR, rare PVC. BP ranges 115-160/60-80's. Team notified of increase in trend of BP/HR. Given 5 mg IV Lopressor at 2100, 0200, 0600, with good effect. Left D/I with DSD. Distal pulses palpable.\n\nResp; Remains intubated and mechanically ventilated on A/C 700x12, 40%, 5 peep. Spont. resp. noted over vent. Lungs coarse, suctioned for small amount thick, yellow secretions q 2-3 hours.\n\nGI:GU: Remains NPO, D51/2NS conts at 100cc/hour. Bowel sounds hypoactive, no stool this shift. Foley to drainage with clear, yellow urine 30-75cc/hour.\n\nID: afebrile on IV Cipro, noted thrush in mouth, team notified, started Nystatin oral susp.\n\nNeuro: Remains sedated on IV Fentanyl at 25mcg/hour and IV Versed at 4mg/hour. to verbal and tactile stimuli. Not following commands, rare movements of extremities. PERL. Gag, cough noted with suctioning. Soft hands restraints in place for safety.\n\nAccess: RIJ TLC with all ports functioning well.\n\nA: stable awaiting CT .\n\nP: Cont to monitor hemodynamics and Pt's response to IV Lopressor. Team to follow up with GI service regarding use of OGT for feeding, otherwise will need to change over TLC and save port for TPN. Follow up with am labs. Maintain sedation, comfort and emotional support to Pt. and family awaiting CT .\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-07-06 00:00:00.000",
"description": "Report",
"row_id": 1611194,
"text": "7p-7a Nursing Note:\n\nNeuro: Pt. cont t/b sedated on Fentanyl 25mcg and Versed 4mg. Pt opens eyes to turning and sxn. NO spontaneous movement noted.\n\nResp: Pt maintained on mech vent: CMV 16/700/.40/5. Pt not breathing above the vent. Sxn'd freq via ETT and orally with yankeur for mod amt thick white secreations. BS course. SPO2 98-100%. Positive sputum culture.\n\nCV: Tele: SB-SR without ectopy. HR 50-70's. NBP 100-110's/60-70's. R IJ TLC patent for D5 1/2 NS @ 100cc. Banana bag QD. UE cool and mottled, pulses palpable. LE cool, pulses audible with DP. Pt scheduled for cardiac cath today.\n\nGI/GU: Pt NPO. ABD flat/soft with decreased BS. NO BM. Foley in place draining clear yellow urine. Positive urine culture. Pt on IV antibiotics. T max 100.4\n\nPlan:\nMonitor hemodynamics/pulm status/I&O's\nMonitor pending labs sent this am\nCont freq repostion/skin care\nPt to cath lab today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-07-06 00:00:00.000",
"description": "Report",
"row_id": 1611195,
"text": "7a-7p Nursing Note\n\nNeuro:Pt remains sedated on Fentanyl 25 and Versed 4mg. Opens eyes only to stimulation, I.E.suctioning and turning. No spont mvmt.\n\nCV:SR w/rare PVC. HR 50-80. BP 140-150'/40-50. To Cath lab this PM. LFA sheath insertion L main dissection not healing. Plan for surgery consult and awaiting for ACT to raise. Bilat. pedal pulses . Bilat feet cool. Sheath to Lt femoral pulled 1715.\n\nPulm:LS course throughout. Sxn freq. for lrg amts thick white/yellow secreations. No changes with settings this shift. O2 sat 95-99%.\n\nGI:abd soft.BS+hypo.Pt remains NPO. No BM. F/C c/y output wnl.\n\nSkin:back reddened turned q 2hr.? rash\n\nID:Con't on ATB.Afebrile.\n\nPlan:Maintain comfort/sedation\n ? nutritional status/start TPN??\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-07-07 00:00:00.000",
"description": "Report",
"row_id": 1611196,
"text": "CCU Nursing Note 1900-0700\nS-Sedated and intubated\n\nO-MS: Remains sedated and intubated on 25mcgs of Fentanyl and 4.0mg of Versed. Pt will opens eyes to verbal command. Unable to follow commands. Rarely moving extremeties in bed.\n\nCV: HR 40s to 60s, SB to NSR. Rare to occasionaly PVCs. Lytes checked and K and MG wnls. SBP 90s to 120s. Moderately hypertensive post suctioning, 150s to 160s. Question further plans for LMA dissection.\nSkin cool and dry to touch. Pulses weakly palpable distal. Right site . With noted .\n\nRESP: Breath sounds course. O2Sats mid to high 90s. Vent changes made for decreased CO2 from PM ABG. Rate decreased to 14. ABG on repeat with CO2 of 27, now rate decreased to 12. Suctioned for moderate to copious amounts of thick white sputum. Bagged lavaged with better effect. Breathing unlabored and appearing comfortable on vent.\n\nGU/GI: Foley draining CYU with brisk UOs overnight. Post cath fluid off. Currently infusin D51/2NS with multivit and additives at 100cc/hr. Questioned team as to if wanting pt to receive considerable amount of fluid QD. Okay with infusions. Abd soft with normoactive BSs. Pt w/o OGT or NGT. (?) as to why. Nor is pt recieving nutrition.\nNo BMs overnight.\n\nID: Afebrile overnight. Continues Cipro IV.\n\nA/P:\nContinue ventilatory support as needed\n? when to extubate\nQuestioned plans if pt needing to scoped\nAwaiting c/s of CTSUrg\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-07-17 00:00:00.000",
"description": "Report",
"row_id": 1611224,
"text": " CSRU SHIFT SUMMARY 7P-7A;\n\nNEURO; ALERT, ORIENTED, FOLLOWS COMMANDS, AND ANSWERS QUESTIONS APPROP. MOVES ALL EXTREMITIES WELL AND EQUAL BILATERAL BUT REMAINS VERY WEAK AND NOT OF NORMAL STRENGTH.\n\nRESP; LUNGS CLEAR COUGHING AND RAISING THICK CLEAR TO SLIGHTLY YELLOWISH SECREATIONS AT TIMES. 02 SAT'S BOARDERLINE RUNNING 91-94% ON 5L N/C. RESP RATE WNL. PT INSTRUCTED IN USE OF I.S. AND ABLE TO PULL TITAL VOL. WITH0UT DIFFICULTY.\n\nCARDIOVAS; SR WITH OCC PAC'S AND PVC'S. MAP AND SBP WNL.\n\nGI; BS PRESENT. TAKING AND TOL. PO'S WELL WITH NO C/O'S OF NAUSEA. FIB AND DRAINING MOD AMTS OF THICK LIQUID DARK BROWN STOOL WHICH WAS GUIAUC POS. THIS AM. WILL LET TEAM KNOWN THIS AM WHEN ROUNDING.\n\nGU; HOURLY URINE OUTPUT > 30CC\n\nCOMFORT; DENIES ANY PAIN WHEN ASKED.\n\nSKIN; POOR TURGOR.\n\nPLAN; CONT TO MONITOR AND ASSESS. PULMONARY TOLIET AND TRANSFER TO 2 THIS AM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-07-12 00:00:00.000",
"description": "Report",
"row_id": 1611211,
"text": "Update\nO: Pt remains minimally responsive despite no sedation. Opens eyes w stim otherwise no other movements noted. Perl at 2-3mm brisk reactive. Opens eyes to verbal stim unable to focus.Facial grimace w suctioning.\n\nCv status: sr w occ pvc noted.Bp stable on no drips.\nCirc adeq distal pulses weak palp bilat.\n\nResp status: rr^ and sats dwn at 2300. Ambu and suction for thick plugs to thick tan secretions. Bilat brth snds distant cl brth snds.O2 sats initially 94% subseq to turning repositioning,ambu and drainage of sm amts pl fld-> sats ^ 96%.Despite suctioned for lg thick sputum brth snds remain relatively unchanged.\n\nGi status: hypoactive bowel snds +. green bilious drng via ogt.on protonix and sucralfate d/t preop hx gib and tear.\n\nGu status: huo qs cl yellow urine.\n\nLabs: Am labs pending. . Abg adeq although paO2 slt decr in past 12hrs.\n\nA/P: Postop day 2 cab w hx agitation(? etoh related) preop req narcotics/sedatives/intubation.Remains unresponsive ? r/t preop sedation requirements. Check am labs and rx. Diminishing paO2 ? fld overload vs secretions. Cont w aggressive pulm toilet , wean to extubate when fully responsive.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-07-12 00:00:00.000",
"description": "Report",
"row_id": 1611212,
"text": "S-Intubated\n\nO-Neuro status essentially unchanged. Not following commands but eyes open most of the time with no tracking however. PS decreased to 10\nand pt tol well with adequate ABG (See CareVue). L/S-coarse to clear with dimished sounds at the bases. Suctioned Q2H for tan/brown thick secretions requiring saline lavage. Chest tube changed to a single tube on the left with a new pleurovac which is draining serosangious fluid. No crepitus. MD off but epi wires remain .\nPt did require short period of APacing prior to off. MD aware.\nFSBS WNL. TF initiated at 20 ccs/hr via NGT. Tolerating well with no residual. JP Bulb to suction leg: scant amt of drainage.\n\nA-Off sedation-awaiting pt to be more alert to extubate\n\nP-Continue to assess neuro's and ability to extubate, follow FSBS,\ncontinue current therapy.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-07-12 00:00:00.000",
"description": "Report",
"row_id": 1611213,
"text": "SEEMS MORE AWARE & SLIGHTLY MORE REACTIVE W PRODING. ABLE TO BLINK ONCE OR TWICE FOR YES & NO. SPONT. MOVEMENT NOTED OF LOWER EXT. W TURNING & HOYERING OOB.+ WITHDRAWAL BILAT. TO NAILBED PRESSURE W HANDS BUT NO MOTOR RESPONSE TO COMMAND. NOT MAKING EYE CONTACT W R.N. OR WIFE. PHONE CONVO W SISTER WHO REPORTS PT. APPEARRED TO BE SEVERELY DEPRESSED PRE OP. NOT INTERACTIVE W FAMILY,ANORECTIC,NOT LEAVING THE HOUSE & ABUSING ETOH & CIGS. SKIN UNCHANGED,WEEPING FROM PUNCTURE SITES,THIN & FRIABLE. WAFFLES APPLIED FOR RED HEELS & 1ST STEP MATTRESS OBTAINED. HOYERED OOB X 3 HRS,TOL.WELL. ADVANCING TF'S AS TOLERATED W MIN. RESIDUAL.LABS AS PER FLOW SHEET.BP IN BETTER CONTROL W LOPRESSOR & HYDALAZINE. 1600 DOSE HELD FOR SBP < 95.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-07-05 00:00:00.000",
"description": "Report",
"row_id": 1611192,
"text": "CCU Nursing Progress Note 7p-7a:\n\nNeuro: Pt conts to be sedated on fentanyl 25mcg and Versed 4.0mg. Pt responds to painful stimuli. Opening eyes with turning. No spontaneous movement of extremities noted.\n\nCV: NSR 50-80's w/o ectopy. BP 97-119/53-63. HCT 30.8 K+ 4.6.\nIVF cont at 100cc/hr. Pt to undergo cardiac cath when afebrile x 24hr. Dopperable pulses. R C/D/I.\nPt with total body edema. +Fluid status .\n\nPULM: Mechanically ventilated on AC 700x12 Fi02 50%(increased last evening in presence of decreased sats to 90%/plug). LS coarse throughout. Pt sxn'd q1-2hr for copious amts of thick white to yellowish sputum requiring lavage. Pt with large amts of oral secretions.\nABG 7.32/29/100/-9 this am, increase rate to 14 please check ABG. ETT rotated. Sats 96-98%. RR 12-20.\n\nGI: Abd soft with hypoactive BS. NPO. No signs of GIB. No stool this shift.\nConts on protonix IV to be discontinued at 8am and changed to .\n\nGU: Foley cath patent draining cyu. Pt autodiuresed overnight. BUN 21 Creat 1.7. + 238 since mn.\n\nID: tmax 99.8R. Conts on abx, covering a sputum and urine.\n\nSKIN: Heels red.\n\nPROPH: Hep sc and pneumoboots for DVT proph.\n\nLINES: R IJ TLC and L radial a-line\n\nSOCIAL: son in law called last evening.\nWatch on R wrist and gold ring on L hand.\n\nDISPO: Full Code.\n\nA: Increased secretions overnight.\n Stable BP and HR.\n Low grade temp to 99.8R.\n\nP: Check ABG at 8am. Follow VS. ?Cardiac Cath today.\nNPO. Skin Care.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-07-05 00:00:00.000",
"description": "Report",
"row_id": 1611193,
"text": "Nursing Progress Note 0700-1900\n\nNeuro: Remains sedated on Fentanyl 25mcg and Versed 4mg drips. Opens eyes with turning and suctioning. +protective reflexes. No spontaneous movements noted. Wrist restraints removed.\n\nCv: hr 50-60s sb/nsr, No ectopy. BP 90s-110s Map >60. IVf d5.45ns @100cc/hr. Pedal pulses . bilateral radial pulses difficult to palpate. L hand/arm cool, +edema, fingers mottled with > 3 sec cap refill. CCU team aware. L radial a-line dc'd with catheter ; drsg . R hand/arm cool, 1+ edema, fingers pale with > 3 sec cap refill. Bilateral arms elevated on pillows. + Generalzied edema noted.\n\nPulm: Intubated. Vent settings: Ac rate 16 Tv 700 fio2 40% Peep 5. Lungs coarse in bases, clearer in apices. Suction Q1-2hr small-moderate amts of thick white. spo2 > 95%. Last ABG: 7.32/28/83/15 before rate change to 16. Repeat ABG not drawn; CCU team (Dr. aware.\n\nGi: Npo. Abdomen soft, non distended, hypoactive BS. No flatus, no bm.\n\nGu : foley patent, draining clear yellow urine.\n\nLines: R IJ TLC\n\nID: afebrile. continues on Vanco, Cefepime, flagyl, cipro.\nSocial: Family visited and updated on pt condition/plan of care.\n\nA/P: Monitor hemodynamics, perfusion to BUEs, Monitor ABG, Metabolic acidosis. Continue antibiotics. Skin care, turn q2hrs. Update family on pt status/plan of care. ?c. cath tomorrow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-07-03 00:00:00.000",
"description": "Report",
"row_id": 1611187,
"text": "ADDENDUM: B/P trending down- MAP's < 60- HO called- T 100.2 rectally-\nNS 500cc fld bolus ordered & infusing B/P 104/56- labs drawn- blood cultures X 2 ordered & done.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-07-04 00:00:00.000",
"description": "Report",
"row_id": 1611188,
"text": "Respiratory Care:\nPt. continues on unchanged vent settings this shift. ABG's well oxygenated with partially compensated metabolic acidosis. Pan CX's sent for temps>>blood and urine pending, sputum + GNR's. B/S scattered rhonchi>>ETS for moderate, thick, yellow. Pt. appears well sedated and synchronous with vent support. Will monitor and adjust settings per clinical picture. Pt. awaiting cath lab procedure; presently on hold due to sepsis.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-07-04 00:00:00.000",
"description": "Report",
"row_id": 1611189,
"text": "7p-7a Nursing Note:\n\nNeuro: Pt. sedated on fentanyl @ 25mcg/hr and versed gtt @ 4mg/hr. Pt opens eyes to verbal stimuli, not following commands. Responsive to painful stimuli, no movement noted of extremities. Bil wrist restraints in place.\n\nResp: Pt maintained on mechanical vent: CMV 12/TV 700/.40/5. Pt sxn's for mod amt of thick white secreation. Sputum culture showing gram neg rods. BS course bil. SPO2 99-100%. Am ABG results: 7.37/25/135/15.\n\nCV: Tele: SB 43-49. Res aware. BP 90-100's/70's via L radial A line. IV lopressor held for SBP < 100. R IJ TLC patent for protonix gtt @8mg/hr and D5 1/2 NS 100cc/hr + Banana bag Qday. 1gm Ca gluconate given, Ca 6.8. Distal pulses palpable at beginning of shift. LE cool, audible with DP toward end of shift. EKG done this am per res order.\n\nGI/GU: Pt NPO ABD flat/soft, no BS present. Pt on IV protonix as mentioned above. No BM this shift. Foley in place draining yellow urine. 1200cc out this shift.\n\nPlan:\nMonitor VS/Pulm status/I&O's\nSurgery pending for increased temp on \n\n , RN\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-07-04 00:00:00.000",
"description": "Report",
"row_id": 1611190,
"text": "Nursing Progress Note 0700-1900\n\nS/O:\nNeuro: Remains sedated on fentanyl and versed drips. Open eyes to stimuli. + protective reflexes. Perrl 3.0mm. Localizes to stimuli; very little movement of extremities.\n\nCv: HR 40-60s NSR/SB no ectopy noted. Occasional irregular rhythm ?Occasional missed beat. AM EKG done; MDs aware. Lopressor dc'd. BP 90-100s MAP > 60. PT/DP pulses; no edema. R IJ TLC patent, drsg . IVF d5.45ns @ 100cc/hr. Serum K and Mg levels 3.7 and 1.7; electrolytes repleted.\n\nPulm: Orally intubated; mechanically ventilated on AC 12 Tv 700 Fio2 40% Peep 5. Lungs diminished in bases. ETT suction for small amts thick white. PM ABG: 7.35/26/85/15 BE -9 - Compensated metabolic acidosis. MD aware; no vent changes ordered.\n\nGI: NPO, ABd soft, non distended. + BS. No flatus/ No bm. NO s/s of GIB\n\nGU: Foley patent, draining clear yellow urine.\n\nID: Tmax 99.9. Urine culture + for S.Aureus and Enterococcus. foley changed. Pt started on flagyl, continues on Cipro, Vanco, and Cefepime.\n\nskin: SKin ; no breakdown noted.\n\nSocial: Family visited and updated on pt status and plan of care.\n\nA/P: Monitor hemodynamics and labs and replete electrolytes, monitor ABGs, acidosis. If pt remains afebrile for 24hrs, then plan for c. cath.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-07-04 00:00:00.000",
"description": "Report",
"row_id": 1611191,
"text": "Addendum to Nursing Note:\n\nPt HIT negative. Heparin SQ started and compression boots on for DVT prophylaxis.\n"
},
{
"category": "Echo",
"chartdate": "2187-06-29 00:00:00.000",
"description": "Report",
"row_id": 73078,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. S/P L Main dissection\nWeight (lb): 141\nBP (mm Hg): 157/80\nStatus: Inpatient\nDate/Time: at 09:50\nTest: Portable TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is normal in size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.\n\nLEFT VENTRICLE: Left ventricular wall thicknesses are normal. The left\nventricular cavity size is normal. Overall left ventricular systolic function\nis mildly depressed.\n\nLV WALL MOTION: The following resting regional left ventricular wall motion\nabnormalities are seen: basal inferolateral - dyskinetic; mid inferolateral -\ndyskinetic; basal anterolateral - hypokinetic; mid anterolateral -\nhypokinetic;\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTA: The aortic root is mildly dilated.\n\nAORTIC VALVE: The aortic valve leaflets appear structurally normal with good\nleaflet excursion. No aortic regurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. Mild (1+) mitral\nregurgitation is seen.\n\nPERICARDIUM: There is no pericardial effusion.\n\nGENERAL COMMENTS: Image quality was suboptimal.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity size is normal. Overall left ventricular\nsystolic function is mildly depressed. Resting regional wall motion\nabnormalities include basal and mid posterolateral dyskinesis and possible\n(though difficult to be sure given the limited views) basal and mid lateral\nwall hypokinesis. Right ventricular chamber size and free wall motion are\nnormal. The aortic root is mildly dilated. The aortic valve leaflets appear\nstructurally normal with good leaflet excursion. No aortic regurgitation is\nseen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral\nregurgitation is seen. There is no pericardial effusion.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2187-06-28 00:00:00.000",
"description": "Report",
"row_id": 174607,
"text": "Sinus tachycardia with probable AV wenckebach\nLead(s) unsuitable for analysis: V4 V6\nInferior ST elevation, consistent acute infarction\nMarked ant/septal STj depression is probably reciprocal to inferior infarct\nLateral T wave changes may be due to myocardial ischemia\nRepolarization changes may be partly due to rhythm\nNo previous report for comparison\n\n"
},
{
"category": "ECG",
"chartdate": "2187-07-10 00:00:00.000",
"description": "Report",
"row_id": 174601,
"text": "Sinus rhythm\nLow limb leads voltage\nPrior inferoposterior myocardial infarction\nT wave changes are nonspecific\nSince previous tracing , sinus bradycardia absent and Q-T interval\ndecreased\n\n"
},
{
"category": "ECG",
"chartdate": "2187-07-04 00:00:00.000",
"description": "Report",
"row_id": 174602,
"text": "Irregular sinus bradycardia\nLow QRS voltages in limb leads\nPrior inferposterior myocardial infarction\nNondiagnostic lateral T wave changes\nSince previous tracing, T wave flattening in lead V1 more pronounced\n\n"
},
{
"category": "ECG",
"chartdate": "2187-07-02 00:00:00.000",
"description": "Report",
"row_id": 174603,
"text": "Irregular sinus bradycardia\nLateral ST-T changes are nonspecific\nLow QRS voltages in limb leads\nPrior inferoposterior myocardial infarction - ? age - possible acute/recent\nP-R interval 0.160\nSince previous tracing , precordial T wave slight less prominent\n\n"
},
{
"category": "ECG",
"chartdate": "2187-06-29 00:00:00.000",
"description": "Report",
"row_id": 174604,
"text": "Sinus rhythm\nInferior infarct - possibly acute\nTall R V1/V2 consistent with posterior myocardial infarct\nLateral ST changes are nonspecific\nSince previous tracing, no significant change except for correwstion of lead\nreversal\n\n"
},
{
"category": "ECG",
"chartdate": "2187-06-29 00:00:00.000",
"description": "Report",
"row_id": 174605,
"text": "Sinus rhythm\n*** arm lead reversal - only aVF, V1 - V6 analyzed ***\nProbable inferior infarct - posterior myocardial infarct\nSince previous tracing, AV block no longer present\nST segment more isoelectric - also evidenece of posterior myocardial infarct\nevolved\n*********Suggest repeat tracing given lead reversal*********\n\n"
},
{
"category": "ECG",
"chartdate": "2187-06-29 00:00:00.000",
"description": "Report",
"row_id": 174606,
"text": "Sinus rhythm with AV wenckebach\nAcute inferior infarct\nMarked ant/septal STj depression is probably reciprocal to inferior infarct\nLateral ST-T changes may be due to myocardial ischemia\nSince previous tracing, sinus rhythm has slowed\n\n"
}
] |
10,912 | 135,957 | The patient was admitted to the for further treatment and evaluation. The plan at this point was to bring the patient to the operating room for total mastectomy. In addition she would also undergo an immediate reconstruction with possible flap that would be performed by Dr. and Dr. , a combination procedure between the breast surgery service and the plastic surgery service. On the day of admission, the patient was brought to the operating room, , and the operation was performed; a skin-sparing right total mastectomy and reconstruction using an SIEA flap. The patient tolerated the procedure well and received 5.7 L of Crystalloid fluid, and her estimated blood loss was 250 ml. In the immediate postoperative period, there was noted loss of Doppler signal over the SIEA flap requiring an immediate return to the operating room. After heparin was bolused at 5000 units, a signal was retrieved, and the arm had been abducted, and temperature was elevated. The patient was intensive care unit at this time being monitored carefully, and heparin drip was started at 500 units/hour with checks of PTT to make sure that she not in a supratherapeutic range, and plan was to keep the body in room temperature, warm. In the period after this, the patient was noted to be stable, and this plan continued to be followed. On postoperative day #1, the patient was able to be extubated, and the heparin drip was continued. Also of note, the patient was able to start taking clears on postoperative day #1. Flap checks were continued at this time and were unchanged while the patient was in the intensive care unit. The patient was receiving IV cephazolin at this point for prophylactic coverage. In the early morning of postoperative day #4, the house officer was called to the bed side in regard to the patient's lost Doppler signal at the 1 a.m. check. The arm was abducted, and supportive maneuvers were made, but the flap was still noted to be pale and cool at this time. Heparin subcutaneously was started stat, and IV heparin was resumed, and Lovenox was started as well at this time while flap monitoring was continued. The plan was for possible return to the operating room for debridement versus excision of tissue that could possibly become nonviable, and on , postoperative day #6, the patient was without complaint and was being monitored closely for any signs of infection or imminent sloughing of the flap. On postoperative day #7, the patient that she was feeling better, and that her pain was very well controlled, and she was tolerating a diet. On exam, the flap was explored with the Doppler, and it revealed good arterial signal and good venous signal at this time. There was some blistering and some signs of congestion, but the flap did not look to be in imminent concern at this time. Thus there was a question of whether we were dealing with epidermolysis versus deeper tissue necrosis and whether there would be need for return to the operating room due to the equivocal nature of our exam. Thus the plan at this time was to discharge the patient to home and bring back to the clinic within 48 hours for further assessment and reevaluation of the plan. The patient was continued on Keflex, continued on Lovenox, and continued on oral pain medicine. | LUNG OSUDNS CLEAR, DIM IN BASES.GI: ABD. pt voiding w/o difficulty via foley cath, u/o in sufficient quantaties. GEN. NONPITTING EDEMA.RESP: ON 2L NC. Pt w/ stable pulses in graft, ? HEMODYNAMICALLY STABLE.P: CONT W/ FREQUENT FLAP CHECKS. accuracy of hct recheck this PM. Mild ecchymosis noted. Pt suctioned for scant secretions, breath sounds clear in upper lobes bilaterally yet diminished at bases.GI- abd soft w/ incision intact and bilateral JP drains. Pt very compliant with this.RESP...Extubated this am after trial of PS. KEFZOL.SKIN: FLAP SITE BENIGN. Abd incision well approximated. WHEN AWAKE, TOLERATES BEING OFF O2. SLIGHT ECCHYMOSIS NOTED. INCISION C&D. Pt medicated w/ percocet two tabs times one at ~1am w/ mild relief noted. ATIVAN AS NEEDED. CLOTS NOED IN R BREAST JP,STRIPPED TUBES X1. TSICU NPN 7P-11P:CARE ASSUMED. +PALP DP AND PT PULSES BILAT. ANZAMET RESOLVED BOUT OF NAUSEA. HCT 29.3ID: TMAX 100.4. HYPO BS. Respiratory Care NotePt received from OR and placed on CPAP + PS as noted. MEDICATED WITH ANZAMET WITH GOOD EFFECT. Flap with good color and cap refill. Well controlled with PCA, but needs use reinforced.CV....NSR with no ectopy seen. RELIEVED BY REPOSITIONING. pt taking PO liquids w/o diff. Hct stable at 30.0. pt con't on IMV 12 x's 600, 40% and 5 of PEEP. LYTES WNL.GI: NPO. Extremities warm and dry w/ easily palpable pulses. EMOTIONAL SUPPORT.CV: SR NO ECTOPY. Graft sites on right breast w/ easily dopplerable pulses through out the shift.A/P - Pt stable over night, pulses remain intact, pt con't on heparin gtt w/ normal PTT. BP STABLE. Successfully weaned from vent and extubated then. FLAP CHECKS Q15MIN W/ STRONG DOPPLER SIGNAL. ADEQUATE U/O. Lung fields clear with mildly diminished bases. TACHYCARDIC TO 130 WHEN LIGHT.RESP: FULLY VENTED ON IMV 600X12, 50% AND 5PEEP W/ STABLE 02SAT AND ABG. Dr. will attempt.SKIN...Dsg intact under R breast--clean and dry. TAKING FLUIDS WELL. MS04 PRN AND WEAN PROPOFOL IN AM. Given precedex bolus and then turned propofol off. Pt readily breathing over vent when light, ABG wnl's. Provide for pt comfort. pt hemodynamically stable, slightly tachycardic w/ HR in the low 100's, increased when light as high as 120. pt hemodynamically stable in SR no ectopy, SBP from 100-120, extremities warm and dry w/ easily palpable pulses, right breast graft w/ easily dopplerable signals throughout the shift. PULM. ABD SOFT, BS ABSENT.HEME: REMAINS ON LOW DOSE HEPARIN GTT AFTER 5000U BOLUS IN OR. CONT IV HEPARIN AT LOW DOSE. d/c heparin gtt today per team. ****Flap checks---strong doppler signal in two spots. MAINTAIN INTUBATED AND SEDATED. REQUIRES FREQ. BRIEF VISIT W/ APPROPRIATE QUESTIONS ASKED. BS's absent at this time. CONT ON CEFAZOLIN.SKIN: PT KEPT IMMOBILE W/ RUE ABDUCTED ABT 60 DEGREES. Tolerated well. Limited scanning of the right upper inner breast was performed. Easily palpable peripheral pulses. STRONG DOPPLER SIGNALS. Dr. aware. Mso4 2mg given q 1-2hrs for pain. Mg repleted this am.ENDO... Coverage with 2U per RISS twice.ID....Tmax 99.7. CONT FAMILY AND PT SUPPORT. Anxious at times with brief periods of crying--ativan 0.5mg given x with good effect. KEEP RM TEMP WARM. Sliding scale for elevated BS's, lytes repleted. Taking in fluids well, doesn't want anything more at this time. Pt denies dizziness yet did c/o HA times one this AM.Resp- 2liters NC w/ RR 16-20, sats 94-98%, desats to 91% w/ o2 off and pt sleeping. Able to move hand--cap refill 3sec, strong radial pulse. FINAL REPORT INDICATION: Assess flap. SOFT, ROUNF. HR 90-110 NSR NO ECTOPY. HR 80's to low 100's. pt recieved from OR and kept on IMV through PM as planned. MEDICATED WITH ATIVAN 0.5MG IV WITH GOOD EFFECT. Abd soft with hypoactive BS.GU...Minimal urine output throughout the day---25-50cc/hr. No new orders.---Pt still needs to maintain R arm abducted and at 60degress. Pt on kefzol q 8hrs.Skin- right breast incision dry and intact, pale around graft area yet CSM's wnl's, no drainage except via JP drains. pt voiding via foley, u/o in sufficient quantities, pt anxious to get rid of foley, reports some burning sensation around cath.ID- temp max 100.0, current 99.6 po, con't on kefzol at this time.Endo- no coverage required this shift.Heme- hct as above, pt con't on 500units of heparin /hr ptt wnl's as well as platelets.A/ pt stable doing well, ? Also notified PLS attending Dr. . Plan to wean towards extubation when pt awakens. PROPOFOL AT 80MCG/KG/MIN AND PT RECEIVING MS04 PRN.CV: BP 100-120'S/65-70. Normal arterial and venous waveforms demonstrated at the site of the upper inner right breast reconstruction tissue flap. Using IS well--needs reminding.GI...Started clears this evening. DOPPLER SIGNALS REMAINS STRONG ON BREAST FLAP.NEURO: ALERT AND ORIENTED. LS CLEAR.RENAL: IVF AT 125CC/HR. DOPPLER SIGNAL RETURNED AND NO PROCEDURE WAS REQUIRED. IMPRESSION: 1. INFORMATION PROVIDED AND FAMILY WENT HOME.A: GD PERFUSION TO FLAP. Abdominal incision as above. Occaisional APC noted this AM, mag repleted for level of 1.4, and IVF changed to D5 w/ 40meq's KCL at 125 hr for k of 3.8. TSICU NPN 11P-7AS/O- pt alert and oriented, appropriate, pt c/o pain in right arm getting PCA yet diffuculty using it effectively secondary to swelling in hands and pain in right arm. ?PERCOCET FOR PAIN. PT NEEDS ASSISTANCE WITH PCA--HANDS TOO WEAK. PT TOLERATED BEING IN CHAIR X 45MINUTES. pt w/ temp max of 100.6 PO, room warmed w/ bair huggers and bair hugger over lower extremities, room kept warm per team for pt's circulation. SHE WAS ADMITTED TODAY FOR R MASTECTOMY AND SIEA FLAP. IVF AT 125/HOUR.ENDO: RISS.ID: LG TEMPS. Abd soft intact w/ lateral incision, hypo active bowel sounds, pt denies nausea yet does not report having any appetite yet. SCANT SECRETIONS. ARM REPOSITIONED, RM TEMP INCREASED AND PT WAS W/ 5000U HEPARIN . pt w/ blood sugars 150-160's so sliding scale initiated per HO. Kefzol coverage.HEME....Heparin drip infusing at 500U/hr. R BREAST JP AND 2 ABD JP'S CONT TO DRAIN SM-MOD AMTS OF THICK SANGUINOUS DNGE. | 10 | [
{
"category": "Radiology",
"chartdate": "2186-04-28 00:00:00.000",
"description": "UNILAT BREAST US",
"row_id": 864534,
"text": " 4:34 PM\n UNILAT BREAST US Clip # \n Reason: Please perform duplex ultrasound to evaluate anastamosis s/p\n Admitting Diagnosis: RIGHT BREAST CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old woman with\n REASON FOR THIS EXAMINATION:\n Please perform duplex ultrasound to evaluate anastamosis s/ flap.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Assess flap.\n\n Limited scanning of the right upper inner breast was performed. Mostly venous\n flow is identified at the upper inner breast at the skin marking. Arterial\n flow is identified at the approximately 1 o'clock position.\n\n IMPRESSION:\n\n 1. Normal arterial and venous waveforms demonstrated at the site of the upper\n inner right breast reconstruction tissue flap.\n\n"
},
{
"category": "Radiology",
"chartdate": "2186-04-24 00:00:00.000",
"description": "ABD (SINGLE VIEW ONLY)",
"row_id": 863967,
"text": " 4:34 PM\n ABD (SINGLE VIEW ONLY) Clip # \n Reason: LOST NEEDLE\n Admitting Diagnosis: RIGHT BREAST CANCER/SDA\n ______________________________________________________________________________\n FINAL REPORT\n\n ABDOMEN SINGLE VIEW:\n\n HISTORY: Lost surgical needle.\n\n No surgical needle is identified. The diaphragms are not included on this\n film.\n\n"
},
{
"category": "Radiology",
"chartdate": "2186-04-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 863968,
"text": " 4:34 PM\n CHEST (PORTABLE AP) Clip # \n Reason: LOST NEEDLE\n Admitting Diagnosis: RIGHT BREAST CANCER/SDA\n ______________________________________________________________________________\n FINAL REPORT\n\n This is an intraoperative examination of the upper abdomen and lower chest.\n\n HISTORY: Lost needle.\n\n There are metallic clips seen in the right axillary area as well as the right\n lower chest and right upper quadrant. There is no evidence of opaque needles\n in the visualized part of the chest or abdomen.the study was obtained in the\n AP portable supine position.\n\n IMPRESSION: The lost needle is not visualized.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-04-24 00:00:00.000",
"description": "Report",
"row_id": 1405894,
"text": "Respiratory Care Note\nPt received from OR and placed on CPAP + PS as noted. Pt is 38 yo female s/p mastectomy with recostruction. Plan to wean towards extubation when pt awakens.\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-04-24 00:00:00.000",
"description": "Report",
"row_id": 1405895,
"text": "TSICU NSG ADMIT NOTE\nO: 38 Y/O FEMALE W/ HX OF R BREAST CA S/P R BREAST LUMPECTOMY W/ F/U CHEMO AND XRT IN . PT WAS NOTED TO HAVE INCREASED CALCIFICATION IN R BREAST NEAR NIPPLE AND HAD NEEDLE BX IN . SHE WAS ADMITTED TODAY FOR R MASTECTOMY AND SIEA FLAP. ADMITTED TO TSICU FOR FREQUENT FLAP CHECKS.\n\nPMH:\nAPPY \nEX LAP FOR LOA \nR BREAST CA AS ABOVE\n\nSH: MARRIED AND LIVES W/ HUSBAND AND 1 CHILD.\n\nALLERGIES:\nLATEX\nPLASTIC TAPE\n\nMEDS:\nLEVOXYL .25 QD\n\nPT ARRIVED FROM OR AT 17:30 PM INTUBATED ON PSV 5/5 W/ STABLE VS. UNABLE TO DOPPLER PULSES OVER FLAP AND CSM DETERIORATING. PT RETURNED TO OR AT 1800. ARM REPOSITIONED, RM TEMP INCREASED AND PT WAS W/ 5000U HEPARIN . DOPPLER SIGNAL RETURNED AND NO PROCEDURE WAS REQUIRED. RETURNED TO AT 19:30PM PARALYZED AND SEDATED W/ STABLE VSS. TUBES/LINES: ETT (7.0), L RADIAL ART LINE, #18 IV L HAND, #18 IV R FOOT, FOLEY CATHETER, R AND L ABD JP TO BULB SXN, R BREEAST JP TO BULB SXN.\n\n\nROS:\nNEURO: PT SEDATED ON PROPOFOL GTT, LIGHTENED X2, UNABLE TO FOCUS OR FOLLOW COMMANDS, THRASHING IN BED. PROPOFOL AT 80MCG/KG/MIN AND PT RECEIVING MS04 PRN.\n\nCV: BP 100-120'S/65-70. HR 90-110 NSR NO ECTOPY. TACHYCARDIC TO 130 WHEN LIGHT.\n\nRESP: FULLY VENTED ON IMV 600X12, 50% AND 5PEEP W/ STABLE 02SAT AND ABG. SCANT SECRETIONS. LS CLEAR.\n\nRENAL: IVF AT 125CC/HR. ADEQUATE U/O. LYTES WNL.\n\nGI: NPO. ABD SOFT, BS ABSENT.\n\nHEME: REMAINS ON LOW DOSE HEPARIN GTT AFTER 5000U BOLUS IN OR. PTT 55.5. HCT 29.3\n\nID: TMAX 100.4. PT W/ BAIR HUGGER ON TO KEEP WARM FOR FLAP. CONT ON CEFAZOLIN.\n\nSKIN: PT KEPT IMMOBILE W/ RUE ABDUCTED ABT 60 DEGREES. FLAP CHECKS Q15MIN W/ STRONG DOPPLER SIGNAL. R BREAST JP AND 2 ABD JP'S CONT TO DRAIN SM-MOD AMTS OF THICK SANGUINOUS DNGE. CLOTS NOED IN R BREAST JP,\nSTRIPPED TUBES X1. RED RASH TO FACE ?D/T PLASTIC TAPE APPLIED IN OR TO SECURE ETT. RETAPED W/ CLOTH TAPE.\n\nSH: HUSBAND, MOTHER AND SISTER WERE IN TO VISIT. ALL ARE CLOSE AND SUPPORTIVE OF EACH OTHER. BRIEF VISIT W/ APPROPRIATE QUESTIONS ASKED. INFORMATION PROVIDED AND FAMILY WENT HOME.\n\nA: GD PERFUSION TO FLAP. HEMODYNAMICALLY STABLE.\n\nP: CONT W/ FREQUENT FLAP CHECKS. KEEP RM TEMP WARM. IMMOBILE OVERNOC W/ R ARM ABDUCTED 60 DEGREES. MAINTAIN INTUBATED AND SEDATED. MS04 PRN AND WEAN PROPOFOL IN AM. CONT IV HEPARIN AT LOW DOSE. CONT FAMILY AND PT SUPPORT.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-04-25 00:00:00.000",
"description": "Report",
"row_id": 1405896,
"text": "TSICU NPN 11p-7a\nS/O\n\n pt con't sedated on propofol w/ intermittant morphine for pain, Propofol at 70-80mcgs/kg/min. When lightened for neuro checks pt very restless, MAE's and squirming in bed, opening eyes to voice yet not able to lighten enough to have pt follow commands secondary to increased activity so pt resedated at this time to allow for minimal movement per plastic surgery team. PERL at 3-4mm. Mso4 2mg given q 1-2hrs for pain.\n\n pt hemodynamically stable, slightly tachycardic w/ HR in the low 100's, increased when light as high as 120. Occaisional APC noted this AM, mag repleted for level of 1.4, and IVF changed to D5 w/ 40meq's KCL at 125 hr for k of 3.8. Extremities warm and dry w/ easily palpable pulses. Pt con't on heparin gtt at 500units per hr , AM ptt 27.4 ( from 55.8 post-op yet pt had recieved bolus in OR). Ho aware, opting to leave gtt at 500 units per hr per plan. Hct stable at 30.0.\n\n pt con't on IMV 12 x's 600, 40% and 5 of PEEP. Pt readily breathing over vent when light, ABG wnl's. Pt consistently saturating at 100%. Pt suctioned for scant secretions, breath sounds clear in upper lobes bilaterally yet diminished at bases.\n\nGI- abd soft w/ incision intact and bilateral JP drains. BS's absent at this time. No gastric tube or GI prophalaxis at this time.\n\n pt voiding w/o difficulty via foley cath, u/o in sufficient quantaties.\n\n pt w/ blood sugars 150-160's so sliding scale initiated per HO. Pt given 2units regular insulin for BS of 160, FS due at 8am.\n\n pt w/ temp max of 100.6 PO, room warmed w/ bair huggers and bair hugger over lower extremities, room kept warm per team for pt's circulation. Pt on kefzol q 8hrs.\n\nSkin- right breast incision dry and intact, pale around graft area yet CSM's wnl's, no drainage except via JP drains. Abdominal incision as above. Unable to visualize backside at this time secondary to movement restrictions. Graft sites on right breast w/ easily dopplerable pulses through out the shift.\n\nA/P - Pt stable over night, pulses remain intact, pt con't on heparin gtt w/ normal PTT. unable to lighten sedation for any great length of time secondary to restlessness and agitation, may need ativan to allow pt to lighten better off propofol. Sliding scale for elevated BS's, lytes repleted.\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-04-25 00:00:00.000",
"description": "Report",
"row_id": 1405897,
"text": "pt recieved from OR and kept on IMV through PM as planned.\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-04-25 00:00:00.000",
"description": "Report",
"row_id": 1405898,
"text": "TSICU NPN (0700-1900)\nREVIEW of SYSTEMS:\n\nNeuro...Intitially on propofol for sedation, but when attempted to lighten in order to wean from vent, pt became very restless, moving about in bed, not following commands. Given precedex bolus and then turned propofol off. Successfully weaned from vent and extubated then. Once extubated, pt very and cooperative, following all commands. A&Ox3. Anxious at times with brief periods of crying--ativan 0.5mg given x with good effect. PCA morphine started to aide with pain control. Pt c/o pain mainly in R arm--occasionally to abd and back. Well controlled with PCA, but needs use reinforced.\n\nCV....NSR with no ectopy seen. HR 80's to low 100's. BP ranging 90-110's/50-60's with MAP's 60-70's. Easily palpable peripheral pulses. ****Flap checks---strong doppler signal in two spots. Flap with good color and cap refill. Mild ecchymosis noted. R hand--pt c/o numbness and tingling in hand and fingers. Able to move hand--cap refill 3sec, strong radial pulse. PLS resident notified and in room to assess pt. Also notified PLS attending Dr. . No new orders.\n---Pt still needs to maintain R arm abducted and at 60degress. Pt very compliant with this.\n\nRESP...Extubated this am after trial of PS. Tolerated well. Quickly weaned to NC at 2L with sats >98%. RR teens. Lung fields clear with mildly diminished bases. Using IS well--needs reminding.\n\nGI...Started clears this evening. Taking in fluids well, doesn't want anything more at this time. Abd soft with hypoactive BS.\n\nGU...Minimal urine output throughout the day---25-50cc/hr. Dr. aware. Did not want bolus at this time. Mg repleted this am.\n\nENDO... Coverage with 2U per RISS twice.\n\nID....Tmax 99.7. Kefzol coverage.\n\nHEME....Heparin drip infusing at 500U/hr. No changes per PLS team. Will leave drip until tomorrow. Attempting to send random PTT, but unable to get blood draw yet. Dr. will attempt.\n\nSKIN...Dsg intact under R breast--clean and dry. Abd incision well approximated. JP x2 to abd and x1 to R breast area with moderate amts of sanguinous drg.\n\nSOCIAL... mom and husband in for visit.\n\nPLAN...Flap checks Q1hr---check with PLS at 1900(24hrs post OR) to see if can decrease checks. Provide for pt comfort. Promote mobility. transfer to floor tomorrow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-04-26 00:00:00.000",
"description": "Report",
"row_id": 1405899,
"text": "TSICU NPN 7P-11P:\n\nCARE ASSUMED. PT OOB TO CHAIR WITH 2 MINIMAL ASSISTS. STEADY ON HER FEET. C/O DIZZINESS AND NAUSEA. MEDICATED WITH ANZAMET WITH GOOD EFFECT. PT TOLERATED BEING IN CHAIR X 45MINUTES. FAMILY IN VISITING. BACK TO BED. MEDICATED WITH ATIVAN 0.5MG IV WITH GOOD EFFECT. PT NEEDS ASSISTANCE WITH PCA--HANDS TOO WEAK. SLEEPING UNLESS DISTURBED FOR FLAP CHECKS. DOPPLER SIGNALS REMAINS STRONG ON BREAST FLAP.\n\nNEURO: ALERT AND ORIENTED. MAE WEAKLY. STRONG ON HER FEET WHEN AMBULATING TO CHAIR. C/O RIGHT ARM PAIN WITH NUMBNESS AND PRICKLING FEELING IN LOWER PART AND HAND. RELIEVED BY REPOSITIONING. REQUIRES FREQ. EMOTIONAL SUPPORT.\n\nCV: SR NO ECTOPY. BP STABLE. +PALP DP AND PT PULSES BILAT. GEN. NONPITTING EDEMA.\n\nRESP: ON 2L NC. WHEN AWAKE, TOLERATES BEING OFF O2. WHEN SLEEPING, SATS TO 92-93% ON ROOM AIR. I.S 500-750CC. LUNG OSUDNS CLEAR, DIM IN BASES.\n\nGI: ABD. SOFT, ROUNF. HYPO BS. TAKING FLUIDS WELL. ANZAMET RESOLVED BOUT OF NAUSEA. NO VOMITING.\n\nGU: FOLEY WITH CLEAR YELLOW URINE. IVF AT 125/HOUR.\n\nENDO: RISS.\n\nID: LG TEMPS. KEFZOL.\n\nSKIN: FLAP SITE BENIGN. STRONG DOPPLER SIGNALS. SLIGHT ECCHYMOSIS NOTED. JP DRAIN WITH SMALL AMOUNT BLOODY DRAINAGE. ABD. INCISION C&D. JP DRAINS X2 WITH BLOODY DRAINAGE. BACK INTACT.\n\nSOCIAL: HUSBAND, SISTER, MOTHER AND SON IN AND UPDATED. VERY ANXIOUS ABOUT HER. ASKING APPROPRIATE QUESTIONS. SUPPORT GIVEN AS NEEDED.\n\nPLAN: CONTINUE WITH FLAP CHECKS Q1 HOUR OVERNIGHT PER PLASTICS TEAM. INCREASE ACTIVITY. EMOTIONAL SUPPORT.?PERCOCET FOR PAIN. ATIVAN AS NEEDED. PULM. TOILET. FAMILY COMMUNICATION.\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-04-26 00:00:00.000",
"description": "Report",
"row_id": 1405900,
"text": "TSICU NPN 11P-7A\nS/O-\n\n pt alert and oriented, appropriate, pt c/o pain in right arm getting PCA yet diffuculty using it effectively secondary to swelling in hands and pain in right arm. Pt medicated w/ percocet two tabs times one at ~1am w/ mild relief noted. Pt able to sleep intermittantly, med w/ ativan .5mg times one this AM as well secondary to pt anxious and not able to get back to sleep, pain after ativan down to 5 on pain scale from earlier. Increased strength in right arm this am.\n\n pt hemodynamically stable in SR no ectopy, SBP from 100-120, extremities warm and dry w/ easily palpable pulses, right breast graft w/ easily dopplerable signals throughout the shift. Hct down this AM to 24.4 from 30 yesterday, sample drawn from IV after discard drawn, ?accuracy vs mobilization of 3rd spaced fluids. Pt denies dizziness yet did c/o HA times one this AM.\n\nResp- 2liters NC w/ RR 16-20, sats 94-98%, desats to 91% w/ o2 off and pt sleeping. BS's clear bilaterally , doing 500-750 cc's on IS.\n\n pt taking PO liquids w/o diff. Abd soft intact w/ lateral incision, hypo active bowel sounds, pt denies nausea yet does not report having any appetite yet. Not passing any gas yet either.\n\n pt voiding via foley, u/o in sufficient quantities, pt anxious to get rid of foley, reports some burning sensation around cath.\n\nID- temp max 100.0, current 99.6 po, con't on kefzol at this time.\n\nEndo- no coverage required this shift.\n\nHeme- hct as above, pt con't on 500units of heparin /hr ptt wnl's as well as platelets.\n\nA/ pt stable doing well, ? accuracy of hct recheck this PM. Pt w/ stable pulses in graft, ? d/c heparin gtt today per team. Con't to advance rehab as tolerated, oob to chair as ordered.\n"
}
] |
93,155 | 137,463 | 69yo M with PMH of seizure disorder, multiple strokes with residual severe neurological deficit with bilateral hemiparesis right worse than left and severe aphasia and history of SDH x 2, prostate CA, MDD, poor swallowing and h/o aspiration PNA, HTN who was transferred from OSH after having at least three witnessed seizures at home and three seizures in OSH ED without intervening return regaining consciousness. This was in the setting of missing his AED doses on the morning of although he had taken his evening doses. He continued to be poorly responsive in OSH ED. He was then transferred to for evaluation of possible status epilepticus. Intubated in ED for airway protection on . He was transferred to the neurological ICU for further observation. He was started on IV Keppra 1g (it had also been the intention of his outpatient neurologist to start him on keppra prior to admission) and given his missed doses of AEDs was given an extra dose of Tegretol 800mg. He was found to have a UTI on U/A which later grew enterococcus and was started on IV Ceftriaxone. He was also found to have right greater than left bibasal opacities on CXR in keeping with possible aspiration pneumonia. CT head revealed extensive hypodensities in the bilateral MCA distributions in keeping with his old infarcts in addition to a hypodensity in the left cerebellum also likely from prior infract. He went on to have an MRI which revealed no acute infarct. His carbamazepine levels were high and this improved after reducing his dose from 800mg to 600mg . His lamotrigine was also increased to the dose intended by his neurologist of 400mg . He was extubated on , observed overnight and transfered to floor on . He was monitored on EEG telemetry from and although this showed slowing in keeping with previous sizeable bilateral MCA infarcts in addition to semi-rhythmic sharp waves in the left central parietal region in keeping with a seizure focus but there were no seizures present either clinically or electrographically. He initially had an NG tube due to poor swallow and latterly passed S&S assessment and was started on pureed solids and thin liquids which he tolerated well although is at chronic risk for aspiration. He was changed to oral augmentin for his UTI/aspiration pneumonia on and will continue this to complete a 10 day course finishing on . He was assessed by PT who found his pivoting ability was poor and per the preference of his wife was discharged home on with a lift and services of , PT and home health aide. He has neurology follow-up with his outpatient neurologist. He will have carbamzepine levels checked on prior to his neurology appointment. | Compared to the previous tracingof ventricular bigeminy is not present on the current tracing.Non-ventricular beats appear similar on both tracings.TRACING #1 Early R wave transition.Non-specific ST-T wave abnormalities. There is hypodensity in the region of the left cerebellum which may be due to a prior infarct. Postoperative changes are seen in the right parietal region. TECHNIQUE: Non-contrast-enhanced CT images of the head were obtained. Bilateral middle cerebral artery chronic infarcts. Bilateral middle cerebral artery chronic infarcts. Bilateral middle cerebral artery chronic infarcts. There is moderate ventriculomegaly likely ex vacuo due to chronic infarcts. Hypodensity in the left cerebellum also likely from prior infract. Patient is status post bilateral craniotomies. Endotracheal and nasogastric tubes in appropriate position. The underlying rhythm is probably sinus rhythm withnormal intervals. WET READ VERSION #1 FINAL REPORT EXAM: Non-contrast-enhanced CT of the head. The aorta is calcified. Sinus rhythm with ventricular trigeminy. Normal sinus rhythm with ventricular bigeminy. Prominence of the sulci and ventricles likely related to age-related parenchymal loss as well as secondary effect from remote infarcts. In view of the clinical history, these could represent zones of aspiration with left effusion. Non-specific ST-T wave changes in thelateral leads. Extensive hypodensities in the bilateral MCA distributions suggesting remote infarcts/insults. Mild bibasilar opacities are seen, right greater than left, which could relate to aspiration though an early infectious process cannot be excluded in the appropriate clinical setting. Mild dependent edema and small bilateral pleural effusions are slightly more pronounced. Mild bibasilar, right greater than left, subtle opacities may relate to aspiration or possible pulmonary vascular engorgement although underlying infectious process is not excluded in the appropriate clinical setting. There are large areas of hypodensity/encephalomalacia in the bilateral MCA distribution, suggesting remote infarction/insult. FINAL REPORT HISTORY: Seizures, to assess for aspiration. Small bilateral pleural effusions are present. HISTORY: Seizures. Slight ST segment elevation seen in lead V6 is likely anormal variant at this patient's age. Endotracheal tube is seen, terminating approximately 6.7 cm above the level of the carina. There are chronic bilateral middle cerebral artery infarcts identified with extensive cystic encephalomalacia and T2 hyperintensities. if concern for acute ischemia, MRI is more sensitive. Moderate bibasilar atelectasis unchanged. FINDINGS: Single supine AP portable view of the chest was obtained. Nasogastric tube is seen coursing below the level of the diaphragm, coiling in the expected location of the gastric fundus. 7:53 PM CHEST (PORTABLE AP) Clip # Reason: s/p intubation. Compared to tracing #1 trigeminy is seen on the currenttracing. Brain atrophy. Brain atrophy. Brain atrophy. Dr. was paged. ET tube in standard placement. Chronic left cerebellar infarcts are also seen. IMPRESSION: No evidence of acute infarct. No acute intracranial hemorrhage. The cardiac silhouette is top normal. extensive hypodensity in bilat MCA territories suggest remote infarcts/insults. LINE PLACEMENT; -76 BY SAME PHYSICIAN # Reason: line in correct place? Admitting Diagnosis: STATUS EPILEPTICUS MEDICAL CONDITION: 69 year old man with seizures, s/p dobhoff placement REASON FOR THIS EXAMINATION: line in correct place? Indistinctness of pulmonary vessel suggests some degree of elevated pulmonary venous pressure. REASON FOR THIS EXAMINATION: Please eval for interval change. REASON FOR THIS EXAMINATION: Please eval for interval change. TECHNIQUE: T1 sagittal and axial and FLAIR T2 susceptibility and diffusion axial images of the brain were acquired. Following gadolinium, no abnormal parenchymal, vascular or meningeal enhancement seen. 3:44 AM CHEST (PORTABLE AP) Clip # Reason: Please eval for interval change. Baseline artifact. FINAL REPORT HISTORY: Seizure, to assess for change. IMPRESSION: AP view of the torso centered at the thoracolumbar junction shows that the feeding tube has been withdrawn and repositioned, now ending in the stomach. FINDINGS: There is no evidence of acute infarct identified. IMPRESSION: 1. IMPRESSION: 1. Pneumonia, resp distress FINAL REPORT EXAM: Chest, single supine AP portable view. Asymmetric pulmonary vascular congestion would also be a possible cause for this appearance. No enhancing brain lesions. No enhancing brain lesions. No enhancing brain lesions. Admitting Diagnosis: STATUS EPILEPTICUS MEDICAL CONDITION: 69 year old man with h/o seizure d/o now presents with cc of seizures, now intubated. 4:38 AM CHEST (PORTABLE AP) Clip # Reason: Please eval for interval change. CLINICAL INFORMATION: 69-year-old male with history of altered mental status, seizures, unequal pupils. Feeding tube ends in the distal stomach. Pneumonia, resp distress REASON FOR THIS EXAMINATION: s/p intubation. IMPRESSION: AP chest compared to at 3:42 a.m.: New feeding tube ends in the right lower lobe bronchial tree and needs to be withdrawn. | 12 | [
{
"category": "Radiology",
"chartdate": "2106-11-06 00:00:00.000",
"description": "MR HEAD W & W/O CONTRAST",
"row_id": 1217235,
"text": " 12:28 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: please evaluate for stroke\n Admitting Diagnosis: STATUS EPILEPTICUS\n Contrast: MAGNEVIST Amt: 13\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with h/o malig, multiple strokes, now with increased seizure\n frequency\n REASON FOR THIS EXAMINATION:\n please evaluate for stroke\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AFSN SAT 4:18 PM\n PFI: No evidence of acute infarct. Bilateral middle cerebral artery chronic\n infarcts. No enhancing brain lesions. No mass effect or hydrocephalus.\n Brain atrophy.\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: MRI brain.\n\n CLINICAL INFORMATION: Patient with history of malignancy and multiple\n strokes, now with increased seizures.\n\n TECHNIQUE: T1 sagittal and axial and FLAIR T2 susceptibility and diffusion\n axial images of the brain were acquired. No prior MRI studies are available\n for comparison.\n\n FINDINGS: There is no evidence of acute infarct identified. There are\n chronic bilateral middle cerebral artery infarcts identified with extensive\n cystic encephalomalacia and T2 hyperintensities. Following gadolinium, no\n abnormal parenchymal, vascular or meningeal enhancement seen. Chronic left\n cerebellar infarcts are also seen. There is moderate ventriculomegaly likely\n ex vacuo due to chronic infarcts. There is no evidence of chronic or acute\n blood products. Postoperative changes are seen in the right parietal region.\n\n IMPRESSION: No evidence of acute infarct. Bilateral middle cerebral artery\n chronic infarcts. No enhancing brain lesions. No mass effect or\n hydrocephalus. Brain atrophy.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2106-11-06 00:00:00.000",
"description": "MR HEAD W & W/O CONTRAST",
"row_id": 1217236,
"text": ", W. NMED SICU-B 12:28 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: please evaluate for stroke\n Admitting Diagnosis: STATUS EPILEPTICUS\n Contrast: MAGNEVIST Amt: 13\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with h/o malig, multiple strokes, now with increased seizure\n frequency\n REASON FOR THIS EXAMINATION:\n please evaluate for stroke\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI: No evidence of acute infarct. Bilateral middle cerebral artery chronic\n infarcts. No enhancing brain lesions. No mass effect or hydrocephalus.\n Brain atrophy.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2106-11-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1217375,
"text": " 3:44 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for interval change.\n Admitting Diagnosis: STATUS EPILEPTICUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with h/o seizure d/o presents with 3 seizures resulting in\n unconsciousness.\n REASON FOR THIS EXAMINATION:\n Please eval for interval change.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Seizures, to assess for aspiration.\n\n FINDINGS: In comparison with the study of , there again are areas of\n increased opacification at the bases, silhouetting the hemidiaphragm on the\n left. In view of the clinical history, these could represent zones of\n aspiration with left effusion. Indistinctness of pulmonary vessel suggests\n some degree of elevated pulmonary venous pressure.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2106-11-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1217176,
"text": " 7:53 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p intubation. Pneumonia, resp distress\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man s/p intubation. Pneumonia, resp distress\n REASON FOR THIS EXAMINATION:\n s/p intubation. Pneumonia, resp distress\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: Chest, single supine AP portable view.\n\n CLINICAL INFORMATION: 69-year-old male with history of intubation, pneumonia,\n respiratory distress, status post intubation.\n\n COMPARISON: None.\n\n FINDINGS: Single supine AP portable view of the chest was obtained.\n Endotracheal tube is seen, terminating approximately 6.7 cm above the level of\n the carina. Nasogastric tube is seen coursing below the level of the\n diaphragm, coiling in the expected location of the gastric fundus. Mild\n bibasilar opacities are seen, right greater than left, which could relate to\n aspiration though an early infectious process cannot be excluded in the\n appropriate clinical setting. No pleural effusion or pneumothorax is seen.\n The cardiac silhouette is top normal. The aorta is calcified.\n\n IMPRESSION:\n 1. Endotracheal and nasogastric tubes in appropriate position.\n 2. Mild bibasilar, right greater than left, subtle opacities may relate to\n aspiration or possible pulmonary vascular engorgement although underlying\n infectious process is not excluded in the appropriate clinical setting.\n\n"
},
{
"category": "Radiology",
"chartdate": "2106-11-05 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1217177,
"text": " 7:58 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: AMS, seizures, unequal pupils, eval for ICH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with AMS, seizures, unequal pupils, eval for ICH\n REASON FOR THIS EXAMINATION:\n AMS, seizures, unequal pupils, eval for ICH\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: RBLd FRI 9:34 PM\n no acute intracranial hemorrhage. extensive hypodensity in bilat MCA\n territories suggest remote infarcts/insults. if concern for acute ischemia,\n MRI is more sensitive.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: Non-contrast-enhanced CT of the head.\n\n CLINICAL INFORMATION: 69-year-old male with history of altered mental status,\n seizures, unequal pupils.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast-enhanced CT images of the head were obtained.\n Reformatted coronal and sagittal images were also obtained.\n\n FINDINGS: There is no acute intracranial hemorrhage, midline shift, acute\n mass effect, or hydrocephalus. There are large areas of\n hypodensity/encephalomalacia in the bilateral MCA distribution, suggesting\n remote infarction/insult. Patient is status post bilateral craniotomies. The\n visualized paranasal sinuses and mastoid air cells are clear. Prominence of\n the sulci and ventricles likely related to age-related parenchymal loss as\n well as secondary effect from remote infarcts. There is hypodensity in the\n region of the left cerebellum which may be due to a prior infarct.\n\n IMPRESSION:\n 1. No acute intracranial hemorrhage.\n 2. Extensive hypodensities in the bilateral MCA distributions suggesting\n remote infarcts/insults. Hypodensity in the left cerebellum also likely from\n prior infract.\n\n"
},
{
"category": "Radiology",
"chartdate": "2106-11-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1217559,
"text": " 3:59 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for interval change\n Admitting Diagnosis: STATUS EPILEPTICUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with status\n REASON FOR THIS EXAMINATION:\n please evaluate for interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 4:00 A.M., .\n\n HISTORY: Seizures. Question change.\n\n IMPRESSION: AP chest compared to and 28:\n\n A largely dependent pulmonary edema is mild to moderate, but increased since\n . Bilateral infrahilar consolidation is generally due to\n atelectasis, but pneumonia is not excluded. Small bilateral pleural effusions\n are present. Heart size is normal. No pneumothorax. Feeding tube ends in\n the distal stomach.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2106-11-08 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1217450,
"text": " 12:16 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: line in correct place?\n Admitting Diagnosis: STATUS EPILEPTICUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with seizures, s/p dobhoff placement\n REASON FOR THIS EXAMINATION:\n line in correct place?\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST AT 12:07 P.M., ON \n\n HISTORY: Dobbhoff repositioned.\n\n IMPRESSION: AP view of the torso centered at the thoracolumbar junction shows\n that the feeding tube has been withdrawn and repositioned, now ending in the\n stomach. Moderate bibasilar atelectasis unchanged. Findings discussed by\n telephone with Dr. , at the time of dictation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2106-11-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1217302,
"text": " 4:38 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for interval change.\n Admitting Diagnosis: STATUS EPILEPTICUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with h/o seizure d/o now presents with cc of seizures, now\n intubated.\n REASON FOR THIS EXAMINATION:\n Please eval for interval change.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Seizure, to assess for change.\n\n FINDINGS: In comparison with the study of , there are bibasilar\n opacifications, more prominent on the right, that appear to be mildly\n increased. In view of the clinical history, the possibility of aspiration\n must be seriously considered. Asymmetric pulmonary vascular congestion would\n also be a possible cause for this appearance.\n\n Monitoring and support devices remain in place.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2106-11-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1217443,
"text": " 11:36 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Line placement\n Admitting Diagnosis: STATUS EPILEPTICUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with s/p feeding tube placement\n REASON FOR THIS EXAMINATION:\n Line placement\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 11:39 A.M., \n\n HISTORY: 69-year-old man with feeding tube placement.\n\n IMPRESSION: AP chest compared to at 3:42 a.m.:\n\n New feeding tube ends in the right lower lobe bronchial tree and needs to be\n withdrawn. Dr. was paged.\n\n Mild dependent edema and small bilateral pleural effusions are slightly more\n pronounced. Heart size is normal. ET tube in standard placement. No\n pneumothorax.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2106-11-07 00:00:00.000",
"description": "Report",
"row_id": 156790,
"text": "Sinus rhythm with ventricular trigeminy. Non-specific ST-T wave changes in the\nlateral leads. Compared to tracing #1 trigeminy is seen on the current\ntracing. The other findings are similar.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2106-11-06 00:00:00.000",
"description": "Report",
"row_id": 156791,
"text": "Baseline artifact. The underlying rhythm is probably sinus rhythm with\nnormal intervals. Slight ST segment elevation seen in lead V6 is likely a\nnormal variant at this patient's age. Compared to the previous tracing\nof ventricular bigeminy is not present on the current tracing.\nNon-ventricular beats appear similar on both tracings.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2106-11-05 00:00:00.000",
"description": "Report",
"row_id": 156792,
"text": "Normal sinus rhythm with ventricular bigeminy. Early R wave transition.\nNon-specific ST-T wave abnormalities. No previous tracing available for\ncomparison.\n\n"
}
] |
12,501 | 187,239 | Patient is a 81-year-old man with history of insulin dependent diabetes, coronary artery disease and ischemic cardiomyopathy, likely metastatic pancreatic cancer by CT scan presented with confusion, found with FSBG of 22, and admitted to the MICU on D5 drip. In the MICU, patient's mental status quickly cleared once blood sugars normalized. Hypokalemia also quickly resolved as insulin/blood sugar was corrected. Patient was noted to be hyoxic on transfer to the floor. His CXR was initially concerning for pneumonia and he received a dose of levofloxacin. Repeat CXR was more consistent with pulmonary edema; he had received 3 L of IVFs in the ED. His hypoxia resolved with Lasix. CXR PA and lateral on the floor showed resolution of pulmonary edema and no infiltrate. His levofloxacin was discontinued. Upon discharge, he was satting in the mid 90s on RA, even with ambulation. He was discharged to home with hospice on his home medications EXCEPT his Lantus was discontinued. In 24 hours, he had only required 2 units of Humalog. For discharge, he was started on metformin extended release 500 mg daily, to be increased to 1000 mg daily if his blood sugars remain >200 after 1 week. | 9:48 AM BILAT LOWER EXT VEINS Clip # Reason: Thrombosis? Left atrial abnormality. , MED 9:48 AM BILAT LOWER EXT VEINS Clip # Reason: Thrombosis? Sinus rhythm with ventricular premature beats and atrial premature beats.Marked left axis deviation. Left anterior fascicular block. Unchanged enlargement of the cardiac silhouette. REASON FOR THIS EXAMINATION: Thrombosis? REASON FOR THIS EXAMINATION: Thrombosis? Leftanterior fascicular block. Consider anteroseptal myocardial infarction. FINAL REPORT CHEST RADIOGRAPH INDICATION: Hypoxia, evaluation for interval change. PROVISIONAL FINDINGS IMPRESSION (PFI): 10:18 AM No DVT in the right or left lower extremity. There is tortuosity of the aorta. Unchanged cardiomegaly. FINAL REPORT INDICATION: Lower extremity pain. Since the previous tracing of ventricular prematurebeats are new. Sinus rhythm. IMPRESSION: No evidence of DVT in the right or left lower extremity. FINDINGS: There is normal grayscale appearance, compressibility, color Doppler flow, and pulse-wave Doppler waveforms with augmentation of the right and left common femoral, superficial femoral, popliteal, peroneal, and posterior tibial veins. Otherwise, no diagnostic interim change. FINDINGS/IMPRESSION: Overall, this examination appears unchanged. Other ST-T waveabnormalities. 6:03 AM CHEST (PORTABLE AP) Clip # Reason: Evaluate for interval change. FINDINGS: As compared to the previous radiograph, there is minimal increase in extent of the overall moderate pulmonary edema. Right bundle-branch block. Relative increased left basilar opacity could represent atelectasis, however infection cannot be entirely excluded. Right bundle-branchblock. PFI REPORT No DVT in the right or left lower extremity. No pleural effusions. There is cardiomegaly with prominent interstitial markings which appear improved. FINDINGS: As compared to the previous examination, there is a marked improvement with regression of the pre-existing signs indicating overhydration. No focal parenchymal opacity suggesting pneumonia. REASON FOR THIS EXAMINATION: Evaluate for interval change. COMPARISON: . COMPARISON: . COMPARISON: . No pleural effusion or pneumothorax is identified. No pleural effusions, no interval appearance of focal parenchymal opacity suggesting pneumonia. 11:12 AM CHEST (PORTABLE AP) Clip # Reason: eval for pna MEDICAL CONDITION: 81 year old man with hypoglycemia REASON FOR THIS EXAMINATION: eval for pna FINAL REPORT INDICATION: Hypoglycemia TECHNIQUE: Single frontal radiograph of the chest was compared to prior examinations, most recent dated . Admitting Diagnosis: HYPOGLYCEMIA;HYPOKALEMIA;PNEUMONIA MEDICAL CONDITION: 81 year old man with hypoxia. Admitting Diagnosis: HYPOGLYCEMIA;HYPOKALEMIA;PNEUMONIA MEDICAL CONDITION: 81 year old man with pancreatic cancer, lower extremity pain, with hypoxia requiring 6L Abx's. Admitting Diagnosis: HYPOGLYCEMIA;HYPOKALEMIA;PNEUMONIA MEDICAL CONDITION: 81 year old man with pancreatic cancer, lower extremity pain, with hypoxia requiring 6L Abx's. 8:56 AM CHEST (PA & LAT) Clip # Reason: pls evaluate for persistent edema vs infiltrate Admitting Diagnosis: HYPOGLYCEMIA;HYPOKALEMIA;PNEUMONIA MEDICAL CONDITION: 81 year old man with CMP & EF of 30% who presented with hypoglycemia and has persistent O2 requirement, now s/p gentle diuresis REASON FOR THIS EXAMINATION: pls evaluate for persistent edema vs infiltrate FINAL REPORT CHEST RADIOGRAPH INDICATION: Hypoxemia, evaluation for edema. | 7 | [
{
"category": "Radiology",
"chartdate": "2155-11-21 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1169510,
"text": " 8:56 AM\n CHEST (PA & LAT) Clip # \n Reason: pls evaluate for persistent edema vs infiltrate\n Admitting Diagnosis: HYPOGLYCEMIA;HYPOKALEMIA;PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with CMP & EF of 30% who presented with hypoglycemia and has\n persistent O2 requirement, now s/p gentle diuresis\n REASON FOR THIS EXAMINATION:\n pls evaluate for persistent edema vs infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Hypoxemia, evaluation for edema.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous examination, there is a marked\n improvement with regression of the pre-existing signs indicating\n overhydration. Unchanged enlargement of the cardiac silhouette. No pleural\n effusions, no interval appearance of focal parenchymal opacity suggesting\n pneumonia.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2155-11-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1169313,
"text": " 6:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for interval change.\n Admitting Diagnosis: HYPOGLYCEMIA;HYPOKALEMIA;PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with hypoxia.\n REASON FOR THIS EXAMINATION:\n Evaluate for interval change.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Hypoxia, evaluation for interval change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is minimal increase\n in extent of the overall moderate pulmonary edema. No pleural effusions. No\n focal parenchymal opacity suggesting pneumonia. Unchanged cardiomegaly.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2155-11-20 00:00:00.000",
"description": "BILAT LOWER EXT VEINS",
"row_id": 1169350,
"text": " 9:48 AM\n BILAT LOWER EXT VEINS Clip # \n Reason: Thrombosis?\n Admitting Diagnosis: HYPOGLYCEMIA;HYPOKALEMIA;PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with pancreatic cancer, lower extremity pain, with hypoxia\n requiring 6L Abx's.\n REASON FOR THIS EXAMINATION:\n Thrombosis?\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 10:18 AM\n No DVT in the right or left lower extremity.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Lower extremity pain.\n\n COMPARISON: .\n\n FINDINGS: There is normal grayscale appearance, compressibility, color\n Doppler flow, and pulse-wave Doppler waveforms with augmentation of the right\n and left common femoral, superficial femoral, popliteal, peroneal, and\n posterior tibial veins.\n\n IMPRESSION: No evidence of DVT in the right or left lower extremity.\n\n"
},
{
"category": "Radiology",
"chartdate": "2155-11-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1169204,
"text": " 11:12 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pna\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with hypoglycemia\n REASON FOR THIS EXAMINATION:\n eval for pna\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hypoglycemia\n\n TECHNIQUE: Single frontal radiograph of the chest was compared to prior\n examinations, most recent dated .\n\n FINDINGS/IMPRESSION: Overall, this examination appears unchanged. There is\n cardiomegaly with prominent interstitial markings which appear improved.\n Relative increased left basilar opacity could represent atelectasis, however\n infection cannot be entirely excluded. No pleural effusion or pneumothorax\n is identified. There is tortuosity of the aorta.\n\n"
},
{
"category": "Radiology",
"chartdate": "2155-11-20 00:00:00.000",
"description": "BILAT LOWER EXT VEINS",
"row_id": 1169351,
"text": ", MED 9:48 AM\n BILAT LOWER EXT VEINS Clip # \n Reason: Thrombosis?\n Admitting Diagnosis: HYPOGLYCEMIA;HYPOKALEMIA;PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with pancreatic cancer, lower extremity pain, with hypoxia\n requiring 6L Abx's.\n REASON FOR THIS EXAMINATION:\n Thrombosis?\n ______________________________________________________________________________\n PFI REPORT\n No DVT in the right or left lower extremity.\n\n"
},
{
"category": "ECG",
"chartdate": "2155-11-21 00:00:00.000",
"description": "Report",
"row_id": 164675,
"text": "Sinus rhythm with ventricular premature beats and atrial premature beats.\nMarked left axis deviation. Left anterior fascicular block. Right bundle-branch\nblock. Consider anteroseptal myocardial infarction. Other ST-T wave\nabnormalities. Since the previous tracing of ventricular premature\nbeats are new.\n\n"
},
{
"category": "ECG",
"chartdate": "2155-11-19 00:00:00.000",
"description": "Report",
"row_id": 164676,
"text": "Sinus rhythm. Left atrial abnormality. Right bundle-branch block. Left\nanterior fascicular block. Compared to the previous tracing of the\nrate has increased. Otherwise, no diagnostic interim change.\n\n"
}
] |
30,748 | 176,141 | 36F, transferred to by following ingestion of 100 tabs of 325mg ASA at 2:50 on day of admission. Also took tylenol pm. PTA in ED patient was given 50 grams of charcoal, 9 grams of mucomyst, and 3 grams of bicarb. In addition, pt received PO and IV potassium In the , pt was tachycardic to the 160s. Pt was seen in the ED by renal and no HD was indicated at that time. Pt was admitted to the MICU for further management of her issues. At 3.5 hour aspirin level 34, noted to be slightly elevated, It was expected to climb over the next several hours reaching a toxic level. Pt was monitored closely for fever, tinnitus, nausea, vomiting, pulmonary edema, hypotension, tachycardia. Her urine was alkalinized with goal pH 7.50-7.59 (to prevent salicylate from crossing BBB, promote urinary excretion) Pt received fluid rehydration and potassium repletion with a goal of maximizing renal excretion. Per recs from toxicology, pt received q2hr asa levels with a goal of discontinuing bicarb at levels less than 20. By 2:42 AM on , pt had negative aspirin level. In addition to aspirin toxicity pt was also exposed to Diphehydramine. She was monitored for hyperthermia, erythema, anhidrosis, mydriasis, delerium, hallucinations, urniary retention, psychomotor aggitation, and seizures. Her QTc was monitored for prolongation with EKG. Pt remained clinically stable from this perspective. In addition to aspirin and diphenhydramine exposure, pt also was exposed to acetaminophen. It was decided, per nomogram, that she would most likely not have hepatic injury from acute acetominophen toxicity. However, her LFT's were monitored as well as her acetaminophen level. She received NAC at 70mg/kg q 4hours for 24 hours. LFT's did not reflect acute injury. At presentation, pt was noted to be hypernatremic which was likely secondary to free-water deficit in the setting of OD, poor po intake. Pt was repleted with D5W and provided with ample free water and allowed her to drink to her thirst. At the time of discharge her sodium had trended downwards to 140. In addition, at presentation, pt was noted to be tachycardic(sinus) with a rate of 165. At baseline patient is known to have sinus tachycardia and she has seen both her PCP and cardiologist for this in past, is on calcium channel blocker. However, it was believed that there was an element of reactive tachcardia from anxiety, diphehydramine toxicity, or dehydration. She was monitored on tele and provided with diltiazem for rate control. On day 2 of her floor admission, her diltiazem was increased to 60 QID and her heart rate was better controlled. For the patient's bipolar disorder we held her home regimen. Psych was consulted for further help with management and she will go to inpatient psych after discharge. For the patient's suicide attempt, psych was consulted. Pt was provided with a 1:1 sitter. Pending clinical improvement and stabilization, pt was transferred to psych for further evaluation and management. | Last VBG 7.48/31, K+ 3.9, mg 2.5, phos 1.6. ASA LEVELS APPEARED TO HAVE PEAKED @57 AND NOW ARE TRENDING DOWN WITH LAST 2-EACH 44.CARDIAC: HR 109-149 ST WITH NO ECTOPY. MOVES INDEPENDENTLY IN BED.RESP : STARTED ON O2 AS MENTIONED ABOVE, RR UNLABORED AND REGULAR, LS CLEAR, MILDLY DIMINSHED AT THE BASES. HCT 39.5/35.2 DILUTIONAL, NO SIGNS OF BLEEDING. RECEIVED 10MG DILTIAZEM 2 WITH LITTLE EFFECT ON HR. HEME NEGATIVE. NO SOB OR COUGH.CVS : NSR/ST WITHOUT ECTOPY, CONTINUED ON PO DILTIAZEM. CREAT 0.7. FLUIDS GIVEN WHICH DID DROP HR OF 150 WHEN SHE ARRIVED. C/O NAUSEA, COMPAZINE GIVEN WITH GOOD EFFECT. COMPLAINED OF HEADACHE, IBUPROFEN ORDERED, PATIENT REFUSED. 2:07 AM CHEST (PORTABLE AP) Clip # Reason: ? PHOS UP TO 3.6, HAD RECEIVED NEUTROPHOS LAST EVENING.GI : ABDOMEN IS SOFT, BS PRESENT, PATIENT REFUSED TO HAVE THE DOCUSATE SODIUM. CXR DONE THIS MORNING.GI/GU: ABD SOFT WITH +BS. COMPLAINED OF BEING VERY ANXIOUS, PO LORAZEPAM 0.5 MGS GIVEN WITH GOOD EFFECT. interval change FINAL REPORT CLINICAL HISTORY: Aspirin, acetaminophen toxicity. TYLENOL LEVEL HAVE GONE FROM 10 TO NEGATIVE. TO PREVENT SALICYLATE FROM CROSSING BBB, ATTEMPTING TO PROMOTE URINARY EXCRETION...IF ASA LEVELS APPROACH >100 OR RENAL FXN WORSENS WILL DO HD...Q2HR NA+, K+, VBG'S, URINE PH, ASA AND APAP LEVELS...AGGRESSIVE LYTE REPLETION ESP K+, GOAL >4.5...?NEED TO FINISH MUCOMYST DOSES WITH NEG APAP LEVEL AND LFT'S NORMAL...PSYCH EVAL...IV DILT PRN...ENCOURAGE WATER...RENAL AND TOXOCOLOGY FOLLOWING...?CONTINUE BICARB GTT. Sinus tachycardia. Sinus tachycardia. COMPAZINE GIVEN WITH GOOD EFFECT FOR NAUSEA. SITTER AT BEDSIDE FOR 1:1 SUICIDE PRECAUTIONS. PLACED ON SS POTASSIUM. Renal consulted for possible HD, but not at this time. PT ATTEMPTED TO CALL SISTER LAST .PLAN: GOAL SERUM PH 7.5-7.59, GOAL URINE PH >8. MICU NURSING PROGRESS NOTES :PLEASE SEE CAREVUE FOR PMH, OBJECTIVE DATA.ALLERGIC TO SULPHA ( NAUSEA).ON SUICIDE PRECAUTIONS. BP STABLE, NO PERIPHERAL EDEMA NOTED. AGGRESSIVE REPLETION OF MAG, K+, PO4, AND CA. CHECKING NA AND K+ Q2HRS. GIVEN 4MG ZOFRAN FOR NAUSEA WITH EFFECT. ARTIFICIAL EYE DROPS INSTILLED AS PATIENT COMPLAINED OF IRRITATION & DRYNESS IN THE LEFT EYE. Non-specific ST-T wave changes. pt later able to tolerate po neutra-phosGU: Foley catheter patent, draining good amounts of yellow urineSkin: Warm to touch, dry & intactAccess: 3 peripheral IV's #18g & #20g in (L) arm #20g (R) ACSocial: Pt with no HCP, sister is involved & supportiveDispo: Pt is call-out, transfer note written Since prior tracingof the rate has decreased. LS CLEAR, NO SOB NOTED. DENIES PAIN. ?PSYCH PLACEMENT. Non-diagnostic repolarization abnormalities. IMPRESSION: No acute cardiopulmonary process. Pt is 36y/o female admitted to micu-6 after ingesting large amounts of aspirin & excedrin pm, with ASA levels peaked @53 now decreased to 11 after sodium bicarb infusion & multiple electrolyte repletion. Frequently calls sister with updates.Resp: RA - Lungs CTA 02 sats 95-99, no cough or SOBCardiac:ST HR 110-130's, no ectopy, BP stable 90-120/70-80's No peripheral edema noted. BP 86-102/57-70. JUST FINISHED LITER OF 3AMPS BICARB WITH 40MEQ KCL. Strong palpable pulsesGI: Soft abdomen +bs, diet changed to regular, minimal po intake c/o nausea, vomited large amount charcoal & food material 10mg IV compazine given with good effect. NO C/O CP. URINE PH ..FEN: SEVERAL CHANGES IN IVF. MICU ADMIT NOTEPLEASE SEE AND MD ADMIT NOTE FOR DETAILS SURROUNDING ADMISSION.NEURO: AAOX3. NO VOMITING THIS SHIFT, NO BM THIS SHIFT.GU : FOLEY DRAINING YELLOW CLEAR URINE.SKIN : WARM TO TOUCH, DRY & INTACT.ACCESS : PIV X 3.SOCIAL : PATIENT WITH NO HCP, SISTER IS INVOLVED & IS SUPPORTIVE.PLAN :1.CALLED OUT, NSG TRANSFER NOTES DONE.2.MONITOR LYTES.3. CHEST Comparison is made with the prior chest x-ray of . AP UPRIGHT CHEST: Cardiac, mediastinal, and hilar contours are normal. ENCOURAGING PATIENT TO DRINK WATER.ID: TMAX 98.4 WITH WBC 8. TOLD HER IT WAS NOT UP TO US TO DETERMINE THAT. IMPRESSION: Chest clear, no change. SERUM PH 7.52-7.55. Evaluate for pulmonary edema. CONTINUES ON MUCOMYST. NO CURRENT ID ISSUES.SKIN: W/D/I.ACCESS: PIV X3.SOCIAL/DISPO: FULL CODE. Toxicology currently following, for further monitoring guidelines. LFT'S WNL. SITTER PRESENT AT BEDSIDE.PT IS A 36 Y/O F, ADMITTED TO MICU 6 AFTER ASPIRIN & EXCEDRIN PM OVERDOSE, WITH ASA LEVELS PEAKED TO 57, TREATED WITH BICARB DRIP, NEEDED MULTIPLE LYTE REPLETION ASA NEG IN TODAY'S AM LABS. COMPARISON: None. There has been no significant change since the prior chest x-ray. The osseous structures appear unremarkable. DOES NOT APPEAR TO REALIZE THE SCOPE OF WHAT SHE HAD DONE TO HERSELF. PATIENT ANXIOUS ABOUT PSYCH PLACEMENT.NEURO : ANXIOUS, EMOTIONAL & CRYING AT TIMES LETHARGIC, ORIENTED X 3, COOPERTAIVE WITH CARE, FOLLOWS COMMANDS, PUPILS BILATERALLY EQUALLY 4 TO 5 MM, BRISK REACTION TO LIGHT. TOXICOLOGY CURRENTLY FOLLOWING UP, PSYCH IS FOLLOWING DAILY UNTIL PATIENT IS MEDICALLY CLEARED FOR PSYCH PLACEMENT.EVENTS : SPO2 89 TO 91%, STARTED ON 2 LITS O2 , PATIENT UNABLE TO TOLERATE THE FLOW, REDUCED TO 1 LIT, SPO2 UP TO 95 %. No previoustracing available for comparison. PPP.RESP: ON ROOM AIR WITH RR 15-27 AND SATS 95-97%. The costophrenic angles are sharp. UOP 100-350CC/HR LT YELLOW AND CLEAR. interval change Admitting Diagnosis: OVERDOSE MEDICAL CONDITION: 36 year old woman with aspirin/acetaminophen toxicity REASON FOR THIS EXAMINATION: ? | 7 | [
{
"category": "Radiology",
"chartdate": "2123-11-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 981714,
"text": " 8:16 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pulm edema\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 36 year old woman with ASA OD\n REASON FOR THIS EXAMINATION:\n eval for pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 36-year-old woman with aspirin overdose. Evaluate for pulmonary\n edema.\n\n COMPARISON: None.\n\n AP UPRIGHT CHEST: Cardiac, mediastinal, and hilar contours are normal. The\n lungs are clear. Pulmonary vascularity is normal. There is no pleural\n effusion. The osseous structures appear unremarkable.\n\n IMPRESSION: No acute cardiopulmonary process.\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-11-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 981727,
"text": " 2:07 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? interval change\n Admitting Diagnosis: OVERDOSE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 36 year old woman with aspirin/acetaminophen toxicity\n REASON FOR THIS EXAMINATION:\n ? interval change\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Aspirin, acetaminophen toxicity.\n\n CHEST\n\n Comparison is made with the prior chest x-ray of .\n\n There has been no significant change since the prior chest x-ray. The lung\n fields remain clear. The costophrenic angles are sharp.\n\n IMPRESSION: Chest clear, no change.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-11-23 00:00:00.000",
"description": "Report",
"row_id": 1657176,
"text": "MICU NURSING PROGRESS NOTES :\n\nPLEASE SEE CAREVUE FOR PMH, OBJECTIVE DATA.\n\nALLERGIC TO SULPHA ( NAUSEA).\n\nON SUICIDE PRECAUTIONS. SITTER PRESENT AT BEDSIDE.\n\nPT IS A 36 Y/O F, ADMITTED TO MICU 6 AFTER ASPIRIN & EXCEDRIN PM OVERDOSE, WITH ASA LEVELS PEAKED TO 57, TREATED WITH BICARB DRIP, NEEDED MULTIPLE LYTE REPLETION ASA NEG IN TODAY'S AM LABS. TOXICOLOGY CURRENTLY FOLLOWING UP, PSYCH IS FOLLOWING DAILY UNTIL PATIENT IS MEDICALLY CLEARED FOR PSYCH PLACEMENT.\n\nEVENTS : SPO2 89 TO 91%, STARTED ON 2 LITS O2 , PATIENT UNABLE TO TOLERATE THE FLOW, REDUCED TO 1 LIT, SPO2 UP TO 95 %. COMPLAINED OF HEADACHE, IBUPROFEN ORDERED, PATIENT REFUSED. COMPLAINED OF BEING VERY ANXIOUS, PO LORAZEPAM 0.5 MGS GIVEN WITH GOOD EFFECT. C/O NAUSEA, COMPAZINE GIVEN WITH GOOD EFFECT. PATIENT ANXIOUS ABOUT PSYCH PLACEMENT.\n\nNEURO : ANXIOUS, EMOTIONAL & CRYING AT TIMES LETHARGIC, ORIENTED X 3, COOPERTAIVE WITH CARE, FOLLOWS COMMANDS, PUPILS BILATERALLY EQUALLY 4 TO 5 MM, BRISK REACTION TO LIGHT. ARTIFICIAL EYE DROPS INSTILLED AS PATIENT COMPLAINED OF IRRITATION & DRYNESS IN THE LEFT EYE. MOVES INDEPENDENTLY IN BED.\n\nRESP : STARTED ON O2 AS MENTIONED ABOVE, RR UNLABORED AND REGULAR, LS CLEAR, MILDLY DIMINSHED AT THE BASES. NO SOB OR COUGH.\n\nCVS : NSR/ST WITHOUT ECTOPY, CONTINUED ON PO DILTIAZEM. BP STABLE, NO PERIPHERAL EDEMA NOTED. PULSES ARE PALPABLE. PHOS UP TO 3.6, HAD RECEIVED NEUTROPHOS LAST EVENING.\n\nGI : ABDOMEN IS SOFT, BS PRESENT, PATIENT REFUSED TO HAVE THE DOCUSATE SODIUM. COMPAZINE GIVEN WITH GOOD EFFECT FOR NAUSEA. NO VOMITING THIS SHIFT, NO BM THIS SHIFT.\n\nGU : FOLEY DRAINING YELLOW CLEAR URINE.\n\nSKIN : WARM TO TOUCH, DRY & INTACT.\n\nACCESS : PIV X 3.\n\nSOCIAL : PATIENT WITH NO HCP, SISTER IS INVOLVED & IS SUPPORTIVE.\n\nPLAN :\n1.CALLED OUT, NSG TRANSFER NOTES DONE.\n2.MONITOR LYTES.\n3.?PSYCH PLACEMENT.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-11-22 00:00:00.000",
"description": "Report",
"row_id": 1657174,
"text": "MICU ADMIT NOTE\nPLEASE SEE AND MD ADMIT NOTE FOR DETAILS SURROUNDING ADMISSION.\n\nNEURO: AAOX3. ANXIOUS. DOES NOT APPEAR TO REALIZE THE SCOPE OF WHAT SHE HAD DONE TO HERSELF. ASKING QUESTIONS MANY TIMES OVER. PT WORRIED ABOUT SPEAKING TO PSYCHIATRY AND DOES NOT WANT TO BE PLACED IN PSYCH . TOLD HER IT WAS NOT UP TO US TO DETERMINE THAT. FOLLOWS COMMANDS APPROPIATELY AND ABLR TO MOVE INDEPENDANTLY IN BED. DENIES PAIN. SITTER AT BEDSIDE FOR 1:1 SUICIDE PRECAUTIONS. TYLENOL LEVEL HAVE GONE FROM 10 TO NEGATIVE. CONTINUES ON MUCOMYST. ASA LEVELS APPEARED TO HAVE PEAKED @57 AND NOW ARE TRENDING DOWN WITH LAST 2-EACH 44.\n\nCARDIAC: HR 109-149 ST WITH NO ECTOPY. RECEIVED 10MG DILTIAZEM 2 WITH LITTLE EFFECT ON HR. TEAM SPOKE TO ATTENDING AND IT WAS DECIDED TO LET IT RIDE FOR NOW. FLUIDS GIVEN WHICH DID DROP HR OF 150 WHEN SHE ARRIVED. BP 86-102/57-70. NO C/O CP. HCT 39.5/35.2 DILUTIONAL, NO SIGNS OF BLEEDING. SERUM PH 7.52-7.55. PPP.\n\nRESP: ON ROOM AIR WITH RR 15-27 AND SATS 95-97%. LS CLEAR, NO SOB NOTED. CXR DONE THIS MORNING.\n\nGI/GU: ABD SOFT WITH +BS. CRAMPING AND HAD 2 LGE BLACK LIQUID STOOLS, S/P CHARCOAL. HEME NEGATIVE. UOP 100-350CC/HR LT YELLOW AND CLEAR. CREAT 0.7. GIVEN 4MG ZOFRAN FOR NAUSEA WITH EFFECT. URINE PH ..\n\nFEN: SEVERAL CHANGES IN IVF. JUST FINISHED LITER OF 3AMPS BICARB WITH 40MEQ KCL. CHECKING NA AND K+ Q2HRS. NA+ 150->145. AGGRESSIVE REPLETION OF MAG, K+, PO4, AND CA. PLACED ON SS POTASSIUM. LFT'S WNL. ENCOURAGING PATIENT TO DRINK WATER.\n\nID: TMAX 98.4 WITH WBC 8. NO CURRENT ID ISSUES.\n\nSKIN: W/D/I.\n\nACCESS: PIV X3.\n\nSOCIAL/DISPO: FULL CODE. PT ATTEMPTED TO CALL SISTER LAST .\n\nPLAN: GOAL SERUM PH 7.5-7.59, GOAL URINE PH >8. TO PREVENT SALICYLATE FROM CROSSING BBB, ATTEMPTING TO PROMOTE URINARY EXCRETION...IF ASA LEVELS APPROACH >100 OR RENAL FXN WORSENS WILL DO HD...Q2HR NA+, K+, VBG'S, URINE PH, ASA AND APAP LEVELS...AGGRESSIVE LYTE REPLETION ESP K+, GOAL >4.5...?NEED TO FINISH MUCOMYST DOSES WITH NEG APAP LEVEL AND LFT'S NORMAL...PSYCH EVAL...IV DILT PRN...ENCOURAGE WATER...RENAL AND TOXOCOLOGY FOLLOWING...?CONTINUE BICARB GTT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-11-22 00:00:00.000",
"description": "Report",
"row_id": 1657175,
"text": "Pt is 36y/o female admitted to micu-6 after ingesting large amounts of aspirin & excedrin pm, with ASA levels peaked @53 now decreased to 11 after sodium bicarb infusion & multiple electrolyte repletion. Last VBG 7.48/31, K+ 3.9, mg 2.5, phos 1.6. Renal consulted for possible HD, but not at this time. Toxicology currently following, for further monitoring guidelines. Psych is following pt daily until medically cleared.\n\nNeuro: A&OX3 periods of anxiety about psych placement\n emotional & crying at times. Frequently calls\n sister with updates.\n\nResp: RA - Lungs CTA 02 sats 95-99, no cough or SOB\n\nCardiac:ST HR 110-130's, no ectopy, BP stable 90-120/70-80's\n No peripheral edema noted. Strong palpable pulses\n\nGI: Soft abdomen +bs, diet changed to regular, minimal po intake\n c/o nausea, vomited large amount charcoal & food material\n 10mg IV compazine given with good effect. pt later able to\n tolerate po neutra-phos\n\nGU: Foley catheter patent, draining good amounts of yellow urine\n\nSkin: Warm to touch, dry & intact\n\nAccess: 3 peripheral IV's #18g & #20g in (L) arm\n #20g (R) AC\n\nSocial: Pt with no HCP, sister is involved & supportive\n\nDispo: Pt is call-out, transfer note written\n"
},
{
"category": "ECG",
"chartdate": "2123-11-23 00:00:00.000",
"description": "Report",
"row_id": 167547,
"text": "Sinus tachycardia. Non-specific ST-T wave changes. Since prior tracing\nof the rate has decreased.\n\n"
},
{
"category": "ECG",
"chartdate": "2123-11-21 00:00:00.000",
"description": "Report",
"row_id": 167548,
"text": "Sinus tachycardia. Non-diagnostic repolarization abnormalities. No previous\ntracing available for comparison.\n\n"
}
] |
56,175 | 152,031 | Pt was transferred on from outside facility with questionable diagnosis of esophageal perforation. Patient does have a history of schizophrenia with prior psychotic episode one year ago. Imaging concerning for pneumomediastinum with no history of vomiting. CT head and chest obtained showing air dissection in prevertebral space, carotid space and extensive pneumomediastinum. When patient first appeared, apparently was too delusional to obtain and pertinent history; she was a poor historian. Because we were not able to get any cooperation for barium swallow, plan was to go to OR for EGD and bronchoscopy. Please refer to dictated note for more information. Procedure completed without difficulty. There were no pathologic findings on exams, no blood in aerodigestive tract. NG tube placed for possible CT study to assess upper GI tract. However, there were also CT finidings of extensive air within spinal canal. After procedure, patient taken directly to the intensive care unit for monitoring. With negative study from CT, she was weaned from ventilator and extubated. On POD1, patient found to be combative and agitated. Pulling out peripheral IV, ripping off clothes, biting at restraints. Code purple called. Patient given haldol for sedation and restrained to bed. POD2, patient transferred to general floors. Triggered called for that evening because patient found to be posturing and drooling. She was tachycardic, EKG shoing QTc prolongation. Psych asked to evaluate patient for possible NMS. Held all psychiatric medications and narcotics. Sitter asked for constant surveillance. Psych also recommended to use cogentin 1mg or benadryl 25mg if any more EPS signs that do not spontaneously resolve. For the rest of her hospital stay, plans to arrange psych outpatient placement. Psych case manager working on finding her an inpatient psych facility. However due to insurance issues, patient stayed an additional day while all arrangements are sorted. She is stable and currently tolerating all regular foods. No acute distress. Minimal subcutaneous emphysema palpated on physical exam. | Still present pneumomediastinum is grossly unchanged in severity, moderate . The ET tube tip is still low at the carina, 1.0 cm above the carina. The ET tube tip is still low, at the subcarinal, less than 1 cm above the carina. The ET tube tip is still low, at the subcarinal, less than 1 cm above the carina. Limited views of the upper abdomen demonstrate the previously described small amount of retrocrural gas. 3:53 AM CHEST (PORTABLE AP) Clip # Reason: verify mid esophagus placement of NGT; NGT IS NOT TO BE MOVE Admitting Diagnosis: ESOPHAGEAL PERFORATION FINAL ADDENDUM ADDENDUM: Findings were discussed with Dr. over the phone by Dr. at the time of dictation. T wave inversions in leads VI-V2 of uncertainsignificance, probably a normal variant. Small focal lucency is seen at the superior aspect of the trachea, likely representing a small tracheal diverticulum. As compared to the previous radiograph, there is a further decrease of the manifestations of pneumomediastinum and pneumopericardium. No free air or contrast is identified within the limited views of the upper abdomen. No suspicious lytic or blastic osseous lesions identified. Bowel gas pattern appears normal. Airways appear patent to the subsegmental level. Since the previous tracing of right precordial lead T wave changes have decreased. This tracing is differentfrom prior tracing of only in the fact that the sinus rate hasincreased and the Q-T interval has shortened. The NG tube tip is in mid-to-distal esophagus. No large amount of gas is seen localized adjacent to the trachea. FINAL REPORT INDICATION: Concern for esophageal perforation. Endotracheal tip at the carina, pointing towards the left main stem (Over) 4:11 AM CT CHEST W/CONTRAST Clip # Reason: r/o extravasation r/o esophageal perforation from NGT which Admitting Diagnosis: ESOPHAGEAL PERFORATION Field of view: 36 Contrast: OPTIRAY Amt: 75 FINAL REPORT (Cont) bronchus. Pt will go OR for exploration Assessment And Plan: Neurologic: currently A&Ox2, mental status waxes and wanes, uncooperative with examination. Pt will go OR for exploration Assessment And Plan: Neurologic: currently A&Ox2, mental status waxes and wanes, uncooperative with examination. Pt was brought to OSH where she was lethargic, HR 110, BP 112/84, T 99.1. Pt was brought to OSH where she was lethargic, HR 110, BP 112/84, T 99.1. Pt was brought to OSH where she was lethargic, HR 110, BP 112/84, T 99.1. Pt was brought to OSH where she was lethargic, HR 110, BP 112/84, T 99.1. Pt was brought to OSH where she was lethargic, HR 110, BP 112/84, T 99.1. Pt was brought to OSH where she was lethargic, HR 110, BP 112/84, T 99.1. Pt was brought to OSH where she was lethargic, HR 110, BP 112/84, T 99.1. Pt was treated with IVF and macrobid for UTI. Pt was treated with IVF and macrobid for UTI. Pt was treated with IVF and macrobid for UTI. Pt was treated with IVF and macrobid for UTI. Pt was treated with IVF and macrobid for UTI. Pt was treated with IVF and macrobid for UTI. Pt was treated with IVF and macrobid for UTI. Pts mom updated by thoracic. Chlorhexidine Gluconate 0.12% Oral Rinse 2. Chlorhexidine Gluconate 0.12% Oral Rinse 2. Chlorhexidine Gluconate 0.12% Oral Rinse 2. Chlorhexidine Gluconate 0.12% Oral Rinse 2. Chief complaint: pneumomediastinum due to ?perforated esophagus? Chief complaint: pneumomediastinum due to ?perforated esophagus? Labs / Radiology [image002.jpg] Assessment and Plan 22 yo F with pneumomediastinum due to ?acute esophageal perforation. Labs / Radiology [image002.jpg] Assessment and Plan 22 yo F with pneumomediastinum due to ?acute esophageal perforation. noted urinary tract infection, treated with macrobid. noted urinary tract infection, treated with macrobid. She was found to be volume depleted with elevated bilirubin and CPK levels, and urinary tract infection. She was found to be volume depleted with elevated bilirubin and CPK levels, and urinary tract infection. She was found to be volume depleted with elevated bilirubin and CPK levels, and urinary tract infection. She was found to be volume depleted with elevated bilirubin and CPK levels, and urinary tract infection. She was found to be volume depleted with elevated bilirubin and CPK levels, and urinary tract infection. She was found to be volume depleted with elevated bilirubin and CPK levels, and urinary tract infection. She was found to be volume depleted with elevated bilirubin and CPK levels, and urinary tract infection. | 26 | [
{
"category": "Radiology",
"chartdate": "2182-09-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1036531,
"text": " 9:32 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval lung fields\n Admitting Diagnosis: ESOPHAGEAL PERFORATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old woman with h/o pneumomediastenium\n REASON FOR THIS EXAMINATION:\n eval lung fields\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: History of pneumomediastinum.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous examination, the patient is now\n extubated. The nasogastric tube has also been removed. The pre-existing\n retrocardiac opacity is resolving. Also resolving are the morphological\n manifestations of pneumomediastinum and pneumopericardium, although remnant\n signs of these changes are still visible, notably at the right-sided upper\n mediastinum. There is no evidence of pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-09-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1036273,
"text": " 3:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: verify mid esophagus placement of NGT; NGT IS NOT TO BE MOVE\n Admitting Diagnosis: ESOPHAGEAL PERFORATION\n ______________________________________________________________________________\n FINAL ADDENDUM\n ADDENDUM:\n\n Findings were discussed with Dr. over the phone by Dr. \n at the time of dictation.\n\n\n\n 3:53 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: verify mid esophagus placement of NGT; NGT IS NOT TO BE MOVE\n Admitting Diagnosis: ESOPHAGEAL PERFORATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old woman with pneumomediastinum s/p esophagoscopy and placement of ngt\n in mid esophagus\n REASON FOR THIS EXAMINATION:\n verify mid esophagus placement of NGT; NGT IS NOT TO BE MOVED INTO THE STOMACH\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLnc FRI 12:43 PM\n The NG tube tip is in distal third of the esophagus. The ET tube tip is still\n low, at the subcarinal, less than 1 cm above the carina.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of patient with suspected esophageal\n rupture.\n\n Portable AP chest radiograph was compared to .\n\n The ET tube tip is still low at the carina, 1.0 cm above the carina. The NG\n tube tip is in mid-to-distal esophagus.\n\n New consolidation in the left retrocardiac area is seen that might be\n consistent with atelectasis versus aspiration. Still present\n pneumomediastinum is grossly unchanged in severity, moderate .\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-09-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1036274,
"text": ", M. TSURG SICU-A 3:53 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: verify mid esophagus placement of NGT; NGT IS NOT TO BE MOVE\n Admitting Diagnosis: ESOPHAGEAL PERFORATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old woman with pneumomediastinum s/p esophagoscopy and placement of ngt\n in mid esophagus\n REASON FOR THIS EXAMINATION:\n verify mid esophagus placement of NGT; NGT IS NOT TO BE MOVED INTO THE STOMACH\n ______________________________________________________________________________\n PFI REPORT\n The NG tube tip is in distal third of the esophagus. The ET tube tip is still\n low, at the subcarinal, less than 1 cm above the carina.\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-09-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1036606,
"text": " 9:56 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: interval change in cxr?\n Admitting Diagnosis: ESOPHAGEAL PERFORATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old woman with pneumomediastinum now with low greade fever and\n ridgidity\n REASON FOR THIS EXAMINATION:\n interval change in cxr?\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Followup.\n\n COMPARISON: .\n\n As compared to the previous radiograph, there is a further decrease of the\n manifestations of pneumomediastinum and pneumopericardium. The remaining\n changes are best seen at the level of the aortopulmonary window and the aorta.\n In unchanged manner, there is no pneumothorax. The size of the cardiac\n silhouette is unchanged, there are no focal parenchymal opacities suggestive\n of pneumonia.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-09-06 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1036264,
"text": ", M. TSURG SICU-A 1:56 AM\n PORTABLE ABDOMEN Clip # \n Reason: metal ring in abd?\n Admitting Diagnosis: ESOPHAGEAL PERFORATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old woman with ? esophageal perf\n REASON FOR THIS EXAMINATION:\n metal ring in abd?\n ______________________________________________________________________________\n PFI REPORT\n No evidence of metallic foreign body seen in the visualized abdomen or pelvis.\n Hemidiaphragms are excluded on the current radiograph, however, are visualized\n on the portable chest obtained 20 minutes prior.\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-09-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1036260,
"text": " 1:04 AM\n CHEST (PORTABLE AP) Clip # \n Reason: suspicion perforated esophagus\n Admitting Diagnosis: ESOPHAGEAL PERFORATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old woman with known ct scan consistent with perforated esophagus\n REASON FOR THIS EXAMINATION:\n suspicion perforated esophagus\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SPfc FRI 12:55 PM\n Pneumomediastinum and subcutaneous emphysema in the neck.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 22-year-old woman with question of perforated esophagus.\n\n COMPARISON: No prior radiographs are available for comparison.\n\n FINDINGS: There is diffuse pneumomediastinum and subcutaneous emphysema in\n the neck.\n\n The lungs are clear. There are no pleural effusions. Cardiac contours are\n normal. Visualized soft tissue structures and bony thorax are otherwise\n normal.\n\n IMPRESSION:\n 1) Pneumomediastinum and subcutaneous emphysema in the neck.\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-09-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1036261,
"text": ", M. TSURG SICU-A 1:04 AM\n CHEST (PORTABLE AP) Clip # \n Reason: suspicion perforated esophagus\n Admitting Diagnosis: ESOPHAGEAL PERFORATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old woman with known ct scan consistent with perforated esophagus\n REASON FOR THIS EXAMINATION:\n suspicion perforated esophagus\n ______________________________________________________________________________\n PFI REPORT\n Pneumomediastinum and subcutaneous emphysema in the neck.\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-09-06 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1036263,
"text": " 1:56 AM\n PORTABLE ABDOMEN Clip # \n Reason: metal ring in abd?\n Admitting Diagnosis: ESOPHAGEAL PERFORATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old woman with ? esophageal perf\n REASON FOR THIS EXAMINATION:\n metal ring in abd?\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AGLc FRI 11:05 AM\n No evidence of metallic foreign body seen in the visualized abdomen or pelvis.\n Hemidiaphragms are excluded on the current radiograph, however, are visualized\n on the portable chest obtained 20 minutes prior.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 22-year-old female with concern for esophageal perforation. Here to\n evaluate for metal ring in the abdomen.\n\n COMPARISON: Portable chest radiograph performed on the same day at 1:22 a.m.\n\n PORTABLE SUPINE ABDOMINAL RADIOGRAPH: The current study includes\n visualization of the pubic symphysis but not the hemidiaphragms, which are\n visualized on the portable chest radiograph obtained 20 minutes prior. No\n evidence of metallic foreign body is seen in the visualized abdomen or pelvis.\n Moderate stool is seen throughout the colon. Bowel gas pattern appears\n normal. No supine evidence of free intra-abdominal air is seen. No abnormal\n calcification is noted within the abdomen or pelvis. The visualized osseous\n structures appear normal.\n\n IMPRESSION: No evidence of metallic foreign body seen in the visualized\n abdomen or pelvis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-09-06 00:00:00.000",
"description": "CT CHEST W/CONTRAST",
"row_id": 1036275,
"text": " 4:11 AM\n CT CHEST W/CONTRAST Clip # \n Reason: r/o extravasation r/o esophageal perforation from NGT which\n Admitting Diagnosis: ESOPHAGEAL PERFORATION\n Field of view: 36 Contrast: OPTIRAY Amt: 75\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old woman s/p NGT placement in mid esophagus with concern for\n esophageal perforation\n REASON FOR THIS EXAMINATION:\n r/o extravasation r/o esophageal perforation from NGT which is in the proximal\n esophagus using READICAT\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: FBr FRI 6:26 AM\n diffuse pneumomediastinum extending to the neck and retroperineum. no definite\n site of the esophaseal perforation is seen. no extravasation.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Concern for esophageal perforation.\n\n COMPARISON: None.\n\n TECHNIQUE: MDCT-acquired axial images of the chest were obtained with\n intravenous contrast. Orally administered diluted Redi-Cat was also\n administered. 5- and 1.25-mm thin section images were displayed. Coronal and\n sagittal reformatted images were also displayed.\n\n FINDINGS: Diffuse pneumomediastinum is seen extending from the\n retroperitoneum to the neck, predominantly along the paraesophageal plane.\n However, foci of gas are also noted in the retrocrural regions bilaterally, as\n well as within the spinal canal, likely within the epidural space.\n Subcutaneous emphysema is present in the right axilla. No significantly\n larger collection of gas is identified at any level to suggest possible\n location of a perforation. There is no discontinuity or dilation of the\n esophagus. No mediastinal collection or extravasation of contrast is\n identified. Small focal lucency is seen at the superior aspect of the\n trachea, likely representing a small tracheal diverticulum. No large amount\n of gas is seen localized adjacent to the trachea. Nasogastric tube is noted\n with tip approximately at the lower third of the esophagus. Endotracheal tube\n tip is near the carina, pointing towards the left main stem bronchus. Airways\n appear patent to the subsegmental level. No focal consolidation is identified\n within the lungs. Linear opacities, most consistent with atelectasis, are\n present at the left base. Limited views of the upper abdomen demonstrate the\n previously described small amount of retrocrural gas. No free air or contrast\n is identified within the limited views of the upper abdomen. No suspicious\n lytic or blastic osseous lesions identified.\n\n IMPRESSION:\n 1. Diffuse pneumomediastinum, air also in the retrocrural areas bilaterally,\n within the spinal canal, and in the right axilla. No other evidence of\n esophageal or tracheal perforation identified.\n 2. Endotracheal tip at the carina, pointing towards the left main stem\n (Over)\n\n 4:11 AM\n CT CHEST W/CONTRAST Clip # \n Reason: r/o extravasation r/o esophageal perforation from NGT which\n Admitting Diagnosis: ESOPHAGEAL PERFORATION\n Field of view: 36 Contrast: OPTIRAY Amt: 75\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n bronchus. This was discussed with Dr. at 11 a.m. on , .\n\n"
},
{
"category": "ECG",
"chartdate": "2182-09-10 00:00:00.000",
"description": "Report",
"row_id": 221479,
"text": "Sinus rhythm. Normal tracing. Since the previous tracing of \nright precordial lead T wave changes have decreased.\n\n"
},
{
"category": "ECG",
"chartdate": "2182-09-07 00:00:00.000",
"description": "Report",
"row_id": 221480,
"text": "Normal sinus rhythm. T wave inversions in leads VI-V2 of uncertain\nsignificance, probably a normal variant. This tracing is different\nfrom prior tracing of only in the fact that the sinus rate has\nincreased and the Q-T interval has shortened.\n\n"
},
{
"category": "ECG",
"chartdate": "2182-09-06 00:00:00.000",
"description": "Report",
"row_id": 221481,
"text": "Sinus rhythm. Prolonged Q-T interval. No previous tracing available for\ncomparison.\n\n"
},
{
"category": "Nursing",
"chartdate": "2182-09-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 636512,
"text": " Problem\n Esophageal perforation\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2182-09-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 636516,
"text": "22 yo female with hx of paranoid schizophrenia (dx ), maintained\n on Haldol, but has not been taking medication x6 months due to\n insurance reasons. 2 days PTA patient had psychotic break and was found\n running naked in street. Pt was brought to OSH where she was lethargic,\n HR 110, BP 112/84, T 99.1. Tox screen neg. She was found to be volume\n depleted with elevated bilirubin and CPK levels, and urinary tract\n infection. Pt was treated with IVF and macrobid for UTI. On , pt\n developed acute mental status changes consistent with catatonia. CT\n head and chest obtained showing air dissection in prevertebral space,\n carotid space, and extensive pneumomediastinum. Pt given zosyn and\n rosefin. Then medflighted to for further evaluation of possible\n esophageal perforation.\n Problem\n Esophageal perforation\n Assessment:\n Arrived in no apparent distress with stable vital sings maintaining\n adequate airway. Remained intubated post op for additional studies this\n morning. Sedated in no apparent distress.\n Action:\n Unable to participate in swallow study so taken to OR for rigid bronch\n and edg. No perforation noted in OR and brought post op to ct for\n scan. Broad spectrum abx coverage initiated.\n Response:\n No perferations noted. Remeains hemodyanically stable.\n Plan:\n Wean to extubate and obtain psych consult.\n"
},
{
"category": "Physician ",
"chartdate": "2182-09-06 00:00:00.000",
"description": "Intensivist Note",
"row_id": 636528,
"text": "SICU\n HPI:\n 22 yo female with hx of paranoid schizophrenia (dx ), maintained\n on Haldol, but has not been taking medication x6 months due to\n insurance reasons. 2 days PTA patient had psychotic break and was found\n running naked in street. Pt was brought to OSH where she was lethargic,\n HR 110, BP 112/84, T 99.1. Tox screen neg. She was found to be volume\n depleted with elevated bilirubin and CPK levels, and urinary tract\n infection. Pt was treated with IVF and macrobid for UTI. On , pt\n developed acute mental status changes consistent with catatonia. CT\n head and chest obtained showing air dissection in prevertebral space,\n carotid space, and extensive pneumomediastinum. Pt given zosyn and\n rosefin. Then medflighted to for further evaluation of possible\n esophageal perforation.\n mom reports that her tongue ring is missing. Pt complains of\n slight difficulty swallowing, febrile, and feeling lethargic. She\n denies any chest pain, recent trauma, or swallowing foreign objects.\n Chief complaint:\n pneumomediastinum due to ?perforated esophagus?\n PMHx:\n Schizophrenia\n Current medications:\n 1. Chlorhexidine Gluconate 0.12% Oral Rinse 2. Fentanyl Citrate 3.\n Fluconazole 4. Heparin 5. Magnesium Sulfate\n 6. Piperacillin-Tazobactam Na 7. Potassium Chloride 8. Propofol 9.\n Vancomycin\n 24 Hour Events:\n CXR, KUB, labs. Pt noncompliant and would not tolerate thin barium\n swallow study. To OR for further evaluation. Bronchoscopy and EGD is\n normal with no site of perforation or bleeding. NGT placed.\n Post operative day:\n POD#0 - Rigid EGD/Bronch\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 02:00 AM\n Fluconazole - 03:00 AM\n Vancomycin - 04:57 AM\n Infusions:\n Propofol - 75 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 09:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.4\nC (99.3\n T current: 36.1\nC (97\n HR: 85 (82 - 129) bpm\n BP: 101/72(67) {92/59(67) - 131/99(104)} mmHg\n RR: 14 (14 - 23) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,360 mL\n PO:\n Tube feeding:\n IV Fluid:\n 2,360 mL\n Blood products:\n Total out:\n 0 mL\n 810 mL\n Urine:\n 750 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,550 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 18 cmH2O\n Plateau: 16 cmH2O\n SPO2: 100%\n ABG: ///22/\n Ve: 6.7 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Distant heart sounds: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), Crepitus on RUE chest\n Abdominal: Soft\n Left Extremities: (Pulse - Dorsalis pedis: Present)\n Right Extremities: (Pulse - Dorsalis pedis: Present)\n Neurologic: Sedated\n Labs / Radiology\n 260 K/uL\n 13.4 g/dL\n 114 mg/dL\n 0.5 mg/dL\n 22 mEq/L\n 3.2 mEq/L\n 3 mg/dL\n 107 mEq/L\n 141 mEq/L\n 37.4 %\n 9.5 K/uL\n [image002.jpg]\n 01:11 AM\n WBC\n 9.5\n Hct\n 37.4\n Plt\n 260\n Creatinine\n 0.5\n Glucose\n 114\n Other labs: PT / PTT / INR:14.7/30.0/1.3, Differential-Neuts:82.6 %,\n Lymph:11.4 %, Mono:4.4 %, Eos:1.1 %, Albumin:4.1 g/dL, Ca:9.1 mg/dL,\n Mg:1.8 mg/dL, PO4:4.2 mg/dL\n Assessment and Plan\n PSYCHIATRIC DISEASE, OTHER (INCLUDING SCHIZOPHRENIA, PERSONALITY\n DISORDERS), PROBLEM - ENTER DESCRIPTION IN COMMENTS\n possible esophageal perforation\n Assessment and Plan: 22 year old female with pneumomediastinum of\n unclear etiology\n Neurologic: Pain controlled, fentanyl prn. propofol. ? air in spinal\n Canal on CT scan. will d/w NS significance\n Cardiovascular: hemodynamically stable\n Pulmonary: (Ventilator mode: CPAP + PS), Wean to extubate as tolerated.\n Gastrointestinal / Abdomen: Advance NGT as per primary team\n Nutrition: NPO\n Renal: Foley, Adequate UO\n Hematology: Stable\n Endocrine: RISS\n Infectious Disease: On empiric Broad spectrum ABX\n Lines / Tubes / Drains: Foley\n Wounds:\n Imaging:\n Fluids:\n Consults: Neuro surgery, CT surgery\n Billing Diagnosis: Sepsis, Other: pneumomediastinum\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 12:45 AM\n 18 Gauge - 04:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 32 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2182-09-06 00:00:00.000",
"description": "Intensivist Note",
"row_id": 636529,
"text": "SICU\n HPI:\n 22 yo female with hx of paranoid schizophrenia (dx ), maintained\n on Haldol, but has not been taking medication x6 months due to\n insurance reasons. 2 days PTA patient had psychotic break and was found\n running naked in street. Pt was brought to OSH where she was lethargic,\n HR 110, BP 112/84, T 99.1. Tox screen neg. She was found to be volume\n depleted with elevated bilirubin and CPK levels, and urinary tract\n infection. Pt was treated with IVF and macrobid for UTI. On , pt\n developed acute mental status changes consistent with catatonia. CT\n head and chest obtained showing air dissection in prevertebral space,\n carotid space, and extensive pneumomediastinum. Pt given zosyn and\n rosefin. Then medflighted to for further evaluation of possible\n esophageal perforation.\n mom reports that her tongue ring is missing. Pt complains of\n slight difficulty swallowing, febrile, and feeling lethargic. She\n denies any chest pain, recent trauma, or swallowing foreign objects.\n Chief complaint:\n pneumomediastinum due to ?perforated esophagus?\n PMHx:\n Schizophrenia\n Current medications:\n 1. Chlorhexidine Gluconate 0.12% Oral Rinse 2. Fentanyl Citrate 3.\n Fluconazole 4. Heparin 5. Magnesium Sulfate\n 6. Piperacillin-Tazobactam Na 7. Potassium Chloride 8. Propofol 9.\n Vancomycin\n 24 Hour Events:\n CXR, KUB, labs. Pt noncompliant and would not tolerate thin barium\n swallow study. To OR for further evaluation. Bronchoscopy and EGD is\n normal with no site of perforation or bleeding. NGT placed.\n Post operative day:\n POD#0 - Rigid EGD/Bronch\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 02:00 AM\n Fluconazole - 03:00 AM\n Vancomycin - 04:57 AM\n Infusions:\n Propofol - 75 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 09:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.4\nC (99.3\n T current: 36.1\nC (97\n HR: 85 (82 - 129) bpm\n BP: 101/72(67) {92/59(67) - 131/99(104)} mmHg\n RR: 14 (14 - 23) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,360 mL\n PO:\n Tube feeding:\n IV Fluid:\n 2,360 mL\n Blood products:\n Total out:\n 0 mL\n 810 mL\n Urine:\n 750 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,550 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 18 cmH2O\n Plateau: 16 cmH2O\n SPO2: 100%\n ABG: ///22/\n Ve: 6.7 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Distant heart sounds: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), Crepitus on RUE chest\n Abdominal: Soft\n Left Extremities: (Pulse - Dorsalis pedis: Present)\n Right Extremities: (Pulse - Dorsalis pedis: Present)\n Neurologic: Sedated\n Labs / Radiology\n 260 K/uL\n 13.4 g/dL\n 114 mg/dL\n 0.5 mg/dL\n 22 mEq/L\n 3.2 mEq/L\n 3 mg/dL\n 107 mEq/L\n 141 mEq/L\n 37.4 %\n 9.5 K/uL\n [image002.jpg]\n 01:11 AM\n WBC\n 9.5\n Hct\n 37.4\n Plt\n 260\n Creatinine\n 0.5\n Glucose\n 114\n Other labs: PT / PTT / INR:14.7/30.0/1.3, Differential-Neuts:82.6 %,\n Lymph:11.4 %, Mono:4.4 %, Eos:1.1 %, Albumin:4.1 g/dL, Ca:9.1 mg/dL,\n Mg:1.8 mg/dL, PO4:4.2 mg/dL\n Assessment and Plan\n PSYCHIATRIC DISEASE, OTHER (INCLUDING SCHIZOPHRENIA, PERSONALITY\n DISORDERS), PROBLEM - ENTER DESCRIPTION IN COMMENTS\n possible esophageal perforation\n Assessment and Plan: 22 year old female with pneumomediastinum of\n unclear etiology\n Neurologic: Pain controlled, fentanyl prn. propofol. ? air in spinal\n Canal on CT scan. will d/w NS significance\n Cardiovascular: hemodynamically stable\n Pulmonary: (Ventilator mode: CPAP + PS), Wean to extubate as tolerated.\n Gastrointestinal / Abdomen: Advance NGT as per primary team\n Nutrition: NPO\n Renal: Foley, Adequate UO\n Hematology: Stable\n Endocrine: RISS\n Infectious Disease: On empiric Broad spectrum ABX\n Lines / Tubes / Drains: Foley\n Wounds:\n Imaging:\n Fluids:\n Consults: Neuro surgery, CT surgery\n Billing Diagnosis: Sepsis, Other: pneumomediastinum\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 12:45 AM\n 18 Gauge - 04:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 32 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2182-09-07 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 636774,
"text": "Patient is a 22 y/o female with a diagnosis of paranoid schizophrenia\n in who was off of haldol X 6 months related to insurance issues\n and was found running naked through the street. Worked up for an\n esophageal tear and that was negative. SICU course included being\n extubated to room air and patient had one incident overnight of\n trying to get OOB and attempting to hurt herself by poking her eyes\n with her fingers. Patient was administered haldol and placed in 4 point\n restraints and provided a 1:1 sitter.\n Psychiatric Disease, Other (including Schizophrenia, Personality\n Disorders)\n Assessment:\n Pt is calm, initiating very little speech; oriented per mother; would\n not respond to this nurse\ns questions, only staring at this nurse\n blankly; at times nods vaguely to information I am telling her.\n Cooperative with care. Ate lunch without incident. Observed speaking to\n her mother. observation of self-harm or attempts to get OOB\n Action:\n Removed restraints as patient has a continuous 1:1 sitter and assured\n patient that she is in a safe environment. Encourage patient to discuss\n feelings with staff if she wants to.\n Response:\n Patient remains calm; remains largely withdrawn from staff. Does not\n appear catatonic however.\n Plan:\n Psychiatric consults recommends inpatient psychiatric treatment; 1:1\n sitter; aripiprazole ordered\n Failure to Void >8 hours of foley removal\n Assessment:\n Patient did not void 11 hours after she self D/C\ned foley\n Action:\n Foley catheter placed, draining 250 cc of light yellow urine\n Response:\n Foley in place continuing to drain urine.\n Plan:\n D/C foley at some point to give patient another chance to void.\n Demographics\n Attending MD:\n M.\n Admit diagnosis:\n ESOPHAGEAL PERFORATION\n Code status:\n Full code\n Height:\n Admission weight:\n 40 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH:\n Additional history: Paranoid schizophrenia dx , Bipolar,\n ? disease - asymptomatic hyperbilirubinemia.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:130\n D:97\n Temperature:\n 96.4\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 17 insp/min\n Heart Rate:\n 105 bpm\n Heart rhythm:\n ST (Sinus Tachycardia)\n O2 delivery device:\n None\n O2 saturation:\n 98 %\n O2 flow:\n FiO2 set:\n 0% %\n 24h total in:\n 405 mL\n 24h total out:\n 1,010 mL\n Pertinent Lab Results:\n Sodium:\n 142 mEq/L\n 04:15 AM\n Potassium:\n 3.6 mEq/L\n 04:15 AM\n Chloride:\n 109 mEq/L\n 04:15 AM\n CO2:\n 26 mEq/L\n 04:15 AM\n BUN:\n 7 mg/dL\n 04:15 AM\n Creatinine:\n 0.5 mg/dL\n 04:15 AM\n Glucose:\n 111 mg/dL\n 04:15 AM\n Hematocrit:\n 33.2 %\n 04:15 AM\n Finger Stick Glucose:\n 103\n 10:00 AM\n Valuables / Signature\n Patient valuables: None\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: \n Transferred to: 7\n Date & time of Transfer: 1600\n"
},
{
"category": "Nursing",
"chartdate": "2182-09-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 636580,
"text": " Problem\n Esophageal \n Assessment:\n CT negative per thoracic for esophageal . Pt is intubated and\n sedated from the OR and CT\n Action:\n Per thoracic ok to wean and extubate patient as no further testing to\n be done at this time.\n Response:\n Pt extubated at 1600. Awake and alert, following commands. Orientated\n to self, family but says nonsensical things to answer questions such as\n date. Moving around in bed independently.\n Plan:\n Psych and neuro consults. Monitor resp status. REorientate and provide\n emotional support. Bed low and locked with 3 rails up and bed alarm\n activated. ?Call out to floor with sitter. Pt\ns mom updated by\n thoracic.\n Please see metaVision flowchart for further details.\n"
},
{
"category": "Nursing",
"chartdate": "2182-09-07 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 636748,
"text": "Psychiatric Disease, Other (including Schizophrenia, Personality\n Disorders)\n Assessment:\n Action:\n Response:\n Plan:\n Problem - Description In Comments\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2182-09-07 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 636750,
"text": "Patient is a 22 y/o female with a diagnosis of paranoid schizophrenia\n in who was off of haldol X 6 months related to insurance issues\n and was found running naked through the street. Worked up for an\n esophageal tear and that was negative. SICU course included being\n extubated to room air and patient had one incident overnight of\n trying to get OOB and attempting to hurt herself by poking her eyes\n with her fingers. Patient was administered haldol and placed in 4 point\n restraints and provided a 1:1 sitter.\n Psychiatric Disease, Other (including Schizophrenia, Personality\n Disorders)\n Assessment:\n Pt is calm, initiating very little speech; oriented per mother; would\n not respond to this nurse\ns questions, only staring at this nurse\n blankly; at times nods vaguely to information I am telling her.\n Cooperative with care. Ate lunch without incident. Observed speaking to\n her mother. observation of self-harm or attempts to get OOB\n Action:\n Removed restraints as patient has a continuous 1:1 sitter and assured\n patient that she is in a safe environment. Encourage patient to discuss\n feelings with staff if she wants to.\n Response:\n Patient remains calm; remains largely withdrawn from staff. Does not\n appear catatonic however.\n Plan:\n Psychiatric consults recommends inpatient psychiatric treatment; 1:1\n sitter; aripiprazole ordered\n Failure to Void >8 hours of foley removal\n Assessment:\n Patient did not void 11 hours after she self D/C\ned foley\n Action:\n Foley catheter placed, draining 250 cc of light yellow urine\n Response:\n Foley in place continuing to drain urine.\n Plan:\n D/C foley at some point to give patient another chance to void.\n"
},
{
"category": "Respiratory ",
"chartdate": "2182-09-06 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 636475,
"text": "Demographics\n Day of intubation: 1\n Day of mechanical ventilation: 1\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: OR\n Reason: Elective; Comments: Intubated for Bronch in OR\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 7 mL / Air\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: To remain intubated for CT Scan.\n Reason for continuing current ventilatory support: Pending procedure /\n OR, Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:Pending CT Scan\n"
},
{
"category": "Physician ",
"chartdate": "2182-09-06 00:00:00.000",
"description": "Physician Surgical Admission Note",
"row_id": 636470,
"text": "Chief Complaint: pneumomediastinum due to ?perforated esophagus\n HPI:\n 22 yo female with hx of paranoid schizophrenia (dx ), maintained\n on Haldol, but has not been taking medication x6 months due to\n insurance reasons. 2 days PTA patient had psychotic break and was found\n running naked in street. Pt was brought to OSH where she was lethargic,\n HR 110, BP 112/84, T 99.1. Tox screen neg. She was found to be volume\n depleted with elevated bilirubin and CPK levels, and urinary tract\n infection. Pt was treated with IVF and macrobid for UTI. On , pt\n developed acute mental status changes consistent with catatonia. CT\n head and chest obtained showing air dissection in prevertebral space,\n carotid space, and extensive pneumomediastinum. Pt given zosyn and\n rosefin. Then medflighted to for further evaluation of possible\n esophageal perforation.\n mom reports that her tongue ring is missing. Pt complains of\n slight difficulty swallowing, febrile, and feeling lethargic. She\n denies any chest pain, recent trauma, or swallowing foreign objects.\n .\n 24 HOUR EVENTS:\n CXR, KUB, labs. Pt noncompliant and would not tolerate thin barium\n swallow study. To OR for repair of possible perforated esophagus\n Post operative day:\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Haldol - not taken for 6 months\n Past medical history:\n Family / Social history:\n Paranoid schizophrenia dx \n Bipolar\n ? disease - asymptomatic hyperbilirubinemia\n lives with mother; boyfriend at bedside with whom they have 1 child;\n denies illicit drugs or alcohol use\n Flowsheet Data as of 02:37 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.3\n Tcurrent: 37.4\nC (99.3\n HR: 129 (129 - 129) bpm\n BP: 130/86(97) {130/86(97) - 130/86(97)} mmHg\n RR: 23 (23 - 23) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 240 mL\n Urine:\n 240 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -240 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ////\n Physical Examination\n General Appearance: Well nourished, No acute distress, Thin\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: cervical crepitus\n Cardiovascular: (S1: Normal), (S2: Normal), Rub\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Responds to: Verbal stimuli, Movement: Purposeful, Tone:\n Normal, paranoid delusions stating that she is God and the devil is out\n to hurt her. Stops mid-sentence in responses.\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n 22 yo F with pneumomediastinum due to ?acute esophageal perforation. Pt\n is uncooperative with further examination. Pt will go OR for\n exploration\n Assessment And Plan:\n Neurologic: currently A&Ox2, mental status waxes and wanes,\n uncooperative with examination. obtain psych consult\n Cardiovascular: tachycardic due to pain and continued agitation\n Pulmonary: stable on room air, stable crepitus, stable lung sounds\n althought diminished centrally\n Gastrointestinal: NPO\n Renal: Urine output currently appropriate, will continue to assess.\n noted urinary tract infection, treated with macrobid. Foley in place\n Hematology: hct stable, WBC normal on transfer (decreased from 20,000\n at )\n Infectious Disease: On vancomycin, zosyn, fluconazole. will monitor\n blood cx due to concern of esophageal perforation\n Endocrine: RISS; maintain blood sugar control less than 150.\n Fluids: maintenance fluids\n Electrolytes: will follow and replete aggressively\n Nutrition: NPO, most likely TPN\n General: hemodynamically stable thus far\n ICU Care\n Nutrition: NPO thus far, will start TPN in the short term for continued\n nutritional support\n Glycemic Control: RISS, maintain target blood sugar < 150\n Lines:\n 20 Gauge - 12:45 AM\n Prophylaxis:\n DVT: heparin sq, boots\n Stress ulcer: PPI\n VAP: HOB, daily wake up, RSBI, mouth care\n Comments:\n Communication: Comments:\n Code status: Full code status\n Disposition: will stay in the ICU\n Total time spent: 31 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2182-09-06 00:00:00.000",
"description": "Physician Surgical Admission Note",
"row_id": 636466,
"text": "Chief Complaint: pneumomediastinum due to ?perforated esophagus\n HPI:\n 22 yo female with hx of paranoid schizophrenia (dx ), maintained\n on Haldol, but has not been taking medication x6 months due to\n insurance reasons. 2 days PTA patient had psychotic break and was found\n running naked in street. Pt was brought to OSH where she was lethargic,\n HR 110, BP 112/84, T 99.1. Tox screen neg. She was found to be volume\n depleted with elevated bilirubin and CPK levels, and urinary tract\n infection. Pt was treated with IVF and macrobid for UTI. On , pt\n developed acute mental status changes consistent with catatonia. CT\n head and chest obtained showing air dissection in prevertebral space,\n carotid space, and extensive pneumomediastinum. Pt given zosyn and\n rosefin. Then medflighted to for further evaluation of possible\n esophageal perforation.\n mom reports that her tongue ring is missing. Pt complains of\n slight difficulty swallowing, febrile, and feeling lethargic. She\n denies any chest pain, recent trauma, or swallowing foreign objects.\n .\n 24 HOUR EVENTS:\n CXR, KUB, labs. Pt noncompliant and would not tolerate thin barium\n swallow study. To OR for repair of possible perforated esophagus\n Post operative day:\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Haldol - not taken for 6 months\n Past medical history:\n Family / Social history:\n Paranoid schizophrenia dx \n Bipolar\n ? disease - asymptomatic hyperbilirubinemia\n lives with mother; boyfriend at bedside with whom they have 1 child;\n denies illicit drugs or alcohol use\n Flowsheet Data as of 02:37 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.3\n Tcurrent: 37.4\nC (99.3\n HR: 129 (129 - 129) bpm\n BP: 130/86(97) {130/86(97) - 130/86(97)} mmHg\n RR: 23 (23 - 23) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 240 mL\n Urine:\n 240 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -240 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ////\n Physical Examination\n General Appearance: Well nourished, No acute distress, Thin\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: cervical crepitus\n Cardiovascular: (S1: Normal), (S2: Normal), Rub\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Responds to: Verbal stimuli, Movement: Purposeful, Tone:\n Normal, paranoid delusions stating that she is God and the devil is out\n to hurt her. Stops mid-sentence in responses.\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n 22 yo F with pneumomediastinum due to ?acute esophageal perforation. Pt\n is uncooperative with further examination. Pt will go OR for\n exploration\n Assessment And Plan:\n Neurologic: currently A&Ox2, mental status waxes and wanes,\n uncooperative with examination. obtain psych consult\n Cardiovascular: tachycardic due to pain and continued agitation\n Pulmonary: stable on room air, stable crepitus, stable lung sounds\n althought diminished centrally\n Gastrointestinal: NPO\n Renal: Urine output currently appropriate, will continue to assess.\n noted urinary tract infection, treated with macrobid. Foley in place\n Hematology: hct stable, WBC normal on transfer (decreased from 20,000\n at )\n Infectious Disease: On vancomycin, zosyn, fluconazole. will monitor\n blood cx due to concern of esophageal perforation\n Endocrine: RISS; maintain blood sugar control less than 150.\n Fluids: maintenance fluids\n Electrolytes: will follow and replete aggressively\n Nutrition: NPO, most likely TPN\n General:\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:45 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2182-09-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 636719,
"text": "Psychiatric Disease, Other (including Schizophrenia, Personality\n Disorders)\n Assessment:\n Pt pulled out iv while in bed. Iv replaced.Pt became agitated and\n jumped out of bed.. Dr and pt received 2 mg iv haldol. Pt\n weeping and aksing .pleading for a hug. She wrapped her arms around\n this RN very gently and put her head on this RN\ns shoulder saying\n am so sorry\n. Patient then lay down and shortly ptput both thumbs up\n to her eyes and started pressing. This RN grabbed her arms down away\n from her eyes and called for help.Hands restrained with soft limb\n restraints but then pt started biting at restraints/wrist . Restraints\n removed and this RN again called for assistance By the time help\n arrived pt was out of the bed and she was wripping off her clothes and\n pulled out her iv. Code purple called and the psych resident was also\n called to come evaluate patient.\n Action:\n Patient helped back into bed and placed in 4 point leather restraints.\n She was thrashing about so haldol 5 mg im given. Mother arrived ~ 2145\n and is sitting at bedside throughout the night. Leg restraints removed\n at 0200.but wrist restraints continued..and pt has has a sitter 1;1.\n Response:\n Pt has been somnolent since she received haldol dose at 2200.\n Plan:\n Monitor mental status. Call psych when pt awakens. Monitor qt interval\n with haldol use. Ekg this a.m.\n"
},
{
"category": "Physician ",
"chartdate": "2182-09-07 00:00:00.000",
"description": "Intensivist Note",
"row_id": 636703,
"text": "SICU\n HPI:\n 22 yo female with hx of paranoid schizophrenia (dx ), maintained\n on Haldol, but has not been taking medication x6 months due to\n insurance reasons. 2 days PTA patient had psychotic break and was found\n running naked in street. Pt was brought to OSH where she was lethargic,\n HR 110, BP 112/84, T 99.1. Tox screen neg. She was found to be volume\n depleted with elevated bilirubin and CPK levels, and urinary tract\n infection. Pt was treated with IVF and macrobid for UTI. On , pt\n developed acute mental status changes consistent with catatonia. CT\n head and chest obtained showing air dissection in prevertebral space,\n carotid space, and extensive pneumomediastinum. Pt given zosyn and\n rosefin. Then medflighted to for further evaluation of possible\n esophageal perforation.\n Chief complaint:\n pneumomediastinum\n PMHx:\n schizophrenia\n Current medications:\n 1. Chlorhexidine Gluconate 0.12% Oral Rinse 2. Famotidine 3. Fentanyl\n Citrate 4. Fluconazole 5. Haloperidol\n 6. Haloperidol 7. Heparin 8. Magnesium Sulfate 9.\n Piperacillin-Tazobactam Na 10. Potassium Chloride\n 11. Propofol 12. Vancomycin\n 24 Hour Events:\n extubated, CODE PURPLE\n Post operative day:\n POD#1 - Rigid EGD/Bronch\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:56 PM\n Fluconazole - 01:00 AM\n Piperacillin/Tazobactam (Zosyn) - 04:30 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:56 PM\n Famotidine (Pepcid) - 10:44 PM\n Other medications:\n Flowsheet Data as of 07:21 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.4\nC (99.4\n T current: 37.3\nC (99.1\n HR: 80 (74 - 125) bpm\n BP: 137/96(105) {91/57(34) - 141/104(110)} mmHg\n RR: 18 (14 - 27) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,317 mL\n 273 mL\n PO:\n Tube feeding:\n IV Fluid:\n 3,317 mL\n 273 mL\n Blood products:\n Total out:\n 2,010 mL\n 0 mL\n Urine:\n 1,950 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,307 mL\n 273 mL\n Respiratory support\n O2 Delivery Device: None\n Ventilator mode: Standby\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 292 (118 - 292) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 0 cmH2O\n FiO2: 0%\n PIP: 0 cmH2O\n Plateau: 14 cmH2O\n SPO2: 97%\n ABG: ///26/\n Ve: 4.8 L/min\n Physical Examination\n General Appearance: No acute distress, sedated\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities, Sedated\n Labs / Radiology\n 238 K/uL\n 11.7 g/dL\n 111 mg/dL\n 0.5 mg/dL\n 26 mEq/L\n 3.6 mEq/L\n 7 mg/dL\n 109 mEq/L\n 142 mEq/L\n 33.2 %\n 9.2 K/uL\n [image002.jpg]\n 01:11 AM\n 04:15 AM\n WBC\n 9.5\n 9.2\n Hct\n 37.4\n 33.2\n Plt\n 260\n 238\n Creatinine\n 0.5\n 0.5\n Glucose\n 114\n 111\n Other labs: PT / PTT / INR:14.7/30.0/1.3, CK / CK-MB / Troponin\n T:389//, ALT / AST:26/25, Alk-Phos / T bili:55/0.5,\n Differential-Neuts:82.6 %, Lymph:11.4 %, Mono:4.4 %, Eos:1.1 %,\n Albumin:3.7 g/dL, LDH:162 IU/L, Ca:8.8 mg/dL, Mg:2.1 mg/dL, PO4:4.9\n mg/dL\n Assessment and Plan\n PSYCHIATRIC DISEASE, OTHER (INCLUDING SCHIZOPHRENIA, PERSONALITY\n DISORDERS), PROBLEM - ENTER DESCRIPTION IN COMMENTS\n possible esophageal perforation\n Assessment and Plan: 22yF with schizophrenia, r/o for esophageal\n perforation\n Neurologic: 1:1 sitter, haldol prn, psych consult\n Cardiovascular: check EKG forQT prolongation\n Pulmonary: stable\n Gastrointestinal / Abdomen: NPO\n Nutrition: NPO until cleared by primary team\n Renal: replace foley catheter\n Hematology: stable\n Endocrine: no issues\n Infectious Disease: recommend stopping antibiotics as no evidence\n perforation\n Lines / Tubes / Drains: PIV\n Wounds:\n Imaging:\n Fluids: KVO\n Consults: CT surgery, psychiatry\n Billing Diagnosis: Other: psychosis\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 10:00 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2182-09-07 00:00:00.000",
"description": "Intensivist Note",
"row_id": 636710,
"text": "SICU\n HPI:\n 22 yo female with hx of paranoid schizophrenia (dx ), maintained\n on Haldol, but has not been taking medication x6 months due to\n insurance reasons. 2 days PTA patient had psychotic break and was found\n running naked in street. Pt was brought to OSH where she was lethargic,\n HR 110, BP 112/84, T 99.1. Tox screen neg. She was found to be volume\n depleted with elevated bilirubin and CPK levels, and urinary tract\n infection. Pt was treated with IVF and macrobid for UTI. On , pt\n developed acute mental status changes consistent with catatonia. CT\n head and chest obtained showing air dissection in prevertebral space,\n carotid space, and extensive pneumomediastinum. Pt given zosyn and\n rosefin. Then medflighted to for further evaluation of possible\n esophageal perforation.\n Chief complaint:\n pneumomediastinum\n PMHx:\n schizophrenia\n Current medications:\n 1. Chlorhexidine Gluconate 0.12% Oral Rinse 2. Famotidine 3. Fentanyl\n Citrate 4. Fluconazole 5. Haloperidol\n 6. Haloperidol 7. Heparin 8. Magnesium Sulfate 9.\n Piperacillin-Tazobactam Na 10. Potassium Chloride\n 11. Propofol 12. Vancomycin\n 24 Hour Events:\n extubated, CODE PURPLE\n Post operative day:\n POD#1 - Rigid EGD/Bronch\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:56 PM\n Fluconazole - 01:00 AM\n Piperacillin/Tazobactam (Zosyn) - 04:30 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:56 PM\n Famotidine (Pepcid) - 10:44 PM\n Other medications:\n Flowsheet Data as of 07:21 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.4\nC (99.4\n T current: 37.3\nC (99.1\n HR: 80 (74 - 125) bpm\n BP: 137/96(105) {91/57(34) - 141/104(110)} mmHg\n RR: 18 (14 - 27) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,317 mL\n 273 mL\n PO:\n Tube feeding:\n IV Fluid:\n 3,317 mL\n 273 mL\n Blood products:\n Total out:\n 2,010 mL\n 0 mL\n Urine:\n 1,950 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,307 mL\n 273 mL\n Respiratory support\n O2 Delivery Device: None\n Ventilator mode: Standby\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 292 (118 - 292) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 0 cmH2O\n FiO2: 0%\n PIP: 0 cmH2O\n Plateau: 14 cmH2O\n SPO2: 97%\n ABG: ///26/\n Ve: 4.8 L/min\n Physical Examination\n General Appearance: No acute distress, sedated\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities, Sedated\n Labs / Radiology\n 238 K/uL\n 11.7 g/dL\n 111 mg/dL\n 0.5 mg/dL\n 26 mEq/L\n 3.6 mEq/L\n 7 mg/dL\n 109 mEq/L\n 142 mEq/L\n 33.2 %\n 9.2 K/uL\n [image002.jpg]\n 01:11 AM\n 04:15 AM\n WBC\n 9.5\n 9.2\n Hct\n 37.4\n 33.2\n Plt\n 260\n 238\n Creatinine\n 0.5\n 0.5\n Glucose\n 114\n 111\n Other labs: PT / PTT / INR:14.7/30.0/1.3, CK / CK-MB / Troponin\n T:389//, ALT / AST:26/25, Alk-Phos / T bili:55/0.5,\n Differential-Neuts:82.6 %, Lymph:11.4 %, Mono:4.4 %, Eos:1.1 %,\n Albumin:3.7 g/dL, LDH:162 IU/L, Ca:8.8 mg/dL, Mg:2.1 mg/dL, PO4:4.9\n mg/dL\n Assessment and Plan\n PSYCHIATRIC DISEASE, OTHER (INCLUDING SCHIZOPHRENIA, PERSONALITY\n DISORDERS), PROBLEM - ENTER DESCRIPTION IN COMMENTS\n possible esophageal perforation\n Assessment and Plan: 22yF with schizophrenia, r/o for esophageal\n perforation\n Neurologic: 1:1 sitter, haldol prn, psych consult\n Cardiovascular: check EKG forQT prolongation\n Pulmonary: stable\n Gastrointestinal / Abdomen: NPO\n Nutrition: NPO until cleared by primary team\n Renal: replace foley catheter\n Hematology: stable\n Endocrine: no issues\n Infectious Disease: recommend stopping antibiotics as no evidence\n perforation\n Lines / Tubes / Drains: PIV\n Wounds:\n Imaging:\n Fluids: KVO\n Consults: CT surgery, psychiatry\n Billing Diagnosis: Other: psychosis\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 10:00 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 31\n"
}
] |
70,764 | 178,319 | The patient was admitted on . After initial evaluation, she was taken to the OR emergently for LLE thrombectomy. She underwent a left iliac, femoral, superficial femoral artery, profunda embolectomy, 4-compartment fasciotomy. Post-operatively, her pulses were pulses (DP and PT) were monophasic. She was taken to the CVICU, intubated and sedated and on pressors, and on a heparin drip. She remained on pressor support, as her pressures could not tolerate her pain/sedation drips. She had new onset atrial fibrillation which was rate controlled. She was aggressively treated for rhabdomyolysis and ARF with hydration. She had a bedside ECHO which showed: severe regional LV systolic dysfunction (EF 20-30%) consistent with multivessel CAD. Mild (1+) MR. Moderate to severe [3+] TR with moderate PA systolic hypertension. She had a head CT which showed right parieto-occipital infarct. The patient remained intubated. She could not be weaned off the ventilator - she would thrash about in the bed, and was unresponsive to commands. She would move her upper extremities, and right lower extremity; muscle twitches were noted in her left lower extremity. Attempts to extubate were not successful - she would hypertensive and very highly aggitated when these attempts were made. She was switched to TPN and made NPO when she vomitted tube feeds - this may have been due to extensive carcinomatosis causing pSBO. She was seen by gyn/onc for her ascites and distension, as well as CT scan, which were concerning for ovarian cancer. She had a CT scan of her abdomen and pelvis on ; this was concerning for peritoneal carcinomatous, including ascites and probable; pSBO; moderate bilateral pleural effusions and adjacent atelectasis; small hiatal hernia; tiny non-obstructing left nephrolithiasis; anasarca. Peritoneal ascites came back positive for adenocarcinoma, suspicious for ovarian cancer. Pleural fluid cytology, from a right thoracentesis on , came back positive for malignant cells. She was not deemed to be a surgical candidate, though may be a chemotherapy candidate; however, discussing these options were deffered as the patient could not be extubated to participate in these discussions. The patient was made DNR/DNI . On the morning of , the patient became acutely hypotensive and was treated with blood (for postoperative blood loss and intravascular depletion), fluids and pressors. Her heparin drip was discontinued. A femoral artery line was placed when the radial line stopped working. The patient's lower extremity and abdomen became mottled, her abdomen tense, and it became more difficult to ventilate her; she became increasingly acidotic. Her family was made aware. The decision was made to make her CMO. Time of death was 0528 on . | parietal-occpit. parietal-occpit. parietal-occpit. Generalized edema++. maligancy, partial SBO,and recent rt. maligancy, partial SBO,and recent rt. maligancy, partial SBO,and recent rt. (+) Popliteal and Femoral pulses. (+) Popliteal and Femoral pulses. Does attempt to pulled out ETT. Moves bilat UE & RLE. Moves bilat UE & RLE. Moves bilat UEs & RLE. Intermittent versed bolus for agitation/Tachycardia and HTN. (+) Diuresis from Lasix. Advacne rate per order. Rhabdomylosis. Rhabdomylosis. Rhabdomylosis. Rhabdomylosis. ABD firm & distended. ABD firm & distended. SBO per CTScan. ABD firm & distended (-)BS. ABD firm & distended (-) BS. Tacypneic/tachycardic and Hypertensive. PERRLA. PERRLA. PERRLA. PERRLA. PERRLA. PERRLA. Palpable pulses DT/PT. Palpable pulses DT/PT. Received pt from O.R. Received pt from O.R. Pt intubated/sedated on neo, Propofol,heparin gtts. Pt intubated/sedated on neo, Propofol,heparin gtts. Cardiovascular: Hypotension resolved, now off neo. Slightly oliguric overnight monitor. Response: Sats in high 90s, ABG WNL, suction as needed. Per d/w RN, low residuals on current TF, however suctioned ?tube feed out of mouth. partial SBO,and recent rt. partial SBO,and recent rt. partial SBO,and recent rt. partial SBO, and recent rt. Pulses by Doppler, continues on Heparin gtt. Decreased sedation with goal of pt triggering her own breaths. Decreased sedation with goal of pt triggering her own breaths. Aspirin, Full anticoagulation. Continue bowel regimen, Reglan * If pt w/ recurrent vomiting, would change to elemental TF formula (Vivonex) Multivitamin / Mineral supplement: cont current Check chemistry 10 panel replete lytes prn Will continue to follow page if ?s * Does attempt to pulled out ETT. Pt with generalized + edema. Pt with generalized + edema. Recheck hct. Recheck hct. partial SBO,and recent rt. Intermittent versed bolus for agitation/Tachycardia and HTN. with re-intubation if needed. re-start TF. Would monitor in PM, if continue to decrease < 20 --> transfuse 1 u PRBC. Continue diurese. parietal-occpit. Plan: Frequent Neuro check. Plan: Frequent Neuro check. Metolazone po given. Status: DNR/DNI (Confirmed today). Tacypneic/tachycardic and Hypertensive. Please d/c gtt today. F with acute ischemic left foot, new onset of PAF with ? Generalized edema++. Briefly started on neo for bp support now off. Briefly started on neo for bp support now off. Briefly started on neo for bp support now off. Administered IV Ativan 1mg resulting in hypotensive BP 78/40 and MAP 48. Pt with generalized + edema. Pt with generalized + edema. Intermittent versed bolus for agitation/Tachycardia and HTN. Intermittent versed bolus for agitation/Tachycardia and HTN. Tolerating tube feeding, f/u on neutritional recs. s/p LLE embolectomy . Heparin drip. This is m/p from rhabdomyoglobinuria. re-intubation. Plan for ex lap, however pt developed acute L foot ischemia. Will recheck hct. Tacypneic/tachycardic and Hypertensive. Tacypneic/tachycardic and Hypertensive. Generalized edema++. partial SBO,and recent rt. partial SBO,and recent rt. parietal-occpit. parietal-occpit. Papable pulses DT/PT. IV heparin gtt and L embolectomy done. IV heparin gtt and L embolectomy done. IV heparin gtt and L embolectomy done. tap for dx. tap for dx. F with acute ischemic left foot, new onset of PAF with ? DNR/DNI(Confirmed after intubation. DNR/DNI(Confirmed after intubation. maligancy, partial SBO,and recent rt. maligancy, partial SBO,and recent rt. maligancy, partial SBO,and recent rt. parietal-occpit. parietal-occpit. parietal-occpit. parietal-occpit. parietal-occpit. parietal-occpit. parietal-occpit. Cardiovascular: Aspirin, Hypotension post-op --> cont neo gtt. partial SBO,and recent rt. partial SBO,and recent rt. partial SBO,and recent rt. partial SBO, and recent rt. Famotidine . Renal failure, acute (Acute renal failure, ARF) Assessment: BUN/Creat slightly up. Renal failure, acute (Acute renal failure, ARF) Assessment: BUN/Creat slightly up. tap for dx. tap for dx. tap for dx. tap for dx. Phenylephrine . Attempting to pulled out ETT. Attempting to pulled out ETT. Reposition Q2 hr. Reposition Q2 hr. Reglan 5mg IV given and bisacodyl suppository. Reglan 5mg IV given and bisacodyl suppository. Phenylephrine 19. Noted high phos, rec take out of TPN. Pneumococcal Vac Polyvalent . recurrent AF.Pleural cytol P from . recurrent AF.Pleural cytol P from . partial SBO,and recent rt. partial SBO,and recent rt. partial SBO,and recent rt. Continue with diuresis as overall fluid overload. Lorazepam . f/u Hct in PM. tap for dx. tap for dx. tap for dx. Chlorhexidine Gluconate 0.12% Oral Rinse9. Chief complaint: PMHx: As above Current medications: 24 Hour Events: - R-sided thoracentesis; cytology sent. If continue to drop --> 1 unit PRBC. to drop Hct-> Protonix . to drop Hct-> Protonix . to drop Hct-> Protonix . parietal-occpit. parietal-occpit. parietal-occpit. Phenylephrine . Metoprolol Tartrate . Neurologic: Neuro checks Q: 1 hr Cardiovascular: Aspirin, Full anticoagulation Pulmonary: Cont ETT, (Ventilator mode: CPAP + PS) Gastrointestinal / Abdomen: Nutrition: TPN Renal: Foley, Adequate UO Endocrine: RISS Infectious Disease: Lines / Tubes / Drains: Foley, NGT, ETT, RT PICC, LT scv TLC Wounds: Dry dressings Fluids: Other, TPN Consults: await decision re: gen. consult for SBO. Preserved -ventricular systolicfunction. Again seen is CHF, with upper zone redistribution, mild diffuse vascular blurring, interstitial edema, and probably subtle alveolar edema, and probable small bilateral pleural effusions, all essentially unchanged. There is interval decrease in the right pleural effusion. Moderate bilateral pleural effusions and adjacent atelectasis. An ET tube is present -- the tip lies approximately 1.5 cm above the carina, slightly low, and points toward the right mainstem bronchus. Stable bilateral pleural effusions and right basilar atelectasis. FINDINGS: There is a endotracheal tube 4.1 cm above the level of the carina in stable position. Small hiatal hernia. No LA mass/thrombus (best excluded by TEE).RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Partial small-bowel obstruction, with transition point in the distal ileum. Stable bilateral pleural effusions. Stable bilateral pleural effusions. Stable bilateral pleural effusions. Mild to moderate [+] TR.Moderate PA systolic hypertension.PERICARDIUM: Small pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor echo windows. | 139 | [
{
"category": "Nursing",
"chartdate": "2160-03-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 436630,
"text": "Pleural effusion, chronic\n Assessment:\n Bilateral pleural effusion.\n Action:\n Right pleural tap done at bedside. Additional sedation given\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n CVA (Stroke, Cerebral infarction), Ischemic\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2160-03-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 436634,
"text": "Pleural effusion, chronic\n Assessment:\n Bilateral pleural effusion.\n Action:\n Right pleural tap done at bedside. Additional sedation given for\n agitation during procedure. Post procedure CXray shows small right\n pneumo. Repeat CXRay OK in afternoon. Fluids sent for cytology. ? Ca.\n Response:\n Removed 300 cc from right. Vented. Resp status stable.\n Plan:\n ? tap left side.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Vented day #9. LS I/Exp wheezing. Bil rhonchi\ns. Suction Q 2-3 hrs.\n Clear pale yellow secretion\n Action:\n CPAP x 2 today. 35%/. Had to put her on CMV this am due to\n agitation.\n Response:\n Continue to wean as tolerated.\n Plan:\n DNR. Husband does want intubation if does not tolerate extubation.\n CVA (Stroke, Cerebral infarction), Ischemic\n Assessment:\n Does not follow commands today. Agitated +++ with minimal stimulation.\n Does not focus. Pupils 3 brisk. Moves Upper extremities and right leg.\n Moves toes on left leg. Moves head side to side. Hct 20.4\n Action:\n Sedated with fentanyl and intermittent bolus. Ativan IV bolus. 1 unit\n RBC given. Restarted heparin @ 1000unit/hr at 15:00.\n Response:\n Repeat Hct 24.9.\n Plan:\n Next PTT @ 20:00. Monitor signs of bleeding. No stool this am. Had\n guiac positive stool.\n Impaired Skin Integrity\n Assessment:\n Generalized edema. Skin oozing serous fluids from incision and puncture\n site.\n Action:\n Lasix 20 mg IV Q 8 hrs.\n Response:\n Creat slightly up(1.9 to 2.1). Net\n 1300 ml so fair.\n Plan:\n Continue lasix. Monitor renal function am.\n Alteration in Nutrition\n Assessment:\n Tfeeding stopped last night due to vomiting. NPO this am until 14:00.\n Abdomen firm and distended (Not new).\n Action:\n Reglan IV given. Restarted tube feeds @ 10 cc/hr.\n Response:\n No vomiting yet. Minimal residuals.\n Plan:\n Residual check Q 4 hrs. HOB 30-45 degrees.\n Code status: DNR---Intubate as needed per husbands wishes (Next of\n ).\n"
},
{
"category": "Physician ",
"chartdate": "2160-02-23 00:00:00.000",
"description": "Intensivist Note",
"row_id": 435183,
"text": "CVICU\n HPI:\n HD2\n POD1 LLE embolectomy\n Cc: acute ischemic left foot, new onset of AF with abdominal ascites\n ? maligancy, partial SBO,and recent rt. parietal-occpit. infarct with\n stenosis 50-69%.\n PMH: negative\n PSH negative\n Plan: IV heparin, rescuscitation. f/u neuro cs and gyn c/s\n Chief complaint:\n PMHx:\n Current medications:\n 150 mEq Sodium Bicarbonate/ 1000 mL D5W 4. 500 ml NS 5. Albuterol\n 0.083% Neb Soln\n 6. Albuterol Inhaler 7. Aspirin 8. Calcium Gluconate 9. Chlorhexidine\n Gluconate 0.12% Oral Rinse\n 10. Famotidine 11. Fentanyl Citrate 12. Heparin 13. 14. Influenza Virus\n Vaccine 15. Magnesium Sulfate\n 16. Metoprolol Tartrate 17. Nitroglycerin Ointment 2% 18. Phenylephrine\n 19. Pneumococcal Vac Polyvalent\n 20. Potassium Chloride 21. Propofol 22. Sodium Chloride 0.9% Flush\n 24 Hour Events:\n OR RECEIVED - At 09:38 PM\n INVASIVE VENTILATION - START 09:38 PM\n ARTERIAL LINE - START 09:43 PM\n INTUBATION - At 09:51 PM\n MULTI LUMEN - START 12:00 AM\n left I.J. quad palced by vascular md.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 850 units/hour\n Phenylephrine - 1 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 07:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.3\nC (97.4\n T current: 36.3\nC (97.4\n HR: 74 (65 - 117) bpm\n BP: 95/56(71) {79/46(59) - 122/73(93)} mmHg\n RR: 14 (14 - 20) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 58.2 kg (admission): 50 kg\n Height: 58 Inch\n CVP: 13 (-3 - 27) mmHg\n Total In:\n 76 mL\n 5,525 mL\n PO:\n Tube feeding:\n IV Fluid:\n 76 mL\n 5,525 mL\n Blood products:\n Total out:\n 33 mL\n 293 mL\n Urine:\n 33 mL\n 293 mL\n NG:\n Stool:\n Drains:\n Balance:\n 43 mL\n 5,232 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 551 (551 - 551) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n RSBI Deferred: FiO2 > 60%\n PIP: 40 cmH2O\n Plateau: 32 cmH2O\n SPO2: 99%\n ABG: 7.51/31/160/24/2\n Ve: 7.3 L/min\n PaO2 / FiO2: 267\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Trace), (Temperature: Cool), (Pulse -\n Dorsalis pedis: Absent), (Pulse - Posterior tibial: Absent)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Moves all extremities, Sedated\n Labs / Radiology\n 256 K/uL\n 11.9 g/dL\n 92 mg/dL\n 0.9 mg/dL\n 24 mEq/L\n 4.2 mEq/L\n 21 mg/dL\n 100 mEq/L\n 131 mEq/L\n 32.7 %\n 18.5 K/uL\n [image002.jpg]\n 10:29 PM\n 10:39 PM\n 04:50 AM\n 05:02 AM\n WBC\n 20.9\n 18.5\n Hct\n 30.4\n 32.7\n Plt\n 239\n 256\n Creatinine\n 0.8\n 0.9\n TCO2\n 30\n 26\n Glucose\n 83\n 92\n 92\n Other labs: PT / PTT / INR:15.0/71.0/1.3, CK / CK-MB / Troponin\n T://, ALT / AST:132/297, Alk-Phos / T bili:108/0.4, Lactic\n Acid:1.1 mmol/L, Albumin:1.7 g/dL, Ca:6.6 mg/dL, Mg:1.3 mg/dL, PO4:3.5\n mg/dL\n Assessment and Plan\n PERIPHERAL VASCULAR DISEASE (PVD) WITH CRITICAL LIMB ISCHEMIA, .H/O\n HYPERTENSION, BENIGN\n Assessment and Plan:\n Neurologic: Neuro checks Q: 1 hr, Follow Neurology Rec's and cont Neuro\n checks; Cont Sedation with PPF and Fent PRN\n Cardiovascular: Aspirin, Full anticoagulation, Beta-blocker, Afib -->\n cont low dose lopressor for rate control; Post-op Hypotension --> cont\n Neo gtt for MAP > 60\n Pulmonary: Cont ETT, (Ventilator mode: CMV)\n Gastrointestinal / Abdomen: OGT\n Nutrition: NPO\n Renal: Foley, Elevated CPK's and Rhabdomyolysis --> agree with\n aggressive hydration and forced diuresis and alkalinization.\n Hyponatremia --> probably SIADH --> will free H2O restrict and cont\n normal tonic fluids and follow --> may need to add lasix.\n Hematology: Hct with mild anemia --> cont to follow\n Endocrine: RISS\n Infectious Disease: No infectious issues at this time.\n Lines / Tubes / Drains: Foley, ETT\n Wounds: Dry dressings\n Imaging: CT scan head today\n Fluids: Bicarbonate infusion.\n Consults: Vascular surgery, Neurology\n Billing Diagnosis: Post-op hypotension\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 09:43 PM\n Multi Lumen - 12:00 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin drip)\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 32 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2160-02-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 435290,
"text": "Unable to locate admission note from @ 2145 from RN.\n Note re-written to supercede previous note.\n Received pt from O.R. at s./p left femoral embolectomy with left\n lower leg fasciotomy. Pt intubated/sedated on neo, Propofol,heparin\n gtts. NSR no ectopy. Labile bp requiring 6 iters LR. Bp transitionally\n responded to fluid then trended back down. Neo tirated to from\n 1.5meq-> 1.0meq. Propofol quickly titrated upward after pt\n spontaneously awoke and became extremely agitated with decompensation\n of hemodynamics. Heparin gtt remained @ 850u/hrs ( even though PTT >\n 150) per vascular team. Left foot cool/dusky with dopplerable pulses.\n Rt foot cold/dusky with absent DP/PT pulses. (+) Popliteal and Femoral\n pulses. DP/PT pulses faintly heard later in shift. Vented On CMV 60%\n 550 5 16. Ls rhonchorous throughout. Abdomen firmly distended d/t\n ascites. Absent bs. Minimal bloody urine out put with sediment,\n clearing to tea color after fluid . Lytes repleted prn. [INS: l :INS]\n Alteration in Nutrition\n Assessment:\n Pt had peditube in nare which fell out today\n Action:\n Vivonex goal of 60 not reached\n Response:\n Feedings turned off\n Plan:\n Pt to go to IR tomorrow for placement of tube under fleuro\n Tachycardia, Other\n Acute Confusion\n Assessment:\n Alert and orientated to person\n Action:\n Reoriented pt as needed\n Response:\n Pt calm and accepting\n Plan:\n Reorient as needed\n Assessment:\n HR >100\n Action:\n Response:\n Pt became tachy around 1500, and lopressor dose increased again to 75mg\n TID\n Plan:\n Keep HR <100\n _______________________\n"
},
{
"category": "Nursing",
"chartdate": "2160-02-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 435655,
"text": "CVA (Stroke, Cerebral infarction), Ischemic\n Assessment:\n Moves R and L upper extremities. Does move right leg on bed. No\n movement of left leg. Intermittent movement of head side to side when\n awake. Pupils 3 Brisk. Follows command intermittently. Withdraws to\n pain. Open\ns eyes to name. Did follow commands when off sedation and\n nod to questions. Sedated. Restless at times. SR with frequent PAC\n and PVC\ns. (COPD).Lytes OK.\n Action:\n Propofol replaced with Fentanyl drip. Intermittent versed bolus for\n agitation/Tachycardia and HTN. Heparin drip @ 800 units\n Response:\n PTT at goal (60-80).PTT in am only.\n Plan:\n Frequent Neuro check. Sedation as needed.\n Peripheral vascular disease (PVD) with critical limb ischemia\n Assessment:\n POD #2 left femoral embolectomy and fasciotomy. Palpable pulses DT/PT.\n No movement of left leg 9Not new). Palpable pulses. Distended and firm\n abdomen. SBO per CTScan. ? Ovarian Ca. Awaiting GUYN encology. Stool x1\n today. Rabdo-CPK trending down.\n Action:\n Attempt to wean Neo. Heparin drip LR @ 80 cc/hr.\n Response:\n Perfusion improving to LE. Skin warm.\n Plan:\n Monitor tissue perfusion. Map>70.\n Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Patient drinks ETOH daily per family. Patient agitated when awake.\n Tacypneic/tachycardic and Hypertensive. Skin dry. No tremors/No\n diaphoresis/no sizure activity.\n Action:\n Propofol changed to fentanyl drip. Intermittent versed bolus given.\n Thiamine/folic acid and MVI started @ 50 ml/hr x 1 litre.\n Response:\n Response well to versed and fentanyl.\n Plan:\n Monitor signs of withdrawal. CIWA. Sadation as needed.\n Positive for UTI. Culture sent. Started on Cipro IV today.\n Sediments in urine. Creat slightly increasing from yesterday. Afebrile.\n Family meeting today with Dr. . Both sons and\n grand-daughter present. Son had spoken to patient\ns husband this am and\n discussed Code status. According to son, agreed with DNR status\n and so did the rest of the family present in the room. Patient\ns wishes\n were to be DNR according to the son and grand-daughter.\n Status: DNR/DNI (Confirmed today). Family considering\n CMO status. Will confirm tomorrow.\n"
},
{
"category": "Respiratory ",
"chartdate": "2160-02-26 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 435730,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\n Ideal body weight: 42.3 None\n Ideal tidal volume: 169.2 / 253.8 / 338.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Ins/Exp Wheeze\n LUL Lung Sounds: Ins/Exp Wheeze\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Scant\n Comments/Plan\n Pt changed to AC mode overnight for persistent diminished minute\n volume. No RSBI this am, secondary to no spontaneous RR. See\n flowsheet for further pt data. Will follow.\n 06:38\n"
},
{
"category": "Respiratory ",
"chartdate": "2160-02-24 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 435316,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 42.3 None\n Ideal tidal volume: 169.2 / 253.8 / 338.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: 8 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Ins/Exp Wheeze\n LUL Lung Sounds: Ins/Exp Wheeze\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Rusty / Thick\n Sputum source/amount: Suctioned / Copious\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments: Pt is stable on AC settings\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Maintain PEEP at current level and reduce FiO2 as tolerated, Adjust\n Min. ventilation to control pH, Increase ventilatory support at night;\n Comments: Pt scored a failing 157 on the RSBI trial due to high rate\n and very low tidal volumes. PT is stbale on AC settings with proper\n sedation.\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Intolerant of weaning attempts, Cannot protect airway, Cannot manage\n secretions, Underlying illness not resolved; Comments: Pt to continue\n current support, ventilate and wean as\n tolerated.\n BEDSIDE RSBI FAILED at 157\n"
},
{
"category": "Nursing",
"chartdate": "2160-02-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 435320,
"text": "CVA (Stroke, Cerebral infarction), Ischemic\n Assessment:\n Propofol shut off q2h to assess neuro status. Pt awoke,became\n restless, moving head and all extremities EXCEPT left leg. No\n tracking or following commands.Perla @ 3mm. tachypneic & tachycardic\n Action:\n Re-sedated for respiratory and hemodynamics stability.\n Response:\n No change in neuro exam w/i the last 24hhrs\n Plan:\n Continue to assess q2h.\n Peripheral vascular disease (PVD) with critical limb ischemia\n Assessment:\n Left lower leg embolectomy and fasciotomy.\n Action:\n Dopplerable pulses DP/PT on bilateral feet. Waffle boots and\n compression sleeve intact.\n Response:\n Feet cool and slightly dusky.(+) blanching.\n Plan:\n Continiue to monitor pulses q2h.\n .H/O hypertension, benign\n Assessment:\n Labile bp s/p surgery requiring neo gtt,\n Action:\n Bp more stable. Neo gtt titrated downward.\n Response:\n Bp stabilizing. U/o remains borderline.\n Plan:\n Wean neo gtt as tolerated.\n"
},
{
"category": "Nursing",
"chartdate": "2160-02-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 435322,
"text": "Unable to locate admission note from @ 2145 from RN.\n Note re-written to supercede previous note.\n Received pt from O.R. at s./p left femoral embolectomy with left\n lower leg fasciotomy. Pt intubated/sedated on neo, Propofol,heparin\n gtts. NSR no ectopy. Labile bp requiring 6 iters LR. Bp transitionally\n responded to fluid then trended back down. Neo tirated to from\n 1.5meq-> 1.0meq. Propofol quickly titrated upward after pt\n spontaneously awoke and became extremely agitated with decompensation\n of hemodynamics. Heparin gtt remained @ 850u/hrs ( even though PTT >\n 150) per vascular team. Left foot cool/dusky with dopplerable pulses.\n Rt foot cold/dusky with absent DP/PT pulses. (+) Popliteal and Femoral\n pulses. DP/PT pulses faintly heard later in shift. Vented On CMV 60%\n 550 5 16. Ls rhonchorous throughout. Abdomen firmly distended d/t\n ascites. Absent bs. Minimal bloody urine out put with sediment,\n clearing to tea color after fluid . Lytes repleted prn. [INS: l :INS]\n Alteration in Nutrition\n Assessment:\n Pt had peditube in nare which fell out today\n Action:\n Vivonex goal of 60 not reached\n Response:\n Feedings turned off\n Plan:\n Pt to go to IR tomorrow for placement of tube under fleuro\n Tachycardia, Other\n Acute Confusion\n Assessment:\n Alert and orientated to person\n Action:\n Reoriented pt as needed\n Response:\n Pt calm and accepting\n Plan:\n Reorient as needed\n Assessment:\n HR >100\n Action:\n Response:\n Pt became tachy around 1500, and lopressor dose increased again to 75mg\n TID\n [: Plan: :]\n Keep HR <100\n"
},
{
"category": "Nursing",
"chartdate": "2160-02-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 435270,
"text": "71 YO F s/p L femoral cut down, embolectomy & fasciotomy for ischemic L\n foot on .\n CVA (Stroke, Cerebral infarction), Ischemic\n Assessment:\n When sedation lightened Pt becomes agitated. PERRLA. Pt does not\n track, does not follow commands. Moves bilat UEs & RLE on bed. Mild\n muscle twitching noted to LLE otherwise no other movement noted to\n LLE.\n Action:\n Frequent neuro checks off sedation. Neurology team consulted.\n Response:\n Pt neuro status unchanged.\n Plan:\n Head CT to r/o hemorrhagic stroke. Continue frequent neuro checks.\n .\n Peripheral vascular disease (PVD) with critical limb ischemia.\n Assessment:\n Hypotensive. CVP >15. Minimal tea colored HUO. Rising CPKs. ABD firm &\n distended (-) BS. R foot cyanotic with absent DP & PT pulses.\n Action:\n Bedside echo done\n ? clots. NEO Gtt continues. NS fluid resuscitation\n x4 liters & NAHC03 Gtt\n ? Rhabdomylosis. Abd CT ordered\n ? SBO. GYN\n team consulted\n ? ovarian CA. Pelvic US ordered. NTG paste applied to\n R foot. Heparin Gtt continues.\n Response:\n Pt vomited CT contrast dye; awaiting results of abdominal CT scan.\n Plan:\n Continue to monitor BP & HUO, with frequent pulse checks. Continue to\n follow Q6hr PTT & CPKs.\n"
},
{
"category": "Respiratory ",
"chartdate": "2160-02-24 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 435438,
"text": "TITLE:\n Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 42.3 None\n Ideal tidal volume: 169.2 / 253.8 / 338.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: 8 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: Clear / Thick\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: awaiting diagnostic results, plan to be determined inam\n rounds\n Reason for continuing current ventilatory support: Cannot protect\n airway, Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Nursing",
"chartdate": "2160-02-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 435234,
"text": "CVA (Stroke, Cerebral infarction), Ischemic\n Assessment:\n When sedation lightened Pt. agitated. Moves bilat UE & RLE. Mild muscle\n contracting to LLE otherwise no other movement noted to LLE. PERRLA.\n Pt. does not track, does not follow commands.\n Action:\n Frequent neuro checks off sedation.\n Response:\n Pt neuro status unchanged.\n Plan:\n Head CT to r/o hemmorhagic stroke.\n Peripheral vascular disease (PVD) with critical limb ischemia\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2160-02-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 435239,
"text": "71 YO F s/p L femoral cut down, embolectomy & fasciotomy for ischemic L\n foot on .\n CVA (Stroke, Cerebral infarction), Ischemic\n Assessment:\n When sedation lightened Pt becomes agitated. PERRLA. Pt does not\n track, does not follow commands. Moves bilat UEs & RLE on bed. Mild\n muscle twitching noted to LLE otherwise no other movement noted to\n LLE.\n Action:\n Frequent neuro checks off sedation. Neurology team consulted.\n Response:\n Pt neuro status unchanged.\n Plan:\n Head CT to r/o hemmorhagic stroke.\n Peripheral vascular disease (PVD) with critical limb ischemia.\n Assessment:\n Hypotensive. CVP >15. Minimal tea colored HUO. Rising CPKs. ABD firm &\n distended (-)BS. R foot cyanotic with absent DP & PT pulses.\n Action:\n Bedside echo done\n ? clots. NEO Gtt continues. NS fluid resuscitation\n x3 liters & NAHC03 Gtt\n ? Rhabdomylosis. Abd CT ordered\n ? SBO. GYN\n team consulted\n ? ovarian CA. Pelvic US ordered. NTG paste applied to\n R foot. Heparin Gtt continues.\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2160-02-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 435235,
"text": "71 YO F s/p L femoral cut down, embolectomy & fasciotomy for ischemic L\n foot on .\n CVA (Stroke, Cerebral infarction), Ischemic\n Assessment:\n When sedation lightened Pt. agitated. Moves bilat UE & RLE. Mild muscle\n twitching noted to LLE otherwise no other movement to LLE. PERRLA.\n Pt. does not track, does not follow commands.\n Action:\n Frequent neuro checks off sedation. Neurology team consulted.\n Response:\n Pt neuro status unchanged.\n Plan:\n Head CT to r/o hemmorhagic stroke.\n Peripheral vascular disease (PVD) with critical limb ischemia\n Assessment:\n Hypotensive. CVP >15. Minimal tea colored HUO. Rising CPKs. ABD firm &\n distended. R foot cyanotic with absent DP & PT pulses.\n Action:\n Bedside echo done. NEO Gtt continues. NS fluid resuscitation x3 liters\n & NAHC03 Gtt\n ? Rhabdomylosis. Abd CT ordered\n ? SBO. GYN team\n consulted\n ? ovarian CA. Pelvic US ordered. NTG paste applied to R\n foot.\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2160-02-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 435238,
"text": "71 YO F s/p L femoral cut down, embolectomy & fasciotomy for ischemic L\n foot on .\n CVA (Stroke, Cerebral infarction), Ischemic\n Assessment:\n When sedation lightened Pt agitated. PERRLA. Pt does not track, does\n not follow commands. Moves bilat UEs & RLE. Mild muscle twitching\n noted to LLE otherwise no other movement to LLE.\n Action:\n Frequent neuro checks off sedation. Neurology team consulted.\n Response:\n Pt neuro status unchanged.\n Plan:\n Head CT to r/o hemmorhagic stroke.\n Peripheral vascular disease (PVD) with critical limb ischemia\n Assessment:\n Hypotensive. CVP >15. Minimal tea colored HUO. Rising CPKs. ABD firm &\n distended. R foot cyanotic with absent DP & PT pulses.\n Action:\n Bedside echo done. NEO Gtt continues. NS fluid resuscitation x3 liters\n & NAHC03 Gtt\n ? Rhabdomylosis. Abd CT ordered\n ? SBO. GYN team\n consulted\n ? ovarian CA. Pelvic US ordered. NTG paste applied to R\n foot.\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2160-02-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 435427,
"text": "71 YO F s/p L femoral cut down, embolectomy & fasciotomy for ischemic L\n foot on .\n CVA (Stroke, Cerebral infarction), Ischemic\n Assessment:\n When sedation lightened, Pt becomes agitated. PERRLA. Pt does not\n track, today inconsistently followed commands. Moves bilat UEs & RLE on\n bed. Mild muscle twitching noted to LLE otherwise no other movement\n noted to LLE.\n Action:\n Frequent neuro checks off sedation. Neurology team following.\n Response:\n Pt displaying slight improvement in neuro status.\n Plan:\n Continue frequent neuro checks.\n Peripheral vascular disease (PVD) with critical limb ischemia.\n Assessment:\n Hypotensive. CVP >10. Minimal dk brown colored HUO with sediment. CPKs\n trending downward. ABD remains firm & distended (-) BS (+) ascities.\n Action:\n NEO Gtt continues. Lasix 20MG IV x1 administered. Vigileo monitor in\n place. Heparin Gtt continues.\n Response:\n Pt continues to require BP support. (+) Diuresis from Lasix. CI > 2.\n Plan:\n Continue to monitor BP & HUO. Continue to follow Q6hr PTT. ?\n Paracentesis, ? Thoracentesis.\n"
},
{
"category": "Nursing",
"chartdate": "2160-02-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 435879,
"text": "Peripheral vascular disease (PVD) with critical limb ischemia\n Assessment:\n POD #3 left femoral embolectomy and fasciotomy. Palpable pulses DT/PT.\n No movement of left leg. Palpable pulses. Distended and firm abdomen.\n Rabdo-CPK continues to trending down.\n Action:\n Neo increased for MAP>60-70.\n Response:\n Skin warm.\n Plan:\n Monitor tissue perfusion. Map>70.\n CVA (Stroke, Cerebral infarction), Ischemic\n Assessment:\n s/p Embolic stroke. Was in RAP at OSH. Moves R and L upper extremities.\n Does move right leg on bed. No movement of left leg. Intermittent\n movement of head side to side when awake. Does attempt to pulled out\n ETT. Pupils 3 Brisk. Follows command intermittently. Tracking RN in\n room during wakeup. Withdraws to pain. Open\ns eyes to name.Restless at\n times with repositioning. SR 60-90\ns with frequent PAC\ns and PVC\n Lytes OK.\n Action:\n Fentanyl drip. Intermittent versed changed to versed drip. Heparin drip\n @ 800 units\nhr. PTT at goal.\n Response:\n PTT at goal (60-80).PTT in am only. Tolerating versed drip @ .25 mg/hr.\n Appears comfortable.\n Plan:\n Frequent Neuro check. Sedation as needed. Repositioning.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Net + -/+ 18 litres since admission. Requiring a lot of fluid: Rabdo\n and BP management. Generalized edema++. Skin weeping at puncture and\n incision sites. Marginal U/O with lasix bolus. Added lasix drip.\n Action:\n Stared lasix drip @ 5mh/hr. Zorozyline po given.\n Response:\n Good response to lasix drip. BUN/Creat slightly up.\n Plan:\n Monitor U/O. Monitor renal function.\n Alteration in Nutrition\n Assessment:\n Abdomen firm and distended. BS hypoactive and distant. Anasarca.\n Action:\n Started TF via Sump today. Currently @ 20 cc/hr. Goal 40 cc.hr.\n Response:\n Lat NB yesterday. No TF residual.\n Plan:\n Check residuel Q4 hr. Advacne rate per order. Due to increase rate @\n 21:00. HOB 30 degree.\n Impaired Skin Integrity\n Assessment:\n Generalized edema. Skin oozing +++. Starting to develop skin blisters\n on LE and UE.\n Action:\n Dressings changed today. Repositioned Q2 hrs. Awaiting PICC line\n placement.\n Response:\n Frequent skin care assessment.\n Plan:\n Monitor skin care. Reduce pressure. Waffles boots. Keep skin dry.\n Continue to diurese.\n Positive for UTI. Day #2 of IV Cipro. Sediments in urine\n decreasing. Afebrile.\n Code Status: DNR/DNI\n Second family meeting:\n Meet with family today. Myself, , NP and Dr.\n present. All children present (2 sons and 1 daughter), 1 grand-son and\n 2 daughter in-laws present. Medical condition discussed with family.\n Patient in showing some clinical signs of improvements. Awaiting\n encology input regarding staging of Ca and prognosis. Family very\n concerned about patient\ns well being and comfort. Family very emotional\n requirering reinforcement and repetition of information given. Son\n did speak with Dr. over the phone late\n"
},
{
"category": "General",
"chartdate": "2160-02-28 00:00:00.000",
"description": "Generic Note",
"row_id": 436206,
"text": "TITLE: Bedside TTE by intensivist\n A bedside TTE was done by intensivist to evaluate for cardiac etiology\n for inability to wean off the vent.\n Findings: Preserved -ventricular systolic function (EF > 55%),\n Moderate tricuspid regurgitation, mild pulmonary artery systolic\n hypertension.\n Chest: Large bilateral pleural effusions\n Time spent: 30 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2160-02-24 00:00:00.000",
"description": "Intensivist Note",
"row_id": 435378,
"text": "CVICU\n HPI:\n HD3\n POD#2 LLE embolectomy\n Cc: acute ischemic left foot, new onset of AF with abdominal ascites\n ? maligancy, partial SBO,and recent rt. parietal-occpit. infarct with\n stenosis 50-69%.\n PMH: negative\n PSH negative\n Plan: IV heparin, rescuscitation. f/u neuro cs and gyn c/s\n Current medications:\n Albuterol 0.083% Neb Soln 4. Albuterol Inhaler 5. Aspirin 6.\n Chlorhexidine Gluconate 0.12% Oral Rinse\n 7. Famotidine 8. Fentanyl Citrate 9. Heparin 10. 11. Influenza Virus\n Vaccine 12. Magnesium Sulfate\n 13. Metoprolol Tartrate 14. Nitroglycerin Ointment 2% 15. Phenylephrine\n 16. Pneumococcal Vac Polyvalent\n 17. Potassium Chloride 18. Propofol 19. Sodium Chloride 0.9% Flush\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 12:00 PM\n Cont Oliguria, but CPK\ns and Creat stable or improving.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Phenylephrine - 0.8 mcg/Kg/min\n Heparin Sodium - 900 units/hour\n Other ICU medications:\n Famotidine (Pepcid) - 12:00 AM\n Other medications:\n Flowsheet Data as of 07:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.1\nC (98.7\n T current: 37.1\nC (98.7\n HR: 97 (67 - 103) bpm\n BP: 109/55(74) {90/50(65) - 136/71(92)} mmHg\n RR: 19 (12 - 24) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 69.8 kg (admission): 50 kg\n Height: 58 Inch\n CVP: 292 (9 - 319) mmHg\n Total In:\n 12,891 mL\n 2,349 mL\n PO:\n Tube feeding:\n IV Fluid:\n 12,081 mL\n 2,349 mL\n Blood products:\n Total out:\n 1,049 mL\n 92 mL\n Urine:\n 699 mL\n 92 mL\n NG:\n 350 mL\n Stool:\n Drains:\n Balance:\n 11,842 mL\n 2,257 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 451 (450 - 451) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 157\n PIP: 30 cmH2O\n Plateau: 27 cmH2O\n SPO2: 97%\n ABG: 7.39/38/168/23/-1\n Ve: 7.4 L/min\n PaO2 / FiO2: 336\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: Bilat bases)\n Abdominal: Soft, Non-tender, Distended\n Left Extremities: (Edema: 2+), (Temperature: Cool), (Pulse - Dorsalis\n pedis: Absent), (Pulse - Posterior tibial: Absent)\n Right Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Neurologic: Moves all extremities, Sedated\n Labs / Radiology\n 250 K/uL\n 11.9 g/dL\n 86 mg/dL\n 1.1 mg/dL\n 23 mEq/L\n 4.0 mEq/L\n 21 mg/dL\n 105 mEq/L\n 135 mEq/L\n 34.2 %\n 12.7 K/uL\n [image002.jpg]\n 10:39 PM\n 04:50 AM\n 05:02 AM\n 08:11 AM\n 11:20 AM\n 12:26 PM\n 05:29 PM\n 09:04 PM\n 09:12 PM\n 03:11 AM\n WBC\n 18.5\n 16.9\n 12.7\n Hct\n 32.7\n 34.6\n 34.2\n Plt\n \n Creatinine\n 0.9\n 1.0\n 1.1\n TCO2\n 30\n 26\n 26\n 24\n 25\n 24\n Glucose\n 92\n 92\n 88\n 97\n 113\n 127\n 104\n 103\n 86\n Other labs: PT / PTT / INR:14.0/66.7/1.2, CK / CK-MB / Troponin\n T:5942//, ALT / AST:175/302, Alk-Phos / T bili:112/0.3, Lactic Acid:1.4\n mmol/L, Albumin:1.5 g/dL, Ca:6.9 mg/dL, Mg:2.0 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n CVA (STROKE, CEREBRAL INFARCTION), ISCHEMIC , PERIPHERAL VASCULAR\n DISEASE (PVD) WITH CRITICAL LIMB ISCHEMIA\n Neurologic: PPF for sedation; Fentanyl for pain. F/U with neurology\n rec's.\n Cardiovascular: Aspirin, Hypotension / shock post-op --> will cont neo\n gtt for now and monitor CO with Vigileo monitor and consider adding\n inotrope given ECHO findings.\n Pulmonary: Cont ETT, (Ventilator mode: CMV); Cont MDI\ns for severe\n expiratory wheeze.\n Gastrointestinal / Abdomen: F/U with OB/Gyn consults today.\n Nutrition: NPO\n Renal: Foley, Rhabdomyolysis --> would cont volume resuscitation and\n consider start Mannitol or lasix to augment and force diruesis\n depending on CO/CI with Vigileo, however, CK is now < 6000, but has\n cont'd to be severely oliguric.\n Hematology: Mod anemia.\n Endocrine: RISS\n Infectious Disease: No infections currently.\n Lines / Tubes / Drains: Foley, OGT, ETT\n Imaging: CXR today\n Fluids: Bicarb infusion with boluses of saline PRN for UOP\n Consults: Vascular surgeryl; Neurology; OB/Gyn\n Billing Diagnosis: (Respiratory distress: Failure)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 09:43 PM\n Multi Lumen - 12:00 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin drip)\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 32 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2160-02-24 00:00:00.000",
"description": "ICU Note - CVI",
"row_id": 435386,
"text": "CVICU\n HPI:\n HD3\n POD#2 LLE embolectomy\n Cc: acute ischemic left foot, new onset of AF with abdominal ascites\n ? maligancy, partial SBO,and recent rt. parietal-occpit. infarct with\n stenosis 50-69%.\n PMH: negative\n PSH negative\n Plan: IV heparin\n Current medications:\n . 1000 mL LR . Albuterol 0.083% Neb Soln . Albuterol Inhaler . Aspirin\n . Chlorhexidine Gluconate 0.12% Oral Rinse\n Heparin . Influenza Virus Vaccine. Magnesium Sulfate . Metoprolol\n Tartrate . Nitroglycerin Ointment 2%. Pantoprazole Phenylephrine.\n Pneumococcal Vac Polyvalent . Potassium Chloride . Propofol Sodium\n Chloride 0.9% Flush\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 12:00 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Phenylephrine - 1 mcg/Kg/min\n Heparin Sodium - 900 units/hour\n Propofol - 50 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 AM\n Other medications:\n Flowsheet Data as of 09:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.1\nC (98.7\n T current: 36.5\nC (97.7\n HR: 81 (67 - 103) bpm\n BP: 122/58(81) {91/51(65) - 136/69(91)} mmHg\n RR: 15 (13 - 24) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 69.8 kg (admission): 50 kg\n Height: 58 Inch\n CVP: 13 (9 - 319) mmHg\n PAP: (17 mmHg) / (0 mmHg)\n Total In:\n 12,891 mL\n 2,945 mL\n PO:\n Tube feeding:\n IV Fluid:\n 12,081 mL\n 2,915 mL\n Blood products:\n Total out:\n 1,049 mL\n 162 mL\n Urine:\n 699 mL\n 162 mL\n NG:\n 350 mL\n Stool:\n Drains:\n Balance:\n 11,842 mL\n 2,783 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 451 (451 - 451) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 157\n PIP: 23 cmH2O\n Plateau: 27 cmH2O\n SPO2: 99%\n ABG: 7.40/34/143/23/-2\n Ve: 6.5 L/min\n PaO2 / FiO2: 286\n Physical Examination\n General Appearance: No acute distress, sedated\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Wheezes :\n )\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Diminished)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Sedated\n Labs / Radiology\n 250 K/uL\n 11.9 g/dL\n 92 mg/dL\n 1.1 mg/dL\n 23 mEq/L\n 3.5 mEq/L\n 21 mg/dL\n 105 mEq/L\n 135 mEq/L\n 34.2 %\n 12.7 K/uL\n [image002.jpg]\n 04:50 AM\n 05:02 AM\n 08:11 AM\n 11:20 AM\n 12:26 PM\n 05:29 PM\n 09:04 PM\n 09:12 PM\n 03:11 AM\n 07:45 AM\n WBC\n 18.5\n 16.9\n 12.7\n Hct\n 32.7\n 34.6\n 34.2\n Plt\n \n Creatinine\n 0.9\n 1.0\n 1.1\n TCO2\n 26\n 26\n 24\n 25\n 24\n 22\n Glucose\n 92\n 92\n 88\n 97\n 113\n 127\n 104\n 103\n 86\n 92\n Other labs: PT / PTT / INR:14.0/66.7/1.2, CK / CK-MB / Troponin\n T:4490//, ALT / AST:175/302, Alk-Phos / T bili:112/0.3, Lactic Acid:1.1\n mmol/L, Albumin:1.5 g/dL, Ca:6.9 mg/dL, Mg:2.0 mg/dL, PO4:3.8 mg/dL\n Fluid Analysis / Other Labs: Cytology on ascites POSITIVE for\n mailignancy(? adeno)\n Imaging: Echo- severe LV depression- 20%.\n Moderate ascites, moderate Bilateral pleural effusions on CT.\n Assessment and Plan\n CVA (STROKE, CEREBRAL INFARCTION), ISCHEMIC , PERIPHERAL VASCULAR\n DISEASE (PVD) WITH CRITICAL LIMB ISCHEMIA\n Assessment and Plan: Vigileo to assess CO/fluid status then either\n Lasix or pressor.\n CK down under 6K\n consider thoracentesis to assess for malig. effusions- this would have\n strong implications for level of aggressiveness of care.\n Neurologic: seadated. No purposeful motion when Propofol off.\n Cardiovascular: Full anticoagulation\n Pulmonary: Cont ETT\n Gastrointestinal / AbdomenSl firm.:\n Nutrition: NPO\n Renal: Foley, increase UO , how depending upon CO findings.\n Lines / Tubes / Drains: Foley, OGT, ETT\n Wounds: Dry dressings\n Fluids: LR, 80/hr\n ICU Care\n Comments: NPO now\n Glycemic Control: Regular insulin sliding scale\n Arterial Line - 09:43 PM\n Multi Lumen - 12:00 AM\n DVT: (Systemic anticoagulation: Heparin drip)\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care\n Communication: Patient discussed on interdisciplinary rounds , ICU\n call in today he said.\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2160-02-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 436315,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt on CPAP most of shift, although pt\ns RR low (/min). O2 sat\n stable. Initially increased pressure support to improve pt\ns pH and\n CO2 from ABG. RR and minute volume remained low, so pt placed on MMV.\n Action:\n Pt not triggering breaths while on MMV. Pt has long apneic periods, so\n placed pt on AC. Decreased sedation with goal of pt triggering her own\n breaths. Pt arousable to voice at this time, but not following\n commands.\n Response:\n Pt\ns O2 sat 100% on AC. Not overbreathing vent at this time.\n Plan:\n Continue to monitor respiratory mechanics, O2 sat. Place pt back on\n CPAP during daytime with sedation vacation.\n Alteration in Nutrition\n Assessment:\n Pt\ns tube feeding at 40cc/hr. At onset of shift, pt had some vomit\n pooled in mouth and in pharynx above ET cuff. Pt suctioned again via\n oropharnyx x 2 with noted vomit very similar to semi-digested tube\n feeding. Abdomen firm and slightly distended with hypoactive BS. Tube\n feed residuals initially 40cc (given back).\n Action:\n Held tube feedings to reassess residuals. Administered one dose of\n Reglan IV as ordered. Pt residuals found to be ~70cc (given back) and\n held for a longer duration of time. See Metavision for details.\n Response:\n No vomit noted while tube feeds on hold. Restarted feeds at half of\n original rate (20cc/hr).\n Plan:\n Reassess tube feed residuals q 4 hours and increase tube feeds to goal\n of 40cc/hr as tolerated. Administer Reglan IV as ordered PRN.\n Pt continues to be hypertensive and tachycardic when stimulated. Pt\n settled back down to baseline on her own. Two doses of Lopressor IV\n given to control BP and HR.\n"
},
{
"category": "Respiratory ",
"chartdate": "2160-03-01 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 436537,
"text": "TITLE:\n Demographics\n Day of intubation: \n Day of mechanical ventilation: 9\n Ideal body weight: 42.3\n Ideal tidal volume: 169.2 / 253.8 / 338.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 8 mL /\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Ins/Exp Wheeze\n LUL Lung Sounds: Ins/Exp Wheeze\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: PSV 10/5/.35\n Visual assessment of breathing pattern: Accessory muscle use\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment: Vigorous inspiratory efforts\n Comments:pt appears labored and air hungry @ times\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts\n Bedside Procedures: MDI albuterol/atrovent as ordered, rsbi 101,\n increased to for overnoc rest d/t apparent air hunger.\n"
},
{
"category": "Respiratory ",
"chartdate": "2160-02-29 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 436475,
"text": "Demographics\n Day of mechanical ventilation: 8\n Ideal body weight: 42.3 None\n Ideal tidal volume: 169.2 / 253.8 / 338.4 mL/kg\n Airway\n Tube Type\n ETT:\n Route: Oral\n Type: Standard\n Size: 7mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Insp Wheeze\n LUL Lung Sounds: Insp Wheeze\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Pt became tachypneic,\n tachycardic & aggitated with SBT; pt not extubated today d/t RSBI\n results.\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Plan:\n Continue with daily RSBI\ns & SBTs.\n"
},
{
"category": "Nursing",
"chartdate": "2160-03-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 436538,
"text": "Pt is DNR.\n Pleural effusion, chronic\n Assessment:\n Lungs diminished at bilateral bases. Bilateral pleural effusions per\n chest x-ray. Intubated on Vent on Cpap 5/5.\n Action:\n Required increased pressure support overnight for effective\n ventilation.\n Response:\n ABG WNL\n Plan:\n One side pleural tap today, heparin gtt shut off at 0500.\n Nausea / vomiting\n Assessment:\n Pt vomiting tube feed when agitated. Hypoactive bowel sounds, abdomen\n firm and distended. Oozing heme + stool.\n Action:\n Tube feed placed on hold, right sump attached to low cont\n suction. Reglan IV x 2.\n Response:\n Abdomen remains firm and distended with very distant hypoactive bowel\n sounds. No further vomiting, Bilious drainage from ngt.\n Plan:\n To remain NPO until after Tap and possible extubation today.\n Hypocalcemia/Hypopotasemia\n Assessment:\n Io Cal 1.08, K 3.6\n Action:\n Replete 2 grams calcium gluconate iv and 40 meq iv potassium chloride.\n Response:\n Pending\n Plan:\n Continue to monitor and replete electrolytes per orders.\n Pain control/sedation\n Assessment:\n Pt severely agitated with stimulation and care, but very calm and\n comfortable when left alone.\n Action:\n Precedex shut off, Fentanyl increased to 50 mcg/hour. Intermittent\n bolus of ativan iv.\n Response:\n Periods of agitation shorter in duration and without as high of a heart\n rate and blood pressure.\n Plan:\n Continue meds as planned, will need moderate sedation for pleural tap\n later today then reassess,\n"
},
{
"category": "Nursing",
"chartdate": "2160-02-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 436134,
"text": " POD#6 LLE embolectomy\n Cc: acute ischemic left foot, new onset of PAF\n ?? partial SBO, and recent rt. parietal-occpit. infarct with \n stenosis 50-69%.\n Cr:0.9 Wt:50kg EF 20%\n PMH: negative\n Plan:Ascites Cytology Pos for malig. adeno (prob. ovarian). Large B\n pleural eff.- ?? tap for dx. Vigileo placed- CI >2.5- Lasix given.\n Echo- severe lv DYSFXN W/ EF 20%\n Peripheral vascular disease (PVD) with critical limb ischemia\n Assessment:\n S/P repair as above. LLE with DSD and ace wrap in place. Pulses by\n Doppler, continues on Heparin gtt.\n Action:\n Continues on Neo, Heparin, Versed and Fentanyl gtts with no change\n through the night.\n Response:\n Had a stable night, good ABG, some agitation with cares.\n Plan:\n Continue to monitor and treat as ordered. Keep Ica above 1.15 to help\n wean Neo.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains on vent with no change in settings, suctioned x 3 for thick\n white sec in small amounts. Lungs course, diminished in the bases.\n Action:\n Suctioned and turned as needed. ABG to monitor current settings.\n Response:\n Sats in high 90\ns, ABG WNL, suction as needed.\n Plan:\n Attempt to wean to PS and see if she can oxygenate well enough to wean\n towards extubation.\n"
},
{
"category": "Respiratory ",
"chartdate": "2160-02-29 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 436311,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 8\n Ideal body weight: 42.3 None\n Ideal tidal volume: 169.2 / 253.8 / 338.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: 8 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Prolonged exhalation\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Respiratory Care:\n Pt remains intubated and vented. Mode of ventilation changed to\n accommodate pts breathing pattern, first attempted PSV, then MMV, then\n AC mode. Sedated and not breathing over vent. ABG pending. Received\n MDI\n"
},
{
"category": "Nursing",
"chartdate": "2160-02-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 435600,
"text": "CVA (Stroke, Cerebral infarction), Ischemic\n Assessment:\n Action:\n Response:\n Plan:\n Peripheral vascular disease (PVD) with critical limb ischemia\n Assessment:\n Action:\n Response:\n Plan:\n Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2160-02-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 435601,
"text": "CVA (Stroke, Cerebral infarction), Ischemic\n Assessment:\n Action:\n Response:\n Plan:\n Peripheral vascular disease (PVD) with critical limb ischemia\n Assessment:\n Action:\n Response:\n Plan:\n Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2160-02-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 435597,
"text": "CVA (Stroke, Cerebral infarction), Ischemic\n Assessment:\n Action:\n Response:\n Plan:\n Peripheral vascular disease (PVD) with critical limb ischemia\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Respiratory ",
"chartdate": "2160-02-27 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 436061,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 6\n Ideal body weight: 42.3 None\n Ideal tidal volume: 169.2 / 253.8 / 338.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: 8 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Insp Wheeze\n LUL Lung Sounds: Insp Wheeze\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments: sputum spec sent to lab for culture\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: attempted to wean to PSV this am however pt become very\n aggitated so she was placed back on ac and given some sedation\n Assessment of breathing comfort: No claim of dyspnea)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Nursing",
"chartdate": "2160-02-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 436247,
"text": " Family meeting occurred today with Dr about plan of\n care. Discussed the possibility of extubating Pt over the weekend in\n the face of Pt showing improvements. Dr spoke to husband of\n the need to re-intubate Pt if she fails extubation. If Pt is\n reintubated, then plan for another family meeting regarding ?trach/PEG\n or making Pt comfort measures only.\n Hyponatremia\n Assessment:\n Na was 131\n Action:\n Changed KVO to NS and started 50ml/hr of NS for 1L and salt tablets\n three times a day\n Response:\n Repeat Na was 132.\n Plan:\n Continue with plan to replete sodium, recheck with level with AM labs\n Peripheral vascular disease (PVD) with critical limb ischemia\n Assessment:\n Pt continues on 0.8mcg of Neo, HR in 80-90s, SBP in 120s, lower EXT\n pulses positive by Doppler, warm to touch, pink color, L fem and L\n lower leg dressing had small serosanguinous drainage\n Action:\n Weaning Neo off, continued with albumin, titrating Fent/Midaz drips for\n adequate sedation, dressings changed\n Response:\n Neo was weaned off, maintained adequate UO\n Plan:\n Continue to monitor vascular status, change dressings as needed\n"
},
{
"category": "Social Work",
"chartdate": "2160-02-29 00:00:00.000",
"description": "Social Work Progress Note",
"row_id": 436408,
"text": "SW spoke with family in ICU waiting room today. They are waiting to\n meet with DR. again to discuss their wishes that patient be\n made CMO. Patient\ns two son\ns, daughter in laws, daughter and\n granddaughter are all in agreement that patient would not want to be on\n a respirator or on any machine that was keeping her alive. Patient\n son reports that patient\ns husband who is currently in rehab at\n Country Manor in , is also in agreement with\n families wishes to make patient CMO. Medical team has seen slight\n improvements in patient\ns labs and does not have a definitive diagnosis\n on the ovarian cancer as of yet and are not ready to say that patient\n can be made CMO. This is very hard for the family who believe that\n patient is already\nangry that she has been kept on tubes this long.\n SW explained that CMO status has to be made by the doctor and accepted\n by the patient\ns HCP or next of and that this could mean a longer\n wait until more tests are complete and more trails to wean patient of\n the respirator are conducted. Family understands but will need support\n through this process. SW let family know that regular floor SW \n will be taking over this case and will continue to support them as\n needed in the upcoming days.\n , LCSW\n #\n"
},
{
"category": "Respiratory ",
"chartdate": "2160-03-02 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 436700,
"text": "TITLE:\n Demographics\n Day of intubation: \n Day of mechanical ventilation: 10\n Ideal body weight: 42.3\n Ideal tidal volume: 169.2 / 253.8 / 338.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 8 mL /\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: PSV12/5/.35\n Visual assessment of breathing pattern: Normal quiet breathing,\n Accessory muscle use\n Assessment of breathing comfort: Periods of tachypnea with rr 40's\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment: Vigorous inspiratory efforts with episodic\n tachypnea\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Periodic SBT's for conditioning\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Underlying illness not resolved\n Comments: Rsbi 87; periodic tachypnea when not sedated with rr 40\n rested briefly on A/C >> back to PSV with Vt ~500 ml, Ve 5-8 L; Plan\n wean as tol.\n"
},
{
"category": "Respiratory ",
"chartdate": "2160-02-28 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 436114,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 7\n Ideal body weight: 42.3 None\n Ideal tidal volume: 169.2 / 253.8 / 338.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: 8 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Crackles\n LUL Lung Sounds: Crackles\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thin\n Sputum source/amount: Suctioned / Small\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt remains on current vent settings. See vent flow sheet for\n details.Sedated with Fentanyl and midazolam. No RSBI done due to no\n spont resp.MDI\nS given . Will cont to monitor resp status.\n"
},
{
"category": "Nursing",
"chartdate": "2160-02-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 436301,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt on CPAP most of shift, although pt\ns RR low (/min). O2 sat\n stable. Initially increased pressure support to improve pt\ns pH and\n CO2 from ABG. RR and minute volume remained low, so pt placed on MMV.\n Action:\n Pt not triggering breaths while on MMV. Pt has long apneic periods, so\n placed pt on AC. Decreased sedation with goal of pt triggering her own\n breaths. Pt arousable to voice at this time, but not following\n commands.\n Response:\n Pt\ns O2 sat 100% on AC. Not overbreathing vent at this time.\n Plan:\n Continue to monitor respiratory mechanics, O2 sat. Place pt back on\n CPAP during daytime with sedation vacation.\n Alteration in Nutrition\n Assessment:\n Pt\ns tube feeding at 40cc/hr. At onset of shift, pt had some vomit\n pooled in mouth and in pharynx above ET cuff. Pt suctioned again via\n oropharnyx x 2 with noted vomit very similar to semi-digested tube\n feeding. Abdomen firm and slightly distended with hypoactive BS. Tube\n feed residuals initially 40cc (given back).\n Action:\n Held tube feedings to reassess residuals. Administered one dose of\n Reglan IV as ordered. Pt residuals found to be ~70cc (given back) and\n held for a longer duration of time. See Metavision for details.\n Response:\n No vomit noted while tube feeds on hold. Restarted feeds at half of\n original rate (20cc/hr).\n Plan:\n Reassess tube feed residuals q 4 hours and increase tube feeds to goal\n of 40cc/hr as tolerated. Administer Reglan IV as ordered PRN.\n Pt continues to be hypertensive and tachycardic when stimulated. Pt\n settled back down to baseline on her own. Two doses of Lopressor IV\n given to control BP and HR.\n"
},
{
"category": "Physician ",
"chartdate": "2160-02-29 00:00:00.000",
"description": "ICU Note - CVI",
"row_id": 436380,
"text": "CVICU\n HPI:\n POD 7\n 71F s/p LLE embolectomy\n Cc: acute ischemic left foot, new onset of PAF\n ?? partial SBO,and recent rt. parietal-occpit. infarct with \n stenosis 50-69%.\n Cr:0.9 Wt:50kg EF 20%\n PMH: negative\n Plan:Ascites Cytology Pos for malig. adeno (prob. ovarian). Large B\n pleural eff.- ?? tap for dx. Vigileo placed- CI >2.5- Lasix given.\n Echo- severe lv DYSFXN W/ EF 20%\n Pt. is DNR only, pt.'s husband has agreed to reintubation if necessary.\n Current medications:\n Albuterol Inhaler, Aspirin, Bisacodyl, Chlorhexidine Gluconate 0.12%\n Oral Rinse, Cosyntropin stim test, Famotidine, Fentanyl gtt, FoLIC\n Acid, Heparin gtt, HydrALAzine, Ipratropium Bromide MDI,\n Metoclopramide, Metoprolol Tartrate, Midazolam gtt, Multivitamins,\n Thiamine\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 11:16 AM\n\n no change from previous reports\n Baseline cortisol and stim test done yesterday\n\n normal results, so d/c\ned florinef per endocrine\n recommendations\n Periods of apea overnight so vent changed to CMV\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 09:40 AM\n Infusions:\n Midazolam (Versed) - 0.5 mg/hour\n Fentanyl - 30 mcg/hour\n Heparin Sodium - 850 units/hour\n Other ICU medications:\n Famotidine (Pepcid) - 09:00 AM\n Metoprolol - 04:45 AM\n Hydralazine - 08:08 AM\n Other medications:\n Flowsheet Data as of 08:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37\nC (98.6\n T current: 37\nC (98.6\n HR: 78 (71 - 124) bpm\n BP: 125/46(64) {98/37(54) - 166/68(99)} mmHg\n RR: 7 (6 - 19) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 69 kg (admission): 50 kg\n Height: 58 Inch\n CVP: 16 (8 - 20) mmHg\n Total In:\n 2,598 mL\n 817 mL\n PO:\n Tube feeding:\n 845 mL\n 186 mL\n IV Fluid:\n 1,533 mL\n 631 mL\n Blood products:\n 100 mL\n Total out:\n 2,320 mL\n 310 mL\n Urine:\n 2,320 mL\n 310 mL\n NG:\n Stool:\n Drains:\n Balance:\n 278 mL\n 507 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 451 (451 - 451) mL\n Vt (Spontaneous): 578 (499 - 670) mL\n PS : 12 cmH2O\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 35%\n RSBI Deferred: No Spon Resp\n PIP: 26 cmH2O\n Plateau: 24 cmH2O\n SPO2: 100%\n ABG: 7.35/49/128/25/0\n Ve: 9.2 L/min\n PaO2 / FiO2: 366\n Physical Examination\n General Appearance: No(t) No acute distress, Anxious\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : , Wheezes : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace, No(t) 1+), (Temperature: Warm), (Pulse\n - Dorsalis pedis: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities, Sedated\n Labs / Radiology\n 291 K/uL\n 7.2 g/dL\n 118 mg/dL\n 2.0 mg/dL\n 25 mEq/L\n 4.2 mEq/L\n 29 mg/dL\n 99 mEq/L\n 132 mEq/L\n 21.3 %\n 8.4 K/uL\n [image002.jpg]\n 03:11 AM\n 06:49 AM\n 08:18 AM\n 01:46 PM\n 01:51 PM\n 09:50 PM\n 10:58 PM\n 01:50 AM\n 01:55 AM\n 06:41 AM\n WBC\n 7.5\n 8.4\n Hct\n 22.1\n 22.6\n 21.3\n Plt\n 283\n 291\n Creatinine\n 2.0\n 2.0\n TCO2\n 27\n 28\n 27\n 26\n 26\n 28\n Glucose\n 97\n 100\n 110\n 127\n 118\n Other labs: PT / PTT / INR:14.8/69.3/1.3, CK / CK-MB / Troponin\n T:571/16/, ALT / AST:129/147, Alk-Phos / T bili:119/0.2, Lactic\n Acid:0.8 mmol/L, Albumin:1.4 g/dL, Ca:7.8 mg/dL, Mg:2.2 mg/dL, PO4:4.8\n mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), HYPOCALCEMIA (LOW CALCIUM),\n HYPOKALEMIA (LOW POTASSIUM, HYPOPOTASSEMIA), CANCER (MALIGNANT\n NEOPLASM), GYNECOLOGICAL (OVARIAN, UTERINE, CERVICAL, ENDOMETRIAL),\n PROBLEM - ENTER DESCRIPTION IN COMMENTS, ALTERATION IN NUTRITION,\n IMPAIRED SKIN INTEGRITY, RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE,\n ARF), HYPOTENSION (NOT SHOCK), ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM\n TREMENS, DTS, SEIZURES), PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN), CVA\n (STROKE, CEREBRAL INFARCTION), ISCHEMIC , PERIPHERAL VASCULAR DISEASE\n (PVD) WITH CRITICAL LIMB ISCHEMIA\n Assessment and Plan:\n Neurologic: Pain controlled with fentanyl gtt. Restraints while\n intubated. D/c Midazolam gtt and start precedex gtt in hope for\n extubation today. D/c Fentanyl gtt.\n Cardiovascular: Hypotension resolved, now off neo. Aspirin, Full\n anticoagulation. start b-blocker later on today if BP is stable.\n Pulmonary: Attempt to extubate today.\n Gastrointestinal / Abdomen: Bowel regimen\n Nutrition: Tube feeding, tube feeds held overnight because of vomiting\n yesterday, now titrating back up (currently 30cc/hr)\n Renal: Foley, BUN and Cr stable. Slightly oliguric overnight\n monitor.\n If tolerating may give lasix\n Hematology: Stable anemia with low, but stable Hct. Would continue to\n monitor and avoid transfusing RBCs for now.\n Endocrine: RISS with adequate glucose control. Goal BS <150\n Infectious Disease: UTI\n cipro x3 days. Will stop after dose today\n Lines / Tubes / Drains: Foley, OGT, ETT\n Wounds: Dry dressings\n Imaging:\n Fluids: NS @ 50 cc/hr\n Consults: Vascular surgery, Hem / Onc , Gynecology, Endocrine\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 08:25 PM 30 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 09:43 PM\n Multi Lumen - 12:00 AM\n PICC Line - 09:31 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin drip)\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: DNR / DNI\n Disposition: ICU\n Time spend : 34 min\n"
},
{
"category": "Nutrition",
"chartdate": "2160-02-29 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 436389,
"text": "Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 147 cm\n 50 kg\n 69 kg ( 04:00 AM)\n 23\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 42.3 kg\n Pertinent medications: Precedex gtt, Fent gtt, NS @ 10ml/hr,\n Famotidine, Thi, Folic Acid, MVI, Biascodyl, Reglan, Ca(2gm repletion),\n Heparin gtt\n Labs:\n Value\n Date\n Glucose\n 131 mg/dL\n 08:43 AM\n Glucose Finger Stick\n 120\n 06:49 PM\n BUN\n 29 mg/dL\n 01:50 AM\n Creatinine\n 2.0 mg/dL\n 01:50 AM\n Sodium\n 132 mEq/L\n 01:50 AM\n Potassium\n 4.0 mEq/L\n 08:43 AM\n Chloride\n 99 mEq/L\n 01:50 AM\n TCO2\n 25 mEq/L\n 01:50 AM\n PO2 (arterial)\n 99. mm Hg\n 10:26 AM\n PCO2 (arterial)\n 39 mm Hg\n 10:26 AM\n pH (arterial)\n 7.41 units\n 10:26 AM\n pH (urine)\n 5.0 units\n 11:29 AM\n CO2 (Calc) arterial\n 26 mEq/L\n 10:26 AM\n Albumin\n 1.4 g/dL\n 01:30 AM\n Calcium non-ionized\n 8.6 mg/dL\n 08:37 AM\n Phosphorus\n 4.8 mg/dL\n 01:50 AM\n Ionized Calcium\n 1.15 mmol/L\n 08:43 AM\n Magnesium\n 2.2 mg/dL\n 08:37 AM\n ALT\n 129 IU/L\n 01:30 AM\n Alkaline Phosphate\n 119 IU/L\n 01:30 AM\n AST\n 147 IU/L\n 01:30 AM\n Total Bilirubin\n 0.2 mg/dL\n 01:30 AM\n Triglyceride\n 152 mg/dL\n 07:13 PM\n WBC\n 8.4 K/uL\n 01:50 AM\n Hgb\n 7.2 g/dL\n 01:50 AM\n Hematocrit\n 28\n 10:26 AM\n Current diet order / nutrition support: DIET: NPO\n TF: Novasource Pulmonary @ 40ml/hr (goal)\n GI: soft/distended, hypoactive bs; (+) sm bm \n Assessment of Nutritional Status\n Estimation of current intake: Adequate\n Specifics:\n Pt remains intubated/sedated, ? extubation today. TF was running at\n goal yesterday then held pt vomited ?semi-digested tube feeding.\n TF resumed at half of goal rate (20ml/hr). Currently, TF running at\n 30ml/hr. Per d/w RN, low residuals on current TF, however suctioned\n ?tube feed out of mouth. Reglan being given q6hours prn. Would\n continue to advance TF to goal as pt stooling and low residuals on\n TF. Noted path results re: CA pending.\n Medical Nutrition Therapy Plan - Recommend the Following\n Current nutrition support is appropriate: Continue to advance TF as\n tolerated to goal of 40ml/hr (1440calories and 65g protein)\n Check residuals, hold TF if >/= 150ml. Monitor vomiting.\n Continue bowel regimen, Reglan\n * If pt w/ recurrent vomiting, would change to\n elemental TF formula (Vivonex)\n Multivitamin / Mineral supplement: cont current\n Check chemistry 10 panel\n replete lytes prn\n Will continue to follow\n page if ?s *\n"
},
{
"category": "General",
"chartdate": "2160-02-28 00:00:00.000",
"description": "ICU Event Note",
"row_id": 436226,
"text": "Clinician: Attending\n Earlier today I called Mr. at ( and updated him on\n Mrs. medical condition. I explained that we know that she has\n cancer but not sure what type and that we are awaiting the cytology\n results. I explained that we got oncology involved and gyn/onc and that\n she is not a surgical candidate, but potentially can be treated with\n chemotheraphy after this acute illness resolves. I explained that she\n is on the breathing machine and that we are hoping to wean her off the\n vent in the next few days. I also explained that we may not be able to,\n and that in this case we would recommend to trach her. In addition, I\n explained to him that if we extubate her there is always a potential\n for her to decompensate again and need to re-intubate her. He agreed to\n this as well. Mr. expressed to me his wishes that she would not\n have pain and that he trusted us in everything that we do. I answered\n all of his questions.\n Given Mr. input, I am going to change her code status from\n DNR/DNI to DNR only as Mr. would like us to intubate her if\n needed. Dr. was notified by e-mail\n Total time spent: 10 minutes\n Patient is critically ill.\n"
},
{
"category": "Physician ",
"chartdate": "2160-02-29 00:00:00.000",
"description": "ICU Note - CVI",
"row_id": 436362,
"text": "CVICU\n HPI:\n POD 7\n 71F s/p LLE embolectomy\n Cc: acute ischemic left foot, new onset of PAF\n ?? partial SBO,and recent rt. parietal-occpit. infarct with \n stenosis 50-69%.\n Cr:0.9 Wt:50kg EF 20%\n PMH: negative\n Plan:Ascites Cytology Pos for malig. adeno (prob. ovarian). Large B\n pleural eff.- ?? tap for dx. Vigileo placed- CI >2.5- Lasix given.\n Echo- severe lv DYSFXN W/ EF 20%\n Pt. is DNR only, pt.'s husband has agreed to reintubation if necessary.\n Current medications:\n Albuterol Inhaler, Aspirin, Bisacodyl, Chlorhexidine Gluconate 0.12%\n Oral Rinse, Cosyntropin stim test, Famotidine, Fentanyl gtt, FoLIC\n Acid, Heparin gtt, HydrALAzine, Ipratropium Bromide MDI,\n Metoclopramide, Metoprolol Tartrate, Midazolam gtt, Multivitamins,\n Thiamine\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 11:16 AM\n\n no change from previous reports\n Baseline cortisol and stim test done yesterday\n\n normal results, so d/c\ned florinef per endocrine\n recommendations\n Periods of apea overnight so vent changed to CMV\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 09:40 AM\n Infusions:\n Midazolam (Versed) - 0.5 mg/hour\n Fentanyl - 30 mcg/hour\n Heparin Sodium - 850 units/hour\n Other ICU medications:\n Famotidine (Pepcid) - 09:00 AM\n Metoprolol - 04:45 AM\n Hydralazine - 08:08 AM\n Other medications:\n Flowsheet Data as of 08:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37\nC (98.6\n T current: 37\nC (98.6\n HR: 78 (71 - 124) bpm\n BP: 125/46(64) {98/37(54) - 166/68(99)} mmHg\n RR: 7 (6 - 19) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 69 kg (admission): 50 kg\n Height: 58 Inch\n CVP: 16 (8 - 20) mmHg\n Total In:\n 2,598 mL\n 817 mL\n PO:\n Tube feeding:\n 845 mL\n 186 mL\n IV Fluid:\n 1,533 mL\n 631 mL\n Blood products:\n 100 mL\n Total out:\n 2,320 mL\n 310 mL\n Urine:\n 2,320 mL\n 310 mL\n NG:\n Stool:\n Drains:\n Balance:\n 278 mL\n 507 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 451 (451 - 451) mL\n Vt (Spontaneous): 578 (499 - 670) mL\n PS : 12 cmH2O\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 35%\n RSBI Deferred: No Spon Resp\n PIP: 26 cmH2O\n Plateau: 24 cmH2O\n SPO2: 100%\n ABG: 7.35/49/128/25/0\n Ve: 9.2 L/min\n PaO2 / FiO2: 366\n Physical Examination\n General Appearance: No(t) No acute distress, Anxious\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : , Wheezes : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace, No(t) 1+), (Temperature: Warm), (Pulse\n - Dorsalis pedis: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities, Sedated\n Labs / Radiology\n 291 K/uL\n 7.2 g/dL\n 118 mg/dL\n 2.0 mg/dL\n 25 mEq/L\n 4.2 mEq/L\n 29 mg/dL\n 99 mEq/L\n 132 mEq/L\n 21.3 %\n 8.4 K/uL\n [image002.jpg]\n 03:11 AM\n 06:49 AM\n 08:18 AM\n 01:46 PM\n 01:51 PM\n 09:50 PM\n 10:58 PM\n 01:50 AM\n 01:55 AM\n 06:41 AM\n WBC\n 7.5\n 8.4\n Hct\n 22.1\n 22.6\n 21.3\n Plt\n 283\n 291\n Creatinine\n 2.0\n 2.0\n TCO2\n 27\n 28\n 27\n 26\n 26\n 28\n Glucose\n 97\n 100\n 110\n 127\n 118\n Other labs: PT / PTT / INR:14.8/69.3/1.3, CK / CK-MB / Troponin\n T:571/16/, ALT / AST:129/147, Alk-Phos / T bili:119/0.2, Lactic\n Acid:0.8 mmol/L, Albumin:1.4 g/dL, Ca:7.8 mg/dL, Mg:2.2 mg/dL, PO4:4.8\n mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), HYPOCALCEMIA (LOW CALCIUM),\n HYPOKALEMIA (LOW POTASSIUM, HYPOPOTASSEMIA), CANCER (MALIGNANT\n NEOPLASM), GYNECOLOGICAL (OVARIAN, UTERINE, CERVICAL, ENDOMETRIAL),\n PROBLEM - ENTER DESCRIPTION IN COMMENTS, ALTERATION IN NUTRITION,\n IMPAIRED SKIN INTEGRITY, RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE,\n ARF), HYPOTENSION (NOT SHOCK), ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM\n TREMENS, DTS, SEIZURES), PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN), CVA\n (STROKE, CEREBRAL INFARCTION), ISCHEMIC , PERIPHERAL VASCULAR DISEASE\n (PVD) WITH CRITICAL LIMB ISCHEMIA\n Assessment and Plan:\n Neurologic: Pain controlled, Restraints\n Cardiovascular: Aspirin, Full anticoagulation, Beta-blocker\n Pulmonary: Cont ETT. Will turn down sedation and change vent back to\n CPAP+PS with goal to extubate today\n Gastrointestinal / Abdomen: Bowel regimen\n Nutrition: Tube feeding, tube feeds held overnight because of vomiting\n yesterday, now titrating back up (currently 30cc/hr)\n Renal: Foley, BUN and Cr stable but high again today. UOP decreased\n this morning - gave lasix\n Hematology: Hct continues to trend down, will repeat this afternoon if\n continues to fall will transfuse\n Endocrine: RISS, goal BS <150\n Infectious Disease: Currently on cipro\n Lines / Tubes / Drains: Foley, OGT, ETT\n Wounds: Dry dressings\n Imaging:\n Fluids: NS, @ 50 cc/hr\n Consults: Vascular surgery, Hem / Onc , Gynecology, Endocrine\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 08:25 PM 30 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 09:43 PM\n Multi Lumen - 12:00 AM\n PICC Line - 09:31 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin drip)\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: DNR / DNI\n Disposition: ICU\n Time spend : 34 min\n"
},
{
"category": "Physician ",
"chartdate": "2160-02-29 00:00:00.000",
"description": "ICU Note - CVI",
"row_id": 436364,
"text": "CVICU\n HPI:\n POD 7\n 71F s/p LLE embolectomy\n Cc: acute ischemic left foot, new onset of PAF\n ?? partial SBO,and recent rt. parietal-occpit. infarct with \n stenosis 50-69%.\n Cr:0.9 Wt:50kg EF 20%\n PMH: negative\n Plan:Ascites Cytology Pos for malig. adeno (prob. ovarian). Large B\n pleural eff.- ?? tap for dx. Vigileo placed- CI >2.5- Lasix given.\n Echo- severe lv DYSFXN W/ EF 20%\n Pt. is DNR only, pt.'s husband has agreed to reintubation if necessary.\n Current medications:\n Albuterol Inhaler, Aspirin, Bisacodyl, Chlorhexidine Gluconate 0.12%\n Oral Rinse, Cosyntropin stim test, Famotidine, Fentanyl gtt, FoLIC\n Acid, Heparin gtt, HydrALAzine, Ipratropium Bromide MDI,\n Metoclopramide, Metoprolol Tartrate, Midazolam gtt, Multivitamins,\n Thiamine\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 11:16 AM\n\n no change from previous reports\n Baseline cortisol and stim test done yesterday\n\n normal results, so d/c\ned florinef per endocrine\n recommendations\n Periods of apea overnight so vent changed to CMV\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 09:40 AM\n Infusions:\n Midazolam (Versed) - 0.5 mg/hour\n Fentanyl - 30 mcg/hour\n Heparin Sodium - 850 units/hour\n Other ICU medications:\n Famotidine (Pepcid) - 09:00 AM\n Metoprolol - 04:45 AM\n Hydralazine - 08:08 AM\n Other medications:\n Flowsheet Data as of 08:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37\nC (98.6\n T current: 37\nC (98.6\n HR: 78 (71 - 124) bpm\n BP: 125/46(64) {98/37(54) - 166/68(99)} mmHg\n RR: 7 (6 - 19) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 69 kg (admission): 50 kg\n Height: 58 Inch\n CVP: 16 (8 - 20) mmHg\n Total In:\n 2,598 mL\n 817 mL\n PO:\n Tube feeding:\n 845 mL\n 186 mL\n IV Fluid:\n 1,533 mL\n 631 mL\n Blood products:\n 100 mL\n Total out:\n 2,320 mL\n 310 mL\n Urine:\n 2,320 mL\n 310 mL\n NG:\n Stool:\n Drains:\n Balance:\n 278 mL\n 507 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 451 (451 - 451) mL\n Vt (Spontaneous): 578 (499 - 670) mL\n PS : 12 cmH2O\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 35%\n RSBI Deferred: No Spon Resp\n PIP: 26 cmH2O\n Plateau: 24 cmH2O\n SPO2: 100%\n ABG: 7.35/49/128/25/0\n Ve: 9.2 L/min\n PaO2 / FiO2: 366\n Physical Examination\n General Appearance: No(t) No acute distress, Anxious\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : , Wheezes : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace, No(t) 1+), (Temperature: Warm), (Pulse\n - Dorsalis pedis: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities, Sedated\n Labs / Radiology\n 291 K/uL\n 7.2 g/dL\n 118 mg/dL\n 2.0 mg/dL\n 25 mEq/L\n 4.2 mEq/L\n 29 mg/dL\n 99 mEq/L\n 132 mEq/L\n 21.3 %\n 8.4 K/uL\n [image002.jpg]\n 03:11 AM\n 06:49 AM\n 08:18 AM\n 01:46 PM\n 01:51 PM\n 09:50 PM\n 10:58 PM\n 01:50 AM\n 01:55 AM\n 06:41 AM\n WBC\n 7.5\n 8.4\n Hct\n 22.1\n 22.6\n 21.3\n Plt\n 283\n 291\n Creatinine\n 2.0\n 2.0\n TCO2\n 27\n 28\n 27\n 26\n 26\n 28\n Glucose\n 97\n 100\n 110\n 127\n 118\n Other labs: PT / PTT / INR:14.8/69.3/1.3, CK / CK-MB / Troponin\n T:571/16/, ALT / AST:129/147, Alk-Phos / T bili:119/0.2, Lactic\n Acid:0.8 mmol/L, Albumin:1.4 g/dL, Ca:7.8 mg/dL, Mg:2.2 mg/dL, PO4:4.8\n mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), HYPOCALCEMIA (LOW CALCIUM),\n HYPOKALEMIA (LOW POTASSIUM, HYPOPOTASSEMIA), CANCER (MALIGNANT\n NEOPLASM), GYNECOLOGICAL (OVARIAN, UTERINE, CERVICAL, ENDOMETRIAL),\n PROBLEM - ENTER DESCRIPTION IN COMMENTS, ALTERATION IN NUTRITION,\n IMPAIRED SKIN INTEGRITY, RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE,\n ARF), HYPOTENSION (NOT SHOCK), ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM\n TREMENS, DTS, SEIZURES), PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN), CVA\n (STROKE, CEREBRAL INFARCTION), ISCHEMIC , PERIPHERAL VASCULAR DISEASE\n (PVD) WITH CRITICAL LIMB ISCHEMIA\n Assessment and Plan:\n Neurologic: Pain controlled with fentanyl gtt. Restraints. Midazolam\n gtt for ? withdrawal symptoms.\n Cardiovascular: Aspirin, Full anticoagulation, Beta-blocker\n Pulmonary: Cont ETT. Will turn down sedation, change vent back to\n CPAP+PS with goal to extubate today\n Gastrointestinal / Abdomen: Bowel regimen\n Nutrition: Tube feeding, tube feeds held overnight because of vomiting\n yesterday, now titrating back up (currently 30cc/hr)\n Renal: Foley, BUN and Cr stable but high again today. UOP decreased\n this morning - gave lasix\n Hematology: Hct continues to trend down, will repeat this afternoon if\n continues to fall will transfuse RBC\n Endocrine: RISS, goal BS <150\n Infectious Disease: UTI\n cipro x3 days. Will stop after dose today\n Lines / Tubes / Drains: Foley, OGT, ETT\n Wounds: Dry dressings\n Imaging:\n Fluids: NS @ 50 cc/hr\n Consults: Vascular surgery, Hem / Onc , Gynecology, Endocrine\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 08:25 PM 30 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 09:43 PM\n Multi Lumen - 12:00 AM\n PICC Line - 09:31 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin drip)\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: DNR / DNI\n Disposition: ICU\n Time spend : 34 min\n"
},
{
"category": "Nutrition",
"chartdate": "2160-02-25 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 435575,
"text": "Pt screened ICU policy. Pt w/ 6 month h/o intermittent abd pain,\n decreased appetite. Also, developed acute ischemic L foot. s/p fem cut\n down, embolectomy and fasciotomy. Abd CT c/w pSBO. Also, concern for\n ovarian malignancy. NP, pt made DNR/DNI after family meeting.\n Plan for follow up family meeting tomorrow to further discuss plan of\n care.\n Will follow up to check plan and provide rec re: nutrition support if\n w/in POC.\n"
},
{
"category": "Nursing",
"chartdate": "2160-03-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 436779,
"text": "Hypotension (not Shock)\n Assessment:\n Pt continues to be difficult to sedate. Fentanyl drip continues at\n 50mcg/hr with boluses prn per PA for agitation. Pt will become\n hypertensive moving all over bed. Sats remain 98%, sbp 170\ns heart rate\n up to 130\ns with some rapi afib/st/pac\ns. Heparin drip remains at 1100\n units/hr. hct 21 this am.\n Action:\n Ativan given .25mg, and an extra dose of .25mg per Pa . Lytes\n repleted. Extra dose of lopressor given 5mg. Recheck hct this\n afternoon.\n Response:\n Pt becomes sedated with rr 8, sbp drops to 70\ns. Then pt will become\n restless when medication wears off. Briefly started on neo for bp\n support now off. Ptt 80, no changes made. Pa aware.\n Plan:\n Fentanyl continues for pain mgmt, prn ativan q4 hours .5mg., and\n lopressor changed to 5mg q4hours.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains orally intubated on cpap 35% 5 peep 12 pressure support. SX\n thick yellow secretions. Tube feeds stopped due to 250cc out of og\n tube. Tpn ordered.\n Action:\n No vent changes made this shift. See flowsheet for abg\ns, due to labile\n bp, and difficulty with sedation, and pt being very agitated and\n restless.\n Response:\n Pa aware.\n Plan:\n Wean vent as tolerates.\n Ineffective Coping\n Assessment:\n Pt\ns granddaughter is spokesperson at this time due to husband in rehab\n facility. Muiltiple family meetings in chart due to ? plan of care.\n Action:\n Granddaughter had numerous questions about trach, and end of life\n discussions. Pa spoke with granddaughter over phone, and\n informed to call DR. \ns office to further discuss poc.\n Response:\n Plan:\n Family meeting Tuesday.\n"
},
{
"category": "Nursing",
"chartdate": "2160-03-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 436783,
"text": "Hypotension (not Shock)\n Assessment:\n Pt continues to be difficult to sedate. Fentanyl drip continues at\n 50mcg/hr with boluses prn per PA for agitation. Pt will become\n hypertensive moving all over bed. Sats remain 98%, sbp 170\ns heart rate\n up to 130\ns with some rapi afib/st/pac\ns. Heparin drip remains at 1100\n units/hr. hct 21 this am.\n Action:\n Ativan given .25mg, and an extra dose of .25mg per Pa . Lytes\n repleted. Extra dose of lopressor given 5mg. Recheck hct.\n Response:\n Pt becomes sedated with rr 8, sbp drops to 70\ns. Then pt will become\n restless when medication wears off. Briefly started on neo for bp\n support now off. Ptt 80, no changes made. Pa aware. Hct 23 Pa\n aware.\n Plan:\n Fentanyl continues for pain mgmt, prn ativan q4 hours .5mg., and\n lopressor changed to 5mg q4hours.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains orally intubated on cpap 35% 5 peep 12 pressure support. SX\n thick yellow secretions. Tube feeds stopped due to 250cc out of og\n tube. Tpn ordered.\n Action:\n No vent changes made this shift. See flowsheet for abg\ns, due to labile\n bp, and difficulty with sedation, and pt being very agitated and\n restless. Ativan changed to .375mg per Pa to attempt to wean\n sedation.\n Response:\n Pa aware.\n Plan:\n Wean vent as tolerates.\n Ineffective Coping\n Assessment:\n Pt\ns granddaughter is spokesperson at this time due to husband in rehab\n facility. Muiltiple family meetings in chart due to ? plan of care.\n Action:\n Granddaughter had numerous questions about trach, and end of life\n discussions. Pa spoke with granddaughter over phone, and\n informed to call DR. \ns office to further discuss poc.\n Response:\n Plan:\n Family meeting Tuesday.\n"
},
{
"category": "Nursing",
"chartdate": "2160-03-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 436784,
"text": "Hypotension (not Shock)\n Assessment:\n Pt continues to be difficult to sedate. Fentanyl drip continues at\n 50mcg/hr with boluses prn per PA for agitation. Pt will become\n hypertensive moving all over bed. Sats remain 98%, sbp 170\ns heart rate\n up to 130\ns with some rapi afib/st/pac\ns. Heparin drip remains at 1100\n units/hr. hct 21 this am.\n Action:\n Ativan given .25mg, and an extra dose of .25mg per Pa . Lytes\n repleted. Extra dose of lopressor given 5mg. Recheck hct.\n Response:\n Pt becomes sedated with rr 8, sbp drops to 70\ns. Then pt will become\n restless when medication wears off. Briefly started on neo for bp\n support now off. Ptt 80, no changes made. Pa aware. Hct 23 Pa\n aware.\n Plan:\n Fentanyl continues for pain mgmt, prn ativan q4 hours .375mg., and\n lopressor changed to 5mg q4hours.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains orally intubated on cpap 35% 5 peep 12 pressure support. SX\n thick yellow secretions. Tube feeds stopped due to 250cc out of og\n tube. Tpn ordered.\n Action:\n No vent changes made this shift. See flowsheet for abg\ns, due to labile\n bp, and difficulty with sedation, and pt being very agitated and\n restless. Ativan changed to .375mg per Pa to attempt to wean\n sedation.\n Response:\n Pa aware.\n Plan:\n Wean vent as tolerates.\n Ineffective Coping\n Assessment:\n Pt\ns granddaughter is spokesperson at this time due to husband in rehab\n facility. Muiltiple family meetings in chart due to ? plan of care.\n Action:\n Granddaughter had numerous questions about trach, and end of life\n discussions. Pa spoke with granddaughter over phone, and\n informed to call DR. \ns office to further discuss poc.\n Response:\n Plan:\n Family meeting Tuesday.\n"
},
{
"category": "Nursing",
"chartdate": "2160-02-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 435884,
"text": "Peripheral vascular disease (PVD) with critical limb ischemia\n Assessment:\n POD #3 left femoral embolectomy and fasciotomy. Palpable pulses DT/PT.\n No movement of left leg. Palpable pulses. Distended and firm abdomen.\n Rabdo-CPK continues to trending down.\n Action:\n Neo increased for MAP>60-70.\n Response:\n Skin warm.\n Plan:\n Monitor tissue perfusion. Map>70.\n CVA (Stroke, Cerebral infarction), Ischemic\n Assessment:\n s/p Embolic stroke. Was in RAP at OSH. Moves R and L upper extremities.\n Does move right leg on bed. No movement of left leg. Intermittent\n movement of head side to side when awake. Does attempt to pulled out\n ETT. Pupils 3 Brisk. Follows command intermittently. Tracking RN in\n room during wakeup. Withdraws to pain. Open\ns eyes to name. Restless at\n times with repositioning. SR 60-90\ns with frequent PAC\ns and PVC\n Lytes OK.\n Action:\n Fentanyl drip. Intermittent versed changed to versed drip. Heparin drip\n @ 800 unit/hr. PTT at goal.\n Response:\n PTT at goal (60-80).PTT in am only. Tolerating versed drip @ .25 mg/hr.\n Appears comfortable.\n Plan:\n Frequent Neuro check. Sedation as needed. Repositioning.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Net + -/+ 18 litres since admission. Requiring a lot of fluid: Rabdo\n and BP management. Generalized edema++. Skin weeping at puncture and\n incision sites. Marginal U/O with lasix bolus. Added lasix drip.\n Action:\n Stared lasix drip @ 5mh/hr. Metolazone po given.\n Response:\n Good response to lasix drip. BUN/Creat slightly up.\n Plan:\n Monitor U/O. Monitor renal function.\n Alteration in Nutrition\n Assessment:\n Abdomen firm and distended. BS hypoactive and distant. Anasarca.\n Action:\n Started TF via Sump today. Currently @ 20 cc/hr. Goal 40 cc.hr.\n Response:\n Lat NB yesterday. No TF residual.\n Plan:\n Check residual Q4 hr. Advance rate per order. Due to increase rate @\n 21:00. HOB 30 degree.\n Impaired Skin Integrity\n Assessment:\n Generalized edema. Skin oozing +++. Starting to develop skin blisters\n on LE and UE.\n Action:\n Dressings changed today. Repositioned Q2 hrs. Awaiting PICC line\n placement.\n Response:\n Frequent skin care assessment.\n Plan:\n Monitor skin care. Reduce pressure. Waffles boots. Keep skin dry.\n Continue diurese.\n Positive for UTI. Day #2 of IV Cipro. Sediments in urine\n decreasing. Afebrile.\n Code Status: DNR/DNI\n Second family meeting:\n Meet with family today. Myself, , NP and Dr. \n present. All children present ,2 sons and 1 daughter,grand-daughter,\n grand-son and 2 daughter in-law present. Medical condition discussed\n with family. Patient is showing some clinical signs of improvements.\n Awaiting oncology input regarding staging of Ca and prognosis. Family\n very concerned about patient\ns well being and comfort. Family very\n emotional. Reinforcement and repetition of information required due to\n difficulty processing the information. Family considering CMO but\n medically not indicated at this time.\n Son spoke with Dr. over the phone late evening. Dr.\n want to wait 24-36 hrs according to family and reassess\n situation. Family OK with this.\n"
},
{
"category": "Physician ",
"chartdate": "2160-03-01 00:00:00.000",
"description": "Intensivist Note",
"row_id": 436571,
"text": "CVICU\n HPI:\n 71F POD 8 from LLE embolectomy with post-op respiratory failure. Pt was\n transferred from OSH with severe ascites m/p due to ovarian CA, new\n onset AF with embolic event to head (CVA) and LLE (s/p embolectomy as\n above).\n Chief complaint:\n PMHx:\n Current medications:\n 24 Hour Events:\n - Precedex d/c'd\n - Gentle diuresis\n - Vomited x 1: TF stopped\n - Anemic: Guiac trace positive\n - Clonidine patch started for withdrawals\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 09:40 AM\n Infusions:\n Fentanyl - 37.5 mcg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 10:05 AM\n Hydralazine - 04:44 PM\n Metoprolol - 05:31 PM\n Fentanyl - 12:02 AM\n Furosemide (Lasix) - 02:09 AM\n Lorazepam (Ativan) - 04:00 AM\n Other medications:\n Flowsheet Data as of 07:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.9\nC (100.3\n T current: 36.1\nC (97\n HR: 85 (81 - 153) bpm\n BP: 111/47(63) {81/38(51) - 193/92(128)} mmHg\n RR: 12 (10 - 36) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 70.5 kg (admission): 50 kg\n Height: 58 Inch\n CVP: 14 (3 - 28) mmHg\n Total In:\n 2,179 mL\n 155 mL\n PO:\n Tube feeding:\n 581 mL\n IV Fluid:\n 1,538 mL\n 155 mL\n Blood products:\n Total out:\n 1,384 mL\n 855 mL\n Urine:\n 1,294 mL\n 595 mL\n NG:\n 90 mL\n 260 mL\n Stool:\n Drains:\n Balance:\n 795 mL\n -700 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 569 (365 - 569) mL\n PS : 10 cmH2O\n RR (Spontaneous): 10\n PEEP: 5 cmH2O\n FiO2: 35%\n RSBI: 101\n PIP: 16 cmH2O\n SPO2: 100%\n ABG: 7.37/45/117/24/0\n Ve: 5.9 L/min\n PaO2 / FiO2: 334\n Physical Examination\n General Appearance: No acute distress, Anxious\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Murmur: No(t) Systolic, No(t)\n Diastolic)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n )\n Abdominal: Soft, Non-distended, Non-tender, Obese, Ascites\n Left Extremities: (Edema: 4+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Right Extremities: (Edema: 4+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities, Sedated\n Labs / Radiology\n 345 K/uL\n 7.0 g/dL\n 91 mg/dL\n 1.9 mg/dL\n 24 mEq/L\n 3.6 mEq/L\n 34 mg/dL\n 102 mEq/L\n 134 mEq/L\n 20.4 %\n 8.8 K/uL\n [image002.jpg]\n 01:50 AM\n 01:55 AM\n 06:41 AM\n 08:43 AM\n 10:26 AM\n 04:41 PM\n 09:08 PM\n 02:55 AM\n 03:05 AM\n 03:24 AM\n WBC\n 8.4\n 8.6\n 8.8\n Hct\n 21.3\n 26\n 28\n 19.9\n 20.4\n Plt\n 291\n 337\n 345\n Creatinine\n 2.0\n 1.9\n TCO2\n 26\n 28\n 25\n 26\n 25\n 27\n Glucose\n 127\n 118\n 131\n 73\n 91\n 91\n Other labs: PT / PTT / INR:14.1/53.1/1.2, CK / CK-MB / Troponin\n T:571/16/, ALT / AST:129/147, Alk-Phos / T bili:119/0.2, Lactic\n Acid:0.6 mmol/L, Albumin:1.4 g/dL, Ca:8.1 mg/dL, Mg:2.1 mg/dL, PO4:4.8\n mg/dL\n Assessment and Plan\n PLEURAL EFFUSION, CHRONIC, NAUSEA / VOMITING, HYPERTENSION, BENIGN,\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), HYPOCALCEMIA (LOW CALCIUM),\n HYPOKALEMIA (LOW POTASSIUM, HYPOPOTASSEMIA), CANCER (MALIGNANT\n NEOPLASM), GYNECOLOGICAL (OVARIAN, UTERINE, CERVICAL, ENDOMETRIAL),\n PROBLEM - ENTER DESCRIPTION IN COMMENTS, ALTERATION IN NUTRITION,\n IMPAIRED SKIN INTEGRITY, RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE,\n ARF), HYPOTENSION (NOT SHOCK), ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM\n TREMENS, DTS, SEIZURES), PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN), CVA\n (STROKE, CEREBRAL INFARCTION), ISCHEMIC , PERIPHERAL VASCULAR DISEASE\n (PVD) WITH CRITICAL LIMB ISCHEMIA\n Assessment and Plan: 71 y.o. F with what appears to be ovarian CA with\n peritoneal spread (final onc diagnosis is pending), new onset PAF (in\n SR while here) and complications from this AF (CVA, LLE embolic event\n s/p embolectomy), SBO, and respiratory failure which seems to be\n improving.\n Neurologic: Neuro checks Q: 4 hr, Pain controlled, Pain well controlled\n with fentanyl gtt. Please d/c gtt today. Precedex d/c'd yesterday. If\n need, may re-start for potential extubation today. Ativan PRN (low\n dose) for agitation. Pt has extensive h/o of EtOH and ativan seems to\n be helping.\n Cardiovascular: Full anticoagulation, Stable hemodynamically. Off neo\n gtt. Hypertensive when agitated, which resolves with ativan.\n Pulmonary: Cont ETT, (Ventilator mode: CPAP + PS), Improved respiratory\n status as able to wean to CPAP. Significant bilateral pleural\n effusions. Will tap today first left, and if stable the right side to\n help with respiratory status. Will send fluid for cytology to better\n define staging. Given hypoalbuminemia pleural effusions may\n re-accumulate, but will use this window to hopefully extubate patient.\n I spoke with husband who told me that he was o.k. with re-intubation if\n needed.\n Gastrointestinal / Abdomen: Vomited once overnight. Please shoot a KUB.\n re-start TF. If vomiting again will start TPN. Monitor guiac for GI\n bleed (trace guiac positive yesterday).\n Nutrition: NPO\n Renal: Foley, Adequate UO, Renal failure --> Cr stable. Continue\n diuresis 1-2 L today.\n Hematology: Serial Hct, Stable anemia. Would monitor in PM, if continue\n to decrease < 20 --> transfuse 1 u PRBC. Heparin gtt held in AM for\n thoracenthesis. check PTT now and resume 2 hours post procedure.\n Endocrine: RISS, Adequate glucose control. Keep < 150\n Infectious Disease: No evidence of infection\n Lines / Tubes / Drains: Foley, OGT, ETT\n Wounds: Dry dressings\n Imaging:\n Fluids: KVO\n Consults: Vascular surgery, Hem / Onc , gyn/onc\n Billing Diagnosis: Arrhythmia, CVA, (Respiratory distress: Failure),\n Post-op hypotension, Acute renal failure\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 09:43 PM\n Multi Lumen - 12:00 AM\n PICC Line - 09:31 PM\n Prophylaxis:\n DVT: Boots (Systemic anticoagulation: Heparin drip)\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: DNR (do not resuscitate)\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Respiratory ",
"chartdate": "2160-02-25 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 435492,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 4\n Ideal body weight: 42.3 None\n Ideal tidal volume: 169.2 / 253.8 / 338.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: 8 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Ins/Exp Wheeze\n LUL Lung Sounds: Insp Wheeze\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Scant\n Comments: Pt has adventitious lung sounds but MDIs and Suctioning does\n not alleviate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments: Pt is sedated and on full support from the vent\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Maintain PEEP at current level and reduce FiO2 as tolerated, Adjust\n Min. ventilation to control pH; Comments: Pt failed RSBI due to apnea\n for 15 seconds, then breathes that were under 100ml in tidal volume.\n Pt put back on AC settings\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Intolerant of weaning attempts, Cannot protect airway, Cannot manage\n secretions; Comments: Pt to continue current support\n"
},
{
"category": "Social Work",
"chartdate": "2160-02-25 00:00:00.000",
"description": "Social Work Admission Note",
"row_id": 435570,
"text": "Family Information\n Next of : (GRANDAUGHTER)\n Health Care Proxy appointed: Proxy\n appointed: patient's husband will make med decisions;\n \n Family Spokesperson designated: son\n Communication or visitation restriction:\n Patient Information:\n Previous living situation:\n Previous level of functioning: Independent\n Previous or other hospital admissions: no doc visits in forty\n years\n Past psychiatric history: none reported\n Past addictions history: none reported\n Employment status: Retired\n Legal involvement: none reported\n Mandated Reporting Information:\n Additional Information:\n 71 yo woman who is now POD #1 s/p left lower extremity\n embolectomy and fasciotomy for limb ischmia who was transferred\n here yesterday from hospital. She initially presented\n on with 2 week history of worsening abdominal distension and\n decreased appetite that started 6 weeks prior. Associated with\n vomiting and small (marble sized) bowel mvts. At the time of her\n eval, she underwent CT and KUB that suggested a partial small\n bowel obstruction associated with ascites and tumor implants in\n the pelvis. Her ovaries were not visualized on CT. She was\n managed expectantly with NGT and underwent pelvic paracentesis on\n during which 2.5 liters of fluid were removed. CEA testing\n was slightly elevated at 6.0. CA-125 result as noted to be\n elevated in a note on but could not be obtained from OSH.\n Cytology results from the OSH show malignant cells likely\n adenocarcinoma. While getting prepped for surgery patient was found to\n be having a stroke. Patient has several life threatening medical issues\n that are all coming to light and is currently intubated and unable to\n be taken off the ventilator.\n Clergy Contact:\n Communication with Team:\n Plan / Follow up:\n Assess need for family meeting\n Continuing issues to be addressed: family concerns about wanting to\n make patient . Family feels very strongly that patient would not\n want to be kept alive on a respirator and with all the support she is\n on now. Family is willing to wait another day to see if she can be\n weaned but would like another family meeting with a Resident tomorrow\n to discuss making her . Patient\ns husband is also in a hospital at\n the moment but is able to make decisions for patient and can do so by\n phone. No official Health Care proxy was ever designated by patient.\n Patient has two sons and a daughter and granddaughter who all agree\n about and are taking turns staying with patient at the hospital. SW\n gave family parking stickers to assist with parking fees. SW will be\n available tomorrow for family meeting and family knows how to page SW\n to attend.\n , LCSW\n #\n"
},
{
"category": "Nursing",
"chartdate": "2160-02-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 435634,
"text": "CVA (Stroke, Cerebral infarction), Ischemic\n Assessment:\n Moves R and L upper extremities. Does move right leg on bed.\n Intermittent movement of head side to side. Pupils 3 Brisk. Follows\n command intermittently. Withdraws to pain. Open\ns eyes to name. Did\n follow commands when off sedation and nod to questions. Sedated.\n Restless at times. SR with frequent PAC\ns and PVC\ns. (COPD).Lytes OK.\n Action:\n Propofol replaced with Fentanyl drip. Intermittent versed bolus for\n agitation/Tachycardia and HTN.\n Response:\n PTT at goal (60-80).PTT in am only.\n Plan:\n Frequent Neuro check. Sedation as needed.\n Peripheral vascular disease (PVD) with critical limb ischemia\n Assessment:\n POD #2 left femoral embolectomy and fasciotomy. Palpable pulses DT/PT.\n No movement of left leg noted. Distended and firm abdomen. SBO per\n CTScan. Stool x1 today. Rabdo-CPK trending down.\n Action:\n Attempt to wean Neo. Heparin drip LR @ 80 cc/hr.\n Response:\n Perfusion improving to LE.\n Plan:\n Monitor tissue perfusion.\n Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Patient drinks ETOH daily per family. Patient agitated when awake.\n Tacypneic/tachycardic and Hypertensive. Skin dry. No tremors/No\n diaphoresis.\n Action:\n Propofol changed to fentanyl drip. Intermittent versed bolus given.\n Thiamine/folic acid and MVI started @ 50 ml/hr x 1 litre.\n Response:\n Response well to versed.\n Plan:\n Monitor signs of withdrawal. CIWA.\n Positive for UTI. Culture sent. Started on Cipro IV.\n Sediments in urine. Creat slightly increasing from yesterday.\n Family meeting today with Dr. . Both sons and\n grand-daughter present. Son had spoken to patient\ns husband this am and\n discussed Code status. According to son, agreed with DNR status\n and so did the rest of the family present in the room. Patient\ns wishes\n were to be DNR according to the son and grand-daughter.\n Status: DNR/DNI (Confirmed today). Family considering\n CMO status. Will confirm tomorrow.\n"
},
{
"category": "Nursing",
"chartdate": "2160-03-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 436925,
"text": "Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n Anxiety\n Assessment:\n Patient thrashing in bed, hypertensive (152/68-165/71), tachycardic\n (101) and tachypneic (33-40) on CPAP\n Action:\n Ativan, Hydralazine, and lopressor given as ordered. Started on\n versed. RT put patient back on a RR 16, ABG obtained.\n Response:\n Patient very calm, stopped thrashing, appears to be resting comfortably\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2160-03-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 436928,
"text": "Atrial fibrillation (Afib)\n Assessment:\n RAF 140\ns, hypotensive 89/72\n Action:\n Bolus\ns of lopressor given as ordered and neo gtt started and titrated\n for SBP>90\n Response:\n Rate controlled AF 70\nconverted to SR 60\ns-70\ns, SBP>90\n Plan:\n Monitor VS, continue with Lopressor 7.5 mg q4 hours, ween off Neo as\n tolerated\n Anxiety\n Assessment:\n Patient thrashing in bed, hypertensive (152/68-165/71), tachycardic\n (101) and tachypneic (33-40) on CPAP\n Action:\n Ativan, Hydralazine, and lopressor given as ordered. Started on\n versed. RT put patient back on a RR 16, ABG obtained.\n Response:\n Patient very calm, stopped thrashing, appears to be resting\n comfortably, SBP > 90, MAP 60, HR 60\ns ABG slightly alkalotic (7.47)\n but otherwise WNL\n Plan:\n Plan to wake and ween after family meeting ?? Tuesday? Awaiting\n cytology results. Maintain adequate VS and provide emotional support.\n"
},
{
"category": "Nursing",
"chartdate": "2160-03-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 437177,
"text": "Anxiety\n Assessment:\n Patient extremely agitated, thrashing in bed, arms flailing,\n hypertensive due to agitation 170/77 and tachycardic 95 NSR\n Action:\n Zyprexia given and emotional support provided with a quiet calm\n atmosphere, lines hidden for safety\n Response:\n Patient rested comfortably all day, no agitation after the zyprexia was\n given\n Plan:\n Zyprexia ordered TID, family meeting 1300 with Dr. ,\n family and husband via conference call\n Hypotension (not Shock)\n Assessment:\n Hypotensive 83/38, on fentanyl gtt, clonidine patch on and newly\n applied fentanyl patch (to posterior left shoulder)\n Action:\n Clonidine patch removed, started on small amounts of Neo, fentanyl gtt\n cut in half this afternoon then off this evening\n Response:\n During periods of calm SBP 90\ns-low 100\ns, still requiring small\n amounts of Neo\n Plan:\n Titrate Neo as tolerated\n"
},
{
"category": "Nursing",
"chartdate": "2160-02-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 436107,
"text": " POD#6 LLE embolectomy\n Cc: acute ischemic left foot, new onset of PAF\n ?? partial SBO,and recent rt. parietal-occpit. infarct with \n stenosis 50-69%.\n Cr:0.9 Wt:50kg EF 20%\n PMH: negative\n Plan:Ascites Cytology Pos for malig. adeno (prob. ovarian). Large B\n pleural eff.- ?? tap for dx. Vigileo placed- CI >2.5- Lasix given.\n Echo- severe lv DYSFXN W/ EF 20%\n Peripheral vascular disease (PVD) with critical limb ischemia\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Respiratory ",
"chartdate": "2160-02-26 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 435872,
"text": "TITLE:\n Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\n Ideal body weight: 42.3 None\n Ideal tidal volume: 169.2 / 253.8 / 338.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: 8 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Insp/Exp Wheeze\n RUL Lung Sounds: Ins/Exp Wheeze\n LUL Lung Sounds: Ins/Exp Wheeze\n LLL Lung Sounds: Ins/Exp Wheeze\n Comments:\n Secretions\n Sputum color / consistency: White / Thin\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Underlying illness not resolved; Comments: more fluid removal required\n prior to extubation and awaiting family decsions on re intubation if\n required\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Nursing",
"chartdate": "2160-02-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 435684,
"text": "Hypotension (not Shock)\n Assessment:\n Neosynephrine gtt required to maintain pt\ns MAP > 60.\n Action:\n Continued to titrate Neo gtt to maintain MAP > 60.\n Response:\n Pt currently at 1.5 mcg/kg/min of Neosynephrine.\n Plan:\n Continue to titrate for MAP > 60\n 70.\n CVA (Stroke, Cerebral infarction), Ischemic\n Assessment:\n Pt opens eyes to voice. Not following commands at this time. Mostly\n moving UEs only. LE movement, although slight, noted upon withdrawal\n of painful stimuli (nail bed pressure).\n Action:\n No further action required at this time.\n Response:\n Pt\ns status remains unchanged.\n Plan:\n Sedation vacation this am, monitor neuro status and assess for movement\n of extremities.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt\ns creatinine continues to increase slightly. Pt with generalized\n + edema. HUO marginal.\n Action:\n Administered Lasix 20mg IV as ordered.\n Response:\n Pt\ns HUO increased slightly for a short time. HUO ~45cc/hr. Repleted\n potassium with 10meq.\n Plan:\n Continue to monitor fluid & electrolyte balance, edema, etc.\n"
},
{
"category": "Respiratory ",
"chartdate": "2160-02-25 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 435618,
"text": "TITLE:\n Demographics\n Day of intubation:\n Day of mechanical ventilation: 4\n Ideal body weight: 42.3 None\n Ideal tidal volume: 169.2 / 253.8 / 338.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: 8 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Ins/Exp Wheeze\n LUL Lung Sounds: Insp Wheeze\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Cannot protect airway, Underlying illness not\n resolved; Comments: some weaning tolerated today... family meeting took\n place today, plan will be revaluated in AM rounds.\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Nursing",
"chartdate": "2160-03-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 437174,
"text": "Anxiety\n Assessment:\n Patient extremely agitated, thrashing in bed, arms flailing,\n hypertensive due to agitation 170/77 and tachycardic 95 NSR\n Action:\n Zyprexia given and emotional support provided with a quiet calm\n atmosphere, lines hidden for safety\n Response:\n Patient rested comfortably all day, no agitation after the zyprexia was\n given\n Plan:\n Zyprexia ordered TID, family meeting 1300 with Dr. ,\n family and husband via conference call\n Hypotension (not Shock)\n Assessment:\n Hypotensive 83/38, on fentanyl gtt, clonidine patch on and newly\n applied fentanyl patch (to posterior left shoulder)\n Action:\n Clonidine patch removed, started on small amounts of Neo, fentanyl gtt\n cut in half this afternoon then off this evening\n Response:\n During periods of calm SBP 90\ns-low 100\ns, still requiring small\n amounts of Neo\n Plan:\n Titrate Neo as tolerated\n"
},
{
"category": "Nursing",
"chartdate": "2160-03-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 437231,
"text": "Pt became acutely hypotensive\n Shock, hypovolemic or hemorrhagic\n Assessment:\n Pt extremely hypotensive; SR-ST with frequent PVCs (Vent\n bigeminy/trigeminy)\n Pt agitated, flailing arms around in bed and bucking ventilator\n Action:\n Labs sent (Hct 20 from 24 earlier on), Lytes low\n 1250cc NS bolus given total\n 2 units PRBCs given\n Transthoracic echo done @ bedside\n CXR done\n Response:\n Repeat Hct\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2160-02-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 435465,
"text": "CVA (Stroke, Cerebral infarction), Ischemic NEURO PT REMAINS IN\n COMA LIKE STATE PROPOFOL OFF FOR 15 MINUTES FOR EVAL NO COMMUNICATION\n RANDOM MOTION UPPER EXTREMITY WITHDRAWS FROM PAINFULL STIMULUS ONLY\n PLEASE SEE NOTES FOR DETAILS PROPOFOL PLACED ON FOR ELEVATION OF BP\n AND VENT FIGHTING\n HEART S1S2 DISTANT TONES NSR PR .16 QRS .08 OCC TO FREQ PAC BP\n AUGMENTED WITH NEO DRIP LOW DOSE PROPOFOL BP LOW MD P DRIP\n AT 800 UNITS PER HOUR PULSES POS 2 THRU OUT C/O WNL SVR ELEVATED\n RESP CLEAR DIM AT BASES NO SOB TOL VENT ON CMV SCANT SPUTUM\n PRODUCTION POOR TO NO GAG REFLEX SAO2 100 MILD CPT ONLY\n ABD NO B/S FIRM HARD DISTENDED U/O QS NPO SCANT N/G DRAINAGE\n SKIN PALE EDEMA REMAINS DRESSING CHANGED\n Action:\n Response:\n Plan:\n SUPPORTIVE FAMILY MEETING IN AM TO EVAL PROGRESS POSSIBY PALITIVE\n CARE LONG TALK GRANDDAUGHTER FAMILY IN AGREEMENT THAT PAT\n WOULD NOT WANT THIS TYPE OF HEALTH CARE WOULD WANT TO DIE FIRST\n"
},
{
"category": "Nursing",
"chartdate": "2160-02-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 435685,
"text": "HPI:\n 73 y.o. F with acute ischemic left foot, new onset of PAF with ??\n partial SBO,and recent R parietal-occpit CVA with stenosis, now\n POD # 3 LLE embolectomy and left fasciotomy for compartment syndrome\n Chief complaint:\n 73 y/o female admitted to for 6 month history of\n intermittent abdominal distention and flatus associated with diminished\n appetite. Denies post pranial abdominal pain. Admitting physical\n abdominal acities and distention. Patient was about to have exploratory\n laparotomy to evaluate abdominal mass but develope acute left\n foot ischemia. Patient was transfered here for further evaluation and\n was evaluated by Dr. . IV heparin gtt and L embolectomy done.\n Hypotension (not Shock)\n Assessment:\n Neosynephrine gtt required to maintain pt\ns MAP > 60.\n Action:\n Continued to titrate Neo gtt to maintain MAP > 60.\n Response:\n Pt currently at 1.5 mcg/kg/min of Neosynephrine.\n Plan:\n Continue to titrate for MAP > 60\n 70.\n CVA (Stroke, Cerebral infarction), Ischemic\n Assessment:\n Pt opens eyes to voice. Not following commands at this time. Mostly\n moving UEs only. LE movement, although slight, noted upon withdrawal\n of painful stimuli (nail bed pressure).\n Action:\n No further action required at this time.\n Response:\n Pt\ns status remains unchanged.\n Plan:\n Sedation vacation this am, monitor neuro status and assess for movement\n of extremities.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt\ns creatinine continues to increase slightly. Pt with generalized\n + edema. HUO marginal.\n Action:\n Administered Lasix 20mg IV as ordered.\n Response:\n Pt\ns HUO increased slightly for a short time. HUO ~45cc/hr. Repleted\n potassium with 10meq.\n Plan:\n Continue to monitor fluid & electrolyte balance, edema, etc.\n"
},
{
"category": "Nursing",
"chartdate": "2160-02-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 435686,
"text": "HPI:\n 73 y.o. F with acute ischemic left foot, new onset of PAF with ??\n partial SBO,and recent R parietal-occpit CVA with stenosis, now\n POD # 3 LLE embolectomy and left fasciotomy for compartment syndrome\n Chief complaint:\n 73 y/o female admitted to for 6 month history of\n intermittent abdominal distention and flatus associated with diminished\n appetite. Denies post pranial abdominal pain. Admitting physical\n abdominal acities and distention. Patient was about to have exploratory\n laparotomy to evaluate abdominal mass but developed acute left\n foot ischemia. Patient was transferred here for further evaluation and\n was evaluated by Dr. . IV heparin gtt and L embolectomy done.\n Hypotension (not Shock)\n Assessment:\n Neosynephrine gtt required to maintain pt\ns MAP > 60.\n Action:\n Continued to titrate Neo gtt to maintain MAP > 60.\n Response:\n Pt currently at 1.5 mcg/kg/min of Neosynephrine.\n Plan:\n Continue to titrate for MAP > 60\n 70.\n CVA (Stroke, Cerebral infarction), Ischemic\n Assessment:\n Pt opens eyes to voice. Not following commands at this time. Mostly\n moving UEs only. LE movement, although slight, noted upon withdrawal\n of painful stimuli (nail bed pressure).\n Action:\n No further action required at this time.\n Response:\n Pt\ns status remains unchanged.\n Plan:\n Sedation vacation this am, monitor neuro status and assess for movement\n of extremities.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt\ns creatinine continues to increase slightly. Pt with generalized\n + edema. HUO marginal.\n Action:\n Administered Lasix 20mg IV as ordered.\n Response:\n Pt\ns HUO increased slightly for a short time. HUO ~45cc/hr. Repleted\n potassium with 10meq.\n Plan:\n Continue to monitor fluid & electrolyte balance, edema, etc.\n"
},
{
"category": "Nursing",
"chartdate": "2160-02-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 435701,
"text": "HPI:\n 73 y.o. F with acute ischemic left foot, new onset of PAF with ??\n partial SBO,and recent R parietal-occpit CVA with stenosis, now\n POD # 3 LLE embolectomy and left fasciotomy for compartment syndrome\n Chief complaint:\n 73 y/o female admitted to for 6 month history of\n intermittent abdominal distention and flatus associated with diminished\n appetite. Denies post pranial abdominal pain. Admitting physical\n abdominal acities and distention. Patient was about to have exploratory\n laparotomy to evaluate abdominal mass but developed acute left\n foot ischemia. Patient was transferred here for further evaluation and\n was evaluated by Dr. . IV heparin gtt and L embolectomy done.\n Hypotension (not Shock)\n Assessment:\n Neosynephrine gtt required to maintain pt\ns MAP > 60.\n Action:\n Continued to titrate Neo gtt to maintain MAP > 60.\n Response:\n Pt currently at 1.4 mcg/kg/min of Neosynephrine.\n Plan:\n Continue to titrate for MAP > 60\n 70.\n CVA (Stroke, Cerebral infarction), Ischemic\n Assessment:\n Pt opens eyes to voice. Not following commands at this time. Mostly\n moving UEs only. LE movement, although slight, noted upon withdrawal\n of painful stimuli (nail bed pressure). Pt agitated at times, becoming\n hypertensive.\n Action:\n No further action required at this time. Versed given PRN for\n agitation.\n Response:\n Pt\ns status remains unchanged.\n Plan:\n Sedation vacation this am, monitor neuro status and assess for movement\n of extremities.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt\ns creatinine continues to increase slightly. Pt with generalized\n + edema. HUO marginal.\n Action:\n Administered Lasix 20mg IV as ordered.\n Response:\n Pt\ns HUO increased slightly for a short time. HUO ~45cc/hr. Repleted\n potassium with 10meq.\n Plan:\n Continue to monitor fluid & electrolyte balance, edema, etc.\n"
},
{
"category": "Physician ",
"chartdate": "2160-02-26 00:00:00.000",
"description": "ICU Note - CVI",
"row_id": 435802,
"text": "CVICU\n HPI:\n HD5\n POD#4 LLE embolectomy\n Cc: acute ischemic left foot, new onset of PAF\n ?? partial SBO,and recent rt. parietal-occpit. infarct with \n stenosis 50-69%.\n Cr:0.9 Wt:50kg EF 20%\n PMH: negative\n Plan:Ascites Cytology Pos for malig. adeno (prob. ovarian). Large B\n pleural eff.- ?? tap for dx. Vigileo placed- CI >2.5- Lasix given.\n Echo- severe lv DYSFXN W/ EF 20%\n Current medications:\n 1.Albuterol 0.083% Neb Soln 3. Albuterol Inhaler 4. Aspirin 5. Calcium\n Gluconate 6. Chlorhexidine Gluconate 0.12% Oral Rinse 7. Ciprofloxacin\n 8. Famotidine 9. Fentanyl Citrate 10. Furosemide 11. Heparin 12.\n Magnesium Sulfate 16. Metoprolol Tartrate 17. Midazolam 18.\n Nitroglycerin Ointment 2%\n 21. Potassium Chloride 22. Sodium Chloride 0.9% Flush\n 24 Hour Events:\n - code status- DNR/DNI discussed with family-, and\n daughter-in-law, and granddaughter , and Social\n work- with Dr. \n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 800 units/hour\n Fentanyl - 50 mcg/hour\n Phenylephrine - 1.3 mcg/Kg/min\n Other ICU medications:\n Furosemide (Lasix) - 08:45 PM\n Midazolam (Versed) - 09:20 AM\n Famotidine (Pepcid) - 09:29 AM\n Other medications:\n Flowsheet Data as of 10:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.3\nC (97.3\n T current: 35.8\nC (96.5\n HR: 118 (55 - 118) bpm\n BP: 151/74(103) {81/43(58) - 151/74(103)} mmHg\n RR: 26 (7 - 27) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 70.5 kg (admission): 50 kg\n Height: 58 Inch\n CVP: 11 (7 - 15) mmHg\n Total In:\n 3,610 mL\n 1,278 mL\n PO:\n Tube feeding:\n IV Fluid:\n 3,580 mL\n 1,278 mL\n Blood products:\n Total out:\n 1,205 mL\n 660 mL\n Urine:\n 1,205 mL\n 660 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,405 mL\n 618 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 451 (450 - 451) mL\n Vt (Spontaneous): 474 (302 - 474) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 37\n RSBI Deferred: No Spon Resp\n PIP: 16 cmH2O\n SPO2: 97%\n ABG: 7.30/45/90./22/-3\n Ve: 5.8 L/min\n PaO2 / FiO2: 225\n Physical Examination\n General Appearance: edematous\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: CTA bilateral : ), (Sternum: Stable )\n Abdominal: No(t) Soft, Distended, reduced bowel sounds\n Left Extremities: (Edema: 3+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 3+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Follows simple commands, (Responds to: No(t) Tactile\n stimuli), Moves all extremities\n Labs / Radiology\n 298 K/uL\n 10.9 g/dL\n 67 mg/dL\n 1.6 mg/dL\n 22 mEq/L\n 3.9 mEq/L\n 25 mg/dL\n 105 mEq/L\n 134 mEq/L\n 31.6 %\n 12.4 K/uL\n [image002.jpg]\n 07:13 PM\n 01:30 AM\n 01:40 AM\n 11:42 AM\n 03:00 PM\n 08:27 PM\n 02:41 AM\n 02:49 AM\n 03:49 AM\n 09:20 AM\n WBC\n 11.7\n 11.4\n 12.4\n Hct\n 30.8\n 30.4\n 31.6\n Plt\n 238\n 240\n 298\n Creatinine\n 1.3\n 1.4\n 1.5\n 1.6\n TCO2\n 24\n 25\n 24\n 24\n 22\n 23\n Glucose\n 84\n 86\n 81\n 90\n 73\n 67\n Other labs: PT / PTT / INR:13.0/70.7/1.1, CK / CK-MB / Troponin\n T:1268/26/, ALT / AST:129/147, Alk-Phos / T bili:119/0.2, Lactic\n Acid:0.8 mmol/L, Albumin:1.4 g/dL, Ca:7.5 mg/dL, Mg:2.3 mg/dL, PO4:5.2\n mg/dL\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF), HYPOTENSION (NOT\n SHOCK), ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES),\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN), CVA (STROKE, CEREBRAL\n INFARCTION), ISCHEMIC , PERIPHERAL VASCULAR DISEASE (PVD) WITH CRITICAL\n LIMB ISCHEMIA\n Assessment and Plan: POD#4 LLE embolectomy\n HD stable, on Neo, Ascites, reduced urine output, increasing\n generalised edema, weaning from respiratory support,\n on PSV+CPAP\n Neurologic: Neuro checks Q: 4 hr, Responds to loud verbal commands\n Cardiovascular: HD stable on Neo gtt. Attempt to wean neo as possible.\n Accept a MAP of 60. Aspirin. B-blocker is held for hypotension, but if\n BP improves may re-start b-blockers.\n Pulmonary: Cont ETT, (Ventilator mode: CPAP + PS), plan to extubate\n after diuresis. Would appreciate clearing code status. Concerned that\n patient may fail in a few days post extubtion and need input from\n family and primary team re: ? re-intubation.\n Gastrointestinal / Abdomen:Tense abdomen, ascites +, Start tube feeds\n today\n Nutrition: Tube feeding\n start low and do not advance until making\n sure that pt tolerate feeding as recovering from SBO\n Renal: Oliguric with raising Cr\n ARF. This is m/p from\n rhabdomyoglobinuria. CK is much improved. Pt well hydrated and is\n normovolemic. Would stop IVF and start diuresis to allow for extubation\n in a day or two.\n Hematology: Stable anemia, on heparin drip at 800 to keep PTT 70\n s for LE clot and CVA.\n Endocrine: RISS with good glycemic control. Keep < 150\n Infectious Disease: afebrile, WBC increased from 11.4 to 12.4. No\n evidence of infection\n Lines / Tubes / Drains: Foley, Dobhoff, ETT\n Wounds: Dry dressings\n Imaging: none\n Fluids: KVO\n Consults: Vascular surgery, Gynecology\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 09:43 PM\n Multi Lumen - 12:00 AM\n Prophylaxis:\n DVT: Boots (Systemic anticoagulation: Heparin drip)\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting planning, ICU consent signed Comments:\n Code status: DNR / DNI\n Disposition: ICU\n Time spent : 35 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2160-02-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 435920,
"text": "Patient is DNR/DNI\n Hypocalcemia\n Assessment:\n Ionized calcium level 1.03\n Action:\n Repleted with 2 grams iv calcium gluconate per orders\n Response:\n Pending\n Plan:\n Continue to monitor ioCa pre orders.\n Hypokalemia\n Assessment:\n K level 3.9\n Action:\n Repleted with 20 meq iv potassium chloride via central line over 1 hour\n Response:\n Pending\n Plan:\n Continue to monitor and treat electrolytes as ordered.\n Impaired Coping/ Family Dynamics\n Assessment:\n Family meeting held yesterday, pt agitated 5 and resisting\n treatment with attempts to self extubate\n Action:\n Sedation increased from versed .25 mg/hr to 1 mg/hr, immobilizers per\n hospital protocol while Intubated.\n Response:\n Pt calmed to 3 remains Intubated\n Plan:\n Continue family communication, attempt to let patient express her\n wishes while sedation is lightened and family present.\n Hypotension (not Shock)\n Assessment:\n Pt on neosynephrine at 2 mcg/kg/min to keep MAP > 60 (per POE orders).\n Action:\n Neosynephrine weaned to 1.3\n Response:\n Pt maintaining MAP >60\n Plan:\n Continue to wean neo as tolerated\n Peripheral vascular disease (PVD) with critical limb ischemia\n Assessment:\n Bilateral feet with palpable dp and pt pulses, left greater than right.\n Left femoral incision with staples draining copious serous third spaced\n fluid. Left lower leg with 2 incisions stapled, hematoma/ecchymosis and\n multiple blisters inferior to incisions.\n Action:\n Dressings changes, pulses rechecked q 4 hours.\n Response:\n Pulses remain palp, feet warm.\n Plan:\n Continue to wean pressors to improve circulation.\n Pain control\n Assessment:\n Pt with 3 suture lines, grimace when dressings changed or area\n palpated.\n Action:\n Fentanyl gtt continue at 50 mcg/hour.\n Response:\n Pt able to return to sleep, appear comfortable after care and dressing\n changes.\n Plan:\n Continue to assess pain and treat accordingly per orders.\n Impaired Skin Integrity\n Assessment:\n Left glute with large red blanchable area\n Action:\n Turned q 2 hours, aloe vesta moisture barrier oint.\n Response:\n Area remains red and unbroken\n Plan:\n Continue pressure ulcer prevention methods\n Alteration in Nutrition\n Assessment:\n Pt remains Intubated unable to take po, fed via sump.\n Action:\n Increased tube feed to goal per orders\n Response:\n No residuals, tolerating well\n Plan:\n Continue to flush and assess placement, monitor for residuals.\n"
},
{
"category": "Nursing",
"chartdate": "2160-03-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 437228,
"text": "Pt became acutely hypot\n Shock, hypovolemic or hemorrhagic\n Assessment:\n Pt extremely hypotensive; SR-ST with frequent PVCs (Vent\n bigeminy/trigeminy)\n Pt agitated, flailing arms around in bed and bucking ventilator\n Action:\n Labs sent (Hct 20 from 24 earlier on), Lytes low\n 1250cc NS bolus given total\n 2 units PRBCs given\n Transthoracic echo done @ bedside\n CXR done\n Response:\n Repeat Hct\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2160-02-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 436280,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt on CPAP most of shift, although pt\ns RR low (/min). O2 sat\n stable.\n Action:\n Initially increased pressure support to improve pt\ns pH and CO2 from\n ABG. RR and minute volume remained low, so pt placed on MMV.\n Response:\n Pt\ns O2 sat 100% on MMV. RR 14. No apneic periods noted.\n Plan:\n Continue to monitor respiratory mechanics, O2 sat. Place pt back on\n CPAP during daytime with sedation vacation.\n Alteration in Nutrition\n Assessment:\n Pt\ns tube feeding at 40cc/hr. At onset of shift, pt had some vomit\n pooled in mouth and in pharynx above ET cuff. Pt suctioned again via\n oropharnyx x 2 with noted vomit very similar to semi-digested tube\n feeding. Abdomen firm and slightly distended with hypoactive BS. Tube\n feed residuals initially 40cc (given back).\n Action:\n Held tube feedings to reassess residuals. Administered one dose of\n Reglan IV as ordered. Pt residuals found to be ~70cc (given back) and\n held for a longer duration of time. See Metavision for details.\n Response:\n No vomit noted while tube feeds on hold. Restarted feeds at half of\n original rate (20cc/hr).\n Plan:\n Reassess tube feed residuals q 4 hours and increase tube feeds to goal\n of 40cc/hr as tolerated. Administer Reglan IV as ordered PRN.\n"
},
{
"category": "Physician ",
"chartdate": "2160-02-25 00:00:00.000",
"description": "Intensivist Note",
"row_id": 435533,
"text": "CVICU\n HPI:\n 73 y.o. F with acute ischemic left foot, new onset of PAF with ??\n partial SBO,and recent R parietal-occpit CVA with stenosis, now\n POD # 3 LLE embolectomy and left fasciotomy for compartment syndrome\n Chief complaint:\n 73 y/o female admitted to for 6 month history of\n intermittent abdominal distention and flatus associated with diminished\n appetite. Denies post pranial abdominal pain. Admitting physical\n abdominal acities and distention. Patient was about to have exploratory\n laparotomy to evaluate abdominal mass but develope acute left\n foot ischemia. Patient was transfered here for further evaluation and\n was evaluated by Dr. . IV heparin gtt and L embolectomy done.\n PMHx:\n No acute illness or previous surgeries\n Current medications:\n 24 Hour Events:\n Post operative day:\n POD # 3\n - Kept intubated\n - Not responding to commands\n - Heparin gtt\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 800 units/hour\n Phenylephrine - 1.5 mcg/Kg/min\n Propofol - 30 mcg/Kg/min\n Other ICU medications:\n Furosemide (Lasix) - 10:30 AM\n Pantoprazole (Protonix) - 07:30 AM\n Other medications:\n Flowsheet Data as of 08:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.6\nC (97.9\n T current: 36.2\nC (97.2\n HR: 78 (64 - 98) bpm\n BP: 117/59(80) {91/46(60) - 130/69(91)} mmHg\n RR: 16 (12 - 19) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 69.8 kg (admission): 50 kg\n Height: 58 Inch\n CVP: 8 (6 - 13) mmHg\n Total In:\n 4,960 mL\n 1,024 mL\n PO:\n Tube feeding:\n IV Fluid:\n 4,900 mL\n 1,024 mL\n Blood products:\n Total out:\n 1,397 mL\n 525 mL\n Urine:\n 1,397 mL\n 525 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,563 mL\n 499 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 451 (451 - 451) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 25 cmH2O\n Plateau: 23 cmH2O\n SPO2: 99%\n ABG: 7.41/37/152/22/0\n Ve: 6.5 L/min\n PaO2 / FiO2: 304\n Physical Examination\n General Appearance: No acute distress, sedated and intubated\n HEENT: PERRL, B/L pupils are sluggishly reactive\n Cardiovascular: (Rhythm: Regular), (Distant heart sounds: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: CTA bilateral : , Wheezes : inspiratory, left side),\n (Sternum: Stable )\n Abdominal: Bowel sounds present, Distended, abdomen is distended and\n tense\n Left Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact, Erythema)\n Neurologic: (Responds to: Noxious stimuli), No(t) Moves all\n extremities, (RUE: Weakness), (LUE: Weakness), (RLE: Weakness), Sedated\n Labs / Radiology\n 240 K/uL\n 10.8 g/dL\n 81 mg/dL\n 1.4 mg/dL\n 22 mEq/L\n 4.0 mEq/L\n 23 mg/dL\n 105 mEq/L\n 135 mEq/L\n 30.4 %\n 11.4 K/uL\n [image002.jpg]\n 12:26 PM\n 05:29 PM\n 09:04 PM\n 09:12 PM\n 03:11 AM\n 07:45 AM\n 12:05 PM\n 07:13 PM\n 01:30 AM\n 01:40 AM\n WBC\n 16.9\n 12.7\n 11.7\n 11.4\n Hct\n 34.6\n 34.2\n 30.8\n 30.4\n Plt\n 40\n Creatinine\n 1.0\n 1.1\n 1.3\n 1.4\n TCO2\n 25\n 24\n 22\n 23\n 24\n Glucose\n 113\n 127\n 104\n 103\n 86\n 92\n 90\n 84\n 86\n 81\n Other labs: PT / PTT / INR:13.6/86.8/1.2, CK / CK-MB / Troponin\n T:1632//, ALT / AST:129/147, Alk-Phos / T bili:119/0.2, Lactic Acid:0.8\n mmol/L, Albumin:1.4 g/dL, Ca:7.7 mg/dL, Mg:2.3 mg/dL, PO4:4.4 mg/dL\n Assessment and Plan\n CVA (STROKE, CEREBRAL INFARCTION), ISCHEMIC , PERIPHERAL VASCULAR\n DISEASE (PVD) WITH CRITICAL LIMB ISCHEMIA\n Assessment and Plan: 73 y.o. F with acute ischemic left foot, new onset\n of PAF with ?? partial SBO,and recent R parietal-occpit CVA with \n stenosis, now POD # 3 LLE embolectomy and left fasciotomy for\n compartment syndrome. Pt has either peritoneal or ovarian CA.\n Neurologic: Neuro checks Q: 2 hr, Pain controlled, Overall poor\n prognosis as pt has both CA (no staging yet as CT was non-contrasted)\n and now CVA. On PPF gtt. Would add prn midaz (long hx of EtOH) to\n prevent DTs. Add a \"banana bag\", folate. Would try to use fentanyl prn\n or gtt and wean PPF off. Family meeting today with Dr. \n Cardiovascular: Hypotensive on neo gtt, m/p due to underlying sepsis\n physiology. Will hopefully be able to wean off neo once PPF is off.\n Pulmonary: Cont ETT, (Ventilator mode: CMV)\n Gastrointestinal / Abdomen: NPO for now, monitor bowel distention.\n Nutrition: NPO, If continue with full therapy after family meeting,\n start TPN\n Renal: Foley, Adequate UO, Continue with LR for hydration (rhabdo). UTI\n positive, send culture and start cipro. Cr - 1.4 ? chronic or acute\n Hematology: Serial Hct, Stable anemia\n Endocrine: RISS, Glucose well controlled, keep < 150\n Infectious Disease: Check cultures, Urine\n Lines / Tubes / Drains: Foley, ETT\n Wounds:\n Imaging: Pelvic u/s per gyn/onc\n Fluids: LR\n Consults: General surgery, Vascular surgery, Gyn/onc\n Billing Diagnosis: Arrhythmia, CVA, Sepsis, Other: Hypotention\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 09:43 PM\n Multi Lumen - 12:00 AM\n Prophylaxis:\n DVT: Boots (Systemic anticoagulation: Heparin drip, Please switch to H2\n blocker)\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting planning Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 min minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2160-02-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 435608,
"text": "CVA (Stroke, Cerebral infarction), Ischemic\n Assessment:\n Moves R and L upper extremities. Does move right leg on bed.\n Intermittent movement of head side to side. Pupills 3 Brisk. Follows\n command intermittently. Withdraws to pain. Open\ns eyes to name. Did\n follow commands when off sedation and nod to questions.\n Action:\n Propofol replaced with Fentanyl drip. Intermittent versed bolus for\n agitation/Tachycardia and HTN.\n Response:\n Plan:\n Peripheral vascular disease (PVD) with critical limb ischemia\n Assessment:\n POD #2 left femoral embolectomy and fasciotomy. Papable pulses DT/PT.\n No movement of left leg noted.\n Action:\n Attempt to wean Neo.\n Response:\n Plan:\n Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Patient drinks ETOH daily per family. Patient agitated when awake.\n Tacypneic/tachycardic and Hypertensive. Skin dry. No tremors/No\n diaphoresis.\n Action:\n Propofol changed to fentanyl drip. Intermittent versed bolus given\n Response:\n Response well to versed.\n Plan:\n Monitor signs of withdrawal. CIWA.\n"
},
{
"category": "Nursing",
"chartdate": "2160-02-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 435611,
"text": "CVA (Stroke, Cerebral infarction), Ischemic\n Assessment:\n Moves R and L upper extremities. Does move right leg on bed.\n Intermittent movement of head side to side. Pupils 3 Brisk. Follows\n command intermittently. Withdraws to pain. Open\ns eyes to name. Did\n follow commands when off sedation and nod to questions.\n Action:\n Propofol replaced with Fentanyl drip. Intermittent versed bolus for\n agitation/Tachycardia and HTN. Heparin drip.\n Response:\n Plan:\n Peripheral vascular disease (PVD) with critical limb ischemia\n Assessment:\n POD #2 left femoral embolectomy and fasciotomy. Palpable pulses DT/PT.\n No movement of left leg noted.\n Action:\n Attempt to wean Neo. Heparin.\n Response:\n Plan:\n Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Patient drinks ETOH daily per family. Patient agitated when awake.\n Tacypneic/tachycardic and Hypertensive. Skin dry. No tremors/No\n diaphoresis.\n Action:\n Propofol changed to fentanyl drip. Intermittent versed bolus given\n Response:\n Response well to versed.\n Plan:\n Monitor signs of withdrawal. CIWA.\n"
},
{
"category": "Physician ",
"chartdate": "2160-02-26 00:00:00.000",
"description": "ICU Note - CVI",
"row_id": 435781,
"text": "CVICU\n HPI:\n HD5\n POD#4 LLE embolectomy\n Cc: acute ischemic left foot, new onset of PAF\n ?? partial SBO,and recent rt. parietal-occpit. infarct with \n stenosis 50-69%.\n Cr:0.9 Wt:50kg EF 20%\n PMH: negative\n Plan:Ascites Cytology Pos for malig. adeno (prob. ovarian). Large B\n pleural eff.- ?? tap for dx. Vigileo placed- CI >2.5- Lasix given.\n Echo- severe lv DYSFXN W/ EF 20%\n Current medications:\n 1.Albuterol 0.083% Neb Soln 3. Albuterol Inhaler 4. Aspirin 5. Calcium\n Gluconate 6. Chlorhexidine Gluconate 0.12% Oral Rinse 7. Ciprofloxacin\n 8. Famotidine 9. Fentanyl Citrate 10. Furosemide 11. Heparin 12.\n Magnesium Sulfate 16. Metoprolol Tartrate 17. Midazolam 18.\n Nitroglycerin Ointment 2%\n 21. Potassium Chloride 22. Sodium Chloride 0.9% Flush\n 24 Hour Events:\n - code status- DNR/DNI discussed with family-, and\n daughter-in-law, and granddaughter , and Social\n work- with Dr. \n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 800 units/hour\n Fentanyl - 50 mcg/hour\n Phenylephrine - 1.3 mcg/Kg/min\n Other ICU medications:\n Furosemide (Lasix) - 08:45 PM\n Midazolam (Versed) - 09:20 AM\n Famotidine (Pepcid) - 09:29 AM\n Other medications:\n Flowsheet Data as of 10:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.3\nC (97.3\n T current: 35.8\nC (96.5\n HR: 118 (55 - 118) bpm\n BP: 151/74(103) {81/43(58) - 151/74(103)} mmHg\n RR: 26 (7 - 27) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 70.5 kg (admission): 50 kg\n Height: 58 Inch\n CVP: 11 (7 - 15) mmHg\n Total In:\n 3,610 mL\n 1,278 mL\n PO:\n Tube feeding:\n IV Fluid:\n 3,580 mL\n 1,278 mL\n Blood products:\n Total out:\n 1,205 mL\n 660 mL\n Urine:\n 1,205 mL\n 660 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,405 mL\n 618 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 451 (450 - 451) mL\n Vt (Spontaneous): 474 (302 - 474) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 37\n RSBI Deferred: No Spon Resp\n PIP: 16 cmH2O\n SPO2: 97%\n ABG: 7.30/45/90./22/-3\n Ve: 5.8 L/min\n PaO2 / FiO2: 225\n Physical Examination\n General Appearance: edematous\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: CTA bilateral : ), (Sternum: Stable )\n Abdominal: No(t) Soft, Distended, reduced bowel sounds\n Left Extremities: (Edema: 3+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 3+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Follows simple commands, (Responds to: No(t) Tactile\n stimuli), Moves all extremities\n Labs / Radiology\n 298 K/uL\n 10.9 g/dL\n 67 mg/dL\n 1.6 mg/dL\n 22 mEq/L\n 3.9 mEq/L\n 25 mg/dL\n 105 mEq/L\n 134 mEq/L\n 31.6 %\n 12.4 K/uL\n [image002.jpg]\n 07:13 PM\n 01:30 AM\n 01:40 AM\n 11:42 AM\n 03:00 PM\n 08:27 PM\n 02:41 AM\n 02:49 AM\n 03:49 AM\n 09:20 AM\n WBC\n 11.7\n 11.4\n 12.4\n Hct\n 30.8\n 30.4\n 31.6\n Plt\n 238\n 240\n 298\n Creatinine\n 1.3\n 1.4\n 1.5\n 1.6\n TCO2\n 24\n 25\n 24\n 24\n 22\n 23\n Glucose\n 84\n 86\n 81\n 90\n 73\n 67\n Other labs: PT / PTT / INR:13.0/70.7/1.1, CK / CK-MB / Troponin\n T:1268/26/, ALT / AST:129/147, Alk-Phos / T bili:119/0.2, Lactic\n Acid:0.8 mmol/L, Albumin:1.4 g/dL, Ca:7.5 mg/dL, Mg:2.3 mg/dL, PO4:5.2\n mg/dL\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF), HYPOTENSION (NOT\n SHOCK), ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES),\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN), CVA (STROKE, CEREBRAL\n INFARCTION), ISCHEMIC , PERIPHERAL VASCULAR DISEASE (PVD) WITH CRITICAL\n LIMB ISCHEMIA\n Assessment and Plan: POD#4 LLE embolectomy\n HD stable, on Neo, Ascites, reduced urine output, increasing\n generalised edema, weaning from respiratory support,\n on PSV+CPAP\n Neurologic: Neuro checks Q: 4 hr, Responds to loud verbal commands\n Cardiovascular: HD stable, on Neo, Aspirin, Beta-blocker\n Pulmonary: Cont ETT, (Ventilator mode: CPAP + PS), plan to extubate\n after diuresis\n Gastrointestinal / Abdomen:Tense abdomen, ascites +, Plan to start\n tube feeds today\n Nutrition: Tube feeding\n Renal: episodes of reduced urine output, Foley, plan to dialyse today\n Hematology: Stable anemia, on heparin drip at 800, PTT -> 70\n 80 s\n Endocrine: RISS, blood sugars to remain < 150 and avoid episodes of\n hypoglycemia\n Infectious Disease: afebrile, WBC increased from 11.4 to 12.4\n Lines / Tubes / Drains: Foley, Dobhoff, ETT\n Wounds: Dry dressings\n Imaging: none\n Fluids: NS, D5NS, KVO\n Consults: Vascular surgery, Gynecology\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 09:43 PM\n Multi Lumen - 12:00 AM\n Prophylaxis:\n DVT: Boots (Systemic anticoagulation: Heparin drip)\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting planning, ICU consent signed Comments:\n Code status: DNR / DNI\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2160-02-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 436486,
"text": "Hypertension, benign\n Assessment:\n Patient was very agitated from onset of shift that persisted through\n out the day. She was thrashing her arms and hands. She frequently moved\n her head from side to side. Patient did not follow commands and was\n unable to appropriately respond to questions. This behavior resulted in\n hypertensive SBP 170\ns -200 and MAP>100.\n Action:\n Medicated patient with IV Hydralazine, IV Lopressor and titrated IV\n Fentanyl rate up to 50mcg.\n Later started IV Precedex to sedate patient inorder to reduce\n hypertension\n Response:\n SBP remained hypertensive most of the day despite receiving the above\n IV meds.\n Administered IV Ativan 1mg resulting in hypotensive BP 78/40 and MAP\n 48. Started IV Neo at .5mcg->S BP increased 120\ns-130\n Plan:\n Manage hypertensive BP with IV Lopressor every 6 hrs and IV Hydralazine\n prn.\n IV Neo if hypotensive BP reoccurs\n Alteration in Nutrition\n Assessment:\n Tube feeding residual 0-10 ML.\n Suctioned small amounts of tube feeding from her mouth x1.\n Abdomen remains firm and distended. No bowel sounds present.\n Action:\n Increased tube feeding rate to 40ML/HR.\n Administered IV Reglan 5ml\n Response:\n Tube feeding residuals minimal, no vomiting and no tube feeding in her\n mouth\n Plan:\n IV Reglan as needed\n Monitor tube feeding residuals and hold if >30ml\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received patient patient on CPAP 35%/PEEP 5/PS12. Patient was agitated\n and thrashing in the bed\n ABG->respiratory alkolosis\n Upper lobes with expiratory wheezing and rhonchi in bases bilat.\n Patient has bilateral pleural effusions per team\n Action:\n Changed vent settings to CPAP with PEEP5/PS 5. Titrated IV Precedex and\n Fentanyl to reduce anxiety due to ETT tube.\n RSBI 107 so unable to extubate patient today\n Response:\n ABG improved on CPAP 35%/ PEEP5/PS 5.\n Plan:\n Tap right or left lung in am. D/c IV Heparin at 0500 on to\n prepare for pleural tap.\n Impaired Skin Integrity\n Assessment:\n Patient is edematous in upper and lower extremeties. She is weeping\n copious amounts from both LE.\n Skin tear on left arm draining copious amounts serous drainage\n Action:\n Applied DSD dressings to LE extremeties and left arm\n Response:\n Patient continuously drains from LE and left arm\n Plan:\n Change dsd dressings as needed\n"
},
{
"category": "Respiratory ",
"chartdate": "2160-03-01 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 436638,
"text": "Demographics\n Day of mechanical ventilation: 9\n Ideal body weight: 42.3 None\n Ideal tidal volume: 169.2 / 253.8 / 338.4 mL/kg\n Airway\n Tube Type\n ETT:\n Route: Oral\n Type: Standard\n Size: 7mm\n Lung sounds\n RLL Lung Sounds: Insp/Exp Wheeze\n RUL Lung Sounds: Ins/Exp Wheeze\n LUL Lung Sounds: Ins/Exp Wheeze\n LLL Lung Sounds: Ins/Exp Wheeze\n Secretions\n Sputum color / consistency: White / Thin\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Pt does appear anxious at times; placed on A/C for procedure\n to remove pleural fluid. Placed back on PSV settings as charted in the\n afternoon.\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n"
},
{
"category": "Nursing",
"chartdate": "2160-02-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 435853,
"text": "Peripheral vascular disease (PVD) with critical limb ischemia\n Assessment:\n POD #3 left femoral embolectomy and fasciotomy. Palpable pulses DT/PT.\n No movement of left leg. Palpable pulses. Distended and firm abdomen.\n Rabdo-CPK continues to trending down.\n Action:\n Neo increased for MAP>60-70.\n Response:\n Skin warm.\n Plan:\n Monitor tissue perfusion. Map>70.\n CVA (Stroke, Cerebral infarction), Ischemic\n Assessment:\n s/p Embolic stroke. Was in RAP at OSH. Moves R and L upper extremities.\n Does move right leg on bed. No movement of left leg. Intermittent\n movement of head side to side when awake. Pupils 3 Brisk. Follows\n command intermittently. Withdraws to pain. Open\ns eyes to name.\n Sedated. Restless at times. SR with frequent PAC\ns and PVC\n (COPD).Lytes OK.\n Action:\n Fentanyl drip. Intermittent versed changed to versed drip. Bolus\n dropped BP. Heparin drip @ 800 units\nhr. PTT at goal.\n Response:\n PTT at goal (60-80).PTT in am only. Tolerating versed drip @ .25 mg/hr.\n Appears comfortable,\n Plan:\n Frequent Neuro check. Sedation as needed.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Net + -/+ 18 litres since admission. Requiring a lot of fluid for Rabdo\n and BP control. Generalized edema++. Skin weeping at puncture and\n incision sites. Marginal U/O with lasix bolus.\n Action:\n Stared lasix drip @ 5mh/hr. Zorozyline po given.\n Response:\n Plan:\n Positive for UTI. Day #2 of IV Cipro. Sediments in urine\n decreasing. Afebrile.\n Second family meeting today.\n Code Status: DNR/DNI\n SKIN:\n"
},
{
"category": "Nutrition",
"chartdate": "2160-02-27 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 435995,
"text": "Subjective\n pt intubated, family not present. Per chart, decreased appetite x 6\n months PTA.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 147 cm\n 50 kg*\n 69.2 kg ( 05:30 AM)\n increase d/t fluid\n 23\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 42.3 kg\n 118*\n Diagnosis: pulseless left leg\n PMH : none\n Food allergies and intolerances: NKFA\n Pertinent medications: Fent gtt, Lasix gtt --> just turned off,\n Heparin, Versed gtt, Phenylephrine gtt, D5W @ 10ml/hr, Famotidine, Thi,\n Folic Acid, MVI, SS lytes - KCl (20mEq repletion), Magnesium Sulfate\n (2gm repletion), Ca (2gm repletion)\n Labs:\n Value\n Date\n Glucose\n 78 mg/dL\n 03:11 AM\n Glucose Finger Stick\n 78\n 04:00 PM\n BUN\n 28 mg/dL\n 03:00 AM\n Creatinine\n 1.9 mg/dL\n 03:00 AM\n Sodium\n 134 mEq/L\n 03:00 AM\n Potassium\n 3.9 mEq/L\n 03:00 AM\n Chloride\n 101 mEq/L\n 03:00 AM\n TCO2\n 23 mEq/L\n 03:00 AM\n PO2 (arterial)\n 153 mm Hg\n 03:11 AM\n PCO2 (arterial)\n 37 mm Hg\n 03:11 AM\n pH (arterial)\n 7.41 units\n 03:11 AM\n CO2 (Calc) arterial\n 24 mEq/L\n 03:11 AM\n Albumin\n 1.4 g/dL\n 01:30 AM\n Calcium non-ionized\n 7.5 mg/dL\n 02:41 AM\n Phosphorus\n 5.2 mg/dL\n 02:41 AM\n Ionized Calcium\n 1.03 mmol/L\n 03:11 AM\n Magnesium\n 2.1 mg/dL\n 03:00 AM\n ALT\n 129 IU/L\n 01:30 AM\n Alkaline Phosphate\n 119 IU/L\n 01:30 AM\n AST\n 147 IU/L\n 01:30 AM\n Total Bilirubin\n 0.2 mg/dL\n 01:30 AM\n Triglyceride\n 152 mg/dL\n 07:13 PM\n WBC\n 11.0 K/uL\n 03:00 AM\n Hgb\n 9.9 g/dL\n 03:00 AM\n Hematocrit\n 28.7 %\n 03:00 AM\n Current diet order / nutrition support: DIET: NPO\n TF: Novasource Pulmonary @ 40ml/hr\n GI: soft/distended, hypoactive bs; (+) sm loose golden stool (guiac\n (-))\n Assessment of Nutritional Status\n At risk for malnutrition\n Pt at risk due to: NPO / hypocaloric diet, poor appetite PTA, ?CA\n Estimated Nutritional Needs\n Calories: 1250-1400 (BEE x or / 25-28 cal/kg)\n Protein: 50-65 (1-1.3 g/kg)\n Fluid: per team\n Estimation of previous intake: ? Inadequate\n Estimation of current intake:\n Specifics:\n 71 y/o female w/ 6 month history of intermittent abd distention and\n decreased appetite. Plan for ex lap, however pt developed acute L foot\n ischemia. s/p LLE embolectomy . Abd CT () showed pSBO and\n tumor implants concerning for ovarian malignancy. Pt remains\n intubated/sedated. Pt made DNR/DNI after family meeting . TF\n started via OGT. TF now at goal. Per d/w RN, residual of 100ml\n this AM, pt given Reglan and next residual check = 90ml, RN plans to\n recheck residuals soon. Plan for now is continue current care, \n RN, awaiting gyn/onc input re: CA staging/prognosis. Agree w/ TF at\n this time. Current TF provides 1440calories and 65g protein, which\n meets 100% of nutrition needs.\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: continue current\n Tube feeding / TPN recommendations: Continue current TF\n Monitor residuals, hold TF if >/= 200ml\n Check chemistry 10 panel\n continue to replete lytes prn\n BS mgmt\n Will follow\n page if ?s *\n"
},
{
"category": "Physician ",
"chartdate": "2160-02-28 00:00:00.000",
"description": "ICU Note - CVI",
"row_id": 436158,
"text": "CVICU\n HPI:\n Do not resuscitate (DNR/DNI) Family meeting with Son - , ,\n daughter in law, and granddaughter - , ,\n Social work - , - with Dr \n medications:\n Albuterol Inhaler, Aspirin, Bisacodyl, Chlorhexidine Gluconate 0.12%\n Oral Rinse, Famotidine, Fentanyl Citrate gtt, FoLIC Acid, Heparin gtt,\n Ipratropium Bromide MDI, Metoclopramide, Metoprolol Tartrate, Midazolam\n gtt, Phenylephrine gtt, Thiamine\n 24 Hour Events:\n PAN CULTURE - At 12:08 PM\n PICC LINE - START 09:31 PM\n by IV Nurse from previous shift. Okay to use per team\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 09:40 AM\n Infusions:\n Midazolam (Versed) - 0.8 mg/hour\n Fentanyl - 50 mcg/hour\n Heparin Sodium - 850 units/hour\n Phenylephrine - 0.8 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 AM\n Other medications:\n Flowsheet Data as of 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.9\nC (98.5\n T current: 36.8\nC (98.2\n HR: 71 (67 - 150) bpm\n BP: 112/48(70) {88/41(59) - 140/68(96)} mmHg\n RR: 14 (12 - 25) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68.3 kg (admission): 50 kg\n Height: 58 Inch\n CVP: 12 (10 - 14) mmHg\n Total In:\n 2,747 mL\n 732 mL\n PO:\n Tube feeding:\n 960 mL\n 287 mL\n IV Fluid:\n 1,527 mL\n 345 mL\n Blood products:\n 200 mL\n 100 mL\n Total out:\n 3,985 mL\n 940 mL\n Urine:\n 3,985 mL\n 940 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,238 mL\n -208 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 451) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: No Spon Resp\n PIP: 25 cmH2O\n Plateau: 21 cmH2O\n Compliance: 28.2 cmH2O/mL\n SPO2: 96%\n ABG: 7.43/40/136/25/2\n Ve: 6.3 L/min\n PaO2 / FiO2: 340\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Wheezes :\n bilateral basal)\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities, Sedated\n Labs / Radiology\n 304 K/uL\n 8.1 g/dL\n 97 mg/dL\n 2.0 mg/dL\n 25 mEq/L\n 4.1 mEq/L\n 28 mg/dL\n 99 mEq/L\n 131 mEq/L\n 22.7 %\n 7.6 K/uL\n [image002.jpg]\n 09:20 AM\n 02:19 PM\n 02:27 PM\n 03:33 PM\n 03:00 AM\n 03:11 AM\n 11:29 AM\n 08:36 PM\n 02:56 AM\n 03:11 AM\n WBC\n 11.0\n 7.6\n Hct\n 28.7\n 22.7\n Plt\n 338\n 304\n Creatinine\n 1.7\n 1.9\n 1.9\n 2.0\n TCO2\n 23\n 25\n 22\n 24\n 27\n 27\n Glucose\n 65\n 78\n 95\n 94\n 103\n 97\n Other labs: PT / PTT / INR:14.9/78.1/1.3, CK / CK-MB / Troponin\n T:571/16/, ALT / AST:129/147, Alk-Phos / T bili:119/0.2, Lactic\n Acid:0.8 mmol/L, Albumin:1.4 g/dL, Ca:7.7 mg/dL, Mg:2.3 mg/dL, PO4:4.0\n mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), HYPOCALCEMIA (LOW CALCIUM),\n HYPOKALEMIA (LOW POTASSIUM, HYPOPOTASSEMIA), CANCER (MALIGNANT\n NEOPLASM), GYNECOLOGICAL (OVARIAN, UTERINE, CERVICAL, ENDOMETRIAL),\n PROBLEM - ENTER DESCRIPTION IN COMMENTS, ALTERATION IN NUTRITION,\n IMPAIRED SKIN INTEGRITY, RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE,\n ARF), HYPOTENSION (NOT SHOCK), ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM\n TREMENS, DTS, SEIZURES), PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN), CVA\n (STROKE, CEREBRAL INFARCTION), ISCHEMIC , PERIPHERAL VASCULAR DISEASE\n (PVD) WITH CRITICAL LIMB ISCHEMIA\n Assessment and Plan:\n Neurologic: Pain controlled, Restraints, Agitation\n with patients\n drinking history - ? DT's\n Cardiovascular: Aspirin, Full anticoagulation, Beta-blocker\n Pulmonary: Cont ETT, Spontaneous breathing trial\n Gastrointestinal / Abdomen: Con't bowel regimen\n Nutrition: Tube feeding, Will con't tube feeds\n Renal: Foley, Adequate UO, Bun/Cr has been trending up, will hold\n diuretics\n Hematology: Anemia, hct drop overnight. Will recheck hct.\n Endocrine: RISS, Adrenal hypoplasia seen on CT. Will discuss with\n heme/onc if steroids are ok in the setting of ? ovarian cancer and get\n an endo consult to help\n Infectious Disease: Ciprofloxicin for bacteria in urine\n Lines / Tubes / Drains: Foley, ETT\n Wounds: Dry dressings\n Imaging:\n Fluids: Other, Albumin\n Consults: Vascular surgery, Hem / Onc , Gynecology\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 07:27 PM 40 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 09:43 PM\n Multi Lumen - 12:00 AM\n PICC Line - 09:31 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: DNR / DNI\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2160-02-28 00:00:00.000",
"description": "ICU Note - CVI",
"row_id": 436169,
"text": "CVICU\n HPI:\n Do not resuscitate (DNR/DNI) Family meeting with Son - , ,\n daughter in law, and granddaughter - , ,\n Social work - , - with Dr \n medications:\n Albuterol Inhaler, Aspirin, Bisacodyl, Chlorhexidine Gluconate 0.12%\n Oral Rinse, Famotidine, Fentanyl Citrate gtt, FoLIC Acid, Heparin gtt,\n Ipratropium Bromide MDI, Metoclopramide, Metoprolol Tartrate, Midazolam\n gtt, Phenylephrine gtt, Thiamine\n 24 Hour Events:\n PAN CULTURE - At 12:08 PM\n PICC LINE - START 09:31 PM\n by IV Nurse from previous shift. Okay to use per team\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 09:40 AM\n Infusions:\n Midazolam (Versed) - 0.8 mg/hour\n Fentanyl - 50 mcg/hour\n Heparin Sodium - 850 units/hour\n Phenylephrine - 0.8 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 AM\n Other medications:\n Flowsheet Data as of 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.9\nC (98.5\n T current: 36.8\nC (98.2\n HR: 71 (67 - 150) bpm\n BP: 112/48(70) {88/41(59) - 140/68(96)} mmHg\n RR: 14 (12 - 25) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68.3 kg (admission): 50 kg\n Height: 58 Inch\n CVP: 12 (10 - 14) mmHg\n Total In:\n 2,747 mL\n 732 mL\n PO:\n Tube feeding:\n 960 mL\n 287 mL\n IV Fluid:\n 1,527 mL\n 345 mL\n Blood products:\n 200 mL\n 100 mL\n Total out:\n 3,985 mL\n 940 mL\n Urine:\n 3,985 mL\n 940 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,238 mL\n -208 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 451) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: No Spon Resp\n PIP: 25 cmH2O\n Plateau: 21 cmH2O\n Compliance: 28.2 cmH2O/mL\n SPO2: 96%\n ABG: 7.43/40/136/25/2\n Ve: 6.3 L/min\n PaO2 / FiO2: 340\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), s1, s2, no murmur\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Wheezes :\n bilateral basal)\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities, Sedated\n Labs / Radiology\n 304 K/uL\n 8.1 g/dL\n 97 mg/dL\n 2.0 mg/dL\n 25 mEq/L\n 4.1 mEq/L\n 28 mg/dL\n 99 mEq/L\n 131 mEq/L\n 22.7 %\n 7.6 K/uL\n [image002.jpg]\n 09:20 AM\n 02:19 PM\n 02:27 PM\n 03:33 PM\n 03:00 AM\n 03:11 AM\n 11:29 AM\n 08:36 PM\n 02:56 AM\n 03:11 AM\n WBC\n 11.0\n 7.6\n Hct\n 28.7\n 22.7\n Plt\n 338\n 304\n Creatinine\n 1.7\n 1.9\n 1.9\n 2.0\n TCO2\n 23\n 25\n 22\n 24\n 27\n 27\n Glucose\n 65\n 78\n 95\n 94\n 103\n 97\n Other labs: PT / PTT / INR:14.9/78.1/1.3, CK / CK-MB / Troponin\n T:571/16/, ALT / AST:129/147, Alk-Phos / T bili:119/0.2, Lactic\n Acid:0.8 mmol/L, Albumin:1.4 g/dL, Ca:7.7 mg/dL, Mg:2.3 mg/dL, PO4:4.0\n mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), HYPOCALCEMIA (LOW CALCIUM),\n HYPOKALEMIA (LOW POTASSIUM, HYPOPOTASSEMIA), CANCER (MALIGNANT\n NEOPLASM), GYNECOLOGICAL (OVARIAN, UTERINE, CERVICAL, ENDOMETRIAL),\n PROBLEM - ENTER DESCRIPTION IN COMMENTS, ALTERATION IN NUTRITION,\n IMPAIRED SKIN INTEGRITY, RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE,\n ARF), HYPOTENSION (NOT SHOCK), ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM\n TREMENS, DTS, SEIZURES), PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN), CVA\n (STROKE, CEREBRAL INFARCTION), ISCHEMIC , PERIPHERAL VASCULAR DISEASE\n (PVD) WITH CRITICAL LIMB ISCHEMIA\n Assessment and Plan:\n Neurologic: Pain controlled, Restraints, Agitation\n m/p related to\n long standing EtOH history. On midazolam gtt for withdrawal symptoms.\n Received folate thiamine x 3 days. CVA: stable. On Heparin gtt\n Cardiovascular: Aspirin, Full anticoagulation for h/o of AF, CVA and\n embolic event to LE. Hypotensive on neo, m/p from adrenal\n insufficiency. No evidence of infection or sepsis.\n Pulmonary: Cont ETT, Spontaneous breathing trial. If tolerating, switch\n to PS. need a trach if unable to extubate, but this mandates a\n discussion with Mrs. \ns husband as she may have not wanted a\n trach.\n Gastrointestinal / Abdomen: Con't bowel regimen\n Nutrition: Malnurished. Tolerating tube feeding, f/u on neutritional\n recs. Pt may benefit from additional protein as hypoalbuminemia.\n Renal: Foley, Adequate UO, ARF (Cr doubled), but still making good u/o.\n M/p pre-renal as pt has extensive ascites and probably intravascularly\n hypovolemic. Please check urine and serum lytes and osmolalities. Will\n gently hydrate today with NS. Hyponatremic, m/p due to adrenal\n insufficiency. Start salt tabs and fludrocortisones (please see endo\n section)\n Hematology: Anemia, hct drop overnight\n m/p due to hydration with\n albumin yesterday. Would not transfuse at this point as m/p dilutional\n and no evidence of ischemia. Please check Hct in PM\n Endocrine: RISS with adequate glucose control. Keep < 150. Adrenal\n hypoplasia seen on CT from OSH. Will send a today to get CT so\n radiology can evaluate findings, including pelvic involvement of CA.\n Will discuss with heme/onc if steroids are ok in the setting of ?\n ovarian cancer. If heme/onc is o.k. with steroids will get endo consult\n to weigh in re: management of adrenal insufficiency. Please send\n cortisol and ACTH levels today.\n Infectious Disease: Ciprofloxicin x 3 days for bacteria in urine\n Lines / Tubes / Drains: Foley, ETT\n Wounds: Dry dressings\n Imaging:\n Fluids: Other, Albumin\n Consults: Vascular surgery, Hem / Onc , Gynecology\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 07:27 PM 40 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 09:43 PM\n Multi Lumen - 12:00 AM\n PICC Line - 09:31 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: DNR / DNI\n Disposition: ICU\n Time spent : 50 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2160-03-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 436645,
"text": "Pleural effusion, chronic\n Assessment:\n Bilateral pleural effusion (Can in with ).\n Action:\n Right pleural tap done at bedside. Additional sedation given for\n agitation during procedure. Post procedure CXray shows small right\n pneumo. Repeat CXRay OK in afternoon. Fluids sent for cytology. ? Ca.\n NP spoke to husband for consent.\n Response:\n Removed 300 cc from right. Vented. Resp status stable.\n Plan:\n ? tap left side.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Vented day #9. LS I/Exp wheezing. Bil rhonchi\ns. Suction Q 2-3 hrs.\n Clear pale yellow secretion\n Action:\n CPAP x 2 today. 35%/. Had to put her on CMV this am due to\n agitation.\n Response:\n Continue to wean as tolerated.\n Plan:\n DNR. Husband does want intubation if does not tolerate extubation.\n CVA (Stroke, Cerebral infarction), Ischemic\n Assessment:\n Does not follow commands today. Agitated +++ with minimal stimulation.\n Does not focus. Pupils 3 brisk. Moves Upper extremities and right leg.\n Moves toes on left leg. Moves head side to side. Hct 20.4\n Action:\n Sedated with fentanyl and intermittent bolus. Ativan IV bolus. 1 unit\n RBC given. Restarted heparin @ 1000unit/hr at 15:00.\n Response:\n Repeat Hct 24.9.\n Plan:\n Next PTT @ 20:00. Monitor signs of bleeding. No stool this am. Had\n guiac positive stool.\n Impaired Skin Integrity\n Assessment:\n Generalized edema. Skin oozing serous fluids from incision and puncture\n site.\n Action:\n Lasix 20 mg IV Q 8 hrs.\n Response:\n Creat slightly up this afternoon (1.9 to 2.1). Net\n 1600 ml so fair.\n Plan:\n Continue lasix NP . Monitor renal function am.\n Alteration in Nutrition\n Assessment:\n Tfeeding stopped last night due to vomiting. NPO this am until 14:00.\n Abdomen firm and distended (Not new).\n Action:\n Reglan IV given. Restarted tube feeds @ 10 cc/hr.\n Response:\n No vomiting today. Minimal residuals.\n Plan:\n Residual check Q 4 hrs. HOB 30-45 degrees.\n Code status: DNR---Intubate as needed per husbands wishes\n (Next of ).\n SR 80-120\ns. PVC\ns. Short episode of ? MAT 140\ns (not new).\n Magnesium and Potassium repleted. Lopressor 5mg IV Q 8 hr.3.\n"
},
{
"category": "Nursing",
"chartdate": "2160-02-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 435846,
"text": "Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2160-02-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 435848,
"text": "Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Respiratory ",
"chartdate": "2160-02-27 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 435906,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 6\n Ideal body weight: 42.3 None\n Ideal tidal volume: 169.2 / 253.8 / 338.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: 8 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Ins/Exp Wheeze\n LLL Lung Sounds: Crackles\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt remains on current vent settings. See vent flow sheet for\n details. MDI\nS given.RSBI not done due to no spont resp.Sedated with\n fentanyl and midazolam. Will cont to monitor resp status.\n"
},
{
"category": "Physician ",
"chartdate": "2160-02-27 00:00:00.000",
"description": "ICU Note - CVI",
"row_id": 435955,
"text": "HPI:\n Chief complaint:\n PMHx:\n Current medications:\n 24 Hour Events:\n Post operative day:\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Respiratory support\n Physical Examination\n Labs / Radiology\n [image002.jpg]\n WBC\n Hct\n Plt\n Creatinine\n Troponin T\n TCO2\n Glucose\n Imaging:\n Microbiology:\n ECG:\n Assessment and Plan\n Assessment and Plan:\n Neurologic:\n Cardiovascular:\n Pulmonary:\n Gastrointestinal / Abdomen:\n Nutrition:\n Renal:\n Hematology:\n Endocrine:\n Infectious Disease:\n Lines / Tubes / Drains:\n Wounds:\n Imaging:\n Fluids:\n Consults:\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP bundle:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2160-02-27 00:00:00.000",
"description": "ICU Note - CVI",
"row_id": 435968,
"text": "CVICU\n HPI:\n Chief complaint:\n HD6\n POD#5 LLE embolectomy\n Cc: acute ischemic left foot, new onset of PAF\n ?? partial SBO,and recent rt. parietal-occpit. infarct with \n stenosis 50-69%.\n Cr:0.9 Wt:50kg EF 20%\n PMH: negative\n Plan:Ascites Cytology Pos for malig. adeno (prob. ovarian). Large B\n pleural eff.- ?? tap for dx. Vigileo placed- CI >2.5- Lasix given.\n Echo- severe lv DYSFXN W/ EF 20%\n Current medications:\n Albuterol Inhaler, Aspirin, Bisacodyl, Chlorhexidine Gluconate 0.12%\n Oral Rinse, Ciprofloxacin, Famotidine, Fentanyl gtt, FoLIC Acid,\n Furosemide gtt, Heparin gtt, Ipratropium Bromide MDI, Metolazone,\n Metoclopramide, Metoprolol Tartrate, Midazolam gtt, Phenylephrine gtt,\n Thiamine\n 24 Hour Events:\n CPAP Trial overnight\n patient became acidotic so placed back on AC\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 10:00 AM\n Infusions:\n Midazolam (Versed) - 0.5 mg/hour\n Furosemide (Lasix) - 5 mg/hour\n Heparin Sodium - 850 units/hour\n Phenylephrine - 2 mcg/Kg/min\n Fentanyl - 50 mcg/hour\n Other ICU medications:\n Midazolam (Versed) - 10:59 AM\n Famotidine (Pepcid) - 08:00 AM\n Other medications:\n Flowsheet Data as of 09:17 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.6\nC (97.9\n T current: 36.4\nC (97.5\n HR: 150 (58 - 150) bpm\n BP: 93/43(60) {88/43(60) - 151/90(103)} mmHg\n RR: 14 (7 - 26) insp/min\n SPO2: 98%\n Heart rhythm: MAT (Multifocal atrial tachycardia)\n Wgt (current): 69.2 kg (admission): 50 kg\n Height: 58 Inch\n CVP: 6 (6 - 14) mmHg\n Total In:\n 2,450 mL\n 974 mL\n PO:\n Tube feeding:\n 219 mL\n 359 mL\n IV Fluid:\n 2,181 mL\n 555 mL\n Blood products:\n Total out:\n 2,485 mL\n 1,685 mL\n Urine:\n 2,485 mL\n 1,685 mL\n NG:\n Stool:\n Drains:\n Balance:\n -35 mL\n -711 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 451 (450 - 451) mL\n Vt (Spontaneous): 581 (581 - 581) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: No Spon Resp\n PIP: 23 cmH2O\n Plateau: 20 cmH2O\n Compliance: 30.1 cmH2O/mL\n SPO2: 98%\n ABG: 7.41/37/153/23/0\n Ve: 3.4 L/min\n PaO2 / FiO2: 383\n Physical Examination\n General Appearance: No acute distress\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: No(t) CTA\n bilateral : , Wheezes : , Crackles : bilateral bases)\n Abdominal: Soft, Non-tender, Bowel sounds present, Tender:\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities, Sedated\n Labs / Radiology\n 338 K/uL\n 9.9 g/dL\n 78 mg/dL\n 1.9 mg/dL\n 23 mEq/L\n 3.9 mEq/L\n 28 mg/dL\n 101 mEq/L\n 134 mEq/L\n 28.7 %\n 11.0 K/uL\n [image002.jpg]\n 08:27 PM\n 02:41 AM\n 02:49 AM\n 03:49 AM\n 09:20 AM\n 02:19 PM\n 02:27 PM\n 03:33 PM\n 03:00 AM\n 03:11 AM\n WBC\n 12.4\n 11.0\n Hct\n 31.6\n 28.7\n Plt\n 298\n 338\n Creatinine\n 1.6\n 1.7\n 1.9\n TCO2\n 24\n 24\n 22\n 23\n 25\n 22\n 24\n Glucose\n 73\n 67\n 65\n 78\n Other labs: PT / PTT / INR:14.1/71.6/1.2, CK / CK-MB / Troponin\n T:1066/21/, ALT / AST:129/147, Alk-Phos / T bili:119/0.2, Lactic\n Acid:0.7 mmol/L, Albumin:1.4 g/dL, Ca:7.5 mg/dL, Mg:2.1 mg/dL, PO4:5.2\n mg/dL\n Assessment and Plan\n HYPOCALCEMIA (LOW CALCIUM), HYPOKALEMIA (LOW POTASSIUM,\n HYPOPOTASSEMIA), CANCER (MALIGNANT NEOPLASM), GYNECOLOGICAL (OVARIAN,\n UTERINE, CERVICAL, ENDOMETRIAL), PROBLEM - ENTER DESCRIPTION IN\n COMMENTS, ALTERATION IN NUTRITION, IMPAIRED SKIN INTEGRITY, RENAL\n FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF), HYPOTENSION (NOT SHOCK),\n ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES), PAIN\n CONTROL (ACUTE PAIN, CHRONIC PAIN), CVA (STROKE, CEREBRAL INFARCTION),\n ISCHEMIC , PERIPHERAL VASCULAR DISEASE (PVD) WITH CRITICAL LIMB\n ISCHEMIA\n Assessment and Plan:\n Neurologic: Pain controlled, Restraints, sedated with fentanyl and\n midazolam\n Cardiovascular: Aspirin, Full anticoagulation, Beta-blocker\n Pulmonary: Cont ETT, (Ventilator mode: Other), Albuterol and\n Ipratropium\n Gastrointestinal / Abdomen: Continue bowel regimen\n Nutrition: Tube feeding\n Renal: Foley, On lasix gtt and metolazone- Bun and Cr trending up\n Hematology: Stable anemia, will continue to watch\n Endocrine:\n Infectious Disease: Positive UA for bacteria, urine culture negative,\n afebrile. Will stop ciprofloxicin\n Lines / Tubes / Drains: ETT\n Wounds: Dry dressings\n Imaging:\n Fluids: KVO\n Consults: Vascular surgery, Gynecology\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 01:00 PM 40 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 09:43 PM\n Multi Lumen - 12:00 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin drip)\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2160-02-27 00:00:00.000",
"description": "ICU Note - CVI",
"row_id": 435971,
"text": "CVICU\n HPI:\n Chief complaint:\n HD6\n POD#5 LLE embolectomy\n Cc: acute ischemic left foot, new onset of PAF\n ?? partial SBO,and recent rt. parietal-occpit. infarct with \n stenosis 50-69%.\n Cr:0.9 Wt:50kg EF 20%\n PMH: negative\n Plan:Ascites Cytology Pos for malig. adeno (prob. ovarian). Large B\n pleural eff.- ?? tap for dx. Vigileo placed- CI >2.5- Lasix given.\n Echo- severe lv DYSFXN W/ EF 20%\n Current medications:\n Albuterol Inhaler, Aspirin, Bisacodyl, Chlorhexidine Gluconate 0.12%\n Oral Rinse, Ciprofloxacin, Famotidine, Fentanyl gtt, FoLIC Acid,\n Furosemide gtt, Heparin gtt, Ipratropium Bromide MDI, Metolazone,\n Metoclopramide, Metoprolol Tartrate, Midazolam gtt, Phenylephrine gtt,\n Thiamine\n 24 Hour Events:\n CPAP Trial overnight\n patient became acidotic so placed back on AC\n Started lasix gtt for diuresis, even fluid balance yesterday\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 10:00 AM\n Infusions:\n Midazolam (Versed) - 0.5 mg/hour\n Furosemide (Lasix) - 5 mg/hour\n Heparin Sodium - 850 units/hour\n Phenylephrine - 2 mcg/Kg/min\n Fentanyl - 50 mcg/hour\n Other ICU medications:\n Midazolam (Versed) - 10:59 AM\n Famotidine (Pepcid) - 08:00 AM\n Other medications:\n Flowsheet Data as of 09:17 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.6\nC (97.9\n T current: 36.4\nC (97.5\n HR: 150 (58 - 150) bpm\n BP: 93/43(60) {88/43(60) - 151/90(103)} mmHg\n RR: 14 (7 - 26) insp/min\n SPO2: 98%\n Heart rhythm: MAT (Multifocal atrial tachycardia)\n Wgt (current): 69.2 kg (admission): 50 kg\n Height: 58 Inch\n CVP: 6 (6 - 14) mmHg\n Total In:\n 2,450 mL\n 974 mL\n PO:\n Tube feeding:\n 219 mL\n 359 mL\n IV Fluid:\n 2,181 mL\n 555 mL\n Blood products:\n Total out:\n 2,485 mL\n 1,685 mL\n Urine:\n 2,485 mL\n 1,685 mL\n NG:\n Stool:\n Drains:\n Balance:\n -35 mL\n -711 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 451 (450 - 451) mL\n Vt (Spontaneous): 581 (581 - 581) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: No Spon Resp\n PIP: 23 cmH2O\n Plateau: 20 cmH2O\n Compliance: 30.1 cmH2O/mL\n SPO2: 98%\n ABG: 7.41/37/153/23/0\n Ve: 3.4 L/min\n PaO2 / FiO2: 383\n Physical Examination\n General Appearance: No acute distress\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: No(t) CTA\n bilateral : , Wheezes : , Crackles : bilateral bases)\n Abdominal: Soft, Non-tender, Bowel sounds present, Tender:\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities, Sedated\n Labs / Radiology\n 338 K/uL\n 9.9 g/dL\n 78 mg/dL\n 1.9 mg/dL\n 23 mEq/L\n 3.9 mEq/L\n 28 mg/dL\n 101 mEq/L\n 134 mEq/L\n 28.7 %\n 11.0 K/uL\n [image002.jpg]\n 08:27 PM\n 02:41 AM\n 02:49 AM\n 03:49 AM\n 09:20 AM\n 02:19 PM\n 02:27 PM\n 03:33 PM\n 03:00 AM\n 03:11 AM\n WBC\n 12.4\n 11.0\n Hct\n 31.6\n 28.7\n Plt\n 298\n 338\n Creatinine\n 1.6\n 1.7\n 1.9\n TCO2\n 24\n 24\n 22\n 23\n 25\n 22\n 24\n Glucose\n 73\n 67\n 65\n 78\n Other labs: PT / PTT / INR:14.1/71.6/1.2, CK / CK-MB / Troponin\n T:1066/21/, ALT / AST:129/147, Alk-Phos / T bili:119/0.2, Lactic\n Acid:0.7 mmol/L, Albumin:1.4 g/dL, Ca:7.5 mg/dL, Mg:2.1 mg/dL, PO4:5.2\n mg/dL\n Assessment and Plan\n HYPOCALCEMIA (LOW CALCIUM), HYPOKALEMIA (LOW POTASSIUM,\n HYPOPOTASSEMIA), CANCER (MALIGNANT NEOPLASM), GYNECOLOGICAL (OVARIAN,\n UTERINE, CERVICAL, ENDOMETRIAL), PROBLEM - ENTER DESCRIPTION IN\n COMMENTS, ALTERATION IN NUTRITION, IMPAIRED SKIN INTEGRITY, RENAL\n FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF), HYPOTENSION (NOT SHOCK),\n ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES), PAIN\n CONTROL (ACUTE PAIN, CHRONIC PAIN), CVA (STROKE, CEREBRAL INFARCTION),\n ISCHEMIC , PERIPHERAL VASCULAR DISEASE (PVD) WITH CRITICAL LIMB\n ISCHEMIA\n Assessment and Plan:\n Neurologic: Pain controlled, Restraints, sedated with fentanyl and\n midazolam\n Cardiovascular: Aspirin, Full anticoagulation, Beta-blocker\n Pulmonary: Cont ETT, (Ventilator mode: Other), Albuterol and\n Ipratropium\n Gastrointestinal / Abdomen: Continue bowel regimen\n Nutrition: Tube feeding\n Renal: Foley, On lasix gtt and metolazone- Bun and Cr trending up.\n Will stop lasix gtt and transfer to bolus dosing. Goal diuresis \n L/day.\n Hematology: Stable anemia, will continue to watch\n Endocrine:\n Infectious Disease: Positive UA for bacteria, urine culture negative,\n afebrile. Will stop ciprofloxicin\n Lines / Tubes / Drains: ETT\n Wounds: Dry dressings\n Imaging:\n Fluids: KVO\n Consults: Vascular surgery, Gynecology\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 01:00 PM 40 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 09:43 PM\n Multi Lumen - 12:00 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin drip)\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"
},
{
"category": "Respiratory ",
"chartdate": "2160-02-28 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 436258,
"text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 7\n Ideal body weight: 42.3 None\n Ideal tidal volume: 169.2 / 253.8 / 338.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Route: Oral\n Type: Standard\n Size: 7mm\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Pt placed on SBT 5/0 as noted. RSBI was 123 with a VT 212 and\n RR 26. ABG on SBT was 7.32/52/78/28/0. Pt placed on PSV 8/5 after SBT\n trial.\n Assessment of breathing comfort: No claim of dyspnea\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved; Comments: Plan to wean toward extubation over the next\n several days.\n"
},
{
"category": "Nursing",
"chartdate": "2160-02-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 436068,
"text": "CVA (Stroke, Cerebral infarction), Ischemic\n Assessment:\n Follows all commands during daily wakeup this am. Moves UE and right\n LE. Did move toes on left side. Intermittently follows commands under\n sedation.\n Action:\n Neuro assessment.\n Response:\n Comfort. ROM. Reassurance.\n Plan:\n Alteration in Nutrition\n Assessment:\n High residuals this am (100 cc). TFeeding at 40 cc/hr. Positive BS.\n Abdomen firm distended (Not new).\n Action:\n Residual rechecked after 2 hours. Reglan 5mg IV given and bisacodyl\n suppository.\n Response:\n Stool x2. Feeding residual decreased. TF at goal (40 cc/hr).\n Plan:\n Reglan IV. Daily suppository prn. Check residual Q4 hrs.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Vented via ETT. Day #5.CIPAP trial this am during daily wakeup. Patient\n became agitated ++. Trashing head side to side. Attempting to pulled\n out ETT.\n Action:\n Restarted sedation. Placed on CMV.\n Response:\n Sat >97 %. RR 14-20\ns. Calmer with sedation. Does require intermittent\n blousing during repositioning.\n Plan:\n Diuresis well. Rest overnight as needed. CPAP trial tomorrow.\n Impaired Skin Integrity\n Assessment:\n General edema decreased. Still weeping from incision sites and puncture\n sites. Skin tears.\n Action:\n Left leg incision has echymotic area under leg. DSD.\n Response:\n Monitor skin integrity.\n Plan:\n Reduce pressures. Reposition Q2 hr. Keep skin dry.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN/Creat slightly up. BUN 28/Creat 1.9. Stable last 2 blood draws.\n Action:\n Lasix stopped. Wean Neo for MAP >60. Started albumin Q 8 hrs. First\n dose given.\n Response:\n Good U/O. Weight down and peripheral edema decreasing.\n Plan:\n Monitor labs. Maintain MAP>60.\n Cancer (Malignant Neoplasm), Gynecological (Ovarian, Uterine, Cervical,\n Endometrial)\n Assessment:\n Seen by medical oncology resident today. Awaiting CA staging and\n prognosis.\n Action:\n Waiting for oncology attending to see patient. Awaiting pathology\n results.\n Response:\n Vaginal ultrasound pending. Staging of Ca pending.\n Plan:\n Family meeting tomorrow or Friday with Dr. .\n PICC line placed today. CXray done. Pulled back by IV nurse.\n Leave TLC until tomorrow.\n PAN cultured today to R/O infection. Afebrile. WBC WNL.\n Still requiring Neo.\n Dr. and social worker spoke with family today.\n Dr. unable to speak with family. Family was instructed to call\n Dr.\ns office tomorrow to set up a follow up meeting.\n DNR/DNI(Confirmed after intubation.\n 18:39\n"
},
{
"category": "Nursing",
"chartdate": "2160-02-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 436069,
"text": "CVA (Stroke, Cerebral infarction), Ischemic\n Assessment:\n Follows all commands during daily wakeup this am. Moves UE and right\n LE. Did move toes on left side. Intermittently follows commands under\n sedation.\n Action:\n Neuro assessment.\n Response:\n Comfort. ROM. Reassurance.\n Plan:\n Alteration in Nutrition\n Assessment:\n High residuals this am (100 cc). TFeeding at 40 cc/hr. Positive BS.\n Abdomen firm distended (Not new).\n Action:\n Residual rechecked after 2 hours. Reglan 5mg IV given and bisacodyl\n suppository.\n Response:\n Stool x2. Feeding residual decreased. TF at goal (40 cc/hr).\n Plan:\n Reglan IV. Daily suppository prn. Check residual Q4 hrs.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Vented via ETT. Day #5.CIPAP trial this am during daily wakeup. Patient\n became agitated ++. Trashing head side to side. Attempting to pulled\n out ETT.\n Action:\n Restarted sedation. Placed on CMV.\n Response:\n Sat >97 %. RR 14-20\ns. Calmer with sedation. Does require intermittent\n blousing during repositioning.\n Plan:\n Diuresis well. Rest overnight as needed. CPAP trial tomorrow.\n Impaired Skin Integrity\n Assessment:\n General edema decreased. Still weeping from incision sites and puncture\n sites. Skin tears.\n Action:\n Left leg incision has echymotic area under leg. DSD.\n Response:\n Monitor skin integrity.\n Plan:\n Reduce pressures. Reposition Q2 hr. Keep skin dry.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN/Creat slightly up. BUN 28/Creat 1.9. Stable last 2 blood draws.\n Action:\n Lasix stopped. Wean Neo for MAP >60. Started albumin Q 8 hrs. First\n dose given.\n Response:\n Good U/O. Weight down and peripheral edema decreasing.\n Plan:\n Monitor labs. Maintain MAP>60.\n Cancer (Malignant Neoplasm), Gynecological (Ovarian, Uterine, Cervical,\n Endometrial)\n Assessment:\n Seen by medical oncology resident today. Awaiting CA staging and\n prognosis.\n Action:\n Waiting for oncology attending to see patient. Awaiting pathology\n results.\n Response:\n Vaginal ultrasound pending. Staging of Ca pending.\n Plan:\n Family meeting tomorrow or Friday with Dr. .\n PICC line placed today. CXray done. Pulled back by IV nurse.\n Leave TLC until tomorrow.\n PAN cultured today to R/O infection. Afebrile. WBC WNL.\n Still requiring Neo.\n Dr. and social worker spoke with family today.\n Dr. unable to speak with family. Family was instructed to call\n Dr.\ns office tomorrow to set up a follow up meeting.\n DNR/DNI(Confirmed after intubation.\n 18:39\n ------ Protected Section ------\n Heparin @ 850 unit\nhr. Therapeutic. Goal 60-90.\n ------ Protected Section Addendum Entered By:\n , RN on: 18:43 ------\n 18:43\n"
},
{
"category": "Physician ",
"chartdate": "2160-02-27 00:00:00.000",
"description": "ICU Note - CVI",
"row_id": 435987,
"text": "CVICU\n HPI:\n Chief complaint:\n HD6\n POD#5 LLE embolectomy\n Cc: acute ischemic left foot, new onset of PAF\n ?? partial SBO,and recent rt. parietal-occpit. infarct with \n stenosis 50-69%.\n Cr:0.9 Wt:50kg EF 20%\n PMH: negative\n Plan:Ascites Cytology Pos for malig. adeno (prob. ovarian). Large B\n pleural eff.- ?? tap for dx. Vigileo placed- CI >2.5- Lasix given.\n Echo- severe lv DYSFXN W/ EF 20%\n Current medications:\n Albuterol Inhaler, Aspirin, Bisacodyl, Chlorhexidine Gluconate 0.12%\n Oral Rinse, Ciprofloxacin, Famotidine, Fentanyl gtt, FoLIC Acid,\n Furosemide gtt, Heparin gtt, Ipratropium Bromide MDI, Metolazone,\n Metoclopramide, Metoprolol Tartrate, Midazolam gtt, Phenylephrine gtt,\n Thiamine\n 24 Hour Events:\n CPAP Trial overnight\n patient became acidotic so placed back on AC\n Started lasix gtt for diuresis, even fluid balance yesterday\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 10:00 AM\n Infusions:\n Midazolam (Versed) - 0.5 mg/hour\n Furosemide (Lasix) - 5 mg/hour\n Heparin Sodium - 850 units/hour\n Phenylephrine - 2 mcg/Kg/min\n Fentanyl - 50 mcg/hour\n Other ICU medications:\n Midazolam (Versed) - 10:59 AM\n Famotidine (Pepcid) - 08:00 AM\n Other medications:\n Flowsheet Data as of 09:17 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.6\nC (97.9\n T current: 36.4\nC (97.5\n HR: 150 (58 - 150) bpm\n BP: 93/43(60) {88/43(60) - 151/90(103)} mmHg\n RR: 14 (7 - 26) insp/min\n SPO2: 98%\n Heart rhythm: MAT (Multifocal atrial tachycardia)\n Wgt (current): 69.2 kg (admission): 50 kg\n Height: 58 Inch\n CVP: 6 (6 - 14) mmHg\n Total In:\n 2,450 mL\n 974 mL\n PO:\n Tube feeding:\n 219 mL\n 359 mL\n IV Fluid:\n 2,181 mL\n 555 mL\n Blood products:\n Total out:\n 2,485 mL\n 1,685 mL\n Urine:\n 2,485 mL\n 1,685 mL\n NG:\n Stool:\n Drains:\n Balance:\n -35 mL\n -711 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 451 (450 - 451) mL\n Vt (Spontaneous): 581 (581 - 581) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: No Spon Resp\n PIP: 23 cmH2O\n Plateau: 20 cmH2O\n Compliance: 30.1 cmH2O/mL\n SPO2: 98%\n ABG: 7.41/37/153/23/0\n Ve: 3.4 L/min\n PaO2 / FiO2: 383\n Physical Examination\n General Appearance: No acute distress\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: No(t) CTA\n bilateral : , Wheezes : , Crackles : bilateral bases)\n Abdominal: Soft, Non-tender, Bowel sounds present, Tender:\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities, Sedated\n Labs / Radiology\n 338 K/uL\n 9.9 g/dL\n 78 mg/dL\n 1.9 mg/dL\n 23 mEq/L\n 3.9 mEq/L\n 28 mg/dL\n 101 mEq/L\n 134 mEq/L\n 28.7 %\n 11.0 K/uL\n [image002.jpg]\n 08:27 PM\n 02:41 AM\n 02:49 AM\n 03:49 AM\n 09:20 AM\n 02:19 PM\n 02:27 PM\n 03:33 PM\n 03:00 AM\n 03:11 AM\n WBC\n 12.4\n 11.0\n Hct\n 31.6\n 28.7\n Plt\n 298\n 338\n Creatinine\n 1.6\n 1.7\n 1.9\n TCO2\n 24\n 24\n 22\n 23\n 25\n 22\n 24\n Glucose\n 73\n 67\n 65\n 78\n Other labs: PT / PTT / INR:14.1/71.6/1.2, CK / CK-MB / Troponin\n T:1066/21/, ALT / AST:129/147, Alk-Phos / T bili:119/0.2, Lactic\n Acid:0.7 mmol/L, Albumin:1.4 g/dL, Ca:7.5 mg/dL, Mg:2.1 mg/dL, PO4:5.2\n mg/dL\n Assessment and Plan\n HYPOCALCEMIA (LOW CALCIUM), HYPOKALEMIA (LOW POTASSIUM,\n HYPOPOTASSEMIA), CANCER (MALIGNANT NEOPLASM), GYNECOLOGICAL (OVARIAN,\n UTERINE, CERVICAL, ENDOMETRIAL), PROBLEM - ENTER DESCRIPTION IN\n COMMENTS, ALTERATION IN NUTRITION, IMPAIRED SKIN INTEGRITY, RENAL\n FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF), HYPOTENSION (NOT SHOCK),\n ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES), PAIN\n CONTROL (ACUTE PAIN, CHRONIC PAIN), CVA (STROKE, CEREBRAL INFARCTION),\n ISCHEMIC , PERIPHERAL VASCULAR DISEASE (PVD) WITH CRITICAL LIMB\n ISCHEMIA\n Assessment and Plan:\n Neurologic: Pain controlled, Restraints, sedated with fentanyl and\n midazolam. Try to minimize sedation as much as possible. Watch for DTs\n as pt has h/o extensive EtOH.\n Cardiovascular: Aspirin, Full anticoagulation. Still requires neo to\n maintain BP, but no clear evidence of sepsis. Panculture again. Would\n not start steroids as patient is not septic.\n Pulmonary: Cont ETT, (Ventilator mode: Other), Albuterol and\n Ipratropium. Attempt to wean to PS as tolerated.\n Gastrointestinal / Abdomen: Continue bowel regimen. Pt has massive\n ascites m/p from CA, and thus probably intravascularely depleted.\n Nutrition: Tolerating tube feeding (neutren/pulm) for low volume\n Renal: Foley, On lasix gtt and metolazone- Bun and Cr trending up.\n Will stop lasix gtt as pt is going into ARF. Start albumin IV and try\n to wean neo.\n Hematology: Stable anemia\n monitor\n Endocrine: RISS with adequate glucose control. Keep < 150\n Infectious Disease: Positive UA for bacteria, urine culture negative,\n afebrile. Will stop ciprofloxicin\n Lines / Tubes / Drains: ETT\n Wounds: Dry dressings\n Imaging:\n Fluids: KVO\n Consults: Vascular surgery, Gynecology\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 01:00 PM 40 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 09:43 PM\n Multi Lumen - 12:00 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin drip)\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up\n Comments:\n Communication: Comments: I spoke with Dr. and we both agreed\n that CMO at this point is inappropriate given the fact that we \n have a definitive diagnosis as far as abdominal/pelvic CA. M/p ovarian\n cancer, but would need gyn/onc input to evaluate further management.\n Patient is alert and seems to be oriented. She follows commands, and so\n as far as management decisions, the husband would be the contact person\n to make decisions. I will try to contact him and update him on Mrs.\n \ns medical condition and get some guidance as far as her wishes.\n Code status: DNR / DNI\n Disposition: ICU\n Time spent : 45 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2160-02-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 436123,
"text": " POD#6 LLE embolectomy\n Cc: acute ischemic left foot, new onset of PAF\n ?? partial SBO, and recent rt. parietal-occpit. infarct with \n stenosis 50-69%.\n Cr:0.9 Wt:50kg EF 20%\n PMH: negative\n Plan:Ascites Cytology Pos for malig. adeno (prob. ovarian). Large B\n pleural eff.- ?? tap for dx. Vigileo placed- CI >2.5- Lasix given.\n Echo- severe lv DYSFXN W/ EF 20%\n Peripheral vascular disease (PVD) with critical limb ischemia\n Assessment:\n S/P repair as above. LLE with DSD and ace wrap in place. Pulses by\n Doppler, continues on Heparin gtt.\n Action:\n Continues on Neo, Heparin, Versed and Fentanyl gtts with no change\n through the night.\n Response:\n Had a stable night, good ABG, some agitation with cares.\n Plan:\n Continue to monitor and treat as ordered.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains on vent with no change in settings, suctioned x 3 for thick\n white sec in small amounts. Lungs course, diminished in the bases.\n Action:\n Suctioned and turned as needed. ABG to monitor current settings.\n Response:\n Sats in high 90\ns, ABG WNL, suction as needed.\n Plan:\n Attempt to wean to PS and see if she can oxygenate well enough to wean\n towards extubation.\n"
},
{
"category": "Nursing",
"chartdate": "2160-02-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 436081,
"text": "Addenum: Shift cover 1900-2300\n No change in status. PTT therapeutic. No change in gtts and vent.\n Weaned NEO gtt to 1.0mcg/kg/min allowing goal map>60. albumin given.\n Con\nt monitor and support\n"
},
{
"category": "Respiratory ",
"chartdate": "2160-02-23 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 435120,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 42.3 None\n Ideal tidal volume: 169.2 / 253.8 / 338.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: 8 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Scant\n Comments: Pt was instilled with saline and suctioned, but nothing was\n retrieved. Lung sounds remained Rhonchrous\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing,\n Tachypneic (RR> 35 b/min)\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment: Frequent alarms (High pressure, High rate, High\n min. ventilation)\n Comments: When pt was first transferred from OR, Pt was very agitated\n and had low Blood Pressure, which hindered the application of\n sedation. When BP rose to normal limits, sedation was given, and pt\n was able to ventilate without issues.\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated, Reduce PEEP as tolerated, Increase ventilatory support at\n night; Comments: NO RSBI done due to high FiO2 demand. At end of\n shift, pt was sedated and able to mechanically ventilate with no\n issues.\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Intolerant of weaning attempts, Cannot protect airway, Cannot manage\n secretions; Comments: Pt still sedated, and should continue current\n vent support.\n"
},
{
"category": "Physician ",
"chartdate": "2160-02-23 00:00:00.000",
"description": "Intensivist Note",
"row_id": 435204,
"text": "CVICU\n HPI:\n HD2\n POD1 LLE embolectomy\n Cc: acute ischemic left foot, new onset of AF with abdominal ascites\n ? maligancy, partial SBO,and recent rt. parietal-occpit. infarct with\n stenosis 50-69%.\n PMH: negative\n PSH negative\n Plan: IV heparin, rescuscitation. f/u neuro cs and gyn c/s\n Current medications:\n 150 mEq Sodium Bicarbonate/ 1000 mL D5W 4. 500 ml NS 5. Albuterol\n 0.083% Neb Soln\n 6. Albuterol Inhaler 7. Aspirin 8. Calcium Gluconate 9. Chlorhexidine\n Gluconate 0.12% Oral Rinse\n 10. Famotidine 11. Fentanyl Citrate 12. Heparin 13. 14. Influenza Virus\n Vaccine 15. Magnesium Sulfate\n 16. Metoprolol Tartrate 17. Nitroglycerin Ointment 2% 18. Phenylephrine\n 19. Pneumococcal Vac Polyvalent\n 20. Potassium Chloride 21. Propofol 22. Sodium Chloride 0.9% Flush\n 24 Hour Events:\n OR RECEIVED - At 09:38 PM\n INVASIVE VENTILATION - START 09:38 PM\n ARTERIAL LINE - START 09:43 PM\n INTUBATION - At 09:51 PM\n MULTI LUMEN - START 12:00 AM\n left I.J. quad palced by vascular md.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 850 units/hour\n Phenylephrine - 1 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 07:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.3\nC (97.4\n T current: 36.3\nC (97.4\n HR: 74 (65 - 117) bpm\n BP: 95/56(71) {79/46(59) - 122/73(93)} mmHg\n RR: 14 (14 - 20) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 58.2 kg (admission): 50 kg\n Height: 58 Inch\n CVP: 13 (-3 - 27) mmHg\n Total In:\n 76 mL\n 5,525 mL\n PO:\n Tube feeding:\n IV Fluid:\n 76 mL\n 5,525 mL\n Blood products:\n Total out:\n 33 mL\n 293 mL\n Urine:\n 33 mL\n 293 mL\n NG:\n Stool:\n Drains:\n Balance:\n 43 mL\n 5,232 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 551 (551 - 551) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n RSBI Deferred: FiO2 > 60%\n PIP: 40 cmH2O\n Plateau: 32 cmH2O\n SPO2: 99%\n ABG: 7.51/31/160/24/2\n Ve: 7.3 L/min\n PaO2 / FiO2: 267\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Trace), (Temperature: Cool), (Pulse -\n Dorsalis pedis: Absent), (Pulse - Posterior tibial: Absent)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Moves all extremities, Sedated\n Labs / Radiology\n 256 K/uL\n 11.9 g/dL\n 92 mg/dL\n 0.9 mg/dL\n 24 mEq/L\n 4.2 mEq/L\n 21 mg/dL\n 100 mEq/L\n 131 mEq/L\n 32.7 %\n 18.5 K/uL\n [image002.jpg]\n 10:29 PM\n 10:39 PM\n 04:50 AM\n 05:02 AM\n WBC\n 20.9\n 18.5\n Hct\n 30.4\n 32.7\n Plt\n 239\n 256\n Creatinine\n 0.8\n 0.9\n TCO2\n 30\n 26\n Glucose\n 83\n 92\n 92\n Other labs: PT / PTT / INR:15.0/71.0/1.3, CK / CK-MB / Troponin\n T://, ALT / AST:132/297, Alk-Phos / T bili:108/0.4, Lactic\n Acid:1.1 mmol/L, Albumin:1.7 g/dL, Ca:6.6 mg/dL, Mg:1.3 mg/dL, PO4:3.5\n mg/dL\n Assessment and Plan\n PERIPHERAL VASCULAR DISEASE (PVD) WITH CRITICAL LIMB ISCHEMIA, .H/O\n HYPERTENSION, BENIGN\n Neurologic: Neuro checks Q: 1 hr, Follow Neurology Rec's and cont Neuro\n checks; Cont Sedation with PPF and Fent PRN\n Cardiovascular: Aspirin, Full anticoagulation, Beta-blocker, Afib -->\n cont low dose lopressor for rate control; Post-op Hypotension --> cont\n Neo gtt for MAP > 60\n Pulmonary: Cont ETT, (Ventilator mode: CMV)\n Gastrointestinal / Abdomen: OGT; c/o acute liver failure\n primary team\n to obtain outside hospital CT\n Nutrition: NPO\n Renal: Foley, Elevated CPK's and Rhabdomyolysis --> agree with\n aggressive hydration and forced diuresis and alkalinization.\n Hyponatremia --> probably SIADH --> will free H2O restrict and cont\n normal tonic fluids and follow --> may need to add lasix.\n Hematology: Hct with mild anemia --> cont to follow\n Endocrine: RISS\n Infectious Disease: No infectious issues at this time.\n Lines / Tubes / Drains: Foley, ETT\n Wounds: Dry dressings\n Imaging: CT scan head today\n Fluids: Bicarbonate infusion.\n Consults: Vascular surgery, Neurology\n Billing Diagnosis: Post-op hypotension\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 09:43 PM\n Multi Lumen - 12:00 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin drip)\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 32 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2160-02-23 00:00:00.000",
"description": "ICU Note - CVI",
"row_id": 435210,
"text": "CVICU\n HPI:\n HD2\n POD1 LLE embolectomy\n Cc: acute ischemic left foot, new onset of AF with abdominal ascites\n ? maligancy, partial SBO,and recent rt. parietal-occpit. infarct with\n stenosis 50-69%.\n PMH: negative\n PSH negative\n Plan: IV heparin, rescuscitation. f/u neuro cs and gyn c/s\n Current medications:\n 150 mEq Sodium Bicarbonate/ 1000 mL D5W Albuterol 0.083% Neb Soln\n Albuterol Inhaler . Aspirin. Calcium Gluconate . Chlorhexidine\n Gluconate 0.12% Oral Rinse . Famotidine . Fentanyl Citrate . Heparin .\n . Influenza Virus Vaccine . Magnesium Sulfate Metoprolol Tartrate .\n Nitroglycerin Ointment 2%. Phenylephrine . Pneumococcal Vac Polyvalent\n Potassium Chloride. Propofol. Sodium Chloride 0.9% Flush\n 24 Hour Events:\n OR RECEIVED - At 09:38 PM\n ARTERIAL LINE - START 09:43 PM\n INTUBATION - At 09:51 PM\n NASAL SWAB - At 12:00 AM\n MULTI LUMEN - START 12:00 AM\n left sub clavian quad placed by vascular md\n Post operative day:\n POD # 1- LT fem embolectomy, Fasciotomies\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Phenylephrine - 1 mcg/Kg/min\n Heparin Sodium - 900 units/hour\n Propofol - 50 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 10:00 AM\n Other medications:\n Flowsheet Data as of 11:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.3\nC (97.4\n T current: 36.2\nC (97.1\n HR: 97 (65 - 117) bpm\n BP: 97/57(74) {79/46(59) - 122/73(93)} mmHg\n RR: 14 (12 - 22) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 58.2 kg (admission): 50 kg\n Height: 58 Inch\n CVP: 17 (-3 - 27) mmHg\n Total In:\n 76 mL\n 9,347 mL\n PO:\n Tube feeding:\n IV Fluid:\n 76 mL\n 9,347 mL\n Blood products:\n Total out:\n 33 mL\n 396 mL\n Urine:\n 33 mL\n 396 mL\n NG:\n Stool:\n Drains:\n Balance:\n 43 mL\n 8,951 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 451 (450 - 551) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: FiO2 > 60%\n PIP: 37 cmH2O\n Plateau: 32 cmH2O\n SPO2: 97%\n ABG: 7.40/37/109/24/0\n Ve: 6.8 L/min\n PaO2 / FiO2: 218\n Physical Examination\n General Appearance: No acute distress, sedated\n HEENT: PERRL\n Cardiovascular: (Rhythm: Irregular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Wheezes :\n bilat.), (Sternum: Stable )\n Abdominal: Distended\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Cool), (Pulse -\n Dorsalis pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Responds to: Noxious stimuli), Sedated\n Labs / Radiology\n 256 K/uL\n 11.9 g/dL\n 97 mg/dL\n 0.9 mg/dL\n 24 mEq/L\n 3.5 mEq/L\n 21 mg/dL\n 100 mEq/L\n 131 mEq/L\n 32.7 %\n 18.5 K/uL\n [image002.jpg]\n 10:29 PM\n 10:39 PM\n 04:50 AM\n 05:02 AM\n 08:11 AM\n 11:20 AM\n WBC\n 20.9\n 18.5\n Hct\n 30.4\n 32.7\n Plt\n 239\n 256\n Creatinine\n 0.8\n 0.9\n TCO2\n 30\n 26\n 26\n 24\n Glucose\n 83\n 92\n 92\n 88\n 97\n Other labs: PT / PTT / INR:15.0/71.0/1.3, CK / CK-MB / Troponin\n T://, ALT / AST:132/297, Alk-Phos / T bili:108/0.4, Lactic\n Acid:0.7 mmol/L, Albumin:1.7 g/dL, Ca:6.6 mg/dL, Mg:2.8 mg/dL, PO4:3.5\n mg/dL\n Imaging: CT head and abd/pelvis today. Echocardiogram\n Assessment and Plan\n PERIPHERAL VASCULAR DISEASE (PVD) WITH CRITICAL LIMB ISCHEMIA, .H/O\n HYPERTENSION, BENIGN\n Assessment and Plan: Remains unresponsive to commands. Thrashing when\n sedation off.\n Neurologic: Neuro checks Q: 1 hr\n Cardiovascular: Full anticoagulation\n Pulmonary: Cont ETT, (Ventilator mode: CMV)\n Gastrointestinal / Abdomen:\n Nutrition: NPO\n Renal: Foley, Adequate UO, alkalinize urine, flush kidnies of myoglobin\n Endocrine: RISS\n Lines / Tubes / Drains: Foley, OGT, ETT\n Wounds: Dry dressings\n Imaging: CT scan head today, CT scan abd today\n Fluids: Other, 150mEq NaHCO3/NS at 125cc/hr\n Consults: Gynecology\n ICU Care\n Glycemic Control: Regular insulin sliding scale\n Arterial Line - 09:43 PM\n Multi Lumen - 12:00 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin drip)\n Stress ulcer: PPI\n VAP bundle: Mouth care\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2160-02-24 00:00:00.000",
"description": "Intensivist Note",
"row_id": 435360,
"text": "CVICU\n HPI:\n HD3\n POD#2 LLE embolectomy\n Cc: acute ischemic left foot, new onset of AF with abdominal ascites\n ? maligancy, partial SBO,and recent rt. parietal-occpit. infarct with\n stenosis 50-69%.\n PMH: negative\n PSH negative\n Plan: IV heparin, rescuscitation. f/u neuro cs and gyn c/s\n Chief complaint:\n PMHx:\n Current medications:\n Albuterol 0.083% Neb Soln 4. Albuterol Inhaler 5. Aspirin 6.\n Chlorhexidine Gluconate 0.12% Oral Rinse\n 7. Famotidine 8. Fentanyl Citrate 9. Heparin 10. 11. Influenza Virus\n Vaccine 12. Magnesium Sulfate\n 13. Metoprolol Tartrate 14. Nitroglycerin Ointment 2% 15. Phenylephrine\n 16. Pneumococcal Vac Polyvalent\n 17. Potassium Chloride 18. Propofol 19. Sodium Chloride 0.9% Flush\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 12:00 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Phenylephrine - 0.8 mcg/Kg/min\n Heparin Sodium - 900 units/hour\n Other ICU medications:\n Famotidine (Pepcid) - 12:00 AM\n Other medications:\n Flowsheet Data as of 07:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.1\nC (98.7\n T current: 37.1\nC (98.7\n HR: 97 (67 - 103) bpm\n BP: 109/55(74) {90/50(65) - 136/71(92)} mmHg\n RR: 19 (12 - 24) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 69.8 kg (admission): 50 kg\n Height: 58 Inch\n CVP: 292 (9 - 319) mmHg\n Total In:\n 12,891 mL\n 2,349 mL\n PO:\n Tube feeding:\n IV Fluid:\n 12,081 mL\n 2,349 mL\n Blood products:\n Total out:\n 1,049 mL\n 92 mL\n Urine:\n 699 mL\n 92 mL\n NG:\n 350 mL\n Stool:\n Drains:\n Balance:\n 11,842 mL\n 2,257 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 451 (450 - 451) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 157\n PIP: 30 cmH2O\n Plateau: 27 cmH2O\n SPO2: 97%\n ABG: 7.39/38/168/23/-1\n Ve: 7.4 L/min\n PaO2 / FiO2: 336\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: Bilat bases)\n Abdominal: Soft, Non-tender, Distended\n Left Extremities: (Edema: 2+), (Temperature: Cool), (Pulse - Dorsalis\n pedis: Absent), (Pulse - Posterior tibial: Absent)\n Right Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Neurologic: Moves all extremities, Sedated\n Labs / Radiology\n 250 K/uL\n 11.9 g/dL\n 86 mg/dL\n 1.1 mg/dL\n 23 mEq/L\n 4.0 mEq/L\n 21 mg/dL\n 105 mEq/L\n 135 mEq/L\n 34.2 %\n 12.7 K/uL\n [image002.jpg]\n 10:39 PM\n 04:50 AM\n 05:02 AM\n 08:11 AM\n 11:20 AM\n 12:26 PM\n 05:29 PM\n 09:04 PM\n 09:12 PM\n 03:11 AM\n WBC\n 18.5\n 16.9\n 12.7\n Hct\n 32.7\n 34.6\n 34.2\n Plt\n \n Creatinine\n 0.9\n 1.0\n 1.1\n TCO2\n 30\n 26\n 26\n 24\n 25\n 24\n Glucose\n 92\n 92\n 88\n 97\n 113\n 127\n 104\n 103\n 86\n Other labs: PT / PTT / INR:14.0/66.7/1.2, CK / CK-MB / Troponin\n T:5942//, ALT / AST:175/302, Alk-Phos / T bili:112/0.3, Lactic Acid:1.4\n mmol/L, Albumin:1.5 g/dL, Ca:6.9 mg/dL, Mg:2.0 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n CVA (STROKE, CEREBRAL INFARCTION), ISCHEMIC , PERIPHERAL VASCULAR\n DISEASE (PVD) WITH CRITICAL LIMB ISCHEMIA\n Assessment and Plan:\n Neurologic: PPF for sedation; Fentanyl for pain. F/U with neurology\n rec's.\n Cardiovascular: Aspirin, Hypotension post-op --> cont neo gtt.\n Pulmonary: Cont ETT, (Ventilator mode: CMV)\n Gastrointestinal / Abdomen: F/U with OB/Gyn consults today.\n Nutrition: NPO\n Renal: Foley, Rhabdomyolysis --> would cont volume resuscitation and\n consider start Mannitol or lasix to augment and force diruesis,\n however, CK is now < 6000, but has cont'd to be severely oliguric.\n Hematology: Mod anemia.\n Endocrine: RISS\n Infectious Disease: No infections currently\n Lines / Tubes / Drains: Foley, OGT, ETT\n Wounds:\n Imaging: CXR today\n Fluids: Bicarb infusion\n Consults: Vascular surgery\n Billing Diagnosis: (Respiratory distress: Failure)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 09:43 PM\n Multi Lumen - 12:00 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin drip)\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 32 minutes\n Patient is critically ill\n"
},
{
"category": "Respiratory ",
"chartdate": "2160-03-03 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 436945,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 11\n Ideal body weight: 42.3 None\n Ideal tidal volume: 169.2 / 253.8 / 338.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 20 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: 8 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n :\n Comments: agitated,tachypneic, placed back on ac in effort to calm pt.\n"
},
{
"category": "Nursing",
"chartdate": "2160-03-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 437017,
"text": "Anxiety\n Assessment:\n Pt extremely agitated with periods escalating to pt thrashing head and\n arms around in bed despite fentanyl & versed gtts. Ativan 0.5mg PRN Q4\n also available and given.\n Pt @ possible risk for self-extubation and removal of Art\n line, as well as injuring BUE d/t friction and force of restraints\n against wrists\n Pt eyes are wide open and pt looks extremely uncomfortable.\n Pt not following commands or tracking\n MAE including LLE slightly.\n PERRL; 2mm brisk\n Pt becomes HTN and tachycardic with agitation\n Action:\n Gtts @ max dose\n 0.5mg Ativan given Q4\n PA called about pt extreme agitation and ?able neuro status\n No changes\n Response:\n Pt seemed to be more comfortable after Ativan given for short period ~2\n hrs except for nursing care (ie turning, suctioning).\n Ativan order increased to 1mg Q4\n Pt remained agitated despite being given 1mg ativan with\n last dose @ 0330\n Plan:\n Ativan 0.5-1 mg Q4\n Fentanly & Versed gtts cont overnight\n Vascular team would like sedation weaned down in AM\n"
},
{
"category": "Nursing",
"chartdate": "2160-03-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 437202,
"text": "Shock, hypovolemic or hemorrhagic\n Assessment:\n Pt extremely hypotensive; SR-ST with frequent PVCs (Vent\n bigeminy/trigeminy)\n Pt agitated, flailing arms around in bed and bucking ventilator\n Action:\n Labs sent (Hct 20 from 24 earlier on), Lytes low\n 1250 NS given\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2160-03-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 437245,
"text": "Shock, hypovolemic or hemorrhagic\n Assessment:\n Pt extremely hypotensive; SR-ST with frequent PVCs (Vent\n bigeminy/trigeminy)\n Pt agitated, flailing arms around in bed and bucking ventilator\n Abdomen pink, firm and distended, especially on LLQ\n Action:\n Labs sent (Hct 20 from 24 earlier on), Lytes low\n 1250cc NS bolus given total\n 2 units PRBCs given\n Transthoracic echo done @ bedside\n CXR done\n Neo gtt started and titrated ^\n Levophed gtt started\n Vasopressin gtt started and titrated ^\n BS ^ 355\n Response:\n Repeat Hct 31, lytes repleted\n Pressors maxed out\n TTE showed hemothorax on R side, normal cardiac function\n Heparin gtt stopped\n Coags checked\n No chest tube placed d/t coags (no reversals given)\n Radial art line stopped working on L side\n Unable to palpate pulses bilaterally \n Pts RLE dusky, dopplerable and warm\n Decision made for R femoral art line placement\n Short time after foot became cool, mottled and pulseless\n Unable to Doppler BLE\n Abdomen more firm, distended and mottled; lactate rising\n Wosening Acidoisis with difficulty ventilating pt\n Amp of Bicarb given\n Little change in acidoisis\n Insulin gtt started and titrated per BS\n Family called and notified of pts decomensation\n Husband (health care proxy) in hospital after stent placed\n (MI), gave verbal consent that his children were to make the final\n decisions in his wife\ns care to make sure that she was not in any pain.\n (myself and PA spoke with Mr on telephone)\n Plan:\n Family made decision to withdraw care and make pt \n Fentanyl IV and Versed IV given\n Pressors turned off\n Family @ bedside\n Family declined to have an autopsy performed\n Organ Bank called (declined for tissue donor )\n"
},
{
"category": "Nursing",
"chartdate": "2160-03-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 436676,
"text": "Respiratory failure, acute (not ARDS/) NEURO PT REMAINS\n AGITATED AT TIMES MAE AROUND BED ANGRY AND SEEMS TO BE IN PAIN NO\n COMMUNICATION RANDOM MOTION PLEASE SEE NOTES FOR DETAILS REMAINS ON\n FENT DRIP POOR EFFECT SUPP ATIVAN GIVEN FAIR RESULTS NOTED MD/PA AT\n BEDSIDE TO PT AND CONDITION ORDER CONT PRESENT PAIN INCREASE\n DOSE OF FENT AND ATIVAN IF NEEDED\n RESP ALT CMV VS CPAP/PS PENDING NEURO STATUS AND AGITATION ETT\n IN PLACE SCATTERED RHONCHI THRU OUT YELLOW RETURNS POSSIBLE T/F MD\n AWARE C/S SENT FREQ SUCTIONING DONE THRU SHIFT ABG ON CPAP 5/5 POOR\n VENTILATION CORRECTED ON CMV\n HEART S1S2 DISTANT TONES NSR TO ST PR .I6 QRS WNL .08 QT NORMAL\n OCC PAC LABS WNL VSS LOW BP ON OCC PENDING LEVEL OF SEDATION PULSES\n POS 2 THRU OUT\n GI NO B/S T/F RESIDUAL 250 FEEDING D/ MD/PA REQUEST FIRM\n ABD NO TENDOR ON PALPATIONS\n PLAN PT DNR AT THIS TIME SUPPORTIVE CARE BE CMO IN\n FUTURE RESP WEAN VENT IF POSSIBLE MAINTAIN NPO FOR\n HIGH RESIDUALS FAMILY SUPPORT MUTIPLE FAMILY MEETINGS NEEDED\n FAMILY WISHES AND MD WANTS VERY WIDE OPINIONS ETHIC TEAM MEETING \n BE NEEDED THIS OPION OF CARE FROM GRANDAUGHTER T/P PT CPT\n BACK CARE NEEDED\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2160-03-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 436771,
"text": "Hypotension (not Shock)\n Assessment:\n Pt continues to be difficult to sedate. Fentanyl drip continues at\n 50mcg/hr with boluses prn per PA for agitation. Pt will become\n hypertensive moving all over bed. Sats remain 98%, sbp 170\ns heart rate\n up to 130\ns with some rapi afib/st/pac\ns. Heparin drip remains at 1100\n units/hr.\n Action:\n Ativan given .25mg, and an extra dose of .25mg per Pa . Lytes\n repleted. Extra dose of lopressor given 5mg.\n Response:\n Pt becomes sedated with rr 8, sbp drops to 70\ns. Then pt will become\n restless when medication wears off. Briefly started on neo for bp\n support now off. Ptt 80, no changes made. Pa aware.\n Plan:\n Fentanyl continues for pain mgmt, prn ativan q4 hours .5mg., and\n lopressor changed to 5mg q4hours.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains orally intubated on cpap 35% 5 peep 12 pressure support. SX\n thick yellow secretions. Tube feeds stopped due to 250cc out of og\n tube. Tpn ordered.\n Action:\n Response:\n Plan:\n Ineffective Coping\n Assessment:\n Pt\ns granddaughter is spokesperson at this time due to husband in rehab\n facility. Muiltiple family meetings in chart due to ? plan of care.\n Action:\n Granddaughter had numerous questions about trach, and end of life\n discussions. Pa spoke with granddaughter over phone, and\n informed to call DR. \ns office to further discuss poc.\n Response:\n Plan:\n Family meeting Tuesday.\n"
},
{
"category": "Respiratory ",
"chartdate": "2160-03-03 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 436843,
"text": "TITLE:\n Demographics\n Day of intubation: \n Day of mechanical ventilation: 11\n Ideal body weight: 42.3\n Ideal tidal volume: 169.2 / 253.8 / 338.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 20 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 8 mL /\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: PSV 12/5/.35\n Visual assessment of breathing pattern: Accessory muscle use\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment: Vigorous inspiratory efforts\n Comments: occ short bouts of tachypnea\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Underlying illness not resolved\n Comments: RSBI 98\n"
},
{
"category": "Respiratory ",
"chartdate": "2160-03-04 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 437007,
"text": "Demographics\n Day of intubation: 12\n Day of mechanical ventilation: 12\n Ideal body weight: 42.3 None\n Ideal tidal volume: 169.2 / 253.8 / 338.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 20 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 7 mL / Air\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Scant\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Tracheostomy planned; Comments: Unable to complete\n RSBI d/t tachypnea >40.\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Underlying illness not resolved\n"
},
{
"category": "Nursing",
"chartdate": "2160-03-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 436674,
"text": "Respiratory failure, acute (not ARDS/) NEURO PT REMAINS\n AGITATED AT TIMES MAE AROUND BED ANGRY AND SEEMS TO BE IN PAIN NO\n COMMUNICATION RANDOM MOTION PLEASE SEE NOTES FOR DETAILS REMAINS ON\n FENT DRIP POOR EFFECT SUPP ATIVAN GIVEN FAIR RESULTS NOTED MD/PA AT\n BEDSIDE TO PT AND CONDITION ORDER CONT PRESENT PAIN INCREASE\n DOSE OF FENT AND ATIVAN IF NEEDED\n RESP ALT CMV VS CPAP/PS PENDING NEURO STATUS AND AGITATION ETT\n IN PLACE SCATTERED RHONCHI THRU OUT YELLOW RETURNS POSSIBLE T/F MD\n AWARE C/S SENT FREQ SUCTIONING DONE THRU SHIFT ABG ON CPAP 5/5 POOR\n VENTILATION CORRECTED ON CMV\n HEART S1S2 DISTANT TONES NSR TO ST PR .I6 QRS WNL .08 QT NORMAL\n OCC PAC LABS WNL VSS LOW BP ON OCC PENDING LEVEL OF SEDATION PULSES\n POS 2 THRU OUT\n GI NO B/S T/F RESIDUAL 250 FEEDING D/ MD/PA REQUEST FIRM\n ABD NO TENDOR ON PALPATIONS\n PLAN PT DNR AT THIS TIME SUPPORTIVE CARE BE CMO IN\n FUTURE RESP WEAN VENT IF POSSIBLE MAINTAIN NPO FOR\n HIGH RESIDUALS FAMILY SUPPORT MUTIPLE FAMILY MEETINGS NEEDED\n FAMILY WISHES AND MD WANTS VERY WIDE OPINIONS ETHIC TEAM MEETING \n BE NEEDED THIS OPION OF CARE FROM GRANDAUGHTER T/P PT CPT\n BACK CARE NEEDED\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2160-03-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 436969,
"text": "Atrial fibrillation (Afib)\n Assessment:\n RAF 140\ns, hypotensive 89/72\n Action:\n Bolus\ns of lopressor given as ordered and neo gtt started and titrated\n for SBP>90\n Response:\n Rate controlled AF 70\nconverted to SR 60\ns-70\ns, SBP>90\n Plan:\n Monitor VS, continue with Lopressor 7.5 mg q4 hours, ween off Neo as\n tolerated\n Anxiety\n Assessment:\n Patient thrashing in bed, hypertensive (152/68-165/71), tachycardic\n (101) NSR\nRAF 140\ns, and tachypneic (33-40) on CPAP\n Action:\n Ativan, Hydralazine, and lopressor given as ordered. Started on\n versed. RT put patient back on a RR 16, ABG obtained.\n Response:\n Patient very calm, stopped thrashing, appears to be resting\n comfortably, SBP > 90, MAP 60, HR 60\ns ABG slightly alkalotic (7.47)\n but otherwise WNL\n Plan:\n Plan to wake and ween after family meeting ?? Tuesday? Awaiting\n cytology results. Maintain adequate VS and provide emotional support.\n"
},
{
"category": "Nursing",
"chartdate": "2160-03-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 437003,
"text": "Anxiety\n Assessment:\n Pt extremely agitated with periods escalating to pt thrashing head and\n arms around in bed despite fentanyl & versed gtts. Ativan 0.5mg PRN Q4\n also available and given.\n Pt eyes are wide open and pt looks extremely uncomfortable.\n Pt not following commands however has MAE including LLE slightly.\n Action:\n Gtts @ max dose and 0.5mg Ativan given Q4.\n Response:\n Pt seemed to be more comfortable after Ativan given for short period ~2\n hrs except for nursing care (ie turning, suctioning)\n Plan:\n Ativan ordered changed per PA to 0.5-1mg Q4.\n Vascular team would like sedation weaned down in AM to see how pt\n responds.\n Hypotension (not Shock)\n Assessment:\n When pt not agitated SBP as low as 70s\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2160-03-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 436675,
"text": "Respiratory failure, acute (not ARDS/) NEURO PT REMAINS\n AGITATED AT TIMES MAE AROUND BED ANGRY AND SEEMS TO BE IN PAIN NO\n COMMUNICATION RANDOM MOTION PLEASE SEE NOTES FOR DETAILS REMAINS ON\n FENT DRIP POOR EFFECT SUPP ATIVAN GIVEN FAIR RESULTS NOTED MD/PA AT\n BEDSIDE TO PT AND CONDITION ORDER CONT PRESENT PAIN INCREASE\n DOSE OF FENT AND ATIVAN IF NEEDED\n RESP ALT CMV VS CPAP/PS PENDING NEURO STATUS AND AGITATION ETT\n IN PLACE SCATTERED RHONCHI THRU OUT YELLOW RETURNS POSSIBLE T/F MD\n AWARE C/S SENT FREQ SUCTIONING DONE THRU SHIFT ABG ON CPAP 5/5 POOR\n VENTILATION CORRECTED ON CMV\n HEART S1S2 DISTANT TONES NSR TO ST PR .I6 QRS WNL .08 QT NORMAL\n OCC PAC LABS WNL VSS LOW BP ON OCC PENDING LEVEL OF SEDATION PULSES\n POS 2 THRU OUT\n GI NO B/S T/F RESIDUAL 250 FEEDING D/ MD/PA REQUEST FIRM\n ABD NO TENDOR ON PALPATIONS\n PLAN PT DNR AT THIS TIME SUPPORTIVE CARE BE CMO IN\n FUTURE RESP WEAN VENT IF POSSIBLE MAINTAIN NPO FOR\n HIGH RESIDUALS FAMILY SUPPORT MUTIPLE FAMILY MEETINGS NEEDED\n FAMILY WISHES AND MD WANTS VERY WIDE OPINIONS ETHIC TEAM MEETING \n BE NEEDED THIS OPION OF CARE FROM GRANDAUGHTER T/P PT CPT\n BACK CARE NEEDED\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2160-03-04 00:00:00.000",
"description": "ICU Note - CVI",
"row_id": 437052,
"text": "CVICU\n HPI:\n POD 11\n 71F s/p LLE embolectomy, 2 compartment fasciotomies\n Cc: acute ischemic left foot, new onset of PAF\n ?? partial SBO,and recent rt. parietal-occpit. infarct with \n stenosis 50-69%.\n Cr:0.9 Wt:50kg EF 20%\n PMH: negative\n Plan:Ascites Cytology Pos for malig. adeno (prob. ovarian). Large B\n pleural eff.- ?? tap for dx. Vigileo placed- CI >2.5- Lasix given.\n Echo- severe LV dysfxn EF 20%\n 1/19- agitated/thrashing/htn/tachypnic, versed added, changed to CMV.\n recurrent AF.Pleural cytol P from .\n Cont. to vomit TF->d/c'd and TPN started. Cont. to drop Hct->\n Protonix . Cont. Hep per vascular.\n Dr. to talk to family on Tues.\n ***Pt. is DNR only- pt.'s husband has agreed to reintubation if\n necessary.***\n Current medications:\n Albuterol Inhaler, Aspirin, Chlorhexidine Gluconate 0.12% Oral Rinse,\n Clonidine Patch 0.1 mg/24 hr, Fentanyl gtt, Furosemide, Heparin gtt,\n HydrALAzine, Insulin sq, Ipratropium Bromide MDI, Lorazepam, Metoprolol\n Tartrate, Midazolam gtt, Pantoprazole, Phenylephrine gtt\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Heparin Sodium - 1,100 units/hour\n Other ICU medications:\n Hydralazine - 10:30 AM\n Pantoprazole (Protonix) - 07:43 PM\n Metoprolol - 08:00 PM\n Furosemide (Lasix) - 02:00 AM\n Lorazepam (Ativan) - 03:36 AM\n Other medications:\n Flowsheet Data as of 06:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.4\nC (99.4\n T current: 36.9\nC (98.4\n HR: 86 (57 - 148) bpm\n BP: 130/51(75) {82/40(53) - 165/71(101)} mmHg\n RR: 17 (8 - 36) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 70.5 kg (admission): 50 kg\n Height: 58 Inch\n CVP: 10 (6 - 23) mmHg\n Total In:\n 2,056 mL\n 585 mL\n PO:\n Tube feeding:\n IV Fluid:\n 1,055 mL\n 313 mL\n Blood products:\n Total out:\n 3,055 mL\n 1,695 mL\n Urine:\n 3,055 mL\n 1,245 mL\n NG:\n 450 mL\n Stool:\n Drains:\n Balance:\n -999 mL\n -1,110 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 451 (451 - 451) mL\n Vt (Spontaneous): 555 (500 - 555) mL\n PS : 12 cmH2O\n RR (Set): 16\n RR (Spontaneous): 4\n PEEP: 5 cmH2O\n FiO2: 35%\n RSBI Deferred: RR >35\n PIP: 22 cmH2O\n Plateau: 19 cmH2O\n SPO2: 97%\n ABG: 7.40/44/92./26/1\n Ve: 8.6 L/min\n PaO2 / FiO2: 266\n Physical Examination\n General Appearance: No(t) No acute distress, Anxious\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: No(t) CTA\n bilateral : , Crackles : , Rhonchorous : )\n Abdominal: Soft, Non-distended, Non-tender, no bowel sounds\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Neurologic: (Responds to: Tactile stimuli), No(t) Moves all\n extremities, (LLE: No movement), Sedated\n Labs / Radiology\n 506 K/uL\n 8.2 g/dL\n 120 mg/dL\n 2.1 mg/dL\n 26 mEq/L\n 4.5 mEq/L\n 53 mg/dL\n 103 mEq/L\n 138 mEq/L\n 23.2 %\n 10.9 K/uL\n [image002.jpg]\n 08:24 AM\n 02:28 PM\n 02:39 PM\n 12:51 AM\n 01:04 AM\n 08:30 AM\n 12:22 PM\n 10:45 PM\n 02:53 AM\n 03:07 AM\n WBC\n 7.1\n 10.9\n Hct\n 23.6\n 21.4\n 26\n 23.2\n Plt\n 364\n 506\n Creatinine\n 2.2\n 2.1\n TCO2\n 27\n 28\n 29\n 26\n 28\n Glucose\n 82\n 145\n 141\n 117\n 162\n 139\n 120\n Other labs: PT / PTT / INR:15.8/77.5/1.4, CK / CK-MB / Troponin\n T:571/16/, ALT / AST:32/17, Alk-Phos / T bili:127/0.4, Lactic Acid:1.2\n mmol/L, Albumin:2.3 g/dL, Ca:8.6 mg/dL, Mg:2.4 mg/dL, PO4:5.1 mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), ANXIETY, INEFFECTIVE COPING, PLEURAL\n EFFUSION, CHRONIC, NAUSEA / VOMITING, HYPERTENSION, BENIGN, RESPIRATORY\n FAILURE, ACUTE (NOT ARDS/), HYPOCALCEMIA (LOW CALCIUM), HYPOKALEMIA\n (LOW POTASSIUM, HYPOPOTASSEMIA), CANCER (MALIGNANT NEOPLASM),\n GYNECOLOGICAL (OVARIAN, UTERINE, CERVICAL, ENDOMETRIAL), PROBLEM\n - ENTER DESCRIPTION IN COMMENTS, ALTERATION IN NUTRITION, IMPAIRED SKIN\n INTEGRITY, RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF), HYPOTENSION\n (NOT SHOCK), ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS,\n SEIZURES), PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN), CVA (STROKE,\n CEREBRAL INFARCTION), ISCHEMIC , PERIPHERAL VASCULAR DISEASE (PVD) WITH\n CRITICAL LIMB ISCHEMIA\n Assessment and Plan: Planned family meeting today to discuss\n respiratory status, ? extubation, long term goals of care\n Neurologic: Pain controlled, Restraints, On midazolam and fentanyl\n infusions. She continues to be agitated.\n Cardiovascular: Aspirin, Full anticoagulation, Beta-blocker\n Pulmonary: Cont ETT, (Ventilator mode: CMV), CMV overnight to see if it\n would help with agitation\n Gastrointestinal / Abdomen: Tube feeds stopped because of continued\n vomiting. Heme positive stool so started PPI.\n Nutrition: TPN\n Renal: Foley, Adequate UO\n Hematology: Moderate anemia, Hct trending up\n Will continue to follow\n Endocrine: RISS\n Infectious Disease: no issues\n Lines / Tubes / Drains: Foley, OGT\n Wounds: Dry dressings\n Imaging:\n Fluids: KVO\n Consults: Vascular surgery, Hem / Onc , Gynecology\n ICU Care\n Nutrition:\n TPN without Lipids - 05:22 PM 41. mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 09:43 PM\n Multi Lumen - 12:00 AM\n PICC Line - 09:31 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin drip)\n Stress ulcer: H2 blocker\n VAP bundle: Chlorhexidine oral, HOB at 30 degrees\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: DNR (do not resuscitate)\n Disposition: ICU\n Time spent :\n"
},
{
"category": "Physician ",
"chartdate": "2160-03-04 00:00:00.000",
"description": "ICU Note - CVI",
"row_id": 437062,
"text": "CVICU\n HPI:\n POD 11\n 71F s/p LLE embolectomy, 2 compartment fasciotomies\n Cc: acute ischemic left foot, new onset of PAF\n ?? partial SBO,and recent rt. parietal-occpit. infarct with \n stenosis 50-69%.\n Cr:0.9 Wt:50kg EF 20%\n PMH: negative\n Plan:Ascites Cytology Pos for malig. adeno (prob. ovarian). Large B\n pleural eff.- ?? tap for dx. Vigileo placed- CI >2.5- Lasix given.\n Echo- severe LV dysfxn EF 20%\n 1/19- agitated/thrashing/htn/tachypnic, versed added, changed to CMV.\n recurrent AF.Pleural cytol P from .\n Cont. to vomit TF->d/c'd and TPN started. Cont. to drop Hct->\n Protonix . Cont. Hep per vascular.\n Dr. to talk to family on Tues.\n ***Pt. is DNR only- pt.'s husband has agreed to reintubation if\n necessary.***\n Current medications:\n Albuterol Inhaler, Aspirin, Chlorhexidine Gluconate 0.12% Oral Rinse,\n Clonidine Patch 0.1 mg/24 hr, Fentanyl gtt, Furosemide, Heparin gtt,\n HydrALAzine, Insulin sq, Ipratropium Bromide MDI, Lorazepam, Metoprolol\n Tartrate, Midazolam gtt, Pantoprazole, Phenylephrine gtt\n 24 Hour Events:\n Cont Diuresis.\n Changed to CMV due to agitation.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Heparin Sodium - 1,100 units/hour\n Other ICU medications:\n Hydralazine - 10:30 AM\n Pantoprazole (Protonix) - 07:43 PM\n Metoprolol - 08:00 PM\n Furosemide (Lasix) - 02:00 AM\n Lorazepam (Ativan) - 03:36 AM\n Other medications:\n Flowsheet Data as of 06:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.4\nC (99.4\n T current: 36.9\nC (98.4\n HR: 86 (57 - 148) bpm\n BP: 130/51(75) {82/40(53) - 165/71(101)} mmHg\n RR: 17 (8 - 36) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 70.5 kg (admission): 50 kg\n Height: 58 Inch\n CVP: 10 (6 - 23) mmHg\n Total In:\n 2,056 mL\n 585 mL\n PO:\n Tube feeding:\n IV Fluid:\n 1,055 mL\n 313 mL\n Blood products:\n Total out:\n 3,055 mL\n 1,695 mL\n Urine:\n 3,055 mL\n 1,245 mL\n NG:\n 450 mL\n Stool:\n Drains:\n Balance:\n -999 mL\n -1,110 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 451 (451 - 451) mL\n Vt (Spontaneous): 555 (500 - 555) mL\n PS : 12 cmH2O\n RR (Set): 16\n RR (Spontaneous): 4\n PEEP: 5 cmH2O\n FiO2: 35%\n RSBI Deferred: RR >35\n PIP: 22 cmH2O\n Plateau: 19 cmH2O\n SPO2: 97%\n ABG: 7.40/44/92 /26/1\n Ve: 8.6 L/min\n PaO2 / FiO2: 266\n Physical Examination\n General Appearance: No(t) No acute distress, Anxious\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Wheezes\n Bilat, Crackles : , Rhonchorous : )\n Abdominal: Soft, Mild distended, Non-tender, no bowel sounds\n Left Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Neurologic: (Responds to: Tactile stimuli), Moves all extremities\n except (LLE: No movement), Follows Commands this AM.\n Labs / Radiology\n 506 K/uL\n 8.2 g/dL\n 120 mg/dL\n 2.1 mg/dL\n 26 mEq/L\n 4.5 mEq/L\n 53 mg/dL\n 103 mEq/L\n 138 mEq/L\n 23.2 %\n 10.9 K/uL\n [image002.jpg]\n 08:24 AM\n 02:28 PM\n 02:39 PM\n 12:51 AM\n 01:04 AM\n 08:30 AM\n 12:22 PM\n 10:45 PM\n 02:53 AM\n 03:07 AM\n WBC\n 7.1\n 10.9\n Hct\n 23.6\n 21.4\n 26\n 23.2\n Plt\n 364\n 506\n Creatinine\n 2.2\n 2.1\n TCO2\n 27\n 28\n 29\n 26\n 28\n Glucose\n 82\n 145\n 141\n 117\n 162\n 139\n 120\n Other labs: PT / PTT / INR:15.8/77.5/1.4, CK / CK-MB / Troponin\n T:571/16/, ALT / AST:32/17, Alk-Phos / T bili:127/0.4, Lactic Acid:1.2\n mmol/L, Albumin:2.3 g/dL, Ca:8.6 mg/dL, Mg:2.4 mg/dL, PO4:5.1 mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), ANXIETY, INEFFECTIVE COPING, PLEURAL\n EFFUSION, CHRONIC, NAUSEA / VOMITING, HYPERTENSION, BENIGN, RESPIRATORY\n FAILURE, ACUTE (NOT ARDS/), HYPOCALCEMIA (LOW CALCIUM), HYPOKALEMIA\n (LOW POTASSIUM, HYPOPOTASSEMIA), CANCER (MALIGNANT NEOPLASM),\n GYNECOLOGICAL (OVARIAN, UTERINE, CERVICAL, ENDOMETRIAL), PROBLEM\n - ENTER DESCRIPTION IN COMMENTS, ALTERATION IN NUTRITION, IMPAIRED SKIN\n INTEGRITY, RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF), HYPOTENSION\n (NOT SHOCK), ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS,\n SEIZURES), PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN), CVA (STROKE,\n CEREBRAL INFARCTION), ISCHEMIC , PERIPHERAL VASCULAR DISEASE (PVD) WITH\n CRITICAL LIMB ISCHEMIA\n Assessment and Plan: Planned family meeting today to discuss\n respiratory status, extubation, long term goals of care\n Neurologic: Pain controlled, Restraints, On midazolam and fentanyl\n infusions. She continues to be agitated\n will start Zyprexa and\n Haldol PRN and try to wean Versed as tolerated.\n Cardiovascular: Aspirin, Full anticoagulation, Beta-blocker\n Pulmonary: Cont ETT, (Ventilator mode: CMV),\n reattempt CPAP/PS this\n AM\n Gastrointestinal / Abdomen: Tube feeds stopped because of continued\n vomiting. Heme positive stool so started PPI\n change back to QD and\n follow Hct.\n Nutrition: TPN per surgery\n decrease Phos and add Folate/Thiamine\n Renal: Foley, Adequate UO\n will decrease Lasix to given increased\n BUN and change goal to euvolemia.\n Hematology: Severe anemia,\n Will tx 1 unit today and cont to follow;\n Cont Heparin gtt.\n Endocrine: RISS\n Infectious Disease: no issues\n Lines / Tubes / Drains: Foley, OGT\n Wounds: Dry dressings\n Imaging: Repeat CXR today.\n Fluids: KVO\n Consults: Vascular surgery, Hem / Onc , Gynecology\n ICU Care\n Nutrition:\n TPN without Lipids - 05:22 PM 41. mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 09:43 PM\n Multi Lumen - 12:00 AM\n PICC Line - 09:31 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin drip)\n Stress ulcer: H2 blocker\n VAP bundle: Chlorhexidine oral, HOB at 30 degrees\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: DNR (do not resuscitate)\n Disposition: ICU\n Time spent : 34\n"
},
{
"category": "Nursing",
"chartdate": "2160-03-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 436770,
"text": "Hypotension (not Shock)\n Assessment:\n Pt continues to be difficult to sedate. Fentanyl drip continues at\n 50mcg/hr with boluses prn per PA for agitation. Pt will become\n hypertensive moving all over bed. Sats remain 98%, sbp 170\ns heart rate\n up to 130\ns with some rapi afib/st/pac\n Action:\n Ativan given .25mg, and an extra dose of .25mg per Pa . Lytes\n repleted. Extra dose of lopressor given 5mg.\n Response:\n Pt becomes sedated with rr 8, sbp drops to 70\ns. Then pt will become\n restless when medication wears off. Briefly started on neo for bp\n support now off.\n Plan:\n Fentanyl continues for pain mgmt, prn ativan q4 hours .5mg., and\n lopressor changed to 5mg q4hours.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains orally intubated on cpap 35% 5 peep 12 pressure support. SX\n thick yellow secretions.\n Action:\n Response:\n Plan:\n"
},
{
"category": "Respiratory ",
"chartdate": "2160-03-04 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 437168,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 12\n Ideal body weight: 42.3 None\n Ideal tidal volume: 169.2 / 253.8 / 338.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 20 cm at teeth\n Route:\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: 8 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts; Comments: extreme agitation requiring sedation\n"
},
{
"category": "Physician ",
"chartdate": "2160-03-02 00:00:00.000",
"description": "Intensivist Note",
"row_id": 436744,
"text": "CVICU\n HPI:\n 71F POD 8 from LLE embolectomy. Pt originally admitted to OSH and while\n waiting for X-lap for SBO, developed AF and complications from it --\n CVA and LLE embolus. Transferred here for LLE embolectomy and\n fasciotomy, complicated by ARF and respiratory failure. Now not\n tolerating TF (m/p due to SBO which has not been addressed yet).\n stenosis 50-69%.\n Chief complaint:\n PMHx:\n As above\n Current medications:\n 24 Hour Events:\n - R-sided thoracentesis; cytology sent. 300 cc drained. u/s\n demonstrated pneumothorax, none seen on CXR. Stable throughout.\n - Vomited again, TF d/c'd.\n - Back on A/C due to agitation/tachypnea\n THORACENTESIS - At 10:27 AM\n Post operative day:\n 8\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,100 units/hour\n Fentanyl - 50 mcg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 AM\n Metoprolol - 08:35 AM\n Furosemide (Lasix) - 10:15 AM\n Fentanyl - 04:00 PM\n Lorazepam (Ativan) - 05:00 PM\n Other medications:\n Flowsheet Data as of 08:21 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.7\nC (98\n T current: 36.5\nC (97.7\n HR: 114 (69 - 124) bpm\n BP: 121/57(79) {74/38(49) - 169/80(112)} mmHg\n RR: 17 (8 - 25) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 70.5 kg (admission): 50 kg\n Height: 58 Inch\n CVP: 13 (12 - 25) mmHg\n Total In:\n 1,111 mL\n 200 mL\n PO:\n Tube feeding:\n 91 mL\n IV Fluid:\n 645 mL\n 200 mL\n Blood products:\n 375 mL\n Total out:\n 3,565 mL\n 1,605 mL\n Urine:\n 2,555 mL\n 1,405 mL\n NG:\n 710 mL\n 200 mL\n Stool:\n Drains:\n Balance:\n -2,454 mL\n -1,405 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 451 (450 - 451) mL\n Vt (Spontaneous): 542 (521 - 542) mL\n PS : 12 cmH2O\n RR (Set): 16\n RR (Spontaneous): 19\n PEEP: 5 cmH2O\n FiO2: 35%\n RSBI: 87\n PIP: 18 cmH2O\n Plateau: 21 cmH2O\n SPO2: 97%\n ABG: 7.38/45/122/25/1\n Ve: 8.1 L/min\n PaO2 / FiO2: 349\n Physical Examination\n General Appearance: No acute distress, Anxious\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Murmur: No(t) Systolic, No(t)\n Diastolic)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : Bilat, Diminished: at bases)\n Abdominal: Soft, Non-distended, Non-tender, Distended\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Right Extremities: (Edema: Absent, 1+), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities, Sedated, Intermittently f/c\n Labs / Radiology\n 352 K/uL\n 7.8 g/dL\n 84 mg/dL\n 2.1 mg/dL\n 25 mEq/L\n 3.8 mEq/L\n 34 mg/dL\n 102 mEq/L\n 137 mEq/L\n 21.6 %\n 8.4 K/uL\n [image002.jpg]\n 02:55 AM\n 03:05 AM\n 03:24 AM\n 07:43 AM\n 03:10 PM\n 07:00 PM\n 07:24 PM\n 09:31 PM\n 12:59 AM\n 01:14 AM\n WBC\n 8.6\n 8.8\n 11.9\n 11.8\n 8.4\n Hct\n 19.9\n 20.4\n 24.9\n 24\n 21.6\n Plt\n 52\n Creatinine\n 1.9\n 2.1\n 2.1\n TCO2\n 27\n 27\n 27\n 27\n 28\n Glucose\n 91\n 82\n 90\n 82\n 84\n Other labs: PT / PTT / INR:15.4/71.5/1.4, CK / CK-MB / Troponin\n T:571/16/, ALT / AST:129/147, Alk-Phos / T bili:119/0.2, Lactic\n Acid:0.6 mmol/L, Albumin:1.4 g/dL, Ca:8.0 mg/dL, Mg:2.5 mg/dL, PO4:4.8\n mg/dL\n Assessment and Plan\n PLEURAL EFFUSION, CHRONIC, NAUSEA / VOMITING, HYPERTENSION, BENIGN,\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), HYPOCALCEMIA (LOW CALCIUM),\n HYPOKALEMIA (LOW POTASSIUM, HYPOPOTASSEMIA), CANCER (MALIGNANT\n NEOPLASM), GYNECOLOGICAL (OVARIAN, UTERINE, CERVICAL, ENDOMETRIAL),\n PROBLEM - ENTER DESCRIPTION IN COMMENTS, ALTERATION IN NUTRITION,\n IMPAIRED SKIN INTEGRITY, RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE,\n ARF), HYPOTENSION (NOT SHOCK), ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM\n TREMENS, DTS, SEIZURES), PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN), CVA\n (STROKE, CEREBRAL INFARCTION), ISCHEMIC , PERIPHERAL VASCULAR DISEASE\n (PVD) WITH CRITICAL LIMB ISCHEMIA\n Assessment and Plan: This is an unfortunate 71 y.o. female with what\n appears to be ovarian CA (awaiting final diagnosis from heme/onc) and\n carcinomatosis (including SBO), complicated by AF and CVA, LLE embolus\n s/p LLE embolectomy (POD #8). In addition, ARF and respiratory failure.\n Neurologic: Neuro checks Q: 4 hr, Pain controlled, On Fentanyl gtt,\n ativan for sedation. In addition, clonidine patch placed yesterday\n (long h/o of EtOH). Periods of agitation. increase ativan as\n needed.\n Cardiovascular: Aspirin, Full anticoagulation, Beta-blocker, Decrease\n b-blocke frequency to Q 4 H as patient is hemodynamically stable and is\n tachycardic (PAF with complications). Would stop heparin gtt as\n positive guiac and Hct significantely decreased in past few days.\n Pulmonary: Cont ETT, (Ventilator mode: CPAP + PS), Continue current\n vent settings, as pt does not tolerate CPAP, and may not be able to\n extubate her safely\n Gastrointestinal / Abdomen: SBO has not been addressed so far. Appears\n to be from extensive spread in the abdomen (carcinomatosis). This is\n worrisom, as prognosis is probably poor. ? general surgery consult if\n continue with full treatment (need to discuss with family). Trace guiac\n positive, which may be from the CA invading the bowel. Please lavage\n stomach. Would switch to PPI for GI bleed\n Nutrition: NPO, If not withdrawaling care would start TPN today\n Renal: Foley, Adequate UO, ARF is stable. Continue with diuresis as\n overall fluid overload. Keep negative 2-3 L today\n Hematology: Serial Hct, Anemia -- m/p from lower GI bleed. f/u Hct in\n PM. If continue to drop --> 1 unit PRBC.\n Endocrine: RISS, Glucose well-controlled. Keep < 150\n Infectious Disease: Check cultures, No evidence of infection\n Lines / Tubes / Drains: Foley, ETT\n Wounds: Dry dressings\n Imaging:\n Fluids: KVO\n Consults: Vascular surgery, Hem / Onc , Gyn/onc\n Billing Diagnosis: Arrhythmia, (Respiratory distress: Failure), Post-op\n complication, Acute renal failure\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 09:43 PM\n Multi Lumen - 12:00 AM\n PICC Line - 09:31 PM\n Prophylaxis:\n DVT: Boots (Systemic anticoagulation: Heparin drip, Would d/c heparin\n gtt as evidence of GI bleed and primary reason for anticoagulation (AF\n with emboli). Now in SR)\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments: Would change H2 blocker to PPI \n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: DNR (do not resuscitate)\n Disposition: ICU\n Total time spent: 31 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2160-03-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 436821,
"text": "Respiratory failure, acute (not ARDS/) NEURO PT\n REMAINS AGITATED AND UNRESPONDSIVE MOVES IN BED WITH NO PURPOSE\n APPEARS ANGRY ON FENT/ATIVAN WITH NO HELP MAX DOSES GIVEN LIMIT\n HYPOTENSION NEO BACK UP MD AWARE PLEASE SEE NOTES FOR DETAILS\n RESP VENTED VIA ETT P/S OVER PEEP TOL WELL SCANT SPUTUM\n THIS AM TOL CPT WELL SAO2 100 ON .35 FIO2\n HEART S1S2 DISTANT TONES PULSES POS 2 THRU OUT NSR PR\n .18 QRS .08 QT WNL FOR AGE AND GENDER VSS PENDING LEVEL OF SEDATION\n GI NO B/S NOTED FIRM ABD U/O Q/S\n PLAN SUPPORTIVE MULTIPLE SYSTEM FAILURE PRESENTLY NO CPR\n /DNR STATUS ETHIC REVIEW NEEDED CMO NEED TO BE EXPLORED FAMILY\n IN AGREEMENT\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nutrition",
"chartdate": "2160-03-03 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 436908,
"text": "Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 147 cm\n 50 kg\n 70.5 kg ( 05:00 AM)\n 23\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 42.3 kg\n Pertinent medications: fent gtt, Heparin gtt, Versed gtt, Norepi gtt,\n Pantoprazole, Lasix, Bisacodyl, D5W @ 10ml/hr, KCl (20mEq repletion)\n Labs:\n Value\n Date\n Glucose\n 117 mg/dL\n 08:30 AM\n Glucose Finger Stick\n 114\n 07:00 PM\n BUN\n 41 mg/dL\n 12:51 AM\n Creatinine\n 2.2 mg/dL\n 12:51 AM\n Sodium\n 136 mEq/L\n 12:51 AM\n Potassium\n 4.6 mEq/L\n 08:30 AM\n Chloride\n 101 mEq/L\n 12:51 AM\n TCO2\n 27 mEq/L\n 12:51 AM\n PO2 (arterial)\n 140 mm Hg\n 01:04 AM\n PCO2 (arterial)\n 49 mm Hg\n 01:04 AM\n pH (arterial)\n 7.36 units\n 01:04 AM\n pH (venous)\n 7.41 units\n 05:01 PM\n pH (urine)\n 5.0 units\n 11:29 AM\n CO2 (Calc) arterial\n 29 mEq/L\n 01:04 AM\n Albumin\n 2.3 g/dL\n 09:37 AM\n Calcium non-ionized\n 8.0 mg/dL\n 12:59 AM\n Phosphorus\n 5.4 mg/dL\n 12:51 AM\n Ionized Calcium\n 1.09 mmol/L\n 01:04 AM\n Magnesium\n 2.5 mg/dL\n 12:51 AM\n ALT\n 32 IU/L\n 12:51 AM\n Alkaline Phosphate\n 127 IU/L\n 12:51 AM\n AST\n 17 IU/L\n 12:51 AM\n Total Bilirubin\n 0.4 mg/dL\n 12:51 AM\n Triglyceride\n 152 mg/dL\n 07:13 PM\n WBC\n 7.1 K/uL\n 12:51 AM\n Hgb\n 7.5 g/dL\n 12:51 AM\n Hematocrit\n 21.4 %\n 12:51 AM\n Current diet order / nutrition support: DIET: NPO\n TF: d/c'd\n TPN (): Day 1 std w/ std electrolytes\n GI: firm/distended, (-) bs\n Assessment of Nutritional Status\n Estimation of current intake: Inadequate\n Specifics:\n Pt w/ likely stage III ovarian CA, remains intubated/sedated. Pt was\n on TF for nutrition support until stopped over weekend d/t emesis, high\n residuals (250ml). KUB showed no clear evidence of obstruction,\n but cannot be ruled out. TPN started last night and currently\n running. Agree w/ TPN at this time given intolerance to TF. TG\n checked = 152 therefore ok to add lipid to TPN. Noted high phos,\n rec take out of TPN. NGT to low continuous suction. Noted family\n meeting planned for Tuesday.\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: via TF\n TPN recommendations: For , rec advance to goal TPN: 50kg 3 in1 std:\n 1250ml: 213gdex/ 75g AA/ 25g lipid = 1250calories\n w/ non std lytes: NaCl 80, NaAc 0, NaPO4 0, KCl 30, KAc 10, KPO4 0,Mg\n 10, Ca 9\n Check chemistry 10 panel\n adjust lytes prn\n Will follow up to check TPN, plan. Page if ?s *\n"
},
{
"category": "Nursing",
"chartdate": "2160-03-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 437166,
"text": "Anxiety\n Assessment:\n Patient extremely agitated, thrashing in bed, arms flailing,\n hypertensive due to agitation 170/77 and tachycardic 95 NSR\n Action:\n Zyprexia given and emotional support provided with a quiet calm\n atmosphere, lines hidden for safety\n Response:\n Patient rested comfortably all day\n Plan:\n Zyprexia ordered TID, family meeting 1300 with Dr. ,\n family and husband via conference call\n Hypotension (not Shock)\n Assessment:\n Hypotensive 83/38, on fentanyl gtt, clonidine patch on and newly\n applied fentanyl patch (to posterior left shoulder)\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2160-03-03 00:00:00.000",
"description": "ICU Note - CVI",
"row_id": 436886,
"text": "CVICU\n HPI:\n HD11\n POD 10\n 71F s/p LLE embolectomy\n Cc: acute ischemic left foot, new onset of PAF\n ?? partial SBO,and recent rt. parietal-occpit. infarct with \n stenosis 50-69%.\n Cr:0.9 Wt:50kg EF 20%\n PMH: negative\n Plan:Ascites Cytology Pos for malig. adeno (prob. ovarian). Large B\n pleural eff.- ?? tap for dx. Vigileo placed- CI >2.5- Lasix given.\n Echo- severe lv DYSFXN W/ EF 20%\n 1/18 24 events: Cont. to vomit TF->d/c'd and TPN started. Cont. to drop\n Hct-> Protonix . Cont. Hep per vascular.\n Plan: Attempt extubation in next few days, if possible. Will need to\n consult Gen. . re obstruction if we want to be more aggressive. Dr.\n to talk to family on Tues.\n ***Pt. is DNR only, pt.'s husband has agreed to reintubation if\n necessary.\n Current medications:\n . Albuterol Inhaler . Artificial Tears Preserv. Free . Aspirin .\n Bisacodyl . Calcium Gluconate . Chlorhexidine Gluconate 0.12% Oral\n Rinse9. Clonidine Patch 0.1 mg/24 hr . Fentanyl Citrate . Furosemide .\n Heparin . HydrALAzine . Influenza Virus Vaccine . Ipratropium Bromide\n MDI . Lorazepam . Magnesium Sulfate . . Metoprolol Tartrate .\n Pantoprazole . Phenylephrine\n . Pneumococcal Vac Polyvalent . Potassium Chloride\n 24 Hour Events:\n Post operative day:\n POd 10\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Fentanyl - 50 mcg/hour\n Heparin Sodium - 1,100 units/hour\n Other ICU medications:\n Fentanyl - 12:15 PM\n Lorazepam (Ativan) - 04:23 PM\n Furosemide (Lasix) - 06:00 PM\n Metoprolol - 09:28 AM\n Other medications:\n Flowsheet Data as of 09:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.3\nC (99.2\n T current: 36.4\nC (97.5\n HR: 100 (71 - 119) bpm\n BP: 124/35(55) {124/35(55) - 131/58(77)} mmHg\n RR: 19 (7 - 23) insp/min\n SPO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 70.5 kg (admission): 50 kg\n Height: 58 Inch\n CVP: 17 (6 - 73) mmHg\n Total In:\n 1,104 mL\n 797 mL\n PO:\n Tube feeding:\n IV Fluid:\n 836 mL\n 393 mL\n Blood products:\n Total out:\n 3,430 mL\n 1,045 mL\n Urine:\n 3,180 mL\n 1,045 mL\n NG:\n 250 mL\n Stool:\n Drains:\n Balance:\n -2,326 mL\n -247 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 555 (320 - 623) mL\n PS : 12 cmH2O\n RR (Spontaneous): 9\n PEEP: 5 cmH2O\n FiO2: 35%\n RSBI: 98\n PIP: 18 cmH2O\n SPO2: 96%\n ABG: 7.36/49/140/27/1\n Ve: 5.2 L/min\n PaO2 / FiO2: 400\n Physical Examination\n General Appearance: Anxious, agitated when interacted with\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : coarse BS bilat)\n Abdominal: Bowel sounds present, Distended, softly distended w/\n hypoactive BS\n Left Extremities: (Edema: 3+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Diminished)\n Right Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Responds to: Verbal stimuli, Noxious stimuli), No(t) Moves\n all extremities, (LLE: No movement)\n Labs / Radiology\n 364 K/uL\n 7.5 g/dL\n 117 mg/dL\n 2.2 mg/dL\n 27 mEq/L\n 4.6 mEq/L\n 41 mg/dL\n 101 mEq/L\n 136 mEq/L\n 21.4 %\n 7.1 K/uL\n [image002.jpg]\n 07:24 PM\n 09:31 PM\n 12:59 AM\n 01:14 AM\n 08:24 AM\n 02:28 PM\n 02:39 PM\n 12:51 AM\n 01:04 AM\n 08:30 AM\n WBC\n 8.4\n 7.1\n Hct\n 24\n 21.6\n 23.6\n 21.4\n Plt\n 352\n 364\n Creatinine\n 2.1\n 2.2\n TCO2\n 27\n 27\n 28\n 27\n 28\n 29\n Glucose\n 82\n 84\n 82\n 145\n 141\n 117\n Other labs: PT / PTT / INR:15.8/ 58.6/1.4, CK / CK-MB / Troponin\n T:571/16/, ALT / AST:32/17, Alk-Phos / T bili:127/0.4, Lactic Acid:0.9\n mmol/L, Albumin:2.1 g/dL, Ca:8.0 mg/dL, Mg:2.5 mg/dL, PO4:5.4 mg/dL\n Fluid Analysis / Other Labs: Pleural fluid cytol not yet in sysytem\n from .\n Assessment and Plan\n INEFFECTIVE COPING, PLEURAL EFFUSION, CHRONIC, NAUSEA / VOMITING,\n HYPERTENSION, BENIGN, RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n HYPOCALCEMIA (LOW CALCIUM), HYPOKALEMIA (LOW POTASSIUM,\n HYPOPOTASSEMIA), CANCER (MALIGNANT NEOPLASM), GYNECOLOGICAL (OVARIAN,\n UTERINE, CERVICAL, ENDOMETRIAL), PROBLEM - ENTER DESCRIPTION IN\n COMMENTS, ALTERATION IN NUTRITION, IMPAIRED SKIN INTEGRITY, RENAL\n FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF), HYPOTENSION (NOT SHOCK),\n ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES), PAIN\n CONTROL (ACUTE PAIN, CHRONIC PAIN), CVA (STROKE, CEREBRAL INFARCTION),\n ISCHEMIC , PERIPHERAL VASCULAR DISEASE (PVD) WITH CRITICAL LIMB\n ISCHEMIA\n Assessment and Plan: Remains neurologically impaired, thick secretions,\n all of which make extubation not possible now. Pleural cytol. will be\n several days to return. On TPN due to SBO. reamins critically ill with\n at least Stage 3 Ovarian carcinoma.\n Neurologic: Neuro checks Q: 1 hr\n Cardiovascular: Aspirin, Full anticoagulation\n Pulmonary: Cont ETT, (Ventilator mode: CPAP + PS)\n Gastrointestinal / Abdomen:\n Nutrition: TPN\n Renal: Foley, Adequate UO\n Endocrine: RISS\n Infectious Disease:\n Lines / Tubes / Drains: Foley, NGT, ETT, RT PICC, LT scv TLC\n Wounds: Dry dressings\n Fluids: Other, TPN\n Consults: await decision re: gen. consult for SBO.\n ICU Care\n Nutrition:\n TPN without Lipids - 05:34 PM 41. mL/hour\n Glycemic Control: Regular insulin sliding scale\n Arterial Line - 09:43 PM\n Multi Lumen - 12:00 AM\n PICC Line - 09:31 PM\n DVT: Boots (Systemic anticoagulation: Heparin drip)\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: DNR (do not resuscitate)/ reintubation OK\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2160-03-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 437157,
"text": "Anxiety\n Assessment:\n Patient extremely agitated, thrashing in bed, arms flailing,\n hypertensive due to agitation 170/77 and tachycardic 95 NSR\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "General",
"chartdate": "2160-03-02 00:00:00.000",
"description": "Generic Note",
"row_id": 436712,
"text": "TITLE:\n"
},
{
"category": "Nursing",
"chartdate": "2160-03-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 437033,
"text": "Anxiety\n Assessment:\n Pt extremely agitated with periods escalating to pt thrashing head and\n arms around in bed despite fentanyl & versed gtts. Ativan 0.5mg PRN Q4\n also available and given.\n Pt @ possible risk for self-extubation and removal of Art\n line, as well as injuring BUE d/t friction and force of restraints\n against wrists\n Pt eyes are wide open and pt looks extremely uncomfortable.\n Pt not following commands or tracking\n MAE including LLE slightly.\n PERRL; 2mm brisk\n Pt becomes HTN and tachycardic with agitation\n Action:\n Gtts @ max dose\n 0.5mg Ativan given Q4\n PA called about pt extreme agitation and ?able neuro status\n No changes from pt earlier state\n Response:\n Pt seemed to be more comfortable after Ativan given for short period ~2\n hrs except for nursing care (ie turning, suctioning).\n Ativan order increased to 1mg Q4\n Pt remained agitated despite being given 1mg ativan with\n last dose @ 0330\n Plan:\n Ativan 0.5-1 mg Q4\n Fentanyl & Versed gtts cont overnight\n Vascular team would like sedation weaned down in AM (@ 0600)\n Family meeting today\n"
},
{
"category": "Respiratory ",
"chartdate": "2160-03-02 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 436802,
"text": "Demographics\n Day of mechanical ventilation: 10\n Ideal body weight: 42.3 None\n Ideal tidal volume: 169.2 / 253.8 / 338.4 mL/kg\n Airway\n Tube Type\n ETT:\n Route: Oral\n Type: Standard\n Size: 7mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Pt has periods of tachypnea which alleviates with sedation.\n No change in PSV settings as charted throughout shift.\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: Wean as tolerated.\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n"
},
{
"category": "Nursing",
"chartdate": "2160-03-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 437211,
"text": "Shock, hypovolemic or hemorrhagic\n Assessment:\n Pt extremely hypotensive; SR-ST with frequent PVCs (Vent\n bigeminy/trigeminy)\n Pt agitated, flailing arms around in bed and bucking ventilator\n Action:\n Labs sent (Hct 20 from 24 earlier on), Lytes low\n 1250cc NS bolus given total\n 2 units PRBCs given\n Transthoracic echo done @ bedside\n CXR done\n Response:\n Plan:\n"
},
{
"category": "Respiratory ",
"chartdate": "2160-03-05 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 437212,
"text": "Demographics\n Day of intubation: 13\n Day of mechanical ventilation: 13\n Ideal body weight: 42.3 None\n Ideal tidal volume: 169.2 / 253.8 / 338.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 20 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 7 mL / Air\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Crackles\n LUL Lung Sounds: Crackles\n LLL Lung Sounds: Exp Wheeze\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Accessory muscle use, Gasping\n efforts, Active exhalations\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Frequent failed trigger efforts, Abnormal\n trigger efforts (efforts during inspiratory)\n Dysynchrony assessment: Possible air trapping, Erratic exhaled Tidal\n Volumes, Frequent alarms (High pressure)\n Comments: Patient now with hem-pneumothorax. High PIP\ns. Switched to\n PCV.\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support: Hemodynimic\n instability, Underlying illness not resolved\n"
},
{
"category": "Echo",
"chartdate": "2160-02-23 00:00:00.000",
"description": "Report",
"row_id": 86917,
"text": "PATIENT/TEST INFORMATION:\nIndication: Atrial fibrillation. ? Thrombus.\nWeight (lb): 127\nBP (mm Hg): 115/67\nHR (bpm): 96\nStatus: Inpatient\nDate/Time: at 12:19\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size. No LA mass/thrombus (best excluded by TEE).\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal IVC diameter (<2.1cm)\nwith 35-50% decrease during respiration (estimated RA pressure (0-10mmHg).\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Severe regional LV\nsystolic dysfunction. No LV mass/thrombus. Severely depressed LVEF. No resting\nLVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior\n- hypo; mid anterior - hypo; basal anteroseptal - akinetic; mid anteroseptal -\nakinetic; basal inferoseptal - hypo; mid inferoseptal - hypo; basal inferior -\nhypo; mid inferior - akinetic; basal anterolateral - hypo; mid anterolateral -\nhypo; anterior apex - hypo; septal apex- akinetic;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild thickening\nof mitral valve chordae. Mild (1+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Moderate [2+] TR.\nModerate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Echocardiographic results were reviewed by telephone with\nthe houseofficer caring for the patient.\n\nConclusions:\nThe left atrium is normal in size. No left atrial mass/thrombus seen (best\nexcluded by transesophageal echocardiography). The estimated right atrial\npressure is 0-10mmHg. Left ventricular wall thicknesses and cavity size are\nnormal. There is severe regional left ventricular systolic dysfunction with\nbasal to mid septal and anterior hypokinesis/akinesis and mid inferior\nakinesis. No masses or thrombi are seen in the left ventricle. Overall left\nventricular systolic function is severely depressed (LVEF= 20-30 %). Right\nventricular chamber size and free wall motion are normal. The aortic valve\nleaflets (3) are mildly thickened but aortic stenosis is not present. The\nmitral valve leaflets are mildly thickened. There is no mitral valve prolapse.\nMild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are\nmildly thickened. Moderate to severe [3+] tricuspid regurgitation is seen.\nThere is moderate pulmonary artery systolic hypertension. There is no\npericardial effusion.\n\nIMPRESSION: Severe regional left ventricular systolic dysfunction consistent\nwith multivessel coronary artery disease. Mild (1+) mitral regurgitation.\nModerate to severe [3+] tricuspid regurgitation with moderate pulmonary artery\nsystolic hypertension.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2160-03-05 00:00:00.000",
"description": "Report",
"row_id": 87012,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Right ventricular function.\nBP (mm Hg): 77/38\nHR (bpm): 100\nStatus: Inpatient\nDate/Time: at 06:11\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolic\nfunction (LVEF>55%). Suboptimal technical quality, a focal LV wall motion\nabnormality cannot be fully excluded. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to moderate [+] TR.\nModerate PA systolic hypertension.\n\nPERICARDIUM: Small pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. The patient\nappears to be in sinus rhythm. Frequent ventricular premature beats. Emergency\nstudy. Results were personally reviewed with the MD caring for the patient.\nLeft pleural effusion.\n\nConclusions:\nLeft ventricular wall thickness, cavity size, and global systolic function are\nnormal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion\nabnormality cannot be fully excluded. Right ventricular chamber size and free\nwall motion are normal. There is mild to moderate tricuspid\nregurgitation.There is moderate pulmonary artery systolic hypertension. There\nis a small pericardial effusion.\n\nIMPRESSION: Suboptimal image quality. Preserved -ventricular systolic\nfunction. Mild to moderate tricuspid regurgitation, moderate pulmonary artery\nsystolic hypertension.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2160-02-27 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1056768,
"text": " 3:57 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: please check tip of 41cm R brachial PICC\n Admitting Diagnosis: PULSELESS LEFT LEG\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with newly placed R PICC\n REASON FOR THIS EXAMINATION:\n please check tip of 41cm R brachial PICC\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLrc WED 5:46 PM\n Right PICC with tip in right atrium can be pulled by approximately 4 cm.\n Nasogastric tube with sideport at esophagogastric junction can be advanced by\n approximately 2 cm. Interval improvement in pulmonary edema. Stable\n bilateral pleural effusions.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient is a 71-year-old female with newly placed right PICC\n line. Please evaluate position.\n\n EXAMINATION: Single portable chest radiograph.\n\n COMPARISONS: Comparison to chest radiographs from .\n\n FINDINGS: Interval placement of a right-sided PICC with tip terminating in\n the right atrium that could be pulled back by approximately 4 cm for optimal\n placement. Endotracheal tube with tip 2.9 cm above the level of the carina,\n NG tube coursing below the diaphragm with tip out of field of view, however,\n side port just at esophagogastric junction can be advanced by 2 cm for optimal\n placement. Large bore left subclavian catheter with tip ending at mid SVC\n noted. Overall, lungs demonstrate interval improvement of fluid overload.\n There are bilateral small to moderate pleural effusions. No pneumothorax is\n seen. The cardiac and mediastinal contours are stable with tortuosity of the\n aorta.\n\n IMPRESSION: Interval placement of right-sided PICC with tip within right\n atrium. Line can be withdrawn by approximately 4 cm for placement within\n cavoatrial junction.\n\n Nasogastric tube with side port just at esophagogastric junction. The line\n can be advanced by approximately 2 cm.\n\n Interval improvement of fluid overload. Stable bilateral pleural effusions.\n\n The PICC line position was relayed with from the IV team at 4:45 p.m.\n on .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2160-02-23 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1056028,
"text": " 1:59 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for hemorrhagic stroke, needs to be heparinized.\n Admitting Diagnosis: PULSELESS LEFT LEG\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71F w acute ischemic left foot, s/p fem cut down, embolectomy, and fasciotomy.\n New onset of AF with abdominal ascities ? maligancy, partial SBO,and recent rt.\n parietal-occpit. infract with stenosis 50-69%.\n REASON FOR THIS EXAMINATION:\n eval for hemorrhagic stroke, needs to be heparinized.\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DSsd SAT 4:24 PM\n Evolving R MCA/PCA watershed territory infarct. No hemorrhage.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old female with left foot ischemia, status post cutdown\n embolectomy and fasciotomy, now with new atrial fibrillation, and recent right\n parietooccipital infarct. Please evaluate for hemorrhagic stroke.\n\n COMPARISON: None available.\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: There is a moderate-sized area of hypodensity in the watershed\n territory between the right MCA and PCA territory, consistent with reported\n history of subacute infarction. There is no sign of hemorrhagic\n transformation within this area. There is no other intracranial hemorrhage.\n There is no mass, mass effect, or evidence of other area of infarction.\n\n There is moderate sulcal prominence in the bilateral frontal lobes, most\n consistent with atrophy, slightly out of proportion to ventricular size. Basal\n cisterns are normal. There is mild mucosal thickening in the ethmoid air\n cells, and nasal passages. Paranasal sinuses and mastoid air cells are\n otherwise normally aerated.\n\n IMPRESSION: Evolving area of infarction in the watershed territory between\n the right MCA and PCA distributions. No sign of intracranial hemorrhage, or\n hemorrhagic transformation of this infarct.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2160-02-23 00:00:00.000",
"description": "CT PELVIS W/O CONTRAST",
"row_id": 1056029,
"text": " 1:59 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: NON-CONTRAST; eval ascites and possible metastatic ovarian d\n Admitting Diagnosis: PULSELESS LEFT LEG\n Field of view: 40\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71F w acute ischemic left foot, s/p fem cut down, embolectomy, and fasciotomy.\n New onset of AF with abdominal ascities ? maligancy, partial SBO,and recent rt.\n parietal-occpit. infract with stenosis 50-69%.\n REASON FOR THIS EXAMINATION:\n NON-CONTRAST; eval ascites and possible metastatic ovarian disease\n CONTRAINDICATIONS for IV CONTRAST:\n rhabdo\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 71-year-old female with ischemic left foot status post embolectomy.\n New-onset atrial fibrillation. Ascites.\n\n TECHNIQUE: CT images were acquired through the abdomen and pelvis after\n administration of oral contrast only. No intravenous contrast was\n administered as per the clinical team request due to rhabdomyolysis.\n\n FINDINGS:\n\n LUNG BASES: Bilateral pleural effusions are moderate in size, with adjacent\n atelectasis. Two punctate calcifications within the left lower lobe\n atelectatic lung (image 2:5) are consistent with calcified granulomata. No\n significant pericardial effusion is present. Nasogastric tube courses from\n the esophagus and into the stomach.\n\n ABDOMEN: A moderate amount of ascites layers around the liver, around the\n spleen, and in the pericolic gutters. A hiatal hernia is small. The\n unenhanced liver, spleen, pancreas, and adrenal glands demonstrate no focal\n lesions. A tiny 2-mm calculus is located in the lower pole of the left kidney\n (image 2:34). No hydronephrosis is present.\n\n PELVIS: The proximal small bowel is dilated up to 3.9 cm in diameter. The\n terminal ileum is decompressed. The transition point is at the distal ileum in\n the right deep pelvis. The wall of the terminal ileum is moderately\n thickened, which may actually represent serosal thickening. A region of soft\n tissue attenuation immediately adjacent to the terminal ileum and the right\n external iliac vessels measures 4.9 x 2.4 cm (image 2:64). The right ovary is\n not clearly visualized separate from this region. A moderate amount of free\n fluid layers in the pelvis. Differential high attenuation is located along\n the posterior aspect of the peritoneal cavity in the pelvis. This could\n represent peritoneal thickening or small hemoperitoneum (image 2:69). The\n urinary bladder contains Foley catheter. The large bowel is relatively\n decompressed and contains oral contrast. Several colonic diverticula are\n present. Stranding and subcutaneous gas is located in the left groin, likely\n secondary to cutdown procedure. Several surgical clips are located adjacent to\n the left common femoral vessels (image 2:74). Subcutaneous edema is extensive\n and diffuse.\n (Over)\n\n 1:59 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: NON-CONTRAST; eval ascites and possible metastatic ovarian d\n Admitting Diagnosis: PULSELESS LEFT LEG\n Field of view: 40\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n Note that sensitivity for peritoneal implants and focal parenchymal lesions is\n significantly decreased in the absence of intravenous contrast.\n\n MUSCULOSKELETAL: No focal osseous destructive lesions are demonstrated.\n\n IMPRESSION:\n\n 1. Findings poorly evaluated without intravenous contrast but potentially\n suspicious for peritoneal carcinomatosis, including ascites and probable\n peritoneal and serosal thickening. If there is an outside hospital CT with\n intravenous contrast, then this can be scanned into the system for comparison.\n\n 2. Partial small-bowel obstruction, with transition point in the distal\n ileum. Contrast does pass into the colon.\n\n 3. Moderate ascites.\n\n 4. Moderate bilateral pleural effusions and adjacent atelectasis.\n\n 5. Small hiatal hernia.\n\n 6. Tiny non-obstructing left nephrolithiasis.\n\n 7. Anasarca.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2160-02-27 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1056769,
"text": ", R. VSURG CSRU 3:57 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: please check tip of 41cm R brachial PICC\n Admitting Diagnosis: PULSELESS LEFT LEG\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with newly placed R PICC\n REASON FOR THIS EXAMINATION:\n please check tip of 41cm R brachial PICC\n ______________________________________________________________________________\n PFI REPORT\n Right PICC with tip in right atrium can be pulled by approximately 4 cm.\n Nasogastric tube with sideport at esophagogastric junction can be advanced by\n approximately 2 cm. Interval improvement in pulmonary edema. Stable\n bilateral pleural effusions.\n\n"
},
{
"category": "Radiology",
"chartdate": "2160-02-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1055926,
"text": " 6:42 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o chf\n Admitting Diagnosis: PULSELESS LEFT LEG\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with acute left leg ischemia\n REASON FOR THIS EXAMINATION:\n r/o chf\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Acute left leg ischemia, rule out CHF.\n\n CHEST, SINGLE AP VIEW.\n\n Lungs are hyperinflated, suggesting background COPD. An NG tube is present --\n the tip and side port lie beneath the diaphragm. Probable mild cardiomegaly.\n There is prominence of the vascular markings bilaterally, consistent with CHF.\n There are small bilateral effusions with underlying collapse and/or\n consolidation.\n\n IMPRESSION:\n 1. CHF with interstitial and alveolar edema and small bilateral pleural\n effusions, with underlying collapse and/or consolidation.\n\n 2. NG tube in satisfactory position beneath diaphragm.\n\n"
},
{
"category": "Radiology",
"chartdate": "2160-02-23 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1055967,
"text": " 1:38 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: eval CVL tip\n Admitting Diagnosis: PULSELESS LEFT LEG\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman s/p line adjustment\n REASON FOR THIS EXAMINATION:\n eval CVL tip\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post adjustment CVL tip.\n\n CHEST, SINGLE AP VIEW\n\n Compared with earlier the same day, the left subclavian central line tip has\n been retracted and now overlies the mid SVC. In addition, the ET tube appears\n to have been repositioned and now lies approximately 2.2 cm above the carina,\n still pointing slightly to the right. Again seen is CHF, with upper zone\n redistribution, mild diffuse vascular blurring, interstitial edema, and\n probably subtle alveolar edema, and probable small bilateral\n pleural effusions, all essentially unchanged.\n\n IMPRESSION:\n\n Status post repositioning of ET tube and left subclavian line both in\n satisfactory position. See comment.\n\n"
},
{
"category": "Radiology",
"chartdate": "2160-03-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1057477,
"text": " 7:37 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Asp. PNA/PTX\n Admitting Diagnosis: PULSELESS LEFT LEG\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman s/p LLE embolectomy/thoracentesis\n REASON FOR THIS EXAMINATION:\n Asp. PNA/PTX\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST\n\n COMPARISON: .\n\n INDICATION: Status post thoracentesis.\n\n FINDINGS: Indwelling devices remain in standard position. Left pleural\n effusion appears slightly decreased compared to the recent radiograph with no\n evidence of pneumothorax. Slight improvement in previously described volume\n overload, and decrease in asymmetrical opacities in the right mid and lower\n lung regions, but no change in the left retrocardiac opacity.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2160-03-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1057721,
"text": " 8:42 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for infiltrate - please do at 0930\n Admitting Diagnosis: PULSELESS LEFT LEG\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with s/p LLE embolectomy\n REASON FOR THIS EXAMINATION:\n evaluate for infiltrate - please do at 0930\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old female with left lower extremity embolectomy.\n Evaluate for infiltrate.\n\n COMPARISON: .\n\n PORTABLE UPRIGHT CHEST RADIOGRAPH: Indwelling devices are in standard\n positions. Allowing for rotation the cardiomediastinal silhouette is stable\n with slight rightward mediastinal shift, which is unchanged and likely due to\n the stable moderate left pleural effusion. The small right pleural effusion\n is also unchanged. There is stable right basilar atelectasis. There is no\n pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2160-02-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1055954,
"text": " 11:27 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: ett positioning\n Admitting Diagnosis: PULSELESS LEFT LEG\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman s/p embolectomy\n REASON FOR THIS EXAMINATION:\n ett positioning\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Check ET tube position.\n\n CHEST, SINGLE AP PORTABLE VIEW.\n\n An ET tube is present -- the tip lies approximately 1.5 cm above the carina,\n slightly low, and points toward the right mainstem bronchus. This should be\n retracted. Left subclavian central line tip overlying right atrium should also\n be retracted. (Note is made that both the ETT and left central line have been\n repositioned as of a subsequent film obtained at 1:52 a.m. on ).\n\n There is cardiomegaly and diffuse vascular plethora with some interstitial\n edema. Possible small amount of pleural fluid bilaterally. There is biapical\n pleural thickening, asymmetrically larger on the left.\n\n Bilateral carotid artery calcification is noted.\n\n IMPRESSION:\n\n 1. ET to and left subclavian tube, as described (both have subsequently been\n repositioned).\n\n 2. CHF with interstitial edema and possible small bilateral effusions. Apical\n pleural thickening asymmetrically larger on the left, and bilateral carotid\n artery calcification noted.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2160-02-22 00:00:00.000",
"description": "Report",
"row_id": 242593,
"text": "Sinus tachycardia. Diffuse ST-T wave abnormality. Cannot rule out\nmyocardial ischemia. Low QRS voltage in the limb leads. No previous tracing\navailable for comparison.\n\n"
},
{
"category": "Radiology",
"chartdate": "2160-03-01 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1057397,
"text": " 2:50 PM\n PORTABLE ABDOMEN Clip # \n Reason: r/o ileus, SBO\n Admitting Diagnosis: PULSELESS LEFT LEG\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with\n REASON FOR THIS EXAMINATION:\n r/o ileus, SBO\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLnc SAT 5:23 PM\n Nonspecific findings. No clear evidence of obstruction but this cannot be\n ruled out and CT abdomen might be considered if clinically warranted.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Abdominal pain.\n\n Portable AP radiograph of the abdomen was obtained in supine position.\n\n The NG tube tip is in the stomach. Remnants of oral contrast are seen in the\n small bowel and in large bowel. There is overall paucity of the bowel gas\n with nonspecific appearance of the small bowel. Although no evidence of bowel\n obstruction is seen, the findings are nonspecific and if clinically warranted,\n evaluation with CT abdomen might be considered.\n\n"
},
{
"category": "Radiology",
"chartdate": "2160-03-01 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1057398,
"text": ", R. VSURG CSRU 2:50 PM\n PORTABLE ABDOMEN Clip # \n Reason: r/o ileus, SBO\n Admitting Diagnosis: PULSELESS LEFT LEG\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with\n REASON FOR THIS EXAMINATION:\n r/o ileus, SBO\n ______________________________________________________________________________\n PFI REPORT\n Nonspecific findings. No clear evidence of obstruction but this cannot be\n ruled out and CT abdomen might be considered if clinically warranted.\n\n"
},
{
"category": "Radiology",
"chartdate": "2160-03-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1057395,
"text": " 2:50 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: check R ptx\n Admitting Diagnosis: PULSELESS LEFT LEG\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with\n REASON FOR THIS EXAMINATION:\n check R ptx\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLnc SAT 5:25 PM\n No evidence of pneumothorax. No evidence of significant change compared to\n the prior study.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of right pneumothorax.\n\n Portable AP chest radiograph was compared to obtained at\n 10:38 a.m.\n\n The ET tube tip is 3.5 cm above the carina. The NG tube tip is in the\n stomach. The left subclavian line tip is in the mid SVC. Bibasal\n consolidations are present, unchanged as well as bilateral pleural effusions.\n The right PICC line tip is at the cavoatrial junction.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2160-03-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1057396,
"text": ", R. VSURG CSRU 2:50 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: check R ptx\n Admitting Diagnosis: PULSELESS LEFT LEG\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with\n REASON FOR THIS EXAMINATION:\n check R ptx\n ______________________________________________________________________________\n PFI REPORT\n No evidence of pneumothorax. No evidence of significant change compared to\n the prior study.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2160-03-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1057364,
"text": " 10:45 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p R chest tap, r/o ptx\n Admitting Diagnosis: PULSELESS LEFT LEG\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with\n REASON FOR THIS EXAMINATION:\n s/p R chest tap, r/o ptx\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLnc SAT 12:15 PM\n No evidence of pneumothorax.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of a patient after right pleural effusion\n drainage.\n Portable AP chest radiograph was compared to .\n\n The ET tube tip is approximately 3.6 cm above the carina. The right PICC line\n tip is at the cavoatrial junction. The left subclavian line tip is in the\n superior SVC. The NG tube tip is in the stomach. There is interval decrease\n in the right pleural effusion. No pneumothorax is demonstrated. Still\n present moderate left pleural effusion is seen. Bibasal atelectasis are\n unchanged. The patient continues to be in volume overload\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2160-03-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1057365,
"text": ", R. VSURG CSRU 10:45 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p R chest tap, r/o ptx\n Admitting Diagnosis: PULSELESS LEFT LEG\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with\n REASON FOR THIS EXAMINATION:\n s/p R chest tap, r/o ptx\n ______________________________________________________________________________\n PFI REPORT\n No evidence of pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2160-03-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1057906,
"text": " 10:09 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ? hypotension\n Admitting Diagnosis: PULSELESS LEFT LEG\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with acute hypotension\n REASON FOR THIS EXAMINATION:\n ? hypotension\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient is a 71-year-old female with acute hypotension. Please\n evaluate for possible etiologies of hypotension.\n\n EXAMINATION: Single portable chest radiograph.\n\n COMPARISONS: Comparison to chest radiograph from .\n\n FINDINGS: There is a endotracheal tube 4.1 cm above the level of the carina\n in stable position. A left subclavian central venous catheter and a right-\n sided PICC line are in stable appropriate positions. A nasogastric tube is\n seen coursing below the diaphragm in appropriate position. There is a linear\n density projecting over the right lung field that is likely artifactual in\n nature. There is hazy opacification overlying both lung fields consistent\n with bilateral pleural effusions. There is a stable appearance of right\n basilar atelectasis. No pneumothorax is seen. The cardiomediastinal\n silhouette is stable in appearance. The visualized osseous structures are\n unremarkable.\n\n IMPRESSION: Linear density projecting over the right hemithorax that is\n likely artifactual in nature, recommend repeat radiographs for further\n evaluation. Stable bilateral pleural effusions and right basilar atelectasis.\n The lines in stable position.\n\n These findings were discussed with Dr. which at time of discussion\n patient was stated to be expired.\n\n"
}
] |
98,344 | 170,039 | 78 year old male with abdominal pain and CTA demonstrating thoracic aortic aneurysm descending to level of celiac artery with contained rupture into lateral wall at level of diaphragm. On he was taken to the OR for an emergent repair of ruptured thoracoabdominal aortic aneurysm with a 30-mm Dacron tube graft from just after the left subclavian artery takeoff all the way down to the mid visceral bearing segment of the abdominal aorta using deep hypothermic circulatory arrest and a separate side branch to revascularize the celiac artery. The graft data is the following: Vascutek Gelweave graft, reference #,lot #, serial #. CO-SURGEONS: ,M.D. and , M.D. CARDIOPULMONARY BYPASS TIME: 144 minutes. The visceral ischemic time was 28 minutes. CIRCULATORY ARREST TIME: 32 minutes. Please see operative report for further surgical details. He was transferred intubated and sedated to the CVICU requiring pressor support, in critical condition. In summary: he had a very complicated postoperative course due to cerebral and spinal infarcts with scans showing multiple areas of slow diffusion, predominantly in Left parietal and occipital lobe concerning for sub-acute infarcts, paraplegia, S. marascens bacteremia with presumed graft infection, VAP and post-op wound infection at the back of the thoracotomy site with coag negative staph. The patient had remained intubated until POD#1. RN, Mr. never followed commands for her and noted a change with the lack of gross motor movement of his extremities. He was noted not to be moving the lower extremities, and had asymmetry in the exam of the arms, along with mental status changes after transient episode of hypotension/ atrial arrhythmia and shocks necessitated. He was reintubated. MRI brain and spine performed. MRI of brain showed no significant ischemic changes to explain such a poor mentation. Neurology was consulted and felt imaging findings are consistent with multiple brain infarcts (left > right) and cord infarction; likely attributed to perioperative hypotension and aortic manipulations. EEG negative. Anticoagulation was not initially started. However, after his continued Paroxysmal Afib, and neuro event, Coumadin was ultimately initiated. The patient remains with afluent aphasia and paraplegic. Mr. was taken to the operating room for Trach and PEG placement on with Dr.. Mr. postoperative course continued to get more complicated when he became bacteremic. ID was consulted. Broad spectrum antibiotics were initiated. Cultures revealed E Coli UTI, serratia PNA and S. marascens bacteremia. POD 15 from initial TA AAA repair now with ischemic eschar around the inferior portion of the wound. General Surgery and Plastics was consulted. It was suspected that the latissimus was perforated below the area of eschar. Due to the perigraft and surrounding intrathoracic inflammatory changes and fluid evident, all teams agreed that debridement was required. On Mr. debridement of open wound left scapular region with debridement of muscle, subcutaneous tissue, and skin; latissimus flap reconstruction. Please see operative report for further details. The patient had a flexiseal in place for several days in the setting of his critical illness. Hematochezia became evident. GI and ACS was consulted. The patient was scoped by GI who visualized active rectal bleeding and was concerned for perforation on anoscopy likely secondary to flexi-seal s/p packing, seemingly with hemostasis.Hematocrits remain stable. Mr. began to slowly improve. ID signed off after recommending: antibiotics for wound infection: would continue Vanco/Flagyl for 2 weeks from day of debridement (),for Serratia AAA graft infection: Plan to continue cipro IV for 4 weeks for presumed serratia endovascular infection (). And will require life long suppression with cipro PO after this given presence of graft. Speech and swallow had been consulted and following throughout Mr. course. He remains NPO with continued nutrition, hydration and medication via the PEG in place. He was fitted for a Passy Muir Valve. He weaned to trach collar and PMV during the day hours and is rested overnight on CPAP. After a complicated course from his initial emergent repair of ruptured thoracoabdominal aortic aneurysm, Mr. has made slow progress. On the day of his discharge to rehab on , he remains paraplegic, anticoagulated for PAF/CVA, with a JP drain and sutures intact s/p thoracoabdominal debridement. He is completing his antibiotics per ID recs. All follow up apppointments were advised. | Simple atheroma in aortic arch. Unchanged position of previously described right internal jugular approach sheath. There are simple atheroma in the aortic arch. Normal aortic arch diameter. The right internal jugular catheter is in unchanged position compared to the prior examination. Physiologic (normal) PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Informed consent was obtained. The pancreas is atrophic but appears unchanged. There is left subcutaneous emphysema. A small amount of peri-aortic hematoma is present, also apparently stable. Status post descending thoracic aortic repair with a fluid collection and hematoma surrounding the descending thoracic aorta, little changed in size since the prior examination. FINDINGS: AP single view of the chest has been obtained with patient in semi-upright position. Stable focal consolidation in the right lower lobe and collapse of the left lower lobe unchanged from CT of . Mild [1+] TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Mild [1+] TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Left lower lobe collapse and a small left pleural effusion are unchanged. The appearance of a prominent mediastinum and aortic knob is unchanged. Right jugular sheath ends above the thoracic inlet, ET tube at the sternal notch in standard placement, nasogastric tube passes below the diaphragm and out of view. Tracheostomy tube is in the standard position. Left pleural effusion, at least small in volume, is unchanged. Mildly dilated ascendingaorta. Trace AR.MITRAL VALVE: Normal mitral valve leaflets with trivial MR.TRICUSPID VALVE: Normal tricuspid valve leaflets. Surrounding the descending thoracic aorta is a small-to-moderate amount of fluid which predominantly measures simple in attenuation, although there is some high-density material; however, the overall volume and distribution of this fluid appears little changed. tracting towa Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM FINAL REPORT (Cont) technique, the spleen, adrenals appear normal. The mitral valveappears structurally normal with trivial mitral regurgitation. Intact thoracoabdominal graftfrom the anastomosis site just below the left subclavian up to 45 cm from theincisors. A small amount of soft tissue stranding surrounding the proximal abdominal aorta is unchanged from the prior study. Aorticregurgitation is now mild. PELVIS: Moderate-to-severe sigmoid diverticulosis without diverticulitis is present. There is minimal intrahepatic biliary ductal dilation, little change. Mitral regurgitation appears now to be mild. Left lower lobe partial collapse atelectasis is unchanged. Trace aortic regurgitation is seen. A tracheostomy tube is in standard position. A Foley decompresses the bladder, which contains a small amount of non-dependent air. FINAL REPORT TYPE OF EXAMINATION: Chest AP portable single view. Moderate-to-severe sigmoid diverticulosis without diverticulitis. Physiologic(normal) PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Written informed consent was obtained from the patient. Good (>20 cm/s) LAA ejection velocity.RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.LEFT VENTRICLE: Overall normal LVEF (>55%).RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Left pleural effusion with possible loculation and pleural enhancement. The major intracranial arterial flow voids are noted. Second mid thoracic aortic graft extending to the celiac axis with end-to-end anastomosis appears well opacified. The right IJ Cordis has been removed. Vague areas of low attenuation are identified in the subcortical white matter, likely representing areas of small vessel disease and subacute ischemic changes, previously noted on MRI of the head dated . Calcified pleural plaques are noted above the right hemidiaphragm. Prior inferior myocardial infarction. In the lower cervical/upper thoracic spine, there is a linear T2 hyperintense signal which may relate to syrinx. Prior inferior myocardial infarction with probablelateral involvement. The major intracranial arterial flow voids are noted on the T2-weighted images. Mild anterior wedging is noted in the mid thoracic spine. Left pleural effusion is noted. The SMA appears to originate below the level of the graft from the native aorta. A possible VP shunt is noted overlying the right hemithorax. New opacification of the left costophrenic angle is consistent with moderate pleural effusion. Bilateral mild foraminal narrowing is noted, with the disc abutting the L5 nerves. The premature atrial contractions are absent.TRACING #2 The nasogastric tube has been removed. Vague areas of low attenuation are noted in the centrum semiovale, likely representing edema or areas of small vessel disease, previously demonstrated by MRI of the brain on . Disc space degenerative changes are noted at L5-S1. Evaluation of the thoracic spine is suboptimal due to the pulsation artifacts. At L4-5: Disc desiccation, diffuse disc bulge with a shallow protrusion, and mild facet degenerative changes. Right bundle-branch block with possible left anteriorfascicular block. A left chest tube and probably mediastinal tube are in place. Left lower lobe collapse with small nonhemorrhagic left pleural effusion. At the right base, there are areas of consolidation with air bronchograms. A second graft originating in the mid descending thoracic aorta extends inferiorly with anastomosis distally to the celiac axis. The native abdominal aorta demonstrates mild ectasia above the bifurcation measuring 2.7 x 2.6 cm. There is redemonstration of the treated thoracic aortic aneurysm, with surrounding heterogeneous signal intensity which may relate to the post-surgical changes/hematoma. There is left chest wall subcutaneous emphysema. Dense coronary artery calcifications as well as faint aortic valvular calcifications are noted. There remains a left retrocardiac opacity and some increased opacity within the left upper lung. Multiple areas of slow diffusion as described above, predominantly in the left parietal lobe and the left cerebellar hemisphere and smaller foci in the right parietal lobe and the left occipital lobe. There is a left pleural effusion which is small and measures simple fluid in Hounsfield units. Left-sided pleural effusion. Both lungs demonstrate dependent atelectasis. ( se 8, im 10) In the mid/lower thoracic spine, there are vague areas of increased signal intensity on the T2-weighted images. There is a stable slightly high-density 1.3 cm lesion in the interpolar region of the right kidney posteriorly, previously seen to be most consistent with a hemorrhagic/proteinaceous cyst. | 23 | [
{
"category": "Echo",
"chartdate": "2153-02-05 00:00:00.000",
"description": "Report",
"row_id": 62712,
"text": "PATIENT/TEST INFORMATION:\nIndication: Atrial fibrillation. Endocarditis. Mitral valve disease. Source of embolism.\nHeight: (in) 74\nWeight (lb): 190\nBSA (m2): 2.13 m2\nBP (mm Hg): 119/64\nHR (bpm): 83\nStatus: Inpatient\nDate/Time: at 11:45\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: No spontaneous echo contrast or thrombus in the LA/LAA or the\nRA/RAA. Good (>20 cm/s) LAA ejection velocity.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No masses or\nvegetations on aortic valve. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No mass or vegetation on\nmitral valve. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. No mass or vegetation on\ntricuspid valve. Mild [1+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. No\nvegetation/mass on pulmonic valve. Physiologic (normal) PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Informed consent was obtained. A TEE was performed in the\nlocation listed above. I certify I was present in compliance with HCFA\nregulations. The patient was monitored by a nurse throughout the\nprocedure. Local anesthesia was provided by benzocaine topical spray.\nEchocardiographic results were reviewed with the houseofficer caring for the\npatient.\n\nConclusions:\nNo spontaneous echo contrast or thrombus is seen in the body of the left\natrium/left atrial appendage or the body of the right atrium/right atrial\nappendage. No atrial septal defect is seen by 2D or color Doppler. The\nthoracoabdominal aortic graft is intact up to 45 cm from the incisors. Overall\nleft ventricular systolic function is normal (LVEF>55%). Right ventricular\nchamber size and free wall motion are normal. The aortic valve leaflets (3)\nare mildly thickened. No masses or vegetations are seen on the aortic valve.\nTrace aortic regurgitation is seen. The mitral valve leaflets are mildly\nthickened. No mass or vegetation is seen on the mitral valve. Trivial mitral\nregurgitation is seen. No vegetation/mass is seen on the pulmonic valve. There\nis no pericardial effusion.\n\nIMPRESSION: No evidence of intracardiac thrombus, PFO, or ASD seen. No\nechocardiographic evidence of endocarditis seen. Intact thoracoabdominal graft\nfrom the anastomosis site just below the left subclavian up to 45 cm from the\nincisors.\n\n was notified in person of the results.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2153-01-27 00:00:00.000",
"description": "Report",
"row_id": 62713,
"text": "PATIENT/TEST INFORMATION:\nIndication: Hypertension. Left ventricular function. Preoperative assessment. Thoracoabdominal aortic aneurysm.\nHeight: (in) 72\nWeight (lb): 181\nBSA (m2): 2.04 m2\nBP (mm Hg): 95/60\nHR (bpm): 50\nStatus: Inpatient\nDate/Time: at 14:29\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Marked LA enlargement. Good (>20 cm/s) LAA ejection velocity. No\nthrombus in the LAA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA\nand extending into the RV. No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Overall\nnormal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Mildly dilated ascending\naorta. Normal aortic arch diameter. Simple atheroma in aortic arch. Markedly\ndilated descending aorta Complex (>4mm) atheroma in the descending thoracic\naorta.\n\nAORTIC VALVE: Three aortic valve leaflets. No AS. Trace AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Physiologic\n(normal) PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Written informed consent was obtained from the patient. The\npatient was under general anesthesia throughout the procedure. No TEE related\ncomplications. The patient appears to be in sinus rhythm. Resting bradycardia\n(HR<60bpm). Results were personally reviewed with the MD caring for the\npatient. See Conclusions for post-bypass data\n\nConclusions:\nPRE-BYPASS: No atrial septal defect is seen by 2D or color Doppler. Left\nventricular wall thicknesses are normal. The left ventricular cavity size is\nnormal. Overall left ventricular systolic function is normal (LVEF>55%). Right\nventricular chamber size and free wall motion are normal. The ascending aorta\nis mildly dilated. There are simple atheroma in the aortic arch. The\ndescending thoracic aorta is markedly dilated. There are complex atheroma in\nthe descending thoracic aorta. There are three aortic valve leaflets. There is\nno aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve\nappears structurally normal with trivial mitral regurgitation. There is no\npericardial effusion. Dr. was notified in person of the results at\ntime of surgery.\n\nPOST-BYPASS: The patient is in sinus rhythm. The patient is on a\nnorepinephrine infusion. Biventricular function is unchanged. Aortic\nregurgitation is now mild. Mitral regurgitation appears now to be mild. There\nis a tube graft in the descending aortic position.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2153-02-12 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1232398,
"text": " 8:32 AM\n PORTABLE ABDOMEN Clip # \n Reason: EVAL FOR EXTRAVASATION OG GASTROGRAFFIN; CHECK PLACEMENT OF GASTRIC TUBE\n Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man s/p gastric foley placement for pulled PEG\n REASON FOR THIS EXAMINATION:\n eval for extravastation of gastrograffin\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 78-year-old male, status post replacement of accidentally pulled\n PEG tube with Foley catheter. Evaluate for extraluminal leak of contrast.\n\n FINDINGS:\n\n Two supine images of the abdomen are submitted for review. One obtained prior\n to injection of contrast demonstrates air within the gastric lumen and a\n catheter projecting over the left upper quadrant. There is residual contrast\n in the colon from prior CT scan. The bowel gas pattern is nonspecific.\n Numerous surgical clips are seen throughout the abdomen. There is no supine\n evidence of free air.\n\n A second view was obtained following instillation of Gastrografin contrast\n through Foley residing in the PEG tube track. Gastrografin contrast is seen\n within the lumen of the stomach, layering dependently along the posterior\n gastric wall. There is no extraluminal contrast to specifically suggest a\n leak, however this single image obtained with the patient supine is not\n adequate to definitively exclude a leak, which would be expected to occur\n anteriorly at PEG insertion site -- a region not well assessed with the\n patient in the supine position.\n\n IMPRESSION:\n\n No extraluminal contrast is identified to specifically suggest a leak, however\n as detailed above the PEG tract anteriorly is inadequately assessed with the\n patient in the supine position.\n\n"
},
{
"category": "Radiology",
"chartdate": "2153-02-16 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1233094,
"text": " 4:51 PM\n PORTABLE ABDOMEN Clip # \n Reason: KUB to eval for retroperitoneal air in patient with BRBPR\n Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man s/p TAA replacement\n REASON FOR THIS EXAMINATION:\n KUB to eval for retroperitoneal air in patient with BRBPR\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient after TAA replacement for\n assessment of retroperitoneal air.\n\n AP radiograph of the abdomen was reviewed in comparison to .\n\n The patient is after cholecystectomy. There is no evidence of bowel\n dilatation. Within the limitations of the study technique, there is\n questionable suggestion of the right retroperitoneal air, projecting inferior\n to the surgical clips, although it might reflect normal bowel pattern. If\n retroperitoneal air is clinically suspected, correlation with CT abdomen is\n required.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2153-02-12 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 1232506,
"text": " 4:56 PM\n CT CHEST W/O CONTRAST; CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: eval for fluid collection surrounding graft/ ? tracting towa\n Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man s/p thoracoabd aneurysm repair with infection in wound\n REASON FOR THIS EXAMINATION:\n eval for fluid collection surrounding graft/ ? tracting towards incision\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Thoracoabdominal aneurysm repair with infected wound.\n\n CT TORSO: MDCT imaging was performed from the thoracic inlet to the pubic\n symphysis without IV, or oral contrast. IV contrast was not given due to\n patient's renal dysfunction.\n\n TOTAL DLP: 529.2 mGy-cm.\n\n COMPARISON: CT torso, .\n\n CHEST: The patient is intubated with satisfactory position of the\n endotracheal tube. A left-sided central catheter tip terminates in the distal\n brachiocephalic vein and is not yet entered into the superior vena cava. The\n patient has undergone a descending thoracic aortic repair with a dense\n circumferential band at the level of the aortic arch, stable (2:20). Minimal\n amount of soft tissue stranding is present at the aortic arch, little changed\n from the prior examination. Surrounding the descending thoracic aorta is a\n small-to-moderate amount of fluid which predominantly measures simple in\n attenuation, although there is some high-density material; however, the\n overall volume and distribution of this fluid appears little changed. A small\n amount of peri-aortic hematoma is present, also apparently stable. A new\n locule of subpleural fluid measuring 3 x 1.8 cm is present abutting the left\n mid pleural (2:33). Left lower lobe partial collapse atelectasis is\n unchanged. No definite pneumothorax is present. Numerous surgical clips abut\n the posterior mediastinum (2:20). Lack of IV contrast does limit evaluation\n of the aortic graft.\n\n Consolidation with patchy ground-glass opacity in the left and right lower\n lobe which may be due to infection appear little changed. Basilar segment of\n the left upper lobe including the lingula areas of patchy ground-glass opacity\n also appear little changed, which may also reflect infection, which could be\n due to aspiration. Biapical emphysema is present. The thyroid appears\n normal. No enlarged axillary lymph nodes are present. Multiple lymph nodes\n are present in the mediastinum, which are not pathologically enlarged but may\n be reactive. Dense calcification is present in the region of the left main\n coronary artery, correlate clinically. No pericardial effusion is present.\n\n ABDOMEN: Surgical clips are present at the diaphragmatic hiatus surrounding\n the abdominal aorta related to the graft repair. A small amount of soft\n tissue stranding surrounding the proximal abdominal aorta is unchanged from\n the prior study. Although evaluation is limited by this non-contrast\n (Over)\n\n 4:56 PM\n CT CHEST W/O CONTRAST; CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: eval for fluid collection surrounding graft/ ? tracting towa\n Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n technique, the spleen, adrenals appear normal. The pancreas is atrophic but\n appears unchanged. Surgical clips are present in the gallbladder fossa.\n There is minimal intrahepatic biliary ductal dilation, little change. The\n unenhanced liver appears normal. Arising off the mid pole of the right kidney\n is a hyperdense nodule measuring 14 mm, incompletely evaluated but little\n changed from the prior study. No hydronephrosis is present, and there are no\n renal calculi. No free air is present in the abdomen. There is a\n percutaneous gastrostomy tube in the stomach.\n\n PELVIS: Moderate-to-severe sigmoid diverticulosis without diverticulitis is\n present. A rectal tube is in place. A Foley decompresses the bladder, which\n contains a small amount of non-dependent air. No free air or free fluid is\n present. Several deep pelvic lymph nodes are present, not pathologically\n enlarged and these may be reactive.\n\n BONE WINDOWS: Lumbar spine degenerative changes are present, most pronounced\n at L5-S1 with loss of intervertebral disc space. No suspicious bone lesions,\n however, are present.\n\n IMPRESSION:\n\n 1. Status post descending thoracic aortic repair with a fluid collection and\n hematoma surrounding the descending thoracic aorta, little changed in size\n since the prior examination. Lack of IV contrast; however, limits this\n evaluation including the integrity of the graft repair.\n\n 2. Bibasilar consolidations with ground-glass opacities concerning for\n infection.\n\n 3. Left central line in the distal brachiocephalic vein.\n\n 4. Moderate-to-severe sigmoid diverticulosis without diverticulitis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2153-02-17 00:00:00.000",
"description": "R UNILAT UP EXT VEINS US RIGHT",
"row_id": 1233224,
"text": " 4:17 PM\n UNILAT UP EXT VEINS US RIGHT Clip # \n Reason: RUE US to eval for DVT in patient with 2+ unilateral edema\n Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man s/p TAA replacement, trach and PEGPlease do RUE US to eval for\n DVT in patient with 2+ unilateral edema\n REASON FOR THIS EXAMINATION:\n RUE US to eval for DVT in patient with 2+ unilateral edema\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 78-year-old male with unilateral right upper extremity swelling.\n\n COMPARISON: None available in the system.\n\n RIGHT UPPER EXTREMITY DOPPLER ULTRASOUND: Grayscale and Doppler son of\n the bilateral subclavian, right internal jugular, right axillary, right\n brachial, right basilic and right cephalic veins were obtained. There is\n occlusive thrombus within the right cephalic vein extending from the\n antecubital fossa to the mid upper arm. The vessel cannot be followed more\n centrally due to significant soft tissue edema. The remainder of the examined\n veins demonstrate normal flow, compressibility, and augmentation.\n\n IMPRESSION:\n 1. Extensive clot within the right cephalic vein extending from the\n antecubital fossa to the mid upper arm.\n 2. No deep venous thrombosis.\n\n Dr. communicated the above results to Dr. at\n 5:09 p.m. on by telephone.\n\n"
},
{
"category": "Radiology",
"chartdate": "2153-02-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1232799,
"text": " 5:15 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate chest s/p flap\n Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man\n REASON FOR THIS EXAMINATION:\n evaluate chest s/p flap\n ______________________________________________________________________________\n WET READ: 1:41 AM\n Presumably postoperative subcutaneous emphysema over left chest wall. Drains\n in place. Otherwise no significant change. - \n ______________________________________________________________________________\n FINAL REPORT\n SINGLE FRONTAL VIEW OF THE CHEST\n\n REASON FOR EXAM: Status post flap.\n\n Comparison is made to prior study .\n\n Cardiomegaly is stable. Tracheostomy tube is in the standard position. There\n is no large pneumothorax. Left lower lobe collapse and a small left pleural\n effusion are unchanged. Right lower lobe consolidation is also unchanged.\n There is left subcutaneous emphysema. A presumed left chest tube is difficult\n to evaluate given technique.\n\n"
},
{
"category": "Radiology",
"chartdate": "2153-02-08 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1231930,
"text": " 9:19 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: 44cm left picc. tip? \n Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with new picc\n REASON FOR THIS EXAMINATION:\n 44cm left picc. tip? \n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 78-year-old male with new left-sided PICC line, here to evaluate\n PICC placement.\n\n COMPARISON: Chest radiograph performed on and CT of the torso\n performed on .\n\n PORTABLE FRONTAL CHEST RADIOGRAPH: A left-sided PICC line has been placed\n with the tip terminating at the origin of the SVC. The course of the line is\n unremarkable without pneumothorax. A tracheostomy tube is in standard\n position. There has been interval removal of the feeding tube from the\n preceding radiograph. The appearance of a prominent mediastinum and aortic\n knob is unchanged. Multiple surgical clips are again seen projecting over the\n left mediastinum. The cardiac silhouette is mildly enlarged but stable.\n Opacification of the left lung base is consistent with collapse of the left\n lower lobe as seen on recent CT of . Focal consolidation within the\n right lower lobe is also unchanged from CT.\n\n IMPRESSION:\n 1. Left-sided PICC line with the tip terminating at the origin of the SVC.\n No pneumothorax.\n 2. Stable focal consolidation in the right lower lobe and collapse of the\n left lower lobe unchanged from CT of .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2153-01-30 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1230846,
"text": " 4:22 PM\n CHEST (PORTABLE AP) Clip # \n Reason: volume overload /?\n Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with hypoxemia - intubated and in coma\n REASON FOR THIS EXAMINATION:\n volume overload /?\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: 78-year-old male patient with hypoxemia, intubated and in coma,\n volume overload? ?\n\n FINDINGS: AP single view of the chest has been obtained with patient in\n semi-upright position. Comparison is made with the next preceding similar\n study of . The position of the ETT has been adjusted and\n terminates now in the trachea some 6 cm above the level of the carina.\n Unchanged position of previously described right internal jugular approach\n sheath. No pneumothorax is seen. Again a similar as on the preceding\n examination, there exists bilateral perivascular haze in the central portions\n of the lungs, consistent with edema. Basal densities on left side, probably\n related to postoperative atelectasis has subsided. No new pulmonary\n abnormalities are present and no pneumothorax is seen.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2153-02-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1231791,
"text": " 7:15 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p repair of thoracic aortic aneurysm-check ETT placement\n Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with as above\n REASON FOR THIS EXAMINATION:\n s/p repair of thoracic aortic aneurysm-check ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 78-year-old man with thoracic aortic aneurysm. Check ET tube\n placement.\n\n COMPARISON: Portable AP chest radiograph .\n\n PORTABLE AP CHEST RADIOGRAPH: The ET tube is approximately 3.2 cm above the\n carina. A feeding tube is noted with tip not visualized in the field of view\n provided. Opacification at the left lung base may represent pleural effusion\n with adjacent atelectasis. Underlying infectious process cannot be excluded\n in the correct clinical setting. Opacification in right lung base has\n improved since the most recent prior examination.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2153-01-31 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1230928,
"text": " 10:08 AM\n CHEST (PORTABLE AP) Clip # \n Reason: volume overload\n Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with hypoxemia\n REASON FOR THIS EXAMINATION:\n volume overload\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 9:55 A.M, \n\n HISTORY: Volume overload.\n\n IMPRESSION: AP chest compared to through 6:\n\n Mild pulmonary edema, most readily recognized in the right lung, improved\n between and , subsequently stable. Large region of\n consolidation or atelectasis in the left mid lung is improving, but the left\n lung base is relatively airless. Left pleural effusion, at least small in\n volume, is unchanged. Heart size top normal, stable. Bulge in the\n mediastinum just above the aortic knob could be venous engorgement. Followup\n advised.\n\n Right jugular sheath ends above the thoracic inlet, ET tube at the sternal\n notch in standard placement, nasogastric tube passes below the diaphragm and\n out of view. No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2153-02-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1231063,
"text": " 11:35 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pneumothorax s/p chest tube removal\n Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man s/p TAAA\n REASON FOR THIS EXAMINATION:\n eval for pneumothorax s/p chest tube removal\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 78-year-old man status post AAA. Evaluate for pneumothorax\n status post chest tube removal.\n\n COMPARISON: Portable AP chest radiograph .\n\n PORTABLE AP CHEST RADIOGRAPH: The ET tube is approximately 6.8 cm above the\n carina. The right internal jugular catheter is in unchanged position compared\n to the prior examination. The feeding tube is noted to pass below the\n diaphragm with tip in expected region of the stomach. There is bilateral\n perivascular haze within the lungs, left greater than right, likely\n representing asymmetric pulmonary edema. Left pleural effusion is increased\n since the most recent prior examination. Adjacent compressive atelectasis\n cannot be excluded. Stable widened mediastinum is again noted.\n\n IMPRESSION:\n 1. Left-sided small pleural effusion is increased in size compared to the\n prior examination with adjacent compressive atelectasis.\n 2. Asymmetric pulmonary edema is mildly improved since most recent prior\n examination.\n 3. Stable widened mediastinum.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2153-01-27 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1230520,
"text": " 9:58 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: FAST TRACK ESXTUBATION CARDIAC SURGERY; R/O EFFUSION,PTX,HTX\n Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man s/p L TAA repair\n REASON FOR THIS EXAMINATION:\n FAST TRACK ESXTUBATION CARDIAC SURGERY; R/O EFFUSION,PTX,HTX;CONTACT \n MD if abnormal\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE FRONTAL VIEW OF THE CHEST\n\n REASON FOR EXAM: Status post cardiac surgery.\n\n There is mild-to-moderate cardiomegaly. Swan-Ganz catheter tip is in the main\n pulmonary artery. NG tube tip is in the stomach, side hole just at the level\n of the GE junction should be advanced for more standard position. ET tube tip\n is 6.4 cm above the carina. A left chest tube and probably mediastinal tube\n are in place. There is mild interstitial edema. There are atelectases in the\n lower lobes bilaterally, right greater than left and in the left upper lobe.\n There is no evident pneumothorax or large pleural effusion. There is left\n chest wall subcutaneous emphysema. There is mild mediastinal widening.\n\n"
},
{
"category": "Radiology",
"chartdate": "2153-02-06 00:00:00.000",
"description": "CT CHEST W/CONTRAST",
"row_id": 1231730,
"text": " 4:13 PM\n CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: identify ifectious source\n Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM\n Contrast: VISAPAQUE Amt: 50\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man s/p thoracoabdm repair of rutured type B aneurysm\n REASON FOR THIS EXAMINATION:\n identify ifectious source\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: EHAb TUE 6:11 PM\n 1. Endotracheal tube tip just above carina, which could be pulled back\n slightly. 2. Right lower lobe consolidation, which could represent pneumonia\n or aspiration. Superior left lower lobe ground glass opacities with inferior\n consolidation may also represent infection. 3. Left pleural effusion with\n possible loculation and pleural enhancement. 4. Fluid around the descending\n aorta, which may represent post-operative appearance, but infection cannot be\n excluded. Findings discussed with by phone at 5:41 p.m. on\n .\n ______________________________________________________________________________\n FINAL REPORT\n CT CHEST, ABDOMEN AND PELVIS WITH CONTRAST\n\n DATES: .\n\n COMPARISON: CTA torso , CT abdomen .\n\n CLINICAL INDICATION: 78-year-old man status post thoracoabdominal repair of\n ruptured type B aneurysm. Identify infectious source.\n\n TECHNIQUE: Axial images of the chest, abdomen and pelvis were obtained after\n the uneventful intravenous administration of 50 mL Visipaque given elevated\n creatinine. The patient is not on hemodialysis. Coronal and sagittal\n reformatted images were constructed.\n\n TOTAL EXAM DLP: 617.16 mGy-cm.\n\n FINDINGS:\n\n CHEST:\n\n The patient is status post thoracoabdominal aneurysm repair with Dacron tube\n graft seen just distal to the left subclavian artery takeoff to the level of\n the abdominal aorta, just proximal to the SMA. A second graft originating in\n the mid descending thoracic aorta extends inferiorly with anastomosis distally\n to the celiac axis. The SMA appears to originate below the level of the graft\n from the native aorta. Given limited contrast bolus, evaluation is limited,\n however, the graft to the celiac axis appears well opacified. Fluid density\n surrounds the descending thoracic aortic graft from the level of the arch\n distally, the majority of this likely representing the native aneurysm sac.\n For baseline reference, the native aneurysm sac measures 5.6 x 5.7 cm (2:58)\n (Over)\n\n 4:13 PM\n CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: identify ifectious source\n Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM\n Contrast: VISAPAQUE Amt: 50\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n just above the diaphragmatic crus.\n\n The heart is normal in size. Dense coronary artery calcifications as well as\n faint aortic valvular calcifications are noted. There is no pericardial\n effusion. There is a left pleural effusion which is small and measures simple\n fluid in Hounsfield units. The left lower lobe is collapsed with superimposed\n consolidation difficult to exclude. At the right base, there are areas of\n consolidation with air bronchograms. In addition, there are multiple\n scattered ground-glass opacities throughout the right lower lobe as well as\n bilateral posterior aspects of the upper lobes. Mild centrilobular emphysema\n noted.\n\n The patient is intubated with the tip of the endotracheal tube approximately\n 1.9 cm above the carina. An enteric tube terminates in the distal gastric\n body. Imaged portions of the thyroid gland are within normal limits. There\n is no axillary, mediastinal or hilar adenopathy.\n\n Calcified pleural plaques are noted above the right hemidiaphragm.\n\n ABDOMEN:\n\n The liver and spleen are unremarkable. The patient is status post\n cholecystectomy. There is no intra- or extra-hepatic biliary dilation. The\n adrenal glands are mildly thickened without discrete nodules. There is fatty\n replacement of the head, neck, body and tail of the pancreas with relative\n sparing of the uncinate process resulting in differential densities. The\n pancreas is otherwise unremarkable. The kidneys demonstrate symmetric uptake\n of contrast. There is no excretion during the scan with bolus time for the\n arterial phase and a low contrast dose noted. There is a stable slightly\n high-density 1.3 cm lesion in the interpolar region of the right kidney\n posteriorly, previously seen to be most consistent with a\n hemorrhagic/proteinaceous cyst. There is no mesenteric or retroperitoneal\n adenopathy. No free fluid or pneumoperitoneum. The native abdominal aorta\n demonstrates mild ectasia above the bifurcation measuring 2.7 x 2.6 cm. There\n are infrarenal atherosclerotic calcifications extending into the iliac and\n femoral arteries.\n\n PELVIS:\n\n The bladder is collapsed with Foley catheter in place. Air within the bladder\n likely relates to Foley catheter placement. The prostate and seminal vesicles\n are grossly unremarkable. The rectum is quite distended and stool-filled with\n mild wall thickening and minimal surrounding hazy appearance of the fat.\n Numerous sigmoid and descending colonic diverticula are noted. There is no\n inguinal or pelvic adenopathy. No free fluid in the pelvis. Small\n (Over)\n\n 4:13 PM\n CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: identify ifectious source\n Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM\n Contrast: VISAPAQUE Amt: 50\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n fat-containing left inguinal hernia noted.\n\n OSSEOUS STRUCTURES:\n\n There are no destructive osseous lesions. There is intercostal narrowing\n between the left fourth and fifth ribs as well as the left seventh and eighth\n ribs, consistent with thoracotomy changes. Disc space degenerative changes\n are noted at L5-S1.\n\n IMPRESSION:\n\n 1. Expected postoperative appearance status post repair of thoracoabdominal\n ruptured aneurysm with Dacron graft extending from the takeoff of the left\n subclavian artery to just proximal to the SMA. Second mid thoracic aortic\n graft extending to the celiac axis with end-to-end anastomosis appears well\n opacified.\n 2. Left lower lobe collapse with small nonhemorrhagic left pleural effusion.\n Right lower lobe consolidation and bilateral ground-glass opacities are\n concerning for pneumonia. Correlate with risk of aspiration given\n distribution.\n 3. Large amount of stool in the rectum with focal colonic wall thickening and\n adjacent stranding of the fat. Clinically, if there is fecal impaction,\n stercoral colitis would be considered and the patient would benefit from fecal\n disimpaction.\n\n"
},
{
"category": "ECG",
"chartdate": "2153-01-27 00:00:00.000",
"description": "Report",
"row_id": 118429,
"text": "Sinus bradycardia. Right bundle-branch block with possible left anterior\nfascicular block. Prior inferior myocardial infarction. Poor R wave\nprogression. Non-specific T wave changes. Compared to tracing #1 bradycardia\nis new. The premature atrial contractions are absent.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2153-01-27 00:00:00.000",
"description": "Report",
"row_id": 118430,
"text": "Baseline artifact. Sinus rhythm with premature atrial contractions. Right\nbundle-branch block. Prior inferior myocardial infarction with probable\nlateral involvement. Poor R wave progression. Compared to the previous\ntracing of no significant change.\nTRACING #1\n\n"
},
{
"category": "Radiology",
"chartdate": "2153-01-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1230727,
"text": " 10:01 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ETT placed - ? proper placement\n Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with thoracoabdominal aneurysm repair\n REASON FOR THIS EXAMINATION:\n ETT placed - ? proper placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 78-year-old man with thoracoabdominal aneurysm repair with ET\n tube placement.\n\n COMPARISON: .\n\n PORTABLE CHEST RADIOGRAPH: Surgical clips are noted within the left\n paratracheal region. An ET tube is noted approximately 7.6 cm above the\n carina. A right internal jugular line is in unchanged position. Mediastinal\n drain is noted in correct position. In the interim since the most recent\n prior examination, there has been removal of the Swan-Ganz catheter. Both\n lungs demonstrate dependent atelectasis. New opacification of the left\n costophrenic angle is consistent with moderate pleural effusion. Mild\n pulmonary edema is noted bilaterally. A possible VP shunt is noted overlying\n the right hemithorax.\n\n IMPRESSION:\n 1. ETT is approximately 7.6cm above the carina and needs to be repositioned.\n Findings were conveyed to SICU nurse in the OR, Ms. , who conveyed it to\n NP, at 11:44 am on via telephone.\n 2. Mild bilateral pulmonary edema.\n 3. Left moderate pleural effusion, new since the prior examination.\n\n"
},
{
"category": "Radiology",
"chartdate": "2153-01-30 00:00:00.000",
"description": "MR HEAD W/O CONTRAST",
"row_id": 1230737,
"text": " 12:20 AM\n MR HEAD W/O CONTRAST Clip # \n Reason: 78 year old man s/p TAAA repair w/ LE paralysis\n Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM\n ______________________________________________________________________________\n FINAL ADDENDUM\n The focus of slightly increased DWI signal in the pon-midbrain relates to\n crossing of the corticospinal tracts and is not associated with decreased ADC\n signal to be considered as an infarct. Attention on f/u.\n\n\n\n 12:20 AM\n MR HEAD W/O CONTRAST Clip # \n Reason: 78 year old man s/p TAAA repair w/ LE paralysis\n Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man s/p TAAA repair w/ LE paralysis\n REASON FOR THIS EXAMINATION:\n 78 year old man s/p TAAA repair w/ LE paralysis\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: GJq TUE 3:37 AM\n Multiple acute infarcts in left parietal lobe, left cerebellar hemisphere,\n bilateral posterior limb of internal capsules, cerebral peduncles\n (corticospinal tracts) and midbrain.\n Discussed by Dr with Dr at 2 am on \n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post thoracic AAA repair with lower extremity paralysis.\n\n COMPARISON: No prior head studies.\n\n TECHNIQUE: MR of the head without contrast.\n\n FINDINGS:\n\n There are multiple areas of increased DWI signal scattered in the brain in the\n left parietal lobe, right parietal lobe- periventricular in location (series\n 702, image 23), left occipital lobe (series 702, image 15), and in the left\n cerebellar hemisphere (series 702, image 5). The lesions located in the left\n parietal lobe and the left cerebellar hemisphere demonstrate slow diffusion on\n the ADC sequence. The lesion in the right parietal lobe is too small to be\n accurately identified on the ADC sequence. The lesion in the left occipital\n lobe is not convincingly hypointense on the ADC sequence. There are areas of\n increased signal intensity in the periventricular white matter, subcortical\n white matter in the frontal and the parietal lobes, and in the pons, likely\n nonspecific in appearance and may relate to small vessel ischemic changes,\n inadequately assessed on the present study. The major intracranial arterial\n flow voids are noted. A few prominent perivascular spaces are noted in the\n centrum semiovale and in the hippocampi.\n Negative susceptibility artifacts are noted from an external object in the\n left frontal/parietal region, which obscure part of the left frontal and\n parietal lobes. There is increased signal intensity in the right mastoid air\n cells from fluid/mucosal thickening. Increased signal intensity is noted in\n the mastoid air cells on both sides, right more than left from fluid and\n mucosal thickening. There is mild mucosal thickening in the ethmoid air cells\n and in the sphenoid sinus and fluid in the nasopharynx. There is a T1\n hyperintense focus in the adenoids, which may represent a cyst with dense\n contents, measuring approximately 12.8 x 9.4 mm.\n\n IMPRESSION:\n\n (Over)\n\n 12:20 AM\n MR HEAD W/O CONTRAST Clip # \n Reason: 78 year old man s/p TAAA repair w/ LE paralysis\n Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 1. Multiple areas of slow diffusion as described above, predominantly in the\n left parietal lobe and the left cerebellar hemisphere and smaller foci in the\n right parietal lobe and the left occipital lobe. These are concerning for\n acute-subacute infarcts. Dedicated MR angiogram is not performed on the\n present study. The major intracranial arterial flow voids are noted on the\n T2-weighted images. Correlate for embolic source.\n\n 2. Mucosal thickening and fluid in the mastoid air cells on both sides, mild\n mucosal thickening in the ethmoid air cells and the sphenoid sinus.\n\n Other details as above.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2153-01-30 00:00:00.000",
"description": "MR THORACIC SPINE W/O CONTRAST",
"row_id": 1230738,
"text": " 12:21 AM\n MR THORACIC SPINE W/O CONTRAST; MR L SPINE W/O CONTRAST Clip # \n Reason: 78 year old man s/p TAAA repair w/ LE paralysis\n Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man s/p TAAA repair w/ LE paralysis\n REASON FOR THIS EXAMINATION:\n 78 year old man s/p TAAA repair w/ LE paralysis\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: GJq TUE 3:39 AM\n Multiple areas of slightly increased signal in mid and lower thoracic cord\n matter suspicious for cord ischemia. No evidence of cord compression.\n Findings discussed by Dr with Dr on at 3:30 am\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post TAAA repair with lower extremity paralysis.\n\n COMPARISON: None.\n\n TECHNIQUE: MR of the thoracic and the lumbar spine without contrast. Axial\n T2-weighted images are not available for the thoracic spine.\n\n FINDINGS:\n\n The numbering used for the present study is shown on series 4.\n\n The thoracic vertebral bodies are normal in height and alignment. Mild\n anterior wedging is noted in the mid thoracic spine. The signal intensity of\n the marrow is heterogeneous. Disc desiccation is noted at all levels. No\n pre- or para-vertebral soft tissue swelling or masses are noted. There are\n small perineural cysts in the mid thoracic spine.\n\n In the lower cervical/upper thoracic spine, there is a linear T2 hyperintense\n signal which may relate to syrinx. However, axial T2-weighted images are not\n available at this level. ( se 8, im 10)\n\n In the mid/lower thoracic spine, there are vague areas of increased signal\n intensity on the T2-weighted images. It is uncertain if these are real or\n artifactual as there is no convincing area of abnormality on the sagittal\n T2-weighted sequence except for faint linear hyperintense appearance. If\n these are real, the differential diagnosis is broad and nonspecific and\n ischemic changes/focal area of edema cannot be excluded.\n\n There is redemonstration of the treated thoracic aortic aneurysm, with\n surrounding heterogeneous signal intensity which may relate to the\n post-surgical changes/hematoma. Left pleural effusion is noted. This can be\n better assessed with CT.\n\n MR OF THE LUMBAR SPINE:\n\n (Over)\n\n 12:21 AM\n MR THORACIC SPINE W/O CONTRAST; MR L SPINE W/O CONTRAST Clip # \n Reason: 78 year old man s/p TAAA repair w/ LE paralysis\n Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n The numbering used for the present study is shown on series 12, image 9.\n\n This may or may not necessarily match if counted from C2 downwards.\n\n Heterogeneous signal intensity of the marrow is noted diffusely. While this\n may relate to the ongoing fat deposition, correlation with hematology labs is\n recommended.\n There is disc desiccation at multiple levels.\n\n At L3-4: Mild bulge and bilateral facet changes, no canal or foraminal\n stenosis.\n\n At L4-5: Disc desiccation, diffuse disc bulge with a shallow protrusion, and\n mild facet degenerative changes.\n\n At L5-S1: Narrowing of the disc space, disc desiccation, and increased signal\n intensity in the disc with disc osteophyte complex/extrusion, indenting the\n ventral epidural fat. Bilateral mild foraminal narrowing is noted, with the\n disc abutting the L5 nerves. Facet changes are noted on both sides.\n\n The spinal cord ends at T12-L1 level.\n\n The nerves of the thecal sac are unremarkable.\n\n Prominent epidural fat is noted in the lower lumbar spine.\n\n There are T2 hyperintense foci in the kidney. Please see the details on the\n prior CTA torso done on . There is a focus, with T2 hypointense\n signal with dense appearance on the CT which may represent a\n hemorrhagic/proteinaceous cyst in the right kidney. This needs followup\n evaluation.\n\n IMPRESSION:\n\n 1. Evaluation of the thoracic spine is suboptimal due to the pulsation\n artifacts. While there is no large area of altered signal intensity in the\n thoracic cord demonstrable on two planes, there are vague areas of increased\n signal intensity in the cord on the axial T2-weighted images. It is unclear\n if these are artifactual or real. These are predominantly seen in the\n mid/lower thoracic spine. If real, the differential diagnosis is broad and\n ischemic changes cannot be completely excluded given the history.\n\n Repeat evaluation can be considered with better quality images.\n\n 2. T2 hyperintense focus in the cord in the lower cervical/upper thoracic\n spine may represent a syrinx. This needs further evaluation with dedicated MR\n (Over)\n\n 12:21 AM\n MR THORACIC SPINE W/O CONTRAST; MR L SPINE W/O CONTRAST Clip # \n Reason: 78 year old man s/p TAAA repair w/ LE paralysis\n Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n of the cervical spine and upper thoracic spine without and with contrast.\n\n 3. Status postTAAA surgery, with post-surgical changes and areas of altered\n signal intensity around the dilated thoracic aorta. Correlate with CT study\n if necessary. Left-sided pleural effusion. Evaluation of the details in the\n thorax is limited on the present study.\n\n 4. Multilevel degenerative changes predominantly in the lower lumbar spine at\n L4-5 and L5-S1 levels. Mild foraminal narrowing.\n\n 5. Heterogeneous signal intensity of the marrow likely due to\n scattered/ongoing fat deposition. However, correlation with hematology labs\n is recommended for myeloproliferative or infiltrative disease.\n\n Discussed with Dr..Das by Dr. on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2153-02-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1231367,
"text": " 7:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for consolidation\n Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man s/p TAA repair\n REASON FOR THIS EXAMINATION:\n eval for consolidation\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST FILM AT 5:59\n\n CLINICAL INDICATION: 78-year-old status post TAA repair, evaluate for\n consolidation.\n\n Comparison is made to the patient's previous study dated at 16:33.\n\n Portable semi-upright chest film, at 5:59 is submitted.\n\n IMPRESSION:\n 1. Endotracheal tube, nasogastric tube and left subclavian central line are\n unchanged in position. There are stable postoperative cardiac and mediastinal\n contours in this patient status post a thoracoabdominal aneurysm repair.\n Overall, there is improving aeration in the left lung, although there is\n persistent retrocardiac opacity which may reflect lower lobe atelectasis,\n although pneumonia cannot be excluded. There is also patchy opacity\n persisting at the right base which may represent atelectasis, although an\n early infectious process cannot be excluded. Given overall interval\n improvement, this is felt to most likely reflect resolving mild pulmonary\n edema. Clinical correlation is advised. No evidence of pneumothorax. Small\n to moderate layering left effusion. No large right effusion is seen.\n\n"
},
{
"category": "Radiology",
"chartdate": "2153-02-02 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1231239,
"text": " 4:26 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: post a line\n Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man was intubated due to resp failure\n REASON FOR THIS EXAMINATION:\n post a line\n ______________________________________________________________________________\n WET READ: PBec FRI 11:46 PM\n ett in standard position. unchanged L central line with tip in mid SVC.\n interval removal of R central line. NGT with tip in stomach. persistent\n pulmonary edema though with increasd opacificaiton in left lung may be due\n combinaton of increased size of pleural effusion and assymetric pulmonary\n edema but cannot exclude developing infectious process. unchanged\n cardiomediastinal contour. pbishop\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest .\n\n CLINICAL HISTORY: 78-year-old man intubated due to respiratory failure.\n\n FINDINGS: Comparison is made to the prior study from 35 minutes earlier.\n\n There has been placement of an orogastric tube whose tip and side port are\n below the esophageal junction. The right IJ Cordis has been removed. There\n is a persistent left central venous line with the distal tip perpendicular to\n the distal SVC wall. The endotracheal tube tip is appropriately sited at the\n aortic knob. There remains a left retrocardiac opacity and some increased\n opacity within the left upper lung. The right base demonstrates improved\n aeration. No pneumothoraces are identified.\n\n"
},
{
"category": "Radiology",
"chartdate": "2153-01-30 00:00:00.000",
"description": "CTA HEAD W&W/O C & RECONS",
"row_id": 1230780,
"text": " 9:43 AM\n CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # \n Reason: r/o basilar infarct\n Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with thorocoabdominal aneurysm repair\n REASON FOR THIS EXAMINATION:\n r/o basilar infarct\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: CTA of the head and CTA of the neck.\n\n CLINICAL INDICATION: 78-year-old man with history of thoracoabdominal\n aneurysm repair, rule out basilar infarct.\n\n COMPARISON: Prior MRI of the head dated .\n\n TECHNIQUE: Contiguous axial MDCT images were obtained through the brain\n without contrast material. Subsequently, rapid axial imaging was performed\n from the aortic arch through the brain during the infusion of Omnipaque\n intravenous contrast material. Images were then processed on a separate\n workstation with display of curved reformats, 3D volume-rendered images and\n maximum intensity projection images.\n\n FINDINGS: HEAD CT: There is no evidence of acute intracranial hemorrhage,\n mass effect or shifting of the normally midline structures. Vague areas of\n low attenuation are noted in the centrum semiovale, likely representing edema\n or areas of small vessel disease, previously demonstrated by MRI of the brain\n on . The bone structures are grossly unremarkable. The patient\n is intubated. The orbits and mastoid air cells as well as the paranasal\n sinuses are grossly normal.\n\n HEAD CTA.\n\n There is vascular enhancement along the internal carotid arteries with no\n evidence of critical stenosis throughout the anterior, middle and posterior\n cerebral arteries. The basilar artery appears patent with codominance of the\n vertebral arteries. No aneurysms larger than 2 mm in size are seen.\n\n CTA OF THE NECK.\n\n The origin of the supra-aortic vessels appears normal with no evidence of\n critical stenosis including the cervical carotid bifurcations. The left\n carotid bifurcation demonstrates mild irregular contour at the posterior wall\n of the left internal carotid artery, consistent with soft plaque material.\n Both vertebral arteries are patent. There is no evidence of dissection. The\n bony structures demonstrate multilevel degenerative changes throughout the\n cervical spine with anterior and posterior spondylosis, more severe at C3/C4,\n C4/C5 and C5/C6 levels.\n\n IMPRESSION: 1. There is no evidence of acute or subacute intracranial\n (Over)\n\n 9:43 AM\n CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # \n Reason: r/o basilar infarct\n Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n hemorrhage or mass effect. Vague areas of low attenuation are identified in\n the subcortical white matter, likely representing areas of small vessel\n disease and subacute ischemic changes, previously noted on MRI of the head\n dated .\n\n 2. There is no evidence of flow stenotic lesions in the circle of .\n The basilar artery appears patent with codominance of the vertebral arteries.\n The neck vessels demonstrate mild irregular contour in the posterior wall of\n the left internal carotid artery at the cervical bifurcation, likely\n consistent with soft plaques, however, there is no evidence of significant\n stenosis.\n\n These findings were communicated to Dr. in person by Dr. \n on at 11:03 hours.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2153-02-02 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1231235,
"text": " 4:08 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: evaluate new left sub-clavian TLC and new ETT\n Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with s/p TAA replacement\n REASON FOR THIS EXAMINATION:\n evaluate new left sub-clavian TLC and new ETT\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest .\n\n CLINICAL HISTORY: 78-year-old man status post TAA replacement. With\n left-sided subclavian central line.\n\n FINDINGS: Comparison is made to prior study from .\n\n The nasogastric tube has been removed. There is a new left-sided central\n venous catheter with distal lead tip within the distal SVC, oblique to the SVC\n wall. Endotracheal tube and right IJ Cordis has remained stable in position.\n There remains left retrocardiac opacity and some mild improvement in the edema\n in the left upper lung. No pneumothoraces are seen.\n\n\n"
}
] |
26,285 | 122,922 | The patient was admitted to the MICU. Acute mental status changes, hypotension, she was thought to have a pulmonary embolism or cardiac tamponade. No obvious evidence of infection. The patient initially improved and was sent back to the floor, then began hypotensive again with ST's in the 60's. Attempted VA catheter placement participant discussion with the family. The patient was made CMO. The patient denied on after being made CMO. | Got a bolus X1 for decreased UO. IMPRESSION: Slight progression of fluid overload. CXR done and placment in good and no pneumo noted.FP's high - probably due to pulm HTN. IVF at 150/hr - recieving bolus' as needed for decreased UO. Pt transferred to ICU on amio, with boarderline BP, respiratory distress and VERY low UOP. K 3.5, to be repleted.GI - Abd distended, +BS. Hct and lactate and BUN/cr elevated - ? 98.0 rectal temp. Compared to the previous tracing of paroxysmal supraventricular tachycardia is no longer seen. QR complexeswith incomplete right bundle-branch block in leads VI-V2. Since the previous tracing of intermittent paroxysmalsupraventricular tachycardia is seen again. In brief, pt went into SVT on floor with hypotension. BUN/CR coming down. Using call light for assistance.Resp - Lungs clear, diminished at bases. QRS abnormalitiesare as reported. SG catheter inserted to right IJ by Dr. with some difficulty. Possiblemultifocal atrial tachycardia, at times. Irregular supraventricular rhythm which could be sinus with marked intra-atrialconduction delay and astrial ectopy versus ectopic atrial rhythm withsuperimposed atrial ectopy. Possible mechanisms include atrial tachycardia,A-V re-entrant tachycardia and A-V nodal re-entrant tachycardia with apparentnegative P waves in the ST segments of the inferior leads and slightly variableR-P interval. Peripheral hl x1 in r hand.Resp- Hi O2 at 95%, sats unreadable, tachypneic at times in the 30s, ls coarse, ins/exp wheezes. Delayed precordialtransition. Intermittent paroxysmal supraventricular tachycardia at a rate of about 150with apparent transient termination with an ectopic atrial beat and resumptionof the paroxysmal supraventricular tachycardia with probable negative P wavesin the ST segment, raising differential diagnosis of somewhat atypical A-Vnodal re-entrant tachycardia versus A-V re-entrant tachycardia versus atrialtachycardia. IMPRESSION: 1) Distal location of Swan-Ganz catheter, terminating in the inferior right hilar region. Nursing Note-78 yr old with irreversible PHTN, She is DNR/DNI, now comfort measures only after meeting with family and healthcare proxy.N- She is alert oriented x2 sometimes x3, verbalized discomfort at times, mso4 2mg iv x2 with good effct. GU Foley is patent--flushed. CV: Afebrile. +BS, very sm liq stool, dark.GU: uo 10-31 cc/hr. Combination of findings is strongly suggestive of right ventricularoverload, for example due to chronic obstructive pulmonary disease, etc.Borderline low voltage diffusely. dehydrated. Previous tracing showed sinus rhythmwith left axis deviation. Sinus versus ectopic atrial tachycardia with frequent atrial ectopy. NPO except meds during line procedures. Dopplerable pedal pulses, +2 pitting edema in feet. Abd softly distended. CPK trending down. Differentialdiagnosis includes A-V nodal re-entrant tachycardia versus A-V re-entranttachycardia versus atrial tachycardia. r/t excessive vaseline application. OB (+). Right axis deviation. There is unchanged patchy scarring within the region of the lingula. Paroxysmal supraventricular tachycardia at a rate of about 180. K and MG repleted. Otherwise, there continues to be some slight prominence of the pulmonary vessels consistent with an element of fluid overload. BP 90-103/systolic. CO by fick method 3.3, CI 1.75. Afebrile. NSR/ST 90s-100s with occ PACs. The aorta is calcified and tortuous. C-diff needs to be sent if pt produces stool. Clinical correlation issuggested.TRACING #2 However, cannot exclude fascicular tachycardia with incompleteright bundle-branch block and right axis deviation pattern. Clinical correlation is suggested.TRACING #1 Clinical correlation is suggested.TRACING #1 Given IVF and pt much more stable. Compared to the previous tracing of relatively regular probable paroxysmal supraventricular tachycardia type rhythmat a rate of 150 has converted to the present rhythm. 150 mg IV amiodarone given on floor and pt converted to NSR. The lungs are slightly hyperinflated. QR complexes inleads VI-V2 may be related to the rate but, in the context of the right axisdeviation, also raise consideration of acute or subacute right ventricularoverloda. CV - NSR with frequent PAC's. She moves all extremities but is limited by dypsnea. On admission to ED here - she was hypotensive and hypoxic. Need doppler to asses pedal pulses. MICU nursingNeuro: A&O x3. PNA started on Levoflox today. BP 98-112/43-68. Fingers are cool and cyanotic. Possibly a left lower lobe infiltrate remains. Since the previous tracing of paroxysmal supraventricular tachycardia is again noted at a more rapid rate.Underlying QRS complex again shows right axis deviation with right precordialQR complexes consistent with severe right ventricular overload, in addition tothe other findings as previously noted. MICU nursing progress note 7P-7ANeuro - A&O x 3, MAE. Please note that the catheter is kinked and there may be poor performance using this catheter. No c/o pain.CV: BP 93-121/58-71. REASON FOR THIS EXAMINATION: Evaluate for pulm edema FINAL REPORT PORTABLE CHEST, AT 13:47: INDICATION: Hypotension and wheezing. Pt has vescicular rash over lips--? FINDINGS: A left subclavian line has been placed and the tip is seen in the brachiocephalic region. Left lower lobe infiltrate possible. IMPRESSION: No pneumothorax following placement of left subclavian line; line is kinked. If she does - she needs a spec sent for CDiff. coarse BS. very supportive.Pt DNR/DNI. Fluid overload. Since the previous tracing of tachy-arrhythmia is new andother findings are new or more apparent. Team attempted swan-ganz placement attempted X 2 but L SC cordis kinked on CXR and it is currently being replaced. Since admission,pt continued to have significant resp distress (DNR/DNI) with BP in 90's and No UOP. Not able to get consistent pleth for O2 Sat. primary doctor was in to see PT, were in agreement with the plan for comfort measures only given the fact that her situation is irreversible.CV- Hr 70s sr, no ectopy, denies cp, bp 66/18 - 88/60. PERL. HR unresponsive to lopressor, fluids (6L) and adenosine. Paroxysmal supraventricular tachycardia with intermittent ventricular prematurebeats, rate about 150. Pt does have a living will and is a DNR/DNI. Bibasilar crackles posteriorally. Fluids at 75cc/o. | 14 | [
{
"category": "Radiology",
"chartdate": "2131-12-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 813803,
"text": " 5:04 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p SC line placement\n Admitting Diagnosis: TACHYCARDIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with hypotension s/p 4 liters of fluid, wheezing.\n\n REASON FOR THIS EXAMINATION:\n s/p SC line placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Subclavian line placement.\n\n FINDINGS: A left subclavian line has been placed and the tip is seen in the\n brachiocephalic region. Please note that the catheter is kinked and there may\n be poor performance using this catheter. Otherwise, there continues to be some\n slight prominence of the pulmonary vessels consistent with an element of fluid\n overload. I see no significant difference including the persistence of\n suspicion for retrocardiac air-space disease. Lateral view recommended when\n feasible.\n\n IMPRESSION: No pneumothorax following placement of left subclavian line; line\n is kinked.\n\n Fluid overload.\n\n Suspicion for retrocardiac air-space consolidation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-12-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 813787,
"text": " 1:16 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for pulm edema\n Admitting Diagnosis: TACHYCARDIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with hypotension s/p 4 liters of fluid, wheezing.\n\n REASON FOR THIS EXAMINATION:\n Evaluate for pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, AT 13:47:\n\n INDICATION: Hypotension and wheezing.\n\n COMPARISON: .\n\n FINDINGS: The Swan-Ganz catheter has been removed and there is no\n pneumothorax. The pulmonary vessels appear more prominent compared to prior\n but this is a subtle change. The left hemidiaphragm is not as well seen but\n this could be due to under-penetration. Possibly a left lower lobe infiltrate\n remains.\n\n Cardiomegaly is unchanged.\n\n IMPRESSION: Slight progression of fluid overload. Left lower lobe infiltrate\n possible.\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-12-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 813502,
"text": " 3:07 PM\n CHEST (PORTABLE AP) Clip # \n Reason: look for infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with hypotension\n REASON FOR THIS EXAMINATION:\n look for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 78 y/o female with hypotension.\n\n FINDINGS: Comparison is made to prior study of .\n\n The heart is enlarged but stable in size when compared to the prior exam. The\n aorta is calcified and tortuous. The mediastinal contours are stable. There\n is no evidence of pulmonary parenchymal consolidation, failure, pneumothorax,\n or pleural effusions. The osseous structures are unremarkable. The lungs are\n slightly hyperinflated. There is unchanged patchy scarring within the region\n of the lingula.\n\n IMPRESSION: No evidence of an acute cardiopulmonary process.\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-12-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 813544,
"text": " 1:50 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p PA\n Admitting Diagnosis: TACHYCARDIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with hypotension\n\n REASON FOR THIS EXAMINATION:\n s/p PA\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: Hypotension.\n\n Comparison is made to previous radiograph from 1 day earlier.\n\n A Swan-Ganz catheter has been placed with the distal tip projecting in the\n distal right hilar region, likely in the distal interlobar pulmonary artery\n near the junction within the right lower lobe branch. The cardiac and\n mediastinal contours are stable. There is no evidence of congestive heart\n failure, and there is no evidence of either pneumothorax or significant\n pleural effusion.\n\n IMPRESSION: 1) Distal location of Swan-Ganz catheter, terminating in the\n inferior right hilar region. No pneumothorax.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-12-21 00:00:00.000",
"description": "Report",
"row_id": 1605709,
"text": "MICU nursing\nNeuro: A&O x3. Calm and cooperative. Slept in naps all day. MAE. PERL. No c/o pain.\n\nCV: BP 93-121/58-71. NSR with occ PACs, 84-99. SG cath in place, PA pressures 80/40, wedge 20. CO by fick method 3.3, CI 1.75. Plan is to pull cath later today, pressures high, but hx Pul HTN. Afebrile. Card . trending down. Plan is to cath pt early next week when stable. K and MG repleted. Weak pulses in feet, somewhat cold. Also weak radial pulses, hands cold, some blue fingertips.\n\nResp: ? PNA started on Levoflox today. coarse BS. On 4 L NC O2 sat dampened most of day, 97% now. No c/o SOB.\n\nGI: clear liquids tol well, progress to renal diet. +BS, very sm liq stool, dark.\n\nGU: uo 10-31 cc/hr. BUN/CR coming down. Got one bolus of 500 mls this shift. Up total of 2L.\n\nSocial: visited by son and friends. very supportive.\n\nPt DNR/DNI.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-12-22 00:00:00.000",
"description": "Report",
"row_id": 1605710,
"text": "MICU nursing progress note 7P-7A\nNeuro - A&O x 3, MAE. Cooperative with care. Ambien 10 mg at HS, slept in naps. Awake frequently to use bedpan. Using call light for assistance.\n\nResp - Lungs clear, diminished at bases. Sats 100% 4 L NC. RR 15-20.\n\nCV - PAC d/c'd tonight, RIJ dsg C&D, site is eccymotic. BP 98-112/43-68. NSR/ST 90s-100s with occ PACs. PACs more frequent when PA line in. CPK trending down. Dopplerable pedal pulses, +2 pitting edema in feet. Toes are warm, pink. Fingers are cool and cyanotic. K 3.5, to be repleted.\n\nGI - Abd distended, +BS. Frequent small green liquid stools on bedpan. OB (+). Taking POs well, very thirsty and drinking plenty of H2O. Also ate soup and jello for dinner. Fluid balance even at midnite.\n\nGU - U/O 30-40cc/hr clear yellow urine.\n\nSkin - Peri area very red and irritated from frequent stool , peri care and aloe vesta applied.\n\nSocial - Pt called her HCP on her phone last night.\n\nID - Afebrile. BC x 1 bottle gram + cocci in pairs and clusters. On Levoquin for ? PNA.\n\nPlan - Cardiac cath Tuesday to evaluate pulmonary Htn. Monitor fluid balance.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-12-23 00:00:00.000",
"description": "Report",
"row_id": 1605711,
"text": "MICU Nursing Admission Note:\n Please refer to nursing admission history for events prior to admission. In brief, pt went into SVT on floor with hypotension. HR unresponsive to lopressor, fluids (6L) and adenosine. 150 mg IV amiodarone given on floor and pt converted to NSR. Amio gtt started at 1300. Pt transferred to ICU on amio, with boarderline BP, respiratory distress and VERY low UOP.\n Since admission,pt continued to have significant resp distress (DNR/DNI) with BP in 90's and No UOP. Team attempted swan-ganz placement attempted X 2 but L SC cordis kinked on CXR and it is currently being replaced. ABG was acceptable but with huge AA gradient with Po2 only 88% on 95%. Awaiting line placement for determination of fluid status and lyte repletion.\n\n Neuro: Pt alert and oriented but she requires frequent reminders during procedures. She moves all extremities but is limited by dypsnea.\n\n CV: Afebrile. 98.0 rectal temp. Pt in NSR with rate in 70's. No ectopy. No episodes of SVT. BP 90-103/systolic. Lytes low from 3pm blood draw, but team has been unable to establish IV access--will infuse once pt is swanned. Pt currently with 1 PIV that the amio is currently infusing a 1 mg/min (due to be turned down to 0.5 mg/min at 1900).\n\n Pulm: UNABLE TO OBTAIN RELIABLE SAT!! When pt was satting 66% (with poor pleth) P02 on blood gas was 88. Pt continues to have primary c/o of SOB--02 currently on95%. Team to place a line later today. Bibasilar crackles posteriorally. No cough.\n\n GI: Pt taking sips and able to swallow pills. NPO except meds during line procedures. Abd softly distended. No episodes of diarrhea. C-diff needs to be sent if pt produces stool.\n\n GU Foley is patent--flushed. Team would like to send urine lytes if pt makes more urine (none produced since flush).\n\n Skin: Groin is red and excoriated--triple barrier cream at bedside. It appears to be helping (skin is less red than previously). Pt has vescicular rash over lips--? r/t excessive vaseline application. Pt encouraged to leave rash alone and let it air out.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-12-24 00:00:00.000",
"description": "Report",
"row_id": 1605712,
"text": "Nursing Note-\n78 yr old with irreversible PHTN, She is DNR/DNI, now comfort measures only after meeting with family and healthcare proxy.\n\nN- She is alert oriented x2 sometimes x3, verbalized discomfort at times, mso4 2mg iv x2 with good effct. pt asked for bed pan, communicate effectively with family members. primary doctor was in to see PT, were in agreement with the plan for comfort measures only given the fact that her situation is irreversible.\n\nCV- Hr 70s sr, no ectopy, denies cp, bp 66/18 - 88/60. Fluids at 75cc/o. All meds dc po and ivs except for pain med and anti-nausea. Peripheral hl x1 in r hand.\n\nResp- Hi O2 at 95%, sats unreadable, tachypneic at times in the 30s, ls coarse, ins/exp wheezes. No blood draws.\n\nGI/GU - Pt asking for sips of water, abd soft, no bm. Kidney function decresed, uop 14 cc over 12 hrs.\n\nSkin- Warm, dry and intact.\n\nSocial- and husband from in to visit, son at bedside for most of shift. They are all in agreement with plan. Another son to fly in from this am.\n\nPlan- CMO, no blood draws, pt can be transferred to a floor bed when available..\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-12-21 00:00:00.000",
"description": "Report",
"row_id": 1605708,
"text": "78 yo female found at home was change in mental status - question as to whether she took too many ambiens. On admission to ED here - she was hypotensive and hypoxic. Hct and lactate and BUN/cr elevated - ? dehydrated. Given IVF and pt much more stable. Transferred to the MICU for further observation and monitoring.\n Pt admitted to MICU at 2300 and transferred onto bed without problem. Pt has 18g AC to the right arm and 16g AC to the left arm. Pt on 4L NC and with a foley catheter.\n Neuro - Alert and oriented X3. Sometimes get slightly confused but easily reoriented to place and time. MAE and very cooperative and helpful with care. Pt very pleasant and has a remarkable memory for names. She is trying to remember the names of all the people who take care of her!\n CV - NSR with frequent PAC's. SG catheter inserted to right IJ by Dr. with some difficulty. CXR done and placment in good and no pneumo noted.\nFP's high - probably due to pulm HTN. Unable to wedge at this time - team plans to advance it in the morning. IVF at 150/hr - recieving bolus' as needed for decreased UO. Pt has been noted to have a few episodes of SVT to rate of 150's but breaks on her own. She is VERY sensitive to movement of the SG and does have increased vent ectopy with one 4 beat run VT.\n Resp - BS cl bilat. O2 at 4L NC. No c/o SOB.\n GI - Abd large and soft. Pt has been having diarrhea for a couple of days - diaper on but pt has had no BM's here. If she does - she needs a spec sent for CDiff. No c/o nausea.\n GU - Foley cath draining marg amt cl yellow urine. Got a bolus X1 for decreased UO.\n Vascular - Pt's hands and feet very cold. Need doppler to asses pedal pulses. Not able to get consistent pleth for O2 Sat.\n Social - son and sister here last evening. They will be back in the morning. Very supportive and asking appropriate questions.\n Pt does have a living will and is a DNR/DNI.\n\n\n\n\n\n"
},
{
"category": "ECG",
"chartdate": "2131-12-21 00:00:00.000",
"description": "Report",
"row_id": 284146,
"text": "Sinus versus ectopic atrial tachycardia with frequent atrial ectopy. Possible\nmultifocal atrial tachycardia, at times. Right axis deviation. QR complexes\nwith incomplete right bundle-branch block in leads VI-V2. Delayed precordial\ntransition. Combination of findings is strongly suggestive of right ventricular\noverload, for example due to chronic obstructive pulmonary disease, etc.\nBorderline low voltage diffusely. Compared to the previous tracing of \nrelatively regular probable paroxysmal supraventricular tachycardia type rhythm\nat a rate of 150 has converted to the present rhythm. Clinical correlation is\nsuggested.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2131-12-23 00:00:00.000",
"description": "Report",
"row_id": 283914,
"text": "Intermittent paroxysmal supraventricular tachycardia at a rate of about 150\nwith apparent transient termination with an ectopic atrial beat and resumption\nof the paroxysmal supraventricular tachycardia with probable negative P waves\nin the ST segment, raising differential diagnosis of somewhat atypical A-V\nnodal re-entrant tachycardia versus A-V re-entrant tachycardia versus atrial\ntachycardia. Since the previous tracing of intermittent paroxysmal\nsupraventricular tachycardia is seen again. Other abnormalities asrse as\nreported. Clinical correlation is suggested.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2131-12-23 00:00:00.000",
"description": "Report",
"row_id": 283915,
"text": "Irregular supraventricular rhythm which could be sinus with marked intra-atrial\nconduction delay and astrial ectopy versus ectopic atrial rhythm with\nsuperimposed atrial ectopy. Compared to the previous tracing of \nparoxysmal supraventricular tachycardia is no longer seen. QRS abnormalities\nare as reported. Clinical correlation is suggested.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2131-12-23 00:00:00.000",
"description": "Report",
"row_id": 283916,
"text": "Paroxysmal supraventricular tachycardia at a rate of about 180. Differential\ndiagnosis includes A-V nodal re-entrant tachycardia versus A-V re-entrant\ntachycardia versus atrial tachycardia. Since the previous tracing of \nparoxysmal supraventricular tachycardia is again noted at a more rapid rate.\nUnderlying QRS complex again shows right axis deviation with right precordial\nQR complexes consistent with severe right ventricular overload, in addition to\nthe other findings as previously noted. Clinical correlation is suggested.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2131-12-20 00:00:00.000",
"description": "Report",
"row_id": 284147,
"text": "Paroxysmal supraventricular tachycardia with intermittent ventricular premature\nbeats, rate about 150. Possible mechanisms include atrial tachycardia,\nA-V re-entrant tachycardia and A-V nodal re-entrant tachycardia with apparent\nnegative P waves in the ST segments of the inferior leads and slightly variable\nR-P interval. However, cannot exclude fascicular tachycardia with incomplete\nright bundle-branch block and right axis deviation pattern. QR complexes in\nleads VI-V2 may be related to the rate but, in the context of the right axis\ndeviation, also raise consideration of acute or subacute right ventricular\noverloda. Since the previous tracing of tachy-arrhythmia is new and\nother findings are new or more apparent. Previous tracing showed sinus rhythm\nwith left axis deviation. Clinical correlation is suggested.\nTRACING #1\n\n"
}
] |
8,499 | 130,407 | 31yo F admitted to Surgery service with presumptive diagnosis of parathyroid tumor causing hypercalcemia. Endocrine and renal consults obtained. Admission labs showed a calcium 15 and the pt was transferred to the SICU. She received aggressive IV hydration and diuresis, electrolyte repletion of K, and pamidronate, calcitonin, and kept NPO. CT abdomen performed showed pancreatitis, 2.9cm mass inferior to aortic bifurcation, no renal vein thrombosis. Thyroid US confirmed R-sided nodule 2x3x2. MRI confirmed no renal vein thrombosis and pelvic mass inferior to aortic bifurcation. On HD 4 she was taken to the operating room for R upper parathyroidectomy and R thyroid lobectomy; please see operative report for details. The PTH decreased dramatically on intra-op sample and post-op calcium was 9.9. The pt remained monitored in the SICU with frequent calcium checks and was provided low-dose po supplementation. She was transferred to the regular floor on POD 2, but subseqeuent calciums continued to decrease to a nadir of 6.1, with hypophosphatemia suggestive of "hungry bones" phenomenon. Endocrine consult remained active and helpful throughout. She was completely asymptomatic but was transferred back to the SICU for aggressive repletion and closer observation. She was begun on a calcium drip, received significant PO and IVF one-time repletions, and calcium level returned to 9.5. When this trended upwards, the calcium drip was discontinued and the calcium level stabilized. She was returned to the regular floor on POD 4 with a PO-only regimen which was confirmed to be stable on serial calcium checks. She was discharged on POD 5 with a stable PO regimen, closely arranged follow-up with endocrine, tolerating a regular diet and without sx's of hyper or hypocalcemia. | REnal: pt with bun/Creat10-13/.9-1.0. pt with 1 formed solid bm o/n. Continues on Calcitonin and Cinaket for hypercalcemia with Ca+ trending down. pt found to be hypercalcemic. 3) Retroperitoneal mass as described. pt alert and oriented in nad w/ the following lines, tubes and dsgs: rscl tri lumen( pulled back on arrival by md's), l fem quentin cath, l rad a-line, #16angio l ant forearm, #20angio rac,foley ->gr, ant neck dsg d&i, nc 3l o2.neuro- a+o, very pleasant, mae's fc, turns selfresp- 3lnc, o2 sao2 98-100%, rr 14-20, bs cta, strong nonproductive cough.cvs- tm 98.9po, hr 90's nsr, no ectopy, sbp 104-130's, cvp 3-5. ivf d5w@100cc/hr. Sinus rhythmNormal ECG Calcitronin Q12/hr. NPN 7p-7a: Review of Systems: Nuero: pt A+O x 3. no c/o pain. if would benefit from alternating 1L of each fluid to maintain optimum K+?). RESP: LS CTA, rr 16-32, O2 sats 98-99 on RA. NPN 7p-7aEvents over NOC. 3) 2.9cm mass in the midline pelvis, just inferior to the aortic bifurcation. t-sicu nsg note:pt arrived from s/p r upper parathyroidectomy and r thyroid lobectomy @1am. cont to follow q2 hrs chem 10, cont vigorous hydration, pamidronate, calcitonin, etc. fluid balance negative 1L. Within the midportion of the right lobe, there is a predominantly solid 2.1 x 3.0 x 2.4 cm nodule. TECHNIQUE: Multiplanar T1 and T2-weighted sequences of the abdomen were obtained with and without gadolinium for angiographic and venographic technique. CONCLUSION: Left-sided, vigorously enhancing scalp mass. CV: HR 90's nsr, no ectopy. Tylenol for H/A. Currently receiving vigorous ivf, pamidronate, calcitonin. MgS04 4 gms for mg 1.6. repeat lytes at 2100. (4grams infusing now) K+ phos infusing currently. The spleen and adrenal glands are within normal limits. repleated with K+ and Kphos earlier in shift. +BS No BM. Cont to follow q 2 hrs labs, cont antihypercalcemic regime. calcitonin q 12 hrs, and . Dominant right-sided thyroid nodule. MRI angio of renal arteries done today to r/u renal thrombosis, results pnding.Skin: Dry, intact. ABDOMEN WITHOUT AND WITH CONTRAST: The lung bases are clear. K goal of 4.0 met.ID: TMAX 99.6 @ 04:00. Continue with Q2/hr labs, conting antihypercalcemia regimen. Last dose of Mucomyst given.F/E: Mag (mag sulfate x1), Phos (K-Phos x1) and K (10meq x2, LR with 20meq KCl gtt currently at 200cc/hr) repleted. No ectopy noted.GI: Abd soft, hypo active BS. There is mild intrahepatic biliary ductal dilatation. SBP 99-130's/50-80's. IMPRESSION: 1) The pancreatic, renal, and biliary tree findings are most consistent with (Over) 2:06 PM CT ABD W&W/O C; CT PELVIS W&W/O C Clip # CT 150CC NONIONIC CONTRAST Reason: renal vein thrombos propogating off IVC, Need triple phase c Admitting Diagnosis: PARATHYROID CANCER Contrast: OPTIRAY Amt: FINAL REPORT (REVISED) (Cont) autoimmune pancreatitis. rr 16-20. gI: ab soft, bs hypo. LS Clear x 4. no cough noted.CV: NSR HR 85-90's. 2) Tiny bilateral nonobstructing renal stones. Remainder of Pamitodrine infusing, since off floor and limited access. No deficits.CV: HR=100-90s, NSR/ST no ectopy. pt receiving protonix. cont on cinacalcet and calcitonin for hypercalcemia. FULL CODE Universal Precautions NKDANeuro: AAOx3, OOB to commode/chair w/ min assistance. KEYWORD: RETROPERITONEUM Pheochromacytoma, ? SUPINE AP CHEST: There has been interval placement of a right subclavian central venous catheter, with the tip overlying the right atrium. Pt with thyroid mass, pancreatitis and L occipital scalp soft tissue mass (? Calcium 12.5 down to 11.4 this am. TECHNIQUE: Contiguous axial images through the abdomen and pelvis were obtained before and multiphases after the administration of 150 cc of Optiray nonionic contrast. GI: ab soft, hypoactive BS. +BS. CT scan to head today to visualize occipital mass, no results read as of current.Resp: RR 14-25. sats 98-100% on RA. Pt with blood cx pending. no antibx.Labs: Ca+=1.21 to 1.15. w/u revealed hyperparathyroid, pancreatitis, decreased flow through vena cava, as well as occipital and parathyroid masses. Evaluate placement and for pneumothorax. Assess for parathyroid mass. The kidneys are slightly prominent, but with symmetric nephrograms. SBP 90's-120's. MRI: Kidneys are enlarged, without solid mass, cortical thinning, or hydronephrosis. Pt c/o nausea at ~03:00, given anzimet x1 with good relief. ON 10, labwork recealed calcium still 15. pt given ivf bolus 1L and 40mg lasix. Monitor resp/cardiac/neuro status. Continue with Q2/hr labs and replete K+ as needed. The remainder of the gland demonstrates normal-appearing homogeneous echotexture. Ca+ trending down with current tx modality. The lesion is T1W dark and T2W bright, and appears to demonstrate enhancement after the administration of gadolinium. There are tiny (2 mm) nonobstructing renal stones bilaterally. PELVIS WITH CONTRAST: There is a soft tissue density mass just inferior to the aortic bifurcation measuring 2.7 x 2.9 cm. Access: 2 piv's and L groin HD line. Access: 2 piv's and L groin HD line. Remains on Q2/hr labs, current 17:00 pnding. Pt a bit sleepy after Compazine dose.Resp: No O2 delivery device. The heart, mediastinal and hilar contours are normal. D5W infusing for hypernatremia, and LR with 20meq of Kcl. 1530/0700 PT TO SICU FROM 9 FOR CAL DRIPNEURO A/O RELAXED NO PAIN OR DISCOMFORT MAE WELL NO SOBRESP ROOM AIR SAO2 100 CLEAR LUNGS RR 18 TO 20HEART S1S2 NO RUB OR M NVD NEG NSR TO ST PR .14 QRS .08GI POS B/S THRU OUT PO WELL U/O QSPLAN Q4 LAB WORK REPORT TO MD WITH RESULTS | 19 | [
{
"category": "Radiology",
"chartdate": "2115-02-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 861161,
"text": " 1:00 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ptx\n Admitting Diagnosis: PARATHYROID CANCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with L SC attempt (line NOT placed), eval for ptx\n REASON FOR THIS EXAMINATION:\n ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post left subclavian line attempt.\n\n COMPARISON: No studies were available for comparison.\n\n AP UPRIGHT VIEW OF THE CHEST: No pneumothorax is identified. The heart size\n is normal. The mediastinal and hilar contours are normal. The lungs are\n clear. There is no pleural effusion.\n\n IMPRESSION: No evidence of pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-02-26 00:00:00.000",
"description": "MRI ABDOMEN W/O & W/CONTRAST",
"row_id": 860907,
"text": " 3:33 PM\n MRI ABDOMEN W/O & W/CONTRAST; MRA KIDNEY W&W/O CONTRAST Clip # \n MR CONTRAST GADOLIN\n Reason: re eval renal thrombosis\n Admitting Diagnosis: PARATHYROID CANCER\n Contrast: MAGNEVIST Amt: 30\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with hypercalcimia, h/o renal thrombosis\n REASON FOR THIS EXAMINATION:\n re eval renal thrombosis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hypercalcemia, reevaluate for renal vein thrombosis.\n\n TECHNIQUE: Multiplanar T1 and T2-weighted sequences of the abdomen were\n obtained with and without gadolinium for angiographic and venographic\n technique. No prior MRIs available. Correlation is made with CT scan\n performed one hour earlier, which demonstrated widely patent renal arteries\n and veins.\n\n FINDINGS:\n\n MRA: Renal arteries and renal veins are widely patent. No evidence of\n thrombus within the inferior vena cava. A left common femoral vein central\n line is noted, which demonstrates thickening at its tip, consistent with\n thrombus at the tip of the catheter.\n\n MRI: Kidneys are enlarged, without solid mass, cortical thinning, or\n hydronephrosis. Right kidney measures approximately 12 cm in length x 7 cm\n transverse x 7 cm AP, and the left kidney measures approximately 13 cm long x\n 8 cm transverse x 7 cm AP. Of note, the kidneys demonstrate unusually\n prominent corticomedullary differentiation on T1-weighted sequences, and\n diffuse bright signal on T2-weighted sequences. Correlation with serum BUN\n and creatinine is advised.\n\n The abdominal and pelvic viscera, the adrenals, spleen, pancreas, gallbladder,\n and liver are grossly unremarkable, with note made of subcentimeter cysts\n within the liver.\n\n Within the retroperitoneum immediately anterior to the aortic bifurcation,\n there is a solid mass measuring approximately 3 cm x 2.3 cm x 3.8 cm. The\n lesion is T1W dark and T2W bright, and appears to demonstrate enhancement\n after the administration of gadolinium. Possibilities include a metastatic\n lymph node, though other possibilities would include a primary retroperitoneal\n neoplasm such as lymphoma, desmoid tumor, or a mesenchymal neoplasm. If there\n is a known history of neurofibromatosis, as suggested by history, then\n neurofibroma or pheochromocytoma would be additional possibilities.\n\n No ascites.\n\n No suspicious bony lesions.\n\n (Over)\n\n 3:33 PM\n MRI ABDOMEN W/O & W/CONTRAST; MRA KIDNEY W&W/O CONTRAST Clip # \n MR CONTRAST GADOLIN\n Reason: re eval renal thrombosis\n Admitting Diagnosis: PARATHYROID CANCER\n Contrast: MAGNEVIST Amt: 30\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Multiplanar reconstructions confirm the above findings, and were essential for\n diagnosis.\n\n IMPRESSION:\n\n 1) No evidence of renal vein or IVC thrombosis.\n\n 2) Thrombus at the tip of the left common femoral vein central line.\n\n 3) Retroperitoneal mass as described.\n\n Discussed with housestaff.\n\n\n KEYWORD: RETROPERITONEUM\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-02-26 00:00:00.000",
"description": "THYROID U.S.",
"row_id": 860847,
"text": " 10:17 AM\n THYROID U.S. Clip # \n Reason: HYPERCALCEMIA\n Admitting Diagnosis: PARATHYROID CANCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with hypercalcemia, PTH \n REASON FOR THIS EXAMINATION:\n look for masses\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: Hypercalcemia, increased PTH. Assess for parathyroid\n mass.\n\n ___ THYROID ULTRASOUND: At the level of the isthmus, the right lobe of the\n thyroid measures 1.9 x 1.5 cm. The left lobe measures 1.2 x 1.5 cm. Within\n the midportion of the right lobe, there is a predominantly solid 2.1 x 3.0 x\n 2.4 cm nodule. The remainder of the gland demonstrates normal-appearing\n homogeneous echotexture. No adjacent nodules suggestive of parathyroid\n adenomas or hyperplasia are identified. No enlarged lymph nodes are present.\n\n IMPRESSION:\n 1. Dominant right-sided thyroid nodule.\n 2. No findings suggestive of parathyroid adenomas.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-02-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 861211,
"text": " 10:26 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: r/o right PTX and check line tip\n Admitting Diagnosis: PARATHYROID CANCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with new left subclavian CVL\n REASON FOR THIS EXAMINATION:\n r/o right PTX and check line tip\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: New subclavian central line. Evaluate placement and for\n pneumothorax.\n\n COMPARISON: at 13:24.\n\n SUPINE AP CHEST: There has been interval placement of a right subclavian\n central venous catheter, with the tip overlying the right atrium. No\n pneumothorax is identified on this supine radiograph. The heart, mediastinal\n and hilar contours are normal. The lungs are clear.\n\n IMPRESSION: Right subclavian central line tip is overlying the right atrium.\n The finding was discussed with the resident caring for the patient at the\n conclusion of the exam.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-02-26 00:00:00.000",
"description": "CT HEAD W/ & W/O CONTRAST",
"row_id": 860892,
"text": " 2:05 PM\n CT HEAD W/ & W/O CONTRAST Clip # \n Reason: re eval occipital mass\n Admitting Diagnosis: PARATHYROID CANCER\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with h/o occipital mass\n REASON FOR THIS EXAMINATION:\n re eval occipital mass\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Occipital mass.\n\n TECHNIQUE: Pre and post intravenously enhanced imaging of the brain.\n\n FINDINGS: Rather than strictly occipital, seen is a large enhancing mass,\n essentially sessile in configuration, occupying nearly the entire left\n parietal as a portion as well as a small portion of the frontal calvarial\n scalp. The mass shows external lobulations, and has an internally striated\n appearance. The lesion itself seemed almost exclusively localized to the\n subcutaneous fat. There is no abnormality involving the brain. The adjacent\n calvarial structures are also normal.\n\n CONCLUSION: Left-sided, vigorously enhancing scalp mass. The lesion is far\n more extensive than indicated in your history. Additionally, as no prior head\n imaging studies are available for comparison, it is impossible to determine\n whether this abnormality has progressed. The diagnosis of exclusion is a\n vascular malformation or some type of vascular neoplasm. Please call this\n office at your earliest convenience () to arrange for a personal\n consultation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-02-26 00:00:00.000",
"description": "CT ABD W&W/O C",
"row_id": 860893,
"text": " 2:06 PM\n CT ABD W&W/O C; CT PELVIS W&W/O C Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: renal vein thrombos propogating off IVC, Need triple phase c\n Admitting Diagnosis: PARATHYROID CANCER\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with\n REASON FOR THIS EXAMINATION:\n renal vein thrombos propogating off IVC, Need triple phase contrast (please\n make certain that venous phase is included)\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION: Question of renal vein thrombosis on an outside hospital CT.\n\n COMPARISON: No priors are available.\n\n TECHNIQUE: Contiguous axial images through the abdomen and pelvis were\n obtained before and multiphases after the administration of 150 cc of Optiray\n nonionic contrast. Oral contrast was not administered. Multiplanar\n reformatted images were obtained.\n\n ABDOMEN WITHOUT AND WITH CONTRAST: The lung bases are clear. There is no\n pleural or pericardial effusion. There are multiple small low-density lesions\n within the liver, too small to definitively characterize, but likely cysts.\n There is mild intrahepatic biliary ductal dilatation. The spleen and adrenal\n glands are within normal limits. There is dense material within the\n gallbladder, likely vicarious contrast excretion from the previous CT scan.\n The pancreas is diffusely enlarged, and there is diffuse hypoattenuation of\n the pancreas, with relatively normal pancreatic enhancement in two small foci\n in the head and neck. Additionally, there is a small amount of fluid about\n the tail of the pancreas. There are tiny (2 mm) nonobstructing renal stones\n bilaterally. The kidneys are slightly prominent, but with symmetric\n nephrograms. There are faint diffuse thin striations within the cortices of\n both kidneys. There is no evidence of renal vein thrombosis. The bowel is\n not well assessed without oral contrast material.\n\n PELVIS WITH CONTRAST: There is a soft tissue density mass just inferior to\n the aortic bifurcation measuring 2.7 x 2.9 cm. A small subcutaneous nodule is\n noted within the anterior left lower abdominal wall. There is a Foley catheter\n within the bladder. A large-bore venous catheter is noted within the left\n iliac vein; there is streak artifact and probable fibrin sheath\n versus thombus surrounding the catheter tip. The uterus is slightly enlarged.\n There are no adnexal masses. There is no inguinal or deep pelvic\n lymphadenopathy. There is no free pelvic fluid.\n\n BONE WINDOWS: The patient is status post left femur surgery. There are no\n suspicious lytic or sclerotic osseous lesions.\n\n IMPRESSION:\n 1) The pancreatic, renal, and biliary tree findings are most consistent with\n (Over)\n\n 2:06 PM\n CT ABD W&W/O C; CT PELVIS W&W/O C Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: renal vein thrombos propogating off IVC, Need triple phase c\n Admitting Diagnosis: PARATHYROID CANCER\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n (Cont)\n autoimmune pancreatitis. Biliary strictures can be seen with autoimmune\n pancreatitis, and MRCP would better delineate these than CT. Other types of\n pancreatitis are possible although the degree of involvement of the pancreatic\n gland and lack of peripancreatic fluid colections seem discordant with the\n clinical presentation.\n 2) Tiny bilateral nonobstructing renal stones.\n 3) 2.9cm mass in the midline pelvis, just inferior to the aortic bifurcation.\n The differential diagnosis includes mesenchymal tumor, pheochromocytoma, and\n lymphadenopathy. There seems to be a possible dianosis of neurofibromatosis in\n this patient based on clinical exam. If this is confirmed, neurofibroma should\n also be considered in this differential.\n 4) Fibrin sheath versus clot at the tip of the i.v line within the left\n iliac vein. No renal vein thrombosis.\n\n Findings were discussed by telephone with Dr. at 4:15 p.m. on , and again at 11am.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2115-03-02 00:00:00.000",
"description": "Report",
"row_id": 190919,
"text": "Sinus rhythm\nNormal ECG\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-02-26 00:00:00.000",
"description": "Report",
"row_id": 1374967,
"text": "MICU NURSING ADMIT NOTE:\n Please see FHPA for details of admit. Briefly pt is a 31 yr old female who p/w n/v loss of appetite to OSH. pt found to be hypercalcemic. w/u revealed hyperparathyroid, pancreatitis, decreased flow through vena cava, as well as occipital and parathyroid masses. pt transferred to for further care. ON 10, labwork recealed calcium still 15. pt given ivf bolus 1L and 40mg lasix. transferred to micu for further care. Currently receiving vigorous ivf, pamidronate, calcitonin. calcium remains 15, may require repeat HD today. labwork being sent q 2 hrs.\n nuero: pt A+O x 3. reports feeling \"out of it\", but approriate in conversation. not lethargic. mae. has deformity to R foot from congenital defect correction to bone structure. reports no pain.\n CV: HR 80's-90's. SbP 130's-140's.\n FE: calcium remains 15. team aware. will continue to follow q 2 hr labs. receiving 60 meq po kcl for am K+ 3.2. magnesium sulfate 2 grams given for am mg 1.6. remains on NS at 300cc's/hr, pamidronate at 45cc's/hr. calcitonin q 12 hrs, and . 7 am labs should begin to reflect calcitonin effect. fluid balance negative 1L. pt received 40 mg iv lasix on 10.\n RESP: LS CTA, sats high 90's on ra. rr 16-20.\n gI: ab soft, bs hypo. last bm yesterday. taking senakot to prevent constipation with high calcium. reports taking po KCL makes her nauseaus. med with 12.5 mg anzamet to prevent nausea/vomiting. good effect so far.\n gU: foley intact. urine clear, light yellow. large quantities.\n Social: pt reports her parents are her next of . she also has a brother.\n : intact.\n Access: 2 piv's and L groin HD line.\n A/P: pt with complicated clinical presentation: hypercalcemic r/t hyperparathyroidis, also with pancreatis and occipital mass. per team, plan to attempt to normalize calcium, and then will need mass remove parathyroid. cont to follow q2 hrs chem 10, cont vigorous hydration, pamidronate, calcitonin, etc.\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-02-26 00:00:00.000",
"description": "Report",
"row_id": 1374968,
"text": "NPN 7A-7P\nNeuro: Pt remains AOx3, reports feeling \"a bit irritable and anxious\" during MRI today. Pt reported feeling better once back up to room. Other wise pleasant, and appropriate. MAE. No c/o pain. CT scan to head today to visualize occipital mass, no results read as of current.\n\nResp: RR 14-25. sats 98-100% on RA. No O2 device. LS clear. One episode of sm. amount blood in mucus blown from nose this AM, team aware none since.\n\nCV: NSR 80-90's, with occ PVC's. SBP 120-150's (up to 160's when Pt was chilled.) No HD today as renal team felt that Ca+ level was decreasing with current tx, thus not need.\n\nF/E: Pt on LR with KCL at 250cc/hr and now has a sliding scale for furthur K+ repletion if indicated. Remainder of Pamitodrine infusing, since off floor and limited access. After that another 1Liter of .45% NS to be infused to flush dye from CT and MRI today. Calcitronin Q12/hr. Remains on Q2/hr labs, current 17:00 pnding. (IVF with KCL in LR hypernatremia, but Dr. wanted .45% NS bolus' to clear kidneys) US of parathyroid done today, no results read as of current.\n\nGI: Pt on low Ca+ diet til midnight, then NPO. Had sm. amount of crackers today, and one italian ice. ABD soft, non-tender. +BS No BM. On Senakot. ABD CT today to visulize renal arteries in case MRI was not able to in time for OR tomorrow.\n\nGU: Foley in place, draining large amounts of light yellow urine. MRI angio of renal arteries done today to r/u renal thrombosis, results pnding.\n\nSkin: Dry, intact. Scar to right foot from s/p graft and hardware placement due to congenital malformation. Hip scar from graft and hardware placement.\n\nID: Cx pnding. Afebrile. WBC 20 team aware, abx probably will be initiated tomorrow since to OR.\n\nSocial: Pt with phone at bedside, had contact today with parents. Parents next of . SW did visit Pt today and offer her services, attempted to check back this PM but we were headed off floor. Pt reported feeling a bit anxious about tomorrow, but felt she had adequate support from her family at this time.\n\nPlan: Pt w/ malignant hypercalcemia ? hyperparathyroid mass ? CA. Ca+ trending down with current tx modality. Pancreatitis, and occipital mass. Pt receiving ivf hydration to tx hypercalcemia, as well as Pamidronate, and Calcitonin. Continue with Q2/hr labs and replete K+ as needed. Plan to continue to stabalize electrolytes,and hydrate, to go to OR tomorrow to remove parathyroid. Continue to provide emotional support.\n\nAccess: RLP 22g/wnl, llp 20g/wnl, Ltf Dia/wnl-oozing this AM. L-aline, wnl, sharp. Plan to place central line in OR tomorrow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-03-03 00:00:00.000",
"description": "Report",
"row_id": 1374978,
"text": " 19/07\n 1900 PT A/O RELAXED NO C/O PAIN OR DISCOMFORT NO NUMBNESS OR TINGINLING AMBULATES WELL\n RESP CLEAR NO SOB R/A SAO2 100\n HEART S1S2 NO OR RUB NSR PR .12 QRS .10 QT WNL FOR AGE AND RATE ST NORMAL ST\n GI POS BS THRU OUT STOOLING U/O QS\n SITE WNL MILD SWELLING STRIPS IN PLACE\n PLAN LAB WORK CAL PHOS K AND MAG LEVELS\n SUPPORTIVE CARE PLAN D/C\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-02-28 00:00:00.000",
"description": "Report",
"row_id": 1374972,
"text": "NPN 0700-1500;\nNPO FROM MN EXCERT FOR MEDS AWAITING SURGERY TO REMOVE PARATHYROID MASS SCHEDULED FOR AFTER 4.30 PT AND FATHER AWARE\n\nNEURO;; VERY PLEASANT NEURO INTACT LADY, FAIRLY CALM DISTRESSED BY ATTEMPT TO PLACE 3LL.\n\nRESP; LUNGS CLEAR STRONG PRODUCTIVE COUGH. SATS 99% ON RA.\n\nCVS; TMAX 98 PO NSR BP 120-140/70 PLEASE SEE CAREVUE FOR DETAILS.\n\nGU; PASSING LARGE AMOUNTS CLEAR YELLOW URINE WITH SOME SEDIMENT .\n\nQ2H LABS NO REPLACEMENTS SINCE AM VARIOUS CHANGES IN I.V REPLACEMENT CURRENTLY WITH LR WITH 20 MEQS KCL AT 200 MLS/HR. D5 AT 100 MLS/HR ADDED AT 11 AM TO CHANGE TO 1/2 NS WITH 10 MEQ' KCL AT 400MLS/HR WHEN FLUID COMES UP FROM PHARMACY.\n\nENDO BS ON RISS DENIES PAIN ANZEMET FOR NAUSEA WITH RELIEF.\n\nHEME STABLE.\n\n LT RAD.A LINE. ACCESS 20G IN RT ANTICUB AND LT FOREARM. ATTEMPTED TO PLACE 3LL BUT WAS EXTREMELY PAINFUL SO WILL BE PLACED IN OR. CXR DONE AWAITING .\n\n\nSO;C FAMILY AND PT AWARE THAT SHE IS ON THE ADD ON LIST AND WONT GO UNTIL AFTER 430 PM. TODAY.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-02-28 00:00:00.000",
"description": "Report",
"row_id": 1374973,
"text": "MICU NPN 1500-1900\nPt remains stable, labs essentially unchanged. NS+10mEq KCL infusing at 400cc/hour prior to being taken to OR. To OR at 1750.\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-03-01 00:00:00.000",
"description": "Report",
"row_id": 1374974,
"text": "t-sicu nsg note:\npt arrived from s/p r upper parathyroidectomy and r thyroid lobectomy @1am. pt alert and oriented in nad w/ the following lines, tubes and dsgs: rscl tri lumen( pulled back on arrival by md's), l fem quentin cath, l rad a-line, #16angio l ant forearm, #20angio rac,foley ->gr, ant neck dsg d&i, nc 3l o2.\n\nneuro- a+o, very pleasant, mae's fc, turns self\n\nresp- 3lnc, o2 sao2 98-100%, rr 14-20, bs cta, strong nonproductive cough.\n\ncvs- tm 98.9po, hr 90's nsr, no ectopy, sbp 104-130's, cvp 3-5. ivf d5w@100cc/hr. labs pnd.\n\ngi- no c/o nausea, no vomiting, abd soft, hypoactive bs.on protonix\n\ngu- strong diuresis, lyt yellow, clear urine.\n\nskin- intact, no pressure areas, neck dsg d&i. multiple sm nodules over skin , on back etc.\n\nendo- bs wnl\n\na:vss\n\np:monitor cvs per routine, enc c+db, follow lytes closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-03-02 00:00:00.000",
"description": "Report",
"row_id": 1374975,
"text": " 1530/0700\n PT TO SICU FROM 9 FOR CAL DRIP\nNEURO A/O RELAXED NO PAIN OR DISCOMFORT MAE WELL NO SOB\nRESP ROOM AIR SAO2 100 CLEAR LUNGS RR 18 TO 20\nHEART S1S2 NO RUB OR M NVD NEG NSR TO ST PR .14 QRS .08\nGI POS B/S THRU OUT PO WELL U/O QS\nPLAN Q4 LAB WORK REPORT TO MD WITH RESULTS\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-03-03 00:00:00.000",
"description": "Report",
"row_id": 1374976,
"text": "FULL CODE Universal Precautions NKDA\n\n\nNeuro: AAOx3, OOB to commode/chair w/ min assistance. No deficits.\n\nCV: HR=100-90s, NSR/ST no ectopy. +Periph pulses, extrems warm, no edema.\n\nResp: R/A w/ 02sat 100-99%, lungs clear bilat, no cough\n\nGI/GU: Abd soft, +BS, no BM, taking house diet/meds well. Voiding clear yellow urine.\n\nPain: No c/o discomfort.\n\nSkin: Neck incision/steri-strips intact.\n\nID: T=99.2 oral. no antibx.\n\nLabs: Ca+=1.21 to 1.15. Repeat lytes due at 2pm. On Ca Carbonate and Calcitriol.\n\nAccess: RSC TLC\n\nSocial: No calls/visitors at this time.\n\nPlan: Check labs, if Ca+ stable, will tx to floor. Monitor resp/cardiac/neuro status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-03-03 00:00:00.000",
"description": "Report",
"row_id": 1374977,
"text": "Tylenol for H/A. MgS04 4 gms for mg 1.6. repeat lytes at 2100.\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-02-27 00:00:00.000",
"description": "Report",
"row_id": 1374970,
"text": "NPN 7A-7P\nToday's Events.... Pt was scheduled for OR today, but after Endocrine team viewed yesterdays test results of ABD CT which showed pelvic mass, ? pheochromacytoma, Endocrine and Surgery teams sent off labs to determine if this may be the case. In meanwhile surgery was canceled as potential for hemodynamic instability present with Pt's with the pheochromacytoma... Surgery rescheduled for tomorrow as anethesia and OR team will be aware of this potential for inc. BP and HR under stress, and it is felt that the Pt will be in greater danger with waiting for since potential for hypercalcemia.\n\nNeuro: Remains AOx3, no c/o pain. MAE. Pt a bit sleepy after Compazine dose.\n\nResp: No O2 delivery device. Sats 97-100%. RR 15-30. LS Clear x 4. no cough noted.\n\nCV: NSR HR 85-90's. SBP 99-130's/50-80's. +pp. No ectopy noted.\n\nGI: Abd soft, hypo active BS. No BM today, senna given. Anzemet given this AM for vomiting x1 and nausea. Compazine x1 given this afternoon given for another episode of nausea and vomiting.\n\nF/E, GU: Repleted a total of 6 grams of Mag today. (4grams infusing now) K+ phos infusing currently. D5W infusing for hypernatremia, and LR with 20meq of Kcl. Continues on Mucamyst to clear dye load from two CT scans yesterday. Continues on Calcitonin and Cinaket for hypercalcemia with Ca+ trending down. Foley in place, 300-400cc/hr of lt. yellow urine out.\n\nID: afebrile. wbc 20.7, no coverage at this time b/c no clinical s&s of infection. bld cx pnding.\n\nPlan: Testing from yest reveals right sided thyroid mass, probable autoimmune pancreatitis, ? a/v malformation of occipital area of scalp. ? pheocytomachroma via abd ct scan. To OR tomorrow to remove thyroid mass, then f/u at later date on for pheo, autoimmune pancreatitis, and occipital skin mass. Continue with Q2/hr labs, conting antihypercalcemia regimen. Continue providing emotional support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-02-28 00:00:00.000",
"description": "Report",
"row_id": 1374971,
"text": "NPN 7p-7a\nEvents over NOC. Potassium, phosphorus, magnesium repleted. K goal of 4.0 met. Pt with no complaints. Awaiting surgery for removal of thyroid mass . Pt has been NPO except meds since midnight.\n\nNEURO: Pt is A&Ox3. No pain reported. MAE. Slept well between interventions and assessments.\n\nRESP: No O2 therapy neccessary. Sat 100% while awake, 97% when asleep. RR 18-22. LS clear and equal bilat. No cough.\n\nCV: NSR 88-98, no ectopy noted. BP 100-130/60s. Palpable peripheral pulses.\n\nGI/GU: ABD is soft, non-tender. +BS. No BM this shift. Pt c/o nausea at ~03:00, given anzimet x1 with good relief. Large amounts of very light yellow, clear urine from foley. >500cc/hour. Last dose of Mucomyst given.\n\nF/E: Mag (mag sulfate x1), Phos (K-Phos x1) and K (10meq x2, LR with 20meq KCl gtt currently at 200cc/hr) repleted. D5W D/C'd. K goal of 4.0 met.\n\nID: TMAX 99.6 @ 04:00. Pt with blood cx pending. No ABX coverage at this time, asymptomatic of WBC count 19.4, trending down.\n\nDISPO: Full Code\n\nSocial: Parents vsiting last evening.\n\nPLAN: To OR today for removal of thyroid mass. Plan to treat ? Pheochromacytoma, ? A/V malformation of scalp and pancreatitis/abd mass out patient. Continue with q2hour labs for electrolyte imbalance prior to . Provide emotional support and education prior to .\n\nnote reviewed and cosignedby: , RN\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-02-27 00:00:00.000",
"description": "Report",
"row_id": 1374969,
"text": "NPN 7p-7a:\n Review of Systems:\n Nuero: pt A+O x 3. no c/o pain. moving independently in bed.\n CV: HR 90's nsr, no ectopy. SBP 90's-120's.\n RESP: LS CTA, rr 16-32, O2 sats 98-99 on RA.\n FE: IVF LR with 40meq kcl infusing most of noc at 300cc'/hr. Changed to LR at 300cc's/hr for am K+ 4.7. (? if would benefit from alternating 1L of each fluid to maintain optimum K+?). repleated with K+ and Kphos earlier in shift. phos 1.8 up to 2.1 so far. Mg 1.7-2.8. received 2 amps MgSO4 earlier in shift. Calcium 12.5 down to 11.4 this am. cont on cinacalcet and calcitonin for hypercalcemia.\n REnal: pt with bun/Creat10-13/.9-1.0. cont on mucomyst s/p dye load for CT yesterday. pt vomited after 2 am dose of mucomyst. HO notified. Ordered for 12.5mg iv anzomet, which relieved nausea, and then ordered to repeat mucomyst dose. pt tolerated repeat dose well. UO 250-750cc's/hr of light yellow urine out.\n GI: ab soft, hypoactive BS. pt with 1 formed solid bm o/n. pt receiving protonix.\n ID: afebrile. WBC remains 20.7.\n : intact.\n Access: 2 piv's and L groin HD line.\n Social: pt's parents in to visit last eve. had to leave before doctors were to meet with them. Dr. in and updated pt r/e results of yesterdays tests. Pt with thyroid mass, pancreatitis and L occipital scalp soft tissue mass (? a/V malformation).\n A/P: plan is for pt to go to OR today to have thyroid mass removed. will then f/u on ? autoimmune pancreatitis and L occipital scalp mass as outpt. Cont to follow q 2 hrs labs, cont antihypercalcemic regime. pt to call parents to update.\n"
}
] |
21,139 | 196,515 | Medicine Floor Course: Ms. is a yo -speaking female with severe dCHF, HTN, HLD, neuropathy, gait abnormalities who presents 3 days after likely mechanical fall without evidence of significant trauma. | Unchanged relatively extensive right lower lobe and retrocardiac opacity, likely associated with small pleural effusions. There is marked periventricular white matter hypodensity, consistent with chronic small vessel ischemia and chroonic right occipital lobe infarct, which is stable in appearance. Stable cortical atrophy and white matter small vessel ischemic change and chronic right occipital infarct. Severe cardiomegaly is unchanged. There is moderate bilateral neural foraminal narrowing. The ET tube tip remains low, less than 1.5 cm above the carina and should be readjusted. Retrocardiac opacity likely represents a small hiatal hernia with adjacent atelectasis. Again seen is prominence of the ventricles and sulci consistent with atrophy. The mediastinal and hilar contours are unchanged, with prominence of the hila bilaterally. Small left pleural effusion stable. There is cortical irregularity of the left superior and inferior pubic rami, which likely relate to chronic fractures in these regions as noted on the prior CT. No new fracture or dislocation is otherwise identified elsewhere. Unchanged mild cardiomegaly without evidence of pulmonary edema. Respiratory motion slightly limits evaluation of the pulmonary parenchyma. At C3-4, there is facet hypertrophy and no significant neural foraminal narrowing. Hiatal hernia with adjacent atelectasis. There is interval improvement of pulmonary edema with still present bibasilar atelectasis and bilateral pleural effusion. Fullness of the right hilus is better appreciated on the current study than on the prior examination and can be seen dating back to , unchanged, most likely reflecting combination of pulmonary hypertension with hilar lymph nodes, unchanged since the prior study. There is slight improvement of pulmonary edema and there are also pleural effusions demonstrated, bilateral. Bibasal opacities are chronic with no definitive evidence of worsening as compared to prior study. FINDINGS: As compared to the previous radiograph, the lung volumes have slightly decreased. IMPRESSION: No acute traumatic injury identified. The vertebral body alignment is largely preserved. Large cardiac silhouette unchanged. IMPRESSION: AP chest compared to through : Mild somewhat asymmetric pulmonary edema and moderate right pleural effusion have increased. The endotracheal tube tip remains somewhat low, about 2.3 cm above the carina. Fullness of the right hilum is again seen, extending back to , which most likely reflects a combination of pulmonary hypertension and hilar lymphadenopathy. The left knee is partially imaged and demonstrates mild-to-moderate degenerative changes within the medial and lateral compartments. Multilevel degenerative changes are noted in the thoracic spine. Small amount of pleural effusion is most likely present. The prevertebral soft tissues are normal in appearance. The visualized soft tissues of the neck appear normal. Cardiomegaly is unchanged. Cardiomegaly is unchanged. TWO VIEWS OF THE LEFT TIBIA AND FIBULA: Diffuse demineralization limits evaluation of the osseous structures. There is osteoporosis. ET tube in standard placement. Sacroiliac joints and pubic symphysis are not diastatic. The patient was intubated in the meantime interval with the ET tube tip being low, 1.5 cm above the carina and should be pulled back. Incidental note is made of hyperostosis frontalis. Unchanged extensive right lower lobe and retrocardiac opacities, likely to reflect atelectasis, combined to bilateral mild-to-moderate pleural effusions. Atrial fibrillation with moderate ventricular response. Compared to theprevious tracing of the ventricular rate is slower.TRACING #1 Endotracheal tube in standard placement. The tip of a right-sided IJ catheter is stable near the cavoatrial junction. Moderate cardiomegaly is chronic. IMPRESSION: AP chest compared to through 29: Mild pulmonary edema, small right pleural effusion and left lower lobe atelectasis are unchanged. Atrial fibrillation persists at a slightly slower rate. FINAL REPORT CHEST RADIOGRAPH INDICATION: Evaluation for interval change. Left central venous line ends low in the SVC. Atrial fibrillation. FINDINGS: In comparison with the earlier study of this date, the nasogastric tube extends well into the stomach, with the side hole below the level of the esophagogastric junction. Baseline artifact.Non-specific ST-T wave changes. FINDINGS: Indwelling devices are in standard position, and cardiomediastinal contours are unchanged since the prior study. FINDINGS: As compared to the previous radiograph, there is no relevant change. ET tube in standard placement. 3:33 AM CHEST (PORTABLE AP) Clip # Reason: interval change? Variation in precordiallead placement as compared to the previous tracing of . Compared totracing #1 no ventricular premature beats are noted.TRACING #2 Bilateral central venous lines end in the mid SVC and a nasogastric tube passes into the stomach and out of view. Multifocalventricular premature beats. ST-T wave abnormalities. IMPRESSION: Left PICC catheter, malpositioned and will require re-positioning. FINDINGS: There is a newly inserted left-sided PICC catheter; however, the catheter coils back on itself with the tip directed out towards the arm likely within the left brachiocephalic vein. FINDINGS: In comparison with the study of , the central catheters remain in place. Left subclavian line ends in the mid SVC. NG tube ends in the distal stomach. Unchanged moderate cardiomegaly without evidence of overt pulmonary edema. Nasogastric tube ends in the upper stomach and a left subclavian line ends in the low SVC. Continued enlargement of the cardiac silhouette with mild elevation of pulmonary venous pressure. 2:17 AM CHEST (PORTABLE AP) Clip # Reason: interval change? 2:22 AM CHEST (PORTABLE AP) Clip # Reason: interval change? | 30 | [
{
"category": "Radiology",
"chartdate": "2169-02-16 00:00:00.000",
"description": "BY SAME PHYSICIAN",
"row_id": 1173224,
"text": " 4:35 AM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: line placement\n Admitting Diagnosis: SYNCOPE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman s/p R IJ placement\n REASON FOR THIS EXAMINATION:\n line placement\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Right internal jugular line placement.\n\n Portable AP chest radiograph was compared to prior study obtained the same day\n earlier at 3:33 a.m.\n\n The ET tube tip remains low, less than 1.5 cm above the carina and should be\n readjusted. The right internal jugular line tip is at the level of cavoatrial\n junction. There is slight improvement of pulmonary edema and there are also\n pleural effusions demonstrated, bilateral. No definitive pneumothorax\n demonstrated after insertion of the internal jugular line.\n\n Findings were discussed with Dr. over the phone by Dr. on\n 10:20 a.m. on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-02-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1173272,
"text": " 10:26 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: ETT appeared low on CXR this AM, but rotated; repeat study\n Admitting Diagnosis: SYNCOPE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with respiratory distress, s/p intubation\n REASON FOR THIS EXAMINATION:\n ETT appeared low on CXR this AM, but rotated; repeat study\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient after intubation.\n\n Portable AP chest radiograph was reviewed in comparison to .\n\n The ET tube tip is slightly higher than on the prior studies, approximately 2\n cm above the carina. There is interval improvement of pulmonary edema with\n still present bibasilar atelectasis and bilateral pleural effusion. Fullness\n of the right hilus is better appreciated on the current study than on the\n prior examination and can be seen dating back to , unchanged, most\n likely reflecting combination of pulmonary hypertension with hilar lymph\n nodes, unchanged since the prior study.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-02-13 00:00:00.000",
"description": "CHEST (SINGLE VIEW)",
"row_id": 1172844,
"text": " 2:49 PM\n CHEST (SINGLE VIEW) Clip # \n Reason: r/o pna\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with s/p fall 4 days ago\n REASON FOR THIS EXAMINATION:\n r/o pna\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fall four days previously.\n\n COMPARISON: .\n\n SUPINE AP VIEW OF THE CHEST: The heart is moderately enlarged. The\n mediastinal and hilar contours are unchanged, with prominence of the hila\n bilaterally. Respiratory motion slightly limits evaluation of the pulmonary\n parenchyma. Retrocardiac opacity likely represents a small hiatal hernia with\n adjacent atelectasis. Pulmonary vascularity is not engorged. No focal\n consolidation, pleural effusion, or pneumothorax is identified. Clips are\n noted in the left hemiabdomen. No new displaced rib fractures are identified.\n Multilevel degenerative changes are noted in the thoracic spine.\n\n IMPRESSION: No acute traumatic injury identified. Enlargement of the hila\n likely reflective of underlying pulmonary arterial hypertension. Hiatal\n hernia with adjacent atelectasis.\n DFDdp\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-02-13 00:00:00.000",
"description": "BILAT HIPS (AP,LAT & AP PELVIS)",
"row_id": 1172845,
"text": " 2:52 PM\n BILAT HIPS (AP,LAT & AP PELVIS) Clip # \n Reason: r/o #\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with s/p fall\n REASON FOR THIS EXAMINATION:\n r/o #\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fall.\n\n COMPARISON: CT torso from .\n\n AP VIEW OF THE PELVIS, TWO VIEWS OF EACH HIP: Diffuse osteopenia limits\n evaluation for subtle fractures. There is cortical irregularity of the left\n superior and inferior pubic rami, which likely relate to chronic fractures in\n these regions as noted on the prior CT. No new fracture or dislocation is\n otherwise identified elsewhere. There are degenerative changes involving both\n hips with joint space narrowing. Sacroiliac joints and pubic symphysis are not\n diastatic. Evaluation of the sacrum is limited due to overlying bowel gas.\n Vascular calcifications are present. No suspicious lytic or sclerotic osseous\n abnormality is seen.\n\n IMPRESSION: Limited evaluation. Chronic fractures of the left superior and\n inferior pubic rami. No definite new fractures seen. If there is continued\n clinical concern for a pelvic fracture, a CT of the pelvis can be obtained for\n further evaluation.\n DFDdp\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-02-13 00:00:00.000",
"description": "L TIB/FIB (AP & LAT) LEFT",
"row_id": 1172846,
"text": " 2:52 PM\n TIB/FIB (AP & LAT) LEFT Clip # \n Reason: eval for fracture/dislocation\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with fall 4 days ago, bruising and tenderness over proximal\n fibula\n REASON FOR THIS EXAMINATION:\n eval for fracture/dislocation\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Four days previously with bruising and tenderness over the\n proximal fibula on the left.\n\n TWO VIEWS OF THE LEFT TIBIA AND FIBULA: Diffuse demineralization limits\n evaluation of the osseous structures. No fracture or dislocation is present.\n The left knee is partially imaged and demonstrates mild-to-moderate\n degenerative changes within the medial and lateral compartments. No focal\n lytic or sclerotic osseous abnormality is seen. There are no radiopaque\n foreign bodies. No focal lytic or sclerotic osseous abnormalities are\n present.\n\n IMPRESSION: No fracture or dislocation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-02-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1173565,
"text": " 3:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: change from prior\n Admitting Diagnosis: SYNCOPE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with respiratory failure, intubated\n REASON FOR THIS EXAMINATION:\n change from prior\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Respiratory failure, evaluation for interval change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the lung volumes have\n slightly decreased. The monitoring and support devices are in unchanged\n position. Unchanged mild cardiomegaly without evidence of pulmonary edema.\n Unchanged relatively extensive right lower lobe and retrocardiac opacity,\n likely associated with small pleural effusions. Bilaterally large pulmonary\n arteries, potentially suggesting pulmonary hypertension. No newly occurred\n focal parenchymal opacity suggesting pneumonia.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-02-15 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1173115,
"text": " 10:55 AM\n CHEST (PA & LAT) Clip # \n Reason: PA and Lat for eval of pnuemonia versus congestion\n Admitting Diagnosis: SYNCOPE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with CHF and increasing respiratory rate\n REASON FOR THIS EXAMINATION:\n PA and Lat for eval of pnuemonia versus congestion\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST ON \n\n HISTORY: -year-old woman with CHF and dyspnea.\n\n IMPRESSION: AP and lateral chest compared to through\n :\n\n Presence of a large heart and large hiatus hernia makes it difficult to\n evaluate the lung bases, where some atelectasis and possibly a small region of\n consolidation could be present. The upper lungs are clear and there is no\n pulmonary edema or appreciable pleural effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-02-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1173200,
"text": " 8:23 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for acute process\n Admitting Diagnosis: SYNCOPE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with hypoxia and chest pain\n REASON FOR THIS EXAMINATION:\n eval for acute process\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Hypoxia and chest pain.\n\n Portable AP chest radiograph was compared to .\n\n Cardiomegaly is unchanged. Bilateral hilar enlargement is re-demonstrated and\n it most likely represents a combination of hilar lymphadenopathy and large\n pulmonary arteries as demonstrated on chest radiograph from .\n Bibasal opacities are chronic with no definitive evidence of worsening as\n compared to prior study. Small amount of pleural effusion is most likely\n present. No interval progression of abnormalities have been demonstrated.\n Severe cardiomegaly is unchanged.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-02-13 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1172833,
"text": " 1:45 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? ICH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with fall, head inj\n REASON FOR THIS EXAMINATION:\n ? ICH\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: NATg MON 2:16 PM\n Neg acute\n Chronic small vessel ischemia and atrophy stable\n Sinus mucosal thickening new compared with prior, correlate for sinusitis\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: -year-old female with fall, question head injury.\n\n COMPARISON: .\n\n TECHNIQUE: Axial images were acquired of the head without contrast. These\n were reformatted in the coronal and sagittal planes.\n\n FINDINGS: There is no acute intracranial hemorrhage, mass effect, or midline\n shift. Again seen is prominence of the ventricles and sulci consistent with\n atrophy. There is marked periventricular white matter hypodensity, consistent\n with chronic small vessel ischemia and chroonic right occipital lobe infarct,\n which is stable in appearance.\n\n The orbits are unremarkable. The visualized soft tissues are normal in\n appearance. There is interval opacification with mucosal thickening and an\n air-fluid level within the left maxillary sinus. The mastoid air cells are\n clear. Mucosal thickening is also seen of the ethmoid air cells. Incidental\n note is made of hyperostosis frontalis.\n\n IMPRESSION:\n\n 1. No acute intracranial process.\n\n 2. Stable cortical atrophy and white matter small vessel ischemic change and\n chronic right occipital infarct.\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-02-13 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 1172834,
"text": " 1:46 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: ? C-sp inj\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with fall, head inj\n REASON FOR THIS EXAMINATION:\n ? C-sp inj\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: NATg MON 2:19 PM\n No fracture or subluxation\n Degenerative change\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: -year-old female status post fall, question C-spine\n injury.\n\n COMPARISON: None available.\n\n TECHNIQUE: Axial images were acquired of the cervical spine and reformatted\n in the coronal and sagittal planes without contrast.\n\n FINDINGS: Degenerative changes of the cervical spine are seen in this elderly\n woman with exaggerated cervical lordosis, which is likely positional. There\n is osteoporosis. The vertebral body alignment is largely preserved. The\n prevertebral soft tissues are normal in appearance.\n\n Degenerative changes are seen at the junction of C1-C2 with ligamentous\n calcification. At C3-4, there is facet hypertrophy and no significant neural\n foraminal narrowing. At C4-5, again bilateral facet hypertrophy is seen.\n There is moderate bilateral neural foraminal narrowing. Visualization of the\n neural foramina inferior to this level is made difficult due to patient\n positioning. There is no fracture. The visualized lung apices are\n unremarkable. The visualized soft tissues of the neck appear normal.\n\n IMPRESSION:\n 1. No acute fracture or subluxation of the cervical spine.\n 2. There is multilevel degenerative disease described above.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-02-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1173219,
"text": " 3:27 AM\n CHEST (PORTABLE AP) Clip # \n Reason: change from prior\n Admitting Diagnosis: SYNCOPE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with respiratory distress\n REASON FOR THIS EXAMINATION:\n change from prior\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Respiratory distress.\n\n Portable AP chest radiograph was compared to prior study obtained on , at 8:37 p.m.\n\n The patient was intubated in the meantime interval with the ET tube tip being\n low, 1.5 cm above the carina and should be pulled back. There is interval\n development of interstitial pulmonary edema and increase in bilateral pleural\n effusions. Cardiomegaly is unchanged.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-02-21 00:00:00.000",
"description": "EXCH PERPHERAL W/O PORT",
"row_id": 1174004,
"text": " 2:53 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: Malpositioned left picc, needs flouro repo in IR\n Admitting Diagnosis: SYNCOPE;TELEMETRY\n ********************************* CPT Codes ********************************\n * EXCH PERPHERAL W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with malpositioned left picc\n REASON FOR THIS EXAMINATION:\n Malpositioned left picc, needs flouro repo in IR\n ______________________________________________________________________________\n FINAL REPORT\n PICC LINE EXCHANGE / REPOSITIONING\n\n INDICATION: Malposition of indwelling PICC line.\n\n The procedure was explained to the patient. A timeout was performed.\n\n RADIOLOGIST: Dr. performed the procedure.\n\n TECHNIQUE: Using sterile technique and local anesthesia, a guidewire was\n advanced through the indwelling right arm PICC line, and subsequently into the\n SVC under fluoroscopic guidance. The old PICC line was then removed and a\n peel-away sheath was then placed over the guidewire. A new double lumen PICC\n line measuring 41 cm in length was then placed through the peel-away sheath\n with its tip positioned in the SVC under fluoroscopic guidance. Position of\n the catheter was confirmed by a fluoroscopic spot film of the chest.\n\n The peel-away sheath and guidewire were then removed. The catheter was\n secured to the skin, flushed, and a sterile dressing applied.\n\n The patient tolerated the procedure well. There were no immediate\n complications.\n\n IMPRESSION: Uncomplicated fluoroscopically guided PICC line exchange for a\n new 5 French double lumen PICC line. Final internal length is 41 cm, with the\n tip positioned in the SVC. The line is ready to use.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-02-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1173404,
"text": " 3:44 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change?\n Admitting Diagnosis: SYNCOPE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with hypoxia\n REASON FOR THIS EXAMINATION:\n interval change?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Hypoxia, to assess for change.\n\n FINDINGS: In comparison with the study of , the monitoring and support\n devices remain in place. The endotracheal tube tip remains somewhat low,\n about 2.3 cm above the carina. There is continued decrease in opacification\n at the right base with continued opacification at the left base, consistent\n with a combination of atelectasis and effusion on both sides. Fullness of the\n right hilum is again seen, extending back to , which most likely\n reflects a combination of pulmonary hypertension and hilar lymphadenopathy.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-02-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1173757,
"text": " 3:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: change from prior\n Admitting Diagnosis: SYNCOPE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with respiratory failure\n REASON FOR THIS EXAMINATION:\n change from prior\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Respiratory failure.\n\n FINDINGS: In comparison with the study of , there is little overall\n change. There is continued enlargement of the cardiac silhouette with\n evidence of elevated pulmonary venous pressure and bilateral pleural\n effusions, more prominent on the right with associated basilar compressive\n atelectasis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-02-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1174489,
"text": " 2:59 AM\n CHEST (PORTABLE AP) Clip # \n Reason: change from prior\n Admitting Diagnosis: SYNCOPE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with respiratory failure\n REASON FOR THIS EXAMINATION:\n change from prior\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 3:14 A.M., \n\n HISTORY: Respiratory failure.\n\n IMPRESSION: AP chest compared to through :\n\n Mild somewhat asymmetric pulmonary edema and moderate right pleural effusion\n have increased. Large cardiac silhouette unchanged. Small left pleural\n effusion stable. ET tube in standard placement. Left subclavian line ends\n low in the SVC. No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-02-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1173658,
"text": " 3:33 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change?\n Admitting Diagnosis: SYNCOPE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with intubation\n REASON FOR THIS EXAMINATION:\n interval change?\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Evaluation for interval change.\n\n FINDINGS: As compared to the previous radiograph, there is no relevant\n change. The monitoring and support devices are in constant position.\n Unchanged moderate cardiomegaly without evidence of overt pulmonary edema.\n Unchanged extensive right lower lobe and retrocardiac opacities, likely to\n reflect atelectasis, combined to bilateral mild-to-moderate pleural effusions.\n Large pulmonary arteries could suggest pulmonary hypertension. No newly\n appeared focal parenchymal opacities suggesting pneumonia.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-02-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1174675,
"text": " 1:51 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Interval progression\n Admitting Diagnosis: SYNCOPE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with hypoxemic respiratory failure\n REASON FOR THIS EXAMINATION:\n Interval progression\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 2:13 A.M. \n\n HISTORY: -year-old woman with hypoxemic respiratory failure, question\n interval progression.\n\n IMPRESSION: AP chest compared to through 30:\n\n Mild pulmonary edema and a small to moderate right pleural effusion have\n improved since . Severe cardiomegaly with particular enlargement of\n the left atrium and pulmonary arteries is longstanding. Small left pleural\n effusion has increased. No pneumothorax. Endotracheal tube in standard\n placement. NG tube ends in the distal stomach. Left subclavian line ends in\n the mid SVC. No pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-02-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1174341,
"text": " 3:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: change from prior\n Admitting Diagnosis: SYNCOPE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with respiratory failure\n REASON FOR THIS EXAMINATION:\n change from prior\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST X-RAY OF \n\n COMPARISON: Radiograph of one day earlier.\n\n FINDINGS: Indwelling devices are in standard position, and cardiomediastinal\n contours are unchanged since the prior study. Bilateral pleural effusions and\n bibasilar atelectasis are again demonstrated is slightly improved since the\n prior study. No new or worsening areas of opacification.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-02-21 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1173951,
"text": " 11:17 AM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: 37cm left picc. tip?\n Admitting Diagnosis: SYNCOPE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with new picc\n REASON FOR THIS EXAMINATION:\n 37cm left picc. tip?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate PICC placement.\n\n SINGLE FRONTAL CHEST RADIOGRAPH.\n\n COMPARISON: .\n\n FINDINGS: There is a newly inserted left-sided PICC catheter; however, the\n catheter coils back on itself with the tip directed out towards the arm likely\n within the left brachiocephalic vein. This catheter will require\n re-positioning. The tip of the ET tube is 3.4 cm from the carina. The tip of\n a right-sided IJ catheter is stable near the cavoatrial junction. An NG tube\n is in stable position. Overall, the appearance of the lungs is unchanged from\n the examination earlier this morning including enlargement of the cardiac\n silhouette, bilateral effusions and bibasilar atelectasis.\n\n IMPRESSION: Left PICC catheter, malpositioned and will require\n re-positioning. These findings were discussed with IV nurse, , via\n telephone at approximately 11:55 a.m. .\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-02-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1174858,
"text": " 2:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval progression\n Admitting Diagnosis: SYNCOPE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with hypoxemic respiratory failure\n REASON FOR THIS EXAMINATION:\n eval for interval progression\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 2:32 A.M., \n\n HISTORY: -year-old woman with hypoxic respiratory failure, check interval\n progression.\n\n IMPRESSION: AP chest compared to through 31:\n\n Moderately severe pulmonary edema, right greater than left, and moderate right\n pleural effusion have increased. Severe cardiomegaly and pulmonary artery is\n dilated by pulmonary hypertension are longstanding. No pneumothorax. Left\n central venous line ends low in the SVC. No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-02-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1173745,
"text": " 9:38 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: s/p OG tube manipulation\n Admitting Diagnosis: SYNCOPE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with hypoxemic respiratory failure with OG tube\n REASON FOR THIS EXAMINATION:\n s/p OG tube manipulation\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: OG tube manipulation.\n\n FINDINGS: In comparison with the earlier study of this date, the nasogastric\n tube extends well into the stomach, with the side hole below the level of the\n esophagogastric junction. Otherwise, little change in the appearance of the\n monitoring and support devices and the heart and lungs.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-02-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1173891,
"text": " 2:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change?\n Admitting Diagnosis: SYNCOPE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with intubated\n REASON FOR THIS EXAMINATION:\n interval change?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Intubation, to assess for change.\n\n FINDINGS: In comparison with the study of , there is little change.\n Monitoring and support devices remain in place. Enlargement of the cardiac\n silhouette persists with evidence of increased pulmonary venous pressure and\n bilateral pleural effusions with associated compressive atelectasis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-02-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1174061,
"text": " 2:07 AM\n CHEST (PORTABLE AP) Clip # \n Reason: change from prior\n Admitting Diagnosis: SYNCOPE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with respiratory failure\n REASON FOR THIS EXAMINATION:\n change from prior\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Respiratory failure, to assess for change.\n\n FINDINGS: In comparison with the study of , the central catheters remain\n in place. Endotracheal tube tip lies about 3.5 cm above the carina.\n Nasogastric tube extends into the stomach. Continued enlargement of the\n cardiac silhouette with mild elevation of pulmonary venous pressure. Probable\n bibasilar effusions with atelectasis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-02-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1174202,
"text": " 2:17 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change?\n Admitting Diagnosis: SYNCOPE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with respiratory failure, intubated\n REASON FOR THIS EXAMINATION:\n interval change?\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 2:49 A.M., \n\n HISTORY: -year-old woman with respiratory failure, question interval\n change.\n\n IMPRESSION: AP chest compared to through :\n\n Bibasilar atelectasis which improved over the past several days is stable,\n small-to-moderate bilateral pleural effusions are also unchanged. Upper lungs\n are grossly clear. The heart is mildly enlarged.\n\n Tip of the endotracheal tube is no less than 2 cm from the carina, probably\n higher, given kyphosis. Bilateral central venous lines end in the mid SVC and\n a nasogastric tube passes into the stomach and out of view. No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-02-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1174585,
"text": " 2:55 AM\n CHEST (PORTABLE AP) Clip # \n Reason: change from prior\n Admitting Diagnosis: SYNCOPE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with respiratory failure\n REASON FOR THIS EXAMINATION:\n change from prior\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 3:06 A.M. \n\n HISTORY: -year-old woman with respiratory failure.\n\n IMPRESSION: AP chest compared to through 29:\n\n Mild pulmonary edema, small right pleural effusion and left lower lobe\n atelectasis are unchanged. Moderate cardiomegaly is chronic. ET tube in\n standard placement. Nasogastric tube ends in the upper stomach and a left\n subclavian line ends in the low SVC. No pneumothorax.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2169-02-20 00:00:00.000",
"description": "Report",
"row_id": 106788,
"text": "Atrial fibrillation. Low limb lead voltage. ST-T wave abnormalities. Since\nthe previous tracing of no significant change.\n\n"
},
{
"category": "ECG",
"chartdate": "2169-02-19 00:00:00.000",
"description": "Report",
"row_id": 106789,
"text": "Atrial fibrillation persists at a slightly slower rate. Compared to\ntracing #1 no ventricular premature beats are noted.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2169-02-18 00:00:00.000",
"description": "Report",
"row_id": 106790,
"text": "Atrial fibrillation with moderate ventricular response. Multifocal\nventricular premature beats. Inferolateral ST-T wave changes. Compared to the\nprevious tracing of the ventricular rate is slower.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2169-02-15 00:00:00.000",
"description": "Report",
"row_id": 106791,
"text": "Atrial fibrillation with rapid ventricular response. Baseline artifact.\nNon-specific ST-T wave changes. Compared to the previous tracing of the\nventricular response has increased. Otherwise, no diagnostic interim change.\n\n"
},
{
"category": "ECG",
"chartdate": "2169-02-13 00:00:00.000",
"description": "Report",
"row_id": 106836,
"text": "Atrial fibrillation with a rapid ventricular response. Variation in precordial\nlead placement as compared to the previous tracing of . The inferior\nST-T wave changes are slightly more prominent. Otherwise, no diagnostic interim\nchange.\n\n"
}
] |
8,030 | 150,442 | 1. RESPIRATORY: The infant has been in room air throughout his hospitalization. The patient has not required any supplemental oxygen or respiratory support. He has not had issues with apnea of prematurity and has not required methylxanthine therapy. CARDIOVASCULAR: blood pressure has been normal throughout his hospitalization. He has not required any fluid boluses or pressors for blood pressure support. Heart rate has been normal. No murmurs have been auscultated. | Voiding and stooling normally.State screen sent. Statescreen done.Resp: RA. PG fed after that. Will cotninue to follow.G&D: Temps are stable in air isolette, isolette temp weanedslightly d/t temp 99.2 this am. Fed via bottle and breast today.Asking appropriate ? Cont on BM24.A. P: Encourage BF/bottle every other care. Independent withtemp and diaper. Min asp. Infants discharge wt 2235. Pedi visit scheduled for . Baby gavaged entireamt. Infant remains slightly jaundiced, Bili tonight8.1--7.8--0.3. continue per plans.6 Resp. sl jaundice.P: check bili in am.#5G&D: Pt. Notyet waking for feeds. Independent w/cares andBF. D-stick63. Remains at 2.09. Pulses+2=Abd: soft active BS, no HSMGU: testes descended.EXT: MAEneuro: flexed position. 's, will continue to update and supportfamily.BILI: infant's rebound level this am 7.6/0.2 , plan to recheck level in am. O: Infant remains in RA. Tolerating rest well by gavage, 0 spits, 0 asp.Voiding, stooling. Bottling well and breastfeeding. MMMPChest is clear with comfortable resp pattern.CV: RRR, nl S1, split S2, no murmur. Howevre once wokenalert. A: Stable P: Cont to monitor for and document A/B's. A: AGA P: Cont tosupport G&D. Baby was discharged home with today. nares patent, MMMpChest is clear, equal BS, comforatble resp pattern.CV: RRR, nl S1, split S2, no murmur, pulses +2=Abd: soft, active BS, cord clamped. O: Temp stable swaddled in OC. waking for feeds Q 3hrs. continues on RA, RR 30-40's w/ mild SCretractions. Abd soft active bowel sounds.Void and stooling guiac neg. VNA to visit . Abd benign. Abd benign. P: continue to support & update.#4Bili: Pt. MAE's approp.Fontanelles soft & flat. No HSMGU: descended testeicles, right hydoceleExt: MARE, WWPNeuro: symmetric tone and reflexes BP 72/39 (55).Wt 2090 (unchanged) on TFI 150 cc/kg/day BM24, tolerating well. D-stick 63,92. P: continue to monitorresp status.See flowsheet for further details.REVISIONS TO PATHWAY: 1 Infant with Potential Sepsis; resolved Both heldbaby. ALternating PO/PG feedings. Abdomen issoft, pink,active bowel sounds, no loops, Voiding andstooling. Nursing Discharge Note0700-1300. P: cont tofollow.GDO: Temp stable in air isolette, swaddled. Stable temp in isolette. BSCEbilat. Bld cx neg to date. SEPSIS Amp/gent continue. Dsticks stable65-72. Fetal survey normal. PCA Note:FEN: O: Wt. On ferinsoland trivisol. WBC normal. Min asp. slow bottler, goodcoordination.#3 parentingno contact thus far this shift.#4 hyperbilipt with jaundice skin. Taking60-70cc q3.5-4h .Abd soft, active bowel sounds. BILI 24hr bili lvl 6.8/0.2, NNP notified, single phtxordered.Plan to commence single lights as ordered. BF fair/well.Abdomen soft, +BS, no loops, sm spit x1, voiding andstooling transitional stools, trace positive, aware. Handsto face.Resp: In RA. Rest well inbetween cares. Cl and = BS. abd benign. Abd benign. Abd benign. Abd benign. Mild sc ret. Mild sc rtxns. rr 30-50's.mild sc retractions noted. Voiding and stooling normally.Waking for feeds. NPN 0700-2. Mom BF and bottledinfant. Will be up later today.Bili: Received infant on single phototherapy with eyeshields on. Neonatology - Progress Note is active with good tone. Neonatology - PRogress Note is active with good tone. calms withhis pacifier. Cont to po feed well.P. Infant is voiding, tracestool x2 thus far. Mompumping. Calms with containmentand pacifier. for this Wed or Thurs. milestones.BIliO: Photo tx d/c'd. Monnitor for respiratory maturity-Cardiac examination is currently normal. Abd soft,pink, no loops, active bs. NPN 7p-7aSepsis: conts on amp and gent. Orally and nasally bulb suctioned, dried, free flow oxygen briefly. NPN NOCSI have examined infant and agree with above note by PCA, . Resolves when removed.No spells thus far.REVISIONS TO PATHWAY: 5 G&D; added Start date: 6 Respiratory; added Start date: Min 21cc q3hrs, still all PO's. NPN 1900-07005 G&D6 RespiratorySepsis: Infant continues on abx, amp and gent. max aspirate 1.8cc. Infant po'ing15-25cc q 3hrs. sucking on binki and hands.fontanelles soft and flat.#6 resppt continues in r/a with sats >96%. A: AGA P: cont to support dev. Active bs. Neonatology Attending NoteDay 6CGA 34 5RA. NPN 0700-19001. wt. Waking on own for some feeds. A: AGa P; cont to supportdev. A: stable P: cont to follow.BILIO: Under single photo tx. A: Stable.P: cont to follow.BIliO: Under single photo tx with eye in place. Calmswith containment and pacifier. Min asp. MIn asp. Suckles well onpacifier. Cont topromote G&D. Rest well inbetween cares. Bottlingwell. abd benign. Abd benign. Abd benign. Abd benign. aware of VNA. Active, alert, AFOF, sutures opposed, good tone. Calms with containment and pacifier.A: AGA P: cont to support dev. Continue to support G+D.RESP: Infant remains in RA. Stable in RA.REVISIONS TO PATHWAY: 6 Respiratory; d/c'd wt. WT. REMAINS SWADDLED IN OAC. Mature breathing control. P:Recheck bili in am.GDO: tEmp stable in servo controlled isolette of 36.0 degrees.Active and then sleepy with cares. rr20-50's.mild sc retraction noted. Neonatology - Progress Note is active with good tone. Abdbenign. TEMPS STABLE. NPN 0700-6 Respiratory2. WAKING FOR SOMECARES. maew. PO FEEDING WELL.#6 RA. PT ALT PO/PG OVERNIGHT. NPN 0700-2. Continue to support/educate family.G+D: Temps stable, swaddled in OAC. PO/PG FEEDINGS. ABD SOFT, NO LOOPS, +BS. Cont to support, update, andeducate .5. Stooling (heme neg). Abd pink, no loops,active bs. BILI SENT THIS A.M.#5 TEMPS ARE STABLE ON SERVO UNDER BILI LIGHTS. lsc=. Under single phototherapy.Parents in and up to date.A: Stable. CONT. CONT. CONT. Tolerating all PO's thus far. P: Follow. HEP B GIVEN WITHOUT INCIDENT.3. Desitinapplied. AFOF. fontanellessoft and flat.#6 resppt continues in r/a with sats 99-100%. voiding and stooling qdiaper,.repeat bili pending. Breath sounds clearand equal bilaterally, mild SCR noted. Abdomen pink, soft, round,+BS, no loops. Infant bottled 30cc with good coordination at1300/remainder gavaged via NG. D/Cteaching done; see NICU D/C instruction form in chart. sucking on binki. ROOTING. see flow sheet for results.#5 g&dpt in servo control isolette with stable temps. MAE. MAE. MAE. MAE. Physical Exam remains in RA. Voiding and trace stool thus far. Invested . Continue to monitor Resp status. Voiding and one hemenegative stool thus far. ABd pink, no loops, active bs.Voiding/ stooling heme (-). | 59 | [
{
"category": "Nursing/other",
"chartdate": "2136-04-04 00:00:00.000",
"description": "Report",
"row_id": 1793065,
"text": "Neonatology Attending\nDOL 8 / CGA 35 weeks\n\nIn room air with no distress and no cardiorespiratory events.\n\nNo murmur. BP 72/39 (55).\n\nWt 2090 (unchanged) on TFI 150 cc/kg/day BM24, tolerating well. Alternating oral and gavage with small volume PO intake. Abd benign. Voiding and stooling (guiac negative).\n\nTemperature stable in open crib.\n\nA&P\n33-6/7 week GA infant with feeding immaturity\n-Continue to await maturation of oral feeding skills\n- updated last night\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-04-04 00:00:00.000",
"description": "Report",
"row_id": 1793066,
"text": "NPN \n\n\n\n #2. O: Infant conts on TF 150cc/k BM 24 (53cc q4hr). Abd\nsoft w/active BS, min asp,no spits, no loops, voiding and\nstooling heme-. Mom attempted to BF at 1300. He was very\nsleepy at the time. He latched but did not suck. She did\nboth sides for a total of 15mins. PG fed after that. A:\nLearnin to po feed. P: Encourage BF/bottle every other care.\n\n\n #3. O: in at 1300 cares. Independent w/cares and\nBF. Updates on infant's progress given at the bedside.\nAsking approp questions. A: Involved, loving . P:\nCont support, educate and keep updated.\n\n #5. O: Temp stable swaddled in OC. A&A w/cares. Settles\neasily and sleeps between cares. MAEW. AF soft and flat. Not\nyet waking for feeds. Mellow personality. A: AGA P: Cont to\nsupport G&D.\n\n #6. O: Infant remains in RA. Breathing comfortably 30-40.\nMild SC retractions. LS cl/=. Sating >95%. No spont A/B's or\ndesats. A: Stable P: Cont to monitor for and document A/B's.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-04-04 00:00:00.000",
"description": "Report",
"row_id": 1793067,
"text": "4 BILI\n\nREVISIONS TO PATHWAY:\n\n 4 BILI; resolved\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-04-04 00:00:00.000",
"description": "Report",
"row_id": 1793068,
"text": "Neonatology NP Exam Note\nPLease refer to Dr note for details regarding evaluation and plan.\n\nPE: small infant nestled in open crib. transitions from sleep to quiet awake without difficulty. Skin is pink, warm well perfused. AFOF, eyes clear, narespatent with ng in place. MMMP\nChest is clear with comfortable resp pattern.\nCV: RRR, nl S1, split S2, no murmur. Pulses+2=\nAbd: soft active BS, no HSM\nGU: testes descended.\nEXT: MAE\nneuro: flexed position. appropraite tone and activity for GA.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-04-05 00:00:00.000",
"description": "Report",
"row_id": 1793069,
"text": "#2FEN\nWt up 20g to 2.11 kg.Baby cont to receive BM24 with Enf\npowder at 150cc/kg. Baby went to breast at 2100 latched on\nand did some sucking intermittently. Baby gavaged entire\namt. At 0100, baby awake and bottled 15cc before tiring.\nMin asp. Small spit. Void and stooling.\nA. Tol feed. Still work on improving po skills.\nP. Cont to monitor.\n#3Parent\n here at 2100. Mom given option of breast feed or\nbottle feed. Mom opted to breast feed. Both held\nbaby. made appointment for lactaion consult on Monday at\n1300. List of days and times of CPR class given for next\nweek. do not want a circumcision. They do have a car\nseat at home. Discussed with that even though the\nbaby may not go home in next day, we need to begin\nconsidering discharge.\n#5Dev\nNeeded to be awoken for feeds tonight. Howevre once woken\nalert. Temp stable in an open crib.\n#6Resp\nLungs clear with mild retractions. Sat in high 90's. RR\n30-50's. No spells.\nP. Cont to monitor.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-03-29 00:00:00.000",
"description": "Report",
"row_id": 1793041,
"text": "NPN 0700-1900\n\n1 Infant with Potential Sepsis\n\n#2FEN: TF increased to min 100cc/kg/day of BM 20 or PE 20 Q\n3hrs. Pt. doing well w/ breastfeeding, latching on &\nsucking for > 10minutes. Pt. taking 20-25cc when bottled.\nAbd soft & round, +BS, no loops. AG 24cm. No spits. Pt.\nvoiding & stooling, heme negative. D/s 72. P: continue to\nencourage breastfeeding.\n\n#3Parenting: Parents & grandmom in today for cares.\nParents taught how to take temp & change diaper. Both\nasking approp questions. Mom breastfeeding very well. Both\nvery affectionate towards pt. Scheduled family mtg for\ntomorrow @ 2pm. P: continue to support & update.\n\n#4Bili: Pt. continues on bili blanket. Pt. sl jaundice.\nP: check bili in am.\n\n#5G&D: Pt. swaddled w/ hat on in open crib, temps stable.\nPt. waking for feeds Q 3hrs. Awake & alert. MAE's approp.\nFontanelles soft & flat. P: continue to support dev needs.\n\n#6Resp: Pt. continues on RA, RR 30-40's w/ mild SC\nretractions. Sats 94-99%. Lungs clear bilaterally. No\nspells. Pt. tends to drift to mid 80's when sucking on\npacifier. No drifts when feeding. P: continue to monitor\nresp status.\nSee flowsheet for further details.\n\nREVISIONS TO PATHWAY:\n\n 1 Infant with Potential Sepsis; resolved\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-03-29 00:00:00.000",
"description": "Report",
"row_id": 1793042,
"text": "Neonatology- Progress Note\n\nPE: Remains in room air, bbs cl=, rrr s1s23 no murmur, bd soft, nontender, V&S, afso, activew ith care, slightly jaundiced, under pt with eye covering in place\n\nSee attending note for plan\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-03-30 00:00:00.000",
"description": "Report",
"row_id": 1793043,
"text": "NPN 1900-0700\n\n\nFEN: wt=2085g (down 15g). TFmin 100cc/kg/d of BM/PE20.\nBreastfeeding and bottling well q3hrs. Abdomen soft, +BS, AG\nstable, no loops, no spits, voiding and stooling. D-stick\n63. Lytes 144/6.1/113/20, grossly hemolyzed.\n\nParents: Both parents in for 2130 cares. Independent with\ntemp and diaper. Mom breastfed and bottled. Dad held infant.\nMom signed consent for state screen and for hep B. Plan to\nbe in later this AM.\n\nBili: Continues on bili blanket. Bili sent 8.0/0.3, grossly\nhemolyzed.\n\nG&D: Temps stable, swaddled with hat in open crib. Alert and\nactive with cares. Occasionally wakes for feeds. State\nscreen done.\n\nResp: RA. RR 30-50's. No WOB. LS clear and equal. Did drift\nto 86-87% with bottling, but self-resolves with no\nintervention. No spells.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-03-30 00:00:00.000",
"description": "Report",
"row_id": 1793044,
"text": "Neonatology Attending\nAddendum\nFamily meeting scheduled for today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-03-30 00:00:00.000",
"description": "Report",
"row_id": 1793045,
"text": "Neonatology Attending\nAddendum\nFamily meeting scheduled for today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-03-30 00:00:00.000",
"description": "Report",
"row_id": 1793046,
"text": "Neonatology Attending\nDOL 3\n\nRemains in room air with no distress and no cardiorespiratory events.\n\nNo murmur. BP 65/39 (56).\n\nUnder phototherapy with bilirubin 8.0/0.3 (inc from 7.3).\n\nWt 2085 (-15) on TFI 100 cc/kg/day including BM20/PE20. D-stick 63,92. Bottling well and breastfeeding. 144/6.1/113/20 (hemolyzed).\n\nTemperature stable in open crib.\n\nA&P\n33-6/7 week GA infant with hyperbilirubinemia.\n-Continue to monitor for respiratory maturity\n-Repeat bilirubin in 24 hours along with electrolytes\n-Increase minimum TFI to 120 cc/kg/day given mild hypernatermia and jaundice.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-03-30 00:00:00.000",
"description": "Report",
"row_id": 1793047,
"text": "Neonatology Attending\nAddendum\nFamily meeting scheduled for today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-04-02 00:00:00.000",
"description": "Report",
"row_id": 1793061,
"text": "NPN days\n\n\nFEN: TF of 150cc/k/d of PE/BM increased calories today to\n24/ounce. ALternating PO/PG feedings. Bottling slow,\ninfant over half hour feeding taking in 15cc with premie\nnipple. Gavaged feedings over 45min. Breastfed X 1 today,\ngood latch and suck, however infant soon tires and falls\nasleep at breast ,and will intermittently suck. Abdomen is\nsoft, pink,active bowel sounds, no loops, Voiding and\nstooling. Min asp. no spits. will continue to monitor\nclosley for signs or symptoms of feeding intolerance.\nContinue to encourage PO feedings, gavage remainder of\nfeeds, continue per current feeding plan.\n\nParenting: Parents in today for the whole day,\nparticipating in cares. Fed via bottle and breast today.\nAsking appropriate ?'s, will continue to update and support\nfamily.\n\nBILI: infant's rebound level this am 7.6/0.2 , plan to re\ncheck level in am. Will cotninue to follow.\n\nG&D: Temps are stable in air isolette, isolette temp weaned\nslightly d/t temp 99.2 this am. Active and alert with\ncares, sleeps well between cares, eagerly sucking on\npacifier. Will continue to support developmental cares.\n\nRESP: Infant continues in room air, no desats, no spells.\nRR 30-50's, lungs are clear and equal, mild SC retractions .\nWill continue to monitor closely.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-04-03 00:00:00.000",
"description": "Report",
"row_id": 1793062,
"text": "2 F/N\n Abdomen soft, + bowel sounds, 0 loops,0 distention, doing\na little better with po feeds , took 30 and 35cc polast two\nfeeds. Tolerating rest well by gavage, 0 spits, 0 asp.\nVoiding, stooling. Wt. up 40gms to 2.090. Continue present\nplans.\n3 \n No contact from so far tonight. Plan to keep\nfamily updated.\n4 Bili.\n Infant remains slightly jaundiced, Bili tonight\n8.1--7.8--0.3. continue per plans.\n6 Resp.\n Infant remains in room air with sats over 95. No spells\nso far tonight. Continue to monitor and record any changes.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-04-03 00:00:00.000",
"description": "Report",
"row_id": 1793063,
"text": "Neonatology Attending\nDOL 7 / CGA 34-6/7 weeks\n\n remains in room air with no distress and no bradycardias/apneas.\n\nNo murmur. BP 79/46 (59).\n\nWt 2095 (+40) on BM24 at TFI 150 cc/kg/day, tolerating well. Bottling half volume with each feed. Abd benign. Voiding and stooling normally.\n\nBilirubin 8.1/0.3 today (rebound).\n\nTemperature stable in off isolette.\n\nA&P\n33-6/7 week GA infant with feeding immaturity, resolving hyperbilirubinemia\n-Continue to await maturation of oral feeding skills\n-No other changes in management as detailed above\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-04-04 00:00:00.000",
"description": "Report",
"row_id": 1793064,
"text": "#2FEN\nWt unchanged. Remains at 2.09. Abd soft active bowel sounds.\nVoid and stooling guiac neg. Min asp with no spits. At 2100,\nfeed gavaged. At 0100, baby bottled 30cc and then tired.\nRemainder of feed gavaged. Cont on BM24.\nA. Tol feed. Learning to po feed.\nP. Cont to monitor tol to feed\n#3Parent\n here with visitors. held baby.\n#4Bili\nBaby remains sl jaundiced.\n#5Dev\nAwakening quietly for feeds. Interested in beginning but\ntires. Temp stable in an open crib.\n#6Resp\nBaby breath comfortably with mild sc retractions. RR20-50's.\nNo spells. Sat in high 90's.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-04-09 00:00:00.000",
"description": "Report",
"row_id": 1793088,
"text": "Neonatology Attending\nDOL 13 / CGA 35-5/7 weeks\n\n remains in room air with no cardiorespiratory events.\n\nNo murmur. BP 69/39 (52).\n\nWt 2235 (+45) on BM24 with intake > 150 cc/kg/day in addition to breastfeeding well. Voiding and stooling normally.\n\nState screen sent. Car seat and hearing screen passed.\n\nA&P\n33-6/7 week GA infant with resolved feeding immaturity\n-For discharge home today\n-VNA and pediatrician follow-up arranged for this week\n\nDischarge time > 30 minutes\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-04-09 00:00:00.000",
"description": "Report",
"row_id": 1793089,
"text": "Parent Teaching/CPR Note\n\nO: Mom here for infant's discharge later today. Stated that she had taken CPR class in the past and just needed a review. Watched video tape and reviewed infant CPR and choking maneuvers with demonstrations of all done on manikin by this RN. Mom stated that she understood all maneuvers and had no further questions. She declined offer to practice on manikin. Reviewed back to sleep positioning and safe sleeping. \"Back to Sleep\" brochure given to mom by RN. Class completed at 12:45 and poster given to mom to take home.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-04-09 00:00:00.000",
"description": "Report",
"row_id": 1793090,
"text": "Nursing Discharge Note\n0700-1300. Baby was discharged home with today. Infants discharge wt 2235. He is breast feeding and supplementing with BM24cal bottles. (24cal/ enfamil powder to BM) Mom has recipe cards and is comfortable preparing 24cal formula. Mom plans to give infant at least 3 bottles per day/breast feed on demand. Mom able to take CPR class prior to discharge. Dad plans to make arrangements to come back to NICU for CPR class. Discharge check list reviewed and complete. Pedi visit scheduled for . Caregroup VNA called and referral faxed. VNA to visit . Meds reviewed with family and Dad able to administer iron independently. (see flow sheet for discharge vital signs and assessment) in to do discharge exam.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-03-28 00:00:00.000",
"description": "Report",
"row_id": 1793036,
"text": "Neonatology NP Exam NOte\nPLease refer to Dr note for details of evaluation and plan.\n\n\nPE: small new infant nested on open radiant warmer. PInk, warm, well perfused in room air.\nAFOF, sutures approximated. nares patent, MMMp\nChest is clear, equal BS, comforatble resp pattern.\nCV: RRR, nl S1, split S2, no murmur, pulses +2=\nAbd: soft, active BS, cord clamped. No HSM\nGU: descended testeicles, right hydocele\nExt: MARE, WWP\nNeuro: symmetric tone and reflexes\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-03-28 00:00:00.000",
"description": "Report",
"row_id": 1793037,
"text": "NPN 0700-1900\n\n\n1. SEPSIS Amp/gent continue. B/C neg to date.\nPlan to continue to monitor for s/s sepsis and administer\nantibx as ordered.\n\n2. FEN Tf increased to a min of 80cc/k/d, BM or PE20.\nInfant bottled b/w 12-25cc each feed, q2-3hrs. Attempted to\nbr'feed--sucessful with latch on, but br feed<5min. Mom\npumping. Belly flat/soft, +BS, no spits. Stooling lg mec\nand voiding 3.5cc/k/hr. D/S 66,63.\nPlan to follow po intake and encourage br'feeding, monitor\ni/o.\n\n3. PARENTS Mom and dad visiting various times throughout\nthe day, bringing relatives through to meet infant. Mom and\ndad very attentive and speaking lovingly to infant, asking\napprop questions. Mom and dad both held infant today.\nPlan to support and update parents regularly, encourage\nparticipation in cares.\n\n4. BILI 24hr bili lvl 6.8/0.2, NNP notified, single phtx\nordered.\nPlan to commence single lights as ordered.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-03-28 00:00:00.000",
"description": "Report",
"row_id": 1793038,
"text": "4 BILI\n\nREVISIONS TO PATHWAY:\n\n 4 BILI; added\n Start date: \n\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-03-29 00:00:00.000",
"description": "Report",
"row_id": 1793039,
"text": "NPN 1900-0700\n\n5 G&D\n6 Respiratory\n\nSepsis: Infant continues on abx, amp and gent. BC NGTD.\n\nFEN: bw=2125g. wt=2100g (down 25g). TFmin 80cc/kg/d of\nBM/PE20. Min 21cc q3hrs, still all PO's. BF fair/well.\nAbdomen soft, +BS, no loops, sm spit x1, voiding and\nstooling transitional stools, trace positive, \naware. D-stick 55, aware. Plan to check d-stick\nprior to next feed.\n\nParents: Both parents in for cares. Mom BF and bottled\ninfant. Will be up later today.\n\nBili: Received infant on single phototherapy with eye\nshields on. Infant transitioned to bili blanket at midnight.\nPlan to check bili with next cares.\n\nG&D: Received infant on servo-controlled warmer. Was\nslightly warm. Swaddled and placed in open crib. Temps\nstable. Wakes for feeds. Alert and active with cares. Hands\nto face.\n\nResp: In RA. O2sat >93%. RR 20-40's. LS clear and equal.\nInfant does desat to 80% with paci. Resolves when removed.\nNo spells thus far.\n\nREVISIONS TO PATHWAY:\n\n 5 G&D; added\n Start date: \n 6 Respiratory; added\n Start date: \n\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-03-29 00:00:00.000",
"description": "Report",
"row_id": 1793040,
"text": "Neonatology Attending\nDOL 2 / CGA 34-1/7 weeks\n\nIn room air with no distress and no cardiorespiratory events.\n\nNo murmur.\n\nBilirubin 7.3/0.3 (inc from 6.8/0.2 under single phototherapy).\n\nWt 2100 (-25) on TFI 80 cc/kg/day min BM20/PE20, tolerating well. D-stick 55,71,72 overnight and this morning. Voiding and stooling (guiac negative). Abd benign.\n\nTemperature stable.\n\n48-hour course of antibiotics completed this morning; culture negative.\n\nA&P\n33-6/7 week GA infant with hyperbilirubinemia\n-Increase min TFI to 100 cc/kg/day.\n-Continue phototherapy and repeat bilirubin in 24 hours. Type and coombs on cord blood.\n-Discontinue antibiotics today\n-Will arrange family meeting for tomorrow\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-04-01 00:00:00.000",
"description": "Report",
"row_id": 1793057,
"text": "NICU nursing progress note\n\n\nPLease refer to flowsheet for specific info.\nResp\nO: remains in room air, RR 30-60's, sat's >98%. BSCE\nbilat. No brady's. Mild sc ret. A: Stable. P: cont to\nfollow.\nFEN\nO: TF ^150cc/k/d of bm 20/ pe 20, alt po/pg. BF fair,\nsleepy. Bottling ~40cc with remainder gavaged. Abd soft,\npink, no loops, active bs. Voiding/ stooling trace amounts\nof liquid stool. No spits. Min asp. A: Stable. P: cont to\nfollow.\nGD\nO: Temp stable in air isolette, swaddled. Active, and alert\nwith cares. MAE. Fonts soft, flat. Calms with containment\nand pacifier. A: AGA P: cont to support dev. milestones.\nBIli\nO: Photo tx d/c'd. Sl. jaundiced. P: Rebound bili level in\nam.\nParenting\nO: Mom and dad in and updated at bedside, verbalizing\nunderstanding. Parents are gaining confidence in the care of\n and are very loving toward him. A: Involved parents.\nP: cont to support, update, educate.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-04-01 00:00:00.000",
"description": "Report",
"row_id": 1793058,
"text": "Neonatology - PRogress Note\n\n is active with good tone. AFOF. He is pink, well perfused, no murmur auscultated. He is comfortable in room air. Breath sounds clear and equal. He is tolerating po/pg feeds. Abd soft, active bowel sounds, no loops, voiding and stooling. Stable temp in isolette. Pleas refer to neonatology attending note for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-04-02 00:00:00.000",
"description": "Report",
"row_id": 1793059,
"text": "npn 1900-0700\n\n\n#2 fen\ntf 150cc/kg bm20/pe20 po/gavage q4hours. wt. 2.050kg\n(-5gms). abd benign. voiding and stooling yellow guiac neg\nstools. no spits. max aspirate 1.8cc. slow bottler, good\ncoordination.\n#3 parenting\nno contact thus far this shift.\n#4 hyperbili\npt with jaundice skin. to repeat bili this am, see flow\nsheet.\n#5 g&d\npt in air control isolette with stable temps. alert and\nactive with cares. maew. sucking on binki and hands.\nfontanelles soft and flat.\n#6 resp\npt continues in r/a with sats >96%. lsc=. rr 30-50's.\nmild sc retractions noted. no spells or drifts thus far\nthis shift.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-04-02 00:00:00.000",
"description": "Report",
"row_id": 1793060,
"text": "Neonatology Attending Note\nDay 6\nCGA 34 5\n\nRA. RR30-50s. Cl and = BS. Mild sc rtxns. No A&Bs. No murmur. HR 140-160s. BP 68/36, 53.\n\nRebound bili 7.6/0.2.\n\nWt 2050, down 5 gms. TF 150 cc/k/day PE/BM20. PO/PG. Tol well. Nl voiding and stooling.\n\nIn air controlled isolette.\n\nA/P:\nGrowing preterm infant learning how to po feed.\nWill increase cals to 24.\nCheck another bili level in am.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-04-08 00:00:00.000",
"description": "Report",
"row_id": 1793081,
"text": "PCA Note:\n\n\nFEN: O: Wt. = 2.190kg (^25g). TF 150cc/kg BM24 w/ enfamil\npowder. Infant waking for feeds q3-4hrs, taking in about\n60cc/feed. Small spit x1 with bottle. Infant's abdomen is\nsoft, nontender, +BS, no loops. Infant is voiding, trace\nstool x2 thus far. A: Infant tolerating feeds well. P:\nContinue to support infant's nutritional needs.\n\n: O: No contact thus far.\n\nDEV: O: Infant is swaddled in an OAC, maintaining stable\ntemps. Infant sleeps well between cares. Wakes for feeds and\nremains alert and active throughout cares. calms with\nhis pacifier. A: Developmentally appropriate. P: Continue to\nsupport infant's developmental needs.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-04-08 00:00:00.000",
"description": "Report",
"row_id": 1793082,
"text": "NPN NOCS\nI have examined infant and agree with above note by PCA, . Possible plan for d/c monday in the works. RT made aware of need for hearing screen. Yesterday, took in 159cc/kg.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-04-08 00:00:00.000",
"description": "Report",
"row_id": 1793083,
"text": "Neonatology Attending\nDOL 12 / CGA 35-4/7 weeks\n\nIn room air with no cardiorespiratory events.\n\nBP 72/40 (50). No murmur.\n\nWt 2190 (+25) on TFI 150 cc/kg/day BM24 with intake 159 cc/kg/day yesterday. Abd benign. Voiding and stooling normally.\n\nWaking for feeds. Temperature stable in open crib.\n\nA&P\n33-6/7 week GA infant with resolving feeding immaturity\n-Continue to await consolidation of oral feeds for another 24 hours then discharge home\n-Discharge planning in progress\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-04-08 00:00:00.000",
"description": "Report",
"row_id": 1793084,
"text": "Neonatology - Progress Note\n\n is active with good tone. AFOf. He is pink, well perfused, no murmur auscultated. He is comfortable in room air. Breath sounds clear and equal. He is tolerating ad-lib breast/bottle feeds. Abd soft, active bowel sounds, no loops. Voiding and stooling. Stable temp in open crib. Plan is for discharge tomorrow. Please refer to neonatology attending note for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-04-08 00:00:00.000",
"description": "Report",
"row_id": 1793085,
"text": "NPN 0700-\n\n\n2. TF 150cc/k/d BM24= 55cc Q4hr. Able to bottle 65cc this\nam. Breast fed for <5mins, then supplemented with 45cc\nafterward. Abd benign. Voiding and stooling. On ferinsol\nand trivisol. Tolerating PO's without emesis. Cont to\nmonitor ability to take all PO's.\n\n3. Mother in this afternoon and updated on plan of care.\nMother independent with infant cares and aware of possible\nD/C date for tomorrow. Invested and independent .\nCont to support, update, and prepare for D/C tomorrow.\n\n5. Temps stable swaddled in open crib. Waking for feeds\nQ3-4hr, alert and active. Rest well inbetween cares. MAE,\nbrings hands to face and mouth. VNA referral called and\nvisit planned for Tuesday. Mother aware to change pedi\nappt. for this Wed or Thurs. Cont to promote G&D.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-04-09 00:00:00.000",
"description": "Report",
"row_id": 1793086,
"text": "#2FEN\nWt 2.235 up 45g. Baby cont to bottle all feeds. Taking\n60-70cc q3.5-4h .Abd soft, active bowel sounds. Void and\nstooling. No spits. Took in 109cc/kg plus BF. Cont to\nreceive BM24 with enf powder.\nA. Cont to po feed well.\nP. Cont to monitor. Discharge today if all continues to go\nwell.\n#3Parent\nNo contact tonight.\n#5Dev\n stable in an open crib. Awoken on his own at 2130.\nHowever awoken at 0100. Temp stable in an open crib. He\npassed his car seat test tonight.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-04-09 00:00:00.000",
"description": "Report",
"row_id": 1793087,
"text": "State screen sent this am in anticipation of discharge.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-03-27 00:00:00.000",
"description": "Report",
"row_id": 1793032,
"text": "Neonatology Attending\n33-6/7 week GA infant admitted for prematurity\n\nMaternal Hx - 40 year old G2P0->1 woman with POBHx notable for SAB x 1, myomectomy. PMHx non-contributory. Prenatal screens: A positive, DAT negaitve, HBsAg negative, RPR non-reactive, rubella immune, HIV negative, GBS unknown.\n\nPregnancy Hx - LMP for and EGA 33-6/7 weeks by LMP and confirmatory first trimester ultrasound. IVF pregnancy complicated by elevated triple screen (Trisomy 21 risk 1:40) but normal amniocentesis. Fetal survey normal. Spontaneous onset of preterm labor with ultrasonographic evidence of placental abruption. PROM approximately 48 hours prior to delivery. Treated with terbutaline and antibiotics (from ), and received full course of betamethasone. Proceeded to cesarean section under epidural anesthesia.\n\nNeonatal course - Infant cried on transfer to warmer. Orally and nasally bulb suctioned, dried, free flow oxygen briefly. Subsequently pink and in no distress in room air. Apgars 8 at one minute, 8 at five minutes. Transferred uneventfully to NICU.\n\nPE\nwell-appearing infant in no distress\nexam consistent with 34 weeks GA\nhr140 rr 48-60 BP 71/39 (50) SaO2 95% in room air\nBW2125g (50th %ile) OFC 30cm (25th %ile) LN 44cm (25-50th %ile)\nHEENT AFSF; non-dysmorphic; palate intact; neck/mouth normal; no nasal flaring\nCHEST no retractions; good bs bilat; no crackles\nCVS well-perfused; RRR; femoral pulses normal; S1S2 normal; no murmur\nABD soft, non-distended; no organomegaly; no masses; bs active; anus patent\nGU normal male genitalia; testes descended bilaterally\nCNS active, alert, resp to stim; axial and appendicular tone AGA and symmetrical; moving all extremities symm; gag intact; grasp/Moro normal\nINTEG normal\nMSK normal spine/limbs/hips/clavicles\n\nIMPRESSION\n33-6/7 week GA infant, currently asymptomatic, admitted with\n1. Sepsis risk, based on preterm labor with preterm prolonged rupture of membranes\n\nPlan\n-Infant has been admitted for cardiorespiratory monitoring. No clinical evidence of surfactant deficiency. Monnitor for respiratory maturity\n-Cardiac examination is currently normal. Monitor for PDA and target mean BP > 38 mmHg\n-Will send CBC and blood culture and start broad-spectrum antibiotic theapy for anticipated course of 48 hours pending culture results and ongoing absence of clinical symptoms\n-Given cardiorespiratory stability, will initiate enteral feedings, with trial of oral feeds and minimum TFI of 80 cc/kg/day. Monitor d-stick, weight, urine output\n-Parents updated regarding current status, diagnostic considerations and our management plan\n\nOB: Dr. . \nPediatrician: Not yet charted\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-03-27 00:00:00.000",
"description": "Report",
"row_id": 1793033,
"text": "NICU NURSING ADMISSION NOTE:\nBaby boy admitted to NICU from L&D, please see attending note for details. Baby alert, active and crying, pink well perfused no audible murmur, pulses normal, b/p stable, VSS, Resp rate easy and unlabored, BBS equal and clear, 02 sats >95%, abd soft and nondistended, good bowel sounds, voided X2. CBC and Blood cultures done and sent to lab. IV started in Right hand for IV antibiotics, Ampi and gent given as ordered. D/S 43, fed well 20 cc PE20 with f/u d/s 56, Vit k and Erytho OU given as ordered. Awaiting visit from parents.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-03-28 00:00:00.000",
"description": "Report",
"row_id": 1793034,
"text": "NPN 7p-7a\n\n\nSepsis: conts on amp and gent. Bld cx neg to date. No signs\nof sepsis noted.\n\nFEn: Infant's tf increased to min of 60cc/kg. Infant po'ing\n15-25cc q 3hrs. Waking on own for some feeds. Dsticks stable\n65-72. Abd soft. Active bs. No stool thus far. Voiding with\neach diaper change. Ag 24-27cm. cont to encourage po feeds.\nand monitor dsticks.\n\nParenting: Dad in briefly this evening with visitors. This\nRN with another pt did not speak to Dad at that time.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-03-28 00:00:00.000",
"description": "Report",
"row_id": 1793035,
"text": "Neonatology Attending\nDOL 1 / CGA 34 weeks\n\nRemains in room air with no cardiorespiratory events other than mild desaturations with feeds.\n\nNo murmur. BP 62/36 (52).\n\nOn ampicillin and gentamicin. WBC normal. Culture negative to date.\n\nWt 2125 (BW) on TFI 60 cc/kg/day PE20, tolerating well orally. D-stick 43-72 (all since feeds started have been >50). Urine output 3.1 cc/kg/hr in the past 12 hours. Abd benign. Small mec stool this morning.\n\nTemperature stable on servo warmer. Active and alert.\n\nA&P\n33-6/7 week GA infant\n-Continue to monitor to confirm maturity of respiratory drive, feeding skills and thermoregulation\n-Encourage breastfeeding\n-Check 24-hour bilirubin\n-Plan to discontinue antibiotics at 48 hours if culture negative\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-03-31 00:00:00.000",
"description": "Report",
"row_id": 1793053,
"text": "Neonatology Attending Progress Note:\nDOL #4\n33 6/7 weeks\nno spells, no caffeine\nvital signs stable\nsingle phototherapy\nbili=7.5 ( from 8.3)\n144/6.6/114 (hemolyzed and QNS for bicarb)\nBW=2125g, 2100g currently\nminimum of 120 cc/kg/d feeds--yesterday gavage tube placed for inadequate po\nservo control isolette\n\nPE: mild jaundice, well appearing, AFOF, normal S1S, no murmur, breath sounds clear, abomen soft, nontender, nondistended, ext warm, well perfused. tone aga.\n\nImp/Plan: premie with indirect hyperbilirubinemia-on phototherapy, learning to po feed\n--increase to 140cc/kg/d\n--continue phototherapy, turn off tomorrow and check rebound on Monday\n--continue gavage feedings\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-03-31 00:00:00.000",
"description": "Report",
"row_id": 1793054,
"text": "NICU nursing progress note\n\n\nPlease refer to flowsheet for specific info.\nFEN\nO: is currently on TF min of 140cc/k/d of PE 20/\nbm20. Bottled well today taking nearly full volume, and\nremainder gavaged. No spits. MIn asp. BF fair today, while\nfeeding being gavaged. ABd pink, no loops, active bs.\nVoiding/ stooling heme (-). A: stable P: cont to follow.\nBILI\nO: Under single photo tx. eye shields in place. P: SHut off\nphoto tx tomorrow and check a rebound on Monday.\nGD\nO: Alert and active w/ cares. MAE. Fonts soft, flat. Calms\nwith containment and pacifier. A: AGa P; cont to support\ndev. milestones.\nParenting\nO: Mom and dad in and updated at bedside, verbalizing\nunderstanding. A: GAining confidence in the care of .\nP: cont to support, update, educate.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-04-01 00:00:00.000",
"description": "Report",
"row_id": 1793055,
"text": "npn 1900-0700\n\n\n#2 fen\ntf min 140cc/kg po/gavage q4hours of bm20/pe20. wt. 2.055kg\n(-45gms). abd benign. voiding and stooling yellow guiac neg\nstools. small spits, max aspirate 3cc partially digested\nmilk.\n#3 parenting\nno contact thus far this shift\n#4 bili.\npt under single phototherapy with eye in place.\nslightly jaundice color. voiding and stooling qdiaper,.\nrepeat bili pending. see flow sheet for results.\n#5 g&d\npt in servo control isolette with stable temps. alert and\nactive with cares. maew. sucking on binki. fontanelles\nsoft and flat.\n#6 resp\npt continues in r/a with sats 99-100%. lsc=. rr20-50's.\nmild sc retraction noted. no spells or drifts thus far this\nshift.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-04-01 00:00:00.000",
"description": "Report",
"row_id": 1793056,
"text": "Neonatology Attending\n\nDOL 5 CGA 34 4/7 weeks\n\nStable in RA. No A/B.\n\nOn 140 cc/kg/d PE/B 20 po/pg. Voiding. Stooling (heme neg). Wt 2055 grams (down 45).\n\nBili 6.5/0.3. Under single phototherapy.\n\nParents in and up to date.\n\nA: Stable. Mature breathing control. Learning to po. Hyperbili resolving.\n\nP: Monitor\n Increase to 150 cc/kg/d\n Encourage pos\n D/C phototherapy\n Rebound bili in am\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-04-06 00:00:00.000",
"description": "Report",
"row_id": 1793076,
"text": "0700-1900 NPN\n\n\nFEN: TF=150cc/kg/d of BM24 with enfamil powder PO/PG q4hr.\nInfant BF for less than 5min at 1300 (see flowsheet for\ndetails). Infant bottled 30cc with good coordination at\n1300/remainder gavaged via NG. Abdomen pink, soft, round,\n+BS, no loops. No spits, minimal aspirates. Voiding and\nstooling (guiac negative). Continue to monitor FEN status.\n\n: Mom and Dad in for the 1300 care, independent,\ninvolved and loving. Updated on patient's current status by\nthis RN. Continue to support/educate family.\n\nG+D: Temps stable, swaddled in OAC. Active and alert with\ncares, sleeps well in between cares. Brings hands to face,\nsucks on pacifier for comfort. MAE. Continue to support G+D.\n\nRESP: Infant remains in RA. RR=30-50's. Breath sounds clear\nand equal bilaterally, mild SCR noted. No bradys so far this\nshift. Continue to monitor Resp status.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-04-07 00:00:00.000",
"description": "Report",
"row_id": 1793077,
"text": "#2FEN\nWt up 15g to 2.165. Baby has been awakening for feeds. He\nhas bottled 2 entire feeds this shift taking 55-60cc BM24.\nAbd soft, active bowel sounds. Void and stooling. Desitin\napplied. Min asp. Feed tube removed due to loose tape.\nA. PO skills improving\nP. Cont to monitor weight and po feed ability\n#3Parent\nNo contact tonight.\n#5Dev\n stable in an open crib. Awakening for feeds. Bottling\nwell.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-04-07 00:00:00.000",
"description": "Report",
"row_id": 1793078,
"text": "Neonatology Attending Progress Note\n\nNow day of life 11, CA 37/ weeks.\nBaby is in RR with RR 30-50s.\nNo apnea and bradycardia.\nHR 150-170s BP 77/38 52\n\nWt. 2165gm up 15gm on 150cc/kg/d of MM24 with Enfamil powder - just started to take all po feedings.\nNormal urine and stool output.\n\nAssessment/plan:\nEncouraging progression of feeding skills.\nWill continue to support breastfeeding.\n\nCar seat screening/ hearing screening and discharge teaching to take place in the next day.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-04-07 00:00:00.000",
"description": "Report",
"row_id": 1793079,
"text": "NPN 0700-\n\n\n2. TF 150cc/k/d BM24 w/enfamil powder= 54cc Q4hr. Infant\nable to take all bottles thus far without difficulty. Abd\nbenign. Voiding and trace stool thus far. Mom plans to\nbreast feed at 1700. Tolerating all PO's thus far. Cont to\nmonitor ability to take all PO's.\n\n3. in to visit and updated on plan of care.\n aware of possible D/C date for this Monday. D/C\nteaching done; see NICU D/C instruction form in chart.\n aware of VNA. Bath to be done this afternoon.\nInvested . Cont to support, update, and educate\n.\n\n5. Temp stable swaddled in open crib. Waking for feeds\nQ3.5- 4hrs. Alert and active with cares. MAE, brings hands\nto face and mouth. Rest well inbetween cares. Cont to\npromote G&D.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-04-07 00:00:00.000",
"description": "Report",
"row_id": 1793080,
"text": "Neonatology NP Note\nPE\nswaddled\nAFOF, sutures opposed\nrespirations unlabored in room air, lungs clear/=\nRRR, no murmur, pink and well perfused\nabdomen soft, nontender and nondistended, active bowel sounds\ngood tone.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-03-30 00:00:00.000",
"description": "Report",
"row_id": 1793048,
"text": "Neonatology- PRogress NOte\n\nPE: remains in room air, pink, slightly jaundiced, bbs cl=, rrr s1s2 no murmur,abd soft, nontender, V&S, afso, active with care, bili blanket in place, swaddled in open crib\n\nSee attending note for plan\n\nTeam met with parents to review clinical issues and criterial for discharge. Parents are quite pleased with and look forward to discharge home. Mom plans to be discharged tomorrow. Have not chosen pedi yet. Do not want circ.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-03-30 00:00:00.000",
"description": "Report",
"row_id": 1793049,
"text": "NICU nursing progress note\n\n\nPLease refer to flowsheet for specific info.\nFEN\nO: is on TF min of 120cc/k/d of PE 20/bm 20,\ncurrently bf and being supplemented with bottle and taking\nfull volume of 43cc q 4 hours by bottle. Abd pink, no loops,\nactive bs. Voiding/ stooling heme (-). No spits. A: Stable.\nP: cont to follow.\nBIli\nO: Under single photo tx with eye in place. P:\nRecheck bili in am.\nGD\nO: tEmp stable in servo controlled isolette of 36.0 degrees.\nActive and then sleepy with cares. MAE. Fonts , soft, flat.\nBrings hands to face. Calms with containment and pacifier.\nA: AGA P: cont to support dev. milestones.\nParenting\nO: Mom and dad in and updated, family meeting and\nverbalizing understanding. Asking appropriate questions. A:\nInvolved and loving parents. P: cont to update, support,\neducate.\nResp\nO: is breathing comfortably without apnea of\nprematurity or periodic breathing pattern. P: Follow.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-03-30 00:00:00.000",
"description": "Report",
"row_id": 1793050,
"text": "NURSING 7p-11p\n\nMom up at 9pm cares and actively participating in temp taking and diapering infant. This RN assessed infant as-- quiet,drowsy, good tone, no crying nor rooting noted on initial assessment. This RN suggested infant go to breast yet defer bottling based on the multiple po attempts earlier today, the current physical assessment and his CGA\nof 34-2/7. Mom became and abruptly left room stating that she was told the plan was to try and avoid having the feeding tube placed.\nRN attempted to provide teaching --ie: BF offers warmth, security, visual contact and baby can self regulate yet bottling ordinarily is\nadvanced slowly-- as baby's cues indicate interest.\nMom opted to bottle son despite the above conversation. Baby sleepy and passive at bottling yet took volume-17cc- over 20+min.\nA/P: Support and reinforce teaching of family re: preemie behaviors.\nCohesive team approach with all practitioners: RN, , MD, LC.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-03-30 00:00:00.000",
"description": "Report",
"row_id": 1793051,
"text": "#2 FEN\ns/o: TF intake for day= 93cc/k/d taken po as of 10 pm. NG\nplaced and PE 20 given to meet ordered vol min of 120cc/k/d\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-03-31 00:00:00.000",
"description": "Report",
"row_id": 1793052,
"text": "#2 TF 120CC/KG OF BM20. PT ALT PO/PG OVERNIGHT. PO FED WELL\nWITH MOM THIS A.M. VOIDING AND STOOLING. WEIGHT INCREASE\n15GM.\n#3 MOM IN FOR FEEDINGS OVERNIGHT. MOM BOTTLED PT THIS A.M.\nMOM ENCOURAGED WITH PT PO PROGRESS.\n#4 PT CONT UNDER SINGLE PHOTO. BILI SENT THIS A.M.\n#5 TEMPS ARE STABLE ON SERVO UNDER BILI LIGHTS. ALERT AND\nACTIVE. PO FEEDING WELL.\n#6 RA. LS ARE CLEAR AND EQUAL. NO SPELLS AT THIS TIME.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-04-05 00:00:00.000",
"description": "Report",
"row_id": 1793070,
"text": "Neonatology Attending\nDOL 9 / CGA 35-1/7 weeks\n\n remains in room air with no distress. No cardiorespiratory events.\n\nNo murmur.\n\nWt 2110 (+20) on TFI 150 cc/kg/day BM24, tolerating well. Alternating oral and gavage, with partial volumes taken slowly on bottling attempts. Abd benign. Voiding and stooling (guiac negative). On iron.\n\nTemperature stable in open crib.\n\nA&P\n33-6/7 week GA infant with feeding immaturity\n-Continue current management as detailed above. Continue to encourage maturation of oral feeding skills\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-04-05 00:00:00.000",
"description": "Report",
"row_id": 1793071,
"text": "NPN 0700-\n\n6 Respiratory\n\n2. Tf 150cc/k/d BM24. Abd benign. Voiding and one heme\nnegative stool thus far. Able to bottle 32cc out of 53cc\nthis morning and tired easily. Mom able to breast feed this\nafternoon. Baby able to latch with some intermittent\nsuckling. Tolerating PO/PG feeds without aspirates or\nemesis. Cont to encourage PO feeds as tolerated.\n\n3. Mother in throughout day and independent with diaper\nchange, temp taking, and feeding. Mother updated on plan of\ncare. Invested . Cont to support, update, and\neducate .\n\n5. Temps stable swaddled in open crib. Infant awake and\nactive with cares, rest well inbetween. Suckles well on\npacifier. MAE. Cont to promote G&D.\n\n6. In RA with sats 96-100%. Oximeter D/C'd as ordered.\nLungs clear, RR 30-50's with mild SC retractions. No A&B\nthus far. Stable in RA.\n\nREVISIONS TO PATHWAY:\n\n 6 Respiratory; d/c'd\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-04-05 00:00:00.000",
"description": "Report",
"row_id": 1793072,
"text": "Neonatology - Progress Note\n\n is active with good tone. AFOF. He is pink, well perfused, no murmur auscultated. He is comfortable in room air. Breath sounds clear and equal. He is tolerating full volume feeds of 24 cal breast milk. Abd soft, active bowel sounds, no loops, voiding and stooling Stable temp in open crib. Please refer to neonatology attending note for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-04-06 00:00:00.000",
"description": "Report",
"row_id": 1793073,
"text": "NPN 1900-0730\n\n\n2. WT. 2.150GMS. UP 40GMS FROM YESTERDAY. NOW EXCEEDING BW\nAT PRESENT. CONT. WITH TF AT 150CC/K/D OF BM24 WITH ENFAMIL\nPOWDER OR 54CC Q4HRS. CONT. PO/PG FEEDINGS. BOTTLING ENTIRE\nFEED AT 0130. ABD SOFT, NO LOOPS, +BS. VOIDING, NO STOOL SO\nFAR THIS SHIFT. GIRTH 26.5CM. NO SPITS AND MIN. ASP NOTED.\n\n5. REMAINS SWADDLED IN OAC. TEMPS STABLE. WAKING FOR SOME\nCARES. ROOTING. A/A MOVING ALL EXTREMETIES. CONT. WITH\nINCREASE IN PO FEEDS BUT STILL NEEDS SOME PG FEEDING AS\nWELL. HEP B GIVEN WITHOUT INCIDENT.\n\n3. NO CONTACT FROM THIS SHIFT.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-04-06 00:00:00.000",
"description": "Report",
"row_id": 1793074,
"text": "Neonatology Attending\nDOL 10 / CGA 35-2/7 weeks\n\nIn room air with no cardiorespiratory events.\n\nNo murmur. Well-perfused.\n\nWt 2150 (+50) on TFI 150 cc/kg/day BM24. Bottled twice for partial volumes last night. Abd benign. Voiding and stooling (guiac negative).\n\nTemperature stable in open crib.\n\nA&P\n\n33-6/7 week GA infant with feeding immaturity\n-Continue to await maturation of oral feeding skills\n-Start vidaylin today (lready on iron)\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-04-06 00:00:00.000",
"description": "Report",
"row_id": 1793075,
"text": " Physical Exam\n\n remains in RA. Active, alert, AFOF, sutures opposed, good tone. BBS clear and equal with good air entry. No murmur, pulses +2, pink, RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds. Please refer to attending progress note for detailed plan.\n"
}
] |
57,171 | 122,863 | She was briefly admitted under the Neurology service, and when she was admitted, on , her neurological examination was remarkable for the fact that she had virtually no strength in her legs, and her tone was increased, with clonus bilaterally. She was given a dose of 10 mg Dexamethasone, and then started on Dexamethasone 4mg Q6h, and the following morning, she was able to move her legs, although the power in her IPs were about 2 bilaterally. She was taken over by the neurosurgical team on after her MRI imaging of the C&T spine and CT myelogram of the C&T spine were completed. On Pt went to the operating room and underwent a C4 corpectomy, Anterior cervical diskectomy, C5-6, and , structural allograft fusion, Anterior plating from C3-T1 and Anterior arthrodesis C3-T1. There were no perioperative complications to report. PT and OT were consulted and following this patient daily, recommending ongoing Physical therapy upon discharge from . | Mild decrease in the height of the C5 vertebral body is noted with multilevel anterior and posterior osteophytes. Small anterior osteophytes with mild anterior wedging are noted in the mid thoracic spine. Mild thoracic and lumbar spondylosis without evidence of compression. Mild thoracic and lumbar spondylosis without evidence of compression. THORACIC SPINE: At T1-T2 through T5-T6, there are mild disc bulges without (Over) 7:13 PM CT C-SPINE W/CONTRAST Clip # Reason: compression Admitting Diagnosis: LOWER EXTREMITY WEAKNESS Field of view: 18 FINAL REPORT (Cont) significant canal or foraminal narrowing. THORACIC SPINE: At T1-T2 through T5-T6, there are mild disc bulges without (Over) 7:14 PM CT T-SPINE W/ CONTRAST; CT L-SPINE W/ CONTRAST Clip # Reason: compression assessment Admitting Diagnosis: LOWER EXTREMITY WEAKNESS Field of view: 36 FINAL REPORT (Cont) significant canal or foraminal narrowing. Relative impediment to the flow of contrast at the level of C7-T1, with eventual passage into the cervical thecal sac. TECHNIQUE: Multiplanar T1- and T2-weighted imaging of the cervical and the thoracic spine was performed without and with IV contrast. Tricompartmental osteoarthritis, mild. There are mild degenerative changes in all three compartments with osteophytes, mild joint space narrowing, and a small joint effusion. At L4-L5 and L5-S1, there is mild bilateral foraminal narrowing secondary to bilateral facet arthropathy. At L4-L5 and L5-S1, there is mild bilateral foraminal narrowing secondary to bilateral facet arthropathy. Contrast was freely flowing through the thoracic thecal sac to the level of C7- T1, where there was a relative obstruction to the flow of contrast. Reason for continuing current ventilatory support: Sedated / Paralyzed; Comments: Just returned from OR, extubation in the am. Pain control (acute pain, chronic pain) Assessment: c/o posterior neck and incisional pain Action: Given one tab Percocet, Cymbalta and Flexeril. Neurologic: Neuro checks Q: 4 hr, Pain controlled, change to PCA, Valium, Flexerol. Imaging showed severe cord compression with obstruction to flow of intrathecal contrast at C7-T1 She presents to the SICU immediately postop intubated and sedated with C-. Imaging showed severe cord compression with obstruction to flow of intrathecal contrast at C7-T1 She presents to the SICU immediately postop intubated and sedated with C-. Chief complaint: cervical cord compression PMHx: Fibromyalgia, Carpal tunnel, Rheumatoid arthritis, chronic paraspinal neck pain Current medications: meds at home: Cymbalta 60 mg daily, Flexeril and Percocet prn (from prior ER visit) Post op corpectecomy Assessment: Received pt from OR s/p corpectomy Pt to remain intubated overnight Hob to remain flat j collar in place Neurologically intact except lower extremities are weak Dsd to anterior neck in place Urine output adequate Action: Neuro checks q2h Dsd intact Pt weaned to minimal vent settings Pt sedated onpropofol Monitor q1h urine output Response: Dsd remains clean dry and intact Pt tolerating cpap 40% ps5 peep 5 Pt tolerating hob flat Pt appears comfortable Plan: Extubate this am if able Neuro checks q2h Propfol for sedation while intubated Incision care Hob flat until order changed Turn and position q2h Address nutritional status if pt does not extubate this am Maintain j collar as ordered Continue q1h urine output Pain control (acute pain, chronic pain) Assessment: Pt nodding head yes to pain appropriately Action: Dilaudid 0.5mg given prn Response: Pt indicates adequate relief of pain Plan: Continue dilaudid prn Surgery / Procedure and date: posterior cervical laminectomy fusion, C3- T1 with lateral mass screws, anterior C4 corpectomy, anterior cervical discectomy C5-C6, C7-T1 with allograft and plate Latest Vital Signs and I/O Non-invasive BP: S:134 D:82 Temperature: 97.3 Arterial BP: S:152 D:130 Respiratory rate: 14 insp/min Heart Rate: 71 bpm Heart rhythm: SR (Sinus Rhythm) O2 delivery device: Nasal cannula O2 saturation: 96% % O2 flow: 2 L/min FiO2 set: 50% % 24h total in: 798 mL 24h total out: 1,985 mL Pertinent Lab Results: Sodium: 136 mEq/L 02:13 AM Potassium: 4.3 mEq/L 02:13 AM Chloride: 99 mEq/L 02:13 AM CO2: 26 mEq/L 02:13 AM BUN: 20 mg/dL 02:13 AM Creatinine: 0.6 mg/dL 02:13 AM Glucose: 104 mg/dL 02:13 AM Hematocrit: 30.1 % 02:13 AM Finger Stick Glucose: 136 04:00 PM Valuables / Signature Patient valuables: none Other valuables: Clothes: Sent home with: pts husband / : No money / Cash / Credit cards sent home with: Jewelry: Transferred from: SICU B Transferred to: Date & time of Transfer: 1740 Pain control (acute pain, chronic pain) Assessment: c/o posterior neck and incisional pain Action: Given one tab Percocet, Cymbalta and Flexeril. | 30 | [
{
"category": "Radiology",
"chartdate": "2122-10-26 00:00:00.000",
"description": "L ANKLE (AP, MORTISE & LAT) LEFT",
"row_id": 1048900,
"text": " 9:36 PM\n ANKLE (AP, MORTISE & LAT) LEFT Clip # \n Reason: ? fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with fall and L ankle swelling\n REASON FOR THIS EXAMINATION:\n ? fx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Left ankle pain status post fall.\n\n No prior examinations.\n\n AP, LATERAL AND MORTISE VIEWS OF THE LEFT ANKLE: There is marked soft tissue\n swelling along the medial and lateral aspect of the left ankle. The mortise\n is congruent and talar dome is intact. A small well-corticated ossific\n fragment off the medial tibia may represent an accessory ossicle or sequela of\n prior trauma. There is no current evidence for fracture. There are prominent\n enthesophytes at the insertion of the Achilles tendon and plantar fascia as\n well as osteophytes at the superior aspect of the navicular and cuboid bones.\n\n IMPRESSION: Extensive soft tissue swelling, with possible underlying\n ligamentous injury. No evidence of fracture.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2122-10-27 00:00:00.000",
"description": "MR C-SPINE W& W/O CONTRAST",
"row_id": 1048940,
"text": " 8:23 AM\n MR W& W/O CONTRAST; MR W &W/O CONTRAST Clip # \n Reason: Evidence of demylinating/inflammatory process or other myelo\n Admitting Diagnosis: LOWER EXTREMITY WEAKNESS\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with known cervical cord compression with a thoracic sensory\n level and paraparesis\n REASON FOR THIS EXAMINATION:\n Evidence of demylinating/inflammatory process or other myelopathic disease?\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: NPw TUE 5:33 PM\n\n Suboptimal study due to motion artifacts.\n Multilevel disc bulges and protrusions/extrusions causing moderate-severe\n compression on the cord at C3-C7 and at multiple levels in the thoracic spine\n causing moderate indentation on the ventral thecal sac and effacement.\n No large areas of enhancement to suggest active lesions. Evaluation for subtle\n lesions is limited.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 40-year-old female patient, with known cervical cord compression\n in the thoracic sensory level and paraparesis, to evaluate for demyelinating\n or inflammatory process or other myelopathic disease.\n\n COMPARISON: MR of the T-spine done on and C-spine done on at\n , scanned onto the PACS, report not available for\n perusal.\n\n TECHNIQUE: Multiplanar T1- and T2-weighted imaging of the cervical and the\n thoracic spine was performed without and with IV contrast.\n\n FINDINGS: MRI OF THE C-SPINE:\n\n There is reversal of the cervical lordosis and gradual kyphosis in the\n cervical spine.\n\n Mild decrease in the height of the C5 vertebral body is noted with multilevel\n anterior and posterior osteophytes.\n\n At C2-3, there is focal central disc protrusion, causing moderate indentation\n on the ventral thecal sac.\n\n At C3-4, there is moderate diffuse disc bulge along with moderate central disc\n protrusion, causing effacement of the ventral thecal sac and moderate to\n severe compression on the cord.\n\n At C4-5, there is moderate to severe disc bulge with left paracentral disc\n herniation, causing effacement of the ventral thecal sac and severe\n compression on the cord and severe neural foraminal narrowing.\n\n (Over)\n\n 8:23 AM\n MR W& W/O CONTRAST; MR W &W/O CONTRAST Clip # \n Reason: Evidence of demylinating/inflammatory process or other myelo\n Admitting Diagnosis: LOWER EXTREMITY WEAKNESS\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n At C5-6, there is moderate to severe disc bulge, with posterior spondylotic\n ridge, causing effacement of the ventral thecal sac and moderate compression\n on the cord.\n\n At C7-T1, there is moderate diffuse disc bulge along with left paracentral\n disc herniation, causing effacement of the ventral thecal sac and moderate\n compression of the cord. At C7-T1 level, similar findings are noted.\n\n The spinal cord is moderate to severely compressed at multiple levels as\n described above. No definite focal areas of increased signal intensity are\n noted on the sagittal STIR sequence which is, however, limited due to\n artifacts. No abnormal foci of enhancement are noted on the axial post-\n contrast images. Sagittal post-contrast images of the cervical spine are not\n available.\n\n No pre- or para-vertebral soft tissue swelling or masses are noted.\n\n MRI OF THE THORACIC SPINE:\n\n The thoracic vertebral bodies are normal in height, signal intensity, and\n alignment. Small anterior osteophytes with mild anterior wedging are noted in\n the mid thoracic spine.\n\n There are moderate disc bulges noted at multiple levels in the thoracic spine,\n with more focal disc protrusions, causing effacement of the ventral thecal sac\n and indentation/mild compression on the thoracic cord, at T6-7 and T7-8.\n\n No pre- or para-vertebral soft tissue swelling or masses are noted. No\n obvious large focal lesions are noted in the thoracic spinal cord. Evaluation\n for subtle lesions being limited due to the suboptimal quality of the study.\n No abnormal foci of enhancement are noted.\n\n IMPRESSION:\n 1.Multilevel disc bulges and disc protrusions in the cervical spine with\n possible ossification of the posterior longitudinal ligament and in the\n thoracic spine, causing effacement of the thecal space as well as moderate to\n severe compression on the cervical cord at multiple levels and mild\n compression at the level of T6-7 and T7-8 levels.\n\n Please see the further details on the CT myelogram done on the same day, to\n evaluate the flow of contrast in the thecal space.\n\n 2. The extent of the disc changes and the compression on the cord is not\n significantly changed compared to the study done on and along\n with possibility of ossification of the posterior longitudinal ligament at\n (Over)\n\n 8:23 AM\n MR W& W/O CONTRAST; MR W &W/O CONTRAST Clip # \n Reason: Evidence of demylinating/inflammatory process or other myelo\n Admitting Diagnosis: LOWER EXTREMITY WEAKNESS\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n C4-5 level. PL. see CT Myelogram report for bony details.\n\n 3. No large abnormally enhancing lesions, within the limitations of the study\n to suggest focal lesions in the cord.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2122-10-27 00:00:00.000",
"description": "C-SPINE NON TRAUMA FLEX & EXT ONLY",
"row_id": 1048915,
"text": " 4:09 AM\n C-SPINE NON TRAUMA FLEX & EXT ONLY Clip # \n Reason: please assess for change in vertebral alignment with motion\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with falls and difficulty walking\n REASON FOR THIS EXAMINATION:\n please assess for change in vertebral alignment with motion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Falls and difficulty walking.\n\n COMPARISON: None.\n\n FINDINGS: Two lateral radiographs of the cervical spine during flexion and\n extension. C1 to C5 are visualized. There is no prevertebral soft tissue\n swelling. There is productive, degenerative, osseous change about the\n anterior arch of C2. No change in the C1-C2 relationship is seen between\n flexion and extension views. Anterior osteophytes are seen at C4/5 and\n narrowing of the intervertebral disc space.\n\n IMPRESSION:\n\n Cervical spondylosis.\n\n Limted study demonstrating C1-C5.\n\n"
},
{
"category": "Radiology",
"chartdate": "2122-11-01 00:00:00.000",
"description": "C-SPINE NON-TRAUMA 2-3 VIEWS",
"row_id": 1049789,
"text": " 12:12 PM\n C-SPINE NON-TRAUMA VIEWS Clip # \n Reason: 40 year old women s/p C4 corpectomy, ACDF C5-6, C6-7, C7T1,\n Admitting Diagnosis: LOWER EXTREMITY WEAKNESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old women s/p C4 corpectomy, ACDF C5-6, C6-7, C7T1, evaluate hardware.\n REASON FOR THIS EXAMINATION:\n 40 year old women s/p C4 corpectomy, ACDF C5-6, C6-7, C7T1, evaluate hardware.\n ______________________________________________________________________________\n FINAL REPORT\n CERVICAL SPINE, \n\n CLINICAL INFORMATION: Status post C4 corpectomy with ACDF C5 through T1.\n\n COMPARISON STUDY: .\n\n Three views of the cervical spine are submitted. Patient has undergone a\n corpectomy at C5 with interposition of a fibular strut graft. There is a\n cervical fusion plate anteriorly traversing C3 through T1 with anterior\n screws. Interbody fusion device is also present at C5-6, C6-7 and C7-T1. No\n immediate hardware complication is identified.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2122-10-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1049322,
"text": " 9:08 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pre-op\n Admitting Diagnosis: LOWER EXTREMITY WEAKNESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with planned surgery today - C4 corpectomy\n REASON FOR THIS EXAMINATION:\n pre-op\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 11:16 AM\n Normal x-ray. Heart size top normal.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, PORTABLE AP\n\n REASON FOR EXAM: 40-year-old woman with planned surgery today. Preop.\n\n No prior study for comparison.\n\n Heart size is probably top normal. Standard PA and lateral could be obtained\n when clinically feasible to confirm this. The cardiomediastinal silhouette\n and hilar contours are otherwise normal. Lungs are clear. There is no\n pleural effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2122-10-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1049323,
"text": ", W. NSURG FA11 9:08 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pre-op\n Admitting Diagnosis: LOWER EXTREMITY WEAKNESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with planned surgery today - C4 corpectomy\n REASON FOR THIS EXAMINATION:\n pre-op\n ______________________________________________________________________________\n PFI REPORT\n Normal x-ray. Heart size top normal.\n\n"
},
{
"category": "Radiology",
"chartdate": "2122-10-27 00:00:00.000",
"description": "CT C-SPINE W/CONTRAST",
"row_id": 1049069,
"text": " 7:13 PM\n CT C-SPINE W/CONTRAST Clip # \n Reason: compression\n Admitting Diagnosis: LOWER EXTREMITY WEAKNESS\n Field of view: 18\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with myelogram performed for compression assessment\n REASON FOR THIS EXAMINATION:\n compression\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT MYELOGRAM \n\n INDICATION: 40-year-old woman with symptoms of compression.\n\n TECHNIQUE: Following intrathecal administration of 12 cc of isoview 300\n during a myelogram, 2.5 mm axial images were obtained through the\n cervical, thoracic and lumbar spine. Sagittal and coronal reformations were\n performed in the bone and soft tissue algorithm.\n\n CERVICAL SPINE: There is reversal of the normal cervical lordosis. Vertebral\n body height and alignment are preserved. The visualized portion of the\n posterior fossa is unremarkable.\n\n At C2-C3, small osteophytes are seen at the endplates, without significant\n canal or foraminal narrowing.\n\n At C3-C4, osteophytes are seen at the endplates, with flattening of the spinal\n . There is moderate canal stenosis at this level.\n\n At C4-C5, osteophytes are seen at the endplates and uncovertebral joints, with\n flattening of the . There is severe canal narrowing at this level as well\n as mild left neural foraminal narrowing.\n\n At C5-C6, there are endplate osteophytes as well as osteophytes at the\n uncovertebral joints causing severe canal narrowing and flattening of the\n spinal . There is severe left- sided and moderate right-sided foraminal\n narrowing.\n\n At C6-C7, disc osteophyte complex causes moderate canal narrowing with\n flattening of the . No significant foraminal narrowing is identified.\n\n At C7-T1, there is severe canal narrowing secondary to a large central disk\n protrusion. There is effacement of the CSF around the spinal and\n compression of the . Obstruction to flow of contrast was encountered at\n this level during the fluoroscopic myelogram. The intrathecal contrast above\n this level is less dense than below this level.\n\n The imaged soft tissues of the neck are unremarkable.\n\n THORACIC SPINE: At T1-T2 through T5-T6, there are mild disc bulges without\n (Over)\n\n 7:13 PM\n CT C-SPINE W/CONTRAST Clip # \n Reason: compression\n Admitting Diagnosis: LOWER EXTREMITY WEAKNESS\n Field of view: 18\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n significant canal or foraminal narrowing.\n\n At T6-T7, there is a left paracentral disc protrusion which contacts the .\n No flattening of the is identified.\n\n At T7-T8, there is a broad-based central disc protrusion which contacts the\n without evidence of flattening.\n\n At T8-T9, there is a right paracentral disc protrusion which contacts the \n without flattening.\n\n The remainder of the thoracic spine is normal.\n\n LUMBAR SPINE: There is limited evaluation of the lumbar spine secondary to\n paucity of intrathecal contrast at this level. No significant mass effect is\n noted on the thecal sac.\n\n At L1-L2, there is facet joint arthropathy, left greater than right. No\n significant foraminal or canal narrowing is identified.\n\n At L4-L5 and L5-S1, there is mild bilateral foraminal narrowing secondary to\n bilateral facet arthropathy.\n\n Note is made of what appears to be an enlarged lower uterine segment, versus\n collapsed bowel abutting the uterus. In the absence of oral or iv contrast,\n evaluation is limited.\n\n IMPRESSION:\n\n 1. Extensive multilevel spondylosis with multilevel spinal canal stenosis in\n the cervical spine. Severe compression with obstruction to flow of\n intrathecal contrast at C7-T1. This was discussed with Dr. from\n neurosurgery and Dr. from neurology at 8 pm on .\n\n 2. Mild thoracic and lumbar spondylosis without evidence of compression.\n\n 3. Questionable enlargement of the lower uterine segment, incompletely\n evaluated. Pelvic ultrasound could be obtained if clinically indicated.\n DFDkq\n\n"
},
{
"category": "Radiology",
"chartdate": "2122-10-27 00:00:00.000",
"description": "CT T-SPINE W/ CONTRAST",
"row_id": 1049070,
"text": " 7:14 PM\n CT T-SPINE W/ CONTRAST; CT L-SPINE W/ CONTRAST Clip # \n Reason: compression assessment\n Admitting Diagnosis: LOWER EXTREMITY WEAKNESS\n Field of view: 36\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with myelogram performed for compression assessment\n REASON FOR THIS EXAMINATION:\n compression assessment\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT MYELOGRAM \n\n INDICATION: 40-year-old woman with symptoms of compression.\n\n TECHNIQUE: Following intrathecal administration of 12 cc of isoview 300\n during a myelogram, 2.5 mm axial images were obtained through the spine.\n Sagittal and coronal reformations were performed in the bone and soft tissue\n algorithm.\n\n CERVICAL SPINE: There is reversal of the normal cervical lordosis. Vertebral\n body height and alignment are preserved. The visualized portion of the\n posterior fossa is unremarkable.\n\n At C2-C3, small osteophytes are seen at the endplates, without significant\n canal or foraminal narrowing.\n\n At C3-C4, osteophytes are seen at the endplates, with flattening of the spinal\n . There is moderate canal stenosis at this level.\n\n At C4-C5, osteophytes are seen at the endplates and uncovertebral joints, with\n flattening of the . There is severe canal narrowing at this level as well\n as mild left neural foraminal narrowing.\n\n At C5-C6, there are endplate osteophytes as well as osteophytes at the\n uncovertebral joints causing severe canal narrowing and flattening of the\n spinal . There is severe left- sided and moderate right-sided foraminal\n narrowing.\n\n At C6-C7, disc osteophyte complex causes moderate canal narrowing with\n flattening of the . No significant foraminal narrowing is identified.\n\n At C7-T1, there is severe canal narrowing secondary to a large central disk\n protrusion. There is effacement of the CSF around the spinal and\n compression of the . Obstruction to flow of contrast was encountered at\n this level during the fluoroscopic myelogram. The intrathecal contrast above\n this level is less dense than below this level.\n\n The imaged soft tissues of the neck are unremarkable.\n\n THORACIC SPINE: At T1-T2 through T5-T6, there are mild disc bulges without\n (Over)\n\n 7:14 PM\n CT T-SPINE W/ CONTRAST; CT L-SPINE W/ CONTRAST Clip # \n Reason: compression assessment\n Admitting Diagnosis: LOWER EXTREMITY WEAKNESS\n Field of view: 36\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n significant canal or foraminal narrowing.\n\n At T6-T7, there is a left paracentral disc protrusion which contacts the .\n No flattening of the is identified.\n\n At T7-T8, there is a broad-based central disc protrusion which contacts the\n without evidence of flattening.\n\n At T8-T9, there is a right paracentral disc protrusion which contacts the \n without flattening.\n\n The remainder of the thoracic spine is normal.\n\n LUMBAR SPINE: There is limited evaluation of the lumbar spine secondary to\n paucity of intrathecal contrast at this level. No significant mass effect is\n noted on the thecal sac.\n\n At L1-L2, there is facet joint arthropathy, left greater than right. No\n significant foraminal or canal narrowing is identified.\n\n At L4-L5 and L5-S1, there is mild bilateral foraminal narrowing secondary to\n bilateral facet arthropathy.\n\n Note is made of what appears to be an enlarged lower uterine segment, versus\n collapsed bowel abutting the uterus. In the absence of oral or iv contrast,\n evaluation is limited.\n\n IMPRESSION:\n\n 1. Extensive multilevel spondylosis with multilevel spinal canal stenosis in\n the cervical spine. Severe compression with obstruction to flow of\n intrathecal contrast at C7-T1. This was discussed with Dr. from\n neurosurgery and Dr. from neurology at 8 pm on .\n\n 2. Mild thoracic and lumbar spondylosis without evidence of compression.\n\n 3. Questionable enlargement of the lower uterine segment, incompletely\n evaluated. Pelvic ultrasound could be obtained if clinically indicated.\n\n DFDkq\n\n"
},
{
"category": "Radiology",
"chartdate": "2122-10-29 00:00:00.000",
"description": "O C-SPINE NON-TRAUMA 2-3 VIEWS IN O.R.",
"row_id": 1049384,
"text": " 2:27 PM\n C-SPINE NON-TRAUMA VIEWS IN O.R. Clip # \n Reason: FUSION\n Admitting Diagnosis: LOWER EXTREMITY WEAKNESS\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Fusion.\n\n FINDINGS: Views from the operating suite show placement of an extensive\n fusion device on the frontal view that appears to extend from the upper\n cervical to the upper thoracic level. It is not adequately seen on the\n lateral projection on this limited set of examinations. Further information\n can be obtained from the operative note.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2122-11-01 00:00:00.000",
"description": "R KNEE (2 VIEWS) RIGHT",
"row_id": 1049830,
"text": " 6:32 PM\n KNEE (2 VIEWS) RIGHT Clip # \n Reason: question of dislocation\n Admitting Diagnosis: LOWER EXTREMITY WEAKNESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with\n REASON FOR THIS EXAMINATION:\n question of dislocation\n ______________________________________________________________________________\n WET READ: RSRc SUN 7:29 PM\n No fracture or dislocation. - 7:10 pm .\n ______________________________________________________________________________\n FINAL REPORT\n RIGHT KNEE, \n\n CLINICAL INFORMATION: Question dislocation.\n\n FINDINGS:\n\n Two views of the right knee are submitted. No fracture or dislocation is\n identified. There are mild degenerative changes in all three compartments\n with osteophytes, mild joint space narrowing, and a small joint effusion.\n There is normal mineralization.\n\n IMPRESSION:\n 1. Tricompartmental osteoarthritis, mild.\n 2. No fracture identified.\n\n"
},
{
"category": "Radiology",
"chartdate": "2122-10-27 00:00:00.000",
"description": "MOD SEDATION, EACH ADDL 15 MIN.",
"row_id": 1049066,
"text": " 5:46 PM\n MYELOGRAM Clip # \n Reason: to look for spinal cord impingement\n Admitting Diagnosis: LOWER EXTREMITY WEAKNESS\n Contrast: NON IONIC Amt: 12\n ********************************* CPT Codes ********************************\n * INJ PROC. FOR MYLEO MYELOGRAM 2 OR MORE REGIONS, S *\n * MOD SEDATION, FIRST 30 MIN. MOD SEDATION, EACH ADDL 15 MIN *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with signs of cord compression, she has 2 levels: C4-5 and\n T3-4\n REASON FOR THIS EXAMINATION:\n to look for spinal cord impingement\n ______________________________________________________________________________\n FINAL REPORT\n MYEOLOGRAM \n\n INDICATION: 40-year-old woman with signs of cord compression and cervical and\n thoracic spondylosis on MRI. Worsening weakness and numbness over the past\n several weeks.\n\n RADIOLOGISTS: Drs. and . Dr. , the attending radiologist,\n present and supervising throuhout.\n\n PROCEDURE: After the risks, benefits, and alternatives to the procedure were\n explained, informed written consent was obtained. A preprocedure timeout was\n performed. The patient was placed prone on the angiographic table. The lower\n back was prepped and draped in the usual sterile fashion.\n\n 1% lidocaine was used for local anesthesia. 125 mcg of fentanyl was also\n administered in divided doses throughout the total intraservice time of 50\n minutes with continuous hemodynamic monitoring.\n\n After local anesthesia was administered, under direct fluoroscopic guidance, a\n 22-gauge spinal needle was introduced into the thecal sac at the L2-3 level.\n 12 cc of Isovue 300 were slowly administered intrathecally under fluoroscopic\n guidance. After the contrast was injected, the needle was withdrawn and\n hemostasis was achieved with direct pressure.\n\n Multiple fluroscopic spot images of the lumbar spine were obtained.\n Subsequently, the patient was placed in Trendelenburg position, and flow of\n contrast was observed into the thoracic and cervical thecal sac.\n\n The patient tolerated the procedure well without immediate complications.\n\n FINDINGS: There is no evidence of significant canal stenosis or obstruction\n to the flow of contrast in the lumbar thecal sac.\n\n Contrast was freely flowing through the thoracic thecal sac to the level of\n C7- T1, where there was a relative obstruction to the flow of contrast. After\n the patient's head was further lowered, eventually contrast was seen flowing\n (Over)\n\n 5:46 PM\n MYELOGRAM Clip # \n Reason: to look for spinal cord impingement\n Admitting Diagnosis: LOWER EXTREMITY WEAKNESS\n Contrast: NON IONIC Amt: 12\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n into the cervical spine. No other areas of obstruction to contrast flow were\n identified.\n\n IMPRESSION:\n 1. Technically successful myelogram.\n\n 2. Relative impediment to the flow of contrast at the level of C7-T1, with\n eventual passage into the cervical thecal sac. The CT myelogram portion of the\n study is reported separately.\n\n Findings discussed with Dr. from neurosurgery and Dr. from\n neurology at 8 pm on .\n\n DFDkq\n\n"
},
{
"category": "Radiology",
"chartdate": "2122-10-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1049444,
"text": " 10:09 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ETT placement\n Admitting Diagnosis: LOWER EXTREMITY WEAKNESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman s/p cervical corpectomy and ACDF\n REASON FOR THIS EXAMINATION:\n ETT placement\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLnc FRI 10:44 AM\n PFI: The ET tube tip is 5.5 cm above the carina. Slight vascular\n engorgement. Recent cervical surgery with subcutaneous air.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of ET tube placement.\n\n Portable AP chest radiograph was reviewed in comparison to .\n\n The ET tube tip is approximately 5.5 cm above the carina. The\n cardiomediastinal silhouette is stable. There is slight increase in bilateral\n perihilar haziness, this may represent some degree of volume overload. These\n might be related to recent surgery as we can see is the new hardware\n projecting over the cervical spine as well as subcutaneous air within the\n neck.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2122-10-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1049445,
"text": ", W. NSURG SICU-B 10:09 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ETT placement\n Admitting Diagnosis: LOWER EXTREMITY WEAKNESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman s/p cervical corpectomy and ACDF\n REASON FOR THIS EXAMINATION:\n ETT placement\n ______________________________________________________________________________\n PFI REPORT\n PFI: The ET tube tip is 5.5 cm above the carina. Slight vascular\n engorgement. Recent cervical surgery with subcutaneous air.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2122-10-27 00:00:00.000",
"description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY",
"row_id": 1048916,
"text": " 4:53 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: please eval for aortic dissection\n Field of view: 36 Contrast: OPTIRAY Amt: 90\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with left scapular pain - ascending neurologic symptoms\n REASON FOR THIS EXAMINATION:\n please eval for aortic dissection\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MRGe TUE 5:45 AM\n No thoracic aortic dissection\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Left scapular pain with ascending neurologic symptoms. Rule out\n dissection.\n\n COMPARISON: None.\n\n CHEST WITH IV CONTRAST: The central airways are patent to the segmental\n levels, bilaterally. The heart and great vessels are normal in size. There\n is no evidence of thoracic aortic dissection. There is no mediastinal, hilar,\n or axillary lymphadenopathy.\n The visualized portions of the upper abdomen demonstrate diffuse\n hypoattenuation of the liver parenchyma consistent with fatty infiltration.\n\n BONE WINDOWS: No suspicious lytic or sclerotic lesions are identified.\n Degenerative changes of the thoracic spine.\n\n IMPRESSION:\n\n 1. No evidence of thoracic aortic dissection.\n\n 2. Fatty liver.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2122-10-29 00:00:00.000",
"description": "Report",
"row_id": 240844,
"text": "Sinus rhythm. Non-specific inferolateral T wave changes. No previous tracing\navailable for comparison.\n\n"
},
{
"category": "Respiratory ",
"chartdate": "2122-10-30 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 647864,
"text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 1\n Ideal body weight: 45.4 None\n Ideal tidal volume: 181.6 / 272.4 / 363.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: OR\n Reason: Elective; Comments: Pt is s/p anterior C4 corpectomy, cervical\n discetomy c5-c6, c6-c7, c7-t1 with allograft and plate.\n Tube Type\n ETT:\n Position: 19 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: White / Thin\n Sputum source/amount: Suctioned / Scant\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Reduce PEEP as tolerated; Comments: Extubate in the am.\n Reason for continuing current ventilatory support: Sedated / Paralyzed;\n Comments: Just returned from OR, extubation in the am.\n Comments:\n"
},
{
"category": "Nursing",
"chartdate": "2122-10-31 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 648240,
"text": "40 yo female with cord compression s/p anterior C4 corpectomy, anterior\n discectomy C5-C6, posterior lam fusion C3-T1 with lateral screws,\n allograft and plate. h/o chronic neck pain since MVA , treated with\n multiple chiropractic sessions with last session day before\n . She then began having ascending numbness from feet to\n umbilicus and then to nipple line and inability to walk. Imaging\n revealed cord compression.\n s/p C4 corpectomy\n Assessment:\n J collar in place at all times. Anterior neck DSD c/d/i.\n Neurologically intact, still experiencing lower extremity weakness.\n Sensation intact.\n Action:\n neuro checks q 4.\n Response:\n Able to lift and hold upper extremities and move LE\ns on\n bed-improvement since surgery.\n Plan:\n PT/OT consults. ?dc to rehab facility.\n Demographics\n Attending MD:\n W.\n Admit diagnosis:\n LOWER EXTREMITY WEAKNESS\n Code status:\n Full code\n Height:\n 60 Inch\n Admission weight:\n 100 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: No Additional Precautions\n PMH:\n CV-PMH:\n Additional history: fibromyalgia, carpal tunnel syndrome, rheumatoid\n arthritis, right foot/ankle fracture after a fall in ,\n appendectomy, neck pain, mvc .\n Surgery / Procedure and date: posterior cervical laminectomy fusion,\n C3- T1 with lateral mass screws, anterior C4 corpectomy, anterior\n cervical discectomy C5-C6, C7-T1 with allograft and plate\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:134\n D:82\n Temperature:\n 97.3\n Arterial BP:\n S:152\n D:130\n Respiratory rate:\n 14 insp/min\n Heart Rate:\n 71 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 96% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 50% %\n 24h total in:\n 798 mL\n 24h total out:\n 1,985 mL\n Pertinent Lab Results:\n Sodium:\n 136 mEq/L\n 02:13 AM\n Potassium:\n 4.3 mEq/L\n 02:13 AM\n Chloride:\n 99 mEq/L\n 02:13 AM\n CO2:\n 26 mEq/L\n 02:13 AM\n BUN:\n 20 mg/dL\n 02:13 AM\n Creatinine:\n 0.6 mg/dL\n 02:13 AM\n Glucose:\n 104 mg/dL\n 02:13 AM\n Hematocrit:\n 30.1 %\n 02:13 AM\n Finger Stick Glucose:\n 136\n 04:00 PM\n Valuables / Signature\n Patient valuables: none\n Other valuables:\n Clothes: Sent home with: pt\ns husband\n / :\n No money / \n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: SICU B\n Transferred to: \n Date & time of Transfer: 1740\n Pain control (acute pain, chronic pain)\n Assessment:\n c/o posterior neck and incisional pain \n Action:\n Given one tab Percocet, Cymbalta and Flexeril.\n Response:\n pain level . Pt states pain is tolerable.\n Plan:\n Continue pain control with Percocet, continue med regimen.\n .H/O hypertension, benign\n Assessment:\n SBP 140\ns-150\n Action:\n Hydralazine q 6 hours.\n Response:\n SBP maintained <160.\n Plan:\n maintain goal SBP <160 per Neurosurg. Continue Hydralazine as needed.\n"
},
{
"category": "Respiratory ",
"chartdate": "2122-10-30 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 648006,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 45.4 None\n Ideal tidal volume: 181.6 / 272.4 / 363.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason: pt extubated\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Nursing",
"chartdate": "2122-10-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 647901,
"text": "HPI:\n 40yo F who is s/p Anterior C4 corpectomy, cervical discectomy C5-C6,\n C6-C7, C7-T1 with allograft and plate on . She p/w ascending\n numbness and inability to walk. H/o chronic paraspinal neck pain\n worsened by MVA , tx w/ multiple chiropractor session. Over\n course of 7 days, numbness progressed from feet to umbilicus to\n breast/arm and LE weakness. Imaging showed severe cord compression\n with obstruction to flow of intrathecal contrast at C7-T1\n She presents to the SICU immediately postop intubated and sedated with\n C-.\n Chief complaint:\n cervical cord compression\n PMHx:\n Fibromyalgia, Carpal tunnel, Rheumatoid arthritis, chronic paraspinal\n neck pain\n Current medications:\n meds at home: Cymbalta 60 mg daily, Flexeril and Percocet prn (from\n prior ER visit)\n Post op corpectecomy\n Assessment:\n Received pt from OR s/p corpectomy\n Pt to remain intubated overnight\n Hob to remain flat\n j collar in place\n Neurologically intact except lower extremities are weak\n Dsd to anterior neck in place\n Urine output adequate\n Action:\n Neuro checks q2h\n Dsd intact\n Pt weaned to minimal vent settings\n Pt sedated onpropofol\n Monitor q1h urine output\n Response:\n Dsd remains clean dry and intact\n Pt tolerating cpap 40% ps5 peep 5\n Pt tolerating hob flat\n Pt appears comfortable\n Plan:\n Extubate this am if able\n Neuro checks q2h\n Propfol for sedation while intubated\n Incision care\n Hob flat until order changed\n Turn and position q2h\n Address nutritional status if pt does not extubate this am\n Maintain j collar as ordered\n Continue q1h urine output\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt nodding head yes to pain appropriately\n Action:\n Dilaudid 0.5mg given prn\n Response:\n Pt indicates adequate relief of pain\n Plan:\n Continue dilaudid prn\n"
},
{
"category": "Nursing",
"chartdate": "2122-10-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 647893,
"text": "HPI:\n 40yo F who is s/p Anterior C4 corpectomy, cervical discectomy C5-C6,\n C6-C7, C7-T1 with allograft and plate on . She p/w ascending\n numbness and inability to walk. H/o chronic paraspinal neck pain\n worsened by MVA , tx w/ multiple chiropractor session. Over\n course of 7 days, numbness progressed from feet to umbilicus to\n breast/arm and LE weakness. Imaging showed severe cord compression\n with obstruction to flow of intrathecal contrast at C7-T1\n She presents to the SICU immediately postop intubated and sedated with\n C-.\n Chief complaint:\n cervical cord compression\n PMHx:\n Fibromyalgia, Carpal tunnel, Rheumatoid arthritis, chronic paraspinal\n neck pain\n Current medications:\n meds at home: Cymbalta 60 mg daily, Flexeril and Percocet prn (from\n prior ER visit)\n"
},
{
"category": "Nursing",
"chartdate": "2122-10-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 647988,
"text": "Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2122-10-30 00:00:00.000",
"description": "Intensivist Note",
"row_id": 647899,
"text": "SICU\n HPI:\n 40yo F who is s/p Anterior C4 corpectomy, cervical discectomy C5-C6,\n C6-C7, C7-T1 with allograft and plate and dural repair on .\n She p/w ascending numbness and inability to walk. H/o chronic\n paraspinal neck pain worsened by MVA , tx w/ multiple\n chiropractor session. Over course of 7 days, numbness progressed from\n feet to umbilicus to breast/arm and LE weakness. Imaging showed severe\n cord compression with obstruction to flow of intrathecal contrast at\n C7-T1\n Chief complaint:\n cervical cord compression\n PMHx:\n Fibromyalgia, Carpal tunnel, Rheumatoid arthritis, chronic paraspinal\n neck pain\n Current medications:\n 24 Hour Events:\n OR RECEIVED - At 09:45 PM\n ARTERIAL LINE - START 09:45 PM\n NASAL SWAB - At 01:07 AM\n INVASIVE VENTILATION - START 03:03 AM\n Post operative day:\n POD#1 - Anterior C4 corpectomy, cervical discectomy C5-C6, C6-C7, C7-T1\n with allograft and plate\n o/n events: tolerated PS , weening in AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Propofol - 75 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Hydromorphone (Dilaudid) - 02:00 AM\n Famotidine (Pepcid) - 03:34 AM\n Other medications:\n Flowsheet Data as of 05:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.6\nC (99.7\n T current: 37.2\nC (99\n HR: 89 (87 - 112) bpm\n BP: 146/111(128) {136/74(99) - 152/111(128)} mmHg\n RR: 15 (13 - 22) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 3,769 mL\n 643 mL\n PO:\n Tube feeding:\n IV Fluid:\n 3,769 mL\n 643 mL\n Blood products:\n Total out:\n 635 mL\n 410 mL\n Urine:\n 160 mL\n 410 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,134 mL\n 233 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 592 (592 - 707) mL\n PS : 5 cmH2O\n RR (Spontaneous): 14\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 26\n PIP: 14 cmH2O\n SPO2: 97%\n ABG: 7.40/44/111/25/1\n Ve: 7.8 L/min\n PaO2 / FiO2: 222\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese, intubated,\n sedated\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: Sedated\n Labs / Radiology\n 351 K/uL\n 10.2 g/dL\n 143 mg/dL\n 0.8 mg/dL\n 25 mEq/L\n 4.2 mEq/L\n 25 mg/dL\n 102 mEq/L\n 138 mEq/L\n 29.9 %\n 17.7 K/uL\n [image002.jpg]\n 09:50 PM\n 09:55 PM\n 02:11 AM\n 02:38 AM\n WBC\n 20.4\n 17.7\n Hct\n 29.5\n 29.9\n Plt\n 435\n 351\n Creatinine\n 1.0\n 0.8\n TCO2\n 25\n 28\n Glucose\n 134\n 143\n Other labs: PT / PTT / INR:14.5/18.9/1.3, Differential-Neuts:93.0 %,\n Lymph:4.0 %, Mono:2.8 %, Eos:0.1 %, Lactic Acid:2.6 mmol/L, Ca:8.8\n mg/dL, Mg:2.1 mg/dL, PO4:4.9 mg/dL\n Assessment and Plan\n Assessment and Plan:\n Neurologic: PPF ween, dilaudid PRN, c- per team, remain flat \n dural tear\n Cardiovascular: stable\n Pulmonary: Extubate today, (Ventilator mode: CPAP + PS)\n Gastrointestinal / Abdomen: hold off on feeds until extubation\n Nutrition: NPO\n Renal: Foley\n Hematology: f/u HCT\n Endocrine: RISS\n Infectious Disease:\n Lines / Tubes / Drains: Foley, ETT\n Wounds: Dry dressings\n Imaging: CXR today\n Fluids: NS, Potassium Chloride\n Consults: Neuro surgery, Ortho-spine, Neurology\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 09:45 PM\n 14 Gauge - 09:47 PM\n 16 Gauge - 09:48 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle: Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n"
},
{
"category": "Nutrition",
"chartdate": "2122-10-30 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 647977,
"text": "Potential for nutrition risk. Patient being monitored. Current\n intervention if any, listed below:\n Comments:\n 40 y.o. F s/p spinal surgeries , now extubated. Pt\ns diet was\n advanced to sips, and expect advancement to regular diet within the\n next 24hrs. Will follow diet advancement and tolerance.\n Please page nutrition is assistance is needed \n"
},
{
"category": "Nursing",
"chartdate": "2122-10-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 648051,
"text": "Pain control (acute pain, chronic pain)\n Assessment:\n pt c/o neck pain\n Action:\n pt receiving .5mg of iv diluadid every 3 hours\n Response:\n pt has adquete relief of pain\n Plan:\n continue to monitor, medicate for pain as ordered\n .H/O hypertension, benign\n Assessment:\n pt sbp up to 198\n dr. notified\n pt received 5mg of iv Lopressor with little effect. Pt\n received 10mg of iv hydralazine\n pt also received .5 diluaidid\n Action:\n sbp remain in 170\ns, dr. , pt received an\n additional 10mg of iv hydralzine\n Response:\n sbp 150-160\n Plan:\n continue to monitor, pt to received Lopressor 5mg iv every\n six hour, hydralzine 10mg iv every six hours as ordered. Medicate for\n pain as needed\n Respiratory failure, acute (not ARDS/)\n Assessment:\n pt extubated at ~1120, pt on 70% open face mask, pt c/o\nbreathing feeling tight\n dr. . das into assess patient. Pt received\n nebulizer by resp. therapy, lungs clear, but diminished at bases. pt\n does have a dry nonproductive cough\n Action:\n as above pt received nebulizer by resp. therapy\n Response:\n pt states she feels better, pt 02 weaned down to 70% open\n face mask\n Plan:\n continue to monitor,\n encourage pt to cough and deep breathe\n encourage pt using incentive spirometer\n Problem - Description In Comments neuro\n Assessment:\n pt pupils equal and reactive to light\n pt follows commands\n pt able to lift and hold both legs on bed\n pt able to lift and hold both arm on bed\n pt c/o of\ntingling in both legs\n dr. , dr. , .c.\n valchon(neurosurgical) aware\n Action:\n Dr. , dr. , c. valchon aware\n Response:\n monitor\n Plan:\n continue to monitor,check nuero assessment every 2 hours as\n ordered.\n"
},
{
"category": "Nursing",
"chartdate": "2122-10-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 648049,
"text": "Pain control (acute pain, chronic pain)\n Assessment:\n pt c/o neck pain\n Action:\n pt receiving .5mg of iv diluadid every 3 hours\n Response:\n pt has adquete relief of pain\n Plan:\n continue to monitor, medicate for pain as ordered\n .H/O hypertension, benign\n Assessment:\n pt sbp up to 198\n dr. notified\n pt received 5mg of iv Lopressor with little effect. Pt\n received 10mg of iv hydralazine\n pt also received .5 diluaidid\n Action:\n sbp remain in 170\ns, dr. , pt received an\n additional 10mg of iv hydralzine\n Response:\n sbp 150-160\n Plan:\n continue to monitor, pt to received Lopressor 5mg iv every\n six hour, hydralzine 10mg iv every six hours as ordered. Medicate for\n pain as needed\n Respiratory failure, acute (not ARDS/)\n Assessment:\n pt extubated at ~1120, pt on 70% open face mask, pt c/o\nbreathing feeling tight\n dr. . das into assess patient. Pt received\n nebulizer by resp. therapy, lungs clear, but diminished at bases. pt\n does have a dry nonproductive cough\n Action:\n as above pt received nebulizer by resp. therapy\n Response:\n pt states she feels better, pt 02 weaned down to 70% open\n face mask\n Plan:\n continue to monitor,\n encourage pt to cough and deep breathe\n encourage pt using incentive spirometer\n"
},
{
"category": "Nursing",
"chartdate": "2122-10-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 648050,
"text": "Pain control (acute pain, chronic pain)\n Assessment:\n pt c/o neck pain\n Action:\n pt receiving .5mg of iv diluadid every 3 hours\n Response:\n pt has adquete relief of pain\n Plan:\n continue to monitor, medicate for pain as ordered\n .H/O hypertension, benign\n Assessment:\n pt sbp up to 198\n dr. notified\n pt received 5mg of iv Lopressor with little effect. Pt\n received 10mg of iv hydralazine\n pt also received .5 diluaidid\n Action:\n sbp remain in 170\ns, dr. , pt received an\n additional 10mg of iv hydralzine\n Response:\n sbp 150-160\n Plan:\n continue to monitor, pt to received Lopressor 5mg iv every\n six hour, hydralzine 10mg iv every six hours as ordered. Medicate for\n pain as needed\n Respiratory failure, acute (not ARDS/)\n Assessment:\n pt extubated at ~1120, pt on 70% open face mask, pt c/o\nbreathing feeling tight\n dr. . das into assess patient. Pt received\n nebulizer by resp. therapy, lungs clear, but diminished at bases. pt\n does have a dry nonproductive cough\n Action:\n as above pt received nebulizer by resp. therapy\n Response:\n pt states she feels better, pt 02 weaned down to 70% open\n face mask\n Plan:\n continue to monitor,\n encourage pt to cough and deep breathe\n encourage pt using incentive spirometer\n"
},
{
"category": "Physician ",
"chartdate": "2122-10-30 00:00:00.000",
"description": "Intensivist Note",
"row_id": 647937,
"text": "SICU\n HPI:\n 40yo F who is s/p Anterior C4 corpectomy, cervical discectomy C5-C6,\n C6-C7, C7-T1 with allograft and plate and dural repair on .\n She p/w ascending numbness and inability to walk. H/o chronic\n paraspinal neck pain worsened by MVA , tx w/ multiple\n chiropractor session. Over course of 7 days, numbness progressed from\n feet to umbilicus to breast/arm and LE weakness. Imaging showed severe\n cord compression with obstruction to flow of intrathecal contrast at\n C7-T1\n Chief complaint:\n cervical cord compression\n PMHx:\n Fibromyalgia, Carpal tunnel, Rheumatoid arthritis, chronic paraspinal\n neck pain\n Current medications:\n 24 Hour Events:\n OR RECEIVED - At 09:45 PM\n ARTERIAL LINE - START 09:45 PM\n NASAL SWAB - At 01:07 AM\n INVASIVE VENTILATION - START 03:03 AM\n Post operative day:\n POD#1 - Anterior C4 corpectomy, cervical discectomy C5-C6, C6-C7, C7-T1\n with allograft and plate\n o/n events: tolerated PS , weening in AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Propofol - 75 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Hydromorphone (Dilaudid) - 02:00 AM\n Famotidine (Pepcid) - 03:34 AM\n Other medications:\n Flowsheet Data as of 05:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.6\nC (99.7\n T current: 37.2\nC (99\n HR: 89 (87 - 112) bpm\n BP: 146/111(128) {136/74(99) - 152/111(128)} mmHg\n RR: 15 (13 - 22) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 3,769 mL\n 643 mL\n PO:\n Tube feeding:\n IV Fluid:\n 3,769 mL\n 643 mL\n Blood products:\n Total out:\n 635 mL\n 410 mL\n Urine:\n 160 mL\n 410 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,134 mL\n 233 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 592 (592 - 707) mL\n PS : 5 cmH2O\n RR (Spontaneous): 14\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 26\n PIP: 14 cmH2O\n SPO2: 97%\n ABG: 7.40/44/111/25/1\n Ve: 7.8 L/min\n PaO2 / FiO2: 222\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese, intubated,\n sedated\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: Sedated\n Labs / Radiology\n 351 K/uL\n 10.2 g/dL\n 143 mg/dL\n 0.8 mg/dL\n 25 mEq/L\n 4.2 mEq/L\n 25 mg/dL\n 102 mEq/L\n 138 mEq/L\n 29.9 %\n 17.7 K/uL\n [image002.jpg]\n 09:50 PM\n 09:55 PM\n 02:11 AM\n 02:38 AM\n WBC\n 20.4\n 17.7\n Hct\n 29.5\n 29.9\n Plt\n 435\n 351\n Creatinine\n 1.0\n 0.8\n TCO2\n 25\n 28\n Glucose\n 134\n 143\n Other labs: PT / PTT / INR:14.5/18.9/1.3, Differential-Neuts:93.0 %,\n Lymph:4.0 %, Mono:2.8 %, Eos:0.1 %, Lactic Acid:2.6 mmol/L, Ca:8.8\n mg/dL, Mg:2.1 mg/dL, PO4:4.9 mg/dL\n Assessment and Plan\n Assessment and Plan:\n Neurologic: PPF wean, dilaudid PRN, c-collar per team, ok to get out of\n bed per neurosurgery, decadron 4 q6 for spinal cord compression\n Cardiovascular: stable\n Pulmonary: Extubate today, (Ventilator mode: CPAP + PS), does have cuff\n leak\n Gastrointestinal / Abdomen: start diet once extubated\n Nutrition: diet once extubated\n Renal: Foley, good UOP\n Hematology: f/u HCT\n Endocrine: RISS\n Infectious Disease: none\n Lines / Tubes / Drains: Foley, ETT, aline\n Wounds: Dry dressings\n Imaging: CXR today\n Fluids: NS, Potassium Chloride, kvo once taking PO\n Consults: Neuro surgery, Ortho-spine, Neurology\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 09:45 PM\n 14 Gauge - 09:47 PM\n 16 Gauge - 09:48 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle: Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU, possibly to floor later once extubated\n Total time spent: 22\n"
},
{
"category": "Physician ",
"chartdate": "2122-10-30 00:00:00.000",
"description": "Intensivist Note",
"row_id": 647939,
"text": "SICU\n HPI:\n 40yo F who is s/p Anterior C4 corpectomy, cervical discectomy C5-C6,\n C6-C7, C7-T1 with allograft and plate and dural repair on .\n She p/w ascending numbness and inability to walk. H/o chronic\n paraspinal neck pain worsened by MVA , tx w/ multiple\n chiropractor session. Over course of 7 days, numbness progressed from\n feet to umbilicus to breast/arm and LE weakness. Imaging showed severe\n cord compression with obstruction to flow of intrathecal contrast at\n C7-T1\n Chief complaint:\n cervical cord compression\n PMHx:\n Fibromyalgia, Carpal tunnel, Rheumatoid arthritis, chronic paraspinal\n neck pain\n Current medications:\n 24 Hour Events:\n OR RECEIVED - At 09:45 PM\n ARTERIAL LINE - START 09:45 PM\n NASAL SWAB - At 01:07 AM\n INVASIVE VENTILATION - START 03:03 AM\n Post operative day:\n POD#1 - Anterior C4 corpectomy, cervical discectomy C5-C6, C6-C7, C7-T1\n with allograft and plate\n o/n events: tolerated PS , weening in AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Propofol - 75 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Hydromorphone (Dilaudid) - 02:00 AM\n Famotidine (Pepcid) - 03:34 AM\n Other medications:\n Flowsheet Data as of 05:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.6\nC (99.7\n T current: 37.2\nC (99\n HR: 89 (87 - 112) bpm\n BP: 146/111(128) {136/74(99) - 152/111(128)} mmHg\n RR: 15 (13 - 22) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 3,769 mL\n 643 mL\n PO:\n Tube feeding:\n IV Fluid:\n 3,769 mL\n 643 mL\n Blood products:\n Total out:\n 635 mL\n 410 mL\n Urine:\n 160 mL\n 410 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,134 mL\n 233 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 592 (592 - 707) mL\n PS : 5 cmH2O\n RR (Spontaneous): 14\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 26\n PIP: 14 cmH2O\n SPO2: 97%\n ABG: 7.40/44/111/25/1\n Ve: 7.8 L/min\n PaO2 / FiO2: 222\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese, intubated,\n sedated\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: Sedated\n Labs / Radiology\n 351 K/uL\n 10.2 g/dL\n 143 mg/dL\n 0.8 mg/dL\n 25 mEq/L\n 4.2 mEq/L\n 25 mg/dL\n 102 mEq/L\n 138 mEq/L\n 29.9 %\n 17.7 K/uL\n [image002.jpg]\n 09:50 PM\n 09:55 PM\n 02:11 AM\n 02:38 AM\n WBC\n 20.4\n 17.7\n Hct\n 29.5\n 29.9\n Plt\n 435\n 351\n Creatinine\n 1.0\n 0.8\n TCO2\n 25\n 28\n Glucose\n 134\n 143\n Other labs: PT / PTT / INR:14.5/18.9/1.3, Differential-Neuts:93.0 %,\n Lymph:4.0 %, Mono:2.8 %, Eos:0.1 %, Lactic Acid:2.6 mmol/L, Ca:8.8\n mg/dL, Mg:2.1 mg/dL, PO4:4.9 mg/dL\n Assessment and Plan\n Assessment and Plan:\n Neurologic: PPF wean, dilaudid PRN, c-collar per team, ok to get out of\n bed per neurosurgery, decadron 4 q6 for spinal cord compression\n Cardiovascular: stable\n Pulmonary: Extubate today, (Ventilator mode: CPAP + PS), does have cuff\n leak\n Gastrointestinal / Abdomen: start diet once extubated\n Nutrition: diet once extubated\n Renal: Foley, good UOP\n Hematology: f/u HCT\n Endocrine: RISS\n Infectious Disease: none\n Lines / Tubes / Drains: Foley, ETT, aline\n Wounds: Dry dressings\n Imaging: CXR today\n Fluids: NS, Potassium Chloride, kvo once taking PO\n Consults: Neuro surgery, Ortho-spine, Neurology\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 09:45 PM\n 14 Gauge - 09:47 PM\n 16 Gauge - 09:48 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle: Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU, possibly to floor later once extubated\n Total time spent: 33\n"
},
{
"category": "Nursing",
"chartdate": "2122-10-31 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 648174,
"text": "40 yo female with cord compression s/p anterior C4 corpectomy, anterior\n discectomy C5-C6, posterior lam fusion C3-T1 with lateral screws,\n allograft and plate. h/o chronic neck pain since MVA , treated with\n multiple chiropractic sessions with last session day before\n . She then began having ascending numbness from feet to\n umbilicus and then to nipple line and inability to walk. Imaging\n revealed cord compression.\n s/p C4 corpectomy\n Assessment:\n J collar in place at all times. Anterior neck DSD c/d/i.\n Neurologically intact, still experiencing lower extremity weakness.\n Sensation intact.\n Action:\n neuro checks q 4.\n Response:\n Able to lift and hold upper extremities and move LE\ns on\n bed-improvement since surgery.\n Plan:\n PT/OT consults.\n Pain control (acute pain, chronic pain)\n Assessment:\n c/o posterior neck and incisional pain \n Action:\n Given one tab Percocet, Cymbalta and Flexeril.\n Response:\n pain level . Pt states pain is tolerable.\n Plan:\n Continue pain control with Percocet, continue med regimen.\n .H/O hypertension, benign\n Assessment:\n SBP 140\ns-150\n Action:\n Hydralazine q 6 hours.\n Response:\n SBP maintained <160.\n Plan:\n maintain goal SBP <160 per Neurosurg. Continue Hydralazine as needed.\n"
},
{
"category": "Physician ",
"chartdate": "2122-10-31 00:00:00.000",
"description": "Intensivist Note",
"row_id": 648129,
"text": "SICU\n HPI:\n 40yo F who is s/p Anterior C4 corpectomy, cervical discectomy C5-C6,\n C6-C7, C7-T1 with allograft and plate and dural repair on .\n She p/w ascending numbness and inability to walk. H/o chronic\n paraspinal neck pain worsened by MVA , tx w/ multiple\n chiropractor session. Over course of 7 days, numbness progressed from\n feet to umbilicus to breast/arm and LE weakness. Imaging showed severe\n cord compression with obstruction to flow of intrathecal contrast at\n C7-T1\n Chief complaint:\n s/p Anterior C4 corpectomy, cervical discectomy C5-C6, C6-C7, C7-T1\n with allograft and plate and dural repair\n PMHx:\n Fibromyalgia, Carpal tunnel, Rheumatoid arthritis, chronic paraspinal\n neck pain\n Current medications:\n 1. 2. 3. 20 mEq Potassium Chloride / 1000 mL NS 4. Acetaminophen 5.\n Cepacol (Menthol) 6. Cyclobenzaprine\n 7. Dexamethasone 8. Diazepam 9. Docusate Sodium 10. Duloxetine 11.\n Famotidine 12. Furosemide 13. HYDROmorphone (Dilaudid)\n 14. HYDROmorphone (Dilaudid) 15. Heparin 16. HydrALAzine 17.\n HydrALAzine 18. Insulin 19. Metoprolol Tartrate\n 20. Ondansetron 21. Propofol 22. Sodium Chloride 0.9% Flush 23. Sodium\n Chloride 0.9% Flush 24. TraMADOL (Ultram)\n 24 Hour Events:\n EXTUBATION - At 11:30 AM\n INVASIVE VENTILATION - STOP 11:30 AM\n ARTERIAL LINE - STOP 12:08 AM\n Post operative day:\n POD#2 - Anterior C4 corpectomy, cervical discectomy C5-C6, C6-C7, C7-T1\n with allograft and plate\n 24 hr events:\n - extubated yesterday\n - neuro exam improving - able to move extremities more\n - lozenges for sore throat\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Metoprolol - 01:15 PM\n Famotidine (Pepcid) - 05:00 PM\n Furosemide (Lasix) - 06:11 PM\n Heparin Sodium (Prophylaxis) - 12:19 AM\n Hydromorphone (Dilaudid) - 05:18 AM\n Hydralazine - 05:19 AM\n Other medications:\n Flowsheet Data as of 06:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.3\nC (99.2\n T current: 36\nC (96.8\n HR: 72 (72 - 96) bpm\n BP: 154/86(102) {141/72(88) - 192/96(125)} mmHg\n RR: 17 (15 - 25) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 2,350 mL\n 461 mL\n PO:\n Tube feeding:\n IV Fluid:\n 2,350 mL\n 461 mL\n Blood products:\n Total out:\n 3,030 mL\n 480 mL\n Urine:\n 3,030 mL\n 480 mL\n NG:\n Stool:\n Drains:\n Balance:\n -680 mL\n -19 mL\n Respiratory support\n O2 Delivery Device: Face tent\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 1,191 (534 - 1,191) mL\n PS : 5 cmH2O\n RR (Spontaneous): 15\n PEEP: 0 cmH2O\n FiO2: 50%\n PIP: 11 cmH2O\n SPO2: 97%\n ABG: ///26/\n Ve: 6.6 L/min\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: No(t) Absent, Trace), (Temperature: Warm,\n No(t) Cool), (Pulse - Dorsalis pedis: Present), (Pulse - Posterior\n tibial: Present)\n Right Extremities: (Edema: No(t) Absent, Trace), (Temperature: Warm),\n (Pulse - Dorsalis pedis: Present), (Pulse - Posterior tibial: Present,\n No(t) Diminished)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities, moves all\n extremities well, still some decreased sensation in some areas\n Labs / Radiology\n 316 K/uL\n 10.5 g/dL\n 104 mg/dL\n 0.6 mg/dL\n 26 mEq/L\n 4.3 mEq/L\n 20 mg/dL\n 99 mEq/L\n 136 mEq/L\n 30.1 %\n 15.6 K/uL\n [image002.jpg]\n 09:50 PM\n 09:55 PM\n 02:11 AM\n 02:38 AM\n 02:13 AM\n WBC\n 20.4\n 17.7\n 15.6\n Hct\n 29.5\n 29.9\n 30.1\n Plt\n \n Creatinine\n 1.0\n 0.8\n 0.6\n TCO2\n 25\n 28\n Glucose\n 134\n 143\n 104\n Other labs: PT / PTT / INR:14.5/18.9/1.3, Differential-Neuts:93.0 %,\n Lymph:4.0 %, Mono:2.8 %, Eos:0.1 %, Lactic Acid:2.6 mmol/L, Ca:8.7\n mg/dL, Mg:2.4 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS, .H/O HYPERTENSION,\n BENIGN, RESPIRATORY FAILURE, ACUTE (NOT ARDS/), PAIN CONTROL (ACUTE\n PAIN, CHRONIC PAIN)\n Assessment and Plan: 40yo F who is s/p Anterior C4 corpectomy, cervical\n discectomy C5-C6, C6-C7, C7-T1 with allograft and plate and dural\n repair on now extubated, neuro exam improving.\n Neurologic: Neuro checks Q: 4 hr, Pain controlled, change to PCA,\n Valium, Flexerol. Add percocet if pt tolerate POs\n Cardiovascular: Beta-blocker, Slightly hypertensive.\n Lopressor/hydralazine PRN\n Pulmonary: Stable on face tent. OOB --> chair.\n Gastrointestinal / Abdomen:\n Nutrition: Regular diet, Advance diet as tolerated\n Renal: Foley, Adequate UO, No issues. Keep negative 1-2 L\n Hematology: Serial Hct, Stable anemia - monitor\n Endocrine: RISS, Glucose better controlled. Keep < 150. Would d/c\n decadron if o.k. with primary team\n Infectious Disease: No evidence of infection\n Lines / Tubes / Drains: Foley\n Wounds: Dry dressings\n Imaging:\n Fluids: NS, KVO fluids\n Consults: Neuro surgery\n Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 14 Gauge - 09:47 PM\n 16 Gauge - 09:48 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin (D/C H2 blocker)\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 15 minutes\n"
}
] |
27,210 | 157,329 | #. GJ tube displacement: The external portion of the GJ tube was not present on transfer from the ICU to the medical floor. Patient and nursing from ICU were unable to relate what happened to the GJ tube. No evidence of infection on u/s or on exam. The ICU resident reported that the patient's initial report of pus changed to no pus after the patient found out she would not receive IV benadryl or IV opiates. On exam of the patient the GJ tube was present at the insertion site in the ICU and on arrival to the medical floor the tube was no longer present. The G tube was replaced by IR on . She was tolerating meals so no tube feeds were started prior to discharge. | A Port-A-Cath catheter is noted with the port in the right thorax and the tip in unchanged position in the lower SVC. A 0.035 angled tip Glidewire was advanced through the jejunal port of partially extracted GJ tube into the jejunum. Uncomplicated percutaneous placement of an 18-French MIC gastrojejunostomy tube. REASON FOR THIS EXAMINATION: Check tube location, please replace FINAL REPORT CLINICAL INDICATION: 1. However, a disruption is noted at the proximal end of the catheter at its connection with the port which appears new from prior exam. Percutaneous retrieval of foreign object (displaced fractured GJ tube) from the stomach under fluoroscopic guidance. Digital scout image of the upper abdomen demonstrated retained fractured GJ tube in the stomach. After appropriate dilatation of the needle tract, a new 18 French MIC gastrojejunostomy tube was advanced through the appropriate peel-away sheath and over a 0.035 angled tip Glidewire into the proximal jejunum. Placement of an 18-French percutaneous transgastric GJ tube under fluoroscopic guidance. 12:58 PM PERC G/J TUBE CHECK/REPLACE Clip # Reason: Check tube location, please replace Admitting Diagnosis: DIABETIC KETOACIDOSIS ********************************* CPT Codes ******************************** * REPLACE G OR C TUBE, ALL INCL. Fractured GJ tube retained within the stomach. Existing GJ tube was removed over the guidewire. The skin tract was cannulated by a 4-French dilator. A Glidewire was exchanged through a 5 French Kumpe catheter for a 0.035 Amplatz (Over) 12:58 PM PERC G/J TUBE CHECK/REPLACE Clip # Reason: Check tube location, please replace Admitting Diagnosis: DIABETIC KETOACIDOSIS FINAL REPORT (Cont) guidewire, which was advanced into the proximal jejunum. Evaluate for location of the tip of the central catheter. Optimal positioning of the gastrojejunostomy tube was documented at the conclusion of the procedure. COMPARISON: Chest radiographs on and CT chest on , . No dysuria but has urinary frequency with polydipsia. The skin of the anterior abdominal wall was prepped and draped in sterile fashion. MONITORED CONSCIOUS SEDATION: The procedure was performed under monitored conscious sedation. Over the Bentson guidewire, a 4-French dilator was exchanged for a 6-French -Tip sheath. A 30 x 16 mm ensnare device contained within a 7 French directional guiding catheter was then advanced into the stomach. Skin tract was dilated additionally up to 16 French and a retained foreign object/fracture of GJ-tube was successfully extracted percutaneously. Successful percutaneous retrieval of retained foreign body/fractured 22 French MIC GJ tube in the stomach using a 30 x 16 mm Ensnare retrieval device. Should evaluation of the abdomen be required, a CT should be performed. The stomach was insufflated by 100 mL of air followed by placement by coiling of 0.035 Bentson guidewire into the stomach. Generous amount of topical 2% lidocaine gel was applied into the existing skin tract. Low-grade fevers. LIMTED ABDOMINAL US: Limited ultrasound around the J-tube site demonstrated no focal fluid collections in the subcutaneous soft tissues. New ill visualized abnormality at the level of the connection between the catheter and the port might represent a disruption at this site. Low grade fevers. Pt with history of IDDM, gastroparesis, s/p JG tube for feeding a few years ago. After additional gastric insufflation, the fractured GJ tube was successfully ensnared. TECHNIQUE: Upright portable chest radiograph. Retention balloon was instilled by 8 mL of sterile water mixed with 1 mL of Omnipaque 350 for easy fluoroscopic identification. Reports purulent drainage from tube site the last few days. Gastroparesis. Patient reports purulent discharge from the tube site over the last few days. The patient received a total quantity of 4 mg of Versed, 2 mg of Dilaudid and 8 mg of Zofran during the total procedural time of 69 minutes while her hemodynamic parameters and pulse oximetry were continually monitored by a trained radiology nurse. 1:59 PM CHEST (PORTABLE AP) Clip # Reason: location of tip of central catheter, port Admitting Diagnosis: DIABETIC KETOACIDOSIS MEDICAL CONDITION: 25 year old woman with port, unable to draw back for labs REASON FOR THIS EXAMINATION: location of tip of central catheter, port FINAL REPORT INDICATION: 25-year-old female with Port-A-Catheter, unable to draw blood for labs. Cardiomediastinal and hilar contours are unremarkable. Timeout protocol was carried out prior to the procedure according to the Hospital policy. | 3 | [
{
"category": "Radiology",
"chartdate": "2168-05-27 00:00:00.000",
"description": "US ABD LIMIT, SINGLE ORGAN",
"row_id": 1236596,
"text": " 1:27 AM\n US ABD LIMIT, SINGLE ORGAN; US ABD LIMIT, SINGLE ORGAN Clip # \n Reason: evaluate for abscess around J tube site\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 25This patient is a 25 year old female who complains of ELEVATED GLUCOSE. Pt\n with history of IDDM, gastroparesis, s/p JG tube for feeding a few years ago.\n Coming in with malaise. Glucose > 600 700 for a few days. Reports purulent\n drainage from tube site the last few days. Low grade fevers. No dysuria but has\n urinary frequency with polydipsia. No cough. + nausea, no vomiting.\n REASON FOR THIS EXAMINATION:\n evaluate for abscess around J tube site\n ______________________________________________________________________________\n WET READ: FRI 1:57 AM\n no focal fluid collections around j tube site\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 25-year-old female with history of IDDM, gastroparesis status\n post GJ tube for feeding a few years ago coming in with malaise. Patient\n reports purulent discharge from the tube site over the last few days.\n Low-grade fevers.\n\n COMPARISON: None.\n\n LIMTED ABDOMINAL US: Limited ultrasound around the J-tube site demonstrated no\n focal fluid collections in the subcutaneous soft tissues. Should evaluation\n of the abdomen be required, a CT should be performed.\n\n"
},
{
"category": "Radiology",
"chartdate": "2168-05-31 00:00:00.000",
"description": "REPLACE G OR C TUBE, ALL INCL.",
"row_id": 1237171,
"text": " 12:58 PM\n PERC G/J TUBE CHECK/REPLACE Clip # \n Reason: Check tube location, please replace\n Admitting Diagnosis: DIABETIC KETOACIDOSIS\n ********************************* CPT Codes ********************************\n * REPLACE G OR C TUBE, ALL INCL. *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 25 year old woman with GJ tube for gastroparesis, tube malfunctioning.\n REASON FOR THIS EXAMINATION:\n Check tube location, please replace\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION:\n 1. Gastroparesis.\n 2. Fractured GJ tube retained within the stomach.\n\n PHYSICIANS: MD (fellow) and MD (attending\n physician, was present and supervising during the procedure).\n\n PROCEDURES:\n 1. Percutaneous retrieval of foreign object (displaced fractured GJ tube)\n from the stomach under fluoroscopic guidance.\n 2. Placement of an 18-French percutaneous transgastric GJ tube under\n fluoroscopic guidance.\n\n Informed consent for the procedure was obtained after risks, benefits, and\n potential complications had been discussed. The patient was placed on the\n angiographic table in supine position. The skin of the anterior abdominal\n wall was prepped and draped in sterile fashion. Timeout protocol was carried\n out prior to the procedure according to the Hospital policy.\n\n MONITORED CONSCIOUS SEDATION: The procedure was performed under monitored\n conscious sedation. The patient received a total quantity of 4 mg of Versed,\n 2 mg of Dilaudid and 8 mg of Zofran during the total procedural time of 69\n minutes while her hemodynamic parameters and pulse oximetry were continually\n monitored by a trained radiology nurse.\n\n Digital scout image of the upper abdomen demonstrated retained fractured GJ\n tube in the stomach. Generous amount of topical 2% lidocaine gel was applied\n into the existing skin tract. The skin tract was cannulated by a 4-French\n dilator. The stomach was insufflated by 100 mL of air followed by placement\n by coiling of 0.035 Bentson guidewire into the stomach. Over the Bentson\n guidewire, a 4-French dilator was exchanged for a 6-French -Tip sheath.\n A 30 x 16 mm ensnare device contained within a 7 French directional guiding\n catheter was then advanced into the stomach. After additional gastric\n insufflation, the fractured GJ tube was successfully ensnared. Skin tract was\n dilated additionally up to 16 French and a retained foreign object/fracture of\n GJ-tube was successfully extracted percutaneously. A 0.035 angled tip\n Glidewire was advanced through the jejunal port of partially extracted GJ tube\n into the jejunum. Existing GJ tube was removed over the guidewire. A\n Glidewire was exchanged through a 5 French Kumpe catheter for a 0.035 Amplatz\n (Over)\n\n 12:58 PM\n PERC G/J TUBE CHECK/REPLACE Clip # \n Reason: Check tube location, please replace\n Admitting Diagnosis: DIABETIC KETOACIDOSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n guidewire, which was advanced into the proximal jejunum. After appropriate\n dilatation of the needle tract, a new 18 French MIC gastrojejunostomy tube was\n advanced through the appropriate peel-away sheath and over a 0.035 angled tip\n Glidewire into the proximal jejunum. Optimal positioning of the\n gastrojejunostomy tube was documented at the conclusion of the procedure.\n\n Retention balloon was instilled by 8 mL of sterile water mixed with 1 mL of\n Omnipaque 350 for easy fluoroscopic identification.\n\n Dr. , the attending radiologist, supervised the procedure.\n\n CONCLUSION:\n\n 1. Successful percutaneous retrieval of retained foreign body/fractured 22\n French MIC GJ tube in the stomach using a 30 x 16 mm Ensnare retrieval device.\n 2. Uncomplicated percutaneous placement of an 18-French MIC gastrojejunostomy\n tube.\n\n"
},
{
"category": "Radiology",
"chartdate": "2168-05-30 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1237021,
"text": " 1:59 PM\n CHEST (PORTABLE AP) Clip # \n Reason: location of tip of central catheter, port\n Admitting Diagnosis: DIABETIC KETOACIDOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 25 year old woman with port, unable to draw back for labs\n REASON FOR THIS EXAMINATION:\n location of tip of central catheter, port\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 25-year-old female with Port-A-Catheter, unable to draw blood for\n labs. Evaluate for location of the tip of the central catheter.\n\n COMPARISON: Chest radiographs on and CT chest on , .\n\n TECHNIQUE: Upright portable chest radiograph.\n\n FINDINGS: Lung volumes are low, but there are no focal opacities.\n Cardiomediastinal and hilar contours are unremarkable. There is no pleural\n effusion or pneumothorax. A Port-A-Cath catheter is noted with the port in\n the right thorax and the tip in unchanged position in the lower SVC. However,\n a disruption is noted at the proximal end of the catheter at its connection\n with the port which appears new from prior exam.\n\n IMPRESSION: No evidence of acute cardiopulmonary process. New ill visualized\n abnormality at the level of the connection between the catheter and the port\n might represent a disruption at this site. A shallow oblique view might allow\n better visualization of this area.\n\n"
}
] |
28,247 | 126,143 | Patient was admitted for head trauma with left subdural and subarachnoid bleeds with left hemispheric edema and uncal herniation. Patient was emergently taken to the OR for caminio bolt placement and left craniectomy for relief of high ICP and evacuation of a small SDH. Patient tolerated the procedure well and was transfered to the trauma SICU for Q1hr neuro checks. A post-operative head CT showed the development of a new right epidural hematoma. He emergently returned to the OR and underwent a craniectomy for evacuation of the right epidural hematoma. He tolerated the procedure well and was again transferred to the trauma SICU. Patient was monitored closely with neuro checks Q1hr. A post-op head CT showed essentially complete evacuation of the right middle cranial fossa epidural hematoma, with resolution of previously noted leftward subfalcine herniation. Post-operatively he was able to intermitently squeeze his hands to commands, but did not open his eyes. His neuro exam continued to improve daily, with R>L withdrawal progressing to purposeful movement on the right. His left upper and lower extremity was largely plegic, but at times he moved his RUE spontaneously and with withdrawal to pain. He ran a fever form most of his post-operative course, with no clear source. His urine and blood cultures have been negative, and there was no clear evidence of an aspiration PNA. We suspected a dilantin-induced fever and was therefore switched to keppra on . On patient was successfully extubated, and on was able to mumble a few intelligible words, such as "hi mom" and "I'm nauseous." He was transferredto neuro stepdown and continued to improve. He was spiking fevers but no source wasfound via CXR, urine cultures, blood cultures and lower extremity dopplers. he was switched from dilantin to keppra and temperatures dropped. His incision is well healing with all staples/sutures removed. He had IVC filter and g tube placed. Tube feedings are at goal. Neuro exam is eyes open, attending examiner, said "good morning". Moves upper extremities purposefully and withdraws lowers to pain. Intermittenetly follows commands. Pupils reactive with minimal subconjunctival hemmorrhages laterally bilaterally. Due to the patients improving activity and ability to move his upper extemities and to manipulate his incision/head, use of a helmet was started at all times. | Lastly, there is a probable minimal degree of pneumocephalus within the former site of the right epidural hematoma. CONCLUSION: Evacuation of right epidural hematoma. NON-CONTRAST CT HEAD: There is a new right convexity epidural hematoma extending up to 2.1 cm from the inner table. Contercoup left frontal parenchymal contusion with 1 cm midline shift. There is interval resolution of the previously noted hemorrhage in the extra-axial location at the sit eof craniotomy. The large left-sided craniectomy defect is again noted. FINDINGS: Since the prior study, there appears to be essentially complete evacuation of the right middle cranial fossa epidural hematoma, with resolution of previously noted leftward subfalcine herniation. There is a newly apparent right epidural hematoma, exerting mass effect with uncal herniation, which abuts the brainstem . COMPARISON: Non-contrast CT head performed . Right parieto-occipital subgaleal hematoma. Left convexity subdural hematoma. Diffuse brain edema is again noted with areas of subarachnoid blood, unchanged. Hypodense areas noted in the bifrontal and left occipital lobes related to previously noted acute infarcts. Left craniectomy changes with pneumocephalus are within the spectrum of post-surgical change. CT ABDOMEN: There is mild periportal edema noted. Post-craniectomy changes are noted in the left convexity with subcutaneous air that is within the spectrum of post-surgical change. Thin right sided subdural hemorrhage is unchanged. There is a left maxillary mucosal retention cyst. FINDINGS: Post-surgical changes from prior right craniotomy, with evacuation of right middle cranial fossa epidural hematoma and large left craniectomy are similar. IMPRESSION: Overall similar post-surgical changes from prior right craniotomy and left craniectomy. There has been interval resolution of the pneumocephalus. As before, there is some degree of cerebral edema. FINDINGS: The patient is status post left frontal, parietal, and temporal craniectomy and right parietal/temporal craniotomy. Superficial abdominal clips in the subcutaneous tissues near the umbilicus (2:82) are likely post surgical. New intracranial hemorrhage. The right lower lobe atelectasis or consolidation is clearing. COMPARISON STUDIES ON PACS ARCHIVE: scan, demonstrating a "newly apparent right epidural hematoma." VAP per protocol.GI:Abd soft with min. Pt placed back on A/C as a results. Calcium to be repleted.Resp: Lung sounds clear/coarse-see Carevue for details. DobbHoff placed by HO, verified placement by xray-ok to use. Pt suctioned as noted. Respiratory carept received on A/C as noted. Staples to scalp C/D/I. RespiratoryPt received on A/C as noted. K+ repleted this am.Resp: Remains on CMV, no spontaneous breathes this am. Pt spoke/communicated more clearly after extubation. Replete with fiber at goal through OGT-no residuals.GU: Foley with marginal amber u/o Qhr. Venodynes for prophlaxis-awaiting SQ Heparin approval N-.RESP: Remains on CMV-attempted to wean further however per Resp. Plan is to extubate once mental status improves and is able to maintain airway.GI/GU: Abd/SNT w/ +BS. Overall stable post-surgical changes from prior right craniotomy and epidural hematoma evacuation, and left craniectomy. Remains on PO Dilantin.CV: Tach up to 120's, SBP 160's when agitated, otherwise goal SBP>160 acheived with repositioning and Fentanyl. Best exam shows pt spontaneously opening eyes, localizes with RUE and LUE internally rotating to nailbed pressure. Suctioned as noted. Has remained hemodynamically stable.Resp: Lungs diminished @ bases. Colace and senna given this am, + flatus though no BM yet. Continue early stages of rehab screen. The previously seen NG tube of Dobbhoff type has advanced further and has passed into the duodenum. A-line dsg changed x2, draining mod amt serosang. LS clear bilat, diminished in bases. The patient is now extubated. NEURO EXAM STABLE.POC: Cont Q2 Neuro checks-monitor icps maintain bp <160 ? NPN 0700-1900PLEASE REFER TO CAREVUE FOR SPECIFIC DATANEURO: off sedation. pan cx.Neuro: Pt. comfortNeuro checks q2Pt. Both LE's withdraw to nailbed pressure. T/SICU Nursing Progress NoteS:O: review of systemsNeuro: initally somewhat lethargic but now alert, opens eyes, seems to focus on speaker and track with eyes. Lung sounds- Bilateral course lung sounds at the beginning of shift, which later turned to clear lung sound by the end of shift. FINDINGS: Post-surgical changes from prior evacuations of right middle cranial fossa epidural hematoma, and large left craniectomy are stable. ANYTIPYRETIC MEASURES-F/U CXS PULM. R radial a-line wnl.Resp: LS coarse to clear, suctioned for sm. PB's for prophylaxis, ? due to Dilantin bolus) He didnt appear to aspirate, and per auscultation OGT appears to be in place (MD notified). Continues on dilantin (am level pending). Replete with fiber cont through OGT with min residuals. Lytes repelted. Nicardipine weaned off, maintaining goal SBP <160. On famotidine. PB's for prophylaxis.Access: PIVx3 wnl, sm. Hl'd. tubefeed/sputum -like subastance (? Affects/questions appropriate, emotional support provided.A: 24yo s/p evac. On kepra. IVC filter placement.Access: PIV x2 wnl, R radial a-line with +fling, changed over wire.Resp: LS clear, suctioned for scant to sm. HYGIENE/CONT TO WEAN VENT AS TOL-? Rehab screen. L sided crani staples appear WNL. Conts. Conts. Conts. Conts. Pepcid for prophylaxis.GU: foley patent draining adequate amts. Pepcid for prophylaxis.GU: foley patent draining adequate amts. Check dilantin level (? JP with mod. Withdraws both LE's to nailbed pressure. site with DSD C/D/I. L crainiectomy site soft. T-SICU NPN 0700-1900Please see carevue for specifics.ROS:Neuro: Off sedation. R side epidural bleed evac. HR down to 59 during coughing spell, ?loss of Pwave briefly, ?valsalva - HO aware.Pt. Respiratory CareNo changes made to vent t/o the noc. Dobhoff in place and will start tube feeds this am. L sided crainectomy site soft. Adv. amts. amts. amts. amts. LE's briskly withdraw to nailbed pressure. serosang. serosang. serosang. On kefzol due to bolt. Nicardipine initiated, titrated to goal SBP <140.ROS:Neuro: Propofol off. EXTUBATE TOMMORROW UPDATE FAMILY AND PROVIDE EMOTI Repeat head CT in am. Cont. Cont. Cont. Cont. Cont. ?consider switching to po dilantin). Dr aware adn notifie dN- who are to come by to evaluate. Pt. Pt. Pt. Pt. Pt. Pt. Pt. Pt. Pt. Pt. Pt. amt. amt. amt. Optimize pt. L craniectomy site with mod. RN Posturing BLE's, lifting BUE's, ?towards ett to noxious stimuli. to mod. Continues to be on nicardipine to maintain sbp <140.RESP: remains intubated with thick blood tinged secretions. | 50 | [
{
"category": "Radiology",
"chartdate": "2167-06-30 00:00:00.000",
"description": "MR HEAD W/O CONTRAST",
"row_id": 1022621,
"text": " 7:56 PM\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: eval for evidence of stroke\n Admitting Diagnosis: SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 24 year old man s/p fall with left subdural s/p left craniectomy and right\n epidural s/p craniotomy and evacuation\n REASON FOR THIS EXAMINATION:\n eval for evidence of stroke\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 24-year-old man status post fall with left subdural hematoma and\n right epidural hematoma status post craniotomy and craniectomy. Evaluate for\n stroke.\n\n COMPARISON: .\n\n MRI BRAIN\n\n TECHNIQUE: Sagittal T1, axial T1, axial FLAIR, axial T2, axial GRE, and\n diffusion- weighted images of the brain were obtained.\n\n FINDINGS: The patient is status post left frontal, parietal, and temporal\n craniectomy and right parietal/temporal craniotomy. Small amount of\n extraaxial blood layers over the cerebral convexities bilaterally. Mild 3-mm\n leftward subfalcine herniation persists.\n\n Over the interval, new acute infarcts have developed in a bilateral PCA\n distribution involving the left temporal, left occipital and right medial\n occipital lobes as well as both thalami and the midbrain and pons,\n predominantly on the right. Additionally, there are \"ribbon-like\" gyriform\n infarcts within the medial parasagittal frontal lobes which may reflect\n variant vascular supply or perioperative event. There is no evidence of\n hemorrhagic conversion at this time.\n\n There is a left maxillary mucosal retention cyst.\n\n IMPRESSION:\n\n 1. Acute infarction largely in a bilateral PCA distribution; this likely\n reflects prior compression of both PCAs (in region of Kernohan's notch), due\n to shifting mass effect of the previously-evacuated bilateral extra-axial\n hematomas.\n\n 2. Acute cortical infarction of the parasagittal frontal lobes which may\n reflect post-operative or embolic event, or variant vascular anatomy.\n\n MRA CIRCLE OF \n\n TECHNIQUE: Three-dimensional time-of-flight MR arteriography was performed\n with rotational reconstructions.\n (Over)\n\n 7:56 PM\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: eval for evidence of stroke\n Admitting Diagnosis: SUBDURAL HEMATOMA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n FINDINGS: The intracranial vertebral and internal carotid arteries and their\n major branches appear normal without evidence of stenosis, occlusion, or\n aneurysm formation. Specifically, aside from a diminutive right PCA, there is\n no evidence of occlusion, stenosis or other abnormality of the posterior\n circulation.\n\n IMPRESSION: Unremarkable MRA of the Circle of .\n\n These findings were discussed with Dr. by Dr. on ,\n at 22:16.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-07-07 00:00:00.000",
"description": "O ABD (SINGLE VIEW ONLY) IN O.R.",
"row_id": 1023774,
"text": " 5:26 PM\n ABD (SINGLE VIEW ONLY) IN O.R.; ABDOMINAL FLUORO WITHOUT RADIOLOGIST IN O.R.Clip # \n Reason: IVC FILTER PLACEMENT\n Admitting Diagnosis: SUBDURAL HEMATOMA\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: IVC filter placement.\n\n No prior studies available for comparison.\n\n FINDINGS: A single spot fluoroscopic image was obtained and submitted for\n review. A vertically oriented IVC filter is seen, with tip of the IVC filter\n projecting to the right of mid L2 vertebral body, in standard position. An NG\n tube is partially visualized.\n\n IMPRESSION: IVC filter in standard position.\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-06-26 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 1022033,
"text": " 11:51 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: r/o injury\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 20 year old man s/p fall from 15-20 feet. GCS 3 at scene\n REASON FOR THIS EXAMINATION:\n r/o injury\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DXAe SAT 12:27 AM\n No fx or malalignment.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 20-year-old man status post 20-foot fall with GCS score of .\n Rule out injury.\n\n COMPARISON: None.\n\n NON-CONTRAST CT C-SPINE: There is no evidence of fracture or malalignment to\n the level of T1. The patient is intubated, limiting evaluation of the\n prevertebral soft tissues. Secretions are noted in the upper airway.\n The upper lungs demonstrate ground-glass opacities, which may represent\n aspiration or pulmonary contusion.\n\n IMPRESSION:\n\n 1. No evidence of fracture or malalignment.\n\n 2. Upper lobe ground-glass opacities may represent aspiration or pulmonary\n contusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-06-26 00:00:00.000",
"description": "CT CHEST W/CONTRAST",
"row_id": 1022034,
"text": " 11:52 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: r/o injury\n Field of view: 36 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 20 year old man s/p fall from 15-20 feet. GCS 3 at scene\n REASON FOR THIS EXAMINATION:\n r/o injury\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DXAe SAT 12:30 AM\n No acute fx or malalignment. Bilateral upper lung contusion/aspiration. No\n evidence of solid organ injury.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 20-year-old man status post 20 feet fall with coma scale\n of 3 on scene. Evaluate for acute injury.\n\n COMPARISON: None.\n\n TECHNIQUE: MDCT-acquired images were obtained through the chest, abdomen, and\n pelvis after the uneventful administration of 130 mL of IV Optiray contrast.\n Multiplanar reformats were reviewed.\n\n CT CHEST: An endotracheal tube terminates 2.5 cm above the carina. The lungs\n demonstrate patchy areas of upper lobe consolidation and other areas of\n subpleural ground- glass opacification, which likley represent pulmonary\n contusion. Bilateral atelectasis is also noted. There is no evidence of\n pleural or pericardial effusion. There is no pneumothorax. The airways are\n patent to the subsegmental level. No evidence of large pulmonary embolus.\n\n CT ABDOMEN: There is mild periportal edema noted. The liver, spleen,\n gallbladder, adrenals, kidneys, pancreas, intra-abdominal loops of large and\n small bowel are unremarkable. The imaged arterial vessels are unremarkable.\n Superficial abdominal clips in the subcutaneous tissues near the umbilicus\n (2:82) are likely post surgical.\n\n CT PELVIS: The rectum, bladder, sigmoid, and distal ureters are unremarkable.\n\n Bone windows demonstrate no fracture, dislocation or suspiscious bony lesion.\n\n IMPRESSION:\n 1. Bilateral lung contusion\n 2. No other evidence of acute injury\n\n\n\n\n\n\n (Over)\n\n 11:52 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: r/o injury\n Field of view: 36 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-07-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1023290,
"text": " 7:29 PM\n CHEST (PORTABLE AP) Clip # \n Reason: check dobhoff position\n Admitting Diagnosis: SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 24 year old man with cerebral contusions s/p dobhoff placement\n REASON FOR THIS EXAMINATION:\n check dobhoff position\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Dobbhoff tube placement.\n\n FINDINGS: In comparison with the study of , the Dobbhoff tube now extends\n to the distal stomach. No acute pneumonia.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-07-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1022660,
"text": " 5:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 24 year old man with\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Intubated patient, history of head trauma.\n\n Comparison is made with prior study performed a day earlier.\n\n ET tube and NG tube remain in standard positions. Cardiomediastinal contours\n are normal, the lungs are clear, there is no pleural effusion or pneumothorax.\n\n\n DR. \n"
},
{
"category": "Radiology",
"chartdate": "2167-06-26 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1022031,
"text": " 11:51 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o hemorrhage\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 20 year old man s/p fall from 15-20 feet. GCS 3 at scene\n REASON FOR THIS EXAMINATION:\n r/o hemorrhage\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DXAe SAT 12:26 AM\n Right parietal cephalohematoma. Left convexity subdural hematoma measuring up\n to 8 mm from the inner table. Contercoup left frontal parenchymal contusion\n with 1 cm midline shift. Early right uncal herniation. Short term followup is\n recommended.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 20-year-old man status post 0 feet with GCS 3 at scene.\n\n COMPARISON: None.\n\n NON-CONTRAST CT HEAD: There is a left convexity left subdural hematoma\n measuring up to 8 mm from the left inner table. There is a right occipital\n cephalohematoma with associated contrecoup injury in the left frontal lobe\n with edema noted diffusely through the brain parenchyma although more\n prominent in the left frontal lobe. There is a 10-mm left-to-right midline\n shift. There is subarachnoid blood in the basal cisterns.\n\n Bone windows demonstrate no evidence of acute fracture.\n\n IMPRESSION:\n\n 1. Right parietal cephalohematoma with likely contrecoup injury in the left\n frontal lobe.\n\n 2. Left convexity subdural hematoma.\n\n 3. 10 mm left-to-right midline shift.\n\n 4. Subarachnoid blood in the basal cisterns with diffuse brain edema.\n\n Short- term followup is recommended.\n\n\n ATTENDING NOTE: There is right temporal fracture extending to parietal bone.\n Diffuse brain edema with obliteration of basal cisterns. Left SDH with midline\n shift. Right parieto-occipital subgaleal hematoma.\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-06-26 00:00:00.000",
"description": "TRAUMA #3 (PORT CHEST ONLY)",
"row_id": 1022032,
"text": " 11:51 PM\n TRAUMA #3 (PORT CHEST ONLY) Clip # \n Reason: TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 24-year-old male who fell downstairs with known subdural\n hematomas, evaluate for acute intrathoracic injury.\n\n COMPARISON: CT torso performed concurrently.\n\n AP PORTABLE CHEST: Underlying trauma board limits evaluation. Heart size is\n mildly enlarged. The lung apices demonstrate increased opacity which may\n represent aspiration or lung contusion. An endotracheal tube terminates 2 cm\n above the carina. The osseous structures are intact.\n\n IMPRESSION: Upper lung contusion versus aspiration. There is no evidence of\n pneumothorax or effusion. The osseous structures are intact.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-07-06 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1023568,
"text": " 5:52 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Assess for blood resolution\n Admitting Diagnosis: SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 24 year old man with evacuated epidural hematoma assess for resolution of blood\n REASON FOR THIS EXAMINATION:\n Assess for blood resolution\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): CHgc MON 11:41 PM\n Stable postoperative changes from evacuation of epidural hematoma with\n interval resolution of blood without evidence of new intracranial hemorrhage.\n ______________________________________________________________________________\n FINAL REPORT\n CT HEAD WITHOUT CONTRAST\n\n INDICATION: 24-year-old man with evacuated epidural hematoma, assess for\n resolution of blood.\n\n TECHNIQUE: MDCT-acquired contiguous axial images of the head were obtained\n without IV contrast.\n\n COMPARISON: .\n\n FINDINGS: Post-surgical changes from prior right craniotomy, with evacuation\n of right middle cranial fossa epidural hematoma and large left craniectomy are\n similar. No new intracranial hemorrhage or infarct. There has been interval\n resolution of the pneumocephalus.\n\n IMPRESSION: Overall similar post-surgical changes from prior right craniotomy\n and left craniectomy. New intracranial hemorrhage.\n\n NOTE ON ATTENDING REVIEW:\n\n There is a change in the configuration of the left cerebral hemisphere part of\n which is protruding contour but likely within the confines of the flap and can\n relate to herniation or expansion of the brain. Hypodense areas are noted\n between the brain and the flap (series 2, im 21) and between the flap and the\n subcutaneous tissues of the flap measuing about -1 to 2.5HU and may represent\n fat or less likely fluid. There is interval resolution of the previously\n noted hemorrhage in the extra-axial location at the sit eof craniotomy.\n As before, there is some degree of cerebral edema. Hypodense areas noted in\n the bifrontal and left occipital lobes related to previously noted acute\n infarcts. To correlate if this is expected appearance of brain post\n craniotomy. Thin right sided subdural hemorrhage is unchanged.\n Findings informed to Dr. by Dr. on at 9.30am\n\n\n\n (Over)\n\n 5:52 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Assess for blood resolution\n Admitting Diagnosis: SUBDURAL HEMATOMA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-07-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1023082,
"text": " 10:55 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval placement of nasojejunal feeding tube\n Admitting Diagnosis: SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 24 year old man with\n REASON FOR THIS EXAMINATION:\n eval placement of nasojejunal feeding tube\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 10:53 A.M. ON \n\n HISTORY: Nasogastric feeding tube.\n\n IMPRESSION: AP chest compared to .\n\n Feeding tube ends in the upper stomach. The right lower lobe atelectasis or\n consolidation is clearing. Left lung is clear. No pneumothorax or pleural\n effusion. Heart size normal.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-07-06 00:00:00.000",
"description": "BILAT LOWER EXT VEINS",
"row_id": 1023572,
"text": " 6:09 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: ? DVT BILATERALLY/SDH'S\n Admitting Diagnosis: SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 24 year old man with limited mobility due to bilateral SDHs\n REASON FOR THIS EXAMINATION:\n ? DVT bilateral legs\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 24-year-old male with limited mobility. Also has bilateral\n subdural hemorrhages.\n\n FINDINGS: -scale, color and pulsed-wave Doppler son were performed\n on the bilateral common femoral, superficial femoral, and popliteal veins.\n Normal flow, compressibility, waveforms, and augmentation are demonstrated.\n No intraluminal thrombus is identified.\n\n IMPRESSION: No evidence of DVT in the bilateral lower extremities.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-06-28 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1022203,
"text": " 6:45 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: F/U\n Admitting Diagnosis: SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 24 year old man with\n REASON FOR THIS EXAMINATION:\n eval interval change s/p left craniectomy and right craniotomy with epidural\n hematoma evacuation; please do at 6am\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n NON-CONTRAST HEAD CT SCAN\n\n HISTORY: Status post left craniectomy and right craniotomy with epidural\n hematoma evacuation.\n\n TECHNIQUE: Non-contrast head CT scan.\n\n COMPARISON STUDIES ON PACS ARCHIVE: scan, demonstrating a\n \"newly apparent right epidural hematoma.\"\n\n FINDINGS: Since the prior study, there appears to be essentially complete\n evacuation of the right middle cranial fossa epidural hematoma, with\n resolution of previously noted leftward subfalcine herniation. The large\n left-sided craniectomy defect is again noted. There is no hydrocephalus. The\n right calvarial craniotomy flap is now apparent, as are overlying surgical\n staples. Lastly, there is a probable minimal degree of pneumocephalus within\n the former site of the right epidural hematoma.\n\n CONCLUSION: Evacuation of right epidural hematoma. Other findings as noted\n in above report.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-06-30 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1022472,
"text": " 4:55 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate OGT placment\n Admitting Diagnosis: SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 24 year old man with\n REASON FOR THIS EXAMINATION:\n evaluate OGT placment\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: OGT placement.\n\n FINDINGS: In comparison with the study of , there has been placement of\n an OGT that extends to the lower body of the stomach. No evidence of\n pneumonia or vascular congestion. Endotracheal tube remains in place.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-06-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1022040,
"text": " 12:44 AM\n CHEST (PORTABLE AP) Clip # \n Reason: reassess ET, OG\n Admitting Diagnosis: SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 20 year old man with severe head trauma\n REASON FOR THIS EXAMINATION:\n reassess ET, OG\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, .\n\n HISTORY: 24-year-old man with severe head trauma.\n\n FINDINGS: Comparison is made to previous study from .\n\n The endotracheal tube and nasogastric tube are appropriately sited. There is\n again noted some increased opacity seen within the upper lung field consistent\n with known pulmonary contusion seen on the CT scan. There are no signs of\n overt pulmonary edema. There is no pleural effusion. No rib fractures are\n seen.\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-06-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1022326,
"text": " 8:50 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval interval change\n Admitting Diagnosis: SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 24 year old man with\n REASON FOR THIS EXAMINATION:\n eval interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Severe head trauma, to evaluate for change.\n\n FINDINGS: In comparison with the study of , the gastric tube and\n endotracheal tube remain in place. The increased opacification in the right\n upper lung zone has substantially cleared. No evidence of acute pneumonia or\n vascular congestion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-07-06 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1023569,
"text": ", NSURG FA11 5:52 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Assess for blood resolution\n Admitting Diagnosis: SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 24 year old man with evacuated epidural hematoma assess for resolution of blood\n REASON FOR THIS EXAMINATION:\n Assess for blood resolution\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Stable postoperative changes from evacuation of epidural hematoma with\n interval resolution of blood without evidence of new intracranial hemorrhage.\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-06-27 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1022061,
"text": " 5:09 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Please eval post-op scan. PLEASE PERFORM AT 6AM ON . Tha\n Admitting Diagnosis: SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 24 year old man with fall s/p left craniectomy\n REASON FOR THIS EXAMINATION:\n Please eval post-op scan. PLEASE PERFORM AT 6AM ON . Thanks\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DXAe SAT 6:18 AM\n New right epidural hematoma extending 2.1 cm from the inner table causing 7mm\n left shift. The right uncus abuts the brianstem, which is concerning for\n worsening uncal herniation.\n\n Discussed with Dr. at 6:10 AM .\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 24-year-old man status post fall with new left craniectomy for a\n left subdural hemorrhage.\n\n COMPARISON: Non-contrast CT head performed .\n\n NON-CONTRAST CT HEAD: There is a new right convexity epidural hematoma\n extending up to 2.1 cm from the inner table. There is associated right uncal\n herniation with the uncus abutting and exerting mass effect on the brainstem.\n Diffuse brain edema is again noted with areas of subarachnoid blood,\n unchanged. Post-craniectomy changes are noted in the left convexity with\n subcutaneous air that is within the spectrum of post-surgical change. There\n is a 7-mm leftward midline shift noted.\n\n IMPRESSION:\n 1. There is a newly apparent right epidural hematoma, exerting mass effect\n with uncal herniation, which abuts the brainstem .\n 2. Left craniectomy changes with pneumocephalus are within the spectrum of\n post-surgical change.\n 3. Extensive subarachnoid blood in the basal cisterns with diffuse brain\n edema, similar to that seen on prior study.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-07-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1022886,
"text": " 10:44 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval placement of feeding tube\n Admitting Diagnosis: SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 24 year old man with\n REASON FOR THIS EXAMINATION:\n eval placement of feeding tube\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Placement of feeding tube.\n\n COMPARISON: . Status post intubation, status post insertion of\n two gastric tubes. Both tubes are in standard position. No evidence of\n complications. Newly occurred is a tiny right basal opacity that would be\n consistent with pneumonia. No other abnormalities.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-06-29 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1022303,
"text": " 5:08 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: inteval change\n Admitting Diagnosis: SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 24 year old man with sdh\n REASON FOR THIS EXAMINATION:\n inteval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DSsd MON 6:17 AM\n stable postsurgical changes s/p left craniectomy and right craniotomy.\n unchanged minimal pneumocephalus.\n\n subtle hypodensity in right thalamus, could possibly represent area of\n evolving infarction.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 24-year-old male with subdural hematoma, and recent evacuation of\n epidural hematoma. Please evaluate for interval change.\n\n COMPARISON: Multiple prior head CTs, most recently .\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: Post-surgical changes from prior evacuations of right middle\n cranial fossa epidural hematoma, and large left craniectomy are stable. There\n is no new intracranial hemorrhage. Ventricles and sulci are unchanged in size\n and configuration. Postoperative pneumocephalus is grossly unchanged. There\n is subtle area of hypodensity in the right thalamus, more prominent on current\n exam than previously, which may represent an area of evolving infarction.\n\n IMPRESSION:\n\n 1. Overall stable post-surgical changes from prior right craniotomy and\n epidural hematoma evacuation, and left craniectomy. No new intracranial\n hemorrhage.\n\n 2. Subtle area of focal hypodensity in the right thalamus could possibly\n represent an area of evolving infarction.\n\n Findings discussed with PA at 6:15 a.m. on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-06-29 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1022304,
"text": ", NSURG TSICU 5:08 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: inteval change\n Admitting Diagnosis: SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 24 year old man with sdh\n REASON FOR THIS EXAMINATION:\n inteval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n stable postsurgical changes s/p left craniectomy and right craniotomy.\n unchanged minimal pneumocephalus.\n\n subtle hypodensity in right thalamus, could possibly represent area of\n evolving infarction.\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-07-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1022903,
"text": " 12:12 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval placement of nasojejunal feeding tube after patient ext\n Admitting Diagnosis: SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 24 year old man with\n REASON FOR THIS EXAMINATION:\n eval placement of nasojejunal feeding tube after patient extubated and OGT\n removed\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: Evaluate position of nasojejunal feeding tube, patient now\n extubated.\n\n FINDINGS: AP single view of the chest obtained with patient in sitting semi-\n upright position is analyzed in direct comparison with a previous similar\n study obtained two hours earlier. The patient is now extubated. No\n pneumothorax is identified. The previously seen NG tube of Dobbhoff type has\n advanced further and has passed into the duodenum. A second gastric tube\n remains in unchanged position. No pneumothorax has occurred. No reoccurrence\n of the previously described contusion damages in the upper lung fields. The\n on previous study described density of pneumonic appearance in the right lung\n base is again seen, it has the characteristics of an atelectasis in the middle\n lobe area. Additional new changes is a more prominent vascularity in the\n upper left hilar area possibly representing a central infiltrate, but no other\n abnormalities are present and no pulmonary congestion is seen. Heart size is\n unchanged.\n\n IMPRESSION: Right middle lobe atelectasis and possible infiltrate in left\n lung. Consider aspiration. Further followup of these lesions is recommended.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2167-07-01 00:00:00.000",
"description": "Report",
"row_id": 1631387,
"text": "0700-1900\n\nNo significant events. 24yoM S/P fall down approx 15 steps at train station; +ETOH. Closed head injury; epidural bleed; S/P Left craniotomy.\n\nNeuro: Mental status waxes and wanes. Inconsistantly follows commands. Nods yes/no to questions occasion. Continues to have residual left-sides weakness. Has good RUE strength; will attempt to reach for ETT; remains restrained. PERRL 3-4mm/brisk. Has not had any sedation this shift. No seizure activity; continue dilantin PO/ATC.\n\nCV: HR 90-120's/NSR-ST; no ectopy. New Aline placed. BP 120-140's/70-80. Has remained hemodynamically stable.\n\nResp: Lungs diminished @ bases. Changed to PSV after am rounds; ABG 177/44/7.45. SATs 98-100%. No tachynea; RR 12-20. Minimal thick, tan sectreions; stronge gag/cough. Plan is to extubate once mental status improves and is able to maintain airway.\n\nGI/GU: Abd/SNT w/ +BS. TF @ goal via OGT. IVF-HL. Foley patent; UOP 30-60cc/hour.\n\nSkin: Intact. Staples to scalp C/D/I. No drainage.\n\nID: Consistantly febrile 100-8-102.5; minimal effect from Tylenol. Cooling blanket and fan on. Cultures pending; NTD. No current anbx.\n\nEndo: RISS; no coverage.\n\nSocial: Parents at bedside T/O the day. Multiple friends and girlfriend in to visit.\n\nPLAN: Continue Q2hour neuro checks; Pulmonary toilet; TF @ goal. Family support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2167-07-02 00:00:00.000",
"description": "Report",
"row_id": 1631388,
"text": "Respiratory Care\nPt remains on vent, with minimal settings, with no significant respiratory issues this shift. Pt is awake and alert. Lung sounds- Bilateral course lung sounds at the beginning of shift, which later turned to clear lung sound by the end of shift. Suctioned as noted. Pt has strong cough and able to lift head of bed. Exp TV/RR/SpO2 all withing normal range. Pt to cont current support; possible extubation candidate.\n"
},
{
"category": "Nursing/other",
"chartdate": "2167-07-02 00:00:00.000",
"description": "Report",
"row_id": 1631389,
"text": "T/SICU Nursing Progress Note\nS:\nO: review of systems\nNeuro: initally somewhat lethargic but now alert, opens eyes, seems to focus on speaker and track with eyes. PERRLA. Strong productive cough, +gag, +corneals. Moves R side > L. Nods yes/no to questions at times and intermittently follows simple commands. Continues on dilantin.\nCVS: tachy to 120's with bp 150-160, received lopressor 5 mg iv X 2 with fair effect.\nRESP: on psv 5/peep 5, 30%. Strong cough of thick yellow secretions. RSBI 51. Coarse breath sounds.\nRENAL: urine output adequate, lytes wnl\ngi: At goal tube feeds of fs replete with fiber @ 75cc/hr with 30cc flushes q 4 hours. Abdomen soft, incontinent of small amount of stool. On colace with prn senna and ducolox.\nheme: hct 29, on sq heparin and venodynes.\nID: t max 103.6 which was refractory to alcohol bath, tylenol. Responded to approximately 2 hours on cooling blanket, went down to 100.2 but not rising again. WBC 10.6 this am (7.4) and pt without positive blood cultures.\nLines: r radial art line. New 20G angio placed L forearm.\nskin: crainiotomy incisions well approximated. Pt positioned R to back and not on L due to crainiectomy site.\nsocial: Many, many visitors. is having a hard time coping with the MRI results that showed \"brain damage\" and was tearful and angry. She was trying to understand how this happened to her son and began to focus on whether he was \"drugged\" prior to his fall. They are frustrated that police have not given them any answers regarding further tests on blood samples. Clinical advisor called lab and found the lab still has the inital blood and urine specimens set aside and they will keep them for one week (today is day 7). Any tests that need to be ordered can be ordered through POE. Mom is worried her son will \"be a vegetable\" and she won't be able to cope with it. Reassurance, information, and encouragement given.\nA: Unfortunate 24 year old man s/p fall with closed head injury s/p crainiectomy, crainotomy. Fever secondary to ??blood in head, drug reaction vs infectious process. Altered coping in family.\nP: Continue to offer reassurance, information to family. ??continue to have social work meet with them. Help them plan for rehab and \"the next steps\". Continue aggressive fever treatment, follow cultures, ??neuro if we can use motrin as a antipyretic. Pt on minimal respiratory support, ??trial of extubation vs. trach. ??if pt will require peg/ivc filter. Consider having patient measured for helmet to protect brain s/p crainiectomy.\n"
},
{
"category": "Nursing/other",
"chartdate": "2167-07-02 00:00:00.000",
"description": "Report",
"row_id": 1631390,
"text": "Respiratory Care\nPatient successfully extubated around 1105 am is now on room air SPO2 upper 90s.\n"
},
{
"category": "Nursing/other",
"chartdate": "2167-07-02 00:00:00.000",
"description": "Report",
"row_id": 1631391,
"text": "Nursing Progress Note\nSee Carevue for Specific Data.\n\nSignificant Events: Pt extubated at 11:15 AM-uneventful, tolerating RA without ventilatory/oxygen support well. Pt fitted and given helmet to be worn when OOB. Pt OOB to chair via . Pt spoke/communicated more clearly after extubation. DobbHoff placed by HO, verified placement by xray-ok to use. Many visitors in to visit pt throughout the day.\n\nNeuro: Pt intermittently alert with eyes open/lethargic, arousing to voice. Most recent neuro exam: Pt alert, unable to determine orientation (pt denies being at home, class, work, restaurant, and hospital.) Pt tracks speaker with eyes, occasionally makes eye contact. Pt verbalized that he felt nauseas directly after extubation, said \"yes/no\" appropriately. Pt spoke to some family/friends today-voice weak. Pupils 4mm/4mm, briskly reactive to light. Pt inconsistently follows commands- will open eyes, squeeze and release right hand, wiggle left foot toes, will answer some questions. Pt : L/R upper extremities lift and hold-right seems stronger than left. L/R lower extremities move on the bed, more withdrawal/movement seen in left leg than right. Dilantin discontinued today, Keppra to start tonight. Pt wearing glasses while in the chair d/t nearsightedness at baseline.\n\nPain: Pt appears to be comfortable, denies pain.\n\nCV: HR 80-110, NSR-ST, no ectopy. BP WNL; 130-165 systolic, MAP > 70. Easily palpable pedal pulses, PBoots/multipodus boots on, heparin sc. Calcium to be repleted.\n\nResp: Lung sounds clear/coarse-see Carevue for details. Pt has strong gag/productive cough. Maintaining O2 sats >96% on RA. Initially after extubation, pt had moderate oral secretions, significantly less at time of note.\n\nGI: Abdomen soft, not distended, nontender. Pt having eruptation, no flatus noted. last BM overnight-small/Tuesday night-large. Tube feeds off since :00 this AM for extubation, to be restarted tomorrow via DobbHoff. IV fluid started: LR 60cc/hr while tube feeds off. Only meds given through dobbhoff at ths time.\n\nGU: Adequate amounts of clear yellow/light yellow UO through foley qhour.\n\nEndo: No insulin required per RISS. BS 110-120.\n\nID: Tmax 102.0. Tylenol 650mg PO administered with adequate effect. Dilantin changed to Keppra to prevent high temps. Motrin ordered per neuro but was not available during shift. Ice packs placed in armpits/neck/groin to cool pt-adequate effect.\n\nSkin: Back intact, no bruising noted. Sutures intact on head incisions, no drainage. Bruising noted behind right ear. Pt occasionally diaphoretic in attempts to decrease temp.\n\nSocial: Many support systems: parents, girlfriend, friends, -workers, roommates all in to visit pt throughout day. All visitors appropriate, caring, and very supportive of pt-appropriately concerned. Pt's music playing in room for comfort. Parents spoke with social worker, case manager, liason, chaplain, HO, and RN about questions, coping, disease process, plan of care.\n\nPlan: \n"
},
{
"category": "Nursing/other",
"chartdate": "2167-07-02 00:00:00.000",
"description": "Report",
"row_id": 1631392,
"text": "Nursing Progress Note\n(Continued)\nnue q2 hr neuro checks v. change to q3 or q4 hrs? D/C arterial line? Give first dose of Keppra tonight. PEG/IVC filter placement? Helmet to be worn when out of bed. Restart tube feeds tomorrow AM through Dobbhoff v. attempt to feed orally if pt lucid/alert enough? Speech/Swallow consult? OT/PT consult now that pt has helmet. Continue to support pt and family. Continue early stages of rehab screen.\n"
},
{
"category": "Nursing/other",
"chartdate": "2167-06-30 00:00:00.000",
"description": "Report",
"row_id": 1631382,
"text": "Respiratory\nPt received on A/C as noted. B.S. clear, and diminished in the bases. attempted PSV this AM, Pt. hypoventilating at a RR of 8, with a MV of 3.98L. Pt placed back on A/C as a results. Ett repositioned and retaped without incidents. Vent circuits changed to heated circuits secondary to thick secretions. Plan to take pt to MRI for reevaluation of head. Plan to attempt PSV weans this evening after MRI.\n"
},
{
"category": "Nursing/other",
"chartdate": "2167-07-01 00:00:00.000",
"description": "Report",
"row_id": 1631383,
"text": "Respiratory Care\nPt remains on vent, with 1-2 spontanous breathes per minute. Pt remains sedated, on full ventilatory support. Pt has clear right sided lung sounds, with slightly course lung sounds to the right. SpO2 96% or greater all shift. Pt suctioned as noted. Apnea was the result of RSBI trial. Pt to remain on current support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2167-07-01 00:00:00.000",
"description": "Report",
"row_id": 1631384,
"text": "Nursing Note\nSee Flowsheet\n\nEvents: MRI last evening, result pending. T-max 102.0, pt. pan cx.\n\nNeuro: Pt. opening eyes spontaneously, following commands intermittenlly, nods yes and no. MAE lifts and holds all extremities off bed. Pt. does not follow commands with lower extremities. Fentanyl given for pain. Remains on PO Dilantin.\n\nCV: Tach up to 120's, SBP 160's when agitated, otherwise goal SBP>160 acheived with repositioning and Fentanyl. T-max 102.0, pt. pan cx, fan and ice packs applied. K+ repleted this am.\n\nResp: Remains on CMV, no spontaneous breathes this am. LS clear bilat, diminished in bases. Very strong cough and gag reflex. Blood gas pending this am.\n\nGI/GU: Large stool last evening, tolerating goal TF 75ml/hr. Abd. benign. Minimal UOP overnight, pt. given 500ml bolus, urine lytes sent.\n\nEndo: Insulin given per RISS\n\nSkin: Scalp sutures CDI as noted.\n\nSocial: Family and multiple friends in to visit last evening, update to POC.\n\nPlan: Wean vent to PS/CPAP\nPain control/ Pt. comfort\nNeuro checks q2\nPt. and family support\n"
},
{
"category": "Nursing/other",
"chartdate": "2167-07-01 00:00:00.000",
"description": "Report",
"row_id": 1631385,
"text": "Addendum\nA-line very positional. redressed multiple times overnight.\n"
},
{
"category": "Nursing/other",
"chartdate": "2167-07-01 00:00:00.000",
"description": "Report",
"row_id": 1631386,
"text": "Respiratory care\npt received on A/C as noted. B.S. are coarse rhonchi. pt suctioned for moderate thick tan secretions. Pt placed on psv 10/5 during rounds, pt is tolerating well with VT 422-563cc and RR 15-29. Abgs on psv are within normal limits with good oxygenation. Plan to continue on PSV as tolerated at this time\n"
},
{
"category": "Nursing/other",
"chartdate": "2167-06-29 00:00:00.000",
"description": "Report",
"row_id": 1631375,
"text": "NPN 0700-1900\nPLEASE REFER TO CAREVUE FOR SPECIFIC DATA\n\nNEURO: off sedation. Best exam shows pt spontaneously opening eyes, localizes with RUE and LUE internally rotating to nailbed pressure. Both LE's withdraw to nailbed pressure. Strong cough and gag. + corneals, PERRLA 3mm and brisk. Pt nodded head multiple times during one exam though was not appropriate RN's with questions or commands50mcg Fentanyl x2 with good pain control.No commands followed. Dilantin changed to PO.\n\nCV: HR 80's-100, no ectopy, NSR. Arterial line dampened and positional, cuff correlates fairly well though. Pedal pulses easily palpable. Venodynes for prophlaxis-awaiting SQ Heparin approval N-.\n\nRESP: Remains on CMV-attempted to wean further however per Resp. pt didnt initiate any breathes when RSBI attempted earlier this am, no further weaning attmeptted as goal Co2 goal 35-40. Lungs clear and dim bibasilar, sm amts thick yellow secretions snxd. Pt biting on tube and coughing with any oral/facial stimuli, therefore ETT not rotated. VAP per protocol.\n\nGI:Abd soft with min. distension. Colace and senna given this am, + flatus though no BM yet. Replete with fiber at goal through OGT-no residuals.\n\nGU: Foley with marginal amber u/o Qhr. Urine 15-40cc/hr-team aware and ok with as goal is to run pt's fluid balance even. IVF KVO. K+ and phosphate repleted this am.\n\nENDO: No RISS coverage required.\n\nID: T-max 101.7, Tylenol given along with ice packs and fan, most recent temp down to 100.3. Cont on Kefzol for bolt.\n\nSKIN: Lg parietel lac with DSD-sm amt serosang. drainage. Both crani sites with new DSD's placed by N-, staples clean and intact, and appear WNl. JP drain also d/c by N- and site sutured. A-line dsg changed x2, draining mod amt serosang. drainage with frequent wrist flexion.Skin elsewhere is unremarkable.\n\nSOCIAL: Multiple family members and friends into visit throughout day. Pt's parents and uncle spoke with Dr. re: POC and CT scans. RN present and showed pt's uncle who is a radiologist CT scans. Family appropriately upset and coping fairly well>social work into speak with them.\n\n24 Y/O MALE S/P FALL DOWN 15 STAIRS WITH CLOSED HEAD INJURY AND HEAD LAC. TAKEN TO OR FOR CRANI THEN TAKEN BACK SHORTLY AFTER DUE TO EPI BLEED. NEURO EXAM STABLE.\n\n\nPOC: Cont Q2 Neuro checks-monitor icps\n maintain bp <160\n ? repeat head ct tommorow\n update and support family on pOC\n ? trach/peg/ivc filter later this week\n\n\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2167-06-29 00:00:00.000",
"description": "Report",
"row_id": 1631376,
"text": "Respiratory\nPt received on AC with no changes this shift. psv was trialed for total 12 minutes, patient hypoventilated to rate 0f 7bpm. Md wants co2 range from 35-40mmhg. bs coarse, but clears with suctions. Plan to continue with current settings and wean as Abgs permits.\n"
},
{
"category": "Nursing/other",
"chartdate": "2167-06-29 00:00:00.000",
"description": "Report",
"row_id": 1631377,
"text": "NPN addendum\nDuring turn at 18:30, pt' bolt cathetert became dislodged. Bolt site and original dsd remain in place, sterile guaze was immediately placed over remaining plastic catherter adn clamped. Dr aware adn notifie dN- who are to come by to evaluate.\n"
},
{
"category": "Nursing/other",
"chartdate": "2167-06-30 00:00:00.000",
"description": "Report",
"row_id": 1631378,
"text": "Nursing (1900-0700)\nNeuro exam Q2hrs without variation. Right pupil slightly larger than left (3.5mm), brisk bilaterally. Pt. opening eyes when coughing, and to noxious stimuli this a.m. Right arm most purposeful and localizing pain. Left arm intermittently localizes or withdraws, and rarely extends with minimal inward rotation and fingertip abduction. LE's briskly withdraw to nailbed pressure. Pt. intermittently sucking on ETT, often bites ETT or oral swabs when agitated. Fentanyl given as noted for pain and/or agitation with excellent effect. Bolt removed from skull by neurosurg this early a.m. At 2200, pt. had a forceful coughing spell, then full body shivering. His breathing pattern changed, RR was 24 for few moments, deep and irregular. HR 120, BP up to 170's. HO and neurosurg made aware. Pt. was given fentanyl and 20mg IV labetolol with resolution of hyperdynamcis and symptoms noted. No further episodes. Pt. cont's to have low grade fevers treated with tylenol, fan, ice packs to axilla.\n\nSince episode noted above, Aline with underdampted waveform; with stopcock open to all three ports waveform wnl and correlates with cuff pressures. VSS. HR down to 59 during coughing spell, ?loss of Pwave briefly, ?valsalva - HO aware.\n\nPt. tolerating present vent settings with stable gas. Secretions as noted, becoming tan/foul this a.m.\n\nNo BM yet, though abd. soft/benign. Awaiting cxr for OGT confirmation to resume TF's as previous tube became clogged this a.m.\n\nPt's family in last eve, asking various questions. Parents have called X3 overnight to check in. ? if family meeting would be appropriate for formal update. SS involved. Friends in last eve, pt. with many supports.\n\nA/P:\nPrognosis unknown at this time, day 4 s/p severe closed head injury.\nContinue to monitor neuro exam closely. Optimize pt. comfort and safety. Keep SBP <160. Follow temp curve, culture data. Family support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2167-06-30 00:00:00.000",
"description": "Report",
"row_id": 1631379,
"text": "Respiratory Care\nPt Device: pt orally intubated on full ventilatory support, no changes made to vent t/o the shift. RSBI attempted this AM, pt became very agitated.\n\nChest: BBS coarse, pt has good cough, clearing secretions into swivel, sx for moderate amt of thick yellow secretions.\n\nGas Exchange: ABG shows a Metabolic Alkalosis.\n\nPlan: Monitor and support, wean as tolerated\n"
},
{
"category": "Nursing/other",
"chartdate": "2167-06-30 00:00:00.000",
"description": "Report",
"row_id": 1631380,
"text": "NPN 0700-1900\nPLEASE REFER TO CAREVUE FOR EXACT DATA\n\n\nNEURO: Exam much brighter today. Opens eyes for prolonged periods of time-at times will visually track speaker, and during 2 exams nodded head either yes/no appropriately in response to speaker. Appears to be attempting to follow commands but ? physically unable to, such as giving thumbs up, sticking out tongue, wiggling toes. Localizes with RUE to noxious stimuli, attempts to with LUE as well-though more of a withdrawal response. Withdraws both LE's to nailbed pressure. Strong cough and gag. PERRLA 3-4mm and briskly react. Dilantin bolus given in divided doses this afternoon. Medicated with 50mcg Fentanyl for pain control.\n\nCV: HR 70's-90's NSR, no ectopy. BP 130's-150's (up to 160's with agitation). Pedal pulses strong and palpabale. Skin warm and slightly flushed at times. SQ Heparin and venodynes for DVT prophalxis.\n\nRESP: Attempted PSV trial this am, pt RR 8 BPM, though Vts remained on lower side, so pt placed back on CMV. Resp to attempt trial later this evening. Pt more aware of ETT now, and when fully awake goes into violent coughing fits due to ETT. Bite block placed after pt found to be biting down on ETT/pilot. Lungs still clear and dim bibasilar, sm amt thick yellowish/tan scolored secretions sxnd.\n\nGI: Abd soft and distended, +BS. Replete with fiber cont through OGT with min residuals. After turning pt this afternoon he spit up a sm amt ? tubefeed/sputum -like subastance (? due to Dilantin bolus) He didnt appear to aspirate, and per auscultation OGT appears to be in place (MD notified). Senna and colace given this am with no result in BM, cont to pass flatus. Dulcolax supp.to be given this afternoon.\n\nGU: Foley with adequate clear yellow u/o Q hr. Given 10 mg Lasix x2 with excellant response to first dose.Pt trending neg 500cc thus far and 2nd lasix dose just given. Hl'd. PM lytes sent.\n\nSKIN:R sided crani staples and parietal lac staples slightly pink but no drainage noted. L sided crani staples appear WNL. All staple sites OTA and cleansed with NS. R eye remains ecchymotic, but swelling has decreased from yesterday. Buttocks slightly pink-no breakdown noted.Turned Q2. (2) PIVs patent. A-line site WNl-no bloody drainage noticed today.\n\nENDO: Blood glucose 113-164, coverage per RISS provided.\n\nID: T-max 100.3, tylenol given Q4-6hrs. Cefazolin d/c post bolt removal.\n\nSOCIAL: Multiple family members and friends into visit throughout day. Family reminded of visisting rules re: hours and number of visitors, however family non-compliant with at times. Family reports they are pleased with pt's progress though still appropriately concerned. Social work not in today, but did meet with them yesterday.\n\nPOC: MRI PLANNED FOR EARLY THIS EVENING TO FURTHER EVAL STROKE\n MONITOR NEURO EXAMS Q2\n GOAL FLUID BALANCE -1L\n MAINTAIN BP <160 WITH PRN LOPRESSOR\n CONT. ANYTIPYRETIC MEASURES-F/U CXS\n PULM. HYGIENE/CONT TO WEAN VENT AS TOL-? EXTUBATE TOMMORROW\n UPDATE FAMILY AND PROVIDE EMOTI\n"
},
{
"category": "Nursing/other",
"chartdate": "2167-06-30 00:00:00.000",
"description": "Report",
"row_id": 1631381,
"text": "NPN 0700-1900\n(Continued)\nONAL SUPPORT-SW F/U\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2167-06-27 00:00:00.000",
"description": "Report",
"row_id": 1631366,
"text": "T/SICU Nursing Admission Note\n is a 24 year old man admitted to the T/SICU from the OR following a L crainiectomy and placement of monitor. Pt. apparently fell down 15 steps at a station, sustained a R parietal laceration. Pt. GCS was 3 at the scene and he was intubated and transported to . CT revealed a r parietal intracerebral hemorrhage and a L frontal countercoup injury with beginning of uncal herniation and swelling.\n\nPMH: s/p pyloroplasty at age 7 months\nAllergies: bees, nkda\n+smoker, +etoh usage.\nPt. works downtown in finance.\nSocial: Pt. lives in with roommates ( and ), has a girlfriend . Parents live in , have been notified and are on their way and will arrive Sunday night. Uncle is a radiologist and lives in and will make medical decisions during the parents travel.\n\nNeuro: Pt. initially with minimal response neurologically. ICP 1-4, then rose to 10 with dampened waveform. PERRLA @ 3mm. Dilantin load completed in OR @ 1 am. Pt with +cough, minimal gag, weak corneals. Flexes to painful stimuli, R>L. Repeat CT of head completed at 6am which revealed a new R sided epidural bleed. Pt. returned to OR for evacuation. L side JP with bloody drainage. Propofol given at low dose\nCVS:stable heart rate and rhythm.\n RESP: orally intubated, suctioned for bloody secretions. Breath sounds clear.\nRENAL:ns @ 70/hr, urine output brisk\nGI: og with bilious output, pepcid for prophylaxis.\nheme: hct 28, p boots in use, platelets give per order\nid: afebrile, given ancef at 1am\nskin: R parietal lac with stable, draining bloody drainage, L sided crainiotomy incision with or dressing. Other skin intact\nsocial: friends visited. Family enroute as described above. Pt. grew up in , went to college in and works in .\n police were here to investigate this incident.\nLines: R sided bolt, R radial art line, Bilateral 16g angios in place\nA: unfortunate 24 year old man with devastating head injury, now new rebleed and poor neuro exam\nP:Continue measures to decrease icp, continue to follow neuro exam closely, support measures to maintain cpp. Support family with information and emotional support.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2167-06-27 00:00:00.000",
"description": "Report",
"row_id": 1631367,
"text": "T-SICU NPN 0700-1900\nPlease see carevue for specifics.\n\nEvents: to OR this am for evacuation of R epidural bleed. Nicardipine initiated, titrated to goal SBP <140.\nROS:\nNeuro: Propofol off. Pupils equal, 2mm, sluggish. +corneals, cough, impaired gag. Posturing BLE's, lifting BUE's, ?towards ett to noxious stimuli. Does not follow commands or open eyes. Conts. dilantin 100mg q8hrs.\nCV: HR 70-80's SR, nicardipine titrated to goal SBP <140. Skin cool, dry. Pedal pulses palpable. PB's for prophylaxis, ? IVC filter placement.\nAccess: PIV x2 wnl, R radial a-line with +fling, changed over wire.\nResp: LS clear, suctioned for scant to sm. amts. brownish/blood tinged sputum. Conts. AC 550x18/5/40%, abg wnl, rare breath over vent.\nGI: abd soft, ND, BS absent to very faint, NPO. OGT to LCWS for brown/bilious drainage. Pepcid for prophylaxis.\nGU: foley patent draining adequate amts. yellow urine, approx. 100-200cc/hr. Lytes repleted.\nEndo: BS 93, 118, no coverage per sliding scale.\nID: tmax 101.4, conts. tylenol prn, fan on.\nSkin: back/buttocks intact. R parietal lac. with staples intact, sm. amts. serosang. drainage on pillow/pad. L craniectomy site with mod. amt. old drainage on dsg. R side epidural bleed evac. site with DSD C/D/I. Increasing facial swelling, ecchymosis blooming to R eye.\npsych/social: friend , , girlfriend and few other friends in this afternoon. will be spokesperson for friends until family arrives; parents updated via phone by Dr. this am (they are en route from ), uncle due to arrive at airport approx. 6pm this eve. SW spoke briefly with girlfriend for support, SW aware of parents scheduled arrival for Sunday night. Affects/questions appropriate, emotional support provided.\nA: 24yo s/p evac. of epidural hematoma requiring nicardipine to maintain SBP <140\nP: Monitor VS, I/O, labs, neuro checks q2hrs. Cont. aggressive pulmonary hygiene/skin care. Titrate nicardipine to goal SBP <140. Repeat head CT in am. Cont. ongoing open communication, comfort, and support to and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2167-06-27 00:00:00.000",
"description": "Report",
"row_id": 1631368,
"text": "pt kept on full support and high Vm in order to keep paCo2 btween 35 and 40. Very strong cough despite sx of minimla secretions. plan to continue with current settings through PM and revaluate in AM rounds.\n"
},
{
"category": "Nursing/other",
"chartdate": "2167-06-28 00:00:00.000",
"description": "Report",
"row_id": 1631369,
"text": "T/SICU Nursing Progress Note\nReview of systems\nNeuro: Pt. remains off sedation. Spontaneously turns head side to side and away from stimulus. Opened eyes X 1 with turning. Makes sucking motions with mouth. +corneals, cough, gag reflexes. At times is purposeful with hands (feels cheek, scratches nose). Varies from extending legs to pain to withdrawing feet from pain. bolt remains in place with icp 3-9. L crainiectomy flap soft. Pupils equal, somewhat sluggish to light. Pt. vigorously resists exam now. Continues on dilantin (am level pending). Fentanyl 25mcg given X2 as pain is difficult to assess as a cause for his tachycardia. L sided jp drain to bulb suction\nCVS: sinus tach, resting rate 100-120, with stimulation may go as high as 170's! Continues to be on nicardipine to maintain sbp <140.\nRESP: remains intubated with thick blood tinged secretions. Coarse breath sounds. Adequate abgs. Mouth care per vap protocol\nRenal: adequate urine output. NS @ 70cc/hr, Lytes repleted per orders\nGI: belly soft, bilious output, on pepcid\nendo: bs slightly elevated @ 160's-170\nID: on kefzol because of . Temp to 101.4, wbc 15\nHeme: hct stable, venodynes in use.\nskin: crainotomy incisions with small amount of drainage, R parietal head laceration with small amount of serosanginous drainage\nIVS: two new peripheral ivs place, art line dampens with patient movement.\nSocial: pt with multiple friends, roommates visiting, uncle is here from . Father called from and they are in the process of a long journey here, plan to arrive in at 2:30pm and at at 3:30pm.\nA: slight improvement in neuro status s/p fall with intercranial bleed, swelling requring crainectomy, crainiotomy and icp placement. Fever ??aspiration vs blood in head, tachycardia\nP: consider using beta blockers to blunt catecholamine response, repeat head ct this am, follow neuro exam, ??need to culture for temp and elevated wbc. Tighten sliding scale. Continue to provide emotional support for family and friends.\n"
},
{
"category": "Nursing/other",
"chartdate": "2167-06-28 00:00:00.000",
"description": "Report",
"row_id": 1631370,
"text": "Respiratory Care\nNo changes made to vent t/o the noc. BBS clear, sx for small amouont of thick bloody secretions, No RSBI this AM. ABG shows a normal acid base balance. Will continue to monitor and support, wean as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2167-06-28 00:00:00.000",
"description": "Report",
"row_id": 1631371,
"text": "T-SICU NPN 0700-1900\nPlease see carevue for specifics.\nROS:\nNeuro: Off sedation. Pupils sluggish, reactive, +gag and cough. Arousable to noxious stimuli, withdraws BLE's to nailbed pressure, +spontaneous, non-purposeful movement of BUE's, withdraws and reaches purposefully towards ett/face during mouth care/suctioning. Does not follow commands. Opening eyes with turning, occasionally with oral care. ICP 7-10. JP with mod. amts. serosang. drainage (more clear than yesterday). CT this am improved per Dr. . Conts. dilantin 100mg q8hrs.\nCV: HR 110-120's, currently 90-110's ST after 5mg IV lopressor. Nicardipine weaned off, maintaining goal SBP <160. Skin cool, dry. Pedal pulses palpable. PB's for prophylaxis.\nAccess: PIVx3 wnl, sm. amt. old blood at R ac insertion site. R radial a-line wnl.\nResp: LS coarse to clear, suctioned for sm. to mod. amts. thick yellow/tan secretions. No vent changes made.\nGI: abd soft, ND, BS+, no stool. Replete with fiber started, advancing to goal 75cc/hr. Pepcid for prophylaxis.\nGU: foley patent draining adequate amts. clear, yellow urine. Lytes repelted. Plan to saline lock IV once TF at goal.\nEndo: BS 129, 119, covered per sliding scale.\nID: tmax 101.5po, wbc 15 this am. Pan cultured. Conts. cefazolin.\nSkin: lac. to back of head with staples intact, sm. amt. serosang. drainage. R crani site with dsd intact, no new drainage. L crani site OTA, dsg removed by neurosurg. Back/buttocks intact.\nPsych/social: pt's parents arrived after long journey from today; appropriately distraught/concerned, emotional support provided. Father updated via phone by Dr. . SW check in with parents. Cont. ongoing support.\nA: s/p crani with slightly improved neuro exam, maintaining SBP<160 off nicardipine\nP: Monitor VS, I/O, labs, neuro checks q2hrs. Adv. TF to goal. ? IVC filter placement this week. Cont. aggressive pulmonary hygiene/skin care. Cont. ongoing open communication, comfort and support to pt and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2167-06-28 00:00:00.000",
"description": "Report",
"row_id": 1631372,
"text": "pt remained on full vent support in order to ensure PaCo2 is kept low. sx'd for minimal secretions. plans to be revaluated in AM rounds.\n"
},
{
"category": "Nursing/other",
"chartdate": "2167-06-29 00:00:00.000",
"description": "Report",
"row_id": 1631373,
"text": "Respiratory Care\nPt Device: Pt remains orally intubated on full ventilatory support, FiO2 weaned to 30% t/o the noc, no other changes made to vent. RSBI attempted this AM, no response from pt. Pt transported to CT this AM.\n\nChest: BBS clear, sx for mod amt of thick yellow secretions.\n\nGas Exchange: ABG this AM shows a metabolic alkalosis.\n\nPlan: Monitor and support, wean as tolerated\n"
},
{
"category": "Nursing/other",
"chartdate": "2167-06-29 00:00:00.000",
"description": "Report",
"row_id": 1631374,
"text": "T/SICU Nursing Progress Note\nS:\nO: Review of systems\nNeuro: Pt. continues with bolt with dampened waveform and icp 5-7, occasionally up to teens with coughing or when hob flat for turning. Pt. moving arms and legs spontaneously (R>L) and purposefully (scratches face, crosses legs). Intermittently opens eyes especially with coughing, etc. At one point he opened his eyes and looked at his four friends who were visiting and nodded his head. Pupils equal but somewhat sluggishly reactive. +cough,corneals, gag. L crainiectomy site soft. Head JP drain with serosanginous drainage which is decreasing in amount. Continues on dilantin, am level pending (yesterday's level 12). Repeat head ct done 6am.\nCVS: lopressor X 1 to keep sbp <160, heart rate 70's-120's.\nRESP: increased secretions, yellow in color. Coarse breath sounds. Adequate abg. Currently on a/c 18X550 30% 5peep. Mouth care per vap protocol\nRENAL: urine output 20-30cc/hr dark amber. Weight down to 71kg, I&O yesterday approximately even. K+ and PO4 levels a little low, awaiting repletion orders.\nGI: tube feeding of fs replete with fiber advanced to goal of 75cc/hr with minimal residual. On pepcid, also receiving 30cc free water flushes q 4 hours. Belly soft, bowel sounds present. To start colace this am.\nendo:ssri, bs 130's\nHeme: hct stable, venodynes on\nID: febrile to 102 and has not deferesced despite tylenol, cool bath, and fan. WBC down to 12 (15). On kefzol due to bolt. Pan cultured yesterday\nskin: L crainectomy incision open to air, small amount of serosanginous oozing, R parietal laceration slightly macerated with serous oozing, R sided crainiotomy incision with original or dressing in place, other skin intact\nSOCIAL: mom, dad, and uncle here at beginning of shift. The left for the night and mom checked in once overnight. Social work met with them briefly before they left. Multiple friends visited on evenings.\nPt. with large social network.\nIV: two 20g angios and R radial art line in place, small amount of bleeding from radial art line.\nA: improved neuro status. Fever continues with no positive cultures todate but increasing sputum is worrisome for pulmonary process. Family very concerned but adequately coping at present. Tolerating tube feedings at goal\nP: Continue to closely follow neuro status. Check dilantin level (??consider switching to po dilantin). Continue careful positioning because of crainial flap. Continue to support family and friends with information as appropriate. Promote continued family/physician . Follow cultures and fever curve. ??CXR to assess for pulmonary process.\n"
},
{
"category": "Nursing/other",
"chartdate": "2167-07-03 00:00:00.000",
"description": "Report",
"row_id": 1631393,
"text": "T/SICU Nursing Progress Note\nS:\nO: Review of systems\nNeuro: sleeping in naps. Wakes, focuses on speaker. Purposefully moves R arm >L, L leg >R. Speaks rarely, but nods to questions. But neuro exam waxes and wanes. On kepra. +strong cough, corneals, gag. L sided crainectomy site soft. Perrla.\nCVS: hr 80's-120's, bp 130-150. Pulses present\nRESP: remains extubated with no supplemental oxygen. Strong productive cough of tan sputum. At times lungs coarse.\nRENAL: receiving lr @60cc/hr. Lytes wnl.\nGI: belly soft, no further c/o nausea. On famotidine. Dobhoff in place and will start tube feeds this am. Ducolox supp given with no results so far.\nHeme: hct stable, on sc heparin and venodynes\nID: temp to 101.8, receiving motrin and acetominophen alternately for control of temp. Also using fan in room. WBC remains flat at 9.4, all cultures have been negative to date. On no antibiotics.\nskin: head incisions open to air with no drainage, other skin intact.\nLines: r radial art line and L forearm peripheral iv in place\nsocial: parents and friends in on evenings, all thrilled with progress pt has made. Uncle from called for update. Parents are planning to visit later today to assess for possible rehab placement.\nA: 24 y/o s/p fall with ich, crainiectomy. Persistent fevers with flat white count ??due to dilantin, vs blood in head\nP: Restart tube feeds this am. PT and OT consults. Pt. requires helmet to get out of bed. Rehab screen.\n"
},
{
"category": "Nursing/other",
"chartdate": "2167-07-03 00:00:00.000",
"description": "Report",
"row_id": 1631394,
"text": "Addendum to transfer note:\nPt noted to have yellow breakdown in tissue to L inner lower lip.\nPt also noted to have pink linear area to back of neck; ? r/t ett tape vs.helmet? No breakdown noted, OTA with relief of any pressure. Pt transferred to 1120, report given to RN. RN\n"
}
] |
14,974 | 150,368 | Patient is a 79 year old right handed woman with past medical history of hypertension, hypercholesterolemia who was transferred from Hospital after acute onset of wobbly gait, nausea/vomiting, and decreased level of responsiveness. Head CT at revealed large subdural hemorrhage with subfalcine herniation. On initial exam, there was evidence of brainstem compression with absent pupillary, corneal, oculocephalic and oculovestibular responses, as well as absent gag reflex. Minimal respiratory effort above the ventilator. She had extensor and triple flexion responses to pain. She was evaluated by Neurosurgery at the time of transfer. Due to absent brainstem reflexes at presentation, she was felt not to be a surgical candidate. The extent of injury was discussed with her family. Transitioned to comfort measures only status on at 7:30pm. Maintenance IVF were discontinued, the patient was extubated, and a morphine drip was initiated for comfort. On at 2:08pm, the patient was pronounced dead after cardiorespiratory arrest. Her brother was at the bedside; her husband was notified via telephone. Due to trauma as a likely cause of the patient's subdural hemorrhage, the medical examiner was notified. Plan for autopsy by the medical examiner on . The patient's family is aware of this plan. | There is incipient left uncal herniation. no edema.Respir: Lungs are coarse to clear and diminished bil at bases. No stool this shift.GU: foley, c/y/u.SKIN: left outer orbital abrasion with small scab no drainage. Suctioned rarely for thivk yellow/tan secretions. Please see carevue for specifics.Neuro: Pupils are unequal and nonreactive. LS COARSE/RHONCHI WITH MOD AMT OF UPPER AIRWAY SECRETIONS, SXN PRN FOR COMFORT SPO2 DROPPED TO 80s, 50-60 sec PERIODS OF APNEA NOTED. Postures upper ext, withdraws lower ext, +gag, -cough.Cardio: NSR with PVC's and PAC's. TECHNIQUE: Head CT without contrast. Sinus rhythm with atrial premature complex and ventricular premature complexesLeft atrial abnormalityNonspecific intraventricular conduction delay with left axis deviation - inpart left anterior fascicular blockLeft ventricular hypertrophy with ST-T abnormalitiesThe ST-T wave abnormalities are diffuse with Probable QT interval prolongedalthough is difficult to measure - clinical correlation is suggestedNo previous tracing available for comparison B/S dim. Pt noted to have no respirations. Slight over breathing by 3-4 bpm.GI: soft, +bsx4, NGT to LWCS with brown bilious drainage. A small amount of fluid is visualized in the right maxillary sinus. There is distortion and dilatation of the ventricular system. SBP 110-120s, HR 80s-90s NSR, NO ECTOPY. FINDINGS: There is a 23 mm thick mixed density convexity subdural hematoma on the left side. Left pupil is 7mm and right 5-6mm. CMV: Peep 0, FiO2 .50, Vt .450, rate 14. The surrounding osseous structures are unremarkable. 13:40pm pt noted to have no heart rate, and no blood pressure. NURSING NOTESEE CAREVUE FOR SPECIFICS:CMO ON MORPHINE GTT TITRATED TO 9MG/HR THIS SHIFT FOR OBVIOUS RESP DISTRESS. No central access. WILL CONTINUE WITH COMFORT MEASURES, TITRATE MORPHINE GTT AND PROVIDE EMOTIONAL SUPPORT TO FAMILY. IMPRESSION: Large left subdural hematoma with significant mass effect causing subfalcine and incipient uncal herniation. SBP 110-130's. Pt DNR/ brother present at bedside. 2:28 AM CT HEAD W/O CONTRAST Clip # Reason: eval bleed in comparison to prior MEDICAL CONDITION: 79 year old woman with ICB REASON FOR THIS EXAMINATION: eval bleed in comparison to prior No contraindications for IV contrast WET READ: AZm MON 2:56 AM Large left SDH with subfalcine and uncal herniation FINAL REPORT INDICATION: 79-year-old woman with intracranial hemorrhage. Respiratory Care Pt continues on full ventilatory support no changes made today. COntinue to monitor neuro, vs, offer emotional support to family. The -white differentiation is preserved. bruise on left hip, right inner thigh, and left knee.POC: Potential for CMO, awaiting family meeting with Neuro Med team. There is extensive mass effect with a 16 mm shift of normally midline structures to the right. Social Worker and aware of pending CMO. Will continue to follow closely. | 6 | [
{
"category": "ECG",
"chartdate": "2181-11-12 00:00:00.000",
"description": "Report",
"row_id": 211605,
"text": "Sinus rhythm with atrial premature complex and ventricular premature complexes\nLeft atrial abnormality\nNonspecific intraventricular conduction delay with left axis deviation - in\npart left anterior fascicular block\nLeft ventricular hypertrophy with ST-T abnormalities\nThe ST-T wave abnormalities are diffuse with Probable QT interval prolonged\nalthough is difficult to measure - clinical correlation is suggested\nNo previous tracing available for comparison\n\n"
},
{
"category": "Radiology",
"chartdate": "2181-11-12 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 883519,
"text": " 2:28 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval bleed in comparison to prior\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with ICB\n REASON FOR THIS EXAMINATION:\n eval bleed in comparison to prior\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: AZm MON 2:56 AM\n Large left SDH with subfalcine and uncal herniation\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 79-year-old woman with intracranial hemorrhage.\n\n TECHNIQUE: Head CT without contrast.\n\n FINDINGS: There is a 23 mm thick mixed density convexity subdural hematoma on\n the left side. There is extensive mass effect with a 16 mm shift of normally\n midline structures to the right. There is distortion and dilatation of the\n ventricular system. There is incipient left uncal herniation. The -white\n differentiation is preserved. The surrounding osseous structures are\n unremarkable. A small amount of fluid is visualized in the right maxillary\n sinus.\n\n IMPRESSION: Large left subdural hematoma with significant mass effect causing\n subfalcine and incipient uncal herniation.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2181-11-12 00:00:00.000",
"description": "Report",
"row_id": 1457217,
"text": "Respiratory Care\n\n Pt continues on full ventilatory support no changes made today. B/S dim. Will continue to follow closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2181-11-12 00:00:00.000",
"description": "Report",
"row_id": 1457218,
"text": "Please see carevue for specifics.\n\nNeuro: Pupils are unequal and nonreactive. Left pupil is 7mm and right 5-6mm. Postures upper ext, withdraws lower ext, +gag, -cough.\n\nCardio: NSR with PVC's and PAC's. SBP 110-130's. No central access. no edema.\n\nRespir: Lungs are coarse to clear and diminished bil at bases. Suctioned rarely for thivk yellow/tan secretions. CMV: Peep 0, FiO2 .50, Vt .450, rate 14. Slight over breathing by 3-4 bpm.\n\nGI: soft, +bsx4, NGT to LWCS with brown bilious drainage. No stool this shift.\n\nGU: foley, c/y/u.\n\nSKIN: left outer orbital abrasion with small scab no drainage. bruise on left hip, right inner thigh, and left knee.\n\nPOC: Potential for CMO, awaiting family meeting with Neuro Med team. COntinue to monitor neuro, vs, offer emotional support to family. Social Worker and aware of pending CMO.\n"
},
{
"category": "Nursing/other",
"chartdate": "2181-11-13 00:00:00.000",
"description": "Report",
"row_id": 1457219,
"text": "NURSING NOTE\nSEE CAREVUE FOR SPECIFICS:\n\nCMO ON MORPHINE GTT TITRATED TO 9MG/HR THIS SHIFT FOR OBVIOUS RESP DISTRESS. LS COARSE/RHONCHI WITH MOD AMT OF UPPER AIRWAY SECRETIONS, SXN PRN FOR COMFORT SPO2 DROPPED TO 80s, 50-60 sec PERIODS OF APNEA NOTED. SBP 110-120s, HR 80s-90s NSR, NO ECTOPY. BROTHER AT BS MOST OF NIGHT. WILL CONTINUE WITH COMFORT MEASURES, TITRATE MORPHINE GTT AND PROVIDE EMOTIONAL SUPPORT TO FAMILY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2181-11-13 00:00:00.000",
"description": "Report",
"row_id": 1457220,
"text": "Pt DNR/ brother present at bedside. 13:40pm pt noted to have no heart rate, and no blood pressure. Pt noted to have no respirations.\n"
}
] |
30,659 | 144,818 | 57-year-old woman with HCV cirrhosis and ESLD with ascites, varices, gastropathy was transferred from OSH for further management of ESLD and hepatic encephalopathy. . # ESLD: Because of refractory ascites, the patient underwent multiple paracenteses then TIPS on with post-TIPS course complicated by hematocrit drop requiring blood transfusions. After TIPS, the patient had more paracenteses with albumin administration. She was given lactulose and rifaximin during this stay. Her mental status improved to baseline by discharge. Her grade three esophageal varices were banded on . She initially had significant post-banding epigastric discomfort, which then quickly resolved. . # Portal vein thrombus: non-occlusive PV thrombus seen on CT abd/pelvis done for liver transplant work-up. Most likely acute thrombus as now seen on liver u/s and was not seen on U/S on admission. Anticoagulation was started initially, however stopped due to BRBPR. . # Left shoulder pain: acromial spur on Xray. Her pain was controlled with hydromorphone and lidocaine patch. . # ARF: Likely secondary to hepatorenal syndrome. Her creatinine gradually trended down by discharge. Nephrology was consulted and saw no indication for a combined liver/kidney transplant. . # Pancytopenia: Most likely secondary to ESLD. Per past records, HCt appeared below baseline. All cell lines low but stable. . # DM2: stable FS. She was continue on an insulin SC regimen. | CT OF THE ABDOMEN WITHOUT AND WITH INTRAVENOUS CONTRAST: Linear opacities at the lung bases including right middle and lower lobes are consistent with atelectasis. The patient is noted to be status post cholecystectomy. The patient is noted to be status post cholecystectomy. A suitable spot was marked in the right lower quadrant for paracentesis. METHOD: Resting perfusion images were obtained with Tc-m sestamibi. OR THERAPEUTIC; GUIDANCE FOR /ABD/PARA CENTESIS USClip # Reason: Please do liter diagnostic and therapeutic paracentesis. FINDINGS: In the interim, a TIPS stent has been placed projected over the right upper quadrant. A suitable spot in the right lower quadrant was selected for ultrasound-guided therapeutic paracentesis. Nonocclusive thrombus involving the main and a portion of the left and right portal veins. Right hemidiaphragm is raised, and there is suggestion of a right basal effusion and atelectasis. REASON FOR THIS EXAMINATION: Please do liter diagnostic and therapeutic paracentesis. Evaluate for acute process and mark suitable spot for paracentesis. TECHNIQUE: Supine and upright radiographs of the abdomen were performed as per departmental protocol. An area in the left lower quadrant was marked for paracentesis. An area in the left lower quadrant was marked for paracentesis. An area in the left lower quadrant was marked for paracentesis. An area in the left lower quadrant was marked for paracentesis. FINDINGS: Again is a shrunken nodular liver with heterogeneous coarsened echotexture consistent with the known history of cirrhosis. Subcutaneous gas in the right mid abdominal wall is noted (3A:117). Conventional hepatic arterial anatomy. Conventional portal venous anatomy. The right hemidiaphragm is raised, and there is suggestion of a right basal effusion and atelectasis. OR THERAPEUTIC; GUIDANCE FOR /ABD/PARA CENTESIS USClip # Reason: pls perform therapeutic para on . The patient is status post cholecystectomy. REASON FOR THIS EXAMINATION: Please evaluate for bleeding s/p TIPS - patient with Hct decrease to 18.9 s/p procedure. Coronal and sagittal reformatted images are provided. CONTRAST: Intravenous nonionic contrast. Right upper quadrant ascites is incompletely imaged. IMPRESSION: Successful ultrasound-guided therapeutic paracentesis with removal of two liters of serosanguineous fluid. A small area of hyperdensity is noted within the right lobe of the liver presumably related to contrast injection during the TIPS procedure. Diffuse stranding in the subcutaneous tissues is present consistent with anasarca. This is a limited examination, It was centered in the thoraco-abdominal junction. Course c/b hepatorenal syndrome which is slowly resolving. 1% lidocaine was used for local anesthesia. 1% lidocaine was used for local anesthesia. 1% lidocaine was used for local anesthesia. 1% lidocaine was used for local anesthesia. 1% lidocaine was used for local anesthesia. COMPARISONS: CT of the abdomen and pelvis dated . Minimal-to-absent flow within the left portal vein and non-occlusive thrombus within the distal main and posterior right portal veins. Please remove one to two liters for therapeutic and diagnostic paracentesis. There is peripheral non-occlusive thrombus within the distal main portal vein and non-occlusive segmental filling defects within the posterior branch of the right portal vein. The needle was removed, and a 0.035 Glidewire was advanced through the catheter, and access was gained into the main portal vein. A 0.035 wire was advanced through the micropuncture sheath into the inferior vena cava under fluoroscopic guidance. REASON FOR THIS EXAMINATION: only 1.5L removed w/ beside para, marked spot; needs more fluid removed FINAL REPORT STUDY: Paracentesis. The catheter was then removed and adequate hemostasis was achieved. Syncope.Height: (in) 63Weight (lb): 175BSA (m2): 1.83 m2BP (mm Hg): 108/68HR (bpm): 73Status: InpatientDate/Time: at 15:56Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Mild LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.LEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/globalsystolic function (LVEF >55%). The right internal jugular vein was accessed with a micropuncture kit system under ultrasonographic guidance. also with HRS resolving REASON FOR THIS EXAMINATION: Please perform on /08please perform THERAPEUTIC paracentesis for 4L fluid removal (maximum) only. Moderate to severe [3+] TR.Borderline PA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR.PERICARDIUM: No pericardial effusion.Conclusions:The left atrium is mildly dilated. REASON FOR THIS EXAMINATION: Please perform (4L) therapeutic paracentesis FINAL REPORT INDICATION: Refractory ascites requiring paracentesis status post TIPS on . 1% lidocaine was used for local anesthesia. 1% lidocaine was used for local anesthesia. 1% lidocaine was used for local anesthesia. 1% lidocaine was used for local anesthesia. IMPRESSION: Successful therapeutic paracentesis with removal of 4 L of serosanguineous ascites. Two passes with a 19-gauge catheter were made with successful removal of 4 L of serosanguineous ascitic fluid. Access was gained into the middle hepatic vein with a combination of a 0.035 Glidewire and a headhunter catheter. she is hemodynamically stable and ?transfer back to 10 soon.pmh: esld hcv cirrhosis; esophageal varicies; portal htn; portal vein thrombus; depression; anxiety; gerd; iddm; seizure disorder; htn; osa; s/p cholyallergies: zanaflex-> hallucinationsreview of systemsrespiratory-> lung exam notable for rll crackles. Doppler examination demonstrates wall-to-wall flow within the TIPS with normal velocities as described above. The patient is status post cholecystectomy. Please perform therapeutic paracentesis. IMPRESSION: Successful therapeutic paracentesis with 7.1 liters of brown- clear fluid removed. Bed alarm on, 4 rails up, order obtained.skin: intact.Resp: sat 98% on RA.Access: DL PICC, #20 angio.A/P: Transfuse with blood products as ordered, follow serial hct, hepatic service following. FINAL REPORT TYPE OF EXAMINATION: Chest, AP portable, single view. ULTRASOUND-GUIDED THERAPEUTIC PARACENTESIS. Cont to monitor neuro status-lactulose as ordered/per stools. Moderate (2+)mitral regurgitation is seen. Admitting Diagnosis: HEPATITIS C;CIRRHOSIS;RENAL FAILURE Contrast: OPTIRAY Amt: 210 FINAL REPORT (Cont) main, right and left portal veins. | 30 | [
{
"category": "Radiology",
"chartdate": "2145-02-15 00:00:00.000",
"description": "ABDOMEN U.S. (COMPLETE STUDY)",
"row_id": 996134,
"text": " 8:43 AM\n ABDOMEN U.S. (COMPLETE STUDY) Clip # \n Reason: Evaluate for acute processes and level of ascited. PLEASE m\n Admitting Diagnosis: HEPATITIS C;CIRRHOSIS;RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with ESLD, ascites, syncope, transfer from OSH for further\n management\n REASON FOR THIS EXAMINATION:\n Evaluate for acute processes and level of ascited. PLEASE mark suitable spot\n for paracentesis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 57-year-old with ascites. Evaluate for acute process and mark\n suitable spot for paracentesis.\n\n COMPARISON: .\n\n RIGHT UPPER QUADRANT ULTRASOUND: The liver is shrunken and nodular consistent\n with cirrhosis. No focal intrahepatic masses are identified, and there is no\n intrahepatic ductal dilatation. The common duct is enlarged measuring 9 mm\n (previously 6 mm). The portal vein is patent with hepatopetal flow. The\n patient is status post cholecystectomy. Splenomegaly is again noted measuring\n up to 17 cm. There is a moderate-to-large amount of ascites, which appears to\n have increased compared to the prior exam. A suitable spot was marked in the\n right lower quadrant for paracentesis.\n\n IMPRESSION: Unchanged cirrhotic liver and splenomegaly. Moderate-to-large\n amount of ascites. A spot was marked in the right lower quadrant for\n paracentesis to be performed by the clinical team.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-02-16 00:00:00.000",
"description": "PERSANTINE MIBI",
"row_id": 996296,
"text": "PERSANTINE MIBI Clip # \n Reason: ESLD WORK-UP NEEDED FOR POSSIBLE TX R/O REVERSIBLE ISCHEMIA\n ______________________________________________________________________________\n FINAL REPORT\n\n RADIOPHARMECEUTICAL DATA:\n 10.6 mCi Tc-m Sestamibi Rest ();\n HISTORY:57 year old female with ESLD. The cardiac work up is required before\n liver transplant.\n\n SUMMARY OF DATA FROM THE EXERCISE LAB:\n\n Dipyridamole was infused intravenously for 4 minutes at a dose of 0.142\n mg/kg/min.\n\n METHOD:\n\n Resting perfusion images were obtained with Tc-m sestamibi. Tracer was\n injected approximately 45 minutes prior to obtaining the resting images.\n\n Stress images were not obtained as the patient left the exam room.\n\n Imaging protocol: Gated SPECT.\n\n INTERPRETATION of the rest images:\n\n Left ventricular cavity size is normal.\n\n Rest perfusion images reveal uniform tracer uptake throughout the left\n ventricular myocardium.\n\n The left ventricular wall motion and ejection fraction were not performed as\n they are obtained from exercise data base.\n\n No comparison is available.\n\n IMPRESSION:\n Limited study with no exercise data, as the patient quit the study. However rest\n images do not show any perfusion defect.\n\n\n , M.D.\n , M.D. Approved: 1:35 PM\n\n\n\n\n RADLINE ; A radiology consult service.\n To hear preliminary results, prior to transcription, call the\n Radiology Listen Line .\n"
},
{
"category": "Radiology",
"chartdate": "2145-02-23 00:00:00.000",
"description": "PARACENTESIS DIAG. OR THERAPEUTIC",
"row_id": 997415,
"text": " 10:09 AM\n PARACENTESIS DIAG. OR THERAPEUTIC; GUIDANCE FOR /ABD/PARA CENTESIS USClip # \n Reason: please remove 2L, no more than that as patient had recent HR\n Admitting Diagnosis: HEPATITIS C;CIRRHOSIS;RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with HCV cirrhosis a/w encephalopathy, developed hepatorenal\n syndrome s/p para\n REASON FOR THIS EXAMINATION:\n please remove 2L, no more than that as patient had recent HRS\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 57-year-old female with HCV cirrhosis. Please perform\n paracentesis to remove 2 liters.\n\n ULTRASOUND-GUIDED THERAPEUTIC PARACENTESIS: Targeted ultrasound of the\n abdomen in four quadrants demonstrates a large amount of ascites. Following\n discussion of risks and benefits of the procedure, written informed consent\n was obtained. The patient was prepped and draped in standard sterile fashion.\n A preprocedure timeout was performed to confirm the nature of the procedure\n and patient identity. A suitable spot in the right lower quadrant was\n selected for ultrasound-guided therapeutic paracentesis. 1% lidocaine was\n used for local anesthesia. Following a small skin incision, an 18-gauge \n catheter was inserted into the peritoneal cavity and approximately two liters\n of serosanguineous fluid was removed. The patient tolerated the procedure\n well with no immediate post-procedure complications.\n\n Dr. , the attending radiologist, was present and supervised the procedure.\n\n IMPRESSION: Successful ultrasound-guided therapeutic paracentesis with\n removal of two liters of serosanguineous fluid.\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-03-09 00:00:00.000",
"description": "PARACENTESIS DIAG. OR THERAPEUTIC",
"row_id": 999745,
"text": " 10:10 AM\n PARACENTESIS DIAG. OR THERAPEUTIC; GUIDANCE FOR /ABD/PARA CENTESIS USClip # \n Reason: pls perform therapeutic para on . note, pt is on hepari\n Admitting Diagnosis: HEPATITIS C;CIRRHOSIS;RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with ascites, ESLD HCV cirrhosis, hepatorenal syndrome,\n on liver transplant list.\n REASON FOR THIS EXAMINATION:\n Please do NOT remove any more than 2L (patient has HRS large volume tap;\n also now with creatinine 2.3 likely contrast nephropathy)\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: A 57-year-old female with ascites, end-stage liver disease\n secondary to hepatitis C, hepatorenal syndrome. Please remove two liters of\n ascites.\n\n COMPARISON: .\n\n ULTRASOUND-GUIDED THERAPEUTIC PARACENTESIS: Targeted son evaluation\n of the four quadrants demonstrates a large amount of ascites. An area in the\n left lower quadrant was marked for paracentesis. The risks and benefits of\n the procedure were explained to the patient and written informed consent was\n obtained. A preprocedure timeout was performed to confirm the nature of the\n procedure and identified the patient by name, medical record number and date\n of birth. The area was prepped and draped in standard sterile fashion. 1%\n lidocaine was used for local anesthesia. One pass with a 19-gauge \n catheter was made with removal of two liters of serosanguineous ascitic fluid.\n There were no immediate post-procedure complications. The patient tolerated\n the procedure well.\n\n Attending radiologist Dr. was present for the procedure.\n\n IMPRESSION: Successful therapeutic paracentesis with removal of two liters of\n ascites.\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-03-05 00:00:00.000",
"description": "PARACENTESIS DIAG. OR THERAPEUTIC",
"row_id": 999140,
"text": " 12:55 PM\n PARACENTESIS DIAG. OR THERAPEUTIC; GUIDANCE FOR /ABD/PARA CENTESIS USClip # \n Reason: please remove 1-2L (no more, had HRS following large volume\n Admitting Diagnosis: HEPATITIS C;CIRRHOSIS;RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with ESLD a/w encephalopathy and HRS, on liver transplant\n list, getting serial para's for symptom management\n REASON FOR THIS EXAMINATION:\n please remove 2L only\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 57-year-old female with end-stage liver disease, referred\n for paracentesis to remove 1-2 liters.\n\n COMPARISON: .\n\n ULTRASOUND-GUIDED THERAPEUTIC PARACENTESIS: Targeted son evaluation\n of the four quadrants demonstrates a large amount of ascites. An area in the\n left lower quadrant was marked for paracentesis. The risks and benefits of\n the procedure were explained to the patient, and written informed consent was\n obtained. A preprocedure timeout was performed to confirm the nature of the\n procedure and identify the patient by name, medical record number, and date of\n birth. The area was prepped and draped in a standard sterile fashion. 1%\n lidocaine was used for local anesthesia. One pass with a 19-gauge \n catheter was made with removal of two liters of brownish ascitic fluid. No\n immediate post-procedure complications. The patient tolerated the procedure\n well.\n\n The attending radiologist, Dr. , was present for the procedure.\n\n IMPRESSION: Successful therapeutic paracentesis with removal of two liters of\n ascites.\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-03-05 00:00:00.000",
"description": "CTA ABD W&W/O C & RECONS",
"row_id": 999211,
"text": " 4:00 PM\n CTA ABD W&W/O C & RECONS Clip # \n Reason: pre-op work up for liver transplant\n Admitting Diagnosis: HEPATITIS C;CIRRHOSIS;RENAL FAILURE\n Contrast: VISAPAQUE Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57F with HCV cirrhosis and ESLD with ascites/varices/gastropathy presents from\n OSH for further work up and management of syncopal episodes and worsening liver\n disease with ascites and encephalopathy. Course c/b hepatorenal syndrome which\n is slowly resolving.\n REASON FOR THIS EXAMINATION:\n pre-op work up for liver transplant\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hepatitis C cirrhosis and end-stage liver disease with ascites,\n varices, and gastropathy, with worsening liver disease and hepatorenal\n syndrome. Pretransplant workup.\n\n COMPARISON: , MR.\n\n TECHNIQUE: Axial MDCT images were obtained through the abdomen prior to and\n following the intravenous administration of 100 mL of Visipaque due to renal\n failure in multiple phases. Coronal and sagittal reformatted images are\n provided.\n\n CONTRAST: Intravenous nonionic contrast.\n\n CT OF THE ABDOMEN WITHOUT AND WITH INTRAVENOUS CONTRAST: Linear opacities at\n the lung bases including right middle and lower lobes are consistent with\n atelectasis. No pulmonary nodules or masses are identified, and the imaged\n portion of the heart and pericardium appear unremarkable. There is a large\n amount of ascites. The liver is small and nodular in contour consistent with\n cirrhosis. There is nonocclusive thrombus within the portal vein involving\n the base of the left portal vein and the right portal vein and extending to\n the right anterior branch. Portal venous anatomy is conventional. Hepatic\n arterial anatomy is conventional, with no replaced or accessory vessels\n identified. No enhancing masses are identified in the hepatic parenchyma.\n There is marked splenomegaly. The splenic vein and superior mesenteric veins\n are patent. Esophageal varices are present. The adrenal glands and kidneys\n appear unremarkable. The gallbladder is surgically absent with surgical clips\n in the gallbladder fossa. The large and small bowel loops are normal in\n caliber, and there is no abnormal bowel wall thickening. The aorta is normal\n in caliber. There are no pathologically enlarged mesenteric or\n retroperitoneal lymph nodes.\n\n Diffuse stranding in the subcutaneous tissues is present consistent with\n anasarca.\n\n Bone windows show no lesions worrisome for osseous metastatic disease.\n Subcutaneous gas in the right mid abdominal wall is noted (3A:117).\n\n (Over)\n\n 4:00 PM\n CTA ABD W&W/O C & RECONS Clip # \n Reason: pre-op work up for liver transplant\n Admitting Diagnosis: HEPATITIS C;CIRRHOSIS;RENAL FAILURE\n Contrast: VISAPAQUE Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION:\n 1. Cirrhosis, ascites, splenomegaly, and varices.\n\n 2. Nonocclusive thrombus involving the main and a portion of the left and\n right portal veins. Conventional portal venous anatomy.\n\n 3. Conventional hepatic arterial anatomy.\n\n 4. Subcutaneous gas in the right mid abdominal wall is of uncertain\n significance and could relate to injections but clinical correlation is\n recommended.\n\n A page was sent to at 5:20 p.m. on . The\n findings were discussed.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-02-26 00:00:00.000",
"description": "ABDOMEN (SUPINE & ERECT)",
"row_id": 998121,
"text": " 8:41 PM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: please rule out obstruction or perforation\n Admitting Diagnosis: HEPATITIS C;CIRRHOSIS;RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with vomiting, s/p paracentesis today\n REASON FOR THIS EXAMINATION:\n please rule out obstruction or perforation\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 57-year-old female with vomiting status post paracentesis to rule\n out bowel obstruction or perforation.\n\n TECHNIQUE: Supine and upright radiographs of the abdomen were performed as\n per departmental protocol.\n\n FINDINGS:\n\n There is diffuse homogeneous increased density in the abdomen and pelvis\n suggestive of ascites. There is paucity of bowel gas.\n\n There is no definite evidence of bowel obstruction. There are multiple\n surgical clips in the right upper quadrant suggestive of a prior\n cholecystectomy. There is no definite evidence of free intra-abdominal air.\n\n The right hemidiaphragm is raised, and there is suggestion of a right basal\n effusion and atelectasis. There is a catheter projected over the course of\n the distal SVC and right atrium suggestive of a central venous line.\n\n CONCLUSION:\n\n 1. Diffuse increased density over the abdomen and pelvis suggestive of\n ascites. There is no evidence of intra-abdominal free air or bowel\n obstruction.\n\n 2. Right hemidiaphragm is raised, and there is suggestion of a right basal\n effusion and atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-02-26 00:00:00.000",
"description": "PARACENTESIS DIAG. OR THERAPEUTIC",
"row_id": 998042,
"text": " 1:07 PM\n PARACENTESIS DIAG. OR THERAPEUTIC; GUIDANCE FOR /ABD/PARA CENTESIS USClip # \n Reason: Please do liter diagnostic and therapeutic paracentesis.\n Admitting Diagnosis: HEPATITIS C;CIRRHOSIS;RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with ESLD with recurrent ascites.\n REASON FOR THIS EXAMINATION:\n Please do liter diagnostic and therapeutic paracentesis.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 57-year-old female with end-stage liver disease with\n recurrent ascites. Please remove one to two liters for therapeutic and\n diagnostic paracentesis.\n\n ULTRASOUND-GUIDED THERAPEUTIC AND DIAGNOSTIC PARACENTESIS: Targeted\n son evaluation of the four quadrants demonstrates a large amount of\n ascites. An area in the left lower quadrant was marked for paracentesis. The\n risks and benefits of the procedure were explained to the patient and written\n informed consent was obtained. A preprocedure timeout was performed to\n confirm the nature of the procedure and identify the patient by name, medical\n record number and date of birth. The area was prepped and draped in standard\n sterile fashion. 1% lidocaine was used for local anesthesia. One pass with a\n 19-gauge catheter was made and 2 liters of brownish fluid was aspirated.\n There were no immediate post- procedure complications. The patient tolerated\n the procedure well.\n\n The attending radiologist, Dr. was present for procedure.\n\n IMPRESSION: Successful therapeutic and diagnostic paracentesis with removal\n of two liters of ascites. Specimens were sent for requested labs.\n\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-03-06 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 999289,
"text": " 8:49 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOPP ABD/PEL\n Reason: with doppler to evaluate for portal vein thrombus; no portal\n Admitting Diagnosis: HEPATITIS C;CIRRHOSIS;RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with ESLD, cirrhosis, admitted with hepato-renal syndrome,\n had CT today for pre-op work up for liver transplant, found to have\n non-occlusive portal vein thrombus.\n REASON FOR THIS EXAMINATION:\n with doppler to evaluate for portal vein thrombus; no portal vein thrombus on\n ultrasound on admission; CT scan today showed non-occlusive portal vein\n thrombus extending into R and L portal veins. If portal vein thrombus now\n visible on ultrasound then likely acute and would warrant heparin therapy. In\n still not seen on ultrasound then likely chronic.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 57-year-old female with end-stage liver disease and hepatorenal\n syndrome with CT demonstrating a non-occlusive portal vein thrombus.\n\n COMPARISON: CTA abdomen from .\n\n FINDINGS: Again is a shrunken nodular liver with heterogeneous coarsened\n echotexture consistent with the known history of cirrhosis. No intrahepatic\n mass or biliary ductal dilatation is identified. The patient is noted to be\n status post cholecystectomy. There is moderate-to-severe perihepatic ascites.\n\n Color and spectral Doppler evaluation demonstrates normal hepatic arterial\n flow. Doppler waveforms from the hepatic veins show normal respiratory\n variability. There is peripheral non-occlusive thrombus within the distal\n main portal vein and non-occlusive segmental filling defects within the\n posterior branch of the right portal vein. Absent-to-minimal flow is seen in\n the left portal vein with several collateral branches identified. The IVC is\n patent.\n\n IMPRESSION:\n\n 1. Large ascites and shrunken nodular liver consistent with history of\n cirrhosis.\n\n 2. Minimal-to-absent flow within the left portal vein and non-occlusive\n thrombus within the distal main and posterior right portal veins.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-03-24 00:00:00.000",
"description": "L SHOULDER 2-3 VIEWS NON TRAUMA LEFT",
"row_id": 1002057,
"text": " 9:34 PM\n SHOULDER VIEWS NON TRAUMA LEFT Clip # \n Reason: Please eval for cause of pain.\n Admitting Diagnosis: HEPATITIS C;CIRRHOSIS;RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with left shoulder pain.\n REASON FOR THIS EXAMINATION:\n Please eval for cause of pain.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Left shoulder. three views. .\n\n HISTORY: 57-year-old woman with left shoulder pain.\n\n FINDINGS: No previous studies available for direct comparison.\n\n There is a large subacromial spur, which can predispose to impingement-type\n syndrome. There are no signs for acute fractures or dislocations. No\n significant degenerative changes are present. The visualized left lung apex\n is clear.\n\n IMPRESSION:\n\n Subacromial spur.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-03-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1000651,
"text": " 12:50 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for infiltrate, effusion\n Admitting Diagnosis: HEPATITIS C;CIRRHOSIS;RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with ESLD HCV cirrhosis, with lg volume ascites,\n worsening HRS, wheezing with exertion.\n REASON FOR THIS EXAMINATION:\n evaluate for infiltrate, effusion\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST:\n\n REASON FOR EXAM: Worsening wheezing, history of ESLD.\n\n Comparison is made with prior study .\n\n This is a limited examination, It was centered in the thoraco-abdominal\n junction. Allowing for this, there has been interval worsening of bibasilar\n atelectasis, greater in the left side. There are lower lung volumes.\n Cardiomediastinal contour is stable. There are probably small bilateral\n pleural effusions.\n\n DR. \n"
},
{
"category": "Radiology",
"chartdate": "2145-03-18 00:00:00.000",
"description": "DUPLEX DOP ABD/PEL LIMITED",
"row_id": 1001079,
"text": " 8:17 AM\n DUPLEX DOP ABD/PEL LIMITED; RENAL U.S. Clip # \n -59 DISTINCT PROCEDURAL SERVICE\n Reason: please assess kidney size also doppler flow\n Admitting Diagnosis: HEPATITIS C;CIRRHOSIS;RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with HCV Cirrhosis for liver transplant, with ARF, for\n evaluation of possible kidney transplant\n REASON FOR THIS EXAMINATION:\n please assess kidney size also doppler flow\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Please assess kidney size and Doppler flow in a patient with\n acute renal failure.\n\n COMPARISONS: CT of the abdomen and pelvis dated .\n\n FINDINGS: -scale images reveal both kidneys to have a preserved cortical\n thickness without hydronephrosis, calculi, or contour deforming mass. The\n right kidney measures 10.2 cm and the left kidney measures 8.9 cm.\n\n Doppler images confirm arterial flow within the renal cortices, with resistive\n indices on the right ranging from 0.5-0.71 and resistive indices on the left\n ranging from 0.66-0.76. Both main renal arteries and veins are patent.\n\n Right upper quadrant ascites is incompletely imaged.\n\n IMPRESSION:\n 1. Preserved cortical thickness of both kidneys, with confirmation of\n arterial and venous flow.\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-03-16 00:00:00.000",
"description": "PARACENTESIS DIAG. OR THERAPEUTIC",
"row_id": 1000748,
"text": " 8:32 AM\n PARACENTESIS DIAG. OR THERAPEUTIC; GUIDANCE FOR /ABD/PARA CENTESIS USClip # \n Reason: please remove 2L only\n Admitting Diagnosis: HEPATITIS C;CIRRHOSIS;RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with ESLD, ascites, hepatorenal syndrome large volume\n tap, with worsening ascites and shortness of breath\n REASON FOR THIS EXAMINATION:\n please remove 2L only\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 57-year-old female with end-stage liver disease, ascites,\n hepatorenal syndrome secondary to large-volume tap with worsening ascites and\n shortness of breath.\n\n COMPARISON: .\n\n ULTRASOUND-GUIDED THERAPEUTIC PARACENTESIS: Targeted son evaluation\n of the four quadrants demonstrates a large amount of ascites. An area in the\n left lower quadrant was marked for paracentesis. The risks and benefits of\n the procedure were explained to the patient and written informed consent was\n obtained. Pre-procedure timeout was performed to confirm the nature of the\n procedure and identify the patient by name, medical record number and date of\n birth. The area was prepped and draped in standard sterile fashion. 1%\n lidocaine was used for local anesthesia. One pass with a 19-gauge \n catheter was made with removal of 2 L of serosanguineous ascitic fluid. There\n were no immediate post-procedure complications. The patient tolerated the\n procedure well.\n\n The attending radiologist, Dr. , was present for the procedure.\n\n IMPRESSION: Successful therapeutic paracentesis with removal of 2 L of\n ascites.\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-03-23 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 1001732,
"text": " 1:58 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: Please evaluate for bleeding s/p TIPS - patient with Hct \n Admitting Diagnosis: HEPATITIS C;CIRRHOSIS;RENAL FAILURE\n Field of view: 36\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with Hep C Cirrhosis, ESLD, a/w recurrent ascites,\n encephalopathy and now s/p TIPS procedure.\n REASON FOR THIS EXAMINATION:\n Please evaluate for bleeding s/p TIPS - patient with Hct decrease to 18.9 s/p\n procedure.\n CONTRAINDICATIONS for IV CONTRAST:\n Kidney function\n ______________________________________________________________________________\n WET READ: AHPb TUE 3:40 AM\n hemo-ascites with sentinel clot along inferior liver edge, likely post-\n traumatic\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: 67-year-old female status post TIPS with decreased\n hematocrit.\n\n TECHNIQUE: 0.625 mm helically acquired images are obtained from the lung\n bases to the pubic symphysis without intravenous contrast.\n\n FINDINGS: Comparison is made to a prior CT dated .\n\n Mild bibasilar atelectasis is noted.\n\n TIPS shunt is noted in appropriate position. A small area of hyperdensity is\n noted within the right lobe of the liver presumably related to contrast\n injection during the TIPS procedure. The patient is noted to be status post\n cholecystectomy. Cirrhotic appearance of the liver is noted.\n\n Moderate ascites is again identified. Compared with the prior CT, there is\n increase in the attenuation of the ascites diffusely. This suggests a\n component of hemorrhage likely related to the recent intervention.\n\n The spleen, adrenal glands, and pancreas appear grossly unremarkable allowing\n for the limitations of a non-contrast CT.\n\n Iodinated contrast is noted within the renal parenchyma as well as collecting\n systems and ureter. Given the temporal relationship with TIPS, this suggests\n renal insufficiency.\n\n The bowel appears grossly unremarkable. Pelvic structures appear grossly\n normal.\n\n No lytic or blastic bony lesions are identified.\n\n IMPRESSION:\n 1. Moderate ascites increased in attenuation since the aforementioned prior\n (Over)\n\n 1:58 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: Please evaluate for bleeding s/p TIPS - patient with Hct \n Admitting Diagnosis: HEPATITIS C;CIRRHOSIS;RENAL FAILURE\n Field of view: 36\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n examination suggesting a component of hemorrhage presumably related to recent\n intervention.\n\n 2. Findings suggestive of renal insufficiency.\n\n 3. TIPS noted in appropriate position.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-03-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1001770,
"text": " 9:08 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for aspiration/acute path\n Admitting Diagnosis: HEPATITIS C;CIRRHOSIS;RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with TIPS complicated by bleed\n REASON FOR THIS EXAMINATION:\n please eval for aspiration/acute path\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest portable AP on .\n\n COMPARISON: .\n\n HISTORY: 57-year-old woman with TIPS complicated by bleeding. Evaluate for\n aspiration, acute pathology.\n\n FINDINGS: In the interim, a TIPS stent has been placed projected over the\n right upper quadrant. There is a well-defined lucency adjacent to the\n vertebral bodies on the right whose location is difficult to evaluate on this\n single image.\n\n The lungs are low in volume. There is some linear atelectasis seen in the\n right mid zone. The heart is not enlarged. The remainder of the lungs is\n clear. There is no pleural effusion.\n\n IMPRESSION:\n 1. An abnormal lucency seen along the right paravertebral margin which could\n either represent a small pneumoperitoneum or pneumomediastinum. The findings\n have been telephoned to Dr. taking care of the patient and we\n recommended a very short followup examination by chest radiograph in three\n hours in an upright position or a left lateral position if the patient cannot\n be placed upright.\n 2. No radiographic evidence of aspiration or pneumonia.\n\n ab\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-03-19 00:00:00.000",
"description": "PARACENTESIS DIAG. OR THERAPEUTIC",
"row_id": 1001291,
"text": " 10:07 AM\n PARACENTESIS DIAG. OR THERAPEUTIC; GUIDANCE FOR /ABD/PARA CENTESIS USClip # \n Reason: Please perform on /08please perform THERAPEUTIC paracent\n Admitting Diagnosis: HEPATITIS C;CIRRHOSIS;RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with refractory ascites ESLD, fails bedside para. also\n with HRS resolving\n REASON FOR THIS EXAMINATION:\n Please perform on /08please perform THERAPEUTIC paracentesis for 4L fluid\n removal (maximum) only.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 57-year-old female with refractory ascites secondary to\n end-stage liver disease. Please perform therapeutic paracentesis.\n\n COMPARISON: .\n\n ULTRASOUND-GUIDED THERAPEUTIC PARACENTESIS. Targeted son evaluation\n of the four quadrants demonstrates a large amount of ascites. An area in the\n left lower quadrant was marked for paracentesis. The risks and benefits of\n the procedure were explained to the patient and written informed consent was\n obtained. A preprocedure timeout was performed confirming the nature of the\n procedure and to identify the patient by name, medical record number, and date\n of birth. The area was prepped in standard sterile fashion. 1% lidocaine was\n used for local anesthesia. Two passes with a 19-gauge catheter were made\n with successful removal of 4 L of serosanguineous ascitic fluid. There was no\n immediate post-procedure complication. The patient tolerated the procedure\n well.\n\n Dr. , the attending radiologist, was present during the procedure.\n\n IMPRESSION: Successful therapeutic paracentesis with removal of 4 L of\n serosanguineous ascites.\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-03-22 00:00:00.000",
"description": "INSERT HEPATIC HUNT TIPS",
"row_id": 1001584,
"text": " 7:25 AM\n TIPS Clip # \n Reason: TIPS: Deploy 10 mm uncovered stent and dilate to 8 mm only.\n Admitting Diagnosis: HEPATITIS C;CIRRHOSIS;RENAL FAILURE\n Contrast: OPTIRAY Amt: 210\n ********************************* CPT Codes ********************************\n * INSERT HEPATIC HUNT TIPS PARACENTESIS INITAL PROC *\n * -51 MULTI-PROCEDURE SAME DAY US GUID FOR NEEDLE PLACEMENT *\n * -59 DISTINCT PROCEDURAL SERVICE *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with HCV cirrhosis, esoph varices, requiring frequent \n for refractory ascites\n REASON FOR THIS EXAMINATION:\n TIPS: Deploy 10 mm uncovered stent and dilate to 8 mm only.Please also perform\n Therapeutic Paracentesis during this procedure.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 57-year-old woman with hep C cirrhosis and portal hypertension\n presenting with recurrent ascites, and history of bleeding from esophageal and\n rectal varices.\n\n RADIOLOGISTS: The procedure was performed by Drs. , , and\n , the attending radiologist, who was present and supervising\n throughout.\n\n PROCEDURE AND FINDINGS: After informed consent was obtained from the patient\n explaining the risks and benefits of the procedure, the patient was placed\n supine on the angiography table, and the right neck was prepped and draped in\n standard sterile fashion. General anesthesia was administered throughout the\n procedure.\n\n Before the procedure was started, the abdomen was also prepped and draped in\n standard sterile fashion, and approximately 5 liters of ascites were drained\n under ultrasonographic guidance.\n\n The right internal jugular vein was accessed with a micropuncture kit system\n under ultrasonographic guidance. A 0.035 wire was advanced through the\n micropuncture sheath into the inferior vena cava under fluoroscopic guidance.\n The micropuncture sheath was exchanged for a 10 French tip sheath\n that was placed with the tip in the inferior vena cava. Access was gained\n into the middle hepatic vein with a combination of a 0.035 Glidewire and a\n headhunter catheter. The catheter was exchanged for a balloon occlusion\n catheter, and a CO2 portogram was performed in AP and lateral projections to\n determine the anatomy of the portal vein.\n\n Using - kit, four passes were performed in order to gain access\n into the right portal vein. After one of the punctures, a glidewire was\n advanced and it traversed the liver capsule. Then access was gained into\n the right portal vein. The needle was removed, and a 0.035 Glidewire was\n advanced through the catheter, and access was gained into the main portal\n vein. The wire was removed, and a portogram was performed demonstrating patent\n (Over)\n\n 7:25 AM\n TIPS Clip # \n Reason: TIPS: Deploy 10 mm uncovered stent and dilate to 8 mm only.\n Admitting Diagnosis: HEPATITIS C;CIRRHOSIS;RENAL FAILURE\n Contrast: OPTIRAY Amt: 210\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n main, right and left portal veins. Pressure measurements were obtained and a\n gradient of 17 mmHg was noted between the portal vein (38) and the right\n atrium (21).\n\n The intra-hepatic parenchymal tract was dilated with an 8 mm balloon, and a 10\n mm x 68 mm Wallstent was deployed. This was followed by balloon dilation with\n an 8 mm balloon.\n\n Subsequent venogram was performed demonstrating good flow through the shunt,\n and good positioning of the stent.\n\n Pressure measurements were repeated, and demonstrated a portosystemic gradient\n decreased to 8 mmHg after the TIPS creation.\n\n Catheter and the vascular sheath were removed, and manual compression was held\n for 20 minutes until hemostasis was achieved. The patient was transferred to\n the PACU in good condition.\n\n COMPLICATIONS: Minor puncture of the liver capsule with a Glidewire.\n\n IMPRESSION: Successful creation of TIPS, with placement of a 10 mm x 68 mm\n Wallstent that was dilated with an 8 mm balloon.\n Initial portosystemic gradient was recorded as 17 mmHg, and the final\n portosystemic gradient was recorded as 8 mmHg.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-03-29 00:00:00.000",
"description": "PARACENTESIS DIAG. OR THERAPEUTIC",
"row_id": 1002740,
"text": " 12:38 PM\n PARACENTESIS DIAG. OR THERAPEUTIC; GUIDANCE FOR /ABD/PARA CENTESIS USClip # \n Reason: Please perform (4L) therapeutic paracentesis\n Admitting Diagnosis: HEPATITIS C;CIRRHOSIS;RENAL FAILURE\n ********************************* CPT Codes ********************************\n * PARACENTESIS DIAG. OR THERAPEUTIC GUIDANCE FOR /ABD/PARA CENTESIS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with refractory ascites, s/p TIPS on , now with worsening\n ascites.\n REASON FOR THIS EXAMINATION:\n Please perform (4L) therapeutic paracentesis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Refractory ascites requiring paracentesis status post TIPS on\n .\n\n PROCEDURE: After explaining potential risks, benefits and alternatives of the\n procedure to the patient, written informed consent was obtained. All\n questions were answered. Patient identity was confirmed with three\n identifiers. A pocket of ascites was localized in the left flank region.\n\n Using aseptic technique, 1% lidocaine for local anesthesia and a 5 French \n catheter, 5 liters of dark red ascites was drained. The catheter was then\n removed and adequate hemostasis was achieved. There were no immediate\n complications. Dr. was an essential participant.\n\n IMPRESSION: Patient status post paracentesis of 5 liters of hemorrhagic\n fluid.\n\n"
},
{
"category": "Echo",
"chartdate": "2145-02-17 00:00:00.000",
"description": "Report",
"row_id": 70584,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Syncope.\nHeight: (in) 63\nWeight (lb): 175\nBSA (m2): 1.83 m2\nBP (mm Hg): 108/68\nHR (bpm): 73\nStatus: Inpatient\nDate/Time: at 15:56\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). Overall normal LVEF (>55%). Estimated cardiac\nindex is normal (>=2.5L/min/m2). No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. No masses or\nvegetations on aortic valve.\n\nMITRAL VALVE: Normal mitral valve leaflets. No MVP. No mass or vegetation on\nmitral valve. Normal mitral valve supporting structures. Moderate (2+) MR.\nNormal LV inflow pattern for age.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate to severe [3+] TR.\nBorderline PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thickness, cavity\nsize and regional/global systolic function are normal (LVEF >55%) Overall left\nventricular systolic function is normal (LVEF>55%). The estimated cardiac\nindex is normal (>=2.5L/min/m2). There is no ventricular septal defect. Right\nventricular chamber size and free wall motion are normal. The aortic valve\nleaflets (3) appear structurally normal with good leaflet excursion and no\naortic regurgitation. No masses or vegetations are seen on the aortic valve.\nThe mitral valve leaflets are structurally normal. There is no mitral valve\nprolapse. No mass or vegetation is seen on the mitral valve. Moderate (2+)\nmitral regurgitation is seen. Moderate to severe [3+] tricuspid regurgitation\nis seen. There is borderline pulmonary artery systolic hypertension. There is\nno pericardial effusion.\n\nIMPRESSION: No cardiac source of syncope identified. Normal regional and\nglobal biventricular function. Moderate mitral regurgitation, moderate to\nsevere tricuspid regurgitation. Borderlie pulmonary artery systolic\nhypertension.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-02-17 00:00:00.000",
"description": "PARACENTESIS DIAG. OR THERAPEUTIC",
"row_id": 996468,
"text": " 10:33 AM\n PARACENTESIS DIAG. OR THERAPEUTIC; GUIDANCE FOR /ABD/PARA CENTESIS USClip # \n Reason: only 1.5L removed w/ beside para, marked spot; needs more fl\n Admitting Diagnosis: HEPATITIS C;CIRRHOSIS;RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with ESLD, INR 1.3.\n REASON FOR THIS EXAMINATION:\n only 1.5L removed w/ beside para, marked spot; needs more fluid removed\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Paracentesis.\n\n INDICATION: 57-year-old female with a history of end-stage liver disease\n presenting for therapeutic paracentesis. 1.5 liters removed the previous day\n at bedside paracentesis.\n\n COMPARISONS: .\n\n FINDINGS: Limited son assessment of the abdomen demonstrates moderate\n abdominal fluid.\n\n PROCEDURE: Following discussion of the risks and benefits of the procedure,\n written informed consent was obtained. The patient was prepped and draped in\n standard sterile fashion. A preprocedure timeout was performed to confirm the\n nature of procedure and patient identity. A suitable spot for paracentesis\n was selected in the left lower quadrant. 1% lidocaine was used for local\n anesthesia. Following a small skin incision, a 5 French catheter was\n inserted into the peritoneal cavity and approximately 7.1 liters of brownish-\n clear fluid were removed. The patient tolerated the procedure well and there\n were no immediate post-procedure complications.\n\n Dr. , the attending radiologist, was present and supervised throughout.\n\n IMPRESSION: Successful therapeutic paracentesis with 7.1 liters of brown-\n clear fluid removed.\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-02-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 996098,
"text": " 11:43 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for acute processes and PICC position\n Admitting Diagnosis: HEPATITIS C;CIRRHOSIS;RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with ESLD and syncope xfer from OSH with PICC\n REASON FOR THIS EXAMINATION:\n eval for acute processes and PICC position\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST ON AT 23:55\n\n INDICATION: Syncope and PICC line recent transfer.\n\n FINDINGS: A left PICC line is seen with the tip in the SVC. There is an oval\n opaque density adjacent to the right hemidiaphragm which has an appearance of\n a partial collapse. A followup is recommended as this could be evolving into\n a pneumonia. Shallow inspiration limits the study. The left CP angle is\n sharply delineated and the pulmonary vascular markings are within normal\n limits for technique.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-03-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1001810,
"text": " 12:49 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: f/u pre-vertebral lucency seen this morning.\n Admitting Diagnosis: HEPATITIS C;CIRRHOSIS;RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with hemoperitoneum after TIPS and new fever\n REASON FOR THIS EXAMINATION:\n f/u pre-vertebral lucency seen this morning.\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest, AP portable, single view.\n\n INDICATION: Status post TIPS and new fever. Follow up for previously\n identified paravertebral lucency on portable chest film.\n\n FINDINGS: AP single view of the chest has been obtained with patient in\n sitting semi-upright position and analysis is performed in direct comparison\n with a similar preceding study obtained four hours earlier during the same\n date. Heart size, mediastinal structures, and lung fields are unchanged.\n Thus, there is no evidence of increasing vascular congestion or new\n parenchymal infiltrates. The previously identified semi-circular small air\n collection at the top of the right upper quadrant in paravertebral position\n cannot be identified anymore. Position of TIPS stent unaltered. No evidence\n of pleural effusions collecting in lateral pleural sinuses and no evidence of\n pneumothorax in the apical area.\n\n IMPRESSION: Disappearance of previously identified small air collection.\n Single view examinations cannot identify conclusively the location of this\n small amount of air in either pericardium or upper portion of peritoneum. No\n evidence of increasing heart silhouette or pulmonary congestion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-03-17 00:00:00.000",
"description": "PARACENTESIS DIAG. OR THERAPEUTIC",
"row_id": 1000976,
"text": " 2:01 PM\n PARACENTESIS DIAG. OR THERAPEUTIC Clip # \n Reason: 3 L theraputic paracentesis\n Admitting Diagnosis: HEPATITIS C;CIRRHOSIS;RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with ESLD, ascites, hepatorenal syndrome large volume\n tap, with worsening ascites and shortness of breath\n REASON FOR THIS EXAMINATION:\n 3 L theraputic paracentesis\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 57-year-old female with end-stage liver disease, ascites,\n hepatorenal syndrome, worsening ascites and shortness of breath.\n\n COMPARISON: .\n\n ULTRASOUND-GUIDED THERAPEUTIC PARACENTESIS: Targeted son evaluation\n of the four quadrants demonstrates a large amount of ascites. An area in the\n left lower quadrant was marked for paracentesis. The risks and benefits of\n the procedure were explained to the patient and written informed consent was\n obtained. A preprocedure timeout was performed to confirm the nature of the\n procedure, identify the patient by name, medical record number and date of\n birth. The area was prepped and draped in standard sterile fashion. 1%\n lidocaine was used for local anesthesia. One pass with a 19 gauge \n catheter was made with removal of three liters of serosanguineous ascitic\n fluid. There were no immediate post-procedure complications. The patient\n tolerated the procedure well.\n\n Dr. , the attending radiologist, was present during the procedure.\n\n IMPRESSION: Successful therapeutic paracentesis with removal of three liters\n of ascitic fluid.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-03-26 00:00:00.000",
"description": "DUPLEX DOP ABD/PEL LIMITED",
"row_id": 1002329,
"text": " 9:55 AM\n DUPLEX DOP ABD/PEL LIMITED Clip # \n Reason: please re-evaluate TIPS, assess for hematoma, biliary dilati\n Admitting Diagnosis: HEPATITIS C;CIRRHOSIS;RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with cirrhosis, TIPS on complicated with hemoperitoneum\n REASON FOR THIS EXAMINATION:\n please re-evaluate TIPS, assess for hematoma, biliary dilation\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 57-year-old female with cirrhosis. TIPS placed on , . Baseline study. Please evaluate TIPS, assess for hematoma, biliary\n dilatation.\n\n COMPARISON: .\n\n ABDOMINAL ULTRASOUND: The liver demonstrates a coarsened, shrunken and nodular\n architecture consistent with cirrhosis. No focal hepatic lesion is identified.\n No intra- or extra-hepatic biliary dilatation is appreciated. The patient is\n status post cholecystectomy. Moderate-to-large amount of ascites is present.\n\n DOPPLER EXAMINATION: Color images demonstrate wall-to-wall flow within the\n TIPS shunt. Velocities within the proximal, mid and distal TIPS are 75, 88\n and 153 cm/sec. Flow within the main portal vein is hepatopetal with a\n velocity of 71 cm/sec. The hepatic veins are patent.\n\n IMPRESSION:\n 1. Greyscale ultrasound demonstrates a nodular, shrunken and coarsened liver\n consistent with cirrhosis. No focal hepatic lesion is identified.\n\n 2. Moderate-to-large amount of ascites.\n\n 3. Doppler examination demonstrates wall-to-wall flow within the TIPS with\n normal velocities as described above.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-03-23 00:00:00.000",
"description": "Report",
"row_id": 1656045,
"text": "CCU Nursing adm note\n57 yr old transferred from 10 with hct drop after TIPS procedure, being transfused with PRBCs, FFP, cryoprecipitate.\n\nGI: takes lactulose for encephalopathy, has liq stool at baseline. HCt 18, serial hcts ordered. 1st u PRBC's up, to get FFP next. Keep NPO.\n\nID: T 101 on floor, BCx2, UA sent, needs C&S.\nAB's ordered.\n\nNeuro; alert, answers questions but is slow in responses, moaning with shoulder pain, though upon transfer denies having any pain. Attempting to get OOB despite reminders not to. Bed alarm on, 4 rails up, order obtained.\n\nskin: intact.\n\nResp: sat 98% on RA.\n\nAccess: DL PICC, #20 angio.\n\nA/P: Transfuse with blood products as ordered, follow serial hct, hepatic service following. lactulose for encephalopathy. follow Temp, IV AB's as ordered. Inform and support pt/family to plan as stated in multidisciplinary pt care rounds.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-03-23 00:00:00.000",
"description": "Report",
"row_id": 1656046,
"text": "CCU NPN 0700-1900 MICU pt\nS: \"Oh my God...this lactulose!\"\n\nO: Please see careview for VS and additional data.\n\nCV: Pt HR 87-103 NSR/ST, NBP 97-137/45-66. Am HCt post 2 units PRBC's 23-> afternoon HCt 23-> 3rd unit PRBC's up (3 units total since arrival to CCU this am), 2 units FFP, 1 bag platelets, 1 bag of cryo. HCt's to be checked Q 4 hours, next HCt d/t be drawn at 2100. INR 1.6. Bilat pedal pulses palp. No c/o CP.\n\nResp: Pt LS clear to faint crackles at RLL. RR 15-26, O2 sats 97-100% on room air.\n\nNeuro: Pt A&Ox3, at times forgetful, tearful, emotional support provided. pt MAE, turning self in bed, sitting up in bed. Pt denies pain, but c/o L shoulder discomfort-> heat pack applied with verbalized effect.\n\nGI/GU/ENDO: Pt abd soft distended, +BS x4, pt eating less than 25% of meals, nutritional shake encouraged. Pt with brown, guaic positive (pt with hx hemorrhiods) liquid stools x7-further doses of lactulose held this afternoon as ordered. FS 166-183, ss insulin coverage given. Foley cath draining clr -yellow u/o approx 25 cc/hr.\n\nID: T max 100.3 oral, cont on IV Cipro/flagyl.\n\nSocial: No calls or visitors this shift.\n\nA/P: 57 y/o female s/p TIPS c/b HCT drop-> pt transfused 3 units PRBC's (3rd infusing), 2 units FFP, 1 cryo and 1 bag platelets. As discussed in MICU rounds, cont to monitor hct-transfuse as ordered. Cont to monitor neuro status-lactulose as ordered/per stools. Cont to monitor for pain, u/o. Cont to encourage PO's. Cont to provide emotional support to pt. Awaiting further POC per MICU Team.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-03-24 00:00:00.000",
"description": "Report",
"row_id": 1656047,
"text": "pmicu npn 2200-0700\n the pt is a 57 yo woman with esld secondary to hcv who is well- known to the micu service. she was inititally admitted last month for syncope which was later thought to be r/t orthostatic hypotension. during her month-long stay, her hospital course has been c/b worsening arf likly secondary to hepatorenal failure. she has had multiple paracenteses to improve her sob. she also had brbpr secondary to hemorrhoids, and the site was packed by surgery w/resolution of bleeding. she has recently been added to the liver transplant list.\n she was readmitted to the micu service as a ccu border on for a hemoperitoneum s/p a tips procedure. her hct fell from 25 to 18, and a subsequent abd ct confirmed the location of the blood loss. in addition to reversing her coagulopathy, the pt has been transfused with a total of 4 units prbc's to maintain a hct >28. she is hemodynamically stable and ?transfer back to 10 soon.\n\npmh: esld hcv cirrhosis; esophageal varicies; portal htn; portal vein thrombus; depression; anxiety; gerd; iddm; seizure disorder; htn; osa; s/p choly\n\nallergies: zanaflex-> hallucinations\n\nreview of systems\n\nrespiratory-> lung exam notable for rll crackles. pt is maintaining sats >97% on room air. she does c/o subjective sob with exertion/ repositioning but does not desaturate.\n\ncardiac-> hemodynamically stable despite hemoperitoneum. hr 80-90's, sr with no noted ectopy. sbp ranging 90-130's.\n\nneuro-> pt has been intermittently confused this admission d/t encephalopathy. lactulose titrated to bm's/day. she is alert and oriented. mae x4 with equal strength.\n\ngi-> abd w/+ascites. no bm overnoc although lactulose held last noc d/t frequent stooling during the day. hct s/p 3 units prbc's was 26 with a goal of 28. the pt has completed a 4th unit prbc's overnoc.\n\nheme-> pt to restart anticoagulation for a portal vein thrombus once current hemoperitoneum has resolved.\n\nid-> the pt was last cultured on following a temp spike to 101. she is currently receiving abx coverage for a possible intra-abdominal process.\n\nendocrine-> receiving insulin per hiss parameters prior to meals.\n\naccess-> left arm dl picc line placed and a #20g angio in hand are patent and intact.\n\nsocial-> no contact w/family overnoc.\n\ndispo-> possible transfer back to 10 today if she remains hemodynamically stable.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-03-24 00:00:00.000",
"description": "Report",
"row_id": 1656048,
"text": "MICU Nursing Progress Note 0700-1900\n\nPlease see nursing transfer note for shift note.\n"
},
{
"category": "ECG",
"chartdate": "2145-02-22 00:00:00.000",
"description": "Report",
"row_id": 162073,
"text": "Sinus rhythm with low QRS voltage in the precordial leads and delayed R wave\nprogression. Cannot rule out prior anterior myocardial infarction. No\nprevious tracing available for comparison.\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-03-01 00:00:00.000",
"description": "PARACENTESIS DIAG. OR THERAPEUTIC",
"row_id": 1260575,
"text": " 11:09 AM\n PARACENTESIS DIAG. OR THERAPEUTIC; GUIDANCE/LOCALIZATION FOR NEEDLE BIOPSY US (S&I)Clip # \n Reason: theraputic, please remove 2 L only (has HRS following prior\n Admitting Diagnosis: HEPATITIS C;CIRRHOSIS;RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with ESLD on transplant list with resolving hepatorenal\n syndrome\n REASON FOR THIS EXAMINATION:\n theraputic, please remove 2 L only (has HRS following prior large volume\n tapplease send fluid for cell count, diff, culture\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 57-year-old female with end-stage liver disease on\n transplant list with resolving hepatorenal syndrome. Please perform\n therapeutic paracentesis and remove two liters only.\n\n COMPARISON: .\n\n ULTRASOUND-GUIDED THERAPEUTIC AND DIAGNOSTIC PARACENTESIS: Targeted\n son evaluation of the four quadrants demonstrates a large amount of\n ascites. An area in the left lower quadrant was marked for paracentesis. The\n risks and benefits of the procedure were explained to the patient and written\n informed consent was obtained. A preprocedure timeout was performed to\n confirm the nature of the procedure, and identify the patient by name, medical\n record number and date of birth. The area was prepped and draped in a\n standard sterile fashion. 1% lidocaine was used for local anesthesia. One\n pass with a 19-gauge catheter was made with removal of two liters of\n brownish fluid. There were no immediate post-procedure complications. The\n patient tolerated the procedure well.\n\n The attending radiologist Dr. was present for the procedure.\n\n IMPRESSION: Successful therapeutic and diagnostic paracentesis with removal\n of 2 liters of ascites. Specimens were sent for requested labs.\n\n"
}
] |
9,035 | 103,660 | A/P: 55yoF s/p appendectomy for ruptured retrocecal appy, still febrile on Abx. . 1. Sepsis: The patient was transferred to with sepsis syndrome from OSH, was hypotensive and with high fevers. Soon after transfer she was hemodynamically stable. She was continued on broad spectrum antibiotics. There was no pathogen identified, although she was treated for a presumed PNA as well as a possible GI source given the history of appendectomy at the OSH. There was an initial concern for a Gyn source of infection, possible L , Gynecology was consulted, and this was found to be less likely. The infection resolved with empiric antibiotics . 2. Altered MS/seizures: After the sepsis was resolving, the pt was noted to have persistent coma. She remained unarousable, with flaccid limbs not withdrawing to pain. Neurology was consulted. She was noted at one point to have jerking movements suggestive of seizure activity, initial ECG was negative for epileptogenic activity. In order to rule out meningitis, LP was attempted by radiology under fluoro although was unsuccessful. She was treated for possible HSV and bacterial meningitis empirically. There was high clinical suspicion for status epilepticus, continuous EEG monitoring was done and confirmed seizure activity. The patient was started on depakote for seizure prophylaxis. The etiology of the initial CNS insult was assessed as likely sustained when hypotensive and febrile to 108. Over the course of the hospitalization, the patient's mental status showed minimal improvement. She was able to interact and follow commands limited to movements of her eyes and tongue. She demonstrated extremely limited ability to perform movements below the neck. She remained quadraplegic She had no gag reflex and could not breathe off of the ventilator. . 3. Withdrawal of Life Support: Extensive discussions were held with the patient as well as members of her immediate family with the attending physician, . as well as other members of the medical team. It was explained to the patient and family that in her current state, she could not live without life support from the venitalor since she was not able to breathe on her own. They were explained the option to have a tracheotomy for ventilation at rehab where she would have an opportunity for a longer-term recovery, although there was no guarantee that she would be able to come off of the ventilator. Whether the patient would make any meaningful neurological recovery was also uncertain. The patient and family expressed a clear decision that the patient did not want to remain on the ventilator and that she wanted to be off of life support. She indicated that she understood the implications. The patient was extubated and passed away shortly therafter with family and friends present. . 4. Respiratory failure: The patient remained ventilator dependent during the hospital stay as noted above, . 5. Pancreatitis: There was an isolated elevation of pancreatic enzymes in the abscence of symptoms. She received a post-pyloric tube for feeding. After several days, this was trending down and tube feeds were done through an NG tube. . 6. Anemia: Hct remained 25 range stable. . 7. Trop leak: trop peak to 0.55 on , elevated CK rhabdo. Likely demand ischemia in setting of septic shock. . 8. Rhabdomyolisis: CK peaked on , and later resolved. Her renal funtion remained intact. | Normal ascending aorta diameter.AORTIC VALVE: Aortic valve not well seen. Mild (1+) aortic regurgitation is seen. CT ABDOMEN WITHOUT AND WITH IV CONTRAST: There continues to be bibasilar atelectasis and small bilateral pleural effusions. Tiny low-attenuation focus is again noted in the right hepatic lobe. Continued bibasilar atelectasis and small bilateral pleural effusions. Mild mitral annularcalcification.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor echo windows.Conclusions:There is mild symmetric left ventricular hypertrophy. Cardiac and mediastinal and hilar contours appear unchanged. AP CHEST RADIOGRAPH: Allowing for different projections, the heart size, mediastinal and hilar contours are unchanged. SINGLE VIEW CHEST, AP: The ET tube is in appropriate position. The aortic valve isnot well seen (probably mildly thickened leaflets). IMPRESSION: Slight improvement in bilateral pleural effusions and bibasilar atelectases. Bilateral pleural effusions again noted along with bibasilar atelectasis. Mild-to-moderate bilateral pleural effusions appear unchanged. PATIENT/TEST INFORMATION:Indication: Left ventricular function.Weight (lb): 280BP (mm Hg): 116/63HR (bpm): 93Status: InpatientDate/Time: at 15:57Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: DefinityTechnical Quality: SuboptimalINTERPRETATION:Findings:RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Mild symmetric LVH. Complex cystic area noted in the left adnexal area on preceding CT of . Bilateral small pleural effusions are identified, right greater than left with associated compressive atelectasis. Nasogastric tube is seen with tip in the area of the distal esophagus/GE junction. Numerous sigmoid diverticula are again seen without evidence of diverticulitis. The fluid within the right maxillary sinus has resolved. Again seen is left hydrosalpinx and enlargement of the left ovary. Tuboovarian abscess is considered less likely. AP CHEST RADIOGRAPH: There has been interval removal of a left-sided subclavian line and Dobbhoff tube. Assessment is this area is limited and the possibility of a cystic ovarian lesion cannot be excluded at present. There is an unchanged focus of increased T2 and FLAIR signal intensity in the right periventricular white matter of unspecific etiology. The patient has been extubated. Re-demonstration of left hydrosalpinx and enlarged ovary. Again seen is evidence of bilateral lower lobe consolidation. The major vascular flow void patterns are normal. Stranding is again noted posterior to the cecum and is stable. Mild (1+) AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. INDICATION: Nasogastric tube placement. Hyperdynamic LVEF.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic root diameter. It contains a subcentimeter calcific focus along the posterior aspect suggesting some chronicity. IMPRESSION: Persistent bibasilar pleural effusions and atelectasis. There is continued cardiomegaly and small bilateral pleural effusion associated with bibasilar patchy atelectasis. IMPRESSION: Nasogastric tube seen with tip at the distal esophagus. FINDINGS: Transabdominal and transvaginal examinations were performed. There are persistent, bilateral pleural effusions with bibasilar atelectasis. Tubular hypoechoic and slightly tortuous structure in the left adnexa measuring up to 1.5 cm in diameter extending over 7 to 8 cm in length which on ultrasound has the appearances of a hydrosalpinx. The airways are patent to the level of the segmental bronchi bilaterally. IMPRESSION: AP chest compared to : Mild cardiomegaly accompanied by moderate distention of the mediastinal vasculature. Sigmoid diverticula are observed without definite diverticulitis. Cardiac and mediastinal, hilar contours appear unchanged. Stranding is noted posterior to the right colon and cecum consistent with the recent operation. Bilateral pleural effusions with associated atelectasis/consolidation is unchanged. Bibasilar atelectasis with small bilateral pleural effusions. FINDINGS: There is a small left frontal extra-axial fluid collection representing a chronic subdural hematoma or hygroma. There remain moderate right and small left pleural effusions. There has been interval placement of an endotracheal tube with its tip terminating several centimeters above the carina. There has been placement of a left subclavian vascular catheter, terminating within the mid superior vena cava with no pneumothorax. A final limited chest radiograph confirmed the catheter tip placement in the proximal superior vena cava. Mild pulmonary edema and small right pleural effusion suggest cardiac decompensation and/or volume overload. AP VIEW OF THE CHEST: The endotracheal tube, nasogastric tube, and left subclavian central venous catheter are in unchanged positions. Small bilateral pleural effusions. Evaluate edema or effusion. IMPRESSION: AP chest compared to : An orogastric tube passes below the diaphragm and out of view. Small left sided extra-axial fluid collection, likely representing chronic subdural hematoma or hygroma. COMPARISON: CT head dated . Scoliosis is again seen. There is continued diffuse bilateral alveolar opacities and vascular engorgement consistent with mild congestive heart failure, unchanged in the interval. TECHNIQUE: Noncontrast head CT scan. Nonspecific small right periventricular increased T2 and FLAIR signal- chronic small vessel infarct or post-inflammatory residuum are the most likely diagnostic considerations. The gallbladder, pancreas, spleen, adrenal glands, kidneys, stomach, and bowel loops are within normal limits. s/p recent extubation and new adnexal ovarian cystic mass. COMPARISON: Chest radiograph dated . Central venous line tip unchanged in positioning. There is atherosclerotic calcification of the supraclinoid carotid arteries. IMPRESSION: Dobhoff tube as described above. Sigmoid diverticulosis. Coronal and sagittal reformatted images were obtained. AP CHEST RADIOGRAPH Compared to prior study, there has been interval placement of a Dobbhoff tube. The major vascular flow void patterns are normal. IMPRESSION: High endotracheal tube. Portable supine frontal radiograph. Nasogastric tube passes to the distal stomach and out of view. Foley catheter and air are noted in the bladder. TECHNIQUE: Multidetector axial images of the abdomen and pelvis were obtained with oral and IV contrast. Examination was exposed for imaging the abdomen therefore detail in the lungs is suboptimal. CT ABDOMEN: There is bibasilar atelectasis and bilateral pleural effusions. Endotracheal tube has been advanced, with its tip now approximately 2 cm above the carina. AP SEMI-ERECT PORTABLE CHEST: The endotracheal tube tip is in a high lying position approximately 2-3 cm above ideal location. Air fluid levels are noted in the maxillary and sphenoid sinuses, likely secondary to intubation. IMPRESSION: Fluoroscopically guided placement of a nasogastric tube with the tip in the stomach. | 32 | [
{
"category": "Echo",
"chartdate": "2110-04-02 00:00:00.000",
"description": "Report",
"row_id": 72804,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nWeight (lb): 280\nBP (mm Hg): 116/63\nHR (bpm): 93\nStatus: Inpatient\nDate/Time: at 15:57\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: Definity\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Overall normal LVEF\n(>55%). Hyperdynamic LVEF.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter. Normal ascending aorta diameter.\n\nAORTIC VALVE: Aortic valve not well seen. No AS. Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nThere is mild symmetric left ventricular hypertrophy. The left ventricular\ncavity size is normal. Overall left ventricular systolic function is normal\n(LVEF>55%). Left ventricular systolic function is hyperdynamic (EF>75%). Right\nventricular chamber size and free wall motion are normal. The aortic valve is\nnot well seen (probably mildly thickened leaflets). There is no aortic valve\nstenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets\nare mildly thickened. There is no pericardial effusion.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2110-04-09 00:00:00.000",
"description": "Report",
"row_id": 170241,
"text": "Sinus tachycardia\nLate R wave progression possible anterior infarct - age undetermined\n Inferior/lateral ST-T changes may be due to myocardial ischemia\nRepolarization changes may be partly due to rate\nSince previous tracing of , heart rate increased, Late R wave\nprogression more prominent, ST-T wave abnormalities\nClinical correlation is suggested\n\n"
},
{
"category": "ECG",
"chartdate": "2110-04-04 00:00:00.000",
"description": "Report",
"row_id": 170476,
"text": "Sinus rhythm\nShort PR interval\nNormal ECG\nSince previous tracing the heart rate has decreased\n\n"
},
{
"category": "ECG",
"chartdate": "2110-04-03 00:00:00.000",
"description": "Report",
"row_id": 170477,
"text": "Sinus tachycardia\nNormal ECG except for rate\nSince previous tracing of , sinus tachycardia rate faster and short PR\ninterval appears slightly longer\n\n"
},
{
"category": "ECG",
"chartdate": "2110-04-02 00:00:00.000",
"description": "Report",
"row_id": 170478,
"text": "Sinus tachycardia with short PR interval, but without evidence of ventricular\npre-excitation\nAtrial premature complexes\nModest nonspecific ST-T wave changes\nNo previous tracing available for comparison\n\n"
},
{
"category": "Radiology",
"chartdate": "2110-04-08 00:00:00.000",
"description": "PELVIS, NON-OBSTETRIC",
"row_id": 909459,
"text": " 10:35 AM\n PELVIS, NON-OBSTETRIC Clip # \n Reason: ABNORMAL CT, EVAL FOR , OVARIAN MASS, REPEAT US WHEN PT IS AMBULATORY\n Admitting Diagnosis: HYPERTHERMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with fever, s/p ruptured appy, ? vs mass on CT\n REASON FOR THIS EXAMINATION:\n eval for , ovarian mass\n ______________________________________________________________________________\n FINAL REPORT\n PELVIC ULTRASOUND SCAN (TRANSABDOMINAL).\n\n CLINICAL DETAILS: Previous appendicectomy. Complex cystic area noted in the\n left adnexal area on preceding CT of . Comparison is made to\n previous imaging.\n\n FINDINGS:\n\n Technically difficult examination.\n No evidence of collection in the right lower quadrant on ultrasound. No free\n intra-abdominal fluid.\n\n Tubular hypoechoic and slightly tortuous structure in the left adnexa\n measuring up to 1.5 cm in diameter extending over 7 to 8 cm in length which on\n ultrasound has the appearances of a hydrosalpinx. Posterior in the left\n adenexal area there is a cystic structure measuring up to 5.1 cm sagittal x\n 3.7 cm AP, comprised of a septated cystic or two adjacent cystic structures.\n It contains a subcentimeter calcific focus along the posterior aspect\n suggesting some chronicity. No mural nodularity, solid component or abnormal\n vascularity demonstrated on ultrasound. No overlying tenderness at present\n (however reliable assessment is not possible as the patient is not fully alert\n at present). This area is similar in size to the recent CT of .\n\n CONCLUSION:\n\n 1. Left hydrosalpinx with an adjacent posterior cystic lesion measuring up to\n 5.1 cm. No strongly concerning features or acute overlying tenderness.\n Assessment is this area is limited and the possibility of a cystic ovarian\n lesion cannot be excluded at present.\n\n Interval followup advised. When the patient recovers from her current surgery,\n this area could be further characterized with MRI or followed up at interval\n with ultrasound.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2110-04-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 909948,
"text": " 3:44 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval if ngt is post-pyloric\n Admitting Diagnosis: HYPERTHERMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman s/p intubation w/ngt.\n\n REASON FOR THIS EXAMINATION:\n eval if ngt is post-pyloric\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post intubation.\n\n COMPARISONS: .\n\n SINGLE VIEW CHEST, AP: The ET tube is in appropriate position. The distal\n tip of the NG tube extends off the lower edge of the film below the diaphragm.\n There are persistent, bilateral pleural effusions with bibasilar atelectasis.\n There is no significant increased interstitial opacities to indicate left\n ventricular heart failure. There is a persistent S-shaped scoliosis to the\n thoracolumbar spine.\n\n IMPRESSION: Persistent bibasilar pleural effusions and atelectasis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2110-04-11 00:00:00.000",
"description": "CTA CHEST W&W/O C &RECONS",
"row_id": 909925,
"text": " 8:23 PM\n CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: please eval for PE.\n Admitting Diagnosis: HYPERTHERMIA\n Field of view: 36 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55yoF s/p open appendectomy, with fevers unknown source, respiratory failure\n now intubated, tachycardia, HTN, concern for PE.\n REASON FOR THIS EXAMINATION:\n please eval for PE.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Intubated, tachycardic, concern for pulmonary embolism.\n\n COMPARISON: Chest x-ray from the same day.\n\n TECHNIQUE: Multidetector CT scanning of the chest was performed before and\n after the administration of intravenous contrast. Multiplanar reformations\n were obtained.\n\n FINDINGS: No central or segmental pulmonary emboli are identified. The\n thoracic aorta is normal in caliber throughout without evidence of intimal\n flap. The heart and pericardium appear unremarkable. Bilateral small pleural\n effusions are identified, right greater than left with associated compressive\n atelectasis. No pathologic axillary, mediastinal, or hilar lymphadenopathy is\n identified. The airways are patent to the level of the segmental bronchi\n bilaterally. An endotracheal tube tip is seen in the mid trachea, and a\n nasogastric tube is seen extending into the stomach.\n\n In the visualized abdomen, the liver, spleen, pancreas, and stomach appear\n unremarkable.\n\n The osseous structures demonstrate a scoliosis of the thoracic spine, concave\n to the right.\n\n IMPRESSION:\n 1. No evidence of pulmonary embolism.\n 2. Bilateral pleural effusions with associated compressive atelectasis, worse\n on the right.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2110-04-22 00:00:00.000",
"description": "MR HEAD W & W/O CONTRAST",
"row_id": 911230,
"text": " 11:31 AM\n MR HEAD W & W/O CONTRAST; MR CONTRAST GADOLIN Clip # \n Reason: please eval for acute intracranial process via a head MR wit\n Admitting Diagnosis: HYPERTHERMIA\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with seizures, prolonged mental status changes\n REASON FOR THIS EXAMINATION:\n please eval for acute intracranial process via a head MR with contrast with\n particular attention for temporal lobes to look for seizure focus\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Seizures, prolonged mental status changes. Evaluate for acute\n intracranial process, question seizure focus temporal lobes.\n\n TECHNIQUE: MR of the head with and without contrast. T1 sagittal, T1, T2,\n FLAIR, susceptibility, and diffusion-weighted axial images as well as T1-\n weighted post-gadolinium sequences were obtained.\n\n COMPARISONS: .\n\n FINDINGS: No significant interval change is seen. There is an unchanged\n focus of increased T2 and FLAIR signal intensity in the right periventricular\n white matter of unspecific etiology. There is no restricted diffusion to\n indicate acute ischemia. There is no susceptibility artifact to indicate\n hemorrhage. The major vascular flow void patterns are normal. There is a\n pineal cyst. No masses or shift of normally midline structures are seen. In\n particular, the temporal lobes appear unremarkable.\n\n Again seen is fluid opacification of the mastoid air cells bilaterally and\n fluid in the left sphenoid air cell. The fluid within the right maxillary\n sinus has resolved.\n\n IMPRESSION:\n 1. No significant interval change. No abnormalities are detected that would\n explain the patient's seizure activity.\n 2. Stable fluid opacification of the mastoid air cells and fluid in the\n sphenoid sinus.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2110-04-14 00:00:00.000",
"description": "LUMBAR SPINAL PUNCTURE",
"row_id": 910266,
"text": " 2:57 PM\n LUMBAR PUNCTURE Clip # \n Reason: rule out meningitis\n Admitting Diagnosis: HYPERTHERMIA\n ********************************* CPT Codes ********************************\n * LUMBAR SPINAL PUNCTURE -52 REDUCED SERVICES *\n * FLUOR GUID FOR SPINE INJ *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with altered mental status\n REASON FOR THIS EXAMINATION:\n rule out meningitis\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Multiple attempts for a lumbar puncture on the floor by the\n referring clinician were unsuccessful. The patient is referred for\n fluoroscopic guided lumbar puncture.\n\n Informed consent was obtained after explaining the risks indications and\n alternative management. The attending radiologist Dr. was present\n throughout the case.\n\n The patient was brought to the Fluoroscopic Suite and placed on the\n fluoroscopic table in the prone position. Access to the lumbar subarachnoid\n space was obtained using a 22 gauge spinal needle under local anesthesia using\n 1% Lidocaine and with aseptic precautions. Access was attempted at the level\n of L2 L3 and L4. Multiple attempts at fluoro guided puncture were made. The\n patient had extensive calcification of the posterior ligaments.\n\n IMPRESSION: Unsuccessful fluoro guided lumbar puncture due to extensive\n calcification of the posterior ligaments.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2110-04-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 910179,
"text": " 7:08 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: HYPERTHERMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 y/o F w/mental status changes, bacteremia, respiratory failure\n\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 55-year-old female with mental status changes, bacteremia,\n respiratory failure, evaluate for interval change.\n\n COMPARISON: .\n\n AP CHEST RADIOGRAPH:\n\n Allowing for different projections, the heart size, mediastinal and hilar\n contours are unchanged. The endotracheal tube is approximately 6 cm from the\n carina, just at the thoracic inlet. This appears slightly more advanced\n compared to prior study. Bilateral pleural effusions again noted along with\n bibasilar atelectasis. Allowing for positional changes, there appears to be\n slight improvement of effusions and atelectases. Visualized lung fields are\n clear.\n\n IMPRESSION:\n\n Slight improvement in bilateral pleural effusions and bibasilar atelectases.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2110-04-09 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 909578,
"text": " 12:12 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: NGT placement\n Admitting Diagnosis: HYPERTHERMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman w/ persistent hyperthermia, intubated w/ hypercarbia\n on spontaneous breathing trial, s/p dobhoff placement\n REASON FOR THIS EXAMINATION:\n NGT placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Intubated, status post NG placement.\n\n COMPARISON: .\n\n AP CHEST RADIOGRAPH:\n\n There has been interval removal of a left-sided subclavian line and Dobbhoff\n tube. Nasogastric tube is seen with tip in the area of the distal\n esophagus/GE junction. Cardiac and mediastinal and hilar contours appear\n unchanged. Again seen is evidence of bilateral lower lobe consolidation.\n Mild-to-moderate bilateral pleural effusions appear unchanged.\n\n IMPRESSION: Nasogastric tube seen with tip at the distal esophagus. This\n could be advanced several centimeters for more optimal placement. This was\n discussed with house officer caring for this patient on .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2110-04-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 909256,
"text": " 10:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval pna, effusion, edema, ptx\n Admitting Diagnosis: HYPERTHERMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman w/ persistent hyperthermia, intubated w/ hypercarbia on\n spontaneous breathing trial.\n REASON FOR THIS EXAMINATION:\n eval pna, effusion, edema, ptx\n ______________________________________________________________________________\n FINAL REPORT\n CHEST ONE VIEW PORTABLE\n\n INDICATION: 55-year-old woman with persistent hyperthermia.\n\n COMMENTS: Portable erect AP radiograph of the chest is reviewed, and compared\n with the previous study of yesterday.\n\n The patient has been extubated. The left subclavian IV catheter remains in\n place. No pneumothorax is identified.\n\n The previously identified mild congestive heart failure has been improving.\n There is continued cardiomegaly and small bilateral pleural effusion\n associated with bibasilar patchy atelectasis.\n\n There is no evidence of pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2110-04-09 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 909609,
"text": " 3:05 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: NGT placement\n Admitting Diagnosis: HYPERTHERMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman w/ persistent hyperthermia, intubated w/ hypercarbia\n on spontaneous breathing trial, s/p dobhoff placement\n REASON FOR THIS EXAMINATION:\n NGT placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE UPRIGHT CHEST at 15:38.\n\n COMPARISON: at 12:55.\n\n INDICATION: Nasogastric tube placement.\n\n A nasogastric tube has been advanced and terminates within the stomach. There\n is otherwise no change from the recent radiograph.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2110-04-05 00:00:00.000",
"description": "P PELVIS LIMITED PORT",
"row_id": 909201,
"text": " 2:58 PM\n PELVIS LIMITED PORT; PELVIS US LIMIT TRANSVAG PORT Clip # \n Reason: ? VS SURGICAL ABSCESS VS HYDROSALPINX ON CT\n Admitting Diagnosis: HYPERTHERMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with ? on abdominal CT, ongoing fever, sepsis\n REASON FOR THIS EXAMINATION:\n eval for \n ______________________________________________________________________________\n WET READ: JCT SAT 6:55 PM\n no biliary ductal dilitation or evidence of choledocholithiasis.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 55-year-old woman with ongoing fever and sepsis and question of\n tubo-ovarian abscess.\n\n FINDINGS: Transabdominal and transvaginal examinations were performed.\n Transvaginal exam was performed for better evaluation of the adnexa. The exam\n is limited due to patient body habitus and inability to tolerate the\n procedure. There are complex cystic areas in the anterior left adnexum. In\n one of the cystic areas there does appear to be some nodularity which is more\n worrisome for malignancy.\n\n IMPRESSION: Limited study. Complex left ovarian mass concerning for\n malignancy. Tuboovarian abscess is considered less likely. Evaluation can be\n reattempted when the patient is better able to tolerate the ultrasound.\n Alternatively MRI could be performed. These findings were discussed with Dr.\n at 7:00 p.m. .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2110-04-10 00:00:00.000",
"description": "CT ABD W&W/O C",
"row_id": 909726,
"text": " 1:04 PM\n CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: eval for pancreatitis, change in mass vs abscess\n Admitting Diagnosis: HYPERTHERMIA\n Field of view: 50 Contrast: OPTIRAY Amt: 150CC\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman s/p appendectomy for perforated retrocecal appy now c\n ongoing fevers, increasing WBC, rhabdo, pancreatitis, transaminitis \n /lipase\n REASON FOR THIS EXAMINATION:\n eval for pancreatitis, change in mass vs abscess\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 55-year-old woman status post removal of perforated retrocecal\n appendix now with ongoing fevers and increasing white blood cell count,\n rhabdomyolysis, pancreatitis, and transaminitis.\n\n COMPARISON: .\n\n TECHNIQUE: Multidetector axial images of the abdomen and pelvis were obtained\n with oral and IV contrast.\n\n CT ABDOMEN WITHOUT AND WITH IV CONTRAST: There continues to be bibasilar\n atelectasis and small bilateral pleural effusions. The liver, gallbladder,\n pancreas, spleen, adrenal glands, kidneys, stomach, and bowel loops are stable\n in appearance. Tiny low-attenuation focus is again noted in the right hepatic\n lobe. There is no free air or free fluid. Stranding is again noted posterior\n to the cecum and is stable. No fluid collection is identified.\n\n CT PELVIS: Foley catheter is again seen in the bladder. The uterus and right\n adnexa are unremarkable. Again seen is left hydrosalpinx and enlargement of\n the left ovary. The appearance is stable. Numerous sigmoid diverticula are\n again seen without evidence of diverticulitis. There is no free fluid and no\n pelvic or inguinal lymphadenopathy.\n\n BONE WINDOWS: Osseous structures are stable.\n\n IMPRESSION:\n 1. Stable appearance of the abdomen and pelvis without hepatobiliary or\n pancreatic abnormalities identified. Continued bibasilar atelectasis and\n small bilateral pleural effusions.\n 2. Re-demonstration of left hydrosalpinx and enlarged ovary. This was better\n evaluated on the recent ultrasounds and as per their recommendation, further\n evaluation could be obtained with MRI or followup ultrasound.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2110-04-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 908918,
"text": " 4:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval pna, effusion, edema, ptx\n Admitting Diagnosis: HYPERTHERMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with possible serotonin syndrome, Tmax 108, s/p appy on\n \n REASON FOR THIS EXAMINATION:\n eval pna, effusion, edema, ptx\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 55-year-old female with possible serotonin syndrome and fever.\n\n COMPARISON: .\n\n AP SEMI-ERECT PORTABLE CHEST: The endotracheal tube tip is in a high lying\n position approximately 2-3 cm above ideal location. The left subclavian\n central line terminates in the proximal SVC. The nasogastric tube courses\n over the left upper abdomen out of the field of view. Top normal heart size\n and cardiomediastinal contours are stable. There remain moderate right and\n small left pleural effusions. Prominence of the central vasculature and\n distention of the azygos vein are likely due to volume overload. There is\n linear atelectasis at the left base.\n\n IMPRESSION: High endotracheal tube. 3cm advancement suggested. Bilateral\n pleural effusions and volume overload.\n\n This was discussed with on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2110-04-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 909018,
"text": " 6:45 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ETT adjustment.\n Admitting Diagnosis: HYPERTHERMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with possible serotonin syndrome, Tmax 108, s/p appy on\n . ETT advanced 2-3cm by respiratory.\n REASON FOR THIS EXAMINATION:\n ETT adjustment.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 55-year-old status post appendectomy, with high temperatures and\n possible serotonin syndrome. ETT advanced check positioning.\n\n SINGLE AP SEMI-UPRIGHT CHEST: Compared to study of earlier in the day.\n Endotracheal tube has been advanced, with its tip now approximately 2 cm above\n the carina. Right CP angles are excluded on this film, however, there likely\n remain small-to-moderate bilateral pleural effusions. Central venous line tip\n unchanged in positioning.\n\n IMPRESSION: Endotracheal tube tip advanced, now approximately 2 cm above the\n carina. No other short interval change.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2110-04-02 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 908836,
"text": " 10:08 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for ICH/mass effect\n Admitting Diagnosis: HYPERTHERMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with AMS, eye deviation, upgoing toes\n REASON FOR THIS EXAMINATION:\n eval for ICH/mass effect\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION: 55-year-old female with change in mental status and upgoing toes.\n Evaluate for intracranial hemorrhage.\n\n There are no prior studies for comparison.\n\n TECHNIQUE: Noncontrast head CT scan.\n\n FINDINGS: There is a small left frontal extra-axial fluid collection\n representing a chronic subdural hematoma or hygroma. There is no evidence of\n acute intracranial hemorrhage, mass effect, or shift of the normally midline\n structures. The -white matter differentiation is preserved. There is no\n hydrocephalus. The osseous structures are unremarkable. Air fluid levels are\n noted in the maxillary and sphenoid sinuses, likely secondary to intubation.\n There is atherosclerotic calcification of the supraclinoid carotid arteries.\n\n IMPRESSION:\n\n 1. Small left sided extra-axial fluid collection, likely representing\n chronic subdural hematoma or hygroma.\n\n 2. No evidence of an acute intracranial hemorrhage or mass effect.\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2110-04-02 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 908877,
"text": " 3:40 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: eval line placement\n Admitting Diagnosis: HYPERTHERMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with possible serotonin syndrome, Tmax 108, s/p appy on \n with new left subclavian\n REASON FOR THIS EXAMINATION:\n eval line placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n COMPARISON: , at 12:32 a.m.\n\n INDICATION: Line placement.\n\n There has been placement of a left subclavian vascular catheter, terminating\n within the mid superior vena cava with no pneumothorax. Other lines and tubes\n are unchanged in position allowing for positional differences of the patient.\n Cardiac and mediastinal contours are stable. There has been slight\n progression of perihilar and basilar edema as well as increase in size of a\n layering right effusion. Patchy left basilar opacity also appears slightly\n worse in the interval.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2110-04-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 908801,
"text": " 11:33 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for infiltrates, edema, effusion\n Admitting Diagnosis: HYPERTHERMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with possible serotonin syndrome, Tmax 108, s/p appy on \n REASON FOR THIS EXAMINATION:\n Eval for infiltrates, edema, effusion\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 12:32 A.M. .\n\n HISTORY: High fever. Evaluate edema or effusion.\n\n IMPRESSION: AP chest compared to :\n\n Mild cardiomegaly accompanied by moderate distention of the mediastinal\n vasculature. Mild pulmonary edema and small right pleural effusion suggest\n cardiac decompensation and/or volume overload. There is no pneumothorax. Tip\n of the endotracheal tube ends above the clavicles, at least 5.5 cm above the\n carina, probably 2-3 cm above optimal placement. Nasogastric tube passes to\n the distal stomach and out of view. Tip of the right jugular central line\n projects over the course of the right brachiocephalic vein. No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2110-04-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 909811,
"text": " 3:35 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval dobhoff--?post-pyloric\n Admitting Diagnosis: HYPERTHERMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman s/p dobhoff placement\n REASON FOR THIS EXAMINATION:\n eval dobhoff--?post-pyloric\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 3:53 A.M., \n\n HISTORY: Dobbhoff tube placement.\n\n IMPRESSION: AP chest compared to and 27:\n\n The feeding tube can be traced as far as the lower esophagus but not beyond\n due to technical limitations of bedside radiographic technique with a supine\n patient of this size. Bilateral pleural effusion, large on the right and\n moderate on the left, has increased since , obscuring the lower lungs\n and heart. There may be mild edema, but the upper lungs are free of\n pneumonia. No pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2110-04-14 00:00:00.000",
"description": "NASAL/OROGASTRC TUBE PLMT, PRO FEE ONLY",
"row_id": 910299,
"text": " 5:31 PM\n N-G TUBE PLACEMENT Clip # \n Reason: please place post pyloric NG\n Admitting Diagnosis: HYPERTHERMIA\n ********************************* CPT Codes ********************************\n * NASAL/OROGASTRC TUBE PLMT, PRO FEE ADJUSTED IN SPECIFIC SITUATION *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with\n REASON FOR THIS EXAMINATION:\n please place post pyloric NG\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Fluoroscopically guided nasogastric tube placement is requested.\n\n RADIOLOGISTS: Dr. .\n\n FINDINGS/TECHNIQUE: The patient was placed supine on the angiographic table\n and a nasogastric tube was advanced with no difficulties under fluoroscopic\n guidance into the stomach. Final fluoroscopic image confirmed correct\n position of the tip of the catheter within the stomach.\n\n IMPRESSION: Fluoroscopically guided placement of a nasogastric tube with the\n tip in the stomach. The catheter is ready for use.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2110-04-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 909162,
"text": " 3:46 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for ETT, infiltrate\n Admitting Diagnosis: HYPERTHERMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman w/ persistent hyperthermia, intubated w/ hypercarbia on\n spontaneous breathing trial.\n REASON FOR THIS EXAMINATION:\n eval for ETT, infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hyperthermia, hypercarbia, intubated.\n\n COMPARISON: .\n\n AP VIEW OF THE CHEST: The endotracheal tube, nasogastric tube, and left\n subclavian central venous catheter are in unchanged positions. The heart\n remains mildly enlarged. There is continued diffuse bilateral alveolar\n opacities and vascular engorgement consistent with mild congestive heart\n failure, unchanged in the interval. Bibasilar opacities are present\n consistent with atelectasis. Small pleural effusions persist. There is no\n pneumothorax.\n\n IMPRESSION:\n\n 1. Persistent congestive heart failure.\n\n 2. Bibasilar atelectasis with small bilateral pleural effusions.\n DFDdp\n\n"
},
{
"category": "Radiology",
"chartdate": "2110-04-11 00:00:00.000",
"description": "P BILAT LOWER EXT VEINS PORT",
"row_id": 909860,
"text": " 11:17 AM\n BILAT LOWER EXT VEINS PORT Clip # \n Reason: eval for clot\n Admitting Diagnosis: HYPERTHERMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with leg swelling, tachycardia\n REASON FOR THIS EXAMINATION:\n eval for clot\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: Leg swelling and tachycardia.\n\n This study was performed as a portable study at the bedside. All of the deep\n veins in both the right and left lower extremity showed normal compressibility\n and all showed normal color flow and normal dynamic pulse Doppler waveforms.\n\n CONCLUSION: No evidence of DVT in the lower extremities.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2110-04-18 00:00:00.000",
"description": "PICC W/O PORT",
"row_id": 910775,
"text": " 10:47 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: please place IR guided PICC - unable to place at bedside\n Admitting Diagnosis: HYPERTHERMIA\n ********************************* CPT Codes ********************************\n * PICC W/O FLUOR GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS C1751 CATH ,/CENT/MID(NOT D *\n * C1769 GUID WIRES INCL INF C1769 GUID WIRES INCL INF *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with status epilepticus and PNA\n\n REASON FOR THIS EXAMINATION:\n please place IR guided PICC - unable to place at bedside\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: PICC placement for TPN and IV antibiotics.\n\n PHYSICIANS: Dr. and Dr. , with Dr. , the\n attending radiologist, present and supervising throughout the procedure.\n\n PROCEDURE: The patient was positioned supine on the angiography table. Pre-\n procedure timeout was performed to confirm patient, procedure, and site.\n Standard sterile prep and drape of the left arm was performed. Local\n anesthesia with 5 cc of 1% lidocaine subcutaneously was administered. Using\n real-time ultrasound guidance, a 21-gauge needle was advanced into the left\n brachial vein. Hard copy ultrasound images pre- and post-puncture were\n obtained. A 0.018-inch guide wire was advanced to the expected region of the\n axillary vein under flouroscopic guidance and the needle was exchanged for the\n micropuncture sheath. The 5-French double-lumen PICC was cut to a length of 44\n cm. The PICC was placed over the wire through the sheath to terminate in the\n proximal superior vena cava. The sheath and wire were removed. Both lumens\n of the catheter flushed and aspirated well, were capped and heplocked. The\n catheter was fixed in place with a StatLock device and a sterile transparent\n dressing was applied. A final limited chest radiograph confirmed the catheter\n tip placement in the proximal superior vena cava. The catheter is ready for\n use. There were no immediate complications.\n\n IMPRESSION: Successful placement of a 44-cm 5-French double-lumen PICC by way\n of the left brachial vein to terminate in the proximal superior vena cava. The\n catheter is ready for use.\n\n\n\n\n\n\n (Over)\n\n 10:47 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: please place IR guided PICC - unable to place at bedside\n Admitting Diagnosis: HYPERTHERMIA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2110-04-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 910729,
"text": " 1:39 AM\n CHEST (PORTABLE AP) Clip # \n Reason: check placement of OGtube\n Admitting Diagnosis: HYPERTHERMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 y/o F w/mental status changes, bacteremia, respiratory failure\n\n REASON FOR THIS EXAMINATION:\n check placement of OGtube\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 1:49 A.M., \n\n HISTORY: Mental status changes and bacteremia. Orogastric tube placed.\n\n IMPRESSION: AP chest compared to :\n\n An orogastric tube passes below the diaphragm and out of view. Examination\n was exposed for imaging the abdomen therefore detail in the lungs is\n suboptimal. There is at least a moderate volume of pleural fluid bilaterally\n increased since . Heart is enlarged and mediastinal veins are engorged.\n ET tube is in standard placement. Pneumothorax cannot be excluded but if\n present, is only small. Detail in the lower lungs is obscured by overlying\n effusion and motion artifact.\n\n"
},
{
"category": "Radiology",
"chartdate": "2110-04-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 909384,
"text": " 4:41 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval dobhoff placement\n Admitting Diagnosis: HYPERTHERMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman w/ persistent hyperthermia, intubated w/ hypercarbia on\n spontaneous breathing trial, s/p dobhoff placement\n REASON FOR THIS EXAMINATION:\n eval dobhoff placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post Dobbhoff placement.\n\n COMPARISON: .\n\n AP CHEST RADIOGRAPH\n\n Compared to prior study, there has been interval placement of a Dobbhoff tube.\n The distal tip is seen looped within the stomach. Left-sided subclavian line\n appears in unchanged position. Cardiac and mediastinal, hilar contours appear\n unchanged. Again seen is no evidence of mild CHF. Small bilateral effusions\n and atelectasis also appear unchanged.\n\n IMPRESSION: Dobhoff tube seen coiled within the stomach. No other\n significant change from prior study.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2110-04-05 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 909190,
"text": " 12:17 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: eval for infectious source\n Admitting Diagnosis: HYPERTHERMIA\n Field of view: 50 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman s/p appendectomy for perforated retrocecal appy now c ongoing\n fevers, increasing WBC, rhabdo, pancreatitis, transaminitis\n REASON FOR THIS EXAMINATION:\n eval for infectious source\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 55-year-old woman status post appendectomy for perforated retrocecal\n appendix now with ongoing fevers and increased white blood cell count,\n rhabdomyolysis, pancreatitis.\n\n TECHNIQUE: Multidetector axial images of the abdomen and pelvis were obtained\n with oral and IV contrast. 130 cc Optiray. Coronal and sagittal reformatted\n images were obtained.\n\n CT ABDOMEN: There is bibasilar atelectasis and bilateral pleural effusions.\n Tiny low-attenuation hepatic foci are noted but too small to be fully\n characterized. The gallbladder, pancreas, spleen, adrenal glands, kidneys,\n stomach, and bowel loops are within normal limits. There is no free air.\n Stranding is noted posterior to the right colon and cecum consistent with the\n recent operation. No discrete fluid collection is identified.\n\n CT PELVIS: Within the left adnexa, there is a complex cystic area. Foley\n catheter and air are noted in the bladder. The uterus and right adnexa are\n unremarkable. Sigmoid diverticula are observed without definite\n diverticulitis. The rectum is unremarkable. There is no free fluid and no\n pelvic or inguinal lymphadenopathy.\n\n BONE WINDOWS: There are no suspicious lytic or sclerotic osseous lesions.\n Fusion of the lumbar spinous processes is noted.\n\n IMPRESSION:\n\n 1. Complex cystic focus in the left adnexa with apparent enlargement of the\n left ovary. This is worrisome for an ovarian malignancy. Tuboovarian abscess\n is considered less likely as there is no inflammatory reaction surrounding\n the ovary. Further evaluation could be obtained with ultrasound.\n 2. No fluid collection is identified in the retrocecal space.\n 3. Sigmoid diverticulosis.\n 4. No acute hepatobiliary or pancreatic abnormalities identified.\n 5. Small bilateral pleural effusions.\n\n These findings were discussed with Dr. at 1:15 p.m. on .\n\n\n (Over)\n\n 12:17 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: eval for infectious source\n Admitting Diagnosis: HYPERTHERMIA\n Field of view: 50 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2110-04-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 909854,
"text": " 10:56 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ?ETT placement\n Admitting Diagnosis: HYPERTHERMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman s/p intubation.\n REASON FOR THIS EXAMINATION:\n ?ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 55-year-old post intubation, assess ET tube position.\n\n Portable supine frontal radiograph. Comparison is made to study done 7 hours\n earlier.\n\n There has been interval placement of an endotracheal tube with its tip\n terminating several centimeters above the carina. The Dobhoff feeding tube\n remains in place and is unchanged. There has been a slight increase in\n perihilar haziness compared to . Bilateral pleural effusions with\n associated atelectasis/consolidation is unchanged.\n\n IMPRESSION:\n\n Interval intubation. Slight increase in perihilar haziness compared to\n , but not significantly changed compared to the study done earlier this\n morning.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2110-04-10 00:00:00.000",
"description": "MR HEAD W & W/O CONTRAST",
"row_id": 909648,
"text": " 12:54 AM\n MR HEAD W & W/O CONTRAST; MR CONTRAST GADOLIN Clip # \n Reason: ?abscess, met or infectious process; WITH GADOLINIUM\n Admitting Diagnosis: HYPERTHERMIA\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with waxing and mental status. s/p recent extubation\n and new adnexal ovarian cystic mass.\n REASON FOR THIS EXAMINATION:\n ?abscess, met or infectious process; WITH GADOLINIUM\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 55-year-old female with waxing and mental status.\n\n COMPARISON: CT head dated .\n\n TECHNIQUE: Multiplanar T1 and T2-weighted images of the brain were obtained.\n Gadolinium enhanced and diffusion-weighted images were also performed.\n\n FINDINGS: The study is limited secondary to motion artifact. Allowing for\n this limitation, no areas of abnormal enhancement are demonstrated on post-\n Gadolinium images. There is a small focus of increased T2 and FLAIR signal\n intensity involving the right periventricular white matter which is\n nonspecific in etiology. There are no areas of slowed diffusion to indicate\n acute brain ischemia. No susceptibility artifacts are present indicating\n prior hemorrhage. The ventricles and sulci are normal in size and\n symmetrical. The major vascular flow void patterns are normal. There are\n small air-fluid levels within a right maxillary and sphenoid sinuses with\n increased signal in the mastoid air cells bilaterally, likely secondary to\n intubation.\n\n IMPRESSION: No abnormal contrast enhancement within the brain parenchyma.\n Nonspecific small right periventricular increased T2 and FLAIR signal- chronic\n small vessel infarct or post-inflammatory residuum are the most likely\n diagnostic considerations. No diffusion- weighted abnormalities to indicate\n acute infarction.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2110-04-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 909783,
"text": " 5:37 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for NGT placement; also eval for new infiltrate\n Admitting Diagnosis: HYPERTHERMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman s/p dobhoff placement, also with new hypoxia\n REASON FOR THIS EXAMINATION:\n eval for NGT placement; also eval for new infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 55-year-old woman with Dobhoff placement, new hypoxia.\n\n TECHNIQUE: Portable AP chest radiograph.\n\n COMPARISON: Chest radiograph dated .\n\n FINDINGS: The Dobhoff tube is terminating at the left upper quadrant,\n probably in the stomach. The study is technically limited due to patient body\n habitus. Again, note is made of bilateral pleural effusion, with bibasilar\n opacities, which appears somewhat increased, especially on the right. The\n evaluation of the bowel gas pattern, however, is unchanged compared to the\n prior study. Scoliosis is again seen.\n\n IMPRESSION: Dobhoff tube as described above. Somewhat increased bilateral\n pleural effusions and bibasilar opacities, especially in the right lower lobe.\n For more information about thorax, please obtain PA and LAT chest radiographs.\n\n"
}
] |
83,570 | 107,946 | 74 yo male s/p fall from tractor and crush injury from tree branch. - Loc. +HD stable with injuries: Mult rib fx: R and P, T4 vert body inf corner fx, comminuted spinous process fx T2-8, R liver lobe contusion, L pubic ramus fx, R iliac fx, B pulmonary contusion, laceration under right eyebrow. 4 PRBCs given, 2 FFP given. On overnight he was reintubated for presumed fluid overload - tachycardic, hypotensive, desated, decreased oxygenation. He went to IR and had an embolization for a bleed secondary to his pelvic fractures. He went into AF after this, was corrected and broken with dilt gtt, and was transitioned to PO diltiazem and remained mostly in NSR with occasional AF - which broke after IV amiodarone and PO amio was then added. He did have a 1st degree AV block when in sinus rhythm. He had an increasing WBC and his BAL grew out klebsiella - he was treated for 10 days with broad spectrum abx for this. On he was trached (perc) and PEG'd, TF were Nutrin 2.0 to a goal of 40. He became hypernatremic and on the discharge day was switched to a less concentrated formula to help correct his hypernatremia. Ortho recommended a TLSO (which he was fit for) while out of bed. he remained in sinus on the amio and no AC was started. We tried to wean him to trach mask, however he became tachypneic on and was put back on CPAP and PS at PS of 10 and PEEP of 5. His HCTs have been stable. His WBC improved and his VAP is presumed to be successfully treated. He is in good condition on for discharge to an acute outpt facility with a need for close watching his sodium, need to wean his vent, and a need to monitor for further episodes of AF. He will also need PT and OT and his TLSO out of bed. | Assessment and Plan Sinus rhythm currently; off pressors with BP slightly hypertensive. On appropriate abx per BAL cx Ceftriaxone. On appropriate abx per BAL cx Ceftriaxone. 2+ tricuspid regurgitation. Trace aortic regurgitation is seen. Hematology: Hct stable 32.1->29.7. Hematology: Hct stable 32.1->29.7. Moderate [2+]tricuspid regurgitation is seen. Cont dilt gtt. Pneumococcal Vac Polyvalent 26. Pneumococcal Vac Polyvalent 26. of themitral chordae (normal variant). Respiratory failure, acute (not ARDS/) Assessment: Action: Response: Plan: Dilated rightventricule with borderline normal function with evidence of right ventricularpressure overload. Wean fentanyl gtt, midazolam gtt Cardiovascular: Aflutter, now reverted to sinus. Wean fentanyl gtt, midazolam gtt Cardiovascular: Aflutter, now reverted to sinus. Wean fentanyl gtt, midazolam gtt Cardiovascular: Aflutter, now reverted to sinus. Cardiovascular: Now back in NSR, off dilt gtt and currently weaning Neo gtt. Assessment and Plan Sinus rhythm currently; off pressors with BP slightly hypertensive. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date: @ 0104 2. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date: @ 0104 2. On appropriate abx per BAL cx -Vanco and Ceftriaxone. On appropriate abx per BAL cx -Vanco and Ceftriaxone. Atrial fibrillation (Afib) Assessment: Remains in 1^st degree HB. Atrial fibrillation (Afib) Assessment: Remains in 1^st degree HB. Atrial fibrillation (Afib) Assessment: Remains in 1^st degree HB. Zyprexa & Haldol PRN (off fent/midaz ). Lasix gtt initiated for diuresis. Lasix gtt initiated for diuresis. Pneumococcal Vac Polyvalent 23. HYDROmorphone (Dilaudid) 0.125-1 mg IV Q3H:PRN pain Order date: @ 0912 28. On appropriate abx per BAL cx - Ceftriaxone. Wean fentanyl gtt, midazolam gtt Cardiovascular: Aflutter, now reverted to sinus. On appropriate abx per BAL cx -Vanco and Ceftriaxone. Zyprexa & Haldol PRN (off fent/midaz ). ------ Protected Section ------ At 630 pt tongued ETT and self extubated. Atrial fibrillation (Afib) Assessment: Remains in 1^st degree HB. (febrile to 101.8 on abx) cultures sent and pnd. Pneumococcal Vac Polyvalent 23. Pneumococcal Vac Polyvalent 23. Lasix gtt initiated for diuresis. Diltiazem drip currently off. Cardiovascular: Aflutter, now reverted to sinus w/1st deg AVB. Cardiovascular: Aflutter, now reverted to sinus w/1st deg AVB. Cardiovascular: Aflutter, now reverted to sinus w/1st deg AVB. On appropriate abx per BAL cx - Ceftriaxone. Wean fentanyl gtt, midazolam gtt Cardiovascular: Aflutter, now reverted to sinus. On appropriate abx per BAL cx -Vanco and Ceftriaxone. On appropriate abx per BAL cx Ceftriaxone. Fever 101.1 o/n, re-pan cx. Fever 101.1 o/n, re-pan cx. Diamox given. Zyprexa & Ativan PRN (off fent/midaz ). Zyprexa & Ativan PRN (off fent/midaz ). Cardiovascular: Aflutter->NSR, on Amio and diltizem 60 QID. Cardiovascular: Aflutter->NSR, on Amio and diltizem 60 QID. Cardiovascular: Aflutter->NSR, on Amio and diltizem 60 QID. Cardiovascular: Aflutter->NSR, on Amio and diltizem 60 QID. Cardiovascular: Aflutter->NSR, on Amio and diltizem 60 QID. Cont on dilt and amioderone. Heme: Stable ID: cont on abx. Cont zyprexa, dilt and amio. Pneumococcal Vac Polyvalent 31. Lansoprazole Oral Disintegrating Tab 18. Lansoprazole Oral Disintegrating Tab 18. Glucagon 18. Metoprolol Tartrate 23. Lansoprazole Oral Disintegrating Tab 24. Diamox with Lasix times 1. Ciprofloxacin HCl 11. Metoprolol Tartrate 24. Cardiovascular: Aflutter->NSR, on Amio and diltizem 60 QID. Cardiovascular: Aflutter->NSR, on Amio and diltizem 60 QID. Cardiovascular: Aflutter->NSR, on Amio and diltizem 60 QID. Cardiovascular: Aflutter->NSR, on Amio and diltizem 60 QID. Lines / Tubes / Drains: Foley, RIJ CVL (d/c if stable), PIV x2, Foley, a-line (). Lines / Tubes / Drains: Foley, RIJ CVL (d/c if stable), PIV x2, Foley, a-line (). Currently on phenylephrine. Pneumococcal Vac Polyvalent 31. Pneumococcal Vac Polyvalent 31. Given ~1L bolus o/n for decreasing uop. Given ~1L bolus o/n for decreasing uop. Action: Dilaudid PCA, abd/pelvic CTA and thoracic MR, Q 4 hr Hct checks, IS per orders. Action: Dilaudid PCA, abd/pelvic CTA and thoracic MR, Q 4 hr Hct checks, IS per orders. Action: Dilaudid PCA, abd/pelvic CTA and thoracic MR, Q 4 hr Hct checks, IS per orders. Given ~1L bolus o/n for decreasing uop. Tighten RISS as slightly hyperglycemic. CXR w/pleural effusion, vasc congestion. CXR w/pleural effusion, vasc congestion. CXR w/pleural effusion, vasc congestion. Gastrointestinal / Abdomen: NPO after MN for possible OR (pelvis). The T4 vertebral body demonstrates a nondisplaced anterior inferior corner fracture. Non-displaced left clavicle and left scapula fractures. Nondisplaced left clavicle distal fracture 7. Non-displaced left T10 transverse process fracture. Mild compression deformity of L1 with additional levels of potential trabecular contusion at T10-11 also inferiorly at T4 with no retropulsion. Mild compression deformity of L1 with additional levels of potential trabecular contusion at T10-11 also inferiorly at T4 with no retropulsion. Mild compression deformity of L1 with additional levels of potential trabecular contusion at T10-11 also inferiorly at T4 with no retropulsion. Multilevel degenerative changes with moderate canal narrowing at T10-11 with cord deformity and no abnormal cord signal. Small contusion in hepatic segment VII again noted. A small ill-defined focus of hypoechogenicity measuring up to approximately 2.3 cm in the posterior right hepatic lobe is consistent with the intrahepatic contusion/laceration seen on CT. On arterial phase, there is a tiny hyperdense linear focus, extending a few millimeters, concerning for active extravasation. Posterior right hepatic laceration/contusion, adjacent to a calcified granuloma, with a small hematoma, without evidence of active extravasation. Posterior right hepatic laceration/contusion adjacent to calcified granuloma, with small hematoma, without active bleeding 5. Cardiac size is top normal, is partially obscured by lung abnormality. | 200 | [
{
"category": "Echo",
"chartdate": "2175-01-30 00:00:00.000",
"description": "Report",
"row_id": 88102,
"text": "PATIENT/TEST INFORMATION:\nIndication: Right ventricular function. Atrial flutter. Hypotension. S/p trauma.\nHeight: (in) 70\nWeight (lb): 198\nBSA (m2): 2.08 m2\nBP (mm Hg): 111/57\nHR (bpm): 84\nStatus: Inpatient\nDate/Time: at 15:32\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Normal LA and RA cavity sizes.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The patient is mechanically ventilated.\nCannot assess RA pressure.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). False LV tendon (normal variant). Transmitral\nDoppler E>A and TDI E/e' <8 suggesting normal diastolic function, and normal\nLV filling pressure (PCWP<12mmHg). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic function.\n\nAORTA: Mildly dilated aortic sinus. Normal ascending aorta diameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. of the\nmitral chordae (normal variant). No resting LVOT gradient.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Mild PA\nsystolic hypertension.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium and right atrium are normal in cavity size. Left ventricular\nwall thickness, cavity size and regional/global systolic function are normal\n(LVEF >55%). Transmitral and tissue Doppler imaging suggests normal diastolic\nfunction, and a normal left ventricular filling pressure (PCWP<12mmHg). Right\nventricular chamber size is mildly dilated with normal free wall motion. The\naortic root is mildly dilated at the sinus level. The aortic valve leaflets\n(3) appear structurally normal with good leaflet excursion and no aortic\nstenosis. Trace aortic regurgitation is seen. The mitral valve appears\nstructurally normal with trivial mitral regurgitation. There is no mitral\nvalve prolapse. There is mild pulmonary artery systolic hypertension. There is\nno pericardial effusion.\n\nCompared with the prior study (images reviewed) of , the right\nventricular cavity is now smaller, the severity of tricuspid regurgitation is\nnow reduced, and the estimated pulmonary artery systolic pressure is now lower\n(previously overestimated on review of the prior study).\n\nCLINICAL IMPLICATIONS:\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate prophylaxis is NOT recommended. Clinical decisions regarding the need\nfor prophylaxis should be based on clinical and echocardiographic data.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2175-01-25 00:00:00.000",
"description": "Report",
"row_id": 88133,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Right ventricular function. Shortness of breath.\nHeight: (in) 70\nWeight (lb): 198\nBSA (m2): 2.08 m2\nBP (mm Hg): 114/54\nHR (bpm): 78\nStatus: Inpatient\nDate/Time: at 16:51\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nPatient hypotensive on phenylephrine drip at 1.5 mcg/kg/min\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). Normal regional LV systolic function.\n\nRIGHT VENTRICLE: Moderately dilated RV cavity. Borderline normal RV systolic\nfunction.\n\nAORTIC VALVE: Three aortic valve leaflets. Moderately thickened aortic valve\nleaflets. No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nTRICUSPID VALVE: Moderate [2+] TR. Severe PA systolic hypertension.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: The patient appears to be in sinus rhythm. Results were\npersonally reviewed with the MD caring for the patient.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thickness, cavity\nsize and regional/global systolic function are normal (LVEF >55%). Regional\nleft ventricular wall motion is normal. The right ventricular cavity is\nmoderately dilated with borderline normal free wall function. Septal motion is\nindicative of right ventricular pressure overload. There are three aortic\nvalve leaflets. The aortic valve leaflets are moderately thickened. There is\nno aortic valve stenosis. No aortic regurgitation is seen. The mitral valve\nappears structurally normal with trivial mitral regurgitation. Moderate [2+]\ntricuspid regurgitation is seen. There is severe pulmonary artery systolic\nhypertension. There is no pericardial effusion.\n\nIMPRESSION: Preserved left ventricular systolic function. Dilated right\nventricule with borderline normal function with evidence of right ventricular\npressure overload. 2+ tricuspid regurgitation. Severe pulmonary artery\nsystolic pressure\n\nDr. was notified in person of the results on at 17:27.\n\n\n"
},
{
"category": "Physician ",
"chartdate": "2175-02-02 00:00:00.000",
"description": "EP NOTE",
"row_id": 714687,
"text": "Cardiac Electrophysiology Note:\n History of Present Illness\n Date: \n Subsequent care\n Events / History of present illness: 74M no known PMH, presented on\n s/p fall from tractor and crush injury with right ribs and pelvic\n fractures and T4 vertebral body fracture. He was given 4 U PRBC, 1 unit\n FFP, and underwent arteriogram on with embolization to the liver\n and pelvis and IVC filter placement for concern of high likelihood of\n development of DVT and inability to anticoagulate. We were consulted\n d/t paroxysmal atrial flutter which has started on the morning of\n . He was started on Amiodarone drip, with subsequent conversion to\n sinus rhythm last evening. He is currently post PEG and tracheostomy,\n awake and alert. He is in sinus rhythm at the 90s, on Amiodarone P.O.\n Medications\n Unchanged\n Physical Exam\n Tmax C last 24 hours: 37.7 C\n Tmax F last 24 hours: 99.9 F\n T current C: 36.3 C\n T current F: 97.4 F\n Previous day:\n Intake: 1,764 mL\n Output: 1,630 mL\n Fluid balance: 134 mL\n Today:\n Intake: 863 mL\n Output: 1,115 mL\n Fluid balance: -252 mL\n General: Awake and alert. Sitting in a chair. No acute distress\n Cardiovascular: (Auscultation: RRR, no murmurs)\n Respiratory: (Auscultation: Limited exam: clear to auscultation, no\n rales or wheezes)\n Abdomen: (Limited exam: Could not appreciate organomegaly )\n Neurological: (Orientation: Awake and alert)\n Labs\n 109\n 10.2\n 110\n 0.8\n 31\n 4.5\n 24\n 105\n 144\n 31.3\n 5.9\n [image002.jpg]\n 01:00 AM\n 05:12 AM\n 01:46 AM\n 01:55 AM\n 02:18 AM\n 08:00 AM\n 02:00 PM\n 08:00 PM\n 01:00 AM\n 01:07 AM\n WBC\n 8.8\n 4.2\n 5.9\n Hgb\n 10.7\n 9.5\n 10.2\n Hct (Serum)\n 32.1\n 29.7\n 31.3\n Plt\n 153\n 104\n 109\n INR\n 1.2\n PTT\n 27.6\n Na+\n 143\n 143\n 142\n 144\n K + (Serum)\n 4.0\n 3.9\n 4.2\n 4.5\n Cl\n 108\n 106\n 106\n 105\n HCO3\n 32\n 32\n 31\n 31\n BUN\n 19\n 22\n 24\n 24\n Creatinine\n 0.7\n 0.7\n 0.7\n 0.8\n Glucose\n 115\n 132\n 122\n 117\n 129\n 100\n 111\n 105\n 117\n 110\n CK\n 225\n 128\n ABG: 7.45 / 49 / 98 / / 8 Values as of 01:18 AM\n Assessment and Plan\n ATRIAL FLUTTER: converted to sinus yesterday evening with I.V\n amiodarome. Would recommend:\n 1. Amiodarone PO 400 mg .\n 2. Metoprolol Succinate PO 25 mg .\n 3. Discontinue Diltiazem P.O.\n 4. Discontinue I.V Metoprolol\n 5. Consider Heparin I.V with a goal of PTT between 60-80 seconds\n if it is not contra-indicated from his trauma standpoint\n ------ Protected Section ------\n 1. Would also recommend liver enzymes follow up given his\n elevated LFT\ns and Amiodarone treatment\n 2. Amiodarone 400mg for 1 week followed by Amiodarone 400 mg\n daily for 1 week, and then Amiodarone 200 mg daily.\n 3. ------ Protected Section Addendum Entered By:\n , MD on: 13:00 ------\n 4.\n 5.\n 6. Electronically signed by , MD \n 13:00\n 7.\n Cardiology Teaching Physician Note\n have seen and examined the patient. I have reviewed the above note\n and plans.\n I would add the following remarks:\n Physical Examination\n bp incr and sinus \n Medical Decision Making\n transition diltiazem to beta blocker and ace inhibitor, they both will\n help prevent atrial tachyarrhythmias. if any concerns about amiodarone\n liver toxicity since in sinus tach can cut back dose\n 8.\n 9. ------ Protected Section Addendum Entered By: \n on: 17:29 ------\n 10.\n 11.\n 12. Electronically signed by 17:29\n 13.\n 14.\n"
},
{
"category": "Respiratory ",
"chartdate": "2175-01-31 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 714230,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 7\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 20 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt cont intub with OETT sedated and on mech vent as per\n Metavision. Lung sounds ess clear after suct mod th tan sput. ABGs\n metabolic alkalosis with adequate oxygenation on current vent settings;\n no vent changes required overnoc. Cont PSV.\n"
},
{
"category": "Nursing",
"chartdate": "2175-01-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 714234,
"text": "Hypotension (not Shock)\n Assessment:\n Cont in aflutter with controlled rate. SBP remains > 90 on neo gtt.\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Respiratory ",
"chartdate": "2175-01-31 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 714336,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 7\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 25 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL / Air\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Pending procedure /\n OR\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Patient remains on ventilator support. Tracheostomy planned for\n tomorrow.\n"
},
{
"category": "Nursing",
"chartdate": "2175-01-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 714041,
"text": "74M s/p fall with multiple rib fx, pelvis fx, clavicle fx, and thoracic\n fx c/b unstable bleeding s/p IR embo, AF with RVR, hematologic\n abnormalities, now with resp failure.\n Atrial fibrillation (Afib), aflutter\n Assessment:\n Pt in and out of aflutter with controlled rate. Predominently\n aflutter. Hypotensive w/ sbp 80\ns while in aflutter.\n Action:\n Pt started dilt gtt 5-10mg/hr. K=3.5 and lytes repleted. Neo gtt to\n support sbp titrated to map >60 and sbp >100\n Response:\n Remains on dilt now at 10mg/hr. Briefly converted to nsr and then back\n to aflutter. Sbp 90-115 w/ neo gtt.\n Plan:\n Cont to monitor hemodynamics. Wean neo gtt as tolerated. Cont dilt\n gtt. PRN Lopressor. Replete lytes.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2175-01-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 713846,
"text": "Atrial fibrillation (Afib)\n Assessment:\n HR 60s-80s SR with 1^st degree AV block.\n Action:\n Continues on diltiazem.\n Response:\n HR stable. Continue on neo for BP.\n Plan:\n Continue to monitor HR and BP.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n On PS 12/12/40%. LS clear and diminished.\n Action:\n Sx\nd for minimal secretions.\n Response:\n O2 Sat stable. ABG marginal and no attempts to wean further at this\n time.\n Plan:\n Continue to attempt to wean vent when able.\n Hypotension (not Shock)\n Assessment:\n Continues on neo gtt to maintain goal map >65. Urine output\n 30-40cc/hr.\n Action:\n Able to wean neo down to 0.3mcg/kg/min. Gave albumin last pm and pt\n BP increased for awhile.\n Response:\n Continues grossly edematous.\n Plan:\n Plan for possible albumin/lasix combination- to be decided.\n"
},
{
"category": "Nursing",
"chartdate": "2175-01-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 713848,
"text": "Atrial fibrillation (Afib)\n Assessment:\n HR 60s-80s SR with 1^st degree AV block.\n Action:\n Continues on diltiazem.\n Response:\n HR stable. Continue on neo for BP.\n Plan:\n Continue to monitor HR and BP.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n On PS 12/12/40%. LS clear and diminished.\n Action:\n Sx\nd for minimal secretions.\n Response:\n O2 Sat stable. ABG marginal and no attempts to wean further at this\n time.\n Plan:\n Continue to attempt to wean vent when able.\n Hypotension (not Shock)\n Assessment:\n Continues on neo gtt to maintain goal map >65. Urine output\n 30-40cc/hr. On 25mcg propofol and when off propofol follows commands\n and denies pain. Very agitated off propofol and placed back on lowest\n dose possible.\n Action:\n Able to wean neo down to 0.3mcg/kg/min. Gave albumin last pm and pt\n BP increased for awhile.\n Response:\n Continues grossly edematous.\n Plan:\n Plan for possible albumin/lasix combination- to be decided.\n"
},
{
"category": "Physician ",
"chartdate": "2175-02-01 00:00:00.000",
"description": "Intensivist Note",
"row_id": 714462,
"text": "TSICU\n HPI:\n 74M s/p fall with multiple rib fx, pelvis fx, clavicle fx, and thoracic\n fx c/b unstable bleeding s/p IR embo, now with AF with RVR/Aflutter,\n persistant hypotension and presumed PNA.\n Chief complaint:\n fall\n PMHx:\n none\n Current medications:\n 1. Acetaminophen 2. Amiodarone 3. Bisacodyl 4. Calcium Gluconate 5.\n CeftriaXONE 6. Chlorhexidine Gluconate 0.12% Oral Rinse 7. Dextrose 50%\n 8. Diltiazem 9. Docusate Sodium (Liquid) 10. Fentanyl Citrate 11.\n Gabapentin 12. Glucagon 13. Heparin 14. Insulin 15. Lactulose 16.\n Magnesium Sulfate 17. Metoprolol Tartrate 18. Midazolam 19. Midazolam\n 20. Milk of Magnesia 21. Ondansetron 22. OxycoDONE Liquid 23.\n Pantoprazole 24. Phenylephrine\n 25. Pneumococcal Vac Polyvalent 26. Potassium Phosphate 27. Potassium\n Chloride 28. Senna 29. Sodium Chloride 0.9% Flush\n 24 Hour Events:\n Changed sedation to po Oxycodone, wean fentanyl gtt, wean Midazolam,\n and start Haldol prn, but stopped due to QTc. Cards consult, started\n amiodarone.\n Post operative day:\n POD#6 - IVC filter via L groin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\n Vancomycin - 08:00 AM\n Ceftriaxone - 12:00 PM\n Infusions:\n Midazolam (Versed) - 5 mg/hour\n Fentanyl (Concentrate) - 50 mcg/hour\n Amiodarone - 0.5 mg/min\n Other ICU medications:\n Haloperidol (Haldol) - 10:45 AM\n Lorazepam (Ativan) - 02:00 PM\n Midazolam (Versed) - 03:25 AM\n Fentanyl - 03:25 AM\n Heparin Sodium (Prophylaxis) - 05:33 AM\n Other medications:\n Flowsheet Data as of 06:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.1\nC (100.6\n T current: 37.2\nC (98.9\n HR: 76 (74 - 104) bpm\n BP: 125/62(81) {90/49(62) - 152/67(89)} mmHg\n RR: 25 (18 - 31) insp/min\n SPO2: 98%\n Heart rhythm: A Flut (Atrial Flutter)\n Wgt (current): 102 kg (admission): 90 kg\n CVP: 12 (10 - 19) mmHg\n Total In:\n 3,718 mL\n 759 mL\n PO:\n Tube feeding:\n 1,920 mL\n 424 mL\n IV Fluid:\n 1,078 mL\n 245 mL\n Blood products:\n Total out:\n 1,755 mL\n 350 mL\n Urine:\n 1,755 mL\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,963 mL\n 409 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 480 (400 - 540) mL\n PS : 10 cmH2O\n RR (Spontaneous): 29\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 21 cmH2O\n SPO2: 98%\n ABG: 7.44/45/119/31/6\n Ve: 11.8 L/min\n PaO2 / FiO2: 238\n Physical Examination\n General Appearance: No acute distress, intubated\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), shallow respirations\n Abdominal: Soft, No(t) Non-distended, Bowel sounds present, Distended\n Left Extremities: (Edema: 1+), (Temperature: Warm)\n Right Extremities: (Edema: 1+), (Temperature: Warm)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities, Sedated\n Labs / Radiology\n 104 K/uL\n 9.5 g/dL\n 129 mg/dL\n 0.7 mg/dL\n 31 mEq/L\n 4.2 mEq/L\n 24 mg/dL\n 106 mEq/L\n 142 mEq/L\n 29.7 %\n 4.2 K/uL\n [image002.jpg]\n 04:45 PM\n 12:45 AM\n 01:00 AM\n 05:12 AM\n 02:40 PM\n 01:46 AM\n 01:55 AM\n 03:40 PM\n 12:07 AM\n 02:18 AM\n WBC\n 13.1\n 8.8\n 4.2\n Hct\n 31.6\n 32.1\n 29.7\n Plt\n 158\n 153\n 104\n Creatinine\n 0.8\n 0.7\n 0.7\n 0.7\n TCO2\n 35\n 35\n 34\n 37\n 35\n 32\n Glucose\n 131\n 115\n 132\n 122\n 117\n 129\n Other labs: PT / PTT / INR:13.7/27.6/1.2, CK / CK-MB / Troponin\n T:128/13/<0.01, ALT / AST:87/109, Alk-Phos / T bili:115/5.0, Amylase /\n Lipase:44/, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic Acid:1.4\n mmol/L, Albumin:2.7 g/dL, LDH:348 IU/L, Ca:7.9 mg/dL, Mg:2.0 mg/dL,\n PO4:3.4 mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, now\n with AF with RVR/Aflutter, persistant hypotension and presumed PNA.\n Neurologic: Intubated. Per ortho spine, no surgery; HOB<30, TLSO when\n OOB (NEOPS will place). Wean sedation as may be causing hypotension.\n Change pain meds to PO. Wean versed.\n Neuro checks Q: shift\n Pain: Oxycodone, Fentanyl gtt (weaning), Midazolam gtt (weaning),\n Neurontin, Tylenol\n Cardiovascular: Aflutter on Dilt 60mg PO QID. Neo off since this AM.\n Cards yesterday rec Amio Pressor requirements may be related to\n AFib/flutter. No plan for electrical cardioversion right now. As pt\n cannot be anticoagulated (recent major trauma), had TTE w/o thrombus,\n Cards would like anticoagulation, will hold on heparin per Trauma\n surgery.\n Pulmonary: Intubated, weaning, tachypneic likely abd distension. On\n appropriate abx per BAL cx\n Ceftriaxone. Plan for trach today.\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin (declining 6.8\n max ->5.0) with CT scan suggesting cirrhosis - Hepatitis panel NEG. TFs\n on hold for PEG. Bowel regimen, no B<M since admission MOM and\n Lactulose added.\n Nutrition: NPO pre-op.\n Renal: Foley, monitor UOP, edematous scrotum.\n Hematology: Hct stable 32.1->29.7. Plt low but stable (100's); d/c'd\n H2B with increasing plt count. Heme onc consulted - smear nl; no\n hemolysis. IVC filter placed.\n Endocrine: RISS\n Infectious Disease: WBC droppping 13.1->8.8->4.2, f/u Cx - BAL:\n Klebsiella - Ceftriaxone\n Lines / Tubes / Drains: R SC CVL (), PIV x2, Foley, L a-line\n (), ETT\n Imaging: CXR today\n Fluids: -\n Consults: Trauma (1o), Ortho Spine, Ortho trauma, Heme\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 04:41 PM\n Arterial Line - 11:30 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin, IVC filter\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 33 min\n"
},
{
"category": "Physician ",
"chartdate": "2175-02-01 00:00:00.000",
"description": "Intensivist Note",
"row_id": 714464,
"text": "TSICU\n HPI:\n 74M s/p fall with multiple rib fx, pelvis fx, clavicle fx, and thoracic\n fx c/b unstable bleeding s/p IR embo, now with AF with RVR/Aflutter,\n persistant hypotension and presumed PNA.\n Chief complaint:\n fall\n PMHx:\n none\n Current medications:\n 1. Acetaminophen 2. Amiodarone 3. Bisacodyl 4. Calcium Gluconate 5.\n CeftriaXONE 6. Chlorhexidine Gluconate 0.12% Oral Rinse 7. Dextrose 50%\n 8. Diltiazem 9. Docusate Sodium (Liquid) 10. Fentanyl Citrate 11.\n Gabapentin 12. Glucagon 13. Heparin 14. Insulin 15. Lactulose 16.\n Magnesium Sulfate 17. Metoprolol Tartrate 18. Midazolam 19. Midazolam\n 20. Milk of Magnesia 21. Ondansetron 22. OxycoDONE Liquid 23.\n Pantoprazole 24. Phenylephrine\n 25. Pneumococcal Vac Polyvalent 26. Potassium Phosphate 27. Potassium\n Chloride 28. Senna 29. Sodium Chloride 0.9% Flush\n 24 Hour Events:\n Changed sedation to po Oxycodone, wean fentanyl gtt, wean Midazolam,\n and start Haldol prn, but stopped due to QTc. Cards consult, started\n amiodarone.\n Post operative day:\n POD#6 - IVC filter via L groin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\n Vancomycin - 08:00 AM\n Ceftriaxone - 12:00 PM\n Infusions:\n Midazolam (Versed) - 5 mg/hour\n Fentanyl (Concentrate) - 50 mcg/hour\n Amiodarone - 0.5 mg/min\n Other ICU medications:\n Haloperidol (Haldol) - 10:45 AM\n Lorazepam (Ativan) - 02:00 PM\n Midazolam (Versed) - 03:25 AM\n Fentanyl - 03:25 AM\n Heparin Sodium (Prophylaxis) - 05:33 AM\n Other medications:\n Flowsheet Data as of 06:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.1\nC (100.6\n T current: 37.2\nC (98.9\n HR: 76 (74 - 104) bpm\n BP: 125/62(81) {90/49(62) - 152/67(89)} mmHg\n RR: 25 (18 - 31) insp/min\n SPO2: 98%\n Heart rhythm: A Flut (Atrial Flutter)\n Wgt (current): 102 kg (admission): 90 kg\n CVP: 12 (10 - 19) mmHg\n Total In:\n 3,718 mL\n 759 mL\n PO:\n Tube feeding:\n 1,920 mL\n 424 mL\n IV Fluid:\n 1,078 mL\n 245 mL\n Blood products:\n Total out:\n 1,755 mL\n 350 mL\n Urine:\n 1,755 mL\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,963 mL\n 409 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 480 (400 - 540) mL\n PS : 10 cmH2O\n RR (Spontaneous): 29\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 21 cmH2O\n SPO2: 98%\n ABG: 7.44/45/119/31/6\n Ve: 11.8 L/min\n PaO2 / FiO2: 238\n Physical Examination\n General Appearance: No acute distress, intubated\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), shallow respirations\n Abdominal: Soft, No(t) Non-distended, Bowel sounds present, Distended\n Left Extremities: (Edema: 1+), (Temperature: Warm)\n Right Extremities: (Edema: 1+), (Temperature: Warm)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities, Sedated\n Labs / Radiology\n 104 K/uL\n 9.5 g/dL\n 129 mg/dL\n 0.7 mg/dL\n 31 mEq/L\n 4.2 mEq/L\n 24 mg/dL\n 106 mEq/L\n 142 mEq/L\n 29.7 %\n 4.2 K/uL\n [image002.jpg]\n 04:45 PM\n 12:45 AM\n 01:00 AM\n 05:12 AM\n 02:40 PM\n 01:46 AM\n 01:55 AM\n 03:40 PM\n 12:07 AM\n 02:18 AM\n WBC\n 13.1\n 8.8\n 4.2\n Hct\n 31.6\n 32.1\n 29.7\n Plt\n 158\n 153\n 104\n Creatinine\n 0.8\n 0.7\n 0.7\n 0.7\n TCO2\n 35\n 35\n 34\n 37\n 35\n 32\n Glucose\n 131\n 115\n 132\n 122\n 117\n 129\n Other labs:\n PT / PTT / INR:13.7/27.6/1.2, CK / CK-MB / Troponin T:128/13/<0.01,\n ALT / AST:87/109, Alk-Phos / T bili:115/5.0, Amylase / Lipase:44/,\n D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic Acid:1.4 mmol/L,\n Albumin:2.7 g/dL, LDH:348 IU/L, Ca:7.9 mg/dL, Mg:2.0 mg/dL, PO4:3.4\n mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, now\n with AF with RVR/Aflutter, persistant hypotension and presumed PNA.\n Neurologic: Intubated. Per ortho spine, no surgery; HOB<30, TLSO when\n OOB (NEOPS will place). Wean sedation as may be causing hypotension.\n Change pain meds to PO. Wean versed.\n Neuro checks Q: shift\n Pain: Oxycodone, Fentanyl gtt (weaning), Midazolam gtt (weaning),\n Neurontin, Tylenol\n Cardiovascular: Aflutter on Dilt 60mg PO QID. Neo off since this AM.\n Cards yesterday rec Amiodarone. Pressor requirements may be related to\n AFib/flutter. No plan for electrical cardioversion right now. As pt\n cannot be anticoagulated (recent major trauma), had TTE w/o thrombus,\n Cards would like anticoagulation, will hold on heparin per Trauma\n surgery.\n Pulmonary: Intubated, weaning, tachypneic likely abd distension. On\n appropriate abx per BAL cx\n Ceftriaxone. Plan for trach today.\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin (declining 6.8\n max\n 5.0) with CT scan suggesting cirrhosis - Hepatitis panel NEG. TFs\n on hold for PEG. Bowel regimen, no BM since admission MOM and Lactulose\n added, will try Methylnaltrexone.\n Nutrition: NPO pre-op.\n Renal: Foley, monitor UOP, edematous scrotum but soft, eccymosis\n improving.\n Hematology: Hct stable 32.1->29.7. Plt low but stable (100's); d/c'd\n H2B with increasing plt count. Heme onc consulted - smear nl; no\n hemolysis. IVC filter placed.\n Endocrine: RISS, goal BS<150, adequate control.\n Infectious Disease: WBC dropping 13.1->8.8->4.2, f/u Cx - BAL:\n Klebsiella\n Ceftriaxone. Will add Vanco back for GPCs coverage if\n patient worsens.\n Lines / Tubes / Drains: R SC CVL (), Foley, L a-line (), ETT\n Imaging: CXR today\n Fluids: KVO\n Consults: Trauma (1o), Ortho Spine, Ortho trauma, Heme\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 04:41 PM\n Arterial Line - 11:30 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin, IVC filter\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 33 min\n"
},
{
"category": "Physician ",
"chartdate": "2175-02-01 00:00:00.000",
"description": "Cardiology Physician Note",
"row_id": 714493,
"text": "TITLE:\n History of Present Illness\n Date: \n Subsequent care\n Seen and examined with: Dr. \n Events / History of present illness: Started amiodarone gtt, weaned off\n neo yesterday. This AM, dropped his sats and hypotensive. Neo\n restarted.\n Medications\n Unchanged\n Dilt 60 QID\n Amio gtt at 0.5\n Neo at 0.8\n Physical Exam\n General appearance: Intubated, sedated\n BP: 105 / 57 mmHg\n HR: 75 bpm\n RR: 24 insp/min\n Tmax C last 24 hours: 37.6 C\n Tmax F last 24 hours: 99.6 F\n T current C: 37.5 C\n T current F: 99.5 F\n Previous day:\n Intake: 3,716 mL\n Output: 1,755 mL\n Fluid balance: 1,961 mL\n Today:\n Intake: 940 mL\n Output: 650 mL\n Fluid balance: 290 mL\n HEENT: (Conjunctiva and lids: NL), (Jugular veins: ~8cm)\n Cardiovascular: (Auscultation: RR, NR, no murmurs)\n Respiratory: (Auscultation: rhonchorous)\n Abdomen: (Palpation: Soft)\n Extremities:\n Right: (Edema: 2+)\n Left: (Edema: 2+)\n Other: Diffuse edema\n Labs\n 104\n 9.5\n 100\n 0.7\n 31\n 4.2\n 24\n 106\n 142\n 29.7\n 4.2\n [image002.jpg]\n 02:55 AM\n 09:45 AM\n 04:21 PM\n 12:45 AM\n 01:00 AM\n 05:12 AM\n 01:46 AM\n 01:55 AM\n 02:18 AM\n 08:00 AM\n WBC\n 6.5\n 13.1\n 8.8\n 4.2\n Hgb\n 10.1\n 10.7\n 10.7\n 9.5\n Hct (Serum)\n 29.3\n 31.6\n 32.1\n 29.7\n Plt\n 86\n 158\n 153\n 104\n INR\n 1.1\n 1.2\n 1.2\n PTT\n 26.8\n 26.9\n 27.6\n Na+\n 143\n 148\n 143\n 143\n 142\n K + (Serum)\n 3.6\n 4.1\n 4.0\n 4.0\n 3.9\n 4.2\n K + (Whole blood)\n 3.5\n Cl\n 106\n 111\n 108\n 106\n 106\n HCO3\n 33\n 34\n 32\n 32\n 31\n BUN\n 19\n 20\n 19\n 22\n 24\n Creatinine\n 0.8\n 0.8\n 0.7\n 0.7\n 0.7\n Glucose\n 141\n 107\n 131\n 115\n 132\n 122\n 117\n 129\n 100\n CK\n 225\n 128\n ABG: / / / 31 / Values as of 02:18 AM\n Tests\n Telemetry: Aflutter at 70s, 3-4:1 up to 2:1 this AM.\n Assessment and Plan\n Continues to be in Aflutter on amio gtt. Able to wean down on neo\n yesterday, but restarted this AM. As mentioned yesterday, very\n unlikely that hypotension is a result of aflutter itself (loss of\n atrial kick) based on echocardiogram (Normal E/A ratio) and he was able\n to be weaned off the drip yesterday despite continued Aflutter. Would\n search for other etiologies of hypotension (infection, hypovolemia); he\n appears to have a large amount of third spacing on my exam, so he may\n be intravascularly deplete despite being total body fluid overloaded.\n Can increase Dilt to 90 QID if necessary for better rate control if BP\n tolerates, but at this point would search for other causes of\n hypotension.\n Recs:\n --Continue amiodarone gtt at 0.5\n --Continue diltiazem\n --Cont to monitor, consider IVFs to wean off neo\n"
},
{
"category": "Respiratory ",
"chartdate": "2175-02-02 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 714574,
"text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 9\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Tube Type\n Tracheostomy tube:\n Type: Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: Rusty / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts\n"
},
{
"category": "Nursing",
"chartdate": "2175-02-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 714840,
"text": "Atrial fibrillation (Afib)\n Assessment:\n Atrial flutter with RVR up to 120\ns. BP stable. Not responding to IV\n beta blockers.\n Action:\n Cont PO lopressor and Amioderone, started Diltiazem gtt and titrating\n up for HR <100.\n Response:\n A flutter continues, rate better controlled.\n Plan:\n Maintain rate control, monitor hemodynamics, titrate dilt gtt for HR.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS rhonchi, SaO2 100%, copious amounts of thick white secretions.\n Patient becoming very agitated and confused at times.\n Action:\n No change in vent settings. PRN anxiety meds given.\n Response:\n Patient responding well to haldol.\n Plan:\n Wean vent settings as tolerated, CXR in AM. Improve confusion.\n"
},
{
"category": "Nursing",
"chartdate": "2175-02-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 714844,
"text": "Atrial fibrillation (Afib)\n Assessment:\n Atrial flutter with RVR up to 120\ns. BP stable. Not responding to IV\n beta blockers.\n Action:\n Cont PO lopressor and Amioderone, started Diltiazem gtt and titrating\n up for HR <100.\n Response:\n A flutter continues, rate better controlled.\n Plan:\n Maintain rate control, monitor hemodynamics, titrate dilt gtt for HR.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS rhonchi, SaO2 100%, copious amounts of thick white secretions.\n Patient becoming very agitated and confused at times.\n Action:\n No change in vent settings. PRN anxiety meds given.\n Response:\n Patient responding well to haldol.\n Plan:\n Wean vent settings as tolerated, CXR in AM. Improve confusion.\n"
},
{
"category": "Rehab Services",
"chartdate": "2175-02-02 00:00:00.000",
"description": "Physical Therapy Evaluation Note",
"row_id": 714650,
"text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: crush injury / 959.9\n Reason of referral: Eval & treat\n History of Present Illness / Subjective Complaint: 74 yo M admitted\n s/p fall from tractor and crush injury from tree branch.\n Sustained multiple fib fxs (R anterolateral and L posterior), R\n pulmonary contusion, T4 vertebral teardrop fx, T2-T8 spinous process\n fx, nondisplaced L T10 transverse process fx, nondisplaced L distal \n clavicle fx, R medial lobe liver contusion with hematoma, comminuted L\n pubic ramus fx with hematoma, nondisplaced comminuted L iliac bone fx\n extending into L SI joint with adjacent iliac muscle hematoma,\n minimally displaced fx of R iliac bone extending to R SI joint.\n Underwent angio on for embolization of pelvic and hepatic\n vessels, IVC filter placed , and trach/peg placement .\n Past Medical / Surgical History: none\n Medications: tylenol, midazolam, metoprolol, diltiazem, gabapentin,\n heparin, oxycodone, fentanyl, lactulose, cefepime, ciprofloxacin,\n lorazepam, vancomycin, amiodarone\n Radiology: CXR - Persistent bilateral pleural effusions and\n bibasilar opacity, likely atelectasis but underlying infection not\n excluded\n Labs:\n 31.3\n 10.2\n 109\n 5.9\n [image002.jpg]\n Other labs:\n Activity Orders: Activity as tolerated, TLSO for OOB\n Social / Occupational History: lives with wife, supportive family at\n bedside\n Living Environment:\n Prior Functional Status / Activity Level: I pta, no DME\n Objective Test\n Arousal / Attention / Cognition / Communication: alert, oriented to\n self and place, follows all simple commands. Mouths words with some\n effectiveness.\n Aerobic Capacity\n HR\n BP\n RR\n O[2] sat\n RPE\n Rest\n 80\n 102/50\n 14\n 97% on CPAP\n Activity\n 94\n 160/74\n 32\n Recovery\n 90\n 154/72\n 20\n 99% on CPAP\n Total distance walked: 0\n Minutes:\n Pulmonary Status: coarse upper BS with congested cough, incline suction\n small amount thin yellow secretions. On CPAP 10/15 PEEP/PS, 60% FiO2.\n Integumentary / Vascular: L radial a-line, R subclavian multi-lumen,\n foley, tele, trach, TLSO\n Sensory Integrity: B LE's intact to light touch\n Pain / Limiting Symptoms: denies pain\n Posture: denies pain\n Range of Motion\n Muscle Performance\n B LE's WNL\n B UE/LE's grossly t/o\n Motor Function: no abnormal movement patterns\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: total assist slide transfers from bed to stretcher\n chair.\n Rolling:\n\n\n\n\n\n T\n Supine /\n Sidelying to Sit:\n\n\n\n\n X2\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n\n\n\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Balance: initially max A to maintain static sitting but was able to\n progress to CG for several seconds at a time and mostly min A. Able to\n weight shift anteriorly and laterally with mod A. Tolerated sitting at\n edge of bed 5-10 min.\n Education / Communication: Reviewed PT , positioning and use of\n TLSO, d/c planning. Communicated with nsg re: status.\n Intervention:\n Diagnosis:\n 1.\n Impaired functional mobility\n 2.\n Impaired endurance\n 3.\n Impaired balance\n 4.\n Impaired strength\n 5.\n Impaired pulmonary hygiene\n Clinical impression / Prognosis: 74 yo M s/p crush injury p/w above\n impairments a/w bony fractures. He is most limited by general weakness\n a/w prolonged icu hospitalization with intubation and sedation, as well\n as ventilator dependency. He is significantly below his baseline, but\n given his age and prior level of function, would anticipate a good\n prognosis and excellent rehab potential to return to independent level\n of function. PT to continue to follow and progress as able at acute\n level.\n Goals\n Time frame: 1 week\n 1.\n Mod A bed mobility, assess sit-to-stand and transfers\n 2.\n Tolerate OOB >/= 3 hours/day\n 3.\n Static/dynamic sitting balance with CG, assess standing balance\n 4.\n Tolerate daily UE/LE strengthening\n 5.\n Tolerates trach mask t/o PT session\n 6.\n Anticipated Discharge: Rehab\n Treatment Plan:\n Frequency / Duration: 3-5x/wk\n bed mobility, transfers, balance, endurance, strengthening, education,\n d/c planning\n T Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n"
},
{
"category": "Physician ",
"chartdate": "2175-02-02 00:00:00.000",
"description": "EP NOTE",
"row_id": 714651,
"text": "Cardiac Electrophysiology Note:\n History of Present Illness\n Date: \n Subsequent care\n Events / History of present illness: 74M no known PMH, presented on\n s/p fall from tractor and crush injury with right ribs and pelvic\n fractures and T4 vertebral body fracture. He was given 4 U PRBC, 1 unit\n FFP, and underwent arteriogram on with embolization to the liver\n and pelvis and IVC filter placement for concern of high likelihood of\n development of DVT and inability to anticoagulate. We were consulted\n d/t paroxysmal atrial flutter which has started on the morning of\n . He was started on Amiodarone drip, with subsequent conversion to\n sinus rhythm last evening. He is currently post PEG and tracheostomy,\n awake and alert. He is in sinus rhythm at the 90s, on Amiodarone P.O.\n Medications\n Unchanged\n Physical Exam\n Tmax C last 24 hours: 37.7 C\n Tmax F last 24 hours: 99.9 F\n T current C: 36.3 C\n T current F: 97.4 F\n Previous day:\n Intake: 1,764 mL\n Output: 1,630 mL\n Fluid balance: 134 mL\n Today:\n Intake: 863 mL\n Output: 1,115 mL\n Fluid balance: -252 mL\n General: Awake and alert. Sitting in a chair. No acute distress\n Cardiovascular: (Auscultation: RRR, no murmurs)\n Respiratory: (Auscultation: Limited exam: clear to auscultation, no\n rales or wheezes)\n Abdomen: (Limited exam: Could not appreciate organomegaly )\n Neurological: (Orientation: Awake and alert)\n Labs\n 109\n 10.2\n 110\n 0.8\n 31\n 4.5\n 24\n 105\n 144\n 31.3\n 5.9\n [image002.jpg]\n 01:00 AM\n 05:12 AM\n 01:46 AM\n 01:55 AM\n 02:18 AM\n 08:00 AM\n 02:00 PM\n 08:00 PM\n 01:00 AM\n 01:07 AM\n WBC\n 8.8\n 4.2\n 5.9\n Hgb\n 10.7\n 9.5\n 10.2\n Hct (Serum)\n 32.1\n 29.7\n 31.3\n Plt\n 153\n 104\n 109\n INR\n 1.2\n PTT\n 27.6\n Na+\n 143\n 143\n 142\n 144\n K + (Serum)\n 4.0\n 3.9\n 4.2\n 4.5\n Cl\n 108\n 106\n 106\n 105\n HCO3\n 32\n 32\n 31\n 31\n BUN\n 19\n 22\n 24\n 24\n Creatinine\n 0.7\n 0.7\n 0.7\n 0.8\n Glucose\n 115\n 132\n 122\n 117\n 129\n 100\n 111\n 105\n 117\n 110\n CK\n 225\n 128\n ABG: 7.45 / 49 / 98 / / 8 Values as of 01:18 AM\n Assessment and Plan\n ATRIAL FLUTTER: converted to sinus yesterday evening with I.V\n amiodarome. Would recommend:\n 1. Amiodarone PO 400 mg .\n 2. Metoprolol Succinate PO 25 mg .\n 3. Discontinue Diltiazem P.O.\n 4. Discontinue I.V Metoprolol\n 5. Consider Heparin I.V with a goal of PTT between 60-80 seconds\n if it is not contra-indicated from his trauma standpoint\n"
},
{
"category": "Physician ",
"chartdate": "2175-02-02 00:00:00.000",
"description": "EP NOTE",
"row_id": 714652,
"text": "Cardiac Electrophysiology Note:\n History of Present Illness\n Date: \n Subsequent care\n Events / History of present illness: 74M no known PMH, presented on\n s/p fall from tractor and crush injury with right ribs and pelvic\n fractures and T4 vertebral body fracture. He was given 4 U PRBC, 1 unit\n FFP, and underwent arteriogram on with embolization to the liver\n and pelvis and IVC filter placement for concern of high likelihood of\n development of DVT and inability to anticoagulate. We were consulted\n d/t paroxysmal atrial flutter which has started on the morning of\n . He was started on Amiodarone drip, with subsequent conversion to\n sinus rhythm last evening. He is currently post PEG and tracheostomy,\n awake and alert. He is in sinus rhythm at the 90s, on Amiodarone P.O.\n Medications\n Unchanged\n Physical Exam\n Tmax C last 24 hours: 37.7 C\n Tmax F last 24 hours: 99.9 F\n T current C: 36.3 C\n T current F: 97.4 F\n Previous day:\n Intake: 1,764 mL\n Output: 1,630 mL\n Fluid balance: 134 mL\n Today:\n Intake: 863 mL\n Output: 1,115 mL\n Fluid balance: -252 mL\n General: Awake and alert. Sitting in a chair. No acute distress\n Cardiovascular: (Auscultation: RRR, no murmurs)\n Respiratory: (Auscultation: Limited exam: clear to auscultation, no\n rales or wheezes)\n Abdomen: (Limited exam: Could not appreciate organomegaly )\n Neurological: (Orientation: Awake and alert)\n Labs\n 109\n 10.2\n 110\n 0.8\n 31\n 4.5\n 24\n 105\n 144\n 31.3\n 5.9\n [image002.jpg]\n 01:00 AM\n 05:12 AM\n 01:46 AM\n 01:55 AM\n 02:18 AM\n 08:00 AM\n 02:00 PM\n 08:00 PM\n 01:00 AM\n 01:07 AM\n WBC\n 8.8\n 4.2\n 5.9\n Hgb\n 10.7\n 9.5\n 10.2\n Hct (Serum)\n 32.1\n 29.7\n 31.3\n Plt\n 153\n 104\n 109\n INR\n 1.2\n PTT\n 27.6\n Na+\n 143\n 143\n 142\n 144\n K + (Serum)\n 4.0\n 3.9\n 4.2\n 4.5\n Cl\n 108\n 106\n 106\n 105\n HCO3\n 32\n 32\n 31\n 31\n BUN\n 19\n 22\n 24\n 24\n Creatinine\n 0.7\n 0.7\n 0.7\n 0.8\n Glucose\n 115\n 132\n 122\n 117\n 129\n 100\n 111\n 105\n 117\n 110\n CK\n 225\n 128\n ABG: 7.45 / 49 / 98 / / 8 Values as of 01:18 AM\n Assessment and Plan\n ATRIAL FLUTTER: converted to sinus yesterday evening with I.V\n amiodarome. Would recommend:\n 1. Amiodarone PO 400 mg .\n 2. Metoprolol Succinate PO 25 mg .\n 3. Discontinue Diltiazem P.O.\n 4. Discontinue I.V Metoprolol\n 5. Consider Heparin I.V with a goal of PTT between 60-80 seconds\n if it is not contra-indicated from his trauma standpoint\n ------ Protected Section ------\n 1. Would also recommend liver enzymes follow up given his\n elevated LFT\ns and Amiodarone treatment\n 2. Amiodarone 400mg for 1 week followed by Amiodarone 400 mg\n daily for 1 week, and then Amiodarone 200 mg daily.\n 3. ------ Protected Section Addendum Entered By:\n , MD on: 13:00 ------\n 4.\n 5.\n 6. Electronically signed by , MD \n 13:00\n 7.\n 8.\n"
},
{
"category": "Physician ",
"chartdate": "2175-02-02 00:00:00.000",
"description": "Cardiology Physician Note",
"row_id": 714655,
"text": "TITLE:\n History of Present Illness\n Date: \n Subsequent care\n Events / History of present illness: Trach/PEG yesterday. Converted to\n sinus rhythm yesterday at 7PM. Off pressors.\n Medications\n Unchanged\n Physical Exam\n General appearance: NAD\n BP: 147 / 73 mmHg\n HR: 93 bpm\n RR: 17 insp/min\n Tmax C last 24 hours: 37.7 C\n Tmax F last 24 hours: 99.9 F\n T current C: 36.3 C\n T current F: 97.4 F\n O2 sat: 98 % on Supplemental oxygen: PSV 16/10 on 60% O2\n Previous day:\n Intake: 1,764 mL\n Output: 1,630 mL\n Fluid balance: 134 mL\n Today:\n Intake: 619 mL\n Output: 1,020 mL\n Fluid balance: -401 mL\n HEENT: (Conjunctiva and lids: NL), (Jugular veins: ~8-10cm)\n Cardiovascular: (Auscultation: RR, NR, No murmurs), (Palpation: NL PMI)\n Respiratory: (Auscultation: rhonchorous bs)\n Abdomen: (Palpation: Soft, No R/G)\n Neurological: (Orientation: Responds to voice)\n Extremities:\n Right: (Edema: 2+)\n Left: (Edema: 2+)\n Other: + diffuse edema with overlying ecchymoses\n Labs\n 109\n 10.2\n 110\n 0.8\n 31\n 4.5\n 24\n 105\n 144\n 31.3\n 5.9\n [image002.jpg]\n 01:00 AM\n 05:12 AM\n 01:46 AM\n 01:55 AM\n 02:18 AM\n 08:00 AM\n 02:00 PM\n 08:00 PM\n 01:00 AM\n 01:07 AM\n WBC\n 8.8\n 4.2\n 5.9\n Hgb\n 10.7\n 9.5\n 10.2\n Hct (Serum)\n 32.1\n 29.7\n 31.3\n Plt\n 153\n 104\n 109\n INR\n 1.2\n PTT\n 27.6\n Na+\n 143\n 143\n 142\n 144\n K + (Serum)\n 4.0\n 3.9\n 4.2\n 4.5\n Cl\n 108\n 106\n 106\n 105\n HCO3\n 32\n 32\n 31\n 31\n BUN\n 19\n 22\n 24\n 24\n Creatinine\n 0.7\n 0.7\n 0.7\n 0.8\n Glucose\n 115\n 132\n 122\n 117\n 129\n 100\n 111\n 105\n 117\n 110\n CK\n 225\n 128\n ABG: 7.45 / 49 / 98 / / 8 Values as of 01:18 AM\n Tests\n Telemetry: Converted to sinus yesterday at 7PM with brief pause. Sinus\n at 90s since.\n Assessment and Plan\n Sinus rhythm currently; off pressors with BP slightly hypertensive.\n Okay to transition to PO amio. Would recommend a baby aspirin if\n possible from a bleeding risk. Would continue diltiazem for now at\n present dose; could increase if desired, although his sinus tachycardia\n is most likely due to pain and/or his acute illness and is thus\n appropriate. Once acute issues improved, should follow up in\n cardiology clinic for further management of AF ().\n Recs:\n --Change to PO amiodarone (400mg TID x 2 weeks, then 400mg daily x 1\n week, then 200mg daily)\n --Monitor LFTs (likely resolving from liver lac, but if increase\n significantly may need to change to a different )\n --Initiate ASA 81mg daily if okay from bleed risk\n --Continue dilt for now (sinus tachy likely from acute illness/pain)\n --Follow up in cardiology clinic as an outpatient\n ------ Protected Section ------\n Spoke with Dr. (EP attending). Please modify above plan as\n following:\n --Would transition to amiodarone 200mg given his liver lacs, prior\n elevated LFTs, and sufficient IV load thus far\n --Would recommend d/c of dilatiazem and initiation of metoprolol 25mg\n \n ------ Protected Section Addendum Entered By: , MD\n on: 13:32 ------\n"
},
{
"category": "Nursing",
"chartdate": "2175-02-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 714664,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt trached and continues on vent, with settings: CPAP: 60%.\n Lung sounds rhonchorous in upper lobes, diminished at bases\n bilaterally. Pt requiring frequent suctioning for thick, tan/white\n secretions. Pt has strong, productive, cough. Pt was minimally\n sedated this AM on Fentanyl and midaz gtts. CXR showed fluid overload.\n Action:\n Fentanyl stopped, midaz stopped, PO roxicodone given for pain. Zyprexa\n given for comfort/anxiety. IV ativan ordered for anxiety but not\n given at time of note. Tube feeds restarted. Pt seen by PT, did ROM\n and dangling at bedside. Pt OOB to stretcher chair this afternoon for\n 3 hours. Pt diuresed with 10mg lasix this AM. Suctioned frequently,\n trach care provided. IV antibiotics ordered and given for suspected\n VAP PNA; ceftriaxone discontinued.\n Response:\n Pt tolerated sitting in the chair well, felt slightly uncomfortable\n with TLSO brace but managed well. Lasix put out ~350cc UO. Pt\n tolerating tube feeds, advancing to goal. Pt unrestrained and\n appropriate. Pt tolerating activity/repositioning, appears to be\n comfortable. Pt remains Afebrile, WBC low.\n Plan:\n Continue to support pt and family, provide disease process education as\n needed. TLSO brace when >30 degrees or OOB to chair. Advance tube\n feeds to goal today as tolerated. Zyprexa/ativan/roxicodone for pain\n as needed. Daily OOB to chair and work with PT. Wean vent as\n tolerated. Pulmonary toileting and diurese as able.\n"
},
{
"category": "Nursing",
"chartdate": "2175-02-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 714556,
"text": "74M s/p crushing injury d/t falling tree. Injuries sustained include\n multiple R sided rib fxs, grade 2 liver lac (w/ assoc hepatic vessel\n extravasation), stable pelvis fxs (w/ associated extravasation), R\n ramus fx, clavicle fx, and T4 vertebral body fx. Episodes of A.\n Flutter with RVR and aflutter, now with resp failure and newly dx\n pneumonia as of .\n intubated for resp distress\n angio embolization of hepatic and pelvic arterial bleeders\n IVC filter in OR\n self extubated and re-intubated immediately after d/t acute resp.\n failure\n Trach and PEG at bedside\n Atrial fibrillation (Afib)\n Assessment:\n Atrial flutter continues, RVR up to 130s this AM. Now rate controlled\n <100.\n Action:\n PO dilt, amioderone gtt continued, Neo gtt titrated for adequate BP\n control.\n Response:\n Rate controlled after PO Dilt.\n Plan:\n Continue Amio gtt, switch to PO amio, ? Cardio version,? Anticoagulant.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Post trach pt back on CPAP 10/10/50%. Ls clear to diminish at bases.\n Strong productive cough, suctioned for copious amounts of thick blood\n tinged secretions. ABG stable.\n Action:\n Trach and PEG at bedside, continue pulmonary toileting.\n Response:\n Tolerated procedure without issue.\n Plan:\n Wean vent settings as tolerated, pulmonary toileting, wean sedation.\n"
},
{
"category": "Physician ",
"chartdate": "2175-02-01 00:00:00.000",
"description": "Cardiology Physician Note",
"row_id": 714562,
"text": "TITLE:\n History of Present Illness\n Date: \n Subsequent care\n Seen and examined with: Dr. \n Events / History of present illness: Started amiodarone gtt, weaned off\n neo yesterday. This AM, dropped his sats and hypotensive. Neo\n restarted.\n Medications\n Unchanged\n Dilt 60 QID\n Amio gtt at 0.5\n Neo at 0.8\n Physical Exam\n General appearance: Intubated, sedated\n BP: 105 / 57 mmHg\n HR: 75 bpm\n RR: 24 insp/min\n Tmax C last 24 hours: 37.6 C\n Tmax F last 24 hours: 99.6 F\n T current C: 37.5 C\n T current F: 99.5 F\n Previous day:\n Intake: 3,716 mL\n Output: 1,755 mL\n Fluid balance: 1,961 mL\n Today:\n Intake: 940 mL\n Output: 650 mL\n Fluid balance: 290 mL\n HEENT: (Conjunctiva and lids: NL), (Jugular veins: ~8cm)\n Cardiovascular: (Auscultation: RR, NR, no murmurs)\n Respiratory: (Auscultation: rhonchorous)\n Abdomen: (Palpation: Soft)\n Extremities:\n Right: (Edema: 2+)\n Left: (Edema: 2+)\n Other: Diffuse edema\n Labs\n 104\n 9.5\n 100\n 0.7\n 31\n 4.2\n 24\n 106\n 142\n 29.7\n 4.2\n [image002.jpg]\n 02:55 AM\n 09:45 AM\n 04:21 PM\n 12:45 AM\n 01:00 AM\n 05:12 AM\n 01:46 AM\n 01:55 AM\n 02:18 AM\n 08:00 AM\n WBC\n 6.5\n 13.1\n 8.8\n 4.2\n Hgb\n 10.1\n 10.7\n 10.7\n 9.5\n Hct (Serum)\n 29.3\n 31.6\n 32.1\n 29.7\n Plt\n 86\n 158\n 153\n 104\n INR\n 1.1\n 1.2\n 1.2\n PTT\n 26.8\n 26.9\n 27.6\n Na+\n 143\n 148\n 143\n 143\n 142\n K + (Serum)\n 3.6\n 4.1\n 4.0\n 4.0\n 3.9\n 4.2\n K + (Whole blood)\n 3.5\n Cl\n 106\n 111\n 108\n 106\n 106\n HCO3\n 33\n 34\n 32\n 32\n 31\n BUN\n 19\n 20\n 19\n 22\n 24\n Creatinine\n 0.8\n 0.8\n 0.7\n 0.7\n 0.7\n Glucose\n 141\n 107\n 131\n 115\n 132\n 122\n 117\n 129\n 100\n CK\n 225\n 128\n ABG: / / / 31 / Values as of 02:18 AM\n Tests\n Telemetry: Aflutter at 70s, 3-4:1 up to 2:1 this AM.\n Assessment and Plan\n Continues to be in Aflutter on amio gtt. Able to wean down on neo\n yesterday, but restarted this AM. As mentioned yesterday, very\n unlikely that hypotension is a result of aflutter itself (loss of\n atrial kick) based on echocardiogram (Normal E/A ratio) and he was able\n to be weaned off the drip yesterday despite continued Aflutter. Would\n search for other etiologies of hypotension (infection, hypovolemia); he\n appears to have a large amount of third spacing on my exam, so he may\n be intravascularly deplete despite being total body fluid overloaded.\n Can increase Dilt to 90 QID if necessary for better rate control if BP\n tolerates, but at this point would search for other causes of\n hypotension.\n Recs:\n --Continue amiodarone gtt at 0.5\n --Continue diltiazem\n --Cont to monitor, consider IVFs to wean off neo\n ------ Protected Section ------\n Cardiology Teaching Physician Note\n have seen and examined the patient. I have reviewed the above note\n and plans.\n I would add the following remarks:\n History\n 7 pm conv to st. now bp 120.\n Physical Examination\n more alert, follows commands\n Medical Decision Making\n consider taper diltiazem\n ------ Protected Section Addendum Entered By: \n on: 09:33 PM ------\n"
},
{
"category": "Nutrition",
"chartdate": "2175-02-02 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 714631,
"text": "Subjective\n intubated\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n cm\n 90 kg\n 102 kg ( 12:00 AM)\n Pertinent medications: amidoarone, fentanyl, normal saline, HISS,\n protonix, heparin, IV abx, others noted\n Labs:\n Value\n Date\n Glucose\n 110 mg/dL\n 01:07 AM\n Glucose Finger Stick\n 124\n 08:00 AM\n BUN\n 24 mg/dL\n 01:07 AM\n Creatinine\n 0.8 mg/dL\n 01:07 AM\n Sodium\n 144 mEq/L\n 01:07 AM\n Potassium\n 4.5 mEq/L\n 01:07 AM\n Chloride\n 105 mEq/L\n 01:07 AM\n TCO2\n 31 mEq/L\n 01:07 AM\n PO2 (arterial)\n 98. mm Hg\n 01:18 AM\n PCO2 (arterial)\n 49 mm Hg\n 01:18 AM\n pH (arterial)\n 7.45 units\n 01:18 AM\n pH (urine)\n 5.0 units\n 04:25 PM\n CO2 (Calc) arterial\n 35 mEq/L\n 01:18 AM\n Albumin\n 2.3 g/dL\n 02:18 AM\n Calcium non-ionized\n 8.1 mg/dL\n 01:07 AM\n Phosphorus\n 3.8 mg/dL\n 01:07 AM\n Ionized Calcium\n 1.17 mmol/L\n 01:18 AM\n Magnesium\n 2.1 mg/dL\n 01:07 AM\n ALT\n 90 IU/L\n 01:07 AM\n Alkaline Phosphate\n 99 IU/L\n 01:07 AM\n AST\n 113 IU/L\n 01:07 AM\n Amylase\n 58 IU/L\n 01:07 AM\n Total Bilirubin\n 5.1 mg/dL\n 01:07 AM\n WBC\n 5.9 K/uL\n 01:07 AM\n Hgb\n 10.2 g/dL\n 01:07 AM\n Hematocrit\n 31.3 %\n 01:07 AM\n Current diet order / nutrition support: (ON HOLD) replete with fiber @\n 80 ml/hr\n GI: soft, nontender, nondistended\n Assessment of Nutritional Status\n Specifics: Patient s/p PEG/trach on . Tube feedings on hold since\n 4am on for procedure. Plan to resume tube feedings today. At goal\n tube feedings provide kcals/ 119 g protein, which is 100% of\n estimated nutritional needs.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. Resume tube feedings when able\n 2. Check chemistry 10 daily\n 3. Will follow page with questions\n"
},
{
"category": "Physician ",
"chartdate": "2175-02-02 00:00:00.000",
"description": "Cardiology Physician Note",
"row_id": 714634,
"text": "TITLE:\n History of Present Illness\n Date: \n Subsequent care\n Events / History of present illness: Trach/PEG yesterday. Converted to\n sinus rhythm yesterday at 7PM. Off pressors.\n Medications\n Unchanged\n Physical Exam\n General appearance: NAD\n BP: 147 / 73 mmHg\n HR: 93 bpm\n RR: 17 insp/min\n Tmax C last 24 hours: 37.7 C\n Tmax F last 24 hours: 99.9 F\n T current C: 36.3 C\n T current F: 97.4 F\n O2 sat: 98 % on Supplemental oxygen: PSV 16/10 on 60% O2\n Previous day:\n Intake: 1,764 mL\n Output: 1,630 mL\n Fluid balance: 134 mL\n Today:\n Intake: 619 mL\n Output: 1,020 mL\n Fluid balance: -401 mL\n HEENT: (Conjunctiva and lids: NL), (Jugular veins: ~8-10cm)\n Cardiovascular: (Auscultation: RR, NR, No murmurs), (Palpation: NL PMI)\n Respiratory: (Auscultation: rhonchorous bs)\n Abdomen: (Palpation: Soft, No R/G)\n Neurological: (Orientation: Responds to voice)\n Extremities:\n Right: (Edema: 2+)\n Left: (Edema: 2+)\n Other: + diffuse edema with overlying ecchymoses\n Labs\n 109\n 10.2\n 110\n 0.8\n 31\n 4.5\n 24\n 105\n 144\n 31.3\n 5.9\n [image002.jpg]\n 01:00 AM\n 05:12 AM\n 01:46 AM\n 01:55 AM\n 02:18 AM\n 08:00 AM\n 02:00 PM\n 08:00 PM\n 01:00 AM\n 01:07 AM\n WBC\n 8.8\n 4.2\n 5.9\n Hgb\n 10.7\n 9.5\n 10.2\n Hct (Serum)\n 32.1\n 29.7\n 31.3\n Plt\n 153\n 104\n 109\n INR\n 1.2\n PTT\n 27.6\n Na+\n 143\n 143\n 142\n 144\n K + (Serum)\n 4.0\n 3.9\n 4.2\n 4.5\n Cl\n 108\n 106\n 106\n 105\n HCO3\n 32\n 32\n 31\n 31\n BUN\n 19\n 22\n 24\n 24\n Creatinine\n 0.7\n 0.7\n 0.7\n 0.8\n Glucose\n 115\n 132\n 122\n 117\n 129\n 100\n 111\n 105\n 117\n 110\n CK\n 225\n 128\n ABG: 7.45 / 49 / 98 / / 8 Values as of 01:18 AM\n Tests\n Telemetry: Converted to sinus yesterday at 7PM with brief pause. Sinus\n at 90s since.\n Assessment and Plan\n Sinus rhythm currently; off pressors with BP slightly hypertensive.\n Okay to transition to PO amio. Would recommend a baby aspirin if\n possible from a bleeding risk. Would continue diltiazem for now at\n present dose; could increase if desired, although his sinus tachycardia\n is most likely due to pain and/or his acute illness and is thus\n appropriate. Once acute issues improved, should follow up in\n cardiology clinic for further management of AF ().\n Recs:\n --Change to PO amiodarone (400mg TID x 2 weeks, then 400mg daily x 1\n week, then 200mg daily)\n --Monitor LFTs (likely resolving from liver lac, but if increase\n significantly may need to change to a different )\n --Initiate ASA 81mg daily if okay from bleed risk\n --Continue dilt for now (sinus tachy likely from acute illness/pain)\n --Follow up in cardiology clinic as an outpatient\n"
},
{
"category": "Respiratory ",
"chartdate": "2175-02-02 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 714661,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 9\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason:\n Tube Type\n Tracheostomy tube:\n Type: Standard, Cuffed, Inner Cannula\n Manufacturer: Portex\n Size: 8.0mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 30 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Crackles\n RUL Lung Sounds: Crackles\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n"
},
{
"category": "Respiratory ",
"chartdate": "2175-02-03 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 714729,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 10\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Tube Type\n Tracheostomy tube:\n Type: Standard, Cuffed\n Manufacturer: Portex\n Size: 8.0mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: White / Thin\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated, Reduce PEEP as tolerated; Comments: continue to wean pt as\n tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Underlying illness not resolved\n"
},
{
"category": "Nursing",
"chartdate": "2175-02-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 714835,
"text": "Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2175-01-27 00:00:00.000",
"description": "Intensivist Note",
"row_id": 713743,
"text": "TSICU\n HPI:\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\n checked and 1.5, 1 more unit FFP given.\n Chief complaint:\n Mult rib fx: R anterolateral and post, L posterior\n T4 vert body inf corner fx\n Commin spinous process fx T2-8\n Nondisplaced L T10 transverse process\n Nondispaced L distal clavicle\n Nondisplaced L clavicle fx\n R medial lobe liver contusion w/hematoma\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny focus of arterial\n bleeding/active extravasation, and larger area of venous bleeding\n Nondisplaced, comminuted L iliac bone fx w/adjacent iliac muscle\n hematoma, extends into L SIJ.\n Minimally displaced fx of R iliac bone extending to R SIJ.\n PMHx:\n None\n Current medications:\n 1. IV access: Peripheral line Order date: @ 2329 12. Glucagon 1\n mg IM Q15MIN:PRN hypoglycemia protocol Order date: @ 0104\n 2. 1000 mL LR\n Continuous at 60 ml/hr\n LR + TF = 60 cc/hr Order date: @ 0103 13. Insulin SC (per\n Insulin Flowsheet)\n Sliding Scale Order date: @ 0104\n 3. Acetaminophen 650 mg PO/NG Q6H:PRN pain Order date: @ 2329\n 14. Magnesium Sulfate IV Sliding Scale Order date: @ 2339\n 4. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL Order date:\n @ 2329 15. Midazolam 2-4 mg IV Q2H:PRN sedation Order date:\n @ 2329\n 5. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date: \n @ 0104 16. Ondansetron 4 mg IV Q8H:PRN nausea Order date: @ 2329\n 6. Diltiazem 5-15 mg/hr IV INFUSION Afib\n titrate titrate to HR<100 Order date: @ 2339 17. Phenylephrine\n 0.5-5 mcg/kg/min IV DRIP TITRATE TO SBP>90 MAP>60 Order date: @\n 2339\n 7. Docusate Sodium (Liquid) 100 mg PO/NG Order date: @ 2329\n 18. Pneumococcal Vac Polyvalent 0.5 ml IM ASDIR Order date: @\n 2316\n 8. Famotidine 20 mg PO/NG Order date: @ 2329 19. Potassium\n Phosphate IV Sliding Scale\n Infuse over 6 hours Order date: @ 2339\n 9. Fentanyl Citrate 25-100 mcg IV Q2H:PRN pain, agitation Order date:\n @ 2329 20. Potassium Chloride IV Sliding Scale Order date: \n @ 2339\n 10. Fentanyl Citrate 25-100 mcg/hr IV DRIP INFUSION Order date: \n @ 2339 21. Propofol 5-20 mcg/kg/min IV DRIP TITRATE TO sedation Order\n date: @ 2339\n 11. Gabapentin 100 mg PO/NG TID Order date: @ 2329 22. Sodium\n Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ 2329\n 24 Hour Events:\n Febrile yesterday AM to 101.3. Pan cx. Placed on Dilt gtt for Afib\n with RVR but since has converted to sinus and is off the dilt gtt.\n Continues to wean off the Neo gtt. Tube feeds started. Bronchoscopy\n performed. IVC filter placed late last PM.\n Post operative day:\n POD#1 - IVC filter via L groin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Fentanyl (Concentrate) - 100 mcg/hour\n Propofol - 20 mcg/Kg/min\n Phenylephrine - 0.5 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 AM\n Diltiazem - 10:07 AM\n Fentanyl - 02:45 AM\n Other medications:\n Flowsheet Data as of 06:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.5\nC (101.3\n T current: 36.7\nC (98.1\n HR: 75 (57 - 147) bpm\n BP: 107/59(76) {92/49(64) - 153/81(106)} mmHg\n RR: 8 (0 - 22) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 102 kg (admission): 90 kg\n CVP: 19 (9 - 27) mmHg\n Total In:\n 2,767 mL\n 520 mL\n PO:\n Tube feeding:\n 52 mL\n 82 mL\n IV Fluid:\n 2,425 mL\n 438 mL\n Blood products:\n Total out:\n 1,078 mL\n 380 mL\n Urine:\n 1,078 mL\n 380 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,689 mL\n 140 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 440 (440 - 440) mL\n Vt (Spontaneous): 612 (612 - 612) mL\n PS : 15 cmH2O\n RR (Set): 18\n RR (Spontaneous): 3\n PEEP: 14 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 27 cmH2O\n Plateau: 19 cmH2O\n SPO2: 100%\n ABG: 7.39/47/154/28/3\n Ve: 9.6 L/min\n PaO2 / FiO2: 385\n Physical Examination\n General Appearance: Intubated\n HEENT: PERRL, Jaundiced\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended\n Left Extremities: (Edema: 1+), (Temperature: Warm)\n Right Extremities: (Edema: 1+), (Temperature: Warm)\n Skin: scrotum eechymotic\n Neurologic: Sedated\n Labs / Radiology\n 99 K/uL\n 10.9 g/dL\n 96 mg/dL\n 0.9 mg/dL\n 28 mEq/L\n 3.8 mEq/L\n 18 mg/dL\n 107 mEq/L\n 141 mEq/L\n 30.6 %\n 11.0 K/uL\n [image002.jpg]\n 07:39 AM\n 08:00 AM\n 10:22 AM\n 01:57 PM\n 02:00 PM\n 02:16 PM\n 05:17 PM\n 12:14 AM\n 12:20 AM\n 05:24 AM\n WBC\n 12.1\n 11.0\n Hct\n 30.5\n 30.6\n Plt\n 105\n 99\n Creatinine\n 1.0\n 0.9\n TCO2\n 32\n 33\n 34\n 33\n 32\n 30\n Glucose\n 84\n 105\n 101\n 96\n Other labs: PT / PTT / INR:13.7/28.7/1.2, CK / CK-MB / Troponin\n T:1334/13/<0.01, ALT / AST:345/278, Alk-Phos / T bili:49/3.0, Amylase /\n Lipase:44/, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic Acid:1.4\n mmol/L, LDH:435 IU/L, Ca:7.8 mg/dL, Mg:2.2 mg/dL, PO4:2.8 mg/dL\n Imaging: MRI: Mild compression deformity of L1 w/additional\n levels of potential trabecular contusion @T10-11 also inf @T4 w/o\n retropulsion. Multilevel degenerative changes with moderate canal\n narrowing at T10-11 w/cord deformity and no abnormal cord signal.\n Extensive edema throughout paraspinal soft tissues, predominantly post\n w/in interspinous ligaments. Incompletely eval'ed c-spine w/severe\n canal narrowing @C4-5 w/cord deformity and no abnormal cord signal.\n CTA: no PE.\n CXR: Moderate bilateral pleural effusions are stable.\n Microbiology: Ucx no growth final\n Sputum: sparse GNR\n Bcx P\n Bcx P\n BAL: GS shows 1+ normal flora\n BAL: GS shows 1+ normal flora\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, AF with\n RVR, hematologic abnormalities.\n Neurologic: Neuro checks Q: 4 hr, Intubated on Propofol gtt and\n Midazolam PRN. Per ortho spine, no surgery; HOB<30, TLSO when OOB\n (NEOPS will place).\n Pain: Fentanyl PRN, Midazolam prn, Neurontin, Tylenol, APS c/s for\n paravertebral catheters.\n Cardiovascular: Now back in NSR, off dilt gtt and currently weaning Neo\n gtt. Give fluid bolus now and assess response. Will check PPV on\n bedside monitor to help assess volume status.\n Pulmonary: Cont ETT, Intubated. Pt developing early ARDS, keep on rate\n with low tidal volumes. Sats 100% on FiO2 40% so will wean down PEEP\n this AM. F/U CXR this AM. F/U on bronch cx. Today will try to\n transition over to pressure support, keep Vt in 6cc/kg range if\n possible with sedation.\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin with CT scan\n suggesting cirrhosis - Hepatitis panel sent. Starting TF and advancing\n to goal. Increase bowel regimen.\n Nutrition: Tube feeding.\n Renal: Foley, Foley, monitor UOP. Cr normalized. Monitoring for\n contrast induced nephropathy.\n Hematology: Hct stable anemia at 29-30. Plt low but stable (100's).\n Heme onc consulted - f/u on hemolysis labs and smear read, Heme recs.\n IVC filter placed.\n Endocrine: RISS, goal BS<150, adequate control.\n Infectious Disease: Check cultures, WBC normal, f/u Cx\n Lines / Tubes / Drains: R SC CVL (), PIV x2, Foley, a-line\n (), ETT\n Wounds: left groin site is c/d/i, no hematoma or pseudoaneurysm\n Imaging:\n Fluids: TF + IVF = 60 cc/hr\n Consults: Trauma surgery, Ortho, Ortho-spine, Heme/Onc\n Billing Diagnosis: Multiple injuries (Trauma)\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 11:52 PM 20 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 10:59 AM\n Multi Lumen - 04:41 PM\n Prophylaxis:\n DVT: Boots, IVC filter\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 32 mins\n"
},
{
"category": "Physician ",
"chartdate": "2175-01-27 00:00:00.000",
"description": "Intensivist Note",
"row_id": 713750,
"text": "TSICU\n HPI:\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\n checked and 1.5, 1 more unit FFP given.\n Chief complaint:\n Mult rib fx: R anterolateral and post, L posterior\n T4 vert body inf corner fx\n Commin spinous process fx T2-8\n Nondisplaced L T10 transverse process\n Nondispaced L distal clavicle\n Nondisplaced L clavicle fx\n R medial lobe liver contusion w/hematoma\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny focus of arterial\n bleeding/active extravasation, and larger area of venous bleeding\n Nondisplaced, comminuted L iliac bone fx w/adjacent iliac muscle\n hematoma, extends into L SIJ.\n Minimally displaced fx of R iliac bone extending to R SIJ.\n PMHx:\n None\n Current medications:\n 1. IV access: Peripheral line Order date: @ 2329 12. Glucagon 1\n mg IM Q15MIN:PRN hypoglycemia protocol Order date: @ 0104\n 2. 1000 mL LR\n Continuous at 60 ml/hr\n LR + TF = 60 cc/hr Order date: @ 0103 13. Insulin SC (per\n Insulin Flowsheet)\n Sliding Scale Order date: @ 0104\n 3. Acetaminophen 650 mg PO/NG Q6H:PRN pain Order date: @ 2329\n 14. Magnesium Sulfate IV Sliding Scale Order date: @ 2339\n 4. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL Order date:\n @ 2329 15. Midazolam 2-4 mg IV Q2H:PRN sedation Order date:\n @ 2329\n 5. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date: \n @ 0104 16. Ondansetron 4 mg IV Q8H:PRN nausea Order date: @ 2329\n 6. Diltiazem 5-15 mg/hr IV INFUSION Afib\n titrate titrate to HR<100 Order date: @ 2339 17. Phenylephrine\n 0.5-5 mcg/kg/min IV DRIP TITRATE TO SBP>90 MAP>60 Order date: @\n 2339\n 7. Docusate Sodium (Liquid) 100 mg PO/NG Order date: @ 2329\n 18. Pneumococcal Vac Polyvalent 0.5 ml IM ASDIR Order date: @\n 2316\n 8. Famotidine 20 mg PO/NG Order date: @ 2329 19. Potassium\n Phosphate IV Sliding Scale\n Infuse over 6 hours Order date: @ 2339\n 9. Fentanyl Citrate 25-100 mcg IV Q2H:PRN pain, agitation Order date:\n @ 2329 20. Potassium Chloride IV Sliding Scale Order date: \n @ 2339\n 10. Fentanyl Citrate 25-100 mcg/hr IV DRIP INFUSION Order date: \n @ 2339 21. Propofol 5-20 mcg/kg/min IV DRIP TITRATE TO sedation Order\n date: @ 2339\n 11. Gabapentin 100 mg PO/NG TID Order date: @ 2329 22. Sodium\n Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ 2329\n 24 Hour Events:\n Febrile yesterday AM to 101.3. Pan cx. Placed on Dilt gtt for Afib\n with RVR but since has converted to sinus and is off the dilt gtt.\n Continues to wean off the Neo gtt. Tube feeds started. Bronchoscopy\n performed. IVC filter placed late last PM.\n Post operative day:\n POD#1 - IVC filter via L groin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Fentanyl (Concentrate) - 100 mcg/hour\n Propofol - 20 mcg/Kg/min\n Phenylephrine - 0.5 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 AM\n Diltiazem - 10:07 AM\n Fentanyl - 02:45 AM\n Other medications:\n Flowsheet Data as of 06:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.5\nC (101.3\n T current: 36.7\nC (98.1\n HR: 75 (57 - 147) bpm\n BP: 107/59(76) {92/49(64) - 153/81(106)} mmHg\n RR: 8 (0 - 22) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 102 kg (admission): 90 kg\n CVP: 19 (9 - 27) mmHg\n Total In:\n 2,767 mL\n 520 mL\n PO:\n Tube feeding:\n 52 mL\n 82 mL\n IV Fluid:\n 2,425 mL\n 438 mL\n Blood products:\n Total out:\n 1,078 mL\n 380 mL\n Urine:\n 1,078 mL\n 380 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,689 mL\n 140 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 440 (440 - 440) mL\n Vt (Spontaneous): 612 (612 - 612) mL\n PS : 15 cmH2O\n RR (Set): 18\n RR (Spontaneous): 3\n PEEP: 14 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 27 cmH2O\n Plateau: 19 cmH2O\n SPO2: 100%\n ABG: 7.39/47/154/28/3\n Ve: 9.6 L/min\n PaO2 / FiO2: 385\n Physical Examination\n General Appearance: Intubated\n HEENT: PERRL, Jaundiced\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended\n Left Extremities: (Edema: 1+), (Temperature: Warm)\n Right Extremities: (Edema: 1+), (Temperature: Warm)\n Skin: scrotum eechymotic\n Neurologic: Sedated\n Labs / Radiology\n 99 K/uL\n 10.9 g/dL\n 96 mg/dL\n 0.9 mg/dL\n 28 mEq/L\n 3.8 mEq/L\n 18 mg/dL\n 107 mEq/L\n 141 mEq/L\n 30.6 %\n 11.0 K/uL\n [image002.jpg]\n 07:39 AM\n 08:00 AM\n 10:22 AM\n 01:57 PM\n 02:00 PM\n 02:16 PM\n 05:17 PM\n 12:14 AM\n 12:20 AM\n 05:24 AM\n WBC\n 12.1\n 11.0\n Hct\n 30.5\n 30.6\n Plt\n 105\n 99\n Creatinine\n 1.0\n 0.9\n TCO2\n 32\n 33\n 34\n 33\n 32\n 30\n Glucose\n 84\n 105\n 101\n 96\n Other labs: PT / PTT / INR:13.7/28.7/1.2, CK / CK-MB / Troponin\n T:1334/13/<0.01, ALT / AST:345/278, Alk-Phos / T bili:49/3.0, Amylase /\n Lipase:44/, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic Acid:1.4\n mmol/L, LDH:435 IU/L, Ca:7.8 mg/dL, Mg:2.2 mg/dL, PO4:2.8 mg/dL\n Imaging: MRI: Mild compression deformity of L1 w/additional\n levels of potential trabecular contusion @T10-11 also inf @T4 w/o\n retropulsion. Multilevel degenerative changes with moderate canal\n narrowing at T10-11 w/cord deformity and no abnormal cord signal.\n Extensive edema throughout paraspinal soft tissues, predominantly post\n w/in interspinous ligaments. Incompletely eval'ed c-spine w/severe\n canal narrowing @C4-5 w/cord deformity and no abnormal cord signal.\n CTA: no PE.\n CXR: Moderate bilateral pleural effusions are stable.\n Microbiology: Ucx no growth final\n Sputum: sparse GNR\n Bcx P\n Bcx P\n BAL: GS shows 1+ normal flora\n BAL: GS shows 1+ normal flora\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, AF with\n RVR, hematologic abnormalities.\n Neurologic: Neuro checks Q: 4 hr, Intubated on Propofol gtt and\n Midazolam PRN. Per ortho spine, no surgery; HOB<30, TLSO when OOB\n (NEOPS will place).\n Pain: Fentanyl drip, propofol gtt for sedation, Neurontin, Tylenol.\n Adequate pain control at this point\n Cardiovascular: Now back in NSR, off dilt gtt and currently weaning Neo\n gtt. Please start PO dilt as appears to be irritable. Will check PPV on\n bedside monitor to help assess volume status.\n Pulmonary: Cont ETT, Intubated. /ARDS\n type picture improving with\n improve CXR and oxygenation,. Sats 100% on FiO2 40% so will wean down\n PEEP this AM. F/U CXR this AM. F/U on bronch cx. Today will try to\n transition over to pressure support, keep Vt in 6cc/kg range if\n possible with sedation.\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin with CT scan\n suggesting cirrhosis - Hepatitis panel sent. Starting TF and advancing\n to goal. Increase bowel regimen.\n Nutrition: Tube feeding.\n Renal: Foley, Foley, monitor UOP. Cr normalized. Monitoring for\n contrast induced nephropathy.\n Hematology: Hct stable anemia at 29-30. Plt low but stable (100's).\n Heme onc consulted - f/u on hemolysis labs and smear read, Heme recs.\n IVC filter placed.\n Endocrine: RISS, goal BS<150, adequate control.\n Infectious Disease: Check cultures, WBC normal, f/u Cx. No signs of\n infection. No Abx started\n Lines / Tubes / Drains: R SC CVL (), PIV x2, Foley, a-line\n (), ETT\n Wounds: left groin site is c/d/i, no hematoma or pseudoaneurysm\n Imaging:\n Fluids: TF + IVF = 60 cc/hr\n Consults: Trauma surgery, Ortho, Ortho-spine, Heme/Onc\n Billing Diagnosis: Multiple injuries (Trauma)\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 11:52 PM 20 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 10:59 AM\n Multi Lumen - 04:41 PM\n Prophylaxis:\n DVT: Boots, IVC filter\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 32 mins\n"
},
{
"category": "Physician ",
"chartdate": "2175-02-01 00:00:00.000",
"description": "Intensivist Note",
"row_id": 714438,
"text": "TSICU\n HPI:\n 74M s/p fall with multiple rib fx, pelvis fx, clavicle fx, and thoracic\n fx c/b unstable bleeding s/p IR embo, now with AF with RVR/Aflutter,\n persistant hypotension and presumed PNA.\n Chief complaint:\n fall\n PMHx:\n none\n Current medications:\n 1. Acetaminophen 2. Amiodarone 3. Bisacodyl 4. Calcium Gluconate 5.\n CeftriaXONE 6. Chlorhexidine Gluconate 0.12% Oral Rinse 7. Dextrose 50%\n 8. Diltiazem 9. Docusate Sodium (Liquid) 10. Fentanyl Citrate 11.\n Gabapentin 12. Glucagon 13. Heparin 14. Insulin 15. Lactulose 16.\n Magnesium Sulfate 17. Metoprolol Tartrate 18. Midazolam 19. Midazolam\n 20. Milk of Magnesia 21. Ondansetron 22. OxycoDONE Liquid 23.\n Pantoprazole 24. Phenylephrine\n 25. Pneumococcal Vac Polyvalent 26. Potassium Phosphate 27. Potassium\n Chloride 28. Senna 29. Sodium Chloride 0.9% Flush\n 24 Hour Events:\n Changed sedation to po Oxycodone, wean fentanyl gtt, wean Midazolam,\n and start Haldol prn, but stopped due to QTc. Cards consult, started\n amiodarone.\n Post operative day:\n POD#6 - IVC filter via L groin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\n Vancomycin - 08:00 AM\n Ceftriaxone - 12:00 PM\n Infusions:\n Midazolam (Versed) - 5 mg/hour\n Fentanyl (Concentrate) - 50 mcg/hour\n Amiodarone - 0.5 mg/min\n Other ICU medications:\n Haloperidol (Haldol) - 10:45 AM\n Lorazepam (Ativan) - 02:00 PM\n Midazolam (Versed) - 03:25 AM\n Fentanyl - 03:25 AM\n Heparin Sodium (Prophylaxis) - 05:33 AM\n Other medications:\n Flowsheet Data as of 06:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.1\nC (100.6\n T current: 37.2\nC (98.9\n HR: 76 (74 - 104) bpm\n BP: 125/62(81) {90/49(62) - 152/67(89)} mmHg\n RR: 25 (18 - 31) insp/min\n SPO2: 98%\n Heart rhythm: A Flut (Atrial Flutter)\n Wgt (current): 102 kg (admission): 90 kg\n CVP: 12 (10 - 19) mmHg\n Total In:\n 3,718 mL\n 759 mL\n PO:\n Tube feeding:\n 1,920 mL\n 424 mL\n IV Fluid:\n 1,078 mL\n 245 mL\n Blood products:\n Total out:\n 1,755 mL\n 350 mL\n Urine:\n 1,755 mL\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,963 mL\n 409 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 480 (400 - 540) mL\n PS : 10 cmH2O\n RR (Spontaneous): 29\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 21 cmH2O\n SPO2: 98%\n ABG: 7.44/45/119/31/6\n Ve: 11.8 L/min\n PaO2 / FiO2: 238\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), shallow respirations\n Abdominal: Soft, No(t) Non-distended, Bowel sounds present, Distended\n Left Extremities: (Edema: 1+), (Temperature: Warm)\n Right Extremities: (Edema: 1+), (Temperature: Warm)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities, Sedated\n Labs / Radiology\n 104 K/uL\n 9.5 g/dL\n 129 mg/dL\n 0.7 mg/dL\n 31 mEq/L\n 4.2 mEq/L\n 24 mg/dL\n 106 mEq/L\n 142 mEq/L\n 29.7 %\n 4.2 K/uL\n [image002.jpg]\n 04:45 PM\n 12:45 AM\n 01:00 AM\n 05:12 AM\n 02:40 PM\n 01:46 AM\n 01:55 AM\n 03:40 PM\n 12:07 AM\n 02:18 AM\n WBC\n 13.1\n 8.8\n 4.2\n Hct\n 31.6\n 32.1\n 29.7\n Plt\n 158\n 153\n 104\n Creatinine\n 0.8\n 0.7\n 0.7\n 0.7\n TCO2\n 35\n 35\n 34\n 37\n 35\n 32\n Glucose\n 131\n 115\n 132\n 122\n 117\n 129\n Other labs: PT / PTT / INR:13.7/27.6/1.2, CK / CK-MB / Troponin\n T:128/13/<0.01, ALT / AST:87/109, Alk-Phos / T bili:115/5.0, Amylase /\n Lipase:44/, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic Acid:1.4\n mmol/L, Albumin:2.7 g/dL, LDH:348 IU/L, Ca:7.9 mg/dL, Mg:2.0 mg/dL,\n PO4:3.4 mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, now\n with AF with RVR/Aflutter, persistant hypotension and presumed PNA.\n Neurologic: Intubated. Per ortho spine, no surgery; HOB<30, TLSO when\n OOB (NEOPS will place). Wean sedation as may be causing hypotension.\n Change pain meds to PO. Wean versed.\n Neuro checks Q: shift\n Pain: Oxycodone, Fentanyl gtt (weaning), Midazolam gtt (weaning),\n Neurontin, Tylenol\n Cardiovascular: Aflutter on Dilt 60mg PO QID. Neo off. Consulting\n cards to assess for cardioversion, rec starting amiodarone. Pressor\n requirements may be related to AFib/flutter. As pt cannot be\n anticoagulated (trauma), will need TEE b/f cardioversion.\n Pulmonary: Intubated, weaning, tachypneic likely abd distension. On\n appropriate abx per BAL cx -Ceftriaxone, will need trach this week\n (likely )\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin (declining 6.8\n max ->5.0) with CT scan suggesting cirrhosis - Hepatitis panel NEG. TFs\n on hold for PEG. Bowel regimen, no B<M since admission MOM and\n Lactulose added.\n Nutrition: NPO\n Renal: Foley, monitor UOP, edematous scrotum.\n Hematology: Hct stable 32.1->29.7. Plt low but stable (100's); d/c'd\n H2B with increasing plt count. Heme onc consulted - smear nl; no\n hemolysis. IVC filter placed.\n Endocrine: RISS\n Infectious Disease: WBC droppping 13.1->8.8->4.2, f/u Cx - BAL:\n Klebsiella - Ceftriaxone\n Lines / Tubes / Drains: R SC CVL (), PIV x2, Foley, L a-line\n (), ETT\n Imaging: CXR today\n Fluids: -\n Consults: Trauma (1o), Ortho Spine, Ortho trauma, Heme\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 04:41 PM\n Arterial Line - 11:30 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin, IVC filter\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2175-02-02 00:00:00.000",
"description": "Intensivist Note",
"row_id": 714642,
"text": "TSICU\n HPI:\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\n checked and 1.5, 1 more unit FFP given.\n .\n Injuries\n Mult rib fx: R anterolateral and post, L posterior\n T4 vert body inf corner fx\n Commin spinous process fx T2-8\n Nondisplaced L T10 transverse process\n Nondispaced L distal clavicle\n Nondisplaced L clavicle fx\n R medial lobe liver contusion w/hematoma\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny focus of arterial\n bleeding/active extravasation, and larger area of venous bleeding\n Nondisplaced, comminuted L iliac bone fx w/adjacent iliac muscle\n hematoma, extends into L SIJ.\n Minimally displaced fx of R iliac bone extending to R SIJ.\n Chief complaint:\n Trauma\n PMHx:\n PMH: None\n PSH: None\n : None\n Current medications:\n 24 Hour Events:\n Trach/PEG. Pt's BP dropped to 80/40 off pressors, sats 88. restarted\n neo. Overnight, pt reverted to sinus, off pressors, weaning sedation.\n PERCUTANEOUS TRACHEOSTOMY - At 12:00 PM\n PEG INSERTION - At 12:00 PM\n Post operative day:\n POD#7 - IVC filter via L groin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\n Vancomycin - 08:00 AM\n Ceftriaxone - 03:00 PM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Amiodarone - 0.5 mg/min\n Fentanyl (Concentrate) - 50 mcg/hour\n Other ICU medications:\n Fentanyl - 01:23 PM\n Pantoprazole (Protonix) - 02:00 PM\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Other medications:\n Flowsheet Data as of 04:33 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.7\nC (99.9\n T current: 37.1\nC (98.8\n HR: 94 (68 - 101) bpm\n BP: 140/66(91) {89/46(63) - 154/68(94)} mmHg\n RR: 26 (11 - 30) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 102 kg (admission): 90 kg\n CVP: 9 (6 - 16) mmHg\n Total In:\n 1,764 mL\n 142 mL\n PO:\n Tube feeding:\n 424 mL\n IV Fluid:\n 1,000 mL\n 82 mL\n Blood products:\n Total out:\n 1,630 mL\n 290 mL\n Urine:\n 1,630 mL\n 290 mL\n NG:\n Stool:\n Drains:\n Balance:\n 134 mL\n -148 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 483 (404 - 506) mL\n PS : 15 cmH2O\n RR (Spontaneous): 16\n PEEP: 10 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10\n PIP: 25 cmH2O\n SPO2: 98%\n ABG: 7.45/49/98./31/8\n Ve: 8.5 L/min\n PaO2 / FiO2: 163\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: Crackles : )\n Abdominal: Soft\n Left Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present)\n Right Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present)\n Neurologic: Follows simple commands, Moves all extremities, Sedated\n Labs / Radiology\n 109 K/uL\n 10.2 g/dL\n 110 mg/dL\n 0.8 mg/dL\n 31 mEq/L\n 4.5 mEq/L\n 24 mg/dL\n 105 mEq/L\n 144 mEq/L\n 31.3 %\n 5.9 K/uL\n [image002.jpg]\n 12:07 AM\n 02:18 AM\n 08:00 AM\n 02:00 PM\n 05:04 PM\n 08:00 PM\n 09:20 PM\n 01:00 AM\n 01:07 AM\n 01:18 AM\n WBC\n 4.2\n 5.9\n Hct\n 29.7\n 31.3\n Plt\n 104\n 109\n Creatinine\n 0.7\n 0.8\n TCO2\n 32\n 36\n 34\n 35\n Glucose\n 129\n 100\n 111\n 105\n 117\n 110\n Other labs: PT / PTT / INR:13.7/27.6/1.2, CK / CK-MB / Troponin\n T:128/13/<0.01, ALT / AST:90/113, Alk-Phos / T bili:99/5.1, Amylase /\n Lipase:58/39, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic\n Acid:1.4 mmol/L, Albumin:2.3 g/dL, LDH:348 IU/L, Ca:8.1 mg/dL, Mg:2.1\n mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, now\n with AF with RVR/Aflutter, persistant hypotension and PNA.\n Neurologic: s/p trach. Per ortho spine, no surgery; HOB<30, TLSO when\n OOB (NEOPS will place). Wean sedation as may be causing hypotension.\n Change pain meds to PO. Will try Geodon today for agitation.\n Neuro checks Q: shift\n Pain: Oxycodone, Neurontin, Tylenol. Wean fentanyl gtt, midazolam\n gtt\n Cardiovascular: Aflutter, now reverted to sinus. Likely cardiac\n contusion. On Dilt 60mg PO QID. Cards rec amio gtt. Neo off. Pt cannot\n be fully anticoagulated for now (trauma). Start PO amio.\n Pulmonary: Intubated, weaning, tachypneic likely abd distension. On\n appropriate abx per BAL cx - Ceftriaxone. Now that pulm status is\n worsening, will broaden coverage with V/C/C.\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin (declining 6.8\n max ->5.0) w/CT scan suggesting cirrhosis - Hepatitis panel NEG. TFs.\n Bowel regimen.\n Nutrition: TF\n Renal: Foley, monitor UOP, edematous scrotum. Diurese with lasix 10mg\n IV. Goal 1 L negative today.\n Hematology: Hct stable 32.1->29.7. Plt stable (100's); d/c'd H2B with\n increasing plt count. Heme onc c/s - smear nl; no hemolysis. IVC\n filter placed.\n Endocrine: RISS, goal BS<150.\n Infectious Disease: WBC dropping 13.1->8.8->4.2, f/u Cx - BAL:\n pan-sensitive Klebsiella\n broaden coverage for VAP.\n Lines / Tubes / Drains: R SC CVL (), Foley, L a-line (),\n trach/PEG\n Wounds: SCDs, IVC filter, SQH\n Imaging:\n Fluids:\n Consults: Trauma surgery\n Billing Diagnosis: Multiple injuries (Trauma)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 04:41 PM\n Arterial Line - 11:30 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 32 min\n"
},
{
"category": "Physician ",
"chartdate": "2175-02-02 00:00:00.000",
"description": "Intensivist Note",
"row_id": 714643,
"text": "TSICU\n HPI:\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\n checked and 1.5, 1 more unit FFP given.\n .\n Injuries\n Mult rib fx: R anterolateral and post, L posterior\n T4 vert body inf corner fx\n Commin spinous process fx T2-8\n Nondisplaced L T10 transverse process\n Nondispaced L distal clavicle\n Nondisplaced L clavicle fx\n R medial lobe liver contusion w/hematoma\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny focus of arterial\n bleeding/active extravasation, and larger area of venous bleeding\n Nondisplaced, comminuted L iliac bone fx w/adjacent iliac muscle\n hematoma, extends into L SIJ.\n Minimally displaced fx of R iliac bone extending to R SIJ.\n Chief complaint:\n Trauma\n PMHx:\n PMH: None\n PSH: None\n : None\n Current medications:\n 24 Hour Events:\n Trach/PEG. Pt's BP dropped to 80/40 off pressors, sats 88. restarted\n neo. Overnight, pt reverted to sinus, off pressors, weaning sedation.\n PERCUTANEOUS TRACHEOSTOMY - At 12:00 PM\n PEG INSERTION - At 12:00 PM\n Post operative day:\n POD#7 - IVC filter via L groin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\n Vancomycin - 08:00 AM\n Ceftriaxone - 03:00 PM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Amiodarone - 0.5 mg/min\n Fentanyl (Concentrate) - 50 mcg/hour\n Other ICU medications:\n Fentanyl - 01:23 PM\n Pantoprazole (Protonix) - 02:00 PM\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Other medications:\n Flowsheet Data as of 04:33 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.7\nC (99.9\n T current: 37.1\nC (98.8\n HR: 94 (68 - 101) bpm\n BP: 140/66(91) {89/46(63) - 154/68(94)} mmHg\n RR: 26 (11 - 30) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 102 kg (admission): 90 kg\n CVP: 9 (6 - 16) mmHg\n Total In:\n 1,764 mL\n 142 mL\n PO:\n Tube feeding:\n 424 mL\n IV Fluid:\n 1,000 mL\n 82 mL\n Blood products:\n Total out:\n 1,630 mL\n 290 mL\n Urine:\n 1,630 mL\n 290 mL\n NG:\n Stool:\n Drains:\n Balance:\n 134 mL\n -148 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 483 (404 - 506) mL\n PS : 15 cmH2O\n RR (Spontaneous): 16\n PEEP: 10 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10\n PIP: 25 cmH2O\n SPO2: 98%\n ABG: 7.45/49/98./31/8\n Ve: 8.5 L/min\n PaO2 / FiO2: 163\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: Crackles : )\n Abdominal: Soft\n Left Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present)\n Right Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present)\n Neurologic: Follows simple commands, Moves all extremities, Sedated\n Labs / Radiology\n 109 K/uL\n 10.2 g/dL\n 110 mg/dL\n 0.8 mg/dL\n 31 mEq/L\n 4.5 mEq/L\n 24 mg/dL\n 105 mEq/L\n 144 mEq/L\n 31.3 %\n 5.9 K/uL\n [image002.jpg]\n 12:07 AM\n 02:18 AM\n 08:00 AM\n 02:00 PM\n 05:04 PM\n 08:00 PM\n 09:20 PM\n 01:00 AM\n 01:07 AM\n 01:18 AM\n WBC\n 4.2\n 5.9\n Hct\n 29.7\n 31.3\n Plt\n 104\n 109\n Creatinine\n 0.7\n 0.8\n TCO2\n 32\n 36\n 34\n 35\n Glucose\n 129\n 100\n 111\n 105\n 117\n 110\n Other labs: PT / PTT / INR:13.7/27.6/1.2, CK / CK-MB / Troponin\n T:128/13/<0.01, ALT / AST:90/113, Alk-Phos / T bili:99/5.1, Amylase /\n Lipase:58/39, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic\n Acid:1.4 mmol/L, Albumin:2.3 g/dL, LDH:348 IU/L, Ca:8.1 mg/dL, Mg:2.1\n mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, now\n with AF with RVR/Aflutter, persistant hypotension and PNA.\n Neurologic: s/p trach. Per ortho spine, no surgery; HOB<30, TLSO when\n OOB (NEOPS will place). Wean sedation as may be causing hypotension.\n Change pain meds to PO. Will try Geodon today for agitation.\n Neuro checks Q: shift\n Pain: Oxycodone, Neurontin, Tylenol. Wean fentanyl gtt, midazolam\n gtt\n Cardiovascular: Aflutter, now reverted to sinus. Likely cardiac\n contusion. On Dilt 60mg PO QID. Cards rec amio gtt. Neo off. Pt cannot\n be fully anticoagulated for now (trauma). Start PO amio.\n Pulmonary: Intubated, weaning, tachypneic likely abd distension. On\n appropriate abx per BAL cx - Ceftriaxone. Now that pulm status is\n worsening, will broaden coverage with V/C/C.\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin (declining 6.8\n max ->5.0) w/CT scan suggesting cirrhosis - Hepatitis panel NEG. TFs.\n Bowel regimen.\n Nutrition: TF\n Renal: Foley, monitor UOP, edematous scrotum. Diurese with lasix 10mg\n IV. Goal 1 L negative today.\n Hematology: Hct stable 32.1->29.7. Plt stable (100's); d/c'd H2B with\n increasing plt count. Heme onc c/s - smear nl; no hemolysis. IVC\n filter placed.\n Endocrine: RISS, goal BS<150.\n Infectious Disease: WBC dropping 13.1->8.8->4.2, f/u Cx - BAL:\n pan-sensitive Klebsiella\n broaden coverage for VAP.\n Lines / Tubes / Drains: R SC CVL (), Foley, L a-line (),\n trach/PEG\n Wounds: SCDs, IVC filter, SQH\n Imaging:\n Fluids:\n Consults: Trauma surgery\n Billing Diagnosis: Multiple injuries (Trauma)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 04:41 PM\n Arterial Line - 11:30 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 32 min\n"
},
{
"category": "Physician ",
"chartdate": "2175-02-02 00:00:00.000",
"description": "Intensivist Note",
"row_id": 714644,
"text": "TSICU\n HPI:\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\n checked and 1.5, 1 more unit FFP given.\n .\n Injuries\n Mult rib fx: R anterolateral and post, L posterior\n T4 vert body inf corner fx\n Commin spinous process fx T2-8\n Nondisplaced L T10 transverse process\n Nondispaced L distal clavicle\n Nondisplaced L clavicle fx\n R medial lobe liver contusion w/hematoma\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny focus of arterial\n bleeding/active extravasation, and larger area of venous bleeding\n Nondisplaced, comminuted L iliac bone fx w/adjacent iliac muscle\n hematoma, extends into L SIJ.\n Minimally displaced fx of R iliac bone extending to R SIJ.\n Chief complaint:\n Trauma\n PMHx:\n PMH: None\n PSH: None\n : None\n Current medications:\n 24 Hour Events:\n Trach/PEG. Pt's BP dropped to 80/40 off pressors, sats 88. restarted\n neo. Overnight, pt reverted to sinus, off pressors, weaning sedation.\n PERCUTANEOUS TRACHEOSTOMY - At 12:00 PM\n PEG INSERTION - At 12:00 PM\n Post operative day:\n POD#7 - IVC filter via L groin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\n Vancomycin - 08:00 AM\n Ceftriaxone - 03:00 PM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Amiodarone - 0.5 mg/min\n Fentanyl (Concentrate) - 50 mcg/hour\n Other ICU medications:\n Fentanyl - 01:23 PM\n Pantoprazole (Protonix) - 02:00 PM\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Other medications:\n Flowsheet Data as of 04:33 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.7\nC (99.9\n T current: 37.1\nC (98.8\n HR: 94 (68 - 101) bpm\n BP: 140/66(91) {89/46(63) - 154/68(94)} mmHg\n RR: 26 (11 - 30) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 102 kg (admission): 90 kg\n CVP: 9 (6 - 16) mmHg\n Total In:\n 1,764 mL\n 142 mL\n PO:\n Tube feeding:\n 424 mL\n IV Fluid:\n 1,000 mL\n 82 mL\n Blood products:\n Total out:\n 1,630 mL\n 290 mL\n Urine:\n 1,630 mL\n 290 mL\n NG:\n Stool:\n Drains:\n Balance:\n 134 mL\n -148 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 483 (404 - 506) mL\n PS : 15 cmH2O\n RR (Spontaneous): 16\n PEEP: 10 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10\n PIP: 25 cmH2O\n SPO2: 98%\n ABG: 7.45/49/98./31/8\n Ve: 8.5 L/min\n PaO2 / FiO2: 163\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: Crackles : )\n Abdominal: Soft\n Left Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present)\n Right Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present)\n Neurologic: Follows simple commands, Moves all extremities, Sedated\n Labs / Radiology\n 109 K/uL\n 10.2 g/dL\n 110 mg/dL\n 0.8 mg/dL\n 31 mEq/L\n 4.5 mEq/L\n 24 mg/dL\n 105 mEq/L\n 144 mEq/L\n 31.3 %\n 5.9 K/uL\n [image002.jpg]\n 12:07 AM\n 02:18 AM\n 08:00 AM\n 02:00 PM\n 05:04 PM\n 08:00 PM\n 09:20 PM\n 01:00 AM\n 01:07 AM\n 01:18 AM\n WBC\n 4.2\n 5.9\n Hct\n 29.7\n 31.3\n Plt\n 104\n 109\n Creatinine\n 0.7\n 0.8\n TCO2\n 32\n 36\n 34\n 35\n Glucose\n 129\n 100\n 111\n 105\n 117\n 110\n Other labs: PT / PTT / INR:13.7/27.6/1.2, CK / CK-MB / Troponin\n T:128/13/<0.01, ALT / AST:90/113, Alk-Phos / T bili:99/5.1, Amylase /\n Lipase:58/39, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic\n Acid:1.4 mmol/L, Albumin:2.3 g/dL, LDH:348 IU/L, Ca:8.1 mg/dL, Mg:2.1\n mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, now\n with AF with RVR/Aflutter, persistant hypotension and PNA.\n Neurologic: s/p trach. Per ortho spine, no surgery; HOB<30, TLSO when\n OOB (NEOPS will place). Wean sedation as may be causing hypotension.\n Change pain meds to PO. Will try Geodon today for agitation.\n Neuro checks Q: shift\n Pain: Oxycodone, Neurontin, Tylenol. Wean fentanyl gtt, midazolam\n gtt\n Cardiovascular: Aflutter, now reverted to sinus. Likely cardiac\n contusion. On Dilt 60mg PO QID. Cards rec amio gtt. Neo off. Pt cannot\n be fully anticoagulated for now (trauma). Start PO amio.\n Pulmonary: Intubated, weaning, tachypneic likely abd distension. On\n appropriate abx per BAL cx - Ceftriaxone. Now that pulm status is\n worsening, will broaden coverage with V/C/C.\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin (declining 6.8\n max ->5.0) w/CT scan suggesting cirrhosis - Hepatitis panel NEG. TFs.\n Bowel regimen.\n Nutrition: TF\n Renal: Foley, monitor UOP, edematous scrotum. Diurese with lasix 10mg\n IV. Goal 1 L negative today.\n Hematology: Hct stable 32.1->29.7. Plt stable (100's); d/c'd H2B with\n increasing plt count. Heme onc c/s - smear nl; no hemolysis. IVC\n filter placed.\n Endocrine: RISS, goal BS<150.\n Infectious Disease: WBC dropping 13.1->8.8->4.2, f/u Cx - BAL:\n pan-sensitive Klebsiella\n broaden coverage for VAP.\n Lines / Tubes / Drains: R SC CVL (), Foley, L a-line (),\n trach/PEG\n Wounds: SCDs, IVC filter, SQH\n Imaging:\n Fluids:\n Consults: Trauma surgery\n Billing Diagnosis: Multiple injuries (Trauma)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 04:41 PM\n Arterial Line - 11:30 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 32 min\n"
},
{
"category": "Nursing",
"chartdate": "2175-02-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 714721,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Following commands. Mouthing words, but incomprehensible.\n Frequently agitated. Administered Ativan/Midazolam and Zyprexa to\n alleve anxiety. Fair results. BP and anxiety slightly improved.\n Febrile. Treated with Tylenol as ordered. MAE x 4 strongly.\n Remains on CPAP. Strong cough. Lungs clear to rhonchi BL\n in upper airways, diminished in bases. Suctioned thick tan/white\n secretions via trach. O2 sat stable, >=95%. AM ABG showed metabolic\n alkalosis. No new orders received. Weaned down PS to 12.\n Hypertensive at times, especially during agitation. BP\n decreased to 130s post Versed bolus. Pulses palpable.\n Abdomen softly distended, non-tender. Positive BS\n throughout abdomen. Small BM (smear) this am. Tube feeds continued at\n goal of 80cc/hr. Tolerating well with little residual noted.\n Foley catheter draining clear amber urine.\n Skin intact. Ecchymosis noted to right flank. Scrotum with\n severe edema.\n Plan:\n Continue to monitor neuro status with improvement in agitation. Wean\n down PEEP/PS as tolerated.\n"
},
{
"category": "Physician ",
"chartdate": "2175-01-27 00:00:00.000",
"description": "Intensivist Note",
"row_id": 713731,
"text": "TSICU\n HPI:\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\n checked and 1.5, 1 more unit FFP given.\n Chief complaint:\n Mult rib fx: R anterolateral and post, L posterior\n T4 vert body inf corner fx\n Commin spinous process fx T2-8\n Nondisplaced L T10 transverse process\n Nondispaced L distal clavicle\n Nondisplaced L clavicle fx\n R medial lobe liver contusion w/hematoma\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny focus of arterial\n bleeding/active extravasation, and larger area of venous bleeding\n Nondisplaced, comminuted L iliac bone fx w/adjacent iliac muscle\n hematoma, extends into L SIJ.\n Minimally displaced fx of R iliac bone extending to R SIJ.\n PMHx:\n None\n Current medications:\n 1. IV access: Peripheral line Order date: @ 2329 12. Glucagon 1\n mg IM Q15MIN:PRN hypoglycemia protocol Order date: @ 0104\n 2. 1000 mL LR\n Continuous at 60 ml/hr\n LR + TF = 60 cc/hr Order date: @ 0103 13. Insulin SC (per\n Insulin Flowsheet)\n Sliding Scale Order date: @ 0104\n 3. Acetaminophen 650 mg PO/NG Q6H:PRN pain Order date: @ 2329\n 14. Magnesium Sulfate IV Sliding Scale Order date: @ 2339\n 4. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL Order date:\n @ 2329 15. Midazolam 2-4 mg IV Q2H:PRN sedation Order date:\n @ 2329\n 5. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date: \n @ 0104 16. Ondansetron 4 mg IV Q8H:PRN nausea Order date: @ 2329\n 6. Diltiazem 5-15 mg/hr IV INFUSION Afib\n titrate titrate to HR<100 Order date: @ 2339 17. Phenylephrine\n 0.5-5 mcg/kg/min IV DRIP TITRATE TO SBP>90 MAP>60 Order date: @\n 2339\n 7. Docusate Sodium (Liquid) 100 mg PO/NG Order date: @ 2329\n 18. Pneumococcal Vac Polyvalent 0.5 ml IM ASDIR Order date: @\n 2316\n 8. Famotidine 20 mg PO/NG Order date: @ 2329 19. Potassium\n Phosphate IV Sliding Scale\n Infuse over 6 hours Order date: @ 2339\n 9. Fentanyl Citrate 25-100 mcg IV Q2H:PRN pain, agitation Order date:\n @ 2329 20. Potassium Chloride IV Sliding Scale Order date: \n @ 2339\n 10. Fentanyl Citrate 25-100 mcg/hr IV DRIP INFUSION Order date: \n @ 2339 21. Propofol 5-20 mcg/kg/min IV DRIP TITRATE TO sedation Order\n date: @ 2339\n 11. Gabapentin 100 mg PO/NG TID Order date: @ 2329 22. Sodium\n Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ 2329\n 24 Hour Events:\n Febrile yesterday AM to 101.3. Pan cx. Placed on Dilt gtt for Afib\n with RVR but since has converted and is off the dilt gtt. Continues to\n wean off the Neo gtt. Tube feeds started. Bronchoscopy performed.\n IVC filter placed late last PM.\n Post operative day:\n POD#1 - IVC filter via L groin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Fentanyl (Concentrate) - 100 mcg/hour\n Propofol - 20 mcg/Kg/min\n Phenylephrine - 0.5 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 AM\n Diltiazem - 10:07 AM\n Fentanyl - 02:45 AM\n Other medications:\n Flowsheet Data as of 06:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.5\nC (101.3\n T current: 36.7\nC (98.1\n HR: 75 (57 - 147) bpm\n BP: 107/59(76) {92/49(64) - 153/81(106)} mmHg\n RR: 8 (0 - 22) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 102 kg (admission): 90 kg\n CVP: 19 (9 - 27) mmHg\n Total In:\n 2,767 mL\n 520 mL\n PO:\n Tube feeding:\n 52 mL\n 82 mL\n IV Fluid:\n 2,425 mL\n 438 mL\n Blood products:\n Total out:\n 1,078 mL\n 380 mL\n Urine:\n 1,078 mL\n 380 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,689 mL\n 140 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 440 (440 - 440) mL\n Vt (Spontaneous): 612 (612 - 612) mL\n PS : 15 cmH2O\n RR (Set): 18\n RR (Spontaneous): 3\n PEEP: 14 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 27 cmH2O\n Plateau: 19 cmH2O\n SPO2: 100%\n ABG: 7.39/47/154/28/3\n Ve: 9.6 L/min\n PaO2 / FiO2: 385\n Physical Examination\n General Appearance: Intubated\n HEENT: PERRL, Jaundiced\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended\n Left Extremities: (Edema: 1+), (Temperature: Warm)\n Right Extremities: (Edema: 1+), (Temperature: Warm)\n Skin: scrotum eechymotic\n Neurologic: Sedated\n Labs / Radiology\n 99 K/uL\n 10.9 g/dL\n 96 mg/dL\n 0.9 mg/dL\n 28 mEq/L\n 3.8 mEq/L\n 18 mg/dL\n 107 mEq/L\n 141 mEq/L\n 30.6 %\n 11.0 K/uL\n [image002.jpg]\n 07:39 AM\n 08:00 AM\n 10:22 AM\n 01:57 PM\n 02:00 PM\n 02:16 PM\n 05:17 PM\n 12:14 AM\n 12:20 AM\n 05:24 AM\n WBC\n 12.1\n 11.0\n Hct\n 30.5\n 30.6\n Plt\n 105\n 99\n Creatinine\n 1.0\n 0.9\n TCO2\n 32\n 33\n 34\n 33\n 32\n 30\n Glucose\n 84\n 105\n 101\n 96\n Other labs: PT / PTT / INR:13.7/28.7/1.2, CK / CK-MB / Troponin\n T:1334/13/<0.01, ALT / AST:345/278, Alk-Phos / T bili:49/3.0, Amylase /\n Lipase:44/, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic Acid:1.4\n mmol/L, LDH:435 IU/L, Ca:7.8 mg/dL, Mg:2.2 mg/dL, PO4:2.8 mg/dL\n Imaging: MRI: Mild compression deformity of L1 w/additional\n levels of potential trabecular contusion @T10-11 also inf @T4 w/o\n retropulsion. Multilevel degenerative changes with moderate canal\n narrowing at T10-11 w/cord deformity and no abnormal cord signal.\n Extensive edema throughout paraspinal soft tissues, predominantly post\n w/in interspinous ligaments. Incompletely eval'ed c-spine w/severe\n canal narrowing @C4-5 w/cord deformity and no abnormal cord signal.\n CTA: no PE.\n CXR: Moderate bilateral pleural effusions are stable.\n Microbiology: Ucx no growth final\n Sputum: sparse GNR\n Bcx P\n Bcx P\n BAL: GS shows 1+ normal flora\n BAL: GS shows 1+ normal flora\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, AF with\n RVR, hematologic abnomalities\n Neurologic: Neuro checks Q: 4 hr, Intubated on Propofol gtt and\n Midazolam PRN. Per ortho spine, no surgery; HOB<30, TLSO when OOB\n (NEOPS will place).\n Pain: Fentanyl PRN, Midazolam prn, Neurontin, Tylenol, APS c/s for\n paravertebral catheters\n Cardiovascular: Now back in NSR, off dilt gtt and currently weaning Neo\n gtt.\n Pulmonary: Cont ETT, Intubated. Pt developing early ARDS, keep on rate\n with low tidal volumes. F/U CXR this AM. F/U on bronch cx.\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin with CT scan\n suggesting cirrhosis - Hepatitis panel sent. Starting TF and advancing\n to goal.\n Nutrition: Tube feeding\n Renal: Foley, Foley, monitor UOP. Cr normalized.\n Hematology: Hct stable at 29-30. Plt low but stable (100's). Heme onc\n consulted - f/u on hemolysis labs. IVC filter placed.\n Endocrine: RISS\n Infectious Disease: Check cultures, WBC normal, f/u Cx\n Lines / Tubes / Drains: R SC CVL (), PIV x2, Foley, a-line\n (), ETT\n Wounds: left groin site is c/d/i, no hematoma or pseudoaneurysm\n Imaging:\n Fluids: TF + IVF = 60 cc/hr\n Consults: Trauma surgery, Ortho, Ortho-spine, Heme/Onc\n Billing Diagnosis: Multiple injuries (Trauma)\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 11:52 PM 20 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 10:59 AM\n Multi Lumen - 04:41 PM\n Prophylaxis:\n DVT: Boots, IVC filter\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent:\n"
},
{
"category": "Respiratory ",
"chartdate": "2175-01-28 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 713834,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 4\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 20 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt cont intub with OETT sedated and on mech vent as per\n Metavision. Lung sounds ess clear after suct mod th yellow sput. ABGs\n stable on current vent settings; no vent changes required overnoc. Cont\n PSV.\n"
},
{
"category": "Physician ",
"chartdate": "2175-01-28 00:00:00.000",
"description": "Intensivist Note",
"row_id": 713835,
"text": "TSICU\n HPI:\n 74M s/p fall with multiple rib fx, pelvis fx, clavicle fx, and thoracic\n fx c/b unstable bleeding s/p IR embo, AF with RVR, hematologic\n abnomalities.\n Chief complaint:\n fall\n PMHx:\n none\n Current medications:\n 1. Acetaminophen 2. Bisacodyl 3. Chlorhexidine Gluconate 0.12% Oral\n Rinse 4. Dextrose 50% 5. Diltiazem 6. Docusate Sodium (Liquid) 7.\n Famotidine 8. Fentanyl Citrate 9. Fentanyl Citrate 10. Gabapentin 11.\n Glucagon 12. Insulin 13. Magnesium Sulfate 14. Midazolam 15.\n Ondansetron 16. Phenylephrine 17. Pneumococcal Vac Polyvalent 18.\n Potassium Phosphate 19. Potassium Chloride 20. Propofol 21. Senna 22.\n Sodium Chloride 0.9% Flush\n 24 Hour Events:\n ARTERIAL LINE - STOP 11:05 AM\n ARTERIAL LINE - START 11:30 AM\n Heme c/s- smear nl. Wean vent, started on po diltiazem for atrial\n ectopy.\n Post operative day:\n POD#2 - IVC filter via L groin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Fentanyl (Concentrate) - 100 mcg/hour\n Propofol - 20 mcg/Kg/min\n Phenylephrine - 0.3 mcg/Kg/min\n Other ICU medications:\n Fentanyl - 08:00 PM\n Other medications:\n Flowsheet Data as of 04:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.6\nC (99.7\n T current: 37.5\nC (99.5\n HR: 69 (62 - 97) bpm\n BP: 102/51(66) {89/48(63) - 135/71(94)} mmHg\n RR: 13 (8 - 20) insp/min\n SPO2: 98%\n Heart rhythm: 1st AV (First degree AV Block)\n Wgt (current): 102 kg (admission): 90 kg\n CVP: 15 (11 - 24) mmHg\n Total In:\n 2,899 mL\n 385 mL\n PO:\n Tube feeding:\n 908 mL\n 228 mL\n IV Fluid:\n 1,471 mL\n 96 mL\n Blood products:\n 50 mL\n Total out:\n 1,050 mL\n 90 mL\n Urine:\n 1,050 mL\n 90 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,849 mL\n 295 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (440 - 500) mL\n Vt (Spontaneous): 495 (495 - 680) mL\n PS : 12 cmH2O\n RR (Set): 10\n RR (Spontaneous): 12\n PEEP: 12 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 25 cmH2O\n SPO2: 98%\n ABG: 7.40/54/92./31/6\n Ve: 7.2 L/min\n PaO2 / FiO2: 232\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: No(t) Regular, Irregular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: 3+), (Temperature: Warm)\n Right Extremities: (Edema: 3+), (Temperature: Warm)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities, Sedated\n Labs / Radiology\n 74 K/uL\n 9.7 g/dL\n 128 mg/dL\n 0.8 mg/dL\n 31 mEq/L\n 3.9 mEq/L\n 19 mg/dL\n 108 mEq/L\n 141 mEq/L\n 28.7 %\n 5.6 K/uL\n [image002.jpg]\n 02:16 PM\n 05:17 PM\n 12:14 AM\n 12:20 AM\n 05:24 AM\n 06:50 AM\n 02:40 PM\n 03:13 PM\n 01:59 AM\n 02:00 AM\n WBC\n 11.0\n 11.0\n 8.0\n 5.6\n Hct\n 30.6\n 30.1\n 29.8\n 28.7\n Plt\n 99\n 97\n 80\n 74\n Creatinine\n 0.9\n 0.8\n 0.8\n TCO2\n 34\n 33\n 32\n 30\n 33\n 35\n Glucose\n 96\n 133\n 125\n 128\n Other labs: PT / PTT / INR:13.7/28.7/1.2, CK / CK-MB / Troponin\n T:1334/13/<0.01, ALT / AST:147/126, Alk-Phos / T bili:52/2.6, Amylase /\n Lipase:44/, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic Acid:1.4\n mmol/L, Albumin:2.7 g/dL, LDH:435 IU/L, Ca:8.0 mg/dL, Mg:2.2 mg/dL,\n PO4:2.8 mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, AF with\n RVR, hematologic abnomalities.\n Neurologic: Intubated on Propofol gtt and Midazolam PRN (have not been\n giving). Per ortho spine, no surgery; HOB<30, TLSO when OOB (NEOPS will\n place).\n Neuro checks Q: shift\n Pain: Fentanyl 100mcg/hr, Midazolam prn, Neurontin, Tylenol\n Cardiovascular: Now back in NSR with occasional PACs, off dilt gtt,\n started po diltiazem 30 qid, and currently weaning Neo gtt. Fluid\n challenge and PPV 6. Also given 25% albumin x1\n Pulmonary: Intubated. Pt developing early ARDS, placed on MMV. F/U on\n bronch cx.\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin with CT scan\n suggesting cirrhosis - Hepatitis panel NEG. TFs advancing to goal.\n Bowel regimen.\n Nutrition: Tube feeding\n Renal: Foley, monitor UOP. Cr normalized.\n Hematology: Hct stable at 29-30-28.7. Plt low but stable (100's).\n Heme onc consulted - smear nl. IVC filter placed.\n Endocrine: RISS\n Infectious Disease: WBC normal, f/u Cx - GNR in sputum and BAL, but\n afebrile, monitor for now, may start abx if spikes.\n Lines / Tubes / Drains: R SC CVL (), PIV x2, Foley, L a-line\n (), ETT\n Wounds:\n Imaging: CXR today\n Fluids: none\n Consults: Trauma (1o), Ortho Spine, Ortho trauma, Heme\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 01:48 AM 50 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 04:41 PM\n Arterial Line - 11:30 AM\n Prophylaxis:\n DVT: Boots, IVC filter\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2175-01-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 713836,
"text": "Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2175-01-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 713837,
"text": "Atrial fibrillation (Afib)\n Assessment:\n HR 60s-80s SR with 1^st degree AV block.\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Continues on neo gtt to maintain goal map >65.\n Action:\n Able to wean neo down to 0.3mcg/kg/min. Gave albumin last pm and pt\n BP increased for awhile.\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2175-01-31 00:00:00.000",
"description": "Cardiology Consult",
"row_id": 714298,
"text": "TITLE: Cardiology Consult\n DIVISION OF CARDIOLOGY\n COMPREHENSIVE CONSULTATION NOTE\nCHIEF COMPLAINT: Patient is seen in consultation today at the\nrequest of Dr. . We are asked to give consultative advice\nregarding evaluation and management of Aflutter with RVR.\nHISTORY OF PRESENT ILLNESS:\n74M no known PMH, who originally presented on s/p fall from\ntractor and crush injury from tree branch. He was initially\nbrought to hospital where he was found to have numerous\nright sided rib fractures and t4 vertebral body fracture. He was\nhypotensive, but in sinus rhythm with HR in the 80s. He was\ntransferred to where he was found to have a complex\nfracture of the left iliac , non displaced fracture of the\nright iliac , complex fracture t2-8, nondisplaced distal left\nclavicle fracture. He was given 4 U PRBC, 1 unit FFP, and\nunderwent arteriogram on with embolization to the liver and\npelvis and IVC filter placement for concern of high likelihood of\ndevelopment of dvt and inability to anticoagulate. In the\nmorning of , he developed aflutter into the 140s, which was\ntreated with diltiazem PO. Over the next 4 days, he continued to\ngo into and out of AFlutter with HRs controlled in the 80s in\nflutter and 60s in sinus. His SBP was noted to drop into the 80s\nwhile in flutter requiring increase in the neosynephrine drip,\nand so we were consulted about DCCV.\nThe patient is intubated and sedated, and could not provide any\nhistory. His family notes that he had no activity limitations\nprior to the accident, and he no known cardiac history of which\nthey were aware. He apparently is followed by his physician, \nper the family, was told he was 'healthy as a horse' when seen\nthe week prior to the accident.\nCardiac ROS could not be obtained.\nPAST MEDICAL HISTORY:\nNone noted\nCardiac Risk Factors include none.\nHOME MEDICATIONS:\nUnknown; reportedly acid reflux pill and sleep medication\nCURRENT MEDICATIONS:\nHaloperidol 2-5 mg PO Q2H:PRN\nMidazolam 0.5-2 mg/hr IV DRIP\nFentanyl Citrate 12.5-50 mcg/hr IV DRIP\nOxycoDONE Liquid 10 mg PO/NG Q3H:PRN pain\nLorazepam 2mg Syringe Study Med 1 mg IV Q6H Duration: 4 Doses\nKetamine Study Drug Study Med 1 dose IV AS SIR Duration: 24 Hours\nCeftriaXONE 1 gm IV Q24H\nGabapentin 400 mg PO/NG TID\nHeparin 5000 UNIT SC TID\nVancomycin 1000 mg IV Q 12H\nDiltiazem 60 mg PO/NG QID\nCalcium Gluconate IV Sliding Scale\nPantoprazole 40 mg IV Q24H\nMetoprolol Tartrate 5 mg IV Q4H:PRN hr>90, SBP>150\nHYDROmorphone (Dilaudid) 0.125-1 mg IV Q3H:PRN\nBowel meds\nInsulin sliding scale\nALLERGIES: NKDA\nSOCIAL HISTORY: Unavailable\nFAMILY HISTORY: Unavailable\nREVIEW OF SYSTEMS: Unable to obtain\nPHYSICAL EXAMINATION\nVitals: T: 100.6 degrees Farenheit, BP: 93-120/50s mmHg supine,\nHR 78-80 bpm, CVP 12, RR 24 bpm, O2: 98 % on PSV 13/10 @ 0.5, TV\n~ 500.\nCONSTITUTIONAL: Intubated, sedated.\nEYES: No conjunctival pallor. No icterus.\nENT/Mouth: ETT in place. OP clear.\nTHYROID: No thyromegaly or thyroid nodules.\nCV: Nondisplaced PMI. Normal rate. Regular rhythm. nl S1, S2. No\nextra heart sounds. No appreciable murmurs. No JVD.\nLUNGS: Rhonchorous breath sounds bilaterally.\nGI: NABS. Soft, NT, ND. No HSM. No abdominal bruits.\nMUSCULO: Limited exam. Normal muscle tone.\nHEME/LYMPH: No palpable LAD. + pitting edema. Scrotal edeam\nwith overlying ecchymoses. Full distal pulses bilaterally. SKIN:\nWarm extremities. Significant ecchymoses along trunk.\nNEURO: Sedated.\nPSYCH: Deferred.\nTELEMETRY: Aflutter at 80s. No other events. Not available > 24\nhours ago, but per report, in sinus on .\nECG (): Aflutter with A rate ~300, VR regular at 86 with\n3:1 AV block. L axis. Nonspecific TW flattening inferior leads.\nCompared to prior ECG from , flutter is more organized.\nOne ECG from (5:56) shows atrial tach.\nTRANSTHORACIC ECHOCARDIOGRAM ():\nThe left atrium and right atrium are normal in cavity size. Left\nventricular wall thickness, cavity size and regional/global\nsystolic function are normal (LVEF >55%). Transmitral and tissue\nDoppler imaging suggests normal diastolic function, and a normal\nleft ventricular filling pressure (PCWP<12mmHg). Right\nventricular chamber size is mildly dilated with normal free wall\nmotion. The aortic root is mildly dilated at the sinus level. The\naortic valve leaflets (3) appear structurally normal with good\nleaflet excursion and no aortic stenosis. Trace aortic\nregurgitation is seen. The mitral valve appears structurally\nnormal with trivial mitral regurgitation. There is no mitral\nvalve prolapse. There is mild pulmonary artery systolic\nhypertension. There is no pericardial effusion. Compared with the\nprior study (images reviewed) of , the right\nventricular cavity is now smaller, the severity of tricuspid\nregurgitation is now reduced, and the estimated pulmonary artery\nsystolic pressure is now lower (previously overestimated on\nreview of the prior study).\nOTHER TESTING:\nCXR : The ET tube tip is 6.2 cm above the carina. The NG\ntube tip is in the proximal stomach. The right subclavian line\ntip is at the level of superior SVC. Cardiomediastinal silhouette\nis unchanged as well as there is no change in mild bilateral\npulmonary edema and parenchymal opacities and there is no pleural\neffusion. There is no clear evidence of pneumothorax, although\nminimal amount cannot be excluded on the left. Multiple rib\nfractures are redemonstrated.\nIliac angiography :\n1. Pelvic arteriography: Multiple arteriographic runs performed\nof distal\naorta, external iliac, internal iliac, lateral sacral and\nsuperior gluteal\narteries. Active contrast extravasation noted from branches of\nthe lateral\nsacral artery and superior gluteal arteries. Successful Gelfoam\nembolization\nof lateral sacral artery and branches of the superior gluteal\nartery.\n2. Hepatic angiography: Multiple arteriographic runs of common\nhepatic and\nright hepatic arteries. Some active contrast extravasation was\nnoted from\nperipheral branches of right hepatic artery. Gelfoam embolization\nof distal\nright hepatic artery branches performed.\nCT Head \nThere is no intracranial hemorrhage, edema, shift of normally\nmidline structures or evidence of major vascular territorial\ninfarct. Ventricles and sulci are normal in size and\nconfiguration. The -white matter differentiation is\npreserved. The basilar cisterns are symmetric. A small mucous\nretention cyst, and a small amount of fluid are noted within the\nright maxillary sinus. Remaining paranasal sinuses are well\naerated. Mastoid air cells are well aerated\nCT C spine \n1. No fracture or malalignment of the cervical spine.\n2. Large posterior disc bulge at C4-5, acuity unknown, resulting\nin deformity of the thecal sac. If neural deficits are\nlocalizable to this level, MRI can be obtained to assess for\nspinal cord injury.\n3 Bilateral neural foraminal narrowing.\nCT Chest \n1. Multiple rib fractures bilaterally, including right\nanterolateral and posterior, and left posterior ribs as detailed\nabove.\n2. T4 vertebral body inferior corner fracture, with no\nretropulsion or malalignment. Comminuted spinous process\nfractures between T2 and T8.\n3. Non-displaced left T10 transverse process fracture.\n4. Non-displaced left clavicle and left scapula fractures.\n5. Dependent consolidation in the lungs bilaterally, which could\nbe sequela\nof aspiration, or could reflect contusion.\n6. No acute vascular injury.\n7. Calcified pleura bilaterally suggesting prior asbestos\nexposure.\nCT abdomen \n1. Contusion/laceration of the medial aspect of the right hepatic\nlobe, with adjacent small hematoma, without definite evidence of\nactive bleeding. Associated irregularity of an adjacent branch of\nthe right hepatic artery and resultant narrowing of the adjacent\nright hepatic vein and right posterior portal vein branches.\nPosterior right hepatic laceration/contusion, adjacent to a\ncalcified granuloma, with a small hematoma, without evidence of\nactive\nextravasation.\n2. Comminuted left pubic ramus fracture with associated hematoma,\nwhich has increased in size from the prior study of approximately\nsix hours prior. Tiny focus of arterially enhancing material,\nwhich enlarges on venous and delayed images, concerning for\nactive extravasation.\n3. Minimally displaced, comminuted left iliac bone fracture, with\nadjacent iliac muscle hematoma, largely unchanged from the prior\nstudy, without evidence of active extravasation. Fracture extends\ninto the left sacroiliac joint.\n4. Minimally displaced fracture of the right iliac bone,\nextending to the right sacroiliac joint.\n5. Bilateral comminuted, minimally displaced posterior rib\nfractures of the eighth through eleventh ribs. Nondisplaced left\n10th vertebral body transverse process fracture.\n6. Interval increase in bilateral pleural effusions (small), with\nincreased bilateral atelectasis or consolidation which could be\nthe result of aspiration.\n7. Cirrhotic liver. Fluid around the nondistended gallbladder may\nbe related to liver disease.\nMR T spine \nIMPRESSION:\n1. Mild compression deformity of L1 with additional levels of\npotential trabecular contusion at T10-11 also inferiorly at T4\nwith no retropulsion.\n2. Multilevel degenerative changes with moderate canal narrowing\nat T10-11 with cord deformity and no abnormal cord signal.\n3. Extensive edema throughout the paraspinal soft tissues,\npredominantly posteriorly within the interspinous ligaments.\n4. Incompletely evaluated cervical spine demonstrates severe\ncanal narrowing at C4-5 with cord deformity and no abnormal cord\nsignal.\nLABORATORY DATA: Reviewed in OMR\nASSESSMENT AND PLAN:\n74M no significant PMH, s/p tractor accident with pelvic, spine,\nand rib fractures, liver laceration requiring embolization, and\ncoagulopathy requiring multiple FFP transfusions and hematology\nconsult, who p/w aflutter. Although tele is unavailable from >\n24 hours, he was reportedly in sinus on , and thus has been\nin the sustained rhythm for over 24 hours but probably not > 48\nhours. Despite appropriate rate control, his blood pressure does\nappear to drop with the aflutter, requiring higher doses of the\nneo gtt, which is a little unusual given his fairly normal\nappearing TTE. At this point, he may in fact benefit from being\nin sinus rhythm, but it is unclear 1) that he will remain in SR\nafter cardioversion without additional meds since he apparently\nhad been going in and out of Aflutter over the past week, and 2)\nwhether the risk of thromboembolism after possibly > 48 hours of\nflutter following CV outweighs the benefit of establishing sinus\nrhythm urgently, especially since he is unable to have any\nanticoagulation. As the clinical situation will dictate urgent\ncare, TEE is unlikely to be helpful, and flutter ablation is not\nan option. The etiology of the aflutter is likely increased\ncatechols in the setting of stress, and thus beta blockers might\nbe preferred as an of rate control, although he appears to\nhave good rate control on diltiazem.\nRec:\n--Continue dilt at present dose\n--Continue pain control, supportive measures\n--Consider initiation of amiodarone (1mg/min x 6 hours, then 0.5\nmg/min) if benefit of SR is determined to outweigh the risk of\nthromboembolism; which could be followed by DCCV if necessary,\nbut will d/w attending\nThe Assessment and Plan will be reviewed with Dr. in\nmulti- disciplinary rounds. Please see his/her note in the\n medical record for further comments and\nrecommendations. Thank you for allowing us to participate in the\ncare of this patient. Please feel free to contact us with any\nquestions or concerns.\n"
},
{
"category": "Nursing",
"chartdate": "2175-02-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 714710,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Following commands. Mouthing words, but incomprehensible.\n Frequently agitated. Administered Ativan/Midazolam and Zyprexa to\n alleve anxiety. Fair results. BP and anxiety slightly improved.\n Febrile. Treated with Tylenol as ordered. MAE x 4 strongly.\n Remains on CPAP. Strong cough. Lungs clear to rhonchi BL\n in upper airways, diminished in bases. Suctioned thick tan/white\n secretions via trach. O2 sat stable, >=95%.\n Hypertensive at times, especially during agitation. BP\n decreased to 130s post Versed bolus. Pulses palpable.\n Abdomen softly distended, non-tender. Positive BS\n throughout abdomen. Small BM (smear) this am. Tube feeds continued at\n goal of 80cc/hr. Tolerating well with little residual noted.\n Foley catheter draining clear amber urine.\n Skin intact. Ecchymosis noted to right flank. Scrotum with\n severe edema.\n Plan:\n Continue to monitor neuro status with improvement in agitation. Wean\n down PEEP/PS as tolerated.\n"
},
{
"category": "Nursing",
"chartdate": "2175-01-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 713929,
"text": "74M s/p fall with multiple rib fx, pelvis fx, clavicle fx, and thoracic\n fx c/b unstable bleeding s/p IR embo, AF with RVR, hematologic\n abnomalities.\n Atrial fibrillation (Afib)\n Assessment:\n Remains in 1^st degree HB. HR to 120\ns with agitation, anxiety.\n Action:\n Continues on Fentanyl gtt, Receiving Dilaudid IV and Midazolam for\n pain & agitation.\n Response:\n Good response with meds for pain, agitation, and anxiety.\n Plan:\n Cont to asses rhythm, BP. Metoprolol PRN for HR > 90, SBP > 150\n Respiratory failure, acute (not ARDS/)\n Assessment:\n BBS= essentially clear throughout all lung fields.\n Action:\n Rested overnight on CPAP/PS. Lasix gtt initiated for diuresis.\n Suctioned Q1-2 hrs for moderate amounts thick, pale yellow secretions.\n Klebsiella growing from sputum\n Response:\n Appears comfortable, no SOB noted or increased WOB.\n Plan:\n Goal for pt to be -500cc, will move towards extubation this morning as\n pt tolerates.\n Trauma, s/p\n Assessment:\n Mult echymotic areas over head torso, extremities. Scrotum echymotic,\n edematous.\n Action:\n Managing pain with Fentanyl gtt, Dilaudid & Midazolam IV. Scrotum\n elevated\n Response:\n Currently denies pain.\n Plan:\n Fentanyl gtt overnight. Keep scrotum elevated.\n"
},
{
"category": "Respiratory ",
"chartdate": "2175-01-29 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 713943,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 20 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt cont intub with OETT sedated and on mech vent as per\n Metavision. Lung sounds ess clear after suct mod th yellow sput. ABGs\n stable on current vent settings; no vent changes required overnoc. Cont\n PSV.\n"
},
{
"category": "Nursing",
"chartdate": "2175-01-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 713947,
"text": "74M s/p fall with multiple rib fx, pelvis fx, clavicle fx, and thoracic\n fx c/b unstable bleeding s/p IR embo, AF with RVR, hematologic\n abnomalities.\n Atrial fibrillation (Afib)\n Assessment:\n Remains in 1^st degree HB. HR to 120\ns with agitation, anxiety.\n Action:\n Continues on Fentanyl gtt, Receiving Dilaudid IV and Midazolam for\n pain & agitation.\n Response:\n Good response with meds for pain, agitation, and anxiety.\n Plan:\n Cont to asses rhythm, BP. Metoprolol PRN for HR > 90, SBP > 150\n Respiratory failure, acute (not ARDS/)\n Assessment:\n BBS= essentially clear throughout all lung fields.\n Action:\n Rested overnight on CPAP/PS. Lasix gtt initiated for diuresis.\n Suctioned Q1-2 hrs for moderate amounts thick, pale yellow secretions.\n Klebsiella growing from sputum\n Response:\n Appears comfortable, no SOB noted or increased WOB.\n Plan:\n Goal for pt to be -500cc, will move towards extubation this morning as\n pt tolerates.\n Trauma, s/p\n Assessment:\n Multiple echymotic areas over head torso, extremities. Scrotum\n echymotic, edematous.\n Action:\n Managing pain with Fentanyl gtt, Dilaudid & Midazolam IV. Scrotum\n elevated\n Response:\n Currently denies pain.\n Plan:\n Fentanyl gtt overnight. Keep scrotum elevated.\n"
},
{
"category": "Physician ",
"chartdate": "2175-01-31 00:00:00.000",
"description": "Intensivist Note",
"row_id": 714367,
"text": "TSICU\n HPI:\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\n checked and 1.5, 1 more unit FFP given.\n Chief complaint:\n Mult rib fx: R anterolateral and post, L posterior\n T4 vert body inf corner fx\n Commin spinous process fx T2-8\n Nondisplaced L T10 transverse process\n Nondispaced L distal clavicle\n Nondisplaced L clavicle fx\n R medial lobe liver contusion w/hematoma\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny focus of arterial\n bleeding/active extravasation, and larger area of venous bleeding\n Nondisplaced, comminuted L iliac bone fx w/adjacent iliac muscle\n hematoma, extends into L SIJ.\n Minimally displaced fx of R iliac bone extending to R SIJ.\n PMHx:\n PMH: None\n PSH: None\n Current medications:\n 1. IV access: Peripheral line Order date: @ 2329 16. Ketamine\n Study Drug Study Med 1 dose IV AS SIR Duration: 24 Hours\n Patient to receive Ketamine/Placebo 0.25mg/kg bolus over 1 hour\n followed by 0.1mg/kg/hr for 23 hours Order date: @ 1338\n 2. Acetaminophen 650 mg PO/NG Q6H:PRN pain Order date: @ 2329\n 17. Lorazepam 2mg Syringe Study Med 1 mg IV Q6H Duration: 4 Doses\n Patient to receive Lorazepam 1mg iv every 6 hours for 4 doses while on\n ketamine study drug Order date: @ 1338\n 3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation Order date: @\n 0823 18. Magnesium Sulfate IV Sliding Scale Order date: @ 2339\n 4. Calcium Gluconate IV Sliding Scale Order date: @ 1657 19.\n Metoprolol Tartrate 5 mg IV Q4H:PRN hr>90, SBP>150\n hold hr<60, SBP<100 Order date: @ 1809\n 5. CeftriaXONE 1 gm IV Q24H Order date: @ 1228 20. Midazolam\n 0.5-1 mg IV Q2H:PRN sedation Order date: @ 0912\n 6. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL Order date:\n @ 2329 21. Midazolam 0.5-10 mg/hr IV DRIP TITRATE TO sedation\n Patient must have adequate airway support prior to administration of\n dose. Order date: @ 0734\n 7. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date: \n @ 0104 22. Ondansetron 4 mg IV Q8H:PRN nausea Order date: @ 2329\n 8. Diltiazem 60 mg PO/NG QID\n hold for HR < 60 or SBP < 100 Order date: @ 23.\n Pantoprazole 40 mg IV Q24H Order date: @ 1321\n 9. Docusate Sodium (Liquid) 100 mg PO/NG Order date: @ 2329\n 24. Phenylephrine 0.5-5 mcg/kg/min IV DRIP TITRATE TO SBP>90 MAP>60\n Order date: @ 2339\n 10. Fentanyl Citrate 25-100 mcg/hr IV DRIP INFUSION\n Please wean with Dilaudid dosing. Thank you. Order date: @ 1136\n 25. Pneumococcal Vac Polyvalent 0.5 ml IM ASDIR Order date: @\n 2316\n 11. Gabapentin 400 mg PO/NG TID Order date: @ 1210 26. Potassium\n Phosphate IV Sliding Scale\n Infuse over 6 hours Order date: @ 2339\n 12. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date:\n @ 0104 27. Potassium Chloride IV Sliding Scale Order date: \n @ 2339\n 13. HYDROmorphone (Dilaudid) 0.125-1 mg IV Q3H:PRN pain Order date:\n @ 0912 28. Senna 1 TAB PO/NG :PRN constipation Order date:\n @ 0823\n 14. Heparin 5000 UNIT SC TID Order date: @ 0931 29. Sodium\n Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ 2329\n 15. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 0104 30. Vancomycin 1000 mg IV\n Q 12H\n ID Approval will be required for this order in 39 hours. Order date:\n @ \n 24 Hour Events:\n Placed on ketamine for study. Continues to be in aflutter and on Neo,\n difficulties weaning, however when pt more awake (ie: turning), he is\n actually HTN. TTE done showing mild TR. RUQ U/S showing mild\n perihepatic fluid collection too small to be drained.\n Post operative day:\n POD#5 - IVC filter via L groin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\n Ceftriaxone - 12:00 PM\n Vancomycin - 08:36 PM\n Infusions:\n Fentanyl (Concentrate) - 100 mcg/hour\n Ketamine - 0.1 mcg/Kg/min\n Phenylephrine - 1.2 mcg/Kg/min\n Midazolam (Versed) - 0.5 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 02:00 PM\n Heparin Sodium (Prophylaxis) - 08:29 PM\n Midazolam (Versed) - 01:15 AM\n Fentanyl - 01:20 AM\n Lorazepam (Ativan) - 02:09 AM\n Other medications:\n Flowsheet Data as of 04:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.2\nC (100.7\n T current: 37.9\nC (100.3\n HR: 78 (75 - 91) bpm\n BP: 103/51(69) {89/48(62) - 152/66(94)} mmHg\n RR: 28 (16 - 29) insp/min\n SPO2: 98%\n Heart rhythm: A Flut (Atrial Flutter)\n Wgt (current): 102 kg (admission): 90 kg\n CVP: 11 (9 - 17) mmHg\n Total In:\n 3,764 mL\n 418 mL\n PO:\n Tube feeding:\n 1,920 mL\n 255 mL\n IV Fluid:\n 1,384 mL\n 163 mL\n Blood products:\n Total out:\n 1,535 mL\n 245 mL\n Urine:\n 1,530 mL\n 245 mL\n NG:\n 5 mL\n Stool:\n Drains:\n Balance:\n 2,229 mL\n 173 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 431 (399 - 596) mL\n PS : 10 cmH2O\n RR (Spontaneous): 25\n PEEP: 10 cmH2O\n FiO2: 50%\n PIP: 20 cmH2O\n SPO2: 98%\n ABG: 7.41/56/91./32/8\n Ve: 11.7 L/min\n PaO2 / FiO2: 184\n Physical Examination\n General Appearance: Overweight / Obese\n Cardiovascular: (Rhythm: No(t) Regular, Irregular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: No(t)\n Crackles : , Rhonchorous : bilaterally)\n Abdominal: Soft, Obese, right flank, right pelvis, and scrotum\n eechymotic\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Skin: right flank, right pelvis, and scrotum eechymotic\n Neurologic: Sedated\n Labs / Radiology\n 153 K/uL\n 10.7 g/dL\n 117 mg/dL\n 0.7 mg/dL\n 32 mEq/L\n 3.9 mEq/L\n 22 mg/dL\n 106 mEq/L\n 143 mEq/L\n 32.1 %\n 8.8 K/uL\n [image002.jpg]\n 02:55 AM\n 04:11 AM\n 09:45 AM\n 04:45 PM\n 12:45 AM\n 01:00 AM\n 05:12 AM\n 02:40 PM\n 01:46 AM\n 01:55 AM\n WBC\n 6.5\n 13.1\n 8.8\n Hct\n 29.3\n 31.6\n 32.1\n Plt\n 86\n 158\n 153\n Creatinine\n 0.8\n 0.8\n 0.7\n 0.7\n TCO2\n 38\n 37\n 35\n 35\n 34\n 37\n Glucose\n 141\n 107\n 131\n 115\n 132\n 122\n 117\n Other labs: PT / PTT / INR:13.7/27.6/1.2, CK / CK-MB / Troponin\n T:128/13/<0.01, ALT / AST:81/93, Alk-Phos / T bili:84/5.8, Amylase /\n Lipase:44/, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic Acid:1.4\n mmol/L, Albumin:2.7 g/dL, LDH:348 IU/L, Ca:8.0 mg/dL, Mg:2.0 mg/dL,\n PO4:3.3 mg/dL\n Imaging: CXR: Cardiac size top nl, interval improvement of\n collapse LLL. Collapse RLL. Atelectasis in lingula unchanged. Mod B\n pleural effusions stable. No PTX.\n CXR: Interval mild incr in cardiac size, b/l pleural effusions,\n and opacities @ bases,c/w overload\n : R foot: Linear density projecting @ expected area of insertion\n of the Achilles to calcaneus, may be min avulsion fx or degenerative\n changes. Otherwise no fx\n CXR: b/l pleural effusions\n CXR: stable.\n RUQ U/S: No perihepatic fluid collection. small amt perihepatic\n free fluid persists. Small contusion in hepatic segment VII. No\n gallstones or significant wall thickening/edema. CBD 4.5 mm\n TTE: LVEF >55%, normal diastolic function, normal left\n ventricular filling pressure (PCWP<12mmHg), Right ventricular chamber\n size is mildly dilated, mild TR\n Microbiology: Ucx no growth final\n Sputum: sparse GNRs, too few to colonize\n Bcx P\n Bcx P\n 12/17 L BAL: Klebsiella Pneumoniae, HAEMOPHILUS SPECIES NOT INFLUENZAE\n R BAL: Klebsiella Pneumoniae, Proteus.\n 12/20 L BAL: gram + cocci pairs on gram stain, GNRs (sparse) on cx\n R BAL: gram + cocci pairs on gram stain, GNRs (10-100K) on cx\n BCX: p\n BCx: P\n UCx: no growth final\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, now\n with AF with RVR/Aflutter, hypotension and presumed PNA.\n Neurologic: Intubated on Fentanyl/Versed gtt. Per ortho spine, no\n surgery; HOB<30, TLSO when OOB (NEOPS will place).\n Neuro checks Q: shift\n Pain: Fentanyl gtt (trying to wean), dilaudid, Midazolam gtt\n switch\n to Precidex. Also on Neurontin, Tylenol\n Cardiovascular: Aflutter on Dilt 60mg PO QID. Reamins o vasopressor\n support (Neo at 1). TTE without e/o cardiac dysfunction. ScVO2 68 so\n cardiogenic shock unlikely. Cortisol 17 which is borderline, although\n scenario not classic for adrenal insufficiency. ? sedation related so\n switch to precidex. Weaning Neo today. .\n Pulmonary: Intubated. Weaning vent. On appropriate abx per BAL cx\n -Vanco and Ceftriaxone. Will need Trach this week.\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin with CT scan\n suggesting cirrhosis - Hepatitis panel NEG. TFs advancing to goal.\n Bowel regimen.\n Nutrition: Tube feeding\n Renal: Foley, monitor UOP.\n Hematology: Hct stable. Plt low but stable (100's); d/c'd H2B with\n increasing plt count. Heme onc consulted - smear nl; no hemolysis. IVC\n filter placed.\n Endocrine: RISS, goal BS<150.\n Infectious Disease: Check cultures, WBC normal, f/u Cx - BAL:\n Klebsiella (b/l)& GNRs (on R)/Haemophilus (on L). Klebsiella\n Pneumoniae, Proteus/Haemophilus. Repeat BAL with gram+ cocci in\n pairs on gram stain, GNRs.\n Lines / Tubes / Drains: R SC CVL (), PIV x2, Foley, L a-line\n (), ETT\n Wounds:\n Imaging: CXR today\n Fluids: KVO\n Consults: Trauma (1o), Ortho Spine, Ortho trauma, Heme\n Billing Diagnosis: Multiple injuries (Trauma)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 04:41 PM\n Arterial Line - 11:30 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin, IVC filter\n Stress ulcer: PPI (? H2B-related thrombocytopenia)\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 32 min\n"
},
{
"category": "Nursing",
"chartdate": "2175-02-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 714601,
"text": "74M s/p crushing injury d/t falling tree. Injuries sustained include\n multiple R sided rib fxs, grade 2 liver lac (w/ assoc hepatic vessel\n extravasation), stable pelvis fxs (w/ associated extravasation), R\n ramus fx, clavicle fx, and T4 vertebral body fx. Episodes of A.\n Flutter with RVR and aflutter, now with resp failure and newly dx\n pneumonia as of .\n intubated for resp distress\n angio embolization of hepatic and pelvic arterial bleeders\n IVC filter in OR\n self extubated and re-intubated immediately after d/t acute resp.\n failure\n Trach and PEG at bedside\n Atrial fibrillation (Afib)\n Assessment:\n Pt converted to NSR @ 1900 w/ rate 80s-100s.\n Action:\n PO dilt, amioderone gtt continued\n Neo gtt weaned off\n Response:\n HR & BP remain well controlled.\n Plan:\n Continue Amio gtt, switch to PO amio, ? Anticoagulant.\n Monitor hemodynamics, monitor BP\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt w/ trach on CPAP/PS 10/10/50%. LS rhonchorous throughout. Strong\n productive cough, large amounts of thick blood tinged secretions. ABG\n stable. VSS. Low grade temps. WBC 5.9\n Action:\n Pulm hygiene, suction PRN\n Ceftriaxone admistered for pna\n Response:\n Exam unchanged.\n Plan:\n Wean vent settings as tolerated, pulmonary toileting, wean\n sedation.\n"
},
{
"category": "Respiratory ",
"chartdate": "2175-02-03 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 714815,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 10\n Airway\n Known difficult intubation: Yes\n Tracheostomy tube:\n Type: Standard, Cuffed\n Manufacturer: Portex\n Size: 8.0mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Physician ",
"chartdate": "2175-02-04 00:00:00.000",
"description": "Intensivist Note",
"row_id": 714875,
"text": "TSICU\n HPI:\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\n checked and 1.5, 1 more unit FFP given.\n Chief complaint:\n Mult rib fx: R anterolateral and post, L posterior\n T4 vert body inf corner fx\n Commin spinous process fx T2-8\n Nondisplaced L T10 transverse process\n Nondispaced L distal clavicle\n Nondisplaced L clavicle fx\n R medial lobe liver contusion w/hematoma\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny focus of arterial\n bleeding/active extravasation, and larger area of venous bleeding\n Nondisplaced, comminuted L iliac bone fx w/adjacent iliac muscle\n hematoma, extends into L SIJ.\n Minimally displaced fx of R iliac bone extending to R SIJ.\n PMHx:\n PMH: cirrhosis and asbestosis dx on CT\n PSH: None\n Current medications:\n 1. 2. 3. Acetaminophen 4. Amiodarone 5. Bisacodyl 6. Calcium Gluconate\n 7. CefePIME 8. Chlorhexidine Gluconate 0.12% Oral Rinse\n 9. Ciprofloxacin HCl 10. Dextrose 50% 11. Diltiazem 12. Docusate Sodium\n (Liquid) 13. Furosemide\n 14. Gabapentin 15. Glucagon 16. Haloperidol 17. Haloperidol 18. Heparin\n 19. Insulin 20. Lactulose\n 21. Lansoprazole Oral Disintegrating Tab 22. Magnesium Sulfate 23.\n Metoprolol Tartrate 24. Metoprolol Tartrate\n 25. Milk of Magnesia 26. Olanzapine (Disintegrating Tablet) 27.\n Ondansetron 28. OxycoDONE Liquid\n 29. Pneumococcal Vac Polyvalent 30. Potassium Phosphate 31. Potassium\n Chloride 32. Senna 33. Sodium Chloride 0.9% Flush\n 34. Sodium Chloride 0.9% Flush 35. Vancomycin\n 24 Hour Events:\n Back to Aflutter with HR in 120's. Stable BP. Given Lopressor with\n adequate rate control but no conversion. Eventually placed on a Dilt\n gtt. Pt converted to NSR. Maintained on Amio PO. TF switched to\n Nutren 2 in order to limit fluids, pt getting Lasix 20 q6 with net neg\n of 1500 cc. US of LE done to r/o clot as cause of fever.\n Post operative day:\n POD#9 - IVC filter via L groin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 03:00 PM\n Vancomycin - 08:09 PM\n Ciprofloxacin - 10:08 PM\n Cefipime - 12:00 AM\n Infusions:\n Other ICU medications:\n Midazolam (Versed) - 12:45 PM\n Lorazepam (Ativan) - 01:39 PM\n Metoprolol - 01:54 PM\n Furosemide (Lasix) - 06:52 PM\n Heparin Sodium (Prophylaxis) - 08:09 PM\n Other medications:\n Flowsheet Data as of 05:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.9\nC (100.3\n T current: 37.7\nC (99.8\n HR: 96 (75 - 125) bpm\n BP: 132/60(83) {121/51(73) - 169/88(115)} mmHg\n RR: 16 (16 - 33) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 104.2 kg (admission): 90 kg\n CVP: 19 (17 - 19) mmHg\n Total In:\n 2,563 mL\n 512 mL\n PO:\n Tube feeding:\n 1,482 mL\n 211 mL\n IV Fluid:\n 821 mL\n 300 mL\n Blood products:\n Total out:\n 4,060 mL\n 635 mL\n Urine:\n 4,055 mL\n 635 mL\n NG:\n 5 mL\n Stool:\n Drains:\n Balance:\n -1,497 mL\n -123 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 554 (380 - 554) mL\n PS : 15 cmH2O\n RR (Spontaneous): 18\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 27 cmH2O\n SPO2: 99%\n ABG: 7.53/39/124/33/9\n Ve: 14.2 L/min\n PaO2 / FiO2: 248\n Physical Examination\n General Appearance: Overweight / Obese, Tracheostomy\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : , Crackles : b/l bases)\n Abdominal: Soft, Non-tender, Obese\n Left Extremities: (Edema: 1+), (Temperature: Warm)\n Right Extremities: (Edema: 1+), (Temperature: Warm)\n Skin: Jaundice\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities, Pt appears to be confused this AM.\n Labs / Radiology\n 124 K/uL\n 9.3 g/dL\n 103 mg/dL\n 0.8 mg/dL\n 33 mEq/L\n 3.9 mEq/L\n 21 mg/dL\n 107 mEq/L\n 144 mEq/L\n 29.0 %\n 6.5 K/uL\n [image002.jpg]\n 01:00 AM\n 01:07 AM\n 01:18 AM\n 02:05 AM\n 03:54 AM\n 05:17 AM\n 01:23 PM\n 07:20 PM\n 12:35 AM\n 01:04 AM\n WBC\n 5.9\n 6.3\n 6.5\n Hct\n 31.3\n 28.9\n 29.0\n Plt\n 109\n 128\n 124\n Creatinine\n 0.8\n 0.8\n 0.8\n 0.8\n TCO2\n 35\n 34\n 35\n 34\n Glucose\n 117\n 110\n 138\n 136\n 130\n 103\n Other labs: PT / PTT / INR:13.7/27.6/1.2, CK / CK-MB / Troponin\n T:128/13/<0.01, ALT / AST:90/122, Alk-Phos / T bili:133/5.4, Amylase /\n Lipase:54/52, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic\n Acid:1.4 mmol/L, Albumin:2.3 g/dL, LDH:348 IU/L, Ca:7.7 mg/dL, Mg:2.2\n mg/dL, PO4:2.7 mg/dL\n Imaging: RUQ U/S: No perihepatic fluid collection. small amt\n perihepatic free fluid persists. Small contusion in hepatic segment\n VII. No\n gallstones or sig wall thickening/edema. CBD 4.5 mm\n TTE: LVEF >55%, NL diastolic function, NL LV filling pressure\n (PCWP<12mmHg), RV chamber size mildly dilated, mild TR\n CXR: mild b/l pulm edema and parenchymal opacities and no\n pl effusion.\n CXR: Persistent b/l pl effusions and bibasilar opacity.\n CXR: Minimal improvement of mod b/l pl effusions. Otherwise\n stable.\n CXR: no relevant change. B/L pleural effusions with basal\n opacities. No evidence of newly appeared focal parenchymal opacities\n suggesting pneumonia.\n : No dvt\n Microbiology: Ucx no growth final\n Sputum: sparse GNRs, too few to colonize\n Bcx x2 no growth final\n 12/17 L BAL: Klebsiella Pneumoniae, HAEMOPHILUS SPECIES NOT INFLUENZAE\n R BAL: Klebsiella Pneumoniae, Proteus.\n 12/20 L &R BAL: Klebsiella Pneumoniae\n BCX: p\n BCx: P\n UCx: no growth final\n BCx: P\n BCx: P\n UCx: P\n SpCx: contamination\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, now\n with AF with RVR/Aflutter, persistant hypotension and PNA.\n Neurologic: Neuro checks Q: 4 hr, s/p trach (). Per ortho spine,\n no surgery; HOB<30, TLSO when OOB. Zyprexa & Haldol PRN (off fent/midaz\n ).\n Pain: Oxycodone, Neurontin, Tylenol.\n Cardiovascular: Aflutter->NSR, on Amio and dilt gtt, will need to\n transition to PO meds. Likely cardiac contusion. Cards for Amio rec\n 400'' x 1wk, then 400'x1 wk, then 200'. Pt cannot be fully\n anticoagulated for now (trauma).\n Pulmonary: Trach, Trach, weaning vent, Vanc/cipro/cefepime for VAP\n (). Increasing pulmonary edema on CXR. consider therapeutic\n thoracentesis 12/26-7 if no improvement on Lasix, lots of secretions,\n consider bronchoscopy\n Gastrointestinal / Abdomen: Unknown elevated LFTs and bilirubin w/CT\n scan suggesting cirrhosis - Hepatitis panel NEG, RUQ U/S r/o\n gallbladder etiology, will continue to trend. On Nutren 2.0 with goal\n 40 cc/hr. Bowel regimen.\n Nutrition: Tube feeding\n Renal: Foley, Foley, monitor UOP, edematous scrotum. Lasix 20 Q6,\n developing contraction alk, consider switching to acetazolamide\n Hematology: Hct stable 28.9->29. Plt stable (100's); d/c'd H2B. Heme\n onc c/s - smear nl; no hemolysis. IVC filter placed.\n Endocrine: RISS, RISS\n Infectious Disease: Check cultures, WBC normal, on Vanc/cipro/cefepime\n for VAP given worsening pulm status, f/u on cx\n Lines / Tubes / Drains: Trach/Peg/foley/L radial a-line/R SCL\n Wounds:\n Imaging: CXR today\n Fluids: KVO\n Consults: Trauma (1o), Ortho Spine, Ortho trauma, Heme\n Billing Diagnosis: Multiple injuries (Trauma)\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 01:00 PM 40 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 04:41 PM\n Arterial Line - 11:30 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin, IVC filter\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2175-01-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 714091,
"text": "74M s/p crushing injury d/t falling tree. Injuries sustained include\n multiple R sided rib fxs, grade 2 liver lac (w/ assoc hepatic vessel\n extravasation), stable pelvis fxs (w/ associated extravasation), R\n ramus fx, clavicle fx, and T4 vertebral body fx. Episodes of AF with\n RVR and aflutter, hematologic abnormalities, now with resp failure and\n newly dx pneumonia as of .\n intubated for resp distress\n angio embolization of hepatic and pelvic arterial bleeders\n IVC filter in OR\n self extubated and reintubated immediately after d/t acute resp\n failure\n Atrial fibrillation (Afib), aflutter\n Assessment:\n Pt in and out of aflutter with controlled rate on dilt drip,\n predominently aflutter. Hypotensive w/ sbp 80\ns while in aflutter.\n Action:\n Dilt weaned off, po dose increased. Lytes followed, stable. Neo gtt\n to support sbp titrated to map >60 and sbp >100. Pt on low dose midaz\n gtt along with fentanyl for sedation.\n Response:\n Converts to longer periods of NSR w/ higher po dilt dose, drip remains\n off, rate holding 80s. Rate well controlled but remains Neo\n dependent. Tolerating sedation titrated to lowest dose to keep\n comfortable and safe.\n Plan:\n Cont to monitor hemodynamics. Wean neo gtt as tolerated. Cont dilt\n gtt. Optimize lytes ongoing. Cardiology consult in am to determine\n need for amio vs. cardioversion to further manage aflutter.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains fully vented after reintubation yest morning. AC mode, 550x15,\n 50% and 10 peep. Stable abg, improved p02. O2sat 96-98%. Moderate\n amt thick, yellow tenacious secretions. LS coarse, clearing w/\n suctioning. Note: upon reintubation pt found to have signif airway\n edema, required bougie catheter for reintubation).\n Action:\n Remains intubated on ac mode, see settings above, tol well. Pulm\n toileting per routine.\n Response:\n Abg acceptable, note compensated metabolic alkalosis. Pao2 improved on\n higher peep. LS improved as well, clearer, remain diminished,\n especially to R sided fields.\n Plan:\n Cont vanco for pneumonia coverage, await ID approval for zosyn. Pulm\n toilet. Maintain sedated for safety and comfort. Pt may benefit from\n trach in the short term if continuing to require vent support w/\n difficulty weaning.\n Trauma, s/p\n Assessment:\n As above, pt s/p liver laceration and resultant angio procedure to\n embolize few hepatic vessels. LFTs continue to be elevated, although\n slowly improving. Urine icteric, clear.\n Action:\n Following LFTs, hct, coags. Monitor s/s bleeding, visual signs of\n jaundice.\n Response:\n As of this am, enzymes remain elevated, await indirect/direct bili\n levels.\n Plan:\n Continue to follow LFTs, coags, hct, serial belly assessments, s/s\n bleeding.\n"
},
{
"category": "Respiratory ",
"chartdate": "2175-02-04 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 714865,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 11\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes:\n Tube Type\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 8.0mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: PS had to be increased to 15 overnight due to pt tachypnea\n and high BP's and HR\n Assessment of breathing comfort: No claim of dyspnea)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated, Reduce PEEP as tolerated; Comments: wean as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Underlying illness not resolved\n"
},
{
"category": "Nursing",
"chartdate": "2175-02-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 714870,
"text": "Atrial fibrillation (Afib)\n Assessment:\n Aflutter 70\n 100\ns w/ occasional pvc\ns. Stable bp,\n Action:\n Cont on po amioderone and iv dilt gtt. Lytes repleted.\n Response:\n Converted to nsr w/ occasional pvc\ns. Stable bp.\n Plan:\n Cont to monitor. Change over to po Diltiazem ATC. Wean dilt gtt.\n Cont po amioderone. Replete lytes.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2175-02-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 714876,
"text": "Atrial fibrillation (Afib)\n Assessment:\n Aflutter 70\n 100\ns w/ occasional pvc\ns. Stable bp,\n Action:\n Cont on po amioderone and iv dilt gtt. Lytes repleted.\n Response:\n Converted to nsr w/ occasional pvc\ns. Stable bp.\n Plan:\n Cont to monitor. Change over to po Diltiazem ATC. Wean dilt gtt.\n Cont po amioderone. Replete lytes.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains on PSV. LS rhonci, diminished bilat. Cont w/ copious\n secretions, thick yellow. Stable 02sats. Increasing tachypnea and\n restlessness overnoc. Tmax 100.3 Fluid balance positive for length\n of stay.\n Action:\n Pulm toilet. Increased psv from . Con on iv Vanco, cefepime and\n po cipro. Lasix at 1900 and cont w/ brisk u/o. Lasix held at mn.\n Given haldol and zyprexa for restlessness and oxycodone x1 for pain.\n Response:\n Cont with copious secretions but w/ strong cough. Less agitated but\n still restless after haldol and zyprexa. No sleep. Persistent\n metabolic alkalosis.\n Plan:\n Cont to monitor and cont aggressive pulm toilet. Titrate ventilatory\n support as needed. Monitor abg\ns and 02sats. ?diamox for alkalosis.\n Decrease frequency of lasix. Replete lytes. Cont zyprexa and haldol\n as needed. Pain control. Cont pt and family support.\n"
},
{
"category": "Respiratory ",
"chartdate": "2175-01-27 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 713715,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated\n Plan\n Next 24-48 hours: Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n OR\n 2200\n"
},
{
"category": "Nursing",
"chartdate": "2175-01-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 713716,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient intubated on CMV 18 x 440. 50%. PEEP 14. Sats 100%. LS clear\n to diminished.\n Action:\n Pulmonary hygiene.\n Response:\n Suctioned for small amounts of thick, yellow secretions. ABG WNL.\n Diminished on R side.\n Plan:\n Continue to monitor respiratory status. Wean vent as tolerated.\n Monitor ABG. Pulmonary hygiene.\n Trauma, s/p\n Assessment:\n Patient sedated on propofol and fentanyl drip. When lightened, patient\n opens eyes to voice and follows commands. MAE on bed. Denies pain.\n Bolus prior to turns. Sent to OR for IVC filter placement. Dsg to L\n groin c/d/i.\n TF restarted post-op.\n Action:\n Monitored CSM of LLE. TF advanced per orders.\n Response:\n No change. TF currently at 20cc/hr.\n Plan:\n Continue to monitor CSM to LLE. Advance TF as ordered/tolerated.\n Assess for pain, titrate fentanyl drip as indicated.\n Atrial fibrillation (Afib)\n Assessment:\n Patient in atrial flutter, HR 70-80s. MAP > 65 on phenylephrine drip.\n PVCs rare.\n Action:\n Diltiazem drip at 5mg/hr, held at . Phenylephrine drip at\n 1.25mcg/kg/min. Patient sent to OR for IVC filter.\n Response:\n Patient hypertensive post-op. Phenylephrine drip weaned to\n 0.5mcg/kg/min. Dilitiazem drip restarted for tachycardia (HR 110\n At 0400, patient converted to sinus bradycardia. Diltiazem drip\n currently off.\n Plan:\n Continue to monitor rhythm. Treat as indicated. Wean phenylephrine as\n tolerated.\n"
},
{
"category": "Nursing",
"chartdate": "2175-01-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 713928,
"text": "74M s/p fall with multiple rib fx, pelvis fx, clavicle fx, and thoracic\n fx c/b unstable bleeding s/p IR embo, AF with RVR, hematologic\n abnomalities.\n Atrial fibrillation (Afib)\n Assessment:\n Remains in 1^st degree HB. HR to 120\ns with agitation, anxiety as well\n as when sast were dropping to high 80\ns on PS 5, PEEP 5 for several\n hours. Neo off since approx 070\n Action:\n Fentanyl gtt increased, Dilaudid IV m I Midazolam for pain & agitation.\n PS, PEEP increased Lasix 10 mg at 1815.\n Response:\n Good response with meds for pain, agitation, and anxiety. Good response\n with increased vent support.\n Plan:\n Rest on PS 10, PEEP 10 overnight. Start lasix gtt for goal equal to\n 500 cc negative at MN. Cont to asses rhythm, BP. Metoprolol PRN for HT\n > 90, SBP > 150\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Put on PS5, PEEP 5. Suctioned Q1-2 rhs for moderate amounts thick, pale\n yellow secretions this afternoon. Klebsiella growing from sputum\n Action:\n Increased PS 10, PEEP 10 when sats dropping to high 80\n Response:\n Sats improved with increased PS as well as HR, BP\n Plan:\n rest on current vent settings overnight. Asse\n Trauma, s/p\n Assessment:\n Mult echymotic areas over head torso, extremities. Scrotum echymotic,\n edematous. On fent gtt.\n Action:\n Transiently able to decrease fent gtt to 25 mcg hr after starting\n Dilaudid & Midazolam IV. Scrotum elevated\n Response:\n Fent back to 100 mc&pain management. Currently denies pain.\n Plan:\n Fentanyl gtt overnight. Keep scrotum elevated.\n"
},
{
"category": "Physician ",
"chartdate": "2175-01-29 00:00:00.000",
"description": "Intensivist Note",
"row_id": 714002,
"text": "TSICU\n HPI:\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\n checked and 1.5, 1 more unit FFP given.\n Chief complaint:\n polytrauma\n PMHx:\n none\n Current medications:\n Acetaminophen 3. Bisacodyl 4. CeftriaXONE 5. Chlorhexidine Gluconate\n 0.12% Oral Rinse 6. Dextrose 50% 7. Diltiazem 8. Docusate Sodium\n (Liquid) 9. Fentanyl Citrate 10. Furosemide 11. Furosemide 12.\n Gabapentin\n 13. Glucagon 14. HYDROmorphone (Dilaudid) 15. Insulin 16. Magnesium\n Sulfate 17. Metoprolol Tartrate 18. Midazolam 19. Omeprazole 20.\n Ondansetron 21. Phenylephrine 22. Pneumococcal Vac Polyvalent 23.\n Potassium Phosphate\n 24. Potassium Chloride 25. Propofol 26. Senna 27. Sodium Chloride 0.9%\n Flush\n 24 Hour Events:\n : agitated w/HTN, tachycardia, incr fent/midaz w/some resolution.\n weaned cpap to -->desat-->incr to & improved hr & BP. started\n dilaudid, incr neurontin 300''', d/c'd H2B decr plt. lasix bolus\n 10, gtt. R ankle films (ecchymosis/edema) WNL. BAL: KLEBSIELLA\n PNEUMONIAE & GNRs-ceftriaxone started.\n Before rounds this AM, pt self-extubated using his tongue (hands were\n restrained), emergently re-intubated for resp distress and hypoxia.\n Post operative day:\n POD#3 - IVC filter via L groin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Furosemide (Lasix) - 5 mg/hour\n Fentanyl (Concentrate) - 50 mcg/hour\n Other ICU medications:\n Fentanyl - 02:15 PM\n Furosemide (Lasix) - 06:19 PM\n Labetalol - 07:00 PM\n Midazolam (Versed) - 04:00 AM\n Hydromorphone (Dilaudid) - 04:00 AM\n Other medications:\n Flowsheet Data as of 06:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.2\nC (99\n T current: 36.9\nC (98.4\n HR: 98 (79 - 127) bpm\n BP: 105/51(69) {91/41(58) - 185/74(110)} mmHg\n RR: 0 (0 - 26) insp/min\n SPO2: 95%\n Heart rhythm: 1st AV (First degree AV Block)\n Wgt (current): 102 kg (admission): 90 kg\n CVP: 8 (6 - 15) mmHg\n Total In:\n 1,861 mL\n 741 mL\n PO:\n Tube feeding:\n 1,330 mL\n 521 mL\n IV Fluid:\n 221 mL\n 160 mL\n Blood products:\n Total out:\n 2,010 mL\n 1,195 mL\n Urine:\n 2,010 mL\n 1,195 mL\n NG:\n Stool:\n Drains:\n Balance:\n -149 mL\n -454 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 540 (456 - 634) mL\n PS : 5 cmH2O\n RR (Spontaneous): 14\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 34\n PIP: 11 cmH2O\n SPO2: 95%\n ABG: 7.42/56/114/33/10\n Ve: 8 L/min\n PaO2 / FiO2: 285\n Physical Examination\n General Appearance: No acute distress, Well nourished; intubated on\n vent.\n HEENT: EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: bibasilar)\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present, Obese\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities, Sedated\n Labs / Radiology\n 86 K/uL\n 10.1 g/dL\n 141 mg/dL\n 0.8 mg/dL\n 33 mEq/L\n 3.6 mEq/L\n 19 mg/dL\n 106 mEq/L\n 143 mEq/L\n 29.3 %\n 6.5 K/uL\n [image002.jpg]\n 05:24 AM\n 06:50 AM\n 02:40 PM\n 03:13 PM\n 01:59 AM\n 02:00 AM\n 11:04 AM\n 01:17 PM\n 02:55 AM\n 04:11 AM\n WBC\n 11.0\n 8.0\n 5.6\n 6.5\n Hct\n 30.1\n 29.8\n 28.7\n 29.3\n Plt\n 97\n 80\n 74\n 86\n Creatinine\n 0.8\n 0.8\n 0.8\n TCO2\n 30\n 33\n 35\n 34\n 34\n 38\n Glucose\n 133\n 125\n 128\n 141\n Other labs: PT / PTT / INR:12.9/26.8/1.1, CK / CK-MB / Troponin\n T:1334/13/<0.01, ALT / AST:109/96, Alk-Phos / T bili:66/3.6, Amylase /\n Lipase:44/, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic Acid:1.4\n mmol/L, Albumin:2.7 g/dL, LDH:435 IU/L, Ca:7.7 mg/dL, Mg:1.9 mg/dL,\n PO4:3.0 mg/dL\n Imaging: CT head OSH: Prelim No ICH or fx.\n CT chest OSH: Mult rib fx: R anterolateral and posterior, L\n posterior; Dependent consolidation, possible aspiration; T4 vertebral\n body inf corner fx, no retropulsion; Comminuted spinous process fx\n T2-8; Nondisplaced L T10 transverse process; Nondisplaced L clavicle\n distal fx; Nondisplaced L scapula fx;\n CT c spine OSH: Prelim No fx or malalignment. Multilevel\n degenerative changes w/large post disk bulge at C4-5, narrowing the\n spinal canal and deforming the thecal sac, acuity unknown. Marked\n neuroforamenal narrowing @multiple levels.\n CTA abd/pel Prelim: Medial R liver lobe contusion w/adj\n hematoma, w/o evidence of active bleeding; Comminuted L pubic ramus\n fracture w/assoc hematoma, with tiny focus of arterial bleeding/active\n extravasation, and larger area of venous bleeding. Hematoma somewhat\n larger than on OSH study. Nondisplaced, comminuted L iliac bone fx\n w/adj iliac muscle hematoma, larger than on prior study, w/o active\n extrav. Fx extends into L SIJ. Post R hepatic laceration/contusion\n adjacent to calcified granuloma, w/small hematoma, w/out active\n bleeding. Min displaced fx of R iliac bone extending to R SIJ.\n Cirrhotic liver. Inc B pl effusions (small), w/inc atelectasis.\n MRI: Mild compression deformity of L1 w/additional levels of\n potential trabecular contusion @T10-11 also inf @T4 w/o retropulsion.\n Multilevel degenerative changes with moderate canal narrowing at T10-11\n w/cord deformity and no abnormal cord signal. Extensive edema\n throughout paraspinal soft tissues, predominantly post w/in\n interspinous ligaments. Incompletely eval'ed c-spine w/severe canal\n narrowing @C4-5 w/cord deformity and no abnormal cord signal.\n CTA: no PE.\n CXR: Moderate bilateral pleural effusions are stable.\n CXR: Cardiac size top nl, interval improvement of collapse LLL.\n Collapse RLL. Atelectasis in lingula unchanged. Mod B\n pleural effusions stable. No PTX.\n CXR: Interval mild incr in cardiac size, b/l pleural effusions,\n and opacities @ bases,c/w overload\n : R foot: Linear density projecting @ expected area of insertion\n of the Achilles to calcaneus, may be min avulsion fx or degenerative\n changes. Otherwise no fx\n CXR: ETT in place, + hazy opacities bilaterally\n Microbiology: Ucx no growth final\n Sputum: sparse GNR\n Bcx P\n Bcx P\n 12/17 L BAL: KLEBSIELLA PNEUMONIAE, HAEMOPHILUS SPECIES NOT INFLUENZAE\n R BAL: KLEBSIELLA PNEUMONIAE & GNRs.\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, AF with\n RVR, hematologic abnormalities, now with resp failure.\n Neurologic: Intubated on fentanyl gtt and Midazolam gtt (drops BP with\n Propofol). Per ortho spine, no surgery; HOB<30, TLSO when OOB (NEOPS\n will place).\n Neuro checks Q: shift\n Pain: Fentanyl gtt (trying to wean), dilaudid, Neurontin, Tylenol\n Cardiovascular: NSR currently, occasional tachycardia & HTN improved\n occasionally w/sedation. Metop started prn. Restart Dilt gtt as pt\n hemodynamics best when in sinus. On PO Dilt.\n Pulmonary: Re-uintubated after unexpected self-extubated and failure.\n Intubated with bougie and partial view of the cords. F/U on BAL:\n KLEBSIELLA PNEUMONIAE & GNRs/Haemophilus. Bronch after rounds.\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin with CT scan\n suggesting cirrhosis - Hepatitis panel NEG. TFs advancing to goal.\n Bowel regimen.\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO, Foley, monitor UOP. Cr normalized. Lasix\n gtt started after bolus 10 mg x1 with goal even to neg 500cc.\n Hematology: Hct stable. Plt low but stable (100's); d/c'd H2B. Heme\n onc consulted - smear nl. IVC filter placed.\n Endocrine: RISS, goal BS<150.\n Infectious Disease: Check cultures, WBC normal, f/u Cx - BAL:\n Klebsiella (b/l)& GNRs (on R)/Haemophilus (on L). Started Ceftriaxone\n () x 10 days.\n Lines / Tubes / Drains: R SC CVL (), PIV x2, Foley, L a-line\n (), ETT\n Wounds:\n Imaging: CXR today\n Fluids:\n Consults: Trauma (1o), Ortho Spine, Ortho trauma, Heme\n Billing Diagnosis: Multiple injuries (Trauma)\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 08:40 PM 80 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 04:41 PM\n Arterial Line - 11:30 AM\n Prophylaxis:\n DVT: Boots, IVC filter\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 33 mins\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2175-01-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 714089,
"text": "74M s/p crushing injury d/t falling tree. Injuries sustained include\n multiple R sided rib fxs, grade 2 liver lac (w/ assoc hepatic vessel\n extravasation), stable pelvis fxs (w/ associated extravasation), R\n ramus fx, clavicle fx, and T4 vertebral body fx. Episodes of AF with\n RVR and aflutter, hematologic abnormalities, now with resp failure and\n newly dx pneumonia as of .\n intubated for resp distress\n angio embolization of hepatic and pelvic arterial bleeders\n IVC filter in OR\n self extubated and reintubated immediately after d/t acute resp\n failure\n Atrial fibrillation (Afib), aflutter\n Assessment:\n Pt in and out of aflutter with controlled rate on dilt drip,\n predominently aflutter. Hypotensive w/ sbp 80\ns while in aflutter.\n Action:\n Dilt weaned off, po dose increased. Lytes followed, stable. Neo gtt\n to support sbp titrated to map >60 and sbp >100. Pt on low dose midaz\n gtt along with fentanyl for sedation.\n Response:\n Converts to longer periods of NSR w/ higher po dilt dose, drip remains\n off, rate holding 80s. Rate well controlled but remains Neo\n dependent. Tolerating sedation titrated to lowest dose to keep\n comfortable and safe.\n Plan:\n Cont to monitor hemodynamics. Wean neo gtt as tolerated. Cont dilt\n gtt. Optimize lytes ongoing. Cardiology consult in am to determine\n need for amio vs. cardioversion to further manage aflutter.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains fully vented after reintubation yest morning. AC mode, 550x15,\n 50% and 10 peep. Stable abg, improved p02. O2sat 96-98%. Moderate\n amt thick, yellow tenacious secretions. LS coarse, clearing w/\n suctioning. Note: upon reintubation pt found to have signif airway\n edema, required bougie catheter for reintubation).\n Action:\n Remains intubated on ac mode, see settings above, tol well. Pulm\n toileting per routine.\n Response:\n Abg acceptable, note compensated metabolic alkalosis. Pao2 improved on\n higher peep. LS improved as well, clearer, remain diminished,\n especially to R sided fields.\n Plan:\n Cont vanco for pneumonia coverage, await ID approval for zosyn. Pulm\n toilet. Maintain sedated for safety and comfort. Pt may benefit from\n trach in the short term if continuing to require vent support w/\n difficulty weaning.\n"
},
{
"category": "Respiratory ",
"chartdate": "2175-01-30 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 714096,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 6\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 20 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt cont intub with OETT sedated and on mech vent as per\n Metavision. Lung sounds ess clear after suct mod th tan sput. ABGs\n metabolic alkalosis with adequate oxygenation on current vent settings;\n no vent changes required overnoc. Cont mech vent support.\n"
},
{
"category": "Nursing",
"chartdate": "2175-01-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 714201,
"text": "Hypotension (not Shock)\n Assessment:\n Pt continues on neo gtt, BP low 90\ns, neo titrating as needed. BP goal\n MAP 65. Pt continues on Fentanyl gtt at 100mcg/hr and Midazolam at\n 2mg/hr.\n Action:\n Neo weaned as tolerated. Midazolam changed/bolused as needed.\n Response:\n Pt tolerating neo wean gradually, but still requires neo gtt at this\n time.\n Plan:\n Wean neo as tolerated. Study to start this evening at 20:00 with\n ketamine and ativan. See information sheet for details (in room).\n Continue to support pt and family, keep pt sedated/comfortable.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt continues on the vent, requiring frequent suctioning. Lung sounds\n diminished on the right side, occasionally rhonchorous. O2 sat >96%.\n +PNA, continues on antibiotics but Afebrile today.\n Action:\n Settings changed to CPAP/PS this AM. Suctioned frequently as\n needed. Pt repositioned frequently. Zosyn discontinued, ceftriaxone\n started, vanco continues.\n Response:\n Pt tolerating vent wean well, occasionally plugging, waking up through\n sedation and getting agitated. Midazolam weaned as needed.\n Plan:\n Wean vent as tolerated, pulmonary toileting. Continue to support pt\n and family. Suction frequently, VAP care, frequent repositioning.\n"
},
{
"category": "Physician ",
"chartdate": "2175-01-31 00:00:00.000",
"description": "Intensivist Note",
"row_id": 714280,
"text": "TSICU\n HPI:\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\n checked and 1.5, 1 more unit FFP given.\n Chief complaint:\n Mult rib fx: R anterolateral and post, L posterior\n T4 vert body inf corner fx\n Commin spinous process fx T2-8\n Nondisplaced L T10 transverse process\n Nondispaced L distal clavicle\n Nondisplaced L clavicle fx\n R medial lobe liver contusion w/hematoma\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny focus of arterial\n bleeding/active extravasation, and larger area of venous bleeding\n Nondisplaced, comminuted L iliac bone fx w/adjacent iliac muscle\n hematoma, extends into L SIJ.\n Minimally displaced fx of R iliac bone extending to R SIJ.\n PMHx:\n PMH: None\n PSH: None\n Current medications:\n 1. IV access: Peripheral line Order date: @ 2329 16. Ketamine\n Study Drug Study Med 1 dose IV AS SIR Duration: 24 Hours\n Patient to receive Ketamine/Placebo 0.25mg/kg bolus over 1 hour\n followed by 0.1mg/kg/hr for 23 hours Order date: @ 1338\n 2. Acetaminophen 650 mg PO/NG Q6H:PRN pain Order date: @ 2329\n 17. Lorazepam 2mg Syringe Study Med 1 mg IV Q6H Duration: 4 Doses\n Patient to receive Lorazepam 1mg iv every 6 hours for 4 doses while on\n ketamine study drug Order date: @ 1338\n 3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation Order date: @\n 0823 18. Magnesium Sulfate IV Sliding Scale Order date: @ 2339\n 4. Calcium Gluconate IV Sliding Scale Order date: @ 1657 19.\n Metoprolol Tartrate 5 mg IV Q4H:PRN hr>90, SBP>150\n hold hr<60, SBP<100 Order date: @ 1809\n 5. CeftriaXONE 1 gm IV Q24H Order date: @ 1228 20. Midazolam\n 0.5-1 mg IV Q2H:PRN sedation Order date: @ 0912\n 6. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL Order date:\n @ 2329 21. Midazolam 0.5-10 mg/hr IV DRIP TITRATE TO sedation\n Patient must have adequate airway support prior to administration of\n dose. Order date: @ 0734\n 7. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date: \n @ 0104 22. Ondansetron 4 mg IV Q8H:PRN nausea Order date: @ 2329\n 8. Diltiazem 60 mg PO/NG QID\n hold for HR < 60 or SBP < 100 Order date: @ 23.\n Pantoprazole 40 mg IV Q24H Order date: @ 1321\n 9. Docusate Sodium (Liquid) 100 mg PO/NG Order date: @ 2329\n 24. Phenylephrine 0.5-5 mcg/kg/min IV DRIP TITRATE TO SBP>90 MAP>60\n Order date: @ 2339\n 10. Fentanyl Citrate 25-100 mcg/hr IV DRIP INFUSION\n Please wean with Dilaudid dosing. Thank you. Order date: @ 1136\n 25. Pneumococcal Vac Polyvalent 0.5 ml IM ASDIR Order date: @\n 2316\n 11. Gabapentin 400 mg PO/NG TID Order date: @ 1210 26. Potassium\n Phosphate IV Sliding Scale\n Infuse over 6 hours Order date: @ 2339\n 12. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date:\n @ 0104 27. Potassium Chloride IV Sliding Scale Order date: \n @ 2339\n 13. HYDROmorphone (Dilaudid) 0.125-1 mg IV Q3H:PRN pain Order date:\n @ 0912 28. Senna 1 TAB PO/NG :PRN constipation Order date:\n @ 0823\n 14. Heparin 5000 UNIT SC TID Order date: @ 0931 29. Sodium\n Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ 2329\n 15. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 0104 30. Vancomycin 1000 mg IV\n Q 12H\n ID Approval will be required for this order in 39 hours. Order date:\n @ \n 24 Hour Events:\n Placed on ketamine for study. Continues to be in aflutter and on Neo,\n difficulties weaning, however when pt more awake (ie: turning), he is\n actually HTN. TTE done showing mild TR. RUQ U/S showing mild\n perihepatic fluid collection too small to be drained.\n Post operative day:\n POD#5 - IVC filter via L groin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\n Ceftriaxone - 12:00 PM\n Vancomycin - 08:36 PM\n Infusions:\n Fentanyl (Concentrate) - 100 mcg/hour\n Ketamine - 0.1 mcg/Kg/min\n Phenylephrine - 1.2 mcg/Kg/min\n Midazolam (Versed) - 0.5 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 02:00 PM\n Heparin Sodium (Prophylaxis) - 08:29 PM\n Midazolam (Versed) - 01:15 AM\n Fentanyl - 01:20 AM\n Lorazepam (Ativan) - 02:09 AM\n Other medications:\n Flowsheet Data as of 04:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.2\nC (100.7\n T current: 37.9\nC (100.3\n HR: 78 (75 - 91) bpm\n BP: 103/51(69) {89/48(62) - 152/66(94)} mmHg\n RR: 28 (16 - 29) insp/min\n SPO2: 98%\n Heart rhythm: A Flut (Atrial Flutter)\n Wgt (current): 102 kg (admission): 90 kg\n CVP: 11 (9 - 17) mmHg\n Total In:\n 3,764 mL\n 418 mL\n PO:\n Tube feeding:\n 1,920 mL\n 255 mL\n IV Fluid:\n 1,384 mL\n 163 mL\n Blood products:\n Total out:\n 1,535 mL\n 245 mL\n Urine:\n 1,530 mL\n 245 mL\n NG:\n 5 mL\n Stool:\n Drains:\n Balance:\n 2,229 mL\n 173 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 431 (399 - 596) mL\n PS : 10 cmH2O\n RR (Spontaneous): 25\n PEEP: 10 cmH2O\n FiO2: 50%\n PIP: 20 cmH2O\n SPO2: 98%\n ABG: 7.41/56/91./32/8\n Ve: 11.7 L/min\n PaO2 / FiO2: 184\n Physical Examination\n General Appearance: Overweight / Obese\n Cardiovascular: (Rhythm: No(t) Regular, Irregular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: No(t)\n Crackles : , Rhonchorous : bilaterally)\n Abdominal: Soft, Obese, right flank, right pelvis, and scrotum\n eechymotic\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Skin: right flank, right pelvis, and scrotum eechymotic\n Neurologic: Sedated\n Labs / Radiology\n 153 K/uL\n 10.7 g/dL\n 117 mg/dL\n 0.7 mg/dL\n 32 mEq/L\n 3.9 mEq/L\n 22 mg/dL\n 106 mEq/L\n 143 mEq/L\n 32.1 %\n 8.8 K/uL\n [image002.jpg]\n 02:55 AM\n 04:11 AM\n 09:45 AM\n 04:45 PM\n 12:45 AM\n 01:00 AM\n 05:12 AM\n 02:40 PM\n 01:46 AM\n 01:55 AM\n WBC\n 6.5\n 13.1\n 8.8\n Hct\n 29.3\n 31.6\n 32.1\n Plt\n 86\n 158\n 153\n Creatinine\n 0.8\n 0.8\n 0.7\n 0.7\n TCO2\n 38\n 37\n 35\n 35\n 34\n 37\n Glucose\n 141\n 107\n 131\n 115\n 132\n 122\n 117\n Other labs: PT / PTT / INR:13.7/27.6/1.2, CK / CK-MB / Troponin\n T:128/13/<0.01, ALT / AST:81/93, Alk-Phos / T bili:84/5.8, Amylase /\n Lipase:44/, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic Acid:1.4\n mmol/L, Albumin:2.7 g/dL, LDH:348 IU/L, Ca:8.0 mg/dL, Mg:2.0 mg/dL,\n PO4:3.3 mg/dL\n Imaging: CXR: Cardiac size top nl, interval improvement of\n collapse LLL. Collapse RLL. Atelectasis in lingula unchanged. Mod B\n pleural effusions stable. No PTX.\n CXR: Interval mild incr in cardiac size, b/l pleural effusions,\n and opacities @ bases,c/w overload\n : R foot: Linear density projecting @ expected area of insertion\n of the Achilles to calcaneus, may be min avulsion fx or degenerative\n changes. Otherwise no fx\n CXR: b/l pleural effusions\n CXR: stable.\n RUQ U/S: No perihepatic fluid collection. small amt perihepatic\n free fluid persists. Small contusion in hepatic segment VII. No\n gallstones or significant wall thickening/edema. CBD 4.5 mm\n TTE: LVEF >55%, normal diastolic function, normal left\n ventricular filling pressure (PCWP<12mmHg), Right ventricular chamber\n size is mildly dilated, mild TR\n Microbiology: Ucx no growth final\n Sputum: sparse GNRs, too few to colonize\n Bcx P\n Bcx P\n 12/17 L BAL: Klebsiella Pneumoniae, HAEMOPHILUS SPECIES NOT INFLUENZAE\n R BAL: Klebsiella Pneumoniae, Proteus.\n 12/20 L BAL: gram + cocci pairs on gram stain, GNRs (sparse) on cx\n R BAL: gram + cocci pairs on gram stain, GNRs (10-100K) on cx\n BCX: p\n BCx: P\n UCx: no growth final\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, now\n with AF with RVR/Aflutter, hypotension and presumed PNA.\n Neurologic: Intubated on Fentanyl/Versed gtt. Per ortho spine, no\n surgery; HOB<30, TLSO when OOB (NEOPS will place).\n Neuro checks Q: shift\n Pain: Fentanyl gtt (trying to wean), dilaudid, Midazolam gtt\n switch\n to Precidex. Also on Neurontin, Tylenol\n Cardiovascular: Aflutter on Dilt 60mg PO QID. Weaning Neo.\n Pulmonary: Intubated. Weaning to extubate. On appropriate abx per BAL\n cx -Vanco and Ceftriaxone. Will need Trach this week.\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin with CT scan\n suggesting cirrhosis - Hepatitis panel NEG. TFs advancing to goal.\n Bowel regimen.\n Nutrition: Tube feeding\n Renal: Foley, monitor UOP.\n Hematology: Hct stable. Plt low but stable (100's); d/c'd H2B with\n increasing plt count. Heme onc consulted - smear nl; no hemolysis. IVC\n filter placed.\n Endocrine: RISS, goal BS<150.\n Infectious Disease: Check cultures, WBC normal, f/u Cx - BAL:\n Klebsiella (b/l)& GNRs (on R)/Haemophilus (on L). Klebsiella\n Pneumoniae, Proteus/Haemophilus. Repeat BAL with gram+ cocci in\n pairs on gram stain, GNRs.\n Lines / Tubes / Drains: R SC CVL (), PIV x2, Foley, L a-line\n (), ETT\n Wounds:\n Imaging: CXR today\n Fluids: KVO\n Consults: Trauma (1o), Ortho Spine, Ortho trauma, Heme\n Billing Diagnosis: Multiple injuries (Trauma)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 04:41 PM\n Arterial Line - 11:30 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin, IVC filter\n Stress ulcer: PPI (? H2B-related thrombocytopenia)\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 32 min\n"
},
{
"category": "Physician ",
"chartdate": "2175-01-31 00:00:00.000",
"description": "Intensivist Note",
"row_id": 714282,
"text": "TSICU\n HPI:\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\n checked and 1.5, 1 more unit FFP given.\n Chief complaint:\n Mult rib fx: R anterolateral and post, L posterior\n T4 vert body inf corner fx\n Commin spinous process fx T2-8\n Nondisplaced L T10 transverse process\n Nondispaced L distal clavicle\n Nondisplaced L clavicle fx\n R medial lobe liver contusion w/hematoma\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny focus of arterial\n bleeding/active extravasation, and larger area of venous bleeding\n Nondisplaced, comminuted L iliac bone fx w/adjacent iliac muscle\n hematoma, extends into L SIJ.\n Minimally displaced fx of R iliac bone extending to R SIJ.\n PMHx:\n PMH: None\n PSH: None\n Current medications:\n 1. IV access: Peripheral line Order date: @ 2329 16. Ketamine\n Study Drug Study Med 1 dose IV AS SIR Duration: 24 Hours\n Patient to receive Ketamine/Placebo 0.25mg/kg bolus over 1 hour\n followed by 0.1mg/kg/hr for 23 hours Order date: @ 1338\n 2. Acetaminophen 650 mg PO/NG Q6H:PRN pain Order date: @ 2329\n 17. Lorazepam 2mg Syringe Study Med 1 mg IV Q6H Duration: 4 Doses\n Patient to receive Lorazepam 1mg iv every 6 hours for 4 doses while on\n ketamine study drug Order date: @ 1338\n 3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation Order date: @\n 0823 18. Magnesium Sulfate IV Sliding Scale Order date: @ 2339\n 4. Calcium Gluconate IV Sliding Scale Order date: @ 1657 19.\n Metoprolol Tartrate 5 mg IV Q4H:PRN hr>90, SBP>150\n hold hr<60, SBP<100 Order date: @ 1809\n 5. CeftriaXONE 1 gm IV Q24H Order date: @ 1228 20. Midazolam\n 0.5-1 mg IV Q2H:PRN sedation Order date: @ 0912\n 6. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL Order date:\n @ 2329 21. Midazolam 0.5-10 mg/hr IV DRIP TITRATE TO sedation\n Patient must have adequate airway support prior to administration of\n dose. Order date: @ 0734\n 7. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date: \n @ 0104 22. Ondansetron 4 mg IV Q8H:PRN nausea Order date: @ 2329\n 8. Diltiazem 60 mg PO/NG QID\n hold for HR < 60 or SBP < 100 Order date: @ 23.\n Pantoprazole 40 mg IV Q24H Order date: @ 1321\n 9. Docusate Sodium (Liquid) 100 mg PO/NG Order date: @ 2329\n 24. Phenylephrine 0.5-5 mcg/kg/min IV DRIP TITRATE TO SBP>90 MAP>60\n Order date: @ 2339\n 10. Fentanyl Citrate 25-100 mcg/hr IV DRIP INFUSION\n Please wean with Dilaudid dosing. Thank you. Order date: @ 1136\n 25. Pneumococcal Vac Polyvalent 0.5 ml IM ASDIR Order date: @\n 2316\n 11. Gabapentin 400 mg PO/NG TID Order date: @ 1210 26. Potassium\n Phosphate IV Sliding Scale\n Infuse over 6 hours Order date: @ 2339\n 12. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date:\n @ 0104 27. Potassium Chloride IV Sliding Scale Order date: \n @ 2339\n 13. HYDROmorphone (Dilaudid) 0.125-1 mg IV Q3H:PRN pain Order date:\n @ 0912 28. Senna 1 TAB PO/NG :PRN constipation Order date:\n @ 0823\n 14. Heparin 5000 UNIT SC TID Order date: @ 0931 29. Sodium\n Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ 2329\n 15. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 0104 30. Vancomycin 1000 mg IV\n Q 12H\n ID Approval will be required for this order in 39 hours. Order date:\n @ \n 24 Hour Events:\n Placed on ketamine for study. Continues to be in aflutter and on Neo,\n difficulties weaning, however when pt more awake (ie: turning), he is\n actually HTN. TTE done showing mild TR. RUQ U/S showing mild\n perihepatic fluid collection too small to be drained.\n Post operative day:\n POD#5 - IVC filter via L groin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\n Ceftriaxone - 12:00 PM\n Vancomycin - 08:36 PM\n Infusions:\n Fentanyl (Concentrate) - 100 mcg/hour\n Ketamine - 0.1 mcg/Kg/min\n Phenylephrine - 1.2 mcg/Kg/min\n Midazolam (Versed) - 0.5 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 02:00 PM\n Heparin Sodium (Prophylaxis) - 08:29 PM\n Midazolam (Versed) - 01:15 AM\n Fentanyl - 01:20 AM\n Lorazepam (Ativan) - 02:09 AM\n Other medications:\n Flowsheet Data as of 04:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.2\nC (100.7\n T current: 37.9\nC (100.3\n HR: 78 (75 - 91) bpm\n BP: 103/51(69) {89/48(62) - 152/66(94)} mmHg\n RR: 28 (16 - 29) insp/min\n SPO2: 98%\n Heart rhythm: A Flut (Atrial Flutter)\n Wgt (current): 102 kg (admission): 90 kg\n CVP: 11 (9 - 17) mmHg\n Total In:\n 3,764 mL\n 418 mL\n PO:\n Tube feeding:\n 1,920 mL\n 255 mL\n IV Fluid:\n 1,384 mL\n 163 mL\n Blood products:\n Total out:\n 1,535 mL\n 245 mL\n Urine:\n 1,530 mL\n 245 mL\n NG:\n 5 mL\n Stool:\n Drains:\n Balance:\n 2,229 mL\n 173 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 431 (399 - 596) mL\n PS : 10 cmH2O\n RR (Spontaneous): 25\n PEEP: 10 cmH2O\n FiO2: 50%\n PIP: 20 cmH2O\n SPO2: 98%\n ABG: 7.41/56/91./32/8\n Ve: 11.7 L/min\n PaO2 / FiO2: 184\n Physical Examination\n General Appearance: Overweight / Obese\n Cardiovascular: (Rhythm: No(t) Regular, Irregular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: No(t)\n Crackles : , Rhonchorous : bilaterally)\n Abdominal: Soft, Obese, right flank, right pelvis, and scrotum\n eechymotic\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Skin: right flank, right pelvis, and scrotum eechymotic\n Neurologic: Sedated\n Labs / Radiology\n 153 K/uL\n 10.7 g/dL\n 117 mg/dL\n 0.7 mg/dL\n 32 mEq/L\n 3.9 mEq/L\n 22 mg/dL\n 106 mEq/L\n 143 mEq/L\n 32.1 %\n 8.8 K/uL\n [image002.jpg]\n 02:55 AM\n 04:11 AM\n 09:45 AM\n 04:45 PM\n 12:45 AM\n 01:00 AM\n 05:12 AM\n 02:40 PM\n 01:46 AM\n 01:55 AM\n WBC\n 6.5\n 13.1\n 8.8\n Hct\n 29.3\n 31.6\n 32.1\n Plt\n 86\n 158\n 153\n Creatinine\n 0.8\n 0.8\n 0.7\n 0.7\n TCO2\n 38\n 37\n 35\n 35\n 34\n 37\n Glucose\n 141\n 107\n 131\n 115\n 132\n 122\n 117\n Other labs: PT / PTT / INR:13.7/27.6/1.2, CK / CK-MB / Troponin\n T:128/13/<0.01, ALT / AST:81/93, Alk-Phos / T bili:84/5.8, Amylase /\n Lipase:44/, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic Acid:1.4\n mmol/L, Albumin:2.7 g/dL, LDH:348 IU/L, Ca:8.0 mg/dL, Mg:2.0 mg/dL,\n PO4:3.3 mg/dL\n Imaging: CXR: Cardiac size top nl, interval improvement of\n collapse LLL. Collapse RLL. Atelectasis in lingula unchanged. Mod B\n pleural effusions stable. No PTX.\n CXR: Interval mild incr in cardiac size, b/l pleural effusions,\n and opacities @ bases,c/w overload\n : R foot: Linear density projecting @ expected area of insertion\n of the Achilles to calcaneus, may be min avulsion fx or degenerative\n changes. Otherwise no fx\n CXR: b/l pleural effusions\n CXR: stable.\n RUQ U/S: No perihepatic fluid collection. small amt perihepatic\n free fluid persists. Small contusion in hepatic segment VII. No\n gallstones or significant wall thickening/edema. CBD 4.5 mm\n TTE: LVEF >55%, normal diastolic function, normal left\n ventricular filling pressure (PCWP<12mmHg), Right ventricular chamber\n size is mildly dilated, mild TR\n Microbiology: Ucx no growth final\n Sputum: sparse GNRs, too few to colonize\n Bcx P\n Bcx P\n 12/17 L BAL: Klebsiella Pneumoniae, HAEMOPHILUS SPECIES NOT INFLUENZAE\n R BAL: Klebsiella Pneumoniae, Proteus.\n 12/20 L BAL: gram + cocci pairs on gram stain, GNRs (sparse) on cx\n R BAL: gram + cocci pairs on gram stain, GNRs (10-100K) on cx\n BCX: p\n BCx: P\n UCx: no growth final\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, now\n with AF with RVR/Aflutter, hypotension and presumed PNA.\n Neurologic: Intubated on Fentanyl/Versed gtt. Per ortho spine, no\n surgery; HOB<30, TLSO when OOB (NEOPS will place).\n Neuro checks Q: shift\n Pain: Fentanyl gtt (trying to wean), dilaudid, Midazolam gtt\n switch\n to Precidex. Also on Neurontin, Tylenol\n Cardiovascular: Aflutter on Dilt 60mg PO QID. Reamins o vasopressor\n support (Neo at 1). TTE without e/o cardiac dysfunction. ScVO2 68 so\n cardiogenic shock unlikely. Cortisol 17 which is borderline, although\n scenario not classic for adrenal insufficiency. ? sedation related so\n switch to precidex. Weaning Neo today. .\n Pulmonary: Intubated. Weaning vent. On appropriate abx per BAL cx\n -Vanco and Ceftriaxone. Will need Trach this week.\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin with CT scan\n suggesting cirrhosis - Hepatitis panel NEG. TFs advancing to goal.\n Bowel regimen.\n Nutrition: Tube feeding\n Renal: Foley, monitor UOP.\n Hematology: Hct stable. Plt low but stable (100's); d/c'd H2B with\n increasing plt count. Heme onc consulted - smear nl; no hemolysis. IVC\n filter placed.\n Endocrine: RISS, goal BS<150.\n Infectious Disease: Check cultures, WBC normal, f/u Cx - BAL:\n Klebsiella (b/l)& GNRs (on R)/Haemophilus (on L). Klebsiella\n Pneumoniae, Proteus/Haemophilus. Repeat BAL with gram+ cocci in\n pairs on gram stain, GNRs.\n Lines / Tubes / Drains: R SC CVL (), PIV x2, Foley, L a-line\n (), ETT\n Wounds:\n Imaging: CXR today\n Fluids: KVO\n Consults: Trauma (1o), Ortho Spine, Ortho trauma, Heme\n Billing Diagnosis: Multiple injuries (Trauma)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 04:41 PM\n Arterial Line - 11:30 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin, IVC filter\n Stress ulcer: PPI (? H2B-related thrombocytopenia)\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 32 min\n"
},
{
"category": "General",
"chartdate": "2175-01-29 00:00:00.000",
"description": "ICU Event Note",
"row_id": 713987,
"text": "Clinician: Fellow\n Called to bedside of patient, who had self-extubated (dislodged ETT\n with his tongue). Pt rapidly developed tachypnea, hypoxia, poor mental\n status. Notified Anesthesia but given dropping SaO2 and respiratory\n distress we positioned pt, pre-oxygenated but difficult to get SaO2>80,\n RSI with Etom 20mg and Succ 100mg, on DL there was notable supraglottic\n edema, with a partial view of the cords (Grade II-III), passed bougie,\n passed ETT over bougie, + EtCO2 color change x 5 breaths, + chest rise,\n + BS bilaterally, + mist in tube. SaO2 rapidly improved to 95%. Pt\n remained HD stable throughout. ETT secured. CXR ordered. Rhonchorous\n breath sounds at bases, will plan for bronch this AM.\n Total time spent: 20 minutes\n Patient is critically ill.\n"
},
{
"category": "Physician ",
"chartdate": "2175-01-29 00:00:00.000",
"description": "Intensivist Note",
"row_id": 713996,
"text": "TSICU\n HPI:\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\n checked and 1.5, 1 more unit FFP given.\n Chief complaint:\n polytrauma\n PMHx:\n none\n Current medications:\n Acetaminophen 3. Bisacodyl 4. CeftriaXONE 5. Chlorhexidine Gluconate\n 0.12% Oral Rinse 6. Dextrose 50% 7. Diltiazem 8. Docusate Sodium\n (Liquid) 9. Fentanyl Citrate 10. Furosemide 11. Furosemide 12.\n Gabapentin\n 13. Glucagon 14. HYDROmorphone (Dilaudid) 15. Insulin 16. Magnesium\n Sulfate 17. Metoprolol Tartrate 18. Midazolam 19. Omeprazole 20.\n Ondansetron 21. Phenylephrine 22. Pneumococcal Vac Polyvalent 23.\n Potassium Phosphate\n 24. Potassium Chloride 25. Propofol 26. Senna 27. Sodium Chloride 0.9%\n Flush\n 24 Hour Events:\n : agitated w/HTN, tachycardia, incr fent/midaz w/some resolution.\n weaned cpap to -->desat-->incr to & improved hr & BP. started\n dilaudid, incr neurontin 300''', d/c'd H2B decr plt. lasix bolus\n 10, gtt. R ankle films (ecchymosis/edema) WNL. BAL: KLEBSIELLA\n PNEUMONIAE & GNRs-ceftriaxone started.\n Before rounds this AM, pt self-extubated using his tongue (hands were\n restrained), emergently re-intubated for resp distress and hypoxia.\n Post operative day:\n POD#3 - IVC filter via L groin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Furosemide (Lasix) - 5 mg/hour\n Fentanyl (Concentrate) - 50 mcg/hour\n Other ICU medications:\n Fentanyl - 02:15 PM\n Furosemide (Lasix) - 06:19 PM\n Labetalol - 07:00 PM\n Midazolam (Versed) - 04:00 AM\n Hydromorphone (Dilaudid) - 04:00 AM\n Other medications:\n Flowsheet Data as of 06:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.2\nC (99\n T current: 36.9\nC (98.4\n HR: 98 (79 - 127) bpm\n BP: 105/51(69) {91/41(58) - 185/74(110)} mmHg\n RR: 0 (0 - 26) insp/min\n SPO2: 95%\n Heart rhythm: 1st AV (First degree AV Block)\n Wgt (current): 102 kg (admission): 90 kg\n CVP: 8 (6 - 15) mmHg\n Total In:\n 1,861 mL\n 741 mL\n PO:\n Tube feeding:\n 1,330 mL\n 521 mL\n IV Fluid:\n 221 mL\n 160 mL\n Blood products:\n Total out:\n 2,010 mL\n 1,195 mL\n Urine:\n 2,010 mL\n 1,195 mL\n NG:\n Stool:\n Drains:\n Balance:\n -149 mL\n -454 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 540 (456 - 634) mL\n PS : 5 cmH2O\n RR (Spontaneous): 14\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 34\n PIP: 11 cmH2O\n SPO2: 95%\n ABG: 7.42/56/114/33/10\n Ve: 8 L/min\n PaO2 / FiO2: 285\n Physical Examination\n General Appearance: No acute distress, Well nourished; intubated on\n vent.\n HEENT: EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: bibasilar)\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present, Obese\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities, Sedated\n Labs / Radiology\n 86 K/uL\n 10.1 g/dL\n 141 mg/dL\n 0.8 mg/dL\n 33 mEq/L\n 3.6 mEq/L\n 19 mg/dL\n 106 mEq/L\n 143 mEq/L\n 29.3 %\n 6.5 K/uL\n [image002.jpg]\n 05:24 AM\n 06:50 AM\n 02:40 PM\n 03:13 PM\n 01:59 AM\n 02:00 AM\n 11:04 AM\n 01:17 PM\n 02:55 AM\n 04:11 AM\n WBC\n 11.0\n 8.0\n 5.6\n 6.5\n Hct\n 30.1\n 29.8\n 28.7\n 29.3\n Plt\n 97\n 80\n 74\n 86\n Creatinine\n 0.8\n 0.8\n 0.8\n TCO2\n 30\n 33\n 35\n 34\n 34\n 38\n Glucose\n 133\n 125\n 128\n 141\n Other labs: PT / PTT / INR:12.9/26.8/1.1, CK / CK-MB / Troponin\n T:1334/13/<0.01, ALT / AST:109/96, Alk-Phos / T bili:66/3.6, Amylase /\n Lipase:44/, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic Acid:1.4\n mmol/L, Albumin:2.7 g/dL, LDH:435 IU/L, Ca:7.7 mg/dL, Mg:1.9 mg/dL,\n PO4:3.0 mg/dL\n Imaging: CT head OSH: Prelim No ICH or fx.\n CT chest OSH: Mult rib fx: R anterolateral and posterior, L\n posterior; Dependent consolidation, possible aspiration; T4 vertebral\n body inf corner fx, no retropulsion; Comminuted spinous process fx\n T2-8; Nondisplaced L T10 transverse process; Nondisplaced L clavicle\n distal fx; Nondisplaced L scapula fx;\n CT c spine OSH: Prelim No fx or malalignment. Multilevel\n degenerative changes w/large post disk bulge at C4-5, narrowing the\n spinal canal and deforming the thecal sac, acuity unknown. Marked\n neuroforamenal narrowing @multiple levels.\n CTA abd/pel Prelim: Medial R liver lobe contusion w/adj\n hematoma, w/o evidence of active bleeding; Comminuted L pubic ramus\n fracture w/assoc hematoma, with tiny focus of arterial bleeding/active\n extravasation, and larger area of venous bleeding. Hematoma somewhat\n larger than on OSH study. Nondisplaced, comminuted L iliac bone fx\n w/adj iliac muscle hematoma, larger than on prior study, w/o active\n extrav. Fx extends into L SIJ. Post R hepatic laceration/contusion\n adjacent to calcified granuloma, w/small hematoma, w/out active\n bleeding. Min displaced fx of R iliac bone extending to R SIJ.\n Cirrhotic liver. Inc B pl effusions (small), w/inc atelectasis.\n MRI: Mild compression deformity of L1 w/additional levels of\n potential trabecular contusion @T10-11 also inf @T4 w/o retropulsion.\n Multilevel degenerative changes with moderate canal narrowing at T10-11\n w/cord deformity and no abnormal cord signal. Extensive edema\n throughout paraspinal soft tissues, predominantly post w/in\n interspinous ligaments. Incompletely eval'ed c-spine w/severe canal\n narrowing @C4-5 w/cord deformity and no abnormal cord signal.\n CTA: no PE.\n CXR: Moderate bilateral pleural effusions are stable.\n CXR: Cardiac size top nl, interval improvement of collapse LLL.\n Collapse RLL. Atelectasis in lingula unchanged. Mod B\n pleural effusions stable. No PTX.\n CXR: Interval mild incr in cardiac size, b/l pleural effusions,\n and opacities @ bases,c/w overload\n : R foot: Linear density projecting @ expected area of insertion\n of the Achilles to calcaneus, may be min avulsion fx or degenerative\n changes. Otherwise no fx\n CXR: ETT in place, + hazy opacities bilaterally\n Microbiology: Ucx no growth final\n Sputum: sparse GNR\n Bcx P\n Bcx P\n 12/17 L BAL: KLEBSIELLA PNEUMONIAE, HAEMOPHILUS SPECIES NOT INFLUENZAE\n R BAL: KLEBSIELLA PNEUMONIAE & GNRs.\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, AF with\n RVR, hematologic abnormalities, now with resp failure.\n Neurologic: Intubated on fentanyl gtt and Midazolam gtt (drops BP with\n Propofol). Per ortho spine, no surgery; HOB<30, TLSO when OOB (NEOPS\n will place).\n Neuro checks Q: shift\n Pain: Fentanyl gtt (trying to wean), dilaudid, Neurontin, Tylenol\n Cardiovascular: NSR currently, occasional tachycardia & HTN improved\n occasionally w/sedation. Metop started prn. Restart Dilt gtt as pt\n hemodynamics best when in sinus. On PO Dilt.\n Pulmonary: Re-uintubated after unexpected self-extubated and failure.\n Intubated with bougie and partial view of the cords. F/U on BAL:\n KLEBSIELLA PNEUMONIAE & GNRs/Haemophilus. Bronch after rounds.\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin with CT scan\n suggesting cirrhosis - Hepatitis panel NEG. TFs advancing to goal.\n Bowel regimen.\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO, Foley, monitor UOP. Cr normalized. Lasix\n gtt started after bolus 10 mg x1 with goal even to neg 500cc.\n Hematology: Hct stable. Plt low but stable (100's); d/c'd H2B. Heme\n onc consulted - smear nl. IVC filter placed.\n Endocrine: RISS, goal BS<150.\n Infectious Disease: Check cultures, WBC normal, f/u Cx - BAL:\n Klebsiella (b/l)& GNRs (on R)/Haemophilus (on L). Started Ceftriaxone\n () x 10 days.\n Lines / Tubes / Drains: R SC CVL (), PIV x2, Foley, L a-line\n (), ETT\n Wounds:\n Imaging: CXR today\n Fluids:\n Consults: Trauma (1o), Ortho Spine, Ortho trauma, Heme\n Billing Diagnosis: Multiple injuries (Trauma)\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 08:40 PM 80 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 04:41 PM\n Arterial Line - 11:30 AM\n Prophylaxis:\n DVT: Boots, IVC filter\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 33 mins\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2175-02-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 714594,
"text": "74M s/p crushing injury d/t falling tree. Injuries sustained include\n multiple R sided rib fxs, grade 2 liver lac (w/ assoc hepatic vessel\n extravasation), stable pelvis fxs (w/ associated extravasation), R\n ramus fx, clavicle fx, and T4 vertebral body fx. Episodes of A.\n Flutter with RVR and aflutter, now with resp failure and newly dx\n pneumonia as of .\n intubated for resp distress\n angio embolization of hepatic and pelvic arterial bleeders\n IVC filter in OR\n self extubated and re-intubated immediately after d/t acute resp.\n failure\n Trach and PEG at bedside\n Atrial fibrillation (Afib)\n Assessment:\n Pt converted to NSR @ 1900 w/ rate 80s-100s.\n Action:\n PO dilt, amioderone gtt continued\n Neo gtt weaned off\n Response:\n HR & BP remain well controlled. Pt\n :\n Continue Amio gtt, switch to PO amio, ? Anticoagulant.\n Monitor hemodynamics, monitor BP\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt w/ trach on CPAP/PS 10/10/50%. LS rhonchorous throughout. Strong\n productive cough, large amounts of thick blood tinged secretions. ABG\n stable. VSS. Low grade temps. WBC 5.9\n Action:\n Pulm hygiene, suction PRN\n Ceftriaxone admistered for pna\n Response:\n Exam unchanged.\n Plan:\n Wean vent settings as tolerated, pulmonary toileting, wean\n sedation.\n"
},
{
"category": "Nursing",
"chartdate": "2175-01-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 713708,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient intubated on CMV 18 x 440. 50%. PEEP 14. Sats 100%. LS clear\n to diminished.\n Action:\n Pulmonary hygiene.\n Response:\n Suctioned for small amounts of thick, yellow secretions. ABG WNL.\n Very diminished on R side.\n Plan:\n Continue to monitor respiratory status. Wean vent as tolerated.\n Monitor ABG. Pulmonary hygiene.\n Trauma, s/p\n Assessment:\n Patient sedated on propofol and fentanyl drip. When lightened, patient\n opens eyes to voice and follows commands. MAE on bed. Denies pain.\n Bolused prior to turns. Sent to OR for IVC filter placement. Dsg to L\n groin c/d/i.\n TF restarted post-op.\n Action:\n Monitored CSM of LLE. TF advanced per orders.\n Response:\n No change. TF currently at 20cc/hr.\n Plan:\n Continue to monitor CSM to LLE. Advance TF as ordered/tolerated.\n Assess for pain, titrate fentanyl drip as indicated.\n Atrial fibrillation (Afib)\n Assessment:\n Patient in atrial flutter, HR 70-80s. MAP > 65 on phenylephrine drip.\n PVCs rare.\n Action:\n Diltiazem drip at 5mg/hr, held at . Phenylephrine drip at\n 1.25mcg/kg/min. Patient sent to OR for IVC filter.\n Response:\n Patient hypertensive post-op. Phenylephrine drip weaned to\n 0.5mcg/kg/min. Dilitiazem drip restarted for tachycardia (HR 110\n At 0400, patient converted to sinus bradycardia. Diltiazem drip\n currently off.\n Plan:\n Continue to monitor rhythm. Treat as indicated. Wean phenylephrine as\n tolerated.\n"
},
{
"category": "Nursing",
"chartdate": "2175-01-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 713926,
"text": "74M s/p fall with multiple rib fx, pelvis fx, clavicle fx, and thoracic\n fx c/b unstable bleeding s/p IR embo, AF with RVR, hematologic\n abnomalities.\n"
},
{
"category": "Physician ",
"chartdate": "2175-01-29 00:00:00.000",
"description": "Intensivist Note",
"row_id": 713985,
"text": "TSICU\n HPI:\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\n checked and 1.5, 1 more unit FFP given.\n Chief complaint:\n pain\n PMHx:\n none\n Current medications:\n Acetaminophen 3. Bisacodyl 4. CeftriaXONE 5. Chlorhexidine Gluconate\n 0.12% Oral Rinse 6. Dextrose 50%\n 7. Diltiazem 8. Docusate Sodium (Liquid) 9. Fentanyl Citrate 10.\n Furosemide 11. Furosemide 12. Gabapentin\n 13. Glucagon 14. HYDROmorphone (Dilaudid) 15. Insulin 16. Magnesium\n Sulfate 17. Metoprolol Tartrate\n 18. Midazolam 19. Omeprazole 20. Ondansetron 21. Phenylephrine 22.\n Pneumococcal Vac Polyvalent 23. Potassium Phosphate\n 24. Potassium Chloride 25. Propofol 26. Senna 27. Sodium Chloride 0.9%\n Flush\n 24 Hour Events:\n : agitated w/HTN, tachycardia, incr fent/midaz w/some resolution.\n weaned cpap to -->desat-->incr to & improved hr & BP. started\n dilaudid, incr neurontin 300''', d/c'd H2B decr plt. lasix bolus\n 10, gtt. R ankle films (ecchymosis/edema) WNL. BAL: KLEBSIELLA\n PNEUMONIAE & GNRs-ceftriaxone started\n Post operative day:\n POD#3 - IVC filter via L groin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Furosemide (Lasix) - 5 mg/hour\n Fentanyl (Concentrate) - 50 mcg/hour\n Other ICU medications:\n Fentanyl - 02:15 PM\n Furosemide (Lasix) - 06:19 PM\n Labetalol - 07:00 PM\n Midazolam (Versed) - 04:00 AM\n Hydromorphone (Dilaudid) - 04:00 AM\n Other medications:\n Flowsheet Data as of 06:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.2\nC (99\n T current: 36.9\nC (98.4\n HR: 98 (79 - 127) bpm\n BP: 105/51(69) {91/41(58) - 185/74(110)} mmHg\n RR: 0 (0 - 26) insp/min\n SPO2: 95%\n Heart rhythm: 1st AV (First degree AV Block)\n Wgt (current): 102 kg (admission): 90 kg\n CVP: 8 (6 - 15) mmHg\n Total In:\n 1,861 mL\n 741 mL\n PO:\n Tube feeding:\n 1,330 mL\n 521 mL\n IV Fluid:\n 221 mL\n 160 mL\n Blood products:\n Total out:\n 2,010 mL\n 1,195 mL\n Urine:\n 2,010 mL\n 1,195 mL\n NG:\n Stool:\n Drains:\n Balance:\n -149 mL\n -454 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 540 (456 - 634) mL\n PS : 5 cmH2O\n RR (Spontaneous): 14\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 34\n PIP: 11 cmH2O\n SPO2: 95%\n ABG: 7.42/56/114/33/10\n Ve: 8 L/min\n PaO2 / FiO2: 285\n Physical Examination\n General Appearance: No acute distress, Well nourished\n HEENT: EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: bibasilar)\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present, Obese\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities, Sedated\n Labs / Radiology\n 86 K/uL\n 10.1 g/dL\n 141 mg/dL\n 0.8 mg/dL\n 33 mEq/L\n 3.6 mEq/L\n 19 mg/dL\n 106 mEq/L\n 143 mEq/L\n 29.3 %\n 6.5 K/uL\n [image002.jpg]\n 05:24 AM\n 06:50 AM\n 02:40 PM\n 03:13 PM\n 01:59 AM\n 02:00 AM\n 11:04 AM\n 01:17 PM\n 02:55 AM\n 04:11 AM\n WBC\n 11.0\n 8.0\n 5.6\n 6.5\n Hct\n 30.1\n 29.8\n 28.7\n 29.3\n Plt\n 97\n 80\n 74\n 86\n Creatinine\n 0.8\n 0.8\n 0.8\n TCO2\n 30\n 33\n 35\n 34\n 34\n 38\n Glucose\n 133\n 125\n 128\n 141\n Other labs: PT / PTT / INR:12.9/26.8/1.1, CK / CK-MB / Troponin\n T:1334/13/<0.01, ALT / AST:109/96, Alk-Phos / T bili:66/3.6, Amylase /\n Lipase:44/, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic Acid:1.4\n mmol/L, Albumin:2.7 g/dL, LDH:435 IU/L, Ca:7.7 mg/dL, Mg:1.9 mg/dL,\n PO4:3.0 mg/dL\n Imaging: CT head OSH: Prelim No ICH or fx.\n CT chest OSH: Mult rib fx: R anterolateral and posterior, L\n posterior; Dependent consolidation, possible aspiration; T4 vertebral\n body inf corner fx, no retropulsion; Comminuted spinous process fx\n T2-8; Nondisplaced L T10 transverse process; Nondisplaced L clavicle\n distal fx; Nondisplaced L scapula fx;\n CT c spine OSH: Prelim No fx or malalignment. Multilevel\n degenerative changes w/large post disk bulge at C4-5, narrowing the\n spinal canal and deforming the thecal sac, acuity unknown. Marked\n neuroforamenal narrowing @multiple levels.\n CTA abd/pel Prelim: Medial R liver lobe contusion w/adj\n hematoma, w/o evidence of active bleeding; Comminuted L pubic ramus\n fracture w/assoc hematoma, with tiny focus of arterial bleeding/active\n extravasation, and larger area of venous bleeding. Hematoma somewhat\n larger than on OSH study. Nondisplaced, comminuted L iliac bone fx\n w/adj iliac muscle hematoma, larger than on prior study, w/o active\n extrav. Fx extends into L SIJ. Post R hepatic laceration/contusion\n adjacent to calcified granuloma, w/small hematoma, w/out active\n bleeding. Min displaced fx of R iliac bone extending to R SIJ.\n Cirrhotic liver. Inc B pl effusions (small), w/inc atelectasis.\n MRI: Mild compression deformity of L1 w/additional levels of\n potential trabecular contusion @T10-11 also inf @T4 w/o retropulsion.\n Multilevel degenerative changes with moderate canal narrowing at T10-11\n w/cord deformity and no abnormal cord signal. Extensive edema\n throughout paraspinal soft tissues, predominantly post w/in\n interspinous ligaments. Incompletely eval'ed c-spine w/severe canal\n narrowing @C4-5 w/cord deformity and no abnormal cord signal.\n CTA: no PE.\n CXR: Moderate bilateral pleural effusions are stable.\n CXR: Cardiac size top nl, interval improvement of collapse LLL.\n Collapse RLL. Atelectasis in lingula unchanged. Mod B\n pleural effusions stable. No PTX.\n CXR: Interval mild incr in cardiac size, b/l pleural effusions,\n and opacities @ bases,c/w overload\n : R foot: Linear density projecting @ expected area of insertion\n of the Achilles to calcaneus, may be min avulsion fx or degenerative\n changes. Otherwise no fx\n Microbiology: Ucx no growth final\n Sputum: sparse GNR\n Bcx P\n Bcx P\n 12/17 L BAL: KLEBSIELLA PNEUMONIAE, HAEMOPHILUS SPECIES NOT INFLUENZAE\n R BAL: KLEBSIELLA PNEUMONIAE & GNRs.\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, AF with\n RVR, hematologic abnomalities.\n Neurologic: Intubated on fentanyl gtt and Midazolam PRN (have not been\n giving). Per ortho spine, no surgery; HOB<30, TLSO when OOB (NEOPS will\n place).\n Neuro checks Q: shift\n Pain: Fentanyl gtt (trying to wean), dilaudid, Midazolam prn,\n Neurontin, Tylenol\n Cardiovascular: NSR currently, occasional tachycardia & HTN improved\n occasionally w/sedation. Metop started prn.\n Pulmonary: Intubated. Weaning to extubate (was on throughout\n , changed to 10/10 after desat). F/U on BAL: KLEBSIELLA PNEUMONIAE\n & GNRs/Haemophilus.\n SElf extubated , reintubated (increased edema, blind intubation\n w/bougie)\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin with CT scan\n suggesting cirrhosis - Hepatitis panel NEG. TFs advancing to goal.\n Bowel regimen.\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO, Foley, monitor UOP. Cr normalized. Lasix\n gtt started after bolus 10 mg x1 with goal even to neg 500cc.\n Hematology: Hct stable. Plt low but stable (100's); d/c'd H2B. Heme\n onc consulted - smear nl. IVC filter placed.\n Endocrine: RISS\n Infectious Disease: Check cultures, WBC normal, f/u Cx - BAL:\n Klebsiella (b/l)& GNRs (on R)/Haemophilus (on L). Started Ceftriaxone\n ()\n Lines / Tubes / Drains: R SC CVL (), PIV x2, Foley, L a-line\n (), ETT\n Wounds:\n Imaging: CXR today\n Fluids:\n Consults: Trauma (1o), Ortho Spine, Ortho trauma, Heme\n Billing Diagnosis: Multiple injuries (Trauma)\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 08:40 PM 80 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 04:41 PM\n Arterial Line - 11:30 AM\n Prophylaxis:\n DVT: Boots, IVC filter\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent:\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2175-01-30 00:00:00.000",
"description": "Intensivist Note",
"row_id": 714085,
"text": "TSICU\n HPI:\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\n checked and 1.5, 1 more unit FFP given.\n Chief complaint:\n Mult rib fx: R anterolateral and post, L posterior\n T4 vert body inf corner fx\n Commin spinous process fx T2-8\n Nondisplaced L T10 transverse process\n Nondispaced L distal clavicle\n Nondisplaced L clavicle fx\n R medial lobe liver contusion w/hematoma\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny focus of arterial\n bleeding/active extravasation, and larger area of venous bleeding\n Nondisplaced, comminuted L iliac bone fx w/adjacent iliac muscle\n hematoma, extends into L SIJ.\n Minimally displaced fx of R iliac bone extending to R SIJ.\n PMHx:\n None\n Current medications:\n Chlorhexidine Gluconate 0.12% Oral Rinse\n Diltiazem\n Furosemide\n Gabapentin\n Metoprolol Tartrate\n Ondansetron\n Phenylephrine\n 24 Hour Events:\n self-extubated in the AM, re-intubated over bougie, NGT replaced, \n with bilateral BALs sent, plan for trach later this week. T spike to\n 101.8 - u/a, urine cx, blood cxs sent. Diltiazem titrated to 60mg PO\n QID. ABX coverage broadened to Vanc/Zosyn. Tbili up to 6.8 (other LFTs\n trending down)\n Post operative day:\n POD#4 - IVC filter via L groin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 11:00 AM\n Piperacillin/Tazobactam (Zosyn) - 08:19 PM\n Vancomycin - 08:56 PM\n Infusions:\n Fentanyl (Concentrate) - 100 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Hydromorphone (Dilaudid) - 04:00 AM\n Metoprolol - 06:33 AM\n Pantoprazole (Protonix) - 02:00 PM\n Midazolam (Versed) - 12:30 AM\n Other medications:\n Flowsheet Data as of 02:07 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.8\nC (101.8\n T current: 37.2\nC (98.9\n HR: 76 (76 - 103) bpm\n BP: 97/51(67) {86/47(62) - 121/858(84)} mmHg\n RR: 18 (0 - 25) insp/min\n SPO2: 99%\n Heart rhythm: A Flut (Atrial Flutter)\n Wgt (current): 102 kg (admission): 90 kg\n CVP: 11 (6 - 18) mmHg\n Total In:\n 3,114 mL\n 207 mL\n PO:\n Tube feeding:\n 1,301 mL\n 148 mL\n IV Fluid:\n 1,682 mL\n 59 mL\n Blood products:\n Total out:\n 2,500 mL\n 180 mL\n Urine:\n 2,500 mL\n 180 mL\n NG:\n Stool:\n Drains:\n Balance:\n 614 mL\n 27 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 540 (540 - 540) mL\n PS : 5 cmH2O\n RR (Set): 15\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI: 34\n PIP: 26 cmH2O\n Plateau: 23 cmH2O\n Compliance: 42.3 cmH2O/mL\n SPO2: 99%\n ABG: 7.44/50/127/34/8\n Ve: 9.5 L/min\n PaO2 / FiO2: 254\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: Aflutter\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present,\n Stable scrotal edema/hematoma, soft, no crepitus\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: Follows simple commands, Moves all extremities, Sedated\n Labs / Radiology\n 158 K/uL\n 10.7 g/dL\n 115 mg/dL\n 0.8 mg/dL\n 34 mEq/L\n 4.0 mEq/L\n 20 mg/dL\n 111 mEq/L\n 148 mEq/L\n 31.6 %\n 13.1 K/uL\n [image002.jpg]\n 01:59 AM\n 02:00 AM\n 11:04 AM\n 01:17 PM\n 02:55 AM\n 04:11 AM\n 09:45 AM\n 04:45 PM\n 12:45 AM\n 01:00 AM\n WBC\n 5.6\n 6.5\n 13.1\n Hct\n 28.7\n 29.3\n 31.6\n Plt\n 74\n 86\n 158\n Creatinine\n 0.8\n 0.8\n 0.8\n TCO2\n 35\n 34\n 34\n 38\n 37\n 35\n 35\n Glucose\n 125\n 128\n 141\n 107\n 131\n 115\n Other labs: PT / PTT / INR:13.9/26.9/1.2, CK / CK-MB / Troponin\n T:1334/13/<0.01, ALT / AST:90/88, Alk-Phos / T bili:63/6.8, Amylase /\n Lipase:44/, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic Acid:1.2\n mmol/L, Albumin:2.7 g/dL, LDH:348 IU/L, Ca:8.4 mg/dL, Mg:2.1 mg/dL,\n PO4:2.9 mg/dL\n Imaging: CT head OSH: Prelim No ICH or fx.\n CT chest OSH: Mult rib fx: R anterolateral and posterior, L\n posterior; Dependent consolidation, possible aspiration; T4 vertebral\n body inf corner fx, no retropulsion; Comminuted spinous process fx\n T2-8; Nondisplaced L T10 transverse process; Nondisplaced L clavicle\n distal fx; Nondisplaced L scapula fx;\n CT c spine OSH: Prelim No fx or malalignment. Multilevel\n degenerative changes w/large post disk bulge at C4-5, narrowing the\n spinal canal and deforming the thecal sac, acuity unknown. Marked\n neuroforamenal narrowing @multiple levels.\n CTA abd/pel Prelim: Medial R liver lobe contusion w/adj\n hematoma, w/o evidence of active bleeding; Comminuted L pubic ramus\n fracture w/assoc hematoma, with tiny focus of arterial bleeding/active\n extravasation, and larger area of venous bleeding. Hematoma somewhat\n larger than on OSH study. Nondisplaced, comminuted L iliac bone fx\n w/adj iliac muscle hematoma, larger than on prior study, w/o active\n extrav. Fx extends into L SIJ. Post R hepatic laceration/contusion\n adjacent to calcified granuloma, w/small hematoma, w/out active\n bleeding. Min displaced fx of R iliac bone extending to R SIJ.\n Cirrhotic liver. Inc B pl effusions (small), w/inc atelectasis.\n MRI: Mild compression deformity of L1 w/additional levels of\n potential trabecular contusion @T10-11 also inf @T4 w/o retropulsion.\n Multilevel degenerative changes with moderate canal narrowing at T10-11\n w/cord deformity and no abnormal cord signal. Extensive edema\n throughout paraspinal soft tissues, predominantly post w/in\n interspinous ligaments. Incompletely eval'ed c-spine w/severe canal\n narrowing @C4-5 w/cord deformity and no abnormal cord signal.\n CTA: no PE.\n CXR: Moderate bilateral pleural effusions are stable.\n CXR: Cardiac size top nl, interval improvement of collapse LLL.\n Collapse RLL. Atelectasis in lingula unchanged. Mod B\n pleural effusions stable. No PTX.\n CXR: Interval mild incr in cardiac size, b/l pleural effusions,\n and opacities @ bases,c/w overload\n : R foot: Linear density projecting @ expected area of insertion\n of the Achilles to calcaneus, may be min avulsion fx or degenerative\n changes. Otherwise no fx\n CXR: bilateral pleural effusions\n Microbiology: Ucx no growth final\n Sputum: sparse GNR\n Bcx P\n Bcx P\n 12/17 L BAL: KLEBSIELLA PNEUMONIAE, HAEMOPHILUS SPECIES NOT INFLUENZAE\n R BAL: KLEBSIELLA PNEUMONIAE & GNRs.\n 12/20 L BAL: gram + cocci pairs on gram stain\n R BAL: gram + cocci pairs on gram stain\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, AF with\n RVR, hematologic abnomalities.\n Neurologic: Intubated on Fentanyl/Versed gtt. Per ortho spine, no\n surgery; HOB<30, TLSO when OOB (NEOPS will place). Neuro checks q\n shift.\n Cardiovascular: Aflutter on Dilt 60mg PO QID. Still on Neo. Likely\n needs chemical/electrical cardioversion to improve atrial contribution\n to CO\n Pulmonary: Intubated. Weaning to extubate (was on throughout\n , changed to 10/10 after desat, but self-extubated and reintubated\n am). F/U on BAL: KLEBSIELLA PNEUMONIAE & GNRs/Haemophilus. Repeat\n BAL with gram+ cocci in pairs on gram stain. Ceftriaxone ()\n changed to Vancomycin/Zosyn (). Plan for Trach early this week.\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin with CT scan\n suggesting cirrhosis - Hepatitis panel NEG. TFs advancing to goal.\n Bowel regimen. Tbili trending up (6.8), other LFTs improving.\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO, Foley, monitor UOP. Cr normalized.\n Hematology: Hct and Plt stable; d/c'd H2B\n Endocrine: RISS\n Infectious Disease: WBC increasing to 13.1, f/u Cx - BAL: Klebsiella\n (b/l)& GNRs (on R)/Haemophilus (on L). Started Ceftriaxone (),\n broadened to Zosyn/Vanc () for continued fevers and gram+ on BAL\n Lines / Tubes / Drains: R SC CVL (), PIV x2, Foley, L a-line\n (), ETT\n Wounds:\n Imaging: CXR today\n Fluids: KVO\n Consults: Trauma surgery, Ortho, Ortho-spine, Heme\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 01:00 PM 80 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 04:41 PM\n Arterial Line - 11:30 AM\n Prophylaxis:\n DVT: (IVC filter, SCDs)\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n"
},
{
"category": "Respiratory ",
"chartdate": "2175-01-30 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 714188,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 6\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: pt weaned to PSV 10/10 tolerated well all shift abgs wnl\n Assessment of breathing comfort: No claim of dyspnea)\n Plan\n Next 24-48 hours: Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n"
},
{
"category": "Nursing",
"chartdate": "2175-02-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 714542,
"text": "74M s/p crushing injury d/t falling tree. Injuries sustained include\n multiple R sided rib fxs, grade 2 liver lac (w/ assoc hepatic vessel\n extravasation), stable pelvis fxs (w/ associated extravasation), R\n ramus fx, clavicle fx, and T4 vertebral body fx. Episodes of A.\n Flutter with RVR and aflutter, now with resp failure and newly dx\n pneumonia as of .\n intubated for resp distress\n angio embolization of hepatic and pelvic arterial bleeders\n IVC filter in OR\n self extubated and re-intubated immediately after d/t acute resp.\n failure\n Trach and PEG at bedside\n Atrial fibrillation (Afib)\n Assessment:\n Atrial flutter continues, RVR up to 130s this AM. Now rate controlled\n <100.\n Action:\n PO dilt, amioderone gtt continued, Neo gtt titrated for adequate BP\n control.\n Response:\n Rate controlled after PO Dilt.\n Plan:\n Continue Amio gtt, switch to PO amio, ? Cardio version,? Anticoagulant.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Post trach pt back on CPAP 10/10/50%. Ls clear to diminish at bases.\n Strong productive cough, suctioned for copious amounts of thick blood\n tinged secretions. ABG stable.\n Action:\n Trach and PEG at bedside, continue pulmonary toileting.\n Response:\n Tolerated procedure without issue.\n Plan:\n Wean vent settings as tolerated, pulmonary toileting, wean sedation.\n"
},
{
"category": "Physician ",
"chartdate": "2175-02-04 00:00:00.000",
"description": "Intensivist Note",
"row_id": 714930,
"text": "TSICU\n HPI:\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\n checked and 1.5, 1 more unit FFP given.\n Chief complaint:\n Mult rib fx: R anterolateral and post, L posterior\n T4 vert body inf corner fx\n Commin spinous process fx T2-8\n Nondisplaced L T10 transverse process\n Nondispaced L distal clavicle\n Nondisplaced L clavicle fx\n R medial lobe liver contusion w/hematoma\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny focus of arterial\n bleeding/active extravasation, and larger area of venous bleeding\n Nondisplaced, comminuted L iliac bone fx w/adjacent iliac muscle\n hematoma, extends into L SIJ.\n Minimally displaced fx of R iliac bone extending to R SIJ.\n PMHx:\n PMH: cirrhosis and asbestosis dx on CT\n PSH: None\n Current medications:\n 1. 2. 3. Acetaminophen 4. Amiodarone 5. Bisacodyl 6. Calcium Gluconate\n 7. CefePIME 8. Chlorhexidine Gluconate 0.12% Oral Rinse\n 9. Ciprofloxacin HCl 10. Dextrose 50% 11. Diltiazem 12. Docusate Sodium\n (Liquid) 13. Furosemide\n 14. Gabapentin 15. Glucagon 16. Haloperidol 17. Haloperidol 18. Heparin\n 19. Insulin 20. Lactulose\n 21. Lansoprazole Oral Disintegrating Tab 22. Magnesium Sulfate 23.\n Metoprolol Tartrate 24. Metoprolol Tartrate\n 25. Milk of Magnesia 26. Olanzapine (Disintegrating Tablet) 27.\n Ondansetron 28. OxycoDONE Liquid\n 29. Pneumococcal Vac Polyvalent 30. Potassium Phosphate 31. Potassium\n Chloride 32. Senna 33. Sodium Chloride 0.9% Flush\n 34. Sodium Chloride 0.9% Flush 35. Vancomycin\n 24 Hour Events:\n Back to Aflutter with HR in 120's. Stable BP. Given Lopressor with\n adequate rate control but no conversion. Eventually placed on a Dilt\n gtt. Pt converted to NSR. Maintained on Amio PO. TF switched to\n Nutren 2 in order to limit fluids, pt getting Lasix 20 q6 with net neg\n of 1500 cc. US of LE done to r/o clot as cause of fever.\n Post operative day:\n POD#9 - IVC filter via L groin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 03:00 PM\n Vancomycin - 08:09 PM\n Ciprofloxacin - 10:08 PM\n Cefipime - 12:00 AM\n Infusions:\n Other ICU medications:\n Midazolam (Versed) - 12:45 PM\n Lorazepam (Ativan) - 01:39 PM\n Metoprolol - 01:54 PM\n Furosemide (Lasix) - 06:52 PM\n Heparin Sodium (Prophylaxis) - 08:09 PM\n Other medications:\n Flowsheet Data as of 05:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.9\nC (100.3\n T current: 37.7\nC (99.8\n HR: 96 (75 - 125) bpm\n BP: 132/60(83) {121/51(73) - 169/88(115)} mmHg\n RR: 16 (16 - 33) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 104.2 kg (admission): 90 kg\n CVP: 19 (17 - 19) mmHg\n Total In:\n 2,563 mL\n 512 mL\n PO:\n Tube feeding:\n 1,482 mL\n 211 mL\n IV Fluid:\n 821 mL\n 300 mL\n Blood products:\n Total out:\n 4,060 mL\n 635 mL\n Urine:\n 4,055 mL\n 635 mL\n NG:\n 5 mL\n Stool:\n Drains:\n Balance:\n -1,497 mL\n -123 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 554 (380 - 554) mL\n PS : 15 cmH2O\n RR (Spontaneous): 18\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 27 cmH2O\n SPO2: 99%\n ABG: 7.53/39/124/33/9\n Ve: 14.2 L/min\n PaO2 / FiO2: 248\n Physical Examination\n General Appearance: Overweight / Obese, Tracheostomy\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : , Crackles : b/l bases)\n Abdominal: Soft, Non-tender, Obese\n Left Extremities: (Edema: 1+), (Temperature: Warm)\n Right Extremities: (Edema: 1+), (Temperature: Warm)\n Skin: Jaundice\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities, Pt appears to be confused this AM.\n Labs / Radiology\n 124 K/uL\n 9.3 g/dL\n 103 mg/dL\n 0.8 mg/dL\n 33 mEq/L\n 3.9 mEq/L\n 21 mg/dL\n 107 mEq/L\n 144 mEq/L\n 29.0 %\n 6.5 K/uL\n [image002.jpg]\n 01:00 AM\n 01:07 AM\n 01:18 AM\n 02:05 AM\n 03:54 AM\n 05:17 AM\n 01:23 PM\n 07:20 PM\n 12:35 AM\n 01:04 AM\n WBC\n 5.9\n 6.3\n 6.5\n Hct\n 31.3\n 28.9\n 29.0\n Plt\n 109\n 128\n 124\n Creatinine\n 0.8\n 0.8\n 0.8\n 0.8\n TCO2\n 35\n 34\n 35\n 34\n Glucose\n 117\n 110\n 138\n 136\n 130\n 103\n Other labs: PT / PTT / INR:13.7/27.6/1.2, CK / CK-MB / Troponin\n T:128/13/<0.01, ALT / AST:90/122, Alk-Phos / T bili:133/5.4, Amylase /\n Lipase:54/52, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic\n Acid:1.4 mmol/L, Albumin:2.3 g/dL, LDH:348 IU/L, Ca:7.7 mg/dL, Mg:2.2\n mg/dL, PO4:2.7 mg/dL\n Imaging: RUQ U/S: No perihepatic fluid collection. small amt\n perihepatic free fluid persists. Small contusion in hepatic segment\n VII. No\n gallstones or sig wall thickening/edema. CBD 4.5 mm\n TTE: LVEF >55%, NL diastolic function, NL LV filling pressure\n (PCWP<12mmHg), RV chamber size mildly dilated, mild TR\n CXR: mild b/l pulm edema and parenchymal opacities and no\n pl effusion.\n CXR: Persistent b/l pl effusions and bibasilar opacity.\n CXR: Minimal improvement of mod b/l pl effusions. Otherwise\n stable.\n CXR: no relevant change. B/L pleural effusions with basal\n opacities. No evidence of newly appeared focal parenchymal opacities\n suggesting pneumonia.\n : No dvt\n Microbiology: Ucx no growth final\n Sputum: sparse GNRs, too few to colonize\n Bcx x2 no growth final\n 12/17 L BAL: Klebsiella Pneumoniae, HAEMOPHILUS SPECIES NOT INFLUENZAE\n R BAL: Klebsiella Pneumoniae, Proteus.\n 12/20 L &R BAL: Klebsiella Pneumoniae\n BCX: p\n BCx: P\n UCx: no growth final\n BCx: P\n BCx: P\n UCx: P\n SpCx: contamination\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, now\n with AF with RVR/Aflutter, persistant hypotension and PNA.\n Neurologic: Neuro checks Q: 4 hr, s/p trach (). Per ortho spine,\n no surgery; HOB<30, TLSO when OOB. Zyprexa & Haldol PRN (off fent/midaz\n ).\n Pain: Oxycodone, Neurontin, Tylenol.\n Cardiovascular: Aflutter->NSR, on Amio and dilt gtt, will need to\n transition to PO meds. Likely cardiac contusion. Cards for Amio rec\n 400'' x 1wk, then 400'x1 wk, then 200'. Pt cannot be fully\n anticoagulated for now (trauma).\n Pulmonary: Trach, Trach, weaning vent, Vanc/cipro/cefepime for VAP\n (). Increasing pulmonary edema on CXR. consider therapeutic\n thoracentesis 12/26-7 if no improvement on Lasix, lots of secretions,\n consider bronchoscopy\n Gastrointestinal / Abdomen: Unknown elevated LFTs and bilirubin w/CT\n scan suggesting cirrhosis - Hepatitis panel NEG, RUQ U/S r/o\n gallbladder etiology, will continue to trend. On Nutren 2.0 with goal\n 40 cc/hr. Bowel regimen.\n Nutrition: Tube feeding\n Renal: Foley, Foley, monitor UOP, edematous scrotum. Lasix 20 Q6,\n developing contraction alk, consider switching to acetazolamide\n Hematology: Hct stable 28.9->29. Plt stable (100's); d/c'd H2B. Heme\n onc c/s - smear nl; no hemolysis. IVC filter placed.\n Endocrine: RISS, RISS\n Infectious Disease: Check cultures, WBC normal, on Vanc/cipro/cefepime\n for VAP given worsening pulm status, f/u on cx\n Lines / Tubes / Drains: Trach/Peg/foley/L radial a-line/R SCL\n Wounds:\n Imaging: CXR today\n Fluids: KVO\n Consults: Trauma (1o), Ortho Spine, Ortho trauma, Heme\n Billing Diagnosis: Multiple injuries (Trauma)\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 01:00 PM 40 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 04:41 PM\n Arterial Line - 11:30 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin, IVC filter\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2175-01-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 713792,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains orally intubated and vented. Pt was on CMV this AM. Lung\n sounds clear in the upper lobes, diminished at the bases bilaterally.\n Daily CXR continue. ABGs show fully compensated metabolic alkalosis.\n Suctioned for thick, yellow/white secretions. Pt has strong,\n productive/congested cough. O2 sat 99-100%.\n Action:\n Vent changed from CMV to MMV 12/12/40%. Pt suctioned as needed. Pt\n repositioned frequently. Tube feeds increased to goal (Replete with\n Fiber FS).\n Response:\n Pt tolerating vent setting, remains afebrile.\n Plan:\n Continue to wean vent as tolerated. Follow up with BAL cultures sent\n on . Start antibiotics? Continue to support pt and family. PT\n consulted, plan to visit pt over the weekend in the event that he is\n extubated.\n Hypotension (not Shock)\n Assessment:\n BP low 80\ns when off neo, on low doses of neo throughout the day.\n Propofol gtt continues for sedation. Pt is uncomfortable being awake\n and off propofol, he is agitated, anxious, and reaches for the ET tube\n as well as sits up in bed. HR converted to NSR early this AM,\n diltiazem gtt stopped. Pt having PAC\ns in the afternoon, electrolytes\n WNL when checked. Pt is edematous throughout, CVP 13, PPV .\n Scrotum is edematous and purple since OR trip last evening (? From IVC\n filter placement?). HCT remains stable. UO marginal, clear, icteric.\n Tube feeds started at midnight.\n Action:\n Heme consulted, recommended starting vitamin K and possibly antibiotics\n for gram negative rods found in sputum. Neo gtt titrated throughout\n the day. Pt remains sedated on propofol, titrated as tolerated.\n Diltiazem 30mg QID PO started. Fluid challenge done this AM with\n little effect. Tube feeds increasing to goal, IV fluids turned off\n when tube feeds reached goal.\n Response:\n Pt becoming more awake on current doses of propofol, had to increase\n gtt to adequately sedate pt. HR remains NSR but with PAC\ns. BP\n remains low and requiring small doses of neo. Pt tolerating goal tube\n feeds well, minimal residuals.\n Plan:\n Start vitamin K (per heme)? Wean neo as tolerated. Consider albumin\n or hespan to draw in fluid from extravascular spaces. Continue goal\n tube feeds. Monitor coags. Continue to support pt and family.\n"
},
{
"category": "Nursing",
"chartdate": "2175-01-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 713986,
"text": "74M s/p fall with multiple rib fx, pelvis fx, clavicle fx, and thoracic\n fx c/b unstable bleeding s/p IR embo, AF with RVR, hematologic\n abnomalities.\n Atrial fibrillation (Afib)\n Assessment:\n Remains in 1^st degree HB. HR to 120\ns with agitation, anxiety.\n Action:\n Continues on Fentanyl gtt, Receiving Dilaudid IV and Midazolam for\n pain & agitation.\n Response:\n Good response with meds for pain, agitation, and anxiety.\n Plan:\n Cont to asses rhythm, BP. Metoprolol PRN for HR > 90, SBP > 150\n Respiratory failure, acute (not ARDS/)\n Assessment:\n BBS= essentially clear throughout all lung fields.\n Action:\n Rested overnight on CPAP/PS. Lasix gtt initiated for diuresis.\n Suctioned Q1-2 hrs for moderate amounts thick, pale yellow secretions.\n Klebsiella growing from sputum\n Response:\n Appears comfortable, no SOB noted or increased WOB.\n Plan:\n Goal for pt to be -500cc, will move towards extubation this morning as\n pt tolerates.\n Trauma, s/p\n Assessment:\n Multiple echymotic areas over head torso, extremities. Scrotum\n echymotic, edematous.\n Action:\n Managing pain with Fentanyl gtt, Dilaudid & Midazolam IV. Scrotum\n elevated\n Response:\n Currently denies pain.\n Plan:\n Fentanyl gtt overnight. Keep scrotum elevated.\n ------ Protected Section ------\n At 630 pt tongued ETT and self extubated. Unable to maintain sats or\n protect airway- emergently reintubated. Pt tolerated well.\n ------ Protected Section Addendum Entered By: , RN\n on: 06:54 ------\n"
},
{
"category": "Physician ",
"chartdate": "2175-01-30 00:00:00.000",
"description": "Intensivist Note",
"row_id": 714190,
"text": "TSICU\n HPI:\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\n checked and 1.5, 1 more unit FFP given.\n Chief complaint:\n Mult rib fx: R anterolateral and post, L posterior\n T4 vert body inf corner fx\n Commin spinous process fx T2-8\n Nondisplaced L T10 transverse process\n Nondispaced L distal clavicle\n Nondisplaced L clavicle fx\n R medial lobe liver contusion w/hematoma\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny focus of arterial\n bleeding/active extravasation, and larger area of venous bleeding\n Nondisplaced, comminuted L iliac bone fx w/adjacent iliac muscle\n hematoma, extends into L SIJ.\n Minimally displaced fx of R iliac bone extending to R SIJ.\n PMHx:\n None\n Current medications:\n Chlorhexidine Gluconate 0.12% Oral Rinse\n Diltiazem\n Furosemide\n Gabapentin\n Metoprolol Tartrate\n Ondansetron\n Phenylephrine\n 24 Hour Events:\n Self-extubated in the AM, re-intubated over bougie, NGT replaced,\n bronch with bilateral BALs sent, plan for trach later this week. T\n spike to 101.8 - u/a, urine cx, blood cxs sent. Diltiazem titrated to\n 60mg PO QID. ABX coverage broadened to Vanc/Zosyn. Tbili up to 6.8\n (other LFTs trending down)\n Post operative day:\n POD#4 - IVC filter via L groin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 11:00 AM\n Piperacillin/Tazobactam (Zosyn) - 08:19 PM\n Vancomycin - 08:56 PM\n Infusions:\n Fentanyl (Concentrate) - 100 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Hydromorphone (Dilaudid) - 04:00 AM\n Metoprolol - 06:33 AM\n Pantoprazole (Protonix) - 02:00 PM\n Midazolam (Versed) - 12:30 AM\n Other medications:\n Flowsheet Data as of 02:07 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.8\nC (101.8\n T current: 37.2\nC (98.9\n HR: 76 (76 - 103) bpm\n BP: 97/51(67) {86/47(62) - 121/858(84)} mmHg\n RR: 18 (0 - 25) insp/min\n SPO2: 99%\n Heart rhythm: A Flut (Atrial Flutter)\n Wgt (current): 102 kg (admission): 90 kg\n CVP: 11 (6 - 18) mmHg\n Total In:\n 3,114 mL\n 207 mL\n PO:\n Tube feeding:\n 1,301 mL\n 148 mL\n IV Fluid:\n 1,682 mL\n 59 mL\n Blood products:\n Total out:\n 2,500 mL\n 180 mL\n Urine:\n 2,500 mL\n 180 mL\n NG:\n Stool:\n Drains:\n Balance:\n 614 mL\n 27 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 540 (540 - 540) mL\n PS : 5 cmH2O\n RR (Set): 15\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI: 34\n PIP: 26 cmH2O\n Plateau: 23 cmH2O\n Compliance: 42.3 cmH2O/mL\n SPO2: 99%\n ABG: 7.44/50/127/34/8\n Ve: 9.5 L/min\n PaO2 / FiO2: 254\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: Aflutter\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present,\n Stable scrotal edema/hematoma, soft, no crepitus\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: Follows simple commands, Moves all extremities, Sedated\n Labs / Radiology\n 158 K/uL\n 10.7 g/dL\n 115 mg/dL\n 0.8 mg/dL\n 34 mEq/L\n 4.0 mEq/L\n 20 mg/dL\n 111 mEq/L\n 148 mEq/L\n 31.6 %\n 13.1 K/uL\n [image002.jpg]\n 01:59 AM\n 02:00 AM\n 11:04 AM\n 01:17 PM\n 02:55 AM\n 04:11 AM\n 09:45 AM\n 04:45 PM\n 12:45 AM\n 01:00 AM\n WBC\n 5.6\n 6.5\n 13.1\n Hct\n 28.7\n 29.3\n 31.6\n Plt\n 74\n 86\n 158\n Creatinine\n 0.8\n 0.8\n 0.8\n TCO2\n 35\n 34\n 34\n 38\n 37\n 35\n 35\n Glucose\n 125\n 128\n 141\n 107\n 131\n 115\n Other labs: PT / PTT / INR:13.9/26.9/1.2, CK / CK-MB / Troponin\n T:1334/13/<0.01, ALT / AST:90/88, Alk-Phos / T bili:63/6.8, Amylase /\n Lipase:44/, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic Acid:1.2\n mmol/L, Albumin:2.7 g/dL, LDH:348 IU/L, Ca:8.4 mg/dL, Mg:2.1 mg/dL,\n PO4:2.9 mg/dL\n Imaging: CT head OSH: Prelim No ICH or fx.\n CT chest OSH: Mult rib fx: R anterolateral and posterior, L\n posterior; Dependent consolidation, possible aspiration; T4 vertebral\n body inf corner fx, no retropulsion; Comminuted spinous process fx\n T2-8; Nondisplaced L T10 transverse process; Nondisplaced L clavicle\n distal fx; Nondisplaced L scapula fx;\n CT c spine OSH: Prelim No fx or malalignment. Multilevel\n degenerative changes w/large post disk bulge at C4-5, narrowing the\n spinal canal and deforming the thecal sac, acuity unknown. Marked\n neuroforamenal narrowing @multiple levels.\n CTA abd/pel Prelim: Medial R liver lobe contusion w/adj\n hematoma, w/o evidence of active bleeding; Comminuted L pubic ramus\n fracture w/assoc hematoma, with tiny focus of arterial bleeding/active\n extravasation, and larger area of venous bleeding. Hematoma somewhat\n larger than on OSH study. Nondisplaced, comminuted L iliac bone fx\n w/adj iliac muscle hematoma, larger than on prior study, w/o active\n extrav. Fx extends into L SIJ. Post R hepatic laceration/contusion\n adjacent to calcified granuloma, w/small hematoma, w/out active\n bleeding. Min displaced fx of R iliac bone extending to R SIJ.\n Cirrhotic liver. Inc B pl effusions (small), w/inc atelectasis.\n MRI: Mild compression deformity of L1 w/additional levels of\n potential trabecular contusion @T10-11 also inf @T4 w/o retropulsion.\n Multilevel degenerative changes with moderate canal narrowing at T10-11\n w/cord deformity and no abnormal cord signal. Extensive edema\n throughout paraspinal soft tissues, predominantly post w/in\n interspinous ligaments. Incompletely eval'ed c-spine w/severe canal\n narrowing @C4-5 w/cord deformity and no abnormal cord signal.\n CTA: no PE.\n CXR: Moderate bilateral pleural effusions are stable.\n CXR: Cardiac size top nl, interval improvement of collapse LLL.\n Collapse RLL. Atelectasis in lingula unchanged. Mod B\n pleural effusions stable. No PTX.\n CXR: Interval mild incr in cardiac size, b/l pleural effusions,\n and opacities @ bases,c/w overload\n : R foot: Linear density projecting @ expected area of insertion\n of the Achilles to calcaneus, may be min avulsion fx or degenerative\n changes. Otherwise no fx\n CXR: bilateral pleural effusions\n Microbiology: Ucx no growth final\n Sputum: sparse GNR\n Bcx P\n Bcx P\n 12/17 L BAL: KLEBSIELLA PNEUMONIAE, HAEMOPHILUS SPECIES NOT INFLUENZAE\n R BAL: KLEBSIELLA PNEUMONIAE & GNRs.\n 12/20 L BAL: gram + cocci pairs on gram stain\n R BAL: gram + cocci pairs on gram stain\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, AF with\n RVR, hematologic abnomalities.\n Neurologic: Intubated on Fentanyl/Versed gtt. Per ortho spine, no\n surgery; HOB<30, TLSO when OOB (NEOPS will place). Neuro checks q\n shift.\n Cardiovascular: Aflutter on Dilt 60mg PO QID. Still on Neo. Likely\n needs chemical/electrical cardioversion to improve atrial contribution\n to CO\n Pulmonary: Intubated. Weaning to extubate (was on throughout\n , changed to 10/10 after desat, but self-extubated and reintubated\n am). F/U on BAL: KLEBSIELLA PNEUMONIAE & GNRs/Haemophilus. Repeat\n BAL with gram+ cocci in pairs on gram stain. Ceftriaxone ()\n changed to Vancomycin/Zosyn (). Plan for Trach early this week.\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin with CT scan\n suggesting cirrhosis - Hepatitis panel NEG. TFs advancing to goal.\n Bowel regimen. Tbili trending up (6.8), other LFTs improving.\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO, Foley, monitor UOP. Cr normalized.\n Hematology: Hct and Plt stable; d/c'd H2B\n Endocrine: RISS\n Infectious Disease: WBC increasing to 13.1, f/u Cx - BAL: Klebsiella\n (b/l)& GNRs (on R)/Haemophilus (on L). Started Ceftriaxone (),\n broadened to Zosyn/Vanc () for continued fevers and gram+ on BAL\n Lines / Tubes / Drains: R SC CVL (), PIV x2, Foley, L a-line\n (), ETT\n Wounds:\n Imaging: CXR today\n Fluids: KVO\n Consults: Trauma surgery, Ortho, Ortho-spine, Heme\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 01:00 PM 80 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 04:41 PM\n Arterial Line - 11:30 AM\n Prophylaxis:\n DVT: (IVC filter, SCDs)\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 32 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2175-01-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 714356,
"text": "Atrial fibrillation (Afib)\n Assessment:\n Pt continues in aflutter, controlled rate 70\ns-80\ns, rare PVCs noted.\n Pt continues on diltiazem 60mg PO tid. Atrial flutter thought to be\n from cardiac contusion as a result of the pt\ns injury.\n Action:\n Cardiology consult obtained as well as electrophysiology consult to\n discuss possibility of cardioversion to correct pt\ns aflutter. Pt\n ultimately started on amiodarone gtt without bolus as recommended by\n cards team and ordered by ICU team.\n Response:\n Pt continues on diltiazem PO while on amiodarone gtt. Pt remains in\n atrial flutter at time of note. HR remains in the 70-80\n Plan:\n Continue amiodarone, change dose to .5mg/hr at 17:45 tonight per order\n for 18 hrs. Monitor HR and rhythm closely and attempt to wean neo as\n tolerated to support heart.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lung sounds clear in the upper lobes, diminished at the bases\n bilaterally. Suctioned frequently for thick, white secretions-moderate\n amounts. Pt remains orally intubated on CPAP/PS 50% FiO2. Pt\n requiring sedation while orally intubated because he is unsafely\n agitated when he wakes-tonguing/biting ET tube, reaching for ET tube,\n sitting up in bed. Pt continues to be lightly sedated (easily\n arousable, follows commands) on midazolam and Fentanyl for sedation\n with boluses as needed. +PNA, low grade temp today (Tmax 100.6),\n antibiotics continue (vanco, ceftriaxone).\n Action:\n Tracheostomy (and PEG procedure) brought up to pt and family today by\n Trauma team and ICU team. Family agreed to got forth with procedure\n but formal consent still needed by son (spokesperson, ). Pt\n suctioned frequently, ET tube inserted by RT further (2cm) per ICU team\n this evening.\n Response:\n Pt continues to have moderate amount of secretions, no weaning of vent\n done today, ABG unchanged.\n Plan:\n Trach and PEG procedures planned for tomorrow per Trauma team, no\n consents done- in room v. OR? Continue to educate family regarding\n plan and rationale for treatment. Pulmonary toileting, frequent\n repositioning, VAP care to continue. Consider diuresis once BP more\n stable?\n Hypotension (not Shock)\n Assessment:\n Pt continues to have low BP, requiring neo gtt for several days now.\n Neo gtt titrating daily as tolerated but ultimately still necessary for\n adequate BP. Pt on midazolam gtt and Fentanyl gtt for sedation. Pt\n able to nod yes/no when he has pain.\n Action:\n Ketamine study continues today, will stop at 20:00 tonight, at which\n point 2 corvac tubes should be drawn for lab tests. Fentanyl gtt\n decreased to assist with BP control, PO pain meds started and given as\n needed today. Midazolam gtt lowered to 1mg/hr as tolerated. Haldol PO\n initially given to assist with sedation, but then stopped d/t\n amiodarone gtt started per pharmacy because of prolonged QTC risk.\n Response:\n Pt tolerating sedation changes, very lightly sedated and encouraging\n minimal simulation to family members who are visiting. Pt is easily\n stimulated and becomes uncomfortable with ET tube and agitated. Pt\n denying pain at this time.\n Plan:\n Pt continues on Fentanyl and midaz gtts since the plan is for him to\n have a trach placed tomorrow, which means sedation can be removed, and\n therefore BP should improve. Continue to keep pt safely sedated and\n comfortable. Wean neo gtt as tolerated. BP goal MAP >60-65. Continue\n to support pt and family. Trach/PEG tomorrow by trauma team, remove\n sedation after procedure.\n"
},
{
"category": "Physician ",
"chartdate": "2175-02-02 00:00:00.000",
"description": "Intensivist Note",
"row_id": 714592,
"text": "TSICU\n HPI:\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\n checked and 1.5, 1 more unit FFP given.\n .\n Injuries\n Mult rib fx: R anterolateral and post, L posterior\n T4 vert body inf corner fx\n Commin spinous process fx T2-8\n Nondisplaced L T10 transverse process\n Nondispaced L distal clavicle\n Nondisplaced L clavicle fx\n R medial lobe liver contusion w/hematoma\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny focus of arterial\n bleeding/active extravasation, and larger area of venous bleeding\n Nondisplaced, comminuted L iliac bone fx w/adjacent iliac muscle\n hematoma, extends into L SIJ.\n Minimally displaced fx of R iliac bone extending to R SIJ.\n Chief complaint:\n Trauma\n PMHx:\n PMH: None\n PSH: None\n : None\n Current medications:\n 24 Hour Events:\n Trach/PEG. Pt's BP dropped to 80/40 off pressors, sats 88. restarted\n neo. Overnight, pt reverted to sinus, off pressors, weaning sedation.\n PERCUTANEOUS TRACHEOSTOMY - At 12:00 PM\n PEG INSERTION - At 12:00 PM\n Post operative day:\n POD#7 - IVC filter via L groin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\n Vancomycin - 08:00 AM\n Ceftriaxone - 03:00 PM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Amiodarone - 0.5 mg/min\n Fentanyl (Concentrate) - 50 mcg/hour\n Other ICU medications:\n Fentanyl - 01:23 PM\n Pantoprazole (Protonix) - 02:00 PM\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Other medications:\n Flowsheet Data as of 04:33 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.7\nC (99.9\n T current: 37.1\nC (98.8\n HR: 94 (68 - 101) bpm\n BP: 140/66(91) {89/46(63) - 154/68(94)} mmHg\n RR: 26 (11 - 30) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 102 kg (admission): 90 kg\n CVP: 9 (6 - 16) mmHg\n Total In:\n 1,764 mL\n 142 mL\n PO:\n Tube feeding:\n 424 mL\n IV Fluid:\n 1,000 mL\n 82 mL\n Blood products:\n Total out:\n 1,630 mL\n 290 mL\n Urine:\n 1,630 mL\n 290 mL\n NG:\n Stool:\n Drains:\n Balance:\n 134 mL\n -148 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 483 (404 - 506) mL\n PS : 15 cmH2O\n RR (Spontaneous): 16\n PEEP: 10 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10\n PIP: 25 cmH2O\n SPO2: 98%\n ABG: 7.45/49/98./31/8\n Ve: 8.5 L/min\n PaO2 / FiO2: 163\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: Crackles : )\n Abdominal: Soft\n Left Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present)\n Right Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present)\n Neurologic: Follows simple commands, Moves all extremities, Sedated\n Labs / Radiology\n 109 K/uL\n 10.2 g/dL\n 110 mg/dL\n 0.8 mg/dL\n 31 mEq/L\n 4.5 mEq/L\n 24 mg/dL\n 105 mEq/L\n 144 mEq/L\n 31.3 %\n 5.9 K/uL\n [image002.jpg]\n 12:07 AM\n 02:18 AM\n 08:00 AM\n 02:00 PM\n 05:04 PM\n 08:00 PM\n 09:20 PM\n 01:00 AM\n 01:07 AM\n 01:18 AM\n WBC\n 4.2\n 5.9\n Hct\n 29.7\n 31.3\n Plt\n 104\n 109\n Creatinine\n 0.7\n 0.8\n TCO2\n 32\n 36\n 34\n 35\n Glucose\n 129\n 100\n 111\n 105\n 117\n 110\n Other labs: PT / PTT / INR:13.7/27.6/1.2, CK / CK-MB / Troponin\n T:128/13/<0.01, ALT / AST:90/113, Alk-Phos / T bili:99/5.1, Amylase /\n Lipase:58/39, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic\n Acid:1.4 mmol/L, Albumin:2.3 g/dL, LDH:348 IU/L, Ca:8.1 mg/dL, Mg:2.1\n mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, now\n with AF with RVR/Aflutter, persistant hypotension and PNA.\n Neurologic: s/p trach. Per ortho spine, no surgery; HOB<30, TLSO when\n OOB (NEOPS will place). Wean sedation as may be causing hypotension.\n Change pain meds to PO.\n Neuro checks Q: shift\n Pain: Oxycodone, Neurontin, Tylenol. Wean fentanyl gtt, midazolam gtt\n Cardiovascular: Aflutter, now reverted to sinus. Likely cardiac\n contusion. On Dilt 60mg PO QID. Cards rec amio gtt. Neo off. Pt cannot\n be fully anticoagulated for now (trauma).\n Pulmonary: Intubated, weaning, tachypneic likely abd distension. On\n appropriate abx per BAL cx - Ceftriaxone. If pt continues to spike or\n have signs of focal infection, breaden abx.\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin (declining 6.8\n max ->5.0) w/CT scan suggesting cirrhosis - Hepatitis panel NEG. TFs on\n hold for PEG. Bowel regimen.\n Nutrition:\n Renal: Foley, monitor UOP, edematous scrotum.\n Hematology: Hct stable 32.1->29.7. Plt stable (100's); d/c'd H2B with\n increasing plt count. Heme onc c/s - smear nl; no hemolysis. IVC\n filter placed.\n Endocrine: RISS\n Infectious Disease: WBC droppping 13.1->8.8->4.2, f/u Cx - BAL:\n pansensitive Klebsiella - continue ceftriaxone; consider broadning\n coverage if indicated.v\n Lines / Tubes / Drains: R SC CVL (), Foley, L a-line (),\n trach/PEG\n Wounds: SCDs, IVC filter, SQH\n Imaging:\n Fluids:\n Consults: Trauma surgery\n Billing Diagnosis: Multiple injuries (Trauma)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 04:41 PM\n Arterial Line - 11:30 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n"
},
{
"category": "Respiratory ",
"chartdate": "2175-01-27 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 713782,
"text": "Demographics\n Day of mechanical ventilation: 3\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Pt placed on MMV this a.m.; has tolerated well breathing over\n MMV of 5L on PSV settings as charted.\n Assessment of breathing comfort: No response (sleeping / sedated)\n Plan\n Next 24-48 hours: Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n"
},
{
"category": "Respiratory ",
"chartdate": "2175-01-28 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 713901,
"text": "Demographics\n Day of mechanical ventilation: 4\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Pt continues on PSV settings as charted; weaned on settings.\n Assessment of breathing comfort: No claim of dyspnea\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Cannot manage\n secretions, Underlying illness not resolved\n"
},
{
"category": "Nursing",
"chartdate": "2175-01-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 714065,
"text": "74M s/p fall with multiple rib fx, pelvis fx, clavicle fx, and thoracic\n fx c/b unstable bleeding s/p IR embo, AF with RVR, hematologic\n abnormalities, now with resp failure.\n Atrial fibrillation (Afib), aflutter\n Assessment:\n Pt in and out of aflutter with controlled rate. Predominently\n aflutter. Hypotensive w/ sbp 80\ns while in aflutter.\n Action:\n Pt started dilt gtt 5-10mg/hr. K=3.5 and lytes repleted. Neo gtt to\n support sbp titrated to map >60 and sbp >100\n Propofol off due to hypotension. Pt started on low dose midaz gtt\n along with fentanyl.\n Response:\n Remains on dilt now at 5mg/hr. Briefly converted to nsr and then back\n to aflutter. Rate well controlled but remains neo dependent.\n Tolerating sedation titrated to lowest dose to keep comfortable and\n safe.\n Plan:\n Cont to monitor hemodynamics. Wean neo gtt as tolerated. Cont dilt\n gtt. Replete lytes. ?amio bolus or if persists possible electrical\n cardioversion. Hold off on Lasix for now.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains fully vented after reintubation ithis am, cmv 550x15, 50% and\n 10 peep. Stable abg, improved p02 this afternoon. O2sat 96-98%.\n Moderate amt thick, tenacious secretions. LS coarse, diminished.\n Clears with sxning.\n Action:\n Pt maintained intubated and bronch done this am. Sxned for thick\n secretions. BAL sent. Cont on abx for klebsiella pna. (febrile to\n 101.8 on abx) cultures sent and pnd.\n Response:\n Stable abg\ns . Cont with tenacious secretions. Cont with failure to\n wean.\n Plan:\n Cont abx for pna. Pulm toilet. Maintain sedated for safety and\n comfort. ? need for trach in future.\n"
},
{
"category": "Nutrition",
"chartdate": "2175-01-30 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 714171,
"text": "Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n cm\n 90 kg\n 102 kg ( 12:00 AM)\n Pertinent medications: fetanyl, versed, phenylephrone.normal saline,\n heparin, IV abx, others noted\n Labs:\n Value\n Date\n Glucose\n 132 mg/dL\n 05:12 AM\n Glucose Finger Stick\n 153\n 08:00 AM\n BUN\n 19 mg/dL\n 05:12 AM\n Creatinine\n 0.7 mg/dL\n 05:12 AM\n Sodium\n 143 mEq/L\n 05:12 AM\n Potassium\n 4.0 mEq/L\n 05:12 AM\n Chloride\n 108 mEq/L\n 05:12 AM\n TCO2\n 32 mEq/L\n 05:12 AM\n PO2 (arterial)\n 127 mm Hg\n 01:00 AM\n PCO2 (arterial)\n 50 mm Hg\n 01:00 AM\n pH (arterial)\n 7.44 units\n 01:00 AM\n pH (urine)\n 5.0 units\n 04:25 PM\n CO2 (Calc) arterial\n 35 mEq/L\n 01:00 AM\n Albumin\n 2.7 g/dL\n 12:14 AM\n Calcium non-ionized\n 8.2 mg/dL\n 05:12 AM\n Phosphorus\n 2.8 mg/dL\n 05:12 AM\n Ionized Calcium\n 1.12 mmol/L\n 01:00 AM\n Magnesium\n 2.0 mg/dL\n 05:12 AM\n ALT\n 90 IU/L\n 12:45 AM\n Alkaline Phosphate\n 63 IU/L\n 12:45 AM\n AST\n 88 IU/L\n 12:45 AM\n Amylase\n 44 IU/L\n 06:01 AM\n Total Bilirubin\n 6.8 mg/dL\n 12:45 AM\n WBC\n 13.1 K/uL\n 12:45 AM\n Hgb\n 10.7 g/dL\n 12:45 AM\n Hematocrit\n 31.6 %\n 12:45 AM\n Current diet order / nutrition support: Replete wtih Fiber @ 80 ml/hr =\n kcals/ 119 g protein\n GI: soft, distended, +bowel sounds\n Assessment of Nutritional Status\n Specifics: 74 year old male s/p fall fromo tractor and crushed by tree\n branch now with multiple fx. Tube feedings started on . Patient\n tolerating tube feedings at goal which provide 100% of nutritional\n needs.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. Continue with goal tube feeding\n 2. Check chemistry 10 daily and replete prn\n 3. Will follow page with questions\n"
},
{
"category": "Nursing",
"chartdate": "2175-02-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 714590,
"text": "74M s/p crushing injury d/t falling tree. Injuries sustained include\n multiple R sided rib fxs, grade 2 liver lac (w/ assoc hepatic vessel\n extravasation), stable pelvis fxs (w/ associated extravasation), R\n ramus fx, clavicle fx, and T4 vertebral body fx. Episodes of A.\n Flutter with RVR and aflutter, now with resp failure and newly dx\n pneumonia as of .\n intubated for resp distress\n angio embolization of hepatic and pelvic arterial bleeders\n IVC filter in OR\n self extubated and re-intubated immediately after d/t acute resp.\n failure\n Trach and PEG at bedside\n Atrial fibrillation (Afib)\n Assessment:\n Pt converted to NSR @ 1900 w/ rate 80s-100s.\n Action:\n PO dilt, amioderone gtt continued\n Neo gtt weaned off\n Response:\n HR & BP remain well controlled. Pt\n :\n Continue Amio gtt, switch to PO amio, ? Anticoagulant.\n Monitor hemodynamics, monitor BP\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt w/ trach on CPAP/PS 10/10/50%. LS rhonchorous throughout. Strong\n productive cough, large amounts of thick blood tinged secretions. ABG\n stable. VSS. Low grade temps\n Action:\n Pulm hygiene, suction PRN\n Ceftriaxone admistered for pna\n Response:\n Exam unchanged.\n Plan:\n Wean vent settings as tolerated, pulmonary toileting, wean\n sedation.\n"
},
{
"category": "Physician ",
"chartdate": "2175-01-28 00:00:00.000",
"description": "Intensivist Note",
"row_id": 713870,
"text": "TSICU\n HPI:\n 74M s/p fall with multiple rib fx, pelvis fx, clavicle fx, and thoracic\n fx c/b unstable bleeding s/p IR embo, AF with RVR, hematologic\n abnomalities.\n Chief complaint:\n fall\n PMHx:\n none\n Current medications:\n 1. Acetaminophen 2. Bisacodyl 3. Chlorhexidine Gluconate 0.12% Oral\n Rinse 4. Dextrose 50% 5. Diltiazem 6. Docusate Sodium (Liquid) 7.\n Famotidine 8. Fentanyl Citrate 9. Fentanyl Citrate 10. Gabapentin 11.\n Glucagon 12. Insulin 13. Magnesium Sulfate 14. Midazolam 15.\n Ondansetron 16. Phenylephrine 17. Pneumococcal Vac Polyvalent 18.\n Potassium Phosphate 19. Potassium Chloride 20. Propofol 21. Senna 22.\n Sodium Chloride 0.9% Flush\n 24 Hour Events:\n ARTERIAL LINE - STOP 11:05 AM\n ARTERIAL LINE - START 11:30 AM\n Heme c/s- smear nl. Wean vent, started on po diltiazem for atrial\n ectopy.\n Post operative day:\n POD#2 - IVC filter via L groin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Fentanyl (Concentrate) - 100 mcg/hour\n Propofol - 20 mcg/Kg/min\n Phenylephrine - 0.3 mcg/Kg/min\n Other ICU medications:\n Fentanyl - 08:00 PM\n Other medications:\n Flowsheet Data as of 04:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.6\nC (99.7\n T current: 37.5\nC (99.5\n HR: 69 (62 - 97) bpm\n BP: 102/51(66) {89/48(63) - 135/71(94)} mmHg\n RR: 13 (8 - 20) insp/min\n SPO2: 98%\n Heart rhythm: 1st AV (First degree AV Block)\n Wgt (current): 102 kg (admission): 90 kg\n CVP: 15 (11 - 24) mmHg\n Total In:\n 2,899 mL\n 385 mL\n PO:\n Tube feeding:\n 908 mL\n 228 mL\n IV Fluid:\n 1,471 mL\n 96 mL\n Blood products:\n 50 mL\n Total out:\n 1,050 mL\n 90 mL\n Urine:\n 1,050 mL\n 90 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,849 mL\n 295 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (440 - 500) mL\n Vt (Spontaneous): 495 (495 - 680) mL\n PS : 12 cmH2O\n RR (Set): 10\n RR (Spontaneous): 12\n PEEP: 12 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 25 cmH2O\n SPO2: 98%\n ABG: 7.40/54/92./31/6\n Ve: 7.2 L/min\n PaO2 / FiO2: 232\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: No(t) Regular, Irregular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: 3+), (Temperature: Warm)\n Right Extremities: (Edema: 3+), (Temperature: Warm)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities, Sedated\n Labs / Radiology\n 74 K/uL\n 9.7 g/dL\n 128 mg/dL\n 0.8 mg/dL\n 31 mEq/L\n 3.9 mEq/L\n 19 mg/dL\n 108 mEq/L\n 141 mEq/L\n 28.7 %\n 5.6 K/uL\n [image002.jpg]\n 02:16 PM\n 05:17 PM\n 12:14 AM\n 12:20 AM\n 05:24 AM\n 06:50 AM\n 02:40 PM\n 03:13 PM\n 01:59 AM\n 02:00 AM\n WBC\n 11.0\n 11.0\n 8.0\n 5.6\n Hct\n 30.6\n 30.1\n 29.8\n 28.7\n Plt\n 99\n 97\n 80\n 74\n Creatinine\n 0.9\n 0.8\n 0.8\n TCO2\n 34\n 33\n 32\n 30\n 33\n 35\n Glucose\n 96\n 133\n 125\n 128\n Other labs: PT / PTT / INR:13.7/28.7/1.2, CK / CK-MB / Troponin\n T:1334/13/<0.01, ALT / AST:147/126, Alk-Phos / T bili:52/2.6, Amylase /\n Lipase:44/, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic Acid:1.4\n mmol/L, Albumin:2.7 g/dL, LDH:435 IU/L, Ca:8.0 mg/dL, Mg:2.2 mg/dL,\n PO4:2.8 mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, AF with\n RVR, hematologic abnormalities.\n Neurologic: Intubated on Propofol gtt and Midazolam PRN (have not been\n giving). Per ortho spine, no surgery; HOB<30, TLSO when OOB (NEOPS will\n place).\n Neuro checks Q: shift\n Pain: Fentanyl 100mcg/hr, start Dilaudid, Neurontin, Tylenol\n Cardiovascular: Now back in NSR with occasional PACs, off dilt gtt,\n started po diltiazem 30 qid, and currently weaning Neo gtt. Fluid\n challenge and PPV 6. Also given 25% albumin x1.\n Pulmonary: Intubated. Pt developing early ARDS, placed on MMV. F/U on\n bronch cx.\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin with CT scan\n suggesting cirrhosis - Hepatitis panel NEG. TFs advancing to goal.\n Bowel regimen.\n Nutrition: Tube feeding\n Renal: Foley, monitor UOP. Cr normalized. Consider diuresis if remains\n off Neo, goal even.\n Hematology: Hct stable at 29-30-28.7. Plt low but stable (100's).\n Heme onc consulted - smear nl, no further recs. H2B stopped in case\n contributing factor. IVC filter placed.\n Endocrine: RISS, goal BS<150.\n Infectious Disease: WBC normal, f/u Cx - GNR in sputum and BAL, but\n afebrile, monitor for now, WBC trending down to 5.6 today, vent support\n decreasing; may start abx if spikes.\n Lines / Tubes / Drains: R SC CVL (), PIV x2, Foley, L a-line\n (), ETT\n Wounds:\n Imaging: CXR today\n Fluids: none\n Consults: Trauma (1o), Ortho Spine, Ortho trauma, Heme\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 01:48 AM 50 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 04:41 PM\n Arterial Line - 11:30 AM\n Prophylaxis:\n DVT: Boots, IVC filter\n Stress ulcer: PPI (changed from H2B)\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 32 min\n"
},
{
"category": "Physician ",
"chartdate": "2175-01-28 00:00:00.000",
"description": "Intensivist Note",
"row_id": 713872,
"text": "TSICU\n HPI:\n 74M s/p fall with multiple rib fx, pelvis fx, clavicle fx, and thoracic\n fx c/b unstable bleeding s/p IR embo, AF with RVR, hematologic\n abnomalities.\n Chief complaint:\n fall\n PMHx:\n none\n Current medications:\n 1. Acetaminophen 2. Bisacodyl 3. Chlorhexidine Gluconate 0.12% Oral\n Rinse 4. Dextrose 50% 5. Diltiazem 6. Docusate Sodium (Liquid) 7.\n Famotidine 8. Fentanyl Citrate 9. Fentanyl Citrate 10. Gabapentin 11.\n Glucagon 12. Insulin 13. Magnesium Sulfate 14. Midazolam 15.\n Ondansetron 16. Phenylephrine 17. Pneumococcal Vac Polyvalent 18.\n Potassium Phosphate 19. Potassium Chloride 20. Propofol 21. Senna 22.\n Sodium Chloride 0.9% Flush\n 24 Hour Events:\n ARTERIAL LINE - STOP 11:05 AM\n ARTERIAL LINE - START 11:30 AM\n Heme c/s- smear nl. Wean vent, started on po diltiazem for atrial\n ectopy.\n Post operative day:\n POD#2 - IVC filter via L groin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Fentanyl (Concentrate) - 100 mcg/hour\n Propofol - 20 mcg/Kg/min\n Phenylephrine - 0.3 mcg/Kg/min\n Other ICU medications:\n Fentanyl - 08:00 PM\n Other medications:\n Flowsheet Data as of 04:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.6\nC (99.7\n T current: 37.5\nC (99.5\n HR: 69 (62 - 97) bpm\n BP: 102/51(66) {89/48(63) - 135/71(94)} mmHg\n RR: 13 (8 - 20) insp/min\n SPO2: 98%\n Heart rhythm: 1st AV (First degree AV Block)\n Wgt (current): 102 kg (admission): 90 kg\n CVP: 15 (11 - 24) mmHg\n Total In:\n 2,899 mL\n 385 mL\n PO:\n Tube feeding:\n 908 mL\n 228 mL\n IV Fluid:\n 1,471 mL\n 96 mL\n Blood products:\n 50 mL\n Total out:\n 1,050 mL\n 90 mL\n Urine:\n 1,050 mL\n 90 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,849 mL\n 295 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (440 - 500) mL\n Vt (Spontaneous): 495 (495 - 680) mL\n PS : 12 cmH2O\n RR (Set): 10\n RR (Spontaneous): 12\n PEEP: 12 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 25 cmH2O\n SPO2: 98%\n ABG: 7.40/54/92./31/6\n Ve: 7.2 L/min\n PaO2 / FiO2: 232\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: No(t) Regular, Irregular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: 3+), (Temperature: Warm)\n Right Extremities: (Edema: 3+), (Temperature: Warm)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities, Sedated\n Labs / Radiology\n 74 K/uL\n 9.7 g/dL\n 128 mg/dL\n 0.8 mg/dL\n 31 mEq/L\n 3.9 mEq/L\n 19 mg/dL\n 108 mEq/L\n 141 mEq/L\n 28.7 %\n 5.6 K/uL\n [image002.jpg]\n 02:16 PM\n 05:17 PM\n 12:14 AM\n 12:20 AM\n 05:24 AM\n 06:50 AM\n 02:40 PM\n 03:13 PM\n 01:59 AM\n 02:00 AM\n WBC\n 11.0\n 11.0\n 8.0\n 5.6\n Hct\n 30.6\n 30.1\n 29.8\n 28.7\n Plt\n 99\n 97\n 80\n 74\n Creatinine\n 0.9\n 0.8\n 0.8\n TCO2\n 34\n 33\n 32\n 30\n 33\n 35\n Glucose\n 96\n 133\n 125\n 128\n Other labs: PT / PTT / INR:13.7/28.7/1.2, CK / CK-MB / Troponin\n T:1334/13/<0.01, ALT / AST:147/126, Alk-Phos / T bili:52/2.6, Amylase /\n Lipase:44/, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic Acid:1.4\n mmol/L, Albumin:2.7 g/dL, LDH:435 IU/L, Ca:8.0 mg/dL, Mg:2.2 mg/dL,\n PO4:2.8 mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, AF with\n RVR, hematologic abnormalities.\n Neurologic: Intubated on Propofol gtt and Midazolam PRN (have not been\n giving). Per ortho spine, no surgery; HOB<30, TLSO when OOB (NEOPS will\n place).\n Neuro checks Q: shift\n Pain: Fentanyl 100mcg/hr, start Dilaudid, Neurontin, Tylenol\n Cardiovascular: Now back in NSR with occasional PACs, off dilt gtt,\n started po diltiazem 30 qid, and currently weaning Neo gtt. Fluid\n challenge and PPV 6. Also given 25% albumin x1.\n Pulmonary: Intubated. Pt developing early ARDS, placed on MMV. F/U on\n bronch cx.\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin with CT scan\n suggesting cirrhosis - Hepatitis panel NEG. TFs advancing to goal.\n Bowel regimen.\n Nutrition: Tube feeding\n Renal: Foley, monitor UOP. Cr normalized. Consider diuresis if remains\n off Neo, goal even.\n Hematology: Hct stable at 29-30-28.7. Plt low but stable (100's).\n Heme onc consulted - smear nl, no further recs. H2B stopped in case\n contributing factor. IVC filter placed.\n Endocrine: RISS, goal BS<150.\n Infectious Disease: WBC normal, f/u Cx - GNR in sputum and BAL, but\n afebrile, monitor for now, WBC trending down to 5.6 today, vent support\n decreasing; may start abx if spikes.\n Lines / Tubes / Drains: R SC CVL (), PIV x2, Foley, L a-line\n (), ETT\n Wounds:\n Imaging: CXR today\n Fluids: none\n Consults: Trauma (1o), Ortho Spine, Ortho trauma, Heme\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 01:48 AM 50 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 04:41 PM\n Arterial Line - 11:30 AM\n Prophylaxis:\n DVT: Boots, IVC filter\n Stress ulcer: PPI (changed from H2B)\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 32 min\n"
},
{
"category": "Nursing",
"chartdate": "2175-02-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 714415,
"text": "74M s/p crushing injury d/t falling tree. Injuries sustained include\n multiple R sided rib fxs, grade 2 liver lac (w/ assoc hepatic vessel\n extravasation), stable pelvis fxs (w/ associated extravasation), R\n ramus fx, clavicle fx, and T4 vertebral body fx. Episodes of AF with\n RVR and aflutter, hematologic abnormalities, now with resp failure and\n newly dx pneumonia as of .\n intubated for resp distress\n angio embolization of hepatic and pelvic arterial bleeders\n IVC filter in OR\n self extubated and reintubated immediately after d/t acute resp\n failure\n Atrial fibrillation (Afib), aflutter\n Assessment:\n Pt in aflutter with controlled rate most of time, w/ stimulation HR\n jumps to 100s-110s. weaned off neo since last evening, BP stable.\n Action:\n Amio drip continues, dose weaned to 0.5mg/min per 18 hr protocol.\n Standing po dose dilt continued, lytes followed, repleted as needed.\n Pt on low dose midaz gtt along with fentanyl for sedation.\n Response:\n Remains in afib despite amio infusion, rate 70s-80s when calm,\n tachycardic when pt agitated. BP remains soft w/ sedation/pain med\n dosing, when stimulated, BP adequate. Urine output remains brisk.\n Tolerating sedation titrated to lowest dose to keep comfortable and\n safe.\n Plan:\n Cont to monitor hemodynamics. Continue amio drip for full 18 hrs, will\n need to be d/c\nd 1400 unless team decides to continue. Optimize\n lytes ongoing. Cardiology consult team following.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Weaned to cpap mode vent support yesterday, 10 psv, 50% and 10 peep.\n Stable abg, improved p02. At rest RR mid to high 20s, when agitated,\n increasingly tachypneic to 30s. abg wnl. Moderate amt thick,\n yellow/white secretions. LS improving, diminished to all fields, less\n rhonchi.\n Action:\n Remains intubated on cpap, signif peep. see settings above, tol well.\n Pulm toileting per routine. Increased sedation overnoc w/ cessation of\n ketamine study drug, pt noted to be increasingly tachypneic,\n hyperdynamic. Midaz increased substantially, requires bolus dosing for\n any care. Given po as well as IV drip pain meds as written to\n potentiate benzo effect.\n Response:\n Abg acceptable, Pao2 improved on higher peep. LS improved as well,\n clearer, remain diminished throughout, more so to R side. Cough\n remains weak w/ sedation. Pt denies pain when asked, nods adamantly\n yes to question of discomfort w/ ett w/ any stimulation at all.\n Remains agitated w/ any physical care or stimulus.\n Plan:\n Cont Vanco, ceftriaxone for hflu and klebsiella pneumonia coverage,\n Pulm toilet. Maintain sedation for safety and comfort until trach\n placement, likely to be today.\n Trauma, s/p\n Assessment:\n As above, pt s/p liver laceration and resultant angio procedure to\n embolize several extravsating hepatic and pelvic vessels. LFTs\n continue to be elevated, tbili from 6.8 w/ direct 5.2. INR\n stable. Urine icteric, clear, pt jaundiced. R hip/flank/torso\n hematoma appears larger than in previous days\n Action:\n Following LFTs, hct, coags. Monitor s/s bleeding, hematoma expansion\n to R hip/flank/torso areas.\n Response:\n WBC 4.2, plts 104 this am, significant drops from last 24h values,\n trauma and ICU teams aware. LFTs added on to this am\ns labs.\n Plan:\n Continue to follow LFTs, coags, hct, serial belly assessments, s/s\n further bleeding.\n"
},
{
"category": "Respiratory ",
"chartdate": "2175-02-01 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 714525,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 8\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Tube Type\n Tracheostomy tube:\n Type: Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Comments: trach placed on \n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Blood Tinged / Thin\n Sputum source/amount: Suctioned / Scant\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Bedside Procedures:\n Bedside tracheostomy (11:00)\n Comments: uneventfull trach placement at bedside\n"
},
{
"category": "Nursing",
"chartdate": "2175-02-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 714528,
"text": "74M s/p crushing injury d/t falling tree. Injuries sustained include\n multiple R sided rib fxs, grade 2 liver lac (w/ assoc hepatic vessel\n extravasation), stable pelvis fxs (w/ associated extravasation), R\n ramus fx, clavicle fx, and T4 vertebral body fx. Episodes of A.\n Flutter with RVR and aflutter, hematologic abnormalities, now with resp\n failure and newly dx pneumonia as of .\n intubated for resp distress\n angio embolization of hepatic and pelvic arterial bleeders\n IVC filter in OR\n self extubated and re-intubated immediately after d/t acute resp.\n failure\n Trach and PEG at bedside\n Atrial fibrillation (Afib)\n Assessment:\n Atrial flutter continues, RVR up to 130s this AM.\n Action:\n PO dilt, amioderone gtt continued, Neo gtt titrated for adequate BP\n control.\n Response:\n Rate controlled after PO Dilt.\n Plan:\n Continue Amio gtt, ? Switch to PO amio, ? Cardio version,?\n Anticoagulant.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Post trach pt back on CPAP 10/10/50%. Ls clear to diminish at bases.\n Strong productive cough, suctioned for copious amounts of thick blood\n tinged secretions.\n Action:\n Trach and PEG at bedside, continue pulmonary toileting.\n Response:\n Tolerated procedure without issue.\n Plan:\n Wean vent settings as tolerated, pulmonary toileting, wean sedation as\n tolerated,\n"
},
{
"category": "Physician ",
"chartdate": "2175-02-03 00:00:00.000",
"description": "Intensivist Note",
"row_id": 714765,
"text": "TSICU\n HPI:\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\n checked and 1.5, 1 more unit FFP given.\n Chief complaint:\n PMHx:\n Current medications:\n Acetaminophen 4. Amiodarone 5. Bisacodyl 6. Calcium Gluconate 7.\n CefePIME 8. CefePIME\n 9. Chlorhexidine Gluconate 0.12% Oral Rinse 10. Ciprofloxacin HCl 11.\n Dextrose 50% 12. Docusate Sodium (Liquid)\n 13. Fentanyl Citrate 14. Furosemide 15. Furosemide 16. Furosemide 17.\n Gabapentin 18. Glucagon 19. Heparin\n 20. Insulin 21. Lactulose 22. Lansoprazole Oral Disintegrating Tab 23.\n Lorazepam 24. Magnesium Sulfate\n 25. Metoprolol Tartrate 26. Metoprolol Tartrate 27. Midazolam 28.\n Midazolam 29. Milk of Magnesia\n 30. Olanzapine (Disintegrating Tablet) 31. Ondansetron 32. OxycoDONE\n Liquid 33. Phenylephrine 34. Pneumococcal Vac Polyvalent\n 35. Potassium Phosphate 36. Potassium Chloride 37. Senna 38. Sodium\n Chloride 0.9% Flush 39. Sodium Chloride 0.9% Flush\n 40. Vancomycin 41. Vancomycin\n 24 Hour Events:\n EKG - At 09:07 PM\n FEVER - 101.1\nF - 12:00 AM\n : TFs increased. Lasix 10x3 with good result. Zyprexa for\n sedation, weaned off versed, fentanyl. Cards rec 400'' x 1wk, then\n 400'x1 wk, then 200'. also rec changing dilt to metop succinate 25''.\n Vanc/cipro/cefepime for VAP.\n : pan cx for temp 101.1\n Post operative day:\n POD#8 - IVC filter via L groin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 03:00 PM\n Ciprofloxacin - 12:00 PM\n Vancomycin - 07:33 PM\n Cefipime - 11:15 PM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 02:00 PM\n Lorazepam (Ativan) - 11:41 PM\n Midazolam (Versed) - 02:16 AM\n Furosemide (Lasix) - 03:55 AM\n Heparin Sodium (Prophylaxis) - 04:02 AM\n Metoprolol - 06:27 AM\n Other medications:\n Flowsheet Data as of 08:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.4\nC (101.1\n T current: 37.7\nC (99.8\n HR: 97 (81 - 111) bpm\n BP: 160/81(110) {111/59(80) - 166/81(110)} mmHg\n RR: 30 (17 - 30) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 104.2 kg (admission): 90 kg\n CVP: 19 (12 - 26) mmHg\n Total In:\n 2,674 mL\n 727 mL\n PO:\n Tube feeding:\n 660 mL\n 637 mL\n IV Fluid:\n 895 mL\n 90 mL\n Blood products:\n Total out:\n 2,485 mL\n 1,055 mL\n Urine:\n 2,485 mL\n 1,055 mL\n NG:\n Stool:\n Drains:\n Balance:\n 189 mL\n -328 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 510 (502 - 660) mL\n PS : 12 cmH2O\n RR (Spontaneous): 28\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 28 cmH2O\n SPO2: 99%\n ABG: 7.50/43/150/31/9\n Ve: 11.8 L/min\n PaO2 / FiO2: 300\n Physical Examination\n General Appearance: Anxious, Well nourished\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: Crackles : , Rhonchorous : ,\n Diminished: )\n Abdominal: Soft, Distended\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities\n Labs / Radiology\n 128 K/uL\n 9.3 g/dL\n 138 mg/dL\n 0.8 mg/dL\n 31 mEq/L\n 3.8 mEq/L\n 23 mg/dL\n 105 mEq/L\n 142 mEq/L\n 28.9 %\n 6.3 K/uL\n [image002.jpg]\n 02:00 PM\n 05:04 PM\n 08:00 PM\n 09:20 PM\n 01:00 AM\n 01:07 AM\n 01:18 AM\n 02:05 AM\n 03:54 AM\n 05:17 AM\n WBC\n 5.9\n 6.3\n Hct\n 31.3\n 28.9\n Plt\n 109\n 128\n Creatinine\n 0.8\n 0.8\n TCO2\n 36\n 34\n 35\n 34\n 35\n Glucose\n 111\n 105\n 117\n 110\n 138\n Other labs: PT / PTT / INR:13.7/27.6/1.2, CK / CK-MB / Troponin\n T:128/13/<0.01, ALT / AST:90/122, Alk-Phos / T bili:133/5.4, Amylase /\n Lipase:54/52, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic\n Acid:1.4 mmol/L, Albumin:2.3 g/dL, LDH:348 IU/L, Ca:8.0 mg/dL, Mg:2.2\n mg/dL, PO4:2.8 mg/dL\n Imaging: CT head OSH: Prelim No ICH or fx.\n CT chest OSH: Mult rib fx: R anterolateral and posterior, L\n posterior; Dependent consolidation, possible aspiration; T4 vertebral\n body inf corner fx, no retropulsion; Comminuted spinous process fx\n T2-8; Nondisplaced L T10 transverse process; Nondisplaced L clavicle\n distal fx; Nondisplaced L scapula fx;\n CT c spine OSH: Prelim No fx or malalignment. Multilevel\n degenerative changes w/large post disk bulge at C4-5, narrowing the\n spinal canal and deforming the thecal sac, acuity unknown. Marked\n neuroforamenal narrowing @multiple levels.\n CTA abd/pel Prelim: Medial R liver lobe contusion w/adj\n hematoma, w/o evidence of active bleeding; Comminuted L pubic ramus\n fracture w/assoc hematoma, with tiny focus of arterial bleeding/active\n extravasation, and larger area of venous bleeding. Hematoma somewhat\n larger than on OSH study. Nondisplaced, comminuted L iliac bone fx\n w/adj iliac muscle hematoma, larger than on prior study, w/o active\n extrav. Fx extends into L SIJ. Post R hepatic laceration/contusion\n adjacent to calcified granuloma, w/small hematoma, w/out active\n bleeding. Min displaced fx of R iliac bone extending to R SIJ.\n Cirrhotic liver. Inc B pl effusions (small), w/inc atelectasis.\n MRI: Mild compression deformity of L1 w/additional levels of\n potential trabecular contusion @T10-11 also inf @T4 w/o retropulsion.\n Multilevel degenerative changes w/moderate canal narrowing @T10-11\n w/cord deformity & no abnl cord signal. Extensive edema throughout\n paraspinal soft tissues, predominantly post w/in interspinous\n ligaments. Incompletely eval'ed c-spine w/severe canal narrowing @C4-5\n w/cord deformity and no abn cord signal.\n CTA: no PE.\n CXR: Moderate b/l pleural effusions are stable.\n CXR: Cardiac size top nl, interval improvement of collapse LLL.\n Collapse RLL. Atelectasis in lingula unchanged. Mod B pleural effusions\n stable. No PTX.\n CXR: Interval mild incr in cardiac size, b/l pl effusions,\n & opacities @ bases,c/w overload\n : R foot: Linear density projecting @ expected area of insertion\n of Achilles to calcaneus, may be min avulsion fx or degenerative\n changes. Otherwise no fx\n CXR: b/l pl effusions\n CXR: stable.\n RUQ U/S: No perihepatic fluid collection. small amt perihepatic\n free fluid persists. Small contusion in hepatic segment VII. No\n gallstones or sig wall thickening/edema. CBD 4.5 mm\n TTE: LVEF >55%, NL diastolic function, NL LV filling pressure\n (PCWP<12mmHg), RV chamber size mildly dilated, mild TR\n CXR: mild b/l pulm edema and parenchymal opacities and no\n pl effusion.\n CXR: Persistent b/l pl effusions and bibasilar opacity.\n CXR: Minimal improvement of mod b/l pl effusions. Otherwise\n stable.\n Microbiology: Ucx no growth final\n Sputum: sparse GNRs, too few to colonize\n Bcx x2 no growth final\n 12/17 L BAL: Klebsiella Pneumoniae, HAEMOPHILUS SPECIES NOT INFLUENZAE\n R BAL: Klebsiella Pneumoniae, Proteus.\n 12/20 L &R BAL: Klebsiella Pneumoniae\n BCX: p\n BCx: P\n UCx: no growth final\n BCx: P\n BCx: P\n UCx: P\n SpCx: P\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, now\n with AF with RVR/Aflutter, persistant hypotension and PNA.\n Neurologic: s/p trach (). Per ortho spine, no surgery; HOB<30,\n TLSO when OOB. Zyprexa & Ativan PRN (off fent/midaz ).\n Neuro checks Q: shift\n Pain: Oxycodone, Neurontin, Tylenol.\n Cardiovascular: Aflutter, now reverted to sinus w/1st deg AVB. Likely\n cardiac contusion. Cards rec 400'' x 1wk, then 400'x1 wk, then\n 200'. also rec changing dilt to metop 25''. Pt cannot be fully\n anticoagulated for now (trauma).\n Pulmonary: Intubated, weaning, Vanc/cipro/cefepime for VAP ().\n Increasing pulmonary edema on CXR (lasix x 2 on , lasix x1 ).\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin (declining 6.8\n max ->5.0) w/CT scan suggesting cirrhosis - Hepatitis panel NEG. TFs\n restarted, increasing to goal . Bowel regimen.\n Nutrition: Tube feeding\n Renal: Foley, monitor UOP, edematous scrotum. Lasix 10 x2 on ,\n lasix x1 .\n Hematology: Hct stable 32.1->29.7. Plt stable (100's); d/c'd H2B. Heme\n onc c/s - smear nl; no hemolysis. IVC filter placed.\n Endocrine: RISS\n Infectious Disease: Check cultures, WBC droppping\n 13.1->8.8->4.2->5.9->6.3, Vanc/cipro/cefepime for VAP given worsening\n pulm status\n Lines / Tubes / Drains: Trach/Peg/foley/L radial a-line/R SCL\n Wounds:\n Imaging: CXR today\n Fluids: KVO\n Consults: Trauma (1o), Ortho Spine, Ortho trauma, Heme\n Billing Diagnosis: (Respiratory distress: Failure), (Shock: Traumatic),\n Multiple injuries (Trauma)\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 04:12 AM 80 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 04:41 PM\n Arterial Line - 11:30 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting planning, ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 33 minutes\n Patient is critically ill\n"
},
{
"category": "Respiratory ",
"chartdate": "2175-01-29 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 714050,
"text": "Demographics\n Day of mechanical ventilation: 5\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Crackles\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Crackles\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Cannot protect\n airway, Underlying illness not resolved\n Respiratory Care Shift Procedures\n Bedside Procedures:\n Bronchoscopy (1000)\n Comments: BAL collected & sent.\n"
},
{
"category": "Physician ",
"chartdate": "2175-01-30 00:00:00.000",
"description": "Intensivist Note",
"row_id": 714145,
"text": "TSICU\n HPI:\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\n checked and 1.5, 1 more unit FFP given.\n Chief complaint:\n Mult rib fx: R anterolateral and post, L posterior\n T4 vert body inf corner fx\n Commin spinous process fx T2-8\n Nondisplaced L T10 transverse process\n Nondispaced L distal clavicle\n Nondisplaced L clavicle fx\n R medial lobe liver contusion w/hematoma\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny focus of arterial\n bleeding/active extravasation, and larger area of venous bleeding\n Nondisplaced, comminuted L iliac bone fx w/adjacent iliac muscle\n hematoma, extends into L SIJ.\n Minimally displaced fx of R iliac bone extending to R SIJ.\n PMHx:\n None\n Current medications:\n Chlorhexidine Gluconate 0.12% Oral Rinse\n Diltiazem\n Furosemide\n Gabapentin\n Metoprolol Tartrate\n Ondansetron\n Phenylephrine\n 24 Hour Events:\n Self-extubated in the AM, re-intubated over bougie, NGT replaced,\n bronch with bilateral BALs sent, plan for trach later this week. T\n spike to 101.8 - u/a, urine cx, blood cxs sent. Diltiazem titrated to\n 60mg PO QID. ABX coverage broadened to Vanc/Zosyn. Tbili up to 6.8\n (other LFTs trending down)\n Post operative day:\n POD#4 - IVC filter via L groin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 11:00 AM\n Piperacillin/Tazobactam (Zosyn) - 08:19 PM\n Vancomycin - 08:56 PM\n Infusions:\n Fentanyl (Concentrate) - 100 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Hydromorphone (Dilaudid) - 04:00 AM\n Metoprolol - 06:33 AM\n Pantoprazole (Protonix) - 02:00 PM\n Midazolam (Versed) - 12:30 AM\n Other medications:\n Flowsheet Data as of 02:07 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.8\nC (101.8\n T current: 37.2\nC (98.9\n HR: 76 (76 - 103) bpm\n BP: 97/51(67) {86/47(62) - 121/858(84)} mmHg\n RR: 18 (0 - 25) insp/min\n SPO2: 99%\n Heart rhythm: A Flut (Atrial Flutter)\n Wgt (current): 102 kg (admission): 90 kg\n CVP: 11 (6 - 18) mmHg\n Total In:\n 3,114 mL\n 207 mL\n PO:\n Tube feeding:\n 1,301 mL\n 148 mL\n IV Fluid:\n 1,682 mL\n 59 mL\n Blood products:\n Total out:\n 2,500 mL\n 180 mL\n Urine:\n 2,500 mL\n 180 mL\n NG:\n Stool:\n Drains:\n Balance:\n 614 mL\n 27 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 540 (540 - 540) mL\n PS : 5 cmH2O\n RR (Set): 15\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI: 34\n PIP: 26 cmH2O\n Plateau: 23 cmH2O\n Compliance: 42.3 cmH2O/mL\n SPO2: 99%\n ABG: 7.44/50/127/34/8\n Ve: 9.5 L/min\n PaO2 / FiO2: 254\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: Aflutter\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present,\n Stable scrotal edema/hematoma, soft, no crepitus\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: Follows simple commands, Moves all extremities, Sedated\n Labs / Radiology\n 158 K/uL\n 10.7 g/dL\n 115 mg/dL\n 0.8 mg/dL\n 34 mEq/L\n 4.0 mEq/L\n 20 mg/dL\n 111 mEq/L\n 148 mEq/L\n 31.6 %\n 13.1 K/uL\n [image002.jpg]\n 01:59 AM\n 02:00 AM\n 11:04 AM\n 01:17 PM\n 02:55 AM\n 04:11 AM\n 09:45 AM\n 04:45 PM\n 12:45 AM\n 01:00 AM\n WBC\n 5.6\n 6.5\n 13.1\n Hct\n 28.7\n 29.3\n 31.6\n Plt\n 74\n 86\n 158\n Creatinine\n 0.8\n 0.8\n 0.8\n TCO2\n 35\n 34\n 34\n 38\n 37\n 35\n 35\n Glucose\n 125\n 128\n 141\n 107\n 131\n 115\n Other labs: PT / PTT / INR:13.9/26.9/1.2, CK / CK-MB / Troponin\n T:1334/13/<0.01, ALT / AST:90/88, Alk-Phos / T bili:63/6.8, Amylase /\n Lipase:44/, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic Acid:1.2\n mmol/L, Albumin:2.7 g/dL, LDH:348 IU/L, Ca:8.4 mg/dL, Mg:2.1 mg/dL,\n PO4:2.9 mg/dL\n Imaging: CT head OSH: Prelim No ICH or fx.\n CT chest OSH: Mult rib fx: R anterolateral and posterior, L\n posterior; Dependent consolidation, possible aspiration; T4 vertebral\n body inf corner fx, no retropulsion; Comminuted spinous process fx\n T2-8; Nondisplaced L T10 transverse process; Nondisplaced L clavicle\n distal fx; Nondisplaced L scapula fx;\n CT c spine OSH: Prelim No fx or malalignment. Multilevel\n degenerative changes w/large post disk bulge at C4-5, narrowing the\n spinal canal and deforming the thecal sac, acuity unknown. Marked\n neuroforamenal narrowing @multiple levels.\n CTA abd/pel Prelim: Medial R liver lobe contusion w/adj\n hematoma, w/o evidence of active bleeding; Comminuted L pubic ramus\n fracture w/assoc hematoma, with tiny focus of arterial bleeding/active\n extravasation, and larger area of venous bleeding. Hematoma somewhat\n larger than on OSH study. Nondisplaced, comminuted L iliac bone fx\n w/adj iliac muscle hematoma, larger than on prior study, w/o active\n extrav. Fx extends into L SIJ. Post R hepatic laceration/contusion\n adjacent to calcified granuloma, w/small hematoma, w/out active\n bleeding. Min displaced fx of R iliac bone extending to R SIJ.\n Cirrhotic liver. Inc B pl effusions (small), w/inc atelectasis.\n MRI: Mild compression deformity of L1 w/additional levels of\n potential trabecular contusion @T10-11 also inf @T4 w/o retropulsion.\n Multilevel degenerative changes with moderate canal narrowing at T10-11\n w/cord deformity and no abnormal cord signal. Extensive edema\n throughout paraspinal soft tissues, predominantly post w/in\n interspinous ligaments. Incompletely eval'ed c-spine w/severe canal\n narrowing @C4-5 w/cord deformity and no abnormal cord signal.\n CTA: no PE.\n CXR: Moderate bilateral pleural effusions are stable.\n CXR: Cardiac size top nl, interval improvement of collapse LLL.\n Collapse RLL. Atelectasis in lingula unchanged. Mod B\n pleural effusions stable. No PTX.\n CXR: Interval mild incr in cardiac size, b/l pleural effusions,\n and opacities @ bases,c/w overload\n : R foot: Linear density projecting @ expected area of insertion\n of the Achilles to calcaneus, may be min avulsion fx or degenerative\n changes. Otherwise no fx\n CXR: bilateral pleural effusions\n Microbiology: Ucx no growth final\n Sputum: sparse GNR\n Bcx P\n Bcx P\n 12/17 L BAL: KLEBSIELLA PNEUMONIAE, HAEMOPHILUS SPECIES NOT INFLUENZAE\n R BAL: KLEBSIELLA PNEUMONIAE & GNRs.\n 12/20 L BAL: gram + cocci pairs on gram stain\n R BAL: gram + cocci pairs on gram stain\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, AF with\n RVR, hematologic abnomalities.\n Neurologic: Intubated on Fentanyl/Versed gtt. Per ortho spine, no\n surgery; HOB<30, TLSO when OOB (NEOPS will place). Neuro checks q\n shift.\n Cardiovascular: Aflutter on Dilt 60mg PO QID. Still on Neo. Likely\n needs chemical/electrical cardioversion to improve atrial contribution\n to CO\n Pulmonary: Intubated. Weaning to extubate (was on throughout\n , changed to 10/10 after desat, but self-extubated and reintubated\n am). F/U on BAL: KLEBSIELLA PNEUMONIAE & GNRs/Haemophilus. Repeat\n BAL with gram+ cocci in pairs on gram stain. Ceftriaxone ()\n changed to Vancomycin/Zosyn (). Plan for Trach early this week.\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin with CT scan\n suggesting cirrhosis - Hepatitis panel NEG. TFs advancing to goal.\n Bowel regimen. Tbili trending up (6.8), other LFTs improving.\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO, Foley, monitor UOP. Cr normalized.\n Hematology: Hct and Plt stable; d/c'd H2B\n Endocrine: RISS\n Infectious Disease: WBC increasing to 13.1, f/u Cx - BAL: Klebsiella\n (b/l)& GNRs (on R)/Haemophilus (on L). Started Ceftriaxone (),\n broadened to Zosyn/Vanc () for continued fevers and gram+ on BAL\n Lines / Tubes / Drains: R SC CVL (), PIV x2, Foley, L a-line\n (), ETT\n Wounds:\n Imaging: CXR today\n Fluids: KVO\n Consults: Trauma surgery, Ortho, Ortho-spine, Heme\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 01:00 PM 80 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 04:41 PM\n Arterial Line - 11:30 AM\n Prophylaxis:\n DVT: (IVC filter, SCDs)\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n"
},
{
"category": "General",
"chartdate": "2175-01-30 00:00:00.000",
"description": "Generic Note",
"row_id": 714146,
"text": "TITLE:\n TSICU\n HPI:\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\n checked and 1.5, 1 more unit FFP given.\n Chief complaint:\n Mult rib fx: R anterolateral and post, L posterior\n T4 vert body inf corner fx\n Commin spinous process fx T2-8\n Nondisplaced L T10 transverse process\n Nondispaced L distal clavicle\n Nondisplaced L clavicle fx\n R medial lobe liver contusion w/hematoma\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny focus of arterial\n bleeding/active extravasation, and larger area of venous bleeding\n Nondisplaced, comminuted L iliac bone fx w/adjacent iliac muscle\n hematoma, extends into L SIJ.\n Minimally displaced fx of R iliac bone extending to R SIJ.\n PMHx:\n None\n Current medications:\n Chlorhexidine Gluconate 0.12% Oral Rinse\n Diltiazem\n Furosemide\n Gabapentin\n Metoprolol Tartrate\n Ondansetron\n Phenylephrine\n 24 Hour Events:\n Self-extubated in the AM, re-intubated over bougie, NGT replaced,\n bronch with bilateral BALs sent, plan for trach later this week. T\n spike to 101.8 - u/a, urine cx, blood cxs sent. Diltiazem titrated to\n 60mg PO QID. ABX coverage broadened to Vanc/Zosyn. Tbili up to 6.8\n (other LFTs trending down)\n Post operative day:\n POD#4 - IVC filter via L groin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 11:00 AM\n Piperacillin/Tazobactam (Zosyn) - 08:19 PM\n Vancomycin - 08:56 PM\n Infusions:\n Fentanyl (Concentrate) - 100 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Hydromorphone (Dilaudid) - 04:00 AM\n Metoprolol - 06:33 AM\n Pantoprazole (Protonix) - 02:00 PM\n Midazolam (Versed) - 12:30 AM\n Other medications:\n Flowsheet Data as of 02:07 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.8\nC (101.8\n T current: 37.2\nC (98.9\n HR: 76 (76 - 103) bpm\n BP: 97/51(67) {86/47(62) - 121/858(84)} mmHg\n RR: 18 (0 - 25) insp/min\n SPO2: 99%\n Heart rhythm: A Flut (Atrial Flutter)\n Wgt (current): 102 kg (admission): 90 kg\n CVP: 11 (6 - 18) mmHg\n Total In:\n 3,114 mL\n 207 mL\n PO:\n Tube feeding:\n 1,301 mL\n 148 mL\n IV Fluid:\n 1,682 mL\n 59 mL\n Blood products:\n Total out:\n 2,500 mL\n 180 mL\n Urine:\n 2,500 mL\n 180 mL\n NG:\n Stool:\n Drains:\n Balance:\n 614 mL\n 27 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 540 (540 - 540) mL\n PS : 5 cmH2O\n RR (Set): 15\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI: 34\n PIP: 26 cmH2O\n Plateau: 23 cmH2O\n Compliance: 42.3 cmH2O/mL\n SPO2: 99%\n ABG: 7.44/50/127/34/8\n Ve: 9.5 L/min\n PaO2 / FiO2: 254\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: Aflutter\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present,\n Stable scrotal edema/hematoma, soft, no crepitus\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: Follows simple commands, Moves all extremities, Sedated\n Labs / Radiology\n 158 K/uL\n 10.7 g/dL\n 115 mg/dL\n 0.8 mg/dL\n 34 mEq/L\n 4.0 mEq/L\n 20 mg/dL\n 111 mEq/L\n 148 mEq/L\n 31.6 %\n 13.1 K/uL\n [image002.jpg]\n 01:59 AM\n 02:00 AM\n 11:04 AM\n 01:17 PM\n 02:55 AM\n 04:11 AM\n 09:45 AM\n 04:45 PM\n 12:45 AM\n 01:00 AM\n WBC\n 5.6\n 6.5\n 13.1\n Hct\n 28.7\n 29.3\n 31.6\n Plt\n 74\n 86\n 158\n Creatinine\n 0.8\n 0.8\n 0.8\n TCO2\n 35\n 34\n 34\n 38\n 37\n 35\n 35\n Glucose\n 125\n 128\n 141\n 107\n 131\n 115\n Other labs: PT / PTT / INR:13.9/26.9/1.2, CK / CK-MB / Troponin\n T:1334/13/<0.01, ALT / AST:90/88, Alk-Phos / T bili:63/6.8, Amylase /\n Lipase:44/, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic Acid:1.2\n mmol/L, Albumin:2.7 g/dL, LDH:348 IU/L, Ca:8.4 mg/dL, Mg:2.1 mg/dL,\n PO4:2.9 mg/dL\n Imaging: CT head OSH: Prelim No ICH or fx.\n CT chest OSH: Mult rib fx: R anterolateral and posterior, L\n posterior; Dependent consolidation, possible aspiration; T4 vertebral\n body inf corner fx, no retropulsion; Comminuted spinous process fx\n T2-8; Nondisplaced L T10 transverse process; Nondisplaced L clavicle\n distal fx; Nondisplaced L scapula fx;\n CT c spine OSH: Prelim No fx or malalignment. Multilevel\n degenerative changes w/large post disk bulge at C4-5, narrowing the\n spinal canal and deforming the thecal sac, acuity unknown. Marked\n neuroforamenal narrowing @multiple levels.\n CTA abd/pel Prelim: Medial R liver lobe contusion w/adj\n hematoma, w/o evidence of active bleeding; Comminuted L pubic ramus\n fracture w/assoc hematoma, with tiny focus of arterial bleeding/active\n extravasation, and larger area of venous bleeding. Hematoma somewhat\n larger than on OSH study. Nondisplaced, comminuted L iliac bone fx\n w/adj iliac muscle hematoma, larger than on prior study, w/o active\n extrav. Fx extends into L SIJ. Post R hepatic laceration/contusion\n adjacent to calcified granuloma, w/small hematoma, w/out active\n bleeding. Min displaced fx of R iliac bone extending to R SIJ.\n Cirrhotic liver. Inc B pl effusions (small), w/inc atelectasis.\n MRI: Mild compression deformity of L1 w/additional levels of\n potential trabecular contusion @T10-11 also inf @T4 w/o retropulsion.\n Multilevel degenerative changes with moderate canal narrowing at T10-11\n w/cord deformity and no abnormal cord signal. Extensive edema\n throughout paraspinal soft tissues, predominantly post w/in\n interspinous ligaments. Incompletely eval'ed c-spine w/severe canal\n narrowing @C4-5 w/cord deformity and no abnormal cord signal.\n CTA: no PE.\n CXR: Moderate bilateral pleural effusions are stable.\n CXR: Cardiac size top nl, interval improvement of collapse LLL.\n Collapse RLL. Atelectasis in lingula unchanged. Mod B\n pleural effusions stable. No PTX.\n CXR: Interval mild incr in cardiac size, b/l pleural effusions,\n and opacities @ bases,c/w overload\n : R foot: Linear density projecting @ expected area of insertion\n of the Achilles to calcaneus, may be min avulsion fx or degenerative\n changes. Otherwise no fx\n CXR: bilateral pleural effusions\n Microbiology: Ucx no growth final\n Sputum: sparse GNR\n Bcx P\n Bcx P\n 12/17 L BAL: KLEBSIELLA PNEUMONIAE, HAEMOPHILUS SPECIES NOT INFLUENZAE\n R BAL: KLEBSIELLA PNEUMONIAE & GNRs.\n 12/20 L BAL: gram + cocci pairs on gram stain\n R BAL: gram + cocci pairs on gram stain\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, AF with\n RVR, hematologic abnomalities.\n Neurologic: Intubated on Fentanyl/Versed gtt. Per ortho spine, no\n surgery; HOB<30, TLSO when OOB (NEOPS will place). Neuro checks q\n shift.\n Cardiovascular: Aflutter on Dilt 60mg PO QID. Still on Neo (was off\n Neof or a time while in NSR). Likely needs chemical/electrical\n cardioversion to improve atrial contribution to CO. Repeat TTE today to\n evaluate function while in flutter.\n Pulmonary: Intubated. Weaning to extubate (was on throughout\n , changed to 10/10 after desat, but self-extubated and reintubated\n am). F/U on BAL: KLEBSIELLA PNEUMONIAE & GNRs/Haemophilus. Repeat\n BAL with gram+ cocci in pairs on gram stain. Ceftriaxone ()\n changed to Vancomycin/Zosyn (). Plan for Trach early this week.\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin with CT scan\n suggesting cirrhosis - Hepatitis panel NEG. TFs advancing to goal.\n Bowel regimen. Tbili trending up (6.8), other LFTs improving. Obtain\n RUQ U/S today to evaluate for acalculous cholecystitis as well as bile\n leak given recent trauma. Plan for PEG this week.\n Nutrition: Tube feeding at goal.\n Renal: Foley, Adequate UO, monitor UOP. Cr normalized.\n Hematology: Hct and Plt stable; d/c'd H2B. F/u Heme recs.\n Endocrine: RISS, goa,l BS<150, adequate control.\n Infectious Disease: WBC increasing to 13.1, f/u Cx - BAL: Klebsiella\n (b/l)& GNRs (on R)/Haemophilus (on L). Started Ceftriaxone (),\n broadened to Zosyn/Vanc () for continued fevers and gram+ on BAL.\n Will add cipor for additional antipseudomonal coverage if deteriorates\n clinically.\n Lines / Tubes / Drains: R SC CVL (), PIV x2, Foley, L a-line\n (), ETT\n Wounds:\n Imaging: CXR today\n Fluids: KVO\n Consults: Trauma surgery, Ortho, Ortho-spine, Heme\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 01:00 PM 80 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 04:41 PM\n Arterial Line - 11:30 AM\n Prophylaxis:\n DVT: (IVC filter, SCDs); start heparin sq\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 mins\n"
},
{
"category": "Physician ",
"chartdate": "2175-01-31 00:00:00.000",
"description": "Intensivist Note",
"row_id": 714239,
"text": "TSICU\n HPI:\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\n checked and 1.5, 1 more unit FFP given.\n Chief complaint:\n Mult rib fx: R anterolateral and post, L posterior\n T4 vert body inf corner fx\n Commin spinous process fx T2-8\n Nondisplaced L T10 transverse process\n Nondispaced L distal clavicle\n Nondisplaced L clavicle fx\n R medial lobe liver contusion w/hematoma\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny focus of arterial\n bleeding/active extravasation, and larger area of venous bleeding\n Nondisplaced, comminuted L iliac bone fx w/adjacent iliac muscle\n hematoma, extends into L SIJ.\n Minimally displaced fx of R iliac bone extending to R SIJ.\n PMHx:\n PMH: None\n PSH: None\n Current medications:\n 1. IV access: Peripheral line Order date: @ 2329 16. Ketamine\n Study Drug Study Med 1 dose IV AS SIR Duration: 24 Hours\n Patient to receive Ketamine/Placebo 0.25mg/kg bolus over 1 hour\n followed by 0.1mg/kg/hr for 23 hours Order date: @ 1338\n 2. Acetaminophen 650 mg PO/NG Q6H:PRN pain Order date: @ 2329\n 17. Lorazepam 2mg Syringe Study Med 1 mg IV Q6H Duration: 4 Doses\n Patient to receive Lorazepam 1mg iv every 6 hours for 4 doses while on\n ketamine study drug Order date: @ 1338\n 3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation Order date: @\n 0823 18. Magnesium Sulfate IV Sliding Scale Order date: @ 2339\n 4. Calcium Gluconate IV Sliding Scale Order date: @ 1657 19.\n Metoprolol Tartrate 5 mg IV Q4H:PRN hr>90, SBP>150\n hold hr<60, SBP<100 Order date: @ 1809\n 5. CeftriaXONE 1 gm IV Q24H Order date: @ 1228 20. Midazolam\n 0.5-1 mg IV Q2H:PRN sedation Order date: @ 0912\n 6. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL Order date:\n @ 2329 21. Midazolam 0.5-10 mg/hr IV DRIP TITRATE TO sedation\n Patient must have adequate airway support prior to administration of\n dose. Order date: @ 0734\n 7. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date: \n @ 0104 22. Ondansetron 4 mg IV Q8H:PRN nausea Order date: @ 2329\n 8. Diltiazem 60 mg PO/NG QID\n hold for HR < 60 or SBP < 100 Order date: @ 23.\n Pantoprazole 40 mg IV Q24H Order date: @ 1321\n 9. Docusate Sodium (Liquid) 100 mg PO/NG Order date: @ 2329\n 24. Phenylephrine 0.5-5 mcg/kg/min IV DRIP TITRATE TO SBP>90 MAP>60\n Order date: @ 2339\n 10. Fentanyl Citrate 25-100 mcg/hr IV DRIP INFUSION\n Please wean with Dilaudid dosing. Thank you. Order date: @ 1136\n 25. Pneumococcal Vac Polyvalent 0.5 ml IM ASDIR Order date: @\n 2316\n 11. Gabapentin 400 mg PO/NG TID Order date: @ 1210 26. Potassium\n Phosphate IV Sliding Scale\n Infuse over 6 hours Order date: @ 2339\n 12. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date:\n @ 0104 27. Potassium Chloride IV Sliding Scale Order date: \n @ 2339\n 13. HYDROmorphone (Dilaudid) 0.125-1 mg IV Q3H:PRN pain Order date:\n @ 0912 28. Senna 1 TAB PO/NG :PRN constipation Order date:\n @ 0823\n 14. Heparin 5000 UNIT SC TID Order date: @ 0931 29. Sodium\n Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ 2329\n 15. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 0104 30. Vancomycin 1000 mg IV\n Q 12H\n ID Approval will be required for this order in 39 hours. Order date:\n @ \n 24 Hour Events:\n Placed on ketamine for study. Continues to be in aflutter and on Neo,\n difficulties weaning, however when pt more awake (ie: turning), he is\n actually HTN. TTE done showing mild TR. RUQ U/S showing mild\n perihepatic fluid collection too small to be drained.\n Post operative day:\n POD#5 - IVC filter via L groin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\n Ceftriaxone - 12:00 PM\n Vancomycin - 08:36 PM\n Infusions:\n Fentanyl (Concentrate) - 100 mcg/hour\n Ketamine - 0.1 mcg/Kg/min\n Phenylephrine - 1.2 mcg/Kg/min\n Midazolam (Versed) - 0.5 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 02:00 PM\n Heparin Sodium (Prophylaxis) - 08:29 PM\n Midazolam (Versed) - 01:15 AM\n Fentanyl - 01:20 AM\n Lorazepam (Ativan) - 02:09 AM\n Other medications:\n Flowsheet Data as of 04:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.2\nC (100.7\n T current: 37.9\nC (100.3\n HR: 78 (75 - 91) bpm\n BP: 103/51(69) {89/48(62) - 152/66(94)} mmHg\n RR: 28 (16 - 29) insp/min\n SPO2: 98%\n Heart rhythm: A Flut (Atrial Flutter)\n Wgt (current): 102 kg (admission): 90 kg\n CVP: 11 (9 - 17) mmHg\n Total In:\n 3,764 mL\n 418 mL\n PO:\n Tube feeding:\n 1,920 mL\n 255 mL\n IV Fluid:\n 1,384 mL\n 163 mL\n Blood products:\n Total out:\n 1,535 mL\n 245 mL\n Urine:\n 1,530 mL\n 245 mL\n NG:\n 5 mL\n Stool:\n Drains:\n Balance:\n 2,229 mL\n 173 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 431 (399 - 596) mL\n PS : 10 cmH2O\n RR (Spontaneous): 25\n PEEP: 10 cmH2O\n FiO2: 50%\n PIP: 20 cmH2O\n SPO2: 98%\n ABG: 7.41/56/91./32/8\n Ve: 11.7 L/min\n PaO2 / FiO2: 184\n Physical Examination\n General Appearance: Overweight / Obese\n Cardiovascular: (Rhythm: No(t) Regular, Irregular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: No(t)\n Crackles : , Rhonchorous : bilaterally)\n Abdominal: Soft, Obese, right flank, right pelvis, and scrotum\n eechymotic\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Skin: right flank, right pelvis, and scrotum eechymotic\n Neurologic: Sedated\n Labs / Radiology\n 153 K/uL\n 10.7 g/dL\n 117 mg/dL\n 0.7 mg/dL\n 32 mEq/L\n 3.9 mEq/L\n 22 mg/dL\n 106 mEq/L\n 143 mEq/L\n 32.1 %\n 8.8 K/uL\n [image002.jpg]\n 02:55 AM\n 04:11 AM\n 09:45 AM\n 04:45 PM\n 12:45 AM\n 01:00 AM\n 05:12 AM\n 02:40 PM\n 01:46 AM\n 01:55 AM\n WBC\n 6.5\n 13.1\n 8.8\n Hct\n 29.3\n 31.6\n 32.1\n Plt\n 86\n 158\n 153\n Creatinine\n 0.8\n 0.8\n 0.7\n 0.7\n TCO2\n 38\n 37\n 35\n 35\n 34\n 37\n Glucose\n 141\n 107\n 131\n 115\n 132\n 122\n 117\n Other labs: PT / PTT / INR:13.7/27.6/1.2, CK / CK-MB / Troponin\n T:128/13/<0.01, ALT / AST:81/93, Alk-Phos / T bili:84/5.8, Amylase /\n Lipase:44/, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic Acid:1.4\n mmol/L, Albumin:2.7 g/dL, LDH:348 IU/L, Ca:8.0 mg/dL, Mg:2.0 mg/dL,\n PO4:3.3 mg/dL\n Imaging: CXR: Cardiac size top nl, interval improvement of\n collapse LLL. Collapse RLL. Atelectasis in lingula unchanged. Mod B\n pleural effusions stable. No PTX.\n CXR: Interval mild incr in cardiac size, b/l pleural effusions,\n and opacities @ bases,c/w overload\n : R foot: Linear density projecting @ expected area of insertion\n of the Achilles to calcaneus, may be min avulsion fx or degenerative\n changes. Otherwise no fx\n CXR: b/l pleural effusions\n CXR: stable.\n RUQ U/S: No perihepatic fluid collection. small amt perihepatic\n free fluid persists. Small contusion in hepatic segment VII. No\n gallstones or significant wall thickening/edema. CBD 4.5 mm\n TTE: LVEF >55%, normal diastolic function, normal left\n ventricular filling pressure (PCWP<12mmHg), Right ventricular chamber\n size is mildly dilated, mild TR\n Microbiology: Ucx no growth final\n Sputum: sparse GNRs, too few to colonize\n Bcx P\n Bcx P\n 12/17 L BAL: Klebsiella Pneumoniae, HAEMOPHILUS SPECIES NOT INFLUENZAE\n R BAL: Klebsiella Pneumoniae, Proteus.\n 12/20 L BAL: gram + cocci pairs on gram stain, GNRs (sparse) on cx\n R BAL: gram + cocci pairs on gram stain, GNRs (10-100K) on cx\n BCX: p\n BCx: P\n UCx: no growth final\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, now\n with AF with RVR/Aflutter, hypotension and presumed PNA.\n Neurologic: Intubated on Fentanyl/Versed gtt. Per ortho spine, no\n surgery; HOB<30, TLSO when OOB (NEOPS will place).\n Neuro checks Q: shift\n Pain: Fentanyl gtt (trying to wean), dilaudid, Midazolam gtt,\n Neurontin, Tylenol\n Cardiovascular: Aflutter on Dilt 60mg PO QID. Weaning Neo.\n Pulmonary: Intubated. Weaning to extubate. On appropriate abx per BAL\n cx -Vanco and Ceftriaxone. Will need Trach this week.\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin with CT scan\n suggesting cirrhosis - Hepatitis panel NEG. TFs advancing to goal.\n Bowel regimen.\n Nutrition: Tube feeding\n Renal: Foley, Foley, monitor UOP.\n Hematology: Hct stable. Plt low but stable (100's); d/c'd H2B with\n increasing plt count. Heme onc consulted - smear nl; no hemolysis. IVC\n filter placed.\n Endocrine: RISS\n Infectious Disease: Check cultures, WBC normal, f/u Cx - BAL:\n Klebsiella (b/l)& GNRs (on R)/Haemophilus (on L). Klebsiella\n Pneumoniae, Proteus/Haemophilus. Repeat BAL with gram+ cocci in\n pairs on gram stain, GNRs.\n Lines / Tubes / Drains: R SC CVL (), PIV x2, Foley, L a-line\n (), ETT\n Wounds:\n Imaging: CXR today\n Fluids: KVO\n Consults: Trauma (1o), Ortho Spine, Ortho trauma, Heme\n Billing Diagnosis: Multiple injuries (Trauma)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 04:41 PM\n Arterial Line - 11:30 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin, IVC filter\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent:\n"
},
{
"category": "Respiratory ",
"chartdate": "2175-02-01 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 714416,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 8\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Tube Type\n ETT:\n Position: 25 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 30 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Tracheostomy planned\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Underlying illness not resolved\n Comments: Pt. remains intubated on IPS overnoc. Plan trach today.\n"
},
{
"category": "Physician ",
"chartdate": "2175-02-03 00:00:00.000",
"description": "Intensivist Note",
"row_id": 714779,
"text": "TSICU\n HPI:\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\n checked and 1.5, 1 more unit FFP given.\n Chief complaint:\n PMHx:\n Current medications:\n Acetaminophen 4. Amiodarone 5. Bisacodyl 6. Calcium Gluconate 7.\n CefePIME 8. CefePIME\n 9. Chlorhexidine Gluconate 0.12% Oral Rinse 10. Ciprofloxacin HCl 11.\n Dextrose 50% 12. Docusate Sodium (Liquid)\n 13. Fentanyl Citrate 14. Furosemide 15. Furosemide 16. Furosemide 17.\n Gabapentin 18. Glucagon 19. Heparin\n 20. Insulin 21. Lactulose 22. Lansoprazole Oral Disintegrating Tab 23.\n Lorazepam 24. Magnesium Sulfate\n 25. Metoprolol Tartrate 26. Metoprolol Tartrate 27. Midazolam 28.\n Midazolam 29. Milk of Magnesia\n 30. Olanzapine (Disintegrating Tablet) 31. Ondansetron 32. OxycoDONE\n Liquid 33. Phenylephrine 34. Pneumococcal Vac Polyvalent\n 35. Potassium Phosphate 36. Potassium Chloride 37. Senna 38. Sodium\n Chloride 0.9% Flush 39. Sodium Chloride 0.9% Flush\n 40. Vancomycin 41. Vancomycin\n 24 Hour Events:\n EKG - At 09:07 PM\n FEVER - 101.1\nF - 12:00 AM\n : TFs increased. Lasix 10x3 with good result. Zyprexa for\n sedation, weaned off versed, fentanyl. Cards rec 400'' x 1wk, then\n 400'x1 wk, then 200'. also rec changing dilt to metop 25''.\n Vanc/cipro/cefepime for VAP.\n : pan cx for temp 101.1\n Post operative day:\n POD#8 - IVC filter via L groin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 03:00 PM\n Ciprofloxacin - 12:00 PM\n Vancomycin - 07:33 PM\n Cefipime - 11:15 PM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 02:00 PM\n Lorazepam (Ativan) - 11:41 PM\n Midazolam (Versed) - 02:16 AM\n Furosemide (Lasix) - 03:55 AM\n Heparin Sodium (Prophylaxis) - 04:02 AM\n Metoprolol - 06:27 AM\n Other medications:\n Flowsheet Data as of 08:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.4\nC (101.1\n T current: 37.7\nC (99.8\n HR: 97 (81 - 111) bpm\n BP: 160/81(110) {111/59(80) - 166/81(110)} mmHg\n RR: 30 (17 - 30) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 104.2 kg (admission): 90 kg\n CVP: 19 (12 - 26) mmHg\n Total In:\n 2,674 mL\n 727 mL\n PO:\n Tube feeding:\n 660 mL\n 637 mL\n IV Fluid:\n 895 mL\n 90 mL\n Blood products:\n Total out:\n 2,485 mL\n 1,055 mL\n Urine:\n 2,485 mL\n 1,055 mL\n NG:\n Stool:\n Drains:\n Balance:\n 189 mL\n -328 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 510 (502 - 660) mL\n PS : 12 cmH2O\n RR (Spontaneous): 28\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 28 cmH2O\n SPO2: 99%\n ABG: 7.50/43/150/31/9\n Ve: 11.8 L/min\n PaO2 / FiO2: 300\n Physical Examination\n General Appearance: Anxious, Well nourished\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: Crackles : , Rhonchorous : ,\n Diminished: )\n Abdominal: Soft, Distended\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities\n Labs / Radiology\n 128 K/uL\n 9.3 g/dL\n 138 mg/dL\n 0.8 mg/dL\n 31 mEq/L\n 3.8 mEq/L\n 23 mg/dL\n 105 mEq/L\n 142 mEq/L\n 28.9 %\n 6.3 K/uL\n [image002.jpg]\n 02:00 PM\n 05:04 PM\n 08:00 PM\n 09:20 PM\n 01:00 AM\n 01:07 AM\n 01:18 AM\n 02:05 AM\n 03:54 AM\n 05:17 AM\n WBC\n 5.9\n 6.3\n Hct\n 31.3\n 28.9\n Plt\n 109\n 128\n Creatinine\n 0.8\n 0.8\n TCO2\n 36\n 34\n 35\n 34\n 35\n Glucose\n 111\n 105\n 117\n 110\n 138\n Other labs: PT / PTT / INR:13.7/27.6/1.2, CK / CK-MB / Troponin\n T:128/13/<0.01, ALT / AST:90/122, Alk-Phos / T bili:133/5.4, Amylase /\n Lipase:54/52, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic\n Acid:1.4 mmol/L, Albumin:2.3 g/dL, LDH:348 IU/L, Ca:8.0 mg/dL, Mg:2.2\n mg/dL, PO4:2.8 mg/dL\n Imaging: CT head OSH: Prelim No ICH or fx.\n CT chest OSH: Mult rib fx: R anterolateral and posterior, L\n posterior; Dependent consolidation, possible aspiration; T4 vertebral\n body inf corner fx, no retropulsion; Comminuted spinous process fx\n T2-8; Nondisplaced L T10 transverse process; Nondisplaced L clavicle\n distal fx; Nondisplaced L scapula fx;\n CT c spine OSH: Prelim No fx or malalignment. Multilevel\n degenerative changes w/large post disk bulge at C4-5, narrowing the\n spinal canal and deforming the thecal sac, acuity unknown. Marked\n neuroforamenal narrowing @multiple levels.\n CTA abd/pel Prelim: Medial R liver lobe contusion w/adj\n hematoma, w/o evidence of active bleeding; Comminuted L pubic ramus\n fracture w/assoc hematoma, with tiny focus of arterial bleeding/active\n extravasation, and larger area of venous bleeding. Hematoma somewhat\n larger than on OSH study. Nondisplaced, comminuted L iliac bone fx\n w/adj iliac muscle hematoma, larger than on prior study, w/o active\n extrav. Fx extends into L SIJ. Post R hepatic laceration/contusion\n adjacent to calcified granuloma, w/small hematoma, w/out active\n bleeding. Min displaced fx of R iliac bone extending to R SIJ.\n Cirrhotic liver. Inc B pl effusions (small), w/inc atelectasis.\n MRI: Mild compression deformity of L1 w/additional levels of\n potential trabecular contusion @T10-11 also inf @T4 w/o retropulsion.\n Multilevel degenerative changes w/moderate canal narrowing @T10-11\n w/cord deformity & no abnl cord signal. Extensive edema throughout\n paraspinal soft tissues, predominantly post w/in interspinous\n ligaments. Incompletely eval'ed c-spine w/severe canal narrowing @C4-5\n w/cord deformity and no abn cord signal.\n CTA: no PE.\n CXR: Moderate b/l pleural effusions are stable.\n CXR: Cardiac size top nl, interval improvement of collapse LLL.\n Collapse RLL. Atelectasis in lingula unchanged. Mod B pleural effusions\n stable. No PTX.\n CXR: Interval mild incr in cardiac size, b/l pl effusions,\n & opacities @ bases,c/w overload\n : R foot: Linear density projecting @ expected area of insertion\n of Achilles to calcaneus, may be min avulsion fx or degenerative\n changes. Otherwise no fx\n CXR: b/l pl effusions\n CXR: stable.\n RUQ U/S: No perihepatic fluid collection. small amt perihepatic\n free fluid persists. Small contusion in hepatic segment VII. No\n gallstones or sig wall thickening/edema. CBD 4.5 mm\n TTE: LVEF >55%, NL diastolic function, NL LV filling pressure\n (PCWP<12mmHg), RV chamber size mildly dilated, mild TR\n CXR: mild b/l pulm edema and parenchymal opacities and no\n pl effusion.\n CXR: Persistent b/l pl effusions and bibasilar opacity.\n CXR: Minimal improvement of mod b/l pl effusions. Otherwise\n stable.\n Microbiology: Ucx no growth final\n Sputum: sparse GNRs, too few to colonize\n Bcx x2 no growth final\n 12/17 L BAL: Klebsiella Pneumoniae, HAEMOPHILUS SPECIES NOT INFLUENZAE\n R BAL: Klebsiella Pneumoniae, Proteus.\n 12/20 L &R BAL: Klebsiella Pneumoniae\n BCX: p\n BCx: P\n UCx: no growth final\n BCx: P\n BCx: P\n UCx: P\n SpCx: P\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, now\n with AF with RVR/Aflutter, persistant hypotension and PNA.\n Neurologic: s/p trach (). Per ortho spine, no surgery; HOB<30,\n TLSO when OOB. Zyprexa & Ativan PRN (off fent/midaz ).\n Neuro checks Q: shift\n Pain: Oxycodone, Neurontin, Tylenol.\n Cardiovascular: Aflutter, now reverted to sinus w/1st deg AVB. Likely\n cardiac contusion. Cards rec 400'' x 1wk, then 400'x1 wk, then\n 200'. also rec changing dilt to metop 25''. Pt cannot be fully\n anticoagulated for now (trauma). Will concentrate meds.\n Pulmonary: Intubated, weaning, Vanc/cipro/cefepime for VAP ().\n Increasing pulmonary edema on CXR (lasix x 2 on , lasix x1 ).\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin (declining 6.8\n max ->5.0) w/CT scan suggesting cirrhosis - Hepatitis panel NEG. TFs\n restarted, increasing to goal . Bowel regimen. Will concentrate\n TFs or change to a different type.\n Nutrition: Tube feeding\n Renal: Foley, monitor UOP, edematous scrotum. Lasix 10 x2 on ,\n lasix x1 . Lasix 20 x1 , if tolerates 20 Q6.\n Hematology: Hct stable 32.1->29.7. Plt stable (100's); d/c'd H2B. Heme\n onc c/s - smear nl; no hemolysis. IVC filter placed.\n Endocrine: RISS\n Infectious Disease: Check cultures, WBC droppping\n 13.1->8.8->4.2->5.9->6.3, Vanc/cipro/cefepime for VAP given worsening\n pulm status. B/l LENIS to r/o DVT as source. Fever 101.1 o/n, re-pan\n cx.\n Lines / Tubes / Drains: Trach/Peg/foley/L radial a-line/R SCL\n Wounds:\n Imaging: CXR today\n Fluids: KVO\n Consults: Trauma (1o), Ortho Spine, Ortho trauma, Heme\n Billing Diagnosis: (Respiratory distress: Failure), (Shock: Traumatic),\n Multiple injuries (Trauma)\n ICU Care\n Nutrition: Replete with Fiber (Full) - 04:12 AM 80 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 04:41 PM\n Arterial Line - 11:30 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting planning, ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 33 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2175-02-03 00:00:00.000",
"description": "Intensivist Note",
"row_id": 714794,
"text": "TSICU\n HPI:\n 74M s/p fall with multiple rib fx, pelvis fx, clavicle fx, and thoracic\n fx c/b unstable bleeding s/p IR embo, now with AF with RVR/Aflutter,\n persistant hypotension and presumed PNA.\n Chief complaint:\n fall\n PMHx:\n none\n Current medications:\n 1. Acetaminophen 2. Amiodarone 3. Bisacodyl 4. Calcium Gluconate 5.\n CeftriaXONE 6. Chlorhexidine Gluconate 0.12% Oral Rinse 7. Dextrose 50%\n 8. Diltiazem 9. Docusate Sodium (Liquid) 10. Fentanyl Citrate 11.\n Gabapentin 12. Glucagon 13. Heparin 14. Insulin 15. Lactulose 16.\n Magnesium Sulfate 17. Metoprolol Tartrate 18. Midazolam 19. Midazolam\n 20. Milk of Magnesia 21. Ondansetron 22. OxycoDONE Liquid 23.\n Pantoprazole 24. Phenylephrine\n 25. Pneumococcal Vac Polyvalent 26. Potassium Phosphate 27. Potassium\n Chloride 28. Senna 29. Sodium Chloride 0.9% Flush\n 24 Hour Events:\n Changed sedation to po Oxycodone, wean fentanyl gtt, wean Midazolam,\n and start Haldol prn, but stopped due to QTc. Cards consult, started\n amiodarone.\n Post operative day:\n POD#6 - IVC filter via L groin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\n Vancomycin - 08:00 AM\n Ceftriaxone - 12:00 PM\n Infusions:\n Midazolam (Versed) - 5 mg/hour\n Fentanyl (Concentrate) - 50 mcg/hour\n Amiodarone - 0.5 mg/min\n Other ICU medications:\n Haloperidol (Haldol) - 10:45 AM\n Lorazepam (Ativan) - 02:00 PM\n Midazolam (Versed) - 03:25 AM\n Fentanyl - 03:25 AM\n Heparin Sodium (Prophylaxis) - 05:33 AM\n Other medications:\n Flowsheet Data as of 06:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.1\nC (100.6\n T current: 37.2\nC (98.9\n HR: 76 (74 - 104) bpm\n BP: 125/62(81) {90/49(62) - 152/67(89)} mmHg\n RR: 25 (18 - 31) insp/min\n SPO2: 98%\n Heart rhythm: A Flut (Atrial Flutter)\n Wgt (current): 102 kg (admission): 90 kg\n CVP: 12 (10 - 19) mmHg\n Total In:\n 3,718 mL\n 759 mL\n PO:\n Tube feeding:\n 1,920 mL\n 424 mL\n IV Fluid:\n 1,078 mL\n 245 mL\n Blood products:\n Total out:\n 1,755 mL\n 350 mL\n Urine:\n 1,755 mL\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,963 mL\n 409 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 480 (400 - 540) mL\n PS : 10 cmH2O\n RR (Spontaneous): 29\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 21 cmH2O\n SPO2: 98%\n ABG: 7.44/45/119/31/6\n Ve: 11.8 L/min\n PaO2 / FiO2: 238\n Physical Examination\n General Appearance: No acute distress, intubated\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), shallow respirations\n Abdominal: Soft, No(t) Non-distended, Bowel sounds present, Distended\n Left Extremities: (Edema: 1+), (Temperature: Warm)\n Right Extremities: (Edema: 1+), (Temperature: Warm)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities, Sedated\n Labs / Radiology\n 104 K/uL\n 9.5 g/dL\n 129 mg/dL\n 0.7 mg/dL\n 31 mEq/L\n 4.2 mEq/L\n 24 mg/dL\n 106 mEq/L\n 142 mEq/L\n 29.7 %\n 4.2 K/uL\n [image002.jpg]\n 04:45 PM\n 12:45 AM\n 01:00 AM\n 05:12 AM\n 02:40 PM\n 01:46 AM\n 01:55 AM\n 03:40 PM\n 12:07 AM\n 02:18 AM\n WBC\n 13.1\n 8.8\n 4.2\n Hct\n 31.6\n 32.1\n 29.7\n Plt\n 158\n 153\n 104\n Creatinine\n 0.8\n 0.7\n 0.7\n 0.7\n TCO2\n 35\n 35\n 34\n 37\n 35\n 32\n Glucose\n 131\n 115\n 132\n 122\n 117\n 129\n Other labs:\n PT / PTT / INR:13.7/27.6/1.2, CK / CK-MB / Troponin T:128/13/<0.01,\n ALT / AST:87/109, Alk-Phos / T bili:115/5.0, Amylase / Lipase:44/,\n D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic Acid:1.4 mmol/L,\n Albumin:2.7 g/dL, LDH:348 IU/L, Ca:7.9 mg/dL, Mg:2.0 mg/dL, PO4:3.4\n mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, now\n with AF with RVR/Aflutter, persistant hypotension and presumed PNA.\n Neurologic: Intubated. Per ortho spine, no surgery; HOB<30, TLSO when\n OOB (NEOPS will place). Wean sedation as may be causing hypotension.\n Change pain meds to PO. Wean versed.\n Neuro checks Q: shift\n Pain: Oxycodone, Fentanyl gtt (weaning), Midazolam gtt (weaning),\n Neurontin, Tylenol\n Cardiovascular: Aflutter on Dilt 60mg PO QID. Neo off since this AM.\n Cards yesterday rec Amiodarone. Pressor requirements may be related to\n AFib/flutter. No plan for electrical cardioversion right now. As pt\n cannot be anticoagulated (recent major trauma), had TTE w/o thrombus,\n Cards would like anticoagulation, will hold on heparin per Trauma\n surgery.\n Pulmonary: Intubated, weaning, tachypneic likely abd distension. On\n appropriate abx per BAL cx\n Ceftriaxone. Plan for trach today.\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin (declining 6.8\n max\n 5.0) with CT scan suggesting cirrhosis - Hepatitis panel NEG. TFs\n on hold for PEG. Bowel regimen, no BM since admission MOM and Lactulose\n added, will try Methylnaltrexone.\n Nutrition: NPO pre-op.\n Renal: Foley, monitor UOP, edematous scrotum but soft, eccymosis\n improving.\n Hematology: Hct stable 32.1->29.7. Plt low but stable (100's); d/c'd\n H2B with increasing plt count. Heme onc consulted - smear nl; no\n hemolysis. IVC filter placed.\n Endocrine: RISS, goal BS<150, adequate control.\n Infectious Disease: WBC dropping 13.1->8.8->4.2, f/u Cx - BAL:\n Klebsiella\n Ceftriaxone. Will add Vanco back for GPCs coverage if\n patient worsens.\n Lines / Tubes / Drains: R SC CVL (), Foley, L a-line (), ETT\n Imaging: CXR today\n Fluids: KVO\n Consults: Trauma (1o), Ortho Spine, Ortho trauma, Heme\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 04:41 PM\n Arterial Line - 11:30 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin, IVC filter\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 33 min\n"
},
{
"category": "Physician ",
"chartdate": "2175-02-03 00:00:00.000",
"description": "Intensivist Note",
"row_id": 714795,
"text": "TSICU\n HPI:\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\n checked and 1.5, 1 more unit FFP given.\n .\n Injuries\n Mult rib fx: R anterolateral and post, L posterior\n T4 vert body inf corner fx\n Commin spinous process fx T2-8\n Nondisplaced L T10 transverse process\n Nondispaced L distal clavicle\n Nondisplaced L clavicle fx\n R medial lobe liver contusion w/hematoma\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny focus of arterial\n bleeding/active extravasation, and larger area of venous bleeding\n Nondisplaced, comminuted L iliac bone fx w/adjacent iliac muscle\n hematoma, extends into L SIJ.\n Minimally displaced fx of R iliac bone extending to R SIJ.\n Chief complaint:\n Trauma\n PMHx:\n PMH: None\n PSH: None\n : None\n Current medications:\n 24 Hour Events:\n Trach/PEG. Pt's BP dropped to 80/40 off pressors, sats 88. restarted\n neo. Overnight, pt reverted to sinus, off pressors, weaning sedation.\n PERCUTANEOUS TRACHEOSTOMY - At 12:00 PM\n PEG INSERTION - At 12:00 PM\n Post operative day:\n POD#7 - IVC filter via L groin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\n Vancomycin - 08:00 AM\n Ceftriaxone - 03:00 PM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Amiodarone - 0.5 mg/min\n Fentanyl (Concentrate) - 50 mcg/hour\n Other ICU medications:\n Fentanyl - 01:23 PM\n Pantoprazole (Protonix) - 02:00 PM\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Other medications:\n Flowsheet Data as of 04:33 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.7\nC (99.9\n T current: 37.1\nC (98.8\n HR: 94 (68 - 101) bpm\n BP: 140/66(91) {89/46(63) - 154/68(94)} mmHg\n RR: 26 (11 - 30) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 102 kg (admission): 90 kg\n CVP: 9 (6 - 16) mmHg\n Total In:\n 1,764 mL\n 142 mL\n PO:\n Tube feeding:\n 424 mL\n IV Fluid:\n 1,000 mL\n 82 mL\n Blood products:\n Total out:\n 1,630 mL\n 290 mL\n Urine:\n 1,630 mL\n 290 mL\n NG:\n Stool:\n Drains:\n Balance:\n 134 mL\n -148 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 483 (404 - 506) mL\n PS : 15 cmH2O\n RR (Spontaneous): 16\n PEEP: 10 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10\n PIP: 25 cmH2O\n SPO2: 98%\n ABG: 7.45/49/98./31/8\n Ve: 8.5 L/min\n PaO2 / FiO2: 163\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: Crackles : )\n Abdominal: Soft\n Left Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present)\n Right Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present)\n Neurologic: Follows simple commands, Moves all extremities, Sedated\n Labs / Radiology\n 109 K/uL\n 10.2 g/dL\n 110 mg/dL\n 0.8 mg/dL\n 31 mEq/L\n 4.5 mEq/L\n 24 mg/dL\n 105 mEq/L\n 144 mEq/L\n 31.3 %\n 5.9 K/uL\n [image002.jpg]\n 12:07 AM\n 02:18 AM\n 08:00 AM\n 02:00 PM\n 05:04 PM\n 08:00 PM\n 09:20 PM\n 01:00 AM\n 01:07 AM\n 01:18 AM\n WBC\n 4.2\n 5.9\n Hct\n 29.7\n 31.3\n Plt\n 104\n 109\n Creatinine\n 0.7\n 0.8\n TCO2\n 32\n 36\n 34\n 35\n Glucose\n 129\n 100\n 111\n 105\n 117\n 110\n Other labs: PT / PTT / INR:13.7/27.6/1.2, CK / CK-MB / Troponin\n T:128/13/<0.01, ALT / AST:90/113, Alk-Phos / T bili:99/5.1, Amylase /\n Lipase:58/39, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic\n Acid:1.4 mmol/L, Albumin:2.3 g/dL, LDH:348 IU/L, Ca:8.1 mg/dL, Mg:2.1\n mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, now\n with AF with RVR/Aflutter, persistant hypotension and PNA.\n Neurologic: s/p trach. Per ortho spine, no surgery; HOB<30, TLSO when\n OOB (NEOPS will place). Wean sedation as may be causing hypotension.\n Change pain meds to PO. Will try Geodon today for agitation.\n Neuro checks Q: shift\n Pain: Oxycodone, Neurontin, Tylenol. Wean fentanyl gtt, midazolam\n gtt\n Cardiovascular: Aflutter, now reverted to sinus. Likely cardiac\n contusion. On Dilt 60mg PO QID. Cards rec amio gtt. Neo off. Pt cannot\n be fully anticoagulated for now (trauma). Start PO amio.\n Pulmonary: Intubated, weaning, tachypneic likely abd distension. On\n appropriate abx per BAL cx - Ceftriaxone. Now that pulm status is\n worsening, will broaden coverage with V/C/C.\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin (declining 6.8\n max ->5.0) w/CT scan suggesting cirrhosis - Hepatitis panel NEG. TFs.\n Bowel regimen.\n Nutrition: TF\n Renal: Foley, monitor UOP, edematous scrotum. Diurese with lasix 10mg\n IV. Goal 1 L negative today.\n Hematology: Hct stable 32.1->29.7. Plt stable (100's); d/c'd H2B with\n increasing plt count. Heme onc c/s - smear nl; no hemolysis. IVC\n filter placed.\n Endocrine: RISS, goal BS<150.\n Infectious Disease: WBC dropping 13.1->8.8->4.2, f/u Cx - BAL:\n pan-sensitive Klebsiella\n broaden coverage for VAP.\n Lines / Tubes / Drains: R SC CVL (), Foley, L a-line (),\n trach/PEG\n Wounds: SCDs, IVC filter, SQH\n Imaging:\n Fluids:\n Consults: Trauma surgery\n Billing Diagnosis: Multiple injuries (Trauma)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 04:41 PM\n Arterial Line - 11:30 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 32 min\n"
},
{
"category": "Physician ",
"chartdate": "2175-02-03 00:00:00.000",
"description": "Intensivist Note",
"row_id": 714796,
"text": "TSICU\n HPI:\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\n checked and 1.5, 1 more unit FFP given.\n Chief complaint:\n PMHx:\n Current medications:\n Acetaminophen 4. Amiodarone 5. Bisacodyl 6. Calcium Gluconate 7.\n CefePIME 8. CefePIME\n 9. Chlorhexidine Gluconate 0.12% Oral Rinse 10. Ciprofloxacin HCl 11.\n Dextrose 50% 12. Docusate Sodium (Liquid)\n 13. Fentanyl Citrate 14. Furosemide 15. Furosemide 16. Furosemide 17.\n Gabapentin 18. Glucagon 19. Heparin\n 20. Insulin 21. Lactulose 22. Lansoprazole Oral Disintegrating Tab 23.\n Lorazepam 24. Magnesium Sulfate\n 25. Metoprolol Tartrate 26. Metoprolol Tartrate 27. Midazolam 28.\n Midazolam 29. Milk of Magnesia\n 30. Olanzapine (Disintegrating Tablet) 31. Ondansetron 32. OxycoDONE\n Liquid 33. Phenylephrine 34. Pneumococcal Vac Polyvalent\n 35. Potassium Phosphate 36. Potassium Chloride 37. Senna 38. Sodium\n Chloride 0.9% Flush 39. Sodium Chloride 0.9% Flush\n 40. Vancomycin 41. Vancomycin\n 24 Hour Events:\n EKG - At 09:07 PM\n FEVER - 101.1\nF - 12:00 AM\n : TFs increased. Lasix 10x3 with good result. Zyprexa for\n sedation, weaned off versed, fentanyl. Cards rec 400'' x 1wk, then\n 400'x1 wk, then 200'. also rec changing dilt to metop 25''.\n Vanc/cipro/cefepime for VAP.\n : pan cx for temp 101.1\n Post operative day:\n POD#8 - IVC filter via L groin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 03:00 PM\n Ciprofloxacin - 12:00 PM\n Vancomycin - 07:33 PM\n Cefipime - 11:15 PM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 02:00 PM\n Lorazepam (Ativan) - 11:41 PM\n Midazolam (Versed) - 02:16 AM\n Furosemide (Lasix) - 03:55 AM\n Heparin Sodium (Prophylaxis) - 04:02 AM\n Metoprolol - 06:27 AM\n Other medications:\n Flowsheet Data as of 08:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.4\nC (101.1\n T current: 37.7\nC (99.8\n HR: 97 (81 - 111) bpm\n BP: 160/81(110) {111/59(80) - 166/81(110)} mmHg\n RR: 30 (17 - 30) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 104.2 kg (admission): 90 kg\n CVP: 19 (12 - 26) mmHg\n Total In:\n 2,674 mL\n 727 mL\n PO:\n Tube feeding:\n 660 mL\n 637 mL\n IV Fluid:\n 895 mL\n 90 mL\n Blood products:\n Total out:\n 2,485 mL\n 1,055 mL\n Urine:\n 2,485 mL\n 1,055 mL\n NG:\n Stool:\n Drains:\n Balance:\n 189 mL\n -328 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 510 (502 - 660) mL\n PS : 12 cmH2O\n RR (Spontaneous): 28\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 28 cmH2O\n SPO2: 99%\n ABG: 7.50/43/150/31/9\n Ve: 11.8 L/min\n PaO2 / FiO2: 300\n Physical Examination\n General Appearance: Anxious, Well nourished\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: Crackles : , Rhonchorous : ,\n Diminished: )\n Abdominal: Soft, Distended\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities\n Labs / Radiology\n 128 K/uL\n 9.3 g/dL\n 138 mg/dL\n 0.8 mg/dL\n 31 mEq/L\n 3.8 mEq/L\n 23 mg/dL\n 105 mEq/L\n 142 mEq/L\n 28.9 %\n 6.3 K/uL\n 02:00 PM\n 05:04 PM\n 08:00 PM\n 09:20 PM\n 01:00 AM\n 01:07 AM\n 01:18 AM\n 02:05 AM\n 03:54 AM\n 05:17 AM\n WBC\n 5.9\n 6.3\n Hct\n 31.3\n 28.9\n Plt\n 109\n 128\n Creatinine\n 0.8\n 0.8\n TCO2\n 36\n 34\n 35\n 34\n 35\n Glucose\n 111\n 105\n 117\n 110\n 138\n Other labs: PT / PTT / INR:13.7/27.6/1.2, CK / CK-MB / Troponin\n T:128/13/<0.01, ALT / AST:90/122, Alk-Phos / T bili:133/5.4, Amylase /\n Lipase:54/52, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic\n Acid:1.4 mmol/L, Albumin:2.3 g/dL, LDH:348 IU/L, Ca:8.0 mg/dL, Mg:2.2\n mg/dL, PO4:2.8 mg/dL\n Imaging: CT head OSH: Prelim No ICH or fx.\n CT chest OSH: Mult rib fx: R anterolateral and posterior, L\n posterior; Dependent consolidation, possible aspiration; T4 vertebral\n body inf corner fx, no retropulsion; Comminuted spinous process fx\n T2-8; Nondisplaced L T10 transverse process; Nondisplaced L clavicle\n distal fx; Nondisplaced L scapula fx;\n CT c spine OSH: Prelim No fx or malalignment. Multilevel\n degenerative changes w/large post disk bulge at C4-5, narrowing the\n spinal canal and deforming the thecal sac, acuity unknown. Marked\n neuroforamenal narrowing @multiple levels.\n CTA abd/pel Prelim: Medial R liver lobe contusion w/adj\n hematoma, w/o evidence of active bleeding; Comminuted L pubic ramus\n fracture w/assoc hematoma, with tiny focus of arterial bleeding/active\n extravasation, and larger area of venous bleeding. Hematoma somewhat\n larger than on OSH study. Nondisplaced, comminuted L iliac bone fx\n w/adj iliac muscle hematoma, larger than on prior study, w/o active\n extrav. Fx extends into L SIJ. Post R hepatic laceration/contusion\n adjacent to calcified granuloma, w/small hematoma, w/out active\n bleeding. Min displaced fx of R iliac bone extending to R SIJ.\n Cirrhotic liver. Inc B pl effusions (small), w/inc atelectasis.\n MRI: Mild compression deformity of L1 w/additional levels of\n potential trabecular contusion @T10-11 also inf @T4 w/o retropulsion.\n Multilevel degenerative changes w/moderate canal narrowing @T10-11\n w/cord deformity & no abnl cord signal. Extensive edema throughout\n paraspinal soft tissues, predominantly post w/in interspinous\n ligaments. Incompletely eval'ed c-spine w/severe canal narrowing @C4-5\n w/cord deformity and no abn cord signal.\n CTA: no PE.\n CXR: Moderate b/l pleural effusions are stable.\n CXR: Cardiac size top nl, interval improvement of collapse LLL.\n Collapse RLL. Atelectasis in lingula unchanged. Mod B pleural effusions\n stable. No PTX.\n CXR: Interval mild incr in cardiac size, b/l pl effusions,\n & opacities @ bases,c/w overload\n : R foot: Linear density projecting @ expected area of insertion\n of Achilles to calcaneus, may be min avulsion fx or degenerative\n changes. Otherwise no fx\n CXR: b/l pl effusions\n CXR: stable.\n RUQ U/S: No perihepatic fluid collection. small amt perihepatic\n free fluid persists. Small contusion in hepatic segment VII. No\n gallstones or sig wall thickening/edema. CBD 4.5 mm\n TTE: LVEF >55%, NL diastolic function, NL LV filling pressure\n (PCWP<12mmHg), RV chamber size mildly dilated, mild TR\n CXR: mild b/l pulm edema and parenchymal opacities and no\n pl effusion.\n CXR: Persistent b/l pl effusions and bibasilar opacity.\n CXR: Minimal improvement of mod b/l pl effusions. Otherwise\n stable.\n Microbiology: Ucx no growth final\n Sputum: sparse GNRs, too few to colonize\n Bcx x2 no growth final\n 12/17 L BAL: Klebsiella Pneumoniae, HAEMOPHILUS SPECIES NOT INFLUENZAE\n R BAL: Klebsiella Pneumoniae, Proteus.\n 12/20 L &R BAL: Klebsiella Pneumoniae\n BCX: p\n BCx: P\n UCx: no growth final\n BCx: P\n BCx: P\n UCx: P\n SpCx: P\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, now\n with AF with RVR/Aflutter, persistant hypotension and PNA.\n Neurologic: s/p trach (). Per ortho spine, no surgery; HOB<30,\n TLSO when OOB. Zyprexa & Ativan PRN (off fent/midaz ).\n Neuro checks Q: shift\n Pain: Oxycodone, Neurontin, Tylenol.\n Cardiovascular: Aflutter, now reverted to sinus w/1st deg AVB. Likely\n cardiac contusion. Cards rec 400'' x 1wk, then 400'x1 wk, then\n 200'. also rec changing dilt to metop 25''. Pt cannot be fully\n anticoagulated for now (trauma). Will concentrate meds.\n Pulmonary: Intubated, weaning, Vanc/cipro/cefepime for VAP ().\n Increasing pulmonary edema on CXR (lasix x 2 on , lasix x1\n ).\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin (declining 6.8\n max ->5.0) w/CT scan suggesting cirrhosis - Hepatitis panel NEG. TFs\n restarted, increasing to goal . Bowel regimen. Will concentrate\n TFs or change to a different type.\n Nutrition: Tube feeding\n Renal: Foley, monitor UOP, edematous scrotum. Lasix 10 x2 on ,\n lasix x1 . Lasix 20 x1 , if tolerates 20 Q6.\n Hematology: Hct stable 32.1->29.7. Plt stable (100's); d/c'd H2B. Heme\n onc c/s - smear nl; no hemolysis. IVC filter placed.\n Endocrine: RISS\n Infectious Disease: Check cultures, WBC droppping\n 13.1->8.8->4.2->5.9->6.3, Vanc/cipro/cefepime for VAP given worsening\n pulm status. B/l LENIS to r/o DVT as source. Fever 101.1 o/n, re-pan\n cx.\n Lines / Tubes / Drains: Trach/Peg/foley/L radial a-line/R SCL\n Wounds:\n Imaging: CXR today\n Fluids: KVO\n Consults: Trauma (1o), Ortho Spine, Ortho trauma, Heme\n Billing Diagnosis: (Respiratory distress: Failure), (Shock: Traumatic),\n Multiple injuries (Trauma)\n ICU Care\n Nutrition: Replete with Fiber (Full) - 04:12 AM 80 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 04:41 PM\n Arterial Line - 11:30 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting planning, ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 33 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2175-02-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 715198,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Trached. Vent settings as charted in metavision. LS rhonchorous at\n times. Sats WNL. Afebrile. WBC count trending down.\n Action:\n Pulmonary hygiene. Cefepime, cipro, and vanco administered as\n ordered. Vent weaned to . ABG drawn. Diamox administered as\n ordered.\n Response:\n Moderate amounts of thick, tan secretions. ABG WNL. Diamox to\n continue for two more doses. Diuresing well, -3L for yesterday\n ().\n Plan:\n ? trach mask today. Begin rehab screening. Administer abx as\n ordered. Monitor I/O\n IV access: PICC placed on currently midline, NOT central.\n Patient did not want IV team to change it; patient preferred them to\n come later today (). HO aware. Discontinue subclavian line once\n PICC placement is confirmed.\n"
},
{
"category": "Nursing",
"chartdate": "2175-01-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 714237,
"text": "Hypotension (not Shock)\n Assessment:\n Cont in aflutter with controlled rate. SBP remains > 90 on neo gtt.\n Gd csm. Adequate u/o.\n Action:\n Neo gtt titrated to support sbp. Remains on dilt 60mg po qid.\n Response:\n Stable sbp on neo gtt. Remains in aflutter of diltiazem. Lytes wnl.\n Stable hct.\n Plan:\n Cont to monitor hemodynamics and titrate neo to SBP >90. Monitor u/o,\n lytes.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains on psv 10/10peep w/ no change in abg\ns. Stable 02sats. Sxned\n for moderate amt thick yellow and white secretions. LS clear,\n diminished. SRR 20\ns. Poor toleration of ett. Pt cont on midaz and\n Fentanyl and is now on ketamine for a study protocol w/ ATC ativan x4\n doses. Midaz briefly weaned off and pt lightened enough to open eyes\n and follow simple commands and then became increasingly agitated and\n unable to focus.\n Attempting to bite ETT and tongue out ETT. Unable to ventilate at that\n time.\n Action:\n Resedated and maintained sedated for safety overnoc. Pulm toilet.\n Response:\n More heavily sedated until ativan wore off. Sedation adjusted\n accordingly. Cont to open eyes and MAE but agitated when light and\n airway at risk. Stable on present vent settings.\n Plan:\n Cont pulm toilet. Monitor 02sats and abg\ns. Cont sedation for airway\n protection. Possibility of Trach to be discussed with family.\n"
},
{
"category": "Nursing",
"chartdate": "2175-02-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 715192,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Trached. Vent settings as charted in metavision. LS rhonchorous at\n times. Sats WNL. Afebrile. WBC count trending down.\n Action:\n Pulmonary hygiene. Cefepime, cipro, and vanco administered as\n ordered. Vent weaned to . ABG drawn. Diamox given.\n Response:\n Moderate amounts of thick, tan secretions. ABG WNL. Diamox to\n continue for two more doses. Diuresing well, -3L for yesterday\n ().\n Plan:\n ? trach mask today. Begin rehab screening. Administer abx as ordered.\n IV access: PICC placed on currently midline, NOT central.\n Patient did not want IV team to change it; patient preferred them to\n come later today (). HO aware. Discontinue subclavian line once\n PICC placement is confirmed.\n"
},
{
"category": "Respiratory ",
"chartdate": "2175-02-07 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 715347,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 14\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Tube Type\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 8.0mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 27 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: pt continues to require frequent suctioning\n Assessment of breathing comfort: No claim of dyspnea)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: attempt to wean off vent to trach collar as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Underlying illness not resolved\n"
},
{
"category": "Physician ",
"chartdate": "2175-02-06 00:00:00.000",
"description": "Intensivist Note",
"row_id": 715177,
"text": "TSICU\n HPI:\n 74M s/p fall from tractor and crush injury from tree branch. +Loc.\n Chief complaint:\n ventilator dependance\n PMHx:\n PMH: cirrhosis and asbestosis dx on CT\n Current medications:\n Acetaminophen 4. AcetaZOLamide 5. Amiodarone 6. Bisacodyl 7. Calcium\n Gluconate 8. CefePIME\n 9. Chlorhexidine Gluconate 0.12% Oral Rinse 10. Ciprofloxacin HCl 11.\n Dextrose 50% 12. Diltiazem\n 13. Docusate Sodium (Liquid) 14. Furosemide 15. Furosemide 16.\n Gabapentin 17. Glucagon 18. Heparin\n 19. Heparin Flush (10 units/ml) 20. 21. Insulin 22. Lactulose 23.\n Lansoprazole Oral Disintegrating Tab\n 24. Magnesium Sulfate 25. Metoprolol Tartrate 26. Milk of Magnesia 27.\n Olanzapine (Disintegrating Tablet)\n 28. Ondansetron 29. OxycoDONE Liquid 30. Pneumococcal Vac Polyvalent\n 31. Potassium Phosphate 32. Potassium Chloride\n 33. Senna 34. Sodium Chloride 0.9% Flush 35. Sodium Chloride 0.9% Flush\n 36. Vancomycin\n 24 Hour Events:\n : Diamox continued. Lasix 20x2 with good result. PICC. Diamox decr\n w/iatrogenic hyperchloremia, hypernatremia.\n Post operative day:\n POD#11 - IVC filter via L groin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 07:41 PM\n Ciprofloxacin - 09:44 PM\n Cefipime - 12:13 AM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 02:24 PM\n Furosemide (Lasix) - 05:14 PM\n Heparin Sodium (Prophylaxis) - 07:35 PM\n Other medications:\n Flowsheet Data as of 03:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.3\nC (99.2\n T current: 37.1\nC (98.7\n HR: 77 (73 - 98) bpm\n BP: 103/42(60) {86/40(55) - 152/70(97)} mmHg\n RR: 29 (20 - 34) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 104.2 kg (admission): 90 kg\n Total In:\n 2,020 mL\n 451 mL\n PO:\n Tube feeding:\n 960 mL\n 152 mL\n IV Fluid:\n 470 mL\n 119 mL\n Blood products:\n Total out:\n 5,030 mL\n 470 mL\n Urine:\n 5,030 mL\n 470 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,010 mL\n -19 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 442 (421 - 612) mL\n PS : 5 cmH2O\n RR (Spontaneous): 29\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 65\n PIP: 16 cmH2O\n SPO2: 98%\n ABG: 7.40/32/123/21/-3\n Ve: 13.5 L/min\n PaO2 / FiO2: 308\n Physical Examination\n General Appearance: No acute distress, Anxious at times\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n bibasilar, occasional, Diminished: bibasilar), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Obese\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities\n Labs / Radiology\n 196 K/uL\n 8.9 g/dL\n 122 mg/dL\n 1.1 mg/dL\n 21 mEq/L\n 3.6 mEq/L\n 25 mg/dL\n 117 mEq/L\n 144 mEq/L\n 28.2 %\n 4.6 K/uL\n [image002.jpg]\n 06:07 PM\n 01:55 AM\n 02:04 AM\n 08:00 AM\n 11:35 AM\n 03:56 PM\n 05:09 PM\n 08:00 PM\n 01:36 AM\n 02:16 AM\n WBC\n 5.2\n 4.6\n Hct\n 28.4\n 28.2\n Plt\n 178\n 196\n Creatinine\n 1.0\n 1.0\n 1.1\n TCO2\n 29\n 25\n 25\n 26\n 21\n Glucose\n 119\n 108\n 120\n 120\n 138\n 122\n Other labs: PT / PTT / INR:14.0/28.1/1.2, CK / CK-MB / Troponin\n T:128/13/<0.01, ALT / AST:104/137, Alk-Phos / T bili:204/4.8, Amylase /\n Lipase:54/52, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic\n Acid:1.1 mmol/L, Albumin:2.3 g/dL, LDH:348 IU/L, Ca:8.1 mg/dL, Mg:2.4\n mg/dL, PO4:3.5 mg/dL\n Imaging: CT head OSH: Prelim No ICH or fx.\n CT chest OSH: Mult rib fx: R anterolateral and posterior, L\n posterior; Dependent consolidation, possible aspiration; T4 vertebral\n body inf corner fx, no retropulsion; Comminuted spinous process fx\n T2-8; Nondisplaced L T10 transverse process; Nondisplaced L clavicle\n distal fx; Nondisplaced L scapula fx;\n CT c spine OSH: Prelim No fx or malalignment. Multilevel\n degenerative changes w/large post disk bulge at C4-5, narrowing the\n spinal canal and deforming the thecal sac, acuity unknown. Marked\n neuroforamenal narrowing @multiple levels.\n CTA abd/pel Prelim: Medial R liver lobe contusion w/adj\n hematoma, w/o evidence of active bleeding; Comminuted L pubic ramus\n fracture w/assoc hematoma, with tiny focus of arterial bleeding/active\n extravasation, and larger area of venous bleeding. Hematoma somewhat\n larger than on OSH study. Nondisplaced, comminuted L iliac bone fx\n w/adj iliac muscle hematoma, larger than on prior study, w/o active\n extrav. Fx extends into L SIJ. Post R hepatic laceration/contusion\n adjacent to calcified granuloma, w/small hematoma, w/out active\n bleeding. Min displaced fx of R iliac bone extending to R SIJ.\n Cirrhotic liver. Inc B pl effusions (small), w/inc atelectasis.\n MRI: Mild compression deformity of L1 w/additional levels of\n potential trabecular contusion @T10-11 also inf @T4 w/o retropulsion.\n Multilevel degenerative changes w/moderate canal narrowing @T10-11\n w/cord deformity & no abnl cord signal. Extensive edema throughout\n paraspinal soft tissues, predominantly post w/in interspinous\n ligaments. Incompletely eval'ed c-spine w/severe canal narrowing @C4-5\n w/cord deformity and no abn cord signal.\n CTA: no PE.\n CXR: Moderate b/l pleural effusions are stable.\n CXR: Cardiac size top nl, interval improvement of collapse LLL.\n Collapse RLL. Atelectasis in lingula unchanged. Mod B pleural effusions\n stable. No PTX.\n CXR: Interval mild incr in cardiac size, b/l pl effusions,\n & opacities @ bases,c/w overload\n : R foot: Linear density projecting @ expected area of insertion\n of Achilles to calcaneus, may be min avulsion fx or degenerative\n changes. Otherwise no fx\n CXR: b/l pl effusions\n CXR: stable.\n RUQ U/S: No perihepatic fluid collection. small amt perihepatic\n free fluid persists. Small contusion in hepatic segment VII. No\n gallstones or sig wall thickening/edema. CBD 4.5 mm\n TTE: LVEF >55%, NL diastolic function, NL LV filling pressure\n (PCWP<12mmHg), RV chamber size mildly dilated, mild TR\n CXR: mild b/l pulm edema and parenchymal opacities and no\n pl effusion.\n CXR: Persistent b/l pl effusions and bibasilar opacity.\n CXR: Minimal improvement of mod b/l pl effusions. Otherwise\n stable.\n CXR: no relevant change. B/L pleural effusions with basal\n opacities. No evidence of newly appeared focal parenchymal opacities\n suggesting pneumonia.\n : No dvt\n CXR: No change, B pleural effusions, no new infiltrates\n CXR: stable\n Microbiology: Ucx neg\n Sputum: sparse GNRs, too few to colonize\n Bcx x2 neg\n 12/17 L BAL: Klebsiella Pneumoniae, HAEMOPHILUS SPECIES NOT INFLUENZAE\n R BAL: Klebsiella Pneumoniae, Proteus.\n 12/20 L &R BAL: Klebsiella Pneumoniae\n BCX: neg\n BCx: neg\n UCx: neg\n BCx: P\n BCx: P\n UCx: neg\n SpCx: contamination\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, AF with\n RVR/Aflutter, now in sinus, and PNA, s/p trach/PEG (), IVC filter\n Neurologic: HOB<30, TLSO when OOB. Zyprexa 10'''\n Neuro checks Q: shift\n Pain: Oxycodone, Neurontin, Tylenol. Pain adequately controlled.\n Cardiovascular: Aflutter->NSR, on Amio and diltizem 60 QID. Likely \n cardiac contusion. Cards for Amio rec 400'' x 1wk, then 400'x1 wk, then\n 200'. Pt cannot be fully anticoagulated for now (trauma).\n Pulmonary: Trach, weaning vent ( currently), Vanc/cipro/cefepime for\n VAP (). Improving pulmonary edema. Continued diuresis.\n Gastrointestinal / Abdomen: Unknown elevated LFTs and bilirubin w/CT\n scan suggesting cirrhosis - Hepatitis panel NEG, RUQ U/S r/o\n gallbladder etiology, will continue to trend. Nutren 2.0 @ goal 40\n cc/hr. Bowel regimen.\n Nutrition: Tube feeding\n Renal: Foley, monitor UOP, edematous scrotum. Diamox 250 q12 for\n contraction alkalosis. Lasix 20x2 on . Hypernatremia,\n hyperchloremia.\n Hematology: Hct stable (28.2). Plt stable (178-196); d/c'd H2B. Heme\n onc c/s - smear nl; no hemolysis. IVC filter.\n Endocrine: RISS\n Infectious Disease: WBC normal, on Vanc/cipro/cefepime for VAP given\n worsening pulm status, f/u on cx\n Lines / Tubes / Drains: Trach/Peg/foley/L radial a-line/L basilic PICC,\n SCL (will d/c SCL once midline)\n Wounds:\n Imaging: CXR today\n Fluids: KVO\n Consults: Trauma (1o), Ortho Spine, Ortho trauma, Heme\n Billing Diagnosis: (Shock: Unspecified), Multiple injuries (Trauma)\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 07:46 PM 40 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 04:41 PM\n Arterial Line - 11:30 AM\n PICC Line - 06:02 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin, IVC filter\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 33 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2175-02-06 00:00:00.000",
"description": "Intensivist Note",
"row_id": 715182,
"text": "TSICU\n HPI:\n 74M s/p fall from bed/standing? tx from osh () with\n acetabular fracture. On w/u in ER, pt found to be increasingly\n tachycardic with abdominal distention and hypotension; found to have\n acetabular fracture, iliac crest fracture, increasing pelvic and\n retroperitoneal hematomas. Coffee ground emesis x1 in ED.\n Chief complaint:\n pain\n PMHx:\n PMH: PVD, emphysema/COPD, dementia, seizure d/o, HTN, anemia, ?aortic\n dissection in past; pureed food diet with honey thick liquids\n PSH: s/p fem-fem bypass, c1-c2 fusion\n Current medications:\n 1000 mL NS 3. Acetaminophen 4. Albuterol 0.083% Neb Soln 5. Bisacodyl\n 6. Calcium Gluconate\n 7. Citalopram Hydrobromide 8. Clozapine 9. Clozapine 10. Dextrose 50%\n 11. Docusate Sodium 12. Glucagon\n 13. HYDROmorphone (Dilaudid) 14. Heparin 15. Insulin 16. Ipratropium\n Bromide Neb 17. LeVETiracetam\n 18. Magnesium Sulfate 19. Magnesium Sulfate 20. Metoprolol Tartrate 21.\n Metoprolol Tartrate 22. Metoprolol Tartrate\n 23. Metoprolol Tartrate 24. Multiple Vitamins Liq. 25. Olanzapine\n (Disintegrating Tablet) 26. Ondansetron\n 27. OxycoDONE (Immediate Release) 28. Pantoprazole 29. Pneumococcal Vac\n Polyvalent 30. Potassium Chloride\n 31. Potassium Chloride 32. Senna 33. Sodium Phosphate 34. Sodium\n Chloride 0.9% Flush\n 24 Hour Events:\n : Persistent tachycardia. Metop inc to 37.5''-->50. Metop 5-10 mg\n IV PRN hr>110 (ST w/PACs, PVCs), 2 mg Mg. SQH started. Chest PT, nebs.\n NPO p MN for ORIF.\n Post operative day:\n POD#11 - IVC filter via L groin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 07:41 PM\n Ciprofloxacin - 09:44 PM\n Cefipime - 12:13 AM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 02:24 PM\n Furosemide (Lasix) - 05:14 PM\n Heparin Sodium (Prophylaxis) - 03:52 AM\n Other medications:\n Flowsheet Data as of 04:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.3\nC (99.2\n T current: 37.1\nC (98.7\n HR: 77 (73 - 98) bpm\n BP: 103/42(60) {86/40(55) - 152/70(97)} mmHg\n RR: 29 (20 - 34) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 104.2 kg (admission): 90 kg\n Total In:\n 2,020 mL\n 456 mL\n PO:\n Tube feeding:\n 960 mL\n 157 mL\n IV Fluid:\n 470 mL\n 120 mL\n Blood products:\n Total out:\n 5,030 mL\n 470 mL\n Urine:\n 5,030 mL\n 470 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,010 mL\n -14 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 442 (421 - 612) mL\n PS : 5 cmH2O\n RR (Spontaneous): 29\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 65\n PIP: 16 cmH2O\n SPO2: 98%\n ABG: 7.40/32/123/21/-3\n Ve: 13.5 L/min\n PaO2 / FiO2: 308\n Physical Examination\n General Appearance: No acute distress, confused at times\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: No(t)\n Resonant : ), (Breath Sounds: Rhonchorous : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 1), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 196 K/uL\n 8.9 g/dL\n 122 mg/dL\n 1.1 mg/dL\n 21 mEq/L\n 3.6 mEq/L\n 25 mg/dL\n 117 mEq/L\n 144 mEq/L\n 28.2 %\n 4.6 K/uL\n [image002.jpg]\n 06:07 PM\n 01:55 AM\n 02:04 AM\n 08:00 AM\n 11:35 AM\n 03:56 PM\n 05:09 PM\n 08:00 PM\n 01:36 AM\n 02:16 AM\n WBC\n 5.2\n 4.6\n Hct\n 28.4\n 28.2\n Plt\n 178\n 196\n Creatinine\n 1.0\n 1.0\n 1.1\n TCO2\n 29\n 25\n 25\n 26\n 21\n Glucose\n 119\n 108\n 120\n 120\n 138\n 122\n Other labs: PT / PTT / INR:14.0/28.1/1.2, CK / CK-MB / Troponin\n T:128/13/<0.01, ALT / AST:104/137, Alk-Phos / T bili:204/4.8, Amylase /\n Lipase:54/52, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic\n Acid:1.1 mmol/L, Albumin:2.3 g/dL, LDH:348 IU/L, Ca:8.1 mg/dL, Mg:2.4\n mg/dL, PO4:3.5 mg/dL\n Imaging: CT c-spine: s/p post c1-c2 fusion. metallic nail\n through L lat C2 extends w/tip in retropharnyngeal/prevertebral jxn\n soft tissues ant to C1. mild anterolisthesis of C4 over C5. very min\n retrolisthesis C5 over C6. mult-level change. no acute fx seen.\n pulmonary emphysema. coarse vertebral and carotid artery calcs. 6mm R\n thyroid lobe hypodensity.\n CT torso: 1.6 x 1.2 cm focal hypodensity in ant mediastinum\n (S2:im15). ?focal hematoma vs thymic cystic lesion. No overlying\n sternal fx or aortic injury. dense aortic calcs. LLL atelect/scarring.\n comminuted, intra-art L acetabular fx involv ant &post columns and ext\n to L sup pubic ramus. adj mod pelvic hematoma w/out active extrav.\n hematoma crosses midline, extends superiorly ant to L psoas muscle and\n iliacus. mild loss of ht of L2 & L3 vert bodies. Grade 1\n spondylolisthesis L5/S1. bladder diverticula .\n CT head: No acute ICH. opacification of inf L maxillary\n sinus w/focal loss of ant inf L max sinus/ant L alveolar bone, adj soft\n tissue swelling and foci of gas. ?infectious process involving L\n alveolar process of maxilla, dental in nature vs chronic sinusitis vs\n injury. recommend direct visualization.\n CXR: No consolidation\n CXR (pm): Increased lung volumes c/w emphysema. Peribronchial\n cuffing and predominantly R-sided interstitial opacities likely fluid\n overload. Subtle opacity @R apex ?superimposition of external\n ventilator apparatus vs. consolidation.\n Microbiology: SCx: contaminated\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, AF with\n RVR/Aflutter, now in sinus, and PNA, s/p trach/PEG (), IVC filter.\n Neurologic: HOB<30, TLSO when OOB. Zyprexa 10'''\n Neuro checks Q: shift\n Pain: Oxycodone, Neurontin, Tylenol. Pain adequately controlled.\n Cardiovascular: Aflutter->NSR, on Amio and diltizem 60 QID. Likely \n cardiac contusion. Cards for Amio rec 400'' x 1wk, then 400'x1 wk, then\n 200'. Pt cannot be fully anticoagulated for now (trauma).\n Pulmonary: Trach, weaning vent ( currently), Vanc/cipro/cefepime for\n VAP (). Improving pulmonary edema. Continued diuresis.\n Gastrointestinal / Abdomen: Unknown elevated LFTs and bilirubin w/CT\n scan suggesting cirrhosis - Hepatitis panel NEG, RUQ U/S r/o\n gallbladder etiology, will continue to trend. Nutren 2.0 @ goal 40\n cc/hr. Bowel regimen.\n RENAL: Foley, monitor UOP, edematous scrotum. Diamox 250 q12 for\n contraction alkalosis. Lasix 20x2 on . Hypernatremia,\n hyperchloremia.\n Nutrition: Tube feeding\n Renal: Foley\n Hematology: Hct stable (28.2). Plt stable (178-196); d/c'd H2B. Heme\n onc c/s - smear nl; no hemolysis. IVC filter.\n Endocrine: RISS\n Infectious Disease: Check cultures, WBC normal (4.6), on\n Vanc/cipro/cefepime for VAP given worsening pulm status, f/u on cx\n Lines / Tubes / Drains: Trach/Peg/foley/L radial a-line/L basilic PICC,\n SCL (will d/c SCL once midline)\n Wounds:\n Imaging: CXR today\n Fluids: KVO\n Consults: Trauma (1o), Ortho Spine, Ortho trauma, Heme\n Billing Diagnosis: (Shock: Unspecified), Multiple injuries (Trauma)\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 07:46 PM 40 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 04:41 PM\n Arterial Line - 11:30 AM\n PICC Line - 06:02 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin, IVC filter\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting planning, ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 33 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2175-02-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 715190,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Trached. Vent settings as charted in metavision. LS rhonchorous at\n times. Sats WNL. Afebrile. WBC count trending down.\n Action:\n Pulmonary hygiene. Cefepime, cipro, and vanco administered as\n ordered. Vent weaned to . ABG drawn.\n Response:\n Moderate amounts of thick, tan secretions. ABG WNL.\n Plan:\n ? trach mask today. Begin rehab screening. Administer abx as ordered.\n IV access: PICC placed on currently midline, NOT central.\n Patient did not want IV team to change it; patient preferred them to\n come later today (). HO aware. Discontinue subclavian line once\n PICC placement is confirmed.\n"
},
{
"category": "Nursing",
"chartdate": "2175-02-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 715281,
"text": "74M s/p crushing injury d/t falling tree. Injuries sustained include\n multiple R sided rib fxs, grade 2 liver lac (w/ assoc hepatic vessel\n extravasation), stable pelvis fxs (w/ associated extravasation), R\n ramus fx, clavicle fx, and T4 vertebral body fx. Episodes of A.\n Flutter with RVR and aflutter, now with resp failure and newly dx\n pneumonia as of .\n intubated for resp distress\n angio embolization of hepatic and pelvic arterial bleeders\n IVC filter in OR\n self extubated and re-intubated immediately after d/t acute resp.\n failure\n Trach and PEG at bedside\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Respiratory ",
"chartdate": "2175-02-06 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 715187,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 13\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Tube Type\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 8.0mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 26 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: wean off ventilator to trach mask as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Underlying illness not resolved\n"
},
{
"category": "Respiratory ",
"chartdate": "2175-02-05 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 715129,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 12\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason:\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: pt weaned to PSV 10/5 tolerated well\n Assessment of breathing comfort: No claim of dyspnea)\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: plan to continue to wean toward TM as tolerated\n"
},
{
"category": "Nursing",
"chartdate": "2175-02-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 715332,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains on psv 10, 5peep and 40% with stable abg and 02sats. Remains\n tachypneic, 30\ns but denies distress. LS w/ rhonci throughout.\n Copious thick yellow secretions. Strong productive cough but cannot\n clear.\n Action:\n Pulm toilet, Frequent suctioning required.\n Response:\n Stable on psv 10/5 but cont with copious secretions despite frequent\n sxning.\n Plan:\n Will attempt psv 5 in am and recheck ABG. Not ready for TM due to\n copious secretions and tachpynea. Cont w/ oob to chair as tolerated.\n Cont pulm toilet.\n"
},
{
"category": "Respiratory ",
"chartdate": "2175-02-05 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 715024,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 12\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Tube Type\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 8.0mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated, Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Underlying illness not resolved\n"
},
{
"category": "Nursing",
"chartdate": "2175-02-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 715171,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Trached. Vent settings as charted in metavision. LS rhonchorous at\n times. Sats WNL. Afebrile. WBC count trending down.\n Action:\n Pulmonary hygiene. Cefepime, cipro, and vanco administered as\n ordered. ABG drawn.\n Response:\n Plan:\n Continue to wean vent settings. ? trach mask today. Begin rehab\n screening. Administer abx as ordered.\n IV access: PICC placed on currently midline, NOT central.\n Patient did not want IV team to change it; patient preferred them to\n come later today (). HO aware. Discontinue subclavian line once\n PICC placement is confirmed.\n"
},
{
"category": "Physician ",
"chartdate": "2175-02-07 00:00:00.000",
"description": "Intensivist Note",
"row_id": 715325,
"text": "TSICU\n HPI:\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\n checked and 1.5, 1 more unit FFP given\n Chief complaint:\n Mult rib fx: R anterolateral and post, L posterior\n T4 vert body inf corner fx\n Commin spinous process fx T2-8\n Nondisplaced L T10 transverse process\n Nondispaced L distal clavicle\n Nondisplaced L clavicle fx\n R medial lobe liver contusion w/hematoma\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny focus of arterial\n bleeding/active extravasation, and larger area of venous bleeding\n Nondisplaced, comminuted L iliac bone fx w/adjacent iliac muscle\n hematoma, extends into L SIJ.\n Minimally displaced fx of R iliac bone extending to R SIJ.\n PMHx:\n cirrhosis and asbestosis dx on CT\n Current medications:\n Acetaminophen\n Amiodarone\n Bisacodyl\n Chlorhexidine Gluconate 0.12% Oral Rinse\n Diltiazem\n Docusate Sodium (Liquid)\n Furosemide\n Gabapentin\n Lansoprazole Oral Disintegrating Tab\n Metoprolol Tartrate\n Milk of Magnesia\n Olanzapine (Disintegrating Tablet)\n Ondansetron\n OxycoDONE Liquid\n 24 Hour Events:\n MIDLINE - START 11:37 AM\n Post operative day:\n POD#12 - IVC filter via L groin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 07:41 PM\n Ciprofloxacin - 09:44 PM\n Cefipime - 12:31 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:04 PM\n Other medications:\n Flowsheet Data as of 03:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.1\nC (100.6\n T current: 37.6\nC (99.6\n HR: 70 (70 - 106) bpm\n BP: 92/42(58) {87/42(57) - 158/70(98)} mmHg\n RR: 27 (22 - 38) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 96 kg (admission): 90 kg\n Total In:\n 1,686 mL\n 134 mL\n PO:\n Tube feeding:\n 854 mL\n 134 mL\n IV Fluid:\n 202 mL\n Blood products:\n Total out:\n 2,930 mL\n 280 mL\n Urine:\n 2,930 mL\n 280 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,244 mL\n -145 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 417 (413 - 534) mL\n PS : 10 cmH2O\n RR (Spontaneous): 33\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 16 cmH2O\n SPO2: 99%\n ABG: 7.42/35/85./22/0\n Ve: 15 L/min\n PaO2 / FiO2: 213\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : Bilateral)\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 201 K/uL\n 8.6 g/dL\n 112 mg/dL\n 1.1 mg/dL\n 22 mEq/L\n 4.0 mEq/L\n 28 mg/dL\n 123 mEq/L\n 150 mEq/L\n 26.7 %\n 4.6 K/uL\n [image002.jpg]\n 03:56 PM\n 05:09 PM\n 08:00 PM\n 01:36 AM\n 02:16 AM\n 04:51 AM\n 08:00 AM\n 02:19 PM\n 07:31 PM\n 02:23 AM\n WBC\n 4.6\n 4.6\n 4.6\n Hct\n 28.2\n 28.2\n 26.7\n Plt\n 196\n 196\n 201\n Creatinine\n 1.0\n 1.1\n 1.1\n TCO2\n 26\n 21\n 22\n 23\n Glucose\n 120\n 138\n 122\n 169\n 112\n Other labs: PT / PTT / INR:14.0/28.1/1.2, CK / CK-MB / Troponin\n T:30/13/<0.01, ALT / AST:89/100, Alk-Phos / T bili:250/2.7, Amylase /\n Lipase:54/52, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic\n Acid:1.1 mmol/L, Albumin:2.3 g/dL, LDH:348 IU/L, Ca:7.7 mg/dL, Mg:2.4\n mg/dL, PO4:2.8 mg/dL\n Imaging: CXR: stable\n CXR: stable\n LUE U/S: neg\n Microbiology: Ucx neg\n Sputum: sparse GNRs, too few to colonize\n Bcx x2 neg\n 12/17 L BAL: Klebsiella Pneumoniae, HAEMOPHILUS SPECIES NOT INFLUENZAE\n R BAL: Klebsiella Pneumoniae, Proteus.\n 12/20 L &R BAL: Klebsiella Pneumoniae\n BCX: neg\n BCx: neg\n UCx: neg\n BCx: P\n BCx: P\n UCx: neg\n SpCx: contamination\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, AF with\n RVR/Aflutter, now in sinus, and PNA, s/p trach/PEG (), IVC filter.\n Neurologic: HOB<30, TLSO when OOB. Zyprexa '''\n Neuro checks Q shift\n Cardiovascular: Aflutter->NSR, on Amio and diltizem 60 QID. Likely \n cardiac contusion. Cards rec'd Amio 400'' x 1wk, then 400'x1 wk, then\n 200'. Pt cannot be fully anticoagulated for now (trauma).\n Will consider electrical cardioversion if goes back into Aflutter/AF\n and difficult to control.\n Pulmonary: Trach, weaning vent ( currently), continue TM trials,\n Cipro/cefepime for VAP () tx for 7 days. Vanc d/c().\n Continue diuresis.\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin w/CT scan\n suggesting cirrhosis - Hepatitis panel NEG, RUQ U/S neg for GB\n etiology, will continue to trend. Nutren 2.0 @ goal 40 cc/hr. Bowel\n regimen.\n Nutrition: Tube feeding\n Renal: Foley, monitor UOP, edematous scrotum. Goal 1-1.5 L neg.\n Hypernatremic to 150, approx. free H20 deficit 3.2L, treating with D5W\n @150cc/hr, will check Na Q6.\n Hematology: Hct stable. Plt stable (178-196); d/c'd H2B. Heme onc c/s\n - smear nl; no hemolysis. IVC filter.\n Endocrine: RISS\n Infectious Disease: WBC normal, on cipro/cefepime for VAP () x 7\n days, Vanc .\n Lines / Tubes / Drains: Trach/PEG/foley/L radial a-line/L basilic\n Midline\n Wounds:\n Imaging: CXR today\n Fluids: KVO\n Consults: Trauma surgery, Ortho, Ortho-spine, Hem / Onc\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 03:41 PM 40 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 11:30 AM\n Midline - 11:37 AM\n Prophylaxis:\n DVT: SQ UF Heparin, IVC filter\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: Transfer to rehab / long term facility\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2175-02-07 00:00:00.000",
"description": "Intensivist Note",
"row_id": 715382,
"text": "TSICU\n HPI:\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\n checked and 1.5, 1 more unit FFP given\n Chief complaint:\n Mult rib fx: R anterolateral and post, L posterior\n T4 vert body inf corner fx\n Commin spinous process fx T2-8\n Nondisplaced L T10 transverse process\n Nondispaced L distal clavicle\n Nondisplaced L clavicle fx\n R medial lobe liver contusion w/hematoma\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny focus of arterial\n bleeding/active extravasation, and larger area of venous bleeding\n Nondisplaced, comminuted L iliac bone fx w/adjacent iliac muscle\n hematoma, extends into L SIJ.\n Minimally displaced fx of R iliac bone extending to R SIJ.\n PMHx:\n cirrhosis and asbestosis dx on CT\n Current medications:\n Acetaminophen\n Amiodarone\n Bisacodyl\n Chlorhexidine Gluconate 0.12% Oral Rinse\n Diltiazem\n Docusate Sodium (Liquid)\n Furosemide\n Gabapentin\n Lansoprazole Oral Disintegrating Tab\n Metoprolol Tartrate\n Milk of Magnesia\n Olanzapine (Disintegrating Tablet)\n Ondansetron\n OxycoDONE Liquid\n 24 Hour Events:\n MIDLINE - START 11:37 AM\n - U/S neg for DVT in UE. Diuresed 1.2 L. On free water for\n hypernatremia. Failed TM trial yesterday. Overnight on .\n Post operative day:\n POD#12 - IVC filter via L groin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 07:41 PM\n Ciprofloxacin - 09:44 PM\n Cefipime - 12:31 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:04 PM\n Other medications:\n Flowsheet Data as of 03:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.1\nC (100.6\n T current: 37.6\nC (99.6\n HR: 70 (70 - 106) bpm\n BP: 92/42(58) {87/42(57) - 158/70(98)} mmHg\n RR: 27 (22 - 38) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 96 kg (admission): 90 kg\n Total In:\n 1,686 mL\n 134 mL\n PO:\n Tube feeding:\n 854 mL\n 134 mL\n IV Fluid:\n 202 mL\n Blood products:\n Total out:\n 2,930 mL\n 280 mL\n Urine:\n 2,930 mL\n 280 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,244 mL\n -145 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 417 (413 - 534) mL\n PS : 10 cmH2O\n RR (Spontaneous): 33\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 16 cmH2O\n SPO2: 99%\n ABG: 7.42/35/85./22/0\n Ve: 15 L/min\n PaO2 / FiO2: 213\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : Bilateral)\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 201 K/uL\n 8.6 g/dL\n 112 mg/dL\n 1.1 mg/dL\n 22 mEq/L\n 4.0 mEq/L\n 28 mg/dL\n 123 mEq/L\n 150 mEq/L\n 26.7 %\n 4.6 K/uL\n [image002.jpg]\n 03:56 PM\n 05:09 PM\n 08:00 PM\n 01:36 AM\n 02:16 AM\n 04:51 AM\n 08:00 AM\n 02:19 PM\n 07:31 PM\n 02:23 AM\n WBC\n 4.6\n 4.6\n 4.6\n Hct\n 28.2\n 28.2\n 26.7\n Plt\n 196\n 196\n 201\n Creatinine\n 1.0\n 1.1\n 1.1\n TCO2\n 26\n 21\n 22\n 23\n Glucose\n 120\n 138\n 122\n 169\n 112\n Other labs: PT / PTT / INR:14.0/28.1/1.2, CK / CK-MB / Troponin\n T:30/13/<0.01, ALT / AST:89/100, Alk-Phos / T bili:250/2.7, Amylase /\n Lipase:54/52, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic\n Acid:1.1 mmol/L, Albumin:2.3 g/dL, LDH:348 IU/L, Ca:7.7 mg/dL, Mg:2.4\n mg/dL, PO4:2.8 mg/dL\n Imaging:\n CXR: stable\n CXR: stable\n LUE U/S: neg\n Microbiology: Ucx neg\n Sputum: sparse GNRs, too few to colonize\n Bcx x2 neg\n 12/17 L BAL: Klebsiella Pneumoniae, HAEMOPHILUS SPECIES NOT INFLUENZAE\n R BAL: Klebsiella Pneumoniae, Proteus.\n 12/20 L &R BAL: Klebsiella Pneumoniae\n BCX: neg\n BCx: neg\n UCx: neg\n BCx: P\n BCx: P\n UCx: neg\n SpCx: contamination\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, AF with\n RVR/Aflutter, now in sinus, and PNA, s/p trach/PEG (), IVC filter.\n Neurologic: HOB<30, TLSO when OOB. Zyprexa '''\n Neuro checks Q shift. Pain well-controlled on regimen.\n Cardiovascular: Aflutter->NSR, on Amio and diltizem 60 QID. Likely \n cardiac contusion. Cards rec'd Amio 400'' x 1wk, then 400'x1 wk, then\n 200'. Pt cannot be fully anticoagulated for now (trauma).\n Remains in sinus, continue meds.\n Pulmonary: Trach, weaning vent ( currently), continue TM trials,\n Cipro/cefepime for VAP () tx for 7 days. Vanc d/c().\n Continue diuresis as tolerated by hypernatremia.\n Gastrointestinal / Abdomen: Elevated LFTs and bilirubin w/CT scan\n suggesting cirrhosis - Hepatitis panel NEG, RUQ U/S neg for GB\n etiology, will continue to trend. Nutren 2.0 @ goal 40 cc/hr. Increase\n free water flushes to 100 q8. Bowel regimen.\n Nutrition: Tube feeding\n Renal: Foley, monitor UOP, edematous scrotum. Goal 1-1.5 L neg.\n Hypernatremic to 150, approx. free H20 deficit 3.2L, treating with D5W\n @150cc/hr, will check Na Q6\n decrease IV free water as increase\n flushes.\n Hematology: Hct stable. Plt stable (178-196); d/c'd H2B. Heme onc c/s\n - smear nl; no hemolysis. IVC filter.\n Endocrine: RISS, goal BS<150.\n Infectious Disease: WBC normal, on cipro/cefepime for VAP () x 7\n days, Vanc .\n Lines / Tubes / Drains: Trach/PEG/foley/L radial a-line/L basilic\n Midline; attempt to obtain PIVs.\n Wounds:\n Imaging: CXR today\n Fluids: KVO\n Consults: Trauma surgery, Ortho, Ortho-spine, Hem / Onc\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 03:41 PM 40 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 11:30 AM\n Midline - 11:37 AM\n Prophylaxis:\n DVT: SQ UF Heparin, IVC filter\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: Transfer to rehab / long term facility\n Total time spent: 32 mins\n"
},
{
"category": "Rehab Services",
"chartdate": "2175-02-07 00:00:00.000",
"description": "Physical Therapy Progress Note",
"row_id": 715393,
"text": "Subjective:\n Objective:\n Follow up PT visit to address goals of: . Patient seen today\n for balance training, patient education\n Updated medical status: UE US - No evidence of deep vein\n thrombosis in the left arm; CXR pending\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Rolling:\n\n\n\n T\n\n Supine/\n Sidelying to Sit:\n\n\n\n T\n\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n\n\n\n X2\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Aerobic Activity Response:\n Position\n HR\n BP\n RR\n O[2] sat\n RPE\n Rest\n Supine\n 88\n 134/64\n 20\n 98% on CPAP\n Activity\n Sit\n 108\n 127/69\n 45\n 92% on CPAP\n Recovery\n Sit\n 95\n 145/71\n 30\n 96% on CPAP\n Total distance walked:\n Minutes:\n Gait: able to stand and shift weight minimally in standing. Unable to\n take any steps\n Balance: S static sitting at edge of bed. Min A static standing with\n posterior bias, able to anterior weight shift and laterally weight\n shift. Tolerated static standing x3-4 minutes.\n Education / Communication: Reviewed PT and d/c planning.\n Communicated with nsg re: status.\n Other: Total assist slide transfer to stretcher chair.\n On CPAP 5/10 PEEP/PS, 40% FIO2\n Denies pain\n Assessment: 74 yo M s/p crush injury making excellent progress in PT\n with mobility and endurance, continues to be limited by general\n weakness a/w prolonged and complicated hospitalization. He is\n demonstrating great motivation and has excellent rehab potential to\n return to prior independent level of function. PT to continue to\n follow daily at acute level\n Anticipated Discharge: Rehab\n Plan: continue with \n"
},
{
"category": "Nursing",
"chartdate": "2175-02-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 715018,
"text": "Trauma, s/p\n Assessment:\n N; Pt more alert and seems oriented, MAE and following commands.\n Attempting to participate in care. Denies pain. Less restless.\n CV: Remains in nsr, no ectopy. HR 70\ns-90. Stable bp.\n Resp: Sxned for copious thick secretions requiring lavage. Strong\n productive cough. Cont on psv 12, 10 peep with stable abg. LS coarse\n throughout.\n Renal: Diuresing well from 1x dose lasix and cont on diamox. Brisk u/o\n with negative body balance.\n GI: tol tf at goal. No stool overnoc.\n Heme: Stable\n ID: cont on abx. Remains Afebrile.\n Skin: Intact\n Social: Family called, updated.\n Action:\n Zyprexa ATC. Cont on dilt and amioderone. Vigorous pulm toilet. Cont\n on colace and lactulose.\n Response:\n Calmer and more appropriate. Intermittent sleep. Hemodynamically\n stable. No stool, abd soft. Stable abg on psv, less tachypneic.\n Diuresing well, alkalosis improved.\n Plan:\n Cont to monitor. Cont zyprexa, dilt and amio. OOB-chair as\n tolerated. Pulm toilet. Wean as tolerated from vent. Diamox and\n diurese as tolerated. Monitor temp, cont abx. Pt and family support.\n"
},
{
"category": "Respiratory ",
"chartdate": "2175-01-26 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 713565,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Plan\n Next 24-48 hours: Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Underlying illness not resolved\n PEEP increased overnight due to low Pao2, pt responded well. Will wean\n as tolerated.\n"
},
{
"category": "Physician ",
"chartdate": "2175-02-05 00:00:00.000",
"description": "Intensivist Note",
"row_id": 715101,
"text": "TSICU\n HPI:\n 74M s/p fall with multiple rib fx, pelvis fx, clavicle fx, and thoracic\n fx c/b unstable bleeding s/p IR embo, AF with RVR/Aflutter, now in\n sinus, and PNA.\n Chief complaint:\n Fall\n PMHx:\n none\n Current medications:\n 1. Acetaminophen 4. AcetaZOLamide 2. Amiodarone 3. Bisacodyl 4. Calcium\n Gluconate 5. CefePIME 6. Chlorhexidine Gluconate 0.12% Oral Rinse 7.\n Ciprofloxacin HCl 8. Dextrose 50% 9. Diltiazem 10. Docusate Sodium\n (Liquid) 11. Furosemide 12. Gabapentin 13. Glucagon 14. Heparin 15.\n Insulin\n 16. Lactulose 17. Lansoprazole Oral Disintegrating Tab 18. Magnesium\n Sulfate 19. Metoprolol Tartrate 20. Milk of Magnesia 21. Olanzapine\n (Disintegrating Tablet) 22. Ondansetron 23. OxycoDONE Liquid 24.\n Pneumococcal Vac Polyvalent 25. Potassium Chloride 26. Potassium\n Phosphate 27. Potassium Chloride 28. Senna 32. Sodium Chloride 0.9%\n Flush 30. Sodium Chloride 0.9% Flush 31. Vancomycin\n 24 Hour Events:\n Started Diamox 500 x4 for contraction alkalosis due to Lasix, also\n given Lasix 20 IV x1 with 1774 off.\n Diltiazem gtt stopped and restarted po.\n d/c'd Haldol and started standing Zyprexa.\n Post operative day:\n POD#10 - IVC filter via L groin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:26 PM\n Ciprofloxacin - 10:48 PM\n Cefipime - 12:48 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 06:00 PM\n Heparin Sodium (Prophylaxis) - 03:48 AM\n Other medications:\n Flowsheet Data as of 05:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38\nC (100.4\n T current: 37.4\nC (99.4\n HR: 87 (71 - 104) bpm\n BP: 143/60(85) {83/38(59) - 158/63(90)} mmHg\n RR: 27 (17 - 32) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 104.2 kg (admission): 90 kg\n Total In:\n 1,956 mL\n 136 mL\n PO:\n Tube feeding:\n 560 mL\n IV Fluid:\n 1,006 mL\n 76 mL\n Blood products:\n Total out:\n 3,730 mL\n 1,140 mL\n Urine:\n 3,730 mL\n 1,140 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,774 mL\n -1,004 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 379 (379 - 713) mL\n PS : 12 cmH2O\n RR (Spontaneous): 33\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 24 cmH2O\n SPO2: 99%\n ABG: 7.45/35/169/24/1\n Ve: 15.2 L/min\n PaO2 / FiO2: 422\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm)\n Right Extremities: (Edema: Trace), (Temperature: Warm)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities\n Labs / Radiology\n 178 K/uL\n 8.8 g/dL\n 108 mg/dL\n 1.0 mg/dL\n 24 mEq/L\n 3.8 mEq/L\n 23 mg/dL\n 113 mEq/L\n 143 mEq/L\n 28.4 %\n 5.2 K/uL\n [image002.jpg]\n 07:20 PM\n 12:35 AM\n 01:04 AM\n 06:28 AM\n 08:00 AM\n 01:10 PM\n 05:03 PM\n 06:07 PM\n 01:55 AM\n 02:04 AM\n WBC\n 6.5\n 5.2\n Hct\n 29.0\n 28.4\n Plt\n 124\n 178\n Creatinine\n 0.8\n 0.9\n 1.0\n TCO2\n 34\n 32\n 30\n 29\n 25\n Glucose\n 130\n 103\n 121\n 130\n 113\n 119\n 108\n Other labs: PT / PTT / INR:14.0/28.1/1.2, CK / CK-MB / Troponin\n T:128/13/<0.01, ALT / AST:104/137, Alk-Phos / T bili:204/4.8, Amylase /\n Lipase:54/52, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic\n Acid:1.1 mmol/L, Albumin:2.3 g/dL, LDH:348 IU/L, Ca:8.3 mg/dL, Mg:2.4\n mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, AF with\n RVR/Aflutter, now in sinus, and PNA.\n Neurologic: s/p trach (). Per ortho spine, no surgery; HOB<30,\n TLSO when OOB. Zyprexa 10 TID (off fent/midaz ).\n Neuro checks Q: shift\n Pain: Oxycodone, Neurontin, Tylenol.\n Cardiovascular: Aflutter->NSR, on Amio and diltizem 60 QID. Likely \n cardiac contusion. Cards for Amio rec 400'' x 1wk, then 400'x1 wk, then\n 200'. Pt cannot be fully anticoagulated for now (trauma).\n Pulmonary: Trach, weaning vent, Vanc/cipro/cefepime for VAP ().\n Improving pulmonary edema.\n Gastrointestinal / Abdomen: Unknown elevated LFTs and bilirubin w/CT\n scan suggesting cirrhosis - Hepatitis panel NEG, RUQ U/S r/o\n gallbladder etiology, will continue to trend. On Nutren 2.0 with goal\n 40 cc/hr. Bowel regimen.\n Nutrition: Tube feeding\n Renal: Foley, monitor UOP, edematous scrotum. Diamox 500 q12 x 4doses\n for contraction alkalosis and Lasix 20 x1.\n Hematology: Hct stable 28.9->29. Plt stable (100's); d/c'd H2B. Heme\n onc c/s - smear nl; no hemolysis. IVC filter placed.\n Endocrine: RISS\n Infectious Disease: WBC normal, on Vanc/cipro/cefepime for VAP given\n worsening pulm status, f/u on cx\n Lines / Tubes / Drains: Trach/Peg/foley/L radial a-line/R SCL\n Wounds:\n Imaging: CXR today\n Fluids: KVO\n Consults: Trauma (1o), Ortho Spine, Ortho trauma, Heme\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 04:41 PM\n Arterial Line - 11:30 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin, IVC filter\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 33 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2175-02-05 00:00:00.000",
"description": "Intensivist Note",
"row_id": 715092,
"text": "TSICU\n HPI:\n 74M s/p fall with multiple rib fx, pelvis fx, clavicle fx, and thoracic\n fx c/b unstable bleeding s/p IR embo, AF with RVR/Aflutter, now in\n sinus, and PNA.\n Chief complaint:\n Fall\n PMHx:\n none\n Current medications:\n 1. Acetaminophen 4. AcetaZOLamide 2. Amiodarone 3. Bisacodyl 4. Calcium\n Gluconate 5. CefePIME 6. Chlorhexidine Gluconate 0.12% Oral Rinse 7.\n Ciprofloxacin HCl 8. Dextrose 50% 9. Diltiazem 10. Docusate Sodium\n (Liquid) 11. Furosemide 12. Gabapentin 13. Glucagon 14. Heparin 15.\n Insulin\n 16. Lactulose 17. Lansoprazole Oral Disintegrating Tab 18. Magnesium\n Sulfate 19. Metoprolol Tartrate 20. Milk of Magnesia 21. Olanzapine\n (Disintegrating Tablet) 22. Ondansetron 23. OxycoDONE Liquid 24.\n Pneumococcal Vac Polyvalent 25. Potassium Chloride 26. Potassium\n Phosphate 27. Potassium Chloride 28. Senna 32. Sodium Chloride 0.9%\n Flush 30. Sodium Chloride 0.9% Flush 31. Vancomycin\n 24 Hour Events:\n Started Diamox 500 x4 for contraction alkalosis due to Lasix, also\n given Lasix 20 IV x1 with 1774 off.\n Diltiazem gtt stopped and restarted po.\n d/c'd Haldol and started standing Zyprexa.\n Post operative day:\n POD#10 - IVC filter via L groin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:26 PM\n Ciprofloxacin - 10:48 PM\n Cefipime - 12:48 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 06:00 PM\n Heparin Sodium (Prophylaxis) - 03:48 AM\n Other medications:\n Flowsheet Data as of 05:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38\nC (100.4\n T current: 37.4\nC (99.4\n HR: 87 (71 - 104) bpm\n BP: 143/60(85) {83/38(59) - 158/63(90)} mmHg\n RR: 27 (17 - 32) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 104.2 kg (admission): 90 kg\n Total In:\n 1,956 mL\n 136 mL\n PO:\n Tube feeding:\n 560 mL\n IV Fluid:\n 1,006 mL\n 76 mL\n Blood products:\n Total out:\n 3,730 mL\n 1,140 mL\n Urine:\n 3,730 mL\n 1,140 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,774 mL\n -1,004 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 379 (379 - 713) mL\n PS : 12 cmH2O\n RR (Spontaneous): 33\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 24 cmH2O\n SPO2: 99%\n ABG: 7.45/35/169/24/1\n Ve: 15.2 L/min\n PaO2 / FiO2: 422\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm)\n Right Extremities: (Edema: Trace), (Temperature: Warm)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities\n Labs / Radiology\n 178 K/uL\n 8.8 g/dL\n 108 mg/dL\n 1.0 mg/dL\n 24 mEq/L\n 3.8 mEq/L\n 23 mg/dL\n 113 mEq/L\n 143 mEq/L\n 28.4 %\n 5.2 K/uL\n [image002.jpg]\n 07:20 PM\n 12:35 AM\n 01:04 AM\n 06:28 AM\n 08:00 AM\n 01:10 PM\n 05:03 PM\n 06:07 PM\n 01:55 AM\n 02:04 AM\n WBC\n 6.5\n 5.2\n Hct\n 29.0\n 28.4\n Plt\n 124\n 178\n Creatinine\n 0.8\n 0.9\n 1.0\n TCO2\n 34\n 32\n 30\n 29\n 25\n Glucose\n 130\n 103\n 121\n 130\n 113\n 119\n 108\n Other labs: PT / PTT / INR:14.0/28.1/1.2, CK / CK-MB / Troponin\n T:128/13/<0.01, ALT / AST:104/137, Alk-Phos / T bili:204/4.8, Amylase /\n Lipase:54/52, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic\n Acid:1.1 mmol/L, Albumin:2.3 g/dL, LDH:348 IU/L, Ca:8.3 mg/dL, Mg:2.4\n mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, AF with\n RVR/Aflutter, now in sinus, and PNA.\n Neurologic: s/p trach (). Per ortho spine, no surgery; HOB<30,\n TLSO when OOB. Zyprexa 10 TID (off fent/midaz ).\n Neuro checks Q: shift\n Pain: Oxycodone, Neurontin, Tylenol.\n Cardiovascular: Aflutter->NSR, on Amio and diltizem 60 QID. Likely \n cardiac contusion. Cards for Amio rec 400'' x 1wk, then 400'x1 wk, then\n 200'. Pt cannot be fully anticoagulated for now (trauma).\n Pulmonary: Trach, weaning vent, Vanc/cipro/cefepime for VAP ().\n Improving pulmonary edema.\n Gastrointestinal / Abdomen: Unknown elevated LFTs and bilirubin w/CT\n scan suggesting cirrhosis - Hepatitis panel NEG, RUQ U/S r/o\n gallbladder etiology, will continue to trend. On Nutren 2.0 with goal\n 40 cc/hr. Bowel regimen.\n Nutrition: Tube feeding\n Renal: Foley, monitor UOP, edematous scrotum. Diamox 500 q12 x 4doses\n for contraction alkalosis and Lasix 20 x1.\n Hematology: Hct stable 28.9->29. Plt stable (100's); d/c'd H2B. Heme\n onc c/s - smear nl; no hemolysis. IVC filter placed.\n Endocrine: RISS\n Infectious Disease: WBC normal, on Vanc/cipro/cefepime for VAP given\n worsening pulm status, f/u on cx\n Lines / Tubes / Drains: Trach/Peg/foley/L radial a-line/R SCL\n Wounds:\n Imaging: CXR today\n Fluids: KVO\n Consults: Trauma (1o), Ortho Spine, Ortho trauma, Heme\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 04:41 PM\n Arterial Line - 11:30 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin, IVC filter\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2175-02-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 715164,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Trached. Vent settings as charted in metavision. LS rhonchorous at\n times. Sats WNL. Afebrile.\n Action:\n Pulmonary hygiene. Cefepime, cipro, and vanco administered as\n ordered. ABG drawn.\n Response:\n Plan:\n Continue to wean vent settings. ? trach mask today. Begin rehab\n screening. Administer abx as ordered.\n IV access: PICC placed on currently midline, NOT central.\n Patient did not want IV to change it; patient preferred them to come\n later today (). HO aware. Discontinue subclavian line once PICC\n placement is confirmed.\n"
},
{
"category": "Nursing",
"chartdate": "2175-02-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 715167,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Trached. Vent settings as charted in metavision. LS rhonchorous at\n times. Sats WNL. Afebrile. WBC count trending down.\n Action:\n Pulmonary hygiene. Cefepime, cipro, and vanco administered as\n ordered. ABG drawn.\n Response:\n Plan:\n Continue to wean vent settings. ? trach mask today. Begin rehab\n screening. Administer abx as ordered.\n IV access: PICC placed on currently midline, NOT central.\n Patient did not want IV to change it; patient preferred them to come\n later today (). HO aware. Discontinue subclavian line once PICC\n placement is confirmed.\n"
},
{
"category": "Respiratory ",
"chartdate": "2175-02-06 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 715258,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 13\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 26 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Tachypneic (RR> 35 b/min);\n Comments: pt vent support increased to due to tachypnia into 40s\n on \n Assessment of breathing comfort: No claim of dyspnea)\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: plan to wean vent support as tolerated down to trach mask\n trials\n Reason for continuing current ventilatory support:\n"
},
{
"category": "Nursing",
"chartdate": "2175-02-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 714991,
"text": "Atrial fibrillation (Afib)\n Assessment:\n Rate controlled all shift in sinus rhythm, Bp stable.\n Action:\n Diltiazem gtt weaned off and PO Dilt restarted.\n Response:\n HR and BP stable, no arrhythmias. Electrolytes checked and replaced as\n needed.\n Plan:\n Continue PO medication regimen, taper Amio as ordered.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS clear to rhonchi but remain diminished at the bases. Strong\n productive cough, expectorating and suctioning out thick yellow\n secretions. ABG stable. SaO2 100%, RR WNL. UOP excellent with\n dieresis.\n Action:\n Cont pulm toileting. OOB to chair for 4 hours today tolerated very\n well. Diamox with Lasix times 1.\n Response:\n Mental status clearing. Weaned vent settings, ABG to be drawn.\n Plan:\n Continue to Dieresis, pulm toileting, wean vent settings as tolerated,\n AM CXR ordered.\n"
},
{
"category": "Nursing",
"chartdate": "2175-02-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 715368,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains on psv 10, 5peep and 40% with stable abg and 02sats. Remains\n tachypneic, 30\ns but denies distress. LS w/ rhonci throughout.\n Copious thick yellow secretions. Strong productive cough but cannot\n clear.\n Action:\n Pulm toilet, Frequent suctioning . Weaned to psv 5 at 0600\n Response:\n Stable on psv 10/5 but cont with copious secretions despite frequent\n sxning. More tachypneic on psv 5 pc02 28. denies sob, dyspnea.\n Plan:\n Placed back on psv 10 . recheck ABG. Not ready for TM due to copious\n secretions and tachpynea. Cont w/ oob to chair as tolerated. Cont\n pulm toilet.\n Activity Intolerance\n Assessment: Pt assisting with movement and aable to use swabs\n independently with supervision. Washing face independently.\n Action: Encourage pt to increase participation in care.\n Response: More interactive and asking to do things for himself.\n Plan: Increase activity as tolerated. Encourage participation in\n care. Have pt assist with bath when oob-chair during the day.\n Encourage normal sleep pattern.\n"
},
{
"category": "Respiratory ",
"chartdate": "2175-02-04 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 714993,
"text": "Day of mechanical ventilation: 11\n Airway Placement Data\n Known difficult intubation: Yes\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 8.0mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: CPAP/PSV\n Assessment of breathing comfort: GOOD\n Invasive ventilation assessment:\n Trigger work assessment: GOOD\n Dysynchrony assessment: LITTLE\n Plan\n Next 24-48 hours: Wean as tolerated\n"
},
{
"category": "Nursing",
"chartdate": "2175-02-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 715001,
"text": "Atrial fibrillation (Afib)\n Assessment:\n Rate controlled all shift in sinus rhythm, Bp stable.\n Action:\n Diltiazem gtt weaned off and PO Dilt restarted.\n Response:\n HR and BP stable, no arrhythmias. Electrolytes checked and replaced as\n needed.\n Plan:\n Continue PO medication regimen, taper Amio as ordered.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS clear to rhonchi but remain diminished at the bases. Strong\n productive cough, expectorating and suctioning out thick yellow\n secretions. ABG stable. SaO2 100%, RR WNL. UOP excellent with\n dieresis.\n Action:\n Cont pulm toileting. OOB to chair for 4 hours today tolerated very\n well. Diamox with Lasix times 1.\n Response:\n Mental status clearing. Weaned vent settings, ABG to be drawn.\n Plan:\n Continue to Dieresis, pulm toileting, wean vent settings as tolerated,\n AM CXR ordered.\n"
},
{
"category": "Rehab Services",
"chartdate": "2175-02-06 00:00:00.000",
"description": "Occupational Therapy Evaluation Note",
"row_id": 715246,
"text": "History\n Attending M.D.: \n Referral Date: \n Reason for Referral: evaluation and treatment\n Medical Dx / ICD - 9: polytrauma/959.9\n Activity Orders: activity as tolerated, TLSO when OOB\n HPI / Subjective Complaint: 74 yo M admitted s/p fall from\n tractor and crush injury from tree branch. Sustained multiple fib fxs\n (R anterolateral and L posterior), R pulmonary contusion, T4 vertebral\n teardrop fx, T2-T8 spinous process fx, nondisplaced L T10 transverse\n process fx, nondisplaced L distal clavicle fx, R medial lobe liver\n contusion with hematoma, comminuted L pubic ramus fx with hematoma,\n nondisplaced comminuted L iliac bone fx extending into L SI joint with\n adjacent iliac muscle hematoma, minimally displaced fx of R iliac bone\n extending to R SI joint. Pt intubated for tachycardia and\n increasing O2 requirement. Underwent angio on for embolization\n of pelvic and hepatic vessels, IVC filter placed , and trach/peg\n placement .\n Past Medical / Surgical History: cirrhosis and asbestosis via imaging,\n none per pt report\n Medications: acetaminophen, cipro, cefepime, amiodarone, diltiazem,\n oxycodone, gabapentin, metoprolol\n Labs\n Hematocrit (serum): 28.2 ...\n Hemoglobin: 8.9 ... g/dl\n WBC: 4.6 ...\n Platelet Count: 196 ...\n Radiology\n Radiology: MRI t-spine: C4-5 cord deformity, otherwise imaging as\n above\n Occupational History\n Occupational Profile: retired pipefitter, enjoys doing things around\n the house\n Performance Patterns: lives w/ wife, supportive family\n Baseline Occupational Performance: I PTA, +driving\n Environmental History: unable to assess difficulty communicating\n via writing or mouthing words\n Current Activities of Daily Living\n Grooming: (min A)\n UE Dressing: (mod A)\n Toileting: (Dependent)\n Specify: pt able to swab mouth and comb hair w/ min assist to sustain\n activity due to UE fatigue. decreased grasp noted B. pt up in\n stretcher chair, LE ADLs not assessed\n Current Instrumental Activities of Daily Living\n Home Management: Dependent\n Money Management: Assist\n Community Integration: Dependent\n Performance Skills\n Process Skills: alert and oriented to person, place, situation, month,\n year, time. following 1-step commands\n Communication / Interactive Skills: mouthing words w/ fair\n intelligibility, unable to communicate via written words given\n tremulousness and illegibility. provided communication board but did\n not attempt to use.\n Motor Skills - Functional Transfers\n Functional Transfers Clarification: pt just gotten OOB w/ PT, TBA\n Functional Balance: pt reclined in stretcher chair\n Aerobic Capacity: Rest\n Rest HR: 90\n Rest BP: 117/47\n Rest RR: 34\n Rest O2 sat: 98 %\n Supplemental O2: on CPAP\n Aerobic Capacity: Activity\n Activity HR: 86\n Activity BP: 116/48\n Activity RR: 35\n Activity O2 sat: 98 %\n Supplemental O2: on CPAP\n Aerobic Capacity: Recovery\n Recovery HR: 87\n Recovery BP: 107/48\n Recovery RR: 32\n Recovery O2 sat: 97 %\n Supplemental O2: on CPAP\n Range of Motion\n Range of Motion: full PROM R UE, unable to tolerate >100degress\n shoulder flexion on L, otherwise WNL\n Muscle Performance: strength, power, endurance\n Muscle Performance: R UE , grip 4-/5\n L UE: shoulder flexion, otherwise , grip 4-/5\n Additional Performance Skills\n Motor Control: moving B UE in isolation, significant tremors w/ gross\n and fine motor movements\n Coordination: impaired B due to mm fatigue and deconditioning\n Pain (0 - 10): 2 / 10\n Limiting Symptoms: discomfort. unable to tolerate full L shoulder\n range 2/2 c/o pain further PROM deferred w/ pain resolved.\n Sensation: intact LT b UE\n Integumentary: trach, peg, foley, tele, PIV, TLSO, R eyebrow lac w/\n sutures in place\n Team Communication: RN aware of pt functional status and recs for\n encouragement of self care and use of L UE.\n Patient Education: role of OT, d/c recs for rehab, recs for self care\n as able and to increase use of L UE as tolerated.\n Other: pt and call bell in reach\n Diagnosis\n Diagnosis 1: impaired ADL function\n Diagnosis 2: impaired B UE strength\n Diagnosis 3: impaired communication\n Diagnosis 4: impaired coordination\n Clinical Impression / Prognosis\n Clinical Impression / Prognosis: Pt is a 74 y.o male w/ mult fx now s/p\n trach and peg and on vent support. Pt presents w/ severe\n deconditioning and demonstrates above impairments. Pt would benefit\n from skilled OT services to maximize functional independence w/ rehab\n potential excellent given current med status, prior level of function\n and health.\n Goals: patient / family, objective, measurable\n Patient Goals: to be able to walk to the bathroom myself\n Goal 1: perform UE adls w/ min assist\n Goal 2: improve B UE strength 1/2 mm grade to improve adl independence\n Goal 3: use communication board to express needs w/ min assist\n Goal 4: write short responses with fair legibility\n Time Frame (expected attainment): 1 week\n Anticipated Discharge: Rehab\n Treatment Plan: Interventions; patient / family education, community\n resources\n Treatment Plan: adls, EOB and OOB assessment, coordination/handwriting,\n communication board d/c planning\n Frequency / Duration: 1-5x/wk\n Recommendations for Nursing: encourage participation w/ self care and\n use L UE as able\n Therapist Information\n Patient agrees with the above goals and is willing to participate in\n the rehabilitation program\n Therapist's Name: /L\n Date: \n Time: 12:50-13:20\n Pager #: \n"
},
{
"category": "Nursing",
"chartdate": "2175-02-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 715149,
"text": "PICC placed.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Ls clear to diminished, strong productive cough, suctioned for large\n amounts of thick yellow sputum. Afebrile all day. Remains in a NSR.\n Pt refused to get OOB due to having to wear TLSO brace.\n Action:\n Continuing diamox and Lasix for diuresis. Electrolytes replaced.\n Response:\n UOP good. Neuro status intact, appropriate.\n Plan:\n PM CXR pending. Continue to wean vent settings. Diuresis per orders.\n Screen for rehab in AM.\n"
},
{
"category": "Physician ",
"chartdate": "2175-02-06 00:00:00.000",
"description": "Intensivist Note",
"row_id": 715211,
"text": "TSICU\n HPI:\n 74M s/p fall from bed/standing? tx from osh () with\n acetabular fracture. On w/u in ER, pt found to be increasingly\n tachycardic with abdominal distention and hypotension; found to have\n acetabular fracture, iliac crest fracture, increasing pelvic and\n retroperitoneal hematomas. Coffee ground emesis x1 in ED.\n Chief complaint:\n pain\n PMHx:\n PMH: PVD, emphysema/COPD, dementia, seizure d/o, HTN, anemia, ?aortic\n dissection in past; pureed food diet with honey thick liquids\n PSH: s/p fem-fem bypass, c1-c2 fusion\n Current medications:\n 1000 mL NS 3. Acetaminophen 4. Albuterol 0.083% Neb Soln 5. Bisacodyl\n 6. Calcium Gluconate\n 7. Citalopram Hydrobromide 8. Clozapine 9. Clozapine 10. Dextrose 50%\n 11. Docusate Sodium 12. Glucagon\n 13. HYDROmorphone (Dilaudid) 14. Heparin 15. Insulin 16. Ipratropium\n Bromide Neb 17. LeVETiracetam\n 18. Magnesium Sulfate 19. Magnesium Sulfate 20. Metoprolol Tartrate 21.\n Metoprolol Tartrate 22. Metoprolol Tartrate\n 23. Metoprolol Tartrate 24. Multiple Vitamins Liq. 25. Olanzapine\n (Disintegrating Tablet) 26. Ondansetron\n 27. OxycoDONE (Immediate Release) 28. Pantoprazole 29. Pneumococcal Vac\n Polyvalent 30. Potassium Chloride\n 31. Potassium Chloride 32. Senna 33. Sodium Phosphate 34. Sodium\n Chloride 0.9% Flush\n 24 Hour Events:\n : Persistent tachycardia. Metop inc to 37.5''-->50. Metop 5-10 mg\n IV PRN hr>110 (ST w/PACs, PVCs), 2 mg Mg. SQH started. Chest PT, nebs.\n NPO p MN for ORIF.\n Post operative day:\n POD#11 - IVC filter via L groin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 07:41 PM\n Ciprofloxacin - 09:44 PM\n Cefipime - 12:13 AM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 02:24 PM\n Furosemide (Lasix) - 05:14 PM\n Heparin Sodium (Prophylaxis) - 03:52 AM\n Other medications:\n Flowsheet Data as of 04:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.3\nC (99.2\n T current: 37.1\nC (98.7\n HR: 77 (73 - 98) bpm\n BP: 103/42(60) {86/40(55) - 152/70(97)} mmHg\n RR: 29 (20 - 34) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 104.2 kg (admission): 90 kg\n Total In:\n 2,020 mL\n 456 mL\n PO:\n Tube feeding:\n 960 mL\n 157 mL\n IV Fluid:\n 470 mL\n 120 mL\n Blood products:\n Total out:\n 5,030 mL\n 470 mL\n Urine:\n 5,030 mL\n 470 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,010 mL\n -14 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 442 (421 - 612) mL\n PS : 5 cmH2O\n RR (Spontaneous): 29\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 65\n PIP: 16 cmH2O\n SPO2: 98%\n ABG: 7.40/32/123/21/-3\n Ve: 13.5 L/min\n PaO2 / FiO2: 308\n Physical Examination\n General Appearance: No acute distress, confused at times\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: No(t)\n Resonant : ), (Breath Sounds: Rhonchorous : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 1), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 196 K/uL\n 8.9 g/dL\n 122 mg/dL\n 1.1 mg/dL\n 21 mEq/L\n 3.6 mEq/L\n 25 mg/dL\n 117 mEq/L\n 144 mEq/L\n 28.2 %\n 4.6 K/uL\n [image002.jpg]\n 06:07 PM\n 01:55 AM\n 02:04 AM\n 08:00 AM\n 11:35 AM\n 03:56 PM\n 05:09 PM\n 08:00 PM\n 01:36 AM\n 02:16 AM\n WBC\n 5.2\n 4.6\n Hct\n 28.4\n 28.2\n Plt\n 178\n 196\n Creatinine\n 1.0\n 1.0\n 1.1\n TCO2\n 29\n 25\n 25\n 26\n 21\n Glucose\n 119\n 108\n 120\n 120\n 138\n 122\n Other labs: PT / PTT / INR:14.0/28.1/1.2, CK / CK-MB / Troponin\n T:128/13/<0.01, ALT / AST:104/137, Alk-Phos / T bili:204/4.8, Amylase /\n Lipase:54/52, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic\n Acid:1.1 mmol/L, Albumin:2.3 g/dL, LDH:348 IU/L, Ca:8.1 mg/dL, Mg:2.4\n mg/dL, PO4:3.5 mg/dL\n Imaging: CT c-spine: s/p post c1-c2 fusion. metallic nail\n through L lat C2 extends w/tip in retropharnyngeal/prevertebral jxn\n soft tissues ant to C1. mild anterolisthesis of C4 over C5. very min\n retrolisthesis C5 over C6. mult-level change. no acute fx seen.\n pulmonary emphysema. coarse vertebral and carotid artery calcs. 6mm R\n thyroid lobe hypodensity.\n CT torso: 1.6 x 1.2 cm focal hypodensity in ant mediastinum\n (S2:im15). ?focal hematoma vs thymic cystic lesion. No overlying\n sternal fx or aortic injury. dense aortic calcs. LLL atelect/scarring.\n comminuted, intra-art L acetabular fx involv ant &post columns and ext\n to L sup pubic ramus. adj mod pelvic hematoma w/out active extrav.\n hematoma crosses midline, extends superiorly ant to L psoas muscle and\n iliacus. mild loss of ht of L2 & L3 vert bodies. Grade 1\n spondylolisthesis L5/S1. bladder diverticula .\n CT head: No acute ICH. opacification of inf L maxillary\n sinus w/focal loss of ant inf L max sinus/ant L alveolar bone, adj soft\n tissue swelling and foci of gas. ?infectious process involving L\n alveolar process of maxilla, dental in nature vs chronic sinusitis vs\n injury. recommend direct visualization.\n CXR: No consolidation\n CXR (pm): Increased lung volumes c/w emphysema. Peribronchial\n cuffing and predominantly R-sided interstitial opacities likely fluid\n overload. Subtle opacity @R apex ?superimposition of external\n ventilator apparatus vs. consolidation.\n Microbiology: SCx: contaminated\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, AF with\n RVR/Aflutter, now in sinus, and PNA, s/p trach/PEG (), IVC filter.\n Neurologic: HOB<30, TLSO when OOB. Zyprexa 10'''\n Neuro checks Q: shift\n Pain: Oxycodone, Neurontin, Tylenol. Pain adequately controlled.\n Cardiovascular: Aflutter->NSR, on Amio and diltizem 60 QID. Likely \n cardiac contusion. Cards for Amio rec 400'' x 1wk, then 400'x1 wk, then\n 200'. Pt cannot be fully anticoagulated for now (trauma).\n Pulmonary: Trach, weaning vent ( currently), Vanc/cipro/cefepime for\n VAP (). Improving pulmonary edema. Continued diuresis.\n Gastrointestinal / Abdomen: Unknown elevated LFTs and bilirubin w/CT\n scan suggesting cirrhosis - Hepatitis panel NEG, RUQ U/S r/o\n gallbladder etiology, will continue to trend. Nutren 2.0 @ goal 40\n cc/hr. Bowel regimen.\n RENAL: Foley, monitor UOP, edematous scrotum. Diamox 250 q12 for\n contraction alkalosis. Lasix 20x2 on . Hypernatremia,\n hyperchloremia.\n Nutrition: Tube feeding\n Renal: Foley\n Hematology: Hct stable (28.2). Plt stable (178-196); d/c'd H2B. Heme\n onc c/s - smear nl; no hemolysis. IVC filter.\n Endocrine: RISS\n Infectious Disease: Check cultures, WBC normal (4.6), on\n Vanc/cipro/cefepime for VAP given worsening pulm status, f/u on cx\n Lines / Tubes / Drains: Trach/Peg/foley/L radial a-line/L basilic PICC,\n SCL (will d/c SCL once midline)\n Wounds:\n Imaging: CXR today\n Fluids: KVO\n Consults: Trauma (1o), Ortho Spine, Ortho trauma, Heme\n Billing Diagnosis: (Shock: Unspecified), Multiple injuries (Trauma)\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 07:46 PM 40 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 04:41 PM\n Arterial Line - 11:30 AM\n PICC Line - 06:02 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin, IVC filter\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting planning, ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 33 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2175-02-06 00:00:00.000",
"description": "Intensivist Note",
"row_id": 715214,
"text": "TSICU\n HPI:\n 74M s/p fall from tractor and crush injury from tree branch. +Loc.\n Chief complaint:\n ventilator dependance\n PMHx:\n PMH: cirrhosis and asbestosis dx on CT\n Current medications:\n Acetaminophen 4. AcetaZOLamide 5. Amiodarone 6. Bisacodyl 7. Calcium\n Gluconate 8. CefePIME 9. Chlorhexidine Gluconate 0.12% Oral Rinse 10.\n Ciprofloxacin HCl 11. Dextrose 50% 12. Diltiazem 13. Docusate Sodium\n (Liquid) 14. Furosemide 15. Furosemide 16. Gabapentin 17. Glucagon 18.\n Heparin\n 19. Heparin Flush (10 units/ml) 20. 21. Insulin 22. Lactulose 23.\n Lansoprazole Oral Disintegrating Tab 24. Magnesium Sulfate 25.\n Metoprolol Tartrate 26. Milk of Magnesia 27. Olanzapine (Disintegrating\n Tablet) 28. Ondansetron 29. OxycoDONE Liquid 30. Pneumococcal Vac\n Polyvalent 31. Potassium Phosphate 32. Potassium Chloride 33. Senna 34.\n Sodium Chloride 0.9% Flush 35. Sodium Chloride 0.9% Flush 36.\n Vancomycin\n 24 Hour Events:\n : Diamox continued. Lasix 20x2 with good result. PICC. Diamox decr\n w/iatrogenic hyperchloremia, hypernatremia.\n Post operative day:\n POD#11 - IVC filter via L groin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 07:41 PM\n Ciprofloxacin - 09:44 PM\n Cefipime - 12:13 AM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 02:24 PM\n Furosemide (Lasix) - 05:14 PM\n Heparin Sodium (Prophylaxis) - 07:35 PM\n Other medications:\n Flowsheet Data as of 03:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.3\nC (99.2\n T current: 37.1\nC (98.7\n HR: 77 (73 - 98) bpm\n BP: 103/42(60) {86/40(55) - 152/70(97)} mmHg\n RR: 29 (20 - 34) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 104.2 kg (admission): 90 kg\n Total In:\n 2,020 mL\n 451 mL\n PO:\n Tube feeding:\n 960 mL\n 152 mL\n IV Fluid:\n 470 mL\n 119 mL\n Blood products:\n Total out:\n 5,030 mL\n 470 mL\n Urine:\n 5,030 mL\n 470 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,010 mL\n -19 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 442 (421 - 612) mL\n PS : 5 cmH2O\n RR (Spontaneous): 29\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 65\n PIP: 16 cmH2O\n SPO2: 98%\n ABG: 7.40/32/123/21/-3\n Ve: 13.5 L/min\n PaO2 / FiO2: 308\n Physical Examination\n General Appearance: No acute distress, Anxious at times\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n bibasilar, occasional, Diminished: bibasilar), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Obese\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities\n Labs / Radiology\n 196 K/uL\n 8.9 g/dL\n 122 mg/dL\n 1.1 mg/dL\n 21 mEq/L\n 3.6 mEq/L\n 25 mg/dL\n 117 mEq/L\n 144 mEq/L\n 28.2 %\n 4.6 K/uL\n [image002.jpg]\n 06:07 PM\n 01:55 AM\n 02:04 AM\n 08:00 AM\n 11:35 AM\n 03:56 PM\n 05:09 PM\n 08:00 PM\n 01:36 AM\n 02:16 AM\n WBC\n 5.2\n 4.6\n Hct\n 28.4\n 28.2\n Plt\n 178\n 196\n Creatinine\n 1.0\n 1.0\n 1.1\n TCO2\n 29\n 25\n 25\n 26\n 21\n Glucose\n 119\n 108\n 120\n 120\n 138\n 122\n Other labs: PT / PTT / INR:14.0/28.1/1.2, CK / CK-MB / Troponin\n T:128/13/<0.01, ALT / AST:104/137, Alk-Phos / T bili:204/4.8, Amylase /\n Lipase:54/52, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic\n Acid:1.1 mmol/L, Albumin:2.3 g/dL, LDH:348 IU/L, Ca:8.1 mg/dL, Mg:2.4\n mg/dL, PO4:3.5 mg/dL\n Imaging: CT head OSH: Prelim No ICH or fx.\n CT chest OSH: Mult rib fx: R anterolateral and posterior, L\n posterior; Dependent consolidation, possible aspiration; T4 vertebral\n body inf corner fx, no retropulsion; Comminuted spinous process fx\n T2-8; Nondisplaced L T10 transverse process; Nondisplaced L clavicle\n distal fx; Nondisplaced L scapula fx;\n CT c spine OSH: Prelim No fx or malalignment. Multilevel\n degenerative changes w/large post disk bulge at C4-5, narrowing the\n spinal canal and deforming the thecal sac, acuity unknown. Marked\n neuroforamenal narrowing @multiple levels.\n CTA abd/pel Prelim: Medial R liver lobe contusion w/adj\n hematoma, w/o evidence of active bleeding; Comminuted L pubic ramus\n fracture w/assoc hematoma, with tiny focus of arterial bleeding/active\n extravasation, and larger area of venous bleeding. Hematoma somewhat\n larger than on OSH study. Nondisplaced, comminuted L iliac bone fx\n w/adj iliac muscle hematoma, larger than on prior study, w/o active\n extrav. Fx extends into L SIJ. Post R hepatic laceration/contusion\n adjacent to calcified granuloma, w/small hematoma, w/out active\n bleeding. Min displaced fx of R iliac bone extending to R SIJ.\n Cirrhotic liver. Inc B pl effusions (small), w/inc atelectasis.\n MRI: Mild compression deformity of L1 w/additional levels of\n potential trabecular contusion @T10-11 also inf @T4 w/o retropulsion.\n Multilevel degenerative changes w/moderate canal narrowing @T10-11\n w/cord deformity & no abnl cord signal. Extensive edema throughout\n paraspinal soft tissues, predominantly post w/in interspinous\n ligaments. Incompletely eval'ed c-spine w/severe canal narrowing @C4-5\n w/cord deformity and no abn cord signal.\n CTA: no PE.\n CXR: Moderate b/l pleural effusions are stable.\n CXR: Cardiac size top nl, interval improvement of collapse LLL.\n Collapse RLL. Atelectasis in lingula unchanged. Mod B pleural effusions\n stable. No PTX.\n CXR: Interval mild incr in cardiac size, b/l pl effusions,\n & opacities @ bases,c/w overload\n : R foot: Linear density projecting @ expected area of insertion\n of Achilles to calcaneus, may be min avulsion fx or degenerative\n changes. Otherwise no fx\n CXR: b/l pl effusions\n CXR: stable.\n RUQ U/S: No perihepatic fluid collection. small amt perihepatic\n free fluid persists. Small contusion in hepatic segment VII. No\n gallstones or sig wall thickening/edema. CBD 4.5 mm\n TTE: LVEF >55%, NL diastolic function, NL LV filling pressure\n (PCWP<12mmHg), RV chamber size mildly dilated, mild TR\n CXR: mild b/l pulm edema and parenchymal opacities and no\n pl effusion.\n CXR: Persistent b/l pl effusions and bibasilar opacity.\n CXR: Minimal improvement of mod b/l pl effusions. Otherwise\n stable.\n CXR: no relevant change. B/L pleural effusions with basal\n opacities. No evidence of newly appeared focal parenchymal opacities\n suggesting pneumonia.\n : No dvt\n CXR: No change, B pleural effusions, no new infiltrates\n CXR: stable\n Microbiology: Ucx neg\n Sputum: sparse GNRs, too few to colonize\n Bcx x2 neg\n 12/17 L BAL: Klebsiella Pneumoniae, HAEMOPHILUS SPECIES NOT INFLUENZAE\n R BAL: Klebsiella Pneumoniae, Proteus.\n 12/20 L &R BAL: Klebsiella Pneumoniae\n BCX: neg\n BCx: neg\n UCx: neg\n BCx: P\n BCx: P\n UCx: neg\n SpCx: contamination\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, AF with\n RVR/Aflutter, now in sinus, and PNA, s/p trach/PEG (), IVC filter\n Neurologic: HOB<30, TLSO when OOB. Zyprexa 10'''\n Neuro checks Q: shift\n Pain: Oxycodone, Neurontin, Tylenol. Pain adequately controlled.\n Cardiovascular: Aflutter->NSR, on Amio and diltizem 60 QID. Likely \n cardiac contusion. Cards for Amio rec 400'' x 1wk, then 400'x1 wk, then\n 200'. Pt cannot be fully anticoagulated for now (trauma). Now in sinus\n so continue Amio.\n Pulmonary: Trach, weaning vent ( currently), Vanc/cipro/cefepime for\n VAP (). Improving pulmonary edema. Continued diuresis. TM trial\n today, follow ABGs. Aggressive chest Pt as e/o collapse on RLL.\n Gastrointestinal / Abdomen: Unknown elevated LFTs and bilirubin w/CT\n scan suggesting cirrhosis - Hepatitis panel NEG, RUQ U/S r/o\n gallbladder etiology, will continue to trend. Nutren 2.0 @ goal 40\n cc/hr. Bowel regimen (d/c Lactulose). C diff negative x 3.\n Nutrition: Tube feeding, Nutren. At goal.\n Renal: Foley, monitor UOP, edematous scrotum. Diamox 250 q12 for\n contraction alkalosis. Lasix 20x2 on . Hypernatremia,\n hyperchloremia. Goal 1.5 L negative today as total volume up from\n admission.\n Hematology: Hct stable (28.2). Plt stable (178-196); d/c'd H2B. Heme\n onc c/s - smear nl; no hemolysis. IVC filter.\n Endocrine: RISS, goal BS<150. Adequate control.\n Infectious Disease: WBC normal, on Vanc/cipro/cefepime for VAP given\n worsening pulm status, f/u on cx. Plan for total 7 days of abx, given\n only GNRs in cx data will d/c Vanco.\n Lines / Tubes / Drains: Trach/Peg/foley/L radial a-line/L basilic PICC,\n SCL (will d/c SCL once midline)\n Wounds:\n Imaging: CXR today\n Fluids: KVO\n Consults: Trauma (1o), Ortho Spine, Ortho trauma, Heme, PT/OT.\n Billing Diagnosis: (Shock: Unspecified), Multiple injuries (Trauma)\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 07:46 PM 40 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 04:41 PM\n Arterial Line - 11:30 AM\n PICC Line - 06:02 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin, IVC filter\n Stress ulcer: PPI (thrombocytopenia possibly from H2B)\n VAP bundle: HOB elevation, Mouth care\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n rehab screen\n Total time spent: 33 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2175-02-06 00:00:00.000",
"description": "Intensivist Note",
"row_id": 715215,
"text": "TSICU\n HPI:\n 74M s/p fall from tractor and crush injury from tree branch. +Loc.\n Chief complaint:\n ventilator dependance\n PMHx:\n PMH: cirrhosis and asbestosis dx on CT\n Current medications:\n Acetaminophen 4. AcetaZOLamide 5. Amiodarone 6. Bisacodyl 7. Calcium\n Gluconate 8. CefePIME 9. Chlorhexidine Gluconate 0.12% Oral Rinse 10.\n Ciprofloxacin HCl 11. Dextrose 50% 12. Diltiazem 13. Docusate Sodium\n (Liquid) 14. Furosemide 15. Furosemide 16. Gabapentin 17. Glucagon 18.\n Heparin\n 19. Heparin Flush (10 units/ml) 20. 21. Insulin 22. Lactulose 23.\n Lansoprazole Oral Disintegrating Tab 24. Magnesium Sulfate 25.\n Metoprolol Tartrate 26. Milk of Magnesia 27. Olanzapine (Disintegrating\n Tablet) 28. Ondansetron 29. OxycoDONE Liquid 30. Pneumococcal Vac\n Polyvalent 31. Potassium Phosphate 32. Potassium Chloride 33. Senna 34.\n Sodium Chloride 0.9% Flush 35. Sodium Chloride 0.9% Flush 36.\n Vancomycin\n 24 Hour Events:\n : Diamox continued. Lasix 20x2 with good result. PICC. Diamox decr\n w/iatrogenic hyperchloremia, hypernatremia.\n Post operative day:\n POD#11 - IVC filter via L groin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 07:41 PM\n Ciprofloxacin - 09:44 PM\n Cefipime - 12:13 AM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 02:24 PM\n Furosemide (Lasix) - 05:14 PM\n Heparin Sodium (Prophylaxis) - 07:35 PM\n Other medications:\n Flowsheet Data as of 03:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.3\nC (99.2\n T current: 37.1\nC (98.7\n HR: 77 (73 - 98) bpm\n BP: 103/42(60) {86/40(55) - 152/70(97)} mmHg\n RR: 29 (20 - 34) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 104.2 kg (admission): 90 kg\n Total In:\n 2,020 mL\n 451 mL\n PO:\n Tube feeding:\n 960 mL\n 152 mL\n IV Fluid:\n 470 mL\n 119 mL\n Blood products:\n Total out:\n 5,030 mL\n 470 mL\n Urine:\n 5,030 mL\n 470 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,010 mL\n -19 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 442 (421 - 612) mL\n PS : 5 cmH2O\n RR (Spontaneous): 29\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 65\n PIP: 16 cmH2O\n SPO2: 98%\n ABG: 7.40/32/123/21/-3\n Ve: 13.5 L/min\n PaO2 / FiO2: 308\n Physical Examination\n General Appearance: No acute distress, Anxious at times\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n bibasilar, occasional, Diminished: bibasilar), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Obese\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities\n Labs / Radiology\n 196 K/uL\n 8.9 g/dL\n 122 mg/dL\n 1.1 mg/dL\n 21 mEq/L\n 3.6 mEq/L\n 25 mg/dL\n 117 mEq/L\n 144 mEq/L\n 28.2 %\n 4.6 K/uL\n [image002.jpg]\n 06:07 PM\n 01:55 AM\n 02:04 AM\n 08:00 AM\n 11:35 AM\n 03:56 PM\n 05:09 PM\n 08:00 PM\n 01:36 AM\n 02:16 AM\n WBC\n 5.2\n 4.6\n Hct\n 28.4\n 28.2\n Plt\n 178\n 196\n Creatinine\n 1.0\n 1.0\n 1.1\n TCO2\n 29\n 25\n 25\n 26\n 21\n Glucose\n 119\n 108\n 120\n 120\n 138\n 122\n Other labs: PT / PTT / INR:14.0/28.1/1.2, CK / CK-MB / Troponin\n T:128/13/<0.01, ALT / AST:104/137, Alk-Phos / T bili:204/4.8, Amylase /\n Lipase:54/52, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic\n Acid:1.1 mmol/L, Albumin:2.3 g/dL, LDH:348 IU/L, Ca:8.1 mg/dL, Mg:2.4\n mg/dL, PO4:3.5 mg/dL\n Imaging: CT head OSH: Prelim No ICH or fx.\n CT chest OSH: Mult rib fx: R anterolateral and posterior, L\n posterior; Dependent consolidation, possible aspiration; T4 vertebral\n body inf corner fx, no retropulsion; Comminuted spinous process fx\n T2-8; Nondisplaced L T10 transverse process; Nondisplaced L clavicle\n distal fx; Nondisplaced L scapula fx;\n CT c spine OSH: Prelim No fx or malalignment. Multilevel\n degenerative changes w/large post disk bulge at C4-5, narrowing the\n spinal canal and deforming the thecal sac, acuity unknown. Marked\n neuroforamenal narrowing @multiple levels.\n CTA abd/pel Prelim: Medial R liver lobe contusion w/adj\n hematoma, w/o evidence of active bleeding; Comminuted L pubic ramus\n fracture w/assoc hematoma, with tiny focus of arterial bleeding/active\n extravasation, and larger area of venous bleeding. Hematoma somewhat\n larger than on OSH study. Nondisplaced, comminuted L iliac bone fx\n w/adj iliac muscle hematoma, larger than on prior study, w/o active\n extrav. Fx extends into L SIJ. Post R hepatic laceration/contusion\n adjacent to calcified granuloma, w/small hematoma, w/out active\n bleeding. Min displaced fx of R iliac bone extending to R SIJ.\n Cirrhotic liver. Inc B pl effusions (small), w/inc atelectasis.\n MRI: Mild compression deformity of L1 w/additional levels of\n potential trabecular contusion @T10-11 also inf @T4 w/o retropulsion.\n Multilevel degenerative changes w/moderate canal narrowing @T10-11\n w/cord deformity & no abnl cord signal. Extensive edema throughout\n paraspinal soft tissues, predominantly post w/in interspinous\n ligaments. Incompletely eval'ed c-spine w/severe canal narrowing @C4-5\n w/cord deformity and no abn cord signal.\n CTA: no PE.\n CXR: Moderate b/l pleural effusions are stable.\n CXR: Cardiac size top nl, interval improvement of collapse LLL.\n Collapse RLL. Atelectasis in lingula unchanged. Mod B pleural effusions\n stable. No PTX.\n CXR: Interval mild incr in cardiac size, b/l pl effusions,\n & opacities @ bases,c/w overload\n : R foot: Linear density projecting @ expected area of insertion\n of Achilles to calcaneus, may be min avulsion fx or degenerative\n changes. Otherwise no fx\n CXR: b/l pl effusions\n CXR: stable.\n RUQ U/S: No perihepatic fluid collection. small amt perihepatic\n free fluid persists. Small contusion in hepatic segment VII. No\n gallstones or sig wall thickening/edema. CBD 4.5 mm\n TTE: LVEF >55%, NL diastolic function, NL LV filling pressure\n (PCWP<12mmHg), RV chamber size mildly dilated, mild TR\n CXR: mild b/l pulm edema and parenchymal opacities and no\n pl effusion.\n CXR: Persistent b/l pl effusions and bibasilar opacity.\n CXR: Minimal improvement of mod b/l pl effusions. Otherwise\n stable.\n CXR: no relevant change. B/L pleural effusions with basal\n opacities. No evidence of newly appeared focal parenchymal opacities\n suggesting pneumonia.\n : No dvt\n CXR: No change, B pleural effusions, no new infiltrates\n CXR: stable\n Microbiology: Ucx neg\n Sputum: sparse GNRs, too few to colonize\n Bcx x2 neg\n 12/17 L BAL: Klebsiella Pneumoniae, HAEMOPHILUS SPECIES NOT INFLUENZAE\n R BAL: Klebsiella Pneumoniae, Proteus.\n 12/20 L &R BAL: Klebsiella Pneumoniae\n BCX: neg\n BCx: neg\n UCx: neg\n BCx: P\n BCx: P\n UCx: neg\n SpCx: contamination\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, AF with\n RVR/Aflutter, now in sinus, and PNA, s/p trach/PEG (), IVC filter\n Neurologic: HOB<30, TLSO when OOB. Zyprexa 10'''\n Neuro checks Q: shift\n Pain: Oxycodone, Neurontin, Tylenol. Pain adequately controlled.\n Cardiovascular: Aflutter->NSR, on Amio and diltizem 60 QID. Likely \n cardiac contusion. Cards for Amio rec 400'' x 1wk, then 400'x1 wk, then\n 200'. Pt cannot be fully anticoagulated for now (trauma). Now in sinus\n so continue Amio.\n Pulmonary: Trach, weaning vent ( currently), Vanc/cipro/cefepime for\n VAP (). Improving pulmonary edema. Continued diuresis. TM trial\n today, follow ABGs. Aggressive chest Pt as e/o collapse on RLL.\n Gastrointestinal / Abdomen: Unknown elevated LFTs and bilirubin w/CT\n scan suggesting cirrhosis - Hepatitis panel NEG, RUQ U/S r/o\n gallbladder etiology, will continue to trend. Nutren 2.0 @ goal 40\n cc/hr. Bowel regimen (d/c Lactulose). C diff negative x 3.\n Nutrition: Tube feeding, Nutren. At goal.\n Renal: Foley, monitor UOP, edematous scrotum. Diamox 250 q12 for\n contraction alkalosis. Lasix 20x2 on . Hypernatremia,\n hyperchloremia. Goal 1.5 L negative today as total volume up from\n admission.\n Hematology: Hct stable (28.2). Plt stable (178-196); d/c'd H2B. Heme\n onc c/s - smear nl; no hemolysis. IVC filter.\n Endocrine: RISS, goal BS<150. Adequate control.\n Infectious Disease: WBC normal, on Vanc/cipro/cefepime for VAP given\n worsening pulm status, f/u on cx. Plan for total 7 days of abx, given\n only GNRs in cx data will d/c Vanco.\n Lines / Tubes / Drains: Trach/Peg/foley/L radial a-line/L basilic PICC,\n SCL (will d/c SCL once midline)\n Wounds:\n Imaging: CXR today\n Fluids: KVO\n Consults: Trauma (1o), Ortho Spine, Ortho trauma, Heme, PT/OT.\n Billing Diagnosis: (Shock: Unspecified), Multiple injuries (Trauma)\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 07:46 PM 40 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 04:41 PM\n Arterial Line - 11:30 AM\n PICC Line - 06:02 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin, IVC filter\n Stress ulcer: PPI (thrombocytopenia possibly from H2B)\n VAP bundle: HOB elevation, Mouth care\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n rehab screen\n Total time spent: 33 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2175-02-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 715230,
"text": "Nursing 0700-1100\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt. s/p crush injury/multiple trauma. Trach in place, received pt. on\n PSV 5/5 with RR 28-35. \n pt. remains in SR with PRI.27.\n Action:\n Pt. turned, CPT\nd Q2hrs. Suctioned hourly for moderate amts pale\n yellowish-white creamy thick secretions. Antibiotics as ordered, Vanco\n d/c\nd this a.m. CVL d/c\n Response:\n Pt. presently restful and less tachypneic. When awake, RR remains 30,\n and after turning RR towards 40 with long recovery time.\n Plan:\n OOB today with TLSO brace. ??Trach mask trial when in chair if\n clinincal picture allows. Rehab screening in progress.\n"
},
{
"category": "Rehab Services",
"chartdate": "2175-02-06 00:00:00.000",
"description": "Physical Therapy Progress Note",
"row_id": 715237,
"text": "Subjective:\n Objective:\n Follow up PT visit to address goals of: . Patient seen today\n for balance training, patient education\n Updated medical status: CXR - Bibasilar opacification persists,\n consistent with atelectasis and effusion; UE US pending\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Rolling:\n\n\n\n\n T\n Supine/\n Sidelying to Sit:\n\n\n\n T\n\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n\n\n\n X2\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Aerobic Activity Response:\n Position\n HR\n BP\n RR\n O[2] sat\n RPE\n Rest\n Supine\n 90\n 134/58\n 26\n 100% on CPAP\n Activity\n Sit\n 98\n 126/50\n 34\n 90% on CPAP\n Recovery\n Sit\n 92\n 130/51\n 28\n 100% on CPAP\n Total distance walked: 0\n Minutes:\n Gait: able to attain full upright standing with max verbal and tactile\n cues to extend hips and trunk.\n Balance: able to maintain static sitting at edge once positioned, able\n to weight shift anteriorly and laterally with min A. Able to attain\n static standing with max A x2, and maintain x10-15 sec with increased\n hip flexion and forward trunk flexion.\n Education / Communication: Reviewed PT and encouraged OOB.\n Communicated with nsg re: status and MD re: bracing.\n Other: On CPAP 5/10 PEEP/PS, 40% FiO2\n c/o R>L hip/thigh pain with standing\n Assessment: 74 yo M s/p crush injury with multiple fractures, making\n good progress in PT with mobility and strength, continues to be limited\n by general weakness and deconditioning a/w prolonged hospitalization.\n He continues to be well below his baseline but has excellent rehab\n potential given his prior level of function.\n Anticipated Discharge: Rehab\n Plan: continue with \n"
},
{
"category": "Rehab Services",
"chartdate": "2175-02-06 00:00:00.000",
"description": "Physical Therapy Progress Note",
"row_id": 715238,
"text": "Subjective:\n Objective:\n Follow up PT visit to address goals of: . Patient seen today\n for balance training, patient education\n Updated medical status: CXR - Bibasilar opacification persists,\n consistent with atelectasis and effusion; UE US pending\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Rolling:\n\n\n\n\n T\n Supine/\n Sidelying to Sit:\n\n\n\n T\n\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n\n\n\n X2\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Aerobic Activity Response:\n Position\n HR\n BP\n RR\n O[2] sat\n RPE\n Rest\n Supine\n 90\n 134/58\n 26\n 100% on CPAP\n Activity\n Sit\n 98\n 126/50\n 34\n 90% on CPAP\n Recovery\n Sit\n 92\n 130/51\n 28\n 100% on CPAP\n Total distance walked: 0\n Minutes:\n Gait: able to attain full upright standing with max verbal and tactile\n cues to extend hips and trunk.\n Balance: able to maintain static sitting at edge once positioned, able\n to weight shift anteriorly and laterally with min A. Able to attain\n static standing with max A x2, and maintain x10-15 sec with increased\n hip flexion and forward trunk flexion.\n Education / Communication: Reviewed PT and encouraged OOB.\n Communicated with nsg re: status and MD re: bracing.\n Other: On CPAP 5/10 PEEP/PS, 40% FiO2\n c/o R>L hip/thigh pain with standing\n Assessment: 74 yo M s/p crush injury with multiple fractures, making\n good progress in PT with mobility and strength, continues to be limited\n by general weakness and deconditioning a/w prolonged hospitalization.\n He continues to be well below his baseline but has excellent rehab\n potential given his prior level of function.\n Anticipated Discharge: Rehab\n Plan: continue with \n"
},
{
"category": "Physician ",
"chartdate": "2175-02-05 00:00:00.000",
"description": "Intensivist Note",
"row_id": 715034,
"text": "TSICU\n HPI:\n 74M s/p fall with multiple rib fx, pelvis fx, clavicle fx, and thoracic\n fx c/b unstable bleeding s/p IR embo, AF with RVR/Aflutter, now in\n sinus, and PNA.\n Chief complaint:\n Fall\n PMHx:\n none\n Current medications:\n 1. Acetaminophen 4. AcetaZOLamide 2. Amiodarone 3. Bisacodyl 4. Calcium\n Gluconate 5. CefePIME 6. Chlorhexidine Gluconate 0.12% Oral Rinse 7.\n Ciprofloxacin HCl 8. Dextrose 50% 9. Diltiazem 10. Docusate Sodium\n (Liquid) 11. Furosemide 12. Gabapentin 13. Glucagon 14. Heparin 15.\n Insulin\n 16. Lactulose 17. Lansoprazole Oral Disintegrating Tab 18. Magnesium\n Sulfate 19. Metoprolol Tartrate 20. Milk of Magnesia 21. Olanzapine\n (Disintegrating Tablet) 22. Ondansetron 23. OxycoDONE Liquid 24.\n Pneumococcal Vac Polyvalent 25. Potassium Chloride 26. Potassium\n Phosphate 27. Potassium Chloride 28. Senna 32. Sodium Chloride 0.9%\n Flush 30. Sodium Chloride 0.9% Flush 31. Vancomycin\n 24 Hour Events:\n Started Diamox 500 x4 for contraction alkalosis due to Lasix, also\n given Lasix 20 IV x1 with 1774 off.\n Diltiazem gtt stopped and restarted po.\n d/c'd Haldol and started standing Zyprexa.\n Post operative day:\n POD#10 - IVC filter via L groin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:26 PM\n Ciprofloxacin - 10:48 PM\n Cefipime - 12:48 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 06:00 PM\n Heparin Sodium (Prophylaxis) - 03:48 AM\n Other medications:\n Flowsheet Data as of 05:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38\nC (100.4\n T current: 37.4\nC (99.4\n HR: 87 (71 - 104) bpm\n BP: 143/60(85) {83/38(59) - 158/63(90)} mmHg\n RR: 27 (17 - 32) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 104.2 kg (admission): 90 kg\n Total In:\n 1,956 mL\n 136 mL\n PO:\n Tube feeding:\n 560 mL\n IV Fluid:\n 1,006 mL\n 76 mL\n Blood products:\n Total out:\n 3,730 mL\n 1,140 mL\n Urine:\n 3,730 mL\n 1,140 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,774 mL\n -1,004 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 379 (379 - 713) mL\n PS : 12 cmH2O\n RR (Spontaneous): 33\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 24 cmH2O\n SPO2: 99%\n ABG: 7.45/35/169/24/1\n Ve: 15.2 L/min\n PaO2 / FiO2: 422\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm)\n Right Extremities: (Edema: Trace), (Temperature: Warm)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities\n Labs / Radiology\n 178 K/uL\n 8.8 g/dL\n 108 mg/dL\n 1.0 mg/dL\n 24 mEq/L\n 3.8 mEq/L\n 23 mg/dL\n 113 mEq/L\n 143 mEq/L\n 28.4 %\n 5.2 K/uL\n [image002.jpg]\n 07:20 PM\n 12:35 AM\n 01:04 AM\n 06:28 AM\n 08:00 AM\n 01:10 PM\n 05:03 PM\n 06:07 PM\n 01:55 AM\n 02:04 AM\n WBC\n 6.5\n 5.2\n Hct\n 29.0\n 28.4\n Plt\n 124\n 178\n Creatinine\n 0.8\n 0.9\n 1.0\n TCO2\n 34\n 32\n 30\n 29\n 25\n Glucose\n 130\n 103\n 121\n 130\n 113\n 119\n 108\n Other labs: PT / PTT / INR:14.0/28.1/1.2, CK / CK-MB / Troponin\n T:128/13/<0.01, ALT / AST:104/137, Alk-Phos / T bili:204/4.8, Amylase /\n Lipase:54/52, D-dimer: ng/mL, Fibrinogen:510 mg/dL, Lactic\n Acid:1.1 mmol/L, Albumin:2.3 g/dL, LDH:348 IU/L, Ca:8.3 mg/dL, Mg:2.4\n mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx c/b unstable bleeding s/p IR embo, AF with\n RVR/Aflutter, now in sinus, and PNA.\n Neurologic: s/p trach (). Per ortho spine, no surgery; HOB<30,\n TLSO when OOB. Zyprexa 10 TID (off fent/midaz ).\n Neuro checks Q: shift\n Pain: Oxycodone, Neurontin, Tylenol.\n Cardiovascular: Aflutter->NSR, on Amio and diltizem 60 QID. Likely \n cardiac contusion. Cards for Amio rec 400'' x 1wk, then 400'x1 wk, then\n 200'. Pt cannot be fully anticoagulated for now (trauma).\n Pulmonary: Trach, weaning vent, Vanc/cipro/cefepime for VAP ().\n Improving pulmonary edema. consider therapeutic thoracentesis \n if no improvement with diuresis, lots of secretions, consider\n bronchoscopy\n Gastrointestinal / Abdomen: Unknown elevated LFTs and bilirubin w/CT\n scan suggesting cirrhosis - Hepatitis panel NEG, RUQ U/S r/o\n gallbladder etiology, will continue to trend. On Nutren 2.0 with goal\n 40 cc/hr. Bowel regimen.\n Nutrition: Tube feeding\n Renal: Foley, monitor UOP, edematous scrotum. Diamox 500 q12 for\n contraction alkalosis.\n Hematology: Hct stable 28.9->29. Plt stable (100's); d/c'd H2B. Heme\n onc c/s - smear nl; no hemolysis. IVC filter placed.\n Endocrine: RISS\n Infectious Disease: WBC normal, on Vanc/cipro/cefepime for VAP given\n worsening pulm status, f/u on cx\n Lines / Tubes / Drains: Trach/Peg/foley/L radial a-line/R SCL\n Wounds:\n Imaging: CXR today\n Fluids: KVO\n Consults: Trauma (1o), Ortho Spine, Ortho trauma, Heme\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 04:41 PM\n Arterial Line - 11:30 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin, IVC filter\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2175-02-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 715142,
"text": "PICC placed.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Ls clear to diminished, strong productive cough, suctioned for large\n amounts of thick yellow sputum. Afebrile all day. Remains in a NSR.\n Pt refused to get OOB due to having to wear TLSO brace.\n Action:\n Continuing diamox and Lasix for diuresis. Electrolytes replaced.\n Response:\n UOP good. Neuro status intact, appropriate.\n Plan:\n PM CXR pending. Screen for rehab in AM.\n"
},
{
"category": "Nursing",
"chartdate": "2175-02-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 715284,
"text": "74M s/p crushing injury d/t falling tree. Injuries sustained include\n multiple R sided rib fxs, grade 2 liver lac (w/ assoc hepatic vessel\n extravasation), stable pelvis fxs (w/ associated extravasation), R\n ramus fx, clavicle fx, and T4 vertebral body fx. Episodes of A.\n Flutter with RVR and aflutter, now with resp failure and newly dx\n pneumonia as of .\n intubated for resp distress\n angio embolization of hepatic and pelvic arterial bleeders\n IVC filter in OR\n self extubated and re-intubated immediately after d/t acute resp.\n failure\n Trach and PEG at bedside\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt alert, follows commands, MAE\ns purposefully. Nods yes to R sided\n rib discomfort, but mouths that it is tolerable, currently declining\n pain meds.\n Pt remains in SR, conts. Diltiazem via PEG. DL midline intact with\n 25cm coiled outside of skin; +blood return, flushes easily.\n LS with rhonchi throughout, suctioned for sm. to moderate amts. Thick\n white secretions. RR remains in 30\n Abd soft, NT/D, BS present, incontinent sm. to medium soft, brown BM.\n Conts. TF at goal 40cc/hr with no residuals.\n Foley patent draining adequate amts. Yellow urine.\n Endo: BS 128, no coverage per sliding scale.\n Tmax 100.6po, conts. Cefipime as ordered.\n Mulitple areas of ecchymosis, see metavision.\n Pt\ns companion in this afternoon, pt\ns son also telephoned\n for update.\n Action:\n Frequent repositioning/pulmonary hygiene provided. Cons. Dilt. As\n ordered.\n Midline dsg changed.\n and updated by this RN; plan for son to touch base\n with case management tomorrow regarding rehab\n possibilities.\n Pt dangled a edge of bed and stood at edge of bed with PT, see PT\n note. OOB to chair for approx. 3hours, tolerated well.\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2175-02-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 715287,
"text": "74M s/p crushing injury d/t falling tree. Injuries sustained include\n multiple R sided rib fxs, grade 2 liver lac (w/ assoc hepatic vessel\n extravasation), stable pelvis fxs (w/ associated extravasation), R\n ramus fx, clavicle fx, and T4 vertebral body fx. Episodes of A.\n Flutter with RVR and aflutter, now with resp failure and newly dx\n pneumonia as of .\n intubated for resp distress\n angio embolization of hepatic and pelvic arterial bleeders\n IVC filter in OR\n self extubated and re-intubated immediately after d/t acute resp.\n failure\n Trach and PEG at bedside\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt alert, follows commands, MAE\ns purposefully. Nods yes to R sided\n rib discomfort, but mouths that it is tolerable, currently declining\n pain meds.\n Pt remains in SR, conts. Diltiazem via PEG. DL midline intact with\n 25cm coiled outside of skin; +blood return, flushes easily.\n LS with rhonchi throughout, suctioned for sm. to moderate amts. Thick\n white secretions. RR remains in 30\n Abd soft, NT/D, BS present, incontinent sm. to medium soft, brown BM.\n Conts. TF at goal 40cc/hr with no residuals.\n Foley patent draining adequate amts. Yellow urine.\n Endo: BS 128, no coverage per sliding scale.\n Tmax 100.6po, conts. Cefipime as ordered.\n Mulitple areas of ecchymosis, see metavision.\n Pt\ns companion in this afternoon, pt\ns son also telephoned\n for update.\n Action:\n Frequent repositioning/pulmonary hygiene provided. Cons. Dilt. As\n ordered.\n Midline dsg changed.\n and updated by this RN; plan for son to touch base\n with case management tomorrow regarding rehab\n possibilities.\n Pt dangled a edge of bed and stood at edge of bed with PT, see PT\n note. OOB to chair for approx. 3hours, tolerated well.\n Response:\n Pt tachypneic with RR up to 40\ns after turning activity with prolonged\n recovery time.\n Currently on 10PS/5 PEEP/40%.\n Plan:\n Monitor VS, hemodynamics, I/O, labs. Cont. aggressive pulmonary\n hygiene, frequent repositioning.\n Wean vent as able, attempt trach mask trial if/when appropriate. Cont.\n rehab screening process.\n Double lumen midline remains coiled outside skin. ?antibiotic course\n complete in next few days. If there is a need for prolonged abx\n course, ? IR for PICC replacement. Follow up with case management and\n family regarding specific rehabs on . Cont. ongoing open\n communication, comfort, and support to pt and family.\n"
},
{
"category": "Nursing",
"chartdate": "2175-02-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 715352,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains on psv 10, 5peep and 40% with stable abg and 02sats. Remains\n tachypneic, 30\ns but denies distress. LS w/ rhonci throughout.\n Copious thick yellow secretions. Strong productive cough but cannot\n clear.\n Action:\n Pulm toilet, Frequent suctioning required.\n Response:\n Stable on psv 10/5 but cont with copious secretions despite frequent\n sxning.\n Plan:\n Will attempt psv 5 in am and recheck ABG. Not ready for TM due to\n copious secretions and tachpynea. Cont w/ oob to chair as tolerated.\n Cont pulm toilet.\n Activity Intolerance\n Assessment: Pt assisting with movement and aable to use swabs\n independently with supervision. Washing face independently.\n Action: Encourage pt to increase participation in care.\n Response: More interactive and asking to do things for himself.\n Plan: Increase activity as tolerated. Encourage participation in\n care. Have pt assist with bath when oob-chair during the day.\n Encourage normal sleep pattern.\n"
},
{
"category": "Nursing",
"chartdate": "2175-01-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 713466,
"text": "s/p hit by falling tree, crushing injury to right chest, pelvis,\n thorasic fx, liver lac.\n Trauma, s/p\n Assessment:\n Patient sleeping comfortably all night. Pain well controlled with\n Dilaudid PCA using IS frequently with TV 1000. Cough weak but\n productive. NPO overnight for ? OR today. UOP marginal with increasing\n Creatinine, responding slightly to IVF bolus. Afebrile, blood sugars\n requiring minimal insulin coverage. At 0600 HR 150s, ST with poor\n respiratory status. ABG showing worsening acidosis. Pt was increasingly\n lethargic but remained oriented times 3. LS very diminished which was a\n change from being clear over night. HR not responding it intervention\n and became hypotensive. Pt was intubated at 0630 successfully. Hct\n drifting to 23.\n Action:\n Fluid bolus for UOP. EKG done, esmolol bolus given, 1 unit PRBC, Lasix\n bolus given, patient intubated at 0630.\n Response:\n Cough improving post intubation suctioning copious amounts of tenacious\n yellow secretions.\n Plan:\n Bicarb gtt prior to IR. Emergently to IR this am, ? CTA of chest to R/O\n PE. Maintain hemodynamic stability with blood product transfusions and\n vasopressors as needed. Awaiting TLSO brace must be less than 30\n degrees without brace.\n"
},
{
"category": "Physician ",
"chartdate": "2175-01-25 00:00:00.000",
"description": "Intensivist Note",
"row_id": 713469,
"text": "TSICU\n HPI:\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\n checked and 1.5, 1 more unit FFP given.\n Injuries\n Mult rib fx: R anterolateral and post, L posterior\n T4 vert body inf corner fx\n Commin spinous process fx T2-8\n Nondisplaced left T10 transverse process\n Nondispaced L distal clavicle\n Nondisplaced L clavicle fx\n R medial lobe liver contusion with hematoma\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny\n focus of arterial bleeding/active extravasation, and larger area\n of venous bleeding\n Nondisplaced, comminuted L iliac bone fracture w/adjacent iliac muscle\n hematoma, Fracture extends into left SI joint.\n Minimally displaced fracture of the right iliac bone extending to right\n SI joint.\n Chief complaint:\n pain\n PMHx:\n none\n Current medications:\n Acetaminophen 5. Calcium Gluconate 6. Dextrose 50% 7. Docusate Sodium\n (Liquid)\n 8. Famotidine 9. Gabapentin 10. Glucagon 11. HYDROmorphone (Dilaudid)\n 12. Insulin 13. Magnesium Sulfate\n 14. Ondansetron 15. Pneumococcal Vac Polyvalent 16. Potassium Chloride\n 17. Sodium Chloride 0.9% Flush\n 18. Sodium Phosphate\n 24 Hour Events:\n ARTERIAL LINE - START 10:59 AM\n : Hct stable. APS c/s for possible epidural--awaiting ortho spine\n plan. Tylenol, neurontin, dilaudid for pain. Ortho non op, will\n reassess . Per ortho spine, no surgical intervention; HOB<30, TLSO\n when OOB.\n : CR increased to 1.6, LFTs elevated in 500s. Bolused 500c x2 for\n low urine output\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 PM\n Other medications:\n Flowsheet Data as of 04:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.3\nC (97.3\n T current: 35.9\nC (96.6\n HR: 99 (80 - 102) bpm\n BP: 96/45(61) {94/45(61) - 126/65(84)} mmHg\n RR: 18 (10 - 25) insp/min\n SPO2: 90%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 90 kg (admission): 90 kg\n Total In:\n 3,960 mL\n 1,473 mL\n PO:\n 510 mL\n Tube feeding:\n IV Fluid:\n 3,450 mL\n 1,473 mL\n Blood products:\n Total out:\n 855 mL\n 195 mL\n Urine:\n 855 mL\n 195 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,105 mL\n 1,278 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SPO2: 90%\n ABG: 7.29/54/77./25/-1\n PaO2 / FiO2: 156\n Physical Examination\n General Appearance: No acute distress, Well nourished\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: Diminished: at bases), (Sternum:\n Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 89 K/uL\n 8.2 g/dL\n 123 mg/dL\n 1.6 mg/dL\n 25 mEq/L\n 5.1 mEq/L\n 36 mg/dL\n 110 mEq/L\n 140 mEq/L\n 24.1 %\n 15.5 K/uL\n [image002.jpg]\n 02:00 AM\n 04:29 AM\n 07:36 AM\n 10:54 AM\n 04:13 PM\n 05:25 PM\n 10:38 PM\n 10:56 PM\n 03:24 AM\n 03:44 AM\n WBC\n 13.7\n 15.5\n Hct\n 31.9\n 28.3\n 28.9\n 27.7\n 25.7\n 24.1\n Plt\n 127\n 89\n Creatinine\n 1.2\n 1.6\n 1.6\n TCO2\n 27\n 28\n 27\n Glucose\n 140\n 181\n 130\n 123\n Other labs: PT / PTT / INR:14.7/27.7/1.3, CK / CK-MB / Troponin\n T:1349//, ALT / AST:559/522, Alk-Phos / T bili:39/0.9, Lactic Acid:1.7\n mmol/L, LDH:616 IU/L, Ca:8.0 mg/dL, Mg:2.3 mg/dL, PO4:5.7 mg/dL\n Imaging: CXR Pend\n Pelvis Pend\n CT head OSH: Prelim No ICH or fracture.\n CT chest OSH: Mult rib fx: R anterolateral and posterior, L\n posterior; Dependent consolidation, possible aspiration; T4 vertebral\n body inf corner fx, no retropulsion; Comminuted spinous process fx\n T2-8; Nondisplaced L T10 transverse process; Nondisplaced L clavicle\n distal fx; Nondisplaced L scapula fx;\n CT c spine OSH: Prelim No fx or malalignment. Multilevel\n degenerative changes w/large post disk bulge at C4-5, narrowing the\n spinal canal and deforming the thecal sac, acuity unknown. Marked\n neuroforamenal narrowing @multiple levels.\n CTA abd/pel Prelim: Medial R liver lobe contusion w/adj\n hematoma, w/o evidence of active bleeding; Comminuted L pubic ramus\n fracture w/assoc hematoma, with tiny focus of arterial bleeding/active\n extravasation, and larger area of venous bleeding. Hematoma somewhat\n larger than on OSH study. Nondisplaced, comminuted L iliac bone fx\n w/adj iliac muscle hematoma, larger than on prior study, w/o active\n extrav. Fx extends into L SI joint. Post R hepatic laceration/contusion\n adjacent to calcified granuloma, w/small hematoma, without active\n bleeding. Min displaced fx of R iliac bone extending to R SI joint.\n Cirrhotic liver. Inc B pleural effusions (small), w/inc atelectasis.\n MRI: Mild compression deformity of L1 with additional levels of\n potential trabecular contusion @T10-11 also inf @T4 w/o retropulsion.\n Multilevel degenerative changes with moderate canal narrowing at T10-11\n w/cord deformity and no abnormal cord signal. Extensive edema\n throughout the paraspinal soft tissues, predominantly\n post w/in interspinous ligaments. Incompletely evaluated c-spine w/\n severe canal narrowing @C4-5 w/cord deformity and no abnormal cord\n signal.\n Assessment and Plan\n TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx.\n Neurologic: Neuro checks Q: 4 hr, Pain controlled, C-spine cleared. Per\n ortho spine, no surgical intervention; HOB<30, TLSO when OOB. Use\n ativan and fentanyl for sedation.\n Neuro checks Q: shift\n Pain: Dilaudid PCA 0.25/2.5, may require epidural (APS awaiting ortho\n spine plan)\n changed to fentanyl while now intubated. Neurontin,\n Tylenol. Will place paravetebral catheters for analgesia.\n Cardiovascular: Stable currently, SBP into 90s on , but in 120s\n after a-line placed. TTE with adequate CO, low SVR state, e/o RV\n pressure overload but good contractility. Place Vigileo.\n Pulmonary: IS, On face tent 70% O2, monitor, may require intubation.\n f/u CXR . Excellent tidal volumes of > 1L. Early this am\n developed progressive respiratory acidosis. Will obtain pulm\n angiogram as well.\n Gastrointestinal / Abdomen: NPO after MN for possible OR (pelvis).\n Increasing LFTs (in 500s on ); h/o cirrhosis.\n Nutrition: Regular diet, Advance diet as tolerated\n Renal: Foley, Adequate UO, Foley, monitor UOP, f/u lytes, and trend\n Cr. Given ~1L bolus o/n for decreasing uop.\n Hematology: Serial Hct, Monitor Hct q6\n 35.1-32.2-31.9-28.3-28.9-27.7-25.7-24.1, Monitor coags INR 1.3. If\n actively bleeding may need Angio.\n Endocrine: RISS, goal BS<150.\n Infectious Disease: Check cultures, afebrile, but elevated wbc to\n 15.5.\n Lines / Tubes / Drains: Foley, RIJ CVL (d/c if stable), PIV x2,\n Foley, a-line (). Will change CVL now.\n Wounds:\n Imaging: CXR today\n Fluids: LR, LR@100 currently, KVO if taking POs\n Consults: Trauma surgery, Ortho, Ortho-spine, Trauma (1o), Ortho Spine,\n Ortho trauma\n Billing Diagnosis: Multiple injuries (Trauma)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 09:00 PM\n 18 Gauge - 09:00 PM\n 20 Gauge - 09:00 PM\n Arterial Line - 10:59 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition:\n Total time spent:\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2175-01-25 00:00:00.000",
"description": "Intensivist Note",
"row_id": 713488,
"text": "TSICU\n HPI:\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\n checked and 1.5, 1 more unit FFP given.\n Injuries\n Mult rib fx: R anterolateral and post, L posterior\n T4 vert body inf corner fx\n Commin spinous process fx T2-8\n Nondisplaced left T10 transverse process\n Nondispaced L distal clavicle\n Nondisplaced L clavicle fx\n R medial lobe liver contusion with hematoma\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny\n focus of arterial bleeding/active extravasation, and larger area\n of venous bleeding\n Nondisplaced, comminuted L iliac bone fracture w/adjacent iliac muscle\n hematoma, Fracture extends into left SI joint.\n Minimally displaced fracture of the right iliac bone extending to right\n SI joint.\n Chief complaint:\n pain\n PMHx:\n none\n Current medications:\n Acetaminophen 5. Calcium Gluconate 6. Dextrose 50% 7. Docusate Sodium\n (Liquid)\n 8. Famotidine 9. Gabapentin 10. Glucagon 11. HYDROmorphone (Dilaudid)\n 12. Insulin 13. Magnesium Sulfate\n 14. Ondansetron 15. Pneumococcal Vac Polyvalent 16. Potassium Chloride\n 17. Sodium Chloride 0.9% Flush\n 18. Sodium Phosphate\n 24 Hour Events:\n ARTERIAL LINE - START 10:59 AM\n : Hct stable. APS c/s for possible epidural--awaiting ortho spine\n plan. Tylenol, neurontin, dilaudid for pain. Ortho non op, will\n reassess . Per ortho spine, no surgical intervention; HOB<30, TLSO\n when OOB.\n : CR increased to 1.6, LFTs elevated in 500s. Bolused 500c x2 for\n low urine output\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 PM\n Other medications:\n Flowsheet Data as of 04:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.3\nC (97.3\n T current: 35.9\nC (96.6\n HR: 99 (80 - 102) bpm\n BP: 96/45(61) {94/45(61) - 126/65(84)} mmHg\n RR: 18 (10 - 25) insp/min\n SPO2: 90%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 90 kg (admission): 90 kg\n Total In:\n 3,960 mL\n 1,473 mL\n PO:\n 510 mL\n Tube feeding:\n IV Fluid:\n 3,450 mL\n 1,473 mL\n Blood products:\n Total out:\n 855 mL\n 195 mL\n Urine:\n 855 mL\n 195 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,105 mL\n 1,278 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SPO2: 90%\n ABG: 7.29/54/77./25/-1\n PaO2 / FiO2: 156\n Physical Examination\n General Appearance: No acute distress, Well nourished\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: Diminished: at bases), (Sternum:\n Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 89 K/uL\n 8.2 g/dL\n 123 mg/dL\n 1.6 mg/dL\n 25 mEq/L\n 5.1 mEq/L\n 36 mg/dL\n 110 mEq/L\n 140 mEq/L\n 24.1 %\n 15.5 K/uL\n [image002.jpg]\n 02:00 AM\n 04:29 AM\n 07:36 AM\n 10:54 AM\n 04:13 PM\n 05:25 PM\n 10:38 PM\n 10:56 PM\n 03:24 AM\n 03:44 AM\n WBC\n 13.7\n 15.5\n Hct\n 31.9\n 28.3\n 28.9\n 27.7\n 25.7\n 24.1\n Plt\n 127\n 89\n Creatinine\n 1.2\n 1.6\n 1.6\n TCO2\n 27\n 28\n 27\n Glucose\n 140\n 181\n 130\n 123\n Other labs: PT / PTT / INR:14.7/27.7/1.3, CK / CK-MB / Troponin\n T:1349//, ALT / AST:559/522, Alk-Phos / T bili:39/0.9, Lactic Acid:1.7\n mmol/L, LDH:616 IU/L, Ca:8.0 mg/dL, Mg:2.3 mg/dL, PO4:5.7 mg/dL\n Imaging: CXR Pend\n Pelvis Pend\n CT head OSH: Prelim No ICH or fracture.\n CT chest OSH: Mult rib fx: R anterolateral and posterior, L\n posterior; Dependent consolidation, possible aspiration; T4 vertebral\n body inf corner fx, no retropulsion; Comminuted spinous process fx\n T2-8; Nondisplaced L T10 transverse process; Nondisplaced L clavicle\n distal fx; Nondisplaced L scapula fx;\n CT c spine OSH: Prelim No fx or malalignment. Multilevel\n degenerative changes w/large post disk bulge at C4-5, narrowing the\n spinal canal and deforming the thecal sac, acuity unknown. Marked\n neuroforamenal narrowing @multiple levels.\n CTA abd/pel Prelim: Medial R liver lobe contusion w/adj\n hematoma, w/o evidence of active bleeding; Comminuted L pubic ramus\n fracture w/assoc hematoma, with tiny focus of arterial bleeding/active\n extravasation, and larger area of venous bleeding. Hematoma somewhat\n larger than on OSH study. Nondisplaced, comminuted L iliac bone fx\n w/adj iliac muscle hematoma, larger than on prior study, w/o active\n extrav. Fx extends into L SI joint. Post R hepatic laceration/contusion\n adjacent to calcified granuloma, w/small hematoma, without active\n bleeding. Min displaced fx of R iliac bone extending to R SI joint.\n Cirrhotic liver. Inc B pleural effusions (small), w/inc atelectasis.\n MRI: Mild compression deformity of L1 with additional levels of\n potential trabecular contusion @T10-11 also inf @T4 w/o retropulsion.\n Multilevel degenerative changes with moderate canal narrowing at T10-11\n w/cord deformity and no abnormal cord signal. Extensive edema\n throughout the paraspinal soft tissues, predominantly\n post w/in interspinous ligaments. Incompletely evaluated c-spine w/\n severe canal narrowing @C4-5 w/cord deformity and no abnormal cord\n signal.\n Assessment and Plan\n TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx.\n Neurologic: Neuro checks Q: 4 hr, Pain controlled, C-spine cleared. Per\n ortho spine, no surgical intervention; HOB<30, TLSO when OOB. Use\n ativan and fentanyl for sedation.\n Neuro checks Q: shift\n Pain: Dilaudid PCA 0.25/2.5, may require epidural (APS awaiting ortho\n spine plan)\n changed to fentanyl while now intubated. Neurontin,\n Tylenol. may place paravetebral catheters for analgesia.\n Cardiovascular: Stable currently, SBP into 90s on , but in 120s\n after a-line placed. TTE with adequate CO, low SVR state, e/o RV\n pressure overload but good contractility. place the or\n Vigilleo. Hypotension/shock on phenylephrine. Normal LV function,\n dilated RV. Could be from PE (See below). Currently on phenylephrine.\n Will re-evaluate post IR procedure.\n Pulmonary:. Early this am developed progressive respiratory acidosis\n and hypotension. Given signs of RV dilatation (although no classical\n sign of PE) will send for CTA (Torso, given continued bleeding).\n Gastrointestinal / Abdomen: NPO after MN for possible OR (pelvis).\n Increasing LFTs (in 500s on ); h/o cirrhosis.\n Nutrition: NPO for now\n Renal: Foley, Adequate UO, Foley, monitor UOP, f/u lytes, and trend\n Cr. Given ~1L bolus o/n for decreasing uop. CRI appears to slightly\n improve. Will hydrate with bicarb gtt for anticipated dye load.\n Hematology: Serial Hct, Monitor Hct q6\n 35.1-32.2-31.9-28.3-28.9-27.7-25.7-24.1, Monitor coags INR 1.3. If\n actively bleeding may need Angio.\n Endocrine: RISS, goal BS<150.\n Infectious Disease: Check cultures, afebrile, but elevated wbc to\n 15.5.\n Lines / Tubes / Drains: Foley, RIJ CVL (d/c if stable), PIV x2,\n Foley, a-line (). Will change CVL today.\n Wounds:\n Imaging: CXR today\n Fluids: LR, LR@100 currently, KVO if taking POs\n Consults: Trauma surgery, Ortho, Ortho-spine, Trauma (1o), Ortho Spine,\n Ortho trauma\n Billing Diagnosis: Multiple injuries (Trauma)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 09:00 PM\n 18 Gauge - 09:00 PM\n 20 Gauge - 09:00 PM\n Arterial Line - 10:59 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 40 min\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2175-01-24 00:00:00.000",
"description": "Intensivist Note",
"row_id": 713330,
"text": "TSICU\n HPI:\n 74 yo male s/p fall from tractor and crush injury from tree branch.\n +Loc. At OSH received 4 units prbcs, 1 unit FFP for INR 4. +HD stable\n here. INR checked and 1.5, 1 more unit FFP given.\n Injuries\n Mult rib fx: R anterolateral and post, L posterior\n T4 vert body inf corner fx\n Commin spinous process fx T2-8\n Nondisplaced left T10 transverse process\n Nondispaced L distal clavicle\n R medial lobe liver contusion with hematoma\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny\n focus of arterial bleeding/active extravasation, and larger area of\n venous bleeding\n Nondisplaced, comminuted L iliac bone fracture w/adjacent iliac muscle\n hematoma, Fracture extends into left SI joint.\n Minimally displaced fracture of the right iliac bone extending to right\n SI joint.\n Chief complaint:\n fall\n PMHx:\n None\n Current medications:\n 1. Calcium Gluconate 2. Dextrose 50% 3. Docusate Sodium (Liquid) 4.\n Famotidine 5. Glucagon 6. HYDROmorphone (Dilaudid) 7. Insulin 8.\n Magnesium Sulfate 9. Pneumococcal Vac Polyvalent 10. Potassium Chloride\n 11. Sodium Chloride 0.9% Flush 12. Sodium Phosphate\n 24 Hour Events:\n MULTI LUMEN - START 09:00 PM\n NASAL SWAB - At 12:00 AM\n C-SPINE CLEARANCE - At 12:00 AM\n MAGNETIC RESONANCE IMAGING - At 02:17 AM Thoracic spine\n - Started on Dilaudid PCA with good effect, breathing improved. Weaned\n down oxygen to face tent. Remained HD stable overnight, although SBP\n dropped to 70s transiently this AM\n bolused 1 L NS. Thoracic MRI\n performed.\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 10:00 PM\n Fentanyl - 12:00 AM\n Other medications:\n Flowsheet Data as of 06:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.7\nC (98\n T current: 35.7\nC (96.2\n HR: 88 (88 - 99) bpm\n BP: 91/65(71) {91/52(66) - 135/72(89)} mmHg\n RR: 25 (24 - 35) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 90 kg (admission): 90 kg\n Total In:\n 6,105 mL\n 593 mL\n PO:\n Tube feeding:\n IV Fluid:\n 305 mL\n 593 mL\n Blood products:\n Total out:\n 595 mL\n 300 mL\n Urine:\n 395 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,510 mL\n 293 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SPO2: 100%\n ABG: 7.35/41/112/23/-2\n PaO2 / FiO2: 160\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: shallow respirations)\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: No(t) Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 127 K/uL\n 10.5 g/dL\n 181 mg/dL\n 1.2 mg/dL\n 23 mEq/L\n 5.2 mEq/L\n 21 mg/dL\n 110 mEq/L\n 140 mEq/L\n 31.9 %\n 13.7 K/uL\n [image002.jpg]\n 09:00 PM\n 11:04 PM\n 11:22 PM\n 04:29 AM\n WBC\n 13.7\n Hct\n 32.2\n 31.9\n Plt\n 127\n Creatinine\n 1.2\n TCO2\n 23\n 24\n Glucose\n 181\n Other labs: PT / PTT / INR:15.0/26.4/1.3, Lactic Acid:2.8 mmol/L,\n LDH:616 IU/L, Ca:8.1 mg/dL, Mg:1.8 mg/dL, PO4:4.9 mg/dL\n Assessment and Plan\n TRAUMA, S/P fall from tractor.\n Assessment and Plan: 74 yo M s/p fall with multiple rib fractures,\n pelvis fractures, clavicle fx, and thoracic fractures.\n Neurologic: A&Ox 3. Using PCA with effect. C-spine cleared. Thoracic\n MRI done per ortho spine, logroll precautions.\n Neuro checks Q: shift\n Pain: Dilaudid PCA 0.25/2.5; start Tylenol as Neurontin once taking\n POs.\n require epidural vs paravertebral catheter, will discuss with APS.\n Cardiovascular: Stable but transient hypoTN this AM. Will place aline.\n Pt has access, type and crossed. need angio if ongoing bleeding.\n Pulmonary: On face tent 70% O2, monitor, may require intubation.\n Splinting due to pain.\n Gastrointestinal / Abdomen: NPO x meds. Elevated transaminases, ? liver\n contusion related. Follow and trend LFTs.\n Nutrition: NPO\n Renal: Foley, Adequate UO\n Hematology: Monitor Hct q6 35.1-32.2-31.9-28.3, Monitor coags INR 1.3.\n If actively bleeding may need Angio, follow Hct closely, recheck 11 AM.\n Endocrine: RISS, goal BS <150. Tighten RISS.\n Infectious Disease: Afebrile.\n Lines / Tubes / Drains: RIJ CVL, PIV, Foley\n will d/c OSH CVL and\n replace CVL.\n Wounds: c/d/i\n Imaging:\n Fluids: LR @ 100.\n Consults: Trauma, Ortho Spine, Ortho trauma\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 09:00 PM\n 18 Gauge - 09:00 PM\n 20 Gauge - 09:00 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: n/a\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 33 min\n"
},
{
"category": "Physician ",
"chartdate": "2175-01-24 00:00:00.000",
"description": "Intensivist Note",
"row_id": 713343,
"text": "TSICU\n HPI:\n 74 yo male s/p fall from tractor and crush injury from tree branch.\n +Loc. At OSH received 4 units prbcs, 1 unit FFP for INR 4. +HD stable\n here. INR checked and 1.5, 1 more unit FFP given.\n Injuries\n Mult rib fx: R anterolateral and post, L posterior\n T4 vert body inf corner fx\n Commin spinous process fx T2-8\n Nondisplaced left T10 transverse process\n Nondispaced L distal clavicle\n R medial lobe liver contusion with hematoma\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny\n focus of arterial bleeding/active extravasation, and larger area of\n venous bleeding\n Nondisplaced, comminuted L iliac bone fracture w/adjacent iliac muscle\n hematoma, Fracture extends into left SI joint.\n Minimally displaced fracture of the right iliac bone extending to right\n SI joint.\n Chief complaint:\n fall\n PMHx:\n None\n Current medications:\n 1. Calcium Gluconate 2. Dextrose 50% 3. Docusate Sodium (Liquid) 4.\n Famotidine 5. Glucagon 6. HYDROmorphone (Dilaudid) 7. Insulin 8.\n Magnesium Sulfate 9. Pneumococcal Vac Polyvalent 10. Potassium Chloride\n 11. Sodium Chloride 0.9% Flush 12. Sodium Phosphate\n 24 Hour Events:\n MULTI LUMEN - START 09:00 PM\n NASAL SWAB - At 12:00 AM\n C-SPINE CLEARANCE - At 12:00 AM\n MAGNETIC RESONANCE IMAGING - At 02:17 AM Thoracic spine\n - Started on Dilaudid PCA with good effect, breathing improved. Weaned\n down oxygen to face tent. Remained HD stable overnight, although SBP\n dropped to 70s transiently this AM\n bolused 1 L NS. Thoracic MRI\n performed.\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 10:00 PM\n Fentanyl - 12:00 AM\n Other medications:\n Flowsheet Data as of 06:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.7\nC (98\n T current: 35.7\nC (96.2\n HR: 88 (88 - 99) bpm\n BP: 91/65(71) {91/52(66) - 135/72(89)} mmHg\n RR: 25 (24 - 35) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 90 kg (admission): 90 kg\n Total In:\n 6,105 mL\n 593 mL\n PO:\n Tube feeding:\n IV Fluid:\n 305 mL\n 593 mL\n Blood products:\n Total out:\n 595 mL\n 300 mL\n Urine:\n 395 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,510 mL\n 293 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SPO2: 100%\n ABG: 7.35/41/112/23/-2\n PaO2 / FiO2: 160\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: shallow respirations)\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: No(t) Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 127 K/uL\n 10.5 g/dL\n 181 mg/dL\n 1.2 mg/dL\n 23 mEq/L\n 5.2 mEq/L\n 21 mg/dL\n 110 mEq/L\n 140 mEq/L\n 31.9 %\n 13.7 K/uL\n [image002.jpg]\n 09:00 PM\n 11:04 PM\n 11:22 PM\n 04:29 AM\n WBC\n 13.7\n Hct\n 32.2\n 31.9\n Plt\n 127\n Creatinine\n 1.2\n TCO2\n 23\n 24\n Glucose\n 181\n Other labs: PT / PTT / INR:15.0/26.4/1.3, Lactic Acid:2.8 mmol/L,\n LDH:616 IU/L, Ca:8.1 mg/dL, Mg:1.8 mg/dL, PO4:4.9 mg/dL\n Assessment and Plan\n TRAUMA, S/P fall from tractor.\n Assessment and Plan: 74 yo M s/p fall with multiple rib fractures,\n pelvis fractures, clavicle fx, and thoracic fractures.\n Neurologic: A&Ox 3. Using PCA with good effect. C-spine cleared.\n Thoracic MRI done per ortho spine, continue logroll precautions.\n Awaiting input from ortho-spine re: surgery vs. TLSO\n Neuro checks Q:4 shift\n Pain: Dilaudid PCA 0.25/2.5; start Tylenol as Neurontin once taking\n POs.\n require epidural vs paravertebral catheter, will discuss with APS.\n Cardiovascular: Stable, but transient hypotension this AM. Will place\n aline. Pt has access, type and crossed. need angio if ongoing\n bleeding. Will do a focused TTE to eval C.O and function.\n Pulmonary: On face tent 70% O2, monitor, may require intubation.\n Splinting due to pain.\n Gastrointestinal / Abdomen: NPO x meds. Elevated transaminases, ? liver\n contusion related. Follow and trend LFTs.\n Nutrition: NPO\n Renal: Foley, Adequate UO\n Hematology: Monitor Hct q6 35.1-32.2-31.9-28.3, Monitor coags INR 1.3.\n If actively bleeding may need Angio, follow Hct closely, recheck 11 AM.\n Endocrine: RISS, goal BS <150. Tighten RISS as slightly hyperglycemic.\n Infectious Disease: Afebrile.\n Lines / Tubes / Drains: RIJ CVL, PIV, Foley. Will keep OSH CVL for now\n and may re-site it tomorrow, as the risk of placing a CVL in this\n respiratory tenuous patient outweighs the benefit today.\n Wounds: c/d/i\n Imaging:\n Fluids: LR @ 100.\n Consults: Trauma, Ortho Spine, Ortho trauma\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 09:00 PM\n 18 Gauge - 09:00 PM\n 20 Gauge - 09:00 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: n/a\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 33 min\n"
},
{
"category": "Physician ",
"chartdate": "2175-01-25 00:00:00.000",
"description": "Intensivist Note",
"row_id": 713436,
"text": "TSICU\n HPI:\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\n checked and 1.5, 1 more unit FFP given.\n Injuries\n Mult rib fx: R anterolateral and post, L posterior\n T4 vert body inf corner fx\n Commin spinous process fx T2-8\n Nondisplaced left T10 transverse process\n Nondispaced L distal clavicle\n Nondisplaced L clavicle fx\n R medial lobe liver contusion with hematoma\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny\n focus of arterial bleeding/active extravasation, and larger area\n of venous bleeding\n Nondisplaced, comminuted L iliac bone fracture w/adjacent iliac muscle\n hematoma, Fracture extends into left SI joint.\n Minimally displaced fracture of the right iliac bone extending to right\n SI joint.\n Chief complaint:\n pain\n PMHx:\n none\n Current medications:\n Acetaminophen 5. Calcium Gluconate 6. Dextrose 50% 7. Docusate Sodium\n (Liquid)\n 8. Famotidine 9. Gabapentin 10. Glucagon 11. HYDROmorphone (Dilaudid)\n 12. Insulin 13. Magnesium Sulfate\n 14. Ondansetron 15. Pneumococcal Vac Polyvalent 16. Potassium Chloride\n 17. Sodium Chloride 0.9% Flush\n 18. Sodium Phosphate\n 24 Hour Events:\n ARTERIAL LINE - START 10:59 AM\n : Hct stable. APS c/s for possible epidural--awaiting ortho spine\n plan. Tylenol, neurontin, dilaudid for pain. Ortho non op, will\n reassess . Per ortho spine, no surgical intervention; HOB<30, TLSO\n when OOB.\n : CR increased to 1.6, LFTs elevated in 500s. Bolused 500c x2 for\n low urine output\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 PM\n Other medications:\n Flowsheet Data as of 04:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.3\nC (97.3\n T current: 35.9\nC (96.6\n HR: 99 (80 - 102) bpm\n BP: 96/45(61) {94/45(61) - 126/65(84)} mmHg\n RR: 18 (10 - 25) insp/min\n SPO2: 90%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 90 kg (admission): 90 kg\n Total In:\n 3,960 mL\n 1,473 mL\n PO:\n 510 mL\n Tube feeding:\n IV Fluid:\n 3,450 mL\n 1,473 mL\n Blood products:\n Total out:\n 855 mL\n 195 mL\n Urine:\n 855 mL\n 195 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,105 mL\n 1,278 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SPO2: 90%\n ABG: 7.29/54/77./25/-1\n PaO2 / FiO2: 156\n Physical Examination\n General Appearance: No acute distress, Well nourished\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: Diminished: at bases), (Sternum:\n Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 89 K/uL\n 8.2 g/dL\n 123 mg/dL\n 1.6 mg/dL\n 25 mEq/L\n 5.1 mEq/L\n 36 mg/dL\n 110 mEq/L\n 140 mEq/L\n 24.1 %\n 15.5 K/uL\n [image002.jpg]\n 02:00 AM\n 04:29 AM\n 07:36 AM\n 10:54 AM\n 04:13 PM\n 05:25 PM\n 10:38 PM\n 10:56 PM\n 03:24 AM\n 03:44 AM\n WBC\n 13.7\n 15.5\n Hct\n 31.9\n 28.3\n 28.9\n 27.7\n 25.7\n 24.1\n Plt\n 127\n 89\n Creatinine\n 1.2\n 1.6\n 1.6\n TCO2\n 27\n 28\n 27\n Glucose\n 140\n 181\n 130\n 123\n Other labs: PT / PTT / INR:14.7/27.7/1.3, CK / CK-MB / Troponin\n T:1349//, ALT / AST:559/522, Alk-Phos / T bili:39/0.9, Lactic Acid:1.7\n mmol/L, LDH:616 IU/L, Ca:8.0 mg/dL, Mg:2.3 mg/dL, PO4:5.7 mg/dL\n Imaging: CXR Pend\n Pelvis Pend\n CT head OSH: Prelim No ICH or fracture.\n CT chest OSH: Mult rib fx: R anterolateral and posterior, L\n posterior; Dependent consolidation, possible aspiration; T4 vertebral\n body inf corner fx, no retropulsion; Comminuted spinous process fx\n T2-8; Nondisplaced L T10 transverse process; Nondisplaced L clavicle\n distal fx; Nondisplaced L scapula fx;\n CT c spine OSH: Prelim No fx or malalignment. Multilevel\n degenerative changes w/large post disk bulge at C4-5, narrowing the\n spinal canal and deforming the thecal sac, acuity unknown. Marked\n neuroforamenal narrowing @multiple levels.\n CTA abd/pel Prelim: Medial R liver lobe contusion w/adj\n hematoma, w/o evidence of active bleeding; Comminuted L pubic ramus\n fracture w/assoc hematoma, with tiny focus of arterial bleeding/active\n extravasation, and larger area of venous bleeding. Hematoma somewhat\n larger than on OSH study. Nondisplaced, comminuted L iliac bone fx\n w/adj iliac muscle hematoma, larger than on prior study, w/o active\n extrav. Fx extends into L SI joint. Post R hepatic laceration/contusion\n adjacent to calcified granuloma, w/small hematoma, without active\n bleeding. Min displaced fx of R iliac bone extending to R SI joint.\n Cirrhotic liver. Inc B pleural effusions (small), w/inc atelectasis.\n MRI: Mild compression deformity of L1 with additional levels of\n potential trabecular contusion @T10-11 also inf @T4 w/o retropulsion.\n Multilevel degenerative changes with moderate canal narrowing at T10-11\n w/cord deformity and no abnormal cord signal. Extensive edema\n throughout the paraspinal soft tissues, predominantly\n post w/in interspinous ligaments. Incompletely evaluated c-spine w/\n severe canal narrowing @C4-5 w/cord deformity and no abnormal cord\n signal.\n Assessment and Plan\n TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx.\n Neurologic: Neuro checks Q: 4 hr, Pain controlled, C-spine cleared. Per\n ortho spine, no surgical intervention; HOB<30, TLSO when OOB.\n Neuro checks Q: shift\n Pain: Dilaudid PCA 0.25/2.5, may require epidural (APS awaiting ortho\n spine plan). Neurontin, Tylenol\n Cardiovascular: Stable currently, SBP into 90s on , but in 120s\n after a-line placed.\n Pulmonary: IS, On face tent 70% O2, monitor, may require intubation.\n f/u CXR . Excellent tidal volumes of > 1L.\n Gastrointestinal / Abdomen: NPO after MN for possible OR (pelvis).\n Increasing LFTs (in 500s on ); h/o cirrhosis.\n Nutrition: Regular diet, Advance diet as tolerated\n Renal: Foley, Adequate UO, Foley, monitor UOP, f/u lytes, and trend\n Cr. Given ~1L bolus o/n for decreasing uop.\n Hematology: Serial Hct, Monitor Hct q6\n 35.1-32.2-31.9-28.3-28.9-27.7-25.7-24.1, Monitor coags INR 1.3. If\n actively bleeding may need Angio.\n Endocrine: RISS\n Infectious Disease: Check cultures, afebrile, no issues\n Lines / Tubes / Drains: Foley, RIJ CVL (d/c if stable), PIV x2,\n Foley, a-line ()\n Wounds:\n Imaging: CXR today\n Fluids: LR, LR@100 currently, KVO if taking POs\n Consults: Trauma surgery, Ortho, Ortho-spine, Trauma (1o), Ortho Spine,\n Ortho trauma\n Billing Diagnosis: Multiple injuries (Trauma)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 09:00 PM\n 18 Gauge - 09:00 PM\n 20 Gauge - 09:00 PM\n Arterial Line - 10:59 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition:\n Total time spent:\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2175-01-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 713538,
"text": "Anemia\n Assessment:\n This AM at 06:00 reportedly pt\ns HR suddenly went to 140\ns, pt\n experienced respiratory distress and poor ABG, was intubated for airway\n protection. HCT was trending down, seen as low as 23.1 today. At the\n beginning of this shift, pt\ns HR converted to NSR, 80-90\ns. BP low and\n neo started at 07:00. Fluid boluses were given on the previous shift.\n Event suggested possible bleeding v. PE but unknown etiology of\n tachycardia and resp distress this AM.\n Action:\n OGT placed this AM for PO meds. HCT checked frequently, total of 6\n units PRBCs given, 1 unit FFP, 1 unit platelets throughout the shift.\n Neo titrated as needed. Propofol gtt titrated to sedation/BP, \n gtt started for pain control. Pt had transthoracic echo done to\n evaluate work of the heart and fluid status. Pt went to IR for\n embolization and gel foam of pelvic/gluteal bleeding from traumatic\n injury (see IR note for procedure details). Pt went directly from IR\n for CTA of chest to rule out PE. Upon arrival back to ,\n subclavian central line placed to replace old OSH central line. CXR\n done to determine placement. Pt lying flat on back (logroll, reverse\n Tberg, side to side flat with pillows). Frequent right femoral checks\n done to evaluate for bleeding.\n Response:\n HCT increasing, BP improved-able to wean propofol, neo. Pt still\n experiencing some pain (able to express this with lightened sedation),\n boluses given. Pt more hemodynamicaly stable, femoral site\n intact, tolerating neo wean well.\n Plan:\n Discontinue old OSH central line and PIVs tonight since central line is\n approved for use per CXR. Continue frequent HCT checks. Wean propofol\n and neo as tolerated; per attending MD /midazolam\n boluses instead of increasing midazolam for sedation/comfort. Consider\n IVC filter? Follow up with blood cultures/urine culture and CTA for\n rule out PE. Consider getting sputum culture tonight d/t large amount\n of secretions. Continue to support pt and family.\n"
},
{
"category": "Physician ",
"chartdate": "2175-01-26 00:00:00.000",
"description": "Intensivist Note",
"row_id": 713619,
"text": "TSICU\n HPI:\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\n checked and 1.5, 1 more unit FFP given.\n Chief complaint:\n Mult rib fx: R anterolateral and post, L posterior\n T4 vert body inf corner fx\n Commin spinous process fx T2-8\n Nondisplaced left T10 transverse process\n Nondispaced L distal clavicle\n Nondisplaced L clavicle fx\n R medial lobe liver contusion with hematoma\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny\n focus of arterial bleeding/active extravasation, and larger area\n of venous bleeding\n Nondisplaced, comminuted L iliac bone fracture w/adjacent iliac muscle\n hematoma, Fracture extends into left SI joint.\n Minimally displaced fracture of the right iliac bone extending to right\n SI joint.\n PMHx:\n Cirrhosis\n Current medications:\n Acetylcysteine 20%\n Chlorhexidine Gluconate 0.12% Oral Rinse\n Docusate Sodium (Liquid)\n Famotidine\n Fentanyl Citrate\n Gabapentin\n 24 Hour Events:\n CR increased to 1.6, LFTs elevated in 500s. Bolused 500c x2 for low\n urine output, which improved up to 100cc/h. @6am, hr incr acutely to\n 140s, ST on ECG. Progressive acidosis. No resp decompensation\n w/continued good tidal volumes w/effort but hypoventilated. CXR\n w/pleural effusion, vasc congestion. Hct gradually decreasing to 23\n @6am. 2u prbcs tx -> 24.3, 20 IV lasix. IR embolization x2 and gelfoam\n x2. CTA neg for large PE. Received another 2u prbcs -> 25.8. 2u\n prbcs -> 29.2. Intermittently on Neo.\n CMV 50/15/550/14.\n Weaning prop & Neo. Had bigeminy overnight. This AM went into AF with\n RVR. Transitioning to PS trial. Transfused unit 50\n 86. No\n hematoma at femoral site. Febrile to 101.3 this AM.\n Post operative day:\n POD1 s/p angio embolization\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Fentanyl (Concentrate) - 75 mcg/hour\n Phenylephrine - 0.5 mcg/Kg/min\n Propofol - 20 mcg/Kg/min\n Other ICU medications:\n Furosemide (Lasix) - 06:00 AM\n Fentanyl - 07:00 PM\n Famotidine (Pepcid) - 08:29 PM\n Other medications:\n Flowsheet Data as of 06:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.3\nC (100.9\n T current: 37.9\nC (100.2\n HR: 82 (63 - 146) bpm\n BP: 99/53(67) {86/49(61) - 133/69(90)} mmHg\n RR: 18 (15 - 23) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 100.9 kg (admission): 90 kg\n CVP: 12 (12 - 30) mmHg\n Total In:\n 9,459 mL\n 1,174 mL\n PO:\n Tube feeding:\n IV Fluid:\n 6,222 mL\n 1,174 mL\n Blood products:\n 2,877 mL\n Total out:\n 2,325 mL\n 285 mL\n Urine:\n 2,325 mL\n 285 mL\n NG:\n Stool:\n Drains:\n Balance:\n 7,134 mL\n 889 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (500 - 550) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 14 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 32 cmH2O\n Plateau: 27 cmH2O\n Compliance: 42.3 cmH2O/mL\n SPO2: 100%\n ABG: 7.50/42/204/30/8\n Ve: 9.4 L/min\n PaO2 / FiO2: 408\n Physical Examination\n General Appearance: No acute distress, intubated\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), Regular Irregular\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: Follows simple commands, Moves all extremities, Sedated\n Labs / Radiology\n 86 K/uL\n 10.6 g/dL\n 116 mg/dL\n 1.1 mg/dL\n 30 mEq/L\n 3.7 mEq/L\n 23 mg/dL\n 105 mEq/L\n 141 mEq/L\n 29.6 %\n 9.5 K/uL\n [image002.jpg]\n 10:40 AM\n 02:00 PM\n 03:41 PM\n 04:11 PM\n 07:14 PM\n 09:29 PM\n 09:59 PM\n 11:10 PM\n 01:19 AM\n 01:38 AM\n WBC\n 9.2\n 6.8\n 9.5\n Hct\n 25.8\n 29.2\n 29.6\n Plt\n 79\n 52\n 86\n Creatinine\n 1.2\n 1.1\n TCO2\n 31\n 32\n 30\n 32\n 30\n 34\n Glucose\n 104\n 99\n 116\n Other labs: PT / PTT / INR:14.1/29.7/1.2, CK / CK-MB / Troponin\n T:1334/13/<0.01, ALT / AST:345/278, Alk-Phos / T bili:49/3.0, Amylase /\n Lipase:44/, Lactic Acid:1.6 mmol/L, LDH:616 IU/L, Ca:8.2 mg/dL, Mg:2.1\n mg/dL, PO4:1.9 mg/dL\n Imaging: CXR Pend\n Pelvis Pend\n CT head OSH: Prelim No ICH or fracture.\n CT chest OSH: Mult rib fx: R anterolateral and posterior, L\n posterior; Dependent consolidation, possible aspiration; T4 vertebral\n body inf corner fx, no retropulsion; Comminuted spinous process fx\n T2-8; Nondisplaced L T10 transverse process; Nondisplaced L clavicle\n distal fx; Nondisplaced L scapula fx;\n CT c spine OSH: Prelim No fx or malalignment. Multilevel\n degenerative changes w/large post disk bulge at C4-5, narrowing the\n spinal canal and deforming the thecal sac, acuity unknown. Marked\n neuroforamenal narrowing @multiple levels.\n CTA abd/pel Prelim: Medial R liver lobe contusion w/adj\n hematoma, w/o evidence of active bleeding; Comminuted L pubic ramus\n fracture w/assoc hematoma, with tiny focus of arterial bleeding/active\n extravasation, and larger area of venous bleeding. Hematoma somewhat\n larger than on OSH study. Nondisplaced, comminuted L iliac bone fx\n w/adj iliac muscle hematoma, larger than on prior study, w/o active\n extrav. Fx extends into L SI joint. Post R hepatic laceration/contusion\n adjacent to calcified granuloma, w/small hematoma, without active\n bleeding. Min displaced fx of R iliac bone extending to R SI joint.\n Cirrhotic liver. Inc B pleural effusions (small), w/inc atelectasis.\n MRI: Mild compression deformity of L1 with additional levels of\n potential trabecular contusion @T10-11 also inf @T4 w/o retropulsion.\n Multilevel degenerative changes with moderate canal narrowing at T10-11\n w/cord deformity and no abnormal cord signal. Extensive edema\n throughout the paraspinal soft tissues, predominantly\n post w/in interspinous ligaments. Incompletely evaluated c-spine w/\n severe canal narrowing @C4-5 w/cord deformity and no abnormal cord\n signal.\n CTA: no PE.\n Microbiology: Ucx P\n Sputum P\n Bcx P\n Bcx P\n Assessment and Plan\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx.\n Neurologic: C-spine cleared. Per ortho spine, no surgical intervention;\n HOB<30, TLSO when OOB. Awake off sedation, follows commands. Midaz prn\n for sedation, please increase dose and frequency and if need put on gtt\n to adequately sedate patient given new AF and ARDS/ . Pain: on\n fentanyl.\n Cardiovascular: Bedside ECHO shows TR and elevated PA pressures but\n adequate contractility. CVP 20s. Wean Neo gtt. Went into AF with RVR\n this AM. Maintaining BP. Start Dilt gtt, use Neo as needed. Would not\n use amiodaron at this point given chronic lung disease with probable\n asbstosis and in addition liver cirrhocis. If cannot rate control,\n though, would bolus with amio for one day\n Pulmonary: Cont ETT, Intubated . /ARDS type picture given\n bilat opacities and P/F ratio < 300. Will use low tidal volume\n ventilation. Will need adequate sedation for this. Also, chronic lung\n dz as demonstrated by CT yesterday.\n Gastrointestinal / Abdomen: Elevated LFTs (in 500s on ). h/o\n cirrhosis - liver panel sent. T bili elevated to 3.0, other LFTs\n trending down. Send Direct bili. Bowel regimen.\n Nutrition: ADAT\n Renal: Foley, monitor UOP, f/u lytes, and trend Cr (1.1). Received\n bicarb gtt and Mucomyst. Monitor creatinine. Check PM lytes.\n Hematology: Monitor Hct q6\n 35.1-32.2-31.9-28.3-28.9-27.7-25.7-24.1-23.1; tx 2u prbcs, 1 plt,\n 1uFFP, (INR 1.3) -> 24.3; Angio embolization. 2u prbcs -> 25.8; 2u\n prbcs -> 29.6 (). Elevated bili could be hematoma resolution, but\n given dropping , ask Heme for consult, sent smear, DIC labs\n this AM. Plt (peak 175) -86. Check PM CBC. Thrombocytopenia\n -- HIT negative. Could be baseline as patient has liver cirrhocis.\n Endocrine: RISS, adequate control, goal BS<150.\n Infectious Disease: f/u pan cx. No abx right now, will bronch.\n Lines / Tubes / Drains: R SC CVL (), PIV x2, Foley, a-line\n (), ETT\n Wounds:\n Imaging: CXR today\n Fluids: maintenance fluids\n Consults: Trauma surgery, Ortho, Ortho-spine, Heme\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Comments: ADAT\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 09:00 PM\n 20 Gauge - 09:00 PM\n Arterial Line - 10:59 AM\n Multi Lumen - 04:41 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker PO\n VAP bundle: HOB elevation, Mouth care, Daily wake up\n Comments:\n Communication: Comments: ICU consent obtained. Discussed in\n multidisciplinary rounds\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 min\n"
},
{
"category": "Nursing",
"chartdate": "2175-01-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 713301,
"text": "s/p crush injury from tree while riding on tractor. At Hospital\n patient was hTN and had dropping HCT, tx to . Injuries include: T4\n vertebral body fracture, grade 2 Liver lac, multiple right side rib\n fracture, lung contusions, right ramous and bilateral pelvic \n fracture.\n No PMH\n NKDA\n Events:\n Abdominal and pelvic CTA\n Thoracic MRI\n Trauma, s/p\n Assessment:\n Alert and oriented times three, MAE with normal strength and has normal\n sensation throughout. Hemodynamics stable. Hct stable at 32. LS clear\n but diminished in right base, sa02 100% 70% face-tent, de-saturating to\n low 90\ns off O2, using IS well but has weak cough. Pain poorly\n controlled upon admission but doing better with PCA. Abdomen soft with\n normal BS, non tender.\n Action:\n Dilaudid PCA, abd/pelvic CTA and thoracic MR, Q 4 hr Hct checks, IS per\n orders.\n Response:\n Pain control improving and pt stating it is easier to breathe now.\n Plan:\n Continue Q 4 hct and coag checks, transfuse as needed, and maintain\n hemodynamic stability, awaiting MRI results for further POC re: spinal\n fractures. Continue to provide emotional support for patient and\n family.\n"
},
{
"category": "Physician ",
"chartdate": "2175-01-24 00:00:00.000",
"description": "Intensivist Note",
"row_id": 713303,
"text": "TSICU\n HPI:\n 74 yo male s/p fall from tractor and crush injury from tree branch.\n +Loc. At OSH received 4 units prbcs, 1 unit FFP for INR 4. +HD stable\n here. INR checked and 1.5, 1 more unit FFP given.\n Injuries\n Mult rib fx: R anterolateral and post, L posterior\n T4 vert body inf corner fx\n Commin spinous process fx T2-8\n Nondisplaced left T10 transverse process\n Nondispaced L distal clavicle\n Nondisplaced L clavicle fx\n R medial lobe liver contusion with hematoma\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny\n focus of arterial bleeding/active extravasation, and larger area\n of venous bleeding\n Nondisplaced, comminuted L iliac bone fracture w/adjacent iliac muscle\n hematoma, Fracture extends into left SI joint.\n Minimally displaced fracture of the right iliac bone extending to right\n SI joint.\n Chief complaint:\n fall\n PMHx:\n None\n Current medications:\n 1. Calcium Gluconate 2. Dextrose 50% 3. Docusate Sodium (Liquid) 4.\n Famotidine 5. Glucagon 6. HYDROmorphone (Dilaudid) 7. Insulin 8.\n Magnesium Sulfate 9. Pneumococcal Vac Polyvalent 10. Potassium Chloride\n 11. Sodium Chloride 0.9% Flush 12. Sodium Phosphate\n 24 Hour Events:\n MULTI LUMEN - START 09:00 PM\n NASAL SWAB - At 12:00 AM\n C-SPINE CLEARANCE - At 12:00 AM\n MAGNETIC RESONANCE IMAGING - At 02:17 AM Thoracic spine\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 10:00 PM\n Fentanyl - 12:00 AM\n Other medications:\n Flowsheet Data as of 06:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.7\nC (98\n T current: 35.7\nC (96.2\n HR: 88 (88 - 99) bpm\n BP: 91/65(71) {91/52(66) - 135/72(89)} mmHg\n RR: 25 (24 - 35) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 90 kg (admission): 90 kg\n Total In:\n 6,105 mL\n 593 mL\n PO:\n Tube feeding:\n IV Fluid:\n 305 mL\n 593 mL\n Blood products:\n Total out:\n 595 mL\n 300 mL\n Urine:\n 395 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,510 mL\n 293 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SPO2: 100%\n ABG: 7.35/41/112/23/-2\n PaO2 / FiO2: 160\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: shallow respirations)\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: No(t) Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 127 K/uL\n 10.5 g/dL\n 181 mg/dL\n 1.2 mg/dL\n 23 mEq/L\n 5.2 mEq/L\n 21 mg/dL\n 110 mEq/L\n 140 mEq/L\n 31.9 %\n 13.7 K/uL\n [image002.jpg]\n 09:00 PM\n 11:04 PM\n 11:22 PM\n 04:29 AM\n WBC\n 13.7\n Hct\n 32.2\n 31.9\n Plt\n 127\n Creatinine\n 1.2\n TCO2\n 23\n 24\n Glucose\n 181\n Other labs: PT / PTT / INR:15.0/26.4/1.3, Lactic Acid:2.8 mmol/L,\n LDH:616 IU/L, Ca:8.1 mg/dL, Mg:1.8 mg/dL, PO4:4.9 mg/dL\n Assessment and Plan\n TRAUMA, S/P\n Assessment and Plan: 74 yo M s/p fall with multiple rib fractures,\n pelvis fractures, clavicle fx, and thoracic fractures.\n Neurologic: C-spine cleared. Thoracic MRI done per ortho spine, logroll\n precautions.\n Neuro checks Q: shift\n Pain: Dilaudid PCA 0.25/2. require epidural vs paravertebral catheter.\n Cardiovascular: Stable\n Pulmonary: On face tent 70% O2, monitor, may require intubation.\n Gastrointestinal / Abdomen: NPO x meds\n Nutrition: NPO\n Renal: Foley, Adequate UO\n Hematology: Monitor Hct q6 35.1-32.2-31.9, Monitor coags INR 1.3. If\n actively bleeding may need Angio.\n Endocrine: RISS\n Infectious Disease:\n Lines / Tubes / Drains: RIJ CVL, PIV, Foley\n Wounds:\n Imaging:\n Fluids: LR @ 100.\n Consults: Trauma, Ortho Spine, Ortho trauma\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 09:00 PM\n 18 Gauge - 09:00 PM\n 20 Gauge - 09:00 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2175-01-26 00:00:00.000",
"description": "Intensivist Note",
"row_id": 713612,
"text": "TSICU\n HPI:\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\n checked and 1.5, 1 more unit FFP given.\n Chief complaint:\n Mult rib fx: R anterolateral and post, L posterior\n T4 vert body inf corner fx\n Commin spinous process fx T2-8\n Nondisplaced left T10 transverse process\n Nondispaced L distal clavicle\n Nondisplaced L clavicle fx\n R medial lobe liver contusion with hematoma\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny\n focus of arterial bleeding/active extravasation, and larger area\n of venous bleeding\n Nondisplaced, comminuted L iliac bone fracture w/adjacent iliac muscle\n hematoma, Fracture extends into left SI joint.\n Minimally displaced fracture of the right iliac bone extending to right\n SI joint.\n PMHx:\n Cirrhosis\n Current medications:\n Acetylcysteine 20%\n Chlorhexidine Gluconate 0.12% Oral Rinse\n Docusate Sodium (Liquid)\n Famotidine\n Fentanyl Citrate\n Gabapentin\n 24 Hour Events:\n CR increased to 1.6, LFTs elevated in 500s. Bolused 500c x2 for low\n urine output, which improved up to 100cc/h. @6am, hr incr acutely to\n 140s, ST on ECG. Progressive acidosis. No resp decompensation\n w/continued good tidal volumes w/effort but hypoventilated. CXR\n w/pleural effusion, vasc congestion. Hct gradually decreasing to 23\n @6am. 2u prbcs tx -> 24.3, 20 IV lasix. IR embolization x2 and gelfoam\n x2. CTA neg for large PE. Received another 2u prbcs -> 25.8. 2u\n prbcs -> 29.2. Intermittently on Neo.\n CMV 50/15/550/14.\n Weaning prop & Neo. Had bigeminy overnight. This AM went into AF with\n RVR. Transitioning to PS trial. Transfused unit 50\n 86. No\n hematoma at femoral site. Febrile to 101.3 this AM.\n Post operative day:\n POD1 s/p angio embolization\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Fentanyl (Concentrate) - 75 mcg/hour\n Phenylephrine - 0.5 mcg/Kg/min\n Propofol - 20 mcg/Kg/min\n Other ICU medications:\n Furosemide (Lasix) - 06:00 AM\n Fentanyl - 07:00 PM\n Famotidine (Pepcid) - 08:29 PM\n Other medications:\n Flowsheet Data as of 06:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.3\nC (100.9\n T current: 37.9\nC (100.2\n HR: 82 (63 - 146) bpm\n BP: 99/53(67) {86/49(61) - 133/69(90)} mmHg\n RR: 18 (15 - 23) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 100.9 kg (admission): 90 kg\n CVP: 12 (12 - 30) mmHg\n Total In:\n 9,459 mL\n 1,174 mL\n PO:\n Tube feeding:\n IV Fluid:\n 6,222 mL\n 1,174 mL\n Blood products:\n 2,877 mL\n Total out:\n 2,325 mL\n 285 mL\n Urine:\n 2,325 mL\n 285 mL\n NG:\n Stool:\n Drains:\n Balance:\n 7,134 mL\n 889 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (500 - 550) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 14 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 32 cmH2O\n Plateau: 27 cmH2O\n Compliance: 42.3 cmH2O/mL\n SPO2: 100%\n ABG: 7.50/42/204/30/8\n Ve: 9.4 L/min\n PaO2 / FiO2: 408\n Physical Examination\n General Appearance: No acute distress, intubated\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), Regular Irregular\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: Follows simple commands, Moves all extremities, Sedated\n Labs / Radiology\n 86 K/uL\n 10.6 g/dL\n 116 mg/dL\n 1.1 mg/dL\n 30 mEq/L\n 3.7 mEq/L\n 23 mg/dL\n 105 mEq/L\n 141 mEq/L\n 29.6 %\n 9.5 K/uL\n [image002.jpg]\n 10:40 AM\n 02:00 PM\n 03:41 PM\n 04:11 PM\n 07:14 PM\n 09:29 PM\n 09:59 PM\n 11:10 PM\n 01:19 AM\n 01:38 AM\n WBC\n 9.2\n 6.8\n 9.5\n Hct\n 25.8\n 29.2\n 29.6\n Plt\n 79\n 52\n 86\n Creatinine\n 1.2\n 1.1\n TCO2\n 31\n 32\n 30\n 32\n 30\n 34\n Glucose\n 104\n 99\n 116\n Other labs: PT / PTT / INR:14.1/29.7/1.2, CK / CK-MB / Troponin\n T:1334/13/<0.01, ALT / AST:345/278, Alk-Phos / T bili:49/3.0, Amylase /\n Lipase:44/, Lactic Acid:1.6 mmol/L, LDH:616 IU/L, Ca:8.2 mg/dL, Mg:2.1\n mg/dL, PO4:1.9 mg/dL\n Imaging: CXR Pend\n Pelvis Pend\n CT head OSH: Prelim No ICH or fracture.\n CT chest OSH: Mult rib fx: R anterolateral and posterior, L\n posterior; Dependent consolidation, possible aspiration; T4 vertebral\n body inf corner fx, no retropulsion; Comminuted spinous process fx\n T2-8; Nondisplaced L T10 transverse process; Nondisplaced L clavicle\n distal fx; Nondisplaced L scapula fx;\n CT c spine OSH: Prelim No fx or malalignment. Multilevel\n degenerative changes w/large post disk bulge at C4-5, narrowing the\n spinal canal and deforming the thecal sac, acuity unknown. Marked\n neuroforamenal narrowing @multiple levels.\n CTA abd/pel Prelim: Medial R liver lobe contusion w/adj\n hematoma, w/o evidence of active bleeding; Comminuted L pubic ramus\n fracture w/assoc hematoma, with tiny focus of arterial bleeding/active\n extravasation, and larger area of venous bleeding. Hematoma somewhat\n larger than on OSH study. Nondisplaced, comminuted L iliac bone fx\n w/adj iliac muscle hematoma, larger than on prior study, w/o active\n extrav. Fx extends into L SI joint. Post R hepatic laceration/contusion\n adjacent to calcified granuloma, w/small hematoma, without active\n bleeding. Min displaced fx of R iliac bone extending to R SI joint.\n Cirrhotic liver. Inc B pleural effusions (small), w/inc atelectasis.\n MRI: Mild compression deformity of L1 with additional levels of\n potential trabecular contusion @T10-11 also inf @T4 w/o retropulsion.\n Multilevel degenerative changes with moderate canal narrowing at T10-11\n w/cord deformity and no abnormal cord signal. Extensive edema\n throughout the paraspinal soft tissues, predominantly\n post w/in interspinous ligaments. Incompletely evaluated c-spine w/\n severe canal narrowing @C4-5 w/cord deformity and no abnormal cord\n signal.\n CTA: no PE.\n Microbiology: Ucx P\n Sputum P\n Bcx P\n Bcx P\n Assessment and Plan\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx.\n Neurologic: C-spine cleared. Per ortho spine, no surgical intervention;\n HOB<30, TLSO when OOB. Awake off sedation, follows commands. Midaz prn\n sedation needs while intubated. Pain: on fentanyl. Will plan to\n transition to Oxycodone. Will discuss with APS again today.\n Cardiovascular: Bedside ECHO shows TR and elevated PA pressures but\n adequate contractility. CVP 20s. Wean Neo gtt. AF with RVR this AM.\n Maintaining BP. Start Dilt gtt, use Neo as needed.\n Pulmonary: Cont ETT, Intubated . Wean as tolerated (improve pain\n control). 50%, checking ABG. Thick secretions, now febrile.\n Bronch today, send BAL.\n Gastrointestinal / Abdomen: Elevated LFTs (in 500s on ). h/o\n cirrhosis - liver panel sent. T bili elevated to 3.0, other LFTs\n trending down. Send Direct bili. Bowel regimen.\n Nutrition: ADAT\n Renal: Foley, monitor UOP, f/u lytes, and trend Cr (1.1). Received\n bicarb gtt and Mucomyst. Monitor creatinine. Check PM lytes.\n Hematology: Monitor Hct q6\n 35.1-32.2-31.9-28.3-28.9-27.7-25.7-24.1-23.1; tx 2u prbcs, 1 plt,\n 1uFFP, (INR 1.3) -> 24.3; Angio embolization. 2u prbcs -> 25.8; 2u\n prbcs -> 29.6 (). Elevated bili could be hematoma resolution, but\n given dropping , ask Heme for consult, sent smear, DIC labs\n this AM. Plt (peak 175) -86. Check PM CBC.\n Endocrine: RISS, adequate control, goal BS<150.\n Infectious Disease: f/u pan cx. No abx right now, will bronch.\n Lines / Tubes / Drains: R SC CVL (), PIV x2, Foley, a-line\n (), ETT\n Wounds:\n Imaging: CXR today\n Fluids: maintenance fluids\n Consults: Trauma surgery, Ortho, Ortho-spine, Heme\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Comments: ADAT\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 09:00 PM\n 20 Gauge - 09:00 PM\n Arterial Line - 10:59 AM\n Multi Lumen - 04:41 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker PO\n VAP bundle: HOB elevation, Mouth care, Daily wake up\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 33 min\n"
},
{
"category": "Nutrition",
"chartdate": "2175-01-26 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 713631,
"text": "Subjective\n Intubated, no family present\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 175 cm\n 90 kg\n 100.9 kg ( 12:00 AM)\n +10.9 kg due to fluid\n 29.2\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 72.6 kg\n 124%\n 77 kg\n Diagnosis: polytrauma\n PMHx: cirrhosis\n Food allergies and intolerances: none noted\n Pertinent medications: RISS, phenylephrine, propofol, fentanyl,\n famotidine, Ca gluconate (2 g repletion), KPhos (15 mmol repletion),\n diltiazem, others noted\n Labs:\n Value\n Date\n Glucose\n 84\n 08:00 AM\n Glucose Finger Stick\n 137\n 08:00 PM\n BUN\n 23 mg/dL\n 01:19 AM\n Creatinine\n 1.1 mg/dL\n 01:19 AM\n Sodium\n 141 mEq/L\n 01:19 AM\n Potassium\n 3.7 mEq/L\n 01:19 AM\n Chloride\n 105 mEq/L\n 01:19 AM\n TCO2\n 30 mEq/L\n 01:19 AM\n PO2 (arterial)\n 138 mm Hg\n 10:22 AM\n PCO2 (arterial)\n 47 mm Hg\n 10:22 AM\n pH (arterial)\n 7.44 units\n 10:22 AM\n pH (urine)\n 6.5 units\n 07:00 PM\n CO2 (Calc) arterial\n 33 mEq/L\n 10:22 AM\n Calcium non-ionized\n 8.2 mg/dL\n 01:19 AM\n Phosphorus\n 1.9 mg/dL\n 01:19 AM\n Ionized Calcium\n 1.15 mmol/L\n 01:38 AM\n Magnesium\n 2.1 mg/dL\n 01:19 AM\n ALT\n 345 IU/L\n 01:19 AM\n Alkaline Phosphate\n 49 IU/L\n 01:19 AM\n AST\n 278 IU/L\n 01:19 AM\n Amylase\n 44 IU/L\n 06:01 AM\n Total Bilirubin\n 3.0 mg/dL\n 01:19 AM\n WBC\n 9.5 K/uL\n 01:19 AM\n Hgb\n 10.6 g/dL\n 01:19 AM\n Hematocrit\n 29.1 %\n 07:26 AM\n Current diet order / nutrition support: Replete with fiber Full\n strength;\n Starting rate: 10 ml/hr; Advance rate by 10 ml q4h Goal rate: 50 ml/hr\n = 1200 kcals/ 74 g protein\n Residual Check: q4h Hold feeding for residual >= : 200 ml\n Flush w/ 50 ml water q8h\n GI: soft, distended, +bowel sounds\n Assessment of Nutritional Status\n At risk for malnutrition\n Patient at risk due to: NPO / hypocaloric diet, trauma\n Estimated Nutritional Needs\n Calories: -2156 (BEE x or / 25-28 cal/kg)\n Protein: 92-116 (1.2-1.5 g/kg)\n Fluid: per team\n Calculations based on: Adjusted weight\n Estimation of previous intake: likely adequate\n Estimation of current intake: Inadequate\n Specifics: 74 year old male s/p fall from tractor and crush injury from\n tree branch. +Loc. Transferred from outside hospital, patient with\n multiple injuries :Mult rib fx: R anterolateral and post, L\n posterior,T4 vert body inf corner fx, Commin spinous process fx T2-8,\n Nondisplaced left T10 transverse process, Nondispaced L distal \n clavicle, Nondisplaced L clavicle fx, R medial lobe liver contusion\n with hematoma, Comminuted L pubic ramus fx w/assoc hematoma, w/tiny\n focus of arterial bleeding/active extravasation, and larger area of\n venous bleeding, Nondisplaced, comminuted L iliac bone fracture\n w/adjacent iliac muscle hematoma, Fracture extends into left SI joint.\n Tube feeding ordered, not yet started. At goal tube feeding underfeeds\n patient. Agree with plan for nutrition support. Propofol is running at\n 13.5 ml/hr which provides 356 kcals/day. Will need to adjust tube\n feeding. Noted repletions.\n Medical Nutrition Therapy Plan - Recommend the Following\n Tube feeding / TPN recommendations: while on current rate of\n propofol recommend Replete with Fiber @ 55 ml/hr = 1320 kcals/ 82 g\n protein\n While off propofol recommend Replete with Fiber @ 80 ml/hr =\n kcals/ 119 g protein\n Multivitamin / Mineral supplement: via tube feeding\n Check chemistry 10 panel daily and replete prn\n Will follow page with questions\n"
},
{
"category": "Nursing",
"chartdate": "2175-01-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 713404,
"text": "Trauma, s/p\n Assessment:\n Patient alert, oriented x3. Pupils 3mm, equal, reactive.\n Moves upper extremities w/ normal strength. Lower extremities move on\n bed, splinted by pain.\n Complaining of pain to R side, constant w/ and w/o\n movement. At worst, . Patient on Dilaudid PCA 02.5mg/dose.\n LS diminished on R side. Clear to diminished on L side.\n Sats WNL on 12L 70% fact tent and 3L NC.\n Hypotensive at beginning of shift, SBP in 70\ns. HR 90\n +PP.\n Denies abdominal pain. Abdomen soft, BS present.\n UOP marginal.\n Action:\n Q4h neuro exams. Encouraged use of PCA prior to activity.\n Tylenol and gabapentin administered.\n Logroll precautions cleared. TLSO brace ordered. NEOPS\n came by to measure for brace this afternoon.\n Encouraged CDB and IS. Oxygen weaned to 12L 50% face tent,\n 2L NC.\n 1L LR fluid bolus administered for hypotension\n Patient ordered for clear diet\n Response:\n Pain decreased to with use of PCA and oral pain\n medications.\n Reaches up to 1000ml with IS. Patient has weak cough,\n splinted by pain.\n Patient may sit up to 30 degrees but will need brace when\n OOB.\n VSS. Hct remains stable. Lactate trending down.\n Plan:\n Continue to assess for pain, medicate as needed. Wean oxygen as\n tolerated. Pulmonary toileting. CXR tomorrow a.m. Patient to be NPO\n after midnight for ? OR tomorrow for pelvis (awaiting final word from\n ortho).\n"
},
{
"category": "Nursing",
"chartdate": "2175-01-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 713406,
"text": "Trauma, s/p\n Assessment:\n Patient alert, oriented x3. Pupils 3mm, equal, reactive.\n Moves upper extremities w/ normal strength. Lower extremities move on\n bed, splinted by pain.\n Complaining of pain to R side, constant w/ and w/o\n movement. At worst, . Patient on Dilaudid PCA 02.5mg/dose.\n LS diminished on R side. Clear to diminished on L side.\n Sats WNL on 12L 70% fact tent and 3L NC.\n Hypotensive at beginning of shift, SBP in 70\ns. HR 90\n +PP.\n Denies abdominal pain. Abdomen soft, BS present.\n UOP marginal.\n Action:\n Q4h neuro exams. Encouraged use of PCA prior to activity.\n Tylenol and gabapentin administered.\n Logroll precautions cleared. TLSO brace ordered. NEOPS\n came by to measure for brace this afternoon.\n Encouraged CDB and IS. Oxygen weaned to 12L 50% face tent,\n 2L NC.\n 1L LR fluid bolus administered for hypotension\n Patient ordered for clear diet\n Response:\n Pain decreased to with use of PCA and oral pain\n medications.\n Reaches up to 1000ml with IS. Patient has weak cough,\n splinted by pain.\n Patient may sit up to 30 degrees but will need brace when\n OOB.\n VSS. Hct remains stable. Lactate trending down.\n Plan:\n Continue to assess for pain, medicate as needed. Wean oxygen as\n tolerated. Pulmonary toileting. CXR tomorrow a.m. Patient to be NPO\n after midnight for ? OR tomorrow for pelvis (awaiting final word from\n ortho).\n ------ Protected Section ------\n IV: Patient has OSH central line and PIV x2. Attempt to place PIV,\n unsuccessful. IV team aware, will come place two new PIV. Per policy,\n OSH central line to be pulled within 24 hour. ICU team aware.\n ------ Protected Section Addendum Entered By: , RN\n on: 18:13 ------\n"
},
{
"category": "Nursing",
"chartdate": "2175-01-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 713588,
"text": "Trauma, s/p\n Assessment:\n Patient sedated on propofol and Fentanyl gtt for pain, able to wake and\n follows commands. MAE. Peripheral pulses present. Right groin site\n soft, no hematoma, dsg CDI. Sinus arrhythmia, BP supported overnight\n with Neo gtt. LS diminished at bases with moderate amounts of thick\n white secretions. Vent support increased per metavision for decreased\n PaO2. Hct stable times 2.\n Action:\n Pulmonary toileting, plt tx, pain control, maintained hemodynamic\n stability.\n Response:\n Remains stable, physical exam unchanged. ABG improved.\n Plan:\n Monitor hct and ABGs. Continue pain control and pulmonary toileting.\n Titrate vasopressor to maintain BP. Wean sedation and vent settings\n towards extubation.\n"
},
{
"category": "Nursing",
"chartdate": "2175-01-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 713566,
"text": "Trauma, s/p\n Assessment:\n Patient sedated on propofol and Fentanyl gtt for pain, able to wake and\n follows commands. MAE. Peripheral pulses present. Right groin site\n soft, no hematoma, dsg CDI. Sinus arrhythmia, BP supported overnight\n with Neo gtt. LS diminished at bases with moderate amounts of thick\n white secretions. Vent support increased per metavision for decreased\n PaO2. Hct stable times 2.\n Action:\n Pulmonary toileting, plt tx, pain control, maintained hemodynamic\n stability.\n Response:\n Remains stable, physical exam unchanged. ABG improved.\n Plan:\n Monitor hct and ABGs. Continue pain control and pulmonary toileting.\n Titrate vasopressor to maintain BP. Wean sedation and vent settings\n towards extubation.\n"
},
{
"category": "Physician ",
"chartdate": "2175-01-26 00:00:00.000",
"description": "Intensivist Note",
"row_id": 713582,
"text": "TSICU\n HPI:\n 74M s/p fall from tractor and crush injury from tree branch. +Loc. At\n OSH received 4u prbcs, 1 unit FFP for INR 4. +HD stable here. INR\n checked and 1.5, 1 more unit FFP given.\n Chief complaint:\n Mult rib fx: R anterolateral and post, L posterior\n T4 vert body inf corner fx\n Commin spinous process fx T2-8\n Nondisplaced left T10 transverse process\n Nondispaced L distal clavicle\n Nondisplaced L clavicle fx\n R medial lobe liver contusion with hematoma\n Comminuted L pubic ramus fx w/assoc hematoma, w/tiny\n focus of arterial bleeding/active extravasation, and larger area\n of venous bleeding\n Nondisplaced, comminuted L iliac bone fracture w/adjacent iliac muscle\n hematoma, Fracture extends into left SI joint.\n Minimally displaced fracture of the right iliac bone extending to right\n SI joint.\n PMHx:\n Cirrhosis\n Current medications:\n Acetylcysteine 20%\n Chlorhexidine Gluconate 0.12% Oral Rinse\n Docusate Sodium (Liquid)\n Famotidine\n Fentanyl Citrate\n Gabapentin\n 24 Hour Events:\n CR increased to 1.6, LFTs elevated in 500s. Bolused 500c x2 for low\n urine output, which improved up to 100cc/h. @6am, hr incr acutely to\n 140s, ST on ECG. Progressive acidosis. No resp decompensation\n w/continued good tidal volumes w/effort but hypoventilated. CXR\n w/pleural effusion, vasc congestion. Hct gradually decreasing to 23\n @6am. 2u prbcs tx -> 24.3, 20 IV lasix. IR embolization x2 and gelfoam\n x2. CTA neg for large PE. Received another 2u prbcs -> 25.8. 2u\n prbcs -> 29.2. Intermittently on Neo.\n CMV 50/15/550/14\n Post operative day:\n POD1 s/p angio embolization\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Fentanyl (Concentrate) - 75 mcg/hour\n Phenylephrine - 0.5 mcg/Kg/min\n Propofol - 20 mcg/Kg/min\n Other ICU medications:\n Furosemide (Lasix) - 06:00 AM\n Fentanyl - 07:00 PM\n Famotidine (Pepcid) - 08:29 PM\n Other medications:\n Flowsheet Data as of 06:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.3\nC (100.9\n T current: 37.9\nC (100.2\n HR: 82 (63 - 146) bpm\n BP: 99/53(67) {86/49(61) - 133/69(90)} mmHg\n RR: 18 (15 - 23) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 100.9 kg (admission): 90 kg\n CVP: 12 (12 - 30) mmHg\n Total In:\n 9,459 mL\n 1,174 mL\n PO:\n Tube feeding:\n IV Fluid:\n 6,222 mL\n 1,174 mL\n Blood products:\n 2,877 mL\n Total out:\n 2,325 mL\n 285 mL\n Urine:\n 2,325 mL\n 285 mL\n NG:\n Stool:\n Drains:\n Balance:\n 7,134 mL\n 889 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (500 - 550) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 14 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 32 cmH2O\n Plateau: 27 cmH2O\n Compliance: 42.3 cmH2O/mL\n SPO2: 100%\n ABG: 7.50/42/204/30/8\n Ve: 9.4 L/min\n PaO2 / FiO2: 408\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), Regular Irregular\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: Follows simple commands, Moves all extremities, Sedated\n Labs / Radiology\n 86 K/uL\n 10.6 g/dL\n 116 mg/dL\n 1.1 mg/dL\n 30 mEq/L\n 3.7 mEq/L\n 23 mg/dL\n 105 mEq/L\n 141 mEq/L\n 29.6 %\n 9.5 K/uL\n [image002.jpg]\n 10:40 AM\n 02:00 PM\n 03:41 PM\n 04:11 PM\n 07:14 PM\n 09:29 PM\n 09:59 PM\n 11:10 PM\n 01:19 AM\n 01:38 AM\n WBC\n 9.2\n 6.8\n 9.5\n Hct\n 25.8\n 29.2\n 29.6\n Plt\n 79\n 52\n 86\n Creatinine\n 1.2\n 1.1\n TCO2\n 31\n 32\n 30\n 32\n 30\n 34\n Glucose\n 104\n 99\n 116\n Other labs: PT / PTT / INR:14.1/29.7/1.2, CK / CK-MB / Troponin\n T:1334/13/<0.01, ALT / AST:345/278, Alk-Phos / T bili:49/3.0, Amylase /\n Lipase:44/, Lactic Acid:1.6 mmol/L, LDH:616 IU/L, Ca:8.2 mg/dL, Mg:2.1\n mg/dL, PO4:1.9 mg/dL\n Imaging: CXR Pend\n Pelvis Pend\n CT head OSH: Prelim No ICH or fracture.\n CT chest OSH: Mult rib fx: R anterolateral and posterior, L\n posterior; Dependent consolidation, possible aspiration; T4 vertebral\n body inf corner fx, no retropulsion; Comminuted spinous process fx\n T2-8; Nondisplaced L T10 transverse process; Nondisplaced L clavicle\n distal fx; Nondisplaced L scapula fx;\n CT c spine OSH: Prelim No fx or malalignment. Multilevel\n degenerative changes w/large post disk bulge at C4-5, narrowing the\n spinal canal and deforming the thecal sac, acuity unknown. Marked\n neuroforamenal narrowing @multiple levels.\n CTA abd/pel Prelim: Medial R liver lobe contusion w/adj\n hematoma, w/o evidence of active bleeding; Comminuted L pubic ramus\n fracture w/assoc hematoma, with tiny focus of arterial bleeding/active\n extravasation, and larger area of venous bleeding. Hematoma somewhat\n larger than on OSH study. Nondisplaced, comminuted L iliac bone fx\n w/adj iliac muscle hematoma, larger than on prior study, w/o active\n extrav. Fx extends into L SI joint. Post R hepatic laceration/contusion\n adjacent to calcified granuloma, w/small hematoma, without active\n bleeding. Min displaced fx of R iliac bone extending to R SI joint.\n Cirrhotic liver. Inc B pleural effusions (small), w/inc atelectasis.\n MRI: Mild compression deformity of L1 with additional levels of\n potential trabecular contusion @T10-11 also inf @T4 w/o retropulsion.\n Multilevel degenerative changes with moderate canal narrowing at T10-11\n w/cord deformity and no abnormal cord signal. Extensive edema\n throughout the paraspinal soft tissues, predominantly\n post w/in interspinous ligaments. Incompletely evaluated c-spine w/\n severe canal narrowing @C4-5 w/cord deformity and no abnormal cord\n signal.\n CTA: no PE.\n Microbiology: Ucx P\n Sputum P\n Bcx P\n Bcx P\n Assessment and Plan\n HYPOTENSION (NOT SHOCK), TRAUMA, S/P\n Assessment and Plan: 74M s/p fall with multiple rib fx, pelvis fx,\n clavicle fx, and thoracic fx.\n Neurologic: C-spine cleared. Per ortho spine, no surgical intervention;\n HOB<30, TLSO when OOB.\n Cardiovascular: Bedside ECHO shows TR and elevated PA pressures but\n adequate contractility. CVP 20s. Wean phenylephrine gtt\n Pulmonary: Cont ETT, Intubated . Wean as tolerated (improve pain\n control)\n Gastrointestinal / Abdomen: Elevated LFTs (in 500s on ). h/o\n cirrhosis - liver panel sent. T bili elevated to 3.0, other LFTs\n trending down\n Nutrition: ADAT\n Renal: Foley, monitor UOP, f/u lytes, and trend Cr (1.1). Received\n bicarb gtt and Mucomyst\n Hematology: Monitor Hct q6\n 35.1-32.2-31.9-28.3-28.9-27.7-25.7-24.1-23.1; tx 2u prbcs, 1 plt,\n 1uFFP, (INR 1.3) -> 24.3; Angio embolization. 2u prbcs -> 25.8; 2u\n prbcs -> 29.6 ()\n Plt (peak 175) -86\n Endocrine: RISS\n Infectious Disease: f/u pan cx.\n Lines / Tubes / Drains: R SC CVL (), PIV x2, Foley, a-line\n (), ETT\n Wounds:\n Imaging: CXR today\n Fluids: LR, KVO when tolerating PO intake\n Consults: Trauma surgery, Ortho, Ortho-spine\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Comments: ADAT\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 09:00 PM\n 20 Gauge - 09:00 PM\n Arterial Line - 10:59 AM\n Multi Lumen - 04:41 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2175-01-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 713668,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains vented throughout the day, AM CXR showed some lower lobe\n consolidation and fluid. ABGs were poor overnight-alkalotic. Pt\n received total of 6 units PRBCs, 2 units platelets, 1 unit FFP\n yesterday and is more fluid overloaded today, general edema, CVP 13-20,\n 10kg heavier this AM. Lung sounds clear in upper lobes, slightly\n diminished in bases. Pt has multiple rib fractures and is currently\n sedated on propofol/fentanyl and on bedrest <30 degrees until TLSO\n brace arrives. Pt febrile today-101.3. Suctioned for thick, yellow\n secretions frequently.\n Action:\n Bronchoscopy done this AM, BAL sent from right and left mainstems\n (sputum culture also pending from last evening). Sedation turned off\n this AM as tolerated then neo was turned off d/t BP WNL. Vent weaned\n to CPAP/PS and pt tolerated breathing well. Pt was wide awake and\n uncomfortable off sedation, requesting more pain medication as well as\n sedation. Fentanyl gtt increased to 100mcg/hr from 75mcg/hr. Pt was\n sedated more for the bronchoscopy and sedation left on after procedure\n per team d/t possible ARDS risk. Team wanted pt to be adequately\n sedated to allow vent to provide PEEP/volume with the intention of\n improving pt\ns ABGs. Fever reduced without intervention, team aware,\n cultures pending from . Vent changed back to CMV PEEP 14, 50%\n FiO2, RR 18, TV 440 based on weight/height for bronch and remainder of\n the shift. VAP care per protocol, repositioned frequently. Bilateral\n CPT performed. Tube feeds started but then stopped for IVC filter\n placement scheduled as add-on tonight.\n Response:\n Pt sedated but arouses to voice, neuro exam remains intact and\n unchanged as evidenced by when pt is awake. Neo required while pt is\n more sedated, titrating as needed, see metavision for details. Pt more\n comfortable with additional sedation and pain medication. Suctioned\n for thick, yellow secretions.\n Plan:\n Continue to monitor ABGs, follow up with cultures. Suction as needed.\n Monitor respiratory status closely, VAP care, daily CXRs. Provide IV\n fluid for when tube feeds off, monitor kidney and liver function.\n Restart tube feeds post-op. Continue to support pt and family.\n Atrial fibrillation (Afib)\n Assessment:\n Pt went into rapid afib this AM, HR seen as high as 149. Change in\n rhythm was abrupt, unknown cause but possibly d/t cardiac contusion?\n Action:\n EKG done immediately which showed afib. Monitor EKG showing atrial\n flutter for the rest of the day. TTEcho done this evening by team in\n room. Diltiazem bolus given per HO this am (20mg over 2min) before\n starting 5mg/hr gtt.\n Response:\n Pt\ns rate better controlled (70\ns), continues in atrial flutter. BP\n lower, neo gtt continues to be titrated as needed d/t dilt gtt and\n propofol gtt.\n Plan:\n IVC filter to be placed this evening in OR by Dr. as add-on\n case. Consider converting this pt to NSR with Amiodarone since it is\n new afib? Continue to support pt and family. Change dilt gtt to PO\n when able.\n"
},
{
"category": "Respiratory ",
"chartdate": "2175-01-26 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 713662,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Maintain PEEP at current level and reduce FiO2 as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Intolerant of weaning attempts, Underlying illness not resolved\n Respiratory Care Shift Procedures\n Bedside Procedures:\n Bronchoscopy (1100)\n Comments: removed large amounts of thick yellow secretions.\n"
},
{
"category": "Nursing",
"chartdate": "2175-01-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 713280,
"text": "s/p crush injury from tree while riding on tractor. At Hospital\n patient was hTN and had dropping HCT, tx to . Injuries include: T4\n vertebral body fracture, grade 2 Liver lac, multiple right side rib\n fracture, lung contusions, right ramous and bilateral pelvic \n fracture.\n No PMH\n NKDA\n Events:\n Abdominal and pelvic CTA\n Thoracic MRI\n Trauma, s/p\n Assessment:\n Alert and oriented times three, MAE with normal strength and has normal\n sensation throughout. Hemodynamics stable. Hct stable at 32. LS clear\n but diminished in right base, sa02 100% on NRB, de-saturating to low\n 90\ns off O2, using IS well but has very weak cough. Pain poorly\n controlled upon admission but doing better with PCA. Abdomen soft with\n normal BS, non tender.\n Action:\n Dilaudid PCA, abd/pelvic CTA and thoracic MR, Q 4 hr Hct checks, IS per\n orders.\n Response:\n Pain control improving and pt stating it is easier to breathe now.\n Plan:\n Continue Q 4 hct and coag checks, transfuse as needed, maintain\n hemodynamic stability, awaiting MRI results for further POC re: spinal\n fractures. Continue to provide emotional support for patient and\n family.\n"
},
{
"category": "Nursing",
"chartdate": "2175-01-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 713289,
"text": "s/p crush injury from tree while riding on tractor. At Hospital\n patient was hTN and had dropping HCT, tx to . Injuries include: T4\n vertebral body fracture, grade 2 Liver lac, multiple right side rib\n fracture, lung contusions, right ramous and bilateral pelvic \n fracture.\n No PMH\n NKDA\n Events:\n Abdominal and pelvic CTA\n Thoracic MRI\n Trauma, s/p\n Assessment:\n Alert and oriented times three, MAE with normal strength and has normal\n sensation throughout. Hemodynamics stable. Hct stable at 32. LS clear\n but diminished in right base, sa02 100% 70% face-tent, de-saturating to\n low 90\ns off O2, using IS well but has weak cough. Pain poorly\n controlled upon admission but doing better with PCA. Abdomen soft with\n normal BS, non tender.\n Action:\n Dilaudid PCA, abd/pelvic CTA and thoracic MR, Q 4 hr Hct checks, IS per\n orders.\n Response:\n Pain control improving and pt stating it is easier to breathe now.\n Plan:\n Continue Q 4 hct and coag checks, transfuse as needed, and maintain\n hemodynamic stability, awaiting MRI results for further POC re: spinal\n fractures. Continue to provide emotional support for patient and\n family.\n"
},
{
"category": "Nursing",
"chartdate": "2175-01-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 713393,
"text": "Trauma, s/p\n Assessment:\n Patient alert, oriented x3. Pupils 3mm, equal, reactive.\n Moves upper extremities w/ normal strength. Lower extremities move on\n bed, splinted by pain.\n Complaining of pain to R side, constant w/ and w/o\n movement. At worst, . Patient on Dilaudid PCA 02.5mg/dose.\n LS diminished on R side. Clear to diminished on L side.\n Sats WNL on 12L 70% fact tent and 3L NC.\n Hypotensive at beginning of shift, SBP in 70\ns. HR 90\n +PP.\n Denies abdominal pain. Abdomen soft, BS present.\n UOP marginal.\n Action:\n Q4h neuro exams. Encouraged use of PCA prior to activity.\n Tylenol and gabapentin administered.\n Logroll precautions cleared. TLSO brace ordered. NEOPS\n came by to measure for brace this afternoon.\n Encouraged CDB and IS. Oxygen weaned to 12L 50% face tent,\n 2L NC.\n 1L LR fluid bolus administered for hypotension\n Patient ordered for clear liquid diet\n Response:\n Pain decreased to with use of PCA and oral pain\n medications.\n Reaches up to 1000ml with IS. Patient has weak cough,\n splinted by pain.\n Patient may sit up to 30 degrees but will need brace when\n OOB.\n VSS\n Plan:\n Continue to assess for pain, medicate as needed. Wean oxygen as\n tolerated. Pulmonary toileting. CXR tomorrow a.m. Patient to be NPO\n after midnight for ? OR tomorrow for pelvis (awaiting final word from\n ortho).\n"
},
{
"category": "ECG",
"chartdate": "2175-02-02 00:00:00.000",
"description": "Report",
"row_id": 233689,
"text": "Resting sinus tachycardia with frequent atrial premature beats. Prolonged\nP-R interval at about 230 milliseconds. Left atrial abnormality. Borderline\nlow limb lead voltage. Non-specific ST-T wave changes. Relatively early\nR wave progression, a non-diagnostic finding. Compared to the previous tracing\nof atrial flutter is no longer present.\n\n"
},
{
"category": "ECG",
"chartdate": "2175-01-29 00:00:00.000",
"description": "Report",
"row_id": 233690,
"text": "Atrial flutter with predominant 3:1 A-V block, atrial rate approximately 260,\nventricular rate approximately 86. There is some variability in ventricular\nresponse suggesting dual level block. Probable inferior myocardial infarction\nof indeterminate age. Compared to the previous tracing of overall\nventricular rate has fallen from 114 to 86.\n\n"
},
{
"category": "ECG",
"chartdate": "2175-01-26 00:00:00.000",
"description": "Report",
"row_id": 233910,
"text": "Atrial fibrillation, rate 114. Early transition. Leftward axis at\nminus 31 degrees. Compared to the previous tracing of no diagnostic\ninterval change.\n\n"
},
{
"category": "ECG",
"chartdate": "2175-01-25 00:00:00.000",
"description": "Report",
"row_id": 233911,
"text": "Atrial flutter. Modest left axis deviation. Early precordial QRS transition.\nFindings are non-specific. No previous tracing available for comparison.\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-02-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1114102,
"text": " 5:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?atelectasis, effusion, consolidation\n Admitting Diagnosis: POLYTAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with trach\n REASON FOR THIS EXAMINATION:\n ?atelectasis, effusion, consolidation\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Tracheostomy, to evaluate for effusions and consolidation.\n\n FINDINGS: In comparison with the study of , there is continued\n enlargement of the cardiac silhouette with pulmonary vascular congestion and\n bilateral pleural effusions. The possibility of supervening pneumonia still\n be considered.\n\n Tracheostomy tube remains in place.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-01-25 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1112506,
"text": " 4:57 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: ?PTX, line placement\n Admitting Diagnosis: POLYTAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man s/p R subclavian placement\n REASON FOR THIS EXAMINATION:\n ?PTX, line placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Right subclavian line placement.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, a right subclavian vein\n catheter has been newly introduced. The tip of the line projects over the mid\n SVC. There is no evidence of complication, notably no pneumothorax. The\n other monitoring and support devices are in unchanged position. The extent of\n the pre-existing right-sided pleural effusion could have mildly decreased.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-01-26 00:00:00.000",
"description": "VENOGRAPHY IVC S&I",
"row_id": 1112703,
"text": " 10:46 PM\n VENOGRAPHY IVC S&I; -52 REDUCED SERVICES Clip # \n Reason: IVC FILTER PLACEMENT AND VENOCAVAGRAM\n Admitting Diagnosis: POLYTAUMA\n ______________________________________________________________________________\n FINAL REPORT\n \"Please see CareWeb Notes for the complete operative report.\"\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-01-25 00:00:00.000",
"description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY",
"row_id": 1112483,
"text": " 2:58 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: r/o PE\n Admitting Diagnosis: POLYTAUMA\n Contrast: VISAPAQUE Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with pelvic fractures and concern for PE\n REASON FOR THIS EXAMINATION:\n r/o PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SHfd WED 7:04 PM\n No evidence of central pulmonary embolism. The subsegmental arteries cannot\n be evaluated due to technique. No aortic dissection.\n\n Multiple bilateral rib fractures and T4 vertebral body fracture, grossly\n stable.\n\n Bilateral lower lobe pneumonia - atelectasis. Mildly increased small\n bilateral pleural effusions.\n\n Enlarged main pulmonary artery may represent underlying pulmonary\n hypertension.\n\n Liver contusion and laceration, grossly stable, incompletely evaluated.\n\n Probable cirrhosis and mild splenomegaly, stable. Bilateral pulmonary\n reticular opacities in the subpleural region with minimal fibrotic changes and\n honeycombing may be chronic in nature.\n\n Calcified pleural plaques compatible with prior asbestos exposure.\n\n Followup chest CT when acute symptoms resolve is recommended to evaluate the\n pulmonary parenchyma.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: 74-year-old man with pelvic fractures and concern for\n pulmonary embolism.\n\n COMPARISON: Chest radiograph from , CT abdomen and pelvis\n from , CT chest without contrast from .\n\n TECHNIQUE: Contiguous multidetector CT images of the chest before and after\n administration of IV contrast with coronal, sagittal and oblique reformats\n were submitted for interpretation.\n\n FINDINGS:\n\n NON-CONTRAST CHEST CT: There is no intramural hematoma. Atherosclerotic\n calcifications of the aorta and coronary arteries are mild-to-moderate. Heart\n is upper limits of normal in size. There is no pericardial effusion. An\n endotracheal tube with the tip above the carina and an NG tube with the tip\n (Over)\n\n 2:58 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: r/o PE\n Admitting Diagnosis: POLYTAUMA\n Contrast: VISAPAQUE Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n within the stomach are noted.\n\n POST-CONTRAST CHEST CT: Study is limited due to patient motion. There is no\n evidence of pulmonary embolism in the main, primary or secondary branches of\n the pulmonary arteries. The subsegmental branches are suboptimally evaluated.\n The main pulmonary artery is dilated, measuring up to 3.5 cm (3:24). Both\n right and left pulmonary arteries are also dilated, right more than left.\n There is no evidence of aortic dissection. Heart is borderline in size.\n There is no pericardial effusion. There is no pathologically enlarged\n mediastinal, hilar, or axial lymphadenopathy. Localized soft tissue\n attenuation area at the rigt aspect of the mediastinum is likely a hematoma\n adjacent to fractured T4 vertebral body.\n\n There has been interval increase in small bilateral pleural effusions with\n associated lower lobe collapse and probable underlying aspiration or\n contusion. Pleural thickening especially in the right hemithorax is likely\n related to adjacent rib fractures and pleural hemorrhage. Calcified pleural\n plaques are most compatible with asbestos exposure, grossly stable. Bilateral\n pulmonary reticular opacities in the subpleural region with minimal\n honeycombing is likely fibrotic.\n\n Suboptimally evaluated and partially imaged upper abdominal organs demonstrate\n an area of hypodensity in the medial aspect of the posterior right lobe\n adjacent to a large vertebral osteophyte compatible with contusion, slightly\n decreased in size, however, incompletely evaluated. Laceration-contusion\n along the posterolateral surface of the liver is partially imaged and grossly\n stable. 12-mm stable hyperdense, likely calcified structure in the posterior\n right lobe of the liver likely represents a calcified granuloma. Spleen is\n upper limit of normal in size. Previously seen nodular contour of the liver\n is not as conspicuous as prior study.\n\n Multiple bilateral rib fractures are again noted. There is also grossly\n stable anterior inferior fracture of one of T4 thoracic vertebral bodies.\n Degenerative changes of the vertebral body are severe. Previously seen\n non-displaced left T10 transverse is not as well seen on the current study,\n likely due to motion artifact.\n\n IMPRESSION:\n 1. No evidence of central pulmonary embolism. The subsegmental arteries\n cannot be evaluated due to motion arifact.\n\n 2. Multiple bilateral rib fractures and T4 vertebral body fracture with\n associated mediastinal hematoma, grossly stable.\n\n 3. Mildly increased small bilateral pleural effusions and adjacent bilateral\n (Over)\n\n 2:58 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: r/o PE\n Admitting Diagnosis: POLYTAUMA\n Contrast: VISAPAQUE Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n lower lobe atelectasis with likely underlying aspiration or contusion.\n\n 4. Enlarged main pulmonary artery may represent underlying pulmonary\n hypertension.\n\n 5. Liver contusion and laceration, grossly stable, incompletely evaluated.\n\n 6. Calcified pleural plaques compatible with prior asbestos exposure. Probable\n mild paranchymal subpleural fibrotic changes may represent asbestosis.\n Followup chest CT when acute symptoms resolve is recommended to evaluate the\n pulmonary parenchyma.\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-01-25 00:00:00.000",
"description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY",
"row_id": 1112484,
"text": ", R. TSICU 2:58 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: r/o PE\n Admitting Diagnosis: POLYTAUMA\n Contrast: VISAPAQUE Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with pelvic fractures and concern for PE\n REASON FOR THIS EXAMINATION:\n r/o PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n No evidence of central pulmonary embolism. The subsegmental arteries cannot\n be evaluated due to technique. No aortic dissection.\n\n Multiple bilateral rib fractures and T4 vertebral body fracture, grossly\n stable.\n\n Bilateral lower lobe pneumonia - atelectasis. Mildly increased small\n bilateral pleural effusions.\n\n Enlarged main pulmonary artery may represent underlying pulmonary\n hypertension.\n\n Liver contusion and laceration, grossly stable, incompletely evaluated.\n\n Probable cirrhosis and mild splenomegaly, stable. Bilateral pulmonary\n reticular opacities in the subpleural region with minimal fibrotic changes and\n honeycombing may be chronic in nature.\n\n Calcified pleural plaques compatible with prior asbestos exposure.\n\n Followup chest CT when acute symptoms resolve is recommended to evaluate the\n pulmonary parenchyma.\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-01-31 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1113231,
"text": " 5:05 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for progression\n Admitting Diagnosis: POLYTAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with multiple rib fx and pulm contusions\n REASON FOR THIS EXAMINATION:\n eval for progression\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of the patient with multiple rib fractures\n and pulmonary contusions.\n\n Portable AP chest radiograph was compared to .\n\n The ET tube tip is 6.2 cm above the carina. The NG tube tip is in the\n proximal stomach. The right subclavian line tip is at the level of superior\n SVC. Cardiomediastinal silhouette is unchanged as well as there is no change\n in mild bilateral pulmonary edema and parenchymal opacities and there is no\n pleural effusion. There is no clear evidence of pneumothorax, although\n minimal amount cannot be excluded on the left. Multiple rib fractures are\n redemonstrated.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-01-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1112413,
"text": " 7:24 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: eval ETT placement\n Admitting Diagnosis: POLYTAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with recent intubation\n REASON FOR THIS EXAMINATION:\n eval ETT placement\n ______________________________________________________________________________\n WET READ: RSRc WED 9:02 AM\n ETT terminates 5.5 cm above carina otherwise similar to prior with atelectasis\n and likely small effusions at both bases. Superimposed\n aspiration/consolidation difficult to exclude. Multiple fractures better\n evaluated on previous CT. (called by Dr. - anesthesia resident\n 8:20 am ).\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of the patient after recent intubation.\n\n Portable AP chest radiograph was compared to prior study obtained the same day\n earlier at 06:13 a.m.\n\n The ET tube tip is 5.5 cm above the carina. The right internal jugular line\n tip is at the level of low SVC. There is interval improvement of pulmonary\n edema which is currently mild. Bilateral pleural effusions and bibasal\n atelectasis are unchanged in the short-term interval.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-02-05 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1113890,
"text": " 5:36 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: 50cm DL L basilic PICC placed ? tip\n Admitting Diagnosis: POLYTAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with new PICC\n REASON FOR THIS EXAMINATION:\n 50cm DL L basilic PICC placed ? tip\n ______________________________________________________________________________\n WET READ: DLrc SUN 6:09 PM\n Left PICC at brachiocephalic junction. Recommend repositioning. Findings\n discussed with at 6:10PM. Otherwise unchanged appearance of the\n lungs.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST \n\n COMPARISON: Radiograph of earlier the same date.\n\n INDICATION: PICC placement.\n\n FINDINGS: Left PICC is visualized to the level of the junction of the left\n brachiocephalic vein and superior vena cava. An opaque external monitoring\n lead overlies this region, and it is difficult to determine whether the\n catheter extends slightly below this level into the proximal SVC. With the\n exception of PICC placement, there has not been a substantial change in the\n appearance of the chest since the recent radiograph of earlier the same date.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-02-06 00:00:00.000",
"description": "LP UNILAT UP EXT VEINS US LEFT PORT",
"row_id": 1113934,
"text": " 8:39 AM\n UNILAT UP EXT VEINS US LEFT PORT Clip # \n Reason: Eval for DVT\n Admitting Diagnosis: POLYTAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with new PICC, and LUE swelling\n REASON FOR THIS EXAMINATION:\n Eval for DVT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 74-year-old man with left upper extremity swelling and new PICC\n line.\n\n COMPARISON: No previous exam for comparison.\n\n FINDINGS: Grayscale, color and Doppler son of the left IJ, subclavian,\n axillary, brachial, and basilic veins were performed. Note is made that the\n left cephalic vein could not be identified. There is normal flow, compression\n and augmentation seen in all of the vessels.\n\n IMPRESSION: No evidence of deep vein thrombosis in the left arm.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-02-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1113735,
"text": " 5:17 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for PNA\n Admitting Diagnosis: POLYTAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with VAP, recent trach, s/p crush injury w/mult rib fx\n REASON FOR THIS EXAMINATION:\n eval for PNA\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Ventilatory associated pneumonia, recent tracheostomy,\n evaluation.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the patient has changed in\n body position. Overall, there is little change. The tracheostomy tube and\n the right-sided central venous access line are in unchanged position. Also\n unchanged are the bilateral pleural effusions as well as the bilateral patchy\n areas of opacity. The size of the cardiac silhouette and the extent of the\n retrocardiac atelectasis are also constant. In the well-ventilated portions\n of the lung parenchyma, there is no evidence of newly appeared focal\n parenchymal opacity suggesting pneumonia.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-01-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1112403,
"text": " 5:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for progression\n Admitting Diagnosis: POLYTAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with multiple broken ribs and pulmonary contusion\n REASON FOR THIS EXAMINATION:\n eval for progression\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of the patient after trauma.\n\n COMPARISON: Chest CT from .\n\n Multiple rib fractures involving the right hemithorax are seen although better\n evaluated by the recent CT of the chest. There is interval development of a\n pulmonary edema that was not seen on the prior studies accompanied by\n bilateral increase of pleural effusions. The cardiomediastinal silhouette is\n grossly unchanged although the comparison is difficult between the chest\n radiograph and the chest CT. The small amount of pneumothorax on the right is\n difficult to appreciate on the chest radiograph.\n\n Overall the significant change is interval development of moderate to severe\n pulmonary edema and increase in bilateral pleural effusions.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-02-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1113401,
"text": " 5:37 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for PNA, edema, interval change\n Admitting Diagnosis: POLYTAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with PNA\n REASON FOR THIS EXAMINATION:\n Evaluate for PNA, edema, interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 74-year-old male with pneumonia, followup chest x-ray for\n interval change.\n\n COMPARISON: Chest radiographs available from through .\n\n SEMI-UPRIGHT AP VIEW OF THE CHEST: A right-sided central venous catheter,\n endotracheal tube, and gastric tube are unchanged in position since , . Cardiomediastinal silhouette is unchanged. There is no change of\n mild bilateral pulmonary edema and parenchymal opacities. There are no new\n focal opacities. There is no pneumothorax.\n\n IMPRESSION: No significant radiographic change since .\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-01-24 00:00:00.000",
"description": "MR THORACIC SPINE W/O CONTRAST",
"row_id": 1112259,
"text": " 1:59 AM\n MR THORACIC SPINE W/O CONTRAST Clip # \n Reason: please do MRI T-spine to further characterize fractures\n Admitting Diagnosis: POLYTAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with fall with thoracic spine fractures\n REASON FOR THIS EXAMINATION:\n please do MRI T-spine to further characterize fractures\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): BLjb TUE 11:55 AM\n 1. Mild compression deformity of L1 with additional levels of potential\n trabecular contusion at T10-11 also inferiorly at T4 with no retropulsion.\n\n 2. Multilevel degenerative changes with moderate canal narrowing at T10-11\n with cord deformity and no abnormal cord signal.\n\n 3. Extensive edema throughout the paraspinal soft tissues, predominantly\n posteriorly within the interspinous ligaments.\n\n 4. Incompletely evaluated cervical spine demonstrates severe canal narrowing\n at C4-5 with cord deformity and no abnormal cord signal.\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: Thoracic spine MRI.\n\n HISTORY: 74-year-old male presents with fall and thoracic spine fractures.\n\n COMPARISON: Abdominal CT scan one day prior.\n\n TECHNIQUE: Sagittal T1, T2 FSE, STIR, axial T2-weighted sequences through the\n thoracic spine were obtained.\n\n FINDINGS: Sagittal alignment is satisfactory. There is a mild compression\n deformity of L1 with minimal loss of vertebral body height. Bone marrow edema\n extends horizontally into the posterior elements. There is mild bone marrow\n edema surrounding the T10-11 disc space and to a lesser extent involving the\n inferior right posterolateral corner of the T4 vertebral body. There is\n extensive edema throughout the paraspinal soft tissues, predominantly within\n the interspinous ligaments within the mid-to-lower thoracic spine.\n\n Multilevel degenerative changes are present, including multilevel Schmorl's\n nodes and central disc herniations. The largest disc herniation is present at\n T10-11 where there is additional facet arthropathy and ligamentum flavum\n mineralization resulting in moderate canal narrowing with slight cord\n deformity, though no abnormal cord signal. The conus terminates at T12.\n\n The known multilevel rib fractures are not well visualized on this\n examination. There are bilateral pleural effusions. Limited views of the\n cervical spine demonstrate multilevel spondylosis with a central disc\n herniation at C4-5 which appears to result in severe canal narrowing with cord\n deformity, though no convincing abnormal cord signal.\n (Over)\n\n 1:59 AM\n MR THORACIC SPINE W/O CONTRAST Clip # \n Reason: please do MRI T-spine to further characterize fractures\n Admitting Diagnosis: POLYTAUMA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n IMPRESSION:\n 1. Mild compression deformity of L1 with additional levels of potential\n trabecular contusion at T10-11 also inferiorly at T4 with no retropulsion.\n\n 2. Multilevel degenerative changes with moderate canal narrowing at T10-11\n with cord deformity and no abnormal cord signal.\n\n 3. Extensive edema throughout the paraspinal soft tissues, predominantly\n posteriorly within the interspinous ligaments.\n\n 4. Incompletely evaluated cervical spine demonstrates severe canal narrowing\n at C4-5 with cord deformity and no abnormal cord signal.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-01-28 00:00:00.000",
"description": "RP FOOT AP,LAT & OBL RIGHT PORT",
"row_id": 1112908,
"text": " 11:43 AM\n FOOT AP,LAT & OBL RIGHT PORT Clip # \n Reason: eval for fracture\n Admitting Diagnosis: POLYTAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man s/p crush injury/trauma with ecchymosis on RLE.\n REASON FOR THIS EXAMINATION:\n eval for fracture\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of the patient with crush injury with\n ecchymosis of right lower extremity.\n\n Three views of the right foot were reviewed. There is no clear evidence of\n fracture. There is no evidence of lytic or sclerotic lesion worrisome for\n neoplasm or infectious process. There is no appreciable soft tissue swelling.\n Minimal degenerative changes are present as well as hallux valgus.\n\n Linear density projecting at the expected area of insertion of the Achilles\n tendon to the calcaneus is noted and might represent either minimal avulsion\n fracture or degenerative changes, correlation with clinical findings is\n recommended.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-01-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1112982,
"text": " 7:03 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Newly intubated\n Admitting Diagnosis: POLYTAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with new intubated\n REASON FOR THIS EXAMINATION:\n Newly intubated\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST.\n\n REASON FOR EXAM: Intubated patient.\n\n Comparison is made with prior study performed one hour earlier.\n\n ET tube tip is 5.6 cm above the carina. No other change\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-01-24 00:00:00.000",
"description": "MR THORACIC SPINE W/O CONTRAST",
"row_id": 1112260,
"text": ", R. TSICU 1:59 AM\n MR THORACIC SPINE W/O CONTRAST Clip # \n Reason: please do MRI T-spine to further characterize fractures\n Admitting Diagnosis: POLYTAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with fall with thoracic spine fractures\n REASON FOR THIS EXAMINATION:\n please do MRI T-spine to further characterize fractures\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n 1. Mild compression deformity of L1 with additional levels of potential\n trabecular contusion at T10-11 also inferiorly at T4 with no retropulsion.\n\n 2. Multilevel degenerative changes with moderate canal narrowing at T10-11\n with cord deformity and no abnormal cord signal.\n\n 3. Extensive edema throughout the paraspinal soft tissues, predominantly\n posteriorly within the interspinous ligaments.\n\n 4. Incompletely evaluated cervical spine demonstrates severe canal narrowing\n at C4-5 with cord deformity and no abnormal cord signal.\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-01-23 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 1112230,
"text": " 7:52 PM\n CT C-SPINE W/O CONTRAST; OUTSIDE FILMS READ ONLY Clip # \n Reason: eval CT C-Spine for acute traumatic injuries.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man hit by tree.\n REASON FOR THIS EXAMINATION:\n eval CT C-Spine for acute traumatic injuries.\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: CXWc MON 9:09 PM\n No fracture or malalignment. Multilevel degenerative changes with large\n posterior disk bulge at C4-5, narrowing the spinal canal and deforming the\n thecal sac, acuity unknown. Marked neuroforamenal narrowing at multiple\n levels.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Transfer for pelvic fracture.\n\n TECHNIQUE: A non-contrast cervical spine CT was obtained earlier today at\n Hospital, at 1600 hours on . A second opinion is requested by\n the referring clinician. No official report is available at the time of\n interpretation.\n\n FINDINGS: There is no fracture or malalignment of the cervical spine.\n Vertebral body heights are preserved. There is loss of intervertebral disc\n height between C5 and C7. Prevertebral soft tissues are not thickened.\n\n At C4-5, a large posterior disc bulge moderately narrows the spinal canal,\n deforming the thecal sac. The acuity is unknown. Posterior disc osteophyte\n complexes at C5-6 and C6-7 results in mild narrowing of the spinal canal.\n Pronounced uncovertebral hypertrophy results in neural foraminal narrowing\n bilaterally at multiple levels.\n\n The visualized lung apices demonstrate atelectasis bilaterally.\n\n IMPRESSIONS:\n\n 1. No fracture or malalignment of the cervical spine.\n\n 2. Large posterior disc bulge at C4-5, acuity unknown, resulting in deformity\n of the thecal sac. If neural deficits are localizable to this level, MRI can\n be obtained to assess for spinal cord injury.\n\n 3. Bilateral neural foraminal narrowing.\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-01-23 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 1112231,
"text": " 7:53 PM\n CT CHEST W/O CONTRAST; OUTSIDE FILMS READ ONLY Clip # \n Reason: eval CT Chest for acute traumatic injuries.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man hit by tree.\n REASON FOR THIS EXAMINATION:\n eval CT Chest for acute traumatic injuries.\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: CXWc MON 11:06 PM\n 1. Multiple rib fractures: right anterolateral and posterior, left posterior\n 2. Dependent consolidation which could be sequela of aspiration\n 3. T4 vertebral body inferior corner fracture, no retropulsion\n 4. Comminuted spinous process fractures T2-8\n 5. Nondisplaced left T10 transverse process\n 6. Nondisplaced left clavicle distal fracture\n 7. Nondisplaced left scapula fracture\n WET READ VERSION #1 CXWc MON 10:17 PM\n 1. Multiple rib fractures: right anterolateral and posterior\n 2. Dependent consolidation which could be sequela of aspiration\n 3. T4 vertebral body inferior corner fracture, no retropulsion\n 4. Comminuted spinous process fractures T2-8\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Transfer for multiple fractures. Hit by tree.\n\n TECHNIQUE: A contrast-enhanced chest CT was obtained earlier today at \n Hospital, at 1620 hours on . A second opinion was requested by the\n referring physician. formal report of that study is available at the time\n of interpretation. By verbal report from the referring physician, is\n concern for rib fractures.\n\n COMPARISON: None.\n\n FINDINGS: The aorta is normal in caliber, without dissection, pseudoaneurysm,\n or other acute abnormality. Atherosclerotic calcification is noted. There is\n no segmental or central pulmonary embolus. The heart size is normal without\n pericardial effusion. Atherosclerotic calcifications are noted. There is no\n mediastinal, hilar, or axillary lymphadenopathy by size criteria.\n\n Lungs demonstrate bilateral, dependent consolidation, which could reflect\n sequela of aspiration, or could indicate atelectasis. Additionally, there are\n peripherally based heterogeneous areas of opacity that could reflect\n contusion. There is no pleural effusion. The tracheobronchial tree is patent\n to subsegmental levels. Bilateral pleural calcifications suggest prior\n asbestos exposure.\n\n In the included portion of the upper abdomen, there is a focal linear area of\n hypodensity in the posterior right lobe of the liver, with adjacent\n intermediate attenuation fluid closely opposed to the hepatic parenchyma and\n extending to the posterior chest wall. In this location in the hepatic\n parenchyma, there is a calcified granuloma. This is concerning for\n (Over)\n\n 7:53 PM\n CT CHEST W/O CONTRAST; OUTSIDE FILMS READ ONLY Clip # \n Reason: eval CT Chest for acute traumatic injuries.\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n laceration/contusion, and is further assessed on the subsequent abdominopelvic\n CT.\n\n OSSEOUS STRUCTURES: Multiple fractures are present. The T4 vertebral body\n demonstrates a nondisplaced anterior inferior corner fracture. There is no\n retropulsion of the main fracture fragment. The remaining vertebral bodies\n are preserved in height. There are multiple comminuted fractures through the\n spinous processes spanning T2 through T8. Additionally, there are multiple\n rib fractures. On the right, there are anterolateral fractures of the third\n through eighth ribs, with extensively comminuted fractures of the seventh and\n eighth ribs. Posteriorly, there are non-displaced fractures through the fifth\n through eleventh ribs. On the left, there are minimally displaced fractures\n through the posterior third through eleventh ribs. There is a minimally\n displaced fracture through the left tenth transverse process. Additionally,\n there are non-displaced fractures through the distal one-third of the left\n clavicle, and through the body of the left scapula.\n\n IMPRESSION:\n 1. Multiple rib fractures bilaterally, including right anterolateral and\n posterior, and left posterior ribs as detailed above.\n 2. T4 vertebral body inferior corner fracture, with no retropulsion or\n malalignment. Comminuted spinous process fractures between T2 and T8.\n 3. Non-displaced left T10 transverse process fracture.\n 4. Non-displaced left clavicle and left scapula fractures.\n 5. Dependent consolidation in the lungs bilaterally, which could be sequela\n of aspiration, or could reflect contusion.\n 6. No acute vascular injury.\n 7. Calcified pleura bilaterally suggesting prior asbestos exposure.\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-01-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1112980,
"text": " 5:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for acute process\n Admitting Diagnosis: POLYTAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man s/p crush trauma\n REASON FOR THIS EXAMINATION:\n eval for acute process\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: S/P crush trauma, intubated patient.\n\n Comparison is made with prior study performed a day earlier.\n\n ET tube tip is 6.4 cm above the carina. Moderate right and small left pleural\n effusions are unchanged. There are low lung volumes. Cardiomediastinal\n silhouette is unchanged with mild cardiomegaly. Right subclavian catheter and\n NG tube remain in place. Mild fluid overload is unchanged.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-01-30 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 1113099,
"text": " 9:35 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: ? acalculous chole vs biloma\n Admitting Diagnosis: POLYTAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with hyperbilirubinemia s/p fall\n REASON FOR THIS EXAMINATION:\n ? acalculous chole vs biloma\n ______________________________________________________________________________\n WET READ: ARHb MON 11:37 AM\n No perihepatic fluid collection. Only a small amount of perihepatic free fluid\n persists. Small contusion in hepatic segment VII again noted. No\n gallstones or significant wall thickening/edema.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 74-year-old male with liver injury and hyperbilirubinemia, status\n post fall.\n\n COMPARISON: CTA abdomen/pelvis .\n\n FINDINGS: The hepatic echotexture and contour is diffusely echogenic without\n intra- or extra-hepatic biliary ductal dilatation. The extrahepatic duct\n measures 5 mm. A small ill-defined focus of hypoechogenicity measuring up to\n approximately 2.3 cm in the posterior right hepatic lobe is consistent with\n the intrahepatic contusion/laceration seen on CT. The main portal vein\n demonstrates normal hepatopedal flow. The gallbladder is mildly distended,\n without significant wall edema, stones, or sludge. Son sign\n cannot be evaluated for in this intubated patient. A small amount of\n perihepatic free fluid has not increased since the recent CT.\n\n IMPRESSION:\n 1. No son evidence for cholecystitis. No cholelithiasis or wall\n edema.\n 2. Small perihepatic free fluid, without focal collection.\n 3. Cirrhotic liver with small contusion noted in the posterior right hepatic\n lobe, as seen on recent CT.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-02-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1113654,
"text": " 5:46 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: POLYTAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with VAP, recent trach, s/p crush injury w/mult rib fx\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Ventilator-associated pneumonia, recent tracheostomy, crush\n injury, evaluation for interval change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous examination, there is no relevant\n change. Tracheostomy, right-sided central venous access line. Bilateral\n pleural effusions with bilateral basal opacities. Unchanged size of the\n cardiac silhouette. No evidence of newly appeared focal parenchymal opacities\n suggesting pneumonia.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-01-29 00:00:00.000",
"description": "BY SAME PHYSICIAN",
"row_id": 1112994,
"text": " 11:04 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: eval for infiltrates s/p brocnh, also eval plaecemnt of NGT\n Admitting Diagnosis: POLYTAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with new NGT\n REASON FOR THIS EXAMINATION:\n eval for infiltrates s/p brocnh, also eval plaecemnt of NGT\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Evaluate NG tube.\n\n Prior exam was performed four hours earlier.\n\n NG tube tip is in the stomach. No other interval change.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-01-25 00:00:00.000",
"description": "PELVIS SEL/SUPERSEL A-GRAM",
"row_id": 1112438,
"text": " 9:37 AM\n ILIAC Clip # \n Reason: eval for bleed\n Admitting Diagnosis: POLYTAUMA\n Contrast: OPTIRAY Amt: 130\n ********************************* CPT Codes ********************************\n * EMBO NON NEURO INITAL 3RD ORDER ABD/PEL/LOWER *\n * -51 MULTI-PROCEDURE SAME DAY INITAL 3RD ORDER ABD/PEL/LOWER *\n * -59 DISTINCT PROCEDURAL SERVICE ADD'L 2ND/3RD ORDER ABD/PEL/LO *\n * -59 DISTINCT PROCEDURAL SERVICE PELVIS SEL/SUPERSEL A-GRAM *\n * -59 DISTINCT PROCEDURAL SERVICE VISERAL SEL/SUPERSEL A-GRAM *\n * -59 DISTINCT PROCEDURAL SERVICE VISERAL SEL/SUPERSEL A-GRAM *\n * -59 DISTINCT PROCEDURAL SERVICE TRANCATHETER EMBOLIZATION *\n * EA ADD'L VESSEL AFTER BASIC A- EA ADD'L VESSEL AFTER BASIC A- *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with acutely dropping Hct s/p trauma with crush injury\n REASON FOR THIS EXAMINATION:\n eval for bleed\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): MGRc WED 8:45 PM\n PFI.\n\n 1. Pelvic arteriography: Multiple arteriographic runs performed of distal\n aorta, external iliac, internal iliac, lateral sacral and superior gluteal\n arteries. Active contrast extravasation noted from branches of the lateral\n sacral artery and superior gluteal arteries. Successful Gelfoam embolization\n of lateral sacral artery and branches of the superior gluteal artery.\n 2. Hepatic angiography: Multiple arteriographic runs of common hepatic and\n right hepatic arteries. Some active contrast extravasation was noted from\n peripheral branches of right hepatic artery. Gelfoam embolization of distal\n right hepatic artery branches performed.\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n MEDICAL HISTORY: 74-year-old man with polytrauma with pelvic fracture and\n liver injury. Patient has been acutely dropping hematocrit and contrast CT\n scan of abdomen and pelvis showed some active extravasation around the left\n superior pubic ramus fracture as well as liver contusion. A request was\n placed for pelvic and hepatic arteriography with embolization of any bleeding\n vessels.\n\n CLINICIANS: Dr. , Dr. and Dr. . Dr. \n is the attending radiologist who was present and supervising throughout.\n\n ANESTHESIA: The patient was brought down from the ICU intubated and sedated .\n Local anesthesia with 1% lidocaine.\n\n PROCEDURE AND FINDINGS: A written informed consent was obtained after\n explaining the procedure, benefits and risks involved. The patient was\n brought to angiography suite and placed supine on the imaging table. The\n right groin was prepped and draped in the usual sterile fashion. A\n preprocedural huddle and timeout were performed as per protocol.\n (Over)\n\n 9:37 AM\n ILIAC Clip # \n Reason: eval for bleed\n Admitting Diagnosis: POLYTAUMA\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n (Cont)\n\n Under palpatory and fluoroscopic guidance the right common femoral artery was\n accessed with a micropuncture needle. A 0.018 guidewire was placed through\n the needle and needle exchanged for a micropuncture sheath which in turn was\n used to upsize the wire to wire. The wire was advanced into\n abdominal aorta under fluoroscopic guidance. The micropuncture sheath was\n removed and replaced with a 5 French vascular sheath, the side arm of which\n was connected to a continuous saline flush. Over the wire, a 5 French\n Omni Flush catheter was placed into the distal aorta and an angiogram\n performed with power injection. Then the Omni Flush catheter was advanced\n into left common iliac artery over a guidewire and Left external iliac\n arteriogram was performed. Then the the catheter exchanged for a C2 cobra\n catheter and a left internal iliac arteriogram was performed. The internal\n iliac arteriogram showed some contrast extravasation from the branches of\n lateral sacral and superior gluteal arteries. There was no contrast\n extravasation seen in the vicinity of the left superior pubic ramus fracture.\n Depending upon these diagnostic findings, it was felt that the patient would\n benefit from embolization of the bleeding vessels. Using a C2 Cobra catheter\n and Renegade high-flow microcatheter and an 0.018 gold glidewire, the left\n lateral sacral artery was selectively catheterized and an arteriogram at this\n level demonstrated multiple small clusters of contrast or micro-extravasations\n from the small peripheral branches. Therefore, the lateral sacral artery was\n embolized using Gelfoam slurry with good angiographic result. The C2 catheter\n was then withdrawn from the lateral sacral artery the superior gluteal artery\n was selectively catheterized and angiogram at this level again demonstrated\n similar small contrast collctions. These branches of the superior gluteal\n artery were therefore embolized with Gelfoam slurry with good angiographic\n result.\n\n Then the C2 Cobra catheter was pulled back into the aorta and the celiac\n artery was cannulated. Using a Glidewire the hepatic artery was cannulated\n and angiography of the hepatic artery demonstrated some small peripheral\n contrast areas of hypervascvlarity supplied from the right hepatic artery\n branches. These were in the region of the hepatic and subcapsular hemorrhage\n from the right lobe. The C2 catheter was advanced distal to origin of the\n cystic artery and the peripheral branches were embolized with Gelfoam slurry\n with good angiographic result. Post- embolization arteriography demonstrated\n no further visible contrast extravasation. The catheter and vascular sheaths\n were pulled out and hemostasis was achieved with digital compression for 20\n minutes. Sterile dressings were applied. The patient tolerated the procedure\n well with no immediate complications.\n\n IMPRESSION:\n 1. Pelvic angiography with multiple arteriographic runs of the distal aorta,\n left external iliac, left internal iliac, left lateral sacral and superior\n (Over)\n\n 9:37 AM\n ILIAC Clip # \n Reason: eval for bleed\n Admitting Diagnosis: POLYTAUMA\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n (Cont)\n gluteal arteries. Abnormal clusters of contrast, ? active contrast\n extravasation noted from branches of lateral sacral artery and superior\n gluteal artery on the left. These arteries were successfully embolized with\n Gelfoam slurry.\n 2. Hepatic angiography with multiple arteriographic runs of common and right\n hepatic arteries demonstrating similar contrast collections in peripheral\n branches of right hepatic artery, adjacent to the known hepatic and\n subcapsular hematomas. These peripheral branches of the right hepatic artery\n were successfully embolized with Gelfoam slurry.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-01-23 00:00:00.000",
"description": "CTA ABD W&W/O C & RECONS",
"row_id": 1112248,
"text": " 9:51 PM\n CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # \n Reason: CTA Abd Pelvis with 5 minute delayed venous imaging to asses\n Admitting Diagnosis: POLYTAUMA\n Field of view: 40 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with fall and pelvis fractures\n REASON FOR THIS EXAMINATION:\n CTA Abd Pelvis with 5 minute delayed venous imaging to assess for active\n bleeding\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: CXWc MON 10:41 PM\n 1. Medial right liver lobe contusion with adjacent hematoma, without evidence\n of active bleeding\n 2. Comminuted left pubic ramus fracture with associated hematoma, with tiny\n focus of arterial bleeding/active extravasation, and larger area of venous\n bleeding. Hematoma somewhat larger than on OSH study.\n 3. Nondisplaced, comminuted left iliac bone fracture with adjacent iliac\n muscle hematoma, larger than on prior study, without active extrav. Fracture\n extends into left SI joint.\n 4. Posterior right hepatic laceration/contusion adjacent to calcified\n granuloma, with small hematoma, without active bleeding\n 5. Minimally displaced fracture of the right iliac bone extending to right SI\n joint.\n 6. Cirrhotic liver. Fluid around nondistended gallbladder likely related to\n liver disease.\n 7. Increased pleural effusions (small), bilaterally, with increased\n atelectasis.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 74-year-old man status post trauma, with pelvic fractures.\n Concern for active bleeding.\n\n COMPARISON: CT abdomen and pelvis obtained at Hospital at\n approximately 1615 hours on .\n\n TECHNIQUE: MDCT-acquired axial images were obtained through the abdomen and\n pelvis before and after administration of intravenous contrast material.\n Post-contrast images were obtained in arterial, venous and delayed phases.\n Multiplanar reformatted images were generated.\n\n CT ABDOMEN WITH IV CONTRAST: At the lung bases, there has been an interval\n increase/development of bilateral pleural effusions, now small. Additionally,\n there is increased consolidation dependently, which could reflect atelectasis\n or the sequela of aspiration. The heart size remains normal, without\n pericardial effusion. Coronary artery calcifications are again noted.\n Pleural calcifications bilaterally suggest prior asbestos exposure.\n\n Within the abdomen, the liver demonstrates multiple abnormalities. Along the\n medial aspect of the posterior right lobe, there is an area of\n hypoattenuation, somewhat irregular in contour, measuring approximately 4.9 x\n (Over)\n\n 9:51 PM\n CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # \n Reason: CTA Abd Pelvis with 5 minute delayed venous imaging to asses\n Admitting Diagnosis: POLYTAUMA\n Field of view: 40 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 4.4 cm. This area lies adjacent to a large protruding vertebral body\n osteophyte, and is consistent with contusion. The area of contusion results\n in narrowing of the adjacent right hepatic vein and the right posterior portal\n vein branches. Additionally, on arterial phase, a branch of the right hepatic\n artery is slightly irregular, although there is no definite evidence of acute\n active extravasation at this time. This area of contusion abuts the inferior\n vena cava, which has improved in caliber since the prior study. There is a\n small degree of fluid and fat stranding along the inferior margin of the liver\n and tracking around the IVC to the level of the renal veins.\n\n Along the posterolateral surface of the right lobe of the liver, there is a\n linear region of hypodensity that could reflect contusion or laceration. This\n is associated with a 12-mm hyperdense structure, most likely a calcified\n granuloma. There is a moderate amount of adjacent fluid or stranding, with\n intermediate density fluid suggesting hematoma. Surrounding this area, there\n is inflammatory stranding.\n\n The liver is shrunken, with a nodular contour, consistent with cirrhosis. No\n worrisome arterially enhancing lesions are identified. The gallbladder is\n decompressed, but demonstrates a small amount of pericholecystic fluid or wall\n thickening, which may be related to chronic liver disease. The main portal\n vein and its branches are patent.\n\n The pancreas, spleen, adrenal glands and duodenum are unremarkable. The\n stomach is within normal limits, with a moderate hiatal hernia. The kidneys\n enhance and excrete contrast symmetrically, with a hypodense lesion at the\n lower pole of the left kidney, too small to accurately characterize.\n\n The abdominal aorta and its major branches are patent, with atherosclerotic\n calcifications. The aorta is normal in caliber. There is no free air in the\n abdomen. There is no mesenteric or retroperitoneal lymphadenopathy by size\n criteria.\n\n CT PELVIS WITH IV CONTRAST: In the anterior pelvis, associated with a\n comminuted pubic ramus fracture (to be described in the next section), there\n has been an interval increase in a multifocal hematoma, now extending more\n cranially into the peritoneal cavity than on the prior study. On arterial\n phase, there is a tiny hyperdense linear focus, extending a few millimeters,\n concerning for active extravasation. On venous phase, this area increases in\n density and size, to 7 x 5 mm. On delayed images, hyperdense material spans a\n larger area measuring roughly 23 x 14 mm. This is concerning for a small\n amount of active, or venous bleeding.\n\n Additionally, there is a retroperitoneal hematoma involving the left iliac\n muscle, associated with an iliac bone fracture (to be described in the next\n (Over)\n\n 9:51 PM\n CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # \n Reason: CTA Abd Pelvis with 5 minute delayed venous imaging to asses\n Admitting Diagnosis: POLYTAUMA\n Field of view: 40 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n section). This hematoma has also increased in size from the prior study. It\n now measures roughly 8.8 x 5.6 cm, previously 9.6 x 5.9 cm. There is no\n evidence of active extravasation at this time. Hyperdense material noted\n within this region on the prior study is no longer seen.\n\n Multiple loops of large and small bowel are notable for sigmoid\n diverticulosis, without diverticulitis. There is no bowel wall thickening,\n evidence of obstruction, or mesenteric fluid to suggest bowel injury. The\n urinary bladder is decompressed around a Foley catheter. Distal ureters and\n prostate gland are within normal limits. There is no pelvic or inguinal\n lymphadenopathy by size criteria.\n\n OSSEOUS STRUCTURES: There is a comminuted fracture of the left superior pubic\n ramus, and a minimally displaced fracture of the left inferior pubic ramus.\n This is associated with a large hematoma containing hyperdense material\n concerning for active extravasation, as described in the previous section.\n\n There is a minimally displaced fracture through the left iliac bone, extending\n from the crest to the sacroiliac joint, and extending into the joint space on\n the left. This is associated with an iliac muscle hematoma, as described in\n the previous section. Additionally, there is a nondisplaced fracture through\n the right iliac bone, extending from the iliac crest to the sacroiliac joint,\n and into the joint space.\n\n Degenerative changes are noted of both hips and the lumbar spine. No\n vertebral body fractures are identified. Posterior rib fractures involving\n the bilateral eleventh, tenth, ninth and eighth ribs are again visualized. A\n nondisplaced 10th vertebral body left transverse process fracture is noted.\n\n IMPRESSIONS:\n\n 1. Contusion/laceration of the medial aspect of the right hepatic lobe, with\n adjacent small hematoma, without definite evidence of active bleeding.\n Associated irregularity of an adjacent branch of the right hepatic artery and\n resultant narrowing of the adjacent right hepatic vein and right posterior\n portal vein branches. Posterior right hepatic laceration/contusion, adjacent\n to a calcified granuloma, with a small hematoma, without evidence of active\n extravasation.\n\n 2. Comminuted left pubic ramus fracture with associated hematoma, which has\n increased in size from the prior study of approximately six hours prior. Tiny\n focus of arterially enhancing material, which enlarges on venous and delayed\n images, concerning for active extravasation.\n\n 3. Minimally displaced, comminuted left iliac bone fracture, with adjacent\n (Over)\n\n 9:51 PM\n CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # \n Reason: CTA Abd Pelvis with 5 minute delayed venous imaging to asses\n Admitting Diagnosis: POLYTAUMA\n Field of view: 40 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n iliac muscle hematoma, largely unchanged from the prior study, without\n evidence of active extravasation. Fracture extends into the left sacroiliac\n joint.\n\n 4. Minimally displaced fracture of the right iliac bone, extending to the\n right sacroiliac joint.\n\n 5. Bilateral comminuted, minimally displaced posterior rib fractures of the\n eighth through eleventh ribs. Nondisplaced left 10th vertebral body\n transverse process fracture.\n\n 6. Interval increase in bilateral pleural effusions (small), with increased\n bilateral atelectasis or consolidation which could be the result of\n aspiration.\n\n 7. Cirrhotic liver. Fluid around the nondistended gallbladder may be related\n to liver disease.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-01-25 00:00:00.000",
"description": "PELVIS SEL/SUPERSEL A-GRAM",
"row_id": 1112439,
"text": ", R. TSICU 9:37 AM\n ILIAC Clip # \n Reason: eval for bleed\n Admitting Diagnosis: POLYTAUMA\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with acutely dropping Hct s/p trauma with crush injury\n REASON FOR THIS EXAMINATION:\n eval for bleed\n ______________________________________________________________________________\n PFI REPORT (REVISED)\n PFI.\n\n 1. Pelvic arteriography: Multiple arteriographic runs performed of distal\n aorta, external iliac, internal iliac, lateral sacral and superior gluteal\n arteries. Active contrast extravasation noted from branches of the lateral\n sacral artery and superior gluteal arteries. Successful Gelfoam embolization\n of lateral sacral artery and branches of the superior gluteal artery.\n 2. Hepatic angiography: Multiple arteriographic runs of common hepatic and\n right hepatic arteries. Some active contrast extravasation was noted from\n peripheral branches of right hepatic artery. Gelfoam embolization of distal\n right hepatic artery branches performed.\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-02-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1113503,
"text": " 7:14 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ? change pulm path\n Admitting Diagnosis: POLYTAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with desats, PNA\n REASON FOR THIS EXAMINATION:\n ? change pulm path\n ______________________________________________________________________________\n WET READ: EAGg WED 8:36 PM\n Persistent bilateral pleural effusions and bibasilar opacity, likely\n atelectasis but underlying infection not excluded.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 74-year-old male with desats and pneumonia.\n\n COMPARISON: Chest radiographs available from at 1:37 p.m.\n\n SEMI-UPRIGHT AP VIEW OF THE CHEST: The right-sided central venous catheter\n and tracheostomy tube are unchanged in position. Moderate bilateral pleural\n effusions and bibasilar opacities are stable. There has been interval\n resolution of the previously seen pneumoperitoneum. There is no pneumothorax.\n The cardiac and mediastinal contours are unchanged.\n\n IMPRESSION: Interval resolution of pneumoperitoneum, otherwise, unchanged\n radiograph.\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-01-23 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1112229,
"text": " 7:52 PM\n CT HEAD W/O CONTRAST; OUTSIDE FILMS READ ONLY Clip # \n Reason: eval CT Head for acute traumatic injuries.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man hit by tree.\n REASON FOR THIS EXAMINATION:\n eval CT Head for acute traumatic injuries.\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: CXWc MON 9:10 PM\n No ICH or fracture.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Transfer for pelvic fractures.\n\n TECHNIQUE: A non-contrast head CT was obtained earlier today at \n Hospital, at 1600 hours . A second opinion is requested by the\n referring clinician. No official report is available at the time of\n interpretation.\n\n FINDINGS: There is no intracranial hemorrhage, edema, shift of normally\n midline structures or evidence of major vascular territorial infarct.\n Ventricles and sulci are normal in size and configuration. The -white\n matter differentiation is preserved. The basilar cisterns are symmetric. A\n small mucous retention cyst, and a small amount of fluid are noted within the\n right maxillary sinus. Remaining paranasal sinuses are well aerated. Mastoid\n air cells are well aerated.\n\n IMPRESSIONS:\n\n No acute intracranial abnormality.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-02-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1113440,
"text": " 1:06 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ? change pulm path\n Admitting Diagnosis: POLYTAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with PNA, desat, hypotension\n REASON FOR THIS EXAMINATION:\n ? change pulm path\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 74-year-old male with pneumonia, continued desats, and\n hypertension.\n\n COMPARISON: Chest radiographs available from through .\n\n UPRIGHT AP VIEW OF THE CHEST:\n The upper mediastinal contour is unchanged since 5:48 a.m. The patient is\n status post tracheostomy. New pneumomediastinum is compatible with recent\n surgery, likely PEG placement, given removal of the NGT. The left-sided PICC\n is unchanged in position. There has been no change in moderate bilateral\n pleural effusions, with significant compressive atelectasis at the bases.\n There is no pneumothorax. Mild pulmonary edema is unchanged.\n\n IMPRESSION:\n 1. Status post tracheostomy. Pneumoperitoneum compatible with PEG placement\n (confirmed with TICU team).\n 2. Stable moderate bilateral pleural effusions and mild pulmonary edema.\n 3. Persistent compressive bibasilar atalectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-01-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1112875,
"text": " 5:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?effusion, atelectasis, pneumonia\n Admitting Diagnosis: POLYTAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with ETT, multiple rib fractures\n REASON FOR THIS EXAMINATION:\n ?effusion, atelectasis, pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: Chest one view at 05:49 hours.\n\n COMPARISON: at 05:59 hours.\n\n HISTORY: A 74-year-old male with endotracheal tube and multiple rib\n fractures, status post trauma.\n\n TECHNIQUE: Single semi-upright portable chest x-ray was obtained.\n\n FINDINGS:\n\n Endotracheal tube is identified with its tip just above the level of the\n thoracic inlet. Nasogastric tube is identified with its tip in the stomach.\n Right subclavian central venous catheter is identified with its tip in the\n cavoatrial junction. There is an IVC filter noted.\n\n Multiple rib fractures are present, and not well appreciated on this portable\n examination.\n\n Cardiopericardial silhouette appears somewhat enlarged, although this may be\n related to low lung volumes. In the interval, there is increasing perihilar\n opacities with an indistinct appearance of interstitium, consistent with\n cephalization of the pulmonary vasculature. Also seen are bibasilar linear\n and hazy opacities, likely related to a combination of pleural effusions and\n associated underlying edema or atelectasis. Opacity in the retrocardiac\n region may be related to atelectasis or edema.\n\n IMPRESSION:\n\n 1. Interval mild increase in cardiac size, cephalization of the vessels\n within indistinct appearance of the interstitium, bilateral pleural effusions,\n and opacities at the lung bases, which may represent edema or atelectasis. The\n constellation of these findings is likely related to fluid overload/congestive\n heart failure.\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-02-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1113544,
"text": " 5:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for acute process\n Admitting Diagnosis: POLYTAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with VAP\n REASON FOR THIS EXAMINATION:\n eval for acute process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: This is a 74-year-old male with VAP.\n\n COMPARISON: Chest radiographs available from .\n\n SEMI-UPRIGHT AP VIEW OF THE CHEST: The tracheostomy tube and right-sided\n central venous catheter are unchanged in position. Cardiac and mediastinal\n contours are unchanged. There remains persistent mild pulmonary edema.\n Moderate-sized bilateral pleural effusions have minimally improved. Bibasilar\n opacities remain present, compatible with atelectasis and/or pneumonia.\n\n IMPRESSION:\n 1. Minimal improvement of moderate-sized bilateral pleural effusions.\n 2. Stable mild pulmonary edema.\n 3. Stable bibasilar opacities compatible with atelectasis with possible\n superimposed infection.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-01-30 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1113074,
"text": " 4:34 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pna, pleural effusions\n Admitting Diagnosis: POLYTAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with pna and pleural effusions, s/p crush injury\n REASON FOR THIS EXAMINATION:\n eval for pna, pleural effusions\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Pneumonia and pleural effusions, status post crush injury.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous examination, there is no relevant\n change. Unchanged monitoring and support devices, unchanged bilateral pleural\n effusions, unchanged size of the cardiac silhouette, unchanged retrocardiac\n and left basal atelectasis. No evidence of pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-01-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1112561,
"text": " 5:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?edema, pneumonia, ETT\n Admitting Diagnosis: POLYTAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with multiple rib fxs, intubated\n REASON FOR THIS EXAMINATION:\n ?edema, pneumonia, ETT\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Multiple rib fractures and intubated.\n\n Comparison is made with prior study, .\n\n ET tube is in standard position. NG tube tip is out of view below the\n diaphragm. Right central catheter tip is in the SVC. There are low lung\n volumes. Moderate bilateral pleural effusions are stable. Collapse of the\n lower lobes bilaterally is better seen in the prior CT from the day before.\n Atelectases in the lingula and in the right upper lobe are better seen in\n prior CT.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-02-03 00:00:00.000",
"description": "BILAT LOWER EXT VEINS",
"row_id": 1113681,
"text": " 10:49 AM\n BILAT LOWER EXT VEINS Clip # \n Reason: eval for DVTs\n Admitting Diagnosis: POLYTAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with persistent fevers despite adequate pna coverage. eval for\n other sources.\n REASON FOR THIS EXAMINATION:\n eval for DVTs\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): RSRc FRI 12:22 PM\n No DVT\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 74-year-old male with pneumonia on treatment, persistent fever.\n Evaluate for DVT as occult second cause for fever.\n\n COMPARISON: None available.\n\n BILATERAL LOWER EXTREMITY VENOUS ULTRASOUND: The common femoral veins,\n superficial femoral veins, deep femoral veins, greater saphenous veins,\n popliteal veins, and calf veins demonstrate normal color flow. There is\n respiratory phasicity, compressibility, and appropriate response to\n augmentation and Valsalva maneuvers.\n\n IMPRESSION: No evidence of DVT in the lower extremities.\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-01-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1112729,
"text": " 5:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: POLYTAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with multiple broken ribs. Intubated.\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Multiple rib fractures and intubated patient.\n\n Comparison is made with prior study performed a day earlier.\n\n ET tube tip is 6.3 cm above the carina. NG tube tip is out of view below the\n diaphragm. Cardiac size is top normal, is partially obscured by lung\n abnormality. There has been interval improvement of collapse in the left\n lower lobe. Collapse of the right lower lobe is persistent. Atelectasis in\n the lingula is unchanged. Cardiomediastinum is midline. Moderate bilateral\n pleural effusions are stable. There is no pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-02-03 00:00:00.000",
"description": "BILAT LOWER EXT VEINS",
"row_id": 1113682,
"text": ", R. TSICU 10:49 AM\n BILAT LOWER EXT VEINS Clip # \n Reason: eval for DVTs\n Admitting Diagnosis: POLYTAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with persistent fevers despite adequate pna coverage. eval for\n other sources.\n REASON FOR THIS EXAMINATION:\n eval for DVTs\n ______________________________________________________________________________\n PFI REPORT\n No DVT\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-02-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1113838,
"text": " 5:05 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for infiltrates, edema, interval change\n Admitting Diagnosis: POLYTAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with multiple trauma and PNA, volume overload\n REASON FOR THIS EXAMINATION:\n Evaluate for infiltrates, edema, interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST \n\n COMPARISON: \n\n INDICATION: Volume overload.\n\n FINDINGS: Allowing for technical differences between the studies, there has\n not been a substantial change in appearance of the chest since the recent\n radiograph of one day earlier.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-02-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1113917,
"text": " 4:55 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: POLYTAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with multi-trauma\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Multiple trauma, to evaluate for change.\n\n FINDINGS: In comparison with the study of , the patient may have taken a\n slightly better inspiration. The left PICC line is not seen in the\n hemithorax, though it may be present in the soft tissues at the edge of the\n film in the axillary region. Bibasilar opacification persists, consistent\n with atelectasis and effusion. Some degree of pulmonary contusion and even\n supervening pneumonia must be considered.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-01-23 00:00:00.000",
"description": "TRAUMA #2 (AP CXR & PELVIS PORT)",
"row_id": 1112226,
"text": " 7:26 PM\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \n Reason: rib fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with fall\n REASON FOR THIS EXAMINATION:\n rib fx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 74-year-old man status post fall.\n\n COMPARISON: None.\n\n SINGLE SUPINE VIEW OF THE CHEST AT HOURS: Underlying trauma board limits\n evaluation. Lung volumes are low. There are heterogeneous parenchymal\n opacities bilaterally, suggesting multifocal contusion and/or atelectasis.\n There is no large pleural effusion. The heart size is normal. There is no\n hilar or mediastinal enlargement. Multiple displaced rib fractures are noted,\n particularly along the right lateral chest wall.\n\n SINGLE FRONTAL VIEW OF THE PELVIS: Underlying trauma board limits evaluation.\n There are minimally displaced fractures of the superior and anterior pubic\n rami on the left. Degenerative changes and fragmented osteophytes are noted\n of both hips. No other displaced fractures are definitively identified. The\n femoral heads are well seated in the acetabuli.\n\n IMPRESSIONS:\n\n 1. Heterogeneous pulmonary opacities suggestive of contusion and/or\n aspiration.\n\n 2. Multiple minimally displaced right lateral rib fractures.\n\n 3. Left pubic rami fractures.\n\n Please refer to concurrently obtained CT abdomen/pelvis, and OSH chest CT for\n further assessment.\n\n"
}
] |
54,592 | 154,299 | 50 year old woman with a history of HIV, Hepatitis C, and opiate abuse admitted with narcotic overdose. She left against medical advice on hospital day X 2. | Right mastoid tip air cells and left lateral mastoid air cells are partially opacified. IMPRESSION: Minimal streaky opacities in the lung bases which could reflect atelectasis. Left lateral mastoid air cells and right mastoid tip air cells are partially opacified. Thereis mild mucosal thickening in a right anterior ethmoid air cell. Concurrent head CT is reported separately. Minimal streaky opacities are noted within the lung bases. The frontal sinuses are not pneumatized. Sinus rhythm and frequent atrial ectopy. TECHNIQUE: Semi-upright AP view of the chest. The pulmonary vascularity is not engorged. Coronal and sagittal reformatted images were reviewed. TECHNIQUE: Axial CT images through the head were acquired without intravenous contrast. Clinicalcorrelation is suggested. The mediastinal and hilar contours are unremarkable. COMPARISON: Chest radiograph . Scarring and emphysema is again noted at the right lung apex. DFDkq DFDkq The basal cisterns appear patent. A 4 x 4 mm osteoma is again seen in a left middle ethmoid air cell. Cervical degenerative disease. IMPRESSION: No CT evidence for acute intracranial injury. TECHNIQUE: Axial CT images through the cervical spine were acquired without intravenous contrast. There is disc space narrowing and disc osteophyte complexes indenting the thecal sac at C4-5, C5-C6, and C6-C7, as before. FINDINGS: There is no acute fracture or malalignment. Concern for trauma. The ventricles and sulci are normal in size. IMPRESSION: No fracture or malalignment. DFDdp There is preservation of -white matter differentiation. FINDINGS: The heart size is normal. There is also uncovertebral arthropathy with neural foraminal narrowing at these levels, as before. COMPARISON: . COMPARISON: . This could reflect atelectasis. Clips are noted in the right upper quadrant of the abdomen denoting prior cholecystectomy. There is no calvarial fracture. FINDINGS: There is no evidence for acute intracranial hemorrhage, mass effect, edema. 4:59 PM CHEST (PORTABLE AP) Clip # Reason: eval for acute pathology MEDICAL CONDITION: History: 50F with found down REASON FOR THIS EXAMINATION: eval for acute pathology No contraindications for IV contrast FINAL REPORT HISTORY: Found down. There is no prevertebral soft tissue swelling. No pleural effusion, focal consolidation or pneumothorax is identified. Prominent nipple shadow is seen on the left. Coronal, sagittal, and thin slice bone reconstructed images were created and reviewed. Compared to the previous tracingof the rate has increased and there is frequent atrial ectopy as wellas new ST segment flattening and slight depression in leads V4-V6 in thecontext of delayed precordial R wave transition previously recorded. 2 additional clips are also seen projecting over the right inferior hemithorax. 5:16 PM CT HEAD W/O CONTRAST Clip # Reason: eval for acute process/injury to cause hypotension Admitting Diagnosis: OVERDOSE MEDICAL CONDITION: History: 50F with likely OD but hypotensive, r/o traumatic injury, PE REASON FOR THIS EXAMINATION: eval for acute process/injury to cause hypotension No contraindications for IV contrast WET READ: EHAb SUN 8:28 PM No CT evidence for acute intracranial process. 6:06 PM CT C-SPINE W/O CONTRAST Clip # Reason: eval for acute process/injury to cause hypotension Admitting Diagnosis: OVERDOSE MEDICAL CONDITION: History: 50F with likely OD but hypotensive, r/o traumatic injury, PE REASON FOR THIS EXAMINATION: eval for acute process/injury to cause hypotension No contraindications for IV contrast WET READ: EHAb SUN 8:34 PM No CT evidence for acute cervical spine fracture. WET READ VERSION #1 FINAL REPORT INDICATION: 50-year-old female who was found down, with likely overdose, hypotension, and concern for traumatic injury. | 4 | [
{
"category": "Radiology",
"chartdate": "2153-07-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1252895,
"text": " 4:59 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for acute pathology\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 50F with found down\n REASON FOR THIS EXAMINATION:\n eval for acute pathology\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Found down.\n\n TECHNIQUE: Semi-upright AP view of the chest.\n\n COMPARISON: Chest radiograph .\n\n FINDINGS:\n\n The heart size is normal. The mediastinal and hilar contours are\n unremarkable. The pulmonary vascularity is not engorged. Minimal streaky\n opacities are noted within the lung bases. This could reflect atelectasis.\n Prominent nipple shadow is seen on the left. No pleural effusion, focal\n consolidation or pneumothorax is identified. Clips are noted in the right\n upper quadrant of the abdomen denoting prior cholecystectomy. 2 additional\n clips are also seen projecting over the right inferior hemithorax.\n\n IMPRESSION:\n\n Minimal streaky opacities in the lung bases which could reflect atelectasis.\n\n DFDdp\n\n"
},
{
"category": "ECG",
"chartdate": "2153-07-22 00:00:00.000",
"description": "Report",
"row_id": 167299,
"text": "Sinus rhythm and frequent atrial ectopy. Compared to the previous tracing\nof the rate has increased and there is frequent atrial ectopy as well\nas new ST segment flattening and slight depression in leads V4-V6 in the\ncontext of delayed precordial R wave transition previously recorded. Clinical\ncorrelation is suggested.\n\n"
},
{
"category": "Radiology",
"chartdate": "2153-07-22 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 1252901,
"text": " 6:06 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: eval for acute process/injury to cause hypotension\n Admitting Diagnosis: OVERDOSE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 50F with likely OD but hypotensive, r/o traumatic injury, PE\n REASON FOR THIS EXAMINATION:\n eval for acute process/injury to cause hypotension\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: EHAb SUN 8:34 PM\n No CT evidence for acute cervical spine fracture.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 50-year-old female who was found down, with likely overdose,\n hypotension, and concern for traumatic injury.\n\n COMPARISON: .\n\n TECHNIQUE: Axial CT images through the cervical spine were acquired without\n intravenous contrast. Coronal and sagittal reformatted images were reviewed.\n\n FINDINGS: There is no acute fracture or malalignment. There is no\n prevertebral soft tissue swelling. There is disc space narrowing and disc\n osteophyte complexes indenting the thecal sac at C4-5, C5-C6, and C6-C7, as\n before. There is also uncovertebral arthropathy with neural foraminal\n narrowing at these levels, as before.\n\n Scarring and emphysema is again noted at the right lung apex.\n\n Right mastoid tip air cells and left lateral mastoid air cells are partially\n opacified. Concurrent head CT is reported separately.\n\n IMPRESSION: No fracture or malalignment. Cervical degenerative disease.\n DFDkq\n\n"
},
{
"category": "Radiology",
"chartdate": "2153-07-22 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1252899,
"text": " 5:16 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for acute process/injury to cause hypotension\n Admitting Diagnosis: OVERDOSE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 50F with likely OD but hypotensive, r/o traumatic injury, PE\n REASON FOR THIS EXAMINATION:\n eval for acute process/injury to cause hypotension\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: EHAb SUN 8:28 PM\n No CT evidence for acute intracranial process.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 50-year-old female who was found down, likely overdose,\n hypotensive. Concern for trauma.\n\n COMPARISON: .\n\n TECHNIQUE: Axial CT images through the head were acquired without intravenous\n contrast. Coronal, sagittal, and thin slice bone reconstructed images were\n created and reviewed.\n\n FINDINGS: There is no evidence for acute intracranial hemorrhage, mass\n effect, edema. There is preservation of -white matter differentiation.\n The basal cisterns appear patent. The ventricles and sulci are normal in size.\n\n There is no calvarial fracture.\n\n A 4 x 4 mm osteoma is again seen in a left middle ethmoid air cell. The\n frontal sinuses are not pneumatized. Thereis mild mucosal thickening in a\n right anterior ethmoid air cell. Left lateral mastoid air cells and right\n mastoid tip air cells are partially opacified.\n\n IMPRESSION: No CT evidence for acute intracranial injury.\n DFDkq\n\n"
}
] |
28,534 | 145,987 | She was admitted to Trauma Service. Neurosurgery, Orthopedics and Plastics were consulted because of her injuries. Her intracranial bleed was nonoperative; she was loaded with Dilantin and started on 100 mg tid; she will remain on this for a total of 4 weeks and will follow up with Dr. at that time for repeat head imaging. Serial head CT scans were followed while in the hospital and were stable. She was seen by Plastics for right thumb laceration; this was irrigated and sutured closed. OT was consulted for a thumb splint. She will follow up as an outpatient in Plastics/Hand Clinic. Orthopedics was consulted for the left clavicle fracture; this injury was also non operative. She was made non weight bearing on that extremity; a sling was provided for comfort. She will follow up as an outpatient in Clinic. She was noted to have a hematocrit drop; likely secondary to a left gluteal hematoma that was noted on exam and on imaging studies. Hematocrit on day of admission was 38; down to 28 on the following day and then several days later down to 21. She was transfused with 2 units PRBC's. Post transfusion Hct was 25. Physical and Occupational therapy were consulted and have recommended rehab following acute hospitalization. | Marked degenerative changes of the thoracolumbar spine with stable, mild superior endplate compression at the L1 level. Left gluteal soft tissue hematoma. Tiny foci of scattered hyperattenuation within the left cerebral hemisphere are consistent with hemorrhagic contusion. NON-CONTRAST HEAD CT: Subdural hematomas along the bilateral cerebral convexities (left greater than right) and adjacent to the falx are redemonstrated. Tiny foci scattered hypoattenuation within the left cerebral hemisphere is consistent with hemorrhagic contusions, unchanged. CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The rectum, sigmoid colon, and bladder are within normal limits. Subcutaneous edema and small left gluteal hematoma. There is a left gluteal soft tissue hematoma. Small scattered foci of hypoattenuation are again seen scattered throughout the left cerebral hemisphere consistent with hemorrhagic contusions. The patient is status post bilateral hip arthroplasty, incompletely assessed. COMPARISON: None NON-CONTRAST HEAD CT: Subdural hematomas are noted along bilateral cerebral convexity (left greater than right) and adjacent to the falx. IMPRESSION: Stable appearance of bilateral cerebral convexity and parasagittal subdural hematoma. Admitting Diagnosis: SUBDURAL HEMATOMA Contrast: OPTIRAY Amt: 130 FINAL REPORT (Cont) drainable collection. Small punctate foci of hyperattenuation are seen scattered throughout the left cerebral hemisphere consistent with hemorrhagic contusions. A moderate- sized left parietal scalp hematoma is present. Large left renal cyst and multiple smaller left renal hypodensities are unchanged. U/O adequate via foleyA: Stable s/p fall with Fx clavicale and ribs. IMPRESSION: Bilateral cerebral convexity (left greater than right) and parasagittal subdural hematoma. The previously described left parietal scalp hematoma has improved. Degenerative changes of the left glenohumeral joint are again noted with surrounding subcutaneous hematoma laterally as well as along the periscapular region. The abdominal aorta shows diffuse calcification. Notes is made of focal ectasia of the infrarenal aorta, proximal celiac and bilateral iliac arteries. FINDINGS: Cervical spine shows an exaggerated lordosis with multilevel degenerative changes. Atherosclerotic calcifications and aortoiliac ectasia again noted. The comminuted left clavicle fracture and non-displaced left rib fractures are again noted. Left apical capping/pleural fluid. No contraindications for IV contrast FINAL REPORT CT TORSO ON CLINICAL HISTORY: Recent trauma, now with decreased hematocrit, question hemorrhage. AP PELVIS: Trauma board obscures fine detail. AP CHEST: Trauma board obscures fine detail. The patient is status post bilateral hip arthroplasty. The remainder of the visualized paranasal sinuses and mastoid air cells remain normally aerated. Patient is status post bilateral hip arthroplasties with cemented femoral stem component. The heart and pericardium are within normal limits. Remainder of the visualized paranasal sinuses and mastoid air cells remain normally aerated. Patient has significant ecchymosis over L shoulder. Left apical pleural fluid/thickening. CT OF THE CHEST WITH INTRAVENOUS CONTRAST: The lungs demonstrate bilateral dependent atelectasis. The thoracic aorta is normal in caliber without evidence of dissection. The gallbladder, spleen, adrenal glands, and pancreas are within normal limits. Deformity over L clavical and bruising over left upper arm present. R thumb laceration with dsd in place. Post-traumatic changes in the left hemithorax including stable rib and clavicle fractures, slightly increased left pleural fluid, not compatible with hemothorax, however, subcutaneous edema and hematomas without a focal (Over) 11:47 AM CT CHEST W&W/O C ; CT ABD W&W/O C Clip # CT PELVIS W&W/O C Reason: Please evaluate for source of bleeding. Extensive degenerative changes are seen involving the left glenohumeral joint. Extensive degenerative changes are seen involving the left glenohumeral joint. Restarted on po antihypertensives.Pulses present. Post-surgical changes related to bilateral hip arthroplasties. Repeat CT of head done. There is increased pleural fluid, low in density and not likely hemothorax. 11:47 AM CT CHEST W&W/O C ; CT ABD W&W/O C Clip # CT PELVIS W&W/O C Reason: Please evaluate for source of bleeding. Also on colace.Heme: hct stable, venodynes in useID: t max 99.4, wbc flat, on no antibiotics.Lines: new 20 g angio placed L forearm, also has 16g angio L antecubital.skin: bruising progressing on L shoulder and L hip. Multilevel degenerative changes are seen involving the thoracolumbar spine. Multilevel degenerative changes are seen involving the thoracolumbar spine. In the left lung apex shows pleural thickening/fluid. The right lobe of the thyroid is not visualized. Extensive degenerative changes are seen involving the glenohumeral joint. Irrigated by Dr and dressed with dsd. ?tendon exposed. The celiac artery, SMA and are patent. TECHNIQUE: Helical acquisition of CT images performed from the thoracic inlet through the ischial tuberosities following administration of 130 cc of intravenous nonionic contrast. The prevertebral soft tissues are within normal limits. Mild mucosal thickening is seen within the left maxillary sinus. CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: The liver shows no focal lesion. Interstial abnormality is likely related to edema. Two views of the left shoulder demonstrate displaced fracture involving the mid left clavicle. | 11 | [
{
"category": "Radiology",
"chartdate": "2176-06-23 00:00:00.000",
"description": "L SHOULDER 1 VIEW LEFT",
"row_id": 1014891,
"text": " 4:10 AM\n SHOULDER 1 VIEW LEFT; HUMERUS (AP & LAT) LEFT Clip # \n HAND (AP, LAT & OBLIQUE) LEFT\n Reason: evaluate for fx/dislocation\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman with left shoulder pain s/p fall\n REASON FOR THIS EXAMINATION:\n evaluate for fx/dislocation\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 76-year-old female with left shoulder pain status post\n fall. Evaluate for fracture, dislocation.\n\n Two views of the left shoulder demonstrate displaced fracture involving the\n mid left clavicle. Extensive degenerative changes are seen involving the\n glenohumeral joint. Multiple left-sided rib fractures are noted, better\n assessed on concurrent chest CT.\n\n Three views of the left hand show degenerative changes involving the first CMC\n and second MCP joints. There is exuberant mineralization of the TFC and about\n the MCP joints, which is likely represents chondrocalcinosis. There is\n cortical irregularity along the radial side of the distal radius, suspicious\n for fracture. Dedicated wrist radiographs are recommended.\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-06-23 00:00:00.000",
"description": "PELVIS (AP ONLY)",
"row_id": 1014892,
"text": " 4:10 AM\n PELVIS (AP ONLY); -76 BY SAME PHYSICIAN # \n Reason: TO SEE END OF PROSTHES.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman with b/l THR s/p fall\n REASON FOR THIS EXAMINATION:\n r/o fracture\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 76-year-old female with bilateral total hip replacement.\n\n AP pelvis shows no fracture or dislocation. Patient is status post bilateral\n hip arthroplasties with cemented femoral stem component. There is no evidence\n of hardware- related complication. Contrast is noted within the bladder.\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-06-23 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1014887,
"text": " 3:47 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o trauma\n ______________________________________________________________________________\n FINAL ADDENDUM\n The foci in left frontal lobe could also be due to subarachnoid blood.\n\n\n 3:47 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o trauma\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman s/p fall\n REASON FOR THIS EXAMINATION:\n r/o trauma\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 26-year-old female status post fall downstairs.\n\n COMPARISON: None\n\n NON-CONTRAST HEAD CT: Subdural hematomas are noted along bilateral cerebral\n convexity (left greater than right) and adjacent to the falx. Small punctate\n foci of hyperattenuation are seen scattered throughout the left cerebral\n hemisphere consistent with hemorrhagic contusions. No shift of normally\n midline structures. The - white matter differentiation is preserved. No\n hydrocephalus or evidence of major vascular territorial infarct. A moderate-\n sized left parietal scalp hematoma is present. No fracture is identified.\n Small air-fluid level is seen within the left maxillary sinus. Remainder of\n the visualized paranasal sinuses and mastoid air cells remain normally\n aerated. Dense vascular calcifications are noted.\n\n IMPRESSION: Bilateral cerebral convexity (left greater than right) and\n parasagittal subdural hematoma. Tiny foci of scattered hyperattenuation within\n the left cerebral hemisphere are consistent with hemorrhagic contusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-06-23 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 1014888,
"text": " 3:48 AM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: r/o trauma\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman s/p fall\n REASON FOR THIS EXAMINATION:\n r/o trauma\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 76 year old female status post fall down stairs.\n\n TECHNIQUE: Non-contrast MDCT-acquired axial images of the cervical spine from\n the skull base to the level of T3. Multiplanar reformatted images were\n obtained.\n\n FINDINGS: Cervical spine shows an exaggerated lordosis with multilevel\n degenerative changes. No evidence of subluxation. Fractures are identified\n involving the left T1 transverse process/superior articulating facet;\n bilateral first ribs; left second and third ribs. In the left lung apex shows\n pleural thickening/fluid. The prevertebral soft tissues are within normal\n limits.\n\n IMPRESSION:\n 1. Fractures involving the left T1 transverse process/superior articulating\n surface as well as bilateral first ribs; left second and third ribs; and left\n clavicle.\n\n 2. Multilevel degenerative changes involving the cervical spine.\n\n 3. Left apical pleural fluid/thickening.\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-06-23 00:00:00.000",
"description": "CT CHEST W/CONTRAST",
"row_id": 1014889,
"text": " 4:02 AM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: eval fractures\n Field of view: 46\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman s/p fall with multiple rib fractures\n REASON FOR THIS EXAMINATION:\n eval fractures\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Status post fall downstairs.\n\n TECHNIQUE: Contrast-enhanced MDCT acquired axial images of the chest, abdomen\n and pelvis from the thoracic inlet to the pubic symphysis. Multiplanar\n reformatted images were obtained.\n\n CT OF THE CHEST WITH INTRAVENOUS CONTRAST: The lungs demonstrate bilateral\n dependent atelectasis. No consolidation, pneumothorax or worrisome pulmonary\n nodule is identified. Left clavicle and multiple left-sided rib fractures are\n identified with accompanying left apical capping/pleural fluid. Note is also\n made of right first rib fracture (better seen on previous cervical spine CT).\n\n The heart and pericardium are within normal limits. The thoracic aorta is\n normal in caliber without evidence of dissection. No mediastinal or axillary\n lymphadenopathy is appreciated. The right lobe of the thyroid is not\n visualized.\n\n CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: The liver shows no focal lesion.\n The gallbladder, spleen, adrenal glands, and pancreas are within normal\n limits. The kidneys enhance and excrete contrast symmetrically. A large cyst\n is seen within the upper pole of the left kidney. The intra-abdominal loops of\n large and small bowel maintain a normal caliber without evidence of\n obstruction. No free air, free fluid or lymphadenopathy is appreciated. The\n abdominal aorta shows diffuse calcification. Notes is made of focal ectasia of\n the infrarenal aorta, proximal celiac and bilateral iliac arteries. The celiac\n artery, SMA and are patent.\n\n CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The rectum, sigmoid colon, and\n bladder are within normal limits. No free fluid or lymphadenopathy is\n appreciated.\n\n BONE WINDOWS AND SOFT TISSUES: Fractures are identified involving multiple\n left-sided ribs, right first rib, and left clavicle. Extensive degenerative\n changes are seen involving the left glenohumeral joint. The patient is status\n post bilateral hip arthroplasty. Multilevel degenerative changes are seen\n involving the thoracolumbar spine. There is a left gluteal soft tissue\n hematoma.\n\n IMPRESSION:\n 1. Fractures involving multiple left-sided ribs, right first rib and and left\n (Over)\n\n 4:02 AM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: eval fractures\n Field of view: 46\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n clavicle. Left apical capping/pleural fluid.\n\n 2. Post-surgical changes related to bilateral hip arthroplasties. Extensive\n degenerative changes are seen involving the left glenohumeral joint.\n\n 3. Multilevel degenerative changes are seen involving the thoracolumbar\n spine.\n\n 4. Multiple hypodensities within bilateral kidneys, the largest of which\n likely represents a cyst. The remainder are too small to characterize.\n\n 5. Left gluteal soft tissue hematoma.\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-06-25 00:00:00.000",
"description": "CT PELVIS W&W/O C",
"row_id": 1015154,
"text": " 11:47 AM\n CT CHEST W&W/O C ; CT ABD W&W/O C Clip # \n CT PELVIS W&W/O C\n Reason: Please evaluate for source of bleeding.\n Admitting Diagnosis: SUBDURAL HEMATOMA\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman s/p multi injury trauma with falling hct. Patient has\n significant ecchymosis over L shoulder. She is hemodynamically stable\n REASON FOR THIS EXAMINATION:\n Please evaluate for source of bleeding.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT TORSO ON \n\n CLINICAL HISTORY: Recent trauma, now with decreased hematocrit, question\n hemorrhage.\n\n TECHNIQUE: Helical acquisition of CT images performed from the thoracic inlet\n through the ischial tuberosities following administration of 130 cc of\n intravenous nonionic contrast. Comparison made to prior examination of two\n days earlier.\n\n FINDINGS: There has been minimal interval change. The comminuted left\n clavicle fracture and non-displaced left rib fractures are again noted. No\n new fractures are seen. There is increased pleural fluid, low in density and\n not likely hemothorax. There is associated atelectasis of the left lower\n lobe. No pneumothorax or focal airspace disease. Degenerative changes of the\n left glenohumeral joint are again noted with surrounding subcutaneous hematoma\n laterally as well as along the periscapular region. No drainable hematoma or\n collection.\n\n ABDOMEN:\n Within the abdomen, the solid organs are intact. Large left renal cyst and\n multiple smaller left renal hypodensities are unchanged. No vascular injury\n is evident.\n\n PELVIS: Bowel loops are unremarkable and non-dilated. Atherosclerotic\n calcifications and aortoiliac ectasia again noted. No free pelvic fluid. No\n new bony injury. Bilateral hip prostheses. Subcutaneous edema and small left\n gluteal hematoma. There is a focus of gas within the bladder, likely related\n to recent instrumentation. No Foley catheter is present. Clinical\n correlation is necessary.\n\n Marked degenerative changes of the thoracolumbar spine with stable, mild\n superior endplate compression at the L1 level.\n\n IMPRESSION:\n 1. Post-traumatic changes in the left hemithorax including stable rib and\n clavicle fractures, slightly increased left pleural fluid, not compatible with\n hemothorax, however, subcutaneous edema and hematomas without a focal\n (Over)\n\n 11:47 AM\n CT CHEST W&W/O C ; CT ABD W&W/O C Clip # \n CT PELVIS W&W/O C\n Reason: Please evaluate for source of bleeding.\n Admitting Diagnosis: SUBDURAL HEMATOMA\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n drainable collection.\n 2. No solid organ injury or evident source of significant change in\n hematocrit.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-06-23 00:00:00.000",
"description": "TRAUMA #2 (AP CXR & PELVIS PORT)",
"row_id": 1014886,
"text": " 3:47 AM\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \n Reason: eval for fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman with 2 stairs\n REASON FOR THIS EXAMINATION:\n eval for fx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 76-year-old female status post fall down 12 flights of stair.\n Evaluate for fracture.\n\n AP CHEST: Trauma board obscures fine detail. The lung volumes are low. No\n consolidation or pneumothorax is detected. The heart is moderately enlarged.\n Interstial abnormality is likely related to edema. Note is made of left apical\n capping, which is likely related to the multiple left- sided rib fractures.\n The left clavicle is fractured in its mid portion.\n\n AP PELVIS: Trauma board obscures fine detail. No fracture or dislocation.\n The patient is status post bilateral hip arthroplasty, incompletely assessed.\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-06-24 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1014990,
"text": " 3:14 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: evaluated for evolution of SDH. Please do at 4am\n Admitting Diagnosis: SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman with bilateral SDH and sm left frontal contusion.\n REASON FOR THIS EXAMINATION:\n evaluated for evolution of SDH. Please do at 4am\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 76-year-old female with bilateral subdural hematoma and\n small left frontal contusion. Evaluate for evolution of hematoma.\n\n COMPARISON: .\n\n NON-CONTRAST HEAD CT: Subdural hematomas along the bilateral cerebral\n convexities (left greater than right) and adjacent to the falx are\n redemonstrated. Compared to prior exam, there is no appreciable change. Small\n scattered foci of hypoattenuation are again seen scattered throughout the left\n cerebral hemisphere consistent with hemorrhagic contusions. No new focus of\n hemorrhage is identified. There is no shift of normally midline structures.\n The -white matter differentiation is preserved. No hydrocephalus or\n evidence of major vascular territorial infarct. The previously described left\n parietal scalp hematoma has improved. No fracture is identified. Mild\n mucosal thickening is seen within the left maxillary sinus. The remainder of\n the visualized paranasal sinuses and mastoid air cells remain normally\n aerated.\n\n IMPRESSION: Stable appearance of bilateral cerebral convexity and\n parasagittal subdural hematoma. Tiny foci scattered hypoattenuation within\n the left cerebral hemisphere is consistent with hemorrhagic contusions,\n unchanged. No new focus of hemorrhage is identified.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2176-06-23 00:00:00.000",
"description": "Report",
"row_id": 1634396,
"text": "T/SICU Brief Admission note\nMrs. is a 76 year old woman admitted to T/SICU from the EW at 05:30 this morning. She was caring for her grandchilden in when she got up to go to the bathroom and fell down approximately 10 stairs. Her injuries include: several small subdural hematomas (one may be a week old from a prior fall), ??cervical fracture, L clavicular fracture, and 4 rib fractures, and a R thumb laceration (with possible tendon exposure).\nPMH: arthritis (s/p bilateral hip replacements), hypertension, hyperlipidemia, hypothyroidism\nMeds: simvatastatin, diovan, synthyroid, norvasc\nReview of systems:\nNeuro: awake, alert, orient, moves all extremities equally, perrla. c/o pain in L shoulder and back. PCA morphine instituted and pt with good understanding.\nCVS: sinus rhythm, rate 80's, bp 120-140/60-70, peripheral pulses present, venodynes initiated\nRESP: breath sounds diminished, on 2L np with sats 99-100%\nRENAL: foley placed in EW, adequate light yellow urine, receiving fluids of ns @ 60/hr. K=3.5\nGI: c/o nausea. Pepcid ordered, belly soft with bowel sounds present\nHeme: INR 1.1 hct 37.9\nendo: fs in er 184, pt takes synthroid at home\nID: cold on arrival, temp 96.4, wbc 15.7, no antibiotics ordered\nskin: Laceration noted on surface of her R thumb with ??tendon exposed. Irrigated by Dr and dressed with dsd. Plastics to evaluate. Deformity over L clavical and bruising over left upper arm present. Cervical collar in place.\nLines: r antecubital iv in place\nSocial: daughter arrived and updated with injuries by Dr. .\nA: 76 year old s/p fall with multiple injuries, currently stable\nP: neuro checks for sdh, ??follow up CT. Radiologist will evaluate possible neck fracture, Reassess movement restrictions. Attempt to achieve excellent pain control either with pca or ??epidural catheter for rib fx to prevent atelectasis. Support family with information as appropriate.\n"
},
{
"category": "Nursing/other",
"chartdate": "2176-06-23 00:00:00.000",
"description": "Report",
"row_id": 1634397,
"text": "Tsicu NPN\nS: It only hurts a little Its a \"2\"\nO: Initially hypertensive, BP down to 90/60 after PCA medication and norvasc which pt takes at home. Temp flat. Adm K+ 3.5, Rechecked this pm. Alert and oriented with no defecits throughout day. OOB to chair X2 H. IS q1-2 HR with volumes 1000-1500. Lungs clear with diminished bases. Tol reg diet, good fluid intake but poor appetite. No BM On colace. U/O adequate via foley\nA: Stable s/p fall with Fx clavicale and ribs. Neck cleared by Dr this am, collar removed\nP: OOB to chair TID, IS q1-2 Hr. Rigorous pulmonary assessment and rx as indicated\n"
},
{
"category": "Nursing/other",
"chartdate": "2176-06-24 00:00:00.000",
"description": "Report",
"row_id": 1634398,
"text": "T/SICU Nursing Progress Note\nS:\"I want to get better so I can go to my granddaughter's dance recital\"\nO: Review of systems\nneuro: awake, alert, oriented, motor intact. Repeat CT of head done. Using pca morphine (1.5mg q 6 min) for good pain control. Able to turn side to side with pain level stated as \"4\". Continues on po dilantin\nCVS: stable heart rate and rhythm. Restarted on po antihypertensives.\nPulses present. Venodynes in use.\nRESP: sats excellent on 2L np. Uses IS up to 1200cc, breath sounds decreased in bases. non productive cough.\nRENAL: D51/2ns @ 60/hr, urine output adequate. Lytes wnl except calcium elevated.\nGI: tolerating liquids, no appetite for other food at present. On prevacid for prophylaxis. Also on colace.\nHeme: hct stable, venodynes in use\nID: t max 99.4, wbc flat, on no antibiotics.\nLines: new 20 g angio placed L forearm, also has 16g angio L antecubital.\nskin: bruising progressing on L shoulder and L hip. R thumb laceration with dsd in place. Also has significant bruising and swelling over L wrist\nsocial: daughters all visited during the evening and were updated with plan and all questions answered.\nA: 76 y/o woman s/p fall with fractured L clavicle, l sided ribs, sdh stable post fall\nP: continue vigorous pulmonary hygiene, mobilize pt as much as possible. Regular diet, restart paxil, asa ? Consider switching to po pain medicine (??torodol).\n"
}
] |
6,917 | 133,450 | The patient was admitted to the CVICU and was briefly on levophed and neo. She had benign abdominal studies and had a swallowing evaluation which she passed successfully. She was transferred to the floor on HD#1 and was aggressively diuresed. Her foley was discontinued and she had urinary retention and it was replaced. She grew yeast from her urine and was treated with vaginal miconazole cream. She was followed by physical therapy. Her son told us that she always complains of abdominal pain and it is related to when she has gas. She was started on simethicone PRN. Her hypotension recurred and her blood pressure in her right arm was much higher than her left arm. She was mentating well during what we thought we hypotensive episodes. She had a large left pleural effusion and interventional pulmonology placed a pigtail catheter and obtained 400 cc and it drained another liter of fluid overnight. She continued to improve and was discharged to House rehab on HD# 9 in stable condition. | There is mild pulmonary artery systolic hypertension.There is a trivial echodense pericardial effusion.IMPRESSION: No clinically-significant pericardial effusion seen.Normally-functioning composite aortic root/aortic valve prosthesis. There is a small reaccumulation of left pleural fluid, without definite pneumothorax. There is mild symmetric leftventricular hypertrophy. FINDINGS: Compared to the prior radiograph, the left pleural effusion has decreased, still with some associated atelectasis. Mild PAsystolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.PERICARDIUM: Trivial/physiologic pericardial effusion.Conclusions:The left atrium is moderately dilated. There is persistent retrocardiac opacity with a moderate-sized left pleural effusion. Diffuse calcification of the aorta is present which is also ectatic. Retrocardiac opacification is consistent with effusion and atelectasis, with a smaller effusion and compressive atelectasis on the right. Small andhypertrophied LV with normal biventricular systolic function.Compared with the prior study (images reviewed) of , the findingsare similar. Right internal jugular and transvenous right atrial and right ventricular pacer leads are unchanged in their respective positions. There is mild pulmonary edema, which is similar to the prior study. Mild tomoderate (+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Mild congestive heart failure persists. Unchanged right-sided central venous access line, unchanged left pectoral pacemaker. Heavy mitral annulus calcifications are unchanged. Right-sided central venous catheter has been removed. Vascular congestion and perhaps mild pulmonary edema are still present. The inferior sternal wires appear unremarkable, post-surgical change is noted adjacent to the sternum. Left-sided dual-chamber pacemaker with leads terminating in the right atrium and right ventricle are in unchanged positions. The heart remains moderately enlarged, but unchanged. IMPRESSION: No significant interval change in mild congestive heart failure, retrocardiac opacification which is likely atelectasis, and left pleural effusion. The left ventricular cavity is unusually small.Regional left ventricular wall motion is normal. PATIENT/TEST INFORMATION:Indication: Pericardial effusion.Height: (in) 62Weight (lb): 160BSA (m2): 1.74 m2BP (mm Hg): 109/50HR (bpm): 80Status: InpatientDate/Time: at 12:41Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Moderate LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. An area of apparent narrowing is noted in the sigmoid colon (series 2, image 46), no associated mucosal thickening is present and there is no proximal obstruction, this is likely related to peristalsis. PELVIS: Visualized loops of large and small bowel are normal. A right internal jugular line and pacemaker are in unchanged position. Moderate mitralannular calcification. IMPRESSION: Decreased left pleural effusion and associated atelectasis. Mild to moderate (+) mitralregurgitation is seen. Enlargement of the cardiac silhouette is stable. The effusion and atelectasis at the right base are less prominent. The cardiomediastinal silhouette and hilar contours are stable. Perihilar haze suggests coexisting mild pulmonary edema. UPRIGHT AP VIEW OF THE CHEST: The patient is status post median sternotomy and CABG. IMPRESSION: Right internal jugular central venous catheter tip terminates in the proximal right atrium. Right ventricular chamber size andfree wall motion are normal. A catheter or pacing wireis seen in the RA and extending into the RV.LEFT VENTRICLE: Mild symmetric LVH. etiology Admitting Diagnosis: HYPOTENSION;UTI FINAL REPORT (Cont) 2. Normal regional LVsystolic function. Diffuse pancreatic atrophy is present. IMPRESSION: AP and lateral chest compared to : Left pleural pigtail catheter has been removed. Moderate-to-severe cardiomegaly with substantial pleural effusions, left more than right. Prior median sternotomy. AVR well seated,normal leaflet/disc motion and transvalvular gradients.MITRAL VALVE: Moderately thickened mitral valve leaflets. UPRIGHT AP VIEW OF THE CHEST: Right internal jugular central venous catheter tip terminates in the proximal right atrium. The aortic valve prosthesis appears well seated,with normal leaflet motion and transvalvular gradients. There has been no reaccumulation of left pleural effusion or pneumothorax, but small-to-moderate right pleural effusion is larger and there is greater opacification at the base of the right lung probably atelectasis. The median sternotomy wires as are the pacing wires remain in unchanged positions. A small right pleural effusion and associated atelectasis are slightly improved or the patient is more upright. A layering small right pleural effusion is also evident. A left chest tube is in place. The degree of pulmonary vascular congestion has decreased. Overall normal LVEF (>55%).RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level. Calcified subcutaneous nodules are noted, likely related to previous injections. etiology CONTRAINDICATIONS for IV CONTRAST: creat PFI REPORT PFI: There is no evidence of bowel obstruction. FINDINGS: As compared to the previous radiograph, there is no relevant change. The spleen, adrenal glands, and kidneys are normal on this non contrast examination. Moderate cardiomegaly is longstanding and the extensive heavy mitral annulus calcification is again seen. Compared to tracing #1 there is no significantdiagnostic change.TRACING #2 This is incompletely imaged without contrast, however, is unchanged since the imaging from . The tip of the right jugular catheter is at the mid portion of the SVC. Overall left ventricularsystolic function is normal (LVEF>55%). Moderate cardiomegaly is longstanding. TECHNIQUE: MDCT images were acquired from the lung bases to pubic symphysis without IV contrast. CT ABDOMEN: An 11-mm low density nodule is noted peripherally within segment VI of the liver. FINDINGS: In comparison with the study of , there is little overall change. Again there is enlargement of the cardiac silhouette in a patient with intact midline sternal wires and dual-channel pacemaker device in place. IMPRESSION: Little overall change. Normal ascending aortadiameter.AORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR). A left pleural effusion is also similar. Large bilateral pleural effusions with associated atelectasis are noted. | 13 | [
{
"category": "Radiology",
"chartdate": "2125-11-18 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 1166427,
"text": " 2:14 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: recurrent nausea/vomiting- ? etiology\n Admitting Diagnosis: HYPOTENSION;UTI\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman Bentall/CABG\n REASON FOR THIS EXAMINATION:\n recurrent nausea/vomiting- ? etiology\n CONTRAINDICATIONS for IV CONTRAST:\n creat\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): PJBj SUN 6:56 PM\n PFI: There is no evidence of bowel obstruction. Large bilateral pleural\n effusions with associated atelectasis are noted.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 79-year-old woman with previous CABG. Recurrent nausea and\n vomiting. Query etiology.\n\n Comparison is made to previous imaging from .\n\n TECHNIQUE: MDCT images were acquired from the lung bases to pubic symphysis\n without IV contrast. Multiplanar reformatted images were obtained for\n evaluation.\n\n CT ABDOMEN: An 11-mm low density nodule is noted peripherally within segment\n VI of the liver. This is incompletely imaged without contrast, however, is\n unchanged since the imaging from . Mild fatty infiltration is present\n within the liver. Diffuse pancreatic atrophy is present. The spleen, adrenal\n glands, and kidneys are normal on this non contrast examination. Extensive\n aortic atheroma is present and calcified atheroma is noted within the celiac,\n SMA and renal arteries.\n\n PELVIS: Visualized loops of large and small bowel are normal. An area of\n apparent narrowing is noted in the sigmoid colon (series 2, image 46), no\n associated mucosal thickening is present and there is no proximal obstruction,\n this is likely related to peristalsis. There is air within the bladder and no\n catheter is noted, has the patient had a recent catheterization or bladder\n instrumentation? If not, this finding should be further evaluated. No\n enlarged pelvic lymph nodes. Calcified subcutaneous nodules are noted, likely\n related to previous injections.\n\n LUNG BASES: There are large bilateral pleural effusions with associated\n atelectasis, particularly in the left lung base. Extensive mitral valve and\n coronary artery calcification is noted as well as a pacemaker wire. The\n inferior sternal wires appear unremarkable, post-surgical change is noted\n adjacent to the sternum.\n\n Bone review is unremarkable. Prior median sternotomy.\n\n IMPRESSION:\n 1. There is no evidence of bowel obstruction.\n (Over)\n\n 2:14 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: recurrent nausea/vomiting- ? etiology\n Admitting Diagnosis: HYPOTENSION;UTI\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 2. Large bilateral pleural effusions with associated atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-11-18 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 1166428,
"text": ", C. CSURG FA6A 2:14 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: recurrent nausea/vomiting- ? etiology\n Admitting Diagnosis: HYPOTENSION;UTI\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman Bentall/CABG\n REASON FOR THIS EXAMINATION:\n recurrent nausea/vomiting- ? etiology\n CONTRAINDICATIONS for IV CONTRAST:\n creat\n ______________________________________________________________________________\n PFI REPORT\n PFI: There is no evidence of bowel obstruction. Large bilateral pleural\n effusions with associated atelectasis are noted.\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-11-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1165904,
"text": " 11:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval chf or pna\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with respiratory distress\n REASON FOR THIS EXAMINATION:\n eval chf or pna\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Respiratory distress.\n\n COMPARISON: .\n\n UPRIGHT AP VIEW OF THE CHEST: The patient is status post median sternotomy\n and CABG. Left-sided dual-chamber pacemaker with leads terminating in the\n right atrium and right ventricle are in unchanged positions. There are\n extensive mitral annular calcifications. The heart remains moderately\n enlarged, but unchanged. Diffuse calcification of the aorta is present which\n is also ectatic. There is mild pulmonary edema, which is similar to the prior\n study. Retrocardiac opacification may reflect atelectasis. A left pleural\n effusion is also similar. No pneumothorax is identified. No acute osseous\n findings are seen. Right-sided central venous catheter has been removed.\n\n IMPRESSION: No significant interval change in mild congestive heart failure,\n retrocardiac opacification which is likely atelectasis, and left pleural\n effusion.\n DFDdp\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-11-15 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1165935,
"text": " 1:25 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: new RT IJ line placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with SOB, recent cardiac surgery\n REASON FOR THIS EXAMINATION:\n new RT IJ line placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Shortness of breath and recent cardiac surgery with new right\n internal jugular central line placement.\n\n COMPARISON: at 11:17.\n\n UPRIGHT AP VIEW OF THE CHEST: Right internal jugular central venous catheter\n tip terminates in the proximal right atrium. No pneumothorax is identified.\n Mild congestive heart failure persists. There is persistent retrocardiac\n opacity with a moderate-sized left pleural effusion. A layering small right\n pleural effusion is also evident. The median sternotomy wires as are the\n pacing wires remain in unchanged positions.\n\n IMPRESSION: Right internal jugular central venous catheter tip terminates in\n the proximal right atrium. No pneumothorax. Findings discussed with Dr.\n at 2 p.m., .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-11-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1166648,
"text": " 8:05 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: s/p AVR w/worsening respiratory status r/o effusions\n Admitting Diagnosis: HYPOTENSION;UTI\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with as above\n REASON FOR THIS EXAMINATION:\n s/p AVR w/worsening respiratory status r/o effusions\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Worsening respiratory status, rule out pleural effusions.\n\n COMPARISON: , 8 a.m.\n\n FINDINGS: As compared to the previous radiograph, there is no relevant\n change. Moderate-to-severe cardiomegaly with substantial pleural effusions,\n left more than right. The effusions cause relatively extensive basal areas of\n atelectasis. Perihilar haze suggests coexisting mild pulmonary edema. No\n newly appeared focal parenchymal opacities. Unchanged right-sided central\n venous access line, unchanged left pectoral pacemaker.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-11-22 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1167186,
"text": " 3:55 PM\n CHEST (PA & LAT) Clip # \n Reason: eval for effusion\n Admitting Diagnosis: HYPOTENSION;UTI\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman s/p bentall\n REASON FOR THIS EXAMINATION:\n eval for effusion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post cardiac surgery, to assess for change.\n\n FINDINGS:\n\n In comparison with the study of , the monitoring and support devices\n remain in place. There is a small reaccumulation of left pleural fluid,\n without definite pneumothorax. The effusion and atelectasis at the right base\n are less prominent. The degree of pulmonary vascular congestion has\n decreased. Moderate cardiomegaly is longstanding and the extensive heavy\n mitral annulus calcification is again seen.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-11-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1167274,
"text": " 8:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for effusion\n Admitting Diagnosis: HYPOTENSION;UTI\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman s/p bentall\n REASON FOR THIS EXAMINATION:\n eval for effusion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Cardiac surgery.\n\n FINDINGS: In comparison with the study of , there appears to be slight\n increase in indistinctness of the pulmonary vessels, suggesting some elevation\n of pulmonary venous pressure. Monitoring and support devices remain in place.\n Enlargement of the cardiac silhouette is stable.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-11-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1166502,
"text": " 7:18 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for effusions\n Admitting Diagnosis: HYPOTENSION;UTI\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman s/p avr/cabg\n REASON FOR THIS EXAMINATION:\n assess for effusions\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Cardiac surgery, post-operative.\n\n FINDINGS: In comparison with the study of , there is little overall\n change. Again there is enlargement of the cardiac silhouette in a patient\n with intact midline sternal wires and dual-channel pacemaker device in place.\n Retrocardiac opacification is consistent with effusion and atelectasis, with a\n smaller effusion and compressive atelectasis on the right. The tip of the\n right jugular catheter is at the mid portion of the SVC.\n\n IMPRESSION: Little overall change.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-11-21 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1166924,
"text": " 10:41 AM\n CHEST (PA & LAT) Clip # \n Reason: eval for effusion\n Admitting Diagnosis: HYPOTENSION;UTI\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman s/p pigtail\n REASON FOR THIS EXAMINATION:\n eval for effusion\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST, \n\n HISTORY: Pigtail catheter, evaluate effusion.\n\n IMPRESSION: AP and lateral chest compared to :\n\n Left pleural pigtail catheter has been removed. There has been no\n reaccumulation of left pleural effusion or pneumothorax, but small-to-moderate\n right pleural effusion is larger and there is greater opacification at the\n base of the right lung probably atelectasis. Vascular congestion and perhaps\n mild pulmonary edema are still present. Moderate cardiomegaly is\n longstanding. Right internal jugular and transvenous right atrial and right\n ventricular pacer leads are unchanged in their respective positions.\n Extremely heavy mitral annulus calcification is longstanding finding.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-11-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1166817,
"text": " 2:58 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for pneumothorax\n Admitting Diagnosis: HYPOTENSION;UTI\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with bilateral pleural effusions, s/p drainage of left with\n chest tube.\n REASON FOR THIS EXAMINATION:\n please eval for pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Bilateral pleural effusion status post drainage of the\n left.\n\n COMPARISON: CXR .\n\n FINDINGS: Compared to the prior radiograph, the left pleural effusion has\n decreased, still with some associated atelectasis. There is no pneumothorax.\n A small right pleural effusion and associated atelectasis are slightly\n improved or the patient is more upright. The cardiomediastinal silhouette and\n hilar contours are stable. A right internal jugular line and pacemaker are in\n unchanged position. A left chest tube is in place. A tracheal stent extends\n to the left bronchus. Heavy mitral annulus calcifications are unchanged.\n\n IMPRESSION: Decreased left pleural effusion and associated atelectasis. No\n pneumothorax.\n\n"
},
{
"category": "Echo",
"chartdate": "2125-11-16 00:00:00.000",
"description": "Report",
"row_id": 62262,
"text": "PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion.\nHeight: (in) 62\nWeight (lb): 160\nBSA (m2): 1.74 m2\nBP (mm Hg): 109/50\nHR (bpm): 80\nStatus: Inpatient\nDate/Time: at 12:41\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. A catheter or pacing wire\nis seen in the RA and extending into the RV.\n\nLEFT VENTRICLE: Mild symmetric LVH. Small LV cavity. Normal regional LV\nsystolic function. Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR). AVR well seated,\nnormal leaflet/disc motion and transvalvular gradients.\n\nMITRAL VALVE: Moderately thickened mitral valve leaflets. Moderate mitral\nannular calcification. Calcified tips of papillary muscles. No MS. Mild to\nmoderate (+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Mild PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nConclusions:\nThe left atrium is moderately dilated. There is mild symmetric left\nventricular hypertrophy. The left ventricular cavity is unusually small.\nRegional left ventricular wall motion is normal. Overall left ventricular\nsystolic function is normal (LVEF>55%). Right ventricular chamber size and\nfree wall motion are normal. A composite bioprosthetic aortic valve /aortic\nroot prosthesis is present. The aortic valve prosthesis appears well seated,\nwith normal leaflet motion and transvalvular gradients. The mitral valve\nleaflets are moderately thickened. Mild to moderate (+) mitral\nregurgitation is seen. There is mild pulmonary artery systolic hypertension.\nThere is a trivial echodense pericardial effusion.\n\nIMPRESSION: No clinically-significant pericardial effusion seen.\nNormally-functioning composite aortic root/aortic valve prosthesis. Small and\nhypertrophied LV with normal biventricular systolic function.\n\nCompared with the prior study (images reviewed) of , the findings\nare similar.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2125-11-15 00:00:00.000",
"description": "Report",
"row_id": 121940,
"text": "Ventricularly paced rhythm. Compared to tracing #1 there is no significant\ndiagnostic change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2125-11-15 00:00:00.000",
"description": "Report",
"row_id": 121941,
"text": "Baseline artifact. Ventricularly paced rhythm. Underlying rhythm is difficult\nto discern but may be sinus rhythm. Compared to the previous tracing\nof ventricularly paced rhythm is new.\nTRACING #1\n\n"
}
] |
1,154 | 199,657 | (By systems including pertinent laboratory data. 1. Respiratory - Initially was placed on continuous positive airway pressure for her respiratory distress. She developed increased work of breathing. She was intubated and received two doses of Survanta. She was extubated to continuous positive airway pressure on day of life #1. She weaned to room nasal cannula oxygen by day of life #2 and was in room air by day of life #4. She remained in room air for the rest of her Neonatal Intensive Care Unit admission. she had many episodes of apnea and bradycardia. She was treated with caffeine citrate. The caffeine was discontinued on . She continued to have intermittent episodes of apnea, her last occurred on . At the time of discharge, she was breathing comfortably in room air with a respiratory rate in the 30s to 50s. 2. Cardiovascular - required a normal saline bolus for a low blood pressure shortly after addition to the Neonatal Intensive Care Unit. She maintained normal heart rates and blood pressures from that time. No murmurs have been noted during admission. 3. Fluids, electrolytes and nutrition - was initially NPO on intravenous fluids. She started on parenteral nutrition on day of life #1. Enteral feeds were started on day of life #2 and gradually advanced to full volume. She received calorie supplementation, to a maximum of 26 cal/oz with added ProMod. She has been on p.o. feeds since . At the time of discharge she is taking breast milk or Enfamil 20, 24 cal/oz breast milk with 4 cal by Enfamil powder. Serum electrolytes were within normal limits during admission. Discharge weight is 2.610 kg with a length of 47 cm and a head circumference of 34 cm. 4. Infectious disease - Due to her respiratory distress and prematurity, was evaluated for sepsis shortly after admission to the Neonatal Intensive Care Unit. A blood culture was obtained prior to starting intravenous ampicillin and gentamicin. The blood culture was no growth at 48 hours and the antibiotics were discontinued. 5. Gastrointestinal - Peak serum bilirubin was 8.0 total/0.3 mg/dl direct, with an indirect of 7.7. On day of life #2, phototherapy was started and continued for six days. Rebound bilirubin was 5.3/0.2 with an indirect of 5.1. 6. Hematology - Hematocrit at birth was 53.2%. did not receive any transfusions of blood products. Most recent hematocrit was on at 31.5%. 7. Neurology - Head ultrasounds were performed on day of life #7 and at one month of age and both were within normal limits. 8. Sensory - Hearing, screening was performed with automated auditory brain stem responses, passed in both ears. Ophthalmology, retinas were most recently examined on and were found to be immature, Zone 3 with a recommended follow up the week of . 9. Social - Parents have been involved and visited regularly. The other triplet siblings have been discharged home. | BSCEbilat. PO/PG feeds as tolerated,gavaged over 1hr. noincreased wob noted. Min asp. LS CLEAR ANFD EQUAL. A/G stable. Tolfeeds well. COLOR JAUDICE/ AND WELL PERFUSED. Mildretractions noted. Respiratory O: Pt. Current feeds + supps meeting weaned recs for kcals/pro/vits and mins. mild subcostal retractions. Mild subcostal retractions. is stable in RA. ABD SOFT, WITH STABLE GIRTH AND +BS. ABD SOFT, WITH STABLE GIRTH AND +BS. P: cont tofollow.Adv feeds as tolerated.GDO: Temp stable in air isolette, swaddled with hat, tshirtand blanket. Tolerating PN with good BS control. Tol proceduresfairly well.7. A: stable. Calms with containmentand pacifier. Nospits and minimal aspirates noted. aBdoinal exam benign. : No contact thus far this shift.G/D: O/A-Temp stable in . Burped well. : No contact with so far this shift.DEV: Temps stable, swaddled in . Mild S/Cretractions. Abd benign. P-Continue with current regimen. Fontssoft/flat. RR stable. A/G stable. Infant remains on adlibdemand schedule with BM24. AFOF.Lungs CTA, heart rrr s m, abd soft, extr well perfused. Abdomen , soft, round,+BS, no loops. Ag stable. Nospells or desats noted. Abdsoft, +, no loops. Hem neg. F&N: TF remain at 150cc/k/d of PE26. A: Well appereance. Update given. ABD SOFT, WITH STABLE GIRTH AND +BS. A: stable in RA, ?reflux. Elec to be checked .BILI: Single Phx. Abd soft, ND, + BS. A: Stable.P: cont to follow.fENO: TF of 140cc/k/d, ivf PN D10 w/ IL at 70cc/k/d and enteralfeeds at 70cc/k/d. RR40-70s, LS clear/=, mild intercostal rtxns. Abd benign, noloops, active bs. min asp. MIn asp. Min asp. Neonatology AttendingAddendum: PESleeping quietly s/p feed; appropriate tone; . Minimal aspirates, small spitx1so far this shift. given asordered. : No contact with so far this shift.G+D: Temps stable, swaddled in . O: Ls clear. P: cont tofollow.GDO: Temp stable swaddled in an air isolette, active and with cares. Ext and well perfused. Respstatus stable. P-Continue with current regimen asordered. Abdomen benign,bowel sounds active. Respiratory O: Pt. Abdomen benign, active BS, girthstable. noincreased wob noted. is stable in RA. LSclear/=. A: Pt. A: Pt. RR 30-60s, LS clear/=, mild ic rtxns. BS cl and =. Continues onIron. Abd soft, +BS. A: AGA. P: Continue tomonitor respiratory status. Tol well. Nospells or desats noted. mild subcostal retractions. 2 Resp. aga. AGA. Cobedding withsiblings. are activeand independent in cares. Lungs CTA, =. Asking appropriatequestions. : No contact thus far this shift.G/D: O/A-Temp stable in . Min asp. MildSC retractions. Grwoth/Development O: Pt. Stable temp cobedding with sibs. Resp. is stable inRA. Respiratory O: Pt. Respiratory O: Pt. Transitioned to open cribwith stable temps. A/ Stable. Continue tomonitor FEN status. A: Pt. A: Pt. A: Pt. A: Pt. Gaining wt. is stable in RA. BSCE bilat. Abd soft, ND, +BS. , well perfused. G&D. Extrem WWP. P:cont. P:cont. P:cont. Min. Pt. to supportnutritional needs.4no known contact thus far.5infant remains swaddled in OAC, temp. neg. Cl and = BS. Continue to support/educatefamily.G+D: Temps stable, swaddled in . P: Cont to assess.#8 O: Temp stable. Updated at the bedside.Independent with cares. 2. remains in RA, RR30-60, mild sc retractions, sats90-99, BBSclear, equal, one brief self-resolving brady P:continue to monitor.3. Abdomin softand round. tosupport nutritional needs.4no known contact thus far.5infant remains swaddled in air isolette, temp. Respiratory O: Pt. Respiratory O: Pt. A; AGA P; cont devsupport. is stable in RA. is stable in RA. +b.s. LSclear/=. A: Pt. A: Pt. A: Pt. Will continue to monitor.FEN: Abd benign, NTND, no HSM. stable, a/awith cares, settles well in between, fonts soft/flat, bringshands to mouth. BSCEbilat. DEV O/A is in an off isolette with stable temp.A/A w/cares. Mildsc ret. Min asp. BBS cl and equal. Temp stable. Abdomen , soft, round, +BS, noloops. Cont to supportfamily.G+D: Temps 97.8-98.0. Girthstable. ABd benign. Abd benign. 1 A/B. BSCE bilat. sepsis: Pt. Updated r/t positivebld cx from . BBS =/clear. Neonatology AttendingAddendum: PEActive, appropriate, . BP STABLE. NNPnotified. Inf voiding, stooling guiac neg. MBM26/PE26 Alt po/pg. soundsclear with mild retractions.#3O: Wt. Resp O/A Rec'd inf in RA. NPN continued3. Pt. Pt. Pt. Br. Mild SCR noted. Inf remains in RA. Mildsc ret. Mildsc ret. Lrgfamily support. Monitor andsupport G/D. Continue to supportG+D. Abd benign. A/G stable. ,well perfused. Mild S/Cretractions. AG stable. Neonatology-NNP Physical ExamInfant remains in RA. : No contact with so far this shift.G+D: Temps stable, swaddled in . BSCE bilat. A:stable. A: stable. A: stable. A: Stable. Cont to suport toward discharge. Girth stable. BS+. Educate and support .G/DInfant cobedding with sibs. HOBelev. Maintainingtemp well. Uses pacifier with support. Abdomen benign. Tol well. Abdomen ,soft, round, +BS, no loops. A: AGA P: contto follow and support dev. Nursing D/C noteInfant ready for d/c. NPN7a7pRespInfant in RA with adeq sats. Settles withpacifier. Mommet with LC. F/U WITH SPELLCOUNTDOWN. Mild S/C rtxs.Caffiene dcd today. Remains NPO on d10w. Abdsoft, lrg round. is stable inRA. noincreased wob noted. NOINCREASED WOB NOTED. LSclear/=. Update given. sounds clear withmild retractions.#3O: wt. LS clear andequal. A: Pt. A: Pt. TO SUPPORT G/D. BSCE bilat. Respiratory O: Pt. Abd soft, ND, +BS. Lrg benign asps overnight and this am(see careview) and lrg spit. Cont to support and educate .G/DInfant in OAC with stable temps. Extrem WWP. Monitor and support G/D. Lytes 139/4.0/108/17. Murmer notaudible. NNP aware of BP 44/28 M34. Intubated and surv x 1 given. A:Stable on CPAP. CXR done. RESP RATE44-72 WITH MILD IC/SC RETRACTIONS. NOT YET ONCAFFEINE.A:STABLE IN LOW NC, STARTING TO SPELLP:CONTINUE TO MONITOR RESP STATUS, MONITOR FOR NEED FORCAFFEINE BS CLEAR, SLDIMINISHED. AP stable, BP stable--see flowsheet. infusing PN D10 andIL at 70/k/d. Diffunshifted. A: beginning to wean P: Followresp status very closely#3 TF's 80cc/k. Remains NPO with at 80cc/k/d. NNP Ambrosine aware. BBS clearand =. RR 60-70, mild ic/scretractions. CBG:7.44/27/31/19/-4. Check bilitonight. LS clear andequal. On ampi and gent. Temp stable. Abd soft, ND, +BS. Remains onAmp and Gent. Temp. Respiratory Care NotePt off CPAP today. | 199 | [
{
"category": "Nursing/other",
"chartdate": "2128-03-08 00:00:00.000",
"description": "Report",
"row_id": 1695787,
"text": "Clinical Nutrition\nO:\n30 wk gestational age BG, AGA, now on DOL 4.\nBirthwt: 1345 g(~25th to 50th %ile); current wt: 1250 g (~25th %ile); wt currently down ~7% from birth wt.\nHC at birth: 29 cm (~50th %ile); current HC: 27.5 cm (~10th to 25th %ile)\nLN at birth: 39 cm (~25th %ile); current LN: 38 cm (~10th to 25th %ile)\nLabs noted.\nNutrition: TF @ 140 cc/kg/day. EN started on DOL 2, currently @ 50 cc/kg/day PE/BM 20, increasing 10 cc/kg/. PN started on DOL 1; lipids added on DOL 2. Remainder of fluids as PN via ; projected intake for next 24 hrs from PN ~47 kcal/kg/day, ~2.1 g pro/kg/day, and ~1.4 g fat/kg/day. From EN: ~40 kcal/kg/day, ~0.6 to 1.2 g pro/kg/day, and ~2 to 2.3 g pro/kg/day.\nGI: Abdomen benign.\n\nA/Goals:\nTolerating feeds without GI problems. Tolerating PN with good BS control. Labs noted and PN adjusted accordingly. Initial goal for feeds is ~150 cc/kg/day PE/BM 24, providing ~120 kcal/kg/day and ~3.2 to 3.6 g pro/kg/day. Further increases in feeds as per growth and tolerance. Appropriate to add Fe and Vit E supps when feeds reach initial goal. PN will be supplemental to feeds and taper off as EN increases. Growth goals after initial diuresis are ~15 to 20 g/kg/day for wt gain, ~0.5 to 1 cm/wk for HC gain, and ~ 1 cm/wk for LN gain. Will follow w/ team and participate in nutrition plans.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-08 00:00:00.000",
"description": "Report",
"row_id": 1695788,
"text": "NPN\n\n\n2. Received infant in RA on CVR and O2 sat. VS as noted on\nflow sheet. Noted to have 2 bradycardic episodes, one\nneeding mild stim. Both episodes around feeding. Mild\nretractions noted. No murmur. Slight jaundice.\nCont to monitor.\n3. TF increased to 140cc/kg today. Currently on PN D10W\nwith IL at 80cc/kg and NG feeds at 60cc/kg MBM/PE20. Tol\nfeeds well. Abd soft, no asp or spits. A/G stable. No stool\nthis shift. Voiding qs, see flow sheet.\nCont to advance feeds as tol 10cc/kg as ordered.\n4. Parents in for feeds. Handling the infant with assist.\nKangaroo x1. Asking appropriate questions. Discussed common\npreemie issues etc and criteria for discharge. Mom pumping.\nDad also handling infant well. Family meeting postponed\nuntil tomorrow.\n5.In air isolette maintaining temp. Tol 30 min of kangaroo\ncare but decreased temp and returned to . Sucks on\npacifier. Nested and boundries applied. Tol procedures\nfairly well.\n7. Reduced to single phototherapy lights today. Bili and\nlytes ordered for Wed. Mask secure. Voiding qs. No stool\nthis shift.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2128-03-11 00:00:00.000",
"description": "NEONATAL HEAD PORTABLE",
"row_id": 820067,
"text": " 7:26 AM\n NEONATAL HEAD PORTABLE Clip # \n Reason: TRIPLET BORN AT 30 WEEKS GESTATION, RULE OUT INTRACRANIAL HEMORRHAGE OR OTHER ABNORMALITY\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant born at 30 weeks gestation\n REASON FOR THIS EXAMINATION:\n rule out intracranial hemorrhage or other abnormality\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Initial study on baby born at 30 weeks who is one of triplets.\n\n Scans through the anterior fontanelle with limited views through the mastoid\n foramen do not demonstrate any abnormalities. There is no evidence of\n hemorrhage or ventriculomegaly.\n\n"
},
{
"category": "Radiology",
"chartdate": "2128-03-05 00:00:00.000",
"description": "BABYGRAM (CHEST ONLY)",
"row_id": 819462,
"text": " 1:13 AM\n BABYGRAM (CHEST ONLY) Clip # \n Reason: verify ETT placement\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with prematurity, RDS\n REASON FOR THIS EXAMINATION:\n verify ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST\n\n Comparison is made with the examination performed earlier in the day. Since\n that time, the patient has been intubated and the endotrachial tip ends above\n the carina. The lungs are much clearer, compatible with improving hyaline\n membrane disease.\n\n"
},
{
"category": "Radiology",
"chartdate": "2128-03-04 00:00:00.000",
"description": "BABYGRAM (CHEST ONLY)",
"row_id": 819458,
"text": " 10:44 PM\n BABYGRAM (CHEST ONLY) Clip # \n Reason: evaluate lung fields\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with prematurity at 31 weeks\n REASON FOR THIS EXAMINATION:\n evaluate lung fields\n ______________________________________________________________________________\n FINAL REPORT\n CHEST\n\n This is our initial x-ray on this baby born prematurely, who is one of\n triplets. The lungs are nearly opaque, and the lung volumes very low,\n compatible with severe hyaline membrane disease. No other abnormalities are\n apparent.\n\n"
},
{
"category": "Radiology",
"chartdate": "2128-04-06 00:00:00.000",
"description": "NEONATAL HEAD PORTABLE",
"row_id": 822576,
"text": " 7:07 AM\n NEONATAL HEAD PORTABLE Clip # \n Reason: PREMATURE INFANT BORN AT 30 WEEKS, FOLLOW UP PREVIOUS NORMAL STUDY; RULE OUT PVL\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant born at 30 weeks gestation, now 1 month old\n REASON FOR THIS EXAMINATION:\n follow up previous normal study; rule out PVL\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Infant born at 30 week gestation, now 1 month old.\n\n COMPARISON: Study on \n\n The ventricles, sulci and cisterns are normal. There is no evidence of\n intracranial hemorrhage. There is no evidence of periventricular\n leukomalacia. Grey/white matter differentiation is normal for the patient's\n age.\n\n IMPRESSION: Normal head ultrasound.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-28 00:00:00.000",
"description": "Report",
"row_id": 1695872,
"text": "PCA Note:\n\n\nResp: O: Infant in RA, sats within limits (>94%). Lung\nsounds are cl/= bilaterally. Mild subcostal retractions. No\nspells, no drifts. A: Infant breathing comfortably. P:\nContinue to monitor respiratory status.\n\nFEN: O: TF 150cc/kg BM/PE26. PO/PG feeds as tolerated,\ngavaged over 1hr. Infant bottled this afternoon, taking in\n45cc. No spits, minimal aspirates. Infant's abdomen is soft,\n+bowel sounds, no loops. Girths stable @25cm. Infant is\nvoiding, no stool. A: Tolerating feeds well. Eager to\nbottle, well coordinated, strong suck. P: Continue ot offer\nPO feeds. Continue to support nutritional needs of infant.\n\n: O: Mom, and big brother in this afternoon. A:\nAppropriate, comfortable, . Big brother very\nexcited about new siblings. P: Continue to support, teach\nand prepare for discharge.\n\nDEV: O: Infant is swaddled, cobedded with brother and sister\nin ; HOB elevated. Infant maintaining stable temps. \nsleeps well between cares, wakes with cares, remains \nand active throughout cares. Calms with pacifier. A:\nDevelopmentally appropriate. P: Continue to support\ndevelopmental needs of infant.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-28 00:00:00.000",
"description": "Report",
"row_id": 1695873,
"text": "agree with above note and assessment by , PCA.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-29 00:00:00.000",
"description": "Report",
"row_id": 1695874,
"text": "npn 1900-0700\n\n\n2: resp\nremains in ra. no spells and no dsats. RR 30-60's. Lung\nsounds clear and equal. mild subcostal retractions. no\nincreased wob noted. sats remain in the high 90%.\n\n3: fen\ncurrent weight 1975gms up 65. total fluids remain at\n150cc/kilo/day of bm/pe 26. no breastmilk available this\nshift. infant po'd her whole volume at 2400. continuing to\nwatch feeding cues. tolerating feeds well. no spits. minimal\naspirates. stable girths. nutritional drawn this shift.\nsee flowsheet.\n\n4: \nno contact this shift.\n\n5: g/d\ntemps stable in an open air crib. and active with\ncares. sleeps well inbetween. sucks on pacifier. brings\nhands to face. aga. continue to monitor for developmental\nmilestones.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-29 00:00:00.000",
"description": "Report",
"row_id": 1695875,
"text": "Neonatology-NNP PRogress Note\n\nPE: Remains in room air, cobedding with her siblings, well perfused, bbs cl=, rrr s1s2 no murmur, abd soft, nontender, V&S, afso, bundled\n\nSee attending note for plan\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-29 00:00:00.000",
"description": "Report",
"row_id": 1695876,
"text": "Neonatology Attending\n is 25do, 34 wks corrected.\nRA, open crib cobedding with sibs\nNo a/b or desats\nWt up 65 on TF150 MM26/PE26 pg>po, did take 2 full-volume bottles past 24hrs. Not waking for feeds\n\nMeds Fe, vit E, Desitin\n\n: Ca 10.2/phos 6.9/alk phos 292\n\nImp/ age-appropriate feeding immaturity.\n\nPlan/ continue to monitor cvr status, growth & development. D/c planning in progress contingent upon further evidence of maturity. Eye exam today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-04-14 00:00:00.000",
"description": "Report",
"row_id": 1695941,
"text": "#2 RA. LS CLEAR ANFD EQUAL. NO SPELLS.\n#3 PT PO FEEDING Q4-5HR. PO FEEDING WELL, >140CC/KG OF\nE24. WEIGHT INCREASE 40GM. VOIDING AND STOOLING.\n#4 NO CONTACT FROM FAMILY ON THIS SHIFT.\n#5 WAKING TO FEED. AND ACTIVE. NO SPELLS AT THIS\nTIME IN SHIFT.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-04-14 00:00:00.000",
"description": "Report",
"row_id": 1695942,
"text": "neonatology Attending\n is 41do, 36 wks\nRA, open crib\nDay without a/b\nWt 2490 up 40g on ad TF140 MM/E24 po.\n\nMeds Fe\n\nimp/ age-appropriate immaturity of cvr coordination\nPlan/ continue to monitor cvr status, growth/development. D/c planning ongoing pending evidence of further maturation...\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-04-14 00:00:00.000",
"description": "Report",
"row_id": 1695943,
"text": "Clinical Nutrition\nO:\n~36 wk CGA BG on DOL 41.\nWt: 2490 g(+40)(~25th %ile); birth wt: 1345 g. Average wt gain over past wk ~37 g/day.\nHC: 33 cm (~50th to 75th %ile); last: 32 cm\nLN: 45 cm (~25th %ile); last: 44 cm\nMeds include Fe.\n not needed\nNutrition: Ad po, minimum 140 cc/kg/day, E 24 or BM 24 w/ 4 kcal/oz Enfamil powder. Infant gets mostly formula. Average of past 3 day intake ~190 cc/kg/day, providing ~152 kcal/kg/day and ~2.5 to 3.2 g pro/kg/day.\nGI: Abdomen benign.\n\nA/Goals:\nTolerating feeds without GI problems; taking all po feeds. not needed. Current feeds + supps meeting weaned recs for kcals/pro/vits and mins. Growth is meeting recs for HC and LN gain. Wt gain is slightly exceeding recommended ~20 to 35 g/day; will monitor daily gains and consider decreasing kcals before d/c if indicated. Will continue to follow w/ team and participate in nutrition plans.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-04-14 00:00:00.000",
"description": "Report",
"row_id": 1695944,
"text": "Nursing NICU Note\n\n\n#2. Respiratory O: Pt. remains in RA, O2 sats >95%. LS\nclear/=, no increase work of breathing noted. No A&B's\nnoted this shift thus far. This is day #2 of 5 for a spell\ncount. A: Pt. is stable in RA. P: Continue to monitor\nrespiratory status. Monitor for A&B's.\n\n#3. FEN O: Pt. is ad 140cc/kg/d of E24. She\ntakes ~70-90cc PO Q feed every 4-5hrs. She is wakeing for\nfeeds and bottleing well. Abdomen is soft, , +BS, no\nloops/spits noted. She is voiding/ no stool noted this\nshift thus far. A: Pt. is tolerating current nutritional\nplan. P: Continue w/ current feeding plan. Monitor for\ns/s of intolerance.\n\n#4. O: in this afternoon to take home \nsister. was updated at bedside on pt's current status\nand daily plan of care. A: Family is and involved.\nP: Continue to update, support and educate. Continue w/\ndischarge teaching/planning.\n\n#5. Growth/Development O: Pt. remains in an open crib,\nswaddled w/ stable temps. She is and active w/ cares,\nsleeps well in between. Fontanelle soft/flat. She loves to\nuse her pacifier, brings hands to face. A: AGA P:\nContinue to provide environment appropriate for growth and\ndevelopment.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-11 00:00:00.000",
"description": "Report",
"row_id": 1695798,
"text": "NURSING PROGRESS NOTE\n\nRESP/CV: REMAINS IN RA WITH 02 SATS >95% ALL NIGHT. NO A&B'S OR DESATS NOTED. BS CL&= WITH MINIMAL RETRACTIONS AND NO MURMER AUDIBLE. COLOR JAUDICE/ AND WELL PERFUSED. REBOUND BILI SENT THIS AM, RESULTS PNDING. BP 64/38-46.\n\nFEN: TOTAL FLUIDS MAINTAINED AT 140CC/KG/D. ENTERAL FEEDS ADVANCED TO 130CC/KG/D TONIGHT. INFILTRATED AT 0400 AND NOT RESTARTED. WILL ADVANCE TO FULL FEEDS AT 1200. D-STICK 89. ABD SOFT, WITH STABLE GIRTH AND +BS. PASSED MODERATE MECONIUM STOOL TONIGHT. NO RESIDUALS AND ONLY ONE SMALL EMESIS.\n\nDEV: TEMP STABLE IN AIR CONTROLLED ISOLETTE. AND ACTIVE WITH CARES. SUCKING INTERMITANTLY ON PACIFIER.\n\nSOCIAL: DAD VISITING TONIGHT. DID TEMP AND DIAPER CHANGE. PLEASED WITH PROGRESS. HELD SISTER.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-11 00:00:00.000",
"description": "Report",
"row_id": 1695799,
"text": "Neonatology note\n7 d.o\nin RA, on caffein, no spells.\nRR with no murmur\nclear lungs\nabdomen soft\nAFOF\njaundice\nbili= 5.3\nwt= 1305 gm +15, off IV, feeding at 130 cc/kg/d with PE/EBM 20.\nnormal tone.\nHUS: normal today.\nA: ex 30 wks GA, resolved RDS, AOP, jaundice.\nP: advance feeding, monitor for episodes on caffeine.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-11 00:00:00.000",
"description": "Report",
"row_id": 1695800,
"text": "NICU nursing progress note\n\n\nPlease refer to flowsheet for specific info.\nResp\nO: remains in room air, RR 40-70's, sat's >93%. BSCE\nbilat. A: Breathing comfortably. Stable. P: Cont to follow.\nFEN\no: TF at 150cc/k/d, currently PG enteral feedings are at\n130cc/k/d. Adv. feeds 15cc/k as tolerated. Abd , no\nloops, active bs. Voiding/ no stool thus far today. One\nsmall spit. Min asp. HOB elev. A: stable. P: cont to\nfollow.Adv feeds as tolerated.\nGD\nO: Temp stable in air isolette, swaddled with hat, tshirt\nand blanket. MAE. Fonts, soft, flat. Calms with containment\nand pacifier. Dark Blanket over the top of isolette. HUS\ndone this morning, please see Dr. note.A: AGA P: Cont\nto support dev. milestones.\nParenting\nO: Mom planning on visiting at noon cares. Dad called and\nupdated, verbalizing understanding. A: Involved and loving\n. P: cont to update, support, educate.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-12 00:00:00.000",
"description": "Report",
"row_id": 1695801,
"text": "NURSING PROGRESS NOTE\n\nRESP/CV: REMAINS IN RA WITH 02 SATS >95%. 2 A&B'S NOTED TONIGHT. NO DESATS. REMAINS ON CAFFEINE. VSS IN ISOLETTE. BS CL&=, NO MURMER.\n\nFEN: WEIGHT 1335GMS, UP 30GMS. TOTAL FLUIDS ADVANCED TO 150CC/KG/D OF PE20CAL. ABD SOFT, WITH STABLE GIRTH AND +BS. PASSING MECONIUM AND VOIDING LG AMTS. NO RESIDUALS AND ONLY SMALL EMESIS X1. HOB ELEVATED AND FEEDS INFUSING OVER 1HR.\n\nDEV: TEMP STABLE IN ISOLETTE. ACTIVE AND WITH INTERVENTIONS AND SLEEPING QUIETLY BETWEEN CARES. SUCKING VIGOROUSLY ON PACIFIER.\n\nSOCIAL: MOM X1 FOR UPDATE. WILL VISIT AT 11AM TODAY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-12 00:00:00.000",
"description": "Report",
"row_id": 1695802,
"text": "Neonatology note\n8 d.o\nin RA, on caffeine, 2 episodes\nRR with no murmur\nclear lungs\nAFOF\nwt= 1335 gm +30, 150 cc/kg/d with EBM/PE 20\nabdomen soft\nnormal tone\n\nA: ex 30 wks GA, AOP, growing preemie\nP: advance calorie density\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-29 00:00:00.000",
"description": "Report",
"row_id": 1695877,
"text": "NPN 7a-7p\n\n\n#2: remains in Ra, breathing comfortably with mild SC\nretractions. RR stable. Sats >/= 96%. Rare drift noted to\nmid 80's x2, during mid feed. Infant corrected on her own.\nNo other drifts noted. BBS cl/=. No apnea/brady spells\nnoted thus far. A: stable in RA P:Cont to monitor and\nprovide support as needed.\n\n#3: TF: 150cc/k/d. conts on BM26/PE26, 49cc q4hrs\ngavaged over 1hr10mins. Bottled 20cc at noon feed for Mom.\nDid well with coordinating suck/swallow/breathe pattern, but\ntired out easily. Burped well. No spits, no asps. Abd\nsoft, +, no loops. Ag stable. Voiding qs. No stool\nthus far. A: tol'ing feeds well, learing to bottle P:Cont\nto follow wt and exam. Monitor tol to feeds. Offer bottle\nqshift as tol'ed.\n\n#4: Mom in for noon care. Update given. Indep with temp\nand diaper. Working on bottling infant. Using good\npositioining. Mom was present for eye exam. Did speak with\nDr. regarding results. Aware of need for F/U in\n3wks. Case manager spoke with Mom regarding\n/insurance coverage. A: Involved, parent\nP:Cont to support and educate.\n\n#5: is maintaining stable temps while swaddled in an\nopen crib. She is and active with cares, but not\nwaking on own for feeds. Tol'ed eye exam well. MAE. Fonts\nsoft/flat. Sucks on pacifier. A: AGA P:Cont to support\ndev needs.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-30 00:00:00.000",
"description": "Report",
"row_id": 1695878,
"text": "NPN\n\n\n#2 Resp- Remains in RA w/o2 sats 95-100%. BS clear.RR=40-70.\nMild retractions.\n#3 F/N- Abd soft,+bs, no loops. Tolerating feeds of BM/PE 26\ncals w/o spits. Minimal asps.Bottled 30cc out of 49cc x1. NG\nfeeds given on a pump over 1 hr+ 10mins. voiding in adeq\namts. No stool yet tonight.Wt up 15gms.TF= 150cc/kg/day.\n#4 - no contact yet tonight.\n#5 Dev- + active w/cares. Temp stable swaddled in open\ncrib.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-30 00:00:00.000",
"description": "Report",
"row_id": 1695879,
"text": "Neonatology NP Note\nPE\n swaddled in crib, cobedding with siblings\nAFOF, sutures opposed\nrespirations comfortable in room air, lungs clear/=\nRRR, no murmur, and well perfused\nabdomen soft, nontender and nondistended, active bowel sounds\ngood tone.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-31 00:00:00.000",
"description": "Report",
"row_id": 1695880,
"text": "1900-0700 NPN\n\n\nRESP: Infant remains in RA, O2 sats=96-100%. RR=40-60's.\nBreath sounds clear and equal bilaterally, mild SCR noted.\nNo desats/no bradys so far this shift. Continue to monitor\nresp status.\n\nFEN: Weight tonight=1.990 kg (no change). TF=150cc/kg/d of\nBM26/PE26 PO/PG q4hr. Attempting to bottle feed infant\nqshift. Infant bottled 15cc at 0000. Gavage feedings given\nover 1hr 10min/tolerated well. Abdomen , soft, round,\n+BS, no loops. No spits, no aspirates so far this shift.\nVoiding, no stool. Continue to monitor FEN status.\n\n: No contact with so far this shift.\n\nDEV: Temps stable, swaddled in . Cobedding with brother\nand sister. Active and with cares, sleeps well in\nbetween cares. Infant not waking for feeds. Brings hands to\nface, sucks on pacifier for comfort. MAE. Continue to\nsupport DEV.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-31 00:00:00.000",
"description": "Report",
"row_id": 1695881,
"text": "1900-0700 NPN\nPlease disregard the above note. This note was written on the wrong patient.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-04-15 00:00:00.000",
"description": "Report",
"row_id": 1695945,
"text": "PCA NOTE\n\n\nRESP: O/A-In RA. Breathing 40-60's. Sats high 90's. No\nspells or desats noted. No drifts. No issues. P-Continue to\nmonitor.\n\nFEN: Current weight 2.520, ^30gm. TF of 140. E 20. PO.\nTotal 24 hour intake 161 cc/ is voiding and\nstooling. Hem neg. Active bowel sounds. Abdomen is\nunremarkable. No spits. P-Continue with current regimen.\n\n: No contact thus far this shift.\n\nG/D: O/A-Temp stable in . Waking q 2-5 hours for feeds.\n and active. Sleeps peacefully. MAE. Awake for longer\nperiods of time. Curious disposition. P-Continue to monitor\nfor developmental milestones.\n\n ****See flowsheet for further information****\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-04-15 00:00:00.000",
"description": "Report",
"row_id": 1695946,
"text": "NPN 1900-0730\nI have examined this infant and agree with the above note written by , PCA.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-04-15 00:00:00.000",
"description": "Report",
"row_id": 1695947,
"text": "Neonatology-NNP Physical Exam\n\n remains in RA. Active, in an open crib, AFOF, sutures opposed, good tone. BBS clear and equal with good air entry. No murmur, pulses +2, , RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds. Please refer to attending progress note for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-04-15 00:00:00.000",
"description": "Report",
"row_id": 1695948,
"text": "Neonatology Attending\n is 42do, 36 wks corrected.\nRA, open crib alone ( went home yesterday)\nNo a/b day \nWt 2520 up 30g on ad po E24/MM24 minTF140 (took 161cc/kg/24hrs)\n\nMeds Fe\n\nImp/ age appropriate cvr immaturity...\nPlan/ continue to monitor cvr status, growth/development. D/C planning in progress for as early as Sat contingent upon evidence of maturity.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-04-15 00:00:00.000",
"description": "Report",
"row_id": 1695949,
"text": "NPN 0700-1900\n\n\n#2: O: Infant remains in room air. Saturations 96-100%.\nRespiratory rate 30's-40's with no retractions. No spells or\ndrifts this shift. Day 3 out of 5 of a spell countdown. Lung\nsounds clear and equal. A: Infant stable in room air. P:\nContinue to monitor infant for spells.\n\n#3: O: Total fluid minimum 140cc/kg/day of E24 or breastmilk\n24 with enfamil powder, 59cc q4 hours. Infant is ad \nfeeding and took 90cc and 75cc so far this shift. Abdomen\nbenign, voiding, no stools. One small spit. A: Infant\ntolerating feeds P: Continue with current feeding plan.\n\n#4: O: called this shift, will be in this evening.\n\n#5: O: Temperature stable in . Infant wakes for feeds,\n and active with cares. Brings hands to face for\ncomfort and calms with pacifier. Sleeps well between cares\nand remains swaddled in crib. A: AGA. P: Continue to support\ngrowth and development.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-04-15 00:00:00.000",
"description": "Report",
"row_id": 1695950,
"text": "Nrsg Progress Note\nAgree with above note fromPCa with fdg witnessed by this RN at 1700 with uncoordinated sucking noted periodically with sucking spilling approx 10 cc's from \"dribbling\"of formula. Abd soft with no stool at 1700. No loops noted this shift. phoned with complete update. No a's or b's noted as of this writing. Report to night RN planned for 1900. Infant remains on cvr and 02 sat monitor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-26 00:00:00.000",
"description": "Report",
"row_id": 1695861,
"text": "NPN 1900-0700\n\n\n2. RESP: pt reains in RA with RR 40-60's. Mild S/C\nretractions. Sats >94%. No spells noted. Will monitor.\n\n3. F&N: TF remain at 150cc/k/d of PE26. She bottled her\nwhole feed at 2400. Abd benign. BS+. A/G stable. No\nspits and minimal aspirates noted. Voiding well. No stool\nnoted. Weight gain 50 grams.\n\n4. PAR: No contact from so far this shift.\n\n5. DEV: is active and during her cares. Temp\nstable swaddled in crib, cobedding with her siblings. Mild\ngen edema noted.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-26 00:00:00.000",
"description": "Report",
"row_id": 1695862,
"text": "Neonatology Attending\nAddendum\n\nPE: active sleep, appropriate tone/activity. . AFOF.\nLungs CTA, heart rrr s m, abd soft, extr well perfused.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-26 00:00:00.000",
"description": "Report",
"row_id": 1695863,
"text": "Neonatology Attending\n22do, 34 wks corrected\nRA, open crib cobedding with sibs\nNo a/b\nWt 1840 up 50 on TF150 PE26 pg>> po (took full bottle overnight!); no spits\n\nMeds Fe, vit E, Desitin\n\nImp/ age-appropriate immaturity of feeding skills, making appropriate progress, growing well.\n\nPlan/ continue to monitor cvr status, growth/development\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-26 00:00:00.000",
"description": "Report",
"row_id": 1695864,
"text": "NPN days\n\n\nRESP: Infant in room air, RR 30-60's, O2 sats 93% and\ngreater, lungs are clear and equal, mild SC retractions. No\nspell, no desats. Will continue to monitor closely.\n\nFEN: total fluids 150cc/k/d of PE/BM 26 po/pg feeds Q4hours\n48cc. Bottled X1 today and took in 35cc!, remainder\ngavaged. Infant to breast today , latched well and sucked\nintermittently for approx 5min. Abdomen is soft, ,\nactive bowel sounds, AG stable, minimal residuals, no spits.\nvoiding , no stool this shift. Will continue to offer\nbottle once per shift, and monitor closely.\n\nParenting: Mother in today for 12 and 4p cares, involved\nand mother, participates in cares, attempted to\nbreastfeed, lactation consult appt. made for at noon.\nWill continue to support and update family.\n\nG/D: Temps are stable in open crib (co bedding). and\nactive with cares, does not wake for all feeds, MAE, sucks\non pacifier /hands. AGA. Will continue to support\ndevelopmetnal needs.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-27 00:00:00.000",
"description": "Report",
"row_id": 1695865,
"text": "NURSING PROGRESS NOTE\n\nRESP/CV: REMAINS IN RA WITH NO A&B'S OR DESATS NOTED. BS CL&=, NO MURMER. COLOR AND WELL PERFUSED. BP 70/42-52.\n\nFEN: WEIGHT 1880GMS, UP 40GMS. TOTAL FLUIDS REMAIN AT 150CC/KG/D OF BM/PE26CAL. BOTTLED FULL FEEDING VIGOROUSLY WITH GOOD COORDINATION X1 TONIGHT. VOIDING & STOOLING WNL. ABD SOFT, WITH STABLE GIRTH AND +BS. NO EMESIS OR RESIDUALS NOTED.\n\nSOCIAL: MOM WILL BE IN AT 8AM THIS AM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-27 00:00:00.000",
"description": "Report",
"row_id": 1695866,
"text": "Attending Note\nDay of life 23 CGA 34 \nstable in room air 30-60\nHR 140-170 BP 70/42 mean 52\n1880 up 40 150 cc/kg/day BM or PE 26\ntaking mostly pg but some po\nvoiding and stooling\n\nA/P doing well\nwill have nutrition on Monday\nwill continue current plan\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-04-11 00:00:00.000",
"description": "Report",
"row_id": 1695929,
"text": "Neonatology Attending\n\nDOL 38 CGA 36 2/7 weeks\n\nStable in RA. No A/B.\n\nOn ad lib feeds. Took 156 cc/kg BM/E 24 yesterday. Voiding. Stooling. Wt 2340 grams (up 30).\n\nCobedding with sister.\n\n in and up to date.\n\nA: Stable. On countdown D2.\n\nP: Monitor\n Home when 5 day spell free\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-04-11 00:00:00.000",
"description": "Report",
"row_id": 1695930,
"text": "Nursing Progress Note:\n#2 - RESP: REmains in room air. Lungs clear and equal. No\nspells/drifts today. Day . Last spell on the 16th. Not\nbeing fed on the monitor. RR (30-50). O2Sats >96%.\n#3 - F&N: Ad lib demand feeder with min of 140cc/kilo.\nBottling well over that. Bottling about 80cc's at each\nfeeding. aBdoinal exam benign. Voiding. No stool thus far\ntoday. Remains on iron.\n#4 - : Mom called this am. in this afternoon.\nUpdated. Independent with cares. Bottled and fed both girls.\n\n#5 - G&D: TEmps stable in open crib. and active with\ncares. MAE. AFSF. Bottling all feeds. Waking for feeds q4-6\nhours.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-04-12 00:00:00.000",
"description": "Report",
"row_id": 1695931,
"text": "NICU NURSING PROGRESS NOTE:\nRESP.O: Infant remains in RA. RR: 40-60. Lungs sound clear\nand equal. No retractions. Infant has had 2x spells to the\ntime of note. 1x with bottling, HR went down to 77 with sats\n88%, bottle was taken out of her mouth, and mild to moderate\nstim for shallow breathing. The second spell was at rest,\nabout 30 min after she ate, HR:56, sat was 70%, her color\ngot dusky. Reguired mode stim for shallow breathing.\nA: Occasionally spells. P: Continue to monitor for spells\nand assess.\n\nFEN.O: Weight=2.385kg, ^45gms. Infant remains on adlib\ndemand schedule with BM24. Bottling slightly uncoordinated.\nTaking 80-90cc. Abd exam is soft, no loops. BS active.\nVoiding, no stools. No spits. Tolerating feeds and gaining\nweight. Continue to support PO feedings.\n\nParenting: No contact from to the time of note. Cont\nto support.\nG/G.O: is cobedding with her twin sister in open crib.\nTemps are stbale. Swaddled. Active and with cares.\nSleeps well in between cares. Wakes for feeds. Likes her\npacifier. A: Well appereance. P: Continue to support\ndevelopmentally needs.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-04-12 00:00:00.000",
"description": "Report",
"row_id": 1695932,
"text": "I am in agreement with documentation done by . Infant had an uneventul night. Brady x2, one at rest and one with when feeding.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-04-12 00:00:00.000",
"description": "Report",
"row_id": 1695933,
"text": "Neonatology Attending Note\nDay 39\nCGA 36 3\n\nRA. RR40-60s. 2 A&Bs overnight, 1 w feed. No murmur. HR 140-170s. , well perfused. BP 79/47, 59.\n\nWt 2385, up 45. PO ad , 140cc/k/d, BM/E24. TFI: 170. Nl voiding and stooling.\n\nIn open crib.\n\nA/P: Immature cardioresp control, plus some po dyscoordination. Cont to monitor. No changes to current medical plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-10 00:00:00.000",
"description": "Report",
"row_id": 1695793,
"text": "NICU NPN 1500-0700\n\n\nRESP O: Baby remains in nco2 100%, 13-25c's during the\nnight. O2 sats 91-99%, rr50-70's, with baseline mild ic/sc\nretractions. No spont bradys noted, received caffeine bolus.\nLungs are clear. Hr 130-160's, color -jaundiced, bp's\nare stable, no audible murmur.\n\nFEN O: Current weight 1290g, up 10g. Tolerating advancing\nenteral feeds of pe20 well. Abdominal exam benign, voiding\nand stooling, ag stable, no loops, min ngt aspirates, no\nspits. D stick stable. IVF of PN, and IL are infusing\nthrough well.\n\nParenting O: Mom and dad in for cares, asking appropriate\nquestions. Family meeting held at 1500. Mom held.\n\nG&D O: temps are stable, nested on sheepskin, in servo\nisolette. baby is and active irritable with cares.\nSettles with pacifier and containment. Fontanells are soft\nand flat.\n\nBili O: Bili todat 5.0/0.2. She remains under single\nphototherapy\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-10 00:00:00.000",
"description": "Report",
"row_id": 1695794,
"text": "NICU NPN ADDENDUM\nError on above note, baby is in room air, and has been throughout the night. rr 40-60's, lungs are clear, with o2 sats 94-100%. One brady, noted, no caffeine bolus.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-10 00:00:00.000",
"description": "Report",
"row_id": 1695795,
"text": "Neonatology note\n6 d.o\nin RA, on caffeine, 2 bradycardia.\nRR with no murmur\nclear lungs\nabdomen soft\nwt= 1290 gm +10, 140 cc/kg/d with feeding at 100 cc/kg/d with PE 20\njaundice\nbili= 5\n\nA: ex 30 wks GA, resolved RDS, jaundice, AOP\nP: advance feeding, d/c phototherapy and f/u bili.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-10 00:00:00.000",
"description": "Report",
"row_id": 1695796,
"text": "Fellow note; physical exam\n and active in isolette. Breathing comfortably in RA. Mild jaundice. AFOF. Lungs with good aeration and clear breath sounds bilaterally. RRR. Nl S1, S2. No murmur. Normal femoral pulses. Abd soft, ND, + BS. Extrem WWP. Normal tone.\n\nFamily meeting yesterday with mom, dad, nurse, social worker and myself. Discussed course so far and goals for coming weeks. Discussed criteria for discharge home. Also discussed possible transfer to next week. well-informed and asking good questions.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-10 00:00:00.000",
"description": "Report",
"row_id": 1695797,
"text": "NICU nursing progress note\n\n\nPlease refer to flowsheet for specific info.\nResp\nO: remains in room air, RR 40-70's, sat's >91%, BSCE\nbilat. A: Stable. P: Cont to follow. On caffeine, no spells\ntoday.\nFEN\nO: TF of 140cc/k/d. IVF currently at 25cc/k/d of D10 2 meq\nNacl, 1 meq Kcl. Enteral feeds are currently at 115cc/k/d of\npe 20 gavaged over 40\". well tolerated. MIn asp. NO spits.\nAbd , no loops, active bs. voiding/ no stool today. UO\n3.5cc/k/hour for last 12 hours. A: stable. P: cont to\nfollow.\nGD\nO: Temp stable swaddled in an air isolette, active and \nwith cares. MAE. fonts, soft, flat. Calms with containment\nand pacifier. A:AGA P: cont to support dev milestones.\nbili\nO: Off photo tx. Check rebound in am.\nParenting\nO: mom and dad in and updated, verbalizing understanding. A:\nInvolved and loving .\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-09 00:00:00.000",
"description": "Report",
"row_id": 1695789,
"text": "NPN:\n\nRESP: Sats 94-98% in RA. RR=50-76 with sl SC retraction. BBS =/clear. Occasional brief sat-drifts w/quick recovery. A&B x 1 tonight; x 3 over past 24 h -> QSR or stim. Remains on Caffeine.\n\nCV: No murmur. HR=140-150s. BP=50/23 (33). Color w/jaundice. Perfusion good.\n\nFEN: Wt=1280g (+ 30g). TF=140cc/kg/d. Enteral feeds at 70cc/kg/d; tolertaing 16cc PE-20 well q 4 h via NG. PN (D-10) and IL at 70cc/kg/d. No spits; abd soft, rounded, active bs, no loops. U/O=3cc/kg/h over 24-h period yesterday. Voiding well tonight. No stool recorded since birth. To increase enteral fdgs 10cc/kg as tolerated. Elec to be checked .\n\nBILI: Single Phx. Bili 5.3/0.3 (). Bili to be done .\n\nG&D: CGA=31 wk. Temp stable in air-controlled isolette. Active and alert w/cares. Small lesion rt actecubital space -> cleansed and open to air. Nested in sheepskin and resting well.\n\nSOCIAL: No contact w/. Family meeting today at 1330.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-09 00:00:00.000",
"description": "Report",
"row_id": 1695790,
"text": "Neonatology note\n5 d.o\nin RA, no spells, on caffeine.\nRR with no murmur\nclear lungs\nabdomen soft\njaundice.\nAFOF\nnormal tone\nwt= 1280 gm +30, 140 cc/kg/d with feeding at 70 cc/kg/d with PE 20/EBM 20\nA: ex 30 wks GA, resolved RDS, Jaundice, AOP\nP: advance feeding, f/u bili.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-31 00:00:00.000",
"description": "Report",
"row_id": 1695882,
"text": "1900-0700 NPN\n\n\nRESP: Infant remains in RA, O2 sats=95-100%. RR=30-60's.\nBreath sounds clear and equal bilaterally, mild SCR noted.\nNo bradys, no desats so far this shift. Will continue to\nmonitor resp status.\n\nFEN: Weight tonight=2.065kg (+5grams). TF=150cc/kg/d of\nPE26/BM26 po/pg q4hr. Attempting to bottle infant qshift.\nInfant bottled 52cc at with good coordination. Gavage\nfeedings given over 1hr 10min/tolerated well. Abdomen ,\nsoft, round, +BS, no loops. Minimal aspirates, small spitx1\nso far this shift. Voiding/no stool. Continue to monitor FEN\nstatus.\n\n: No contact with so far this shift.\n\nG+D: Temps stable, swaddled in . Cobedding with sister\nand brother. Active and with cares, sleeps well in\nbetween cares. Infant does not wake independently for feeds.\nBrings hands to face, sucks on pacifier for comfort. MAE.\nYellow drainage noted to both eyes/warm soaks applied.\nContinue to support G+D.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-31 00:00:00.000",
"description": "Report",
"row_id": 1695883,
"text": "Neonatology Attending\nAddendum: PE\nSleeping quietly s/p feed; appropriate tone; . AFOF.\nLungs CTA, heart RRR s murmur, abd soft, extr well perfused.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-31 00:00:00.000",
"description": "Report",
"row_id": 1695884,
"text": "Neonatology Attending\n is 27do, 34 wks corrected.\nRA, open crib\nNo a/b; occ desats mostly with feeds, some with bradycardia all self-resolved\nwt unchanged on TF150 MM/PE26 pg>>po\n\nMeds Fe, vit E\n\nImp/ age-appropriate cvr & feeding immaturity\nPlan/ continue to monitor cvr status, growth/development.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-31 00:00:00.000",
"description": "Report",
"row_id": 1695885,
"text": "NPN 7a-7p\n\n\n#2: remains in RA, sating >/= 96%. RR stable.\nBreathing comfortably with mild SC retractions. BBS cl/=.\nNo apnea/brady spells noted. Did have 2 brief drifts with\nbottling to high 80's- QSR. Also had desat at rest to 76%,\nwith HR drop to 86. Occurred after gavage feed had finished.\nQSR. Team aware. A: stable in RA, ?reflux. P:Cont to\nmonitor resp status and provide support as needed.\n\n#3: TF: 150cc/k/d. Conts on BM26/PE26, tol'ing 50cc q4hrs\ngavaged over 1hr10mins. No asps. No spits thus far. HOB\nslighlty elevated. Bottled at 12 feed, taking 32cc. Fair-\ngood coordination. Tires toward end of feed. Abd soft,\n+, no loops. Voiding qs. No stool thus far. A: tol'ing\nfeeds. P:Cont to follow wt and exam. Monitor tol to feeds.\nOffer bottle qshift as tol'ed.\n\n#4: Mom in for noon care. Indep with care and bottling.\nUpdated on infant's status. Rescheduled her LC appt for Sat\nand Mon. A: Involved, parent P:Cont to support and\neducate.\n\n#5: Temps stable while swaddled in an open crib. Molyy\nloves co-bedding with her siblings. MAE. Fonts soft/flat.\nBrings hands to face. Sucks on fingers and pacifier.\nSleeps well in btw cares. A: AGA P:Cont to support dev\nneeds.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-09 00:00:00.000",
"description": "Report",
"row_id": 1695791,
"text": "NICU nursing progress note\n\n\nPLease refer to flowsheet for specific info.\nResp\nO: remains in room air, RR 40-70's, sat's 94-98%, occ\ndrift in sat to high 80 's then quickly returns to baseline.\nBSCE bilat. ic/sc ret. On caffeine , no brady's. A: Stable.\nP: cont to follow.\nfEN\nO: TF of 140cc/k/d, ivf PN D10 w/ IL at 70cc/k/d and enteral\nfeeds at 70cc/k/d. NO spits, min. asp. Abd benign, no\nloops, active bs. voiding/ no stool. Glycerin supp. given as\nordered. No results. No spits. min asp. A: Stable. P: Plan\nfor adv of feeds 15cc/k at 1600, cont to follow.\nGD\nO: TEmp stable in air isolette, active and alert with cares,\nocc irritable though calms with containment and pacifier.\nMAE. Font soft, flat. A: AGA P: cont to support dev.\nmilestones.\nBIli\nO: Under single photo tx, eye in place. A: Labs on\nWeds.\nParenting\nPlease see trip #3 note.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-09 00:00:00.000",
"description": "Report",
"row_id": 1695792,
"text": "PT/OT\n was observed during her cares. Noted stress signals, strengths and techniques for comfort. Met with and explained role of PT and OT, and initiated education regarding developmental care, stress signs, handling and comfort techniques. were very receptive and demonstrated good understanding of all education. Will continue to f/u for developmental care and parent education.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-27 00:00:00.000",
"description": "Report",
"row_id": 1695867,
"text": "PCA Note:\n\n\nResp: O: Infant in RA, sats within limits. Lung sounds are\nclear and equal, mild subcostal retractions. No drifts, no\nspells. A: Infant breathing comfortably, no apparent\nrespiratory distress. P: Continue to monitor infant's\nrespiratory status.\n\nFEN: O: TF 150cc/kg BM or PE26. PO/PG feeds as tolerated\nq4h, gavaged over 1hr 10min. Infant bottled 33cc this\nmorning for Mom; well coordinated, eager, strong suck. No\nspits. Infant's abdomen is soft, nontender, +bowel sounds,\nno loops. Girths stable @ 25cm. Max aspirate = 4cc. Infant\nis voiding, no stool thus far. A: Infant tolerating feeds\nwell. P: Continue to offer PO feeds as tolerated. Continue\nto support nutritional needs of infant.\n\n: O: Mom and Dad in this morning. Mom assisted with\ncares, bottled and held infant. A: appear\ncomfortable, appropriate and very . P: Continue to\nsupport, teach and prepare for discharge.\n\nDEV: O: is swaddled, cobedded with brother and sister\nin an , maintaining stable temps. sleeps well\nbetween cares. Infant wakes with cares and remains and\nactive throughout cares. calms with her pacifier. A:\nDevelopmentally appropriate. P: Continue to support\ndevelopmental needs of infant.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-27 00:00:00.000",
"description": "Report",
"row_id": 1695868,
"text": "Neonatology NP note\nPe\nAFOF, sutures opposed\nrespirations comfortable in room air, lungs clear/=\nRRR, no murmur, and well perfused\nabdomen soft\ngood tone.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-12 00:00:00.000",
"description": "Report",
"row_id": 1695803,
"text": "Nursing Progress Note\n\n\nRESP O/A: Infant remains in RA; maintaining O2 sats >95%. RR\n40-70s, LS clear/=, mild intercostal rtxns. No spells/desats\nnoted thus far today. Continues on pg caffeine qd. P: Cont\nto monitor resp status.\n\nFEN O/A: TF @ 150cc/k/d. Calories increased to BM/PE22.\nInfant receives 33cc q4h pg. Tolerating feeds well; no\nspits, minimal aspirates. Abodomen benign, active BS. Girth\nstable. Voiding/mec stooling. P: Cont to monitor for s/s of\nfeeding intolerance.\n\nPAR O/A: Mom in @ 1230 to visit. Very affectionate towards\ndaughter. Asking appropriate questions. P: Cont to support\nNICU family.\n\nDEV O/A: is swaddled in an Air isolette; temps stable.\nSleeps well b/t feeds, A/A with cares. Likes pacifier. P:\nCont to support developmental needs.\n\nBILI O/A: Infant appears slightly juandice. Problem\nresolved.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-13 00:00:00.000",
"description": "Report",
"row_id": 1695804,
"text": "NPN Nights\n\n\n2. O: Ls clear. RR 40-60's. Mild intercostal retractions. No\nspells/ desats. On Caffeine. RA. A/P: Cont to monitor resp\nstatus.\n\n3. O: Wt 1360gms, up 25. Tf 150cc/kg of BM/PE22 via ngt. 3\nsmall spits. Min asp. Voiding. +bs. No stool. A/P: Cont to\nmonitor wt,a bd, and tol of feeds.\n\n4. O: Mom called X1. MOm asking appropriate questions. Rn\nupdated Mom. A/P: Cont to educate and support.\n\n5. O: Temp 99.4 X1. Removed hat. Otherwise, temp stable.\n and active with cares. Occ Sucking on pacifier. A/p:\nCont to monitor temp. Cont to cluster cares.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-13 00:00:00.000",
"description": "Report",
"row_id": 1695805,
"text": "7 Bili\n\nREVISIONS TO PATHWAY:\n\n 7 Bili; resolved\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-13 00:00:00.000",
"description": "Report",
"row_id": 1695806,
"text": "Neonatology\nRemains in rA. Comfortable apepairng. Single spell ove course of evening.\n\nWT 1360 up 25. TF at 150 cc/k/d of 22 cal. Abdomen benign. Will advance to 24 cal. Few spits overnight.\n\nTemp stable in isollette.\n\nSl jaundiced. Rbd bili ok.\n\n investigating retrotransfer to area.\n\nHUS for Tuesday.\n\nContinue current monitoring and feed advancement as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-13 00:00:00.000",
"description": "Report",
"row_id": 1695807,
"text": "Nursing Progress Note\n\n\nRESP O/A: Infant remains stable in RA; maintaining O2 sats\n>94%. RR 30-60s, LS clear/=, mild ic rtxns. One spell noted\n@ 0900: HR 74, no desat, QSR. Continues on caffeine. Resp\nstatus stable. P: Cont to monitor for As & Bs.\n\nFEN O/A: TF @ 150cc/k/d; calories increased to BM/PE24.\nInfant receives ~34cc q4h, gavaged over 70 minutes. Minimal\naspirates, no spits. Abdomen benign, active BS, girth\nstable. Voiding/transitional stooling. Started on Vit E & Fe\ntoday. P: Cont to monitor for s/s of feeding intolerance.\n\nPAR O/A: Mom in for 1200 cares, independent. Held \nduring gavage feed. Very loving. Asking appropriate\nquestions. Dad plans to be in for afternoon cares. P: Cont\nto support NICU .\n\nG&D O/A: Infant is swaddled in an Air isolette; temps\nstable. Sleeps well b/t feeds, A/A with cares. Likes\npacifier. MAE, brings hands to face, AFSF. P: Cont to\nsupport developmental needs.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-13 00:00:00.000",
"description": "Report",
"row_id": 1695808,
"text": "Neonatology NP Note\nPE\nswaddled in isolette\nAFOF, sutures opposed\ncomfortable respirations in room air, lungs clear/=\nRRR, no murmur, and well perfused\nabdomen sfot, nontender and nondistended, active bowel sounds\ngood tone.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-04-16 00:00:00.000",
"description": "Report",
"row_id": 1695951,
"text": "PCA NOTE\n\n\nRESP: O/A-In RA. Breathing 30-50's. Sats High 90's. No\nspells or desats noted. No drifts. No issues. P-Continue to\nmonitor.\n\nFEN: O/A-Current weight 2.545, ^ 25gm. TF 140cc/k/d. E\n24. PO. Exceeding required amount. Total 24 is 191 cc/\n is voiding, no stool thus far. Abdomen is\nunremarkable. Active bowel sounds. Small spit noted.\nTolerating feeds. P-Continue with current regimen as\nordered.\n\n: No contact thus far this shift.\n\nG/D: O/A-Temp stable in . Waking Q4-5 hours for feeds.\n and active with cares. Sleeping peacefully. Curious\ndisposition. Adores being held. Awake for longer periods of\ntime. MAE. AGA. P-Continue to monitor for developmental\nmilestones.\n\n ****See flowsheet for specifics****\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-04-16 00:00:00.000",
"description": "Report",
"row_id": 1695952,
"text": "NPN 1900-0730\nI have examined the infant and agree with the above note by , PCA.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-04-16 00:00:00.000",
"description": "Report",
"row_id": 1695953,
"text": "Neonatology Attending\n is 43do, 37 wks corrected\nRA, open crib alone (sibs have been d/c'd)\nNo a/b day \nWt 2545 up 45 on ad TF140 E/MM24 po\n\nMeds Fe\n\nImp/ age appropriate cvr immaturity, approaching readiness for d/c.\n\nPlan/ continue to monitor cvr status, growth/development. D/c planning in progress for tomorrow contingent upon further evidence of maturity.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-04-16 00:00:00.000",
"description": "Report",
"row_id": 1695954,
"text": "Neonatology - NP Physical Exam\nAwake and with cares, temp stable in open crib. BS clear and equal, color . RRR, without murmur, pulses 2+ and symmetrical. Active bowel sounds, without loops, without HSM, tolerating feeds well. Normal female genitalia. Without rashes. Good tone, AFSF, PFSF, +suck, +, +plantar reflexes. Please see attending neonatologist note for detailed plan of care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-04-16 00:00:00.000",
"description": "Report",
"row_id": 1695955,
"text": "Nursing NICU Note\n\n\n#2. Respiratory O: Pt. remains in RA, O2 sats >96%. LS\nclear/=. RR ~30-50's, no increase work of breathing noted.\nNo A&B's this shift thus far. Today is Day #4 of a 5 day\nspell count. A: Pt. is stable in RA. P: Continue to\nmonitor respiratory status. Monitor for A&B's.\n\n#3. FEN O: Ad 140cc/kg/d of BM24/E24. She takes\n~70-90cc PO q feed. She wakes for feeds and bottles well.\nAbdomen is soft, , +BS, no loops/spits noted. She is\nvoiding/ no stool passed this shift thus far. A: Pt. is\ntolerateing current nutritional plan. P: Continue w/\ncurrrent feeding plan. Monitor for s/s of intolerance.\n\n#4. O: Mom called this am and was updated on pt's\ncurrent status and daily plan of care. are active\nand independent in cares. A: are lvoing and\ninvolved. P: Continue to update, support and educate.\nContinue w/ discharge teaching/planning.\n\n#5. Growth/Development O: Pt. remains in an open crib,\nswaddled w/ stable temps. She is and active w/ cares,\nsleeps well in between. Fontanelle soft/flat. She loves to\nuse her pacifier, brings hands to face. A: AGA P:\nContinue to provide environment appropriate for growth and\ndevelopment.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-28 00:00:00.000",
"description": "Report",
"row_id": 1695869,
"text": "npn 1900-0700\n\n\n2: resp\n\nRemains in ra. no spells and no dsats. RR 30-70's. Lung\nsounds clear and equal. mild subcostal retractions. no\nincreased wob noted. continue to monitor for changes in resp\nstatus.\n\n3: fen\ncurrent weight 1910gms up 30gms. total fluids remain at\n150cc/kilo/day of bm/pe 26. tolerating feeds well. no spits.\nminimal aspirates. abd soft with no loops. alt po/pg feeds.\ninfant took whole volume at 2400 care. girths stable.\nvoiding, no stool thus far this shift. continue to encourage\npo feeds.\n\n\n4: :\nNo contact thus far this shift.\n\n5: G/D\ntemp stable in an open crib. and active with cares.\nsleeps well inbetween. brings hands to face. sucks on\npacifier. brings hands to face. aga. continue to monitor for\ndevelopmental milestones.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-28 00:00:00.000",
"description": "Report",
"row_id": 1695870,
"text": "Neonatology Attending Note\nDay 24\nCGA 34 2\n\nRA. RR30-50s. No A&Bs. BS cl and =. Mild sc rtxns.\n\nWt , up 30 gms. TF 150 cc/k/day PE26 po/pg. Tol well. Nl voiding and stooling.\n\nStable temps in open crib.\n\nA/P:\nGrowing preterm infant learning how to po feed. Will cont to encourage feeding skills and monitor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-28 00:00:00.000",
"description": "Report",
"row_id": 1695871,
"text": "Neonatology Attending Note\nExam:\n\nResting comfortably in open crib. AFSF. Lungs CTA, =. CV RRR, no murmur. 2+FP. Abd soft, +BS. Ext and well perfused.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-04-12 00:00:00.000",
"description": "Report",
"row_id": 1695934,
"text": "NPN 0700-1900\n\n\n#2: O: Infant remains in room air. Saturations greater than\n95%. Respiratory rate 30's-50's with no retractions. Lung\nsounds clear and equal. No spells. A: Infant stable in room\nair. P: Continue to monitor infant for spells.\n\n#3: O: Infant is feeding ad demand, breastmilk or E24.\nBottled 90cc each feed so far this shift. Abdomen benign,\nbowel sounds active. Voiding, no stools this shift. One\nsmall spit. A: Infant tolerating feeds. P: Continue with\ncurrent feeding plan.\n\n#4: O: called this shift.\n\n#5: O: Temperature stable in . Wakes for feeds, and\nactive with cares. Brings hands to face for comfort and\ncalms with pacifier. A: AGA. P: Continue to support growth\nand development.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-04-12 00:00:00.000",
"description": "Report",
"row_id": 1695935,
"text": "0700-1900 NPN\nI have read and agree with the above note written by , PCA.\n\n: Mom called this am, updated on patient's current status by this RN. Mom states she will be in for the evening care. Continue to support family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-04-13 00:00:00.000",
"description": "Report",
"row_id": 1695936,
"text": "2 Resp.\n Infant remains in room air with sats over 95.No spells so\nfar tonight.Lungs clear and equal.continue to monitor and\nrecord any changes.\n3 F/N\n Abdomen soft, + bowel sounds, 0 loops, 0 distention,\nbottled well all shift. Total fluids in last 24 hours were\n205cc per K.Voiding, stooling.Wt up 65gms to 2.450. Continue\nper plans.\n4 \n called early part of shift, given updates. Plan to\nkeep family informed.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-04-13 00:00:00.000",
"description": "Report",
"row_id": 1695937,
"text": "Neonatology Attending\naddendum: PE\n\nActive sleep, appropriate activity, . AFOF. Lungs cta, heart rrr s murmur, abd soft, extr well perfused.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-04-13 00:00:00.000",
"description": "Report",
"row_id": 1695938,
"text": "Neonatology Attending\n is 40do, 36 wks\nRA, open crib cobedding with \n a/b day \nwt 2450 up 65g on adlib minTF140 Mm24/E24\n\nMeds Fe\n\nImp/ age appropriate cvr immaturity, improving; demonstrating mature feeding skills. Had late (~48hr) +Bcx for S epi last week, repeat cx negative, likely contaminant.\n\nPlan/ continue to monitor cvr status, growth/development\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-04-13 00:00:00.000",
"description": "Report",
"row_id": 1695939,
"text": "Neonatology Attending\naddendum: PE\n\nActive sleep, appropriate activity, . AFOF. Lungs cta, heart rrr s murmur, abd soft, extr well perfused.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-04-13 00:00:00.000",
"description": "Report",
"row_id": 1695940,
"text": "0700-1900 NPN\n\n\nRESP: Infant remains in RA, O2 sats=96-100%. RR=30=60's.\nBreath sounds clear and equal bilaterally, no retractions\nnoted. No bradys, no desats so far this shift. Continue to\nto monitor resp status.\n\nFEN: Ad with a minimum of 140cc/kg/d of BM24 with\nenfamil powder/E24, all PO's. Infant has bottled 90cc and\n55cc with good coordination so far this shift. Waking approx\nq4hr for feeds. Abdomen , soft, round, +BS, no loops. No\nspits. Voiding and stooling (guiac negative). Continues on\nIron. Continue to monitor FEN status.\n\n: Mom called this afternoon,, updated on patient's\ncurrent status by this RN. Mom states she will be in later\ntoday. Continue to support family.\n\nG+D: Temps stable, swaddled in . Cobedding with sister.\nActive and with cares, sleeps well in between cares.\nBrings hands to face, sucks on pacifier for comfort.\nContinue to support G+D.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-04-06 00:00:00.000",
"description": "Report",
"row_id": 1695908,
"text": "NPN 1900-0700\n\n\nRESP: Infant remains in RA. O2sat 97-100%. RR 30-50's.\nOccasional mild IC/SC rtx. LS clear and equal. No spells, no\ndesats. Did have some HR and sat drifts when choking with\nfeed or spits.\n\nFEN: wt2200g (up 45g). TFmin 140cc/kg of BM/E24. Yest\nTFI=174cc/kg. Bottling adequate volumes with good\ncoordination. Abdomen soft, +BS, no loops, spits X2,\nvoiding, no stool. On Fe.\n\n: Mom called X1, updated over the phone. Asking about\nrepeat hearing screen. Will be in later today.\n\nG&D: Temps stable, swaddled in open crib. Cobedding with\nsiblings. and active with cares. Occasionally wakes\nfor feeds. Hands to face. Continues with small amt of\nyellow/green right eye drainage, warm soaks done every care.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-04-06 00:00:00.000",
"description": "Report",
"row_id": 1695909,
"text": "Neonatology Attending\n is 33do, 35 wks corrected\nRA, open crib cobedding with sibs\nDay without a/b (last episode at 4am)\nDesat to 85 post feed this am - selfresolved\n\nWt 2200 up 45 on ad lib minTF140 MM/E24 po\n\nMeds Fe\n\nHead u/s this am prelim nl\nPassed hearing screen\n\nImp/ age appropriate cvr/feeding immaturity, approaching readiness for d/c\nPlan/ continue to monitor cvr status, growth/development. D/c planning in progress for as early as Thurs contingent upon further evidence of maturity.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-04-06 00:00:00.000",
"description": "Report",
"row_id": 1695910,
"text": "Neonatology - NNP Progress Note\n\n is active with good tone. AFOF. She is , well perfused, no murmur auscultated. She is comfortable in room air. No spells today. Breath sounds clear and equal. She is tolerating full volume po feeds. Abd soft, active bowel sounds, no loops. Voiding and stooling. Stable temp cobedding with sibs. Head ultrasound today normal. Please refer to neonatology attending note for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-04-06 00:00:00.000",
"description": "Report",
"row_id": 1695911,
"text": "NPN 0700-\n\n\n2. In RA with sats 95-100%. Lungs clear, RR 30-60's. Mild\nSC retractions. One desat to 85% after 0830 feed, QSR. No\nA&B's thus far. Day brady countdown. Cont to monitor\nfor A&B's or desats.\n\n3. Infant on ad lib with min. 140cc/k/d BM24 or E24. Abd\nbenign. Voiding and no stool thus far. Min. Tf intake 51cc\nevery 4hrs and infant able to bottle 65 and 67cc Q4hr well.\nOne small spit thus far. Tolerating all PO's. Cont to\nmonitor ability to take bottles or breast feed.\n\n4. Mother called and updated on plan of care. Mother\nunable to visit today and plans to visit tomorrow at noon.\nSpoke with mother about possible D/C date for Thursday.\nFather is out of town on business in and is trying\nto get home for Thursday. Mother aware that we may be able\nto D/C triplets on Friday if Father is unable to get home by\nThurs. Cont to support, update, and prepare for D/C.\n\n5. Temp stable swaddled in open crib. Infant is cobedding\nwith siblings. and active with cares, resting well\ninbetween. MAE, suckles well on pacifier. Cont to promote\nG&D.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-19 00:00:00.000",
"description": "Report",
"row_id": 1695828,
"text": "PCA 1900-0700\n\n\n2\ninfant remains in RA, RR 20-60, SATing 93-99%, lung sounds\ncl=, sc retractions, no spells. P:cont. to monitor.\n\n3\ninfant's current weight 1580g up 20g, remains on TF min of\n150cc/kg/d of BM/PE 26 with promod=40cc q4h gavaged over 90\nminutes. abd full/soft, bs+, no loops, ag stable 23.5-24.5,\nmax asp. 5.2cc partially digested BM, small spit X1,\nvoiding/stooling qs heme. neg. P:cont. to support\nnutritional needs.\n\n4\nno known contact thus far.\n\n5\ninfant remains swaddled in OAC, temp. stable, and\nquietly active during cares,settles well in between, likes\npacifier, fonts soft/flat. P:cont. to support dev. needs.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-19 00:00:00.000",
"description": "Report",
"row_id": 1695829,
"text": "PCA 1900-0700\n#3 Infant's AG remains stable at 24.5cm, active bowel soundAddendum to above: I have examined this infant and agree wis, soft abdomen, non tender (no guarding), transient soft loth note above, see above correction for additional information. ops noted at 4am, residual at this time 8.2cc. No spits. Discussed with NNP, residual refed, and regualr feeding given. Will Contnue to monitor abdominal exam very closely.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-19 00:00:00.000",
"description": "Report",
"row_id": 1695830,
"text": "PCA 1900-0700\n#3 Infant's AG remains stable at 24.5cm, active bowel soundAddendum to above: I have examined this infant and agree wis, soft abdomen, non tender (no guarding), transient soft loth note above, see above correction for additional information. ops noted at 4am, residual at this time 8.2cc. No spits. Discussed with NNP, residual refed, and regualr feeding given. Will Contnue to monitor abdominal exam very closely.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-19 00:00:00.000",
"description": "Report",
"row_id": 1695831,
"text": "Neonatology Attending Note\nDay 15\nCGA 33\n\nRA. RR20-60s. Cl and = BS. +SC/IC rtxns. On caffeine. No A&Bs. HR 160-180s. No murmur. , well perfused. BP 66/39, 49.\n\nWt 1580, up 20 gms. TF 150 cc/k/day PE/BM26 w promod. PG over 90 minutes. Small spits.\nPassing stool. Nl voiding.\n\nIn open crib.\n\nA/P:\nGrowing preterm infant with resolving , learning how to po feed. Will try smaller feedings at closer intervals to reduce degree of spitting.\n\nImproved , will d/c caffeine which may also improve spitting.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-04-05 00:00:00.000",
"description": "Report",
"row_id": 1695902,
"text": "1900-0700 NPN\n\n\nRESP: Infant remains in RA, O2 sats=95-100%. RR=30-50's.\nBreath sounds clear and equal, no retractions noted. No\nbradys, no desats so far this shift. Continue to monitor\nresp status.\n\n: Mom called this evening, updated on patient's\nstatus by this RN. Mom states she will be in for afternoon\ncares. Continue to support/educate family.\n\nG+D: Temps stable, swaddled in . Cobedding with sister\nand brother. Active and with cares, sleeps well in\nbetween cares. Brings hands to face, sucks on pacifier for\ncomfort. Continue to support G+D.\n\nFEN: Weight tonight=2.155kg (-10grams). Ad lib on demand\nwith a min of 140cc/kg/d of BM24 with enfamil powder/E24.\nInfant has taken all PO's so far this shift. Infant has\nbottled 55cc and 54cc so far this shift with good\ncoordination. Waking q4hr for feeds. Abdomen , soft,\nround, +BS, no loops. Minimal aspirates, no spits. Voiding,\nno stool. Continue to support FEN status.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-18 00:00:00.000",
"description": "Report",
"row_id": 1695823,
"text": "NICU NSG NOTE\n\n\n#2. Resp. O/ RA. LS clear and equal. RR 30-60's. Baseline\nretractions. No spells. A/ Stable. P/ Cont to monitor.\n\n#3. FEN. O/ Wt up 50g. TF 150cc/k/d BM26 with PM. Receiving\nq4h volumes via gavage over 90 mins for hx spits. No spits\nthus far. Abd soft. No loops. +BS. Voiding and stooling. A/\nTolerating feeds. Gaining wt. P/ Cont to monitor for feeding\nintolerances. Daily wts.\n\n#4. Parenting. No contact with family thus far this shift.\n\n#5. G&D. O/ Warm in off isolette. Transitioned to open crib\nwith stable temps. and active for cares. Not waking on\nown for feeds. Nested and swaddled on sheepskin. A/ AGA. P/\nCont to support developmental needs of infant.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-18 00:00:00.000",
"description": "Report",
"row_id": 1695824,
"text": "NICU nursing progress note\n\n\nPlease refer to flowsheet for specific info.\nResp\nO: remains in room air, RR 40-60's occ 70's. Sat's\n>97%, mild sc ret. BSCE bilat. NO brady's, on caffeine. A:\nStable P: cont to follow.\nFEN\nO: TF are 150cc/k/d of PE or BM 26 with promod. Abd , no\nloops, active bs Voiding/ stooling. Feedings are gavaged\nover 90\" due to hx of spits. Min asp. A: Stable. P: cont to\nfollow.\nGD\nO: Temps stable in oac cobedding with trip #3 brother,\nactive and with cares, does not wake for feeds. MAE.\nFonts soft, flat. Brings hands to face. Calms with\ncontainment and pacifier. A: AGA P: cont to support\ndev.milestones.\nParenting\nO: Mom planning on visiting at 12pm, also awaiting transfer\nto Hosp. when beds are avail. for triplets.\nA: and invested with extensive family support\nsystem on mother's side. P: cont to update, support,\neducate. D/C planning is ongoing. Will transfer to when beds are avail.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-04-05 00:00:00.000",
"description": "Report",
"row_id": 1695903,
"text": "Neonatology Attending\n i s 32do, 35 /47 wks\nDay without a/b\nWt 2155 down 10 on ad lib minTF140 MM/E24 -- took 160cc/kg/24hrs\n\nPE active, appropriate, . AFOF. Lungs cta, heart rrr s murmur, abd soft, extr well perfused.\n\nImp/ approaching readiness for d/c\nPlan/ continue to monitor cvr status, growth/development. Tentative d/c Thurs contingent upon further evidence of maturity.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-04-05 00:00:00.000",
"description": "Report",
"row_id": 1695904,
"text": "Nursing NICU Note\n\n\n#2. Respiratory O: Pt. remains in RA, O2 sats >95%. RR\n~30-50's, no increase work of breathing noted. LS clear/=.\nNo A&B's or sat drifts noted this shift thus far. This is\nDay #2 of 5 for a spell count. A: Pt. is stable in RA. P:\n Continue to monitor respiratory status. Monitor for A&B's.\n\n#3. FEN O: Pt. is ad lib Min 140cc/kg/d of BM24 w/Enfamil\npowder or E24 =50cc Q 4hrs. She is takeing all PO feeds\n45-70cc PO in addition to breastfeeding x1. Abdomen is\nsoft, , +BS, no loops/spits noted. A: Pt. is\ntolerating current nutritional plan. P: Continue w/\ncurrent feeding plan. Monitor for s/s of intolerance.\nEncourage PO feeds.\n\n#4. O: Mom in to visit this afternoon and was\nupdated on pt's current status and daily plan of care.\n are active and involved in cares, asking appropriate\nquestions. A: Family is and involved. P: Continue\nto udpate, support and educate. Continue w/ discharge\nteaching/planning.\n\n#5. Grwoth/Development O: Pt. remains in an open crib,\nco-bedding w/ her siblings. She is and active w/\ncares, sleeps well in between. Fontanelle soft/flat. She\nloves to use her pacifier, brings hands to face. A: AGA\nP: Continue to provide environment appropriate for growth\nand development.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-04-05 00:00:00.000",
"description": "Report",
"row_id": 1695905,
"text": "PT\n seen for developmental evaluation. She was positioned in prone and supported sitting positions. She tolerated them well. She is able to clear her airway in prone but is unable to turn her head. Talked to Mom briefly and will meet with her later in week to discuss discharge teaching and developmental play.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-04-06 00:00:00.000",
"description": "Report",
"row_id": 1695906,
"text": "NPN 1900-0700\nInfant passed hearing screen.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-04-06 00:00:00.000",
"description": "Report",
"row_id": 1695907,
"text": "NPN 1900-0700\nInfant passed hearing screen.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-18 00:00:00.000",
"description": "Report",
"row_id": 1695825,
"text": "Neonatology Attending Note\nDay 14\nCGA 36 2\n\nRA. RR50-60s. No A&Bs. No murmur. On caffeine.\n\nWt 1560, up 50 g. TF 150 cc/k/day BM/PE26 w promod. PG over 90 min. Nl voiding and stooling.\nOn Fe and Fe.\n\nIn open crib.\n\nA/P:\nGrowing preterm infant learning how to po feed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-18 00:00:00.000",
"description": "Report",
"row_id": 1695826,
"text": "Clinical Nutrition\nO:\n~33 wk CGA BG on DOL 14.\nWT: 1560g(+50); birth wt: 1345g. Average wt gain over past wk ~23g/kg/day.\nHC: 28.75cm( %ile); last wk: 27.5cm\nLN: 38cm(<10 %ile); last wk: 38cm\nMeds include Fe & Vit.E\nLabs noted.\nNutrition: 150cc/kg/day as PE/BM 26 w/promod, all pg over 90 mins. Average of past 3-day intake ~141cc/kg/day, providing ~122kcal/kg/day & ~3.8-4.1g pro/kg/day.\nGI: Abdomen benign.\n\nA/Goals:\nTolerating feeds w/o GI problems over extended feeding times d/t h/o spits; all pg. Labs noted & within acceptable range. Current feeds & supps meeting recs for kcal/pro/vits/mins. Growth is exceeding recs for WT/HC gains of ~15-20g/kg/day for WT gain & of ~0.5-1cm/wk for HC gain. LN gain is not meeting recs of ~1cm/wk. Will monitor long term trends. Will continue to follow w/ team & participate in nutrition plans.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-18 00:00:00.000",
"description": "Report",
"row_id": 1695827,
"text": "Fellow note; physical exam\n and active in open crib. Breathing comfortably in RA. SKin . AFOF. Lungs clear. No murmur. Abd soft, ND, +BS. Extrem WWP. Good tone.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-04-04 00:00:00.000",
"description": "Report",
"row_id": 1695899,
"text": "1900-0700 NPN\n\n\nRESP: Infant remains in RA, O2 sats=96-100%. RR=30-50's.\nBreath sounds clear and equal, occasional mild SCR noted. No\nbradys, no desats so far this shift. Continue to monitor\nresp status.\n\nFEN: Weight tonight=2.165kg (+30 grams). TF=150cc/kg/d of\nBM26/PE26 alternating PO/PG q4hr. Infant bottled 35cc at\n0000 with good coordination but does tire easily. Abdomen\n, soft, round, +BS, no loops. Minimal aspirates, small\nspit x 1 so far this shift. Voiding/no stool. Continue to\nmonitor FEN status.\n\n: Mom called this evening, updated on patient's\ncurrent status by this RN. Mom states she will be in\ntomorrow for the afternoon care. Continue to support/educate\nfamily.\n\nG+D: Temps stable, swaddled in . Cobedding with sister\nand brother. Active and with cares, sleeps well in\nbetween cares. Brings hands to face, sucks on pacifier for\ncomfort. MAE. Continue to support G+D.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-04-04 00:00:00.000",
"description": "Report",
"row_id": 1695900,
"text": "Newborn Med Attending\n\nDOL#31. Cont in RA, no spells. AF flat, clear BS, no murmur, abd soft, MAE. WT=2165 up 30, on 150 cc/kg/d BM26 PO/PG.\nA/P: Growing infant working up on PO feeds.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-04-04 00:00:00.000",
"description": "Report",
"row_id": 1695901,
"text": "Nursing NICU Note\n\n\n#2. Respiratory O: Pt. remains in RA, O2 sats >96%. RR\n~40-70's, no increase work of breathing noted. LS clear/=.\nNo A&B's noted this shift thus far. A: Pt. is stable in\nRA. P: Continue to monitor respiratory status. Monitor\nfor A&B's.\n\n#3. FEN O: Pt. is now ad lib Min 140cc/kg/d of BM24\nw/Enfamil powder or E24 =51cc Q 4hrs. She has taken all PO\nfeeds this shift thus far ~48-54cc PO Q feed. Pt. requires\nfrequent burping. Abdomen is soft, , +BS, no\nloops/spits noted. She is voiding/ no stool noted this\nshift thus far. A: Pt. is tolerating current nutritional\nplan. P: Continue w/ current feeding plan. Monitor for s/s\nof intolerance. Continue to encourage PO feeds as pt. looks\ninterested and tolerates.\n\n#4. O: Mom called this am and was updated on pt's\ncurrent status and daily plan of care. are active\nand involved in cares. A: Family is and involved.\nP: Continue to update, support and educate. Continue w/\ndischarge teaching/planning.\n\n#5. Growth/Development O: Pt. remains in an open crib,\nswaddled and co-bedding w/ siblings. Temps stable. She is\n and active w/ cares, sleeps well in between.\nFontanelle soft/flat. She loves to use her pacifier, brings\nhands to face. A: AGA P: Continue to provide environment\nappropriate for growth and development.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-25 00:00:00.000",
"description": "Report",
"row_id": 1695856,
"text": "npn 1900-0700\n\n\n\n2: resp\nremains in ra. no spells. no dsats. RR 30-50's. Lung sounds\nclear and equal. mild subcostal retractions. no increased\nwob noted. continue to monitor for changes in resp status.\n\n3: fen\ncurrent weight 1790gms up 20gms. total fluids remain at\n150cc/kilo/day of pe 26. tolerating feeds well. no spits\nthus far this shift. minimal aspirates. abd soft with no\nloops. stable girths. voiding, stooled x's 1 hem negative.\ncontinues on vit e and iron. hob elevated for spiting.\n\n4: \nmom called this shift x's 1. updated by this rn. very \nand involved. asking appropriate questions. continue to\nsupport family needs.\n\n\n5: G/D\ntemps stable in an open crib. co-bedded with sibblings.\n and active with cares. sleeps well inbetween.\nsucks vigorously on pacifier. brings hands to face. continue\nto monitor for developmental milestones.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-17 00:00:00.000",
"description": "Report",
"row_id": 1695820,
"text": "NPN 1900-0700\n\n\n2.Resp: Infant remains in room air with RRs 20s-50s, 02\nsats> 98%. Lung sounds are clear and equal with mild\nsubcostal retractions. She remains on caffeine, no spells\nthus far this shift. Continue to monitor respiratory status.\n\n3.FEN: Infant's weight tonight 1510g (up 60g). She remains\non TF 150cc/kg/day of PE/BM 26cal/oz with Promod via NGT\nover 1 hr 30 minutes. Infant is tolerating feeds well with\none small spit, max aspirate 2.4cc of non-bilious, partially\ndigested formula. Abdomen is soft and round with active\nbowel sounds, no loops. Abdominal girth consistent 22-23cm.\nShe is voiding, one trace stool thus far this shift.\nRemains on vitamin E and Fe+ dietary supplements. Vitamin E\ngiven this shift. Continue to monitor FEN status and weight\ngain.\n\n4.: Dad in to visit this evening, updated at bedside.\n He participated in the care of this infant and then held\nfor one hour. Dad is and appropriate, asking\nappropriate questions. Mother is planning to visit\ntomorrow, will call to confirm. Possible transfer to . Transfer paperwork on front of chart.\n need to sign consent for transfer. Continue to\nsupport and keep informed.\n\n5.DEV: Infant remains in an off isolette with stable temps.\nShe is swaddled with head of bed at 45 degrees. She is \nand active with cares, irritable at times. She brings hands\nto face and sucks vigorously on pacifier. Mom wants to\nbathe tomorrow. Continue to support growth and development.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-17 00:00:00.000",
"description": "Report",
"row_id": 1695821,
"text": "Neonatology Attending Note\nDay 13\nCGA 32 5\n\nRA. RR20-50s. Cl and =. Mild sc retractions. >96% sats. On caffeine. No A&Bs. No murmur. HR 140-160s. BP 57/39, 44.\n\nWt 1510, up 60 gms. TF 150 cc/k/day BM/PE26 w promod. PG over 1.5 hrs. Tol well. Nl voiding and stooling, g-.\n\nOn Vit E and Fe.\n\nIn off warmer.\n\nA/P:\nGrowing preterm infant.\n- monitor AOP\n- cont to monitor growth on current nutrition\n- awaiting bed availability at Hospital\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-17 00:00:00.000",
"description": "Report",
"row_id": 1695822,
"text": "Nursing NICU Note\n\n\n#2. Respiratory O: Pt. remains in RA, O2 sats ~ 97-99%.\nRR ~50-60's. No increase work of breathing noted. LS\nclear/=. She has mild SC retractions noted. No A&B's noted\nthis shift thus far. A: Pt. is stable in RA. P: Continue\nto monitor respiratory status. Monitor for A&B's.\n\n#3. FEN O: TF 150cc/kg/d of BM26 w/PM or PE26w/PM =38cc Q\n4hrs, gavaged over 1hr 30min, tolerated well. Abdomen is\nsoft, , +BS, no loops/spits noted. Abdominal girth is\n22.5-23cm. She is voiding/ passed tiny amount of stool x1.\nA: Pt. is tolerateing current nutritioanl plan. P:\nContinue w/ current feeding plan. Monitor for s/s of\nintolerance.\n\n#4. O: Mom and grandmom in to visit for 1200\ncares. They were updated at bedside on pt's current status\nand daily plan of care. Mom is actively participateing in\ncares, asking appropriate questions. A: Family is \nand involved. P: Continue to update, support and educate.\n\n#5. Growth/Development O: Pt. remains in an off Isolette,\nswaddled w/ stable temps. She is and active w/ cares,\nsleeps well in between. Fontanelle soft/flat. She uses her\npacifier on occasion, brings hands to face. A: AGA P:\nContinue to provide environment appropriate for growth and\ndevelopment. Plan to transition infant into crib later\ntoday.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-25 00:00:00.000",
"description": "Report",
"row_id": 1695857,
"text": "Clinical Nutrition\nO:\n~34 wk CGA BG on DOL 21\nWT: 1790 g (+20)(~25th %ile); birth wt: 1345 g. Average wt gain over past wk ~18 g/kg/day.\nHC: 30 cm (~25th %ile); last: 28.75 cm\nLN: 41.5 cm (~10th to 25th %ile); last: 38 cm\nMeds include Fea dn Vit E\n not due yet\nNutrition: 150 cc/kg/day PE 26 (no BM for now due to mom dumping since she is on medication). Average of past 3 day intake ~150 cc/kg/day, providing ~130 kcal/kg/day and ~3.6 g pro/kg/day.\nGI: Abdomen benign.\n\nA/Goals:\nTolerating feeds without GI problems. not due. Current feeds + supps meeting recs for kcals/pro/vits and mins. Growth is meeting recs for wt gain. HC and LN gain are exceeding recommended ~0.5 to 1 cm/wk for HC gain and ~1 cm /wk for LN gain. Will follow long term trends. Will continue to follow w/ team and participate in nutrition plans.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-25 00:00:00.000",
"description": "Report",
"row_id": 1695858,
"text": "Neonatology-NNP Physical Exam\n\n remains in RA. Active, in an open crib, AFOF, sutures opposed, good tone. BBS clear and equal with good air entry. No murmur, pulses +2, , RRR. Abdomen soft, non-distended, tolerating feeds. Please refer to attending progress note for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-25 00:00:00.000",
"description": "Report",
"row_id": 1695859,
"text": "Neonatology Attending\n21do, 33 wks corrected.\n remains in RA, open crib cobedding with sibs.\nNo a/b.\nWt up 20g to 1790 on TF150 PE26 pg\n\nMeds vit E, Fe\n\nImp/ age-appropriate feeding immaturity; growing well.\nPlan/ continue to monitor cvr status, growth & development.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-25 00:00:00.000",
"description": "Report",
"row_id": 1695860,
"text": "2. remains in RA, RR30-60, mild sc retractions, sats\n90-99, BBSclear, equal, one brief self-resolving brady P:\ncontinue to monitor.\n3. TF 150cc/k/d PE26 45cc pg over 80 min, abd soft, no\nloops, active bowel sounds, minimal aspirates, no spits,\nvoiding, no stool.\n4. Mom here at 1300, held babies, planning to bring in\nbreast milk tommorrow A: very involved and concerned P:\ncontinue to update and offer support.\n5. temp stable swaddled in open crib with siblings, active\nwith cares, soon to try po feedings P: continue to support\ngrowth and development.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-04-10 00:00:00.000",
"description": "Report",
"row_id": 1695925,
"text": "Nursing progress note\n\n\n #2 O: Remains in room air with equal & clear breath sounds\n& no retractions. No A's, B's or desats noted. A: Stable. P:\nCont to assess.\n#3 O: Wgt up 65 gms. Waking for feeds & feeding well with\nyel nipple. Voidng with diaper changes. No stool. Abd soft\nwith active bowel sounds & no loops. No spits. A: Tolerating\nfeeds & gaining wgt. P: Cont to assess.\n#5 O: Temp stable, co-beeding with twin. Waking for feeds &\nbottling well. with cares. A: AGA. P: Cont to assess.\n#8 O: Temp stable. with cares. No spells. A: No signs\nof sepsis. P: Cont to assess.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-04-03 00:00:00.000",
"description": "Report",
"row_id": 1695897,
"text": "NICU Attending Note\n\nDOL # 30 = 35 1/7 weeks CGA with resolving A/B learning to PO feed.\n\nAll interval hx and data reviewed, patient examined, care discussed.\n\nCVR/RESP: RRR without murmur, and well perfused, no increaased WOB, BS clear/=, remains in RA, occasional O2 drifts with bottles, day of spell countdown. Will continue to monitor.\n\nFEN: Abd benign, NTND, no HSM. Weight 2135 gm, up 60 gm on 150 cc/kg/d MM/PE 26, PO/PG. Will continue to encourage PO intake.\n\nNEURO: AFSOF, appropriate tone and strength, active and .\nHead U/S Tuesday.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-04-03 00:00:00.000",
"description": "Report",
"row_id": 1695898,
"text": "Nursing NICU Note\n\n\n#2. Respiratory O: Pt. remains in RA, O2 sats ~91-100%.\nLS clear/=. RR ~30-60's, no increase work of breathing\nnoted. She has occasional sat drifts w/ feeds that self\nresolve. No A&B's noted this shift thus far. This is Day\n#1 of 5 day spell count. A: Pt. is stable in RA. P:\nContinue to monitor respiratory status. Monitor for A&B's.\n\n#3. FEN O: TF 150cc/kg/d of BM26/PE26 =53cc Q 4hrs\nalternateing PO/PG feeds. She has taken 50cc and 35cc w/\nthe remainder gavaged. Pt. tireing out easily by the end of\nher last feed. Abdomen is soft, , +BS, no loops/spits\nnoted. She is voiding/ sm. stool passed x1. A: Pt. is\ntolerating current nutritional plan. P: Continue w/\ncurrent feeding plan. Montor for s/s of intolerance.\nContinue to encourage PO feeds as pt. looks interested and\ntolerates.\n\n#4. O: Mom in to visit for afternoon cares. She\nwas updated at bedside on pt's current status and daily plan\nof care. are active and involved in cares, asking\nappropriate questions. A: Family is and involved.\nP: Continue to update, support and educate. Continue w/\ndischarge teaching.\n\n#5. Growth/Development O: Pt. remains in an open crib,\nswaddled and co-bedding w/ her siblings. Temps stable. She\nis and active w/ cares, sleeps well in between.\nFontanelle soft/flat. She loves to use her pacifier, brings\nhands to face. A: AGA P: Continue to provide environment\nappropriate for growth and development.\n\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-04-10 00:00:00.000",
"description": "Report",
"row_id": 1695926,
"text": "Neonatology Attending Progress Note:\n\nDOL #37, CGA 36 1/7 weeks\nRA, RR=30-60's, one brady yesterday with feeds (Day #1 of 5)\nHR=150-160's\nsepsis eval this week for decreased temp, blood culture #1 GPC pairs/chains and repeat blood culture off antibiotics negative\n2310g (inc 65g), ad lib min 140cc/kg/d (taking 161 in past 24 hours)\nvoiding, stooling\nco-bedding\n\nPE: well appearing, AFOF, normal S1S2, no murmur, breath sounds clear, abdomen soft, nontender, nondistended, ext warm, well perfused. tone aga.\n\nImp/Plan: premie twin with and positive blood culture probable contaminant.\n--monitor for spells\n--check second blood culture, if change in symptoms or positive blood culture, will have low threshold for starting antibiotics.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-04-10 00:00:00.000",
"description": "Report",
"row_id": 1695927,
"text": "8 Infant with Potential Sepsis\n\nNursing PRogress Note:\n#2 - RESP: REmains in room air. Lungs clear and equal. RR\n30-50. O2Sat > 93%. No spells/desats today. Not being fed\non monitor. Day brady count.\n\n#3 - F&N: Ad lib demand feeder with min of 140cc/kilo =\n54cc's q 4 hours. Bottling between 65-80cc's of E24/BM24.\nOccassionally small spits or wet burps noted. Abdomin soft\nand round. Voiding good amount. Stooling with each diaper\nchange. Iron given.\n\n#4 - : Mom in this afternoon. Updated at the bedside.\nIndependent with cares. Holding and feeding babies.\nEncouraged to get help set up for when the babies are all\nhome. Mom states that plenty of people in the community\noffered to help when needed. All ready setting up dinners\nfor the family for the next 2 months.\n\n#5 - G&D: Temps stable in open crib. Co-bedding with\nsibling. and active with cares. MAE> AFSF. Bottling\nall feeds. Hx of normal head US.\n\n#8 - Potential sepsis: 2nd blood culture neg. Believe first\npositive culture to be a contaminent. Problem resolved.\n\n\nREVISIONS TO PATHWAY:\n\n 8 Infant with Potential Sepsis; resolved\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-04-11 00:00:00.000",
"description": "Report",
"row_id": 1695928,
"text": "NPN 2300-0700\n\n\n2. O: Infant remains in room air. O2 sats 98-100%. RR\n40-50's. No A&B's thus far. Last A&B . A: brady\ncountdown continues.P: Continue to assess.\n\n3. O: Wt.+30g 2340g. Yesterday received 156cc/kg/d. Infant\nbottling 75cc every 4-5 hours. Abdomen soft. +b.s. No loops\nnoted. No spits noted. Wet burps noted. vdg & stooling q.s.\nA; Bottling well. P: Continue to assess weight gain.\n\n4. O : No parental contact noted thus far.\n\n5. O: co-bedding with sister. Maintaining temperature.\nMAE. Brings hands to face. Active & . Waking for feeds.\nNested with boundaries. A: AGA P: Continue to support\ndevelopment.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-15 00:00:00.000",
"description": "Report",
"row_id": 1695815,
"text": "NPNOte;\n\n\n#2. Remains in R air, BBS clear, equal, easy resp effort, no\nspells thus far this shift. On Caffine given as ordered.A;\nNo spells thus far this shift. P; cont to monitor.\n\n#3. TF=150cc/kg/day,MBM26/PE26 with promod, pg fed over 1hr\n30mts, no spits, BS+, no loops, voided, no stool thus far\nthis shift. A; Feeds tolerated. P; cont current feeding\nplan.\n\n#5.,active with care, temp stable in a air mode\nisolette, swaddled with blanket, mae. A; AGA P; cont dev\nsupport.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-16 00:00:00.000",
"description": "Report",
"row_id": 1695816,
"text": "PCA 1900-0700\n\n\n2\ninfant remains in RA, RR 30-50, lung sounds cl=, sc\nretractions, no spells, P:cont. to monitor.\n\n3\ninfant's CW 1450g up 70g, remains on TF min. 150cc/kg/d of\nPE/BM 26 with promod=36cc q4h gavaged over 90 minutes. abd\nsoft, bs+, no loops, ag stable 22.5-23.5 cm, min. asp.,\nsmall spit X1, voiding stooling qs heme. neg. P:cont. to\nsupport nutritional needs.\n\n4\nno known contact thus far.\n\n5\ninfant remains swaddled in air isolette, temp. stable, a/a\nwith cares, settles well in between, fonts soft/flat, brings\nhands to mouth. P:cont. to support dev needs\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-16 00:00:00.000",
"description": "Report",
"row_id": 1695817,
"text": "Addendum NPN\nI have examined this infant and agree with the above written statement by , PCA.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-16 00:00:00.000",
"description": "Report",
"row_id": 1695818,
"text": "Neonatology note\n12 d.o\nin , caffeine, no spells.\nAFOF\nRR with no mumrur\nclear lungs\nwt= 1450 gm +70, 150 cc/klg/d with EBM 26 + promod.\nabdomen osft\nnormal tone\nmild jaundice.\nA: ex 30 wks GA, AOP, growing preemie.\nP: continue current management.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-24 00:00:00.000",
"description": "Report",
"row_id": 1695850,
"text": "npn 1900-0700\n\n\n2: resp\nremains in ra. one spell thus far this shift. see flow\nsheet. rr 40-70's. sats >93%. Lung sounds clear and equal.\nmild subcostal retractions. no increased wob noted. continue\nto monitor for changes in resp status.\n\n3: fen\ncurrent weight 1770gms up 40gms. total fluids remain at\n150cc/kilo/day of PE 26. tolerating feeds well. no spits\nthus far. minimal aspirates. voiding and stooling. stable\ngirths. abd soft with no loops. feeds run over 1hr 15min for\nhx of spits.\n\n4: \nno contact thus far this shift.\n\n5: g/d\ntemps stable in an open crib. and active with cares.\nsleeps well inbetween. co-bedded with sibblings. brings\nhands to face. aga. continue to monitor for developmental\nmilestones.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-24 00:00:00.000",
"description": "Report",
"row_id": 1695851,
"text": "Neonatology\nRA. Comfortable. SIngle spell over night. Off caffeine.\n\nWt 1760 up 40. TF at 150 cc/k/d of 26 cal. Abdomen benign. STill requiring gavage. Extended infusion time for spits. Abdomen benign.\n\nLeg slightly swollen last night, b ut this am looks normal to exam. No swelling or tenderness. Hips normal.\n\nDiaper rash improved. Will dc local rx.\n\nAwaiuting maturation of resp control and feeds.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-24 00:00:00.000",
"description": "Report",
"row_id": 1695852,
"text": "Neonatology-NNP Physical Exam\nNo edema in lower extremities.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-24 00:00:00.000",
"description": "Report",
"row_id": 1695853,
"text": "Neonatology-NNP Physical Exam\n\n remains in RA. Active, in an open crib, AFOF, sutures opposed, good tone, nevus simplex on left eyelid. BBS clear and equal with good air entry. No murmur, pulses +2, , RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds. Please refer to attending progress note for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-24 00:00:00.000",
"description": "Report",
"row_id": 1695854,
"text": "NICU nursing progress note\n\n\nPLease refer to flowsheet for specific info.\nResp\nO: remains in room air, RR 20-50's, sat's 94%. BSCE\nbilat. NO brady's. Off of caffeine. A: Stable. P: cont to\nfollow.\nFEN\nO: Tf of 150cc/k/d of PE 26 gavaged over 80\" due to hx of\nspits. No spits. Min asp. Abd soft, , no loops, active\nbs. Voiding/ no stool thus far today. HOB ^15 degrees due to\nhx of spits and placed prone. A: Stable. P: Infant HOB\n^15degrees and place prone to prevent spits. Follow.\nGD\nO: Temp stable in oac, co-bedding with siblings, active and\n with cares. MaE. Fonts, soft, flat. Calms with\ncontainment and pacifier. Left eye with elevated and\npossibly ^ vascularization making more . Cont to follow.\nA: AGA P: cont to follow.\nParenting\nMom is pumping and discarding bm due to cytotec med. Please\nrefer to Trip 32 note.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-24 00:00:00.000",
"description": "Report",
"row_id": 1695855,
"text": "NICU nursing progress note\n referred to is #2.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-16 00:00:00.000",
"description": "Report",
"row_id": 1695819,
"text": "NICU nursing progress note\n\n\nPLease refer to flowsheet for specific info.\nResp\nO: remains in room air, rr 30-50's, sat's >97%. Mild\nsc ret. BSCE bilat. On caffeine, no brady's. A: Stable. P:\ncont to follow.\nFEN\nO: TF of 150cc/k/d of PE or BM 26 w/ promod, gavaged over\n90\". No spits. Max asp of 3cc partially digested formula.\nAbd , no loops, active bs. Voiding/ stooling. Girth\nstable at 22cm. A: stable. P: cont to follow.\nGD\nO: Temp stable in off isolette. Active and with cares.\nMAE. Fonts soft, flat. A: AGA P: cont to support dev.\nmilestones.\nParenting\nO: Mom in and updated at bedside, verbalizing understanding.\n Agreeable to transfer to SCN\nwhen beds are available. A: Mom and dad are and\ninvested with large network of family support on\nmom's side. P: cont to update, support, educate.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-04-02 00:00:00.000",
"description": "Report",
"row_id": 1695891,
"text": "Nursing\n\n\n#2O: In room air with o2 sats> 94% with occ. rare desat;\nhad 1 spell with apnea and desat, self-resolved. Br. sounds\nclear with mild retractions.\n#3O: Wt. up 40g on 150cc/kg, BM26, q 4 hr. feeds. Belly\nsoft, voids qs, 1 stool. Bottled 1 feed well, 1 feed fair,\nand gav. x 1. Minimal asp. and no spits.\n#4O: Mom visited and is independent with cares. Handles\nwell and competently.\n#5O: Co-bedding with siblings. Active with cares, likes\nbeing swaddled.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-04-02 00:00:00.000",
"description": "Report",
"row_id": 1695892,
"text": "Neonatology Attending\n is 29do, 35 wks corrected\nRA, open crib cobedding with sibs\nHas had one spont a/b episode with stim (1hr after eating); one feed-associated\nWt 2075 up 40 on TF150MM/PE24 pg/po (getting close to 50% po)\nMeds Fe, vit E\n\nImp/ age-appropriate feeding & cvr immaturity.\nPlan/ continue to monitor cvr status, growth/development. Will need at least 5 days more for \"apnea countdown\".\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-04-02 00:00:00.000",
"description": "Report",
"row_id": 1695893,
"text": "Neonatology Attending\nAddendum: PE\nActive, appropriate, . AFOF. Lungs cta, heart rrr s murmur, abd soft, extr well-perfused.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-04-02 00:00:00.000",
"description": "Report",
"row_id": 1695894,
"text": "NPN\n\n\n2. Infant in RA on O2sat and CVR monitor. VSS as charted on\nflow sheet. and well perfused. BBS cl and equal. No\nmurmur. Brady x1 with HR 66/ O2sat 72% requiring mild stim.\nStable in RA. Cont to have occ apnea/bradycardia.\nCont to monitor.\n3.TF 150cc/kg/day. MBM26/PE26 Alt po/pg. Attempted po at\n1200 and required supplemental pg to meet min. requirement.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-04-02 00:00:00.000",
"description": "Report",
"row_id": 1695895,
"text": "NPN continued\n\n\n3. ABd benign. Soft no loops. Voiding and stooling.\nInfant attempting to advance on po feeds. Still requiring\npg.\nCont to attempt po as tol. PG as necessary.\n4. in for 1200 feeding. Held infant comfortably and\noffered po feeding. Discussed discharge criteria and plan\nfor support when infants go home. will be in \nfrom Mon through Friday next week. Mat grandmother plans to\nbe with mom.\nIntact involved family. Cont to support.\n5. In open crib cobedding with siblings. Temp stable. Sucks\nvigorously on pacifier. Settles with swaddling and\nboundries.\nCont to promote optimal growth and development.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-04-09 00:00:00.000",
"description": "Report",
"row_id": 1695921,
"text": "1900-0700 NPN\n\n\nRESP: Infant remains in RA, O2 sats=97-100%. RR=30-50's.\nBreath sounds clear and equal bilaterally, no retractions\nnoted. Brady x2 with feeds so far this shift (see flowsheet\nfor details). Continue to monitor resp status.\n\nFEN: Weight=2.245 (-5 grams). Ad lib with a min of\n140cc/kg/d of BM24 with enfamil powder/E24/ all PO's. Infant\nhas bottled 56cc and 60cc with fair coordination so far this\nshift (brady x2 with feeds, see flowsheet). Waking approx\nq4-4.5hrs for feeds. Abdomen , soft, round, +BS, no\nloops. No spits. Voiding and stooling (guiac negative).\nContinue to monitor FEN status.\n\n: Mom called this evening, updated on patient's\ncurrent status by this RN. Mom states she does not want to\ntransfer girls to at this time. Cont to support\nfamily.\n\nG+D: Temps 97.8-98.0. Infant swaddled in , cobedding with\nsister. Active and with cares, sleeps well in between\ncares. Brings hands to face, sucks on pacifier for comfort.\nMAE. Continue to support G+D.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-04-09 00:00:00.000",
"description": "Report",
"row_id": 1695922,
"text": "Neonatology NP Exam Note\nPlease refer to attending note for deatils of evalaution and plan.\n\nPE: small infant cobedding in open crib. and well perfused, and active.\nAFOF, eyes clear, MMMP\nChest clear and equal.\nCV: RRR, no murmru, pulses+2=.\nAbd: soft, active BS, NTND\nGU: normal external female genitalia\nExt: MEA, WWP\nNeuro: symmetric tone and reflexes\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-04-09 00:00:00.000",
"description": "Report",
"row_id": 1695923,
"text": "Neonatology Attending\n is 36do, 36wks corrected\nRA, open crib cobedding with \n without spont a/b; 3 bradycardic episodes with bottling overnight\nWt 2245 down 5 on minTF140 MM/E24 po -- taking well over minimum\n\nImp/ age-appropriate cvr/feeding immaturity\nPlan/ continue to monitor cvr status, growth/development; d/c planning in progress contingent upon further evidence of maturity.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-04-09 00:00:00.000",
"description": "Report",
"row_id": 1695924,
"text": "NPN 0700-1900\n\n8 Infant with Potential Sepsis\n\n#2Resp: Pt. remains on RA, RR 30-50's, sats > 96%. No\nretractions. Lungs clear bilaterally. No spells so far\nthis shift. Pt. is on day#2 of a 5 day spell count. P:\ncontinue to monitor resp status.\n\n#3FEN: Pt remains adlib w/ min 140cc/kg/day of BM 24cal/oz\nor E 24cal/oz. Pt. is taking 55-60cc po Q 4hrs. Abd soft &\nround, +BS, no loops. Spit X 1. Pt. voiding. No stool so\nfar this shift. D/S 88. P: continue to monitor FEN.\n\n#4Parenting: called this am. Updated r/t positive\nbld cx from . asking questions. P:\ncontinue to support & update.\n\n#5G&D: Temps stable swaddled cobedding w/ sister. Awake &\n for cares. Wakes quietly for feeds. MAE's .\nLikes pacifier. P: continue to support dev needs.\n\n#8Pot. sepsis: Pt. had positive bld cx from . NNP\nnotified. CBC & bld cx drawn NNP. No abx started @\nthis time. P: continue to monitor.\nSee flowsheet for further details.\n\n\n\nREVISIONS TO PATHWAY:\n\n 8 Infant with Potential Sepsis; added\n Start date: \n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-14 00:00:00.000",
"description": "Report",
"row_id": 1695809,
"text": "NPN:\n\nRESP: Sats 95-100% in RA. RR=40-70 w/SC retraction. BBS =/clear. No A&Bs thus far tonight; x 1 over past 24 h. Remains on Caffeine.\n\nCV: No murmur. HR=130-150s. BP=65/54 (59). Color w/jaundice. Perfusion good.\n\nFEN: Wt=1370g (+ 10g). TF=150c/kg/d; 34cc BM/PE-24 q 4 h via NG over 70 min. Tolertating fdgs well w/o spits; minimal residuals. Abd benign. Voiding qs; sm stool. Vit E and FeS04 to begin today.\n\nG&D: CGA=32 wk. Temp stable in air-controlled isolette. Active and w/cares. Nested in sheepskin and resting well. AF soft, flat. HUS planned for .\n\nSOCIAL: No contact w/. Possible transfer to w/i near future; live in Canterbury, NH.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-04-03 00:00:00.000",
"description": "Report",
"row_id": 1695896,
"text": "NPN 1900-0700\n\n\n #1 RESP S/O: Infant in RA, rr 40-70's. Lungs are clear with\nno retractions. O2 sats >95% with some drifting with\nbottling into the high 80's. No spells. A: Stable P:\nContinue to support.\n\n#2 FEN S/O: TF 150cc/k/d. Infant to get bm or pe 26, 53cc\nq4h po/pg. Infant bottled 60cc x1 so far this shift. Abdomen\nis benign, voiding. Desitin applied to bottom. No asp, one\nsmall spit. A: Tolerating feeds. P: Continue to support.\n\n#4 Parenting S/O: No contact.\n\n#5 DEV S/O: Infant cobedding with siblings in . and\nactive. Waking for cares. Clear eye drainage both eyes, warm\nsoaks. A: AGA P: Continue to support dev.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-14 00:00:00.000",
"description": "Report",
"row_id": 1695810,
"text": "Neonatology Attending\n\nDOL 10 CGA 32 2/7 weeks\n\nStable in RA. 1 A/B. On caffeine.\n\nBP 65/54 mean 59\n\nOn 150 cc/kg/d BM/PE 24 pg over 1 hr 10 min. Voiding. Stooling. Wt 1370 grams (up 10).\n\n visiting and up to date.\n\nA: Doing well. Spells controlled on caffeine. Tolerating feeds.\n\nP: Monitor\n Advance to 26 cal\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-14 00:00:00.000",
"description": "Report",
"row_id": 1695811,
"text": "Neonatology Attending\nExam AF soft, flat, clear bs, no murmur, benign abd, and comfortable in RA, active and responsive to exam\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-14 00:00:00.000",
"description": "Report",
"row_id": 1695812,
"text": "Nursing Progress Note\n\n\n2. Resp O/A Rec'd inf in RA. Inf remains in RA. 1X\nspell thus far, see flowsheet. Mild SCR noted. Inf\ncontinues on caffeine. P cont to assess resp needs.\n3. FEN O/A TF=150cc/kg/day. Cal increased today to BM or\nPE26. All feedings PG over 1 hr 10 min. Tol feedings well,\nmin asp, sm spit thus far. Belly soft, no loops. Girth\nstable. Inf voiding, stooling guiac neg. P cont to assess\nFEN needs.\n4. O/A Mom in for visit and cares. Held all 3\ntriplets. Mom independent with temp taking, diapering\ninfants. Dad in for visit. Updates to both paretns. P\ncont to support, educate. ? transfer to .\n5. DEV O/A is in an off isolette with stable temp.\nA/A w/cares. Sleeping well between cares. P cont to assess\ndev needs.\nSee flowsheet for further details.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-15 00:00:00.000",
"description": "Report",
"row_id": 1695813,
"text": "NURSING PROGRESS NOTE\n\nRESP/CV: REMAINS IN RA WITH 02 SATS >94%. BS CL&=, NO MURMER. COLOR AND WELL PERFUSED. BP STABLE. NO A&B'S OR DESATS NOTED THIS SHIFT. REMAINS ON CAFFEINE.\n\nFEN: WEIGHT UP 10GMS TO 1380GMS. TOTAL FLUIDS REMAIN AT 150CC/KG/D OF PE26CAL. ABD SOFT, WITH STABLE GIRTH AND +BS. VOIDING AND STOOLING WNL. NO SIGNIFICANT RESIDUALS AND OCCAS EMESIS NOTED.\n\nDEV: TEMP STABLE IN HEATED ISOLETTE. ACTIVE AN WITH INTERVENTIONS.\n\nSOCIAL: MOM X 1, WILL VISIT IN AM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-15 00:00:00.000",
"description": "Report",
"row_id": 1695814,
"text": "Neonatology note\n11 d.o\nin RA, 1 spells, on caffeine\nRR with no murmur\nclear lungs\nabdomen soft\nwt= 1380 gm +10, 150 cc/kg/d with PE 26\nAFOF\nnormal tone\nA: ex 30 wks GA, AOP, growing preemie\nP: consider transfering to if acceptable to , add promod.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-04-01 00:00:00.000",
"description": "Report",
"row_id": 1695886,
"text": "1900-0700 NPN\n\n\nRESP: Infant remains in RA, O2 sats=97-100%. RR=40-60's.\nBreath sounds clear and equal bilaterally, mild SCR noted.\nNo bradys, no desats so far this shift. Continue to monitor\nresp status.\n\nFEN: Weight tonight=2.035kg (+45 grams). TF=150cc/kg/d of\nPE26/BM26 PO/PG q4hr. Attempting to bottle feed infant\nqshift. Infant bottled 50cc at with good coordination.\nGavage feedings given over 1hr/tolerated well. Abdomen ,\nsoft, round, +BS, no loops. No spits, no aspirates.\nVoiding/no stool. Continue to monitor fen status.\n\n: No contact with so far this shift.\n\nG+D: Temps stable, swaddled in . Cobedding with sister\nand brother. Active and with cares, sleeps well in\nbetween. Brings hands to face, sucks on pacifier for\ncomfort. MAE. Hepatitis B vaccine given (see\nflowsheet/patient's chart for details). Continue to support\nG+D.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-04-01 00:00:00.000",
"description": "Report",
"row_id": 1695887,
"text": "Clinical Nutrition\nO:\n~35 wk CGA BG on DOL 28\nWt: 2035 g (+45)(~25th to 50th %ile); birthwt: 1345 g. Average wt gain over past wk ~17 g/kg/day.\nHC: 30 cm (~10th to 25th %ile); last: 30 cm\nLN: 42.5 cm (~10th to 25th %ile); last: 41.5 cm\nMeds include Fe and Vit E\n noted\nNutrition: 150 cc/kg/day BM/PE 26, po/pg. Infant po feeds ~1x per shift, takes ~ volume po. Average of past 3 day intake ~150 cc/kg/day, providing ~130 kcal/kg/day and ~3.2 to 3.6 g pro/kg/day.\nGI: Abdomen benign.\n\nA/Goals:\nTolerating feeds without GI problems. noted and within acceptable range. Current feeds + supps meeting recs for kcals/pro/vits and mins. Growth is meeting recs for wt gain and LN gain. HC shows no change over past wk; will follow long term trends. Will continue to follow w/ team and participate in nutrition plans.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-04-01 00:00:00.000",
"description": "Report",
"row_id": 1695888,
"text": "Neonatology Attending\n is 28do, 34 wks corrected.\nRA, open crib cobedding with sibs\nNo a/b; occ desat with feeds\nWt 2035 up 45 on TF150 MM/PE24 pg>po - did take full bottle this am!\n\nMeds Fe, vit E\nGot HBV this am\n\nImp/ age-appropriate cvr/feeding immaturity; making good progress.\nPlan/ continue to monitor cvr status, growth/development. D/C planning in progress contingent upon further evidence of maturity.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-04-01 00:00:00.000",
"description": "Report",
"row_id": 1695889,
"text": "Neonatology Attending\nAddendum: PE\nActive sleep, appropriate activity, s distress. AFOF.\nLungs CTA, heart RRR s murmur, abd soft, extr well perfused.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-04-01 00:00:00.000",
"description": "Report",
"row_id": 1695890,
"text": "NPN .\n\n\n# Received infant in RA on CVR and O2sat monitors. VSS as\ncharted on flow sheet. BBS clear and equal. No murmur. ,\nwell perfused. No A's or B's at this time. Abd soft, no\nloops. Active bowel sounds. A/G stable. Tol full volume of\n150cc/kg/day. No spits, no asp. PO full volume x1, ng fed\nx1. Mom due in for next feed at 1600. Currently on MBM26/PE\n26. Will approach mom about attempting BF. Plan to request\n to bring in carseat soon for testing prior to\ndischarge. Cobedding with siblings. Tol well. Maintaining\ntemp well. Needs hearing screen.\nStable growing preemie advancing on po feedings. \ninvolved.\nCont to monitor for apnea and bradycardia. Cont to suport\n toward discharge. Cont to offer po as tol. NG feed\nas necessary. Encourage mom to put infant to breast.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-04-17 00:00:00.000",
"description": "Report",
"row_id": 1695956,
"text": "NURSING PROGRESS NOTE\n\n\n2. RESPIRATORY\nNO ISSUES. NO SPELLS.\n3. F/N\nTONIGHT'S WEIGHT UP 65 GRAMS TO 2.61KG. TOOK IN 189CC/KG.\nVOIDING AND STOOLING.\n4. \nNO CONTACT.\n5. G&D\nREADY FOR DISCHARGE.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-04-17 00:00:00.000",
"description": "Report",
"row_id": 1695957,
"text": "Neonatology Attending Progress Note\n\nAddendum - PE\nSee Physician Exam form.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-04-17 00:00:00.000",
"description": "Report",
"row_id": 1695958,
"text": "Neonatology Attending Progress Note\n\nAddendum - PE\nSee Physician Exam form.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-04-17 00:00:00.000",
"description": "Report",
"row_id": 1695959,
"text": "Neonatology Attending Progress Note\n\nNow day of life 44, CA 1/7 weeks.\nIn RA with RR 40-60s.\nNo apnea and bradycardia since .\nHR - 140-160s.\n\nWt. 2610gm up 65gm on ad volumes of feedings - took in 189cc/kg/d yesterday.\nFeedings well tolerated.\nNormal urine and stool output.\n\nAssessment/plan:\nBaby is doing very well.\nReady for discharge to home today.\nAppointment wtih pediatrician to be set for early this week.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-22 00:00:00.000",
"description": "Report",
"row_id": 1695845,
"text": "NICU nursing progress note\n\n\nPlease refer to flowsheet for specific info.\nResp\nO: remains in room air, RR 40-60's, sat's >95%. Mild\nsc ret. Off of caffeine, no brady's for >48 hours. A:\nstable. Breathing comfortably. P: cont to follow.\nFEN\nO: TF of 150c/k/d of pe 26 or bm 26 gavaged over 75\". HOB\nelev. feedings well tolerated, though does wake at times and\ncry, then falls back asleep most likely refluxing. Abd ,\nno loops, active bs. voiding/ no stool today. No spits min\nasp. A: stable. P: follow.\nGD\nO: TEmp stable in oac co-bedding with siblings. Active and\n with cares. MAE. Fonts soft, flat. Left eye with\nslightly more raised area? Examined by Dr. , no\nnew orders at this time/ monitor for changes. A: AGA P: cont\nto follow and support dev. milestones.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-23 00:00:00.000",
"description": "Report",
"row_id": 1695846,
"text": "NPN 1900-0700\n\n\n2. RESP: pt remains in RA with RR 30-50's. Mild S/C\nretractions. Sats >95%. No spells noted so far this shift.\nWill monitor closely.\n\n3. F&N: TF remain at 150cc/k/dof BM/PE26. Feeds gavaged\nin over 1 hour 15 minutes. Abd benign. BS+. A/G stable.\nNo spits and minimal aspirates noted. Voiding and passing\nlarge green guiac negative stool. Weight gain 25 grams.\n\n4. PAR: No contact from so far this shift.\n\n5. DEV: is active and during her cares. Temp\nstable swaddled in open crib. Red non-draining area noted\non her right eye lid. Will monitor. Micostatin powder to\nbuttocks as ordered.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-23 00:00:00.000",
"description": "Report",
"row_id": 1695847,
"text": "Neonatology\nRA. Comfortable apeparing. Spells not a problem.\n\nWt 1730 up 25. toleraing feeds at 150 cc/k/d of 26 cal. Abdomen benign. Still requiring gavage.\n\nOn mycostatin for diaper rash. Will contiunue through tomorrow as is improving.\n\nLeft eye drainage noted w/o signs of infection.\n\nContinue to await maturation of feeds.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-23 00:00:00.000",
"description": "Report",
"row_id": 1695848,
"text": "Neonatology-NNP Physical Exam\n\nInfant remains in RA. Active, in an open crib, AFOF, sutures opposed, good tone. BBS clear and equal with good air entry. No murmur, pulses +2, , RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds. Left eye slightly edematous, miost likely dependent edema. Please refer to attending progress note for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-23 00:00:00.000",
"description": "Report",
"row_id": 1695849,
"text": "NPN7a7p\n\n\nResp\nInfant in RA with adeq sats. LSC. No bradys. Monitor and\nsupport resp status.\nFen\nInfant on TF 150 cc/k/d of BM or PE26. BM on hold until\nthursday (2nd to Moms medication) Abd soft, round with\nactive BS. No spits today. Max asp of 4 cc partially\ndigested formula. AG stable. Voiding. No stool. Monitor\nweight and exam.\nParenting\nSee #3 note for details. invested and . Lrg\nfamily support. Educate and support .\nG/D\nInfant cobedding with sibs. Stable temps. Warm this\nafternoon with hat on. No evidence of yeast in groin.\nTomorrow will be day 5, prob DC nystatin powder then. Infant\nwith some dependent edema of eyes and limbs. Edema of left\nlower leg not improved with different position. Pitting. Dr\n aware and assessed, cont to monitor. A/A for cares.\nSleeps quietly in between. Does not disturb easily by sibs.\nMAEs. FS&F. Uses pacifier with support. AGA. Monitor and\nsupport G/D.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-04-17 00:00:00.000",
"description": "Report",
"row_id": 1695960,
"text": "Nursing D/C note\n\n\nInfant ready for d/c. Vitals stable this shift, now day \nof spell countdown (no spells since ).\nInfant bottling well on E24, taking > than minimum\nrequirements, voiding and stooling. Will be d/c'd home on\niron.\nVNA and pedi appt scheduled. All other d/c requirements\ncompleted. Currently awaiting : plan to review car\nseat positioning and any other infant care topics they might\nwant to review.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-20 00:00:00.000",
"description": "Report",
"row_id": 1695836,
"text": "NICU nursing progress note\n\n\nPlease refer to flowsheet for specific info,\nResp\nO: remains in room air, RR 30-60's, sat's >95%. Mild\nsc ret. BSCE bilat. A: stable. breathing comfortably. No\nbrady's off of caffeine. P: cont to follow.\nFEN\nO: TF of 150cc/ k/ d of PE or bm 26 with promod, gavaged\nover 80\", and fed q 4 hours. Abd , no loops, active bs.\nVoiding/ stooling heme (-). Girth stable. Max asp of 5cc\npartially digested formula. No spits. A: Stable. P: cont to\nfollow.\nGD\nO: Temp stable in oac co-bedding with brother and .\nActive and with cares, though does not wake for feeds.\nMAE. Fonts soft, flat. Brings hands to face. A: AGA P: cont\nto support dev.milestones.\nParenting\nO: Mom, dad and older brother in and visited at bedside.\n updated and verbalizing understanding. A: Involved\nand invested . P: cont to update, support, educate.\nPlan is to transfer to Gen. Hospital when beds are\navailable for triplets.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-20 00:00:00.000",
"description": "Report",
"row_id": 1695837,
"text": "Neonatology NP EXAM NOTE\nPLease refer to Dr note for detials of evaluation and plan,\n\n\nPE: samll infant in open crib cobedded with sibs.\nHEENT: AFOF, ng in place MMMP\nChest is clear with comfortable resp pattern\nCVB: RRR, nio murmu, pulses +2=\nABD: soft, active BS\nGU: deferred\nEXT: MAE< WWP\nNeuro: active and responsive, good tone\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-04-08 00:00:00.000",
"description": "Report",
"row_id": 1695918,
"text": "Neonatology - NNP Progress Note\n\n is active, with her exam today. AFOF. She is , well perfused, no murmur auscultated. She is comfortable in room air. Breath sounds clear and equal. She had some desats associated with apnea overnight - spell countdown restarted. She is tolerating full volume feeds, abd soft, active bowel sounds, no loops. Not quite as vigorous with po feeds yesterday and had moderate drop in temp to 97.5 while cobedding with sibs. In light of temp drop, decrease in feeding efforts and apnea, CBC with diff and blood culture sent. CBC: WBC 11.2, Hct-31.5, plt-671, 26% polys, 0% bands.\n\nA/P Active, well appearing infant this am, but some mild symptoms that may be suggestive of infection. Will continue to monitor closely. Will consider antibiotics if clinical picture deteriorates. Please refer to neonatology attending note for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-04-08 00:00:00.000",
"description": "Report",
"row_id": 1695919,
"text": "Neonatology Attending\n is 35do, 35 wks corrected\nRA, open crib; occ sat drifts at rest and with bottles\nApnea/desat episode last pm, apparently obstructive (tongue at roof of mouth); now day 0-1/5\nAlso had temp drop (97.5 with good response to swaddling) - sepsis eval as noted by NNP Rivers\n\nWt 2250 up 20 on min TF130 MM/E24; not consistently waking for feeds\n\nMeds Fe\n\nImp/ immaturity of feeding/cvr/thermoregulation -- vs infection. Appears well overall.\n\nPlan/ continue to monitor cvr status, temp, growth/development. Will start abx if increased clinical suspicion.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-04-08 00:00:00.000",
"description": "Report",
"row_id": 1695920,
"text": "NPN 7a-7p\n\n\n#2: remains in RA, sating >/= 94%. Occ drift in sat\nto mid 80's noted with QSR. RR stable. Rare intermittent\nSC retraction. BBS cl/=. Did have brady x1 with bottling\nfor Mom. responded appropriately and infant recovered\nwith removal of bottle and stim. Also had brady at rest.\nA: Stable in RA, Restart brady countdown. P:Cont to monitor\nand provide support as needed.\n\n#3: TF:min140cc/k/d. Conts on BM24 with Enfamil powder/E24.\nFeeding ~q4hrs, taking 54-70cc, with fair to good\ncoordination. Abd soft, +, no loops. Voiding qs.\nStooled x1. Small spits/wet burps at times. FeSO4 given.\nMom correctly drew up and administered dose. A: tol'ing all\nPO feeds, working on coordination P:Cont with current\nfeeding plan. Follow wt and exam. Monitor tol to feeds.\n\n#4: in for most of the afternoon. Update given. Mom\nmet with LC. Has scheduled for appt this weekend on Sat.\nA: Involved family, indep with care P:Cont to support and\neducate.\n\n#5: has been very /active today with cares. MAE.\nFonts soft/flat. Temps stable while swaddled in an open\ncrib. She is co-bedding with her sibling. A:AGA P:Cont to\nsupport dev needs.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-21 00:00:00.000",
"description": "Report",
"row_id": 1695838,
"text": "NPN\n\n\n#2\nInfant remains in RA with sats >94% BS clear= with mild\nretractions. Color is ; well perfused. Murmer not\naudible. Infant has had one spell after a feed that was\nQSR.\n\n#3\nInfant remains on TF=150cc/k of BM/PE26 with promad q4\nhours. Infant has tolerated feeds via gavage over 80\nminutes without spits and only scant aspirates. Abd is soft\nand round; voiding well. Hypoactive/active BS. Trace/small\ngreen stools(g-) x2. Wt is up 30gms-1650.\n\n#4\nNo contact thus far from the .\n\n#5\nInfant remains in an open crib cobedding with her siblings.\nInfant is with cares; sucks on the pacifier. Fussy at\ntimes while feeding is infusing (?gassy)..settles once feed\nis complete.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-21 00:00:00.000",
"description": "Report",
"row_id": 1695839,
"text": "Neonatology Attending\nDOL 17 / CGA 33-2/7 weeks\n\n remains in room air with no distress and one bradycardia in 24 hours (off caffeine).\n\nNo murmur. BP normal.\n\nWt 1650 (+30) on TFI 150 cc/kg/day BM26PM/PE26PM, tolerating by gavage over 75 minutes. Voiding and stooling normally. Abdomen benign.\n\nTemperature stable in open crib.\n\nFather and sibling have viral gastroenteritis.\n\nA&P\n30-6/7 week GA infant with respiratory and feeding immaturity\n-Continue to await maturation of oral feeding skills and respiratory drive\n-No changes in management as detailed above.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-04-07 00:00:00.000",
"description": "Report",
"row_id": 1695912,
"text": "nursing\n\n\n#2O: In room air with O2 sats > 90% even with car seat\ntest. No spells or desats noted. br. sounds clear with\nmild retractions.\n#3O: wt. up 30g on BM24/B24. Wakes on own about every 4\nhrs. and bottles fairly well. Took in 188cc/kg . Belly\nsoft, voiding and stooling.\n#4O: No contact, mom will be into visit later and lactation\nappt. scheduled for today.\n#5O: Co-bedding with siblings, stable temp. Active with\ncares. Passed car seat screen.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-04-07 00:00:00.000",
"description": "Report",
"row_id": 1695913,
"text": "Neonatology-NNP Physical Exam\n\nInfant remains in RA. Active, in an open crib, AFOF, sutures opposed, good tone. BBS clear and equal with good air entry. No murmur, pulses +2, , RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds. Please refer to attending progress note for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-04-07 00:00:00.000",
"description": "Report",
"row_id": 1695914,
"text": "Neonatology Attending\n is 34do, 35 wks corrected\nRA, open crib cobedding with sibs\nDay s a/b\nWt 2230 up 30 g on ad lib min TF130 MM/E24 po\n\nMeds Fe\n\nImp/ age appropriate cvr immaturity, approaching readiness for d/c\nPlan/ continue to monitor cvr status, growth/development. Potential d/c tomorrow\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-21 00:00:00.000",
"description": "Report",
"row_id": 1695840,
"text": "NICU nursing progress note\n\n\nPlease refer to flowsheet for specific info.\nResp\nO: remains in room air, 30-70's, sat's >96%. Mild sc\nret. BSCE bilat. A: stable. breathing comfortably. No spells\noff of caffeine today.P: cont to follow.\nFEN\nO: TF of 150cc/k/d of PE or bm 26 w/ promod. GAvage fed\nover 75\" well tolerated. Abd , no loops, active bs.\nStable girth. No spits. Max asp of 2.2cc and benign.\nVoiding/ stooling heme (-). A: stable. P: cont to support\ndev.milestones.\nGD\nO: Temp stable in oac co-bedding with siblings. MAE. active\nand with cares. Font soft, flat. Brings hands to face.\nCalms with containment and pacifier. Irritable during\nfeedings/ waking, then crying and falls back asleep. A: AGA\nP: cont to follow and support dev.milestones.\nParenting\nO: Mom called and updated, sibling and dad have viral\ngastroenteritis. Mom states that she feels well, but will\ncall later instead of coming in to hospital. First night and\nfull day back in home in Canterbury NH. Plan is to transfer\ntriplets to when beds available. A:\n and invested . P: cont to update, support,\neducate.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-21 00:00:00.000",
"description": "Report",
"row_id": 1695841,
"text": "Neonatology NP Exam NOte\nPE: small well appearing infant in open crib, cobedding with sibs.\nHEENT: AFOF, eyes with clear drainage, MMMP, ng in place.\nChest is clear,comfortable\nCV: RRR, pulses +2=, no murmur\nABd: soft active BS\nGU immature female genoitalia\nEXT, lean MAE, WWp\nNeuro: active and responsive symmetric tone and reflexes\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-22 00:00:00.000",
"description": "Report",
"row_id": 1695842,
"text": "NICU Nursing Note 1900-0700\n\n\n#1 RESP\nRA, RR 30-60's,clear and equal with mild subcostal\nretracitons. No spells.\nStable in room air, continue to follow.\n\n#3 FEN\nWeight tonight 1705gm (+55). TF 150 cc/kg/day of PE26PM. PG\nfed over 1hr 15min. No spits, minimal aspirates. Voiding and\nstooling. No loops. Tolerating feeds well. Continue to\nfollow.\n\n#4 Parenting\nNo contact.\n\n#5 G&D\nTemp stable cobedding with siblings in open crib. and\nactive with cares, irritable at times. Settles with\npacifier. MAE, symmetrical tone. AFSF. AGA. Continue to\npromote developmental growth.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-22 00:00:00.000",
"description": "Report",
"row_id": 1695843,
"text": "Neonatology note\n18 d.o\nin RA, no spells, off caffeine.\nAFOF\n\nwt= 1705 gm +55, 150 cc/kg/d with 26 cal/oz\nRR with no murmur\nclear lungs\nabdomen soft\nMRSA(+) on skin\n\nA: ex 30 wks GA, growing preemie\nP: continue current management.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-22 00:00:00.000",
"description": "Report",
"row_id": 1695844,
"text": "Neonatology note\ncorrection for above: skin culture negative.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-19 00:00:00.000",
"description": "Report",
"row_id": 1695832,
"text": "NPN 7a7p\n\n\nRESP\nInfant in RA with adeq sats. No bradys. LSC. Mild S/C rtxs.\nCaffiene dcd today. Monitor and support resp status.\nFEN\nInfant on TF 150 cc/k/d of PE or BM26PM. Had been gavaging\nover 1.5 hrs q 4 hrs. Lrg benign asps overnight and this am\n(see careview) and lrg spit. Attempt to change feeds to q 3\nhrs per fellow. Next asp was 14 cc, benign, undigested\nformula, refed to infant and will wait 1 hr. Resume q 3 hr\nfeeds, changing gavage time to only 1 hr, per fellow. Abd\nsoft, lrg round. AG 24-25 cm, consistant. Some soft loops on\noccasion. Lrg loose liquid green stool, heme -. Infant with\nlrg benign asps, not tolerating TF regime presently. Cont to\nmonitor, maintain reflux precautions.\n\nMom and uncle came to visit and participate in cares. Mom\nindependent with cares. and appropiate with infants.\nAwaiting word on transfer to Hosp, maybe Monday.\nSigned up for CPR for Tuesday if infants are still here.\nPlans to drive home, NH this weekend. Anxious as this is her\n1st time back home since early . She is unsure if\nshe will visit tomorrow. She hopes to come in early before\nheading north. Mom had a number of hospital staff visitors\nshe became friendly with during her bedrest stay, come to\nsay hello and see babies. Mom appears to enjoy the attention\nand support. Cont to support and educate .\nG/D\nInfant in OAC with stable temps. Bedding alone without sibs\npresently due to need of lrger crib. A/A with cares. MAES.\nFS&F. Has new yeast rash in groin, ordered for nystatin\npowder. AGA. Monitor and support G/D.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-19 00:00:00.000",
"description": "Report",
"row_id": 1695833,
"text": "Fellow note; physical exam\nSleeping comfortably in open crib. In RA. Skin . AFOF. Eyes clear. Lungs clear. RRR. No murmur. Normal femoral pulses. Abd soft, ND, +BS. Extrem WWP. Good tone.\n\nPossible transfer to on Monday.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-20 00:00:00.000",
"description": "Report",
"row_id": 1695834,
"text": "npn 1900-0700\n\n\n2: resp\nremains in ra. no spells and no dsats. Rr 30-60's. Lung\nsounds clear and equal. mild subcostal retractions. no\nincreased wob noted. caffeine dc'd on day shift.\n\n3: fen\ncurrent weight 1620gms up 40gms. total fluids remain at\n150cc/kilo/day of pe/bm 26 with prom. infant having\naspirates of 4-6cc's. no spits. infant changed back to q 4\nhour feeds after 1am care. At 0100 infant had a 6cc aspirate\nof partially digested formula. 6cc's refed and subtracted to\nthe total feeding. abd soft with no loops. voiding, no stool\nthus far this shift. positive bowel sounds. stable girths.\ncontinue to monitor for changes in nutritional status.\n\n4: \nno contact thus far this shift.\n\n\n5: G/D\ntemps stable in an open crib. co-bedded with sister and\nbrother. and active with cares. sleeps well inbetween.\n\nbrings hands to face. aga. sucks vigorously on pacifier.\ncontinue to monitor for developmental milestones.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-20 00:00:00.000",
"description": "Report",
"row_id": 1695835,
"text": "Neonatology Attending\n\nDay 16- CGA 33 1/7 weeks\n\nRemains in RA. RR 30-60. Mild retractions. No bradycardia- now off caffeine. BP mean 58. Weight 1620 gms (+40). TF at 150 cc/kg/d- PE 26 with Promod. Minimal aspirates overnight. Gavage fed every four hours. No spits. Benign abdomen. On iron, vitamin E. Stable temperature- co-bedding.\n\nDoing well overall. Monitoring closely. Gaining weight well. Tolerating feeds well. No changes for now. Mother up to date.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-04-07 00:00:00.000",
"description": "Report",
"row_id": 1695915,
"text": "Clinical Nutrition\nO:\n~35 wk CGA BG on DOL 34\nWT: 2230 g (+30)(~25th %ile); birthwt: 1345 g. Average wt gain over past wk ~34 g/day.\nHC: 32 cm (~25th to 50th %ile); last: 30 cm\nLN: 44 cm (~10th to 25th %ile); last: 42.5 cm\nMeds include Fe\n not needed\nNutrition: Ad lib po's, minimum 140 cc/kg/day E24/BM 24 w/ Enfamil powder. Average of past 3 day intake ~164 cc/kg/day, providing ~2.2 to 2.8 g pro/kg/day and ~131 kcal/kg/day.\nGI: Abdomen benign.\n\nA/Goals:\nTolerating feeds without GI problems. not needed. Current feeds + supps meeting weaned recs for kcals/pro/vits and mins. Growth is meeting recs for wt gain. HC and LN gain are exceeding recommended ~0.5 to 1 cm/wk for HC gain and ~1 cm/wk for LN gain. Will follow long term trends. Will continue to follow w/ team and participate in nutrition plans.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-04-07 00:00:00.000",
"description": "Report",
"row_id": 1695916,
"text": "Nursing NICU Note\n\n\n#2. Respiratory O: Pt. remains in RA, O2 sats >95%. LS\nclear/=. RR ~ 30-50's, no increase work of breathing noted.\n No A&B's noted this shfit thus far. A: Pt. is stable in\nRA. P: Continue to monitor respiratory status. Monitor\nfor A&B's.\n\n#3. FEN O: Ad lib w/ Min 140cc/kg/d of E24 or BM24w/\nEnfamil powder. She takes ~56-70cc PO Q feed, starting to\nwake more for feeds now. Abdomen is soft, , +BS, no\nloops, occasional wet burps/sm.spits noted. She is\nvoiding/ no stool noted this shfit. A: Pt. is tolerating\ncurrent nutritional plan. P: Continue w/ current feeding\nplan. Monitor for s/s of intolerance. Encourage PO feeds.\n\n#4. O: Mom in to visit and called in this am.\n Both updated on pt's current status and daily plan\nof care. are active and independent in cares. A:\nFamily is and involved. P: continue to update,\nsupport and educate. Continue w/ discharge\nteaching/planning.\n\n#5. Growth/Developement O: Pt. remains in an open crib,\nswaddled and co-bedding w/ her siblings. Temps stable. She\nis and active w/ cares, sleeps well in betweeen.\nFontanelle soft/flat. She loves to use her pacifier, brings\nhands to face. A: AGA P: Continue to provide environment\nappropriate for growth and development.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-04-08 00:00:00.000",
"description": "Report",
"row_id": 1695917,
"text": "NPN 1900-0730\n\n\n2. RECEIVED INFANT IN RA. SAO2 B/T 93-99%. RR 50'S-60'S. NO\nINCREASED WOB NOTED. SPONTANOUS DESAT AT WITH SAO2 DOWN\nTO 61. NO CHANGE IN HR. +COLOR CHANGE. MILD STIM PROVIDED\nD/T APNEA. NOW STARTING DAY COUNT DOWN. MOTHER AWARE.\nSOME DRIFTING WITH FEEDS. WILL OBTAIN BCX, CBC PER ORDER OF\nNNP. PLAN; MONITOR FOR S/SX RESP/ DISTRESS. F/U WITH SPELL\nCOUNTDOWN. MONITOR CBC AND BCX.\n\n3. WT. 2.250GMS UP 20GMS FROM YESTEDAY. CONT. ADLIB WITH\n140CC MIN. TAKING B/T 45-55CC Q 4HR FEEDING. TOTAL IN 24HRS,\n136CC/K/D. STILL APPEARS SLIGHTLY UNCOORDINATED THIS SHIFT.\nABD SOFT, NO LOOPS, +BS. VOIDING, STOOLING GREENISH BROWN\nGUIAC- STOOL. PLAN; CONT. TO MONITOR INTAKE ON ADLIB\nSCHEDULE. BCX, CBC TO BE DRAWN.\n\n4. RN NOTIFIED MOM OF INFANT DESAT EPISODE AND THAT 5 DAY\nCOUNTDOWN WILL START AGAIN. MOM SOUNDING AND\nCONCERNED BUT ALSO RELEIVED THAT INFANT IS IN HOSPITAL WHEN\nEPISODE HAPPENED. PLAN; CONT. TO SUPPORT AND EDUCATE \n\n\n5. CONT. SWADDLED. CO-BEDDING WITH SIBLINGS. TEMP DOWN TO\n97.5. EXTRA BLANKET AND HAT ADDED. TEMP UP TO 98.1 WITHIN 10\nMINUTES. APPEARING UNCOORDINATED WITH FEEDS. SOME DRIFTING\nWITH SAO2. NP. BCX, CBC TO BE OBTAINED. MOVING ALL\nEXTREMETIES. WAKING FOR CARES. PLAN; F/U WITH BLOOD WORK.\nCONT. TO SUPPORT G/D.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-05 00:00:00.000",
"description": "Report",
"row_id": 1695771,
"text": "Neonatology\nOn SIMV after second dose of surfactant this am. Mainly in RA, but increases with crying. Single bolus of NS last night. Will wean PIP again this am and recheck CBG. No evidence of PDA.\n\nWt 1345. Remains NPO on d10w. Abdomen benign. BS in good range.\n\nOn abx for 48 h r/o.\n\nBili to be checked with lytes later today.\n\nHUS for beginning of next week.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-05 00:00:00.000",
"description": "Report",
"row_id": 1695772,
"text": "NPN DAYS\n\n\nInfant with Potential Sepsis: Blood cx pending. Remains on\nAmpicillin and Gent for 48 hr r/o. Will repeat CBC in the\nam.\n\nAlt in Resp: Received baby on settings of 20/5 rate 22.\nSurf'd for the 2nd time. Weaned to 18/5 rate 20 where she\nremains at this time. FiO2 21%. Occasional desats to the\n70's and 80's needing temporary increase of O2. LS clear and\nequal. Mild retractions. Sxn'd for small amounts cloudy\nsecretions. Will check blood gas with next set of cares to\nsee if vent settings can be weaned some more.\n\nAlt in FEN: NPO. TF 80cc/kg/day D10 via , change to\nPN this evening. Voiding. No stool. Belly benign. No spits.\nD/S 93. Lytes 139/4.0/108/17. Bili 4.2/0.2. Will continue\nwith current plan of care.\n\nAlt in Parenting: Dad up to visit several times during the\nday. Mom up x1 so far. Parents may hold this afternoon or\nevening. Updated them on the babies day. Will continue to\nprovide teaching and support.\n\nAlt in Growth and Dev: Temp up and down on warmer, ? r/t\nenvironmental temp changes. Awake and alert with cares.\nNested on sheepskin with boundaries in place. Will place in\nisolette this eve to try to regulate temp.\n\nAlt in CV: No murmur. Color pink and well perfused. BP\nstable, see flow sheet. NNP aware of BP 44/28 M34. Will\ncontinue to monitor closely.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-05 00:00:00.000",
"description": "Report",
"row_id": 1695773,
"text": "Respiratory Care Note\nReceived pt on SIMV 20/5, RR 22, 21% Second dose of 5cc's of Survanta given at 0730. Given per protocol. Tol well. Weaned to 18/5, RR 20. CBG:7.44/27/31/19/-4. Extubated and placed on +5 prong CPAP, FiO2 25%. BS clear. RR 40-70's. Will follow on CPAP.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-05 00:00:00.000",
"description": "Report",
"row_id": 1695774,
"text": "Fellow note; physical exam\nAlert and active. Breathing comfortably on SIMV. Skin pink. AFOF. Lungs with good aeration on vented and spontaneous breaths. RRR. Nl S1, S2. No murmur. Normal femoral pulses. Abd soft, ND, +BS. Normal female external genitalia. Extremities WWP. Good tone.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-06 00:00:00.000",
"description": "Report",
"row_id": 1695775,
"text": "Respiratory Care\nBaby remains on cpap 5 21%.BS clear throughout.RR 30-70's.No spells documented thus far this shift.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-06 00:00:00.000",
"description": "Report",
"row_id": 1695776,
"text": "Nursing progress note\n\n1 Infant with Potential Sepsis\n\n#2 O: Remains on 5cm prong CPAP, 21% O2. Breath sounds equal\n& clear with mild SC retractions. No A's, B's or desats. A:\nStable on CPAP. Cont to assess.\n#3 O: Wgt down 15gms. Remains NPO with at 80cc/k/d. DS\n82. UOP for previous 24 hrs was 2.8cc/k/h. No stool. Abd\nsoft with active bowel sounds & no loops. A: Receiving\nfluids as ordered. P: Cont to assess.\n#4 O: Parents up for visit. Mom held & Dad took\npictures. Parents spoke with Dr at bedside. A:\nInvolved parents. P: Supprot.\n#5 O: Received baby on warmer. Transferred to servo\nisolette. Temp stable. Nested in sheepskin. Alert with cares\n& irritable at times. A: Easily stressed. P: Cluster cares.\nCont to assess.\n#6 O: Mild gen edema. No murmur heard. BP mean was 38. Ruddy\n& well perfused. A: Stable. P: Cont to assess.\n\nOUTCOME EVALUATION:\n\n 1 Infant with Potential Sepsis\n MET [1] Infant will be free of signs and\n symptoms of sepsis.;\n Blood cultures neg to date.\n Remains on antibiotics. Repeat CBC\n & diff sent.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-06 00:00:00.000",
"description": "Report",
"row_id": 1695777,
"text": "Neonatology Attending\n\nNow day of life 2 for this 30 week gestation .\nBaby remains stable on CPAP of 5 and in RA.\nRR - 50-60s.\nNo apnea and bradycardia.\n\nHR 130-150s BP 47/33 38\n\nWt. 1330gm down 15gm on PN/IL 80cc/kg/d\nNPO\nDS 82\nUO 2.8cc/kg/hr, no stool.\n\nID - repeat cbc pending - FU for neutropenia.\nOn amp and gent.\n\nBili - 4.2/0.2\n\nAssessment/plan\nVery nice progress.\nWill trial off CPAP today.\nFeedings to be initiated with PE.\nWill continue antibiotics while awaiting results of cbc.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-06 00:00:00.000",
"description": "Report",
"row_id": 1695778,
"text": "Respiratory Care Note\nPt off CPAP today. Briefly on a 23%, 100cc nasal cannula. BS clear. RR 40-60's. No bradys or desats noted. IC/SubC retractions.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-06 00:00:00.000",
"description": "Report",
"row_id": 1695779,
"text": "NPN DAYS\n\n6 ALt in CV d/t prematurity\n7 Bili\n\nInfant with Potential Sepsis: Blood cx pending. Remains on\nAmp and Gent. CBC with diff repeated today, see lab results.\n? d/c antibiotics if blood cx at 48hrs remains negative.\n\nAlt in Resp: CPAP removed at 12pm and baby placed on NC\n100cc flow, 21% FiO2. LS clear and equal. Mild retractions.\nNo spells. Tolerating NC without problems. Continue to\nmonitor.\n\nAlt in FEN: TF 80cc/kg/day. Enteral feeds of BM20 at\n20cc/kg/day, increasing 10cc/kg/ as tolerated. PND10 and\nlipids currently infusing via at 60cc/kg/day. D/S 79.\nVoiding, no stool. Belly benign. No spits. Will continue to\nincrease feeds as tolerated .\n\nAlt in Parenting: Parents up to visit and dad participated\nin cares. Updated them on the babies day. Family meeting to\nbe held 2pm Monday. Will continue to provide support and\nteaching.\n\nAlt in Growth and Dev: Temp stable in servo isolette until\nphototherapy started and then temp of isolette needed to be\nweaned, see flow sheet. Nested on sheepskin with boundaries\nin place. Will continue to monitor temp closely.\n\nAlt in CV: No murmur noted. Pink and well perfused, BP\nstable. Problem resolved.\n\nBili: Bili this afternoon 8.0/0.3 up from 4.2/0.2. Placed\nunder double phototherapy.\n\nREVISIONS TO PATHWAY:\n\n 6 ALt in CV d/t prematurity; resolved\n 7 Bili; added\n Start date: \n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-05 00:00:00.000",
"description": "Report",
"row_id": 1695767,
"text": "Neonatology-NNP Procedure Note\n\nProcedure: Endotracheal intubation\nIndication: Respiratory distress\n\nInfant placed in supine position with cardio-respiratory monitor in place. Under direct laryngoscopy, the vocal cords were visualized using a size 0 blade. A 3.0 Fr ETT was inserted through the vocal cords and secured at 7cm. BBS were equal on auscultation. The infant tolerated the procedure without incident. A CXR will be obtained to confirm placement.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-05 00:00:00.000",
"description": "Report",
"row_id": 1695768,
"text": "Nursing Admission Note\n\nInfant is a 30 week triplet (#1) born via c-section. Apgars 8,9.\nPlease refer to Dr. note for complete maternal history and\ndelivery room course. Infant admitted to NICU at 2150; G/F/R on admission, required BBO2 and then placed on nasal prong CPAP 6cm with\nFiO2 28-42% in order to maintain O2 sats in the 90's. RR 40-60's, LSC=, mild inter/subcostal retractions noted. AP stable, BP stable--\nsee flowsheet. No murmur. Capillary refill brisk, color ruddy. Infant\nalert and active, MAE, AFOF. CBC,diff. and blood cx drawn and sent\nto lab. Infant started on Ampicillin and Gentamicin as ordered.\nReceived baby care meds as per flowsheet. Infant's wt.1345 gms. NPO.\nPIV placed in infant's (R) hand; IVf infusing without incident; D10W\nat 80cc/k/day. Blood sugar 139. No void or stool output. Abd. soft,\nbowel sounds hypoactive. Temp. stable on open warmer with infant on\nservo control mode. CXR done.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-05 00:00:00.000",
"description": "Report",
"row_id": 1695769,
"text": "NPN 11p-7a\n\n\n#1 Temp max 100.6x. On ampi and gent. Blood cx pending. Diff\nunshifted. Tone and activity level wnl. A: r/o sepsis P:\nfollow cx and exam\n\n#2 Received infant on CPAP 6cm but moderate amt resp\ndistress persisted. Intubated and surv x 1 given. Placement\nconfirmed via xray. Initial settings weaned from 22/5 x 25\nto 20/5 x 22 after CBG: 7.39,32. Mainly in RA. BBS clear\nand =. Mild IC/SC retractions evident. Suctioned for\nsmall-mod amt secretions. A: beginning to wean P: Follow\nresp status very closely\n\n#3 TF's 80cc/k. Receiving D10W via PIV without incident. DS\n106. Abdominal exam unremarkable. Beginning to void. No\nstool since birth. A: npo with ivf P; Follow hydration\nstatus and weight, 24hr lytes and bili\n\n#4 Mom and Dad in to visit on way down to floor, Update\nprovided and questions answered. A: impaired parenting\nP:Cont to support and educate through nicu stay\n\n#5 Temp max 100.6x. Warmer weaned. Fiesty with and between\ncares. Nested on sheepskin with boundaries in place.\nRepositioned with cares and prn. A: AGA P: Support\ndeveklopmental needs\n\n#6 BP maps drifting to 28-29. Received NS bolus x 1 with\nimprovement to 30-34. NNP Ambrosine aware. Color is ruddy.\nWell perfused. A: low maps P:Follow serial BP's to watch\nfor trends\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-05 00:00:00.000",
"description": "Report",
"row_id": 1695770,
"text": "Respiratory Care\nBaby is # 1 of 30 week .Please see M.D admit note for hx.Apgars .Received facial cpap in d.r..trans to nicu,placed on cpap 6 fio2 req ^ to ~ 45%,and continued to grunt on cpap.cxr revealed\"white out\".Decsion made to intubate,and give surf.Intubated with 3.0 ett taped @ 7cm,given 5.2 cc survanta @ 0130,tol well.Initial settings R 25 22/5,cbg 7.39/32,weaned R 22 pip to 20.Mainly in 21%.BS = clear.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-04 00:00:00.000",
"description": "Report",
"row_id": 1695766,
"text": "NICU Attending Admission Note\n\nID: 30 week gestation female triplet #1, delivered by repeat C section due to progressive PTL, triplet gestation.\n\nPre/perinatal Hx: Mother is 29 y.o. G4 P now 2 (2 deliveries, 4 children), IUI triplet conception, EDC . PNS: 0+, Ab-, RPRNR, RI, HepBSAg-, reportedly GBS- (all PNS redrawn on and pending). Pregnancy complicated by GDM, then ? PTL (abdominal discomfort and vaginal pressure) at 23 1/7 weeks, admitted, receiveed complete course of beta at 24 weeks, in house since. Tonight presented with PTL, cervical dilation therefore delivered by repeat C section. Clear fluid. This triplet emerged with spontaneous cry, required only BBO2 and routine care in DR, apgars 8 and 9, but demonstrated mild increased WOB, needed supplemental O2, transported to NICU without incident.\n\nAdmission PEx: Weight 1455 gm (50%), L 41.5 cm (50%), HC 29.25 cm (50%), nondysmorphic with overall appearance c/w known gestational age, AFSOF, RR present bilaterally, palate intact, intermittent grunting, moderate intercostal retractions, diminished air entry bilaterally, RRR without murmur, 2+ femoral pulses, abdomen benign with no HSM, no masses, normal female external genitalia for g.a. normal back and ext with stable hips, appropriate tone, skin pink with fair perfusion.\n\nA/P: 30 week gestation AGA triplet #2, moderate respiratory distress, likely surfactant deficiency +/- component of retained fetal lung fluid, can not rule out pneumonia/sepsis with only perinatal risk factor of preterm labor (not unexpected in setting of triplet gestation). Also at risk of other complications of moderate prematurity including A/B, hypoglycemia, fluid and electrolyte imbalance, suck swallow dyscoordination, hyperbilirubinemia, feeding intolerance/nec, IVH/PVL, ROP.\n\n-CPAP, supplemental O2, monitor, CXR, may need intubation and exogenous surfactant tx.\n-NPO for now, D10W at 80 cc/kg/d, PN/IL asap, monitor glucose, lytes, bili, treat as indicated,\n- CBC, blood cx, amp and gent pending clinicla course and 48 horu blood bulture results\n- Follow up on repeat pending PNS results.\n- Head U/S and eye exam per routine\n\nI updated parents in OR. will keep informed/supported.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-06 00:00:00.000",
"description": "Report",
"row_id": 1695780,
"text": "Addendum - PE\n\nBaby is /jaundiced breathing comfortably in nasal cannula O2.\nAF soft and flat.\nLungs clear and equal, no retractions.\nCVS - S1 S2 normal - no murmur, perfusion good\nAbd - soft with normal bowel sounds, slightly full.\nGU- normal female\nNeuro - tone appropriate, symmetrical movements\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-07 00:00:00.000",
"description": "Report",
"row_id": 1695781,
"text": "1900-0700 NPN\n\n\n#1SEPSIS\nO:BLOOD CX NGTD AT 48HR OF AGE. ANTIBIOTICS D/ MD\nORDER\nA:SEPSIS RULED OUT\nP:D/C PROBLEM\n\n#2RESPIRATORY\nO:REMAINS IN NC 100CC 21% W/SATS 92-97%. BS CLEAR, SL\nDIMINISHED. INTERMITTENT GRUNTING NOTED AT START OF\nSHIFT--MD AWARE AND HAS SUBSEQUENTLY RESOLVED. RESP RATE\n44-72 WITH MILD IC/SC RETRACTIONS. HAS HAD 4 SPELLS THUS\nFAR, ALL MILD STIM WITHOUT DESATS--MD AWARE. NOT YET ON\nCAFFEINE.\nA:STABLE IN LOW NC, STARTING TO SPELL\nP:CONTINUE TO MONITOR RESP STATUS, MONITOR FOR NEED FOR\nCAFFEINE\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-07 00:00:00.000",
"description": "Report",
"row_id": 1695784,
"text": "NPN DAYS\n\n\nAlt in Resp: Received Caffeine loading dose at change of\nshift this am r/t 11 spells overnight. Remains on NC 100cc\nflow 21% FiO2, no further spells this shift. LS clear and\nequal. Mild retractions. Continue with current plan of care.\n\nAlt in FEN: TF increased to 120cc/kg/day. PND10 and lipids\ncurrently infusing at 60cc/kg/day via . D10 infusing at\n30cc/kg/day. Feeds of BM20/Pe20 at 30cc/kg/day. Increasing\nfeeds by 10cc/kg/ at 4/4. Belly soft and round with\nactive bowel sounds. No spits or aspirates. No stool since\nbirth. Urine out 1.9cc/kg/hr. Will continue to increase\nfeeds as tolerated.\n\nAlt in Parenting: Parents in to visit and participating in\nall cares. Updated them on day. Family meeting\nscheduled for Monday at 2pm. Will continue to provide\nsupport and teaching.\n\nAlt in Growth and Dev: Temp stable in air isolette. Nested\non sheepskin with boundaries in place. Passivley sucks on\npacifier. Awake and alert with cares, settles well between\ncares. Will continue to provide for developmental needs.\n\nBili: Remains under double phototherapy for bili. Check bili\ntonight.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-08 00:00:00.000",
"description": "Report",
"row_id": 1695785,
"text": "NPN\n\n\n#2RESP:\nO; Weaned to RA with sats in high 90's. RR 60-70, mild ic/sc\nretractions. Lungs cl=, no spells\nA/P; Cont to monitor. Caffeine as ordered.\n\n#3FEN:\no: Advanced feeds PE20 to 50cc/k/d. infusing PN D10 and\nIL at 70/k/d. Ad soft, round, no asp or spits. Voiding\n1.7cc/k/h. no stools\nA: Tol feeds\np: Cont to advance as tol. check labs.\n\n#4Parenting:\no: Mom in to visit, happy with progress. dad unable to\nvisit.\nA/P: Cont to support and inform, family mtg today at 1400\n\n#5G@D:\nO: Temps stable in heated isolette with temp adjustments.\nAlert and active with cares, MAE. Opening eyes. sucking on\npacifier.\nA/p: Cont to support dev.\n\n#7Bili:\no: Under double photherapy with eye patches in place.Bili\ndrawn.\nA/p: Cont with tx. check lab results.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-08 00:00:00.000",
"description": "Report",
"row_id": 1695786,
"text": "Neonatology note\n4 d.o\nin RA now, off NC O2 last night.\nAFOF, jaundice\nNormal tone for preemie\nRR with no murmur\nclear lungs\nabdomen soft\nwt= 1250 gm +5, 120 cc/kg/d with PN+Il, feeding at 50 cc/kg/d\nbili= 5.3\n\nA: ex 30 wks GA, resolved RDS, jaundice\nP: advancing feeding, monitor jaundice and possible immaturity of breathing.-\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-07 00:00:00.000",
"description": "Report",
"row_id": 1695782,
"text": "1900-0700 NPN\n\n\n#2RESPIRATORY\nO:BABY HAS HAD AN ADDITIONAL 4 SPELLS SINCE MD NOTIFIED\n~2400. NNP NOTIFIED OF ADDITIONAL 4 SPELLS-->8 IN 12HR.\nORDER RECEIVED TO BEGIN CAFFEINE.\nA:INCREASED SPELLS\nP:START CAFFEINE, MONITOR CLOSELY FOR NEED FOR CPAP\n\n#3F/E/N\nO:TF INCREASED TO 100CC/KG. INCREASED ENTERAL FEEDS TO\n30CC/KG BM/PE 6.7CC Q4HR GAVAGE AND IVF D10PN/IL AT 60CC/KG\nAND D1OW IVPB INTO LINE AT 10CC/KG. ABDOMEN SOFT WITH GOOD\nBS. NO LOOPS AND NO SPITS, MINIMAL ASPIRATES. AG 20-20.5CM.\nVOIDING 1.8CC/KG X12HR; NO STOOL. WT DOWN 85GM. DS 63. LYTES\nTHIS AM 145/4.3/113/20\nA:STABLE\nP:CONTINUE TO MONITOR TOLERANCE TO FEEDS, FOLLOW U/O AND DS\n\n#4PARENTING\nO:PARENTS EACH CALLED THIS AM FOR UPDATE ON BABIES. SEE\nSIBLINGS #3 NOTE\nA:INVOLVED, INVESTED\nP:CONTINUE TO SUPPORT, EDUCATE AND KEEP UP TO DATE\n\n#5G&D\nO:IN AIR CONTROL ISOLETTE WITH STABLE TEMPEDRATURE. TEMP\nDROP WITH KC-->PLACED UNDER WARMING LIGHTS WITH RESOLUTION.\nACTIVE/MAE WITH CARES; SLEEPING WELL BETWEEN\nA:AGA\nP:CONTINUE TO SUPPORT AND MONITOR\n\n#7BILI\nO:REMAINS UNDER DOUBLE PHOTOTHERAPY WITH BILIMASK IN PLACE.\nBILI THIS AM 7.8/0.3\nA:HYPERBILI\nP:CONTINUE PHOTOTHERAPY, CHECK BILI AS ORDERED\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-03-07 00:00:00.000",
"description": "Report",
"row_id": 1695783,
"text": "Neonatology Attending Note\nDay 3\n\nNC 100cc, 21%. RR40-70s. 11 A&Bs last pm, started caffeine this am. No spells since. No murmur. HR 120-150s. BP 55/41, 45. Mild gen edema.\n\nBili 7.8/0.3\nUnder double photot.\n\nWt 1245, down 85 gms. TF 100 cc/k/day BM/PE20 at 30, remainder PN/IL. Tol well. Nl voiding and stooling.\n145/4.3/11/20\nd/s 63\n\nNow off abx.\n\nIn isolette.\n\nExam: Infant active, alert with exam. AFOF. She is , well perfused, no murmur auscultated. She is comfortable in NCO2. Breath sounds clear and equal. Abd soft, active bowel sounds, no loops. Stable temp in air isolette.\n\nA/P:\n - wean O2 as tol\n - monitor AOP on caffeine\n - adv TF\n - adv enteral feedings\n - cont photot and follow bili levels\n"
}
] |
45,393 | 173,107 | # Patient expired on from hypoxic respiratory failure secondary to multifactorial etiologies including aspiration, HAP, mucus plugging, chronic COPD and atelectasis. Patient coughed and began to have increased work of breathing and the team was called for evaluation. The patient initially had rapid, shallowing breath, followed by agonal breathing. Additional supplemental O2 were given. Patient was DNR/DNI and goals of care were reviewed with patient's daughter and family at bedside. As consistent with their wishes, no invasive interventions were performed and patient was not transferred to the ICU. The patient subsequently expired. . # Hypoxic respiratory distress/HAP: Patient developed multiple episodes of hypoxic respiratory distress throughout her hospitalization, likely secondary to multifactorial etiologies including mucus plugging, COPD, chronic atelectasis and aspiration event/pneumonia. CXR showed bibasilar opacities. She was treated for HAP with 7-day course of Vancomycin, Aztreonam, and Levaquin (patient with documented penicillin and clindamycin). Per family wishes, patient was DNR/DNI, and O2 desaturations were managed with repositioning, suction, and supplemental O2 with goal O2 sat>90. . # Coag neg Staph bacteremia: Positive cultures from and , but subsequent cultures have been negative. Source believed to be from PICC. TTE negative for vegetations. Patient was treated with a 7-day course of vancomycin. Infectious diseases agreed with management. . # Abdominal Distension/Pain: Found to have an SBO on CT scan. Also, found to have large amounts of stool in rectal vault and distal colon. G-tube placed to suction with decompression. Disimpacted and given aggressive bowel regimen with good results, decreased pain, and decreased distension. After bowel movements had repeat KUB which showed an interval decrease in bowel distension and resolution of ileus. Patient's symptoms improved. She failed a speech and swallow evaluation with video fibroscopy, which revealed aspiration. Following family meeting, decision was made to keep NGT and tube feeds given intermittently as tolerated. . # Afib w/ RVR: On diltiazem and metoprolol at home. Not anticoagulated given fall risk. Originally placed on diltiazem gtt given NPO status on admission per above. Rate controlled with discontinuation of diltiazem gtt. Transitioned to IV metoprolol 5 mg q4hrs with PO diltiazem after patient showd signs of improving obstruction. She had one episode of AFib with RVR to 140s with stable hemodynamics. She was transitioned to PO metoprolol 50 qid and diltiazem 30 qid with good rate control in 90-100s . # Acute Kidney Injury: BUN to Cr ratio> 20:1 on admission most consistent with prerenal azotemia secondary to dehydration. Resolved with IVF's. . # Delirium: Likely multifactorial due to constipation/ileus, dehydration, afib w/ RVR, and pneumonia/bacteremia. Treated with low dose Zyprexa in the evening. Throughout her hospitalization, her baseline deteriorated and became unresponsive to voice and pain the day prior to passing away. Her family understook the deterioration of her status, and wished to continue with DNR/DNI status. . # Chronic C2 fracture: Stable for some time and pt does not need collar for stability but used it for management of cervical disk disease and upper extremity symptoms. . # Lumbar fracture: Incidental L1 compression fracture seen on CT scan of unknown chroniciity. Patient without symptoms. Likely due to osteoporosis. | Moderate (2+) aortic regurgitation isseen. Moderate aortic andmitral regurgitation. Mild symmetric left ventricularhypertrophy with normal global biventricular systolic function. Probable normal sinus rhythm with atrial prematurebeats. No PS.Physiologic PR.PERICARDIUM: No pericardial effusion.Conclusions:The left atrium is moderately dilated. There is mild aorticvalve stenosis (valve area 1.2-1.9cm2). Mild mitral annular calcification. There is mild pulmonary artery systolichypertension. Moderate (2+)mitral regurgitation is seen. There is mild symmetric leftventricular hypertrophy with normal cavity size. Mild to moderate [+] TR.Mild PA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. Mild aortic stenosis. Moderate (2+)MR.TRICUSPID VALVE: Normal tricuspid valve leaflets. Since the previous tracingof ventricular rate is slower and irregular, atrial wave forms aresuggested of atrial fibrillation and further left axis deviation is present. Moderate (2+) AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Mildly dilated ascendingaorta.AORTIC VALVE: Moderately thickened aortic valve leaflets. Left anterior fascicular block. Moderate baseline artifact. The ascendingaorta is mildly dilated. Mild AS (area 1.2-1.9cm2). Noresting LVOT gradient.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level. Consider prior inferior andanterior myocardial infarctions of undetermined age. Compared to the previoustracing of probably no diagnostic interval change.TRACING #1 Mitral valve disease.Height: (in) 60Weight (lb): 126BSA (m2): 1.54 m2BP (mm Hg): 136/81HR (bpm): 100Status: InpatientDate/Time: at 14:41Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Moderate LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Delayed R waveprogression may be due to left anterior fascicular block but cannot excludepossible prior septal myocardial infarction. Poor R wave progression. The aortic valve leaflets are moderately thickened.No masses or vegetations are seen on the aortic valve. Atrial fibrillation. Atrial fibrillation. Tissue Dopplerimaging suggests an increased left ventricular filling pressure (PCWP>18mmHg).Right ventricular chamber size and free wall motion are normal. Baseline is not steady butthere may be ST segment depressions in the precordial leads V2-V5 which arenew. Suboptimaltechnical quality, a focal LV wall motion abnormality cannot be fullyexcluded. Supraventricular tachycardia at a rateof 153. P waves are not clearly enough seen to determine the exactmechanism but there appears to be a P wave in the ST segment, perhapssuggesting catrialv flutter with 2:1 A-V block. The mitral valve leaflets are mildly thickened. Endocarditis. There is no mitral valveprolapse. Hypertrophic cardiomyopathy. Leftward axis. Due to suboptimal technicalquality, a focal wall motion abnormality cannot be fully excluded. No masses orvegetations on aortic valve. Overallleft ventricular systolic function is normal (LVEF>55%). No mass orvegetation on mitral valve. Marked baseline artifact. No MVP. There is no pericardial effusion.IMPRESSION: No echocardiographic evidence of endocarditis. Compared to tracing #1 and compared to .TRACING #2 PATIENT/TEST INFORMATION:Indication: Aortic valve disease. Overall normal LVEF (>55%). Elevatedestimated PCWP.If clinically indicated, a transesophageal echocardiogram may better assessfor valvular vegetations. TDI E/e' >15, suggesting PCWP>18mmHg. | 4 | [
{
"category": "Echo",
"chartdate": "2198-05-28 00:00:00.000",
"description": "Report",
"row_id": 88552,
"text": "PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease. Atrial fibrillation. Endocarditis. Hypertrophic cardiomyopathy. Mitral valve disease.\nHeight: (in) 60\nWeight (lb): 126\nBSA (m2): 1.54 m2\nBP (mm Hg): 136/81\nHR (bpm): 100\nStatus: Inpatient\nDate/Time: at 14:41\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Suboptimal\ntechnical quality, a focal LV wall motion abnormality cannot be fully\nexcluded. Overall normal LVEF (>55%). TDI E/e' >15, suggesting PCWP>18mmHg. No\nresting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Mildly dilated ascending\naorta.\n\nAORTIC VALVE: Moderately thickened aortic valve leaflets. No masses or\nvegetations on aortic valve. Mild AS (area 1.2-1.9cm2). Moderate (2+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. No mass or\nvegetation on mitral valve. Mild mitral annular calcification. Moderate (2+)\nMR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to moderate [+] TR.\nMild PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is moderately dilated. There is mild symmetric left\nventricular hypertrophy with normal cavity size. Due to suboptimal technical\nquality, a focal wall motion abnormality cannot be fully excluded. Overall\nleft ventricular systolic function is normal (LVEF>55%). Tissue Doppler\nimaging suggests an increased left ventricular filling pressure (PCWP>18mmHg).\nRight ventricular chamber size and free wall motion are normal. The ascending\naorta is mildly dilated. The aortic valve leaflets are moderately thickened.\nNo masses or vegetations are seen on the aortic valve. There is mild aortic\nvalve stenosis (valve area 1.2-1.9cm2). Moderate (2+) aortic regurgitation is\nseen. The mitral valve leaflets are mildly thickened. There is no mitral valve\nprolapse. No mass or vegetation is seen on the mitral valve. Moderate (2+)\nmitral regurgitation is seen. There is mild pulmonary artery systolic\nhypertension. There is no pericardial effusion.\n\nIMPRESSION: No echocardiographic evidence of endocarditis. Moderate aortic and\nmitral regurgitation. Mild aortic stenosis. Mild symmetric left ventricular\nhypertrophy with normal global biventricular systolic function. Elevated\nestimated PCWP.\n\nIf clinically indicated, a transesophageal echocardiogram may better assess\nfor valvular vegetations.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2198-05-29 00:00:00.000",
"description": "Report",
"row_id": 231629,
"text": "Atrial fibrillation. Left anterior fascicular block. Delayed R wave\nprogression may be due to left anterior fascicular block but cannot exclude\npossible prior septal myocardial infarction. Since the previous tracing\nof ventricular rate is slower and irregular, atrial wave forms are\nsuggested of atrial fibrillation and further left axis deviation is present.\n\n"
},
{
"category": "ECG",
"chartdate": "2198-05-23 00:00:00.000",
"description": "Report",
"row_id": 231859,
"text": "Moderate baseline artifact. Supraventricular tachycardia at a rate\nof 153. P waves are not clearly enough seen to determine the exact\nmechanism but there appears to be a P wave in the ST segment, perhaps\nsuggesting catrialv flutter with 2:1 A-V block. Baseline is not steady but\nthere may be ST segment depressions in the precordial leads V2-V5 which are\nnew. Compared to tracing #1 and compared to .\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2198-05-23 00:00:00.000",
"description": "Report",
"row_id": 231860,
"text": "Marked baseline artifact. Probable normal sinus rhythm with atrial premature\nbeats. Leftward axis. Poor R wave progression. Consider prior inferior and\nanterior myocardial infarctions of undetermined age. Compared to the previous\ntracing of probably no diagnostic interval change.\nTRACING #1\n\n"
}
] |
60,431 | 116,904 | Brief Hospital Course: . #R hip injury s/p fall Pt suffered multiple injuries during her fall. In addition to broken teeth (some cemented in the ED) and ecchymoses over her chin and R temple, there was persistent concern for R hip fracture given limited range of motion on exam. Therefore, despite initial negative plain films of her R hip and leg in the ED, a follow-up CT was obtained and showed a peri-prosthetic proximal femur fracture. Ortho trauma recommended non-operative management of her right hip fracture, with outpatient follow-up with in weeks with repeat x-rays of her right hip. Pain was controlled with standing tylenol and a lidocaine patch. Initially anticoagulated with Sq heparin alone, changed to lovenox per discussions with ortho. . #Small Bowel Obstruction On the medicine service on hospital day 4 the pt developed acute epigastric pain associated with nausea, nonbloody vomiting, and dyspnea. Abdominal x-ray showed a distended stomach and small bowel with multiple air-fluid levels with no free air, consistent with possible small bowel obstruction. In the ICU, an NGT tube was placed (required left lateral decubitus positioning given known Zenker's diverticulum) with >2L bilious gastric fluid drainage. Surgery was consulted to evaluate her recurrent small bowel obstruction; they recommended non-operative management, keeping patient NPO with NGT/IV fluids. She also received an agressive bowel regimen to relieve obstruction, and was passing gas within 24 hours. Her symptoms improved, NGT was removed on and her diet advanced to regular. #Acute Hypoxia/severe atelectasis with lung collapse. Vital signs obtained at the onset of nausea/vomiting showed oxygen desaturation to 84% with tachypnea to RR 24. Pt denied chest pain and palpitations. ABG pH 7.43 pCO2 42 pO2 65. Supplemental oxygen via non-rebreather improved O2sats to 91-94%. SErial EKG's were monitored. EKG performed at 3am on morning prior to hypoxic episode showed possible STE in v3-v4 (performed as pre-op for possible OR but not reviewed by overnight physician). Repeat EKG at 6am did not show this finding. However, serial cardiac enzymes ruled out MI. Reviewed EKG with cardiology. Pt was empirically started on heparin gtt, PR aspirin, statin and beta-blocker and transferred to the ICU for stabilization of her respiratory status. She was afebrile, without elevated WBC or consolidation/infiltration on CXR or cough. Negative CTA ruled out pulmonary emboli, but showed bilateral lower lobe collapse due to lobar atelectasis. Echo showed normal biventricular function and no evidence of pulmonary hypertension. Cardiac enzymes were negative. As ACS and PE were ruled out, BB, statin, heparin were discontinued. After transfer to the ICU she denied SOB but continued to require 5-6L supplemental oxygen to keep O2 sats>90%. Used frequent incentive spirometry to promote re-inflation of collapsed lower lobes. Pt required no further oxygen on day of discharge and had clinical improvement in crackles in right base *******PT SHOULD HAVE STRESS TESTING AS AN OUTPT GIVEN ISOLATED TRANSIENT V3-4 STE ON EKG*** . # Hypothyroid - Treated with home levothyroxine. . # GERD - Treated with home omeprazole. #UTI-s/p course of PO cipro x3 days. Cx with mixed flora. . #osteoporosis-continued calcium . FEN:adat to clears . PPX: hep SC, bowel regimen (PR dulcolax/enemas) . #CODE: Full (confirmed) . #Contact: (handicapped. per patient he is not able to make decisions for the patient. Patient has no one who she says can make decisions for her. | Moderate mitral annularcalcification. Trivial mitral regurgitationis seen. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. The P-R interval is prolonged.Non-specific ST-T wave changes. Non-specific ST-T wave changes. Probable left atrial abnormality.Non-specific anterolateral ST-T wave changes. No aortic regurgitation is seen.The mitral valve leaflets are mildly thickened. Diffuse T wave flatteningwhich is non-specific. Trivial MR.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. The estimatedpulmonary artery systolic pressure is normal. Mild [1+] TR.Normal PA systolic pressure.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.PERICARDIUM: No pericardial effusion.Conclusions:The left atrium is normal in size. No change compared to . Low voltage in the precordialleads. Borderline P-R interval prolongation. First degree A-V delay. First degree A-V delay. Sinus rhythm. Sinus rhythm. Sinus rhythm. Sinus rhythm. Sinus rhythm. Compared tothe previous tracing of there is no change. Right ventricular chambersize and free wall motion are normal. Nopulmonary hypertension or pathologic valvular disease seen.Compared with the resting images of the prior study of , the findingsare similar. Compared to the previous tracing of there is no significant change. Compared to the previous tracingof precordial lead voltage is much less. Theestimated cardiac index is normal (>=2.5L/min/m2). The diameters of aorta at the sinus,ascending and arch levels are normal. There is no pericardialeffusion.IMPRESSION: Normal global and regional biventricular systolic function. Estimated cardiac index is normal(>=2.5L/min/m2). Compared to the previous tracing of there is nosignificant diagnostic change. No resting LVOT gradient.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal diameter of aorta at the sinus, ascending and arch levels.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). The aortic valve leaflets (3) are mildlythickened but aortic stenosis is not present. Anterior T wave inversion. The tricuspid valve leaflets are mildly thickened. Evaluate valves, right and left ventricular function.Height: (in) 60Weight (lb): 112BSA (m2): 1.46 m2BP (mm Hg): 130/67HR (bpm): 72Status: InpatientDate/Time: at 11:30Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/globalsystolic function (LVEF >55%). No AS. There is a late transitionconsistent with possible myocardial infarction. The P-R interval is prolonged. Left ventricular wall thickness, cavitysize and regional/global systolic function are normal (LVEF >55%). Artifact is present. | 6 | [
{
"category": "Echo",
"chartdate": "2137-06-12 00:00:00.000",
"description": "Report",
"row_id": 96538,
"text": "PATIENT/TEST INFORMATION:\nIndication: Unexplained hypoxia, dyspnea. Evaluate valves, right and left ventricular function.\nHeight: (in) 60\nWeight (lb): 112\nBSA (m2): 1.46 m2\nBP (mm Hg): 130/67\nHR (bpm): 72\nStatus: Inpatient\nDate/Time: at 11:30\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). Estimated cardiac index is normal\n(>=2.5L/min/m2). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate mitral annular\ncalcification. Trivial MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR.\nNormal PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thickness, cavity\nsize and regional/global systolic function are normal (LVEF >55%). The\nestimated cardiac index is normal (>=2.5L/min/m2). Right ventricular chamber\nsize and free wall motion are normal. The diameters of aorta at the sinus,\nascending and arch levels are normal. The aortic valve leaflets (3) are mildly\nthickened but aortic stenosis is not present. No aortic regurgitation is seen.\nThe mitral valve leaflets are mildly thickened. Trivial mitral regurgitation\nis seen. The tricuspid valve leaflets are mildly thickened. The estimated\npulmonary artery systolic pressure is normal. There is no pericardial\neffusion.\n\nIMPRESSION: Normal global and regional biventricular systolic function. No\npulmonary hypertension or pathologic valvular disease seen.\n\nCompared with the resting images of the prior study of , the findings\nare similar.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2137-06-12 00:00:00.000",
"description": "Report",
"row_id": 262899,
"text": "Sinus rhythm. The P-R interval is prolonged. There is a late transition\nconsistent with possible myocardial infarction. Low voltage in the precordial\nleads. Non-specific ST-T wave changes. Compared to the previous tracing\nof precordial lead voltage is much less.\n\n"
},
{
"category": "ECG",
"chartdate": "2137-06-11 00:00:00.000",
"description": "Report",
"row_id": 262900,
"text": "Artifact is present. Sinus rhythm. The P-R interval is prolonged.\nNon-specific ST-T wave changes. Compared to the previous tracing of \nthere is no significant change.\n\n"
},
{
"category": "ECG",
"chartdate": "2137-06-08 00:00:00.000",
"description": "Report",
"row_id": 262901,
"text": "Sinus rhythm. First degree A-V delay. Probable left atrial abnormality.\nNon-specific anterolateral ST-T wave changes. No change compared to .\n\n"
},
{
"category": "ECG",
"chartdate": "2137-06-14 00:00:00.000",
"description": "Report",
"row_id": 262897,
"text": "Sinus rhythm. Anterior T wave inversion. First degree A-V delay. Compared to\nthe previous tracing of there is no change.\n\n"
},
{
"category": "ECG",
"chartdate": "2137-06-13 00:00:00.000",
"description": "Report",
"row_id": 262898,
"text": "Sinus rhythm. Borderline P-R interval prolongation. Diffuse T wave flattening\nwhich is non-specific. Compared to the previous tracing of there is no\nsignificant diagnostic change.\n\n"
}
] |
11,947 | 199,058 | The patient was admitted on , and underwent a coronary artery bypass graft times three with left internal mammary artery to the left anterior descending, reversed saphenous vein graft to the obtuse marginal and right coronary artery, cross-plant time 44 minutes, total bypass time 70 minutes. He was transferred to the CSRU on Neo-Synephrine and Propofol in stable condition. He did have labile blood pressure swings immediately postoperative and required volume for this. He was extubated on postoperative night. Postoperative day number one, his chest tubes were discontinued and he remained on Neo-Synephrine. This was slowly weaned off and on postoperative day three, he was transferred to the floor in stable condition. He had his epicardial pacing wires discontinued. He continued to have a stable postoperative course. He did have some tachycardia which responded well to beta blocker. He got very anxious and got combative and was seen by psychiatry who recommended low dose Ativan which eventually his anxiety subsided. He continued to progress and, on postoperative day number eight, he was discharged to home in stable condition. His laboratories on discharge included a hematocrit of 32.4, white blood cell count 7.2, platelet count 390,000. Sodium 141, potassium 4.1, chloride 105, CO2 25, blood urea nitrogen 13, creatinine 0.9, blood sugar 95. | Resp alkolotic. volume,weaning neo as tolerated. REPLETE K+ PRN. Weaned neo gtt off. Hypoactive bs. Titrated to NBP. Pt requested percocet. Rehab: As above.A: Less neo. ID: Tmax 100.7, down after percocet. IMPRESSION: Small pleural effusions and focal left basilar atelectasis following CABG. Pt w/ low PAP's and CVP. Encouraged pt to CDB and IS. Palpable dp, dopplerable pt pulses. SPo2 100 2L Np.GU: Brisk Uop >100c qhr.GI: Soft abd. Endo: SSRI. Continue to wean neo. Restarted Neo. Rule out pneumothorax. Patient is s/p median sternotomy and CABG. Notified Dr. . PT. PT. IMPRESSION: 1) Tubes and lines as described. COMPARISON made to cxr. + periph pulses, trace edema, hands cool.Resp: R/A w/ 02sat 95-98%. extubated to np's w/o incident. Tolerating clear liquids.A/P Labile bp in the setting of low filling pressures and autodiurese.Wean Neo as tol. Clinical correlation issuggested. DELINE CORDIS & ALINE. Periph line and dc cordis. 2) Possible tiny right apical pneumothorax. Monitor BP off neo. A/P Continuing to require neo. CSRU Progress NoteS/O: Neuro: A+O, med with percocet. Effect pending at this time.CV: Remains on Neo gtt for bp. Poor exercise tolerance.P: Cont efforts to wean neo. Pao2 65. cuff leak + w vocalization around ett cuff. darvocet given.importance of pain control reiterated.bp stabilizing after signif. DENIES NEED FOR PAIN MED.DIURESING WELL; K+ REPLETED.PLAN: WEAN NEO TO OFF & TRANSFER TO FLOOR IF STABLE. Heme: Aspirin. Pulm toilet. Pulm toilet. s/p cabg x 3 csru npn 7a-7ps-"i'm anxious about getting up"o-neuro-intactcv-bp remains labile 60's-110's on neo gtt 1.5-2mcg/k/min.+dp/pt ble,hr 80's-100's nsr->st no vea.mediastinal/pleural ct's dc'd this pm,pa cath dc'd this pm.resp-ls cta decreased @ bases,c+db well w/ enc,o2 weaned to off,ra o2 sats97-99%.rr 18-20's nard.flovent mdi this pm.gi/gu-pt tol clear w/o diff,ate some fruit for lunch,u/o adeq amts clear yellow urine via foley cath.pt abd soft +hypoactive bs.skin-pt back and buttock grossly intact.soc-pt wife and son visited this pm.endo-fsbs99-110id-afebrilea-labile bp on neo gttp-vs,neo prn to maint sbp>90 map>60/tm,monitor resp status qs and prn,enc c+db wa,i+o,monitor skin integrity qs and prn,fsbs. amts crystalloid.discussed w team,lr to continue for now. 2 Given. COMPARISON: AP SUPINE SINGLE VIEW OF THE CHEST: ET tube is in good position. There is a possible tiny right apical pneumothorax. ENCOURAGE PULM TOILET. Pain mgmt. ct's w scant sero sang. remains on neo as recorded. There are post operative changes of CABG with sternal wires and mediastinal clips. Sinus rhythmNonspecific T wave flattening ( lll, aVL, V4-5 )Poor R wave progressionSince previous tracing, T wave changes Using IS to 1250.GU/GI: Abd soft, +BS, no BM. There is a left chest tube. The heart size and mediastinal contours are within normal limits. Med prn for incisional discomfort.Access: RIJ cordic d/cl'd. Hr St 100's. ? Interval improvement in degree of atelectasis with prior postoperative radiograph. A+Ox3, pleasantly following commands. There has been interval removal of various lines and tubes. There is interval improvement in degree of left lower lobe atelectasis with residual area of atelectasis remaining in the retrocardiac region. Sinus tachycardia. hct essentially unchanged despite lg. Resp: Room air. ST 100-115. CV: Neo .25 with BP 90s. NEURO: A+Ox3. c & r thick blood tinged tan.advanced to clear liqs,tolerated well. HR 90's. Following commands. CI 3.03-3.19.RESP: Lungs are clear. #20PIV placed in RFA. incisional splinting w cough pillow reinforced. Small pleural effusions are noted bilaterally, left greater than right. At 1330, Pt ambulated again w/o any difficulties. Medicated w/ 2 darvocet for pain. There are T wave inversions in leads V3-V4. The NG tube is in the stomach. Taking diet fair, po fluids well. Renal: Foley out, voiding large amts. dng sespite ooziness intra op.exrubation deferred,no cuff leak detected.lethargic,appropriate when awakened.telephone update to wife given. Continue to monitor cardiac/resp/neuro status. Medicated w/ 2 percocet for pain. Nontender. Continues to autodiurese >100cc hr. BP at this time = 125/70. Maintained BP, no sx. FULL CODE Universal Precautions NKDANeuro/Cardiac: AAOx3, MAEx4 - OOB to chair, ambulated in hallx2. Pt continued to have pain 2hours following darcocet. extremely labile bp w wide swings from high 60's to mid 160's w increasing hr,continued low filling pressures w huge dilute appearing huo.multiple lr boluses given w transient effect.cuff correlates well. Since the previous tracing of the heart rate hasincreased. Advance activity as tol, but monitor closely. cuff now ~ 10 mm hg higher in lt. arm. more volume. Stable transfer bed-chair. But pt is very anxious and will tell you so! He sat in the chair and BP back to 90-100/ and he felt ok. Neo was not restarted. reluctant to take pain med but w incisional splinting/grimacing noted. Spo2 > 96%. Pleasant. Bp dropped to 82/51 Map 50's. No ectopy. No ectopy. Raising small amts thick tan secretions. Med w/ Percocet for insisional discomfort when back to bed after ambulating and RIJ cordis and chest dreassings redressed/pacer d/c'd. NEO BEING WEANED SLOWLY TO MAP> 60.TAKING PO'S (PILLS) WITHOUT DIFFICULTY. The pulmonary vascularity is normal. Voids in urinal. Pt raised thick tan blood tinged secretions. The Swan- Ganz catheter tip is located in the right pulmonary artery. Lungs clear bilat, Good cough effort producing clear white sputum. The first time he walked this am w/ PT, SBP down to 80/ (from 98-100s), but he became light-headed. Neo had been off since 7am. refusing percocet & mso4 as he states it makes him "loopy". 11:09 AM CHEST (PA & LAT) Clip # Reason: s/p CABG w/decreased BS-r/o effusion/atelectasis Admitting Diagnosis: CORONARY ARTERY DISEASE\CORONARY ARTERY BYPASS GRAFT/SDA MEDICAL CONDITION: 63 year old man with as above REASON FOR THIS EXAMINATION: s/p CABG w/decreased BS-r/o effusion/atelectasis FINAL REPORT TWO VIEWS CHEST: INDICATION: Decreased breath sounds following CABG. | 12 | [
{
"category": "Radiology",
"chartdate": "2144-01-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 814752,
"text": " 10:25 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ro ptx\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with\n REASON FOR THIS EXAMINATION:\n ro ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 63 y/o male status post CABG. Rule out pneumothorax.\n\n COMPARISON: \n\n AP SUPINE SINGLE VIEW OF THE CHEST: ET tube is in good position. The Swan-\n Ganz catheter tip is located in the right pulmonary artery. There is a left\n chest tube. There are post operative changes of CABG with sternal wires and\n mediastinal clips.\n\n There is a possible tiny right apical pneumothorax. There is no evidence of a\n left pneumothorax. The NG tube is in the stomach.\n\n IMPRESSION:\n\n 1) Tubes and lines as described.\n 2) Possible tiny right apical pneumothorax. No evidence of a left\n pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2144-01-14 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 815456,
"text": " 11:09 AM\n CHEST (PA & LAT) Clip # \n Reason: s/p CABG w/decreased BS-r/o effusion/atelectasis\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with as above\n REASON FOR THIS EXAMINATION:\n s/p CABG w/decreased BS-r/o effusion/atelectasis\n ______________________________________________________________________________\n FINAL REPORT\n\n TWO VIEWS CHEST:\n\n INDICATION: Decreased breath sounds following CABG.\n\n COMPARISON made to cxr.\n\n There has been interval removal of various lines and tubes. Patient is s/p\n median sternotomy and CABG. The heart size and mediastinal contours are\n within normal limits. The pulmonary vascularity is normal. There is\n interval improvement in degree of left lower lobe atelectasis with residual\n area of atelectasis remaining in the retrocardiac region. Small pleural\n effusions are noted bilaterally, left greater than right. No pneumothorax is\n identified.\n\n IMPRESSION: Small pleural effusions and focal left basilar atelectasis\n following CABG. Interval improvement in degree of atelectasis with prior\n postoperative radiograph.\n\n\n\n"
},
{
"category": "ECG",
"chartdate": "2144-01-12 00:00:00.000",
"description": "Report",
"row_id": 261696,
"text": "Sinus tachycardia. Since the previous tracing of the heart rate has\nincreased. There are T wave inversions in leads V3-V4. Clinical correlation is\nsuggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2144-01-07 00:00:00.000",
"description": "Report",
"row_id": 261697,
"text": "Sinus rhythm\nNonspecific T wave flattening ( lll, aVL, V4-5 )\nPoor R wave progression\nSince previous tracing, T wave changes\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2144-01-10 00:00:00.000",
"description": "Report",
"row_id": 1418990,
"text": "A+Ox3, pleasantly following commands. Medicated w/ 2 percocet for pain. Weaned neo gtt off. Bp dropped to 82/51 Map 50's. Restarted Neo. Hr St 100's. No ectopy. Resp alkolotic. Pao2 65. Spo2 > 96%. Encouraged pt to CDB and IS. Raising small amts thick tan secretions. Voids in urinal. A/P Continuing to require neo. Continue to wean neo. Pulm toilet.\n"
},
{
"category": "Nursing/other",
"chartdate": "2144-01-10 00:00:00.000",
"description": "Report",
"row_id": 1418991,
"text": "FULL CODE Universal Precautions NKDA\n\n\nNeuro/Cardiac: AAOx3, MAEx4 - OOB to chair, ambulated in hallx2. The first time he walked this am w/ PT, SBP down to 80/ (from 98-100s), but he became light-headed. Neo had been off since 7am. He sat in the chair and BP back to 90-100/ and he felt ok. Neo was not restarted. At 1330, Pt ambulated again w/o any difficulties. Maintained BP, no sx. BP at this time = 125/70. But pt is very anxious and will tell you so! Med w/ Percocet for insisional discomfort when back to bed after ambulating and RIJ cordis and chest dreassings redressed/pacer d/c'd. + periph pulses, trace edema, hands cool.\n\nResp: R/A w/ 02sat 95-98%. Lungs clear bilat, Good cough effort producing clear white sputum. Using IS to 1250.\n\nGU/GI: Abd soft, +BS, no BM. Taking diet fair, po fluids well. Voiding 400cc at a time via urinal.\n\nPlan: TX to floor when bed available. Continue to monitor cardiac/resp/neuro status. Monitor BP off neo. Med prn for incisional discomfort.\n\nAccess: RIJ cordic d/cl'd. #20PIV placed in RFA.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2144-01-07 00:00:00.000",
"description": "Report",
"row_id": 1418984,
"text": "extremely labile bp w wide swings from high 60's to mid 160's w increasing hr,continued low filling pressures w huge dilute appearing huo.multiple lr boluses given w transient effect.cuff correlates well. remains on neo as recorded. hct essentially unchanged despite lg. amts crystalloid.discussed w team,lr to continue for now. ct's w scant sero sang. dng sespite ooziness intra op.exrubation deferred,no cuff leak detected.lethargic,appropriate when awakened.telephone update to wife given.\n"
},
{
"category": "Nursing/other",
"chartdate": "2144-01-07 00:00:00.000",
"description": "Report",
"row_id": 1418985,
"text": "cuff leak + w vocalization around ett cuff. extubated to np's w/o incident. incisional splinting w cough pillow reinforced. c & r thick blood tinged tan.advanced to clear liqs,tolerated well. reluctant to take pain med but w incisional splinting/grimacing noted. refusing percocet & mso4 as he states it makes him \"loopy\". darvocet given.importance of pain control reiterated.bp stabilizing after signif. volume,weaning neo as tolerated. cuff now ~ 10 mm hg higher in lt. arm.\n"
},
{
"category": "Nursing/other",
"chartdate": "2144-01-08 00:00:00.000",
"description": "Report",
"row_id": 1418986,
"text": "NEURO: A+Ox3. Pleasant. Following commands. Medicated w/ 2 darvocet for pain. Pt continued to have pain 2hours following darcocet. Pt requested percocet. 2 Given. Effect pending at this time.\n\nCV: Remains on Neo gtt for bp. Titrated to NBP. Pt w/ low PAP's and CVP. Continues to autodiurese >100cc hr. Notified Dr. . HR 90's. No ectopy. Palpable dp, dopplerable pt pulses. CI 3.03-3.19.\n\nRESP: Lungs are clear. Pt raised thick tan blood tinged secretions. SPo2 100 2L Np.\n\nGU: Brisk Uop >100c qhr.\n\nGI: Soft abd. Hypoactive bs. Nontender. Tolerating clear liquids.\n\nA/P Labile bp in the setting of low filling pressures and autodiurese.\n\nWean Neo as tol. ? more volume. Pulm toilet. Pain mgmt.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2144-01-08 00:00:00.000",
"description": "Report",
"row_id": 1418987,
"text": "s/p cabg x 3 csru npn 7a-7p\ns-\"i'm anxious about getting up\"\no-neuro-intact\ncv-bp remains labile 60's-110's on neo gtt 1.5-2mcg/k/min.+dp/pt ble,hr 80's-100's nsr->st no vea.mediastinal/pleural ct's dc'd this pm,pa cath dc'd this pm.\nresp-ls cta decreased @ bases,c+db well w/ enc,o2 weaned to off,ra o2 sats97-99%.rr 18-20's nard.flovent mdi this pm.\ngi/gu-pt tol clear w/o diff,ate some fruit for lunch,u/o adeq amts clear yellow urine via foley cath.pt abd soft +hypoactive bs.\nskin-pt back and buttock grossly intact.\nsoc-pt wife and son visited this pm.\nendo-fsbs99-110\nid-afebrile\na-labile bp on neo gtt\np-vs,neo prn to maint sbp>90 map>60/tm,monitor resp status qs and prn,enc c+db wa,i+o,monitor skin integrity qs and prn,fsbs.\n"
},
{
"category": "Nursing/other",
"chartdate": "2144-01-09 00:00:00.000",
"description": "Report",
"row_id": 1418988,
"text": "PT. SLEPT MOST OF THE NIGHT. NEO BEING WEANED SLOWLY TO MAP> 60.\nTAKING PO'S (PILLS) WITHOUT DIFFICULTY. PT. DENIES NEED FOR PAIN MED.\nDIURESING WELL; K+ REPLETED.\nPLAN: WEAN NEO TO OFF & TRANSFER TO FLOOR IF STABLE. DELINE CORDIS & ALINE. REPLETE K+ PRN. ENCOURAGE PULM TOILET.\n"
},
{
"category": "Nursing/other",
"chartdate": "2144-01-09 00:00:00.000",
"description": "Report",
"row_id": 1418989,
"text": "CSRU Progress Note\nS/O: Neuro: A+O, med with percocet.\n CV: Neo .25 with BP 90s. ST 100-115. Walked with physical therapists, c/o dizziness with mom LOC, sat in chair with instant recovery. Stable transfer bed-chair.\n Resp: Room air.\n Renal: Foley out, voiding large amts.\n Heme: Aspirin.\n ID: Tmax 100.7, down after percocet.\n GI: Eating small amts.\n Endo: SSRI.\n Rehab: As above.\nA: Less neo. Poor exercise tolerance.\nP: Cont efforts to wean neo. Advance activity as tol, but monitor closely. Periph line and dc cordis.\n\n"
}
] |
2,365 | 198,301 | The patient is a 48-year- old female with a history of HIV diagnosed on and HCV confection, since complicated by cirrhosis, portal hypertension and esophagovariceal hemorrhage. The patient underwent a prior transhepatic intraportal systemic shunt(TIPS) procedure and has had severe hepatic encephalopathy and recent recurrent hemorrhage. The patient was evaluated for a liver transplantation and was found to be a suitable candidate. She was brought to the operating room on /5 for an OLT. During the procedure It was difficult and ultimately not possible to fit the donor liver into the abdominal cavity of the patient. The decision to perform a portal caval shunt was made. And At this point, the patient was listed as a status 1 for liver transplantation. She remained in the operating room, receiving blood and blood products. During this time, she was oxygenating well and remained hemodynamically stable. Her coagulopathy was able to be corrected and maintained. A donor liver was made available and ultimately brought to the operating room. Successful OLT was perform patient was to the ICU, with no neurological deficit. Was extuated on transfered to the floor 2 days after. And this point is stable tolerating regular diet and tube feedings. | An inferior vena cava filter is again noted in an infrarenal position. Suboptimal evaluation of the hepatic vasculature. Stable appearance of right lower lobe collapse/consolidation and small right pleural effusion. Right pleural effusion with associated right lower zone atelectasis. A perihepatic drain exits in the right lower quadrant. Again note is made of bilateral pleural effusions with right lower lobe atelectasis. A right internal jugular venous access catheter is in place with the tip terminating at the level of the SVC/RA junction. FINDINGS: An endotracheal tube is in place with the tip terminating 3.1 cm from the carina. A Swan-Ganz catheter has been removed, and a right internal jugular catheter terminates in the superior vena cava. CT OF THE PELVIS WITH IV CONTRAST: A small amount of free fluid is noted within the pelvis. A nasogastric tube is present, and an IVC filter is noted. A small caliber left subclavian central venous catheter is present with the tip overlying the distal SVC. There is new hazy opacity at the right base with relative preservation of the right hemidiaphragm, findings that could be related to layering small pleural effusion at the right base. Mild (1+) aorticregurgitation is seen. FINDINGS: The endotracheal tube, left subclavian venous line, and right-sided drainage tube are unchanged compared to the prior study. SUPINE AP CHEST: The endotracheal tube, left internal jugular central venous catheter sheath, left subclavian central venous catheter, and NG tubes are unchanged in position. A right pleural effusion remains with associated compression atelectasis of the right lower lobe. A right internal jugular vascular catheter is unchanged in position. On the current study, a right pleural effusion layering posteriorly is well visualized. The right subdiaphragmatic drainage tube has been removed. Cardiac and mediastinal contours are within normal limits. SUPINE AP CHEST: The endotracheal tube, left internal jugular catheter sheath, right internal jugular Swan-Ganz catheter, left subclavian central line, NG tube, surgical drains, and IVC filter are unchanged in position compared to the prior exam. The cardiac and mediastinal contours are within normal limits. IMPRESSION: 1) Low position of right internal jugular vascular catheter, terminating within the lower portion of the right atrium. bp stable, tolerating ^ dose lopressor.resp status: weaned to cpap peep8 ps 18. bbs coarse to slt coarse after suctioning. CONDITION UPDATEPLEASE SEE CAREVUE FLOWSHEET FOR SPECIFICS.NEURO: PROPOFOL AND FENT GTT'S WEANED DOWN. SCANT SECRETIONS, CLEAR.CV: TMAX 100.9 THIS SHIFT. Incision C/D/I. FLUID BAL SL POS SINCE MN.GI: SBD SOFT. Tube feeding restarted through NG. Cont wean PSV. F/U CXR, U/S, CT RESULTS. INFORMED, PAN CX.ENDO: REMAINS ON INS GTT FOR FS CONTROL.PLAN: MONIOTR VS, LABS, RESP STATUS, NEURO STATUS. Plan to extub if am mechanics acceptable. Cont PSV/wean. Resp Care Note:Pt cont intub with OETT and on mech vent as per Carevue. Resp Care Note:Pt cont intub with OETT and on mech vent as per Carevue. Resp Care Note:Pt cont intub with OETT and on mech vent as per Carevue. Pt episode of ^RR/HR/BP and dropped Vt; increased PSV with good result; later returned to previous settings. TACHYCARDIC TO 130S. PA CATH CHANGED TO NON-HEPARIN COATED AND PLACEMENT CONFIRMED BY CXR MD . Scleral jaundice.ETT tube intact; tape changed. PROPOFOL RESUMED WITH IMPROVED VS. SEDATION WITH EFFECT.LUNGS COARSE BILAT. PERRL.RESP: LS CTA. BS coarse R>L. NGT WITH SM AMT CLEAR O/P. PRECEDEX DISCONTINUED D/T POOR EFFECT. COAGS STABLE.GI: ABD SOFT. Resp CarePt. FOCUS: STATUS UPDATEDATA:PT SEDATED ON PROPOFOL. SM AMT SECRETIONS VIA ETT SUCTION.CV: AFEBRILE. HYPOACTIVE BS. SUCTIONED FOR MODERATE AMOUNTS CLEAR SECRETIONS. LSC dual-lumen and left rad. HR 115-130, BP 110-120/80-85, and temp 38.4 oral (cooling blanket still on). WEAN OFF PROPOFOL AS ABLE. HYPOACTIVE BS.CONTINUES ON LASIX WITH GOOD EFFECT.PLAN:CONTINUE TO WEAN OFF VENT AS ABLE. Temp 99.9 oral. T-tube intact and draining moderate amounts bilious. D/C ALL HEPARIN. Resp. T-tube intact and draining bilious. CONTINUES ON CPAP WITH PS. Last ABG 730/36/159/18/-7/100. a-line extremely positional; going by cuff pressure.ETT intact. HCT stable. CONDITION UPDATEPLEASE SEE CAREVUE FLOWSHEET FOR SPECIFICS.NEURO: PT SEDATED ON PROPOFOL AND FENTANYL GTTS. to wean from vent and wean from propofol. FOCUS: STATUS UPDATEDATA:PT LIGHTLY SEDATED ON PROPOFOL DRIP. ABG STABLE.CONTINUES ON LASIX WITH GOOD EFFECT. CONDITION UPDATED.AFEBRILE,SR-ST,RR16-26,O2 SAT=99 ON 2L NP,BP 117-140/60. POSSIBLE EXTUBATION THIS AM.GI: ABD SOFT, NT/ND, +HYPO BOWEL SOUNDS, REMAINS NPO FOR POSSIBLE EXTUBATION THIS AM. SBP 90S-130.HCT 25.7 DR. STRTED ON IVF FOR U/O AND DUE TO PT REMAINING NPO. SVO2 RECAL'D. Resp CarePt. MEDS RESUMED (EXCEPT HEPARIN). NS 250CC X 2 GIVEN WITH MINIMAL EFFECT.ENDO-BS QID WITH SC COVERAGESKIN- TMAX 98.6 ABD STAPLES C/D/I OTA, T-TUBE DSG C/D/I, RLQ DSG INATCT ? care note - Pt. care note - Pt. secreations minimal thick.Plan: continue current support. NO DISTRESS NOTED.GI-ABD SOFT, SLIGHTLY DISTENDED, (+) BSX4, LG LOOSE BM X2, T-TUBE IN PLACE AND PATENT. ?POST-PYLORIC DOBHOFF PLACEMENT FOR TF TODAY. OLD DRAIN SITE.COMFORT-DENIES PAIN/DISC.A/P-CONTINUE WITH CURRENT CARE PLAN. Dr notified. INCISION REMAINS C/D/I W/ CLIPS. TOL CLRS (30CC/HR) WITHOUT DIFF. WEAN OFF O2 AS TOL. Respiratory Care:Pt. NO C/O OF PAIN EXCEPT AT 0400,PT C/O ABD PAIN AND CONFIRMED ABD CRAMPS..PT HAD STOOL,LOOSE X2 THRU THE NITE.A. remaines intubated and vented, transffered to CT and back to SICUB without incident. Last ABG: pH 7.38, PaCO2 51, PaO2 102, bicarb 31, BE 3. CXR TO BE DONE IN AM.GI: ABD SOFT NT/ND, HYPO BOWEL SOUNDS, TF IMPACT W/ FIBER AT 60CC/HR W/ GOAL RATE 90CC/HR, MINIMAL RESIDUALS. RESPONSE TO DIAMOX PENDING.ENDO: FSBG COVERED PER RISS.SKIN: SURGICAL ABD DSG INTACT. MDI'S Q4, SUCTIONING MINIMAL SECRECTIONS. Q4 CBC, Fibrinogen, PT, PTT, and ABG's. DUIRESE WITH DIAMOX AS ORDERED. Left femoral A-line tip sent for cx. SMA MT OLD SEROUS DRG. ARRIVED TO SICU, INTUBATED ON PROPOFOL AND NTG. LAST ABG 7.38/52/132/32/4/98. lungs exp wheeze/coarse/clear sx sm amt of thick tan secretions albuterol tx given cxr taken to determine reason for decreasing o2 sat, adjustments made as aboveCVS HR 127-107 ST without ectopy PAP s/D 61/36-50/31 CO 9.1 CI 5.2 CVP 16 bp 161/87-137/75 lopressor 5mg IV given x2 skin w+d pp+4 Hct 36.4GI abd soft BS absent Dsg D+I JP lat 70cc, T 75cc, JP med 22, ngt 200cc bilious, amylase 111, LDH 659, AST 735, ALT 927, alk phos 119. | 102 | [
{
"category": "Radiology",
"chartdate": "2179-03-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 857753,
"text": " 3:24 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: confirm line positioning\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48F s/p liver txp, now s/p line replacment\n REASON FOR THIS EXAMINATION:\n confirm line positioning\n ______________________________________________________________________________\n FINAL REPORT\n Portable supine chest compared to previous study of earlier the same\n date.\n\n CLINICAL INDICATION: Line repositioning.\n\n FINDINGS:\n\n The examination is limited due to exclusion of the extreme lung apices from\n the radiograph.\n\n A left subclavian catheter has been advanced in the interval into the superior\n vena cava. A Swan-Ganz catheter has been removed, and a right internal\n jugular catheter terminates in the superior vena cava. Endotracheal tube\n remains in satisfactory position. A nasogastric tube is notable for the\n sideport above the GE junction level although the distal tip is in the\n stomach. There is patchy right lower lobe opacity, most suggestive of\n atelectasis. A drain is seen in the upper abdomen. No pneumothorax is\n identified on the supine study although exclusion of the extreme apices limits\n assessment for this finding.\n\n IMPRESSION:\n\n 1) Satisfactory position of vascular catheter. No pneumothorax on this\n limited study.\n\n 2) Proximal location of NG tube sideport, which should be advanced for more\n optimal placement.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-03-07 00:00:00.000",
"description": "CTA ABD W&W/O C & RECONS",
"row_id": 857175,
"text": " 10:01 AM\n CTA ABD W&W/O C & RECONS; 200CC NON IONIC CONTRAST SUPPLY Clip # \n Reason: SPIKING TEMPS, OPEN FASCIA, S/P LIVER TRANSPLANT, EVALUATE FOR HEPATIC FLOW IN PHASES\n Admitting Diagnosis: LIVER FAILURE\n Field of view: 40 Contrast: OPTIRAY Amt: 200\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman with\n REASON FOR THIS EXAMINATION:\n CT abdomen ANGIOGRAM to evalaute for heptic flow in phases.ALSO CT abdomen to\n r/o abcess or collection.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Spiking fevers. Status post liver transplant.\n\n TECHNIQUE: Multidetector, multiphasic, helical axial imaging of the abdomen\n and pelvis before and after the administration of intravenous contrast.\n Coronal and sagittal reformatting.\n\n CONTRAST: 200 cc of Optiray intravenously. Nonionic contrast was administered\n due to the fast bolus requirement.\n\n COMPARISON: Direct comparison is made with the prior study dated . The\n most recent studies of and are unavailable for direct\n comparison at this time. The reports were reviewed. That are no comparison\n studies since the patient's liver transplant.\n\n CTA ABDOMEN WITH AND WITHOUT CONTRAST:\n\n The patient had suboptimal intravenous access, and a suitable peripheral IV\n could not be obtained. As a result, there is suboptimal timing of the\n contrast bolus, limiting the evaluation of the hepatic vascularture and\n particulary the hepatic artery. The celiac axis is grossly patent proximally.\n The hepatic and portal veins are grossly patent. There is a triangular\n irregularity in the region of the hepatic vein confluence, but this appearance\n may be projectional given the fact that it appears normal on the coronal and\n sagittal reconstructions. There is no hepatic perfusion defect detected. The\n periportal edema is a common post-transplant finding. The spleen remains\n enlarged. The pancreas, adrenal glands and kidneys are unremarkable. Small\n retroperitoneal nodes are present. There is no abnormal bowel wall thickening\n or bowel loop dilatation. There are minor scattered amounts of fluid without\n discrete collections. There is no free air.\n\n A perihepatic drain exits in the right lower quadrant. Another drain,\n possibly biliary, extends from the region of the porta and exits the anterior\n abdomen near the midline below the umbilicus. A nasogastric tube is present,\n and an IVC filter is noted.\n\n Limited imaging of the lung bases shows consolidation with air bronchograms in\n the right lung base, possibly representing pneumonia, particularly in the\n given clinical setting. A small right pleural effusion has developed.\n\n (Over)\n\n 10:01 AM\n CTA ABD W&W/O C & RECONS; 200CC NON IONIC CONTRAST SUPPLY Clip # \n Reason: SPIKING TEMPS, OPEN FASCIA, S/P LIVER TRANSPLANT, EVALUATE FOR HEPATIC FLOW IN PHASES\n Admitting Diagnosis: LIVER FAILURE\n Field of view: 40 Contrast: OPTIRAY Amt: 200\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n CT PELVIS WITH CONTRAST: A Foley catheter is present in the mostly\n decompressed bladder. There is mild presacral edema. The pelvic viscera are\n unremarkable. No pelvic mass, lymphadenopathy or fluid collection is detected.\n\n CT RECONSTRUCTIONS: Coronal and sagittal reformatting was performed for\n additional assessment of the abdominal and pelvic viscera. As stated above,\n the suboptimal intravenous access and bolus timing limits the evaluation of\n the hepatic vasculature. There is minimal scattered fluid without discrete\n collection.\n\n BONE WINDOWS: No suspicious lytic or blastic lesions are detected.\n\n IMPRESSION:\n 1. Suboptimal evaluation of the hepatic vasculature.\n 2. Persistent splenomegaly.\n 3. A small right pleural effusion. Right basilar consolidation may represent\n pneumonia, particularly in the given clinical scenario.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-03-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 858446,
"text": " 1:56 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate, plugging\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48F s/p liver txp, now with desats\n REASON FOR THIS EXAMINATION:\n eval for infiltrate, plugging\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE AP FILM:\n\n HISTORY: Liver transplant with oxygen desaturation.\n\n Endotracheal tube is 3 cm above the carina. Right jugular CV line is in right\n atrium. Suggest withdrawal 3-4 cm. NG tube is in stomach with distal\n end not included on the film. No pneumothorax. Allowing for technique, the\n heart size is normal. No evidence for CHF. There is a right sided pleural\n effusion with associated atelectasis in the right lower zone.\n\n IMPRESSION:\n\n Jugular CV line is in right atrium. No pneumothorax. Right pleural effusion\n with associated right lower zone atelectasis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-03-16 00:00:00.000",
"description": "BILAT LOWER EXT VEINS",
"row_id": 858317,
"text": " 2:08 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: please evaluate for DVT\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman with\n REASON FOR THIS EXAMINATION:\n please evaluate for DVT\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: Lower extremity swelling, assess for DVT.\n\n BILATERAL LOWER EXTREMITY VEINS ULTRASOUND: Grayscale and color Doppler\n images of both common femoral, superficial femoral, and popliteal veins were\n obtained. Normal waveforms, compressibility and augmentation are\n demonstrated. No intraluminal thrombus is identified.\n\n IMPRESSION: No evidence of lower extremity DVT.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-03-17 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 858492,
"text": " 8:40 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOPP ABD/PEL\n Reason: ELEV LFTS, LIVER TX, ASSESS VASCULAR STRUCTURES\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman with HCV cirrhosis and varices admitted with hematemisis\n - now s/p redo tips - would like to re-eval tips to obtain baseline flow\n velocities\n REASON FOR THIS EXAMINATION:\n sp liver transplant asesse vascular structures\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post liver transplant with elevated LFTs.\n\n COMPARISON: Comparison is made to .\n\n TRANSPLANT ULTRASOUND WITH COLOR DOPPLER: -scale images show no focal or\n diffuse hepatic abnormalities. There is no evidence of intrahepatic bile duct\n dilatation. Trace amount of fluid around the liver in the Morison's pouch.\n\n Color Doppler images of the liver were obtained. The main, right, and left\n portal veins are patent with blood flow in the appropriate direction. The\n intrahepatic portions of the left and right hepatic arteries are also\n demonstrated with normal appearing waveforms. Resistive indices are\n 0.83-0.84. The main hepatic artery is patent. The hepatic veins and the\n inferior vena cava are patent.\n\n IMPRESSION:\n 1) The hepatic vessels are patent.\n 2) Trace amount of fluid around the liver.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-03-16 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 858349,
"text": " 4:54 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: SP Liver tx please eval for intraabdominal abscess\n Admitting Diagnosis: LIVER FAILURE\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman with\n\n REASON FOR THIS EXAMINATION:\n SP Liver tx please eval for intraabdominal abscess\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post liver transplant. Evaluate for intraabdominal abscess.\n\n COMPARISON: .\n\n TECHNIQUE: MDCT acquired contiguous axial images from the lung bases to the\n pubic symphysis were obtained following the administration of 150 cc of IV\n Optiray. Nonionic contrast was administered secondary to patient request.\n\n CT OF THE ABDOMEN WITH IV CONTRAST: Again demonstrated is right lower lobe\n collapse/consolidation with air bronchograms, not significantly changed since\n the prior examination, along with a small right pleural effusion.\n Additionally, within the periphery of the right middle lobe, there is an ill-\n defined nodular opacity seen measuring approximately 1 cm. A second nodular,\n peripherally based opacity is also demonstrated within the right lower lobe\n which measures approximately 1.1 cm. Minor atelectatic changes are noted\n within the left lower lobe.\n\n Again, demonstrated within the transplanted liver are several tiny\n hypodensities, unchanged since the prior examination, too small to fully\n characterize. A mild amount of periportal edema is again noted. The portal\n vein is patent. There is no intrahepatic biliary ductal dilatation seen. A\n catheter is again noted, likely representing a biliary drain, extending from\n the region of the porta and exiting via the anterior abdomen near the\n umbilicus. The gallbladder is not visualized. Small amount of perihepatic\n fluid is present as well as fluid within pouch extending anterior\n to the duodenum; the amount of fluid has mildly increased since the prior\n exam. No focal fluid collections are identified. The spleen is stablely\n enlarged. The adrenal glands, kidneys, ureters, stomach, and loops of large\n and small bowel, all appear within normal limits. A nasogastric tube is\n identified with tip in the stomach. Multiple surgical clips are noted within\n the pericaval region, they are unchanged since the prior examination. An\n inferior vena cava filter is again noted in an infrarenal position. There is\n no definite evidence for bowel obstruction.\n\n CT OF THE PELVIS WITH IV CONTRAST: A small amount of free fluid is noted\n within the pelvis. The ureters, rectum, sigmoid colon are all within normal\n limits. A Foley catheter is again visualized within the bladder with a small\n amount of air. There is no pelvic or inguinal lymphadenopathy.\n (Over)\n\n 4:54 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: SP Liver tx please eval for intraabdominal abscess\n Admitting Diagnosis: LIVER FAILURE\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n Some soft tissue stranding is demonstrated along the right lateral\n subcutaneous tissues, likely related to postoperative changes.\n\n BONE WINDOWS: No suspicious lytic or sclerotic lesions are seen.\n\n IMPRESSION:\n 1. No definite focal fluid collections identified to suggest an abscess.\n\n 2. Stable appearance of right lower lobe collapse/consolidation and small\n right pleural effusion.\n\n 3. Two ill-defined nodular opacities identified within the right middle lobe\n and right lower lobe peripherally, which may represent an infectious etiology.\n\n 4. Mildly increased amount of fluid within pouch and anterior to\n the duodenum.\n\n 5. Stable splenomegaly.\n\n\n\n\n\n DFDdp\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-03-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 857820,
"text": " 8:11 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pneumonia\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48F s/p liver txp, now s/p swan replacement\n\n REASON FOR THIS EXAMINATION:\n r/o pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 48-year-old female status post liver transplant. Please\n evaluate Swan-Ganz catheter placement.\n\n FINDINGS:\n\n Single AP view of the chest dated is compared with a single AP view\n of the chest dated . Endotracheal tube is 2.5 cm above the carina.\n The right internal jugular line terminates in the right atrium. The new left\n subclavian central line also terminates in the right atrium. The NG tube has\n been advanced, and its sideport is now located 3 cm distal to the GE junction.\n NG tube tip is in the body of the stomach. A drain remains in the right upper\n quadrant. There are skin staples overlying the mid abdomen. Clips and an IVC\n filter are seen in the mid abdomen.\n\n The lung volumes are low, likely secondary to technique. The lungs are clear\n without focal consolidation. There is no significant pulmonary venous\n congestion. There are no pleural effusions or pneumothorax. Heart and\n mediastinal contours remain unchanged.\n\n IMPRESSION:\n\n New left subclavian central line with its tip terminating in the right atrium.\n No pneumothorax. The lung fields are clear.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-03-21 00:00:00.000",
"description": "NASO-INTESTINAL TUBE PLACEMENT (W/FLUORO)",
"row_id": 858896,
"text": " 3:29 PM\n -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # \n Reason: post pyloric tube\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n please place post piloric tube this am for feedings sp liver transplant\n\n REASON FOR THIS EXAMINATION:\n post pyloric tube\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Dobbhoff tube placed. Please advance to postpyloric position for\n feeding status post liver transplant. The patient has a history of\n aspiration.\n\n COMPARISON: Portable abdomen dated .\n\n The patient arrived in the department with a Dobbhoff tube in place, with the\n tip located within the stomach at the pylorus. Under fluoroscopic guidance,\n the tip of the tube was advanced into the postpyloric position, approximately\n into the third portion of the duodenum. Approximately 10 cc of nonionic\n contrast was instilled, confirming the tube's positioning within the duodenum.\n Surgical staples overly the skin of the abdomen, and there are surgical clips\n located within the right upper quadrant.\n\n IMPRESSION: Successful advancement of the Dobbhoff feeding tube into the\n third portion of the duodenum.\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-03-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 857906,
"text": " 7:35 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval R TLC position\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48F s/p liver txp, now s/p line replacment\n\n REASON FOR THIS EXAMINATION:\n eval R TLC position\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post line replacement, evaluate triple lumen catheter\n position.\n\n COMPARISON: .\n\n TECHNIQUE: Single AP portable semiupright chest.\n\n FINDINGS: An endotracheal tube is in place with the tip terminating 3.1 cm\n from the carina. A nasogastric tube extends below the diaphragm, with the tip\n terminating below the borders of the radiograph. A right internal jugular\n venous access catheter is in place with the tip terminating at the level of\n the SVC/RA junction. Left subclavian venous access catheter with tip in the\n distal SVC. JP drain in the right upper quadrant. Surgical clips in the\n right upper quadrant. Inferior vena cava filter. Surgical skin staples\n overlying the mid abdomen. The heart size and mediastinal contours are\n unchanged. There is new hazy opacity at the right base with relative\n preservation of the right hemidiaphragm, findings that could be related to\n layering small pleural effusion at the right base. No pneumothorax. The\n osseous structures are unchanged.\n\n IMPRESSION:\n\n 1) Right internal jugular venous access catheter tip at the RA/SVC junction.\n The nasogastric tube has been advanced. Other lines and tubes are in\n unchanged position.\n\n 2) New hazy opacity at the right base, consistent with layering right pleural\n effusion.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-03-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 858735,
"text": " 3:17 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval tip position\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48F s/p liver txp, now S/P LINE EXCHANGE\n REASON FOR THIS EXAMINATION:\n eval tip position\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 48-year-old woman status post liver transplant, line exchange.\n\n TECHNIQUE: Portable AP chest radiograph.\n\n Comparison is made with the prior chest radiograph dated .\n\n FINDINGS: Right IJ line terminates at the junction of SVC and right atrium.\n No pneumothorax is identified. The patient has been extubated. The cardiac\n and mediastinal contours are unchanged. Again note is made of bilateral\n pleural effusions with right lower lobe atelectasis.\n\n IMPRESSION:\n\n Tubes and lines as described above. Persistent pleural effusion with right\n lower lobe atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-03-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 856645,
"text": " 2:40 PM\n CHEST (PORTABLE AP) Clip # \n Reason: line placement\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year s/p liver transplant\n REASON FOR THIS EXAMINATION:\n line placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post liver transplant. Line placement.\n\n COMPARISON: .\n\n SUPINE AP CHEST: There is interval placement of an endotracheal tube, with\n the tip located approximately 5 cm from the carina. A right internal jugular\n Swan-Ganz catheter has been placed, with the tip overlying the expected main\n pulmonary artery. A left internal jugular central venous catheter sheath is\n present, with the tip overlying the left brachiocephalic vein. A small\n caliber left subclavian central venous catheter is present with the tip\n overlying the distal SVC. An NG tube is seen with the tip in the expected\n stomach. The cardiac and mediastinal contours are unchanged. There are\n bilateral effusions layering posteriorly, with associated left lower lobe\n atelectasis. Within the abdomen, there is a surgical drain within the right\n upper quadrant. There is also an inferior vena cava filter. No pneumothorax\n is detected on this supine radiograph.\n\n IMPRESSION:\n\n Status post liver transplant. Multiple tubes and lines as described. No\n pneumothorax detected.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-03-01 00:00:00.000",
"description": "CHEST (PRE-OP PA & LAT)",
"row_id": 856461,
"text": " 7:28 AM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: LIVER FAILURE\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman with\n REASON FOR THIS EXAMINATION:\n pre-op\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: Preoperative assessment.\n\n Comparison is made to previous chest radiograph of .\n\n The heart size, mediastinal, and hilar contours are normal. Previously noted\n pulmonary vascular redistribution and perihilar haziness have resolved in the\n interval. There are no pleural effusions. Scoliosis is noted.\n\n IMPRESSION:\n\n No evidence of acute cardiopulmonary process.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-03-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 857086,
"text": " 9:01 AM\n CHEST (PORTABLE AP) Clip # \n Reason: follow up chf\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year s/p liver transplant\n\n REASON FOR THIS EXAMINATION:\n follow up chf\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 48-year-old female with status post liver transplant, follow up\n CHF.\n\n COMPARISON: .\n\n TECHNIQUE: AP upright single view of the chest.\n\n FINDINGS:\n\n There is a right IJ Swan-Ganz catheter with the tip in the pulmonary artery\n trunk. There is interval removal of the left IJ Cordis. The ET tube is\n located at the level of the thoracic inlet. There is an NG tube with the tip\n in the stomach. There is a left subclavian central line with the tip in the\n SVC. Cardiac, mediastinal, and hilar contours are unchanged when compared to\n prior study. There is interval slight improvement in the pulmonary edema.\n There is a right effusion. There is no evidence of pneumothorax. There are\n skin staples overlying the upper abdomen. There are multiple surgical clips\n in the right upper quadrant.\n\n IMPRESSION:\n Slight improvement of pulmonary edema. Lines and tubes as described above.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-03-02 00:00:00.000",
"description": "DUPLEX DOP ABD/PEL LIMITED",
"row_id": 856634,
"text": " 1:53 PM\n DUPLEX DOP ABD/PEL LIMITED Clip # \n Reason: liver transplant duplex: hepatic artery, hepatic veins, port\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman with HCV cirrhosis and varices admitted with hematemisis -\n now s/p redo tips - would like to re-eval tips to obtain baseline flow\n velocities\n REASON FOR THIS EXAMINATION:\n liver transplant duplex: hepatic artery, hepatic veins, portal vein, blie duct\n dil, peri hepatic fluid\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: A 48-year-old woman with HCV cirrhosis and varices, status post\n liver transplant, for evaluation.\n\n TECHNIQUE: Duplex Doppler examination of the liver.\n\n FINDINGS: The echotexture of the liver is somewhat coarse. The main, right,\n and left hepatic arteries are patent with appropriate arterial flow, and\n resistive indices ranging from 0.53-0.61. The main, left, and right portal\n veins are patent and show appropriate hepatpetal flow on Doppler color and\n waveform examinations. The right, middle, and left hepatic veins are patent\n with appropriate directional flow.\n\n IMPRESSION: Appropriate flow in the major hepatic arteries and veins, and in\n major portal veins.\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-03-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 857456,
"text": " 12:01 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval tip position\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48F s/p liver txp, now s/p swan replacement\n REASON FOR THIS EXAMINATION:\n eval tip position\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 48-year-old female status post liver transplant with placement\n of Swan-Ganz catheter. Please evaluate position of tip.\n\n FINDINGS:\n\n Single AP view of the chest dated is compared with the previous\n exam dated , also a single AP view. The tip of the Swan-Ganz\n catheter is positioned in the right lower lobe pulmonary artery. There has\n been interval improvement in the right pleural effusion. Overall, the degree\n of congestive heart failure has improved. The endotracheal tube is\n approximately 3 cm above the carina. The left subclavian central line tip\n terminates in the mid SVC. The NG tube terminates in the mid stomach. The\n cardiac, mediastinal, and hilar contours are essentially unchanged from the\n prior exam. There is a drain within the right upper quadrant. Skin staples\n overlie the upper abdomen.\n\n IMPRESSION:\n\n Swan-Ganz catheter in the right pulmonary artery. Interval improvement in the\n right pleural effusion. Improved CHF.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-03-21 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 858870,
"text": " 2:01 PM\n PORTABLE ABDOMEN; -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: eval tip position\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48F s/p dobhoff placement\n REASON FOR THIS EXAMINATION:\n eval tip position\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Chest, single view.\n\n HISTORY: Status post Dobbhoff placement.\n\n FINDINGS: Feeding tube is present with tip probably in the first portion of\n the duodenum. Skin staples are present. There is some prominent loops of\n bowel that measure up to 5 cm. It is unclear if these are small or large\n bowel. There is a right pleural effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-03-10 00:00:00.000",
"description": "CHALNAGIOGRAPHY VIA EXISTING CATHETER",
"row_id": 857613,
"text": " 2:35 PM\n CHALNAGIOGRAPHY VIA EXISTING CATHETER Clip # \n Reason: evaluate biliary tree, please do to gravity, page with\n Admitting Diagnosis: LIVER FAILURE\n Contrast: OPTIRAY Amt: 15\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman s/p liver transplant with rising bilirubin\n REASON FOR THIS EXAMINATION:\n evaluate biliary tree, please do to gravity, page with questions\n ______________________________________________________________________________\n FINAL REPORT\n\n\n\n\n\n HISTORY: 48 year-old female status post liver transplant with elevated liver\n function tests. Please performe gravity injection tube cholangiogram.\n\n PROCEDURE/FINDINGS: The procedure was performed by Dr. and Dr.\n . Dr. , the staff radiologist, was present and supervising\n throughout. The patient was placed supine on the angiography table. Her\n abdomen was prepped and draped in the standard sterile fashion. A\n fluoroscopic spot film of the abdomen was obtained, demonstrating multiple\n surgical clips within the abdominal cavity, along with an IVC filter. A tube\n cholangiogram was then performed via gravity injection of nonionic contrast.\n This revealed opacification of the left and right hepatic ducts. The left\n hepatic duct appears mildly prominent. Upon further imaging, there was free\n but slow filling of the bowel lumen beyond the choledocho-jejunal anastomosis.\n No leak or stricture was identified. Following the cholangiogram, the\n contrast was gently aspirated from the catheter and the catheter was again\n placed to external bag drainage.\n\n COMPLICATIONS: None.\n\n CONTRAST: 15 cc of 60% Optiray.\n\n IMPRESSION: Tube cholangiography via the indwelling surgical T-tube\n demonstrates normal common and right hepatic ducts. There is mild prominence\n of the left hepatic duct. There was free but delayed emptying into the bowel\n lumen beyond the choledocho-jejunal anastomosis without evidence of narrowing\n or leak.\n\n These findings were discussed with the transplant surgery service at the time\n of the procedure.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-03-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 856850,
"text": " 10:40 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p OLT, ? fluid overload\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year s/p liver transplant\n\n REASON FOR THIS EXAMINATION:\n s/p OLT, ? fluid overload\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post liver transplant. Question fluid overload.\n\n COMPARISON: .\n\n SUPINE AP CHEST: The endotracheal tube, left internal jugular catheter\n sheath, right internal jugular Swan-Ganz catheter, left subclavian central\n line, NG tube, surgical drains, and IVC filter are unchanged in position\n compared to the prior exam. The Swan-Ganz catheter tip may be slightly\n retracted and within the main pulmonary artery. No pneumothorax is detected\n on this supine radiograph. The cardiac and mediastinal contours are stable.\n The lungs are relatively clear, without frank vascular congestion or\n consolidation present. The right pleural effusion is not as prominent on the\n current study.\n\n IMPRESSION:\n\n Relatively unchanged appearance of the chest compared to 12 hours previous.\n No evidence of frank fluid overload.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-03-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 859003,
"text": " 2:05 PM\n CHEST (PORTABLE AP) Clip # \n Reason: UPRIGHT FILM to eval right effusion\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48F s/p liver txp\n REASON FOR THIS EXAMINATION:\n UPRIGHT FILM to eval right effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 48-year-old female status post liver transplant. Single AP view\n of the chest dated , is compared to the same examination on\n . The right internal jugular central venous catheter is again\n seen terminating at the junction of the superior vena cava and right atrium.\n There is no pneumothorax. A Dobhoff nasogastric tube terminates in the third\n part of the duodenum. Cardiac and mediastinal contours are unchanged. There\n is interval improvement in the bilateral small pleural effusions. Right\n basilar atelectasis remains. There are no focal areas of opacity to suggest a\n consolidation. Splenomegaly.\n\n IMPRESSION:\n 1. Interval improvement in bilateral pleural effusions. Right basilar\n atelectasis.\n 2. No focal consolidations noted.\n 3. Splenomegaly.\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-03-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 856965,
"text": " 7:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: monitor ? pleural effusion\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year s/p liver transplant\n\n REASON FOR THIS EXAMINATION:\n monitor ? pleural effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post liver transplant. Assess pleural effusion.\n\n COMPARISON: .\n\n SUPINE AP CHEST: The endotracheal tube, left internal jugular central venous\n catheter sheath, left subclavian central venous catheter, NG tube, and\n surgical drains are unchanged in position. The right internal jugular\n Swan-Ganz catheter tip has been advanced into the right main pulmonary artery.\n The cardiac and mediastinal contours are stable. On the current study, a\n right pleural effusion layering posteriorly is well visualized. Differences\n in the appearance of the right pleural effusion in the recent preceding exams\n is likely related to differences in patient positioning. No evidence of left\n effusion. The lungs are relatively well aerated, without vascular congestion\n or consolidation.\n\n IMPRESSION:\n\n Right pleural effusion. Differences in recent examinations likely reflects\n differences in patient positioning.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-03-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 856811,
"text": " 10:50 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: dropping sats\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year s/p liver transplant\n\n REASON FOR THIS EXAMINATION:\n dropping sats\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Portable chest .\n\n COMPARISON: To previous study of earlier the same date.\n\n INDICATION: Liver transplantation. Dropping oxygen saturation.\n\n FINDINGS:\n\n Various lines and tubes are in satisfactory position. Cardiac and mediastinal\n contours appear stable. Bilateral perihilar haziness is again demonstrated.\n There is an increasing pleural effusion on the right, small to moderate in\n size. Atelectatic changes are noted at the lung bases. With the exception of\n increasing pleural effusion on the right, there has otherwise been no\n significant change. Postoperative changes are noted in the abdomen.\n\n IMPRESSION:\n\n Increasing right pleural effusion with otherwise stable chest radiographic\n appearance.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-03-18 00:00:00.000",
"description": "BX-NEEDLE LIVER BY RADIOLOGIST",
"row_id": 858555,
"text": " 9:32 AM\n BX-NEEDLE LIVER BY RADIOLOGIST Clip # \n Reason: r/o rejection\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48F HCV cirrhosis s/p OLT with rising LFTs\n REASON FOR THIS EXAMINATION:\n r/o rejection\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: Status post liver transplant, now with rising liver\n function tests. The patient presents for ultrasound-guided liver biopsy.\n\n The proposed procedure was explained in detail with the patient's sister, who\n serves as her healthcare proxy. The potential risks and benefits of the\n procedure were discussed. Signed consent was then obtained from the patient's\n sister. timeout was employed to verify the patient's identity\n and the planned biopsy site.\n\n LIVER BIOPSY BY RADIOLOGIST: The procedure took place within the surgical\n intensive care unit. An appropriate spot was marked on the skin of the\n patient's anterior abdomen, overlying the anterior aspect of the liver\n transplant, using son localization. The area was then prepped and\n draped in the standard sterile fashion. Local anesthesia was achieved with 1%\n lidocaine. Using continuous son guidance, a single 18-gauge core\n biopsy of the transplanted liver was obtained. The patient tolerated the\n procedure well without any immediate post-procedure complications. The\n specimen was immediately transported to pathology for further analysis.\n\n Dr. , the staff radiologist, was present and supervised the entire\n procedure.\n\n IMPRESSION: Successful 18-gauge core biopsy of a transplanted liver.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-03-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 858249,
"text": " 9:01 AM\n CHEST (PORTABLE AP) Clip # \n Reason: slow weaning off vent. ? pna\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48F s/p liver txp, now s/p line replacment\n\n REASON FOR THIS EXAMINATION:\n slow weaning off vent. ? pna\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 48-year-old woman status post liver transplant with replacement\n of central line. Difficulty weaning off the ventilator.\n\n Single AP view of the chest dated is compared with a single AP\n view of the chest from . An endotracheal tube terminates 3.5 cm\n above the carina. The NG tube terminates below the diaphragm, however, the\n tip courses off the imaged portion of the film. The left subclavian central\n line has been removed. A right interval jugular central line terminates in\n the right atrium. The right subdiaphragmatic drainage tube has been removed.\n Clips are present in the mid-right abdomen. Skin staples are seen overlying\n the mid-abdomen.\n\n There are no focal areas of opacity to suggest consolidation. A right pleural\n effusion remains with associated compression atelectasis of the right lower\n lobe. The heart size and mediastinal contours are unchanged. There is no\n pneumothorax. The osseous structures are unchanged.\n\n IMPRESSION:\n 1. Persistent right-sided pleural effusion with associated right lower lobe\n compression atelectasis. No focal areas of consolidation to suggest\n pneumonia.\n 2. Tubes and lines changed as above.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-03-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 857687,
"text": " 7:30 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval changes\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48F s/p liver txp, now s/p swan replacement\n REASON FOR THIS EXAMINATION:\n interval changes\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 48-year-old female with liver transplant. Swan-Ganz catheter\n placement.\n\n TECHNIQUE: Portable AP chest radiograph.\n\n The comparison is made with a prior chest radiograph dated .\n\n FINDINGS:\n\n The endotracheal tube, left subclavian venous line, and right-sided drainage\n tube are unchanged compared to the prior study. Swan-Ganz catheter is\n terminating in the right interlobar pulmonary artery. Left apex is not\n included in the present study; however, no pneumothorax is noted. The cardiac\n and mediastinal contours are within normal limits. No consolidation noted.\n\n IMPRESSION:\n\n Tubes and lines as described above. Swan-Ganz catheter terminating in the\n right interlobar pulmonary artery. Left apex is not included in the present\n study.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-03-04 00:00:00.000",
"description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT",
"row_id": 856846,
"text": " 9:11 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT; -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOPP ABD/PEL\n Reason: transplant liver. assess portal vein, hepatic vein, hepatic\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman with HCV cirrhosis and varices admitted with hematemisis -\n now s/p redo tips - would like to re-eval tips to obtain baseline flow\n velocities\n REASON FOR THIS EXAMINATION:\n transplant liver. assess portal vein, hepatic vein, hepatic artery, and bile\n ducts.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: Recent history of a liver transplant, assess bile ducts\n and blood flow.\n\n COMPARISONS: Liver ultrasound of .\n\n LIVER ULTRASOUND WITH COLOR DOPPLER: Grayscale images show no focal or\n diffuse hepatic abnormalities. There is no evidence of intrahepatic ductal\n dilatation. No perihepatic fluid collections are identified.\n\n Color Doppler images of the liver were also obtained. The main, right, and\n left portal veins are patent, with blood flow in the appropriate direction.\n Velocities within the main portal vein ranged from 60-80 cm/sec. The\n intrahepatic portions of the left and right hepatic arteries also demonstrate\n normal-appearing waveforms, with brisk upstrokes. The resistive indices range\n from 0.62-0.77. The main hepatic artery is patent. The hepatic veins and\n inferior vena cava are also patent, with flow in the appropriate direction.\n\n IMPRESSION: Son appearance of the transplant liver is within normal\n limits. Patent intrahepatic vasculature, as discussed above.\n\n These findings were discussed with the surgical house staff caring for the\n patient at the time of the exam on .\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-03-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 856711,
"text": " 7:49 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for pulm edema\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year s/p liver transplant\n\n REASON FOR THIS EXAMINATION:\n evaluate for pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post liver transplant. Evaluate for pulmonary edema.\n\n COMPARISON: .\n\n SUPINE AP CHEST: The endotracheal tube, left internal jugular central venous\n catheter sheath, left subclavian central venous catheter, and NG tubes are\n unchanged in position. The right internal jugular Swan-Ganz catheter is\n probably unchanged in position, though multiple wires overlie the region of\n interest on this exam. The surgical clips and drain are unchanged as well.\n The cardiac and mediastinal contours are stable. There is no definite\n evidence of pulmonary edema, appearance of the lungs and vasculature is\n unchanged from one day ago. No pleural effusions identified. No pneumothorax\n identified.\n\n IMPRESSION:\n\n No evidence of pulmonary edema. The appearance of the chest is unchanged from\n one day ago.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-03-24 00:00:00.000",
"description": "NASO-INTESTINAL TUBE PLACEMENT (W/FLUORO)",
"row_id": 859326,
"text": " 4:25 PM\n -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # \n Reason: please plase post-pyloric Dobhoff on AM.\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman s/p OLT, needing post-pyloric Dobhoff\n REASON FOR THIS EXAMINATION:\n please plase post-pyloric Dobhoff on AM.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: A 48-year-old woman status post liver transplant requiring\n postpyloric feeding tube.\n\n PROCEDURE AND FINDINGS: After coating the weighted feeding tube with\n lidocaine jelly, the tube was advanced through the right nostril into the\n stomach. Air and 5 cc of Conray were infused to elucidate the gastric\n anatomy. The wire was then replaced and the tube was advanced into the\n duodenum and past the ligament of Treitz. The wire was removed. Final\n injection of contrast demonstrated appropriate positioning of the tube tip in\n the proximal jejunum. The tube was secured with tape. The patient tolerated\n the procedure well and there are no immediate post-procedural complications.\n\n IMPRESSION: Successful placement of nasojejunal feeding tube.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-03-30 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 859975,
"text": " 9:27 AM\n CHEST (PORTABLE AP) Clip # \n Reason: sp guide wire line\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n sp liver tx/ wire line\n REASON FOR THIS EXAMINATION:\n sp guide wire line\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Guide wire line placement.\n\n Comparison .\n\n A right internal jugular vascular catheter is present, terminating in the\n lower portion of the right atrium. There is no pneumothorax. A feeding tube\n terminates in the duodenum. Cardiac and mediastinal contours are within\n normal limits. There is improving opacity at the right base with minimal\n residual patchy opacity remaining. The lungs are otherwise clear.\n\n IMPRESSION:\n\n 1) Low position of right internal jugular vascular catheter, terminating\n within the lower portion of the right atrium. No pneumothorax.\n\n 2) Resolving right basilar opacity, most likely due to atelectasis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-03-30 00:00:00.000",
"description": "ABDOMEN (SUPINE & ERECT)",
"row_id": 860053,
"text": " 4:46 PM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: assess for obstruction\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman with diarrhea s/p liver transplant\n REASON FOR THIS EXAMINATION:\n assess for obstruction\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 48-year-old woman with diarrhea status post liver transplant.\n\n SUPINE AND UPRIGHT ABDOMEN: There is a normal bowel gas pattern without\n evidence of dilatation or obstruction. There is no free intraperitoneal air.\n A feeding tube is seen with the tip in the third portion of the duodenum. A\n TrapEase IVC filter is noted. Surgical clips are seen within the right upper\n quadrant of the abdomen. A surgical tube is seen with the tip terminating in\n the right upper quadrant. Osseous structures are remarkable for degenerative\n changes at the lower lumbar spine.\n\n IMPRESSION: Normal bowel gas pattern without evidence of obstruction.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-03-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 859804,
"text": " 6:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please perform a thoracoabdominal film. For feeding tube pos\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48F s/p liver txp\n\n REASON FOR THIS EXAMINATION:\n please perform a thoracoabdominal film. For feeding tube position\n ______________________________________________________________________________\n FINAL REPORT\n This is a portable chest .\n\n COMPARISON: .\n\n INDICATION: Feeding tube placement.\n\n The radiograph was obtained centered at the thoracoabdominal junction for\n feeding tube assessment. It demonstrates a feeding tube within the duodenum.\n A right internal jugular vascular catheter is unchanged in position. Cardiac\n and mediastinal contours are stable. A small right pleural effusion and\n patchy right basilar opacity are unchanged allowing for positional\n differences.\n\n IMPRESSION: Feeding tube terminates within the duodenum.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2179-03-05 00:00:00.000",
"description": "Report",
"row_id": 100266,
"text": "PATIENT/TEST INFORMATION:\nIndication: Tachycardia. Assess left ventricular function.\nHeight: (in) 62\nWeight (lb): 165\nBSA (m2): 1.76 m2\nBP (mm Hg): 123/74\nHR (bpm): 142\nStatus: Inpatient\nDate/Time: at 13:57\nTest: Portable TTE (Complete)\nDoppler: Full doppler and color doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or pacing wire is\nseen in the RA and/or RV.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function\n(LVEF>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No valvular\nAS. The increased transaortic gradient related to high cardiac output. Mild\n(1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Trivial MR.\n\nTRICUSPID VALVE: Tricuspid valve not well visualized.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Resting\ntachycardia (HR>100bpm).\n\nConclusions:\nThe patient is tachycardic. The left atrium is normal in size. Left\nventricular wall thickness, cavity size, and systolic function are normal\n(LVEF>55%). Right ventricular chamber size and free wall motion are normal.\nThe aortic valve leaflets (3) are mildly thickened but aortic stenosis is not\npresent. There is no valvular aortic stenosis. The increased transaortic\ngradient is likely related to high cardiac output. Mild (1+) aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. There\nis no mitral valve prolapse. Trivial mitral regurgitation is seen. There is no\npericardial effusion.\n\nCompared with the findings of the prior study (tape reviewed) of , other\nthan the tachycardia, probably no significant change.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2179-03-12 00:00:00.000",
"description": "Report",
"row_id": 276275,
"text": "Sinus tachycardia. Borderline low voltage in the limb leads. Compared to the\nprevious tracing of the rate has slowed. Although, tachycardia persists.\n\n"
},
{
"category": "ECG",
"chartdate": "2179-03-11 00:00:00.000",
"description": "Report",
"row_id": 276276,
"text": "Sinus tachycardia. Otherwise, probably normal ECG. Since the previous tracing\nof sinus tachycardia rate has increased.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2179-03-08 00:00:00.000",
"description": "Report",
"row_id": 276277,
"text": "Sinus tachycardia\nNormal ECG except for rate\nSince previous tracing of , increased heart rate\n\n"
},
{
"category": "ECG",
"chartdate": "2179-03-01 00:00:00.000",
"description": "Report",
"row_id": 276278,
"text": "Normal sinus rhythm. Normal ECG. Compared to the previous tracing of \nno significant change.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-09 00:00:00.000",
"description": "Report",
"row_id": 1293270,
"text": "D:See carevue flowsheets for specifics\nNeuro:Pt remains unresponsive on propofol and fentynal drips. Both increased overnoc for resp inconsistent MVs and Hypertensive and tachycardic.\nCV:Hyperdynamic state with temp max 102.4. Pt pan cultured (Blood line and venipuncture, urine and sputum). Hypothermia blanket on at 0300. SBP 200+ and tachy up to 140, lopressor given as ordered.\nResp:No vent changes overnoc. Increased sedation to prevent MV inconsistencies with vent despite suctioning.\nGI:BS hypoactive s/p closure of fascia . Abd dsg reinforcedx1, small am't of serosang drg.\nGU:Additional lasix 40mg IVP for elevated PA#s and cvp #s.\nFamily: called and wanted to know what time pt would be weaned from sedation today. He will call this am. Do not weaning sedation as SBP hypertensive if prop is decreased.\nPlan/Goals:Normothermic-Use hypothermia blanket, tepid baths.\nNormotensive: Lopressor as ordered. Maintain fluid balance even.\nFamily coping-provide explanation concerning realistic expectations while pt in ICU.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-09 00:00:00.000",
"description": "Report",
"row_id": 1293271,
"text": "CONDITION UPDATE\nPLEASE SEE CAREVUE FLOWSHEET FOR SPECIFICS.\nNEURO: PROPOFOL AND FENT GTT'S WEANED DOWN. WITH PROP NEARLY OFF, PT OPENED EYES TO VOICE. DID NOT FOLLOW COMMANDS. PERRL. LOCALIZED WITH ALL EXTREMTITIED ON BED TO TRAP SQUEEZE. PROPOFOL INCREASED THIS EVE FOR PT COMFORT ON VENT.\nRESP: LS CTA. VENT CHANGED TO CPAP WITH 8PEEP AND 16 PS, BUT PT DID NOT TOL, BECOMMING TACHYPNEIC, LABORED, LOW TV'S, TACHYCARDIC AND HYPERTENSIVE TO 200S SYS. PROPOFOL INCREASED AND VENT RETURNED TO CMV. REATTEMPTING PS THIS EVE WITH LIGHTER PROPOFOL THAN THIS AM. BP, HR AND RR STABLE, PA NUMBERS DECREASED WITH 16 PS, AND TV'S > 450. ABG PENDING. PT THIS AFTERNOON. SCANT SECRETIONS, CLEAR.\nCV: TMAX 100.9 THIS SHIFT. COOLING BLANKET REMOVED D/T SL MOTTLING OF SKIN AT LEGS. SICU TEAM WITNESSED. ICE TO AXILLA FOR TEMP CONTROL. TACHYCARDIC TO 130S. METOPROLOL STARTED AND DOSE INCREASED TO EFFECT. PA CATH CHANGED TO NON-HEPARIN COATED AND PLACEMENT CONFIRMED BY CXR MD . CO DECREASED AS COMPARED WITH LAST SEVERAL DAYS. LASIX DOSE INCREASED WITH SOME EFFECT ON U/O AND MIN EFFECT ON PA#S. FLUID BAL SL POS SINCE MN.\nGI: SBD SOFT. NO BM. CLEAR OUTPUT VIA NGT.\nGU: CLEAR AMBER U/O.\nSKIN: DRESSING INTACT WITH OLD STAINING. T-TUBE WITH MOD AMTS DK AMBER O/P. JP WITH SM AMTS DK MAROON O/P. NO S/S BREAKDOWN AT PT'S BACK OR HEELS.\nPLAN: ASSESS TOLERANCE OF CPAP. AWAIT ABG RESULTS. WEAN SEDATIONAS TOLERATED. ? EXTUBATE TOMORROW. MONITOR HEMODYNAMICS. TREAT TACHYCARDIA AND HTN WITH LOPRESSOR. DIURESE AS ORDERED. EXPECT FLUID MOBILIZATION ON NEXT 2 DAYS. EMOTIONAL SUPPORT TO FAMILY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-16 00:00:00.000",
"description": "Report",
"row_id": 1293294,
"text": "PLEASE REFER TO CAREVUE FOR COMPLETE ASSESSMENT AND SPECIFICS.\n\nNEURO: PROPOFOL STOPPED THIS AM AND REMAINS OFF FOR THE REST OF THE DAY. PT ALERT, FOLLOWING SIMPLE COMMANDS, MAE SPONT/PURP, PERL. DOZING INTERMITTENTLY.\n\nCV: HR 101-121 ST, NO ECTOPY. SBP 124-157 W/ MAP>60. CVP 4-6. BIL LE'S U/S OBTAINED TO R/O DVT, F/U REPORT.\n\nRESP: LUNG SOUNDS COARSE, SXN AS NEDED FOR THICK YELLOW SECRETIONS. VENT SETTINGS CURRENTLY CPAP+PS 5PEEP /10 PS( PS WEANED FROM 15-10),RR 14-22, FIO2 40%, TV 400'S. ABG 7.38/46/148/28/1/98. O2 SAT 99-100%. CXR DONE, F/U RESULTS.\n\nGI: ABD SOFTLY DISTENDED, HYPO BOWEL SOUNDS, TF STARTED IMPACT W/ FIBER AT 20CC/HR W/ GOAL 90CC/HR, INC BY 20CC/HR Q6 HRS, NO RESIDUALS.\nT-TUBE DRAINING CLEAR DARK AMBER FLUID. CT ABD AND PELVIS DONE, F/U RESULTS.\n\nGU: FOLEY DRAINING CLEAR AMBER URINE, LASIX 20MG IVP X2 W/ GOOD DIURESIS.\n\nID: TMAX 101.7, DR. INFORMED, PAN CX.\n\nENDO: REMAINS ON INS GTT FOR FS CONTROL.\n\nPLAN: MONIOTR VS, LABS, RESP STATUS, NEURO STATUS. F/U CXR, U/S, CT RESULTS. ADVANCE TF TO GOAL. ?ATTEMPT TO WEAN VENT DOWN FOR POSSIBLE EXTUBATION TOMORROW AND STOP TF AT 4AM. CONT CURRENT MGMT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-17 00:00:00.000",
"description": "Report",
"row_id": 1293295,
"text": "Resp Care Note:\n\nPt cont intub with OETT and on mech vent as per Carevue. Lung sounds coarse with rhonchi improving with suct for mod th sput. Pt in NARD on current vent settings; no vent changes made overnoc. Cont wean PSV.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-17 00:00:00.000",
"description": "Report",
"row_id": 1293296,
"text": "FOCUS: STATUS UPDATE\nDATA:\nPT ALERT AND RESPONDING TO HER NAME. FOLLOWING COMMANDS AND MOVING ALL EXTREMITIES IN BED WITH UPPER EXTREMITIES VERY WEAK.\n\nLUNGS COARSE BILATERALLY WITH SCATTERED RHONCHI IMPROVING WITH SUCTIONING OF THICK SPUTUM. CONTINUES ON 10 PS, NO VENT CHANGES OVERNIGHT.\n\nABDOMEN SOFT WITH HYPOACTIVE BOWEL SOUNDS. TOLERATED TUBE FEEDS WITH MINIMAL RESIDUALS UNTIL 0400. STOPPED IN PREPERATION FOR POSSIBLE AM EXTUBATION. INCISIONAL ABD STAPLES DRY AND INTACT, OPEN TO AIR. T TUBE WITH BILIOUS OUTPUT.\n\nLASIX X1 OVERNIGHT FOR NEGATIVE I/O GOAL OF 1L WHICH WAS ATTAINED.\n\nPLAN:\nWEAN AND EXTUBATE IF POSSIBLE, OTHERWISE TRACH TO BE CONSIDERED. F/U CT SCAN RESULTS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-17 00:00:00.000",
"description": "Report",
"row_id": 1293297,
"text": "Respiratory Care\n\n Pt continues on PSV weaned as documented. In NARD. B/S equal dim at bases. Suctioned for min amount thick yellow. Plan ? extubation in A.M. Will continue to follow closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-17 00:00:00.000",
"description": "Report",
"row_id": 1293298,
"text": "Nursing\nSee flowsheet for details.\n\nPt. had uneventful day. HR remained 100-115 NSR, no ectopy. BP 115-150/75. T. max 99.9 oral. Tube feeding restarted through NG. Hypoactive BS; max residual 30cc. TPN d/c. Insulin gtt cont. Incision C/D/I. Good urine output. Goal of -1000cc fluid balance; received two doses of lasix. Cont. to medicate prn with fentanyl. Family in to visit today.\n\nPlan to cont. to wean for possible extubation in a.m. Also plan for pt. to be NPO after midnight.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-13 00:00:00.000",
"description": "Report",
"row_id": 1293281,
"text": "Resp Care Note:\n\nPt cont intub with OETT sedated and on mech vent as per Carevue. Lung sounds coarse with rhonchi improving with suct for mod th tan/brown sput. ABGs metabolic acidosis with good oxygenation; adjusting vent to help increase pH. Cont mech vent support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-13 00:00:00.000",
"description": "Report",
"row_id": 1293282,
"text": "STATUS\nD: REMAINS ON FENT/PROPOFOL/INSULIN GTT'S..OPENS EYES TO NAME..WILL FOLLOW SOME SIMPLE COMMANDS\nA: FENT GTT DC'D & STARTED ON PRN DOSE..TOL WELL..JP DC'D SITE OOZING SEROUS DSD APPLIED..LF SUBCL LINE DC'D & TIP SENT FOR CULT..PROPOFOL @ 30MCG..INSULIN GTT @ 5-7U TO KEEP BS <120..LASIX GIVEN X1 WITH GOOD EFFECT..INCT MOD AMT MUCOID STOOL..FIB PLACED..STARTED ON TF'S @ 10CC/H INITIALLY WILL CHECK RESIDUALS Q6H..NO VENT CHANGES ABG'S ACIDOTIC GIVEN 2 AMPS BICARB GIVEN WITH IMPROVEMENT\nR: STABLE\nP: WILL ATTEMPT VENT WEAN IN AM..MONITOR LABS Q6..BS'S Q1-2H REGULATE INSULIN GTT ACCORDINGLY\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-14 00:00:00.000",
"description": "Report",
"row_id": 1293283,
"text": "Resp Care Note:\n\nPt cont intub with OETT and on mech vent as per Carevue. Lung sounds coarse with rhonchi improving with suct sm=>mod th tan sput. Pt switched to PSV and tol well on present settings; ABGs ess unchanged on PSV. Cont PSV/wean.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-14 00:00:00.000",
"description": "Report",
"row_id": 1293284,
"text": "Update\nO: cv status: to sr w lopressor ^'d to 50mg . bp stable, tolerating ^ dose lopressor.\n\nresp status: weaned to cpap peep8 ps 18. bbs coarse to slt coarse after suctioning. abg unchanged mild acidosis\n\nneuro status: sedated on propfol, arousable to voice and following simple commands.perl 2-3mm.\n\ngi status: tol tf's ^ to 20cc/hr w min resids . incont loose mucoid stool-> fib bag.\nglucoses managed w insulin gtt.\ngu status: huo qs amber urine via foley.\n\nheme/id: am labs sent results pending.\n sin: mid abd incision site dry. oozy around old jp site-> ostomy bag to measure and contain drng. ttube to w bilious drng.\nA/P: weaning from vent wean peep and ps as tol.\ncheck am lab results & rx as ordered any lyte imbalance.titrate tf toward goal 45 cc/hr nepro.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-14 00:00:00.000",
"description": "Report",
"row_id": 1293285,
"text": "STATUS\nD: REMAINS ON PROPOFOL & INSULIN GTT'S..EASILY AROUSED FOLLOWS SIMPLE COMMANDS WITH MUCH ENCOURAGEMENT..MOVES ALL EXTREM'S\nA: PROPOFOL DECREASED TO 20MCG..VENT WEANED TO C-PAP WITH 0 IPS TOL WELL FOR FEW HOURS BUT THEN TIRED WITH RR 30'S..BP 150/'S..HR 120-130'S PLACED BACK ON IPS 5..GOOD SAT'S & ABG'S..RESTING COMF NOW.. SUCTIONED FOR MOD AMT THIN /YELLOW..SUCTIONED FOR COPIOUS AMT ORAL SECREATIONS..TF'S ON HOLD FOR HIGH RESIDUALS..FIB INTACT SM AMT MUCOID STOOL..ADQUATE HUO'S..OOZING LGE AMT FROM JP SITE STITCH PLACED BY HO..NO FURTHER OOZING NOTED..T TUBE DRAINING MOD AMT BILIOUS\nR: STABLE\nP: CONTINUE TO WEAN AS TOL..? EXTUBATE IN NEXT COUPLE OF DAYS\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-14 00:00:00.000",
"description": "Report",
"row_id": 1293286,
"text": "Respiratory Care\nPt spent a few hours on SBT, back on for increased rr, and hr. Suctioning large amts of thick yellow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-15 00:00:00.000",
"description": "Report",
"row_id": 1293287,
"text": "Resp Care Note:\n\nPt cont intub with OETT and on mech vent as per Carevue. Lung sounds coarse suct sm=>mod th off sput. ABGs resp acidosis with good oxygenation. Pt episode of ^RR/HR/BP and dropped Vt; increased PSV with good result; later returned to previous settings. Plan to extub if am mechanics acceptable.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-15 00:00:00.000",
"description": "Report",
"row_id": 1293288,
"text": "Update\nO: Arousable,follows simple commands w stim. mae to command. w htn improved w ^ lopressor dosing & fentanyl for pain/discomfort.GI: abd soft no active bowel snds,Tf's on hold for potential extubation this a.m.Glucoses managed w insulin gtt. huo qs amber urine w brisk diuresis w lasix 20 iv.\n\nA/P: Wean vent? extub today.Follow glucoses and titrate insulin gtt. Hr/bp still ^,? ^ lopressor dose/frequency.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-15 00:00:00.000",
"description": "Report",
"row_id": 1293289,
"text": "Respiratory Care:\nPt. was to be extubated today if at all possible, however, she developed a rather high RR and had an episode of respiratory distress\nwith increased WOB and decreasing O2 sat. to 90-91%. She was rested on 50% PSV 20/5peep. This has been weaned down to 40% and a PS of over the course of this shift, and presently is slowly increasing her RR, and ? WOB...\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-15 00:00:00.000",
"description": "Report",
"row_id": 1293290,
"text": "Nursing\nSee flowsheet for details.\n\nAttempted to wean from vent with no success. Propofol turned off at 0700 and by 0930 pt. was alert and following commands consistently. Pt. remained on and 40% until 1300 when propofol had to be restarted to help the pt. to be less anxious. Dr. stated that pt. would not be extubated due to possible anxiety/pain and low tidal volumes.\n\nAt this time pt. is on and 40% sa02 99%. Sxn small amounts of thick clear from ETT and large amounts thick clear from mouth. HR 125 NSR with no ectopy. BP 139/77. Temp 99.9 oral. Propofol at 30mcg/kg/min and insulin at 4units/hr. Urinary output remains adequate. T-tube intact and draining bilious. Abdominal incision C/D/I.\n\nPlan to cont. to wean from vent and keep pt. comfortable.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-16 00:00:00.000",
"description": "Report",
"row_id": 1293291,
"text": "FOCUS: STATUS UPDATE\nDATA:\nPT LIGHTLY SEDATED ON PROPOFOL DRIP. FOLLOWING COMMANDS INCONSISTENTLY, OPENING EYES SPONT AND TO COMMAND.\n\nLUNGS COARSE BILAT LOWER LOBES. SUCTIONED FOR THICK YELLOW SPUTUM. PS INCREASED TO 20 DUE TO RR IN THE 40'S AND LOWER TV. NOW WITH TV >500 AND RR <20. PT ALSO CALMER ON THIS SETTING ALLOWING WEANING DOWN OF PROPOFOL.\n\nABD SOFT AND NONTENDER. HYPOACTIVE BS. INCISION WITH STAPLES INTACT AND OPEN TO AIR.\n\nPLAN:\nMAINTAIN INTUBATED ON HIGHER PS REQUIREMENT AND REEVALUATE WEANING IN AM. WEAN OFF PROPOFOL AS ABLE.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-16 00:00:00.000",
"description": "Report",
"row_id": 1293292,
"text": "Resp Care Note:\n\nPt cont intub with OETT and on mech vent as per Carevue. Lung sounds coarse suct sm=>mod th off sput.ABGs ess same however pt requiring higher levels of PSV to maintain adequate Vt/RR. PSV increased overnoc to a high of 22 to present value of 15cm to stabilize Ve. Pt does not appear ready for extub even though RSBIs have been consistantly < 100. Cont PSV; ? trach soon.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-16 00:00:00.000",
"description": "Report",
"row_id": 1293293,
"text": "Respiratory Care:\nPt began shift on PSV 15/5. she was slowly weaned to @ 40%.\nRR inc some but not excessively w/a good MV. At ~ 16:30 she went to CT for a scan of her Abdomen, looking for a collection that may be causing her temp. spikes and complicating her wean off the Vent.\nThe plan is to try extubation soon (tomorrow) to see if she will do well. If not we will reintubate and trach sometime in the next 2-3 days. Please check CareVue for details and ABG's.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-12 00:00:00.000",
"description": "Report",
"row_id": 1293276,
"text": "Resp Care Note:\n\nPt cont intub on mech vent as per Carevue. Lung sounds coarse bilat suct sm th tan sput. Pt appears comfortable on A/C though she cont to overbreathe vent but in NARD; no vent changes required overnoc. Cont mech vent support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-12 00:00:00.000",
"description": "Report",
"row_id": 1293277,
"text": "Condition Update\nPlease see carevue for specifics.\n\nNeuro: PPF gtt at 80 mcqs/hour. Off the gtt, pt did not follow commands. Only would open her eyes to voice. Fentanyl gtt at 100mcs/hour. PERRL.\n\nCV: SR - ST. No ectopy noted. HR 96-119. Aline dampened, used cuff for pressures. Temperature down to 97.7 Cooling blanket off.\n\nResp: No vent changes made. o2 sats 97-100% Pt sxn'd several times for small amts of thick tan sputum. LS coarse b/L.\n\nGI/GU: Foley is patent and draining amber urine. Decreased u/o approx 25-35 cc hour. FIB bag intact. Immeasureable amt of liquid brown stool out. TPN infusing for nutrition. NGT to low continuous sxn and draining brown fluid. Left T tube intact, right jp drain to bulb sxn and draining dark brown fluid.\n\nEndo: Pt on a regular insulin gtt. BS checked q hour and gtt titrated accordingly.\n\nInteg: s/p Liver tx. abdominal staples intact. Incision is reddened. Small amt of drainage noted. DSD to cover.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-12 00:00:00.000",
"description": "Report",
"row_id": 1293278,
"text": "Nursing\nSee flowsheet for details.\n\nPt. sedated on 40mcg/kg propofol. Opens eyes and moves all extremities on propofol holiday; not following commands. PERRLA 2-3mm, brisk, scleral jaundice.\n\nHR 100-120 NST, no ectopy. BP low this a.m. and all antihypertensive meds d/c. CVP connected and read 15-17 throughout day. Given 500cc NS . BP 95-125/65. Temp 97.1 ax. Pulses weakly palpable. /hr, Fentanyl at 100mcg/hr and Insulin gtt on. Left rad. a-line extremely positional; going by cuff pressure.\n\nETT intact. CMV 40%, 500Vt, 5PEEP, sa02 95-100%. Lungs coarse in upper lobes and diminished at times in lower lobes. Not sxn much from tube. Sxn moderate amounts clear from mouth.\n\nAbdomen soft/non-distended with pos. BS. Incision C/D with staples intact; no drainage, no dressing. T-tube intact and draining moderate amounts bilious. JP intact and draining small amounts brown. NG to LCWS with brown output. Fecal bag intact with tan mucous foul-smelling drainage.\n\nFoley intact with clear yellow urine. Output increased significantly after NS .\n\nPt. potassium high. Received 4 units Hum. Reg. insulin IV and 25gm D50 IV. Also receieved 2gm calcium gluconate.\n\nFamily updated several times throughout the by RN.\n\nPlan to cont. to monitor lab values and resp. status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-12 00:00:00.000",
"description": "Report",
"row_id": 1293279,
"text": "Respiratory Care\nPt. remains on a/c with increased tidal volume to 500cc. Last ABG 730/36/159/18/-7/100. BS coarse R>L.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-13 00:00:00.000",
"description": "Report",
"row_id": 1293280,
"text": " 19/07\n PT REMAINS ON FENT WITH PROPOFOL DRIP FOR MILD SEDATION PLEASE SEE CAREVIEW FOR DETAILS ON NEURO STATUS PT WILL OPEN EYES AND TRIES TO FOLLOW COMANDS\n RESP CMV RATE 20 FIO2 .40 PEEP5 T/V 500 SPUTUM BROWN IN COLOR RHONCHI THRU OUT\n HEART S1S2 PULSES POS 2 THRU OUT M EDEMA THRU OUT ST 110 TO 120\n GI HYPOACTIVE B/S SCANT STOOL SOFT ABD T TUBE AND JP IN PLACE U/O QS\n NOTE ELEVATED LEVELS MD AWARE SEE ORDERS\n SUPPORTIVE CARE MONITOR LYTES AND HCT SKIN CARE T/P WITH ROM\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-10 00:00:00.000",
"description": "Report",
"row_id": 1293272,
"text": "FOCUS: STATUS UPDATE\nDATA:\nPT SEDATED ON PROPOFOL. ALERT AND FOLLOWING COMMANDS OFF SEDATION BUT WITH HYPERTENSION, TACHYCARDIA AND AGITATION. CONTINUES ON FENTANYL DRIP.\n\nHYPERTENSION TO >200SYS WITH STIMULATION SUCH AS BATHING. TACHYCARDIA TO 130'S, IMPROVED WITH INCREASE IN LOPRESSOR.\n\nLUNGS BILATERALLY CLEAR. CONTINUES ON CPAP WITH PS. PS INCREASED THIS AM D/T PCO2 55. SUCTIONED FOR MODERATE AMOUNTS CLEAR SECRETIONS. LESS FEBRILE O/N.\n\nABDOMINAL SL DISTENDED, SOFT AND WITH STAPLES INTACT. HYPOACTIVE BS.\n\nCONTINUES ON LASIX WITH GOOD EFFECT.\n\nPLAN:\nCONTINUE TO WEAN OFF VENT AS ABLE. DECREASE SEDATION AS TOLERATED.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-10 00:00:00.000",
"description": "Report",
"row_id": 1293273,
"text": "Nursing\nSee flowsheet for details.\nPt. hard to wean from propofol; becomes very restless and . Propofol currently at 50mcg/kg; Fentanyl at 50mcg/hr. Insulin gtt currently at 7units/hr.\nWent for cholangiogram for elevated bilirubin; found no problems with tube.\nIncision intact with no drainage. T-tube with good output. JP with small amounts brown drainage.\nPlan to cont. to wean from vent and wean from propofol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-11 00:00:00.000",
"description": "Report",
"row_id": 1293274,
"text": "FOCUS: STATUS UPDATE\nDATA:\nEXTREME AGITATION OFF PROPOFOL, MOSTLY EVIDENT BY HYPERTENSION AT TIMES TO >200 SYSTOLIC, TACHYCARDIA TO 120'S AND INCREASED RESPIRATORY EFFORT, RATE TO 40'S. PRECEDEX DISCONTINUED D/T POOR EFFECT. HALDOL AND FENTANYL PRN WITH SOME EFFECT. PROPOFOL RESUMED WITH IMPROVED VS. FOLLOWING COMAMNDS AND MOVING ALL EXTREMITIES OFF SEDATION.\n\nHYPERTENSION WITH AGITATION. HYDRALAZINE WITH MINIMAL EFFECT. SEDATION WITH EFFECT.\n\nLUNGS COARSE BILAT. SUCTIONED FOR THICK CLEAR SECRETIONS OCCAS. PLACED BACK ON AC WITH RATE OF 18 D/T TIRING WITH INCREASED RESPIRATORY EFFORT. ABG STABLE.\n\nCONTINUES ON LASIX WITH GOOD EFFECT. +3 PITTING EDEMA BILAT HANDS.\n\nPLAN:\nWEAN OFF VENT AND EXTUBATE IF POSSIBLE.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-11 00:00:00.000",
"description": "Report",
"row_id": 1293275,
"text": "Nursing\nSee flowsheet for details.\n\nAt beginning of shift pt. HR 150-160, BP 160-180 systolic and temp 39C (blood). Propofol increased to 80mcg/kg, fentanyl gtt restarted at 100mcg/hr and cooling blanket placed on pt. Pt. pan-cultured to include all lines and fungal cx. Right IJ swan changed to quad-lumen. LSC dual-lumen and left rad. a-line intact. Insulin gtt between 7-10units/hr.\n\nCurrently, pt. HR 115-130, BP 110-120/80-85, and temp 38.4 oral (cooling blanket still on). Extremities with +3 edema. Weakly palpable peripheral pulses.\n\nPt. will open eyes to pain when propofol decreased. Moves all extremities. Follows commands inconsistently. PERRLA 3mm brisk. Scleral jaundice.\n\nETT tube intact; tape changed. Currently on CMV VT450, 8PEEP, 40%. Sa02 95-98%. Sxn scant amounts thick clear. Sxn moderate amounts from mouth thin tan. Thrush on tongue noted.\n\nNG to LCWS and draining moderate amounts dark brown. Pos. BS. Abdomen soft and slightly distended. Abdominal incision intact/approximated with no drainage; DSD intact. T-tube with moderate amounts of bilious drainage; intact. RLQ JP intact with dark brown drainage approx. 10cc for 12 hours. Fecal bag reinforced with small amount of mucoid stool present.\n\nFamily updated several times throughout day.\n\nPlan to cont. to monitor HR and BP. Also plan to monitor temp and to keep cooling blanket on until temp. decreases.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-08 00:00:00.000",
"description": "Report",
"row_id": 1293264,
"text": "Resp Care\nPt. remains intubated sedated on ventilator w/o change overnight.\nBs: coarse sxn'd for sm. amts. of thick.\nabgs: mild metabolic alkalosis with hyperoxia.\nPlan: scheduled to have fascia closed in OR today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-08 00:00:00.000",
"description": "Report",
"row_id": 1293265,
"text": "D:Pt is PODS#6 and 7 s/p OLT for ESLD. See carevue flowsheets for specifics.\nNeuro:Pt sedated on propofol and fentynal and does not respond to verbal or tactile stimuli. PERRLA.\nCV:VSS, CO stable at 7.5 CVP 11-12, PAD 20. SR to ST 90s-100 no ectopics. Ulnar arterial line left wrist patent and is 20mm higher than NBP.\nResp:Pt remains intubated on ventilator FIO2 40%. O2 sats 97-99. ABGs improving.\nGI:NGT draing BRB in small am'ts started around 0500. H.O. notified. HCT stable. Platlets 70.\nGU:foley to BSD draining small am'ts of hematuria.\nSkin with the exception of incisions intact. Eccymotic areas lt groin abd near incisions (old).\nLab:K repeted for 3.5 level. BS treated by titrating insulin gtt.\nA:Stable s/p OLT.\nP:Check cyclosporin level at 10:30.\n check vanco level at 11:30\n Pt expected to go to the OR for closure today TF.\n Provide emotional support to pt and family.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-08 00:00:00.000",
"description": "Report",
"row_id": 1293266,
"text": "Resp. Care Note\nPt remains intubated and vented on settings as charted on resp flowsheet. No vent changes made this shift. Pt back to OR for abd. closure.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-08 00:00:00.000",
"description": "Report",
"row_id": 1293267,
"text": "CONDITION UPDATE\nPLEASE SEE CAREVUE FLOWSHEET FOR SPECIFICS.\nNEURO: PT SEDATED ON PROPOFOL AND FENTANYL GTTS. OCCASIONALLY OPENS EYES TO STIM. MOVES ALL EXTREMITIES ON BED TO STIM. PERRL.\nRESP: LS CTA. ABG STABLE. NO VENT CHANGES. SM AMT SECRETIONS VIA ETT SUCTION.\nCV: AFEBRILE. HEMODYNAMICALLY STABLE. FLUID BAL NEG 180CC SINCE MN. PLT GIVEN FOR 70, POST 105. HIT PANEL SENT AND POS PER BLOOD BANK. SICU AND TRANSPLANT TEAMS INFORMED. COAGS STABLE.\nGI: ABD SOFT. NGT WITH SM AMT CLEAR O/P. NO BM.\nGU: CLEAR AMBER U/O. SM RESPONSE TO AM LASIX.\nENDO: INSULIN GTT TITRATED TO FSBG.\nSKIN: T-TUBE WITH MOD AMTS DK AMBER DRG. JP WITH SM AMTS DK MAROON DRG. ABD INC DSG CDI.\nMISC: CYCLO GTT CONTS AT 2MG/HOUR. PT SENT TO OR FOR FASCIA CLOSURE AT 1600 WITH ANESTHESIA. SENT ON PPF AND CYCLO GTTS.\nPLAN: AWAIT RETURN FROM OR. D/C ALL HEPARIN.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-08 00:00:00.000",
"description": "Report",
"row_id": 1293268,
"text": "CONDITION UPDATE\nPT RETURNED FROM OR AT 1800 S/P FASCIA CLOSURE. PT STABLE. ALL TUBES AND LINES INTACT. MEDS RESUMED (EXCEPT HEPARIN). SVO2 RECAL'D. LABS SENT. REPEAT HIT TO BE SENT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-09 00:00:00.000",
"description": "Report",
"row_id": 1293269,
"text": "Resp Care\nPt. remains intubated/sedated overnight. No changes made abg's within normal parameters.\nBs: coarse bilat. secreations minimal thick.\nPlan: continue current support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-21 00:00:00.000",
"description": "Report",
"row_id": 1293308,
"text": "CONDITION UPDATE\nD.AFEBRILE,SR-ST,RR16-26,O2 SAT=99 ON 2L NP,BP 117-140/60.\n PT WAS GIVEN LASIX THIS EVENING.DESPITE MOD. DIURESIS,PT REMAINED POSITIVE BY 1700ML/24 HRS.\n PT CONFUSED AT TIMES TO TIME AND PLACE BUT COOPERATIVE.PT DID NOT SLEEP ALL NITE.\n NO C/O OF PAIN EXCEPT AT 0400,PT C/O ABD PAIN AND CONFIRMED ABD CRAMPS..PT HAD STOOL,LOOSE X2 THRU THE NITE.\nA.?NEED TO DECREASE TF RATE..?NEED FOR FT PLACMENT TODAY.\nR. STABLE\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-21 00:00:00.000",
"description": "Report",
"row_id": 1293309,
"text": "please see carevue for specifics:\nNeuro: pt alert and oriented to person. able to follow directions,but confused when answering questions.\nCV: afebrile, HR 90-110's sinus tach with no ectopy, SBP 120-150's, CVP 9-13. extremities warm with +PP. lytes repleated.\nRESP: lungs clear to dim at bases, On room air O2 sats >96%.\nGI: tube feed at 70cc/hr via dopoff tube (post pyloric). Having frequent loose stool.\nGU: foley draining adequate amounts of amber clear urine.\nENDO: blood sugars SLightly elevated, covered with RISS.\nPLAN: continue to monitor VS, monitor labs for LFT's, ? transfer to floor monday.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-22 00:00:00.000",
"description": "Report",
"row_id": 1293310,
"text": "See flowsheet for specifics\nD:Pt confused oriented to name only. One leg over side rail x1. Pt awakwe all night, finally fell asleep at 0600. No changes overnight. Pt continues to complain of abd cramping. Liquid stool via mushroom rectal tube-intact. C-diff specimen sent last night.\nA:Pt improving s/p LTX.\nP:Advance to floorcare if alright with attending. \n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-06 00:00:00.000",
"description": "Report",
"row_id": 1293257,
"text": "Respiratory Care:\nPatient remains on ventilatory support (A/C) with no parameter changes made throughout the night. Morning abg results were compatible with a partially compensated metabolic alkalemia with excellent oxygenation on the current settings (see CareVue).\n\nNo RSBI performed due to lack of spontaneous respiration.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-06 00:00:00.000",
"description": "Report",
"row_id": 1293258,
"text": "Resp. care note - Pt. remaines intubated and vented, no vent changes made at this time, BS clear.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-06 00:00:00.000",
"description": "Report",
"row_id": 1293259,
"text": "npn\nNeuro- propofol gtt weaning, cont fentanyl, pearl, no response to stim/+ cough with suction.\n\nResp- AC vent with acceptable abg pr md, lungs clear uper/ lower, suction thin sec.\n\nHemodynmics- PA in place- see flow sheet for all #'s, lasix gtt dc , currently + 2 liters- sicu md aware.\n\nHeme_ hct 32-35, platelet count decrease to 61- sicu aware- awaiting transplant service. (transplant intern notified).\n\nID- temp max 101.5- blood cx done\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-07 00:00:00.000",
"description": "Report",
"row_id": 1293260,
"text": "D:TPN changed to D5Aminosyn 4.5% due to elevated K. Insulin drip titrated to maintain BS < 120. Pain control maintained with Fentynal drip, sedation maintained with propofol drip which was increased when pt was having inconsistent MV with ventilator due to stimulation. No vent changes overnoc. ABGs improved. Coffee ground NGT secretions changed to tan overnight. HCT stable at 32. Frank blood noted in stool. 2 medium stools both with frank blood in small am't. Dr notified. Pt had positive fluid balance, Lasix 20 mg IVP given per d.o.. Response to lasix 450ml then 380ml. u/o dwindled down x 1hr to 22ml h.o. aware. Cyclosporin drip started in addition to ngt cyclosporin per Dr and Dr . Cyclo level to be drawn at 0800.\nA:Pt stable overnoc.\nPlan:OR today for probable liver biopsy and closure of fascia.\n \n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-07 00:00:00.000",
"description": "Report",
"row_id": 1293261,
"text": "Respiratory Care:\nPt. well oxygenated with essentially normal range acid-base. Pt. very tenuous to stimulation (Suctioning, turning, etc.)>>recovers slowly to baseline, and has required increased sedation. Pt. going to O.R. today for ? closure of Abd. Will follow compliance closely post-op.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-07 00:00:00.000",
"description": "Report",
"row_id": 1293262,
"text": "Resp. care note - Pt. remaines intubated and vented, transffered to CT and back to SICUB without incident.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-07 00:00:00.000",
"description": "Report",
"row_id": 1293263,
"text": "npn\nNeuro- sedated with propofol and fentanyl gtts, fent decrease to 100 mcg, facial grimace with suction, no ext movement noted, not foll command.\n\nResp- ac vent, fio2 decrease to .40 with good abg, lungs decreased right upper/lower, suction thin copiuos secretions- ett and oral.\n\nGI- + c diff from stool, po flagyl started, cont tpn, (over noc tpn change to quick fix as kcl in ordered bag 100 meq kcl and pts k 5.4).\n\nHeme- platelet count decreaseing to 58- received 2 6 pack platelet this shift- current count 88. hct stable.\n\nGen- abd/pelvis ct this am to r/o abcess- (neg) plan OR for closure of fascia.\n\nHemodynamics- in place- see flow sheet for #'s, temp max 100.1, hr 90's to 110. new left ulna a line placed this pm by md.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-05 00:00:00.000",
"description": "Report",
"row_id": 1293255,
"text": "npn\nNeuro- sedated with propofol and fentanyl gtts, cista gtt dc this am 1030, inc cough after dc, pearl but no ext movement noted yet.\n\nResp- Tol fio2 .40 and peep decrease to 5, abg metabolic alk, lungs diminished right upper/lower, suction thick secretions, sputum cx sent.\n\nHemodynimics- temp max 102 via pa- pan cx done, hr cont up to 150's with occasional pvc's- lytes wnl, lasix gtt initially decrease to 5 from 8 mg- then dc 6pm, currently 800 neg. pa advanced by md waveform- looking like wedge and then right vent, adv to 48. see flow sheet for all pa#'s.\n\nendocrine- cont insulin gtt 7-9u/hr, glu 110-157. tpn cont.\n\nID- temp max 102- cx done. cont vanco, merepenum, fluconazole, gangcylovir, ID stated due to + antibodies pt at high risk delayed transfusion reaction- coombs and sed rate sent this am. stool sent for c diff this pm.\n\nHeme- hct stable- see labs- platelet count 69- 1 6 pk givin- repaet count 83- md - to notify transplant and ? give additional 6 pack. inr 1.0.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-19 00:00:00.000",
"description": "Report",
"row_id": 1293304,
"text": "PLEASE REFER TO CAREVUE FOR COMPLETE ASSESSMENT AND SPECIFICS.\n\nNEURO: PT ALERT MOST OF NIGHT, ABLE TO TRACK, . FOLLOWS COMMANDS CONSISTENTLY, MAE SPONT/PURP.\n\nCV: HR 101-124 ST, SBP 94-155. CVP 6-16.\n\nRESP: LUNG SOUNDS CLEAR BUT COARSE AT BASES. SXN PRN FOR THICK WHITISH/YELLOWISH SECRETIONS. VENT SETTINGS CPAP+PS W/ 5PEEP/10PS, FIO2 40%, TV 400'S, RR 11-23, O2 SAT 100%, ABG 7.39/52/119/33/5/98. POSSIBLE EXTUBATION THIS AM.\n\nGI: ABD SOFT, NT/ND, +HYPO BOWEL SOUNDS, REMAINS NPO FOR POSSIBLE EXTUBATION THIS AM. STRTED ON IVF FOR U/O AND DUE TO PT REMAINING NPO. INCISION REMAINS C/D/I W/ CLIPS. ?CLIP REMOVAL. T-TUBE DRAINING CLEAR DARK AMBER FLUID.\n\nGU: FOLEY DRAINING CLEAR AMBER URINE, PT RECEIVED NS 250CC W/ POSITIVE EFFECT.\n\nID: TMAX 101.9, PAN CX.\n\nPLAN: MONIOTR VS, LABS, RESP STATUS, NEURO STATUS, U/O. ?EXTUBATE THIS MORNING. ?POST-PYLORIC DOBHOFF PLACEMENT FOR TF TODAY. PHYSICAL THERAPY CONSULT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-19 00:00:00.000",
"description": "Report",
"row_id": 1293305,
"text": "see carevue for details\nfocus data update.\n\ntol extubation well, talking, tol sips of clears, ivf d/c impact with fiber started @ 20/hr with minimal residual, foley changed per infectious disease, wire change over on right central line, family into visit, medicated q2h with fentanyl\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-06 00:00:00.000",
"description": "Report",
"row_id": 1293256,
"text": "focus update note\ntemperature improving overnight currently 100.1, heart rate decreased from 130-140s to 115 with decreasing temperature, sbp 105/60, cvp 9, pa pressures 29/20- swan advanced by icu resident and recalabrated at approx 0100. pt transfused with 1 pack platlets for plat count 82 post plat count 97, to transfuse with 1 unit prbc awaiting unit from blood bank. current hct 33. pt possibly volume depleted- lasix gtt now off since 1830 last night uo 30-100cc/hr dark amber clear. please see flowsheet for hemodynamic cco swan values\n\npain/neuro: pt cont on fentanyl gtt at 200 mcq/hr, sedated with propofol at 120 mcq/kg/min. pt very sedated, no movement on exam or spontaneous, pupils 2mm brisk, pt does not open eyes or follow commands.\n\nresp: no vent changes overnight, lsc dim at right base, o2sat 95%.\n\nabdomen:soft/distended, bs hypoactive, small stool X 2 soft brown, surgical dressing changed c/d/i, medial JP removed by transplant surgery overnight, lateral jp drainage 35 cc brown sero sang fluid q 2-4 hours, some drainage at insertion site liver transplant team and icu team made aware. T tube bag exhibits bilious drainage, ngt drainage scant pink/blood tinged drainage transplant team aware\n\ninsulin gtt cont with hourly finger sticks- goal fs 70-110 currently insulin gtt at 6 units /hr\n\nnutrition: tpn continues\n\nplan: continue to monitor hemodynamic status closly using cco swan, pt to go back to OR for closure ? sunday, monitor for sepsis, control blood sugar with insulin gtt, pain and sedation with fentanyl and propofol gtt, monitor resp staus closely\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-20 00:00:00.000",
"description": "Report",
"row_id": 1293306,
"text": "NURSING NOTE\nSEE CAREVUE FOR SPECIFICS:\n\nNEURO-A&OX2(SELF&HOSPITAL),PERRLA AT 2-3MM WITH BRISK RX. FOLLOWS COMMANDS CONSISTANTLY. DROWSY AT BEGINNING OF SHIFT, INCREASE ALERTNESS THROUGHOUT NOC. NON-SENSICAL TALK AT TIMES EASILY REDIRECTED.\n\nCV-HR 90S-LOW 100S, NSR, NO ECTOPY. SBP 90S-130.HCT 25.7 DR. AWARE. CVP 2-8.\n\nRESP-FT AT 50%, LS COARSE AND SLIGHTLY DIMINISHED AT BASES. SPO2 95-100%. NO DISTRESS NOTED.\n\nGI-ABD SOFT, SLIGHTLY DISTENDED, (+) BSX4, LG LOOSE BM X2, T-TUBE IN PLACE AND PATENT. DRNG MOD AMTS OF BILIOUS DRAINAGE. TOL CLRS (30CC/HR) WITHOUT DIFF. NO N&V NOTED. NGT IN PLACE WITH TFs BEING TITRATED UP TO GOAL OF 90 (CURRENTLY AT 60), MININMAL RESIDUALS NOTED.\n\nGU-FOLEY WITH BOARDERLINE U/O. 20-50CC/HR. NS 250CC X 2 GIVEN WITH MINIMAL EFFECT.\n\nENDO-BS QID WITH SC COVERAGE\n\nSKIN- TMAX 98.6 ABD STAPLES C/D/I OTA, T-TUBE DSG C/D/I, RLQ DSG INATCT ? OLD DRAIN SITE.\n\nCOMFORT-DENIES PAIN/DISC.\n\nA/P-CONTINUE WITH CURRENT CARE PLAN. MONITOR LABS, HEMODYNAMICS & RESP STATUS. WEAN OFF O2 AS TOL. ? ADVANCE DIET. PROVIDE EMOTIONAL SUPPORT.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-20 00:00:00.000",
"description": "Report",
"row_id": 1293307,
"text": "Neuro: Pt alert and oriented to self. Answering questions inappropriately, but able to follow directions. Having generalized pain, med with fentanyl with minimal effect.\nCV: low grade temp 99.9, HR 100-110's sinus tach with no ectopy, SBP 100-130's. extremities warm with +PP. HCT 25.7, treated with 2units or PRBC's.\nRESP: lungs clear to dim at bases. requiring 2l via N/C.\nGI: tol tube feed at goal, having numerous liquid stool, incontinent.\nGU: foley draining adequate amounts of amber clear urine.\nENDO: blood sugars elevated this eve. med with 11u regular insulin will recheck in one hour.\nPLAN: monitor HCT, awaiting transfer to floor\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-04 00:00:00.000",
"description": "Report",
"row_id": 1293250,
"text": "Respiratory Care:\nPatient required vent changes due to increased hypoxia. FIO2 increased to 80% and PEEP to 7 cm. RR decreased to 20. FIO2 titrated down to 60%. Morning abg results revealed a compensated respiratory acidosis with good oxygenation on 70% with 7 cm PSV (see CareVue).\n\nNo RSBI due to required vent settings.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-04 00:00:00.000",
"description": "Report",
"row_id": 1293251,
"text": "CONDITION UPDATE (7A-3P)\nASSESSMENT:\n PT SEDATED AND PARALYZED ON PPF/FENTANYL/CISATRACURIUM GTTS. PT NOT MOVING OR OVERBREATHING VENTILATOR, BUT BP AND HR INCREASE WITH SUCTIONING AND MOVEMENT. PUPILS EQUAL AND BRISK BILATERALLY.\n HR ~ 120, TEMP DECREASING, FOLLOWED BY INFECTIOUS DISEASE TEAM. SBP RANGING 140'S-170'S. PA PRESSURES REMAIN HIGH (GOAL PAD IN 20'S). LASIX GTT CONTINUES FOR GOAL OF NEGATIVE 2 LITERS BY MIDNIGHT (CURRENTLY -1 L). SV02 79-80 AND PATIENT REMAINS HYPERDYNAMIC (SEE FLOWSHEET). FOLLOWING LABS EVERY 4 HOURS, NO BLOOD PRODUCTS GIVEN.\n PT ON ASSIST CONTROL 20 X 550, 60% FI02 AND 7 PEEP THIS MORNING. DESATTING TO 90% IN AFTERNOON AFTER BEING REPOSITIONED. FI02 INCREASED TO 70%, RR UP TO 28 WITH DECREASED TV TO 450 TO IMPROVE OXYGENATION BUT NOT EXERT MORE PRESSURE ON VENA CAVA. UNABLE TO OBTAIN REPEAT ABG AFTER CHANGE, A-LINE NOT DRAWING. LUNG SOUNDS OCCASIONALLY RHONCHOROUS, MINIMAL SECRETIONS.\n ABDOMEN SOFT, NONDISTENDED, DRESSING OP DRESSING INTACT. JPS X 2 TO SELF SUCTION; T-TUBE DRAINING HEALTHY BILE. TPN INFUSING, INSULIN GTT STARTED FOR BLOOD SUGARS > 150. LIVER US DONE, ADEQUATE FLOW EVERYWHERE EXCEPT ? HEPATIC ARTERY.\nPLAN:\n A-LINE TO BE REWIRED BY DR. (ICU). FOLLOW FREQUENT ABGS AND OTHER LABS. CONTINUE WITH DIURESIS FOR GOAL - 2LITERS. POSSIBLE RETURN TO OR THIS WEEKEND.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-04 00:00:00.000",
"description": "Report",
"row_id": 1293252,
"text": "RESPIRATORY CARE\nPT REMAINS ON A/C VENT. WITH TIDAL VOLUMES 450 X 25 7PEEP 60%, PT REQUIRED INCREASED FIO2 FOR DESAT. DURING TURNING. TEAM DOES NOT WANT PEEP INCREASED, INCREASE FIO2 IF DESAT. MDI'S Q4, SUCTIONING MINIMAL SECRECTIONS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-05 00:00:00.000",
"description": "Report",
"row_id": 1293253,
"text": "Respiratory Care:\nPatient's rr increased from 25 to 27 to accomodate increased PCO2. Repeat abg results determined little change. Results consistent with a compensated respiratory acidosis with good oxygenation on the current settings.\n\nNo RSBI performed due to the patient's hemodynamic instability.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-05 00:00:00.000",
"description": "Report",
"row_id": 1293254,
"text": "Nursing Progress Note:\nPlease refer to CareVue for details.\n\nNeuro: Pt remains sedated and paralyzed on Ppf/fentanyl/Cist. No spontaneous movement noted. PERRLA (2-3mm; brisk). TOF q2hr ( twitches of left eye noted). Per Dr. (transplant team), ? d/c Cist in AM.\n\nCV: Febrile overnight (Tmax 38.5; svc aware). Per Dr. , blood cx sent. Left femoral A-line tip sent for cx. HR 140s-sinus tach, no ectopy noted (Dr. , Dr. , and Dr. aware); Ppf gtt rate increased to 120mcg/kg/min to ?decrease HR without effect. ABP 130-150s/70-80s. PAP 38-50/21-32. CVP 7-12. CO down to 7.7 towards end of shift (CO was 8.6-12.4 at beginning of shift). SV down to 50s (Per Dr. , no IVB ordered). Cont to monitor. DP/PT pulses strongly palpable. Generalized edema. Q4hr blood draws. Plt 60; transfused with 1unit platelet. No electrolyte replacements ordered.\n\nPulm: Lungs sound CTA, diminished at bases. CMV: FiO2 decreased to 40%, Vt 450, freq increased to 27 to blow off CO2 (without much effect), PEEP 7. Last ABG: pH 7.38, PaCO2 51, PaO2 102, bicarb 31, BE 3. Pt not breathing over vent. O2 sat >/= 93%. O2 sat down to 92% during T&R.\n\nGI: Abdomen soft w/ +BS. NGT to LWS; drainage was dark brown at beginning of shift, but became bright red (Dr. , Dr. , and Dr. aware; Protonix increased to q12hr). Insulin gtt to keep BS<120. BS checked q1hr.\n\nGU: Foley intact w/ clear, yellow urine. Lasix gtt decreased to 8mg/hr to keep I's and O's even (per Dr. and Dr. .\n\nInteg: Primary dsg to abd removed and replaced w/ DSD. Abd staples intact; no drainage noted. DSD applied over drains. JPx2 to bulb suction. Medial JP w/ serous drainage; lateral JP w/ dark brown drainage. T-tube w/ bilious drainage.\n\nSocial: sister called x1 overnight; updated w/ pt's plan of care.\n\nPlan: Continue ICU care and treatments. Monitor VS, I's and O's (keep even). Blood draw and ABG q4hr; replace lytes/blood products as needed. Monitor resp status, TOF. Cont drips. Plan to take pt back to OR for fascia closure (?date). Maintain skin integrity. Discuss plan of care w/ pt's sister.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-18 00:00:00.000",
"description": "Report",
"row_id": 1293299,
"text": "PLEASE REFER TO CAREVUE FOR COMPLETE ASSESSMENT AND SPECIFICS.\n\nNEURO: PT ALERT, FOLLOWING SIMPLE COMMANDS, ABLE TO TRACK AND , SPONT/PURP BUT VERY WEAK, NODS APPROPRIATELY TO SIMPLE COMMANDS.\n\nCV: HR 98-122, NSR-ST, NO ECTOPY, SBP 10-135. CVP 3-7.\n\nRESP: LUNG SOUNDS COARSE, SXN FOR SMALL AMT THICK WHITISH SECRETIONS. VENT SETTINGS CURRENTLY CPAP+PS, 5PEEP/10PS (PS INC FROM 5 TO 10)40% FIO2, RR 12-27, TV 300-400. LAST ABG 7.38/52/132/32/4/98. CXR TO BE DONE IN AM.\n\nGI: ABD SOFT NT/ND, HYPO BOWEL SOUNDS, TF IMPACT W/ FIBER AT 60CC/HR W/ GOAL RATE 90CC/HR, MINIMAL RESIDUALS. TF TO BE STOPPED AT 4AM FOR POSSIBLE EXTUBATION. INC W/ CLIPS C/D/I, DRAIN W/ LRG AMT DARK CLEAR BILIOUS FLUID. LIVER U/S DONE, F/U RESULTS.\n\nGU: FOLEY DRAINING 80-300CC/HR POST LASIX DOSE, CLEAR AMBER TO YELLOW URINE. I/O BALANCE GOA IS FOR PT TO BE NEG 1L, BY 7AM.\n\nID: TMAX 101.7 DOWN TO 99.8\n\nENDO: PR REMAINS ON INS GTT FOR FS CONTROL.\n\nPLAN: MONIOTR VS, LABS, RESP STATUS, NEURO STATUS. PHYS THERAPY TO FOLLOW PT. FOLLOW UP U/S RESULTS. AWAITING CXR. STOP TF AT 4AM FOR ? EXTUBATIN THIS AM. CONT CURRENT MGMT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-18 00:00:00.000",
"description": "Report",
"row_id": 1293300,
"text": "Respiratory Care:\nPt. continues on low level PS ventilation. Increased PS level overnight to decrease WOB. ABG's well oxygenated with a fully compensated respiratory acidosis. RSBI was 69 this a.m.>>started on SBT 04:10. B/S scattered course>>ETS small to moderate, thick, pale yellow. Good gag, excellent cough. Team to eval for extubation on rounds.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-18 00:00:00.000",
"description": "Report",
"row_id": 1293301,
"text": "Nursing\nSee flowsheet for details.\n\nPt. fairly calm and cooperative today. Following commands and strength increasing. Remained on minimal vent settings all day. Prior to liver bx this afternoon, pt. placed back on propofol. Procedure was unremarkable and propofol d/c. Insulin gtt on.\n\nCont. to receive fentanyl prn with good results. Abdomen soft and slightly tender. Good BS. Stool thick, brown and moderate amounts. NG clamped. Cont. to receive lasix for -1000cc fluid balance.\n\nPlan to rest over night for pending extubation tomorrow. Also plan for post-pyloric tube placement tomorrow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-18 00:00:00.000",
"description": "Report",
"row_id": 1293302,
"text": "Resp Care\nPt remains on vent. Required increased in support for lung biospy. Plan to wean to extubate tomorrow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-19 00:00:00.000",
"description": "Report",
"row_id": 1293303,
"text": "Respiratory Care:\nPt. continues on low level PS settings per flowsheet. Increased PS level from 5 to 10 overnight to \"rest\". B/S with course crackles>>ETS small to moderate secretions ranging from pale yellow to . Sputum sample \"cross contaminated with oralpharyngeal secretions\" per lab. ABG's well oxygenated with a fully compensated respiratory acidosis. RSBI was 71 this a.m. (done with ATC off, 0 peep, 0 PS). Pt. has good gag/cough. Starting SBT ~ 04:30. Evaluate for extubation on rounds.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-03 00:00:00.000",
"description": "Report",
"row_id": 1293248,
"text": "7a-7p nursing note:\nNursing Assessment:\n\nNeuro: Currently 2 twitches on cisatracurium Besylate, Propofol, and Fentanyl gtts. Pupils equal and reactive.\n\nCV/GU: PAD to try to keep low 20's. HIght 20's to low 30's for shift, Nitro off and Dr. is aware. Tachycardic in 120's. Lasix gtt for goal 1 liter negative for day. FC putting out large amounts clear yellow urine.\n\nResp: CMV decreased to FiO2 .60, O2 sats 92% and frequent blood gases with vent changes, otherwise Q 4 hour gases and labs as ordered. Dr. is aware of oxygenation issues. Please see flowsheet for specifics. Tidal volume 500 X 25 with 5 of PEEP. Lung sounds clear to coarse. Only scant amounts of thick secretions on suctioning.\n\nSkin/GI: Abdominal incisions with DSD's CD&I. Bowel sounds absent, abdomen soft. NGT to suction with brown drainage. TPN initiated.\n\nPlan: Titrate all gtts as required. Monitor PAD pressures and O2 sats. Q4 CBC, Fibrinogen, PT, PTT, and ABG's. Chem 10 and LFT's Q 8.\n\nPlease see nursing flowsheet for all specifics.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-04 00:00:00.000",
"description": "Report",
"row_id": 1293249,
"text": "Neuro sedated fentanyl 100mcg and propofol 100mcg/kg/min paralyzed cisatracurium .14mg/kg/hr TOF 1/lid, pupils equal and reactive\nResp 70%/550/20/7peep abg 7.37/53/136/32/4 fio2 dropped to 60% hydrochloric acid gtt d/c. lungs exp wheeze/coarse/clear sx sm amt of thick tan secretions albuterol tx given cxr taken to determine reason for decreasing o2 sat, adjustments made as above\nCVS HR 127-107 ST without ectopy PAP s/D 61/36-50/31 CO 9.1 CI 5.2 CVP 16 bp 161/87-137/75 lopressor 5mg IV given x2 skin w+d pp+4 Hct 36.4\nGI abd soft BS absent Dsg D+I JP lat 70cc, T 75cc, JP med 22, ngt 200cc bilious, amylase 111, LDH 659, AST 735, ALT 927, alk phos 119. Sm amt soft brown stool\nGU u/o > 200cc neg 652 mn to 0500 lasix gtt 4mg IV q hr cr .9\nID temp max 100.8 core lact acid 2.6 wbc 7.7 on vanco fluconazole zoysn, bactrium\nendo BS > 200\nTPN\nA. s/p liver transplant HIV+ HCV cirrohois esophageal varices hx liver enzymes relatively unchanged overnight, IVDU, asthma + smoker 1ppd ? rt pleural effusion by cxr\np. keep sedated paralyzed, wean fi02 as tol albuterol tx prn, monitor labs q 4, keep u/o > 100cc titrate lasix monitor lytes replete prn, goal pap diastolic <20, needs peak cyclosporine level after 0800 dose, Blood bank requests direct coomb's antiglobulin and antibody screen be sent to bld bank today. Monitor s/s blding. Add insulin to TPN cont SS q 4hr tx per scale,\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-02 00:00:00.000",
"description": "Report",
"row_id": 1293244,
"text": "FOCUS: CONDITION UPDATE/ADMISSION NOTE\nSEE CAREVUE FOR SPECIFIC VITAL SIGNS/LAB VALUES/ASSESSMENT\nD: PATIENT ADMITTED TO SICU FROM OR AT 1300, S/P LIVER TRANSPLANT--STARTED ON , UNABLE TO ANASTAMOSE FIRST LIVER, WAS ANAHEPATIC FOR APPROX. 14 HOURS, RECEIVED 2ND LIVER THIS AM, CASE FINISHING AROUND 1230. RECEIVED MASSIVE AMOUNTS OF COLLOIDS (SEE FLOW SHEET FOR EXACT NUMBERS). ARRIVED TO SICU, INTUBATED ON PROPOFOL AND NTG. DID AWAKE IN THAT SHE MOVES EVERYTHING, RESPONDS APPROPRIATELY TO PAINFUL STIMULATION (WITHDRAWS, NOT POSTURING), AND PUPILS EQUAL AND REACTIVE TO LIGHT. DOES NOT FOLLOW COMMANDS, AND IS BEING KEPT PRETTY SEDATED ON PROPOFOL 50 MCG/ AND PRN MSO4.\nRECEIVED 1 U PRBC SINCE ADMISSION , NO OTHER COLLOIDS. LABS PER FLOW SHEET.HAS BEEN TACHYCARDIC SINCE ADMISSION, PA / CARDIAC NUMBERS PER FLOW SHEET. HO AWARE.\nBELLY COVERED WITH POSTOP DRESSING AND COVERED WITH LARGE OPSITE, SKIN IS CLOSED, YET FASCIA REMAINS OPENED, AS COULD NOT CLOSE IN OR DUE TO HIGH PA NUMBERS AND HIGH PIP ON VENTILATOR.\nJPS DRAINING MINMAL AMOUNTS DARK FLUID, T TUBE DRAINING SMALL AMOUNT OF LIGHT COLORED BILE. NGT +PLACEMENT, DRAINING OLD BLOODY DRAINAGE.\nRECEIVED LASIX 20 MG AND DIURESED WELL, ON IV NTG TO LOWER PAD (CURRENTLY AROUND 24-25 WHICH SHOULD BE GOAL).\nFAMILY IN, SPOKE WITH DR. , AWARE OF SITUATION.\nULTRA SOUND DONE, +FLOW ALL VESSELS.,\nCULTURED FOR BLOOD/SPUTUM FOR TEM>38.0\nP: CONTINUE TO DRAW LABS Q 4/8 HRS. AS ORDERED.\nTRY TO WEAN FIO2, YET PO2 LOW ON HIGH FIO2, CXRAY DONE, TEAM AWARE.\nCONTINUE WITH PLAN, CALL HO WITH ANY CHANGES.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-02 00:00:00.000",
"description": "Report",
"row_id": 1293245,
"text": "Pt remains on current vent settings, see carevue for details.Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-03 00:00:00.000",
"description": "Report",
"row_id": 1293246,
"text": "RESP CARE: Pt remains intubated/on vent on AC 550/15/.70/5 PEEP. Lungs coarse bilat R>L. No RSBI at this time due to high FI02. Will continue to wean FI02 as tol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-03 00:00:00.000",
"description": "Report",
"row_id": 1293247,
"text": "CONDITION UPDATE\nPLEASE SEE CAREVUE FLOWSHEET FOR SPECIFICS.\nNEURO: PT SEDATED WITH PROPOFOL AND FENTANYL GTTS, PARALYZED WITH CISATRICURIUM. CIS GTT TITRATED UP FOR RR, 0-1 THUMB TWITCH WITH 40MA STIM TO ULNAR NERVE. SEDATION INCREASED WHILE PARALYZED BASED ON CHANGES IN VS WITH STIMULATION. PERRL. PRIOR TO INCREASE IN SEDATION AND START OF PARALYTIC, PT MOVING SPONT AND IN RESPONSE TO PAIN. LOCALIZED WITH BUE TO TRAP SQUEEZE.\nRESP: LS CTA. SCANT SECRETIONS VIA ETT SUCTION. ABG'S WITH INCREASING PCO2 DESPITE DECREASED RR WITH ADEQUATE SEDATION/PARALYSIS. PH STABLE WITH INCREASE IN HCO3. DIAMOX ORDERED FOR DIURESIS THIS AM. FIO2 WEANED TO 70% WITH STABLE O2 SATS.\nCV: LOW GRADE TEMPS. CONTS TACHYCARDIC, HYPERDYNAMIC. PULMONARY HTN CONTINUES DESPITE DIURESIS WITH LASIX, INCREASE IN NTG GTT PER DISCUSSION WITH MD . K AND MAG REPLETED AS ORDERED. CBC AND COAGS STABLE.\nGI: NGT TO LCWS WITH SM AMT O/P, BROWN TO BLOODY AT TIMES. MD INFORMED.\nGU: POS DIURETIC RESPONSE TO LASIX. RESPONSE TO DIAMOX PENDING.\nENDO: FSBG COVERED PER RISS.\nSKIN: SURGICAL ABD DSG INTACT. SMA MT OLD SEROUS DRG. MEDIAL JP WITH SMAMT SEROSANG O/P. LATERAL JP WITH SMA MT MAROON O/P. T-TUBE WITH SM AMT DK AMBER O/P.\nPLAN: MAINTAIN ADEQUATE SEDATION WHILE PARALYZED. CONT TO MONITOR LABS Q4H AS ORDERED. MONITOR HEMODYNAMICS CLOSELY. DUIRESE WITH DIAMOX AS ORDERED. EMOTIONAL SUPPORT TO FAMILY. AWAIT RETURN TO OR FOR FACIA CLOSURE.\n"
}
] |
5,307 | 168,261 | The patient was admitted to the neuro ICU. Blood pressure was controlled with Labetalol drip to maintain systolic blood pressure 140's to 160's. He was given FFP for a total of 6 units to reverse elevated INR. Head of bed was kept 30 degrees. Frequent neuro checks were done to watch for any sign of hydrocephalus. He was placed on gentle hydration with IV fluids at 50 cc per hour. He was evaluated by neurosurgery who felt that his intraparenchymal bleed was not operable. Throughout his hospital course his neurologic exam did not significantly change. He remained with flaccid right arm and leg and with good spontaneous movements on his left arm and leg. He remained intubated and sedated. The sedation was withdrawn on with no significant change in his neurologic status or responsiveness other than opening his eyes to stimulation. Repeat head CT was done on to evaluate for any change in hemorrhage or mass effect or hydrocephalus. Repeat head CT showed a stable hemorrhage with no significant change from the prior study. It continued to require aggressive blood pressure control. He again had a repeat head CT done on for question of decreased responsiveness and again no significant change was seen in the hemorrhage or small amount of shift. His ventilatory requirements continued to be weaned. He was weaned to pressure support and C-pap, though continued to require intubation for airway protection. After discussion with the family it was decided to place tracheostomy as well as PEG tube which was done on . He did become febrile over his hospital course with cultures showing an enterococcus UTI and MSSA in his sputum. He was started on antibiotics including Levaquin and Oxacillin. He received a total course of a 7 day course of Levaquin and is to continue for a total of 7 days of Oxacillin requiring one more day, to be discontinued after dose. He did have an episode of acute respiratory distress on . At that time the episode resolved spontaneously. Chest x-ray at that time showed mild CHF, the episode was felt to possibly be a PE. Lower extremity dopplers were done which were negative. The patient had been on boots for DVT prophylaxis and was started on subcu Heparin. Neurologic exam on discharge remained not significantly changed. The patient is awake, alert, opens eyes to verbal stimuli. He does not follow commands. he does squeeze with his left hand but not consistently to command. He continues with a left gaze deviation, both eyes sometimes do cross midline. He does not track with his eyes, his pupils are equal, round and reactive to light. The left gaze deviation is able to be overcome by dolls. He continues with a dense right hemiplegia. He has good spontaneous movements on the left arm and leg. He withdraws his left arm and leg to painful stimuli. There is occasionally triple flexion response to painful stimuli of the right leg. There is no withdrawal on the right arm. | SETTING UNCHGED-AM ABG SENT. MD notified and pt again placed on Labetolol gtt. Weaned labetolol gtt to off with SBP <110. CV=HEMODY STABLE. AM ABG-7.43/40/139/27/2BREATH SOUNDS=COURSE THROUGHOUT. PULM=TRACHED & VENTED. WO MOVEMENT OF R EXTREM. ID=LOW GRADE T. LABS=AM SENT.A:FRESH TRACH & PEG.P:CONTIN PRESENT RX. LASIX PO W GD RESPONSE. OPENS EYES TO STIM-?TRACTS/FOLLOWS. ?WEAN TO EXTUBATE. PULM=TRACHED. BP, HR and RR began trending down back to baseline. K REPLACED.A:UNCHGED.P:CONTIN PRESENT MED MANAGEMENT. Suction prn. Conts on levo and oxacillin for coverage. PULM=REMAINS /VENTED. WO BM. CCU NSG PROGRESS NOTE-NSICU BORDER.O:NEURO=UNCHGED. BUN 51 creat 1.4. SX FREQ. +BS Abd softly distended. ABG 7.35/49/97/28. ABG 7.43/42/173/29. begining vemt wean as tolerated. CV=CONTIN ON LOPRESSOR/HYDRAL FOR RATE/BP CONTROL. Tolerating well, ABG confirms. ?trach. GU=CONDOM CATH. TLC in R subclavian flushing w/o incidence. Abluterol/Atrovent mdi given as ordered. ?LBM. FS QID. TREATED X1 THIS SHIFT. CCU NSG NOTE: THALMIC BLEEDO: For complete VS see CCU flow sheet.ID: T-max 100.6.NEURO: Pt remains minimally responsive. CCU NSG PROGRESS NOTE 7P-7A/ S/P THALMIC BLEED.S- , SEDATED, NONRESPONSIVE.O- SEE FLOWSHEET FOR OBJECTIVE DATA.CV- VS REMAIN STABLE- BP LABILE ACCORDING TO AGITATION/SEDATION LEVEL.MOSTLY B/T 100/50- 150/70.GOAL- SPB- 120-140/. Started on LEVOFLOXACIN IV qd.RESP: LS coarse. s/c Heparin and pneumoboots.ID: Tmax 100.6 PO, 101.5 rectal today. suction q3-4h and prn. AMBUED & SUCTIONED & SEDATED WITH VERSED 1MG VP WITH GOOD EFFECT.CARDIAC: HR 87-109 AF, NO ECTOPICS. Respir. abd soft, +BS. placed back on PS 12/ peep 5 w/ good effect. ON IV LEVOFLOX.ENDO: BS 173->166. reverting back into above respiratory pattern. excellant cough. BP-115/- 160/REMAINS ON LOPRESSOR/NTP/CLONIDINE/HYDRALAZINE. purposful movements L side. TV- 800'S,.ABG EXCELLENT.PLAN TO EXTUBATE THIS AM.NPO EXCEPT FOR MEDS.RR- .MIN SECRETIONS.ID- AFEBRILE.GU- FAIR UO- 20-60/HOUR- RESUMED ON LASIX PO.I/O CLOSE TO EVEN AS OF 12 AM.GI- OGT IN PLACE - NPO FOR POSSIBLE EXTUBATION.MINIMAL ASPIRATES. EPISODES OF TACHIPNEA & LABORED RESPIRATIONS-RXED W HALDOL PRN W LIMITED EFFECT. CV=NTG WEANED & DCED. ?RESUME TF-IF NOT EXTUBATABLE. b/s +/cta/dim bilat. PULM= & VENTED. generalized +edema.RESP: remains on PS today. ID=FEBRILE W T MAX 100.4 PO. HAS HX MI, HTN, AFIB. OVER DIURESIS ...? Abd +BS, distended soft. ABG'S SDEQUATE. pneumoboots on. sxn thk wh. TF WELL WITH MIN RESIDUAL. BP 120-160/60-70s.GI: Pt had lg soft G- bm. RT gave inhalers.CVS: BP 97 -178/60 - 80. ?HEAD CT REDO. abg 7.43/44/116/30. current abg 7.40/42/131/27. ?WEAN VENT TO EXTUBATE (FREQ SX & COUPIOUS SECRETIONS). c/w tc as tolerates. Cont TF overnight.Keep R arm elevated. CK AM LABS-REPLACE AS INDICATED. status, BS, tube feedings off in am. TEGADEM APPLIED. admin albuterol/atrovent q4-6 with mdi/. Suction prn. BP STABLE ON LABETOLOL GTT. MDI/neb treaments per RESP.GI/GU: abd soft, distended. +generalized edema.ACCESS: R PIV d/c'd. TMAX 101.4 rectally. Resp.---- Pt. C/W TRACH MASK AS TOLERATES. admin albuterol/atrovent mdi q6h. Albuterol/Atrovent MDI's given Q6hr. ADMIN ALBUTEROL/ATROVENT MDI X3. advance to GR as tolerated. SXNED AS NEEDED. NTP has been D/C'd. OXACILLIN D/C. CCU NSG PROGRESS NOTE 7P-7A/ S/P THALMIC BLEEDS- O- SEE FLOWSHEET FOR OBJECTIVE DATA.CV- VS REMAIN AT BASELINE.HR- 108-112 AF. of tan sputum.I.D. Sx for lrg amts. : Pt. : Pt. : Pt. Suctioned for a mod. Receiving albuterol and atrovent MDI as needed. TOLERATING VERY WELL, CUFF IS DEFLATED. : afebrile. Pt. Pt. Pt. Pt. Pt. Pt. ABG: compensated metabolic alkalosis. Plan is to cont. PSV, weaned to 10/5/0.40. Continues on oxa.CVS: BP labile 140 - 180's/70's. TOLERATING WELL. RN AWARE. u/a and CS sent.PLAN: sent sputum spec. amt. DOES NOT FOLLOW COMANDSCV: HR 85-115 A FIB, BP 140-180/60-70, ^ TO 190/100 W/ ATTEMPT TO LOWER PS.RESP: REMAINS ON PS 14, PEEP5. Pt rxd t/o shift with Albuterol/atrovent mdis. +generalized edema.ACCESS: R radial Aline. CXR done. Tolerating TF. ABG 7.45/37/119/2. Resp CarePt. ABG ->60/7.43/43/29. AM ABG-7.39/48/117/30/3. Pulm toliet. +Flatus today. REPLACED X1.ID: T 97.7->98.8(PO).PLAN: TO REHAB THIS AM. Started on Vancomycin today.RESP: LS clear, dim bases. placement confirmed by CXR. Pt with +cough reflex but w/o gag reflex.CV: NTG gtt at 115mcg to maintain SBp<160. BUN 32 Creat 1.4. ETT.ID: Febrile today. +corneals. REMAINS ON LABETALOL GTT.P:CONTIN PRESENT MANAGEMENT. : Pt. con't w/ +generalized edema.RESP: LS Diminished to bases, generally clear upper. Pt tol current settings fairly. ?ADUMENT DIURESIS W PRN LASIX-?SOME COMPONENT OM HTN RELATED TO FL STATUS. Tmax today 100.7 oral. LBM. remains flaccid on R side. ?ATTEMPT TO WEAN & DC LABETOLAL. BS+. +1393 LOS.ID: tmax 99.6.SKIN: intactENDO: FS 127 and 147. Pt. Pt. Pt. Pt. Pt. Pt. +BS. Resp Care,pt. DUODERM TO BUTTOCKS INTACT.DISPOSITION: DNRA: STABLEP: BEDSIDE TRACH TODAY. Right subclavian CV line is in mid SVC. pt tol procedure well. DIURESING WELL FROM LASIX. DIURESING WELL FROM LASIX.GI: + BOWEL SOUNDS. IMPRESSION: PICC tip in proximal SVC. Pt tol PSV well. r hemiparesis. NSG NOTECV: REMAINS IN A-FIB. cont on oxacillin. cont po lasix.id: afeb. pt tol well. tol well.p: begin vent wean as tol. sxn'd for sm amt bld tinged secretions. continues very bronchospastic to SXN. Respiratory Care:Pt. RESPIRATORY CARE:Pt. ABG 7.47/40/151/30. PT BECOMING WITH SUCTIONING. ABG'S ADEQUATE.GU: FOLEY PATENT. bp 130-150/70 via r rad aline. has note visited.act: pt and ot eval pt. ABD SOFT WITH + BS. moves l hand to face/tubes and req soft wrist restraint.cv: hr 80s afib. Rec'g IV lasix . FOLLOWS WITH EYES.CV: CONT ON LABETOLOL GTT. IMPRESSION: Stable left basal ganglionic and intraventricular hemorrhage. There is edema associated with the left basal ganglia hemorrhage that does not appear significantly changed. There is a calcified extra-axial mass off the higher convexities on the right which is unchanged and probably represents a calcified meningioma. There has been interval removal of the right subclavian central venous line. Mild ventricular dilatation. There is a tiny amount of hemorrhage seen within the posterior of the right lateral ventricle as well as in the left temporal and third ventricle. There is a stable old right temporal lobe infarct. There is a stable old right temporal lobe infarct. Mild congestive failure and probably a right-sided effusion. The calcified presumed meningioma in the right frontal region is unchanged. Interval removal of the right subclavian central venous line. There has been decreased interval perihilar haziness and patchy bibasilar opacities. | 127 | [
{
"category": "Nursing/other",
"chartdate": "2147-12-11 00:00:00.000",
"description": "Report",
"row_id": 1332335,
"text": "No ABG drawn over night,yesterday abg was normal. Patient head scan from yesterday is unchanged. Remains on mechanical ventilation PS 8/5 with FI02 40% sat 98%,HR 100, BP179/82 BS diminished, not much secretion present on ventolin and atrovent inhalers.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-11 00:00:00.000",
"description": "Report",
"row_id": 1332336,
"text": "CCU NSG PROGRESS NOTE-NSICU BORDER.\nO:NEURO=STABLE. MOVING L ARM-?PURPOSEFULLY. MOVES L LEG ON BED. WO MOVEMENT R SIDE. OPENS EYES TO STIM-?TRACTS/FOLLOWS. SEE FLOW SHEET FOR FURTHER NEURO CKS.\n PULM=REMAINS /VENTED. SETTING UNCHGED-AM ABG SENT. BREATH SOUNDS=COURSE THROUGHOUT. SX-THICK TANNISH SECRETIONS.\n CV=CONTIN ON LOPRESSOR/HYDRAL FOR RATE/BP CONTROL.\n GI=TF @ GOAL W MINIMAL RESIDUALS. WO STOOL.\n ID=LOW GRADE T.\n LABS=AM SENT.\n\nA:UNCHGED NEURO ASSESSMENT.\n\nP:?ADD MILD SEDATION-HEPL W ?ANXIETY & W HYPERTENSION. ?WEAN TO EXTUBATE. SUPPORT PT/FAMILY AS NEEDED.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-18 00:00:00.000",
"description": "Report",
"row_id": 1332359,
"text": "CCU Nursing Progress Note 3p-7p:\n\nNeuro: Pt opening eyes spontaneously. Moving neck and LUE frequently wrasping side rails. No spontaneous movement of lower extremities notes. PT consulted today regaring increasing pt's activity, please see eval for details.\n\nCV: Afib HR 90's w/o ectopy. SBP 119-125. Pt conts on cardiac regimen 2in NTP,lopressor and hydralazine. IVF changed to d51/2 NS 40meq KCL at 80cc/hr.\n\nPULM: Mechanically ventilated via trach on PS 14 5 peep 40% fi02 with tv 460. ABG 7.43/42/173/29. Pt with strong spontaneous cough. Pt sxn'd for small to moderate amts of blood tinged sputum. Await RT to locate in line sxn for trach. Pt rec'd last dose of diamox for metabolic alkalosis.\n\nGI: Abd soft +BS. No stool this shift. Peg tube site c/d/i. Place check done with bilious aspirate. Pt rec'd meds crushed w/o incidence.\n\nGU: Foley cath patent draining cyu in adequate amts. -140cc since mn + LOS.\n\nLINES: A-line removed today. TLC in R subclavian flushing w/o incidence. Pt evaluated by IV for PICC placement per IV pt with marginal access secondary to edema. IV team will reevaluate they are also concerned with recent temps and would like line order checked out with ID.\n\nENDO: FS 115 no reg insulin coverage indicated.\n\nID: Afebrile. Rec'd last dose of levo po. Conts on oxacillin iv atc.\n\nSOCIAL: wife and friend in to visit this evening.\n\nDISPO: DNR\n\n\nA: s/p trach and peg placement today. VSS.\nPeg tube flushing w/o incidence.\n\nP: Follow for neuro status changes.\n monitor bp on current regimen.\n ? begining vemt wean as tolerated.\n NPO except meds, start TF in am \n skin care.\n follow u/o.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-19 00:00:00.000",
"description": "Report",
"row_id": 1332360,
"text": "CCU NSG PROGRESS NOTE-NSICU BORDER.\nO:NEURO=OPENS EYES & TURNS HEAD TO NOISE, BUT DOES NOT FOCUS, TRACT OR FOLLOW W EYES-APPEARS TO LOOK RIGHT THROUGH YOU!\n PULM=TRACHED. VENTED W SETTINGS-CPAP/PS, 40%, 490-700 STV, 20-30 RR, 5 PEEP, & 14 PRESSURE SUPPORT. BREATH SOUNDS=COURSE THROUGHOUT. SX-LT PINKISH SECRETIONS. TRACH CARE DONE.\n CV=HEMODY STABLE.\n GI=PEG. MEDS WO DIFFICULTLY-?INCREASE AMT OF AIR PRESENT.\n GU=FOLEY. LASIX PO W GD RESPONSE.\n ID=LOW GRADE T.\n LABS=AM SENT.\nA:FRESH TRACH & PEG.\nP:CONTIN PRESENT RX. ?PICC LINE PLACEMENT. ?SCREEN FOR PLACEMENT. SUPPORT AS NEEDED.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-19 00:00:00.000",
"description": "Report",
"row_id": 1332361,
"text": "CCU Nursing Progress Note 7a-7p:\n\nNeuro: Pt alert moving LUE up and down off bed and holding side rail. RUE w/o movement, RLE moves toes and LLE moves on bed. Pt turning head side to side but does not track.\n\nCV: Pt rec'd ADL's, MDI's and was sxn'd at appox 9:30am pt's BP increased to 190-200's, RR high 30's to 40 and HR AFib to 115. Team notified EKG and CXR obtained CK sent. During this event pt appeared air hungry and Diaphoretic. pt w/o difficulty. Dr. was in unit evlauated pt less than 24 hour post trach insertion. Dr not find any issues with trach. Pt rec'd a total of 4mg mso4 with effect. BP, HR and RR began trending down back to baseline. ? PE so pt rec'd duplex US of lower extremities to r/o DVT, await results. rec'd 40mg iv lasix with +diuresis.\nPt conts on current cardiac regimen. HCT 32.7\n\nPULM: Mechanically ventilated via trach on ps 14 5 peep 505 fi02 with tv 700-900. ABG 7.35/49/97/28. Ls course throughout. Sxn'd via trach for yellow sputum. Trach site clean and intact.\n\nGI: Peg tube patent flushing w/o incidence. +BS Abd softly distended. Pt conts on bowel regimen with no stool this shift. TF at goal 65cc/hr.\n\nGU: Foley cath patent draining cyu in adequate amts s/p lasix dose. -952 since mn +1102 LOS.\n\nID: t max 100.0 orally. WBC 19.7. Conts on levo and oxacillin for coverage. + enterococcus in urine on . Sputum on with gram +cocci and gram neg rods.\n\nENDO: FS QID with reg insulin coverage. FS <200.\n\nSKIN: Blister on R heel, remains elevated off bed.\n\nLINES: R radial a-line placed today. R TLC cath flushing w/o incidence.\n\nDISPO: DNR\n\nSOCIAL: wife in to visit today. Sister in law phoned from .\n\nA: resp event this am ?etiology.\n VS now stable.\n TF at goal.\n No change in neuro status.\n\nP: Cont current cardiac regimen. Follow for neuro changes.\n Follow ABG's begin vent wean when indicated.\n Provide support. Await picc line placement when less edematous.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-11 00:00:00.000",
"description": "Report",
"row_id": 1332337,
"text": "CCU Nursing Progress Note 7a-7p:\n\nNeuro: Pt awake looking around the room and up at the tv. Pt with minimal tracking. No gag reflex and impaired cough reflex. Responding to commands ie opening eyes and sqeexzing left hand. Purposeful movement noted of LUE, moving LLE on bed. No spontaneous movement noted on the R side. HOB 30 degrees. Pt rec'd haldol 2mg IV with minimal effect.\n\nCV: Afib HR 80-100 w/o ectopy. Pt hypertensive throughout the day, Res aware. SBP 160-180's trending to 200 with nursing interventions. Hydralazine dose increased to 30mg po and lopressor dose increased to 125mg po, please follow effect. K+ 4.3 HCT 35.1\nHead CT from neg.\n\nPULM: Mechanically ventilated on PS 8 5 peep 40% fi02. Spont tv 390-490. RR 20's trending into the 30's with sxning and turning. LS coarse throughout. Pt sxn'd q2 hr for thick yellow secretions in moderate amts at times requiring lavage. MDI's by RT. Secondary to no gag reflex pt to be consulted for a trach per team await team to discuss with pt's wife.\nIf pt spikes team with aquire at CXR.\n\nGI: Abd soflty distended +BS + flatus. Pt reached goal of TF impact with fiber today 80cc/hr. Minimal residuals to 25cc.\n\nGU: Foley cath patent draining cyu in adequate amts. BUN 51 creat 1.4. +2455 LOS. Pt with 50cc/hr u/o. Urine with enteroccus.\n\nID: low grade temp to 100.9 Res. aware. WBC 13.2. No abx indicated at this time, follow temps.\n\nSKIN: R heel blister, multipodus boots in place.\nButtocks redened w/o breakdown.\n\nENDO: FS QID <160 reg ss insulin for coverage.\n\nDISPO: Full Code\n\nSOCIAL: wife in to visit today.\n\nA: Improved neuro exam\n resp status stable on current vent settings\n hypertensive\n Tolerating TF at goal\n\nP: Follow neuro assessment. Await effects of increased cardiac regimen. Follow resp status no changes in vent settings. ?trach. TF at goal. ?LBM. Provide support to pt and family.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-11 00:00:00.000",
"description": "Report",
"row_id": 1332338,
"text": "Respiratory Care\nPt remains and mechanically ventilated, please see carevue flowsheet for specific info, no vent changes made this shift,no ABG's, 02 sats stable. Suctioning thick yellow, plan to continue with mechanical support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-31 00:00:00.000",
"description": "Report",
"row_id": 1332402,
"text": "CCU NSG NOTE: ALT IN NEURO\nO: For complete VS see CCU flow sheet.\nID: Pt afebrile.\nNEURO: Pt conts to have no movement seen on R side of body. He was very alert much of the day, making eye contact and intermittently, and occasionally following commands.\nCV: Stable with hr 80-90s a-fib and bp better controlled in 125-160/60-80s. Pt lifted out of bed to chair for ~2.5 hrs.\nRESP: Pt off the vent for over 48hrs now. He still requires suctioning ~Q3hr for lt yellow sputum. His cough is strong cough and he get much up on his own. Breath sounds are course.\n GI: Pt had lg soft G- BM in am. He continues on replete with fiber from 4p until 8am at 120cc/hr.\nGU: Pt voiding thru condom cath without problem.\nELECTROLYTES: up to 145 today and D5W boluses decreased to 200cc Q6.\nENDO: Blood sugars 162 st noon and 134 at 6p. Pt received 5u NPH at 6p\nA: Decreasing secretion/off vent >48hr\nP: ? transfer to neuro floor tomorrow. Monitor for change. Suction prn. Monitor for change.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-12 00:00:00.000",
"description": "Report",
"row_id": 1332339,
"text": "SICU Nursing Progress Note\nNeuro: Pt responsive to voice. Pt will open eyes and track for a short period. Pt will follow very simple commands inconsistantly. Pt able to move LUE freely, I have not observed any movement of other extremeties. Neuro checks q2 hours. Pt inconsistantly responds to painful sensation. Pupils PEARL. Pt has -gag reflex, and impaired cough reflex.\n\nCardiac: Pt in controlled AF in 80-90's. BP hypertensive in 180's-190's. MD notified and pt again placed on Labetolol gtt. Started at 2345, initially at 4mg/min, decreased to 2 mg/min. Where he remains currently. BP decreased to about 160's sys. Pt con't on large doses of cardiac meds, lopressor and hydralizine. BP dramaticaly improved with am lopressor and tylenol. BP currently 118/55.\n\nResp: Pt , ? trach at some point, (has not been discussed with wife...will need to be, MD's notified). Pt on CPAP .4%, . Tolerating well, ABG confirms. Pts BS are decreased. Pt has moderate amt of thick yellow sputum, needs lavage.\n\nGI: Pt has OGT, TF, impact with fiber tolerating well minimal residual, at goal of 80. Pts abd is soft and distended, +BS, -BM? how long?\n\nGU: Pt has f/c, with 50-100 cc/hr out. Amber in color and has slight sediment. Pt gets 100 cc of free H2O q8/hr. Lasix is being held. Pt has eneerococcus in urine.\n\nID: Tmax 101.8 pt pan cultured at 0400, pt given tylenol with good response. MD's wanted pt to have CXR with spike, MD notified and decided to have CXR in am.\n\nSkin: Pt has sheepskin boots on bilaterally placed for R heel blister, pneumo sleeves on. Pt turned q3/hr.\n\nEndo: Pt covered with R insulin for BG of 159.\n\nAccess: Pt has R SC TL, and R rad .\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-20 00:00:00.000",
"description": "Report",
"row_id": 1332362,
"text": "Respiratory care:\nPatient remains trached with a # 8 portex and mechanically vented. Vent checked and alarms functioning. Settings CPap/PS with IP 14\npeep 5. Abluterol/Atrovent mdi given as ordered. Please see respiratory Section of carevue for further data.\nPlan: Continue mechanical ventilation. Wean PS as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-20 00:00:00.000",
"description": "Report",
"row_id": 1332363,
"text": "CCU NSG PROGRESS NOTE-NSICU BORDER.\nO:NEURO=REMAINS UNCHANGED. RESPONDS TO NOISE-TURNS HEAD TOWARDS, BUT DOES NOR ENGAGE W EYES.\n PULM=TRACHED & VENTED. SETTINGS-CPAP/PRESSURE SUPPORT, FIO2 50%, STV 640-730, RR 12-20, PEEP 5, & PRESS SUPPORT 14. AM ABG-7.43/40/139/27/2\nBREATH SOUNDS=COURSE THROUGHOUT. SX-THICK TANNISH SECRETIONS. TRACH CARE DONE.\n CV=BORDERLINE HYPERTENSIVE DESPITE RX W HYDRALAZINE, LOPRESSOR, & NTP.\n GI=TF-PROMOTE W FIBER @ 65ML/HR W MINIMAL RESIDUALS. WO BM.\n GU=I&O -.9L @ 2300 & -.8L @ 0600.\n ID=LOW GRADE T.\n LABS=AM SENT. K REPLACED.\nA:UNCHGED.\nP:CONTIN PRESENT MED MANAGEMENT. ?PICC LINE. ?START EVALUATION FOR PLACEMENT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-07 00:00:00.000",
"description": "Report",
"row_id": 1332319,
"text": "CCU Nursing Progress Note 7p-7a:\n\nNeuro: Pt sedated on propofol gtt at 25mcg. Pt responding to sternal rub and nail bed pressure. Pt moving all extremities on bed. Pupils pinpoint, reactivity sluggish. No gag or cough reflex. Lightened sedation w/o change. Await results from CT scan.\n\nCV: Afib HR 70-80's w/o ectopy. Goal SBP <120. Weaned labetolol gtt to off with SBP <110. Am hydralazine iv held per parameters. Conts on lopressor 12.5mg . HCT 35.5.\n\nPULM: Mechanically ventilated on PS 5 last evening with RR in high 30's, tv 310-380 with pt diaphoretic. Team notified PS increased to 15 and within 5 min pt's RR down to the teens and tv increased to the 700's. Pt appeared more comfortable. Began PS wean this am currently at 13 7.5 peep 40% fi02 RR 13 and Tv 600. ABG 7.43/40/118/2.\nPt sxn'd q2hr for small amts of thick yellow secretions.\n\nGI: Abd softly distended with hypoactive BS. OGT clamped. +bile in stomach. No stool this shift. Pt remains NPO on maintainence IVF for posible extubation.\n\nGU: Foley cath patent draining concentrated yellow urine in adequate amts 30cc/hr. +305 since mn +1128 LOS.\n\nSKIN: intact\n\nENDO: FS 189 and 134. Reg insulin ss for coverage.\n\nPROPH: Pneumoboots and protonix.\n\nLINES: L radial a-line and PIV.\n\nDISPO: Full Code\n\nSOCIAL: No phone calls this shift.\n\nA: stable BP off labetalol gtt\n neuro status stable\n requiring increased PS.\n\nP: Maintain SBP <120.\n Follow Afib. Wean PS as tolerated.\n NPO. Follow u/o.\n Neuro checks q1hr.\n FS QID. Provide support to family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-07 00:00:00.000",
"description": "Report",
"row_id": 1332320,
"text": "Respiratory Care note: Pt is on CPAP 7.5. PSV decreased from 13 to 11. Tidal Volumes= 500-650ml. RR= 17. Spo2= 97% on an Fio2= .40. When ETT was placed at 20cm at lip, there was an enormous air leak that would not go away with the administration of air to the cuff. As a result, we had to advance the ETT to a level that below the vocal cords. Currently the ETT is placed at 26 cm. A CXR has beendered to check tube placement. Suctioned pt after repositioning for a large amount of thick, yellow sputum.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-07 00:00:00.000",
"description": "Report",
"row_id": 1332321,
"text": "N SICU NPN\nNEURO: PROPOFOL D/C 09:00, PT RESPONSIVE TO NOXIOUS STIMULI. OPENS EYES, OCC SPONTANEOUSLY HOWEVER DOES NOT TRACK. PUPILS 2MM AND SLUGGISH. MOVING L SIDE OCCASIONALLY, VERY SLIGHT MOVEMENT OF R HAND AND FOOT NOTED THIS AM. + COUGH GAG ABSENT.\n\nCV: HEMODYNAMICALLY STABLE IN A FIB 80-90'S, BP 110-160/50-70.\n\nRESP: PS DECREASED TO 11, TV 400-500.RR 14-20. APPEARS VERY COMFORTABLE. SECRETIONS BECAME COPIOUS THIS AFTERNOON, THICK, TAN. SPECIMENT SENT FOR CULTRE. LG AMTS ORAL SECRETIONS. LESS PAST 2 HRS. ETT REPOSITIONED BY SICU RESIDENT. PLACEMENT CONFIRMED BY X RAY.\n\nGI: IMPACT W/ FIBER STARTED AT 16:00 AT 10CC/HR. NO STOOL THS SHIFT.\n\nGU: U/O 15-25CC/HR, CURRENTLY ~ 800CC +. CURRENTLY BEING GIVEN 500CC NS BOLUS.\n\nID: TM 100.2 R.\n\nSOCIAL: WIFE, BROTHER AND SISTER IN LAW IN ALL AFTERNOON, UPDATED BY MD.\n\nA: NEURO STATUS UNCHANGED, HEMODYNAMICALLY STABLE OFF LABATELOL, TOLERATING DECREASED PS.\n\nP: MONITOR NEURO STATUS, KEEP SBP > 120, FOLLOW U/O, ? SWAN.\nEMOTIONAL SUPPORT TO FAMILY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-07 00:00:00.000",
"description": "Report",
"row_id": 1332322,
"text": "NPN ADDENDUM\nBP ^ 190'S/ STARTED ON NTG GTT AT 40 MCG/MIN AT 18:00,INCREASED TO 60 MCG/MIN. ALSO LOPRESSOR ^ TO 25MG , AND DOSE GIVEN AT 18:00.\nCURRENTLY HR 108 A FIB, BP 140/73.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-01-01 00:00:00.000",
"description": "Report",
"row_id": 1332403,
"text": "CCU NSG PROGRESS NOTE-NSICU BORDER.\nO:NEURO=RESPONSIVE. APPROPRIATE TO SIMPLE QUESTIONS-\"ARE YOU OK?\"- SHAKES HEAD NO & SAYS \"HELP\". CONTIN TO MOVE LUE PURPOSEFULLY-TAKING TRACH MASK OFF, PLAYING W COMDOM CATH, & SCRATHCHING NOSE. WO MOVEMENT OF R EXTREM.\n PULM=TRACH MASK-50% W ADEQ SATS. SX-THICK WHITEISH SECRETIONS. BREATH SOUNDS=COURSE THROUGHOUT.\n GI=TF @ GOAL. WO STOOL.\n GU=CONDOM CATH. GD RESPONSE TO LASIX.\n LABS=AM SENT. EXTREMELY DIFFICULT STICK-POOR ACCESS.\nA:SLOWLY IMPROVING NEURO STATUS.\nP:CONTIN PRESENT MED MANAGEMENT. ?CALL-OUT.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-01-01 00:00:00.000",
"description": "Report",
"row_id": 1332404,
"text": "ccu nursing progress note\nremains on trach mask\nO: see flowsheet for objective data. VSS with BP good on current meds.\nremains in afib without vea. resp: remains on .5 trach mask with good sats. requiring suctioning q2-3hr for thick yellow/white secretions with occassional plugs. lungs coarse. afebrile. u/o qs via condom cath. cont tube feeds at goal rate, no BM today. PEG site d/i, PICC site D/I , coccyx reddened, duoderm intact. pt. oob-chair with 4 assists for 2 hours, tolerated well. neuro: pt. alert at times, following simple commands inconsistently, moving LUE purposefully, moving LLE on bed, right side remains flacid. wife called x 2, updated on condition. turned q2hr.\nA: stable, cont with secretions\nP: cont pulm toilet, follow neuro status, cont supportive care. ?Placement on per resident to \n"
},
{
"category": "Nursing/other",
"chartdate": "2148-01-02 00:00:00.000",
"description": "Report",
"row_id": 1332405,
"text": "CCU NSG PROGRESS NOTE-NSICU BORDER.\nO:NEURO=UNCHGED.\n PULM=THICK SECRETIONS. SX FREQ.\n LABS=UNABLE TO OBTAIN. PICC LINE DOES NOT DRAW BACK.\nA:UNCHGED.\nP:CONTIN PRESENT MED MANAGEMENT. ?TRANSFER TO REHAB.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-01-02 00:00:00.000",
"description": "Report",
"row_id": 1332406,
"text": "RESPIRATORY CARE:\nPATIENT FOLLOWED FOR ALBUTEROL/ATROVENT NEBS. TREATED X1 THIS SHIFT. TOLERATED WELL. BS COARSE.\nWILL CONTINUE TO FOLLOW. PATIENT WITH 50% COOL AEROSOL ON.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-01-02 00:00:00.000",
"description": "Report",
"row_id": 1332407,
"text": "ccu nursing progress note\nS' remains trached\nO: see flowsheet for objective data. VSS on current meds. cont on .5 trach mask with good sats, suctioned frequently for thick white secretions, lungs remain coarse with upper airway exp. wheezing, cont nebs per RT, afebrile, GI: tube feeds restarted at goal rate at 4pm, BS+, no BM today, GU: voiding via condom cath, neuro: more alert his am, at times following commands but not consistently, moving LUE purposefully, moving LLE in bed, right side remains flacid. sent for head CT this am, pnd RUE remains edemetous, elevated on pillow. turned q2hr, skin intact. PICC line cont, able to flush but not draw blood, pt. extremely difficult to stick for bloods.\nA: stable\nP: to be eval for tx to , cont to follow neuro status, cont pulm toilet\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-01-02 00:00:00.000",
"description": "Report",
"row_id": 1332408,
"text": "Resp Care\nadmin albuterol/atrovent 4 puffs each q4h via trach/. sxning sm amts clear to white secretions. good cough. cuff deflated. occas.audible wheezing ?from tracheal irritation vs.bronchospasm.\nremains on 50% trach collar in nard.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-01-03 00:00:00.000",
"description": "Report",
"row_id": 1332409,
"text": "CCU progress note\nNEURO: no changes noted. PERLA 2mm reactive. no movement R side. +sensation. purposful movements L side. pt sleeping most of nite. not obeying verbal or gestured commands tonite.\n\nCARDIAC: AFIB 90s. SBP stable.\n\nRESP: remains on Trach collar 50%. suctioned for small amts thin white secretions. no resp distress. RR 6-40s varying, sats >98%.\n\nGI/GU: voiding in condom cath. incontinent x 1 large amt urine when condom fell off. abd soft. +BS. Large soft formed BM tonite. TF overnite via peg.\n\nPLAN: ?rehab placement. cont' to monitor neuro and VS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-01-03 00:00:00.000",
"description": "Report",
"row_id": 1332410,
"text": "Respir. Care Note\nFollowed overnight with q 4 Albuterol/Atrovent MDIs via trach. Breath sounds are coarse bilaterally, suctioned for thick white/tan secretions. O2 sat 97-99% on 50% trach mask.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-01-03 00:00:00.000",
"description": "Report",
"row_id": 1332411,
"text": "Resp care\nc/w 40% trch collar/cuff deflated. excellant cough. prod sm amts green sputum. less wheezing today. mdi's changed to prn. awaiting transfer to rehab facility.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-01-03 00:00:00.000",
"description": "Report",
"row_id": 1332412,
"text": "N SICU NPN\nNEURO: NO MOVEMENT R SIDE. MOVING L SIDE IN PURPOSEFUL MANNER. FOLLOWING COMMANDS INCONSISTENTLY. OCCASIONALLY WILL SPEAK WORD OR TWO, ANSWERING SIMPLE QUESTIONS.\nCV: HEMODYNAMICALLY STABLE\nRESP: DOING WELL ON TRACH MASK AT 50%.W/ CUFF DOWN. SEEN BY SPEECH AND FITTED W/ PASSEY MUIR VALVE. (DO NOT HAVE ON WHILE PT IS COUGH PRODUCTIVE FOR THICK YEL SPUTUM, NEB RX HAVE BEEN CHANGED TO PRN.\nGI: TOLERATING TF. NO STOOL TODAY\nGU: CONDOM CATH DRAINING CL YEL URINE QS.\nID: AFEBRILE\nEND: BS 179 AT 6PM.\nACTIVITY: SEEN BY PT TODAY. OOB TO CHAIR, SAT ON EDGE OF CHAIR BALANCING W/ L HAND, ATTEMPTED TO STAND.\nDISPO: PT HAS BED AT OLYMPUS/ FOR , AT 9AM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-27 00:00:00.000",
"description": "Report",
"row_id": 1332387,
"text": "Respiratory care:\nPt. remained on vent overnight. SPO2 high 90's to 100%, with RR generally mid teens. B/S course>>ETS for moderate amounts of thick, tan/yellow. MDI's given for induced bronchospasm with good effect. Will continue pulmonary hygiene and TM trials in a.m.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-27 00:00:00.000",
"description": "Report",
"row_id": 1332388,
"text": "NEURO: AWAKE & ALERT. FOCUSES BUT DOES NOT TRACK. PERL. FOLLOWS SIMPLE\n COMMANDS, BUT NOT CONSISTENTLY. NO MOVEMENT ON R. SIDE. L. ARM\n LIFTS & HOLDS OFF BED. L. LEG LIFTS & FALLS. DOES NOT ATTEMPT\n TO COMMUNICATE.\nRESP: TRACHED & ON VENT: 50% 14 IPS 5 PEEP. BS COARSE THROUGHOUT, &\n SLIGHTLY DIMINISHED AT BASES. RR 8-15. O2 SATS 98-100%. SX FOR\n SM.-MOD. AMTS. THICK YELLOW-TAN SECRETIONS. ONE EPISODE EARLY\n IN SHIFT WHEN BECAME TACHYPNEIC TO RR 40-50. AMBUED & SUCTIONED\n & SEDATED WITH VERSED 1MG VP WITH GOOD EFFECT.\nCARDIAC: HR 87-109 AF, NO ECTOPICS. BP 111-139/42-70. CONT. ON NTP,\n LOPRESSOR, & IV HYDRALAZINE.\nGI: TF:FS PROMOTE WITH FIBER AT 65CC/HR. ABD. SL. DISTENDED. BS+. NO\n STOOL. RECEIVING FREE H2O 300CC Q4HRS FOR ELEVATED NA 160.\nGU: FOLEY->CD PATENT & DRAINING CLEAR YELLOW URINE. U/O 60-235CC/HR.\nID: T 99.8->100.1(PO). CONT. ON IV LEVOFLOX.\nENDO: BS 173->166. RECEIVED REG. HUMALIN INSULIN 2U SC X2 PER SLIDING\n SCALE.\nLABS: WBC 12.8, HCT 33.6, PLAT CT 198K, NA 156, K 3.9, BUN/CREAT 44/\n 1.1, CA 8.3, MG 2.3, & PO4 2.5.\nAWAITING REHAB!!!!!!!\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-27 00:00:00.000",
"description": "Report",
"row_id": 1332389,
"text": "CCU progress note 7a-7p\nNEURO: unchanged. inconsistently obeying verbal + gestured commands. pt brushed teeth today and washed face w/ encouragement. pt helped to place glasses on face. pt occasionally doing arm curls w/ 1lb weight. Moves L side well. No movement to R side. +sensation to all extremieites. pupils 2mm brisk. started on serax 10mg TID. ?start antidepressant? ?increase serax if not noted to have good effect on anxiety levels.\n\nCARDIAC: no change in hypertensive meds. BP 120-180 today. AFIB 80-100s.\n\nRESP: attempted to trach collar today, but pt became stridorous and agitated today. placed back on PS 12/ peep 5 w/ good effect. has had episodes of tachypnea on vent this afternoon. settled on own. sats remains >97%. Sx small amts yellow thin secretions.\n\nGI/GU: foley patent. good u/o. on lasix 20mg . On free water 300cc Q6h. TF increased to 80cc/hr GR. PEG intact to abd.\n\nSKIN: duoderm changed to coccyx, stage II ulcerated area to R buttock, new duoderm applied. Ordered first step air mattress. heels intact. old blister to R heel healing well. multipodus boots on. peg site looks healthy, dsg changed today. trach site slightly reddened, cleansed w/ H2O2.\n\nPLAN: con't to monitor VS and neuro status. keep pt comfortable. Awaiting PLACEMENT TO REHAB.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-06 00:00:00.000",
"description": "Report",
"row_id": 1332315,
"text": "addendum to day note\npt's breathing appears more labored than this am. rr is 28 but much more abd breathing irregular. stroke team in to assess.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-06 00:00:00.000",
"description": "Report",
"row_id": 1332316,
"text": "Patient went to CT Scan today plan to extubate aborted on PSV 5/7.5 with spy VT 500. Large IPH not improved from previous film.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-06 00:00:00.000",
"description": "Report",
"row_id": 1332317,
"text": "CCU NSG NOTE: THALMIC BLEED\nO: For complete VS see CCU flow sheet.\nID: T-max 100.6.\nNEURO: Pt remains minimally responsive. With sternal rub some movement of L arm seen. Early in shiftmoving left arm pulling against restaint. Some movements of L leg also seen. R sid showed some minimal ?flexor activity. Pupil small and minmimally reactive. When oral suctioning done no gag observed. Pt has tachypnic abnormal breathing pattern with rr 22-30.\nCV: Pt has remained on 2mg/min labetalol with bp varying between 1-teens to 140/50-60. He is also received lopressor 12.5 and hydralazine 10mg IV Q6.\nRESP: Pt remains on c-pap 40%, 7.5 PEEP and 5 PS with last gas on that setting 7.39/ 46/ 108/ 29. He has very decreased breath sounds. He is useing accesory muscles to breath and even with sedation appears to be working hard at breathing. He does have history of COPD, though does not seem to have used inhalors. He requires suctioning ~Q2hr for thick lt yellow secretions. One lg plug was aspirated.\nGU: Urine output remains poor, between 12-35cc/hr. He received 40mg ng lasix at 8pm with minimal response. He is presently 2500+ cc pos for the day. HO notified about poor output. He had received 250NS bolus earlier today with minimal response. Creatinine up to 1.4 today from 1.0 yesterday.\nGI: Pt has OG tube. He has small amt green G+ bile in stomach. Bowels sounds are very decreased. No BM.\nSEDATION: Pt restless early in shift with swings in blood pressure. Propofol increased from 20mic/kilo to 25mic/kilo with pt appearing more comfortable with less aggitated movements.\nENDO: FS at 6p was 159 and pt received ss reg insulin per order.\nFAMILY: Family in to visit. They remains appopriately concerned.\nA: Minimally responsive/poor urine output/bizaare resp pattern\nP: Monitor I & O closely. Wean labetalol as tolerated. Monitor for change in MS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-07 00:00:00.000",
"description": "Report",
"row_id": 1332318,
"text": "Respiratory Care:\nPt. with a very dysynchronous respiratory pattern (gasping inspiration with forced expiration), and VT's decreasing with RR increased to mid 30's. Obtained PS order to titrate for VT 450-550cc. Increased to 15 to finally capture, then slowly weaned through the course of the shift. Unable to make larger decreases due to Pt. reverting back into above respiratory pattern. ABG's throughout have remained well oxygenated with a slight resp. alkalosis. Will continue support as needed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-25 00:00:00.000",
"description": "Report",
"row_id": 1332382,
"text": "NPN\n7 PM - 7 AM\nS/O\nPLS SEE CAREVIEW FLOWSHEET FOR ALL OBJ/NUMERICAL DATA\nCV HEMODYN STABLE .....\nRESP ON 50% TRACH MASK THROUGHOUT THE NITE...LUNGS COARSE ...RR 36-44...ABLE TO COUGH THIN CREAMY YELLOW SXNS INTO TRACH COLLAR ...AND SXD'D Q3 ...\nGI ON TF VIA G-TUBE ON PROMOTE AT 65 CC/HR ..INC SMALL AMOUNT OF SOFT STOOL\nGU U/O GD\nNEURO GIVEN VERSED 1 MG Q4 ...DURING THE NITE ..BUT PT AWAKE ALL NITE\nA STABLE\nP CONTINUE TO ASSESS NUERO STATUS CLOSELY\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-25 00:00:00.000",
"description": "Report",
"row_id": 1332383,
"text": "CCU progress note 7a-7p\nNEURO: Pt very tired today, to recieve ?serax or ativan for sleep tonite (pt did not sleep at all last nite). Slept in short naps today. Obeyed gestured commands. Will shake/hold hand when you indicated for him to reach and hold it. Pt attempted to brush his teeth and use electric today (still weak). Pt holds washcloth and lightly washed L side of face. Pt helped to place glasses on face. Pt sometimes nods to actions. Will look at people and activities outside room, does not always track. Seems withdrawn at times ?angry/depressed? Continues to lift and move L arm and leg. No movement to R side. R side neglect, no vision noted on R side. +sensation to R side.\n\nCARDIAC: AFIB 90-110s. SBP 130-170s today. On hydralazine 50mg IV q6h, Lopressor 150mg TID, Norvasc 10mg, NTP 2inches q6h, clonodine 0.3mg . s/c Heparin and pneumoboots.\n\nID: Tmax 100.6 PO, 101.5 rectal today. PAN CULTURED BCx1, sputum + urine cx sent. CXR obtained. Tylenol given x 1. Started on LEVOFLOXACIN IV qd.\n\nRESP: LS coarse. Remains on Trach collar 50% humidified. Pt has productive cough for thick tan sputum. CX sent. trach suctioned for mod amts secretions also. RR ranges from 14 to 40s, but sats maintained >96% at all times, even when pt occasionally moved trach mask off trach, RA sats >96%. No decrease in sats noted w/ suctioning either.\n\nGI/GU: foley patent, good amts urine. remains on LASIX 20mg PO BID. abd soft, +BS. had large formed BM this afternoon. TF promote w/ fibre at goal rate @ 65cc/hr. PEG intact to abd.\n\nSKIN: duoderm intact to coccyx. duoderm placed on shin area on R leg (some skin breakdown noted ?from pneumoboots). R heel blister healed, both heels remain elevated off bed. placed in multipodus boots occasionally - rotating schedule.\n\n\nPLAN: cont' to monitor neuro signs. attempt to give gestured commands as pt may not be able to understand language d/t stroke. give sleep medication tonite. suction q3-4h and prn. pt is in the process of being rescreened by rehab today (pt improved - is off ventilator and is able to follow gestured commands and perform some small ADLs).\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-26 00:00:00.000",
"description": "Report",
"row_id": 1332384,
"text": "Respiratory Care:\nPt. had been TM trial for >24hours. Increasing RR with severe bronchospasm>>attempted MDI's with limited success, but Pt. responded well to manual ventilation. Pt. then placed back on the vent with IPS=14 cmH20, 5 peep, and FIO2 of 50%. Pt. immediately had decrease bronchospasm, decreased RR, and VT's up to 850cc. Will continue on PS vent for the remainder of the shift, then attempt to TM trial again in the a.m.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-26 00:00:00.000",
"description": "Report",
"row_id": 1332385,
"text": "CCU NSG PROGRESS NOTE 7P-7A/ S/P THALMIC BLEED\n\nS- TRACHED, NOT VERBAL\n\n0 SEE FLOWSHEET FOR OBJECTIVE DATA.\n\n PT REMAINS HEMODYNAMICALLY UNCHANGED.\nHR- 90-100'S AF. BP-115/- 160/\nREMAINS ON LOPRESSOR/NTP/CLONIDINE/HYDRALAZINE.\n\n PT ON TRACH MASK- 50%, TOLERATED WELL UNITL 2:30 AM- MUCH I/E WHEEZE, REPS DISTRESS, WITH RATE 40'S. COMFORTED BY BAGGING, BUT NOT IMPROVED AFTER INHALERS. SWITCHED OVER TO 14 PRESSURE SUPPORT AND CURRENTLY GOOD SATS AND APPEARING STABLE/COMFORTABLE.\n\nID- AFEBRILE- TO LOW GRADE.\n\nGI- REMAINS ON TUBE FEEDS- 65 CC/HOUR- (+) BOWEL SOUNDS- NO STOOL THIS SHIFT- ABD SOFT/DISTENDED.\n\nGU- FAIR UO- 50-80/HOUR.\nNO ISSUES.\n\n PT AWAKE AND ALERT- NOT CONSISTENTLY OBEYING COMMANDS OR WITH PURPOSEFUL ACTIONS.\nSEE FLOWSHEET.\n\nA/ PT S/P LARGE HEAD BLEED/RESP FX- ON/OFF TRACH MASK- DEVELOPING SOME RESP DISTRESS AND NEEDING PRESSURE SUPPORT AGAIN.\n\nCONTINUE TO CLOSELY FOLLOW RESP STATUS AND MAINTAIN AIRWAY- SUCTIONING/NEBS.\nCONSIDER ADDITION OF STEROID NEB PER RT.\nCONTINUE TO CONTROL RPP WITH CV MEDS, AND OBSERVE FOR ANY IMPROVEMENT OF NEURO STATUS.\nCONTINUE SCREENING PROCESS FOR REHAB/LONG TERM FACILITY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-26 00:00:00.000",
"description": "Report",
"row_id": 1332386,
"text": "CCU progress note 7a-7p\nNEURO: neuro's unchanged. purposful movement of L arm and leg. looks at subjects, occasionally tracks. does not obey verbal commands. will occasionally obey gestured commands. pt very tired today, not really interacting much. did attempt to brush teeth with alot of encouragement.\n\nCARDIAC: SBP 110-150s. remains on same BP meds. given MSO4 this afternoon w/ decrease in BP to 90s, noon BP meds held. resumed this evening.\n\nRESP: LS coarse, sx creamy tan secretions. small amts. Pt kept having episodes of tachypnea 40-60s this morning after being taken off vent to trach collar. sats remained 100%. Attempted to sedate w/ 2mg MSO4 per HO, w/ no effect. Placed back on PS 14/ Peep 5 50%, RR 6-40s w/ episodes of 20-30sec periods of apnea. TV 600-1000cc. sats 100%.\n\nID: Tmax 100.2. remains on LEVO IV.\n\nGI/GU: foley patent, good u/o. remains on lasix 20mg po. abd soft. +BS. had large soft formed BM this afternoon. On free water boluses 300cc QID. TF promote w/ fibre @ 65cc/hr. PEG intact.\n\nPLAN: con't to monitor neuro and resp status. monitor vs. keep pt comfortable.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-06 00:00:00.000",
"description": "Report",
"row_id": 1332313,
"text": "CCU NSG PROGRESS NOTE 7P-7A/ S/P THALMIC BLEED.\n\nS- , SEDATED, NONRESPONSIVE.\n\nO- SEE FLOWSHEET FOR OBJECTIVE DATA.\n\nCV- VS REMAIN STABLE- BP LABILE ACCORDING TO AGITATION/SEDATION LEVEL.\nMOSTLY B/T 100/50- 150/70.\nGOAL- SPB- 120-140/. CURRENTLY OFF 1 LABETELOL GTT FOR BP <110.\nTOLERATING HYDRALAZINE 10 QID AND LOW DOSE LOPRESSOR PO.\nREMAINS OFF NIPRIDE GTT.\n\nRESP- REMAINS FOR AIRWAY PROTECTION- 40% WITH 15 PS AND 7.5 PEEP. TV- 800'S,.ABG EXCELLENT.\nPLAN TO EXTUBATE THIS AM.\nNPO EXCEPT FOR MEDS.\nRR- .\nMIN SECRETIONS.\n\nID- AFEBRILE.\n\nGU- FAIR UO- 20-60/HOUR- RESUMED ON LASIX PO.\nI/O CLOSE TO EVEN AS OF 12 AM.\n\nGI- OGT IN PLACE - NPO FOR POSSIBLE EXTUBATION.\nMINIMAL ASPIRATES. NO STOOL.\n\nHEME- S/P VIT K AND 6 U FFP ON ADMIT- AWAIT REPEAT COAGS.\n\nMS/NEURO- NO CHANGE IN NEURO VS- REQUIRING PROPOFOL GTT TO REMAIN SAFELY AND VENTILATED.\nSEE FLOWSHEET FOR DETAIL.\nPROPOFOL GTT REMAINS AT 10-30 MCG, WITH NEEDS FOR BOLUS WITH AGITATION EPISODES AND REACHING FOR ETT.\n\nA/ PT ADMITTED TO CCU FOR NEURO EVENT/BLEED.\nCURRENTLY STATUS QUO ON CURRENT CV MEDS ON VENTILATORY SUPPORT WITH NO CHANGE IN NEURO VS OR EVIDENCE OF WORSENED BLEED.\n\nCONTINUE TO CLOSELY MONITOR, CALL NEURO WITH ANY CHANGE IN SIGNS FOR EMERGENT REPEAT CT SCAN/POSSIBLE INTERVENTION.\nAWAIT COAGS- REPEAT VIT K AND FFP AS NEEDED/ORDERED.\nKEEP BP WITHIN GOAL RANGE OF 120-140.\nKEEP FAMILY AWARE OF PLAN OF CARE AND PROGRESS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-10 00:00:00.000",
"description": "Report",
"row_id": 1332331,
"text": "NURSING PROGRESS NOTE 7P-7A\nS: \n\nO: NEURO: DOES NOT RESPOND TO COMMANDS. WILL OCC OPEN EYES TO STIMULI. NO PURPOSEFUL MOVEMENT. PUPILS 2MM BILAT, SLUGGISH TO REACT. DOES NOT MOVE RIGHT SIDE. ABLE TO PICK UP LEFT ARM, FALLS TO BED. MOVES LEFT LEG ON BED. UNABLE TO GRASP HANDS.\n\nCV: HR 80'S A-FIB NO VEA NOTED. BP STABLE ON LABETOLOL GTT. BP RANGE 120-140'S. RECEIVING HYDRALAZINE IV.\n\nRESP: VENTED. SUCTIONING FOR MIN WHITE, THIN SECRETIONS. VENT SETTINGS OVERNIGHT FIO2 40%, PEEP 5, PS 5 CPAP. BECOMING TACHYPNEIC EARLIER THIS AM. RESTED FOR 2 HRS ON IMV. NOW BACK ON ORIGINAL SETTINGS. RR NOW 37 LABORED BREATHING. ABG'S SDEQUATE. LUNGS COARSE IN BASES.\n\nGU: FOLEY DRAINING AMBER COLORED URINE 30-50 CC/HR. IV FLUIDS AT KVO. RECEIVING FREE WATER BOLUS Q 8 HRS.\n\nGI; NO BM. BOWEL SOUNDS PRESENT, ABD SOFT, DISTENDED. TOL. TF WELL WITH MIN RESIDUAL. RECEIVING PROMOTE W/ FIBER. RATE 30 CC/HR.(GOAL 80 CC/HR)\n\nSKIN INTACT. 2 PIV'S PATENT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-10 00:00:00.000",
"description": "Report",
"row_id": 1332332,
"text": "Continue to wean patient on psv5/5-40% . Patient occasionally went into rapid RR , rested for 1 hr on A/C to slow down rythm. ABG 7.45-41.115-29- 4-98% sputum induced for lab will continue to follow\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-10 00:00:00.000",
"description": "Report",
"row_id": 1332333,
"text": "resp care\n\npt remains and mech ventilated. ps 8 peep 5 fio2 40%. ps ^ to 8 to maintain vt 500-600 w/good effect. rr ess 20's occ teens. b/s coarse. sxn thk wh. mdi's given x3. current abg 7.40/42/131/27. pt tx w/o incident to ct scan. pt ambu 100% o2 to/from. plan: cont w/mech support. wean ps as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-10 00:00:00.000",
"description": "Report",
"row_id": 1332334,
"text": "CCU progress note 7a-7p\nNEURO: pt was obtunded this morning, not responding to stimuli except for suctioning ETT. Pupils remained 2mm sluggish. no movement R side. lifts/falls on L arm, no random squeezing of L hand noted, slight movement/withdraw from pain L foot. Repeat CT scan done this afternoon, no changes or new bleed noted. Pt noted to be 'waking' up this evening, opening eyes at times to tactile stimuli and having increased RR. Noting to hold siderail w/ L hand. given 30mg (3cc) of Propofol for light sedation during central line insertion this evening.\n\nCARDIAC: AFIB 90s. Labetolol gtt d/c'd this morning. Lopressor 100mg restarted at TID dosing. remains on Hydralazine 20mg QID. SBP 120-150s today. generalized +edema.\n\nRESP: remains on PS today. increased RR this morning w/ TV 300-400s. Increased PS to 8 w/ noted decrease to 18-20 RR, and TV 600s. Sats >97%. good abgs. Sx small amts yellow/tan secretions. CPT given with turns. sputum spec sent early this am.\n\nID: TMAX 99.8 po. no abx. remains diaphoretic all day.\n\nGI/GU: foley had decreased u/o this morning. given IVF x 6hrs today and increased TF to 60cc/hr Promote w/ fibre. Noted increase to ~30cc/hr urine. Abd +BS, distended soft. OGT patent. NO BM. no stools since admission. pt may need bowel regimin!!\n\nSKIN: mulipodus boots ordered for pt. L heel has blister on outer heel. otherwise skin intact.\n\nACCESS: R s/c TLC placed this evening. both peripheral IVs intersticial and d/c'd.\n\nPLAN: con't to monitor Neuro status. need bowel meds ordered in am. monitor temp (BC for temp >102). keep L heel elevated. place mulitpodus boots on pt when they arrive on floor (ordered). awaiting CXR and confirmation of placement of R s/c TLC.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-06 00:00:00.000",
"description": "Report",
"row_id": 1332314,
"text": "NURSING PROGRESS NOTE 0700-1500\nNEURO---PT LIGHTLY SEDATED ON PROPOFOL AT 20 MCG/KG/MIN. WHEN GTT TURNED OFF TO ASSESS NEURO STATUS, PT DOES NOT FOLLOW COMMANDS. PUPILS AT 1MM AND REACT SLOWLY. R ARM NO MOVEMENT. R LEG WITHDRAWS TO NOXIOUS STIMULI BUT ? WHETHER THIS IS REFLEXIVE PER NEURO. L ARM WILL HAVE SOME PURPOSEFUL MOVEMENT AND ATTEMPT TO PULL ETT OUT. NO FINE MOTOR MOVEMENT OBSERVED IN EITHER UPPER EXT. L LEG WILL FLEX AND WITHDRAW TO NOXIOUS STIMULI. DOWN FOR CT OF HEAD WITHOUT CONTRAST AT 1200. RESULTS PENDING.\n\nCARDIAC--HTN AND RESTARTED ON LABETALOL GTT AT 2MG. PT BECOMES AGITATED WITH NON-PURPOSEFUL FLAILING OF LUE AND LLE. ON IVF AT 50 CC HR. IN A-FIB AT 80'S . OCCASIONAL UNIFOCAL PVC'S.\n\nRESP--BREATHING APPEARS LABORED WHEN PT IS LIGHT. RR INCREASES TO 38-44 WHEN LIGHT. SAO2 98%. ABG'S OK ON 5PEEP AND 7.5 IPS. PLAN IS TO WEAN TO EXTUBATE. IT IS UNCLEAR IF PT WILL BE ABLE TO PROTECT AIRWAY AS HE HAS A WEAK GAG AND WEAK COUGH.\n\nGI--NGT TO LCS DRAINING BILIOUS DRAINAGE. NO STOOL.\n\nGU--FOLEY CATH PATENT DRAINING CONCENTRATED URINE IN ~30 CC HR.\n\nENDO--UNREMARKABLE AT PRESENT.\n\nSKIN-- BUTTOCKS INTACT WITHOUT BREAKDOWN. SMALL RASH IN R GROIN.\n\nA--HTN NEEDING INCREASE IN LABETOLOL.\n\nP--PLAN TO EXTUBATE. CON'T Q1HR NEURO CHECKS. ? ANTIHTN THERAPY.\n\nLINES--PT HAS 2 PERIPHERAL IV'S.\n\n AND WIFE FLEW IN FROM CALIF TODAY. WIFE IS .\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-23 00:00:00.000",
"description": "Report",
"row_id": 1332375,
"text": "NPN\n11 PM - 7 AM\nS/P LARGE THALMIC BLD\nS/O\nPLS SEE CAREVIEW FLOWSHEET FOR ALL OBJ/NUMERICAL DATA\nCV HR 90-100'S..AFIB....SBP LABILE 190'S-80'S/40-80'S....DROPPING SBP TO THE 80'S...AFTER .3 MG OF CLONIDINE ...SLOW HYDRALAZINE INFUSION STOPPED ...NTP WIPED OFF ...ABLE TO TOLERATE 150 MG OF PO LOPRESSOR ...\nRESP CONTINUES ON CPAP AND PS OF 15..5 PEEP...50%...TV 700...FREQUENT EPISODES OF TACHYPNEA WITH RATES IN THE 40'S..TV 190-260 ..SUCTIONED Q3 FOR SMALL AMOUNT OF THICK YELLOW SPUTUM..MINIMAL ORAL SXNS....LUNGS COARSE ....RESPONDING TO 2 MG OF IV VERSED ..\n\nGI ON PROMOTE WITH FIBER ..AT 65 CC/HR ..SMALL AMOUNT OF SOFT STOOL ...OB NEG...\n\nGU U/O GD\n\nTURNED Q3...RIGHT ARM ELEVATED ON PILLOWS ..\n\nACCESS...DOUBLE LUMEN PIC LINE FLUSHED WITH HEPARIN AND SALINE ..BUT UNABLE TO OBTAIN AM LABS ...NO PERIPHERAL ACCESS ...\n\nNEURO..SLEEPY,..INTER OPENS EYES TO VOICE ...LEFT GAZE ...RIGHT HEMIPLEGIA ..OCCAS DRAWS UP LEFT LEG ...SQUEEZING LEFT HAND BUT NOT TO COMMAND ...\n\nA LABILE BP/RESP STATUS\n\nP CAUTION WITH CARDIAC DRUGS ...? OVER DIURESIS ...? ALINE\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-23 00:00:00.000",
"description": "Report",
"row_id": 1332376,
"text": "CCU progress note : 7a-7p\nEVENTS OF DAY:: NEURO CHANGEs NOTED!!! PT OFF VENTILATOR, on TRACH collar 50% w/ good sats.\n\n\nNEURO: Pt had episode of agitation this morning, ^BP^HR^RR 40s, NEURO team in to assess at this time ?neuro agitation or ?agitation d/t ventilator. Attempt bagging which pt relaxed with, then post would go back to ^RR again. tried pt off vent on trach collar and pt settled. kept off ventilator. No further episodes of ?neuro agitation noted. PERLA 2mm brisk. alert most of time, occasionally rests/sleeps in naps. Tracks and looks at people, to voice and movements outside room. occasionally looks at TV. Sometimes nods head to questions. inconsisently obeys simple gestured/voiced commands to take objects or wash face w/ washcloth. if you hold out your hand to shake, he will lift his hand and hold your hand. if you show him something interesting to him , he will take it from your hand and hold it properly (keys, comb, toothbrush, washcloth), and will give it back to you if you hold out your hand and ask for it. Wife assisted pt to place eyeglasses on face. NEURO team and NSICU team notified of changes. Wife in this afternoon and aware of changes.\nPt still moves only L limbs, but no movement on R side, +sensation to R, noting some reflexive movements on R leg to painful stimuli. nothing to R arm. R side neglect, R vision defecit. +gag +cough.\n\nCARDIAC: AF 100-110s, SBP 120-170s today. On Hydralazine 50mg IV q6h, NTP 2\" CW Q6H, Lopressor 150mg TID ngt, Norvasc 10mg qd. generalized edema +, 3+edema to R arm.\n\nRESP: pt had episode of TACHYPNEA 40s, on vent settings early this morning 15 PS/ 5 Peep. Sats remained 100% the whole time. attempted changing PS settings from PS 15 to higher w/ no results, when 'd pt RR went to 12 w/ periods of apnea and seemed to sleep, then after 'ing pt woke and went back to rapid RR 40s again. attempted to take off vent, room air, sats remained 100% with some decrease in RR. placed on Trach collar w/ cuff down, 50% FIO2 w/ decrease in RR to 14-30s the rest of the day. No extreme agitation noted. having neuro respiratory periods, some occasional apnea noted w/ some 'panting' to normal breathing cycled. Sx'd trach for small amts tan secretions. pt has PRODUCTIVE cough. LS coarse bilat. MDI/neb treaments per RESP.\n\nGI/GU: abd soft, distended. no BM, last BM last nite. TF promote w/ fibre. minimal residuals. PEG tube intact. FOLEY patent good amts urine. Lasix decreased to 20mg po.\n\nSKIN: old R heel blister healing well. multipodus boots on. pneumoboots on. old skin tear healing on L outer hip, cleansed w/ NS and new opsite placed over site. Duoderm intact to coccyx. Sat in Chair today for a few hours.\n\n\nPLAN: con't to monitor neuro status.con't to monitor VS. wife to bring in pictures of his favorite cat at home, and stuffed animal (cat), ?1-2lb dumbbell weight to see if he uses it, to bring in his electric in to shave. Plan to have Case Manager rehab facilities to re-evaluate pt's eligibility/rehabi\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-23 00:00:00.000",
"description": "Report",
"row_id": 1332377,
"text": "CCU progress note : 7a-7p\n(Continued)\nbility.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-23 00:00:00.000",
"description": "Report",
"row_id": 1332378,
"text": "Resp Care\npt changed to 50% trach collar.. tolerating very well with cuff deflated. has cyclical episodes of tachypnea..usually self-limiting. seems to do better with cuff deflated. when inflated requires lg amt air to seal. sxning sm amts tan. good strong cough. admin albuterol/atrovent q4-6 with mdi/. c/w tc as tolerates. vent on standby.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-09 00:00:00.000",
"description": "Report",
"row_id": 1332329,
"text": "CCU NSG PROGRESS NOTE-NSICU BORDER.\n73 YO MALE ADMITTED W R-SIDED WEAKNESS. HEAD CT SCAN-LARGE BASAL GANGLIA HEMMORRHAGE W EXTENSION INTO VENTRICLES & POS MASS EFFECT W SM AMT OF HERNIATION.\n\nO:NEURO=OPENS EYES SPONTANEOUSLY-TRACKING/FOLLOWING. SQUEEZES W L HAND ON COMMAND. NOT ABLE TO HOLD L SIDED EXTREM UP ON OWN-MOVING L SIDE ON BED. SL WDRAWL TO NOXIOUS STIM ON R. PERL-SLUGGISHLY.\n PULM= & VENTED. SETTING=CPAP/PS, FIO2 40%, SPONTAN TV 450-550, RR 24-36, MIV 11.6-13.6, PEEP 5, & PRESSURT SUPPORT 5. BREATH SOUNDS=COURSE THROUGHOUT. SX-THICK COUPIOUS SECRETIONS @ X'S-REQUIRING LEAVAGING. SATS UPPER 90'S. AM ABG PENDING. EPISODES OF TACHIPNEA & LABORED RESPIRATIONS-RXED W HALDOL PRN W LIMITED EFFECT.\n CV=NTG WEANED & DCED. LOPRESSOR 100MG & HYDRAL 10MG QID-CONTIN TO BE TACHYCARDIC & @ X'S HYPERTENSIVE @ X'S--?MORE RELATED TO AGITATION.\n GI=TF CHGED TO PROMOTE W FIBER. STOPPED @ 0000.\n GU=FOLEY. ADEQ UO.\n ID=FEBRILE W T MAX 100.4 PO.\n LABS=AM SENT.\n\nA:STABLE NEURO EXAM. REQUIRING FREQ SX FOR THICK COUPIOUS SECRETIONS. ?TACHYCARDIA & HYPERTENSION RELATED TO AGITATION/FRUSTRATION.\n\nP:CONTIN FREQ NEURO CKS. ?HEAD CT REDO. HALDO PRN. PULM TOILET. ?WEAN VENT TO EXTUBATE (FREQ SX & COUPIOUS SECRETIONS). ?ADD MILD TRANQUILIZER-AGITATION/FRUSTRATION. ?RESUME TF-IF NOT EXTUBATABLE. FOLLOW T-CULTURE W SPIKE. CK AM LABS-REPLACE AS INDICATED. SUPPORT PT/FAMILY AS NEEDED.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-30 00:00:00.000",
"description": "Report",
"row_id": 1332397,
"text": "NEURO-ALERT TO SURROUNDINGS,TRACKES VOICES,INCONSISTENTLY FOLLOWS COMMANDS WITH NON-PURPOSEFUL AND OCCASIONALLY PURPSOEFUL MOVEMENT.PERLA (4mm). RESTLESS AT TIMES. MEDICATED WITH 0.5MG VERSED IV X1 WITH LITTLE RELIEF.\n.\n\n\nCV-REMAINS IN AFIB 85-95 WITH NO ECTOPY. BP INCREASING THROUGHOUT NOC. 135->160/85.+PP.\n\nRESP-50% TRACH-COLLOR,SATS=100%.LS WTIH OCC. EXP. WHEEZE.DIMINISHED\n THROUGHOUT. STRONG COUGH WITH THICK YELLOW SPUTUM &\n SXD FOR S.AMT. THICK YELLOW SPUTUM.\n\nG.I.-TOLERATING PROMOTE WITH FIBER AT 120CC/HR. +BS. NO STOOL.\n\nG.U.-CONDOM CATH WITH CLEAR YELLOW URINE.\n\nSKIN-RT POSTERIOR THIGH WITH CLEAN PINK ABRAIN. TEGADEM APPLIED. RT OUTE HEEL WITH 4/4CM RED BLISTER WITH BROWN DRY CENTER. COCCYX WITH 6X6CM ULCER. DUODERM INTACT.\n\nENDO-SSC PRN. LABS-REPLACED PRN.\n\nA/P-AS ABOVE. CONTINUE MONITORING HEMODYNAMICS,NEUR0\n/RESP/G.I/G.U.\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-30 00:00:00.000",
"description": "Report",
"row_id": 1332398,
"text": "CCU NSG NOTE: ALT IN NEURO\nO: For complete VS see CCU flow sheet.\nID: Pt afebrile.\nNEURO: Pt alert much of the day. At times trying to talk, will follow some commands. No movement seen on R side. Using L arm purposefully.\nCV: HR 80s-90s a-fib on lopressor 150. BP 120-160/60-70s.\nGI: Pt had lg soft G- bm. Tube feed of replete with fiber off at 8am and restarted at 4pm at 120cc/hr. Tolerating well.\nGU:Pt voiding thru condom. He is ~1700cc positive for the day and ~ 5L positive LOS.\nRESP: Pt remains on trach mask at 50%. He is sating 97-100%. He does require suctioning ~Q3-4 hrs for thick lt yellow sputum. Some wheezing heard. Pt getting nebs Q 4 hrs.\nELECTROLYTES: Na up to 149. D5W boluses decreased to 300cc QID.\nENDO: BS 147-151. 2u Reg given twice and 5u NPH given at 6p.\nA: Stable on trach mask/ alert\nP: Continue to turn Q3 hour. Suction prn. Cont TF overnight.Keep R arm elevated. Support pt and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-30 00:00:00.000",
"description": "Report",
"row_id": 1332399,
"text": "Patient remains on T-Mask all day suctioned PRN for sign of resp distress. BS wheezy, treated with albuterol/atrvent neb Q4. More alert follow commands today will continue frequent bronchial hygien and neb Rx Q4. HR now 84,BP 154/70, Sat 98%.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-31 00:00:00.000",
"description": "Report",
"row_id": 1332400,
"text": "CCu NPN 7pm - 7am\nS/O: Resp: Pt. continues on trach mask at 50%. O2sats are 97 - 100%. Suctioned Q3 hours for small to moderate amount of light yellow sputum. RR 20 - 30 slightly labored at times. RT gave inhalers.\nCVS: BP 97 -178/60 - 80. HR 70 - 100afib. Continues on lopressor, hydralazine, norvasc.\nG.I.: tube feedings at 120 cc/hr from 7pm - 7 am.\nD.M: FS 145, 109. SS insulin as written.\nF/E:continues 300 cc free H2O boluses Q 6 hours.\nA: s/p thalmic bleed, tolerating trach mask\nP: continue pulmonary toilet, monitor resp. status, BS, tube feedings off in am.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-31 00:00:00.000",
"description": "Report",
"row_id": 1332401,
"text": "PATIENT CONTINUES TO DO WELL ON T-COLLAR. SAT 100%,BP 147/65, HR 96,BS COARSE. DEEPLY SUCTIONED Q4HRS WILL CONTINUE NEB TREATMENT IN LIEU OF MDIS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-05 00:00:00.000",
"description": "Report",
"row_id": 1332309,
"text": "DEEP INTERCRANIAL HEMMORHAGE\n72 YR OLD GENTLEMAN AWOKE 4 AM C R SIDED WKNESS, ,SLURRED SPEECH ,COLLAPSED ,BROUGHT TO HOSPITAL ,INTUBATED.HAS BEEN HYPERTENSIVE ,ON IV NIPRIDE,LABETOLOL IN ER. HAS HX MI, HTN, AFIB. ON COUMADIN .ADMITTING INR 4.2.GIVEN 6 FFP ,VIT K.HAS BEEN SEDATED FOR RESTLESSNESS C ATIVAN, 150 SUC,30 ETOMADATE, 10 VEC FOR INTUBATION.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-05 00:00:00.000",
"description": "Report",
"row_id": 1332310,
"text": "oett pulled back 1.5cm md s/p cxr . resecured at 20cm @lip. post change + bilat b/s.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-05 00:00:00.000",
"description": "Report",
"row_id": 1332311,
"text": "resp care\n\npt arrived to ccu intubated w/# 7.5 oett secured 22cm @lip. pt placed on mech vent ps 15 peep 7.5 fio2 50%. b/s +/cta/dim bilat. spont vt 600's rr teens. pt appears comfortable. abg 7.43/44/116/30. fio2 to 40%. plan: cont w/mech support. wean as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-05 00:00:00.000",
"description": "Report",
"row_id": 1332312,
"text": "LARGE L THALMIC BLEED\nSR 60S TO 70S. BP 100 TO 180. ON NIPRIDE,LABETOLOL GTTS .IV HYDRALAZINE GIVEN .NIPRIDE D/C.WEANING LABETOLOLTO OFF IF POSSIBLE .\n\nVENTED , CPAP 15 PS/PEEP7.5 ,FIO2 40% RR 14 TO 17 C TV 6OO TO 8OO. SAT 98. BS DISTANT ,HX EMPHYSEMA .\n\nINR 1.4 P 6U FFP .VIT K IV GIVEN\n\nOG DRAINING CL GREEN ,HYPOACTIVE BS .ABD SOFT DISTENDED .\n\nCONCENTRATED BLOOD TINGED URINE 20CC HR VIA FOLEY\n\nPT RESTLESS ON ADMISSION, TRIED TO EXTUBATE SELF C L HAND.KICKING C L LEG . MOVES R ARM AND LEG ON BED TO PAINFUL STIMULI. PT STARTED ON PROPOFOL LOW DOSE STARTED TO KEEP PT ,WILL WEAN IF POSSIBLE.\n\nGOAL BP 120 TO 160\nWEAN LABETOLOL TO OFF\nWEAN PROPOFOL TO OFF IF POSSIBLE\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-21 00:00:00.000",
"description": "Report",
"row_id": 1332370,
"text": "NSICU PNP\nNEURO: NO CHANGE IN NEURO STATUS. OPENS EYES SPONTANEOUSLY, MOVES L SIDE. DOES NOT FOLLOW COMANDS\nCV: HR 85-115 A FIB, BP 140-180/60-70, ^ TO 190/100 W/ ATTEMPT TO LOWER PS.\nRESP: REMAINS ON PS 14, PEEP5. ATTEMPTED TO LOWER PS, TV DOWN, ^ RR TO 40'S, ^ BP. SX FOR MOD AMTS THICK TAN SECRETIONS.\nID: TM 99.4, CONT ON OXACILLIN\nGI: TF CONT AT 65CC/HR, TOL WELL, SM BRN FORMED STOOL\nGU: FOLEY DRAINING DK YEL URINE QS.\nSOCIAL: WIFE CALLED, HAS NOT BEEN IN TO VISIT TODAY.\nDISPO: IS BEING SCREENED FOR REHAB.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-22 00:00:00.000",
"description": "Report",
"row_id": 1332371,
"text": "Pt. maintained on psv ventilation with mostly a comfortable night except for these intermittent spikes in BP and RR. Sats are good. Sx for lrg amts. Plan is to cont. with current management with eventual rehab placement.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-24 00:00:00.000",
"description": "Report",
"row_id": 1332379,
"text": "NPN\n7 PM - 7 AM\nS/O PLS SEE CAREVIEW FLOWSHEET FOR ALL OBJ/NUMERICAL DATA\nLOW GRADE 100.2...\nCV HEMODYN STABLE ..TOLERATING BETABLOCKERS AND ANTI-HYPERTENSIVES WELL\nRESP ..INITIALLY RR IN THE 40'S...TV IN THE LOW 200'S...WITH DIFFUSE EXP WHEEZES ...AMBUED AND SUCTIONED ...BUT RR REMAINED IN THE 40'S...AND PT LOOKING VERY UNCOMFORTABLE ....PLACED BACK ON VENT PS15/5PEEP..FI02 OF 50%...AND GIVEN VERSED 1 MG Q4-5 H...WITH BETTER TIDAL VOLUMES ...\nNEURO..OPENS EYES TO VOICE ..SQUEEZING LEFT HAND BUT INCONSIST TO COMMAND\nGI/GU TOLERATING TUBE FEEDS ..U/O GD\nA STABLE\nP CONSIDER INCREASING VERSED MED...OR ATIVAN ORDER ROUND THE CLOCK..TO KEEP PT COMFORTABLE ..\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-24 00:00:00.000",
"description": "Report",
"row_id": 1332380,
"text": "N SICU NPN\nNEURO: SLEEPING MOST OF MORNING, MORE AWAKE THIS AFTERNOON.TRACKING, MOVING L ARM TO FACE, SCRATCHING EAR, BUT NOT FOLLOWING COMMANDS.NOT MOVING R SIDE.\nCV: HEMODYNAMICALLY STABLE\nRESP: ON TRACH MASK ALL DAY. SATS 97-98%, RR 12-24, APPEARS VERY COMFORTABLE. SX Q3-4HR FOR SM-MOD AMTS YELLOW/TAN THICK SECRETIONS.\nGI: TOL TF, NO STOOL\nGU: FLOLEY DRAINING CL, DK YEL URINE, CURRENTLY ~ 500CC NEG.\nEND: BS 186 AT 6PM, COVERED PER SS\nSKIN: DUODERM ON COCCYX, R HEEL BLISTER HEALING, OP XITE ON R HIP.\nACTIVITY: OOB TO CHAIR, USING SLIDE BOARD. TOLERATED WELL.\nSOCIAL: WIFE AND COUSIN IN TO VISIT MOST OF AFTERNOON.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-24 00:00:00.000",
"description": "Report",
"row_id": 1332381,
"text": "RESP CARE\nPT CHANGED TO TRACH COLLAR AT BEGINNING OF SHIFT. TOLERATING VERY WELL, CUFF IS DEFLATED. STRONG COUGH. SXNED AS NEEDED. ADMIN ALBUTEROL/ATROVENT MDI X3. C/W TRACH MASK AS TOLERATES. VENT ON SB.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-09 00:00:00.000",
"description": "Report",
"row_id": 1332330,
"text": "CCU progress note: 7a-7p\nNEURO: neuro signs unchanged. unable to move R side. able to lift and fall/withdraw from painful stimuli w/ L arm, moves L foot on bed. Pupils 2mm equal and sluggish reaction. opens eyes to verbal stimuli. +tracking. inconsistent squeezing of L hand to command ?reflex. non-purposful movement. ?agitation today w/ ^BP 200s, given multiple doses of haldol w/ little effect.\n\nSOCIAL: family in to visit today. talked w/ nurse and house staff re pt condition.\n\nID: WBC count elevated to 17. repeat WBC pending tonite w/ diff. no abx ordered. TMAX 101.4 rectally. to culture w/ temp>102 per HO. urine culture sent today.\n\nCARDIAC: AFIB 90-100s. no ectopy noted. SBP 170-200s during the day, given hydralazine 20mg QID IV and was on Lopressor 100mg , but this afternoon started on LABETOLOL gtt titrated to 5mg/min for SBP 130-150. +generalized edema.\n\nACCESS: R PIV d/c'd. New access LLA #20g and old LLA #20g intact but reddened at site, but patent. HO aware. NEED CENTRAL ACCESS. IV therapy in to start new access w/ difficutly.\n\nRESP: Remains on CPAP/PS 40% TV 300-500. Peep 5/ PS 5. RR24-36. LS coarse. CXR worsening. WBC elevated. Thick tenacious secretions - yellow tan, needing instillation of saline and ambu for good suctioning. sats > 96%. PM ABG: 134/43/7.43.\n\nGI/GU: no BM. TF restarted promote w/ fibre @ 20cc/hr. advance to GR as tolerated. on Free water boluses 100cc TID. FOley draining good amts clear yellow urine. u/a and CS sent.\n\nPLAN: sent sputum spec. monitor temps blood cultures for >102. need central access. titrate labetolol for ABP 130-150 goal.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-28 00:00:00.000",
"description": "Report",
"row_id": 1332392,
"text": "Respiratory Therapy\nTrached with an 8.0 Portex. PSV, weaned to 10/5/0.40. ABG: compensated metabolic alkalosis. Had to pt this afternoon for low Vt and increased WOB. Suctioned pink frothy secretions at that time. Pt does have periods of apnea lasting about 5sec which are self resolved. Receiving albuterol and atrovent MDI as needed. Plan to continue with PSV as tolerated and TM when ready.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-28 00:00:00.000",
"description": "Report",
"row_id": 1332393,
"text": "NSICU NPN\nNEURO: VERY LETHARGIC TODAY. OPENS EYES TO VOICE, OCC SPONTANEOUSLY. NOT FOLLOWING COMMANDS. LIFTS L ARM AND MOVES IN ? PURPOSEFUL MANNER, MOVES L LEG ON BED. NOT MOVING R ARM.\nCV: HEMODYNAMICALLY STABLE\nRESP: PS 14, PEEP 5 THIS AM DOWN TO 10/5, UNABLE TO WEAN FURTHER D/T ^ TACHYPNEA, LOW TV, GENERAL DISTRESS.\nGI: TF CHANGED TO CYCLE FROM 4P->8AM AT 120CC/HR. TOLERATING WELL. SOFT BRN STOOL.\nGU: FOLEY PULLED AT 17:00, CONDOM CATH PLACED.\nID: AFEBRILE\nEND: WNL\nACTIVITY: OOB TO CHAIR, FULL LIFT, PT HERE.\nPT BEING SCREENED FOR REHAB.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-22 00:00:00.000",
"description": "Report",
"row_id": 1332372,
"text": "CCU NSG PROGRESS NOTE 7P-7A/ S/P THALMIC BLEED\n\n\nS- \n\nO- SEE FLOWSHEET FOR OBJECTIVE DATA.\n\nCV- VS REMAIN AT BASELINE.\nHR- 108-112 AF. BP- 120-180/.\nREMAINS ON SAME CV MEDS.\n\n PT ON PRESSURE SUPPORT 14/40%.\nO2 SATS 99-100%.\nSUCTIONED FOR THICK WHITISH SPUTUM.\nCOARSE BREATH SOUNDS.\n\nID- AFEBRILE.\nREMAINS ON OXACILLIN .\n\nGU- GOOD UO VIA FOLEY/LASIX AS ORDERED.\nI/O EVEN.\n\nGI- PROMOTE AT 65/HOUR.\nLARGE FORMED STOOL X 1 G (-).\n\nMS- NO SIGNIFICANT NEURO CHANGES.\nSEE FLOWSHEET.\n\nA/ PT STATUS S/P THALMIC BLEED, ON VENTILATORY SUPPORT.\nAWAITING PLACEMENT.\nCONTINUE PULM TOILET/NUTRITION/BP CONTROL.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-22 00:00:00.000",
"description": "Report",
"row_id": 1332373,
"text": "NSICU NPN\nS: TRACHED\nO: SEE CAREVUE FOR ALL OBJECTIVE DATA.\n\nNEURO: NO CHANGES\nCV: HEMODYNAMICALLY STABLE A FIB 90-110, BP 115-180/60-70, NO CHANGES MADE TO CV MED REGIME.\nRESP: UNABLE TO WEAN PS, PT BECAME , DISTRESSED AND W/ LOW TV. REQUIRING PS ^20 BRIEFLY. SX FOR SM-MOD AMTS THICK TAN SECRETIONS. LUNG SOUNDS COARSE.\nID: TM 100.5 PO, BLOOD, URINE AND SPUTUM CX SENT. OXACILLIN D/C. TLC D/C AND TIP CX.\nGU: FOLEY DRAINING DK YEL URINE, 50-70CC/HR.\nGI: TOLERATING PROMOTE W/ FIBER AT GOAL, 65CC/HR. NO STOOL TODAY.\nLINES: PICC PLACED L ARM, PLACEMENT CONFIRMED BY X RAY, TLC AND A LINE D/C.\nSOCIAL: WIFE IN TO VISIT.\nDISPO: REHAB PLACEMENT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-23 00:00:00.000",
"description": "Report",
"row_id": 1332374,
"text": "Respiratory Care:\n\nPatient trached with 8.0 Portex. Current vent settings Psv 15, Cpap 5, Fio2 50%, with Flowby . Spont vols 500-700's with RR 11-16. Bs slightly coarse bilaterally. Sx'd/lavaged for sm amounts of thick tan sputum. Albuterol/Atrovent MDI's given Q6hr. O2 sats 98-100%. No further changes made. Continue to wean Psv as tolerated.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-29 00:00:00.000",
"description": "Report",
"row_id": 1332394,
"text": "CCU NSG PROGRESS NOTE 7P-7A/ S/P THALMIC BLEED\n\nS- TRACHED\n\nO- SEE FLOWSHEET FOR OBJECTIVE DATA.\n\n PT REMAINS WELL CONTROLED ON CURRENT CV MEDS.\n\nHR- 80-90'S AFIB.\nBP- 120/- 150/\nNO CHANGES IN CV MED REGIMEN.\nAM LABS PENDING.\n\n PT REMAINS ON VENT SUPPORT:\n50%/PRESSURE SUPPORT- 14, 5 PEEP.\nSUCTIONED FOR YELLOWISH THIN SPUTUM.\nFAIR AMOUNT VIA TRACH.\nSITE CLEAN.\n\nID- AFEBRILE- 99 T MAX.\nREMAINS ON PO LEVO.\n\nGU- CHANGED FOLEY TO CONDOM CATH- 600CC/HOUR.\nREMAINS ON 300CC H20 EVERY 4 HOURS.\n\nGI- SWITCHED TO TUBE FEED OVERNT ONLY- 4P-8A- 120CC/HOUR.\n(+) BOWEL SOUNDS- NO STOOL THIS SHIFT.\nREMAINS ON COLACE.\n\nSKIN- HEEL WITH BLISTER AND COCCYX WITH OPEN ABRASION AREA- DUODERM ON PLACE, AREA CLEAN.\nMULTIPODIS BOOTS/SLEEVES IN PLACE.\n\nNEURO= NO SIGNIFICANT CHANGES IN NEURO STATUS.\nWATCHING AND ALERT, BUT NO RESPONSE VERBALLY AND INCONSISTENT FOLLOW OF COMMANDS.\n\nA/ PT S/P LARGE CVA ON VENTILATOR SUPPORT- AWAITING PLACEMENT.\n\nCONTINUE TO ADMINISTER CV MEDS/MAINTAIN STABLE HEMODYNAMICS.\nNEURO VITAL SIGNS, SKIN CARE/COMFORT.\nCONTINUE NUTRITION/INCREASE ACTIVITY AS TOLERATED.\nKEEP FAMILY AWARE OF PLAN OF CARE/CURRENT PROGRESS.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-29 00:00:00.000",
"description": "Report",
"row_id": 1332395,
"text": "7am - 7 pm\nS/O: Resp.: Pt. trached and vented initially. Put on a trach mask at 50% and tolerating it well so far. Pt. has a strong productive cough and has been able to clear secretions fairly well. Lung sounds are coarse. Pt. had 1 episode of tachypnea this morning which resolved with cuff deflation and 100% O2. Continues on levaquin.\nCVS: Continues on lopressor, hydralazine, norvasc and clonidine patch to control HTN. NTP has been D/C'd. BP 106 -140's/50 - 60. HR 90 - 110's.\nG.I.: Pt. tolerating TF at 120 cc/hr. Started at 4 pm and continue until 8 am. Pt. continues on free H2O for Na of 154 today.\nG.U.: Pt. voiding via condom catheter.\nDM: FS 130 this morning. Pt. received 2 units of regular insulin.\n\nA: s/p thalmic bleed\nP: monitor response to trach mask, continue aggressive pulm toilet, antibx.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-29 00:00:00.000",
"description": "Report",
"row_id": 1332396,
"text": "Resp Care\nchanged to trach collar with cuff deflated...actually seems more relaxed with no episodes of tachypnea/diaphoresis. sxning sm amts yellow thick. strong cough. admin albuterol/atrovent mdi q6h. plan to leave on trach collar as tolerates. clearly looks better on trach collar with cuff down vs. on vent with cuff inflated. ?air trapping.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-20 00:00:00.000",
"description": "Report",
"row_id": 1332364,
"text": "SICU NPN\nNEURO: NEURO STATUS REMAINS UNCHANGED. OPENS EYES SPONTANEOUSLY, MOVES LEFT SIDE W/ ? PURPOSEFUL MOVEMEMT. RLE WITHDRAWS TO PAINFUL STIMULI OTHERWISE NO MOVEMENT ON R SIDE. PERRL.\nCV: HEMODYNAMICALLY STABLE W/ HR 80-100 A FIB, BP 140-170/50-80 ON CURENT MED REGEIME. NO CHANGES MADE TODAY.\nRESP: TRACH AREA CLEAN W/O SSI, SX Q3 HR FOR MOD AMT THICK TAN SECRETIONS., LUNG SOUNDS COARSE. PS DOWN TO 5/5, TOLERATING WELL, TO HAVE TRIAL W/ TRACH MASK.\nGI: PEG IN PLACE, TOLERATING PROMOTE W/ FIBER AT 65CC/HR, NO STOOL TODAY.\nGU: FOLEY DRAINING CL YEL URINE. CURRENTLY ~1000CC NEG, (GOAL FOR DAY)\nID: TM 100.1 PO, CONT ON OXACILLIN, LEVO D/C AFTER THIS AFTERNOON'S DOSE.\nSKIN: BLISTER ON R HEEL, OPEN ABRASION ON COCCYX, DUODERM APPLIED.\nSOCIAL: WIFE IN MOST OF AFTERNOON. PT HAS BEEN ACCEPTED AT AND GO IF BED AVAILABLE, WIFE AWARE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-20 00:00:00.000",
"description": "Report",
"row_id": 1332365,
"text": "ATTEMPTED TRACH COLLAR TRIAL. AFTER APPROX. 15 MINS PT'S RR UP TO 30'S, BP UP, LOOKED UNCOMFORTABLE... PLACED BACK ON VENT. RN AWARE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-20 00:00:00.000",
"description": "Report",
"row_id": 1332366,
"text": "PT PLACED ON IPS 14 TO REST. TOLERATED IPS 5 FOR 8 HOURS WELL. WILL ATTEMPT AGAIN IN AM\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-20 00:00:00.000",
"description": "Report",
"row_id": 1332367,
"text": "CCU NPN 7PM - 11PM\nS/O:RESP: Pt. remains trached and vented. Changed back to 14 PS from 5. due to tachypnea. Suctioned for a mod. amt. of tan sputum.\nI.D.: afebrile. Continues on oxa.\nCVS: BP labile 140 - 180's/70's. HR 100's.\nG.I.: PEG. continues on TF. Please see careview for specific data.\nA: s/p thalmic bleed, awaits placement for tomorrow.\nP: continue pulm. toilet, monitor neuro signs, meds for HTN.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-21 00:00:00.000",
"description": "Report",
"row_id": 1332368,
"text": "Resp.---- Pt. maintained on psv ventilation of 14 overnight with good oxygenation. Pt. had episode of hypertension and tachypnea that was relieved by placing pt on a/c ventilation for brief period followed by mdi administration and sx. Returned to psv with no pt distress. Plan is to cont with current status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-21 00:00:00.000",
"description": "Report",
"row_id": 1332369,
"text": "CCU NSG PROGRESS NOTE 11P-7A/ S/P THALMIC BLEED\n\nS- TRACH/NONVERBAL OR RESPONSIVE\n\nO- SEE FLOWSHEET FOR OBJECTIVE DATA.\n\n PT REMAINS WITH LABILE HEMODYNAMICS- BP-110-130/ AT REST WITH\nINCREASE TO 220-180/ WITH ANY SORT OF AGITATION.\nREMAINS ON LOPRESSOR/HYDRAL/CLON/NTP.\nHR- 90-110 AF, NO VEA.\nAM LYTES PENDING.\n\nRESP- REMAINS ON VENTILATORY SUPPORT- TRACH WITH 50%/CPAP- 14 PRESSURE SUPPORT/5 PEEP.\nRESP RATE SPONTANEOUSLY- 12-36- RESTING/AGITATED.\nSUCTIONED FOR THICK YELLOWISH SPUTUM, MINIMAL AMT.\nO2 SATS 100-99%\n\nID- AFEBRILE- REMAINS ON OXACILLIN.\n\nGU- FAIR TO GOOD UO= 40-130/HOUR.\nI/O (-) 1200CC.\n\nGI- PEG IN PLACE- RECEIVING PROMOTE WITH FIBER 65/HOUR.\nNO STOOL THIS SHIFT., (+) BOWEL SOUNDS.\n\n PT AWAKE/ALERT, BUT NOT PURPOSEFUL IN BEHAVIOR.\nTRACKING WITH EYES BUT NO EVIDENCE OF UNDERSTANDING/ORIENTATION.\nNO SIGNIFICANT CHANGES.\n\nA/ PT S/P THALMIC BLEED REMAINS WITH NEED FOR VENTILATORY SUPPORT.\nLABILE HEMODYNAMICS PERSISTS IN SPITE OF HIGH DOSE CV MEDS.\n\nPLAN TO D/C TO REHAB TODAY.\nCONTINUE TO ATTEMPT TO CONTROL HEMODYNAMICS .\nPULM TOILET.\nKEEP FAMILY AWARE OF PLAN OF CARE AND PROGRESS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-12 00:00:00.000",
"description": "Report",
"row_id": 1332340,
"text": "CCU progress note 7a-7p\nNEURO: no neuro changes noted. does not respond to commands. non-purposful movements of L arm and L foot. R side resists movement/stiff and non-moving. Opens eyes to stimuli occasionally and has R sided neglect, pt does not seem to track. Pupils 2-3mm brisk reactive. +corneals. NO GAG. +cough with suctioning. +sensation to L side.\n\nCARDIAC: AF 80-90s. SBP remains labile 130-170s today. LABETOLOL gtt remains on, decreased from 5mg to 2mg/min this evening. Remains on Lopressor 125mg TID, Hydralazine 40mg QID and VASOTEC 5mg started today for pressure con't. Con't to wean labetolol as tolerated. con't w/ +generalized edema.\n\nRESP: LS Diminished to bases, generally clear upper. Sx small amts thick tan/yellow secretions. PS 8/Peep 5 40% all day, decreasing TV this evening, increased RR 30s, increased PS to 14 w/ good improvement in TV to 600s. Sats >97%.\n\nID: pan cultured overnite, cx pending. Tmax today 100.7 oral. R S/C TLC changed overwire , cath tip sent for cx, new R s/c DL line placed. placement confirmed by CXR. No abx as yet.\n\nGI/GU: foley patent, clear yellow urine good amts. abd soft/distended. +BS. started on colace . +Flatus today. rectal check by HO showed soft stool in rectum, not impaced. no bm as yet. TF goal of promote w/ fibre @ 65cc/hr. OGT intact, patent.\n\nSKIN: R outer heel blister intact. mulitpodus boots on. opsite on coccyx redened area. no breakdown noted.\n\nSOCIAL: wife would like family meeting (to discuss code status, ?pt outcome, trach/peg, long term care, what to expect?) with NSICU team, NEURO team and STROKE team and Social worker ?maybe tomorrow afternoon (wife will be in anyways). to attempt to plan in am.\n\nCODE STATUS: FULL\n\nPLAN: Con't to monitor neuro status for changes. ?trach/peg, cont' to wean off Labetolol.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-13 00:00:00.000",
"description": "Report",
"row_id": 1332341,
"text": "Resp Care: Pt continues and on ventilatory support with psv14/fio2 .4/+5 peep maintaining Vt 3-600 ml with Vt 9-12 L, spo2 98%; BS coarse, sxn thick tan secretions, rx with mdi albuterol/atrovent, see carevue for details.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-13 00:00:00.000",
"description": "Report",
"row_id": 1332342,
"text": "CCU NSG PROGRESS NOTE 7P-7A/ S/P THALMIC BLEED\n\nS- INUTBATED\n\nO- SEE FLOWSHEET FOR OBJECTIVE DATA.\n\nCV- HR REMAINS AFIB, 80-90'S, NO VEA.\nBP- 140-150/ WITH OCCASIONAL INCREASES TO 160/- 170 WITH AGITATION/STIMULATION- INCREASED LABETELOL TO 2 MG, REMAINS ON LOPRESSOR AND HYDRALAZINE FOR BP CONTROL.\n\nRESP- REMAINS INUTUBATED FOR AIRWAY PROTECTION, NO GAG REFLEX.\nSUCTIONED FOR THICK WHITISH SPUTUM, MUCH ORAL SECRETIONS.\nPRESSURE SUPORT- 14, FI02- 40%.\nABG WML.\n\nID- AFBRILE AFTER T AMX- 101-\nTYLENOL, PAN CULTURED ON .\nAWAIT RESULTS.\n\nGI- TUBE FEEDS AT 65/HOUR, STARTED D5 AT 30/HOUR.\nNO STOOL AS OF YET, MIN RESID, COLACE TID.\n\nGU- UO- 40-60/HOUR VIA FOLEY CATHETER.\n\nMS/NEURO- NO CHANGES IN NEURO STATUS- REMAINS WITH OPEN EYES, NO FOLLOWING COMANDS, USING LEFT SIDE, NOT RIGHT SIDE.\nNO ACUTE CHANGES.\n\nA/ PT S/P HEAD BLEED REMAINS FOR AIRWAY PROTECTION, FUO AND LABILE BP ON/OFF LABETELOL GTT.\n\nCONTINUE TO MANAGE BP WITH MULTIPLE MEDS- ATTEMPT TO MAX PO MEDS TO WEAN OFF IV LABETELOL.\nWATCH FOR FURTHER FEVER/AWAIT CULTURE RESULTS.\nCOMFORT/SAFETY/FREQ NEURO CHECKS.\nKEEP FAMILY AWARE OF PLAN OF CARE.\nD/C PLANNING, ?PLAN TRACH.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-13 00:00:00.000",
"description": "Report",
"row_id": 1332343,
"text": "CCU progress note 7a-7p\nFAMILY MEETING this afternoon. Discussed pt's prognosis, possiblity of trach/peg, ?rehab rehab/nsg home, and discussed with wife pt's wishes. Wife decided to make him a DNR at this point, but needs to talk to brother-in-law in and have him talk to Dr . She hopes to have a decision re: ?extuabtion or ?trach/peg after brother-in-law talks to Dr and she talks again to the brother.\n\nNEURO: no changes noted. More alert today. opens eyes to verbal stimuli. R sided neglect, not noted to track. remains flaccid on R side. +sensation to R side noted at times to painful stimuli (reacting w/ lifting of L leg). pt restless and moving L knee up in bed and trying to lift up restrained L arm. Pt noted to hold onto side rail at times and inconsistently squeezes hand, but not to command. Pupils remain 2mm brisk.\n\nCARDIAC: AFib 70-90s. SBP 140-170s today. Remains on Lopressor 125mg TID, Hydralazine 40mg po QID, Norvasc increased to 10mg QD, and Clonodin patch 0.3mg added. On LABETOLOL gtt titrating between 2-5mg/min. +generalized edema.\n\nACCESS: R radial Aline. R s/c DL central line. OGT. ETT.\n\nID: Febrile today. Gram + cocci pairs/clusters in sputum, BC anaerobic culture growing + cocci clusters. Started on Vancomycin today.\n\nRESP: LS clear, dim bases. Sx small amt thick tan/yellow sputum. Gram + cocci. pm ABG 7.40/44/186 on PS 12/Peep 5/ 40% TV 300-400s, RR 20-30s. Pt RR in high 30s-40s on PS 12 and has frothy tan sputum large amts, suctioned and placed back on PS 14. RR back to high 20s, TV 300-400s. CPT today/Pulm toliet.\n\nGI/GU: foley patent, good amts urine. abd soft, +BS. TF GR 65cc/hr Promote w/ fibre via OGT. on colace . given Dulcolax PR today w/ good results, soft brown BM.\n\nSKIN: R outer heel blister remains intact, healing well, elevated off bed or in multipodus boots. coccyx slightly reddened tegaderm intact. no other breakdown noted.\n\nPLAN: con't to monitor neuro status. con't to give wife emotional support and keep her informed of pt status/changes. Pulm toliet. titrate PS for good tidal volumes. titrate Labetolol for goal SBP 130-150s.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-01-04 00:00:00.000",
"description": "Report",
"row_id": 1332413,
"text": "NEURO: AWAKE & ALERT. FOLLOWS SIMPLE COMMANDS, BUT NOT CONSISTENTLY.\n DOES NOT MOVE R. SIDE. LIFTS & HOLDS L. ARM UP OFF BED. L. LEG\n LIFTS & FALLS. PERL.\nRESP: 50% TRACH COLLAR. O2 SATS 97-100%. RR 23-28. SX FOR THICK YELLOW\n ->THIN WHITE SECRETIONS Q4HRS. BS COARSE BUT DIMINISHED AT\n BASES.\nCARDIAC: HR 85-93 AF, NO ECTOPY. BP 112-140/54-69.\nGI: CYCLED TF: FS PROMOTE WITH FIBER AT 120CC/HR VIA PEG TOLERATED\n WELL. ABD. SL. DISTENDED. BS+. NO STOOL. FREE H2O 150CC Q8HRS.\nGU: CONDOM CATH DRAINING CLEAR YELLOW URINE. REPLACED X1.\nID: T 97.7->98.8(PO).\nPLAN: TO REHAB THIS AM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-01-04 00:00:00.000",
"description": "Report",
"row_id": 1332414,
"text": "N SICU NPN\nPT ACCEPTED AT OLYMPUS/. WIFE AWARE OF TRANSFER. PT TRANSFERRED AT 09:00 W/ MULTIPOSUS BOOTS, GLASSES, ELECTRIC RAZOR, PICTURES AND WEIGHTS. PT IN STABLE CONDITION.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-08 00:00:00.000",
"description": "Report",
"row_id": 1332323,
"text": "CCU Nursing Progress Note 7p-7a:\n\nNeuro: Pt opening eyes to name tracking inconsistently. Pupils equal and reactive. Sqeezing left hand on command. Moving L side on bed. R hand and leg responding to painful stimuli. Pt with +cough reflex but w/o gag reflex.\n\nCV: NTG gtt at 115mcg to maintain SBp<160. SBP 130-150's. Afib HR 92-108. Pt conts on lopressor 25mg and hydralazine 10mg IV. H.O. aware of VS ? increasing lopressor this am.\nHCT 34.5 K+4.0\n\nRESP: Mechanically ventilated decreased to PS 10 with Tv 500 40% fi02 and 7.4 peep. ABG 7.45/37/119/2. Pt did not tolerate PS 8 per RT, tv dropped into the 300's.\nLS coarse. Sxn'd for thick yellow sputum in small amts. Sputum cx pending from .\nNo peripheral edema.\n\nGI: Abd softly distended with hypoactive BS. ? LBM. OGT in place with impact with fiber infusing at 30cc/hr. Minimal residuals advance as tolerated for goal rate of 70cc/hr.\n\nGU: Foley cath patent draining yellow urine in good amts. u/o 500cc/hr. BUN 32 Creat 1.4. Fluid balance -43cc since mn. +1393 LOS.\n\nID: tmax 99.6.\n\nSKIN: intact\n\nENDO: FS 127 and 147. No regular insulin required per SS.\n\nPROPH: protonix iv and pneumoboots.\n\nLINES: R radial a-line and 2 piv.\n\nSOCIAL: No phone calls this shift.\n\nDISPO: Full Code\n\nA: cont on ntg gtt to maintian sbp <160.\n increased spontaneous movement on L side.\n Tolerating TF.\n good u/o.\nP: Follow neuro checks q2hr.\n maintain SBP <160.\n ? increasing lopressor dose\n increase TF rate to reach goal as tolerated.\n Wean PS as tv improve.\n Provide support to pt and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-08 00:00:00.000",
"description": "Report",
"row_id": 1332324,
"text": "n micu npn\nNeuro: pt opens eyes to voice, occasionally spontaneously. Moves l side in non purposeful manner, only withdraws from pain on r side. PEARL.\nCV: Continures on ntg gtt at 113 mcg/min, lopressor ^ to 50 mg pngt tid, and hydralazine ^ to 20 mg . hr90- low 100's sr-st, occ pvc. bp 130-165/50-70.\nResp: ps to 8, 5 peep w/ good abg. Mod -lg amts thick yellow/tan secretions. lung sounds coarse.\nGI: tf ^ to 60cc/hr w/ goal 70cc/hr. tolerating well w/ 5cc residuals. No stooo today.\nGU: foley draining dk yel urine\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-08 00:00:00.000",
"description": "Report",
"row_id": 1332325,
"text": "Pt remains on vent, CPAP mode. Changes to the vent settings: decrease in PSV from 10 to 8. Fio2= .40 with spo2= 98%. Suctioned pt several times throughout shift for mod amts of thick yellow sputum.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-08 00:00:00.000",
"description": "Report",
"row_id": 1332326,
"text": "n sicu nsg addendum\nCurrently +240cc.\n\nid: tm 100.4 po\n\nend: bs wnl\n\nsocial: wife and brother in to visit most of day.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-08 00:00:00.000",
"description": "Report",
"row_id": 1332327,
"text": "Pt PSV decreased to 5 and Peep decreased to 5 at 1840. Fio2 still= .40. VT= 450ml. RR= 25.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-09 00:00:00.000",
"description": "Report",
"row_id": 1332328,
"text": "Resp Care\nPt. continues on CPAP 5/5 with VTs 350-550. BS coarse bilaterally, ambued sxn'd x2 for copious thick yellow. Pt. had periods of agitation, diaphoresis, increased BP, desats to 87%. Would not recommend extubation this morning, secreations too thick\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-28 00:00:00.000",
"description": "Report",
"row_id": 1332390,
"text": "Respiratory Care:\nPt. remains on IPS=14, peep=5, and FIO2 of 50%. At times, Pt. becomes very tachypneac and agitated, and appears to become very bronchospastic. He responds well to manual ventilation and/or brief periods on A/C until FRC is restored. Pt. also has periods of bradypnea, with increased VT's ~1L and RR in single digits. This would lead me to want ot wean IPS, but when this is attempted (with targetted VT's ~ 600cc), Pt. soon reverts to tachypnea and agitation. B/S course and at times very wheezy. ETS for small to moderate, thick, yellow. Alb./Atr MDI's given with good effect. Will continue on present settings, and perform as outlined above when needed. Pt. may also benefit from the addition of inhaled steroids. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-28 00:00:00.000",
"description": "Report",
"row_id": 1332391,
"text": "CCU NSG PROGRESS NOTE 7P-7A-S/P HEAD BLEED;FX WEAN\n\nS- TRACHED\n\nO- SEE FLOWSHEET FOR OBJECTIVE DATA.\n\n PT REMAINS ON MULTIPLE MEDS FOR BP/HR.\nCURRENTLY- HR- 90'S AFIB WITH BP- 120-140/.\nNO VEA. AM LYTES PENDING.\n\n PT ON VENTILATORY SUPPORT- 50%/14PRESSURE SUPPORT/5 PEEP.\nSUCTIONED FOR FAIR TO MINIMAL AMT WHITISH/YELLOW SPUTUM.\nCOARSE BREATH SOUNDS.\nIRREGULAR BREATHING PATTERN PERSISTS.\nAT TIMES PERIODS OF APNEA, AT TIMES PERIODS OF TACHYPNEA TO 30'S.\nIMPROVING WITH .\nRECEIVING NEBS AS ORDERED.\nPER RESP- SUGGESTS ADDITION OF STEROIDAL BASED NEBS TO PREVENT\nBRONCHOSPASM/EPISODES OF TACHYPNEA.\n\nID- AFEBRILE- LOW GRADE.\nLEVOQUIN IV.\n\nGI- REMAINS ON TUBE FEEDS AS ORDERED.\nABD DISTENDED BUT SOFT.\nSMALL AMT STOOL G (-). SOFT FORMED.\n\nGU- FAIR AMT URINE VIA CATHETER.\nREMAINS ON LASIX AS ORDERED.\n\nSKIN- LEFT BUTTOCK/AT COCCYX WITH ABRASION/STAGE 11- COVERED AND PROTECTED WITH DUODERM\nHEELS ALSO WITH (+) BLISTER. MULTIPODUS BOOTS ON AS WELL AS ANTIEMB SLEEVES.\nPUT PT ON FIRST STEP BED 12 AM FOR SKIN PROTECTION,\n\n PT AT TIMES ALERT, TRACKING= REPSONDING TO STIMULI SLIGHTLY.\nOTHER TIMES NOT.\nSEE FLOWSHEET FOR DATA RE: NEURO VS- UNCHANGED.\n\nENDO- BS<180'S- NO SS REG INSULIN COVERAGE.\n\nA/ PT S/P HEAD BLEED REMAINS IN NEED OF VENTILATORY SUPPORT.\nCONTINUE PULM TOILET AND SKIN CARE AS WELL AS CLOSE ASSESSMENT OF NEURO STATUS.\nKEEP PT AND FAMILY AWARE OF PLAN OF CARE.\nPLACEMENT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-13 00:00:00.000",
"description": "Report",
"row_id": 1332344,
"text": "Respiratory Care Note\n\nPt currently on CPAP 5 PSV 14. Pt tol current settings fairly. ? increasing PSV. Pt rxd t/o shift with Albuterol/atrovent mdis. Will continue to support and wean as tolerated\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-14 00:00:00.000",
"description": "Report",
"row_id": 1332345,
"text": "CCU NSG PROGRESS NOTE-SICU BORDER.\nO:NEURO=WO CHG-SEE FLOW SHEET.\n PULM=REMAINS /VENTED W SETTINGS-CPAP/PS, 40%, STV 350-500, RR 20-32, PEEP 5, & PS 14. BREATH SOUNDS=COURSE THROUGHOUT. SX-THICK TANNISH SECRETIONS.\n GI=LABETOLAL GTT @ 5MG/MIN W SBP 110-150.\n GU=TF @ GOAL (65ML/HR). LAST BM .\n GU=FOLEY. POSITIVE I&0 SINCE ADMISSION.\n ID=LOW GRADE T.\n LABS=AM SENT.\n SOCIAL=PT MADE DNR BY WIFE ON . FURTHER DISCUSSION RE:LONG TERM CARE CONTINUES.\n\nA:UNCHGED.\n\nP:CONTIN PRESENT MANAGEMENT. ?ATTEMPT TO WEAN & DC LABETOLAL. ?ADUMENT DIURESIS W PRN LASIX-?SOME COMPONENT OM HTN RELATED TO FL STATUS. CK AM LABS-REPLACE AS INDICATED. SUPPORT PT WIFE IN DECISION MAKING REGARDING LONG TERM OPTIONS.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-14 00:00:00.000",
"description": "Report",
"row_id": 1332346,
"text": "CCU NPN 7am - 7pm\nS/O: Resp: Pt. remains . PS was decreased to 12. Pt. tolerated this well for a couple of hours with ABG of 132/7.40/45/29. RR 24-30 slightly labored. At 1630 O2sats dropped to 89%and pt. looked more labored. PS was increased back to 14. ABG ->60/7.43/43/29. Pt. was agressively suctioned and CPT was done. O2 sat up to 96%. CXR done. Suctioning done Q2 hours for moderate amount of tan secretions.\nI.D: T max 100 rectal. Vanco D/C'd and levoquin was started per OGT.\nCVS: HR 70 - 80's afib. BP 140-160/70's. Continues on labetelol drip, lopressor, hydralazine, and norvasc.\nG.U.: voiding via foley catheter. sediment noted. urine dark and concentrated. Pt. received 20 mg of lasix pOGT.\nG.I.: Pt. continues on TF at 65cc/hr. residuals are less than 50cc. Aspirates are negative. BM x2.\nA: s/p thalmic bleed\nP: continue antihypertensive measures, aggressive pulm toilet, antibx as written, monitor neuro status for changes.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-15 00:00:00.000",
"description": "Report",
"row_id": 1332347,
"text": "CCU NSG PROGRESS NOTE-NSICU BORDER.\nO:NEURO=PERIODS OF APPROPRIATENESS-FOLLOWS SIMPLE COMMANDS (RISES ARM & SQUEEZES HAND L-SIDE ONLY-NODS HEAD TO ?'S-FOLLOWS W EYES). PURPOSEFUL MOVEMENT OF L ARM-ATTEMPTS TO SCRATCH HEAD-MOVES HAND TOWARDS ETT.\n PULM:VENT SETTINGS UNCHGED-CPAP/PS, FIO2 40%, STV 350-48-, RR 16-32, PEEP 5, * PS 14. SATS UPPER 90'S. AM ABG-7.39/48/117/30/3. BREATH SOUNDS=COURSE THROUGHOUT. SX-THICK TANNISH SECRETIONS.\n CV=ON LABETALOL GTT @ 4MG/MIN. SBP <150.\n GI=TF @ GOAL-65ML/HR W MINIMAL RESIDUALS.\n GU=FOLEY. LASIX X2 ON DAY/EVES -REMAINS POS @ 2300-1.9L.\n ID=LOW GRADE T.\n LABS=AM SENT. WNL.\n\nA:?SL IMPROVING NEURO STATUS. REMAINS ON LABETALOL GTT.\n\nP:CONTIN PRESENT MANAGEMENT. CONTIN ATTEMPT @ WEANING PRESSURE SUPPORT. SUPPORT AS NEEDED.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-15 00:00:00.000",
"description": "Report",
"row_id": 1332348,
"text": "Resp Care Note:\n\nPt cont intub on mech vent as per Carevue. Lung sounds coarse suct mod th tan sput. Pt tol PSV well. No changes made overnoc. Cont wean from mech vent with PSV.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-18 00:00:00.000",
"description": "Report",
"row_id": 1332356,
"text": "NSG NOTE\n\nCV: REMAINS IN A-FIB. RATE CONTROLLED 83-90. SBP 126-150. CON'T ON NTG TP 2\",HYDRALAZINE 50MG AND LOPRESSOR. NO VEA NOTED.\n\nRESP: CPAP/PS-14,PEEP 5, 40%, VT 710-940. 7.47,40,151,30,5,99%. METABOLIC ALKALOSIS BEING TX WITH DIAMOX X4 DOSES.PT HAS ALREADY RECEIVED 3 DOSES. SUCTIONED FOR SM AMT TAN SECRETIONS.\n\nNEURO: OPENS EYES SPONTANEOUSLY. 2MM/2MM BRISK. BOTH RUE/RLE NO MOVEMENT. LUE LIFTS AND HOLDS,LLE MOVES ON BED. HE FOLLOWS COMMANDS IN CONSISTENTLY.\n\nGI: PT WAS ON TF @ GOAL RATE 65. TOL WELL WITH LOW RESIDUALS. ABD SOFT WITH + BS. NO STOOL THIS SHIFT. TF D/CD @ 0400 IN PREP FOR TRACH TODAY. LAST BM \n\nLABS: BS 168- RECEIVED 2 UNITS REG PER SSI\n\nID: TEMP MAX 99.5 PT IS ON . AND OXACILLIN IV FOR COVERAGE\n\nSKIN: HAS BLISTER ON R LATERAL ASPECT OF HEEL. LEG AND FOOT ELEVATED ON PILLOW. DUODERM TO BUTTOCKS INTACT.\n\nDISPOSITION: DNR\n\nA: STABLE\n\nP: BEDSIDE TRACH TODAY. KIT AT BEDSIDE\n SUGGEST PICC LINE. IV NEEDS TO BE NOTIFIED.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-18 00:00:00.000",
"description": "Report",
"row_id": 1332357,
"text": "Resp Care,\npt. remains on CPAP IPS 14/.4/5peep. Vt 600's, RR15. Plan to today. ABG 7.47/40/151/30. See vent flowsheet.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-18 00:00:00.000",
"description": "Report",
"row_id": 1332358,
"text": "ccu nursing progress note\ns/o: pls see carevue flowsheet for complete vs/data/events\nneuro: opens eyes spon. occ appears to track. r hemiparesis. withdraws rle to pain but not upper. l moves spon but not to command. moves l hand to face/tubes and req soft wrist restraint.\ncv: hr 80s afib. bp 130-150/70 via r rad aline. no changes to bp/cardiac meds. k repleted 80meq for k 3.1.\nresp: cont on ps 14. rr low 20s. tv 500-800. sats >96% on .4 fio2. percutaneous trach placed at bedside. pt tol procedure well. sxn'd for sm amt bld tinged secretions. bs scatt coarse.\ngi: npo. peg placed at bedside. pt tol well. will remain npo until tomorrow am but peg may be used for essential meds. rec'ing ns at 80cc/hr while tf on hold.\ngu: good uop. cont po lasix.\nid: afeb. cont on oxacillin. levo to be dc'd after today's dose.\ncultures from pend.\naccess: rsc double lumen. iv team contact to eval for picc line. (pt may need 1 more week of oxacillin for mssa in sputum.) r rad aline will be pulled this afternoon.\nsocial: wife called this am. has note visited.\nact: pt and ot eval pt. will require full lift to get oob.\na: s/p trach and peg. tol well.\np: begin vent wean as tol. pulm toilet. neuro rehab. follow temp. f/u w/ iv team re: picc. ready for screening for rehab placement.\nsupport to family and pt.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-17 00:00:00.000",
"description": "Report",
"row_id": 1332353,
"text": "Respiratory Care:\nPt. initially tachypneac to 30's, VT's ~400cc, and appearing diaphoretic and agitated>>increased IPS to 14cmH20>>RR slowly decreased over course of the shift to mid teens, with VT's increasing to 6-800cc. ABG's essentially unchanged on both settings. Well oxygenated with a slight metabolic alkalosis. B/S continue course>>ETS for small to moderate yellow. Pt. continues very bronchospastic to SXN. Good relief with MDI's. Will continue pulmonary hygiene and attempts to wean as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-17 00:00:00.000",
"description": "Report",
"row_id": 1332354,
"text": "NURSING PROGRESS NOTE 7P-7A\nS/O: PT. MECH VENTILATED.\n\nNEURO: OPENS EYES SPONTANEOUSLY, MOVES LEFT ARM LIFTS AND HOLDS, MOVES LEFT LEG ON BED. NO MOVEMENT ON RIGHT SIDE. FOLLOWS SIMPLE COMMANDS. SQUEEZES WITH LEFT HAND. FOLLOWS WITH EYES.\n\nCV: CONT ON LABETOLOL GTT. NEEDED TO INCREASE GTT RATE TO 3 MG FOR PERIOD OF TIME D/T BP 160-170'S. LABETOLOL GTT NOW AT 1 MG. CLONIDINE DOSE INCREASED AND TOL WELL. HR 90'S AFIB.\n\nRESP: SEE PROGRESS NOTE FROM RESP THERAPY. PRESENT VENT SETTINGS FIO2 40%, TV 800, PS 14 CPAP SUCTIONING FOR THICK WHITE SPUTUM. PT BECOMING WITH SUCTIONING. O2 SATS 97%. ABG UNCHANGED. SL. ALKALOTIC, RECEIVING DIAMOX 250 MG IV X 2 DOSES.\n\nGI: REMAINS ON TF PROMOTE WITH FIBER AT GOAL RATE OF 65 CC/HR. MIN RESIDUALS. + BOWEL SOUNDS, HOWEVER NO BM. ON COLACE . ? NEED FOR LAXATIVE TODAY.\n\nGU: FOLEY PATENT AND DRAINING CLEAR YELLOW URINE. DIURESING WELL FROM LASIX. CONT ON ABX FOR UTI.\n\nSKIN: SMALL QUARTER SIZE BLISTER NOTED ON RIGHT HEEL. BLISTER INTACT. MULTIPODUS SPLINTS ON. SMALL ABRSSION ON COCCYX COVERED WITH TEGADERM. SMALL SKIN ABRASION NOTED ON RIGHT FLANK. LEFT OPEN TO AIR. WASHED WITH SOAP AND WATER.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-17 00:00:00.000",
"description": "Report",
"row_id": 1332355,
"text": "CCU NURSING PROGRESS NOTE 7A-7P\n\nNEURO: Pt awake and moving head side to side, however does not appear to be tracking with his eyes. PERL. Will squeeze left hand, however does not let go when asked. ?reflex vs. purposeful movement. No movement of right side.\n\nRESP: Remains vented on PSV 14/ peep 5. RR 20's most of the day. Sats maintained >97%. Suctioned q4 hrs for small-> mod amt thick white sputum. No plans to wean today given febrile state. Scheduled for trach Monday morning ~10am.\n\nCARDIAC: BP range 120-160's. Hydralazine and clonidine increased; able to d/c labetolol gtt while maintaining SBP 140-160 range. Remains in afib with rate 80-90's.\n\nGI: Abd soft distended with +BS. Given dulcolax suppository this am with good effect. Passed small amt soft brown stool. Tolerating goal tube feeds at 65cc/hr. To be NPO after 4am for trach and peg in am.\n\nGU: foley draining clear yellow urine. Pt is +435cc this evening. Conts on lasix and diamox.\n\nID: T max 102.2. Was fully cultured. Right SC DL was changed over a wire and tip was sent for cx. Pt may be a candidate for PICC given potential need for 10-14 days of IV abx. COnts on po levo and IV oxacillin for MSSA in urine and sputum. WBC up to 20 today. Given tylenol x2 today with temp down to 100.8 this evening.\n\nA/P: New temp spike on abx-> follow up with cx results.\n Awaiting trach and peg in am. D/C tube feeds at 4am\n Consult IV team for PICC placement.\n Cont to assess for acute neuro changes\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-15 00:00:00.000",
"description": "Report",
"row_id": 1332349,
"text": "SICU NPN\nNEURO: OPENS EYES TO VOICE, AT TIMES SEEMS TO TRACK. VERY OCCASIONALLY FOLLOWING COMMANDS SUCH AS WIGGLING TOES (L SIDE ONLY), LIFTS L HAND, MOVES L LEG ON BED. NO MOVEMENT I R SIDE EXCEPT WITHDRAWAL OF R LEG TO PAINFUL STIMULI.\n\nCV: LABATELOL WEANED TO 1 MG/MIN. LOPRESSOR ^ TO 150MG TID, CLONIDINE .2MG , HYDRALAZINE REMAINS AT 40MG QID, NTP 1\" Q6HR. BP 137-160/58-70. (GOAL <160) HR 70'S A FIB.\n\nRESP: PS TO 10 (FROM 14) TV 400-500, RR 20'S, APPEARS COMFORTABLE.\nSX Q 3 HRS FOT SM/MOD AMTS YEL SECRETIONS. LUNG SOUNDS COARSE.\n\nID: LOW GRADE TEMP, CONT ON LEVOQUIN\n\nGU: FOLEY DRAINING YEL URINE. GIVEN LASIX 40MG IV W/ EXCELLENT RESPONSE.\n\nGI: TOLERATING TF AT GOAL, NO STOOL TODAY. MINIMAL RESIDUALS.\n\nSOCIAL: WIFE MET W/ DR. THIS AFTERNOON. PLAN IS FOR PT TO HAVE TRACH AND PEG PLACEMENT MON OR TUES.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-16 00:00:00.000",
"description": "Report",
"row_id": 1332350,
"text": "RESPIRATORY CARE:\nPt. remains on unchanged vent support. RR low to high 20's, VT's 4-500cc on IPS=10cmH20. ABG was well oxygenated with with normal range acid-base. B/S continue course>>ETS for moderate to large amounts of thick yellow. Pt. very bronchospastic to SXN>>MDI's given post with good effect. Pt. appears to be tolerating present level of support. Will continue pulmonary hygiene.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-16 00:00:00.000",
"description": "Report",
"row_id": 1332351,
"text": "NURSING PROGRESS NOTE 7P-7A\nNEURO: PT. OPENS EYES TO COMMAND. FOLLOWS WITH EYES. MOVING LEFT ARM OFF BED AND ABLE TO HOLD. MOVING LEFT LEG ON BED. NO MOVEMENT OF RIGHT SIDE. WILL FOLLOW SOME SIMPLE COMMANDS. NO SEIZURE ACTIVITY NOTED.\n\nCV: CONT IN AFIB. RATE 80'S NO VEA BP STABLE ON LABETOLOL I MG. BP RANGE 150-160'S. TOL CARDIAC MEDS WELL.\n\nRESP: SEE FLOWSHEET FOR VENT SETTINGS. SUCTIONING FOR THICK YELLOW SPUTUM. LUNGS SOUNDS COARSE. O2 SATS 96-98%. ABG'S ADEQUATE.\n\nGU: FOLEY PATENT. DRAINING CLEAR YELLOW URINE. GIVEN LASIX AS ORDERED. DIURESING WELL FROM LASIX.\n\nGI: + BOWEL SOUNDS. TOL TF AT GOAL RATE OF 65 CC/HR. MIN RESIDUALS. NO BM OVERNIGHT. ABD SOFT, DISTENDED.\n\nSKIN: SMALL BLISTER NOTED ON RIGHT HEEL. OPEN TO AIR. SMALL ABRASION NOTED ON COCCYX.\n\nSTABLE OVERNIGHT, WAITING FOR TRACH AND PEG PLACEMENT NEXT WEEK.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-12-16 00:00:00.000",
"description": "Report",
"row_id": 1332352,
"text": "CCU NURSING PROGRESS NOTE 7A-7P\n\nNEURO: Pt awake and following simple commands intermittently. Moving left arm and left leg; no movements noted of right side. PERL.\n\nRESP: LS coarse. Sxn'd q2-4 hrs for moderate amt thick white sputum. Attempted to decrease PSV to 8 however pt's rr increased to high 30's\n(ABG essentially unchanged: 115/44/7.47). Placed back on PSV 10/5 with RR 27 Vt 400's. Awaiting trach and peg on Mon or Tues.\n\nCARDIAC: Bp 140-160's most of the day (which is goal range). Conts on labetolol gtt as well as multiple po cardiac meds. Tolerating well.\n\nGI: Tolerating tube feeds at goal rate of 65cc/hr. Abd soft distended. +BS. no stool this shift.\n\nGU: foley draining clear yellow urine. Rec'g IV lasix . Pt is >500cc negative this evening. Bun 36/ Creat 1.2.\n\nID: T max 99.8. WBC 12.1. Conts on po levo for UTI and started on IV oxacillin for MSSA in sputum.\n\nA/P: Stable day. Awaiting trach and peg\n Maintain SBP 140-160 range.\n Follow t-curve on abx.\n Assess for acute neuro changes.\n\n"
},
{
"category": "ECG",
"chartdate": "2147-12-28 00:00:00.000",
"description": "Report",
"row_id": 150624,
"text": "Atrial fibrillation\nSince last ECG, , no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2147-12-05 00:00:00.000",
"description": "Report",
"row_id": 150625,
"text": "Atrial fibrillation\nEarly R wave progressing\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-12-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 748454,
"text": " 1:23 PM\n CHEST (PORTABLE AP) Clip # \n Reason: PLEASE CONFIRM PICC TIP PLACEMENT TO RIGHT ARM; PAGE \n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with ICH.\n temp spike r/o PNA\n for central line position check\n temp spike today- rt subclavian line changed over a wire today\n for correct placement check\n REASON FOR THIS EXAMINATION:\n PLEASE CONFIRM PICC TIP PLACEMENT TO RIGHT ARM; PAGE WITH RESULTS.\n THANKS..\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Intracranial hemorrhage and temperature spike, PICC placement.\n\n COMPARISON: .\n\n PORTABLE AP CHEST: The left PICC line terminates with tip in the proximal\n SVC. The right subclavian central venous line and endotracheal tube are\n unchanged. There are bibasilar nonspecific opacities, which could represent\n atelectasis or alternatively, aspiration. The cardiomediastinal silhouette\n and pulmonary vasculature are stable.\n\n IMPRESSION:\n PICC tip in proximal SVC. Nonsecific patchy bibasilar opacities could\n represent atelectasis or aspiration.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-12-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 747902,
"text": " 5:00 PM\n CHEST (PORTABLE AP) Clip # \n Reason: desatting on vent. on levoquin ? pneumonia\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with ICH.\n temp spike r/o PNA\n for central line position check\n REASON FOR THIS EXAMINATION:\n desatting on vent. on levoquin ? pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Intracranial hemorrhage with new temperature spike.\n\n COMPARISON: .\n\n PORTABLE AP CHEST: Allowing for lordotic position, the ETT and right\n subclavian central venous catheter and NG tube are in unchanged and\n satisfactory position. The lung volumes are low but there is no consolidation.\n There is continued improvement in patchy left basilar opacity likely related\n to atelectasis.\n\n IMPRESSION: No evidence of pneumonia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-12-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 748083,
"text": " 1:39 PM\n CHEST (PORTABLE AP) Clip # \n Reason: post line change\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with ICH.\n temp spike r/o PNA\n for central line position check\n temp spike today- rt subclavian line changed over a wire today\n for correct placement check\n REASON FOR THIS EXAMINATION:\n post line change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE AP FILM.\n\n HISTORY: Fever with change in right CV line. Evaluate for location and\n pneumothorax.\n\n Endotracheal tube is 3 cm above carina. Right subclavian CV line is in mid\n SVC. No pneumothorax. Apart from discoid atelectasis in the left lower zone\n and linear atelectasis in the right midzone, the lungs are grossly clear.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-12-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 748174,
"text": " 9:57 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p trach, please eval lung volumes; infiltrates\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with ICH.\n temp spike r/o PNA\n for central line position check\n temp spike today- rt subclavian line changed over a wire today\n for correct placement check\n REASON FOR THIS EXAMINATION:\n s/p trach\n please eval lung volumes; infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post tracheostomy with fever, check line placement.\n\n AP radiograph dated is compared with AP radiograph dated .\n The ET tube has been removed. A tracheostomy tube is in proper position. The\n right subclavian central venous catheter tip is located in the mid SVC. There\n are adequate lung volumes. There is discoid atelectasis in the left lower lung\n Zone. The lungs are otherwise clear.\n\n IMPRESSION: Satisfactory position of tracheostomy and right subclavian\n central venous catheter. Adequate expansion of the lungs. No evidence of\n infiltrate.\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-12-19 00:00:00.000",
"description": "VEN DUP EXTEXT BIL (MAP/DVT)",
"row_id": 748219,
"text": " 12:54 PM\n DUP EXTEXT BIL (MAP/DVT) Clip # \n Reason: ACUTELY DESATTED AND HYPERTENSIVE WITH RESIDUAL LOWER O/2 SATURATION,SOB ,EVAL FOR DVT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with BASAL GANGLIA CVA\n REASON FOR THIS EXAMINATION:\n ACUTELY DESATTED AND HYPERTENSIVE WITH RESIDUAL LOWER O2 SATS\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Basal ganglia CVA, acutely desated and hypertensive with\n bilateral lower extremity swelling.\n\n BILATERAL DVT STUDY:\n\n scale and Doppler son of both common femoral, superficial femoral,\n and popliteal veins were performed. Normal flow, augmentation and\n compressibility and wave forms are demonstrated. Intraluminal thrombus is not\n identified.\n\n IMPRESSION: No evidence of DVT in either leg.\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-12-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 748200,
"text": " 9:49 AM\n CHEST (PORTABLE AP) Clip # \n Reason: hemodynamics unsteady w/ decreased sats\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with ICH.\n temp spike r/o PNA\n for central line position check\n temp spike today- rt subclavian line changed over a wire today\n for correct placement check\n REASON FOR THIS EXAMINATION:\n hemodynamics unsteady w/ decreased sats\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Unsteady hemodynamics with decreased sats and fever.\n\n AP radiograph dated is compared with the radiograph dated .\n\n The heart size is normal. The mediastinal and hilar contours are normal. The\n right subclavian central venous catheter tip is i proper position. The\n endotracheal tube is in proper position. There is increased interstitial\n pattern of opacification in the bases bilaterally. This likely represents\n pulmonary edema. There are no pleural effusions. The soft tissues and\n osseous structures are unremarkable.\n\n IMPRESSION: Though it is difficult to assess the pulmonary vasculature in\n this supine radiograph, the increased interstitial pattern of pulmonary\n opacity is suggestive of evolving pulmonary edema.\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-12-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 747547,
"text": " 2:28 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pt has elevated WBC count and increased secretions., rule ou\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with ICH.\n eval ETT position\n REASON FOR THIS EXAMINATION:\n pt has elevated WBC count and increased secretions.\n rule out infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Elevated white count and increased secretions. Rule out infiltrate.\n\n CHEST, SINGLE AP PORTABLE VIEW.\n\n Lordotic positioning and low inspiratory volumes. Allowing for this, no\n definite infiltrate. There is bibasilar atelectasis, presumably related to\n low lung volumes. An ET tube is present, tip approximately 1.3 cm above the\n carina, relatively low. An NG tube is present, tip obscured due to\n underpenetration.\n\n IMPRESSION: Low lung volumes. Allowing for this, no definite infiltrate.\n Attention to ET tube is recommended, as the positioning on today's exam seems\n relatively low compared with 11/29.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-12-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 748839,
"text": " 10:15 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o infiltrate, chf\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with ICH. prolonged resp failure w/ trach, now w/ inc WBC,\n agitation, need to go back on vent\n REASON FOR THIS EXAMINATION:\n r/o infiltrate, chf\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 73 year old man with history of intracerebral hemorrhage and\n prolonged respiratory failure, now with increasing white blood cell count,\n aggitation and respiratory distress.\n\n AP portable radiograph of the chest dated , compared with prior AP\n portable on .\n\n There is stable cardiomegaly. The mediastinal and hilar contours are\n unchanged. There is a possible small left pleural effusion with atelectasis\n at the left lung base. The remainder of the lung fields are clear. A\n tracheostomy tube is seen in good position. The soft tissue and osseous\n structures are unremarkable.\n\n IMPRESSION: Small left pleural effusion with left lower lobe atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-01-02 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 749159,
"text": " 9:50 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o progression of previous hemorrhage\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with left hemisphere hemorrhage. No significant change in his\n neurological status over the last weeks. Resorption of hemorrhage?\n REASON FOR THIS EXAMINATION:\n r/o progression of previous hemorrhage\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Intraparenchymal hemorrhage, assess change. There has been interval\n change in neurological status.\n\n There is a prior study dated .\n\n TECHNIQUE: Contiguous axial images were obtained from skull base to higher\n convexities. No intravenous contrast was administered.\n\n FINDINGS: There is evolution of the left basal ganglia hemorrhage and\n currently measures 3.1 x 1.7 cm with surrounding hypodensity consistent with\n vasogenic edema. There was mild left-to-right midline shift of the normally\n midline structures. This is decreased in comparison to the prior examination.\n There is mass effect upon the left lateral ventricle. There is a small amount\n of hemorrhage within the occipital horns bilaterally. There are no other areas\n of hemorrhage. There is a stable old right temporal lobe infarct. There is a\n calcified extra-axial mass off the higher convexities on the right which is\n unchanged and probably represents a calcified meningioma. The bony calvarium\n and paranasal sinuses are clear. The bony calvarium is intact.\n\n IMPRESSION: Evolution of the left basal ganglia hemorrhage. There is no\n evidence of new hemorrhage.\n\n There is a small amount of intraventricular hemorrhage, as well.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-12-06 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 747344,
"text": " 12:01 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: known intraparenchymal hem, eval interval extension, shift,\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man transferred for ICH with mass effect. Intubated.\n REASON FOR THIS EXAMINATION:\n known intraparenchymal hem, eval interval extension, shift, hydrocephalus\n ______________________________________________________________________________\n FINAL REPORT\n CT SCAN OF THE BRAIN, :\n\n INDICATION: Follow up intracranial hemorrhage, assess for shift and\n hydrocephalus.\n\n TECHNIQUE: Axial noncontrast CT scans of the brain were obtained.\n\n FINDINGS:\n Comparison is made to the previous study of .\n\n There has been no extension of the large left basal ganglionic hemorrhage.\n there is an intraventricular component of the hemorrhage, which is also\n stable. The lateral ventricles are mildly dilated, but not significantly\n changed in size, compared to the previous study. There is mild midline shift\n to the right. This is not changed. The basal cisterns remain well visualized.\n\n There are no other changes in the appearance of the brain. Again noted is an\n old right temporal lobe infarction and a high right frontal region calcified\n mass, presumably a meningioma.\n\n IMPRESSION: Stable left basal ganglionic and intraventricular hemorrhage.\n Mild ventricular dilatation.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-12-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 747437,
"text": " 2:38 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval ETT position\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with ICH.\n eval ETT position\n REASON FOR THIS EXAMINATION:\n eval ETT position\n ______________________________________________________________________________\n FINAL REPORT\n\n CHEST, SINGLE AP FILM.\n\n ET Tube is 4 cm above carina. NG tube is in proximal stomach. There are\n bibasilar subsegmental atelectases. No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-12-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 747605,
"text": " 6:14 PM\n CHEST (PORTABLE AP) Clip # \n Reason: status post right subclavian catheter\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with ICH.\n eval ETT position\n for position of right subclavian catheter\n REASON FOR THIS EXAMINATION:\n status post right subclavian catheter\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 73 y/o man with intracranial hemorrhage, s/p ETT placement and\n subclavian catheter placement.\n\n Portable AP radiograph of the chest dated at 6:28 P.M. is compared\n with a portable AP radiograph of the chest dated .\n\n The ETT is approximately 3 cm above the carina. The right subclavian central\n venous catheter tip is at the distal superior vena cava. There is lordotic\n positioning and low lung volumes. Allowing for this, the cardiomediastinal\n silhouette is within normal limits and stable. There is no consolidation,\n effusion, or pneumothorax.\n\n IMPRESSION: ETT and right subclavian central venous catheter in satisfactory\n position.\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-12-10 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 747597,
"text": " 1:37 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: change in mental status, s/p intracranial bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man transferred for ICH with mass effect. Intubated.\n REASON FOR THIS EXAMINATION:\n change in mental status\n s/p intracranial bleed\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Intracranial hemorrhage with mass effect, intubated with change\n in mental status.\n\n COMPARISON: .\n\n TECHNIQUE: CT of the head without IV contrast.\n\n FINDINGS: Again seen is a left basal ganglia hemorrhage with a large amount\n of hemorrhage present within the left lateral ventricle as well as hemorrhage\n within the occipital of the right lateral ventricle. There is a stable\n old right temporal lobe infarct. The calcified presumed meningioma in the\n right frontal region is unchanged. Compared with the prior study there does\n not appear to be a significant interval change in the ventricular size. The\n hemorrhage within the third ventricle is less apparent on the present study.\n There continues to be a small amount of shift of normal midline structures\n which are not significantly changed from the prior study. There is edema\n associated with the left basal ganglia hemorrhage that does not appear\n significantly changed.\n\n IMPRESSION: No significant change from the prior study.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-12-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 747678,
"text": " 7:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: TEMP SPIKE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with ICH.\n temp spike r/o PNA\n REASON FOR THIS EXAMINATION:\n r/o infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 73 y/o man with intracranial hemorrhage and fever spike.\n\n COMPARISON: .\n\n PORTABLE SUPINE AP CHEST: The ETT, NG tube, and right subclavian line remain\n in stable and satisfactory position. There are low lung volumes. The\n cardiomediastinal silhouette is stable. There is no consolidation, CHF, or\n effusion.\n\n IMPRESSION: No evidence of pneumonia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-12-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 747715,
"text": " 1:47 PM\n CHEST (PORTABLE AP) Clip # \n Reason: post change of central venous catheter over a wire- for posi\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with ICH.\n temp spike r/o PNA\n for central line position check\n REASON FOR THIS EXAMINATION:\n post change of central venous catheter over a wire- for position of central\n venous catheter\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: Central line catheter placement.\n\n Comparison is made to previous radiograph of earlier the same day.\n\n A right subclavian central venous catheter has been placed and terminates in\n the distal superior vena cava. No pneumothorax is identified. However,\n exclusion of the right costophrenic angle area from the radiograph limits\n assessment for basilar pneumothorax.\n\n An endotracheal tube is in satisfactory position, allowing for flexed position\n of the patient's neck. The nasogastric tube courses below the diaphragm.\n\n Cardiac and mediastinal contours are stable. A patchy left lower lobe opacity\n shows some interval improvement. The right lung is grossly clear, allowing\n for low lung volumes.\n\n IMPRESSION:\n 1. Satisfactory placement of central venous catheter. No pneumothorax is\n detected, but additional view to include entire right lung base would be\n helpful to exclude basilar pneumothorax.\n\n 2. Improving left lower lobe opacity, likely due to atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-12-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 747283,
"text": " 3:15 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/o intubation....distant BS on left...r/o PTX, ET tube migr\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with ICH.\n REASON FOR THIS EXAMINATION:\n s/o intubation....distant BS on left...r/o PTX, ET tube migration\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Intracranial hemorrhage, status post intubation with decreased\n breath sounds on the left.\n\n FINDINGS: Single frontal view of the chest. Enotracheal tube tip resides 2.4\n cm above the carina. There is bibasilar atelectasis which appears more\n pronounced when compared with the prior study from five hours prior. There is\n no congestive heart failure or dense consolidations. No pneumothoraces seen.\n\n IMPRESSION: Increased atelectasis at the bases bilaterally.\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-12-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 747242,
"text": " 10:01 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval position of EG and OG\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with ICH.\n REASON FOR THIS EXAMINATION:\n eval position of EG and OG\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Tube check.\n\n Portable AP chest radiograph was performed. No prior studies.\n\n The ETT and OGT are appropriately positioned. There is tortuosity and\n calcification of the aorta. The heart is difficult to assess but appears\n slightly enlarged. There is vascular redistribution suggesting mild\n congestive failure. There is a hazy opacity involving the entire right lung,\n which may represent layering pleural effusion. There is no pneumothorax. The\n osseous structures are unremarkable.\n\n IMPRESSION: Appropriately positioned ET and OG tube. Mild congestive failure\n and probably a right-sided effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-12-05 00:00:00.000",
"description": "CT EMERGENCY HEAD W/O CONTRAST",
"row_id": 747238,
"text": " 9:25 AM\n CT EMERGENCY HEAD W/O CONTRAST Clip # \n Reason: eval ICH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man transferred for ICH with mass effect. Intubated.\n REASON FOR THIS EXAMINATION:\n eval ICH\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Intracranial hemorrhage.\n\n TECHNIQUE: Noncontrast head CT.\n\n HEAD CT WITHOUT CONTRAST: There is a large intraparenchymal hemorrhage\n centered in the left basal ganglia extending superiorly to the left corona\n radiata and centrum semiovale and inferiorly to the posterior limb of the\n internal capsule and thalamus. There is significant amount of\n intraventricular blood, predominantly involving the left lateral ventricle.\n There is a tiny amount of hemorrhage seen within the posterior of the\n right lateral ventricle as well as in the left temporal and third\n ventricle. There is some shift of normally midline structures to the right\n with some subfalcine herniation. There is no evidence of uncal displacement.\n\n There is an area of hypodensity within the right temporal lobe with loss of\n -white differentiation consistent with an old infarct. There is a large\n calcified right frontal convexity meningioma measuring 2.8 cm.\n\n Mild mucosal thickening is noted within the ethmoid air cells.\n\n IMPRESSION: Large intraparenchymal hemorrhage centered in the left basal\n ganglia, slight subfalcine herniation and intraventricular hemorrhage.\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-12-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 748626,
"text": " 1:34 PM\n CHEST (PORTABLE AP) Clip # \n Reason: fever work up- r/o pnuemonia\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with ICH.\n temp spike r/o PNA\n for central line position check\n temp spike today- rt subclavian line changed over a wire today\n for correct placement check\n fever work up r/o pneumonia\n REASON FOR THIS EXAMINATION:\n fever work up- r/o pnuemonia\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 73 YEAR OLD MAN WITH INTRACRANIAL HEMORRHAGE AND FEVER. EVALUATE\n FOR PNEUMONIA.\n\n FINDINGS: The heart, mediastinal and hilar contours are unremarkable. There\n has been decreased interval perihilar haziness and patchy bibasilar opacities.\n There are no pleural effusions. A tracheostomy tube is seen with its tip\n approximately 5 cm above the carina. The soft tissues and osseous structures\n are unremarkable. There has been interval removal of the right subclavian\n central venous line.\n\n IMPRESSION:\n 1. Interval improvement in perihilar haziness and bibasilar patchy opacities.\n 2. Interval removal of the right subclavian central venous line.\n\n"
}
] |
84,629 | 111,966 | 51yoW h/o prior R basal ganglia stroke, syncope, HTN, PFO/ASD, and prior left cerebellar mass p/w right arm and leg weakness, dysarthria and dysphagia, subsequently developing a basilar artery occlusion which was removed via mechanical clot retrieval. [] Acute Cerebral Infarction - The patient presented initially with right-sided weakness, dysarthria and dysphagia with an NIHSS of more than 12 hours after the onset of symptoms after an initial evaluation at an outside hospital. She was not eligible for intravenous tPA or for mechanical thrombectomy initially. The patient said that her code status should be DNR/DNI. She was initially going to be uptitrated from Aspirin to Clopidogrel, but her MRI/MRA brain and MRA neck showed multiple bilateral posterior circulation strokes with flow voids in the basilar artery and poor flow in the vertebral arteries. The patient was placed on a Heparin infusion instead of Clopidogrel and was transferred to the Neuro ICU. The patient was asked by Dr. if she would agree to a clot retrieval procedure if it became necessary at a later time. The patient said that she might potentially agree to a clot retrieval procedure. Later at 3pm on , the patient started drooling and had nystagmus in all directions. She deteriorated rapidly. She became anarthric and quadiparetic. Given her contrast allergy, she was premedicated before she underwent CTA head and neck. The CTA subsequently showed a basilar artery occlusion. The patient was unable to give consent at this time. Her daughter gave consent for a clot retrieval and/or balloon angioplasty and/or stenting procedure. The daughter agreed that her mother's code status could be reversed to FULL code during the procedure. She was intubated and brought to the angiography suite for emergent mechanical clot retrieval which resulted in partial recanalization. After two passes with the MERCI clot retrieval device, the proximal half of the basilar artery was partially opened up. However, the basilar artery reoccluded twice and required intra-arterial tPA, eptifibatide, and balloon angioplasty to remain patent. She was brought back to the Neuro ICU for further stabilization and management. Her daughter asked that her code status be changed to DNR at that time. Her exam improved and stabilized. On while still intubated, she was alert, oriented to year and place. She was able to show two fingers with the left hand. She had 3/5 strength of the left forearm, 2/5 strength of the right arm, and 2/5 strength of both legs. MRA head, CTA head, and conventional angiogram showed a severe distal V4 segment stenosis of the left vertebral artery. This stenosis likely served as the nidus from which the proximal basilar artery thrombosis and occlusion evolved. There were multiple emboli from the proximal basilar artery to distal parts of the posterior circulation. Unfortunately, there was no prior vessel imaging from her or admissions for our review. Her prior HgbA1c and lipid panel from were relatively unremarkable. TTE with bubble study did not reveal significant valvular disease or an intracardiac shunt. She had autoimmmune and coagulopathy studies sent. During conversation with her daughter , said that once her mother was extubated, that her code status should be DNR/DNI. Given her stable clinical status, she was extubated just before 5pm on , but about 25 minutes later she suddenly became bradycardic and hypotensive. Code status was reconfirmed as DNR/DNI by the patient's daughter who was at the bedside. Attempts were made with IV fluids and three pressor agents to improve her hemodynamic status, but this never recovered, and the patient was declared deceased at 7:20PM. The family agreed to an autopsy. | There is thrombus sitting in the basilar artery with occlusion of the right PCA. The axial T2-weighted images demonstrate a loss of the normal flow void in the basilar artery. A check angiogram showed persistent partial occlusion of the basilar artery. Unchanged 1-cm left pontine hypodensity representing infarct seen on MRI of . A firm Merci 2 2.5 self-retrieval device was then deployed, and withdrawn under roadmap guidance into the right vertebral artery. Susceptibility artifact in the left mid brain and left cerebellum indicated petechial hemorrhages. CTA demonstrated occlusion of the basilar artery. MRI c/w distal vertebral and basilar artery thrombosis. Interval small amount of subarachnoid hemorrhage layering along the left parietal sulci. COMPARISON: MRI/MRA head dated . A preliminary report was issued that read "no enhancement of distal bilateral V4 segments and basilar artery presumably secondary to distal vertebral and basilar artery thrombosis. FINDINGS: HEAD CT: There is a vague hypodensity in the left paramedian pontine region indicative of an infarct seen on the previous MRI. FINAL REPORT MRI AND MRA BRAIN AND NECK WITHOUT AND WITH CONTRAST HISTORY: Prior infarction. Scattered small acute infarcts in the left occipital lobe, right cerebellum, right pons, and possibly left pons. Scattered small acute infarcts in the left occipital lobe, right cerebellum, right pons, and possibly left pons. Right vertebral artery angiogram. A repeat right vertebral artery angiogram was then performed. Head CT shows a left paramedian pontine hypodensity indicative of infarcts seen on the MR done earlier. Left thalamic and bilateral cerebellar infarcts are seen and some extension in the left pontine infarct is noted. FINDINGS: Single portable view of the chest shows a right upper extremity PICC line whose tip terminates within the atriocaval junction. Right posterior cerebral artery angiogram. Right basilar artery angiogram. Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK Contrast: OPTIRAY Amt: 70 FINAL REPORT (Cont) Right ventricular chamber size and free wall motion arenormal. FINDINGS: Single portable frontal view of the chest shows a right upper extremity PICC line which courses into the left brachiocephalic. A selective arteriogram through the right vertebral artery was performed, and confirmed placement. CT angiography of the head demonstrates high-grade stenosis of the distal left vertebral artery and proximal basilar artery with diminished flow distally as described above. FINDINGS: Right vertebral arteriogram showed a dominant right vertebral artery. Right superior cerebellar artery angiogram. There has been placement of an endotracheal tube whose distal tip is 3.4 cm above the carina, appropriately sited. A repeat angiogram showed persistent occlusion. Susceptibility abnormalities are seen in left side of midbrain and left cerebellum indicating petechial hemorrhages. Merci thrombectomy of basilar artery thrombus. These findings are indicative of stenosis or clot within the basilar artery. PATIENT/TEST INFORMATION:Indication: ?PFO LV/RV FunctionHeight: (in) 69Weight (lb): 175BSA (m2): 1.95 m2BP (mm Hg): 108/49HR (bpm): 61Status: InpatientDate/Time: at 10:19Test: Portable TTE (Congenital, complete)Doppler: Full Doppler and color DopplerContrast: SalineTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. INDICATION: For reperfusion and recanalization of the vertebrobasilar system. A repeat arteriogram through the right vertebral artery was then performed, and this showed persistent clot in the basilar artery. Following this, the right common femoral artery arteriogram was done. Petechial hemorrhages are seen in the left mid brain and left cerebellum. Petechial hemorrhages are seen in the left mid brain and left cerebellum. CONCLUSION: Apparent mid basilar severe stenosis or occlusion with multiple posterior circulation infarctions. Incidental note is made of right maxillary sinus opacification. Following recanalization of the basilar artery, the vessel demonstrates flow-related enhancement with high-grade irregularity of the lumen diameter, which is difficult to evaluate with regard to motion artifacts, but most likely represents residual stenosis. REASON FOR THIS EXAMINATION: s/p clot retrieval. The superior cerebellar artery was patent. A Merci retriever V 3.0 firm device was then deployed across the thrombus in the proximal basilar artery, and withdrawn into the (Over) 5:07 PM CAROT/CEREB Clip # Reason: New vascular insult Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK Contrast: OPTIRAY Amt: 241 FINAL REPORT (Cont) right vertebral artery under constant suction with a Penumbra System. Right superior cerebellar artery arteriogram showed a patent right superior cerebellar artery. Minor T wave abnormalities. MRA NECK: (Over) 3:09 PM MR HEAD W/O CONTRAST; MRA NECK W/O CONTRAST Clip # Reason: evaluate evolution Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK FINAL REPORT (Cont) The neck MRA demonstrates normal flow in the carotid and vertebral arteries without stenosis or occlusion. | 15 | [
{
"category": "Radiology",
"chartdate": "2195-07-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1203713,
"text": " 3:59 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ETT position\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman s/p intubation\n REASON FOR THIS EXAMINATION:\n ETT position\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest, .\n\n CLINICAL HISTORY: Patient with endotracheal tube placement.\n\n FINDINGS: Comparison is made to previous study from .\n\n There has been placement of an endotracheal tube whose distal tip is 3.4 cm\n above the carina, appropriately sited. There is a feeding tube whose distal\n tip and sideport are below the gastroesophageal junction. The cardiac\n silhouette and mediastinum are normal. There is focal consolidation in the\n right upper lobe which may represent pneumonia. Followup to resolution is\n recommended. There are no signs of pulmonary edema or pleural effusions.\n\n"
},
{
"category": "Radiology",
"chartdate": "2195-07-13 00:00:00.000",
"description": "BILAT LOWER EXT VEINS",
"row_id": 1203913,
"text": " 11:04 AM\n BILAT LOWER EXT VEINS Clip # \n Reason: assess for DVT\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman with stroke.\n REASON FOR THIS EXAMINATION:\n assess for DVT\n ______________________________________________________________________________\n WET READ: KKgc MON 4:42 PM\n No DVT in both lower extremities.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 51-year-old woman with stroke, to evaluate for DVT.\n\n COMPARISON: None available.\n\n TECHNIQUE: Grayscale and Doppler son of bilateral common femoral,\n superficial femoral, deep femoral, popliteal and proximal calf veins were\n performed. There is normal compressibility, flow and augmentation throughout.\n\n IMPRESSION: No DVT in both lower extremities.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2195-07-12 00:00:00.000",
"description": "MR HEAD W/O CONTRAST",
"row_id": 1203810,
"text": " 3:09 PM\n MR HEAD W/O CONTRAST; MRA NECK W/O CONTRAST Clip # \n Reason: evaluate evolution\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman with vertebral and basilar artery thrombosis s/p clot removal\n REASON FOR THIS EXAMINATION:\n evaluate evolution\n CONTRAINDICATIONS for IV CONTRAST:\n lack of IV access\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AFSN SUN 5:19 PM\n PFI: Since the previous MRI, there have been multiple new small infarcts in\n both cerebellar hemispheres and in the left thalamus as well as some extension\n of the left pontine infarct. Petechial hemorrhages are seen in the left mid\n brain and left cerebellum. MRA of the neck is unremarkable.\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: MRI BRAIN AND MRA OF THE NECK.\n\n CLINICAL INFORMATION: Patient with vertebrobasilar thrombosis status post\n clot retraction, for further evaluation.\n\n TECHNIQUE: T1 sagittal and T2 susceptibility and diffusion axial images\n of the brain were acquired. 2D and 3D time-of-flight MRA of the neck vessels\n were obtained. Gadolinium-enhanced MRA of the neck was not obtained as per\n the clinical request as the patient has no IV access.\n\n FINDINGS: BRAIN MRI:\n\n Comparison was made with the previous MRI examination of .\n\n There are now multiple new infarcts seen in the posterior circulation.\n Several new cerebellar infarcts are identified in both hemispheres. A left\n thalamic infarct is also now apparent, as well as the previously seen left\n paramedian pontine infarct has slightly increased in size. Susceptibility\n abnormalities are seen in left side of midbrain and left cerebellum indicating\n petechial hemorrhages. There is no midline shift or hydrocephalus. There are\n soft tissue changes in the left maxillary sinus and mucosal thickening in the\n remaining sinuses with retained secretions in the nasopharynx.\n\n Note is made of increased signal within the left transverse sinus on\n T2-weighted images could be secondary to slow flow as this sinus was well\n visualized on the previous MRA study.\n\n IMPRESSION: Multiple new infarcts are now identified since the previous MRI\n examination of . Left thalamic and bilateral cerebellar infarcts are\n seen and some extension in the left pontine infarct is noted. Susceptibility\n artifact in the left mid brain and left cerebellum indicated petechial\n hemorrhages.\n\n MRA NECK:\n (Over)\n\n 3:09 PM\n MR HEAD W/O CONTRAST; MRA NECK W/O CONTRAST Clip # \n Reason: evaluate evolution\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n The neck MRA demonstrates normal flow in the carotid and vertebral arteries\n without stenosis or occlusion.\n\n IMPRESSION: Normal MRA of the neck.\n\n"
},
{
"category": "Radiology",
"chartdate": "2195-07-12 00:00:00.000",
"description": "MR HEAD W/O CONTRAST",
"row_id": 1203811,
"text": ", C. NMED SICU-B 3:09 PM\n MR HEAD W/O CONTRAST; MRA NECK W/O CONTRAST Clip # \n Reason: evaluate evolution\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman with vertebral and basilar artery thrombosis s/p clot removal\n REASON FOR THIS EXAMINATION:\n evaluate evolution\n CONTRAINDICATIONS for IV CONTRAST:\n lack of IV access\n ______________________________________________________________________________\n PFI REPORT\n PFI: Since the previous MRI, there have been multiple new small infarcts in\n both cerebellar hemispheres and in the left thalamus as well as some extension\n of the left pontine infarct. Petechial hemorrhages are seen in the left mid\n brain and left cerebellum. MRA of the neck is unremarkable.\n\n"
},
{
"category": "Radiology",
"chartdate": "2195-07-13 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1203924,
"text": " 12:30 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: 44cm DL R brachial PICC placed ? tip - \n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman with new R PICC\n REASON FOR THIS EXAMINATION:\n 44cm DL R brachial PICC placed ? tip - \n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: PICC placement.\n\n FINDINGS: Single portable frontal view of the chest shows a right upper\n extremity PICC line which courses into the left brachiocephalic. Withdrawal\n and repositioning is recommended. The ET tube and feeding tube are in\n standard position. There is atelectasis of the left lung base. Otherwise,\n the lungs are unchanged.\n\n IMPRESSION: Poorly positioned. Right upper extremity PICC.\n\n These findings were discussed with by telephone at the time of this\n dictation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2195-07-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1203979,
"text": " 5:33 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: evidence of consolidation?\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman recently extubated with productive cough\n REASON FOR THIS EXAMINATION:\n evidence of consolidation?\n ______________________________________________________________________________\n WET READ: DLrc MON 8:24 PM\n Right upper lobe consolidation is improving since . No new areas of\n consolidation.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 6:22 P.M. ON \n\n HISTORY: Recently extubated patient with a productive cough, question\n consolidation.\n\n IMPRESSION: AP chest compared to through 22 at 1:55 p.m.:\n\n There is the suggestion of a region of greater opacity in the right mid lung,\n but I am hesitant to call at pneumonia. PA and lateral view should really be\n obtained to see if there is any pulmonary abnormality. Lungs are otherwise\n clear and there is no pleural effusion. Heart size is normal and there is no\n pleural effusion. Right PIC line ends in the right atrium at least 5 cm\n beyond the estimated location of the superior cavoatrial junction. No\n endotracheal tube visible on the imaged portion of the trachea below the level\n of C7.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2195-07-12 00:00:00.000",
"description": "MRA BRAIN W/O CONTRAST",
"row_id": 1203836,
"text": " 9:15 PM\n MRA BRAIN W/O CONTRAST Clip # \n Reason: eval evolution\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman with basal ganglia infarct s/p clot removal + tPA, integrelin\n REASON FOR THIS EXAMINATION:\n eval evolution\n CONTRAINDICATIONS for IV CONTRAST:\n lack of IV access\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 51-year-old man with basilar artery occlusion and interventional\n recanalization.\n\n COMPARISON: MRI/MRA head dated .\n\n TECHNIQUE: Axial 3D TOF of the intracranial vessels was obtained without\n contrast and multiple MIP reconstructions were displayed.\n\n FINDINGS: The image quality of the current study is somewhat degraded by\n motion artifacts.\n Following recanalization of the basilar artery, the vessel demonstrates\n flow-related enhancement with high-grade irregularity of the lumen diameter,\n which is difficult to evaluate with regard to motion artifacts, but most\n likely represents residual stenosis.\n\n Diffuse atherosclerotic changes are, moreover, seen in the posterior cerebral\n arteries as well as the anterior circulation, most notably the intracranial\n carotid arteries at the level of the cavernous and ophthalmic segments.\n Otherwise, the anterior and middle cerebral arteries demonstrate normal\n flow-related enhancement with no evidence of occlusion.\n\n Incidental note is made of right maxillary sinus opacification.\n\n IMPRESSION: High-grade lumen irregularity of the recanalized basilar artery\n which is difficult to evaluate in the setting of extensive motion artifacts,\n but may represent persistent stenosis.Suggest follow up imaging evaluation\n with CTA.\n\n"
},
{
"category": "Radiology",
"chartdate": "2195-07-10 00:00:00.000",
"description": "MR HEAD W & W/O CONTRAST",
"row_id": 1203627,
"text": " 10:10 PM\n MR HEAD W & W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n MRA NECK W&W/O CONTRAST\n Reason: Infarct versus mass versus evidence of infection versus vasc\n Contrast: MAGNEVIST Amt: 18\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51F status post CVA in , went to outside hospital this morning, complaints\n of worsened dysarthria and right-sided weakness of the arm and leg since she\n awoke this morning. Also complained of generalized weakness since yesterday. He\n head CT is outside hospital negative for bleed, concerning for possible\n subacute infarct, transferred to for neurologic evaluation.\n REASON FOR THIS EXAMINATION:\n Infarct versus mass versus evidence of infection versus vasculitis\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: SAT 3:07 AM\n 1. No enhancement of distal bilateral V4 segments and basilar artery\n presumably secondary to distal vertebral and basilar artery thrombosis. The\n right P1 segment is vaguely seen, but the remaining portions of the PCAs\n bilaterally are not visualized. Small PCOMMs are seen bilaterally.\n 2. Left A1 segment is narrowed, could be due to hypoplasia and/or\n atherosclerosis.\n 3. Scattered small acute infarcts in the left occipital lobe, right\n cerebellum, right pons, and possibly left pons.\n 4. Complete opacification of the left maxillary sinus.\n ______________________________________________________________________________\n FINAL REPORT\n MRI AND MRA BRAIN AND NECK WITHOUT AND WITH CONTRAST \n\n HISTORY: Prior infarction. Now with worsening dysarthria and right-sided\n weakness.\n\n Sagittal short TR, short TE spin echo imaging was performed through the brain.\n Axial imaging was performed with , TR, long TE fast spin echo,\n gradient echo, diffusion, and 3D time-of-flight MRA technique.\n Gadolinium-enhanced MRA was performed through the neck. Comparison to a brain\n MR .\n\n FINDINGS: There are multiple areas of new infarction since the prior study.\n These are most prominent in the pons, predominantly on the left, where there\n is associated hemorrhage. There are also small infarctions in the right\n cerebellar hemisphere of the left occipital lobe, and the right cerebral\n peduncle. These all implicate posterior circulation abnormalities. The brain\n MRA demonstrates very poor signal arising from the basilar artery and its\n branches. The distal vertebral arteries are visualized on the non-contrast\n MRA but the vertebrobasilar junction is not. The axial T2-weighted images\n demonstrate a loss of the normal flow void in the basilar artery. The\n gadolinium-enhanced neck MRA source images demonstrate the distal vertebral\n arteries, the vertebrobasilar junction, and the distal basilar artery. This\n suggests that these vessels are patent but experiencing extremely slow flow,\n responsible for the poor visualization on the non-contrast time-of-flight\n images. However, the mid basilar is not opacified on the gadolinium MRA.\n (Over)\n\n 10:10 PM\n MR HEAD W & W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n MRA NECK W&W/O CONTRAST\n Reason: Infarct versus mass versus evidence of infection versus vasc\n Contrast: MAGNEVIST Amt: 18\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Overall, these findings suggest a focal area of severe stenosis or thrombosis\n in the mid basilar artery with poor runoff for the vertebral arteries and\n reduced flow through the superior cerebellar and posterior cerebral arteries.\n This would explain the distribution of infarction seen on the diffusion\n images.\n\n The MRA also demonstrates loss of the A1 segment of the left anterior cerebral\n artery, which was present on the MR examination of . There is\n no evidence of infarction in the A1 distribution.\n\n Images of the remainder of the brain demonstrate no other areas of hemorrhage\n or infarction. The remainder of the intracranial branches appear normal.\n\n A preliminary report was issued that read \"no enhancement of distal bilateral\n V4 segments and basilar artery presumably secondary to distal vertebral and\n basilar artery thrombosis. The right P1 segment is vaguely seen, but\n remaining portions of the PCAs bilaterally are not well visualized. Small\n posterior communicating arteries are seen bilaterally.\n\n 2. Left A1 segment is narrowed, could be due to hypoplasia or\n atherosclerosis.\n\n 3. Scattered small acute infarcts in the left occipital lobe, right\n cerebellum, right pons, and possibly left pons.\n\n 4. Complete opacification of the left maxillary sinus.\n\n discussed with Dr. at 3:03 a.m. via telephone on .\"\n\n CONCLUSION: Apparent mid basilar severe stenosis or occlusion with multiple\n posterior circulation infarctions. There is a small amount of hemorrhage in\n the pons associated with these infarctions.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2195-07-11 00:00:00.000",
"description": "CTA HEAD W&W/O C & RECONS",
"row_id": 1203717,
"text": " 4:30 PM\n CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # \n Reason: bleeding?\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n Contrast: OPTIRAY Amt: 70\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman with basilar clot with acute decompensation.\n REASON FOR THIS EXAMINATION:\n bleeding?\n CONTRAINDICATIONS for IV CONTRAST:\n allergic;stat - confirmed with rads attending\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: CTA of the head and neck.\n\n CLINICAL INFORMATION: Patient with basilar artery clot, for further\n evaluation.\n\n TECHNIQUE: Axial images of the head were obtained without contrast.\n Following this using departmental protocol CT angiography of the head and neck\n acquired. 3D reformatted images were obtained on independent workstation.\n\n FINDINGS:\n\n HEAD CT: There is a vague hypodensity in the left paramedian pontine region\n indicative of an infarct seen on the previous MRI. No hemorrhage seen.\n\n CT ANGIOGRAPHY NECK: CT angiography of the neck demonstrates normal flow in\n the carotid and vertebral arteries. The left vertebral artery is smaller in\n size compared to the right which could be a variation. The V1, V2, and V3\n segments of the vertebral arteries are patent without stenosis or occlusion.\n\n CT ANGIOGRAPHY HEAD: The CT angiography of the head demonstrates narrowing of\n the distal left vertebral artery prior to the vertebrobasilar junction. In\n addition, the proximal one-half of the basilar artery is markedly narrowed\n with diminished flow. There is also diminished flow seen in the distal\n basilar artery. The right posterior cerebral artery is not well visualized\n and the left posterior cerebral artery flow is markedly diminished. These\n findings are indicative of stenosis or clot within the basilar artery.\n\n The anterior circulation is patent without stenosis or occlusion. Both A1\n segments of the anterior cerebral arteries are seen although the left side is\n slightly smaller than the right, in variation.\n\n IMPRESSION:\n 1. Head CT shows a left paramedian pontine hypodensity indicative of infarcts\n seen on the MR done earlier.\n 2. CT angiography of the neck demonstrates no evidence of dissection,\n stenosis, or occlusion in the neck vessels.\n 3. CT angiography of the head demonstrates high-grade stenosis of the distal\n left vertebral artery and proximal basilar artery with diminished flow\n distally as described above.\n (Over)\n\n 4:30 PM\n CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # \n Reason: bleeding?\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n Contrast: OPTIRAY Amt: 70\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2195-07-12 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1203753,
"text": " 2:10 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: s/p clot retrieval. Please perform at 0200 on .\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman with basilar clot s/p clot retrieval.\n REASON FOR THIS EXAMINATION:\n s/p clot retrieval. Please perform at 0200 on .\n CONTRAINDICATIONS for IV CONTRAST:\n not indicated\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 51-year-old woman, with basilar clot. Status post clot retrieval.\n\n COMPARISON: Multiple prior studies including CTA head on and\n cerebral on at 1707.\n\n TECHNIQUE: Non-contrast MDCT images were acquired through the brain.\n Multiplanar reformatted images were obtained for evaluation.\n\n FINDINGS: Small amount of subarachnoid layering in the high parietal sulci is\n new. There is no evidence of intraventricular hemorrhagic extension. No\n acute major vascular territorial infarct is noted. The -white matter\n differentiation is well preserved. The ventricles and sulci remained normal\n in size and symmetric in configuration. There is no shift of normally midline\n structure. A 10 mm rounded hypodensity (image 2:8) in the left pons is\n unchanged, likely represent an old infarct. There is no acute fracture.\n\n IMPRESSION:\n 1. Interval small amount of subarachnoid hemorrhage layering along the left\n parietal sulci. No intraventricular hemorrhagic extension. No evidence of\n developing hydrocephalus.\n 2. Unchanged 1-cm left pontine hypodensity representing infarct seen on MRI\n of .\n\n"
},
{
"category": "Radiology",
"chartdate": "2195-07-11 00:00:00.000",
"description": "PRIMARY MECH THROMBECTOMY ART/BPG; INITIAL VESSEL",
"row_id": 1203723,
"text": " 5:07 PM\n CAROT/CEREB Clip # \n Reason: New vascular insult\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n Contrast: OPTIRAY Amt: 241\n ********************************* CPT Codes ********************************\n * PRIMARY MECH THROMBECTOMY ART/ SEL CATH 3RD ORDER *\n * -51 MULTI-PROCEDURE SAME DAY VERT/CAROTID A-GRAM *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 RHF with precent right basal ganglia infarct in , transferred from\n an outside hospital more than 12 hours after new onset right sided weakness in\n arm and leg, dysarthria and dysphagia. MRI c/w distal vertebral and basilar\n artery thrombosis.\n REASON FOR THIS EXAMINATION:\n New vascular insult\n ______________________________________________________________________________\n FINAL REPORT\n DATE OF SERVICE: .\n\n PREOPERATIVE DIAGNOSIS: Acute stroke with basilar artery occlusion.\n\n INDICATION: For reperfusion and recanalization of the vertebrobasilar system.\n The patient had presented with a significant stroke. CTA demonstrated\n occlusion of the basilar artery. We felt it would be worthwhile to reopen the\n basilar artery which was occluded with thrombus.\n\n PROCEDURE PERFORMED:\n\n 1. Right vertebral artery angiogram.\n 2. Right superior cerebellar artery angiogram.\n 3. Right posterior cerebral artery angiogram.\n 4. Right basilar artery angiogram.\n 5. Merci thrombectomy of basilar artery thrombus.\n 6. Chemical thrombolysis of right posterior cerebral artery and basilar\n artery.\n\n DETAILS OF PROCEDURE:\n\n The patient was brought to the angiography suite. Following this, a safety\n timeout was obtained. The entire procedure was performed under general\n anesthesia. We gained access to the right common femoral artery using a\n Seldinger technique, and an 8 French long vascular sheath was advanced into\n the right common femoral artery. Subsequently, a 5 French 2 catheter\n was advanced, and the right vertebral artery was selected. On CTA, this was\n the dominant vertebral artery. Over a long exchange glidewire, the 2\n catheter was exchanged for an 8 French Merci sheath, which was placed in the\n right vertebral artery. The basilar artery was then selected. It was\n catheterized with an 18 L microcatheter, and an X-Pedion 014 wire. A\n selective arteriogram through the right vertebral artery was performed, and\n confirmed placement. A Merci retriever V 3.0 firm device was then deployed\n across the thrombus in the proximal basilar artery, and withdrawn into the\n (Over)\n\n 5:07 PM\n CAROT/CEREB Clip # \n Reason: New vascular insult\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n Contrast: OPTIRAY Amt: 241\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n right vertebral artery under constant suction with a Penumbra System.\n Following this, a check arteriogram was performed. This demonstrated\n non-filling of the right PCA. The microcatheter was advanced into the right\n PCA, and this was injected with approximately 3 mg of TPA. A repeat\n arteriogram through the right vertebral artery was then performed, and this\n showed persistent clot in the basilar artery. A firm Merci 2 2.5\n self-retrieval device was then deployed, and withdrawn under roadmap guidance\n into the right vertebral artery. A repeat angiogram showed persistent\n occlusion. A further 4 mg of TPA was injected into the basilar artery.\n\n A repeat right vertebral artery angiogram was then performed. There was\n persistent clot formation in the basilar artery. A discussion was held with\n the neurologist, and a decision was made to administer further TPA into the\n basilar artery. However, there was persistent irregularity of the basilar\n artery, and this was felt to be due to endothelial denudation. A Sprinter\n Legend RX 2.5 mm x 20 mm balloon was then advanced into the basilar artery,\n and this was angioplastied. The balloon was inflated with an insufflation\n device, and held at 8 atmospheres for approximately 30 seconds. The balloon\n catheter was then withdrawn. A check angiogram showed persistent partial\n occlusion of the basilar artery. A decision was then made to administer 15 mg\n of Integrilin, and a repeat right vertebral arteriogram was performed after\n five minutes. This showed relative patency of the basilar artery with\n improved flow. The consideration towards placement of a stent was\n subsequently abandoned. An OGT was then placed, and the patient was given 600\n mg of Plavix. Following this, the right common femoral artery arteriogram was\n done. This showed a widely patent right common femoral artery. At this\n point, an 8 French Angio-Seal was used for closure, and to secure hemostasis.\n\n FINDINGS: Right vertebral arteriogram showed a dominant right vertebral\n artery. There is thrombus sitting in the basilar artery with occlusion of the\n right PCA. The superior cerebellar artery was patent.\n\n Right superior cerebellar artery arteriogram showed a patent right superior\n cerebellar artery.\n\n Right posterior cerebral artery arteriogram showed an occluded right posterior\n cerebral artery, which was subsequently recanalized with 3 mg of TPA.\n\n IMPRESSION:\n\n Basilar artery thrombus was treated with successful recanalization of the\n basilar artery. The patient underwent TPA administration into the basilar\n artery, as well as the right posterior cerebral artery. She was also\n angioplastied with a 2.5 mm balloon, and 15 mg of Integrilin was administered\n iv. The patient was placed on 600 mg of Plavix. The neurologist was present\n (Over)\n\n 5:07 PM\n CAROT/CEREB Clip # \n Reason: New vascular insult\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n Contrast: OPTIRAY Amt: 241\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n throughout the entire procedure.\n\n"
},
{
"category": "Radiology",
"chartdate": "2195-07-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1203939,
"text": " 1:48 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: rue picc powerflushed x 4: re-assess tip #\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman with right picc crossing midline. powerflushed x 4 to help\n re-position picc\n REASON FOR THIS EXAMINATION:\n rue picc powerflushed x 4: re-assess tip #\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: PICC re-positioning.\n\n FINDINGS: Single portable view of the chest shows a right upper extremity\n PICC line whose tip terminates within the atriocaval junction. The ET tube is\n approximately 3 cm above the carina. Feeding tube is within the stomach.\n Lungs are unchanged. No pneumothorax.\n\n IMPRESSION: Properly positioned right upper extremity PICC.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2195-07-11 00:00:00.000",
"description": "R KNEE (2 VIEWS) RIGHT",
"row_id": 1203650,
"text": " 7:35 AM\n KNEE (2 VIEWS) RIGHT Clip # \n Reason: fracture? effusion? arthritis?\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman with CVA who is complaining of right knee pain.\n REASON FOR THIS EXAMINATION:\n fracture? effusion? arthritis?\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Right knee, two views, .\n\n CLINICAL HISTORY: 51-year-old woman with CVA with complaint of right knee\n pain. Evaluate for fracture.\n\n FINDINGS: There are no signs for acute fractures or dislocations. There is\n minimal spurring involving the medial compartment as well as the inferior\n aspect of the patella. There is no joint effusion. There are no focal lytic\n or blastic lesions.\n\n IMPRESSION:\n\n Mild spurring without signs for acute bony injury.\n\n"
},
{
"category": "Echo",
"chartdate": "2195-07-11 00:00:00.000",
"description": "Report",
"row_id": 65171,
"text": "PATIENT/TEST INFORMATION:\nIndication: ?PFO LV/RV Function\nHeight: (in) 69\nWeight (lb): 175\nBSA (m2): 1.95 m2\nBP (mm Hg): 108/49\nHR (bpm): 61\nStatus: Inpatient\nDate/Time: at 10:19\nTest: Portable TTE (Congenital, complete)\nDoppler: Full Doppler and color Doppler\nContrast: Saline\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD or PFO by 2D, color\nDoppler or saline contrast with maneuvers.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. Normal mitral\nvalve supporting structures. No MS. Trivial MR. Normal LV inflow pattern for\nage.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal\ntricuspid valve supporting structures. No TS. Normal PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR. Normal main PA. No Doppler evidence for PDA\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Contrast study was performed with 3 iv injections of 8 ccs\nof agitated normal saline, at rest, with cough and post-Valsalva maneuver.\n\nConclusions:\nThe left atrium is normal in size. No atrial septal defect or patent foramen\novale is seen by 2D, color Doppler or saline contrast with maneuvers. Left\nventricular wall thickness, cavity size and regional/global systolic function\nare normal (LVEF 70%). Right ventricular chamber size and free wall motion are\nnormal. The aortic valve leaflets (3) appear structurally normal with good\nleaflet excursion and no aortic stenosis or aortic regurgitation. The mitral\nvalve appears structurally normal with trivial mitral regurgitation. Trivial\nmitral regurgitation is seen. The estimated pulmonary artery systolic pressure\nis normal. There is no pericardial effusion.\n\nCompared with the findings of the prior transesophageal study with agitated\nsaline contrast infusion (images reviewed) of , once again no\nevidence of an intracardiac shunt is found during agitated saline contrast\ninfusion.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2195-07-13 00:00:00.000",
"description": "Report",
"row_id": 130689,
"text": "Sinus rhythm. Short P-R interval. Minor T wave abnormalities. Since the\nprevious tracing of probably no significant change.\n\n"
}
] |
29,770 | 197,088 | As mentioned in the HPI, Mrs. was admitted for cardiac cath which showed severe coronary disease. She was evaluated for bypass surgery and appropriately worked up. She remained medically managed for several days awaiting Plavix washout. On she was brought to the operating room where she underwent a coronary artery bypass graft x 5. Please see operative report for surgical details. Following surgery she was transferred to the CVICU for invasive monitoring in stable condition. She remained intubated until post-op day two when she was weaned from sedation, awoke neurologically intact and extubated. On post-op day one she was started on IV Lasix and gently diuresed towards her pre-op weight. On post-op day two she had episodes of atrial fibrillation and she was started on Amiodarone. On post-op day three her chest tubes were removed. She remained in the CVICU until post-op day five when she was transferred to the telemetry floor for further care. On post-op day six her epicardial pacing wires were removed. She worked with physical therapy during her post-op course for strength and mobility. On post-op day eight she was discharged to home with the appropriate medications and follow-up appointments. | Mild (1+) mitral regurgitationis seen. Mild (1+) MR. LV inflow pattern c/w impairedrelaxation.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal descending aortadiameter. Mild mitral regurgitation. Normal ascending aorta diameter. Normal aortic arch diameter. Normal aortic arch diameter. Moderateregional LV systolic dysfunction. Mild mitralannular calcification. Mild (1+) MR.TRICUSPID VALVE: Mild [1+] TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: A TEE was performed in the location listed above. Mild to moderate (+) aortic regurgitation is seen. BS COURSE UPPER, DIMINISHED BIBASILAR. Mild tomoderate (+) AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild to moderate aorticregurgitation. Mildly dilated ascending aorta. Mildly thickened aortic valveleaflets. Mitral valve disease.Height: (in) 62Weight (lb): 159BSA (m2): 1.74 m2BP (mm Hg): 130/88HR (bpm): 54Status: InpatientDate/Time: at 11:52Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA and RA cavity sizes.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.LEFT VENTRICLE: Normal LV wall thickness. No VSD.LV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior- hypo; mid inferior - hypo; basal inferolateral - hypo; mid inferolateral -hypo; septal apex - hypo; inferior apex - hypo; apex - akinetic;RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level. The left ventricular cavity sizeis normal. There is an anterior space which mostlikely represents a fat pad, though a loculated anterior pericardial effusioncannot be excluded.Conclusions:The left atrium and right atrium are normal in cavity size. Probable small, if present, left pleural effusion. Sternal dressing CDI. There is unchanged mild pulmonary edema. BorderlinePA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR.PERICARDIUM: No pericardial effusion. Mildly dilated LV cavity. The left ventricular cavity is mildly dilated.There is moderate regional left ventricular systolic dysfunction withhypokinesis of the basal to mid inferolateral segments, inferior wall andseptal apex. Moderate regional LV systolic dysfunction.LV WALL MOTION: Regional LV wall motion abnormalities include: mid anterior -hypo; mid anteroseptal - hypo; mid inferoseptal - hypo; anterior apex - hypo;septal apex - hypo; apex - akinetic;RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level. The left hemidiaphragm is now obscured by a small-to-moderate left pleural effusion with associated atelectasis. Mild to moderate (+) AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild to moderate (+) aortic regurgitation is seen.The mitral valve leaflets are mildly thickened. There is moderate regionalleft ventricular systolic dysfunction with hypokinesis notable in the LADdistribution.Right ventricular chamber size and free wall motion are normal.There are simple atheroma in the descending thoracic aorta.The aortic valve leaflets (3) are mildly thickened but aortic stenosis is notpresent. Rule out pneumothorax. ABD SOFT+DISTENDED, ABSENT BOWEL SOUNDS. No2D or Doppler evidence of distal arch coarctation.AORTIC VALVE: ?# aortic valve leaflets. IMPRESSION: Small left pleural effusion with associated atelectasis. Mild pulmonary edema, small, if present, left pleural effusion, status post CABG. c/o pain , Given dilaudid PO with good relief.CV: Pt in NSR 60s-70s with no ectopy noted. +palpable pulses.Resp: LS clear diminished bases. 2+ generalized edema. chest tubes with serosang, drainage slowing overnoc. ?need precedex for extubation.CV: sinus rhythm 80's few PVC noted overnoc. To go by FICk per PA . Albuterol MDI given as ordered. VENODYNES AND SC HEPARIN PER DR. . continue diuresis. UPDATED A STO PLAN.A: CI IMPROVED WITH DOBUTAMINE,CXR WET, DIURESING WITH LASIX GTT, PO2 ^ WITH ^ PEEP AND FIO2, ^ AGITATION WITH LIGHTENING ,P: MONITOR COMFORT, HR AND RYTHYM, SBP-USE LEVO IF NEED TO SUPPORT BP, CI-CONTINUE DOBUTAMINE, MVO2, CT DRAINAGE, DSGS, PP, RESP STATUS-WEAN FIO2 AND PEEP, NEURO STATUS-CONTINUE PROPOFOL-?PRECEDEX WHEN ABLE TO WEAN, I+O-CONTINUE LASIX GTT GOAL UO 100-150 ML/HR, LABS PENDING. CXR REVEALS WET-HOPE TO IMPROVE WITH IV LASIX GTT.BS COURSE TO CLEAR UPPER, DIMINISHED BIBASILAR. PA aware, CI>2 via FICK. Pain med changed to dilaudid po w/ effect. LLE with hemovacscant sang drainage, steristrips intact dsd changed and ace re-wrapped. Most recent ABG: 7.45/38/103/27/2. On Diamox(one more dose), Lasix Labs- lytes repleted, no RISS coverage Hct 28 Plan- SBP<140 Pain control ^ act as tolerated Monitor resp. + BOWEL SOUNDS-HYPOACTIVE. Bringing up thick tannish secretions small amts.GI/GU: Abd softly distended. CARAFATE AND ZANTAC GIVEN. CPT done. Non-specific ST-T wave changes.Compared to the previous tracing of Q-T interval is no longerprolonged. continues on dobutamine, lasix gtts, diureseing well, weight down, -600 since midnoc. CREAT WNL. Pao2 improved on subsqueint abg's. PEEP 10, fio2 50. getting alkalotic from diuresis. lungs clear with diminished bases bilat. CI> 2 via thermodilution w/ HR 80. DSGS REMAIN D+I. REPEAT ABG PO2 86. ABG AND VENT SETTINGS PER FLOW. +BS. Tolerating clears. Sinus rhythm. Sinus rhythm. Morphine 2mg ivp w/fair effect, given x4 CVMP Apaced at 80, BP<140 ion NTG up to 3mcg/kg/min,presently off.Hydralazine 10mg iv x2 w/effect. HCT 31. Perrla. SUCTIONED FOR A SMALL AMOUNT OF THICK BLOOD TINGED SPUTUM X1. Pulmonary hygeine.Encourage po intake. 7a-7pneuro: received sedated on propofol, not following commands; now rouses to voice, oriented x2 (reoriented to time), follows commands, mae, good pain control w/ morphine 1mg ivp q1-2hcv: sr 85-97 no ectopy, sbp 95-140, ntg gtt to keep map<90/sbp<120, ci 2.1-2.6, dobutamine gtt weaned off, swan left in place md, cvp 7-15, pad 17-25, ct draining small/moderate amts s/s drainage, max temp 38.2resp: lungs cta, dim to left base, extubated at 1430 to nc 4L & face tent at 50%, now sats >95% on 5L nc & face tent 70%, strong non-productive cough, w/ extubation pt expectorated large bloody/mucoid sputum (md aware, no further bleeding noted), is to 250mlgi: abdomen soft/distended, hypoactive bowel sounds, tolerating ice chips, fingersticks ssrigu: foley to gravity, copious diuresis this am w/ lasix gtt, lasix gtt weaned off & pt continues to autodiurese, pt currently -3L for dayassess: stableplan: start po metoprolol, wean ntg as tolerated to keep sbp<120, map<90, pulmonary toilet, deline and transfer to 6 in am | 30 | [
{
"category": "Radiology",
"chartdate": "2176-04-27 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1006803,
"text": " 9:03 AM\n CHEST (PA & LAT) Clip # \n Reason: eval pleural effusions\n Admitting Diagnosis: ANGINA\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman s/p CABG\n REASON FOR THIS EXAMINATION:\n eval pleural effusions\n ______________________________________________________________________________\n FINAL REPORT\n TWO-VIEW CHEST, \n\n COMPARISON: .\n\n INDICATION: Status post coronary bypass surgery.\n\n Cardiac silhouette is mildly enlarged but stable in size from the prior\n post-operative radiograph. Areas of patchy and linear atelectasis in the\n lower lobes have slightly improved, and small bilateral pleural effusions are\n not substantially changed.\n\n IMPRESSION: Persistent small bilateral pleural effusions. Improving\n bibasilar atelectasis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-04-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1005724,
"text": " 11:47 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: overload\n Admitting Diagnosis: ANGINA\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman with increasing lactate\n REASON FOR THIS EXAMINATION:\n overload\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Followup.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous examination, there are no major\n changes. The monitoring and support devices are in unchanged position. There\n is unchanged mild pulmonary edema. The size of the cardiac silhouette is also\n unchanged.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-04-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1006017,
"text": " 9:41 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o ptx s/p ct's removed\n Admitting Diagnosis: ANGINA\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman with\n REASON FOR THIS EXAMINATION:\n r/o ptx s/p ct's removed\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 76-year-old female status post chest tube removal. Rule out\n pneumothorax.\n\n COMPARISON: .\n\n UPRIGHT CHEST RADIOGRAPH: Patient is status post CABG and median sternotomy\n wires are intact. The right-sided Swan-Ganz catheter is in unchanged\n position. Left-sided chest tubes have been removed and there is no evidence\n of pneumothorax. Left basilar atelectasis has increased at the site of prior\n chest tube removal. The remainder of this examination is unchanged.\n\n IMPRESSION: Status post removal of left-sided chest tubes with no evidence of\n pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-04-19 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1005660,
"text": " 1:16 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: ptx\n Admitting Diagnosis: ANGINA\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman with s/p CABG\n REASON FOR THIS EXAMINATION:\n ptx\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest portable for line placement on .\n\n COMPARISON: chest radiograph.\n\n HISTORY: 76-year-old woman status post CABG, evaluate for pneumothorax.\n\n FINDINGS: Baseline postoperative examination showing multiple median\n sternotomy wires with no wire complications. The lungs are mildly edematous.\n Two chest drainage catheters are seen projecting over the left lower\n hemithorax.\n\n A feeding tube distal tip is in the stomach. An endotracheal tube distal tip\n is only 1.5 cm above the carina. A right internal jugular Swan-Ganz catheter\n terminates in the main pulmonary outflow tract. No right pleural effusion.\n Probable small, if present, left pleural effusion. No pneumothorax.\n\n IMPRESSION:\n 1. No radiographic evidence of pneumothorax.\n 2. Mild pulmonary edema, small, if present, left pleural effusion, status\n post CABG.\n 3. The endotracheal tube distal tip is approximately 1.5 cm above the carina\n bifurcation.\n\n The information was delivered by phone to for Dr. \n . Dr. to inform her about the position of the\n endotracheal tube.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-04-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1005876,
"text": " 7:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p cabg CHF\n Admitting Diagnosis: ANGINA\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman with\n REASON FOR THIS EXAMINATION:\n s/p cabg CHF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Followup.\n\n COMPARISON: , 00:10 a.m.\n\n FINDINGS: As compared to the previous examination, there is no relevant\n change. The monitoring and support devices are in unchanged position. The\n size of the cardiac silhouette is unchanged. There are no signs suggestive of\n pneumonia and no signs suggestive of relevant overhydration. Pleural\n effusions cannot be detected. No evidence of pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-04-25 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1006520,
"text": " 1:02 PM\n CHEST (PA & LAT) Clip # \n Reason: eval for pleural effusions\n Admitting Diagnosis: ANGINA\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman s/p cabgx5\n REASON FOR THIS EXAMINATION:\n eval for pleural effusions\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 76-year-old woman with five vessel CABG.\n\n COMPARISON: .\n\n PA AND LATERAL VIEWS OF THE CHEST: There has been interval removal of a Swan-\n Ganz catheter via a right internal jugular approach. Median sternotomy wires\n are intact. The left hemidiaphragm is now obscured by a small-to-moderate\n left pleural effusion with associated atelectasis. Elsewhere, the lungs are\n well expanded with no foci of consolidation. There may be a tiny right\n pleural effusion. There is no pneumothorax. The mild cardiomegaly is\n unchanged. Pulmonary vasculature is normal.\n\n IMPRESSION: Small left pleural effusion with associated atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-04-17 00:00:00.000",
"description": "CHEST (PRE-OP PA & LAT)",
"row_id": 1005376,
"text": " 2:42 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: ANGINA\\CATH\n Admitting Diagnosis: ANGINA\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman with 3VD, unstable angina awaiting CABG \n REASON FOR THIS EXAMINATION:\n evaluate for infiltrates/CHF\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Unstable engine awaiting CABG.\n\n FINDINGS: No previous images. There is enlargement of the cardiac silhouette\n with tortuosity of the aorta. Some prominence of interstitial markings could\n reflect elevated pulmonary venous pressure, chronic lung disease, or both. No\n acute focal pneumonia.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2176-04-19 00:00:00.000",
"description": "Report",
"row_id": 78950,
"text": "PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease;\nHeight: (in) 62\nWeight (lb): 159\nBSA (m2): 1.74 m2\nBP (mm Hg): 110/70\nHR (bpm): 74\nStatus: Inpatient\nDate/Time: at 11:07\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Dilated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or color\nDoppler.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. No LV\naneurysm. Moderate regional LV systolic dysfunction.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: mid anterior -\nhypo; mid anteroseptal - hypo; mid inferoseptal - hypo; anterior apex - hypo;\nseptal apex - hypo; apex - akinetic;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root. Normal ascending aorta diameter. Focal calcifications in\nascending aorta. Normal aortic arch diameter. Normal descending aorta\ndiameter. Simple atheroma in descending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild to\nmoderate (+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR.\n\nTRICUSPID VALVE: Mild [1+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was under\ngeneral anesthesia throughout the procedure. No TEE related complications. The\npatient appears to be in sinus rhythm. Results were personally reviewed with\nthe MD caring for the patient.\n\nConclusions:\nPRE-BYPASS:\nThe left atrium is dilated. No atrial septal defect is seen by 2D or color\nDoppler.\nLeft ventricular wall thicknesses are normal. The left ventricular cavity size\nis normal. No left ventricular aneurysm is seen. There is moderate regional\nleft ventricular systolic dysfunction with hypokinesis notable in the LAD\ndistribution.\nRight ventricular chamber size and free wall motion are normal.\nThere are simple atheroma in the descending thoracic aorta.\nThe aortic valve leaflets (3) are mildly thickened but aortic stenosis is not\npresent. Mild to moderate (+) aortic regurgitation is seen.\nThe mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation\nis seen. There is no pericardial effusion. Dr. was notified in person\nof the results on at 8AM on .\n\nPOST_BYPASS:\nLVEF 45% on no inotropic support.\nMild AI, Mild MR and Mild TR.\nNormal RV systolic function.\nAscending aortic contour is intact.\nLAD terriotry WMA is the same.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2176-04-17 00:00:00.000",
"description": "Report",
"row_id": 78951,
"text": "PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease. Mitral valve disease.\nHeight: (in) 62\nWeight (lb): 159\nBSA (m2): 1.74 m2\nBP (mm Hg): 130/88\nHR (bpm): 54\nStatus: Inpatient\nDate/Time: at 11:52\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA and RA cavity sizes.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Normal LV wall thickness. Mildly dilated LV cavity. Moderate\nregional LV systolic dysfunction. No resting LVOT gradient. No VSD.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior\n- hypo; mid inferior - hypo; basal inferolateral - hypo; mid inferolateral -\nhypo; septal apex - hypo; inferior apex - hypo; apex - akinetic;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root. Mildly dilated ascending aorta. Normal aortic arch diameter. No\n2D or Doppler evidence of distal arch coarctation.\n\nAORTIC VALVE: ?# aortic valve leaflets. Mildly thickened aortic valve\nleaflets. No AS. Mild to moderate (+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Mild (1+) MR. LV inflow pattern c/w impaired\nrelaxation.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Borderline\nPA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion. There is an anterior space which most\nlikely represents a fat pad, though a loculated anterior pericardial effusion\ncannot be excluded.\n\nConclusions:\nThe left atrium and right atrium are normal in cavity size. Left ventricular\nwall thicknesses are normal. The left ventricular cavity is mildly dilated.\nThere is moderate regional left ventricular systolic dysfunction with\nhypokinesis of the basal to mid inferolateral segments, inferior wall and\nseptal apex. The apex is akinetic. There is no ventricular septal defect.\nRight ventricular chamber size and free wall motion are normal. The ascending\naorta is mildly dilated. The number of aortic valve leaflets cannot be\ndetermined. The aortic valve leaflets are mildly thickened. There is no aortic\nvalve stenosis. Mild to moderate (+) aortic regurgitation is seen. The\nmitral valve leaflets are mildly thickened. Mild mitral regurgitation is seen.\nThere is no mitral valve prolapse. The left ventricular inflow pattern\nsuggests impaired relaxation. There is borderline pulmonary artery systolic\nhypertension. There is no pericardial effusion. There is an anterior space\nwhich most likely represents a fat pad.\n\nIMPRESSION: Mildly dilated left ventricular cavity with moderate focal left\nventricular systolic dysfunction likely due to multi-vessel CAD. Probable\ndiastolic dysfunction. Mild mitral regurgitation. Mild to moderate aortic\nregurgitation. Borderline pulmonary artery systolic hypertension.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2176-04-19 00:00:00.000",
"description": "Report",
"row_id": 1647214,
"text": "Resp Care\n\nPt received from OR and placed on full vent support. BS were bilateral. Mode was changed to a/c. OETT pulled back 2cm. Will wean fast wean appropriate.\n"
},
{
"category": "Nursing/other",
"chartdate": "2176-04-24 00:00:00.000",
"description": "Report",
"row_id": 1647229,
"text": "2300-0700\n\nNEURO: Pt slept most of shift. Ox3 when awake, followed commands, MAE, assists with turning. c/o pain , Given dilaudid PO with good relief.\n\nCV: Pt in NSR 60s-70s with no ectopy noted. 2As/2Vs, pacer turned off. Both sense and capture. SBP 110s-140s, MAP 70s-80s. Captopril ^ 50mg TID. PP palpable. Hct 32.9.\n\nRESP: Pt on 2L NC, sats>96%. LS clear, little dim in bases. Pt well, producing sputum on own, thick yellow sputum.\n\nGI/GU: + BS; pt denies nausea, no appetite. Pt on PO lasix , diuresing well. K+ pnd. Lytes repleated prn.\n\nENDO: BS tx per RISS. BS WNL.\n\nID: Afebrile, skin cool to touch- warm blankets. WBC 10.9\n\nPLAN: Peripheral access and d/c cordus. ^ diet, ^ activity. pulm toilet & comfort/support. transfer to 6 in am.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2176-04-19 00:00:00.000",
"description": "Report",
"row_id": 1647215,
"text": "S/P CABG X 5\nO: CARDIAC: A PACED WITH UNDERLYING RYTHYM 70-60'S. SR 70'S PRESENTLY A PACED @88 DUE TO HYPOTENSION. SBP REQUIRED NEO WITH LABILE BP/ NTG WHEN AWAKE AND . BOTH OFF. CI <2 RECEIVED 5L LR THEREFORE EPI STARTED @.O2 MCQ ^ .O3 MCQ.CI>2. RECEIVED 1UPC FOR HCT 27 REPEAT 32-36. MVO2 55-63. EXTREMITIES DRY BUT COOL. PALP PP. DSGS D+I. JP FROM LEFT UPPER LEG. REPEAT HCT 32-36. PH 7.28 WITH -7 RECEIVED AN ADDITIONAL 2L LR , REPEAT LABS PENDING. CT OOZY WITH ACT 162 RECEIVED 50 MG PROTAMINE. K,CALCIUM + MAG REPLACED. PACS NOTED INFREQUENTLY.LACTATE 3-5.7.\n RESP: VENT SETTINGS AND ABG PER FLOW.ABG PRIOR TO CPAP SENT AND PH 7.29 WITH -7 THEREFORE RESEDATED AND PLACED BACK ON RATE (ONCPAP PT .) BS COURSE UPPER, DIMINISHED BIBASILAR. ETT PULLED BACK 2 CM AS PER ABOVE. INTEMITTENT CT LEAK. SUCTIONED FOR A MOD AMOUNT OF BLOOD TINGED TO YELLOW SPUTUM. LAVAGED.\n NEURO: SEDATED ON PROPOFOL 50 AND PT . DID FOLLOW COMMANDS +MAE, RESEDATED ON 60 MCQ. PERL,\n GI+ + OGT PLACEMENT DRAINED 100ML. ABD SOFT+DISTENDED, ABSENT BOWEL SOUNDS.\n GU: AUTODIURESING HAS SLOWED.\n ENDO: INSULIN GTT AT 8 UNITS/HR.\n ID: VANCO AT .\n PAIN: WHEN AWAKE PT ADMITTED TO PAIN. RECEIVED 2 MG MORPHINE X2. 2 MG MORPHINE PREVIOUSLY PRIOR TO BEING AWAKE DUE TO CHANGE IN SBP.\n SKIN: INTACT. NOTED NOSE BLLED. NP INTO ASSESS.HAS STOPPED SINCE ARRIVAL FROM OR/\n SOCIAL: SPOKE TO DAUGHTER WHO IS THE SPOKESPERSON AND UPDATED.\nA: CI LOW REQUIRING LR,UPC,AUTODIURESING, WITH AWAKENING, ^ LACTATE? ETIOLOGY.\nP: MONITOR COMFORT, HR AND RYTHYM, SBP, CI, MVO2,CONTINUE EPI,CT DRAINAGE, DSGS, PP, RESP STATUS-TO REMAIN INTUBATED OVERNIGHT, NEURO STATUS-PROPOFOL, I+O, LABS PENDING, IF STABLE THROUGHTOUT THE NIGHT/ WAKE AND WEAN. AS PER ORDERS\n"
},
{
"category": "Nursing/other",
"chartdate": "2176-04-20 00:00:00.000",
"description": "Report",
"row_id": 1647216,
"text": "Resp Care: Pt continues on mechanical ventilation: AC 450x20 60%+8. Most recent ABG: 7.39/35/79/22/-2-> PEEP briefly inreased to 10-> returned to 8 MD. Pt fluid overloaded. LS coarse bilaterally. Sxn'd small amounts of thick yellow secretions. MDI's given as ordered. PLAN: continue current support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2176-04-20 00:00:00.000",
"description": "Report",
"row_id": 1647217,
"text": "Nursing Progress Note\nNeuro: sedated propofol at 25 mcg/kg/min. Awoke at 5 am off sedation, followed commands, gag and cough intact, perla 4 brisk. Resedated for resp compromise while awake.\n\nCVS: t max 98.1, hr 95 apaced underlying 70's sr. pa 25/18, co 4.08/ci 2.25, mvo2 63. EPI gtt off at 0130, on/off neo overnight, currently prop as above and insulin at 8 units/hour. Pacer ademand rate of 94, appropriately sensing and pacing a and V, skin warm, pale, dry. Pedal pulses doppler, right weaker than left. Troponin .53, EKG no significant changes from post op. Right Ij introducer with thermo swan, right radial a line and 3 peripheral iv's. Left leg ace wrap changed, echymosis and edema knee and calf, hemovac left groin with scant sang drainage. Sternal dressing CDI. Chest tubes to suction with serosang drainage. Initially acidosis, after 2 amps sodium bicarb acidosis is resolving.\n\nResp: ls coarse in uppers to dim throughout. Intubated, vent on AC .6/450/20/peep 8 now 10 after desat episode. ABG on 8 peep 7.39/35/79/22/-2/95% When waking from sedation attempted CPAP became bronchospastic, desating to 90-91, placed on 100 fio2 with no change, returned to cmv with sedation sats now 96%. Suctioned x 1 for thick blood tinged, otherwise no seretions with suction.\n\nGI: abdomen obese, distended, bs hypo. OGT with brown to golden secretions with coffee ground. 450 cc overnight. Appeared to be wretching with waking, given reglan IVP with relief.\n\nGU: Foley catheter draining clear yellow urien to gravity.\n\nEndo: fs bs covered with insulin drip per cvicu guidelines.\n\nPain: Grimacing and crying when awake, morphine 2 mg ivp with sleep as relief.\n\nLabs: lactate initially 6.8, down to 2.8 at 0500.\n\nSocial: no calls or family contact this shift.\n\nActivity: right side lying not well tolerated, numbers improve on back or left side.\n\nPlan: Wean ventilator support as tolerated. Wean pacing and sedation as numbers and hemodynamics tolerate.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2176-04-21 00:00:00.000",
"description": "Report",
"row_id": 1647224,
"text": " 7a-7p addendum\nat ~ 1730 pt went into RAF 110-180, lopressor 5mg iv x2 and amio 150mg iv bolus w/out return to nsr, RAF continues 110-145, md aware, awaiting amio gtt to arrive\n"
},
{
"category": "Nursing/other",
"chartdate": "2176-04-22 00:00:00.000",
"description": "Report",
"row_id": 1647225,
"text": "Neuro: pt oriented x 1 to name only she does know she is in a hospital but not where, and she thinks it is . pt reoriented but does not remember when asked again. MOving all extremities weakly.\nResp: pt found on 70& FIO@ face tent with sats of 98% weaned down to 50% pt did well with this until about 0200 when sats started to fall. FIO@ increased and NP but sats remained low. pt coughing and raising moderate amounts of thick tan secretions. CPT done. Albuterol inhalers given but pt did not take well so changed to neb. BReath sounds clear with crackes in left base. Cough was tight and wheezy. ABG sent with po2 returning 60 pt placed on hiflow 95% with plan to wean as tolerated.\nC/V: pt was in afib at the begining of shift rate 120-150 with stable BP and borderline CI. pt given additional 10mg IVP lopressor without effect., Amiodarone drip at 1mg started and pt given additional bolus of amio when pt did not slow down. Hemodynamics rechecked and CI by thermodilution had dropped to 1.5 SVO2 came backat 47% which gave a CI of 1.99. Hct check was stable at 28. Resdient notified Dr and additional Amio bolus of 150mg given and Diltiazem drip was ordered but before drip was ready but converted to sinus rhythm of 60. Hemodynamic rechecked and CI remained low with HR of 60 pt apaced at rate of 80 with SVO@ increased to 53% and CI >2.0 HO aware to monitor for now. Repeat SVO@ pending. SBP increasing throughout evening pt required nitro to be started presently on 2.5mcg with SBP 138/67.\nPedal pulses present. Chest tubes continue to drainig small to moderate amounts of serous sangunious drainage.\nGI: pt tolerating sips of clear liquids.\nEndo: Blood sugars treated with sliding scale.\nGU: adequate urine outputs off lasix drip.\nPain: pt complaining of pain in chest and leg last evening medicated with percocet 1 tab with good effect except pt seemed alittle more confused and lethargic after taking. THis am compalianing of pain so pt trying tylenol 650mg.\\\nskin: Incisions clean and dry no redness or drainage.\nPlan: Wean nitro as tolerated. OOB to chair CPT and IS\n"
},
{
"category": "Nursing/other",
"chartdate": "2176-04-22 00:00:00.000",
"description": "Report",
"row_id": 1647226,
"text": "3*24 7a-7p\nneuro: a+ox2, reoriented to place, mae, follows commands, up with PT to chair w/ assist x1, steady on feet, perrlaa, darvocet started for incisional pain w/ good response\n\ncv: a paced 70-80, underlying rhythm sb/sr high 50s-low 60s, sbp 15-145, ntg gtt to keep sbp <140, lopressor/captopril po for bp control, ci 1.7-2.8, pt a paced for ci support, amio gtt turned off this am, amio po started, afeb, ct d/ced this am\n\nresp: lungs cta, dim to bases, weaned o2 to nc 4L, sats currently>95%, is to 375ml, strong cough productive of clear/tan secretions\n\ngi: abdomen soft/distended, tolerating clear liquid diet, fingersticks ssri\n\ngu: foley to gravity draining clear yellow urine\n\nlabs: HIT panel from negative, heparin sc given this pm\n\nassess: improving respiratory status\n\nplan: wean ntg to off, goal sbp<140, pace as needed to keep ci>2.1, pulmonary toilet, increase activity\n"
},
{
"category": "Nursing/other",
"chartdate": "2176-04-23 00:00:00.000",
"description": "Report",
"row_id": 1647227,
"text": "TSICU Progress Note 1900-0700\n See carevue for exact data\n ROS_\n Neuro- alert, ox2, MAE equally. C/o significant incisional pain,Darvocet 2tabs given w/poor efect. N/V x2, ? form pain med. Morphine 2mg ivp w/fair effect, given x4\n CV_MP Apaced at 80, BP<140 ion NTG up to 3mcg/kg/min,presently off.Hydralazine 10mg iv x2 w/effect. Hct 28 s/p 2u PC's, last CO4.31,CI 2.38. Generalized edema persists, pulses+, SCD's off part of night for comfort, moving legs frequently.Excellent diuresis form Diamox.\n Resp- NC4lpm, desat briefly after vomiting to mid 80's, improved w/ Db+C, raising mod amts thick tan sputum\n GI- water taken well overnight, intermittent N/V. BS+, no stool\n GU-Foley, u/o clear yellow. On Diamox(one more dose), Lasix\n Labs- lytes repleted, no RISS coverage Hct 28\n Plan-\n SBP<140\n Pain control\n ^ act as tolerated\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2176-04-23 00:00:00.000",
"description": "Report",
"row_id": 1647228,
"text": "7A-7P\nNeuro: Pt alert and oriented, forgetful at times. Perrla. MAE. Pain med changed to dilaudid po w/ effect. See flowsheet.\n\nCV: Received pt via epicardial wires at 80. CI> 2 via thermodilution w/ HR 80. To go by FICk per PA . Epicardial wires turned off per PA. SVO2 sent, resulted as 59. PA aware, CI>2 via FICK. Ok to dc swan per PA . See flowsheet for filling pressures. Captorpil increased to 37.5mg tid. GOAL SBP <140. Hydralazine iv prn ordered for SBP>140. 2+ generalized edema. +palpable pulses.\n\nResp: LS clear diminished bases. Sats >94% on 4Lnc. Encouraged coughing and deep breathing. Bringing up thick tannish secretions small amts.\n\nGI/GU: Abd softly distended. +BS. Tolerating clears. Poor appetite. Foley draining clear yellow urine adequate amts, see flowsheet.\n\nEndo: RISS.\n\nPlan: Monitor hemodynamics. Monitor resp. status. Pulmonary hygeine.\nEncourage po intake. Transfer to floor in am.\n"
},
{
"category": "Nursing/other",
"chartdate": "2176-04-20 00:00:00.000",
"description": "Report",
"row_id": 1647218,
"text": "S/P CABG X 5\nO: CARDIAC: A PACED 94-80 TO SR 60'S HOWEVER SBP DROPS TO HIGH 80'S THEREFORE A PACED. PRESENTLY A PACED AT 80. ISOLATED PVC'S NOTED. K 4.1 RECEIVED 20 MEQ WITH K 4.7. MAGNESIUM 2 GM X1. SBP HIGH 80'S TO 140 WITH AGITATION.CI<2 AT 1000 DOBUTAMINE BEGAN AT 1100 WITH CI>2.MVO2 61-66. PADS LOW TWENTIES,CVP LOW TEENS. CT DRAINAGE 10-50ML/HR. DSGS REMAIN D+I. EXTREMITIES COOL TO TOUCH. WEAK PALP PP. JP DRAINED 30 ML SANGUINOUS DRAINAGE AT 0900. HCT 31. VENODYNES AND SC HEPARIN PER DR. .\n RESP: PO2 68 FIO2 ^ TO 70% AND PEEP ^ TO 12. REPEAT ABG PO2 86. ABG AND VENT SETTINGS PER FLOW. SUCTIONED FOR A SMALL AMOUNT OF THICK BLOOD TINGED SPUTUM X1. CXR REVEALS WET-HOPE TO IMPROVE WITH IV LASIX GTT.BS COURSE TO CLEAR UPPER, DIMINISHED BIBASILAR. NO CHEST TUBE LEAK NOTED THIS SHIFT.\n NEURO: MAE NOT TO COMMAND, PROPOFOL ^ FROM 25 MCQ TO 40 MCQ WITH AGITATION AND HTN. PERL, TO REMAIN SEDATED AND INTUBATED UNTIL FLUID REMOVED.\n GI: +PLACEMENT OF OGT, ABD DISTENDED NOT AS SOFT AS LAST NIGHT. + BOWEL SOUNDS-HYPOACTIVE. NO STOOL. CARAFATE AND ZANTAC GIVEN. 75 ML BROWN DRAINAGE NOTED.\n GU: RECEIVED 10 MG IV LASIX WITH BRISK 840 ML DIURESIS, IV LASIX GTT STARTED AT 2 MG ^ TO 3 MG AT 1530 DUE TO UO <100ML/HR. GOAL 100-150 ML /HR. CREAT WNL.\n ID: RECEIVED VANCO AT 0830. WBC 10. AFEBRILE.\n ENDO: INSULIN GTT DC'D AT 1100. 1400 GLUCOSE 95.\n PAIN: 2 MG MORPHINE PRIOR TO MOVEMENT OR CHANGE IN VS.\n SKIN: INTACT- NOTED BRUISING OF LEFT ANKLE WITH EDEMA.\n SOCIAL: DAUGHTER INTO VISIT ASKING QUESTIONS. UPDATED A STO PLAN.\nA: CI IMPROVED WITH DOBUTAMINE,CXR WET, DIURESING WITH LASIX GTT, PO2 ^ WITH ^ PEEP AND FIO2, ^ AGITATION WITH LIGHTENING ,\nP: MONITOR COMFORT, HR AND RYTHYM, SBP-USE LEVO IF NEED TO SUPPORT BP, CI-CONTINUE DOBUTAMINE, MVO2, CT DRAINAGE, DSGS, PP, RESP STATUS-WEAN FIO2 AND PEEP, NEURO STATUS-CONTINUE PROPOFOL-?PRECEDEX WHEN ABLE TO WEAN, I+O-CONTINUE LASIX GTT GOAL UO 100-150 ML/HR, LABS PENDING. AS PER ORDERS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2176-04-20 00:00:00.000",
"description": "Report",
"row_id": 1647219,
"text": "Resp care\n\nFio2 to 70% and peep to 12 after am abg with pao2 of 68. Pao2 improved on subsqueint abg's. Cxr being read as pulmonary edema. Bs are generally clear. Suctioning scant white sputum.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2176-04-21 00:00:00.000",
"description": "Report",
"row_id": 1647220,
"text": "Resp Care: Pt continues on mechanical ventilation: AC 450x18 60%+10. Most recent ABG: 7.45/38/103/27/2. LS diminished bilaterally. Pt suctioned for small amounts of blood-tinged secretions. Albuterol MDI given as ordered. RSBI not done secondary to high oxygen and PEEP requirements. PLAN: continue mechanical ventilation. Wean as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2176-04-21 00:00:00.000",
"description": "Report",
"row_id": 1647221,
"text": "NEURO: sedated on propofol. opens eyes, MAE, PERRL. not following commands but becomes with any stimulation. treated with morphine IV for pain with turning/moving. ?need precedex for extubation.\nCV: sinus rhythm 80's few PVC noted overnoc. continues on dobutamine, lasix gtts, diureseing well, weight down, -600 since midnoc. CI>2 and CO>4 by thermodilution. sov2 70. a and v wires in place both sense and pace, a demand some pacing spikes noted so sensitivity turned up, resolved. sbp >100 map>60 so no need to start levo. warm and dry +palp pedal pulses.\nRESP: remains orally intubated PEEP and fio2 weaned overnoc with good oxygenation on abg. PEEP 10, fio2 50. getting alkalotic from diuresis. lungs clear with diminished bases bilat. suctioned for scant yellow thick secretions. chest tubes with serosang, drainage slowing overnoc. no leak or crepitus.\nGI/GU: abd obese, +bowel sounds- hypoactive. OGT draining coffee grounds-->brown drainage. +placement. foley with clear yellow urine.\nENDO: CVICU RISS\nID: vanco\nSKIN: sternal incision with operative dressing intact. mediastinal chest tube site clean, no drainage dsd changed. LLE with hemovacscant sang drainage, steristrips intact dsd changed and ace re-wrapped. back and buttocks intact.\nA/P: continue to monitor cv, resp. continue diuresis. to remain intubated until fluid balance improves. ?need precedex to extubate. ?need diamox for matabolic alkalosis. ?nutrition consult.\n"
},
{
"category": "Nursing/other",
"chartdate": "2176-04-21 00:00:00.000",
"description": "Report",
"row_id": 1647222,
"text": "Respiratory Care:\nPt extubated to a 50% cool neb plus 4L/M NC Sat = 94% HR = 99,\nRR = 22, BP = 129/56. Seems to be OK at present.\n"
},
{
"category": "Nursing/other",
"chartdate": "2176-04-21 00:00:00.000",
"description": "Report",
"row_id": 1647223,
"text": " 7a-7p\nneuro: received sedated on propofol, not following commands; now rouses to voice, oriented x2 (reoriented to time), follows commands, mae, good pain control w/ morphine 1mg ivp q1-2h\n\ncv: sr 85-97 no ectopy, sbp 95-140, ntg gtt to keep map<90/sbp<120, ci 2.1-2.6, dobutamine gtt weaned off, swan left in place md, cvp 7-15, pad 17-25, ct draining small/moderate amts s/s drainage, max temp 38.2\n\nresp: lungs cta, dim to left base, extubated at 1430 to nc 4L & face tent at 50%, now sats >95% on 5L nc & face tent 70%, strong non-productive cough, w/ extubation pt expectorated large bloody/mucoid sputum (md aware, no further bleeding noted), is to 250ml\n\ngi: abdomen soft/distended, hypoactive bowel sounds, tolerating ice chips, fingersticks ssri\n\ngu: foley to gravity, copious diuresis this am w/ lasix gtt, lasix gtt weaned off & pt continues to autodiurese, pt currently -3L for day\n\nassess: stable\n\nplan: start po metoprolol, wean ntg as tolerated to keep sbp<120, map<90, pulmonary toilet, deline and transfer to 6 in am\n"
},
{
"category": "ECG",
"chartdate": "2176-04-26 00:00:00.000",
"description": "Report",
"row_id": 192589,
"text": "Sinus rhythm. Left anterior fascicular block. Non-specific ST-T wave changes.\nCompared to the previous tracing of Q-T interval is no longer\nprolonged.\n\n"
},
{
"category": "ECG",
"chartdate": "2176-04-25 00:00:00.000",
"description": "Report",
"row_id": 192590,
"text": "Sinus rhythm\nLeft anterior fascicular block\nAnterolateral T wave changes are nonspecific\nQT interval prolonged for rate\nSince previous tracing of , QT interval prolonged, T wave abnormalities\nmore marked\n\n"
},
{
"category": "ECG",
"chartdate": "2176-04-20 00:00:00.000",
"description": "Report",
"row_id": 192591,
"text": "Sinus rhythm. Left anterior fascicular block. Compared to the previous\ntracing pacing is no longer seen.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2176-04-19 00:00:00.000",
"description": "Report",
"row_id": 192592,
"text": "Atrial paced rhythm. Compared to the previous tracing of pacing\nis new.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2176-04-16 00:00:00.000",
"description": "Report",
"row_id": 192593,
"text": "Sinus bradycardia\nLeft anterior fascicular block\nPossible anterior myocardial infarction - age undetermined\nInferior/lateral T changes may be due to ischemia\nNo previous tracing available for comparison\n\n"
}
] |
91,053 | 144,816 | This is a 76 year old male with IPF on prednisone and azathioprine, Bactrim PPX, exertional hypoxia, AS with LVH, AAA, and pulmonary HTN, who was admitted for increased SOB likely due to an exacerbation of his underlying pulmonary fibrosis. . #. SOB- He was admitted to the ICU The patient has end stage pulmonary fibrosis on 5L of NC at home and therefore has poor respiratory functional reserve. The patient has had several CXRs this admission which do not show any signs of infection. It is also likely that his mild leukocytosis was due to an increase in his steroid dosing. His SOB this admission is likely secondary to an IPF exacerbation which responded to increased steroid dosing with a 3 day burst of prednisone 60mg that was decreased down to his home prednisone 20mg dose prior to discharge. He was started on antibiotics on admission to cover a hospital acquired pneumonia and he was continued on his empiric antibiotics despite minimal evidence of infection given that he has poor baseline pulmonary reserve. He therefore was continued on levofloxacin, linezolid, and cefepime to complete an 8 day course at home. Linezolid was chosen after the patient developed an erythemic eruption on his chest and back while being dosed with vancomyin in the ED. He was continued on his home azathioprine and bactrim prohylaxis. He was set up for home PT and home O2 of Liters with a face mask upon discharge. . #. Thrombocytopenia: Felt to be secondary to PPI. Resolved since patient has been switched to H2 blocker. . #. Pancreatic ductal dilation: Per a prior discharge summary, he should be scheduled for an outpatient CT abd/pelvis for further evaluation and monitoring. . #. Aortic Stenosis: It does not seem like his aortic stenosis is contributing to his current symptoms. Continued home ASA and lasix. . #. Anemia- His hematocrit has drifted down from 40 earlier this month to 38 on admission. He would likely benefit from having as high a hematocrit as possible to give him maximal oxygen carrying capacity in the setting of his chronic hypoxia. Continue to monitor closely as an outpatient. . #. Anxiety - When the patient develops anxiety, he becomes short of breath, tachypneic, and tachycardic. It was noted that he responded well to lorazepam 0.5mg PRN which relieved his anxiety and improved his oxygen saturation. He was discharged with a new prescription for lorazepam 0.5mg q8 PRN. . #. Access: Right sided PICC placed . #. Emergency Contact: wife- . #. Code: Confirmed DNR/DNI | IMPRESSION: Advanced interstitial pattern bilaterally consistent with diagnosis of idiopathic pulmonary fibrosis. There existed already at that time rather advanced diffuse bilateral interstitial process suggesting the diagnosis of idiopathic pulmonary fibrosis. There are extensive bilateral reticular interstitial markings, compatible with interstitial fibrosis, similar compared to prior. Atelectasis at the right lung base. Additionally, there is mild opacification at the right lung base, which could be dependent atelectasis; however, cannot exclude focal area of consolidation. IMPRESSION: New right PICC with tip in low SVC in satisfactory position. Bilateral interstitial fibrosis. FINDINGS: The new right PICC is with tip in the lower SVC in satisfactory position. There pleural effusions or pneumothorax. COMPARISON: Compared to chest radiograph from . The findings are described in the accompanying report making the diagnosis of rather advanced interstitial fibrosis. EXAMINATION: Single frontal chest radiograph. New right PICC placement. The lung parenchyma is unchanged with diffuse interstitial prominence, compatible with known interstitial lung disease now with superimposed left lower lobe consolidation compatible with pneumonia. FINDINGS: PA and lateral chest views were obtained with patient in upright position. FINDINGS: There is new interval consolidation of the left lobe, which could be atelectasis; however, cannot exclude pneumonia, or pleural effusion. COMPARISONS: and CT from . Comparison is first made with the next preceding AP single view chest examination of . Sinus tachycardia. Cardiomediastinal and hilar contours are unchanged. Occasional atrial premature beats. Otherwise, no change in known chronic interstitial lung disease and left lower lobe pneumonia. Evaluate for worsened lung process. Right bundle-branchblock. Pulmonary vascularity is normal. No new major pleural effusions. TECHNIQUE: Portable upright chest radiograph, single view. New opacity at the left lung base, concerning for pneumonia in appropriate clinical setting; however, atelectasis can have a similar appearance. The lateral and posterior pleural sinuses are free. A previous chest CT of is also reviewed. IMPRESSION: 1. Evaluate for pneumonia. INDICATION: 76-year-old male patient with IPF and worsened pulmonary status. Comparison is extended to multiple previous chest examinations beginning with . No pneumothorax in the apical area. No evidence of new discrete parenchymal infiltrates. Evaluate position. 3. The process may have increased slightly, but again there is no evidence of new discrete additional infiltrates. 1:15 PM CHEST (PA & LAT) Clip # Reason: Evaluation of worsened L lung process Admitting Diagnosis: PNEUMONIA MEDICAL CONDITION: 76 year old man with IPF and worsened pulmonary status REASON FOR THIS EXAMINATION: Evaluation of worsened L lung process FINAL REPORT TYPE OF EXAMINATION: Chest PA and lateral. 2:39 AM CHEST (PORTABLE AP) Clip # Reason: ?PNA MEDICAL CONDITION: 76 year old man with SOB, h/o pulm fibrosis REASON FOR THIS EXAMINATION: ?PNA FINAL REPORT HISTORY: 76-year-old man with shortness of breath, and history of pulmonary fibrosis. FINAL REPORT INDICATION: Patient is a 76-year-old male with pneumonia. 2. Compared to the previous tracing of the rate has increased. There is no evidence of pneumothorax. LINE PLACEMENT Clip # Reason: R picc 48cm Admitting Diagnosis: PNEUMONIA MEDICAL CONDITION: 76 year old man with pneumonia REASON FOR THIS EXAMINATION: R picc 48cm WET READ: IPf WED 12:24 AM Tip of PICC line at the cavoatrial junction. 10:15 PM CHEST PORT. | 4 | [
{
"category": "Radiology",
"chartdate": "2177-06-24 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1137440,
"text": " 1:15 PM\n CHEST (PA & LAT) Clip # \n Reason: Evaluation of worsened L lung process\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with IPF and worsened pulmonary status\n REASON FOR THIS EXAMINATION:\n Evaluation of worsened L lung process\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest PA and lateral.\n\n INDICATION: 76-year-old male patient with IPF and worsened pulmonary status.\n Evaluate for worsened lung process.\n\n FINDINGS: PA and lateral chest views were obtained with patient in upright\n position. Comparison is first made with the next preceding AP single view\n chest examination of . No significant interval change can be\n identified, thus no evidence of rapidly progressing processes or new discrete\n infiltrates. Comparison is extended to multiple previous chest examinations\n beginning with . There existed already at that time rather\n advanced diffuse bilateral interstitial process suggesting the diagnosis of\n idiopathic pulmonary fibrosis. The process may have increased slightly, but\n again there is no evidence of new discrete additional infiltrates. The\n lateral and posterior pleural sinuses are free. No pneumothorax in the apical\n area. A previous chest CT of is also reviewed. The findings\n are described in the accompanying report making the diagnosis of rather\n advanced interstitial fibrosis.\n\n IMPRESSION: Advanced interstitial pattern bilaterally consistent with\n diagnosis of idiopathic pulmonary fibrosis. No evidence of new discrete\n parenchymal infiltrates. No new major pleural effusions.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2177-06-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1137260,
"text": " 2:39 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?PNA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with SOB, h/o pulm fibrosis\n REASON FOR THIS EXAMINATION:\n ?PNA\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 76-year-old man with shortness of breath, and history of pulmonary\n fibrosis. Evaluate for pneumonia.\n\n TECHNIQUE: Portable upright chest radiograph, single view.\n\n COMPARISON: Compared to chest radiograph from .\n\n FINDINGS:\n\n There is new interval consolidation of the left lobe, which could be\n atelectasis; however, cannot exclude pneumonia, or pleural effusion.\n Additionally, there is mild opacification at the right lung base, which could\n be dependent atelectasis; however, cannot exclude focal area of consolidation.\n There are extensive bilateral reticular interstitial markings, compatible with\n interstitial fibrosis, similar compared to prior. There is no evidence of\n pneumothorax.\n\n IMPRESSION:\n 1. New opacity at the left lung base, concerning for pneumonia in appropriate\n clinical setting; however, atelectasis can have a similar appearance.\n 2. Atelectasis at the right lung base.\n 3. Bilateral interstitial fibrosis.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2177-06-24 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1137508,
"text": " 10:15 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: R picc 48cm\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with pneumonia\n REASON FOR THIS EXAMINATION:\n R picc 48cm\n ______________________________________________________________________________\n WET READ: IPf WED 12:24 AM\n Tip of PICC line at the cavoatrial junction.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient is a 76-year-old male with pneumonia. New right PICC\n placement. Evaluate position.\n\n EXAMINATION: Single frontal chest radiograph.\n\n COMPARISONS: and CT from .\n\n FINDINGS: The new right PICC is with tip in the lower SVC in satisfactory\n position. The lung parenchyma is unchanged with diffuse interstitial\n prominence, compatible with known interstitial lung disease now with\n superimposed left lower lobe consolidation compatible with pneumonia. There\n pleural effusions or pneumothorax. Cardiomediastinal and hilar contours are\n unchanged. Pulmonary vascularity is normal.\n\n IMPRESSION:\n New right PICC with tip in low SVC in satisfactory position. Otherwise, no\n change in known chronic interstitial lung disease and left lower lobe\n pneumonia.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2177-06-23 00:00:00.000",
"description": "Report",
"row_id": 233712,
"text": "Sinus tachycardia. Occasional atrial premature beats. Right bundle-branch\nblock. Compared to the previous tracing of the rate has increased.\n\n"
}
] |
69,370 | 125,185 | He was taken to interventional radiology, where an attempt was made to find and embolize the vessel leading to the bleeding. During the course of the procedure he received 27+ units of packed cells and additional units of FFP, cryoprecipitate and platelets. He was found to have extravasation of contrast from the GDA and a duodenal branch of the SMA. Both were coiled to stasis during the procedure and there was no evidence of further extravasation. The L gastric artery was also embolized with gelfoam. He was taken to the MICU afterwards. While in the MICU, he again became hypertensive and continued to have blood come out of his PEG tube and his flexi-seal tube. He was taken emergently to the operating room. While in the operating room, he received an additional unit of packed red cells, but was found to have an intra-operative hematocrit around thirty, so no more units were given. During the course of the exploratory laparotomy, he was found to have a bleeding duodenal ulcer which was oversewn. There were no other sources of bleeding identified and he was closed primarily and taken to the surgical ICU. His post-operative was uncomplicated initially. His hematocrit was stable, he passed some small amounts of melanotic stool post-operatively, but these resolved by POD 1. His trauma line was discontinued on POD 1 as his hematocrit had been stable, and he was transferred out of the SICU on POD 2. His tube feeds through his g-tube were restarted on POD 3 early in the AM. At some point around 7-8am on POD 3 (), he had a large amount of emesis which appeared very similar to tube feed material. He had immidiate respiratory distress and was coughing copiously. He was transferred back to the SICU and he was re-intubated. He had a bronchoscopy which showed a small amounts of fluid in the lungs and erythema consistent with pneumonitis. He was placed on CMV and began having increasing FiO2 and PEEP requirements to maintain even modest PaO2 in the 50s. By POD 4, he was requiring FiO2 of 100% and high PEEP settings up to 20cmH2o, and he was also started on inhaled nitric oxide to attempt to improve his oxygenation. As POD 4 went on, he continued to have very poor PaO2 and was also requiring increasing levels of vasopressors to maintain his systolic pressures adequately. His lactate, which had been 1.8 on and 5.7 a few hours after the aspiration, had now climbed to 11.3, and the decision was made to place the patient on ECMO to attempt to improve his oxygenation. He continued to have PaO2 in the 50s and 40s and was eventually maxed out on norepinepherine, vasopression and neosynepherine. His lactate rose to 23.3 and he began to have episodes of ventricular fibrillation. A code was called during his first episode of ventricular fibrillation but was shortly cancelled after two rounds of epinepherine, bicarbonate and shocks did nothing to alter his heart rhythm. Compressions were not started as the patient was already on ECMO at the time of the code. At roughly 1145pm on , the decision was made to make the patient comfort measures only and he expired shortly thereafter at 0035 . | Right internal jugular, check placement. Having achieved this, the catheter was withdrawn from the celiac origin and brought inferiorly into the superior mesenteric artery. There is now a new right internal jugular approach central venous line that terminates in similar position as the subclavian line. Injection of a small volume of contrast at this point no longer demonstrated active extravasation; however, we are concerned inflow from the additional branch to the GDA so this was cannulated using a combination of the microcatheter and wire and additional larger coils and gelfoam slurry were placed in this branch extending up into the origin of the gastroduodenal artery from the common hepatic. Right subclavian catheter tip is in the mid SVC. Mild (1+) mitral regurgitation is seen. Superior mesenteric artery angiography. Right femoral arterial access. Selective GDA angiography. A previously identified NG line is seen unchanged and reaches well below the diaphragm. The inner portion was removed along with nitinol wire and wire was advanced up into the IVC. With some manipulation, we successfully cannulated the inferior pancreaticoduodenal artery, which continued to (Over) 11:31 AM MESSENERTIC Clip # Reason: please embolize bleeder Admitting Diagnosis: UPPER GI BLEED Contrast: OPTIRAY Amt: 214 FINAL REPORT (Cont) demonstrate active extravasation. (Over) 11:31 AM MESSENERTIC Clip # Reason: please embolize bleeder Admitting Diagnosis: UPPER GI BLEED Contrast: OPTIRAY Amt: 214 FINAL REPORT (Cont) Hypoxia,Height: (in) 68Weight (lb): 155BSA (m2): 1.84 m2BP (mm Hg): 96/61HR (bpm): 96Status: InpatientDate/Time: at 14:59Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: SalineTechnical Quality: SuboptimalINTERPRETATION:Findings:This study was compared to the report of the prior study (images notavailable) of .LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Normal LV cavity size. A right subclavian approach central venous line can be identified and appears unchanged in comparison with the previous study. Celiac angiography. Mild-moderate global left ventricularhypokinesis. Left gastric Gelfoam embolization. The aortic root is mildly dilated at the sinus level. From that point, an STC microcatheter and Transend wire were advanced into the common hepatic artery and then to the gastroduodenal artery. Suboptimal image quality - ventilator.Conclusions:The left atrium is normal in size. There is mild pulmonary artery systolichypertension. Mild (1+) MR.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Left ventricular function. Using a combination of palpatory, fluoroscopic and ultrasound guidance, the right femoral artery was accessed with a micropuncture needle. Left gastric arteriography. Contrast was injected via the side arm to confirm adequate positioning with the point of entry overlying the femoral head. The catheter was removed. An 018 nitinol wire was passed via the needle which was removed and exchanged for a 4F micropuncture sheath, the inner portions of which and the nitinol wire were removed and exchanged for wire. AP single view of the chest has been obtained with patient in supine position. A nitinol wire was advanced via the needle which was removed and exchanged for a micropuncture sheath. As per the request of the MICU team, the right femoral arterial sheath was left in situ as an arterial line access point. 11:31 AM MESSENERTIC Clip # Reason: please embolize bleeder Admitting Diagnosis: UPPER GI BLEED Contrast: OPTIRAY Amt: 214 ********************************* CPT Codes ******************************** * EMBO NON NEURO NON-TUNNELED * * INITAL 3RD ORDER ABD/PEL/LOWER -59 DISTINCT PROCEDURAL SERVICE * * INITAL 2ND ORDER ABD/PEL/LOWER -59 DISTINCT PROCEDURAL SERVICE * * VISERAL SEL/SUPERSEL A-GRAM -59 DISTINCT PROCEDURAL SERVICE * * VISERAL SEL/SUPERSEL A-GRAM -59 DISTINCT PROCEDURAL SERVICE * * EA ADD'L VESSEL AFTER BASIC A- -59 DISTINCT PROCEDURAL SERVICE * * EA ADD'L VESSEL AFTER BASIC A- -59 DISTINCT PROCEDURAL SERVICE * * TRANCATHETER EMBOLIZATION * **************************************************************************** MEDICAL CONDITION: 63 year old man with . | 5 | [
{
"category": "Echo",
"chartdate": "2119-10-10 00:00:00.000",
"description": "Report",
"row_id": 103452,
"text": "PATIENT/TEST INFORMATION:\nIndication: Chronic lung disease. Left ventricular function. Hypoxia,\nHeight: (in) 68\nWeight (lb): 155\nBSA (m2): 1.84 m2\nBP (mm Hg): 96/61\nHR (bpm): 96\nStatus: Inpatient\nDate/Time: at 14:59\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: Saline\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the report of the prior study (images not\navailable) of .\n\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV cavity size. Mild-moderate global left ventricular\nhypokinesis. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Mild global RV free wall hypokinesis.\n\nAORTA: Mildy dilated aortic root.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. Mild (1+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR. Mild\nPA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: Very small pericardial effusion. No echocardiographic signs of\ntamponade.\n\nGENERAL COMMENTS: Contrast study was performed with 1 iv injection of 8 ccs of\nagitated normal saline at rest. Suboptimal image quality - ventilator.\n\nConclusions:\nThe left atrium is normal in size. The left ventricular cavity size is normal.\nThere is mild to moderate global left ventricular hypokinesis (LVEF = 40 %).\nThe right ventricle is borderline dilated with mild global free wall\nhypokinesis. The aortic root is mildly dilated at the sinus level. The aortic\nvalve leaflets (3) appear structurally normal with good leaflet excursion and\nno aortic stenosis or aortic regurgitation. The mitral valve leaflets are\nstructurally normal. Mild (1+) mitral regurgitation is seen. The tricuspid\nvalve leaflets are mildly thickened. There is mild pulmonary artery systolic\nhypertension. There is a very small pericardial effusion. There are no\nechocardiographic signs of tamponade.\n\nAgitated saline contrast study at rest revealed no evidence of an intracardiac\nshunt.\n\nCompared with the prior report (images unavailable) of , ventricular\ndysfunction is new.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-10-05 00:00:00.000",
"description": "NON-TUNNELED",
"row_id": 1252516,
"text": " 11:31 AM\n MESSENERTIC Clip # \n Reason: please embolize bleeder\n Admitting Diagnosis: UPPER GI BLEED\n Contrast: OPTIRAY Amt: 214\n ********************************* CPT Codes ********************************\n * EMBO NON NEURO NON-TUNNELED *\n * INITAL 3RD ORDER ABD/PEL/LOWER -59 DISTINCT PROCEDURAL SERVICE *\n * INITAL 2ND ORDER ABD/PEL/LOWER -59 DISTINCT PROCEDURAL SERVICE *\n * VISERAL SEL/SUPERSEL A-GRAM -59 DISTINCT PROCEDURAL SERVICE *\n * VISERAL SEL/SUPERSEL A-GRAM -59 DISTINCT PROCEDURAL SERVICE *\n * EA ADD'L VESSEL AFTER BASIC A- -59 DISTINCT PROCEDURAL SERVICE *\n * EA ADD'L VESSEL AFTER BASIC A- -59 DISTINCT PROCEDURAL SERVICE *\n * TRANCATHETER EMBOLIZATION *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with . Posterior duodenal bulb artery bleeding\n REASON FOR THIS EXAMINATION:\n please embolize bleeder\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 63-year-old man with posterior duodenal bulb artery bleeding,\n please embolize bleeder.\n\n PHYSICIANS: Dr. Mhuircheartaigh (radiology fellow), Dr. \n , Dr (radiology attending) who was present throughout and\n supervised the procedure.\n\n MEDICATIONS: The patient was intubated and sedated prior to transfer to the\n angiographic suite, please see dedicated ICU note for additional information.\n\n RADIATION: 2900 mGy, 94 minutes fluoroscopy time.\n\n CONTRAST: 214 cc of Optiray 320.\n\n PROCEDURES:\n 1. Right femoral arterial access.\n 2. Celiac angiography.\n 3. Selective GDA angiography.\n 4. Embolization of a branch of the GDA which demonstrated active\n extravasation. In addition, embolization of the GDA was performed.\n 5. Left gastric arteriography.\n 6. Left gastric Gelfoam embolization.\n 7. Superior mesenteric artery angiography.\n 8. Embolization of a bleeding duodenal branch of the SMA.\n 9. Right femoral angiography demonstrating appropriate placement of a 5\n French femoral sheath.\n 10. Placement of a 9 French trauma line into the left common femoral vein.\n\n PROCEDURE DETAILS:\n\n Informed patient consent was waived by the referring physician in view of the\n (Over)\n\n 11:31 AM\n MESSENERTIC Clip # \n Reason: please embolize bleeder\n Admitting Diagnosis: UPPER GI BLEED\n Contrast: OPTIRAY Amt: 214\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n patient's need for emergent interventions. The patient was brought to\n angiographic suite, intubated and sedated and was placed supine on the\n angiographic table. A preprocedure timeout was performed using three patient\n identifiers.\n\n Using a combination of palpatory, fluoroscopic and ultrasound guidance, the\n right femoral artery was accessed with a micropuncture needle. An 018 nitinol\n wire was passed via the needle which was removed and exchanged for a 4F\n micropuncture sheath, the inner portions of which and the nitinol wire were\n removed and exchanged for wire. This was advanced up into the\n abdominal aorta. The micropuncture sheath was exchanged for a 5 French\n -Tip sheath, the side arm of which was kept continuously flushed with\n heparinized saline throughout procedure. catheter was advanced\n over the wire, formed in the aortic arch and brought down to\n successfully cannulate the origin of the celiac artery.\n A hand injection of contrast at this point demonstrated active extravasation\n into the duodenum from a branch of gastroduodenal artery. From that point,\n an STC microcatheter and Transend wire were advanced into the common hepatic\n artery and then to the gastroduodenal artery. With some difficulty, we\n manipulated our wire and microcatheter into the branch which was actively\n extravasating into duodenum. Having achieved this, we rapidly placed two 1 x\n 0.5 cm straight coils into this branch. Injection of a small volume of\n contrast at this point no longer demonstrated active extravasation; however,\n we are concerned inflow from the additional branch to the GDA so this was\n cannulated using a combination of the microcatheter and wire and additional\n larger coils and gelfoam slurry were placed in this branch extending up into\n the origin of the gastroduodenal artery from the common hepatic.\n Approximately, two-thirds of gastroduodenal artery were coiled with only a\n small residual component of the vessel remaining patent at its origin. Having\n achieved this, the microcatheter and wire were withdrawn and repeat celiac\n angiography demonstrated no further extravasation. Because there was concern\n of gastric fundal bleeding on the EGD, we selectively cannulated the left\n gastric artery using our microcatheter and microwire system. An angiographic\n run at this point showed no definite extravasation, but possibly hyperemia\n around the gastroesophageal junction, therefore, we elected to perform Gelfoam\n embolization at this level.\n\n Having achieved this, the catheter was withdrawn from the celiac\n origin and brought inferiorly into the superior mesenteric artery. An\n angiographic run performed at this point demonstrated active extravasation\n from a branch to the duodenal region, feeding into the same area that had been\n bleeding on our celiac interrogation. Our STC microcatheter could not\n successfully cannulated the vessel, therefore, we exchanged for a Merit\n Maestro microcatheter and wire. With some manipulation, we successfully\n cannulated the inferior pancreaticoduodenal artery, which continued to\n (Over)\n\n 11:31 AM\n MESSENERTIC Clip # \n Reason: please embolize bleeder\n Admitting Diagnosis: UPPER GI BLEED\n Contrast: OPTIRAY Amt: 214\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n demonstrate active extravasation. Additional coils and gelfoam slurry were\n placed along the vessel. Following completion of this maneuver, superior\n mesenteric angiography did not demonstrate any further extravasation. The\n catheter was removed. As per the request of the MICU team, the right femoral\n arterial sheath was left in situ as an arterial line access point. Contrast\n was injected via the side arm to confirm adequate positioning with the point\n of entry overlying the femoral head.\n Following completion of the embolisation procedure the patient remained on\n pressor support and had received over 30 units of packed red cells. The\n patient was transferred to the ICU in a critical condition.\n\n PLACEMENT OF LEFT COMMON FEMORAL VEIN TRAUMA LINE\n\n The MICU team in addition requested that we place a left common femoral trauma\n venous line for access. Once again, a preprocedure timeout was performed\n using three patient identifiers. The skin in the left groin had already been\n prepped and draped in usual sterile fashion. Using ultrasound guidance, a\n micropuncture needle was advanced into the left common femoral vein. A\n nitinol wire was advanced via the needle which was removed and exchanged for a\n micropuncture sheath. The inner portion was removed along with nitinol wire\n and wire was advanced up into the IVC. Serial dilatation was\n performed with subsequent placement of a 14 French peel-away sheath and a\n triple-lumen trauma line was advanced over the wire via the peel-away sheath,\n the tip lies in the left common iliac vein. All three lumens were aspirated\n and flushed without difficulty. The catheter was secured to the skin with a\n silk suture and a sterile dressing was applied. There were no immediate\n post-procedure complications.\n\n IMPRESSION:\n 1. Rapid active contrast extravasation from a branch of the gastroduodenal\n artery and from a duodenal branch of the superior mesenteric artery. Both\n vessels have been coiled to stasis with no residual extravasation on\n completion angiography. A total of two 0.5 x 0 coils, fifteen 1 cm x 2 mm\n coils and two 2 cm x 3 mm coils were used in this procedure.\n 2. Gelfoam embolization of the left gastric artery as a potential gastric\n source of bleeding.\n 3. Right femoral arterial sheath has been left in situ, this is a 5 French\n sheath which will need to be continuously flushed with heparinized saline\n while in use.\n 4. Placement of a triple lumen trauma line in the left common femoral vein.\n (Over)\n\n 11:31 AM\n MESSENERTIC Clip # \n Reason: please embolize bleeder\n Admitting Diagnosis: UPPER GI BLEED\n Contrast: OPTIRAY Amt: 214\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-10-09 00:00:00.000",
"description": "BY SAME PHYSICIAN",
"row_id": 1252951,
"text": " 12:27 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: Line placement\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with central line\n REASON FOR THIS EXAMINATION:\n Line placement\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE FRONTAL VIEW OF THE CHEST\n\n REASON FOR EXAM: Assess line.\n\n Right subclavian catheter tip is in the mid SVC. There is no evident\n pneumothorax. Moderate right and a small left pleural effusion have increased\n with increasing associated adjacent opacities. It could be atelectasis or\n pneumonia. ET tube is in standard position. NG tube tip is in the stomach.\n Cardiomediastinal contours are normal. There is persistent dilatation of\n small bowel loops visualized in the upper abdomen.\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-10-10 00:00:00.000",
"description": "BY DIFFERENT PHYSICIAN",
"row_id": 1253105,
"text": " 3:57 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: check placement\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with new line, R IJ\n REASON FOR THIS EXAMINATION:\n check placement\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: 63-year-old male patient with new line. Right internal jugular,\n check placement. Contact , .\n\n AP single view of the chest has been obtained with patient in supine position.\n Comparison is made with the next preceding portable chest examination with the\n patient in semi-erect position obtained 12 hours earlier during the same day.\n The patient remains intubated, the ETT terminating in the trachea 5 cm above\n the level of carina. The position is unchanged compared with the previous\n study. Multiple metallic cables overlying the upper chest. A right subclavian\n approach central venous line can be identified and appears unchanged in\n comparison with the previous study. There is now a new right internal jugular\n approach central venous line that terminates in similar position as the\n subclavian line. Unfortunately, the external cables are overlying the area so\n detail is difficult to see. As, however, there is no line structure lower\n than the carina, inappropriate advancement of the line is excluded. A\n previously identified NG line is seen unchanged and reaches well below the\n diaphragm. An additional line traverses the chest from the upper left to the\n lower right that must be external. Patient's heart size is unaltered;\n however, the previously described multiple patchy densities ascribed to\n aspirations have increased and are more confluenting. No pneumothorax is\n seen. Page to was placed at 4:50 p.m.\n\n"
},
{
"category": "ECG",
"chartdate": "2119-10-06 00:00:00.000",
"description": "Report",
"row_id": 297044,
"text": "Sinus rhythm. Non-specific ST-T wave changes. Compared to the previous\ntracing of T waves are more flattened. Otherwise, no significant\nchange.\n\n\n"
}
] |
29,458 | 165,088 | Patient is a 57 yo M w/ hx of hypercholesterolemia, asthma presenting after positive stress test found to have severe distal left main bifurcation disease. . #. CAD: Severe LMCA and ostial LAD and LCx disease seen on cardiac catheterization. Pt to have emergent CABG in am. No rest pain or sign of MI so no heparin O/N per CT - pre-op for CABG tomorrow - T & S, U/A, CXR - low dose B-blocker, to start after surgery when BP allows - NPO at midnight - monitor on telemetry . #. Pump: Mild systolic dysfunction with preserved EF on cardiac catheterization. Treatment of CAD as above . #. Rhythm: NSR, monitor on telemetry . #. Asthma: Stable with no active sx, cont. flovent inhaler . #. Hypothyroidism: Cont. outpatient dose of Levoxyl . #. FEN: NPO at midnight for CABG tomorrow . #. Access: PIV . #. PPx: to OR in am . #. Code: Full . #. Dispo: pending CABG and recovery . #. Contact: wife cell Underwent urgent cabg x2 on with Dr. .Transferred to the CVICU in stbale condition on phenylephrine and propofol drips.Extubated that afternoon and transferred to the floor on POD #1. Chest tubes and pacing wires removed without incident. Gently diuresed toward his preoperative weight. Cleared for discharge to home with services on POD #3. Pt. is to make all followup visits as per discharge instructions. | Generalized ST segment elevation and PR segmentdepression with PR segment elevation in lead aVR consistent with pericarditis.Compared to the previous tracing of atrial ectopy is absent. IMPRESSION: Stable mild post-operative widened mediastinum. There is mildsymmetric left ventricular hypertrophy. Trivial MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.GENERAL COMMENTS: A TEE was performed in the location listed above. There is mild regional leftventricular systolic dysfunction with mild anterior and anteroseptal wallhypokinesis. Mild regional LV systolic dysfunction.LV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior- hypo; mid anterior - hypo; basal anteroseptal - hypo; mid anteroseptal -hypo; anterior apex - hypo; septal apex - hypo; remaining LV segments contractnormally.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal descending aorta diameter. Zantac for prophylaxis.GU: adequate huo.SKin: intact: sternal dsg intact. Mild widespread ST segmentelevation of uncertain significance. Right ventricular chamber size and free wall motion are normal.There are simple atheroma in the descending thoracic aorta. The mediastinal drain the left chest tube is in expected position. Trivial mitral regurgitation is seen.POSTBYPASSLV systolic function and regional wall motion abnormalities remain unchangedfrom prebypass. Preoperative assessment.Status: InpatientDate/Time: at 10:00Test: TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.LEFT VENTRICLE: Mild symmetric LVH. Simple atheroma in descending aorta.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Post-operative widened mediastinum is stable. The remaining left ventricular segments contractnormally. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Small pneumopericardium is noted in the lateral view. Left ventricular function. Patient is post median sternotomy and CABG. Patient S/P CABG. Cardiac size is top normal. Sinus rhythm with an atrial premature beat. ekg nsr, no ectopy, rate 90s. There has been interval worsening of left lower atelectasis and less in right lower atelectasis. The cardiomediastinal silhouette is stable. No TEE related complications.Conclusions:PREBYPASSNo atrial septal defect is seen by 2D or color Doppler. There are small bilateral pleural effusions. The cardiomediastinal silhouette and pulmonary vessels are within normal limits and there is no significant pleural effusion (the extreme left CP angle is excluded from the study). DL DR. CI >2.5.Pacer sensing; no pacing required.Pulm: IS reinforced. filling pressures low, pad is 11, cvp is 9, ci 2.53. uo marginal, 35cc this hour, may need more volume. jr DR. This Swan-Ganz catheter tip is at the right ventricle outflow tract. There is persistent widened mediastinum with bulging of the right paramediastinal contour that still is worrisome for postsurgical hematoma. sternal and mediastinal dressings intact, small amts sang ct drainage, no air leak. coverage.Plan: de-line. The aortic valveleaflets (3) are mildly thickened. Cardiac size is normal. updateD: pt underwent CAbg x 2 today--L main - or uneventful-pt to vicu B intubated, on propofol-pt warmed-min ct drainage- pt reversed, weane dpropofol- work crazy x 2- added precedex--still woke agitated- extubated fast.pt groggy-yet c/o mod pain=percocet given prior to extub-and mso4 iv--added toradol for pain.plan: obtain pain relief. Normal sinus rhythm, rate 80. DR. SSRI instituted.ID: kefzol for periop. Portable AP chest radiograph compared to . The patient was undergeneral anesthesia throughout the procedure. breath sounds clear, decreased at bases, encouraged to deep breathe, incentive spirometer introduced, used but only achieved 250-300cc d/t to discomfort. The remaining study is also unchanged from prebypass. Clinical correlation is suggested. Allowing for slight motion-blurring and overlying soft tissues, the lungs appear well-inflated and clear. Possible pericarditis. feet warm, dp and pt pulses palp bilat, ace wrap inatct. New rounded opacity projects in the right lower lobe medially. mainataining spo2 99%, on 4l nc, decreased to 2l, with spo2 99%. Advance DAT and ADL's. Lobulation of the left mediastinal contours are unusual after surgery and might represent postsurgical hematoma. updateD: pt warm- min ct drainage- vvs- on no drips other than sedation. resp careweaned and extubated as per cardiac surgery fast track protocol.refer to flow sheet. The NG tube tip passes below the diaphragm, most likely terminating in the stomach. sbp stable in 100s, no pressors. Discoid atelectasis are in the left lower lobe. Pt. Pt. Pt. percocet given x 1 and morphine 2 mg x 1 for breakthrough pain. FINDINGS: Single bedside AP examination labeled "upright" with no comparisons on record. The mitralvalve leaflets are mildly thickened. alert and oriented, conversational, pain control is an issue. Otherwise,no significant change. re-assured that his vital signs are stable and that his labs are wnl and that we will manage his pain and make him as comfortable as possible.CV: aline dampening, therefore NBP recorded as well. I certifyI was present in compliance with HCFA regulations. calciulm rx with 2 gm ca gluc. Transfer to floor. Coronary artery disease. Increase in bibasilar atelectasis, worse in the left side. PATIENT/TEST INFORMATION:Indication: Chest pain. 1:42 PM CHEST PORT. Encourage use of IS. 2lNP.Explained the importance of deep breathing and repositioning.GI: taking pills with water. Overall increase in bilateral perihilar haziness might represent pulmonary edema. reversed, propofol to off-A: pt woke WILD..initially followed commands--then would not not--mae--extremely agitatedA: placed back on propofol intially 20 mcq--had to inc to 50.plan: obtain precedex for extubation Close attention to this area would be recommended to exclude the possibility of growing hematoma. LVEF~ 45%. Comparison is made with prior study . No cough. glucose up to 181, rx with 2 unit bolus and gtt started at 3 units. no n/v. This examination was performed at 11:30. There is no pneumothorax or substantial pleural effusion. Findings were discussed with Dr. at the time of the interpretation of the study. Left leg bruising from medial knee to thigh: ace bandage changed.Endo: insulin drip off for BS 75. able to push to 500cc volume. states that he knows he''s asking a lot of questions.Pt. No aortic regurgitation is seen. There is no pneumothorax or sizable pleural effusion. | 12 | [
{
"category": "Radiology",
"chartdate": "2194-03-03 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1000641,
"text": " 11:20 AM\n CHEST (PA & LAT) Clip # \n Reason: widened mediastinum post CT removal\n Admitting Diagnosis: CHEST PAIN;+ ETT\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with post CT removal, had AP / shows questionable widened\n mediastinum, reevaluate mediastinum\n REASON FOR THIS EXAMINATION:\n widened mediastinum post CT removal\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL VIEWS OF THE CHEST\n\n REASON FOR EXAM: Assess widened mediastinum described in prior study.\n\n Comparison is made with prior study performed at 20:00. This\n examination was performed at 11:30.\n\n Post-operative widened mediastinum is stable. There has been interval\n worsening of left lower atelectasis and less in right lower atelectasis. There\n are small bilateral pleural effusions. Patient is post median sternotomy and\n CABG. Small pneumopericardium is noted in the lateral view. Cardiac size is\n normal.\n\n IMPRESSION: Stable mild post-operative widened mediastinum. Increase in\n bibasilar atelectasis, worse in the left side.\n\n jr\n\n DR. \n"
},
{
"category": "Radiology",
"chartdate": "2194-02-28 00:00:00.000",
"description": "CHEST (PRE-OP AP ONLY)",
"row_id": 1000380,
"text": " 8:32 PM\n CHEST (PRE-OP AP ONLY) Clip # \n Reason: Evaluate for cardiopulm process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with CAD, preop for CABG in am\n REASON FOR THIS EXAMINATION:\n Evaluate for cardiopulm process\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE VIEW OF THE CHEST, \n\n HISTORY: 57-year-old man with CAD, preop for CABG in AM, ; evaluate\n for acute process.\n\n FINDINGS: Single bedside AP examination labeled \"upright\" with no comparisons\n on record. Allowing for slight motion-blurring and overlying soft tissues,\n the lungs appear well-inflated and clear. The cardiomediastinal silhouette\n and pulmonary vessels are within normal limits and there is no significant\n pleural effusion (the extreme left CP angle is excluded from the study).\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2194-03-01 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1000451,
"text": " 1:42 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: postop film- contact MD # if abnormal\n Admitting Diagnosis: CHEST PAIN;+ ETT\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man s/p urgent cabg x2\n REASON FOR THIS EXAMINATION:\n postop film- contact MD # if abnormal\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of a patient after urgent CABG.\n\n Portable AP chest radiograph compared to .\n\n The ET tube tip is 5 cm above the carina. This Swan-Ganz catheter tip is at\n the right ventricle outflow tract. The mediastinal drain the left chest tube\n is in expected position. The NG tube tip passes below the diaphragm, most\n likely terminating in the stomach. The cardiomediastinal silhouette is\n stable. Overall increase in bilateral perihilar haziness might represent\n pulmonary edema. Lobulation of the left mediastinal contours are unusual\n after surgery and might represent postsurgical hematoma. Close attention to\n this area would be recommended to exclude the possibility of growing hematoma.\n There is no pneumothorax or substantial pleural effusion.\n\n DL\n\n DR. \n"
},
{
"category": "Nursing/other",
"chartdate": "2194-03-02 00:00:00.000",
"description": "Report",
"row_id": 1643613,
"text": "Pt. alert and pleasant but very talkative. Asking many questions re: care, procedures, asking to be repositioned, wanting to know when pain meds are due. Pt. states that he knows he''s asking a lot of questions.\nPt. re-assured that his vital signs are stable and that his labs are wnl and that we will manage his pain and make him as comfortable as possible.\nCV: aline dampening, therefore NBP recorded as well. CI >2.5.\nPacer sensing; no pacing required.\nPulm: IS reinforced. Pt. able to push to 500cc volume. No cough. 2lNP.\nExplained the importance of deep breathing and repositioning.\nGI: taking pills with water. no n/v. Zantac for prophylaxis.\nGU: adequate huo.\nSKin: intact: sternal dsg intact. Left leg bruising from medial knee to thigh: ace bandage changed.\nEndo: insulin drip off for BS 75. SSRI instituted.\nID: kefzol for periop. coverage.\nPlan: de-line. Advance DAT and ADL's. Encourage use of IS. Transfer to floor.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2194-03-01 00:00:00.000",
"description": "Report",
"row_id": 1643609,
"text": "update\nD: pt warm- min ct drainage- vvs- on no drips other than sedation. reversed, propofol to off-\nA: pt woke WILD..initially followed commands--then would not not--mae--extremely agitated\nA: placed back on propofol intially 20 mcq--had to inc to 50.\n\nplan: obtain precedex for extubation\n"
},
{
"category": "Nursing/other",
"chartdate": "2194-03-01 00:00:00.000",
"description": "Report",
"row_id": 1643610,
"text": "resp care\nweaned and extubated as per cardiac surgery fast track protocol.refer to flow sheet.\n"
},
{
"category": "Nursing/other",
"chartdate": "2194-03-01 00:00:00.000",
"description": "Report",
"row_id": 1643611,
"text": "update\nD: pt underwent CAbg x 2 today--L main - or uneventful-pt to vicu B intubated, on propofol-pt warmed-min ct drainage- pt reversed, weane dpropofol- work crazy x 2- added precedex--still woke agitated- extubated fast.pt groggy-yet c/o mod pain=percocet given prior to extub-and mso4 iv--added toradol for pain.\nplan: obtain pain relief.\n"
},
{
"category": "Nursing/other",
"chartdate": "2194-03-01 00:00:00.000",
"description": "Report",
"row_id": 1643612,
"text": "ekg nsr, no ectopy, rate 90s. sbp stable in 100s, no pressors. filling pressures low, pad is 11, cvp is 9, ci 2.53. uo marginal, 35cc this hour, may need more volume. calciulm rx with 2 gm ca gluc. glucose up to 181, rx with 2 unit bolus and gtt started at 3 units. breath sounds clear, decreased at bases, encouraged to deep breathe, incentive spirometer introduced, used but only achieved 250-300cc d/t to discomfort. mainataining spo2 99%, on 4l nc, decreased to 2l, with spo2 99%. sternal and mediastinal dressings intact, small amts sang ct drainage, no air leak. feet warm, dp and pt pulses palp bilat, ace wrap inatct. alert and oriented, conversational, pain control is an issue. percocet given x 1 and morphine 2 mg x 1 for breakthrough pain.\n"
},
{
"category": "Radiology",
"chartdate": "2194-03-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1000583,
"text": " 7:57 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ?PTX, hemothorax, s/p tube removal\n Admitting Diagnosis: CHEST PAIN;+ ETT\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man pod1 s/p CABG, now s/p chest tube and mediastinal tube removal\n REASON FOR THIS EXAMINATION:\n ?PTX, hemothorax, s/p tube removal\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Assess for pneumothorax S/P tube removal. Patient S/P CABG.\n\n Comparison is made with prior study .\n\n There is no pneumothorax or sizable pleural effusion. There is persistent\n widened mediastinum with bulging of the right paramediastinal contour that\n still is worrisome for postsurgical hematoma. New rounded opacity projects in\n the right lower lobe medially. Cardiac size is top normal. Discoid\n atelectasis are in the left lower lobe.\n\n Findings were discussed with Dr. at the time of the interpretation of\n the study.\n\n\n DR. \n"
},
{
"category": "Echo",
"chartdate": "2194-03-01 00:00:00.000",
"description": "Report",
"row_id": 98939,
"text": "PATIENT/TEST INFORMATION:\nIndication: Chest pain. Coronary artery disease. Left ventricular function. Preoperative assessment.\nStatus: Inpatient\nDate/Time: at 10:00\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Mild symmetric LVH. Mild regional LV systolic dysfunction.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior\n- hypo; mid anterior - hypo; basal anteroseptal - hypo; mid anteroseptal -\nhypo; anterior apex - hypo; septal apex - hypo; remaining LV segments contract\nnormally.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal descending aorta diameter. Simple atheroma in descending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was under\ngeneral anesthesia throughout the procedure. No TEE related complications.\n\nConclusions:\nPREBYPASS\nNo atrial septal defect is seen by 2D or color Doppler. There is mild\nsymmetric left ventricular hypertrophy. There is mild regional left\nventricular systolic dysfunction with mild anterior and anteroseptal wall\nhypokinesis. LVEF~ 45%. The remaining left ventricular segments contract\nnormally. Right ventricular chamber size and free wall motion are normal.\nThere are simple atheroma in the descending thoracic aorta. The aortic valve\nleaflets (3) are mildly thickened. No aortic regurgitation is seen. The mitral\nvalve leaflets are mildly thickened. Trivial mitral regurgitation is seen.\n\nPOSTBYPASS\nLV systolic function and regional wall motion abnormalities remain unchanged\nfrom prebypass. The remaining study is also unchanged from prebypass.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2194-03-01 00:00:00.000",
"description": "Report",
"row_id": 279466,
"text": "Normal sinus rhythm, rate 80. Generalized ST segment elevation and PR segment\ndepression with PR segment elevation in lead aVR consistent with pericarditis.\nCompared to the previous tracing of atrial ectopy is absent. Otherwise,\nno significant change.\n\n"
},
{
"category": "ECG",
"chartdate": "2194-03-02 00:00:00.000",
"description": "Report",
"row_id": 279467,
"text": "Sinus rhythm with an atrial premature beat. Mild widespread ST segment\nelevation of uncertain significance. Possible pericarditis. No previous\ntracing available for comparison. Clinical correlation is suggested.\n\n\n"
}
] |
7,632 | 149,404 | He was subsequently taken for CT angiogram to assess for possible vascular abnormalities contributing to his bleed. The CT angiogram was suggestive of some venous dilatation in the area of the bleed. Given the CTA findings, he was taken for an angiogram urgently. The angiogram did not show any vascular malformations or abnormalities. In the interim, an A-line was placed for blood pressure control. Blood pressure medications were started to keep the systolic blood pressure less than 140. He received mannitol 50 q six hours. He received a Dilantin load. He also received platelets and DDAVP. After his angiogram, he was immediately taken to the Operating Room for evacuation of the right intraparenchymal hemorrhage. Consent was obtained from the family and the situation was explained. He underwent a right craniotomy with evacuation of the hemorrhage. He tolerated the procedure with no complications. Post procedure, his examination remained unremarkable. He had minimal movement of his extremities. His pupils remained 2.5 mm and unreactive. He did not appear to have a corneal or gag reflex initially. He received another dose of DDAVP at the end of the procedure. On postoperative day one, he was much more responsive. He opened his eyes to stimulation and started lifting his right lower extremity and arm to stimulation. He remained afebrile with stable vital signs during his course in the hospital. His platelet count and coagulopathy labs were normal. He remained in Intensive Care Unit for several days for close monitoring while he was intubated. Again, his course in the hospital remained uneventful. He was afebrile with stable vital signs. He received perioperative Ancef. Repeat CT scans, as well as postoperative CT scans showed good evacuation of the clot with minimal, if any, residual component. He was rapidly weaned off the Dilantin over 2-3 days. Serial CT scans performed during the wean showed no significant change. Ultimately, he was transferred to the floor for further care. He was extubated prior to transfer and tolerated the extubation well. He started following commands and moving his right extremities spontaneously. Over time, he started to move his left extremities as well, initially the leg more than the arm. Currently, he moves all four extremities at least to antigravity. Speech and _______ assessments were completed. Initially, he failed the bedside assessment but video esophageal studies showed that he was able to tolerate thickened and _____ thick food. He has since been placed on ________ solids and allowed to take p.o. intake. He does, however, display a significant left neglect. On over the night, he leaned to the right and banged his head against the railing of the bed. No significant trauma was induced. However, he did have slight drainage from his wound. Upon inspection, there was a dry thin layer of blood with no apparent wound dehiscence. He is being continued to be seen by Occupational Therapy and Physical Therapy for further help in strengthening. He has had good improvement. He has continued to do well. Ultimately, he is discharged to rehabilitation to further strengthen his extremities. He has remained stable and is currently ready for discharge to rehabilitation. He should follow-up with Dr. in two weeks with a repeat head CT prior to his appointment. He should follow-up with his primary care physician in one week for further assessment. He should continue on his Dilantin until seen in follow-up. He should have serial Dilantin levels checked while in rehabilitation to assure that he is at a therapeutic level. His incision requires daily dry dressing changes, as well as antibiotic ointment application daily. Please reassess his ability to take oral food after a few days of rehabilitation. | COMPARISON: TECHNIQUE: Non-contrast head CT. HEAD CT WITHOUT IV CONTRAST: There has been interval evacuation of the previously identified right temporoparietal intraparenchymal hemorrhage with interval development of gas within the right frontal, temporal, and parietal lobes. The previously seen uncal herniation has resolved. A right parietal craniotomy defect is demonstrated. Small amount of residual blood is seen within the right temporoparietal lobe. HEAD CT: There is postoperative change in the right parietal region. Enlarged left scalp fluid collection. change No contraindications for IV contrast FINAL REPORT NONCONTRAST HEAD CT: INDICATION: Status post fall with ICH, status post evacuation of hematoma, please evaluate status. COMPARISON: Noncontrast head CT of and . ETT is well secured.Hemodynamically:SR 80s, 90s when agitated. FINDINGS: In the area of the previously evacuated right temporoparietal intraparenchymal hemorrhage, there is pneumocephalus and trace areas of high density suggestive of residual blood. There is partial opacification of the ethmoid, sphenoid, and maxillary sinuses bilaterally. TECHNIQUE: Noncontrast head CT. Endotracheal tube and NG tube are unchanged compared with the previous study. cv stable tol lopressor and hydralazine. hr nsrresp sats adequate, congested spont cough breathsounds coarse.gi tol tube feeds at goal. There is cardiomegaly, with a right perihilar infiltrate, and left lower lobe and upper lobe infiltrates. COMPARISON: Head CT, . Started on levofloxacin for same. These findings suggest aspiration vs. left heart failure. Levofloxacin commenced pending sputum cultures.Renal:Urine output declining but still satisfactory.Skin:Essentially intact. IMPRESSION: Aspiration vs. left heart failure. Two peripheral IV's started. Patient is status post right parietal craniotomy. Dosing antihypertensives by , underdamped. IMPRESSION: Interval evacuation of large right temporoparietal intraparenchymal hemorrhage with resolution of uncal herniation and improvement in right to left subfalcine herniation. Normal flow is noted in the intracranial circulation. K repleated.Pulm - Extubated today. The basal cisterns and foramen magnum are patent. L SC TLC dc'd. There is stable layering of hemorrhage within the left lateral ventricle. ETT and left subclavian line satisfactorily positioned. There continues to be mass effect upon the adjacent right lateral and frontal ventricle with minimal right to left subfalcine herniation, much improved since the prior study. CT OF HEAD today--per Dr. . FINDINGS: Single portable AP view of the chest shows an ETT that is well positioned. Bowel sounds present, no BM.GU - Diuresing well with lasix, mannitol.Skin - No areas of pressure, breakdown.A - Hypertensive s/p bleed. Lung fields coarse bilateral upper lobes with diminsihed bases. On lopressor and hydralazine PO--scheduled. There is a stable right scalp fluid collection at the operative site. FREQUENT STOOLING-FORMEDID/LABS: LOW GRADE TEMP, WBC DOWN TO TODAY. There is stable continued mass effect on the right lateral ventricle. Interval development of pneumocephalus within the area of prior hemorrhage. Resolved left scalp fluid collection. CLEARS WITH SXN. LUE WITH OCC WITHDRAWAL AND OCC EXTENSOR POSTURING NOTED. Withdraws to painfull stim. K REPLETED.R: LUNGS OCC COURSE. CXR taken. Cough, gag, and corneal reflex's +. Respiratory Care:Pt. The left scalp fluid collection is resolved. Initially was on labetalol. DP & PT dopplerable only. Interval decrease in the pneumocephalus. There is left lower lobe atelectasis/infiltrate. VENT SETTINGS UNCHANGED.GI: ABD SOFT/DISTENDED WITH +BS. FINDINGS: There are post-operative changes of right parietotemporal craniotomy. Resp assessment as noted above in RT's note.CV: RSR no ectopy noted. extubate. +CORNEALS. OGT to suction with bilious output. b/s coarse, sc rhonchi. Right groin lump unchanged. OS 3MM/SLUGGISH. Femoral line removed by Dr . There are again noted encephalomalacic changes in the right temporoparietal region. The Dobbhoff tube has been repositioned, and there is a loop of tubing in the stomach, but the Dobbhoff tip is back in the distal esophagus, above the GE junction. TECHNIQUE: Noncontrast head CT. DP and PT pulses w/doppler only. To nailbed stimuli, Lt arm rotates internally, moves laterally with elbow bent (unchanged). BRISKLY LOCALIZES WITH RUE TO STERNAL RUB. Has right radial ABP line and right femoral (venous) cortis. + cough,gag, and corneal reflexes. pt currently on cpap+ps 5/5 - tol well. WEAK WITHDRAWAL OF LLE. Pupils = to un= w/left pupil brisk,slugish, to nonreactive, see careview for complete neuro assessment. LIFTS/HOLDS WITH RUE/RLE. Left pupil 3mm and fluctuates b/t sluggish to non reactive. IMPRESSION: Dobbhoff coiled in distal esophagus with tip likely in upper neck or oropharynx. ABG WNL. continues on minimal level vent support. J collar in situ. BS coarse. There is again noted a very slight leftward midline shift, which is unchanged when compared to the prior study. Head midline. Head midline. Labatolol on/off this shift to maintain SBP < 140. Neurologicaly intact post fall. The left upper lobe infiltrate persists. There is patchy left lower lobe atelectasis. Nursing Progress Note: Please see CareVue for details.Pt condition essentially stable today.Events:CT brain.TLS films.New subclavian line placed.Femoral line removed.On exam,Resp:Chest clear, occasionally coarse this am. There was poorly timed airway closure with moderate aspiration with thin liquids. Note is made of likely external tubing overlying the left clavicular region. Surgical area swollen, dressing intact. CPK 1900's w/MB 13.Resp: Orally intubated and on vent. IMPRESSION: Moderate aspiration with thin liquids, intermittent trace aspiration with thickened liquids with adequate clearance. ETT is at 27cm, and was at 27cm at time of CXR.Hemodynamically:Weaned off labetolol infusion. Occasional episodes of SBP mid 90s, spontaneously resolving. 11:45 PM CHEST (PORTABLE AP) Clip # Reason: readjustment of second dobhouf. Radial pulses strong and =. pain.Resp: Remains orally intubated and on vent. | 31 | [
{
"category": "Radiology",
"chartdate": "2200-08-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 838576,
"text": " 9:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? ETT placement\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man s/p a fall with ICH and evacuation of hematoma\n REASON FOR THIS EXAMINATION:\n ? ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: ?ETT placement.\n\n FINDINGS: Single portable AP view of the chest shows an ETT that is well\n positioned. There is cardiomegaly, with a right perihilar infiltrate, and left\n lower lobe and upper lobe infiltrates. These findings suggest aspiration vs.\n left heart failure. Also noted is an NG tube, the tip of which is in the\n distal stomach.\n\n IMPRESSION: Aspiration vs. left heart failure. ETT well-positioned.\n\n"
},
{
"category": "Radiology",
"chartdate": "2200-08-14 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 838701,
"text": " 7:31 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: BLEED\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man s/p fall with ICH, s/p evacuation of hematoma\n\n REASON FOR THIS EXAMINATION:\n interval changeS?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 56 y/o man status post fall with intracranial hemorrhage, status\n post evacuation of hematoma.\n\n TECHNIQUE: Axial images of the head were obtained from the occiput to the\n vertex without intravenous contrast.\n\n COMPARISON: Head CT, .\n\n HEAD CT: There is postoperative change in the right parietal region.\n Scattered surrounding high-attenuation foci are present and are stable in the\n interval. Several bubbles of gas are present in the right parietal region and\n in the right superior temporal region. The overall appearance of this area is\n unchanged from the prior study. There is stable continued mass effect on the\n right lateral ventricle. There is very slight leftward midline shift. The\n basal cisterns and foramen magnum are patent. There is stable layering of\n hemorrhage within the left lateral ventricle.\n\n There is a left scalp fluid collection measuring 6.3 x 1.3 cm. This has\n increased in size in the interval. There is a stable right scalp fluid\n collection at the operative site. Patient is status post right parietal\n craniotomy.\n\n IMPRESSION:\n\n 1. Stable appearance of the head from one day prior.\n\n 2. Enlarged left scalp fluid collection.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2200-08-11 00:00:00.000",
"description": "CTA HEAD W&W/O C & RECONS",
"row_id": 838424,
"text": " 11:56 PM\n CTA HEAD W&W/O C & RECONS; -59 DISTINCT PROCEDURAL SERVICE Clip # \n CT 100CC NON IONIC CONTRAST; -59 DISTINCT PROCEDURAL SERVICE\n Reason: R/O AVM or anuerysm\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with large right temporal parietal bleed\n REASON FOR THIS EXAMINATION:\n R/O AVM or anuerysm\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT ANGIOGRAPHY, \n\n INDICATION: Large right temporal lobe hemorrhage, rule out AVM or aneurysm.\n\n TECHNIQUE: Dynamically-acquired contrast-enhanced CT scans through the brain\n were obtained for acquisition of a CT angiogram of the circle of . The\n superior cervical portion of the vasculature is also included. Two\n dimensional reformatted images are provided for evaluation.\n\n Comparison is made to the previous CT scan of the brain from .\n\n FINDINGS: There is a large hematoma expanding the right temporal lobe and\n elevating the Sylvian branches of the right middle cerebral artery. This is\n grossly unchanged since the previous CT scan.\n\n The right lateral ventricle is flattened and the left lateral ventricle is\n mildly dilated due to right to left subfalcian herniation. The basal\n cisternal spaces are narrowed as the medial right temporal lobe is medially\n displaced.\n\n CT angiographic images demonstrate displacement of vessels around the hematoma\n but no abnormal vascularity is detected. Additionally, no aneurysms are\n detected within the right internal carotid artery or middle cerebral arterial\n branches.\n\n IMPRESSION:\n\n CT angiography reveals no vascular abnormality to explain the presence of\n a right temporal lobe hematoma. Conventional angiography should be\n considered for further evaluation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2200-08-12 00:00:00.000",
"description": "SEL CATH 3RD ORDER THOR",
"row_id": 838428,
"text": " 2:37 AM\n CAROT/CEREB Clip # \n Reason: HEADACHES\n Contrast: OPTIRAY Amt: 308\n ********************************* CPT Codes ********************************\n * SEL CATH 3RD ORDER SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE ADD'L 2ND/3RD ORDER *\n * ADD'L 2ND/3RD ORDER ADD'L 2ND/3RD ORDER *\n * CAROTID/CEREBRAL BILAT CAROTID/CEREBRAL BILAT *\n * EXT CAROTID BILAT VERT/CAROTID A-GRAM *\n * VERT/CAROTID A-GRAM -59 DISTINCT PROCEDURAL SERVICE *\n ****************************************************************************\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY:\n Intracerebral hemorrhage.\n\n TECHNIQUE:\n Informed consent was obtained from the patient and the patient's family after\n explaining the risks, indications and alternative management. Risks explained\n included stroke, loss of vision and speech, temporary or permanent, with\n possible treatment with stent and coils if needed.\n\n The patient was brought to the Interventional Neuroradiology Theater and\n placed on the biplane table in supine position. Both groins were prepped and\n draped in the usual sterile fashion. Access to the right common femoral artery\n was obtained using a 19-gauge single wall needle, under local anesthesia using\n 1% lidocaine mixed with sodium bicarbonate and with aseptic precautions.\n Through the needle, a 0.35 wire was introduced and the needle taken\n out. Over the wire, a 5 Fr vascular sheath was placed and connected to a\n saline infusion (mixed with heparin 500 units in 500 cc of saline) with a\n continuous drip. Through the sheath, a 4 Fr Berenstein catheter was introduced\n and connected to continuous saline infusion (with mixture of 1000 units of\n heparin in 1000 cc of saline).\n\n The following blood vessels were selectively catherized, and arteriograms were\n performed from these locations.\n\n right common carotid artery:\n\n right internal carotid artery:\n\n right external carotid artery:\n\n left common carotid artery:\n\n left internal carotid artery:\n\n left external carotid artery:\n\n left vertebral artery:\n\n (Over)\n\n 2:37 AM\n CAROT/CEREB Clip # \n Reason: HEADACHES\n Contrast: OPTIRAY Amt: 308\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n right vertebral artery.\n\n Evaluation of the right common carotid artery, right internal carotid artery,\n right external carotid artery, left common carotid artery, left internal\n carotid artery, left external carotid artery, left vertebral artery and right\n vertebral artery demonstrates no evidence of vascular malformation or\n aneurysm. Normal flow is noted in the intracranial circulation. No significant\n atherosclerotic stenosis noted in the carotid bifurcation.\n\n IMPRESSION: No evidence of aneurysm or vascular malformation.\n\n Mild-to-moderate vasospasm noted in the right and middle cerebral artery\n branches and posterior cerebral artery branch may be related to hemorrhage.\n\n If clinically warranted a followup angiogram may be performed in six weeks\n after the hemorrhage has resolved to exclude subtle abnormalities.\n\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2200-08-12 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 838465,
"text": " 9:30 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: s/p right craniotomy for evacuation of hemorrhage\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man s/p fall\n\n REASON FOR THIS EXAMINATION:\n s/p right craniotomy for evacuation of hemorrhage\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: S/P right craniotomy for evacuation of hemorrhage.\n\n COMPARISON: \n\n TECHNIQUE: Non-contrast head CT.\n\n HEAD CT WITHOUT IV CONTRAST: There has been interval evacuation of the\n previously identified right temporoparietal intraparenchymal hemorrhage with\n interval development of gas within the right frontal, temporal, and parietal\n lobes. Minimal high density material is seen within these areas suggestive of\n residual blood. The previously seen uncal herniation has resolved. There\n continues to be mass effect upon the adjacent right lateral and frontal\n ventricle with minimal right to left subfalcine herniation, much improved\n since the prior study. A right parietal craniotomy defect is demonstrated.\n There is partial opacification of the ethmoid, sphenoid, and maxillary sinuses\n bilaterally.\n\n IMPRESSION: Interval evacuation of large right temporoparietal\n intraparenchymal hemorrhage with resolution of uncal herniation and\n improvement in right to left subfalcine herniation. Interval development of\n pneumocephalus within the area of prior hemorrhage. Small amount of residual\n blood is seen within the right temporoparietal lobe.\n\n"
},
{
"category": "Radiology",
"chartdate": "2200-08-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 838614,
"text": " 12:48 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval tip position & r/o PTX\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man s/p a fall with ICH and evacuation of hematoma, s/p L SCV line\n plaqcment\n REASON FOR THIS EXAMINATION:\n eval tip position & r/o PTX\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 56 year old man status post fall, intracranial hemorrhage, left\n subclavian vein placement.\n\n TECHNIQUE: Portable AP chest radiograph. Comparison is made with the\n previous chest radiograph dated , 9:00AM.\n\n FINDINGS: The tip of the left subclavian line is terminating in the SVC.\n There is no pneumothorax. Endotracheal tube and NG tube are unchanged\n compared with the previous study.\n\n The heart is mildly enlarged in size.\n\n There is infiltration in left lower lobe, most likely representing atelectasis\n vs. pneumonia. There is a new focal opacity in the left upper lobe, which can\n represent either pneumonia, aspiration, or edema.\n\n The right lung is clear.\n\n There is no evidence of pleural effusion on chest radiograph.\n\n IMPRESSION: Continued left lower lobe infiltration with increased left upper\n lobe infiltration, which can represent pneumonia vs. aspiration.\n\n"
},
{
"category": "Radiology",
"chartdate": "2200-08-13 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 838620,
"text": " 1:43 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? change\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man s/p fall with ICH, s/p evacuation of hematoma\n\n REASON FOR THIS EXAMINATION:\n ? change\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n NONCONTRAST HEAD CT:\n\n INDICATION: Status post fall with ICH, status post evacuation of hematoma,\n please evaluate status.\n\n TECHNIQUE: Noncontrast head CT.\n\n COMPARISON: Noncontrast head CT of and .\n\n FINDINGS: In the area of the previously evacuated right temporoparietal\n intraparenchymal hemorrhage, there is pneumocephalus and trace areas of high\n density suggestive of residual blood. Additionally, there is pneumocephalus in\n the right frontal region. These findings show no change from the previous\n study. There continues to be mild mass effect upon the adjacent right lateral\n and frontal ventricle, with no change from the previous study. On the current\n study, however, due to technical factors during scanning, there is poor\n visualization of the /white interface, which drastically reduces the\n ability of this study to be accurately interpreted. If clinically indicated,\n recommendation is made to repeat the scan.\n\n IMPRESSION: Extremely limited study due to technical factors during scanning\n resulting in extensive blurring of the /white interface. Despite these\n limitations, there is an apparent stable appearance of the drainage bed with\n no significant change in amount of pneumocephalus or residual blood. However,\n a repeat scan is hightly recommended due to the low quality of this scan. Dr.\n covering for referring clinician was paged and given this\n recommendation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2200-08-13 00:00:00.000",
"description": "T-SPINE",
"row_id": 838624,
"text": " 2:10 PM\n T-SPINE; L-SPINE (AP & LAT) Clip # \n Reason: ? fx or dislocation\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man s/p a fall with ICH\n REASON FOR THIS EXAMINATION:\n ? fx or dislocation\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Fall. Pain.\n\n These two exams consist of AP and lateral views of the thoracic and lumbar\n spine (five images). Normal vertebral body alignment. No fracture identified\n and normal discs. The hips and SI joints are normal. Incidentally noted is\n prominent enthesopathy at multiple sites. Tip of NG tube in distal stomach\n and right inguinal blood access line, tip lying in iliac vessel. Normal bowel\n gas pattern and no ascites. Instantly noted is air space disease in the left\n mid and lower lungs with air bronchograms. ETT and left subclavian line\n satisfactorily positioned.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-08-17 00:00:00.000",
"description": "Report",
"row_id": 1364609,
"text": "ASSESSMENT AS NOTED\n\nNEURO: FOLLOWS, ANSWERS QUESTIONS, DISORIENTED IN TIME/PLACE(TELLS HE IS IN WEREHOUSE), KNOWS HIS FAMILY. IS SLOW AND UNCLEAR AT TIMES. L ARM POSTURES. R SIDE IS STRONG. STRONG COUGH. REMAINS IN CER COLLAR. CON'T ON MANNITOL AND DILANTIN. NO SEIZURE ACTIVITY\nNO SEDATION WAS GIVEN. DENIES PAIN\n\nRES: COUGHING AND SWALOWING SECRETIONS, LS CLEAR/COARSE , ON RA 100%\n\nCV: TRYING TO MAINTAIN 140-160 SBP, ON LOPRESSOR, HYDRALAZINE. GOT 500CC BOLUS(WAS NEG TOO MUCH )\n\nGU: 100-50 CC/H CLEAR\n\nGI: AT THGE GOAL 85 CC/H T. FEED. FREQUENT STOOLING-FORMED\n\nID/LABS: LOW GRADE TEMP, WBC DOWN TO TODAY. K WAS REPLETED\n BS DOWN TO 109 IN AM- COVERAGE BY RISS.\n\nSOCIAL: FAMILY IN LAST NIGHT\n\nA: ALTERATION IN NEURO STATUS\n\nP: WEAN OFF TRANSFER TO STEPDOWN OR FLOOR. MAINTAIN SBP<160\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-08-17 00:00:00.000",
"description": "Report",
"row_id": 1364610,
"text": "TSICU NPN (0700-1900)\nREVIEW of SYSTEMS\n\nNeuro....Dozing off and on for most of day. Awakens to voice or light stimuli. When awake, light voice, but answers questions and follows commands. Moves R sided extremities with good strength and purposefully. L leg moves slightly on bed--withdrawl. Extnesor posturing with LUE. R pupil slightly smaller than L, but both briskly reactive. CT OF HEAD today--per Dr. . Mannitol stopped. Continues on dilantin with no seziure activity noted. OOB to chair for almost 4 hours. Tolerated well. No c/o pain.\nFlexion/Extension x-rays done. Not cleared yet per Dr. . J collar remains on.\n\nCV....NSR with no ectopy noted. HR 80-90's. Goal SBP <160 per Dr. . On lopressor and hydralazine PO--scheduled. BP ranging 160-130/60-70's. PRN lopressor dose available if needed. Two peripheral IV's started. L SC TLC dc'd. Dr. did not want tip cultured.\n\nRESP...Stable on RA with sats >94%. Lung fields coarse bilateral upper lobes with diminsihed bases. Strong congested cough--minimally productive thought. NT suctioned x1 this afternoon with moderate amts of thick yellow secretions returned.\n\nGI....Promote with fiber TF's remain at goal of 85cc/hr. Tolerating well. No BM today, but multiple stools overnight. Abd soft with active BS.\n\nGU....Foley to gravity with adequate clear yellow urine. Lytes stable.\n\nENDO...Blood sugars peaked at 406, noon. Given 12U regular and 8U NPH. No effect seen 1hr later. Started on insulin drip--requiring up to 12U/hr in order to bring sugars down. Dropped quickly when NPH peaked, down to 75. 1/2 amp D50 given at 1700. Will continue to check frequently.\n\nHEME...HCT stable. Heparin subq and pneumo boots on.\n\nID...Tmax 99.9. Levofloxacin coverage on board. TLC dc'd.\n\nSKIN...Staples to incision on head with no redness or drg note. Poor dentation with loose teeth noted. Backside intact.\n\nSOCIAL... son and daughter in earlier today. Updated on pt's condition and plan of care. Not aware of events with blood sugars.\n\nPLAN...Pt is possible bump to neuro step down floor if necessary. Would like to keep pt here overnight d/t sugar issues unless bed issues arise. Swallow study ordered for tomorrow. ??Check into flex-ex films tomorrow. Needs encouragement with pulmonary toilet. SBP around 160. Montior blood sugars.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-08-18 00:00:00.000",
"description": "Report",
"row_id": 1364611,
"text": "nsg note:\nneuro moving t side to command lt side posturing very spastic answers questions simply slightly confused knows hes in a hospital. cv stable tol lopressor and hydralazine. hr nsr\n\nresp sats adequate, congested spont cough breathsounds coarse.\n\ngi tol tube feeds at goal. given insulin per sliding scale. one lg bm\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-08-18 00:00:00.000",
"description": "Report",
"row_id": 1364612,
"text": "TRAUMA ICU NURSING PROGRESS NOTE\nSEE TRANSFER NOTE....AWAITING BED.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-08-15 00:00:00.000",
"description": "Report",
"row_id": 1364606,
"text": "TSICU Nursing Progress Note\nNeuro - Less alert most of today. Opening eyes occasionally to voice. Localizes with left arm with suctioning, stimulation. Right arm with extensor posturing. Moves bilateral LE right>left. Pupils unequal, reactive. Impaired gag, strong cough.\n\nCV - Tachycardic to 100s despite increased Metoprolol. No ectopy noted. Hypertensive requiring PRN Metoprolol, hydralyzine and fentanyl. Dosing antihypertensives by , underdamped. Neurosurgery wants SBP < 150 at all times. Added lasix. K repleated.\n\nPulm - Extubated today. Tolerating 3L NC with face tent for humidification. Strong cough, productive of thick yellow sputum.\n\nGI - OGT discontinued in preparation for extubation. Small bore feeding tube placed, currently in stomach. Maintained NPO until tomorrow. Bowel sounds present, no BM.\n\nGU - Diuresing well with lasix, mannitol.\n\nSkin - No areas of pressure, breakdown.\n\nA - Hypertensive s/p bleed. Tolerating extubation .\n\nP - Maintain SBP< 150 per . Aggressive pulmonary toilet, oral care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-08-16 00:00:00.000",
"description": "Report",
"row_id": 1364607,
"text": "ASSESSMENT AS NOTED\n\nNEURO: FOLLOWS SIMPLE COMMANDS, L. ARM POSTURES. UNCLEAR . ANSWERS QUESTIONS Y/N. STILL IN CERVICAL COLLAR, NO SEIZURE ACTIVITY\nCON'T ON DILANTIN AND MANNITOL\n\nRES: STRONG PROD. COUGH, MAINTAINS S02>9% ON COOL AIRSOLE TENT 35% AND NC2L, LS COARSE T/0.\n\nCV: GOAL TO MAINTAIN SBP 140-160, UNABLE TO CONTROL WITH LOPRESSOR AND HYDRALAZINE AND LABETALLOL GTT WAS STERTED DURING THE NIGHT WITH GOOD SBP CONTROL., REMAINS IN NSR NO ECTOPY.\nA-LINE IS WITH FLING, GOING BY CUFF.\n\nGI: UNREMARCABLE, + BS, FEEDING TUBE IS CLAMPED: WAITING FOR IT TO DROP INTO JEJUNO.\n\nGU: BRISK U/O WITH LASIX AND MANNITOL. ON DOSE OF 5MG ZAROXYLIN WAS GIVEN 2100 LAST NIGHT.\n\nLABS: K WAS REPLACED FOR 3.3, STILL WAITING FOR OSMO SINCE 4AM.\n\nSKIN :INTACT , INCISION INTACT\n\nSOCIAL: FAMILY IS IN ALL NIGHT IN AND OUT\n\nID : NO FEVER\n\nA: FALL, HEAD BLEED-->CRANI, SEVERE HTN\n\nP:CONTROL BP, NEURO, PULM TOILET\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-08-16 00:00:00.000",
"description": "Report",
"row_id": 1364608,
"text": "NSG NOTE:\n\nROS:\n\n CV:LOPRESSOR PO INCREASED,HYDRALIZINE IV ADDED,THEN CHANGED TO PO.SYS BP BELOW 170 ALL DAY,LABETALOL DC'D.CVP - TO 1.\n\n RESP:NOW ON 4L NP WITH SAT 99.HAS STRONG PROD COUGH,SWALLOWS ALL SPUTUM.\n\n NEURO:ANSWERS APPROPIATELY TO YES/NO QUESTIONS.DIFF TO UNDERSTAND WHEN HE SPEAKS IN SENTENCES.MOVES R ARM,LEG NORMALLY.\nPOSTURES WITH L ARM,MOVES L LEG ON BED.PUPILS REACTING BRISKLY.\nOOB IN CHAIR.\n\n GU:GOOD UO,DIURESING WITH 12N DOSE LASIX.\n\n GI:STARTED TF,PROMOTE WITH FIBER.GOAL 85,ON 60CC AT 4PM.\n+ BS,NO STOOL\n\n ID:99+.\n\n ENDO:BS 188-189,GIVEN INSULIN AS ORDERED.\n\n SOCIAL:MULTIPLE FSMILY MEMBERS IN,WIFE IN MOST OF PM.\n\n PLAN:CAN TRANSFER TO 5 STEPDOWN UNIT.BED FACILITATOR AWARE.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-08-14 00:00:00.000",
"description": "Report",
"row_id": 1364604,
"text": "Nursing Progress Note.\nPlease see CareVue for specifics.\n\nPt condition improved today.\n\nNeuro:\nPt more alert today, moving Rt side spontaneously, lifting legs spont, shifting position, regarding examiner. Still has episodes where much less alert, rousing to stimuli. Has obeyed commands by squeezing and releasing Rt hand, although does not obey all times. Pupils still Lt > Rt. Fentanyl in CT scan to keep pt still. TLS cleared today. J remains insitu. Strong cough, occasional gag.\nStill weaning mannitol.\n\nResp:\nRemains on PSV 5/5 40%. Very thick secretions. Started on levofloxacin for same. Chest clear. ETT not rotated due to very loose teeth and risk of dislodging one. ETT is well secured.\n\nHemodynamically:\nSR 80s, 90s when agitated. No ectopy. Weaned labetolol infusion off with additional oral metoprolol. Hydralazine very effective. Goal SBP 100-150. Peripherally warm and well pewrfused.\n\nEndocrine:\nBetter control of sugers with tighter sliding scale, but has still needed coverage today.\n\nFluids:\nNS with 20KCl to total input 75mls/hr.\n\nGI:\nAbd soft, non distended.\nTube feeds recommenced.\n\nID:\nAfebrile. Levofloxacin commenced pending sputum cultures.\n\nRenal:\nUrine output declining but still satisfactory.\n\nSkin:\nEssentially intact. See CareVue. No new issues.\n\nSocial:\nFamily very concerned that they have not yet had an update from team. Paged resident and NP, neithor available to speak with family. Social work involved. Also suggested family contact patient relations if they would like another outlet for their concern.\n\nPlan:\nContinue to monitor.\nPlan for extubation tomorrow.\nContinued support for family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-08-13 00:00:00.000",
"description": "Report",
"row_id": 1364598,
"text": "Admit note:\n\nUnwitnessed fall from standing position. Neurologicaly intact post fall. Approx 3 hrs after fall family was unable to arouse for dinner and called 911. Transported here. CT=>right tempral/parietal bleed with IPH and midline shift=> OR for evacuation of hematoma. 4 vessel angio negative, CTA head/neck = AVM\n\nROS:\n\nNeuro: Initially off propofol, would open eyes w/coughing. Right pupil consistanly 3 mm and brisk. Left pupil 3mm and fluctuates b/t sluggish to non reactive. Cough, gag, and corneal reflex's +. Withdraws to painfull stim. Propofol had to be restarted at 40 mcg/kg/min do to coughing against ETT. Bed in Reverse T- at 30 degreees. J collar on. Head midline. On dilantin 100mg q 8 hr. Manitol q 6hr. Crani dressing intact w/ scant amt of red drainage..\n\nCV: RSR no ectopy noted. S1S2. Initially was on labetalol. On admission to unit SBP 88. Labetalol turned off, later resumed and titrated to 1.5 mg/min to keep sbp <140 and > 100 ( ). Has right radial ABP line and right femoral (venous) cortis. Radial pulses palpable. DP and PT pulses w/doppler only. Right DP very difficult to auscultate w/doppler. CPK 1900's w/MB 13.\n\nResp: Orally intubated and on vent. Vent changed to SIMV 600x12, peep 5, PS 5, 40%. Breathing over vent w/RR of 14-22. Lung sound clear upper lung fields. Diminished and coarse in bases. Sx thick light green sputum. Sats 100%. ABGs WNL this AM. No resp distress noted, = rise and fall of chest\n\nGI: Oral sump to LCS draining bile colored fluid. Abd soft w/active Bowel sounds in all four quads af abd. Prophylactic protonix changed to H2 blocker.\n\nGU:Foley patent draining clear yellow urine in QS\n\nLabs: pending at this hour\n\nSocial: Here in working and staying w/daughter . Wife and other children living in (all are here)\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-08-13 00:00:00.000",
"description": "Report",
"row_id": 1364599,
"text": "Resp care\nWeaned pt to minimal vent support today. ABG's acceptable, well oxygenated and ventilated. BS coarse. Sx mod-lg thick green secretions. Head CT done today, TLS films done. Results pending. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-08-13 00:00:00.000",
"description": "Report",
"row_id": 1364600,
"text": "Nursing Progress Note: Please see CareVue for details.\n\nPt condition essentially stable today.\n\nEvents:\nCT brain.\nTLS films.\nNew subclavian line placed.\nFemoral line removed.\n\nOn exam,\n\nResp:\nChest clear, occasionally coarse this am. Moving large tidal volumes >500mls. Weaned to Pressure Support 40%. Tolerating well, ABGs improved. Has strong cough, productive of thick greenish sputum. CXR taken. ETT is at 27cm, and was at 27cm at time of CXR.\n\nHemodynamically:\nWeaned off labetolol infusion. Maintaining SBP within goal of 100-140mmHg. Occasional episodes of SBP mid 90s, spontaneously resolving. HR 80s, SR. Peripheries warming. Femoral line removed by Dr . Soft mass in Rt groin unchanged. New subclavian line in use. CVP 13.\n\nNeuro:\nPropofol off except for scans and turns- coughs violently without. Poor exam. Rouses to stimuli, localizes with Rt arm to sternal rub, lifts both legs at knee, Rt more briskly than left, but with essentially equal strength. To nailbed stimuli, Lt arm rotates internally, moves laterally with elbow bent (unchanged). Pupils: Lt>Rt, Rt reactive, Lt sluggish at best. Slight left gaze, pt's head turns to Lt. Corneals present, blink to threat absent. J collar in situ. Surgical area swollen, dressing intact. No new ooze. Mannitol q6 according to osm and Na.\n\nEndocrine:\nCovered with regular insulin per sliding scale.\n\nFluids:\nNS with 20meq KCl at 75/hr.\n\nGI:\nABd soft, non distended, bowel sounds present. OGT to suction with bilious output. For commencement of tube feeds. GI prophylaxis being reviewed in light of pt's history of thrombocytopenia.\n\nID:\nLow grade fever only. Antibiotics complete.\nSputum culture sent.\n\nRenal:\nGood urine output.\n\nSkin:\nIntact except for surgical wound and forehead lac.\nPt has very poor dentition and loose teeth, shown to team.\n\nSocial:\nFamily here. Daughter and wife updated by physician. discarded by family.\n\nPlan:\nContinue to monitor.\nFollow up TLS films.\nTube feeds.\nPossible extubation tomorrow.\nContinued support for family.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-08-14 00:00:00.000",
"description": "Report",
"row_id": 1364601,
"text": "Respiratory Care:\nPt. continues on minimal level vent support. ABG's well oxygenated with normal range acid-base. B/S with scattered rhonchi>>ETS small to moderate, thick, green. Foul smelling oral secretions. RSBI was 42 this a.m.. Started on SBT. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-08-15 00:00:00.000",
"description": "Report",
"row_id": 1364605,
"text": "NPN\nN: PT NOT THOUGH PURPOSEFUL WITH RUE TOWARDS GROIN & ETT. BRISKLY LOCALIZES WITH RUE TO STERNAL RUB. LIFTS/HOLDS WITH RUE/RLE. WEAK WITHDRAWAL OF LLE. LUE WITH OCC WITHDRAWAL AND OCC EXTENSOR POSTURING NOTED. PUPILS UNEQUAL. OD 2MM/BRISK. OS 3MM/SLUGGISH. STRONG COUGH/IMPAIRED GAG. +CORNEALS. DILANTIN LEVEL 14. RESTLESS AT TIMES PULLING AT RESTRAINTS/SHIFTING WEIGHT IN BED. GIVEN FENTANYL WITH SOME EFFECT PRN. CONT MANNITOL.\nCV: HYPERDYNAMIC AND REQUIRING INCREASED DOSES OF LOPRESSOR AND USE OF PRN LOPRESSOR/HYDRALAZINE. ALINE WITH SOME FLING. NBP CYCLING AND TREATING BP PER NBP. K REPLETED.\nR: LUNGS OCC COURSE. CLEARS WITH SXN. SXN'D FOR SM AMT THICK TAN. ABG WNL. VENT SETTINGS UNCHANGED.\nGI: ABD SOFT/DISTENDED WITH +BS. TF OFF AT 4AM FOR PROBABLE EXTUBATION. NO STOOL.\nGU: CLEAR YELLOW URINE DRAINING VIA FOLEY IN GOOD AMTS.\nHEME: HCT STABLE\nID: TMAX 100. WBC 15.9\nENDO: GLUCOSE TREATED PER RISS.\nSOC: PT'S DAUGHTER CAME IN LAST EVENING AND GIVEN UPDATE. DAUGHTER VOICING CONCERN.\nA/P: EXTUBATE IF ABLE TODAY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-08-14 00:00:00.000",
"description": "Report",
"row_id": 1364602,
"text": "ROS:\n\nNeuro: Has periods where he is more alert then other times. When he is more alert has eyes open spontaniously and has protective blink reflex. + cough,gag, and corneal reflexes. Pupils = to un= w/left pupil brisk,slugish, to nonreactive, see careview for complete neuro assessment. Bed in Reverse T-. j collar on. Head midline. Dilantin level 16, receiving dilantin 100mg q 8 hr and manitol 25 Gm q 6 hr. Serum osmo trending up as well as Na+. Fentanyl for ? pain.\n\nResp: Remains orally intubated and on vent. Resp assessment as noted above in RT's note.\n\nCV: RSR no ectopy noted. S1S2. Has right radial ABP line and left subclavian MML w/distal port transduced for cvp=8->12. Radial pulses strong and =. DP & PT dopplerable only. Right groin line site clean dry and intact. Right groin lump unchanged. Labatolol on/off this shift to maintain SBP < 140. Metoprolol 12.5mg via ng initiated.\n\nGI: Oral gastric tube w/TF infusing at 30cc/hr w/minimal residuals. Abd soft w/active bowel sounds thoughout.\n\nGU: Foley patent draining clear yellow urine in QS\n\nLabs: Stable\n\nSocial: Children and spouse present this shift for support.\n\nPlan: BP management. ? extubate.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-08-14 00:00:00.000",
"description": "Report",
"row_id": 1364603,
"text": "resp care\npt remains intubated and mech ventilated. pt currently on cpap+ps 5/5 - tol well. b/s coarse, sc rhonchi. sxn thk yel>>green secretions. pt tx to/from ct scan w/o incident. plan: cont w/mech support. ? extubation tomorrow.\n"
},
{
"category": "Radiology",
"chartdate": "2200-08-17 00:00:00.000",
"description": "C-SPINE FLEX AND EXT ONLY 2 VIEWS",
"row_id": 839022,
"text": " 12:42 PM\n C-SPINE FLEX AND EXT ONLY 2 VIEWS Clip # \n Reason: eval c spine for instability\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56M s/p trauma, SDH\n REASON FOR THIS EXAMINATION:\n eval c spine for instability\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 56 year old man status post trauma. Evaluate C-spine for stability.\n\n CERVICAL SPINE FOUR VIEWS. There is no prevertebral soft-tissue swelling.\n There is no evidence of fracture. The cervical vertebral bodies are in normal\n alignment without loss of body or disc height. However, C6, C7 and T1 are not\n well visualized. Alignment is stable in flexion and extension views.\n\n IMPRESSION: No cervical spine fracture. Stable alignment in flexion and\n extension. Somewhat limited study due to poor visualization of C6, C7 and T1.\n\n"
},
{
"category": "Radiology",
"chartdate": "2200-08-17 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 839021,
"text": " 12:37 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval interval changes. please coordinate schedule with flex\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56M with SDH s/p evac\n REASON FOR THIS EXAMINATION:\n eval interval changes. please coordinate schedule with flex-ext films\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 56-year-old male status-post evacuation of subdural hemorrhage.\n\n COMPARISON: .\n\n TECHNIQUE: Noncontrast head CT.\n\n FINDINGS: There are post-operative changes of right parietotemporal\n craniotomy. There are again noted encephalomalacic changes in the right\n temporoparietal region. There is slight decrease in the amount of air. There\n is no new hemorrhage. There is again noted a hyperdense foci in the right\n temporal lobe that is unchanged when compared to the previous studies, and may\n represent blood. The ventricles are unchanged in size. There is still a\n small amount of blood in the occipital of the left lateral ventricle.\n There is again noted a very slight leftward midline shift, which is unchanged\n when compared to the prior study. The left scalp fluid collection is\n resolved.\n\n IMPRESSION\n\n 1. There is no evidence of new hemorrhage.\n 2. Interval decrease in the pneumocephalus.\n 3. Resolved left scalp fluid collection.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2200-08-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 839278,
"text": " 8:14 PM\n CHEST (PORTABLE AP) Clip # \n Reason: post dophouf placement\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man s/p a fall with ICH and evacuation of hematoma, s/p L SCV\n line plaqcment\n REASON FOR THIS EXAMINATION:\n post dophouf placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Dobbhoff and left subclavian central venous line placement.\n\n : Comparison is made to . Dobbhoff tubing is looped\n in the distal esophagus with the tip not visualized, but likely in the upper\n neck or oropharynx. This needs to be repositioned. Note is made of likely\n external tubing overlying the left clavicular region. This is not in the\n region expected for a left subclavian central venous line. The patient's\n previous left subclavian central venous line has been removed. There is patchy\n left lower lobe atelectasis.\n\n IMPRESSION: Dobbhoff coiled in distal esophagus with tip likely in upper neck\n or oropharynx. This needs to be repositioned. Note is made that the patient\n has had multiple subsequent prior films which show repositioning of the tube.\n\n"
},
{
"category": "Radiology",
"chartdate": "2200-08-20 00:00:00.000",
"description": "VIDEO OROPHARYNGEAL SWALLOW",
"row_id": 839357,
"text": " 1:51 PM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: please eval swallow function per speech and swallow\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56M s/p trauma, SDH\n\n REASON FOR THIS EXAMINATION:\n please eval swallow function per speech and swallow\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 56 year old man status post trauma and subdural hematoma\n presenting for swallowing function evaluation.\n\n COMPARISONS: None.\n\n TECHNIQUE: The study was performed in conjunction with the speech\n pathologist. Various consistencies of barium were administered orally. The\n study was recorded on a video tape.\n\n FINDINGS: The patient exhibited weakness of the oral musculature and bolus\n control. There was some spillover of thick and thin liquids into the\n hypopharynx. There was poorly timed airway closure with moderate aspiration\n with thin liquids. There was also trace aspiration with nectar thick liquids\n intermittently, which cleared, and was improved with the chin tuck technique.\n Please see the report of the speech pathologist for further details.\n\n IMPRESSION: Moderate aspiration with thin liquids, intermittent trace\n aspiration with thickened liquids with adequate clearance.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2200-08-19 00:00:00.000",
"description": "BILAT LOWER EXT VEINS",
"row_id": 839227,
"text": " 1:06 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: CEREBRAL ANEURYSM, R/O DVT\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with cerebral hemorrhage\n REASON FOR THIS EXAMINATION:\n r/o dvt\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: Bilateral lower extremity venous Doppler ultrasound.\n\n INDICATION: 56 year old man with cerebral hemorrhage and suspicion for DVT.\n\n COMPARISON: None.\n\n FINDINGS: Doppler son were performed of the left and right common\n femoral veins, superficial femoral veins, popliteal veins. All vessels showed\n normal flow, augmentation, compressibility, and respiratory variation.\n Intraluminal thrombus is not identified.\n\n IMPRESSION: No evidence for deep vein thrombosis in either lower extremity.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2200-08-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 839283,
"text": " 9:56 PM\n CHEST (PORTABLE AP) Clip # \n Reason: second dophouf placement at 75cm\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man s/p a fall with ICH and evacuation of hematoma, s/p L SCV\n line plaqcment\n REASON FOR THIS EXAMINATION:\n second dophouf placement at 75cm\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Dobhoff repositioning.\n\n PORTABLE AP CHEST: Comparison is made to the study from two hours earlier. The\n Dobbhoff tube has been repositioned, and there is a loop of tubing in the\n stomach, but the Dobbhoff tip is back in the distal esophagus, above the GE\n junction. This needs to be repositioned. The heart and lungs are unchanged.\n The previously seen tubing overlying the left clavicular region is no longer\n present.\n\n IMPRESSION: Dobbhoff tubing looped in stomach but tip is in the distal\n esophagus, above the GE junction, requiring repositioning.\n\n"
},
{
"category": "Radiology",
"chartdate": "2200-08-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 838824,
"text": " 10:04 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? tube feed placement\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man s/p a fall with ICH and evacuation of hematoma, s/p L SCV\n line plaqcment\n REASON FOR THIS EXAMINATION:\n ? tube feed placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Feeding tube placement check.\n\n FINDINGS: Single AP portable view of the chest show a feeding tube, with the\n tip in the fundus. There is left lower lobe atelectasis/infiltrate. The left\n upper lobe infiltrate persists. Right lung appears clear. The ETT and central\n venous line remain in good position.\n\n IMPRESSION: Feeding tube in fundus of stomach. Otherwise no significant\n interval change.\n\n"
},
{
"category": "Radiology",
"chartdate": "2200-08-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 839290,
"text": " 11:45 PM\n CHEST (PORTABLE AP) Clip # \n Reason: readjustment of second dobhouf. this is the third film \n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man s/p a fall with ICH and evacuation of hematoma, s/p L SCV\n line plaqcment\n REASON FOR THIS EXAMINATION:\n readjustment of second dobhouf. this is the third film tonight s/p adjustment\n at 11:20pm\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Dobbhoff repositioning.\n\n PORTABLE AP CHEST: Comparison is made with the study from ,\n approximately 2 hours earlier. The Dobbhoff tubing is now coiled in the\n stomach in satisfactory position. There is residual patchy left lower lobe\n atelectasis, but the appearance of the heart and lungs are unchanged.\n\n IMPRESSION: Successful Dobbhoff tube positioning, coiled in stomach.\n\n\n\n"
}
] |
55,672 | 193,172 | 55 year old woman with history of EtOH abuse presenting following mechanical fall and traumatic T spine fracture. She was intubated at an outside hospital for unclear etiology and was transferred while intubated. # Respiratory failure and Ventilator Associated PNA: Upon transfer, the patietn was already intubated for initial unclear etiology. With further evaluation, the cause was likely multifactorial and she was found to have a significant pneumonia soon after transfer. Initial blood and sputum cultures were negative. Given poor status, patient was started on Vancomycin, Aztreonam, Flagyl and Levofloxacin. Metronidazole was discontinued. Aztreonam was discontinued. Levofloxacin was discontinued. During this time, she continued to be diuresed and had stress-dose steroids and required vasopressor support. Interventional Pulmonology was consulted to perform bronchoscopy and provide further information regarding difficulty in weaning patient and BAL was performed on . The pansensitive KLEBSIELLA OXYTOCA and KLEBSIELLA PNEUMONIAE grew from BAL. She was optimized with inhalers including Albuterol and Ipratroprium. She continued to be of a marginal respiratory status and given failure to wean from the vent, she underwent tracheostomy on . On she was restarted on Vancomycin 1000 mg IV Q 12H, Aztreonam mg IV Q8H, and Levofloxacin 750 mg IV Q24H for concern for recurrent VAP and aspiration. Aztreonam and Vancomycin were stopped on . On Levofloxacin was changed to Ceftriaxone. Ceftriaxone was discontinued . Given concern for recurrent aspiration, ENT was consulted to evaluate the patient. On VC exam, revealed an inability to adduct the true vocal cords posteriorly, raising concern for high aspiration risk. Despite this, from that point on, Ms. has continued to improve and has tolerated her tubefeeding with minimal residuals. She continues to have intermittent mucous plugging with appropriate desaturations, but these resolve with deep suctioning. the patient had further evaluation for Passe-Muir valve. They left the following recommendations including always deflate cuff prior to placing the Passy-Muir valve; monitor O2 Sats / respiration while valve is in place; do not allow the patient to sleep with the valve in place; patient must be supervised wtih valve in place; and requires frequent suctioning via yankauer with PMV in place. Ultimately, the PMV wear schedule is up to the discretion of then nurse and/or respiratory therapist. Scopalomine was started to decrease secretions but was later discontinued due to possible etiology of delirium. # Hypotension. Patient was hypotensive upon presentation and throughout a large portion of her hospital course. This was intially concerning for hypovolemia and she was responsive to transfusion. There was also concern for sepsis, and she was treated with broad spectrum antibiotics as above. Ultimately, she was successfully weaned from her pressor support on . | REASON FOR THIS EXAMINATION: atelectasis vs edema FINAL REPORT HISTORY: Intubated with the recent desaturation. Right IJ catheter terminates in the superior vena cava. ETT terminates in the mid thoracic trachea. There is a 7.5 cm x 3.0 cm tubular fluid density (Over) 4:59 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST Reason: eval structures, bleeding, spinal cord impingement Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA Field of view: 42 Contrast: OPTIRAY Amt: 130 FINAL REPORT (Cont) structure in continuation with the cecum in the anticipated location of the appendix without adjacent inflammatory stranding. REASON FOR THIS EXAMINATION: eval for infiltrate, effusion PFI REPORT Unchanged right middle lobe and right lower lobe collapse and left lower lobe atelectasis. PORTABLE SUPINE ABDOMINAL RADIOGRAPH FINDINGS: Positioning of the J-tube is unchanged with contrast noted to have advanced antegrade into the mid to distal jejunum. Right basal atelectasis and small bilateral pleural effusions unchanged. Resolution of nonocclusive thrombus in the right axillary and basilic veins. Resolution of nonocclusive thrombus in the right axillary and basilic veins. FINAL REPORT INDICATION: History of upper extremity DVT and tachycardia. Compared to the previoustracing of sinus tachycardia with first degree A-V block has givenway to the current rhythm. Compared to the previous tracing of the A-V nodal re-entrant tachycardia is no longer present.TRACING #1 - wean FiO2 as tolerated - attempt wean PS today and hopeful for trach mask trial # Sedation: Continue to have issues with pain/delirium causing tachycardia and hypertension with intermittent hypotension. Deep Venous Thrombosis (DVT), Upper extremity Assessment: Heparin gtt off this am for possible trip to OR. ## Adrenal Insufficency: Minimal response to stim test again. Response: After 1 hr pt became tachycardic and tachypnic. Response: After 1 hr pt became tachycardic and tachypnic. - hydrocortt (day 1 = ), wean per endo recs # Hypotension: Likely adrenal insufficiency and sedation. INR is high and HCT is down; will hold coumadin and guiac stool, confirm BBS and check PM HCT. Bradycardia Assessment: Pt conts with HR 50-70s at rest, 100-140s during care, pt asymptomatic; easily arousable Action: Sedation decreased, Lasix off @0200 Response: HR 60 Plan: Cont to wean sedation, ?cardiac consult Deep Venous Thrombosis (DVT), Upper extremity Assessment: Action: Cont with IV Heparin @ 1500u/hr, Coumadin dcd for? Action: MD notified and valium PO continues. Action: MD notified and valium PO continues. # EKG changes: Sinus bradycardia, responsive to stress. Bradycardia Assessment: Pt conts with HR 50-70s at rest, 100-140s during care, pt asymptomatic; easily arousable Action: Sedation decreased, Lasix off @0200 Response: HR 60 Plan: Cont to wean sedation, ?cardiac consult Deep Venous Thrombosis (DVT), Upper extremity Assessment: Action: Cont with IV Heparin @ 1500u/hr, Coumadin dcd for? - Weaning FiO2 as tolerated # Tachycardia: Pt in ST 120s to 150s. - needs A-line for monitoring - cortisol stim to rule out persistent adrenal insufficiency # RUE DVT: Started on heparin gtt on , now off for trach that was planned for today. - Weaning FiO2 as tolerated # Tachycardia: Pt in ST 120s to 150s. Resp Failure Trach mask trials as tolerating (needing QHS support at present) PMV trials S/P rx for pan Klebs PNA. - Weaning FiO2 as tolerated # Tachycardia: Pt in ST 120s to 150s. - Weaning FiO2 as tolerated - Will attempt trach collar today # Sedation: Pt has pain/delirium causing tachycardia and hypertension with intermittent hypotension. - Weaning FiO2 as tolerated # Tachycardia: Pt in ST 120s to 150s. - Weaning FiO2 as tolerated # Tachycardia: Pt in ST 120s to 150s. - Weaning FiO2 as tolerated # Tachycardia: Pt in ST 120s to 150s. Today pt had a US of LUE to R/O DVT as a source of tachycardia. Today pt had a US of LUE to R/O DVT as a source of tachycardia. Today pt had a US of LUE to R/O DVT as a source of tachycardia. - wean PEEP as tolerated # # Adrenal Insufficency: Minimal response to stim test again. DVT: Treatment dose heparin Ulcer: Ranitidine VAP: Prevention per routine ICU Care Nutrition: Glycemic Control: Lines: PICC Line - 09:19 PM Arterial Line - 02:00 PM Prophylaxis: DVT: Stress ulcer: VAP: Comments: Communication: Comments: Code status: Full code Disposition: Belly: repeat LFTs, KUB OK, check residuals. Belly: repeat LFTs, KUB OK, check residuals. - wean PEEP as tolerated # # Adrenal Insufficency: Minimal response to stim test again. - hold heparin gtt when anticipate trach/peg # Adrenal Insufficency: Minimal response to stim test again. - hold heparin gtt when anticipate trach/peg # Adrenal Insufficency: Minimal response to stim test again. Vanc trough pending today - Also on flagyl for empiric coverage of c. diff - Per CT, unlikely to be abdominal process # Hypotension, requiring Levophed: - Hypovolemia is possibly a factor- responded to a transfusion; HCT had been dropping - Sepsis also a factor- on broad spectrum abs - Central line in place. Vanc trough pending today - Also on flagyl for empiric coverage of c. diff - Per CT, unlikely to be abdominal process # Hypotension, requiring Levophed: - Hypovolemia is possibly a factor- responded to a transfusion; HCT had been dropping - Sepsis also a factor- on broad spectrum abs - Central line in place. Plan: Titrate lasix gtt and sedation as tol by b/p restart levophed if b/p drops and remains low. Bradycardia Assessment: Pt conts with HR 50-70s at rest, 100-140s during care, pt asymptomatic; easily arousable Action: Sedation decreased, Lasix off @0200 Response: HR 60 Plan: Cont to wean sedation, ?cardiac consult Deep Venous Thrombosis (DVT), Upper extremity Assessment: Action: Cont with IV Heparin @ 1500u/hr Response: Pt therapeutic, cont with daily PTT Plan: Cont to labs, adjust per Heparin protocol Respiratory failure, acute (not ARDS/) Assessment: Pt cont on AC 18/400/50%/10, LS clear bilat, occ scat rhonchi Action: Pt suct for sm thin tan secretions Response: Plan: Cont to ABGs, Hypotension (not Shock) Assessment: SBP 140s when pt is agitated, SBP dropping to 70s-80s, UO 200/hr (total 2500 in 2hr) Action: Fent/Versed turned down @ 0000, Lasix gtt on hold, team informed Response: Pt SBPs in 80 Plan: Cardiac consult to further eval SB/ST, re-evalu cont. which lead to VAP most likely with GNR (by one sputum). which lead to VAP most likely with GNR (by one sputum). Action: Levophed gtt weaned off. Response: ABG WNL Plan: Cont to try to wean vent settings as tolerated, cont monitoring ABG Hypotension (not Shock) Assessment: SBP 90-110s MAP 62-66 Goal MAP >65 Levophed gtt @ 0.020 mcg/kg/min. Vanc trough pending today - Also on flagyl for empiric coverage of c. diff - Per CT, unlikely to be abdominal process # Hypotension, requiring Levophed: - Hypovolemia is possibly a factor- responded to a transfusion; HCT had been dropping - Sepsis also a factor- on broad spectrum abs - Central line in place. require further imaging # Transient hypotension: Has been somewhat fluid responsive; UOP ccs/hr. require further imaging # Transient hypotension: Has been somewhat fluid responsive; UOP ccs/hr. - f/u Cards recs # Sedation/Anxiolysis/AlteredMS: Resolved O/N with risperdal. - continue scopolamine patch q72hrs for secretions - Holding sedation with exception of Risperidal 0.5mg PRN - F/u CXR tomorrow # Sedation/Anxiolysis/AlteredMS: Resolved O/N with risperdal. - continue scopolamine patch q72hrs for secretions - Holding sedation with exception of Risperidal 0.5mg PRN - F/u CXR tomorrow # Sedation/Anxiolysis/AlteredMS: Resolved O/N with risperdal. # Sedation/Anxiolysis/AlteredMS: Resolved O/N with risperdal. # Sedation/Anxiolysis/AlteredMS: Resolved O/N with risperdal. # Sedation/Anxiolysis/AlteredMS: Resolving. A-FIB -- rate controlled on amioderone. Continue PT rehab. Scolpolamine patch d/cd d/t mental status. - CXR today - F/u cx data - If remains febrile, send sputum cx. # Fluid Status: Likely approaching euvolemia, though still has mild hypernatramia which may suggest is still intravascularly depleated. - f/u Cards recs # Sedation/Anxiolysis/AlteredMS: Resolved O/N. - f/u Cards recs # Sedation/Anxiolysis/AlteredMS: Resolved O/N with risperdal. - f/u Cards recs # Sedation/Anxiolysis/AlteredMS: Resolved O/N with risperdal. - f/u Cards recs # Sedation/Anxiolysis/AlteredMS: Resolved O/N. - f/u Cards recs # Sedation/Anxiolysis/AlteredMS: Resolved O/N. Today pt had a US of LUE to R/O DVT as a source of tachycardia. - CXR today - F/u cx data - If remains febrile, send sputum cx. # Fluid Status: Likely approaching euvolemia, though still has mild hypernatramia which may suggest is still intravascularly depleated. DVT and coagulopathy: reversed with IV Vit k hold coumadin today 4. DVT and coagulopathy: reversed with IV Vit k hold coumadin today 4. start PPN today if KUB + illeus Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin) Assessment: Tmax this shift 101.4 rectally Action: BC x2 sent and U/A C+S sent . # Code: Full # Dispo: ICU, Will d/w case management re rehab facilities. # Nutrition/Vomiting: Currently receiving TPN;. Will call and f/u psych recs. # UE DVT and elevated INR: Decision made to d/c Coumadin given her labile INR, and start Lovenox . | 703 | [
{
"category": "Physician ",
"chartdate": "2167-10-14 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 637511,
"text": "Chief Complaint: resp failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n s/p t spine fx with resp failure\n 24 Hour Events:\n BLOOD CULTURED - At 02:18 AM\n SPUTUM CULTURE - At 02:18 AM\n URINE CULTURE - At 02:18 AM\n FEVER Pan cx\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Ceftriaxone - 12:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Atrovent/Albuterol, Miralax, Chlorhex, Ceftriaxone, Thiamine Folate\n Valium 5 mg QID COumadin 2.5\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fever\n Flowsheet Data as of 08:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.8\n Tcurrent: 37.2\nC (99\n HR: 137 (120 - 151) bpm\n BP: 125/55(73) {98/41(54) - 202/97(111)} mmHg\n RR: 23 (12 - 39) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,934 mL\n 497 mL\n PO:\n TF:\n 1,104 mL\n 447 mL\n IVF:\n 1,000 mL\n 50 mL\n Blood products:\n Total out:\n 530 mL\n 240 mL\n Urine:\n 530 mL\n 240 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,404 mL\n 257 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 318 (318 - 475) mL\n PS : 10 cmH2O\n RR (Spontaneous): 34\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 171\n SpO2: 98%\n ABG: ///32/\n Ve: 9 L/min\n Physical Examination\n Gen sitting up in , on trach mask, interactive\n CV tachy RRR\n Chest good air movement ANT\n Abd soft NT + NS\n Ext: no edema\n Neuro: alert follows simple commands\n Labs / Radiology\n 8.8 g/dL\n 306 K/uL\n 134 mg/dL\n 0.6 mg/dL\n 32 mEq/L\n 4.0 mEq/L\n 11 mg/dL\n 106 mEq/L\n 146 mEq/L\n 26.8 %\n 7.5 K/uL\n [image002.jpg]\n 03:10 AM\n 03:08 PM\n 03:00 AM\n 03:36 AM\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n 05:00 AM\n 02:06 AM\n WBC\n 11.3\n 7.3\n 6.1\n 7.2\n 5.2\n 5.9\n 7.5\n Hct\n 24.9\n 27.6\n 26.5\n 26.9\n 26.0\n 27.2\n 26.8\n Plt\n 227\n 189\n 209\n 238\n 240\n 296\n 306\n Cr\n 0.7\n 0.6\n 0.6\n 0.9\n 0.7\n 0.6\n 0.7\n 0.6\n TCO2\n 26\n Glucose\n 114\n 99\n 115\n 106\n 100\n 134\n 134\n Other labs: PT / PTT / INR:13.5/23.6/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:27/19, Alk Phos / T Bili:118/0.3,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:243 IU/L, Ca++:9.2 mg/dL, Mg++:2.1 mg/dL, PO4:4.0\n mg/dL\n - Sputum: 3+ GPC cocci in prs and chains\n yeast\n Assessment and Plan 55 yr old alcoholic s/p t spine fx s/p trcah and\n PEG with persistent resp failure\n 1. Resp Failure: currently on trach mask, can do a few hours per\n day, then needs for support. New pan Klebs in sputum, day\n . Re- try. Holding off on stent by IP until after pulm rehab.\n 2. Fevers: DDx - line infection VAP, check LFTs, check blood and\n urine cx, LUE ultrasounds -\n 3 Hemodynamics: persistant simus tachy\n check CTPA to look for\n emboli- has been off on anti coag - tachycardia with slightly decreased\n UOP\n bolus IVF and trend UOP. Watch to see if response with\n tachycardia.\n 4. Anti coag: for upper ext DVT but INR elevated on coumadin +\n quinolone\n repeat inr low- trend with po COumadin\n 5. Adrenal Insufficiency: proper stim this AM, off steroids\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 06:23 AM 60 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-23 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 639169,
"text": "Chief Complaint: resp distress\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n UNPLANNED EXTUBATION (PATIENT-INITIATED) - At 03:50 PM\n Pt pulled out her trach tube, tube replaced\n FEVER - 101.4\nF - 12:00 AM\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Amiodarone - 0.5 mg/min\n Other ICU medications:\n Metoprolol - 01:00 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.4\n Tcurrent: 36.8\nC (98.2\n HR: 116 (84 - 142) bpm\n BP: 147/84(96) {86/39(53) - 181/113(137)} mmHg\n RR: 23 (13 - 27) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,127 mL\n 994 mL\n PO:\n TF:\n IVF:\n 2,127 mL\n 994 mL\n Blood products:\n Total out:\n 995 mL\n 900 mL\n Urine:\n 995 mL\n 900 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,132 mL\n 94 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: CPAP/PPS\n Vt (Set): 0 (0 - 0) mL\n Vt (Spontaneous): 360 (208 - 360) mL\n PS : 10 cmH2O\n RR (Set): 0\n RR (Spontaneous): 21\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 0 cmH2O\n SpO2: 99%\n ABG: ///31/\n Physical Examination\n Gen: lying in bed, alert, responding to questions, PMV placed\n CV; tachy RR\n Chest: bibasilar decreased BS, faint exp wheeze\n Abd: soft NT+BS\n Ext: no edema\n Skin: warm\n Neurologic: confused, stating that p[eople are trying to kill kill,\n that a owmna named is coming into her room\n Labs / Radiology\n 8.4 g/dL\n 346 K/uL\n 123 mg/dL\n 0.7 mg/dL\n 31 mEq/L\n 3.8 mEq/L\n 4 mg/dL\n 107 mEq/L\n 144 mEq/L\n 27.3 %\n 7.3 K/uL\n [image002.jpg]\n 02:58 AM\n 03:43 AM\n 05:02 PM\n 03:36 AM\n 02:30 AM\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n 03:00 AM\n WBC\n 7.1\n 7.1\n 6.9\n 7.6\n 9.5\n 5.7\n 7.3\n Hct\n 28.9\n 29.2\n 27.8\n 32.7\n 28.6\n 28.9\n 30.0\n 26.9\n 27.3\n Plt\n 462\n 452\n 467\n 548\n 528\n 356\n 346\n Cr\n 0.6\n 0.7\n 0.8\n 0.7\n 0.8\n 1.0\n 0.7\n 0.7\n Glucose\n 137\n 104\n 108\n 131\n 128\n 121\n 129\n 123\n Other labs: PT / PTT / INR:14.1/23.7/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.8 mg/dL, Mg++:1.9 mg/dL, PO4:3.7\n mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 06:31 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-23 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 639171,
"text": "Chief Complaint: resp distress\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n UNPLANNED EXTUBATION (PATIENT-INITIATED) - At 03:50 PM\n Pt pulled out her trach tube, tube replaced\n FEVER - 101.4\nF - 12:00 AM\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Amiodarone - 0.5 mg/min\n Other ICU medications:\n Metoprolol - 01:00 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.4\n Tcurrent: 36.8\nC (98.2\n HR: 116 (84 - 142) bpm\n BP: 147/84(96) {86/39(53) - 181/113(137)} mmHg\n RR: 23 (13 - 27) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,127 mL\n 994 mL\n PO:\n TF:\n IVF:\n 2,127 mL\n 994 mL\n Blood products:\n Total out:\n 995 mL\n 900 mL\n Urine:\n 995 mL\n 900 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,132 mL\n 94 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: CPAP/PPS\n Vt (Set): 0 (0 - 0) mL\n Vt (Spontaneous): 360 (208 - 360) mL\n PS : 10 cmH2O\n RR (Set): 0\n RR (Spontaneous): 21\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 0 cmH2O\n SpO2: 99%\n ABG: ///31/\n Physical Examination\n Gen: lying in bed, alert, responding to questions, PMV placed\n CV; tachy RR\n Chest: bibasilar decreased BS, faint exp wheeze\n Abd: soft NT+BS\n Ext: no edema\n Skin: warm\n Neurologic: confused, stating that p[eople are trying to kill kill,\n that a owmna named is coming into her room\n Labs / Radiology\n 8.4 g/dL\n 346 K/uL\n 123 mg/dL\n 0.7 mg/dL\n 31 mEq/L\n 3.8 mEq/L\n 4 mg/dL\n 107 mEq/L\n 144 mEq/L\n 27.3 %\n 7.3 K/uL\n [image002.jpg]\n 02:58 AM\n 03:43 AM\n 05:02 PM\n 03:36 AM\n 02:30 AM\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n 03:00 AM\n WBC\n 7.1\n 7.1\n 6.9\n 7.6\n 9.5\n 5.7\n 7.3\n Hct\n 28.9\n 29.2\n 27.8\n 32.7\n 28.6\n 28.9\n 30.0\n 26.9\n 27.3\n Plt\n 462\n 452\n 467\n 548\n 528\n 356\n 346\n Cr\n 0.6\n 0.7\n 0.8\n 0.7\n 0.8\n 1.0\n 0.7\n 0.7\n Glucose\n 137\n 104\n 108\n 131\n 128\n 121\n 129\n 123\n Other labs: PT / PTT / INR:14.1/23.7/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.8 mg/dL, Mg++:1.9 mg/dL, PO4:3.7\n mg/dL\n Assessment and Plan\n 1. Tachycardia: runs of attach Appreciate EP consult\n trying IV Amio.\n will increase bblocker. Have to convert to metoprolol 7.5mg IV Q4\n because unable to take pos.\n 2. Persistent Nausea/Vomiting: we have ruled out\n pSBO/SBO, very poor\n bowel sounds, tube study this AM shows contrast not moving out of the\n jejunum. GI consult to discuss any role for EGD. Place PICC for TPN as\n she has not had nutrition.\n 2. Resp Failure\n Trach mask trials all day, PSV\n PMV trials\n Per IP not stent planned as technically not possible to\n place into her airway\n 3. DVT and coagulopathy: reversed with IV Vit k\n hold coumadin today\n 4. Hypernatremia Replete free water.\n Please see today\ns ICU team note for other issues.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 06:31 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-29 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 640089,
"text": "Chief Complaint: Delerium\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Remains with delerium.\n Experienced episode of SVT --> responded to extra iv dose metoprolol.\n History obtained from Medical records\n Patient unable to provide history: Encephalopathy\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, Tube feeds, No(t) Parenteral nutrition\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, No(t) Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: No(t) Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 11:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.2\nC (97.2\n HR: 78 (61 - 115) bpm\n BP: 108/48(60) {91/36(50) - 156/79(101)} mmHg\n RR: 24 (17 - 30) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,952 mL\n 760 mL\n PO:\n TF:\n 646 mL\n 685 mL\n IVF:\n 950 mL\n 75 mL\n Blood products:\n Total out:\n 2,430 mL\n 610 mL\n Urine:\n 2,430 mL\n 380 mL\n NG:\n Stool:\n Drains:\n Balance:\n 522 mL\n 150 mL\n Respiratory support\n SpO2: 100%\n ABG: ///35/\n Physical Examination\n General Appearance: No(t) Well nourished, No acute distress, No(t)\n Overweight / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic,\n No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, Paradoxical), (Percussion:\n Resonant : , No(t) Hyperresonant: , No(t) Dullness : ), (Breath Sounds:\n Clear : , No(t) Crackles : , No(t) Bronchial: , No(t) Wheezes : , No(t)\n Diminished: , No(t) Absent : , No(t) Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\n Extremities: No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, No(t) Oriented (to): , Movement: Purposeful, No(t) Sedated,\n No(t) Paralyzed, Tone: Normal\n Labs / Radiology\n 7.2 g/dL\n 187 K/uL\n 105 mg/dL\n 0.5 mg/dL\n 35 mEq/L\n 3.8 mEq/L\n 17 mg/dL\n 108 mEq/L\n 147 mEq/L\n 23.7 %\n 5.1 K/uL\n [image002.jpg]\n 03:00 AM\n 04:00 AM\n 05:45 AM\n 03:51 AM\n 04:45 PM\n 04:00 AM\n 07:37 PM\n 04:05 AM\n 06:05 PM\n 03:23 AM\n WBC\n 7.3\n 8.0\n 8.7\n 5.5\n 5.7\n 5.8\n 5.1\n Hct\n 27.3\n 27.0\n 28.7\n 24.7\n 25.2\n 25.3\n 23.7\n 24.7\n 23.7\n Plt\n 346\n 316\n 271\n 249\n 231\n 203\n 187\n Cr\n 0.7\n 0.7\n 0.7\n 0.5\n 0.4\n 0.5\n 0.5\n 0.5\n Glucose\n 123\n 114\n 112\n 122\n 145\n 137\n 149\n 105\n Other labs: PT / PTT / INR:13.3/32.4/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.8 mg/dL, Mg++:2.1 mg/dL, PO4:3.5\n mg/dL\n Assessment and Plan\n T-spine fracture, delerium.\n DELERIUM -- persistent. Etiology may be related to prior EtOH use,\n contribution of medications. Intermittently oriented. Continue\n respiradol. Avoid medications that have psych complications or side\n effects.\n RESPIRATORY FAILURE -- s/p trach. Maintain trach for pulmonary\n toilet/frequent suctioning.\n TACHYCARDIA -- SVT. Continue amiodarone. Continue beta-blocker, with\n extra doses prn if needed.\n NUTRITIONAL SUPPORT -- TF via PEJ approaching goal.\n T-SPINE FRACTURE -- s/p fall. Tolerating back brace as per ortho\n service. Activity as tolerated (up in chair).\n ASPIRATION RISK -- poor adduction of vocal cords (post. portion).\n Eventually may require intervention.\n TRANCHEOBRONCHOMALACIA -- no interventions planned at present.\n ICU Care\n Nutrition:\n Replete with Fiber () - 09:45 PM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 55 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2167-09-24 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 634562,
"text": "Chief Complaint: respiratory failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n BLOOD CULTURED - At 12:24 AM\n URINE CULTURE - At 12:24 AM\n SPUTUM CULTURE - At 03:30 AM\n EKG - At 05:20 AM\n pt in junctional rhythem, holding stable BP, intern aware and came to\n assess pt. HR 47-50.\n Fever spike to 101\n Steroids started\n Antibiotics tailored\n PEEP decreased\n History obtained from Medical records, ICU team\n Patient unable to provide history: Sedated\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Metronidazole - 08:00 AM\n Levofloxacin - 08:39 AM\n Aztreonam - 06:00 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 100 mcg/hour\n Other ICU medications:\n Midazolam (Versed) - 03:50 PM\n Fentanyl - 03:50 PM\n Ranitidine (Prophylaxis) - 08:31 PM\n Other medications:\n versed, fentanyl, colace, H2B, CHG, SQI, MDIs, heparin infusion,\n levoflox, aztreonam, hydrocortisone 50 q6, fludrocort\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (101\n Tcurrent: 37.1\nC (98.8\n HR: 57 (48 - 86) bpm\n BP: 102/48(61) {102/46(61) - 121/52(66)} mmHg\n RR: 22 (17 - 23) insp/min\n SpO2: 99%\n Heart rhythm: JR (Junctional Rhythm)\n Wgt (current): 101 kg (admission): 94.2 kg\n Height: 67 Inch\n CVP: 11 (11 - 20)mmHg\n Bladder pressure: 12 (12 - 12) mmHg\n Total In:\n 1,708 mL\n 460 mL\n PO:\n TF:\n 182 mL\n 138 mL\n IVF:\n 1,267 mL\n 321 mL\n Blood products:\n Total out:\n 877 mL\n 1,305 mL\n Urine:\n 727 mL\n 1,275 mL\n NG:\n 30 mL\n Stool:\n Drains:\n Balance:\n 831 mL\n -845 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 21 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 36 cmH2O\n Plateau: 29 cmH2O\n Compliance: 50 cmH2O/mL\n SpO2: 99%\n ABG: 7.46/38/96./26/2\n Ve: 8.6 L/min\n PaO2 / FiO2: 242\n Physical Examination\n General Appearance: Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear :\n anteriorly)\n Abdominal: Soft, Non-tender, Obese\n Extremities: Right: 1+, Left: 1+\n Musculoskeletal: Unable to stand\n Skin: Warm\n Neurologic: Responds to: Unresponsive, Movement: No spontaneous\n movement, Sedated, Tone: Normal\n Labs / Radiology\n 8.9 g/dL\n 326 K/uL\n 151 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 3.6 mEq/L\n 2 mg/dL\n 108 mEq/L\n 141 mEq/L\n 28.6 %\n 8.9 K/uL\n [image002.jpg]\n 02:02 AM\n 03:59 AM\n 09:14 PM\n 01:04 AM\n 05:54 AM\n 06:11 AM\n 11:07 PM\n 03:51 AM\n 06:17 AM\n 08:18 AM\n WBC\n 8.4\n 8.1\n 8.9\n Hct\n 28.1\n 28.0\n 28.6\n Plt\n 376\n 358\n 326\n Cr\n 0.6\n 0.7\n 0.7\n TCO2\n 25\n 28\n 28\n 26\n 26\n 21\n 28\n Glucose\n 120\n 126\n 151\n Other labs: PT / PTT / INR:24.3/68.6/2.4, CK / CKMB / Troponin-T:24//,\n ALT / AST:24/16, Alk Phos / T Bili:117/0.7, Amylase / Lipase:,\n Differential-Neuts:82.5 %, Lymph:11.6 %, Mono:3.3 %, Eos:2.2 %, Lactic\n Acid:0.7 mmol/L, Albumin:2.4 g/dL, LDH:204 IU/L, Ca++:8.5 mg/dL,\n Mg++:2.1 mg/dL, PO4:2.5 mg/dL\n Imaging: CXR: increased right base opacity\n Microbiology: Sputum from overnight: GPCs with 2+ GPCs in\n pairs/clusters and 2+ GPRs\n Prior sputum growing GNRs\n Assessment and Plan\n Fever\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 01:36 AM\n Arterial Line - 03:00 AM\n Multi Lumen - 11:30 AM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Heparin gtt)\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent:\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-14 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 637507,
"text": "Chief Complaint: resp failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n s/p t spine fx with resp failure\n 24 Hour Events:\n BLOOD CULTURED - At 02:18 AM\n SPUTUM CULTURE - At 02:18 AM\n URINE CULTURE - At 02:18 AM\n FEVER Pan cx\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Ceftriaxone - 12:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fever\n Flowsheet Data as of 08:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.8\n Tcurrent: 37.2\nC (99\n HR: 137 (120 - 151) bpm\n BP: 125/55(73) {98/41(54) - 202/97(111)} mmHg\n RR: 23 (12 - 39) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,934 mL\n 497 mL\n PO:\n TF:\n 1,104 mL\n 447 mL\n IVF:\n 1,000 mL\n 50 mL\n Blood products:\n Total out:\n 530 mL\n 240 mL\n Urine:\n 530 mL\n 240 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,404 mL\n 257 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 318 (318 - 475) mL\n PS : 10 cmH2O\n RR (Spontaneous): 34\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 171\n SpO2: 98%\n ABG: ///32/\n Ve: 9 L/min\n Physical Examination\n Labs / Radiology\n 8.8 g/dL\n 306 K/uL\n 134 mg/dL\n 0.6 mg/dL\n 32 mEq/L\n 4.0 mEq/L\n 11 mg/dL\n 106 mEq/L\n 146 mEq/L\n 26.8 %\n 7.5 K/uL\n [image002.jpg]\n 03:10 AM\n 03:08 PM\n 03:00 AM\n 03:36 AM\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n 05:00 AM\n 02:06 AM\n WBC\n 11.3\n 7.3\n 6.1\n 7.2\n 5.2\n 5.9\n 7.5\n Hct\n 24.9\n 27.6\n 26.5\n 26.9\n 26.0\n 27.2\n 26.8\n Plt\n 227\n 189\n 209\n 238\n 240\n 296\n 306\n Cr\n 0.7\n 0.6\n 0.6\n 0.9\n 0.7\n 0.6\n 0.7\n 0.6\n TCO2\n 26\n Glucose\n 114\n 99\n 115\n 106\n 100\n 134\n 134\n Other labs: PT / PTT / INR:13.5/23.6/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:27/19, Alk Phos / T Bili:118/0.3,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:243 IU/L, Ca++:9.2 mg/dL, Mg++:2.1 mg/dL, PO4:4.0\n mg/dL\n Assessment and Plan 55 yr old alcoholic s/p t spine fx s/p trcah and\n PEG with persistent resp failure\n 1. Resp Failure: currently on trach mask, can do a few hours per\n day, then needs for support. New pan Klebs in sputum, day\n . Re- try. Holding off on stent by IP until after pulm rehab.\n 2. Hemodynamics: tachycardia with slightly decreased UOP\n bolus\n IVF and trend UOP. Watch to see if response with tachycardia.\n 3. Anti coag: for upper ext DVT but INR elevated on coumadin +\n quinolone\n repeat inr low- trend with po COumadin\n 4. Adrenal Insufficiency: proper stim this AM, off steroids\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 06:23 AM 60 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2167-09-29 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 635064,
"text": "Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - STOP 09:00 PM - attempted to re-wire but\n patient was very agitated and re-wire was unsuccessful\n Patient alternated between tachycardia and normotension and hypotension\n in the high-80s/low 90s and HRs in the 50s\n Given haldol, valium, midaz and fentanyl for sedation\n ABG with low paO2 on PEEP 10, had to increase -- went back up to 15 and\n then attempted to re-wean down with goal 8 in anticipation of OR\n To OR for trach and PEG today (thoracics)\n Put on lasix drip and put out >1L in just over an hour\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 08:06 AM\n Infusions:\n Midazolam (Versed) - 1.5 mg/hour\n Fentanyl - 200 mcg/hour\n Other ICU medications:\n Fentanyl - 06:45 PM\n Ranitidine (Prophylaxis) - 08:00 PM\n Haloperidol (Haldol) - 10:00 PM\n Midazolam (Versed) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.7\nC (99.8\n HR: 109 (55 - 134) bpm\n BP: 120/56(70) {80/43(51) - 133/85(94)} mmHg\n RR: 20 (16 - 28) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 101 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 3,064 mL\n 404 mL\n PO:\n TF:\n 1,440 mL\n IVF:\n 1,014 mL\n 314 mL\n Blood products:\n Total out:\n 4,257 mL\n 1,195 mL\n Urine:\n 4,257 mL\n 1,195 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,193 mL\n -791 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 18\n RR (Spontaneous): 10\n PEEP: 15 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10\n PIP: 23 cmH2O\n Plateau: 24 cmH2O\n SpO2: 97%\n ABG: 7.46/48/65/31/8\n Ve: 7.8 L/min\n PaO2 / FiO2: 108\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 320 K/uL\n 8.0 g/dL\n 94 mg/dL\n 0.6 mg/dL\n 31 mEq/L\n 3.6 mEq/L\n 13 mg/dL\n 110 mEq/L\n 147 mEq/L\n 25.8 %\n 9.0 K/uL\n [image002.jpg]\n 10:18 AM\n 02:33 PM\n 02:46 PM\n 03:31 AM\n 02:26 PM\n 05:53 PM\n 05:01 AM\n 03:32 PM\n 10:19 PM\n 02:50 AM\n WBC\n 9.7\n 9.5\n 9.0\n Hct\n 26.0\n 27.6\n 25.8\n Plt\n \n Cr\n 0.5\n 0.5\n 0.5\n 0.6\n 0.6\n TCO2\n 29\n 26\n 27\n 30\n 30\n 35\n Glucose\n 195\n 195\n 163\n 133\n 102\n 94\n Other labs: PT / PTT / INR:14.1/59.6/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:71.2 %, Lymph:22.7 %,\n Mono:4.0 %, Eos:1.7 %, Lactic Acid:1.5 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:8.2 mg/dL, Mg++:2.1 mg/dL, PO4:4.6 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with respiratory failure\n and difficulty weaning from vent.\n # Respiratory failure: Intubated on for resp decompensation.\n Likely VAP. Transferred here for tracheomalacia, but not sure this\n is a component. Will need bronch eval when improved\n - will discuss PEEP goal for trach placement with IP.\n - wean PEEP\n - repeat ABG this AM\n - discuss need for trach with patient and her family\n - Volume overload may be contributing.\n # Volume overload\n Currently with hypernatremia, Cr increase, contract\n alk, but mild\n - continue gentle diuresis\n - FW in TF at 150 cc q4hrs\n - PM lytes.\n # Sedation: On versed 3mg/hr + .5 q 1hr and fentanyl 150 mcg/hr + 50\n bolus q 1hr.\n - Start fentanyl patch and diazepam to provide long acting analgesia\n and wean from drips\n - Haldol 1 mg Q4h PRN agitation\n # Pneumonia: Pansensitive Kleb oxytoca pneumonia and sputum with GPCs\n on gram stain. Afebrile off abx.\n # EKG changes: Sinus bradycardia, responsive to stress. Related to\n sedation, increased vagal tone, possibly related to steroid\n replacement. Atrial EKG shows p-waves and cardiac enzymes normal.\n - Continue to monitor\n # Hypotension: Improved, off levophed for 2-3 days now, with good urine\n output. s/p 5 d course of steroids for adrenal insufficiency. High\n PEEP may have been contributing. Now likely related to sedation and\n decreased intravascular volume,\n -monitor, expect improvement with continual reduction in\n PEEP\n # RUE DVT: Started on heparin gtt on , now therapeutic. Follow\n PTTs. Would hold off on coumadin at least until s/p trach.\n - continue to monitor\n # Adrenal Insufficency: Random cortisol was approx 3 when it should\n have been maximally stimulated.\n - hydrocortisone and florinef for 5 days\n # Anemia: Stable.\n - Trend HCT\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n FEN/GI: Tube feeds @ goal\n DVT: Treatment dose heparin\n Ulcer: Ranitidine\n VAP: Prevention per routine\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 639585,
"text": "Chief Complaint:\n 24 Hour Events:\n Pt agitated overnight given extra Risperidone 0.5 mg x 2 overnight.\n (1.5mg total)\n 1000 mL D5W for Hypernatremia\n Changed B-Blocker from IV to PO, Metoprolol Tartrate 25 mg PO TID\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:17 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.7\nC (98\n HR: 120 (67 - 120) bpm\n BP: 110/64(76) {109/47(60) - 141/115(118)} mmHg\n RR: 26 (18 - 30) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 3,820 mL\n 856 mL\n PO:\n TF:\n 117 mL\n 20 mL\n IVF:\n 2,612 mL\n 572 mL\n Blood products:\n Total out:\n 2,460 mL\n 1,180 mL\n Urine:\n 2,460 mL\n 1,180 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,360 mL\n -324 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 100%\n ABG: ///33/\n Physical Examination\n Gen: Awake, Mouthing words, More agitated compared to previous\n mornings.\n HEENT: EOMI, No pallor in conjunctiva, MMM\n Resp: CTAB, no rales, rhonchi, or wheezing, good airway movement.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, decreased bowel sounds,, G-Tube in\n place with no erythema/induration\n Exte: No edema, DP 2+ bil\n NEURO: Gross Motor and Sensation in 4 extremities\n Labs / Radiology\n 249 K/uL\n 8.0 g/dL\n 122 mg/dL\n 0.5 mg/dL\n 33 mEq/L\n 3.7 mEq/L\n 13 mg/dL\n 108 mEq/L\n 146 mEq/L\n 24.7 %\n 5.5 K/uL\n [image002.jpg] CXR: L Picc, trach tip at midline, bibasilar\n opacities, low lung volumes, Bil pleural effusions.\n 03:36 AM\n 02:30 AM\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n 03:00 AM\n 04:00 AM\n 05:45 AM\n 03:51 AM\n WBC\n 6.9\n 7.6\n 9.5\n 5.7\n 7.3\n 8.0\n 8.7\n 5.5\n Hct\n 27.8\n 32.7\n 28.6\n 28.9\n 30.0\n 26.9\n 27.3\n 27.0\n 28.7\n 24.7\n Plt\n 467\n 548\n 528\n 356\n 346\n 316\n 271\n 249\n Cr\n 0.7\n 0.8\n 1.0\n 0.7\n 0.7\n 0.7\n 0.7\n 0.5\n Glucose\n 131\n 128\n 121\n 129\n 123\n 114\n 112\n 122\n Other labs: PT / PTT / INR:13.6/31.1/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:9.0 mg/dL, Mg++:2.2 mg/dL, PO4:3.1\n mg/dL\n Assessment and Plan\n 56yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach/PEG with resolving respiratory failure and HAP.\n .\n # Respiratory failure: s/p intubation/extubation, now on trach mask,\n FiO2 70%. Tolerating well with good O2 sat. No further\n self-decanulations overnight.\n - Tach mask as tolerated.\n - Holding sedation with exception of Risperidal 0.5mg .\n - F/u CXR tomorrow\n .\n # Nutrition/Vomiting: Currently receiving TPN;. One large BM in past\n 24 hrs to indicate potential improvement in ileus.\n - Cont Reglan 20mg IV Q 8 hours; meds via G-J tube,\n - Will obtain recommendations from Nutrition re TPN before starting TPN\n tomorrow\n - Increase TF as tolerated\n - Speech and Swallow eval\n - PICC line in place with TPN given when pt not tolerating TF\n - GI consult, appreciate recs\n .\n # Tachycardia: Improved HR max of 120\ns versus 160s previously;\n elevated this am secondary to agitation. Pt now on PO Amiodarone 200\n TID and PO metoprolol 25mg TID\n - Continue current med regimen. Will continue amiodarone 200 TID for\n three weeks and then switch to qday.\n - Will schedule f/u in 4wks with Dr. upon d/c.\n - f/u Cards recs\n # Sedation/Anxiolysis/AlteredMS: Agitation O/N, continues to be\n agitated most likely secondary to long hospital course and multiple\n psychotropic medications as well as hx of EtOH abuse. Risperdal given\n O/N.\n - started Risperdal 0.5mg PO BID\n - continue to hold all benzos. opiates, and antihistamines\n - Appreciate psych. Will f/u psych recs.\n .\n # Hypernatremia/Fluid Status: Mild hypernatramia with good UOP\n (hypervolemic hypernatremia). On TPN/TF.\n - providing D5W IVF PRN and follow lytes (check Na this afternoon).\n # UE DVT and elevated INR: Decision made to d/c Coumadin given her\n labile INR, and start Lovenox . Current INR 1.2.\n - Will flush L PICC with TPA\n .\n # Spine fracture: Stable\n - Brace for OOB, will discuss with Neurosurgery if current brace is\n optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n .\n # Tracheomalacia. Was initially addressed with IP and they wanted to\n follow up as outpatient. IP reevaluated and does not believe that a\n stent would be feasible.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # ACCESS: PIV x 1, L PICC\n # Ppx: Lovenox, PPi, Bowel Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n - Social Work and Case management involved, have discussed situation\n w/ brother and boyfriend.\n # Code: Full\n # Dispo: ICU, Screening for vent facilities\n"
},
{
"category": "Radiology",
"chartdate": "2167-10-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1034896,
"text": " 3:25 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? interval change, ? RLL process\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with respiratory failure\n REASON FOR THIS EXAMINATION:\n ? interval change, ? RLL process\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 3:31 A.M. ON \n\n HISTORY: Respiratory failure, question interval change in right lower lobe\n process.\n\n IMPRESSION: AP chest compared to , 7:58 p.m.\n\n Pulmonary vascular congestion and mild edema have developed. Consolidation in\n the right lower lung has progressed, probably worsening atelectasis. The\n examination is positioned though as to underestimate the distance of the ET\n tube from the carina. It ends above the level of the clavicles, and with the\n chin down, and is at least 5 cm too high.\n\n Dr. was paged to report these at the time of dictation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-09-30 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1034491,
"text": ", F. MED MICU 7:28 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: please eval ET tube placement\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with respiratory failure, unable to see ET tube and carina on\n film from this AM.\n REASON FOR THIS EXAMINATION:\n please eval ET tube placement\n ______________________________________________________________________________\n PFI REPORT\n ET tube tip 5.5 cm above the carina. Impingement of the left tracheal wall by\n the ET tube that should be re-positioned.\n\n Interval improvement of pulmonary edema.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-09-27 00:00:00.000",
"description": "BY SAME PHYSICIAN",
"row_id": 1033999,
"text": " 2:21 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: Pt had a left sided picc line placed,51cm and needs tip conf\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with Respiratory Failure who needs picc line for IV access.\n REASON FOR THIS EXAMINATION:\n Pt had a left sided picc line placed,51cm and needs tip confirmation please\n page at with wet read,thanks.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST \n\n CLINICAL INFORMATION: PICC line placement.\n\n FINDINGS:\n\n COMPARISON STUDY: at 04:22 hours.\n\n Left PICC has been placed. The tip terminates at the right atrium. The\n endotracheal tube terminates at the carina and should be pulled back. The\n nasogastric tube terminates in the stomach. Right IJ catheter terminates in\n the superior vena cava. The heart is enlarged. Mediastinum is within normal\n limits. There is a small left pleural effusion with a very small right\n pleural effusion. There is elevation of the right hemidiaphragm. There is\n bibasilar atelectasis.\n\n IMPRESSION:\n\n 1. Left PICC terminates in the right atrium.\n\n 2. Small bilateral pleural effusions with bibasilar atelectasis.\n Cardiomegaly.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-10-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1034678,
"text": " 3:43 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval lines/tubes/infiltrates\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with VAP and ARDS\n REASON FOR THIS EXAMINATION:\n eval lines/tubes/infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Ventilator-associated pneumonia and ARDS.\n\n FINDINGS: A semi-upright frontal bedside chest radiograph compared to\n and demonstrates no significant change. The lung volumes\n are low. There are moderate bilateral layering effusions. There is a large\n left retrocardiac atelectasis. There is mild pulmonary overload. The ETT is\n 3 cm above the carina. NG tube is in the stomach. A left central venous\n catheter tip terminates in the SVC.\n\n IMPRESSION: No marked interval change in mild pulmonary edema, bilateral\n effusions, and large left retrocardiac atelectasis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-09-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1033919,
"text": " 1:28 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval lines/tubes/infiltrates\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with respiratory failure with VAP\n REASON FOR THIS EXAMINATION:\n eval lines/tubes/infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST \n\n CLINICAL INFORMATION: Respiratory failure.\n\n FINDINGS:\n\n Endotracheal tube terminates just above the thoracic inlet in appropriate\n position. Nasogastric tube courses below the diaphragm. Right IJ catheter\n terminates in the superior vena cava.\n\n There are moderate bilateral pleural effusions and bibasilar atelectasis.\n There is essentially no change in the appearance of the chest since the prior\n study.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-09-20 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1032610,
"text": " 7:01 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: position of Left IJ\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with resp failure s/p left IJ placement.\n REASON FOR THIS EXAMINATION:\n position of Left IJ\n ______________________________________________________________________________\n FINAL REPORT\n\n\n HISTORY: Left IJ placement.\n\n FINDINGS: Left IJ central line is malpositioned, coursing towards the left\n axilla. New left apical pleural capping could reflect the re-distribution of\n effusion since the patient was in the Trendelenburg position for the\n procedure, though the possibility of a hematoma complicating the line\n placement must be considered. This information was discussed by the radiology\n resident with Dr. .\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-09-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1032921,
"text": " 9:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Assess tube position\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with respiratory distress, intubated. S/P repositioning of\n ET tube.\n REASON FOR THIS EXAMINATION:\n Assess tube position\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Respiratory distress status post re-positioning of endotracheal\n tube.\n\n FINDINGS: In comparison with the study of , the endotracheal tube tip now\n lies approximately 7.4 cm above the carina. There is little overall change in\n the appearance of heart and lungs. Elevation of the right hemidiaphragm\n persists with bibasilar effusions and atelectatic change.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-09-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1033342,
"text": " 2:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Assess ET tube placement\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with repiratory failure, intubated\n REASON FOR THIS EXAMINATION:\n Assess ET tube placement\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 9:52 AM\n No change.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Assessment of endotracheal tube placement.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is no relevant\n change. The monitoring and support devices are in unchanged position. The\n tip of the endotracheal tube projects 5.7 cm above the carina.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-09-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1033343,
"text": ", D. MED MICU 2:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Assess ET tube placement\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with repiratory failure, intubated\n REASON FOR THIS EXAMINATION:\n Assess ET tube placement\n ______________________________________________________________________________\n PFI REPORT\n No change.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-09-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1034241,
"text": " 2:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? Interval change\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with recent ARDS\n REASON FOR THIS EXAMINATION:\n ? Interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Desaturation.\n\n FINDINGS: In comparison with study of , there is little overall change.\n Again, there is enlargement of the cardiac silhouette with basilar atelectasis\n and bilateral effusions. Elevation of the right hemidiaphragmatic contour\n persists. Again, it is difficult to evaluate the area behind the heart in the\n absence of a lateral view. Tubes remain in place.\n\n IMPRESSION: Little change.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-09-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1034222,
"text": " 10:24 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: atelectasis vs edema\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman intubated with recent desats.\n REASON FOR THIS EXAMINATION:\n atelectasis vs edema\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Intubated with the recent desaturation.\n\n FINDINGS: In comparison with study earlier in this date, there is again\n enlargement of the cardiac silhouette with bilateral pleural effusion and\n bibasilar atelectasis. Elevation of the right hemidiaphragmatic contour\n persists. The area behind the heart is difficult to evaluate in the absence\n of a lateral view. Tubes remain in place.\n\n IMPRESSION: Little change.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-09-30 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1034454,
"text": ", F. MED MICU 3:16 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?Interval change\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with respiratory failure\n REASON FOR THIS EXAMINATION:\n ?Interval change\n ______________________________________________________________________________\n PFI REPORT\n Increase in bilateral pleural effusions.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-09-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1033096,
"text": " 2:45 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? tube/line position, infiltrates\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with respiratory failure, T8 fracture.\n REASON FOR THIS EXAMINATION:\n ? tube/line position, infiltrates\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): PSS WED 10:36 AM\n ET tube, right jugular line, NG tube okay. Left lower lobe atelectasis\n improved. Mild pulmonary edema improved.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 3 A.M. \n\n HISTORY: Respiratory failure. T8 fracture. Check lines and tubes.\n\n IMPRESSION: AP chest compared to :\n\n ET tube, right jugular line, in standard placements. Nasogastric tube passes\n below the diaphragm and out of view. Mild pulmonary edema has improved,\n previously severe left lower lobe atelectasis and milder right basal\n atelectasis have also improved. No pneumothorax. Small pleural effusion is\n presumed. Heart size normal.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-09-20 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1032618,
"text": " 8:20 PM\n PORTABLE ABDOMEN Clip # \n Reason: ? ileus v obstruction\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with respiratory failure, distended abdomen.\n REASON FOR THIS EXAMINATION:\n ? ileus v obstruction\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 55-year-old woman with respiratory failure and distended abdomen.\n Concern for ileus versus obstruction.\n\n COMPARISON: Portable abdominal radiograph .\n\n FINDINGS: A single AP supine portable radiograph of the abdomen was obtained\n demonstrating a nasogastric tube with termination in the stomach. There are\n no air-fluid levels or dilated loops of large or small bowel. There is no\n evidence of pneumatosis or pneumoperitoneum. A few surgical clips are noted\n to project over the right sacroiliac joint. Patient is status post left hip\n arthroplasty. Mild convex left thoracolumbar scoliosis may be explained by\n positioning.\n\n IMPRESSION: No obstruction.\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-09-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1032860,
"text": " 11:12 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Assess ET tube possition\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with acute respiraotry distress. Acute desaturation.\n REASON FOR THIS EXAMINATION:\n Assess ET tube possition\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: To assess for endotracheal tube position.\n\n FINDINGS: In comparison with earlier study of this date, there are continued\n bilateral pleural effusions with atelectatic changes especially in the\n retrocardiac region. The endotracheal tube tip lies approximately 6.7 cm\n above the carina. Nasogastric tube and right IJ catheter remain in place.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-09-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1033097,
"text": ", D. MED MICU 2:45 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? tube/line position, infiltrates\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with respiratory failure, T8 fracture.\n REASON FOR THIS EXAMINATION:\n ? tube/line position, infiltrates\n ______________________________________________________________________________\n PFI REPORT\n ET tube, right jugular line, NG tube okay. Left lower lobe atelectasis\n improved. Mild pulmonary edema improved.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-09-20 00:00:00.000",
"description": "RP UNILAT UP EXT VEINS US RIGHT PORT",
"row_id": 1032570,
"text": " 11:50 AM\n UNILAT UP EXT VEINS US RIGHT PORT Clip # \n Reason: EVAL FOR UPPER EXT DVT, SWELLING\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with PICC with arm swelling\n REASON FOR THIS EXAMINATION:\n eval upper extremity DVT\n ______________________________________________________________________________\n WET READ: DXAe SUN 1:21 PM\n 1. 2 cm Nonocclusive DVT in the right axillary vein\n\n 2. 1 cm superficial nonocclusive thrombus in the basillic vein).\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 55-year-old woman with PICC line and arm swelling, evaluate for\n upper extremity DVT.\n\n COMPARISON: None.\n\n FINDINGS: Grayscale and Doppler imaging of the right superficial and deep\n veins was performed. There is a non-occlusive thrombus in the right axillary\n vein spanning 2 cm. There is also a non-occlusive thrombus in the right\n basilic vein. The other veins including the internal jugular, brachial veins\n demonstrate normal compressibility, augmentation, and waveforms.\n\n IMPRESSION:\n\n 1. Non-occlusive right axillary deep vein thrombus.\n\n 2. Non-occlusive right basilic superficial thrombosis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-09-30 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1034490,
"text": " 7:28 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: please eval ET tube placement\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with respiratory failure, unable to see ET tube and carina on\n film from this AM.\n REASON FOR THIS EXAMINATION:\n please eval ET tube placement\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLnc WED 11:20 AM\n ET tube tip 5.5 cm above the carina. Impingement of the left tracheal wall by\n the ET tube that should be re-positioned.\n\n Interval improvement of pulmonary edema.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of ET tube tip.\n\n Portable AP chest radiograph was compared to .\n\n The ET tube tip is impinging the left tracheal wall and should be\n re-positioned. Its tip is approximately 5.5 cm above the carina.\n\n The NG tube tip is in the stomach. The interval improvement in pulmonary\n edema and slight decrease in pleural effusions is demonstrated. There is no\n change in left retrocardiac opacity consistent with atelectasis. There is no\n pneumothorax.\n\n IMPRESSION: ET tube tip 5.5 cm above the carina impinging the left tracheal\n wall and should be re-positioned.\n\n Interval improvement of pulmonary edema and slight decrease in pleural\n effusions.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-09-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1033806,
"text": " 3:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate tubes/lines, infiltrates\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with respiratory failure, ARDS, VAP.\n REASON FOR THIS EXAMINATION:\n please evaluate tubes/lines, infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST \n\n CLINICAL INFORMATION: Respiratory failure, ARDS.\n\n FINDINGS:\n\n Since the prior study from , there has been increased bilateral pleural\n effusions, moderate on the right, small to moderate on the left, with\n bilateral lower lobe consolidation. There is cardiomegaly.\n\n Endotracheal tube terminates in the thoracic inlet. Right IJ catheter\n terminates in the superior vena cava. Endotracheal tube courses below the\n diaphragm and the tip is not seen. Multiple lines project over the chest.\n\n IMPRESSION:\n\n Interval worsening, with increased bilateral pleural effusions and bibasilar\n consolidation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-09-20 00:00:00.000",
"description": "BY SAME PHYSICIAN",
"row_id": 1032632,
"text": " 10:37 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: ? pneumothorax\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with respiratory failure, s/p attempted right sided CVL.\n REASON FOR THIS EXAMINATION:\n ? pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Respiratory failure status post attempted right central venous\n pressure insertion.\n\n FINDINGS: In comparison with study of , there is little change in the\n appearance of the heart and lungs. Specifically, no evidence of pneumothorax\n after the attempted central line placement.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-09-21 00:00:00.000",
"description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY",
"row_id": 1032824,
"text": " 4:59 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: eval structures, bleeding, spinal cord impingement\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n Field of view: 42 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with respiratory failure, T5-T8 fracture, hypotension\n REASON FOR THIS EXAMINATION:\n eval structures, bleeding, spinal cord impingement\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AHPb MON 9:28 PM\n Right lower lobe consolidation, and superimposed atelectasis/lower lobe\n collapse, and effusions. Acute T8 compression deformity, with no posterior\n retropulsion of fracture fragments. No associated hematoma.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Respiratory failure, T5 through T8 fracture, hypotension,\n evaluate structures, bleeding, spinal cord impingement.\n\n COMPARISON: None.\n\n TECHNIQUE: MDCT of the chest, abdomen, and pelvis performed before and after\n the uneventful administration of 130 cc Optiray contrast. Multiplanar\n reformatted images were also obtained and reviewed.\n\n CTA CHEST: The pulmonary arteries opacify normally without evidence for\n filling defects. Evaluation of the subsegmental pulmonary arteries is limited\n lower lobe collapse and body habitus. The main pulmonary artery is top normal\n in size which could be secondary to mild pulmonary hypertension. The heart\n and great vessels of the mediastinum are otherwise unremarkable. There are\n coronary artery calcifications. NG tube terminates in the stomach.\n Endotracheal tube terminates in the mid thoracic trachea. The airways are\n patent to the segmental level but collapsed more distally in the right middle\n and lower lobes.\n\n There is total collapse of the right middle and lower lobes. There is\n atelectasis of the right upper lobe and superimposed patchy opacities and most\n prominent in the basal portions of the right upper lobe, consistent with\n aspiration or infection. There is also partial collapse of the left lower lobe\n and left upper lobe. There are small bilateral pleural effusions. There is\n presternal fluid and soft tissue stranding (3:15).\n\n CT ABDOMEN WITH CONTRAST: The liver, gallbladder, pancreas, spleen, stomach,\n adrenal glands, kidneys, and small bowel loops are unremarkable aside from\n small gallstones and right upper pole renal cyst. There is no free air, free\n fluid, or pathologic adenopathy. Incidental note of a small duodenal\n diverticulum.\n\n CT PELVIS WITH CONTRAST: The rectum, sigmoid, and large bowel are remarkable\n for sigmoid diverticulosis. There is a 7.5 cm x 3.0 cm tubular fluid density\n (Over)\n\n 4:59 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: eval structures, bleeding, spinal cord impingement\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n Field of view: 42 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n structure in continuation with the cecum in the anticipated location of the\n appendix without adjacent inflammatory stranding. Surgical sutures are\n present at the tip of this lesion. Foley is present within a collapsed\n bladder. There is mild diffuse anasarca.\n\n OSSEOUS STRUCTURES: There is an acute compression deformity of the T8\n vertebral body with approximately 25% loss of height, and no retropulsion of\n fracture fragments, and no associated hematoma. Evaluation of the contents of\n the spinal canal is limited by CT, but there is no evidence for gross cord\n compression. Please see CT T-spine from today for further details.\n\n IMPRESSION:\n 1. Collapse of the right middle and lower lobes with atelectasis of the right\n upper lobe.\n 2. Superimposed patchy opacities in right upper lobe consistent with\n aspiration, infection, or combination.\n 3. Partial collapse of left lower lobe and upper lobe.\n 4. Acute T8 compression deformity without retropulsion of fracture fragments.\n 5. Incidental appendiceal mucocele versus mucinous cystadenoma. Correlation\n of abdominal surgery recommended given adjacent sutures. Recurrence of\n previously excised lesion is a possibility.\n\n These findings were communicated with Dr. at 6:30 p.m., .\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-09-21 00:00:00.000",
"description": "CT PELVIS W/CONTRAST",
"row_id": 1032825,
"text": ", D. MED MICU 4:59 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: eval structures, bleeding, spinal cord impingement\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n Field of view: 42 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with respiratory failure, T5-T8 fracture, hypotension\n REASON FOR THIS EXAMINATION:\n eval structures, bleeding, spinal cord impingement\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Right lower lobe consolidation, and superimposed atelectasis/lower lobe\n collapse, and effusions. Acute T8 compression deformity, with no posterior\n retropulsion of fracture fragments. No associated hematoma.\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-09-21 00:00:00.000",
"description": "CT T-SPINE W/ CONTRAST",
"row_id": 1032826,
"text": " 5:00 PM\n CT T-SPINE W/ CONTRAST Clip # \n Reason: eval structures, bleeding, spinal cord impingement\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with respiratory failure, T5-T8 fracture, hypotension\n REASON FOR THIS EXAMINATION:\n eval structures, bleeding, spinal cord impingement\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Respiratory failure, T5 through 8 fracture, hypotension. Please\n evaluate for spinal cord impingement.\n\n TECHNIQUE: MDCT of the thoracic spine without contrast displayed in 3.75 mm\n axial collimation. Coronal and sagittal reformatted images were also obtained\n and reviewed.\n\n COMPARISON: CT chest, abdomen and pelvis from same day.\n\n CT THORACIC SPINE WITHOUT CONTRAST: There is an acute compression deformity\n of the T8 vertebral body with approximately 25% loss of height. There is no\n retropulsion of fracture fragments. Fracture lines do not extend into the\n posterior elements. Although evaluation of the spinal cord is limited by CT,\n there is no evidence for gross cord compression. There is also mild loss of\n height at T5. The remaining thoracic and visualized lumbar vertebrae are\n normal.\n\n Evaluation of the lung fields demonstrates complete collapse of the right\n lower and middle lobes with partial collapse/atelectasis of the right upper\n and left upper lobes. Superimposed patchy opacities in the right upper lobe\n suggest aspiration, infection, or combination. Note is also made of a 1-cm\n calcified granuloma in the left lung. NG tube courses into the stomach. ETT\n terminates in the mid thoracic trachea.\n\n IMPRESSION:\n 1. T8 compression deformity with 25% loss of height and no retropulsion of\n fracture fragments. Mild loss of height at T5.\n 2. Multifocal pumonary collapse and consolidation. Please see the\n accompanying CT chest, abdomen and pelvis for further details.\n\n These findings were communicated with Dr. at the time of this study.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-10-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1034868,
"text": " 7:45 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: confirm ETT placement\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman intubated with difficult sedation, pulling at ETT.\n REASON FOR THIS EXAMINATION:\n confirm ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 7:58 P.M., \n\n HISTORY: Difficult intubation. Confirmed tube placement.\n\n IMPRESSION: AP chest compared to and at 4:13 a.m.:\n\n Tip of the ET tube, at the upper margin of the clavicles with the chin down is\n 3 cm above optimal placement. Severe bibasilar atelectasis unchanged. Upper\n lungs clear. Heart is top normal size, remains shifted to the left.\n Nasogastric tube ends in the region of the pylorus.\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-09-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1032505,
"text": " 11:37 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval lines/ tubes/infiltrates\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with respiratory failure transfer to for vent wean\n REASON FOR THIS EXAMINATION:\n eval lines/ tubes/infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Transfer to for vent wean. Check lines and tubes.\n\n FINDINGS: There is no old film available for comparison. The endotracheal\n tube tip is 4.5 cm above the carina. The NG tube tip is in the stomach. The\n right hemidiaphragm is mildly elevated. The heart is upper limits normal in\n size. There is pulmonary vascular redistribution with volume loss/infiltrate\n in the right mid lung. The left lateral lung is off the film.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-09-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1033584,
"text": " 2:54 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ETT and line loactions\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with respiratory failure of unclear etiology.\n REASON FOR THIS EXAMINATION:\n ETT and line loactions\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Respiratory failure for ET tube and line locations.\n\n FINDINGS: In comparison with the study of , there is little overall\n change. The endotracheal tube lies approximately 5 cm above the carina and\n the right IJ catheter extends to the lower portion of the SVC. Little overall\n change in the appearance of the heart and lungs.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-09-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1034039,
"text": ", D. MED MICU 3:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval infiltrates, lines\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with respiratory failure, VAP, intubated.\n REASON FOR THIS EXAMINATION:\n please eval infiltrates, lines\n ______________________________________________________________________________\n PFI REPORT\n PFI: No interval change.\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-09-21 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1032743,
"text": " 11:39 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: placement of right IJ\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with resp failure, hypotension, oliguria. s/p placement of\n right IJ\n REASON FOR THIS EXAMINATION:\n placement of right IJ\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Respiratory failure, for placement of a right IJ catheter.\n\n FINDINGS: In comparison with the study of , there has been placement of a\n right IJ catheter that extends to the lower portion of the SVC. Endotracheal\n and nasogastric tubes remain in place. Overlying artifacts make it very\n difficult to properly evaluate the lungs.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-09-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1032518,
"text": " 3:16 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ETT tube placement\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with resp distress s/p intubation transferred from OSH for\n management of weaning.\n REASON FOR THIS EXAMINATION:\n ETT tube placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE VIEW ON .\n\n HISTORY: Check endotracheal tube.\n\n FINDINGS: The endotracheal tube tip is 5 cm above the carina. There is a\n right subclavian line with tip at the SVC/RA junction. The NG tube tip is in\n the stomach. There is a small right effusion. There continues to be\n right-sided volume loss/infiltrate. There is perihilar haze and pulmonary\n vascular redistribution but slightly worse compared to the prior study\n suggesting worsening fluid overload.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-09-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1032944,
"text": " 10:31 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: please re-eval tube positioning\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with respiratory failure, s/p tube repositioning.\n REASON FOR THIS EXAMINATION:\n please re-eval tube positioning\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Respiratory failure status post tube repositioning.\n\n FINDINGS: In comparison with the earlier study of this date, the tip of the\n endotracheal tube is approximately 5.2 cm above the carina. Nasogastric tube\n and right IJ line remain in place. The opacification in the retrocardiac\n region persists. There is some increasing opacification at the right base.\n Although some of this could reflect atelectasis, the possibility of\n supervening atelectasis or pneumonia should be considered.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-09-30 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1034453,
"text": " 3:16 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?Interval change\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with respiratory failure\n REASON FOR THIS EXAMINATION:\n ?Interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLnc WED 10:33 AM\n Increase in bilateral pleural effusions.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Interval change in a patient with respiratory\n failure.\n\n Portable AP chest radiograph was compared to obtained at\n 02:59 a.m.\n\n The ET tube tip is 3.8 cm above the carina. The NG tube is in the stomach.\n The cardiomediastinal silhouette is unchanged. Interval increase in bilateral\n pleural effusions is present but no change in bibasal consolidations\n consistent with atelectasis.\n\n IMPRESSION: No significant interval change except for increase in bilateral\n pleural effusions.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-09-19 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1032503,
"text": " 11:22 PM\n PORTABLE ABDOMEN Clip # \n Reason: eval gas pattern for obstruction\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with respiratory failure and abdominal distension\n REASON FOR THIS EXAMINATION:\n eval gas pattern for obstruction\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMEN FILM ON \n\n HISTORY: Respiratory failure and abdominal distention.\n\n FINDINGS: Patient is status post left total hip replacement. Gas is seen in\n the stomach and a small amount of gas is seen in the colon and in the rectum\n but otherwise there is a paucity of bowel gas. An NG tube is noted in the\n stomach.\n\n IMPRESSION: Nonspecific bowel gas pattern.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-09-20 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1032623,
"text": " 8:47 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: ? pneumothorax\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with respiratory failure, s/p CVL placement. ? pneumo.\n REASON FOR THIS EXAMINATION:\n ? pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Respiratory failure with central line placement.\n\n FINDINGS: In comparison with the earlier study, the malpositioned left\n subclavian line has been removed.\n\n Little change in the left apical opacification.\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-09-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1034038,
"text": " 3:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval infiltrates, lines\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with respiratory failure, VAP, intubated.\n REASON FOR THIS EXAMINATION:\n please eval infiltrates, lines\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AHPb MON 10:51 AM\n PFI: No interval change.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Respiratory failure, ventilator-associated pneumonia.\n\n FINDINGS: Portable semi-upright chest radiograph is compared to at 14:33 and demonstrates no marked interval change in bilateral pleural\n effusions, large bibasilar atelectases (left greater than right),\n cardiomegaly. Lines and tubes are in standard fashion with left PICC\n terminates at the cavoatrial junction.\n\n IMPRESSION: No interval changed in bibasilar pleural effusions and\n atelectasis.\n\n"
},
{
"category": "Echo",
"chartdate": "2167-09-30 00:00:00.000",
"description": "Report",
"row_id": 87285,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Braddycardia. Hypotension.\nWeight (lb): 235\nBP (mm Hg): 108/56\nHR (bpm): 49\nStatus: Inpatient\nDate/Time: at 15:40\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal interatrial septum.\nNo ASD by 2D or color Doppler. Normal IVC diameter (<2.1cm) with <35% decrease\nduring respiration (estimated RA pressure indeterminate).\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. No MS.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR.\nModerate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: No PS.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nThe left atrium is elongated. No atrial septal defect is seen by 2D or color\nDoppler. The right atrial pressure is indeterminate. Left ventricular wall\nthickness, cavity size and regional/global systolic function are normal (LVEF\n>55%). There is no ventricular septal defect. Right ventricular chamber size\nand free wall motion are normal. The aortic valve leaflets (3) are mildly\nthickened but aortic stenosis is not present. No aortic regurgitation is seen.\nThe mitral valve appears structurally normal with trivial mitral\nregurgitation. There is no mitral valve prolapse. The tricuspid valve leaflets\nare mildly thickened. There is moderate pulmonary artery systolic\nhypertension. There is no pericardial effusion.\n\nCompared with the prior study (images reviewed) of , no change.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2167-09-21 00:00:00.000",
"description": "Report",
"row_id": 87286,
"text": "PATIENT/TEST INFORMATION:\nIndication: Right ventricular function. Shortness of breath. Hypotension. Bubble study.\nHeight: (in) 68\nWeight (lb): 230\nBSA (m2): 2.17 m2\nBP (mm Hg): 101/67\nHR (bpm): 72\nStatus: Inpatient\nDate/Time: at 15:37\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: Saline\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA and RA cavity sizes.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolic\nfunction (LVEF>55%). Suboptimal technical quality, a focal LV wall motion\nabnormality cannot be fully excluded. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTIC VALVE: Normal aortic valve leaflets. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Mild PA\nsystolic hypertension.\n\nPERICARDIUM: There is an anterior space which most likely represents a fat\npad, though a loculated anterior pericardial effusion cannot be excluded.\n\nGENERAL COMMENTS: Contrast study was performed with 3 iv injections of 8 ccs\nof agitated normal saline, at rest, with cough and post-Valsalva maneuver.\n\nConclusions:\nThe left atrium and right atrium are normal in cavity size. Suboptimal saline\ncontrast study does not suggest an intracardiac shunt. Left ventricular wall\nthickness, cavity size, and global systolic function are normal (LVEF>55%).\nDue to suboptimal technical quality, a focal wall motion abnormality cannot be\nfully excluded. Right ventricular chamber size and free wall motion are\nnormal. The aortic valve leaflets appear structurally normal with good leaflet\nexcursion. No aortic regurgitation is seen. .The mitral valve appears\nstructurally normal with trivial mitral regurgitation. There is mild-moderate\npulmonary artery systolic hypertension. There is an anterior space which most\nlikely represents a fat pad.\n\nIMPRESSION: Suboptimal image quality. Preserved global biventricular systolic\nfunction. Mild-moderate pulmonary artery systolic hypertension.\n\nCLINICAL IMPLICATIONS:\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate prophylaxis is NOT recommended. Clinical decisions regarding the need\nfor prophylaxis should be based on clinical and echocardiographic data.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-10-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1040102,
"text": " 3:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? interval change\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with TBM, s/p trach\n REASON FOR THIS EXAMINATION:\n ? interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLnc WED 11:40 AM\n No significant change compared to the prior studies. Extensive basal\n atelectasis.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of a patient with tracheobronchomalacia\n after tracheostomy.\n\n COMPARISON: Chest radiographs from and .\n\n The study is limited due to motion artifact, but overall, there is no change\n in bilateral significant atelectasis involving lower lobes and right middle\n lobe. The upper lungs are ventilated. The tracheostomy is low with its tip\n projecting less than 2 cm above the carina. Pleural effusion cannot be\n excluded.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-10-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1040103,
"text": ", MED MICU 3:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? interval change\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with TBM, s/p trach\n REASON FOR THIS EXAMINATION:\n ? interval change\n ______________________________________________________________________________\n PFI REPORT\n No significant change compared to the prior studies. Extensive basal\n atelectasis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-10-23 00:00:00.000",
"description": "PICC W/O PORT",
"row_id": 1039213,
"text": " 11:27 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: Needs double lumen PICC; has Hx of DVT in upper extremities.\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ********************************* CPT Codes ********************************\n * PICC W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with ilius needs TPN\n REASON FOR THIS EXAMINATION:\n Needs double lumen PICC; has Hx of DVT in upper extremities.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JRCi 3:58 PM\n PICC line ready for use. Non-occlusive thrombus bilateral upper extremity.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: PICC line placement.\n\n INDICATION: Inability to perform bedside PICC line with patient needing TPN.\n\n The procedure was explained to the patient's proxy. A timeout was performed.\n\n RADIOLOGISTS: Dr. performed the procedure. Dr. , the Attending\n Radiologist, was present and supervised the entire procedure.\n\n TECHNIQUE: Using sterile technique and local anesthesia, the left basilic\n vein was punctured under direct ultrasound guidance using a micropuncture set.\n A small focal non-occlusive thrombus was detected within the vein more\n distally. Hard copy of ultrasound images were obtained before and immediately\n after establishing intravenous access. A peel-away sheath was then placed\n over a guidewire and a double-lumen PICC line measuring 41 cm in length was\n then placed through the peel-away sheath with its tip positioned in the SVC\n under fluoroscopic guidance. Position of the catheter was confirmed by a\n fluoroscopic spot film of the chest.\n\n The peel-away sheath and guidewire were then removed. The catheter was\n secured to the skin, flushed, and a sterile dressing applied.\n\n The patient was uncooperative during the procedure. There were no immediate\n post- procedural complications.\n\n IMPRESSION:\n 1. Uncomplicated ultrasound and fluoroscopically guided double-lumen PICC line\n via the left basilic venous approach. Final internal length is 41 cm, with\n the tip positioned in the SVC. The line is ready to use.\n\n 2. Small amount of non-occlusive thrombus was detected within bilateral\n basilic veins.\n\n Findings discussed with Dr. at 4:44 pm the day of examination.\n (Over)\n\n 11:27 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: Needs double lumen PICC; has Hx of DVT in upper extremities.\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-10-23 00:00:00.000",
"description": "FLUORO GUID PLCT/REPLCT/REMOVE CENTRAL LINE",
"row_id": 1039214,
"text": ", C. MED MICU 11:27 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: Needs double lumen PICC; has Hx of DVT in upper extremities.\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with ilius needs TPN\n REASON FOR THIS EXAMINATION:\n Needs double lumen PICC; has Hx of DVT in upper extremities.\n ______________________________________________________________________________\n PFI REPORT\n PICC line ready for use. Non-occlusive thrombus bilateral upper extremity.\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-10-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1038109,
"text": " 3:18 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for change from prior\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with tracheostomy\n REASON FOR THIS EXAMINATION:\n Please eval for change from prior\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Tracheostomy.\n\n COMPARISON: .\n\n PORTABLE CHEST RADIOGRAPH: Tracheostomy tube appears in unchanged position.\n Gastric tube is seen overlying the abdomen. Cardiac and mediastinal contours\n are unchanged. Bibasilar atelectasis and likely small pleural effusions are\n also unchanged. Unusual opacity is seen overlying the left mid lung, possibly\n atelectasis, although attention on followup is recommended.\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-10-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1039135,
"text": " 7:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? aspiration, ? PNA\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 yo F, w/ trach and peg, s/p self-extubation, now w/ fever, ? aspiration\n REASON FOR THIS EXAMINATION:\n ? aspiration, ? PNA\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Tracheostomy and PEG status post self-extubation, now with fever and\n possible aspiration.\n\n FINDINGS: In comparison with the study of , there is opacification at the\n left base that again could reflect atelectasis or aspiration. Right lower\n lobe collapse is long-standing. Enlargement of the cardiac silhouette\n persists. No definite vascular congestion, raising the possibility of\n underlying cardiomyopathy.\n\n Tracheostomy tube remains in place.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-10-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1038849,
"text": " 2:54 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? Interval change\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with spinal injury, PEG tube in place but vomiting all tube\n feeds and no bowel sounds on exam.\n REASON FOR THIS EXAMINATION:\n ? Interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 2:54 A.M. ON .\n\n HISTORY: Spinal injury, PEG tube in place. Vomiting.\n\n IMPRESSION: AP chest compared to and 8.\n\n Developing opacification in left lower lobe could represent atelectasis or\n aspiration. Right lower lobe collapse is longstanding. Mild cardiomegaly is\n worsened. Tracheostomy tube is turned and has a very short intratracheal\n excursion. Clinical evaluation is advised. No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-10-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1037930,
"text": ", C. MED MICU 2:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate, effusion\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with long MICU admission, s/p trach, intermittently\n mechanically ventilated.\n REASON FOR THIS EXAMINATION:\n eval for infiltrate, effusion\n ______________________________________________________________________________\n PFI REPORT\n Unchanged right middle lobe and right lower lobe collapse and left lower lobe\n atelectasis. No enlarging pleural effusions.\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-10-22 00:00:00.000",
"description": "UGI SGL CONTRAST W/ KUB",
"row_id": 1038939,
"text": " 10:29 AM\n UGI SGL CONTRAST W/ KUB Clip # \n Reason: evaluate for dysmotility\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman s/p t-spine fx, repeated emesis with TFs.\n REASON FOR THIS EXAMINATION:\n evaluate for dysmotility\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 12:25 PM\n PFI: Findings are suggestive of underlying dysmotility with minimal antegrade\n or retrograde movement.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post thoracic spine fracture with repeated emesis, recently\n placed GJ tube with port in jejunum and still not tolerating tube feeds with\n episodes of tube feed vomiting.\n\n Comparison is made to CT examination dated and images from\n recent J-tube placement.\n\n Initial scout radiograph demonstrates appropriately positioned GJ tube with\n inflated balloon. Approximately 30 cc of Optiray contrast was injected\n through the port and was noted to predominantly pool within the loop of\n jejunum at the tube exit site with minimal retro and forward pulsion of\n contents. Intermittent fluoroscopy was performed for approximately 5 minutes\n to evaluate for motility pattern. Subsequently, an additional 10 mL of thin\n barium was instilled and displayed a similar pattern with only mild motility\n noted. No contrast is noted to reflux into the duodenum/stomach. Oral\n contrast is noted within the large bowel from prior CT examination.\n\n IMPRESSION:\n\n Findings are suggestive of underlying intestinal dysmotility with limited\n movement of injected contrast through the J-tube in either antegrade or\n retrograde direction. A repeat KUB is recommended centered over the upper\n abdomen in 15 minutes to evaluate for contrast progression.\n\n Findings discussed with Dr. shortly after exam acquisition.\n\n\n *\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-10-22 00:00:00.000",
"description": "UGI SGL CONTRAST W/ KUB",
"row_id": 1038940,
"text": ", C. MED MICU 10:29 AM\n UGI SGL CONTRAST W/ KUB Clip # \n Reason: evaluate for dysmotility\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman s/p t-spine fx, repeated emesis with TFs.\n REASON FOR THIS EXAMINATION:\n evaluate for dysmotility\n ______________________________________________________________________________\n PFI REPORT\n PFI: Findings are suggestive of underlying dysmotility with minimal antegrade\n or retrograde movement.\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-10-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1039350,
"text": " 3:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for change from prior\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with trach, fever, recurrent vomiting, desaturation\n REASON FOR THIS EXAMINATION:\n Please eval for change from prior\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST \n\n COMPARISON: .\n\n INDICATION: Fever.\n\n PICC terminates within the mid superior vena cava. There is otherwise no\n substantial change since the recent radiograph allowing for marked leftward\n patient rotation on the current study.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-10-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1039489,
"text": ", C. MED MICU 2:55 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for change from prior\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with respiratory failure, trach\n REASON FOR THIS EXAMINATION:\n please eval for change from prior\n ______________________________________________________________________________\n PFI REPORT\n The left PICC line tip is at the junction of brachiocephalic vein and SVC,\n more proximal than on the prior study, otherwise worsening of atelectasis in\n the left lower lung.\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-10-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1039687,
"text": " 3:41 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for change from prior\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with trach ?aspiration\n REASON FOR THIS EXAMINATION:\n please eval for change from prior\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLnc MON 9:18 AM\n PFI: No appreciable change.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Suspected aspiration.\n\n Portable AP chest radiograph was compared to prior study obtained on , , at 03:38 a.m.\n\n No appreciable change is demonstrated in this approximately 24 hours interval.\n Bibasilar atelectasis is unchanged, left more than right. The tracheostomy is\n in unchanged position. The upper lungs are aerated. The patient's head\n overlies the apices.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-10-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1037929,
"text": " 2:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate, effusion\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with long MICU admission, s/p trach, intermittently\n mechanically ventilated.\n REASON FOR THIS EXAMINATION:\n eval for infiltrate, effusion\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JRld SUN 2:35 PM\n Unchanged right middle lobe and right lower lobe collapse and left lower lobe\n atelectasis. No enlarging pleural effusions.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Intermittently mechanically ventilated, long MICU admission.\n\n Comparison is made with prior studies including most recent one on .\n\n Right middle lobe and right lower lobe collapse are unchanged as are left\n lower lobe atelectasis. If any, there is a small left pleural effusion.\n No PTX. Tracheostomy tube in standard position. Low lung volumes.\n Cardiomediastinal silhouette is unchanged.\n\n DR. \n"
},
{
"category": "Radiology",
"chartdate": "2167-10-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1039688,
"text": ", C. MED MICU 3:41 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for change from prior\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with trach ?aspiration\n REASON FOR THIS EXAMINATION:\n please eval for change from prior\n ______________________________________________________________________________\n PFI REPORT\n PFI: No appreciable change.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-10-22 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1039027,
"text": " 3:31 PM\n PORTABLE ABDOMEN; -76 BY SAME PHYSICIAN # \n Reason: eval for movement of contrast\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with GI dysmotility, s/p UGI series this AM\n REASON FOR THIS EXAMINATION:\n eval for movement of contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 4:23 PM\n Continued progression of oral contrast into the distal small bowel/proximal\n large bowel. Findings are again suggestive of underlying intestinal\n dysmotility without evidence of obstruction. No further radiographic followup\n is deemed necessary.\n ______________________________________________________________________________\n FINAL REPORT\n Evaluate for interval movement of contrast in patient with probable underlying\n intestinal dysmotility.\n\n Comparison is made to prior portable abdominal radiograph and upper GI series\n from same date.\n\n There continues to be progression of the oral contrast instilled during the\n fluoroscopy examination from the morning, now in the distal small\n bowel/proximal large bowel. No definite contrast is noted within the\n duodenum/stomach.\n\n IMPRESSION:\n\n Findings again consistent with mild-to-moderate underlying intestinal\n dysmotility but no evidence of retrograde contrast movement into the\n duodenum/stomach was noted on real-time fluoroscopy or initial followup\n radiograph. No further films are deemed necessary.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-10-22 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1039028,
"text": ", C. MED MICU 3:31 PM\n PORTABLE ABDOMEN; -76 BY SAME PHYSICIAN # \n Reason: eval for movement of contrast\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with GI dysmotility, s/p UGI series this AM\n REASON FOR THIS EXAMINATION:\n eval for movement of contrast\n ______________________________________________________________________________\n PFI REPORT\n Continued progression of oral contrast into the distal small bowel/proximal\n large bowel. Findings are again suggestive of underlying intestinal\n dysmotility without evidence of obstruction. No further radiographic followup\n is deemed necessary.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-10-20 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 1038473,
"text": " 3:39 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: eval for transition point or evidence of obstruction\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with spinal injury, PEG tube in place but vomiting all tube\n feeds and no bowel sounds on exam.\n REASON FOR THIS EXAMINATION:\n eval for transition point or evidence of obstruction\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JXKc TUE 7:51 PM\n No evidence of obstruction. No acute intra-abdominal process.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 56-year-old female with spinal injury, PEG tube in place, but\n vomiting all tube feeds and no bowel sounds on examination. Evaluate for\n evidence of obstruction.\n\n COMPARISON: .\n\n TECHNIQUE: MDCT axial images were obtained from the lung bases symphysis\n pubis with administration of IV and oral contrast. Coronal and sagittal\n reformations were obtained.\n\n CT OF THE ABDOMEN WITH IV CONTRAST: The visualized heart and pericardium are\n unremarkable. There is atelectasis within both lung bases, with the\n visualized airways suggestive of tracheobronchomalacia. A 1- cm rounded\n calcific density within the left atelectatic left lower lobe is of unclear\n etiology, could represent a calcified granuloma, or sequela from prior trauma.\n There is no pleural effusion.\n\n The liver, spleen, adrenal glands, left kidney, and pancreas are unremarkable.\n Gallstones are present, without secondary findings for cholecystitis. There\n is a 3.5-cm cyst within the upper pole of the right kidney. Otherwise, the\n right kidney is unremarkable.\n\n There is a gastrostomy tube in place. The stomach, small bowel, and colon are\n collapsed, without evidence of bowel obstruction. There are scattered\n diverticula throughout the colon, without evidence of diverticulitis. A 2.5 cm\n rounded structure adjacent to the second/third portion of duodenum, likely\n reflects a duodenal diverticulum. There is no free fluid, free air, or\n pathologic adenopathy. Surgical clips are present within the right lower\n quadrant of the abdomen.\n\n CT OF THE PELVIS WITH IV CONTRAST: Foley catheter courses into the bladder.\n Rectum is unremarkable. There is no pelvic free fluid or adenopathy.\n\n OSSEOUS STRUCTURES: Patient is status post left hip replacement. There is a\n compression fracture of the T8 vertebral body as well as likely the T6\n vertebral body, as seen on , with a slightly increased loss\n (Over)\n\n 3:39 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: eval for transition point or evidence of obstruction\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n of vertebral body height.\n\n IMPRESSION:\n\n 1. No acute intra-abdominal process, without evidence of obstruction.\n\n 2. Atelectasis of both lung bases, with suggestion of tracheobronchomalacia,\n which may be related to chronic tracheostomy. This can be further evaluated\n with a CT trachea.\n\n 3. Cholelithiasis.\n\n 4. Diverticulosis without diverticulitis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-10-20 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 1038474,
"text": ", C. MED MICU 3:39 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: eval for transition point or evidence of obstruction\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with spinal injury, tube in place but vomiting all tube\n feeds and no bowel sounds on exam.\n REASON FOR THIS EXAMINATION:\n eval for transition point or evidence of obstruction\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n No evidence of obstruction. No acute intra-abdominal process.\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-10-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1039488,
"text": " 2:55 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for change from prior\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with respiratory failure, trach\n REASON FOR THIS EXAMINATION:\n please eval for change from prior\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLnc SUN 9:26 AM\n The left PICC line tip is at the junction of brachiocephalic vein and SVC,\n more proximal than on the prior study, otherwise worsening of atelectasis in\n the left lower lung.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Interval change in intubated patient with respiratory\n failure and tracheostomy.\n\n Portable AP chest radiograph was compared to and .\n\n The left PICC line tip is at the junction of brachiocephalic vein and SVC,\n slightly more proximal than on the prior study. The tracheostomy tip is at\n the midline. The bibasilar opacities have increased, obscuring the right and\n left heart border. The lung volumes remain low. Bilateral pleural effusion\n is most likely present.\n\n The radiodense opacity projecting over the left lower lobe corresponds to\n known calcified granuloma.\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-10-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1038566,
"text": ", C. MED MICU 3:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate or effusion\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with trach, concern for aspiration\n REASON FOR THIS EXAMINATION:\n eval for infiltrate or effusion\n ______________________________________________________________________________\n PFI REPORT\n Tracheostomy tube oriented horizontally should be evaluated clinically. Right\n basal atelectasis and small bilateral pleural effusions unchanged. Heart size\n normal. No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-10-22 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1038965,
"text": " 11:46 AM\n PORTABLE ABDOMEN; -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: Need f/u study s/p tube study; requested by radiology\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with PEG/TRACH s/p t-spine frx, resp failure, and PNA, w/\n vomitting and now new Jtube via G-tube\n REASON FOR THIS EXAMINATION:\n Need f/u study s/p tube study; requested by radiology\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 2:30 PM\n PFI: Appropriate antegrade movement of injected contrast into the mid and\n distal jejunum. No reflux of contrast noted within the duodenum or stomach.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Evaluate progression of contrast from prior J-tube study.\n\n Comparison is made to J-tube study performed on same date.\n\n PORTABLE SUPINE ABDOMINAL RADIOGRAPH\n\n FINDINGS: Positioning of the J-tube is unchanged with contrast noted to have\n advanced antegrade into the mid to distal jejunum. No contrast is noted\n within the duodenum or stomach. Oral contrast from prior CT examination is\n again noted within the colon.\n\n IMPRESSION:\n\n No reflux contrast noted within the duodenum/stomach. Appropriate antegrade\n movement of the stomach into the loops of mid and distal jejunum.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-10-22 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1038966,
"text": ", C. MED MICU 11:46 AM\n PORTABLE ABDOMEN; -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: Need f/u study s/p tube study; requested by radiology\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with PEG/TRACH s/p t-spine frx, resp failure, and PNA, w/\n vomitting and now new Jtube via G-tube\n REASON FOR THIS EXAMINATION:\n Need f/u study s/p tube study; requested by radiology\n ______________________________________________________________________________\n PFI REPORT\n PFI: Appropriate antegrade movement of injected contrast into the mid and\n distal jejunum. No reflux of contrast noted within the duodenum or stomach.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-10-21 00:00:00.000",
"description": "CONVERT G TO GJ, ALL INCL.",
"row_id": 1038769,
"text": " 3:49 PM\n PERC G/G-J TUBE PLMT Clip # \n Reason: Please place J tube\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n Contrast: OPTIRAY Amt: 20\n ********************************* CPT Codes ********************************\n * CONVERT G TO GJ, ALL INCL. *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with PEG tube. Please place smaller G-J tube through G tube.\n REASON FOR THIS EXAMINATION:\n Please place J tube\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 56-year-old female with PEG tube. Please convert to J-tube.\n\n RADIOLOGISTS: Dr. , , and attending radiologist, Dr. ,\n who was present and supervised the entire procedure.\n\n PROCEDURE AND FINDINGS: The risks and benefits of the procedure were\n explained to the healthcare proxy and informed consent was obtained.\n A pre-procedure timeout was performed to confirm the identity of the patient\n by name, medical record number, date of birth, and the nature of the procedure\n to be performed. The patient was placed supine on the angiography table and\n the patient's mid abdomen and indwelling G-tube were prepped and draped in\n standard sterile fashion.\n\n Initial fluoroscopic image demonstrates gastrostomy tube located within the\n stomach. Injection of contrast through the indwelling G-tube demonstrates\n passage of contrast. After local anesthesia administration to the existing\n site with 1% lidocaine, a 0.035 wire was passed through the pre-\n existing G-tube and with the aid of a 5 French catheter was advanced\n under fluoroscopic guidance past the pylorus into the jejunum. The \n wire was replaced with a 0.035 Amplatz wire. After removal of the 5 French\n catheter, a 10 French -Alvatecoons gastrojejunostomy catheter was\n advanced over the wire through the indwelling gastrostomy tube with tip\n positioned in the jejunum. Appropriate position of the catheter was confirmed\n by injection of contrast. The wire was removed and the GJ tube secured to the\n skin with 0 silk sutures and a Flexi-Trak device. The patient tolerated the\n procedure well and there were no immediate complications.\n\n MODERATE SEDATION was provided by administering 180 mcg of Fentanyl and 3 mg\n of Versed via divided doses throughout the 43 minute intraservice time with\n continuous hemodynamic monitoring.\n\n IMPRESSION: Successful placement of a GJ tube through existing G-tube with\n tip positioned in the jejunum.\n (Over)\n\n 3:49 PM\n PERC G/G-J TUBE PLMT Clip # \n Reason: Please place J tube\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n Contrast: OPTIRAY Amt: 20\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-10-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1039854,
"text": " 2:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with TBM, s/p trach\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Follow up.\n\n COMPARISON: , 4:18 a.m.\n\n FINDINGS: The current radiograph is markedly impaired by severe motion\n artifacts. On this limited basis, there is no obvious radiological change.\n The tracheostomy tube is in unchanged position. The retrocardiac lung areas\n could be minimally better ventilated.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-10-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1038565,
"text": " 3:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate or effusion\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with trach, concern for aspiration\n REASON FOR THIS EXAMINATION:\n eval for infiltrate or effusion\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): PSS WED 2:00 PM\n Tracheostomy tube oriented horizontally should be evaluated clinically. Right\n basal atelectasis and small bilateral pleural effusions unchanged. Heart size\n normal. No pneumothorax.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 3:14 A.M. \n\n HISTORY: Tracheostomy. Concern for aspiration.\n\n IMPRESSION: AP chest compared to and 6:\n\n Tracheostomy tube is oriented horizontally and should be evaluated clinically.\n Heart size normal. Right lower lobe atelectasis persists. Pleural effusion\n is bilateral and small. No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-10-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1035231,
"text": " 3:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: lung fields\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with resp failure\n REASON FOR THIS EXAMINATION:\n lung fields\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DJRX SUN 10:25 AM\n No significant change.\n ______________________________________________________________________________\n FINAL REPORT\n SUPINE PORTABLE CHEST\n\n HISTORY: Respiratory failure, check lungs.\n\n One view. Comparison with . Lung volumes are somewhat low. There is\n continued evidence of pulmonary vascular congestion and bilateral pleural\n effusions unchanged. There is increased density in the retrocardiac area as\n before. Mediastinal structures are stable. A tracheostomy tube remains in\n place.\n\n IMPRESSION: No definite interval change.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-10-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1035232,
"text": ", F. MED MICU 3:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: lung fields\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with resp failure\n REASON FOR THIS EXAMINATION:\n lung fields\n ______________________________________________________________________________\n PFI REPORT\n No significant change.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-10-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1036271,
"text": " 3:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?interval change\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with t-spine frx and respiratory failure, s/p VAP, and\n PEG/trach\n REASON FOR THIS EXAMINATION:\n ?interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLnc FRI 12:08 PM\n No appreciable change during the short-time interval.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of a patient with T-spine fractures and\n respiratory failure.\n\n Portable AP chest radiograph was compared to obtained at\n 8:30 p.m.\n\n The current study demonstrates no significant change in the degree of left\n retrocardiac consolidation, consistent with atelectasis/aspiration. The right\n hemidiaphragm remains high. The upper lungs are grossly unremarkable. The\n position of the tracheostomy is unchanged. The PICC line tip can be followed\n till the cavoatrial junction.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-10-14 00:00:00.000",
"description": "L UNILAT UP EXT VEINS US LEFT",
"row_id": 1037258,
"text": ", C. MED MICU 3:29 PM\n UNILAT UP EXT VEINS US LEFT Clip # \n Reason: Pleas eeval for DVT\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with fever, h/o UE DVT with PICC line\n REASON FOR THIS EXAMINATION:\n Pleas eeval for DVT\n ______________________________________________________________________________\n PFI REPORT\n PFI: Very small segment (1-cm in length) of nonocclusive thrombus in the left\n axillary vein. A PICC catheter is present on the left.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-10-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1036725,
"text": " 2:50 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? interval change\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with traumatic T-spine frx, HAP/VAP and respiratory ditress,\n now extubated, but spiking fevers and slowly improving MS\n REASON FOR THIS EXAMINATION:\n ? interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Status post respiratory distress.\n\n COMPARISON: , 12:44 a.m.\n\n FINDINGS: As compared to the previous radiograph, there is little overall\n change. Small newly occurred left-sided atelectasis that project over the\n costophrenic sinus. The right lung base has slightly increased in\n transparency. Unchanged is a small right-sided pleural effusion. The size of\n the cardiac silhouette is unchanged and at the upper range of normal. No\n obvious overhydration. No newly occurred focal parenchymal opacities\n suggestive of pneumonia.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-10-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1036272,
"text": ", F. MED MICU 3:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?interval change\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with t-spine frx and respiratory failure, s/p VAP, and\n PEG/trach\n REASON FOR THIS EXAMINATION:\n ?interval change\n ______________________________________________________________________________\n PFI REPORT\n No appreciable change during the short-time interval.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-10-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1037316,
"text": " 3:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for change\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with elevated diaphragm, ? effusion\n REASON FOR THIS EXAMINATION:\n Please eval for change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 56-year-old woman with question of effusion and interval change.\n\n COMPARISON: Comparison is made to chest radiograph from .\n\n FINDINGS: A tracheostomy tube and left PICC are in good position, unchanged\n from previous study.\n\n Small right pleural effusion is unchanged. There is no left pleural effusion.\n Right middle and lower lobe collapse is unchanged. There is interval increase\n in left lung base opacity, likely progressive atelectasis. Lungs are\n otherwise clear. Cardiac contours are obscured by adjacent atelectasis and\n effusion. Mediastinal contours are normal. Visualized soft tissue structures\n and bony thorax are unremarkable.\n\n IMPRESSION:\n 1. Persistent right middle/lower lobe collapse and progressive left basilar\n atelectasis.\n 2. Unchanged small right pleural effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-10-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1036618,
"text": " 12:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o aspiration/infection\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with recent aspiration and fever.\n REASON FOR THIS EXAMINATION:\n r/o aspiration/infection\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Followup.\n\n COMPARISON: , 4:24 a.m.\n\n FINDINGS: As compared to the previous radiograph, the tracheostomy tube is in\n unchanged position. The size of the cardiac silhouette is also unchanged.\n The retrocardiac lung areas are slightly better ventilated than before, the\n right basal opacities are unchanged. There is no evidence of newly occurred\n focal parenchymal opacities. Unchanged moderate cardiomegaly without signs of\n obvious overhydration. No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-10-14 00:00:00.000",
"description": "L UNILAT UP EXT VEINS US LEFT",
"row_id": 1037257,
"text": " 3:29 PM\n UNILAT UP EXT VEINS US LEFT Clip # \n Reason: Pleas eeval for DVT\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with fever, h/o UE DVT with PICC line\n REASON FOR THIS EXAMINATION:\n Pleas eeval for DVT\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AHPb WED 7:35 PM\n PFI: Very small segment (1-cm in length) of nonocclusive thrombus in the left\n axillary vein. A PICC catheter is present on the left.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fever, history of upper extremity DVT with PICC line.\n\n FINDINGS: -scale and color Doppler son of the left upper extremity\n including the subclavian, internal jugular, axillary, basilic, and cephalic\n veins demonstrate very small segment of nonocclusive thrombus in the left\n axillary (1-cm in length). Otherwise, there is normal flow, compressibility,\n and waveforms. A PICC catheter is present entering the left basilic.\n\n IMPRESSION: Very small nonocclusive DVT in the left axillary vein.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-10-05 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 1035524,
"text": " 5:23 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: ? loculated effusion,\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n Field of view: 40\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with resp failure s/p fall and T-spine frx, now w/ worsening\n bilateral effusions, s/p treated VAP, considering Tap of effusion\n REASON FOR THIS EXAMINATION:\n ? loculated effusion,\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): KCLd TUE 5:10 PM\n 1. Improving bilateral consolidations, atelectasis, and effusions. No\n loculated effusion identified. Persistent smaller bilateral pleural effusions\n and atelectasis/consolidation could be secondary to aspiration.\n 2. Evidence of tracheobronchomalacia.\n 3. Evidence of overinflation of the tracheostomy cuff.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Respiratory failure, status post fall with T-spine fracture,\n worsening bilateral effusions. Evaluate for loculated effusion.\n\n COMPARISON: .\n\n TECHNIQUE: MDCT-acquired axial images of the chest were obtained without\n contrast. 5- and 1.25-mm thin section images were displayed. Coronal and\n sagittal reformatted images were also displayed.\n\n FINDINGS: Patient is status post tracheostomy. Small amount of hematoma is\n seen surrounding the tracheostomy tube. The tracheal cuff appears slightly\n overinflated. Right hypoattenuating thyroid nodule is noted.\n\n Compared to prior study, there is improved aeration of the lungs bilaterally.\n There has been interval decrease in the pleural effusions not atelectasis\n bilaterally. Persistent lower lobe atelectasis is seen bilaterally, with\n small pleural effusions. There is no loculated effusion. There has been\n interval improvement of the patchy nodular densities as well, suggesting\n improving infection. Persistent large calcified granuloma measuring upwards\n of 13 mm again seen in the left lower lobe.\n\n There is a severe collapse of the tracheal and bronchial airways, consistent\n with tracheobronchomalacia. Pulmonary artery appears enlarged measuring\n upwards of 3.5 cm, raising concern for possible pulmonary arterial\n hypertension. Coronary artery calcifications are seen. Heart size appears\n upper limits of normal. No pathologically enlarged mediastinal or hilar\n lymphadenopathy identified. Gastric tube is seen in the stomach. Calcified\n stones seen within the gallbladder. A cystic lesion in the right kidney again\n identified. Otherwise, limited views of the upper abdomen are grossly\n unremarkable.\n\n IMPRESSION:\n (Over)\n\n 5:23 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: ? loculated effusion,\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n Field of view: 40\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 1. Improving bilateral consolidations and effusions. No loculated effusion\n identified. Persistent atelectasis/consolidation at the lower lobes\n bilaterally with small effusions, possibly secondary to aspiration.\n 2. Evidence of tracheobronchomalacia.\n 3. Evidence of slight overinflation of the tracheostomy cuff.\n 4. Cholelithiasis.\n 5. Right thyroid nodule. Ultrasound for further evaluation as clinically\n indicated would be recommended when patient is stable.\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-10-05 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 1035525,
"text": ", F. MED MICU 5:23 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: ? loculated effusion,\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n Field of view: 40\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with resp failure s/p fall and T-spine frx, now w/ worsening\n bilateral effusions, s/p treated VAP, considering Tap of effusion\n REASON FOR THIS EXAMINATION:\n ? loculated effusion,\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n 1. Improving bilateral consolidations, atelectasis, and effusions. No\n loculated effusion identified. Persistent smaller bilateral pleural effusions\n and atelectasis/consolidation could be secondary to aspiration.\n 2. Evidence of tracheobronchomalacia.\n 3. Evidence of overinflation of the tracheostomy cuff.\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-10-15 00:00:00.000",
"description": "CONVERT G TO GJ, ALL INCL.",
"row_id": 1037472,
"text": " 5:01 PM\n PERC G/J TUBE CHECK Clip # \n Reason: Please reposition gastric tube into duodenum or jejunum.\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n Contrast: OPTIRAY Amt: 15\n ********************************* CPT Codes ********************************\n * CONVERT G TO GJ, ALL INCL. -52 REDUCED SERVICES *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with PEG and Trach, s/p traumatic T-spine frx and respiratory\n failure, HAP/VAP,now w/ multiple episodes of emesis into oropharynx.\n REASON FOR THIS EXAMINATION:\n Please reposition gastric tube into duodenum or jejunum.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JXXb FRI 10:08 AM\n Exchange of existing G tube for a GJ tube without success.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: The patient is a 56-year-old woman with a PEG and\n tracheostomy, status post traumatic thoracic spinal fracture and respiratory\n failure. A G tube was placed surgically, and multiple episodes reflux. A\n request was made for conversion of G to a gasrto-jejunal feeding tube.\n\n OPERATORS: Dr. and Dr. , the attending radiologist\n who was present and supervised during the whole procedure.\n\n PROCEDURE: G tube injection.\n\n SEDATION: Lidocaine was used for local anesthesia.\n\n PROCEDURE AND FINDINGS: After the risks and benefits of the procedure as well\n as the conscious sedation were explained, informed consent was obtained. The\n patient was brought to the angiographic suite and placed supine on the imaging\n table. The catheter area was prepared and draped in the usual sterile\n fashion.\n\n A scout image and contrast injection verified the existing gastric tube with\n its tip in the gastric lumen. A guide wire from a MIC GJ feeding tube kit was\n advanced into the gastric lumen through the existing G tube. The external\n skin sutures were removed, but the existing G tube could not be removed due to\n the existence of an internal securing disc which could not be removed. A\n portion of the external gastric tube was cut and a connector was placed. Tube\n exchange can be performed only after surgical removal of the existing tube.\n\n The existing gastric tube was sutured to the skin and a sterile dressing was\n applied.\n\n There were no immediate complications.\n\n IMPRESSION:\n 1. Unsuccessful exchange of the existing gastric tube for a jejunal feeding\n tube due to the existence of internal securing disc of the gastric tube that\n (Over)\n\n 5:01 PM\n PERC G/J TUBE CHECK Clip # \n Reason: Please reposition gastric tube into duodenum or jejunum.\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n Contrast: OPTIRAY Amt: 15\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n requires surgical removal.\n 2. Existing tube has it's tip within the gastric lumen.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-10-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1035989,
"text": " 2:52 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? Interval change\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with tramatic T-spine frx, and respiratory failure\n REASON FOR THIS EXAMINATION:\n ? Interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 9:24 AM\n No relevant change.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Respiratory failure, interval change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there are extensive motion\n artifacts that clearly limits the interpretation. Unchanged moderate\n retrocardiac opacity and elevation of the hemidiaphragm. There could be a\n minimal right-sided pleural effusion. The size of the cardiac silhouette is\n unchanged. No newly occurred focal parenchymal opacity suggestive of\n pneumonia.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-10-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1035990,
"text": ", F. MED MICU 2:52 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? Interval change\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with tramatic T-spine frx, and respiratory failure\n REASON FOR THIS EXAMINATION:\n ? Interval change\n ______________________________________________________________________________\n PFI REPORT\n No relevant change.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-10-11 00:00:00.000",
"description": "P ABDOMEN (SUPINE ONLY) PORT",
"row_id": 1036673,
"text": " 11:35 AM\n ABDOMEN (SUPINE ONLY) PORT Clip # \n Reason: Eval for signs of obstruction,\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman s/p T-spine frx, HAP/, and trach w/ episodes of\n vomiting and ?aspiration. Long course of narcotics. ?ileus/obstruction\n REASON FOR THIS EXAMINATION:\n Eval for signs of obstruction,\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Episodes of vomiting, signs of obstruction.\n\n FINDINGS: Normal borders of the psoas muscle. Total hip replacement, left.\n Air in the rectum. tube in situ. No secure evidence of free air. No\n evidence of pathologic air-fluid levels.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-10-15 00:00:00.000",
"description": "CONVERT G TO GJ, ALL INCL.",
"row_id": 1037473,
"text": ", C. MED MICU 5:01 PM\n PERC G/J TUBE CHECK Clip # \n Reason: Please reposition gastric tube into duodenum or jejunum.\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n Contrast: OPTIRAY Amt: 15\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with PEG and Trach, s/p traumatic T-spine frx and respiratory\n failure, HAP/VAP,now w/ multiple episodes of emesis into oropharynx.\n REASON FOR THIS EXAMINATION:\n Please reposition gastric tube into duodenum or jejunum.\n ______________________________________________________________________________\n PFI REPORT\n Exchange of existing G tube for a GJ tube without success.\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-10-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1037530,
"text": ", C. MED MICU 3:49 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? interval change\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with respiratory failure, s/p traumatic t-spine frx, s/pHAP\n REASON FOR THIS EXAMINATION:\n ? interval change\n ______________________________________________________________________________\n PFI REPORT\n No change since at least in right middle and lower lobe collapse,\n left lower lobe atelectasis, and small bilateral pleural effusions.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-10-14 00:00:00.000",
"description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY",
"row_id": 1037218,
"text": " 12:55 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: Pleas eevaluate for PE\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with persistent sinus tachycardia, h/o UE DVT, fever,\n abnormal CXR\n REASON FOR THIS EXAMINATION:\n Pleas eevaluate for PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): MLKb WED 3:12 PM\n No PE centrally.\n Study limited due to motion.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 56-year-old female with persistent sinus tachycardia, history of\n upper extremity DVT, fever, abnormal chest x-ray. Please evaluate for PE.\n\n TECHNIQUE: MDCT of the chest was performed before and after administration of\n intravenous contrast. Images were reformatted in the axial, sagittal, coronal\n and oblique planes.\n\n COMPARISON: CT performed .\n\n FINDINGS: No filling defect can be identified in the central pulmonary\n arteries, that could suggest pulmonary embolism. Study is limited due to\n motion and poor contrast enhancement of pulmonary arteries.\n A central line is seen with the tip in the cavoatrial junction. The patient is\n status post tracheostomy. Minimal soft tissue edema is seen surrounding the\n tracheostomy tube at its insertion. Above the level of the tracheal cuff,\n pulling secretions are noted. Stable calcified granuloma in the left lower\n lobe, (measuring 12 mm). Increased in number of borderline size lymph nodes in\n the mediastinum, measuring up to 10 mm in the APW . Air- trapping is noted.\n There is resolution of pleural effusions bilaterally. There is complete\n collapse of the right middle lobe and partial collapse of the right lower\n lobe. Dependent atelectases are seen in the lingula and left lower lobe. A\n wedge-shaped consolidation is seen in the right upper lobe could correspond to\n an area of infarction. There is severe collapsability of the tracheal and\n bronchial airways, as previously described, consistent with\n tracheobronchomalacia. Coronary artery calcifications are seen. Heart size\n appears in the normal limits. Minimal pericardial effusion. Enlarged pulmonary\n arteries measuring up to 30 mm suggest presence of pulmonary hypertension.\n Limited evaluation of abdominal organs represents of calcified stones within\n the gallbladder.\n\n BONE WINDOWS: Multiple collapsed fractures are seen in the thoracic spine.\n\n IMPRESSION:\n\n 1. No evidence of the central pulmonary embolism. The study is limited due\n (Over)\n\n 12:55 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: Pleas eevaluate for PE\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n to motion and poor enhancement of pulmonary artery branches.\n 2. Persistent collapse of the right middle lobe and right lower lobe.\n 3. Evidence of tracheobronchomalacia.\n 4. Cholelithiasis.\n 5. A wedge-shaped opacity in the right upper lobe on today's study but not\n seen in the prior study on , is nonspecific but could\n potentially represent infarction.\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-10-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1036239,
"text": " 8:04 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval for infiltrate\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with respiratory failure, recent pneumonia, on mechanical\n vent, now with new fever.\n REASON FOR THIS EXAMINATION:\n eval for infiltrate\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLnc FRI 10:15 AM\n Newly developed left lower lobe retrocardiac opacity most likely consistent\n with atelectasis. Infectious process cannot be excluded.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Respiratory failure in a patient on mechanical\n ventilation.\n\n Portable AP chest radiograph was compared to prior study obtained the same day\n earlier at 03:23 a.m. and .\n\n The tracheostomy is at the midline with the tip terminating 3 cm above the\n carina. The left PICC line tip terminates approximately at the level of\n cavoatrial junction.\n\n The cardiomediastinal silhouette is unchanged. Interval worsening in left\n retrocardiac opacity is demonstrated consistent with a newly developed\n atelectasis. Aspiration is another possibility. Left pleural effusion is\n noted, small, grossly unchanged. The rest of the findings are unchanged.\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-10-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1036240,
"text": ", F. MED MICU 8:04 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval for infiltrate\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with respiratory failure, recent pneumonia, on mechanical\n vent, now with new fever.\n REASON FOR THIS EXAMINATION:\n eval for infiltrate\n ______________________________________________________________________________\n PFI REPORT\n Newly developed left lower lobe retrocardiac opacity most likely consistent\n with atelectasis. Infectious process cannot be excluded.\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-10-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1037126,
"text": " 1:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change. evaluate for new infiltrate\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with traumatic T-spine frx, HAP/VAP and respiratory ditress,\n now extubated, fevers, agitation and tachypnic\n REASON FOR THIS EXAMINATION:\n interval change. evaluate for new infiltrate\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JRld WED 1:03 PM\n Unchanged appearance of the chest with small atelectasis in the left lower\n lobe, small right pleural effusion and right lower lobe atelectasis.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: T-spine fracture, respiratory distress with fever.\n\n Comparison is made with prior study of .\n\n Mildly improved left lower lobe opacities. Likely improving atelectasis.\n There is a small left pleural effusion. Tracheostomy tube is in place.\n Cardiomediastinal contours are unchanged. Small right pleural effusion and\n right lower lobe atelectasis are unchanged.\n\n jr\n\n DR. \n"
},
{
"category": "Radiology",
"chartdate": "2167-10-14 00:00:00.000",
"description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY",
"row_id": 1037219,
"text": ", C. MED MICU 12:55 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: Pleas eevaluate for PE\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with persistent sinus tachycardia, h/o UE DVT, fever,\n abnormal CXR\n REASON FOR THIS EXAMINATION:\n Pleas eevaluate for PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n No PE centrally.\n Study limited due to motion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-10-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1035784,
"text": " 3:38 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with asp PNA, intubated\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Bedside supine AP chest radiograph.\n\n HISTORY: 56-year-old woman with aspiration pneumonia. Question interval\n change.\n\n COMPARISON: Comparison is made to chest radiograph from .\n\n FINDINGS: There has been interval improvement in the retrocardiac\n consolidation with minimal areas of residual consolidations seen at the left\n lung base and right lung base. Small right and tiny left pleural effusions\n are also improved from the most recent radiograph. The lungs are otherwise\n clear. The right hemidiaphragm is elevated. Cardiomediastinal contours is\n normal. Visualized soft tissue structures and bony thorax are normal. A\n tracheostomy tube and left PICC line are again seen in good position.\n\n IMPRESSION:\n 1. Interval improvement in retrocardiac consolidation with minimal residual\n consolidation.\n 2. Interval improvement in bilateral pleural effusions.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-10-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1037127,
"text": ", C. MED MICU 1:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change. evaluate for new infiltrate\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with traumatic T-spine frx, HAP/ and respiratory ditress,\n now extubated, fevers, agitation and tachypnic\n REASON FOR THIS EXAMINATION:\n interval change. evaluate for new infiltrate\n ______________________________________________________________________________\n PFI REPORT\n Unchanged appearance of the chest with small atelectasis in the left lower\n lobe, small right pleural effusion and right lower lobe atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-10-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1036501,
"text": " 3:27 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? interval change\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with traumatic T-spine frx, respiratory distress follwed by\n HAP/VAP, resolving, now w/ ? new aspiration vs brewing LLL process.\n REASON FOR THIS EXAMINATION:\n ? interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Traumatic T spine fracture, concern for aspiration or left lower\n lobe pneumonia.\n\n FINDINGS: A single frontal chest radiograph was compared to . No new\n opacities seen. There is improved aeration within the retrocardiac\n space. There is stable elevation of the right hemidiaphragm. There is a\n stable appearance of the cardiac and mediastinal contours. Tracheostomy\n remains in place. The osseous structures are stable.\n\n IMPRESSION: No new opacities identified, as questioned. Improved\n aeration within the retrocardiac space. Stable elevation of the right\n hemidiaphragm.\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-10-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1035114,
"text": " 2:50 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Volume status, interval change\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with respiratory distress, s/p trach placement.\n REASON FOR THIS EXAMINATION:\n Volume status, interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 4:02 A.M., \n\n HISTORY: 56-year-old woman with respiratory distress. Trach placement.\n\n IMPRESSION: AP chest compared to , through 19.\n\n Large right pleural effusion and moderate pulmonary edema have worsened since\n . Heart size top normal. Tracheostomy tube midline. No\n pneumothorax. Left pleural effusion is small-to-moderate, but more difficult\n to assess.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-10-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1037529,
"text": " 3:49 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? interval change\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with respiratory failure, s/p traumatic t-spine frx, s/pHAP\n REASON FOR THIS EXAMINATION:\n ? interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): PSS 3:34 PM\n No change since at least in right middle and lower lobe collapse,\n left lower lobe atelectasis, and small bilateral pleural effusions.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 4:18 AM \n\n HISTORY: Respiratory failure, spine fracture.\n\n IMPRESSION: AP chest compared to :\n\n Right middle and lower lobe collapse, less severe left lower lobe atelectasis\n and small bilateral pleural effusions unchanged since . Tracheostomy\n tube in standard placement.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-10-15 00:00:00.000",
"description": "PR UNILAT UP EXT VEINS US PORT RIGHT",
"row_id": 1037340,
"text": " 7:34 AM\n UNILAT UP EXT VEINS US PORT RIGHT Clip # \n Reason: please eval for DVT\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with h/o UE DVT and tachycardia, please eval for clot.\n REASON FOR THIS EXAMINATION:\n please eval for DVT\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 10:09 AM\n No evidence of DVT in the right upper extremity. Resolution of nonocclusive\n thrombus in the right axillary and basilic veins.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of upper extremity DVT and tachycardia. Assess for clot.\n\n COMPARISON: Upper extremity ultrasound of .\n\n RIGHT UPPER EXTREMITY ULTRASOUND: -scale and Doppler son of the\n right internal jugular, subclavian, axillary, basilic, cephalic, and brachial\n veins was performed. Normal flow, compressibility and waveforms were\n demonstrated. No thrombus was identified today, particularly in the axillary\n and basilic veins where nonocclusive thrombus was seen previously. The wall of\n the axillary vein appeared diffusely thickened, possibly an inflammatory\n change related to prior non- occlusive thrombus. Augmentation was not\n performed on this examination due to the concern for clot that was previously\n present.\n\n IMPRESSION: No evidence of DVT in the right upper extremity.\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-10-15 00:00:00.000",
"description": "PR UNILAT UP EXT VEINS US PORT RIGHT",
"row_id": 1037341,
"text": ", C. MED MICU 7:34 AM\n UNILAT UP EXT VEINS US PORT RIGHT Clip # \n Reason: please eval for DVT\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with h/o UE DVT and tachycardia, please eval for clot.\n REASON FOR THIS EXAMINATION:\n please eval for DVT\n ______________________________________________________________________________\n PFI REPORT\n No evidence of DVT in the right upper extremity. Resolution of nonocclusive\n thrombus in the right axillary and basilic veins.\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-10-02 00:00:00.000",
"description": "BY DIFFERENT PHYSICIAN",
"row_id": 1035051,
"text": " 3:11 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: interval change\n Admitting Diagnosis: TRACHEOBRONCHEAL MALACIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman S/P trach/PEG\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n INDICATION: Status post tracheostomy.\n\n Tracheostomy tube is in standard position with tip terminating about 5 cm\n above the carina. Left PICC terminates in superior vena cava, and nasogastric\n tube has been removed. Cardiomediastinal contour appears slightly less\n widened, and pulmonary edema has slightly improved. Moderate right and small-\n to-moderate left pleural effusion have also slightly decreased. No\n pneumothorax or pneumomediastinum. Incidental left lower lobe granuloma.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2167-09-29 00:00:00.000",
"description": "Report",
"row_id": 222651,
"text": "Narrow complex tachycardia at rate 123. Atrial mechanism is uncertain.\nThe differential is between sinus tachycardia, supraventricular\ntachy-arrhythmia and accelerated junctional rhythm. Compared to the previous\ntracing of sinus tachycardia with first degree A-V block has given\nway to the current rhythm. Both tracings show borderline low voltage with\ngeneralized non-specific repolarization abnormality.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2167-10-27 00:00:00.000",
"description": "Report",
"row_id": 222642,
"text": "Normal sinus rhythm with A-V conduction delay. Borderline voltage criteria for\nleft ventricular hypertrophy. Compared to tracing #1 the A-V conduction delay\nis new.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2167-10-26 00:00:00.000",
"description": "Report",
"row_id": 222643,
"text": "Normal sinus rhythm. Voltage criteria for left ventricular hypertrophy with\nsecondary ST-T wave abnormalities. Compared to the previous tracing of \nthe A-V nodal re-entrant tachycardia is no longer present.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2167-10-18 00:00:00.000",
"description": "Report",
"row_id": 222644,
"text": "Supraventricular tachycardia, probable A-V nodal re-entrant tachycardia.\nCompared to the previous tracing of the supraventricular tachycardia\nis as previously described. There is also delayed R wave transition.\n\n"
},
{
"category": "ECG",
"chartdate": "2167-10-07 00:00:00.000",
"description": "Report",
"row_id": 222645,
"text": "There is a run of supraventricular tachycardia followed by a premature atrial\ncontraction and then sinus rhythm with probable left atrial abnormality.\nCompared to tracing #3 the premature atrial contraction and sinus rhythm are\nboth new.\nTRACING #4\n\n"
},
{
"category": "ECG",
"chartdate": "2167-10-07 00:00:00.000",
"description": "Report",
"row_id": 222646,
"text": "Supraventricular tachycardia or sinus tachycardia. Compared to tracing #2\nearlier the same date supraventricular tachycardia is present in the entire\nstrip.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2167-10-07 00:00:00.000",
"description": "Report",
"row_id": 222647,
"text": "There appears to be a run of supraventricular tachycardia followed by a\npremature atrial contraction and then sinus rhythm with probable left\natrial abnormality and borderline first degree A-V block. Compared to the\nprevious tracing of no significant change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2167-10-06 00:00:00.000",
"description": "Report",
"row_id": 222648,
"text": "There is a run of supraventricular tachycardia followed by a premature atrial\ncontraction and then sinus rhythm. Consider left atrial abnormality. Compared\nto the previous tracing of supraventricular tachycardia is present.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2167-10-05 00:00:00.000",
"description": "Report",
"row_id": 222649,
"text": "Narrow complex rhythm with probable low amplitude P waves. A wider complex\nbeat may be supraventricular with aberration or ventricular premature beat.\nThere are probable atrial premature beats of multifocal origin. Borderline\nlow voltage throughout. Since the previous tracing of the rate is\nfaster.\n\n"
},
{
"category": "ECG",
"chartdate": "2167-10-01 00:00:00.000",
"description": "Report",
"row_id": 222650,
"text": "Compared with the prior tracing undisclosed narrow complex tachycardia has\ngiven way once again to sinus bradycardia with first degree A-V block and\noccasional interpolated ventricular premature beat. Non-specific\nrepolarization change and low voltage. Pericardial disease should be included\nin the differential.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2167-09-21 00:00:00.000",
"description": "Report",
"row_id": 222871,
"text": "Regular supraventricular rhythm. Some semblance of P waves is discerned in\nlead V3 but this is not definite. Borderline low voltage in the limb leads.\nDiffuse non-specific ST-T wave changes. Compared to the previous tracing\nof the findings are similar.\n\n"
},
{
"category": "ECG",
"chartdate": "2167-09-20 00:00:00.000",
"description": "Report",
"row_id": 222872,
"text": "Sinus rhythm. Non-specific ST-T wave changes. Compared to the previous\ntracing of no significant change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2167-09-19 00:00:00.000",
"description": "Report",
"row_id": 222873,
"text": "Sinus rhythm. Non-specific ST-T wave changes. No previous tracing available\nfor comparison.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2167-09-26 00:00:00.000",
"description": "Report",
"row_id": 222869,
"text": "Sinus rhythm. First degree A-V block. Low QRS voltage in the precordial leads\nwith a delayed R wave progression, probably a normal variant. Diffuse\nnon-specific T wave flattening. Compared to the previous tracing of \nno significant change.\n\n"
},
{
"category": "ECG",
"chartdate": "2167-09-24 00:00:00.000",
"description": "Report",
"row_id": 222870,
"text": "Atrial mechanism is unclear but probable sinus bradycardia with first\ndegree A-V blcok. Generalized low voltage. Generalized non-specific\nrepolarization abnormalities. Consider electrolyte abnormality, consider\npericardial effusion, consider drug effect. A junctional mechanism at\nrate 48 cannot be excluded but is somewhat less likely. Compared to the\nprevious tracing of normal sinus rhythm at rate 80 has given way to\nsinus bradycardia with first degree A-V block.\n\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 637207,
"text": "Tachycardia, Other\n Assessment:\n Pt restless and awake with tachycardia at 140-150. Md notified and in\n to assess. Pt also denies any pain every time asked.\n Action:\n Pt given haldol po and IV, valium po/IV and morphine IVP. Emotional\n support also given w/o effect.\n Response:\n Sedation given with NO effect. MD aware. No more interventions for now.\n HR decreased to 120 once pt back in bed and sleeping.\n Plan:\n Continue to eval tachycardia.\n Hypernatremia (high sodium)\n Assessment:\n NA elevated this am .\n Action:\n H2O flushes increased to 100 cc q 4hrs.\n Response:\n Na level to be drawn in am.\n Plan:\n Continue current plan.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS coarse throughout and slight improved after deep sx.\n Action:\n Pt placed on TC this am at 9am x 8hrs and tol well by pt with O2sat\n 93-96%. Pt was able to have prod cough of now green-yellow secretions.\n Pt placed on CPAP +PS once back in bed in order to rest pt overnight.\n Response:\n Pt tol being on TC very well. Pt was placed on pass\n muir valve, but\n was only able to tol it for 15 min inability to clear secretions.\n Plan:\n Needs sputum sample for culture.\n Altered mental status (not Delirium)\n Assessment:\n Pt awake almost the whole day and has been restless. MD aware.\n Action:\n Pt given haldol, valium and Morphine.\n Response:\n No effect from sedation.\n Plan:\n Continue to eval MS.\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 636097,
"text": "55 yr old transferred from OSH on ^th. Pt with PNA/ARDS and\n T-spine fracture. Pt now with trach and PEG.\n Altered mental status (not Delirium)\n Assessment:\n Versed and fentanyl gtt stopped and pt had PO doses of valium and\n haldol given\n Action:\n Pt lethargic throughout the day, did wake more during the day.\n Response:\n Follows all commands but intermittently, does get very aggited with\n stimulation but PO meds did help\n Plan:\n Try to keep pt off IV sedation meds. And give PO haldol and valium.\n Hypotension (not Shock)\n Assessment:\n Pt lethargic and hypotensive throughout entire day, team aware and\n feels its d/t her being over sedated. Pt SBP will go into the 70\n when asleep and not being stimulated.\n Action:\n Fentanyl and versed gtt turned off, and pt did not have any sedation\n meds until 1400 when she became more alert and her HR went into 130\n and SBP 120-130\n Response:\n As the day went on pt became more awake and her SBP stayed in the 90\n but she will still drop into SBP of low 80\ns when she is asleep.\n Plan:\n Keep pt off IV sedation meds\n Hypernatremia (high sodium)\n Assessment:\n NA level of 147\n Action:\n Free water flushed given 300 Q 4 hr.\n Response:\n NA level 141\n Plan:\n Free water flush decreased to 150 Q4 hr.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Vent settings weaned to Pressure support 12 and Peep 10.\n Action:\n ABG on these settings acceptable to team, O2 sats in 92-94 range and\n team accepting that.\n Response:\n Pt cont to be on this vent setting and doing fine.\n Plan:\n Cont to monitor resp status, wean as tolerated.\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-07 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 636204,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n EKG - At 11:53 PM for qrs (<500)\n Continued to have alternating tachy and bradycadia with associated\n pressure swings on adjusted pain regimen. Unable to diurese given\n intermittant hypotension. Finally got one dose lasix when BP in an\n acceptable range.\n Much more anxious than previous nights. Increased Valium back to 10 mg\n QID.\n CT showed cuff distention. Per respiratory, still has a leak, likely\n needs a larger cuff.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,500 units/hour\n Other ICU medications:\n Diazepam (Valium) - 02:00 AM\n Furosemide (Lasix) - 03:56 AM\n Haloperidol (Haldol) - 03:57 AM\n Midazolam (Versed) - 05:11 AM\n Other medications:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37.1\nC (98.7\n HR: 124 (66 - 135) bpm\n BP: 137/67(92) {74/35(48) - 150/81(106)} mmHg\n RR: 15 (7 - 28) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 3,707 mL\n 723 mL\n PO:\n TF:\n 1,457 mL\n 364 mL\n IVF:\n 810 mL\n 150 mL\n Blood products:\n Total out:\n 2,535 mL\n 2,760 mL\n Urine:\n 2,535 mL\n 2,760 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,172 mL\n -2,037 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 964 (260 - 964) mL\n PS : 12 cmH2O\n RR (Set): 10\n RR (Spontaneous): 8\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI Deferred: Agitated\n PIP: 21 cmH2O\n SpO2: 94%\n ABG: 7.41/53/86/35/6\n Ve: 7.8 L/min\n PaO2 / FiO2: 172\n Physical Examination\n General Appearance: Trached and sedated. Responsive, following\n commands, Overweight / Obese, mild agitation but NAD\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\n deviation\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Respiratory / Chest: (Expansion: Symmetric), CTA anteriorly, decreased\n BS\n Abdominal: Obese, soft, Non-tender, no rebound, no guarding, + BS, PEG\n in place with dressing C/D/I\n Extremities: no CCE\n Skin: no rashes or jaundice\n Lines: r brachioceph ART with large amount of bloody drainage and L\n PICC C/D/I\n Labs / Radiology\n 213 K/uL\n 8.3 g/dL\n 118 mg/dL\n 0.6 mg/dL\n 32 mEq/L\n 3.5 mEq/L\n 11 mg/dL\n 108 mEq/L\n 146 mEq/L\n 27.4 %\n 8.2 K/uL\n [image002.jpg]\n 02:47 AM\n 11:01 AM\n 04:40 PM\n 05:08 PM\n 03:44 AM\n 06:04 AM\n 09:09 AM\n 05:07 PM\n 03:31 AM\n 03:46 AM\n WBC\n 11.2\n 9.6\n 8.2\n Hct\n 27.4\n 25.3\n 27.4\n Plt\n 272\n 229\n 213\n Cr\n 0.6\n 0.6\n 0.6\n 0.8\n 0.6\n TCO2\n 31\n 34\n 33\n 32\n 35\n Glucose\n 128\n 138\n 107\n 121\n 118\n Other labs: PT / PTT / INR:18.4/68.9/1.7, Ca++:9.0 mg/dL, Mg++:2.5\n mg/dL, PO4:4.8 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA and\n ARDS intubated since the end of now s/p trach and PEG placement.\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation. Stenting\n unlikely to help for trachiomalacia as airways have poor structure\n diffusely. S/P Trach and PEG on .\n - wean FiO2 as tolerated\n - attempt wean PS today and hopeful for trach mask trial\n # Adrenal Insufficency: Hypotension that resolved with steroids,\n returned as they came off and is now improved again. Possible primary\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\n started on .\n - wean per endo recs, decrease to 20q am and 10 q pm today\n - ok to go to 10 q am and 5 q pm tomorrow ()\n # Volume overloaded in setting of hypernatremia with TBW deficit and\n metabolic alkalosis\n - Lasix boluses with diamox today\n - electrolytes\n - continue tube feeds with free water flushes 300 cc q4\n # Sedation: Sedation control remains somewhat poor although fentanyl\n patch and diazpem are likely therapeutic range today. On Versed 2.0,\n Fentanyl 100, Fentanyl patch, Diazepam standing and haldo 2.5-5 mg\n PRN. QTc increased to 480.\n - Wean versed/fentanyl as tolerated, continue diazepam in\n hopes for vent facility placement\n - Continue diazepam 10 mg q8 with haldol 5 mg q8 with 2.5-5\n prn haldol\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\n coumadin at least until s/p trach. INR 1.7 today.\n - heparin gtt restarted\n - coumadin 5mg G-tube today, INR in am\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n -f/u full trauma spine eval from OSH to determine need for further back\n imaging in-house (to be done )\n #. Thyroid Nodule on CT\n -outpatient follow up\n # Nutrition: Tube feeds with free water flushes, tolerating well,\n continue Replete (Full) - 11:20 AM 30 mL/hour\n # Glycemic control: SSI, well controlled\n # Lines L PICC () and R ART ()\n d/c art and re-site today\n # Ppx: heparin drip until INR therapeutic for 2 days, ranitidine, VAP\n prevention, colace and senna\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n Code: Full\n Dispo: ICU, being screening for vent facilities\n"
},
{
"category": "Nursing",
"chartdate": "2167-09-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 635164,
"text": "55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP now with prolonged\n hospital course c/o by PNA anxiety,RUE DVD with high PEEP requirement\n .\n Plan : Plan for trach and peg today or the next few days, if pt tol\n peep of 10.\n Hypernatremia (high sodium)\n Assessment:\n Na level elevated\n Action:\n H2O flushes increased to 250 cc q 4hrs.\n Response:\n Na level remains elevated this am at 146 (sl improved).\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains intubated on CMV settings, now at 60%/400x18/10. LS coarse\n to upper resp area with diminished bases. Pt has been deep sx\nd for\n scant amounts of yellow secretions q 2hrs. Pt cont to have copious\n amounts of clear oral secretions and in need of freq oral care. Pt\n noted to have a decrease in O2sat, while she is on her Lt side, but it\n has improved throughout the night.\n Action:\n Peep weaned to 10, and tol well by pt with good ABGs. Fio2 weaned to 50\n %, but pt\ns O2sat decreased to 88% right away.\n Response:\n LS clear to upper resp area after sx.\n Plan:\n Plan for trach and Peg today if p[t cont to tol peep of 10.\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt on heparin gtt protocol for DVT to Rt arm. No signs of bleeding\n noted. Hct stable.\n Action:\n Response:\n PTT drawn q 6hrs; and it has been therapeutic.\n Plan:\n Plan to check PTT now daily.\n"
},
{
"category": "Nursing",
"chartdate": "2167-09-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 635166,
"text": "55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP now with prolonged\n hospital course c/o by PNA anxiety,RUE DVD with high PEEP requirement\n .\n Plan : Plan for trach and peg today or the next few days, if pt tol\n peep of 10.\n Hypernatremia (high sodium)\n Assessment:\n Na level elevated\n Action:\n H2O flushes increased to 250 cc q 4hrs.\n Response:\n Na level remains elevated this am at 146 (sl improved).\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains intubated on CMV settings, now at 60%/400x18/10. LS coarse\n to upper resp area with diminished bases. Pt has been deep sx\nd for\n scant amounts of yellow secretions q 2hrs. Pt cont to have copious\n amounts of clear oral secretions and in need of freq oral care. Pt\n noted to have a decrease in O2sat, while she is on her Lt side, but it\n has improved throughout the night.\n Action:\n Peep weaned to 10, and tol well by pt with good ABGs. Fio2 weaned to 50\n %, but pt\ns O2sat decreased to 88% right away.\n Response:\n LS clear to upper resp area after sx.\n Plan:\n Plan for trach and Peg today if p[t cont to tol peep of 10.\n Altered mental status (not Delirium)\n Assessment:\n Pt found at 8pm to 10pm to be awake, alert and following commands. Pt\n was slight restless, but appropriate. 10pm, pt became very restless in\n bed, trying to sit up and was reaching for ETT. Once reposition and\n back rubs did not work, MD notified and haldol given and diazepam given\n with only effect for one hr. When pt is awake and restless, her HR will\n increase to 120-130\ns (ST) and BP will increase to 120-130\ns. When pt\n was sleeping (after sedation), Hr will deacrease to 50\ns with a SBP in\n the 80\ns. Fentanyl patch increased and diazepam changed to q6hrs, with\n no effect.\n Action:\n 2:30am, versed gtt was initiated again with good effect. Pt more\n relaxed and fell back to sleep with stable HR and BP.\n Response:\n Plan:\n Continue to evaluate restlessness.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt on heparin gtt protocol for DVT to Rt arm. No signs of bleeding\n noted. Hct stable.\n Action:\n Response:\n PTT drawn q 6hrs; and it has been therapeutic.\n Plan:\n Plan to check PTT now daily.\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 637018,
"text": "56 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\n with prolonged hospital course c/b by PNA, anxiety/altered mental\n status, RUE DVT .\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on PSV 10/5/50%. RR 20-30. )2 sat > 97%\n Action:\n Pt remained on PSV rather than AC overnight. Suctioned ~q 3-4 hrs for\n sm amt yellow bld-tinged secretions. Continues to have copious oral\n secretions\n removed with yankeur.\n Response:\n Tolerated PSV well, no tachypnea or desaturation.\n Plan:\n Attempt trach collar trial again in am. On-going pulm hygiene\n Hypotension (not Shock)\n Assessment:\n BP 90/40 with urine output falling to 10-15ccs/hr via foley. HR remains\n tachycardic (110-140ST) even when pt is not agitated or febrile.\n Action:\n Given 1 500cc d5\n ns fluid bolus\n Response:\n SBP > 90, Urine output improving to >30ccs/hr\n Plan:\n Continue to monitor hemodynamic status and f+e balance.\n Altered mental status (not Delirium)\n Assessment:\n Pt lethargic after receiving benedryl for several hrs but then awoke\n agitated, attempting to climb OOB and pull at trach despite restraints.\n Denies pain ( fentanyl patch in place) or need to go to the bathroom.\n c/o itchiness on back secondary to rash.\n Action:\n Medicated with iv benedryl.\n Response:\n Less agitated. Slept again\n Plan:\n Continue to reorient pt, benedryl for pruritis, safety precautions.\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 637208,
"text": "Tachycardia, Other\n Assessment:\n Pt restless and awake with tachycardia at 140-150. Md notified and in\n to assess. Pt also denies any pain every time asked. ? if pt is\n dehydrated with U/O 15-30cc/hr, but no IVF for now MD. Pt remains\n afebrile.\n Action:\n Pt given haldol po and IV, valium po/IV and morphine IVP. Emotional\n support also given w/o effect.\n Response:\n Sedation given with NO effect. MD aware. No more interventions for now.\n HR decreased to 120 once pt back in bed and sleeping.\n Plan:\n Continue to eval tachycardia.\n Hypernatremia (high sodium)\n Assessment:\n NA elevated this am .\n Action:\n H2O flushes increased to 100 cc q 4hrs.\n Response:\n Na level to be drawn in am.\n Plan:\n Continue current plan.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS coarse throughout and slight improved after deep sx. RR 18-24.\n Action:\n Pt placed on TC this am at 9am x 8hrs and tol well by pt with O2sat\n 93-96%. Pt was able to have prod cough of now green-yellow secretions.\n Pt placed on CPAP +PS once back in bed in order to rest pt overnight.\n Response:\n Pt tol being on TC very well. Pt was placed on pass\n muir valve, but\n was only able to tol it for 15 min inability to clear secretions.\n Plan:\n Needs sputum sample for culture.\n Altered mental status (not Delirium)\n Assessment:\n Pt awake almost the whole day and has been restless. MD aware.\n Action:\n Pt given haldol, valium and Morphine.\n Response:\n No effect from sedation.\n Plan:\n Continue to eval MS.\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-07 00:00:00.000",
"description": "Physician Resident/Attending Progress Note - MICU",
"row_id": 636214,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n EKG - At 11:53 PM for qrs (<500)\n Continued to have alternating tachy and bradycadia with associated\n pressure swings on adjusted pain regimen. Unable to diurese given\n intermittant hypotension. Finally got one dose lasix when BP in an\n acceptable range.\n Much more anxious than previous nights. Increased Valium back to 10 mg\n QID.\n CT showed cuff distention. Per respiratory, still has a leak, likely\n needs a larger cuff.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,500 units/hour\n Other ICU medications:\n Diazepam (Valium) - 02:00 AM\n Furosemide (Lasix) - 03:56 AM\n Haloperidol (Haldol) - 03:57 AM\n Midazolam (Versed) - 05:11 AM\n Other medications:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37.1\nC (98.7\n HR: 124 (66 - 135) bpm\n BP: 137/67(92) {74/35(48) - 150/81(106)} mmHg\n RR: 15 (7 - 28) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 3,707 mL\n 723 mL\n PO:\n TF:\n 1,457 mL\n 364 mL\n IVF:\n 810 mL\n 150 mL\n Blood products:\n Total out:\n 2,535 mL\n 2,760 mL\n Urine:\n 2,535 mL\n 2,760 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,172 mL\n -2,037 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 964 (260 - 964) mL\n PS : 12 cmH2O\n RR (Set): 10\n RR (Spontaneous): 8\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI Deferred: Agitated\n PIP: 21 cmH2O\n SpO2: 94%\n ABG: 7.41/53/86/35/6\n Ve: 7.8 L/min\n PaO2 / FiO2: 172\n Physical Examination\n General Appearance: Trached and sedated. Responsive, following\n commands, Overweight / Obese, mild agitation but NAD\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\n deviation\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Respiratory / Chest: (Expansion: Symmetric), CTA anteriorly, decreased\n BS\n Abdominal: Obese, soft, Non-tender, no rebound, no guarding, + BS, PEG\n in place with dressing C/D/I\n Extremities: no CCE\n Skin: no rashes or jaundice\n Lines: r brachioceph ART with large amount of bloody drainage and L\n PICC C/D/I\n Labs / Radiology\n 213 K/uL\n 8.3 g/dL\n 118 mg/dL\n 0.6 mg/dL\n 32 mEq/L\n 3.5 mEq/L\n 11 mg/dL\n 108 mEq/L\n 146 mEq/L\n 27.4 %\n 8.2 K/uL\n [image002.jpg]\n 02:47 AM\n 11:01 AM\n 04:40 PM\n 05:08 PM\n 03:44 AM\n 06:04 AM\n 09:09 AM\n 05:07 PM\n 03:31 AM\n 03:46 AM\n WBC\n 11.2\n 9.6\n 8.2\n Hct\n 27.4\n 25.3\n 27.4\n Plt\n 272\n 229\n 213\n Cr\n 0.6\n 0.6\n 0.6\n 0.8\n 0.6\n TCO2\n 31\n 34\n 33\n 32\n 35\n Glucose\n 128\n 138\n 107\n 121\n 118\n Other labs: PT / PTT / INR:18.4/68.9/1.7, Ca++:9.0 mg/dL, Mg++:2.5\n mg/dL, PO4:4.8 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA and\n ARDS intubated since the end of now s/p trach and PEG placement.\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation. Stenting\n unlikely to help for trachiomalacia as airways have poor structure\n diffusely. S/P Trach and PEG on .\n - wean FiO2 as tolerated\n - attempt wean PS today and hopeful for trach mask trial\n # Adrenal Insufficency: Hypotension that resolved with steroids,\n returned as they came off and is now improved again. Possible primary\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\n started on .\n - wean per endo recs, decrease to 20q am and 10 q pm today\n - ok to go to 10 q am and 5 q pm tomorrow ()\n # Volume overloaded in setting of hypernatremia with TBW deficit and\n metabolic alkalosis\n - Lasix boluses with diamox today\n - electrolytes\n - continue tube feeds with free water flushes 300 cc q4\n # Sedation: Sedation control remains somewhat poor although fentanyl\n patch and diazpem are likely therapeutic range today. On Versed 2.0,\n Fentanyl 100, Fentanyl patch, Diazepam standing and haldo 2.5-5 mg\n PRN. QTc increased to 480.\n - Wean versed/fentanyl as tolerated, continue diazepam in\n hopes for vent facility placement\n - Continue diazepam 10 mg q8 with haldol 5 mg q8 with 2.5-5\n prn haldol\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\n coumadin at least until s/p trach. INR 1.7 today.\n - heparin gtt restarted\n - coumadin 5mg G-tube today, INR in am\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n -f/u full trauma spine eval from OSH to determine need for further back\n imaging in-house (to be done )\n #. Thyroid Nodule on CT\n -outpatient follow up\n # Nutrition: Tube feeds with free water flushes, tolerating well,\n continue Replete (Full) - 11:20 AM 30 mL/hour\n # Glycemic control: SSI, well controlled\n # Lines L PICC () and R ART ()\n d/c art and re-site today\n # Ppx: heparin drip until INR therapeutic for 2 days, ranitidine, VAP\n prevention, colace and senna\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n Code: Full\n Dispo: ICU, being screening for vent facilities\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 55F T5-8 fractures with retropulsion and ARDS\n from klebsiella VAP; on heparin for UE DVT and lasix for volume\n overload.\n Exam notable for Tm 99.6 BP 110/50 HR 110 RR 18-20 with sat 97%\n on PSV 12/8 FiO2 0.5, ABG 7.41/53/86. TBB -3L/8h, +6L/MICU LOS. Eyes\n opens, will squeeze hands and wiggle toes but very drowsy. Clearer BS\n bilaterally with RRR s1s2 SM at base. Abdomen is distended with\n decreased BS. Trace edema in BLE, no cords. Labs notable for WBC 8K,\n HCT 27, K+ 3.5, Na 146, Cr 0.6, INR 1.7. CXR with resolving B LL\n airspace disease and RLL collapse.\n Agree with plan to continue supportive care, wean PSV to , and\n continue diuresis with lasix / diamox as BP allows. Will continue\n fentanyl patch at 150mcg, haldol 5q8h alternating with valium 10q6h at\n lower dose, now off drips. Will use haldol for breakthrough agitation.\n Will wean hydrocortisone 20/10q12 PGT today and will discuss more\n aggressive wean with endocrine as I think she has a component of\n steroid psychosis. Will continue IV heparin for UE DVT and transition\n to anticoagulation with coumadin. Will continue tube feeds and continue\n FW boluses for hypernatremia. Arterial line to be resited today.\n Continue spinal stabilization with brace when OOB and discuss follow-up\n plan with spine surgery. Will eventually need MRI for surgical\n planning; remainder of plan as outlined above.\n Patient is critically ill\n Total time: 50 min\n ------ Protected Section Addendum Entered By: , MD\n on: 03:06 PM ------\n"
},
{
"category": "Respiratory ",
"chartdate": "2167-10-01 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 635396,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 13\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Clear / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments: Patient remains on mechanical ventilation with hypoxemic ABG\n on A/C 400*18-.50-8p.Patient more alert today,BS clear,suctioned for\n minimal to moderate amount of thick tan secretion.Plan to go to OR in\n AM for tracheostomy and PEG procedure.Trial of SBT failed as patient\n quickly desaturated with increase in HR.\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-02 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 635495,
"text": "Chief Complaint:\n 24 Hour Events:\n Patient agitated and combative overnight - restarted midazolam gtt and\n patient was becoming increasingly tachycardic and hypertensive\n Thoracics to take to OR this am for trach and PEG\n Discussion with patient's boyfriend yesterday - her should be here this\n weekend, wants to be involved, just hard for him to get here\n On lasix drip with excellent response (200 cc urine/hour)\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Fentanyl - 100 mcg/hour\n Furosemide (Lasix) - 1 mg/hour\n Heparin Sodium - 1,700 units/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:07 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.3\nC (99.2\n HR: 118 (45 - 138) bpm\n BP: 155/84(118) {91/38(56) - 177/106(139)} mmHg\n RR: 18 (17 - 27) insp/min\n SpO2: 90%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,604 mL\n 1,447 mL\n PO:\n TF:\n 675 mL\n 17 mL\n IVF:\n 1,089 mL\n 730 mL\n Blood products:\n Total out:\n 4,130 mL\n 2,430 mL\n Urine:\n 4,130 mL\n 2,430 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,526 mL\n -983 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n PS : 5 cmH2O\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n PIP: 22 cmH2O\n Plateau: 19 cmH2O\n Compliance: 48.2 cmH2O/mL\n SpO2: 90%\n ABG: 7.45/50/67/36/8\n Ve: 7.5 L/min\n PaO2 / FiO2: 134\n Physical Examination\n General Appearance: Responsive, following commands, Overweight / Obese,\n NAD\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\n deviation\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Respiratory / Chest: (Expansion: Symmetric), referred breath sounds\n from ETT, mild rhonchi diffusely\n Abdominal: Obese, Soft, Non-tender, no rebound, no guarding\n Extremities: No clubbing or cyanosis, + nonpitting edema of b/l\n hands, anasarca\n Skin: no rashes or jaundice\n Neuro: alert. Strength 4/5 upper and lower extremeties, light touch\n sensation intact bil.\n Lines: r brachioceph ART and L PICC C/D/I\n Labs / Radiology\n 306 K/uL\n 8.5 g/dL\n 165 mg/dL\n 0.7 mg/dL\n 29 mEq/L\n 3.7 mEq/L\n 10 mg/dL\n 108 mEq/L\n 146 mEq/L\n 27.1 %\n 11.2 K/uL\n [image002.jpg]\n WBC 11.2 up from 8.6\n HCT 27.1 up from 25.9\n HCO2 32 up from 29\n 02:18 AM\n 01:27 PM\n 03:06 PM\n 10:04 PM\n 03:00 AM\n 10:47 AM\n 04:10 PM\n 12:13 AM\n 05:08 AM\n 05:20 AM\n WBC\n 8.6\n 11.2\n Hct\n 25.9\n 27.1\n Plt\n 280\n 306\n Cr\n 0.6\n 0.5\n 0.7\n TCO2\n 33\n 32\n 32\n 34\n 36\n 36\n Glucose\n 176\n 136\n 165\n Other labs: PT / PTT / INR:13.2/68.7/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:89.7 %, Lymph:8.7 %, Mono:1.1\n %, Eos:0.4 %, Lactic Acid:0.9 mmol/L, Albumin:2.4 g/dL, LDH:204 IU/L,\n Ca++:10.6 mg/dL, Mg++:2.8 mg/dL, PO4:4.3 mg/dL\n MICRO: sputum Gram stain: 2+ GPC in P/C, 2+ GPR. Cx: sparse\n flora, sparse yeast\n MICRO: MiniBAL: Gram stain: 2+PMNs, Cx: GNR #1, GNR#2, yeast.\n CXR: Poor penetration, hazy opacification of both lung fields R>L,\n patchy opacities in LLL, new. Focal atelectasis vs. PNA\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA and\n ARDS intubated since the end of .\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation.\n Transferred here for airway stenting.\n - attempt SBT yesterday. Failed.\n -To OR today , add-on for trach and PEG with Dr. (tube feeds\n off after MN, heparin off after 6am)\n - Repeat CXR in PM post trach.\n ## Adrenal Insufficency: Minimal response to stim test again.\n Appreciate endocrine recommendations.\n - hydrocort and fludrocort (day 1 = )\n - will continue at current dose until s/p trach and PEG and\n hemodynamically stable for 24 hours\n will then plan to taper\n hydrocortisone to 25mg IV q6 with a slow taper\n - f/u daily endocrine recs\n - Endocrine recs: d/c Fludrocort. Continue Hydrocort for now.\n # Hypotension: Likely adrenal insufficiency and sedation. Goal map\n > 60. Much improved since re-administration of steroids.\n - hydrocortisone as above\n - restart levophed if necessary to maintain MAP > 60\n # Volume overloaded in setting of hypernatremia with TBW deficit.\n - goal -1000cc I/Os yesterday, was -1500cc for last 24 hours.\n - continue FW in TF at 250 cc q4hrs\n - lasix drip (1-5mg/hr) held before surgery, will restart when returns\n to MICU.\n - may have some contraction alkalosis, w/ rising pH and bicarb. Start\n Diamox 500mg TID to decrease bicarb and pH and may improve respiratory\n drive.\n # Sedation: Sedation control remains somewhat poor although fentanyl\n patch and diazpem are likely therapeutic range today. On Versed 2.0,\n Fentanyl 100, Fentanyl patch, Diazepam standing and haldo 2.5-5 mg\n PRN. QTc increased to 480.\n - Wean versed/fentanyl as tolerated, continue diazepam. Avoid haldol\n use if possible to avoid further prolongation of QTc\n - Will reassess sedation/agitation after PEG/Trach.\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\n coumadin at least until s/p trach.\n - hold heparin gtt when anticipate trach/peg\n - will restart heparin gtt per recs from surgery post-op\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n # FEN/GI: Tube feeds with FWF @ goal.\n -held for surgery. Will restart based on post-op recs after PEG\n placement.\n DVT: Treatment dose heparin, holding until post-op recs from PEG/Trach\n Ulcer: Ranitidine\n VAP: Prevention per routine\n # Access: L PICC line, and R brachial a-line\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n - touch base with SW today\n Code: Full\n Dispo: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Arterial Line - 02:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-02 00:00:00.000",
"description": "Physician Resident/Attending Progress Note - MICU",
"row_id": 635496,
"text": "Chief Complaint:\n 24 Hour Events:\n Patient agitated and combative overnight - restarted midazolam gtt and\n patient was becoming increasingly tachycardic and hypertensive\n Thoracics to take to OR this am for trach and PEG\n Discussion with patient's boyfriend yesterday - her should be here this\n weekend, wants to be involved, just hard for him to get here\n On lasix drip with excellent response (200 cc urine/hour)\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Fentanyl - 100 mcg/hour\n Furosemide (Lasix) - 1 mg/hour\n Heparin Sodium - 1,700 units/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:07 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.3\nC (99.2\n HR: 118 (45 - 138) bpm\n BP: 155/84(118) {91/38(56) - 177/106(139)} mmHg\n RR: 18 (17 - 27) insp/min\n SpO2: 90%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,604 mL\n 1,447 mL\n PO:\n TF:\n 675 mL\n 17 mL\n IVF:\n 1,089 mL\n 730 mL\n Blood products:\n Total out:\n 4,130 mL\n 2,430 mL\n Urine:\n 4,130 mL\n 2,430 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,526 mL\n -983 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n PS : 5 cmH2O\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n PIP: 22 cmH2O\n Plateau: 19 cmH2O\n Compliance: 48.2 cmH2O/mL\n SpO2: 90%\n ABG: 7.45/50/67/36/8\n Ve: 7.5 L/min\n PaO2 / FiO2: 134\n Physical Examination\n General Appearance: Responsive, following commands, Overweight / Obese,\n NAD\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\n deviation\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Respiratory / Chest: (Expansion: Symmetric), referred breath sounds\n from ETT, mild rhonchi diffusely\n Abdominal: Obese, Soft, Non-tender, no rebound, no guarding\n Extremities: No clubbing or cyanosis, + nonpitting edema of b/l\n hands, anasarca\n Skin: no rashes or jaundice\n Neuro: alert. Strength 4/5 upper and lower extremeties, light touch\n sensation intact bil.\n Lines: r brachioceph ART and L PICC C/D/I\n Labs / Radiology\n 306 K/uL\n 8.5 g/dL\n 165 mg/dL\n 0.7 mg/dL\n 29 mEq/L\n 3.7 mEq/L\n 10 mg/dL\n 108 mEq/L\n 146 mEq/L\n 27.1 %\n 11.2 K/uL\n [image002.jpg]\n WBC 11.2 up from 8.6\n HCT 27.1 up from 25.9\n HCO2 32 up from 29\n 02:18 AM\n 01:27 PM\n 03:06 PM\n 10:04 PM\n 03:00 AM\n 10:47 AM\n 04:10 PM\n 12:13 AM\n 05:08 AM\n 05:20 AM\n WBC\n 8.6\n 11.2\n Hct\n 25.9\n 27.1\n Plt\n 280\n 306\n Cr\n 0.6\n 0.5\n 0.7\n TCO2\n 33\n 32\n 32\n 34\n 36\n 36\n Glucose\n 176\n 136\n 165\n Other labs: PT / PTT / INR:13.2/68.7/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:89.7 %, Lymph:8.7 %, Mono:1.1\n %, Eos:0.4 %, Lactic Acid:0.9 mmol/L, Albumin:2.4 g/dL, LDH:204 IU/L,\n Ca++:10.6 mg/dL, Mg++:2.8 mg/dL, PO4:4.3 mg/dL\n MICRO: sputum Gram stain: 2+ GPC in P/C, 2+ GPR. Cx: sparse\n flora, sparse yeast\n MICRO: MiniBAL: Gram stain: 2+PMNs, Cx: GNR #1, GNR#2, yeast.\n CXR: Poor penetration, hazy opacification of both lung fields R>L,\n patchy opacities in LLL, new. Focal atelectasis vs. PNA\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA and\n ARDS intubated since the end of .\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation.\n Transferred here for airway stenting.\n - attempt SBT yesterday. Failed.\n -To OR today , add-on for trach and PEG with Dr. (tube feeds\n off after MN, heparin off after 6am)\n - Repeat CXR in PM post trach.\n ## Adrenal Insufficency: Minimal response to stim test again.\n Appreciate endocrine recommendations.\n - hydrocort and fludrocort (day 1 = )\n - will continue at current dose until s/p trach and PEG and\n hemodynamically stable for 24 hours\n will then plan to taper\n hydrocortisone to 25mg IV q6 with a slow taper\n - f/u daily endocrine recs\n - Endocrine recs: d/c Fludrocort. Continue Hydrocort for now.\n # Hypotension: Likely adrenal insufficiency and sedation. Goal map\n > 60. Much improved since re-administration of steroids.\n - hydrocortisone as above\n - restart levophed if necessary to maintain MAP > 60\n # Volume overloaded in setting of hypernatremia with TBW deficit.\n - goal -1000cc I/Os yesterday, was -1500cc for last 24 hours.\n - continue FW in TF at 250 cc q4hrs\n - lasix drip (1-5mg/hr) held before surgery, will restart when returns\n to MICU.\n - may have some contraction alkalosis, w/ rising pH and bicarb. Start\n Diamox 500mg TID to decrease bicarb and pH and may improve respiratory\n drive.\n # Sedation: Sedation control remains somewhat poor although fentanyl\n patch and diazpem are likely therapeutic range today. On Versed 2.0,\n Fentanyl 100, Fentanyl patch, Diazepam standing and haldo 2.5-5 mg\n PRN. QTc increased to 480.\n - Wean versed/fentanyl as tolerated, continue diazepam. Avoid haldol\n use if possible to avoid further prolongation of QTc\n - Will reassess sedation/agitation after PEG/Trach.\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\n coumadin at least until s/p trach.\n - hold heparin gtt when anticipate trach/peg\n - will restart heparin gtt per recs from surgery post-op\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n # FEN/GI: Tube feeds with FWF @ goal.\n -held for surgery. Will restart based on post-op recs after PEG\n placement.\n DVT: Treatment dose heparin, holding until post-op recs from PEG/Trach\n Ulcer: Ranitidine\n VAP: Prevention per routine\n # Access: L PICC line, and R brachial a-line\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n - touch base with SW today\n Code: Full\n Dispo: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Arterial Line - 02:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 55F T5-8 fractures with retropulsion and ARDS\n from VAP; on heparin for UE DVT. Tolerating slow vent wean but failed\n SBT. Was TBB negative yesterday with lasix drip; sedation remains\n challenging. Plan for T+G today.\n Exam notable for Tm 99.2 BP 105/45 HR 45-120 RR 18-20 with sat 93-96%\n on VAC 400x18 PEEP 8 FiO2 0.5 for 7.45/50/67. TBB -2.6L/24h, +15L/MICU\n LOS. Eyes opens, will squeeze hands and wiggle toes but very\n drowsyBronchial BS bilaterally with RRR s1s2 SM at base. Abdomen is\n distended with decreased BS. 3+ edema in BLE, no cords. Labs notable\n for WBC 11K, HCT 27, K+ 3.8, Na 146, Cr 0.5. CXR with resolving B LL\n airspace disease and effusions.\n Agree with plan to continue supportive care and wean vent after\n procedures today. Needs diamox and aggressive KCl repletion in addition\n to lasix given progressive alkalosis and rising pCO2. Once sedation\n requirements are clarified following T+G, will try PSV. For now,\n continue fentanyl patch and valium 10 TID po in addition to drips. Will\n continue hydrocortisone 50 q6 today and reduce to q8 tomorrow, with\n long term goal for oral prednisone. Will d/c fludrocortisone. Will\n resume IV heparin for UE DVT when cleared from a surgical perspective\n with plan for eventual transition to coumadin. Will restart tube feeds\n and continue FW boluses for hypernatremia once PEG cleared by surgery.\n Continue spinal stabilization with brace when OOB; will eventually need\n MRI for surgical planning; remainder of plan as outlined above.\n Patient is critically ill\n Total time: 40 min\n ------ Protected Section Addendum Entered By: , MD\n on: 02:53 PM ------\n"
},
{
"category": "Respiratory ",
"chartdate": "2167-10-10 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 636796,
"text": "TITLE:\n Demographics\n Day of intubation:\n Day of mechanical ventilation: 22\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Cuffed\n Manufacturer: Portex\n Size: 7.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Cannot protect\n airway; Comments: some weaning to trach collar tolerated today\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Respiratory ",
"chartdate": "2167-10-11 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 636848,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 23\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason:\n Tube Type\n Tracheostomy tube:\n Type: Cuffed\n Manufacturer: Portex\n Size: 7.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thin\n Sputum source/amount: Suctioned / Moderate\n Comments: Pt had excessive coughing all shift\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment: Frequent alarms (High pressure, High rate)\n Comments: Pt coughing all shift, very agitated by thrashing in bed\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Adjust Min. ventilation to control pH, Increase ventilatory support at\n night; Comments: Pt needed to be suctioned many times this shift.\n Sputum culture sent. Pt thrashes in bed, causing tracheostomy to shift\n and causing her cough.\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Cannot protect airway, Cannot manage secretions,\n Underlying illness not resolved\n Bedside RSBI- deferred due to agitation\n"
},
{
"category": "Respiratory ",
"chartdate": "2167-10-12 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 637200,
"text": "TITLE:\n Demographics\n Day of intubation:\n Day of mechanical ventilation: 24\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Not applicable\n Size: Not applicable\n Tracheostomy tube:\n Type: Cuffed\n Manufacturer: Portex\n Size: 7.0mm\n PMV: No\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments: PMV eval done today... only partially\n successful\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Cannot protect\n airway, Cannot manage secretions, Underlying illness not resolved;\n Comments: weaning to trach collar as tolerated each day\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-07 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 636189,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n EKG - At 11:53 PM for qrs (<500)\n Continued to have alternating tachy and bradycadia with associated\n pressure swings on adjusted pain regimen. Unable to diurese given\n intermittant hypotension. Finally got one dose lasix when BP in an\n acceptable range.\n Much more anxious than previous nights. Increased Valium back to 10 mg\n QID.\n CT showed cuff distention. Per respiratory, still has a leak, likely\n needs a larger cuff.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,500 units/hour\n Other ICU medications:\n Diazepam (Valium) - 02:00 AM\n Furosemide (Lasix) - 03:56 AM\n Haloperidol (Haldol) - 03:57 AM\n Midazolam (Versed) - 05:11 AM\n Other medications:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37.1\nC (98.7\n HR: 124 (66 - 135) bpm\n BP: 137/67(92) {74/35(48) - 150/81(106)} mmHg\n RR: 15 (7 - 28) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 3,707 mL\n 723 mL\n PO:\n TF:\n 1,457 mL\n 364 mL\n IVF:\n 810 mL\n 150 mL\n Blood products:\n Total out:\n 2,535 mL\n 2,760 mL\n Urine:\n 2,535 mL\n 2,760 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,172 mL\n -2,037 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 964 (260 - 964) mL\n PS : 12 cmH2O\n RR (Set): 10\n RR (Spontaneous): 8\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI Deferred: Agitated\n PIP: 21 cmH2O\n SpO2: 94%\n ABG: 7.41/53/86/35/6\n Ve: 7.8 L/min\n PaO2 / FiO2: 172\n Physical Examination\n General Appearance: Trached and sedated. Responsive, following\n commands, Overweight / Obese, mild agitation but NAD\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\n deviation\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Respiratory / Chest: (Expansion: Symmetric), CTA anteriorly, decreased\n BS\n Abdominal: Obese, Firm, Non-tender, no rebound, no guarding, + BS, PEG\n in place with dressing C/D/I\n Extremities: no CCE\n Skin: no rashes or jaundice\n Lines: r brachioceph ART with large amount of bloody drainage and L\n PICC C/D/I\n Labs / Radiology\n 213 K/uL\n 8.3 g/dL\n 118 mg/dL\n 0.6 mg/dL\n 32 mEq/L\n 3.5 mEq/L\n 11 mg/dL\n 108 mEq/L\n 146 mEq/L\n 27.4 %\n 8.2 K/uL\n [image002.jpg]\n 02:47 AM\n 11:01 AM\n 04:40 PM\n 05:08 PM\n 03:44 AM\n 06:04 AM\n 09:09 AM\n 05:07 PM\n 03:31 AM\n 03:46 AM\n WBC\n 11.2\n 9.6\n 8.2\n Hct\n 27.4\n 25.3\n 27.4\n Plt\n 272\n 229\n 213\n Cr\n 0.6\n 0.6\n 0.6\n 0.8\n 0.6\n TCO2\n 31\n 34\n 33\n 32\n 35\n Glucose\n 128\n 138\n 107\n 121\n 118\n Other labs: PT / PTT / INR:18.4/68.9/1.7, Ca++:9.0 mg/dL, Mg++:2.5\n mg/dL, PO4:4.8 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA and\n ARDS intubated since the end of now s/p trach and PEG placement.\n Thyroid nodule on CT\n Watch phos product\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation. Stenting\n unlikely to help for trachiomalacia as airways have poor structure\n diffusely. S/P Trach and PEG on . Increased effusion on recent\n CXR.\n - wean FiO2 as tolerated\n # Adrenal Insufficency: Hypotension that resolved with steroids,\n returned as they came off and is now improved again. Possible primary\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\n started on .\n - wean per endo recs, decrease to 20q am and 10 q pm starting\n tonight\n will maintain this maintenance dose and check am cortisol\n level one week later\n # Volume overloaded in setting of hypernatremia with TBW deficit.\n - Lasix gtt, continue with goal -1-2 L per day\n currently off as\n patient is somewhat hypotensive\n will restart once/if BP increases and\n remains stable for several hours\n - electrolytes\n - continue tube feeds with free water flushes 300 cc q4\n # Sedation: Sedation control remains somewhat poor although fentanyl\n patch and diazpem are likely therapeutic range today. On Versed 2.0,\n Fentanyl 100, Fentanyl patch, Diazepam standing and haldo 2.5-5 mg\n PRN. QTc increased to 480.\n - Wean versed/fentanyl as tolerated, continue diazepam in\n hopes for vent facility placement\n - Change diazepam to 5mg q8 with haldol 5 mg q8\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\n coumadin at least until s/p trach.\n - heparin gtt restarted\n - coumadin 5mg G-tube today, INR in am\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n -f/u full trauma spine eval from OSH to determine need for further back\n imaging in-house (to be done )\n #. Thyroid Nodule\n # Nutrition: Tube feeds with free water flushes, tolerating well,\n continue Replete (Full) - 11:20 AM 30 mL/hour\n # Glycemic control: SSI, well controlled\n # Lines L PICC () and R ART ()\n similarly but will\n keep in setting of hypotension\n # Ppx: heparin drip until INR therapeutic for 2 days, ranitidine, VAP\n prevention, colace and senna\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n Code: Full\n Dispo: ICU, being screening for vent facilities\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 01:39 AM 60 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Arterial Line - 02:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nutrition",
"chartdate": "2167-10-07 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 636190,
"text": "Objective\n Pertinent medications: nted\n Labs:\n Value\n Date\n Glucose\n 155 mg/dL\n 10:20 AM\n Glucose Finger Stick\n 115\n 04:00 AM\n BUN\n 12 mg/dL\n 10:20 AM\n Creatinine\n 0.8 mg/dL\n 10:20 AM\n Sodium\n 150 mEq/L\n 10:20 AM\n Potassium\n 4.8 mEq/L\n 10:20 AM\n Chloride\n 109 mEq/L\n 10:20 AM\n TCO2\n 32 mEq/L\n 10:20 AM\n Albumin\n 2.4 g/dL\n 03:59 AM\n Calcium non-ionized\n 10.0 mg/dL\n 10:20 AM\n Phosphorus\n 4.8 mg/dL\n 10:20 AM\n Ionized Calcium\n 1.17 mmol/L\n 03:32 PM\n Magnesium\n 2.8 mg/dL\n 10:20 AM\n Current diet order / nutrition support: Replete c/ Fiber @ 60mL/hr\n (1440 kcals/89 graa) Flush c/ 150mL q4hr per medbook\n GI: Abd: soft/+bs\n Assessment of Nutritional Status\n Estimation of current intake: Adequate\n Specifics:\n Pt continues on TF\ns for full nutrition support via PEG. TF\ns meeting\n 100% estimated nutrition needs. Asked by RN to evaluate TF in relation\n to high Na and PO4. Pt is receiving TF\ns c/ the most free H2O able in\n a standard formula, therefore will need to increase FWB to increase\n free H2O in. A low PO4 formula would also have low K, which is not\n appropriate in this pt given need for frequent K repletions. Would\n consider PO4 binder instead.\n Medical Nutrition Therapy Plan - Recommend the Following\n Increase FWB to 250mL q 4 hr\n Consider CaCO3 500mg daily for high Po4\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-08 00:00:00.000",
"description": "Generic Note",
"row_id": 636274,
"text": "TITLE:\n 55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\n Now with prolonged hospital course c/b by PNA with high PEEP\n requirement, anxiety, RUE DVT ,continued on heparin qtt.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lungs clear bilat upper lobes and diminished bilat bases with\n occasional scattered rhonchi, prod cough thick yellow/tan sputum, trach\n sx for mod.amt. Placed on MMV for the night with good effect.\n Action:\n Vent changed from CPAP+PS to MMV overnight, Peep @ to 8cm. Freq.\n pulmonary toileting.\n Response:\n Tolerating slow vent wean, requiring pulmonary toileting, good\n diuresis in attempt to wean vent further\n Plan:\n Attempt to wean PS and FI02 down further today as tolerated, Continue\n aggressive pulmonary toileting, Diurese as tolerated.\n Altered mental status (not Delirium)\n Assessment:\n Increased agitation throughout night with pt wriggling in bed and\n attempting to get OOB and attempting to pull at all lines and tubes,\n makes eye contact and follows commands but doesn\nt stay calm for long,\n HR up to 130- with agitation and BP up to 130-150\ns/60-70\n received valium and Haldol as ordered. Prn Midazolam given as per\n orders. dosing in between scheduled doses with poor effect. appears\n generally uncomfortable but denies pain when asked.\n Action:\n Freq. attempts to reorient and calm pt with no effect, Is on Haldol po\n q 8 & also on prn dosing. On po diazepam 10 mgs q 6 & iv versed 0.5 mg\n to 2 mgs q 1 hr. stimulation decreased, bilat soft wrist restraints to\n prevent pt from pulling at lines and tubes\n Response:\n Increased agitation off of continuous IV sedation, poor effect from\n current medical regime, MICU team aware.\n Plan:\n Continue meds to control agitation.\n Hypernatremia (high sodium)\n Assessment:\n No seizure activity noted, Na= 150 yesterday during the day\n Action:\n Free water flushes 300ml Q 4hr\n Response:\n Na --MICU team aware\n Plan:\n Continue free water flushes, address tube feedings with nutrition and\n possible change to a lower sodium tube feeding. monitor Na levels. Will\n follow up on am labs.\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-08 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 636396,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - STOP 12:23 PM\n ARTERIAL LINE - START 02:00 PM\n A-line resited, not working again\n tube feed machine not working\n failed SBT - low MV with PSV - switched to MMV overnight\n tachycardic to 140-142\n Ortho spine ok with documented final read of CT trauma from attending\n at OSH and week f/u - faxed request and spoke with med recs at\n Medical re: sending report which was agreed upon.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,500 units/hour\n Other ICU medications:\n Morphine Sulfate - 12:15 PM\n Midazolam (Versed) - 03:50 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:13 AM\n Vital signs\n Cardiac monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.1\nC (98.8\n HR: 105 (70 - 148) bpm\n BP: 85/55(66) {85/41(57) - 158/110(323)} mmHg\n RR: 23 (10 - 31) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n QTc: 411\n Total In:\n 3,562 mL\n 965 mL\n PO:\n TF:\n 1,685 mL\n 150 mL\n IVF:\n 548 mL\n 215 mL\n Blood products:\n Total out:\n 5,695 mL\n 1,740 mL\n Urine:\n 5,695 mL\n 1,740 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,133 mL\n -775 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 359 (137 - 695) mL\n PS : 8 cmH2O\n RR (Set): 10\n RR (Spontaneous): 26\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI: 58\n PIP: 16 cmH2O\n SpO2: 95%\n ABG: 7.40/49/114/32/3\n Ve: 7.2 L/min\n PaO2 / FiO2: 228\n Physical Examination\n General Appearance: Trached and sedated. Responsive, following\n commands, Overweight / Obese, mild agitation but NAD\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\n deviation\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Respiratory / Chest: (Expansion: Symmetric), CTA anteriorly, decreased\n BS\n Abdominal: Obese, soft, Non-tender, no rebound, no guarding, + BS, PEG\n in place with dressing C/D/I\n Extremities: no CCE\n Skin: no rashes or jaundice\n Lines: r brachioceph ART with large amount of bloody drainage and L\n PICC C/D/I\n Labs / Radiology\n 213 K/uL\n 8.8 g/dL\n 123 mg/dL\n 0.6 mg/dL\n 32 mEq/L\n 3.6 mEq/L\n 13 mg/dL\n 107 mEq/L\n 145 mEq/L\n 29.4 %\n 11.1 K/uL\n [image002.jpg]\n 03:44 AM\n 06:04 AM\n 09:09 AM\n 05:07 PM\n 03:31 AM\n 03:46 AM\n 10:20 AM\n 03:46 PM\n 01:37 AM\n 05:32 AM\n WBC\n 9.6\n 8.2\n 11.1\n Hct\n 25.3\n 27.4\n 29.4\n Plt\n \n Cr\n 0.6\n 0.8\n 0.6\n 0.8\n 0.6\n TCO2\n 33\n 32\n 35\n 37\n 31\n Glucose\n 107\n 121\n 118\n 155\n 123\n Other labs: PT / PTT / INR:22.3/69.7/2.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:13.1 %,\n Mono:2.7 %, Eos:0.6 %, Lactic Acid:1.1 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:9.2 mg/dL, Mg++:2.5 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA, and\n ARDS, intubated since the end of now s/p trach and PEG\n placement.\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation. S/P Trach\n and PEG on .\n - wean FiO2 as tolerated\n - attempt wean PS today and hopeful for trach mask trial\n # Sedation: Continue to have issues with pain/delirium causing\n tachycardia and hypertension with intermittent hypotension. On Haldol\n 5 TID, Fentanyl 100-150 mcg TP, Diazapam 10 QID; Haldol, midazolam and\n morphine PRN. Had good response to morphine, minimal response to\n haldol bolus.\n - Will d/c midazolam and haldol PRN and use morphine for now.\n - If stable, would d/c standing Haldol tonight or tomorrow\n # Adrenal Insufficency: Hypotension that resolved with steroids,\n returned as they came off and is now improved again. Possible primary\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\n started on .\n - ok to go to 10 q am and 5 q pm prednisone, will wean to\n maintenance dose as tolerated, in consultation with endo.\n # Volume overloaded in setting of hypernatremia with TBW deficit and\n metabolic alkalosis\n - Lasix boluses, goal -1L today\n - Diamox until HCO3 < 30\n - electrolytes\n - continue tube feeds with free water flushes 300 cc q4\n # RUE DVT: INR now therapeutic on coumadin. Goal \n - stop heparin gtt\n - coumadin 5mg QHS\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - Brace for OOB\n - will f/u full trauma spine eval from OSH to determine need for\n further back imaging in-house.\n # Tracheomalacia: Discussed with IP. Stenting unlikely to help for\n trachiomalacia as airways have poor structure diffusely.\n - Outpatient f/u once off pressure support to assess for possible\n stenting\n #. Thyroid Nodule on CT\n -outpatient follow up\n # Nutrition: Tube feeds with free water flushes, tolerating well,\n continue Replete (Full) - 11:20 AM 30 mL/hour\n # Glycemic control: SSI, well controlled\n # Lines L PICC () and R ART ()\n d/c art today. Correlate ABG\n and VBG.\n # Ppx: INR therapeutic, ranitidine, colace and senna\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n Code: Full\n Dispo: ICU, being screening for vent facilities\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Arterial Line - 02:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-11 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 636943,
"text": "Chief Complaint:\n 24 Hour Events:\n Spiked to 102.2 after aspiration of tube feeds (only at 10 cc/hr) - pan\n cultured and given tylenol\n INR rising\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Aztreonam - 03:42 AM\n Vancomycin - 09:40 AM\n Levofloxacin - 11:15 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 07:47 AM\n Morphine Sulfate - 05:16 AM\n Other medications:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39\nC (102.2\n Tcurrent: 37.1\nC (98.7\n HR: 129 (86 - 137) bpm\n BP: 102/52(64) {78/26(42) - 155/89(100)} mmHg\n RR: 15 (12 - 65) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,299 mL\n 500 mL\n PO:\n TF:\n 55 mL\n IVF:\n 699 mL\n 500 mL\n Blood products:\n Total out:\n 2,990 mL\n 485 mL\n Urine:\n 2,990 mL\n 485 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,691 mL\n 15 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 513 (328 - 561) mL\n PS : 0 cmH2O\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: Agitated\n PIP: 22 cmH2O\n SpO2: 99%\n ABG: ///26/\n Ve: 6.6 L/min\n Physical Examination\n General Appearance: Trached. Interactive. Responsive, following\n commands, Overweight / Obese, mild agitation but NAD\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\n deviation\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Respiratory / Chest: (Expansion: Symmetric), b/l rhonchi R>L, decreased\n BS\n Abdominal: Obese, soft, Non-tender, no rebound, no guarding, + BS, PEG\n in place with dressing C/D/I\n Extremities: no CCE\n Skin: no rashes or jaundice\n Lines: L PICC C/D/I\n Labs / Radiology\n 238 K/uL\n 8.4 g/dL\n 106 mg/dL\n 0.9 mg/dL\n 26 mEq/L\n 3.9 mEq/L\n 11 mg/dL\n 108 mEq/L\n 143 mEq/L\n 26.9 %\n 7.2 K/uL\n [image002.jpg]\n 02:43 PM\n 03:03 PM\n 08:11 PM\n 02:51 AM\n 03:10 AM\n 03:08 PM\n 03:00 AM\n 03:36 AM\n 04:40 PM\n 03:00 AM\n WBC\n 9.4\n 11.3\n 7.3\n 6.1\n 7.2\n Hct\n 26.6\n 24.9\n 27.6\n 26.5\n 26.9\n Plt\n 09\n 238\n Cr\n 0.9\n 0.7\n 0.6\n 0.6\n 0.9\n TCO2\n 31\n 30\n 29\n 26\n Glucose\n 128\n 114\n 114\n 99\n 115\n 106\n Other labs: PT / PTT / INR:72.4/42.1/9.0, Ca++:9.3 mg/dL, Mg++:2.5\n mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA, and\n ARDS, intubated since the end of now s/p trach and PEG\n placement.\n # Recent Aspiration of tube feeds. Given prolonged hospitalization and\n tenuous respiratory status will treat with antibiotics while cultures\n pending\n - Levoflox for 48 hours while waiting for sputum results.\n - hold tube feeds\n - Follow cultures\n - check tube placement\n .\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation. S/P Trach\n and PEG on .\n - wean FiO2 as tolerated\n - attempt wean PS today and hopeful for trach mask trial\n # Sedation: Continue to have issues with pain/delirium causing\n tachycardia and hypertension with intermittent hypotension. On Haldol\n 5 TID, Fentanyl 75 mcg TP, Diazapam 10 QID; Haldol, midazolam and\n morphine PRN. Had good response to morphine, minimal response to\n haldol bolus.\n - tolerating current regimen well, no changes today\n # Adrenal Insufficency: Hypotension that resolved with steroids,\n returned as they came off and is now improved again. Possible primary\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\n started on .\n - stopped steroids as per endocrine today\n # Volume overloaded in setting of hypernatremia\n Goal even today.\n - monitor urine output\n # RUE DVT: INR super-therapeutic on coumadin. Goal . Hasn\n received coumadin in days yet INR continues to rise. Likely\n contributors are nutritional and antibiotics.\n - will start coumadin 2.5 mg QHS once INR < 3\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - Brace for OOB\n - report from full trauma series from OSH is in chart. No evidence of\n other fracture and no need for further spinal imaging based on this\n report and ortho note.\n # Tracheomalacia: Discussed with IP. Stenting unlikely to help for\n trachiomalacia as airways have poor structure diffusely.\n - Outpatient f/u once off pressure support to assess for possible\n stenting\n #. Thyroid Nodule on CT\n -outpatient follow up\n # Nutrition: Replete (Full)\n hold\n # Glycemic control: SSI, well controlled\n # Lines L PICC\n ().\n # Ppx: INR therapeutic, ranitidine, colace and senna, miralax,\n bisacodyl.\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n Code: Full\n Dispo: ICU, being screening for vent facilities\n ------ Protected Section ------\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 55F T5-8 fractures with retropulsion and ARDS\n from klebsiella VAP; on heparin for UE DVT and lasix for volume\n overload. Overnight spiked to 102.2 after apparent aspiration of TF\n despite low rate (suctioned whitish material from trache).\n On exam:\n Tmax: 39\nC (102.2\n Tcurrent: 37.1\nC (98.7\n HR: 129 (86 - 137) bpm\n BP: 102/52(64) {78/26(42) - 155/89(100)} mmHg\n RR: 15 (12 - 65) insp/min\n SpO2: 99%\n Trached, lightly sedated, following commands.\n CV RRR, distant\n Lungs\n distant bs, otherwise clear\n abd: soft NTND BS+, +PEG site\n Ext- no c/c/e\n 55F h/o EtOH abuse presenting following mech fall -> traumatic T spine\n fracture with K. oxytoca PNA, and ARDS, intubated since the end of\n now s/p trach and PEG placement.\n Cont efforts to wean mech vent including spont breathing trials w/\n monitoring given RR. Resp failure related to ARDS, tracheomalacia,\n VAP (resolved) and component of fluid overload. Now w/ apparent\n aspiration of TF. Check position of FT to ensure intragastric. Hold\n TF until confirmed. SCx/GS. Sedation continues to be challenge given\n delirium, agitation and tolerance for medications. Ortho following re:\n fx. Cont brace. Agree with recs as outlined above.\n Code: FULL\n ------ Protected Section Addendum Entered By: , MD\n on: 04:14 PM ------\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-08 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 636389,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - STOP 12:23 PM\n ARTERIAL LINE - START 02:00 PM\n A-line resited, not working again\n tube feed machine not working\n failed SBT - low MV with PSV - switched to MMV overnight\n tachycardic to 140-142\n Ortho spine ok with documented final read of CT trauma from attending\n at OSH and week f/u - faxed request and spoke with med recs at\n Medical re: sending report which was agreed upon.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,500 units/hour\n Other ICU medications:\n Morphine Sulfate - 12:15 PM\n Midazolam (Versed) - 03:50 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:13 AM\n Vital signs\n Cardiac monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.1\nC (98.8\n HR: 105 (70 - 148) bpm\n BP: 85/55(66) {85/41(57) - 158/110(323)} mmHg\n RR: 23 (10 - 31) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n QTc: 411\n Total In:\n 3,562 mL\n 965 mL\n PO:\n TF:\n 1,685 mL\n 150 mL\n IVF:\n 548 mL\n 215 mL\n Blood products:\n Total out:\n 5,695 mL\n 1,740 mL\n Urine:\n 5,695 mL\n 1,740 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,133 mL\n -775 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 359 (137 - 695) mL\n PS : 8 cmH2O\n RR (Set): 10\n RR (Spontaneous): 26\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI: 58\n PIP: 16 cmH2O\n SpO2: 95%\n ABG: 7.40/49/114/32/3\n Ve: 7.2 L/min\n PaO2 / FiO2: 228\n Physical Examination\n General Appearance: Trached and sedated. Responsive, following\n commands, Overweight / Obese, mild agitation but NAD\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\n deviation\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Respiratory / Chest: (Expansion: Symmetric), CTA anteriorly, decreased\n BS\n Abdominal: Obese, soft, Non-tender, no rebound, no guarding, + BS, PEG\n in place with dressing C/D/I\n Extremities: no CCE\n Skin: no rashes or jaundice\n Lines: r brachioceph ART with large amount of bloody drainage and L\n PICC C/D/I\n Labs / Radiology\n 213 K/uL\n 8.8 g/dL\n 123 mg/dL\n 0.6 mg/dL\n 32 mEq/L\n 3.6 mEq/L\n 13 mg/dL\n 107 mEq/L\n 145 mEq/L\n 29.4 %\n 11.1 K/uL\n [image002.jpg]\n 03:44 AM\n 06:04 AM\n 09:09 AM\n 05:07 PM\n 03:31 AM\n 03:46 AM\n 10:20 AM\n 03:46 PM\n 01:37 AM\n 05:32 AM\n WBC\n 9.6\n 8.2\n 11.1\n Hct\n 25.3\n 27.4\n 29.4\n Plt\n \n Cr\n 0.6\n 0.8\n 0.6\n 0.8\n 0.6\n TCO2\n 33\n 32\n 35\n 37\n 31\n Glucose\n 107\n 121\n 118\n 155\n 123\n Other labs: PT / PTT / INR:22.3/69.7/2.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:13.1 %,\n Mono:2.7 %, Eos:0.6 %, Lactic Acid:1.1 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:9.2 mg/dL, Mg++:2.5 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA, and\n ARDS, intubated since the end of now s/p trach and PEG\n placement.\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation. Stenting\n unlikely to help for trachiomalacia as airways have poor structure\n diffusely. S/P Trach and PEG on .\n - wean FiO2 as tolerated\n - attempt wean PS today and hopeful for trach mask trial\n # Sedation: Sedation control remains somewhat poor although fentanyl\n patch and diazpem are likely therapeutic range today. On Versed 2.0,\n Fentanyl 100, Fentanyl patch, Diazepam standing and haldo 2.5-5 mg\n PRN. QTc increased to 480.\n - Wean versed/fentanyl as tolerated, continue diazepam in\n hopes for vent facility placement\n - Continue diazepam 10 mg q8 with haldol 5 mg q8 with 2.5-5\n prn haldol\n # Adrenal Insufficency: Hypotension that resolved with steroids,\n returned as they came off and is now improved again. Possible primary\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\n started on .\n - wean per endo recs, decrease to 20q am and 10 q pm today\n - ok to go to 10 q am and 5 q pm tomorrow ()\n # Volume overloaded in setting of hypernatremia with TBW deficit and\n metabolic alkalosis\n - Lasix boluses with diamox today, goal -1L\n - electrolytes\n - continue tube feeds with free water flushes 300 cc q4\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\n coumadin at least until s/p trach. INR 1.7 today.\n - heparin gtt restarted\n - coumadin 5mg G-tube today, INR in am\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n -f/u full trauma spine eval from OSH to determine need for further back\n imaging in-house (to be done )\n # Tracheomalacia: Discussed with IP.\n - Outpatient f/u once off pressure support to assess for possible\n stenting\n #. Thyroid Nodule on CT\n -outpatient follow up\n # Nutrition: Tube feeds with free water flushes, tolerating well,\n continue Replete (Full) - 11:20 AM 30 mL/hour\n # Glycemic control: SSI, well controlled\n # Lines L PICC () and R ART ()\n d/c art and re-site today\n # Ppx: heparin drip until INR therapeutic for 2 days, ranitidine, VAP\n prevention, colace and senna\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n Code: Full\n Dispo: ICU, being screening for vent facilities\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Arterial Line - 02:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 635675,
"text": "55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\n Now with prolonged hospital course c/b by PNA with high PEEP\n requirement, anxiety, RUE DVT on heparin qtt.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt on Vent settings AC 55%/18 X 400/+10 with no overbreathing of\n set RR. O2 sat 92-98%. Lung snds clear, diminished in bases. Pt sxn\n for small-moderate amts thick white secretions. Trach site with small\n amt serosang drainage.\n Action:\n Cont same vent settings\n Response:\n Pt doesn\nt over breath on the vent and never desat.\n Plan:\n Wean from vent as she tolerates,monitor sats,ABG?.\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-13 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 637258,
"text": "Chief Complaint:\n 24 Hour Events:\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 09:40 AM\n Levofloxacin - 11:15 PM\n Ceftriaxone - 07:50 PM\n Infusions:\n Other ICU medications:\n Haloperidol (Haldol) - 10:26 AM\n Diazepam (Valium) - 11:33 AM\n Morphine Sulfate - 02:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.7\nC (98.1\n HR: 118 (118 - 148) bpm\n BP: 90/37(48) {90/37(48) - 171/111(115)} mmHg\n RR: 14 (12 - 36) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,614 mL\n 439 mL\n PO:\n TF:\n 884 mL\n 279 mL\n IVF:\n 100 mL\n Blood products:\n Total out:\n 834 mL\n 20 mL\n Urine:\n 834 mL\n 20 mL\n NG:\n Stool:\n Drains:\n Balance:\n 780 mL\n 419 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 354 (244 - 376) mL\n PS : 10 cmH2O\n RR (Spontaneous): 12\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 56\n PIP: 15 cmH2O\n SpO2: 95%\n ABG: ////\n Ve: 4.1 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 240 K/uL\n 7.9 g/dL\n 100 mg/dL\n 0.6 mg/dL\n 30 mEq/L\n 3.4 mEq/L\n 12 mg/dL\n 108 mEq/L\n 146 mEq/L\n 26.0 %\n 5.2 K/uL\n [image002.jpg]\n 08:11 PM\n 02:51 AM\n 03:10 AM\n 03:08 PM\n 03:00 AM\n 03:36 AM\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n WBC\n 9.4\n 11.3\n 7.3\n 6.1\n 7.2\n 5.2\n Hct\n 26.6\n 24.9\n 27.6\n 26.5\n 26.9\n 26.0\n Plt\n \n Cr\n 0.9\n 0.7\n 0.6\n 0.6\n 0.9\n 0.7\n 0.6\n TCO2\n 29\n 26\n Glucose\n 128\n 114\n 114\n 99\n 115\n 106\n 100\n Other labs: PT / PTT / INR:17.6/27.4/1.6, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:33/22, Alk Phos / T Bili:143/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:0.5 mmol/L,\n Albumin:3.5 g/dL, LDH:199 IU/L, Ca++:8.9 mg/dL, Mg++:2.4 mg/dL, PO4:4.1\n mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 10:31 PM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n 20 Gauge - 04:59 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-13 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 637259,
"text": "Chief Complaint:\n 24 Hour Events:\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 09:40 AM\n Levofloxacin - 11:15 PM\n Ceftriaxone - 07:50 PM\n Infusions:\n Other ICU medications:\n Haloperidol (Haldol) - 10:26 AM\n Diazepam (Valium) - 11:33 AM\n Morphine Sulfate - 02:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.7\nC (98.1\n HR: 118 (118 - 148) bpm\n BP: 90/37(48) {90/37(48) - 171/111(115)} mmHg\n RR: 14 (12 - 36) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,614 mL\n 439 mL\n PO:\n TF:\n 884 mL\n 279 mL\n IVF:\n 100 mL\n Blood products:\n Total out:\n 834 mL\n 20 mL\n Urine:\n 834 mL\n 20 mL\n NG:\n Stool:\n Drains:\n Balance:\n 780 mL\n 419 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 354 (244 - 376) mL\n PS : 10 cmH2O\n RR (Spontaneous): 12\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 56\n PIP: 15 cmH2O\n SpO2: 95%\n ABG: ////\n Ve: 4.1 L/min\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n Eyes / Conjunctiva: PERRL, Pupils dilated\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Bowel sounds present, Obese, Patient with thoracic\n brace on\n Skin: Not assessed, No(t) Rash: , Per Nursing: Pt with vesicular rash\n on inferior back.\n Neurologic: Follows simple commands, Responds to: Not assessed,\n Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 240 K/uL\n 7.9 g/dL\n 100 mg/dL\n 0.6 mg/dL\n 30 mEq/L\n 3.4 mEq/L\n 12 mg/dL\n 108 mEq/L\n 146 mEq/L\n 26.0 %\n 5.2 K/uL\n [image002.jpg]\n 08:11 PM\n 02:51 AM\n 03:10 AM\n 03:08 PM\n 03:00 AM\n 03:36 AM\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n WBC\n 9.4\n 11.3\n 7.3\n 6.1\n 7.2\n 5.2\n Hct\n 26.6\n 24.9\n 27.6\n 26.5\n 26.9\n 26.0\n Plt\n \n Cr\n 0.9\n 0.7\n 0.6\n 0.6\n 0.9\n 0.7\n 0.6\n TCO2\n 29\n 26\n Glucose\n 128\n 114\n 114\n 99\n 115\n 106\n 100\n Other labs: PT / PTT / INR:17.6/27.4/1.6, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:33/22, Alk Phos / T Bili:143/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:0.5 mmol/L,\n Albumin:3.5 g/dL, LDH:199 IU/L, Ca++:8.9 mg/dL, Mg++:2.4 mg/dL, PO4:4.1\n mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 10:31 PM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n 20 Gauge - 04:59 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-13 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 637260,
"text": "Chief Complaint:\n 24 Hour Events:\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 09:40 AM\n Levofloxacin - 11:15 PM\n Ceftriaxone - 07:50 PM\n Infusions:\n Other ICU medications:\n Haloperidol (Haldol) - 10:26 AM\n Diazepam (Valium) - 11:33 AM\n Morphine Sulfate - 02:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.7\nC (98.1\n HR: 118 (118 - 148) bpm\n BP: 90/37(48) {90/37(48) - 171/111(115)} mmHg\n RR: 14 (12 - 36) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,614 mL\n 439 mL\n PO:\n TF:\n 884 mL\n 279 mL\n IVF:\n 100 mL\n Blood products:\n Total out:\n 834 mL\n 20 mL\n Urine:\n 834 mL\n 20 mL\n NG:\n Stool:\n Drains:\n Balance:\n 780 mL\n 419 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 354 (244 - 376) mL\n PS : 10 cmH2O\n RR (Spontaneous): 12\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 56\n PIP: 15 cmH2O\n SpO2: 95%\n ABG: ////\n Ve: 4.1 L/min\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n Eyes / Conjunctiva: PERRL, Pupils dilated\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Bowel sounds present, Obese, Patient with thoracic\n brace on\n Skin: Not assessed, No(t) Rash: , Per Nursing: Pt with vesicular rash\n on inferior back.\n Neurologic: Follows simple commands, Responds to: Not assessed,\n Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 240 K/uL\n 7.9 g/dL\n 100 mg/dL\n 0.6 mg/dL\n 30 mEq/L\n 3.4 mEq/L\n 12 mg/dL\n 108 mEq/L\n 146 mEq/L\n 26.0 %\n 5.2 K/uL\n [image002.jpg]\n 08:11 PM\n 02:51 AM\n 03:10 AM\n 03:08 PM\n 03:00 AM\n 03:36 AM\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n WBC\n 9.4\n 11.3\n 7.3\n 6.1\n 7.2\n 5.2\n Hct\n 26.6\n 24.9\n 27.6\n 26.5\n 26.9\n 26.0\n Plt\n \n Cr\n 0.9\n 0.7\n 0.6\n 0.6\n 0.9\n 0.7\n 0.6\n TCO2\n 29\n 26\n Glucose\n 128\n 114\n 114\n 99\n 115\n 106\n 100\n Other labs: PT / PTT / INR:17.6/27.4/1.6, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:33/22, Alk Phos / T Bili:143/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:0.5 mmol/L,\n Albumin:3.5 g/dL, LDH:199 IU/L, Ca++:8.9 mg/dL, Mg++:2.4 mg/dL, PO4:4.1\n mg/dL\n Assessment and Plan\n 55yoF with history of EtOH abuse presenting following mechanical fall\n and traumatic T spine fracture with K. oxytoca PNA, and ARDS, intubated\n since the end of now s/p trach and PEG placement.\n# Recent Aspiration on Tube Feeds. Cultures growing Klebsiella Oxytoca and Klebs\niella Pneumoniae. Pt received developed rash on Levofloxacin, switched to Ceftri\naxone overnight. Will treat for potential HAP for 8 days.\n - Continue Ceftriaxone day #1.\n - Tube Feeds restarted with goal of 60/hr\n - Follow cultures\n - check tube placement\n .\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation. S/P Trach\n and PEG on .\n - Weaning FiO2 as tolerated\n - Will attempt trach collar today\n # Tachycardia: Pt in ST for most of the day 120\ns to 140s. Etiology\n remains unclear although she has been tachy since admission. Etiologies\n include pain (especially when sitting upright with thoracic brace on),\n infection (pt with known klebsiella, possibly acquired HAP). DDx also\n includes PE, hyperthyroidism.\n - Will keep pt\ns INR therapeutic\n - TSH 2.4 on early , will check free T3, T4.\n - Continue Pain Control\n - Treat underlying infection\n # Sedation: Pt has pain/delirium causing tachycardia and hypertension\n with intermittent hypotension. On Haldol 5 TID, Fentanyl 75 mcg TP,\n Diazapam 10 QID; Haldol, midazolam and morphine PRN. Had good response\n to morphine, minimal response to haldol bolus.\n - tolerating current regimen well, no changes today\n # Adrenal Insufficency: Hypotension that resolved with steroids,\n returned as they came off and is now improved again. Possible primary\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\n started on .\n - stopped steroids as per endocrine today\n # Volume overloaded in prior setting of hypernatremia\n Goal even\n today.\n - Monitoring urine output\n # RUE DVT: INR was super-therapeutic on coumadin. Goal . Hasn\n received coumadin in days yet INR continues to rise. Likely\n contributors are nutritional and antibiotics.\n - will start coumadin 2.5 mg QHS once INR < 3\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - Brace for OOB\n - Report from full trauma series from OSH is in chart.\n - Pt to follow up with Dr. in weeks\n # Tracheomalacia: Discussed with IP. Stenting unlikely to help for\n trachiomalacia as airways have poor structure diffusely.\n - Outpatient f/u once off pressure support to assess for possible\n stenting\n #. Thyroid Nodule on CT\n - Outpatient follow up\n # Nutrition: Replete (Full)\n hold\n # Glycemic control: SSI, well controlled\n # Lines L PICC ().\n # Ppx: INR remains therapeutic, ranitidine, colace and senna, miralax,\n bisacodyl.\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n Code: Full\n Dispo: ICU, being screening for vent facilities\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 11:38 AM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n 20 Gauge - 04:59 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 10:31 PM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n 20 Gauge - 04:59 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 636150,
"text": "55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\n Now with prolonged hospital course c/b by PNA with high PEEP\n requirement, anxiety, RUE DVT on heparin qtt.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lungs clear bilat upper lobes and diminished bilat bases with\n occasional scattered rhonchi, prod cough thick yellow/tan sputum, trach\n sx for mod. Amt of same, tolerated CPAP+PS until fell asleep and then\n RR down to 4-5 breaths with MV down to 1-5. Placed on MMV for\n remainder of night with good effect.\n Action:\n Vent changed from CPAP+PS to MMV overnight and weaned back to CPAP+PS\n this am, Peep decreased to 8cm. Freq. pulmonary toileting, diuresing\n with 40mg. IV Lasix dose\n Response:\n Tolerating slow vent wean, ABG: 7.41-53-86, requiring pulmonary\n toileting, good diuresis in attempt to wean vent further\n Plan:\n Attempt to wean PS and FI02 down further today as tolerated, may need\n MMV mode at night or when sedated, Continue aggressive pulmonary\n toileting, Diurese as tolerated.\n Altered mental status (not Delirium)\n Assessment:\n Increased agitation throughout night with pt writhing in bed and\n attempting to get OOB and attempting to pull at all lines and tubes,\n makes eye contact and follows commands but doesn\nt stay calm for long,\n HR up to 130- with agitation and BP up to 130-150\ns/60-70\n received valium and Haldol as ordered with prn dosing in between\n scheduled doses with poor effect, received 4 mg. Iv versed with poor\n effect, appears generally uncomfortable but denies pain when asked.\n Action:\n Freq. attempts to reorient and calm pt, Valium 5mg x 2 with no effect,\n Haldol 5mg po and additional 1 mg. IV with no effect, Versed 4 mg. with\n no effect, stimulation decreased, bilat soft wrist restraints to\n prevent pt from pulling at lines and tubes\n Response:\n Increased agitation off of continuous IV sedation, poor effect from\n current medical regime, MICU team aware and addressing\n Plan:\n Valium dose to be increased, Potential head CT today, obtain psych and\n neuro consults if pt\ns mental status doesn\nt improve\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 636153,
"text": "55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\n Now with prolonged hospital course c/b by PNA with high PEEP\n requirement, anxiety, RUE DVT on heparin qtt.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lungs clear bilat upper lobes and diminished bilat bases with\n occasional scattered rhonchi, prod cough thick yellow/tan sputum, trach\n sx for mod. Amt of same, tolerated CPAP+PS until fell asleep and then\n RR down to 4-5 breaths with MV down to 1-5. Placed on MMV for\n remainder of night with good effect.\n Action:\n Vent changed from CPAP+PS to MMV overnight and weaned back to CPAP+PS\n this am, Peep decreased to 8cm. Freq. pulmonary toileting, diuresing\n with 40mg. IV Lasix dose\n Response:\n Tolerating slow vent wean, ABG: 7.41-53-86, requiring pulmonary\n toileting, good diuresis in attempt to wean vent further\n Plan:\n Attempt to wean PS and FI02 down further today as tolerated, may need\n MMV mode at night or when sedated, Continue aggressive pulmonary\n toileting, Diurese as tolerated.\n Altered mental status (not Delirium)\n Assessment:\n Increased agitation throughout night with pt writhing in bed and\n attempting to get OOB and attempting to pull at all lines and tubes,\n makes eye contact and follows commands but doesn\nt stay calm for long,\n HR up to 130- with agitation and BP up to 130-150\ns/60-70\n received valium and Haldol as ordered with prn dosing in between\n scheduled doses with poor effect, received 4 mg. Iv versed with poor\n effect, appears generally uncomfortable but denies pain when asked.\n Action:\n Freq. attempts to reorient and calm pt, Valium 5mg x 2 with no effect,\n Haldol 5mg po and additional 1 mg. IV with no effect, Versed 4 mg. with\n no effect, stimulation decreased, bilat soft wrist restraints to\n prevent pt from pulling at lines and tubes\n Response:\n Increased agitation off of continuous IV sedation, poor effect from\n current medical regime, MICU team aware and addressing\n Plan:\n Valium dose to be increased, Potential head CT today, obtain psych and\n neuro consults if pt\ns mental status doesn\nt improve\n Hypernatremia (high sodium)\n Assessment:\n No seizure activity noted, Na= 141 last evening\n Action:\n Free water flushes decreased to 150 ml Q4hr from 300ml Q 4hr\n Response:\n Na back up to 146---MICU team aware\n Plan:\n Continue free water flushes, address tube feedings with nutrition and\n possible change to a lower sodium tube feeding, potential need to\n increase free water amts back to 300ml, monitor Na levels\n"
},
{
"category": "Respiratory ",
"chartdate": "2167-10-08 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 636432,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 20\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Cuffed\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments: Patient ewaned to then back on due to increase RR and\n HR.Was oob/chair today for many hours with neck brace on.ABG on \n shows hypoxemia with pao2 66 mmhg and compensated resp acidosis,has # 8\n Portex,suctioned for small thick sputum.\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 635388,
"text": "55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP now with prolonged\n hospital course c/o by PNA anxiety,RUE DVD with high PEEP requirement\n .\n Events:. Failed spont. Breathing trial. pt to go to OR on for\n trach/PEG\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd on AC 400x18 50% +PEEP 8, 02 sat 88-93% ABG last night 7.42/47/87\n Action:\n Pt changed to PSV 5/0 for spontaneous breathing trial,\n Response:\n Pt immediately deatted to the low 80%\ns, sbp increased to the\n 150\ns-160\ns and HR increased to the 120\ns-130\ns. pt placed back on\n above vent settings and VS returned to baseline.\n Plan:\n Pt to have trach placed in the OR in the am.\n Altered mental status (not Delirium)\n Assessment:\n Pt w/ periods of agitation and sleeping at other times, but overall\n more alert, following commands intermittently.\n Action:\n Midazolam remains off, Fentanyl at 100mcg/hr. pt rec\nd Haldol x1 and\n cont on q6hr diazepam.\n Response:\n HR ranging from SB in the 40\ns when asleep to the 120\ns when agitated,\n b/p ranging from 90\ns/40\ns when asleep to 140-150\ns/ 70\ns when\n agitated. When pt awake appropriate and following commands HR\n 80\ns-100\ns and b/p 100\ns-120\ns/ 60-70\n Plan:\n Cont scheduled valium for anxiety w/ haldol for breakthrough, titrate\n Fentanyl for pain control.\n Alteration in Nutrition\n Assessment:\n TF on hold this am for possible procedure in OR, FS 123 this am. Pt\n total body fluid balance remains +~16L for LOS. UOP improving since\n midnight\n Action:\n TF restarted at goal rate 60ml/hr w/ H20 boluses 250ml Q4hrs. when OR\n procedure moved until tomorrow. Lasix gtt continues at 3mg/hr\n Response:\n Pt tol TF well stools x2 this shift, serum Na 146 at 1600. K= 4.1UOP\n 140-540ml/hr on lasix gtt at 3mg/hr\n Plan:\n Cont lasix gtt as b/p tol w/ goal 24 FB neg 1-2L. cont TF and free H20\n boluses until midnight. Pt NPO after midnight for trach/PEG placement\n in am.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Heparin gtt off this am for possible trip to OR. Ptt 26.6 INR 1.1\n Action:\n Heparin gtt restarted at 1700units/hr this am when OR time changed\n until tomorrow.\n Response:\n Repeat PTT pending at the time of this note\n Plan:\n Cont to monitor PTT and titrate heparin gtt per protocol, heparin to be\n shut off at 6am for procedure in OR.\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-13 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 637263,
"text": "Chief Complaint:\n 24 Hour Events:\n Low UOP. UOP 10-20cc/hr, tachy to 130s\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 09:40 AM\n Levofloxacin - 11:15 PM\n Ceftriaxone - 07:50 PM\n Infusions:\n Other ICU medications:\n Haloperidol (Haldol) - 10:26 AM\n Diazepam (Valium) - 11:33 AM\n Morphine Sulfate - 02:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.7\nC (98.1\n HR: 118 (118 - 148) bpm\n BP: 90/37(48) {90/37(48) - 171/111(115)} mmHg\n RR: 14 (12 - 36) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,614 mL\n 439 mL\n PO:\n TF:\n 884 mL\n 279 mL\n IVF:\n 100 mL\n Blood products:\n Total out:\n 834 mL\n 20 mL\n Urine:\n 834 mL\n 20 mL\n NG:\n Stool:\n Drains:\n Balance:\n 780 mL\n 419 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 354 (244 - 376) mL\n PS : 10 cmH2O\n RR (Spontaneous): 12\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 56\n PIP: 15 cmH2O\n SpO2: 95%\n ABG: ////\n Ve: 4.1 L/min\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n Eyes / Conjunctiva: PERRL, Pupils dilated\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Bowel sounds present, Obese, Patient with thoracic\n brace on\n Skin: Not assessed, No(t) Rash: , Per Nursing: Pt with vesicular rash\n on inferior back.\n Neurologic: Follows simple commands, Responds to: Not assessed,\n Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 240 K/uL\n 7.9 g/dL\n 100 mg/dL\n 0.6 mg/dL\n 30 mEq/L\n 3.4 mEq/L\n 12 mg/dL\n 108 mEq/L\n 146 mEq/L\n 26.0 %\n 5.2 K/uL\n [image002.jpg]\n 08:11 PM\n 02:51 AM\n 03:10 AM\n 03:08 PM\n 03:00 AM\n 03:36 AM\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n WBC\n 9.4\n 11.3\n 7.3\n 6.1\n 7.2\n 5.2\n Hct\n 26.6\n 24.9\n 27.6\n 26.5\n 26.9\n 26.0\n Plt\n \n Cr\n 0.9\n 0.7\n 0.6\n 0.6\n 0.9\n 0.7\n 0.6\n TCO2\n 29\n 26\n Glucose\n 128\n 114\n 114\n 99\n 115\n 106\n 100\n Other labs: PT / PTT / INR:17.6/27.4/1.6, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:33/22, Alk Phos / T Bili:143/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:0.5 mmol/L,\n Albumin:3.5 g/dL, LDH:199 IU/L, Ca++:8.9 mg/dL, Mg++:2.4 mg/dL, PO4:4.1\n mg/dL\n Assessment and Plan\n 55yoF with history of EtOH abuse presenting following mechanical fall\n and traumatic T spine fracture with K. oxytoca PNA, and ARDS, intubated\n since the end of now s/p trach and PEG placement.\n# Recent Aspiration on Tube Feeds. Cultures growing Klebsiella Oxytoca and Klebs\niella Pneumoniae. Pt received developed rash on Levofloxacin, switched to Ceftri\naxone overnight. Will treat for potential HAP for 8 days.\n - Continue Ceftriaxone day #1.\n - Tube Feeds restarted with goal of 60/hr\n - Follow cultures\n - check tube placement\n .\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation. S/P Trach\n and PEG on .\n - Weaning FiO2 as tolerated\n - Will attempt trach collar today\n # Tachycardia: Pt in ST for most of the day 120\ns to 140s. Etiology\n remains unclear although she has been tachy since admission. Etiologies\n include pain (especially when sitting upright with thoracic brace on),\n infection (pt with known klebsiella, possibly acquired HAP). DDx also\n includes PE, hyperthyroidism.\n - Will keep pt\ns INR therapeutic\n - TSH 2.4 on early , will check free T3, T4.\n - Continue Pain Control\n - Treat underlying infection\n # Sedation: Pt has pain/delirium causing tachycardia and hypertension\n with intermittent hypotension. On Haldol 5 TID, Fentanyl 75 mcg TP,\n Diazapam 10 QID; Haldol, midazolam and morphine PRN. Had good response\n to morphine, minimal response to haldol bolus.\n - tolerating current regimen well, no changes today\n # Adrenal Insufficency: Hypotension that resolved with steroids,\n returned as they came off and is now improved again. Possible primary\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\n started on .\n - stopped steroids as per endocrine today\n # Volume overloaded in prior setting of hypernatremia\n Goal even\n today.\n - Monitoring urine output\n # RUE DVT: INR was super-therapeutic on coumadin. Goal . Hasn\n received coumadin in days yet INR continues to rise. Likely\n contributors are nutritional and antibiotics.\n - will start coumadin 2.5 mg QHS once INR < 3\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - Brace for OOB\n - Report from full trauma series from OSH is in chart.\n - Pt to follow up with Dr. in weeks\n # Tracheomalacia: Discussed with IP. Stenting unlikely to help for\n trachiomalacia as airways have poor structure diffusely.\n - Outpatient f/u once off pressure support to assess for possible\n stenting\n #. Thyroid Nodule on CT\n - Outpatient follow up\n # Nutrition: Replete (Full)\n hold\n # Glycemic control: SSI, well controlled\n # Lines L PICC\n ().\n # Ppx: INR remains therapeutic, ranitidine, colace and senna, miralax,\n bisacodyl.\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n Code: Full\n Dispo: ICU, being screening for vent facilities\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 11:38 AM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n 20 Gauge - 04:59 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 10:31 PM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n 20 Gauge - 04:59 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-07 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 636133,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n EKG - At 11:53 PM for qrs\n Continued to have alternating tachy and bradycadia with associated\n pressure swings on adjusted pain regimen. Unable to diurese given\n intermittant hypotension. Finally got one dose lasix.\n Much more anxious than previous nights. Increased Valium back to 10 mg\n QID.\n CT showed cuff distention. Per respiratory, still has a leak, likely\n needs a larger cuff.\n Hypernatremia resolved, cut back on FWB\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,500 units/hour\n Other ICU medications:\n Diazepam (Valium) - 02:00 AM\n Furosemide (Lasix) - 03:56 AM\n Haloperidol (Haldol) - 03:57 AM\n Midazolam (Versed) - 05:11 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37.1\nC (98.7\n HR: 124 (66 - 135) bpm\n BP: 137/67(92) {74/35(48) - 150/81(106)} mmHg\n RR: 15 (7 - 28) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 3,707 mL\n 723 mL\n PO:\n TF:\n 1,457 mL\n 364 mL\n IVF:\n 810 mL\n 150 mL\n Blood products:\n Total out:\n 2,535 mL\n 2,760 mL\n Urine:\n 2,535 mL\n 2,760 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,172 mL\n -2,037 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 964 (260 - 964) mL\n PS : 12 cmH2O\n RR (Set): 10\n RR (Spontaneous): 8\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI Deferred: Agitated\n PIP: 21 cmH2O\n SpO2: 94%\n ABG: 7.41/53/86/32/6\n Ve: 7.8 L/min\n PaO2 / FiO2: 172\n Physical Examination\n General Appearance: Trached and sedated. Responsive, following\n commands, Overweight / Obese, mild agitation but NAD\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\n deviation\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Respiratory / Chest: (Expansion: Symmetric), CTA anteriorly, decreased\n BS\n Abdominal: Obese, Firm, Non-tender, no rebound, no guarding, + BS, PEG\n in place with dressing C/D/I\n Extremities: No clubbing or cyanosis, trace edema of b/l hands,\n anasarca\n Skin: no rashes or jaundice\n Lines: r brachioceph ART with small amount of bloody drainage and L\n PICC C/D/I\n Labs / Radiology\n 213 K/uL\n 8.3 g/dL\n 118 mg/dL\n 0.6 mg/dL\n 32 mEq/L\n 3.5 mEq/L\n 11 mg/dL\n 108 mEq/L\n 146 mEq/L\n 27.4 %\n 8.2 K/uL\n [image002.jpg]\n 02:47 AM\n 11:01 AM\n 04:40 PM\n 05:08 PM\n 03:44 AM\n 06:04 AM\n 09:09 AM\n 05:07 PM\n 03:31 AM\n 03:46 AM\n WBC\n 11.2\n 9.6\n 8.2\n Hct\n 27.4\n 25.3\n 27.4\n Plt\n 272\n 229\n 213\n Cr\n 0.6\n 0.6\n 0.6\n 0.8\n 0.6\n TCO2\n 31\n 34\n 33\n 32\n 35\n Glucose\n 128\n 138\n 107\n 121\n 118\n Other labs: PT / PTT / INR:18.4/68.9/1.7, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:13.1 %,\n Mono:2.7 %, Eos:0.6 %, Lactic Acid:1.1 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:9.0 mg/dL, Mg++:2.5 mg/dL, PO4:4.8 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA and\n ARDS intubated since the end of now s/p trach and PEG placement.\n Thyroid nodule on CT\n Watch phos product\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation. Stenting\n unlikely to help for trachiomalacia as airways have poor structure\n diffusely. S/P Trach and PEG on . Increased effusion on recent\n CXR.\n - wean FiO2 as tolerated\n # Adrenal Insufficency: Hypotension that resolved with steroids,\n returned as they came off and is now improved again. Possible primary\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\n started on .\n - wean per endo recs, decrease to 20q am and 10 q pm starting\n tonight\n will maintain this maintenance dose and check am cortisol\n level one week later\n # Volume overloaded in setting of hypernatremia with TBW deficit.\n - Lasix gtt, continue with goal -1-2 L per day\n currently off as\n patient is somewhat hypotensive\n will restart once/if BP increases and\n remains stable for several hours\n - electrolytes\n - continue tube feeds with free water flushes 300 cc q4\n # Sedation: Sedation control remains somewhat poor although fentanyl\n patch and diazpem are likely therapeutic range today. On Versed 2.0,\n Fentanyl 100, Fentanyl patch, Diazepam standing and haldo 2.5-5 mg\n PRN. QTc increased to 480.\n - Wean versed/fentanyl as tolerated, continue diazepam in\n hopes for vent facility placement\n - Change diazepam to 5mg q8 with haldol 5 mg q8\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\n coumadin at least until s/p trach.\n - heparin gtt restarted\n - coumadin 5mg G-tube today, INR in am\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n -f/u full trauma spine eval from OSH to determine need for further back\n imaging in-house (to be done )\n # Nutrition: Tube feeds with free water flushes, tolerating well,\n continue Replete (Full) - 11:20 AM 30 mL/hour\n # Glycemic control: SSI, well controlled\n # Lines L PICC () and R ART ()\n similarly but will\n keep in setting of hypotension\n # Ppx: heparin drip until INR therapeutic for 2 days, ranitidine, VAP\n prevention, colace and senna\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n Code: Full\n Dispo: ICU, being screening for vent facilities\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 01:39 AM 60 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Arterial Line - 02:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 636259,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Following commands, but pt with flat affect most of the day. Does at\n times nod to questions of pain. But does not see to understand what I\n am telling her.\n Action:\n Tried to give pain meds for agitation today instead of the valium and\n haldol which see to sedate her. Gave her 2 mg morphine\n Response:\n To 2 mg morhphine pt settles down just as well as when haldol and\n valium are used, but it still seem to sedate her.\n Plan:\n Possibly cont to try pain med for agitation but give lower doses.\n Hypernatremia (high sodium)\n Assessment:\n NA level 150\n Action:\n 300 ml flushes Q 4hr. free water.\n Response:\n Plan:\n Draw AM labs and either increase or decrease flushes depending on NA\n level\n Hypotension (not Shock)\n Assessment:\n Hypotensive SBP in 80/40 when she is sleeping and or given\n pain/sedation meds For her aggitaiton\n Action:\n Tried to give pt pain meds instead of the haldol and valium\n Response:\n 2mg of morphine sedates pt just as much but her BP doesn\nt seem to drop\n as low.\n Plan:\n Cont to try pain meds for agitation but give lower doses.\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 636260,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Lung sounds clear, thick yellow secretions out of ET tube, O2 sats\n 92-94 team aware.\n Action:\n Pt on MMV mode overnight, changed to CPAP this AM pt with metabolic\n alkolosis ABG and diomox given, pt then weaned to CPAP .\n Response:\n Pt started desaturating into 87-89%, ABG 7.33/68/78, put pt back to\n CPAP \n Plan:\n Possibly put pt back on MMV mode to rest for the night like last night\n and wean again in the AM.\n Altered mental status (not Delirium)\n Assessment:\n Following commands, but pt with flat affect most of the day. Does at\n times nod to questions of pain. But does not see to understand what I\n am telling her.\n Action:\n Tried to give pain meds for agitation today instead of the valium and\n haldol which see to sedate her. Gave her 2 mg morphine\n Response:\n To 2 mg morhphine pt settles down just as well as when haldol and\n valium are used, but it still seem to sedate her.\n Plan:\n Possibly cont to try pain med for agitation but give lower doses.\n Hypernatremia (high sodium)\n Assessment:\n NA level 150\n Action:\n 300 ml flushes Q 4hr. free water.\n Response:\n Plan:\n Draw AM labs and either increase or decrease flushes depending on NA\n level\n Hypotension (not Shock)\n Assessment:\n Hypotensive SBP in 80/40 when she is sleeping and or given\n pain/sedation meds For her aggitaiton\n Action:\n Tried to give pt pain meds instead of the haldol and valium\n Response:\n 2mg of morphine sedates pt just as much but her BP doesn\nt seem to drop\n as low.\n Plan:\n Cont to try pain meds for agitation but give lower doses.\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 635763,
"text": "55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\n Now with prolonged hospital course c/b by PNA with high PEEP\n requirement, anxiety, RUE DVT on heparin qtt.\n Edema, peripheral\n Assessment:\n Fluid balance for previous 24hrs decreased by 3 liters D/T diuresis.\n Rec\nd pt off of Lasix qtt. Urine output decreased to 45ml/hr @1000.\n Action:\n Lasix qtt restarted @ 2mg/hr to maintain urine output 1-2liters/day.\n Response:\n Fluid balance approx -50ml/hr, with 24hr fluid balance -650ml @ 1500.\n However, SBP 78 when pt soundly sleeping/sedated. Lasix qtt stopped @\n 1530.\n Plan:\n Restart Lasix qtt when BP stabilized.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Rec\nd pt on Heparin qtt @ 1500units/hr.\n Action:\n PTT 92.1 @ 1230.\n Response:\n Per goal PTT 60-100, Heparin rate unchanged.\n Plan:\n Repeat PTT @ 1830. Start po Coumadin tonight.\n Altered mental status (not Delirium)\n Assessment:\n Rec\nd pt on Versed @ 2mg/hr, Fentanyl @ 100mcg/hr, as well as Fentanyl\n patches totaling 150mcg in place. Pt also rec\ning Diazepam 10mg po\n Q6hrs, in hope of weaning pt from IV sedation. Pt alternately appears\n very sedated and very restless. When she appears alert, she intermit\n responds to commands approp but not attempting to mouth words or nod to\n communicate. Moving arms purposefully towards trach, so soft wrist\n restraints remain in place. When very sedated @ 1530, SBP to 78 per\n below.\n Action:\n Versed \nd to 1mg/hr, Fentanyl \nd to 75mcg/hr.\n Response:\n Pt restless/squirming in bed when she appears awake. Not responding to\n verbal reassurance.\n Plan:\n Cont to attempt weaning from IV sedation. Cont to freq reorient pt,\n emotional support.\n Hypotension (not Shock)\n Assessment:\n VS generally stable with HR 68-123SR with occas PVC\ns, BP\n 122/65-144/76. However, when pt sleeping/sedated soundly @ 1530 SBP\n remained in high 70\n Action:\n Sedation decreased per above, Lasix qtt stopped. Pt woken and turned\n STS in bed.\n Response:\n VS returned to baseline, with BP presently 133/76.\n Plan:\n Restart Lasix qtt when BP stabilized WNL.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt on vent settings AC 55%/18 X 400/+10, with no over-breathing\n of rate by pt. O2 sat 95-99%. ABG 7.44/42/93. Lung snds clear but\n diminished in lower lobes. Suctionned for mod-lg amts thick white\n secretions.\n Action:\n Vent changed to CMV with PS 8/+10 on 55%.\n Response:\n Pt tolerated PS approx 3hrs, but after rec\ning scheduled dose Diazepam\n @ 1200 began having extended pauses apnea. She was then returned to AC\n 55%/9 X 500/+10.\n Plan:\n Cont wean from vent with PS trials, as well as \ning FiO2.\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-04 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 635764,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n Hydrocortisone decreased from 50 to 25 mg Q6 per endocrine recs.\n Lasix drip turned off yesterday after 3L negative.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Heparin Sodium - 1,700 units/hour\n Fentanyl - 125 mcg/hour\n Other ICU medications:\n Ranitidine (Prophylaxis) - 09:00 AM\n Midazolam (Versed) - 07:30 PM\n Other medications:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36.8\nC (98.3\n HR: 66 (50 - 131) bpm\n BP: 103/46(65) {100/46(65) - 157/102(127)} mmHg\n RR: 18 (15 - 21) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,984 mL\n 948 mL\n PO:\n TF:\n 103 mL\n 121 mL\n IVF:\n 747 mL\n 277 mL\n Blood products:\n Total out:\n 5,270 mL\n 1,420 mL\n Urine:\n 5,270 mL\n 1,420 mL\n NG:\n Stool:\n 0\n Drains:\n Balance:\n -3,286 mL\n LOS + 10.5 L\n -472 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 55%\n RSBI Deferred: PEEP > 10\n PIP: 25 cmH2O\n Plateau: 14 cmH2O\n Compliance: 100 cmH2O/mL\n SpO2: 93%\n ABG: 7.44/42/93/29\n Ve: 6.8 L/min\n Physical Examination\n General Appearance: Intubated and sedated. Responsive, following some\n commands, Overweight / Obese, mild agitation but NAD\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\n deviation\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Respiratory / Chest: (Expansion: Symmetric), CTA anteriorly, decreased\n BS\n Abdominal: Obese, Firm, Non-tender, no rebound, no guarding, + BS, PEG\n in place with dressing C/D/I\n Extremities: No clubbing or cyanosis, 1+ nonpitting edema of b/l hands,\n anasarca\n Skin: no rashes or jaundice\n Lines: r brachioceph ART and L PICC C/D/I\n Labs / Radiology\n 279 K/uL\n 8.0 g/dL\n 123 mg/dL\n 0.5 mg/dL\n 27 mEq/L\n 3.6 mEq/L\n 6 mg/dL\n 109 mEq/L\n 143 mEq/L\n 24.6 %\n 8.3 K/uL\n [image002.jpg]\n 04:10 PM\n 12:13 AM\n 05:08 AM\n 05:20 AM\n 05:17 PM\n 11:41 PM\n 03:06 AM\n 03:38 AM\n 04:05 PM\n 03:55 AM\n WBC\n 11.2\n 10.6\n 10.0\n 8.3\n Hct\n 27.1\n 27.3\n 25.8\n 24.6\n Plt\n 79\n Cr\n 0.7\n 0.5\n 0.5\n 0.6\n 0.6\n 0.5\n TCO2\n 36\n 36\n 32\n 31\n Glucose\n 165\n 143\n 110\n 94\n 111\n 106\n 121\n Other labs: PT / PTT / INR:15.9/107.7/1.4, Ca++:8.8 mg/dL, Mg++:3.1\n mg/dL, PO4:4.2 mg/dL\n No new culture data\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA and\n ARDS intubated since the end of now s/p trach and PEG placement.\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation. Stenting\n unlikely to help for trachiomalacia as airways have poor structure\n diffusely. S/P Trach and PEG on .\n - wean FiO2 today\n # Adrenal Insufficency: Hypotension that resolved with steroids,\n returned as they came off and is now improved again. Possible primary\n adrenal insufficency. Appreciate endocrine recommendations. Halved\n dose today.\n - hydrocortt (day 1 = ), wean per endo recs\n # Volume overloaded in setting of hypernatremia with TBW deficit.\n - Lasix gtt, continue with goal -1-2 L per day.\n - electrolytes\n - continue tube feeds with free water flushes 250 cc q4\n # Sedation: Sedation control remains somewhat poor although fentanyl\n patch and diazpem are likely therapeutic range today. On Versed 2.0,\n Fentanyl 100, Fentanyl patch, Diazepam standing and haldo 2.5-5 mg\n PRN. QTc increased to 480.\n - Wean versed/fentanyl as tolerated, continue diazepam. Avoid haldol\n use if possible to avoid further prolongation of QTc\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\n coumadin at least until s/p trach.\n - heparin gtt restarted\n - coumadin 5mg G-tube today\n # Constipation\n current regimen of colace and senna, no BM over last\n 24 hours\n - dulcolax PO/PR today\n - reassess and increase bowel regimen PRN\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n -f/u full trauma spine eval from OSH to determine need for further back\n imaging in-house (to be done )\n # Nutrition: Tube feeds with free water flushes, tolerating well,\n continue Replete (Full) - 11:20 AM 30 mL/hour\n # Glycemic control: SSI, well controlled\n # Lines L PICC () and R ART ()\n both working well, mainitain\n # Ppx: heparin, ranitidine, VAP prevention, colace and senna\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n Code: Full\n Dispo: ICU\n"
},
{
"category": "Respiratory ",
"chartdate": "2167-10-05 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 635822,
"text": "TITLE:\n Demographics\n Day of mechanical ventilation: 17\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Tracheostomy tube:\n Type: Cuffed\n Manufacturer: Portex\n Size: 7.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: A/C400x18/+10 peep/.5\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: occ periods of agitation with increased rr\n Assessment of breathing comfort: comf\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment: none noted\n Plan\n Next 24-48 hours: Reduce PEEP as tolerated; Comments: periodic psv\n trials for conditioning\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-08 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 636337,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - STOP 12:23 PM\n ARTERIAL LINE - START 02:00 PM\n A-line resited, not working again\n tube feed machine not working\n failed SBT - low MV with PSV - switched to MMV overnight\n tachycardic to 140-142\n Ortho spine ok with documented final read of CT trauma from attending\n at OSH and week f/u - faxed request and spoke with med recs at\n Medical re: sending report which was agreed upon.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,500 units/hour\n Other ICU medications:\n Morphine Sulfate - 12:15 PM\n Midazolam (Versed) - 03:50 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.1\nC (98.8\n HR: 105 (70 - 148) bpm\n BP: 85/55(66) {85/41(57) - 158/110(323)} mmHg\n RR: 23 (10 - 31) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 3,562 mL\n 965 mL\n PO:\n TF:\n 1,685 mL\n 150 mL\n IVF:\n 548 mL\n 215 mL\n Blood products:\n Total out:\n 5,695 mL\n 1,740 mL\n Urine:\n 5,695 mL\n 1,740 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,133 mL\n -775 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 359 (137 - 695) mL\n PS : 8 cmH2O\n RR (Set): 10\n RR (Spontaneous): 26\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI: 58\n PIP: 16 cmH2O\n SpO2: 95%\n ABG: 7.40/49/114/32/3\n Ve: 7.2 L/min\n PaO2 / FiO2: 228\n Physical Examination\n General Appearance: Trached and sedated. Responsive, following\n commands, Overweight / Obese, mild agitation but NAD\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\n deviation\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Respiratory / Chest: (Expansion: Symmetric), CTA anteriorly, decreased\n BS\n Abdominal: Obese, soft, Non-tender, no rebound, no guarding, + BS, PEG\n in place with dressing C/D/I\n Extremities: no CCE\n Skin: no rashes or jaundice\n Lines: r brachioceph ART with large amount of bloody drainage and L\n PICC C/D/I\n Labs / Radiology\n 213 K/uL\n 8.8 g/dL\n 123 mg/dL\n 0.6 mg/dL\n 32 mEq/L\n 3.6 mEq/L\n 13 mg/dL\n 107 mEq/L\n 145 mEq/L\n 29.4 %\n 11.1 K/uL\n [image002.jpg]\n 03:44 AM\n 06:04 AM\n 09:09 AM\n 05:07 PM\n 03:31 AM\n 03:46 AM\n 10:20 AM\n 03:46 PM\n 01:37 AM\n 05:32 AM\n WBC\n 9.6\n 8.2\n 11.1\n Hct\n 25.3\n 27.4\n 29.4\n Plt\n \n Cr\n 0.6\n 0.8\n 0.6\n 0.8\n 0.6\n TCO2\n 33\n 32\n 35\n 37\n 31\n Glucose\n 107\n 121\n 118\n 155\n 123\n Other labs: PT / PTT / INR:22.3/69.7/2.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:13.1 %,\n Mono:2.7 %, Eos:0.6 %, Lactic Acid:1.1 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:9.2 mg/dL, Mg++:2.5 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA and\n ARDS intubated since the end of now s/p trach and PEG placement.\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation. Stenting\n unlikely to help for trachiomalacia as airways have poor structure\n diffusely. S/P Trach and PEG on .\n - wean FiO2 as tolerated\n - attempt wean PS today and hopeful for trach mask trial\n # Adrenal Insufficency: Hypotension that resolved with steroids,\n returned as they came off and is now improved again. Possible primary\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\n started on .\n - wean per endo recs, decrease to 20q am and 10 q pm today\n - ok to go to 10 q am and 5 q pm tomorrow ()\n # Volume overloaded in setting of hypernatremia with TBW deficit and\n metabolic alkalosis\n - Lasix boluses with diamox today\n - electrolytes\n - continue tube feeds with free water flushes 300 cc q4\n # Sedation: Sedation control remains somewhat poor although fentanyl\n patch and diazpem are likely therapeutic range today. On Versed 2.0,\n Fentanyl 100, Fentanyl patch, Diazepam standing and haldo 2.5-5 mg\n PRN. QTc increased to 480.\n - Wean versed/fentanyl as tolerated, continue diazepam in\n hopes for vent facility placement\n - Continue diazepam 10 mg q8 with haldol 5 mg q8 with 2.5-5\n prn haldol\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\n coumadin at least until s/p trach. INR 1.7 today.\n - heparin gtt restarted\n - coumadin 5mg G-tube today, INR in am\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n -f/u full trauma spine eval from OSH to determine need for further back\n imaging in-house (to be done )\n #. Thyroid Nodule on CT\n -outpatient follow up\n # Nutrition: Tube feeds with free water flushes, tolerating well,\n continue Replete (Full) - 11:20 AM 30 mL/hour\n # Glycemic control: SSI, well controlled\n # Lines L PICC () and R ART ()\n d/c art and re-site today\n # Ppx: heparin drip until INR therapeutic for 2 days, ranitidine, VAP\n prevention, colace and senna\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n Code: Full\n Dispo: ICU, being screening for vent facilities\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Arterial Line - 02:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 636607,
"text": "Event: Pt had a stable day and was OOB for 4 hrs. VSS throughout the\n day.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt has a clot to RUE and was taken off heparin gtt . inr this am\n 4.4. No signs of bleeding noted.\n Action:\n No interventions done at this time.\n Response:\n Plan:\n F/U coags.\n Hypernatremia (high sodium)\n Assessment:\n Na level increased this am from 140 to 145.\n Action:\n H2O flushes DC\nd NPO and started on D5 IVF at 100 cc/hr x 1 lliter.\n Response:\n Plan:\n Follow up Na level in am.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Pt has been Afebrile throughout the day. IV ABXs to continue for 48hrs\n until cultures back.\n Action:\n No actions done. WBC now WNLs.\n Response:\n Plan:\n Follow up cultures.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LA this am very coarse and was sx\nd for copious amounts of thick tan\n secretions. Aggressive pulm toilet done and resp status improved\n throughout the day. LS now CTA and pt is being deep sx\nd for scant\n amounts of yellow secretions. Pt placed on CPAP this am and weaned down\n to 50/5/5 and was placed on TC. Pt tol it for 2 hrs and was then placed\n back on CPAP. Pt in need of freq oral care for copious amounts of\n clear-white secretions.\n Action:\n As noted above.\n Response:\n Resp status has improved.\n Plan:\n Continue aggressive oral care and pulm toilet and wean vent as tol.\n Altered mental status (not Delirium)\n Assessment:\n Pt found this am to be very awake and follows commands. Pt able to have\n eye contact and tracking people. = strength. Pt noted to have some\n restlessness at times, but no prn meds needed.\n Action:\n Pt given MSo4 for pain while she was OOB in brace with good effect.\n Response:\n Plan:\n Continue to eval MS.\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 636689,
"text": "55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\n Now with prolonged hospital course c/b by PNA with high PEEP\n requirement, anxiety, RUE DVT .\n Altered mental status (not Delirium)\n Assessment:\n Pt more alert, following commands intermittently. Periods of agitation\n with HR rising to 130\n Action:\n Fentanyl patch in place. Valium RTC. MSO4 given x 2 for discomfort.\n Response:\n Pt with less episodes of agitation previously. ? steroid psychosis.\n Plan:\n Check cortisol level in am and wean hydrocortisone MD. Continue to\n reorient pt. MSO4 prn for discomfort.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on PSV 8/5/50%.RR 19-24. Tidal volumes 200-250. 02 sats\n variable 90-100%. LS rhoncherous to clear, diminished at bases.\n Action:\n Pt maintained at current settings given reduced tv\ns and sats. Orally\n suctioned q 2 hrs for copious secretions. Deep suctioned q 3-4 hrs for\n sm amt thick white secretions.\n Response:\n ABG 7.37/40/120/0/26 on PSV. At 0530 pt hypoventilating with RR 4-6,\n changed to AC mode of ventilation (500x 12 x 5 50%)\n Plan:\n Attempt PSV again this am. Pulm hygiene.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt with RUE DVT. Heparin dcd on .\n Action:\n Coags being monitored. INR 4.4 yest. Hct was falling.\n Response:\n Hct 26.5 today, previously 27.6. INR pend.\n Plan:\n Coumadin to be started when INR < 3\n Hypernatremia (high sodium)\n Assessment:\n Na 140. Pt volume overloaded. LOS + ~10,000ccs.\n Action:\n Treated with 1 liter d5w iv.\n Response:\n Urine output 120-400ccs/hr via foley. TFB neg 100cc. Na 145. Goal ~\n even fluid balance.\n Plan:\n Continue to monitor f+e status.\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-03 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 635586,
"text": "Chief Complaint:\n 24 Hour Events:\n # To OR for Peg and Trach placement\n # Desatted in the evening to 84%, increased PEEP and FiO2\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Furosemide (Lasix) - 2 mg/hour\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.4\nC (97.6\n HR: 111 (44 - 133) bpm\n BP: 127/63(90) {90/46(63) - 165/89(123)} mmHg\n RR: 18 (15 - 24) insp/min\n SpO2: 93%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,751 mL\n 534 mL\n PO:\n TF:\n 17 mL\n IVF:\n 1,834 mL\n 84 mL\n Blood products:\n Total out:\n 6,600 mL\n 950 mL\n Urine:\n 6,600 mL\n 950 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,849 mL\n -416 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 23 cmH2O\n Plateau: 25 cmH2O\n SpO2: 93%\n ABG: 7.45/43/81./29/4\n Ve: 7.6 L/min\n PaO2 / FiO2: 137\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 256 K/uL\n 7.8 g/dL\n 106 mg/dL\n 0.6 mg/dL\n 29 mEq/L\n 4.1 mEq/L\n 7 mg/dL\n 110 mEq/L\n 144 mEq/L\n 25.8 %\n 10.0 K/uL\n [image002.jpg]\n 03:00 AM\n 10:47 AM\n 04:10 PM\n 12:13 AM\n 05:08 AM\n 05:20 AM\n 05:17 PM\n 11:41 PM\n 03:06 AM\n 03:38 AM\n WBC\n 8.6\n 11.2\n 10.6\n 10.0\n Hct\n 25.9\n 27.1\n 27.3\n 25.8\n Plt\n 280\n 306\n 321\n 256\n Cr\n 0.5\n 0.7\n 0.5\n 0.5\n 0.6\n TCO2\n 34\n 36\n 36\n 32\n 31\n Glucose\n 136\n 165\n 143\n 110\n 94\n 111\n 106\n Other labs: PT / PTT / INR:13.6/24.4/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:13.1 %,\n Mono:2.7 %, Eos:0.6 %, Lactic Acid:0.9 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:8.4 mg/dL, Mg++:2.5 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Arterial Line - 02:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-03 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 635587,
"text": "Chief Complaint:\n 24 Hour Events:\n # To OR for Peg and Trach placement\n # Desatted in the evening to 84%, increased PEEP and FiO2\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Furosemide (Lasix) - 2 mg/hour\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.4\nC (97.6\n HR: 111 (44 - 133) bpm\n BP: 127/63(90) {90/46(63) - 165/89(123)} mmHg\n RR: 18 (15 - 24) insp/min\n SpO2: 93%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,751 mL\n 534 mL\n PO:\n TF:\n 17 mL\n IVF:\n 1,834 mL\n 84 mL\n Blood products:\n Total out:\n 6,600 mL\n 950 mL\n Urine:\n 6,600 mL\n 950 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,849 mL\n -416 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 23 cmH2O\n Plateau: 25 cmH2O\n SpO2: 93%\n ABG: 7.45/43/81./29/4\n Ve: 7.6 L/min\n PaO2 / FiO2: 137\n Physical Examination\n General Appearance: Responsive, following commands, Overweight / Obese,\n NAD\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\n deviation\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Respiratory / Chest: (Expansion: Symmetric), referred breath sounds\n from ETT, mild rhonchi diffusely\n Abdominal: Obese, Soft, Non-tender, no rebound, no guarding\n Extremities: No clubbing or cyanosis, + nonpitting edema of b/l\n hands, anasarca\n Skin: no rashes or jaundice\n Neuro: alert. Strength 4/5 upper and lower extremeties, light touch\n sensation intact bil.\n Lines: r brachioceph ART and L PICC C/D/I\n Labs / Radiology\n 256 K/uL\n 7.8 g/dL\n 106 mg/dL\n 0.6 mg/dL\n 29 mEq/L\n 4.1 mEq/L\n 7 mg/dL\n 110 mEq/L\n 144 mEq/L\n 25.8 %\n 10.0 K/uL\n [image002.jpg]\n 03:00 AM\n 10:47 AM\n 04:10 PM\n 12:13 AM\n 05:08 AM\n 05:20 AM\n 05:17 PM\n 11:41 PM\n 03:06 AM\n 03:38 AM\n WBC\n 8.6\n 11.2\n 10.6\n 10.0\n Hct\n 25.9\n 27.1\n 27.3\n 25.8\n Plt\n 280\n 306\n 321\n 256\n Cr\n 0.5\n 0.7\n 0.5\n 0.5\n 0.6\n TCO2\n 34\n 36\n 36\n 32\n 31\n Glucose\n 136\n 165\n 143\n 110\n 94\n 111\n 106\n Other labs: PT / PTT / INR:13.6/24.4/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:13.1 %,\n Mono:2.7 %, Eos:0.6 %, Lactic Acid:0.9 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:8.4 mg/dL, Mg++:2.5 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Arterial Line - 02:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-03 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 635588,
"text": "Chief Complaint:\n 24 Hour Events:\n # To OR for Peg and Trach placement\n # Desatted in the evening to 84%, increased PEEP and FiO2\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Furosemide (Lasix) - 2 mg/hour\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.4\nC (97.6\n HR: 111 (44 - 133) bpm\n BP: 127/63(90) {90/46(63) - 165/89(123)} mmHg\n RR: 18 (15 - 24) insp/min\n SpO2: 93%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,751 mL\n 534 mL\n PO:\n TF:\n 17 mL\n IVF:\n 1,834 mL\n 84 mL\n Blood products:\n Total out:\n 6,600 mL\n 950 mL\n Urine:\n 6,600 mL\n 950 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,849 mL\n -416 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 23 cmH2O\n Plateau: 25 cmH2O\n SpO2: 93%\n ABG: 7.45/43/81./29/4\n Ve: 7.6 L/min\n PaO2 / FiO2: 137\n Physical Examination\n General Appearance: Responsive, following commands, Overweight / Obese,\n NAD\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\n deviation\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Respiratory / Chest: (Expansion: Symmetric), referred breath sounds\n from ETT, mild rhonchi diffusely\n Abdominal: Obese, Soft, Non-tender, no rebound, no guarding\n Extremities: No clubbing or cyanosis, + nonpitting edema of b/l\n hands, anasarca\n Skin: no rashes or jaundice\n Neuro: alert. Strength 4/5 upper and lower extremeties, light touch\n sensation intact bil.\n Lines: r brachioceph ART and L PICC C/D/I\n Labs / Radiology\n 256 K/uL\n 7.8 g/dL\n 106 mg/dL\n 0.6 mg/dL\n 29 mEq/L\n 4.1 mEq/L\n 7 mg/dL\n 110 mEq/L\n 144 mEq/L\n 25.8 %\n 10.0 K/uL\n [image002.jpg]\n 03:00 AM\n 10:47 AM\n 04:10 PM\n 12:13 AM\n 05:08 AM\n 05:20 AM\n 05:17 PM\n 11:41 PM\n 03:06 AM\n 03:38 AM\n WBC\n 8.6\n 11.2\n 10.6\n 10.0\n Hct\n 25.9\n 27.1\n 27.3\n 25.8\n Plt\n 280\n 306\n 321\n 256\n Cr\n 0.5\n 0.7\n 0.5\n 0.5\n 0.6\n TCO2\n 34\n 36\n 36\n 32\n 31\n Glucose\n 136\n 165\n 143\n 110\n 94\n 111\n 106\n Other labs: PT / PTT / INR:13.6/24.4/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:13.1 %,\n Mono:2.7 %, Eos:0.6 %, Lactic Acid:0.9 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:8.4 mg/dL, Mg++:2.5 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA and\n ARDS intubated since the end of .\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation.\n Transferred here for airway stenting.\n - attempt SBT yesterday. Failed.\n -To OR today , add-on for trach and PEG with Dr. (tube feeds\n off after MN, heparin off after 6am)\n - Repeat CXR in PM post trach.\n ## Adrenal Insufficency: Minimal response to stim test again.\n Appreciate endocrine recommendations.\n - hydrocort and fludrocort (day 1 = )\n - will continue at current dose until s/p trach and PEG and\n hemodynamically stable for 24 hours\n will then plan to taper\n hydrocortisone to 25mg IV q6 with a slow taper\n - f/u daily endocrine recs\n - Endocrine recs: d/c Fludrocort. Continue Hydrocort for now.\n # Hypotension: Likely adrenal insufficiency and sedation. Goal map\n > 60. Much improved since re-administration of steroids.\n - hydrocortisone as above\n - restart levophed if necessary to maintain MAP > 60\n # Volume overloaded in setting of hypernatremia with TBW deficit.\n - goal -1000cc I/Os yesterday, was -1500cc for last 24 hours.\n - continue FW in TF at 250 cc q4hrs\n - lasix drip (1-5mg/hr) held before surgery, will restart when returns\n to MICU.\n - may have some contraction alkalosis, w/ rising pH and bicarb. Start\n Diamox 500mg TID to decrease bicarb and pH and may improve respiratory\n drive.\n # Sedation: Sedation control remains somewhat poor although fentanyl\n patch and diazpem are likely therapeutic range today. On Versed 2.0,\n Fentanyl 100, Fentanyl patch, Diazepam standing and haldo 2.5-5 mg\n PRN. QTc increased to 480.\n - Wean versed/fentanyl as tolerated, continue diazepam. Avoid haldol\n use if possible to avoid further prolongation of QTc\n - Will reassess sedation/agitation after PEG/Trach.\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\n coumadin at least until s/p trach.\n - hold heparin gtt when anticipate trach/peg\n - will restart heparin gtt per recs from surgery post-op\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n # FEN/GI: Tube feeds with FWF @ goal.\n -held for surgery. Will restart based on post-op recs after PEG\n placement.\n DVT: Treatment dose heparin, holding until post-op recs from PEG/Trach\n Ulcer: Ranitidine\n VAP: Prevention per routine\n # Access: L PICC line, and R brachial a-line\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n - touch base with SW today\n Code: Full\n Dispo: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Arterial Line - 02:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 635759,
"text": "55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\n Now with prolonged hospital course c/b by PNA with high PEEP\n requirement, anxiety, RUE DVT on heparin qtt.\n Edema, peripheral\n Assessment:\n Fluid balance for previous 24hrs decreased by 3 liters D/T diuresis.\n Rec\nd pt off of Lasix qtt. Urine output decreased to 45ml/hr @1000.\n Action:\n Lasix qtt restarted @ 2mg/hr to maintain urine output 1-2liters/day.\n Response:\n Fluid balance approx -50ml/hr, with 24hr fluid balance -650ml @ 1500.\n However, SBP 78 when pt soundly sleeping/sedated. Lasix qtt stopped @\n 1530.\n Plan:\n Restart Lasix qtt when BP stabilized.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Rec\nd pt on Heparin qtt @ 1500units/hr.\n Action:\n PTT 92.1 @ 1230.\n Response:\n Per goal PTT 60-100, Heparin rate unchanged.\n Plan:\n Repeat PTT @ 1830. Start po Coumadin tonight.\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Respiratory ",
"chartdate": "2167-10-07 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 636126,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 19\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Tube Type\n Tracheostomy tube:\n Type: Cuffed, Extra Length\n Manufacturer: Portex\n Size: 7.0mm\n PMV: No\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Rhonchi\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Placed on MMV for constant LMV\n alarms/apnea. Weaned PEEp to ~8cmH20.\n Invasive ventilation assessment:\n Trigger work assessment: Frequent failed trigger efforts\n Dysynchrony assessment: Frequent alarms (Low min. ventilation)\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: rsbi deffered for agitation, req sedation\n Reason for continuing current ventilatory support: Sedated / Paralyzed\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 636127,
"text": "55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\n Now with prolonged hospital course c/b by PNA with high PEEP\n requirement, anxiety, RUE DVT on heparin qtt.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lungs clear bilat upper lobes and diminished bilat bases with\n occasional scattered rhonchi, prod cough thick yellow/tan sputum, trach\n sx for mod. Amt of same, tolerated CPAP+PS until fell asleep and then\n RR down to 4-5 breaths with MV down to 1-5. Placed on MMV for\n remainder of night with good effect.\n Action:\n Vent changed from CPAP+PS to MMV overnight and weaned back to CPAP+PS\n this am, Peep decreased to 8cm. Freq. pulmonary toileting, diuresing\n with 40mg. IV Lasix dose\n Response:\n Tolerating slow vent wean, requiring pulmonary toileting, good diuresis\n in attempt to wean vent further\n Plan:\n Attempt to wean PS and FI02 down further today as tolerated, may need\n MMV mode at night or when sedated, Continue aggressive pulmonary\n toileting, Diurese as tolerated.\n Altered mental status (not Delirium)\n Assessment:\n Increased agitation throughout night with pt writhing in bed and\n attempting to get OOB and attempting to pull at all lines and tubes,\n makes eye contact and follows commands but doesn\nt stay calm for long,\n HR up to 130- with agitation and BP up to 130-150\ns/60-70\n received valium and Haldol as ordered with prn dosing in between\n scheduled doses with poor effect, received 4 mg. Iv versed with poor\n effect, appears generally uncomfortable but denies pain when asked.\n Action:\n Freq. attempts to reorient and calm pt, Valium 5mg x 2 with no effect,\n Haldol 5mg po and additional 1 mg. IV with no effect, Versed 4 mg. with\n no effect, stimulation decreased, bilat soft wrist restraints to\n prevent pt from pulling at lines and tubes\n Response:\n Increased agitation off of continuous IV sedation, poor effect from\n current medical regime, MICU team aware and addressing\n Plan:\n Valium dose to be increased, Potential head CT today, obtain psych and\n neuro consults if pt\ns mental status doesn\nt improve\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 636128,
"text": "55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\n Now with prolonged hospital course c/b by PNA with high PEEP\n requirement, anxiety, RUE DVT on heparin qtt.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lungs clear bilat upper lobes and diminished bilat bases with\n occasional scattered rhonchi, prod cough thick yellow/tan sputum, trach\n sx for mod. Amt of same, tolerated CPAP+PS until fell asleep and then\n RR down to 4-5 breaths with MV down to 1-5. Placed on MMV for\n remainder of night with good effect.\n Action:\n Vent changed from CPAP+PS to MMV overnight and weaned back to CPAP+PS\n this am, Peep decreased to 8cm. Freq. pulmonary toileting, diuresing\n with 40mg. IV Lasix dose\n Response:\n Tolerating slow vent wean, ABG: 7.41-53-86, requiring pulmonary\n toileting, good diuresis in attempt to wean vent further\n Plan:\n Attempt to wean PS and FI02 down further today as tolerated, may need\n MMV mode at night or when sedated, Continue aggressive pulmonary\n toileting, Diurese as tolerated.\n Altered mental status (not Delirium)\n Assessment:\n Increased agitation throughout night with pt writhing in bed and\n attempting to get OOB and attempting to pull at all lines and tubes,\n makes eye contact and follows commands but doesn\nt stay calm for long,\n HR up to 130- with agitation and BP up to 130-150\ns/60-70\n received valium and Haldol as ordered with prn dosing in between\n scheduled doses with poor effect, received 4 mg. Iv versed with poor\n effect, appears generally uncomfortable but denies pain when asked.\n Action:\n Freq. attempts to reorient and calm pt, Valium 5mg x 2 with no effect,\n Haldol 5mg po and additional 1 mg. IV with no effect, Versed 4 mg. with\n no effect, stimulation decreased, bilat soft wrist restraints to\n prevent pt from pulling at lines and tubes\n Response:\n Increased agitation off of continuous IV sedation, poor effect from\n current medical regime, MICU team aware and addressing\n Plan:\n Valium dose to be increased, Potential head CT today, obtain psych and\n neuro consults if pt\ns mental status doesn\nt improve\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 636428,
"text": "Alteration in Nutrition\n Assessment:\n Abd dist, soft with hypoactive BS. No BM on this shift.\n Action:\n TF restarted at goal at 60 cc/hr with minimal residuals.\n Response:\n Plan:\n Follow FSBS. ? adding more laxatives until BM.\n Fracture, other\n Assessment:\n Pt out of bed in stretcher chair with brace in place most of day. Pt\n did very well.\n Action:\n Pt tol being OOb well in regards to resp status and MS.\n Response:\n Plan:\n Plan to take pt OOB to cahir tomorrow also.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains on vent via trach in CPAP+PS at 50 %/. LS CTA with\n diminished bases. Pt has been deep sx\nd for sml amounts of tan to thick\n yellow secretions.\n Action:\n Vent changed to 5/5, but was only tolerated for 1 hr.\n Response:\n After 1 hr pt became tachycardic and tachypnic. O2sat decreased to 95%.\n Plan:\n Continue to wean vent settings as tolerated. Plan to IP to follow up\n regarding ? need for stent tomorrow.\n Altered mental status (not Delirium)\n Assessment:\n Pt opens eyes to voice, but will only follow simple commands very\n inconsistently. Pt is very lethargic. Pt found this am to be very\n restless and given versed with no effect.\n Action:\n After pt placed in a chair, and pt more relaxed. Pt was calm, but her\n HR was in the 120-130\ns (while awake). Pt given Morphine with good\n effect. Fentanyl patches weaned down to 100 mcg.\n Response:\n Plan:\n Continue to eval restlessness.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt was on heparin gtt for clot to Rt upper arm. Inr 2.1 . No signs of\n any bleeding.\n Action:\n Heparin was dc\nd this am.\n Response:\n Plan:\n ? coumadin tonight. Continue to eval for bleeding.\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 636430,
"text": "Alteration in Nutrition\n Assessment:\n Abd dist, soft with hypoactive BS. No BM on this shift.\n Action:\n TF restarted at goal at 60 cc/hr with minimal residuals.\n Response:\n Plan:\n Follow FSBS. ? adding more laxatives until BM.\n Fracture, other\n Assessment:\n Pt out of bed in stretcher chair with brace in place most of day. Pt\n did very well.\n Action:\n Pt tol being OOb well in regards to resp status and MS.\n Response:\n Plan:\n Plan to take pt OOB to cahir tomorrow also.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains on vent via trach in CPAP+PS at 50 %/. LS CTA with\n diminished bases. Pt has been deep sx\nd for sml amounts of tan to thick\n yellow secretions.\n Action:\n Vent changed to 5/5, but was only tolerated for 1 hr.\n Response:\n After 1 hr pt became tachycardic and tachypnic. O2sat decreased to 95%.\n Plan:\n Continue to wean vent settings as tolerated. Plan to IP to follow up\n regarding ? need for stent tomorrow.\n Altered mental status (not Delirium)\n Assessment:\n Pt opens eyes to voice, but will only follow simple commands very\n inconsistently. Pt is very lethargic. Pt found this am to be very\n restless and given versed with no effect.\n Action:\n After pt placed in a chair, and pt more relaxed. Pt was calm, but her\n HR was in the 120-130\ns (while awake). Pt given Morphine with good\n effect. Fentanyl patches weaned down to 100 mcg.\n Response:\n Plan:\n Continue to eval restlessness.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt was on heparin gtt for clot to Rt upper arm. Inr 2.1 . No signs of\n any bleeding.\n Action:\n Heparin was dc\nd this am.\n Response:\n Plan:\n ? coumadin tonight. Continue to eval for bleeding.\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-09 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 636500,
"text": "Chief Complaint:\n 24 Hour Events:\n Arterial line d/c'd\n Spiked a fever of 101.4, blood and urine cultures sent, CXR. Started\n Vanc, Levo, Aztreonam\n Persistently hypotensive to 70s SBP overnight with low urine output and\n poor O2 sats.\n Started on Levophed, and given 1.75L NS. BPs improved to 90-120s SBP,\n and urine output increased significantly.\n Large amount of oral secretions, ?gastric in origin\n Tube feeds held for ? of aspiration.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 11:00 PM\n Levofloxacin - 11:43 PM\n Aztreonam - 04:07 AM\n Infusions:\n Norepinephrine - 0.03 mcg/Kg/min\n Other ICU medications:\n Midazolam (Versed) - 09:30 AM\n Morphine Sulfate - 03:17 PM\n Furosemide (Lasix) - 06:36 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.4\n Tcurrent: 36.7\nC (98.1\n HR: 131 (73 - 142) bpm\n BP: 127/43(60) {71/29(42) - 137/97(101)} mmHg\n RR: 21 (12 - 36) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 4,627 mL\n 1,084 mL\n PO:\n TF:\n 839 mL\n IVF:\n 2,288 mL\n 1,084 mL\n Blood products:\n Total out:\n 2,407 mL\n 2,220 mL\n Urine:\n 2,407 mL\n 2,220 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,220 mL\n -1,136 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 412 (236 - 480) mL\n PS : 8 cmH2O\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI: 126\n PIP: 21 cmH2O\n Plateau: 17 cmH2O\n Compliance: 44.4 cmH2O/mL\n SpO2: 97%\n ABG: 7.35/50/81./26/0\n Ve: 7 L/min\n PaO2 / FiO2: 162\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 227 K/uL\n 7.7 g/dL\n 114 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 4.0 mEq/L\n 16 mg/dL\n 112 mEq/L\n 145 mEq/L\n 24.9 %\n 11.3 K/uL\n [image002.jpg]\n 03:46 AM\n 10:20 AM\n 03:46 PM\n 01:37 AM\n 05:32 AM\n 02:43 PM\n 03:03 PM\n 08:11 PM\n 02:51 AM\n 03:10 AM\n WBC\n 11.1\n 9.4\n 11.3\n Hct\n 29.4\n 26.6\n 24.9\n Plt\n \n Cr\n 0.8\n 0.6\n 0.9\n 0.7\n TCO2\n 35\n 37\n 31\n 31\n 30\n 29\n Glucose\n 155\n 123\n 128\n 114\n 114\n Other labs: PT / PTT / INR:37.2/37.9/4.0, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Lactic Acid:0.5 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:8.7 mg/dL, Mg++:2.6 mg/dL, PO4:4.2 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n 18 Gauge - 08:15 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-09 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 636501,
"text": "Chief Complaint:\n 24 Hour Events:\n Arterial line d/c'd\n Spiked a fever of 101.4, blood and urine cultures sent, CXR. Started\n Vanc, Levo, Aztreonam\n Persistently hypotensive to 70s SBP overnight with low urine output and\n poor O2 sats.\n Started on Levophed, and given 1.75L NS. BPs improved to 90-120s SBP,\n and urine output increased significantly.\n Large amount of oral secretions, ?gastric in origin\n Tube feeds held for ? of aspiration.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 11:00 PM\n Levofloxacin - 11:43 PM\n Aztreonam - 04:07 AM\n Infusions:\n Norepinephrine - 0.03 mcg/Kg/min\n Other ICU medications:\n Midazolam (Versed) - 09:30 AM\n Morphine Sulfate - 03:17 PM\n Furosemide (Lasix) - 06:36 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.4\n Tcurrent: 36.7\nC (98.1\n HR: 131 (73 - 142) bpm\n BP: 127/43(60) {71/29(42) - 137/97(101)} mmHg\n RR: 21 (12 - 36) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 4,627 mL\n 1,084 mL\n PO:\n TF:\n 839 mL\n IVF:\n 2,288 mL\n 1,084 mL\n Blood products:\n Total out:\n 2,407 mL\n 2,220 mL\n Urine:\n 2,407 mL\n 2,220 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,220 mL\n -1,136 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 412 (236 - 480) mL\n PS : 8 cmH2O\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI: 126\n PIP: 21 cmH2O\n Plateau: 17 cmH2O\n Compliance: 44.4 cmH2O/mL\n SpO2: 97%\n ABG: 7.35/50/81./26/0\n Ve: 7 L/min\n PaO2 / FiO2: 162\n Physical Examination\n General Appearance: Trached and sedated. Responsive, following\n commands, Overweight / Obese, mild agitation but NAD\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\n deviation\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Respiratory / Chest: (Expansion: Symmetric), CTA anteriorly, decreased\n BS\n Abdominal: Obese, soft, Non-tender, no rebound, no guarding, + BS, PEG\n in place with dressing C/D/I\n Extremities: no CCE\n Skin: no rashes or jaundice\n Lines: r brachioceph ART with large amount of bloody drainage and L\n PICC C/D/I\n Labs / Radiology\n 227 K/uL\n 7.7 g/dL\n 114 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 4.0 mEq/L\n 16 mg/dL\n 112 mEq/L\n 145 mEq/L\n 24.9 %\n 11.3 K/uL\n [image002.jpg]\n 03:46 AM\n 10:20 AM\n 03:46 PM\n 01:37 AM\n 05:32 AM\n 02:43 PM\n 03:03 PM\n 08:11 PM\n 02:51 AM\n 03:10 AM\n WBC\n 11.1\n 9.4\n 11.3\n Hct\n 29.4\n 26.6\n 24.9\n Plt\n \n Cr\n 0.8\n 0.6\n 0.9\n 0.7\n TCO2\n 35\n 37\n 31\n 31\n 30\n 29\n Glucose\n 155\n 123\n 128\n 114\n 114\n Other labs: PT / PTT / INR:37.2/37.9/4.0, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Lactic Acid:0.5 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:8.7 mg/dL, Mg++:2.6 mg/dL, PO4:4.2 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA, and\n ARDS, intubated since the end of now s/p trach and PEG\n placement.\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation. S/P Trach\n and PEG on .\n - wean FiO2 as tolerated\n - attempt wean PS today and hopeful for trach mask trial\n # Sedation: Continue to have issues with pain/delirium causing\n tachycardia and hypertension with intermittent hypotension. On Haldol\n 5 TID, Fentanyl 100-150 mcg TP, Diazapam 10 QID; Haldol, midazolam and\n morphine PRN. Had good response to morphine, minimal response to\n haldol bolus.\n - Will d/c midazolam and haldol PRN and use morphine for now.\n - If stable, would d/c standing Haldol tonight or tomorrow\n # Adrenal Insufficency: Hypotension that resolved with steroids,\n returned as they came off and is now improved again. Possible primary\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\n started on .\n - ok to go to 10 q am and 5 q pm prednisone, will wean to\n maintenance dose as tolerated, in consultation with endo.\n # Volume overloaded in setting of hypernatremia with TBW deficit and\n metabolic alkalosis\n - Lasix boluses, goal -1L today\n - Diamox until HCO3 < 30\n - electrolytes\n - continue tube feeds with free water flushes 300 cc q4\n # RUE DVT: INR now therapeutic on coumadin. Goal \n - stop heparin gtt\n - coumadin 5mg QHS\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - Brace for OOB\n - will f/u full trauma spine eval from OSH to determine need for\n further back imaging in-house.\n # Tracheomalacia: Discussed with IP. Stenting unlikely to help for\n trachiomalacia as airways have poor structure diffusely.\n - Outpatient f/u once off pressure support to assess for possible\n stenting\n #. Thyroid Nodule on CT\n -outpatient follow up\n # Nutrition: Tube feeds with free water flushes, tolerating well,\n continue Replete (Full) - 11:20 AM 30 mL/hour\n # Glycemic control: SSI, well controlled\n # Lines L PICC () and R ART ()\n d/c art today. Correlate ABG\n and VBG.\n # Ppx: INR therapeutic, ranitidine, colace and senna\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n Code: Full\n Dispo: ICU, being screening for vent facilities\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n 18 Gauge - 08:15 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 636605,
"text": "Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt has a clot to RUE and was taken off heparin gtt . inr this am\n 4.4. No signs of bleeding noted.\n Action:\n No interventions done at this time.\n Response:\n Plan:\n F/U coags.\n Hypernatremia (high sodium)\n Assessment:\n Na level increased this am from 140 to 145.\n Action:\n H2O flushes DC\nd NPO and started on D5 IVF at 100 cc/hr x 1 lliter.\n Response:\n Plan:\n Follow up Na level in am.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Pt has been Afebrile throughout the day. IV ABXs to continue for 48hrs\n until cultures back.\n Action:\n No actions done.\n Response:\n Plan:\n Follow up cultures.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS this am very coarse and sx\nd for copious amounts amount secretions.\n Pt was given aggressive pulm toilet, and respm status improved\n throughout the day\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 635668,
"text": "55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\n Now with prolonged hospital course c/b by PNA with high PEEP\n requirement, anxiety, RUE DVT on heparin qtt.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt on Vent settings AC 60%/18 X 400/+10 with no overbreathing of\n set RR. O2 sat 92-98%. Lung snds clear, diminished in bases. Pt sxn\n for small amts thick white secretions. Trach site with small amt\n serosang drainage.\n Action:\n FiO2 \nd to 55%.\n Response:\n ABG to follow.\n Plan:\n Cont to gently wean from vent.\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-04 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 635669,
"text": "Chief Complaint:\n 24 Hour Events:\n # To OR for Peg and Trach placement\n # Desatted in the evening to 84%, increased PEEP and FiO2\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Furosemide (Lasix) - 2 mg/hour\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.4\nC (97.6\n HR: 111 (44 - 133) bpm\n BP: 127/63(90) {90/46(63) - 165/89(123)} mmHg\n RR: 18 (15 - 24) insp/min\n SpO2: 93%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,751 mL\n 534 mL\n PO:\n TF:\n 17 mL\n IVF:\n 1,834 mL\n 84 mL\n Blood products:\n Total out:\n 6,600 mL\n 950 mL\n Urine:\n 6,600 mL\n 950 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,849 mL\n -416 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 23 cmH2O\n Plateau: 25 cmH2O\n SpO2: 93%\n ABG: 7.45/43/81./29/4\n Ve: 7.6 L/min\n PaO2 / FiO2: 137\n Physical Examination\n General Appearance: Responsive, following commands, Overweight / Obese,\n NAD\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\n deviation\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Respiratory / Chest: (Expansion: Symmetric), referred breath sounds\n from ETT, mild rhonchi diffusely\n Abdominal: Obese, Soft, Non-tender, no rebound, no guarding\n Extremities: No clubbing or cyanosis, + nonpitting edema of b/l\n hands, anasarca\n Skin: no rashes or jaundice\n Neuro: alert. Strength 4/5 upper and lower extremeties, light touch\n sensation intact bil.\n Lines: r brachioceph ART and L PICC C/D/I\n Labs / Radiology\n 256 K/uL\n 7.8 g/dL\n 106 mg/dL\n 0.6 mg/dL\n 29 mEq/L\n 4.1 mEq/L\n 7 mg/dL\n 110 mEq/L\n 144 mEq/L\n 25.8 %\n 10.0 K/uL\n [image002.jpg]\n 03:00 AM\n 10:47 AM\n 04:10 PM\n 12:13 AM\n 05:08 AM\n 05:20 AM\n 05:17 PM\n 11:41 PM\n 03:06 AM\n 03:38 AM\n WBC\n 8.6\n 11.2\n 10.6\n 10.0\n Hct\n 25.9\n 27.1\n 27.3\n 25.8\n Plt\n 280\n 306\n 321\n 256\n Cr\n 0.5\n 0.7\n 0.5\n 0.5\n 0.6\n TCO2\n 34\n 36\n 36\n 32\n 31\n Glucose\n 136\n 165\n 143\n 110\n 94\n 111\n 106\n Other labs: PT / PTT / INR:13.6/24.4/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:13.1 %,\n Mono:2.7 %, Eos:0.6 %, Lactic Acid:0.9 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:8.4 mg/dL, Mg++:2.5 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA and\n ARDS intubated since the end of .\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation. Stenting\n unlikely to help for trachiomalacia as airways have poor structure\n diffusely. S/P Trach yesterday\n - Continue to wean O2 as tolerated\n # Adrenal Insufficency: Hypotension that resolved with steroids,\n returned as they came off and is now improved again. Possible primary\n adrenal insufficency. Appreciate endocrine recommendations.\n - hydrocortt (day 1 = ), wean per endo recs\n # Hypotension: Likely adrenal insufficiency and sedation. Goal map\n > 60. Much improved since re-administration of steroids.\n - hydrocortisone as above\n - restart levophed if necessary to maintain MAP > 60\n # Volume overloaded in setting of hypernatremia with TBW deficit.\n - Lasix gtt, continue with goal -1L per day.\n - electrolytes\n - may have some contraction alkalosis, w/ rising pH and bicarb. Start\n Diamox 500mg TID to decrease bicarb and pH and may improve respiratory\n drive.\n # Sedation: Sedation control remains somewhat poor although fentanyl\n patch and diazpem are likely therapeutic range today. On Versed 2.0,\n Fentanyl 100, Fentanyl patch, Diazepam standing and haldo 2.5-5 mg\n PRN. QTc increased to 480.\n - Wean versed/fentanyl as tolerated, continue diazepam. Avoid haldol\n use if possible to avoid further prolongation of QTc\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\n coumadin at least until s/p trach.\n - heparin gtt restarted\n - plan to start coumadin night of if stable\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n # FEN/GI: Tube feeds\n DVT: Treatment dose heparin\n Ulcer: Ranitidine\n VAP: Prevention per routine\n # Access: L PICC line, and R brachial a-line\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n - touch base with SW today\n Code: Full\n Dispo: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Arterial Line - 02:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-08 00:00:00.000",
"description": "Generic Note",
"row_id": 636314,
"text": "TITLE:\n 55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\n Now with prolonged hospital course c/b by PNA with high PEEP\n requirement, anxiety, RUE DVT ,continued on heparin qtt.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lungs clear bilat upper lobes and diminished bilat bases with\n occasional scattered rhonchi, prod cough thick yellow/tan sputum, trach\n sx for mod.amt. Placed on MMV for the night with good effect.\n Action:\n Vent changed from CPAP+PS to MMV overnight, Peep @ to 8cm. Freq.\n pulmonary toileting.\n Response:\n Tolerating slow vent wean, requiring pulmonary toileting, Mode\n changed to Cpap+ PS Peep 8, PS 8.\n Plan:\n Attempt to wean PS and FI02 down further today as tolerated, Continue\n aggressive pulmonary toileting.\n Altered mental status (not Delirium)\n Assessment:\n Increased agitation throughout night with pt wriggling in bed and\n attempting to get OOB and attempting to pull at all lines and tubes,\n makes eye contact and follows commands but doesn\nt stay calm for long,\n HR up to 130- with agitation and BP up to 130-150\ns/60-70\n received valium and Haldol as ordered. Prn Midazolam given as per\n orders. dosing in between scheduled doses with poor effect. appears\n generally uncomfortable but denies pain when asked.\n Action:\n Freq. attempts to reorient and calm pt with no effect, Is on Haldol po\n q 8 & also on prn dosing. On po diazepam 10 mgs q 6 & iv versed 0.5 mg\n to 2 mgs q 1 hr. stimulation decreased, bilat soft wrist restraints to\n prevent pt from pulling at lines and tubes\n Response:\n Increased agitation off of continuous IV sedation, poor effect from\n current medical regime, MICU team aware.\n Plan:\n Continue meds to control agitation.\n Hypernatremia (high sodium)\n Assessment:\n NA+ 145 in am labs.\n Action:\n Orders to continue Free water flushes 300ml Q 4hr\n Response:\n Na level has comparatively reduced since yesterday.\n Plan:\n Continue free water flushes. monitor Na levels.\n Arterial line has no return, Team aware. A-line Dressing\n changed. Labs obtained from Picc. ABG done by Intern. Reassess A-line\n ? change A-line .\n Alteration in Nutrition\n Assessment:\n Tube feeds held as per orders . Had problems with priming the new\n tubing. Changed 3 pumps & 2 new tubing set. Tried by 3 RN\ns. Unable to\n prime the tubing in the auto or the manual mode. Orders by team not to\n continue feeds for now, Only to continue the water flushes manually.\n Action:\n Peg Feeds held as of now.\n Response:\n Peg tube flushed & clamped.\n Plan:\n Follow up with the Problem. Monitor Glucose.\n"
},
{
"category": "Respiratory ",
"chartdate": "2167-10-08 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 636320,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 20\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Tube Type\n Tracheostomy tube:\n Type: Cuffed\n Manufacturer: Portex\n Size: 8.0mm\n PMV: No\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: mL /\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Accessory muscle use; Comments:\n Switch to MMV @ beginning of shift till this morning/\n Back to CPAP.\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment: Frequent alarms (Low min. ventilation)\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: Rsbi done ~56.------\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Intolerant of weaning attempts\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 636671,
"text": "55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\n Now with prolonged hospital course c/b by PNA with high PEEP\n requirement, anxiety, RUE DVT .\n Altered mental status (not Delirium)\n Assessment:\n Pt more alert, following commands intermittently. Periods of agitation\n with HR rising to 130\n Action:\n Fentanyl patch in place. Valium RTC. MSO4 given x 1 for discomfort.\n Response:\n Pt with less episodes of agitation previously. ? steroid psychosis.\n Plan:\n Check cortisol level in am and wean hydrocortisone MD. Continue to\n reorient pt. MSO4 prn for discomfort.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on PSV 8/5/50%.RR 19-24. Tidal volumes 200-250. 02 sats\n variable 90-100%. LS rhoncherous to clear, diminished at bases.\n Action:\n Pt maintained at current settings given reduced tv\ns and sats. Orally\n suctioned q 2 hrs for copious secretions. Deep suctioned q 3-4 hrs for\n sm amt thick white secretions.\n Response:\n ABG 7.37/40/120/0/26 on PSV. At 0530 pt hypoventilating with RR 4-6,\n changed to AC mode of ventilation (500x 12 x 5 50%)\n Plan:\n Attempt PSV again this am. Pulm hygiene.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt with RUE DVT. Heparin dcd on .\n Action:\n Coags being monitored. INR 4.4 yest. Hct was falling.\n Response:\n Hct 26.5 today, previously 27.6. INR pend.\n Plan:\n Coumadin to be started when INR < 3\n Hypernatremia (high sodium)\n Assessment:\n Na 140. Pt volume overloaded. LOS + ~10,000ccs.\n Action:\n Treated with 1 liter d5w iv.\n Response:\n Urine output 120-400ccs/hr via foley. TFB neg 100cc. Na 145. Goal ~\n even fluid balance.\n Plan:\n Continue to monitor f+e status.\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 636837,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on trach collar 50%. Sats fell to 78%. Pt ambu\nd and\n lavaged with no plugs detected. RR 30-40 . Pt diaphoretic.\n Action:\n Placed on PSV 10/5/50%\n Response:\n Apneic with RR 3-5\n Plan:\n Rested on AC 500/12/5/50%. No further episodes of desating or\n tachypnea.\n Hypotension (not Shock)\n Assessment:\n BP falling to 78/37. Urine output 5-30ccs/hr via foley\n Action:\n Given 500ccs\n NS fluid bolus\n Response:\n Pt normotensive, improved urine output\n Plan:\n Continue to monitor.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Temp spike to 102.2 po\n Action:\n Blood, urine and sputum cxs sent. Sputum white, not yellow or\n consistant with TF. Chest x-ray taken. Tylenol pr given. Cool cloths\n applied.\n Response:\n Pt normothermic\n Plan:\n Monitor fever curve, cooling measures. Follow-up on cx results.\n Alteration in Nutrition\n Assessment:\n Pt vomiting yellow fluid with coughing and when turned\n Action:\n TF held. Peg to gravity. Medicated with 4 mg zofran iv.\n Response:\n No further episodes of vomiting.\n Plan:\n Continue to monitor. Aspiration precautions. ? need for alternative\n form of nutrition.\n Altered mental status (not Delirium)\n Assessment:\n Onset of shift, pt lethargic, not following commands but MAE. ~ 12 mn\n pt agitated, attempting to climb oob, disconnecting self from vent\n despite restraints\n Action:\n 5 mg valium given q 8hrs\n Response:\n Pt still agitated\n Plan:\n Needs better sedation at bedtime - ? zyprexa or alternative med\n"
},
{
"category": "General",
"chartdate": "2167-10-04 00:00:00.000",
"description": "Generic Note",
"row_id": 635747,
"text": "TITLE: Addendum to Dr. \ns note\n MICU ATTENDING ADDENDUM \n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points:\n trauma thoracic spine fracture\n intubated\n VAP\n tracheomalacia\n trached\n desaturated and PEEP increased\n Exam notable for Tm 98.5 BP 86/42 HR 91 RR 14 with 94 sat on PS\n /.55\n anasarca\n awake, occasional purposeful movements\n decreased breath sounds ant and lat\n tachy, regular\n abd benign\n 7.39/46/118\n Labs notable for WBC 8 K, HCT 25 , K+ 3.6 , Cr .5 , HCO3 27\n CXR reviewed - bilat effusion, trach ok\n Problems:\n respiratory failure\n airway malacia\n anasarca, effusions\n spine fracture\n agitation\n adrenal insufficiency\n UE DVT\n hypernatremia\n Agree with plan to wean O2 as tolerated, diurese, wean sedation though\n continue pain medications, wean steroids, continue heparin - start\n coumadin, continue H2O\n Remainder of plan as outlined above.\n Patient is critically ill.\n Total time: 36 min\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 635755,
"text": "55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\n Now with prolonged hospital course c/b by PNA with high PEEP\n requirement, anxiety, RUE DVT on heparin qtt.\n Edema, peripheral\n Assessment:\n Action:\n Response:\n Plan:\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Respiratory ",
"chartdate": "2167-10-05 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 635906,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 17\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 7.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Exp Wheeze\n LUL Lung Sounds: Exp Wheeze\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Green / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern:\n Assessment of breathing comfort: No claim of dyspnea)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment: Erratic exhaled Tidal Volumes\n Comments: pt dysynchrones at times though PSV attempted and pt had\n periods of apnea >30 seconds\n Plan\n Next 24-48 hours: Reduce PEEP as tolerated\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n CT\n 1730\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-06 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 636054,
"text": "Chief Complaint:\n 24 Hour Events:\n CT showed small effusions, not amenable for tap and so given warfarin\n (2^nd night)\n Extremely labile pressures over night, trying to wean off Fentanyl and\n use more Haldol.\n Tapering hydrocortisone\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 0.5 mg/hour\n Heparin Sodium - 1,500 units/hour\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:00 AM\n Haloperidol (Haldol) - 01:00 AM\n Other medications:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:12 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.6\n Tcurrent: 37.1\nC (98.8\n HR: 100 (56 - 142) bpm\n BP: 98/47(65) {77/40(53) - 164/93(123)} mmHg\n RR: 18 (15 - 24) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 4,228 mL\n 1,123 mL\n PO:\n TF:\n 1,440 mL\n 360 mL\n IVF:\n 978 mL\n 343 mL\n Blood products:\n Total out:\n 6,725 mL\n 780 mL\n Urine:\n 6,725 mL\n 780 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,497 mL\n 343 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 450 (450 - 450) mL\n PS : 8 cmH2O\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 23 cmH2O\n Plateau: 19 cmH2O\n SpO2: 94%\n ABG: 7.50/41/81./29/7\n Ve: 7.2 L/min\n PaO2 / FiO2: 164\n Physical Examination\n General Appearance: Trached and sedated. Responsive, following\n commands, Overweight / Obese, mild agitation but NAD\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\n deviation\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Respiratory / Chest: (Expansion: Symmetric), CTA anteriorly, decreased\n BS\n Abdominal: Obese, Firm, Non-tender, no rebound, no guarding, + BS, PEG\n in place with dressing C/D/I\n Extremities: No clubbing or cyanosis, trace edema of b/l hands,\n anasarca\n Skin: no rashes or jaundice\n Lines: r brachioceph ART with small amount of bloody drainage and L\n PICC C/D/I\n Labs / Radiology\n 229 K/uL\n 7.9 g/dL\n 107 mg/dL\n 0.6 mg/dL\n 29 mEq/L\n 3.8 mEq/L\n 11 mg/dL\n 109 mEq/L\n 147 mEq/L\n 25.3 %\n 9.6 K/uL\n [image002.jpg]\n 03:55 AM\n 07:19 AM\n 11:24 AM\n 03:18 PM\n 02:47 AM\n 11:01 AM\n 04:40 PM\n 05:08 PM\n 03:44 AM\n 06:04 AM\n WBC\n 8.3\n 11.2\n 9.6\n Hct\n 24.6\n 27.4\n 25.3\n Plt\n 279\n 272\n 229\n Cr\n 0.5\n 0.6\n 0.6\n 0.6\n 0.6\n TCO2\n 29\n 29\n 31\n 34\n 33\n Glucose\n 123\n 137\n 128\n 138\n 107\n Other labs: PT / PTT / INR:16.5/78.5/1.5, Ca++:8.7 mg/dL, Mg++:2.4\n mg/dL, PO4:4.7 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA and\n ARDS intubated since the end of now s/p trach and PEG placement.\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation. Stenting\n unlikely to help for trachiomalacia as airways have poor structure\n diffusely. S/P Trach and PEG on . Increased effusion on recent\n CXR.\n - wean FiO2 as tolerated\n # Adrenal Insufficency: Hypotension that resolved with steroids,\n returned as they came off and is now improved again. Possible primary\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\n started on .\n - wean per endo recs, decrease to 20q am and 10 q pm starting\n tonight\n will maintain this maintenance dose and check am cortisol\n level one week later\n # Volume overloaded in setting of hypernatremia with TBW deficit.\n - Lasix gtt, continue with goal -1-2 L per day\n currently off as\n patient is somewhat hypotensive\n will restart once/if BP increases and\n remains stable for several hours\n - electrolytes\n - continue tube feeds with free water flushes 300 cc q4\n # Sedation: Sedation control remains somewhat poor although fentanyl\n patch and diazpem are likely therapeutic range today. On Versed 2.0,\n Fentanyl 100, Fentanyl patch, Diazepam standing and haldo 2.5-5 mg\n PRN. QTc increased to 480.\n - Wean versed/fentanyl as tolerated, continue diazepam in\n hopes for vent facility placement\n - Change diazepam to 5mg q8 with haldol 5 mg q8\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\n coumadin at least until s/p trach.\n - heparin gtt restarted\n - coumadin 5mg G-tube today, INR in am\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n -f/u full trauma spine eval from OSH to determine need for further back\n imaging in-house (to be done )\n # Nutrition: Tube feeds with free water flushes, tolerating well,\n continue Replete (Full) - 11:20 AM 30 mL/hour\n # Glycemic control: SSI, well controlled\n # Lines L PICC () and R ART ()\n similarly but will\n keep in setting of hypotension\n # Ppx: heparin drip until INR therapeutic for 2 days, ranitidine, VAP\n prevention, colace and senna\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n Code: Full\n Dispo: ICU, being screening for vent facilities\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Arterial Line - 02:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-06 00:00:00.000",
"description": "Physician Resident/Attending Progress Note - MICU",
"row_id": 636058,
"text": "Chief Complaint:\n 24 Hour Events:\n CT showed small effusions, not amenable for tap and so given warfarin\n (2^nd night)\n Extremely labile pressures over night, trying to wean off Fentanyl and\n use more Haldol.\n Tapering hydrocortisone\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 0.5 mg/hour\n Heparin Sodium - 1,500 units/hour\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:00 AM\n Haloperidol (Haldol) - 01:00 AM\n Other medications:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:12 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.6\n Tcurrent: 37.1\nC (98.8\n HR: 100 (56 - 142) bpm\n BP: 98/47(65) {77/40(53) - 164/93(123)} mmHg\n RR: 18 (15 - 24) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 4,228 mL\n 1,123 mL\n PO:\n TF:\n 1,440 mL\n 360 mL\n IVF:\n 978 mL\n 343 mL\n Blood products:\n Total out:\n 6,725 mL\n 780 mL\n Urine:\n 6,725 mL\n 780 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,497 mL\n 343 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 450 (450 - 450) mL\n PS : 8 cmH2O\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 23 cmH2O\n Plateau: 19 cmH2O\n SpO2: 94%\n ABG: 7.50/41/81./29/7\n Ve: 7.2 L/min\n PaO2 / FiO2: 164\n Physical Examination\n General Appearance: Trached and sedated. Responsive, following\n commands, Overweight / Obese, mild agitation but NAD\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\n deviation\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Respiratory / Chest: (Expansion: Symmetric), CTA anteriorly, decreased\n BS\n Abdominal: Obese, Firm, Non-tender, no rebound, no guarding, + BS, PEG\n in place with dressing C/D/I\n Extremities: No clubbing or cyanosis, trace edema of b/l hands,\n anasarca\n Skin: no rashes or jaundice\n Lines: r brachioceph ART with small amount of bloody drainage and L\n PICC C/D/I\n Labs / Radiology\n 229 K/uL\n 7.9 g/dL\n 107 mg/dL\n 0.6 mg/dL\n 29 mEq/L\n 3.8 mEq/L\n 11 mg/dL\n 109 mEq/L\n 147 mEq/L\n 25.3 %\n 9.6 K/uL\n [image002.jpg]\n 03:55 AM\n 07:19 AM\n 11:24 AM\n 03:18 PM\n 02:47 AM\n 11:01 AM\n 04:40 PM\n 05:08 PM\n 03:44 AM\n 06:04 AM\n WBC\n 8.3\n 11.2\n 9.6\n Hct\n 24.6\n 27.4\n 25.3\n Plt\n 279\n 272\n 229\n Cr\n 0.5\n 0.6\n 0.6\n 0.6\n 0.6\n TCO2\n 29\n 29\n 31\n 34\n 33\n Glucose\n 123\n 137\n 128\n 138\n 107\n Other labs: PT / PTT / INR:16.5/78.5/1.5, Ca++:8.7 mg/dL, Mg++:2.4\n mg/dL, PO4:4.7 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA and\n ARDS intubated since the end of now s/p trach and PEG placement.\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation. Stenting\n unlikely to help for trachiomalacia as airways have poor structure\n diffusely. S/P Trach and PEG on . Increased effusion on recent\n CXR.\n - wean FiO2 as tolerated\n # Adrenal Insufficency: Hypotension that resolved with steroids,\n returned as they came off and is now improved again. Possible primary\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\n started on .\n - wean per endo recs, decrease to 20q am and 10 q pm starting\n tonight\n will maintain this maintenance dose and check am cortisol\n level one week later\n # Volume overloaded in setting of hypernatremia with TBW deficit.\n - Lasix gtt, continue with goal -1-2 L per day\n currently off as\n patient is somewhat hypotensive\n will restart once/if BP increases and\n remains stable for several hours\n - electrolytes\n - continue tube feeds with free water flushes 300 cc q4\n # Sedation: Sedation control remains somewhat poor although fentanyl\n patch and diazpem are likely therapeutic range today. On Versed 2.0,\n Fentanyl 100, Fentanyl patch, Diazepam standing and haldo 2.5-5 mg\n PRN. QTc increased to 480.\n - Wean versed/fentanyl as tolerated, continue diazepam in\n hopes for vent facility placement\n - Change diazepam to 5mg q8 with haldol 5 mg q8\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\n coumadin at least until s/p trach.\n - heparin gtt restarted\n - coumadin 5mg G-tube today, INR in am\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n -f/u full trauma spine eval from OSH to determine need for further back\n imaging in-house (to be done )\n # Nutrition: Tube feeds with free water flushes, tolerating well,\n continue Replete (Full) - 11:20 AM 30 mL/hour\n # Glycemic control: SSI, well controlled\n # Lines L PICC () and R ART ()\n similarly but will\n keep in setting of hypotension\n # Ppx: heparin drip until INR therapeutic for 2 days, ranitidine, VAP\n prevention, colace and senna\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n Code: Full\n Dispo: ICU, being screening for vent facilities\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Arterial Line - 02:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 55F T5-8 fractures with retropulsion and ARDS\n from klebsiella VAP; on heparin for UE DVT and lasix for volume\n overload. Tolerating slow vent wean but failed SBT. Was TBB positive\n yesterday despite lasix drip; sedation remains challenging. CT without\n tappable effusions and resolving airspace disease.\n Exam notable for Tm 100.6 BP 100/50 HR 62 RR 18-20 with sat 97% on VAC\n 400x18 PEEP 8 FiO2 0.5, ABG 7.50/41/82. TBB -2L/24h, +9L/MICU LOS. Eyes\n opens, will squeeze hands and wiggle toes but very drowsy. Bronchial BS\n bilaterally with RRR s1s2 SM at base. Abdomen is distended with\n decreased BS. 1+ edema in BLE, no cords. Labs notable for WBC 9K, HCT\n 25, K+ 3.8, Na 147, Cr 0.6. CXR with resolving B LL airspace disease\n and effusions.\n Agree with plan to continue supportive care, wean vent to PSV, and\n continue diuresis as BP allows. CT without drainable effusions. Will\n continue fentanyl patch at 100mcg, haldol 5q8h alternating with\n valium 5q8h at lower dose, now off drips. Will wean hydrocortisone\n 20/10q12 PGT today. Will continue IV heparin for UE DVT and transition\n to anticoagulation with coumadin. Will continue tube feeds and continue\n FW boluses for hypernatremia. Continue spinal stabilization with brace\n when OOB and discuss followup plan with spine surgery. Will eventually\n need MRI for surgical planning; remainder of plan as outlined above.\n Patient is critically ill\n Total time: 40 min\n ------ Protected Section Addendum Entered By: , MD\n on: 03:04 PM ------\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 636122,
"text": "55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\n Now with prolonged hospital course c/b by PNA with high PEEP\n requirement, anxiety, RUE DVT on heparin qtt.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-09 00:00:00.000",
"description": "Generic Note",
"row_id": 636488,
"text": "TITLE:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received Pt on vent via trach in CPAP+PS at 50 %/. LS finely\n coarse with diminished bases.. RR 28 to 30/min sats intermittently down\n to 91 %.\n Action:\n Suctioned fro small amts of tan thick mildly blood tinged sputum. Vent\n Mode changed to AC TV 400, RR 10, peep 8 for the night as per\n discussion By Resident & MD to rest for the night.\n Response:\n Sats maintained in Mid 90\ns to high 90\ns. ABG done in am PH\n 7.35/50/81/29/ Sats 96. Set RR ^ to 12 post abg\n Plan:\n Wean vent settings as tolerated. Plan to IP to follow up regarding ?\n need for stent tomorrow.\n Altered mental status (not Delirium)\n Assessment:\n Pt lethargic, arousable to stimuli, Po diazepam dose was held at 1800\n hrs,.haldol po dose was given at hrs to keep the patient calm\n Action:\n HR was in the 120-130\ns (while awake) Fentanyl patch weaned down to 75\n micgs. off fentanyl patch From Midnight till 530am.\n Response:\n Patient wide awake at 4am, Calm & still after being restless for few\n minutes. responds to name & follows commands inconsistently,Tracks\n well. Continues to be lethargic.\n Plan:\n Continue to eval restlessness & treat as needed.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Temp up to 101.4. axillary at hrs .\n Action:\n Tylenol 650 mgs given, Pan cultured, started on vanco, aztreonam &\n Levofloxacin.\n Response:\n Temp down to 98.1 orally at 4 am.\n Plan:\n Continue monitoring temp, continue anbx, follow up on cultures.\n Anemia, other\n Assessment:\n Blood tinged sputum obtained when suctioned via trach. INR 4.0 ( Goal\n INR 2 to 3.0), HCT down to 24.9, HgB 7.7 in am labs, (Total of 2lits NS\n was given at this time)\n Action:\n Coumadin not given on the night of \n Response:\n No other bleeding seen.\n Plan:\n Monitor Labs, S/S bleeding\n Hypotension (not Shock)\n Assessment:\n Received with NIBP systolic in mid 90\ns, maps of mid 50\ns. At \n hrs Sbp\ns 70\ns to 80\ns, Maps in low to high 40\n Action:\n Total 2.25 litres of fluid given, started on Levophed gtt at 0040 hrs.\n Response:\n Sbp\ns in 100\ns to 120\ns, maps in 60\ns to 70\n Plan:\n Continue monitoring BP, I/O\n Alteration in Nutrition\n Assessment:\n Obtained large feed like secretions orally. ? aspiration Abd\n dist, soft with hypoactive BS. No BM on this shift. Pt\ns head needs to\n be lowered down as BP is Low.\n Action:\n TF held . Peg tube flushed & clamped.\n Response:\n Towards morning changed to thick secretions like the color of the\n feeds mixed with saliva. By MD . At 4am obtained tannish\n loose copious amts of oral secretions.\n Plan:\n Hold feeds till am rounds as MD . Intern Discussed about a\n dye test. No plans at present to do the dye study to determine\n aspiration.\n Hypernatremia (high sodium)\n Assessment:\n Na 140 in pm labs. As feeds were held water boluses held too.\n Action:\n Orders to give NS Fluid bolus( discussed about the chances of ^ Na\n levels) . Team would like to go ahead with NS fluid boluses. Total of\n 2250 mls given overnight. Patient diuresed a total of mls.\n Response:\n Na 145 in am labs\n Plan:\n Continue to monitor I/O, Lytes.\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-09 00:00:00.000",
"description": "Generic Note",
"row_id": 636494,
"text": "TITLE:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received Pt on vent via trach in CPAP+PS at 50 %/. LS coarse\n with diminished bases.. RR 28 to 30/min sats intermittently down to 91\n %.\n Action:\n Suctioned fro small amts of tan thick mildly blood tinged sputum. Vent\n Mode changed to AC TV 400, RR 10, peep 8 for the night as per\n discussion By Resident & MD to rest for the night.\n Response:\n Sats maintained in Mid 90\ns to high 90\ns. ABG done in am PH\n 7.35/50/81/29/ Sats 96. Set RR ^ to 12 post abg\n Plan:\n Wean vent settings as tolerated. Plan to IP to follow up regarding ?\n need for stent tomorrow.\n Altered mental status (not Delirium)\n Assessment:\n Pt lethargic, arousable to stimuli, Po diazepam dose was held at 1800\n hrs, Haldol po dose was given at hrs to continue to rest the\n patient & keep her calm .\n Action:\n Fentanyl patch weaned down to 75 micgs. off fentanyl patch From\n Midnight till 530am.\n Response:\n Patient wide awake at 0345 am, Calm & still after being restless for\n few minutes. responds to name & follows commands inconsistently, Tracks\n well. Continues to be lethargic. Further haldol & diazepam doses held .\n Plan:\n Continue to eval restlessness & treat as needed.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Temp up to 101.4. axillary at hrs . WBC Upto 11.3 in am labs. Was\n 9.4 in pm labs.\n Action:\n Tylenol 650 mgs given, Pan cultured, started on vanco, aztreonam &\n Levofloxacin.\n Response:\n Temp down to 98.1 orally at 4 am.\n Plan:\n Continue monitoring temp, continue anbx, follow up on cultures.\n Anemia, other\n Assessment:\n Blood tinged sputum obtained when suctioned via trach. INR 4.0 ( Goal\n INR 2 to 3.0as MD ), HCT down to 24.9, HgB 7.7 in am labs, (Total\n of 2lits NS was given at this time)\n Action:\n Coumadin not given on the night of \n Response:\n No other bleeding seen.\n Plan:\n Monitor Labs, S/S bleeding\n Hypotension (not Shock)\n Assessment:\n Received with NIBP systolic in mid 90\ns, maps of mid 50\ns. At \n hrs Sbp\ns 70\ns to 80\ns, Maps in low to high 40\n Action:\n Total 2.25 litres of fluid given, started on Levophed gtt at 0040 hrs.\n Response:\n Sbp\ns in 100\ns to 130\ns, maps in 60\ns to 70\ns.Patient diuresing copious\n amts when she is awake & bp is higher Weaned Levophed titrated to\n maintain BP. Currently @ 0.03 mics/kg/min, BP is 119/55(68).\n Plan:\n Continue monitoring BP, I/O.\n Alteration in Nutrition\n Assessment:\n Obtained large feed like secretions orally. ? aspiration Abd\n dist, soft with hypoactive BS. No BM on this shift. Pt\ns head needs to\n be lowered down as BP is Low.\n Action:\n TF held . Peg tube flushed & clamped.\n Response:\n Towards morning changed to thick secretions like the color of the\n feeds mixed with saliva. By MD . At 4am obtained tannish\n loose copious amts of oral secretions.\n Plan:\n Hold feeds till am rounds as MD . Intern Discussed about a\n dye test. No plans at present to do the dye study to determine\n aspiration.\n Hypernatremia (high sodium)\n Assessment:\n Na 140 in pm labs. As feeds were held water boluses held too.\n Action:\n Orders to give NS Fluid bolus( discussed about the chances of ^ Na\n levels) . Team would like to go ahead with NS fluid boluses. Total of\n 2250 mls of Fluid bolus given overnight. Patient diuresed a total of\n 2220 mls from 7pm to 6am.\n Response:\n Na 145 in am labs\n Plan:\n Continue to monitor I/O, Lytes.\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 636772,
"text": "Altered mental status (not Delirium)\n Assessment:\n Rec\nd pt restless, intermit following commands. MAEE with good\n strength. Pt shaking head\n when asked if has pain or SOB.\n Action:\n Torso brace applied\nwith difficulty\nand pt OOB to stretcher/chair with\n transfer via board.\n Response:\n Pt increasingly restless with HR 130-140ST, grimacing. Pt attempting to\n stand and/or exit chair. Pt rec\nd scheduled Valium 5mg po early, as\n well as Morphine Sulfate 2mg IVP without relief of discomfort. Pt\n returned to bed after 45mins. When brace removed, chin noted to be\n abraided from chin rest. Pt cont to be restless all afternoon, freq\n attempting to sit up in bed. Soft wrist restraints in place for pt\n safety.\n Plan:\n Duoderm to chin or chin-rest when brace applied. Attempt OOB to chair\n again tomorrow.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt on vent settings AC 50%/ 12 X 500/+5 with rare over-breathing\n of rate. O2 sat 100%. Lung snds with rhonchi in RUL, clear in LUL, and\n diminished bilat in bases. Pt requiring sxn\ning Q2-4hrs for mod amts\n yellow/white thick secretions. Pt also intermit with copious thick,\n clear oral secretions.\n Action:\n Vent changed to CPAP/PS 8/+5/50% with SRR 14-25 and regular, O2 sat\n remaining 98-100%. Pt then placed on trach mask @ 80%.\n Response:\n Pt has tolerated TM for several hrs, with RR remaining regular @\n 14-25/min, O2 sat 100%.\n Plan:\n"
},
{
"category": "Respiratory ",
"chartdate": "2167-10-11 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 636930,
"text": "TITLE:\n Demographics\n Day of intubation:\n Day of mechanical ventilation: 23\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Cuffed\n Manufacturer: Portex\n Size: 7.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments: probable for PMV eval tomorrow by speech\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: pt tolerating trach collar through majority of shift thus\n far, will contiue to eval periodically\n Assessment of breathing comfort: No claim of dyspnea)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: weaning as tolerated\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 635811,
"text": "55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\n Now with prolonged hospital course c/b by PNA with high PEEP\n requirement, anxiety, RUE DVT on heparin qtt.\n Edema, peripheral\n Assessment:\n Fluid balance for previous 24hrs decreased by 3 liters D/T diuresis.\n Rec\nd pt off of Lasix qtt. Urine output decreased to 45ml/hr @1000.\n Action:\n Lasix qtt restarted @ 2mg/hr to maintain urine output 1-2liters/day.\n Response:\n Fluid balance approx -50ml/hr, with 24hr fluid balance -650ml @ 1500.\n However, SBP 78 when pt soundly sleeping/sedated. Lasix qtt stopped @\n 1530.\n Plan:\n Restart Lasix qtt when BP stabilized.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Rec\nd pt on Heparin qtt @ 1500units/hr.\n Action:\n PTT 92.1 @ 1230.\n Response:\n Per goal PTT 60-100, Heparin rate unchanged.\n Plan:\n Repeat PTT @ 1830. Start po Coumadin tonight.\n Altered mental status (not Delirium)\n Assessment:\n Rec\nd pt on Versed @ 2mg/hr, Fentanyl @ 75 mcg/hr, as well as Fentanyl\n patches totaling 150mcg in place. Pt also rec\ning Diazepam 10mg po\n Q6hrs, in hope of weaning pt from IV sedation. Agitated most time\n moving around intermittently following commands. Moving arms\n purposefully towards trach, so soft wrist restraints remain in place..\n Action:\n Pt required bolus sedation x2 with care and activity.\n Response:\n Pt restless/squirming in bed when she appears awake..\n Plan:\n Cont to attempt weaning from IV sedation. emotional support to pt and\n family,reorient pt .\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt on vent settings AC 50%/18 X 400/+10, with no over-breathing\n of rate by pt. O2 sa\\94-96%. ABG done yesterday was 7.44/42/93. Lung\n snds clear but diminished in lower lobes. Suctionned for small-moderate\n amts thick white secretions.\n Action:\n .Cont same Vent settings.\n Response:\n Pts secretions got better\n Plan:\n Cont wean from vent with PS trials,Monitor mental status.\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 635814,
"text": "55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\n Now with prolonged hospital course c/b by PNA with high PEEP\n requirement, anxiety, RUE DVT on heparin qtt.\n Edema, peripheral\n Assessment:\n Fluid balance for previous 24hrs decreased by 3 liters D/T diuresis.\n Rec\nd pt off of Lasix qtt. Urine output decreased to 45ml/hr @1000.\n Action:\n Lasix qtt restarted @ 2mg/hr to maintain urine output 1-2liters/day.\n Response:\n Fluid balance approx -50ml/hr, with 24hr fluid balance -650ml @ 1500.\n However, SBP 78 when pt soundly sleeping/sedated. Lasix qtt stopped @\n 1530.\n Plan:\n Restart Lasix qtt when BP stabilized.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Rec\nd pt on Heparin qtt @ 1500units/hr.\n Action:\n PTT 62,2 @ 0230.\n Response:\n Heparin rate unchanged.pt had 2 therapeutic PTT,started on coumadin\n 5mg at 2200,.\n Plan:\n Cont heparin gtt as well as Coumadin until INR ^ 2.\n Altered mental status (not Delirium)\n Assessment:\n Rec\nd pt on Versed @ 2mg/hr, Fentanyl @ 75 mcg/hr, as well as Fentanyl\n patches totaling 150mcg in place. Pt also rec\ning Diazepam 10mg po\n Q6hrs, in hope of weaning pt from IV sedation. Agitated most time\n moving around intermittently following commands. Moving arms\n purposefully towards trach, so soft wrist restraints remain in place..\n Action:\n Pt required bolus sedation x2 with care and activity.\n Response:\n Pt restless/squirming in bed when she appears awake..\n Plan:\n Cont to attempt weaning from IV sedation. emotional support to pt and\n family,reorient pt .\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt on vent settings AC 50%/18 X 400/+10, with no over-breathing\n of rate by pt. O2 sa\\94-96%. ABG done yesterday was 7.44/42/93. Lung\n snds clear but diminished in lower lobes. Suctionned for small-moderate\n amts thick white secretions.\n Action:\n .Cont same Vent settings.\n Response:\n Pts secretions got better\n Plan:\n Cont wean from vent with PS trials,Monitor mental status.\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 635952,
"text": "Bradycardia\n Assessment:\n Pt conts with HR 50-70\ns at rest, 100-140\ns during care, pt\n asymptomatic; easily arousable\n Action:\n Sedation decreased, Lasix off @0200\n Response:\n HR 60\n Plan:\n Cont to wean sedation, ?cardiac consult\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Action:\n Cont with IV Heparin @ 1500u/hr, Coumadin d\ncd for? thoracentesis\n Response:\n Pt therapeutic, cont with daily PTT\n Plan:\n Cont to labs, cont to wean off Heparin, Coumadin 5mg given x 1dose\n @ 2200, re-eval dosing this am\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt cont on AC 18/400/50%/10, LS clear bilat, occ scat rhonchi\n Action:\n Pt suct for sm thin tan secretions\n Response:\n Plan:\n Cont to ABGs,\n Hypotension (not Shock)\n Assessment:\n SBP 140\ns when pt is agitated, SBP dropping to 70\ns-80\ns, UO 200/hr\n (total 2500 in 2hr)\n Action:\n Fent/Versed turned down @ 0000, Lasix gtt on hold, team informed\n Response:\n Pt SBP\ns in 80\n Plan:\n Cardiac consult to further eval SB/ST, re-evalu cont. Lasix gtt\n Hypernatremia (high sodium)\n Assessment:\n Na 146\n Action:\n Cont with 300cc free water flush Q4hrs\n Response:\n Plan:\n Cont to sodium levels, treat as ordered\n Altered mental status (not Delirium)\n Assessment:\n Pt alert and agitated throughout shift, pt following commands\n inconsistently; sleeping off and off throughout shift\n Action:\n Fent/Versed decreased low SBP\ns, pt recved prn dose of Haldol 1mg @\n 0100; cont with bilat. Wrist restraints for safety\n Response:\n pt sleeping off/on throughout shift, with periods of\n agitation/restlessness\n Plan:\n Cont to wean fent/versed gtt down, cont with scheduled Haldol/Valium;\n cont to QTC intervals daily\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 635953,
"text": "55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\n Now with prolonged hospital course c/b by PNA with high PEEP\n requirement, anxiety, RUE DVT on heparin qtt.\n Bradycardia\n Assessment:\n Pt conts with HR 50-70\ns at rest, 100-140\ns during care, pt\n asymptomatic; easily arousable\n Action:\n Sedation decreased, Lasix off @0200\n Response:\n HR 60\n Plan:\n Cont to wean sedation, ?cardiac consult\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Action:\n Cont with IV Heparin @ 1500u/hr, Coumadin d\ncd for? thoracentesis\n Response:\n Pt therapeutic, cont with daily PTT\n Plan:\n Cont to labs, cont to wean off Heparin, Coumadin 5mg given x 1dose\n @ 2200, re-eval dosing this am\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt cont on AC 18/400/50%/10, LS clear bilat, occ scat rhonchi\n Action:\n Pt suct for sm thin tan secretions\n Response:\n Plan:\n Cont to ABGs,\n Hypotension (not Shock)\n Assessment:\n SBP 140\ns when pt is agitated, SBP dropping to 70\ns-80\ns, UO 200/hr\n (total 2500 in 2hr)\n Action:\n Fent/Versed turned down @ 0000, Lasix gtt on hold, team informed\n Response:\n Pt SBP\ns in 80\n Plan:\n Cardiac consult to further eval SB/ST, re-evalu cont. Lasix gtt\n Hypernatremia (high sodium)\n Assessment:\n Na 146\n Action:\n Cont with 300cc free water flush Q4hrs\n Response:\n Plan:\n Cont to sodium levels, treat as ordered\n Altered mental status (not Delirium)\n Assessment:\n Pt alert and agitated throughout shift, pt following commands\n inconsistently; sleeping off and off throughout shift\n Action:\n Fent/Versed decreased low SBP\ns, pt recved prn dose of Haldol 1mg @\n 0100; cont with bilat. Wrist restraints for safety\n Response:\n pt sleeping off/on throughout shift, with periods of\n agitation/restlessness\n Plan:\n Cont to wean fent/versed gtt down, cont with scheduled Haldol/Valium;\n cont to QTC intervals daily\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 636425,
"text": "Alteration in Nutrition\n Assessment:\n Abd dist, soft with hypoactive BS. No BM on this shift.\n Action:\n TF restarted at goal at 60 cc/hr with minimal residuals.\n Response:\n Plan:\n Follow FSBS. ? adding more laxatives until BM.\n Fracture, other\n Assessment:\n Pt out of bed in stretcher chair with brace in place most of day. Pt\n did very well.\n Action:\n Pt tol being OOb well in regards to resp status and MS.\n Response:\n Plan:\n Plan to take pt OOB to cahir tomorrow also.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains on vent via trach in CPAP+PS at 50 %/. LS CTA with\n diminished bases. Pt has been deep sx\nd for sml amounts of tan to thick\n yellow secretions.\n Action:\n Vent changed to 5/5, but was only tolerated for 1 hr.\n Response:\n After 1 hr pt became tachycardic and tachypnic. O2sat decreased to 95%.\n Plan:\n Continue to wean vent settings as tolerated. Plan to IP to follow up\n regarding ? need for stent tomorrow.\n Altered mental status (not Delirium)\n Assessment:\n Pt opens eyes to voice, but will only follow simple commands very\n inconsistently. Pt is very lethargic. Pt found this am to be very\n restless and given versed with no effect.\n Action:\n After pt placed in a chair, and pt more relaxed. Pt was calm, but her\n HR was in the 120-130\ns (while awake). Pt given Morphine with good\n effect. Fentanyl patches weaned down to 100 mcg.\n Response:\n Plan:\n Continue to eval restlessness.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Respiratory ",
"chartdate": "2167-10-09 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 636480,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 21\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason:\n Tube Type\n Tracheostomy tube:\n Type: Cuffed\n Manufacturer: Portex\n Size: 7.0mm\n PMV: No\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments: Large cuff volume needed for air tight seal\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Copious\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing,\n Frequent desaturation episodes; Comments: Pt had some episodes of\n desaturations after turning and suctioning. Pt was switched to AC as\n MD orders due to lowing SpO2 and increased WOB\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments: Pt is stable on vent (AC settings)as per Expiratory Tv, RR\n and SpO2\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Periodic SBT's for conditioning, Adjust Min. ventilation to control pH;\n Comments: Pt to con't current support. Pt showed poor RSBI trial, due\n to low Tidal volumes.\n Reason for continuing current ventilatory support: Cannot protect\n airway, Cannot manage secretions, Underlying illness not resolved\n BEDSIDE RSBI- 126\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-09 00:00:00.000",
"description": "Generic Note",
"row_id": 636485,
"text": "TITLE:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received Pt on vent via trach in CPAP+PS at 50 %/. LS finely\n coarse with diminished bases.. RR 28 to 30/min sats intermittently down\n to 91 %.\n Action:\n Suctioned fro small amts of tan thick mildly blood tinged sputum. Vent\n Mode changed to AC TV 400, RR 10, peep 8 for the night as per\n discussion By Resident & MD to rest for the night.\n Response:\n Sats maintained in Mid 90\ns to high 90\ns. ABG done in am PH\n 7.35/50/81/29/ Sats 96. Set RR ^ to 12 post abg\n Plan:\n Wean vent settings as tolerated. Plan to IP to follow up regarding ?\n need for stent tomorrow.\n Altered mental status (not Delirium)\n Assessment:\n Pt lethargic, arousable to stimuli, Po diazepam dose was held at 1800\n hrs,.haldol po dose was given at hrs\n Action:\n HR was in the 120-130\ns (while awake) Fentanyl patches weaned down to\n 75 micgs. Currently off fentanyl patch.\n Response:\n Patient wide awake at 4am, Calm & still after being restless for few\n minutes. responds to name & follows commands inconsistently, continues\n to be lethargic.\n Plan:\n Continue to eval restlessness.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Temp up to 101.4. axillary at hrs .\n Action:\n Tylenol 650 mgs given, Pan cultured, started on vanco, aztreonam &\n Levofloxacin.\n Response:\n Temp down to 98.1 orally at 4 am.\n Plan:\n Continue monitoring temp, continue anbx, follow up on cultures.\n Anemia, other\n Assessment:\n Blood tinged sputum obtained when suctioned via trach. INR 4.0 ,HCT\n down to 24.9, HgB 7.7 in am labs, (Total of 2lits NS was given at this\n time)\n Action:\n Coumadin not given on the night of \n Response:\n No other bleeding seen.\n Plan:\n Monitor Labs, S/S bleeding\n Hypotension (not Shock)\n Assessment:\n Received with NIBP systolic in mid 90\ns, maps of mid 50\ns. At \n hrs Sbp\ns 70\ns to 80\ns, Maps in low to high 40\n Action:\n Total 2.25 litres of fluid given, started on Levophed gtt at 0040 hrs.\n Response:\n Sbp\ns in 100\ns to 120\ns, maps in 60\ns to 70\n Plan:\n Continue monitoring BP, I/O\n Alteration in Nutrition\n Assessment:\n Obtained large feed like secretions orally. ? aspiration Abd\n dist, soft with hypoactive BS. No BM on this shift. Pt\ns head needs to\n be lowered down as BP is Low.\n Action:\n TF held . Peg tube flushed & clamped.\n Response:\n Towards morning changed to thick secretions like the color of the\n feeds mixed with saliva. By MD . At 4am obtained tannish\n loose copious amts of oral secretions.\n Plan:\n Hold feeds till am rounds as MD . Intern Discussed about a\n dye test. No plans at present to do the dye study to determine\n aspiration.\n Hypernatremia (high sodium)\n Assessment:\n Na 140 in pm labs. As feeds were held water boluses held too.\n Action:\n Orders to give NS Fluid bolus( discussed about the chances of ^ Na\n levels) . Team would like to go ahead with NS fluid boluses. Total of\n 2250 mls given overnight. Patient diuresed a total of mls.\n Response:\n Na 145 in am labs\n Plan:\n Continue to monitor I/O, Lytes.\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-09 00:00:00.000",
"description": "Physician Resident/Attending Progress Note - MICU",
"row_id": 636590,
"text": "Chief Complaint:\n 24 Hour Events:\n Arterial line d/c'd\n Spiked a fever of 101.4, blood and urine cultures sent, CXR. Started\n Vanc, Levo, Aztreonam\n Persistently hypotensive to 70s SBP overnight with low urine output and\n poor O2 sats.\n Started on Levophed, and given 1.75L NS. BPs improved to 90-120s SBP,\n and urine output increased significantly.\n Large amount of oral secretions, ?gastric in origin\n Tube feeds held for ? of aspiration.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 11:00 PM\n Levofloxacin - 11:43 PM\n Aztreonam - 04:07 AM\n Infusions:\n Norepinephrine\n Off at 7:30 AM\n Other ICU medications:\n Midazolam (Versed) - 09:30 AM\n Morphine Sulfate - 03:17 PM\n Furosemide (Lasix) - 06:36 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.4\n Tcurrent: 36.7\nC (98.1\n HR: 131 (73 - 142) bpm\n BP: 127/43(60) {71/29(42) - 137/97(101)} mmHg\n RR: 21 (12 - 36) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 4,627 mL\n 1,084 mL\n PO:\n TF:\n 839 mL\n IVF:\n 2,288 mL\n 1,084 mL\n Blood products:\n Total out:\n 2,407 mL\n 2,220 mL\n Urine:\n 2,407 mL\n 2,220 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,220 mL\n -1,136 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 412 (236 - 480) mL\n PS : 8 cmH2O\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI: 126\n PIP: 21 cmH2O\n Plateau: 17 cmH2O\n Compliance: 44.4 cmH2O/mL\n SpO2: 97%\n ABG: 7.35/50/81./26/0\n Ve: 7 L/min\n PaO2 / FiO2: 162\n Physical Examination\n General Appearance: Trached and sedated. Responsive, following\n commands, Overweight / Obese, mild agitation but NAD\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\n deviation\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Respiratory / Chest: (Expansion: Symmetric), CTA anteriorly, decreased\n BS\n Abdominal: Obese, soft, Non-tender, no rebound, no guarding, + BS, PEG\n in place with dressing C/D/I\n Extremities: no CCE\n Skin: no rashes or jaundice\n Lines: r brachioceph ART with large amount of bloody drainage and L\n PICC C/D/I\n Labs / Radiology\n 227 K/uL\n 7.7 g/dL\n 114 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 4.0 mEq/L\n 16 mg/dL\n 112 mEq/L\n 145 mEq/L\n 24.9 %\n 11.3 K/uL\n [image002.jpg]\n 03:46 AM\n 10:20 AM\n 03:46 PM\n 01:37 AM\n 05:32 AM\n 02:43 PM\n 03:03 PM\n 08:11 PM\n 02:51 AM\n 03:10 AM\n WBC\n 11.1\n 9.4\n 11.3\n Hct\n 29.4\n 26.6\n 24.9\n Plt\n \n Cr\n 0.8\n 0.6\n 0.9\n 0.7\n TCO2\n 35\n 37\n 31\n 31\n 30\n 29\n Glucose\n 155\n 123\n 128\n 114\n 114\n Other labs: PT / PTT / INR:37.2/37.9/4.0, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Lactic Acid:0.5 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:8.7 mg/dL, Mg++:2.6 mg/dL, PO4:4.2 mg/dL\n Blood/Urine/Sputum culture pending\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA, and\n ARDS, intubated since the end of now s/p trach and PEG\n placement.\n # Fever: Likely secondary to aspiration pneumonitis. Given prolonged\n hospitalization and tenuous respiratory status will treat with\n antibiotics while cultures pending\n - Vanc/Cef/Azithro for 48 hours while waiting for sputum results.\n - Hold tube feeds for 24 hours\n - Follow cultures\n - Off levophed\n .\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation. S/P Trach\n and PEG on .\n - wean FiO2 as tolerated\n - attempt wean PS today and hopeful for trach mask trial\n # Sedation: Continue to have issues with pain/delirium causing\n tachycardia and hypertension with intermittent hypotension. On Haldol\n 5 TID, Fentanyl 75 mcg TP, Diazapam 10 QID; Haldol, midazolam and\n morphine PRN. Had good response to morphine, minimal response to\n haldol bolus.\n - Reduce diazepam to 5 q 8hrs.\n - d/c standing Haldol\n # Adrenal Insufficency: Hypotension that resolved with steroids,\n returned as they came off and is now improved again. Possible primary\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\n started on .\n - 10 q am and 5 q pm prednisone day 2 of 3, will wean to\n maintenance dose as tolerated, in consultation with endo.\n # Volume overloaded in setting of hypernatremia with TBW deficit and\n metabolic alkalosis\n - Goal of even in the setting of recent hypotension.\n - Off diamox\n - electrolytes\n - Will give IV free water rather than flushes. D5W 1L@100 cc/hr\n # Falling Hct: Likely dilutional. Concern given elevated INR\n - Recheck in PM\n - Type and screen\n # RUE DVT: INR now therapeutic on coumadin. Goal \n - stop heparin gtt\n - will start coumadin 2.5 mg QHS once INR < 3\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - Brace for OOB\n - report from full trauma series from OSH is in chart. No evidence of\n other fracture and no need for further spinal imaging based on this\n report and ortho note.\n # Tracheomalacia: Discussed with IP. Stenting unlikely to help for\n trachiomalacia as airways have poor structure diffusely.\n - Outpatient f/u once off pressure support to assess for possible\n stenting\n #. Thyroid Nodule on CT\n -outpatient follow up\n # Nutrition: Hold tube feeds x 24 hours, continue Replete (Full)\n will reintroduce slowly\n - advance bowel regimen\n # Glycemic control: SSI, well controlled\n # Lines L PICC (). ABG and VBG correlate well.\n # Ppx: INR therapeutic, ranitidine, colace and senna, miralax,\n bisacodyl.\n # Communication:\n - Boyfriend of 10 \n - Brother is her HCP, also involved\n Code: Full\n Dispo: ICU, being screening for vent facilities\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n 18 Gauge - 08:15 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 55F T5-8 fractures with retropulsion and ARDS\n from klebsiella VAP; on heparin for UE DVT and lasix for volume\n overload. Febrile overnight with ? aspiration, now back on antibiotics\n with HCT drop, hypotensive requiring levophed.\n Exam notable for Tm 101.4 BP 120/43 HR 100-130 RR 18-20 with sat 97% on\n VAC 400x12 PEEP 8, FiO2 0.4, ABG 7.35/50/81. Eyes opens, more alert.\n Clearer BS bilaterally with RRR s1s2 SM at base. Abdomen is\n distended with decreased BS. Trace edema in BLE, no cords. Labs notable\n for WBC 11K, HCT 25, K+ 4.0, Na 145, Cr 0.7, INR 4.0. CXR without\n significant change.\n Agree with plan to transition back from VAC to PSV and to continue\n antibiotics x48 while awaiting cultures. Abdomen is distended; will\n hold tube feeds and increase bowel regimen including possible PO\n narcan. INR is high and HCT is down; will hold coumadin and guiac\n stool, confirm BBS and check PM HCT. Will continue fentanyl patch at\n 150mcg and valium 5q8h. Will change haldol to PRN, and wean\n hydrocortisone per endocrine. Will continue FW boluses for\n hypernatremia. Continue spinal stabilization with brace when OOB; will\n review outside images with spine surgery but no plan for acute\n intervention. Remainder of plan as outlined above.\n Patient is critically ill\n Total time: 45 min\n ------ Protected Section Addendum Entered By: , MD\n on: 05:19 PM ------\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 636829,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on trach collar 50%. Sats fell to 78%. Pt ambu\nd and\n lavaged with no plugs detected. RR 30-40 . Pt diaphoretic.\n Action:\n Placed on PSV 10/5/50%\n Response:\n Apneic with RR 3-5\n Plan:\n Rested on AC 500/12/5/50%. No further episodes of desating or\n tachypnea.\n Hypotension (not Shock)\n Assessment:\n BP falling to 78/37. Urine output 5-30ccs/hr via foley\n Action:\n Given 500ccs\n NS fluid bolus\n Response:\n Plan:\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Temp spike to 102.2 po\n Action:\n Blood, urine and sputum cxs sent. Chest x-ray taken. Tylenol pr given.\n Cool cloths applied.\n Response:\n Temp down to 100.4\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 636830,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on trach collar 50%. Sats fell to 78%. Pt ambu\nd and\n lavaged with no plugs detected. RR 30-40 . Pt diaphoretic.\n Action:\n Placed on PSV 10/5/50%\n Response:\n Apneic with RR 3-5\n Plan:\n Rested on AC 500/12/5/50%. No further episodes of desating or\n tachypnea.\n Hypotension (not Shock)\n Assessment:\n BP falling to 78/37. Urine output 5-30ccs/hr via foley\n Action:\n Given 500ccs\n NS fluid bolus\n Response:\n Pt normotensive, improved urine output\n Plan:\n Continue to monitor.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Temp spike to 102.2 po\n Action:\n Blood, urine and sputum cxs sent. Sputum white, not yellow or\n consistant with TF. Chest x-ray taken. Tylenol pr given. Cool cloths\n applied.\n Response:\n Temp down to 100.4\n Plan:\n Monitor fever curve, cooling measures. Follow-up on cx results.\n Alteration in Nutrition\n Assessment:\n Pt vomiting yellow fluid with coughing and when turned\n Action:\n TF held. Peg to gravity. Medicated with 4 mg zofran iv.\n Response:\n No further episodes of vomiting.\n Plan:\n Continue to monitor. Aspiration precautions.\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 636833,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on trach collar 50%. Sats fell to 78%. Pt ambu\nd and\n lavaged with no plugs detected. RR 30-40 . Pt diaphoretic.\n Action:\n Placed on PSV 10/5/50%\n Response:\n Apneic with RR 3-5\n Plan:\n Rested on AC 500/12/5/50%. No further episodes of desating or\n tachypnea.\n Hypotension (not Shock)\n Assessment:\n BP falling to 78/37. Urine output 5-30ccs/hr via foley\n Action:\n Given 500ccs\n NS fluid bolus\n Response:\n Pt normotensive, improved urine output\n Plan:\n Continue to monitor.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Temp spike to 102.2 po\n Action:\n Blood, urine and sputum cxs sent. Sputum white, not yellow or\n consistant with TF. Chest x-ray taken. Tylenol pr given. Cool cloths\n applied.\n Response:\n Temp down to 100.4\n Plan:\n Monitor fever curve, cooling measures. Follow-up on cx results.\n Alteration in Nutrition\n Assessment:\n Pt vomiting yellow fluid with coughing and when turned\n Action:\n TF held. Peg to gravity. Medicated with 4 mg zofran iv.\n Response:\n No further episodes of vomiting.\n Plan:\n Continue to monitor. Aspiration precautions.\n Altered mental status (not Delirium)\n Assessment:\n Onset of shift, pt lethargic, not following commands but MAE. ~ 12 mn\n pt agitated, attempting to climb oob, disconnecting self from vent\n despite restraints\n Action:\n 5 mg valium given q 8hrs\n Response:\n Pt still agitated\n Plan:\n Needs better sedation at bedtime - ? zyprexa or alternative med\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-11 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 636905,
"text": "Chief Complaint:\n 24 Hour Events:\n Spiked to 102.2 after aspiration of tube feeds (only at 10 cc/hr) - pan\n cultured and given tylenol\n INR rising\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Aztreonam - 03:42 AM\n Vancomycin - 09:40 AM\n Levofloxacin - 11:15 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 07:47 AM\n Morphine Sulfate - 05:16 AM\n Other medications:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39\nC (102.2\n Tcurrent: 37.1\nC (98.7\n HR: 129 (86 - 137) bpm\n BP: 102/52(64) {78/26(42) - 155/89(100)} mmHg\n RR: 15 (12 - 65) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,299 mL\n 500 mL\n PO:\n TF:\n 55 mL\n IVF:\n 699 mL\n 500 mL\n Blood products:\n Total out:\n 2,990 mL\n 485 mL\n Urine:\n 2,990 mL\n 485 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,691 mL\n 15 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 513 (328 - 561) mL\n PS : 0 cmH2O\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: Agitated\n PIP: 22 cmH2O\n SpO2: 99%\n ABG: ///26/\n Ve: 6.6 L/min\n Physical Examination\n Labs / Radiology\n 238 K/uL\n 8.4 g/dL\n 106 mg/dL\n 0.9 mg/dL\n 26 mEq/L\n 3.9 mEq/L\n 11 mg/dL\n 108 mEq/L\n 143 mEq/L\n 26.9 %\n 7.2 K/uL\n [image002.jpg]\n 02:43 PM\n 03:03 PM\n 08:11 PM\n 02:51 AM\n 03:10 AM\n 03:08 PM\n 03:00 AM\n 03:36 AM\n 04:40 PM\n 03:00 AM\n WBC\n 9.4\n 11.3\n 7.3\n 6.1\n 7.2\n Hct\n 26.6\n 24.9\n 27.6\n 26.5\n 26.9\n Plt\n 09\n 238\n Cr\n 0.9\n 0.7\n 0.6\n 0.6\n 0.9\n TCO2\n 31\n 30\n 29\n 26\n Glucose\n 128\n 114\n 114\n 99\n 115\n 106\n Other labs: PT / PTT / INR:72.4/42.1/9.0, Ca++:9.3 mg/dL, Mg++:2.5\n mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA, and\n ARDS, intubated since the end of now s/p trach and PEG\n placement.\n # Recent Aspiration of tube feeds. Given prolonged hospitalization and\n tenuous respiratory status will treat with antibiotics while cultures\n pending\n - Levoflox for 48 hours while waiting for sputum results.\n - restart tube feeds slowly\n - Follow cultures\n .\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation. S/P Trach\n and PEG on .\n - wean FiO2 as tolerated\n - attempt wean PS today and hopeful for trach mask trial\n # Sedation: Continue to have issues with pain/delirium causing\n tachycardia and hypertension with intermittent hypotension. On Haldol\n 5 TID, Fentanyl 75 mcg TP, Diazapam 10 QID; Haldol, midazolam and\n morphine PRN. Had good response to morphine, minimal response to\n haldol bolus.\n - Reduce diazepam to 5 q 8hrs.\n - d/c standing Haldol\n # Adrenal Insufficency: Hypotension that resolved with steroids,\n returned as they came off and is now improved again. Possible primary\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\n started on .\n - 10 q am and 5 q pm prednisone day 2 of 3, will wean to\n maintenance dose as tolerated, in consultation with endo.\n # Volume overloaded in setting of hypernatremia\n Goal even today.\n - Off diamox\n - electrolytes\n - Free water flushes with tube feeds.\n # Falling Hct: Likely dilutional. Concern given elevated INR. Stable\n today.\n - monitor\n - maintain active type and screen\n # RUE DVT: INR now therapeutic on coumadin. Goal \n - will start coumadin 2.5 mg QHS once INR < 3\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - Brace for OOB\n - report from full trauma series from OSH is in chart. No evidence of\n other fracture and no need for further spinal imaging based on this\n report and ortho note.\n # Tracheomalacia: Discussed with IP. Stenting unlikely to help for\n trachiomalacia as airways have poor structure diffusely.\n - Outpatient f/u once off pressure support to assess for possible\n stenting\n #. Thyroid Nodule on CT\n -outpatient follow up\n # Nutrition: Replete (Full)\n will reintroduce slowly\n - advance bowel regimen\n # Glycemic control: SSI, well controlled\n # Lines L PICC\n ().\n # Ppx: INR therapeutic, ranitidine, colace and senna, miralax,\n bisacodyl.\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n Code: Full\n Dispo: ICU, being screening for vent facilities\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-11 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 636906,
"text": "Chief Complaint:\n 24 Hour Events:\n Spiked to 102.2 after aspiration of tube feeds (only at 10 cc/hr) - pan\n cultured and given tylenol\n INR rising\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Aztreonam - 03:42 AM\n Vancomycin - 09:40 AM\n Levofloxacin - 11:15 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 07:47 AM\n Morphine Sulfate - 05:16 AM\n Other medications:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39\nC (102.2\n Tcurrent: 37.1\nC (98.7\n HR: 129 (86 - 137) bpm\n BP: 102/52(64) {78/26(42) - 155/89(100)} mmHg\n RR: 15 (12 - 65) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,299 mL\n 500 mL\n PO:\n TF:\n 55 mL\n IVF:\n 699 mL\n 500 mL\n Blood products:\n Total out:\n 2,990 mL\n 485 mL\n Urine:\n 2,990 mL\n 485 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,691 mL\n 15 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 513 (328 - 561) mL\n PS : 0 cmH2O\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: Agitated\n PIP: 22 cmH2O\n SpO2: 99%\n ABG: ///26/\n Ve: 6.6 L/min\n Physical Examination\n General Appearance: Trached. Interactive. Responsive, following\n commands, Overweight / Obese, mild agitation but NAD\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\n deviation\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Respiratory / Chest: (Expansion: Symmetric), b/l rhonchi R>L, decreased\n BS\n Abdominal: Obese, soft, Non-tender, no rebound, no guarding, + BS, PEG\n in place with dressing C/D/I\n Extremities: no CCE\n Skin: no rashes or jaundice\n Lines: L PICC C/D/I\n Labs / Radiology\n 238 K/uL\n 8.4 g/dL\n 106 mg/dL\n 0.9 mg/dL\n 26 mEq/L\n 3.9 mEq/L\n 11 mg/dL\n 108 mEq/L\n 143 mEq/L\n 26.9 %\n 7.2 K/uL\n [image002.jpg]\n 02:43 PM\n 03:03 PM\n 08:11 PM\n 02:51 AM\n 03:10 AM\n 03:08 PM\n 03:00 AM\n 03:36 AM\n 04:40 PM\n 03:00 AM\n WBC\n 9.4\n 11.3\n 7.3\n 6.1\n 7.2\n Hct\n 26.6\n 24.9\n 27.6\n 26.5\n 26.9\n Plt\n 09\n 238\n Cr\n 0.9\n 0.7\n 0.6\n 0.6\n 0.9\n TCO2\n 31\n 30\n 29\n 26\n Glucose\n 128\n 114\n 114\n 99\n 115\n 106\n Other labs: PT / PTT / INR:72.4/42.1/9.0, Ca++:9.3 mg/dL, Mg++:2.5\n mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA, and\n ARDS, intubated since the end of now s/p trach and PEG\n placement.\n # Recent Aspiration of tube feeds. Given prolonged hospitalization and\n tenuous respiratory status will treat with antibiotics while cultures\n pending\n - Levoflox for 48 hours while waiting for sputum results.\n - hold tube feeds\n - Follow cultures\n - check tube placement\n .\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation. S/P Trach\n and PEG on .\n - wean FiO2 as tolerated\n - attempt wean PS today and hopeful for trach mask trial\n # Sedation: Continue to have issues with pain/delirium causing\n tachycardia and hypertension with intermittent hypotension. On Haldol\n 5 TID, Fentanyl 75 mcg TP, Diazapam 10 QID; Haldol, midazolam and\n morphine PRN. Had good response to morphine, minimal response to\n haldol bolus.\n - tolerating current regimen well, no changes today\n # Adrenal Insufficency: Hypotension that resolved with steroids,\n returned as they came off and is now improved again. Possible primary\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\n started on .\n - stopped steroids as per endocrine today\n # Volume overloaded in setting of hypernatremia\n Goal even today.\n - monitor urine output\n # RUE DVT: INR super-therapeutic on coumadin. Goal . Hasn\n received coumadin in days yet INR continues to rise. Likely\n contributors are nutritional and antibiotics.\n - will start coumadin 2.5 mg QHS once INR < 3\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - Brace for OOB\n - report from full trauma series from OSH is in chart. No evidence of\n other fracture and no need for further spinal imaging based on this\n report and ortho note.\n # Tracheomalacia: Discussed with IP. Stenting unlikely to help for\n trachiomalacia as airways have poor structure diffusely.\n - Outpatient f/u once off pressure support to assess for possible\n stenting\n #. Thyroid Nodule on CT\n -outpatient follow up\n # Nutrition: Replete (Full)\n hold\n # Glycemic control: SSI, well controlled\n # Lines L PICC\n ().\n # Ppx: INR therapeutic, ranitidine, colace and senna, miralax,\n bisacodyl.\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n Code: Full\n Dispo: ICU, being screening for vent facilities\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-09 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 636576,
"text": "Chief Complaint:\n 24 Hour Events:\n Arterial line d/c'd\n Spiked a fever of 101.4, blood and urine cultures sent, CXR. Started\n Vanc, Levo, Aztreonam\n Persistently hypotensive to 70s SBP overnight with low urine output and\n poor O2 sats.\n Started on Levophed, and given 1.75L NS. BPs improved to 90-120s SBP,\n and urine output increased significantly.\n Large amount of oral secretions, ?gastric in origin\n Tube feeds held for ? of aspiration.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 11:00 PM\n Levofloxacin - 11:43 PM\n Aztreonam - 04:07 AM\n Infusions:\n Norepinephrine\n Off at 7:30 AM\n Other ICU medications:\n Midazolam (Versed) - 09:30 AM\n Morphine Sulfate - 03:17 PM\n Furosemide (Lasix) - 06:36 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.4\n Tcurrent: 36.7\nC (98.1\n HR: 131 (73 - 142) bpm\n BP: 127/43(60) {71/29(42) - 137/97(101)} mmHg\n RR: 21 (12 - 36) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 4,627 mL\n 1,084 mL\n PO:\n TF:\n 839 mL\n IVF:\n 2,288 mL\n 1,084 mL\n Blood products:\n Total out:\n 2,407 mL\n 2,220 mL\n Urine:\n 2,407 mL\n 2,220 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,220 mL\n -1,136 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 412 (236 - 480) mL\n PS : 8 cmH2O\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI: 126\n PIP: 21 cmH2O\n Plateau: 17 cmH2O\n Compliance: 44.4 cmH2O/mL\n SpO2: 97%\n ABG: 7.35/50/81./26/0\n Ve: 7 L/min\n PaO2 / FiO2: 162\n Physical Examination\n General Appearance: Trached and sedated. Responsive, following\n commands, Overweight / Obese, mild agitation but NAD\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\n deviation\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Respiratory / Chest: (Expansion: Symmetric), CTA anteriorly, decreased\n BS\n Abdominal: Obese, soft, Non-tender, no rebound, no guarding, + BS, PEG\n in place with dressing C/D/I\n Extremities: no CCE\n Skin: no rashes or jaundice\n Lines: r brachioceph ART with large amount of bloody drainage and L\n PICC C/D/I\n Labs / Radiology\n 227 K/uL\n 7.7 g/dL\n 114 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 4.0 mEq/L\n 16 mg/dL\n 112 mEq/L\n 145 mEq/L\n 24.9 %\n 11.3 K/uL\n [image002.jpg]\n 03:46 AM\n 10:20 AM\n 03:46 PM\n 01:37 AM\n 05:32 AM\n 02:43 PM\n 03:03 PM\n 08:11 PM\n 02:51 AM\n 03:10 AM\n WBC\n 11.1\n 9.4\n 11.3\n Hct\n 29.4\n 26.6\n 24.9\n Plt\n \n Cr\n 0.8\n 0.6\n 0.9\n 0.7\n TCO2\n 35\n 37\n 31\n 31\n 30\n 29\n Glucose\n 155\n 123\n 128\n 114\n 114\n Other labs: PT / PTT / INR:37.2/37.9/4.0, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Lactic Acid:0.5 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:8.7 mg/dL, Mg++:2.6 mg/dL, PO4:4.2 mg/dL\n Blood/Urine/Sputum culture pending\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA, and\n ARDS, intubated since the end of now s/p trach and PEG\n placement.\n # Fever: Likely secondary to aspiration pneumonitis. Given prolonged\n hospitalization and tenuous respiratory status will treat with\n antibiotics while cultures pending\n - Vanc/Cef/Azithro for 48 hours while waiting for sputum results.\n - Hold tube feeds for 24 hours\n - Follow cultures\n - Off levophed\n .\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation. S/P Trach\n and PEG on .\n - wean FiO2 as tolerated\n - attempt wean PS today and hopeful for trach mask trial\n # Sedation: Continue to have issues with pain/delirium causing\n tachycardia and hypertension with intermittent hypotension. On Haldol\n 5 TID, Fentanyl 75 mcg TP, Diazapam 10 QID; Haldol, midazolam and\n morphine PRN. Had good response to morphine, minimal response to\n haldol bolus.\n - Reduce diazepam to 5 q 8hrs.\n - d/c standing Haldol\n # Adrenal Insufficency: Hypotension that resolved with steroids,\n returned as they came off and is now improved again. Possible primary\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\n started on .\n - 10 q am and 5 q pm prednisone day 2 of 3, will wean to\n maintenance dose as tolerated, in consultation with endo.\n # Volume overloaded in setting of hypernatremia with TBW deficit and\n metabolic alkalosis\n - Goal of even in the setting of recent hypotension.\n - Off diamox\n - electrolytes\n - Will give IV free water rather than flushes. D5W 1L@100 cc/hr\n # Falling Hct: Likely dilutional. Concern given elevated INR\n - Recheck in PM\n - Type and screen\n # RUE DVT: INR now therapeutic on coumadin. Goal \n - stop heparin gtt\n - will start coumadin 2.5 mg QHS once INR < 3\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - Brace for OOB\n - report from full trauma series from OSH is in chart. No evidence of\n other fracture and no need for further spinal imaging based on this\n report and ortho note.\n # Tracheomalacia: Discussed with IP. Stenting unlikely to help for\n trachiomalacia as airways have poor structure diffusely.\n - Outpatient f/u once off pressure support to assess for possible\n stenting\n #. Thyroid Nodule on CT\n -outpatient follow up\n # Nutrition: Hold tube feeds x 24 hours, continue Replete (Full)\n will reintroduce slowly\n - advance bowel regimen\n # Glycemic control: SSI, well controlled\n # Lines L PICC (). ABG and VBG correlate well.\n # Ppx: INR therapeutic, ranitidine, colace and senna, miralax,\n bisacodyl.\n # Communication:\n - Boyfriend of 10 \n - Brother is her HCP, also involved\n Code: Full\n Dispo: ICU, being screening for vent facilities\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n 18 Gauge - 08:15 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-11 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 636884,
"text": "Chief Complaint:\n 24 Hour Events:\n Spiked to 102.2 after aspiration of tube feeds (only at 10 cc/hr) - pan\n cultured and given tylenol\n INR rising\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Aztreonam - 03:42 AM\n Vancomycin - 09:40 AM\n Levofloxacin - 11:15 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 07:47 AM\n Morphine Sulfate - 05:16 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39\nC (102.2\n Tcurrent: 37.1\nC (98.7\n HR: 129 (86 - 137) bpm\n BP: 102/52(64) {78/26(42) - 155/89(100)} mmHg\n RR: 15 (12 - 65) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,299 mL\n 500 mL\n PO:\n TF:\n 55 mL\n IVF:\n 699 mL\n 500 mL\n Blood products:\n Total out:\n 2,990 mL\n 485 mL\n Urine:\n 2,990 mL\n 485 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,691 mL\n 15 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 513 (328 - 561) mL\n PS : 0 cmH2O\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: Agitated\n PIP: 22 cmH2O\n SpO2: 99%\n ABG: ///26/\n Ve: 6.6 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 238 K/uL\n 8.4 g/dL\n 106 mg/dL\n 0.9 mg/dL\n 26 mEq/L\n 3.9 mEq/L\n 11 mg/dL\n 108 mEq/L\n 143 mEq/L\n 26.9 %\n 7.2 K/uL\n [image002.jpg]\n 02:43 PM\n 03:03 PM\n 08:11 PM\n 02:51 AM\n 03:10 AM\n 03:08 PM\n 03:00 AM\n 03:36 AM\n 04:40 PM\n 03:00 AM\n WBC\n 9.4\n 11.3\n 7.3\n 6.1\n 7.2\n Hct\n 26.6\n 24.9\n 27.6\n 26.5\n 26.9\n Plt\n 09\n 238\n Cr\n 0.9\n 0.7\n 0.6\n 0.6\n 0.9\n TCO2\n 31\n 30\n 29\n 26\n Glucose\n 128\n 114\n 114\n 99\n 115\n 106\n Other labs: PT / PTT / INR:72.4/42.1/9.0, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Lactic Acid:0.5 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:9.3 mg/dL, Mg++:2.5 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA, and\n ARDS, intubated since the end of now s/p trach and PEG\n placement.\n # Recent Aspiration of tube feeds. Given prolonged hospitalization and\n tenuous respiratory status will treat with antibiotics while cultures\n pending\n - Levoflox for 48 hours while waiting for sputum results.\n - restart tube feeds slowly\n - Follow cultures\n .\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation. S/P Trach\n and PEG on .\n - wean FiO2 as tolerated\n - attempt wean PS today and hopeful for trach mask trial\n # Sedation: Continue to have issues with pain/delirium causing\n tachycardia and hypertension with intermittent hypotension. On Haldol\n 5 TID, Fentanyl 75 mcg TP, Diazapam 10 QID; Haldol, midazolam and\n morphine PRN. Had good response to morphine, minimal response to\n haldol bolus.\n - Reduce diazepam to 5 q 8hrs.\n - d/c standing Haldol\n # Adrenal Insufficency: Hypotension that resolved with steroids,\n returned as they came off and is now improved again. Possible primary\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\n started on .\n - 10 q am and 5 q pm prednisone day 2 of 3, will wean to\n maintenance dose as tolerated, in consultation with endo.\n # Volume overloaded in setting of hypernatremia\n Goal even today.\n - Off diamox\n - electrolytes\n - Free water flushes with tube feeds.\n # Falling Hct: Likely dilutional. Concern given elevated INR. Stable\n today.\n - monitor\n - maintain active type and screen\n # RUE DVT: INR now therapeutic on coumadin. Goal \n - will start coumadin 2.5 mg QHS once INR < 3\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - Brace for OOB\n - report from full trauma series from OSH is in chart. No evidence of\n other fracture and no need for further spinal imaging based on this\n report and ortho note.\n # Tracheomalacia: Discussed with IP. Stenting unlikely to help for\n trachiomalacia as airways have poor structure diffusely.\n - Outpatient f/u once off pressure support to assess for possible\n stenting\n #. Thyroid Nodule on CT\n -outpatient follow up\n # Nutrition: Replete (Full)\n will reintroduce slowly\n - advance bowel regimen\n # Glycemic control: SSI, well controlled\n # Lines L PICC\n ().\n # Ppx: INR therapeutic, ranitidine, colace and senna, miralax,\n bisacodyl.\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n Code: Full\n Dispo: ICU, being screening for vent facilities\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 637037,
"text": "56 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\n with prolonged hospital course c/b by PNA, anxiety/altered mental\n status, RUE DVT .\n Events\n stim test performed. TF restarted. INR down to 1.6 from 9\n ( pt given vit K yesterday)\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on PSV 10/5/50%. RR 20-30. )2 sat > 97%\n Action:\n Pt remained on PSV rather than AC overnight. Suctioned ~q 3-4 hrs for\n sm amt yellow bld-tinged secretions. Continues to have copious oral\n secretions\n removed with yankeur.\n Response:\n Tolerated PSV well, no tachypnea or desaturation.\n Plan:\n Attempt trach collar trial again in am. On-going pulm hygiene\n Hypotension (not Shock)\n Assessment:\n BP 90/40 with urine output falling to 10-15ccs/hr via foley. HR remains\n tachycardic (110-140ST) even when pt is not agitated or febrile.\n Action:\n Given 1 500cc d5\n ns fluid bolus\n Response:\n SBP > 90, Urine output improving to >30ccs/hr\n Plan:\n Continue to monitor hemodynamic status and f+e balance.\n Altered mental status (not Delirium)\n Assessment:\n Pt lethargic after receiving benedryl for several hrs but then awoke\n agitated, attempting to climb OOB and pull at trach despite restraints.\n Denies pain ( fentanyl patch in place) or need to go to the bathroom.\n c/o itchiness on back secondary to rash.\n Action:\n Medicated with iv benedryl.\n Response:\n Less agitated. Slept again for a few hours.\n Plan:\n Continue to reorient pt, benedryl for pruritis, safety precautions.\n Alteration in Nutrition\n Assessment:\n Pt with previous episodes of vomiting last eve. Kub showed no evidence\n of obstruction. Na 146\n Action:\n TF initiated with 50ccs free h20 boluses q 4hrs\n Response:\n No nausea or vomiting. No residuals.\n Plan:\n Advance TF as tolerated. ? increase free h20 boluses for hypernatremia.\n"
},
{
"category": "Physician ",
"chartdate": "2167-09-28 00:00:00.000",
"description": "Physician Resident / Attending Progress Note - MIC",
"row_id": 634984,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n PICC placed, Central line d/c'd\n Lasix 10 mg given with 400 cc UOP in afternoon, pH improved\n Lasix 20 mg given at ~ 4AM.\n Lots of thick sinus secreations\n Delerium/anxiety overnight with periods of hypertension.\n Could not draw of A-line.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Aztreonam - 06:00 AM\n Vancomycin - 09:00 AM\n Levofloxacin - 08:06 AM\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Fentanyl - 150 mcg/hour\n Heparin Sodium - 1,700 units/hour\n Other ICU medications:\n Furosemide (Lasix) - 03:01 AM\n Midazolam (Versed) - 04:36 AM\n Fentanyl - 04:36 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36.4\nC (97.6\n HR: 90 (47 - 92) bpm\n BP: 118/59(80) {80/40(53) - 137/105(111)} mmHg\n RR: 17 (15 - 24) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101 kg (admission): 94.2 kg\n Height: 67 Inch\n CVP: 19 (16 - 19)mmHg\n Total In:\n 2,560 mL\n 543 mL\n PO:\n TF:\n 1,441 mL\n 342 mL\n IVF:\n 1,020 mL\n 201 mL\n Blood products:\n Total out:\n 1,680 mL\n 860 mL\n Urine:\n 1,680 mL\n 860 mL\n NG:\n Stool:\n Drains:\n Balance:\n 880 mL\n -317 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 15 cmH2O\n FiO2: 50%\n PIP: 27 cmH2O\n Plateau: 23 cmH2O\n SpO2: 98%\n ABG: 7.41/45/77./28/2\n Ve: 6.5 L/min\n PaO2 / FiO2: 156\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese, opens eyes\n but no purposeful movement\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric)\n Abdominal: No(t) Soft, Non-tender, Bowel sounds present, Distended\n Extremities: No clubbing or cyanosis, 3+ nonpitting edema of b/l hands,\n LE without edema\n Skin: no rashes or jaundice\n Labs / Radiology\n 411 K/uL\n 8.3 g/dL\n 133 mg/dL\n 0.5 mg/dL\n 28 mEq/L\n 4.1 mEq/L\n 13 mg/dL\n 111 mEq/L\n 145 mEq/L\n 26.0 %\n 9.7 K/uL\n [image002.jpg]\n 04:05 PM\n 01:12 AM\n 04:00 AM\n 04:09 AM\n 10:18 AM\n 02:33 PM\n 02:46 PM\n 03:31 AM\n 02:26 PM\n 05:53 PM\n WBC\n 9.6\n 9.7\n Hct\n 27.8\n 26.0\n Plt\n 374\n 411\n Cr\n 0.5\n 0.5\n 0.5\n 0.5\n TCO2\n 26\n 27\n 28\n 29\n 26\n 27\n 30\n Glucose\n 194\n 195\n 195\n 163\n 133\n Other labs: PT / PTT / INR:15.3/69.9/1.3, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:86.1 %, Lymph:10.3 %,\n Mono:2.8 %, Eos:0.5 %, Lactic Acid:2.0 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:8.3 mg/dL, Mg++:2.2 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with respiratory failure\n and difficulty weaning from vent.\n # Respiratory failure: Intubated on for resp decompensation.\n Likely VAP. Transferred here for tracheomalacia, but not sure this\n is a component. Will need bronch eval when improved\n - will discuss PEEP goal for trach placement with IP.\n - wean PEEP\n - repeat ABG this AM\n - discuss need for trach with patient and her family\n - Volume overload may be contributing.\n # Volume overload\n Currently with hypernatremia, Cr increase, contract\n alk, but mild\n - continue gentle diuresis\n - FW in TF at 150 cc q4hrs\n - PM lytes.\n # Sedation: On versed 3mg/hr + .5 q 1hr and fentanyl 150 mcg/hr + 50\n bolus q 1hr.\n - Start fentanyl patch and diazepam to provide long acting analgesia\n and wean from drips\n - Haldol 1 mg Q4h PRN agitation\n # Pneumonia: Pansensitive Kleb oxytoca pneumonia and sputum with GPCs\n on gram stain. Afebrile off abx.\n # EKG changes: Sinus bradycardia, responsive to stress. Related to\n sedation, increased vagal tone, possibly related to steroid\n replacement. Atrial EKG shows p-waves and cardiac enzymes normal.\n - Continue to monitor\n # Hypotension: Improved, off levophed for 2-3 days now, with good urine\n output. s/p 5 d course of steroids for adrenal insufficiency. High\n PEEP may have been contributing. Now likely related to sedation and\n decreased intravascular volume,\n -monitor, expect improvement with continual reduction in\n PEEP\n # RUE DVT: Started on heparin gtt on , now therapeutic. Follow\n PTTs. Would hold off on coumadin at least until s/p trach.\n - continue to monitor\n # Adrenal Insufficency: Random cortisol was approx 3 when it should\n have been maximally stimulated.\n - hydrocortisone and florinef for 5 days\n # Anemia: Stable.\n - Trend HCT\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n FEN/GI: Tube feeds @ goal\n DVT: Treatment dose heparin\n Ulcer: Ranitidine\n VAP: Prevention per routine\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 08:12 PM 60 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 04:00 PM\n PICC Line - 09:19 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 55F T5-8 fractures with retropulsion and ARDS\n from VAP; on heparin for UE DVT.\n Exam notable for Tm 97.5 BP 90/45 HR 67 RR with sat 95 on VAC 400x18\n PEEP 15 FiO2 0.5 for 7.41/45/78. Eyes opens, will squeeze hands and\n wiggle toes but very drowsy. Bronchial BS bilaterally with RRR s1s2 \n SM at base. Abdomen is mildly distended with decreased BS. 3+ edema in\n BLE, no cords. Labs notable for WBC 9K, HCT 26, K+ 4.1, Cr 0.5. CXR\n with resolving B LL airspace disease and effusions.\n Agree with plan to start fentanyl patch and po valium and wean IV\n sedation while slowly coming down on PEEP. Will start gentle IV lasix\n (drip or bolus) to affect a negative fluid balance and use haldol for\n breakthrough agitiation. In addition, we will continue IV heparin for\n UE DVT; consider transition to coumadin only after tracheostomy and\n feeding tube placement, which will require lower ventilator settings.\n Will ask IP to reevaluate today, given need for tracheostomy and\n possible tracheobronchomalacia. Continue spinal stabilization with\n brace when OOB; will eventually need MRI for surgical planning.\n Continue TF; remainder of plan as outlined above.\n Patient is critically ill\n Total time: 40 min\n ------ Protected Section Addendum Entered By: , MD\n on: 01:45 PM ------\n"
},
{
"category": "Nursing",
"chartdate": "2167-09-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 635035,
"text": "Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n RUE edematous, warm, red\n Action:\n Heparin gtt WNL\n Response:\n No change\n Plan:\n Heparin off at 0600 for procedure\n Altered mental status (not Delirium)\n Assessment:\n Periods of agitation\n Action:\n Fentanyl and Versed Gtt, haldol and valium started. Fentanyl patch\n Response:\n Calm with increased sedation needed\n Plan:\n Monitor, continue with sedation as tolerates.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt desatted to 87%\n Action:\n Peep increased\n Response:\n O2 sat improved\n Plan:\n Team to attempt to replace aline or will draw am abg. AM RSBI\n Hypotension (not Shock)\n Assessment:\n Sbp 70\n Action:\n Sedation weaned, but pt agitated\n Response:\n Sbp > 90\n Plan:\n Maintain sbp > 90 with adequate sedation\n Bradycardia\n Assessment:\n HR 50\ns with increased sedation\n Action:\n Sedation weaned, but pt agitated\n Response:\n HR 70-130\ns, with decreased sedation\n Plan:\n Maintain sedation, monitor hr\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-10 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 636651,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n Discussed imaging with ortho. They do not need further imaging. She\n should wear TLSO for 2 months and f/u with at 2 months\n prior to removal of TLSO.\n Changed to PSV, was stable on trach mask for 1-2 hrs\n Tube feeds held\n Endo recs: check AM cortisol prior to dose\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 10:04 PM\n Levofloxacin - 10:49 PM\n Aztreonam - 03:42 AM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 10:49 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.7\nC (98\n HR: 125 (74 - 151) bpm\n BP: 121/64(77) {89/32(45) - 179/99(120)} mmHg\n RR: 20 (13 - 30) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 5,817 mL\n 457 mL\n PO:\n TF:\n IVF:\n 5,277 mL\n 327 mL\n Blood products:\n Total out:\n 5,205 mL\n 1,460 mL\n Urine:\n 5,205 mL\n 1,460 mL\n NG:\n Stool:\n Drains:\n Balance:\n 612 mL\n -1,003 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 429 (340 - 480) mL\n PS : 8 cmH2O\n RR (Set): 0\n RR (Spontaneous): 25\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 13 cmH2O\n SpO2: 100%\n ABG: 7.37/44/120/25/0\n Ve: 6.3 L/min\n PaO2 / FiO2: 240\n Physical Examination\n General Appearance: Trached and sedated. Responsive, following\n commands, Overweight / Obese, mild agitation but NAD\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\n deviation\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Respiratory / Chest: (Expansion: Symmetric), CTA anteriorly, decreased\n BS\n Abdominal: Obese, soft, Non-tender, no rebound, no guarding, + BS, PEG\n in place with dressing C/D/I\n Extremities: no CCE\n Skin: no rashes or jaundice\n Lines: r brachioceph ART with large amount of bloody drainage and L\n PICC C/D/I\n Labs / Radiology\n 209 K/uL\n 8.3 g/dL\n 99 mg/dL\n 0.6 mg/dL\n 25 mEq/L\n 4.3 mEq/L\n 9 mg/dL\n 111 mEq/L\n 145 mEq/L\n 26.5 %\n 6.1 K/uL\n [image002.jpg]\n 01:37 AM\n 05:32 AM\n 02:43 PM\n 03:03 PM\n 08:11 PM\n 02:51 AM\n 03:10 AM\n 03:08 PM\n 03:00 AM\n 03:36 AM\n WBC\n 11.1\n 9.4\n 11.3\n 7.3\n 6.1\n Hct\n 29.4\n 26.6\n 24.9\n 27.6\n 26.5\n Plt\n 89\n 209\n Cr\n 0.6\n 0.9\n 0.7\n 0.6\n TCO2\n 31\n 31\n 30\n 29\n 26\n Glucose\n 123\n 128\n 114\n 114\n 99\n Other labs: PT / PTT / INR:40.1/40.7/4.4, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Lactic Acid:0.5 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:8.9 mg/dL, Mg++:2.6 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA, and\n ARDS, intubated since the end of now s/p trach and PEG\n placement.\n # Fever: Likely secondary to aspiration pneumonitis. Given prolonged\n hospitalization and tenuous respiratory status will treat with\n antibiotics while cultures pending\n - Vanc/Cef/Azithro for 48 hours while waiting for sputum results.\n - Hold tube feeds for 24 hours\n - Follow cultures\n - Off levophed\n .\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation. S/P Trach\n and PEG on .\n - wean FiO2 as tolerated\n - attempt wean PS today and hopeful for trach mask trial\n # Sedation: Continue to have issues with pain/delirium causing\n tachycardia and hypertension with intermittent hypotension. On Haldol\n 5 TID, Fentanyl 75 mcg TP, Diazapam 10 QID; Haldol, midazolam and\n morphine PRN. Had good response to morphine, minimal response to\n haldol bolus.\n - Reduce diazepam to 5 q 8hrs.\n - d/c standing Haldol\n # Adrenal Insufficency: Hypotension that resolved with steroids,\n returned as they came off and is now improved again. Possible primary\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\n started on .\n - 10 q am and 5 q pm prednisone day 2 of 3, will wean to\n maintenance dose as tolerated, in consultation with endo.\n # Volume overloaded in setting of hypernatremia with TBW deficit and\n metabolic alkalosis\n - Goal of even in the setting of recent hypotension.\n - Off diamox\n - electrolytes\n - Will give IV free water rather than flushes. D5W 1L@100 cc/hr\n # Falling Hct: Likely dilutional. Concern given elevated INR\n - Recheck in PM\n - Type and screen\n # RUE DVT: INR now therapeutic on coumadin. Goal \n - stop heparin gtt\n - will start coumadin 2.5 mg QHS once INR < 3\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - Brace for OOB\n - report from full trauma series from OSH is in chart. No evidence of\n other fracture and no need for further spinal imaging based on this\n report and ortho note.\n # Tracheomalacia: Discussed with IP. Stenting unlikely to help for\n trachiomalacia as airways have poor structure diffusely.\n - Outpatient f/u once off pressure support to assess for possible\n stenting\n #. Thyroid Nodule on CT\n -outpatient follow up\n # Nutrition: Hold tube feeds x 24 hours, continue Replete (Full)\n will reintroduce slowly\n - advance bowel regimen\n # Glycemic control: SSI, well controlled\n # Lines L PICC (). ABG and VBG correlate well.\n # Ppx: INR therapeutic, ranitidine, colace and senna, miralax,\n bisacodyl.\n # Communication:\n - Boyfriend of 10 \n - Brother is her HCP, also involved\n Code: Full\n Dispo: ICU, being screening for vent facilities\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n 18 Gauge - 08:15 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Respiratory ",
"chartdate": "2167-10-10 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 636655,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 22\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason:\n Tube Type\n Tracheostomy tube:\n Type: Cuffed\n Manufacturer: Portex\n Size: 7.0mm\n PMV: No\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Periodic SBT's for conditioning, Adjust Min. ventilation to control pH,\n Increase ventilatory support at night; Comments: During RSBI trial,\n ptwould not breathe in normal pattern, very deep but slow breaths\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Cannot protect airway, Underlying illness not\n resolved\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-10 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 636749,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n Discussed imaging with ortho. They do not need further imaging. She\n should wear TLSO for 2 months and f/u with at 2 months\n prior to removal of TLSO.\n Changed to PSV, was stable on trach mask for 1-2 hrs\n Tube feeds held\n Endo recs: check AM cortisol prior to dose\n At 5:45 am --- RR 4, switched from CPAP/PSV to AC\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 10:04 PM\n Levofloxacin - 10:49 PM\n Aztreonam - 03:42 AM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 10:49 PM\n Other medications:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.7\nC (98\n HR: 125 (74 - 151) bpm\n BP: 121/64(77) {89/32(45) - 179/99(120)} mmHg\n RR: 20 (13 - 30) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 5,817 mL\n 457 mL\n PO:\n TF:\n IVF:\n 5,277 mL\n 327 mL\n Blood products:\n Total out:\n 5,205 mL\n 1,460 mL\n Urine:\n 5,205 mL\n 1,460 mL\n NG:\n Stool:\n Drains:\n Balance:\n 612 mL\n -1,003 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 429 (340 - 480) mL\n PS : 8 cmH2O\n RR (Set): 0\n RR (Spontaneous): 25\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 13 cmH2O\n SpO2: 100%\n ABG: 7.37/44/120/25/0\n Ve: 6.3 L/min\n PaO2 / FiO2: 240\n Physical Examination\n On CMV\n Peep 5, FiO2 40%, Vt 500, R 14\n General Appearance: Trached and sedated. Responsive, following\n commands, Overweight / Obese, mild agitation but NAD\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\n deviation\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Respiratory / Chest: (Expansion: Symmetric), CTA anteriorly, decreased\n BS\n Abdominal: Obese, soft, Non-tender, no rebound, no guarding, + BS, PEG\n in place with dressing C/D/I\n Extremities: no CCE\n Skin: no rashes or jaundice\n Lines: L PICC C/D/I\n Labs / Radiology\n 209 K/uL\n 8.3 g/dL\n 99 mg/dL\n 0.6 mg/dL\n 25 mEq/L\n 4.3 mEq/L\n 9 mg/dL\n 111 mEq/L\n 145 mEq/L\n 26.5 %\n 6.1 K/uL\n [image002.jpg]\n 01:37 AM\n 05:32 AM\n 02:43 PM\n 03:03 PM\n 08:11 PM\n 02:51 AM\n 03:10 AM\n 03:08 PM\n 03:00 AM\n 03:36 AM\n WBC\n 11.1\n 9.4\n 11.3\n 7.3\n 6.1\n Hct\n 29.4\n 26.6\n 24.9\n 27.6\n 26.5\n Plt\n 89\n 209\n Cr\n 0.6\n 0.9\n 0.7\n 0.6\n TCO2\n 31\n 31\n 30\n 29\n 26\n Glucose\n 123\n 128\n 114\n 114\n 99\n Other labs: PT / PTT / INR:36.4/38.8/3.9, Ca++:8.9 mg/dL, Mg++:2.6\n mg/dL, PO4:4.1 mg/dL\n Cx: endotrach \n GN diplococci, budding yeast\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA, and\n ARDS, intubated since the end of now s/p trach and PEG\n placement.\n # Recent Aspiration of tube feeds. Given prolonged hospitalization and\n tenuous respiratory status will treat with antibiotics while cultures\n pending\n - Levoflox for 48 hours while waiting for sputum results.\n - restart tube feeds slowly\n - Follow cultures\n .\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation. S/P Trach\n and PEG on .\n - wean FiO2 as tolerated\n - attempt wean PS today and hopeful for trach mask trial\n # Sedation: Continue to have issues with pain/delirium causing\n tachycardia and hypertension with intermittent hypotension. On Haldol\n 5 TID, Fentanyl 75 mcg TP, Diazapam 10 QID; Haldol, midazolam and\n morphine PRN. Had good response to morphine, minimal response to\n haldol bolus.\n - Reduce diazepam to 5 q 8hrs.\n - d/c standing Haldol\n # Adrenal Insufficency: Hypotension that resolved with steroids,\n returned as they came off and is now improved again. Possible primary\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\n started on .\n - 10 q am and 5 q pm prednisone day 2 of 3, will wean to\n maintenance dose as tolerated, in consultation with endo.\n # Volume overloaded in setting of hypernatremia\n Goal even today.\n - Off diamox\n - electrolytes\n - Free water flushes with tube feeds.\n # Falling Hct: Likely dilutional. Concern given elevated INR. Stable\n today.\n - monitor\n - maintain active type and screen\n # RUE DVT: INR now therapeutic on coumadin. Goal \n - will start coumadin 2.5 mg QHS once INR < 3\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - Brace for OOB\n - report from full trauma series from OSH is in chart. No evidence of\n other fracture and no need for further spinal imaging based on this\n report and ortho note.\n # Tracheomalacia: Discussed with IP. Stenting unlikely to help for\n trachiomalacia as airways have poor structure diffusely.\n - Outpatient f/u once off pressure support to assess for possible\n stenting\n #. Thyroid Nodule on CT\n -outpatient follow up\n # Nutrition: Replete (Full)\n will reintroduce slowly\n - advance bowel regimen\n # Glycemic control: SSI, well controlled\n # Lines L PICC ().\n # Ppx: INR therapeutic, ranitidine, colace and senna, miralax,\n bisacodyl.\n # Communication:\n - Boyfriend of 10 \n - Brother is her HCP, also involved\n Code: Full\n Dispo: ICU, being screening for vent facilities\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 636873,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on trach collar 50%. Sats fell to 78%. Pt ambu\nd and\n lavaged with no plugs detected. RR 30-40 . Pt diaphoretic.\n Action:\n Placed on PSV 10/5/50%\n Response:\n Apneic with RR 3-5\n Plan:\n Rested on AC 500/12/5/50%. No further episodes of desating or\n tachypnea.\n Hypotension (not Shock)\n Assessment:\n BP falling to 78/37. Urine output 5-30ccs/hr via foley\n Action:\n Given 500ccs\n NS fluid bolus\n Response:\n Pt normotensive, improved urine output\n Plan:\n Continue to monitor.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Temp spike to 102.2 po\n Action:\n Blood, urine and sputum cxs sent. Sputum white, not yellow or\n consistant with TF. Chest x-ray taken. Tylenol pr given. Cool cloths\n applied.\n Response:\n Pt normothermic. WBC 7.2\n Plan:\n Monitor fever curve, cooling measures. Follow-up on cx results.\n Alteration in Nutrition\n Assessment:\n Pt vomiting yellow fluid with coughing and when turned\n Action:\n TF held. Peg to gravity. Medicated with 4 mg zofran iv.\n Response:\n No further episodes of vomiting.\n Plan:\n Continue to monitor. Aspiration precautions. ? need for alternative\n form of nutrition.\n Altered mental status (not Delirium)\n Assessment:\n Onset of shift, pt lethargic, not following commands but MAE. ~ 12 mn\n pt agitated, attempting to climb oob, disconnecting self from vent\n despite restraints\n Action:\n 5 mg valium given q 8hrs. Haldol 2.5 mg given.\n Response:\n Pt still agitated\n Plan:\n Needs better sedation at bedtime - ? zyprexa or alternative med\n Addendum\n PT and INR rising to 72.4 and 9.0 ( venipuncture, not drawn\n from PIC ). MD notified. No intervention at this time.\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-12 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 637162,
"text": "Chief Complaint: resp failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n rash- vesicular and d/c l;evoquin and started Ceftriaxone\n More tachycardic this AM - autonomic dysregulation\n Trach Mask for several hours\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Aztreonam - 03:42 AM\n Vancomycin - 09:40 AM\n Levofloxacin - 11:15 PM\n Ceftriaxone - 07:50 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 09:45 AM\n Haloperidol (Haldol) - 10:26 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 36.9\nC (98.5\n HR: 143 (113 - 145) bpm\n BP: 153/89(102) {85/40(50) - 153/89(102)} mmHg\n RR: 24 (9 - 30) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,362 mL\n 537 mL\n PO:\n TF:\n 47 mL\n 287 mL\n IVF:\n 1,061 mL\n 100 mL\n Blood products:\n Total out:\n 1,203 mL\n 615 mL\n Urine:\n 1,203 mL\n 615 mL\n NG:\n Stool:\n Drains:\n Balance:\n 159 mL\n -78 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Set): 0 (0 - 0) mL\n Vt (Spontaneous): 244 (110 - 504) mL\n PS : 10 cmH2O\n RR (Set): 0\n RR (Spontaneous): 19\n PEEP: 5 cmH2O\n FiO2: 70%\n RSBI: 245\n PIP: 16 cmH2O\n SpO2: 98%\n ABG: ///30/\n Ve: 10 L/min\n Physical Examination\n Gen sitting up in , on trach mask, interactive\n CV tachy RRR\n Chest good movement ANT\n Abd soft NT + NS\n Ext: no edema\n Neuroalert follows simple commands\n Labs / Radiology\n 7.9 g/dL\n 240 K/uL\n 100 mg/dL\n 0.6 mg/dL\n 30 mEq/L\n 3.4 mEq/L\n 12 mg/dL\n 108 mEq/L\n 146 mEq/L\n 26.0 %\n 5.2 K/uL\n [image002.jpg]\n 08:11 PM\n 02:51 AM\n 03:10 AM\n 03:08 PM\n 03:00 AM\n 03:36 AM\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n WBC\n 9.4\n 11.3\n 7.3\n 6.1\n 7.2\n 5.2\n Hct\n 26.6\n 24.9\n 27.6\n 26.5\n 26.9\n 26.0\n Plt\n \n Cr\n 0.9\n 0.7\n 0.6\n 0.6\n 0.9\n 0.7\n 0.6\n TCO2\n 29\n 26\n Glucose\n 128\n 114\n 114\n 99\n 115\n 106\n 100\n Other labs: PT / PTT / INR:17.6/27.4/1.6, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:33/22, Alk Phos / T Bili:143/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:0.5 mmol/L,\n Albumin:3.5 g/dL, LDH:199 IU/L, Ca++:8.9 mg/dL, Mg++:2.4 mg/dL, PO4:4.1\n mg/dL\n Assessment and Plan 55 yr old alcoholic s/p t spine fx s/p trcah and\n PEG with persistent resp failure\n 1. Resp Failure: currently on trach mask, can do a few hours per\n day, then needs for support. New pan Klebs in sputum, day\n . Get Speech consult for PMV evaluation. Holding off on stent by IP\n until after pulm rehab.\n 2. Hemodynamics: tachycardia seems most likely due to agitation\n at present, did taper Valium aggressively, may be need to increase\n benzo slightly and see f it helps (haldol and morphione have not helped\n yet this AM)\n 3. Anti coag: for upper ext DVT but INR elevated on coumadin +\n quinolone\n repeat\n 4. Adrenal Insufficny: proper stim this AM, off steroids\n ICU Care\n Nutrition: Replete with Fiber (Full) - 07:46 AM 30 mL/hour\n Glycemic Control:\n Lines: PICC Line - 09:19 PM\n Prophylaxis:\n DVT: inr levetaed recheck, and start coumadin when at 2.0\n Stress ulcer: ppi\n Communication:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 637226,
"text": "56 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\n with prolonged hospital course c/b by PNA, anxiety/altered mental\n status, RUE DVT .\n Tachycardia, Other\n Assessment:\n HR\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 636001,
"text": "55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\n Now with prolonged hospital course c/b by PNA with high PEEP\n requirement, anxiety, RUE DVT on heparin qtt.\n Bradycardia\n Assessment:\n Pt conts with HR 50-70\ns at rest, 100-140\ns during care, pt\n asymptomatic; easily arousable\n Action:\n Sedation decreased, Lasix off @0200\n Response:\n HR 60\n Plan:\n Cont to wean sedation, ?cardiac consult\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Action:\n Cont with IV Heparin @ 1500u/hr, Coumadin d\ncd for? thoracentesis\n Response:\n Pt therapeutic, cont with daily PTT\n Plan:\n Cont to labs, cont to wean off Heparin, Coumadin 5mg given x 1dose\n @ 2200, re-eval dosing this am\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt cont on AC 18/400/50%/10, LS clear bilat, occ scat rhonchi\n Action:\n Pt suct for sm thin tan secretions\n Response:\n Pt 02 Sats 94-97%,\n Plan:\n Cont to ABGs, Rate decreased to 16 this am to PC02 elevated\n Hypotension (not Shock)\n Assessment:\n SBP 140\ns when pt is agitated, SBP dropping to 70\ns-80\ns, UO 200/hr\n (total 2500 in 2hr) K 3.3\n Action:\n Fent/Versed turned down @ 0000, Lasix gtt on hold, team informed ; pt\n recvd 1x dose of 40meg/Peg, 20meqK/250D5W x 1 dose\n Response:\n Pt SBP\ns in 80\n Plan:\n Cardiac consult to further eval SB/ST, re-evalu cont. Lasix gtt,\n recheck am labs\n Hypernatremia (high sodium)\n Assessment:\n Na 146\n Action:\n Cont with 300cc free water flush Q4hrs\n Response:\n Plan:\n Cont to sodium levels, treat as ordered\n Altered mental status (not Delirium)\n Assessment:\n Pt alert and agitated throughout shift, pt following commands\n inconsistently; sleeping off and off throughout shift\n Action:\n Fent/Versed decreased low SBP\ns, pt recved prn dose of Haldol 1mg @\n 0100; cont with bilat. Wrist restraints for safety\n Response:\n pt sleeping off/on throughout shift, with periods of\n agitation/restlessness\n Plan:\n Cont to wean fent/versed gtt down, cont with scheduled Haldol/Valium;\n cont to QTC intervals daily\n"
},
{
"category": "Physician ",
"chartdate": "2167-09-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 634960,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n PICC placed, Central line d/c'd\n Lasix 10 mg given with 400 cc UOP in afternoon, pH improved\n Lasix 20 mg given at ~ 4AM.\n Lots of thick sinus secreations\n Delerium/anxiety overnight with periods of hypertension.\n Could not draw of A-line.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Aztreonam - 06:00 AM\n Vancomycin - 09:00 AM\n Levofloxacin - 08:06 AM\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Fentanyl - 150 mcg/hour\n Heparin Sodium - 1,700 units/hour\n Other ICU medications:\n Furosemide (Lasix) - 03:01 AM\n Midazolam (Versed) - 04:36 AM\n Fentanyl - 04:36 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36.4\nC (97.6\n HR: 90 (47 - 92) bpm\n BP: 118/59(80) {80/40(53) - 137/105(111)} mmHg\n RR: 17 (15 - 24) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101 kg (admission): 94.2 kg\n Height: 67 Inch\n CVP: 19 (16 - 19)mmHg\n Total In:\n 2,560 mL\n 543 mL\n PO:\n TF:\n 1,441 mL\n 342 mL\n IVF:\n 1,020 mL\n 201 mL\n Blood products:\n Total out:\n 1,680 mL\n 860 mL\n Urine:\n 1,680 mL\n 860 mL\n NG:\n Stool:\n Drains:\n Balance:\n 880 mL\n -317 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 15 cmH2O\n FiO2: 50%\n PIP: 27 cmH2O\n Plateau: 23 cmH2O\n SpO2: 98%\n ABG: 7.41/45/77./28/2\n Ve: 6.5 L/min\n PaO2 / FiO2: 156\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese, opens eyes\n but no purposeful movement\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric)\n Abdominal: No(t) Soft, Non-tender, Bowel sounds present, Distended\n Extremities: No clubbing or cyanosis, 3+ nonpitting edema of b/l hands,\n LE without edema\n Skin: no rashes or jaundice\n Labs / Radiology\n 411 K/uL\n 8.3 g/dL\n 133 mg/dL\n 0.5 mg/dL\n 28 mEq/L\n 4.1 mEq/L\n 13 mg/dL\n 111 mEq/L\n 145 mEq/L\n 26.0 %\n 9.7 K/uL\n [image002.jpg]\n 04:05 PM\n 01:12 AM\n 04:00 AM\n 04:09 AM\n 10:18 AM\n 02:33 PM\n 02:46 PM\n 03:31 AM\n 02:26 PM\n 05:53 PM\n WBC\n 9.6\n 9.7\n Hct\n 27.8\n 26.0\n Plt\n 374\n 411\n Cr\n 0.5\n 0.5\n 0.5\n 0.5\n TCO2\n 26\n 27\n 28\n 29\n 26\n 27\n 30\n Glucose\n 194\n 195\n 195\n 163\n 133\n Other labs: PT / PTT / INR:15.3/69.9/1.3, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:86.1 %, Lymph:10.3 %,\n Mono:2.8 %, Eos:0.5 %, Lactic Acid:2.0 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:8.3 mg/dL, Mg++:2.2 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with respiratory failure\n and difficulty weaning from vent.\n # Respiratory failure: Intubated on for resp decompensation.\n Likely VAP. Transferred here for tracheomalacia, but not sure this\n is a component. Will need bronch eval when improved\n - wean PEEP\n - repeat ABG this AM\n - discuss need for trach with patient and her family\n - Will continue gentle diuresis once alkalosis resolved\n # Diuresis\n Currently with hypernatremia, Cr increase, contract alk\n suggestive of overdiuresis\n - FW in TF at 150 cc q4hrs\n - PM lytes. Can restart lasix if resolved\n # Pneumonia: Pansensitive Kleb oxytoca pneumonia and sputum with GPCs\n on gram stain. Afebrile off abx.\n # Sedation: On versed 3mg/hr + .5 q 1hr and fentanyl 150 mcg/hr + 50\n bolus q 1hr.\n - seroquil 25 \n # EKG changes: Sinus bradycardia, responsive to stress. Related to\n sedation, increased vagal tone, possibly related to steroid\n replacement. Atrial EKG shows p-waves and cardiac enzymes normal.\n - Continue to monitor\n # Hypotension: Improved, off levophed for 2-3 days now, with good urine\n output. s/p 5 d courserof steroids and getting high PEEP. Now likely\n related to sedation and decreased intravascual volume,\n -monitor, expect improvement with continual reduction in PEEP\n # RUE DVT: Started on heparin gtt on , now therapeutic. Follow\n PTTs. Would hold off on coumadin at least until s/p trach.\n - continue to monitor\n # Adrenal Insufficency: Random cortisol was approx 3 when it should\n have been maximally stimulated.\n - hydrocortisone and florinef for 5 days\n # Anemia: Stable.\n - Trend HCT\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n FEN/GI: Tube feeds @ goal\n DVT: Treatment dose heparin\n Ulcer: Ranitidine\n VAP: Prevention per routine\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 08:12 PM 60 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 04:00 PM\n PICC Line - 09:19 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2167-09-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 634969,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n PICC placed, Central line d/c'd\n Lasix 10 mg given with 400 cc UOP in afternoon, pH improved\n Lasix 20 mg given at ~ 4AM.\n Lots of thick sinus secreations\n Delerium/anxiety overnight with periods of hypertension.\n Could not draw of A-line.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Aztreonam - 06:00 AM\n Vancomycin - 09:00 AM\n Levofloxacin - 08:06 AM\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Fentanyl - 150 mcg/hour\n Heparin Sodium - 1,700 units/hour\n Other ICU medications:\n Furosemide (Lasix) - 03:01 AM\n Midazolam (Versed) - 04:36 AM\n Fentanyl - 04:36 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36.4\nC (97.6\n HR: 90 (47 - 92) bpm\n BP: 118/59(80) {80/40(53) - 137/105(111)} mmHg\n RR: 17 (15 - 24) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101 kg (admission): 94.2 kg\n Height: 67 Inch\n CVP: 19 (16 - 19)mmHg\n Total In:\n 2,560 mL\n 543 mL\n PO:\n TF:\n 1,441 mL\n 342 mL\n IVF:\n 1,020 mL\n 201 mL\n Blood products:\n Total out:\n 1,680 mL\n 860 mL\n Urine:\n 1,680 mL\n 860 mL\n NG:\n Stool:\n Drains:\n Balance:\n 880 mL\n -317 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 15 cmH2O\n FiO2: 50%\n PIP: 27 cmH2O\n Plateau: 23 cmH2O\n SpO2: 98%\n ABG: 7.41/45/77./28/2\n Ve: 6.5 L/min\n PaO2 / FiO2: 156\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese, opens eyes\n but no purposeful movement\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric)\n Abdominal: No(t) Soft, Non-tender, Bowel sounds present, Distended\n Extremities: No clubbing or cyanosis, 3+ nonpitting edema of b/l hands,\n LE without edema\n Skin: no rashes or jaundice\n Labs / Radiology\n 411 K/uL\n 8.3 g/dL\n 133 mg/dL\n 0.5 mg/dL\n 28 mEq/L\n 4.1 mEq/L\n 13 mg/dL\n 111 mEq/L\n 145 mEq/L\n 26.0 %\n 9.7 K/uL\n [image002.jpg]\n 04:05 PM\n 01:12 AM\n 04:00 AM\n 04:09 AM\n 10:18 AM\n 02:33 PM\n 02:46 PM\n 03:31 AM\n 02:26 PM\n 05:53 PM\n WBC\n 9.6\n 9.7\n Hct\n 27.8\n 26.0\n Plt\n 374\n 411\n Cr\n 0.5\n 0.5\n 0.5\n 0.5\n TCO2\n 26\n 27\n 28\n 29\n 26\n 27\n 30\n Glucose\n 194\n 195\n 195\n 163\n 133\n Other labs: PT / PTT / INR:15.3/69.9/1.3, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:86.1 %, Lymph:10.3 %,\n Mono:2.8 %, Eos:0.5 %, Lactic Acid:2.0 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:8.3 mg/dL, Mg++:2.2 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with respiratory failure\n and difficulty weaning from vent.\n # Respiratory failure: Intubated on for resp decompensation.\n Likely VAP. Transferred here for tracheomalacia, but not sure this\n is a component. Will need bronch eval when improved\n - will discuss PEEP goal for trach placement with IP.\n - wean PEEP\n - repeat ABG this AM\n - discuss need for trach with patient and her family\n - Volume overload may be contributing.\n # Volume overload\n Currently with hypernatremia, Cr increase, contract\n alk, but mild\n - continue gentle diuresis\n - FW in TF at 150 cc q4hrs\n - PM lytes.\n # Sedation: On versed 3mg/hr + .5 q 1hr and fentanyl 150 mcg/hr + 50\n bolus q 1hr.\n - Start fentanyl patch and diazepam to provide long acting analgesia\n and wean from drips\n - Haldol 1 mg Q4h PRN agitation\n # Pneumonia: Pansensitive Kleb oxytoca pneumonia and sputum with GPCs\n on gram stain. Afebrile off abx.\n # EKG changes: Sinus bradycardia, responsive to stress. Related to\n sedation, increased vagal tone, possibly related to steroid\n replacement. Atrial EKG shows p-waves and cardiac enzymes normal.\n - Continue to monitor\n # Hypotension: Improved, off levophed for 2-3 days now, with good urine\n output. s/p 5 d course of steroids for adrenal insufficiency. High\n PEEP may have been contributing. Now likely related to sedation and\n decreased intravascular volume,\n -monitor, expect improvement with continual reduction in\n PEEP\n # RUE DVT: Started on heparin gtt on , now therapeutic. Follow\n PTTs. Would hold off on coumadin at least until s/p trach.\n - continue to monitor\n # Adrenal Insufficency: Random cortisol was approx 3 when it should\n have been maximally stimulated.\n - hydrocortisone and florinef for 5 days\n # Anemia: Stable.\n - Trend HCT\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n FEN/GI: Tube feeds @ goal\n DVT: Treatment dose heparin\n Ulcer: Ranitidine\n VAP: Prevention per routine\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 08:12 PM 60 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 04:00 PM\n PICC Line - 09:19 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-10 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 636755,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n Discussed imaging with ortho. They do not need further imaging. She\n should wear TLSO for 2 months and f/u with at 2 months\n prior to removal of TLSO.\n Changed to PSV, was stable on trach mask for 1-2 hrs\n Tube feeds held\n Endo recs: check AM cortisol prior to dose\n At 5:45 am --- RR 4, switched from CPAP/PSV to AC\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 10:04 PM\n Levofloxacin - 10:49 PM\n Aztreonam - 03:42 AM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 10:49 PM\n Other medications:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.7\nC (98\n HR: 125 (74 - 151) bpm\n BP: 121/64(77) {89/32(45) - 179/99(120)} mmHg\n RR: 20 (13 - 30) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 5,817 mL\n 457 mL\n PO:\n TF:\n IVF:\n 5,277 mL\n 327 mL\n Blood products:\n Total out:\n 5,205 mL\n 1,460 mL\n Urine:\n 5,205 mL\n 1,460 mL\n NG:\n Stool:\n Drains:\n Balance:\n 612 mL\n -1,003 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 429 (340 - 480) mL\n PS : 8 cmH2O\n RR (Set): 0\n RR (Spontaneous): 25\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 13 cmH2O\n SpO2: 100%\n ABG: 7.37/44/120/25/0\n Ve: 6.3 L/min\n PaO2 / FiO2: 240\n Physical Examination\n On CMV\n Peep 5, FiO2 40%, Vt 500, R 14\n General Appearance: Trached and sedated. Responsive, following\n commands, Overweight / Obese, mild agitation but NAD\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\n deviation\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Respiratory / Chest: (Expansion: Symmetric), CTA anteriorly, decreased\n BS\n Abdominal: Obese, soft, Non-tender, no rebound, no guarding, + BS, PEG\n in place with dressing C/D/I\n Extremities: no CCE\n Skin: no rashes or jaundice\n Lines: L PICC C/D/I\n Labs / Radiology\n 209 K/uL\n 8.3 g/dL\n 99 mg/dL\n 0.6 mg/dL\n 25 mEq/L\n 4.3 mEq/L\n 9 mg/dL\n 111 mEq/L\n 145 mEq/L\n 26.5 %\n 6.1 K/uL\n [image002.jpg]\n 01:37 AM\n 05:32 AM\n 02:43 PM\n 03:03 PM\n 08:11 PM\n 02:51 AM\n 03:10 AM\n 03:08 PM\n 03:00 AM\n 03:36 AM\n WBC\n 11.1\n 9.4\n 11.3\n 7.3\n 6.1\n Hct\n 29.4\n 26.6\n 24.9\n 27.6\n 26.5\n Plt\n 89\n 209\n Cr\n 0.6\n 0.9\n 0.7\n 0.6\n TCO2\n 31\n 31\n 30\n 29\n 26\n Glucose\n 123\n 128\n 114\n 114\n 99\n Other labs: PT / PTT / INR:36.4/38.8/3.9, Ca++:8.9 mg/dL, Mg++:2.6\n mg/dL, PO4:4.1 mg/dL\n Cx: endotrach \n GN diplococci, budding yeast\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA, and\n ARDS, intubated since the end of now s/p trach and PEG\n placement.\n # Recent Aspiration of tube feeds. Given prolonged hospitalization and\n tenuous respiratory status will treat with antibiotics while cultures\n pending\n - Levoflox for 48 hours while waiting for sputum results.\n - restart tube feeds slowly\n - Follow cultures\n .\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation. S/P Trach\n and PEG on .\n - wean FiO2 as tolerated\n - attempt wean PS today and hopeful for trach mask trial\n # Sedation: Continue to have issues with pain/delirium causing\n tachycardia and hypertension with intermittent hypotension. On Haldol\n 5 TID, Fentanyl 75 mcg TP, Diazapam 10 QID; Haldol, midazolam and\n morphine PRN. Had good response to morphine, minimal response to\n haldol bolus.\n - Reduce diazepam to 5 q 8hrs.\n - d/c standing Haldol\n # Adrenal Insufficency: Hypotension that resolved with steroids,\n returned as they came off and is now improved again. Possible primary\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\n started on .\n - 10 q am and 5 q pm prednisone day 2 of 3, will wean to\n maintenance dose as tolerated, in consultation with endo.\n # Volume overloaded in setting of hypernatremia\n Goal even today.\n - Off diamox\n - electrolytes\n - Free water flushes with tube feeds.\n # Falling Hct: Likely dilutional. Concern given elevated INR. Stable\n today.\n - monitor\n - maintain active type and screen\n # RUE DVT: INR now therapeutic on coumadin. Goal \n - will start coumadin 2.5 mg QHS once INR < 3\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - Brace for OOB\n - report from full trauma series from OSH is in chart. No evidence of\n other fracture and no need for further spinal imaging based on this\n report and ortho note.\n # Tracheomalacia: Discussed with IP. Stenting unlikely to help for\n trachiomalacia as airways have poor structure diffusely.\n - Outpatient f/u once off pressure support to assess for possible\n stenting\n #. Thyroid Nodule on CT\n -outpatient follow up\n # Nutrition: Replete (Full)\n will reintroduce slowly\n - advance bowel regimen\n # Glycemic control: SSI, well controlled\n # Lines L PICC ().\n # Ppx: INR therapeutic, ranitidine, colace and senna, miralax,\n bisacodyl.\n # Communication:\n - Boyfriend of 10 \n - Brother is her HCP, also involved\n Code: Full\n Dispo: ICU, being screening for vent facilities\n ------ Protected Section ------\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 55F T5-8 fractures with retropulsion and ARDS\n from klebsiella VAP; on heparin for UE DVT and lasix for volume\n overload. Overnight transitioned to PSV and trial spont breathing\n performed. RR down to 4 terminated trial\n mode changed back to AC.\n On exam:\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.7\nC (98\n HR: 125 (74 - 151) bpm\n BP: 121/64(77) {89/32(45) - 179/99(120)} mmHg\n RR: 20 (13 - 30) insp/min\n SpO2: 100%\n Trached, lightly sedated, following commands.\n CV RRR, distantstant\n Lungs\n distant bs, otherwise clear\n abd: soft NTND BS+, +PEG site\n Ext- no c/c/e\n Data: WBC 6.1 hct 26.5 creat 0.6\n 55F h/o EtOH abuse presenting following mech fall -> traumatic T spine\n fracture with K. oxytoca PNA, and ARDS, intubated since the end of\n now s/p trach and PEG placement. Cont efforts to wean mech vent\n including spont breathing trials w/ monitoring given RR. Check ABG\n prior to d/c to assess adequacy of vent. Tracheomalacia\n indication for intervention per IP. Ortho following re: fx. Cont\n brace. Agree with recs as outlined above.\n ------ Protected Section Addendum Entered By: , MD\n on: 02:09 PM ------\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 636806,
"text": "55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\n with prolonged hospital course c/b by PNA with high PEEP requirement,\n anxiety, RUE DVT .\n Altered mental status (not Delirium)\n Assessment:\n Rec\nd pt restless, intermit following commands. MAEE with good\n strength. Pt shaking head\n when asked if has pain or SOB.\n Action:\n Torso brace applied\nwith difficulty\nand pt OOB to stretcher/chair with\n transfer via board.\n Response:\n Pt increasingly restless with HR 130-140ST, grimacing. Pt attempting to\n stand and/or exit chair. She dislodged her periph IV. Pt rec\n scheduled Valium 5mg po early, as well as Morphine Sulfate 2mg IVP\n without relief of discomfort. Pt returned to bed after 45mins. When\n brace removed, chin noted to be abraided from chin rest. Pt cont to be\n restless until approx 1600, freq attempting to sit up in bed. Soft\n wrist restraints in place for pt safety.\n Plan:\n Duoderm to chin or chin-rest when brace applied. Attempt OOB to chair\n again tomorrow, but meanwhile bed as chair intermit.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt on vent settings AC 50%/ 12 X 500/+5 with rare over-breathing\n of rate. O2 sat 100%. Lung snds with rhonchi in RUL, clear in LUL, and\n diminished bilat in bases. Pt requiring sxn\ning Q2-4hrs for mod amts\n yellow/white thick secretions. Pt also intermit with copious thick,\n clear oral secretions.\n Action:\n Vent changed to CPAP/PS 8/+5/50% with SRR 14-25 and regular, O2 sat\n remaining 98-100%. Pt then placed on trach mask @ 80% at 1230.\n Response:\n Pt has tolerated TM for several hrs, with RR remaining regular @\n 14-25/min, O2 sat generally 100%. However, desated to 70\ns X 2,\n returning to baseline after suctioning and ambu.\n Plan:\n Cont pt on TM as tol, monitoring for ? plugs requiring ambu/suctioning.\n"
},
{
"category": "Respiratory ",
"chartdate": "2167-10-12 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 637021,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 24\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason:\n Tube Type\n Tracheostomy tube:\n Type: Cuffed\n Manufacturer: Portex\n Size: 7.0mm\n PMV: No\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments: Lung sounds are rhonchi, but clear up after suction. Pt has\n consistent cough, but minimal secretions are sucitoned\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Pt has strong, consistent productive cough\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment: Frequent alarms (High pressure)\n Comments: Pt is always coughing, although minimal is suctioned out\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Periodic SBT's for conditioning, Increase ventilatory support at night\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Cannot protect airway, Cannot manage secretions;\n Comments: Pt is stable on current vent settings, switch to trachmask\n during the day, vent usage at night.\n BEDSIDE RSBI FAILED due to small tidal volumes\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 637228,
"text": "56 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\n with prolonged hospital course c/b by PNA, anxiety/altered mental\n status, RUE DVT .\n Tachycardia, Other\n Assessment:\n HR at rest and sleeping 120-130 , when awake pt is very restless and at\n times seems agitated also. When restless HR is 140-155 w/o ectopy.\n Pt shakes head no when asked if in pain. Attempted to reposition pt,\n but wiggles back to her back.\n Action:\n MD notified and valium PO continues. Morphine 2 mg IV given\n Response:\n No effect noted on HR after valium or morphine\n Plan:\n Will discuss in am rounds\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Pt has fungal rash noted under bil breasts\n Action:\n Nystatin powder to affected areas\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2167-09-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 635033,
"text": "Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n RUE edematous, warm, red\n Action:\n Heparin gtt WNL\n Response:\n No change\n Plan:\n Heparin off at 0600 for procedure\n Altered mental status (not Delirium)\n Assessment:\n Periods of agitation\n Action:\n Fentanyl and Versed Gtt, haldol and valium started. Fentanyl patch\n Response:\n Calm with increased sedation needed\n Plan:\n Monitor, continue with sedation as tolerates.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt desatted to 87%\n Action:\n Peep increased\n Response:\n O2 sat improved\n Plan:\n Team to attempt to replace aline or will draw am abg. AM RSBI\n Hypotension (not Shock)\n Assessment:\n Sbp 70\n Action:\n Sedation weaned, but pt agitated\n Response:\n Sbp > 90\n Plan:\n Maintain sbp > 90 with adequate sedation\n Bradycardia\n Assessment:\n HR 50\ns with increased sedation\n Action:\n Sedation weaned, but pt agitated\n Response:\n HR 70-130\ns, with increased sedation noted\n Plan:\n Maintain sedation, monitor hr\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 636645,
"text": "55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\n Now with prolonged hospital course c/b by PNA with high PEEP\n requirement, anxiety, RUE DVT .\n Altered mental status (not Delirium)\n Assessment:\n Pt more alert, following commands intermittently. Periods of agitation\n with HR rising to 130\n Action:\n Fentanyl patch in place. Valium RTC. MSO4 given x 1 for discomfort.\n Response:\n Pt with less episodes of agitation previously. ? steroid psychosis.\n Plan:\n Check cortisol level in am and wean hydrocortisone MD. Continue to\n reorient pt. MSO4 prn for discomfort.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on PSV 8/5/50%.RR 19-24. Tidal volumes 200-250. 02 sats\n variable 90-100%. LS rhoncherous to clear, diminished at bases.\n Action:\n Pt maintained at current settings given reduced tv\ns and sats. Orally\n suctioned q 2 hrs for copious secretions. Deep suctioned q 3-4 hrs for\n sm amt thick white secretions.\n Response:\n Resp status continues to improve. ABG 7.37/40/120/0/26\n Plan:\n Wean fio2 and peep as tolerated. Vigorous pulm hygiene.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt with RUE DVT. Heparin dcd on .\n Action:\n Coags being monitored. INR 4.4 yest. Hct waws falling.\n Response:\n Hct 26.5 today, previously 27.6.\n Plan:\n Coumadin to be started when INR < 3\n Hypernatremia (high sodium)\n Assessment:\n Na 140. Pt volume overloaded. LOS + ~10,000ccs.\n Action:\n Treated with 1 liter d5w iv.\n Response:\n Urine output 120-400ccs/hr via foley. TFB neg 100cc. Na 145. Goal ~\n even fluid balance.\n Plan:\n Continue to monitor f+e status.\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 636804,
"text": "Altered mental status (not Delirium)\n Assessment:\n Rec\nd pt restless, intermit following commands. MAEE with good\n strength. Pt shaking head\n when asked if has pain or SOB.\n Action:\n Torso brace applied\nwith difficulty\nand pt OOB to stretcher/chair with\n transfer via board.\n Response:\n Pt increasingly restless with HR 130-140ST, grimacing. Pt attempting to\n stand and/or exit chair. Pt rec\nd scheduled Valium 5mg po early, as\n well as Morphine Sulfate 2mg IVP without relief of discomfort. Pt\n returned to bed after 45mins. When brace removed, chin noted to be\n abraided from chin rest. Pt cont to be restless until approx 1600, freq\n attempting to sit up in bed. Soft wrist restraints in place for pt\n safety.\n Plan:\n Duoderm to chin or chin-rest when brace applied. Attempt OOB to chair\n again tomorrow, but meanwhile bed as chair intermit.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt on vent settings AC 50%/ 12 X 500/+5 with rare over-breathing\n of rate. O2 sat 100%. Lung snds with rhonchi in RUL, clear in LUL, and\n diminished bilat in bases. Pt requiring sxn\ning Q2-4hrs for mod amts\n yellow/white thick secretions. Pt also intermit with copious thick,\n clear oral secretions.\n Action:\n Vent changed to CPAP/PS 8/+5/50% with SRR 14-25 and regular, O2 sat\n remaining 98-100%. Pt then placed on trach mask @ 80% at 1230.\n Response:\n Pt has tolerated TM for several hrs, with RR remaining regular @\n 14-25/min, O2 sat generally 100%. However, desated to 70\ns X 2,\n returning to baseline after suctioning and ambu.\n Plan:\n Cont pt on TM as tol, monitoring for ? plugs requiring ambu/suctioning.\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 637026,
"text": "56 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\n with prolonged hospital course c/b by PNA, anxiety/altered mental\n status, RUE DVT .\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on PSV 10/5/50%. RR 20-30. )2 sat > 97%\n Action:\n Pt remained on PSV rather than AC overnight. Suctioned ~q 3-4 hrs for\n sm amt yellow bld-tinged secretions. Continues to have copious oral\n secretions\n removed with yankeur.\n Response:\n Tolerated PSV well, no tachypnea or desaturation.\n Plan:\n Attempt trach collar trial again in am. On-going pulm hygiene\n Hypotension (not Shock)\n Assessment:\n BP 90/40 with urine output falling to 10-15ccs/hr via foley. HR remains\n tachycardic (110-140ST) even when pt is not agitated or febrile.\n Action:\n Given 1 500cc d5\n ns fluid bolus\n Response:\n SBP > 90, Urine output improving to >30ccs/hr\n Plan:\n Continue to monitor hemodynamic status and f+e balance.\n Altered mental status (not Delirium)\n Assessment:\n Pt lethargic after receiving benedryl for several hrs but then awoke\n agitated, attempting to climb OOB and pull at trach despite restraints.\n Denies pain ( fentanyl patch in place) or need to go to the bathroom.\n c/o itchiness on back secondary to rash.\n Action:\n Medicated with iv benedryl.\n Response:\n Less agitated. Slept again\n Plan:\n Continue to reorient pt, benedryl for pruritis, safety precautions.\n Alteration in Nutrition\n Assessment:\n Pt with previous episodes of vomiting last eve. Kub showed no evidence\n of obstruction. Na 146\n Action:\n TF initiated with 50ccs free h20 boluses q 4hrs\n Response:\n No nausea or vomiting. No residuals.\n Plan:\n Advance TF as tolerated. ? increase free h20 boluses for hypernatremia.\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 637220,
"text": "Tachycardia, Other\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 637221,
"text": "Tachycardia, Other\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 637223,
"text": "56 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\n with prolonged hospital course c/b by PNA, anxiety/altered mental\n status, RUE DVT .\n Tachycardia, Other\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 637284,
"text": "56 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\n with prolonged hospital course c/b by PNA, anxiety/altered mental\n status, RUE DVT .\n Tachycardia, Other\n Assessment:\n HR at rest and sleeping 120-130 , when awake pt is very restless and at\n times seems agitated also. When restless HR is 140-155 w/o ectopy.\n Pt shakes head no when asked if in pain. Attempted to reposition pt,\n but wiggles back to her back.\n Action:\n MD notified and valium PO continues. Morphine 2 mg IV given\n Response:\n No effect noted on HR after valium or morphine\n Plan:\n Will discuss in am rounds\n Altered mental status (not Delirium)\n Assessment:\n Pt very restless at times and seems not to follow verbal commands at\n times. Pt will nod head appropriately when asked simple questions. Ie\n if she has pain\n Action:\n Pt continues to be reoriented to surrounding\n Response:\n Pt not following commands consistently and not able to use call light\n Plan:\n Continue to reorient\n Alteration in Nutrition\n Assessment:\n Abd distended , TF residuals >50cc and TF held at 6am. BS present, no\n BM\n Action:\n Will continue to assess\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Pt has fungal rash noted under bil breasts\n Action:\n Nystatin powder to affected areas\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2167-09-30 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 635174,
"text": "Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - START 02:00 PM - in right brachial atery\n Hypotensive- started on levophed, weaned off over night\n Low cortisol and failed stim test - started on steroids\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 08:06 AM\n Infusions:\n Heparin Sodium - 1,700 units/hour\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 150 mcg/hour\n Other ICU medications:\n Haloperidol (Haldol) - 12:15 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 36.7\nC (98\n HR: 63 (48 - 138) bpm\n BP: 91/41(58) {68/30(49) - 143/78(105)} mmHg\n RR: 18 (13 - 23) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Mixed Venous O2% Sat: 59 - 59\n Total In:\n 3,898 mL\n 1,155 mL\n PO:\n TF:\n 802 mL\n 348 mL\n IVF:\n 2,126 mL\n 247 mL\n Blood products:\n Total out:\n 2,367 mL\n 800 mL\n Urine:\n 2,367 mL\n 800 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,531 mL\n 355 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 401) mL\n RR (Set): 18\n RR (Spontaneous): 1\n PEEP: 10 cmH2O\n FiO2: 60%\n PIP: 23 cmH2O\n Plateau: 19 cmH2O\n Compliance: 57.1 cmH2O/mL\n SpO2: 91%\n ABG: 7.42/49/92./30/5\n Ve: 8.1 L/min\n PaO2 / FiO2: 155\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 355 K/uL\n 9.1 g/dL\n 168 mg/dL\n 0.5 mg/dL\n 30 mEq/L\n 3.9 mEq/L\n 11 mg/dL\n 108 mEq/L\n 146 mEq/L\n 29.9 %\n 11.8 K/uL\n [image002.jpg]\n 03:32 PM\n 10:19 PM\n 02:50 AM\n 02:30 PM\n 02:44 PM\n 03:33 PM\n 07:26 PM\n 07:46 PM\n 02:04 AM\n 02:18 AM\n WBC\n 9.0\n 8.4\n 11.8\n Hct\n 25.8\n 23.0\n 28.1\n 29.9\n Plt\n \n Cr\n 0.6\n 0.7\n 0.5\n TCO2\n 30\n 35\n 33\n 31\n 33\n Glucose\n 94\n 97\n 168\n Other labs: PT / PTT / INR:13.8/70.4/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:89.7 %, Lymph:8.7 %, Mono:1.1\n %, Eos:0.4 %, Lactic Acid:0.9 mmol/L, Albumin:2.4 g/dL, LDH:204 IU/L,\n Ca++:8.5 mg/dL, Mg++:2.2 mg/dL, PO4:5.4 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with respiratory failure\n and difficulty weaning from vent.\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation.\n Transferred here for tracheomalacia, but not sure this is a component.\n Will need bronch eval when improved\n - Thoracics will do trach and PEG once stable on PEEPs around 10. Had\n been planned for today but currently holding as PEEP is 15.\n - wean PEEP as tolerated\n - needs A-line\n # Volume overload\n Currently with hypernatremia, Cr increase, contract\n alk, but mild\n - continue gentle diuresis with goal -1L per day as tolerated by blood\n pressure. IV lasix drip at 1-5 mg/hr.\n - FW in TF at 150 cc q4hrs\n - PM lytes.\n # Sedation: Now well seadated on Versed 1.5, Fentanyl 175, Fentanyl\n patch, Diazepam standing and haldo 2.5-5 mg PRN. QTc stable at .44\n - Wean versed/fentanyl as tolerated\n # HCT\n Has had slow decline while in ICU.\n - Xfuse PRN Hct < 21\n - continue to follow, guiac stools\n # Hypotension: Related to sedation, but high PEEP, adrenial\n insufficiency, sepsis have previously been contributing.\n - needs A-line for monitoring\n - cortisol stim to rule out persistent adrenal insufficiency\n # RUE DVT: Started on heparin gtt on , now off for trach that was\n planned for today. Follow PTTs. Would hold off on coumadin at least\n until s/p trach.\n - restart heparin\n # Adrenal Insufficency: Random cortisol was approx 3 when it should\n have been maximally stimulated. S/P 5 days of hydrocortisone and\n florinef.\n - will recheck as above and start at 50 q8 if needed\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n # FEN/GI: Tube feeds @ goal. No need to be NPO while awaiting stable\n PEEP\n DVT: Treatment dose heparin\n Ulcer: Ranitidine\n VAP: Prevention per routine\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 09:51 PM 60 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Arterial Line - 02:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Respiratory ",
"chartdate": "2167-10-07 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 636226,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 19\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Not applicable\n Size: Not applicable\n Tracheostomy tube:\n Type: Cuffed, Extra Length\n Manufacturer: Portex\n Size: 7.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-09 00:00:00.000",
"description": "Generic Note",
"row_id": 636471,
"text": "TITLE:\n Alteration in Nutrition\n Assessment:\n Obtained large feed like secretions orally. ? aspiration Abd\n dist, soft with hypoactive BS. No BM on this shift. Pt\ns head needs to\n be lowered down as BP is Low.\n Action:\n TF held .\n Response:\n Continues to have thick secretions like the color of the feeds mixed\n with saliva. By MD .\n Plan:\n Hold feeds till am rounds. Intern Discussed about a dye test. No plans\n at present to do the dye study to determine aspiration.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received Pt on vent via trach in CPAP+PS at 50 %/. LS finely\n coarse with diminished bases.. RR 28 to 30/min sats intermittently down\n to 91 %.\n Action:\n Suctioned fro small amts of tan thick mildly blood tinged sputum. Vent\n Mode changed to AC TV 400, RR 10, peep 8 for the night as per\n discussion By Resident & MD to rest for the night.\n Response:\n Sats maintained in Mid 90\ns to high 90\ns. ABG done in am PH\n 7.35/50/81/29/ Sats 96. Set RR ^ to 12 post abg\n Plan:\n Wean vent settings as tolerated. Plan to IP to follow up regarding ?\n need for stent tomorrow.\n Altered mental status (not Delirium)\n Assessment:\n Pt opens eyes to voice, but will only follow simple commands very\n inconsistently. Pt is very lethargic. Pt found this am to be very\n restless and given versed with no effect.\n Action:\n After pt placed in a chair, and pt more relaxed. Pt was calm, but her\n HR was in the 120-130\ns (while awake). Pt given Morphine with good\n effect. Fentanyl patches weaned down to 100 mcg.\n Response:\n Plan:\n Continue to eval restlessness.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt was on heparin gtt for clot to Rt upper arm. Inr 2.1 . No signs of\n any bleeding.\n Action:\n Heparin was dc\nd this am,\n Response:\n Plan:\n ? coumadin tonight. Continue to eval for bleeding.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Temp up to 101.4. Axillary at hrs\n Action:\n Tylenol 650 mgs given, Pan cultured, started on vanco, aztreonam &\n Levofloxacin.\n Response:\n Temp down to 97.5 axillary.\n Plan:\n Continue monitoring temp, continue anbx, follow up on cultures.\n Alteration in Nutrition\n Assessment:\n Oral secretions large feedlike. Pt\ns head needs to be lowered down as\n BP was Low.\n Action:\n Feeds held . by MD. as BP improved.\n Response:\n Continues to have small amts of the same color mixed with saliva .\n Plan:\n Anemia, other\n Assessment:\n HCT down to\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-15 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 637663,
"text": "Chief Complaint:\n 24 Hour Events:\n ULTRASOUND - At 03:48 PM\n US of Lt arm to R/O DVT. Shows small , nonobstructing clot in axillary\n vein of LEFT arm\n CTA- neg for PE, though study limited by movement artifact\n Coumadin increased to 5mg last night\n Episode of emesis w/ tube gastric contents/ TFs extruding from\n tracheostomy site, around tube. TFs held.\n L PICC line left in place until AM.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Ceftriaxone - 10:00 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 36.3\nC (97.3\n HR: 135 (123 - 146) bpm\n BP: 141/65(82) {106/41(56) - 185/128(142)} mmHg\n RR: 19 (11 - 32) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,888 mL\n 360 mL\n PO:\n TF:\n 1,268 mL\n IVF:\n 100 mL\n Blood products:\n Total out:\n 1,530 mL\n 240 mL\n Urine:\n 1,510 mL\n 240 mL\n NG:\n 20 mL\n Stool:\n Drains:\n Balance:\n 358 mL\n 120 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 227 (227 - 397) mL\n PS : 8 cmH2O\n RR (Spontaneous): 20\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 194\n PIP: 16 cmH2O\n SpO2: 96%\n ABG: ////\n Ve: 6.5 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 306 K/uL\n 8.8 g/dL\n 134 mg/dL\n 0.6 mg/dL\n 32 mEq/L\n 4.0 mEq/L\n 11 mg/dL\n 106 mEq/L\n 146 mEq/L\n 26.8 %\n 7.5 K/uL\n [image002.jpg]\n 03:10 AM\n 03:08 PM\n 03:00 AM\n 03:36 AM\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n 05:00 AM\n 02:06 AM\n WBC\n 11.3\n 7.3\n 6.1\n 7.2\n 5.2\n 5.9\n 7.5\n Hct\n 24.9\n 27.6\n 26.5\n 26.9\n 26.0\n 27.2\n 26.8\n Plt\n 227\n 189\n 209\n 238\n 240\n 296\n 306\n Cr\n 0.7\n 0.6\n 0.6\n 0.9\n 0.7\n 0.6\n 0.7\n 0.6\n TCO2\n 26\n Glucose\n 114\n 99\n 115\n 106\n 100\n 134\n 134\n Other labs: PT / PTT / INR:15.5/24.8/1.4, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:27/19, Alk Phos / T Bili:118/0.3,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:243 IU/L, Ca++:9.2 mg/dL, Mg++:2.1 mg/dL, PO4:4.0\n mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-15 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 637665,
"text": "Chief Complaint:\n 24 Hour Events:\n ULTRASOUND - At 03:48 PM\n US of Lt arm to R/O DVT. Shows small , nonobstructing clot in axillary\n vein of LEFT arm\n CTA- neg for PE, though study limited by movement artifact\n Coumadin increased to 5mg last night\n Episode of emesis w/ tube gastric contents/ TFs extruding from\n tracheostomy site, around tube. TFs held.\n L PICC line left in place until AM.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Ceftriaxone - 10:00 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 36.3\nC (97.3\n HR: 135 (123 - 146) bpm\n BP: 141/65(82) {106/41(56) - 185/128(142)} mmHg\n RR: 19 (11 - 32) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,888 mL\n 360 mL\n PO:\n TF:\n 1,268 mL\n IVF:\n 100 mL\n Blood products:\n Total out:\n 1,530 mL\n 240 mL\n Urine:\n 1,510 mL\n 240 mL\n NG:\n 20 mL\n Stool:\n Drains:\n Balance:\n 358 mL\n 120 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 227 (227 - 397) mL\n PS : 8 cmH2O\n RR (Spontaneous): 20\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 194\n PIP: 16 cmH2O\n SpO2: 96%\n ABG: ////\n Ve: 6.5 L/min\n Physical Examination\n GEN: Awake, alert, responsive. Sitting in chair, in back brace.\n Following commands.\n HEENT: PERRL\n PULM: CTA anteriorly, no r/r/w\n CARD: tachycardic, regular, ,s1, s2,\n ABD: abdomen, inferior to brace, soft, nontender\n EXT: DP 2+\n NEURO: able to move all extremeties, strength 5/5 upper and lower, R\n hip < L hip.\n Labs / Radiology\n 306 K/uL\n 8.8 g/dL\n 134 mg/dL\n 0.6 mg/dL\n 32 mEq/L\n 4.0 mEq/L\n 11 mg/dL\n 106 mEq/L\n 146 mEq/L\n 26.8 %\n 7.5 K/uL\n [image002.jpg]\n 03:10 AM\n 03:08 PM\n 03:00 AM\n 03:36 AM\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n 05:00 AM\n 02:06 AM\n WBC\n 11.3\n 7.3\n 6.1\n 7.2\n 5.2\n 5.9\n 7.5\n Hct\n 24.9\n 27.6\n 26.5\n 26.9\n 26.0\n 27.2\n 26.8\n Plt\n 227\n 189\n 209\n 238\n 240\n 296\n 306\n Cr\n 0.7\n 0.6\n 0.6\n 0.9\n 0.7\n 0.6\n 0.7\n 0.6\n TCO2\n 26\n Glucose\n 114\n 99\n 115\n 106\n 100\n 134\n 134\n Other labs: PT / PTT / INR:15.5/24.8/1.4, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:27/19, Alk Phos / T Bili:118/0.3,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:243 IU/L, Ca++:9.2 mg/dL, Mg++:2.1 mg/dL, PO4:4.0\n mg/dL\n Assessment and Plan\n 55yoF with history of EtOH abuse presenting following mechanical fall\n and traumatic T spine fracture, now s/p trach, PEG, placement being\n treated for HAP.\n# HAP vs Aspiration PNA: Cultures grew, Klebsiella Oxytoca, Klebsiella Pneumonia\ne, GNR, GP Cocci. Will continue to treat for potential HAP for 8 days.Pt continu\ning to have some fevers, last night 100.8, and new sputum on today w/ gram stain\n showing GPC p/c. New VAP/HAP w/ staph possible, but given no clear infiltrate o\nn CXR and good respiratory status, significant PNA is unlikely, colonization of\ntrach is possible, as is contamination of sputum. Given improving clinical \n, wait until CX data or change in clinical status or CXR to initiate HAP\n/VAP treatment.\n - Continue Ceftriaxone HAP (Day #6 of 8)\n - Continue to f/u cultures\n .\n # Respiratory failure: Improving status. Will continue to increase\n time on trach mask as tolerated.\n - PMV with suctioning.\n - Weaning FiO2 as tolerated\n # Tachycardia: Pt in ST 120\ns to 150s. Etiology remains unclear and\n etiologies include hypovolemia, pain, infection (pt with known\n klebsiella), . DDx also includes PE given hx of RUE DVT, mucus\n plugging given large amount of secretions, and spinal injury.\n - Treating underlying infection\n - Restarting patients Coumadin, last INR 1.2 yesterday, not\n therapeutic, will recheck this PM\n - TSH 2.4 on early , will check free T3, T4.\n - Continue Pain Control\n - Assess for PE w/ CTPA and UE u/s\n # Sedation: Pt has pain/delirium causing tachycardia and hypertension\n with intermittent hypotension. Had good response to morphine, minimal\n response to haldol bolus.\n - Haldol 5 PRN, Fentanyl 75 mcg TP, Diazapam 5 QID;\n - tolerating current regimen well, will continue to wean\n # Adrenal Insufficency: Followed up with endocrine that suggested if\n the patient under goes major stressors such as major surgery, sepsis,\n she may need stress dosed steroids.\n - Will consider MRI at later date for evaluation of pituitary\n # Fluid Status: Volume overloaded in prior setting of Hypernatremia\n Goal even today.\n - Monitoring urine output\n - increasse Free H20, for mild hypernatremia\n # RUE DVT: restarted Coumadin for INR 1.2, will follow INR carefully,\n given Abx.\n - Check INR this PM\n # Spine fracture: Stable\n - Brace for OOB, will discuss with Neurosurgery if current brace is\n optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n # Tracheomalacia?: Discussed with IP.\n - Outpatient f/u once off pressure support to assess for possible\n stenting\n #. Thyroid Nodule on CT\n - Outpatient follow up\n # Nutrition: TFs with goal of 60\n # Glycemic control: SSI, well controlled\n # Lines L PICC\n ().\n # Ppx: Restarting Coumadin, Ranitidine, Bowel Regimen\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n # Code: Full\n # Dispo: ICU, Screening for vent facilities\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 637796,
"text": "Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Left hand to elbow area with edema 2mm\nknown DVT to left axillary vein;\n US of right arm\n Action:\n DL PICC d/c\nd; left arm elevated on pillow; US results pnd for right\n arm\n Response:\n PIV placed for access issues to right arm; edema unchanged;\n Plan:\n Cont to monitor left arm status; no BP/blood draws left arm. NIBP cuff\n to right calf. F/U w/ team Re: right arm status\n Hypernatremia (high sodium)\n Assessment:\n hypernatremic\n Action:\n Free water boluses cont; bloused with D5W/500cc\n Response:\n Remains hypernatremic with min improvement\n Plan:\n Cont with free water boluses; check labs am\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Restless, anxious am\n Action:\n Trach collar placed 70% early am--\n Response:\n Brief episode of desaturation to mid 80\ns requiring increase of Fi02 to\n 100% briefly (approx 20min); placed on 70% remainder of shift with\n adequate o2 sats in low 90\n Plan:\n Passer muir valve for brief periods of time with direct supervision by\n nsg or resp as tolerated by patient; keep on trach collar thru night\n and try to avoid PSV; nebs changed to prn status for ?partial cause for\n tachycardia\n Tachycardia, Other\n Assessment:\n Tachy to 130-140\ns continuous while awake; continuous tachy in 120\n while sound asleep\n Action:\n Standing valium decreased; cont with fent patch; morphine and haldol\n prn\n Response:\n No significant change in level of restlessness/anxiety; freq pulling at\n any objects/lines with short term memory issues; no significant\n response to IV morphine; was able to obtain some sleep after 2mg haldol\n ivp\n Plan:\n Cont to closely monitor mental status; maintain safety w/use of\n restraints, soft wrist restraints and bed alarm. Assess degree of\n change with titration of meds\n"
},
{
"category": "Social Work",
"chartdate": "2167-10-07 00:00:00.000",
"description": "Social Work Progress Note",
"row_id": 636222,
"text": "Social Work:\n Received phone call from pt\ns brother, (c: ).\n He is back at his home in but reports he has been in touch by\n phone with MICU daily for updates and any issues re consent for\n procedures. As previously mentioned, brother is pt\ns legal and\n therefore the primary person to give consent when pt is unable to speak\n for herself re her healthcare wishes. Per brother and pt\ns long-time\n boyfriend, (h: ), pt has not completed a HCP\n form. However, per pt\ns wishes (verbally expressed to MICU team at\n beginning of her admission), boyfriend should also be consulted, if\n possible, re plan of care. In prior discussion with brother and\n boyfriend, both are in agreement with this and seem to have been\n communicating well with each other and with MICU team. Confirmed this\n with brother again today.\n Brother states he is planning on flying in from this Saturday\n () to visit pt in hospital and meet with MICU team. He plans to be\n here from about noon\n 3:00 p.m. before flying back home.\n Brother asks about pt\ns long-term prognosis with regards to how long\n she might not be able to speak for herself or attend to her financial\n matters. Brother is concerned about how pt will pay her bills (i.e.\n new car payments and car insurance, etc.). Discussed with him that\n physicians at hospital can write letter as needed to state that pt is\n unable to attend to her financial matters at this time and that this\n often suffices for a temporary period. Brother understands that\n boyfriend is already assisting with this and has been in touch with a\n lawyer for help around this issue as well. Brother also states he is\n able to pay pt\ns bills temporarily. However, his main concern seems to\n be how long pt might be in this\nlimbo\n place and what her longer-term\n prognosis is. He is wondering if it makes sense to pursue\n conservatorship or guardianship for pt at this time. SW discussed with\n MICU team who report more information re pt\ns prognosis may be\n available in the next few days, and this can be shared with pt\n brother during his meeting with MICU team on Saturday.\n SW discussed with RNCM who will begin to screen pt for rehab facilities\n as appropriate. While brother will remain primary point of contact\n during this process, encouraged him to remain in good communication\n with pt\ns boyfriend around dispo planning issues as well. He clearly\n states his intention to do so. Attempted to call pt\ns boyfriend to\n discuss as well, but was unable to reach him by phone.\n SW will remain available to pt/family for continued emotional support\n and for facilitation re communication with team as needed. Please page\n with any questions or concerns.\n , LCSW, #\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 637793,
"text": "Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Left hand to elbow area with edema 2mm\nknown DVT to left axillary vein;\n US of right arm\n Action:\n DL PICC d/c\nd; left arm elevated on pillow; US results pnd for right\n arm\n Response:\n PIV placed for access issues to right arm; edema unchanged;\n Plan:\n Cont to monitor left arm status; no BP/blood draws left arm. NIBP cuff\n to right calf. F/U w/ team Re: right arm status\n Hypernatremia (high sodium)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Restless, anxious am\n Action:\n Trach collar placed 70% early am--\n Response:\n Brief episode of desaturation to mid 80\ns requiring increase of Fi02 to\n 100% briefly (approx 20min); placed on 70% remainder of shift with\n adequate o2 sats in low 90\n Plan:\n Passer muir valve for brief periods of time with direct supervision by\n nsg or resp as tolerated by patient; keep on trach collar thru night\n and try to avoid PSV; nebs changed to prn status for ?partial cause for\n tachycardia\n Tachycardia, Other\n Assessment:\n Tachy to 130-140\ns continuous while awake; continuous tachy in 120\n while sound asleep\n Action:\n Standing valium decreased; cont with fent patch; morphine and haldol\n prn\n Response:\n No significant change in level of restlessness/anxiety; freq pulling at\n any objects/lines with short term memory issues; no significant\n response to IV morphine; was able to obtain some sleep after 2mg haldol\n ivp\n Plan:\n Cont to closely monitor mental status; maintain safety w/use of\n restraints, soft wrist restraints and bed alarm. Assess degree of\n change with titration of meds\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 637897,
"text": "56 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\n with prolonged hospital course c/b by PNA, anxiety/altered mental\n status, RUE DVT .Pt found to have small non occlusive Clot on her right\n axial vein via Ultrasound.Yesterday Pt went down to IR for Peg revision\n aspiration riskcouldn\nt do it,due the type of peg she has now.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt has known DVT to left axillary vein; US of right arm showed no\n clots.\n Action:\n DL PICC d/c\nd; from left arm and elevated on pillow and received\n Coumadin scheduled dose.\n Response:\n PIV placed for access issues to right arm; edema looks better;\n Plan:\n Cont to monitor left arm status; no BP/blood draws left arm PICC line\n to right arm?.\n Hypernatremia (high sodium)\n Assessment:\n Hypernatremic NA was 146 yesterday evening.\n Action:\n Started on D5 W at 100cc/hr for 1000cc,held free wqater bolus \n aspiration..\n Response:\n Awaiting for AM lab report.\n Plan:\n Cont with D5W,follow up with AM lab,resume Free water bolus via PEG\n tube?.\n Tachycardia, Other\n Assessment:\n Tachy to 130-140\ns continuous while awake; HR stayed 90- 120 sound\n asleep\n Action:\n Standing valium decreased; cont with fent patch; morphine and haldol\n prn.Bilateral restraints on\n Response:\n No significant change in level of restlessness/anxiety; freq pulling at\n any objects/lines with short term memory issues. She keeps\n disconnecting from vent,desat to low 80s within seconds.\n Plan:\n Cont to closely monitor mental status; maintain safety w/use of\n restraints, soft wrist restraints and bed alarm. PRN Haldol or\n Morphine.\n Altered mental status (not Delirium)\n Assessment:\n Pt has been slept most of the time,hard to wake up.responded to deep\n stimuli.\n Action:\n Held Scheduled dose of valium at 2200.Pt has Fentanyl 75 mcg patch on\n her lleft thigh.\n Response:\n Pt start waking up around 0300,got disconnected from vent by\n herself,given valium 2.5 mg at 0315.\n Plan:\n Continue to eval MS,Valium and PRN Morphine and haldol?,cont reorient\n and emotional support to pt .\n"
},
{
"category": "Respiratory ",
"chartdate": "2167-10-17 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 638138,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 29\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type:\n Manufacturer: Portex\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Unassisted spontaneous breathing\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Increase ventilatory support at night\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Maintained on Trach Collar all day, plan to stay on TC as tolerated\n overnoc\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-17 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 638116,
"text": "Chief Complaint: respiratory distress\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n episode of SVT -- beta blocker begun\n valium decreased, haldol d/c'd, zyprexa started\n c collar removed\n History obtained from Medical records, ICU team\n Patient unable to provide history: Encephalopathy\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Ceftriaxone - 10:00 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:11 AM\n Other medications:\n , , docusate, senna, SQI, thiamine, folate, warfarin,\n lopressor, valium, reglan\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:37 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 36.4\nC (97.5\n HR: 131 (119 - 149) bpm\n BP: 118/95(99) {99/28(50) - 185/99(144)} mmHg\n RR: 28 (11 - 31) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,408 mL\n 370 mL\n PO:\n 50 mL\n TF:\n IVF:\n 2,358 mL\n 210 mL\n Blood products:\n Total out:\n 1,795 mL\n 1,445 mL\n Urine:\n 1,795 mL\n 1,445 mL\n NG:\n Stool:\n Drains:\n Balance:\n 613 mL\n -1,075 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 415 (244 - 415) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 70%\n RSBI Deferred: No Spon Resp\n PIP: 22 cmH2O\n Plateau: 17 cmH2O\n SpO2: 99%\n ABG: ///38/\n Ve: 5.5 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 9.0 g/dL\n 462 K/uL\n 137 mg/dL\n 0.6 mg/dL\n 38 mEq/L\n 3.9 mEq/L\n 5 mg/dL\n 101 mEq/L\n 146 mEq/L\n 28.9 %\n 7.1 K/uL\n [image002.jpg]\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n 05:00 AM\n 02:06 AM\n 07:34 AM\n 03:50 AM\n 06:22 AM\n 02:58 AM\n WBC\n 7.2\n 5.2\n 5.9\n 7.5\n 5.6\n 6.1\n 7.0\n 7.1\n Hct\n 26.9\n 26.0\n 27.2\n 26.8\n 27.0\n 27.0\n 29.7\n 28.9\n Plt\n 238\n 240\n 296\n \n 395\n 462\n Cr\n 0.6\n 0.9\n 0.7\n 0.6\n 0.7\n 0.6\n 0.5\n 0.7\n 0.7\n 0.6\n Glucose\n 115\n 106\n 100\n 134\n 134\n 121\n \n Other labs: PT / PTT / INR:36.6/30.0/3.9, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:9.8 mg/dL, Mg++:2.2 mg/dL, PO4:3.3\n mg/dL\n Assessment and Plan\n 1. Resp Failure: currently on trach mask, can do sevreal hours per\n day and increasing each day, then needs for support QHS. Completed\n Rx for pan Klebs PNA. Per IP not stent planned as technically\n not possible to place into her airway\n 2. Hemodynamics: persistant simus tachy but also has runs of SVT-\n will add low dose bblocker today\n watch MAPs at night as\n she tends to run low. Anticoagulated.\n 3. New L Ext DVT: PICC out, on coumadin\n 4. Emesis: start Reglan, watch qt and restart low dose tf tonight-\n discuss with TSurg role of J prior to hospital d/c\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 08:39 AM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Coumadin)\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent:\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-17 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 638119,
"text": "Chief Complaint:\n 24 Hour Events:\n Pt continued on B-Blocker for prior runs of SVT, HR peaked in 135\n Olanzapine 5mg QHS, Haldol d/c\nd, diazepam decreased\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Ceftriaxone - 10:00 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history: None\n Review of systems is unchanged from admission except as noted below\n Review of systems: Pt denies pain in chest, abdomen. Pt unable to\n further communicate,\n Flowsheet Data as of 08:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 36.4\nC (97.5\n HR: 131 (119 - 149) bpm\n BP: 111/53(67) {99/28(50) - 185/99(144)} mmHg\n RR: 11 (11 - 30) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,408 mL\n 200 mL\n PO:\n 50 mL\n TF:\n IVF:\n 2,358 mL\n 200 mL\n Blood products:\n Total out:\n 1,795 mL\n 1,320 mL\n Urine:\n 1,795 mL\n 1,320 mL\n NG:\n Stool:\n Drains:\n Balance:\n 613 mL\n -1,120 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: MMV/PSV/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 415 (244 - 415) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 22 cmH2O\n Plateau: 17 cmH2O\n SpO2: 98%\n ABG: ///38/\n Ve: 5.5 L/min\n Physical Examination\n Gen: NAD, A0X3\n HEENT: PERRLA, EOMI\n Resp: Limited by patients mobility, but CTA anteriorly\n Card: S1S2 tachy\n Abd: Soft, Non-tender, Non-distended, BS+\n Exte: No edema\n Labs / Radiology\n 462 K/uL\n 9.0 g/dL\n 137 mg/dL\n 0.6 mg/dL\n 38 mEq/L\n 3.9 mEq/L\n 5 mg/dL\n 101 mEq/L\n 146 mEq/L\n 28.9 %\n 7.1 K/uL\n [image002.jpg]\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n 05:00 AM\n 02:06 AM\n 07:34 AM\n 03:50 AM\n 06:22 AM\n 02:58 AM\n WBC\n 7.2\n 5.2\n 5.9\n 7.5\n 5.6\n 6.1\n 7.0\n 7.1\n Hct\n 26.9\n 26.0\n 27.2\n 26.8\n 27.0\n 27.0\n 29.7\n 28.9\n Plt\n 238\n 240\n 296\n \n 395\n 462\n Cr\n 0.6\n 0.9\n 0.7\n 0.6\n 0.7\n 0.6\n 0.5\n 0.7\n 0.7\n 0.6\n Glucose\n 115\n 106\n 100\n 134\n 134\n 121\n \n Other labs: PT / PTT / INR:36.6/30.0/3.9, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:9.8 mg/dL, Mg++:2.2 mg/dL, PO4:3.3\n mg/dL\n Assessment and Plan\n 55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach, PEG, placement no with respiratory failure secondary to\n tracheomalacia , resolving HAP.\n .\n # Respiratory failure: Slowly Improving. Pressure support of at\n night.\n - Continue to increase time on trach mask as tolerated.\n - PMV with suctioning.\n .\n # HAP vs Aspiration PNA: Afebrile without leukocytosis\n - Completed course of ceftriaxone\n - Continue to f/u cultures\n - Continue trach mask as tolerated\n .\n # Tachycardia: Sinus Tach with occasional runs of SVT, now on low dose\n b-blocker. . HR decreased overnight with ranges of 115-135. From\n yesterday when pt found had runs of SVT as well as ST 120\ns to 150s.\n SBPs approx 65.\n Had Negative CTA, thyroid fxn WNL,\n - HR became tachy on , will further investigate events surrounding\n the event for further data\n - cont metoprolol 12.5mg TID and up titrate as tolerated\n - monitor on telemetry\n - Continue Pain Control\n .\n # Sedation: Inconsistent response to sedation, unclear what is best\n regime. Will continue to wean overall\n - Started on Olanzapine QHS\n - DC\nd haldol and taper valium to 2.5 mg PRN TID, taper off\n # Nutrition: Pt had emesis overnight. TFs currently held. Given\n Reglan.\n - Restart Nutrition as tolerated\n .\n # Adrenal Insufficency: Endocrine following. Followed Suggesting if\n the patient under goes major stressors such as major surgery, sepsis,\n she may need stress dosed steroids.\n - Endocrine s/o\n no need for steroids currently\n .\n # Fluid Status: Volume overloaded in prior setting of Hypernatremia\n - Monitoring urine output\n - increase Free H20, for mild hypernatremia 200cc Free bolus PEG, and\n - 500cc D5W at 125.\n - PM lytes to assess hypernatremia\n .\n # UE DVT: right has resolved, new non occlusive in left axillary. INR\n supratherapeutic today\n - decrease coumadin to home dose of 2.5mg\n - follow INR\n .\n # Spine fracture: Stable\n - Brace for OOB, will discuss with Neurosurgery if current brace is\n optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n .\n # Tracheomalacia. Was initially addressed with IP and they wanted to\n follow up as outpatient.\n - Consult IP for stent placement given improved clinical status, will\n readdresses\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # PIV x 1\n # Ppx: Coumadin, Ranitidine, Bowel Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n # Code: Full\n # Dispo: ICU, Screening for vent facilities\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:10 AM\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-17 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 638123,
"text": "Chief Complaint: respiratory distress\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n episode of SVT -- beta blocker begun\n valium decreased, haldol d/c'd, zyprexa started\n c collar removed\n History obtained from Medical records, ICU team\n Patient unable to provide history: Encephalopathy\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Ceftriaxone - 10:00 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:11 AM\n Other medications:\n , , docusate, senna, SQI, thiamine, folate, warfarin,\n lopressor, valium, reglan\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:37 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 36.4\nC (97.5\n HR: 131 (119 - 149) bpm\n BP: 118/95(99) {99/28(50) - 185/99(144)} mmHg\n RR: 28 (11 - 31) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,408 mL\n 370 mL\n PO:\n 50 mL\n TF:\n IVF:\n 2,358 mL\n 210 mL\n Blood products:\n Total out:\n 1,795 mL\n 1,445 mL\n Urine:\n 1,795 mL\n 1,445 mL\n NG:\n Stool:\n Drains:\n Balance:\n 613 mL\n -1,075 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 415 (244 - 415) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 70%\n RSBI Deferred: No Spon Resp\n PIP: 22 cmH2O\n Plateau: 17 cmH2O\n SpO2: 99%\n ABG: ///38/\n Ve: 5.5 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 9.0 g/dL\n 462 K/uL\n 137 mg/dL\n 0.6 mg/dL\n 38 mEq/L\n 3.9 mEq/L\n 5 mg/dL\n 101 mEq/L\n 146 mEq/L\n 28.9 %\n 7.1 K/uL\n [image002.jpg]\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n 05:00 AM\n 02:06 AM\n 07:34 AM\n 03:50 AM\n 06:22 AM\n 02:58 AM\n WBC\n 7.2\n 5.2\n 5.9\n 7.5\n 5.6\n 6.1\n 7.0\n 7.1\n Hct\n 26.9\n 26.0\n 27.2\n 26.8\n 27.0\n 27.0\n 29.7\n 28.9\n Plt\n 238\n 240\n 296\n \n 395\n 462\n Cr\n 0.6\n 0.9\n 0.7\n 0.6\n 0.7\n 0.6\n 0.5\n 0.7\n 0.7\n 0.6\n Glucose\n 115\n 106\n 100\n 134\n 134\n 121\n \n Other labs: PT / PTT / INR:36.6/30.0/3.9, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:9.8 mg/dL, Mg++:2.2 mg/dL, PO4:3.3\n mg/dL\n Assessment and Plan\n Resp Failure\n Trach mask trials as tolerating (needing QHS support at\n present)\n S/P rx for pan Klebs PNA.\n Per IP not stent planned as technically not possible to\n place into her airway\n Tachycardia\n Extensive evaluation. Will test whether BZD or opiate withdrawal might\n be playing a role. Review hx of medication additions that might\n contribute. Otherwise, will continue beta blocker.\n DVT\n On warfarin\n Emesis\n Getting raglan trial. Restart TF\n Hypernatremia\n Replete free water.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 08:39 AM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Coumadin)\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition :ICU. Screen for rehab.\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-09 00:00:00.000",
"description": "Generic Note",
"row_id": 636465,
"text": "TITLE:\n Alteration in Nutrition\n Assessment:\n Abd dist, soft with hypoactive BS. No BM on this shift.\n Action:\n TF restarted at goal at 60 cc/hr with minimal residuals.\n Response:\n Plan:\n Follow FSBS. ? adding more laxatives until BM.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains on vent via trach in CPAP+PS at 50 %/. LS CTA with\n diminished bases. Pt has been deep sx\nd for sml amounts of tan to thick\n yellow secretions.\n Action:\n Vent changed to 5/5, but was only tolerated for 1 hr.\n Response:\n After 1 hr pt became tachycardic and tachypnic. O2sat decreased to 95%.\n Plan:\n Continue to wean vent settings as tolerated. Plan to IP to follow up\n regarding ? need for stent tomorrow.\n Altered mental status (not Delirium)\n Assessment:\n Pt opens eyes to voice, but will only follow simple commands very\n inconsistently. Pt is very lethargic. Pt found this am to be very\n restless and given versed with no effect.\n Action:\n After pt placed in a chair, and pt more relaxed. Pt was calm, but her\n HR was in the 120-130\ns (while awake). Pt given Morphine with good\n effect. Fentanyl patches weaned down to 100 mcg.\n Response:\n Plan:\n Continue to eval restlessness.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt was on heparin gtt for clot to Rt upper arm. Inr 2.1 . No signs of\n any bleeding.\n Action:\n Heparin was dc\nd this am.\n Response:\n Plan:\n ? coumadin tonight. Continue to eval for bleeding.\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 637889,
"text": "Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Left hand to elbow area with edema 2mm\nknown DVT to left axillary vein;\n US of right arm\n Action:\n DL PICC d/c\nd; left arm elevated on pillow; US results pnd for right\n arm\n Response:\n PIV placed for access issues to right arm; edema unchanged;\n Plan:\n Cont to monitor left arm status; no BP/blood draws left arm. NIBP cuff\n to right calf. F/U w/ team Re: right arm status\n Hypernatremia (high sodium)\n Assessment:\n Hypernatremic NA was 146 yesterday evening.\n Action:\n Started on D5 W at 100cc/hr for 1000cc.\n Response:\n Awaiting for AM lab report.\n Plan:\n Cont with D5W,follow up with AM lab,resume Free water bolus via PEG\n tube\n Tachycardia, Other\n Assessment:\n Tachy to 130-140\ns continuous while awake; Hr stayed 90- 120 sound\n asleep\n Action:\n Standing valium decreased; cont with fent patch; morphine and haldol\n prn.Bilateral restraints on\n Response:\n No significant change in level of restlessness/anxiety; freq pulling at\n any objects/lines with short term memory issues. She keeps\n disconnecting from vent,desat to low 80s within seconds.\n Plan:\n Cont to closely monitor mental status; maintain safety w/use of\n restraints, soft wrist restraints and bed alarm. PRN Haldol or\n Morphine.\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 637893,
"text": "Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt has known DVT to left axillary vein; US of right arm showed no\n clots.\n Action:\n DL PICC d/c\nd; from left arm and elevated on pillow and received\n Coumadin scheduled dose.\n Response:\n PIV placed for access issues to right arm; edema looks better;\n Plan:\n Cont to monitor left arm status; no BP/blood draws left arm PICC line\n to right arm?.\n Hypernatremia (high sodium)\n Assessment:\n Hypernatremic NA was 146 yesterday evening.\n Action:\n Started on D5 W at 100cc/hr for 1000cc.\n Response:\n Awaiting for AM lab report.\n Plan:\n Cont with D5W,follow up with AM lab,resume Free water bolus via PEG\n tube?.\n Tachycardia, Other\n Assessment:\n Tachy to 130-140\ns continuous while awake; HR stayed 90- 120 sound\n asleep\n Action:\n Standing valium decreased; cont with fent patch; morphine and haldol\n prn.Bilateral restraints on\n Response:\n No significant change in level of restlessness/anxiety; freq pulling at\n any objects/lines with short term memory issues. She keeps\n disconnecting from vent,desat to low 80s within seconds.\n Plan:\n Cont to closely monitor mental status; maintain safety w/use of\n restraints, soft wrist restraints and bed alarm. PRN Haldol or\n Morphine.\n Altered mental status (not Delirium)\n Assessment:\n Pt has been slept most of the time,hard to wake up.responded to deep\n stimuli.\n Action:\n Held Scheduled dose of valium at 2200.Pt has Fentanyl 75 mcg patch on\n her lleft thigh.\n Response:\n Pt start waking up around 0300,got disconnected from vent by\n herself,given valium 2.5 mg at 0315.\n Plan:\n Continue to eval MS,Valium and PRN Morphine and haldol?,cont reorient\n and emotional support to pt .\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 637894,
"text": "56 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\n with prolonged hospital course c/b by PNA, anxiety/altered mental\n status, RUE DVT .Pt found to have small non occlusive Clot on her right\n axial vein via Ultrasound.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt has known DVT to left axillary vein; US of right arm showed no\n clots.\n Action:\n DL PICC d/c\nd; from left arm and elevated on pillow and received\n Coumadin scheduled dose.\n Response:\n PIV placed for access issues to right arm; edema looks better;\n Plan:\n Cont to monitor left arm status; no BP/blood draws left arm PICC line\n to right arm?.\n Hypernatremia (high sodium)\n Assessment:\n Hypernatremic NA was 146 yesterday evening.\n Action:\n Started on D5 W at 100cc/hr for 1000cc.\n Response:\n Awaiting for AM lab report.\n Plan:\n Cont with D5W,follow up with AM lab,resume Free water bolus via PEG\n tube?.\n Tachycardia, Other\n Assessment:\n Tachy to 130-140\ns continuous while awake; HR stayed 90- 120 sound\n asleep\n Action:\n Standing valium decreased; cont with fent patch; morphine and haldol\n prn.Bilateral restraints on\n Response:\n No significant change in level of restlessness/anxiety; freq pulling at\n any objects/lines with short term memory issues. She keeps\n disconnecting from vent,desat to low 80s within seconds.\n Plan:\n Cont to closely monitor mental status; maintain safety w/use of\n restraints, soft wrist restraints and bed alarm. PRN Haldol or\n Morphine.\n Altered mental status (not Delirium)\n Assessment:\n Pt has been slept most of the time,hard to wake up.responded to deep\n stimuli.\n Action:\n Held Scheduled dose of valium at 2200.Pt has Fentanyl 75 mcg patch on\n her lleft thigh.\n Response:\n Pt start waking up around 0300,got disconnected from vent by\n herself,given valium 2.5 mg at 0315.\n Plan:\n Continue to eval MS,Valium and PRN Morphine and haldol?,cont reorient\n and emotional support to pt .\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 638197,
"text": "Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Hypernatremia (high sodium)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 638198,
"text": "56 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\n with prolonged hospital course c/b by PNA, anxiety/altered mental\n status, RUE DVT .Pt found to have small non occlusive Clot on her right\n axial vein via Ultrasound.Yesterday Pt went down to IR for Peg revision\n aspiration risk couldn\nt do it due the type of peg she has now.\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Hypernatremia (high sodium)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nutrition",
"chartdate": "2167-10-14 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 637523,
"text": "Objective\n Pertinent medications: noted\n Labs:\n Value\n Date\n Glucose\n 134 mg/dL\n 02:06 AM\n Glucose Finger Stick\n 139\n 10:00 AM\n BUN\n 11 mg/dL\n 02:06 AM\n Creatinine\n 0.6 mg/dL\n 02:06 AM\n Sodium\n 146 mEq/L\n 02:06 AM\n Potassium\n 4.0 mEq/L\n 02:06 AM\n Chloride\n 106 mEq/L\n 02:06 AM\n TCO2\n 32 mEq/L\n 02:06 AM\n Albumin\n 3.5 g/dL\n 03:00 AM\n Calcium non-ionized\n 9.2 mg/dL\n 02:06 AM\n Phosphorus\n 4.0 mg/dL\n 02:06 AM\n Ionized Calcium\n 1.24 mmol/L\n 02:51 AM\n Magnesium\n 2.1 mg/dL\n 02:06 AM\n Current diet order / nutrition support: Replete c. Fiber @60mL/hr (1440\n kcals/89 gr aa)\n GI: Abd: soft/dist/+bs\n Assessment of Nutritional Status\n Estimation of current intake: Adequate\n Specifics:\n Pt continues on TF\ns for full nutrition support via PEG, currently\n tolerating @ goal s/ problems. (Noted TF\ns were off over weekend / ?\n aspiration event) FWB down to 100mL q 4 hr c/ Na WNL. BG\ns well\n controlled.\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: via TF\n Tube feeding recommendations: Continue TF's @ goal\n Monitor fluid status and adjust FWB prn.\n BG and lyte management as you are\n Please check current wt\n"
},
{
"category": "Nutrition",
"chartdate": "2167-10-14 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 637524,
"text": "Objective\n Pertinent medications: noted\n Labs:\n Value\n Date\n Glucose\n 134 mg/dL\n 02:06 AM\n Glucose Finger Stick\n 139\n 10:00 AM\n BUN\n 11 mg/dL\n 02:06 AM\n Creatinine\n 0.6 mg/dL\n 02:06 AM\n Sodium\n 146 mEq/L\n 02:06 AM\n Potassium\n 4.0 mEq/L\n 02:06 AM\n Chloride\n 106 mEq/L\n 02:06 AM\n TCO2\n 32 mEq/L\n 02:06 AM\n Albumin\n 3.5 g/dL\n 03:00 AM\n Calcium non-ionized\n 9.2 mg/dL\n 02:06 AM\n Phosphorus\n 4.0 mg/dL\n 02:06 AM\n Ionized Calcium\n 1.24 mmol/L\n 02:51 AM\n Magnesium\n 2.1 mg/dL\n 02:06 AM\n Current diet order / nutrition support: Replete c. Fiber @60mL/hr (1440\n kcals/89 gr aa)\n GI: Abd: soft/dist/+bs\n Assessment of Nutritional Status\n Estimation of current intake: Adequate\n Specifics:\n Pt continues on TF\ns for full nutrition support via PEG, currently\n tolerating @ goal s/ problems. (Noted TF\ns were off over weekend / ?\n aspiration event) FWB down to 100mL q 4 hr c/ Na WNL. BG\ns well\n controlled.\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: via TF\n Tube feeding recommendations: Continue TF's @ goal\n Monitor fluid status and adjust FWB prn.\n BG and lyte management as you are\n Please check current wt\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 638171,
"text": "Airway Clearance, Impaired\n Assessment:\n Pt placed on trach mask this am (on vent o/n). She continues to have\n moderate amts of thick secretions, requiring frequent sxn. Pt does have\n a strong/productive cough.\n Action:\n Sxn prn; chest pt; pt repositioned frequently (including OOB to chair)\n to help mobilize secretions.\n Response:\n Unchanged at this time.\n Plan:\n Continue to sxn prn; chest pt prn; OOB as tolerated.\n Altered mental status (not Delirium)\n Assessment:\n Pt extremely restless/agitated today. Attempting to get OOB/chair. Very\n difficult to redirect.\n Action:\n Pt reoriented frequently; Valium given prn; Morphine given per presumed\n pain.\n Response:\n Pt had no improvement after Valium; however, she appeared more\n calm/comfortable after Morphine administration.\n Plan:\n Medicate for agitation prn; continue to follow exam.\n Alteration in Nutrition\n Assessment:\n Pt NPO for past few days ( recurrent aspiration/risk for of TFs)\n Action:\n Response:\n Plan:\n Tachycardia, Other\n Assessment:\n HR 120\ns-140\ns today (baseline for ~ 1 week).\n Action:\n Lopressor given per orders.\n Response:\n HR in low 120\ns after Morphine, but otherwise unchanged.\n Plan:\n Continue Lopressor; ? need to increase dose.\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-08 00:00:00.000",
"description": "Physician Resident/Attending Progress Note - MICU",
"row_id": 636409,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - STOP 12:23 PM\n ARTERIAL LINE - START 02:00 PM\n A-line resited, not working again\n tube feed machine not working\n failed SBT - low MV with PSV - switched to MMV overnight\n tachycardic to 140-142\n Ortho spine ok with documented final read of CT trauma from attending\n at OSH and week f/u - faxed request and spoke with med recs at\n Medical re: sending report which was agreed upon.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,500 units/hour\n Other ICU medications:\n Morphine Sulfate - 12:15 PM\n Midazolam (Versed) - 03:50 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:13 AM\n Vital signs\n Cardiac monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.1\nC (98.8\n HR: 105 (70 - 148) bpm\n BP: 85/55(66) {85/41(57) - 158/110(323)} mmHg\n RR: 23 (10 - 31) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n QTc: 411\n Total In:\n 3,562 mL\n 965 mL\n PO:\n TF:\n 1,685 mL\n 150 mL\n IVF:\n 548 mL\n 215 mL\n Blood products:\n Total out:\n 5,695 mL\n 1,740 mL\n Urine:\n 5,695 mL\n 1,740 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,133 mL\n -775 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 359 (137 - 695) mL\n PS : 8 cmH2O\n RR (Set): 10\n RR (Spontaneous): 26\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI: 58\n PIP: 16 cmH2O\n SpO2: 95%\n ABG: 7.40/49/114/32/3\n Ve: 7.2 L/min\n PaO2 / FiO2: 228\n Physical Examination\n General Appearance: Trached and sedated. Responsive, following\n commands, Overweight / Obese, mild agitation but NAD\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\n deviation\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Respiratory / Chest: (Expansion: Symmetric), CTA anteriorly, decreased\n BS\n Abdominal: Obese, soft, Non-tender, no rebound, no guarding, + BS, PEG\n in place with dressing C/D/I\n Extremities: no CCE\n Skin: no rashes or jaundice\n Lines: r brachioceph ART with large amount of bloody drainage and L\n PICC C/D/I\n Labs / Radiology\n 213 K/uL\n 8.8 g/dL\n 123 mg/dL\n 0.6 mg/dL\n 32 mEq/L\n 3.6 mEq/L\n 13 mg/dL\n 107 mEq/L\n 145 mEq/L\n 29.4 %\n 11.1 K/uL\n [image002.jpg]\n 03:44 AM\n 06:04 AM\n 09:09 AM\n 05:07 PM\n 03:31 AM\n 03:46 AM\n 10:20 AM\n 03:46 PM\n 01:37 AM\n 05:32 AM\n WBC\n 9.6\n 8.2\n 11.1\n Hct\n 25.3\n 27.4\n 29.4\n Plt\n \n Cr\n 0.6\n 0.8\n 0.6\n 0.8\n 0.6\n TCO2\n 33\n 32\n 35\n 37\n 31\n Glucose\n 107\n 121\n 118\n 155\n 123\n Other labs: PT / PTT / INR:22.3/69.7/2.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:13.1 %,\n Mono:2.7 %, Eos:0.6 %, Lactic Acid:1.1 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:9.2 mg/dL, Mg++:2.5 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA, and\n ARDS, intubated since the end of now s/p trach and PEG\n placement.\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation. S/P Trach\n and PEG on .\n - wean FiO2 as tolerated\n - attempt wean PS today and hopeful for trach mask trial\n # Sedation: Continue to have issues with pain/delirium causing\n tachycardia and hypertension with intermittent hypotension. On Haldol\n 5 TID, Fentanyl 100-150 mcg TP, Diazapam 10 QID; Haldol, midazolam and\n morphine PRN. Had good response to morphine, minimal response to\n haldol bolus.\n - Will d/c midazolam and haldol PRN and use morphine for now.\n - If stable, would d/c standing Haldol tonight or tomorrow\n # Adrenal Insufficency: Hypotension that resolved with steroids,\n returned as they came off and is now improved again. Possible primary\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\n started on .\n - ok to go to 10 q am and 5 q pm prednisone, will wean to\n maintenance dose as tolerated, in consultation with endo.\n # Volume overloaded in setting of hypernatremia with TBW deficit and\n metabolic alkalosis\n - Lasix boluses, goal -1L today\n - Diamox until HCO3 < 30\n - electrolytes\n - continue tube feeds with free water flushes 300 cc q4\n # RUE DVT: INR now therapeutic on coumadin. Goal \n - stop heparin gtt\n - coumadin 5mg QHS\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - Brace for OOB\n - will f/u full trauma spine eval from OSH to determine need for\n further back imaging in-house.\n # Tracheomalacia: Discussed with IP. Stenting unlikely to help for\n trachiomalacia as airways have poor structure diffusely.\n - Outpatient f/u once off pressure support to assess for possible\n stenting\n #. Thyroid Nodule on CT\n -outpatient follow up\n # Nutrition: Tube feeds with free water flushes, tolerating well,\n continue Replete (Full) - 11:20 AM 30 mL/hour\n # Glycemic control: SSI, well controlled\n # Lines L PICC () and R ART ()\n d/c art today. Correlate ABG\n and VBG.\n # Ppx: INR therapeutic, ranitidine, colace and senna\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n Code: Full\n Dispo: ICU, being screening for vent facilities\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Arterial Line - 02:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 55F T5-8 fractures with retropulsion and ARDS\n from klebsiella VAP; on heparin for UE DVT and lasix for volume\n overload. Failed SBT but mental status slowly stabilizing off drip\n sedation. Awaiting OSH spine films.\n Exam notable for Tm 99.5 BP 110/50 HR 70-120 RR 18-20 with sat 97%\n on PSV 8/8 FiO2 0.5, 350x 20, ABG 7.41/53/86. TBB -2L/8h, +7L/MICU LOS.\n Eyes opens, will squeeze hands and wiggle toes but very drowsy. Clearer\n BS bilaterally with RRR s1s2 SM at base. Abdomen is distended with\n decreased BS. Trace edema in BLE, no cords. Labs notable for WBC 11K,\n HCT 29, K+ 3.6, Na 145, Cr 0.6, INR 2.1. CXR without significant\n change.\n Agree with plan to continue supportive care, continue PSV at 8/8, and\n continue diuresis with lasix / diamox as BP allows. Will discuss\n management of TBM with IP but would favor supportive care and slow wean\n until she has recovered from her severe pneumonia / ARDS. Will continue\n fentanyl patch at 150mcg, haldol 5q8h alternating with valium 10q6h\n with morphine PRN pain. Will wean hydrocortisone 20/10q12 PGT today and\n will discuss more aggressive wean with endocrine, as I think she has a\n component of steroid psychosis. Will stop IV heparin for UE DVT and\n continue coumadin now that her INR is >2. Will continue tube feeds and\n continue FW boluses for hypernatremia. Continue spinal stabilization\n with brace when OOB; will review outside images with spine surgery but\n no plan for acute intervention. Remainder of plan as outlined above.\n Total time 50 minutes\n Patient is critically ill\n ------ Protected Section Addendum Entered By: , MD\n on: 03:32 PM ------\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-09 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 636566,
"text": "Chief Complaint:\n 24 Hour Events:\n Arterial line d/c'd\n Spiked a fever of 101.4, blood and urine cultures sent, CXR. Started\n Vanc, Levo, Aztreonam\n Persistently hypotensive to 70s SBP overnight with low urine output and\n poor O2 sats.\n Started on Levophed, and given 1.75L NS. BPs improved to 90-120s SBP,\n and urine output increased significantly.\n Large amount of oral secretions, ?gastric in origin\n Tube feeds held for ? of aspiration.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 11:00 PM\n Levofloxacin - 11:43 PM\n Aztreonam - 04:07 AM\n Infusions:\n Norepinephrine - 0.03 mcg/Kg/min\n Other ICU medications:\n Midazolam (Versed) - 09:30 AM\n Morphine Sulfate - 03:17 PM\n Furosemide (Lasix) - 06:36 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.4\n Tcurrent: 36.7\nC (98.1\n HR: 131 (73 - 142) bpm\n BP: 127/43(60) {71/29(42) - 137/97(101)} mmHg\n RR: 21 (12 - 36) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 4,627 mL\n 1,084 mL\n PO:\n TF:\n 839 mL\n IVF:\n 2,288 mL\n 1,084 mL\n Blood products:\n Total out:\n 2,407 mL\n 2,220 mL\n Urine:\n 2,407 mL\n 2,220 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,220 mL\n -1,136 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 412 (236 - 480) mL\n PS : 8 cmH2O\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI: 126\n PIP: 21 cmH2O\n Plateau: 17 cmH2O\n Compliance: 44.4 cmH2O/mL\n SpO2: 97%\n ABG: 7.35/50/81./26/0\n Ve: 7 L/min\n PaO2 / FiO2: 162\n Physical Examination\n General Appearance: Trached and sedated. Responsive, following\n commands, Overweight / Obese, mild agitation but NAD\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\n deviation\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Respiratory / Chest: (Expansion: Symmetric), CTA anteriorly, decreased\n BS\n Abdominal: Obese, soft, Non-tender, no rebound, no guarding, + BS, PEG\n in place with dressing C/D/I\n Extremities: no CCE\n Skin: no rashes or jaundice\n Lines: r brachioceph ART with large amount of bloody drainage and L\n PICC C/D/I\n Labs / Radiology\n 227 K/uL\n 7.7 g/dL\n 114 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 4.0 mEq/L\n 16 mg/dL\n 112 mEq/L\n 145 mEq/L\n 24.9 %\n 11.3 K/uL\n [image002.jpg]\n 03:46 AM\n 10:20 AM\n 03:46 PM\n 01:37 AM\n 05:32 AM\n 02:43 PM\n 03:03 PM\n 08:11 PM\n 02:51 AM\n 03:10 AM\n WBC\n 11.1\n 9.4\n 11.3\n Hct\n 29.4\n 26.6\n 24.9\n Plt\n \n Cr\n 0.8\n 0.6\n 0.9\n 0.7\n TCO2\n 35\n 37\n 31\n 31\n 30\n 29\n Glucose\n 155\n 123\n 128\n 114\n 114\n Other labs: PT / PTT / INR:37.2/37.9/4.0, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Lactic Acid:0.5 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:8.7 mg/dL, Mg++:2.6 mg/dL, PO4:4.2 mg/dL\n Blood/Urine/Sputum culture pending\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA, and\n ARDS, intubated since the end of now s/p trach and PEG\n placement.\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation. S/P Trach\n and PEG on .\n - wean FiO2 as tolerated\n - attempt wean PS today and hopeful for trach mask trial\n # Sedation: Continue to have issues with pain/delirium causing\n tachycardia and hypertension with intermittent hypotension. On Haldol\n 5 TID, Fentanyl 100-150 mcg TP, Diazapam 10 QID; Haldol, midazolam and\n morphine PRN. Had good response to morphine, minimal response to\n haldol bolus.\n - Will d/c midazolam and haldol PRN and use morphine for now.\n - If stable, would d/c standing Haldol tonight or tomorrow\n # Adrenal Insufficency: Hypotension that resolved with steroids,\n returned as they came off and is now improved again. Possible primary\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\n started on .\n - ok to go to 10 q am and 5 q pm prednisone, will wean to\n maintenance dose as tolerated, in consultation with endo.\n # Volume overloaded in setting of hypernatremia with TBW deficit and\n metabolic alkalosis\n - Lasix boluses, goal -1L today\n - Diamox until HCO3 < 30\n - electrolytes\n - continue tube feeds with free water flushes 300 cc q4\n # RUE DVT: INR now therapeutic on coumadin. Goal \n - stop heparin gtt\n - coumadin 5mg QHS\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - Brace for OOB\n - will f/u full trauma spine eval from OSH to determine need for\n further back imaging in-house.\n # Tracheomalacia: Discussed with IP. Stenting unlikely to help for\n trachiomalacia as airways have poor structure diffusely.\n - Outpatient f/u once off pressure support to assess for possible\n stenting\n #. Thyroid Nodule on CT\n -outpatient follow up\n # Nutrition: Tube feeds with free water flushes, tolerating well,\n continue Replete (Full) - 11:20 AM 30 mL/hour\n # Glycemic control: SSI, well controlled\n # Lines L PICC () and R ART ()\n d/c art today. Correlate ABG\n and VBG.\n # Ppx: INR therapeutic, ranitidine, colace and senna\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n Code: Full\n Dispo: ICU, being screening for vent facilities\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n 18 Gauge - 08:15 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-18 00:00:00.000",
"description": "ICU Attending Addendum",
"row_id": 638264,
"text": "CRITICAL CARE STAFF ADDENDUM\n 10A\n I saw and physically examined with the ICU team, whose note today\n reflects my input. I would add/emphasize that she had an episode of\n normal heart rate today that allowed further elucidation of her\n rhythm. Her INR is also quite elevated today.\n Tachycardia\n * My examination of telemetry suggests that this was a brisk\n conversion into sinus. Her fast rate is a narrow complex\n tachycardia without obvious p waves. DDx for this is AVNRT, atrial\n tach, AVRT, Aflutter. Suspect AVNRT and atrial tach.\n * Check 12 lead.\n * No response to carotid massage.\n * Will try to increase beta blockade for now. If cannot maintain\n sinus, will consult cardiology. We are already anticoagulating\n her.\n Resp Failure\n Trach mask trials as tolerating (needing QHS support at\n present)\n PMV trials\n S/P rx for pan Klebs PNA.\n Per IP not stent planned as technically not possible to\n place into her airway\n DVT and coagulopathy\n On warfarin. Hold warfarin\n Feeding tube\n Getting reglan trial. See thoracic surgery note for plans if this\n does not succeed.\n Hypernatremia\n Replete free water.\n After feeding tube and tachycardia more settled, will be appropriate\n for rehab.\n Please see today\ns ICU team note for other issues.\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-18 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 638270,
"text": "Chief Complaint:\n 24 Hour Events:\n Pt was agitated during the day with no response to PRN zyprexa.\n Her sodium was increased to 150 yesterday, and she was given 500cc D5W\n bolus and her FW flushes for her tube feeds were increases from 100 to\n 150.\n Overnight, pt received zyprexa, valium, and was placed back on the\n ventilator, after which she was more sedated and her SBP dropped to the\n 70s and HR remained 120-130s. Her BP came back up to 110s-120s when she\n was woken up.\n She was agitated again until approx 5am when she was given her\n Metoprolol and 2.5 mg valium, after which her HR dropped to the 80s and\n stayed there for 2+ hours.\n Careful examination of telemetry revealed that she has likely been in\n an SVT and that after getting her BB, converted back to a sinus rhythm.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:11 AM\n Morphine Sulfate - 04:00 AM\n Diazepam (Valium) - 05:24 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.4\nC (97.5\n HR: 126 (118 - 140) bpm\n BP: 98/62(70) {74/38(47) - 145/105(114)} mmHg\n RR: 29 (11 - 35) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 959 mL\n 1,250 mL\n PO:\n TF:\n 176 mL\n 140 mL\n IVF:\n 463 mL\n 810 mL\n Blood products:\n Total out:\n 1,980 mL\n 130 mL\n Urine:\n 1,980 mL\n 130 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,021 mL\n 1,120 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: MMV/PSV/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 408 (408 - 499) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 26\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 149\n PIP: 16 cmH2O\n Plateau: 21 cmH2O\n SpO2: 95%\n ABG: ///36/\n Ve: 6.4 L/min\n Physical Examination\n Gen: NAD, difficult to assess orientation as patient is nonverbal on\n trach mask, but she appeared alert, and resonded appropriately to\n questions and followed commands.\n HEENT: PERRLA, EOMI, OP w/o erythema.\n Resp: Limited by patients mobility, but CTA anteriorly and laterally\n Card: S1S2 tachicardic, no m/r/g\n Abd: Soft, Non-tender, Non-distended, BS+\n Exte: No edema, DP 2+, RP2+ bil.\n NEURO: CN II\nXII grossly intact. Strength 4/5 upper and lower\n bilaterally. Reflexes 2+ bilaterally, 3+ at L patellar tendon, with\n mild adductor crossover\n Labs / Radiology\n 452 K/uL\n 8.9 g/dL\n 104 mg/dL\n 0.7 mg/dL\n 36 mEq/L\n 3.5 mEq/L\n 6 mg/dL\n 103 mEq/L\n 145 mEq/L\n 29.2 %\n 7.1 K/uL\n [image002.jpg]\n 03:00 AM\n 07:05 PM\n 03:00 AM\n 05:00 AM\n 02:06 AM\n 07:34 AM\n 03:50 AM\n 06:22 AM\n 02:58 AM\n 03:43 AM\n WBC\n 7.2\n 5.2\n 5.9\n 7.5\n 5.6\n 6.1\n 7.0\n 7.1\n 7.1\n Hct\n 26.9\n 26.0\n 27.2\n 26.8\n 27.0\n 27.0\n 29.7\n 28.9\n 29.2\n Plt\n 238\n 240\n 296\n \n 395\n 462\n 452\n Cr\n 0.9\n 0.7\n 0.6\n 0.7\n 0.6\n 0.5\n 0.7\n 0.7\n 0.6\n 0.7\n Glucose\n 106\n 100\n 134\n 134\n 121\n 619\n 126\n 137\n 104\n Other labs: PT / PTT / INR:66.1/32.7/8.0, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:9.3 mg/dL, Mg++:2.2 mg/dL, PO4:3.8\n mg/dL\n Assessment and Plan\n 55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach, PEG, placement no with respiratory failure secondary to\n tracheomalacia , resolving HAP.\n .\n # Respiratory failure: Slowly Improving. Now remaining on trach mask\n for most of the day and night, with periods of pressure support of \n over night.\n - Continue to increase time on trach mask as tolerated.\n - PMV with suctioning again today.\n .\n # HAP vs Aspiration PNA: Afebrile without leukocytosis\n - Completed course of ceftriaxone\n - Continue to f/u cultures\n - Continue trach mask as tolerated\n .\n # Tachycardia: Previously was assessed as sinus tach with occasional\n runs of SVT and sources such as hypovolemia, PE, infection, and pain\n were assessed as possibly etiologies. But, now appears to be SVT for\n much of time, rhythm,/rate nonresponsive to carotid massage. HR\n decreased to 80s w/ stable BPs for approx 2 hour period overnight that\n seems to be associated with administration of her BB and valium. Rhythm\n strip shows conversion from a narrow complex non-sinus tachycardia to\n normal sinus rhythm.\n - Increase Metroprolol from 25mg TID to 25mg QID\n - Consider further adjustment of BB as tolerated by BP.\n - If not sufficient for rhythm conversion, consult cardiology for\n management.\n .\n # Sedation: Inconsistent response to sedation, unclear what is best\n regime. Will continue to wean overall. Possibly improved level of\n agitation when rhytm returned to sinus.\n - Continue w Olanzapine QHS\n - DC\nd haldol and taper valium to 2.5 mg PRN TID w/ 2.5 mg PRNs.\n # Nutrition: Tube feeds have been restarted and pt started on raglan.\n Has been tolerating feeds well so far.\n - Continue TFs, w/ FW flushes\n - Nutrition recs appreciated.\n .\n # Adrenal Insufficency: Endocrine following. Pt does not appear to be\n adrenally insufficient at baseline. Suggesting if the patient under\n goes major stressors such as major surgery, sepsis, she may need stress\n dosed steroids.\n .\n # Fluid Status: Likely approaching euvolemia, though still has\n hypernatramia which may suggest is still intravascularly depleated.\n - Monitoring urine output\n - FW flushes at 100/hr w/ tube feeds\n - PM lytes to trend Na\n .\n # UE DVT and elevated INR: DVT in right UE has resolved, new\n non-occlusive in left axillary vein. INR supratherapeutic today\n - COumadin held, will restart at low dose when INR approaches\n therapeutic range.\n - follow INR\n .\n # Spine fracture: Stable\n - Brace for OOB, will discuss with Neurosurgery if current brace is\n optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n .\n # Tracheomalacia. Was initially addressed with IP and they wanted to\n follow up as outpatient.\n - Consult IP for stent placement given improved clinical status, will\n readdress\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # PIV x 1\n # Ppx: Coumadin, Ranitidine, Bowel Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n # Code: Full\n # Dispo: ICU, Screening for vent facilities\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 12:38 PM 30 mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 12:35 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Respiratory ",
"chartdate": "2167-10-15 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 637824,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 27\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Known difficult intubation: Yes\n Reason:\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 7.0mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Expectorated / Small\n Ventilation Assessment\n Level of breathing assistance: Unassisted spontaneous breathing\n Visual assessment of breathing pattern: Supra-sternal retractions,\n Accessory muscle use\n Assessment of breathing comfort: No claim of dyspnea)\n Plan to keep pt on trach collar over night. Vent is on stand-by.\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 636630,
"text": "55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\n Now with prolonged hospital course c/b by PNA with high PEEP\n requirement, anxiety, RUE DVT .\n Altered mental status (not Delirium)\n Assessment:\n Pt more alert, following commands intermittently. Periods of agitation\n with HR rising to 130\n Action:\n Fentanyl patch in place. Valium RTC. MSO4 given x 1 for discomfort.\n Response:\n Pt with less episodes of agitation previously. ? steroid psychosis.\n Plan:\n Check cortisol level in am and wean hydrocortisone MD. Continue to\n reorient pt. MSO4 prn for discomfort.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on PSV 8/5/50%.RR 19-24. Tidal volumes 200-250. 02 sats\n variable 90-100%. LS rhoncherous to clear, diminished at bases.\n Action:\n Pt maintained at current settings given reduced tv\ns and sats. Orally\n suctioned q 2 hrs for copious secretions. Deep suctioned q 3-4 hrs for\n sm amt thick white secretions.\n Response:\n Resp status continues to improve\n Plan:\n Wean fio2 and peep as tolerated. Vigorous pulm hygiene.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt with RUE DVT. Heparin dcd on .\n Action:\n Coags being monitored.\n Response:\n Plan:\n Coumadin to be started when INR < 3\n Hypernatremia (high sodium)\n Assessment:\n Na 140. Pt volume overloaded.\n Action:\n Treated with 1 liter d5w iv.\n Response:\n TFB Na Goal ~ even fluid balance.\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-15 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 637734,
"text": "Chief Complaint: resp failuire\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n ULTRASOUND - At 03:48 PM\n US of Lt arm shows small 1 cm axillary clot non occlusive near PICC\n RUS US shows resolutyion of formal clot\n Vomting tube feeds around trach\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Ceftriaxone - 10:00 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 06:20 AM\n Pantoprazole (Protonix) - 08:12 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Gastrointestinal: Emesis\n Flowsheet Data as of 10:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 36.2\nC (97.1\n HR: 146 (123 - 146) bpm\n BP: 153/129(134) {106/41(56) - 185/129(142)} mmHg\n RR: 26 (11 - 33) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,888 mL\n 520 mL\n PO:\n TF:\n 1,268 mL\n IVF:\n 100 mL\n Blood products:\n Total out:\n 1,530 mL\n 845 mL\n Urine:\n 1,510 mL\n 820 mL\n NG:\n 20 mL\n 25 mL\n Stool:\n Drains:\n Balance:\n 358 mL\n -325 mL\n Respiratory support\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 227 (227 - 397) mL\n PS : 8 cmH2O\n RR (Spontaneous): 20\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 194\n PIP: 16 cmH2O\n SpO2: 96%\n ABG: ///34/\n Ve: 6.5 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 8.5 g/dL\n 335 K/uL\n 121 mg/dL\n 0.5 mg/dL\n 34 mEq/L\n 3.8 mEq/L\n 7 mg/dL\n 107 mEq/L\n 147 mEq/L\n 27.0 %\n 5.6 K/uL\n [image002.jpg]\n 03:08 PM\n 03:00 AM\n 03:36 AM\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n 05:00 AM\n 02:06 AM\n 07:34 AM\n WBC\n 7.3\n 6.1\n 7.2\n 5.2\n 5.9\n 7.5\n 5.6\n Hct\n 27.6\n 26.5\n 26.9\n 26.0\n 27.2\n 26.8\n 27.0\n Plt\n 189\n 209\n 238\n \n 335\n Cr\n 0.6\n 0.6\n 0.9\n 0.7\n 0.6\n 0.7\n 0.6\n 0.5\n TCO2\n 26\n Glucose\n 99\n 115\n 106\n 100\n 134\n 134\n 121\n Other labs: PT / PTT / INR:16.6/25.0/1.5, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:9.3 mg/dL, Mg++:2.3 mg/dL, PO4:4.1\n mg/dL\n Assessment and Plan\n 55 yr old alcoholic s/p t spine fx s/p trcah and PEG with persistent\n resp failure\n 1. Resp Failure: currently on trach mask, can do a few hours per\n day, then needs for support. New pan Klebs in sputum, day\n . Try more vent support and see if it helps her.\n 2. Fevers: did not persist- cultures neg to date.\n 3 Hemodynamics: persistant simus tachy\n CTPA to look for emboli\n negative for proximal clot. IOs the of trach mask and her TB\n malacia too much for her. We will see what happens if we out her on\n 15-20 and 5.\n 4. New L Ext DVT\n 5. Emesis: call IR and get g pushed to a j tube\n ICU Care\n Nutrition: tfs held for vomiting\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Prophylaxis:\n DVT: coumadin\n Stress ulcer: ppi\n Communication: try to reach boyfriend\n status: Full code\n Disposition :ICU\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 636941,
"text": "56 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\n with prolonged hospital course c/b by PNA, anxiety/altered mental\n status, RUE DVT .\n Altered mental status (not Delirium)\n Assessment:\n Rec\nd pt very restless/agitated, repeatedly attempting to sit up in bed\n and pulling at soft wrist restraints. When arms freed, she immediately\n disconnected trach from vent. Agitation did not subside with verbal\n reassurance or scheduled dose valium. Pt follows commands\n inconsistently, has difficulty initiating cough on command. MAEE with\n good strength. Not grimacing and denied pain by mouthing words.\n Action:\n Pt noted to have rash per below, nodded\n to\nDoes you back itch?\n and rec\nd Benadryl 25mg IV @ 1345.\n Response:\n Pt finally sleeping after having been awake most of night and very\n restless all morning.\n Plan:\n Benadryl Q6hrs PRN. Cont freq mental/neuro eval.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt on AC vent settings 50%/12 X 500/+5 with SRR 17-20\ns and\n regular. O2 sat 96-100%. Lungs snds rhonchorous bilat, diminished in\n bases. Pt with weak cough, raising mod amts thick white sputum but not\n fully expectorating it from trach.\n Action:\n Pt placed on TM @ 70% @ 0900. Suctionned PRN for mod amts sputum.\n Response:\n O2 sat stable until pt soundly sleeping and de-sated to 80\ns. TM inc\n to 100% with return of O2 sat to high 90\n Plan:\n Cont to wean from vent as tolerated. Cont to encourage C&DB.\n Tachycardia, Other\n Assessment:\n HR 130\ns @ rest throughout shift, and still > 125 when pt soundly\n sleeping. Pt Afebrile.\n Action:\n Response:\n Plan:\n Rash\n Assessment:\n Pt noted to have raised red rash evenly distributed over mid/lower\n back. Pt has been very restless, and nodded\n to\nDoes your back\n itch?\n. No new meds recently.\n Action:\n Team made aware, and they examined rash. Pt rec\nd Benadryl 25mg IV X 1.\n Response:\n Pt finally able to sleep after very restless night and morning. HR\n 130\ns->125ST. O2 sat \nd to 80\ns with RR inc\nd to high 20\ns and\n shallow.\n Plan:\n Benadryl PRN Q6hrs. ? Sarna lotion. Cont to monitor rash. FiO2 inc\nd to\n 100% on TM while pt sleeping with good response per O2 sat.\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-19 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 638411,
"text": "Chief Complaint: resp failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Another episode of emesis\n Was on MMV\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Diazepam (Valium) - 12:00 AM\n Furosemide (Lasix) - 01:30 AM\n Morphine Sulfate - 02:00 AM\n Pantoprazole (Protonix) - 08:24 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:35 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.6\nC (97.8\n HR: 101 (74 - 137) bpm\n BP: 105/57(67) {75/42(50) - 130/73(108)} mmHg\n RR: 24 (12 - 28) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 3,165 mL\n 1,720 mL\n PO:\n TF:\n 691 mL\n IVF:\n 1,574 mL\n 1,665 mL\n Blood products:\n Total out:\n 1,670 mL\n 1,020 mL\n Urine:\n 1,470 mL\n 965 mL\n NG:\n 200 mL\n 55 mL\n Stool:\n Drains:\n Balance:\n 1,495 mL\n 700 mL\n Respiratory support\n O2 Delivery Device: Trach mask , Tracheostomy tube\n Ventilator mode: MMV/PSV/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 94 (94 - 450) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n RSBI Deferred: No Spon Resp\n PIP: 20 cmH2O\n SpO2: 97%\n ABG: ///38/\n Ve: 5.6 L/min\n Physical Examination\n Labs / Radiology\n 8.6 g/dL\n 467 K/uL\n 131 mg/dL\n 0.7 mg/dL\n 38 mEq/L\n 3.4 mEq/L\n 8 mg/dL\n 101 mEq/L\n 145 mEq/L\n 27.8 %\n 6.9 K/uL\n [image002.jpg]\n 03:00 AM\n 05:00 AM\n 02:06 AM\n 07:34 AM\n 03:50 AM\n 06:22 AM\n 02:58 AM\n 03:43 AM\n 05:02 PM\n 03:36 AM\n WBC\n 5.2\n 5.9\n 7.5\n 5.6\n 6.1\n 7.0\n 7.1\n 7.1\n 6.9\n Hct\n 26.0\n 27.2\n 26.8\n 27.0\n 27.0\n 29.7\n 28.9\n 29.2\n 27.8\n Plt\n 35\n 52\n 467\n Cr\n 0.6\n 0.7\n 0.6\n 0.5\n 0.7\n 0.7\n 0.6\n 0.7\n 0.8\n 0.7\n Glucose\n 100\n 134\n 134\n 121\n 04\n 108\n 131\n Other labs: PT / PTT / INR:38.8/34.5/4.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:9.4 mg/dL, Mg++:2.3 mg/dL, PO4:4.2\n mg/dL\n Assessment and Plan\n 1. Tachycardia: runs of atach versus AVNRT. On bblocker be not very\n effective- EP cinsult for ? is there an ablatable focus.\n 2. Resp Failure\n Trach mask trials as tolerating (needing QHS support at\n present)\n PMV trials\n S/P rx for pan Klebs PNA.\n Per IP not stent planned as technically not possible to\n place into her airway\n 3. DVT and coagulopathy On warfarin. Hold warfarin\n 4. Feeding tube Getting reglan trial but still with emesis.\n 5. Hypernatremia Replete free water.\n Please see today\ns ICU team note for other issues.\n ICU Care\n Nutrition: TFs\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n Prophylaxis:\n DVT: anti coag\n Stress ulcer: ppi\n Communication: trying to reach boyfriend\n status: Full code\n Disposition : ICU, start screening still need to fix tachycardia\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-15 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 637745,
"text": "Chief Complaint:\n 24 Hour Events:\n ULTRASOUND - At 03:48 PM\n US of Lt arm to R/O DVT. Shows small , nonobstructing clot in axillary\n vein of LEFT arm\n CTA- wet read neg for PE, though study limited by movement artifact\n Coumadin increased to 5mg last night\n Episode of emesis w/ tube gastric contents/ TFs extruding from\n tracheostomy site, around tube. TFs held.\n L PICC line left in place until AM.\n RUE U/S in am showed no DVT in right arm, resolved old clot.\n Endocrine consult left impressions/recs\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Ceftriaxone - 10:00 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 36.3\nC (97.3\n HR: 135 (123 - 146) bpm\n BP: 141/65(82) {106/41(56) - 185/128(142)} mmHg\n RR: 19 (11 - 32) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,888 mL\n 360 mL\n PO:\n TF:\n 1,268 mL\n IVF:\n 100 mL\n Blood products:\n Total out:\n 1,530 mL\n 240 mL\n Urine:\n 1,510 mL\n 240 mL\n NG:\n 20 mL\n Stool:\n Drains:\n Balance:\n 358 mL\n 120 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 227 (227 - 397) mL\n PS : 8 cmH2O\n RR (Spontaneous): 20\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 194\n PIP: 16 cmH2O\n SpO2: 96%\n ABG: ////\n Ve: 6.5 L/min\n Physical Examination\n GEN: Awake, alert, responsive. Sitting in bed. Indicated that she\n wanted to get out of the hospital. Cooperative.\n HEENT: PERRL, EOMI, no scleral icterus or injections.\n PULM: Large secretions, diffuse loud wet upperairway sounds/rhonchi, no\n wheezes, no rales, but difficult exam w/ poor inspiration.\n CARD: tachycardic, regular, ,s1, s2,\n ABD: abdomen obese, mildly distended, nontender, no rebound, no\n guarding.\n EXT: DP 2+\n NEURO: able to move all extremeties, strength 5/5 upper and 4-5/5\n lower, R hip < L hip.\n Labs / Radiology\n 306 K/uL\n 8.8 g/dL\n 134 mg/dL\n 0.6 mg/dL\n 32 mEq/L\n 4.0 mEq/L\n 11 mg/dL\n 106 mEq/L\n 146 mEq/L\n 26.8 %\n 7.5 K/uL\n [image002.jpg]\n 03:10 AM\n 03:08 PM\n 03:00 AM\n 03:36 AM\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n 05:00 AM\n 02:06 AM\n WBC\n 11.3\n 7.3\n 6.1\n 7.2\n 5.2\n 5.9\n 7.5\n Hct\n 24.9\n 27.6\n 26.5\n 26.9\n 26.0\n 27.2\n 26.8\n Plt\n 227\n 189\n 209\n 238\n 240\n 296\n 306\n Cr\n 0.7\n 0.6\n 0.6\n 0.9\n 0.7\n 0.6\n 0.7\n 0.6\n TCO2\n 26\n Glucose\n 114\n 99\n 115\n 106\n 100\n 134\n 134\n Other labs: PT / PTT / INR:15.5/24.8/1.4, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:27/19, Alk Phos / T Bili:118/0.3,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:243 IU/L, Ca++:9.2 mg/dL, Mg++:2.1 mg/dL, PO4:4.0\n mg/dL\n CXR: no sig change from previous, some R sided infiltrate vs effusion,\n redistrubted from previous\n RUE U/S: (PRELIM) No evidence of DVT in the right upper extremity.\n Resolution of nonocclusive thrombus in the right axillary and basilic\n veins.\n LUE U/S: (PRELIM) Very small segment (1-cm in length) of nonocclusive\n thrombus in the left axillary vein. A PICC catheter is present on the\n left.\n Assessment and Plan\n 55yoF with history of EtOH abuse presenting following mechanical fall\n and traumatic T spine fracture, now s/p trach, PEG, placement being\n treated for HAP.\n# HAP vs Aspiration PNA: Cultures grew, Klebsiella Oxytoca, Klebsiella Pneumonia\ne, GNR, GP Cocci. Has completed 8 day course of Ceftriaxone. Has had occasional\nlow grade fevers, but has continued to improve clinically. Had a sputum gram sta\nin from w/ GPC p/c. a new VAP/HAP w/ staph possible, but given no clear inf\niltrate on CXR and good respiratory status, significant PNA is unlikely, coloniz\nation of tracheostomy tube is more likely, as is contamination of sputum. Given\n improving clinical picture, will wait until CX data or change in clinical statu\ns or CXR to initiate HAP/VAP treatment.\n - D/c Ceftriaxone\n - Continue to f/u cultures\n .\n # Respiratory failure: Improving status. Will continue to increase\n time on trach mask as tolerated.\n - PMV with suctioning.\n - Weaning FiO2 as tolerated\n # Tachycardia: Pt in ST 120\ns to 150s. Etiology remains unclear and\n include hypovolemia, pain, infection (pt with known klebsiella), and\n incrased work of breathing from secretions and tracheomalacia, . DDx\n also includes PE given hx of RUE DVT, mucus plugging given large\n amount of secretions, and spinal injury. Tachycardia is unresponsive to\n IVF, Pt has had a negative CT-PA and has not had sig response to pain\n meds. Has completed treatment for her HAP. Thyroid function was checked\n and had normal TSH and T3 and free T4. Had been on albuterol q4 and\n atrovent , she has not been wheezing, and perhaps she is sensitive to\n the B-agonist.\n - Continue Pain Control\n - Change albuterol to PRN\n - Test if HR decreases when placed on higher pressure support\n for period of time.\n # Sedation: Has had inconsistent response to sedation, unclear what is\n best regime. Will continue to wean overall\n - Change to haldol 2.5 PRN, Fentanyl 75 mcg TP, Morphine PRN,\n Benadryl, Valium 5mg PRN\n # Adrenal Insufficency: Followed up with endocrine that suggested if\n the patient under goes major stressors such as major surgery, sepsis,\n she may need stress dosed steroids.\n - Will consider MRI at later date for evaluation of pituitary\n # Fluid Status: Volume overloaded in prior setting of Hypernatremia\n - Monitoring urine output\n - increasse Free H20, for mild hypernatremia 200cc Free bolus PEG, and\n - 500cc D5W at 125.\n - PM lytes to assess hypernatremia\n # UE DVT: right has resolved, new non occlusive in left axillary. INR\n 1.5\n -continue coumadin\n -follow INR\n - D/c Left PICC line, and place peripheral IVs. If unable, can place a\n R PICC.\n # Spine fracture: Stable\n - Brace for OOB, will discuss with Neurosurgery if current brace is\n optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n # Tracheomalacia?: Was initially addressed with IP and they wanted to\n follow up as outpatient.\n - Consult IP for stent placement given improved clinical status, will\n readdresses\n #. Thyroid Nodule on CT\n - Outpatient follow up\n # Nutrition: Pt had emesis and extrusion of gastric contents through\n tracheostomy site (not through tube).\n - TFs held\n - Consult IR for advancement of her PEG to jejunum.\n # Glycemic control: SSI, well controlled\n # PIV x 1\n # Ppx: Restarting Coumadin, Ranitidine, Bowel Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n # Code: Full\n # Dispo: ICU, Screening for vent facilities\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nutrition",
"chartdate": "2167-10-14 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 637522,
"text": "Objective\n Pertinent medications: noted\n Labs:\n Value\n Date\n Glucose\n 134 mg/dL\n 02:06 AM\n Glucose Finger Stick\n 139\n 10:00 AM\n BUN\n 11 mg/dL\n 02:06 AM\n Creatinine\n 0.6 mg/dL\n 02:06 AM\n Sodium\n 146 mEq/L\n 02:06 AM\n Potassium\n 4.0 mEq/L\n 02:06 AM\n Chloride\n 106 mEq/L\n 02:06 AM\n TCO2\n 32 mEq/L\n 02:06 AM\n Albumin\n 3.5 g/dL\n 03:00 AM\n Calcium non-ionized\n 9.2 mg/dL\n 02:06 AM\n Phosphorus\n 4.0 mg/dL\n 02:06 AM\n Ionized Calcium\n 1.24 mmol/L\n 02:51 AM\n Magnesium\n 2.1 mg/dL\n 02:06 AM\n Current diet order / nutrition support: Replete c. Fiber @60mL/hr (1440\n kcals/89 gr aa)\n GI: Abd: soft/dist/+bs\n Assessment of Nutritional Status\n Estimation of current intake: Adequate\n Specifics:\n Pt continues on TF\ns for full nutrition support via PEG, currently\n tolerating @ goal s/ problems. (Noted TF\ns were off over weekend / ?\n aspiration event) FWB down to 100mL q 4 hr c/ Na WNL. BG\ns well\n controlled.\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: via TF\n Tube feeding recommendations: Continue TF's @ goal\n Monitor fluid status and adjust FWB prn.\n BG and lyte management as you are\n Please check current wt\n"
},
{
"category": "Respiratory ",
"chartdate": "2167-10-16 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 637872,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 28\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 7.0mm\n PMV: No\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Increase ventilatory support at night; Comments: Trach Trials as\n tolerated.\n Reason for continuing current ventilatory support:\n Note: rsbi 52\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-17 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 638106,
"text": "Chief Complaint:\n 24 Hour Events:\n Pt continued on B-Blocker for prior runs of SVT, HR peaked in 135\n Olanzapine 5mg QHS\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Ceftriaxone - 10:00 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 36.4\nC (97.5\n HR: 131 (119 - 149) bpm\n BP: 111/53(67) {99/28(50) - 185/99(144)} mmHg\n RR: 11 (11 - 30) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,408 mL\n 200 mL\n PO:\n 50 mL\n TF:\n IVF:\n 2,358 mL\n 200 mL\n Blood products:\n Total out:\n 1,795 mL\n 1,320 mL\n Urine:\n 1,795 mL\n 1,320 mL\n NG:\n Stool:\n Drains:\n Balance:\n 613 mL\n -1,120 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: MMV/PSV/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 415 (244 - 415) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 22 cmH2O\n Plateau: 17 cmH2O\n SpO2: 98%\n ABG: ///38/\n Ve: 5.5 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 462 K/uL\n 9.0 g/dL\n 137 mg/dL\n 0.6 mg/dL\n 38 mEq/L\n 3.9 mEq/L\n 5 mg/dL\n 101 mEq/L\n 146 mEq/L\n 28.9 %\n 7.1 K/uL\n [image002.jpg]\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n 05:00 AM\n 02:06 AM\n 07:34 AM\n 03:50 AM\n 06:22 AM\n 02:58 AM\n WBC\n 7.2\n 5.2\n 5.9\n 7.5\n 5.6\n 6.1\n 7.0\n 7.1\n Hct\n 26.9\n 26.0\n 27.2\n 26.8\n 27.0\n 27.0\n 29.7\n 28.9\n Plt\n 238\n 240\n 296\n \n 395\n 462\n Cr\n 0.6\n 0.9\n 0.7\n 0.6\n 0.7\n 0.6\n 0.5\n 0.7\n 0.7\n 0.6\n Glucose\n 115\n 106\n 100\n 134\n 134\n 121\n \n Other labs: PT / PTT / INR:36.6/30.0/3.9, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:9.8 mg/dL, Mg++:2.2 mg/dL, PO4:3.3\n mg/dL\n Assessment and Plan\n 55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach, PEG, placement being with respiratory failure secondary to\n tracheomalacia and HAP.\n .\n # Respiratory failure: Improving status. Will continue to increase\n time on trach mask as tolerated.\n - PMV with suctioning.\n - Continue to increase time on trach mask as tolerated.\n .\n # HAP vs Aspiration PNA: Cultures Positive for, Klebsiella Oxytoca,\n Klebsiella Pneumoniae, GNR, GP Cocci. 8 day course of Ceftriaxone\n completed. Occasional low grade fevers, clinically improved. Sputum\n gram stain from w/ GPC p/c. new VAP/HAP w/ staph possible, no\n clear infiltrate on CXR and good respiratory status. Potential\n colonization of tracheostomy and contamination of sputum. Given\n improving clinical picture, will wait until CX data or change in\n clinical status or CXR to initiate HAP/VAP treatment.\n - Completed course of ceftriaxone\n - Continue to f/u cultures\n - Continue trach mask as tolerated\n .\n # Tachycardia: Sinus Tach. HR decreases overnight with ranges of\n 115-135. From yesterday when pt found had runs of SVT as well as ST\n 120\ns to 150s. SBPs approx 65.\n Negative CT to evaluate for DVT, resp failure likely contributing\n - cont metoprolol 12.5mg TID and uptitrate as tolerated\n - monitor on telemetry\n - Continue Pain Control\n - Change albuterol to PRN\n .\n # Mental Status / Sedation: Has had inconsistent response to sedation,\n unclear what is best regime. Will continue to wean overall\n - DC haldol and taper valium to 2.5 mg PRN TID, taper off\n # Adrenal Insufficency: Followed up with endocrine that suggested if\n the patient under goes major stressors such as major surgery, sepsis,\n she may need stress dosed steroids.\n - Endocrine s/o\n no need for steroids currently\n .\n # Fluid Status: Volume overloaded in prior setting of Hypernatremia\n - Monitoring urine output\n - increasse Free H20, for mild hypernatremia 200cc Free bolus PEG, and\n - 500cc D5W at 125.\n - PM lytes to assess hypernatremia\n .\n # UE DVT: right has resolved, new non occlusive in left axillary. INR\n 1.5\n - continue coumadin\n - follow INR\n - PICC lines DC\n .\n # Spine fracture: Stable\n - Brace for OOB, will discuss with Neurosurgery if current brace is\n optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n .\n # Tracheomalacia?: Was initially addressed with IP and they wanted to\n follow up as outpatient.\n - Consult IP for stent placement given improved clinical status, will\n readdresses\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Nutrition: Pt had emesis and extrusion of gastric contents through\n tracheostomy site (not through tube).\n - TFs held\n - Appreciate thoracic\ns recs\n will add reglan 10mg Q6\n .\n # Glycemic control: SSI, well controlled\n # PIV x 1\n # Ppx: Restarting Coumadin, Ranitidine, Bowel Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n # Code: Full\n # Dispo: ICU, Screening for vent facilities\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:10 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 638167,
"text": "Airway Clearance, Impaired\n Assessment:\n Pt placed on trach mask this am (on vent o/n). She continues to have\n moderate amts of thick secretions, requiring frequent sxn. Pt does have\n a strong/productive cough.\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n Tachycardia, Other\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 638356,
"text": "Hypernatremia (high sodium)\n Assessment:\n Na 148, pt vomited and tube feeds on hold as well as fluid boluses on\n hold.\n Action:\n Iv fluids of D5w at 125 cc/hr\n Response:\n Na decreased to 145 at 0330 lab check\n Plan:\n Continue with D5w at 125 cc/hr. check with ho in am regarding further\n iv orders and next na level check.\n Altered mental status (not Delirium)\n Assessment:\n Pt restless and moving all over bed.. There are also times when pt\n sleeps. pt nodded yes to generalized pain times once and at another\n time she nodded yes when asked if she was itichy.\n Action:\n Medicated with valium 2.5 mg gtube atc dose. Pt also received one dose\n of 2.5 mg iv for increased restlessness. Medicated with benadryl 25 mg\n iv for the c/o itch. Pt also received a dose of morphine 2 mg iv for\n c/o generalized discomfort.\n Response:\n Pt behaviour continues with episodic agitation followed by a period of\n sleep\n Plan:\n Continue atc valium. Evaluate pt for c/o itch/ pain and medicate\n accordingly\n Alteration in Nutrition\n Assessment:\n Pt vomited large amounts of tube feed. Copious amounts gushing from her\n mouth times three. Tube feeds stopped and hydration with iv fluids\n initiated. Pt continues to gag and have small amounts of brownish\n emesis when she coughs.\n Action:\n Regaln iv ATC, zofran 4 mg iv times 2, gtube to drainage.\n Response:\n Gtube drained 50 cc brownish/bilious.\n Plan:\n Airway Clearance, Impaired\n Assessment:\n Pt vomiting and tube feed gushing from mouth. Later when pt resting o2\n sats decreased to 90 %.\n Action:\n Pt turned to side to prevent aspiration. Suctioned trach for sm/mod\n white and blood tinged time 2 , pt placed on vent for decreased o2\n saturation.\n Response: sats improved to 97-99 % on 50 % mmv\n Plan: monitor sats, follow temp, chest xray done am rounds.. check\n results\n Response:\n [image002.jpg]\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-12 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 637102,
"text": "Chief Complaint: resp failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n rash- vesicular and d/c l;evoquin and started Ceftriaxone\n More tachycardic this AM - autonomic dysregulation\n Trach Mask for several hours\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Aztreonam - 03:42 AM\n Vancomycin - 09:40 AM\n Levofloxacin - 11:15 PM\n Ceftriaxone - 07:50 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 09:45 AM\n Haloperidol (Haldol) - 10:26 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 36.9\nC (98.5\n HR: 143 (113 - 145) bpm\n BP: 153/89(102) {85/40(50) - 153/89(102)} mmHg\n RR: 24 (9 - 30) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,362 mL\n 537 mL\n PO:\n TF:\n 47 mL\n 287 mL\n IVF:\n 1,061 mL\n 100 mL\n Blood products:\n Total out:\n 1,203 mL\n 615 mL\n Urine:\n 1,203 mL\n 615 mL\n NG:\n Stool:\n Drains:\n Balance:\n 159 mL\n -78 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Set): 0 (0 - 0) mL\n Vt (Spontaneous): 244 (110 - 504) mL\n PS : 10 cmH2O\n RR (Set): 0\n RR (Spontaneous): 19\n PEEP: 5 cmH2O\n FiO2: 70%\n RSBI: 245\n PIP: 16 cmH2O\n SpO2: 98%\n ABG: ///30/\n Ve: 10 L/min\n Physical Examination\n Gen\n Heent\n CV\n Chest\n Abd\n Ext\n Neuro\n Labs / Radiology\n 7.9 g/dL\n 240 K/uL\n 100 mg/dL\n 0.6 mg/dL\n 30 mEq/L\n 3.4 mEq/L\n 12 mg/dL\n 108 mEq/L\n 146 mEq/L\n 26.0 %\n 5.2 K/uL\n [image002.jpg]\n 08:11 PM\n 02:51 AM\n 03:10 AM\n 03:08 PM\n 03:00 AM\n 03:36 AM\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n WBC\n 9.4\n 11.3\n 7.3\n 6.1\n 7.2\n 5.2\n Hct\n 26.6\n 24.9\n 27.6\n 26.5\n 26.9\n 26.0\n Plt\n \n Cr\n 0.9\n 0.7\n 0.6\n 0.6\n 0.9\n 0.7\n 0.6\n TCO2\n 29\n 26\n Glucose\n 128\n 114\n 114\n 99\n 115\n 106\n 100\n Other labs: PT / PTT / INR:17.6/27.4/1.6, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:33/22, Alk Phos / T Bili:143/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:0.5 mmol/L,\n Albumin:3.5 g/dL, LDH:199 IU/L, Ca++:8.9 mg/dL, Mg++:2.4 mg/dL, PO4:4.1\n mg/dL\n Assessment and Plan 55 yr old alcoholic s/p t spine fx s/p trcah and\n PEG with persistent resp failure\n 1. Resp Failure: currently on trach mask, can do a few hours per\n day, then needs for support. New pan Klebs in sputum, day\n . Get Speech consult for PMV evaluation. Holding off on stent by IP\n until after pulm rehab.\n 2. Hemodynamics: tachycardia seems most likely due to agitation\n at present, did taper Valium aggressively, may be need to increase\n benzo slightly and see f it helps (haldol and morphione have not helped\n yet this AM)\n 3.\n ICU Care\n Nutrition: Replete with Fiber (Full) - 07:46 AM 30 mL/hour\n Glycemic Control:\n Lines: PICC Line - 09:19 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n Communication:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-12 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 637104,
"text": "Chief Complaint: resp failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n rash- vesicular and d/c l;evoquin and started Ceftriaxone\n More tachycardic this AM - autonomic dysregulation\n Trach Mask for several hours\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Aztreonam - 03:42 AM\n Vancomycin - 09:40 AM\n Levofloxacin - 11:15 PM\n Ceftriaxone - 07:50 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 09:45 AM\n Haloperidol (Haldol) - 10:26 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 36.9\nC (98.5\n HR: 143 (113 - 145) bpm\n BP: 153/89(102) {85/40(50) - 153/89(102)} mmHg\n RR: 24 (9 - 30) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,362 mL\n 537 mL\n PO:\n TF:\n 47 mL\n 287 mL\n IVF:\n 1,061 mL\n 100 mL\n Blood products:\n Total out:\n 1,203 mL\n 615 mL\n Urine:\n 1,203 mL\n 615 mL\n NG:\n Stool:\n Drains:\n Balance:\n 159 mL\n -78 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Set): 0 (0 - 0) mL\n Vt (Spontaneous): 244 (110 - 504) mL\n PS : 10 cmH2O\n RR (Set): 0\n RR (Spontaneous): 19\n PEEP: 5 cmH2O\n FiO2: 70%\n RSBI: 245\n PIP: 16 cmH2O\n SpO2: 98%\n ABG: ///30/\n Ve: 10 L/min\n Physical Examination\n Gen\n Heent\n CV\n Chest\n Abd\n Ext\n Neuro\n Labs / Radiology\n 7.9 g/dL\n 240 K/uL\n 100 mg/dL\n 0.6 mg/dL\n 30 mEq/L\n 3.4 mEq/L\n 12 mg/dL\n 108 mEq/L\n 146 mEq/L\n 26.0 %\n 5.2 K/uL\n [image002.jpg]\n 08:11 PM\n 02:51 AM\n 03:10 AM\n 03:08 PM\n 03:00 AM\n 03:36 AM\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n WBC\n 9.4\n 11.3\n 7.3\n 6.1\n 7.2\n 5.2\n Hct\n 26.6\n 24.9\n 27.6\n 26.5\n 26.9\n 26.0\n Plt\n \n Cr\n 0.9\n 0.7\n 0.6\n 0.6\n 0.9\n 0.7\n 0.6\n TCO2\n 29\n 26\n Glucose\n 128\n 114\n 114\n 99\n 115\n 106\n 100\n Other labs: PT / PTT / INR:17.6/27.4/1.6, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:33/22, Alk Phos / T Bili:143/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:0.5 mmol/L,\n Albumin:3.5 g/dL, LDH:199 IU/L, Ca++:8.9 mg/dL, Mg++:2.4 mg/dL, PO4:4.1\n mg/dL\n Assessment and Plan 55 yr old alcoholic s/p t spine fx s/p trcah and\n PEG with persistent resp failure\n 1. Resp Failure: currently on trach mask, can do a few hours per\n day, then needs for support. New pan Klebs in sputum, day\n . Get Speech consult for PMV evaluation. Holding off on stent by IP\n until after pulm rehab.\n 2. Hemodynamics: tachycardia seems most likely due to agitation\n at present, did taper Valium aggressively, may be need to increase\n benzo slightly and see f it helps (haldol and morphione have not helped\n yet this AM)\n 3. Anti coag: for upper ext DVT but INR elevated on coumadin +\n quinolone\n repeat\n 4. Adrenal Insufficny: proper stim this AM\n ICU Care\n Nutrition: Replete with Fiber (Full) - 07:46 AM 30 mL/hour\n Glycemic Control:\n Lines: PICC Line - 09:19 PM\n Prophylaxis:\n DVT: inr levetaed recheck, and start coumadin when at 2.0\n Stress ulcer: ppi\n Communication:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-14 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 637493,
"text": "Chief Complaint: resp failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n s/p t spine fx with resp failure\n 24 Hour Events:\n BLOOD CULTURED - At 02:18 AM\n SPUTUM CULTURE - At 02:18 AM\n URINE CULTURE - At 02:18 AM\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Ceftriaxone - 12:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fever\n Flowsheet Data as of 08:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.8\n Tcurrent: 37.2\nC (99\n HR: 137 (120 - 151) bpm\n BP: 125/55(73) {98/41(54) - 202/97(111)} mmHg\n RR: 23 (12 - 39) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,934 mL\n 497 mL\n PO:\n TF:\n 1,104 mL\n 447 mL\n IVF:\n 1,000 mL\n 50 mL\n Blood products:\n Total out:\n 530 mL\n 240 mL\n Urine:\n 530 mL\n 240 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,404 mL\n 257 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 318 (318 - 475) mL\n PS : 10 cmH2O\n RR (Spontaneous): 34\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 171\n SpO2: 98%\n ABG: ///32/\n Ve: 9 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 8.8 g/dL\n 306 K/uL\n 134 mg/dL\n 0.6 mg/dL\n 32 mEq/L\n 4.0 mEq/L\n 11 mg/dL\n 106 mEq/L\n 146 mEq/L\n 26.8 %\n 7.5 K/uL\n [image002.jpg]\n 03:10 AM\n 03:08 PM\n 03:00 AM\n 03:36 AM\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n 05:00 AM\n 02:06 AM\n WBC\n 11.3\n 7.3\n 6.1\n 7.2\n 5.2\n 5.9\n 7.5\n Hct\n 24.9\n 27.6\n 26.5\n 26.9\n 26.0\n 27.2\n 26.8\n Plt\n 227\n 189\n 209\n 238\n 240\n 296\n 306\n Cr\n 0.7\n 0.6\n 0.6\n 0.9\n 0.7\n 0.6\n 0.7\n 0.6\n TCO2\n 26\n Glucose\n 114\n 99\n 115\n 106\n 100\n 134\n 134\n Other labs: PT / PTT / INR:13.5/23.6/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:27/19, Alk Phos / T Bili:118/0.3,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:243 IU/L, Ca++:9.2 mg/dL, Mg++:2.1 mg/dL, PO4:4.0\n mg/dL\n Assessment and Plan\n Assessment and Plan 55 yr old alcoholic s/p t spine fx s/p trcah and\n PEG with persistent resp failure\n 1. Resp Failure: currently on trach mask, can do a few hours per\n day, then needs for support. New pan Klebs in sputum, day\n . Re- try. Holding off on stent by IP until after pulm rehab.\n 2. Hemodynamics: tachycardia with slightly decreased UOP\n bolus\n IVF and trend UOP. Watch to see if response with tachycardia.\n 3. Anti coag: for upper ext DVT but INR elevated on coumadin +\n quinolone\n repeat inr low- trend with po COumadin\n 4. Adrenal Insufficiency: proper stim this AM, off steroids\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 06:23 AM 60 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 637630,
"text": "Tachycardia, Other\n Assessment:\n Continues to be Tachycardia in 120-145 (anxiety). SBP has been 100-145\n without ectopy.\n Action:\n No medication given for tachycardia.Pt gets Valium 5 mg scheduled Q6H\n with little effect. CTA done to r/o pe as a source of tachycardia.\n Response:\n Results pending on CTA.\n Plan:\n Continue to evaluate HR and BP for need of treatment.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt has a known DVT to RUE. Today pt had a US of LUEand ruled out small\n non occlusive clot on her left axial vein.\n Action:\n Dr ,pt received ceftriaxone via PICC line.Coumadin dosage\n increased from 2.5 to 5 mg ( INR 1.4).\n Response:\n Repeat ultrasound orderd for right arm to check old clot. Pt received 5\n mg coumadin at 2200.\n Plan:\n Ultrasound today,cont coumadin and closely monitor INR.\n Altered mental status (not Delirium)\n Assessment:\n Pt has been restless most of the night. Pt nodded her head for pain and\n simple yes or no questions.\n Action:\n Pt given scheduled Valium with little effect.\n Response:\n Pt slept for a while,Hr dropped to 120s at the time of rest.\n Plan:\n Continue to eval MS,Valium and PRN Morphine and haldol?.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt rested on CPAP+ PS 50%/,sats stayed upper 90\ns,Pt found to have\n TF coming around Tracheostomy. As well as from her mouth\n Action:\n Cont pulm toilet as needed,Held TF throughout the night .\n Response:\n Pt suctioned for small- moderate amount thick yellow secretions.No more\n leakage noted around the tracheostomy as well as Minimal residuals from\n PEG tube\n Plan:\n Continue to wean pt off vent and place on TC once pt can tol it again\n and frequent pulmonary toileting. Restart TF?\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 637633,
"text": "56 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\n with prolonged hospital course c/b by PNA, anxiety/altered mental\n status, RUE DVT .Pt found to have small non occlusive Clot on her right\n axial vein via Ultrasound.\n Tachycardia, Other\n Assessment:\n Continues to be Tachycardia in 120-145 (anxiety). SBP has been 100-145\n without ectopy.\n Action:\n No medication given for tachycardia.Pt gets Valium 5 mg scheduled Q6H\n with little effect. CTA done to r/o pe as a source of tachycardia.\n Response:\n Results pending on CTA.\n Plan:\n Continue to evaluate HR and BP for need of treatment.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt has a known DVT to RUE. Today pt had a US of LUEand ruled out small\n non occlusive clot on her left axial vein.\n Action:\n Dr ,pt received ceftriaxone via PICC line.Coumadin dosage\n increased from 2.5 to 5 mg ( INR 1.4).\n Response:\n Repeat ultrasound orderd for right arm to check old clot. Pt received 5\n mg coumadin at 2200.\n Plan:\n Ultrasound today,cont coumadin and closely monitor INR.\n Altered mental status (not Delirium)\n Assessment:\n Pt has been restless most of the night. Pt nodded her head for pain and\n simple yes or no questions.\n Action:\n Pt given scheduled Valium with little effect.\n Response:\n Pt slept for a while,Hr dropped to 120s at the time of rest.\n Plan:\n Continue to eval MS,Valium and PRN Morphine and haldol?.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt rested on CPAP+ PS 50%/,sats stayed upper 90\ns,Pt found to have\n TF coming around Tracheostomy. As well as from her mouth\n Action:\n Cont pulm toilet as needed,Held TF throughout the night .\n Response:\n Pt suctioned for small- moderate amount thick yellow secretions.No more\n leakage noted around the tracheostomy as well as Minimal residuals from\n PEG tube\n Plan:\n Continue to wean pt off vent and place on TC once pt can tol it again\n and frequent pulmonary toileting. Restart TF?\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-16 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 638014,
"text": "Chief Complaint: Tracheomalacia\n 24 Hour Events:\n ULTRASOUND - At 08:11 AM\n right arm - negative for DVT\n PICC LINE - STOP 12:02 PM\n - IR unable to advance PEG\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Ceftriaxone - 10:00 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:12 AM\n Morphine Sulfate - 12:00 PM\n Haloperidol (Haldol) - 02:00 PM\n Diazepam (Valium) - 03:52 PM\n Furosemide (Lasix) - 06:40 AM\n Other medications:\n Changes to medical and family history:\n None\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.2\nC (97.1\n HR: 139 (97 - 146) bpm\n BP: 133/67(84) {93/43(55) - 183/129(134)} mmHg\n RR: 18 (13 - 33) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,220 mL\n 568 mL\n PO:\n TF:\n IVF:\n 500 mL\n 568 mL\n Blood products:\n Total out:\n 1,514 mL\n 150 mL\n Urine:\n 1,439 mL\n 150 mL\n NG:\n 75 mL\n Stool:\n Drains:\n Balance:\n -294 mL\n 418 mL\n Respiratory support\n O2 Delivery Device: Trach mask , Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 384 (311 - 675) mL\n PS : 10 cmH2O\n RR (Spontaneous): 12\n PEEP: 5 cmH2O\n FiO2: 70%\n RSBI: 52\n PIP: 15 cmH2O\n SpO2: 96%\n ABG: ///31/\n Ve: 4.6 L/min\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic,\n No(t) Diastolic), tachy, regular\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Attentive,\n Labs / Radiology\n 395 K/uL\n 9.0 g/dL\n 619 mg/dL\n 0.7 mg/dL\n 31 mEq/L\n 3.3 mEq/L\n 6 mg/dL\n 91 mEq/L\n 129 mEq/L\n 29.7 %\n 7.0 K/uL\n [image002.jpg]\n 03:36 AM\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n 05:00 AM\n 02:06 AM\n 07:34 AM\n 03:50 AM\n 06:22 AM\n WBC\n 7.2\n 5.2\n 5.9\n 7.5\n 5.6\n 6.1\n 7.0\n Hct\n 26.9\n 26.0\n 27.2\n 26.8\n 27.0\n 27.0\n 29.7\n Plt\n 238\n 240\n 296\n \n 395\n Cr\n 0.6\n 0.9\n 0.7\n 0.6\n 0.7\n 0.6\n 0.5\n 0.7\n TCO2\n 26\n Glucose\n 115\n 106\n 100\n 134\n 134\n 121\n 619\n Other labs: PT / PTT / INR:23.4/29.6/2.3, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:8.4 mg/dL, Mg++:1.9 mg/dL, PO4:3.9\n mg/dL\n Microbiology: 7:34 am STOOL CONSISTENCY: FORMED\n Source: Stool.\n **FINAL REPORT **\n CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final ):\n Feces negative for C.difficile toxin A & B by EIA.\n (Reference Range-Negative).\n .\n 7:33 am BLOOD CULTURE Source: Line-picc.\n **FINAL REPORT **\n Blood Culture, Routine (Final ): NO GROWTH\n Assessment and Plan\n Assessment and Plan\n 55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach, PEG, placement being with respiratory failure secondary to\n tracheomalacia and HAP.\n .\n # HAP vs Aspiration PNA: Cultures grew, Klebsiella Oxytoca, Klebsiella\n Pneumoniae, GNR, GP Cocci. Has completed 8 day course of Ceftriaxone.\n Has had occasional low grade fevers, but has continued to improve\n clinically. Had a sputum gram stain from w/ GPC p/c. a new VAP/HAP\n w/ staph possible, but given no clear infiltrate on CXR and good\n respiratory status, significant PNA is unlikely, colonization of\n tracheostomy tube is more likely, as is contamination of sputum. Given\n improving clinical picture, will wait until CX data or change in\n clinical status or CXR to initiate HAP/VAP treatment.\n - Completed course of ceftriaxone\n - Continue to f/u cultures\n - Continue trach mask as tolerated\n .\n # Respiratory failure: Improving status. Will continue to increase\n time on trach mask as tolerated.\n - PMV with suctioning.\n - Tolerating trach mask\n .\n # Tachycardia: Pt found to have runs of SVT as well as ST 120\ns to\n 150s. She had a negative CT to evaluate for DVT, resp failure likely\n contributing\n - start metoprolol 12.5mg TID and uptitrate as tolerated\n - monitor on telemetry\n - Continue Pain Control\n - Change albuterol to PRN\n .\n # Sedation: Has had inconsistent response to sedation, unclear what is\n best regime. Will continue to wean overall\n - DC haldol and taper valium to 2.5 mg PRN TID, taper off\n - .\n # Adrenal Insufficency: Followed up with endocrine that suggested if\n the patient under goes major stressors such as major surgery, sepsis,\n she may need stress dosed steroids.\n - Endocrine s/o\n no need for steroids currently\n .\n # Fluid Status: Volume overloaded in prior setting of Hypernatremia\n - Monitoring urine output\n - increasse Free H20, for mild hypernatremia 200cc Free bolus PEG, and\n - 500cc D5W at 125.\n - PM lytes to assess hypernatremia\n .\n # UE DVT: right has resolved, new non occlusive in left axillary. INR\n 1.5\n -continue coumadin\n -follow INR\n - PICC lines DC\n .\n # Spine fracture: Stable\n - Brace for OOB, will discuss with Neurosurgery if current brace is\n optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n .\n # Tracheomalacia?: Was initially addressed with IP and they wanted to\n follow up as outpatient.\n - Consult IP for stent placement given improved clinical status, will\n readdresses\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Nutrition: Pt had emesis and extrusion of gastric contents through\n tracheostomy site (not through tube).\n - TFs held\n - Appreciate thoracic\ns recs\n will add reglan 10mg Q6\n .\n # Glycemic control: SSI, well controlled\n .\n # PIV x 1\n .\n # Ppx: Restarting Coumadin, Ranitidine, Bowel Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n # Code: Full\n # Dispo: ICU, Screening for vent facilities\n ICU Care\n Nutrition:\n Comments: Tube feeds\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 12:26 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-18 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 638227,
"text": "Chief Complaint:\n 24 Hour Events:\n Pt was agitated during the day with no response to PRN zyprexa.\n Her sodium was increased to 150 yesterday, and she was given 500cc D5W\n bolus and her FW flushes for her tube feeds was increases from 100 to\n 150.\n Overnight, pt received zyprexa, valium, and was placed back on the\n ventilator, after which she was more sedated and her SBP dropped to the\n 70s and HR remained 120-130s. Her BP came back up to 110s-120s when she\n was woken up.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:11 AM\n Morphine Sulfate - 04:00 AM\n Diazepam (Valium) - 05:24 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.4\nC (97.5\n HR: 126 (118 - 140) bpm\n BP: 98/62(70) {74/38(47) - 145/105(114)} mmHg\n RR: 29 (11 - 35) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 959 mL\n 1,250 mL\n PO:\n TF:\n 176 mL\n 140 mL\n IVF:\n 463 mL\n 810 mL\n Blood products:\n Total out:\n 1,980 mL\n 130 mL\n Urine:\n 1,980 mL\n 130 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,021 mL\n 1,120 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: MMV/PSV/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 408 (408 - 499) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 26\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 149\n PIP: 16 cmH2O\n Plateau: 21 cmH2O\n SpO2: 95%\n ABG: ///36/\n Ve: 6.4 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 452 K/uL\n 8.9 g/dL\n 104 mg/dL\n 0.7 mg/dL\n 36 mEq/L\n 3.5 mEq/L\n 6 mg/dL\n 103 mEq/L\n 145 mEq/L\n 29.2 %\n 7.1 K/uL\n [image002.jpg]\n 03:00 AM\n 07:05 PM\n 03:00 AM\n 05:00 AM\n 02:06 AM\n 07:34 AM\n 03:50 AM\n 06:22 AM\n 02:58 AM\n 03:43 AM\n WBC\n 7.2\n 5.2\n 5.9\n 7.5\n 5.6\n 6.1\n 7.0\n 7.1\n 7.1\n Hct\n 26.9\n 26.0\n 27.2\n 26.8\n 27.0\n 27.0\n 29.7\n 28.9\n 29.2\n Plt\n 238\n 240\n 296\n \n 395\n 462\n 452\n Cr\n 0.9\n 0.7\n 0.6\n 0.7\n 0.6\n 0.5\n 0.7\n 0.7\n 0.6\n 0.7\n Glucose\n 106\n 100\n 134\n 134\n 121\n 619\n 126\n 137\n 104\n Other labs: PT / PTT / INR:66.1/32.7/8.0, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:9.3 mg/dL, Mg++:2.2 mg/dL, PO4:3.8\n mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 12:38 PM 30 mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 12:35 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-18 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 638228,
"text": "Chief Complaint:\n 24 Hour Events:\n Pt was agitated during the day with no response to PRN zyprexa.\n Her sodium was increased to 150 yesterday, and she was given 500cc D5W\n bolus and her FW flushes for her tube feeds was increases from 100 to\n 150.\n Overnight, pt received zyprexa, valium, and was placed back on the\n ventilator, after which she was more sedated and her SBP dropped to the\n 70s and HR remained 120-130s. Her BP came back up to 110s-120s when she\n was woken up.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:11 AM\n Morphine Sulfate - 04:00 AM\n Diazepam (Valium) - 05:24 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.4\nC (97.5\n HR: 126 (118 - 140) bpm\n BP: 98/62(70) {74/38(47) - 145/105(114)} mmHg\n RR: 29 (11 - 35) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 959 mL\n 1,250 mL\n PO:\n TF:\n 176 mL\n 140 mL\n IVF:\n 463 mL\n 810 mL\n Blood products:\n Total out:\n 1,980 mL\n 130 mL\n Urine:\n 1,980 mL\n 130 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,021 mL\n 1,120 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: MMV/PSV/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 408 (408 - 499) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 26\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 149\n PIP: 16 cmH2O\n Plateau: 21 cmH2O\n SpO2: 95%\n ABG: ///36/\n Ve: 6.4 L/min\n Physical Examination\n Gen: NAD, A0X3\n HEENT: PERRLA, EOMI\n Resp: Limited by patients mobility, but CTA anteriorly\n Card: S1S2 tachy\n Abd: Soft, Non-tender, Non-distended, BS+\n Exte: No edema\n Labs / Radiology\n 452 K/uL\n 8.9 g/dL\n 104 mg/dL\n 0.7 mg/dL\n 36 mEq/L\n 3.5 mEq/L\n 6 mg/dL\n 103 mEq/L\n 145 mEq/L\n 29.2 %\n 7.1 K/uL\n [image002.jpg]\n 03:00 AM\n 07:05 PM\n 03:00 AM\n 05:00 AM\n 02:06 AM\n 07:34 AM\n 03:50 AM\n 06:22 AM\n 02:58 AM\n 03:43 AM\n WBC\n 7.2\n 5.2\n 5.9\n 7.5\n 5.6\n 6.1\n 7.0\n 7.1\n 7.1\n Hct\n 26.9\n 26.0\n 27.2\n 26.8\n 27.0\n 27.0\n 29.7\n 28.9\n 29.2\n Plt\n 238\n 240\n 296\n \n 395\n 462\n 452\n Cr\n 0.9\n 0.7\n 0.6\n 0.7\n 0.6\n 0.5\n 0.7\n 0.7\n 0.6\n 0.7\n Glucose\n 106\n 100\n 134\n 134\n 121\n 619\n 126\n 137\n 104\n Other labs: PT / PTT / INR:66.1/32.7/8.0, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:9.3 mg/dL, Mg++:2.2 mg/dL, PO4:3.8\n mg/dL\n Assessment and Plan\n 55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach, PEG, placement no with respiratory failure secondary to\n tracheomalacia , resolving HAP.\n .\n # Respiratory failure: Slowly Improving. Pressure support of at\n night.\n - Continue to increase time on trach mask as tolerated.\n - PMV with suctioning.\n .\n # HAP vs Aspiration PNA: Afebrile without leukocytosis\n - Completed course of ceftriaxone\n - Continue to f/u cultures\n - Continue trach mask as tolerated\n .\n # Tachycardia: Sinus Tach with occasional runs of SVT, now on low dose\n b-blocker. . HR decreased overnight with ranges of 115-135. From\n yesterday when pt found had runs of SVT as well as ST 120\ns to 150s.\n SBPs approx 65.\n Had Negative CTA, thyroid fxn WNL,\n - HR became tachy on , will further investigate events surrounding\n the event for further data\n - cont metoprolol 12.5mg TID and up titrate as tolerated\n - monitor on telemetry\n - Continue Pain Control\n .\n # Sedation: Inconsistent response to sedation, unclear what is best\n regime. Will continue to wean overall\n - Started on Olanzapine QHS\n - DC\nd haldol and taper valium to 2.5 mg PRN TID, taper off\n # Nutrition: Pt had emesis overnight. TFs currently held. Given\n Reglan.\n - Restart Nutrition as tolerated\n .\n # Adrenal Insufficency: Endocrine following. Followed Suggesting if\n the patient under goes major stressors such as major surgery, sepsis,\n she may need stress dosed steroids.\n - Endocrine s/o\n no need for steroids currently\n .\n # Fluid Status: Volume overloaded in prior setting of Hypernatremia\n - Monitoring urine output\n - increase Free H20, for mild hypernatremia 200cc Free bolus PEG, and\n - 500cc D5W at 125.\n - PM lytes to assess hypernatremia\n .\n # UE DVT: right has resolved, new non occlusive in left axillary. INR\n supratherapeutic today\n - decrease coumadin to home dose of 2.5mg\n - follow INR\n .\n # Spine fracture: Stable\n - Brace for OOB, will discuss with Neurosurgery if current brace is\n optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n .\n # Tracheomalacia. Was initially addressed with IP and they wanted to\n follow up as outpatient.\n - Consult IP for stent placement given improved clinical status, will\n readdresses\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # PIV x 1\n # Ppx: Coumadin, Ranitidine, Bowel Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n # Code: Full\n # Dispo: ICU, Screening for vent facilities\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 12:38 PM 30 mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 12:35 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 636842,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on trach collar 50%. Sats fell to 78%. Pt ambu\nd and\n lavaged with no plugs detected. RR 30-40 . Pt diaphoretic.\n Action:\n Placed on PSV 10/5/50%\n Response:\n Apneic with RR 3-5\n Plan:\n Rested on AC 500/12/5/50%. No further episodes of desating or\n tachypnea.\n Hypotension (not Shock)\n Assessment:\n BP falling to 78/37. Urine output 5-30ccs/hr via foley\n Action:\n Given 500ccs\n NS fluid bolus\n Response:\n Pt normotensive, improved urine output\n Plan:\n Continue to monitor.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Temp spike to 102.2 po\n Action:\n Blood, urine and sputum cxs sent. Sputum white, not yellow or\n consistant with TF. Chest x-ray taken. Tylenol pr given. Cool cloths\n applied.\n Response:\n Pt normothermic. WBC 7.2\n Plan:\n Monitor fever curve, cooling measures. Follow-up on cx results.\n Alteration in Nutrition\n Assessment:\n Pt vomiting yellow fluid with coughing and when turned\n Action:\n TF held. Peg to gravity. Medicated with 4 mg zofran iv.\n Response:\n No further episodes of vomiting.\n Plan:\n Continue to monitor. Aspiration precautions. ? need for alternative\n form of nutrition.\n Altered mental status (not Delirium)\n Assessment:\n Onset of shift, pt lethargic, not following commands but MAE. ~ 12 mn\n pt agitated, attempting to climb oob, disconnecting self from vent\n despite restraints\n Action:\n 5 mg valium given q 8hrs. Haldol 2.5 mg given.\n Response:\n Pt still agitated\n Plan:\n Needs better sedation at bedtime - ? zyprexa or alternative med\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 636935,
"text": "56 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\n with prolonged hospital course c/b by PNA, anxiety/altered mental\n status, RUE DVT .\n Altered mental status (not Delirium)\n Assessment:\n Rec\nd pt very restless/agitated, repeatedly attempting to sit up in bed\n and pulling at soft wrist restraints. When arms freed, she immediately\n disconnected trach from vent. Agitation did not subside with verbal\n reassurance or scheduled dose valium. Pt follows commands\n inconsistently, has difficulty initiating cough on command. MAEE with\n good strength. Not grimacing and denied pain by mouthing words.\n Action:\n Pt noted to have rash per below, nodded\n to\nDoes you back itch?\n and rec\nd Benadryl 25mg IV @ 1345.\n Response:\n Pt finally sleeping after having been awake most of night and very\n restless all morning.\n Plan:\n Benadryl Q6hrs PRN. Cont freq mental/neuro eval.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt on AC vent settings 50%/12 X 500/+5.\n Action:\n Response:\n Plan:\n Tachycardia, Other\n Assessment:\n HR 130\ns @ rest throughout shift, and still > 125 when pt soundly\n sleeping. Pt Afebrile.\n Action:\n Response:\n Plan:\n Rash\n Assessment:\n Pt noted to have raised red rash evenly distributed over mid/lower\n back. Pt has been very restless, and nodded\n to\nDoes your back\n itch?\n. No new meds recently.\n Action:\n Team made aware, and they examined rash. Pt rec\nd Benadryl 25mg IV X 1.\n Response:\n Pt finally able to sleep after very restless night and morning.\n Plan:\n Benadryl PRN Q6hrs. ? Sarna lotion. Cont to monitor rash.\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 638376,
"text": "Addendum:\n Decreased urine ouput:\n Urine ouput decreased to 20 -10 cc/hr. foley catheter flushed easily\n and return clear. D 5 w increased to 125 cc/hr. urine ouput did not\n pick up until after pt given lasix dose of 10 mg iv. Diuresed. 0600\n urine ouput again decreased to 15 cc/hr\n Plan: monitor urine ouput.. notify ho if uo continues < 30 cc/hr.\n Altered rhythm: pt in a sinus tachycardia throughout the night, about\n 6:05 this morning pt converted to a first degree avb. O0600 lopressor\n dose held for sbp 86/\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-14 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 637419,
"text": "Chief Complaint:\n 24 Hour Events:\n UOP 10-20cc/hr, tachy to 150s while sitting upright, 120s at rest.\n Pt on PMV but had heavy secretions. Trach collar for 5 hours.\n Repeat Sputum Cx + for GNR, fungal, 1+ Gram + Cocci in Pairs.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 09:40 AM\n Levofloxacin - 11:15 PM\n Ceftriaxone - 07:50 PM\n Infusions:\n Other ICU medications:\n Haloperidol (Haldol) - 10:26 AM\n Diazepam (Valium) - 11:33 AM\n Morphine Sulfate - 02:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.7\nC (98.1\n HR: 118 (118 - 148) bpm\n BP: 90/37(48) {90/37(48) - 171/111(115)} mmHg\n RR: 14 (12 - 36) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,614 mL\n 439 mL\n PO:\n TF:\n 884 mL\n 279 mL\n IVF:\n 100 mL\n Blood products:\n Total out:\n 834 mL\n 20 mL\n Urine:\n 834 mL\n 20 mL\n NG:\n Stool:\n Drains:\n Balance:\n 780 mL\n 419 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 354 (244 - 376) mL\n PS : 10 cmH2O\n RR (Spontaneous): 12\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 56\n PIP: 15 cmH2O\n SpO2: 95%\n ABG: ////\n Ve: 4.1 L/min\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n Eyes / Conjunctiva: PERRL, Pupils dilated\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Bowel sounds present, Obese, Patient with thoracic\n brace on\n Skin: Not assessed, No(t) Rash: , Per Nursing: Pt with vesicular rash\n on inferior back.\n Neurologic: Follows simple commands, Responds to: Not assessed,\n Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 240 K/uL\n 7.9 g/dL\n 100 mg/dL\n 0.6 mg/dL\n 30 mEq/L\n 3.4 mEq/L\n 12 mg/dL\n 108 mEq/L\n 146 mEq/L\n 26.0 %\n 5.2 K/uL\n [image002.jpg]\n 08:11 PM\n 02:51 AM\n 03:10 AM\n 03:08 PM\n 03:00 AM\n 03:36 AM\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n WBC\n 9.4\n 11.3\n 7.3\n 6.1\n 7.2\n 5.2\n Hct\n 26.6\n 24.9\n 27.6\n 26.5\n 26.9\n 26.0\n Plt\n \n Cr\n 0.9\n 0.7\n 0.6\n 0.6\n 0.9\n 0.7\n 0.6\n TCO2\n 29\n 26\n Glucose\n 128\n 114\n 114\n 99\n 115\n 106\n 100\n Other labs: PT / PTT / INR:17.6/27.4/1.6, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:33/22, Alk Phos / T Bili:143/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:0.5 mmol/L,\n Albumin:3.5 g/dL, LDH:199 IU/L, Ca++:8.9 mg/dL, Mg++:2.4 mg/dL, PO4:4.1\n mg/dL\n Assessment and Plan\n 55yoF with history of EtOH abuse presenting following mechanical fall\n and traumatic T spine fracture, now s/p trach, PEG, placement being\n treated for HAP.\n# HAP vs Aspiration PNA: Cultures growing Klebsiella Oxytoca, Klebsiella Pneumon\niae, GNR, GP Cocci. Pt received developed rash on Levofloxacin, switched to Ceft\nriaxone overnight. Will treat for potential HAP for 8 days.\n - Continue Ceftriaxone HAP (Day #6 of 8)\n - Tube Feeds now at 50 with goal of 60/hr\n - Following Cultures\n .\n # Respiratory failure: 5 hours on Trach mask yesterday, will assess\n length of tolerance today.\n - PMV with suctioning.\n - Weaning FiO2 as tolerated\n # Tachycardia: Pt in ST 120\ns to 150s. Etiology remains unclear and\n etiologies include hypovolemia, pain, infection (pt with known\n klebsiella), . DDx also includes PE\n - Treating underlying infection\n - Bolus NS 500cc x 2 today and assess HR\n - Restarting patients Coumadin\n - TSH 2.4 on early , will check free T3, T4.\n - Continue Pain Control\n # Sedation: Pt has pain/delirium causing tachycardia and hypertension\n with intermittent hypotension. Had good response to morphine, minimal\n response to haldol bolus.\n - Haldol 5 TID, Fentanyl 75 mcg TP, Diazapam 10 QID;\n - Haldol, midazolam and morphine PRN.\n - tolerating current regimen well\n # Adrenal Insufficency: Followed up with endocrine that suggested if\n the patient under goes major stressors such as major surgery, sepsis,\n she may need stress dosed steroids.\n - Will consider MRI at later date for evaluation of pituitary\n # Fluid Status: Volume overloaded in prior setting of Hypernatremia\n Goal even today.\n - Monitoring urine output\n # RUE DVT: INR was super-therapeutic on coumadin. Goal . Received 5\n of coumadin overnight.\n - Restarting Coumadin 2.5 mg QHS once INR < 3\n # Spine fracture: Stable\n - Brace for OOB, will discuss with Neurosurgery if current brace is\n optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n # Tracheomalacia?: Discussed with IP.\n - Outpatient f/u once off pressure support to assess for possible\n stenting\n #. Thyroid Nodule on CT\n - Outpatient follow up\n # Nutrition: TFs with goal of 60\n # Glycemic control: SSI, well controlled\n # Lines L PICC\n ().\n # Ppx: Restarting Coumadin, Ranitidine, Bowel Regimen\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n # Code: Full\n # Dispo: ICU, Screening for vent facilities\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 11:38 AM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n 20 Gauge - 04:59 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-15 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 637728,
"text": "Chief Complaint: resp failuire\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n ULTRASOUND - At 03:48 PM\n US of Lt arm shows small 1 cm axillary clot non occlusive near PICC\n RUS US shows resolutyion of formal clot\n Vomting tube feeds around trach\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Ceftriaxone - 10:00 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 06:20 AM\n Pantoprazole (Protonix) - 08:12 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Gastrointestinal: Emesis\n Flowsheet Data as of 10:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 36.2\nC (97.1\n HR: 146 (123 - 146) bpm\n BP: 153/129(134) {106/41(56) - 185/129(142)} mmHg\n RR: 26 (11 - 33) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,888 mL\n 520 mL\n PO:\n TF:\n 1,268 mL\n IVF:\n 100 mL\n Blood products:\n Total out:\n 1,530 mL\n 845 mL\n Urine:\n 1,510 mL\n 820 mL\n NG:\n 20 mL\n 25 mL\n Stool:\n Drains:\n Balance:\n 358 mL\n -325 mL\n Respiratory support\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 227 (227 - 397) mL\n PS : 8 cmH2O\n RR (Spontaneous): 20\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 194\n PIP: 16 cmH2O\n SpO2: 96%\n ABG: ///34/\n Ve: 6.5 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 8.5 g/dL\n 335 K/uL\n 121 mg/dL\n 0.5 mg/dL\n 34 mEq/L\n 3.8 mEq/L\n 7 mg/dL\n 107 mEq/L\n 147 mEq/L\n 27.0 %\n 5.6 K/uL\n [image002.jpg]\n 03:08 PM\n 03:00 AM\n 03:36 AM\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n 05:00 AM\n 02:06 AM\n 07:34 AM\n WBC\n 7.3\n 6.1\n 7.2\n 5.2\n 5.9\n 7.5\n 5.6\n Hct\n 27.6\n 26.5\n 26.9\n 26.0\n 27.2\n 26.8\n 27.0\n Plt\n 189\n 209\n 238\n \n 335\n Cr\n 0.6\n 0.6\n 0.9\n 0.7\n 0.6\n 0.7\n 0.6\n 0.5\n TCO2\n 26\n Glucose\n 99\n 115\n 106\n 100\n 134\n 134\n 121\n Other labs: PT / PTT / INR:16.6/25.0/1.5, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:9.3 mg/dL, Mg++:2.3 mg/dL, PO4:4.1\n mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 638220,
"text": "56 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\n with prolonged hospital course c/b by PNA, anxiety/altered mental\n status, RUE DVT .Pt found to have small non occlusive Clot on her right\n axial vein via Ultrasound.Yesterday Pt went down to IR for Peg revision\n aspiration risk couldn\nt do it due the type of peg she has now.\n Altered mental status (not Delirium)\n Assessment:\n Restless, attempting to get OOB, kicking and hitting siderails,\n attempting to sit up, attempting to grab at all lines and tubes, bilat\n wrist restraints and waist belt on for pt\ns safety, mouthing words and\n following simple commands, slept soundly for 3-4 hours following\n zyprexa and valium\n Action:\n Morphine 2 mg. IV x 2 with no effect, Zyprexa and valium at bedtime\n with pt asleep for 3-4 hours, Valium 2.5 mg again this am with no\n effect, When pt asleep s BP dips to 70-80\ns---MICU team assessed and pt\n received LR 500ml fluid bolus x 1, scheduled 2am valium dose held d/t\n low BP, freq. reorientation and freq. safety checks\n Response:\n Good response with combination of zyprexa and valium, otherwise no sig.\n improvement with other interventions\n Plan:\n Continue freq. safety checks and reorientation, INR level is 8 this am\n and with pt a high fall risk pt will need to be a 1:1 if gets OOB to\n chair today, continue valium and zyprexa, obtain psych consult to\n assist with management of anxiety issues and for advice on other\n medicines available that may help pt\ns agitation.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Tachypneic but with good Sats on trach mask during eves, Tolerating\n trach mask until received zyprexa and valium and then pt RR drive down\n with apneic periods requiring rest on vent overnight, mod. Amts thick\n secretions continue\n Action:\n Placed on MMV mode overnight, suctioned Q2-3 hours for thick\n tan/bloodtinged sputum, CPT, trach care\n Response:\n Sats >95 % on vent overnight\n Plan:\n Wean back to trach mask this am, continue to rest on vent overnight as\n needed, continue aggressive pulmonary toileting.\n Hypernatremia (high sodium)\n Assessment:\n Na up to 150 during eves, low urine output, low BP when asleep\n Action:\n 500 ml of D5W over 4hours followed by 500 ml LR over 4 hours for both\n high sodium and low urine output, Free water fluid boluses via PEG\n increased to 150ml q 4hrs.\n Response:\n Sodium down to 145 this am, urine output increased from 10-15ml/hr to\n 20-30ml/hr\n Plan:\n Continue free water via PEG, continue to monitor lytes QD.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Good peripheral pulses bilat, no BP on upper extremities, on coumadin\n Action:\n Assessed for evidence of bleeding\n Response:\n No signs of bleeding noted, INR reported as 8.0 this am---MICU team\n aware, Hct stable at 29.2 and platelets WNL\n Plan:\n Hold coumadin dose today and resend coags this evening, send clot to BB\n at next blood draw, monitor for signs of bleeding\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 637005,
"text": "56 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\n with prolonged hospital course c/b by PNA, anxiety/altered mental\n status, RUE DVT .\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on PSV 10/5/50%. RR 20-30. )2 sat > 97%\n Action:\n Pt remained on PSV rather than AC overnight. Suctioned ~q 3-4 hrs for\n sm amt yellow bld-tinged secretions. Continues to have copious oral\n secretions\n removed with yankeur.\n Response:\n Tolerated PSV well, no tachypnea or desaturation.\n Plan:\n Attempt trach collar trial again in am. On-going pulm hygiene\n Hypotension (not Shock)\n Assessment:\n BP 90/40 with urine output falling to 10-15ccs/hr via foley. HR remains\n tachycardic (110-140ST) even when pt is not agitated or febrile.\n Action:\n Given 1 500cc d5\n ns fluid bolus\n Response:\n SBP > 90, Urine output improving to >30ccs/hr\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Pt lethargic after receiving benedryl for several hrs but then awoke\n agitated, attempting to climb OOB and pull at trach despite restraints.\n Denies pain ( fentanyl patch in place) or need to go to the bathroom.\n c/o itchiness on back\n Action:\n Medicated with iv benedryl.\n Response:\n Less agitated. Slept again\n Plan:\n Continue to reorient pt, benedryl for pruritis, safety precautions.\n"
},
{
"category": "Respiratory ",
"chartdate": "2167-10-13 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 637241,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 25\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Cuffed\n Manufacturer: Portex\n Size: 7.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Bronchial\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 638221,
"text": "56 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\n with prolonged hospital course c/b by PNA, anxiety/altered mental\n status, RUE DVT .Pt found to have small non occlusive Clot on her right\n axial vein via Ultrasound.Yesterday Pt went down to IR for Peg revision\n aspiration risk couldn\nt do it due the type of peg she has now.\n Altered mental status (not Delirium)\n Assessment:\n Restless, attempting to get OOB, kicking and hitting siderails,\n attempting to sit up, attempting to grab at all lines and tubes, bilat\n wrist restraints and waist belt on for pt\ns safety, mouthing words and\n following simple commands, slept soundly for 3-4 hours following\n zyprexa and valium\n Action:\n Morphine 2 mg. IV x 2 with no effect, Zyprexa and valium at bedtime\n with pt asleep for 3-4 hours, Valium 2.5 mg again this am with no\n effect, When pt asleep s BP dips to 70-80\ns---MICU team assessed and pt\n received LR 500ml fluid bolus x 1, scheduled 2am valium dose held d/t\n low BP, freq. reorientation and freq. safety checks\n Response:\n Good response with combination of zyprexa and valium, otherwise no sig.\n improvement with other interventions\n Plan:\n Continue freq. safety checks and reorientation, INR level is 8 this am\n and with pt a high fall risk pt will need to be a 1:1 if gets OOB to\n chair today, continue valium and zyprexa, obtain psych consult to\n assist with management of anxiety issues and for advice on other\n medicines available that may help pt\ns agitation.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Tachypneic but with good Sats on trach mask during eves, Tolerating\n trach mask until received zyprexa and valium and then pt RR drive down\n with apneic periods requiring rest on vent overnight, mod. Amts thick\n secretions continue\n Action:\n Placed on MMV mode overnight, suctioned Q2-3 hours for thick\n tan/bloodtinged sputum, CPT, trach care\n Response:\n Sats >95 % on vent overnight\n Plan:\n Wean back to trach mask this am, continue to rest on vent overnight as\n needed, continue aggressive pulmonary toileting.\n Hypernatremia (high sodium)\n Assessment:\n Na up to 150 during eves, low urine output, low BP when asleep\n Action:\n 500 ml of D5W over 4hours followed by 500 ml LR over 4 hours for both\n high sodium and low urine output, Free water fluid boluses via PEG\n increased to 150ml q 4hrs.\n Response:\n Sodium down to 145 this am, urine output increased from 10-15ml/hr to\n 20-30ml/hr\n Plan:\n Continue free water via PEG, continue to monitor lytes QD.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Good peripheral pulses bilat, no BP on upper extremities, on coumadin\n Action:\n Assessed for evidence of bleeding\n Response:\n No signs of bleeding noted, INR reported as 8.0 this am---MICU team\n aware, Hct stable at 29.2 and platelets WNL\n Plan:\n Hold coumadin dose today and resend coags this evening, send clot to BB\n at next blood draw, monitor for signs of bleeding\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 638222,
"text": "56 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\n with prolonged hospital course c/b by PNA, anxiety/altered mental\n status, RUE DVT .Pt found to have small non occlusive Clot on her right\n axial vein via Ultrasound.Yesterday Pt went down to IR for Peg revision\n aspiration risk couldn\nt do it due the type of peg she has now.\n Altered mental status (not Delirium)\n Assessment:\n Restless, attempting to get OOB, kicking and hitting siderails,\n attempting to sit up, attempting to grab at all lines and tubes, bilat\n wrist restraints and waist belt on for pt\ns safety, mouthing words and\n following simple commands, slept soundly for 3-4 hours following\n zyprexa and valium\n Action:\n Morphine 2 mg. IV x 2 with no effect, Zyprexa and valium at bedtime\n with pt asleep for 3-4 hours, Valium 2.5 mg again this am with no\n effect, When pt asleep s BP dips to 70-80\ns---MICU team assessed and pt\n received LR 500ml fluid bolus x 1, scheduled 2am valium dose held d/t\n low BP, freq. reorientation and freq. safety checks\n Response:\n Good response with combination of zyprexa and valium, otherwise no sig.\n improvement with other interventions\n Plan:\n Continue freq. safety checks and reorientation, INR level is 8 this am\n and with pt a high fall risk pt will need to be a 1:1 if gets OOB to\n chair today, continue valium and zyprexa, obtain psych consult to\n assist with management of anxiety issues and for advice on other\n medicines available that may help pt\ns agitation.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Tachypneic but with good Sats on trach mask during eves, Tolerating\n trach mask until received zyprexa and valium and then pt RR drive down\n with apneic periods requiring rest on vent overnight, mod. Amts thick\n secretions continue\n Action:\n Placed on MMV mode overnight, suctioned Q2-3 hours for thick\n tan/bloodtinged sputum, CPT, trach care\n Response:\n Sats >95 % on vent overnight\n Plan:\n Wean back to trach mask this am, continue to rest on vent overnight as\n needed, continue aggressive pulmonary toileting.\n Hypernatremia (high sodium)\n Assessment:\n Na up to 150 during eves, low urine output, low BP when asleep\n Action:\n 500 ml of D5W over 4hours followed by 500 ml LR over 4 hours for both\n high sodium and low urine output, Free water fluid boluses via PEG\n increased to 150ml q 4hrs.\n Response:\n Sodium down to 145 this am, urine output increased from 10-15ml/hr to\n 20-30ml/hr\n Plan:\n Continue free water via PEG, continue to monitor lytes QD.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Good peripheral pulses bilat, no BP on upper extremities, on coumadin\n Action:\n Assessed for evidence of bleeding\n Response:\n No signs of bleeding noted, INR reported as 8.0 this am---MICU team\n aware, Hct stable at 29.2 and platelets WNL\n Plan:\n Hold coumadin dose today and resend coags this evening, send clot to BB\n at next blood draw, monitor for signs of bleeding\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 636932,
"text": "56 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\n with prolonged hospital course c/b by PNA, anxiety/altered mental\n status, RUE DVT .\n Altered mental status (not Delirium)\n Assessment:\n Rec\nd pt very restless/agitated, repeatedly attempting to sit up in bed\n and pulling at soft wrist restraints. When arms freed, she immediately\n disconnected trach from vent. Agitation did not subside with verbal\n reassurance or scheduled dose valium. Pt follows commands\n inconsistently, has difficulty initiating cough on command. MAEE with\n good strength. Not grimacing and denied pain by mouthing words.\n Action:\n Pt noted to have rash per below, nodded\n to\nDoes you back itch?\n and rec\nd Benadryl 25mg IV @ 1345.\n Response:\n Pt finally sleeping after having been awake most of night and very\n restless all morning.\n Plan:\n Benadryl Q6hrs PRN. Cont freq mental/neuro eval.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 636986,
"text": "56 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\n with prolonged hospital course c/b by PNA, anxiety/altered mental\n status, RUE DVT .\n Altered mental status (not Delirium)\n Assessment:\n Rec\nd pt very restless/agitated, repeatedly attempting to sit up in bed\n and pulling at soft wrist restraints. When arms freed, she immediately\n disconnected trach from vent. Agitation did not subside with verbal\n reassurance or scheduled dose valium. Pt follows commands\n inconsistently, has difficulty initiating cough on command. MAEE with\n good strength. Not grimacing and denied pain by mouthing words.\n Action:\n Pt noted to have rash per below, nodded\n to\nDoes you back itch?\n and rec\nd Benadryl 25mg IV @ 1345.\n Response:\n Pt finally slept for 2hrs after having been awake most of night and\n very restless all morning.\n Plan:\n Benadryl Q6hrs PRN. Cont freq mental/neuro eval.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt on AC vent settings 50%/12 X 500/+5 with SRR 17-20\ns and\n regular. O2 sat 96-100%. Lungs snds rhonchorous bilat, diminished in\n bases. Pt with weak cough, raising mod amts thick white sputum but not\n fully expectorating it from trach.\n Action:\n Pt placed on TM @ 70% @ 0900. Suctionned PRN for mod amts sputum.\n Response:\n O2 sat stable until pt soundly sleeping and de-sated to 80\ns. TM inc\n to 100% with return of O2 sat to high 90\ns. However, when she woke @\n 1600 RR inc\nd and HR 140\ns with pt becoming diaphoretic. Pt returned to\n CPAP/PS 8/+5/50% @ 1800. HR presently in 120\ns with pt appearing\n comfortable.\n Plan:\n Cont to wean from vent as tolerated. Cont to encourage C&DB.\n Tachycardia, Other\n Assessment:\n HR 130- without VEA @ rest throughout shift, and still > 125\n when pt soundly sleeping. Pt Afebrile.\n Action:\n MD aware. After being on TM all day, pt returned to CPAP/PS @ 1800.\n Response:\n HR presently in 120\ns with pt looking comfortable.\n Plan:\n ? pt dry->monitor I/O\ns. Cont emotional support.\n Rash\n Assessment:\n Pt noted to have raised red rash evenly distributed over mid/lower\n back. Pt has been very restless, and nodded\n to\nDoes your back\n itch?\n. No new meds recently.\n Action:\n Team made aware, and they examined rash. Pt rec\nd Benadryl 25mg IV X 1.\n Levofloxacin D/C\n Response:\n Pt finally able to sleep after very restless night and morning. HR\n 130\ns->125ST. O2 sat \nd to 80\ns with RR inc\nd to high 20\ns and\n shallow.\n Plan:\n Benadryl PRN Q6hrs. ? Sarna lotion. Cont to monitor rash.\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-12 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 637175,
"text": "Chief Complaint:\n 24 Hour Events:\n Developed papular rash over entire back, bilaterally in multidermatomal\n distributions, opaque vesicles on erythematous base, non-painful,\n possibly pruritic\n Levofloxacin d/c'd\n Ceftriaxone Initiated for pan-sensitive\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Aztreonam - 03:42 AM\n Vancomycin - 09:40 AM\n Levofloxacin - 11:15 PM\n Ceftriaxone - 07:50 PM\n Infusions:\n Other ICU medications:\n Haloperidol (Haldol) - 10:26 AM\n Diazepam (Valium) - 11:33 AM\n Morphine Sulfate - 02:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Ear, Nose, Throat: Dry mouth\n Cardiovascular: No(t) Chest pain\n Respiratory: No(t) Tachypnea\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea\n Flowsheet Data as of 05:15 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 37.1\nC (98.7\n HR: 129 (113 - 148) bpm\n BP: 100/45(57) {85/40(50) - 171/111(115)} mmHg\n RR: 21 (9 - 36) insp/min\n SpO2: 93%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,362 mL\n 1,102 mL\n PO:\n TF:\n 47 mL\n 532 mL\n IVF:\n 1,061 mL\n 100 mL\n Blood products:\n Total out:\n 1,203 mL\n 755 mL\n Urine:\n 1,203 mL\n 755 mL\n NG:\n Stool:\n Drains:\n Balance:\n 159 mL\n 347 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Set): 0 (0 - 0) mL\n Vt (Spontaneous): 244 (110 - 504) mL\n PS : 10 cmH2O\n RR (Set): 0\n RR (Spontaneous): 19\n PEEP: 5 cmH2O\n FiO2: 70%\n RSBI: 245\n PIP: 16 cmH2O\n SpO2: 93%\n ABG: ///30/\n Ve: 10 L/min\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n Eyes / Conjunctiva: PERRL, Pupils dilated\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Bowel sounds present, Obese, Patient with thoracic\n brace on\n Skin: Not assessed, No(t) Rash: , Per Nursing: Pt with vesicular rash\n on inferior back.\n Neurologic: Follows simple commands, Responds to: Not assessed,\n Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 240 K/uL\n 7.9 g/dL\n 100 mg/dL\n 0.6 mg/dL\n 30 mEq/L\n 3.4 mEq/L\n 12 mg/dL\n 108 mEq/L\n 146 mEq/L\n 26.0 %\n 5.2 K/uL\n [image002.jpg]\n 08:11 PM\n 02:51 AM\n 03:10 AM\n 03:08 PM\n 03:00 AM\n 03:36 AM\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n WBC\n 9.4\n 11.3\n 7.3\n 6.1\n 7.2\n 5.2\n Hct\n 26.6\n 24.9\n 27.6\n 26.5\n 26.9\n 26.0\n Plt\n \n Cr\n 0.9\n 0.7\n 0.6\n 0.6\n 0.9\n 0.7\n 0.6\n TCO2\n 29\n 26\n Glucose\n 128\n 114\n 114\n 99\n 115\n 106\n 100\n Other labs: PT / PTT / INR:17.6/27.4/1.6, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:33/22, Alk Phos / T Bili:143/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:0.5 mmol/L,\n Albumin:3.5 g/dL, LDH:199 IU/L, Ca++:8.9 mg/dL, Mg++:2.4 mg/dL, PO4:4.1\n mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 11:38 AM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n 20 Gauge - 04:59 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-12 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 637177,
"text": "Chief Complaint:\n 24 Hour Events:\n Developed papular rash over entire back, bilaterally in multidermatomal\n distributions, opaque vesicles on erythematous base, non-painful,\n possibly pruritic\n Levofloxacin d/c'd\n Ceftriaxone Initiated for pan-sensitive\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Aztreonam - 03:42 AM\n Vancomycin - 09:40 AM\n Levofloxacin - 11:15 PM\n Ceftriaxone - 07:50 PM\n Infusions:\n Other ICU medications:\n Haloperidol (Haldol) - 10:26 AM\n Diazepam (Valium) - 11:33 AM\n Morphine Sulfate - 02:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Ear, Nose, Throat: Dry mouth\n Cardiovascular: No(t) Chest pain\n Respiratory: No(t) Tachypnea\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea\n Flowsheet Data as of 05:15 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 37.1\nC (98.7\n HR: 129 (113 - 148) bpm\n BP: 100/45(57) {85/40(50) - 171/111(115)} mmHg\n RR: 21 (9 - 36) insp/min\n SpO2: 93%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,362 mL\n 1,102 mL\n PO:\n TF:\n 47 mL\n 532 mL\n IVF:\n 1,061 mL\n 100 mL\n Blood products:\n Total out:\n 1,203 mL\n 755 mL\n Urine:\n 1,203 mL\n 755 mL\n NG:\n Stool:\n Drains:\n Balance:\n 159 mL\n 347 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Set): 0 (0 - 0) mL\n Vt (Spontaneous): 244 (110 - 504) mL\n PS : 10 cmH2O\n RR (Set): 0\n RR (Spontaneous): 19\n PEEP: 5 cmH2O\n FiO2: 70%\n RSBI: 245\n PIP: 16 cmH2O\n SpO2: 93%\n ABG: ///30/\n Ve: 10 L/min\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n Eyes / Conjunctiva: PERRL, Pupils dilated\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Bowel sounds present, Obese, Patient with thoracic\n brace on\n Skin: Not assessed, No(t) Rash: , Per Nursing: Pt with vesicular rash\n on inferior back.\n Neurologic: Follows simple commands, Responds to: Not assessed,\n Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 240 K/uL\n 7.9 g/dL\n 100 mg/dL\n 0.6 mg/dL\n 30 mEq/L\n 3.4 mEq/L\n 12 mg/dL\n 108 mEq/L\n 146 mEq/L\n 26.0 %\n 5.2 K/uL\n [image002.jpg]\n 08:11 PM\n 02:51 AM\n 03:10 AM\n 03:08 PM\n 03:00 AM\n 03:36 AM\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n WBC\n 9.4\n 11.3\n 7.3\n 6.1\n 7.2\n 5.2\n Hct\n 26.6\n 24.9\n 27.6\n 26.5\n 26.9\n 26.0\n Plt\n \n Cr\n 0.9\n 0.7\n 0.6\n 0.6\n 0.9\n 0.7\n 0.6\n TCO2\n 29\n 26\n Glucose\n 128\n 114\n 114\n 99\n 115\n 106\n 100\n Other labs: PT / PTT / INR:17.6/27.4/1.6, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:33/22, Alk Phos / T Bili:143/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:0.5 mmol/L,\n Albumin:3.5 g/dL, LDH:199 IU/L, Ca++:8.9 mg/dL, Mg++:2.4 mg/dL, PO4:4.1\n mg/dL\n Assessment and Plan\n 55yoF with history of EtOH abuse presenting following mechanical fall\n and traumatic T spine fracture with K. oxytoca PNA, and ARDS, intubated\n since the end of now s/p trach and PEG placement.\n# Recent Aspiration on Tube Feeds. Cultures growing Klebsiella Oxytoca and Klebs\niella Pneumoniae. Pt received developed rash on Levofloxacin, switched to Ceftri\naxone overnight. Will treat for potential HAP for 8 days.\n - Continue Ceftriaxone day #1.\n - Tube Feeds restarted with goal of 60/hr\n - Follow cultures\n - check tube placement\n .\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation. S/P Trach\n and PEG on .\n - Weaning FiO2 as tolerated\n - Will attempt trach collar today\n # Sedation: Pt has pain/delirium causing tachycardia and hypertension\n with intermittent hypotension. On Haldol 5 TID, Fentanyl 75 mcg TP,\n Diazapam 10 QID; Haldol, midazolam and morphine PRN. Had good response\n to morphine, minimal response to haldol bolus.\n - tolerating current regimen well, no changes today\n # Adrenal Insufficency: Hypotension that resolved with steroids,\n returned as they came off and is now improved again. Possible primary\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\n started on .\n - stopped steroids as per endocrine today\n # Volume overloaded in prior setting of hypernatremia\n Goal even\n today.\n - monitor urine output\n # RUE DVT: INR was super-therapeutic on coumadin. Goal . Hasn\n received coumadin in days yet INR continues to rise. Likely\n contributors are nutritional and antibiotics.\n - will start coumadin 2.5 mg QHS once INR < 3\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - Brace for OOB\n - Report from full trauma series from OSH is in chart.\n - No evidence of other fracture and no need for further spinal imaging\n based on this report and ortho note.\n # Tracheomalacia: Discussed with IP. Stenting unlikely to help for\n trachiomalacia as airways have poor structure diffusely.\n - Outpatient f/u once off pressure support to assess for possible\n stenting\n #. Thyroid Nodule on CT\n - Outpatient follow up\n # Nutrition: Replete (Full)\n hold\n # Glycemic control: SSI, well controlled\n # Lines L PICC\n ().\n # Ppx: INR remains therapeutic, ranitidine, colace and senna, miralax,\n bisacodyl.\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n Code: Full\n Dispo: ICU, being screening for vent facilities\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 11:38 AM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n 20 Gauge - 04:59 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-12 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 637179,
"text": "Chief Complaint:\n 24 Hour Events:\n Developed papular rash over entire back, bilaterally in multidermatomal\n distributions, opaque vesicles on erythematous base, non-painful,\n possibly pruritic\n Levofloxacin d/c'd\n Ceftriaxone Initiated for pan-sensitive\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Aztreonam - 03:42 AM\n Vancomycin - 09:40 AM\n Levofloxacin - 11:15 PM\n Ceftriaxone - 07:50 PM\n Infusions:\n Other ICU medications:\n Haloperidol (Haldol) - 10:26 AM\n Diazepam (Valium) - 11:33 AM\n Morphine Sulfate - 02:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Ear, Nose, Throat: Dry mouth\n Cardiovascular: No(t) Chest pain\n Respiratory: No(t) Tachypnea\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea\n Flowsheet Data as of 05:15 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 37.1\nC (98.7\n HR: 129 (113 - 148) bpm\n BP: 100/45(57) {85/40(50) - 171/111(115)} mmHg\n RR: 21 (9 - 36) insp/min\n SpO2: 93%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,362 mL\n 1,102 mL\n PO:\n TF:\n 47 mL\n 532 mL\n IVF:\n 1,061 mL\n 100 mL\n Blood products:\n Total out:\n 1,203 mL\n 755 mL\n Urine:\n 1,203 mL\n 755 mL\n NG:\n Stool:\n Drains:\n Balance:\n 159 mL\n 347 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Set): 0 (0 - 0) mL\n Vt (Spontaneous): 244 (110 - 504) mL\n PS : 10 cmH2O\n RR (Set): 0\n RR (Spontaneous): 19\n PEEP: 5 cmH2O\n FiO2: 70%\n RSBI: 245\n PIP: 16 cmH2O\n SpO2: 93%\n ABG: ///30/\n Ve: 10 L/min\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n Eyes / Conjunctiva: PERRL, Pupils dilated\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Bowel sounds present, Obese, Patient with thoracic\n brace on\n Skin: Not assessed, No(t) Rash: , Per Nursing: Pt with vesicular rash\n on inferior back.\n Neurologic: Follows simple commands, Responds to: Not assessed,\n Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 240 K/uL\n 7.9 g/dL\n 100 mg/dL\n 0.6 mg/dL\n 30 mEq/L\n 3.4 mEq/L\n 12 mg/dL\n 108 mEq/L\n 146 mEq/L\n 26.0 %\n 5.2 K/uL\n [image002.jpg]\n 08:11 PM\n 02:51 AM\n 03:10 AM\n 03:08 PM\n 03:00 AM\n 03:36 AM\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n WBC\n 9.4\n 11.3\n 7.3\n 6.1\n 7.2\n 5.2\n Hct\n 26.6\n 24.9\n 27.6\n 26.5\n 26.9\n 26.0\n Plt\n \n Cr\n 0.9\n 0.7\n 0.6\n 0.6\n 0.9\n 0.7\n 0.6\n TCO2\n 29\n 26\n Glucose\n 128\n 114\n 114\n 99\n 115\n 106\n 100\n Other labs: PT / PTT / INR:17.6/27.4/1.6, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:33/22, Alk Phos / T Bili:143/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:0.5 mmol/L,\n Albumin:3.5 g/dL, LDH:199 IU/L, Ca++:8.9 mg/dL, Mg++:2.4 mg/dL, PO4:4.1\n mg/dL\n Assessment and Plan\n 55yoF with history of EtOH abuse presenting following mechanical fall\n and traumatic T spine fracture with K. oxytoca PNA, and ARDS, intubated\n since the end of now s/p trach and PEG placement.\n# Recent Aspiration on Tube Feeds. Cultures growing Klebsiella Oxytoca and Klebs\niella Pneumoniae. Pt received developed rash on Levofloxacin, switched to Ceftri\naxone overnight. Will treat for potential HAP for 8 days.\n - Continue Ceftriaxone day #1.\n - Tube Feeds restarted with goal of 60/hr\n - Follow cultures\n - check tube placement\n .\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation. S/P Trach\n and PEG on .\n - Weaning FiO2 as tolerated\n - Will attempt trach collar today\n # Tachycardia: Pt in ST for most of the day 120\ns to 140s. Etiology\n remains unclear although she has been tachy since admission. Etiologies\n include pain (especially when sitting upright with thoracic brace on),\n infection (pt with known klebsiella, possibly acquired HAP). DDx also\n includes PE, hyperthyroidism.\n - Will keep pt\ns INR therapeutic\n - TSH 2.4 on early , will check free T3, T4.\n - Continue Pain Control\n - Treat underlying infection\n # Sedation: Pt has pain/delirium causing tachycardia and hypertension\n with intermittent hypotension. On Haldol 5 TID, Fentanyl 75 mcg TP,\n Diazapam 10 QID; Haldol, midazolam and morphine PRN. Had good response\n to morphine, minimal response to haldol bolus.\n - tolerating current regimen well, no changes today\n # Adrenal Insufficency: Hypotension that resolved with steroids,\n returned as they came off and is now improved again. Possible primary\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\n started on .\n - stopped steroids as per endocrine today\n # Volume overloaded in prior setting of hypernatremia\n Goal even\n today.\n - Monitoring urine output\n # RUE DVT: INR was super-therapeutic on coumadin. Goal . Hasn\n received coumadin in days yet INR continues to rise. Likely\n contributors are nutritional and antibiotics.\n - will start coumadin 2.5 mg QHS once INR < 3\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - Brace for OOB\n - Report from full trauma series from OSH is in chart.\n - Pt to follow up with Dr. in weeks\n # Tracheomalacia: Discussed with IP. Stenting unlikely to help for\n trachiomalacia as airways have poor structure diffusely.\n - Outpatient f/u once off pressure support to assess for possible\n stenting\n #. Thyroid Nodule on CT\n - Outpatient follow up\n # Nutrition: Replete (Full)\n hold\n # Glycemic control: SSI, well controlled\n # Lines L PICC\n ().\n # Ppx: INR remains therapeutic, ranitidine, colace and senna, miralax,\n bisacodyl.\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n Code: Full\n Dispo: ICU, being screening for vent facilities\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 11:38 AM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n 20 Gauge - 04:59 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Respiratory ",
"chartdate": "2167-10-14 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 637595,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 26\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 7.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Periodic SBT's for conditioning\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Cannot manage secretions\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-12 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 637047,
"text": "Chief Complaint:\n 24 Hour Events:\n Developed papular rash over entire back, bilateraly, in multiple\n dermatomal distributions, opaque vesicles on erythematous base,\n nonpainful, possibly pruritic.\n Levofloxaxin was d/c'd.\n Ceftriaxone started.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Aztreonam - 03:42 AM\n Vancomycin - 09:40 AM\n Levofloxacin - 11:15 PM\n Ceftriaxone - 07:50 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:14 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 37.2\nC (98.9\n HR: 139 (113 - 145) bpm\n BP: 97/61(68) {85/28(50) - 127/86(90)} mmHg\n RR: 12 (9 - 30) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,362 mL\n 302 mL\n PO:\n TF:\n 47 mL\n 152 mL\n IVF:\n 1,061 mL\n 100 mL\n Blood products:\n Total out:\n 1,203 mL\n 460 mL\n Urine:\n 1,203 mL\n 460 mL\n NG:\n Stool:\n Drains:\n Balance:\n 159 mL\n -158 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 0 (0 - 0) mL\n Vt (Spontaneous): 504 (110 - 504) mL\n PS : 10 cmH2O\n RR (Set): 0\n RR (Spontaneous): 14\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 245\n PIP: 16 cmH2O\n SpO2: 100%\n ABG: ///30/\n Ve: 5.9 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 240 K/uL\n 7.9 g/dL\n 100 mg/dL\n 0.6 mg/dL\n 30 mEq/L\n 3.4 mEq/L\n 12 mg/dL\n 108 mEq/L\n 146 mEq/L\n 26.0 %\n 5.2 K/uL\n [image002.jpg]\n 08:11 PM\n 02:51 AM\n 03:10 AM\n 03:08 PM\n 03:00 AM\n 03:36 AM\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n WBC\n 9.4\n 11.3\n 7.3\n 6.1\n 7.2\n 5.2\n Hct\n 26.6\n 24.9\n 27.6\n 26.5\n 26.9\n 26.0\n Plt\n \n Cr\n 0.9\n 0.7\n 0.6\n 0.6\n 0.9\n 0.7\n 0.6\n TCO2\n 29\n 26\n Glucose\n 128\n 114\n 114\n 99\n 115\n 106\n 100\n Other labs: PT / PTT / INR:17.6/27.4/1.6, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:33/22, Alk Phos / T Bili:143/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:0.5 mmol/L,\n Albumin:3.5 g/dL, LDH:199 IU/L, Ca++:8.9 mg/dL, Mg++:2.4 mg/dL, PO4:4.1\n mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 03:36 AM 30 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Respiratory ",
"chartdate": "2167-10-13 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 637399,
"text": "TITLE:\n Demographics\n Day of intubation:\n Day of mechanical ventilation: 25\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Not applicable\n Size: Not applicable\n Tracheostomy tube:\n Type: Cuffed\n Manufacturer: Portex\n Size: 7.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: weaning daily to\n trach collar as tolerated\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 637402,
"text": "Tachycardia, Other\n Assessment:\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 637407,
"text": "56 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\n with prolonged hospital course c/b by PNA, anxiety/altered mental\n status, RUE DVT .\n Tachycardia, Other\n Assessment:\n Pt\ns HR was 120\ns this am when asleep. When she woke up her HR went to\n 140\ns. When she was placed in the chair her HR increased to 150\n Her U/O was marginal at 5-10cc/hr. Her B/P 110/70\ns when in bed to\n 160-180/80 when in the chair.\n Action:\n She was given 2 boluses of 500cc NS.\n Response:\n The fluid boluses had no effect on her HR at all. Her U/O increased to\n 35-40cc/hr\n Plan:\n Continue to monitor her HR, B/P and U/O.\n Alteration in Nutrition\n Assessment:\n Tube feeding had been stopped for high residuals.\n Action:\n She was restarted at 8am back at 50cc/hr.\n Response:\n She tolerated the tube feeding with 10 cc residuals, and she had a very\n large stool.\n Plan:\n Continue to monitor TF residuals.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt\ns resp status stable, with RR 18-24 and O2 sats 95-97%.\n Action:\n She was placed in a chair at 10am and then put on the trach collar at\n 10:30.\n Response:\n She tolerated being up in the chair for 8hours and she is still on the\n trach collar\n Plan:\n Place back on PSV 8/5 for the night.\n Pt has been accepted at rehab. They were awaiting insurance\n approval and could have gone today but will probably go tomorrow.\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-13 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 637412,
"text": "Chief Complaint:\n 24 Hour Events:\n UOP 10-20cc/hr, tachy to 150s while sitting upright, 120s at rest.\n Pt on PMV but had heavy secretions. Trach collar for 5 hours.\n Repeat Sputum Cx + for GNR, fungal, 1+ Gram + Cocci in Pairs.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 09:40 AM\n Levofloxacin - 11:15 PM\n Ceftriaxone - 07:50 PM\n Infusions:\n Other ICU medications:\n Haloperidol (Haldol) - 10:26 AM\n Diazepam (Valium) - 11:33 AM\n Morphine Sulfate - 02:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.7\nC (98.1\n HR: 118 (118 - 148) bpm\n BP: 90/37(48) {90/37(48) - 171/111(115)} mmHg\n RR: 14 (12 - 36) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,614 mL\n 439 mL\n PO:\n TF:\n 884 mL\n 279 mL\n IVF:\n 100 mL\n Blood products:\n Total out:\n 834 mL\n 20 mL\n Urine:\n 834 mL\n 20 mL\n NG:\n Stool:\n Drains:\n Balance:\n 780 mL\n 419 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 354 (244 - 376) mL\n PS : 10 cmH2O\n RR (Spontaneous): 12\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 56\n PIP: 15 cmH2O\n SpO2: 95%\n ABG: ////\n Ve: 4.1 L/min\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n Eyes / Conjunctiva: PERRL, Pupils dilated\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Bowel sounds present, Obese, Patient with thoracic\n brace on\n Skin: Not assessed, No(t) Rash: , Per Nursing: Pt with vesicular rash\n on inferior back.\n Neurologic: Follows simple commands, Responds to: Not assessed,\n Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 240 K/uL\n 7.9 g/dL\n 100 mg/dL\n 0.6 mg/dL\n 30 mEq/L\n 3.4 mEq/L\n 12 mg/dL\n 108 mEq/L\n 146 mEq/L\n 26.0 %\n 5.2 K/uL\n [image002.jpg]\n 08:11 PM\n 02:51 AM\n 03:10 AM\n 03:08 PM\n 03:00 AM\n 03:36 AM\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n WBC\n 9.4\n 11.3\n 7.3\n 6.1\n 7.2\n 5.2\n Hct\n 26.6\n 24.9\n 27.6\n 26.5\n 26.9\n 26.0\n Plt\n \n Cr\n 0.9\n 0.7\n 0.6\n 0.6\n 0.9\n 0.7\n 0.6\n TCO2\n 29\n 26\n Glucose\n 128\n 114\n 114\n 99\n 115\n 106\n 100\n Other labs: PT / PTT / INR:17.6/27.4/1.6, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:33/22, Alk Phos / T Bili:143/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:0.5 mmol/L,\n Albumin:3.5 g/dL, LDH:199 IU/L, Ca++:8.9 mg/dL, Mg++:2.4 mg/dL, PO4:4.1\n mg/dL\n Assessment and Plan\n 55yoF with history of EtOH abuse presenting following mechanical fall\n and traumatic T spine fracture with K. oxytoca PNA, and ARDS, intubated\n since the end of now s/p trach and PEG placement.\n# Recent Aspiration on Tube Feeds. Cultures growing Klebsiella Oxytoca and Klebs\niella Pneumoniae. Pt received developed rash on Levofloxacin, switched to Ceftri\naxone overnight. Will treat for potential HAP for 8 days.\n - Continue Ceftriaxone day #1.\n - Tube Feeds restarted with goal of 60/hr\n - Follow cultures\n - check tube placement\n .\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation. S/P Trach\n and PEG on .\n - Weaning FiO2 as tolerated\n - Will attempt trach collar today\n # Tachycardia: Pt in ST for most of the day 120\ns to 140s. Etiology\n remains unclear although she has been tachy since admission. Etiologies\n include pain (especially when sitting upright with thoracic brace on),\n infection (pt with known klebsiella, possibly acquired HAP). DDx also\n includes PE, hyperthyroidism.\n - Will keep pt\ns INR therapeutic\n - TSH 2.4 on early , will check free T3, T4.\n - Continue Pain Control\n - Treat underlying infection\n # Sedation: Pt has pain/delirium causing tachycardia and hypertension\n with intermittent hypotension. On Haldol 5 TID, Fentanyl 75 mcg TP,\n Diazapam 10 QID; Haldol, midazolam and morphine PRN. Had good response\n to morphine, minimal response to haldol bolus.\n - tolerating current regimen well, no changes today\n # Adrenal Insufficency: Hypotension that resolved with steroids,\n returned as they came off and is now improved again. Possible primary\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\n started on .\n - stopped steroids as per endocrine today\n # Volume overloaded in prior setting of hypernatremia\n Goal even\n today.\n - Monitoring urine output\n # RUE DVT: INR was super-therapeutic on coumadin. Goal . Hasn\n received coumadin in days yet INR continues to rise. Likely\n contributors are nutritional and antibiotics.\n - will start coumadin 2.5 mg QHS once INR < 3\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - Brace for OOB\n - Report from full trauma series from OSH is in chart.\n - Pt to follow up with Dr. in weeks\n # Tracheomalacia: Discussed with IP. Stenting unlikely to help for\n trachiomalacia as airways have poor structure diffusely.\n - Outpatient f/u once off pressure support to assess for possible\n stenting\n #. Thyroid Nodule on CT\n - Outpatient follow up\n # Nutrition: Replete (Full)\n hold\n # Glycemic control: SSI, well controlled\n # Lines L PICC\n ().\n # Ppx: INR remains therapeutic, ranitidine, colace and senna, miralax,\n bisacodyl.\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n Code: Full\n Dispo: ICU, being screening for vent facilities\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 11:38 AM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n 20 Gauge - 04:59 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 10:31 PM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n 20 Gauge - 04:59 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-13 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 637413,
"text": "Chief Complaint:\n 24 Hour Events:\n UOP 10-20cc/hr, tachy to 150s while sitting upright, 120s at rest.\n Pt on PMV but had heavy secretions. Trach collar for 5 hours.\n Repeat Sputum Cx + for GNR, fungal, 1+ Gram + Cocci in Pairs.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 09:40 AM\n Levofloxacin - 11:15 PM\n Ceftriaxone - 07:50 PM\n Infusions:\n Other ICU medications:\n Haloperidol (Haldol) - 10:26 AM\n Diazepam (Valium) - 11:33 AM\n Morphine Sulfate - 02:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.7\nC (98.1\n HR: 118 (118 - 148) bpm\n BP: 90/37(48) {90/37(48) - 171/111(115)} mmHg\n RR: 14 (12 - 36) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,614 mL\n 439 mL\n PO:\n TF:\n 884 mL\n 279 mL\n IVF:\n 100 mL\n Blood products:\n Total out:\n 834 mL\n 20 mL\n Urine:\n 834 mL\n 20 mL\n NG:\n Stool:\n Drains:\n Balance:\n 780 mL\n 419 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 354 (244 - 376) mL\n PS : 10 cmH2O\n RR (Spontaneous): 12\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 56\n PIP: 15 cmH2O\n SpO2: 95%\n ABG: ////\n Ve: 4.1 L/min\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n Eyes / Conjunctiva: PERRL, Pupils dilated\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Bowel sounds present, Obese, Patient with thoracic\n brace on\n Skin: Not assessed, No(t) Rash: , Per Nursing: Pt with vesicular rash\n on inferior back.\n Neurologic: Follows simple commands, Responds to: Not assessed,\n Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 240 K/uL\n 7.9 g/dL\n 100 mg/dL\n 0.6 mg/dL\n 30 mEq/L\n 3.4 mEq/L\n 12 mg/dL\n 108 mEq/L\n 146 mEq/L\n 26.0 %\n 5.2 K/uL\n [image002.jpg]\n 08:11 PM\n 02:51 AM\n 03:10 AM\n 03:08 PM\n 03:00 AM\n 03:36 AM\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n WBC\n 9.4\n 11.3\n 7.3\n 6.1\n 7.2\n 5.2\n Hct\n 26.6\n 24.9\n 27.6\n 26.5\n 26.9\n 26.0\n Plt\n \n Cr\n 0.9\n 0.7\n 0.6\n 0.6\n 0.9\n 0.7\n 0.6\n TCO2\n 29\n 26\n Glucose\n 128\n 114\n 114\n 99\n 115\n 106\n 100\n Other labs: PT / PTT / INR:17.6/27.4/1.6, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:33/22, Alk Phos / T Bili:143/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:0.5 mmol/L,\n Albumin:3.5 g/dL, LDH:199 IU/L, Ca++:8.9 mg/dL, Mg++:2.4 mg/dL, PO4:4.1\n mg/dL\n Assessment and Plan\n 55yoF with history of EtOH abuse presenting following mechanical fall\n and traumatic T spine fracture, now s/p trach, PEG, placement being\n treated for HAP.\n# HAP vs Aspiration PNA: Cultures growing Klebsiella Oxytoca, Klebsiella Pneumon\niae, GNR, GP Cocci. Pt received developed rash on Levofloxacin, switched to Ceft\nriaxone overnight. Will treat for potential HAP for 8 days.\n - Continue Ceftriaxone HAP (Day #6 of 8)\n - Tube Feeds now at 50 with goal of 60/hr\n - Following Cultures\n .\n # Respiratory failure: 5 hours on Trach mask yesterday, will assess\n length of tolerance today.\n - PMV with suctioning.\n - Weaning FiO2 as tolerated\n # Tachycardia: Pt in ST 120\ns to 150s. Etiology remains unclear and\n etiologies include hypovolemia, pain, infection (pt with known\n klebsiella), . DDx also includes PE\n - Treating underlying infection\n - Bolus NS 500cc x 2 today and assess HR\n - Restarting patients Coumadin\n - TSH 2.4 on early , will check free T3, T4.\n - Continue Pain Control\n # Sedation: Pt has pain/delirium causing tachycardia and hypertension\n with intermittent hypotension. Had good response to morphine, minimal\n response to haldol bolus.\n - Haldol 5 TID, Fentanyl 75 mcg TP, Diazapam 10 QID;\n - Haldol, midazolam and morphine PRN.\n - tolerating current regimen well\n # Adrenal Insufficency: Followed up with endocrine that suggested if\n the patient under goes major stressors such as major surgery, sepsis,\n she may need stress dosed steroids.\n - Will consider MRI at later date for evaluation of pituitary\n # Fluid Status: Volume overloaded in prior setting of Hypernatremia\n Goal even today.\n - Monitoring urine output\n # RUE DVT: INR was super-therapeutic on coumadin. Goal . Received 5\n of coumadin overnight.\n - Restarting Coumadin 2.5 mg QHS once INR < 3\n # Spine fracture: Stable\n - Brace for OOB, will discuss with Neurosurgery if current brace is\n optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n # Tracheomalacia?: Discussed with IP.\n - Outpatient f/u once off pressure support to assess for possible\n stenting\n #. Thyroid Nodule on CT\n - Outpatient follow up\n # Nutrition: TFs with goal of 60\n # Glycemic control: SSI, well controlled\n # Lines L PICC\n ().\n # Ppx: Restarting Coumadin, Ranitidine, Bowel Regimen\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n # Code: Full\n # Dispo: ICU, Screening for vent facilities\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 11:38 AM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n 20 Gauge - 04:59 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 637626,
"text": "Tachycardia, Other\n Assessment:\n Continues to be Tachycardia in 120-145 (anxiety). SBP has been 100-145\n without ectopy.\n Action:\n No medication given for tachycardia.Pt gets Valium 5 mg scheduled Q6H\n with little effect. CTA done to r/o pe as a source of tachycardia.\n Response:\n Results pending on CTA.\n Plan:\n Continue to evaluate HR and BP for need of treatment.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt has a known DVT to RUE. Today pt had a US of LUEand ruled out small\n non occlusive clot on her left axial vein.\n Action:\n Dr ,pt received ceftriaxone via PICC line.Coumadin dosage\n increased from 2.5 to 5 mg ( INR 1.4).\n Response:\n Repeat ultrasound orderd for right arm . Pt received 5 mg coumadin at\n 2200.\n Plan:\n Ultrasound today,cont coumadin and closely monitor INR.\n Altered mental status (not Delirium)\n Assessment:\n Pt has been restless most of the night. Pt nodded her head for pain and\n simple yes or no questions.\n Action:\n Pt given scheduled Valium with little effect.\n Response:\n Pt slept for a while,Hr dropped to 120s at the time of rest.\n Plan:\n Continue to eval MS,Valium and Prn Morphine and haldol?.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt rested on CPAP+ PS 50%/,sats stayed upper 90\ns,Pt found to have\n TF coming aroundTracheostomy\n Action:\n Cont pulm toilet as needed. Pt in need of freq oral care.\n Response:\n Plan:\n Continue to wean pt off vent and place on TC once pt can tol it again.\n"
},
{
"category": "Rehab Services",
"chartdate": "2167-10-16 00:00:00.000",
"description": "Physical Therapy Evaluation Note",
"row_id": 637950,
"text": "Attending Physician:\n date: \n Medical Diagnosis / ICD 9: / e888.9\n Reason of : eval and tx\n History of Present Illness / Subjective Complaint: 55 y/o female with\n h/o obesity admitted to OSH in on after falling down\n stairs at home. She suffered traumatic T8 fx, course was complicated by\n respiratory failure requiring intubation. Respiratory failure was felt\n to be hypoventilation from pain meds. She was transferred to \n on for further intervention after CT chest showed narrowing of\n her central airways. She was evaluated for airway stenting. Course was\n complicated by VAP and became septic. Pt is s/p trach/PEG on . Pt\n has had continues tachycardia and developed B UE DVTs.\n Past Medical / Surgical History: GERD, s/p TAH, s/p appendectomy,\n remote benign breast mass , L THA\n Medications:\n Radiology: Mildly improved left lower lobe opacities. Likely improving\n atelectasis. There is a small left pleural effusion. Small right\n pleural effusion and right lower lobe atelectasis are unchanged.\n Labs:\n 29.7\n 9.0\n 395\n 7.0\n [image002.jpg]\n Other labs:\n Activity Orders:\n Social / Occupational History: Unable to obtain history from pt due to\n mental status per chart pt lives with boyfriend\n Environment:\n Prior Functional Status / Activity Level: Assume pt was I PTA\n Objective Test\n Arousal / Attention / Cognition / Communication: Pt alert, poor\n attention, pt agitated pulling at brace and trach. Pt was able to\n follow 90% of 1 step commands with frequent cues and re-direction. Pt\n nodding \"yes no\" inappropriately to questions. Pt impulsive, trying to\n crawl over bedrails.\n Hemodynamic Response\n Aerobic Capacity\n HR\n BP\n RR\n O[2 ]sat\n HR\n BP\n RR\n O[2] sat\n RPE\n Supine\n 140-150\n 117/85\n 98% TM\n Rest\n /\n Sit\n 130-155\n 110/80\n 98%TM\n Activity\n /\n Stand\n /\n Recovery\n /\n Total distance walked:\n Minutes:\n Pulmonary Status: Strong cough productive of thick yellow sputum\n Integumentary / Vascular: Trach, Peg, foley, , pt has breakdown on\n her chin\n Sensory Integrity: withdraws to pain x 4\n Pain / Limiting Symptoms: Pt appears uncomfortable in bracing, pulling\n at cervical extension\n Posture: unremarkable\n Range of Motion\n Muscle Performance\n B UE and LE \n Pt moving all extremities against gravity\n Motor Function: Purposeful movement patterns\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: Transfer: Pt was able to scoot from bed to stretcher\n chair with Min A\n Rolling:\n\n\n\n T\n\n\n Supine /\n Sidelying to Sit:\n\n\n T\n\n\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n\n\n\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Balance: Fair sitting balance at EOB. Deferred standing due to pts MS\n Education / Communication: Pt status discussed with RN, MDs. Talked to\n Dr. regarding pts current brace. She agrees that a cervical\n extension is not needed. Neops was called and are planning to come\n assess brace today and either remove cervical extension or make a new\n TLSO.\n Intervention:\n Other:\n Diagnosis:\n 1.\n Airway Clearance, Impaired\n 2.\n Arousal, Attention, and Cognition, Impaired\n 3.\n Balance, Impaired\n 4.\n Knowledge, Impaired\n 5.\n Respiration / Gas Exchange, Impaired\n Clinical impression / Prognosis: 55 yo f s/p fall with resultant T8 fx\n and hospital course c/b prolonged intubation, resp failure, and\n tachycardia. Pt is functioning well below baseline, most significantly\n limited by mental status. Feel with new brace, increased time OOB, pts\n pulmonary status should improve. Pts mental status maybe related to\n prolonged ICU stay or medications, if it does not improve may also\n benefit from further w/u given h/o trauma. Pts mobility is good and\n anticipates she will rapidly progress with continued PT in rehab\n setting.\n Goals\n Time frame: 1 wk\n 1.\n follow all 1 step commands\n 2.\n sit at EOB I'ly > 10 mins\n 3.\n tolerate PMV during treatment and maintain SaO2> 95% on 35% TM\n 4.\n transfer goals to follow\n 5.\n 6.\n Anticipated Discharge: Rehab\n Treatment Plan:\n Frequency / Duration: 3-5x/wk\n f/u balance, cognitive training. Progress to transfer training and\n ambulation as appropriate.\n T Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-16 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 637951,
"text": "Chief Complaint: resp failuire\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n ULTRASOUND - At 03:48 PM\n US of Lt arm shows small 1 cm axillary clot non occlusive near PICC\n RUS US shows resolution of formal clot\n Vomiting tube feeds around trach\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Ceftriaxone - 10:00 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 06:20 AM\n Pantoprazole (Protonix) - 08:12 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Gastrointestinal: Emesis\n Flowsheet Data as of 10:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 36.2\nC (97.1\n HR: 146 (123 - 146) bpm\n BP: 153/129(134) {106/41(56) - 185/129(142)} mmHg\n RR: 26 (11 - 33) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,888 mL\n 520 mL\n PO:\n TF:\n 1,268 mL\n IVF:\n 100 mL\n Blood products:\n Total out:\n 1,530 mL\n 845 mL\n Urine:\n 1,510 mL\n 820 mL\n NG:\n 20 mL\n 25 mL\n Stool:\n Drains:\n Balance:\n 358 mL\n -325 mL\n Respiratory support\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 227 (227 - 397) mL\n PS : 8 cmH2O\n RR (Spontaneous): 20\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 194\n PIP: 16 cmH2O\n SpO2: 96%\n ABG: ///34/\n Ve: 6.5 L/min\n Physical Examination\n Gen: up in bed, alert, follows simples commands\n Tachy regular\n Fair air movement ant\n No edema\n Labs / Radiology\n 8.5 g/dL\n 335 K/uL\n 121 mg/dL\n 0.5 mg/dL\n 34 mEq/L\n 3.8 mEq/L\n 7 mg/dL\n 107 mEq/L\n 147 mEq/L\n 27.0 %\n 5.6 K/uL\n [image002.jpg]\n 03:08 PM\n 03:00 AM\n 03:36 AM\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n 05:00 AM\n 02:06 AM\n 07:34 AM\n WBC\n 7.3\n 6.1\n 7.2\n 5.2\n 5.9\n 7.5\n 5.6\n Hct\n 27.6\n 26.5\n 26.9\n 26.0\n 27.2\n 26.8\n 27.0\n Plt\n 189\n 209\n 238\n \n 335\n Cr\n 0.6\n 0.6\n 0.9\n 0.7\n 0.6\n 0.7\n 0.6\n 0.5\n TCO2\n 26\n Glucose\n 99\n 115\n 106\n 100\n 134\n 134\n 121\n Other labs: PT / PTT / INR:16.6/25.0/1.5, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:9.3 mg/dL, Mg++:2.3 mg/dL, PO4:4.1\n mg/dL\n Assessment and Plan\n 55 yr old alcoholic s/p t spine fx s/p trcah and PEG with persistent\n resp failure\n 1. Resp Failure: currently on trach mask, can do a few hours per\n day, then needs for support. New pan Klebs in sputum, day\n . Try more vent support and see if it helps her.\n 2. Fevers: did not persist- cultures neg to date.\n 3 Hemodynamics: persistant simus tachy\n CTPA to look for emboli\n negative for proximal clot. IOs the of trach mask and her TB\n malacia too much for her. We will see what happens if we out her on\n 15-20 and 5.\n 4. New L Ext DVT\n 5. Emesis: call IR and get g pushed to a j tube\n ICU Care\n Nutrition: tfs held for vomiting\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Prophylaxis:\n DVT: coumadin\n Stress ulcer: ppi\n Communication: try to reach boyfriend\n status: Full code\n Disposition :ICU\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-16 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 637952,
"text": "Chief Complaint: resp failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n ULTRASOUND - At 08:11 AM\n right arm\n PICC LINE - STOP 12:02 PM\n PEG INSERTION - At 05:33 PM\n placed PEG which\n cannot be advanced by IR. TSurg by and felt needs to fail Reglan first\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Ceftriaxone - 10:00 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 12:00 PM\n Haloperidol (Haldol) - 02:00 PM\n Diazepam (Valium) - 03:52 PM\n Furosemide (Lasix) - 06:40 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.8\nC (98.3\n HR: 137 (97 - 146) bpm\n BP: 153/66(87) {93/43(55) - 183/129(134)} mmHg\n RR: 18 (13 - 33) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,220 mL\n 807 mL\n PO:\n TF:\n IVF:\n 500 mL\n 807 mL\n Blood products:\n Total out:\n 1,514 mL\n 150 mL\n Urine:\n 1,439 mL\n 150 mL\n NG:\n 75 mL\n Stool:\n Drains:\n Balance:\n -294 mL\n 657 mL\n Respiratory support\n O2 Delivery Device: Trach mask , Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 384 (311 - 675) mL\n PS : 10 cmH2O\n RR (Spontaneous): 12\n PEEP: 5 cmH2O\n FiO2: 70%\n RSBI: 52\n PIP: 15 cmH2O\n SpO2: 95%\n ABG: ///35/\n Ve: 4.6 L/min\n Physical Examination\n Gen: sitting up in bed, answers simples questions\n CV: tachy RR\n Chest: good air moevemtn but long exp time and bibasilar rales\n Abd: soft NT + BS PEG CDI\n Ext: no edema\n Neuro: attentive, mouths answers to words, moving all ext\n Labs / Radiology\n 9.0 g/dL\n 395 K/uL\n 126 mg/dL\n 0.7 mg/dL\n 35 mEq/L\n 4.0 mEq/L\n 7 mg/dL\n 102 mEq/L\n 144 mEq/L\n 29.7 %\n 7.0 K/uL\n [image002.jpg]\n 03:36 AM\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n 05:00 AM\n 02:06 AM\n 07:34 AM\n 03:50 AM\n 06:22 AM\n WBC\n 7.2\n 5.2\n 5.9\n 7.5\n 5.6\n 6.1\n 7.0\n Hct\n 26.9\n 26.0\n 27.2\n 26.8\n 27.0\n 27.0\n 29.7\n Plt\n 238\n 240\n 296\n \n 395\n Cr\n 0.6\n 0.9\n 0.7\n 0.6\n 0.7\n 0.6\n 0.5\n 0.7\n 0.7\n TCO2\n 26\n Glucose\n 115\n 106\n 100\n 134\n 134\n 121\n 619\n 126\n Other labs: PT / PTT / INR:24.2/27.7/2.4, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:9.5 mg/dL, Mg++:2.1 mg/dL, PO4:4.2\n mg/dL\n Assessment and Plan 55 yr old alcoholic s/p t spine fx s/p trcah and\n PEG with persistent resp failure\n 1. Resp Failure: currently on trach mask, can do sevreal hours per\n day and increasing each day, then needs for support QHS. Completed\n Rx for pan Klebs PNA. Per IP not stent planned as technically\n not possible to place into her airway\n 2. Hemodynamics: persistant simus tachy but also has runs of SVT-\n will add low dose bblocker today\n watch MAPs at night as\n she tends to run low. Anticoagulated.\n 3. New L Ext DVT: PICC out, on coumadin\n 4. Emesis: start Reglan, watch qt and restart low dose tf tonight-\n discuss with TSurg role of J prior to hospital d/c\n ICU Care\n Nutrition: restart TFs\n Glycemic Control:\n Lines:\n 20 Gauge - 12:26 PM\n Prophylaxis:\n DVT: couadin\n Stress ulcer: PPI\n Communication: trying to reach boyfriend\n status: Full code\n Disposition :screening for rehab\n"
},
{
"category": "Respiratory ",
"chartdate": "2167-10-16 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 638002,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 28\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type:\n Manufacturer: Portex\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Copious\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Unassisted spontaneous breathing\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Increase ventilatory support at night\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Maintained on Trach Collar all day. Plan to stay as tolerated\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-19 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 638347,
"text": "Chief Complaint:\n 24 Hour Events:\n 8pm: Vomited tube feeds while receiving free water flushes. Suctioned\n by RT and no apparent aspiration, only blood tinged sputum. O2 sats\n 99-100%. No increased O2 requirement. Held TF, given free water via IV\n 100 cc/hr x 1L since Na 148. Will need to reassess in am, CXR ordered\n for am.\n Thoracics recs: place dophoff post pyloric or have GI place pedi GT\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Diazepam (Valium) - 12:00 AM\n Furosemide (Lasix) - 01:30 AM\n Morphine Sulfate - 02:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:21 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.3\n Tcurrent: 36.8\nC (98.3\n HR: 113 (81 - 137) bpm\n BP: 78/45(52) {78/39(50) - 130/73(108)} mmHg\n RR: 12 (12 - 32) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 3,165 mL\n 700 mL\n PO:\n TF:\n 691 mL\n IVF:\n 1,574 mL\n 700 mL\n Blood products:\n Total out:\n 1,670 mL\n 680 mL\n Urine:\n 1,470 mL\n 680 mL\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n 1,495 mL\n 20 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: MMV/PSV/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 94 (94 - 450) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 7\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 25 cmH2O\n SpO2: 97%\n ABG: ///38/\n Ve: 5.1 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 467 K/uL\n 8.6 g/dL\n 131 mg/dL\n 0.7 mg/dL\n 38 mEq/L\n 3.4 mEq/L\n 8 mg/dL\n 101 mEq/L\n 145 mEq/L\n 27.8 %\n 6.9 K/uL\n [image002.jpg]\n 03:00 AM\n 05:00 AM\n 02:06 AM\n 07:34 AM\n 03:50 AM\n 06:22 AM\n 02:58 AM\n 03:43 AM\n 05:02 PM\n 03:36 AM\n WBC\n 5.2\n 5.9\n 7.5\n 5.6\n 6.1\n 7.0\n 7.1\n 7.1\n 6.9\n Hct\n 26.0\n 27.2\n 26.8\n 27.0\n 27.0\n 29.7\n 28.9\n 29.2\n 27.8\n Plt\n 35\n 52\n 467\n Cr\n 0.6\n 0.7\n 0.6\n 0.5\n 0.7\n 0.7\n 0.6\n 0.7\n 0.8\n 0.7\n Glucose\n 100\n 134\n 134\n 121\n 04\n 108\n 131\n Other labs: PT / PTT / INR:66.1/32.7/8.0, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:9.4 mg/dL, Mg++:2.3 mg/dL, PO4:4.2\n mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-19 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 638348,
"text": "Chief Complaint:\n 24 Hour Events:\n 8pm: Vomited tube feeds while receiving free water flushes. Suctioned\n by RT and no apparent aspiration, only blood tinged sputum. O2 sats\n 99-100%. No increased O2 requirement. Held TF, given free water via IV\n 100 cc/hr x 1L since Na 148. Will need to reassess in am, CXR ordered\n for am.\n Thoracics recs: place dophoff post pyloric or have GI place pedi GT\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Diazepam (Valium) - 12:00 AM\n Furosemide (Lasix) - 01:30 AM\n Morphine Sulfate - 02:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:21 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.3\n Tcurrent: 36.8\nC (98.3\n HR: 113 (81 - 137) bpm\n BP: 78/45(52) {78/39(50) - 130/73(108)} mmHg\n RR: 12 (12 - 32) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 3,165 mL\n 700 mL\n PO:\n TF:\n 691 mL\n IVF:\n 1,574 mL\n 700 mL\n Blood products:\n Total out:\n 1,670 mL\n 680 mL\n Urine:\n 1,470 mL\n 680 mL\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n 1,495 mL\n 20 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: MMV/PSV/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 94 (94 - 450) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 7\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 25 cmH2O\n SpO2: 97%\n ABG: ///38/\n Ve: 5.1 L/min\n Physical Examination\n Gen: NAD, difficult to assess orientation as patient is nonverbal on\n trach mask, but she appeared alert, and resonded appropriately to\n questions and followed commands.\n HEENT: PERRLA, EOMI, OP w/o erythema.\n Resp: Limited by patients mobility, but CTA anteriorly and laterally\n Card: S1S2 tachicardic, no m/r/g\n Abd: Soft, Non-tender, Non-distended, BS+\n Exte: No edema, DP 2+, RP2+ bil.\n NEURO: CN II\nXII grossly intact. Strength 4/5 upper and lower\n bilaterally. Reflexes 2+ bilaterally, 3+ at L patellar tendon, with\n mild adductor crossover\n Labs / Radiology\n 467 K/uL\n 8.6 g/dL\n 131 mg/dL\n 0.7 mg/dL\n 38 mEq/L\n 3.4 mEq/L\n 8 mg/dL\n 101 mEq/L\n 145 mEq/L\n 27.8 %\n 6.9 K/uL\n [image002.jpg]\n 03:00 AM\n 05:00 AM\n 02:06 AM\n 07:34 AM\n 03:50 AM\n 06:22 AM\n 02:58 AM\n 03:43 AM\n 05:02 PM\n 03:36 AM\n WBC\n 5.2\n 5.9\n 7.5\n 5.6\n 6.1\n 7.0\n 7.1\n 7.1\n 6.9\n Hct\n 26.0\n 27.2\n 26.8\n 27.0\n 27.0\n 29.7\n 28.9\n 29.2\n 27.8\n Plt\n 35\n 52\n 467\n Cr\n 0.6\n 0.7\n 0.6\n 0.5\n 0.7\n 0.7\n 0.6\n 0.7\n 0.8\n 0.7\n Glucose\n 100\n 134\n 134\n 121\n 04\n 108\n 131\n Other labs: PT / PTT / INR:66.1/32.7/8.0, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:9.4 mg/dL, Mg++:2.3 mg/dL, PO4:4.2\n mg/dL\n Assessment and Plan\n 55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach, PEG, placement no with respiratory failure secondary to\n tracheomalacia , resolving HAP.\n .\n # Respiratory failure: Slowly Improving. Now remaining on trach mask\n for most of the day and night, with periods of pressure support of \n over night.\n - Continue to increase time on trach mask as tolerated.\n - PMV with suctioning again today.\n .\n # HAP vs Aspiration PNA: Afebrile without leukocytosis\n - Completed course of ceftriaxone\n - Continue to f/u cultures\n - Continue trach mask as tolerated\n .\n # Tachycardia: Previously was assessed as sinus tach with occasional\n runs of SVT and sources such as hypovolemia, PE, infection, and pain\n were assessed as possibly etiologies. But, now appears to be SVT for\n much of time, rhythm,/rate nonresponsive to carotid massage. HR\n decreased to 80s w/ stable BPs for approx 2 hour period overnight that\n seems to be associated with administration of her BB and valium. Rhythm\n strip shows conversion from a narrow complex non-sinus tachycardia to\n normal sinus rhythm.\n - Increase Metroprolol from 25mg TID to 25mg QID\n - Consider further adjustment of BB as tolerated by BP.\n - If not sufficient for rhythm conversion, consult cardiology for\n management.\n .\n # Sedation: Inconsistent response to sedation, unclear what is best\n regime. Will continue to wean overall. Possibly improved level of\n agitation when rhytm returned to sinus.\n - Continue w Olanzapine QHS\n - DC\nd haldol and taper valium to 2.5 mg PRN TID w/ 2.5 mg PRNs.\n # Nutrition: Tube feeds have been restarted and pt started on raglan.\n Has been tolerating feeds well so far.\n - Continue TFs, w/ FW flushes\n - Nutrition recs appreciated.\n .\n # Adrenal Insufficency: Endocrine following. Pt does not appear to be\n adrenally insufficient at baseline. Suggesting if the patient under\n goes major stressors such as major surgery, sepsis, she may need stress\n dosed steroids.\n .\n # Fluid Status: Likely approaching euvolemia, though still has\n hypernatramia which may suggest is still intravascularly depleated.\n - Monitoring urine output\n - FW flushes at 100/hr w/ tube feeds\n - PM lytes to trend Na\n .\n # UE DVT and elevated INR: DVT in right UE has resolved, new\n non-occlusive in left axillary vein. INR supratherapeutic today\n - COumadin held, will restart at low dose when INR approaches\n therapeutic range.\n - follow INR\n .\n # Spine fracture: Stable\n - Brace for OOB, will discuss with Neurosurgery if current brace is\n optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n .\n # Tracheomalacia. Was initially addressed with IP and they wanted to\n follow up as outpatient.\n - Consult IP for stent placement given improved clinical status, will\n readdress\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # PIV x 1\n # Ppx: Coumadin, Ranitidine, Bowel Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n # Code: Full\n # Dispo: ICU, Screening for vent facilities\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Respiratory ",
"chartdate": "2167-10-15 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 637649,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 27\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Tube Type\n Tracheostomy tube:\n Type: Standard, Cuffed\n Manufacturer: Portex\n Size: 7.0mm\n PMV: No\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Invasive ventilation assessment:\n Dysynchrony assessment: Frequent alarms (Low min. ventilation)\n Comments: with PSV at 10 pt demonstrating frequent periods of decreased\n RR and low minute ventilation, PVS decreased to 8 resulting in more\n consistent RR and minute ventilation. Attempted to further decrease PSV\n to 5 but pt RR increased to 35-40 with very small Vt less then 200ml,\n PS returned to 8, eventually required return to PS 10 due to increasing\n tachypnea.\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated.\n Comments:\n Tol decrease in PS to 8 from 10 for 2 hours eventually becoming\n tachypneac with smaller Vt, PS returned to 10.\n Continue with trach collar trials as tol, return to PSV for rest.\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-12 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 637049,
"text": "Chief Complaint:\n 24 Hour Events:\n Developed papular rash over entire back, bilateraly, in multiple\n dermatomal distributions, opaque vesicles on erythematous base,\n nonpainful, possibly pruritic.\n Levofloxaxin was d/c'd.\n Ceftriaxone started.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Aztreonam - 03:42 AM\n Vancomycin - 09:40 AM\n Levofloxacin - 11:15 PM\n Ceftriaxone - 07:50 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:14 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 37.2\nC (98.9\n HR: 139 (113 - 145) bpm\n BP: 97/61(68) {85/28(50) - 127/86(90)} mmHg\n RR: 12 (9 - 30) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,362 mL\n 302 mL\n PO:\n TF:\n 47 mL\n 152 mL\n IVF:\n 1,061 mL\n 100 mL\n Blood products:\n Total out:\n 1,203 mL\n 460 mL\n Urine:\n 1,203 mL\n 460 mL\n NG:\n Stool:\n Drains:\n Balance:\n 159 mL\n -158 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 0 (0 - 0) mL\n Vt (Spontaneous): 504 (110 - 504) mL\n PS : 10 cmH2O\n RR (Set): 0\n RR (Spontaneous): 14\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 245\n PIP: 16 cmH2O\n SpO2: 100%\n ABG: ///30/\n Ve: 5.9 L/min\n Physical Examination\n General Appearance: Trached. Interactive. Responsive, following\n commands, Overweight / Obese, mild agitation but NAD\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\n deviation\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Respiratory / Chest: (Expansion: Symmetric), b/l rhonchi R>L, decreased\n BS\n Abdominal: Obese, soft, Non-tender, no rebound, no guarding, + BS, PEG\n in place with dressing C/D/I\n Extremities: no CCE\n Skin: no rashes or jaundice\n Lines: L PICC C/D/I\n Labs / Radiology\n 240 K/uL\n 7.9 g/dL\n 100 mg/dL\n 0.6 mg/dL\n 30 mEq/L\n 3.4 mEq/L\n 12 mg/dL\n 108 mEq/L\n 146 mEq/L\n 26.0 %\n 5.2 K/uL\n [image002.jpg]\n 08:11 PM\n 02:51 AM\n 03:10 AM\n 03:08 PM\n 03:00 AM\n 03:36 AM\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n WBC\n 9.4\n 11.3\n 7.3\n 6.1\n 7.2\n 5.2\n Hct\n 26.6\n 24.9\n 27.6\n 26.5\n 26.9\n 26.0\n Plt\n \n Cr\n 0.9\n 0.7\n 0.6\n 0.6\n 0.9\n 0.7\n 0.6\n TCO2\n 29\n 26\n Glucose\n 128\n 114\n 114\n 99\n 115\n 106\n 100\n Other labs: PT / PTT / INR:17.6/27.4/1.6, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:33/22, Alk Phos / T Bili:143/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:0.5 mmol/L,\n Albumin:3.5 g/dL, LDH:199 IU/L, Ca++:8.9 mg/dL, Mg++:2.4 mg/dL, PO4:4.1\n mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA, and\n ARDS, intubated since the end of now s/p trach and PEG\n placement.\n # Recent Aspiration of tube feeds. Given prolonged hospitalization and\n tenuous respiratory status will treat with antibiotics while cultures\n pending\n - Levoflox for 48 hours while waiting for sputum results.\n - hold tube feeds\n - Follow cultures\n - check tube placement\n .\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation. S/P Trach\n and PEG on .\n - wean FiO2 as tolerated\n - attempt wean PS today and hopeful for trach mask trial\n # Sedation: Continue to have issues with pain/delirium causing\n tachycardia and hypertension with intermittent hypotension. On Haldol\n 5 TID, Fentanyl 75 mcg TP, Diazapam 10 QID; Haldol, midazolam and\n morphine PRN. Had good response to morphine, minimal response to\n haldol bolus.\n - tolerating current regimen well, no changes today\n # Adrenal Insufficency: Hypotension that resolved with steroids,\n returned as they came off and is now improved again. Possible primary\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\n started on .\n - stopped steroids as per endocrine today\n # Volume overloaded in setting of hypernatremia\n Goal even today.\n - monitor urine output\n # RUE DVT: INR super-therapeutic on coumadin. Goal . Hasn\n received coumadin in days yet INR continues to rise. Likely\n contributors are nutritional and antibiotics.\n - will start coumadin 2.5 mg QHS once INR < 3\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - Brace for OOB\n - report from full trauma series from OSH is in chart. No evidence of\n other fracture and no need for further spinal imaging based on this\n report and ortho note.\n # Tracheomalacia: Discussed with IP. Stenting unlikely to help for\n trachiomalacia as airways have poor structure diffusely.\n - Outpatient f/u once off pressure support to assess for possible\n stenting\n #. Thyroid Nodule on CT\n -outpatient follow up\n # Nutrition: Replete (Full)\n hold\n # Glycemic control: SSI, well controlled\n # Lines L PICC ().\n # Ppx: INR therapeutic, ranitidine, colace and senna, miralax,\n bisacodyl.\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n Code: Full\n Dispo: ICU, being screening for vent facilities\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 03:36 AM 30 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-14 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 637472,
"text": "Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 02:18 AM\n SPUTUM CULTURE - At 02:18 AM\n URINE CULTURE - At 02:18 AM\n Pt tachy to mid 150's yesterday.\n Restarted on Warfarin 2.5mg\n Bolused 500cc x2 without change in HR\n Overnight Tm 100.8, BCx, UCx, CXR\n Tachypnic to high 30's.\n Given Valium 5mg IV x 1, Tylenol\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Ceftriaxone - 12:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.8\n Tcurrent: 37.2\nC (99\n HR: 137 (120 - 151) bpm\n BP: 125/55(73) {91/41(54) - 202/97(111)} mmHg\n RR: 21 (12 - 39) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,934 mL\n 390 mL\n PO:\n TF:\n 1,104 mL\n 340 mL\n IVF:\n 1,000 mL\n 50 mL\n Blood products:\n Total out:\n 530 mL\n 240 mL\n Urine:\n 530 mL\n 240 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,404 mL\n 150 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 318 (318 - 475) mL\n PS : 10 cmH2O\n RR (Spontaneous): 34\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 171\n SpO2: 97%\n ABG: ///32/\n Ve: 9 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 306 K/uL\n 8.8 g/dL\n 134 mg/dL\n 0.6 mg/dL\n 32 mEq/L\n 4.0 mEq/L\n 11 mg/dL\n 106 mEq/L\n 146 mEq/L\n 26.8 %\n 7.5 K/uL\n [image002.jpg]\n 03:10 AM\n 03:08 PM\n 03:00 AM\n 03:36 AM\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n 05:00 AM\n 02:06 AM\n WBC\n 11.3\n 7.3\n 6.1\n 7.2\n 5.2\n 5.9\n 7.5\n Hct\n 24.9\n 27.6\n 26.5\n 26.9\n 26.0\n 27.2\n 26.8\n Plt\n 227\n 189\n 209\n 238\n 240\n 296\n 306\n Cr\n 0.7\n 0.6\n 0.6\n 0.9\n 0.7\n 0.6\n 0.7\n 0.6\n TCO2\n 26\n Glucose\n 114\n 99\n 115\n 106\n 100\n 134\n 134\n Other labs: PT / PTT / INR:13.5/23.6/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:27/19, Alk Phos / T Bili:118/0.3,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:243 IU/L, Ca++:9.2 mg/dL, Mg++:2.1 mg/dL, PO4:4.0\n mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 06:23 AM 60 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-14 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 637473,
"text": "Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 02:18 AM\n SPUTUM CULTURE - At 02:18 AM\n URINE CULTURE - At 02:18 AM\n Pt tachy to mid 150's yesterday.\n Restarted on Warfarin 2.5mg\n Bolused 500cc x2 without change in HR\n Overnight Tm 100.8, BCx, UCx, CXR\n Tachypnic to high 30's.\n Given Valium 5mg IV x 1, Tylenol\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Ceftriaxone - 12:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.8\n Tcurrent: 37.2\nC (99\n HR: 137 (120 - 151) bpm\n BP: 125/55(73) {91/41(54) - 202/97(111)} mmHg\n RR: 21 (12 - 39) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,934 mL\n 390 mL\n PO:\n TF:\n 1,104 mL\n 340 mL\n IVF:\n 1,000 mL\n 50 mL\n Blood products:\n Total out:\n 530 mL\n 240 mL\n Urine:\n 530 mL\n 240 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,404 mL\n 150 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 318 (318 - 475) mL\n PS : 10 cmH2O\n RR (Spontaneous): 34\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 171\n SpO2: 97%\n ABG: ///32/\n Ve: 9 L/min\n Physical Examination\n GEN:\n HEENT:\n PULM\n CARD:\n ABD:\n EXT:\n NEURO:\n Labs / Radiology\n 306 K/uL\n 8.8 g/dL\n 134 mg/dL\n 0.6 mg/dL\n 32 mEq/L\n 4.0 mEq/L\n 11 mg/dL\n 106 mEq/L\n 146 mEq/L\n 26.8 %\n 7.5 K/uL\n [image002.jpg]\n 03:10 AM\n 03:08 PM\n 03:00 AM\n 03:36 AM\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n 05:00 AM\n 02:06 AM\n WBC\n 11.3\n 7.3\n 6.1\n 7.2\n 5.2\n 5.9\n 7.5\n Hct\n 24.9\n 27.6\n 26.5\n 26.9\n 26.0\n 27.2\n 26.8\n Plt\n 227\n 189\n 209\n 238\n 240\n 296\n 306\n Cr\n 0.7\n 0.6\n 0.6\n 0.9\n 0.7\n 0.6\n 0.7\n 0.6\n TCO2\n 26\n Glucose\n 114\n 99\n 115\n 106\n 100\n 134\n 134\n Other labs: PT / PTT / INR:13.5/23.6/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:27/19, Alk Phos / T Bili:118/0.3,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:243 IU/L, Ca++:9.2 mg/dL, Mg++:2.1 mg/dL, PO4:4.0\n mg/dL\n Assessment and Plan\n 55yoF with history of EtOH abuse presenting following mechanical fall\n and traumatic T spine fracture, now s/p trach, PEG, placement being\n treated for HAP.\n# HAP vs Aspiration PNA: Cultures growing Klebsiella Oxytoca, Klebsiella Pneumon\niae, GNR, GP Cocci. Pt received developed rash on Levofloxacin, switched to Ceft\nriaxone overnight. Will treat for potential HAP for 8 days.\n - Continue Ceftriaxone HAP (Day #6 of 8)\n - Tube Feeds now at 50 with goal of 60/hr\n - Following Cultures\n .\n # Respiratory failure: 5 hours on Trach mask yesterday, will assess\n length of tolerance today.\n - PMV with suctioning.\n - Weaning FiO2 as tolerated\n # Tachycardia: Pt in ST 120\ns to 150s. Etiology remains unclear and\n etiologies include hypovolemia, pain, infection (pt with known\n klebsiella), . DDx also includes PE\n - Treating underlying infection\n - Bolus NS 500cc x 2 today and assess HR\n - Restarting patients Coumadin\n - TSH 2.4 on early , will check free T3, T4.\n - Continue Pain Control\n # Sedation: Pt has pain/delirium causing tachycardia and hypertension\n with intermittent hypotension. Had good response to morphine, minimal\n response to haldol bolus.\n - Haldol 5 TID, Fentanyl 75 mcg TP, Diazapam 10 QID;\n - Haldol, midazolam and morphine PRN.\n - tolerating current regimen well\n # Adrenal Insufficency: Followed up with endocrine that suggested if\n the patient under goes major stressors such as major surgery, sepsis,\n she may need stress dosed steroids.\n - Will consider MRI at later date for evaluation of pituitary\n # Fluid Status: Volume overloaded in prior setting of Hypernatremia\n Goal even today.\n - Monitoring urine output\n # RUE DVT: INR was super-therapeutic on coumadin. Goal . Received 5\n of coumadin overnight.\n - Restarting Coumadin 2.5 mg QHS once INR < 3\n # Spine fracture: Stable\n - Brace for OOB, will discuss with Neurosurgery if current brace is\n optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n # Tracheomalacia?: Discussed with IP.\n - Outpatient f/u once off pressure support to assess for possible\n stenting\n #. Thyroid Nodule on CT\n - Outpatient follow up\n # Nutrition: TFs with goal of 60\n # Glycemic control: SSI, well controlled\n # Lines L PICC\n ().\n # Ppx: Restarting Coumadin, Ranitidine, Bowel Regimen\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n # Code: Full\n # Dispo: ICU, Screening for vent facilities\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 06:23 AM 60 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 638287,
"text": "Airway Clearance, Impaired\n Assessment:\n Pt placed TM50% this am, changed to high flow TM 60% @ for low\n O2Sats, cont with mod thick tan secretions.\n Action:\n Suctioned prn, pt repositioned frequently\n Response:\n No s/sx resp distress; pt tolerating trach mask\n Plan:\n Cont prn suctioning; repositioning; monitor CXry as ordered\n Altered mental status (not Delirium)\n Assessment:\n Pt cont with extreme restlessness and periods of agitation, requiring\n frequent redirection\n Action:\n Cont with scheduled valium, prn meds offered, pt oriented to , pt\n given IV morphine for presumed pain\n Response:\n Pt cont with periods of restlessness, minimal effect with valium; pt\n responded well to IV Morphine\n Plan:\n Medicate as needed for agitation; attempt to try PMV when pt secretions\n lessen to initiate communication\n Tachycardia, Other\n Assessment:\n HR 110-140\ns today\n Action:\n Cont with Lopressor as ordered\n Response:\n HR in 110\ns, otherwise unchanged\n Plan:\n Cont. Lopressor, ? cardiology consult\n Alteration in Nutrition\n Assessment:\n Pt cont on Promote w/ Fiber, currently at 50ml/hr goal 60ml, no\n episodes of emesis today\n Action:\n Advanced TF as tolerated for goal 60ml, IV Reglan given per order\n Response:\n No residuals noted, no further emesis\n Plan:\n Advance TF\ns as tolerated, cont IV reglan\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-13 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 637378,
"text": "Chief Complaint: resp failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Trach Mask x 5 hours\n Tried PMV but had secretions\n History obtained from Patient\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 11:15 PM\n Ceftriaxone - 07:50 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:13 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37\nC (98.6\n HR: 135 (118 - 151) bpm\n BP: 137/78(91) {90/37(48) - 202/96(111)} mmHg\n RR: 37 (13 - 39) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,614 mL\n 2,451 mL\n PO:\n TF:\n 884 mL\n 761 mL\n IVF:\n 100 mL\n 1,000 mL\n Blood products:\n Total out:\n 834 mL\n 320 mL\n Urine:\n 834 mL\n 320 mL\n NG:\n Stool:\n Drains:\n Balance:\n 780 mL\n 2,131 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Spontaneous): 354 (316 - 376) mL\n PS : 10 cmH2O\n RR (Spontaneous): 12\n PEEP: 5 cmH2O\n FiO2: 70%\n RSBI: 56\n PIP: 15 cmH2O\n SpO2: 92%\n ABG: ///32/\n Ve: 4.1 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 8.7 g/dL\n 296 K/uL\n 134 mg/dL\n 0.7 mg/dL\n 32 mEq/L\n 3.8 mEq/L\n 14 mg/dL\n 107 mEq/L\n 147 mEq/L\n 27.2 %\n 5.9 K/uL\n [image002.jpg]\n 02:51 AM\n 03:10 AM\n 03:08 PM\n 03:00 AM\n 03:36 AM\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n 05:00 AM\n WBC\n 11.3\n 7.3\n 6.1\n 7.2\n 5.2\n 5.9\n Hct\n 24.9\n 27.6\n 26.5\n 26.9\n 26.0\n 27.2\n Plt\n 227\n 189\n 209\n 238\n 240\n 296\n Cr\n 0.7\n 0.6\n 0.6\n 0.9\n 0.7\n 0.6\n 0.7\n TCO2\n 29\n 26\n Glucose\n 114\n 114\n 99\n 115\n 106\n 100\n 134\n Other labs: PT / PTT / INR:13.5/23.6/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:27/19, Alk Phos / T Bili:118/0.3,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:0.5 mmol/L,\n Albumin:3.5 g/dL, LDH:178 IU/L, Ca++:9.2 mg/dL, Mg++:2.3 mg/dL, PO4:4.6\n mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 10:29 AM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n 20 Gauge - 04:59 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-13 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 637379,
"text": "Chief Complaint: resp failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Trach Mask x 5 hours\n Tried PMV but had secretions\n History obtained from Patient\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 11:15 PM\n Ceftriaxone - 07:50 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:13 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37\nC (98.6\n HR: 135 (118 - 151) bpm\n BP: 137/78(91) {90/37(48) - 202/96(111)} mmHg\n RR: 37 (13 - 39) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,614 mL\n 2,451 mL\n PO:\n TF:\n 884 mL\n 761 mL\n IVF:\n 100 mL\n 1,000 mL\n Blood products:\n Total out:\n 834 mL\n 320 mL\n Urine:\n 834 mL\n 320 mL\n NG:\n Stool:\n Drains:\n Balance:\n 780 mL\n 2,131 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Spontaneous): 354 (316 - 376) mL\n PS : 10 cmH2O\n RR (Spontaneous): 12\n PEEP: 5 cmH2O\n FiO2: 70%\n RSBI: 56\n PIP: 15 cmH2O\n SpO2: 92%\n ABG: ///32/\n Ve: 4.1 L/min\n Physical Examination\n Gen sitting up in , on trach mask, interactive\n CV tachy RRR\n Chest good movement ANT\n Abd soft NT + NS\n Ext: no edema\n Neuroalert follows simple commands\n Labs / Radiology\n 8.7 g/dL\n 296 K/uL\n 134 mg/dL\n 0.7 mg/dL\n 32 mEq/L\n 3.8 mEq/L\n 14 mg/dL\n 107 mEq/L\n 147 mEq/L\n 27.2 %\n 5.9 K/uL\n [image002.jpg]\n 02:51 AM\n 03:10 AM\n 03:08 PM\n 03:00 AM\n 03:36 AM\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n 05:00 AM\n WBC\n 11.3\n 7.3\n 6.1\n 7.2\n 5.2\n 5.9\n Hct\n 24.9\n 27.6\n 26.5\n 26.9\n 26.0\n 27.2\n Plt\n 227\n 189\n 209\n 238\n 240\n 296\n Cr\n 0.7\n 0.6\n 0.6\n 0.9\n 0.7\n 0.6\n 0.7\n TCO2\n 29\n 26\n Glucose\n 114\n 114\n 99\n 115\n 106\n 100\n 134\n Other labs: PT / PTT / INR:13.5/23.6/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:27/19, Alk Phos / T Bili:118/0.3,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:0.5 mmol/L,\n Albumin:3.5 g/dL, LDH:178 IU/L, Ca++:9.2 mg/dL, Mg++:2.3 mg/dL, PO4:4.6\n mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 10:29 AM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n 20 Gauge - 04:59 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-13 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 637380,
"text": "Chief Complaint: resp failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI: 56 yr old with t spine fx, resp failure\n 24 Hour Events:\n Trach Mask x 5 hours\n Tried PMV but had secretions\n History obtained from Patient\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 11:15 PM\n Ceftriaxone - 07:50 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:13 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37\nC (98.6\n HR: 135 (118 - 151) bpm\n BP: 137/78(91) {90/37(48) - 202/96(111)} mmHg\n RR: 37 (13 - 39) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,614 mL\n 2,451 mL\n PO:\n TF:\n 884 mL\n 761 mL\n IVF:\n 100 mL\n 1,000 mL\n Blood products:\n Total out:\n 834 mL\n 320 mL\n Urine:\n 834 mL\n 320 mL\n NG:\n Stool:\n Drains:\n Balance:\n 780 mL\n 2,131 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Spontaneous): 354 (316 - 376) mL\n PS : 10 cmH2O\n RR (Spontaneous): 12\n PEEP: 5 cmH2O\n FiO2: 70%\n RSBI: 56\n PIP: 15 cmH2O\n SpO2: 92%\n ABG: ///32/\n Ve: 4.1 L/min\n Physical Examination\n Gen sitting up in , on trach mask, interactive\n CV tachy RRR\n Chest good air movement ANT\n Abd soft NT + NS\n Ext: no edema\n Neuro: alert follows simple commands\n Labs / Radiology\n 8.7 g/dL\n 296 K/uL\n 134 mg/dL\n 0.7 mg/dL\n 32 mEq/L\n 3.8 mEq/L\n 14 mg/dL\n 107 mEq/L\n 147 mEq/L\n 27.2 %\n 5.9 K/uL\n [image002.jpg]\n 02:51 AM\n 03:10 AM\n 03:08 PM\n 03:00 AM\n 03:36 AM\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n 05:00 AM\n WBC\n 11.3\n 7.3\n 6.1\n 7.2\n 5.2\n 5.9\n Hct\n 24.9\n 27.6\n 26.5\n 26.9\n 26.0\n 27.2\n Plt\n 227\n 189\n 209\n 238\n 240\n 296\n Cr\n 0.7\n 0.6\n 0.6\n 0.9\n 0.7\n 0.6\n 0.7\n TCO2\n 29\n 26\n Glucose\n 114\n 114\n 99\n 115\n 106\n 100\n 134\n Other labs: PT / PTT / INR:13.5/23.6/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:27/19, Alk Phos / T Bili:118/0.3,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:0.5 mmol/L,\n Albumin:3.5 g/dL, LDH:178 IU/L, Ca++:9.2 mg/dL, Mg++:2.3 mg/dL, PO4:4.6\n mg/dL\n Assessment and Plan 55 yr old alcoholic s/p t spine fx s/p trcah and\n PEG with persistent resp failure\n 1. Resp Failure: currently on trach mask, can do a few hours per\n day, then needs for support. New pan Klebs in sputum, day\n . Re- try. Holding off on stent by IP until after pulm rehab.\n 2. Hemodynamics: tachycardia with slightly decreased UOP\n bolus\n IVF and trend UOP. Watch to see if response with tachycardia.\n 3. Anti coag: for upper ext DVT but INR elevated on coumadin +\n quinolone\n repeat inr low- trend with po COumadin\n 4. Adrenal Insufficiency: proper stim this AM, off steroids\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 10:29 AM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n 20 Gauge - 04:59 PM\n Prophylaxis:\n DVT: coumadin\n Stress ulcer: ppi\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 637594,
"text": "Tachycardia, Other\n Assessment:\n Action:\n Response:\n Plan:\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-14 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 637564,
"text": "Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 02:18 AM\n SPUTUM CULTURE - At 02:18 AM\n URINE CULTURE - At 02:18 AM\n Pt tachy to mid 150's yesterday.\n Restarted on Warfarin 2.5mg\n Bolused 500cc x2 without change in HR\n Overnight Tm 100.8, BCx, UCx, CXR\n Tachypnic to high 30's.\n Given Valium 5mg IV x 1, Tylenol\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Ceftriaxone - 12:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.8\n Tcurrent: 37.2\nC (99\n HR: 137 (120 - 151) bpm\n BP: 125/55(73) {91/41(54) - 202/97(111)} mmHg\n RR: 21 (12 - 39) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,934 mL\n 390 mL\n PO:\n TF:\n 1,104 mL\n 340 mL\n IVF:\n 1,000 mL\n 50 mL\n Blood products:\n Total out:\n 530 mL\n 240 mL\n Urine:\n 530 mL\n 240 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,404 mL\n 150 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 318 (318 - 475) mL\n PS : 10 cmH2O\n RR (Spontaneous): 34\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 171\n SpO2: 97%\n ABG: ///32/\n Ve: 9 L/min\n Physical Examination\n GEN: Awake, alert, responsive. Sitting in chair, in back brace.\n Following commands.\n HEENT: PERRL\n PULM: CTA anteriorly, no r/r/w\n CARD: tachycardic, regular, ,s1, s2,\n ABD: abdomen, inferior to brace, soft, nontender\n EXT: DP 2+\n NEURO: able to move all extremeties, strength 5/5 upper and lower, R\n hip < L hip.\n Labs / Radiology\n 306 K/uL\n 8.8 g/dL\n 134 mg/dL\n 0.6 mg/dL\n 32 mEq/L\n 4.0 mEq/L\n 11 mg/dL\n 106 mEq/L\n 146 mEq/L\n 26.8 %\n 7.5 K/uL\n [image002.jpg]\n LACTATE 1.1\n 03:10 AM\n 03:08 PM\n 03:00 AM\n 03:36 AM\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n 05:00 AM\n 02:06 AM\n WBC\n 11.3\n 7.3\n 6.1\n 7.2\n 5.2\n 5.9\n 7.5\n Hct\n 24.9\n 27.6\n 26.5\n 26.9\n 26.0\n 27.2\n 26.8\n Plt\n 227\n 189\n 209\n 238\n 240\n 296\n 306\n Cr\n 0.7\n 0.6\n 0.6\n 0.9\n 0.7\n 0.6\n 0.7\n 0.6\n TCO2\n 26\n Glucose\n 114\n 99\n 115\n 106\n 100\n 134\n 134\n Other labs: PT / PTT / INR:13.5/23.6/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:27/19, Alk Phos / T Bili:118/0.3,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:243 IU/L, Ca++:9.2 mg/dL, Mg++:2.1 mg/dL, PO4:4.0\n mg/dL\n UA: WBC, RBC, EPI, trace bld, trace leuk, few bacter\n CXR: not sig changed from prev, R diaphragm elevated, possibly improved\n L costophrenic angle effusion, PICC line terminus difficult to\n visualize.\n Assessment and Plan\n 55yoF with history of EtOH abuse presenting following mechanical fall\n and traumatic T spine fracture, now s/p trach, PEG, placement being\n treated for HAP.\n# HAP vs Aspiration PNA: Cultures grew, Klebsiella Oxytoca, Klebsiella Pneumonia\ne, GNR, GP Cocci. Will continue to treat for potential HAP for 8 days.Pt continu\ning to have some fevers, last night 100.8, and new sputum on today w/ gram stain\n showing GPC p/c. New VAP/HAP w/ staph possible, but given no clear infiltrate o\nn CXR and good respiratory status, significant PNA is unlikely, colonization of\ntrach is possible, as is contamination of sputum. Given improving clinical \n, wait until CX data or change in clinical status or CXR to initiate HAP\n/VAP treatment.\n - Continue Ceftriaxone HAP (Day #6 of 8)\n - Continue to f/u cultures\n .\n # Respiratory failure: Improving status. Will continue to increase\n time on trach mask as tolerated.\n - PMV with suctioning.\n - Weaning FiO2 as tolerated\n # Tachycardia: Pt in ST 120\ns to 150s. Etiology remains unclear and\n etiologies include hypovolemia, pain, infection (pt with known\n klebsiella), . DDx also includes PE given hx of RUE DVT, mucus\n plugging given large amount of secretions, and spinal injury.\n - Treating underlying infection\n - Restarting patients Coumadin, last INR 1.2 yesterday, not\n therapeutic, will recheck this PM\n - TSH 2.4 on early , will check free T3, T4.\n - Continue Pain Control\n - Assess for PE w/ CTPA and UE u/s\n # Sedation: Pt has pain/delirium causing tachycardia and hypertension\n with intermittent hypotension. Had good response to morphine, minimal\n response to haldol bolus.\n - Haldol 5 PRN, Fentanyl 75 mcg TP, Diazapam 5 QID;\n - tolerating current regimen well, will continue to wean\n # Adrenal Insufficency: Followed up with endocrine that suggested if\n the patient under goes major stressors such as major surgery, sepsis,\n she may need stress dosed steroids.\n - Will consider MRI at later date for evaluation of pituitary\n # Fluid Status: Volume overloaded in prior setting of Hypernatremia\n Goal even today.\n - Monitoring urine output\n - increasse Free H20, for mild hypernatremia\n # RUE DVT: restarted Coumadin for INR 1.2, will follow INR carefully,\n given Abx.\n - Check INR this PM\n # Spine fracture: Stable\n - Brace for OOB, will discuss with Neurosurgery if current brace is\n optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n # Tracheomalacia?: Discussed with IP.\n - Outpatient f/u once off pressure support to assess for possible\n stenting\n #. Thyroid Nodule on CT\n - Outpatient follow up\n # Nutrition: TFs with goal of 60\n # Glycemic control: SSI, well controlled\n # Lines L PICC ().\n # Ppx: Restarting Coumadin, Ranitidine, Bowel Regimen\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n # Code: Full\n # Dispo: ICU, Screening for vent facilities\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 06:23 AM 60 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-14 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 637565,
"text": "Chief Complaint: resp failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n s/p t spine fx with resp failure\n 24 Hour Events:\n BLOOD CULTURED - At 02:18 AM\n SPUTUM CULTURE - At 02:18 AM\n URINE CULTURE - At 02:18 AM\n FEVER Pan cx\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Ceftriaxone - 12:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Atrovent/Albuterol, Miralax, Chlorhex, Ceftriaxone, Thiamine Folate\n Valium 5 mg QID COumadin 2.5\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fever\n Flowsheet Data as of 08:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.8\n Tcurrent: 37.2\nC (99\n HR: 137 (120 - 151) bpm\n BP: 125/55(73) {98/41(54) - 202/97(111)} mmHg\n RR: 23 (12 - 39) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,934 mL\n 497 mL\n PO:\n TF:\n 1,104 mL\n 447 mL\n IVF:\n 1,000 mL\n 50 mL\n Blood products:\n Total out:\n 530 mL\n 240 mL\n Urine:\n 530 mL\n 240 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,404 mL\n 257 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 318 (318 - 475) mL\n PS : 10 cmH2O\n RR (Spontaneous): 34\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 171\n SpO2: 98%\n ABG: ///32/\n Ve: 9 L/min\n Physical Examination\n Gen sitting up in , on trach mask, interactive\n CV tachy RRR\n Chest good air movement ANT\n Abd soft NT + NS\n Ext: no edema\n Neuro: alert follows simple commands\n Labs / Radiology\n 8.8 g/dL\n 306 K/uL\n 134 mg/dL\n 0.6 mg/dL\n 32 mEq/L\n 4.0 mEq/L\n 11 mg/dL\n 106 mEq/L\n 146 mEq/L\n 26.8 %\n 7.5 K/uL\n [image002.jpg]\n 03:10 AM\n 03:08 PM\n 03:00 AM\n 03:36 AM\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n 05:00 AM\n 02:06 AM\n WBC\n 11.3\n 7.3\n 6.1\n 7.2\n 5.2\n 5.9\n 7.5\n Hct\n 24.9\n 27.6\n 26.5\n 26.9\n 26.0\n 27.2\n 26.8\n Plt\n 227\n 189\n 209\n 238\n 240\n 296\n 306\n Cr\n 0.7\n 0.6\n 0.6\n 0.9\n 0.7\n 0.6\n 0.7\n 0.6\n TCO2\n 26\n Glucose\n 114\n 99\n 115\n 106\n 100\n 134\n 134\n Other labs: PT / PTT / INR:13.5/23.6/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:27/19, Alk Phos / T Bili:118/0.3,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:243 IU/L, Ca++:9.2 mg/dL, Mg++:2.1 mg/dL, PO4:4.0\n mg/dL\n - Sputum: 3+ GPC cocci in prs and chains\n yeast\n Assessment and Plan 55 yr old alcoholic s/p t spine fx s/p trcah and\n PEG with persistent resp failure\n 1. Resp Failure: currently on trach mask, can do a few hours per\n day, then needs for support. New pan Klebs in sputum, day\n . Re- try. Holding off on stent by IP until after pulm rehab.\n 2. Fevers: DDx - line infection VAP, check LFTs, check blood and\n urine cx, LUE ultrasounds -\n 3 Hemodynamics: persistant simus tachy\n check CTPA to look for\n emboli- has been off on anti coag - tachycardia with slightly decreased\n UOP\n bolus IVF and trend UOP. Watch to see if response with\n tachycardia.\n 4. Anti coag: for upper ext DVT but INR elevated on coumadin +\n quinolone\n repeat inr low- trend inr with po COumadin\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 06:23 AM 60 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n Communication: try to contact boyfriend\n status: Full code\n Disposition : call case management for screening options\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 637622,
"text": "Tachycardia, Other\n Assessment:\n Continues to be Tachycardia in 120-145 (anxiety). SBP has been 100-145\n without ectopy.\n Action:\n No medication given for tachycardia.Pt gets Valium 5 mg scheduled Q6H\n with little effect. CTA done to r/o pe as a source of tachycardia.\n Response:\n Results pending on CTA.\n Plan:\n Continue to evaluate HR and BP for need of treatment.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt has a known DVT to RUE. Today pt had a US of LUEand ruled out small\n non occlusive clot on her left axial vein.\n Action:\n Dr ,pt received ceftriaxone via PICC line.Coumadin dosage\n increased from 2.5 to 5 mg ( INR 1.4).\n Response:\n Repeat ultrasound orderd for right arm . Pt received 5 mg coumadin at\n 2200.\n Plan:\n Ultrasound today,cont coumadin and closely monitor INR.\n Altered mental status (not Delirium)\n Assessment:\n Pt has been restless most of the night. Pt nodded her head for pain and\n simple yes or no questions.\n Action:\n Pt given scheduled Valium with little effect.\n Response:\n Pt slept for a while,Hr dropped to 120s at the time of rest.\n Plan:\n Continue to eval MS,Valium and Prn Morphine and haldol?.\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-16 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 637931,
"text": "Chief Complaint: resp failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n ULTRASOUND - At 08:11 AM\n right arm\n PICC LINE - STOP 12:02 PM\n PEG INSERTION - At 05:33 PM\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Ceftriaxone - 10:00 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 12:00 PM\n Haloperidol (Haldol) - 02:00 PM\n Diazepam (Valium) - 03:52 PM\n Furosemide (Lasix) - 06:40 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.8\nC (98.3\n HR: 137 (97 - 146) bpm\n BP: 153/66(87) {93/43(55) - 183/129(134)} mmHg\n RR: 18 (13 - 33) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,220 mL\n 807 mL\n PO:\n TF:\n IVF:\n 500 mL\n 807 mL\n Blood products:\n Total out:\n 1,514 mL\n 150 mL\n Urine:\n 1,439 mL\n 150 mL\n NG:\n 75 mL\n Stool:\n Drains:\n Balance:\n -294 mL\n 657 mL\n Respiratory support\n O2 Delivery Device: Trach mask , Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 384 (311 - 675) mL\n PS : 10 cmH2O\n RR (Spontaneous): 12\n PEEP: 5 cmH2O\n FiO2: 70%\n RSBI: 52\n PIP: 15 cmH2O\n SpO2: 95%\n ABG: ///35/\n Ve: 4.6 L/min\n Physical Examination\n Labs / Radiology\n 9.0 g/dL\n 395 K/uL\n 126 mg/dL\n 0.7 mg/dL\n 35 mEq/L\n 4.0 mEq/L\n 7 mg/dL\n 102 mEq/L\n 144 mEq/L\n 29.7 %\n 7.0 K/uL\n [image002.jpg]\n 03:36 AM\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n 05:00 AM\n 02:06 AM\n 07:34 AM\n 03:50 AM\n 06:22 AM\n WBC\n 7.2\n 5.2\n 5.9\n 7.5\n 5.6\n 6.1\n 7.0\n Hct\n 26.9\n 26.0\n 27.2\n 26.8\n 27.0\n 27.0\n 29.7\n Plt\n 238\n 240\n 296\n \n 395\n Cr\n 0.6\n 0.9\n 0.7\n 0.6\n 0.7\n 0.6\n 0.5\n 0.7\n 0.7\n TCO2\n 26\n Glucose\n 115\n 106\n 100\n 134\n 134\n 121\n 619\n 126\n Other labs: PT / PTT / INR:24.2/27.7/2.4, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:9.5 mg/dL, Mg++:2.1 mg/dL, PO4:4.2\n mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:26 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-16 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 637932,
"text": "Chief Complaint: resp failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n ULTRASOUND - At 08:11 AM\n right arm\n PICC LINE - STOP 12:02 PM\n PEG INSERTION - At 05:33 PM\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Ceftriaxone - 10:00 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 12:00 PM\n Haloperidol (Haldol) - 02:00 PM\n Diazepam (Valium) - 03:52 PM\n Furosemide (Lasix) - 06:40 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.8\nC (98.3\n HR: 137 (97 - 146) bpm\n BP: 153/66(87) {93/43(55) - 183/129(134)} mmHg\n RR: 18 (13 - 33) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,220 mL\n 807 mL\n PO:\n TF:\n IVF:\n 500 mL\n 807 mL\n Blood products:\n Total out:\n 1,514 mL\n 150 mL\n Urine:\n 1,439 mL\n 150 mL\n NG:\n 75 mL\n Stool:\n Drains:\n Balance:\n -294 mL\n 657 mL\n Respiratory support\n O2 Delivery Device: Trach mask , Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 384 (311 - 675) mL\n PS : 10 cmH2O\n RR (Spontaneous): 12\n PEEP: 5 cmH2O\n FiO2: 70%\n RSBI: 52\n PIP: 15 cmH2O\n SpO2: 95%\n ABG: ///35/\n Ve: 4.6 L/min\n Physical Examination\n Labs / Radiology\n 9.0 g/dL\n 395 K/uL\n 126 mg/dL\n 0.7 mg/dL\n 35 mEq/L\n 4.0 mEq/L\n 7 mg/dL\n 102 mEq/L\n 144 mEq/L\n 29.7 %\n 7.0 K/uL\n [image002.jpg]\n 03:36 AM\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n 05:00 AM\n 02:06 AM\n 07:34 AM\n 03:50 AM\n 06:22 AM\n WBC\n 7.2\n 5.2\n 5.9\n 7.5\n 5.6\n 6.1\n 7.0\n Hct\n 26.9\n 26.0\n 27.2\n 26.8\n 27.0\n 27.0\n 29.7\n Plt\n 238\n 240\n 296\n \n 395\n Cr\n 0.6\n 0.9\n 0.7\n 0.6\n 0.7\n 0.6\n 0.5\n 0.7\n 0.7\n TCO2\n 26\n Glucose\n 115\n 106\n 100\n 134\n 134\n 121\n 619\n 126\n Other labs: PT / PTT / INR:24.2/27.7/2.4, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:9.5 mg/dL, Mg++:2.1 mg/dL, PO4:4.2\n mg/dL\n Assessment and Plan 55 yr old alcoholic s/p t spine fx s/p trcah and\n PEG with persistent resp failure\n 1. Resp Failure: currently on trach mask, can do sevreal hours per\n day, then needs for support QHS. Completed Rx for\n pan Klebs PNA.\n 2. Hemodynamics: persistant simus tachy but also has runs of SVT-\n will add low dose bblocker today\n watch MAPs at night as\n she tends to run low\n 3. New L Ext DVT: PICC out, coumadin\n 4. Emesis: start Reglan, watch qt and restart low dose tf tonight-\n discuss with TSurg\n ICU Care\n Nutrition: restart TFs\n Glycemic Control:\n Lines:\n 20 Gauge - 12:26 PM\n Prophylaxis:\n DVT: couadin\n Stress ulcer: PPI\n Communication: try to reach boyfriend\n status: Full code\n Disposition :screening for rehab\n"
},
{
"category": "Respiratory ",
"chartdate": "2167-10-18 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 638207,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 30\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Tracheostomy tube:\n Type: Standard, Cuffed\n Manufacturer: Portex\n Size: 7.0mm\n PMV: No\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Rhonchi\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Periodic SBT's for conditioning; Comments: Continue trach trials\n Rsbi: 150\n Mdis given as ordered.\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 637452,
"text": "Tachycardia, Other\n Assessment:\n Continues to be tachycardic 120-150\n Action:\n Given pain meds PRN\n Response:\n HR down to 120\ns when sleeping\n Plan:\n No current RX for tachycardia manage pain & fever\n Alteration in Nutrition\n Assessment:\n TF currently infusing at goal of 50 cc/hr with minimal residuals\n Action:\n Strict aspiration precautions HOB 30 degrees\n Response:\n Plan:\n Continue to monitor tolerance to TF\n Altered mental status (not Delirium)\n Assessment:\n Pt continues to be confused & up most of the night. PERRLA following\n commands consistently.\n Action:\n Continues on Valium QTC, given Morphine 4 mg Q 4 hours, Haldol PO x 2.\n Response:\n Pt able to rest in short naps, then awake and aggitated\n Plan:\n Continues on soft wrist restraints, needs titrated on of medications to\n prevent agitation\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Placed back on PS overnight. RR up to 40\ns when agitated. Sats\n 94-98% on 50%. Lungs rhonchorous throughout. Suctionned for moderate\n amounts of thick tan secretions Q 3-4 hours.\n Action:\n Tolerated PS when not agitated. Trialed on CMV became dysnchrous with\n the vent\n Response:\n Plan:\n Continue trach collar trials during the day.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Temp spike to 100.8\n Action:\n Pan cultured, Tylenol given\n Response:\n Lactate stable, WBC stable continues on ceftriaxone\n Plan:\n Follow temp curve, follow up on culture results\n"
},
{
"category": "Respiratory ",
"chartdate": "2167-10-07 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 636228,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 19\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Not applicable\n Size: Not applicable\n Tracheostomy tube:\n Type: Cuffed, Extra Length\n Manufacturer: Portex\n Size: 7.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n ------ Protected Section------\n Original note did not copy!\n ------ Protected Section Error Entered By: , \n on: 16:51 ------\n"
},
{
"category": "Respiratory ",
"chartdate": "2167-10-07 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 636229,
"text": "Demographics\n Day of mechanical ventilation: 19\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Tracheostomy tube:\n Type: Standard, Cuffed, Inner Cannula\n Manufacturer: Portex\n Size: 7.0mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Pt placed on MMV due to periods of apnea after given\n sedatives. Then pt was weaned back to PS.\n Assessment of breathing comfort: No claim of dyspnea)\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts; Comments: Pt desating to 87% when PEEP weaned to 5\n from 8.\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 637621,
"text": "Tachycardia, Other\n Assessment:\n Continues to be Tachycardia in 120-145 (anxiety). SBP has been 100-145\n without ectopy.\n Action:\n No medication given for tachycardia.Pt gets Valium 5 mg scheduled Q6H\n with little effect. CTA done to r/o pe as a source of tachycardia.\n Response:\n Results pending on CTA.\n Plan:\n Continue to evaluate HR and BP for need of treatment.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt has a known DVT to RUE. Today pt had a US of LUE to R/O DVT as a\n source of tachycardia.\n Action:\n After DVT found, IVF stopped.\n Response:\n Pt found to have a clot to Lt ax vein and MD notified.\n Plan:\n Pt to cont coumadin tonight, awaiting dosage for inr 1.4 . ? Access now\n that Lt arm has a DVT.\n Altered mental status (not Delirium)\n Assessment:\n Pt has been restless most of the day. Pt only follow direct commands.\n When asked to keep her hand off the TC, she will for only 3sec, and\n then she will reach for it again.\n Action:\n Pt given valium, morphine and haldol prn.\n Response:\n Little effect noted from sedations.\n Plan:\n Continue to eval MS.\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 637674,
"text": "56 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\n with prolonged hospital course c/b by PNA, anxiety/altered mental\n status, RUE DVT .Pt found to have small non occlusive Clot on her right\n axial vein via Ultrasound.\n Tachycardia, Other\n Assessment:\n Continues to be Tachycardia in 120-145 (anxiety). SBP has been 100-145\n without ectopy.\n Action:\n No medication given for tachycardia.Pt gets Valium 5 mg scheduled Q6H\n with little effect. CTA done to r/o pe as a source of tachycardia.\n Response:\n Results pending on CTA.\n Plan:\n Continue to evaluate HR and BP for need of treatment.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt has a known DVT to RUE. Today pt had a US of LUEand ruled out small\n non occlusive clot on her left axial vein.\n Action:\n Dr ,pt received ceftriaxone via PICC line.Coumadin dosage\n increased from 2.5 to 5 mg ( INR 1.4).\n Response:\n Repeat ultrasound orderd for right arm to check old clot. Pt received 5\n mg coumadin at 2200.\n Plan:\n Ultrasound today,cont coumadin and closely monitor INR.\n Altered mental status (not Delirium)\n Assessment:\n Pt has been restless most of the night. Pt nodded her head for pain and\n simple yes or no questions.pt got disconnected byself from vent onetime\n Action:\n Pt given scheduled Valium with little effect.Pt received 2 mg morphine\n PRN at 0620 .\n Response:\n Pt slept for a while,Hr dropped to 120s at the time of rest.\n Plan:\n Continue to eval MS,Valium and PRN Morphine and haldol?.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt rested on CPAP+ PS 50%/,sats stayed upper 90\ns,Pt found to have\n TF coming around Tracheostomy. As well as from her mouth\n Action:\n Cont pulm toilet as needed,Held TF throughout the night .Pressure\n support dropped to 8 from10\n Response:\n Pt suctioned for small- moderate amount thick yellow secretions.No more\n leakage noted around the tracheostomy as well as Minimal residuals from\n PEG tube.Pt had to put back on 10 tachypnea and tachycardia\n Plan:\n Continue to wean pt off vent and place on TC once pt can tol it again\n and frequent pulmonary toileting. Restart TF?\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 637844,
"text": "Pt down to IR for replacement of PEG with J-tube d/t high risk of\n aspiration. Unable to place jtube at this time d/t type of peg in\n place. Will need surgery to remove PEG in IR and IR will place j tube\n at later date.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Left hand to elbow area with edema 2mm\nknown DVT to left axillary vein;\n US of right arm\n Action:\n DL PICC d/c\nd; left arm elevated on pillow; US results pnd for right\n arm\n Response:\n PIV placed for access issues to right arm; edema unchanged;\n Plan:\n Cont to monitor left arm status; no BP/blood draws left arm. NIBP cuff\n to right calf. F/U w/ team Re: right arm status\n Hypernatremia (high sodium)\n Assessment:\n hypernatremic\n Action:\n Free water boluses cont; bloused with D5W/500cc\n Response:\n Remains hypernatremic with min improvement\n Plan:\n Cont with free water boluses; check labs am\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Restless, anxious am\n Action:\n Trach collar placed 70% early am--\n Response:\n Brief episode of desaturation to mid 80\ns requiring increase of Fi02 to\n 100% briefly (approx 20min); placed on 70% remainder of shift with\n adequate o2 sats in low 90\ns;NOTE: pt vomited approx 50cc clear liquid\n prior to going to IR also had some clear lix come from trach\npossible\n aspiration\nteam notified. Placed on PSV at 1840 to rest\n Plan:\n Rest overnight; ?aspiration. Hold TF for now\nf/u team re: free water\n boluses. CXR am. Monitor resp status closely.\n Tachycardia, Other\n Assessment:\n Tachy to 130-140\ns continuous while awake; continuous tachy in 120\n while sound asleep\n Action:\n Standing valium decreased; cont with fent patch; morphine and haldol\n prn\n Response:\n No significant change in level of restlessness/anxiety; freq pulling at\n any objects/lines with short term memory issues; no significant\n response to IV morphine; was able to obtain some sleep after 2mg haldol\n ivp\n Plan:\n Cont to closely monitor mental status; maintain safety w/use of\n restraints, soft wrist restraints and bed alarm. Assess degree of\n change with titration of meds\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 637909,
"text": "56 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\n with prolonged hospital course c/b by PNA, anxiety/altered mental\n status, RUE DVT .Pt found to have small non occlusive Clot on her right\n axial vein via Ultrasound.Yesterday Pt went down to IR for Peg revision\n aspiration riskcouldn\nt do it,due the type of peg she has now.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt has known DVT to left axillary vein; US of right arm showed no\n clots.\n Action:\n DL PICC d/c\nd; from left arm and elevated on pillow and received\n Coumadin scheduled dose.\n Response:\n PIV placed for access issues to right arm; edema looks better;\n Plan:\n Cont to monitor left arm status; no BP/blood draws left arm PICC line\n to right arm?.\n Hypernatremia (high sodium)\n Assessment:\n Hypernatremic NA was 146 yesterday evening.\n Action:\n Started on D5 W at 100cc/hr for 1000cc,held free wqater bolus \n aspiration..\n Response:\n Awaiting for AM lab report.\n Plan:\n Cont with D5W,follow up with AM lab,resume Free water bolus via PEG\n tube?.\n Tachycardia, Other\n Assessment:\n Tachy to 130-140\ns continuous while awake; HR stayed 90- 120 sound\n asleep\n Action:\n Standing valium decreased; cont with fent patch; morphine and haldol\n prn.Bilateral restraints on\n Response:\n No significant change in level of restlessness/anxiety; freq pulling at\n any objects/lines with short term memory issues. She keeps\n disconnecting from vent,desat to low 80s within seconds.\n Plan:\n Cont to closely monitor mental status; maintain safety w/use of\n restraints, soft wrist restraints and bed alarm. PRN Haldol or\n Morphine.\n Altered mental status (not Delirium)\n Assessment:\n Pt has been slept most of the time,hard to wake up.responded to deep\n stimuli.\n Action:\n Held Scheduled dose of valium at 2200.Pt has Fentanyl 75 mcg patch on\n her lleft thigh.\n Response:\n Pt start waking up around 0300,got disconnected from vent by\n herself,given valium 2.5 mg at 0315.\n Plan:\n Continue to eval MS,Valium and PRN Morphine and haldol?,cont reorient\n and emotional support to pt .\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 637910,
"text": "56 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\n with prolonged hospital course c/b by PNA, anxiety/altered mental\n status, RUE DVT .Pt found to have small non occlusive Clot on her right\n axial vein via Ultrasound.Yesterday Pt went down to IR for Peg revision\n aspiration riskcouldn\nt do it,due the type of peg she has now.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt has known DVT to left axillary vein; US of right arm showed no\n clots.\n Action:\n DL PICC d/c\nd; from left arm and elevated on pillow and received\n Coumadin scheduled dose.\n Response:\n PIV placed for access issues to right arm; edema looks better;\n Plan:\n Cont to monitor left arm status; no BP/blood draws left arm PICC line\n to right arm?.\n Hypernatremia (high sodium)\n Assessment:\n Hypernatremic NA was 146 yesterday evening.\n Action:\n Started on D5 W at 100cc/hr for 1000cc,held free wqater bolus \n aspiration..\n Response:\n Awaiting for AM lab report.\n Plan:\n Cont with D5W,follow up with AM lab,resume Free water bolus via PEG\n tube?.\n Tachycardia, Other\n Assessment:\n Tachy to 130-140\ns continuous while awake; HR stayed 90- 120 sound\n asleep\n Action:\n Standing valium decreased; cont with fent patch; morphine and haldol\n prn.Bilateral restraints on\n Response:\n No significant change in level of restlessness/anxiety; freq pulling at\n any objects/lines with short term memory issues. She keeps\n disconnecting from vent,desat to low 80s within seconds.\n Plan:\n Cont to closely monitor mental status; maintain safety w/use of\n restraints, soft wrist restraints and bed alarm. PRN Haldol or\n Morphine.\n Altered mental status (not Delirium)\n Assessment:\n Pt has been slept most of the time,hard to wake up.responded to deep\n stimuli.\n Action:\n Held Scheduled dose of valium at 2200.Pt has Fentanyl 75 mcg patch on\n her lleft thigh.\n Response:\n Pt start waking up around 0300,got disconnected from vent by\n herself,given valium 2.5 mg at 0315.\n Plan:\n Continue to eval MS,Valium and PRN Morphine and haldol?,cont reorient\n and emotional support to pt .\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-16 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 637915,
"text": "Chief Complaint: Tracheomalacia\n 24 Hour Events:\n ULTRASOUND - At 08:11 AM\n right arm - negative for DVT\n PICC LINE - STOP 12:02 PM\n - IR unable to advance PEG\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Ceftriaxone - 10:00 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:12 AM\n Morphine Sulfate - 12:00 PM\n Haloperidol (Haldol) - 02:00 PM\n Diazepam (Valium) - 03:52 PM\n Furosemide (Lasix) - 06:40 AM\n Other medications:\n Changes to medical and family history:\n None\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.2\nC (97.1\n HR: 139 (97 - 146) bpm\n BP: 133/67(84) {93/43(55) - 183/129(134)} mmHg\n RR: 18 (13 - 33) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,220 mL\n 568 mL\n PO:\n TF:\n IVF:\n 500 mL\n 568 mL\n Blood products:\n Total out:\n 1,514 mL\n 150 mL\n Urine:\n 1,439 mL\n 150 mL\n NG:\n 75 mL\n Stool:\n Drains:\n Balance:\n -294 mL\n 418 mL\n Respiratory support\n O2 Delivery Device: Trach mask , Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 384 (311 - 675) mL\n PS : 10 cmH2O\n RR (Spontaneous): 12\n PEEP: 5 cmH2O\n FiO2: 70%\n RSBI: 52\n PIP: 15 cmH2O\n SpO2: 96%\n ABG: ///31/\n Ve: 4.6 L/min\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic,\n No(t) Diastolic), tachy\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 395 K/uL\n 9.0 g/dL\n 619 mg/dL\n 0.7 mg/dL\n 31 mEq/L\n 3.3 mEq/L\n 6 mg/dL\n 91 mEq/L\n 129 mEq/L\n 29.7 %\n 7.0 K/uL\n [image002.jpg]\n 03:36 AM\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n 05:00 AM\n 02:06 AM\n 07:34 AM\n 03:50 AM\n 06:22 AM\n WBC\n 7.2\n 5.2\n 5.9\n 7.5\n 5.6\n 6.1\n 7.0\n Hct\n 26.9\n 26.0\n 27.2\n 26.8\n 27.0\n 27.0\n 29.7\n Plt\n 238\n 240\n 296\n \n 395\n Cr\n 0.6\n 0.9\n 0.7\n 0.6\n 0.7\n 0.6\n 0.5\n 0.7\n TCO2\n 26\n Glucose\n 115\n 106\n 100\n 134\n 134\n 121\n 619\n Other labs: PT / PTT / INR:23.4/29.6/2.3, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:8.4 mg/dL, Mg++:1.9 mg/dL, PO4:3.9\n mg/dL\n Microbiology: 7:34 am STOOL CONSISTENCY: FORMED\n Source: Stool.\n **FINAL REPORT **\n CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final ):\n Feces negative for C.difficile toxin A & B by EIA.\n (Reference Range-Negative).\n .\n 7:33 am BLOOD CULTURE Source: Line-picc.\n **FINAL REPORT **\n Blood Culture, Routine (Final ): NO GROWTH\n Assessment and Plan\n Assessment and Plan\n 55yoF with history of EtOH abuse presenting following mechanical fall\n and traumatic T spine fracture, now s/p trach, PEG, placement being\n treated for HAP.\n # HAP vs Aspiration PNA: Cultures grew, Klebsiella Oxytoca, Klebsiella\n Pneumoniae, GNR, GP Cocci. Has completed 8 day course of Ceftriaxone.\n Has had occasional low grade fevers, but has continued to improve\n clinically. Had a sputum gram stain from w/ GPC p/c. a new VAP/HAP\n w/ staph possible, but given no clear infiltrate on CXR and good\n respiratory status, significant PNA is unlikely, colonization of\n tracheostomy tube is more likely, as is contamination of sputum. Given\n improving clinical picture, will wait until CX data or change in\n clinical status or CXR to initiate HAP/VAP treatment.\n - D/c Ceftriaxone\n - Continue to f/u cultures\n .\n # Respiratory failure: Improving status. Will continue to increase\n time on trach mask as tolerated.\n - PMV with suctioning.\n - Weaning FiO2 as tolerated\n .\n # Tachycardia: Pt in ST 120\ns to 150s. Etiology remains unclear and\n include hypovolemia, pain, infection (pt with known klebsiella), and\n incrased work of breathing from secretions and tracheomalacia, . DDx\n also includes PE given hx of RUE DVT, mucus plugging given large\n amount of secretions, and spinal injury. Tachycardia is unresponsive to\n IVF, Pt has had a negative CT-PA and has not had sig response to pain\n meds. Has completed treatment for her HAP. Thyroid function was checked\n and had normal TSH and T3 and free T4. Had been on albuterol q4 and\n atrovent , she has not been wheezing, and perhaps she is sensitive to\n the B-agonist.\n - Continue Pain Control\n - Change albuterol to PRN\n - Test if HR decreases when placed on higher pressure support\n for period of time.\n .\n # Sedation: Has had inconsistent response to sedation, unclear what is\n best regime. Will continue to wean overall\n - Change to haldol 2.5 PRN, Fentanyl 75 mcg TP, Morphine PRN,\n Benadryl, Valium 5mg PRN\n .\n # Adrenal Insufficency: Followed up with endocrine that suggested if\n the patient under goes major stressors such as major surgery, sepsis,\n she may need stress dosed steroids.\n - Will consider MRI at later date for evaluation of pituitary\n .\n # Fluid Status: Volume overloaded in prior setting of Hypernatremia\n - Monitoring urine output\n - increasse Free H20, for mild hypernatremia 200cc Free bolus PEG, and\n - 500cc D5W at 125.\n - PM lytes to assess hypernatremia\n .\n # UE DVT: right has resolved, new non occlusive in left axillary. INR\n 1.5\n -continue coumadin\n -follow INR\n - D/c Left PICC line, and place peripheral IVs. If unable, can place a\n R PICC.\n .\n # Spine fracture: Stable\n - Brace for OOB, will discuss with Neurosurgery if current brace is\n optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n .\n # Tracheomalacia?: Was initially addressed with IP and they wanted to\n follow up as outpatient.\n - Consult IP for stent placement given improved clinical status, will\n readdresses\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n # Nutrition: Pt had emesis and extrusion of gastric contents through\n tracheostomy site (not through tube).\n - TFs held\n - Consult IR for advancement of her PEG to jejunum.\n # Glycemic control: SSI, well controlled\n # PIV x 1\n # Ppx: Restarting Coumadin, Ranitidine, Bowel Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n # Code: Full\n # Dispo: ICU, Screening for vent facilities\n ICU Care\n Nutrition:\n Comments: Tube feeds\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 12:26 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 637994,
"text": "Airway Clearance, Impaired\n Assessment:\n Action:\n Response:\n Plan:\n Tachycardia, Other\n Assessment:\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 637997,
"text": "56 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\n with prolonged hospital course c/b by PNA, anxiety/altered mental\n status, RUE DVT .Pt found to have small non occlusive Clot on her right\n axial vein via Ultrasound.Yesterday Pt went down to IR for Peg revision\n aspiration risk couldn\nt do it due the type of peg she has now.\n Airway Clearance, Impaired\n Assessment:\n Pt continues to have copious amount of secretions. She was placed on\n 50% trach mask at 6am and continues on it. She was on a passey muir\n valve for several hours during the afternoon but was only removed due\n to secretions.\n Action:\n Pt has been suctioned q1-2h for a large amount of creamy white\n secretions.\n Response:\n O2 sats have been between 95-98% with RR 24-32\n Plan:\n Suction PRN, continue to monitor\n Tachycardia, Other\n Assessment:\n Her HR continues to be tachy, 130-140. B/P 140-150/60-70.\n Action:\n She was started on lopressor this am. The first dose was 12.5 mg with\n no change in HR, she has received 25mg at 1600.\n Response:\n She continues to be tachy but her HR is 130\ns vs her normal 140\n Plan:\n Continue to monitor HR, ask MD\ns about increasing her dose.\n Alteration in Nutrition\n Assessment:\n She remains NPO while the MD\ns decide what to do to get a post pyloric\n feeding tube in place.\n Action:\n PEG in her stomach so free water and meds have been given into her PEG.\n Response:\n Remains NPO.\n Plan:\n Continue to give meds and free water into peg, await medical plan from\n MD\n Impaired Skin Integrity\n Assessment:\n The area around her trach is slightly reddened. The surgeons came by\n this am and removed the remaining stitches that held the trach tube on\n to her skin\n Action:\n Trach care done with some antibiotic ointment.\n Response:\n Area still reddened but no longer being pulled by the stitches\n Plan:\n Continue to monitor the redness, continue trach \n"
},
{
"category": "Physician ",
"chartdate": "2167-10-19 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 638436,
"text": "Chief Complaint: resp failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Another episode of emesis\n Was on MMV\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Diazepam (Valium) - 12:00 AM\n Furosemide (Lasix) - 01:30 AM\n Morphine Sulfate - 02:00 AM\n Pantoprazole (Protonix) - 08:24 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:35 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.6\nC (97.8\n HR: 101 (74 - 137) bpm\n BP: 105/57(67) {75/42(50) - 130/73(108)} mmHg\n RR: 24 (12 - 28) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 3,165 mL\n 1,720 mL\n PO:\n TF:\n 691 mL\n IVF:\n 1,574 mL\n 1,665 mL\n Blood products:\n Total out:\n 1,670 mL\n 1,020 mL\n Urine:\n 1,470 mL\n 965 mL\n NG:\n 200 mL\n 55 mL\n Stool:\n Drains:\n Balance:\n 1,495 mL\n 700 mL\n Respiratory support\n O2 Delivery Device: Trach mask , Tracheostomy tube\n Ventilator mode: MMV/PSV/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 94 (94 - 450) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n RSBI Deferred: No Spon Resp\n PIP: 20 cmH2O\n SpO2: 97%\n ABG: ///38/\n Ve: 5.6 L/min\n Physical Examination\n Gen: sitting in bed, alert NAD\n CV: tachy RR\n Ches: bibasilar rhonchi no hweezest\n Abd; soft NT\n Ex: no edemat\n Neuro: alert, follows simple commands and mouth words grip and \n strength inlower ext\n Labs / Radiology\n 8.6 g/dL\n 467 K/uL\n 131 mg/dL\n 0.7 mg/dL\n 38 mEq/L\n 3.4 mEq/L\n 8 mg/dL\n 101 mEq/L\n 145 mEq/L\n 27.8 %\n 6.9 K/uL\n [image002.jpg]\n 03:00 AM\n 05:00 AM\n 02:06 AM\n 07:34 AM\n 03:50 AM\n 06:22 AM\n 02:58 AM\n 03:43 AM\n 05:02 PM\n 03:36 AM\n WBC\n 5.2\n 5.9\n 7.5\n 5.6\n 6.1\n 7.0\n 7.1\n 7.1\n 6.9\n Hct\n 26.0\n 27.2\n 26.8\n 27.0\n 27.0\n 29.7\n 28.9\n 29.2\n 27.8\n Plt\n 35\n 52\n 467\n Cr\n 0.6\n 0.7\n 0.6\n 0.5\n 0.7\n 0.7\n 0.6\n 0.7\n 0.8\n 0.7\n Glucose\n 100\n 134\n 134\n 121\n 04\n 108\n 131\n Other labs: PT / PTT / INR:38.8/34.5/4.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:9.4 mg/dL, Mg++:2.3 mg/dL, PO4:4.2\n mg/dL\n Assessment and Plan\n 1. Tachycardia: runs of atach versus AVNRT. On bblocker be not very\n effective- EP consult for ? is there an ablatable focus.\n 2. Resp Failure\n Trach mask trials as tolerating (needing QHS support at\n present)\n PMV trials\n S/P rx for pan Klebs PNA.\n Per IP not stent planned as technically not possible to\n place into her airway\n 3. DVT and coagulopathy On warfarin but high inr. Hold warfarin until\n inr 2-2.5 range or bridge with loveox if may get procedures\n 4. Feeding tube Getting reglan trial but still with emesis. Need to\n coordinate IR advance of G to J tube with Thoracics\n 5. Hypernatremia Replete free water.\n Please see today\ns ICU team note for other issues.\n ICU Care\n Nutrition: TFs\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n Prophylaxis:\n DVT: anti coag\n Stress ulcer: ppi\n Communication: trying to reach boyfriend\n status: Full code\n Disposition : ICU, start screening still need to fix tachycardia\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-19 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 638444,
"text": "Chief Complaint:\n 24 Hour Events:\n 8pm: Vomited tube feeds while receiving free water flushes. Suctioned\n by RT and no apparent aspiration, only blood tinged sputum. O2 sats\n 99-100%. No increased O2 requirement. Held TF, given free water via IV\n 100 cc/hr x 1L since Na 148. Will need to reassess in am, CXR ordered\n for am.\n Thoracics recs: place dophoff post pyloric or have GI place pedi GT\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Diazepam (Valium) - 12:00 AM\n Furosemide (Lasix) - 01:30 AM\n Morphine Sulfate - 02:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:21 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.3\n Tcurrent: 36.8\nC (98.3\n HR: 113 (81 - 137) bpm\n BP: 78/45(52) {78/39(50) - 130/73(108)} mmHg\n RR: 12 (12 - 32) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 3,165 mL\n 700 mL\n PO:\n TF:\n 691 mL\n IVF:\n 1,574 mL\n 700 mL\n Blood products:\n Total out:\n 1,670 mL\n 680 mL\n Urine:\n 1,470 mL\n 680 mL\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n 1,495 mL\n 20 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: MMV/PSV/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 94 (94 - 450) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 7\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 25 cmH2O\n SpO2: 97%\n ABG: ///38/\n Ve: 5.1 L/min\n Physical Examination\n Gen: Obtunded this am, not responsive to voice, minimally responsive to\n noxious stimuli, on MMV through trach tube\n HEENT: PERRL, MMM,\n Resp: Limited by patients mobility, but CTA anteriorly and laterally,\n no rales, rhonchi, or wheezing, some referred upper airway noises from\n secretions.\n Card: S1S2 tachicardic, no m/r/g\n Abd: Obese, soft, Non-distended, BS+\n Exte: No edema, DP 2+, RP2+ bil.\n NEURO: Toes downgoing bilaterally, patellar reflexs 2+ bil, biceps 2+\n bil,\n Labs / Radiology\n 467 K/uL\n 8.6 g/dL\n 131 mg/dL\n 0.7 mg/dL\n 38 mEq/L\n 3.4 mEq/L\n 8 mg/dL\n 101 mEq/L\n 145 mEq/L\n 27.8 %\n 6.9 K/uL\n [image002.jpg]\n COAGs: 38.8/34.5/4.2\n 03:00 AM\n 05:00 AM\n 02:06 AM\n 07:34 AM\n 03:50 AM\n 06:22 AM\n 02:58 AM\n 03:43 AM\n 05:02 PM\n 03:36 AM\n WBC\n 5.2\n 5.9\n 7.5\n 5.6\n 6.1\n 7.0\n 7.1\n 7.1\n 6.9\n Hct\n 26.0\n 27.2\n 26.8\n 27.0\n 27.0\n 29.7\n 28.9\n 29.2\n 27.8\n Plt\n 35\n 52\n 467\n Cr\n 0.6\n 0.7\n 0.6\n 0.5\n 0.7\n 0.7\n 0.6\n 0.7\n 0.8\n 0.7\n Glucose\n 100\n 134\n 134\n 121\n 04\n 108\n 131\n Other labs: PT / PTT / INR:66.1/32.7/8.0, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:9.4 mg/dL, Mg++:2.3 mg/dL, PO4:4.2\n mg/dL\n Assessment and Plan\n 55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach, PEG, placement no with respiratory failure secondary to\n tracheomalacia , resolving HAP.\n .\n # Respiratory failure: Slowly Improving. Now remaining on trach mask\n for most of the day and night, with periods of pressure support of \n over night. Last night required MMV and was not breathing well while\n asleep, likely oversedated with Benadryl, Morhpine, and Valium\n administered in the early morning. Pt awake and alert at rounds,\n interactive, and breathing comfortably on trach mask\n - Continue to increase time on trach mask as tolerated.\n - Decrease sedation and valium use see Sedation below\n - PMV with suctioning again today.\n .\n # HAP vs Aspiration PNA: Afebrile without leukocytosis\n - Completed course of ceftriaxone\n - good O2 saturation on trach mask\n - Continue to f/u cultures\n .\n # Tachycardia: Previously was assessed as sinus tach with occasional\n runs of SVT and sources such as hypovolemia, PE, infection, and pain\n were assessed as possibly etiologies. But, now appears to be SVT for\n much of time, rhythm/rate nonresponsive to carotid massage. HR\n occaisonaly decreases to 70s-80s w/ stable BPs at times that might be\n associated with administration of her BB and valium. Rhythm strip shows\n conversion from a narrow complex SVT to normal sinus rhythm and then\n back. Metroprolol was increased from 25mg TID to QID yesterday, without\n any affect on the SVT.\n - EP consulted for conversion of SVT, appreciate recs\n .\n # Sedation: Inconsistent response to sedation, unclear what is best\n regime. Will continue to wean overall.\n - Continue w Olanzapine QHS\n - D/d valium to 2.5 mg TID and leave just valium 2.5 mg PRN.\n # Nutrition: Pt has had several episodes of vomiting up her TFs,\n reglan started to increase GI motility, but pt had another episode of\n vomiting last night.\n - Hold TFs\n - Thoracic surgery recs: 1) oral/nasal tube in post-piloric position,\n or 2) IR to place a pediatric feeding tube through her PEG site to a\n post-piloric position.\n - Will attempt to coordinate thoracic surgery and IR for tube placement\n tomorrow.\n .\n # Adrenal Insufficency: Endocrine following. Pt does not appear to be\n adrenally insufficient at baseline. Suggesting if the patient under\n goes major stressors such as major surgery, sepsis, she may need stress\n dosed steroids.\n .\n # Fluid Status: Likely approaching euvolemia, though still has mild\n hypernatramia which may suggest is still intravascularly depleated.\n - Monitoring urine output\n - FW flushes w/ tube feeds held due to vomitting\n - will provide D5W IVF as need for hypernatremia and follow lytes\n .\n # UE DVT and elevated INR: DVT in right UE has resolved, new\n non-occlusive in left axillary vein. INR supratherapeutic today\n - COumadin held, will restart at low dose when INR approaches\n therapeutic range.\n - INR 4.2 today, will check PM coags and consider restarting at a low\n dose tonight or tomorrow morning.\n .\n # Spine fracture: Stable\n - Brace for OOB, will discuss with Neurosurgery if current brace is\n optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n .\n # Tracheomalacia. Was initially addressed with IP and they wanted to\n follow up as outpatient. IP reevaluated and does not believe that a\n stent would be feasible.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # PIV x 1\n # Ppx: Coumadin, Ranitidine, Bowel Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n - Will contact Social and Case management today\n # Code: Full\n # Dispo: ICU, Screening for vent facilities\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Respiratory ",
"chartdate": "2167-10-14 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 637448,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 26\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason:\n Tube Type\n Tracheostomy tube:\n Type: Standard, Cuffed, Inner Cannula\n Manufacturer: Portex\n Size: 7.0mm\n PMV: No\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: Yellow / Plug\n Sputum source/amount: Suctioned / Small\n Comments/Plan\n Pt agitated overnight, more sedation received with fairly good effect.\n Administering Albuterol and Atrovent MDI\ns as ordered, see flowsheet\n for rx times and data. RSBI=171 this am. Will follow, trache mask\n trials as tolerated.\n 05:38\n"
},
{
"category": "Nutrition",
"chartdate": "2167-10-15 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 637769,
"text": "Objective\n Pertinent medications: noted\n Labs:\n Value\n Date\n Glucose\n 134 mg/dL\n 02:06 AM\n Glucose Finger Stick\n 139\n 10:00 AM\n BUN\n 11 mg/dL\n 02:06 AM\n Creatinine\n 0.6 mg/dL\n 02:06 AM\n Sodium\n 146 mEq/L\n 02:06 AM\n Potassium\n 4.0 mEq/L\n 02:06 AM\n Chloride\n 106 mEq/L\n 02:06 AM\n TCO2\n 32 mEq/L\n 02:06 AM\n Albumin\n 3.5 g/dL\n 03:00 AM\n Calcium non-ionized\n 9.2 mg/dL\n 02:06 AM\n Phosphorus\n 4.0 mg/dL\n 02:06 AM\n Ionized Calcium\n 1.24 mmol/L\n 02:51 AM\n Magnesium\n 2.1 mg/dL\n 02:06 AM\n Current diet order / nutrition support: Replete c. Fiber @60mL/hr (1440\n kcals/89 gr aa)\n GI: Abd: soft/dist/+bs\n Assessment of Nutritional Status\n Estimation of current intake: Adequate\n Specifics:\n Pt continues on TF\ns for full nutrition support via PEG, currently\n tolerating @ goal s/ problems. (Noted TF\ns were off over weekend / ?\n aspiration event) FWB down to 100mL q 4 hr c/ Na WNL. BG\ns well\n controlled.\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: via TF\n Tube feeding recommendations: Continue TF's @ goal\n Monitor fluid status and adjust FWB prn.\n BG and lyte management as you are\n Please check current wt\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-15 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 637774,
"text": "Chief Complaint: resp failuire\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n ULTRASOUND - At 03:48 PM\n US of Lt arm shows small 1 cm axillary clot non occlusive near PICC\n RUS US shows resolution of formal clot\n Vomiting tube feeds around trach\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Ceftriaxone - 10:00 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 06:20 AM\n Pantoprazole (Protonix) - 08:12 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Gastrointestinal: Emesis\n Flowsheet Data as of 10:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 36.2\nC (97.1\n HR: 146 (123 - 146) bpm\n BP: 153/129(134) {106/41(56) - 185/129(142)} mmHg\n RR: 26 (11 - 33) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,888 mL\n 520 mL\n PO:\n TF:\n 1,268 mL\n IVF:\n 100 mL\n Blood products:\n Total out:\n 1,530 mL\n 845 mL\n Urine:\n 1,510 mL\n 820 mL\n NG:\n 20 mL\n 25 mL\n Stool:\n Drains:\n Balance:\n 358 mL\n -325 mL\n Respiratory support\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 227 (227 - 397) mL\n PS : 8 cmH2O\n RR (Spontaneous): 20\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 194\n PIP: 16 cmH2O\n SpO2: 96%\n ABG: ///34/\n Ve: 6.5 L/min\n Physical Examination\n Labs / Radiology\n 8.5 g/dL\n 335 K/uL\n 121 mg/dL\n 0.5 mg/dL\n 34 mEq/L\n 3.8 mEq/L\n 7 mg/dL\n 107 mEq/L\n 147 mEq/L\n 27.0 %\n 5.6 K/uL\n [image002.jpg]\n 03:08 PM\n 03:00 AM\n 03:36 AM\n 04:40 PM\n 03:00 AM\n 07:05 PM\n 03:00 AM\n 05:00 AM\n 02:06 AM\n 07:34 AM\n WBC\n 7.3\n 6.1\n 7.2\n 5.2\n 5.9\n 7.5\n 5.6\n Hct\n 27.6\n 26.5\n 26.9\n 26.0\n 27.2\n 26.8\n 27.0\n Plt\n 189\n 209\n 238\n \n 335\n Cr\n 0.6\n 0.6\n 0.9\n 0.7\n 0.6\n 0.7\n 0.6\n 0.5\n TCO2\n 26\n Glucose\n 99\n 115\n 106\n 100\n 134\n 134\n 121\n Other labs: PT / PTT / INR:16.6/25.0/1.5, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:9.3 mg/dL, Mg++:2.3 mg/dL, PO4:4.1\n mg/dL\n Assessment and Plan\n 55 yr old alcoholic s/p t spine fx s/p trcah and PEG with persistent\n resp failure\n 1. Resp Failure: currently on trach mask, can do a few hours per\n day, then needs for support. New pan Klebs in sputum, day\n . Try more vent support and see if it helps her.\n 2. Fevers: did not persist- cultures neg to date.\n 3 Hemodynamics: persistant simus tachy\n CTPA to look for emboli\n negative for proximal clot. IOs the of trach mask and her TB\n malacia too much for her. We will see what happens if we out her on\n 15-20 and 5.\n 4. New L Ext DVT\n 5. Emesis: call IR and get g pushed to a j tube\n ICU Care\n Nutrition: tfs held for vomiting\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Prophylaxis:\n DVT: coumadin\n Stress ulcer: ppi\n Communication: try to reach boyfriend\n status: Full code\n Disposition :ICU\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 637612,
"text": "Tachycardia, Other\n Assessment:\n Hr has been in sinus tachycardia all day at 130-140\ns, Hr noted to also\n stay elevated in the 130\ns while at rest also. SBP has been elevated\n throughout the day at 150-170\ns while awake and 120-130\ns while at\n rest. Pt also very restless.\n Action:\n No med to be given for tachycardia or BP MD. Pt given Morphine and\n haldol for restlessness w/o effect. Pt also on valium ATC w/little\n effect. CTA done to r/o pe as a source of tachycardia.\n Response:\n Results pending on CTA.\n Plan:\n Continue to evaluate HR and BP for need of treatment.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt has a known DVT to RUE. Today pt had a US of LUE to R/O DVT as a\n source of tachycardia.\n Action:\n After DVT found, IVF stopped.\n Response:\n Pt found to have a clot to Lt ax vein and MD notified.\n Plan:\n Pt to cont coumadin tonight, awaiting dosage for inr 1.4 . ? Access now\n that Lt arm has a DVT.\n Altered mental status (not Delirium)\n Assessment:\n Pt has been restless most of the day. Pt only follow direct commands.\n When asked to keep her hand off the TC, she will for only 3sec, and\n then she will reach for it again.\n Action:\n Pt given valium, morphine and haldol prn.\n Response:\n Little effect noted from sedations.\n Plan:\n Continue to eval MS.\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 637618,
"text": "Tachycardia, Other\n Assessment:\n Continues to be Tachycardia in 120-145 (anxiety). SBP has been 100-145\n without ectopy.\n Action:\n No medication given for tachycardia.Pt gets Valium 5 mg scheduled Q6H\n with little effect. CTA done to r/o pe as a source of tachycardia.\n Response:\n Results pending on CTA.\n Plan:\n Continue to evaluate HR and BP for need of treatment.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt has a known DVT to RUE. Today pt had a US of LUE to R/O DVT as a\n source of tachycardia.\n Action:\n After DVT found, IVF stopped.\n Response:\n Pt found to have a clot to Lt ax vein and MD notified.\n Plan:\n Pt to cont coumadin tonight, awaiting dosage for inr 1.4 . ? Access now\n that Lt arm has a DVT.\n Altered mental status (not Delirium)\n Assessment:\n Pt has been restless most of the day. Pt only follow direct commands.\n When asked to keep her hand off the TC, she will for only 3sec, and\n then she will reach for it again.\n Action:\n Pt given valium, morphine and haldol prn.\n Response:\n Little effect noted from sedations.\n Plan:\n Continue to eval MS.\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 638072,
"text": "Tachycardia, Other\n Assessment:\n HR continues to be 120-140\n Action:\n On Lopressor 25 mg TID\n Response:\n Needs further titration upwards\n Plan:\n Continue to titrate BB as BP allows\n Airway Clearance, Impaired\n Assessment:\n Pt with copious secretions Suctioned A 30-1 hour for thick white\n secretions Sats stable 92-96%\n Action:\n Placed back on vent overnight to allow for periods of rest, Lavaged by\n RT x 2\n Response:\n Secretions diminished as night when on\n Plan:\n Continue with aggressive pulmonary toliet\n Altered mental status (not Delirium)\n Assessment:\n Pt continues to be agitated, following commands inconsistently. MAE,\n PERRLA. Soft restraints remain in place to prevent dislodgement of\n trach\n Action:\n On valium TID given dose of Zyprexa at HS\n Response:\n Pt able to sleep in extended naps overnight, less agitated\n Plan:\n Continue to follow mental status, try to D/C restraints when able\n Impaired Skin Integrity\n Assessment:\n Area around track red & excoriated\n Action:\n Trach care provided, Antibiotic ointment placed\n Response:\n Plan:\n Continue to monitor\n Alteration in Nutrition\n Assessment:\n Pt remains NPO DT high aspiration risk, no residual overnight\n Action:\n Started on raglan QID, ? needs feeding tube changed to post pyloric\n Response:\n No evidence of aspiration overnight\n Plan:\n Awaiting surgery input re: Advancement of feeding tube\n"
},
{
"category": "Respiratory ",
"chartdate": "2167-10-18 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 638279,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 30\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Tracheostomy tube:\n Type: Standard, Cuffed\n Manufacturer: Portex\n Size: 7.0mm\n PMV: Not wearing\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n :\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Plan\n Next 24-48 hours:\n : Continue T-collar as tolerated\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Respiratory ",
"chartdate": "2167-10-19 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 638339,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 31\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Tracheostomy tube:\n Type: Standard, Cuffed\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Periodic SBT's for conditioning; Comments: Continue with trach trials\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 635876,
"text": "Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt cont on Heparin gtt @ 1500units/h. PTT in therapeutic range.\n Coumadin po HS.\n Action:\n No further action taken.\n Response:\n Plan:\n Daily PT/PTT levels,? Plan to transition off heparin and increase\n coumadin dose.\n Altered mental status (not Delirium)\n Assessment:\n PT alert and very agitated throughout shift- making several attempts to\n pull at trach\n.fell asleep briefly following afternoon valium dose-\n Systolic dropped into low 80s, HR in the 50s- SB. Following commands\n inconsistently.\n Action:\n Fentanyl/versed titrated throughout shift. Restarted on Haldol IV prn,\n and given addititional one time dose of valium. Soft wrist restraints\n in place for safety. EKG done of QTC interval\n Response:\n Cont to be anxious, attempting to pull at trach. QTI -442\n Plan:\n Cont daily QTC Intervals, titrate down Fent/versed Gtt as able.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Hypernatremia (high sodium)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 635877,
"text": "55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\n Now with prolonged hospital course c/b by PNA with high PEEP\n requirement, anxiety, RUE DVT on heparin qtt.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt cont on Heparin gtt @ 1500units/h. PTT in therapeutic range.\n Coumadin po HS.\n Action:\n No further action taken.\n Response:\n Plan:\n Daily PT/PTT levels-? Plan to transition off heparin and increase\n coumadin dose.\n Altered mental status (not Delirium)\n Assessment:\n PT alert and very agitated throughout shift- making several attempts to\n pull at trach\n.fell asleep briefly following afternoon valium dose-\n Systolic dropped into low 80s, HR in the 50s- SB. Following commands\n inconsistently.\n Action:\n Fentanyl/versed titrated throughout shift. Restarted on Haldol IV prn,\n and given addititional one time dose of valium. Soft wrist restraints\n in place for safety. EKG done of QTC interval\n Response:\n Cont to be anxious, attempting to pull at trach. QTI -442\n Plan:\n Cont daily QTC Intervals, titrate down Fent/versed Gtt as able, cont w/\n prn haldol and standing valium.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Cont to be trached/vented on AC. Pleural effusions on CXR worsening.\n Action:\n Tolerated PS briefly this am. ABG/VBG collected\n Response:\n Pt w/ periods of apnea on PS.\n Plan:\n Non-contrast CT today to check size of pleural effusions, ? tap\n effusions following CT, make vent changes as needed, wean fent/versed\n as able to tolerate vent changes. Recheck ABG/VBG this evening.\n Hypernatremia (high sodium)\n Assessment:\n NA level cont to be ^^\n Action:\n FWB increased to 300cc every 4 hrs.\n Response:\n Lytes to be rechecked this evening\n Plan:\n Check day and evening lytes, cont w/ q 4h boluses\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-05 00:00:00.000",
"description": "Physician Resident/Attending Progress Note - MICU",
"row_id": 635878,
"text": "Chief Complaint:\n 24 Hour Events:\n On lasix drip\n Attempted to wean FiO2\n No acute events\n No BM\n Agitated this am\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions :\n Midazolam (Versed)\n 1 mg/hour\n Furosemide (Lasix)\n 2 mg/hour\n Heparin Sodium\n 1,500 units/hour\n Fentanyl\n 75 mcg/hour\n Other ICU medications:\n Other medications:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.9\nC (98.5\n HR: 126 (49 - 131) bpm\n BP: 156/84(117) {78/38(52) - 164/95(125)} mmHg\n RR: 20 (9 - 21) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 4,160 mL\n 1,185 mL\n PO:\n TF:\n 1,267 mL\n 315 mL\n IVF:\n 1,018 mL\n 260 mL\n Blood products:\n Total out:\n 4,015 mL\n 2,090 mL\n Urine:\n 4,015 mL\n 2,090 mL\n NG:\n Stool:\n Drains:\n Balance:\n 145 mL\n -905 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 500) mL\n Vt (Spontaneous): 675 (675 - 675) mL\n PS : 8 cmH2O\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 19 cmH2O\n Plateau: 16 cmH2O\n SpO2: 96%\n ABG: 7.39/46/118/28/2\n Ve: 8.9 L/min\n PaO2 / FiO2: 236\n Physical Examination\n General Appearance: Intubated and sedated. Responsive, following\n commands, Overweight / Obese, mild agitation but NAD\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\n deviation\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Respiratory / Chest: (Expansion: Symmetric), CTA anteriorly, decreased\n BS\n Abdominal: Obese, Firm, Non-tender, no rebound, no guarding, + BS, PEG\n in place with dressing C/D/I\n Extremities: No clubbing or cyanosis, 1+ nonpitting edema of b/l hands,\n anasarca\n Skin: no rashes or jaundice\n Lines: r brachioceph ART and L PICC C/D/I\n Labs / Radiology\n 272 K/uL\n 8.6 g/dL\n 128 mg/dL\n 0.6 mg/dL\n 28 mEq/L\n 3.1 mEq/L\n 8 mg/dL\n 110 mEq/L\n 148 mEq/L\n 27.4 %\n 11.2 K/uL\n [image002.jpg]\n 05:17 PM\n 11:41 PM\n 03:06 AM\n 03:38 AM\n 04:05 PM\n 03:55 AM\n 07:19 AM\n 11:24 AM\n 03:18 PM\n 02:47 AM\n WBC\n 10.6\n 10.0\n 8.3\n 11.2\n Hct\n 27.3\n 25.8\n 24.6\n 27.4\n Plt\n 72\n Cr\n 0.5\n 0.6\n 0.6\n 0.5\n 0.6\n 0.6\n TCO2\n 32\n 31\n 29\n 29\n Glucose\n 110\n 94\n 111\n 106\n 121\n 123\n 137\n 128\n Other labs: Ca++:9.0 mg/dL, Mg++:2.6 mg/dL, PO4:4.3 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA and\n ARDS intubated since the end of now s/p trach and PEG placement.\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation. Stenting\n unlikely to help for trachiomalacia as airways have poor structure\n diffusely. S/P Trach and PEG on . Increased effusion on recent\n CXR.\n - wean FiO2 as tolerated\n - non-con head CT to further characterize pulmonary effusions,\n det potential for thoracentesis\n # Adrenal Insufficency: Hypotension that resolved with steroids,\n returned as they came off and is now improved again. Possible primary\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\n started on .\n - wean per endo recs, decrease to q8 today, likely q12 dosing\n tomorrow\n # Volume overloaded in setting of hypernatremia with TBW deficit.\n - Lasix gtt, continue with goal -1-2 L per day.\n - electrolytes\n - continue tube feeds with free water flushes increase from 250 to 300\n cc q4\n # Sedation: Sedation control remains somewhat poor although fentanyl\n patch and diazpem are likely therapeutic range today. On Versed 2.0,\n Fentanyl 100, Fentanyl patch, Diazepam standing and haldo 2.5-5 mg\n PRN. QTc increased to 480.\n - Wean versed/fentanyl as tolerated, continue diazepam in\n hopes for vent facility placement\n - Increase diazepam to 12mg q4\n - Check ekg for QTc\n if <480, restart haldol and/or increase\n fentanyl patch\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\n coumadin at least until s/p trach.\n - heparin gtt restarted\n - coumadin 5mg G-tube today\n hold coumadin today for possible \n # Constipation\n current regimen of colace and senna, stooled during\n rounds\n - dulcolax PO/PR\n - reassess and increase bowel regimen PRN\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n -f/u full trauma spine eval from OSH to determine need for further back\n imaging in-house (to be done )\n # Nutrition: Tube feeds with free water flushes, tolerating well,\n continue Replete (Full) - 11:20 AM 30 mL/hour\n # Glycemic control: SSI, well controlled\n # Lines L PICC () and R ART ()\n both working well, check\n ABG/VBG today\n if correlate well, d/c art line\n # Ppx: heparin, ranitidine, VAP prevention, colace and senna\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n Code: Full\n Dispo: ICU, being screening for vent facilities\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 55F T5-8 fractures with retropulsion and ARDS\n from klebsiella VAP; on heparin for UE DVT and lasix for volume\n overload. Tolerating slow vent wean but failed SBT. Was TBB negative\n yesterday with lasix drip; sedation remains challenging.\n Exam notable for Tm 99.4 BP 145/77 HR 120 RR 18-20 with sat 97% on VAC\n 400x18 PEEP 8 FiO2 0.5. TBB -2L/24h, +9L/MICU LOS. Eyes opens, will\n squeeze hands and wiggle toes but very drowsy. Bronchial BS bilaterally\n with RRR s1s2 SM at base. Abdomen is distended with decreased BS.\n 1+ edema in BLE, no cords. Labs notable for WBC 11K, HCT 27, K+ 3.1, Na\n 148, Cr 0.6. CXR with resolving B LL airspace disease and effusions.\n Agree with plan to continue supportive care and wean vent as we\n continue diuresis with attention to contraction alkalosis. Will check\n CT without contrast to assess lung parenchyma and effusions. Will\n increase fentanyl patch to 200 and valium to 15 TID po in addition to\n drips. Will check EKG prior to reinitiating haldol, which worked very\n well for her. Will wean hydrocortisone 25 q8 today and reduce to q12\n tomorrow, with long term goal for oral prednisone. Will continue IV\n heparin for UE DVT and continue transition to anticoagulation with\n coumadin. Will restart tube feeds and continue FW boluses for\n hypernatremia. Continue spinal stabilization with brace when OOB. Will\n eventually need MRI for surgical planning; remainder of plan as\n outlined above.\n Patient is critically ill\n Total time: 40 min\n ------ Protected Section Addendum Entered By: , MD\n on: 02:40 PM ------\n"
},
{
"category": "Nursing",
"chartdate": "2167-09-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 635021,
"text": "Events: Wean from vent to 10 PEEP- tolerating w/ goal sat >90%. Lasix\n gtt started for volume overload. IP then consulted for ?\n trach/PEG . Plan NPO @ MS, Hep gtt off @ 0600 anticipation add on\n in or for open trach/PEG. MS n to acutely agitation-\n Versed and Fent gtt titrated- bolus PRN and starting PO Valium, Fent\n patch and IV Haldol for improved and longer acting pain control and ?\n delirium.\n Edema, peripheral\n Assessment:\n 3+ anasarca, pitting and dependent edema\n Action:\n Starting Lasix gtt @ 5cc/gr for goal >100cc/hr output\n Response:\n Initial reaction > 1L / 1 and\n hrs, titrated down to 2cc/hr with\n recent history of hypotensive w/ sedation\n Plan:\n monitor I+O, Resume Lasix gtt for goal UOP > 100cc/hr, BP\n monitoring, monitor edema\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Hep gtt infusing @ 1700 units/hr, no s/s bleeding\n Action:\n gtt\n Response:\n No change\n Plan:\n Hep gtt PT w/ AM Labs- off @ 0600 for anticipated trach/page \n Impaired Skin Integrity\n Assessment:\n Anasarca, excoriated/mild rash/reddened but blancking perianal area,\n mild shearing tear in perianal area, pannus folds w/o infection, left\n palp near ? friction skin impairment\n Action:\n Multipodus boots on, thin duoderm to bilat elbows, duoderm to left\n palm, barrier cream on perianal area-attempting to reposition,\n attempting IV/PO, pain patch and emotional support for decrease\n shearing movement in bed\n Response:\n No new breakdown in skin integrity noted\n Plan:\n comitor breakdown in skin integrity, minimize fracture and\n pressure- turning and pressure reduction as tolerated, duodern,\n emotional support and medications\n Altered mental status (not Delirium)\n Assessment:\n MS variable from sedated to acutely agitated attempting to hit while\n being turned,/oral care, intermittently alert, following commands\n nodding and mouthing words-pt unable to use white board, BP w/\n MS- when sedated SBP 88-90\ns, agitated 140-160\ns- art line positional\n Action:\n IV sedation as HD necessary, blousing PRN, inc dose on IV Haldol,\n attempting to wean IV sedation w/ additional of Fentanyl patch and PO\n valium, emotional support\n Response:\n MS , occ apears in pain and attempting to move in bed,\n others acutely agitated- pulling @ line and actively pointing and\n attempting to pull @ ETT\n Plan:\n IV medication, patch and PO medication for sedation/pain\n medication, emotional support, encourage nodding/use of white boad for\n expression as tolerated, repositioning\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS diminished throughout, scant suctioning clear white secretions, goal\n sat >90%\n Action:\n PEEP from 15-10, administering IV Lasix gtt,\n Response:\n LS unchanges, ABD w/I pt normal limits, - inc WOB w/ agitation,\n Plan:\n Monitor resp status, ABG as needed, wean as tolerated, monitor sat,\n emotional support- trach/PEG \n Hypernatremia (high sodium)\n Assessment:\n NA 146\n Action:\n Administering changed flush to 150cc free water Q 4hrs\n Response:\n minimal residuals\n Plan:\n free water flushes, monitor NA, s/s hypernatremia\n"
},
{
"category": "Nursing",
"chartdate": "2167-09-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 635022,
"text": "Events: Wean from vent to 10 PEEP- tolerating w/ goal sat >90%. Lasix\n gtt started for volume overload. IP then consulted for ?\n trach/PEG . Plan NPO @ MS, Hep gtt off @ 0600 anticipation add on\n in or for open trach/PEG. MS n to acutely agitation-\n Versed and Fent gtt titrated- bolus PRN and starting PO Valium, Fent\n patch and IV Haldol for improved and longer acting pain control and ?\n delirium.\n Edema, peripheral\n Assessment:\n 3+ anasarca, pitting and dependent edema\n Action:\n Starting Lasix gtt @ 5cc/gr for goal >100cc/hr output\n Response:\n Initial reaction > 1L / 1 and\n hrs, titrated down to 2cc/hr with\n recent history of hypotensive w/ sedation\n Plan:\n monitor I+O, Resume Lasix gtt for goal UOP > 100cc/hr, BP\n monitoring, monitor edema\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Hep gtt infusing @ 1700 units/hr, no s/s bleeding\n Action:\n gtt\n Response:\n No change\n Plan:\n Hep gtt PT w/ AM Labs- off @ 0600 for anticipated trach/page \n Impaired Skin Integrity\n Assessment:\n Anasarca, excoriated/mild rash/reddened but blancking perianal area,\n mild shearing tear in perianal area, pannus folds w/o infection, left\n palp near ? friction skin impairment\n Action:\n Multipodus boots on, thin duoderm to bilat elbows, duoderm to left\n palm, barrier cream on perianal area-attempting to reposition,\n attempting IV/PO, pain patch and emotional support for decrease\n shearing movement in bed\n Response:\n No new breakdown in skin integrity noted\n Plan:\n comitor breakdown in skin integrity, minimize fracture and\n pressure- turning and pressure reduction as tolerated, duodern,\n emotional support and medications\n Altered mental status (not Delirium)\n Assessment:\n MS variable from sedated to acutely agitated attempting to hit while\n being turned,/oral care, intermittently alert, following commands\n nodding and mouthing words-pt unable to use white board, BP w/\n MS- when sedated SBP 88-90\ns, agitated 140-160\ns- art line positional\n Action:\n IV sedation as HD necessary, blousing PRN, inc dose on IV Haldol,\n attempting to wean IV sedation w/ additional of Fentanyl patch and PO\n valium, emotional support\n Response:\n MS , occ apears in pain and attempting to move in bed,\n others acutely agitated- pulling @ line and actively pointing and\n attempting to pull @ ETT\n Plan:\n IV medication, patch and PO medication for sedation/pain\n medication, emotional support, encourage nodding/use of white boad for\n expression as tolerated, repositioning\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS diminished throughout, scant suctioning clear white secretions, goal\n sat >90%\n Action:\n PEEP from 15-10, administering IV Lasix gtt,\n Response:\n LS unchanges, ABD w/I pt normal limits, - inc WOB w/ agitation,\n Plan:\n Monitor resp status, ABG as needed, wean as tolerated, monitor sat,\n emotional support- trach/PEG \n Hypernatremia (high sodium)\n Assessment:\n NA 146\n Action:\n Administering changed flush to 150cc free water Q 4hrs\n Response:\n minimal residuals\n Plan:\n free water flushes, monitor NA, s/s hypernatremia\n"
},
{
"category": "Physician ",
"chartdate": "2167-09-20 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 634095,
"text": "TITLE: PGY3 MICU Admission Note\n Chief Complaint: persistent respiratory failure\n HPI:\n 55 year old woman with hx of obesity presented to Medical Center\n on after falling down stairs while at home. She suffered a\n traumatic T5-8 fracture with retropulsion of fragments. Per medical\n records and discussion with her brother, she was awake for the fall (no\n LOC) and the fall was triggered by unsteady gait, potentially\n influenced by alcohol. Her fracture was managed concervatively. She\n was placed in a torso brace but her course was complicated by\n respiratory failure requiring intubation. At that time a CT was\n negative for PE but showed bilateral bibasilar consolidations vs\n atelectasis. At that time an ABG was 7.20/89/57 (unknown FIO2 but\n likely >6L facemask). She was intubated on at 08:40. The\n respiratory failure was thought likely to be related to pain med\n induced hypoventilation, bronchospasm, or restricted breathing duet to\n the back brace. The hospital course was complicated by\n difficulty weaning form the ventilator. Her periodic agitation was\n managed with seroquel. Prior to transfer her vent settings were: SIMV\n 12x600 FIO2 0.45.\n The neurosurgery service evaluated her and recommended concervative\n management of her fracture including a back brace and outpatient\n neurosurgery followup. The CT chest showed notable narrowing of her\n central airways and the patient was referred for Interventional\n Pulmonary evaluation for airway stenting.\n Patient admitted from: Transfer from other hospital\n History obtained from Family / Medical records\n Patient unable to provide history: Sedated\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Other medications:\n Home Medications:\n ativan prn\n prilosec OTC\n Medications on transfer:\n dexmedetomidine\n senna 2 tabs qhs\n zofran 4 mg IV q6hr:prn\n tinzaparin 4500 units q24\n acetaminophen 650 mg q6prn\n famotidine 20 mg IV daily\n colace 100 mg \n albuterol/ipratropium INH q4\n seroquel 50 mg \n lactated ringer's @75cc/hr\n Past medical history:\n Family history:\n Social History:\n GERD\n s/p TAH\n s/p left total hip replacement\n s/p appendectomy\n remote benign breast mass\n nc\n Occupation: regional manager at insurance company\n Drugs: denies\n Tobacco: unknown\n Alcohol: heavy\n Other:\n Review of systems:\n Flowsheet Data as of 03:00 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36\nC (96.8\n Tcurrent: 36\nC (96.8\n HR: 75 (75 - 90) bpm\n BP: 106/43(59) {106/43(59) - 154/71(103)} mmHg\n RR: 12 (12 - 18) insp/min\n SpO2: 100%\n Total In:\n 10 mL\n 32 mL\n PO:\n TF:\n IVF:\n 10 mL\n 32 mL\n Blood products:\n Total out:\n 425 mL\n 225 mL\n Urine:\n 425 mL\n 225 mL\n NG:\n Stool:\n Drains:\n Balance:\n -416 mL\n -194 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 100%\n PIP: 34 cmH2O\n SpO2: 100%\n ABG: 7.42/47/61/30/4\n Ve: 6.1 L/min\n PaO2 / FiO2: 61\n Physical Examination\n General Appearance: Overweight / Obese\n Eyes / Conjunctiva: PERRL, Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Rhonchorous: bilaterally)\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended, Obese\n Extremities: Right: Trace, Left: Trace, Cyanosis\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Purposeful, Sedated, Tone: Not assessed\n Labs / Radiology\n 333 K/uL\n 9.7 g/dL\n 103 mg/dL\n 0.6 mg/dL\n 6 mg/dL\n 30 mEq/L\n 109 mEq/L\n 3.8 mEq/L\n 150 mEq/L\n 30.7 %\n 9.7 K/uL\n [image002.jpg]\n \n 2:33 A9/6/ 11:54 PM\n \n 10:20 P9/7/ 01:00 AM\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 9.7\n Hct\n 30.7\n Plt\n 333\n Cr\n 0.6\n TC02\n 32\n Glucose\n 103\n Other labs: PT / PTT / INR:13.8/22.4/1.2, ALT / AST:30/19, Alk Phos / T\n Bili:149/0.7, Differential-Neuts:76.9 %, Lymph:17.3 %, Mono:3.0 %,\n Eos:2.5 %, Albumin:3.0 g/dL, LDH:222 IU/L, Ca++:8.6 mg/dL, Mg++:2.1\n mg/dL, PO4:4.1 mg/dL\n ECG: sinus @ @86. low voltage. nl axis and intervals. no ischemic\n changes.\n Assessment and Plan\n A/P: 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture\n Respiratory failure: initially likely multifactorial including\n bronchspasm, hypoventilation from narcotics, and potential aspiration.\n prior evaluation negative for PE. still with significant A-a gradient.\n cxr appears under penetrated with small lung fields and potential\n effusion on right. potentially from additional pulmonary edema, however\n hypernatremia would limit ability to diurese.\n - daily chest xray\n - will hold on CT chest or airway pending IP consult\n - IP consult\n - vent settings: AC 500 x14 PEEP >8 (given body habitus), FIO2 as\n needed\n - sedation: fentanyl gtt/versed bolus\n - trial of diuresis when able\n Spine fracture: neurologically intact distal to the lesion. prior notes\n from MMC neurosurgeons indicated no surgical procedure needed and would\n continue with spine brace.\n - monitor distal neurologic function\n - cto brace x3 months unless supine in bed\n Anemia: admission to MMC was ~40 now down to 30% w/o sign of active GI\n bleed or other source of blood loss. likely related to crystalloid\n administration, anemia of inflammation, chronic phlebotomy. given bili\n and LDH normal would be unlikely for hemolysis.\n - trend Hct\n - guaiac stools\n Hypernatremia: most likely related to inadequate free water repletion.\n free water defecit ~3L.\n - replete via OGT primarily\n - D5W x1 L\n ICU Care\n Nutrition:\n Comments: tube feed with free water\n nutrition consult\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 10:30 PM\n 18 Gauge - 10:30 PM\n 20 Gauge - 01:36 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Family meeting held , ICU consent signed Comments: \n (brother) \n (boyfriend/POA) \n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Respiratory ",
"chartdate": "2167-10-03 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 635640,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation:\n Ideal body weight:\n Ideal tidal volume:\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position:\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure:\n Cuff volume:\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds:\n RUL Lung Sounds:\n LUL Lung Sounds:\n LLL Lung Sounds:\n Comments:\n Secretions\n Sputum color / consistency:\n Sputum source/amount:\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Specialized Gas Therapy\n Nitric Oxide\n PPM used: ppm\n Indication:\n Effect of therapy: []\n Nitric Oxide trial:\n Comments:\n HeliOx:\n Additional O[2] by cannula: L/min\n Continuous nebulized bronchodilator:\n Comments:\n Recruitment Maneuvers Done\n CPAP pressure used: cm H2O\n Duration: sec\n Times per shift:\n Comments:\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 635868,
"text": "Impaired Skin Integrity\n Assessment:\n Skin warm to touch, yeast-like red rash under skin folds, coccyx\n red,\n skin intact.\n Action:\n Miconazole powder applied to skin folds/periarea. Miconazole skin\n cream barrier applied to coccyx. Frequent repositioning.\n Response:\n Cont w/ rash\n Plan:\n Cont w/ frequent repositioning and current skin care regimen\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt cont on Heparin gtt @ 1500units/h. PTT in therapeutic range.\n Coumadin po HS.\n Action:\n No further action taken.\n Response:\n Plan:\n Daily PT/PTT levels,? Plan to transition off heparin and increase\n coumadin dose.\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Hypernatremia (high sodium)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 635874,
"text": "Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt cont on Heparin gtt @ 1500units/h. PTT in therapeutic range.\n Coumadin po HS.\n Action:\n No further action taken.\n Response:\n Plan:\n Daily PT/PTT levels,? Plan to transition off heparin and increase\n coumadin dose.\n Altered mental status (not Delirium)\n Assessment:\n PT alert and very agitated throughout shift\n.fell asleep briefly\n following afternoon valium dose- Systolic dropped into low 80s, HR in\n the 50s- SB. Following commands inconsistently.\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Hypernatremia (high sodium)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2167-09-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 634940,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n PICC placed, Central line d/c'd\n Lasix 10 mg given with 400 cc UOP in afternoon, pH improved\n Lasix 20 mg given at ~ 4AM.\n Lots of thick sinus secreations\n Delerium/anxiety overnight with periods of hypertension.\n Could not draw of A-line.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Aztreonam - 06:00 AM\n Vancomycin - 09:00 AM\n Levofloxacin - 08:06 AM\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Fentanyl - 150 mcg/hour\n Heparin Sodium - 1,700 units/hour\n Other ICU medications:\n Furosemide (Lasix) - 03:01 AM\n Midazolam (Versed) - 04:36 AM\n Fentanyl - 04:36 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36.4\nC (97.6\n HR: 90 (47 - 92) bpm\n BP: 118/59(80) {80/40(53) - 137/105(111)} mmHg\n RR: 17 (15 - 24) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101 kg (admission): 94.2 kg\n Height: 67 Inch\n CVP: 19 (16 - 19)mmHg\n Total In:\n 2,560 mL\n 543 mL\n PO:\n TF:\n 1,441 mL\n 342 mL\n IVF:\n 1,020 mL\n 201 mL\n Blood products:\n Total out:\n 1,680 mL\n 860 mL\n Urine:\n 1,680 mL\n 860 mL\n NG:\n Stool:\n Drains:\n Balance:\n 880 mL\n -317 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 15 cmH2O\n FiO2: 50%\n PIP: 27 cmH2O\n Plateau: 23 cmH2O\n SpO2: 98%\n ABG: 7.41/45/77./28/2\n Ve: 6.5 L/min\n PaO2 / FiO2: 156\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese, opens eyes\n but no purposeful movement\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric)\n Abdominal: No(t) Soft, Non-tender, Bowel sounds present, Distended\n Extremities: No clubbing or cyanosis, 3+ nonpitting edema of b/l hands,\n LE without edema\n Skin: no rashes or jaundice\n Labs / Radiology\n 411 K/uL\n 8.3 g/dL\n 133 mg/dL\n 0.5 mg/dL\n 28 mEq/L\n 4.1 mEq/L\n 13 mg/dL\n 111 mEq/L\n 145 mEq/L\n 26.0 %\n 9.7 K/uL\n [image002.jpg]\n 04:05 PM\n 01:12 AM\n 04:00 AM\n 04:09 AM\n 10:18 AM\n 02:33 PM\n 02:46 PM\n 03:31 AM\n 02:26 PM\n 05:53 PM\n WBC\n 9.6\n 9.7\n Hct\n 27.8\n 26.0\n Plt\n 374\n 411\n Cr\n 0.5\n 0.5\n 0.5\n 0.5\n TCO2\n 26\n 27\n 28\n 29\n 26\n 27\n 30\n Glucose\n 194\n 195\n 195\n 163\n 133\n Other labs: PT / PTT / INR:15.3/69.9/1.3, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:86.1 %, Lymph:10.3 %,\n Mono:2.8 %, Eos:0.5 %, Lactic Acid:2.0 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:8.3 mg/dL, Mg++:2.2 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with respiratory failure\n and difficulty weaning from vent.\n # Respiratory failure: Intubated on for resp decompensation.\n Likely VAP. Unlikely to have tracheomalacia as initially\n transferred for.\n - wean PEEP\n - Given mild alkalosis, will decrease RR to 18, repeat ABG\n - discuss need for trach with patient and her family\n - Will continue gentle diuresis once alkalosis resolved\n # Pneumonia: Pansensitive Kleb oxytoca pneumonia and sputum with GPCs\n on gram stain. Afebrile overnight. On levofloxacin since .\n Vancomycin, aztreonam have been stopped. Resp status seems to be\n improving.\n - Follow cultures\n - d/c levofloxacin having completed 8 day course\n # Sedation: On versed and fentanyl\n # EKG changes: Sinus bradycardia, now somewhat improved. Likely\n related to increased vagal tone possibly related to steroid\n replacement. Atrial EKG shows p-waves and cardiac enzymes normal.\n - Continue to monitor\n # Hypotension: Improved, off levophed for 2-3 days now, with good urine\n output. CVP increasing with reduction in PEEP. Likely poor\n adrenal response in setting of acute illness and very high PEEP.\n -D/C fludricort and hydrocortisone now that the 5 day steroid course is\n complete\n -monitor, expect improvement with continual reduction in PEEP\n # RUE DVT: Started on heparin gtt on , now therapeutic. Follow\n PTTs. Would hold off on coumadin at least until s/p trach.\n - continue to monitor\n # Adrenal Insufficency: Random cortisol was approx 3 when it should\n have been maximally stimulated.\n - hydrocortisone and florinef for 5 days\n # Anemia: Stable.\n - Trend HCT\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n FEN/GI: Tube feeds @ goal\n DVT: Treatment dose heparin\n Ulcer: Ranitidine\n VAP: Prevention per routine\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 08:12 PM 60 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 04:00 PM\n PICC Line - 09:19 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2167-09-29 00:00:00.000",
"description": "Physician Resident / Attending Progress Note - MIC",
"row_id": 635107,
"text": "Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - STOP 09:00 PM - attempted to re-wire but\n patient was very agitated and re-wire was unsuccessful\n Patient alternated between tachycardia and normotension and hypotension\n in the high-80s/low 90s and HRs in the 50s\n Given haldol, valium, midaz and fentanyl for sedation\n ABG with low paO2 on PEEP 10, had to increase -- went back up to 15 and\n then attempted to re-wean down with goal 8 in anticipation of OR\n To OR for trach and PEG today (thoracics)\n Put on lasix drip and put out >1L in just over an hour\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 08:06 AM\n Infusions:\n Midazolam (Versed) - 1.5 mg/hour\n Fentanyl - 200 mcg/hour\n Other ICU medications:\n Fentanyl - 06:45 PM\n Ranitidine (Prophylaxis) - 08:00 PM\n Haloperidol (Haldol) - 10:00 PM\n Midazolam (Versed) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.7\nC (99.8\n HR: 109 (55 - 134) bpm\n BP: 120/56(70) {80/43(51) - 133/85(94)} mmHg\n RR: 20 (16 - 28) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 101 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 3,064 mL\n 404 mL\n PO:\n TF:\n 1,440 mL\n IVF:\n 1,014 mL\n 314 mL\n Blood products:\n Total out:\n 4,257 mL\n 1,195 mL\n Urine:\n 4,257 mL\n 1,195 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,193 mL\n -791 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 18\n RR (Spontaneous): 10\n PEEP: 15 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10\n PIP: 23 cmH2O\n Plateau: 24 cmH2O\n SpO2: 97%\n ABG: 7.46/48/65/31/8 @ 10:20 PM\n Ve: 7.8 L/min\n PaO2 / FiO2: 108\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 320 K/uL\n 8.0 g/dL\n 94 mg/dL\n 0.6 mg/dL\n 31 mEq/L\n 3.6 mEq/L\n 13 mg/dL\n 110 mEq/L\n 147 mEq/L\n 25.8 %\n 9.0 K/uL\n [image002.jpg]\n 10:18 AM\n 02:33 PM\n 02:46 PM\n 03:31 AM\n 02:26 PM\n 05:53 PM\n 05:01 AM\n 03:32 PM\n 10:19 PM\n 02:50 AM\n WBC\n 9.7\n 9.5\n 9.0\n Hct\n 26.0\n 27.6\n 25.8\n Plt\n \n Cr\n 0.5\n 0.5\n 0.5\n 0.6\n 0.6\n TCO2\n 29\n 26\n 27\n 30\n 30\n 35\n Glucose\n 195\n 195\n 163\n 133\n 102\n 94\n Other labs: PT / PTT / INR:14.1/59.6/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:71.2 %, Lymph:22.7 %,\n Mono:4.0 %, Eos:1.7 %, Lactic Acid:1.5 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:8.2 mg/dL, Mg++:2.1 mg/dL, PO4:4.6 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with respiratory failure\n and difficulty weaning from vent.\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation.\n Transferred here for tracheomalacia, but not sure this is a component.\n Will need bronch eval when improved\n - Thoracics will do trach and PEG once stable on PEEPs around 10. Had\n been planned for today but currently holding as PEEP is 15.\n - wean PEEP as tolerated\n - needs A-line\n # Volume overload\n Currently with hypernatremia, Cr increase, contract\n alk, but mild\n - continue gentle diuresis with goal -1L per day as tolerated by blood\n pressure. IV lasix drip at 1-5 mg/hr.\n - FW in TF at 150 cc q4hrs\n - PM lytes.\n # Sedation: Now well seadated on Versed 1.5, Fentanyl 175, Fentanyl\n patch, Diazepam standing and haldo 2.5-5 mg PRN. QTc stable at .44\n - Wean versed/fentanyl as tolerated\n # HCT\n Has had slow decline while in ICU.\n - Xfuse PRN Hct < 21\n - continue to follow, guiac stools\n # Hypotension: Related to sedation, but high PEEP, adrenial\n insufficiency, sepsis have previously been contributing.\n - needs A-line for monitoring\n - cortisol stim to rule out persistent adrenal insufficiency\n # RUE DVT: Started on heparin gtt on , now off for trach that was\n planned for today. Follow PTTs. Would hold off on coumadin at least\n until s/p trach.\n - restart heparin\n # Adrenal Insufficency: Random cortisol was approx 3 when it should\n have been maximally stimulated. S/P 5 days of hydrocortisone and\n florinef.\n - will recheck as above and start at 50 q8 if needed\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n FEN/GI: Tube feeds @ goal. No need to be NPO while awaiting stable\n PEEP\n DVT: Treatment dose heparin\n Ulcer: Ranitidine\n VAP: Prevention per routine\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 55F T5-8 fractures with retropulsion and ARDS\n from VAP; on heparin for UE DVT. PEEP as low as 10 yesterday but now up\n to 15; good response to lasix. Arterial line is out; sedation remains\n challenging despite multiple interventions.\n Exam notable for Tm 98.5 BP 90/45 HR 67 RR 16-28 with sat 97 on VAC\n 400x18 PEEP 15 FiO2 0.6 for 7.46/48/65. TBB -1.2/24, +14L/MICU LOS.\n Eyes opens, will squeeze hands and wiggle toes but very drowsy.\n Bronchial BS bilaterally with RRR s1s2 SM at base. Abdomen is\n distended with decreased BS. 3+ edema in BLE, no cords. Labs notable\n for WBC 9K, HCT 26, K+ 4.1, Na 147, Cr 0.5. CXR with resolving B LL\n airspace disease and effusions.\n Agree with plan to replace arterial line in R axillary artery today and\n try to wean PEEP. If BP remains low, will need stim and\n supplementation with hydrocortisone 50 q6-8h; will check bladder\n pressure, rule out auto-PEEP and continue to monitor for occult\n infection, but will hold off on antibiotics for now. Will continue\n fentanyl patch and po valium as we wean IV sedation. Will retry gentle\n IV lasix to affect a negative fluid balance and use haldol for\n breakthrough agitiation. Will restart IV heparin for UE DVT; consider\n transition to coumadin only after tracheostomy and feeding tube\n placement, which will require lower ventilator settings. Will restart\n tube feeds and add FW boluses for hypernatremia. Continue spinal\n stabilization with brace when OOB; will eventually need MRI for\n surgical planning; remainder of plan as outlined above.\n Patient is critically ill\n Total time: 40 min\n ------ Protected Section Addendum Entered By: , MD\n on: 02:46 PM ------\n"
},
{
"category": "General",
"chartdate": "2167-10-03 00:00:00.000",
"description": "Generic Note",
"row_id": 635631,
"text": "TITLE: Addendum to Dr. \ns note\n MICU ATTENDING ADDENDUM \n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points:\n trauma thoracic spine fracture\n intubated\n VAP\n tracheomalacia\n trached yesterday\n desaturated and PEEP increased\n Exam notable for Tm 99.2 BP 127/63 HR 111 RR 18 with 95 sat on\n AC/18/400/10/.6\n anasarca\n awake, no purposeful movements\n decreased breath sounds ant and lat\n tachy, regular\n abd benign\n 7.45/43/82\n Labs notable for WBC 10 K, HCT 26 , K+ 4.1 , Cr .6 , HCO3 29\n CXR reviewed - bilat effusion, trach ok\n Problems:\n respiratory failure\n airway malacia\n anasarca, effusions\n spine fracture\n agitation\n adrenal insufficiency\n DVT\n Agree with plan to wean vent as tolerated, diurese, wean sedation\n though continue pain medications, continue steroids, continue heparin -\n eventual coumadin\n Remainder of plan as outlined above.\n Patient is critically ill.\n Total time: 37 min\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 635680,
"text": "55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\n Now with prolonged hospital course c/b by PNA with high PEEP\n requirement, anxiety, RUE DVT on heparin qtt.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt on Vent settings AC 55%/18 X 400/+10 with no overbreathing of\n set RR. O2 sat 92-98%. Lung snds clear, diminished in bases. Pt sxn\n for small-moderate amts thick white secretions. Trach site with small\n amt serosang drainage.\n Action:\n Cont same vent settings\n Response:\n Pt doesn\nt over breath on the vent and never desat.\n Plan:\n Wean from vent as she tolerates,monitor sats,ABG?.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt rec\nd with Heparin qtt off post trach/PEG yesterday.\n Action:\n Heparin restarted @ 1100 @ previous rate 1700units/hr.\n Response:\n PTT @ 1630 58.5. Heparin inc\nd to 1900units/hr per sliding scale @\n 1715.\n Plan:\n Repeat PTT @ 2300.\n Alteration in Nutrition\n Assessment:\n Received pt on TF 10cc/hr\n Action:\n Pt tolerated TF with minimal residuals as well as free water bolus Q4H\n Response:\n TF ^ as tolerated, currently at 30cc/hr.\n Plan:\n Cont to monitor TF residuals, hold if more than 100cc\n Altered mental status (not Delirium)\n Assessment:\n Pt w/ periods of agitation and sleeping at other times, while she\n aweake follow commands intermittently.\n Action:\n Cont on fent 100 mics ,Versed 2mg/hr and requires frequent boluses .\n Cont diazepam 10 mg PO Q6H. Fent ^ 125 mics/hr\n Response:\n HR ranging from SB in the 40\ns when asleep to the 120-140\ns when\n agitated, b/p ranging from 90\ns/40\ns when asleep to 140-170\ns/ 70\n when agitated. When pt awake appropriate and following commands HR\n 80\ns-100\ns and b/p 100\ns-120\ns/ 60-70\n Plan:\n Titrate sedation as needed\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 635685,
"text": "55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\n Now with prolonged hospital course c/b by PNA with high PEEP\n requirement, anxiety, RUE DVT on heparin qtt.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt on Vent settings AC 55%/18 X 400/+10 with no overbreathing of\n set RR. O2 sat 92-98%. Lung snds clear, diminished in bases. Pt sxn\n for small-moderate amts thick white secretions. Trach site with small\n amt serosang drainage.\n Action:\n Cont same vent settings\n Response:\n Pt doesn\nt over breath on the vent and never desat.Kept same Vent\n settings.\n Plan:\n Wean from vent as she tolerates,monitor sats,ABG?.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt rec\nd with Heparin qtt 1900units/hr.\n Action:\n PTT drawn at 2300.\n Response:\n PTT @ 2300 was 107,Decreased Heparin gtt 1700 u/hr as per sliding\n scale.Next PTT due at 0600. .\n Plan:\n Cont monitor PTT,titrate accordingly,next PTT due at 0600.\n Alteration in Nutrition\n Assessment:\n Received pt on TF 10cc/hr\n Action:\n Pt tolerated TF with minimal residuals as well as free water bolus Q4H\n Response:\n TF ^ as tolerated, currently at 30cc/hr.\n Plan:\n Cont to monitor TF residuals, hold if more than 100cc\n Altered mental status (not Delirium)\n Assessment:\n Pt w/ periods of agitation and sleeping at other times, while she\n aweake follow commands intermittently.\n Action:\n Cont on fent 100 mics ,Versed 2mg/hr and requires frequent boluses .\n Cont diazepam 10 mg PO Q6H. Fent ^ 125 mics/hr,Versed 3mg/hr.\n Response:\n HR ranging from SB in the 40\ns when asleep to the 120-140\ns when\n agitated, b/p ranging from 90\ns/40\ns when asleep to 140-170\ns/ 70\n when agitated. When pt awake appropriate and following commands HR\n 80\ns-100\ns and b/p 100\ns-120\ns/ 60-70\n Plan:\n Titrate sedation as needed\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-05 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 635862,
"text": "Chief Complaint:\n 24 Hour Events:\n On lasix drip\n Attempted to wean FiO2\n No acute events\n No BM\n Agitated this am\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions :\n Midazolam (Versed)\n 1 mg/hour\n Furosemide (Lasix)\n 2 mg/hour\n Heparin Sodium\n 1,500 units/hour\n Fentanyl\n 75 mcg/hour\n Other ICU medications:\n Other medications:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.9\nC (98.5\n HR: 126 (49 - 131) bpm\n BP: 156/84(117) {78/38(52) - 164/95(125)} mmHg\n RR: 20 (9 - 21) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 4,160 mL\n 1,185 mL\n PO:\n TF:\n 1,267 mL\n 315 mL\n IVF:\n 1,018 mL\n 260 mL\n Blood products:\n Total out:\n 4,015 mL\n 2,090 mL\n Urine:\n 4,015 mL\n 2,090 mL\n NG:\n Stool:\n Drains:\n Balance:\n 145 mL\n -905 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 500) mL\n Vt (Spontaneous): 675 (675 - 675) mL\n PS : 8 cmH2O\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 19 cmH2O\n Plateau: 16 cmH2O\n SpO2: 96%\n ABG: 7.39/46/118/28/2\n Ve: 8.9 L/min\n PaO2 / FiO2: 236\n Physical Examination\n Labs / Radiology\n 272 K/uL\n 8.6 g/dL\n 128 mg/dL\n 0.6 mg/dL\n 28 mEq/L\n 3.1 mEq/L\n 8 mg/dL\n 110 mEq/L\n 148 mEq/L\n 27.4 %\n 11.2 K/uL\n [image002.jpg]\n 05:17 PM\n 11:41 PM\n 03:06 AM\n 03:38 AM\n 04:05 PM\n 03:55 AM\n 07:19 AM\n 11:24 AM\n 03:18 PM\n 02:47 AM\n WBC\n 10.6\n 10.0\n 8.3\n 11.2\n Hct\n 27.3\n 25.8\n 24.6\n 27.4\n Plt\n 72\n Cr\n 0.5\n 0.6\n 0.6\n 0.5\n 0.6\n 0.6\n TCO2\n 32\n 31\n 29\n 29\n Glucose\n 110\n 94\n 111\n 106\n 121\n 123\n 137\n 128\n Other labs: PT / PTT / INR:15.2/62.2/1.3, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:13.1 %,\n Mono:2.7 %, Eos:0.6 %, Lactic Acid:0.9 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:9.0 mg/dL, Mg++:2.6 mg/dL, PO4:4.3 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA and\n ARDS intubated since the end of now s/p trach and PEG placement.\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation. Stenting\n unlikely to help for trachiomalacia as airways have poor structure\n diffusely. S/P Trach and PEG on .\n - wean FiO2 today\n # Adrenal Insufficency: Hypotension that resolved with steroids,\n returned as they came off and is now improved again. Possible primary\n adrenal insufficency. Appreciate endocrine recommendations. Halved\n dose today.\n - hydrocortt (day 1 = ), wean per endo recs\n # Volume overloaded in setting of hypernatremia with TBW deficit.\n - Lasix gtt, continue with goal -1-2 L per day.\n - electrolytes\n - continue tube feeds with free water flushes 250 cc q4\n # Sedation: Sedation control remains somewhat poor although fentanyl\n patch and diazpem are likely therapeutic range today. On Versed 2.0,\n Fentanyl 100, Fentanyl patch, Diazepam standing and haldo 2.5-5 mg\n PRN. QTc increased to 480.\n - Wean versed/fentanyl as tolerated, continue diazepam. Avoid haldol\n use if possible to avoid further prolongation of QTc\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\n coumadin at least until s/p trach.\n - heparin gtt restarted\n - coumadin 5mg G-tube today\n # Constipation\n current regimen of colace and senna, no BM over last\n 24 hours\n - dulcolax PO/PR today\n - reassess and increase bowel regimen PRN\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n -f/u full trauma spine eval from OSH to determine need for further back\n imaging in-house (to be done )\n # Nutrition: Tube feeds with free water flushes, tolerating well,\n continue Replete (Full) - 11:20 AM 30 mL/hour\n # Glycemic control: SSI, well controlled\n # Lines L PICC () and R ART ()\n both working well, mainitain\n # Ppx: heparin, ranitidine, VAP prevention, colace and senna\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n Code: Full\n Dispo: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Arterial Line - 02:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-05 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 635863,
"text": "Chief Complaint:\n 24 Hour Events:\n On lasix drip\n Attempted to wean FiO2\n No acute events\n No BM\n Agitated this am\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions :\n Midazolam (Versed)\n 1 mg/hour\n Furosemide (Lasix)\n 2 mg/hour\n Heparin Sodium\n 1,500 units/hour\n Fentanyl\n 75 mcg/hour\n Other ICU medications:\n Other medications:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.9\nC (98.5\n HR: 126 (49 - 131) bpm\n BP: 156/84(117) {78/38(52) - 164/95(125)} mmHg\n RR: 20 (9 - 21) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 4,160 mL\n 1,185 mL\n PO:\n TF:\n 1,267 mL\n 315 mL\n IVF:\n 1,018 mL\n 260 mL\n Blood products:\n Total out:\n 4,015 mL\n 2,090 mL\n Urine:\n 4,015 mL\n 2,090 mL\n NG:\n Stool:\n Drains:\n Balance:\n 145 mL\n -905 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 500) mL\n Vt (Spontaneous): 675 (675 - 675) mL\n PS : 8 cmH2O\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 19 cmH2O\n Plateau: 16 cmH2O\n SpO2: 96%\n ABG: 7.39/46/118/28/2\n Ve: 8.9 L/min\n PaO2 / FiO2: 236\n Physical Examination\n General Appearance: Intubated and sedated. Responsive, following\n commands, Overweight / Obese, mild agitation but NAD\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\n deviation\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Respiratory / Chest: (Expansion: Symmetric), CTA anteriorly, decreased\n BS\n Abdominal: Obese, Firm, Non-tender, no rebound, no guarding, + BS, PEG\n in place with dressing C/D/I\n Extremities: No clubbing or cyanosis, 1+ nonpitting edema of b/l hands,\n anasarca\n Skin: no rashes or jaundice\n Lines: r brachioceph ART and L PICC C/D/I\n Labs / Radiology\n 272 K/uL\n 8.6 g/dL\n 128 mg/dL\n 0.6 mg/dL\n 28 mEq/L\n 3.1 mEq/L\n 8 mg/dL\n 110 mEq/L\n 148 mEq/L\n 27.4 %\n 11.2 K/uL\n [image002.jpg]\n 05:17 PM\n 11:41 PM\n 03:06 AM\n 03:38 AM\n 04:05 PM\n 03:55 AM\n 07:19 AM\n 11:24 AM\n 03:18 PM\n 02:47 AM\n WBC\n 10.6\n 10.0\n 8.3\n 11.2\n Hct\n 27.3\n 25.8\n 24.6\n 27.4\n Plt\n 72\n Cr\n 0.5\n 0.6\n 0.6\n 0.5\n 0.6\n 0.6\n TCO2\n 32\n 31\n 29\n 29\n Glucose\n 110\n 94\n 111\n 106\n 121\n 123\n 137\n 128\n Other labs: Ca++:9.0 mg/dL, Mg++:2.6 mg/dL, PO4:4.3 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA and\n ARDS intubated since the end of now s/p trach and PEG placement.\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation. Stenting\n unlikely to help for trachiomalacia as airways have poor structure\n diffusely. S/P Trach and PEG on . Increased effusion on recent\n CXR.\n - wean FiO2 as tolerated\n - non-con head CT to further characterize pulmonary effusions,\n det potential for thoracentesis\n # Adrenal Insufficency: Hypotension that resolved with steroids,\n returned as they came off and is now improved again. Possible primary\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\n started on .\n - wean per endo recs, decrease to q8 today, likely q12 dosing\n tomorrow\n # Volume overloaded in setting of hypernatremia with TBW deficit.\n - Lasix gtt, continue with goal -1-2 L per day.\n - electrolytes\n - continue tube feeds with free water flushes increase from 250 to 300\n cc q4\n # Sedation: Sedation control remains somewhat poor although fentanyl\n patch and diazpem are likely therapeutic range today. On Versed 2.0,\n Fentanyl 100, Fentanyl patch, Diazepam standing and haldo 2.5-5 mg\n PRN. QTc increased to 480.\n - Wean versed/fentanyl as tolerated, continue diazepam in\n hopes for vent facility placement\n - Increase diazepam to 12mg q4\n - Check ekg for QTc\n if <480, restart haldol and/or increase\n fentanyl patch\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\n coumadin at least until s/p trach.\n - heparin gtt restarted\n - coumadin 5mg G-tube today\n hold coumadin today for possible \n # Constipation\n current regimen of colace and senna, stooled during\n rounds\n - dulcolax PO/PR\n - reassess and increase bowel regimen PRN\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n -f/u full trauma spine eval from OSH to determine need for further back\n imaging in-house (to be done )\n # Nutrition: Tube feeds with free water flushes, tolerating well,\n continue Replete (Full) - 11:20 AM 30 mL/hour\n # Glycemic control: SSI, well controlled\n # Lines L PICC () and R ART ()\n both working well, check\n ABG/VBG today\n if correlate well, d/c art line\n # Ppx: heparin, ranitidine, VAP prevention, colace and senna\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n Code: Full\n Dispo: ICU, being screening for vent facilities\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 635866,
"text": "Impaired Skin Integrity\n Assessment:\n Skin warm to touch, yeast-like red rash under skin folds, coccyx\n red,\n skin intact.\n Action:\n Miconazole powder applied to skin folds/periarea. Miconazole skin\n cream barrier applied to coccyx. Frequent repositioning.\n Response:\n Cont w/ rash\n Plan:\n Cont w/ frequent repositioning, apply miconazole powder to infected\n areas\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt cont on Heparin gtt @ 1500units/h. PTT in therapeutic range.\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Hypernatremia (high sodium)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-06 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 635981,
"text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 11:00 AM\n Started on Warfarin\n Extremely labile pressures over night\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 0.5 mg/hour\n Heparin Sodium - 1,500 units/hour\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:00 AM\n Haloperidol (Haldol) - 01:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:12 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.6\n Tcurrent: 37.1\nC (98.8\n HR: 100 (56 - 142) bpm\n BP: 98/47(65) {77/40(53) - 164/93(123)} mmHg\n RR: 18 (15 - 24) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 4,228 mL\n 1,123 mL\n PO:\n TF:\n 1,440 mL\n 360 mL\n IVF:\n 978 mL\n 343 mL\n Blood products:\n Total out:\n 6,725 mL\n 780 mL\n Urine:\n 6,725 mL\n 780 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,497 mL\n 343 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 450 (450 - 450) mL\n PS : 8 cmH2O\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 23 cmH2O\n Plateau: 19 cmH2O\n SpO2: 94%\n ABG: 7.50/41/81./29/7\n Ve: 7.2 L/min\n PaO2 / FiO2: 164\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 229 K/uL\n 7.9 g/dL\n 107 mg/dL\n 0.6 mg/dL\n 29 mEq/L\n 3.8 mEq/L\n 11 mg/dL\n 109 mEq/L\n 147 mEq/L\n 25.3 %\n 9.6 K/uL\n [image002.jpg]\n 03:55 AM\n 07:19 AM\n 11:24 AM\n 03:18 PM\n 02:47 AM\n 11:01 AM\n 04:40 PM\n 05:08 PM\n 03:44 AM\n 06:04 AM\n WBC\n 8.3\n 11.2\n 9.6\n Hct\n 24.6\n 27.4\n 25.3\n Plt\n 279\n 272\n 229\n Cr\n 0.5\n 0.6\n 0.6\n 0.6\n 0.6\n TCO2\n 29\n 29\n 31\n 34\n 33\n Glucose\n 123\n 137\n 128\n 138\n 107\n Other labs: PT / PTT / INR:16.5/78.5/1.5, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:13.1 %,\n Mono:2.7 %, Eos:0.6 %, Lactic Acid:1.1 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:8.7 mg/dL, Mg++:2.4 mg/dL, PO4:4.7 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Arterial Line - 02:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-06 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 635982,
"text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 11:00 AM\n Started on Warfarin\n Extremely labile pressures over night\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 0.5 mg/hour\n Heparin Sodium - 1,500 units/hour\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:00 AM\n Haloperidol (Haldol) - 01:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:12 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.6\n Tcurrent: 37.1\nC (98.8\n HR: 100 (56 - 142) bpm\n BP: 98/47(65) {77/40(53) - 164/93(123)} mmHg\n RR: 18 (15 - 24) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 4,228 mL\n 1,123 mL\n PO:\n TF:\n 1,440 mL\n 360 mL\n IVF:\n 978 mL\n 343 mL\n Blood products:\n Total out:\n 6,725 mL\n 780 mL\n Urine:\n 6,725 mL\n 780 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,497 mL\n 343 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 450 (450 - 450) mL\n PS : 8 cmH2O\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 23 cmH2O\n Plateau: 19 cmH2O\n SpO2: 94%\n ABG: 7.50/41/81./29/7\n Ve: 7.2 L/min\n PaO2 / FiO2: 164\n Physical Examination\n General Appearance: Intubated and sedated. Responsive, following\n commands, Overweight / Obese, mild agitation but NAD\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\n deviation\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Respiratory / Chest: (Expansion: Symmetric), CTA anteriorly, decreased\n BS\n Abdominal: Obese, Firm, Non-tender, no rebound, no guarding, + BS, PEG\n in place with dressing C/D/I\n Extremities: No clubbing or cyanosis, 1+ nonpitting edema of b/l hands,\n anasarca\n Skin: no rashes or jaundice\n Lines: r brachioceph ART and L PICC C/D/I\n Labs / Radiology\n 229 K/uL\n 7.9 g/dL\n 107 mg/dL\n 0.6 mg/dL\n 29 mEq/L\n 3.8 mEq/L\n 11 mg/dL\n 109 mEq/L\n 147 mEq/L\n 25.3 %\n 9.6 K/uL\n [image002.jpg]\n 03:55 AM\n 07:19 AM\n 11:24 AM\n 03:18 PM\n 02:47 AM\n 11:01 AM\n 04:40 PM\n 05:08 PM\n 03:44 AM\n 06:04 AM\n WBC\n 8.3\n 11.2\n 9.6\n Hct\n 24.6\n 27.4\n 25.3\n Plt\n 279\n 272\n 229\n Cr\n 0.5\n 0.6\n 0.6\n 0.6\n 0.6\n TCO2\n 29\n 29\n 31\n 34\n 33\n Glucose\n 123\n 137\n 128\n 138\n 107\n Other labs: PT / PTT / INR:16.5/78.5/1.5, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:13.1 %,\n Mono:2.7 %, Eos:0.6 %, Lactic Acid:1.1 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:8.7 mg/dL, Mg++:2.4 mg/dL, PO4:4.7 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Arterial Line - 02:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-06 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 635984,
"text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 11:00 AM\n Started on Warfarin\n Extremely labile pressures over night, trying to wean off Fentanyl and\n use more Haldol.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 0.5 mg/hour\n Heparin Sodium - 1,500 units/hour\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:00 AM\n Haloperidol (Haldol) - 01:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:12 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.6\n Tcurrent: 37.1\nC (98.8\n HR: 100 (56 - 142) bpm\n BP: 98/47(65) {77/40(53) - 164/93(123)} mmHg\n RR: 18 (15 - 24) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 4,228 mL\n 1,123 mL\n PO:\n TF:\n 1,440 mL\n 360 mL\n IVF:\n 978 mL\n 343 mL\n Blood products:\n Total out:\n 6,725 mL\n 780 mL\n Urine:\n 6,725 mL\n 780 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,497 mL\n 343 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 450 (450 - 450) mL\n PS : 8 cmH2O\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 23 cmH2O\n Plateau: 19 cmH2O\n SpO2: 94%\n ABG: 7.50/41/81./29/7\n Ve: 7.2 L/min\n PaO2 / FiO2: 164\n Physical Examination\n General Appearance: Intubated and sedated. Responsive, following\n commands, Overweight / Obese, mild agitation but NAD\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\n deviation\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Respiratory / Chest: (Expansion: Symmetric), CTA anteriorly, decreased\n BS\n Abdominal: Obese, Firm, Non-tender, no rebound, no guarding, + BS, PEG\n in place with dressing C/D/I\n Extremities: No clubbing or cyanosis, 1+ nonpitting edema of b/l hands,\n anasarca\n Skin: no rashes or jaundice\n Lines: r brachioceph ART and L PICC C/D/I\n Labs / Radiology\n 229 K/uL\n 7.9 g/dL\n 107 mg/dL\n 0.6 mg/dL\n 29 mEq/L\n 3.8 mEq/L\n 11 mg/dL\n 109 mEq/L\n 147 mEq/L\n 25.3 %\n 9.6 K/uL\n [image002.jpg]\n 03:55 AM\n 07:19 AM\n 11:24 AM\n 03:18 PM\n 02:47 AM\n 11:01 AM\n 04:40 PM\n 05:08 PM\n 03:44 AM\n 06:04 AM\n WBC\n 8.3\n 11.2\n 9.6\n Hct\n 24.6\n 27.4\n 25.3\n Plt\n 279\n 272\n 229\n Cr\n 0.5\n 0.6\n 0.6\n 0.6\n 0.6\n TCO2\n 29\n 29\n 31\n 34\n 33\n Glucose\n 123\n 137\n 128\n 138\n 107\n Other labs: PT / PTT / INR:16.5/78.5/1.5, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:13.1 %,\n Mono:2.7 %, Eos:0.6 %, Lactic Acid:1.1 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:8.7 mg/dL, Mg++:2.4 mg/dL, PO4:4.7 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA and\n ARDS intubated since the end of now s/p trach and PEG placement.\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation. Stenting\n unlikely to help for trachiomalacia as airways have poor structure\n diffusely. S/P Trach and PEG on . Increased effusion on recent\n CXR.\n - wean FiO2 as tolerated\n - non-con head CT to further characterize pulmonary effusions,\n det potential for thoracentesis\n # Adrenal Insufficency: Hypotension that resolved with steroids,\n returned as they came off and is now improved again. Possible primary\n adrenal insufficency. Appreciate endocrine recommendations. Hydrocort\n started on .\n - wean per endo recs, decrease to q8 today, likely q12 dosing\n tomorrow\n # Volume overloaded in setting of hypernatremia with TBW deficit.\n - Lasix gtt, continue with goal -1-2 L per day.\n - electrolytes\n - continue tube feeds with free water flushes increase from 250 to 300\n cc q4\n # Sedation: Sedation control remains somewhat poor although fentanyl\n patch and diazpem are likely therapeutic range today. On Versed 2.0,\n Fentanyl 100, Fentanyl patch, Diazepam standing and haldo 2.5-5 mg\n PRN. QTc increased to 480.\n - Wean versed/fentanyl as tolerated, continue diazepam in\n hopes for vent facility placement\n - Increase diazepam to 12mg q4\n - Check ekg for QTc\n if <480, restart haldol and/or increase\n fentanyl patch\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\n coumadin at least until s/p trach.\n - heparin gtt restarted\n - coumadin 5mg G-tube today\n hold coumadin today for possible \n # Constipation\n current regimen of colace and senna, stooled during\n rounds\n - dulcolax PO/PR\n - reassess and increase bowel regimen PRN\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n -f/u full trauma spine eval from OSH to determine need for further back\n imaging in-house (to be done )\n # Nutrition: Tube feeds with free water flushes, tolerating well,\n continue Replete (Full) - 11:20 AM 30 mL/hour\n # Glycemic control: SSI, well controlled\n # Lines L PICC () and R ART ()\n both working well, check\n ABG/VBG today\n if correlate well, d/c art line\n # Ppx: heparin, ranitidine, VAP prevention, colace and senna\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n Code: Full\n Dispo: ICU, being screening for vent facilities\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Arterial Line - 02:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Respiratory ",
"chartdate": "2167-09-29 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 635110,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 11\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Patient remains on ventilatory support, all settings documented on flow\n sheet. Breath sounds diminished throughout, bronchodilators\n administered. A-line placed and ABG\ns drawn. Slow deliberate decrease\n in PEEP as ordered.\n"
},
{
"category": "Nursing",
"chartdate": "2167-09-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 634170,
"text": "Obese woman s/p t spine injury tx from Med for failure to wean\n from mech ventilation and evaluation for stent for\n tracheobronchomalacia.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Pt cont w/ low grade fever.\n Action:\n Given tyelenol q6 h prn, pt pan cultured. PICC line and foley d/c\n (new foley placed). IV antibiotics started.\n Response:\n Fever slightly improved to 99.\n Plan:\n Cont w/ q 6 hr tyelenol prn, closely monitor temp and f/u w/ cultures.\n Fracture, other\n Assessment:\n Pt w/ T5-T8 compression fracture.\n Action:\n Pt on log-roll precautions, back brace at bedside- to be used when pt\n is OOB.\n Response:\n Pt denies pain when asked.\n Plan:\n Cont on log roll precautions, Neuro- consult ordered to clarify\n order for brace.\n Anemia, other\n Assessment:\n HCT 25 from 30.0. No active bleeding noted.\n Action:\n Cont to check HCT and s/s of bleeding.\n Response:\n No action taken.\n Plan:\n Type & Screen to be collected. Cont to monitor HCT, guiac all stools.\n Hypernatremia (high sodium)\n Assessment:\n NA level 150-> 147. No seizure activity.\n Action:\n Free H2O boluses q 4hrs were started, but currently on hold d/t high\n residuals. Pt on D5W for 1L .\n Response:\n NA level slightly improved.\n Plan:\n Cont w/ free-water boluses as tolerated, cont to monitor lytes, bolus\n w/ LR prn.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS rhonchorous throughout, diminished to bilateral bases, deep sxn\n thick tan/bloody secretions.\n Action:\n Given MDIs, cont to be orally intubated on A/C, mini-BAL performed by\n RT and sample sent to lab. Increased sedation for adequate\n ventilation.\n Response:\n Cont to be orally intubated and sedated.\n Plan:\n Consult w/ IP for eval for stent, wean vent as tolerated\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 635677,
"text": "55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\n Now with prolonged hospital course c/b by PNA with high PEEP\n requirement, anxiety, RUE DVT on heparin qtt.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt on Vent settings AC 55%/18 X 400/+10 with no overbreathing of\n set RR. O2 sat 92-98%. Lung snds clear, diminished in bases. Pt sxn\n for small-moderate amts thick white secretions. Trach site with small\n amt serosang drainage.\n Action:\n Cont same vent settings\n Response:\n Pt doesn\nt over breath on the vent and never desat.\n Plan:\n Wean from vent as she tolerates,monitor sats,ABG?.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt rec\nd with Heparin qtt off post trach/PEG yesterday.\n Action:\n Heparin restarted @ 1100 @ previous rate 1700units/hr.\n Response:\n PTT @ 1630 58.5. Heparin inc\nd to 1900units/hr per sliding scale @\n 1715.\n Plan:\n Repeat PTT @ 2300.\n Alteration in Nutrition\n Assessment:\n Rec\nd pt NPO post OR yesterday. Abd obese/distended with + BS. No BM\n today.\n Action:\n Restarted TF Replete with fiber @ 1000 per surgical team @ 10ml/hr, as\n well as FWB of 250ml Q4hrs for elevated Na.\n Response:\n Residual @ 1600 140ml of TF/water/yellow bilious. TF stopped and FWB\n held.\n Plan:\n Resume TF @ 1830. Cont to monitor residuals, holding TF if >100ml.\n"
},
{
"category": "Respiratory ",
"chartdate": "2167-10-04 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 635682,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 16\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 7.0mm\n PMV: No\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Pt was trached yesterday with #7 Portex. Trach site appears clean,\n little oozing around site. Suctioned at beginning of shift for blood\n tinged thick tan sputum, less blood tinged later in shift. Plan is to\n continue with weaning attempts.\n"
},
{
"category": "Respiratory ",
"chartdate": "2167-10-04 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 635771,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 16\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Standard, Cuffed, Inner Cannula\n Manufacturer: Portex\n Size: 7.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Copious\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern:\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Respiratory ",
"chartdate": "2167-10-06 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 636070,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 18\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Standard, Extra Length\n Manufacturer: Portex\n Size: 7.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: pt weaned to PSV tolerated well for msot of the shift\n aroun d 1600 vt began to drop and rr increased so ips increased to 12\n with improved vt and rr\n Assessment of breathing comfort: No claim of dyspnea)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Reduce PEEP as tolerated\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Nursing",
"chartdate": "2167-09-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 635159,
"text": " Problem - Description In Comments\n Assessment:\n Action:\n Response:\n Plan:\n Hypernatremia (high sodium)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Action:\n Response:\n Plan:\n Bradycardia\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2167-09-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 635160,
"text": " Problem - Description In Comments\n Assessment:\n Action:\n Response:\n Plan:\n Hypernatremia (high sodium)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Action:\n Response:\n Plan:\n Bradycardia\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-01 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 635302,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n Thorasics will take to OR if 24 hours stable on PEEP < 10, was on PEEP\n of 8 since AM\n Weaned off midazolam drip\n NPO past midnight for possible OR tomorrow (attendings are in clinic,\n however)\n Endocrine recs: Continue steroids until stable, then taper\n ABG for low O2 sat, looked good, held on FiO2 of 50\n Broncoscopy (11:30AM) : Diffuse stuctural instability c/w\n tracheomalacia\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Furosemide (Lasix) - 3 mg/hour\n Fentanyl - 100 mcg/hour\n Other ICU medications:\n Haloperidol (Haldol) - 11:47 PM\n Midazolam (Versed) - 02:45 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.2\nC (97.2\n HR: 104 (46 - 134) bpm\n BP: 134/69(98) {88/41(57) - 143/76(103)} mmHg\n RR: 18 (18 - 27) insp/min\n SpO2: 91%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 4,162 mL\n 139 mL\n PO:\n TF:\n 1,448 mL\n 1 mL\n IVF:\n 1,003 mL\n 138 mL\n Blood products:\n Total out:\n 1,615 mL\n 640 mL\n Urine:\n 1,615 mL\n 640 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,547 mL\n -501 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n PIP: 35 cmH2O\n Plateau: 25 cmH2O\n Compliance: 24.7 cmH2O/mL\n SpO2: 91%\n ABG: 7.42/47/86./29/4\n Ve: 6.8 L/min\n PaO2 / FiO2: 174\n Physical Examination\n General Appearance: Easily agitated, appears uncomfortable, Overweight\n / Obese, opens eyes but no purposeful movement\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\n deviation\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Respiratory / Chest: (Expansion: Symmetric), referred breath sounds\n from ETT\n Abdominal: No(t) Soft, Non-tender, Few Bowel sounds present, Distended\n Extremities: No clubbing or cyanosis, 3+ nonpitting edema of b/l hands,\n anasarca\n Skin: no rashes or jaundice\n Neuro: diffusely hyperreflexic with LE clonus\n Lines: r brachioceph ART and L PICC C/D/I\n Labs / Radiology\n 280 K/uL\n 8.0 g/dL\n 136 mg/dL\n 0.5 mg/dL\n 29 mEq/L\n 4.0 mEq/L\n 11 mg/dL\n 105 mEq/L\n 143 mEq/L\n 25.9 %\n 8.6 K/uL\n [image002.jpg]\n 02:44 PM\n 03:33 PM\n 07:26 PM\n 07:46 PM\n 02:04 AM\n 02:18 AM\n 01:27 PM\n 03:06 PM\n 10:04 PM\n 03:00 AM\n WBC\n 8.4\n 11.8\n 8.6\n Hct\n 23.0\n 28.1\n 29.9\n 25.9\n Plt\n \n Cr\n 0.5\n 0.6\n 0.5\n TCO2\n 33\n 31\n 33\n 32\n 32\n Glucose\n 168\n 176\n 136\n Other labs: PT / PTT / INR:13.2/26.6/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:89.7 %, Lymph:8.7 %, Mono:1.1\n %, Eos:0.4 %, Lactic Acid:0.9 mmol/L, Albumin:2.4 g/dL, LDH:204 IU/L,\n Ca++:8.4 mg/dL, Mg++:2.4 mg/dL, PO4:4.1 mg/dL\n Fluid analysis / Other labs: BAL fluid:\n WBC: 0\n RBC: 0\n Polys: 82\n Lymphs: 3\n Monos: 6\n Eos: 2\n Macro: 7\n Imaging: ECHOCARDIOGRAM: The left atrium is elongated. No atrial\n septal defect is seen by 2D or color Doppler. The right atrial pressure\n is indeterminate. Left ventricular wall thickness, cavity size and\n regional/global systolic function are normal (LVEF >55%). There is no\n ventricular septal defect. Right ventricular chamber size and free wall\n motion are normal. The aortic valve leaflets (3) are mildly thickened\n but aortic stenosis is not present. No aortic regurgitation is seen.\n The mitral valve appears structurally normal with trivial mitral\n regurgitation. There is no mitral valve prolapse. The tricuspid valve\n leaflets are mildly thickened. There is moderate pulmonary artery\n systolic hypertension. There is no pericardial effusion.\n Compared with the prior study (images reviewed) of , no\n change.\n Microbiology: BRONCHIAL LAVAGE:\n GRAM STAIN (Final ):\n 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.\n NO MICROORGANISMS SEEN.\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA and\n ARDS intubated since the end of .\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation.\n Transferred here for airway stenting. Will need bronch eval when\n improved.\n - Thoracics will do trach and PEG once stable on PEEPs around 10.\n Re-c/s today.\n - wean PEEP as tolerated\n # # Adrenal Insufficency: Minimal response to stim test again.\n - hydrocort and fludrocort (day 1 = )\n - endocrine c/s for further elucidation of etiology\n # Hypotension: Likely adrenal insufficiency. Goal map > 60.\n - hydrocortisol and fludrocortisone as above\n - restart levophed if necessary to maintain MAP > 60\n # Volume overloaded in setting of hypernatremia (? Relationship to\n adrenal insufficiency), TBW deficit 2.6L.\n - goal even to -500cc I/Os today\n - continue FW in TF at 250 cc q4hrs\n - lasix drip (1-5mg/hr) when MAP > 60\n # Hyperreflexia - ? meds vs central pathology. Unlikely to be \n intracranial hemorrhage as patient is diffusely hyperreflexic.\n Possible relationship to endocrine pathology?\n - consider head CT in setting of heparin gtt\n - monitor\n # Sedation: Sedation control remains somewhat poor although fentanyl\n patch and diazpem are likely starting increase to therapeutic range\n today. On Versed 1.5, Fentanyl 175, Fentanyl patch, Diazepam standing\n and haldo 2.5-5 mg PRN. QTc stable at .44.\n - Wean versed/fentanyl as tolerated, continue diazepam and prn\n haldol\n - Recheck EKG today\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\n coumadin at least until s/p trach.\n - hold heparin gtt when anticipate trach/peg\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n # FEN/GI: Tube feeds @ goal.\n DVT: Treatment dose heparin\n Ulcer: Ranitidine\n VAP: Prevention per routine\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Arterial Line - 02:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2167-09-20 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 634155,
"text": "Chief Complaint:\n 24 Hour Events:\n -cultured for fever to 102.7 at 4:00 am\n -Patient developed hypotension to 102.7 at 6:15 a.m. BP responded well\n to LR 500 cc. However, urine output remained low despite bolus and\n additional LR 500 cc bolus. Antibiotics initiated (levofloxacin,\n aztreonam, vancomycin, metronidazole).\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.3\nC (102.7\n Tcurrent: 39.3\nC (102.7\n HR: 89 (72 - 97) bpm\n BP: 96/41(55) {96/41(55) - 154/71(103)} mmHg\n RR: 12 (12 - 18) insp/min\n SpO2: 95%\n Total In:\n 10 mL\n 232 mL\n PO:\n TF:\n IVF:\n 10 mL\n 232 mL\n Blood products:\n Total out:\n 425 mL\n 570 mL\n Urine:\n 425 mL\n 570 mL\n NG:\n Stool:\n Drains:\n Balance:\n -416 mL\n -338 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 32 cmH2O\n SpO2: 95%\n ABG: 7.42/47/61/30/4\n Ve: 8 L/min\n PaO2 / FiO2: 102\n Physical Examination\n Gen: Appears uncomfortable on vent.\n HEENT: Anicteric. Pupils 3 mm non-reactive bilaterally.\n Resp: Symmetric expansion. Vesicular sounds throughout. Inspiratory\n and expiratory tracheal sounds (?related to ET tube).\n CV: Cannot see jugular veins due to neck size. RRR. Normal s1 and\n s2. No M/G/R.\n Abd: Quiet. Distended. Non-tender.\n Ext: Edema in RUE, especially right hand. Mildly increased warmth of\n RUE compared with LUE.\n Peripheral vascular: Radial pulses 2+ bilaterally.\n Neuro: Pupils as above. Moving all 4 extremities.\n Labs / Radiology\n 333 K/uL\n 9.7 g/dL\n 103 mg/dL\n 0.6 mg/dL\n 30 mEq/L\n 3.8 mEq/L\n 6 mg/dL\n 109 mEq/L\n 150 mEq/L\n 30.7 %\n 9.7 K/uL\n [image002.jpg]\n 11:54 PM\n 01:00 AM\n WBC\n 9.7\n Hct\n 30.7\n Plt\n 333\n Cr\n 0.6\n TCO2\n 32\n Glucose\n 103\n Other labs: PT / PTT / INR:13.8/22.4/1.2, ALT / AST:30/19, Alk Phos / T\n Bili:149/0.7, Differential-Neuts:76.9 %, Lymph:17.3 %, Mono:3.0 %,\n Eos:2.5 %, Albumin:3.0 g/dL, LDH:222 IU/L, Ca++:8.6 mg/dL, Mg++:2.1\n mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n A/P: 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture\n # Respiratory failure: initially likely multifactorial including\n bronchspasm, hypoventilation from narcotics, and potential aspiration.\n prior evaluation negative for PE. still with significant A-a gradient.\n cxr appears under penetrated with small lung fields and potential\n effusion on right. potentially from pneumonia given patient\ns fever.\n - daily CXR\n - will hold on CT chest or airway pending IP consult\n - IP consult\n - vent settings: AC 500 x 12 PEEP 10, FIO2 60%\n - sedation: fentanyl and midazolam infusions\n - trial of diuresis when able\n # Fever: Differential diagnosis includes infection cause (VAP, infected\n PICC line, UTI) or DVT. Cultures sent. Will treat with empiric\n antibiotics. Tylenol PRN for fever.\n - Flagyl, aztreonam, vancomycin, levofloxacin for coverage of gram\n positives, gram negatives, anaerobes, MRSA, and MDR pathogens.\n - f/u blood and urine cultures\n - Once further IV access is established, remove PICC and culture tip.\n # Hypotension: Differential diagnosis includes hypovolemia, sepsis, and\n cardiogenic. Sepsis likely given fever, although hypovolemia remains\n in differential given falling hematocrit. BP responded well to fluid\n boluses but urine output low.\n - Monitor BP and urine output.\n - Consider additional fluid boluses.\n - If patient\ns hypotension becomes refractory to fluid boluses, would\n place central line for CVP monitoring and initiate pressors.\n # Spine fracture: neurologically intact distal to the lesion. prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - monitor distal neurologic function\n - cto brace x3 months unless supine in bed\n # Anemia: admission to MMC was ~40 now down to 30% w/o sign of active\n GI bleed or other source of blood loss. likely related to crystalloid\n administration, anemia of inflammation, chronic phlebotomy. given bili\n and LDH normal would be unlikely for hemolysis.\n - trend Hct\n - guaiac stools\n Hypernatremia: most likely related to inadequate free water repletion.\n free water defecit ~3L.\n - replete via OGT primarily\n - D5W x1 L\n ICU Care\n Nutrition:\n Comments: tube feed with free water\n nutrition consult\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 10:30 PM\n 18 Gauge - 10:30 PM\n 20 Gauge - 01:36 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Family meeting held , ICU consent signed Comments: \n (brother) \n (boyfriend/POA) \n Code status: Full code\n Disposition: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 10:30 PM\n 20 Gauge - 01:36 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2167-09-20 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 634156,
"text": "Chief Complaint:\n 24 Hour Events:\n -cultured for fever to 102.7 at 4:00 am\n -Patient developed hypotension to 102.7 at 6:15 a.m. BP responded well\n to LR 500 cc. However, urine output remained low despite bolus and\n additional LR 500 cc bolus. Antibiotics initiated (levofloxacin,\n aztreonam, vancomycin, metronidazole).\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.3\nC (102.7\n Tcurrent: 39.3\nC (102.7\n HR: 89 (72 - 97) bpm\n BP: 96/41(55) {96/41(55) - 154/71(103)} mmHg\n RR: 12 (12 - 18) insp/min\n SpO2: 95%\n Total In:\n 10 mL\n 232 mL\n PO:\n TF:\n IVF:\n 10 mL\n 232 mL\n Blood products:\n Total out:\n 425 mL\n 570 mL\n Urine:\n 425 mL\n 570 mL\n NG:\n Stool:\n Drains:\n Balance:\n -416 mL\n -338 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 32 cmH2O\n SpO2: 95%\n ABG: 7.42/47/61/30/4\n Ve: 8 L/min\n PaO2 / FiO2: 102\n Physical Examination\n Gen: Appears uncomfortable on vent.\n HEENT: Anicteric. Pupils 3 mm non-reactive bilaterally.\n Resp: Symmetric expansion. Vesicular sounds throughout. Inspiratory\n and expiratory tracheal sounds (?related to ET tube).\n CV: Cannot see jugular veins due to neck size. RRR. Normal s1 and\n s2. No M/G/R.\n Abd: Quiet. Distended. Non-tender.\n Ext: Edema in RUE, especially right hand. Mildly increased warmth of\n RUE compared with LUE.\n Peripheral vascular: Radial pulses 2+ bilaterally.\n Neuro: Pupils as above. Moving all 4 extremities.\n Labs / Radiology\n 333 K/uL\n 9.7 g/dL\n 103 mg/dL\n 0.6 mg/dL\n 30 mEq/L\n 3.8 mEq/L\n 6 mg/dL\n 109 mEq/L\n 150 mEq/L\n 30.7 %\n 9.7 K/uL\n [image002.jpg]\n 11:54 PM\n 01:00 AM\n WBC\n 9.7\n Hct\n 30.7\n Plt\n 333\n Cr\n 0.6\n TCO2\n 32\n Glucose\n 103\n Other labs: PT / PTT / INR:13.8/22.4/1.2, ALT / AST:30/19, Alk Phos / T\n Bili:149/0.7, Differential-Neuts:76.9 %, Lymph:17.3 %, Mono:3.0 %,\n Eos:2.5 %, Albumin:3.0 g/dL, LDH:222 IU/L, Ca++:8.6 mg/dL, Mg++:2.1\n mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n A/P: 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture\n # Respiratory failure: initially likely multifactorial including\n bronchspasm, hypoventilation from narcotics, and potential aspiration.\n prior evaluation negative for PE. still with significant A-a gradient.\n cxr appears under penetrated with small lung fields and potential\n effusion on right. potentially from pneumonia given patient\ns fever.\n - daily CXR\n - will hold on CT chest or airway pending IP consult\n - IP consult\n - vent settings: AC 500 x 12 PEEP 10, FIO2 60%\n - sedation: fentanyl and midazolam infusions\n - ipratropium and atrovent nebs\n # Fever: Differential diagnosis includes infection cause (VAP, infected\n PICC line, UTI) or DVT. Cultures sent. Will treat with empiric\n antibiotics. Tylenol PRN for fever.\n - Flagyl, aztreonam, vancomycin, levofloxacin for coverage of gram\n positives, gram negatives, anaerobes, MRSA, and MDR pathogens.\n - f/u blood, urine, and sputum cultures\n - BAL\n - Once further IV access is established, remove PICC and culture tip.\n # Hypotension: Differential diagnosis includes hypovolemia, sepsis, and\n cardiogenic. Sepsis likely given fever, although hypovolemia remains\n in differential given falling hematocrit. BP responded well to fluid\n boluses but urine output low.\n - Monitor BP and urine output.\n - Consider additional fluid boluses.\n - If patient\ns hypotension becomes refractory to fluid boluses, would\n place central line for CVP monitoring and initiate pressors.\n # Anemia: On admission to Medical Center, Hct was ~40, now down\n to 30 and then 25 w/o sign of active GI bleed or other source of blood\n loss. be related to fluid administration, phlebotomy, anemia of\n inflammation, active bleed still considered in differential.\n -Follow Hct\n -guaiac stools\n # Spine fracture: neurologically intact distal to the lesion. prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - monitor distal neurologic function\n - cto brace x3 months unless supine in bed\n - consult neurosurgery for further recs\n # Anemia: admission to MMC was ~40 now down to 30% w/o sign of active\n GI bleed or other source of blood loss. likely related to crystalloid\n administration, anemia of inflammation, chronic phlebotomy. given bili\n and LDH normal would be unlikely for hemolysis.\n - trend Hct\n - guaiac stools\n - insert additional PIV\n Hypernatremia: Na improved to 147 (from 150) today, most likely\n related to inadequate free water repletion. Free water defecit ~2 L.\n - replete via OGT primarily\n - D5W x1 L\n ICU Care\n Nutrition:\n Comments: tube feed with free water\n nutrition consult\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 10:30 PM\n 18 Gauge - 10:30 PM\n 20 Gauge - 01:36 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Family meeting held , ICU consent signed Comments: \n (brother) \n (boyfriend/POA) \n Code status: Full code\n Disposition: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 10:30 PM\n 20 Gauge - 01:36 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2167-09-20 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 634157,
"text": "Chief Complaint:\n 24 Hour Events:\n -cultured for fever to 102.7 at 4:00 am\n -Patient developed hypotension to 102.7 at 6:15 a.m. BP responded well\n to LR 500 cc. However, urine output remained low despite bolus and\n additional LR 500 cc bolus. Antibiotics initiated (levofloxacin,\n aztreonam, vancomycin, metronidazole).\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.3\nC (102.7\n Tcurrent: 39.3\nC (102.7\n HR: 89 (72 - 97) bpm\n BP: 96/41(55) {96/41(55) - 154/71(103)} mmHg\n RR: 12 (12 - 18) insp/min\n SpO2: 95%\n Total In:\n 10 mL\n 232 mL\n PO:\n TF:\n IVF:\n 10 mL\n 232 mL\n Blood products:\n Total out:\n 425 mL\n 570 mL\n Urine:\n 425 mL\n 570 mL\n NG:\n Stool:\n Drains:\n Balance:\n -416 mL\n -338 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 32 cmH2O\n SpO2: 95%\n ABG: 7.42/47/61/30/4\n Ve: 8 L/min\n PaO2 / FiO2: 102\n Physical Examination\n Gen: Appears uncomfortable on vent.\n HEENT: Anicteric. Pupils 3 mm non-reactive bilaterally.\n Resp: Symmetric expansion. Vesicular sounds throughout. Inspiratory\n and expiratory tracheal sounds (?related to ET tube).\n CV: Cannot see jugular veins due to neck size. RRR. Normal s1 and\n s2. No M/G/R.\n Abd: Quiet. Distended. Non-tender.\n Ext: Edema in RUE, especially right hand. Mildly increased warmth of\n RUE compared with LUE.\n Peripheral vascular: Radial pulses 2+ bilaterally.\n Neuro: Pupils as above. Moving all 4 extremities.\n Labs / Radiology\n 333 K/uL\n 9.7 g/dL\n 103 mg/dL\n 0.6 mg/dL\n 30 mEq/L\n 3.8 mEq/L\n 6 mg/dL\n 109 mEq/L\n 150 mEq/L\n 30.7 %\n 9.7 K/uL\n [image002.jpg]\n 11:54 PM\n 01:00 AM\n WBC\n 9.7\n Hct\n 30.7\n Plt\n 333\n Cr\n 0.6\n TCO2\n 32\n Glucose\n 103\n Other labs: PT / PTT / INR:13.8/22.4/1.2, ALT / AST:30/19, Alk Phos / T\n Bili:149/0.7, Differential-Neuts:76.9 %, Lymph:17.3 %, Mono:3.0 %,\n Eos:2.5 %, Albumin:3.0 g/dL, LDH:222 IU/L, Ca++:8.6 mg/dL, Mg++:2.1\n mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n A/P: 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture\n # Respiratory failure: initially likely multifactorial including\n bronchspasm, hypoventilation from narcotics, and potential aspiration.\n prior evaluation negative for PE. still with significant A-a gradient.\n cxr appears under penetrated with small lung fields and potential\n effusion on right. potentially from pneumonia given patient\ns fever.\n - daily CXR\n - will hold on CT chest or airway pending IP consult\n - IP consult\n - vent settings: AC 500 x 12 PEEP 10, FIO2 60%\n - sedation: fentanyl and midazolam infusions\n - ipratropium and atrovent nebs\n # Fever: Differential diagnosis includes infection cause (VAP, infected\n PICC line, UTI) or DVT. Cultures sent. Will treat with empiric\n antibiotics. Tylenol PRN for fever.\n - Flagyl, aztreonam, vancomycin, levofloxacin for coverage of gram\n positives, gram negatives, anaerobes, MRSA, and MDR pathogens.\n - f/u blood, urine, and sputum cultures\n - BAL\n - Once further IV access is established, remove PICC and culture tip.\n # Hypotension: Differential diagnosis includes hypovolemia, sepsis, and\n cardiogenic. Sepsis likely given fever, although hypovolemia remains\n in differential given falling hematocrit. BP responded well to fluid\n boluses but urine output low.\n - Monitor BP and urine output.\n - Consider additional fluid boluses.\n - If patient\ns hypotension becomes refractory to fluid boluses, would\n place central line for CVP monitoring and initiate pressors.\n # Anemia: On admission to Medical Center, Hct was ~40, now down\n to 30 and then 25 w/o sign of active GI bleed or other source of blood\n loss. be related to fluid administration, phlebotomy, anemia of\n inflammation, active bleed still considered in differential. given\n bili and LDH normal would be unlikely for hemolysis.\n - trend Hct\n -Follow Hct\n -guaiac stools\n # Spine fracture: neurologically intact distal to the lesion. prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - monitor distal neurologic function\n - cto brace x3 months unless supine in bed\n - consult neurosurgery for further recs\n # Hypernatremia: Na improved to 147 (from 150) today, most likely\n related to inadequate free water repletion. Free water defecit ~2 L.\n - replete via OGT primarily\n - D5W x1 L\n # Right upper extremity edema: Could be caused by DVT related to PICC.\n - d/c PICC\n - RUE U/S\n ICU Care\n Nutrition:\n Comments: tube feed with free water\n nutrition consult\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 10:30 PM\n 18 Gauge - 10:30 PM\n 20 Gauge - 01:36 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Family meeting held , ICU consent signed Comments: \n (brother) \n (boyfriend/POA) \n Code status: Full code\n Disposition: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 10:30 PM\n 20 Gauge - 01:36 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2167-09-20 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 634158,
"text": "Chief Complaint:\n 24 Hour Events:\n -cultured for fever to 102.7 at 4:00 am\n -Patient developed hypotension to 83/38 at 6:15 a.m. BP responded well\n to LR 500 cc. However, urine output remained low despite bolus and\n additional LR 500 cc bolus. Antibiotics initiated (levofloxacin,\n aztreonam, vancomycin, metronidazole).\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.3\nC (102.7\n Tcurrent: 39.3\nC (102.7\n HR: 89 (72 - 97) bpm\n BP: 96/41(55) {96/41(55) - 154/71(103)} mmHg\n RR: 12 (12 - 18) insp/min\n SpO2: 95%\n Total In:\n 10 mL\n 232 mL\n PO:\n TF:\n IVF:\n 10 mL\n 232 mL\n Blood products:\n Total out:\n 425 mL\n 570 mL\n Urine:\n 425 mL\n 570 mL\n NG:\n Stool:\n Drains:\n Balance:\n -416 mL\n -338 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 32 cmH2O\n SpO2: 95%\n ABG: 7.42/47/61/30/4\n Ve: 8 L/min\n PaO2 / FiO2: 102\n Physical Examination\n Gen: Appears uncomfortable on vent.\n HEENT: Anicteric. Pupils 3 mm non-reactive bilaterally.\n Resp: Symmetric expansion. Vesicular sounds throughout. Inspiratory\n and expiratory tracheal sounds (?related to ET tube).\n CV: Cannot see jugular veins due to neck size. RRR. Normal s1 and\n s2. No M/G/R.\n Abd: Quiet. Distended. Non-tender.\n Ext: Edema in RUE, especially right hand. Mildly increased warmth of\n RUE compared with LUE.\n Peripheral vascular: Radial pulses 2+ bilaterally.\n Neuro: Pupils as above. Moving all 4 extremities.\n Labs / Radiology\n 333 K/uL\n 9.7 g/dL\n 103 mg/dL\n 0.6 mg/dL\n 30 mEq/L\n 3.8 mEq/L\n 6 mg/dL\n 109 mEq/L\n 150 mEq/L\n 30.7 %\n 9.7 K/uL\n [image002.jpg]\n 11:54 PM\n 01:00 AM\n WBC\n 9.7\n Hct\n 30.7\n Plt\n 333\n Cr\n 0.6\n TCO2\n 32\n Glucose\n 103\n Other labs: PT / PTT / INR:13.8/22.4/1.2, ALT / AST:30/19, Alk Phos / T\n Bili:149/0.7, Differential-Neuts:76.9 %, Lymph:17.3 %, Mono:3.0 %,\n Eos:2.5 %, Albumin:3.0 g/dL, LDH:222 IU/L, Ca++:8.6 mg/dL, Mg++:2.1\n mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n A/P: 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture\n # Respiratory failure: initially likely multifactorial including\n bronchspasm, hypoventilation from narcotics, and potential aspiration.\n prior evaluation negative for PE. still with significant A-a gradient.\n cxr appears under penetrated with small lung fields and potential\n effusion on right. potentially from pneumonia given patient\ns fever.\n - daily CXR\n - will hold on CT chest or airway pending IP consult\n - IP consult\n - vent settings: AC 500 x 12 PEEP 10, FIO2 60%\n - sedation: fentanyl and midazolam infusions\n - ipratropium and atrovent nebs\n # Fever: Differential diagnosis includes infection cause (VAP, infected\n PICC line, UTI) or DVT. Cultures sent. Will treat with empiric\n antibiotics. Tylenol PRN for fever.\n - Flagyl, aztreonam, vancomycin, levofloxacin for coverage of gram\n positives, gram negatives, anaerobes, MRSA, and MDR pathogens.\n - f/u blood, urine, and sputum cultures\n - BAL\n - Once further IV access is established, remove PICC and culture tip.\n # Hypotension: Differential diagnosis includes hypovolemia, sepsis, and\n cardiogenic. Sepsis likely given fever, although hypovolemia remains\n in differential given falling hematocrit. BP responded well to fluid\n boluses but urine output low.\n - Monitor BP and urine output.\n - Consider additional fluid boluses.\n - If patient\ns hypotension becomes refractory to fluid boluses, would\n place central line for CVP monitoring and initiate pressors.\n # Anemia: On admission to Medical Center, Hct was ~40, now down\n to 30 and then 25 w/o sign of active GI bleed or other source of blood\n loss. be related to fluid administration, phlebotomy, anemia of\n inflammation, active bleed still considered in differential. given\n bili and LDH normal would be unlikely for hemolysis.\n - trend Hct\n -Follow Hct\n -guaiac stools\n # Spine fracture: neurologically intact distal to the lesion. prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - monitor distal neurologic function\n - cto brace x3 months unless supine in bed\n - consult neurosurgery for further recs\n # Hypernatremia: Na improved to 147 (from 150) today, most likely\n related to inadequate free water repletion. Free water defecit ~2 L.\n - replete via OGT primarily\n - D5W x1 L\n # Right upper extremity edema: Could be caused by DVT related to PICC.\n - d/c PICC\n - RUE U/S\n ICU Care\n Nutrition:\n Comments: tube feed with free water\n nutrition consult\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 10:30 PM\n 18 Gauge - 10:30 PM\n 20 Gauge - 01:36 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Family meeting held , ICU consent signed Comments: \n (brother) \n (boyfriend/POA) \n Code status: Full code\n Disposition: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 10:30 PM\n 20 Gauge - 01:36 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2167-09-20 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 634159,
"text": "Chief Complaint:\n 24 Hour Events:\n -cultured for fever to 102.7 at 4:00 am\n -Patient developed hypotension to 83/38 at 6:15 a.m. BP responded well\n to LR 500 cc. However, urine output remained low despite bolus and\n additional LR 500 cc bolus. Antibiotics initiated (levofloxacin,\n aztreonam, vancomycin, metronidazole).\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.3\nC (102.7\n Tcurrent: 39.3\nC (102.7\n HR: 89 (72 - 97) bpm\n BP: 96/41(55) {96/41(55) - 154/71(103)} mmHg\n RR: 12 (12 - 18) insp/min\n SpO2: 95%\n Total In:\n 10 mL\n 232 mL\n PO:\n TF:\n IVF:\n 10 mL\n 232 mL\n Blood products:\n Total out:\n 425 mL\n 570 mL\n Urine:\n 425 mL\n 570 mL\n NG:\n Stool:\n Drains:\n Balance:\n -416 mL\n -338 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 32 cmH2O\n SpO2: 95%\n ABG: 7.42/47/61/30/4\n Ve: 8 L/min\n PaO2 / FiO2: 102\n Physical Examination\n Gen: Appears uncomfortable on vent.\n HEENT: Anicteric. Pupils 3 mm non-reactive bilaterally.\n Resp: Symmetric expansion. Vesicular sounds throughout. Inspiratory\n and expiratory tracheal sounds (?related to ET tube).\n CV: Cannot see jugular veins due to neck size. RRR. Normal s1 and\n s2. No M/G/R.\n Abd: Quiet. Distended. Non-tender.\n Ext: Edema in RUE, especially right hand. Mildly increased warmth of\n RUE compared with LUE.\n Peripheral vascular: Radial pulses 2+ bilaterally.\n Neuro: Pupils as above. Moving all 4 extremities.\n Labs / Radiology\n 333 K/uL\n 9.7 g/dL\n 103 mg/dL\n 0.6 mg/dL\n 30 mEq/L\n 3.8 mEq/L\n 6 mg/dL\n 109 mEq/L\n 150 mEq/L\n 30.7 %\n 9.7 K/uL\n [image002.jpg]\n 11:54 PM\n 01:00 AM\n WBC\n 9.7\n Hct\n 30.7\n Plt\n 333\n Cr\n 0.6\n TCO2\n 32\n Glucose\n 103\n Other labs: PT / PTT / INR:13.8/22.4/1.2, ALT / AST:30/19, Alk Phos / T\n Bili:149/0.7, Differential-Neuts:76.9 %, Lymph:17.3 %, Mono:3.0 %,\n Eos:2.5 %, Albumin:3.0 g/dL, LDH:222 IU/L, Ca++:8.6 mg/dL, Mg++:2.1\n mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n A/P: 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture\n # Respiratory failure: initially likely multifactorial including\n bronchspasm, hypoventilation from narcotics, and potential aspiration.\n prior evaluation negative for PE. still with significant A-a gradient.\n cxr appears under penetrated with small lung fields and potential\n effusion on right. potentially from pneumonia given patient\ns fever.\n - daily CXR\n - will hold on CT chest or airway pending IP consult\n - IP consult\n - vent settings: AC 500 x 12 PEEP 10, FIO2 60%\n - sedation: fentanyl and midazolam infusions\n - ipratropium and atrovent nebs\n # Fever: Differential diagnosis includes infection cause (VAP, infected\n PICC line, UTI) or DVT. Cultures sent. Will treat with empiric\n antibiotics. Tylenol PRN for fever.\n - Flagyl, aztreonam, vancomycin, levofloxacin for coverage of gram\n positives, gram negatives, anaerobes, MRSA, and MDR pathogens.\n - f/u blood, urine, and sputum cultures\n - mini-BAL\n - Once further IV access is established, remove PICC and culture tip.\n # Hypotension: Differential diagnosis includes hypovolemia, sepsis, and\n cardiogenic. Sepsis likely given fever, although hypovolemia remains\n in differential given falling hematocrit. BP responded well to fluid\n boluses but urine output low.\n - Monitor BP and urine output.\n - Consider additional fluid boluses.\n - If patient\ns hypotension becomes refractory to fluid boluses, would\n place central line for CVP monitoring and initiate pressors.\n # Anemia: On admission to Medical Center, Hct was ~40, now down\n to 30 and then 25 w/o sign of active GI bleed or other source of blood\n loss. be related to fluid administration, phlebotomy, anemia of\n inflammation, active bleed still considered in differential. given\n bili and LDH normal would be unlikely for hemolysis.\n - trend Hct\n -Follow Hct\n -guaiac stools\n # Spine fracture: neurologically intact distal to the lesion. prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - monitor distal neurologic function\n - cto brace x3 months unless supine in bed\n - consult neurosurgery for further recs\n # Hypernatremia: Na improved to 147 (from 150) today, most likely\n related to inadequate free water repletion. Free water defecit ~2 L.\n - replete via OGT primarily\n - D5W x1 L\n # Right upper extremity edema: Could be caused by DVT related to PICC.\n - d/c PICC\n - RUE U/S\n ICU Care\n Nutrition:\n Comments: tube feed with free water\n nutrition consult\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 10:30 PM\n 18 Gauge - 10:30 PM\n 20 Gauge - 01:36 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Family meeting held , ICU consent signed Comments: \n (brother) \n (boyfriend/POA) \n Code status: Full code\n Disposition: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 10:30 PM\n 20 Gauge - 01:36 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n This note was written by , HMS IV, to be cosigned by the\n on-call MICU resident. I had to have the on-call intern sign me in to\n MetaVision because I do not yet have access to edit.\n"
},
{
"category": "Nursing",
"chartdate": "2167-09-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 634169,
"text": "Obese woman s/p t spine injury tx from Med for failure to wean\n from mech ventilation and evaluation for stent for\n tracheobronchomalacia.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Pt cont w/ low grade fever.\n Action:\n Given tyelenol q6 h prn, pt pan cultured. PICC line and foley d/c\n (new foley placed).\n Response:\n Fever slightly improved to 99.\n Plan:\n Cont w/ q 6 hr tyelenol prn, closely monitor temp and f/u w/ cultures.\n Fracture, other\n Assessment:\n Pt w/ T5-T8 compression fracture.\n Action:\n Pt on log-roll precautions, back brace at bedside- to be used when pt\n is OOB.\n Response:\n Pt denies pain when asked.\n Plan:\n Cont on log roll precautions, Neuro- consult ordered to clarify\n order for brace.\n Anemia, other\n Assessment:\n HCT 25 from 30.0. No active bleeding noted.\n Action:\n Cont to check HCT and s/s of bleeding.\n Response:\n No action taken.\n Plan:\n Type & Screen to be collected. Cont to monitor HCT, guiac all stools.\n Hypernatremia (high sodium)\n Assessment:\n NA level 150-> 147. No seizure activity.\n Action:\n Given free H2O boluses q 4hrs. Pt on D5W for 1L .\n Response:\n NA level slightly improved.\n Plan:\n Cont w/ free-water boluses as tolerated, cont to monitor lytes, bolus\n w/ LR prn.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS rhonchorous throughout, diminished to bilateral bases, deep sxn\n thick tan/bloody secretions.\n Action:\n Given MDIs, cont to be orally intubated on A/C, mini-BAL performed by\n RT and sample sent to lab.\n Response:\n Cont to be orally intubated and sedated.\n Plan:\n Consult w/ IP for eval for stent, wean vent as tolerated\n"
},
{
"category": "Respiratory ",
"chartdate": "2167-09-21 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 634211,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Tube Type\n ETT:\n Position: 19 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Utilize ARDSnet protocol, Maintain PEEP at current\n level and reduce FiO2 as tolerated, Adjust Min. ventilation to control\n pH\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Intolerant of weaning attempts, Cannot protect airway, Underlying\n illness not resolved\n"
},
{
"category": "Physician ",
"chartdate": "2167-09-21 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 634217,
"text": "Chief Complaint:\n 24 Hour Events:\n Removed PICC line because RUE was noted to be warm and erythematous;\n ultrasound revealed DVT. No definitive treatment was started given\n difficulty obtaining central venous access.\n Multiple attempts at central access; tried left and then right.\n Acute episode of oxygen desat during first central line attempt. Pt\n recovered, however, increased FiO2.\n Decreased UOP (10-30mL/hr) and hypotension overnight. However,\n lactate remains low.\n Placed art line x 2. NBP and ABP similar\n mini- BAL, sputum, urine, blood cultures pending. Yesterday, started\n on levofloxicin and aztreonam instead of cefepime. Switched due to\n question of PCN allergy\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 09:30 AM\n Metronidazole - 12:00 AM\n Vancomycin - 01:00 AM\n Aztreonam - 04:00 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 150 mcg/hour\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:00 AM\n Midazolam (Versed) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (100.9\n Tcurrent: 37.3\nC (99.2\n HR: 76 (71 - 116) bpm\n BP: 116/51(70) {60/46(54) - 146/71(91)} mmHg\n RR: 18 (12 - 24) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 94.2 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 5,600 mL\n 1,811 mL\n PO:\n TF:\n 120 mL\n IVF:\n 4,700 mL\n 1,511 mL\n Blood products:\n Total out:\n 798 mL\n 110 mL\n Urine:\n 798 mL\n 110 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,802 mL\n 1,701 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 80%\n RSBI Deferred: PEEP > 10\n PIP: 36 cmH2O\n Plateau: 25 cmH2O\n SpO2: 93%\n ABG: 7.45/42/95./28/4\n Ve: 9.5 L/min\n PaO2 / FiO2: 120\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 319 K/uL\n 7.6 g/dL\n 129 mg/dL\n 0.6 mg/dL\n 28 mEq/L\n 4.3 mEq/L\n 6 mg/dL\n 109 mEq/L\n 144 mEq/L\n 24.1 %\n 6.4 K/uL\n [image002.jpg]\n 11:54 PM\n 01:00 AM\n 06:14 AM\n 08:56 AM\n 08:57 AM\n 05:01 PM\n 08:03 PM\n 11:00 PM\n 03:01 AM\n 03:13 AM\n WBC\n 9.7\n 9.4\n 7.6\n 6.4\n Hct\n 30.7\n 25.1\n 24.1\n 24.1\n Plt\n 333\n 281\n 306\n 319\n Cr\n 0.6\n 0.6\n 0.7\n 0.6\n 0.6\n TCO2\n 32\n 33\n 35\n 33\n 30\n Glucose\n 103\n 126\n 126\n 127\n 129\n Other labs: PT / PTT / INR:16.9/26.3/1.5, ALT / AST:27/18, Alk Phos / T\n Bili:113/0.7, Differential-Neuts:76.9 %, Lymph:17.3 %, Mono:3.0 %,\n Eos:2.5 %, Lactic Acid:0.7 mmol/L, Albumin:2.3 g/dL, LDH:154 IU/L,\n Ca++:8.2 mg/dL, Mg++:2.6 mg/dL, PO4:3.1 mg/dL\n RUE ultrasound:\n - Non-occlusive right axillary deep vein thrombus\n - Non-occlusive right basilic superficial thrombosis.\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 01:16 AM\n 20 Gauge - 01:36 AM\n 22 Gauge - 02:00 PM\n Arterial Line - 03:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2167-09-21 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 634290,
"text": "Chief Complaint: respiratory failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n URINE CULTURE - At 08:09 AM\n EKG - At 09:00 AM\n PICC LINE - STOP 10:30 AM\n BLOOD CULTURED - At 10:30 AM\n ULTRASOUND - At 01:00 PM\n U/S of RUE\n URINE CULTURE - At 03:00 PM\n UA/UC collected after new foley inserted.\n BAL FLUID CULTURE - At 03:00 PM\n mini-BAL\n ARTERIAL LINE - START 04:45 PM\n ARTERIAL LINE - STOP 02:03 AM\n ARTERIAL LINE - START 03:00 AM\n Multiple attempts at central access were unsuccessful due to\n malposition and difficulty threading wire.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 09:30 AM\n Vancomycin - 01:00 AM\n Aztreonam - 04:00 AM\n Metronidazole - 08:50 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 150 mcg/hour\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:00 AM\n Midazolam (Versed) - 09:32 AM\n Other medications:\n colace, CHG, SQI, H2B, SQH, MDIs, Flagyl, vanco, levo, aztreonam,\n versed, fentanyl\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (100.9\n Tcurrent: 37.9\nC (100.3\n HR: 72 (70 - 116) bpm\n BP: 100/48(60) {89/47(60) - 139/75(79)} mmHg\n RR: 18 (12 - 24) insp/min\n SpO2: 89%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 94.2 kg (admission): 94.2 kg\n Height: 67 Inch\n Bladder pressure: 18 (18 - 18) mmHg\n Total In:\n 5,600 mL\n 2,088 mL\n PO:\n TF:\n 120 mL\n IVF:\n 4,700 mL\n 1,728 mL\n Blood products:\n Total out:\n 798 mL\n 205 mL\n Urine:\n 798 mL\n 205 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,802 mL\n 1,883 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 80%\n RSBI Deferred: PEEP > 10\n PIP: 37 cmH2O\n Plateau: 25 cmH2O\n SpO2: 89%\n ABG: 7.45/42/95./28/4\n Ve: 9.1 L/min\n PaO2 / FiO2: 96\n Physical Examination\n Sedated. Breath sounds are coarse. Heart sounds are distant. Abdomen\n is protuberant with quiet breath sounds. Some peripheral edema. She\n is not able to cooperate with peripheral strength or sensory exam.\n Labs / Radiology\n 7.6 g/dL\n 319 K/uL\n 129 mg/dL\n 0.6 mg/dL\n 28 mEq/L\n 4.3 mEq/L\n 6 mg/dL\n 109 mEq/L\n 144 mEq/L\n 24.1 %\n 6.4 K/uL\n [image002.jpg]\n 11:54 PM\n 01:00 AM\n 06:14 AM\n 08:56 AM\n 08:57 AM\n 05:01 PM\n 08:03 PM\n 11:00 PM\n 03:01 AM\n 03:13 AM\n WBC\n 9.7\n 9.4\n 7.6\n 6.4\n Hct\n 30.7\n 25.1\n 24.1\n 24.1\n Plt\n 333\n 281\n 306\n 319\n Cr\n 0.6\n 0.6\n 0.7\n 0.6\n 0.6\n TCO2\n 32\n 33\n 35\n 33\n 30\n Glucose\n 103\n 126\n 126\n 127\n 129\n Other labs: PT / PTT / INR:16.9/26.3/1.5, ALT / AST:27/18, Alk Phos / T\n Bili:113/0.7, Differential-Neuts:76.9 %, Lymph:17.3 %, Mono:3.0 %,\n Eos:2.5 %, Lactic Acid:0.7 mmol/L, Albumin:2.3 g/dL, LDH:154 IU/L,\n Ca++:8.2 mg/dL, Mg++:2.6 mg/dL, PO4:3.1 mg/dL\n Imaging: CXR with bilateral opacities; ETT a little high. No PTX.\n Assessment and Plan\n 55-year-old woman with\n Respiratory failure\n Traumatic thoracic spinal fractures\n Probable VAP\n Upper extremity DVT\n Oliguria\n Anemia\n Possible tracheobronchomalacia (reason for transfer)\n I am uncertain about both the risks of anticoagulation and the risks of\n moving to radiology (e.g. CT or IR) in the context of her spinal\n fractures. Therefore we will consult spine surgery urgently for help\n with these questions.\n Her respiratory failure is likely multifactorial, including obesity,\n probable VAP, probable PE, and possible tracheobronchomalacia. She may\n also have weakness, but she is sedated and cannot cooperate with exam\n at present. We will check an echo to examine her RV. We will\n ventilate per ARDSnet; she may warrant esophageal-balloon-guided\n therapy if she does not improve in the next few hours.\n Oliguria is concerning, though BUN/Creatinine are reassuring. NG to\n suction to relieve abdominal distention. We will check urine lytes and\n assess stroke volume variation with the Vigileo. We will consider\n volume challenge based on this result.\n For central access, if we are able to safely move her we will ask I.R.\n to help with central access.\n We will continue broad antibiotics while awaiting cultures.\n ICU Care\n Nutrition: NPO for now\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 01:16 AM\n 20 Gauge - 01:36 AM\n 22 Gauge - 02:00 PM\n Arterial Line - 03:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 45 min\n Patient is critically ill\n ------ Protected Section ------\n Critical Care Staff Addendum\n 5:45p\n CVL successfully placed. CVP and SVV argue that she is adequately\n volume-replete. Hypoxemia has been a major issue, and we have taken\n her to CT this afternoon. We are awaiting final reads of the images.\n We will pursue esophageal balloon to help guide PEEP; first attempt was\n unsuccessful due to oropharyngeal coiling.\n Discussed in detail with patient\ns brother at bedside. Unable to reach\n her significant other.\n 35 minutes\n ------ Protected Section Addendum Entered By: , MD\n on: 17:55 ------\n Critical Care Staff\n 7:30p\n Stable on PEEP 15, FiO2 0.8, low-dose Levophed. RT was unable to place\n esophageal balloon. CT reviewed and shows basilar >> apical collapse\n but no PE. Echo was limited but reassuring, with normal RV function\n and no obvious shunt.\n We will continue to pursue 6cc/kg PBW ventilation. If unable to wean\n FiO2 further, will increase PEEP. If difficulties, will repeat\n attempts at esophageal balloon and consider proning.\n Since sputum is growing GNR, suspect that much of this may be related\n to VAP acquired at OSH. Since we do not know their resistance\n patterns, will continue extended-spectrum GNR coverage with aztreonam\n and levofloxacin.\n Await spine surgery\ns input on risks of anticoagulation. If OK, begin\n full-dose heparin tonight.\n Discussed with , RN, and RT.\n 30 minutes\n ------ Protected Section Addendum Entered By: , MD\n on: 07:49 PM ------\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-05 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 635843,
"text": "Chief Complaint:\n 24 Hour Events:\n On lasix drip\n Attempted to wean FiO2\n No acute events\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Furosemide (Lasix) - 2 mg/hour\n Heparin Sodium - 1,500 units/hour\n Fentanyl - 75 mcg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.9\nC (98.5\n HR: 126 (49 - 131) bpm\n BP: 156/84(117) {78/38(52) - 164/95(125)} mmHg\n RR: 20 (9 - 21) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 4,160 mL\n 1,185 mL\n PO:\n TF:\n 1,267 mL\n 315 mL\n IVF:\n 1,018 mL\n 260 mL\n Blood products:\n Total out:\n 4,015 mL\n 2,090 mL\n Urine:\n 4,015 mL\n 2,090 mL\n NG:\n Stool:\n Drains:\n Balance:\n 145 mL\n -905 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 500) mL\n Vt (Spontaneous): 675 (675 - 675) mL\n PS : 8 cmH2O\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 19 cmH2O\n Plateau: 16 cmH2O\n SpO2: 96%\n ABG: 7.39/46/118/28/2\n Ve: 8.9 L/min\n PaO2 / FiO2: 236\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 272 K/uL\n 8.6 g/dL\n 128 mg/dL\n 0.6 mg/dL\n 28 mEq/L\n 3.1 mEq/L\n 8 mg/dL\n 110 mEq/L\n 148 mEq/L\n 27.4 %\n 11.2 K/uL\n [image002.jpg]\n 05:17 PM\n 11:41 PM\n 03:06 AM\n 03:38 AM\n 04:05 PM\n 03:55 AM\n 07:19 AM\n 11:24 AM\n 03:18 PM\n 02:47 AM\n WBC\n 10.6\n 10.0\n 8.3\n 11.2\n Hct\n 27.3\n 25.8\n 24.6\n 27.4\n Plt\n 72\n Cr\n 0.5\n 0.6\n 0.6\n 0.5\n 0.6\n 0.6\n TCO2\n 32\n 31\n 29\n 29\n Glucose\n 110\n 94\n 111\n 106\n 121\n 123\n 137\n 128\n Other labs: PT / PTT / INR:15.2/62.2/1.3, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:13.1 %,\n Mono:2.7 %, Eos:0.6 %, Lactic Acid:0.9 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:9.0 mg/dL, Mg++:2.6 mg/dL, PO4:4.3 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA and\n ARDS intubated since the end of now s/p trach and PEG placement.\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation. Stenting\n unlikely to help for trachiomalacia as airways have poor structure\n diffusely. S/P Trach and PEG on .\n - wean FiO2 today\n # Adrenal Insufficency: Hypotension that resolved with steroids,\n returned as they came off and is now improved again. Possible primary\n adrenal insufficency. Appreciate endocrine recommendations. Halved\n dose today.\n - hydrocortt (day 1 = ), wean per endo recs\n # Volume overloaded in setting of hypernatremia with TBW deficit.\n - Lasix gtt, continue with goal -1-2 L per day.\n - electrolytes\n - continue tube feeds with free water flushes 250 cc q4\n # Sedation: Sedation control remains somewhat poor although fentanyl\n patch and diazpem are likely therapeutic range today. On Versed 2.0,\n Fentanyl 100, Fentanyl patch, Diazepam standing and haldo 2.5-5 mg\n PRN. QTc increased to 480.\n - Wean versed/fentanyl as tolerated, continue diazepam. Avoid haldol\n use if possible to avoid further prolongation of QTc\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\n coumadin at least until s/p trach.\n - heparin gtt restarted\n - coumadin 5mg G-tube today\n # Constipation\n current regimen of colace and senna, no BM over last\n 24 hours\n - dulcolax PO/PR today\n - reassess and increase bowel regimen PRN\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n -f/u full trauma spine eval from OSH to determine need for further back\n imaging in-house (to be done )\n # Nutrition: Tube feeds with free water flushes, tolerating well,\n continue Replete (Full) - 11:20 AM 30 mL/hour\n # Glycemic control: SSI, well controlled\n # Lines L PICC () and R ART ()\n both working well, mainitain\n # Ppx: heparin, ranitidine, VAP prevention, colace and senna\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n Code: Full\n Dispo: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Arterial Line - 02:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nutrition",
"chartdate": "2167-10-05 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 635848,
"text": "Subjective\n Patient intubated\n Objective\n Pertinent medications: fentanyl, versed, lasix gtt\n Labs:\n Value\n Date\n Glucose\n 128 mg/dL\n 02:47 AM\n Glucose Finger Stick\n 134\n 04:00 AM\n BUN\n 8 mg/dL\n 02:47 AM\n Creatinine\n 0.6 mg/dL\n 02:47 AM\n Sodium\n 148 mEq/L\n 02:47 AM\n Potassium\n 3.1 mEq/L\n 02:47 AM\n Chloride\n 110 mEq/L\n 02:47 AM\n TCO2\n 28 mEq/L\n 02:47 AM\n Albumin\n 2.4 g/dL\n 03:59 AM\n Calcium non-ionized\n 9.0 mg/dL\n 02:47 AM\n Phosphorus\n 4.3 mg/dL\n 02:47 AM\n Ionized Calcium\n 1.17 mmol/L\n 03:32 PM\n Magnesium\n 2.6 mg/dL\n 02:47 AM\n Current diet order / nutrition support: Replete with Fiber at 60ml/hr x\n 24 hours - provides 1440kcal and 89g protein\n GI: Abdomen soft/distended with positive bowel sounds\n Assessment of Nutritional Status\n Specifics:\n 55 year old female s/p fall with t-spine fracture now with pneumonia\n and ARDS requiring intubation now s/p trach/PEG placement. Patient is\n tolerating tube feedings well with residuals of 10 and 35ml noted.\n Would continue with tube feedings as ordered.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. Continue to provide patient with Replete with Fiber at 60ml/hr\n x 24 hours\n 2. Monitor residuals q4H and hold tube feedings if >150ml\n 08:14\n"
},
{
"category": "Physician ",
"chartdate": "2167-09-29 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 635091,
"text": "Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - STOP 09:00 PM - attempted to re-wire but\n patient was very agitated and re-wire was unsuccessful\n Patient alternated between tachycardia and normotension and hypotension\n in the high-80s/low 90s and HRs in the 50s\n Given haldol, valium, midaz and fentanyl for sedation\n ABG with low paO2 on PEEP 10, had to increase -- went back up to 15 and\n then attempted to re-wean down with goal 8 in anticipation of OR\n To OR for trach and PEG today (thoracics)\n Put on lasix drip and put out >1L in just over an hour\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 08:06 AM\n Infusions:\n Midazolam (Versed) - 1.5 mg/hour\n Fentanyl - 200 mcg/hour\n Other ICU medications:\n Fentanyl - 06:45 PM\n Ranitidine (Prophylaxis) - 08:00 PM\n Haloperidol (Haldol) - 10:00 PM\n Midazolam (Versed) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.7\nC (99.8\n HR: 109 (55 - 134) bpm\n BP: 120/56(70) {80/43(51) - 133/85(94)} mmHg\n RR: 20 (16 - 28) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 101 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 3,064 mL\n 404 mL\n PO:\n TF:\n 1,440 mL\n IVF:\n 1,014 mL\n 314 mL\n Blood products:\n Total out:\n 4,257 mL\n 1,195 mL\n Urine:\n 4,257 mL\n 1,195 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,193 mL\n -791 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 18\n RR (Spontaneous): 10\n PEEP: 15 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10\n PIP: 23 cmH2O\n Plateau: 24 cmH2O\n SpO2: 97%\n ABG: 7.46/48/65/31/8 @ 10:20 PM\n Ve: 7.8 L/min\n PaO2 / FiO2: 108\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 320 K/uL\n 8.0 g/dL\n 94 mg/dL\n 0.6 mg/dL\n 31 mEq/L\n 3.6 mEq/L\n 13 mg/dL\n 110 mEq/L\n 147 mEq/L\n 25.8 %\n 9.0 K/uL\n [image002.jpg]\n 10:18 AM\n 02:33 PM\n 02:46 PM\n 03:31 AM\n 02:26 PM\n 05:53 PM\n 05:01 AM\n 03:32 PM\n 10:19 PM\n 02:50 AM\n WBC\n 9.7\n 9.5\n 9.0\n Hct\n 26.0\n 27.6\n 25.8\n Plt\n \n Cr\n 0.5\n 0.5\n 0.5\n 0.6\n 0.6\n TCO2\n 29\n 26\n 27\n 30\n 30\n 35\n Glucose\n 195\n 195\n 163\n 133\n 102\n 94\n Other labs: PT / PTT / INR:14.1/59.6/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:71.2 %, Lymph:22.7 %,\n Mono:4.0 %, Eos:1.7 %, Lactic Acid:1.5 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:8.2 mg/dL, Mg++:2.1 mg/dL, PO4:4.6 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with respiratory failure\n and difficulty weaning from vent.\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation.\n Transferred here for tracheomalacia, but not sure this is a component.\n Will need bronch eval when improved\n - Thoracics will do trach and PEG once stable on PEEPs around 10. Had\n been planned for today but currently holding as PEEP is 15.\n - wean PEEP as tolerated\n - needs A-line\n # Volume overload\n Currently with hypernatremia, Cr increase, contract\n alk, but mild\n - continue gentle diuresis with goal -1L per day as tolerated by blood\n pressure. IV lasix drip at 1-5 mg/hr.\n - FW in TF at 150 cc q4hrs\n - PM lytes.\n # Sedation: Now well seadated on Versed 1.5, Fentanyl 175, Fentanyl\n patch, Diazepam standing and haldo 2.5-5 mg PRN. QTc stable at .44\n - Wean versed/fentanyl as tolerated\n # HCT\n Has had slow decline while in ICU.\n - Xfuse PRN Hct < 21\n - continue to follow, guiac stools\n # Hypotension: Related to sedation, but high PEEP, adrenial\n insufficiency, sepsis have previously been contributing.\n - needs A-line for monitoring\n - cortisol stim to rule out persistent adrenal insufficiency\n # RUE DVT: Started on heparin gtt on , now off for trach that was\n planned for today. Follow PTTs. Would hold off on coumadin at least\n until s/p trach.\n - restart heparin\n # Adrenal Insufficency: Random cortisol was approx 3 when it should\n have been maximally stimulated. S/P 5 days of hydrocortisone and\n florinef.\n - will recheck as above and start at 50 q8 if needed\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n FEN/GI: Tube feeds @ goal. No need to be NPO while awaiting stable\n PEEP\n DVT: Treatment dose heparin\n Ulcer: Ranitidine\n VAP: Prevention per routine\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nutrition",
"chartdate": "2167-09-29 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 635093,
"text": "Objective\n Pertinent medications: noted\n Labs:\n Value\n Date\n Glucose\n 94 mg/dL\n 02:50 AM\n Glucose Finger Stick\n 98, 101\n \n BUN\n 13 mg/dL\n 02:50 AM\n Creatinine\n 0.6 mg/dL\n 02:50 AM\n Sodium\n 147 mEq/L\n 02:50 AM\n Potassium\n 3.6 mEq/L\n 02:50 AM\n Chloride\n 110 mEq/L\n 02:50 AM\n TCO2\n 31 mEq/L\n 02:50 AM\n Albumin\n 2.4 g/dL\n 03:59 AM\n Calcium non-ionized\n 8.2 mg/dL\n 02:50 AM\n Phosphorus\n 4.6 mg/dL\n 02:50 AM\n Ionized Calcium\n 1.17 mmol/L\n 03:32 PM\n Magnesium\n 2.1 mg/dL\n 02:50 AM\n Current diet order / nutrition support: Replte c/ Fiber @60mL/hr (1440\n kcals/89 gr aa)\n GI: Abd soft/+bs/+bm\n Assessment of Nutritional Status\n Estimation of current intake: Adequate\n Specifics:\n Pt continues on TF\ns for full nutrition support. TF\ns well tolerated @\n goal, meeting 100% estimated needs. They were opn hold last night as\n plan was for trach and PEG today, but not done 2/2 PEEP to high. PT on\n lasix gtt for diuresis. Na trending up daily, today is 147. need\n to increase FWB if level continues to increase.\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: via TF\n Tube feeding recommendations: Continue current TF's @ goal\n Adjust FWB prn c/ diuresis\n Will follow- page c/ ?\ns #\n"
},
{
"category": "Physician ",
"chartdate": "2167-09-30 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 635225,
"text": "Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - START 02:00 PM - in right brachial atery\n Hypotensive- started on levophed, weaned off over night\n Low cortisol and failed stim test - started on steroids\n TTE ordered\n Free water flushes were increased for hypernatremia (250cc q4)\n Able to hear patient breathing at times during exam this am (poor am\n CXR, reordered)\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 08:06 AM\n Infusions:\n Heparin Sodium - 1,700 units/hour\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 150 mcg/hour\n Other ICU medications:\n Haloperidol (Haldol) - 12:15 AM\n Other medications:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 36.7\nC (98\n HR: 63 (48 - 138) bpm\n BP: 91/41(58) {68/30(49) - 143/78(105)} mmHg\n RR: 18 (13 - 23) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Mixed Venous O2% Sat: 59 - 59\n Total In:\n 3,898 mL\n 1,155 mL\n PO:\n TF:\n 802 mL\n 348 mL\n IVF:\n 2,126 mL\n 247 mL\n Blood products:\n Total out:\n 2,367 mL\n 800 mL\n Urine:\n 2,367 mL\n 800 mL\n NG:\n Stool:\n ?\n ?\n Drains:\n Balance:\n 1,531 mL\n 355 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 401) mL\n RR (Set): 18\n RR (Spontaneous): 1\n PEEP: 10 cmH2O\n FiO2: 40%\n PIP: 23 cmH2O\n Plateau: 19 cmH2O\n Compliance: 57.1 cmH2O/mL\n SpO2: 91%\n ABG: 7.42/49/93/33/5\n Ve: 8.1 L/min\n PaO2 / FiO2: 155\n Physical Examination\n General Appearance: Easily agitated, appears uncomfortable, Overweight\n / Obese, opens eyes but no purposeful movement\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\n deviation\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Respiratory / Chest: (Expansion: Symmetric), referred breath sounds\n from ETT\n Abdominal: No(t) Soft, Non-tender, Few Bowel sounds present, Distended\n Extremities: No clubbing or cyanosis, 3+ nonpitting edema of b/l hands,\n anasarca\n Skin: no rashes or jaundice\n Neuro: diffusely hyperreflexic with LE clonus\n Lines: r brachioceph ART and L PICC C/D/I\n Labs / Radiology\n 355 K/uL\n 9.1 g/dL\n 168 mg/dL\n 0.5 mg/dL\n 30 mEq/L\n 3.9 mEq/L\n 11 mg/dL\n 108 mEq/L\n 146 mEq/L\n 29.9 %\n 11.8 K/uL\n [image002.jpg]\n 03:32 PM\n 10:19 PM\n 02:50 AM\n 02:30 PM\n 02:44 PM\n 03:33 PM\n 07:26 PM\n 07:46 PM\n 02:04 AM\n 02:18 AM\n WBC\n 9.0\n 8.4\n 11.8\n Hct\n 25.8\n 23.0\n 28.1\n 29.9\n Plt\n \n Cr\n 0.6\n 0.7\n 0.5\n TCO2\n 30\n 35\n 33\n 31\n 33\n Glucose\n 94\n 97\n 168\n Other labs: PT / PTT / INR:13.8/70.4/1.2, Differential-Neuts:89.7 %,\n Lymph:8.7 %, Mono:1.1 %, Eos:0.4 %, Ca++:8.5 mg/dL, Mg++:2.2 mg/dL,\n PO4:5.4 mg/dL\n TSH 2.9; FT4 1.5; stim 3.1, 10.5, 10.6\n Culture Data: endotrach with K oxytoca; gram stain GPCs in\n pairs and clusters\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA and\n ARDS intubated since the end of .\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation.\n Transferred here for airway stenting. Will need bronch eval when\n improved.\n - Thoracics will do trach and PEG once stable on PEEPs around 10.\n Re-c/s today.\n - wean PEEP as tolerated\n # # Adrenal Insufficency: Minimal response to stim test again.\n - hydrocort and fludrocort (day 1 = )\n - endocrine c/s for further elucidation of etiology\n # Hypotension: Likely adrenal insufficiency. Goal map > 60.\n - hydrocortisol and fludrocortisone as above\n - restart levophed if necessary to maintain MAP > 60\n # Volume overloaded in setting of hypernatremia (? Relationship to\n adrenal insufficiency), TBW deficit 2.6L.\n - goal even to -500cc I/Os today\n - continue FW in TF at 250 cc q4hrs\n - lasix drip (1-5mg/hr) when MAP > 60\n # Hyperreflexia - ? meds vs central pathology. Unlikely to be \n intracranial hemorrhage as patient is diffusely hyperreflexic.\n Possible relationship to endocrine pathology?\n - consider head CT in setting of heparin gtt\n - monitor\n # Sedation: Sedation control remains somewhat poor although fentanyl\n patch and diazpem are likely starting increase to therapeutic range\n today. On Versed 1.5, Fentanyl 175, Fentanyl patch, Diazepam standing\n and haldo 2.5-5 mg PRN. QTc stable at .44.\n - Wean versed/fentanyl as tolerated, continue diazepam and prn\n haldol\n - Recheck EKG today\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\n coumadin at least until s/p trach.\n - hold heparin gtt when anticipate trach/peg\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n # FEN/GI: Tube feeds @ goal.\n DVT: Treatment dose heparin\n Ulcer: Ranitidine\n VAP: Prevention per routine\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 09:51 PM 60 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Arterial Line - 02:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "General",
"chartdate": "2167-10-01 00:00:00.000",
"description": "Generic Note",
"row_id": 635300,
"text": "55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP now with prolonged\n hospital course c/o by PNA anxiety,RUE DVD with high PEEP requirement\n .\n Events\n Heparin gtt and TF held since MN for ? trach and peg\n placement today.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on AC 400/18/8/50%. 02 sats mainly 88-92% but did fall to\n 86% when pt positioned on L side. Pt fluid overloaded with TFB for LOS\n ~ ccs.\n Action:\n ABG taken while sat 88%. Lasix gtt increased to 3mg/hr\n Response:\n ABG 7.42/47/87/4/32. Urine output initially 25 ccs/hr but pt began\n autodiuresing after MN with output improving to ~140ccs/hr\n Plan:\n Continue with current vent settings. Trach today. Titrate lasix gtt to\n maintain MAP > 60 and u/o 100-150ccs/hr.\n Altered mental status (not Delirium)\n Assessment:\n Pt restless at times, thrashing in bed with HR up to 140 ST . Denies\n pain or doesn\nt respond when questioned if she is having pain.\n Action:\n Fentanyl drip infusing at 100mcgs/hr. Fentanyl patch in place. Also\n treated with haldol and valium . Bolused with 2 mg versed when acutely\n agitated. Bilateral wrist restraints in place.\n Response:\n Pt falls back to sleep, HR decreases (occasionally as low as 45 SB)\n Plan:\n Continue to assess MS. as indicated. Reorientation. Restraints\n for safety.\n Hypernatremia (high sodium)\n Assessment:\n Na 146 on \n Action:\n Treated with free h20 boluses\n Response:\n Na 143 this am\n Plan:\n Continue to monitor f+e status.\n Impaired Skin Integrity\n Assessment:\n Pt with excoriated yeast infection on abd and in perineal area. +\n reddened perirectal area.\n Action:\n Barrier cream and miconazole powder applied\n Response:\n To be determined.\n Plan:\n Diligent skin care.\n"
},
{
"category": "Respiratory ",
"chartdate": "2167-09-30 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 635162,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 12\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Pt remains stable on current support. When pt is placed on\n \"sides\" (pillows) of her back by RN, she tends to desaturate and is\n intolerant of weaning attempts\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Reduce PEEP as tolerated, Adjust Min. ventilation to\n control pH, Tracheostomy planned; Comments: Pt is stable on current\n vent settings, but SpO2 is too sensitive to weaning attempts of FiO2 or\n PEEP\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts; Comments: Although Work of breathing and RR are\n without fault, pt desaturates with weaning attempts.\n"
},
{
"category": "Physician ",
"chartdate": "2167-09-20 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 634163,
"text": "Chief Complaint: respiratory failure\n HPI:\n 24 Hour Events:\n PICC LINE - START 10:30 PM\n INVASIVE VENTILATION - START 10:45 PM\n EKG - At 11:25 PM\n BLOOD CULTURED - At 05:30 AM\n TMax 102.7 BCX1 drawn\n FEVER - 102.7\nF - 04:00 AM\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Metronidazole - 08:00 AM\n Infusions:\n Fentanyl - 75 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.3\nC (102.7\n Tcurrent: 37.2\nC (99\n HR: 88 (72 - 97) bpm\n BP: 110/55(64) {83/38(48) - 154/71(103)} mmHg\n RR: 14 (12 - 18) insp/min\n SpO2: 100%\n Total In:\n 10 mL\n 1,043 mL\n PO:\n TF:\n 54 mL\n IVF:\n 10 mL\n 988 mL\n Blood products:\n Total out:\n 425 mL\n 585 mL\n Urine:\n 425 mL\n 585 mL\n NG:\n Stool:\n Drains:\n Balance:\n -416 mL\n 458 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 32 cmH2O\n SpO2: 100%\n ABG: 7.39/53/81./30/5\n Ve: 8 L/min\n PaO2 / FiO2: 135\n Physical Examination\n Labs / Radiology\n 9.7 g/dL\n 333 K/uL\n 103 mg/dL\n 0.6 mg/dL\n 30 mEq/L\n 3.8 mEq/L\n 6 mg/dL\n 109 mEq/L\n 150 mEq/L\n 30.7 %\n 9.7 K/uL\n [image002.jpg]\n 11:54 PM\n 01:00 AM\n 06:14 AM\n WBC\n 9.7\n Hct\n 30.7\n Plt\n 333\n Cr\n 0.6\n TCO2\n 32\n 33\n Glucose\n 103\n Other labs: PT / PTT / INR:13.8/22.4/1.2, ALT / AST:30/19, Alk Phos / T\n Bili:149/0.7, Differential-Neuts:76.9 %, Lymph:17.3 %, Mono:3.0 %,\n Eos:2.5 %, Albumin:3.0 g/dL, LDH:222 IU/L, Ca++:8.6 mg/dL, Mg++:2.1\n mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n Obese woman s/p t spine injury tx from Med for failure to wean\n from mech ventilation and evaluation for stent for\n tracheobronchomalacia\n 1. Resp Failure: initial etiology unclear\n but currently\n we need to assess what she can do here. Switch to PSV 10/5 and see what\n she can pull, check NIF. not act on this info. Let IP know she is\n here though not stable for intervention at this point.\n 2. New fevers and hypotension\n Is fluid responsive, watch\n UOP, goal 30 cc/hr. Check lactate.\n DDx VAP, asp PNA, lines. Has PCN and blactam allergy.\n For VAP- mini , change to Levoquin, Aztreonam, Vanco, and add\n Flagyl for asp.\n Lines: D/C PICC send cultures, try for 2nd PIV and if unable will\n place CVL. Check lactate.\n Belly: repeat LFTs, KUB OK, check residuals.\n 3. HyperNa: correcting with g tube free flush and D5W\n repeat lytes this evening and recalculate\n 4. Spine Fx: consult NSurg here re reccs for back bracing and\n activity\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 03:30 AM 10 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 10:30 PM\n 20 Gauge - 01:36 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition :\n Total time spent:\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2167-09-20 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 634166,
"text": "Chief Complaint: respiratory failure\n HPI: 55 yr old woman s/p t soine injury from Med with difficulty\n vent weaning ? tbmalacia requiring stent\n Hour Events:\n PICC LINE - START 10:30 PM\n INVASIVE VENTILATION - START 10:45 PM\n EKG - At 11:25 PM\n BLOOD CULTURED - At 05:30 AM\n TMax 102.7 BCX1 drawn\n FEVER - 102.7\nF - 04:00 AM\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Metronidazole - 08:00 AM\n Infusions:\n Fentanyl - 75 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.3\nC (102.7\n Tcurrent: 37.2\nC (99\n HR: 88 (72 - 97) bpm\n BP: 110/55(64) {83/38(48) - 154/71(103)} mmHg\n RR: 14 (12 - 18) insp/min\n SpO2: 100%\n Total In:\n 10 mL\n 1,043 mL\n PO:\n TF:\n 54 mL\n IVF:\n 10 mL\n 988 mL\n Blood products:\n Total out:\n 425 mL\n 585 mL\n Urine:\n 425 mL\n 585 mL\n NG:\n Stool:\n Drains:\n Balance:\n -416 mL\n 458 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 32 cmH2O\n SpO2: 100%\n ABG: 7.39/53/81./30/5\n Ve: 8 L/min\n PaO2 / FiO2: 135\n Physical Examination\n Gen: intubated and sedated\n CV: RR\n Chest: fair air movement\n Abd: obese soft NT+BS\n Ext RUEgreater than LUE edema\n Labs / Radiology\n 9.7 g/dL\n 333 K/uL\n 103 mg/dL\n 0.6 mg/dL\n 30 mEq/L\n 3.8 mEq/L\n 6 mg/dL\n 109 mEq/L\n 150 mEq/L\n 30.7 %\n 9.7 K/uL\n [image002.jpg]\n 11:54 PM\n 01:00 AM\n 06:14 AM\n WBC\n 9.7\n Hct\n 30.7\n Plt\n 333\n Cr\n 0.6\n TCO2\n 32\n 33\n Glucose\n 103\n Other labs: PT / PTT / INR:13.8/22.4/1.2, ALT / AST:30/19, Alk Phos / T\n Bili:149/0.7, Differential-Neuts:76.9 %, Lymph:17.3 %, Mono:3.0 %,\n Eos:2.5 %, Albumin:3.0 g/dL, LDH:222 IU/L, Ca++:8.6 mg/dL, Mg++:2.1\n mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n Obese woman s/p t spine injury tx from Med for failure to wean\n from mech ventilation and evaluation for stent for\n tracheobronchomalacia\n 1. Resp Failure: initial etiology unclear\n but we need to\n assess current mechanics and reserve. Switch to PSV 10/5 and see what\n she can pull, check NIF. not act on this info in light of issue\n sbelow but important for us to understand. Let IP know she is here\n though not stable for intervention at this point.\n 2. New fevers and transient hypotension\n Is fluid\n responsive, watch UOP, goal 30 cc/hr.\n DDx VAP, asp PNA, lines. Has PCN and blactam allergy.\n For VAP- mini , change to Levoquin, Aztreonam, Vanco, and add\n Flagyl for asp.\n Lines: D/C PICC send cultures, try for 2nd PIV and if unable will\n place CVL. Check lactate.\n Belly: repeat LFTs, KUB OK, check residuals.\n 3. HyperNa: correcting with g tube free flush and D5W\n repeat lytes this evening and recalculate\n 4. Spine Fx: consult NSurg here re reccs for back bracing and\n activity\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 03:30 AM 10 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 10:30 PM\n 20 Gauge - 01:36 AM\n Prophylaxis:\n DVT: SC hep\n Stress ulcer: Zantac\n VAP: chlorhex HOB daily wake ups\n Comments:\n Communication: boyfriend is proxy not the brother but need to clarify\n paperwork.\n Code status: FULL\n Disposition :ICU\n Total time spent: 45\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2167-09-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 634282,
"text": "55-year-old woman with\n Respiratory failure\n Traumatic thoracic spinal fractures\n Probable VAP\n Upper extremity DVT\n Oliguria\n Anemia\n * Possible tracheobronchomalacia (reason for transfer from OSH)\n Alteration in Nutrition\n Assessment:\n Pt NPO, Pt w/ high residuals yesterday. Abdomen distended/obese/soft.\n BS hypoactive. Low albumin.\n Action:\n OGT to low wall suction. TF off.\n Response:\n Small amount of gastric fluid suctioned- approx 30cc-50cc.\n Plan:\n Plan for CT of Abdomen, cont NPO at this time.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n RUE + DVT\n Action:\n Cont on sq heparin\n Response:\n No change\n Plan:\n Consult neuro-surgery regarding anti-coagulation w/ T-spine fx, elevate\n RUE, no blood draws or blood pressures to RUE.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Temp max 100\n Action:\n Antibiotics given and dosage changed to vanco and aztreonam.\n Response:\n No further temp spike.\n Plan:\n Cont w/ antibiotics, f/u on cultures, tyelenol prn, vanco trough to be\n drawn prior to evening dose.\n Fracture, other\n Assessment:\n T-spine compression fx, Back brace at bedside when OOB.\n Action:\n Ortho tech consulted for placement of back brace. Cont w/ log roll\n precautions.\n Response:\n Pt denies c/o pain when asked.\n Plan:\n Cont w/ log roll precautions, back brace for OOB, CT scan, consult w/\n neurosurg.\n Anemia, other\n Assessment:\n HCT 24.1 from 28\n Action:\n Given 1 unit of PRBCs\n Response:\n HCT to be drawn.\n Plan:\n Cont to follow HCTs, guiac stools, monitor of s/s of bleeding.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS- bronchial throughout, deep sxn\nd for thick/tan secretions, copious\n clear oral secretions suctioned, PO2 68% on 70% FIO2 and 12 peep. ?\n PE/? VAP.\n Action:\n Vent changes made throughout shift.\n Response:\n Plan:\n Esophageal balloon placement to be performed, monitor ABGs, vent\n changes as needed.\n Hypotension (not Shock)\n Assessment:\n Pt hypotensive into low-mid 80s systolic, HR 70s-90s. Low uop-\n BUN/Creat negative. Bladder pressure 18-20.\n Action:\n Vigeleo set up, given 1 unit of blood, bloused x 1, multi-lumen RIJ\n placed at bedside.\n Response:\n No response to blusing, SBP improved following blood transfusion, RIJ\n okay to use. CVP 18.\n Plan:\n Levophed to be started if needed, transfuse as needed.\n"
},
{
"category": "Nursing",
"chartdate": "2167-09-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 634283,
"text": "55-year-old woman with\n Respiratory failure\n Traumatic thoracic spinal fractures\n Probable VAP\n Upper extremity DVT\n Oliguria\n Anemia\n * Possible tracheobronchomalacia (reason for transfer from OSH)\n Events:\n Alteration in Nutrition\n Assessment:\n Pt NPO, Pt w/ high residuals yesterday. Abdomen distended/obese/soft.\n BS hypoactive. Low albumin.\n Action:\n OGT to low wall suction. TF off.\n Response:\n Small amount of gastric fluid suctioned- approx 30cc-50cc.\n Plan:\n Plan for CT of Abdomen, cont NPO at this time.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n RUE + DVT\n Action:\n Cont on sq heparin\n Response:\n No change\n Plan:\n Consult neuro-surgery regarding anti-coagulation w/ T-spine fx, elevate\n RUE, no blood draws or blood pressures to RUE.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Temp max 100\n Action:\n Antibiotics given and dosage changed to vanco and aztreonam.\n Response:\n No further temp spike.\n Plan:\n Cont w/ antibiotics, f/u on cultures, tyelenol prn, vanco trough to be\n drawn prior to evening dose.\n Fracture, other\n Assessment:\n T-spine compression fx, Back brace at bedside when OOB.\n Action:\n Ortho tech consulted for placement of back brace. Cont w/ log roll\n precautions.\n Response:\n Pt denies c/o pain when asked.\n Plan:\n Cont w/ log roll precautions, back brace for OOB, CT scan, consult w/\n neurosurg.\n Anemia, other\n Assessment:\n HCT 24.1 from 28\n Action:\n Given 1 unit of PRBCs\n Response:\n HCT to be drawn.\n Plan:\n Cont to follow HCTs, guiac stools, monitor of s/s of bleeding.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS- bronchial throughout, deep sxn\nd for thick/tan secretions, copious\n clear oral secretions suctioned, PO2 68% on 70% FIO2 and 12 peep. ?\n PE/? VAP.\n Action:\n Vent changes made throughout shift.\n Response:\n Plan:\n Esophageal balloon placement to be performed, monitor ABGs, vent\n changes as needed.\n Hypotension (not Shock)\n Assessment:\n Pt hypotensive into low-mid 80s systolic, HR 70s-90s. Low uop-\n BUN/Creat negative. Bladder pressure 18-20.\n Action:\n Vigeleo set up, given 1 unit of blood, bloused x 1, multi-lumen RIJ\n placed at bedside.\n Response:\n No response to blusing, SBP improved following blood transfusion, RIJ\n okay to use. CVP 18.\n Plan:\n Levophed to be started if needed, transfuse as needed.\n"
},
{
"category": "Nursing",
"chartdate": "2167-09-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 634365,
"text": "Alteration in Nutrition\n Assessment:\n TF d/c\nd d/t high residuals; abd soft, mod distended; hypoactive\n BSx4; abd CT without evidence of obstruction\n Action:\n Sedation weaned down; TF restarted; bowel regimen w/reglan\nsoap suds\n enema and fleet enema given; begun naloxone for Gi motility\n Response:\n Tol TF; sm amt stool w/enemas; stool for c-diff\n Plan:\n Monitor bowel status; do not advance TF beyond 10cc/hr. Cont with bowel\n meds; place rectal tube for decompression\n Hypotension (not Shock)\n Assessment:\n Bp improved with MAP >65 and SBP >90\n Action:\n Levophed weaned off\n Response:\n Adequate Bp off pressor\n Plan:\n Cont to monitor BP; restart levophed prn\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Bil effusions L>R, RLL consolidation. Tol ACV\n Action:\n Esophageal balloon placed; bladder pressure elevated; increased PEEP;\n freq suctioning\n Response:\n Tol elevated PEEP and freq position changes\n Plan:\n Cont to monitor resp status and titrate vent settings accordingly.\n Suction prn. Await further micro data.\n Fracture, other\n Assessment:\n Logrolling; reverse tredelenberg pnd clarification of spinal fx\n Action:\n Spine/ortho consult-off logrolling prec. HoB>30\n Response:\n Tol position changes\n Plan:\n Activity as tol; needs to wear TLSO brace when OOB or sitting up for T8\n compression fx\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n DVT RUE-3+ edema\n Action:\n Awaiting clearance for heparin gtt from /spine service\n Response:\n Cleared for heparin gtt\n Plan:\n Awaiting further orders from MICU team\n"
},
{
"category": "Respiratory ",
"chartdate": "2167-09-22 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 634367,
"text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 4\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location: Outside hospital\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Utilize ARDSnet protocol\n Reason for continuing current ventilatory support: Hemodynimic\n instability, Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Pleural pressure measurement (1330hrs)\n Comments: Approximate time\n, RRT 17:21\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 635825,
"text": "55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\n Now with prolonged hospital course c/b by PNA with high PEEP\n requirement, anxiety, RUE DVT on heparin qtt.\n Edema, peripheral\n Assessment:\n Fluid balance for previous 24hrs decreased by 3 liters D/T diuresis.\n Rec\nd pt off of Lasix qtt. Urine output decreased to 45ml/hr @1000.\n Action:\n Lasix qtt restarted @ 2mg/hr to maintain urine output 1-2liters/day.\n Response:\n Fluid balance approx -50ml/hr, with 24hr fluid balance -650ml @ 1500.\n However, SBP 78 when pt soundly sleeping/sedated. Lasix qtt stopped @\n 1530.\n Plan:\n Restart Lasix qtt when BP stabilized.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Rec\nd pt on Heparin qtt @ 1500units/hr.\n Action:\n PTT 62,2 @ 0230.\n Response:\n Heparin rate unchanged.pt had 2 therapeutic PTT,started on coumadin\n 5mg at 2200,.\n Plan:\n Cont heparin gtt as well as Coumadin until INR ^ 2.\n Altered mental status (not Delirium)\n Assessment:\n Rec\nd pt on Versed @ 2mg/hr, Fentanyl @ 75 mcg/hr, as well as Fentanyl\n patches totaling 150mcg in place. Pt also rec\ning Diazepam 10mg po\n Q6hrs, in hope of weaning pt from IV sedation. Agitated most time\n moving around intermittently following commands. Moving arms\n purposefully towards trach, so soft wrist restraints remain in place..\n Action:\n Pt required bolus sedation x2 with care and activity.\n Response:\n Pt restless/squirming in bed when she appears awake..\n Plan:\n Cont to attempt weaning from IV sedation. emotional support to pt and\n family,reorient pt .\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt on vent settings AC 50%/18 X 400/+10, no over-breathing of\n rate . O2 sats 94-96%. ABG done yesterday was 7.44/42/93. Lung sounds\n clear but diminished in lower lobes. Suctioned for small-moderate amts\n thick white secretions.\n Action:\n Cont same Vent settings.Getting breathing rx by respitory\n Response:\n Pts secretions got better\n Plan:\n Cont wean from vent with PS trials,Monitor mental status.\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 635826,
"text": "55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\n Now with prolonged hospital course c/b by PNA with high PEEP\n requirement, anxiety, RUE DVT on heparin qtt.\n Edema, peripheral\n Assessment:\n Rec\nd pt on 2mg/hr lasix gtt\n Action:\n Pt putting out 400-500cc/hr.\n Response:\n Fluid balance approx -50ml/hr, with 24hr fluid balance -650ml @ 1500.\n However, SBP 78 when pt soundly sleeping/sedated. Lasix qtt stopped @\n 1530.\n Plan:\n Cont Lasix gtt goal Negative 1-2L,monitor BPclosely\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Rec\nd pt on Heparin qtt @ 1500units/hr.\n Action:\n PTT 62,2 @ 0230.\n Response:\n Heparin rate unchanged.pt had 2 therapeutic PTT,started on coumadin\n 5mg at 2200,.\n Plan:\n Cont heparin gtt as well as Coumadin until INR ^ 2.\n Altered mental status (not Delirium)\n Assessment:\n Rec\nd pt on Versed @ 2mg/hr, Fentanyl @ 75 mcg/hr, as well as Fentanyl\n patches totaling 150mcg in place. Pt also rec\ning Diazepam 10mg po\n Q6hrs, in hope of weaning pt from IV sedation. Agitated most time\n moving around intermittently following commands. Moving arms\n purposefully towards trach, so soft wrist restraints remain in place..\n Action:\n Pt required bolus sedation x2 with care and activity.\n Response:\n Pt restless/squirming in bed when she appears awake..\n Plan:\n Cont to attempt weaning from IV sedation. emotional support to pt and\n family,reorient pt .\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt on vent settings AC 50%/18 X 400/+10, no over-breathing of\n rate . O2 sats 94-96%. ABG done yesterday was 7.44/42/93. Lung sounds\n clear but diminished in lower lobes. Suctioned for small-moderate amts\n thick white secretions.\n Action:\n Cont same Vent settings.Getting breathing rx by respitory\n Response:\n Pts secretions got better\n Plan:\n Cont wean from vent with PS trials,Monitor mental status.\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 635834,
"text": "55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\n Now with prolonged hospital course c/b by PNA with high PEEP\n requirement, anxiety, RUE DVT on heparin qtt.\n Edema, peripheral\n Assessment:\n Rec\nd pt on 2mg/hr lasix gtt\n Action:\n Pt putting out 400-500cc/hr.K was 3.1 this morning.\n Response:\n Pt still putting out 400-500cc.hr,BP stayed stable.K repleted w/total\n of 80 Meq\n Plan:\n Cont Lasix gtt goal Negative 1-2L,monitor BPclosely\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Rec\nd pt on Heparin qtt @ 1500units/hr.\n Action:\n PTT 62,2 @ 0230.\n Response:\n Heparin rate unchanged two therapeutic PTT level,started on\n coumadin 5mg yesterday at 2200,.\n Plan:\n Cont heparin gtt as well as Coumadin until INR ^ 2.\n Altered mental status (not Delirium)\n Assessment:\n Rec\nd pt on Versed @ 2mg/hr, Fentanyl @ 75 mcg/hr, as well as Fentanyl\n patches totaling 150mcg in place. Pt also rec\ning Diazepam 10mg po\n Q6hrs, in hope of weaning pt from IV sedation. Agitated most time\n moving around intermittently following commands. Moving arms\n purposefully towards trach, so soft wrist restraints remain in place..\n Action:\n Pt required bolus sedation x2 with care and activity.\n Response:\n Pt restless/squirming in bed when she appears awake..\n Plan:\n Cont to attempt weaning from IV sedation. emotional support to pt and\n family,reorient pt .\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt on vent settings AC 50%/18 X 400/+10, no over-breathing of\n rate . O2 sats 94-96%. ABG done yesterday was 7.44/42/93. Lung sounds\n clear but diminished in lower lobes. Suctioned for small-moderate amts\n thick white secretions.\n Action:\n Cont same Vent settings.Getting breathing rx by respitory\n Response:\n Pts secretions got better\n Plan:\n Cont wean from vent with PS trials,Monitor mental status.\n"
},
{
"category": "Physician ",
"chartdate": "2167-09-29 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 635063,
"text": "Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - STOP 09:00 PM - attempted to re-wire but\n patient was very agitated and re-wire was unsuccessful\n Patient alternated between tachycardia and normotension and hypotension\n in the high-80s/low 90s and HRs in the 50s\n Given haldol, valium, midaz and fentanyl for sedation\n ABG with low paO2 on PEEP 10, had to increase -- went back up to 15 and\n then attempted to re-wean down with goal 8 in anticipation of OR\n To OR for trach and PEG today (thoracics)\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 08:06 AM\n Infusions:\n Midazolam (Versed) - 1.5 mg/hour\n Fentanyl - 200 mcg/hour\n Other ICU medications:\n Fentanyl - 06:45 PM\n Ranitidine (Prophylaxis) - 08:00 PM\n Haloperidol (Haldol) - 10:00 PM\n Midazolam (Versed) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.7\nC (99.8\n HR: 109 (55 - 134) bpm\n BP: 120/56(70) {80/43(51) - 133/85(94)} mmHg\n RR: 20 (16 - 28) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 101 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 3,064 mL\n 404 mL\n PO:\n TF:\n 1,440 mL\n IVF:\n 1,014 mL\n 314 mL\n Blood products:\n Total out:\n 4,257 mL\n 1,195 mL\n Urine:\n 4,257 mL\n 1,195 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,193 mL\n -791 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 18\n RR (Spontaneous): 10\n PEEP: 15 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10\n PIP: 23 cmH2O\n Plateau: 24 cmH2O\n SpO2: 97%\n ABG: 7.46/48/65/31/8\n Ve: 7.8 L/min\n PaO2 / FiO2: 108\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 320 K/uL\n 8.0 g/dL\n 94 mg/dL\n 0.6 mg/dL\n 31 mEq/L\n 3.6 mEq/L\n 13 mg/dL\n 110 mEq/L\n 147 mEq/L\n 25.8 %\n 9.0 K/uL\n [image002.jpg]\n 10:18 AM\n 02:33 PM\n 02:46 PM\n 03:31 AM\n 02:26 PM\n 05:53 PM\n 05:01 AM\n 03:32 PM\n 10:19 PM\n 02:50 AM\n WBC\n 9.7\n 9.5\n 9.0\n Hct\n 26.0\n 27.6\n 25.8\n Plt\n \n Cr\n 0.5\n 0.5\n 0.5\n 0.6\n 0.6\n TCO2\n 29\n 26\n 27\n 30\n 30\n 35\n Glucose\n 195\n 195\n 163\n 133\n 102\n 94\n Other labs: PT / PTT / INR:14.1/59.6/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:71.2 %, Lymph:22.7 %,\n Mono:4.0 %, Eos:1.7 %, Lactic Acid:1.5 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:8.2 mg/dL, Mg++:2.1 mg/dL, PO4:4.6 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with respiratory failure\n and difficulty weaning from vent.\n # Respiratory failure: Intubated on for resp decompensation.\n Likely VAP. Transferred here for tracheomalacia, but not sure this\n is a component. Will need bronch eval when improved\n - will discuss PEEP goal for trach placement with IP.\n - wean PEEP\n - repeat ABG this AM\n - discuss need for trach with patient and her family\n - Volume overload may be contributing.\n # Volume overload\n Currently with hypernatremia, Cr increase, contract\n alk, but mild\n - continue gentle diuresis\n - FW in TF at 150 cc q4hrs\n - PM lytes.\n # Sedation: On versed 3mg/hr + .5 q 1hr and fentanyl 150 mcg/hr + 50\n bolus q 1hr.\n - Start fentanyl patch and diazepam to provide long acting analgesia\n and wean from drips\n - Haldol 1 mg Q4h PRN agitation\n # Pneumonia: Pansensitive Kleb oxytoca pneumonia and sputum with GPCs\n on gram stain. Afebrile off abx.\n # EKG changes: Sinus bradycardia, responsive to stress. Related to\n sedation, increased vagal tone, possibly related to steroid\n replacement. Atrial EKG shows p-waves and cardiac enzymes normal.\n - Continue to monitor\n # Hypotension: Improved, off levophed for 2-3 days now, with good urine\n output. s/p 5 d course of steroids for adrenal insufficiency. High\n PEEP may have been contributing. Now likely related to sedation and\n decreased intravascular volume,\n -monitor, expect improvement with continual reduction in PEEP\n # RUE DVT: Started on heparin gtt on , now therapeutic. Follow\n PTTs. Would hold off on coumadin at least until s/p trach.\n - continue to monitor\n # Adrenal Insufficency: Random cortisol was approx 3 when it should\n have been maximally stimulated.\n - hydrocortisone and florinef for 5 days\n # Anemia: Stable.\n - Trend HCT\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n FEN/GI: Tube feeds @ goal\n DVT: Treatment dose heparin\n Ulcer: Ranitidine\n VAP: Prevention per routine\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2167-09-30 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 635216,
"text": "Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - START 02:00 PM - in right brachial atery\n Hypotensive- started on levophed, weaned off over night\n Low cortisol and failed stim test - started on steroids\n TTE ordered\n Free water flushes were increased for hypernatremia (250cc q4)\n Able to hear patient breathing at times during exam this am (poor am\n CXR, reordered)\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 08:06 AM\n Infusions:\n Heparin Sodium - 1,700 units/hour\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 150 mcg/hour\n Other ICU medications:\n Haloperidol (Haldol) - 12:15 AM\n Other medications:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 36.7\nC (98\n HR: 63 (48 - 138) bpm\n BP: 91/41(58) {68/30(49) - 143/78(105)} mmHg\n RR: 18 (13 - 23) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Mixed Venous O2% Sat: 59 - 59\n Total In:\n 3,898 mL\n 1,155 mL\n PO:\n TF:\n 802 mL\n 348 mL\n IVF:\n 2,126 mL\n 247 mL\n Blood products:\n Total out:\n 2,367 mL\n 800 mL\n Urine:\n 2,367 mL\n 800 mL\n NG:\n Stool:\n ?\n ?\n Drains:\n Balance:\n 1,531 mL\n 355 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 401) mL\n RR (Set): 18\n RR (Spontaneous): 1\n PEEP: 10 cmH2O\n FiO2: 40%\n PIP: 23 cmH2O\n Plateau: 19 cmH2O\n Compliance: 57.1 cmH2O/mL\n SpO2: 91%\n ABG: 7.42/49/93/33/5\n Ve: 8.1 L/min\n PaO2 / FiO2: 155\n Physical Examination\n General Appearance: Easily agitated, appears uncomfortable, Overweight\n / Obese, opens eyes but no purposeful movement\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\n deviation\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Respiratory / Chest: (Expansion: Symmetric), referred breath sounds\n from ETT\n Abdominal: No(t) Soft, Non-tender, Few Bowel sounds present, Distended\n Extremities: No clubbing or cyanosis, 3+ nonpitting edema of b/l hands,\n anasarca\n Skin: no rashes or jaundice\n Neuro: diffusely hyperreflexic with LE clonus\n Lines: r brachioceph ART and L PICC C/D/I\n Labs / Radiology\n 355 K/uL\n 9.1 g/dL\n 168 mg/dL\n 0.5 mg/dL\n 30 mEq/L\n 3.9 mEq/L\n 11 mg/dL\n 108 mEq/L\n 146 mEq/L\n 29.9 %\n 11.8 K/uL\n [image002.jpg]\n 03:32 PM\n 10:19 PM\n 02:50 AM\n 02:30 PM\n 02:44 PM\n 03:33 PM\n 07:26 PM\n 07:46 PM\n 02:04 AM\n 02:18 AM\n WBC\n 9.0\n 8.4\n 11.8\n Hct\n 25.8\n 23.0\n 28.1\n 29.9\n Plt\n \n Cr\n 0.6\n 0.7\n 0.5\n TCO2\n 30\n 35\n 33\n 31\n 33\n Glucose\n 94\n 97\n 168\n Other labs: PT / PTT / INR:13.8/70.4/1.2, Differential-Neuts:89.7 %,\n Lymph:8.7 %, Mono:1.1 %, Eos:0.4 %, Ca++:8.5 mg/dL, Mg++:2.2 mg/dL,\n PO4:5.4 mg/dL\n TSH 2.9; FT4 1.5; stim 3.1, 10.5, 10.6\n Culture Data: endotrach with K oxytoca; gram stain GPCs in\n pairs and clusters\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca, .\n # Respiratory failure: Related to ARDS, ? trachiomalacia, resolved\n VAP, volume overload. Intubated on for resp decompensation.\n Transferred here for tracheomalacia, but not sure this is a component.\n Will need bronch eval when improved\n - Thoracics will do trach and PEG once stable on PEEPs around 10.\n Re-c/s today.\n - wean PEEP as tolerated\n # Volume overload\n Hypernatremic (? Relationship to adrenal\n insufficiency), TBW deficit 2.6L.\n - goal even I/Os today\n - FW in TF at 250 cc q4hrs\n - PM lytes\n # Hyperreflexia - ? meds vs central pathology\n - consider head CT in context of heparin gtt to r/o intracranial\n hemmorhage\n # Sedation: Poor sedation control. On Versed 1.5, Fentanyl 175,\n Fentanyl patch, Diazepam standing and haldo 2.5-5 mg PRN. QTc stable\n at .44\n - Wean versed/fentanyl as tolerated\n - Recheck EKG today\n -\n # Hypotension: Related to sedation, but high PEEP, adrenial\n insufficiency, sepsis have previously been contributing. Monitor with\n A-line. Failed stim again.\n - hydrocortisol and fludrocortisone\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\n coumadin at least until s/p trach.\n - hold heparin gtt when anticipate trach/peg\n # Adrenal Insufficency: Minimal response to stim test again.\n - hydrocort and fludrocort\n - consider endocrine c/s for further elucidation of etiology\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n # FEN/GI: Tube feeds @ goal.\n DVT: Treatment dose heparin\n Ulcer: Ranitidine\n VAP: Prevention per routine\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 09:51 PM 60 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Arterial Line - 02:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2167-09-30 00:00:00.000",
"description": "Physician Resident/Attending Progress Note - MICU",
"row_id": 635227,
"text": "Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - START 02:00 PM - in right brachial atery\n Hypotensive- started on levophed, weaned off over night\n Low cortisol and failed stim test - started on steroids\n TTE ordered\n Free water flushes were increased for hypernatremia (250cc q4)\n Able to hear patient breathing at times during exam this am (poor am\n CXR, reordered)\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 08:06 AM\n Infusions:\n Heparin Sodium - 1,700 units/hour\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 150 mcg/hour\n Other ICU medications:\n Haloperidol (Haldol) - 12:15 AM\n Other medications:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 36.7\nC (98\n HR: 63 (48 - 138) bpm\n BP: 91/41(58) {68/30(49) - 143/78(105)} mmHg\n RR: 18 (13 - 23) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Mixed Venous O2% Sat: 59 - 59\n Total In:\n 3,898 mL\n 1,155 mL\n PO:\n TF:\n 802 mL\n 348 mL\n IVF:\n 2,126 mL\n 247 mL\n Blood products:\n Total out:\n 2,367 mL\n 800 mL\n Urine:\n 2,367 mL\n 800 mL\n NG:\n Stool:\n ?\n ?\n Drains:\n Balance:\n 1,531 mL\n 355 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 401) mL\n RR (Set): 18\n RR (Spontaneous): 1\n PEEP: 10 cmH2O\n FiO2: 40%\n PIP: 23 cmH2O\n Plateau: 19 cmH2O\n Compliance: 57.1 cmH2O/mL\n SpO2: 91%\n ABG: 7.42/49/93/33/5\n Ve: 8.1 L/min\n PaO2 / FiO2: 155\n Physical Examination\n General Appearance: Easily agitated, appears uncomfortable, Overweight\n / Obese, opens eyes but no purposeful movement\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\n deviation\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Respiratory / Chest: (Expansion: Symmetric), referred breath sounds\n from ETT\n Abdominal: No(t) Soft, Non-tender, Few Bowel sounds present, Distended\n Extremities: No clubbing or cyanosis, 3+ nonpitting edema of b/l hands,\n anasarca\n Skin: no rashes or jaundice\n Neuro: diffusely hyperreflexic with LE clonus\n Lines: r brachioceph ART and L PICC C/D/I\n Labs / Radiology\n 355 K/uL\n 9.1 g/dL\n 168 mg/dL\n 0.5 mg/dL\n 30 mEq/L\n 3.9 mEq/L\n 11 mg/dL\n 108 mEq/L\n 146 mEq/L\n 29.9 %\n 11.8 K/uL\n [image002.jpg]\n 03:32 PM\n 10:19 PM\n 02:50 AM\n 02:30 PM\n 02:44 PM\n 03:33 PM\n 07:26 PM\n 07:46 PM\n 02:04 AM\n 02:18 AM\n WBC\n 9.0\n 8.4\n 11.8\n Hct\n 25.8\n 23.0\n 28.1\n 29.9\n Plt\n \n Cr\n 0.6\n 0.7\n 0.5\n TCO2\n 30\n 35\n 33\n 31\n 33\n Glucose\n 94\n 97\n 168\n Other labs: PT / PTT / INR:13.8/70.4/1.2, Differential-Neuts:89.7 %,\n Lymph:8.7 %, Mono:1.1 %, Eos:0.4 %, Ca++:8.5 mg/dL, Mg++:2.2 mg/dL,\n PO4:5.4 mg/dL\n TSH 2.9; FT4 1.5; stim 3.1, 10.5, 10.6\n Culture Data: endotrach with K oxytoca; gram stain GPCs in\n pairs and clusters\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA and\n ARDS intubated since the end of .\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation.\n Transferred here for airway stenting. Will need bronch eval when\n improved.\n - Thoracics will do trach and PEG once stable on PEEPs around 10.\n Re-c/s today.\n - wean PEEP as tolerated\n # # Adrenal Insufficency: Minimal response to stim test again.\n - hydrocort and fludrocort (day 1 = )\n - endocrine c/s for further elucidation of etiology\n # Hypotension: Likely adrenal insufficiency. Goal map > 60.\n - hydrocortisol and fludrocortisone as above\n - restart levophed if necessary to maintain MAP > 60\n # Volume overloaded in setting of hypernatremia (? Relationship to\n adrenal insufficiency), TBW deficit 2.6L.\n - goal even to -500cc I/Os today\n - continue FW in TF at 250 cc q4hrs\n - lasix drip (1-5mg/hr) when MAP > 60\n # Hyperreflexia - ? meds vs central pathology. Unlikely to be \n intracranial hemorrhage as patient is diffusely hyperreflexic.\n Possible relationship to endocrine pathology?\n - consider head CT in setting of heparin gtt\n - monitor\n # Sedation: Sedation control remains somewhat poor although fentanyl\n patch and diazpem are likely starting increase to therapeutic range\n today. On Versed 1.5, Fentanyl 175, Fentanyl patch, Diazepam standing\n and haldo 2.5-5 mg PRN. QTc stable at .44.\n - Wean versed/fentanyl as tolerated, continue diazepam and prn\n haldol\n - Recheck EKG today\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\n coumadin at least until s/p trach.\n - hold heparin gtt when anticipate trach/peg\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n # FEN/GI: Tube feeds @ goal.\n DVT: Treatment dose heparin\n Ulcer: Ranitidine\n VAP: Prevention per routine\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 09:51 PM 60 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Arterial Line - 02:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 55F T5-8 fractures with retropulsion and ARDS\n from VAP; on heparin for UE DVT. Yesterday, hypotension confirmed by\n placement of R axillary arterial line, required levophed for several\n hours. Random cortisol 3, increased to 10 s/p ACTH; restarted on\n hydrocortisone 50IV q6h with improved BP, able to come off pressors.\n Has made progress on the vent, with PEEP back down to 10 and FiO2 0.5.\n On rounds, has audible ETT cuff leak, tube appears high on CXR.\n Exam notable for Tm 99.5 BP 105/45 HR 50-115 RR 18-20 with sat 93% on\n VAC 400x18 PEEP 10 FiO2 0.5 for 7.42/49/93. TBB +14L/MICU LOS. Eyes\n opens, will squeeze hands and wiggle toes but very drowsy. Positive\n cuff leak, bronchial BS bilaterally with RRR s1s2 SM at base.\n Abdomen is distended with decreased BS. 3+ edema in BLE, no cords. Labs\n notable for WBC 11K, HCT 30, K+ 3.9, Na 146, Cr 0.5. CXR with resolving\n B LL airspace disease and effusions.\n Agree with plan to continue supplementation with hydrocortisone 50\n q6-8h and discuss with endocrine as she seems to have adrenal\n insufficiency. Needs bronchoscopy now to confirm tube position, will\n continue vent weaning by dropping PEEP to 8 and discuss with T-\n regarding T+G in AM. Will continue fentanyl patch and po valium as we\n wean IV sedation. Consider head CT if neuro exam becomes more focal\n while on heparin, but will hold off for now. Will continue diuresis\n with IV lasix to affect a negative fluid balance and use haldol for\n breakthrough agitiation. Will continue IV heparin for UE DVT; consider\n transition to coumadin only after tracheostomy and feeding tube\n placement, which will require lower ventilator settings. Will restart\n tube feeds and add FW boluses for hypernatremia. Continue spinal\n stabilization with brace when OOB; will eventually need MRI for\n surgical planning; remainder of plan as outlined above.\n Patient is critically ill\n Total time: 40 min\n ------ Protected Section Addendum Entered By: , MD\n on: 12:55 PM ------\n"
},
{
"category": "Respiratory ",
"chartdate": "2167-10-01 00:00:00.000",
"description": "Generic Note",
"row_id": 635294,
"text": "TITLE:\n Respiratory Care: Rec\nd pt on a/c 18/400/+8/50%. Ett 7.5, retaped,\n rotated and secured @ 20 lip. BS are coarse with diminished bases.\n Suctioned for small amounts of thick white secretions. MDI\n administered as ordered alb/atr with no adverse reactions AM ABG\n 7.42/47/87. No rsbi due to trach/peg procedure possibly in OR.\n"
},
{
"category": "General",
"chartdate": "2167-10-01 00:00:00.000",
"description": "Generic Note",
"row_id": 635295,
"text": "55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP now with prolonged\n hospital course c/o by PNA anxiety,RUE DVD with high PEEP requirement\n .\n Events\n Heparin gtt and TF held since MN for ? trach and peg\n placement today.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on AC 400/18/8/50%. 02 sats mainly 88-92% but did fall to\n 86% when pt positioned on L side. Pt fluid overloaded with TFB for LOS\n ~ ccs.\n Action:\n ABG taken while sat 88%. Lasix gtt increased to 3mg/hr\n Response:\n ABG 7.42/47/87/4/32. Urine output initially 25 ccs/hr but pt began\n autodiuresing after MN with output improving to ~140ccs/hr\n Plan:\n Continue with current vent settings. Trach today. Titrate lasix gtt to\n maintain MAP > 60 and u/o 100-150ccs/hr.\n Altered mental status (not Delirium)\n Assessment:\n Pt restless at times, thrashing in bed with HR up to 140 ST . Denies\n pain or doesn\nt respond when questioned if she is having pain.\n Action:\n Fentanyl drip infusing at 100mcgs/hr. Fentanyl patch in place. Also\n treated with haldol and valium . Bolused with 2 mg versed when acutely\n agitated. Bilateral wrist restraints in place.\n Response:\n Pt falls back to sleep, HR decreases (occasionally as low as 45 SB)\n Plan:\n Continue to assess MS. as indicated. Reorientation. Restraints\n for safety.\n Hypernatremia (high sodium)\n Assessment:\n Na 146 on \n Action:\n Treated with free h20 boluses\n Response:\n Na 143 this am\n Plan:\n Continue to monitor f+e status.\n Impaired Skin Integrity\n Assessment:\n Pt with excoriated yeast infection on abd and in perineal area. +\n reddened perirectal area.\n Action:\n Barrier cream and miconazole powder applied\n Response:\n To be determined.\n Plan:\n Diligent skin care.\n"
},
{
"category": "Respiratory ",
"chartdate": "2167-09-21 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 634284,
"text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 3\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Crackles\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Crackles\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Pt went to CT this PM for CT of head and chest, attempted to place\n Esoph balloon but kept tangeling on the OET and\n tube\n Will try again later. Ventrac in room..\n, RRT 18:43\n"
},
{
"category": "Nursing",
"chartdate": "2167-09-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 634286,
"text": "55-year-old woman with\n Respiratory failure\n Traumatic thoracic spinal fractures\n Probable VAP\n Upper extremity DVT\n Oliguria\n Anemia\n * Possible tracheobronchomalacia (reason for transfer from OSH)\n Events: Multi-lumen CVL placed at bedside. CXR cleared for use. Bedside\n Echo performed and Non-contrast CT of spine and Torso done.\n Alteration in Nutrition\n Assessment:\n NPO, Pt w/ high residuals yesterday. Abdomen increasingly distended and\n slightly firm. BS hypoactive. Low albumin. Bladder pressure performed\n d/t distended abdomen and low UOP: 18-20.\n Action:\n OGT to low wall suction to decompress abdomen. TF off. CT of abdomen\n done.\n Response:\n OGT putting out clear/pink drainage <100cc. CT scan results pending.\n Plan:\n Cont NPO at this time and OGT to low wall sxn. ? Restart TF.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n RUE + DVT\n Action:\n Cont on sq heparin\n Response:\n No change\n Plan:\n Consult neuro-surgery regarding anti-coagulation w/ T-spine fx, elevate\n RUE, no blood draws or blood pressures to RUE. ? Start heparin gtt once\n cleared from neurosurgery.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Temp max 100\n Action:\n Antibiotics given. Dosage changes made to vanco and aztreonam.\n Response:\n No further temp spike.\n Plan:\n Cont w/ antibiotics, f/u on cultures, Tylenol prn, vanco trough to be\n drawn prior to 8am dose on per pharmacy (if drawn earlier than\n results will be falsely elevated d/t dosage changes).\n Fracture, other\n Assessment:\n T-spine compression fx, Back brace at bedside when OOB.\n Action:\n Ortho tech consulted for placement of back brace. Cont w/ log roll\n precautions. CT scan done\n Response:\n Pt denies c/o pain when asked.\n Plan:\n Cont w/ log roll precautions, back brace for OOB, consult w/\n neurosurgery, pain mgmt.\n Anemia, other\n Assessment:\n HCT 24.1 from 28 yesterday (30 on admission)\n Action:\n Given 1 unit of PRBCs\n Response:\n Post HCT pending.\n Plan:\n Cont to follow HCTs, guiac stools, monitor of s/s of bleeding.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS- bronchial/rhonchorous throughout diminished to bilateral bases,\n deep sxn\nd for thick/tan secretions, copious clear oral secretions\n suctioned. ? PE/? VAP.\n Action:\n Vent changes made throughout shift. Esophageal balloon attempted-\n unable to place. CT scan of chest done.\n Response:\n Pt w/ high O2 requirements.\n Plan:\n Monitor ABGs, vent changes as needed.\n Hypotension (not Shock)\n Assessment:\n Pt hypotensive into low-mid 80s systolic, HR 70s-90, SR. Low uop-\n BUN/Creat negative.\n Action:\n Vigeleo set up, given 1 unit of blood, bloused x 1, multi-lumen RIJ\n placed at bedside. Levophed started.\n Response:\n No response to bolusing, RIJ okay to use. CVP 18. CO . Stroke\n volume 3.0.\n Plan:\n Cont to monitor VS closely, monitor I&O, levophed for MAPS >65\n"
},
{
"category": "Nursing",
"chartdate": "2167-09-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 634362,
"text": "Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Fracture, other\n Assessment:\n Action:\n Response:\n Plan:\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2167-09-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 634442,
"text": "Events: Attempt to lighten sedation, stop Levophed gtt- MS \n stability labile from lethargic to restless in bed/crying w/\n intermittent BP 120\ns/ w/ and W/O stimulation. UOP cont 10-30cc/hr.\n Vigileo monitor on- SVV . Bladder pressure 14. TF restarted w/ goal\n slow inc as tolerated w/ recent high residuals.\n Alteration in Nutrition\n Assessment:\n Minimal residuals\n Action:\n Restarting TF replete w/ fiber @ 10cc/hr w/ Q6hr 20cc flush\n Response:\n Tolerating, goal advance Q6hr as tolerated\n Plan:\n Cont TF, monitor residuals, inc Q6hrs as tolerated\n Hypotension (not Shock)\n Assessment:\n BP labile- SBP 86-120, UOP down to 10cc/hr\n Action:\n Vigileo on- SVV , In AM attempt wean off Levo gtt\n Response:\n No fluid blousing, Levophed gtt started- titrated for MAP .65, UOP,\n Levo @ .02\n Plan:\n Cont Vigeligo monitoring,\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 635959,
"text": "55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\n Now with prolonged hospital course c/b by PNA with high PEEP\n requirement, anxiety, RUE DVT on heparin qtt.\n Bradycardia\n Assessment:\n Pt conts with HR 50-70\ns at rest, 100-140\ns during care, pt\n asymptomatic; easily arousable\n Action:\n Sedation decreased, Lasix off @0200\n Response:\n HR 60\n Plan:\n Cont to wean sedation, ?cardiac consult\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Action:\n Cont with IV Heparin @ 1500u/hr, Coumadin d\ncd for? thoracentesis\n Response:\n Pt therapeutic, cont with daily PTT\n Plan:\n Cont to labs, cont to wean off Heparin, Coumadin 5mg given x 1dose\n @ 2200, re-eval dosing this am\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt cont on AC 18/400/50%/10, LS clear bilat, occ scat rhonchi\n Action:\n Pt suct for sm thin tan secretions\n Response:\n Pt 02 Sats 94-97%,\n Plan:\n Cont to ABGs,\n Hypotension (not Shock)\n Assessment:\n SBP 140\ns when pt is agitated, SBP dropping to 70\ns-80\ns, UO 200/hr\n (total 2500 in 2hr)\n Action:\n Fent/Versed turned down @ 0000, Lasix gtt on hold, team informed\n Response:\n Pt SBP\ns in 80\n Plan:\n Cardiac consult to further eval SB/ST, re-evalu cont. Lasix gtt\n Hypernatremia (high sodium)\n Assessment:\n Na 146\n Action:\n Cont with 300cc free water flush Q4hrs\n Response:\n Plan:\n Cont to sodium levels, treat as ordered\n Altered mental status (not Delirium)\n Assessment:\n Pt alert and agitated throughout shift, pt following commands\n inconsistently; sleeping off and off throughout shift\n Action:\n Fent/Versed decreased low SBP\ns, pt recved prn dose of Haldol 1mg @\n 0100; cont with bilat. Wrist restraints for safety\n Response:\n pt sleeping off/on throughout shift, with periods of\n agitation/restlessness\n Plan:\n Cont to wean fent/versed gtt down, cont with scheduled Haldol/Valium;\n cont to QTC intervals daily\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 635961,
"text": "55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\n Now with prolonged hospital course c/b by PNA with high PEEP\n requirement, anxiety, RUE DVT on heparin qtt.\n Bradycardia\n Assessment:\n Pt conts with HR 50-70\ns at rest, 100-140\ns during care, pt\n asymptomatic; easily arousable\n Action:\n Sedation decreased, Lasix off @0200\n Response:\n HR 60\n Plan:\n Cont to wean sedation, ?cardiac consult\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Action:\n Cont with IV Heparin @ 1500u/hr, Coumadin d\ncd for? thoracentesis\n Response:\n Pt therapeutic, cont with daily PTT\n Plan:\n Cont to labs, cont to wean off Heparin, Coumadin 5mg given x 1dose\n @ 2200, re-eval dosing this am\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt cont on AC 18/400/50%/10, LS clear bilat, occ scat rhonchi\n Action:\n Pt suct for sm thin tan secretions\n Response:\n Pt 02 Sats 94-97%,\n Plan:\n Cont to ABGs,\n Hypotension (not Shock)\n Assessment:\n SBP 140\ns when pt is agitated, SBP dropping to 70\ns-80\ns, UO 200/hr\n (total 2500 in 2hr) K 3.3\n Action:\n Fent/Versed turned down @ 0000, Lasix gtt on hold, team informed ; pt\n recvd 1x dose of 40meg/Peg, 20meqK/250D5W x 1 dose\n Response:\n Pt SBP\ns in 80\n Plan:\n Cardiac consult to further eval SB/ST, re-evalu cont. Lasix gtt,\n recheck am labs\n Hypernatremia (high sodium)\n Assessment:\n Na 146\n Action:\n Cont with 300cc free water flush Q4hrs\n Response:\n Plan:\n Cont to sodium levels, treat as ordered\n Altered mental status (not Delirium)\n Assessment:\n Pt alert and agitated throughout shift, pt following commands\n inconsistently; sleeping off and off throughout shift\n Action:\n Fent/Versed decreased low SBP\ns, pt recved prn dose of Haldol 1mg @\n 0100; cont with bilat. Wrist restraints for safety\n Response:\n pt sleeping off/on throughout shift, with periods of\n agitation/restlessness\n Plan:\n Cont to wean fent/versed gtt down, cont with scheduled Haldol/Valium;\n cont to QTC intervals daily\n"
},
{
"category": "Physician ",
"chartdate": "2167-09-30 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 635219,
"text": "Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - START 02:00 PM - in right brachial atery\n Hypotensive- started on levophed, weaned off over night\n Low cortisol and failed stim test - started on steroids\n TTE ordered\n Free water flushes were increased for hypernatremia (250cc q4)\n Able to hear patient breathing at times during exam this am (poor am\n CXR, reordered)\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 08:06 AM\n Infusions:\n Heparin Sodium - 1,700 units/hour\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 150 mcg/hour\n Other ICU medications:\n Haloperidol (Haldol) - 12:15 AM\n Other medications:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 36.7\nC (98\n HR: 63 (48 - 138) bpm\n BP: 91/41(58) {68/30(49) - 143/78(105)} mmHg\n RR: 18 (13 - 23) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Mixed Venous O2% Sat: 59 - 59\n Total In:\n 3,898 mL\n 1,155 mL\n PO:\n TF:\n 802 mL\n 348 mL\n IVF:\n 2,126 mL\n 247 mL\n Blood products:\n Total out:\n 2,367 mL\n 800 mL\n Urine:\n 2,367 mL\n 800 mL\n NG:\n Stool:\n ?\n ?\n Drains:\n Balance:\n 1,531 mL\n 355 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 401) mL\n RR (Set): 18\n RR (Spontaneous): 1\n PEEP: 10 cmH2O\n FiO2: 40%\n PIP: 23 cmH2O\n Plateau: 19 cmH2O\n Compliance: 57.1 cmH2O/mL\n SpO2: 91%\n ABG: 7.42/49/93/33/5\n Ve: 8.1 L/min\n PaO2 / FiO2: 155\n Physical Examination\n General Appearance: Easily agitated, appears uncomfortable, Overweight\n / Obese, opens eyes but no purposeful movement\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\n deviation\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Respiratory / Chest: (Expansion: Symmetric), referred breath sounds\n from ETT\n Abdominal: No(t) Soft, Non-tender, Few Bowel sounds present, Distended\n Extremities: No clubbing or cyanosis, 3+ nonpitting edema of b/l hands,\n anasarca\n Skin: no rashes or jaundice\n Neuro: diffusely hyperreflexic with LE clonus\n Lines: r brachioceph ART and L PICC C/D/I\n Labs / Radiology\n 355 K/uL\n 9.1 g/dL\n 168 mg/dL\n 0.5 mg/dL\n 30 mEq/L\n 3.9 mEq/L\n 11 mg/dL\n 108 mEq/L\n 146 mEq/L\n 29.9 %\n 11.8 K/uL\n [image002.jpg]\n 03:32 PM\n 10:19 PM\n 02:50 AM\n 02:30 PM\n 02:44 PM\n 03:33 PM\n 07:26 PM\n 07:46 PM\n 02:04 AM\n 02:18 AM\n WBC\n 9.0\n 8.4\n 11.8\n Hct\n 25.8\n 23.0\n 28.1\n 29.9\n Plt\n \n Cr\n 0.6\n 0.7\n 0.5\n TCO2\n 30\n 35\n 33\n 31\n 33\n Glucose\n 94\n 97\n 168\n Other labs: PT / PTT / INR:13.8/70.4/1.2, Differential-Neuts:89.7 %,\n Lymph:8.7 %, Mono:1.1 %, Eos:0.4 %, Ca++:8.5 mg/dL, Mg++:2.2 mg/dL,\n PO4:5.4 mg/dL\n TSH 2.9; FT4 1.5; stim 3.1, 10.5, 10.6\n Culture Data: endotrach with K oxytoca; gram stain GPCs in\n pairs and clusters\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA and\n ARDS intubated since the end of .\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation.\n Transferred here for airway stenting. Will need bronch eval when\n improved.\n - Thoracics will do trach and PEG once stable on PEEPs around 10.\n Re-c/s today.\n - wean PEEP as tolerated\n # Hypotension: Likely adrenal insufficiency.\n - hydrocortisol and fludrocortisone\n # Volume overload\n Hypernatremic (? Relationship to adrenal\n insufficiency), TBW deficit 2.6L.\n - goal even I/Os today\n - FW in TF at 250 cc q4hrs\n - PM lytes\n # Hyperreflexia - ? meds vs central pathology\n - consider head CT in context of heparin gtt to r/o intracranial\n hemmorhage\n # Sedation: Poor sedation control. On Versed 1.5, Fentanyl 175,\n Fentanyl patch, Diazepam standing and haldo 2.5-5 mg PRN. QTc stable\n at .44\n - Wean versed/fentanyl as tolerated\n - Recheck EKG today\n -\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\n coumadin at least until s/p trach.\n - hold heparin gtt when anticipate trach/peg\n # Adrenal Insufficency: Minimal response to stim test again.\n - hydrocort and fludrocort\n - consider endocrine c/s for further elucidation of etiology\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n # FEN/GI: Tube feeds @ goal.\n DVT: Treatment dose heparin\n Ulcer: Ranitidine\n VAP: Prevention per routine\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 09:51 PM 60 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Arterial Line - 02:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-02 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 635440,
"text": "Chief Complaint:\n 24 Hour Events:\n Patient agitated and combative overnight - restarted midazolam gtt and\n patient was becoming increasingly tachycardic and hypertensive\n Thoracics to take to OR this am for trach and PEG\n Discussion with patient's boyfriend yesterday - her should be here this\n weekend, wants to be involved, just hard for him to get here\n On lasix drip with excellent response (200 cc urine/hour)\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Fentanyl - 100 mcg/hour\n Furosemide (Lasix) - 1 mg/hour\n Heparin Sodium - 1,700 units/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:07 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.3\nC (99.2\n HR: 118 (45 - 138) bpm\n BP: 155/84(118) {91/38(56) - 177/106(139)} mmHg\n RR: 18 (17 - 27) insp/min\n SpO2: 90%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,604 mL\n 1,447 mL\n PO:\n TF:\n 675 mL\n 17 mL\n IVF:\n 1,089 mL\n 730 mL\n Blood products:\n Total out:\n 4,130 mL\n 2,430 mL\n Urine:\n 4,130 mL\n 2,430 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,526 mL\n -983 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n PS : 5 cmH2O\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n PIP: 22 cmH2O\n Plateau: 19 cmH2O\n Compliance: 48.2 cmH2O/mL\n SpO2: 90%\n ABG: 7.45/50/67/29/8\n Ve: 7.5 L/min\n PaO2 / FiO2: 134\n Physical Examination\n General Appearance: Responsive, following commands, Overweight / Obese,\n NAD\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\n deviation\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Respiratory / Chest: (Expansion: Symmetric), referred breath sounds\n from ETT\n Abdominal: No(t) Soft, Non-tender, Few Bowel sounds present, Distended\n Extremities: No clubbing or cyanosis, 3+ nonpitting edema of b/l hands,\n anasarca\n Skin: no rashes or jaundice\n Neuro: 3+ UE b/l, 4+ LE b/l\n Lines: r brachioceph ART and L PICC C/D/I\n Labs / Radiology\n 306 K/uL\n 8.5 g/dL\n 165 mg/dL\n 0.7 mg/dL\n 29 mEq/L\n 3.7 mEq/L\n 10 mg/dL\n 108 mEq/L\n 146 mEq/L\n 27.1 %\n 11.2 K/uL\n [image002.jpg]\n 02:18 AM\n 01:27 PM\n 03:06 PM\n 10:04 PM\n 03:00 AM\n 10:47 AM\n 04:10 PM\n 12:13 AM\n 05:08 AM\n 05:20 AM\n WBC\n 8.6\n 11.2\n Hct\n 25.9\n 27.1\n Plt\n 280\n 306\n Cr\n 0.6\n 0.5\n 0.7\n TCO2\n 33\n 32\n 32\n 34\n 36\n 36\n Glucose\n 176\n 136\n 165\n Other labs: PT / PTT / INR:13.2/68.7/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:89.7 %, Lymph:8.7 %, Mono:1.1\n %, Eos:0.4 %, Lactic Acid:0.9 mmol/L, Albumin:2.4 g/dL, LDH:204 IU/L,\n Ca++:10.6 mg/dL, Mg++:2.8 mg/dL, PO4:4.3 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA and\n ARDS intubated since the end of .\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation.\n Transferred here for airway stenting.\n - attempt SBT today\n - OR add on for trach and PEG with Dr. (tube feeds off\n after MN, heparin off after 6am)\n # # Adrenal Insufficency: Minimal response to stim test again.\n Appreciate endocrine recommendations.\n - hydrocort and fludrocort (day 1 = )\n - will continue at current dose until s/p trach and PEG and\n hemodynamically stable for 24 hours\n will then plan to taper\n hydrocortisone to 25mg IV q6 with a slow taper\n - will repreat ACTH stim test after tapered to <30mg\n hydrocortisone or off steroids\n - f/u daily endocrine recs\n # Hypotension: Likely adrenal insufficiency and sedation. Goal map\n > 60. Much improved since re-administration of steroids.\n - hydrocortisone and fludrocortisone as above\n - restart levophed if necessary to maintain MAP > 60\n # Volume overloaded in setting of hypernatremia with TBW deficit.\n - goal -1000cc I/Os today\n - continue FW in TF at 250 cc q4hrs\n - lasix drip (1-5mg/hr) when MAP >\n 60\n # Sedation: Sedation control remains somewhat poor although fentanyl\n patch and diazpem are likely therapeutic range today. On Versed 1.5,\n Fentanyl 175, Fentanyl patch, Diazepam standing and haldo 2.5-5 mg\n PRN. QTc increased to 480.\n - Wean versed/fentanyl as tolerated, continue diazepam. Avoid\n haldol use if possible to avoid further prolongation of QTc\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\n coumadin at least until s/p trach.\n - hold heparin gtt when anticipate trach/peg\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n # FEN/GI: Tube feeds with FWF @ goal.\n DVT: Treatment dose heparin\n Ulcer: Ranitidine\n VAP: Prevention per routine\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n - touch base with SW today\n Code: Full\n Dispo: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Arterial Line - 02:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 635441,
"text": "55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP now with prolonged\n hospital course c/o by PNA anxiety,RUE DVD with high PEEP requirement\n .\n Events:\n Pt found at 19:30 to have loose restraints and was pulling on ETT. Pt\n found to have pulled out her esophageal tube and disconnected IV lines.\n CXR done and ETT and OGGT in right position.\n Plan: Plan for OR this am for trach and peg. Heparin gtt off at 6am.\n Edema, peripheral\n Assessment:\n Pt has gen edema with +2 pitting.\n Action:\n Pt is on lasix gtt, now at 1 mg/hr. Goal to remove 1-2 liters/24hrs. Pt\n is currently + 17.3 liters for LOS.\n Response:\n Pt is diuresing well to lasix .\n Plan:\n Continue to evaluate need for Lasix. Follow K level closely lasix\n gtt and need for freq replacements as nted.\n Hypernatremia (high sodium)\n Assessment:\n Hypernatremia.\n Action:\n D5W x 1 liter at 75 cc/hr in conjunction with H2O flushes.\n Response:\n Awaiting am Na level.\n Plan:\n Follow Na level.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains intubated on CMV settings at 50%/400x18/8. ABGs stable as\n noted. Goal PO2 > 60. LS coarse to upper resp areas with diminished\n bases. Pt has been deep sx\nd for scant amounts of yellow/tan\n secretions. Oral care q 4hrs. Pt noted to desat to 85% when turned onto\n her Rt side, but recovered within seconds. Ftom 5am, pt noted to desat\n to 85% with any restlessness and agitation. MD notified and sedation\n increased with good effect.\n Action:\n Response:\n Continue to eval need for sedation in order to support resp status.\n Plan:\n Plan for trach and Peg today this am.\n Altered mental status (not Delirium)\n Assessment:\n Pt has been awake and alert most of this shift. Pt follows immediate\n commands only. When told not to reach for ETT, she stopps, but within 2\n sec she will reach for ETT again. Pt continues to have freq episodes\n of being restless in bed and agitation, trying to sit up and reaching\n for ETT. Haldol DC\nd sl prolonged QT interval and versed prn\n boluses initiated as need with some effect. While resting (with\n sedation); Hr is in the 50\ns and SBP 99-105. While awake and agitated;\n HR now increases to 140-150\ns and SBP increases to high 170\ns, and pt\n noted to start to desat to 85% since 5am.\n Action:\n Emotional support given, but very short lived. Versed gtt initiated\n with good effect to protect resp status until trach placed.\n Response:\n Pt more relaxed.\n Plan:\n Continue to eval MS.\n Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt has a clot to her Rt arm. Rt arm with good radial pulses to palp and\n cap refill < 3 sec.\n Action:\n Pt on heparin gtt protocol. Gtt was DC\nd at 6am in preparation for OR.\n Response:\n PTT has been therapeutic at 1700 units/hr.\n Plan:\n ? need to restart heparin gtt post-op.\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 635534,
"text": "55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP now with prolonged\n hospital course c/o by PNA anxiety,RUE DVD with high PEEP requirement\n .\n EVENTS: trach PEG done, PEG OK for meds, restart TF in am. restart hep\n gtt tomorrow, diamox/ KCL added for alkalosis.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt rec\nd intubated, on AC 400x18 50% +PEEP 8\n Action:\n Trach placed in the OR, pt returned from OR and placed on previous vent\n settings, failed att at CPAP wean.\n Response:\n Plan:\n Att to wean vent/ sedation slowly in am. Cont to monitor\n Altered mental status (not Delirium)\n Assessment:\n Pt w/ periods of agitation and sleeping at other times, but overall\n more alert, following commands intermittently.\n Action:\n Midaz/ fentanyl changed to propofol in OR, changerd back to midazolam\n 2mg/hr and fentanyl 100mcg/hr upon return from OR r/t SB/ hypotension,\n cont on q6hr diazepam.\n Response:\n HR ranging from SB in the 40\ns when asleep to the 120\ns when agitated,\n b/p ranging from 90\ns/40\ns when asleep to 140-150\ns/ 70\ns when\n agitated. When pt awake appropriate and following commands HR\n 80\ns-100\ns and b/p 100\ns-120\ns/ 60-70\n Plan:\n Cont Fent/ versed gtt\ns titrate. As needed\n Alteration in Nutrition\n Assessment:\n Pt on lasix gtt at 1mg/hr, TF on hold for PEG placement\n Action:\n PEG placed in OR, lasix gtt restarted upon return from OR, diamox and\n KCL added to replete K+ and treat alkalosis\n Response:\n UOP 600mg after diamox, repeat K+ 4.1, PEG dsg D/I,\n Plan:\n PEG tube OK for meds restart TF in am, monitor and replete K+ as\n needed.\n"
},
{
"category": "Physician ",
"chartdate": "2167-09-21 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 634278,
"text": "Chief Complaint: respiratory failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n URINE CULTURE - At 08:09 AM\n EKG - At 09:00 AM\n PICC LINE - STOP 10:30 AM\n BLOOD CULTURED - At 10:30 AM\n ULTRASOUND - At 01:00 PM\n U/S of RUE\n URINE CULTURE - At 03:00 PM\n UA/UC collected after new foley inserted.\n BAL FLUID CULTURE - At 03:00 PM\n mini-BAL\n ARTERIAL LINE - START 04:45 PM\n ARTERIAL LINE - STOP 02:03 AM\n ARTERIAL LINE - START 03:00 AM\n Multiple attempts at central access were unsuccessful due to\n malposition and difficulty threading wire.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 09:30 AM\n Vancomycin - 01:00 AM\n Aztreonam - 04:00 AM\n Metronidazole - 08:50 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 150 mcg/hour\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:00 AM\n Midazolam (Versed) - 09:32 AM\n Other medications:\n colace, CHG, SQI, H2B, SQH, MDIs, Flagyl, vanco, levo, aztreonam,\n versed, fentanyl\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (100.9\n Tcurrent: 37.9\nC (100.3\n HR: 72 (70 - 116) bpm\n BP: 100/48(60) {89/47(60) - 139/75(79)} mmHg\n RR: 18 (12 - 24) insp/min\n SpO2: 89%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 94.2 kg (admission): 94.2 kg\n Height: 67 Inch\n Bladder pressure: 18 (18 - 18) mmHg\n Total In:\n 5,600 mL\n 2,088 mL\n PO:\n TF:\n 120 mL\n IVF:\n 4,700 mL\n 1,728 mL\n Blood products:\n Total out:\n 798 mL\n 205 mL\n Urine:\n 798 mL\n 205 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,802 mL\n 1,883 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 80%\n RSBI Deferred: PEEP > 10\n PIP: 37 cmH2O\n Plateau: 25 cmH2O\n SpO2: 89%\n ABG: 7.45/42/95./28/4\n Ve: 9.1 L/min\n PaO2 / FiO2: 96\n Physical Examination\n Sedated. Breath sounds are coarse. Heart sounds are distant. Abdomen\n is protuberant with quiet breath sounds. Some peripheral edema. She\n is not able to cooperate with peripheral strength or sensory exam.\n Labs / Radiology\n 7.6 g/dL\n 319 K/uL\n 129 mg/dL\n 0.6 mg/dL\n 28 mEq/L\n 4.3 mEq/L\n 6 mg/dL\n 109 mEq/L\n 144 mEq/L\n 24.1 %\n 6.4 K/uL\n [image002.jpg]\n 11:54 PM\n 01:00 AM\n 06:14 AM\n 08:56 AM\n 08:57 AM\n 05:01 PM\n 08:03 PM\n 11:00 PM\n 03:01 AM\n 03:13 AM\n WBC\n 9.7\n 9.4\n 7.6\n 6.4\n Hct\n 30.7\n 25.1\n 24.1\n 24.1\n Plt\n 333\n 281\n 306\n 319\n Cr\n 0.6\n 0.6\n 0.7\n 0.6\n 0.6\n TCO2\n 32\n 33\n 35\n 33\n 30\n Glucose\n 103\n 126\n 126\n 127\n 129\n Other labs: PT / PTT / INR:16.9/26.3/1.5, ALT / AST:27/18, Alk Phos / T\n Bili:113/0.7, Differential-Neuts:76.9 %, Lymph:17.3 %, Mono:3.0 %,\n Eos:2.5 %, Lactic Acid:0.7 mmol/L, Albumin:2.3 g/dL, LDH:154 IU/L,\n Ca++:8.2 mg/dL, Mg++:2.6 mg/dL, PO4:3.1 mg/dL\n Imaging: CXR with bilateral opacities; ETT a little high. No PTX.\n Assessment and Plan\n 55-year-old woman with\n Respiratory failure\n Traumatic thoracic spinal fractures\n Probable VAP\n Upper extremity DVT\n Oliguria\n Anemia\n Possible tracheobronchomalacia (reason for transfer)\n I am uncertain about both the risks of anticoagulation and the risks of\n moving to radiology (e.g. CT or IR) in the context of her spinal\n fractures. Therefore we will consult spine surgery urgently for help\n with these questions.\n Her respiratory failure is likely multifactorial, including obesity,\n probable VAP, probable PE, and possible tracheobronchomalacia. She may\n also have weakness, but she is sedated and cannot cooperate with exam\n at present. We will check an echo to examine her RV. We will\n ventilate per ARDSnet; she may warrant esophageal-balloon-guided\n therapy if she does not improve in the next few hours.\n Oliguria is concerning, though BUN/Creatinine are reassuring. NG to\n suction to relieve abdominal distention. We will check urine lytes and\n assess stroke volume variation with the Vigileo. We will consider\n volume challenge based on this result.\n For central access, if we are able to safely move her we will ask I.R.\n to help with central access.\n We will continue broad antibiotics while awaiting cultures.\n ICU Care\n Nutrition: NPO for now\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 01:16 AM\n 20 Gauge - 01:36 AM\n 22 Gauge - 02:00 PM\n Arterial Line - 03:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 45 min\n Patient is critically ill\n ------ Protected Section ------\n Critical Care Staff Addendum\n 5:45p\n CVL successfully placed. CVP and SVV argue that she is adequately\n volume-replete. Hypoxemia has been a major issue, and we have taken\n her to CT this afternoon. We are awaiting final reads of the images.\n We will pursue esophageal balloon to help guide PEEP; first attempt was\n unsuccessful due to oropharyngeal coiling.\n Discussed in detail with patient\ns brother at bedside. Unable to reach\n her significant other.\n 35 minutes\n ------ Protected Section Addendum Entered By: , MD\n on: 17:55 ------\n"
},
{
"category": "Physician ",
"chartdate": "2167-09-23 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 634435,
"text": "Chief Complaint:\n 24 Hour Events:\n ESOPHOGEAL BALLOON - At 01:46 PM - went well, were able to\n increase PEEP to improve oxygenation\n - started naloxone to encourage bowel motility, with some success,\n rectal tube in place with some stool\n -started heparin gtt for RUE DVT\n -borderline hypotensive at times (low 90s) with low urine output,\n received boluses and norepi back on at 0.04 (now down to 0.02)\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 09:45 AM\n Metronidazole - 03:32 PM\n Vancomycin - 08:00 PM\n Aztreonam - 10:00 PM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Heparin Sodium - 1,700 units/hour\n Fentanyl - 100 mcg/hour\n Norepinephrine - 0.04 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38\nC (100.4\n Tcurrent: 37.3\nC (99.2\n HR: 73 (60 - 102) bpm\n BP: 90/46(61) {76/38(56) - 160/71(97)} mmHg\n RR: 23 (16 - 25) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101 kg (admission): 94.2 kg\n Height: 67 Inch\n CVP: 8 (8 - 15)mmHg\n Bladder pressure: 18 (18 - 21) mmHg\n Esophageal Pressure:\n 26\n Total In:\n 3,524 mL\n 234 mL\n PO:\n TF:\n 48 mL\n IVF:\n 3,236 mL\n 234 mL\n Blood products:\n Total out:\n 935 mL\n 215 mL\n Urine:\n 650 mL\n 215 mL\n NG:\n 285 mL\n Stool:\n Drains:\n Balance:\n 2,589 mL\n 19 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: AC\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 0 (0 - 0) mL\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 23 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 42 cmH2O\n Plateau: 32 cmH2O\n Compliance: 44.4 cmH2O/mL\n SpO2: 100%\n ABG: 7.37/44/160 (6am)\n Ve: 9.5 L/min\n PaO2 / FiO2: 255\n Physical Examination\n Gen: Does not arouse to voice\n HEENT: Pupils 3 mm reactive bilaterally. Scleral edema bilat\n Resp: Symmetric expansion. Coarse breath sounds throughout. Cannot\n adeq listen to post bases\n CV: RRR.\n Abd: Hypoactive bowel sounds. Distended.\n Ext: Edema in bilat UE.\n Peripheral vascular: Radial pulses 2+ bilaterally.\n Neuro: Moving all 4 extremities.\n Labs / Radiology\n 358 K/uL\n 8.9 g/dL\n 126 mg/dL\n 0.7 mg/dL\n 25 mEq/L\n 3.5 mEq/L\n 4 mg/dL\n 108 mEq/L\n 143 mEq/L\n 28.0 %\n 8.1 K/uL\n [image002.jpg]\n 03:01 AM\n 03:13 AM\n 12:05 PM\n 06:08 PM\n 06:11 PM\n 07:53 PM\n 02:02 AM\n 03:59 AM\n 09:14 PM\n 01:04 AM\n WBC\n 6.4\n 8.4\n Hct\n 24.1\n 29.0\n 28.1\n Plt\n 319\n 376\n Cr\n 0.6\n 0.6\n TCO2\n 30\n 29\n 29\n 25\n 25\n 28\n 28\n Glucose\n 129\n 120\n PT 22.2 PTT 76.0 INR 2.1\n Differential-Neuts:74.7 %, Lymph:17.6 %, Mono:3.5 %, Eos:3.8 %\n Ca++:8.2 mg/dL, Mg++:2.0 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture\n # Respiratory failure: initial etiology unclear, likely multifactorial\n now with significant pneumonia. Had one sputum that showed GNR.\n - Concern for ARDS given clinical and radiographic picture. Will hold\n on bronch given high PEEP; can consider proning. Have some room to\n increase PEEP based on esoph balloon\n - Placed esophageal balloon and increased PEEP\n - Will allow her to stay on current vent settings today in order to let\n her lungs rest\n # VAP: Had been febrile, now resolved\n - be aspiration or be VAP. Sputum from grew rare GNR;\n awaiting speciation.\n - Has been Vanc, aztreonam, levofloxicin. Vanc trough today was 20\n - Will d/c vanc today () as no current evidence to suggest a gram\n positive infection\n - Will d/c flagyl because had one neg c. diff toxin and CT did not show\n evidence of colitis\n - Continue aztreonam and levofloxicin for gram neg pneumonia for 8 days\n pending speciation (at that time can increase to 15 days if necessary)\n # Hypotension, requiring Levophed:\n - Hypovolemia is possibly a factor- responded to a transfusion; HCT had\n been dropping\n - Sepsis also a factor- on broad spectrum abs\n - Central line in place.\n - Will check a SVV (with vigileo) today to determine volume status\n # Oliguria:\n -BUN and Cr reassuring.\n - Continue to monitor\n # RUE DVT: Started on heparin gtt on .\n -Therapeutic in one day; may be related to poor nutritional status.\n Will continue to closely monitor\n # Abd distention: be chronic condition not requiring immediate\n medical attention\n - CT abd only showed appendiceal mucocele without inflammation, not\n concerning, most likely chronic. No concern for intraabd disaster\n - Now having BMs; c. diff toxin neg\n - amylase and lipase wnl\n # Anemia:\n - Trend HCT\n - Gave 1 un pRBC with good results\n - INR rising, now 2.0, may be nutritional\n # Spine fracture: neurologically intact distal to the lesion. prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per verbal report.\n # Hypernatremia, resolved: correcting with g tube free flush and D5W\n -Holding on g tube feeds at present due to high residuals\n -Replete lytes as necessary\n # Communication:\n - Brother has been with pt, although, live in boyfriend of 10 is\n her HCP. Boyfriend will hopefully visit pt today\n ICU Care\n Nutrition: tube feed with free water when able\n Glycemic Control: Regular insulin sliding scale\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Communication: ICU consent signed, (brother) \n (boyfriend/POA) \n Code status: Full code\n Disposition: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 01:36 AM\n Arterial Line - 03:00 AM\n Multi Lumen - 11:30 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2167-09-23 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 634436,
"text": "Chief Complaint: respiratory failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n ESOPHOGEAL BALLOON - At 01:46 PM\n Restarted levophed overnight\n Patient unable to provide history: Sedated\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Aztreonam - 06:09 AM\n Metronidazole - 08:00 AM\n Levofloxacin - 08:39 AM\n Infusions:\n Midazolam (Versed) - 1.5 mg/hour\n Fentanyl - 75 mcg/hour\n Norepinephrine - 0.02 mcg/Kg/min\n Other ICU medications:\n Other medications:\n vanc, aztreonam, flagyl (day ), CHG, SQI, nebs, naloxone enteral,\n heparin infusion\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38\nC (100.4\n Tcurrent: 37.6\nC (99.6\n HR: 75 (64 - 102) bpm\n BP: 96/49(65) {76/38(56) - 160/71(97)} mmHg\n RR: 22 (16 - 25) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101 kg (admission): 94.2 kg\n Height: 67 Inch\n CVP: 20 (8 - 339)mmHg\n Bladder pressure: 18 (18 - 21) mmHg\n Total In:\n 3,524 mL\n 848 mL\n PO:\n TF:\n 48 mL\n IVF:\n 3,236 mL\n 698 mL\n Blood products:\n Total out:\n 935 mL\n 325 mL\n Urine:\n 650 mL\n 325 mL\n NG:\n 285 mL\n Stool:\n Drains:\n Balance:\n 2,589 mL\n 523 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 0 (0 - 0) mL\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 23 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 37 cmH2O\n Plateau: 33 cmH2O\n Compliance: 40 cmH2O/mL\n SpO2: 99%\n ABG: 7.37/44/160/25/0\n Ve: 8.9 L/min\n PaO2 / FiO2: 320\n Physical Examination\n General Appearance: Overweight / Obese\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: coarse breath sounds\n Abdominal: Soft, Obese\n Extremities: Right: 1+, Left: 1+\n Skin: Warm\n Neurologic: Responds to: Unresponsive, Movement: No spontaneous\n movement, Tone: Normal\n Labs / Radiology\n 8.9 g/dL\n 358 K/uL\n 126 mg/dL\n 0.7 mg/dL\n 25 mEq/L\n 3.5 mEq/L\n 4 mg/dL\n 108 mEq/L\n 143 mEq/L\n 28.0 %\n 8.1 K/uL\n [image002.jpg]\n 12:05 PM\n 06:08 PM\n 06:11 PM\n 07:53 PM\n 02:02 AM\n 03:59 AM\n 09:14 PM\n 01:04 AM\n 05:54 AM\n 06:11 AM\n WBC\n 8.4\n 8.1\n Hct\n 29.0\n 28.1\n 28.0\n Plt\n 376\n 358\n Cr\n 0.6\n 0.7\n TCO2\n 29\n 29\n 25\n 25\n 28\n 28\n 26\n Glucose\n 120\n 126\n Other labs: PT / PTT / INR:22.2/76.0/2.1, ALT / AST:24/16, Alk Phos / T\n Bili:117/0.7, Amylase / Lipase:, Differential-Neuts:74.7 %,\n Lymph:17.6 %, Mono:3.8 %, Eos:3.4 %, Lactic Acid:0.7 mmol/L,\n Albumin:2.4 g/dL, LDH:204 IU/L, Ca++:8.2 mg/dL, Mg++:2.0 mg/dL, PO4:3.2\n mg/dL\n Assessment and Plan\n 55-year-old woman with\n Respiratory failure\n End-exp transpulmonary pressure: -2\n End-insp transpulmonary pressure: +5\n Esophageal pressures suggest that she is at safe pressures.\n Traumatic thoracic spinal fracture\n Eventual MRI. Too high-risk at present. Brace when out of\n bed.\n Probable VAP\n Discuss GNRs with lab\n Complete 8\n 15d course of present ABX pending cultures\n D/C vancomycin since no identified GPCs\n D/C Flagyl since no CT or toxin evidence of C diff\n Shock\n now back on levophed\n CVP is 20 mm Hg but Pes is ~25 cm H20\n Re-assess SVV with Vigileo and consider volume challenge\n Upper extremity DVT\n Therapeutic heparin\n Anemia\n Follow\n Possible tracheobronchomalacia (reason for transfer)\n Incidental peri-appendiceal finding (will need eventual\n follow-up)\n Although differential remains open, the most compelling course of\n events is probably that she required intubation at the outside hospital\n (?sedation ?restriction from obesity/brace ?other) and subsequently\n developed a GNR-related VAP. Her pattern of acute lung injury,\n combined with obesity, is resulting in basilar and\n posterior-predominant atelectasis/consolidation with a high proportion\n of shunt. Given her very high PEEP, will try to avoid bronchoscopy if\n possible.\n Other issues as per ICU team note.\n ICU Care\n Nutrition: resume tube feeds\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 01:36 AM\n Arterial Line - 03:00 AM\n Multi Lumen - 11:30 AM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Heparin gtt)\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 60 minutes\n Patient is critically ill\n"
},
{
"category": "Respiratory ",
"chartdate": "2167-10-06 00:00:00.000",
"description": "Generic Note",
"row_id": 635962,
"text": "TITLE:\n Respiratory: Rec\nd pt on a/c 18/400/10+/50%. Pt has #7 portex trach.\n BS are coarse to clear with diminished bases. Suctioning for small\n amounts of tan thick secretions. MDI\ns administered as ordered of\n alb/atr with no adverse reactions. Pt continues to move around a lot\n in the bed, and anxious at times. No RSBI done due to increased peep\n of 10. Plan is to wean to psv as tolerated and eventually t/c trials.\n No abg\ns noc.\n"
},
{
"category": "Respiratory ",
"chartdate": "2167-09-29 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 635050,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 11\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: appears agitated and\n uncomfortable at times,overbreathing by 10-15 breaths\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt required increased peep back up to 15 overnight due to\n desaturation into low 80s at times. She appears much more comfortable\n and in synch with the vent now.\n"
},
{
"category": "Nursing",
"chartdate": "2167-09-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 635138,
"text": "55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP now with prolonged\n hospital course c/o by PNA anxiety,RUE DVD with high PEEP requirement\n . had tolerated peep wean up until last night when pt dropped sats and\n po2 requring increase in peep and fio2. Sedated with fentanyl and\n versed gtts. Trach and peg scheduled for today was cancelled for\n increased peep requirements.\n Hypotension (not Shock)\n Assessment:\n Pt hypotensive throughout morning but because was having difficulty\n maintaining a consistent bp on extremities felt that it was poss\n inaccurate u/o decreasing over course of am, pt with variable hr from\n sb40 with bp 120-130\ns-to junctional tach 130 when awake and agitated ,\n with lower bp making it difficult to titrate gtts\n Both levophed and sedatives.\n Action:\n Axillary aline placed by md\n Response:\n Aline confirmed hypotension given 1000 ml FB with min effect. started\n on neo at .5 mcgs/kg/min but pt became bradycardic to 40 switched to\n levophed .04 mcg/kg/min with desired effect stim test performed\n 50mgs hydrocortisone given x1\n Increasing u/o to 50 mls /hr\n Plan:\n Goal to maintain maps greater than 65\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lungs with coarse rhonchii upper and diminished at bases with sats\n 92-93% on peep 15 fio 60% cyanotic when agitated.\n Action:\n Suctioned for mod to copious amounts thick tan secretions. increased\n sedation continued rtc diazepam\n Response:\n Improved control over agitation pt sedated but easily rouseable\n maintained o2 sats greater than 93% allowing a gradual slow wean of\n peep from 15-12\n Plan:\n To wean to peep of 10 and fio2of 50%. Accepting sats 88-92% and po2 in\n 60\n When bp maintained off levophed poss to start lasix gtt at low dose\n 1mg/hr pt 106 kgs up approx 12kgs from baseline.\n"
},
{
"category": "General",
"chartdate": "2167-10-01 00:00:00.000",
"description": "Generic Note",
"row_id": 635278,
"text": "55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP now with prolonged\n hospital course c/o by PNA anxiety,RUE DVD with high PEEP requirement\n .\n Events\n Heparin gtt and TF held since MN for ? trach and peg\n placement today.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on AC 400/18/8/50%. 02 sats mainly 88-92% but did fall to\n 86% when pt positioned on L side. Pt fluid overloaded with TFB for LOS\n ~ ccs.\n Action:\n ABG taken while sat 88%. Lasix gtt increased to 3mg/hr\n Response:\n ABG 7.42/47/87/4/32. Urine output 25-45ccs/hr (not meeting goal of neg\n 100-150ccs/hr)\n Plan:\n Continue with current vent settings. Trach today. Titrate lasix gtt up\n if can maintain MAP > 60.\n Altered mental status (not Delirium)\n Assessment:\n Pt restless at times, thrashing in bed with HR up to 140 ST . Denies\n pain or doesn\nt respond when questioned if she is having pain.\n Action:\n Fentanyl drip infusing at 100mcgs/hr. Also treated with haldol and\n valium . Bolused with 2 mg versed when acutely agitated. Bilateral\n wrist restraints in place.\n Response:\n Pt falls back to sleep, HR decreases (occasionally as low as 45 SB)\n Plan:\n Continue to assess MS. as indicated. Reorientation. Restraints\n for safety.\n Hypernatremia (high sodium)\n Assessment:\n Na 146 this am\n Action:\n Treated with free h20 boluses\n Response:\n Plan:\n Continue to monitor f+e status.\n Impaired Skin Integrity\n Assessment:\n Pt with excoriated yeast infection on abd and in perineal area.\n Action:\n Barrier cream and miconazole powder applied\n Response:\n To be determined.\n Plan:\n Diligent skin care.\n"
},
{
"category": "General",
"chartdate": "2167-10-01 00:00:00.000",
"description": "Generic Note",
"row_id": 635280,
"text": "55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP now with prolonged\n hospital course c/o by PNA anxiety,RUE DVD with high PEEP requirement\n .\n Events\n Heparin gtt and TF held since MN for ? trach and peg\n placement today.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on AC 400/18/8/50%. 02 sats mainly 88-92% but did fall to\n 86% when pt positioned on L side. Pt fluid overloaded with TFB for LOS\n ~ ccs.\n Action:\n ABG taken while sat 88%. Lasix gtt increased to 3mg/hr\n Response:\n ABG 7.42/47/87/4/32. Urine output initially 25 ccs/hr but pt began\n autodiuresing after MN with output improving to ~140ccs/hr\n Plan:\n Continue with current vent settings. Trach today. Titrate lasix gtt to\n maintain MAP > 60 and u/o 100-150ccs/hr.\n Altered mental status (not Delirium)\n Assessment:\n Pt restless at times, thrashing in bed with HR up to 140 ST . Denies\n pain or doesn\nt respond when questioned if she is having pain.\n Action:\n Fentanyl drip infusing at 100mcgs/hr. Also treated with haldol and\n valium . Bolused with 2 mg versed when acutely agitated. Bilateral\n wrist restraints in place.\n Response:\n Pt falls back to sleep, HR decreases (occasionally as low as 45 SB)\n Plan:\n Continue to assess MS. as indicated. Reorientation. Restraints\n for safety.\n Hypernatremia (high sodium)\n Assessment:\n Na 146 this am\n Action:\n Treated with free h20 boluses\n Response:\n Plan:\n Continue to monitor f+e status.\n Impaired Skin Integrity\n Assessment:\n Pt with excoriated yeast infection on abd and in perineal area.\n Action:\n Barrier cream and miconazole powder applied\n Response:\n To be determined.\n Plan:\n Diligent skin care.\n"
},
{
"category": "Respiratory ",
"chartdate": "2167-10-02 00:00:00.000",
"description": "Generic Note",
"row_id": 635432,
"text": "TITLE:\n Respiratory Care: Rec\nd pt on a/c 15/400/+8/50%. Ett 7.5 taped @ 21\n lip. BS are coarse bilaterally with diminished bases. Suctioned for\n small to moderate amounts of thick yellow/tan secretions. MDI\n administered as ordered alb/atr with no adverse reactions. AM ABG\n 7.44/52/70. No rsbi due to Trach/peg procedure today. No further\n changes noted.\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-02 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 635438,
"text": "Chief Complaint:\n 24 Hour Events:\n Patient agitated and combative overnight - restarted midazolam gtt and\n patient was becoming increasingly tachycardic and hypertensive\n Thoracics to take to OR this am for trach and PEG\n Discussion with patient's boyfriend yesterday - her should be here this\n weekend, wants to be involved, just hard for him to get here\n On lasix drip with excellent response (200 cc urine/hour)\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Fentanyl - 100 mcg/hour\n Furosemide (Lasix) - 1 mg/hour\n Heparin Sodium - 1,700 units/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:07 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.3\nC (99.2\n HR: 118 (45 - 138) bpm\n BP: 155/84(118) {91/38(56) - 177/106(139)} mmHg\n RR: 18 (17 - 27) insp/min\n SpO2: 90%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,604 mL\n 1,447 mL\n PO:\n TF:\n 675 mL\n 17 mL\n IVF:\n 1,089 mL\n 730 mL\n Blood products:\n Total out:\n 4,130 mL\n 2,430 mL\n Urine:\n 4,130 mL\n 2,430 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,526 mL\n -983 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n PS : 5 cmH2O\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n PIP: 22 cmH2O\n Plateau: 19 cmH2O\n Compliance: 48.2 cmH2O/mL\n SpO2: 90%\n ABG: 7.45/50/67/29/8\n Ve: 7.5 L/min\n PaO2 / FiO2: 134\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 306 K/uL\n 8.5 g/dL\n 165 mg/dL\n 0.7 mg/dL\n 29 mEq/L\n 3.7 mEq/L\n 10 mg/dL\n 108 mEq/L\n 146 mEq/L\n 27.1 %\n 11.2 K/uL\n [image002.jpg]\n 02:18 AM\n 01:27 PM\n 03:06 PM\n 10:04 PM\n 03:00 AM\n 10:47 AM\n 04:10 PM\n 12:13 AM\n 05:08 AM\n 05:20 AM\n WBC\n 8.6\n 11.2\n Hct\n 25.9\n 27.1\n Plt\n 280\n 306\n Cr\n 0.6\n 0.5\n 0.7\n TCO2\n 33\n 32\n 32\n 34\n 36\n 36\n Glucose\n 176\n 136\n 165\n Other labs: PT / PTT / INR:13.2/68.7/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:89.7 %, Lymph:8.7 %, Mono:1.1\n %, Eos:0.4 %, Lactic Acid:0.9 mmol/L, Albumin:2.4 g/dL, LDH:204 IU/L,\n Ca++:10.6 mg/dL, Mg++:2.8 mg/dL, PO4:4.3 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA and\n ARDS intubated since the end of .\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation.\n Transferred here for airway stenting.\n - attempt SBT today\n - OR add on for trach and PEG with Dr. (tube feeds off\n after MN, heparin off after 6am)\n # # Adrenal Insufficency: Minimal response to stim test again.\n Appreciate endocrine recommendations.\n - hydrocort and fludrocort (day 1 = )\n - will continue at current dose until s/p trach and PEG and\n hemodynamically stable for 24 hours\n will then plan to taper\n hydrocortisone to 25mg IV q6 with a slow taper\n - will repreat ACTH stim test after tapered to <30mg\n hydrocortisone or off steroids\n - f/u daily endocrine recs\n # Hypotension: Likely adrenal insufficiency and sedation. Goal map\n > 60. Much improved since re-administration of steroids.\n - hydrocortisone and fludrocortisone as above\n - restart levophed if necessary to maintain MAP > 60\n # Volume overloaded in setting of hypernatremia with TBW deficit.\n - goal -1000cc I/Os today\n - continue FW in TF at 250 cc q4hrs\n - lasix drip (1-5mg/hr) when MAP >\n 60\n # Sedation: Sedation control remains somewhat poor although fentanyl\n patch and diazpem are likely therapeutic range today. On Versed 1.5,\n Fentanyl 175, Fentanyl patch, Diazepam standing and haldo 2.5-5 mg\n PRN. QTc increased to 480.\n - Wean versed/fentanyl as tolerated, continue diazepam. Avoid\n haldol use if possible to avoid further prolongation of QTc\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\n coumadin at least until s/p trach.\n - hold heparin gtt when anticipate trach/peg\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n # FEN/GI: Tube feeds with FWF @ goal.\n DVT: Treatment dose heparin\n Ulcer: Ranitidine\n VAP: Prevention per routine\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n - touch base with SW today\n Code: Full\n Dispo: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Arterial Line - 02:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2167-09-20 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 634144,
"text": "Chief Complaint:\n HPI:\n 24 Hour Events:\n PICC LINE - START 10:30 PM\n INVASIVE VENTILATION - START 10:45 PM\n EKG - At 11:25 PM\n BLOOD CULTURED - At 05:30 AM\n TMax 102.7 BCX1 drawn\n FEVER - 102.7\nF - 04:00 AM\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Metronidazole - 08:00 AM\n Infusions:\n Fentanyl - 75 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.3\nC (102.7\n Tcurrent: 37.2\nC (99\n HR: 88 (72 - 97) bpm\n BP: 110/55(64) {83/38(48) - 154/71(103)} mmHg\n RR: 14 (12 - 18) insp/min\n SpO2: 100%\n Total In:\n 10 mL\n 1,043 mL\n PO:\n TF:\n 54 mL\n IVF:\n 10 mL\n 988 mL\n Blood products:\n Total out:\n 425 mL\n 585 mL\n Urine:\n 425 mL\n 585 mL\n NG:\n Stool:\n Drains:\n Balance:\n -416 mL\n 458 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 32 cmH2O\n SpO2: 100%\n ABG: 7.39/53/81./30/5\n Ve: 8 L/min\n PaO2 / FiO2: 135\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 9.7 g/dL\n 333 K/uL\n 103 mg/dL\n 0.6 mg/dL\n 30 mEq/L\n 3.8 mEq/L\n 6 mg/dL\n 109 mEq/L\n 150 mEq/L\n 30.7 %\n 9.7 K/uL\n [image002.jpg]\n 11:54 PM\n 01:00 AM\n 06:14 AM\n WBC\n 9.7\n Hct\n 30.7\n Plt\n 333\n Cr\n 0.6\n TCO2\n 32\n 33\n Glucose\n 103\n Other labs: PT / PTT / INR:13.8/22.4/1.2, ALT / AST:30/19, Alk Phos / T\n Bili:149/0.7, Differential-Neuts:76.9 %, Lymph:17.3 %, Mono:3.0 %,\n Eos:2.5 %, Albumin:3.0 g/dL, LDH:222 IU/L, Ca++:8.6 mg/dL, Mg++:2.1\n mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n Obese woman s/p t spine injury tx from Med for failure to wean\n from mech ventilation and evaluation for stent for\n tracheobronchomalacia\n 1. Resp Failure: initial etiology unclear\n but currently\n we need to assess what she can do here. Switch to PSV 10/5 and see what\n she can pull, check NIF. not act on this info. Let IP know she is\n here though not stable for intervention at this point.\n 2. New fevers and hypotension\n Is fluid responsive, watch\n UOP, goal 30 cc/hr. Check lactate.\n DDx VAP, asp PNA, lines. Has PCN and blactam allergy.\n For VAP- mini , change to Levoquin, Aztreonam, Vanco, and add\n Flagyl for asp.\n Lines: D/C PICC send cultures, try for 2nd PIV and if unable will\n place CVL. Check lactate.\n Belly: repeat LFTs, KUB OK, check residuals.\n 3. HyperNa: correcting with g tube free flush and D5W\n repeat lytes this evening and recalculate\n 4. Spine Fx: consult NSurg here re reccs for back bracing and\n activity\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 03:30 AM 10 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 10:30 PM\n 20 Gauge - 01:36 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition :\n Total time spent:\n Patient is critically ill\n"
},
{
"category": "Nutrition",
"chartdate": "2167-09-22 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 634347,
"text": "Subjective\n Pt intubated /sedated\n Objective\n Pertinent medications: noted\n Labs:\n Value\n Date\n Glucose\n 120 mg/dL\n 03:59 AM\n Glucose Finger Stick\n 124\n 10:00 AM\n FSBG\n 111, 111, 145, 123\n \n BUN\n 4 mg/dL\n 03:59 AM\n Creatinine\n 0.6 mg/dL\n 03:59 AM\n Sodium\n 141 mEq/L\n 03:59 AM\n Potassium\n 3.7 mEq/L\n 03:59 AM\n Chloride\n 108 mEq/L\n 03:59 AM\n Albumin\n 2.4 g/dL\n 03:59 AM\n Calcium non-ionized\n 8.2 mg/dL\n 03:59 AM\n Phosphorus\n 3.1 mg/dL\n 03:59 AM\n Ionized Calcium\n 1.16 mmol/L\n 12:05 PM\n Magnesium\n 2.2 mg/dL\n 03:59 AM\n Corrented Ca\n 9.48\n Current diet order / nutrition support: replete c/ Fiber @60mL/hr (1440\n kcals 89 gr aa)- currently on hold\n GI: Abd: softly dist/absent bs/no BM\n Assessment of Nutritional Status\n Specifics:\n TF\ns trialed. Held high residuals and OGT placed to suction. OGT\n is currently clamped. Pt has not had a BM since admission. Would\n consider increasing bowel regimen and adding a promotility . If\n unable to resume TFs in next 2-3 days, will need to TPN for nutrition\n support.\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: via nutrition support\n Consider reglan +/- increase bowel regimen\n Resume TF's as medically feasible, if unable in next 2-3 days, will\n need to consider PN to prevent nutritional decline\n BG/lyte management\n"
},
{
"category": "Physician ",
"chartdate": "2167-09-22 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 634352,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n -Neurosurg: ok to transport. Will decide on anticoagulation in AM\n -Central line placed\n -NGT to suction\n -Bowel regimen\n -Respiratory attempted to place esophageal ballon in order to measure\n intrathoracic pressure, unsuccessful\n -Desaturation around 23:00 to low 80s on 400/22/15/0.9 following turn.\n Recruitment maneuver (PEEP to 30) done x2 with good effect, Sat came up\n to 100%. PEEP left at 17\n -Transfused 1 un pRBC\n - Started levophed yesterday for hypotension\n - No BM\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 10:00 AM\n Aztreonam - 02:00 PM\n Vancomycin - 12:00 AM\n Metronidazole - 12:00 AM\n Infusions:\n Norepinephrine - 0.02 mcg/Kg/min\n Fentanyl - 200 mcg/hour\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:00 AM\n Midazolam (Versed) - 02:20 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 37.6\nC (99.6\n HR: 73 (64 - 96) bpm\n BP: 119/48(69) {85/39(55) - 142/67(91)} mmHg\n RR: 22 (11 - 22) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 94.2 kg (admission): 94.2 kg\n Height: 67 Inch\n CVP: 20 (11 - 21)mmHg\n Bladder pressure: 14 (14 - 18) mmHg\n Total In:\n 3,482 mL\n 465 mL\n PO:\n TF:\n IVF:\n 2,845 mL\n 465 mL\n Blood products:\n 277 mL\n Total out:\n 580 mL\n 65 mL\n Urine:\n 580 mL\n 65 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,902 mL\n 400 mL\n Respiratory support\n Ventilator mode: AC\n Vt (Set): 400 (400 - 500) mL\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 17 cmH2O\n FiO2: 80%\n PIP: 33 cmH2O\n Plateau: 30 cmH2O\n Compliance: 30.8 cmH2O/mL\n SpO2: 98%\n ABG: 7.38/41/86./24/0\n Ve: 9.1 L/min\n PaO2 / FiO2: 109\n Physical Examination\n Gen: Does not arouse to voice\n HEENT: Pupils 3 mm non-reactive bilaterally. Scleral edema bilat\n Resp: Symmetric expansion. Vesicular sounds throughout. Inspiratory\n and expiratory tracheal sounds (?related to ET tube).\n CV: RRR.\n Abd: Hypoactive bowel sounds. Distended.\n Ext: Edema in bilat UE.\n Peripheral vascular: Radial pulses 2+ bilaterally.\n Neuro: Moving all 4 extremities.\n Labs / Radiology\n 376 K/uL\n 9.0 g/dL\n 120 mg/dL\n 0.6 mg/dL\n 24 mEq/L\n 3.7 mEq/L\n 4 mg/dL\n 108 mEq/L\n 141 mEq/L\n 28.1 %\n 8.4 K/uL\n [image002.jpg]\n ALT 24 PT 18.7\n AST 16 PTT 25.4\n AP 117 INR 1.7\n Tbili 0.7\n Alb 2.4\n 08:03 PM\n 11:00 PM\n 03:01 AM\n 03:13 AM\n 12:05 PM\n 06:08 PM\n 06:11 PM\n 07:53 PM\n 02:02 AM\n 03:59 AM\n WBC\n 7.6\n 6.4\n 8.4\n Hct\n 24.1\n 24.1\n 29.0\n 28.1\n Plt\n \n Cr\n 0.6\n 0.6\n 0.6\n TCO2\n 33\n 30\n 29\n 29\n 25\n 25\n Glucose\n 127\n 129\n 120\n Differential-Neuts:80.8 %, Lymph:12.0 %, Mono:3.5 %, Eos:3.3 %\n Ca++:8.2 mg/dL, Mg++:2.2 mg/dL, PO4:3.1 mg/dL, ion Ca++ () 1.16\n Cortisol:\n : 2:15am 24.2 Midnight 2.7\n : 3am 4.5\n Micro: neg or NGTD if not mentioned\n : blood, \n : urine, sputum-OP flora\n : BAL, - coag neg staph, lactobacillus, cath tip, sputum- OP\n flora, rare GNR, blood\n U/a:\n Color\n Amber\n Appear\n Clear\n SpecGr\n 1.015\n pH\n 5.5\n Urobil\n 2\n Bili\n Mod\n Leuk\n Tr\n Bld\n Tr\n Nitr\n Pos\n Prot\n 100\n Glu\n Neg\n Ket\n 40\n RBC\n 0-2\n WBC\n 0-2\n Bact\n Few\n Yeast\n None\n Epi\n 0-2\n Imaging:\n Echo\n post recruitment CXR showed deep sulcus but no pnumothorax per rads.\n CT: Prelim Read\n Right lower lobe consolidation, and superimposed atelectasis/lower lobe\n collapse, and effusions. Acute T8 compression deformity, with no\n posterior\n retropulsion of fracture fragments. No associated hematoma.\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture\n # Respiratory failure: initial etiology unclear, likely multifactorial\n now with significant pneumonia. Had one sputum that showed GNR.\n - Had a desat event yesterday. Responded positively to recruitment\n maneuvers.\n - Will attempt placement of an esophageal balloon; with knowledge of\n intrathoracic pressures, can consider going up on PEEP\n # Infectious process: Had been febrile, now resolved\n - be aspiration or be VAP. Sputum from grew rare GNR;\n awaiting speciation.\n - Continues on Vanc, aztreonam, levofloxicin. Vanc trough pending today\n - Also on flagyl for empiric coverage of c. diff\n - Per CT, unlikely to be abdominal process\n # Hypotension, requiring Levophed:\n - Hypovolemia is possibly a factor- responded to a transfusion; HCT had\n been dropping\n - Sepsis also a factor- on broad spectrum abs\n - Central line in place.\n # Oliguria:\n -BUN and Cr reassuring.\n # RUE DVT: Have held on starting treatment in light of need for central\n access. Can start therapeutic heparin vs Lovenox with bridge to\n coumadin.\n - No PE noted on CT scan.\n # Abd distention:\n - CT abd only showed appendiceal mucocele without inflammation, not\n concerning, most likely chronic\n - No BM in several days, continue bowel regimen, add fleets enema\n - Can test for c.diff when pt stool\ns. Continue flagyl empirically\n - Check amylase and lipase\n # Anemia:\n - Trend HCT\n - Gave 1 un pRBC with good results\n - Will guiac stools when she has a BM\n - INR rising, now 1.7, may be nutritional\n # Spine fracture: neurologically intact distal to the lesion. prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - Will have spine see pt today for recs regarding pt movement and\n anticoagulation\n # Hypernatremia, resolved: correcting with g tube free flush and D5W\n -Holding on g tube feeds at present due to high residuals\n -Replete lytes as necessary\n # Communication:\n - Brother has been with pt, although, live in boyfriend of 10 is\n her HCP. Boyfriend will hopefully visit pt today\n ICU Care\n Nutrition: tube feed with free water when able\n Glycemic Control: Regular insulin sliding scale\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Communication: ICU consent signed, (brother) \n (boyfriend/POA) \n Code status: Full code\n Disposition: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 01:36 AM\n 22 Gauge - 02:00 PM\n Arterial Line - 03:00 AM\n Multi Lumen - 11:30 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2167-09-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 634404,
"text": "55 yr old women admitted from outside hospital. Patient fell down\n stairs at home per boyfriend pt with fracture and placed in torso\n brace at OSH, pt became hypoxic and was intubated (family requested a\n second opinion and pt was trans to ) Pt admitted for Resp failure,\n failure to wean, and ? tracheal bronchial malacia. Full code,\n Allergies: PCN, Tetracycline, Sulfta.\n Per boyfriend tonight he reported that for the last two months pt has\n been drinking 2 bottles of wine almost every night.\n And that this is an increase from what she previously did which was a\n couple of beers per night.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n RLL consolidation, bilat effusions, R < L ; suct for thick yellowish\n secretions from ETT; copious thick secretions suct from mouth\n Action:\n Pt 2 down to 60%, Peep @ 23 0600 Fio2 decreased to 50% 2/2 Pao2 of\n 160\n Response:\n Pt tolerating turns and current vent settings well\n Plan:\n Cont to ABGS, VS;\n Hypotension (not Shock)\n Assessment:\n SBP down in 80\ns, MAP 60\n Action:\n Levophed restarted @0130, currently running @ 0.02mcg\n Response:\n BP improved 110-90\ns MAP 65\n Plan:\n Cont to BP, MAP goal >65 , Levo as needed\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt (+) DVT RUE\n Action:\n Pt started on IV Heparin @1700U/hr\n Response:\n Pt PTT@ 0030 62.7, no changes to infusion\n Plan:\n Cont to PTT, adjust heparin accordingly; cont with no BP/LAB draws\n to R arm\n Alteration in Nutrition\n Assessment:\n TF currently on hold high residuals, abd distended soft, hypoactive\n bowel sounds\n Action:\n Pt started on Naloxone x 3 doses, rectal tube in place for\n decompression; bowel regimen continued\n Response:\n Pt passing sm. Amt loose green stool with dose of Naxolone\n Plan:\n Re-evaluate for increase in Naloxone dose; ? restarting TF/advancing\n Fracture, other\n Assessment:\n Pt T5/T8 fracture s/p fall \n Action:\n Spine/ortho consult done\n Response:\n Pt off logroll precautions, tolerates position changes\n Plan:\n Activity as tolerated, needs to wear TorsoBrace when OOB or sitting up\n"
},
{
"category": "Nursing",
"chartdate": "2167-09-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 634440,
"text": "Events: Attempt to lighten sedation, stop Levophed gtt- MS \n stability labile from lethargic to restless in bed/crying w/\n intermittent BP 120\ns/ w/ and W/O stimulation. UOP cont 10-30cc/hr.\n Vigileo monitor on- SVV . Bladder pressure 14.\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2167-09-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 634585,
"text": "24 Hour Events:\n -Yesterday, stopped vanc and flagyl. Continued Aztreonam and\n Levofloxicin\n -Febrile to 101- pan cultured; cxr\n -Micro on sputum GNR due back today\n -Decreased FiO2 and PEEP to 21 (from 23 for ABG 7.42/39/116 at 11PM)\n -Early am, HR dropped to 40s-50s. EKG suggestive of junctional rhythm.\n Held pressures, making good UOP, good O2 sats\n -This am, art line is intermittently working. Drew ABG - pending\n -Yesterday, SVV was 7; held on giving more fluids\n -Random cortisol was very low; started hydrocortisone and florinef\n -UOP picked up this AM\n -Restarted tube feeds\n -K, Phos given this AM\n -New possible junctional rhythm (low voltage) at 5AM. Enzymes added on\n -Spine -> request CT C, L spine, MRI, TLSO, non-operative, d/c log roll\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Metronidazole - 08:00 AM\n Levofloxacin - 08:39 AM\n Aztreonam - 02:00 PM\n Infusions:\n Norepinephrine - 0.02 mcg/Kg/min\n Midazolam (Versed) - 4 mg/hour\n Other ICU medications:\n Midazolam (Versed) - 03:50 PM\n Fentanyl - 03:50 PM\n Ranitidine (Prophylaxis) - 08:31 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (101\n Tcurrent: 37.1\nC (98.8\n HR: 60 (60 - 86) bpm\n BP: 103/46(61) {103/46(61) - 121/50(66)} mmHg\n RR: 22 (17 - 23) insp/min\n SpO2: 99%\n Heart rhythm: JR (Junctional Rhythm)\n Wgt (current): 101 kg (admission): 94.2 kg\n Height: 67 Inch\n CVP: 12 (12 - 339)mmHg\n Total In:\n 1,675 mL\n 232 mL\n PO:\n TF:\n 182 mL\n 134 mL\n IVF:\n 1,233 mL\n 98 mL\n Blood products:\n Total out:\n 877 mL\n 565 mL\n Urine:\n 727 mL\n 535 mL\n NG:\n 30 mL\n Stool:\n Drains:\n Balance:\n 798 mL\n -333 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 22\n RR (Spontaneous): 2\n PEEP: 21 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 33 cmH2O\n Plateau: 30 cmH2O\n Compliance: 44.4 cmH2O/mL\n SpO2: 99%\n ABG: 7.46/28/129 at 6AM\n Repeated at 9AM 7.4/38/97\n Ve: 9.7 L/min\n PaO2 / FiO2: 290\n Physical Examination\n Gen: Does not arouse to voice\n HEENT: Pupils 3 mm reactive bilaterally. Scleral edema bilat\n Resp: Symmetric expansion. Coarse breath sounds throughout. Cannot\n adeq listen to post bases\n CV: RRR.\n Abd: Hypoactive bowel sounds. Distended.\n Ext: Edema in bilat UE.\n Peripheral vascular: Radial pulses 2+ bilaterally.\n Neuro: Moving all 4 extremities.\n Labs / Radiology\n 326 K/uL\n 8.9 g/dL\n 151 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 3.6 mEq/L\n 2 mg/dL\n 108 mEq/L\n 141 mEq/L\n 28.6 %\n 8.9 K/uL\n [image002.jpg]\n 06:11 PM\n 07:53 PM\n 02:02 AM\n 03:59 AM\n 09:14 PM\n 01:04 AM\n 05:54 AM\n 06:11 AM\n 11:07 PM\n 03:51 AM\n WBC\n 8.4\n 8.1\n 8.9\n Hct\n 28.1\n 28.0\n 28.6\n Plt\n 376\n 358\n 326\n Cr\n 0.6\n 0.7\n 0.7\n TCO2\n 29\n 25\n 25\n 28\n 28\n 26\n 26\n Glucose\n 120\n 126\n 151\n Other labs: PT / PTT / INR:24.3/68.6/2.4, ALT / AST:24/16, Alk Phos / T\n Bili:117/0.7, Amylase / Lipase:, Differential-Neuts:82.5 %,\n Lymph:11.6 %, Mono:3.3 %, Eos:2.2 %, Lactic Acid:0.7 mmol/L,\n Albumin:2.4 g/dL, LDH:204 IU/L, Ca++:8.5 mg/dL, Mg++:2.1 mg/dL, PO4:2.5\n mg/dL\nMicro: 2:38 am SPUTUM Site: ENDOTRACHEAL\n GRAM STAIN (Final ):\n >25 PMNs and <10 epithelial cells/100X field.\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.\n IN PAIRS AND CLUSTERS.\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).\n RESPIRATORY CULTURE (Pending)\n GRAM STAIN (Final ) SPUTUM Site: ENDOTRACHEAL:\n <10 PMNs and <10 epithelial cells/100X field.\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.\n IN PAIRS.\n 1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).\n CULTURE: GRAM NEGATIVE ROD(S). RARE GROWTH. WORK-UP PER DR ().\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with respiratory failure\n and difficulty weaning from vent.\n # Respiratory failure: Over the evening yesterday, were able to\n decrease FiO2 and PEEP. Clinical and imaging suggestive of ARDS.\n Initial preceptiationg factors: sedation, hypovent obesity,\n orthotic brace. Now thought to have VAP.\n - Placed esophageal balloon on which will help guide PEEP settings.\n # VAP: Re-spiked fever overnight. Stopped vanc yesterday, , as\n treating for GNR infection. Current GS shows GPC\n - Follow cultures\n - Restart Vanc.\n - Continue aztreonam, levofloxicin for 8 days pending speciation (at\n that time can increase to 15 days if necessary)\n - Also, stopped flagyl because had one neg c. diff toxin and CT did not\n show evidence of colitis\n # EKG changes: very low voltages and no change in QRS morphology.\n P-waves may be buried.\n -repeat\n -f/u enzymes\n # Hypotension, requiring Levophed: Increased urine output c/w\n autodiuresing\n - Attempt to wean from levophed with MAP goal 65 and UOP goal >30 cc/hr\n - Hypovolemia is possibly a factor- responded to a transfusion; HCT had\n been dropping. However, SVV with Vigileo was 13, making her CO less\n likely to respond to fluids. Held on giving any boluses overnight.\n - Sepsis also a factor- on broad spectrum abs\n - Central line in place.\n # Oliguria: Improved recently. BUN and Cr reassuring.\n -Continue to monitor\n # RUE DVT: Started on heparin gtt on .\n -Therapeutic in one day; may be related to poor nutritional status.\n Will continue to closely monitor\n # Abd distention: be chronic condition not requiring immediate\n medical attention\n - CT abd only showed appendiceal mucocele without inflammation, not\n concerning, most likely chronic. No concern for intraabd disaster\n - Now having BMs; c. diff toxin neg\n - amylase and lipase wnl\n # Adrenal Insufficency:\n -Random cortisol was approx 3 when it should have been maximally\n stimulated.\n -Started hydrocortisone and florinef. ? switch to methylpred\n # Anemia:\n - Trend HCT\n - Gave 1 un pRBC with good results\n - INR rising, now 2.0, may be nutritional\n # Spine fracture: neurologically intact distal to the lesion. prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - Repeat CT C, L spine.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n # Hypernatremia, resolved: correcting with g tube free flush and D5W\n -Holding on g tube feeds at present due to high residuals\n -Replete lytes as necessary\n # Communication:\n - Brother has been with pt, although, live in boyfriend of 10 is\n her HCP. Boyfriend will hopefully visit pt today\n ICU Care\n Nutrition: tube feed with free water when able\n Glycemic Control: Regular insulin sliding scale\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Communication: ICU consent signed, (brother) \n (boyfriend/POA) \n Code status: Full code\n Disposition: ICU\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 10:55 PM 30 mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 01:36 AM\n Arterial Line - 03:00 AM\n Multi Lumen - 11:30 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2167-09-30 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 635194,
"text": "Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - START 02:00 PM - in right brachial atery\n Hypotensive- started on levophed, weaned off over night\n Low cortisol and failed stim test - started on steroids\n TTE ordered\n Free water flushes were increased for hypernatremia (250cc q4)\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 08:06 AM\n Infusions:\n Heparin Sodium - 1,700 units/hour\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 150 mcg/hour\n Other ICU medications:\n Haloperidol (Haldol) - 12:15 AM\n Other medications:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 36.7\nC (98\n HR: 63 (48 - 138) bpm\n BP: 91/41(58) {68/30(49) - 143/78(105)} mmHg\n RR: 18 (13 - 23) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Mixed Venous O2% Sat: 59 - 59\n Total In:\n 3,898 mL\n 1,155 mL\n PO:\n TF:\n 802 mL\n 348 mL\n IVF:\n 2,126 mL\n 247 mL\n Blood products:\n Total out:\n 2,367 mL\n 800 mL\n Urine:\n 2,367 mL\n 800 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,531 mL\n 355 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 401) mL\n RR (Set): 18\n RR (Spontaneous): 1\n PEEP: 10 cmH2O\n FiO2: 40%\n PIP: 23 cmH2O\n Plateau: 19 cmH2O\n Compliance: 57.1 cmH2O/mL\n SpO2: 91%\n ABG: 7.42/49/93/33/5\n Ve: 8.1 L/min\n PaO2 / FiO2: 155\n Physical Examination\n Labs / Radiology\n 355 K/uL\n 9.1 g/dL\n 168 mg/dL\n 0.5 mg/dL\n 30 mEq/L\n 3.9 mEq/L\n 11 mg/dL\n 108 mEq/L\n 146 mEq/L\n 29.9 %\n 11.8 K/uL\n [image002.jpg]\n 03:32 PM\n 10:19 PM\n 02:50 AM\n 02:30 PM\n 02:44 PM\n 03:33 PM\n 07:26 PM\n 07:46 PM\n 02:04 AM\n 02:18 AM\n WBC\n 9.0\n 8.4\n 11.8\n Hct\n 25.8\n 23.0\n 28.1\n 29.9\n Plt\n \n Cr\n 0.6\n 0.7\n 0.5\n TCO2\n 30\n 35\n 33\n 31\n 33\n Glucose\n 94\n 97\n 168\n Other labs: PT / PTT / INR:13.8/70.4/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:89.7 %, Lymph:8.7 %, Mono:1.1\n %, Eos:0.4 %, Lactic Acid:0.9 mmol/L, Albumin:2.4 g/dL, LDH:204 IU/L,\n Ca++:8.5 mg/dL, Mg++:2.2 mg/dL, PO4:5.4 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with respiratory failure\n and difficulty weaning from vent.\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation.\n Transferred here for tracheomalacia, but not sure this is a component.\n Will need bronch eval when improved\n - Thoracics will do trach and PEG once stable on PEEPs around 10. Had\n been planned for today but currently holding as PEEP is 15.\n - wean PEEP as tolerated\n - needs A-line\n # Volume overload\n Currently with hypernatremia, Cr increase, contract\n alk, but mild\n - continue gentle diuresis with goal -1L per day as tolerated by blood\n pressure. IV lasix drip at 1-5 mg/hr.\n - FW in TF at 150 cc q4hrs\n - PM lytes.\n # Sedation: Now well seadated on Versed 1.5, Fentanyl 175, Fentanyl\n patch, Diazepam standing and haldo 2.5-5 mg PRN. QTc stable at .44\n - Wean versed/fentanyl as tolerated\n # HCT\n Has had slow decline while in ICU.\n - Xfuse PRN Hct < 21\n - continue to follow, guiac stools\n # Hypotension: Related to sedation, but high PEEP, adrenial\n insufficiency, sepsis have previously been contributing.\n - needs A-line for monitoring\n - cortisol stim to rule out persistent adrenal insufficiency\n # RUE DVT: Started on heparin gtt on , now off for trach that was\n planned for today. Follow PTTs. Would hold off on coumadin at least\n until s/p trach.\n - restart heparin\n # Adrenal Insufficency: Random cortisol was approx 3 when it should\n have been maximally stimulated. S/P 5 days of hydrocortisone and\n florinef.\n - will recheck as above and start at 50 q8 if needed\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n # FEN/GI: Tube feeds @ goal. No need to be NPO while awaiting stable\n PEEP\n DVT: Treatment dose heparin\n Ulcer: Ranitidine\n VAP: Prevention per routine\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 09:51 PM 60 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Arterial Line - 02:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2167-09-30 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 635196,
"text": "Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - START 02:00 PM - in right brachial atery\n Hypotensive- started on levophed, weaned off over night\n Low cortisol and failed stim test - started on steroids\n TTE ordered\n Free water flushes were increased for hypernatremia (250cc q4)\n Able to hear patient breathing at times during exam this am (poor am\n CXR, reordered)\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 08:06 AM\n Infusions:\n Heparin Sodium - 1,700 units/hour\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 150 mcg/hour\n Other ICU medications:\n Haloperidol (Haldol) - 12:15 AM\n Other medications:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 36.7\nC (98\n HR: 63 (48 - 138) bpm\n BP: 91/41(58) {68/30(49) - 143/78(105)} mmHg\n RR: 18 (13 - 23) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Mixed Venous O2% Sat: 59 - 59\n Total In:\n 3,898 mL\n 1,155 mL\n PO:\n TF:\n 802 mL\n 348 mL\n IVF:\n 2,126 mL\n 247 mL\n Blood products:\n Total out:\n 2,367 mL\n 800 mL\n Urine:\n 2,367 mL\n 800 mL\n NG:\n Stool:\n ?\n ?\n Drains:\n Balance:\n 1,531 mL\n 355 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 401) mL\n RR (Set): 18\n RR (Spontaneous): 1\n PEEP: 10 cmH2O\n FiO2: 40%\n PIP: 23 cmH2O\n Plateau: 19 cmH2O\n Compliance: 57.1 cmH2O/mL\n SpO2: 91%\n ABG: 7.42/49/93/33/5\n Ve: 8.1 L/min\n PaO2 / FiO2: 155\n Physical Examination\n General Appearance: Easily agitated, appears uncomfortable, Overweight\n / Obese, opens eyes but no purposeful movement\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\n deviation\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Respiratory / Chest: (Expansion: Symmetric), referred breath sounds\n from ETT\n Abdominal: No(t) Soft, Non-tender, Few Bowel sounds present, Distended\n Extremities: No clubbing or cyanosis, 3+ nonpitting edema of b/l hands,\n anasarca\n Skin: no rashes or jaundice\n Neuro: diffusely hyperreflexic with LE clonus\n Lines: r brachioceph ART and L PICC C/D/I\n Labs / Radiology\n 355 K/uL\n 9.1 g/dL\n 168 mg/dL\n 0.5 mg/dL\n 30 mEq/L\n 3.9 mEq/L\n 11 mg/dL\n 108 mEq/L\n 146 mEq/L\n 29.9 %\n 11.8 K/uL\n [image002.jpg]\n 03:32 PM\n 10:19 PM\n 02:50 AM\n 02:30 PM\n 02:44 PM\n 03:33 PM\n 07:26 PM\n 07:46 PM\n 02:04 AM\n 02:18 AM\n WBC\n 9.0\n 8.4\n 11.8\n Hct\n 25.8\n 23.0\n 28.1\n 29.9\n Plt\n \n Cr\n 0.6\n 0.7\n 0.5\n TCO2\n 30\n 35\n 33\n 31\n 33\n Glucose\n 94\n 97\n 168\n Other labs: PT / PTT / INR:13.8/70.4/1.2, Differential-Neuts:89.7 %,\n Lymph:8.7 %, Mono:1.1 %, Eos:0.4 %, Ca++:8.5 mg/dL, Mg++:2.2 mg/dL,\n PO4:5.4 mg/dL\n Culture Data: endotrach with K oxytoca; gram stain GPCs in\n pairs and clusters\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with respiratory failure\n and difficulty weaning from vent.\n # Respiratory failure: Related to ARDS, ? trachiomalacia, resolved\n VAP, volume overload. Intubated on for resp decompensation.\n Transferred here for tracheomalacia, but not sure this is a component.\n Will need bronch eval when improved\n - Thoracics will do trach and PEG once stable on PEEPs around 10.\n Re-c/s today.\n - wean PEEP as tolerated\n # Volume overload\n Hypernatremic (? Relationship to adrenal\n insufficiency), TBW deficit 2.6L.\n - goal even I/Os today\n - FW in TF at 250 cc q4hrs\n - PM lytes\n # Hyperreflexia - ? meds vs central pathology\n - consider head CT in context of heparin gtt to r/o intracranial\n hemmorhage\n # Sedation: Poor sedation control. On Versed 1.5, Fentanyl 175,\n Fentanyl patch, Diazepam standing and haldo 2.5-5 mg PRN. QTc stable\n at .44\n - Wean versed/fentanyl as tolerated\n - Recheck EKG today\n -\n # Hypotension: Related to sedation, but high PEEP, adrenial\n insufficiency, sepsis have previously been contributing. Monitor with\n A-line. Failed stim again.\n - hydrocortisol and fludrocortisone\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\n coumadin at least until s/p trach.\n - hold heparin gtt when anticipate trach/peg\n # Adrenal Insufficency: Minimal response to stim test again.\n - hydrocort and fludrocort\n - consider endocrine c/s for further elucidation of etiology\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n # FEN/GI: Tube feeds @ goal.\n DVT: Treatment dose heparin\n Ulcer: Ranitidine\n VAP: Prevention per routine\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 09:51 PM 60 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Arterial Line - 02:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 635377,
"text": "55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP now with prolonged\n hospital course c/o by PNA anxiety,RUE DVD with high PEEP requirement\n .\n Events: pt to go to OR on for trach/PEG. Failed spont. Breathing\n trial.\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 635434,
"text": "55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP now with prolonged\n hospital course c/o by PNA anxiety,RUE DVD with high PEEP requirement\n .\n Events:\n Pt found at 19:30 to have loose restraints and was pulling on ETT. Pt\n found to have pulled out her esophageal tube and disconnected IV lines.\n CXR done and ETT and OGGT in right position.\n Plan: Plan for OR this am for trach and peg. Heparin gtt off at 6am.\n Edema, peripheral\n Assessment:\n Pt has gen edema with +2 pitting.\n Action:\n Pt is on lasix gtt, now at 1 mg/hr. Goal to remove 1-2 liters/24hrs. Pt\n is currently + 17.3 liters for LOS.\n Response:\n Pt is diuresing well to lasix .\n Plan:\n Continue to evaluate need for lasix and follow K level closely. K level\n replaced x 1 with 80m meq of Kcl 3.0 ,\n Hypernatremia (high sodium)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 635531,
"text": "55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP now with prolonged\n hospital course c/o by PNA anxiety,RUE DVD with high PEEP requirement\n .\n EVENTS: trach PEG done, PEG OK for meds, restart TF in am. restart hep\n gtt tomorrow, diamox/ KCL added for alkalosis.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt rec\nd intubated, on AC 400x18 50% +PEEP 8\n Action:\n Trach placed in the OR, pt returned from OR and placed on previous vent\n settings, failed att at CPAP wean.\n Response:\n Plan:\n Att to wean vent/ sedation slowly in am. Cont to monitor\n Altered mental status (not Delirium)\n Assessment:\n Pt rec\nd on fent/ versed gtt\ns at 100mcg/hr/ 2mg/hr respectively,\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 635532,
"text": "55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP now with prolonged\n hospital course c/o by PNA anxiety,RUE DVD with high PEEP requirement\n .\n EVENTS: trach PEG done, PEG OK for meds, restart TF in am. restart hep\n gtt tomorrow, diamox/ KCL added for alkalosis.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt rec\nd intubated, on AC 400x18 50% +PEEP 8\n Action:\n Trach placed in the OR, pt returned from OR and placed on previous vent\n settings, failed att at CPAP wean.\n Response:\n Plan:\n Att to wean vent/ sedation slowly in am. Cont to monitor\n Altered mental status (not Delirium)\n Assessment:\n Pt rec\nd on fent/ versed gtt\ns at 100mcg/hr/ 2mg/hr respectively,\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Respiratory ",
"chartdate": "2167-09-23 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 634402,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Comments: Pt continues to be intubated on full vent support. This\n shift , peep was increased to 23 cmh20 while the fio2 was wean down to\n 50%, and is tolerated well. Pt was suctioned for small thick tan\n secretions. No other vent changes were made.\n"
},
{
"category": "Physician ",
"chartdate": "2167-09-23 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 634412,
"text": "Chief Complaint:\n 24 Hour Events:\n ESOPHOGEAL BALLOON - At 01:46 PM - went well, were able to\n increase PEEP to improve oxygenation\n - started naloxone to encourage bowel motility, with some success,\n rectal tube in place\n -started heparin gtt for RUE DVT\n -borderline hypotensive at times (low 90s) with low urine output,\n received boluses and norepi back on at 0.04\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 09:45 AM\n Metronidazole - 03:32 PM\n Vancomycin - 08:00 PM\n Aztreonam - 10:00 PM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Heparin Sodium - 1,700 units/hour\n Fentanyl - 100 mcg/hour\n Norepinephrine - 0.04 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38\nC (100.4\n Tcurrent: 37.3\nC (99.2\n HR: 73 (60 - 102) bpm\n BP: 90/46(61) {76/38(56) - 160/71(97)} mmHg\n RR: 23 (16 - 25) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101 kg (admission): 94.2 kg\n Height: 67 Inch\n CVP: 8 (8 - 15)mmHg\n Bladder pressure: 18 (18 - 21) mmHg\n Total In:\n 3,524 mL\n 234 mL\n PO:\n TF:\n 48 mL\n IVF:\n 3,236 mL\n 234 mL\n Blood products:\n Total out:\n 935 mL\n 215 mL\n Urine:\n 650 mL\n 215 mL\n NG:\n 285 mL\n Stool:\n Drains:\n Balance:\n 2,589 mL\n 19 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 0 (0 - 0) mL\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 23 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 42 cmH2O\n Plateau: 32 cmH2O\n Compliance: 44.4 cmH2O/mL\n SpO2: 100%\n ABG: 7.36/47/153//0\n Ve: 9.5 L/min\n PaO2 / FiO2: 255\n Physical Examination\n Gen: Does not arouse to voice\n HEENT: Pupils 3 mm non-reactive bilaterally. Scleral edema bilat\n Resp: Symmetric expansion. Vesicular sounds throughout. Inspiratory\n and expiratory tracheal sounds (?related to ET tube).\n CV: RRR.\n Abd: Hypoactive bowel sounds. Distended.\n Ext: Edema in bilat UE.\n Peripheral vascular: Radial pulses 2+ bilaterally.\n Neuro: Moving all 4 extremities.\n Labs / Radiology\n 376 K/uL\n 9.0 g/dL\n 120 mg/dL\n 0.6 mg/dL\n 24 mEq/L\n 3.7 mEq/L\n 4 mg/dL\n 108 mEq/L\n 141 mEq/L\n 28.1 %\n 8.4 K/uL\n [image002.jpg]\n 03:01 AM\n 03:13 AM\n 12:05 PM\n 06:08 PM\n 06:11 PM\n 07:53 PM\n 02:02 AM\n 03:59 AM\n 09:14 PM\n 01:04 AM\n WBC\n 6.4\n 8.4\n Hct\n 24.1\n 29.0\n 28.1\n Plt\n 319\n 376\n Cr\n 0.6\n 0.6\n TCO2\n 30\n 29\n 29\n 25\n 25\n 28\n 28\n Glucose\n 129\n 120\n Other labs: PT / PTT / INR:18.7/62.7/1.7, ALT / AST:24/16, Alk Phos / T\n Bili:117/0.7, Amylase / Lipase:, Differential-Neuts:80.8 %,\n Lymph:12.0 %, Mono:3.5 %, Eos:3.3 %, Lactic Acid:0.7 mmol/L,\n Albumin:2.4 g/dL, LDH:204 IU/L, Ca++:8.2 mg/dL, Mg++:2.2 mg/dL, PO4:3.1\n mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture\n # Respiratory failure: initial etiology unclear, likely multifactorial\n now with significant pneumonia. Had one sputum that showed GNR.\n - Had a desat event yesterday. Responded positively to recruitment\n maneuvers.\n - Will attempt placement of an esophageal balloon; with knowledge of\n intrathoracic pressures, can consider going up on PEEP\n # Infectious process: Had been febrile, now resolved\n - be aspiration or be VAP. Sputum from grew rare GNR;\n awaiting speciation.\n - Continues on Vanc, aztreonam, levofloxicin. Vanc trough pending today\n - Also on flagyl for empiric coverage of c. diff\n - Per CT, unlikely to be abdominal process\n # Hypotension, requiring Levophed:\n - Hypovolemia is possibly a factor- responded to a transfusion; HCT had\n been dropping\n - Sepsis also a factor- on broad spectrum abs\n - Central line in place.\n # Oliguria:\n -BUN and Cr reassuring.\n # RUE DVT: Have held on starting treatment in light of need for central\n access. Can start therapeutic heparin vs Lovenox with bridge to\n coumadin.\n - No PE noted on CT scan.\n # Abd distention:\n - CT abd only showed appendiceal mucocele without inflammation, not\n concerning, most likely chronic\n - No BM in several days, continue bowel regimen, add fleets enema\n - Can test for c.diff when pt stool\ns. Continue flagyl empirically\n - Check amylase and lipase\n # Anemia:\n - Trend HCT\n - Gave 1 un pRBC with good results\n - Will guiac stools when she has a BM\n - INR rising, now 1.7, may be nutritional\n # Spine fracture: neurologically intact distal to the lesion. prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per verbal report.\n # Hypernatremia, resolved: correcting with g tube free flush and D5W\n -Holding on g tube feeds at present due to high residuals\n -Replete lytes as necessary\n # Communication:\n - Brother has been with pt, although, live in boyfriend of 10 is\n her HCP. Boyfriend will hopefully visit pt today\n ICU Care\n Nutrition: tube feed with free water when able\n Glycemic Control: Regular insulin sliding scale\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Communication: ICU consent signed, (brother) \n (boyfriend/POA) \n Code status: Full code\n Disposition: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 01:36 AM\n Arterial Line - 03:00 AM\n Multi Lumen - 11:30 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2167-09-23 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 634413,
"text": "Chief Complaint:\n 24 Hour Events:\n ESOPHOGEAL BALLOON - At 01:46 PM - went well, were able to\n increase PEEP to improve oxygenation\n - started naloxone to encourage bowel motility, with some success,\n rectal tube in place with some stool\n -started heparin gtt for RUE DVT\n -borderline hypotensive at times (low 90s) with low urine output,\n received boluses and norepi back on at 0.04 (now down to 0.02)\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 09:45 AM\n Metronidazole - 03:32 PM\n Vancomycin - 08:00 PM\n Aztreonam - 10:00 PM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Heparin Sodium - 1,700 units/hour\n Fentanyl - 100 mcg/hour\n Norepinephrine - 0.04 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38\nC (100.4\n Tcurrent: 37.3\nC (99.2\n HR: 73 (60 - 102) bpm\n BP: 90/46(61) {76/38(56) - 160/71(97)} mmHg\n RR: 23 (16 - 25) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101 kg (admission): 94.2 kg\n Height: 67 Inch\n CVP: 8 (8 - 15)mmHg\n Bladder pressure: 18 (18 - 21) mmHg\n Total In:\n 3,524 mL\n 234 mL\n PO:\n TF:\n 48 mL\n IVF:\n 3,236 mL\n 234 mL\n Blood products:\n Total out:\n 935 mL\n 215 mL\n Urine:\n 650 mL\n 215 mL\n NG:\n 285 mL\n Stool:\n Drains:\n Balance:\n 2,589 mL\n 19 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: AC\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 0 (0 - 0) mL\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 23 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 42 cmH2O\n Plateau: 32 cmH2O\n Compliance: 44.4 cmH2O/mL\n SpO2: 100%\n ABG: 7.37/44/160 (6am)\n Ve: 9.5 L/min\n PaO2 / FiO2: 255\n Physical Examination\n Gen: Does not arouse to voice\n HEENT: Pupils 3 mm non-reactive bilaterally. Scleral edema bilat\n Resp: Symmetric expansion. Vesicular sounds throughout. Inspiratory\n and expiratory tracheal sounds (?related to ET tube).\n CV: RRR.\n Abd: Hypoactive bowel sounds. Distended.\n Ext: Edema in bilat UE.\n Peripheral vascular: Radial pulses 2+ bilaterally.\n Neuro: Moving all 4 extremities.\n Labs / Radiology\n 358 K/uL\n 8.9 g/dL\n 126 mg/dL\n 0.7 mg/dL\n 25 mEq/L\n 3.5 mEq/L\n 4 mg/dL\n 108 mEq/L\n 143 mEq/L\n 28.0 %\n 8.1 K/uL\n [image002.jpg]\n 03:01 AM\n 03:13 AM\n 12:05 PM\n 06:08 PM\n 06:11 PM\n 07:53 PM\n 02:02 AM\n 03:59 AM\n 09:14 PM\n 01:04 AM\n WBC\n 6.4\n 8.4\n Hct\n 24.1\n 29.0\n 28.1\n Plt\n 319\n 376\n Cr\n 0.6\n 0.6\n TCO2\n 30\n 29\n 29\n 25\n 25\n 28\n 28\n Glucose\n 129\n 120\n PT 22.2 PTT 76.0 INR 2.1\n Differential-Neuts:74.7 %, Lymph:17.6 %, Mono:3.5 %, Eos:3.8 %\n Ca++:8.2 mg/dL, Mg++:2.0 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture\n # Respiratory failure: initial etiology unclear, likely multifactorial\n now with significant pneumonia. Had one sputum that showed GNR.\n - Had a desat event yesterday. Responded positively to recruitment\n maneuvers.\n - Will attempt placement of an esophageal balloon; with knowledge of\n intrathoracic pressures, can consider going up on PEEP\n # Infectious process: Had been febrile, now resolved\n - be aspiration or be VAP. Sputum from grew rare GNR;\n awaiting speciation.\n - Continues on Vanc, aztreonam, levofloxicin. Vanc trough pending today\n - Also on flagyl for empiric coverage of c. diff\n - Per CT, unlikely to be abdominal process\n # Hypotension, requiring Levophed:\n - Hypovolemia is possibly a factor- responded to a transfusion; HCT had\n been dropping\n - Sepsis also a factor- on broad spectrum abs\n - Central line in place.\n # Oliguria:\n -BUN and Cr reassuring.\n # RUE DVT: Have held on starting treatment in light of need for central\n access. Can start therapeutic heparin vs Lovenox with bridge to\n coumadin.\n - No PE noted on CT scan.\n # Abd distention:\n - CT abd only showed appendiceal mucocele without inflammation, not\n concerning, most likely chronic\n - No BM in several days, continue bowel regimen, add fleets enema\n - Can test for c.diff when pt stool\ns. Continue flagyl empirically\n - Check amylase and lipase\n # Anemia:\n - Trend HCT\n - Gave 1 un pRBC with good results\n - Will guiac stools when she has a BM\n - INR rising, now 1.7, may be nutritional\n # Spine fracture: neurologically intact distal to the lesion. prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per verbal report.\n # Hypernatremia, resolved: correcting with g tube free flush and D5W\n -Holding on g tube feeds at present due to high residuals\n -Replete lytes as necessary\n # Communication:\n - Brother has been with pt, although, live in boyfriend of 10 is\n her HCP. Boyfriend will hopefully visit pt today\n ICU Care\n Nutrition: tube feed with free water when able\n Glycemic Control: Regular insulin sliding scale\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Communication: ICU consent signed, (brother) \n (boyfriend/POA) \n Code status: Full code\n Disposition: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 01:36 AM\n Arterial Line - 03:00 AM\n Multi Lumen - 11:30 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2167-09-23 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 634419,
"text": "Chief Complaint: respiratory failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n ESOPHOGEAL BALLOON - At 01:46 PM\n Restarted levophed overnight\n Patient unable to provide history: Sedated\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Aztreonam - 06:09 AM\n Metronidazole - 08:00 AM\n Levofloxacin - 08:39 AM\n Infusions:\n Midazolam (Versed) - 1.5 mg/hour\n Fentanyl - 75 mcg/hour\n Norepinephrine - 0.02 mcg/Kg/min\n Other ICU medications:\n Other medications:\n vanc, aztreonam, flagyl (day ), CHG, SQI, nebs, naloxone enteral,\n heparin infusion\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38\nC (100.4\n Tcurrent: 37.6\nC (99.6\n HR: 75 (64 - 102) bpm\n BP: 96/49(65) {76/38(56) - 160/71(97)} mmHg\n RR: 22 (16 - 25) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101 kg (admission): 94.2 kg\n Height: 67 Inch\n CVP: 20 (8 - 339)mmHg\n Bladder pressure: 18 (18 - 21) mmHg\n Total In:\n 3,524 mL\n 848 mL\n PO:\n TF:\n 48 mL\n IVF:\n 3,236 mL\n 698 mL\n Blood products:\n Total out:\n 935 mL\n 325 mL\n Urine:\n 650 mL\n 325 mL\n NG:\n 285 mL\n Stool:\n Drains:\n Balance:\n 2,589 mL\n 523 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 0 (0 - 0) mL\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 23 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 37 cmH2O\n Plateau: 33 cmH2O\n Compliance: 40 cmH2O/mL\n SpO2: 99%\n ABG: 7.37/44/160/25/0\n Ve: 8.9 L/min\n PaO2 / FiO2: 320\n Physical Examination\n General Appearance: Overweight / Obese\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: coarse breath sounds\n Abdominal: Soft, Obese\n Extremities: Right: 1+, Left: 1+\n Skin: Warm\n Neurologic: Responds to: Unresponsive, Movement: No spontaneous\n movement, Tone: Normal\n Labs / Radiology\n 8.9 g/dL\n 358 K/uL\n 126 mg/dL\n 0.7 mg/dL\n 25 mEq/L\n 3.5 mEq/L\n 4 mg/dL\n 108 mEq/L\n 143 mEq/L\n 28.0 %\n 8.1 K/uL\n [image002.jpg]\n 12:05 PM\n 06:08 PM\n 06:11 PM\n 07:53 PM\n 02:02 AM\n 03:59 AM\n 09:14 PM\n 01:04 AM\n 05:54 AM\n 06:11 AM\n WBC\n 8.4\n 8.1\n Hct\n 29.0\n 28.1\n 28.0\n Plt\n 376\n 358\n Cr\n 0.6\n 0.7\n TCO2\n 29\n 29\n 25\n 25\n 28\n 28\n 26\n Glucose\n 120\n 126\n Other labs: PT / PTT / INR:22.2/76.0/2.1, ALT / AST:24/16, Alk Phos / T\n Bili:117/0.7, Amylase / Lipase:, Differential-Neuts:74.7 %,\n Lymph:17.6 %, Mono:3.8 %, Eos:3.4 %, Lactic Acid:0.7 mmol/L,\n Albumin:2.4 g/dL, LDH:204 IU/L, Ca++:8.2 mg/dL, Mg++:2.0 mg/dL, PO4:3.2\n mg/dL\n Assessment and Plan\n End-exp transpulmonary pressure: -2\n End-insp transpulmonary pressure: +5\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 01:36 AM\n Arterial Line - 03:00 AM\n Multi Lumen - 11:30 AM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Heparin gtt)\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent:\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2167-09-23 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 634421,
"text": "Chief Complaint: respiratory failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n ESOPHOGEAL BALLOON - At 01:46 PM\n Restarted levophed overnight\n Patient unable to provide history: Sedated\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Aztreonam - 06:09 AM\n Metronidazole - 08:00 AM\n Levofloxacin - 08:39 AM\n Infusions:\n Midazolam (Versed) - 1.5 mg/hour\n Fentanyl - 75 mcg/hour\n Norepinephrine - 0.02 mcg/Kg/min\n Other ICU medications:\n Other medications:\n vanc, aztreonam, flagyl (day ), CHG, SQI, nebs, naloxone enteral,\n heparin infusion\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38\nC (100.4\n Tcurrent: 37.6\nC (99.6\n HR: 75 (64 - 102) bpm\n BP: 96/49(65) {76/38(56) - 160/71(97)} mmHg\n RR: 22 (16 - 25) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101 kg (admission): 94.2 kg\n Height: 67 Inch\n CVP: 20 (8 - 339)mmHg\n Bladder pressure: 18 (18 - 21) mmHg\n Total In:\n 3,524 mL\n 848 mL\n PO:\n TF:\n 48 mL\n IVF:\n 3,236 mL\n 698 mL\n Blood products:\n Total out:\n 935 mL\n 325 mL\n Urine:\n 650 mL\n 325 mL\n NG:\n 285 mL\n Stool:\n Drains:\n Balance:\n 2,589 mL\n 523 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 0 (0 - 0) mL\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 23 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 37 cmH2O\n Plateau: 33 cmH2O\n Compliance: 40 cmH2O/mL\n SpO2: 99%\n ABG: 7.37/44/160/25/0\n Ve: 8.9 L/min\n PaO2 / FiO2: 320\n Physical Examination\n General Appearance: Overweight / Obese\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: coarse breath sounds\n Abdominal: Soft, Obese\n Extremities: Right: 1+, Left: 1+\n Skin: Warm\n Neurologic: Responds to: Unresponsive, Movement: No spontaneous\n movement, Tone: Normal\n Labs / Radiology\n 8.9 g/dL\n 358 K/uL\n 126 mg/dL\n 0.7 mg/dL\n 25 mEq/L\n 3.5 mEq/L\n 4 mg/dL\n 108 mEq/L\n 143 mEq/L\n 28.0 %\n 8.1 K/uL\n [image002.jpg]\n 12:05 PM\n 06:08 PM\n 06:11 PM\n 07:53 PM\n 02:02 AM\n 03:59 AM\n 09:14 PM\n 01:04 AM\n 05:54 AM\n 06:11 AM\n WBC\n 8.4\n 8.1\n Hct\n 29.0\n 28.1\n 28.0\n Plt\n 376\n 358\n Cr\n 0.6\n 0.7\n TCO2\n 29\n 29\n 25\n 25\n 28\n 28\n 26\n Glucose\n 120\n 126\n Other labs: PT / PTT / INR:22.2/76.0/2.1, ALT / AST:24/16, Alk Phos / T\n Bili:117/0.7, Amylase / Lipase:, Differential-Neuts:74.7 %,\n Lymph:17.6 %, Mono:3.8 %, Eos:3.4 %, Lactic Acid:0.7 mmol/L,\n Albumin:2.4 g/dL, LDH:204 IU/L, Ca++:8.2 mg/dL, Mg++:2.0 mg/dL, PO4:3.2\n mg/dL\n Assessment and Plan\n Assessment and Plan\n 55-year-old woman with\n Respiratory failure\n End-exp transpulmonary pressure: -2\n End-insp transpulmonary pressure: +5\n Esophageal pressures suggest that she is at safe pressures.\n Traumatic thoracic spinal fracture\n Eventual MRI. Too high-risk at present. Brace when out of\n bed.\n Probable VAP\n Discuss GNRs with lab\n Complete 8\n 15d course of present ABX pending cultures\n D/C vancomycin since no identified GPCs\n D/C Flagyl since no CT or toxin evidence of C diff\n Shock\n now back on levophed\n CVP is 20 mm Hg but Pes is ~25 cm H20\n Re-assess SVV with Vigileo and consider volume challenge\n Upper extremity DVT\n Therapeutic heparin\n Anemia\n Follow\n Possible tracheobronchomalacia (reason for transfer)\n Incidental peri-appendiceal finding (will need eventual\n follow-up)\n Although differential remains open, the most compelling course of\n events is probably that she required intubation at the outside hospital\n (?sedation ?restriction from obesity/brace ?other) and subsequently\n developed a GNR-related VAP. Her pattern of acute lung injury,\n combined with obesity, is resulting in basilar and\n posterior-predominant atelectasis/consolidation with a high proportion\n of shunt. Given her very high PEEP, will try to avoid bronchoscopy if\n possible.\n Other issues as per ICU team note.\n ICU Care\n Nutrition: resume tube feeds\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 01:36 AM\n Arterial Line - 03:00 AM\n Multi Lumen - 11:30 AM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Heparin gtt)\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent:\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2167-09-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 634499,
"text": "55 yr old woman admitted from OSH after she fell down the stairs and\n had traumatic T-spine fracture. Pt came to us with PNA from unknown\n etiology? VAP. Full code, Allergies: PCN, tetracycline, Sulfa. PMH:\n ETOH, smoker, Gerd, Hip replacement.\n Alteration in Nutrition\n Assessment:\n Tube feeds at 20ml/hr. Tube feed residual 20ml.\n Action:\n Kept TF at 20ml/hr and will cont to check residuals and try to increase\n rate\n Response:\n No change\n Plan:\n Try to increase Tube feeds to goal rate.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n RUE DVT, pt on heparin gtt at 1700units/hr.\n Action:\n Ptt was therapeutic x2, AM PTT\n Response:\n Plan:\n Cont heparin gtt, check PTT adjust heparin gtt per scale.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Moderate thick white in-line secretions, copious clear oral secretions,\n clear/diminished lung sounds. Esophageal balloon in place. Previous\n Sputum culture shows GNR, speciation PND.\n Action:\n Lots of suctioning through the night, decreased FiO2 from 50% to 40%,\n decreased Peep from 23 to 21, HOB >30, oral care.\n Response:\n ABG WNL\n Plan:\n Cont to try to wean vent settings as tolerated, cont monitoring ABG\n Hypotension (not Shock)\n Assessment:\n SBP 90-110\ns MAP 62-66 Goal MAP >65 Levophed gtt @ 0.020 mcg/kg/min.\n Action:\n Trying to wean levophed gtt off\n Response:\n Plan:\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n T-max 101.0\n Action:\n Sent blood, urine, and sputum cultures, treated with tylenol\n Response:\n Temp decreased\n Plan:\n Follow up on cultures\n CT scan from earlier in the week confirms fracture but did not detect\n retropulsion. Neuro want pt in back brace when she is out of bed.\n Log rolling pt has been d/c.\n"
},
{
"category": "Physician ",
"chartdate": "2167-09-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 634552,
"text": "24 Hour Events:\n -Yesterday, stopped vanc and flagyl. Continued Aztreonam and\n Levofloxicin\n -Febrile to 101- pan cultured; cxr\n -Micro on sputum GNR due back today\n -Decreased FiO2 and PEEP to 21 (from 23 for ABG 7.42/39/116 at 11PM)\n -Early am, HR dropped to 40s-50s. EKG suggestive of junctional rhythm.\n Held pressures, making good UOP, good O2 sats\n -This am, art line is intermittently working. Drew ABG - pending\n -Yesterday, SVV was 7; held on giving more fluids\n -Random cortisol was very low; started hydrocortisone and florinef\n -UOP picked up this AM\n -Restarted tube feeds\n -K, Phos given this AM\n -New possible junctional rhythm (low voltage) at 5AM. Enzymes added on\n -Spine -> request CT C, L spine, MRI, TLSO, non-operative, d/c log roll\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Metronidazole - 08:00 AM\n Levofloxacin - 08:39 AM\n Aztreonam - 02:00 PM\n Infusions:\n Norepinephrine - 0.02 mcg/Kg/min\n Midazolam (Versed) - 4 mg/hour\n Other ICU medications:\n Midazolam (Versed) - 03:50 PM\n Fentanyl - 03:50 PM\n Ranitidine (Prophylaxis) - 08:31 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (101\n Tcurrent: 37.1\nC (98.8\n HR: 60 (60 - 86) bpm\n BP: 103/46(61) {103/46(61) - 121/50(66)} mmHg\n RR: 22 (17 - 23) insp/min\n SpO2: 99%\n Heart rhythm: JR (Junctional Rhythm)\n Wgt (current): 101 kg (admission): 94.2 kg\n Height: 67 Inch\n CVP: 12 (12 - 339)mmHg\n Total In:\n 1,675 mL\n 232 mL\n PO:\n TF:\n 182 mL\n 134 mL\n IVF:\n 1,233 mL\n 98 mL\n Blood products:\n Total out:\n 877 mL\n 565 mL\n Urine:\n 727 mL\n 535 mL\n NG:\n 30 mL\n Stool:\n Drains:\n Balance:\n 798 mL\n -333 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 22\n RR (Spontaneous): 2\n PEEP: 21 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 33 cmH2O\n Plateau: 30 cmH2O\n Compliance: 44.4 cmH2O/mL\n SpO2: 99%\n ABG: 7.46/28/129\n Ve: 9.7 L/min\n PaO2 / FiO2: 290\n Physical Examination\n Gen: Does not arouse to voice\n HEENT: Pupils 3 mm reactive bilaterally. Scleral edema bilat\n Resp: Symmetric expansion. Coarse breath sounds throughout. Cannot\n adeq listen to post bases\n CV: RRR.\n Abd: Hypoactive bowel sounds. Distended.\n Ext: Edema in bilat UE.\n Peripheral vascular: Radial pulses 2+ bilaterally.\n Neuro: Moving all 4 extremities.\n Labs / Radiology\n 326 K/uL\n 8.9 g/dL\n 151 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 3.6 mEq/L\n 2 mg/dL\n 108 mEq/L\n 141 mEq/L\n 28.6 %\n 8.9 K/uL\n [image002.jpg]\n 06:11 PM\n 07:53 PM\n 02:02 AM\n 03:59 AM\n 09:14 PM\n 01:04 AM\n 05:54 AM\n 06:11 AM\n 11:07 PM\n 03:51 AM\n WBC\n 8.4\n 8.1\n 8.9\n Hct\n 28.1\n 28.0\n 28.6\n Plt\n 376\n 358\n 326\n Cr\n 0.6\n 0.7\n 0.7\n TCO2\n 29\n 25\n 25\n 28\n 28\n 26\n 26\n Glucose\n 120\n 126\n 151\n Other labs: PT / PTT / INR:24.3/68.6/2.4, ALT / AST:24/16, Alk Phos / T\n Bili:117/0.7, Amylase / Lipase:, Differential-Neuts:82.5 %,\n Lymph:11.6 %, Mono:3.3 %, Eos:2.2 %, Lactic Acid:0.7 mmol/L,\n Albumin:2.4 g/dL, LDH:204 IU/L, Ca++:8.5 mg/dL, Mg++:2.1 mg/dL, PO4:2.5\n mg/dL\nMicro: 2:38 am SPUTUM Site: ENDOTRACHEAL\n GRAM STAIN (Final ):\n >25 PMNs and <10 epithelial cells/100X field.\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.\n IN PAIRS AND CLUSTERS.\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).\n RESPIRATORY CULTURE (Pending)\n GRAM STAIN (Final ) SPUTUM Site: ENDOTRACHEAL:\n <10 PMNs and <10 epithelial cells/100X field.\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.\n IN PAIRS.\n 1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).\n CULTURE: GRAM NEGATIVE ROD(S). RARE GROWTH. WORK-UP PER DR ().\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with respiratory failure\n and difficulty weaning from vent.\n # Respiratory failure: Over the evening yesterday, were able to\n decrease FiO2 and PEEP. Clinical and imaging suggestive of ARDS.\n Initial preceptiationg factors: sedation, hypovent obesity,\n orthotic brace. Now thought to have VAP.\n - Placed esophageal balloon on which will help guide PEEP settings.\n # VAP: Re-spiked fever overnight. Stopped vanc yesterday, , as\n treating for GNR infection. Current GS shows GPC\n - Follow cultures\n - Restart Vanc.\n - Continue aztreonam, levofloxicin for 8 days pending speciation (at\n that time can increase to 15 days if necessary)\n - Also, stopped flagyl because had one neg c. diff toxin and CT did not\n show evidence of colitis\n # EKG changes: very low voltages and no change in QRS morphology.\n P-waves may be buried.\n -repeat\n -f/u enzymes\n # Hypotension, requiring Levophed: Increased urine output c/w\n autodiuresing\n - Attempt to wean from levophed with MAP goal 65 and UOP goal >30 cc/hr\n - Hypovolemia is possibly a factor- responded to a transfusion; HCT had\n been dropping. However, SVV with Vigileo was 13, making her CO less\n likely to respond to fluids. Held on giving any boluses overnight.\n - Sepsis also a factor- on broad spectrum abs\n - Central line in place.\n # Oliguria: Improved recently. BUN and Cr reassuring.\n -Continue to monitor\n # RUE DVT: Started on heparin gtt on .\n -Therapeutic in one day; may be related to poor nutritional status.\n Will continue to closely monitor\n # Abd distention: be chronic condition not requiring immediate\n medical attention\n - CT abd only showed appendiceal mucocele without inflammation, not\n concerning, most likely chronic. No concern for intraabd disaster\n - Now having BMs; c. diff toxin neg\n - amylase and lipase wnl\n # Adrenal Insufficency:\n -Random cortisol was approx 3 when it should have been maximally\n stimulated.\n -Started hydrocortisone and florinef. ? switch to methylpred\n # Anemia:\n - Trend HCT\n - Gave 1 un pRBC with good results\n - INR rising, now 2.0, may be nutritional\n # Spine fracture: neurologically intact distal to the lesion. prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - Repeat CT C, L spine.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n # Hypernatremia, resolved: correcting with g tube free flush and D5W\n -Holding on g tube feeds at present due to high residuals\n -Replete lytes as necessary\n # Communication:\n - Brother has been with pt, although, live in boyfriend of 10 is\n her HCP. Boyfriend will hopefully visit pt today\n ICU Care\n Nutrition: tube feed with free water when able\n Glycemic Control: Regular insulin sliding scale\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Communication: ICU consent signed, (brother) \n (boyfriend/POA) \n Code status: Full code\n Disposition: ICU\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 10:55 PM 30 mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 01:36 AM\n Arterial Line - 03:00 AM\n Multi Lumen - 11:30 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2167-09-24 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 634564,
"text": "Chief Complaint: respiratory failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n BLOOD CULTURED - At 12:24 AM\n URINE CULTURE - At 12:24 AM\n SPUTUM CULTURE - At 03:30 AM\n EKG - At 05:20 AM\n pt in junctional rhythem, holding stable BP, intern aware and came to\n assess pt. HR 47-50.\n Fever spike to 101\n Steroids started\n Antibiotics tailored\n PEEP decreased\n History obtained from Medical records, ICU team\n Patient unable to provide history: Sedated\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Metronidazole - 08:00 AM\n Levofloxacin - 08:39 AM\n Aztreonam - 06:00 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 100 mcg/hour\n Other ICU medications:\n Midazolam (Versed) - 03:50 PM\n Fentanyl - 03:50 PM\n Ranitidine (Prophylaxis) - 08:31 PM\n Other medications:\n versed, fentanyl, colace, H2B, CHG, SQI, MDIs, heparin infusion,\n levoflox, aztreonam, hydrocortisone 50 q6, fludrocort\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (101\n Tcurrent: 37.1\nC (98.8\n HR: 57 (48 - 86) bpm\n BP: 102/48(61) {102/46(61) - 121/52(66)} mmHg\n RR: 22 (17 - 23) insp/min\n SpO2: 99%\n Heart rhythm: JR (Junctional Rhythm)\n Wgt (current): 101 kg (admission): 94.2 kg\n Height: 67 Inch\n CVP: 11 (11 - 20)mmHg\n Bladder pressure: 12 (12 - 12) mmHg\n Total In:\n 1,708 mL\n 460 mL\n PO:\n TF:\n 182 mL\n 138 mL\n IVF:\n 1,267 mL\n 321 mL\n Blood products:\n Total out:\n 877 mL\n 1,305 mL\n Urine:\n 727 mL\n 1,275 mL\n NG:\n 30 mL\n Stool:\n Drains:\n Balance:\n 831 mL\n -845 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 21 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 36 cmH2O\n Plateau: 29 cmH2O\n Compliance: 50 cmH2O/mL\n SpO2: 99%\n ABG: 7.46/38/96./26/2\n Ve: 8.6 L/min\n PaO2 / FiO2: 242\n Physical Examination\n General Appearance: Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear :\n anteriorly)\n Abdominal: Soft, Non-tender, Obese\n Extremities: Right: 1+, Left: 1+\n Musculoskeletal: Unable to stand\n Skin: Warm\n Neurologic: Responds to: Unresponsive, Movement: No spontaneous\n movement, Sedated, Tone: Normal\n Labs / Radiology\n 8.9 g/dL\n 326 K/uL\n 151 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 3.6 mEq/L\n 2 mg/dL\n 108 mEq/L\n 141 mEq/L\n 28.6 %\n 8.9 K/uL\n [image002.jpg]\n 02:02 AM\n 03:59 AM\n 09:14 PM\n 01:04 AM\n 05:54 AM\n 06:11 AM\n 11:07 PM\n 03:51 AM\n 06:17 AM\n 08:18 AM\n WBC\n 8.4\n 8.1\n 8.9\n Hct\n 28.1\n 28.0\n 28.6\n Plt\n 376\n 358\n 326\n Cr\n 0.6\n 0.7\n 0.7\n TCO2\n 25\n 28\n 28\n 26\n 26\n 21\n 28\n Glucose\n 120\n 126\n 151\n Other labs: PT / PTT / INR:24.3/68.6/2.4, CK / CKMB / Troponin-T:24//,\n ALT / AST:24/16, Alk Phos / T Bili:117/0.7, Amylase / Lipase:,\n Differential-Neuts:82.5 %, Lymph:11.6 %, Mono:3.3 %, Eos:2.2 %, Lactic\n Acid:0.7 mmol/L, Albumin:2.4 g/dL, LDH:204 IU/L, Ca++:8.5 mg/dL,\n Mg++:2.1 mg/dL, PO4:2.5 mg/dL\n Imaging: CXR: increased right base opacity\n Microbiology: Sputum from overnight: GPCs with 2+ GPCs in\n pairs/clusters and 2+ GPRs\n Prior sputum growing GNRs\n Assessment and Plan\n 55-year-old woman with\n Respiratory failure\n Recheck esophageal pressures today.\n Wean PEEP as tolerated and guided by Pes\n On our ultrasound exam, effusion would be high risk to tap\n Adrenal insufficiency\n Based on very low random cortisol while in shock and\n respiratory failure\n On steroids\n Bradycardia\n Rhythm appear sinus.\n Will try to check an atrial EKG via her CVL to confirm\n Heart rate increases with stimulation, suggesting that this\n is mostly vagal in etiology\n Sedation and high ventilatory pressures may contribute to\n high vagal tone\n Continues to have signs of good perfusion\n This may be reflex bradycardia from increased perfusion\n relating to steroid dosing\n Probable VAP\n Discuss GNRs with lab\n Complete 8\n 15d course of present ABX pending cultures\n D/C vancomycin since no identified GPCs\n D/C Flagyl since no CT or toxin evidence of C diff\n Shock\n now off of levophed (again)\n SVV is low, suggesting adequate volume repletion\n Treating adrenal insufficiency\n Polyuria\n be response to increased perfusion (comes at right time\n course to be an effect of treating adrenal insufficiency)\n Upper extremity DVT\n Therapeutic heparin\n Anemia\n Follow\n Possible tracheobronchomalacia (reason for transfer)\n Incidental peri-appendiceal finding (will need eventual\n follow-up)\n Traumatic thoracic spinal fracture\n Eventual MRI. Too high-risk at present. Brace when out of\n bed.\n Fever\n Restart vanco (GPCs on G/S of sputum)\n Follow cultures\n Resite art line (dysfunctional).\n CVL is within 3 days; will follow\n Although differential remains open, the most compelling course of\n events is probably that she required intubation at the outside hospital\n (?sedation ?restriction from obesity/brace ?other) and subsequently\n developed a GNR-related VAP. Her pattern of acute lung injury,\n combined with obesity, is resulting in basilar and\n posterior-predominant atelectasis/consolidation with a high proportion\n of shunt. Will consider bronchoscopy based on course today, given\n apparent increased atelectasis on CXR.\n Other issues as per ICU team note.\n ICU Care\n Nutrition: tube feeds\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 01:36 AM\n Arterial Line - 03:00 AM\n Multi Lumen - 11:30 AM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Heparin gtt)\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 40 min\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2167-09-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 634591,
"text": "24 Hour Events:\n -Yesterday, stopped vanc and flagyl. Continued Aztreonam and\n Levofloxicin\n -Febrile to 101- pan cultured; cxr\n -Micro on sputum GNR due back today\n -Decreased FiO2 and PEEP to 21 (from 23 for ABG 7.42/39/116 at 11PM)\n -Early am, HR dropped to 40s-50s. EKG suggestive of junctional rhythm.\n Held pressures, making good UOP, good O2 sats\n -This am, art line is intermittently working. Drew ABG - pending\n -Yesterday, SVV was 7; held on giving more fluids\n -Random cortisol was very low; started hydrocortisone and florinef\n -UOP picked up this AM\n -Restarted tube feeds\n -K, Phos given this AM\n -New possible junctional rhythm (low voltage) at 5AM. Enzymes added on\n -Spine -> request CT C, L spine, MRI, TLSO, non-operative, d/c log roll\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Metronidazole - 08:00 AM\n Levofloxacin - 08:39 AM\n Aztreonam - 02:00 PM\n Infusions:\n Norepinephrine - 0.02 mcg/Kg/min\n Midazolam (Versed) - 4 mg/hour\n Other ICU medications:\n Midazolam (Versed) - 03:50 PM\n Fentanyl - 03:50 PM\n Ranitidine (Prophylaxis) - 08:31 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (101\n Tcurrent: 37.1\nC (98.8\n HR: 60 (60 - 86) bpm\n BP: 103/46(61) {103/46(61) - 121/50(66)} mmHg\n RR: 22 (17 - 23) insp/min\n SpO2: 99%\n Heart rhythm: JR (Junctional Rhythm)\n Wgt (current): 101 kg (admission): 94.2 kg\n Height: 67 Inch\n CVP: 12 (12 - 339)mmHg\n Total In:\n 1,675 mL\n 232 mL\n PO:\n TF:\n 182 mL\n 134 mL\n IVF:\n 1,233 mL\n 98 mL\n Blood products:\n Total out:\n 877 mL\n 565 mL\n Urine:\n 727 mL\n 535 mL\n NG:\n 30 mL\n Stool:\n Drains:\n Balance:\n 798 mL\n -333 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 22\n RR (Spontaneous): 2\n PEEP: 21 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 33 cmH2O\n Plateau: 30 cmH2O\n Compliance: 44.4 cmH2O/mL\n SpO2: 99%\n ABG: 7.46/28/129 at 6AM\n Repeated at 9AM 7.4/38/97\n Ve: 9.7 L/min\n PaO2 / FiO2: 290\n Physical Examination\n Gen: Does not arouse to voice\n HEENT: Pupils 3 mm reactive bilaterally. Scleral edema bilat\n Resp: Symmetric expansion. Coarse breath sounds throughout. Cannot\n adeq listen to post bases\n CV: RRR.\n Abd: Hypoactive bowel sounds. Distended.\n Ext: Edema in bilat UE.\n Peripheral vascular: Radial pulses 2+ bilaterally.\n Neuro: Moving all 4 extremities.\n Labs / Radiology\n 326 K/uL\n 8.9 g/dL\n 151 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 3.6 mEq/L\n 2 mg/dL\n 108 mEq/L\n 141 mEq/L\n 28.6 %\n 8.9 K/uL\n [image002.jpg]\n 06:11 PM\n 07:53 PM\n 02:02 AM\n 03:59 AM\n 09:14 PM\n 01:04 AM\n 05:54 AM\n 06:11 AM\n 11:07 PM\n 03:51 AM\n WBC\n 8.4\n 8.1\n 8.9\n Hct\n 28.1\n 28.0\n 28.6\n Plt\n 376\n 358\n 326\n Cr\n 0.6\n 0.7\n 0.7\n TCO2\n 29\n 25\n 25\n 28\n 28\n 26\n 26\n Glucose\n 120\n 126\n 151\n Other labs: PT / PTT / INR:24.3/68.6/2.4, ALT / AST:24/16, Alk Phos / T\n Bili:117/0.7, Amylase / Lipase:, Differential-Neuts:82.5 %,\n Lymph:11.6 %, Mono:3.3 %, Eos:2.2 %, Lactic Acid:0.7 mmol/L,\n Albumin:2.4 g/dL, LDH:204 IU/L, Ca++:8.5 mg/dL, Mg++:2.1 mg/dL, PO4:2.5\n mg/dL\nMicro: 2:38 am SPUTUM Site: ENDOTRACHEAL\n GRAM STAIN (Final ):\n >25 PMNs and <10 epithelial cells/100X field.\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.\n IN PAIRS AND CLUSTERS.\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).\n RESPIRATORY CULTURE (Pending)\n GRAM STAIN (Final ) SPUTUM Site: ENDOTRACHEAL:\n <10 PMNs and <10 epithelial cells/100X field.\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.\n IN PAIRS.\n 1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).\n CULTURE: GRAM NEGATIVE ROD(S). RARE GROWTH. WORK-UP PER DR ().\n US of effusion (by MICU staff): small effusion, accessible but\n difficult to tap\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with respiratory failure\n and difficulty weaning from vent.\n # Respiratory failure: Over the evening yesterday, were able to\n decrease FiO2 and PEEP. Clinical and imaging suggestive of ARDS.\n Initial precipitating factors were thought to be: sedation, hypovent\n obesity, orthotic brace. Now thought to have VAP.\n - Placed esophageal balloon on which will help guide PEEP settings.\n - Given small size of effusion and high PEEP (risk of pneumothorax),\n will not attempt to tap\n - Appreciate IP recs. Will consider tracheomalacia workup when more\n stable.\n # VAP/ID: Re-spiked fever overnight. Stopped vanc yesterday, , as\n treating for GNR infection. Current GS shows GPC\n - Follow cultures\n - Restart Vanc.\n - Continue aztreonam, levofloxicin for 8 days pending speciation (at\n that time can increase to 15 days if necessary)\n - Also, stopped flagyl because had one neg c. diff toxin and CT did not\n show evidence of colitis\n - Will replace A-line today.\n # EKG changes: Sinus bradycardia. Very low voltages and no change in\n QRS morphology. P-waves are visible and prolonged PR interval is old.\n CK and troponins flat. Likely related to increased vagal tone possibly\n related to steroid replacement.\n - Will avoid excessive alpha-agonism\n - Continue to monitor\n - could consider atrial EKG\n .\n # Hypotension: now off levophed, with good urine output. Hypovolemia\n is possibly a factor- responded to a transfusion; HCT had been\n dropping. However, SVV with Vigileo was 7, making her CO less likely\n to respond to fluids. Held on giving any boluses overnight. Today CVP\n is low given PEEP. Sepsis also a consideration\n - continue on broad spectrum abs\n - replete fluids.\n - Restart pressors as needed. Consider dopamine over levophed given\n bradycardia.\n - Central line in place.\n # Urine output: Previously oliguric, now with high urine output.\n Concern for autodiuresis but BUN and Cr reassuring.\n -Continue to monitor\n # RUE DVT: Started on heparin gtt on .\n -Therapeutic in one day; may be related to poor nutritional status.\n Will continue to closely monitor\n # Adrenal Insufficency:\n -Random cortisol was approx 3 when it should have been maximally\n stimulated.\n -Started hydrocortisone and florinef. ? switch to methylpred\n # Anemia:\n - Trend HCT\n - Gave 1 un pRBC with good results\n - INR rising, now 2.0, may be nutritional\n # Spine fracture: neurologically intact distal to the lesion. prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n # Hypernatremia, resolved: correcting with g tube free flush and D5W\n -Continue to follow\n # Communication:\n - Brother has been with pt, although, live in boyfriend of 10 is\n her HCP. Boyfriend will hopefully visit pt today\n ICU Care\n Nutrition: tube feed with free water when able\n Glycemic Control: Regular insulin sliding scale\n DVT: Theraputic Heparin gtt\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Communication: ICU consent signed, (brother) \n (boyfriend/POA) \n Code status: Full code\n Disposition: ICU\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 10:55 PM 30 mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 01:36 AM\n Arterial Line - 03:00 AM\n Multi Lumen - 11:30 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Respiratory ",
"chartdate": "2167-09-30 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 635270,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 12\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location: Medical Center\n Reason: Emergent (1st time); Comments: Mechanical fall\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments: Bronchoscopic procedure done today,BAL collected.\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments: 55 yr old female transfered from Medical Center to\n intubated post mechanical fall. Patient now @ for\n evaluation of tracheomalacia.It has been very difficult to wean her off\n mechanical ventilation.Easily desaturated and agitated with the lesser\n interaction.Very PEEP sensitive , but was able to decrease level of\n PEEP down to 8 cmH20 today.Plan to trach and PEG in AM if PEEP level\n remains bellow 10cmH20.Last ABG acceptable with hypoxemia;hypernatremic\n ? renal insufficiency free water given. Bronchoscopic procedure\n performed by MD today,sample collected,sent to lab for culture.\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 635714,
"text": "55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\n Now with prolonged hospital course c/b by PNA with high PEEP\n requirement, anxiety, RUE DVT on heparin qtt.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt on Vent settings AC 55%/18 X 400/+10 with no overbreathing of\n set RR. O2 sat 92-98%. Lung snds clear, diminished in bases. Pt sxn\n for small-moderate amts thick white secretions. Trach site with small\n amt serosang drainage.\n Action:\n Cont same vent settings\n Response:\n Pt doesn\nt over breath on the vent and never desat.Kept same Vent\n settings overnight.\n Plan:\n Monitor sats,resp and titrate Vent as she tolerats.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt rec\nd with Heparin qtt 1900units/hr.\n Action:\n PTT drawn at 2300.RUE elevated with pillow and no BP or blood drawn\n from that arm.\n Response:\n PTT @ 2300 was 107, Decreased Heparin gtt 1700 u/hr as per sliding\n scale. Next PTT due at 0600. .\n Plan:\n Cont monitor PTT,titrate accordingly, next PTT due at 0600.\n Alteration in Nutrition\n Assessment:\n Received pt on TF 10cc/hr.Abd soft w/+ BS.\n Action:\n Pt tolerated TF with minimal residuals as well as free water bolus\n Q4H.Received scheduled Colace\n Response:\n TF ^ as tolerated, currently at 30cc/hr.No BM noted this shift.HCt 24.6\n (25.8)\n Plan:\n Cont to monitor TF residuals, hold if more than 100cc\n Altered mental status (not Delirium)\n Assessment:\n Pt w/ periods of agitation and sleeping at other times, while she\n aweake follow commands intermittently.\n Action:\n Cont on fent 100 mics ,Versed 2mg/hr and requires frequent boluses .\n Cont diazepam 10 mg PO Q6H. Fent ^ 125 mics/hr,Versed 3mg/hr.\n Response:\n HR ranging from SB in the 40\ns when asleep to the 120-140\ns when\n agitated, b/p ranging from 90\ns/40\ns when asleep to 140-170\ns/ 70\n when agitated. When pt awake appropriate and following commands HR\n 80\ns-100\ns and b/p 100\ns-120\ns/ 60-70\n Plan:\n Titrate sedation as needed\n"
},
{
"category": "Social Work",
"chartdate": "2167-09-21 00:00:00.000",
"description": "Social Work Progress Note",
"row_id": 634274,
"text": "Social Work:\n Received referral re pt/family coping and questions re HCP for this 55\n y.o. pt admitted with dx of tracheobroncheal malacia. Reviewed\n chart and discussed with RN. Spoke with pt\ns brother, (c:\n ), by phone. He asks questions re who pt\ns legal NOK would\n be and who should be involved in decision making re healthcare issues\n given that pt also has a live-in boyfriend of 10 years in . He\n mentions his understanding of a Companion Law in ME where a domestic\n partner might have automatic rights to decision-making responsibilities\n in the event that pt cannot make decisions for herself. SW discussed\n with attorney on call who will do some research into this question. In\n the meantime, assured brother that both he and pt\ns bf will be\n consulted re any healthcare decisions while pt is intubated and\n sedated. Brother is satisfied with this and states he does not\n anticipate any conflicts. He is visiting from and bf is\n reportedly on his way in from ME.\n SW will continue to follow for pt/family support as needed. Brother\n seems to be coping well at this time. Please page PRN.\n , LCSW, #\n"
},
{
"category": "Physician ",
"chartdate": "2167-09-22 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 634330,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n -Neurosurg: ok to transport. Will decide on anticoagulation in AM\n -Central line placed\n -NGT to suction\n -Bowel regimen\n -Respiratory attempted to place esophageal ballon in order to measure\n intrathoracic pressure, unsuccessful\n -Desaturation around 23:00 to low 80s on 400/22/15/0.9 following turn.\n Recruitment maneuver (PEEP to 30) done x2 with good effect, Sat came up\n to 100%. PEEP left at 17\n -Transfused 1 un pRBC\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 10:00 AM\n Aztreonam - 02:00 PM\n Vancomycin - 12:00 AM\n Metronidazole - 12:00 AM\n Infusions:\n Norepinephrine - 0.02 mcg/Kg/min\n Fentanyl - 200 mcg/hour\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:00 AM\n Midazolam (Versed) - 02:20 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 37.6\nC (99.6\n HR: 73 (64 - 96) bpm\n BP: 119/48(69) {85/39(55) - 142/67(91)} mmHg\n RR: 22 (11 - 22) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 94.2 kg (admission): 94.2 kg\n Height: 67 Inch\n CVP: 20 (11 - 21)mmHg\n Bladder pressure: 14 (14 - 18) mmHg\n Total In:\n 3,482 mL\n 465 mL\n PO:\n TF:\n IVF:\n 2,845 mL\n 465 mL\n Blood products:\n 277 mL\n Total out:\n 580 mL\n 65 mL\n Urine:\n 580 mL\n 65 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,902 mL\n 400 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 500) mL\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 17 cmH2O\n FiO2: 80%\n PIP: 33 cmH2O\n Plateau: 30 cmH2O\n Compliance: 30.8 cmH2O/mL\n SpO2: 98%\n ABG: 7.38/41/86./24/0\n Ve: 9.1 L/min\n PaO2 / FiO2: 109\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 376 K/uL\n 9.0 g/dL\n 120 mg/dL\n 0.6 mg/dL\n 24 mEq/L\n 3.7 mEq/L\n 4 mg/dL\n 108 mEq/L\n 141 mEq/L\n 28.1 %\n 8.4 K/uL\n [image002.jpg]\n ALT 24 PT 18.7\n AST 16 PTT 25.4\n AP 117 INR 1.7\n Tbili 0.7\n Alb 2.4\n 08:03 PM\n 11:00 PM\n 03:01 AM\n 03:13 AM\n 12:05 PM\n 06:08 PM\n 06:11 PM\n 07:53 PM\n 02:02 AM\n 03:59 AM\n WBC\n 7.6\n 6.4\n 8.4\n Hct\n 24.1\n 24.1\n 29.0\n 28.1\n Plt\n \n Cr\n 0.6\n 0.6\n 0.6\n TCO2\n 33\n 30\n 29\n 29\n 25\n 25\n Glucose\n 127\n 129\n 120\n Differential-Neuts:80.8 %, Lymph:12.0 %, Mono:3.5 %, Eos:3.3 %\n Ca++:8.2 mg/dL, Mg++:2.2 mg/dL, PO4:3.1 mg/dL, ion Ca++ () 1.16\n Cortisol:\n : 2:15am 24.2 Midnight 2.7\n : 3am 4.5\n Micro: neg or NGTD if not mentioned\n : blood, \n : urine, sputum-OP flora\n : BAL, - coag neg staph, lactobacillus, cath tip, sputum- OP\n flora, rare GNR, blood\n U/a:\n Color\n Amber\n Appear\n Clear\n SpecGr\n 1.015\n pH\n 5.5\n Urobil\n 2\n Bili\n Mod\n Leuk\n Tr\n Bld\n Tr\n Nitr\n Pos\n Prot\n 100\n Glu\n Neg\n Ket\n 40\n RBC\n 0-2\n WBC\n 0-2\n Bact\n Few\n Yeast\n None\n Epi\n 0-2\n Imaging:\n Echo\n post recruitment CXR showed deep sulcus but no pnumothorax per rads.\n CT: Prelim Read\n Right lower lobe consolidation, and superimposed atelectasis/lower lobe\n collapse, and effusions. Acute T8 compression deformity, with no\n posterior\n retropulsion of fracture fragments. No associated hematoma.\n Assessment and Plan\n comm with fam, vanc dosing\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture\n # Respiratory failure: initial etiology unclear, likely multifactorial\n including bronchspasm, hypoventilation from narcotics, potential\n aspiration, infection. By report, had a neg evaluation for PE at OSH,\n however, unable to open disc to confirm. Concern for VAP.\n - Failed yesterday\ns NIF; score was -15\n - Increased FiO2 overnight. Had increased pCO2 which resolved with\n increasing RR\n - IP stopped by but will complete official consult today; suggested\n repeating CT scan\n - Need to contact Medical re previous CT scan. Can attempt to\n resend disc. Otherwise, will most likely benefit from repeat CT to\n look for acute pulm process such as PE or PNA.\n # Fever: Likely due to combination of infection and DVT. Cultures\n sent. Will treat with empiric antibiotics. Tylenol PRN for fever.\n - Known RUE DVT\n - Infectious etiologies include VAP, asp PNA, line infections. Removed\n PICC yesterday and cultured tip. Mini-BAL- gram stain neg. Sputum\n grew GPC in pairs and GPR. Flagyl, aztreonam, vancomycin, levofloxacin\n for coverage of gram positives, gram negatives, anaerobes, MRSA. Urine\n and blood cultures NGTD\n - f/u blood, urine, and sputum cultures.\n - Concern for abd cause; KUB unrevealing. High residuals. require\n further imaging\n # Transient hypotension: Has been somewhat fluid responsive; UOP \n ccs/hr. Diff dx includes hypovolemia, sepsis, cardiogenic.\n - Sepsis most likely given fever.\n - HCT decreasing; ? stable at 24-25\n - Unable to place central line despite multiple attempts. First tired\n left IJ RUE DVT. 2^nd attempt in left IJ. Can place femoral if pt\n requires more active repletion\n - Consider another attempt at a line.\n # Oliguria:\n -BUN and Cr as well as lactate reassuring.\n -Increased bladder pressures this am- 20. Further imaging may be\n helpful\n # RUE DVT: Have held on starting treatment in light of need for central\n access. Can start therapeutic heparin vs Lovenox with bridge to\n coumadin.\n -Can consider rescanning for PE. High risk for PE given UE DVT.\n # Abd distention:\n -KUB unrevealing\n -High residuals\n - benefit from further imaging; if unstable consider ultrasound,\n however, if pt can tolerate it, a CT scan might be more helpful. Can\n also scan chest and pelvis.\n # Anemia: On admission to Medical Center, Hct was ~40, now down\n to 30 and then 25 w/o sign of active GI bleed or other source of blood\n loss. be related to fluid administration, phlebotomy, anemia of\n inflammation, active bleed still considered in differential.\n - trend Hct\n - guaiac stools\n - S/p failed attempts at line placement; watch for neck hematomas\n - INR elev at 1.5. ? may be related to poor nutrition as albumin is\n 2.3\n # Spine fracture: neurologically intact distal to the lesion. prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - Need to talk to neurosurg to see if pt can tolerate a CT scan as well\n as the risks of anticoag for DVT\n - monitor distal neurologic function\n - cto brace x3 months unless supine in bed\n - consult neurosurgery for further recs\n # Hypernatremia: correcting with g tube free flush and D5W\n -Holding on g tube feeds at present due to high residuals\n -Replete lytes as necessary\n # Communication:\n SW discussed with attorney on call who will do some research into this\n question. In the meantime, assured brother that both he and pt\ns bf\n will be consulted re any healthcare decisions while pt is intubated and\n sedated. Brother is satisfied with this and states he does not\n anticipate any conflicts. He is visiting from and bf is\n reportedly on his way in from ME.\n ICU Care\n Nutrition: tube feed with free water\n Glycemic Control: Regular insulin sliding scale\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Communication: ICU consent signed, (brother) \n (boyfriend/POA) \n Code status: Full code\n Disposition: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 01:36 AM\n 22 Gauge - 02:00 PM\n Arterial Line - 03:00 AM\n Multi Lumen - 11:30 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2167-09-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 634493,
"text": "55 yr old woman admitted from OSH after she fell down the stairs. Pt\n came to us with ? PNA from VAP. Full code, Allergies: PCN,\n tetracycline, Sulfa. PMH: ETOH, smoker, Gerd, Hip replacement.\n Alteration in Nutrition\n Assessment:\n Tube feeds at 20ml/hr. Tube feed residual 20ml.\n Action:\n Kept TF at 20ml/hr and will cont to check residuals and try to increase\n rate\n Response:\n No change\n Plan:\n Try to increase Tube feeds to goal rate.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n RUE DVT, pt on heparin gtt at 1700units/hr.\n Action:\n Ptt was therapeutic x2, AM PTT\n Response:\n Plan:\n Cont heparin gtt, check PTT adjust heparin gtt per scale.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Moderate thick white in-line secretions, copious clear oral secretions,\n clear/diminished lung sounds. Esophageal balloon in place.\n Action:\n Lots of suctioning through the night, decreased FiO2 from 50% to 40%,\n decreased Peep from 23 to 21\n Response:\n ABG WNL\n Plan:\n Cont to try to wean vent settings as tolerated, cont monitoring ABG\n Hypotension (not Shock)\n Assessment:\n SBP 90-110\ns MAP 64-66 Goal MAP >65 Levophed gtt @ 0.020 mcg/kg/min.\n Action:\n Trying to wean levophed gtt off\n Response:\n Plan:\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n T-max 101.0\n Action:\n Sent blood, urine, and sputum cultures, treated with tylenol\n Response:\n Temp decreased\n Plan:\n Follow up on cultures\n"
},
{
"category": "Nursing",
"chartdate": "2167-09-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 634494,
"text": "55 yr old woman admitted from OSH after she fell down the stairs. Pt\n came to us with ? PNA from VAP. Full code, Allergies: PCN,\n tetracycline, Sulfa. PMH: ETOH, smoker, Gerd, Hip replacement.\n Alteration in Nutrition\n Assessment:\n Tube feeds at 20ml/hr. Tube feed residual 20ml.\n Action:\n Kept TF at 20ml/hr and will cont to check residuals and try to increase\n rate\n Response:\n No change\n Plan:\n Try to increase Tube feeds to goal rate.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n RUE DVT, pt on heparin gtt at 1700units/hr.\n Action:\n Ptt was therapeutic x2, AM PTT\n Response:\n Plan:\n Cont heparin gtt, check PTT adjust heparin gtt per scale.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Moderate thick white in-line secretions, copious clear oral secretions,\n clear/diminished lung sounds. Esophageal balloon in place.\n Action:\n Lots of suctioning through the night, decreased FiO2 from 50% to 40%,\n decreased Peep from 23 to 21\n Response:\n ABG WNL\n Plan:\n Cont to try to wean vent settings as tolerated, cont monitoring ABG\n Hypotension (not Shock)\n Assessment:\n SBP 90-110\ns MAP 62-66 Goal MAP >65 Levophed gtt @ 0.020 mcg/kg/min.\n Action:\n Trying to wean levophed gtt off\n Response:\n Plan:\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n T-max 101.0\n Action:\n Sent blood, urine, and sputum cultures, treated with tylenol\n Response:\n Temp decreased\n Plan:\n Follow up on cultures\n"
},
{
"category": "Nursing",
"chartdate": "2167-09-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 634718,
"text": "Events: PT found on CXR ETT 5cm too high- bronched and repositioning,\n sample sent- tolerated w/ w/ mod amt sedation. Sadation weaned w/\n boluses for agitation. No IVF bolus, cont off Levo gtt. Resting post\n bronch w/ plan to wean PEEP as tolerated.\n Bradycardia\n Assessment:\n When sedated pt sinus bradycardic 49-50\ns, BP remaining stable.\n Action:\n Sedation monitored weaned w/ blousing PRN\n Response:\n Cont bradycardia when sedated\n Plan:\n Cont monitoring HS stability, sedation as tolerated- MS labile from\n awake and pulling at tube/lines/moving in bed to sedation w/ able to\n wake up to voice\n Alteration in Nutrition\n Assessment:\n TF residuals 5-70cc, cont hypoactive BS\n Action:\n Inc to goal TF- replete w/ fiber @ 60cc/hr\n Response:\n Tolerating @ this time\n Plan:\n Monitor residuals, bowel sounds, cont @ goal 60cc/hr, monitor stool\n output\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Hep gtt infusing @ 1700 units/hr, no s/s bleeding\n Action:\n Cont Hep gtt, check PTT w/ AM labs\n Response:\n Plan:\n Cont Hep gtt per order, check PTT w/ AM labs and adjust per scale,\n monitor s/s bleeding\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS diminished/rhonchi, minimal thin clear secretions, desat to 92%\n while on R side,\n Action:\n Cont pulm toilet as tolerated, turning side-middle side Q2hrs, bronch,\n Response:\n Sat > 95% post repositioning,\n Plan:\n Cont pulm toilet, wean from vent as tolerated\n Hypotension (not Shock)\n Assessment:\n A line positional, intermittently correlating W/ NBP w/ intermittent\n dampened waveform and over dampened, able to draw ABG, BP labile w/\n sedation Map >65 throughout day, CVP 15-19\n Action:\n A Line not re-sited, positioning art line, correlating NBP and ABP\n Response:\n MAP >65 throughout shift\n Plan:\n Cont monitor, cont IV steroids, CVP monitoring w/ UOP for additional\n fluid bolus\n"
},
{
"category": "Respiratory ",
"chartdate": "2167-09-28 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 634998,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 10\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Decreasing PEEP as talerated with intent to possible\n preform tracheostomy within the next day or two.\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: patient remains on ventilatory support with all settings and\n changes documented on flow sheet. PEEP decreased to 10cm with plan to\n perform tracheostomy within the next day or two. Patient appears to be\n agitated but talerating PEEP change. MDI\ns administered as ordered.\n"
},
{
"category": "Nursing",
"chartdate": "2167-09-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 635133,
"text": "55yrold lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n consertively with pain meds and back brace. Developed resp distress\n requiring intubation on ct neg for PE cxr showed pna pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia /\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 635658,
"text": "55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\n Now with prolonged hospital course c/b by PNA with high PEEP\n requirement, anxiety, RUE DVT on heparin qtt.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt on Vent settings AC 60%/18 X 400/+10 with no overbreathing of\n set RR. O2 sat 92-98%. Lung snds clear, diminished in bases. Pt sxn\n for small amts thick white secretions. Trach site with small amt\n serosang drainage.\n Action:\n FiO2 \nd to 55%.\n Response:\n ABG to follow.\n Plan:\n Cont to gently wean from vent.\n Edema, peripheral\n Assessment:\n Pt with general edema. LOS fluid balance +approx 13 liters. Lasix\n stopped as PICC line clogged.\n Action:\n TPA used to clear PICC line. Lasix restarted @ 2mg/hr.\n Response:\n By 1330 24hr fluid balance\n 2liters. Lasix qtt stopped @ 1330, but pt\n cont to autodiurese. Pt presently\n 3 liters since MN. Lytes sent @\n 1630.\n Plan:\n Cont to monitor urine output, restarting Lasix if necessary to maintain\n goal -1-2liters/day. Monitor lytes.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt rec\nd with Heparin qtt off post trach/PEG yesterday.\n Action:\n Heparin restarted @ 1100 @ previous rate 1700units/hr.\n Response:\n PTT @ 1630 58.5. Heparin inc\nd to 1900units/hr per sliding scale @\n 1715.\n Plan:\n Repeat PTT @ 2300.\n Alteration in Nutrition\n Assessment:\n Rec\nd pt NPO post OR yesterday. Abd obese/distended with + BS. No BM\n today.\n Action:\n Restarted TF Replete with fiber @ 1000 per surgical team @ 10ml/hr, as\n well as FWB of 250ml Q4hrs for elevated Na.\n Response:\n Residual @ 1600 140ml of TF/water/yellow bilious. TF stopped and FWB\n held.\n Plan:\n Resume TF @ 1830. Cont to monitor residuals, holding TF if >100ml.\n"
},
{
"category": "Nutrition",
"chartdate": "2167-09-22 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 634346,
"text": "Subjective\n Pt intubated /sedated\n Objective\n Pertinent medications: noted\n Labs:\n Value\n Date\n Glucose\n 120 mg/dL\n 03:59 AM\n Glucose Finger Stick\n 124\n 10:00 AM\n FSBG\n 111, 111, 145, 123\n \n BUN\n 4 mg/dL\n 03:59 AM\n Creatinine\n 0.6 mg/dL\n 03:59 AM\n Sodium\n 141 mEq/L\n 03:59 AM\n Potassium\n 3.7 mEq/L\n 03:59 AM\n Chloride\n 108 mEq/L\n 03:59 AM\n Albumin\n 2.4 g/dL\n 03:59 AM\n Calcium non-ionized\n 8.2 mg/dL\n 03:59 AM\n Phosphorus\n 3.1 mg/dL\n 03:59 AM\n Ionized Calcium\n 1.16 mmol/L\n 12:05 PM\n Magnesium\n 2.2 mg/dL\n 03:59 AM\n Corrented Ca\n 9.48\n Current diet order / nutrition support: replete c/ Fiber @60mL/hr (1440\n kcals 89 gr aa)- currently on hold\n GI: Abd: softly dist/absent bs/no BM\n Assessment of Nutritional Status\n Specifics:\n TF\ns trialed. Held high residuals and OGT placed to suction. OGT\n is currently clamped.\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: via nutrition support\n Consider reglan +/- increase bowel regimen\n Resume TF's as medically feasible, if unable in next 2-3 days, will\n need to consider PN to prevent nutritional decline\n BG/lyte management\n"
},
{
"category": "Respiratory ",
"chartdate": "2167-09-25 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 634642,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 7\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Tube Type\n ETT:\n Position: 18 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Comments: Pt. remains on A/C overnoc, no vent changes this shift.\n Maintain current vent settings.\n"
},
{
"category": "Physician ",
"chartdate": "2167-09-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 634722,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n New A-line placed (left), good tracing but positional\n Vanco restarted\n Atrial EKG->p-waves\n Multiple IVF boluses for MAPs < 65. Did not restart pressors\n Brother came, confirmed history\n Eye drops\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Metronidazole - 08:00 AM\n Levofloxacin - 10:00 AM\n Vancomycin - 08:09 PM\n Aztreonam - 10:00 PM\n Infusions:\n Midazolam (Versed) - 4 mg/hour\n Heparin Sodium - 1,700 units/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 04:29 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.7\nC (98.1\n HR: 56 (45 - 63) bpm\n BP: 103/54(72) {83/44(59) - 142/105(109)} mmHg\n RR: 22 (0 - 22) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101 kg (admission): 94.2 kg\n Height: 67 Inch\n CVP: 12 (11 - 14)mmHg\n Total In:\n 4,750 mL\n 868 mL\n PO:\n TF:\n 773 mL\n 223 mL\n IVF:\n 3,827 mL\n 645 mL\n Blood products:\n Total out:\n 2,365 mL\n 60 mL\n Urine:\n 2,325 mL\n 60 mL\n NG:\n 40 mL\n Stool:\n Drains:\n Balance:\n 2,385 mL\n 808 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 21 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 34 cmH2O\n Plateau: 29 cmH2O\n Compliance: 50 cmH2O/mL\n SpO2: 99%\n ABG: 7.46/38/96./23/2\n Ve: 8.6 L/min\n PaO2 / FiO2: 242\n Physical Examination\n General Appearance: Obese\n Eyes / Conjunctiva: PERRL, subconjunctival hematoma on left\n Cardiovascular: brady, regular, no MRG, nL S1, S2\n Respiratory / Chest: CTA b/l\n Abdominal: Soft, Non-tender, Obese, +BS\n Extremities: Right: 1+, Left: 1+\n Skin: Warm\n Neurologic: Responds to: Verbal stimuli, Movement: Purposeful, Tone:\n Normal\n Labs / Radiology\n 326 K/uL\n 8.9 g/dL\n 153 mg/dL\n 0.6 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n 6 mg/dL\n 113 mEq/L\n 141 mEq/L\n 28.6 %\n 8.9 K/uL\n [image002.jpg]\n 09:14 PM\n 01:04 AM\n 05:54 AM\n 06:11 AM\n 11:07 PM\n 03:51 AM\n 06:17 AM\n 07:00 AM\n 08:18 AM\n 04:18 PM\n WBC\n 8.1\n 8.9\n Hct\n 28.0\n 28.6\n Plt\n 358\n 326\n Cr\n 0.7\n 0.7\n 0.6\n TropT\n <0.01\n <0.01\n TCO2\n 28\n 28\n 26\n 26\n 21\n 28\n Glucose\n 126\n 151\n 153\n Other labs: PT / PTT / INR:24.3/68.6/2.4, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:82.5 %, Lymph:11.6 %,\n Mono:3.3 %, Eos:2.2 %, Lactic Acid:0.7 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:7.8 mg/dL, Mg++:2.1 mg/dL, PO4:2.6 mg/dL\n Culture data: Sputum with Klebsiella Oxytoca\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with respiratory failure\n and difficulty weaning from vent.\n # Respiratory failure: Over the evening yesterday, were able to\n decrease FiO2 and PEEP. Clinical and imaging suggestive of ARDS.\n Initial precipitating factors were thought to be: sedation, hypovent\n obesity, orthotic brace. Now thought to have VAP.\n - Placed esophageal balloon on which will help guide PEEP settings.\n - Given small size of effusion and high PEEP (risk of pneumothorax),\n will not attempt to tap\n - Appreciate IP recs. Will consider tracheomalacia workup when more\n stable.\n - Approaching 2-week intubation point (intubated ); Trach?\n # VAP/ID: Re-spiked fever overnight. Stopped vanc yesterday, , as\n treating for GNR infection. Current GS shows GPC\n - Follow cultures\n - Restart Vanc.\n - Continue aztreonam, levofloxicin for 8 days pending speciation (at\n that time can increase to 15 days if necessary)\n - Also, stopped flagyl because had one neg c. diff toxin and CT did not\n show evidence of colitis\n - Will replace A-line today.\n # EKG changes: Sinus bradycardia. Very low voltages and no change in\n QRS morphology. P-waves are visible and prolonged PR interval is old.\n CK and troponins flat. Likely related to increased vagal tone possibly\n related to steroid replacement.\n - Will avoid excessive alpha-agonism\n - Continue to monitor\n - could consider atrial EKG\n .\n # Hypotension: now off levophed, with good urine output. Hypovolemia\n is possibly a factor- responded to a transfusion; HCT had been\n dropping. However, SVV with Vigileo was 7, making her CO less likely\n to respond to fluids. Held on giving any boluses overnight. Today CVP\n is low given PEEP. Sepsis also a consideration\n - continue on broad spectrum abs\n - replete fluids.\n - Restart pressors as needed. Consider dopamine over levophed given\n bradycardia.\n - Central line in place.\n # Urine output: Previously oliguric, now with high urine output.\n Concern for autodiuresis but BUN and Cr reassuring.\n -Continue to monitor\n # RUE DVT: Started on heparin gtt on .\n -Therapeutic in one day; may be related to poor nutritional status.\n Will continue to closely monitor\n # Adrenal Insufficency:\n -Random cortisol was approx 3 when it should have been maximally\n stimulated.\n -Started hydrocortisone and florinef. ? switch to methylpred\n # Anemia:\n - Trend HCT\n - Gave 1 un pRBC with good results\n - INR rising, now 2.0, may be nutritional\n # Spine fracture: neurologically intact distal to the lesion. prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n # Hypernatremia, resolved: correcting with g tube free flush and D5W\n -Continue to follow\n # Communication:\n - Brother has been with pt, although, live in boyfriend of 10 is\n her HCP. Boyfriend will hopefully visit pt today\n ICU Care\n Nutrition: tube feed with free water when able\n Glycemic Control: Regular insulin sliding scale\n DVT: Theraputic Heparin gtt\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Communication: ICU consent signed, (brother) \n (boyfriend/POA) \n Code status: Full code\n Disposition: ICU\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 07:00 AM 50 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 11:30 AM\n Arterial Line - 04:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2167-09-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 634723,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n New A-line placed (left), good tracing but positional\n Vanco restarted\n Atrial EKG->p-waves\n Multiple IVF boluses for MAPs < 65. Did not restart pressors\n Brother came, confirmed history\n Eye drops\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Metronidazole - 08:00 AM\n Levofloxacin - 10:00 AM\n Vancomycin - 08:09 PM\n Aztreonam - 10:00 PM\n Infusions:\n Midazolam (Versed) - 4 mg/hour\n Heparin Sodium - 1,700 units/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 04:29 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.7\nC (98.1\n HR: 56 (45 - 63) bpm\n BP: 103/54(72) {83/44(59) - 142/105(109)} mmHg\n RR: 22 (0 - 22) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101 kg (admission): 94.2 kg\n Height: 67 Inch\n CVP: 12 (11 - 14)mmHg\n Total In:\n 4,750 mL\n 868 mL\n PO:\n TF:\n 773 mL\n 223 mL\n IVF:\n 3,827 mL\n 645 mL\n Blood products:\n Total out:\n 2,365 mL\n 60 mL\n Urine:\n 2,325 mL\n 60 mL\n NG:\n 40 mL\n Stool:\n Drains:\n Balance:\n 2,385 mL\n 808 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 21 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 34 cmH2O\n Plateau: 29 cmH2O\n Compliance: 50 cmH2O/mL\n SpO2: 99%\n ABG: 7.46/38/96./23/2\n Ve: 8.6 L/min\n PaO2 / FiO2: 242\n Physical Examination\n General Appearance: Obese\n Eyes / Conjunctiva: PERRL, subconjunctival hematoma on left\n Cardiovascular: brady, regular, no MRG, nL S1, S2\n Respiratory / Chest: CTA b/l\n Abdominal: Soft, Non-tender, Obese, +BS\n Extremities: Right: 1+, Left: 1+\n Skin: Warm\n Neurologic: Responds to: Verbal stimuli, Movement: Purposeful, Tone:\n Normal\n Labs / Radiology\n 326 K/uL\n 8.9 g/dL\n 153 mg/dL\n 0.6 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n 6 mg/dL\n 113 mEq/L\n 141 mEq/L\n 28.6 %\n 8.9 K/uL\n [image002.jpg]\n 09:14 PM\n 01:04 AM\n 05:54 AM\n 06:11 AM\n 11:07 PM\n 03:51 AM\n 06:17 AM\n 07:00 AM\n 08:18 AM\n 04:18 PM\n WBC\n 8.1\n 8.9\n Hct\n 28.0\n 28.6\n Plt\n 358\n 326\n Cr\n 0.7\n 0.7\n 0.6\n TropT\n <0.01\n <0.01\n TCO2\n 28\n 28\n 26\n 26\n 21\n 28\n Glucose\n 126\n 151\n 153\n Other labs: PT / PTT / INR:24.3/68.6/2.4, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:82.5 %, Lymph:11.6 %,\n Mono:3.3 %, Eos:2.2 %, Lactic Acid:0.7 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:7.8 mg/dL, Mg++:2.1 mg/dL, PO4:2.6 mg/dL\n Culture data: Sputum with Klebsiella Oxytoca\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with respiratory failure\n and difficulty weaning from vent.\n 55-year-old woman with\n Unclear location of ETT\n Since only 18cm in holder, we will bronch to confirm correct\n position since an inadvertent extubation might be fatal.\n Respiratory failure\n Oxygenation is improving\n Wean PEEP as tolerated by hypoxemia\n eventually need investigation for TBM\n At present, her PEEP is too high to consider tracheostomy\n but if we are able to wean it (and not able to extubate her) would\n consider tracheostomy soon\n Adrenal insufficiency\n Based on very low random cortisol while in shock and\n respiratory failure\n On steroids, has come off and stayed off of pressors.\n Eventually wean, but still getting fluid boluses\n Bradycardia\n Rhythm is sinus, confirmed by CVL-directed\natrial\n lead\n Heart rate increases with stimulation, suggesting that this\n is mostly vagal in etiology\n Klebsiella VAP\n Complete 8d course of levofloxacin\n Discontinue aztreonam\n If sputum culture remains negative (GPCs on G/S),\n discontinue vancomycin tomorrow\n Shock\n now off of levophed\n Intermittent fluid boluses\n Treating adrenal insufficiency\n Upper extremity DVT\n Therapeutic heparin\n Anemia\n Follow\n Possible tracheobronchomalacia (reason for transfer)\n Incidental peri-appendiceal finding (will need eventual\n follow-up)\n Traumatic thoracic spinal fracture\n Eventual MRI. Too high-risk at present. Brace when out of\n bed.\n # Respiratory failure currently with unclear ETT location: Intubated\n on for resp decompensation. Likely VAP. Unlikely to have\n tracheomalacia as initially transferred for.\n - bronch for ETT location\n - wean PEEP\n # Pneumonia: Kleb oxytoca pneumonia and sputum with GPCs on gram stain.\n Afebrile overnight. On levofloxacin, vancomycin, aztreonam. Resp\n status seems to be improving.\n - Follow cultures\n - d/c aztreonam\n - Continue levofloxacin for 8 days\n # EKG changes: Sinus bradycardia. Very low voltages and no change in\n QRS morphology. P-waves are visible and prolonged PR interval is old.\n CK and troponins flat. Likely related to increased vagal tone possibly\n related to steroid replacement. Atrial EKG with p-waves c/w sinus\n bradycardia.\n - Will avoid excessive alpha-agonism\n - Continue to monitor\n .\n # Hypotension: now off levophed, with good urine output. Hypovolemia\n is possibly a factor- responded to a transfusion; HCT had been\n dropping. However, SVV with Vigileo was 7, making her CO less likely\n to respond to fluids. Held on giving any boluses overnight. Today CVP\n is low given PEEP. Sepsis also a consideration.\n - continue abx as above (vanc and levofloxacin)\n - replete fluids.\n - Restart pressors as needed. Consider dopamine given bradycardia.\n # RUE DVT: Started on heparin gtt on .\n - closely monitor\n # Adrenal Insufficency: Random cortisol was approx 3 when it should\n have been maximally stimulated.\n - hydrocortisone and florinef for 5 days\n # Anemia: Stable.\n - Trend HCT\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n # Communication:\n - Brother has been with pt, although, live in boyfriend of 10 is\n her HCP.\n ICU \n Nutrition: tube feed with free water when able, INR rising likely \n nutritional deficiencies\n Glycemic Control: Regular insulin sliding scale\n DVT: Theraputic Heparin gtt\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Communication: ICU consent signed, (brother) \n (boyfriend/POA) \n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Social Work",
"chartdate": "2167-10-01 00:00:00.000",
"description": "Social Work Progress Note",
"row_id": 635364,
"text": "Social Work:\n Spoke by phone with pt\ns boyfriend, (), to\n offer support re pt\ns hospitalization and to facilitate communication\n with MICU team. He and pt have been living together in ME for the past\n 12 years. He speaks of how it is difficult to come to to visit\n pt because of the distance and the financial cost of taking the train.\n SW offered a cab voucher between train and hospital, if this would\n defray the cost and feel more manageable for him. He states he\nll let\n SW know if this would be helpful in the future. However, he also\n speaks of his own health problems which have limited his ability to\n travel this summer, and he describes feeling as if he is doing the best\n he can to come in.\n Mr. that even though he may not be able to come into\n the hospital as much as he\nd like, he still very much wants to stay\n involved in pt\ns care by communicating with team by phone. Discussed\n how pt\ns brother, as , has also been involved in communicating with\n team and, per Intern, has been giving consent for certain procedures\n when pt has been unable to speak for herself. Mr. confirms that\n he is not aware of pt having signed a HCP form and he understands and\n accepts that pt\ns brother as been involved re questions of consent.\n Discussed how it is important to Mr. that he, too, be consulted by\n phone re any major decisions re direction of care.\n SW discussed above with Intern and recommended she call Mr. today\n to discuss direction of care issues.\n Encouraged Mr. to contact SW as needed for further support and\n provided contact info. continue to follow for ongoing support.\n Please page PRN.\n , LCSW, #\n"
},
{
"category": "Respiratory ",
"chartdate": "2167-10-02 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 635521,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation:\n Ideal body weight:\n Ideal tidal volume:\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position:\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure:\n Cuff volume:\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds:\n RUL Lung Sounds:\n LUL Lung Sounds:\n LLL Lung Sounds:\n Comments:\n Secretions\n Sputum color / consistency:\n Sputum source/amount:\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Specialized Gas Therapy\n Nitric Oxide\n PPM used: ppm\n Indication:\n Effect of therapy: []\n Nitric Oxide trial:\n Comments:\n HeliOx:\n Additional O[2] by cannula: L/min\n Continuous nebulized bronchodilator:\n Comments:\n Recruitment Maneuvers Done\n CPAP pressure used: cm H2O\n Duration: sec\n Times per shift:\n Comments:\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 635576,
"text": "55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP now with prolonged\n hospital course c/o by PNA anxiety,RUE DVD with high PEEP requirement\n .\n Pt has had an uneventful night. Plan to start heparin and TF this am.\n Awaiting time. Wean sedation today as tol by pt.\n Edema, peripheral\n Assessment:\n Pt has gen edema with gen pitting. Gen swelling has improved over the\n last 24hrs after lasix gtt initiated.\n Action:\n Lasix gtt infusing with goal of negative 1-2 liters over 24hrs. Lasix\n stopped at 5am access issues.\n Response:\n Pt is very sensitive to lasix, and is diuresing well while it is\n infusing with stable BP. K level has been stable and no replaements\n needed.\n Plan:\n Restart lasix once access available.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt has a clot to Rt arm and has been on heparin gtt per protocol.\n Heparin stopped yesterday trach and PEG placed.\n Action:\n Response:\n Plan:\n Heparin to be started today and ? time.\n Altered mental status (not Delirium)\n Assessment:\n Pt has been sedated throughout the night with plans to wean sedation\n today. Pt has a HR in the 40-50\ns while asleep with SBP 99-110. Pt has\n a HR in the 70\ns with a SBP 110-140\ns while awake. Pt will open eyes to\n voice and will follow most commands. While awake, pt is restless and\n will try to sit up and pull on trach.\n Action:\n Emotional support given with short lived effect. Pt continues on\n fentanyl and versed gtt for sedation and diazepam ATC.\n Response:\n Plan:\n Plan to wean pt off sedation gtts today.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt was trached yesterday failure to wean of vent ? tracheal\n malacia. Pt noted to be desatting while awake and while sedated to 85%.\n LS clear to coarse to upper resp areas with diminished bases. Pt has\n been sx\nd for sml amounts of rusty blood tinged secretions.\n Action:\n CMV settings changed to 60% FiO2 and peep increased to 10 after episode\n of low O2sat.\n Response:\n After vent changes, O2sat d and ABGs improved.\n Plan:\n Wean vent settings as pt tol.\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 635706,
"text": "55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\n Now with prolonged hospital course c/b by PNA with high PEEP\n requirement, anxiety, RUE DVT on heparin qtt.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt on Vent settings AC 55%/18 X 400/+10 with no overbreathing of\n set RR. O2 sat 92-98%. Lung snds clear, diminished in bases. Pt sxn\n for small-moderate amts thick white secretions. Trach site with small\n amt serosang drainage.\n Action:\n Cont same vent settings\n Response:\n Pt doesn\nt over breath on the vent and never desat.Kept same Vent\n settings overnight.\n Plan:\n Monitor sats,resp and titrate Vent as she tolerats.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt rec\nd with Heparin qtt 1900units/hr.\n Action:\n PTT drawn at 2300.RUE elevated with pillow and no BP or blood drawn\n from that arm.\n Response:\n PTT @ 2300 was 107, Decreased Heparin gtt 1700 u/hr as per sliding\n scale. Next PTT due at 0600. .\n Plan:\n Cont monitor PTT,titrate accordingly, next PTT due at 0600.\n Alteration in Nutrition\n Assessment:\n Received pt on TF 10cc/hr.Abd soft w/+ BS.\n Action:\n Pt tolerated TF with minimal residuals as well as free water bolus\n Q4H.Received scheduled Colace\n Response:\n TF ^ as tolerated, currently at 30cc/hr.No BM noted this shift.HCt 24.6\n (25.8)\n Plan:\n Cont to monitor TF residuals, hold if more than 100cc\n Altered mental status (not Delirium)\n Assessment:\n Pt w/ periods of agitation and sleeping at other times, while she\n aweake follow commands intermittently.\n Action:\n Cont on fent 100 mics ,Versed 2mg/hr and requires frequent boluses .\n Cont diazepam 10 mg PO Q6H. Fent ^ 125 mics/hr,Versed 3mg/hr.\n Response:\n HR ranging from SB in the 40\ns when asleep to the 120-140\ns when\n agitated, b/p ranging from 90\ns/40\ns when asleep to 140-170\ns/ 70\n when agitated. When pt awake appropriate and following commands HR\n 80\ns-100\ns and b/p 100\ns-120\ns/ 60-70\n Plan:\n Titrate sedation as needed\n"
},
{
"category": "Nursing",
"chartdate": "2167-09-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 635177,
"text": "55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP now with prolonged\n hospital course c/o by PNA anxiety,RUE DVD with high PEEP requirement\n .\n Plan : Plan for trach and peg today or the next few days, if pt tol\n peep of 10.\n Hypernatremia (high sodium)\n Assessment:\n Na level elevated\n Action:\n H2O flushes increased to 250 cc q 4hrs.\n Response:\n Na level remains elevated this am at 146 (sl improved).\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains intubated on CMV settings, now at 60%/400x18/10. LS coarse\n to upper resp area with diminished bases. Pt has been deep sx\nd for\n scant amounts of yellow secretions q 2hrs. Pt cont to have copious\n amounts of clear oral secretions and in need of freq oral care. Pt\n noted to have a decrease in O2sat, while she is on her Lt side, but it\n has improved throughout the night.\n Action:\n Peep weaned to 10, and tol well by pt with good ABGs. Fio2 weaned to 50\n %, but pt\ns O2sat decreased to 88% right away.\n Response:\n LS clear to upper resp area after sx.\n Plan:\n Plan for trach and Peg today if p[t cont to tol peep of 10.\n Altered mental status (not Delirium)\n Assessment:\n Pt found at 8pm to 10pm to be awake, alert and following commands. Pt\n was slight restless, but appropriate. 10pm, pt became very restless in\n bed, trying to sit up and was reaching for ETT. Once reposition and\n back rubs did not work, MD notified and haldol given and diazepam given\n with only effect for one hr. When pt is awake and restless, her HR will\n increase to 120-130\ns (ST) and BP will increase to 120-130\ns. When pt\n was sleeping (after sedation), Hr will deacrease to 50\ns with a SBP in\n the 80\ns. Fentanyl patch increased and diazepam changed to q6hrs, with\n no effect.\n Action:\n 2:30am, versed gtt was initiated again with good effect. Pt more\n relaxed and fell back to sleep with stable HR and BP.\n Response:\n Plan:\n Continue to evaluate restlessness.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt on heparin gtt protocol for DVT to Rt arm. No signs of bleeding\n noted. Hct stable.\n Action:\n Response:\n PTT drawn q 6hrs; and it has been therapeutic.\n Plan:\n Plan to check PTT now daily.\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 635805,
"text": "55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\n Now with prolonged hospital course c/b by PNA with high PEEP\n requirement, anxiety, RUE DVT on heparin qtt.\n Edema, peripheral\n Assessment:\n Fluid balance for previous 24hrs decreased by 3 liters D/T diuresis.\n Rec\nd pt off of Lasix qtt. Urine output decreased to 45ml/hr @1000.\n Action:\n Lasix qtt restarted @ 2mg/hr to maintain urine output 1-2liters/day.\n Response:\n Fluid balance approx -50ml/hr, with 24hr fluid balance -650ml @ 1500.\n However, SBP 78 when pt soundly sleeping/sedated. Lasix qtt stopped @\n 1530.\n Plan:\n Restart Lasix qtt when BP stabilized.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Rec\nd pt on Heparin qtt @ 1500units/hr.\n Action:\n PTT 92.1 @ 1230.\n Response:\n Per goal PTT 60-100, Heparin rate unchanged.\n Plan:\n Repeat PTT @ 1830. Start po Coumadin tonight.\n Altered mental status (not Delirium)\n Assessment:\n Rec\nd pt on Versed @ 2mg/hr, Fentanyl @ 100mcg/hr, as well as Fentanyl\n patches totaling 150mcg in place. Pt also rec\ning Diazepam 10mg po\n Q6hrs, in hope of weaning pt from IV sedation. Pt alternately appears\n very sedated and very restless. When she appears alert, she intermit\n responds to commands approp but not attempting to mouth words or nod to\n communicate. Moving arms purposefully towards trach, so soft wrist\n restraints remain in place. When very sedated @ 1530, SBP to 78 per\n below.\n Action:\n Versed \nd to 1mg/hr, Fentanyl \nd to 75mcg/hr.\n Response:\n Pt restless/squirming in bed when she appears awake. Not responding to\n verbal reassurance.\n Plan:\n Cont to attempt weaning from IV sedation. Cont to freq reorient pt,\n emotional support.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt on vent settings AC 55%/18 X 400/+10, with no over-breathing\n of rate by pt. O2 sat 95-99%. ABG 7.44/42/93. Lung snds clear but\n diminished in lower lobes. Suctionned for mod-lg amts thick white\n secretions.\n Action:\n Vent changed to CMV with PS 8/+10 on 55%.\n Response:\n Pt tolerated PS approx 3hrs, but after rec\ning scheduled dose Diazepam\n @ 1200 began having extended pauses apnea. She was then returned to AC\n 55%/9 X 500/+10.\n Plan:\n Cont wean from vent with PS trials, as well as \ning FiO2.\n"
},
{
"category": "Nursing",
"chartdate": "2167-09-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 634795,
"text": "Events:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2167-09-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 635254,
"text": "55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP now with prolonged\n hospital course c/o by PNA anxiety,RUE DVD with high PEEP requirement\n .\n Events: PEEP weaned to 8, tol well, restarted on lasix gtt, midazolam\n weaned off, fentanyl decreased. ? trach and PEG in AM.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt on AC 400x18 50% +PEEP 10, 02 sat mid 90%\ns, ABG this AM\n 7.42/49/93\n Action:\n PEEP weaned to 8, thoracic surgery reconsulted r/t trach placement.\n Response:\n 02 sat dropped to 89-92% ABG on current settings 7.44/45/66 team is\n aware.\n Plan:\n Cont on current vent settings as tol. Plan for trach placement in am.\n Hypotension (not Shock)\n Assessment:\n Pt b/p when asleep 90\ns-100\ns/ 40\ns-50\ns. increases when pt is awake/\n agitated. Pt rec\nd on fentanyl gtt at 150mcg/hr and Midazolam 2mg/hr.\n stim test from shows adrenal insuff.\n Action:\n Midazolam weaned off, fentanyl decreased, pt restarted on florinef and\n hydrocortisone. Started on lasix gtt. Currently at 2mg/hr.\n Response:\n b/p stable in the 90\ns-110\ns/ 40\ns-60\ns. UOP 35-50ml/hr.\n Plan:\n Titrate lasix gtt and sedation as tol by b/p restart levophed if b/p\n drops and remains low.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt on heparin gtt at 1700 units/hr, PTT therapeutic x 2\n Action:\n Monitor heparin gtt\n Response:\n n/a\n Plan:\n Cont heparin gtt at current rate, recheck PTT in the am.\n Alteration in Nutrition\n Assessment:\n TF currently at goal rate 60ml/hr tol well, serum Na 146 (down from\n 147). Last BM \n Action:\n Cont free H20 boluses to decrease Na,\n Response:\n Plan:\n Cont TF/ free H20 as tol, cont bowel regime.\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 635890,
"text": "55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\n Now with prolonged hospital course c/b by PNA with high PEEP\n requirement, anxiety, RUE DVT on heparin qtt.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt cont on Heparin gtt @ 1500units/h. PTT in therapeutic range.\n Coumadin po HS.\n Action:\n No further action taken.\n Response:\n Plan:\n Daily PT/PTT levels-? Plan to transition off heparin and increase\n coumadin dose.\n Altered mental status (not Delirium)\n Assessment:\n PT alert and very agitated throughout shift- making several attempts to\n pull at trach\n.fell asleep briefly following afternoon valium dose-\n Systolic dropped into low 80s, HR in the 50s- SB. Following commands\n inconsistently.\n Action:\n Fentanyl/versed titrated throughout shift. Restarted on Haldol IV prn,\n and given addititional one time dose of valium. Soft wrist restraints\n in place for safety. EKG done of QTC interval\n Response:\n Cont to be anxious, attempting to pull at trach. QTI -442\n Plan:\n Cont daily QTC Intervals, titrate down Fent/versed Gtt as able, cont w/\n prn haldol and standing valium.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Cont to be trached/vented on AC. Pleural effusions on CXR worsening.\n Action:\n Tolerated PS briefly this am. ABG/VBG collected\n Response:\n Pt w/ periods of apnea on PS.\n Plan:\n Non-contrast CT today to further characterize effusions, ? possible\n thoracentesis following CT, make vent changes as needed, wean\n fent/versed as able to tolerate vent changes. Recheck ABG/VBG this\n evening.\n Hypernatremia (high sodium)\n Assessment:\n NA level cont to be ^^, pt cont on lasix gtt\n Action:\n FWB increased to 300cc every 4 hrs.\n Response:\n Lytes to be rechecked this evening\n Plan:\n Check day and evening lytes, cont w/ q 4h boluses\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 635948,
"text": "Bradycardia\n Assessment:\n Pt conts with HR 50-70\ns at rest, 100-140\ns during care, pt\n asymptomatic; easily arousable\n Action:\n Sedation decreased, Lasix off @0200\n Response:\n HR 60\n Plan:\n Cont to wean sedation, ?cardiac consult\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Action:\n Cont with IV Heparin @ 1500u/hr\n Response:\n Pt therapeutic, cont with daily PTT\n Plan:\n Cont to labs, adjust per Heparin protocol\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt cont on AC 18/400/50%/10, LS clear bilat, occ scat rhonchi\n Action:\n Pt suct for sm thin tan secretions\n Response:\n Plan:\n Cont to ABGs,\n Hypotension (not Shock)\n Assessment:\n SBP 140\ns when pt is agitated, SBP dropping to 70\ns-80\ns, UO 200/hr\n (total 2500 in 2hr)\n Action:\n Fent/Versed turned down @ 0000, Lasix gtt on hold, team informed\n Response:\n Pt SBP\ns in 80\n Plan:\n Cardiac consult to further eval SB/ST, re-evalu cont. Lasix gtt\n Hypernatremia (high sodium)\n Assessment:\n Na 143\n Action:\n Cont with 300cc free water flush\n Response:\n Plan:\n Cont to sodium levels, treat as ordered\n"
},
{
"category": "Respiratory ",
"chartdate": "2167-09-27 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 634888,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 9\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Patient remains on mechanical ventilation with all changes documented\n on flow sheet. MDI\ns given as ordered. Breath sounds diminished with\n scattered.\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-01 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 635334,
"text": "Chief Complaint: respiratory failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n BRONCHOSCOPY - At 11:30 AM\n Midaz weaned.\n Heparin held due to potential OR today, but now on schedule for\n tomorrow for trach.\n History obtained from Medical records, ICU team\n Patient unable to provide history: Sedated\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Furosemide (Lasix) - 3 mg/hour\n Fentanyl - 100 mcg/hour\n Other ICU medications:\n Haloperidol (Haldol) - 11:47 PM\n Midazolam (Versed) - 02:45 AM\n Other medications:\n SQI, H2B, MDIs, CHG, colace, tears, florinef, hydrocort 50q6,\n duragesic, valium 10mg q6, Lasix @ 3\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:21 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.2\nC (97.2\n HR: 107 (46 - 121) bpm\n BP: 147/79(111) {88/41(57) - 148/85(113)} mmHg\n RR: 18 (18 - 20) insp/min\n SpO2: 89%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 4,162 mL\n 266 mL\n PO:\n TF:\n 1,448 mL\n 1 mL\n IVF:\n 1,003 mL\n 235 mL\n Blood products:\n Total out:\n 1,615 mL\n 1,500 mL\n Urine:\n 1,615 mL\n 1,500 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,547 mL\n -1,234 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n PIP: 27 cmH2O\n Plateau: 22 cmH2O\n Compliance: 44.4 cmH2O/mL\n SpO2: 89%\n ABG: 7.42/47/86./29/4\n Ve: 7.3 L/min\n PaO2 / FiO2: 174\n Physical Examination\n General Appearance: Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : anterior exam)\n Abdominal: Soft, No(t) Tender: , Obese\n Extremities: Right: 1+, Left: 1+\n Skin: Warm\n Neurologic: Responds to: Verbal stimuli, Movement: Non -purposeful,\n Tone: Normal\n Labs / Radiology\n 8.0 g/dL\n 280 K/uL\n 136 mg/dL\n 0.5 mg/dL\n 29 mEq/L\n 4.0 mEq/L\n 11 mg/dL\n 105 mEq/L\n 143 mEq/L\n 25.9 %\n 8.6 K/uL\n [image002.jpg]\n 02:44 PM\n 03:33 PM\n 07:26 PM\n 07:46 PM\n 02:04 AM\n 02:18 AM\n 01:27 PM\n 03:06 PM\n 10:04 PM\n 03:00 AM\n WBC\n 8.4\n 11.8\n 8.6\n Hct\n 23.0\n 28.1\n 29.9\n 25.9\n Plt\n \n Cr\n 0.5\n 0.6\n 0.5\n TCO2\n 33\n 31\n 33\n 32\n 32\n Glucose\n 168\n 176\n 136\n Other labs: PT / PTT / INR:13.2/26.6/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:89.7 %, Lymph:8.7 %, Mono:1.1\n %, Eos:0.4 %, Lactic Acid:0.9 mmol/L, Albumin:2.4 g/dL, LDH:204 IU/L,\n Ca++:8.4 mg/dL, Mg++:2.4 mg/dL, PO4:4.1 mg/dL\n CXR with slightly increased right base opacity, but lower lung\n volumes. Retrocardiac opacity.\n Assessment and Plan\n 55 y/o woman with thoracic spinal fracture (mechanical after fall)\n complicated by ARDS from VAP, UE DVT, and adrenal insufficiency.\n Respiratory failure\n Try RSBI/SBT today. If not extubatable, plan trach/G tomorrow\n Diurese with Lasix gtt\n eventually need rx of tracheobronchomalacia\n s/p treatment for Klebsiella VAP acquired at OSH\n Shock / adrenal insufficiency\n She has essentially proven adrenal insufficiency, with a baseline\n cortisol that was very low on pressors and a vent, followed by\n resolution of shock with steroids, followed by recrudescence of shock\n when steroids stopped, followed by resolution of shock with steroids (a\n second time).\n Continue steroids at current dose until after tracheostomy/PEG.\n Appreciate endocrine\ns help.\n DVT (UE)\n Resume heparin until several hours before O.R.\n Nutrition / Lytes\n Will restart tube feeds and free water boluses for hypernatremia.\n Spine fractures\n Continue spinal stabilization with brace when OOB; will eventually need\n MRI for further evaluation. Would wait until she has a surgical airway\n if she does not pass SBT today.\n ICU Care\n Nutrition: resume TF\n Comments: Held for possible OR\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 09:19 PM\n Arterial Line - 02:00 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Restart Heparin gtt)\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments: with brother and boyfriend \n Code status: Full code\n Disposition :ICU\n Total time spent: 45 min\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-01 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 635347,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n Thoracics will take to OR if stable on PEEP < 10 for 24 hours, was on\n PEEP of 8 since AM\n due to scheduling, will not be able to go to OR\n today, but rather tomorrow with Dr. ()\n Weaned off midazolam drip\n Endocrine saw patient for adrenal insufficiency: Continue steroids\n until stable, then taper; assoc between Precedex and adrenal\n insufficiency in animal studies\n ABG for low O2 sat, looked good, held on FiO2 of 50\n Broncoscopy (11:30AM) : Diffuse stuctural instability c/w\n tracheomalacia\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Furosemide (Lasix) - 3 mg/hour\n Fentanyl - 100 mcg/hour\n Other ICU medications:\n Haloperidol (Haldol) - 11:47 PM\n Midazolam (Versed) - 02:45 AM\n Other medications:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.2\nC (97.2\n HR: 104 (46 - 134) bpm\n BP: 134/69(98) {88/41(57) - 143/76(103)} mmHg\n RR: 18 (18 - 27) insp/min\n SpO2: 91%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 4,162 mL\n 139 mL\n PO:\n TF:\n 1,448 mL\n 1 mL\n IVF:\n 1,003 mL\n 138 mL\n Blood products:\n Total out:\n 1,615 mL\n 640 mL\n Urine:\n 1,615 mL\n 640 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,547 mL\n -501 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n PIP: 35 cmH2O\n Plateau: 25 cmH2O\n Compliance: 24.7 cmH2O/mL\n SpO2: 91%\n ABG: 7.42/47/87/33/4\n Ve: 6.8 L/min\n PaO2 / FiO2: 174\n Physical Examination\n General Appearance: Responsive, following commands, Overweight / Obese,\n NAD\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\n deviation\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Respiratory / Chest: (Expansion: Symmetric), referred breath sounds\n from ETT\n Abdominal: No(t) Soft, Non-tender, Few Bowel sounds present, Distended\n Extremities: No clubbing or cyanosis, 3+ nonpitting edema of b/l hands,\n anasarca\n Skin: no rashes or jaundice\n Neuro: 3+ UE b/l, 4+ LE b/l\n Lines: r brachioceph ART and L PICC C/D/I\n Labs / Radiology\n 280 K/uL\n 8.0 g/dL\n 136 mg/dL\n 0.5 mg/dL\n 29 mEq/L\n 4.0 mEq/L\n 11 mg/dL\n 105 mEq/L\n 143 mEq/L\n 25.9 %\n 8.6 K/uL\n [image002.jpg]\n 02:44 PM\n 03:33 PM\n 07:26 PM\n 07:46 PM\n 02:04 AM\n 02:18 AM\n 01:27 PM\n 03:06 PM\n 10:04 PM\n 03:00 AM\n WBC\n 8.4\n 11.8\n 8.6\n Hct\n 23.0\n 28.1\n 29.9\n 25.9\n Plt\n \n Cr\n 0.5\n 0.6\n 0.5\n TCO2\n 33\n 31\n 33\n 32\n 32\n Glucose\n 168\n 176\n 136\n Other labs: PT / PTT / INR:13.2/26.6/1.1, Ca++:8.4 mg/dL, Mg++:2.4\n mg/dL, PO4:4.1 mg/dL, FSH 4.1, prolactin 48\n Fluid analysis / Other labs: BAL fluid:\n WBC: 0\n RBC: 0\n Polys: 82\n Lymphs: 3\n Monos: 6\n Eos: 2\n Macro: 7\n G.S\n PMNs\n Sputum culture - + GPCs in pairs and clusters, gram + rods\n Imaging: ECHOCARDIOGRAM: The left atrium is elongated. No atrial\n septal defect is seen by 2D or color Doppler. The right atrial pressure\n is indeterminate. Left ventricular wall thickness, cavity size and\n regional/global systolic function are normal (LVEF >55%). There is no\n ventricular septal defect. Right ventricular chamber size and free wall\n motion are normal. The aortic valve leaflets (3) are mildly thickened\n but aortic stenosis is not present. No aortic regurgitation is seen.\n The mitral valve appears structurally normal with trivial mitral\n regurgitation. There is no mitral valve prolapse. The tricuspid valve\n leaflets are mildly thickened. There is moderate pulmonary artery\n systolic hypertension. There is no pericardial effusion.\n Compared with the prior study (images reviewed) of , no\n change.\n EKG = sinus bradycardia\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA and\n ARDS intubated since the end of .\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation.\n Transferred here for airway stenting.\n - attempt SBT today\n - OR add on for trach and PEG with Dr. (tube feeds off\n after MN, heparin off after 6am)\n # # Adrenal Insufficency: Minimal response to stim test again.\n Appreciate endocrine recommendations.\n - hydrocort and fludrocort (day 1 = )\n - will continue at current dose until s/p trach and PEG and\n hemodynamically stable for 24 hours\n will then plan to taper\n hydrocortisone to 25mg IV q6 with a slow taper\n - will repreat ACTH stim test after tapered to <30mg\n hydrocortisone or off steroids\n - f/u daily endocrine recs\n # Hypotension: Likely adrenal insufficiency and sedation. Goal map\n > 60. Much improved since re-administration of steroids.\n - hydrocortisone and fludrocortisone as above\n - restart levophed if necessary to maintain MAP > 60\n # Volume overloaded in setting of hypernatremia with TBW deficit.\n - goal -1000cc I/Os today\n - continue FW in TF at 250 cc q4hrs\n - lasix drip (1-5mg/hr) when MAP > 60\n # Sedation: Sedation control remains somewhat poor although fentanyl\n patch and diazpem are likely therapeutic range today. On Versed 1.5,\n Fentanyl 175, Fentanyl patch, Diazepam standing and haldo 2.5-5 mg\n PRN. QTc increased to 480.\n - Wean versed/fentanyl as tolerated, continue diazepam. Avoid\n haldol use if possible to avoid further prolongation of QTc\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\n coumadin at least until s/p trach.\n - hold heparin gtt when anticipate trach/peg\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n # FEN/GI: Tube feeds with FWF @ goal.\n DVT: Treatment dose heparin\n Ulcer: Ranitidine\n VAP: Prevention per routine\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n - touch base with SW today\n Code: Full\n Dispo: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 635567,
"text": "55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP now with prolonged\n hospital course c/o by PNA anxiety,RUE DVD with high PEEP requirement\n .\n Edema, peripheral\n Assessment:\n Action:\n Response:\n Plan:\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Hypernatremia (high sodium)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Respiratory ",
"chartdate": "2167-10-03 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 635569,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 15\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Tracheostomy tube:\n Type: Standard, Cuffed, Inner Cannula\n Manufacturer: Portex\n Size: 7.0mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: mL /\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Visual assessment of breathing pattern: Normal quiet breathing\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Comments: Patient desaturated during the shift, requiring an increase\n to 10 cm PEEP and 60% FIO2. Latest abg results determined a metabolic\n alkalemia with adequate oxygenation on the current settings. No RSBI\n measured due to the level of PEEP and the high FIO2 currently required.\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-04 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 635696,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n Hydrocortisone dose to 25 Q6 per renal recs.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Heparin Sodium - 1,700 units/hour\n Fentanyl - 125 mcg/hour\n Other ICU medications:\n Ranitidine (Prophylaxis) - 09:00 AM\n Midazolam (Versed) - 07:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36.8\nC (98.3\n HR: 66 (50 - 131) bpm\n BP: 103/46(65) {100/46(65) - 157/102(127)} mmHg\n RR: 18 (15 - 21) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,984 mL\n 948 mL\n PO:\n TF:\n 103 mL\n 121 mL\n IVF:\n 747 mL\n 277 mL\n Blood products:\n Total out:\n 5,270 mL\n 1,420 mL\n Urine:\n 5,270 mL\n 1,420 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,286 mL\n -472 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 55%\n RSBI Deferred: PEEP > 10\n PIP: 25 cmH2O\n Plateau: 14 cmH2O\n Compliance: 100 cmH2O/mL\n SpO2: 93%\n ABG: ///32/\n Ve: 6.8 L/min\n Physical Examination\n General Appearance: Responsive, following commands, Overweight / Obese,\n NAD\n Eyes / Conjunctiva: PERRL, mildly disconjugate gaze w left eye lateral\n deviation\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Respiratory / Chest: (Expansion: Symmetric), referred breath sounds\n from ETT, mild rhonchi diffusely\n Abdominal: Obese, Soft, Non-tender, no rebound, no guarding\n Extremities: No clubbing or cyanosis, + nonpitting edema of b/l\n hands, anasarca\n Skin: no rashes or jaundice\n Neuro: alert. Strength 4/5 upper and lower extremeties, light touch\n sensation intact bil.\n Lines: r brachioceph ART and L PICC C/D/I\n Labs / Radiology\n 279 K/uL\n 8.0 g/dL\n 121 mg/dL\n 0.5 mg/dL\n 32 mEq/L\n 3.6 mEq/L\n 8 mg/dL\n 109 mEq/L\n 143 mEq/L\n 24.6 %\n 8.3 K/uL\n [image002.jpg]\n 04:10 PM\n 12:13 AM\n 05:08 AM\n 05:20 AM\n 05:17 PM\n 11:41 PM\n 03:06 AM\n 03:38 AM\n 04:05 PM\n 03:55 AM\n WBC\n 11.2\n 10.6\n 10.0\n 8.3\n Hct\n 27.1\n 27.3\n 25.8\n 24.6\n Plt\n 79\n Cr\n 0.7\n 0.5\n 0.5\n 0.6\n 0.6\n 0.5\n TCO2\n 36\n 36\n 32\n 31\n Glucose\n 165\n 143\n 110\n 94\n 111\n 106\n 121\n Other labs: PT / PTT / INR:15.9/107.7/1.4, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:13.1 %,\n Mono:2.7 %, Eos:0.6 %, Lactic Acid:0.9 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:8.8 mg/dL, Mg++:3.1 mg/dL, PO4:4.2 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with K. oxytoca PNA and\n ARDS intubated since the end of .\n # Respiratory failure: Related to ARDS, trachiomalacia, resolved VAP,\n volume overload. Intubated on for resp decompensation. Stenting\n unlikely to help for trachiomalacia as airways have poor structure\n diffusely. S/P Trach yesterday\n - Continue to wean O2 as tolerated\n # Adrenal Insufficency: Hypotension that resolved with steroids,\n returned as they came off and is now improved again. Possible primary\n adrenal insufficency. Appreciate endocrine recommendations.\n - hydrocortt (day 1 = ), wean per endo recs\n # Hypotension: Likely adrenal insufficiency and sedation. Goal map\n > 60. Much improved since re-administration of steroids.\n - hydrocortisone as above\n - restart levophed if necessary to maintain MAP > 60\n # Volume overloaded in setting of hypernatremia with TBW deficit.\n - Lasix gtt, continue with goal -1L per day.\n - electrolytes\n - may have some contraction alkalosis, w/ rising pH and bicarb. Start\n Diamox 500mg TID to decrease bicarb and pH and may improve respiratory\n drive.\n # Sedation: Sedation control remains somewhat poor although fentanyl\n patch and diazpem are likely therapeutic range today. On Versed 2.0,\n Fentanyl 100, Fentanyl patch, Diazepam standing and haldo 2.5-5 mg\n PRN. QTc increased to 480.\n - Wean versed/fentanyl as tolerated, continue diazepam. Avoid haldol\n use if possible to avoid further prolongation of QTc\n # RUE DVT: Started on heparin gtt on . PTTs. Would hold off on\n coumadin at least until s/p trach.\n - heparin gtt restarted\n - plan to start coumadin night of if stable\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n # FEN/GI: Tube feeds\n DVT: Treatment dose heparin\n Ulcer: Ranitidine\n VAP: Prevention per routine\n # Access: L PICC line, and R brachial a-line\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n - touch base with SW today\n Code: Full\n Dispo: ICU\n ICU Care\n Nutrition:\n Replete (Full) - 11:20 AM 30 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 09:19 PM\n Arterial Line - 02:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2167-09-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 634788,
"text": "Events:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Respiratory ",
"chartdate": "2167-10-03 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 635642,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation:\n Ideal body weight:\n Ideal tidal volume:\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position:\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure:\n Cuff volume:\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds:\n RUL Lung Sounds:\n LUL Lung Sounds:\n LLL Lung Sounds:\n Comments:\n Secretions\n Sputum color / consistency:\n Sputum source/amount:\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Specialized Gas Therapy\n Nitric Oxide\n PPM used: ppm\n Indication:\n Effect of therapy: []\n Nitric Oxide trial:\n Comments:\n HeliOx:\n Additional O[2] by cannula: L/min\n Continuous nebulized bronchodilator:\n Comments:\n Recruitment Maneuvers Done\n CPAP pressure used: cm H2O\n Duration: sec\n Times per shift:\n Comments:\n"
},
{
"category": "Respiratory ",
"chartdate": "2167-10-03 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 635643,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 15\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 7.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Brown / Thick\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Maintain PEEP at current level and reduce FiO2 as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 635781,
"text": "55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\n Now with prolonged hospital course c/b by PNA with high PEEP\n requirement, anxiety, RUE DVT on heparin qtt.\n Edema, peripheral\n Assessment:\n Fluid balance for previous 24hrs decreased by 3 liters D/T diuresis.\n Rec\nd pt off of Lasix qtt. Urine output decreased to 45ml/hr @1000.\n Action:\n Lasix qtt restarted @ 2mg/hr to maintain urine output 1-2liters/day.\n Response:\n Fluid balance approx -50ml/hr, with 24hr fluid balance -650ml @ 1500.\n However, SBP 78 when pt soundly sleeping/sedated. Lasix qtt stopped @\n 1530.\n Plan:\n Restart Lasix qtt when BP stabilized.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Rec\nd pt on Heparin qtt @ 1500units/hr.\n Action:\n PTT 92.1 @ 1230.\n Response:\n Per goal PTT 60-100, Heparin rate unchanged.\n Plan:\n Repeat PTT @ 1830. Start po Coumadin tonight.\n Altered mental status (not Delirium)\n Assessment:\n Rec\nd pt on Versed @ 2mg/hr, Fentanyl @ 100mcg/hr, as well as Fentanyl\n patches totaling 150mcg in place. Pt also rec\ning Diazepam 10mg po\n Q6hrs, in hope of weaning pt from IV sedation. Pt alternately appears\n very sedated and very restless. When she appears alert, she intermit\n responds to commands approp but not attempting to mouth words or nod to\n communicate. Moving arms purposefully towards trach, so soft wrist\n restraints remain in place. When very sedated @ 1530, SBP to 78 per\n below.\n Action:\n Versed \nd to 1mg/hr, Fentanyl \nd to 75mcg/hr.\n Response:\n Pt restless/squirming in bed when she appears awake. Not responding to\n verbal reassurance.\n Plan:\n Cont to attempt weaning from IV sedation. Cont to freq reorient pt,\n emotional support.\n Hypotension (not Shock)\n Assessment:\n VS generally stable with HR 68-123SR with occas PVC\ns, BP\n 122/65-144/76. However, when pt sleeping/sedated soundly @ 1530 SBP\n remained in high 70\n Action:\n Sedation decreased per above, Lasix qtt stopped. Pt woken and turned\n STS in bed.\n Response:\n VS returned to baseline, with BP presently 133/76.\n Plan:\n Restart Lasix qtt when BP stabilized WNL.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt on vent settings AC 55%/18 X 400/+10, with no over-breathing\n of rate by pt. O2 sat 95-99%. ABG 7.44/42/93. Lung snds clear but\n diminished in lower lobes. Suctionned for mod-lg amts thick white\n secretions.\n Action:\n Vent changed to CMV with PS 8/+10 on 55%.\n Response:\n Pt tolerated PS approx 3hrs, but after rec\ning scheduled dose Diazepam\n @ 1200 began having extended pauses apnea. She was then returned to AC\n 55%/9 X 500/+10.\n Plan:\n Cont wean from vent with PS trials, as well as \ning FiO2.\n"
},
{
"category": "Nursing",
"chartdate": "2167-09-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 634951,
"text": "TITLE: This is a 55 yr old female admitted from an OSH to on\n with resp failure, +PNA s/p fall down stairs with fracture of\n T5-T8 and possible tracheobronchomalacia for IP consult and possible Y\n stenting. Pt now s/p IP consult with no tracheobronchomalacia found on\n exam. Pt has been diff to wean with high PEEP requirements. The pt\n has finished a course of IV Levofloxacin, Vanco, and Aztreonam antibx\n for Klebsiella PNA/VAP. Pt found to have RUE DVT and maintained on an\n IV Heparin gtt (no NBP or blood draw in this appendage please). The pt\n is net input more than fifteen liters for LOS @ this time. The pt has\n documented allergies to Tetracycline, PCN & Hydrazaline. The pt is a\n Full Code. The pt has a boyfriend and a brother, the brother is the\n designated HCP.\n Events: Optimal sedation continues to be a challenge for this pt with\n pt either oversedated with resulting borderline hypotension and\n bradycardia and acute agitation with HTN, tachycardia, dysphoria,\n agitation. TLC d/c\ned by team overnight, now utilizing RUE AC PICC for\n IV therapy. RUE radial a-line remains positional, unable to send and\n ABG this AM\n team aware. 20mg IVP Lasix provided overnight for\n hypervolemia with approx one liter output.\n Altered mental status (not Delirium)\n Assessment:\n Pt MS noted to wax/wane overnight. Pt intermittently able to follow\n simple commands (wiggle toes) and mouthed her name correctly. However,\n pt also has periods of acute delirious agitation with thrashing and\n pulling on soft wrist restraints.\n Action:\n Pt received/maintained on IV Fentanyl & Midazolam gtt\ns with multiple\n IVP boluses of these agents for acute agitation. Pt also freq\n re-oriented to person/place/time/care rationale to assist with nl\n cogntion. Soft wrist restraints maintained in place for pt safety.\n Pts episodes of agitation/delirium discussed with team, PRN Seroquil\n med therapy discussed.\n Response:\n Pt responds transiently to IV Fentanyl/Midazolam boluses.\n Plan:\n Cont to provide both gtt & IVP sedation for pt comfort. Reviewing the\n use of additional agents 2^nd current limitations with present regime.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt received/maintained on AC-18-50-400-15 with nl sats, RR and resp\n effort. Unable to send AM ABG 2^nd declining a-line function\n issue\n discussed with team.\n Action:\n Pt seems to be doing well with current MV support. 20mg IVP Lasix\n admin @ 02:30 for hypervolemia to optimize resp fxn. Pt sat upright 30\n to 45 degrees. Small amounts of thick tan sec per ETT. The pt is\n currently off all antibx cov @ this time. Of note, pt noted to have\n large yellowish oral sec, ?sinusitis\n issue discussed with team.\n Response:\n Pt seems to be doing well with current MV support despite inability to\n send an AM ABG.\n Plan:\n Cont to follow pts MS, resp fxn closely to ensure optimal resp fxn.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt with documented RUE DVT. No NBP nor blood sticks/FS in this\n appendage please.\n Action:\n Pt received/maintained on IV Heparin gtt infusing @ 1,700 units/hr.\n Response:\n Serial therapeutic PTT values noted with an AM PTT today of 59.6.\n Plan:\n Edema, peripheral\n Assessment:\n Pt remains +2 generalized anasarcoid and positive 16 liters for LOS.\n Action:\n Pt med with 20mg IVP Lasix @ 02:30 this AM.\n Response:\n Pt with approx one liter output to 20mg IV Lasix.\n Plan:\n Pt remains + 16 liters for LOS despite IV Lasix therapy (pt receives\n high hourly input esp with tube feeds @ 60ml/hr). Of note, pts AM\n sodium value is 146 and pt has a free water deficit.\n"
},
{
"category": "Nursing",
"chartdate": "2167-09-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 634794,
"text": "Events:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 635691,
"text": "55 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done .\n Now with prolonged hospital course c/b by PNA with high PEEP\n requirement, anxiety, RUE DVT on heparin qtt.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt on Vent settings AC 55%/18 X 400/+10 with no overbreathing of\n set RR. O2 sat 92-98%. Lung snds clear, diminished in bases. Pt sxn\n for small-moderate amts thick white secretions. Trach site with small\n amt serosang drainage.\n Action:\n Cont same vent settings\n Response:\n Pt doesn\nt over breath on the vent and never desat.Kept same Vent\n settings overnight.\n Plan:\n Monitor sats,resp and titrate Vent as she tolerats.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt rec\nd with Heparin qtt 1900units/hr.\n Action:\n PTT drawn at 2300.RUE elevated with pillow and no BP or blood drawn\n from that arm.\n Response:\n PTT @ 2300 was 107,Decreased Heparin gtt 1700 u/hr as per sliding\n scale.Next PTT due at 0600. .\n Plan:\n Cont monitor PTT,titrate accordingly,next PTT due at 0600.\n Alteration in Nutrition\n Assessment:\n Received pt on TF 10cc/hr.\n Action:\n Pt tolerated TF with minimal residuals as well as free water bolus Q4H\n Response:\n TF ^ as tolerated, currently at 30cc/hr.\n Plan:\n Cont to monitor TF residuals, hold if more than 100cc\n Altered mental status (not Delirium)\n Assessment:\n Pt w/ periods of agitation and sleeping at other times, while she\n aweake follow commands intermittently.\n Action:\n Cont on fent 100 mics ,Versed 2mg/hr and requires frequent boluses .\n Cont diazepam 10 mg PO Q6H. Fent ^ 125 mics/hr,Versed 3mg/hr.\n Response:\n HR ranging from SB in the 40\ns when asleep to the 120-140\ns when\n agitated, b/p ranging from 90\ns/40\ns when asleep to 140-170\ns/ 70\n when agitated. When pt awake appropriate and following commands HR\n 80\ns-100\ns and b/p 100\ns-120\ns/ 60-70\n Plan:\n Titrate sedation as needed\n"
},
{
"category": "Physician ",
"chartdate": "2167-09-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 634520,
"text": "24 Hour Events:\n -Yesterday, stopped vanc and flagyl. Continued Aztreonam and\n Levofloxicin\n -Micro on sputum GNR due back today\n -Febrile to 101- pan cultured; cxr\n -Decreased FiO2 and PEEP to 21\n -Early am, HR dropped to 40s-50s. EKG suggestive of junctional rhythm.\n Held pressures, making good UOP, good O2 sats\n -Yesterday, SVV was 13; held on giving more fluids\n -Random cortisol was very low; started hydrocortisone and florinef\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Metronidazole - 08:00 AM\n Levofloxacin - 08:39 AM\n Aztreonam - 02:00 PM\n Infusions:\n Norepinephrine - 0.02 mcg/Kg/min\n Midazolam (Versed) - 4 mg/hour\n Other ICU medications:\n Midazolam (Versed) - 03:50 PM\n Fentanyl - 03:50 PM\n Ranitidine (Prophylaxis) - 08:31 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (101\n Tcurrent: 37.1\nC (98.8\n HR: 60 (60 - 86) bpm\n BP: 103/46(61) {103/46(61) - 121/50(66)} mmHg\n RR: 22 (17 - 23) insp/min\n SpO2: 99%\n Heart rhythm: JR (Junctional Rhythm)\n Wgt (current): 101 kg (admission): 94.2 kg\n Height: 67 Inch\n CVP: 12 (12 - 339)mmHg\n Total In:\n 1,675 mL\n 232 mL\n PO:\n TF:\n 182 mL\n 134 mL\n IVF:\n 1,233 mL\n 98 mL\n Blood products:\n Total out:\n 877 mL\n 565 mL\n Urine:\n 727 mL\n 535 mL\n NG:\n 30 mL\n Stool:\n Drains:\n Balance:\n 798 mL\n -333 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 22\n RR (Spontaneous): 2\n PEEP: 21 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 33 cmH2O\n Plateau: 30 cmH2O\n Compliance: 44.4 cmH2O/mL\n SpO2: 99%\n ABG: 7.42/39/116/26/0\n Ve: 9.7 L/min\n PaO2 / FiO2: 290\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 326 K/uL\n 8.9 g/dL\n 151 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 3.6 mEq/L\n 2 mg/dL\n 108 mEq/L\n 141 mEq/L\n 28.6 %\n 8.9 K/uL\n [image002.jpg]\n 06:11 PM\n 07:53 PM\n 02:02 AM\n 03:59 AM\n 09:14 PM\n 01:04 AM\n 05:54 AM\n 06:11 AM\n 11:07 PM\n 03:51 AM\n WBC\n 8.4\n 8.1\n 8.9\n Hct\n 28.1\n 28.0\n 28.6\n Plt\n 376\n 358\n 326\n Cr\n 0.6\n 0.7\n 0.7\n TCO2\n 29\n 25\n 25\n 28\n 28\n 26\n 26\n Glucose\n 120\n 126\n 151\n Other labs: PT / PTT / INR:24.3/68.6/2.4, ALT / AST:24/16, Alk Phos / T\n Bili:117/0.7, Amylase / Lipase:, Differential-Neuts:82.5 %,\n Lymph:11.6 %, Mono:3.3 %, Eos:2.2 %, Lactic Acid:0.7 mmol/L,\n Albumin:2.4 g/dL, LDH:204 IU/L, Ca++:8.5 mg/dL, Mg++:2.1 mg/dL, PO4:2.5\n mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with respiratory failure\n and difficulty weaning from vent.\n # Respiratory failure: initial etiology unclear, likely multifactorial\n (sedation vs hypovent obesity/orthotic brace vs ?) which lead to\n VAP most likely with GNR (by one sputum).\n - Concern for ARDS given clinical and radiographic picture.\n - Placed esophageal balloon on which will help guide PEEP\n settings.\n - Over the evening yesterday, were able to decrease FiO2 and PEEP.\n # VAP: Re-spiked fever overnight.\n - Sputum from grew rare GNR; awaiting speciation.\n - Has been Vanc, aztreonam, levofloxicin. Vanc trough today was 20\n - Stopped vanc yesterday, , as there was no current evidence to\n suggest a gram positive infection\n - Also, stopped flagyl because had one neg c. diff toxin and CT did not\n show evidence of colitis\n - Continued aztreonam and levofloxicin for gram neg pneumonia for 8\n days pending speciation (at that time can increase to 15 days if\n necessary)\n - need to reconsider restarting d/c'd meds if she continues to\n spike a fever\n # Hypotension, requiring Levophed:\n - Hypovolemia is possibly a factor- responded to a transfusion; HCT had\n been dropping. However, SVV with Vigileo was 13, making her CO less\n likely to respond to fluids. Held on giving any boluses overnight.\n - Sepsis also a factor- on broad spectrum abs\n - Central line in place.\n # Oliguria:\n -BUN and Cr reassuring.\n -Continues to be low. Hopefully, by decreasing PEEP and using levophed\n to keep MAPs high, UOP will increase.\n # RUE DVT: Started on heparin gtt on .\n -Therapeutic in one day; may be related to poor nutritional status.\n Will continue to closely monitor\n # Abd distention: be chronic condition not requiring immediate\n medical attention\n - CT abd only showed appendiceal mucocele without inflammation, not\n concerning, most likely chronic. No concern for intraabd disaster\n - Now having BMs; c. diff toxin neg\n - amylase and lipase wnl\n # Adrenal Insufficency:\n -Random cortisol was approx 3 when it should have been maximally\n stimulated.\n -Started hydrocortisone and florinef. ? switch to methylpred\n # Anemia:\n - Trend HCT\n - Gave 1 un pRBC with good results\n - INR rising, now 2.0, may be nutritional\n # Spine fracture: neurologically intact distal to the lesion. prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per verbal report.\n # Hypernatremia, resolved: correcting with g tube free flush and D5W\n -Holding on g tube feeds at present due to high residuals\n -Replete lytes as necessary\n # Communication:\n - Brother has been with pt, although, live in boyfriend of 10 is\n her HCP. Boyfriend will hopefully visit pt today\n ICU Care\n Nutrition: tube feed with free water when able\n Glycemic Control: Regular insulin sliding scale\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Communication: ICU consent signed, (brother) \n (boyfriend/POA) \n Code status: Full code\n Disposition: ICU\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 10:55 PM 30 mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 01:36 AM\n Arterial Line - 03:00 AM\n Multi Lumen - 11:30 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2167-09-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 634525,
"text": "55 yr old woman admitted from OSH after she fell down the stairs and\n had traumatic T-spine fracture. Pt came to us with PNA from unknown\n etiology? VAP. Full code, Allergies: PCN, tetracycline, Sulfa. PMH:\n ETOH, smoker, Gerd, Hip replacement.\n Alteration in Nutrition\n Assessment:\n Tube feeds increased to 30ml/hr. Tube feed residual 10-20ml.\n Action:\n cont to check residuals and try to increase rate\n Response:\n Residual staying 10ml/hr, kept rate at 30ml\n Plan:\n Try to increase Tube feeds to goal rate.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n RUE DVT, pt on heparin gtt at 1700units/hr.\n Action:\n Ptt was therapeutic x2, AM PTT 68.6 WNL\n Response:\n No change to drip made, therapeutic dose.\n Plan:\n Cont heparin gtt, check PTT adjust heparin gtt per scale.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Moderate thick white in-line secretions, copious clear oral secretions,\n clear/diminished lung sounds. Esophageal balloon in place. Previous\n Sputum culture shows GNR, speciation PND.\n Action:\n Lots of suctioning through the night, decreased FiO2 from 50% to 40%,\n decreased Peep from 23 to 21, HOB >30, oral care.\n Response:\n ABG WNL, could not draw a AM ABG because A-line no longer drawing,\n intern aware.\n Plan:\n Cont to try to wean vent settings as tolerated, cont monitoring ABG\n Hypotension (not Shock)\n Assessment:\n SBP 90-110\ns MAP 62-66 Goal MAP >65 Levophed gtt @ 0.018 mcg/kg/min.\n Action:\n Trying to wean levophed gtt off\n Response:\n MAP tend to drop below 65 when weaned all the way off levophed.\n Plan:\n Cont to try to wean gtt off\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n T-max 101.0\n Action:\n Sent blood, urine, and sputum cultures, treated with Tylenol\n Response:\n Temp decreased\n Plan:\n Follow up on cultures\n CT scan from earlier in the week confirms fracture but did not detect\n retropulsion. Neuro want pt in back brace when she is out of bed.\n Log rolling pt has been d/c.\n Bradycardia\n Assessment:\n At 0515 Patient HR dropped from 60-70\ns to 45-50.\n Action:\n EKG done, showed pt was in junctional rhythm, intern came to assess pt.\n Electrolytes WNL.\n Response:\n No intervention done yet because pt BP cont to be stable and all other\n vital signs stable.\n Plan:\n Cont to monitor pt HR.\n Fracture, other\n Assessment:\n Log roll precautions removed from day shift. Back brace needs to be\n applied if pt is out of bed. Please read CT scan results from above\n portion of note.\n Action:\n Still taking precautions to carefully turn pt but no longer long\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2167-09-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 634527,
"text": "55 yr old woman admitted from OSH after she fell down the stairs and\n had traumatic T-spine fracture. Pt came to us with PNA from unknown\n etiology? VAP. Full code, Allergies: PCN, tetracycline, Sulfa. PMH:\n ETOH, smoker, Gerd, Hip replacement.\n Alteration in Nutrition\n Assessment:\n Tube feeds increased to 30ml/hr. Tube feed residual 10-20ml.\n Action:\n cont to check residuals and try to increase rate\n Response:\n Residual staying 10ml/hr, kept rate at 30ml\n Plan:\n Try to increase Tube feeds to goal rate.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n RUE DVT, pt on heparin gtt at 1700units/hr.\n Action:\n Ptt was therapeutic x2, AM PTT 68.6 WNL\n Response:\n No change to drip made, therapeutic dose.\n Plan:\n Cont heparin gtt, check PTT adjust heparin gtt per scale.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Moderate thick white in-line secretions, copious clear oral secretions,\n clear/diminished lung sounds. Esophageal balloon in place. Previous\n Sputum culture shows GNR, speciation PND.\n Action:\n Lots of suctioning through the night, decreased FiO2 from 50% to 40%,\n decreased Peep from 23 to 21, HOB >30, oral care.\n Response:\n ABG WNL, could not draw an AM ABG because A-line no longer drawing,\n intern aware. Intern and resp therapy to get ABG for AM.\n Plan:\n Cont to try to wean vent settings as tolerated, cont monitoring ABG\n Hypotension (not Shock)\n Assessment:\n SBP 90-110\ns MAP 62-66 Goal MAP >65 Levophed gtt @ 0.018 mcg/kg/min.\n Action:\n Trying to wean levophed gtt off\n Response:\n MAP tends to drop below 65 when weaned all the way off levophed.\n Plan:\n Cont to try to wean gtt off\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n T-max 101.0\n Action:\n Sent blood, urine, and sputum cultures, treated with Tylenol\n Response:\n Temp decreased\n Plan:\n Follow up on cultures\n CT scan from earlier in the week confirms fracture but did not detect\n retropulsion. Neuro want pt in back brace when she is out of bed.\n Log rolling pt has been d/c.\n Bradycardia\n Assessment:\n At 0515 Patient HR dropped from 60-70\ns to 45-50.\n Action:\n EKG done, showed pt was in junctional rhythm, intern came to assess pt.\n Electrolytes WNL.\n Response:\n No intervention done yet because pt BP cont to be stable and all other\n vital signs stable.\n Plan:\n Cont to monitor pt HR.\n Fracture, other\n Assessment:\n Log roll precautions removed from day shift. Back brace needs to be\n applied if pt is out of bed. Please read CT scan results from above\n portion of note.\n Action:\n Still taking precautions to carefully turn pt but no longer on log roll\n precautions\n Response:\n Pt tolerating turning fine.\n Plan:\n Use back brace if pt get out of bed. Back brace in room\n"
},
{
"category": "Physician ",
"chartdate": "2167-09-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 634528,
"text": "24 Hour Events:\n -Yesterday, stopped vanc and flagyl. Continued Aztreonam and\n Levofloxicin\n -Micro on sputum GNR due back today\n -Febrile to 101- pan cultured; cxr\n -Decreased FiO2 and PEEP to 21\n -Early am, HR dropped to 40s-50s. EKG suggestive of junctional rhythm.\n Held pressures, making good UOP, good O2 sats\n -This am, art line is intermittently working. Drew ABG - pending\n -Yesterday, SVV was 13; held on giving more fluids\n -Random cortisol was very low; started hydrocortisone and florinef\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Metronidazole - 08:00 AM\n Levofloxacin - 08:39 AM\n Aztreonam - 02:00 PM\n Infusions:\n Norepinephrine - 0.02 mcg/Kg/min\n Midazolam (Versed) - 4 mg/hour\n Other ICU medications:\n Midazolam (Versed) - 03:50 PM\n Fentanyl - 03:50 PM\n Ranitidine (Prophylaxis) - 08:31 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (101\n Tcurrent: 37.1\nC (98.8\n HR: 60 (60 - 86) bpm\n BP: 103/46(61) {103/46(61) - 121/50(66)} mmHg\n RR: 22 (17 - 23) insp/min\n SpO2: 99%\n Heart rhythm: JR (Junctional Rhythm)\n Wgt (current): 101 kg (admission): 94.2 kg\n Height: 67 Inch\n CVP: 12 (12 - 339)mmHg\n Total In:\n 1,675 mL\n 232 mL\n PO:\n TF:\n 182 mL\n 134 mL\n IVF:\n 1,233 mL\n 98 mL\n Blood products:\n Total out:\n 877 mL\n 565 mL\n Urine:\n 727 mL\n 535 mL\n NG:\n 30 mL\n Stool:\n Drains:\n Balance:\n 798 mL\n -333 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 22\n RR (Spontaneous): 2\n PEEP: 21 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 33 cmH2O\n Plateau: 30 cmH2O\n Compliance: 44.4 cmH2O/mL\n SpO2: 99%\n ABG: 7.42/39/116/26/0\n Ve: 9.7 L/min\n PaO2 / FiO2: 290\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 326 K/uL\n 8.9 g/dL\n 151 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 3.6 mEq/L\n 2 mg/dL\n 108 mEq/L\n 141 mEq/L\n 28.6 %\n 8.9 K/uL\n [image002.jpg]\n 06:11 PM\n 07:53 PM\n 02:02 AM\n 03:59 AM\n 09:14 PM\n 01:04 AM\n 05:54 AM\n 06:11 AM\n 11:07 PM\n 03:51 AM\n WBC\n 8.4\n 8.1\n 8.9\n Hct\n 28.1\n 28.0\n 28.6\n Plt\n 376\n 358\n 326\n Cr\n 0.6\n 0.7\n 0.7\n TCO2\n 29\n 25\n 25\n 28\n 28\n 26\n 26\n Glucose\n 120\n 126\n 151\n Other labs: PT / PTT / INR:24.3/68.6/2.4, ALT / AST:24/16, Alk Phos / T\n Bili:117/0.7, Amylase / Lipase:, Differential-Neuts:82.5 %,\n Lymph:11.6 %, Mono:3.3 %, Eos:2.2 %, Lactic Acid:0.7 mmol/L,\n Albumin:2.4 g/dL, LDH:204 IU/L, Ca++:8.5 mg/dL, Mg++:2.1 mg/dL, PO4:2.5\n mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with respiratory failure\n and difficulty weaning from vent.\n # Respiratory failure: initial etiology unclear, likely multifactorial\n (sedation vs hypovent obesity/orthotic brace vs ?) which lead to\n VAP most likely with GNR (by one sputum).\n - Concern for ARDS given clinical and radiographic picture.\n - Placed esophageal balloon on which will help guide PEEP\n settings.\n - Over the evening yesterday, were able to decrease FiO2 and PEEP.\n # VAP: Re-spiked fever overnight.\n - Sputum from grew rare GNR; awaiting speciation.\n - Has been Vanc, aztreonam, levofloxicin. Vanc trough today was 20\n - Stopped vanc yesterday, , as there was no current evidence to\n suggest a gram positive infection\n - Also, stopped flagyl because had one neg c. diff toxin and CT did not\n show evidence of colitis\n - Continued aztreonam and levofloxicin for gram neg pneumonia for 8\n days pending speciation (at that time can increase to 15 days if\n necessary)\n - need to reconsider restarting d/c'd meds if she continues to\n spike a fever\n # Hypotension, requiring Levophed:\n - Hypovolemia is possibly a factor- responded to a transfusion; HCT had\n been dropping. However, SVV with Vigileo was 13, making her CO less\n likely to respond to fluids. Held on giving any boluses overnight.\n - Sepsis also a factor- on broad spectrum abs\n - Central line in place.\n # Oliguria:\n -BUN and Cr reassuring.\n -Continues to be low. Hopefully, by decreasing PEEP and using levophed\n to keep MAPs high, UOP will increase.\n # RUE DVT: Started on heparin gtt on .\n -Therapeutic in one day; may be related to poor nutritional status.\n Will continue to closely monitor\n # Abd distention: be chronic condition not requiring immediate\n medical attention\n - CT abd only showed appendiceal mucocele without inflammation, not\n concerning, most likely chronic. No concern for intraabd disaster\n - Now having BMs; c. diff toxin neg\n - amylase and lipase wnl\n # Adrenal Insufficency:\n -Random cortisol was approx 3 when it should have been maximally\n stimulated.\n -Started hydrocortisone and florinef. ? switch to methylpred\n # Anemia:\n - Trend HCT\n - Gave 1 un pRBC with good results\n - INR rising, now 2.0, may be nutritional\n # Spine fracture: neurologically intact distal to the lesion. prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per verbal report.\n # Hypernatremia, resolved: correcting with g tube free flush and D5W\n -Holding on g tube feeds at present due to high residuals\n -Replete lytes as necessary\n # Communication:\n - Brother has been with pt, although, live in boyfriend of 10 is\n her HCP. Boyfriend will hopefully visit pt today\n ICU Care\n Nutrition: tube feed with free water when able\n Glycemic Control: Regular insulin sliding scale\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Communication: ICU consent signed, (brother) \n (boyfriend/POA) \n Code status: Full code\n Disposition: ICU\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 10:55 PM 30 mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 01:36 AM\n Arterial Line - 03:00 AM\n Multi Lumen - 11:30 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2167-09-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 634882,
"text": "Chief Complaint:\n 24 Hour Events:\n - Anxiety yesterday afternoon and poor sleep overnight per nursing\n - Per ABG, increased FiO2 (40->50%), holding PEEP (15)\n - Gave Lasix 10 mg x 3, with small urine output response.\n - Today is last day of steroids as well as last day of abx\n (levofloxicin)\n - Tightened sliding scale insulin yesterday\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Aztreonam - 06:00 AM\n Vancomycin - 09:00 AM\n Levofloxacin - 08:00 AM\n Infusions:\n Midazolam (Versed) - 4 mg/hour\n Heparin Sodium - 1,700 units/hour\n Fentanyl - 150 mcg/hour\n Other ICU medications:\n Haloperidol (Haldol) - 04:26 PM\n Furosemide (Lasix) - 04:30 PM\n Midazolam (Versed) - 06:16 AM\n Fentanyl - 06:16 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 35.7\nC (96.2\n HR: 66 (53 - 93) bpm\n BP: 111/56(74) {103/52(69) - 135/78(93)} mmHg\n RR: 20 (16 - 28) insp/min\n SpO2: 95% on 400/20/15/.5\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101 kg (admission): 94.2 kg\n Height: 67 Inch\n CVP: 18 (6 - 21)mmHg\n Total In:\n 2,681 mL\n 687 mL\n PO:\n TF:\n 1,443 mL\n 432 mL\n IVF:\n 888 mL\n 255 mL\n Blood products:\n Total out:\n 3,135 mL\n 185 mL\n Urine:\n 3,035 mL\n 185 mL\n NG:\n Stool:\n 100 mL\n Drains:\n Balance:\n -454 mL\n 502 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 20\n RR (Spontaneous): 23\n PEEP: 15 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 31 cmH2O\n Plateau: 25 cmH2O\n SpO2: 95%\n ABG: 7.46/39/68/27/3\n Ve: 7.7 L/min\n PaO2 / FiO2: 136\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese, opens eyes\n but no purposeful movement\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric)\n Abdominal: No(t) Soft, Non-tender, Bowel sounds present, Distended\n Extremities: No clubbing or cyanosis, 3+ nonpitting edema of b/l hands,\n LE without edema\n Skin: no rashes or jaundice\n Labs / Radiology\n 411 K/uL\n 8.3 g/dL\n 163 mg/dL\n 0.5 mg/dL\n 27 mEq/L\n 3.8 mEq/L\n 12 mg/dL\n 111 mEq/L\n 144 mEq/L\n 26.0 %\n 9.7 K/uL\n [image002.jpg]\n 03:47 AM\n 02:14 PM\n 04:05 PM\n 01:12 AM\n 04:00 AM\n 04:09 AM\n 10:18 AM\n 02:33 PM\n 02:46 PM\n 03:31 AM\n WBC\n 10.5\n 9.6\n 9.7\n Hct\n 27.5\n 27.8\n 26.0\n Plt\n 374\n 374\n 411\n Cr\n 0.6\n 0.5\n 0.5\n 0.5\n TCO2\n 27\n 26\n 27\n 28\n 29\n 26\n 27\n Glucose\n 187\n 194\n 195\n 195\n 163\n Other labs: PT / PTT / INR:15.3/69.9/1.3, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:86.1 %, Lymph:10.3 %,\n Mono:2.8 %, Eos:0.5 %, Lactic Acid:2.0 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:8.3 mg/dL, Mg++:2.1 mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with respiratory failure\n and difficulty weaning from vent.\n # Respiratory failure: Intubated on for resp decompensation.\n Likely VAP. Unlikely to have tracheomalacia as initially\n transferred for.\n - wean PEEP\n - Given mild alkalosis, will decrease RR to 18, repeat ABG\n - discuss need for trach with patient and her family\n - Will continue gentle diuresis once alkalosis resolved\n # Pneumonia: Pansensitive Kleb oxytoca pneumonia and sputum with GPCs\n on gram stain. Afebrile overnight. On levofloxacin since .\n Vancomycin, aztreonam have been stopped. Resp status seems to be\n improving.\n - Follow cultures\n - d/c levofloxacin having completed 8 day course\n # Sedation: On versed and fentanyl\n # EKG changes: Sinus bradycardia, now somewhat improved. Likely\n related to increased vagal tone possibly related to steroid\n replacement. Atrial EKG shows p-waves and cardiac enzymes normal.\n - Continue to monitor\n # Hypotension: Improved, off levophed for 2-3 days now, with good urine\n output. CVP increasing with reduction in PEEP. Likely poor\n adrenal response in setting of acute illness and very high PEEP.\n -D/C fludricort and hydrocortisone now that the 5 day steroid course is\n complete\n -monitor, expect improvement with continual reduction in PEEP\n # RUE DVT: Started on heparin gtt on , now therapeutic. Follow\n PTTs. Would hold off on coumadin at least until s/p trach.\n - continue to monitor\n # Adrenal Insufficency: Random cortisol was approx 3 when it should\n have been maximally stimulated.\n - hydrocortisone and florinef for 5 days\n # Anemia: Stable.\n - Trend HCT\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n FEN/GI: Tube feeds @ goal\n DVT: Treatment dose heparin\n Ulcer: Ranitidine\n VAP: Prevention per routine\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 08:13 PM 60 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 11:30 AM\n Arterial Line - 04:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2167-09-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 634883,
"text": "Chief Complaint:\n 24 Hour Events:\n - Anxiety yesterday afternoon and poor sleep overnight per nursing\n - Per ABG, increased FiO2 (40->50%), holding PEEP (15)\n - Gave Lasix 10 mg x 3, with small urine output response.\n - Today is last day of steroids as well as last day of abx\n (levofloxicin)\n - Tightened sliding scale insulin yesterday\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Aztreonam - 06:00 AM\n Vancomycin - 09:00 AM\n Levofloxacin - 08:00 AM\n Infusions:\n Midazolam (Versed) - 4 mg/hour\n Heparin Sodium - 1,700 units/hour\n Fentanyl - 150 mcg/hour\n Other ICU medications:\n Haloperidol (Haldol) - 04:26 PM\n Furosemide (Lasix) - 04:30 PM\n Midazolam (Versed) - 06:16 AM\n Fentanyl - 06:16 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 35.7\nC (96.2\n HR: 66 (53 - 93) bpm\n BP: 111/56(74) {103/52(69) - 135/78(93)} mmHg\n RR: 20 (16 - 28) insp/min\n SpO2: 95% on 400/20/15/.5\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101 kg (admission): 94.2 kg\n Height: 67 Inch\n CVP: 18 (6 - 21)mmHg\n Total In:\n 2,681 mL\n 687 mL\n PO:\n TF:\n 1,443 mL\n 432 mL\n IVF:\n 888 mL\n 255 mL\n Blood products:\n Total out:\n 3,135 mL\n 185 mL\n Urine:\n 3,035 mL\n 185 mL\n NG:\n Stool:\n 100 mL\n Drains:\n Balance:\n -454 mL\n 502 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 20\n RR (Spontaneous): 23\n PEEP: 15 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 31 cmH2O\n Plateau: 25 cmH2O\n SpO2: 95%\n ABG: 7.46/39/68/27/3\n Ve: 7.7 L/min\n PaO2 / FiO2: 136\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese, opens eyes\n but no purposeful movement\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric)\n Abdominal: No(t) Soft, Non-tender, Bowel sounds present, Distended\n Extremities: No clubbing or cyanosis, 3+ nonpitting edema of b/l hands,\n LE without edema\n Skin: no rashes or jaundice\n Labs / Radiology\n 411 K/uL\n 8.3 g/dL\n 163 mg/dL\n 0.5 mg/dL\n 27 mEq/L\n 3.8 mEq/L\n 12 mg/dL\n 111 mEq/L\n 144 mEq/L\n 26.0 %\n 9.7 K/uL\n [image002.jpg]\n 03:47 AM\n 02:14 PM\n 04:05 PM\n 01:12 AM\n 04:00 AM\n 04:09 AM\n 10:18 AM\n 02:33 PM\n 02:46 PM\n 03:31 AM\n WBC\n 10.5\n 9.6\n 9.7\n Hct\n 27.5\n 27.8\n 26.0\n Plt\n 374\n 374\n 411\n Cr\n 0.6\n 0.5\n 0.5\n 0.5\n TCO2\n 27\n 26\n 27\n 28\n 29\n 26\n 27\n Glucose\n 187\n 194\n 195\n 195\n 163\n Other labs: PT / PTT / INR:15.3/69.9/1.3, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:86.1 %, Lymph:10.3 %,\n Mono:2.8 %, Eos:0.5 %, Lactic Acid:2.0 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:8.3 mg/dL, Mg++:2.1 mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with respiratory failure\n and difficulty weaning from vent.\n # Respiratory failure: Intubated on for resp decompensation.\n Likely VAP. Unlikely to have tracheomalacia as initially\n transferred for.\n - wean PEEP\n - Given mild alkalosis, will decrease RR to 18, repeat ABG\n - discuss need for trach with patient and her family\n - Will continue gentle diuresis once alkalosis resolved\n # Pneumonia: Pansensitive Kleb oxytoca pneumonia and sputum with GPCs\n on gram stain. Afebrile overnight. On levofloxacin since .\n Vancomycin, aztreonam have been stopped. Resp status seems to be\n improving.\n - Follow cultures\n - d/c levofloxacin having completed 8 day course\n # Sedation: On versed and fentanyl\n # EKG changes: Sinus bradycardia, now somewhat improved. Likely\n related to increased vagal tone possibly related to steroid\n replacement. Atrial EKG shows p-waves and cardiac enzymes normal.\n - Continue to monitor\n # Hypotension: Improved, off levophed for 2-3 days now, with good urine\n output. CVP increasing with reduction in PEEP. Likely poor\n adrenal response in setting of acute illness and very high PEEP.\n -D/C fludricort and hydrocortisone now that the 5 day steroid course is\n complete\n -monitor, expect improvement with continual reduction in PEEP\n # RUE DVT: Started on heparin gtt on , now therapeutic. Follow\n PTTs. Would hold off on coumadin at least until s/p trach.\n - continue to monitor\n # Adrenal Insufficency: Random cortisol was approx 3 when it should\n have been maximally stimulated.\n - hydrocortisone and florinef for 5 days\n # Anemia: Stable.\n - Trend HCT\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n # Communication:\n - Boyfriend of 10 is her HCP. Also brother is involved\n FEN/GI: Tube feeds @ goal\n DVT: Treatment dose heparin\n Ulcer: Ranitidine\n VAP: Prevention per routine\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 08:13 PM 60 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 11:30 AM\n Arterial Line - 04:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2167-09-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 634459,
"text": "Events: Attempt to lighten sedation, stop Levophed gtt- MS \n stability labile from lethargic to restless in bed/crying w/\n intermittent BP 120\ns/ w/ and W/O stimulation. UOP cont 10-30cc/hr.\n Vigileo monitor on- SVV . Bladder pressure 14. TF restarted w/ goal\n slow inc as tolerated w/ recent high residuals.\n Alteration in Nutrition\n Assessment:\n Minimal residuals\n Action:\n Restarting TF replete w/ fiber @ 10cc/hr w/ Q6hr 20cc flush\n Response:\n Tolerating, goal advance Q6hr as tolerated\n Plan:\n Cont TF, monitor residuals, inc Q6hrs as tolerated\n Hypotension (not Shock)\n Assessment:\n BP labile- SBP 86-120, UOP down to 10cc/hr\n Action:\n Vigileo on- SVV , In AM attempt wean off Levo gtt\n Response:\n No fluid blousing, Levophed gtt started- titrated for MAP >65, UOP,\n Levo gtt @ .020mcg/kg/min\n Plan:\n Cont Vigeligo monitoring, CVP monitoring, UOP, Levophed gtt, fluid\n bolus if inc in SVV, in CVP\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Heparin gtt @ 1700units/hr, PTT 76\n Action:\n Heparin gtt therapeutic x2, cont @ 1700units/hr\n Response:\n No s/s bleeding, guiac neg gastric secretions, stool\n Plan:\n Cont Hep gtt as ordered w/I scale parameters, check PTT w/ AM labs,\n monitor s/s bleeding\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS clear bilat upper lobes, diminished bilat lower lobes, turning w/o\n desating, suctioning minimally for thin clear secretions, Sat 96-100%,\n w/ decres in sedation waking in afternoon and overbreathing vent 1-3\n bpm\n Action:\n No vent changes, suctioned post coughing x1, turning as tolerated,\n sedation titrated- currently @ 100mcg/hr Fentanyl gtt, 2 mg/hr Versed\n gtt. 1x blousing w/ .5mg Versed and 50mcg Fentanyl for sig inc in\n agitation/breathing over vent/pulling @ lines, resp tesing w/\n esophageal balloon\n Response:\n Synchronous w/ vent, RN care/turning/mouth care w/ decreased agitation,\n Sat >96%,\n Plan:\n Cont IV ABX, pulm toilet, esophageal balloon readins, monitor sat\n"
},
{
"category": "Nursing",
"chartdate": "2167-09-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 634460,
"text": "Events: Attempt to lighten sedation, stop Levophed gtt- MS \n stability labile from lethargic to restless in bed/crying w/\n intermittent BP 120\ns/ w/ and W/O stimulation. UOP cont 10-30cc/hr.\n Vigileo monitor on- SVV . Bladder pressure 14. TF restarted w/ goal\n slow inc as tolerated w/ recent high residuals.\n Alteration in Nutrition\n Assessment:\n Minimal residuals\n Action:\n Restarting TF replete w/ fiber @ 10cc/hr w/ Q6hr 20cc flush\n Response:\n Tolerating, goal advance Q6hr as tolerated\n Plan:\n Cont TF, monitor residuals, inc Q6hrs as tolerated\n Hypotension (not Shock)\n Assessment:\n BP labile- SBP 86-120, UOP down to 10cc/hr\n Action:\n Vigileo on- SVV , In AM attempt wean off Levo gtt\n Response:\n No fluid blousing, Levophed gtt started- titrated for MAP >65, UOP,\n Levo gtt @ .020mcg/kg/min\n Plan:\n Cont Vigeligo monitoring, CVP monitoring, UOP, Levophed gtt, fluid\n bolus if inc in SVV, in CVP\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Heparin gtt @ 1700units/hr, PTT 76\n Action:\n Heparin gtt therapeutic x2, cont @ 1700units/hr\n Response:\n No s/s bleeding, guiac neg gastric secretions, stool\n Plan:\n Cont Hep gtt as ordered w/I scale parameters, check PTT w/ AM labs,\n monitor s/s bleeding\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS clear bilat upper lobes, diminished bilat lower lobes, turning w/o\n desating, suctioning minimally for thin clear secretions, Sat 96-100%,\n w/ decres in sedation waking in afternoon and overbreathing vent 1-3\n bpm, afebrile\n Action:\n No vent changes, suctioned post coughing x1, turning as tolerated,\n sedation titrated- currently @ 100mcg/hr Fentanyl gtt, 2 mg/hr Versed\n gtt. 1x blousing w/ .5mg Versed and 50mcg Fentanyl for sig inc in\n agitation/breathing over vent/pulling @ lines, resp tesing w/\n esophageal balloon\n Response:\n Synchronous w/ vent, RN care/turning/mouth care w/ decreased agitation,\n Sat >96%,\n Plan:\n Cont IV ABX, pulm toilet, esophageal balloon readins, monitor sat\n"
},
{
"category": "Nursing",
"chartdate": "2167-09-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 634608,
"text": "Synopsis per prior nursing note:\n 55 yr old woman admitted from OSH after she fell down the stairs and\n had traumatic T-spine fracture. Pt came to us with PNA from unknown\n etiology? VAP. Full code, Allergies: PCN, tetracycline, Sulfa. PMH:\n ETOH, smoker, Gerd, Hip replacement.\n Alteration in Nutrition\n Assessment:\n Tube feeds increased to 40ml/hr. Residuals ~10ml. Hypoactive BS.\n Continues to have brown, liquid stool.\n Action:\n Residuals and BS checked. Rate increased to 40ml/hr.\n Response:\n Residual continued at 10ml/hr, continued rate of 40cc/hr.\n Plan:\n Advance TF to goal as tolerated. Monitor BS.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n RUE DVT, pt on heparin gtt at 1700units/hr.\n Action:\n Ptt was therapeutic x3. Heparin gtt continued.\n Response:\n No change to drip made, therapeutic dose.\n Plan:\n Cont heparin gtt, check PTT w/ am labs and adjust heparin gtt per\n scale.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Suctioned moderate, thick white ET tube secretions and copious clear,\n oral secretions. LS rhonchi w/ dim bases. Esophageal balloon in\n place.\n Action:\n Continued to suction frequently, HOB >30, oral care. Continued\n steroids.\n Response:\n ABG WNL. Continued to need suctioning. O2 sats >98%.\n Plan:\n Monitor LS. Suction as needed. Wean vent as tolerated.\n Hypotension (not Shock)\n Assessment:\n BP 89-106/43-53. MAP 56-67. Goal MAP >60. Urine output>40cc/hr.\n Action:\n Levophed gtt weaned off. Given 2.5 L NS total in bolus\n for low BP. New\n A-line placed-positional.\n Response:\n MAPs continued to be ~60-65.\n Plan:\n Monitor BP. ?fluid bolus vs levophed gtt. ?need for new a-line.\n Bradycardia\n Assessment:\n SB, HR 45-63. HR increased w/ activity.\n Action:\n HR monitored.\n Response:\n No intervention done because BP cont to be stable and all other vital\n signs stable.\n Plan:\n Monitor HR. EKG if indicated.\n"
},
{
"category": "Respiratory ",
"chartdate": "2167-09-24 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 634611,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 6\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Utilize ARDSnet protocol, Reduce PEEP as tolerated;\n Comments: Pt remains on 21 of\n PEEP. Ballon measurements taken, which showed that pt was -3cm of peep.\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Intolerant of weaning attempts\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Pleural pressure measurement (930)\n Comments:\n"
},
{
"category": "Respiratory ",
"chartdate": "2167-09-25 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 634686,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 7\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Reason: re-positioned 21cm this shift - confirmed correct placement via\n bronchoscopy at bedside\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Continues on A/C ventilation w/ PIP/Pplat = 34/28, not\n overbreathing set vent rate. PEEP remains at +21cm. Bronch at bedside\n to confirm ETT placement after ETT was not clearly visible on CXR.\n Sputum spec sent.\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Plan\n Next 24-48 hours: Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved; Comments: esophogeal balloon remains in place w/ PEEP at\n +21. no measurements made this shift.\n Respiratory Care Shift Procedures\n Bedside Procedures:\n Bronchoscopy (1100)\n Comments: bronchoscopy at bedside w/out complication.\n"
},
{
"category": "Respiratory ",
"chartdate": "2167-09-26 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 634783,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 8\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Patient remains on mechanical ventilation, with oxygenation issues\n persisting. Decrease in PEEP followed by increase in Fi02 as noted on\n flow sheet. Bilateral breath sounds diminished with few scattered\n rhonchi. MDI\ns given as ordered.\n"
},
{
"category": "Physician ",
"chartdate": "2167-09-27 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 634870,
"text": "Chief Complaint: respiratory failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 55 yo F w/ prolonged hospital course, etoh abuse with fall and thoracic\n compression fxs who was tranferred from OSH for evaluation of Y stent\n for BTM, course has been c/b R UE DVT and sepsis with hypotension,\n pressor needs, and resp failure likely VAP,TBM now with failure to\n wean, still with high PEEP requirements.\n 24 Hour Events:\n EKG - At 12:00 PM\n low voltage, pre Haldol administration QRS .46\n lasix X 3 doses with good urine output\n peep held at 15, fio2 increased to 50%\n History obtained from ho\n Patient unable to provide history: Sedated, intubated\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Aztreonam - 06:00 AM\n Vancomycin - 09:00 AM\n Levofloxacin - 08:06 AM\n Infusions:\n Midazolam (Versed) - 4 mg/hour\n Fentanyl - 150 mcg/hour\n Heparin Sodium - 1,700 units/hour\n Other ICU medications:\n Haloperidol (Haldol) - 04:26 PM\n Furosemide (Lasix) - 04:30 PM\n Midazolam (Versed) - 06:16 AM\n Fentanyl - 06:16 AM\n Other medications:\n per (reviewed)\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.8\nC (98.2\n HR: 61 (53 - 93) bpm\n BP: 137/70(95) {103/52(69) - 137/70(95)} mmHg\n RR: 20 (16 - 28) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101 kg (admission): 94.2 kg\n Height: 67 Inch\n CVP: 19 (6 - 21)mmHg\n Total In:\n 2,679 mL\n 1,165 mL\n PO:\n TF:\n 1,443 mL\n 639 mL\n IVF:\n 886 mL\n 526 mL\n Blood products:\n Total out:\n 3,135 mL\n 305 mL\n Urine:\n 3,035 mL\n 305 mL\n NG:\n Stool:\n 100 mL\n Drains:\n Balance:\n -456 mL\n 860 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 15 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 29 cmH2O\n Plateau: 26 cmH2O\n SpO2: 96%\n ABG: 7.46/39/68/27/3\n Ve: 7.8 L/min\n PaO2 / FiO2: 136\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Endotracheal tube\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Diminished), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n )\n Extremities: Right: 1+, Left: 1+, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: No(t) Muscle wasting\n Skin: Warm\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Not assessed, Movement: Non -purposeful, Sedated, No(t) Paralyzed,\n Tone: Not assessed\n Labs / Radiology\n 8.3 g/dL\n 411 K/uL\n 163 mg/dL\n 0.5 mg/dL\n 27 mEq/L\n 3.8 mEq/L\n 12 mg/dL\n 111 mEq/L\n 144 mEq/L\n 26.0 %\n 9.7 K/uL\n [image002.jpg]\n 03:47 AM\n 02:14 PM\n 04:05 PM\n 01:12 AM\n 04:00 AM\n 04:09 AM\n 10:18 AM\n 02:33 PM\n 02:46 PM\n 03:31 AM\n WBC\n 10.5`\n 1q\n 9.6\n 9.7\n Hct\n 27.5\n 27.8\n 26.0\n Plt\n 374\n 374\n 411\n Cr\n 0.6\n 0.5\n 0.5\n 0.5\n TCO2\n 27\n 26\n 27\n 28\n 29\n 26\n 27\n Glucose\n 187\n 194\n 195\n 195\n 163\n Other labs: PT / PTT / INR:15.3/69.9/1.3, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:86.1 %, Lymph:10.3 %,\n Mono:2.8 %, Eos:0.5 %, Lactic Acid:2.0 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:8.3 mg/dL, Mg++:2.1 mg/dL, PO4:3.3 mg/dL\n Imaging: cxr--et, og,r IJ in good position, slightly improved aeration\n at r and l base, still with b/l effusions, opacaities\n Microbiology: no new data\n Assessment and Plan\n 55 yo F w/ prolonged hospital course, etoh abuse with fall and thoracic\n compression fxs who was tranferred from OSH for evaluation of Y stent\n for BTM, course has been c/b R UE DVT and sepsis with hypotension,\n pressor needs, and resp failure likely VAP,TBM now with failure to\n wean, still with high PEEP requirements.\n Main issues remain--\n # Respiratory failure\n Continue to wean PEEP as tolerated following abg/sats\n Once PEEP lower, heading toward trach, given prolonged course,\n poor MS, vol overload\n Vol overload with effusions likely also contributing to poor\n wean\noff pressors and no longer needing boluses to maintain BP, keep\n I/O goal even to neg 500 cc neg, trend I/os and continue IV lasix today\n ultimately benefit form investigation for TBM\n Decrease RR on vent to optimize pH\n # Adrenal insufficiency\n Had very low random cortisol while in shock and respiratory\n failure\n On steroids, has come off and stayed off of pressors.\n cpmplete 5 day course of stress dose steroids--will discontinue\n after today.\n # Bradycardia\n Rhythm is sinus, confirmed by CVL-directed\natrial\n lead\n Heart rate increases with stimulation, suggesting mostly vagal\n in etiology\n # Klebsiella VAP\n complete course of levofloxacin today (day ), received vanco\n and which where d/c\nd given neg cx data.\n # Shock\nresolved, remains hemdynamically stable off pressors\n Treating adrenal insufficiency as above\n # R Upper extremity DVT\n Therapeutic heparin gtt (continue for now as heading toward trach)\n # Traumatic thoracic spinal fracture\n Eventual MRI. Too high-risk at present. Brace when out of bed.\n Ortho trauma following.\n # Glycemic control--imporved control with tightened SSI while on\n steroids\n Other issues as per ICU team note. Put in for picc placement.\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 08:13 PM 60 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 11:30 AM\n Arterial Line - 04:00 PM\n Comments: put in for picc line\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer:\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 45 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2167-09-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 634753,
"text": "Chief Complaint:\n 24 Hour Events:\n BRONCHOSCOPY - At 10:45 AM\n bronchoscopy for reposition of ETT not seen on CHX. Sedated on total\n 250mcg IVP FEntanyl, 2 MG IVP Midaz and cont on IV sedation for\n precedure. Provedure completed w/o incedence bacn on previous AC vent\n settings\n Able to wean PEEP throughout the day after bronch\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Metronidazole - 08:00 AM\n Aztreonam - 06:00 AM\n Vancomycin - 09:00 AM\n Levofloxacin - 09:30 AM\n Infusions:\n Midazolam (Versed) - 4 mg/hour\n Fentanyl - 125 mcg/hour\n Heparin Sodium - 1,700 units/hour\n Other ICU medications:\n Ranitidine (Prophylaxis) - 09:28 AM\n Fentanyl - 01:36 AM\n Midazolam (Versed) - 01:37 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.1\nC (97\n HR: 64 (47 - 79) bpm\n BP: 105/55(348) {89/45(61) - 125/84(348)} mmHg\n RR: 20 (20 - 30) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101 kg (admission): 94.2 kg\n Height: 67 Inch\n CVP: 19 (13 - 19)mmHg\n Total In:\n 4,142 mL\n 640 mL\n PO:\n TF:\n 2,219 mL\n 411 mL\n IVF:\n 1,833 mL\n 229 mL\n Blood products:\n Total out:\n 1,000 mL\n 660 mL\n Urine:\n 800 mL\n 660 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,142 mL\n -20 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 15 cmH2O\n FiO2: 40%\n PIP: 28 cmH2O\n Plateau: 23 cmH2O\n Compliance: 50 cmH2O/mL\n SpO2: 95%\n ABG: 7.43/41/80/24/2\n Ve: 7.4 L/min\n PaO2 / FiO2: 200\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric)\n Abdominal: No(t) Soft, Non-tender, Bowel sounds present, Distended\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Sedated, Tone: Not assessed\n Labs / Radiology\n 374 K/uL\n 8.7 g/dL\n 194 mg/dL\n 0.5 mg/dL\n 24 mEq/L\n 4.9 mEq/L\n 8 mg/dL\n 111 mEq/L\n 142 mEq/L\n 27.8 %\n 9.6 K/uL\n [image002.jpg]\n 06:17 AM\n 07:00 AM\n 08:18 AM\n 04:18 PM\n 03:47 AM\n 02:14 PM\n 04:05 PM\n 01:12 AM\n 04:00 AM\n 04:09 AM\n WBC\n 10.5\n 9.6\n Hct\n 27.5\n 27.8\n Plt\n 374\n 374\n Cr\n 0.6\n 0.6\n 0.5\n TropT\n <0.01\n <0.01\n TCO2\n 21\n 28\n 27\n 26\n 27\n 28\n Glucose\n 153\n 187\n 194\n Other labs: PT / PTT / INR:17.0/84.8/1.5, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:86.1 %, Lymph:10.3 %,\n Mono:2.8 %, Eos:0.5 %, Lactic Acid:2.0 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:8.4 mg/dL, Mg++:2.1 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with respiratory failure\n and difficulty weaning from vent.\n # Respiratory failure currently with unclear ETT location: Intubated\n on for resp decompensation. Likely VAP. Unlikely to have\n tracheomalacia as initially transferred for.\n - bronch for ETT location\n - wean PEEP\n # Pneumonia: Kleb oxytoca pneumonia and sputum with GPCs on gram\n stain. Afebrile overnight. On levofloxacin, vancomycin, aztreonam.\n Resp status seems to be improving.\n - Follow cultures\n - d/c aztreonam\n - Continue levofloxacin for 8 days\n # EKG changes: Sinus bradycardia. Very low voltages and no change in\n QRS morphology. P-waves are visible and prolonged PR interval is old.\n CK and troponins flat. Likely related to increased vagal tone possibly\n related to steroid replacement. Atrial EKG with p-waves c/w sinus\n bradycardia.\n - Will avoid excessive alpha-agonism\n - Continue to monitor\n # Hypotension: now off levophed, with good urine output. Hypovolemia\n is possibly a factor- responded to a transfusion; HCT had been\n dropping. However, SVV with Vigileo was 7, making her CO less likely\n to respond to fluids. Held on giving any boluses overnight. Today CVP\n is low given PEEP. Sepsis also a consideration.\n - continue abx as above (vanc and levofloxacin)\n - replete fluids.\n - Restart pressors as needed. Consider dopamine given bradycardia.\n # RUE DVT: Started on heparin gtt on .\n - closely monitor\n # Adrenal Insufficency: Random cortisol was approx 3 when it should\n have been maximally stimulated.\n - hydrocortisone and florinef for 5 days\n # Anemia: Stable.\n - Trend HCT\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n # Communication:\n - Brother has been with pt, although, live in boyfriend of 10 is\n her HCP.\n ICU \n Nutrition:\n Replete with Fiber (Full) - 08:13 PM 60 mL/hour, INR rising\n (? Nutritional deficiencies)\n Glycemic Control: ISS\n Lines:\n Multi Lumen - 11:30 AM\n Arterial Line - 04:00 PM\n Prophylaxis:\n DVT: heparin gtt\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: ICU consent signed, (brother) \n (boyfriend/POA) \n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2167-09-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 634761,
"text": "Chief Complaint:\n 24 Hour Events:\n BRONCHOSCOPY - At 10:45 AM\n bronchoscopy for reposition of ETT not seen on CHX. Sedated on total\n 250mcg IVP FEntanyl, 2 MG IVP Midaz and cont on IV sedation for\n precedure. Provedure completed w/o incedence bacn on previous AC vent\n settings\n Able to wean PEEP throughout the day after bronch\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Metronidazole - 08:00 AM\n Aztreonam - 06:00 AM\n Vancomycin - 09:00 AM\n Levofloxacin - 09:30 AM\n Infusions:\n Midazolam (Versed) - 4 mg/hour\n Fentanyl - 125 mcg/hour\n Heparin Sodium - 1,700 units/hour\n Other ICU medications:\n Ranitidine (Prophylaxis) - 09:28 AM\n Fentanyl - 01:36 AM\n Midazolam (Versed) - 01:37 AM\n Other medications:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.1\nC (97\n HR: 64 (47 - 79) bpm\n BP: 105/55(348) {89/45(61) - 125/84(348)} mmHg\n RR: 20 (20 - 30) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101 kg (admission): 94.2 kg\n Height: 67 Inch\n CVP: 19 (13 - 19)mmHg\n Total In:\n 4,142 mL\n 640 mL\n PO:\n TF:\n 2,219 mL\n 411 mL\n IVF:\n 1,833 mL\n 229 mL\n Blood products:\n Total out:\n 1,000 mL\n 660 mL\n Urine:\n 800 mL\n 660 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,142 mL\n -20 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 15 cmH2O\n FiO2: 40%\n PIP: 28 cmH2O\n Plateau: 23 cmH2O\n Compliance: 50 cmH2O/mL\n SpO2: 95%\n ABG: 7.43/41/80/24/2\n Ve: 7.4 L/min\n PaO2 / FiO2: 200\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese, opens eyes\n but no purposeful movement\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric)\n Abdominal: No(t) Soft, Non-tender, Bowel sounds present, Distended\n Extremities: No clubbing or cyanosis, 3+ nonpitting edema of b/l hands,\n LE without edema\n Skin: no rashes or jaundice\n Labs / Radiology\n 374 K/uL\n 8.7 g/dL\n 194 mg/dL\n 0.5 mg/dL\n 24 mEq/L\n 4.9 mEq/L\n 8 mg/dL\n 111 mEq/L\n 142 mEq/L\n 27.8 %\n 9.6 K/uL\n [image002.jpg]\n 06:17 AM\n 07:00 AM\n 08:18 AM\n 04:18 PM\n 03:47 AM\n 02:14 PM\n 04:05 PM\n 01:12 AM\n 04:00 AM\n 04:09 AM\n WBC\n 10.5\n 9.6\n Hct\n 27.5\n 27.8\n Plt\n 374\n 374\n Cr\n 0.6\n 0.6\n 0.5\n TropT\n <0.01\n <0.01\n TCO2\n 21\n 28\n 27\n 26\n 27\n 28\n Glucose\n 153\n 187\n 194\n Other labs: PT / PTT / INR:17.0/84.8/1.5, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:86.1 %, Lymph:10.3 %,\n Mono:2.8 %, Eos:0.5 %, Lactic Acid:2.0 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:8.4 mg/dL, Mg++:2.1 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with respiratory failure\n and difficulty weaning from vent.\n # Respiratory failure: Intubated on for resp decompensation.\n Likely VAP. Unlikely to have tracheomalacia as initially\n transferred for.\n - wean PEEP\n - discuss need for trach with patient and her family\n # Pneumonia: Pansensitive Kleb oxytoca pneumonia and sputum with GPCs\n on gram stain. Afebrile overnight. On levofloxacin since .\n Vancomycin, aztreonam have been stopped. Resp status seems to be\n improving.\n - Follow cultures\n - d/c aztreonam\n - Continue levofloxacin for 8 days (today = day )\n # EKG changes: Sinus bradycardia. Very low voltages and no change in\n QRS morphology. P-waves are visible and prolonged PR interval is old.\n CK and troponins flat. Likely related to increased vagal tone possibly\n related to steroid replacement. Atrial EKG with p-waves c/w sinus\n bradycardia.\n - Will avoid excessive alpha-agonism\n - Continue to monitor\n # Hypotension: Improved, off levophed for 2 days, with good urine\n output. SVV with Vigileo was 7, making her CO less likely to respond\n to fluids. CVP increasing with reduction in PEEP. Unlikely\n hypovolemic or septic. Likely poor adrenal response in setting of\n acute illness and very high PEEP.\n -continue fludricort and hydrocortisone for total 5 days (begun )\n -monitor, expect improvement with continual reduction in PEEP\n # RUE DVT: Started on heparin gtt on .\n - closely monitor\n # Adrenal Insufficency: Random cortisol was approx 3 when it should\n have been maximally stimulated.\n - hydrocortisone and florinef for 5 days\n # Anemia: Stable.\n - Trend HCT\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n # Communication:\n - Brother has been with pt, although, live in boyfriend of 10 is\n her HCP.\n ICU \n Nutrition:\n Replete with Fiber (Full) - 08:13 PM 60 mL/hour, INR rising\n (? Nutritional deficiencies)\n Glycemic Control: ISS\n titrate sliding scale up if persistent\n hyperglycemia\n Lines:\n Multi Lumen - 11:30 AM\n Arterial Line - 04:00 PM\n Prophylaxis:\n DVT: heparin gtt\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: ICU consent signed, (brother) \n (boyfriend/POA) \n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2167-09-26 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 634764,
"text": "Chief Complaint: resp failure, VAP, compression fx,\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n bronch for reposiitoning of ET tube, peep weaned down to 15 post-bronch\n 24 Hour Events:\n BRONCHOSCOPY - At 10:45 AM\n bronchoscopy for reposition of ETT not seen on CHX, samile. Sedated on\n total 250mcg IVP FEntanyl, 2 MG IVP Midaz and cont on IV sedation for\n precedure. Provedure completed w/o incedence bacn on previous AC vent\n settings\n BRONCHOSCOPY - At 11:03 AM\n History obtained from Medical records, HO\n Patient unable to provide history: Sedated\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Aztreonam - 06:00 AM\n Vancomycin - 09:00 AM\n Levofloxacin - 08:00 AM\n Infusions:\n Fentanyl - 125 mcg/hour\n Heparin Sodium - 1,700 units/hour\n Other ICU medications:\n Ranitidine (Prophylaxis) - 09:28 AM\n Midazolam (Versed) - 08:25 AM\n Fentanyl - 08:25 AM\n Other medications:\n per (reviewed)\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36\nC (96.8\n HR: 55 (47 - 88) bpm\n BP: 116/60(80) {89/45(61) - 135/78(348)} mmHg\n RR: 20 (20 - 25) insp/min\n SpO2: 93%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 101 kg (admission): 94.2 kg\n Height: 67 Inch\n CVP: 20 (13 - 20)mmHg\n Total In:\n 4,142 mL\n 1,082 mL\n PO:\n TF:\n 2,219 mL\n 564 mL\n IVF:\n 1,833 mL\n 408 mL\n Blood products:\n Total out:\n 1,000 mL\n 775 mL\n Urine:\n 800 mL\n 775 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,142 mL\n 307 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 15 cmH2O\n FiO2: 40%\n PIP: 28 cmH2O\n Plateau: 24 cmH2O\n Compliance: 44.4 cmH2O/mL\n SpO2: 93%\n ABG: 7.43/41/80./24/2\n Ve: 7.6 L/min\n PaO2 / FiO2: 200\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear :\n ant, Crackles : , Diminished: at bases, No(t) Absent : )\n Abdominal: Bowel sounds present, Distended, No(t) Tender: , Obese, BS\n hypoactive\n Extremities: Right: Absent, Left: Absent, 3+ UE/hand edema\n Skin: Warm, Rash:\n Neurologic: Attentive, No(t) Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 8.7 g/dL\n 374 K/uL\n 194 mg/dL\n 0.5 mg/dL\n 24 mEq/L\n 4.9 mEq/L\n 8 mg/dL\n 111 mEq/L\n 142 mEq/L\n 27.8 %\n 9.6 K/uL\n [image002.jpg]\n 06:17 AM\n 07:00 AM\n 08:18 AM\n 04:18 PM\n 03:47 AM\n 02:14 PM\n 04:05 PM\n 01:12 AM\n 04:00 AM\n 04:09 AM\n WBC\n 10.5\n 9.6\n Hct\n 27.5\n 27.8\n Plt\n 374\n 374\n Cr\n 0.6\n 0.6\n 0.5\n TropT\n <0.01\n <0.01\n TCO2\n 21\n 28\n 27\n 26\n 27\n 28\n Glucose\n 153\n 187\n 194\n Other labs: PT / PTT / INR:17.0/84.8/1.5, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:86.1 %, Lymph:10.3 %,\n Mono:2.8 %, Eos:0.5 %, Lactic Acid:2.0 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:8.4 mg/dL, Mg++:2.1 mg/dL, PO4:3.1 mg/dL\n Imaging: cxr--et ok, r ij, b/l effusions layering, increased haziness R\n base\n Microbiology: Kleb pan \n Assessment and Plan\n Assessment and Plan\n 55-year-old woman with prolonged hospital course, etoh abuse tranferred\n from OSH with fall and compression fx course c/b sepsis and resp\n failure likely VAP,TBM, failure to wean, with high PEEP\n requirements, R UE DVT\n Respiratory failure\n Oxygenation is improving\n continue to wean PEEP as tolerated\n eventually need investigation for TBM\n Once PEEP lower, would consider trach\n vol overload and effusions liekly also contrinuting to poor wean--goal\n 500 cc neg, trend I/os and consider gently IV lasix\n Adrenal insufficiency\n Based on very low random cortisol while in shock and\n respiratory failure\n On steroids, has come off and stayed off of pressors.\n Eventually wean, but still getting fluid boluses\n Bradycardia\n Rhythm is sinus, confirmed by CVL-directed\natrial\n lead\n Heart rate increases with stimulation, suggesting that this\n is mostly vagal in etiology\n Klebsiella VAP\n Complete 8d course of levofloxacin (day )\n If sputum culture remains negative (GPCs on G/S),\n discontinue vancomycin tomorrow\n Shock\n remains hemdynamically stable off pressors\n Intermittent fluid boluses\n Treating adrenal insufficiency\n R Upper extremity DVT\n Therapeutic heparin gtt (heading toward trach)\n Anemia\n Follow\n Possible tracheobronchomalacia (reason for transfer)\n Traumatic thoracic spinal fracture\n Eventual MRI. Too high-risk at present. Brace when out of\n bed. Ortho trauma following.\n glycemic control--tighten SSI\n Other issues as per ICU team note.\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 08:13 PM 60 mL/hour\n Comments: increase bowel reg\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 11:30 AM\n Arterial Line - 04:00 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer:\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 45 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2167-09-26 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 634778,
"text": "Chief Complaint: shock (resolved), adrenal insuff, resp failure, VAP,\n compression fx,\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI: 55 yo F w/ prolonged hospital course, etoh abuse with fall and\n thoracic compression fxs who was tranferred from OSH for evaluation of\n Y stent for BTM, course has been c/b R UE DVT and sepsis with\n hypotension, pressor needs, and resp failure likely VAP,TBM now\n with failure to wean, still with high PEEP requirements.\n 24 Hour Events:\n BRONCHOSCOPY - At 10:45 AM\n bronchoscopy for reposition of ETT not seen on CHX, samile. Sedated on\n total 250mcg IVP FEntanyl, 2 MG IVP Midaz and cont on IV sedation for\n precedure. Provedure completed w/o incedence bacn on previous AC vent\n settings\n BRONCHOSCOPY - At 11:03 AM\n Peep decreased to 15\n History obtained from Medical records, HO\n Patient unable to provide history: Sedated\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Aztreonam - 06:00 AM\n Vancomycin - 09:00 AM\n Levofloxacin - 08:00 AM\n Infusions:\n Fentanyl - 125 mcg/hour\n Heparin Sodium - 1,700 units/hour\n Other ICU medications:\n Ranitidine (Prophylaxis) - 09:28 AM\n Midazolam (Versed) - 08:25 AM\n Fentanyl - 08:25 AM\n Other medications:\n per (reviewed)\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36\nC (96.8\n HR: 55 (47 - 88) bpm\n BP: 116/60(80) {89/45(61) - 135/78(348)} mmHg\n RR: 20 (20 - 25) insp/min\n SpO2: 93%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 101 kg (admission): 94.2 kg\n Height: 67 Inch\n CVP: 20 (13 - 20)mmHg\n Total In:\n 4,142 mL\n 1,082 mL\n PO:\n TF:\n 2,219 mL\n 564 mL\n IVF:\n 1,833 mL\n 408 mL\n Blood products:\n Total out:\n 1,000 mL\n 775 mL\n Urine:\n 800 mL\n 775 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,142 mL\n 307 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 15 cmH2O\n FiO2: 40%\n PIP: 28 cmH2O\n Plateau: 24 cmH2O\n Compliance: 44.4 cmH2O/mL\n SpO2: 93%\n ABG: 7.43/41/80./24/2\n Ve: 7.6 L/min\n PaO2 / FiO2: 200\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n Eyes / Conjunctiva: PERRL, MMM\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear :\n ant, Crackles : , Diminished: at bases, No(t) Absent : )\n Abdominal: Bowel sounds present but decreased, Distended, No(t)\n Tender:, Obese,\n Extremities: Right: trace, Left:trace, + depedent, 2+ UE/hand edema\n Skin: Warm, Rash:\n Neurologic: Attentive, No(t) Follows simple commands,:, Movement:non\n purposeful, Tone: wnl\n Labs / Radiology\n 8.7 g/dL\n 374 K/uL\n 194 mg/dL\n 0.5 mg/dL\n 24 mEq/L\n 4.9 mEq/L\n 8 mg/dL\n 111 mEq/L\n 142 mEq/L\n 27.8 %\n 9.6 K/uL\n [image002.jpg]\n 06:17 AM\n 07:00 AM\n 08:18 AM\n 04:18 PM\n 03:47 AM\n 02:14 PM\n 04:05 PM\n 01:12 AM\n 04:00 AM\n 04:09 AM\n WBC\n 10.5\n 9.6\n Hct\n 27.5\n 27.8\n Plt\n 374\n 374\n Cr\n 0.6\n 0.6\n 0.5\n TropT\n <0.01\n <0.01\n TCO2\n 21\n 28\n 27\n 26\n 27\n 28\n Glucose\n 153\n 187\n 194\n Other labs: PT / PTT / INR:17.0/84.8/1.5, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:86.1 %, Lymph:10.3 %,\n Mono:2.8 %, Eos:0.5 %, Lactic Acid:2.0 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:8.4 mg/dL, Mg++:2.1 mg/dL, PO4:3.1 mg/dL\n Imaging: cxr--et ok, r ij, b/l effusions layering, increased haziness R\n base\n Microbiology: Kleb--pan \n Assessment and Plan\n 55 yo F w/ prolonged hospital course, etoh abuse with fall and thoracic\n compression fxs who was tranferred from OSH for evaluation of Y stent\n for BTM, course has been c/b R UE DVT and sepsis with hypotension,\n pressor needs, and resp failure likely VAP,TBM now with failure to\n wean, still with high PEEP requirements.\n Main issues remain--\n # Respiratory failure\n Oxygenation is improving\n Continue to wean PEEP as tolerated following abg/sats\n Once PEEP lower, would consider trach, given prolonged course,\n poor MS, vol overload\n Vol overload with effusions likely also contributing to poor\n wean\noff pressors and no longer needing boluses to maintain BP, keep\n I/O goal even to neg 500 cc neg, trend I/os and consider gently IV\n lasix later today\n ultimately benefit form investigation for TBM\n # Adrenal insufficiency\n Had very low random cortisol while in shock and respiratory\n failure\n On steroids, has come off and stayed off of pressors.\n Continue current doses, consider starting wean tomorrow as no\n longer needing fluid boluses and off pressors\n # Bradycardia\n Rhythm is sinus, confirmed by CVL-directed\natrial\n lead\n Heart rate increases with stimulation, suggesting mostly vagal\n in etiology\n # Klebsiella VAP\n Complete 8d course of levofloxacin (day ), received vanco and\n which where d/c\nd given neg cx data.\n # Shock\nresolved, remains hemdynamically stable off pressors\n Treating adrenal insufficiency\n # R Upper extremity DVT\n Therapeutic heparin gtt (continue for now as heading toward trach)\n # Traumatic thoracic spinal fracture\n Eventual MRI. Too high-risk at present. Brace when out of bed.\n Ortho trauma following.\n # Glycemic control--tighten SSI for improved control, on steroids\n Other issues as per ICU team note.\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 08:13 PM 60 mL/hour\n Comments: increase bowel reg\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 11:30 AM\n Arterial Line - 04:00 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer:\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 45 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2167-09-27 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 634875,
"text": "Chief Complaint: respiratory failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 55 yo F w/ prolonged hospital course, etoh abuse with fall and thoracic\n compression fxs who was tranferred from OSH for evaluation of Y stent\n for BTM, course has been c/b R UE DVT and sepsis with hypotension,\n pressor needs, and resp failure likely VAP,TBM now with failure to\n wean, still with high PEEP requirements.\n 24 Hour Events:\n EKG - At 12:00 PM\n low voltage, pre Haldol administration QRS .46\n lasix X 3 doses with good urine output\n peep held at 15, fio2 increased to 50%\n History obtained from ho\n Patient unable to provide history: Sedated, intubated\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Aztreonam - 06:00 AM\n Vancomycin - 09:00 AM\n Levofloxacin - 08:06 AM\n Infusions:\n Midazolam (Versed) - 4 mg/hour\n Fentanyl - 150 mcg/hour\n Heparin Sodium - 1,700 units/hour\n Other ICU medications:\n Haloperidol (Haldol) - 04:26 PM\n Furosemide (Lasix) - 04:30 PM\n Midazolam (Versed) - 06:16 AM\n Fentanyl - 06:16 AM\n Other medications:\n per (reviewed)\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.8\nC (98.2\n HR: 61 (53 - 93) bpm\n BP: 137/70(95) {103/52(69) - 137/70(95)} mmHg\n RR: 20 (16 - 28) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101 kg (admission): 94.2 kg\n Height: 67 Inch\n CVP: 19 (6 - 21)mmHg\n Total In:\n 2,679 mL\n 1,165 mL\n PO:\n TF:\n 1,443 mL\n 639 mL\n IVF:\n 886 mL\n 526 mL\n Blood products:\n Total out:\n 3,135 mL\n 305 mL\n Urine:\n 3,035 mL\n 305 mL\n NG:\n Stool:\n 100 mL\n Drains:\n Balance:\n -456 mL\n 860 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 15 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 29 cmH2O\n Plateau: 26 cmH2O\n SpO2: 96%\n ABG: 7.46/39/68/27/3\n Ve: 7.8 L/min\n PaO2 / FiO2: 136\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Endotracheal tube\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Diminished), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n ) bases b/l, coarse\n Extremities: Right: 1+, Left: 1+, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: No(t) Muscle wasting\n Skin: Warm\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Not assessed, Movement: Non -purposeful, Sedated, No(t) Paralyzed,\n Tone: Not assessed\n Labs / Radiology\n 8.3 g/dL\n 411 K/uL\n 163 mg/dL\n 0.5 mg/dL\n 27 mEq/L\n 3.8 mEq/L\n 12 mg/dL\n 111 mEq/L\n 144 mEq/L\n 26.0 %\n 9.7 K/uL\n [image002.jpg]\n 03:47 AM\n 02:14 PM\n 04:05 PM\n 01:12 AM\n 04:00 AM\n 04:09 AM\n 10:18 AM\n 02:33 PM\n 02:46 PM\n 03:31 AM\n WBC\n 10.5`\n 1q\n 9.6\n 9.7\n Hct\n 27.5\n 27.8\n 26.0\n Plt\n 374\n 374\n 411\n Cr\n 0.6\n 0.5\n 0.5\n 0.5\n TCO2\n 27\n 26\n 27\n 28\n 29\n 26\n 27\n Glucose\n 187\n 194\n 195\n 195\n 163\n Other labs: PT / PTT / INR:15.3/69.9/1.3, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:86.1 %, Lymph:10.3 %,\n Mono:2.8 %, Eos:0.5 %, Lactic Acid:2.0 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:8.3 mg/dL, Mg++:2.1 mg/dL, PO4:3.3 mg/dL\n Imaging: cxr--et, og,r IJ in good position, slightly improved aeration\n at r and l base, still with b/l effusions, opacaities\n Microbiology: no new data\n Assessment and Plan\n 55 yo F w/ prolonged hospital course, etoh abuse with fall and thoracic\n compression fxs who was tranferred from OSH for evaluation of Y stent\n for BTM, course has been c/b R UE DVT and sepsis with hypotension,\n pressor needs, and resp failure likely VAP,TBM now with failure to\n wean, still with high PEEP requirements.\n Main issues remain--\n # Respiratory failure\n Continue to wean PEEP as tolerated following abg/sats\n Once PEEP lower, heading toward trach, given prolonged course,\n poor MS, vol overload\n IV lasix for goal neg 500 cc i/o\n ultimately benefit form investigation for TBM\n Decrease RR on vent to optimize pH given alkalosis (mixed,\n mainly resp)\n # Adrenal insufficiency\n Had very low random cortisol while in shock and respiratory\n failure\n On steroids, has come off and stayed off of pressors\n Today completes 5 day course of stress dose steroids--will\n discontinue tomorrow\n # Klebsiella VAP\n complete course of levofloxacin today (day ), received vanco\n and which where d/c\nd given neg cx data.\n # R Upper extremity DVT\n Therapeutic heparin gtt (continue for now as heading toward trach)\n # Traumatic thoracic spinal fracture\n Eventual MRI. Too high-risk at present. Brace when out of bed.\n Ortho trauma following.\n # Glycemic control--improved with tightened SSI while on steroids\n Other issues as per ICU team note.\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 08:13 PM 60 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 11:30 AM\n Arterial Line - 04:00 PM\n Comments: put in for picc line\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer:\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 45 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2167-09-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 634596,
"text": "55 yr old woman admitted from OSH after she fell down the stairs and\n had traumatic T-spine fracture. Pt came to us with PNA from unknown\n etiology? VAP. Full code, Allergies: PCN, tetracycline, Sulfa. PMH:\n ETOH, smoker, Gerd, Hip replacement.\n Alteration in Nutrition\n Assessment:\n Tube feeds increased to 40ml/hr. Tube feed residual 10ml. Hypoactive\n BS.\n Action:\n cont to check residuals and try to increase rate\n Response:\n Residual staying 10ml/hr, continued rate of 40cc/hr.\n Plan:\n Try to increase Tube feeds to goal rate.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n RUE DVT, pt on heparin gtt at 1700units/hr.\n Action:\n Ptt was therapeutic x2, AM PTT 68.6 WNL\n Response:\n No change to drip made, therapeutic dose.\n Plan:\n Cont heparin gtt, check PTT adjust heparin gtt per scale.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Moderate thick white in-line secretions, copious clear oral secretions,\n clear/diminished lung sounds. Esophageal balloon in place. Previous\n Sputum culture shows GNR, speciation PND.\n Action:\n Lots of suctioning through the night, decreased FiO2 from 50% to 40%,\n decreased Peep from 23 to 21, HOB >30, oral care.\n Response:\n ABG WNL, could not draw an AM ABG because A-line no longer drawing,\n intern aware. Intern and resp therapy to get ABG for AM.\n Plan:\n Cont to try to wean vent settings as tolerated, cont monitoring ABG\n Hypotension (not Shock)\n Assessment:\n SBP 90-110\ns MAP 62-66 Goal MAP >65 Levophed gtt @ 0.018 mcg/kg/min.\n Action:\n Trying to wean levophed gtt off\n Response:\n MAP tends to drop below 65 when weaned all the way off levophed.\n Plan:\n Cont to try to wean gtt off\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n T-max 101.0\n Action:\n Sent blood, urine, and sputum cultures, treated with Tylenol\n Response:\n Temp decreased\n Plan:\n Follow up on cultures\n CT scan from earlier in the week confirms fracture but did not detect\n retropulsion. Neuro want pt in back brace when she is out of bed.\n Log rolling pt has been d/c.\n Bradycardia\n Assessment:\n At 0515 Patient HR dropped from 60-70\ns to 45-50.\n Action:\n EKG done, showed pt was in junctional rhythm, intern came to assess pt.\n Electrolytes WNL.\n Response:\n No intervention done yet because pt BP cont to be stable and all other\n vital signs stable.\n Plan:\n Cont to monitor pt HR.\n Fracture, other\n Assessment:\n Log roll precautions removed from day shift. Back brace needs to be\n applied if pt is out of bed. Please read CT scan results from above\n portion of note.\n Action:\n Still taking precautions to carefully turn pt but no longer on log roll\n precautions\n Response:\n Pt tolerating turning fine.\n Plan:\n Use back brace if pt get out of bed. Back brace in room\n"
},
{
"category": "Nursing",
"chartdate": "2167-09-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 634599,
"text": "55 yr old woman admitted from OSH after she fell down the stairs and\n had traumatic T-spine fracture. Pt came to us with PNA from unknown\n etiology? VAP. Full code, Allergies: PCN, tetracycline, Sulfa. PMH:\n ETOH, smoker, Gerd, Hip replacement.\n Alteration in Nutrition\n Assessment:\n Tube feeds increased to 40ml/hr. Residuals ~10ml. Hypoactive BS.\n Action:\n Residuals and BS checked. Rate increased to 40ml/hr.\n Response:\n Residual continued at 10ml/hr, continued rate of 40cc/hr.\n Plan:\n Advance TF to goal as tolerated. Monitor BS.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n RUE DVT, pt on heparin gtt at 1700units/hr.\n Action:\n Ptt was therapeutic x2, AM PTT 68.6 WNL\n Response:\n No change to drip made, therapeutic dose.\n Plan:\n Cont heparin gtt, check PTT adjust heparin gtt per scale.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Moderate thick white in-line secretions, copious clear oral secretions,\n clear/diminished lung sounds. Esophageal balloon in place. Previous\n Sputum culture shows GNR, speciation PND.\n Action:\n Lots of suctioning through the night, decreased FiO2 from 50% to 40%,\n decreased Peep from 23 to 21, HOB >30, oral care.\n Response:\n ABG WNL, could not draw an AM ABG because A-line no longer drawing,\n intern aware. Intern and resp therapy to get ABG for AM.\n Plan:\n Cont to try to wean vent settings as tolerated, cont monitoring ABG\n Hypotension (not Shock)\n Assessment:\n SBP 90-110\ns MAP 62-66 Goal MAP >65 Levophed gtt @ 0.018 mcg/kg/min.\n Action:\n Trying to wean levophed gtt off\n Response:\n MAP tends to drop below 65 when weaned all the way off levophed.\n Plan:\n Cont to try to wean gtt off\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n T-max 101.0\n Action:\n Sent blood, urine, and sputum cultures, treated with Tylenol\n Response:\n Temp decreased\n Plan:\n Follow up on cultures\n CT scan from earlier in the week confirms fracture but did not detect\n retropulsion. Neuro want pt in back brace when she is out of bed.\n Log rolling pt has been d/c.\n Bradycardia\n Assessment:\n At 0515 Patient HR dropped from 60-70\ns to 45-50.\n Action:\n EKG done, showed pt was in junctional rhythm, intern came to assess pt.\n Electrolytes WNL.\n Response:\n No intervention done yet because pt BP cont to be stable and all other\n vital signs stable.\n Plan:\n Cont to monitor pt HR.\n Fracture, other\n Assessment:\n Log roll precautions removed from day shift. Back brace needs to be\n applied if pt is out of bed. Please read CT scan results from above\n portion of note.\n Action:\n Still taking precautions to carefully turn pt but no longer on log roll\n precautions\n Response:\n Pt tolerating turning fine.\n Plan:\n Use back brace if pt get out of bed. Back brace in room\n"
},
{
"category": "Respiratory ",
"chartdate": "2167-09-23 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 634451,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Utilize ARDSnet protocol, Maintain PEEP at current\n level and reduce FiO2 as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Nursing",
"chartdate": "2167-09-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 634513,
"text": "55 yr old woman admitted from OSH after she fell down the stairs and\n had traumatic T-spine fracture. Pt came to us with PNA from unknown\n etiology? VAP. Full code, Allergies: PCN, tetracycline, Sulfa. PMH:\n ETOH, smoker, Gerd, Hip replacement.\n Alteration in Nutrition\n Assessment:\n Tube feeds at 20ml/hr. Tube feed residual 20ml.\n Action:\n Kept TF at 20ml/hr and will cont to check residuals and try to increase\n rate\n Response:\n No change\n Plan:\n Try to increase Tube feeds to goal rate.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n RUE DVT, pt on heparin gtt at 1700units/hr.\n Action:\n Ptt was therapeutic x2, AM PTT\n Response:\n Plan:\n Cont heparin gtt, check PTT adjust heparin gtt per scale.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Moderate thick white in-line secretions, copious clear oral secretions,\n clear/diminished lung sounds. Esophageal balloon in place. Previous\n Sputum culture shows GNR, speciation PND.\n Action:\n Lots of suctioning through the night, decreased FiO2 from 50% to 40%,\n decreased Peep from 23 to 21, HOB >30, oral care.\n Response:\n ABG WNL\n Plan:\n Cont to try to wean vent settings as tolerated, cont monitoring ABG\n Hypotension (not Shock)\n Assessment:\n SBP 90-110\ns MAP 62-66 Goal MAP >65 Levophed gtt @ 0.020 mcg/kg/min.\n Action:\n Trying to wean levophed gtt off\n Response:\n Plan:\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n T-max 101.0\n Action:\n Sent blood, urine, and sputum cultures, treated with tylenol\n Response:\n Temp decreased\n Plan:\n Follow up on cultures\n CT scan from earlier in the week confirms fracture but did not detect\n retropulsion. Neuro want pt in back brace when she is out of bed.\n Log rolling pt has been d/c.\n"
},
{
"category": "Nursing",
"chartdate": "2167-09-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 634514,
"text": "55 yr old woman admitted from OSH after she fell down the stairs and\n had traumatic T-spine fracture. Pt came to us with PNA from unknown\n etiology? VAP. Full code, Allergies: PCN, tetracycline, Sulfa. PMH:\n ETOH, smoker, Gerd, Hip replacement.\n Alteration in Nutrition\n Assessment:\n Tube feeds at 20ml/hr. Tube feed residual 20ml.\n Action:\n Kept TF at 20ml/hr and will cont to check residuals and try to increase\n rate\n Response:\n No change\n Plan:\n Try to increase Tube feeds to goal rate.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n RUE DVT, pt on heparin gtt at 1700units/hr.\n Action:\n Ptt was therapeutic x2, AM PTT\n Response:\n Plan:\n Cont heparin gtt, check PTT adjust heparin gtt per scale.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Moderate thick white in-line secretions, copious clear oral secretions,\n clear/diminished lung sounds. Esophageal balloon in place. Previous\n Sputum culture shows GNR, speciation PND.\n Action:\n Lots of suctioning through the night, decreased FiO2 from 50% to 40%,\n decreased Peep from 23 to 21, HOB >30, oral care.\n Response:\n ABG WNL\n Plan:\n Cont to try to wean vent settings as tolerated, cont monitoring ABG\n Hypotension (not Shock)\n Assessment:\n SBP 90-110\ns MAP 62-66 Goal MAP >65 Levophed gtt @ 0.020 mcg/kg/min.\n Action:\n Trying to wean levophed gtt off\n Response:\n Plan:\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n T-max 101.0\n Action:\n Sent blood, urine, and sputum cultures, treated with tylenol\n Response:\n Temp decreased\n Plan:\n Follow up on cultures\n CT scan from earlier in the week confirms fracture but did not detect\n retropulsion. Neuro want pt in back brace when she is out of bed.\n Log rolling pt has been d/c.\n Bradycardia\n Assessment:\n Action:\n Response:\n Plan:\n Fracture, other\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2167-09-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 634853,
"text": "Chief Complaint:\n 24 Hour Events:\n - Rec\nd one dose of Haldol yesterday afternoon\n - Poor sleep overnight per nursing\n - Per ABG, holding steady on FiO2 (50%) and PEEP (15)\n - Gave Lasix, net neg ~ 500 yesterday\n - Today is last day of steroids as well as last day of abx\n (levofloxicin)\n - Tightened sliding scale insulin yesterday\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Aztreonam - 06:00 AM\n Vancomycin - 09:00 AM\n Levofloxacin - 08:00 AM\n Infusions:\n Midazolam (Versed) - 4 mg/hour\n Heparin Sodium - 1,700 units/hour\n Fentanyl - 150 mcg/hour\n Other ICU medications:\n Haloperidol (Haldol) - 04:26 PM\n Furosemide (Lasix) - 04:30 PM\n Midazolam (Versed) - 06:16 AM\n Fentanyl - 06:16 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 35.7\nC (96.2\n HR: 66 (53 - 93) bpm\n BP: 111/56(74) {103/52(69) - 135/78(93)} mmHg\n RR: 20 (16 - 28) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101 kg (admission): 94.2 kg\n Height: 67 Inch\n CVP: 18 (6 - 21)mmHg\n Total In:\n 2,681 mL\n 687 mL\n PO:\n TF:\n 1,443 mL\n 432 mL\n IVF:\n 888 mL\n 255 mL\n Blood products:\n Total out:\n 3,135 mL\n 185 mL\n Urine:\n 3,035 mL\n 185 mL\n NG:\n Stool:\n 100 mL\n Drains:\n Balance:\n -454 mL\n 502 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 20\n RR (Spontaneous): 23\n PEEP: 15 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 31 cmH2O\n Plateau: 25 cmH2O\n SpO2: 95%\n ABG: 7.46/39/68/27/3\n Ve: 7.7 L/min\n PaO2 / FiO2: 136\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 411 K/uL\n 8.3 g/dL\n 163 mg/dL\n 0.5 mg/dL\n 27 mEq/L\n 3.8 mEq/L\n 12 mg/dL\n 111 mEq/L\n 144 mEq/L\n 26.0 %\n 9.7 K/uL\n [image002.jpg]\n 03:47 AM\n 02:14 PM\n 04:05 PM\n 01:12 AM\n 04:00 AM\n 04:09 AM\n 10:18 AM\n 02:33 PM\n 02:46 PM\n 03:31 AM\n WBC\n 10.5\n 9.6\n 9.7\n Hct\n 27.5\n 27.8\n 26.0\n Plt\n 374\n 374\n 411\n Cr\n 0.6\n 0.5\n 0.5\n 0.5\n TCO2\n 27\n 26\n 27\n 28\n 29\n 26\n 27\n Glucose\n 187\n 194\n 195\n 195\n 163\n Other labs: PT / PTT / INR:15.3/69.9/1.3, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:86.1 %, Lymph:10.3 %,\n Mono:2.8 %, Eos:0.5 %, Lactic Acid:2.0 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:8.3 mg/dL, Mg++:2.1 mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 08:13 PM 60 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 11:30 AM\n Arterial Line - 04:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2167-09-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 634854,
"text": "Chief Complaint:\n 24 Hour Events:\n - Rec\nd one dose of Haldol yesterday afternoon\n - Poor sleep overnight per nursing\n - Per ABG, holding steady on FiO2 (50%) and PEEP (15)\n - Gave Lasix, net neg ~ 500 yesterday\n - Today is last day of steroids as well as last day of abx\n (levofloxicin)\n - Tightened sliding scale insulin yesterday\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Aztreonam - 06:00 AM\n Vancomycin - 09:00 AM\n Levofloxacin - 08:00 AM\n Infusions:\n Midazolam (Versed) - 4 mg/hour\n Heparin Sodium - 1,700 units/hour\n Fentanyl - 150 mcg/hour\n Other ICU medications:\n Haloperidol (Haldol) - 04:26 PM\n Furosemide (Lasix) - 04:30 PM\n Midazolam (Versed) - 06:16 AM\n Fentanyl - 06:16 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 35.7\nC (96.2\n HR: 66 (53 - 93) bpm\n BP: 111/56(74) {103/52(69) - 135/78(93)} mmHg\n RR: 20 (16 - 28) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101 kg (admission): 94.2 kg\n Height: 67 Inch\n CVP: 18 (6 - 21)mmHg\n Total In:\n 2,681 mL\n 687 mL\n PO:\n TF:\n 1,443 mL\n 432 mL\n IVF:\n 888 mL\n 255 mL\n Blood products:\n Total out:\n 3,135 mL\n 185 mL\n Urine:\n 3,035 mL\n 185 mL\n NG:\n Stool:\n 100 mL\n Drains:\n Balance:\n -454 mL\n 502 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 20\n RR (Spontaneous): 23\n PEEP: 15 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 31 cmH2O\n Plateau: 25 cmH2O\n SpO2: 95%\n ABG: 7.46/39/68/27/3\n Ve: 7.7 L/min\n PaO2 / FiO2: 136\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese, opens eyes\n but no purposeful movement\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric)\n Abdominal: No(t) Soft, Non-tender, Bowel sounds present, Distended\n Extremities: No clubbing or cyanosis, 3+ nonpitting edema of b/l hands,\n LE without edema\n Skin: no rashes or jaundice\n Labs / Radiology\n 411 K/uL\n 8.3 g/dL\n 163 mg/dL\n 0.5 mg/dL\n 27 mEq/L\n 3.8 mEq/L\n 12 mg/dL\n 111 mEq/L\n 144 mEq/L\n 26.0 %\n 9.7 K/uL\n [image002.jpg]\n 03:47 AM\n 02:14 PM\n 04:05 PM\n 01:12 AM\n 04:00 AM\n 04:09 AM\n 10:18 AM\n 02:33 PM\n 02:46 PM\n 03:31 AM\n WBC\n 10.5\n 9.6\n 9.7\n Hct\n 27.5\n 27.8\n 26.0\n Plt\n 374\n 374\n 411\n Cr\n 0.6\n 0.5\n 0.5\n 0.5\n TCO2\n 27\n 26\n 27\n 28\n 29\n 26\n 27\n Glucose\n 187\n 194\n 195\n 195\n 163\n Other labs: PT / PTT / INR:15.3/69.9/1.3, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:86.1 %, Lymph:10.3 %,\n Mono:2.8 %, Eos:0.5 %, Lactic Acid:2.0 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:8.3 mg/dL, Mg++:2.1 mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with respiratory failure\n and difficulty weaning from vent.\n # Respiratory failure: Intubated on for resp decompensation.\n Likely VAP. Unlikely to have tracheomalacia as initially\n transferred for.\n - wean PEEP\n - discuss need for trach with patient and her family\n # Pneumonia: Pansensitive Kleb oxytoca pneumonia and sputum with GPCs\n on gram stain. Afebrile overnight. On levofloxacin since .\n Vancomycin, aztreonam have been stopped. Resp status seems to be\n improving.\n - Follow cultures\n - d/c aztreonam\n - Continue levofloxacin for 8 days (today = day )\n # EKG changes: Sinus bradycardia. Very low voltages and no change in\n QRS morphology. P-waves are visible and prolonged PR interval is old.\n CK and troponins flat. Likely related to increased vagal tone possibly\n related to steroid replacement. Atrial EKG with p-waves c/w sinus\n bradycardia.\n - Will avoid excessive alpha-agonism\n - Continue to monitor\n # Hypotension: Improved, off levophed for 2 days, with good urine\n output. SVV with Vigileo was 7, making her CO less likely to respond\n to fluids. CVP increasing with reduction in PEEP. Unlikely\n hypovolemic or septic. Likely poor adrenal response in setting of\n acute illness and very high PEEP.\n -continue fludricort and hydrocortisone for total 5 days (begun )\n -monitor, expect improvement with continual reduction in PEEP\n # RUE DVT: Started on heparin gtt on .\n - closely monitor\n # Adrenal Insufficency: Random cortisol was approx 3 when it should\n have been maximally stimulated.\n - hydrocortisone and florinef for 5 days\n # Anemia: Stable.\n - Trend HCT\n # Spine fracture: Neurologically intact distal to the lesion. Prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n # Communication:\n - Brother has been with pt, although, live in boyfriend of 10 is\n her HCP.\n ICU \n Nutrition:\n Replete with Fiber (Full) - 08:13 PM 60 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 11:30 AM\n Arterial Line - 04:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2167-09-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 634654,
"text": "Pt is a 55 yr old women admitted from OSH after she fell down the\n stairs (did not have LOC per boyfriend) and had a traumatic T-spine\n Fracture. Pt came to us with PNA from unknown etiology? VAP. Full\n code, Allergies: PCN, tetracycline, sulfa. PMH: ETOH, smoker, Gerd, Hip\n replacement. Pt afebrile during the night, was Pan cultured\n yesterday. Pt brother is her spokesperson. Pt boyfriend was in last\n night to see her, it is a 2 hr train ride from for him to get\n here. Pt boyfriend reported on night that for the last 2 months\n pt has been drinking 2 large bottles of wine almost every night and\n that this is an increase from what she used to drink.\n Bradycardia\n Assessment:\n HR 46-60\ns, HR decreases when pt is asleep. Stays in the 45-50 range\n when she is asleep. BP stable with low HR.\n Action:\n Monitor HR, monitor SBP with low HR\n Response:\n No action taken because vital sign have been stable.\n Plan:\n Cont to monitor\n Alteration in Nutrition\n Assessment:\n Replete with fiber Goal rate 60ml/hr. distended firm belly but pt is\n stooling now. Hypoactive bowel sounds.\n Action:\n Increased rate to 50ml/hr. cont to watch TF residuals. Pt did have past\n problems with high residuals.\n Response:\n Residuals 10ml.\n Plan:\n Cont to advance TF as tolerated. Cont stool softners/monitor for high\n residuals.\n Deep Venous Thrombosis (DVT), Upper extremity,\n Assessment:\n RUE DVT, Pt on heparin gtt at 1700 units/hr. No blood draws or BP on\n RUE.\n Action:\n PTT has been at therapeutic dose.\n Response:\n Repeat PTT in AM\n Plan:\n If PTT cont to be therapeutic cont to check PTT Q 24 hr., if not make\n changes per protocol.\n Fracture, other\n Assessment:\n Ortho reported that pt has T8 fracture. Pt does move all extremities,\n needs to wear back brace when out of bed. Brace is in the room, pt no\n longer on log roll precautions. Hard to tell if pt is in pain from\n fracture but she is on fentanyl and versed gtts.\n Action:\n Per ortho pt will need MRI of the spine and CT scan of the C and L\n portions of the spine to check for any other spinal injury. Ortho\n states we can do this when pt is more stable.\n Response:\n Plan:\n Will do MRI and CT at a later date.\n Hypotension (not Shock)\n Assessment:\n SBP ranges 80-100\ns with MAPs 55-70 Goal MAP >60. levophed off for\n almost 24hr. pt did get total of 3 liters in fluid boluses over the\n last 24 hr. CVP 12-14 but pt on 21 of peep. A-line very positional\n and was just re-sited yesterday. Pt was on vigileo monitor but D/C\n during the day because A-line tracing is so positional that the\n accuracy of this monitoring is questionable.\n Action:\n Gave 500ml fluid bolus for MAP of 55. and low urine output 10-20ml/hr.\n Response:\n Urine output increased, and MAP/BP increased\n Plan:\n Cont to monitor BP and MAPs and urine output.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Suctioning clear/white thick secretions in-line, copious amounts of\n clear secretions suctioned orally. Cough intact. Lung sounds clear\n diminished, no vent setting changes, Vent mode CMV: 40%/400/22/21,\n esophageal balloon in place.\n Action:\n VAP protocol: HOB 30 degrees, oral care. Suctioning, cont steroids.\n Chest x-ray done in AM. Cont antibiotics.\n Response:\n Cont to needs lots of suctioning.\n Plan:\n Wean vent as ordered by the Micu team. Cont to check ABG\ns when\n indicated.\n"
},
{
"category": "Nutrition",
"chartdate": "2167-09-25 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 634666,
"text": "Objective\n Pertinent medications: noted\n Labs:\n Value\n Date\n Glucose\n 187 mg/dL\n 03:47 AM\n Glucose Finger Stick\n 207, 190\n \n BUN\n 6 mg/dL\n 03:47 AM\n Creatinine\n 0.6 mg/dL\n 03:47 AM\n Sodium\n 144 mEq/L\n 03:47 AM\n Potassium\n 4.3 mEq/L\n 03:47 AM\n Chloride\n 113 mEq/L\n 03:47 AM\n TCO2\n 26 mEq/L\n 03:47 AM\n Albumin\n 2.4 g/dL\n 03:59 AM\n Calcium non-ionized\n 9.0 mg/dL\n 03:47 AM\n Phosphorus\n 2.7 mg/dL\n 03:47 AM\n Ionized Calcium\n 1.20 mmol/L\n 08:18 AM\n Magnesium\n 2.0 mg/dL\n 03:47 AM\n Current diet order / nutrition support: Replte c/ Fiber @60mL/hr (1440\n kcals/89 gr aa)\n GI: Abd: firm/dist/+bs/+bm\n Assessment of Nutritional Status\n Specifics:\n Pt remains intubated. TF\ns retrialed . Currently infusing @50mL/\n hr c/ minimal residuals, advancing slowly to goal of 60mL/hr. Pt\ns abd\n remains firm, but pt now stooling. BG\ns elevated on steroids.\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: via TF\n Advance TF's to goal rate of 60mL/hr, as ordered\n Residual checks q 4 hr, hold if >200mL\n Consider tighter SS insulin\n"
},
{
"category": "Physician ",
"chartdate": "2167-09-25 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 634672,
"text": "Chief Complaint:\n HPI:\n 24 Hour Events:\n ARTERIAL LINE - STOP 04:00 PM\n ARTERIAL LINE - START 04:00 PM\n Patient unable to provide history: Sedated\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Metronidazole - 08:00 AM\n Levofloxacin - 10:00 AM\n Aztreonam - 06:00 AM\n Vancomycin - 09:00 AM\n Infusions:\n Heparin Sodium - 1,700 units/hour\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 4 mg/hour\n Other ICU medications:\n Midazolam (Versed) - 09:17 AM\n Ranitidine (Prophylaxis) - 09:28 AM\n Other medications:\n midaz, fent, colace, H2B, CHG, SQI, MDIs, IV heparin, levoflox,\n aztreonam, vanco, hydrocort, fludrocort,\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.9\nC (98.4\n HR: 61 (45 - 79) bpm\n BP: 125/65(87) {83/44(59) - 125/84(134)} mmHg\n RR: 22 (0 - 30) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101 kg (admission): 94.2 kg\n Height: 67 Inch\n CVP: 16 (12 - 17)mmHg\n Total In:\n 4,751 mL\n 1,813 mL\n PO:\n TF:\n 773 mL\n 523 mL\n IVF:\n 3,828 mL\n 1,200 mL\n Blood products:\n Total out:\n 2,365 mL\n 465 mL\n Urine:\n 2,325 mL\n 265 mL\n NG:\n 40 mL\n Stool:\n Drains:\n Balance:\n 2,386 mL\n 1,348 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 22\n RR (Spontaneous): 5\n PEEP: 21 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 33 cmH2O\n Plateau: 28 cmH2O\n Compliance: 57.2 cmH2O/mL\n SpO2: 99%\n ABG: ///26/\n Ve: 10.4 L/min\n Physical Examination\n General Appearance: Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Percussion: Resonant : ), (Breath Sounds: Clear :\n anterior exam)\n Abdominal: Soft, Non-tender, Obese\n Extremities: Right: 1+, Left: 1+\n Musculoskeletal: Unable to stand\n Skin: Warm\n Neurologic: Responds to: Verbal stimuli, Movement: Purposeful, Tone:\n Normal\n Labs / Radiology\n 8.3 g/dL\n 374 K/uL\n 187 mg/dL\n 0.6 mg/dL\n 26 mEq/L\n 4.3 mEq/L\n 6 mg/dL\n 113 mEq/L\n 144 mEq/L\n 27.5 %\n 10.5 K/uL\n [image002.jpg]\n 01:04 AM\n 05:54 AM\n 06:11 AM\n 11:07 PM\n 03:51 AM\n 06:17 AM\n 07:00 AM\n 08:18 AM\n 04:18 PM\n 03:47 AM\n WBC\n 8.1\n 8.9\n 10.5\n Hct\n 28.0\n 28.6\n 27.5\n Plt\n 358\n 326\n 374\n Cr\n 0.7\n 0.7\n 0.6\n 0.6\n TropT\n <0.01\n <0.01\n TCO2\n 28\n 26\n 26\n 21\n 28\n Glucose\n 126\n 151\n 153\n 187\n Other labs: PT / PTT / INR:20.3/89.3/1.9, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:84.8 %, Lymph:12.5 %,\n Mono:2.4 %, Eos:0.1 %, Lactic Acid:0.7 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:9.0 mg/dL, Mg++:2.0 mg/dL, PO4:2.7 mg/dL\n Imaging: CXR: right base opacity; difficult to identify endotracheal\n tube\n Microbiology: Sputum: pan-sensitive Klebs\n Assessment and Plan\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 07:00 AM 60 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 11:30 AM\n Arterial Line - 04:00 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Heparin gtt)\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent:\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2167-09-25 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 634673,
"text": "Chief Complaint:\n HPI:\n 24 Hour Events:\n ARTERIAL LINE - STOP 04:00 PM\n ARTERIAL LINE - START 04:00 PM\n Patient unable to provide history: Sedated\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Metronidazole - 08:00 AM\n Levofloxacin - 10:00 AM\n Aztreonam - 06:00 AM\n Vancomycin - 09:00 AM\n Infusions:\n Heparin Sodium - 1,700 units/hour\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 4 mg/hour\n Other ICU medications:\n Midazolam (Versed) - 09:17 AM\n Ranitidine (Prophylaxis) - 09:28 AM\n Other medications:\n midaz, fent, colace, H2B, CHG, SQI, MDIs, IV heparin, levoflox,\n aztreonam, vanco, hydrocort, fludrocort,\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.9\nC (98.4\n HR: 61 (45 - 79) bpm\n BP: 125/65(87) {83/44(59) - 125/84(134)} mmHg\n RR: 22 (0 - 30) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101 kg (admission): 94.2 kg\n Height: 67 Inch\n CVP: 16 (12 - 17)mmHg\n Total In:\n 4,751 mL\n 1,813 mL\n PO:\n TF:\n 773 mL\n 523 mL\n IVF:\n 3,828 mL\n 1,200 mL\n Blood products:\n Total out:\n 2,365 mL\n 465 mL\n Urine:\n 2,325 mL\n 265 mL\n NG:\n 40 mL\n Stool:\n Drains:\n Balance:\n 2,386 mL\n 1,348 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 22\n RR (Spontaneous): 5\n PEEP: 21 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 33 cmH2O\n Plateau: 28 cmH2O\n Compliance: 57.2 cmH2O/mL\n SpO2: 99%\n ABG: ///26/\n Ve: 10.4 L/min\n Physical Examination\n General Appearance: Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Percussion: Resonant : ), (Breath Sounds: Clear :\n anterior exam)\n Abdominal: Soft, Non-tender, Obese\n Extremities: Right: 1+, Left: 1+\n Musculoskeletal: Unable to stand\n Skin: Warm\n Neurologic: Responds to: Verbal stimuli, Movement: Purposeful, Tone:\n Normal\n Labs / Radiology\n 8.3 g/dL\n 374 K/uL\n 187 mg/dL\n 0.6 mg/dL\n 26 mEq/L\n 4.3 mEq/L\n 6 mg/dL\n 113 mEq/L\n 144 mEq/L\n 27.5 %\n 10.5 K/uL\n [image002.jpg]\n 01:04 AM\n 05:54 AM\n 06:11 AM\n 11:07 PM\n 03:51 AM\n 06:17 AM\n 07:00 AM\n 08:18 AM\n 04:18 PM\n 03:47 AM\n WBC\n 8.1\n 8.9\n 10.5\n Hct\n 28.0\n 28.6\n 27.5\n Plt\n 358\n 326\n 374\n Cr\n 0.7\n 0.7\n 0.6\n 0.6\n TropT\n <0.01\n <0.01\n TCO2\n 28\n 26\n 26\n 21\n 28\n Glucose\n 126\n 151\n 153\n 187\n Other labs: PT / PTT / INR:20.3/89.3/1.9, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:84.8 %, Lymph:12.5 %,\n Mono:2.4 %, Eos:0.1 %, Lactic Acid:0.7 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:9.0 mg/dL, Mg++:2.0 mg/dL, PO4:2.7 mg/dL\n Imaging: CXR: right base opacity; difficult to identify endotracheal\n tube\n Microbiology: Sputum: pan-sensitive Klebs\n Assessment and Plan\n 55-year-old woman with\n Unclear location of ETT\n Since only 18cm in holder, we will bronch to confirm correct\n position since an inadvertent extubation might be fatal.\n Respiratory failure\n Oxygenation is improving\n Wean PEEP as tolerated by hypoxemia\n eventually need investigation for TBM\n At present, her PEEP is too high to consider tracheostomy\n but if we are able to wean it (and not able to extubate her) would\n consider tracheostomy soon\n Adrenal insufficiency\n Based on very low random cortisol while in shock and\n respiratory failure\n On steroids, has come off and stayed off of pressors.\n Eventually wean, but still getting fluid boluses\n Bradycardia\n Rhythm is sinus, confirmed by CVL-directed\natrial\n lead\n Heart rate increases with stimulation, suggesting that this\n is mostly vagal in etiology\n Klebsiella VAP\n Complete 8d course of levofloxacin\n Discontinue aztreonam\n If sputum culture remains negative (GPCs on G/S),\n discontinue vancomycin tomorrow\n Shock\n now off of levophed\n Intermittent fluid boluses\n Treating adrenal insufficiency\n Upper extremity DVT\n Therapeutic heparin\n Anemia\n Follow\n Possible tracheobronchomalacia (reason for transfer)\n Incidental peri-appendiceal finding (will need eventual\n follow-up)\n Traumatic thoracic spinal fracture\n Eventual MRI. Too high-risk at present. Brace when out of\n bed.\n Other issues as per ICU team note.\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 07:00 AM 60 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 11:30 AM\n Arterial Line - 04:00 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Heparin gtt)\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 50 min\n Patient is critically ill\n"
},
{
"category": "Respiratory ",
"chartdate": "2167-09-27 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 634836,
"text": "TITLE:\n Demographics\n :\n Day of mechanical ventilation: 9\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:MOV\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: A/C400x20/+15 peep/.5\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n :\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Dysynchrony assessment: none noted\n Plan\n Next 24-48 hours: Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Underlying illness not resolved\n"
},
{
"category": "Nursing",
"chartdate": "2167-09-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 634729,
"text": "TITLE: This is a 55 yr old female admitted from an OSH to on\n with resp failure, +PNA s/p fall down stairs with fracture of\n T5-T8 and possible tracheobronchomalacia for IP consult and possible Y\n stenting. Pt now s/p IP consult with no tracheobronchomalacia found on\n exam. Pt has been diff to wean with high PEEP requirements. The pt\n has finished a course of IV Levofloxacin, Vanco, and Aztreonam antibx\n for Klebsiella PNA/VAP. Pt found to have RUE DVT and maintained on an\n IV Heparin gtt (no NBP or blood draw in this appendage please). The pt\n is net input more than fifteen liters for LOS @ this time. The pt has\n documented allergies to Tetracycline, PCN & Hydrazaline. The pt is a\n Full Code. The pt has a boyfriend and a brother, the brother is the\n designated HCP.\n Bradycardia\n Assessment:\n NSR/Sinus bradycardia all shift. Pt maintains good cardiac output\n whether in NSR or SB with good hourly urine output and MAP\ns > 65 as\n desired by team.\n Action:\n No specific action required.\n Response:\n Pt remains hemodynamically stable on current pt care regime.\n Plan:\n Cont to follow pts hemodynamic status closely.\n Alteration in Nutrition\n Assessment:\n Pt received/maintained on full strength Replete with Fiber @ target\n rate of 60ml/hr via OGT with low residuals noted all shift.\n Action:\n Pt maintained on Replete with Fiber tube feeds @ target rate of\n 60ml/hr. Rectal tube d/c\ned 2^nd low output.\n Response:\n Pt appears to be tolerating current tube feeds.\n Plan:\n Cont to provide tube feeds @ stated target goal per Nutrition recs.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt has a documented RUE DVT and received on IV Heparin gtt infusing @\n 1,700 units/hr with serial therapeutic PTT noted.\n Action:\n Pt maintained on a 1,700 unit/hr Heparin gtt infusion rate.\n Response:\n Therapeutic AM PTT value of 84.8 noted.\n Plan:\n Cont with current IV Heparin gtt, hope to transistion to PO anti-coag\n when medically suited.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt received on CMV:22-40%-400-21 with normal sats, RR @ set rate and no\n evidence of SOB/dyspnea. Of note, the pts O2 sat perfectly correlates\n with ABG sat.\n Action:\n Rate dropped to 20, PEEP slowly/cautiously reduced down to 16. Pt\n sxn\ned for small amounts of thick tan sec per ETT overnight. AM CXR\n obtained this AM, results pending.\n Response:\n Pt cont to do well on reduced levels of MV support with last ABG\n values; 7.43-41-80.\n Plan:\n Cont to wean PEEP down as tol. Hope to avoid trach placement if\n possible.\n Hypotension (not Shock)\n Assessment:\n Pt has remained hemodynamically stable and afebrile all shift. CVP\n values in the low/mid teens, real value likely < 10 in setting of high\n PEEP (16).\n Action:\n Reduced PEEP overnight may be helping to improve cardiac output with\n increased venous return.\n Response:\n Pt has been maintained off pressors.\n Plan:\n Cont to follow hemodynamic status closely.\n"
},
{
"category": "Respiratory ",
"chartdate": "2167-09-26 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 634731,
"text": "TITLE:\n Demographics\n Day of intubation: 13\n Day of mechanical ventilation: 13\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: mL /\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: A/C 400x20/+16 peep/.4\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Dysynchrony assessment: none noted\n Comments: tolerated decrease in rate/Ve and decrease in peep from +21\n to +16 overnoc\n Plan\n Next 24-48 hours: Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n"
},
{
"category": "Nursing",
"chartdate": "2167-09-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 634807,
"text": "Events: MS labile from resting to agitated/ ? in pain in bed.\n Titrating sedation and adding IV Haldol for agitation. Tolerating TF\n and tightened RISS w/ recent high blood sugars. TF w/ minimal\n residual- firm abd and given Ducolax supp w/ good effect. Unable to\n wean from vent\n sat 90-93%, desat to 88-90% w/ cleaning and turning.\n Starting IV diuresis for edema/vent weaning.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS clear bilat upper lobes, diminished bilat lower lobes, pt w/ strong\n cough but minimal amts or thin clear secretions, large amt oral\n secretions, sat 90-95%\n Action:\n Turning as tolerated, suctioned PRN, up FiO2 w/ repete ABG O2 72,\n starting diuresis 10mg IVP Lasix x2\n Response:\n Sat 95-96%, 50%/400/x20/+15, post each dose Lasix mod response\n 500-700cc out/2hrs then tapering, BP w/o change post Lasix,\n Plan:\n Cont IV duiresis for goal envolemic to neg 500cc for decrease in angio\n and pulm edema to wean from vent, possibly Lasix gtt if not negative\n and BP tolerates\n Impaired Skin Integrity\n Assessment:\n Post supp- inc soft, semi formed brown guiac neg BM- while cleaning\n noted peri anal rash and sm area R glut/peri anal area\n? Skin tear\n from excoriation and resistance w/ turning and agitation/moving self in\n bed, skin tear site pink, clear w/ no odor, peri wound tissue mild\n excoriated/reddened\n Action:\n Pressure reduction as tolerated, barrier cream and criticaid cream,\n heals and elbows elevated, multipudus boots\n Response:\n No additional breakdown noted\n Plan:\n Cont monitor skin integrity, pressure reduction and shearing\n protection, cont support nutrition\n Altered mental status (not Delirium)\n Assessment:\n Pt will track follow, when released from restraints will reach in air\n and intermittently attempt pull @ ETT, ? nodding to questioning x 1,\n unable to write to make needs known, pt frequently attempting to turn\n in bed\n Action:\n Repositionged in afternoon for ? back pain, x1 sig inc in agitation\n administering 1mg IVP Haldol w/ good effect\n Response:\n Resting comfortable, VSS for several hours- able to mild titrate down\n Versed gtt,\n Plan:\n Cont monitor MS, emotional support, frequent reorientation, cont\n sedation as tolerated ? dilerium w/ PRN Haldol for aggitation\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n afebrile\n Action:\n Cont IV ABD Levoflox day \n Response:\n Plan:\n Cont monitor for temp spike, VAP prevention, skin care, IV ABX\n team\n to D/C Levoflox \n Edema, peripheral\n Assessment:\n 2+ generalized/dependent edema, CVP 15-21\n Action:\n Arms, hands, and legs elevated as tolerated, administering 10mg IVP\n Lasix x 2\n Response:\n Mod output w/ >500cc/2hrs and tapering post both doses\n Plan:\n Goal envolemic to neg 500 cc\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Heparin gtt @ 1700 units/hr, no S/S bleeding\n Action:\n Cont Hep gtt\n Response:\n Plan:\n Cont Hep gtt check PTT w/ Am labs, cont IV anticoagulation likely\n slow wean from vent and possible trach placement\n"
},
{
"category": "Nursing",
"chartdate": "2167-09-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 634809,
"text": "Events: MS labile from resting to agitated/ ? in pain in bed.\n Titrating sedation and adding IV Haldol for agitation. Tolerating TF\n and tightened RISS w/ recent high blood sugars. TF w/ minimal\n residual- firm abd and given Ducolax supp w/ good effect. Unable to\n wean from vent\n sat 90-93%, desat to 88-90% w/ cleaning and turning.\n Starting IV diuresis for edema/vent weaning.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS clear bilat upper lobes, diminished bilat lower lobes, pt w/ strong\n cough but minimal amts or thin clear secretions, large amt oral\n secretions, sat 90-95%\n Action:\n Turning as tolerated, suctioned PRN, up FiO2 w/ repete ABG O2 72,\n starting diuresis 10mg IVP Lasix x2\n Response:\n Sat 95-96%, 50%/400/x20/+15, post each dose Lasix mod response\n 500-700cc out/2hrs then tapering, BP w/o change post Lasix,\n Plan:\n Cont IV duiresis for goal envolemic to neg 500cc for decrease in angio\n and pulm edema to wean from vent, possibly Lasix gtt if not negative\n and BP tolerates\n Impaired Skin Integrity\n Assessment:\n Post supp- inc soft, semi formed brown guiac neg BM- while cleaning\n noted peri anal rash and sm area R glut/peri anal area\n? Skin tear\n from excoriation and resistance w/ turning and agitation/moving self in\n bed, skin tear site pink, clear w/ no odor, peri wound tissue mild\n excoriated/reddened\n Action:\n Pressure reduction as tolerated, barrier cream and criticaid cream,\n heals and elbows elevated, multipudus boots\n Response:\n No additional breakdown noted\n Plan:\n Cont monitor skin integrity, pressure reduction and shearing\n protection, cont support nutrition\n Altered mental status (not Delirium)\n Assessment:\n Pt will track follow, when released from restraints will reach in air\n and intermittently attempt pull @ ETT, ? nodding to questioning x 1,\n unable to write to make needs known, pt frequently attempting to turn\n in bed\n Action:\n Repositioned in afternoon for ? back pain, x1 sig inc in agitation\n administering 1mg IVP Haldol w/ good effect\n Response:\n Resting comfortable, in afternoon VSS for several hours- able to mild\n titrate down Versed gtt,\n Plan:\n Cont monitor MS, emotional support, frequent reorientation, cont\n sedation as tolerated ? dilerium w/ PRN Haldol for aggitation\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n afebrile\n Action:\n Cont IV ABD Levoflox day \n Response:\n Plan:\n Cont monitor for temp spike, VAP prevention, skin care, IV ABX\n team\n to D/C Levoflox \n Edema, peripheral\n Assessment:\n 2+ generalized/dependent edema, CVP 15-21\n Action:\n Arms, hands, and legs elevated as tolerated, administering 10mg IVP\n Lasix x 2\n Response:\n Mod output w/ >500cc/2hrs and tapering post both doses\n Plan:\n Goal envolemic to neg 500 cc\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Heparin gtt @ 1700 units/hr, no S/S bleeding\n Action:\n Cont Hep gtt\n Response:\n No change\n Plan:\n Cont Hep gtt check PTT w/ Am labs, cont IV anticoagulation likely\n slow wean from vent and possible trach placement\n"
},
{
"category": "Respiratory ",
"chartdate": "2167-09-27 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 634816,
"text": "TITLE:\n Demographics\n Day of intubation:\n Day of mechanical ventilation: 9\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: A/C400x20/+15 peep/.5\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Nursing",
"chartdate": "2167-09-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 634817,
"text": "TITLE:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n Edema, peripheral\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2167-09-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 634818,
"text": "TITLE: This is a 55 yr old female admitted from an OSH to on\n with resp failure, +PNA s/p fall down stairs with fracture of\n T5-T8 and possible tracheobronchomalacia for IP consult and possible Y\n stenting. Pt now s/p IP consult with no tracheobronchomalacia found on\n exam. Pt has been diff to wean with high PEEP requirements. The pt\n has finished a course of IV Levofloxacin, Vanco, and Aztreonam antibx\n for Klebsiella PNA/VAP. Pt found to have RUE DVT and maintained on an\n IV Heparin gtt (no NBP or blood draw in this appendage please). The pt\n is net input more than fifteen liters for LOS @ this time. The pt has\n documented allergies to Tetracycline, PCN & Hydrazaline. The pt is a\n Full Code. The pt has a boyfriend and a brother, the brother is the\n designated HCP.\n Overnight Events: No significant events overnight. Unable to wean MV\n support. Pt sedation needs appear to be increasing with increased\n levels of agitation requiring increased Midazolam & Fentanyl gtt rates\n and more freq IVP bolus dosing.\n Altered mental status (not Delirium)\n Assessment:\n Pt received/maintained on IV Fentanyl & Midazolam gtt\ns infusing @\n 125mcg/hr & 3mg/hr respectively. Unfortunately, pt easily becomes\n agitated with the slightest stimulation and does not respond to verbal\n re- assurance. Pt intermittently follows commands. At one point the\n pt nodded her head negatively when asked if she was in pain.\n Action:\n IV Fentanyl & IV Midazolam gtts titrated up, freq sedation boluses also\n provided. Soft wrist restraints maintained for pt safety. Pt freq\n re-oriented to person/place/time/care rationale to assist with nl\n cognition.\n Response:\n Pt seems to do well when left alone with lights out. Pt does not seem\n to get agitated to verbal stimuli, but does is not appeased by verbal &\n non-verbal reassurance.\n Plan:\n Pt responded well to IV Haldol on , may need to repeat?\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt received/maintained on AC-20-50%-400-15 with adequate ABG values\n (7.46-39-68) and subsequently no MV setting changes.\n Actioin:\n HOB kept @ 30 to 45 degrees. Sxn\ning provided to ETT Q 2-3 hr for sm\n amounts of thick tan sec. No RSBI 2^nd PEEP >/= 10.\n Response:\n Current AM ABG is acceptable.\n Plan:\n Pt appears to be moving in the direction of tracheostomy placement when\n PEEP reduced to more tolerable levels.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt has a documented DVT in RUE. No blood draws nor NBP measurements in\n this extremity please.\n Action:\n Pt received/maintained on IV Heparin gtt infusing @ 1,700 units/hr.\n Response:\n Pt has had serial therapeutic PTT values on current IV Heparin gtt rate\n of 1,700 units/hr.\n Plan:\n Currently awaiting AM PTT value to ensure optimal anti-coagulation\n status.\n Alteration in Nutrition\n Assessment:\n Pt received/maintained on full strength Replete with Fiber.\n Action:\n Pt continues to tol Replete with Fiber @ target rate of 60ml/hr.\n Response:\n Pt appears to be tol enteral nutrition @ this time with minimal\n residual per OGT.\n Plan:\n Cont to maintain pt on current tube feeds.\n Edema, peripheral\n Assessment:\n The pt is net input 16 liters for LOS and is +3 generalized\n anasarcoid. CVP values in the low teens in setting of high PEEP\n needs(15).\n Action:\n 10mg IVP Lasix provided @ 20:00.\n Response:\n Pt voided approximately 750ml dilute clear urine s/p 10mg IVP Lasix\n dose.\n Plan:\n Pt remains approx 16 liters input for LOS.\n"
},
{
"category": "Respiratory ",
"chartdate": "2167-09-28 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 634929,
"text": "TITLE:\n Demographics\n Day of intubation:\n Day of mechanical ventilation: 10\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management: MOV\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: A/C 400x18/+15 peep/.5\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: occ periods of agitation\n Assessment of breathing comfort: comf\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved; rsbi held d/t peep level\n"
},
{
"category": "Nursing",
"chartdate": "2167-09-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 634911,
"text": "TITLE: This is a 55 yr old female admitted from an OSH to on\n with resp failure, +PNA s/p fall down stairs with fracture of\n T5-T8 and possible tracheobronchomalacia for IP consult and possible Y\n stenting. Pt now s/p IP consult with no tracheobronchomalacia found on\n exam. Pt has been diff to wean with high PEEP requirements. The pt\n has finished a course of IV Levofloxacin, Vanco, and Aztreonam antibx\n for Klebsiella PNA/VAP. Pt found to have RUE DVT and maintained on an\n IV Heparin gtt (no NBP or blood draw in this appendage please). The pt\n is net input more than fifteen liters for LOS @ this time. The pt has\n documented allergies to Tetracycline, PCN & Hydrazaline. The pt is a\n Full Code. The pt has a boyfriend and a brother, the brother is the\n designated HCP.\n Events: PICC line placed at bedside, RR decreased from 20 to 18,\n levaquin d/c\nd. cont to diurese w/ lasix.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt on AC 20x400 50% PEEP 15. ABG n these settings 7.46/ 39/68\n Action:\n RR decreased to 18 to correct pH\n Response:\n Repeat ABG\ns 7.41/ 45/78\n Plan:\n Wean vent as tol, ? trach if unable to extubate\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n PTT 69.9 on heparin at 1700 units/hr\n Action:\n Response:\n Plan:\n Cont to monitor PTT, titrate heparin per protocol\n Edema, peripheral\n Assessment:\n Generalized edema r/t +FB of ~16.5L for LOS\n Action:\n Lasix 10mg IV given a/o\n Response:\n Pt diuresed 700ml over 2hrs.\n Plan:\n Monitor lytes, cont diuresis as tol.\n"
},
{
"category": "Nursing",
"chartdate": "2167-09-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 634115,
"text": "55 year old woman with hx of obesity presented to Medical Center\n on after falling down stairs while at home. She suffered a\n traumatic T5-8 fracture with retropulsion of fragments. Per medical\n records and discussion with her brother, she was awake for the fall (no\n LOC) and the fall was triggered by unsteady gait, potentially\n influenced by alcohol. Her fracture was managed concervatively. She\n was placed in a torso brace but her course was complicated by\n respiratory failure requiring intubation. At that time a CT was\n negative for PE but showed bilateral bibasilar consolidations vs\n atelectasis. At that time an ABG was 7.20/89/57 (unknown FIO2 but\n likely >6L facemask). She was intubated on at 08:40. The\n respiratory failure was thought likely to be related to pain med\n induced hypoventilation, bronchospasm, or restricted breathing due\n to the back brace. The hospital course was complicated by\n difficulty weaning form the ventilator. Her periodic agitation was\n managed with seroquel. Prior to transfer her vent settings were: SIMV\n 12x600 FIO2 0.45.\n The neurosurgery service evaluated her and recommended concervative\n management of her fracture including a back brace and outpatient\n neurosurgery followup. The CT chest showed notable narrowing of her\n central airways and the patient was referred for Interventional\n Pulmonary evaluation for airway stenting.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt O2Sats down 80-90\ns upon arrival, ABG\ns showed PaO2 61%, pt up to\n 100%Fio2, bilat rhonchi, Dim bases, suct for mod thick tan secretions;\n copious oral secretions; pt RR with care, breathing against vent\n Action:\n FIO2 increased 100%, weaning down as tolerated; sedation increased for\n ventilation\n Response:\n Pt O2Sats 98-100%\n Plan:\n ABG\ns, VS; Wean Fio2 as tolerated; CXRAY; cont with sedation\n for improved ventilation\n Fracture, other\n Assessment:\n pt s/p fall---T7 fracture/no surgical intervention\n Action:\n pt on log roll precautions, reverse t @30 degrees\n Response:\n pt tolerating turns well, no s/sx pain with care\n Plan:\n f/u with PT consult, cont log roll precautions\n Hypernatremia (high sodium)\n Assessment:\n Na 150\n Action:\n pt to receive D5W @50 X1L, TF started with 150 free water flushes every\n 4hrs\n Response:\n TF @ 10, no residual noted repeat labs in am\n Plan:\n labs, cont with free water flushes\n Anemia, other\n Assessment:\n HCT 30, down from 40 upon admission to OSH\n Action:\n No s/sx of bleeding noted,\n Response:\n Plan:\n hct, quiac stools\n"
},
{
"category": "Nursing",
"chartdate": "2167-09-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 634116,
"text": "55 year old woman with hx of obesity presented to Medical Center\n on after falling down stairs while at home. She suffered a\n traumatic T5-8 fracture with retropulsion of fragments. Per medical\n records and discussion with her brother, she was awake for the fall (no\n LOC) and the fall was triggered by unsteady gait, potentially\n influenced by alcohol. Her fracture was managed concervatively. She\n was placed in a torso brace but her course was complicated by\n respiratory failure requiring intubation. At that time a CT was\n negative for PE but showed bilateral bibasilar consolidations vs\n atelectasis. At that time an ABG was 7.20/89/57 (unknown FIO2 but\n likely >6L facemask). She was intubated on at 08:40. The\n respiratory failure was thought likely to be related to pain med\n induced hypoventilation, bronchospasm, or restricted breathing due\n to the back brace. The hospital course was complicated by\n difficulty weaning form the ventilator. Her periodic agitation was\n managed with seroquel. Prior to transfer her vent settings were: SIMV\n 12x600 FIO2 0.45.\n The neurosurgery service evaluated her and recommended concervative\n management of her fracture including a back brace and outpatient\n neurosurgery followup. The CT chest showed notable narrowing of her\n central airways and the patient was referred for Interventional\n Pulmonary evaluation for airway stenting.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt O2Sats down 80-90\ns upon arrival, ABG\ns showed PaO2 61%, pt up to\n 100%Fio2, bilat rhonchi, Dim bases, suct for mod thick tan secretions;\n copious oral secretions; pt RR with care, breathing against vent\n Action:\n FIO2 increased 100%, weaning down as tolerated; sedation increased for\n ventilation\n Response:\n Pt O2Sats 98-100%\n Plan:\n ABG\ns, VS; Wean Fio2 as tolerated; CXRAY; cont with sedation\n for improved ventilation\n Fracture, other\n Assessment:\n pt s/p fall---T7 fracture/no surgical intervention\n Action:\n pt on log roll precautions, reverse t @30 degrees\n Response:\n pt tolerating turns well, no s/sx pain with care\n Plan:\n f/u with PT consult, cont log roll precautions:\n Hypernatremia (high sodium)\n Assessment:\n Na 150\n Action:\n pt to receive D5W @50 X1L, TF started with 150 free water flushes every\n 4hrs\n Response:\n TF @ 10, no residual noted repeat labs in am\n Plan:\n labs, cont with free water flushes\n Anemia, other\n Assessment:\n HCT 30, down from 40 upon admission to OSH\n Action:\n No s/sx of bleeding noted,\n Response:\n Plan:\n hct, quiac stools\n"
},
{
"category": "Physician ",
"chartdate": "2167-09-20 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 634117,
"text": "Chief Complaint:\n 24 Hour Events:\n -cultured for fever to 102.7 at 4:00 am\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.3\nC (102.7\n Tcurrent: 39.3\nC (102.7\n HR: 89 (72 - 97) bpm\n BP: 96/41(55) {96/41(55) - 154/71(103)} mmHg\n RR: 12 (12 - 18) insp/min\n SpO2: 95%\n Total In:\n 10 mL\n 232 mL\n PO:\n TF:\n IVF:\n 10 mL\n 232 mL\n Blood products:\n Total out:\n 425 mL\n 570 mL\n Urine:\n 425 mL\n 570 mL\n NG:\n Stool:\n Drains:\n Balance:\n -416 mL\n -338 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 32 cmH2O\n SpO2: 95%\n ABG: 7.42/47/61/30/4\n Ve: 8 L/min\n PaO2 / FiO2: 102\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 333 K/uL\n 9.7 g/dL\n 103 mg/dL\n 0.6 mg/dL\n 30 mEq/L\n 3.8 mEq/L\n 6 mg/dL\n 109 mEq/L\n 150 mEq/L\n 30.7 %\n 9.7 K/uL\n [image002.jpg]\n 11:54 PM\n 01:00 AM\n WBC\n 9.7\n Hct\n 30.7\n Plt\n 333\n Cr\n 0.6\n TCO2\n 32\n Glucose\n 103\n Other labs: PT / PTT / INR:13.8/22.4/1.2, ALT / AST:30/19, Alk Phos / T\n Bili:149/0.7, Differential-Neuts:76.9 %, Lymph:17.3 %, Mono:3.0 %,\n Eos:2.5 %, Albumin:3.0 g/dL, LDH:222 IU/L, Ca++:8.6 mg/dL, Mg++:2.1\n mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n A/P: 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture\n # Respiratory failure: initially likely multifactorial including\n bronchspasm, hypoventilation from narcotics, and potential aspiration.\n prior evaluation negative for PE. still with significant A-a gradient.\n cxr appears under penetrated with small lung fields and potential\n effusion on right. potentially from additional pulmonary edema, however\n hypernatremia would limit ability to diurese.\n - daily chest xray\n - will hold on CT chest or airway pending IP consult\n - IP consult\n - vent settings: AC 500 x14 PEEP >8 (given body habitus), FIO2 as\n needed\n - sedation: fentanyl gtt/versed bolus\n - trial of diuresis when able\n # Spine fracture: neurologically intact distal to the lesion. prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - monitor distal neurologic function\n - cto brace x3 months unless supine in bed\n # Anemia: admission to MMC was ~40 now down to 30% w/o sign of active\n GI bleed or other source of blood loss. likely related to crystalloid\n administration, anemia of inflammation, chronic phlebotomy. given bili\n and LDH normal would be unlikely for hemolysis.\n - trend Hct\n - guaiac stools\n Hypernatremia: most likely related to inadequate free water repletion.\n free water defecit ~3L.\n - replete via OGT primarily\n - D5W x1 L\n ICU Care\n Nutrition:\n Comments: tube feed with free water\n nutrition consult\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 10:30 PM\n 18 Gauge - 10:30 PM\n 20 Gauge - 01:36 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Family meeting held , ICU consent signed Comments: \n (brother) \n (boyfriend/POA) \n Code status: Full code\n Disposition: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 10:30 PM\n 20 Gauge - 01:36 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2167-09-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 634136,
"text": "55 year old woman with hx of obesity presented to Medical Center\n on after falling down stairs while at home. She suffered a\n traumatic T5-8 fracture with retropulsion of fragments. Per medical\n records and discussion with her brother, she was awake for the fall (no\n LOC) and the fall was triggered by unsteady gait, potentially\n influenced by alcohol. Her fracture was managed concervatively. She\n was placed in a torso brace but her course was complicated by\n respiratory failure requiring intubation. At that time a CT was\n negative for PE but showed bilateral bibasilar consolidations vs\n atelectasis. At that time an ABG was 7.20/89/57 (unknown FIO2 but\n likely >6L facemask). She was intubated on at 08:40. The\n respiratory failure was thought likely to be related to pain med\n induced hypoventilation, bronchospasm, or restricted breathing due\n to the back brace. The hospital course was complicated by\n difficulty weaning form the ventilator. Her periodic agitation was\n managed with seroquel. Prior to transfer her vent settings were: SIMV\n 12x600 FIO2 0.45.\n The neurosurgery service evaluated her and recommended concervative\n management of her fracture including a back brace and outpatient\n neurosurgery followup. The CT chest showed notable narrowing of her\n central airways and the patient was referred for Interventional\n Pulmonary evaluation for airway stenting.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt O2Sats down 80-90\ns upon arrival, ABG\ns showed PaO2 61%, pt up to\n 100%Fio2, bilat rhonchi, Dim bases, suct for mod thick tan secretions;\n copious oral secretions; pt RR with care, breathing against vent\n Action:\n FIO2 increased 100%, weaning down as tolerated; sedation increased for\n ventilation\n Response:\n Pt O2Sats 98-100%\n Plan:\n ABG\ns, VS; Wean Fio2 as tolerated; CXRAY; cont with sedation\n for improved ventilation\n Fracture, other\n Assessment:\n pt s/p fall---T7 fracture/no surgical intervention\n Action:\n pt on log roll precautions, reverse t @30 degrees\n Response:\n pt tolerating turns well, no s/sx pain with care\n Plan:\n f/u with PT consult, cont log roll precautions:\n Hypernatremia (high sodium)\n Assessment:\n Na 150\n Action:\n pt to receive D5W @50 X1L, TF started with 150 free water flushes every\n 4hrs\n Response:\n TF @ 10, no residual noted repeat labs in am\n Plan:\n labs, cont with free water flushes\n Anemia, other\n Assessment:\n HCT 30, down from 40 upon admission to OSH\n Action:\n No s/sx of bleeding noted,\n Response:\n Plan:\n hct, quiac stools\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Pt TMax 102.6 orally @ 0400\n Action:\n BC X1 obtained, sputum cx, pt recvd APAP 650mg\n Response:\n Pt down 99.8 orally\n Plan:\n Obtain second set cultures, urine cultures; start IV Abx as ordered,\n administer APAP as ordered\n"
},
{
"category": "Nursing",
"chartdate": "2167-09-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 634325,
"text": "55 yr old women admitted from outside hospital. Patient fell down\n stairs at home per boyfriend pt with fracture and placed in torso\n brace at OSH, pt became hypoxic and was intubated (family requested a\n second opinion and pt was trans to ) Pt admitted for Resp failure,\n failure to wean, and ? tracheal bronchial malacia. Full code,\n Allergies: PCN, Tetracycline, Sulfta. Pt on log roll precautions for\n spine.\n Per boyfriend tonight he reported that for the last two months pt has\n been drinking 2 bottles of wine almost every night.\n And that this is an increase from what she previously did which was a\n couple of beers per night.\n Alteration in Nutrition\n Assessment:\n Increase in residuals out of OG tube. Tube feeds have not been\n restarted. Bowel sounds hypoactive, per family abdomen is about 30%\n larger than normal, no BM since admission.\n Action:\n Senna and colace given. OG tube to low int. suction, was able to clamp\n tube for 2hr but residuals returned.\n Response:\n 100 ml yellow-pinkish fluid out OG tube\n Plan:\n Cont to check residuals, restart tube feeds as tolerated, ? if raglan\n would help. Increase bowel regimen if needed.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n DVT in RUE\n Action:\n No BP or blood draws in RUE. Neuro to see pt in AM to see if we\n can start heparin gtt (neuro to okay because of the spine\n fracture)\n Response:\n Plan:\n Wait for decision by Neuro and anticoagulate with heparin if\n possible.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n T-max for this shift 100.5\n Action:\n Pt on Vanco, Aztreonam, Levoflaxacin, Flagyl., pt blood from\n central/A-line/peripheral drawn, urine also sent\n Response:\n Pt went down to 99.2 without any Tylenol\n Plan:\n Cont to monitor Temp, cont antibiotics, follow up cultures, re-culture\n if pt does spike temp again.\n Fracture, other\n Assessment:\n Reported that pt has a T5-T8 spinal fracture, Wet read from yesterdays\n CT may show just a T-9 compression, still waiting for the true results\n of this CT.\n Action:\n Log roll pt, pt increased with reverse trandelenburg positionsing,\n back brace in room if pt OOB.\n Response:\n Pt not tolerating turning\n Plan:\n Consult with neuro /wait for true CT scan results to know if spine\n is actually fractured or not and if not ? removing spine precautions.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lung sounds clear/diminished, ? VAP and possibly ARDS on top of that.\n small amounts thick yellow secretions, vent setting changed during the\n night. Pt desats to 80% with turning and takes a long time to\n recover. Face becomes blue/purple. On ARDS type vent settings\n Action:\n Did not turn pt during the night, Vent setting changed during night\n currently CMV 80%/400/22/17. cont suctioning/oral care/ subglottal\n suctioning. Resp tried to place esophageal balloon again tonight\n Response:\n Small secretions out of in-line suction. Last ABG better at 7.38/41/87,\n esophageal balloon placement unsuccessful\n Plan:\n ? if team will have respiratory try to place esophageal balloon again,\n wean vent as tolerated. Cont ABG\ns with vent changes.\n Hypotension (not Shock)\n Assessment:\n Pt received on 0.04 mcg/kg/min of norepi gtt.\n Action:\n Weaned gtt off in early evening but MAPs dropped <65\n Response:\n Turned norepi gtt back on at 0.02 mg/kg/min\n Plan:\n Cont to wean norepi gtt as tolerated.\n Goals: switch pt to air mattress bed if okayed by neuro that pt\n can be moved, start heparin gtt for RUE DVT if neuro okays. Wean\n norepi gtt. Restart Tube feeds when tolerates, ? if team will try to\n float esophageal balloon again.\n"
},
{
"category": "Respiratory ",
"chartdate": "2167-09-22 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 634326,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 4\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7mm\n Manufacturer:\n Size:\n PMV:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Comments: Pt was received on AC settings 400x 22 peep 17 and 70%. Pt\n peep and fio2 was increased by MD d/t significant oxygen desaturation.\n Recruitment maneuver was done with good results. Abgs post maneuver\n 7.38/41/87. Pt spo2 remained stable through the night. Attempt to\n insert Esophageal balloon without success. Will await sedation order\n from MD.\n"
},
{
"category": "Physician ",
"chartdate": "2167-09-21 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 634250,
"text": "Chief Complaint:\n 24 Hour Events:\n Removed PICC line because RUE was noted to be warm and erythematous;\n ultrasound revealed DVT. No definitive treatment was started given\n difficulty obtaining central venous access.\n Multiple attempts at central access; tried left and then right.\n Acute episode of oxygen desat during first central line attempt. Pt\n recovered, however, increased FiO2.\n Decreased UOP (10-30mL/hr) and hypotension overnight. However,\n lactate remains low. Originally, hypotension resolved with fluid\n boluses however by early am, oliguria was persistent despite bolus.\n Placed art line x 2. NBP and ABP similar\n mini- BAL, sputum, urine, blood cultures pending. Yesterday, started\n on levofloxicin and aztreonam instead of cefepime. Switched due to\n question of PCN allergy\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 09:30 AM\n Metronidazole - 12:00 AM\n Vancomycin - 01:00 AM\n Aztreonam - 04:00 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 150 mcg/hour\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:00 AM\n Midazolam (Versed) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (100.9\nF at 10am on )\n Tcurrent: 37.3\nC (99.2\n HR: 76 (71 - 116) bpm\n BP: 116/51(70) {60/46(54) - 146/71(91)} mmHg\n RR: 18 (12 - 24) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 94.2 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 5,600 mL\n 1,811 mL\n PO:\n TF:\n 120 mL\n IVF:\n 4,700 mL\n 1,511 mL\n Blood products:\n Total out:\n 798 mL\n 110 mL\n Urine:\n 798 mL\n 110 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,802 mL\n 1,701 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 80%\n RSBI Deferred: PEEP > 10\n PIP: 36 cmH2O\n Plateau: 25 cmH2O\n SpO2: 93%\n ABG: 7.45/42/95./28/4\n Ve: 9.5 L/min\n PaO2 / FiO2: 120\n Physical Examination\n Gen: Appears uncomfortable on vent.\n HEENT: Pupils 3 mm non-reactive bilaterally. Scleral edema bilat\n Resp: Symmetric expansion. Vesicular sounds throughout. Inspiratory\n and expiratory tracheal sounds (?related to ET tube).\n CV: RRR.\n Abd: Hypoactive bowel sounds. Distended. Non-tender.\n Ext: Edema in bilat UE, especially right hand.\n Peripheral vascular: Radial pulses 2+ bilaterally.\n Neuro: Moving all 4 extremities.\n Labs / Radiology\n 319 K/uL\n 7.6 g/dL\n 129 mg/dL\n 0.6 mg/dL\n 28 mEq/L\n 4.3 mEq/L\n 6 mg/dL\n 109 mEq/L\n 144 mEq/L\n 24.1 %\n 6.4 K/uL\n [image002.jpg]\n 11:54 PM\n 01:00 AM\n 06:14 AM\n 08:56 AM\n 08:57 AM\n 05:01 PM\n 08:03 PM\n 11:00 PM\n 03:01 AM\n 03:13 AM\n WBC\n 9.7\n 9.4\n 7.6\n 6.4\n Hct\n 30.7\n 25.1\n 24.1\n 24.1\n Plt\n 333\n 281\n 306\n 319\n Cr\n 0.6\n 0.6\n 0.7\n 0.6\n 0.6\n TCO2\n 32\n 33\n 35\n 33\n 30\n Glucose\n 103\n 126\n 126\n 127\n 129\n Other labs: PT / PTT / INR:16.9/26.3/1.5, ALT / AST:27/18, Alk Phos / T\n Bili:113/0.7, Differential-Neuts:76.9 %, Lymph:17.3 %, Mono:3.0 %,\n Eos:2.5 %, Lactic Acid:0.7 mmol/L, Albumin:2.3 g/dL, LDH:154 IU/L,\n Ca++:8.2 mg/dL, Mg++:2.6 mg/dL, PO4:3.1 mg/dL\n RUE ultrasound:\n - Non-occlusive right axillary deep vein thrombus\n - Non-occlusive right basilic superficial thrombosis.\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture\n # Respiratory failure: initial etiology unclear, likely multifactorial\n including bronchspasm, hypoventilation from narcotics, potential\n aspiration, infection. By report, had a neg evaluation for PE at OSH,\n however, unable to open disc to confirm. Concern for VAP.\n - Failed yesterday\ns NIF; score was -15\n - Increased FiO2 overnight. Had increased pCO2 which resolved with\n increasing RR\n - IP stopped by but will complete official consult today; suggested\n repeating CT scan\n - Need to contact Medical re previous CT scan. Can attempt to\n resend disc. Otherwise, will most likely benefit from repeat CT to\n look for acute pulm process such as PE or PNA.\n # Fever: Likely due to combination of infection and DVT. Cultures\n sent. Will treat with empiric antibiotics. Tylenol PRN for fever.\n - Known RUE DVT\n - Infectious etiologies include VAP, asp PNA, line infections. Removed\n PICC yesterday and cultured tip. Mini-BAL- gram stain neg. Sputum\n grew GPC in pairs and GPR. Flagyl, aztreonam, vancomycin, levofloxacin\n for coverage of gram positives, gram negatives, anaerobes, MRSA. Urine\n and blood cultures NGTD\n - f/u blood, urine, and sputum cultures.\n - Concern for abd cause; KUB unrevealing. High residuals. require\n further imaging\n # Transient hypotension: Has been somewhat fluid responsive; UOP \n ccs/hr. Diff dx includes hypovolemia, sepsis, cardiogenic.\n - Sepsis most likely given fever.\n - HCT decreasing; ? stable at 24-25\n - Unable to place central line despite multiple attempts. First tired\n left IJ RUE DVT. 2^nd attempt in left IJ. Can place femoral if pt\n requires more active repletion\n - Consider another attempt at a line.\n # Oliguria:\n -BUN and Cr as well as lactate reassuring.\n -Increased bladder pressures this am- 20. Further imaging may be\n helpful\n # RUE DVT: Have held on starting treatment in light of need for central\n access. Can start therapeutic heparin vs Lovenox with bridge to\n coumadin.\n -Can consider rescanning for PE. High risk for PE given UE DVT.\n # Abd distention:\n -KUB unrevealing\n -High residuals\n - benefit from further imaging; if unstable consider ultrasound,\n however, if pt can tolerate it, a CT scan might be more helpful. Can\n also scan chest and pelvis.\n # Anemia: On admission to Medical Center, Hct was ~40, now down\n to 30 and then 25 w/o sign of active GI bleed or other source of blood\n loss. be related to fluid administration, phlebotomy, anemia of\n inflammation, active bleed still considered in differential.\n - trend Hct\n - guaiac stools\n - S/p failed attempts at line placement; watch for neck hematomas\n - INR elev at 1.5. ? may be related to poor nutrition as albumin is\n 2.3\n # Spine fracture: neurologically intact distal to the lesion. prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - Need to talk to neurosurg to see if pt can tolerate a CT scan as well\n as the risks of anticoag for DVT\n - monitor distal neurologic function\n - cto brace x3 months unless supine in bed\n - consult neurosurgery for further recs\n # Hypernatremia: correcting with g tube free flush and D5W\n -Holding on g tube feeds at present due to high residuals\n -Replete lytes as necessary\n ICU Care\n Nutrition: tube feed with free water\n Glycemic Control: Regular insulin sliding scale\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Communication: Family meeting held , ICU consent signed, \n (brother) (boyfriend/POA) \n Code status: Full code\n Disposition: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 01:16 AM\n 20 Gauge - 01:36 AM\n 22 Gauge - 02:00 PM\n Arterial Line - 03:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2167-09-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 634263,
"text": "Alteration in Nutrition\n Assessment:\n Pt NPO, Pt w/ high residuals yesterday. Abdomen distended/obese/soft.\n BS hypoactive. Low albumin.\n Action:\n OGT to low wall suction. TF off.\n Response:\n Small amount of gastric fluid suctioned- approx 30cc-50cc.\n Plan:\n Plan for CT of Abdomen, cont NPO at this time.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n RUE + DVT\n Action:\n Cont on sq heparin\n Response:\n No change\n Plan:\n Consult neuro-surgery regarding anti-coagulation w/ T-spine fx, elevate\n RUE, no blood draws or blood pressures to RUE.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Temp max 100\n Action:\n Antibiotics given and dosage changed to vanco and aztreonam.\n Response:\n No further temp spike.\n Plan:\n Cont w/ antibiotics, f/u on cultures, tyelenol prn, vanco trough to be\n drawn prior to evening dose.\n Fracture, other\n Assessment:\n T-spine compression fx, Back brace at bedside when OOB.\n Action:\n Ortho tech consulted for placement of back brace. Cont w/ log roll\n precautions.\n Response:\n Pt denies c/o pain when asked.\n Plan:\n Cont w/ log roll precautions, back brace for OOB, CT scan, consult w/\n neurosurg.\n Anemia, other\n Assessment:\n HCT 24.1 from 28\n Action:\n Given 1 unit of PRBCs\n Response:\n HCT to be drawn.\n Plan:\n Cont to follow HCTs, guiac stools, monitor of s/s of bleeding.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS bronchial, deep sxn\nd for thick/tan secretions, copious clear\n secretions suctioned from mouth, PO2 68% on 70% FIO2 and 12 peep.\n Action:\n Vent changes made throughout shift.\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Pt hypotensive into low-mid 80s systolic, HR 70s-90s. Low uop- bladder\n pressure 18-20.\n Action:\n Vigeleo set up, given 1 unit of blood, bloused x 1, multi-lumen RIJ\n placed at bedside.\n Response:\n No response to blusing, SBP improved following blood transfusion, RIJ\n okay to use. CVP 18.\n Plan:\n Levophed to be started if needed, transfuse as needed.\n"
},
{
"category": "Nursing",
"chartdate": "2167-09-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 634264,
"text": "55-year-old woman with\n Respiratory failure\n Traumatic thoracic spinal fractures\n Probable VAP\n Upper extremity DVT\n Oliguria\n Anemia\n * Possible tracheobronchomalacia (reason for transfer\n Alteration in Nutrition\n Assessment:\n Pt NPO, Pt w/ high residuals yesterday. Abdomen distended/obese/soft.\n BS hypoactive. Low albumin.\n Action:\n OGT to low wall suction. TF off.\n Response:\n Small amount of gastric fluid suctioned- approx 30cc-50cc.\n Plan:\n Plan for CT of Abdomen, cont NPO at this time.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n RUE + DVT\n Action:\n Cont on sq heparin\n Response:\n No change\n Plan:\n Consult neuro-surgery regarding anti-coagulation w/ T-spine fx, elevate\n RUE, no blood draws or blood pressures to RUE.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Temp max 100\n Action:\n Antibiotics given and dosage changed to vanco and aztreonam.\n Response:\n No further temp spike.\n Plan:\n Cont w/ antibiotics, f/u on cultures, tyelenol prn, vanco trough to be\n drawn prior to evening dose.\n Fracture, other\n Assessment:\n T-spine compression fx, Back brace at bedside when OOB.\n Action:\n Ortho tech consulted for placement of back brace. Cont w/ log roll\n precautions.\n Response:\n Pt denies c/o pain when asked.\n Plan:\n Cont w/ log roll precautions, back brace for OOB, CT scan, consult w/\n neurosurg.\n Anemia, other\n Assessment:\n HCT 24.1 from 28\n Action:\n Given 1 unit of PRBCs\n Response:\n HCT to be drawn.\n Plan:\n Cont to follow HCTs, guiac stools, monitor of s/s of bleeding.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS bronchial, deep sxn\nd for thick/tan secretions, copious clear\n secretions suctioned from mouth, PO2 68% on 70% FIO2 and 12 peep.\n Action:\n Vent changes made throughout shift.\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Pt hypotensive into low-mid 80s systolic, HR 70s-90s. Low uop- bladder\n pressure 18-20.\n Action:\n Vigeleo set up, given 1 unit of blood, bloused x 1, multi-lumen RIJ\n placed at bedside.\n Response:\n No response to blusing, SBP improved following blood transfusion, RIJ\n okay to use. CVP 18.\n Plan:\n Levophed to be started if needed, transfuse as needed.\n"
},
{
"category": "Nursing",
"chartdate": "2167-09-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 634265,
"text": "55-year-old woman with\n Respiratory failure\n Traumatic thoracic spinal fractures\n Probable VAP\n Upper extremity DVT\n Oliguria\n Anemia\n * Possible tracheobronchomalacia (reason for transfer\n Alteration in Nutrition\n Assessment:\n Pt NPO, Pt w/ high residuals yesterday. Abdomen distended/obese/soft.\n BS hypoactive. Low albumin.\n Action:\n OGT to low wall suction. TF off.\n Response:\n Small amount of gastric fluid suctioned- approx 30cc-50cc.\n Plan:\n Plan for CT of Abdomen, cont NPO at this time.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n RUE + DVT\n Action:\n Cont on sq heparin\n Response:\n No change\n Plan:\n Consult neuro-surgery regarding anti-coagulation w/ T-spine fx, elevate\n RUE, no blood draws or blood pressures to RUE.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Temp max 100\n Action:\n Antibiotics given and dosage changed to vanco and aztreonam.\n Response:\n No further temp spike.\n Plan:\n Cont w/ antibiotics, f/u on cultures, tyelenol prn, vanco trough to be\n drawn prior to evening dose.\n Fracture, other\n Assessment:\n T-spine compression fx, Back brace at bedside when OOB.\n Action:\n Ortho tech consulted for placement of back brace. Cont w/ log roll\n precautions.\n Response:\n Pt denies c/o pain when asked.\n Plan:\n Cont w/ log roll precautions, back brace for OOB, CT scan, consult w/\n neurosurg.\n Anemia, other\n Assessment:\n HCT 24.1 from 28\n Action:\n Given 1 unit of PRBCs\n Response:\n HCT to be drawn.\n Plan:\n Cont to follow HCTs, guiac stools, monitor of s/s of bleeding.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS- bronchial throughout, deep sxn\nd for thick/tan secretions, copious\n clear oral secretions suctioned, PO2 68% on 70% FIO2 and 12 peep. ?\n PE/? VAP.\n Action:\n Vent changes made throughout shift.\n Response:\n Plan:\n Esophageal balloon placement to be performed, monitor ABGs, vent\n changes as needed.\n Hypotension (not Shock)\n Assessment:\n Pt hypotensive into low-mid 80s systolic, HR 70s-90s. Low uop-\n BUN/Creat negative. Bladder pressure 18-20.\n Action:\n Vigeleo set up, given 1 unit of blood, bloused x 1, multi-lumen RIJ\n placed at bedside.\n Response:\n No response to blusing, SBP improved following blood transfusion, RIJ\n okay to use. CVP 18.\n Plan:\n Levophed to be started if needed, transfuse as needed.\n"
},
{
"category": "Nursing",
"chartdate": "2167-09-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 634388,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n RLL consolidation, bilat effusions, R < L ; suct for thick yellowish\n secretions from ETT; copious thick secretions suct from mouth\n Action:\n Pt 2 down to 60%, Peep @ 23\n Response:\n Pt tolerating turns and current vent settings well\n Plan:\n Cont to ABGS, VS;\n Hypotension (not Shock)\n Assessment:\n SBP down in 80\ns, MAP 60\n Action:\n Levophed restarted @0130\n Response:\n BP improved 110-90\ns MAP 65\n Plan:\n Cont to BP, MAP goal >65 , Levo as needed\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt (+) DVT RUE\n Action:\n Pt started on IV Heparin @1700U/hr\n Response:\n Pt PTT@ 0030 62.7, no changes to infusion\n Plan:\n Cont to PTT, adjust heparin accordingly; cont with no BP/LAB draws\n to R arm\n Alteration in Nutrition\n Assessment:\n TF currently on hold high residuals, abd distended soft, hypoactive\n bowel sounds\n Action:\n Pt started on Naloxone x 3 doses, rectal tube in place for\n decompression; bowel regimen continued\n Response:\n Pt passing sm. Amt loose green stool with dose of Naxolone\n Plan:\n Re-evaluate for increase in Naloxone dose; ? restarting TF/advancing\n Fracture, other\n Assessment:\n Pt T5/T8 fracture s/p fall \n Action:\n Spine/ortho consult done\n Response:\n Pt off logroll precautions, tolerates position changes\n Plan:\n Activity as tolerated, needs to wear TorsoBrace when OOB or sitting up\n"
},
{
"category": "Nursing",
"chartdate": "2167-09-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 634389,
"text": "55 yr old women admitted from outside hospital. Patient fell down\n stairs at home per boyfriend pt with fracture and placed in torso\n brace at OSH, pt became hypoxic and was intubated (family requested a\n second opinion and pt was trans to ) Pt admitted for Resp failure,\n failure to wean, and ? tracheal bronchial malacia. Full code,\n Allergies: PCN, Tetracycline, Sulfta.\n Per boyfriend tonight he reported that for the last two months pt has\n been drinking 2 bottles of wine almost every night.\n And that this is an increase from what she previously did which was a\n couple of beers per night.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n RLL consolidation, bilat effusions, R < L ; suct for thick yellowish\n secretions from ETT; copious thick secretions suct from mouth\n Action:\n Pt 2 down to 60%, Peep @ 23\n Response:\n Pt tolerating turns and current vent settings well\n Plan:\n Cont to ABGS, VS;\n Hypotension (not Shock)\n Assessment:\n SBP down in 80\ns, MAP 60\n Action:\n Levophed restarted @0130\n Response:\n BP improved 110-90\ns MAP 65\n Plan:\n Cont to BP, MAP goal >65 , Levo as needed\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt (+) DVT RUE\n Action:\n Pt started on IV Heparin @1700U/hr\n Response:\n Pt PTT@ 0030 62.7, no changes to infusion\n Plan:\n Cont to PTT, adjust heparin accordingly; cont with no BP/LAB draws\n to R arm\n Alteration in Nutrition\n Assessment:\n TF currently on hold high residuals, abd distended soft, hypoactive\n bowel sounds\n Action:\n Pt started on Naloxone x 3 doses, rectal tube in place for\n decompression; bowel regimen continued\n Response:\n Pt passing sm. Amt loose green stool with dose of Naxolone\n Plan:\n Re-evaluate for increase in Naloxone dose; ? restarting TF/advancing\n Fracture, other\n Assessment:\n Pt T5/T8 fracture s/p fall \n Action:\n Spine/ortho consult done\n Response:\n Pt off logroll precautions, tolerates position changes\n Plan:\n Activity as tolerated, needs to wear TorsoBrace when OOB or sitting up\n"
},
{
"category": "Physician ",
"chartdate": "2167-09-23 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 634393,
"text": "Chief Complaint:\n 24 Hour Events:\n ESOPHOGEAL BALLOON - At 01:46 PM - went well, were able to\n increase PEEP to improve oxygenation\n - started naloxone to encourage bowel motility, with some success,\n rectal tube in place\n -started heparin gtt for RUE DVT\n -borderline hypotensive at times (low 90s), received boluses and norepi\n back on at 0.04\n -did well with 0/7 yesterday and overnight with prn fentanyl for\n pain and prn haldol for agitation (did not require haldol), back on 0/7\n this am\n -gave extra dose metoprolol 25 via OG\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 09:45 AM\n Metronidazole - 03:32 PM\n Vancomycin - 08:00 PM\n Aztreonam - 10:00 PM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Heparin Sodium - 1,700 units/hour\n Fentanyl - 100 mcg/hour\n Norepinephrine - 0.04 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38\nC (100.4\n Tcurrent: 37.3\nC (99.2\n HR: 73 (60 - 102) bpm\n BP: 90/46(61) {76/38(56) - 160/71(97)} mmHg\n RR: 23 (16 - 25) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101 kg (admission): 94.2 kg\n Height: 67 Inch\n CVP: 8 (8 - 15)mmHg\n Bladder pressure: 18 (18 - 21) mmHg\n Total In:\n 3,524 mL\n 234 mL\n PO:\n TF:\n 48 mL\n IVF:\n 3,236 mL\n 234 mL\n Blood products:\n Total out:\n 935 mL\n 215 mL\n Urine:\n 650 mL\n 215 mL\n NG:\n 285 mL\n Stool:\n Drains:\n Balance:\n 2,589 mL\n 19 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 0 (0 - 0) mL\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 23 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 42 cmH2O\n Plateau: 32 cmH2O\n Compliance: 44.4 cmH2O/mL\n SpO2: 100%\n ABG: 7.36/47/153//0\n Ve: 9.5 L/min\n PaO2 / FiO2: 255\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 376 K/uL\n 9.0 g/dL\n 120 mg/dL\n 0.6 mg/dL\n 24 mEq/L\n 3.7 mEq/L\n 4 mg/dL\n 108 mEq/L\n 141 mEq/L\n 28.1 %\n 8.4 K/uL\n [image002.jpg]\n 03:01 AM\n 03:13 AM\n 12:05 PM\n 06:08 PM\n 06:11 PM\n 07:53 PM\n 02:02 AM\n 03:59 AM\n 09:14 PM\n 01:04 AM\n WBC\n 6.4\n 8.4\n Hct\n 24.1\n 29.0\n 28.1\n Plt\n 319\n 376\n Cr\n 0.6\n 0.6\n TCO2\n 30\n 29\n 29\n 25\n 25\n 28\n 28\n Glucose\n 129\n 120\n Other labs: PT / PTT / INR:18.7/62.7/1.7, ALT / AST:24/16, Alk Phos / T\n Bili:117/0.7, Amylase / Lipase:, Differential-Neuts:80.8 %,\n Lymph:12.0 %, Mono:3.5 %, Eos:3.3 %, Lactic Acid:0.7 mmol/L,\n Albumin:2.4 g/dL, LDH:204 IU/L, Ca++:8.2 mg/dL, Mg++:2.2 mg/dL, PO4:3.1\n mg/dL\n Assessment and Plan\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture\n # Respiratory failure: initial etiology unclear, likely multifactorial\n now with significant pneumonia. Had one sputum that showed GNR.\n - Had a desat event yesterday. Responded positively to recruitment\n maneuvers.\n - Will attempt placement of an esophageal balloon; with knowledge of\n intrathoracic pressures, can consider going up on PEEP\n # Infectious process: Had been febrile, now resolved\n - be aspiration or be VAP. Sputum from grew rare GNR;\n awaiting speciation.\n - Continues on Vanc, aztreonam, levofloxicin. Vanc trough pending today\n - Also on flagyl for empiric coverage of c. diff\n - Per CT, unlikely to be abdominal process\n # Hypotension, requiring Levophed:\n - Hypovolemia is possibly a factor- responded to a transfusion; HCT had\n been dropping\n - Sepsis also a factor- on broad spectrum abs\n - Central line in place.\n # Oliguria:\n -BUN and Cr reassuring.\n # RUE DVT: Have held on starting treatment in light of need for central\n access. Can start therapeutic heparin vs Lovenox with bridge to\n coumadin.\n - No PE noted on CT scan.\n # Abd distention:\n - CT abd only showed appendiceal mucocele without inflammation, not\n concerning, most likely chronic\n - No BM in several days, continue bowel regimen, add fleets enema\n - Can test for c.diff when pt stool\ns. Continue flagyl empirically\n - Check amylase and lipase\n # Anemia:\n - Trend HCT\n - Gave 1 un pRBC with good results\n - Will guiac stools when she has a BM\n - INR rising, now 1.7, may be nutritional\n # Spine fracture: neurologically intact distal to the lesion. prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - Will have spine see pt today for recs regarding pt movement and\n anticoagulation\n # Hypernatremia, resolved: correcting with g tube free flush and D5W\n -Holding on g tube feeds at present due to high residuals\n -Replete lytes as necessary\n # Communication:\n - Brother has been with pt, although, live in boyfriend of 10 is\n her HCP. Boyfriend will hopefully visit pt today\n ICU Care\n Nutrition: tube feed with free water when able\n Glycemic Control: Regular insulin sliding scale\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Communication: ICU consent signed, (brother) \n (boyfriend/POA) \n Code status: Full code\n Disposition: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 01:36 AM\n Arterial Line - 03:00 AM\n Multi Lumen - 11:30 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2167-09-23 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 634394,
"text": "Chief Complaint:\n 24 Hour Events:\n ESOPHOGEAL BALLOON - At 01:46 PM - went well, were able to\n increase PEEP to improve oxygenation\n - started naloxone to encourage bowel motility, with some success,\n rectal tube in place\n -started heparin gtt for RUE DVT\n -borderline hypotensive at times (low 90s) with low urine output,\n received boluses and norepi back on at 0.04\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 09:45 AM\n Metronidazole - 03:32 PM\n Vancomycin - 08:00 PM\n Aztreonam - 10:00 PM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Heparin Sodium - 1,700 units/hour\n Fentanyl - 100 mcg/hour\n Norepinephrine - 0.04 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38\nC (100.4\n Tcurrent: 37.3\nC (99.2\n HR: 73 (60 - 102) bpm\n BP: 90/46(61) {76/38(56) - 160/71(97)} mmHg\n RR: 23 (16 - 25) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101 kg (admission): 94.2 kg\n Height: 67 Inch\n CVP: 8 (8 - 15)mmHg\n Bladder pressure: 18 (18 - 21) mmHg\n Total In:\n 3,524 mL\n 234 mL\n PO:\n TF:\n 48 mL\n IVF:\n 3,236 mL\n 234 mL\n Blood products:\n Total out:\n 935 mL\n 215 mL\n Urine:\n 650 mL\n 215 mL\n NG:\n 285 mL\n Stool:\n Drains:\n Balance:\n 2,589 mL\n 19 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 0 (0 - 0) mL\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 23 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 42 cmH2O\n Plateau: 32 cmH2O\n Compliance: 44.4 cmH2O/mL\n SpO2: 100%\n ABG: 7.36/47/153//0\n Ve: 9.5 L/min\n PaO2 / FiO2: 255\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 376 K/uL\n 9.0 g/dL\n 120 mg/dL\n 0.6 mg/dL\n 24 mEq/L\n 3.7 mEq/L\n 4 mg/dL\n 108 mEq/L\n 141 mEq/L\n 28.1 %\n 8.4 K/uL\n [image002.jpg]\n 03:01 AM\n 03:13 AM\n 12:05 PM\n 06:08 PM\n 06:11 PM\n 07:53 PM\n 02:02 AM\n 03:59 AM\n 09:14 PM\n 01:04 AM\n WBC\n 6.4\n 8.4\n Hct\n 24.1\n 29.0\n 28.1\n Plt\n 319\n 376\n Cr\n 0.6\n 0.6\n TCO2\n 30\n 29\n 29\n 25\n 25\n 28\n 28\n Glucose\n 129\n 120\n Other labs: PT / PTT / INR:18.7/62.7/1.7, ALT / AST:24/16, Alk Phos / T\n Bili:117/0.7, Amylase / Lipase:, Differential-Neuts:80.8 %,\n Lymph:12.0 %, Mono:3.5 %, Eos:3.3 %, Lactic Acid:0.7 mmol/L,\n Albumin:2.4 g/dL, LDH:204 IU/L, Ca++:8.2 mg/dL, Mg++:2.2 mg/dL, PO4:3.1\n mg/dL\n Assessment and Plan\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture\n # Respiratory failure: initial etiology unclear, likely multifactorial\n now with significant pneumonia. Had one sputum that showed GNR.\n - Had a desat event yesterday. Responded positively to recruitment\n maneuvers.\n - Will attempt placement of an esophageal balloon; with knowledge of\n intrathoracic pressures, can consider going up on PEEP\n # Infectious process: Had been febrile, now resolved\n - be aspiration or be VAP. Sputum from grew rare GNR;\n awaiting speciation.\n - Continues on Vanc, aztreonam, levofloxicin. Vanc trough pending today\n - Also on flagyl for empiric coverage of c. diff\n - Per CT, unlikely to be abdominal process\n # Hypotension, requiring Levophed:\n - Hypovolemia is possibly a factor- responded to a transfusion; HCT had\n been dropping\n - Sepsis also a factor- on broad spectrum abs\n - Central line in place.\n # Oliguria:\n -BUN and Cr reassuring.\n # RUE DVT: Have held on starting treatment in light of need for central\n access. Can start therapeutic heparin vs Lovenox with bridge to\n coumadin.\n - No PE noted on CT scan.\n # Abd distention:\n - CT abd only showed appendiceal mucocele without inflammation, not\n concerning, most likely chronic\n - No BM in several days, continue bowel regimen, add fleets enema\n - Can test for c.diff when pt stool\ns. Continue flagyl empirically\n - Check amylase and lipase\n # Anemia:\n - Trend HCT\n - Gave 1 un pRBC with good results\n - Will guiac stools when she has a BM\n - INR rising, now 1.7, may be nutritional\n # Spine fracture: neurologically intact distal to the lesion. prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - Will have spine see pt today for recs regarding pt movement and\n anticoagulation\n # Hypernatremia, resolved: correcting with g tube free flush and D5W\n -Holding on g tube feeds at present due to high residuals\n -Replete lytes as necessary\n # Communication:\n - Brother has been with pt, although, live in boyfriend of 10 is\n her HCP. Boyfriend will hopefully visit pt today\n ICU Care\n Nutrition: tube feed with free water when able\n Glycemic Control: Regular insulin sliding scale\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Communication: ICU consent signed, (brother) \n (boyfriend/POA) \n Code status: Full code\n Disposition: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 01:36 AM\n Arterial Line - 03:00 AM\n Multi Lumen - 11:30 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nutrition",
"chartdate": "2167-09-20 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 634175,
"text": "Subjective\n Intubated & versed.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 170 cm\n 94.2 kg\n 32.4\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 61.2 kg\n 126% based on EDW of 77.2kg\n 65.2kg\n 77.2kg ( adm WT at OSH)\n ?122\n Diagnosis: Tracheobroncheal malacia\n PMH : obesity, GERD, s/p TAH, s/p L THR, s/p appy, ETOH abuse.\n Food allergies and intolerances: none noted in record.\n Pertinent medications: fentanyl, midazolam, colace, heparin, zantac,\n RISS, flagyl.\n Labs:\n Value\n Date\n Glucose\n 126 mg/dL\n 08:57 AM\n Glucose Finger Stick\n 137\n 04:00 PM\n BUN\n 6 mg/dL\n 08:57 AM\n Creatinine\n 0.7 mg/dL\n 08:57 AM\n Sodium\n 147 mEq/L\n 08:57 AM\n Potassium\n 3.5 mEq/L\n 08:57 AM\n Chloride\n 108 mEq/L\n 08:57 AM\n TCO2\n 28 mEq/L\n 08:57 AM\n PO2 (arterial)\n 81. mm Hg\n 06:14 AM\n PCO2 (arterial)\n 53 mm Hg\n 06:14 AM\n pH (arterial)\n 7.39 units\n 06:14 AM\n pH (urine)\n 5.0 units\n 02:46 PM\n CO2 (Calc) arterial\n 33 mEq/L\n 06:14 AM\n Albumin\n 3.0 g/dL\n 01:00 AM\n Calcium non-ionized\n 8.6 mg/dL\n 01:00 AM\n Phosphorus\n 3.8 mg/dL\n 08:57 AM\n Magnesium\n 1.8 mg/dL\n 08:57 AM\n ALT\n 30 IU/L\n 01:00 AM\n Alkaline Phosphate\n 149 IU/L\n 01:00 AM\n AST\n 19 IU/L\n 01:00 AM\n Total Bilirubin\n 0.7 mg/dL\n 08:57 AM\n WBC\n 9.4 K/uL\n 08:57 AM\n Hgb\n 8.2 g/dL\n 08:57 AM\n Hematocrit\n 25.1 %\n 08:57 AM\n Current diet order / nutrition support: NPO. TF: FS Replete w/ Fiber at\n 60mL/hr with 150mL Q 4hrs via OGT.\n GI:\n Assessment of Nutritional Status\n Obese, At risk for malnutrition\n Pt at risk due to: Low protein stores\n Estimated Nutritional Needs based on Est Dry WT of 77.2kg\n Calories: 1300 - 1625 (BEE x or / 20 - 25 cal/kg)\n Protein: 78 - 98 (1.2 - 1.5 g/kg)\n Fluid: per team.\n Specifics:\n 55 YO Female hospitalized at OSH after a fall resulting in traumatic\n T5-8 fracture w/ retropulsion of fragments. Was intubated & was c/b\n difficulty weaning from vent, referred here for interventional pulm\n evaluation for airway stenting. Consulted for TF recs. Currently\n tolerating TF at 10mL/hr. Would recommend decrease current TF goal rate\n to 55mL/hr to feed at 20kcal/kg while intubated otherwise higher\n calories would make it difficult to wean or extubated. Noted documented\n as -3L water deficit upon admission & is being hydrated with IFV\ns but\n is still slightly hypernatremic. Suggest increasing free water boluses\n via OGT.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. Decrease TF goal rate to 55mL/hr of Replete with Fiber\n 2. Continue to advance by 10mL Q 4-6hrs to goal\n 3. check residuals Q 4hrs, hold x 1hr if >150mL\n 4. Adjust free water flushes per hydration\n 5. Monitor & replete lytes PRN\n"
},
{
"category": "Physician ",
"chartdate": "2167-09-22 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 634311,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n Neurosurg: ok to transport. Will decide on anticoagulation in AM\n Central line placed\n NGT to suction\n Bowel regimen\n Resperatory attempted to place esophageal ballon, unsuccessful\n Desaturation around 23:00 to low 80s on 400/22/15/0.9 following turn.\n Recruitment maneuver (PEEP to 30) done x2 with good effect, Sat came up\n to 100%. PEEP left at 17\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 10:00 AM\n Aztreonam - 02:00 PM\n Vancomycin - 12:00 AM\n Metronidazole - 12:00 AM\n Infusions:\n Norepinephrine - 0.02 mcg/Kg/min\n Fentanyl - 200 mcg/hour\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:00 AM\n Midazolam (Versed) - 02:20 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 37.6\nC (99.6\n HR: 73 (64 - 96) bpm\n BP: 119/48(69) {85/39(55) - 142/67(91)} mmHg\n RR: 22 (11 - 22) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 94.2 kg (admission): 94.2 kg\n Height: 67 Inch\n CVP: 20 (11 - 21)mmHg\n Bladder pressure: 14 (14 - 18) mmHg\n Total In:\n 3,482 mL\n 465 mL\n PO:\n TF:\n IVF:\n 2,845 mL\n 465 mL\n Blood products:\n 277 mL\n Total out:\n 580 mL\n 65 mL\n Urine:\n 580 mL\n 65 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,902 mL\n 400 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 500) mL\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 17 cmH2O\n FiO2: 80%\n PIP: 33 cmH2O\n Plateau: 30 cmH2O\n Compliance: 30.8 cmH2O/mL\n SpO2: 98%\n ABG: 7.38/41/86./24/0\n Ve: 9.1 L/min\n PaO2 / FiO2: 109\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 376 K/uL\n 9.0 g/dL\n 120 mg/dL\n 0.6 mg/dL\n 24 mEq/L\n 3.7 mEq/L\n 4 mg/dL\n 108 mEq/L\n 141 mEq/L\n 28.1 %\n 8.4 K/uL\n [image002.jpg]\n 08:03 PM\n 11:00 PM\n 03:01 AM\n 03:13 AM\n 12:05 PM\n 06:08 PM\n 06:11 PM\n 07:53 PM\n 02:02 AM\n 03:59 AM\n WBC\n 7.6\n 6.4\n 8.4\n Hct\n 24.1\n 24.1\n 29.0\n 28.1\n Plt\n \n Cr\n 0.6\n 0.6\n 0.6\n TCO2\n 33\n 30\n 29\n 29\n 25\n 25\n Glucose\n 127\n 129\n 120\n Other labs: PT / PTT / INR:18.7/25.4/1.7, ALT / AST:24/16, Alk Phos / T\n Bili:117/0.7, Differential-Neuts:80.8 %, Lymph:12.0 %, Mono:3.5 %,\n Eos:3.3 %, Lactic Acid:0.7 mmol/L, Albumin:2.4 g/dL, LDH:204 IU/L,\n Ca++:8.2 mg/dL, Mg++:2.2 mg/dL, PO4:3.1 mg/dL\n Fluid analysis / Other labs: sputum, stimm\n Imaging:\n Echo\n post recruitment CXR showed deep sulcus but no pnumothorax per rads.\n Assessment and Plan\n comm with fam, vanc dosing\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture\n # Respiratory failure: initial etiology unclear, likely multifactorial\n including bronchspasm, hypoventilation from narcotics, potential\n aspiration, infection. By report, had a neg evaluation for PE at OSH,\n however, unable to open disc to confirm. Concern for VAP.\n - Failed yesterday\ns NIF; score was -15\n - Increased FiO2 overnight. Had increased pCO2 which resolved with\n increasing RR\n - IP stopped by but will complete official consult today; suggested\n repeating CT scan\n - Need to contact Medical re previous CT scan. Can attempt to\n resend disc. Otherwise, will most likely benefit from repeat CT to\n look for acute pulm process such as PE or PNA.\n # Fever: Likely due to combination of infection and DVT. Cultures\n sent. Will treat with empiric antibiotics. Tylenol PRN for fever.\n - Known RUE DVT\n - Infectious etiologies include VAP, asp PNA, line infections. Removed\n PICC yesterday and cultured tip. Mini-BAL- gram stain neg. Sputum\n grew GPC in pairs and GPR. Flagyl, aztreonam, vancomycin, levofloxacin\n for coverage of gram positives, gram negatives, anaerobes, MRSA. Urine\n and blood cultures NGTD\n - f/u blood, urine, and sputum cultures.\n - Concern for abd cause; KUB unrevealing. High residuals. require\n further imaging\n # Transient hypotension: Has been somewhat fluid responsive; UOP \n ccs/hr. Diff dx includes hypovolemia, sepsis, cardiogenic.\n - Sepsis most likely given fever.\n - HCT decreasing; ? stable at 24-25\n - Unable to place central line despite multiple attempts. First tired\n left IJ RUE DVT. 2^nd attempt in left IJ. Can place femoral if pt\n requires more active repletion\n - Consider another attempt at a line.\n # Oliguria:\n -BUN and Cr as well as lactate reassuring.\n -Increased bladder pressures this am- 20. Further imaging may be\n helpful\n # RUE DVT: Have held on starting treatment in light of need for central\n access. Can start therapeutic heparin vs Lovenox with bridge to\n coumadin.\n -Can consider rescanning for PE. High risk for PE given UE DVT.\n # Abd distention:\n -KUB unrevealing\n -High residuals\n - benefit from further imaging; if unstable consider ultrasound,\n however, if pt can tolerate it, a CT scan might be more helpful. Can\n also scan chest and pelvis.\n # Anemia: On admission to Medical Center, Hct was ~40, now down\n to 30 and then 25 w/o sign of active GI bleed or other source of blood\n loss. be related to fluid administration, phlebotomy, anemia of\n inflammation, active bleed still considered in differential.\n - trend Hct\n - guaiac stools\n - S/p failed attempts at line placement; watch for neck hematomas\n - INR elev at 1.5. ? may be related to poor nutrition as albumin is\n 2.3\n # Spine fracture: neurologically intact distal to the lesion. prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - Need to talk to neurosurg to see if pt can tolerate a CT scan as well\n as the risks of anticoag for DVT\n - monitor distal neurologic function\n - cto brace x3 months unless supine in bed\n - consult neurosurgery for further recs\n # Hypernatremia: correcting with g tube free flush and D5W\n -Holding on g tube feeds at present due to high residuals\n -Replete lytes as necessary\n ICU Care\n Nutrition: tube feed with free water\n Glycemic Control: Regular insulin sliding scale\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Communication: Family meeting held , ICU consent signed, \n (brother) (boyfriend/POA) \n Code status: Full code\n Disposition: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 01:36 AM\n 22 Gauge - 02:00 PM\n Arterial Line - 03:00 AM\n Multi Lumen - 11:30 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2167-09-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 634477,
"text": "Events: Attempt to lighten sedation, stop Levophed gtt- MS \n stability labile from lethargic to restless in bed/crying w/\n intermittent BP 120\ns/ w/ and W/O stimulation. UOP cont 10-30cc/hr.\n Vigileo monitor on- SVV . Bladder pressure 14. TF restarted w/ goal\n slow inc as tolerated w/ recent high residuals. Sm amt bowel\n movement.\n Alteration in Nutrition\n Assessment:\n Minimal residuals\n Action:\n Restarting TF replete w/ fiber @ 10cc/hr w/ Q6hr 20cc flush\n Response:\n Tolerating, goal advance Q6hr as tolerated\n Plan:\n Cont TF, monitor residuals, inc Q6hrs as tolerated, monitor stool\n output for improving GI motility w/ PO Narcan\n Hypotension (not Shock)\n Assessment:\n BP labile- SBP 86-120, UOP down to 10cc/hr\n Action:\n Vigileo on- SVV , In AM attempt wean off Levo gtt\n Response:\n No fluid blousing, Levophed gtt started- titrated for MAP >65, UOP,\n Levo gtt @ .020mcg/kg/min\n Plan:\n Cont Vigilieo monitoring, CVP monitoring, UOP, Levophed gtt, fluid\n bolus if inc in SVV, in CVP\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Heparin gtt @ 1700units/hr, PTT 76\n Action:\n Heparin gtt therapeutic x2, cont @ 1700units/hr\n Response:\n No s/s bleeding, guiac neg gastric secretions, stool\n Plan:\n Cont Hep gtt as ordered w/I scale parameters, check PTT w/ AM labs,\n monitor s/s bleeding\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS clear bilat upper lobes, diminished bilat lower lobes, turning w/o\n desating, suctioning minimally for thin clear secretions, Sat 96-100%,\n w/ decres in sedation waking in afternoon and overbreathing vent 1-3\n bpm, afebrile\n Action:\n No vent changes, suctioned post coughing x1, turning as tolerated,\n sedation titrated- currently @ 100mcg/hr Fentanyl gtt, 2 mg/hr Versed\n gtt. 1x blousing w/ .5mg Versed and 50mcg Fentanyl for sig inc in\n agitation/breathing over vent/pulling @ lines, resp tesing w/\n esophageal balloon\n Response:\n Synchronous w/ vent, RN care/turning/mouth care w/ decreased agitation,\n Sat >96%, pt on appropriate PEEP\n Plan:\n Cont IV ABX, pulm toilet, esophageal balloon readings, monitor sat\n"
},
{
"category": "Physician ",
"chartdate": "2167-09-23 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 634478,
"text": "Chief Complaint: respiratory failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n ESOPHOGEAL BALLOON - At 01:46 PM\n Restarted levophed overnight\n Patient unable to provide history: Sedated\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Aztreonam - 06:09 AM\n Metronidazole - 08:00 AM\n Levofloxacin - 08:39 AM\n Infusions:\n Midazolam (Versed) - 1.5 mg/hour\n Fentanyl - 75 mcg/hour\n Norepinephrine - 0.02 mcg/Kg/min\n Other ICU medications:\n Other medications:\n vanc, aztreonam, flagyl (day ), CHG, SQI, nebs, naloxone enteral,\n heparin infusion\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38\nC (100.4\n Tcurrent: 37.6\nC (99.6\n HR: 75 (64 - 102) bpm\n BP: 96/49(65) {76/38(56) - 160/71(97)} mmHg\n RR: 22 (16 - 25) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101 kg (admission): 94.2 kg\n Height: 67 Inch\n CVP: 20 (8 - 339)mmHg\n Bladder pressure: 18 (18 - 21) mmHg\n Total In:\n 3,524 mL\n 848 mL\n PO:\n TF:\n 48 mL\n IVF:\n 3,236 mL\n 698 mL\n Blood products:\n Total out:\n 935 mL\n 325 mL\n Urine:\n 650 mL\n 325 mL\n NG:\n 285 mL\n Stool:\n Drains:\n Balance:\n 2,589 mL\n 523 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 0 (0 - 0) mL\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 23 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 37 cmH2O\n Plateau: 33 cmH2O\n Compliance: 40 cmH2O/mL\n SpO2: 99%\n ABG: 7.37/44/160/25/0\n Ve: 8.9 L/min\n PaO2 / FiO2: 320\n Physical Examination\n General Appearance: Overweight / Obese\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: coarse breath sounds\n Abdominal: Soft, Obese\n Extremities: Right: 1+, Left: 1+\n Skin: Warm\n Neurologic: Responds to: Unresponsive, Movement: No spontaneous\n movement, Tone: Normal\n Labs / Radiology\n 8.9 g/dL\n 358 K/uL\n 126 mg/dL\n 0.7 mg/dL\n 25 mEq/L\n 3.5 mEq/L\n 4 mg/dL\n 108 mEq/L\n 143 mEq/L\n 28.0 %\n 8.1 K/uL\n [image002.jpg]\n 12:05 PM\n 06:08 PM\n 06:11 PM\n 07:53 PM\n 02:02 AM\n 03:59 AM\n 09:14 PM\n 01:04 AM\n 05:54 AM\n 06:11 AM\n WBC\n 8.4\n 8.1\n Hct\n 29.0\n 28.1\n 28.0\n Plt\n 376\n 358\n Cr\n 0.6\n 0.7\n TCO2\n 29\n 29\n 25\n 25\n 28\n 28\n 26\n Glucose\n 120\n 126\n Other labs: PT / PTT / INR:22.2/76.0/2.1, ALT / AST:24/16, Alk Phos / T\n Bili:117/0.7, Amylase / Lipase:, Differential-Neuts:74.7 %,\n Lymph:17.6 %, Mono:3.8 %, Eos:3.4 %, Lactic Acid:0.7 mmol/L,\n Albumin:2.4 g/dL, LDH:204 IU/L, Ca++:8.2 mg/dL, Mg++:2.0 mg/dL, PO4:3.2\n mg/dL\n Assessment and Plan\n 55-year-old woman with\n Respiratory failure\n End-exp transpulmonary pressure: -2\n End-insp transpulmonary pressure: +5\n Esophageal pressures suggest that she is at safe pressures.\n Traumatic thoracic spinal fracture\n Eventual MRI. Too high-risk at present. Brace when out of\n bed.\n Probable VAP\n Discuss GNRs with lab\n Complete 8\n 15d course of present ABX pending cultures\n D/C vancomycin since no identified GPCs\n D/C Flagyl since no CT or toxin evidence of C diff\n Shock\n now back on levophed\n CVP is 20 mm Hg but Pes is ~25 cm H20\n Re-assess SVV with Vigileo and consider volume challenge\n Upper extremity DVT\n Therapeutic heparin\n Anemia\n Follow\n Possible tracheobronchomalacia (reason for transfer)\n Incidental peri-appendiceal finding (will need eventual\n follow-up)\n Although differential remains open, the most compelling course of\n events is probably that she required intubation at the outside hospital\n (?sedation ?restriction from obesity/brace ?other) and subsequently\n developed a GNR-related VAP. Her pattern of acute lung injury,\n combined with obesity, is resulting in basilar and\n posterior-predominant atelectasis/consolidation with a high proportion\n of shunt. Given her very high PEEP, will try to avoid bronchoscopy if\n possible.\n Other issues as per ICU team note.\n ICU Care\n Nutrition: resume tube feeds\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 01:36 AM\n Arterial Line - 03:00 AM\n Multi Lumen - 11:30 AM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Heparin gtt)\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 60 minutes\n Patient is critically ill\n ------ Protected Section ------\n CRITICAL CARE STAFF\n 7p\n Oxygenation has continued to improved throughout the day.\n Remains on levophed.\n Repeat baseline cortisol < 5.\n Had relative oliguria for several hours.\n Her baseline cortisol should be substantially higher than it is; she\n should be maximally stimulated given her degree of illness. I\n therefore think this represents meaningful cortisol deficiency. Since\n she is vasopressor-requiring, we will treat for adrenal insufficiency.\n We will wean FiO2 to 0.4. If tolerates, then wean PEEP.\n These maneuvers are likely to help with urine output, as well. If they\n do not, will increase levophed and see if higher blood pressures result\n in higher UOP.\n Critical Care Time: 30 minutes\n ------ Protected Section Addendum Entered By: , MD\n on: 19:13 ------\n"
},
{
"category": "Respiratory ",
"chartdate": "2167-09-20 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 634099,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: Outside hospital\n Tube Type\n ETT:\n Position: 19 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous non-invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Episodes of coughing with high pips, Bs clear, mdis and\n sedation given, subsides.\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Utilize ARDSnet protocol, Maintain PEEP at current level and reduce\n FiO2 as tolerated, Reduce PEEP as tolerated, Adjust Min. ventilation to\n control pH; Comments: Further workup of Tracheal malacia status.\n possible bronch\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Pending procedure / OR, Underlying illness not\n resolved\n"
},
{
"category": "Respiratory ",
"chartdate": "2167-09-20 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 634177,
"text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 2\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments: Pt had a MINI BAL @ 1500hrs \n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Bronchoscopy (1500hrs)\n Comments: MINI BAL spec sent to micro\n, RRT 16:44\n"
},
{
"category": "Nursing",
"chartdate": "2167-09-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 634180,
"text": "Obese woman s/p t spine injury tx from Med for failure to wean\n from mech ventilation and evaluation for stent for\n tracheobronchomalacia.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Pt cont w/ low grade fever.\n Action:\n Given tyelenol q6 h prn, pt pan cultured. PICC line and foley d/c\n (new foley placed). IV antibiotics started.\n Response:\n Fever slightly improved to 99.\n Plan:\n Cont w/ q 6 hr tyelenol prn, closely monitor temp and f/u w/ cultures.\n Fracture, other\n Assessment:\n Pt w/ T5-T8 compression fracture.\n Action:\n Pt on log-roll precautions, back brace at bedside- to be used when pt\n is OOB.\n Response:\n Pt denies pain when asked.\n Plan:\n Cont on log roll precautions, Neuro- consult ordered to clarify\n order for brace.\n Anemia, other\n Assessment:\n HCT 25 from 30.0. No active bleeding noted.\n Action:\n Cont to check HCT and s/s of bleeding.\n Response:\n No action taken.\n Plan:\n Type & Screen to be collected. Cont to monitor HCT, guiac all stools.\n Hypernatremia (high sodium)\n Assessment:\n NA level 150-> 147. No seizure activity.\n Action:\n Free H2O boluses q 4hrs were started, but currently on hold d/t high\n residuals. Pt on D5W for 1L .\n Response:\n NA level slightly improved.\n Plan:\n Cont w/ free-water boluses as tolerated, cont to monitor lytes, bolus\n w/ LR prn.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS rhonchorous throughout, diminished to bilateral bases, deep sxn\n thick tan/bloody secretions.\n Action:\n Given MDIs, cont to be orally intubated on A/C, mini-BAL performed by\n RT and sample sent to lab. Increased sedation for adequate\n ventilation. Arterial line placed to Lt wrist.\n Response:\n Cont to be orally intubated and sedated.\n Plan:\n Consult w/ IP for eval for stent, wean vent as tolerated\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n RUE edematous\n Action:\n U/S done, RUE elevated, Pt cont on sq heparin\n Response:\n US + for DVT to RUE\n Plan:\n No blood draws or NBP to RUE, elevate RUE, cont w/ heparin sq\n"
},
{
"category": "Nursing",
"chartdate": "2167-09-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 634181,
"text": "Obese woman s/p t spine injury tx from Med for failure to wean\n from mechanical ventilation and evaluation for stent for\n tracheobronchomalacia.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Pt cont w/ low grade fever.\n Action:\n Given tyelenol q6 h prn, pt pan cultured. PICC line and foley d/c\n (new foley placed). IV antibiotics started.\n Response:\n Fever slightly improved to 99.\n Plan:\n Cont w/ q 6 hr tyelenol prn, closely monitor temp and f/u w/ cultures.\n Fracture, other\n Assessment:\n Pt w/ T5-T8 compression fracture.\n Action:\n Pt on log-roll precautions, back brace at bedside- to be used when pt\n is OOB.\n Response:\n Pt denies pain when asked.\n Plan:\n Cont on log roll precautions, Neuro- consult ordered to clarify\n order for brace.\n Anemia, other\n Assessment:\n HCT 25 from 30.0. No active bleeding noted.\n Action:\n Cont to check HCT and s/s of bleeding.\n Response:\n No action taken.\n Plan:\n Type & Screen to be collected. Cont to monitor HCT, guiac all stools.\n Hypernatremia (high sodium)\n Assessment:\n NA level 150-> 147. No seizure activity.\n Action:\n Free H2O boluses q 4hrs were started, but currently on hold d/t high\n residuals. Pt on D5W for 1L .\n Response:\n NA level slightly improved.\n Plan:\n Cont w/ free-water boluses as tolerated, cont to monitor lytes, bolus\n w/ LR prn.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS rhonchorous throughout, diminished to bilateral bases, deep sxn\n thick tan/bloody secretions.\n Action:\n Given MDIs, cont to be orally intubated on A/C, mini-BAL performed by\n RT and sample sent to lab. Increased sedation for adequate\n ventilation. Arterial line placed to Lt wrist.\n Response:\n Cont to be orally intubated and sedated.\n Plan:\n Consult w/ IP for eval for stent, wean vent as tolerated\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n RUE edematous\n Action:\n U/S done, RUE elevated, Pt cont on sq heparin\n Response:\n US + for DVT to RUE\n Plan:\n No blood draws or NBP to RUE, elevate RUE, cont w/ heparin sq\n Hypotension (not Shock)\n Assessment:\n Pt hypotensive into mid 80s systolic, SR/ST, HR 80s-120s. Low UOP\n /h.\n Action:\n Given 500cc LR boluses x 3. Arterial line placed. EKG done-no change.\n Response:\n Minimal response to UOP. BP improved\n> 100s-130s systolic.\n Plan:\n Central line to be placed, cont to bolus as needed.\n"
},
{
"category": "Respiratory ",
"chartdate": "2167-09-24 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 634535,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 6\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt received intubated and vented on AC . 400x22 23 peep and\n 40%. peep was decreased 21 cmh20 and tolerated well.pt sp02 remains\n 98-99. BS reveals rhonchi to auscultation,but clears with suctioning.\n Sputum sample sent to lab d/t ^ temp. will continue to wean peep as\n tolerated. Close monitoring will continue\n"
},
{
"category": "Nursing",
"chartdate": "2167-09-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 634628,
"text": "Pt is a 55 yr old women admitted from OSH after she fell down the\n stairs (did not have LOC per boyfriend) and had a traumatic T-spine\n Fracture. Pt came to us with PNA from unknown etiology? VAP. Full\n code, Allergies: PCN, tetracycline, sulfa. PMH: ETOH, smoker, Gerd, Hip\n replacement. Pt afebrile during the night, was Pan cultured\n yesterday. Pt brother is her spokesperson. Pt boyfriend was in last\n night to see her, it is a 2 hr train ride from for him to get\n here. Pt boyfriend reported on night that for the last 2 months\n pt has been drinking 2 large bottles of wine almost every night and\n that this is an increase from what she used to drink.\n Bradycardia\n Assessment:\n HR 46-60\ns, HR decreases when pt is asleep. Stays in the 45-50 range\n when she is asleep. BP stable with low HR.\n Action:\n Monitor HR, monitor SBP with low HR\n Response:\n No action taken because vital sign have been stable.\n Plan:\n Cont to monitor\n Alteration in Nutrition\n Assessment:\n Replete with fiber Goal rate 60ml/hr. distended firm belly but pt is\n stooling now. Hypoactive bowel sounds.\n Action:\n Increased rate to 50ml/hr. cont to watch TF residuals. Pt did have past\n problems with high residuals.\n Response:\n Residuals 10ml.\n Plan:\n Cont to advance TF as tolerated. Cont stool softners/monitor for high\n residuals.\n Deep Venous Thrombosis (DVT), Upper extremity,\n Assessment:\n RUE DVT, Pt on heparin gtt at 1700 units/hr. No blood draws or BP on\n RUE.\n Action:\n PTT has been at therapeutic dose.\n Response:\n Repeat PTT in AM\n Plan:\n If PTT cont to be therapeutic cont to check PTT Q 24 hr., if not make\n changes per protocol.\n Fracture, other\n Assessment:\n Ortho reported that pt has T8 fracture. Pt does move all extremities,\n needs to wear back brace when out of bed. Brace is in the room, pt no\n longer on log roll precautions. Hard to tell if pt is in pain from\n fracture but she is on fentanyl and versed gtts.\n Action:\n Per ortho pt will need MRI of the spine and CT scan of the C and L\n portions of the spine to check for any other spinal injury. Ortho\n states we can do this when pt is more stable.\n Response:\n Plan:\n Will do MRI and CT at a later date.\n Hypotension (not Shock)\n Assessment:\n SBP ranges 80-100\ns with MAPs 55-70 Goal MAP >60. levophed off for\n almost 24hr. pt did get total of 3 liters in fluid boluses over the\n last 24 hr. CVP 12-14 but pt on 21 of peep. A-line very positional\n and was just re-sited yesterday. Pt was on vigileo monitor but D/C\n during the day because A-line tracing is so positional that the\n accuracy of this monitoring is questionable.\n Action:\n Gave 500ml fluid bolus for MAP of 55. and low urine output 10-20ml/hr.\n Response:\n Urine output increased, and MAP/BP increased\n Plan:\n Cont to monitor BP and MAPs and urine output.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Suctioning clear/white thick secretions in-line, copious amounts of\n clear secretions suctioned orally. Cough intact. Lung sounds clear\n diminished, no vent setting changes, Vent mode CMV: 40%/400/22/21,\n esophageal balloon in place.\n Action:\n VAP protocol: HOB 30 degrees, oral care. Suctioning, cont steroids.\n Chest x-ray done in AM. Cont antibiotics.\n Response:\n Cont to needs lots of suctioning.\n Plan:\n Wean vent as ordered by the Micu team. Cont to check ABG\ns when\n indicated.\n"
},
{
"category": "Physician ",
"chartdate": "2167-09-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 634629,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n New A-line placed (left), good tracing but positional\n Vanco restarted\n Atrial EKG->p-waves\n Multiple IVF boluses for MAPs < 65. Did not restart pressors\n Brother came, confirmed history\n Eye drops\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Metronidazole - 08:00 AM\n Levofloxacin - 10:00 AM\n Vancomycin - 08:09 PM\n Aztreonam - 10:00 PM\n Infusions:\n Midazolam (Versed) - 4 mg/hour\n Heparin Sodium - 1,700 units/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 04:29 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.7\nC (98.1\n HR: 56 (45 - 63) bpm\n BP: 103/54(72) {83/44(59) - 142/105(109)} mmHg\n RR: 22 (0 - 22) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101 kg (admission): 94.2 kg\n Height: 67 Inch\n CVP: 12 (11 - 14)mmHg\n Total In:\n 4,750 mL\n 868 mL\n PO:\n TF:\n 773 mL\n 223 mL\n IVF:\n 3,827 mL\n 645 mL\n Blood products:\n Total out:\n 2,365 mL\n 60 mL\n Urine:\n 2,325 mL\n 60 mL\n NG:\n 40 mL\n Stool:\n Drains:\n Balance:\n 2,385 mL\n 808 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 21 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 34 cmH2O\n Plateau: 29 cmH2O\n Compliance: 50 cmH2O/mL\n SpO2: 99%\n ABG: 7.46/38/96./23/2\n Ve: 8.6 L/min\n PaO2 / FiO2: 242\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 326 K/uL\n 8.9 g/dL\n 153 mg/dL\n 0.6 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n 6 mg/dL\n 113 mEq/L\n 141 mEq/L\n 28.6 %\n 8.9 K/uL\n [image002.jpg]\n 09:14 PM\n 01:04 AM\n 05:54 AM\n 06:11 AM\n 11:07 PM\n 03:51 AM\n 06:17 AM\n 07:00 AM\n 08:18 AM\n 04:18 PM\n WBC\n 8.1\n 8.9\n Hct\n 28.0\n 28.6\n Plt\n 358\n 326\n Cr\n 0.7\n 0.7\n 0.6\n TropT\n <0.01\n <0.01\n TCO2\n 28\n 28\n 26\n 26\n 21\n 28\n Glucose\n 126\n 151\n 153\n Other labs: PT / PTT / INR:24.3/68.6/2.4, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:24/16, Alk Phos / T Bili:117/0.7,\n Amylase / Lipase:, Differential-Neuts:82.5 %, Lymph:11.6 %,\n Mono:3.3 %, Eos:2.2 %, Lactic Acid:0.7 mmol/L, Albumin:2.4 g/dL,\n LDH:204 IU/L, Ca++:7.8 mg/dL, Mg++:2.1 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture with respiratory failure\n and difficulty weaning from vent.\n # Respiratory failure: Over the evening yesterday, were able to\n decrease FiO2 and PEEP. Clinical and imaging suggestive of ARDS.\n Initial precipitating factors were thought to be: sedation, hypovent\n obesity, orthotic brace. Now thought to have VAP.\n - Placed esophageal balloon on which will help guide PEEP settings.\n - Given small size of effusion and high PEEP (risk of pneumothorax),\n will not attempt to tap\n - Appreciate IP recs. Will consider tracheomalacia workup when more\n stable.\n - Approaching 2-week intubation point (intubated ); Trach?\n # VAP/ID: Re-spiked fever overnight. Stopped vanc yesterday, , as\n treating for GNR infection. Current GS shows GPC\n - Follow cultures\n - Restart Vanc.\n - Continue aztreonam, levofloxicin for 8 days pending speciation (at\n that time can increase to 15 days if necessary)\n - Also, stopped flagyl because had one neg c. diff toxin and CT did not\n show evidence of colitis\n - Will replace A-line today.\n # EKG changes: Sinus bradycardia. Very low voltages and no change in\n QRS morphology. P-waves are visible and prolonged PR interval is old.\n CK and troponins flat. Likely related to increased vagal tone possibly\n related to steroid replacement.\n - Will avoid excessive alpha-agonism\n - Continue to monitor\n - could consider atrial EKG\n .\n # Hypotension: now off levophed, with good urine output. Hypovolemia\n is possibly a factor- responded to a transfusion; HCT had been\n dropping. However, SVV with Vigileo was 7, making her CO less likely\n to respond to fluids. Held on giving any boluses overnight. Today CVP\n is low given PEEP. Sepsis also a consideration\n - continue on broad spectrum abs\n - replete fluids.\n - Restart pressors as needed. Consider dopamine over levophed given\n bradycardia.\n - Central line in place.\n # Urine output: Previously oliguric, now with high urine output.\n Concern for autodiuresis but BUN and Cr reassuring.\n -Continue to monitor\n # RUE DVT: Started on heparin gtt on .\n -Therapeutic in one day; may be related to poor nutritional status.\n Will continue to closely monitor\n # Adrenal Insufficency:\n -Random cortisol was approx 3 when it should have been maximally\n stimulated.\n -Started hydrocortisone and florinef. ? switch to methylpred\n # Anemia:\n - Trend HCT\n - Gave 1 un pRBC with good results\n - INR rising, now 2.0, may be nutritional\n # Spine fracture: neurologically intact distal to the lesion. prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - CT of C, L spine when stable. Currently, unlikely to change\n management and high risk for complications with transport.\n - Spine recommends MRI C/T/L/S if possible but likelihood for surgery\n is low. Brace for OOB. Ok for anticoag per note.\n # Hypernatremia, resolved: correcting with g tube free flush and D5W\n -Continue to follow\n # Communication:\n - Brother has been with pt, although, live in boyfriend of 10 is\n her HCP. Boyfriend will hopefully visit pt today\n ICU Care\n Nutrition: tube feed with free water when able\n Glycemic Control: Regular insulin sliding scale\n DVT: Theraputic Heparin gtt\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Communication: ICU consent signed, (brother) \n (boyfriend/POA) \n Code status: Full code\n Disposition: ICU\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 07:00 AM 50 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 11:30 AM\n Arterial Line - 04:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2167-09-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 634224,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n LS cont rhonchi throughout, dim bilat in base, occ. bronchospasms with\n care; abg showed resp. acidosis\n Action:\n Cont to suct for smll thick tan secretions, copious oral secretions\n suctioned, vent settings changed to 18/500/80/10\n Response:\n ABG improved, O2 Sats 97-98%\n Plan:\n f/f with IP ? tracheabronchial malacia, abgs, neb tx as needed\n Hypotension (not Shock)\n Assessment:\n Sbp down in high 90\ns, Aline damped\n Action:\n pt bolused x 1L LR, 500mg NS for low urinary output, L-aline d/cd\n Response:\n R-wrist Aline placed, SBP 110-120\n Plan:\n Cont . VS, I &O; treat as ordered\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n +DVT\n Action:\n Cont SC heparin\n Response:\n Plan:\n Cont SC heparin,\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n TMax 99.2\n Action:\n Cont with IV ABX, second UA sent\n Response:\n Remains low grade temp\n Plan:\n f/u with pending cultures; attempt repeat sputum culture, treat temp as\n ordered\n Fracture, other\n Assessment:\n T7 fracture to fall on \n Action:\n Cont in Reverse Trend., log roll precautions HOB 30\n Response:\n Remains stable\n Plan:\n Cont log roll precautions, f/u with PT, ? specialty mattress??\n Anemia, other\n Assessment:\n H/H 24.1/7.6, no active bleeding noted\n Action:\n Stool guiac negative\n Response:\n Plan:\n Cont to Hct, guiac stools\n"
},
{
"category": "Physician ",
"chartdate": "2167-09-21 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 634225,
"text": "Chief Complaint:\n 24 Hour Events:\n Removed PICC line because RUE was noted to be warm and erythematous;\n ultrasound revealed DVT. No definitive treatment was started given\n difficulty obtaining central venous access.\n Multiple attempts at central access; tried left and then right.\n Acute episode of oxygen desat during first central line attempt. Pt\n recovered, however, increased FiO2.\n Decreased UOP (10-30mL/hr) and hypotension overnight. However,\n lactate remains low.\n Placed art line x 2. NBP and ABP similar\n mini- BAL, sputum, urine, blood cultures pending. Yesterday, started\n on levofloxicin and aztreonam instead of cefepime. Switched due to\n question of PCN allergy\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 09:30 AM\n Metronidazole - 12:00 AM\n Vancomycin - 01:00 AM\n Aztreonam - 04:00 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 150 mcg/hour\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:00 AM\n Midazolam (Versed) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (100.9\nF at 10am on )\n Tcurrent: 37.3\nC (99.2\n HR: 76 (71 - 116) bpm\n BP: 116/51(70) {60/46(54) - 146/71(91)} mmHg\n RR: 18 (12 - 24) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 94.2 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 5,600 mL\n 1,811 mL\n PO:\n TF:\n 120 mL\n IVF:\n 4,700 mL\n 1,511 mL\n Blood products:\n Total out:\n 798 mL\n 110 mL\n Urine:\n 798 mL\n 110 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,802 mL\n 1,701 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 80%\n RSBI Deferred: PEEP > 10\n PIP: 36 cmH2O\n Plateau: 25 cmH2O\n SpO2: 93%\n ABG: 7.45/42/95./28/4\n Ve: 9.5 L/min\n PaO2 / FiO2: 120\n Physical Examination\n Gen: Appears uncomfortable on vent.\n HEENT: Anicteric. Pupils 3 mm non-reactive bilaterally.\n Resp: Symmetric expansion. Vesicular sounds throughout. Inspiratory\n and expiratory tracheal sounds (?related to ET tube).\n CV: Cannot see jugular veins due to neck size. RRR. Normal s1 and\n s2. No M/G/R.\n Abd: Quiet. Distended. Non-tender.\n Ext: Edema in RUE, especially right hand. Mildly increased warmth of\n RUE compared with LUE.\n Peripheral vascular: Radial pulses 2+ bilaterally.\n Neuro: Pupils as above. Moving all 4 extremities.\n Labs / Radiology\n 319 K/uL\n 7.6 g/dL\n 129 mg/dL\n 0.6 mg/dL\n 28 mEq/L\n 4.3 mEq/L\n 6 mg/dL\n 109 mEq/L\n 144 mEq/L\n 24.1 %\n 6.4 K/uL\n [image002.jpg]\n 11:54 PM\n 01:00 AM\n 06:14 AM\n 08:56 AM\n 08:57 AM\n 05:01 PM\n 08:03 PM\n 11:00 PM\n 03:01 AM\n 03:13 AM\n WBC\n 9.7\n 9.4\n 7.6\n 6.4\n Hct\n 30.7\n 25.1\n 24.1\n 24.1\n Plt\n 333\n 281\n 306\n 319\n Cr\n 0.6\n 0.6\n 0.7\n 0.6\n 0.6\n TCO2\n 32\n 33\n 35\n 33\n 30\n Glucose\n 103\n 126\n 126\n 127\n 129\n Other labs: PT / PTT / INR:16.9/26.3/1.5, ALT / AST:27/18, Alk Phos / T\n Bili:113/0.7, Differential-Neuts:76.9 %, Lymph:17.3 %, Mono:3.0 %,\n Eos:2.5 %, Lactic Acid:0.7 mmol/L, Albumin:2.3 g/dL, LDH:154 IU/L,\n Ca++:8.2 mg/dL, Mg++:2.6 mg/dL, PO4:3.1 mg/dL\n RUE ultrasound:\n - Non-occlusive right axillary deep vein thrombus\n - Non-occlusive right basilic superficial thrombosis.\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture\n # Respiratory failure: initial etiology unclear, likely multifactorial\n including bronchspasm, hypoventilation from narcotics, potential\n aspiration, infection. By report, had a neg evaluation for PE at OSH,\n however, unable to open disc to confirm. Concern for VAP.\n - Failed yesterday\ns NIF; score was -15\n - Increased FiO2 overnight. Had increased pCO2 which resolved with\n increasing RR\n - IP stopped by but will complete official consult today; suggested\n repeating CT scan\n - Need to contact Medical re previous CT scan. Can attempt to\n resend disc. Otherwise, will most likely benefit from repeat CT to\n look for acute pulm process such as PE or PNA.\n # Fever: Likely due to combination of infection and DVT. Cultures\n sent. Will treat with empiric antibiotics. Tylenol PRN for fever.\n - Known RUE DVT\n - Infectious etiologies include VAP, asp PNA, line infections. Removed\n PICC yesterday and cultured tip. Mini-BAL- gram stain neg. Sputum\n grew GPC in pairs and GPR. Flagyl, aztreonam, vancomycin, levofloxacin\n for coverage of gram positives, gram negatives, anaerobes, MRSA. Urine\n and blood cultures NGTD\n - f/u blood, urine, and sputum cultures.\n - Concern for abd cause; KUB unrevealing. High residuals. require\n further imaging\n # Transient hypotension: Has been somewhat fluid responsive; UOP \n ccs/hr. Diff dx includes hypovolemia, sepsis, cardiogenic.\n - Sepsis most likely given fever.\n - HCT decreasing; ? stable at 24-25\n - Unable to place central line despite multiple attempts. First tired\n left IJ RUE DVT. 2^nd attempt in left IJ. Can place femoral if pt\n requires more active repletion\n # RUE DVT: Have held on starting treatment in light of need for central\n access. Can start therapeutic heparin vs Lovenox with bridge to\n coumadin.\n # Abd distention:\n -KUB unrevealing\n -High residuals\n - benefit from further imaging; if unstable consider ultrasound,\n however, if pt can tolerate it, a CT scan might be more helpful. Can\n also scan chest and pelvis.\n # Anemia: On admission to Medical Center, Hct was ~40, now down\n to 30 and then 25 w/o sign of active GI bleed or other source of blood\n loss. be related to fluid administration, phlebotomy, anemia of\n inflammation, active bleed still considered in differential.\n - trend Hct\n - guaiac stools\n - S/p failed attempts at line placement; watch for neck hematomas\n # Spine fracture: neurologically intact distal to the lesion. prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - monitor distal neurologic function\n - cto brace x3 months unless supine in bed\n - consult neurosurgery for further recs\n # Hypernatremia: correcting with g tube free flush and D5W\n -Holding on g tube feeds at present due to high residuals\n -Replete lytes as necessary\n ICU Care\n Nutrition: tube feed with free water\n Glycemic Control: Regular insulin sliding scale\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Communication: Family meeting held , ICU consent signed, \n (brother) (boyfriend/POA) \n Code status: Full code\n Disposition: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 01:16 AM\n 20 Gauge - 01:36 AM\n 22 Gauge - 02:00 PM\n Arterial Line - 03:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2167-09-21 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 634226,
"text": "Chief Complaint:\n 24 Hour Events:\n Removed PICC line because RUE was noted to be warm and erythematous;\n ultrasound revealed DVT. No definitive treatment was started given\n difficulty obtaining central venous access.\n Multiple attempts at central access; tried left and then right.\n Acute episode of oxygen desat during first central line attempt. Pt\n recovered, however, increased FiO2.\n Decreased UOP (10-30mL/hr) and hypotension overnight. However,\n lactate remains low.\n Placed art line x 2. NBP and ABP similar\n mini- BAL, sputum, urine, blood cultures pending. Yesterday, started\n on levofloxicin and aztreonam instead of cefepime. Switched due to\n question of PCN allergy\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 09:30 AM\n Metronidazole - 12:00 AM\n Vancomycin - 01:00 AM\n Aztreonam - 04:00 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 150 mcg/hour\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:00 AM\n Midazolam (Versed) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (100.9\nF at 10am on )\n Tcurrent: 37.3\nC (99.2\n HR: 76 (71 - 116) bpm\n BP: 116/51(70) {60/46(54) - 146/71(91)} mmHg\n RR: 18 (12 - 24) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 94.2 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 5,600 mL\n 1,811 mL\n PO:\n TF:\n 120 mL\n IVF:\n 4,700 mL\n 1,511 mL\n Blood products:\n Total out:\n 798 mL\n 110 mL\n Urine:\n 798 mL\n 110 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,802 mL\n 1,701 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 80%\n RSBI Deferred: PEEP > 10\n PIP: 36 cmH2O\n Plateau: 25 cmH2O\n SpO2: 93%\n ABG: 7.45/42/95./28/4\n Ve: 9.5 L/min\n PaO2 / FiO2: 120\n Physical Examination\n Gen: Appears uncomfortable on vent.\n HEENT: Anicteric. Pupils 3 mm non-reactive bilaterally.\n Resp: Symmetric expansion. Vesicular sounds throughout. Inspiratory\n and expiratory tracheal sounds (?related to ET tube).\n CV: Cannot see jugular veins due to neck size. RRR. Normal s1 and\n s2. No M/G/R.\n Abd: Quiet. Distended. Non-tender.\n Ext: Edema in RUE, especially right hand. Mildly increased warmth of\n RUE compared with LUE.\n Peripheral vascular: Radial pulses 2+ bilaterally.\n Neuro: Pupils as above. Moving all 4 extremities.\n Labs / Radiology\n 319 K/uL\n 7.6 g/dL\n 129 mg/dL\n 0.6 mg/dL\n 28 mEq/L\n 4.3 mEq/L\n 6 mg/dL\n 109 mEq/L\n 144 mEq/L\n 24.1 %\n 6.4 K/uL\n [image002.jpg]\n 11:54 PM\n 01:00 AM\n 06:14 AM\n 08:56 AM\n 08:57 AM\n 05:01 PM\n 08:03 PM\n 11:00 PM\n 03:01 AM\n 03:13 AM\n WBC\n 9.7\n 9.4\n 7.6\n 6.4\n Hct\n 30.7\n 25.1\n 24.1\n 24.1\n Plt\n 333\n 281\n 306\n 319\n Cr\n 0.6\n 0.6\n 0.7\n 0.6\n 0.6\n TCO2\n 32\n 33\n 35\n 33\n 30\n Glucose\n 103\n 126\n 126\n 127\n 129\n Other labs: PT / PTT / INR:16.9/26.3/1.5, ALT / AST:27/18, Alk Phos / T\n Bili:113/0.7, Differential-Neuts:76.9 %, Lymph:17.3 %, Mono:3.0 %,\n Eos:2.5 %, Lactic Acid:0.7 mmol/L, Albumin:2.3 g/dL, LDH:154 IU/L,\n Ca++:8.2 mg/dL, Mg++:2.6 mg/dL, PO4:3.1 mg/dL\n RUE ultrasound:\n - Non-occlusive right axillary deep vein thrombus\n - Non-occlusive right basilic superficial thrombosis.\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture\n # Respiratory failure: initial etiology unclear, likely multifactorial\n including bronchspasm, hypoventilation from narcotics, potential\n aspiration, infection. By report, had a neg evaluation for PE at OSH,\n however, unable to open disc to confirm. Concern for VAP.\n - Failed yesterday\ns NIF; score was -15\n - Increased FiO2 overnight. Had increased pCO2 which resolved with\n increasing RR\n - IP stopped by but will complete official consult today; suggested\n repeating CT scan\n - Need to contact Medical re previous CT scan. Can attempt to\n resend disc. Otherwise, will most likely benefit from repeat CT to\n look for acute pulm process such as PE or PNA.\n # Fever: Likely due to combination of infection and DVT. Cultures\n sent. Will treat with empiric antibiotics. Tylenol PRN for fever.\n - Known RUE DVT\n - Infectious etiologies include VAP, asp PNA, line infections. Removed\n PICC yesterday and cultured tip. Mini-BAL- gram stain neg. Sputum\n grew GPC in pairs and GPR. Flagyl, aztreonam, vancomycin, levofloxacin\n for coverage of gram positives, gram negatives, anaerobes, MRSA. Urine\n and blood cultures NGTD\n - f/u blood, urine, and sputum cultures.\n - Concern for abd cause; KUB unrevealing. High residuals. require\n further imaging\n # Transient hypotension: Has been somewhat fluid responsive; UOP \n ccs/hr. Diff dx includes hypovolemia, sepsis, cardiogenic.\n - Sepsis most likely given fever.\n - HCT decreasing; ? stable at 24-25\n - Unable to place central line despite multiple attempts. First tired\n left IJ RUE DVT. 2^nd attempt in left IJ. Can place femoral if pt\n requires more active repletion\n # RUE DVT: Have held on starting treatment in light of need for central\n access. Can start therapeutic heparin vs Lovenox with bridge to\n coumadin.\n # Abd distention:\n -KUB unrevealing\n -High residuals\n - benefit from further imaging; if unstable consider ultrasound,\n however, if pt can tolerate it, a CT scan might be more helpful. Can\n also scan chest and pelvis.\n # Anemia: On admission to Medical Center, Hct was ~40, now down\n to 30 and then 25 w/o sign of active GI bleed or other source of blood\n loss. be related to fluid administration, phlebotomy, anemia of\n inflammation, active bleed still considered in differential.\n - trend Hct\n - guaiac stools\n - S/p failed attempts at line placement; watch for neck hematomas\n # Spine fracture: neurologically intact distal to the lesion. prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - monitor distal neurologic function\n - cto brace x3 months unless supine in bed\n - consult neurosurgery for further recs\n # Hypernatremia: correcting with g tube free flush and D5W\n -Holding on g tube feeds at present due to high residuals\n -Replete lytes as necessary\n ICU Care\n Nutrition: tube feed with free water\n Glycemic Control: Regular insulin sliding scale\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Communication: Family meeting held , ICU consent signed, \n (brother) (boyfriend/POA) \n Code status: Full code\n Disposition: ICU\n 55 year old woman with hx of obesity presented to Medical Center\n on after falling down stairs while at home. She suffered a\n traumatic T5-8 fracture with retropulsion of fragments. Per medical\n records and discussion with her brother, she was awake for the fall (no\n LOC) and the fall was triggered by unsteady gait, potentially\n influenced by alcohol. Her fracture was managed concervatively. She\n was placed in a torso brace but her course was complicated by\n respiratory failure requiring intubation. At that time a CT was\n negative for PE but showed bilateral bibasilar consolidations vs\n atelectasis. At that time an ABG was 7.20/89/57 (unknown FIO2 but\n likely >6L facemask). She was intubated on at 08:40. The\n respiratory failure was thought likely to be related to pain med\n induced hypoventilation, bronchospasm, or restricted breathing duet to\n the back brace. The hospital course was complicated by\n difficulty weaning form the ventilator. Her periodic agitation was\n managed with seroquel. Prior to transfer her vent settings were: SIMV\n 12x600 FIO2 0.45.\n The neurosurgery service evaluated her and recommended concervative\n management of her fracture including a back brace and outpatient\n neurosurgery followup. The CT chest showed notable narrowing of her\n central airways and the patient was referred for Interventional\n Pulmonary evaluation for airway stenting.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 01:16 AM\n 20 Gauge - 01:36 AM\n 22 Gauge - 02:00 PM\n Arterial Line - 03:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2167-09-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 634231,
"text": "55yo admitted from OSH. Pt s/p fall , sustained T5-T8\n fracture. Pt transf to failure to wean from vent. ? stent for\n tracheobronchialmalacia.\n Events: Pt had 2 attempts at Central line placement; unsuccessful at\n this point; team will attempt for femoral line placement this am.\n R-wrist Aline placed this am. Pt had KUB abdomen appears more\n distended and firm, ? possible ABD CT today.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS cont rhonchi throughout, dim bilat in base, occ. bronchospasms with\n care; abg showed resp. acidosis\n Action:\n Cont to suct for smll thick tan secretions, copious oral secretions\n suctioned, vent settings changed to 18/500/80/10\n Response:\n ABG improved, PC02 42 ; O2 Sats 95-97%\n Plan:\n f/u with IP ? tracheabronchial malacia, abgs, neb tx as needed\n Hypotension (not Shock)\n Assessment:\n Sbp down in high 90\ns, Aline damped, cont wit low UO 15-30cc/hr\n Action:\n pt bolused x 1L LR, 500mg NS for low urinary output, L-aline d/cd\n Response:\n R-radial Aline placed, SBP 110-120\n Plan:\n Cont . VS, I &O; treat as ordered\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n +DVT\n Action:\n Cont SC heparin, no BP\ns or Lab draws to R arm\n Response:\n Cont to elevate RUE\n Plan:\n Cont SC heparin,\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n TMax 99.2\n Action:\n Cont with IV ABX, second UA sent\n Response:\n Remains low grade temp\n Plan:\n f/u with pending cultures; attempt repeat sputum culture, treat temp as\n ordered\n Fracture, other\n Assessment:\n T5-T8 fracture to fall on \n Action:\n Cont in Reverse Trend., log roll precautions HOB 30\n Response:\n No s/sx pain noted\n Plan:\n Cont log roll precautions, f/u with PT, ? specialty mattress??\n Anemia, other\n Assessment:\n H/H 24.1/7.6, no active bleeding noted\n Action:\n Stool guiac negative\n Response:\n No action taken\n Plan:\n Cont to Hct, guiac stools\n"
},
{
"category": "Physician ",
"chartdate": "2167-09-21 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 634244,
"text": "Chief Complaint: respiratory failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n URINE CULTURE - At 08:09 AM\n EKG - At 09:00 AM\n PICC LINE - STOP 10:30 AM\n BLOOD CULTURED - At 10:30 AM\n ULTRASOUND - At 01:00 PM\n U/S of RUE\n URINE CULTURE - At 03:00 PM\n UA/UC collected after new foley inserted.\n BAL FLUID CULTURE - At 03:00 PM\n mini-BAL\n ARTERIAL LINE - START 04:45 PM\n ARTERIAL LINE - STOP 02:03 AM\n ARTERIAL LINE - START 03:00 AM\n Multiple attempts at central access were unsuccessful due to\n malposition and difficulty threading wire.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 09:30 AM\n Vancomycin - 01:00 AM\n Aztreonam - 04:00 AM\n Metronidazole - 08:50 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 150 mcg/hour\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:00 AM\n Midazolam (Versed) - 09:32 AM\n Other medications:\n colace, CHG, SQI, H2B, SQH, MDIs, Flagyl, vanco, levo, aztreonam,\n versed, fentanyl\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (100.9\n Tcurrent: 37.9\nC (100.3\n HR: 72 (70 - 116) bpm\n BP: 100/48(60) {89/47(60) - 139/75(79)} mmHg\n RR: 18 (12 - 24) insp/min\n SpO2: 89%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 94.2 kg (admission): 94.2 kg\n Height: 67 Inch\n Bladder pressure: 18 (18 - 18) mmHg\n Total In:\n 5,600 mL\n 2,088 mL\n PO:\n TF:\n 120 mL\n IVF:\n 4,700 mL\n 1,728 mL\n Blood products:\n Total out:\n 798 mL\n 205 mL\n Urine:\n 798 mL\n 205 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,802 mL\n 1,883 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 80%\n RSBI Deferred: PEEP > 10\n PIP: 37 cmH2O\n Plateau: 25 cmH2O\n SpO2: 89%\n ABG: 7.45/42/95./28/4\n Ve: 9.1 L/min\n PaO2 / FiO2: 96\n Physical Examination\n Sedated. Breath sounds are coarse. Heart sounds are distant. Abdomen\n is protuberant with quiet breath sounds. Some peripheral edema. She\n is not able to cooperate with peripheral strength or sensory exam.\n Labs / Radiology\n 7.6 g/dL\n 319 K/uL\n 129 mg/dL\n 0.6 mg/dL\n 28 mEq/L\n 4.3 mEq/L\n 6 mg/dL\n 109 mEq/L\n 144 mEq/L\n 24.1 %\n 6.4 K/uL\n [image002.jpg]\n 11:54 PM\n 01:00 AM\n 06:14 AM\n 08:56 AM\n 08:57 AM\n 05:01 PM\n 08:03 PM\n 11:00 PM\n 03:01 AM\n 03:13 AM\n WBC\n 9.7\n 9.4\n 7.6\n 6.4\n Hct\n 30.7\n 25.1\n 24.1\n 24.1\n Plt\n 333\n 281\n 306\n 319\n Cr\n 0.6\n 0.6\n 0.7\n 0.6\n 0.6\n TCO2\n 32\n 33\n 35\n 33\n 30\n Glucose\n 103\n 126\n 126\n 127\n 129\n Other labs: PT / PTT / INR:16.9/26.3/1.5, ALT / AST:27/18, Alk Phos / T\n Bili:113/0.7, Differential-Neuts:76.9 %, Lymph:17.3 %, Mono:3.0 %,\n Eos:2.5 %, Lactic Acid:0.7 mmol/L, Albumin:2.3 g/dL, LDH:154 IU/L,\n Ca++:8.2 mg/dL, Mg++:2.6 mg/dL, PO4:3.1 mg/dL\n Imaging: CXR with bilateral opacities; ETT a little high. No PTX.\n Assessment and Plan\n 55-year-old woman with\n Respiratory failure\n Traumatic thoracic spinal fractures\n Probable VAP\n Upper extremity DVT\n Oliguria\n Anemia\n Possible tracheobronchomalacia (reason for transfer)\n I am uncertain about both the risks of anticoagulation and the risks of\n moving to radiology (e.g. CT or IR) in the context of her spinal\n fractures. Therefore we will consult spine surgery urgently for help\n with these questions.\n Her respiratory failure is likely multifactorial, including obesity,\n probable VAP, probable PE, and possible tracheobronchomalacia. She may\n also have weakness, but she is sedated and cannot cooperate with exam\n at present. We will check an echo to examine her RV. We will\n ventilate per ARDSnet; she may warrant esophageal-balloon-guided\n therapy if she does not improve in the next few hours.\n Oliguria is concerning, though BUN/Creatinine are reassuring. NG to\n suction to relieve abdominal distention. We will check urine lytes and\n assess stroke volume variation with the Vigileo. We will consider\n volume challenge based on this result.\n For central access, if we are able to safely move her we will ask I.R.\n to help with central access.\n We will continue broad antibiotics while awaiting cultures.\n ICU Care\n Nutrition: NPO for now\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 01:16 AM\n 20 Gauge - 01:36 AM\n 22 Gauge - 02:00 PM\n Arterial Line - 03:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 45 min\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2167-09-22 00:00:00.000",
"description": "Resident / Attending Notes",
"row_id": 634383,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n -Neurosurg: ok to transport. Will decide on anticoagulation in AM\n -Central line placed\n -NGT to suction\n -Bowel regimen\n -Respiratory attempted to place esophageal ballon in order to measure\n intrathoracic pressure, unsuccessful\n -Desaturation around 23:00 to low 80s on 400/22/15/0.9 following turn.\n Recruitment maneuver (PEEP to 30) done x2 with good effect, Sat came up\n to 100%. PEEP left at 17\n -Transfused 1 un pRBC\n - Started levophed yesterday for hypotension\n - No BM\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 10:00 AM\n Aztreonam - 02:00 PM\n Vancomycin - 12:00 AM\n Metronidazole - 12:00 AM\n Infusions:\n Norepinephrine - 0.02 mcg/Kg/min\n Fentanyl - 200 mcg/hour\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:00 AM\n Midazolam (Versed) - 02:20 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 37.6\nC (99.6\n HR: 73 (64 - 96) bpm\n BP: 119/48(69) {85/39(55) - 142/67(91)} mmHg\n RR: 22 (11 - 22) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 94.2 kg (admission): 94.2 kg\n Height: 67 Inch\n CVP: 20 (11 - 21)mmHg\n Bladder pressure: 14 (14 - 18) mmHg\n Total In:\n 3,482 mL\n 465 mL\n PO:\n TF:\n IVF:\n 2,845 mL\n 465 mL\n Blood products:\n 277 mL\n Total out:\n 580 mL\n 65 mL\n Urine:\n 580 mL\n 65 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,902 mL\n 400 mL\n Respiratory support\n Ventilator mode: AC\n Vt (Set): 400 (400 - 500) mL\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 17 cmH2O\n FiO2: 80%\n PIP: 33 cmH2O\n Plateau: 30 cmH2O\n Compliance: 30.8 cmH2O/mL\n SpO2: 98%\n ABG: 7.38/41/86./24/0\n Ve: 9.1 L/min\n PaO2 / FiO2: 109\n Physical Examination\n Gen: Does not arouse to voice\n HEENT: Pupils 3 mm non-reactive bilaterally. Scleral edema bilat\n Resp: Symmetric expansion. Vesicular sounds throughout. Inspiratory\n and expiratory tracheal sounds (?related to ET tube).\n CV: RRR.\n Abd: Hypoactive bowel sounds. Distended.\n Ext: Edema in bilat UE.\n Peripheral vascular: Radial pulses 2+ bilaterally.\n Neuro: Moving all 4 extremities.\n Labs / Radiology\n 376 K/uL\n 9.0 g/dL\n 120 mg/dL\n 0.6 mg/dL\n 24 mEq/L\n 3.7 mEq/L\n 4 mg/dL\n 108 mEq/L\n 141 mEq/L\n 28.1 %\n 8.4 K/uL\n [image002.jpg]\n ALT 24 PT 18.7\n AST 16 PTT 25.4\n AP 117 INR 1.7\n Tbili 0.7\n Alb 2.4\n 08:03 PM\n 11:00 PM\n 03:01 AM\n 03:13 AM\n 12:05 PM\n 06:08 PM\n 06:11 PM\n 07:53 PM\n 02:02 AM\n 03:59 AM\n WBC\n 7.6\n 6.4\n 8.4\n Hct\n 24.1\n 24.1\n 29.0\n 28.1\n Plt\n \n Cr\n 0.6\n 0.6\n 0.6\n TCO2\n 33\n 30\n 29\n 29\n 25\n 25\n Glucose\n 127\n 129\n 120\n Differential-Neuts:80.8 %, Lymph:12.0 %, Mono:3.5 %, Eos:3.3 %\n Ca++:8.2 mg/dL, Mg++:2.2 mg/dL, PO4:3.1 mg/dL, ion Ca++ () 1.16\n Cortisol:\n : 2:15am 24.2 Midnight 2.7\n : 3am 4.5\n Micro: neg or NGTD if not mentioned\n : blood, \n : urine, sputum-OP flora\n : BAL, - coag neg staph, lactobacillus, cath tip, sputum- OP\n flora, rare GNR, blood\n U/a:\n Color\n Amber\n Appear\n Clear\n SpecGr\n 1.015\n pH\n 5.5\n Urobil\n 2\n Bili\n Mod\n Leuk\n Tr\n Bld\n Tr\n Nitr\n Pos\n Prot\n 100\n Glu\n Neg\n Ket\n 40\n RBC\n 0-2\n WBC\n 0-2\n Bact\n Few\n Yeast\n None\n Epi\n 0-2\n Imaging:\n Echo\n post recruitment CXR showed deep sulcus but no pnumothorax per rads.\n CT: Prelim Read\n Right lower lobe consolidation, and superimposed atelectasis/lower lobe\n collapse, and effusions. Acute T8 compression deformity, with no\n posterior\n retropulsion of fracture fragments. No associated hematoma.\n Assessment and Plan\n 55 year old woman with history of EtOH abuse presenting following\n mechanical fall and traumatic T spine fracture\n # Respiratory failure: initial etiology unclear, likely multifactorial\n now with significant pneumonia. Had one sputum that showed GNR.\n - Had a desat event yesterday. Responded positively to recruitment\n maneuvers.\n - Will attempt placement of an esophageal balloon; with knowledge of\n intrathoracic pressures, can consider going up on PEEP\n # Infectious process: Had been febrile, now resolved\n - be aspiration or be VAP. Sputum from grew rare GNR;\n awaiting speciation.\n - Continues on Vanc, aztreonam, levofloxicin. Vanc trough pending today\n - Also on flagyl for empiric coverage of c. diff\n - Per CT, unlikely to be abdominal process\n # Hypotension, requiring Levophed:\n - Hypovolemia is possibly a factor- responded to a transfusion; HCT had\n been dropping\n - Sepsis also a factor- on broad spectrum abs\n - Central line in place.\n # Oliguria:\n -BUN and Cr reassuring.\n # RUE DVT: Have held on starting treatment in light of need for central\n access. Can start therapeutic heparin vs Lovenox with bridge to\n coumadin.\n - No PE noted on CT scan.\n # Abd distention:\n - CT abd only showed appendiceal mucocele without inflammation, not\n concerning, most likely chronic\n - No BM in several days, continue bowel regimen, add fleets enema\n - Can test for c.diff when pt stool\ns. Continue flagyl empirically\n - Check amylase and lipase\n # Anemia:\n - Trend HCT\n - Gave 1 un pRBC with good results\n - Will guiac stools when she has a BM\n - INR rising, now 1.7, may be nutritional\n # Spine fracture: neurologically intact distal to the lesion. prior\n notes from MMC neurosurgeons indicated no surgical procedure needed and\n would continue with spine brace.\n - Will have spine see pt today for recs regarding pt movement and\n anticoagulation\n # Hypernatremia, resolved: correcting with g tube free flush and D5W\n -Holding on g tube feeds at present due to high residuals\n -Replete lytes as necessary\n # Communication:\n - Brother has been with pt, although, live in boyfriend of 10 is\n her HCP. Boyfriend will hopefully visit pt today\n ICU Care\n Nutrition: tube feed with free water when able\n Glycemic Control: Regular insulin sliding scale\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Communication: ICU consent signed, (brother) \n (boyfriend/POA) \n Code status: Full code\n Disposition: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 01:36 AM\n 22 Gauge - 02:00 PM\n Arterial Line - 03:00 AM\n Multi Lumen - 11:30 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n Critical Care Staff Addendum\n 6:15pm\n I saw and examined Ms. with the ICU team this morning and have\n seen Ms. several times throughout the day; Dr. \ns note\n reflects my input. I would add/emphasize that she continues to have\n severe hypoxemic respiratory failure. She has come off of her\n vasopressor.\n CT imaging did not show PE or an intrabdominal catastrophe. Spine\n imaging confirms a compression fracture but did not detect\n retropulsion. Her lungs shows basilar and posterior atelectasis that\n is consistent with one of the CT patterns of ARDS [see Intensive Care\n Med. ;26(7):857-69], probably exacerbated by\n obesity/extra-pulmonary chest wall issues. In addition, there are\n patchy, more-apical consolidations suggestive of pneumonia. There is\n also a peri-appendiceal finding that will eventually need follow-up to\n exclude malignancy.\n CVP and stroke-volume variation suggest she is adequately\n volume-replete.\n Esophageal manometry confirmed the clinical impression that she has\n substantial extrapulmonary contribution to her plateau pressures: at\n PEEP 20, her end-expiratory transpulmonary pressure is -3 cm H2O. Her\n end-inspiratory transpulmonary pressures are minimal on current Vt of\n 400.\n Sputum is growing GNR; speciation is pending.\n Assessment and Plan\n 55-year-old woman with\n Respiratory failure\n Traumatic thoracic spinal fracture\n Probable VAP\n Shock -- improved\n Upper extremity DVT\n Anemia\n Possible tracheobronchomalacia (reason for transfer)\n Incidental peri-appendiceal finding (will need eventual\n follow-up)\n Although differential remains open, the most compelling course of\n events is probably that she required intubation at the outside hospital\n (?sedation ?restriction from obesity/brace ?other) and subsequently\n developed a GNR-related VAP. Her pattern of acute lung injury,\n combined with obesity, is resulting in basilar and\n posterior-predominant atelectasis/consolidation with a high proportion\n of shunt.\n We will\n Continue broad antibiotics pending speciation of organisms\n Ventilate with approximately 6 cc/kg predicted body weight\n Use esophageal-manometry guideded PEEP, with goal of weaning\n FiO2 to below 60% in next 12-24 hours. If unable to do so, will\n increase PEEP to end-expiratory transpulmonary pressure of 0-+3 as long\n as hemodynamics and intra-abdominal pressures allow\n If OK with spine surgery, begin anticoagulation for her\n PICC-related DVT\n Prophylaxis: full-dose heparin, H2-blocker, HOB elevation,\n oral care, CHG, etc.\n Other issues as per ICU team note.\n I discussed Ms. \ns status with her brother at bedside, including\n review of images and discussion of her critical status. All questions\n answered.\n CC Time: 75 minutes\n ------ Protected Section Addendum Entered By: , MD\n on: 18:35 ------\n"
},
{
"category": "Nursing",
"chartdate": "2167-09-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 634617,
"text": "Synopsis per prior nursing note:\n 55 yr old woman admitted from OSH after she fell down the stairs and\n had traumatic T-spine fracture. Pt came to us with PNA from unknown\n etiology? VAP. Full code, Allergies: PCN, tetracycline, Sulfa. PMH:\n ETOH, smoker, Gerd, Hip replacement.\n Alteration in Nutrition\n Assessment:\n Tube feeds increased to 40ml/hr. Residuals ~10ml. Hypoactive BS.\n Continues to have brown, liquid stool.\n Action:\n Residuals and BS checked. Rate increased to 40ml/hr.\n Response:\n Residual continued at 10ml/hr, continued rate of 40cc/hr.\n Plan:\n Advance TF to goal as tolerated. Monitor BS.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n RUE DVT, pt on heparin gtt at 1700units/hr.\n Action:\n Ptt was therapeutic x3. Heparin gtt continued.\n Response:\n No change to drip made, therapeutic dose.\n Plan:\n Cont heparin gtt, check PTT w/ am labs and adjust heparin gtt per\n scale.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Suctioned moderate, thick white ET tube secretions and copious clear,\n oral secretions. LS rhonchi w/ dim bases. Esophageal balloon in\n place.\n Action:\n Continued to suction frequently, HOB >30, oral care. Continued\n steroids.\n Response:\n ABG WNL. Continued to need suctioning. O2 sats >98%.\n Plan:\n Monitor LS. Suction as needed. Wean vent as tolerated.\n Hypotension (not Shock)\n Assessment:\n BP 89-106/43-53. MAP 56-67. Goal MAP >60. Urine output>40cc/hr.\n Action:\n Levophed gtt weaned off. Given 2.5 L NS total in bolus\n for low BP. New\n A-line placed-positional.\n Response:\n MAPs continued to be ~60-65.\n Plan:\n Monitor BP. ?fluid bolus vs levophed gtt. ?need for new a-line.\n Bradycardia\n Assessment:\n SB, HR 45-63. HR increased w/ activity.\n Action:\n HR monitored.\n Response:\n No intervention done because BP cont to be stable and all other vital\n signs stable.\n Plan:\n Monitor HR. EKG if indicated.\n"
},
{
"category": "Nursing",
"chartdate": "2167-09-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 634229,
"text": "55yo admitted from OSH. Pt s/p fall , sustained T5-T8\n fracture. Pt transf to failure to wean from vent. ? stent for\n tracheobronchialmalacia.\n Events: Pt had 2 attempts at Central line placement; unsuccessful at\n this point; team will attempt for femoral line placement this am.\n R-wrist Aline placed this am. Pt had KUB abdomen appears more\n distended and firm, ? possible ABD CT today.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS cont rhonchi throughout, dim bilat in base, occ. bronchospasms with\n care; abg showed resp. acidosis\n Action:\n Cont to suct for smll thick tan secretions, copious oral secretions\n suctioned, vent settings changed to 18/500/80/10\n Response:\n ABG improved, PC02 42 ; O2 Sats 95-97%\n Plan:\n f/u with IP ? tracheabronchial malacia, abgs, neb tx as needed\n Hypotension (not Shock)\n Assessment:\n Sbp down in high 90\ns, Aline damped, cont wit low UO 15-30cc/hr\n Action:\n pt bolused x 1L LR, 500mg NS for low urinary output, L-aline d/cd\n Response:\n R-radial Aline placed, SBP 110-120\n Plan:\n Cont . VS, I &O; treat as ordered\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n +DVT\n Action:\n Cont SC heparin, no BP\ns or Lab draws to R arm\n Response:\n Cont to elevate RUE\n Plan:\n Cont SC heparin,\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n TMax 99.2\n Action:\n Cont with IV ABX, second UA sent\n Response:\n Remains low grade temp\n Plan:\n f/u with pending cultures; attempt repeat sputum culture, treat temp as\n ordered\n Fracture, other\n Assessment:\n T5-T8 fracture to fall on \n Action:\n Cont in Reverse Trend., log roll precautions HOB 30\n Response:\n No s/sx pain noted\n Plan:\n Cont log roll precautions, f/u with PT, ? specialty mattress??\n Anemia, other\n Assessment:\n H/H 24.1/7.6, no active bleeding noted\n Action:\n Stool guiac negative\n Response:\n No action taken\n Plan:\n Cont to Hct, guiac stools\n"
},
{
"category": "Nursing",
"chartdate": "2167-09-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 634295,
"text": "55 yr old women admitted from outside hospital. Patient fell down\n stairs at home per boyfriend pt with fracture and placed in torso\n brace at OSH, pt became hypoxic and was intubated (family requested a\n second opinion and pt was trans to ) Pt admitted for Resp failure,\n failure to wean, and ? trachial bronchial malacia. Full code,\n Allergies: PCN, Tetracycline, Sulfta.\n Per boyfriend tonight he reported that for the last two months pt has\n been drinking 2 bottles of wine almost every night.\n And that this is an increase from what she previously did which was a\n couple of beers per night.\n Alteration in Nutrition\n Assessment:\n Increase in residuals out of OG tube. Tube feeds have not been\n restarted. Bowel sounds hypoactive, per family abdomen is about 30%\n larger than normal, no BM since admission.\n Action:\n Senna and colace given. OG tube to low int. suction, was able to clamp\n tube for 2hr but residuals returned.\n Response:\n 100 ml yellow-pinkish fluid out OG tube\n Plan:\n Cont to check residuals, restart tube feeds as tolerated, ? if raglan\n would help. Increase bowel regimen if needed.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n DVT in RUE\n Action:\n No BP or blood draws in RUE. Neuro to see pt in AM to see if we\n can start heparin gtt (neuro to okay because of the spine\n fracture)\n Response:\n Plan:\n Wait for decision by Neuro and anticoagulate with heparin if\n possible.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Action:\n Response:\n Plan:\n Fracture, other\n Assessment:\n Action:\n Response:\n Plan:\n Anemia, other\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2167-09-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 634297,
"text": "55 yr old women admitted from outside hospital. Patient fell down\n stairs at home per boyfriend pt with fracture and placed in torso\n brace at OSH, pt became hypoxic and was intubated (family requested a\n second opinion and pt was trans to ) Pt admitted for Resp failure,\n failure to wean, and ? trachial bronchial malacia. Full code,\n Allergies: PCN, Tetracycline, Sulfta. Pt on log roll precautions for\n spine.\n Per boyfriend tonight he reported that for the last two months pt has\n been drinking 2 bottles of wine almost every night.\n And that this is an increase from what she previously did which was a\n couple of beers per night.\n Alteration in Nutrition\n Assessment:\n Increase in residuals out of OG tube. Tube feeds have not been\n restarted. Bowel sounds hypoactive, per family abdomen is about 30%\n larger than normal, no BM since admission.\n Action:\n Senna and colace given. OG tube to low int. suction, was able to clamp\n tube for 2hr but residuals returned.\n Response:\n 100 ml yellow-pinkish fluid out OG tube\n Plan:\n Cont to check residuals, restart tube feeds as tolerated, ? if raglan\n would help. Increase bowel regimen if needed.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n DVT in RUE\n Action:\n No BP or blood draws in RUE. Neuro to see pt in AM to see if we\n can start heparin gtt (neuro to okay because of the spine\n fracture)\n Response:\n Plan:\n Wait for decision by Neuro and anticoagulate with heparin if\n possible.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n T-max for this shift 99.6\n Action:\n Pt on Vanco, Aztreonam, Levoflaxacin, Flagyl.\n Response:\n Pt not spiking over 100\n Plan:\n Cont to monitor Temp, cont antibiotics, follow up cultures, re-culture\n if pt does spike temp again.\n Fracture, other\n Assessment:\n Reported that pt has a T5-T8 spinal fracture, Wet read from yesterdays\n CT may show just a T-9 compression, still waiting for the true results\n of this CT.\n Action:\n Log roll pt, pt increased with reverse trandelenburg positionsing,\n back brace in room if pt OOB.\n Response:\n Pt not tolerating turning\n Plan:\n Consult with neuro /wait for true CT scan results to know if spine\n is actually fractured or not and if not ? removing spine precautions.\n Anemia, other\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lung sounds clear/diminished, ? VAP and possibly ARDS on top of that.\n small amounts thick yellow secretions, vent setting changed during the\n night. Pt desats to 80% with turning and takes a long time to\n recover. Face becomes blue/purple.\n Action:\n Did not turn pt during the night, Vent setting changed during night\n currently CMV 80%/400/22/17. cont suctioning/oral care/ subglottal\n suctioning. Resp tried to place esophageal balloon again tonight\n Response:\n Small secretions out of in-line suction. Last ABG better at 7.38/41/87,\n esophageal balloon placement unsuccessful\n Plan:\n ? if team will have respiratory try to place esophageal balloon again,\n wean vent as tolerated. Cont ABG\ns with vent changes.\n Hypotension (not Shock)\n Assessment:\n Pt received on 0.04 mcg/kg/min of norepi gtt.\n Action:\n Weaned gtt off in early evening but MAPs dropped <65\n Response:\n Turned norepi gtt back on at 0.02 mg/kg/min\n Plan:\n Cont to wean norepi gtt as tolerated.\n Goals: switch pt to air mattress bed if okayed by neuro that pt\n can be moved, start heparin gtt for RUE DVT if neuro okays. Wean\n norepi gtt. Restart Tube feeds when tolerates, ? if team will try to\n float esophageal balloon again.\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-30 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 640202,
"text": "Chief Complaint:\n 24 Hour Events:\n - ENT team believes that vocal cord adductor dysfunction is NOT a risk\n for aspiration, rather her increased secretions put her at risk for\n aspiration. They will follow-up in clinic in two weeks with Dr.\n , call in am to schedule appt.\n - Psych recs: consider head CT if patient does not improve off\n scopolamine and metoclopramide; address anemia and\nerratic BP\n consider increasing am dose of risperdal; monitor \n - Pt continued to be agitated O/N (eg: pulled rectal tubex2 and\n foleyx1, disoriented). To receive head CT this AM\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.9\n HR: 77 (66 - 114) bpm\n BP: 128/40(60) {90/37(31) - 164/75(87)} mmHg\n RR: 23 (16 - 29) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,726 mL\n 595 mL\n PO:\n TF:\n 1,388 mL\n 301 mL\n IVF:\n 249 mL\n 105 mL\n Blood products:\n Total out:\n 1,666 mL\n 222 mL\n Urine:\n 836 mL\n 222 mL\n NG:\n Stool:\n Drains:\n Balance:\n 60 mL\n 373 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 100%\n ABG: ///34/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 183 K/uL\n 7.1 g/dL\n 115 mg/dL\n 0.5 mg/dL\n 34 mEq/L\n 3.6 mEq/L\n 13 mg/dL\n 106 mEq/L\n 145 mEq/L\n 22.8 %\n 5.4 K/uL\n [image002.jpg]\n 04:00 AM\n 05:45 AM\n 03:51 AM\n 04:45 PM\n 04:00 AM\n 07:37 PM\n 04:05 AM\n 06:05 PM\n 03:23 AM\n 02:54 AM\n WBC\n 8.0\n 8.7\n 5.5\n 5.7\n 5.8\n 5.1\n 5.4\n Hct\n 27.0\n 28.7\n 24.7\n 25.2\n 25.3\n 23.7\n 24.7\n 23.7\n 22.8\n Plt\n \n 183\n Cr\n 0.7\n 0.7\n 0.5\n 0.4\n 0.5\n 0.5\n 0.5\n 0.5\n Glucose\n 114\n 112\n 122\n 145\n 137\n 149\n 105\n 115\n Other labs: PT / PTT / INR:13.3/32.4/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.4 mg/dL, Mg++:1.9 mg/dL, PO4:3.6\n mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-30 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 640203,
"text": "Chief Complaint:\n 24 Hour Events:\n Tube Feed goals increased from 30cc to 60cc/hr. No issues O/N with\n regard to vomiting.\n Calm overnight. Risperdal decreased from 0.5mg to 0.25mg qam.\n runs of asymptomatic SVT peaking in 110-120\ns, metoprolol 37.5mg\n changed from TID\nQID and first daily dose given early after runs;\n decrease of HR to 80\n Loose, brown, malodorous stools O/N, afebrile, C.dif cx sent.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Enoxaparin (Lovenox) - 06:33 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.5\nC (97.7\n HR: 114 (61 - 122) bpm\n BP: 119/54(75) {91/36(50) - 167/84(101)} mmHg\n RR: 19 (10 - 30) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,952 mL\n 429 mL\n PO:\n TF:\n 646 mL\n 376 mL\n IVF:\n 950 mL\n 54 mL\n Blood products:\n Total out:\n 2,430 mL\n 470 mL\n Urine:\n 2,430 mL\n 240 mL\n NG:\n Stool:\n Drains:\n Balance:\n 522 mL\n -41 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 100%\n ABG: ///35/\n Physical Examination\n Gen: Alert, NAD, lying in bed, comfortable, mouthing words, less\n sedated than yest.\n HEENT: No pallor in conjunctiva, MMM, TM in place\n Resp: Transmitted upper airway sounds/coarse breath sounds.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, decreased bowel sounds, G-Tube in\n place with no erythema/induration\n Exte: No edema, DP 2+ bil\n NEURO: Alert, difficult to assess orientation due to poor voice\n although pt oriented to year not place. MAE\n Labs / Radiology\n 187 K/uL\n 7.2 g/dL\n 105 mg/dL\n 0.5 mg/dL\n 35 mEq/L\n 3.8 mEq/L\n 17 mg/dL\n 108 mEq/L\n 147 mEq/L\n 23.7 %\n 5.1 K/uL\n [image002.jpg]\n 03:00 AM\n 04:00 AM\n 05:45 AM\n 03:51 AM\n 04:45 PM\n 04:00 AM\n 07:37 PM\n 04:05 AM\n 06:05 PM\n 03:23 AM\n WBC\n 7.3\n 8.0\n 8.7\n 5.5\n 5.7\n 5.8\n 5.1\n Hct\n 27.3\n 27.0\n 28.7\n 24.7\n 25.2\n 25.3\n 23.7\n 24.7\n 23.7\n Plt\n 346\n 316\n 271\n 249\n 231\n 203\n 187\n Cr\n 0.7\n 0.7\n 0.7\n 0.5\n 0.4\n 0.5\n 0.5\n 0.5\n Glucose\n 123\n 114\n 112\n 122\n 145\n 137\n 149\n 105\n Other labs: PT / PTT / INR:13.3/32.4/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.8 mg/dL, Mg++:2.1 mg/dL, PO4:3.5\n mg/dL\n Assessment and Plan\n 56yoF s/p mechanical fall and traumatic T spine fracture transferred\n from OSH to for TBM eval with hospitalization complicated by\n respiratory failure and HAP, s/p trach/PEG, atrial tachycardia, ileus,\n and delirium/agitation.\n .\n # Respiratory: s/p intubation/extubation, now on trach mask, FiO2 50%.\n Tolerating well with good O2 sat in mid-high 90\ns. Pt continues to be\n at risk for aspiration given recent history of vomiting with tube feed\n trials and increased secretions. ENT believes that the posterior gap is\n not a risk factor for aspiration as this is a common finding in females\n and that her increased secretions and edema pose a greater aspiration\n threat; no intervention was recommended.\n - Appreciate ENT and S&S input.\n - ENT recs to f/u in 2wks with Dr. () for an\n outpatient/clinic re-evaluation.\n - ppi for aspiration prophylaxis, PMV precautions: \nt use w/o\n supervision, frequent suctioning\n - TM as tolerated.\n - d/c scopolamine as it was a cause for delirium.\n - Holding sedation with exception of Risperidal 0.25mg qam PRN\n # Delirium: Pt continues to be slightly agitated with paranoia and\n disorientation. Delirium and agitation most likely secondary to long\n hospital course and multiple psychotropic medications as well as hx of\n EtOH abuse.\n - Risperdal 0.25mg PO qam.\n - continue to hold all benzos. opiates, and antihistamines. Will\n decrease or d/c raglan and scopolamine.\n - Appreciate psych. Will call and f/u psych recs.\n -Follow EKG to assess for prolongation (last EKG ; 457).\n #Loose Stools: Multiple, loose stools O/N; afebrile, tachycardia,\n without abdominal pain\n -F/u stool c.dif cultures\n -f/u WBC and vital signs daily\n -Hold bowel regimen\n # Atrial Tachycardia: Compared to recent b/l, HR increased to max of\n 120\ns. Pt now on PO Amiodarone 200 TID and PO increased metoprolol\n 37.5mg QID.\n - Will continue amiodarone 200 TID for three weeks and then switch to\n qday for 1week and then d/c amiodarone.\n - Will need to schedule f/u in 4wks with Dr. upon d/c/transfer.\n #Anemia: HCT low compared to b/l. No known etiology of blood loss.\n -Will continue to follow HCT daily.\n - Guaiac stools.\n # Hypernatremia/Fluid Status: Mild hypernatramia resolving with free\n water administration. On TPN/TF. Good UOP. Free water deficit of 2.8L\n - increase D5W IVFx 1L from 10cc/hr to 150cc/hr, free water flushes\n with TF\n -Will f/u lytes in afternoon (5pm)\n # UE DVT and h/o labile INR: Decision made to d/c Coumadin given her\n labile INR, and start Lovenox . INR at 1.1\n - Will flush L PICC with TPA if does not flush\n - Daily coags\n .\n # Spine fracture: Stable. T5-T8.\n - Brace for OOB.\n - Pt to follow up with Dr. in .\n .\n # Tracheomalacia. Reevaluation bronchoscopy by IP as written above;\n patient not a candidate for stent; pt to follow up as outpatient. No\n new issues.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # FEN: Currently receiving TF at 50cc/hr, w/o issue.\n - Appreciate GI input and S&S eval\n -D/c Reglan for emesis precaution as pt is tolerating TF without\n vomiting and Reglan increases agitation/delirium risk.\n -meds via G-J tube,\n .\n # ACCESS: PIV x 1, L PICC\n # Ppx: Lovenox, PPi , Bowel Regimen PRN\n # Communication:\n - (brother) is primary contact\n - Boyfriend of 10 , but minimal contact has been maintained at\n this point\n - Social Work and Case management involved; have discussed situation\n w/ brother and boyfriend.\n # Code: Full\n # Dispo: ICU, Will d/w case management re rehab facilities, likely d/c\n today/tomorrow if insurance/bed confirmed\n MSIV\n PGY1 addendum: \n Agree with assessment and plan in excellent MSIV note as detailed\n above. Briefly, 56 F s/p fall with T spine fracture (T5-T8),\n respiratory failure now s/p trach/PEG. Now on trach mask. Nutrition\n issues continue; will follow up with psychiatry recs. Etiology of\n delirium/agitation still unclear but likely prolonged hospital\n course, illness and multiple medications. Currently discussing with CM\n about potential placement to rehab.\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-30 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 640204,
"text": "Chief Complaint:\n 24 Hour Events:\n - ENT team believes that vocal cord adductor dysfunction is NOT a risk\n for aspiration, rather her increased secretions put her at risk for\n aspiration. They will follow-up in clinic in two weeks with Dr.\n , call in am to schedule appt.\n - Psych recs: consider head CT if patient does not improve off\n scopolamine and metoclopramide; address anemia and\nerratic BP\n consider increasing am dose of risperdal; monitor \n - Pt continued to be agitated O/N (eg: pulled rectal tubex2 and\n foleyx1, disoriented). To receive head CT this AM\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.9\n HR: 77 (66 - 114) bpm\n BP: 128/40(60) {90/37(31) - 164/75(87)} mmHg\n RR: 23 (16 - 29) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,726 mL\n 595 mL\n PO:\n TF:\n 1,388 mL\n 301 mL\n IVF:\n 249 mL\n 105 mL\n Blood products:\n Total out:\n 1,666 mL\n 222 mL\n Urine:\n 836 mL\n 222 mL\n NG:\n Stool:\n Drains:\n Balance:\n 60 mL\n 373 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 100%\n ABG: ///34/\n Physical Examination\n Gen: Alert, NAD, lying in bed, comfortable, mouthing words, less\n sedated than yest.\n HEENT: No pallor in conjunctiva, MMM, TM in place\n Resp: Transmitted upper airway sounds/coarse breath sounds.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, decreased bowel sounds, G-Tube in\n place with no erythema/induration\n Exte: No edema, DP 2+ bil\n NEURO: Alert, difficult to assess orientation due to poor voice\n although pt oriented to year not place. MAE\n Labs / Radiology\n 183 K/uL\n 7.1 g/dL\n 115 mg/dL\n 0.5 mg/dL\n 34 mEq/L\n 3.6 mEq/L\n 13 mg/dL\n 106 mEq/L\n 145 mEq/L\n 22.8 %\n 5.4 K/uL\n [image002.jpg]\n 04:00 AM\n 05:45 AM\n 03:51 AM\n 04:45 PM\n 04:00 AM\n 07:37 PM\n 04:05 AM\n 06:05 PM\n 03:23 AM\n 02:54 AM\n WBC\n 8.0\n 8.7\n 5.5\n 5.7\n 5.8\n 5.1\n 5.4\n Hct\n 27.0\n 28.7\n 24.7\n 25.2\n 25.3\n 23.7\n 24.7\n 23.7\n 22.8\n Plt\n \n 183\n Cr\n 0.7\n 0.7\n 0.5\n 0.4\n 0.5\n 0.5\n 0.5\n 0.5\n Glucose\n 114\n 112\n 122\n 145\n 137\n 149\n 105\n 115\n Other labs: PT / PTT / INR:13.3/32.4/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.4 mg/dL, Mg++:1.9 mg/dL, PO4:3.6\n mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-30 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 640206,
"text": "Chief Complaint:\n 24 Hour Events:\n - ENT team believes that vocal cord adductor dysfunction is NOT a risk\n for aspiration, rather her increased secretions put her at risk for\n aspiration. They will follow-up in clinic in two weeks with Dr.\n , call in am to schedule appt.\n - Psych recs: consider head CT if patient does not improve off\n scopolamine and metoclopramide; address anemia and\nerratic BP\n consider increasing am dose of risperdal; monitor \n - Pt continued to be agitated O/N (eg: pulled rectal tubex2 and\n foleyx1, disoriented). To receive head CT this AM\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.9\n HR: 77 (66 - 114) bpm\n BP: 128/40(60) {90/37(31) - 164/75(87)} mmHg\n RR: 23 (16 - 29) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,726 mL\n 595 mL\n PO:\n TF:\n 1,388 mL\n 301 mL\n IVF:\n 249 mL\n 105 mL\n Blood products:\n Total out:\n 1,666 mL\n 222 mL\n Urine:\n 836 mL\n 222 mL\n NG:\n Stool:\n Drains:\n Balance:\n 60 mL\n 373 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 100%\n ABG: ///34/\n Physical Examination\n Gen: Alert, NAD, lying in bed, comfortable, mouthing words, less\n sedated than yest.\n HEENT: No pallor in conjunctiva, MMM, TM in place\n Resp: Transmitted upper airway sounds/coarse breath sounds.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, decreased bowel sounds, G-Tube in\n place with no erythema/induration\n Exte: No edema, DP 2+ bil\n NEURO: Alert, difficult to assess orientation due to poor voice\n although pt oriented to year not place. MAE\n Labs / Radiology\n 183 K/uL\n 7.1 g/dL\n 115 mg/dL\n 0.5 mg/dL\n 34 mEq/L\n 3.6 mEq/L\n 13 mg/dL\n 106 mEq/L\n 145 mEq/L\n 22.8 %\n 5.4 K/uL\n [image002.jpg]\n 04:00 AM\n 05:45 AM\n 03:51 AM\n 04:45 PM\n 04:00 AM\n 07:37 PM\n 04:05 AM\n 06:05 PM\n 03:23 AM\n 02:54 AM\n WBC\n 8.0\n 8.7\n 5.5\n 5.7\n 5.8\n 5.1\n 5.4\n Hct\n 27.0\n 28.7\n 24.7\n 25.2\n 25.3\n 23.7\n 24.7\n 23.7\n 22.8\n Plt\n \n 183\n Cr\n 0.7\n 0.7\n 0.5\n 0.4\n 0.5\n 0.5\n 0.5\n 0.5\n Glucose\n 114\n 112\n 122\n 145\n 137\n 149\n 105\n 115\n Other labs: PT / PTT / INR:13.3/32.4/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.4 mg/dL, Mg++:1.9 mg/dL, PO4:3.6\n mg/dL\n Assessment and Plan\n 56yoF s/p mechanical fall and traumatic T spine fracture transferred\n from OSH to for TBM eval with hospitalization complicated by\n respiratory failure and HAP, s/p trach/PEG, atrial tachycardia, ileus,\n and delirium/agitation.\n .\n # Respiratory: s/p intubation/extubation, now on trach mask, FiO2 50%.\n Tolerating well with good O2 sat in mid-high 90\ns. Pt continues to be\n at risk for aspiration given recent history of vomiting with tube feed\n trials and increased secretions. ENT believes that the posterior gap is\n not a risk factor for aspiration as this is a common finding in females\n and that her increased secretions and edema pose a greater aspiration\n threat; no intervention was recommended.\n - Appreciate ENT and S&S input.\n - ENT recs to f/u in 2wks with Dr. () for an\n outpatient/clinic re-evaluation.\n - ppi for aspiration prophylaxis, PMV precautions: \nt use w/o\n supervision, frequent suctioning\n - TM as tolerated.\n - d/c scopolamine as it was a cause for delirium.\n - Holding sedation with exception of Risperidal 0.25mg qam PRN\n # Delirium: Pt continues to be slightly agitated with paranoia and\n disorientation. Delirium and agitation most likely secondary to long\n hospital course and multiple psychotropic medications as well as hx of\n EtOH abuse.\n - Risperdal 0.25mg PO qam.\n - continue to hold all benzos. opiates, and antihistamines. Will\n decrease or d/c raglan and scopolamine.\n - Appreciate psych. Will call and f/u psych recs.\n -Follow EKG to assess for prolongation (last EKG ; 457).\n #Loose Stools: Multiple, loose stools O/N; afebrile, tachycardia,\n without abdominal pain\n -F/u stool c.dif cultures\n -f/u WBC and vital signs daily\n -Hold bowel regimen\n # Atrial Tachycardia: Compared to recent b/l, HR increased to max of\n 120\ns. Pt now on PO Amiodarone 200 TID and PO increased metoprolol\n 37.5mg QID.\n - Will continue amiodarone 200 TID for three weeks and then switch to\n qday for 1week and then d/c amiodarone.\n - Will need to schedule f/u in 4wks with Dr. upon d/c/transfer.\n #Anemia: HCT low compared to b/l. No known etiology of blood loss.\n -Will continue to follow HCT daily.\n - Guaiac stools.\n # Hypernatremia/Fluid Status: Mild hypernatramia resolving with free\n water administration. On TPN/TF. Good UOP. Free water deficit of 2.8L\n - increase D5W IVFx 1L from 10cc/hr to 150cc/hr, free water flushes\n with TF\n -Will f/u lytes in afternoon (5pm)\n # UE DVT and h/o labile INR: Decision made to d/c Coumadin given her\n labile INR, and start Lovenox . INR at 1.1\n - Will flush L PICC with TPA if does not flush\n - Daily coags\n .\n # Spine fracture: Stable. T5-T8.\n - Brace for OOB.\n - Pt to follow up with Dr. in .\n .\n # Tracheomalacia. Reevaluation bronchoscopy by IP as written above;\n patient not a candidate for stent; pt to follow up as outpatient. No\n new issues.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # FEN: Currently receiving TF at 50cc/hr, w/o issue.\n - Appreciate GI input and S&S eval\n -D/c Reglan for emesis precaution as pt is tolerating TF without\n vomiting and Reglan increases agitation/delirium risk.\n -meds via G-J tube,\n .\n # ACCESS: PIV x 1, L PICC\n # Ppx: Lovenox, PPi , Bowel Regimen PRN\n # Communication:\n - (brother) is primary contact\n - Boyfriend of 10 , but minimal contact has been maintained at\n this point\n - Social Work and Case management involved; have discussed situation\n w/ brother and boyfriend.\n # Code: Full\n # Dispo: ICU, Will d/w case management re rehab facilities, likely d/c\n today/tomorrow if insurance/bed confirmed\n MSIV\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Respiratory ",
"chartdate": "2167-10-29 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 640135,
"text": "Demographics\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Tube Type\n Tracheostomy tube:\n Type: Cuffed\n Manufacturer: Portex\n Size: 7.0mm\n PMV: Yes\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Copious\n Comments: Pt continues to require frequent suctioning. Did wear PMV\n for 15 mins today.\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 639845,
"text": "Chief Complaint:\n 24 Hour Events:\n BRONCHOSCOPY by IP- At 09:43 AM. Tracheomalacia, lack of\n posterior complete closure above cords resulting in possible etiology\n of recurrent aspiration\n Per nursing had increased secretions requiring deep suctioning\n overnight\n Restarted TF\n Changed PPI to per IP recs\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:05 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.1\nC (97\n HR: 86 (62 - 122) bpm\n BP: 146/61(82) {87/42(53) - 152/87(98)} mmHg\n RR: 23 (19 - 36) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 3,692 mL\n 1,252 mL\n PO:\n TF:\n 116 mL\n 116 mL\n IVF:\n 2,175 mL\n 775 mL\n Blood products:\n Total out:\n 3,790 mL\n 400 mL\n Urine:\n 3,790 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n -98 mL\n 854 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 95%\n ABG: ///32/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 203 K/uL\n 7.5 g/dL\n 137 mg/dL\n 0.5 mg/dL\n 32 mEq/L\n 3.8 mEq/L\n 13 mg/dL\n 110 mEq/L\n 148 mEq/L\n 23.7 %\n 5.8 K/uL\n [image002.jpg]\n 03:20 PM\n 03:23 AM\n 03:00 AM\n 04:00 AM\n 05:45 AM\n 03:51 AM\n 04:45 PM\n 04:00 AM\n 07:37 PM\n 04:05 AM\n WBC\n 5.7\n 7.3\n 8.0\n 8.7\n 5.5\n 5.7\n 5.8\n Hct\n 30.0\n 26.9\n 27.3\n 27.0\n 28.7\n 24.7\n 25.2\n 25.3\n 23.7\n Plt\n 356\n 346\n 316\n 271\n 249\n 231\n 203\n Cr\n 0.7\n 0.7\n 0.7\n 0.7\n 0.5\n 0.4\n 0.5\n Glucose\n 129\n 123\n 114\n 112\n 122\n 145\n 137\n Other labs: PT / PTT / INR:13.3/32.4/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.9 mg/dL, Mg++:2.1 mg/dL, PO4:3.6\n mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Replete with Fiber () - 06:00 PM 20 mL/hour\n TPN w/ Lipids - 06:02 PM 62.5 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 639846,
"text": "Chief Complaint:\n 24 Hour Events:\n BRONCHOSCOPY by IP- At 09:43 AM. Severe diffuse\n Tracheobronchomalacia, large gap posterior commisure above cords\n resulting in possible etiology of recurrent aspiration\n Seen by ENT, no attg note. Consider posterior augmentation\n Per nursing had increased secretions requiring deep suctioning\n overnight\n Restarted TF\n Changed PPI to per IP recs\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:05 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.1\nC (97\n HR: 86 (62 - 122) bpm\n BP: 146/61(82) {87/42(53) - 152/87(98)} mmHg\n RR: 23 (19 - 36) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 3,692 mL\n 1,252 mL\n PO:\n TF:\n 116 mL\n 116 mL\n IVF:\n 2,175 mL\n 775 mL\n Blood products:\n Total out:\n 3,790 mL\n 400 mL\n Urine:\n 3,790 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n -98 mL\n 854 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 95%\n ABG: ///32/\n Physical Examination\n Gen: Sedating post-bronchoscopy; Sleeping; pt would not wake for exam.\n HEENT: No pallor in conjunctiva, MMM\n Resp: Course breath sounds anteriorly, mild exp wheeze.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, decreased bowel sounds, G-Tube in\n place with no erythema/induration\n Exte: No edema, DP 2+ bil\n NEURO: Sedated\n Labs / Radiology\n 203 K/uL\n 7.5 g/dL\n 137 mg/dL\n 0.5 mg/dL\n 32 mEq/L\n 3.8 mEq/L\n 13 mg/dL\n 110 mEq/L\n 148 mEq/L\n 23.7 %\n 5.8 K/uL\n [image002.jpg]\n 03:20 PM\n 03:23 AM\n 03:00 AM\n 04:00 AM\n 05:45 AM\n 03:51 AM\n 04:45 PM\n 04:00 AM\n 07:37 PM\n 04:05 AM\n WBC\n 5.7\n 7.3\n 8.0\n 8.7\n 5.5\n 5.7\n 5.8\n Hct\n 30.0\n 26.9\n 27.3\n 27.0\n 28.7\n 24.7\n 25.2\n 25.3\n 23.7\n Plt\n 356\n 346\n 316\n 271\n 249\n 231\n 203\n Cr\n 0.7\n 0.7\n 0.7\n 0.7\n 0.5\n 0.4\n 0.5\n Glucose\n 129\n 123\n 114\n 112\n 122\n 145\n 137\n Other labs: PT / PTT / INR:13.3/32.4/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.9 mg/dL, Mg++:2.1 mg/dL, PO4:3.6\n mg/dL\n Assessment and Plan\n 56yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach/PEG with resolving respiratory failure and HAP.\n .\n # Respiratory failure/Aspiration Risk: s/p intubation/extubation, now\n on trach mask, FiO2 50%. Tolerating well with good O2 sat. No further\n self-decanulations overnight. Pt continues to be at risk for aspiration\n given new IP finding of opening defect in posterior vocal cord space\n and given recent history of vomiting with tube feed trials.\n - ENT consulted for evaluation of larynx and possible intervention;\n will follow ENT recs\n - increase ppi from qday to for aspiration prophylaxis\n - Trach mask as tolerated.\n - scopolamine patch q72hrs for secretions\n - Holding sedation with exception of Risperidal 0.5mg PRN\n - F/u CXR tomorrow\n .\n # Nutrition/Vomiting: Currently receiving TPN; BMx2 in past 24 hrs to\n indicate possible improvement in ileus. TF tolerated during trial O/N\n without emesis.\n - Cont Reglan 20mg IV Q 8 hours; meds via G-J tube,\n - Will obtain recommendations from Nutrition re TPN today and will\n provide TF as tolerated\n - Speech and Swallow eval today for Passy Muir valve eval;\n - GI consult, will f/u recs\n .\n # Tachycardia: Improved HR max of 120\ns versus 160s previously. Pt now\n on PO Amiodarone 200 TID and PO metoprolol 37.5mg TID\n - Continue current med regimen. Will continue amiodarone 200 TID for\n three weeks and then switch to qday for 1week and then d/c amiodarone.\n - Will need to schedule f/u in 4wks with Dr. upon d/c/transfer.\n - f/u Cards recs\n # Sedation/Anxiolysis/AlteredMS: Resolved O/N with risperdal. Previous\n delirium and agitation most likely secondary to long hospital course\n and multiple psychotropic medications as well as hx of EtOH abuse.\n - started Risperdal 0.5mg PO BID PRN.\n - continue to hold all benzos. opiates, and antihistamines\n - Appreciate psych. Will call and f/u psych recs.\n -Obtain EKG to assess for QTc prolongation.\n #Anemia: HCT stable at 25. No known etiology of blood loss.\n -Will repeat HCT in am .\n # Hypernatremia/Fluid Status: Mild hypernatramia resolving with free\n water administration. On TPN/TF. Good UOP.\n - providing D5W IVFx 1L at 125cc/hr, free water flushes with TF\n -Will f/u lytes in afternoon (5pm)\n # UE DVT and elevated INR: Decision made to d/c Coumadin given her\n labile INR, and start Lovenox .\n - Will flush L PICC with TPA if does not flush\n - Add coags to am labs\n .\n # Spine fracture: Stable\n - Brace for OOB, need to discuss with Neurosurgery before d/c if\n current brace is optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n .\n # Tracheomalacia. Reevaluation bronchoscopy by IP as written above;\n patient not a candidate for stent; pt to follow up as outpatient. No\n new issues.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # ACCESS: PIV x 1, L PICC\n # Ppx: Lovenox, PPi-to increase to , Bowel Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n - Social Work and Case management involved; have discussed situation\n w/ brother and boyfriend.\n # Code: Full\n # Dispo: ICU, Will d/w case management re rehab facilities.\n MSIV\n PGY2 addendum:\n Agree with assessment and plan in MSIV note as detailed above.\n Briefly, 56 F s/p fall with T spine fracture, respiratory failure now\n s/p trach/PEG. Now on trach mask. Patient s/p bronch with IP today;\n ENT to see and follow for ?intervention. Nutrition issues continue;\n will receive TPN today plus possible restart of tube feeds as tolerated\n (later today), continue reglan. Appreciate psych recs; continuing\n risperidone for agitation. Etiology of delirium/agitation still\n unclear. Likely eventual dispo to rehab facility directly from ICU\n given high nursing requirements.\n ICU Care\n Nutrition:\n Replete with Fiber () - 06:00 PM 20 mL/hour\n TPN w/ Lipids - 06:02 PM 62.5 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Respiratory ",
"chartdate": "2167-10-28 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 639853,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 40\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason:\n Tube Type\n Tracheostomy tube:\n Type: Cuffed\n Manufacturer: Portex\n Size: 7.0mm\n PMV: No\n Cuff Management:\n Vol/Press:\n Cuff pressure: 23 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thin\n Sputum source/amount: Suctioned / Copious\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Unassisted spontaneous breathing\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-29 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 640120,
"text": "Chief Complaint:\n 24 Hour Events:\n Tube Feed goals increased from 30cc to 60cc/hr. No issues O/N with\n regard to vomiting.\n Calm overnight. Risperdal decreased from 0.5mg to 0.25mg qam.\n runs of asymptomatic SVT peaking in 110-120\ns, metoprolol 37.5mg\n changed from TID\nQID and first daily dose given early after runs;\n decrease of HR to 80\n Loose, brown, malodorous stools O/N, afebrile, C.dif cx sent.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Enoxaparin (Lovenox) - 06:33 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.5\nC (97.7\n HR: 114 (61 - 122) bpm\n BP: 119/54(75) {91/36(50) - 167/84(101)} mmHg\n RR: 19 (10 - 30) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,952 mL\n 429 mL\n PO:\n TF:\n 646 mL\n 376 mL\n IVF:\n 950 mL\n 54 mL\n Blood products:\n Total out:\n 2,430 mL\n 470 mL\n Urine:\n 2,430 mL\n 240 mL\n NG:\n Stool:\n Drains:\n Balance:\n 522 mL\n -41 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 100%\n ABG: ///35/\n Physical Examination\n Gen: Alert, NAD, lying in bed, comfortable, mouthing words, less\n sedated than yest.\n HEENT: No pallor in conjunctiva, MMM, TM in place\n Resp: Transmitted upper airway sounds/coarse breath sounds.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, decreased bowel sounds, G-Tube in\n place with no erythema/induration\n Exte: No edema, DP 2+ bil\n NEURO: Alert, difficult to assess orientation due to poor voice\n although pt oriented to year not place. MAE\n Labs / Radiology\n 187 K/uL\n 7.2 g/dL\n 105 mg/dL\n 0.5 mg/dL\n 35 mEq/L\n 3.8 mEq/L\n 17 mg/dL\n 108 mEq/L\n 147 mEq/L\n 23.7 %\n 5.1 K/uL\n [image002.jpg]\n 03:00 AM\n 04:00 AM\n 05:45 AM\n 03:51 AM\n 04:45 PM\n 04:00 AM\n 07:37 PM\n 04:05 AM\n 06:05 PM\n 03:23 AM\n WBC\n 7.3\n 8.0\n 8.7\n 5.5\n 5.7\n 5.8\n 5.1\n Hct\n 27.3\n 27.0\n 28.7\n 24.7\n 25.2\n 25.3\n 23.7\n 24.7\n 23.7\n Plt\n 346\n 316\n 271\n 249\n 231\n 203\n 187\n Cr\n 0.7\n 0.7\n 0.7\n 0.5\n 0.4\n 0.5\n 0.5\n 0.5\n Glucose\n 123\n 114\n 112\n 122\n 145\n 137\n 149\n 105\n Other labs: PT / PTT / INR:13.3/32.4/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.8 mg/dL, Mg++:2.1 mg/dL, PO4:3.5\n mg/dL\n Assessment and Plan\n 56yoF s/p mechanical fall and traumatic T spine fracture transferred\n from OSH to for TBM eval with hospitalization complicated by\n respiratory failure and HAP, s/p trach/PEG, atrial tachycardia, ileus,\n and delirium/agitation.\n .\n # Respiratory: s/p intubation/extubation, now on trach mask, FiO2 50%.\n Tolerating well with good O2 sat in mid-high 90\ns. Pt continues to be\n at risk for aspiration given recent history of vomiting with tube feed\n trials and increased secretions. ENT believes that the posterior gap is\n not a risk factor for aspiration as this is a common finding in females\n and that her increased secretions and edema pose a greater aspiration\n threat; no intervention was recommended.\n - Appreciate ENT and S&S input.\n - ENT recs to f/u in 2wks with Dr. () for an\n outpatient/clinic re-evaluation.\n - ppi for aspiration prophylaxis, PMV precautions: \nt use w/o\n supervision, frequent suctioning\n - TM as tolerated.\n - d/c scopolamine as it was a cause for delirium.\n - Holding sedation with exception of Risperidal 0.25mg qam PRN\n # Delirium: Pt continues to be slightly agitated with paranoia and\n disorientation. Delirium and agitation most likely secondary to long\n hospital course and multiple psychotropic medications as well as hx of\n EtOH abuse.\n - Risperdal 0.25mg PO qam.\n - continue to hold all benzos. opiates, and antihistamines. Will\n decrease or d/c raglan and scopolamine.\n - Appreciate psych. Will call and f/u psych recs.\n -Follow EKG to assess for QTc prolongation (last EKG ; QTc 457).\n #Loose Stools: Multiple, loose stools O/N; afebrile, tachycardia,\n without abdominal pain\n -F/u stool c.dif cultures\n -f/u WBC and vital signs daily\n -Hold bowel regimen\n # Atrial Tachycardia: Compared to recent b/l, HR increased to max of\n 120\ns. Pt now on PO Amiodarone 200 TID and PO increased metoprolol\n 37.5mg QID.\n - Will continue amiodarone 200 TID for three weeks and then switch to\n qday for 1week and then d/c amiodarone.\n - Will need to schedule f/u in 4wks with Dr. upon d/c/transfer.\n #Anemia: HCT low compared to b/l. No known etiology of blood loss.\n -Will continue to follow HCT daily.\n - Guaiac stools.\n # Hypernatremia/Fluid Status: Mild hypernatramia resolving with free\n water administration. On TPN/TF. Good UOP. Free water deficit of 2.8L\n - increase D5W IVFx 1L from 10cc/hr to 150cc/hr, free water flushes\n with TF\n -Will f/u lytes in afternoon (5pm)\n # UE DVT and h/o labile INR: Decision made to d/c Coumadin given her\n labile INR, and start Lovenox . INR at 1.1\n - Will flush L PICC with TPA if does not flush\n - Daily coags\n .\n # Spine fracture: Stable. T5-T8.\n - Brace for OOB.\n - Pt to follow up with Dr. in .\n .\n # Tracheomalacia. Reevaluation bronchoscopy by IP as written above;\n patient not a candidate for stent; pt to follow up as outpatient. No\n new issues.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # FEN: Currently receiving TF at 50cc/hr, w/o issue.\n - Appreciate GI input and S&S eval\n -D/c Reglan for emesis precaution as pt is tolerating TF without\n vomiting and Reglan increases agitation/delirium risk.\n -meds via G-J tube,\n .\n # ACCESS: PIV x 1, L PICC\n # Ppx: Lovenox, PPi , Bowel Regimen PRN\n # Communication:\n - (brother) is primary contact\n - Boyfriend of 10 , but minimal contact has been maintained at\n this point\n - Social Work and Case management involved; have discussed situation\n w/ brother and boyfriend.\n # Code: Full\n # Dispo: ICU, Will d/w case management re rehab facilities, likely d/c\n today/tomorrow if insurance/bed confirmed\n MSIV\n PGY2 addendum: , \n Agree with assessment and plan in excellent MSIV note as detailed\n above. Briefly, 56 F s/p fall with T spine fracture (T5-T8),\n respiratory failure now s/p trach/PEG. Now on trach mask. Patient s/p\n bronch with IP yesterday. Nutrition issues continue; have discontinued\n TPN today and will continue tubefeeding to goal of 60cc/hr per\n Nutrition. Will continue reglan until at goal feedings, and decrease\n and d/c as able given potential for delirium. Appreciate psych recs;\n continuing risperidone for agitation. Etiology of delirium/agitation\n still unclear but likely prolonged hospital course, illness and\n multiple medications. Currently discussing with CM about potential\n placement to rehab tomorrow.\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 640121,
"text": "Synopsis per prior nursing note:\n 56 yr old woman, who was transferred from osh for evaluation of\n tracheal bronchial malacia on .Pt presented to Medical\n Center on s/p fall down a flight of stairs fracturing, t5-t8 with\n propulsion treated conservatively with pain meds and back brace. She\n developed resp distress requiring intubation on . Trach/PEG done\n . Now with prolonged hospital course c/b by PNA, anxiety/altered\n mental status, R&LUE DVT .Pt found to have small non occlusive clot on\n her right axial vein via Ultrasound, now rec\ning Lovenox. She has had\n problems with vomiting tube feedings, so feeding tube passed through\n g-tube to her jejunenum. However, she continued to intermit raise\n gastric contents assoc with bronchospasm. Has not required ventilation\n since , on humidified TM @ 50%. Presently on TPN and restarted on\n TF\nings at low rate via J-tube.\n BRONCHOSCOPY by IP- At 09:43 AM. Severe diffuse\n Tracheobronchomalacia, large gap posterior commisure above true vocal\n cords resulting in possible etiology of recurrent aspiration\n Airway Clearance, Impaired\n Assessment:\n LS-bilat rhonchi. O2 sat >95% on 50% trach collar. Suctioned large amts\n of thick, white secretions. Passy-muir valve in only while being\n evaluated by Psych d/t large amt of secretions.\n Action:\n Suctioned every one hour. Scolpolamine patch d/c\nd d/t mental status.\n Response:\n Needed suctioning every 1hour.\n Plan:\n to monitor and clear airway as needed.\n Alteration in Nutrition\n Assessment:\n Continues on replete w/fiber full strength.. Advance by 10ml q6 hours.\n Flush w/ 100 ml hour every 4 hours. Denies nausea. No vomiting.\n Mushroom cath in place.\n Action:\n J tube in place, unable to check resuduals. Increased TF as tolerated.\n Reglan d/c\nd d/t to mental status. Colace/senna/polyethylene glycol\n held.\n Response:\n Continues to have liquid stool. Currently tolerating TF.\n Plan:\n Advance TF to goal as tolerated.\n Fracture, other\n Assessment:\n Patient has a fracture of t5-t8. Denied pain. Brace on while OOB in\n chair.\n Action:\n Changed position. Brace on while OOB.\n Response:\n Continued to deny pain.\n Plan:\n Assess/treat pain. Brace on while OOB.\n Altered mental status (not Delirium)\n Assessment:\n When passy-muir valve on, patient had +VH and +AH. She was paranoid\n about her brother in hallway (brother was not at hospital). Stated that\n she will be driving her car home tomorrow. Stated that she is scared.\n Follows commands. Continues to try to pull out lines/tubes. Continues\n to throw her legs over the side of the bed.\n Action:\n w/ soft wrist restraints. Reoriented frequently. Assured patient\n that she is safe in hospital.\n Response:\n Patient remains safe. Able to be calmed when told she is safe in\n hospital.\n Plan:\n current safety plan. Reorient frequently. Psych will continue to\n follow.\n"
},
{
"category": "Rehab Services",
"chartdate": "2167-10-30 00:00:00.000",
"description": "Physical Therapy Progress Note",
"row_id": 640295,
"text": "Subjective:\n I thought I could stand but then I couldn't when I tried!\n Objective:\n Follow up PT visit to address goals of: . Patient seen today\n for balance training, patient education\n Updated medical status: improving mental status\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Rolling:\n\n\n\n\n\n Supine/\n Sidelying to Sit:\n\n\n\n\n\n Transfer:\n\n\n\n T\n\n Sit to Stand:\n\n\n\n T\n\n Ambulation:\n\n\n\n T\n\n Stairs:\n\n\n\n\n\n Aerobic Activity Response:\n Position\n HR\n BP\n RR\n O[2] sat\n RPE\n Rest\n Sit\n 84\n 100/44\n Activity\n Sit\n 84\n 186/64\n Recovery\n /\n Total distance walked: 3 steps\n Minutes:\n Gait: able to bear wt B. took three steps bed-chair, chair-bed,\n bed-chair. transfer performed x 3.\n Balance: falling forward in standing with mod a to recover\n Education / Communication: pt ed: role of PT\n case discussed with rn\n Other: strong congested cough productive for mod amounts of thick\n sputum.\n tlso attempted to fit brace but brace is too large excessive weight\n loss\n ms: oriented to self. following commands.\n Assessment: 56 f s/p fall with T8fx presents with improved ability to\n participate in PT today. She continues to require extensive rehab but\n given improvements in mental status her potential is good to return to\n ambulation. She may be limited by confusion. She needs to be fit for a\n new brace as her most recent CT showed worsening vertebral body height.\n Anticipated Discharge: Rehab\n Plan: F/u if pt not d/c to rehab for new brace and continued mobility\n and gait traininig.\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-30 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 640278,
"text": "Chief Complaint: Delerium, respiratory failure (chronic)\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n STOOL CULTURE - At 06:33 AM\n Remains delerious, confused. Remains somewhat paranoid.\n Up in chair.\n History obtained from Medical records\n Patient unable to provide history: Encephalopathy\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 PM\n Enoxaparin (Lovenox) - 06:00 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, Tube feeds, No(t) Parenteral nutrition\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation, PEG\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, No(t) Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: No(t) Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 12:02 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.1\nC (96.9\n HR: 70 (66 - 112) bpm\n BP: 96/52(61) {90/37(31) - 164/75(87)} mmHg\n RR: 22 (16 - 29) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,726 mL\n 901 mL\n PO:\n TF:\n 1,388 mL\n 301 mL\n IVF:\n 249 mL\n 330 mL\n Blood products:\n Total out:\n 1,666 mL\n 282 mL\n Urine:\n 836 mL\n 282 mL\n NG:\n Stool:\n Drains:\n Balance:\n 60 mL\n 619 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 100%\n ABG: ///34/\n Physical Examination\n General Appearance: No(t) Well nourished, No acute distress, Overweight\n / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic,\n No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: No(t) Clear : , No(t) Crackles : , No(t) Bronchial: ,\n No(t) Wheezes : , No(t) Diminished: , No(t) Absent : , Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): , Movement: Purposeful, No(t) Sedated, No(t)\n Paralyzed, Tone: Normal\n Labs / Radiology\n 7.1 g/dL\n 183 K/uL\n 115 mg/dL\n 0.5 mg/dL\n 34 mEq/L\n 3.6 mEq/L\n 13 mg/dL\n 106 mEq/L\n 145 mEq/L\n 22.8 %\n 5.4 K/uL\n [image002.jpg]\n 04:00 AM\n 05:45 AM\n 03:51 AM\n 04:45 PM\n 04:00 AM\n 07:37 PM\n 04:05 AM\n 06:05 PM\n 03:23 AM\n 02:54 AM\n WBC\n 8.0\n 8.7\n 5.5\n 5.7\n 5.8\n 5.1\n 5.4\n Hct\n 27.0\n 28.7\n 24.7\n 25.2\n 25.3\n 23.7\n 24.7\n 23.7\n 22.8\n Plt\n \n 183\n Cr\n 0.7\n 0.7\n 0.5\n 0.4\n 0.5\n 0.5\n 0.5\n 0.5\n Glucose\n 114\n 112\n 122\n 145\n 137\n 149\n 105\n 115\n Other labs: PT / PTT / INR:13.3/32.4/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.4 mg/dL, Mg++:1.9 mg/dL, PO4:3.6\n mg/dL\n Assessment and Plan\n Delerium.\n DELERIUM -- likely multifactorial. EtOH withdrawl-related,\n medications, ICU psychosis.\n RESPIRATORY FUNCTION -- stable with trach. Remains on trach collar.\n TRACHEOBRONCHOMALACIA --\n VOCAL CORD DYSFUNCTION -- adduction problem. need ENT f/u in\n future.\n NUTRITIONAL SUPPORT -- TF via PEG\n FLUIDS -- euvolemic. Monitor I/O.\n REHABILITATION placement in progress.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 55 minutes\n Patient is critically ill\n"
},
{
"category": "Nutrition",
"chartdate": "2167-10-30 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 640283,
"text": "Objective\n Pertinent medications: noted\n Labs:\n Value\n Date\n Glucose\n 115 mg/dL\n 02:54 AM\n Glucose Finger Stick\n 111\n 10:00 AM\n BUN\n 13 mg/dL\n 02:54 AM\n Creatinine\n 0.5 mg/dL\n 02:54 AM\n Sodium\n 145 mEq/L\n 02:54 AM\n Potassium\n 3.6 mEq/L\n 02:54 AM\n Chloride\n 106 mEq/L\n 02:54 AM\n TCO2\n 34 mEq/L\n 02:54 AM\n PO2 (arterial)\n 120 mm Hg\n 03:36 AM\n PO2 (venous)\n 62 mm Hg\n 02:35 AM\n PCO2 (arterial)\n 44 mm Hg\n 03:36 AM\n PCO2 (venous)\n 58 mm Hg\n 02:35 AM\n pH (arterial)\n 7.37 units\n 03:36 AM\n pH (venous)\n 7.37 units\n 02:35 AM\n pH (urine)\n 5.0 units\n 03:05 AM\n CO2 (Calc) arterial\n 26 mEq/L\n 03:36 AM\n CO2 (Calc) venous\n 35 mEq/L\n 02:35 AM\n Albumin\n 3.1 g/dL\n 03:23 AM\n Calcium non-ionized\n 8.4 mg/dL\n 02:54 AM\n Phosphorus\n 3.6 mg/dL\n 02:54 AM\n Ionized Calcium\n 1.24 mmol/L\n 02:51 AM\n Magnesium\n 1.9 mg/dL\n 02:54 AM\n Current diet order / nutrition support: Replte c/ Fiber @60mL/hr (1440\n kcals/89 graa)\n GI: abd soft/+bs.+BM\n Assessment of Nutritional Status\n Specifics:\n TF\ns advanced over past 2 days, were infusing @ goal, until held p/\n suctioned for thick mucous and ? possible aspiration. Per rounds plan\n to resume TF\ns this afternoon and advance back to goal slowly. IF pt\n c/ continuous need to held TF\ns will need to resume TPN to prevent\n nutritional decline.\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: via TF\n Resume TF's as able c/ low threshold for resumption of TPN to avoid\n nutritional decline\n Aspiration precautions keep HOB .45 degrees when feeding\n BG and lyte management as you are\n Will follow- please call c/ ?\ns #\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-30 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 640284,
"text": "Chief Complaint:\n 24 Hour Events:\n - ENT team believes that vocal cord adductor dysfunction is NOT a risk\n for aspiration, rather her increased secretions put her at risk for\n aspiration. They will follow-up in clinic in two weeks with Dr.\n , call in am to schedule appt.\n - Psych recs: consider head CT if patient does not improve off\n scopolamine and metoclopramide; address anemia and\nerratic BP\n consider increasing am dose of risperdal; monitor \n - Pt continued to be agitated O/N (eg: pulled rectal tubex2 and\n foleyx1, disoriented). To receive head CT this AM\n -HCT at 22.8 down 1pt with b/l in high 20\n -Suctioned thick green mucus from mouth (not trach) this am, TF held.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.9\n HR: 77 (66 - 114) bpm\n BP: 128/40(60) {90/37(31) - 164/75(87)} mmHg\n RR: 23 (16 - 29) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,726 mL\n 595 mL\n PO:\n TF:\n 1,388 mL\n 301 mL\n IVF:\n 249 mL\n 105 mL\n Blood products:\n Total out:\n 1,666 mL\n 222 mL\n Urine:\n 836 mL\n 222 mL\n NG:\n Stool:\n Drains:\n Balance:\n 60 mL\n 373 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 100%\n ABG: ///34/\n Physical Examination\n Gen: NAD, lying in bed, comfortable, PMV on, able to vocalize. HEENT:\n No pallor in conjunctiva, MMM, TM in place\n Resp: Transmitted upper airway sounds/coarse breath sounds, improved\n compared to yesterday.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, decreased bowel sounds, G-Tube in\n place with no s/s of infection\n Exte: No edema, DP 2+ bil\n NEURO: AxO to year (not to place or day-thinks it is\nthe day before\n \n), MAE\n Labs / Radiology\n 183 K/uL\n 7.1 g/dL\n 115 mg/dL\n 0.5 mg/dL\n 34 mEq/L\n 3.6 mEq/L\n 13 mg/dL\n 106 mEq/L\n 145 mEq/L\n 22.8 %\n 5.4 K/uL\n [image002.jpg]\n C.dif negative x1; Cdif#2 pending. BCx and Urine Cx No Growth.\n 04:00 AM\n 05:45 AM\n 03:51 AM\n 04:45 PM\n 04:00 AM\n 07:37 PM\n 04:05 AM\n 06:05 PM\n 03:23 AM\n 02:54 AM\n WBC\n 8.0\n 8.7\n 5.5\n 5.7\n 5.8\n 5.1\n 5.4\n Hct\n 27.0\n 28.7\n 24.7\n 25.2\n 25.3\n 23.7\n 24.7\n 23.7\n 22.8\n Plt\n \n 183\n Cr\n 0.7\n 0.7\n 0.5\n 0.4\n 0.5\n 0.5\n 0.5\n 0.5\n Glucose\n 114\n 112\n 122\n 145\n 137\n 149\n 105\n 115\n Other labs: PT / PTT / INR:13.3/32.4/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.4 mg/dL, Mg++:1.9 mg/dL, PO4:3.6\n mg/dL\n Assessment and Plan\n 56yoF s/p mechanical fall and traumatic T spine fracture transferred\n from OSH to for TBM eval with hospitalization complicated by\n respiratory failure and HAP, s/p trach/PEG, atrial tachycardia, ileus,\n and delirium/agitation.\n .\n # Delirium: Pt continues to be agitated with paranoia, disorientation\n and hallucinations. Most likely secondary to long hospital course and\n recent multiple psychotropic medications. Other lab values (lytes, past\n LFTs within normal limits), infections processes negative on culture.\n CT of head at OSH negative. d/c\ned Reglan and scopolamine.\n - Appreciate psych. Will call and f/u psych recs.\n -Consider CT of head with contrast if mental status does not improve\n this am.\n - Risperdal 0.25mg PO qam. Consider increasing per psych recs to 0.5mg\n if continues to be agitated. Will d/w psych re any additional meds we\n could use for night time agitation.\n - continue to hold all benzos. opiates, and antihistamines.\n -Follow EKG to assess for prolongation (last EKG ; 457).\n #Anemia: HCT continues to decrease, currently at 22.8 from 23.7 with\n b/l in high 20\ns. No known etiology of blood loss.\n -Will continue to follow HCT\n - Guaiac stools.\n # Respiratory: s/p trach on trach mask, FiO2 50%. Tolerating well with\n good O2 sat in mid-high 90\ns. Pt continues to be at risk for aspiration\n given recent history of vomiting with tube feed trials and increased\n secretions. ENT believes that the posterior gap is not a risk factor\n for aspiration as this is a common finding in females and that her\n increased secretions and edema pose a greater aspiration threat; no\n intervention was recommended.\n - Appreciate ENT and S&S input.\n - Pt to f/u on ^th at 3:30pm with Dr. \n () for an outpatient/clinic re-evaluation.\n - ppi for aspiration prophylaxis, PMV precautions: \nt use w/o\n supervision, frequent suctioning\n - TM as tolerated.\n - Holding sedation with exception of Risperidal 0.25mg PO qam\n #Loose Stools: rectal tube pulled out x2; afebrile, HD stable, without\n abdominal pain. Stool cdif cx negativex1.\n -F/u stool c.dif cultures\n -f/u WBC and vital signs daily\n -Hold bowel regimen\n # Atrial Tachycardia: Stable without issue O/N. Pt now on PO Amiodarone\n 200 TID and PO metoprolol 50mg TID\n - Will continue amiodarone 200 TID for three weeks (start ) and\n then switch to qday for 1week and then d/c amiodarone.\n - Will need to schedule f/u in 4wks with Dr. upon d/c/transfer.\n # Hypernatremia/Fluid Status: resolving after free water\n administration. On TPN/TF. Free water deficit of 1.6L\n - increase NS at 10cc/hr, water flushes with TF\n -Will f/u lytes \n # UE DVT and h/o labile INR: Decision made to d/c Coumadin given her\n labile INR, and start Lovenox . INR at 1.1\n - Will flush L PICC with TPA if does not flush\n - Daily coags\n .\n # Spine fracture: Stable. T5-T8.\n - Brace for OOB.\n - Pt to follow up with Dr. in .\n .\n # Tracheomalacia. Reevaluation bronchoscopy by IP as written above;\n patient not a candidate for stent; pt to follow up as outpatient. No\n new issues.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # FEN: Currently TF held secondary to possible risk of aspiration O/N;\n will increase TF back slowly to max goal.\n - Appreciate GI input and S&S eval\n -D/c\ned Reglan for emesis precaution as pt is tolerating TF without\n vomiting and Reglan increases agitation/delirium risk.\n -meds via G-J tube\n .\n # ACCESS: L PICC\n # Ppx: Lovenox, PPi , Bowel Regimen PRN currently held\n # Communication:\n - (brother) is primary contact; visiting\n patient today and aware of status and disposition\n - Boyfriend of 10 , but minimal contact has been maintained at\n this point\n - Social Work and Case management involved\n # Code: Full\n # Dispo: ICU, Will currently has bed at Rehab and waiting\n insurance approval before transfer of care.\n MSIV\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 640438,
"text": "56yoF s/p mechanical fall and traumatic T spine fracture transferred\n from OSH to for TBM eval with hospitalization complicated by\n respiratory failure and HAP, s/p trach/PEG, atrial tachycardia, ileus,\n and delirium/agitation.\n Airway Clearance, Impaired\n Assessment:\n Cont on TM 50% O2 sats 96-94%, suct for copious amts of thin white\n secretions, bilat rhonchi, dim bases.\n Action:\n Frequent suctioning, pt able to cough up some secretions on her own\n Response:\n Pt able to cough up secretions on her own at times\n Plan:\n Cont to resp status, encourage CDB\n Altered mental status (not Delirium)\n Assessment:\n Alert/oriented with some confusion, follows commands consistently, but\n requires frequent re-direction\n Action:\n Pt oriented to place/time\n Response:\n Pt still makes attempts to remove TM despite re-direction, pt remains\n with bilat wrist restraints for safety\n Plan:\n Cont to orient pt, frequent monitor for safety\n Alteration in Nutrition\n Assessment:\n TF restarted @ 0000, BS present x 4Quads, soft, NT\n Action:\n HOB 45 when TF on, TF off prior to turning, TF currently running at\n goal\n Response:\n No n/v reported or witness, TTFW\n Plan:\n Cont to nutritional status\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-29 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 640018,
"text": "Chief Complaint:\n 24 Hour Events:\n Tube Feed goals increased\n Calm overnight\n 3 runs of SVT peaking in 110s.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Enoxaparin (Lovenox) - 06:33 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.5\nC (97.7\n HR: 114 (61 - 122) bpm\n BP: 119/54(75) {91/36(50) - 167/84(101)} mmHg\n RR: 19 (10 - 30) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,952 mL\n 429 mL\n PO:\n TF:\n 646 mL\n 376 mL\n IVF:\n 950 mL\n 54 mL\n Blood products:\n Total out:\n 2,430 mL\n 470 mL\n Urine:\n 2,430 mL\n 240 mL\n NG:\n Stool:\n Drains:\n Balance:\n 522 mL\n -41 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 100%\n ABG: ///35/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 187 K/uL\n 7.2 g/dL\n 105 mg/dL\n 0.5 mg/dL\n 35 mEq/L\n 3.8 mEq/L\n 17 mg/dL\n 108 mEq/L\n 147 mEq/L\n 23.7 %\n 5.1 K/uL\n [image002.jpg]\n 03:00 AM\n 04:00 AM\n 05:45 AM\n 03:51 AM\n 04:45 PM\n 04:00 AM\n 07:37 PM\n 04:05 AM\n 06:05 PM\n 03:23 AM\n WBC\n 7.3\n 8.0\n 8.7\n 5.5\n 5.7\n 5.8\n 5.1\n Hct\n 27.3\n 27.0\n 28.7\n 24.7\n 25.2\n 25.3\n 23.7\n 24.7\n 23.7\n Plt\n 346\n 316\n 271\n 249\n 231\n 203\n 187\n Cr\n 0.7\n 0.7\n 0.7\n 0.5\n 0.4\n 0.5\n 0.5\n 0.5\n Glucose\n 123\n 114\n 112\n 122\n 145\n 137\n 149\n 105\n Other labs: PT / PTT / INR:13.3/32.4/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.8 mg/dL, Mg++:2.1 mg/dL, PO4:3.5\n mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Replete with Fiber () - 09:45 PM 40 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-29 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 640020,
"text": "Chief Complaint:\n 24 Hour Events:\n Tube Feed goals increased\n Calm overnight\n 3 runs of SVT peaking in 110s.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Enoxaparin (Lovenox) - 06:33 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.5\nC (97.7\n HR: 114 (61 - 122) bpm\n BP: 119/54(75) {91/36(50) - 167/84(101)} mmHg\n RR: 19 (10 - 30) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,952 mL\n 429 mL\n PO:\n TF:\n 646 mL\n 376 mL\n IVF:\n 950 mL\n 54 mL\n Blood products:\n Total out:\n 2,430 mL\n 470 mL\n Urine:\n 2,430 mL\n 240 mL\n NG:\n Stool:\n Drains:\n Balance:\n 522 mL\n -41 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 100%\n ABG: ///35/\n Physical Examination\n Gen: Alert, NAD, lying in bed, comfortable, mouthing words, less\n sedated than yest.\n HEENT: No pallor in conjunctiva, MMM, TM in place\n Resp: Transmitted upper airway sounds/coarse breath sounds.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, decreased bowel sounds, G-Tube in\n place with no erythema/induration\n Exte: No edema, DP 2+ bil\n NEURO: Alert, difficult to assess orientation due to poor voice. MAE\n Labs / Radiology\n 187 K/uL\n 7.2 g/dL\n 105 mg/dL\n 0.5 mg/dL\n 35 mEq/L\n 3.8 mEq/L\n 17 mg/dL\n 108 mEq/L\n 147 mEq/L\n 23.7 %\n 5.1 K/uL\n [image002.jpg]\n 03:00 AM\n 04:00 AM\n 05:45 AM\n 03:51 AM\n 04:45 PM\n 04:00 AM\n 07:37 PM\n 04:05 AM\n 06:05 PM\n 03:23 AM\n WBC\n 7.3\n 8.0\n 8.7\n 5.5\n 5.7\n 5.8\n 5.1\n Hct\n 27.3\n 27.0\n 28.7\n 24.7\n 25.2\n 25.3\n 23.7\n 24.7\n 23.7\n Plt\n 346\n 316\n 271\n 249\n 231\n 203\n 187\n Cr\n 0.7\n 0.7\n 0.7\n 0.5\n 0.4\n 0.5\n 0.5\n 0.5\n Glucose\n 123\n 114\n 112\n 122\n 145\n 137\n 149\n 105\n Other labs: PT / PTT / INR:13.3/32.4/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.8 mg/dL, Mg++:2.1 mg/dL, PO4:3.5\n mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Replete with Fiber () - 09:45 PM 40 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-29 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 640021,
"text": "Chief Complaint:\n 24 Hour Events:\n Tube Feed goals increased\n Calm overnight\n 3 runs of SVT peaking in 110s.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Enoxaparin (Lovenox) - 06:33 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.5\nC (97.7\n HR: 114 (61 - 122) bpm\n BP: 119/54(75) {91/36(50) - 167/84(101)} mmHg\n RR: 19 (10 - 30) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,952 mL\n 429 mL\n PO:\n TF:\n 646 mL\n 376 mL\n IVF:\n 950 mL\n 54 mL\n Blood products:\n Total out:\n 2,430 mL\n 470 mL\n Urine:\n 2,430 mL\n 240 mL\n NG:\n Stool:\n Drains:\n Balance:\n 522 mL\n -41 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 100%\n ABG: ///35/\n Physical Examination\n Gen: Alert, NAD, lying in bed, comfortable, mouthing words, less\n sedated than yest.\n HEENT: No pallor in conjunctiva, MMM, TM in place\n Resp: Transmitted upper airway sounds/coarse breath sounds.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, decreased bowel sounds, G-Tube in\n place with no erythema/induration\n Exte: No edema, DP 2+ bil\n NEURO: Alert, difficult to assess orientation due to poor voice. MAE\n Labs / Radiology\n 187 K/uL\n 7.2 g/dL\n 105 mg/dL\n 0.5 mg/dL\n 35 mEq/L\n 3.8 mEq/L\n 17 mg/dL\n 108 mEq/L\n 147 mEq/L\n 23.7 %\n 5.1 K/uL\n [image002.jpg]\n 03:00 AM\n 04:00 AM\n 05:45 AM\n 03:51 AM\n 04:45 PM\n 04:00 AM\n 07:37 PM\n 04:05 AM\n 06:05 PM\n 03:23 AM\n WBC\n 7.3\n 8.0\n 8.7\n 5.5\n 5.7\n 5.8\n 5.1\n Hct\n 27.3\n 27.0\n 28.7\n 24.7\n 25.2\n 25.3\n 23.7\n 24.7\n 23.7\n Plt\n 346\n 316\n 271\n 249\n 231\n 203\n 187\n Cr\n 0.7\n 0.7\n 0.7\n 0.5\n 0.4\n 0.5\n 0.5\n 0.5\n Glucose\n 123\n 114\n 112\n 122\n 145\n 137\n 149\n 105\n Other labs: PT / PTT / INR:13.3/32.4/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.8 mg/dL, Mg++:2.1 mg/dL, PO4:3.5\n mg/dL\n Assessment and Plan\n 56yoF s/p mechanical fall and traumatic T spine fracture with resolving\n respiratory failure and HAP s/p trach with complicating TBM and s/p\n PEG.\n .\n # Respiratory: s/p intubation/extubation, now on trach mask, FiO2 50%.\n Tolerating well with good O2 sat in mid-high 90\ns. Pt continues to be\n at risk for aspiration given new IP finding of opening defect in\n posterior vocal cord space and given recent history of vomiting with\n tube feed trials.\n - Appreciate ENT and S&S input.\n - will follow ENT recs; awaiting input for possible intervention.\n - ppi for aspiration prophylaxis, PMV precautions: \nt use w/o\n supervision, frequent suctioning\n - TM as tolerated.\n - continue scopolamine patch q72hrs for secretions\n - Holding sedation with exception of Risperidal 0.5mg PRN\n - F/u CXR tomorrow\n # Sedation/Anxiolysis/AlteredMS: Resolved O/N with risperdal. Previous\n delirium and agitation most likely secondary to long hospital course\n and multiple psychotropic medications as well as hx of EtOH abuse.\n - started Risperdal 0.5mg PO BID PRN.\n - continue to hold all benzos. opiates, and antihistamines\n - Appreciate psych. Will call and f/u psych recs.\n -Obtain EKG to assess for QTc prolongation.\n #Anemia: HCT low compared to b/l at 23.7. No known etiology of blood\n loss.\n -Will continue to follow HCT daily.\n - Guaiac stools.\n -f/u HCT this afternoon\n -T&S\n # Atrial Tachycardia: Improved HR max of 120\ns versus 160s previously.\n Pt now on PO Amiodarone 200 TID and PO metoprolol 37.5mg TID\n - Will continue amiodarone 200 TID for three weeks and then switch to\n qday for 1week and then d/c amiodarone.\n - Will need to schedule f/u in 4wks with Dr. upon d/c/transfer.\n # Hypernatremia/Fluid Status: Mild hypernatramia resolving with free\n water administration. On TPN/TF. Good UOP.\n - providing D5W IVFx 1L at 150cc/hr, free water flushes with TF\n -Will f/u lytes in afternoon (5pm)\n # UE DVT and h/o labile INR: Decision made to d/c Coumadin given her\n labile INR, and start Lovenox . INR at 1.9\n - Will flush L PICC with TPA if does not flush\n - Daily coags\n .\n # Spine fracture: Stable. T5-T8.\n - Brace for OOB, need to discuss with Neurosurgery before d/c if\n current brace is optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in .\n .\n # Tracheomalacia. Reevaluation bronchoscopy by IP as written above;\n patient not a candidate for stent; pt to follow up as outpatient. No\n new issues.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # FEN: Currently receiving TPN, restarted TF yest, currently at\n 20cc/hr, w/o issue.\n - Appreciate GI input and S&S eval\n -Cont Reglan 20mg IV Q 8 hours for emesis precaution; meds via G-J\n tube,\n -D/w GI; rec: continue bowel regimen if no BM\n .\n # ACCESS: PIV x 1, L PICC\n # Ppx: Lovenox, PPi , Bowel Regimen PRN\n # Communication:\n - (brother) is primary contact\n - Boyfriend of 10 , but minimal contact has been maintained at\n this point\n - Social Work and Case management involved; have discussed situation\n w/ brother and boyfriend.\n # Code: Full\n # Dispo: ICU, Will d/w case management re rehab facilities, likely d/c\n tomorrow if insurance/bed confirmed\n MSIV\n PGY2 addendum: , \n Agree with assessment and plan in excellent MSIV note as detailed\n above. Briefly, 56 F s/p fall with T spine fracture (T5-T8),\n respiratory failure now s/p trach/PEG. Now on trach mask. Patient s/p\n bronch with IP yesterday. Nutrition issues continue; have discontinued\n TPN today and will continue tubefeeding to goal of 60cc/hr per\n Nutrition. Will continue reglan until at goal feedings, and decrease\n and d/c as able given potential for delirium. Appreciate psych recs;\n continuing risperidone for agitation. Etiology of delirium/agitation\n still unclear but likely prolonged hospital course, illness and\n multiple medications. Currently discussing with CM about potential\n placement to rehab tomorrow.\n ICU Care\n Nutrition:\n Replete with Fiber () - 09:45 PM 40 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 640182,
"text": "Synopsis per prior nursing note:\n 56 yr old woman, who was transferred from osh for evaluation of\n tracheal bronchial malacia on .Pt presented to Medical\n Center on s/p fall down a flight of stairs fracturing, t5-t8 with\n propulsion treated conservatively with pain meds and back brace. She\n developed resp distress requiring intubation on . Trach/PEG done\n . Now with prolonged hospital course c/b by PNA, anxiety/altered\n mental status, R&LUE DVT .Pt found to have small non occlusive clot on\n her right axial vein via Ultrasound, now rec\ning Lovenox. She has had\n problems with vomiting tube feedings, so feeding tube passed through\n g-tube to her jejunenum. However, she continued to intermit raise\n gastric contents assoc with bronchospasm. Has not required ventilation\n since , on humidified TM @ 50%. Presently on TPN and restarted on\n TF\nings at low rate via J-tube.\n Airway Clearance, Impaired\n Assessment:\n LS-bilat rhonchi. O2 sat >95% on 50% trach collar. Suctioned small to\n moderate amts of thick, white secretions and pt clearing secretions\n independently with strong cough. Passy-muir valve in only while being\n evaluated by Psych d/t large amt of secretions.\n Action:\n Suctioned every one hour. Scolpolamine patch d/c\nd d/t mental status.\n Response:\n Needed suctioning every 1hour.\n Plan:\n to monitor and clear airway as needed.\n Alteration in Nutrition\n Assessment:\n Continues on replete w/fiber full strength.. Advance by 10ml q6 hours.\n Flush w/ 100 ml hour every 4 hours. Denies nausea. No vomiting.\n Mushroom cath in place.\n Action:\n J tube in place, unable to check resuduals. Increased TF as tolerated.\n Reglan d/c\nd d/t to mental status. Colace/senna/polyethylene glycol\n held.\n Response:\n Continues to have liquid stool. Currently tolerating TF.\n Plan:\n Advance TF to goal as tolerated.\n Fracture, other\n Assessment:\n Patient has a fracture of t5-t8. Denied pain. Brace on while OOB in\n chair.\n Action:\n Changed position. Brace on while OOB.\n Response:\n Continued to deny pain.\n Plan:\n Assess/treat pain. Brace on while OOB.\n Altered mental status (not Delirium)\n Assessment:\n When passy-muir valve on, patient had +VH and +AH. She was paranoid\n about her brother in hallway (brother was not at hospital). Stated that\n she will be driving her car home tomorrow. Stated that she is scared.\n Follows commands. Continues to try to pull out lines/tubes. Continues\n to throw her legs over the side of the bed.\n Action:\n w/ soft wrist restraints. Reoriented frequently. Assured patient\n that she is safe in hospital.\n Response:\n Patient remains safe. Able to be calmed when told she is safe in\n hospital.\n Plan:\n current safety plan. Reorient frequently. Psych will continue to\n follow.\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 640183,
"text": "Synopsis per prior nursing note:\n 56 yr old woman, who was transferred from osh for evaluation of\n tracheal bronchial malacia on .Pt presented to Medical\n Center on s/p fall down a flight of stairs fracturing, t5-t8 with\n propulsion treated conservatively with pain meds and back brace. She\n developed resp distress requiring intubation on . Trach/PEG done\n . Now with prolonged hospital course c/b by PNA, anxiety/altered\n mental status, R&LUE DVT .Pt found to have small non occlusive clot on\n her right axial vein via Ultrasound, now rec\ning Lovenox. She has had\n problems with vomiting tube feedings, so feeding tube passed through\n g-tube to her jejunenum. However, she continued to intermit raise\n gastric contents assoc with bronchospasm. Has not required ventilation\n since , on humidified TM @ 50%. Presently on TPN and restarted on\n TF\nings at low rate via J-tube.\n Airway Clearance, Impaired\n Assessment:\n LS-bilat rhonchi. O2 sat >95% on 50% humidified trach collar. Suctioned\n small to moderate amts of frothy and thin, white secretions and pt\n clearing secretions independently with strong cough.\n Action:\n Repositioned frequently and CPT. Suctioned q2-3hours.\n Response:\n n/a\n Plan:\n to monitor resp status and clear airway as needed.\n Alteration in Nutrition\n Assessment:\n Continues on replete w/fiber full strength.. Advance by 10ml q6 hours.\n Flush w/ 100 ml hour every 4 hours. Denies nausea. No vomiting.\n Mushroom cath in place.\n Action:\n J tube in place, unable to check resuduals. Increased TF as tolerated.\n Reglan d/c\nd d/t to mental status. Colace/senna/polyethylene glycol\n held.\n Response:\n Continues to have liquid stool. Currently tolerating TF.\n Plan:\n Advance TF to goal as tolerated.\n Fracture, other\n Assessment:\n Patient has a fracture of t5-t8. Denied pain. Brace on while OOB in\n chair.\n Action:\n Changed position. Brace on while OOB.\n Response:\n Continued to deny pain.\n Plan:\n Assess/treat pain. Brace on while OOB.\n Altered mental status (not Delirium)\n Assessment:\n When passy-muir valve on, patient had +VH and +AH. She was paranoid\n about her brother in hallway (brother was not at hospital). Stated that\n she will be driving her car home tomorrow. Stated that she is scared.\n Follows commands. Continues to try to pull out lines/tubes. Continues\n to throw her legs over the side of the bed.\n Action:\n w/ soft wrist restraints. Reoriented frequently. Assured patient\n that she is safe in hospital.\n Response:\n Patient remains safe. Able to be calmed when told she is safe in\n hospital.\n Plan:\n current safety plan. Reorient frequently. Psych will continue to\n follow.\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-29 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 640111,
"text": "Chief Complaint:\n 24 Hour Events:\n Tube Feed goals increased from 30cc to 60cc/hr. No issues O/N with\n regard to vomiting.\n Calm overnight. Risperdal decreased from 0.5mg to 0.25mg qam.\n runs of asymptomatic SVT peaking in 110-120\ns, metoprolol 37.5mg\n changed from TID\nQID and first daily dose given early after runs;\n decrease of HR to 80\n Loose, brown, malodorous stools O/N, afebrile, C.dif cx sent.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Enoxaparin (Lovenox) - 06:33 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.5\nC (97.7\n HR: 114 (61 - 122) bpm\n BP: 119/54(75) {91/36(50) - 167/84(101)} mmHg\n RR: 19 (10 - 30) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,952 mL\n 429 mL\n PO:\n TF:\n 646 mL\n 376 mL\n IVF:\n 950 mL\n 54 mL\n Blood products:\n Total out:\n 2,430 mL\n 470 mL\n Urine:\n 2,430 mL\n 240 mL\n NG:\n Stool:\n Drains:\n Balance:\n 522 mL\n -41 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 100%\n ABG: ///35/\n Physical Examination\n Gen: Alert, NAD, lying in bed, comfortable, mouthing words, less\n sedated than yest.\n HEENT: No pallor in conjunctiva, MMM, TM in place\n Resp: Transmitted upper airway sounds/coarse breath sounds.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, decreased bowel sounds, G-Tube in\n place with no erythema/induration\n Exte: No edema, DP 2+ bil\n NEURO: Alert, difficult to assess orientation due to poor voice\n although pt oriented to year not place. MAE\n Labs / Radiology\n 187 K/uL\n 7.2 g/dL\n 105 mg/dL\n 0.5 mg/dL\n 35 mEq/L\n 3.8 mEq/L\n 17 mg/dL\n 108 mEq/L\n 147 mEq/L\n 23.7 %\n 5.1 K/uL\n [image002.jpg]\n 03:00 AM\n 04:00 AM\n 05:45 AM\n 03:51 AM\n 04:45 PM\n 04:00 AM\n 07:37 PM\n 04:05 AM\n 06:05 PM\n 03:23 AM\n WBC\n 7.3\n 8.0\n 8.7\n 5.5\n 5.7\n 5.8\n 5.1\n Hct\n 27.3\n 27.0\n 28.7\n 24.7\n 25.2\n 25.3\n 23.7\n 24.7\n 23.7\n Plt\n 346\n 316\n 271\n 249\n 231\n 203\n 187\n Cr\n 0.7\n 0.7\n 0.7\n 0.5\n 0.4\n 0.5\n 0.5\n 0.5\n Glucose\n 123\n 114\n 112\n 122\n 145\n 137\n 149\n 105\n Other labs: PT / PTT / INR:13.3/32.4/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.8 mg/dL, Mg++:2.1 mg/dL, PO4:3.5\n mg/dL\n Assessment and Plan\n 56yoF s/p mechanical fall and traumatic T spine fracture transferred\n from OSH to for TBM eval with hospitalization complicated by\n respiratory failure and HAP, s/p trach/PEG, atrial tachycardia, ileus,\n and delirium/agitation.\n .\n # Respiratory: s/p intubation/extubation, now on trach mask, FiO2 50%.\n Tolerating well with good O2 sat in mid-high 90\ns. Pt continues to be\n at risk for aspiration given recent history of vomiting with tube feed\n trials and increased secretions. ENT believes that the posterior gap is\n not a risk factor for aspiration as this is a common finding in females\n and that her increased secretions and edema pose a greater aspiration\n threat; no intervention was recommended.\n - Appreciate ENT and S&S input.\n - ENT recs to f/u in 2wks with Dr. () for an\n outpatient/clinic re-evaluation.\n - ppi for aspiration prophylaxis, PMV precautions: \nt use w/o\n supervision, frequent suctioning\n - TM as tolerated.\n - d/c\ned scopolamine as it was a cause for delirium.\n - Holding sedation with exception of Risperidal 0.25mg qam PRN\n # Delirium/Anxiolysis/AlteredMS: Resolving although pt continues to be\n slightly agitated. Previous delirium and agitation most likely\n secondary to long hospital course and multiple psychotropic medications\n as well as hx of EtOH abuse.\n - Risperdal 0.25mg PO qam.\n - continue to hold all benzos. opiates, and antihistamines. Will\n decrease or d/c raglan and scopolamine.\n - Appreciate psych. Will call and f/u psych recs.\n -Follow EKG to assess for QTc prolongation (last EKG ; QTc 457).\n #Loose Stools: Multiple, loose stools O/N; afebrile, tachycardia,\n without abdominal pain\n -F/u stool c.dif cultures\n -f/u WBC and vital signs daily\n -Hold bowel regimen\n # Atrial Tachycardia: Compared to recent b/l, HR increased to max of\n 120\ns. Pt now on PO Amiodarone 200 TID and PO increased metoprolol\n 37.5mg QID.\n - Will continue amiodarone 200 TID for three weeks and then switch to\n qday for 1week and then d/c amiodarone.\n - Will need to schedule f/u in 4wks with Dr. upon d/c/transfer.\n #Anemia: HCT low compared to b/l. No known etiology of blood loss.\n -Will continue to follow HCT daily.\n - Guaiac stools.\n # Hypernatremia/Fluid Status: Mild hypernatramia resolving with free\n water administration. On TPN/TF. Good UOP. Free water deficit of 2.8L\n - increase D5W IVFx 1L from 10cc/hr to 150cc/hr, free water flushes\n with TF\n -Will f/u lytes in afternoon (5pm)\n # UE DVT and h/o labile INR: Decision made to d/c Coumadin given her\n labile INR, and start Lovenox . INR at 1.1\n - Will flush L PICC with TPA if does not flush\n - Daily coags\n .\n # Spine fracture: Stable. T5-T8.\n - Brace for OOB.\n - Pt to follow up with Dr. in .\n .\n # Tracheomalacia. Reevaluation bronchoscopy by IP as written above;\n patient not a candidate for stent; pt to follow up as outpatient. No\n new issues.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # FEN: Currently receiving TF at 50cc/hr, w/o issue.\n - Appreciate GI input and S&S eval\n -D/c Reglan for emesis precaution as pt is tolerating TF without\n vomiting and Reglan increases agitation/delirium risk.\n -meds via G-J tube,\n .\n # ACCESS: PIV x 1, L PICC\n # Ppx: Lovenox, PPi , Bowel Regimen PRN\n # Communication:\n - (brother) is primary contact\n - Boyfriend of 10 , but minimal contact has been maintained at\n this point\n - Social Work and Case management involved; have discussed situation\n w/ brother and boyfriend.\n # Code: Full\n # Dispo: ICU, Will d/w case management re rehab facilities, likely d/c\n today/tomorrow if insurance/bed confirmed\n MSIV\n PGY2 addendum: , \n Agree with assessment and plan in excellent MSIV note as detailed\n above. Briefly, 56 F s/p fall with T spine fracture (T5-T8),\n respiratory failure now s/p trach/PEG. Now on trach mask. Patient s/p\n bronch with IP yesterday. Nutrition issues continue; have discontinued\n TPN today and will continue tubefeeding to goal of 60cc/hr per\n Nutrition. Will continue reglan until at goal feedings, and decrease\n and d/c as able given potential for delirium. Appreciate psych recs;\n continuing risperidone for agitation. Etiology of delirium/agitation\n still unclear but likely prolonged hospital course, illness and\n multiple medications. Currently discussing with CM about potential\n placement to rehab tomorrow.\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 640235,
"text": "Synopsis per prior nursing note:\n 56 yr old woman, who was transferred from osh for evaluation of\n tracheal bronchial malacia on .Pt presented to Medical\n Center on s/p fall down a flight of stairs fracturing, t5-t8 with\n propulsion treated conservatively with pain meds and back brace. She\n developed resp distress requiring intubation on . Trach/PEG done\n . Now with prolonged hospital course c/b by PNA, anxiety/altered\n mental status, R&LUE DVT .Pt found to have small non occlusive clot on\n her right axial vein via Ultrasound, now rec\ning Lovenox. She has had\n problems with vomiting tube feedings, so feeding tube passed through\n g-tube to her jejunenum. However, she continued to intermit raise\n gastric contents assoc with bronchospasm. Has not required ventilation\n since , on humidified TM @ 50%. Presently on TPN and restarted on\n TF\nings at low rate via J-tube.\n Airway Clearance, Impaired\n Assessment:\n LS-bilat rhonchi. O2 sat >95% on 50% humidified trach collar. Suctioned\n small to moderate amts of frothy and thin, white secretions and pt\n clearing secretions independently with strong cough.\n Action:\n Repositioned frequently and CPT. Suctioned q2-3hours.\n Response:\n n/a\n Plan:\n Continue to monitor resp status, reposition, CPT as needed.\n Alteration in Nutrition\n Assessment:\n Pt received with tube feeds at goal 60cc/hr and 50cc free water flush\n q4hour via J-tube. Denies nausea, stomach pain or cramping. No\n vomiting. K 3.6.\n Action:\n Unable to check residuals. Tube feeds stopped at 5AM after ?tube feeds\n were suctioned from back of throat. Unlikely aspirated sats 100%.\n Colace/senna/polyethylene glycol held for loose stool. Mushroom\n catheter pulled out x2 this shift and not replaced after 2^nd time.\n Stool #2 sent for c.diff. Repleted with 40 mEq KCl.\n Response:\n Currently TF stopped, team aware.\n Plan:\n Restart TF. Monitor labs and replete lytes as needed.\n Altered mental status (not Delirium)\n Assessment:\n Alert and oriented x2. Continues to think she is in a hotel. Pt\n restless and agitated many times throughout night. Pulled out rectal\n tube x2 and foley x1 this shift. Follows commands. PERL brisk.\n Action:\n Soft wrist restraints for pt safetly to pulling at lines and hx to\n decanulating herself. Bed locked in low position and bed alarm on.\n Reoriented frequently. All meds and interventions explained.\n Response:\n Patient remains safe. Continues to throw her legs over the side of the\n bed and pull at lines.\n Plan:\n Continue current safety plan. Reorient frequently. Psych consulting.\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-30 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 640247,
"text": "Chief Complaint:\n 24 Hour Events:\n - ENT team believes that vocal cord adductor dysfunction is NOT a risk\n for aspiration, rather her increased secretions put her at risk for\n aspiration. They will follow-up in clinic in two weeks with Dr.\n , call in am to schedule appt.\n - Psych recs: consider head CT if patient does not improve off\n scopolamine and metoclopramide; address anemia and\nerratic BP\n consider increasing am dose of risperdal; monitor \n - Pt continued to be agitated O/N (eg: pulled rectal tubex2 and\n foleyx1, disoriented). To receive head CT this AM\n -HCT at 22.8 down 1pt with b/l in high 20\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.9\n HR: 77 (66 - 114) bpm\n BP: 128/40(60) {90/37(31) - 164/75(87)} mmHg\n RR: 23 (16 - 29) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,726 mL\n 595 mL\n PO:\n TF:\n 1,388 mL\n 301 mL\n IVF:\n 249 mL\n 105 mL\n Blood products:\n Total out:\n 1,666 mL\n 222 mL\n Urine:\n 836 mL\n 222 mL\n NG:\n Stool:\n Drains:\n Balance:\n 60 mL\n 373 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 100%\n ABG: ///34/\n Physical Examination\n Gen: Alert, NAD, lying in bed, comfortable, mouthing words, less\n sedated than yest.\n HEENT: No pallor in conjunctiva, MMM, TM in place\n Resp: Transmitted upper airway sounds/coarse breath sounds.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, decreased bowel sounds, G-Tube in\n place with no erythema/induration\n Exte: No edema, DP 2+ bil\n NEURO: Alert, difficult to assess orientation due to poor voice\n although pt oriented to year not place. MAE\n Labs / Radiology\n 183 K/uL\n 7.1 g/dL\n 115 mg/dL\n 0.5 mg/dL\n 34 mEq/L\n 3.6 mEq/L\n 13 mg/dL\n 106 mEq/L\n 145 mEq/L\n 22.8 %\n 5.4 K/uL\n [image002.jpg]\n 04:00 AM\n 05:45 AM\n 03:51 AM\n 04:45 PM\n 04:00 AM\n 07:37 PM\n 04:05 AM\n 06:05 PM\n 03:23 AM\n 02:54 AM\n WBC\n 8.0\n 8.7\n 5.5\n 5.7\n 5.8\n 5.1\n 5.4\n Hct\n 27.0\n 28.7\n 24.7\n 25.2\n 25.3\n 23.7\n 24.7\n 23.7\n 22.8\n Plt\n \n 183\n Cr\n 0.7\n 0.7\n 0.5\n 0.4\n 0.5\n 0.5\n 0.5\n 0.5\n Glucose\n 114\n 112\n 122\n 145\n 137\n 149\n 105\n 115\n Other labs: PT / PTT / INR:13.3/32.4/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.4 mg/dL, Mg++:1.9 mg/dL, PO4:3.6\n mg/dL\n Assessment and Plan\n 56yoF s/p mechanical fall and traumatic T spine fracture transferred\n from OSH to for TBM eval with hospitalization complicated by\n respiratory failure and HAP, s/p trach/PEG, atrial tachycardia, ileus,\n and delirium/agitation.\n .\n # Delirium: Pt continues to be agitated with paranoia and\n disorientation with paranoia and hallucinations. Delirium and agitation\n most likely secondary to long hospital course and multiple psychotropic\n medications as well as hx of EtOH abuse; yet could also be due to\n anemia. Other lab values (lytes, past LFTs within normal limits). CT of\n head at OSH negative. d/c\ned Reglan and scopolamine.\n - Consider CT of head with contrast if mental status does not improve\n this am.\n - U/A\n - Risperdal 0.25mg PO qam. Consider increasing per psych recs to 0.5mg\n if continues to be agitated.\n - continue to hold all benzos. opiates, and antihistamines. Will\n decrease or d/c raglan and scopolamine.\n - Appreciate psych. Will call and f/u psych recs.\n -Follow EKG to assess for prolongation (last EKG ; 457).\n #Anemia: HCT continues to decrease, currently at 22.8 from 23.7 with\n b/l in high 20\ns. No known etiology of blood loss.\n -Will continue to follow HCT with 1pm HCT.\n - Guaiac stools.\n -T&S. Transfuse 1unit\n # Respiratory: s/p trach on trach mask, FiO2 50%. Tolerating well with\n good O2 sat in mid-high 90\ns. Pt continues to be at risk for aspiration\n given recent history of vomiting with tube feed trials and increased\n secretions. ENT believes that the posterior gap is not a risk factor\n for aspiration as this is a common finding in females and that her\n increased secretions and edema pose a greater aspiration threat; no\n intervention was recommended.\n - Appreciate ENT and S&S input.\n - ENT recs to f/u in 2wks with Dr. () for an\n outpatient/clinic re-evaluation. Will schedule appt today.\n - ppi for aspiration prophylaxis, PMV precautions: \nt use w/o\n supervision, frequent suctioning\n - TM as tolerated.\n - Holding sedation with exception of Risperidal 0.25mg PO qam\n #Loose Stools: rectal tube pulled out x2; afebrile, HD stable, without\n abdominal pain\n -F/u stool c.dif cultures\n -f/u WBC and vital signs daily\n -Hold bowel regimen\n # Atrial Tachycardia: Stable without issue O/N. Pt now on PO Amiodarone\n 200 TID and PO metoprolol 50mg TID\n - Will continue amiodarone 200 TID for three weeks (start ?) and\n then switch to qday for 1week and then d/c amiodarone.\n - Will need to schedule f/u in 4wks with Dr. upon d/c/transfer.\n # Hypernatremia/Fluid Status: Mild hypernatramia resolving with free\n water administration. On TPN/TF. Good UOP. Free water deficit of 2.8L\n - increase D5W IVFx 1L from 10cc/hr to 150cc/hr, free water flushes\n with TF\n -Will f/u lytes in afternoon (5pm)\n # UE DVT and h/o labile INR: Decision made to d/c Coumadin given her\n labile INR, and start Lovenox . INR at 1.1\n - Will flush L PICC with TPA if does not flush\n - Daily coags\n .\n # Spine fracture: Stable. T5-T8.\n - Brace for OOB.\n - Pt to follow up with Dr. in .\n .\n # Tracheomalacia. Reevaluation bronchoscopy by IP as written above;\n patient not a candidate for stent; pt to follow up as outpatient. No\n new issues.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # FEN: Currently receiving TF at 50cc/hr, w/o issue.\n - Appreciate GI input and S&S eval\n -D/c Reglan for emesis precaution as pt is tolerating TF without\n vomiting and Reglan increases agitation/delirium risk.\n -meds via G-J tube,\n .\n # ACCESS: PIV x 1, L PICC\n # Ppx: Lovenox, PPi , Bowel Regimen PRN\n # Communication:\n - (brother) is primary contact\n - Boyfriend of 10 , but minimal contact has been maintained at\n this point\n - Social Work and Case management involved; have discussed situation\n w/ brother and boyfriend.\n # Code: Full\n # Dispo: ICU, Will d/w case management re rehab facilities, likely d/c\n today/tomorrow if insurance/bed confirmed\n MSIV\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-29 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 640108,
"text": "Chief Complaint:\n 24 Hour Events:\n Tube Feed goals increased from 30cc to 60cc/hr. No issues O/N with\n regard to vomiting.\n Calm overnight. Risperdal decreased from 0.5mg to 0.25mg qam.\n runs of asymptomatic SVT peaking in 110-120\ns, metoprolol 37.5mg\n changed from TID\nQID and first daily dose given early after runs;\n decrease of HR to 80\n Loose, brown, malodorous stools O/N, afebrile, C.dif cx sent.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Enoxaparin (Lovenox) - 06:33 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.5\nC (97.7\n HR: 114 (61 - 122) bpm\n BP: 119/54(75) {91/36(50) - 167/84(101)} mmHg\n RR: 19 (10 - 30) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,952 mL\n 429 mL\n PO:\n TF:\n 646 mL\n 376 mL\n IVF:\n 950 mL\n 54 mL\n Blood products:\n Total out:\n 2,430 mL\n 470 mL\n Urine:\n 2,430 mL\n 240 mL\n NG:\n Stool:\n Drains:\n Balance:\n 522 mL\n -41 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 100%\n ABG: ///35/\n Physical Examination\n Gen: Alert, NAD, lying in bed, comfortable, mouthing words, less\n sedated than yest.\n HEENT: No pallor in conjunctiva, MMM, TM in place\n Resp: Transmitted upper airway sounds/coarse breath sounds.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, decreased bowel sounds, G-Tube in\n place with no erythema/induration\n Exte: No edema, DP 2+ bil\n NEURO: Alert, difficult to assess orientation due to poor voice\n although pt oriented to year not place. MAE\n Labs / Radiology\n 187 K/uL\n 7.2 g/dL\n 105 mg/dL\n 0.5 mg/dL\n 35 mEq/L\n 3.8 mEq/L\n 17 mg/dL\n 108 mEq/L\n 147 mEq/L\n 23.7 %\n 5.1 K/uL\n [image002.jpg]\n 03:00 AM\n 04:00 AM\n 05:45 AM\n 03:51 AM\n 04:45 PM\n 04:00 AM\n 07:37 PM\n 04:05 AM\n 06:05 PM\n 03:23 AM\n WBC\n 7.3\n 8.0\n 8.7\n 5.5\n 5.7\n 5.8\n 5.1\n Hct\n 27.3\n 27.0\n 28.7\n 24.7\n 25.2\n 25.3\n 23.7\n 24.7\n 23.7\n Plt\n 346\n 316\n 271\n 249\n 231\n 203\n 187\n Cr\n 0.7\n 0.7\n 0.7\n 0.5\n 0.4\n 0.5\n 0.5\n 0.5\n Glucose\n 123\n 114\n 112\n 122\n 145\n 137\n 149\n 105\n Other labs: PT / PTT / INR:13.3/32.4/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.8 mg/dL, Mg++:2.1 mg/dL, PO4:3.5\n mg/dL\n Assessment and Plan\n 56yoF s/p mechanical fall and traumatic T spine fracture transferred\n from OSH to for TBM eval with hospitalization complicated by\n respiratory failure and HAP, s/p trach/PEG, atrial tachycardia, ileus,\n and delirium/agitation.\n .\n # Respiratory: s/p intubation/extubation, now on trach mask, FiO2 50%.\n Tolerating well with good O2 sat in mid-high 90\ns. Pt continues to be\n at risk for aspiration given recent history of vomiting with tube feed\n trials and increased secretions. ENT believes that the posterior gap is\n not a risk factor for aspiration as this is a common finding in females\n and that her increased secretions and edema pose a greater aspiration\n threat; no intervention was recommended.\n - Appreciate ENT and S&S input.\n - ENT recs to f/u in 2wks with Dr. () for an\n outpatient/clinic re-evaluation.\n - ppi for aspiration prophylaxis, PMV precautions: \nt use w/o\n supervision, frequent suctioning\n - TM as tolerated.\n - d/c\ned scopolamine as it was a cause for delirium.\n - Holding sedation with exception of Risperidal 0.25mg qam PRN\n #Loose Stools: Multiple, loose stools O/N; afebrile, tachycardia,\n without abdominal pain\n -F/u stool c.dif cultures\n -f/u WBC and vital signs daily\n -Hold bowel regimen\n # Atrial Tachycardia: Compared to recent b/l, HR increased to max of\n 120\ns. Pt now on PO Amiodarone 200 TID and PO increased metoprolol\n 37.5mg QID.\n - Will continue amiodarone 200 TID for three weeks and then switch to\n qday for 1week and then d/c amiodarone.\n - Will need to schedule f/u in 4wks with Dr. upon d/c/transfer.\n # Delirium/Anxiolysis/AlteredMS: Resolving although pt continues to be\n slightly agitated. Previous delirium and agitation most likely\n secondary to long hospital course and multiple psychotropic medications\n as well as hx of EtOH abuse.\n - Risperdal 0.25mg PO qam.\n - continue to hold all benzos. opiates, and antihistamines\n - Appreciate psych. Will call and f/u psych recs.\n -Follow EKG to assess for QTc prolongation (last EKG ; QTc 457).\n #Anemia: HCT low compared to b/l. No known etiology of blood loss.\n -Will continue to follow HCT daily.\n - Guaiac stools.\n # Hypernatremia/Fluid Status: Mild hypernatramia resolving with free\n water administration. On TPN/TF. Good UOP. Free water deficit of 2.8L\n - increase D5W IVFx 1L from 10cc/hr to 150cc/hr, free water flushes\n with TF\n -Will f/u lytes in afternoon (5pm)\n # UE DVT and h/o labile INR: Decision made to d/c Coumadin given her\n labile INR, and start Lovenox . INR at 1.1\n - Will flush L PICC with TPA if does not flush\n - Daily coags\n .\n # Spine fracture: Stable. T5-T8.\n - Brace for OOB.\n - Pt to follow up with Dr. in .\n .\n # Tracheomalacia. Reevaluation bronchoscopy by IP as written above;\n patient not a candidate for stent; pt to follow up as outpatient. No\n new issues.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # FEN: Currently receiving TF at 50cc/hr, w/o issue.\n - Appreciate GI input and S&S eval\n -D/c Reglan for emesis precaution as pt is tolerating TF without\n vomiting and Reglan increases agitation/delirium risk.\n -meds via G-J tube,\n .\n # ACCESS: PIV x 1, L PICC\n # Ppx: Lovenox, PPi , Bowel Regimen PRN\n # Communication:\n - (brother) is primary contact\n - Boyfriend of 10 , but minimal contact has been maintained at\n this point\n - Social Work and Case management involved; have discussed situation\n w/ brother and boyfriend.\n # Code: Full\n # Dispo: ICU, Will d/w case management re rehab facilities, likely d/c\n today/tomorrow if insurance/bed confirmed\n MSIV\n PGY2 addendum: , \n Agree with assessment and plan in excellent MSIV note as detailed\n above. Briefly, 56 F s/p fall with T spine fracture (T5-T8),\n respiratory failure now s/p trach/PEG. Now on trach mask. Patient s/p\n bronch with IP yesterday. Nutrition issues continue; have discontinued\n TPN today and will continue tubefeeding to goal of 60cc/hr per\n Nutrition. Will continue reglan until at goal feedings, and decrease\n and d/c as able given potential for delirium. Appreciate psych recs;\n continuing risperidone for agitation. Etiology of delirium/agitation\n still unclear but likely prolonged hospital course, illness and\n multiple medications. Currently discussing with CM about potential\n placement to rehab tomorrow.\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-29 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 640112,
"text": "Chief Complaint:\n 24 Hour Events:\n Tube Feed goals increased from 30cc to 60cc/hr. No issues O/N with\n regard to vomiting.\n Calm overnight. Risperdal decreased from 0.5mg to 0.25mg qam.\n runs of asymptomatic SVT peaking in 110-120\ns, metoprolol 37.5mg\n changed from TID\nQID and first daily dose given early after runs;\n decrease of HR to 80\n Loose, brown, malodorous stools O/N, afebrile, C.dif cx sent.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Enoxaparin (Lovenox) - 06:33 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.5\nC (97.7\n HR: 114 (61 - 122) bpm\n BP: 119/54(75) {91/36(50) - 167/84(101)} mmHg\n RR: 19 (10 - 30) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,952 mL\n 429 mL\n PO:\n TF:\n 646 mL\n 376 mL\n IVF:\n 950 mL\n 54 mL\n Blood products:\n Total out:\n 2,430 mL\n 470 mL\n Urine:\n 2,430 mL\n 240 mL\n NG:\n Stool:\n Drains:\n Balance:\n 522 mL\n -41 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 100%\n ABG: ///35/\n Physical Examination\n Gen: Alert, NAD, lying in bed, comfortable, mouthing words, less\n sedated than yest.\n HEENT: No pallor in conjunctiva, MMM, TM in place\n Resp: Transmitted upper airway sounds/coarse breath sounds.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, decreased bowel sounds, G-Tube in\n place with no erythema/induration\n Exte: No edema, DP 2+ bil\n NEURO: Alert, difficult to assess orientation due to poor voice\n although pt oriented to year not place. MAE\n Labs / Radiology\n 187 K/uL\n 7.2 g/dL\n 105 mg/dL\n 0.5 mg/dL\n 35 mEq/L\n 3.8 mEq/L\n 17 mg/dL\n 108 mEq/L\n 147 mEq/L\n 23.7 %\n 5.1 K/uL\n [image002.jpg]\n 03:00 AM\n 04:00 AM\n 05:45 AM\n 03:51 AM\n 04:45 PM\n 04:00 AM\n 07:37 PM\n 04:05 AM\n 06:05 PM\n 03:23 AM\n WBC\n 7.3\n 8.0\n 8.7\n 5.5\n 5.7\n 5.8\n 5.1\n Hct\n 27.3\n 27.0\n 28.7\n 24.7\n 25.2\n 25.3\n 23.7\n 24.7\n 23.7\n Plt\n 346\n 316\n 271\n 249\n 231\n 203\n 187\n Cr\n 0.7\n 0.7\n 0.7\n 0.5\n 0.4\n 0.5\n 0.5\n 0.5\n Glucose\n 123\n 114\n 112\n 122\n 145\n 137\n 149\n 105\n Other labs: PT / PTT / INR:13.3/32.4/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.8 mg/dL, Mg++:2.1 mg/dL, PO4:3.5\n mg/dL\n Assessment and Plan\n 56yoF s/p mechanical fall and traumatic T spine fracture transferred\n from OSH to for TBM eval with hospitalization complicated by\n respiratory failure and HAP, s/p trach/PEG, atrial tachycardia, ileus,\n and delirium/agitation.\n .\n # Respiratory: s/p intubation/extubation, now on trach mask, FiO2 50%.\n Tolerating well with good O2 sat in mid-high 90\ns. Pt continues to be\n at risk for aspiration given recent history of vomiting with tube feed\n trials and increased secretions. ENT believes that the posterior gap is\n not a risk factor for aspiration as this is a common finding in females\n and that her increased secretions and edema pose a greater aspiration\n threat; no intervention was recommended.\n - Appreciate ENT and S&S input.\n - ENT recs to f/u in 2wks with Dr. () for an\n outpatient/clinic re-evaluation.\n - ppi for aspiration prophylaxis, PMV precautions: \nt use w/o\n supervision, frequent suctioning\n - TM as tolerated.\n - d/c scopolamine as it was a cause for delirium.\n - Holding sedation with exception of Risperidal 0.25mg qam PRN\n # Delirium/Anxiolysis/AlteredMS: Resolving although pt continues to be\n slightly agitated. Previous delirium and agitation most likely\n secondary to long hospital course and multiple psychotropic medications\n as well as hx of EtOH abuse.\n - Risperdal 0.25mg PO qam.\n - continue to hold all benzos. opiates, and antihistamines. Will\n decrease or d/c raglan and scopolamine.\n - Appreciate psych. Will call and f/u psych recs.\n -Follow EKG to assess for QTc prolongation (last EKG ; QTc 457).\n #Loose Stools: Multiple, loose stools O/N; afebrile, tachycardia,\n without abdominal pain\n -F/u stool c.dif cultures\n -f/u WBC and vital signs daily\n -Hold bowel regimen\n # Atrial Tachycardia: Compared to recent b/l, HR increased to max of\n 120\ns. Pt now on PO Amiodarone 200 TID and PO increased metoprolol\n 37.5mg QID.\n - Will continue amiodarone 200 TID for three weeks and then switch to\n qday for 1week and then d/c amiodarone.\n - Will need to schedule f/u in 4wks with Dr. upon d/c/transfer.\n #Anemia: HCT low compared to b/l. No known etiology of blood loss.\n -Will continue to follow HCT daily.\n - Guaiac stools.\n # Hypernatremia/Fluid Status: Mild hypernatramia resolving with free\n water administration. On TPN/TF. Good UOP. Free water deficit of 2.8L\n - increase D5W IVFx 1L from 10cc/hr to 150cc/hr, free water flushes\n with TF\n -Will f/u lytes in afternoon (5pm)\n # UE DVT and h/o labile INR: Decision made to d/c Coumadin given her\n labile INR, and start Lovenox . INR at 1.1\n - Will flush L PICC with TPA if does not flush\n - Daily coags\n .\n # Spine fracture: Stable. T5-T8.\n - Brace for OOB.\n - Pt to follow up with Dr. in .\n .\n # Tracheomalacia. Reevaluation bronchoscopy by IP as written above;\n patient not a candidate for stent; pt to follow up as outpatient. No\n new issues.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # FEN: Currently receiving TF at 50cc/hr, w/o issue.\n - Appreciate GI input and S&S eval\n -D/c Reglan for emesis precaution as pt is tolerating TF without\n vomiting and Reglan increases agitation/delirium risk.\n -meds via G-J tube,\n .\n # ACCESS: PIV x 1, L PICC\n # Ppx: Lovenox, PPi , Bowel Regimen PRN\n # Communication:\n - (brother) is primary contact\n - Boyfriend of 10 , but minimal contact has been maintained at\n this point\n - Social Work and Case management involved; have discussed situation\n w/ brother and boyfriend.\n # Code: Full\n # Dispo: ICU, Will d/w case management re rehab facilities, likely d/c\n today/tomorrow if insurance/bed confirmed\n MSIV\n PGY2 addendum: , \n Agree with assessment and plan in excellent MSIV note as detailed\n above. Briefly, 56 F s/p fall with T spine fracture (T5-T8),\n respiratory failure now s/p trach/PEG. Now on trach mask. Patient s/p\n bronch with IP yesterday. Nutrition issues continue; have discontinued\n TPN today and will continue tubefeeding to goal of 60cc/hr per\n Nutrition. Will continue reglan until at goal feedings, and decrease\n and d/c as able given potential for delirium. Appreciate psych recs;\n continuing risperidone for agitation. Etiology of delirium/agitation\n still unclear but likely prolonged hospital course, illness and\n multiple medications. Currently discussing with CM about potential\n placement to rehab tomorrow.\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-31 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 640424,
"text": "Chief Complaint:\n 24 Hour Events:\n Going to rehab 10am on Saturday\n DC summary up to date\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Enoxaparin (Lovenox) - 06:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 04:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.2\nC (97.2\n HR: 72 (66 - 88) bpm\n BP: 104/63(70) {78/34(48) - 186/71(98)} mmHg\n RR: 25 (15 - 33) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,197 mL\n 380 mL\n PO:\n TF:\n 301 mL\n 285 mL\n IVF:\n 577 mL\n 95 mL\n Blood products:\n Total out:\n 867 mL\n 245 mL\n Urine:\n 867 mL\n 245 mL\n NG:\n Stool:\n Drains:\n Balance:\n 330 mL\n 135 mL\n Respiratory support\n SpO2: 98%\n ABG: ///36/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 197 K/uL\n 7.1 g/dL\n 117\n 0.6 mg/dL\n 36 mEq/L\n 4.0 mEq/L\n 11 mg/dL\n 106 mEq/L\n 146 mEq/L\n 22.7 %\n 4.9 K/uL\n [image002.jpg]\n 04:45 PM\n 04:00 AM\n 07:37 PM\n 04:05 AM\n 06:05 PM\n 03:23 AM\n 02:54 AM\n 04:14 PM\n 10:00 PM\n 03:46 AM\n WBC\n 5.7\n 5.8\n 5.1\n 5.4\n 5.2\n 4.9\n Hct\n 25.2\n 25.3\n 23.7\n 24.7\n 23.7\n 22.8\n 24.0\n 22.7\n Plt\n 83\n 185\n 197\n Cr\n 0.4\n 0.5\n 0.5\n 0.5\n 0.5\n 0.6\n Glucose\n 145\n 137\n 149\n 105\n 115\n 95\n 117\n Other labs: PT / PTT / INR:13.2/23.9/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.9 mg/dL, Mg++:1.9 mg/dL, PO4:3.6\n mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 12:00 AM 60 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-31 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 640425,
"text": "Chief Complaint:\n 24 Hour Events:\n Going to rehab 10am on Saturday\n DC summary up to date\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Enoxaparin (Lovenox) - 06:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 04:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.2\nC (97.2\n HR: 72 (66 - 88) bpm\n BP: 104/63(70) {78/34(48) - 186/71(98)} mmHg\n RR: 25 (15 - 33) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,197 mL\n 380 mL\n PO:\n TF:\n 301 mL\n 285 mL\n IVF:\n 577 mL\n 95 mL\n Blood products:\n Total out:\n 867 mL\n 245 mL\n Urine:\n 867 mL\n 245 mL\n NG:\n Stool:\n Drains:\n Balance:\n 330 mL\n 135 mL\n Respiratory support\n SpO2: 98%\n ABG: ///36/\n Physical Examination\n Gen: NAD, lying in bed, comfortable, PMV on, able to vocalize. HEENT:\n No pallor in conjunctiva, MMM, TM in place\n Resp: Transmitted upper airway sounds/coarse breath sounds, improved\n compared to yesterday.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, decreased bowel sounds, G-Tube in\n place with no s/s of infection\n Exte: No edema, DP 2+ bil\n NEURO: AxO to year (not to place or day-thinks it is\nthe day before\n \n), MAE\n Labs / Radiology\n 197 K/uL\n 7.1 g/dL\n 117\n 0.6 mg/dL\n 36 mEq/L\n 4.0 mEq/L\n 11 mg/dL\n 106 mEq/L\n 146 mEq/L\n 22.7 %\n 4.9 K/uL\n [image002.jpg]\n 04:45 PM\n 04:00 AM\n 07:37 PM\n 04:05 AM\n 06:05 PM\n 03:23 AM\n 02:54 AM\n 04:14 PM\n 10:00 PM\n 03:46 AM\n WBC\n 5.7\n 5.8\n 5.1\n 5.4\n 5.2\n 4.9\n Hct\n 25.2\n 25.3\n 23.7\n 24.7\n 23.7\n 22.8\n 24.0\n 22.7\n Plt\n 83\n 185\n 197\n Cr\n 0.4\n 0.5\n 0.5\n 0.5\n 0.5\n 0.6\n Glucose\n 145\n 137\n 149\n 105\n 115\n 95\n 117\n Other labs: PT / PTT / INR:13.2/23.9/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.9 mg/dL, Mg++:1.9 mg/dL, PO4:3.6\n mg/dL\n Assessment and Plan\n 56yoF s/p mechanical fall and traumatic T spine fracture transferred\n from OSH to for TBM eval with hospitalization complicated by\n respiratory failure and HAP, s/p trach/PEG, atrial tachycardia, ileus,\n and delirium/agitation.\n .\n # Delirium: Pt continues to be agitated with paranoia, disorientation\n and hallucinations. Most likely secondary to long hospital course and\n recent multiple psychotropic medications. Other lab values (lytes, past\n LFTs within normal limits), infections processes negative on culture.\n CT of head at OSH negative. d/c\ned Reglan and scopolamine.\n - Appreciate psych. Will call and f/u psych recs.\n -Consider CT of head with contrast if mental status does not improve\n this am.\n - Risperdal 0.25mg PO qam. Consider increasing per psych recs to 0.5mg\n if continues to be agitated. Will d/w psych re any additional meds we\n could use for night time agitation.\n - continue to hold all benzos. opiates, and antihistamines.\n -Follow EKG to assess for QTc prolongation (last EKG ; QTc 457).\n #Anemia: HCT continues to decrease, currently at 22.8 from 23.7 with\n b/l in high 20\ns. No known etiology of blood loss.\n -Will continue to follow HCT\n - Guaiac stools.\n # Respiratory: s/p trach on trach mask, FiO2 50%. Tolerating well with\n good O2 sat in mid-high 90\ns. Pt continues to be at risk for aspiration\n given recent history of vomiting with tube feed trials and increased\n secretions. ENT believes that the posterior gap is not a risk factor\n for aspiration as this is a common finding in females and that her\n increased secretions and edema pose a greater aspiration threat; no\n intervention was recommended.\n - Appreciate ENT and S&S input.\n - Pt to f/u on ^th at 3:30pm with Dr. \n () for an outpatient/clinic re-evaluation.\n - ppi for aspiration prophylaxis, PMV precautions: \nt use w/o\n supervision, frequent suctioning\n - TM as tolerated.\n - Holding sedation with exception of Risperidal 0.25mg PO qam\n #Loose Stools: rectal tube pulled out x2; afebrile, HD stable, without\n abdominal pain. Stool cdif cx negativex1.\n -F/u stool c.dif cultures\n -f/u WBC and vital signs daily\n -Hold bowel regimen\n # Atrial Tachycardia: Stable without issue O/N. Pt now on PO Amiodarone\n 200 TID and PO metoprolol 50mg TID\n - Will continue amiodarone 200 TID for three weeks (start ) and\n then switch to qday for 1week and then d/c amiodarone.\n - Will need to schedule f/u in 4wks with Dr. upon d/c/transfer.\n # Hypernatremia/Fluid Status: resolving after free water\n administration. On TPN/TF. Free water deficit of 1.6L\n - increase NS at 10cc/hr, water flushes with TF\n -Will f/u lytes \n # UE DVT and h/o labile INR: Decision made to d/c Coumadin given her\n labile INR, and start Lovenox . INR at 1.1\n - Will flush L PICC with TPA if does not flush\n - Daily coags\n .\n # Spine fracture: Stable. T5-T8.\n - Brace for OOB.\n - Pt to follow up with Dr. in .\n .\n # Tracheomalacia. Reevaluation bronchoscopy by IP as written above;\n patient not a candidate for stent; pt to follow up as outpatient. No\n new issues.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # FEN: Currently TF held secondary to possible risk of aspiration O/N;\n will increase TF back slowly to max goal.\n - Appreciate GI input and S&S eval\n -D/c\ned Reglan for emesis precaution as pt is tolerating TF without\n vomiting and Reglan increases agitation/delirium risk.\n -meds via G-J tube\n .\n # ACCESS: L PICC\n # Ppx: Lovenox, PPi , Bowel Regimen PRN currently held\n # Communication:\n - (brother) is primary contact; visiting\n patient today and aware of status and disposition\n - Boyfriend of 10 , but minimal contact has been maintained at\n this point\n - Social Work and Case management involved\n # Code: Full\n # Dispo: ICU, Will currently has bed at Rehab and waiting\n insurance approval before transfer of care.\n MSIV\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 12:00 AM 60 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 639938,
"text": "56 yr old woman, who was transferred from osh for evaluation of\n tracheal bronchial malacia on .Pt presented to Medical\n Center on s/p fall down a flight of stairs fracturing, t5-t8 with\n propulsion treated conservatively with pain meds and back brace. She\n developed resp distress requiring intubation on . Trach/PEG done\n . Now with prolonged hospital course c/b by PNA, anxiety/altered\n mental status, R&LUE DVT .Pt found to have small non occlusive clot on\n her right axial vein via Ultrasound, now rec\ning Lovenox. She has had\n problems with vomiting tube feedings, so feeding tube passed through\n g-tube to her jejunenum. However, she continued to intermit raise\n gastric contents assoc with bronchospasm. Has not required ventilation\n since , on humidified TM @ 50%. Presently on TPN and restarted on\n TF\nings at low rate via J-tube.\n Airway Clearance, Impaired\n Assessment:\n Pt conts to have a large amount of secreations, she has been requiring\n q1 hr suctioning from her trache\n light yellow in color. Her 02 SATs\n have been in the upper 90s on 50% trache mask.\n Action:\n Scopolamine patch added, freaquent suctioning\n Response:\n Large amounts of secreations through the day\n Plan:\n Cont to watch, cont with the scopolamine patch\n Altered mental status (not Delirium)\n Assessment:\n Pt was somulent this morning but was awake enough this afternoon to\n help us get her out of bed with 2 strong assists. She is able to\n follow commands but continues to require wrist restraints to keep her\n trache in place and her in bed.\n Action:\n Reperidol conts\n Response:\n Not as agitated as she has been, able to cooperate with some care\n Plan:\n Cont with the resperidol, cont to follow\n"
},
{
"category": "Respiratory ",
"chartdate": "2167-10-30 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 640225,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 42\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Tracheostomy tube:\n Type: Standard, Cuffed, Inner Cannula\n Manufacturer: Portex\n Size: 7.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 22 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: White / Thin\n Sputum source/amount: Suctioned / Small\n Comments:\n Pt has not required ventiatory assistance over past several days.\n Remains on 50% humidified trach collar.\n"
},
{
"category": "Respiratory ",
"chartdate": "2167-10-28 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 639939,
"text": "Demographics\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Tube Type\n Tracheostomy tube:\n Type: Standard, Cuffed\n Manufacturer: Portex\n Size: 7.0mm\n PMV: as tolerated\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Copious\n Visual assessment of breathing pattern: Pt off ventilatory support.\n FiO2 = 50% via trach collar.\n"
},
{
"category": "Respiratory ",
"chartdate": "2167-10-29 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 640003,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 41\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Tracheostomy tube:\n Type: Cuffed\n Manufacturer: Portex\n Size: 7.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 22 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Patient required frequent suctioning overnight for thick yellow/white\n sputum.\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 640343,
"text": "Synopsis per prior nursing note:\n 56 yr old woman, who was transferred from osh for evaluation of\n tracheal bronchial malacia on .Pt presented to Medical\n Center on s/p fall down a flight of stairs fracturing, t5-t8 with\n propulsion treated conservatively with pain meds and back brace. She\n developed resp distress requiring intubation on . Trach/PEG done\n . Now with prolonged hospital course c/b by PNA, anxiety/altered\n mental status, R&LUE DVT .Pt found to have small non occlusive clot on\n her right axial vein via Ultrasound, now rec\ning Lovenox. She has had\n problems with vomiting tube feedings, so feeding tube passed through\n g-tube to her jejunenum. However, she continued to intermit raise\n gastric contents assoc with bronchospasm. Has not required ventilation\n since , on humidified TM @ 50%. Presently on TPN and restarted on\n TF\nings at low rate via J-tube.\n BRONCHOSCOPY by IP- At 09:43 AM. Severe diffuse\n Tracheobronchomalacia, large gap posterior commisure above true vocal\n cords resulting in possible etiology of recurrent aspiration\n Airway Clearance, Impaired\n Assessment:\n LS-bilat rhonchi. O2 sat >95% on 50% trach collar. Suctioned small to\n moderate amts of thick, white/dark yellow secretions. Passy-muir valve\n on during day/while in chair. Able to cough secretions into tissue\n when passy-muir valve on.\n Action:\n Suctioned every 2 hour. Encouraged to CDB.\n Response:\n Able to cough secretions into tissue. Need for suctioning decreased\n throughout shift.\n Plan:\n to monitor and clear airway as needed. Encourage CDB.\n Alteration in Nutrition\n Assessment:\n Continues on replete w/fiber full strength. Restarted @30cc/hr. Flush\n w/ 100 ml hour every 4 hours. Denies nausea. No vomiting. Small loose\n stool in am.\n Action:\n J tube in place, unable to check residuals. Colace/senna/polyethylene\n glycol held.\n Response:\n Continues to have loose stool. Currently tolerating TF.\n Plan:\n Advance TF to goal as tolerated.\n Fracture, other\n Assessment:\n Patient has a fracture of t5-t8. Denied pain. Brace on while OOB in\n chair.\n Action:\n Changed position. Brace on while OOB.\n Response:\n Continued to deny pain.\n Plan:\n Assess/treat pain. Brace on while OOB. ? transfer to \n @ Medical Center tomorrow @ 10am.\n Altered mental status (not Delirium)\n Assessment:\n When passy-muir valve on, patient had +VH and +AH. Stated paranoid\n thoughts. Stated that she is scared. She is starting to acknowledge\n that hallucinations may not be real. Acknowledges that even though she\n her friend die, she knows that her friend is alive. Follows\n commands. Not pulling at lines/tubes very often.\n Action:\n w/ soft wrist restraints. Reoriented frequently. Assured patient\n that she is safe in hospital. Feels more calm when told that she is\n safe.\n Response:\n Patient remains safe. Able to be calmed when told she is safe in\n hospital.\n Plan:\n current safety plan. Reorient frequently. Psych will continue to\n follow.\n"
},
{
"category": "Respiratory ",
"chartdate": "2167-10-27 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 639761,
"text": "Demographics\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Tracheostomy tube:\n Type: Standard, Cuffed\n Manufacturer: Portex\n Size: 7.0mm\n PMV:Yes\n Cuff Management:\n Vol/Press:\n Cuff pressure: 23 cmH2O\n Cuff volume: mL /\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: White / Thin\n Sputum source/amount: Suctioned / Moderate\n Plan\n Next 24-48 hours: Continue to monitor patients respiratory status; sxn\n & tx as indicated.\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 638886,
"text": "Nausea / vomiting\n Assessment:\n Tube feeds started Promote\n @ 10cc/hr. via new jtube. Pt vomited ~ 1\n hr after TF started ->>coffee grounds, TF, H2O(flush). Also\n expectorating same from trach.\n Action:\n Tube feeds stopped. Zofran 4 mg.\n Response:\n No further vomiting, although pt coughing with copious thick tan\n secretions after vomiting episode.\n Plan:\n NPO. Meds given IV for now. Pt to have tube study today.\n Altered mental status (not Delirium)\n Assessment:\n Pt very agitated attempting to get OOB, legs through side rails.\n Mouthing words but difficlt to understand.\n Action:\n Frequent re-orientation. Zyprexa 5 mg x 2. MSO4 2 mg. Valium 2.5 mg.\n Response:\n 1^st dose Zyprexa seemed to have transient calming effect but then pt\n agitated again, 2^nd dose with no effect. Valium with very good effect,\n pt is sleeping but arouseable to voice.\n Plan:\n Zyprexa @ hs (usually effective). Valium 2.5 IV prn, please use\n sparingly d/t ongoing delerium. Re-orientation, emotional support.\n Hypernatremia (high sodium)\n Assessment:\n Na 148 last evening.\n Action:\n D5W c 40 KCL @ 100/hr x 1 liter. Repeat labs sent this AM.\n Response:\n Plan:\n Continue to monitor lytes.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Coughing frequently with copious thick tan secretions after vomiting.\n Asking to be suctioned, also coughing secretions to end of trach.\n Action:\n Frequent suctioning. Placed on CPAP 5/5 this AM to rest.\n Response:\n RR 22 on vent when sedated. Sats 100%\n Plan:\n Wean from vent as tolerated. Pulmonary hygiene.\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 640414,
"text": "Airway Clearance, Impaired\n Assessment:\n Cont on TM 50% O2 sats 96-94%, suct for copious amts of thin white\n secretions, bilat rhonchi, dim bases.\n Action:\n Frequent suctioning, pt able to cough up some secretions on her own\n Response:\n Pt able to cough up secretions on her own at times\n Plan:\n Cont to resp status, encourage CDB\n Altered mental status (not Delirium)\n Assessment:\n Alert/oriented with some confusion, follows commands consistently, but\n requires frequent re-direction\n Action:\n Pt oriented to place/time\n Response:\n Pt still makes attempts to remove TM despite re-direction, pt remains\n with bilat wrist restraints for safety\n Plan:\n Cont to orient pt, frequent monitor for safety\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 639825,
"text": "56 yr old woman, who was transferred from osh for evaluation of\n tracheal bronchial malacia on .Pt presented to Medical\n Center on s/p fall down a flight of stairs fracturing, t5-t8 with\n propulsion treated conservatively with pain meds and back brace. She\n developed resp distress requiring intubation on . Trach/PEG done\n . Now with prolonged hospital course c/b by PNA, anxiety/altered\n mental status, R&LUE DVT .Pt found to have small non occlusive clot on\n her right axial vein via Ultrasound, now rec\ning Lovenox. She has had\n problems with vomiting tube feedings, so feeding tube passed through\n g-tube to her jejunenum. However, she continued to intermit raise\n gastric contents assoc with bronchospasm. Has not required ventilation\n since , on humidified TM @ 50%. Presently on TPN and restarted on\n TF\nings at low rate via J-tube.\n Airway Clearance, Impaired\n Assessment:\n On 50% trach collar overnight, 02 sats 92-100%\n LS rhonchi upper, diminished bases.\n Increased sputum production overnight, strong cough.\n Episode of mucus plugging overnight with desat to <80%, quickly\n recovered with 100% 02 and suctioning.\n Action:\n Suctioned q1-2 hrs for mod/copious amt thick tan secretions.\n Trach care performed.\n AM CXR done.\n Response:\n 02 sats remain 92-100%\n Hemodynamically stable.\n Plan:\n Cont to monitor oxygenation and need for suctioning.\n Altered mental status (not Delirium)\n Assessment:\n Opens eyes, follows commands (squeezes hands), swings legs over side of\n bed, unable to assess orientation (did not use PM valve overnight r/t\n increased secretions/plugging episode.)\n Does move hands near airway and attempted to pull at J-tube/foley cath.\n Action:\n Remains in bilateral soft wrist restraints MD order.\n Response:\n Pt continues altered MS.\n :\n Cont to re-orient pt, monitor pt safety (bed low and locked, bed\n alarm).\n Evaluate need for restraints and obtain MD order.\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-29 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 640099,
"text": "Chief Complaint: Delerium\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Remains with delerium.\n Experienced episode of SVT --> responded to extra iv dose metoprolol.\n History obtained from Medical records\n Patient unable to provide history: Encephalopathy\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, Tube feeds, No(t) Parenteral nutrition\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, No(t) Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: No(t) Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 11:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.2\nC (97.2\n HR: 78 (61 - 115) bpm\n BP: 108/48(60) {91/36(50) - 156/79(101)} mmHg\n RR: 24 (17 - 30) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,952 mL\n 760 mL\n PO:\n TF:\n 646 mL\n 685 mL\n IVF:\n 950 mL\n 75 mL\n Blood products:\n Total out:\n 2,430 mL\n 610 mL\n Urine:\n 2,430 mL\n 380 mL\n NG:\n Stool:\n Drains:\n Balance:\n 522 mL\n 150 mL\n Respiratory support\n SpO2: 100%\n ABG: ///35/\n Physical Examination\n General Appearance: No(t) Well nourished, No acute distress, No(t)\n Overweight / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic,\n No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, Paradoxical), (Percussion:\n Resonant : , No(t) Hyperresonant: , No(t) Dullness : ), (Breath Sounds:\n Clear : , No(t) Crackles : , No(t) Bronchial: , No(t) Wheezes : , No(t)\n Diminished: , No(t) Absent : , No(t) Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\n Extremities: No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, No(t) Oriented (to): , Movement: Purposeful, No(t) Sedated,\n No(t) Paralyzed, Tone: Normal\n Labs / Radiology\n 7.2 g/dL\n 187 K/uL\n 105 mg/dL\n 0.5 mg/dL\n 35 mEq/L\n 3.8 mEq/L\n 17 mg/dL\n 108 mEq/L\n 147 mEq/L\n 23.7 %\n 5.1 K/uL\n [image002.jpg]\n 03:00 AM\n 04:00 AM\n 05:45 AM\n 03:51 AM\n 04:45 PM\n 04:00 AM\n 07:37 PM\n 04:05 AM\n 06:05 PM\n 03:23 AM\n WBC\n 7.3\n 8.0\n 8.7\n 5.5\n 5.7\n 5.8\n 5.1\n Hct\n 27.3\n 27.0\n 28.7\n 24.7\n 25.2\n 25.3\n 23.7\n 24.7\n 23.7\n Plt\n 346\n 316\n 271\n 249\n 231\n 203\n 187\n Cr\n 0.7\n 0.7\n 0.7\n 0.5\n 0.4\n 0.5\n 0.5\n 0.5\n Glucose\n 123\n 114\n 112\n 122\n 145\n 137\n 149\n 105\n Other labs: PT / PTT / INR:13.3/32.4/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.8 mg/dL, Mg++:2.1 mg/dL, PO4:3.5\n mg/dL\n Assessment and Plan\n T-spine fracture, delerium.\n DELERIUM -- persistent. Etiology may be related to prior EtOH use,\n contribution of medications. Intermittently oriented. Continue\n respiradol. Avoid medications that have psych complications or side\n effects.\n RESPIRATORY FAILURE -- s/p trach. Maintain trach for pulmonary\n toilet/frequent suctioning.\n TACHYCARDIA -- SVT. Continue amiodarone loading schedule. Continue\n beta-blocker, with extra doses prn if needed.\n NUTRITIONAL SUPPORT -- TF via PEJ approaching goal.\n T-SPINE FRACTURE -- s/p fall. Tolerating back brace as per ortho\n service. Activity as tolerated (up in chair).\n ASPIRATION RISK -- poor adduction of vocal cords (post. portion).\n Eventually may require intervention.\n TRANCHEOBRONCHOMALACIA -- no interventions planned at present.\n ICU Care\n Nutrition:\n Replete with Fiber () - 09:45 PM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 55 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 640220,
"text": "Synopsis per prior nursing note:\n 56 yr old woman, who was transferred from osh for evaluation of\n tracheal bronchial malacia on .Pt presented to Medical\n Center on s/p fall down a flight of stairs fracturing, t5-t8 with\n propulsion treated conservatively with pain meds and back brace. She\n developed resp distress requiring intubation on . Trach/PEG done\n . Now with prolonged hospital course c/b by PNA, anxiety/altered\n mental status, R&LUE DVT .Pt found to have small non occlusive clot on\n her right axial vein via Ultrasound, now rec\ning Lovenox. She has had\n problems with vomiting tube feedings, so feeding tube passed through\n g-tube to her jejunenum. However, she continued to intermit raise\n gastric contents assoc with bronchospasm. Has not required ventilation\n since , on humidified TM @ 50%. Presently on TPN and restarted on\n TF\nings at low rate via J-tube.\n Airway Clearance, Impaired\n Assessment:\n LS-bilat rhonchi. O2 sat >95% on 50% humidified trach collar. Suctioned\n small to moderate amts of frothy and thin, white secretions and pt\n clearing secretions independently with strong cough.\n Action:\n Repositioned frequently and CPT. Suctioned q2-3hours.\n Response:\n n/a\n Plan:\n Continue to monitor resp status, reposition, CPT as needed.\n Alteration in Nutrition\n Assessment:\n Pt received with tube feeds at goal 60cc/hr and 50cc free water flush\n q4hour via J-tube. Denies nausea, stomach pain or cramping. No\n vomiting. K 3.6.\n Action:\n Unable to check residuals. Tube feeds stopped at 5AM after ?tube feeds\n were suctioned from back of throat. Unlikely aspirated sats 100%.\n Colace/senna/polyethylene glycol held for loose stool. Mushroom\n catheter pulled out x2 this shift and not replaced after 2^nd time.\n Stool #2 sent for c.diff. Repleted with 40 mEq KCl.\n Response:\n Currently TF stopped, team aware.\n Plan:\n Restart TF. Monitor labs and replete lytes as needed.\n Altered mental status (not Delirium)\n Assessment:\n Alert and oriented x2. Continues to think she is in a hotel. Pt\n restless and agitated many times throughout night. Pulled out rectal\n tube x2 and foley x1 this shift. Follows commands. PERL brisk.\n Action:\n Soft wrist restraints for pt safetly to pulling at lines and hx to\n decanulating herself. Bed locked in low position and bed alarm on.\n Reoriented frequently. All meds and interventions explained.\n Response:\n Patient remains safe. Continues to throw her legs over the side of the\n bed and pull at lines.\n Plan:\n Continue current safety plan. Reorient frequently. Psych consulting.\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 639937,
"text": "Chief Complaint:\n 24 Hour Events:\n BRONCHOSCOPY by IP- At 09:43 AM. Severe diffuse\n Tracheobronchomalacia, large gap posterior commisure above true vocal\n cords resulting in possible etiology of recurrent aspiration\n Seen by ENT, no note from attg (Dr. re possible posterior\n augmentation.\nWill require better exam in clinic with stroboscopic\n video\n S&S PMV Eval: Pt not to have PMV without supervision and only for short\n periods of time aspiration risk and vocal cord edema with freq\n suctioning when PMV in place. Per nursing had increased secretions\n requiring deep suctioning overnight, otherwise pt is able to clear with\n productive cough.\n Restarted TF yest: 10\n20cc/hr, no issues.\n Changed PPI to per IP recs\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:05 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.1\nC (97\n HR: 86 (62 - 122) bpm\n BP: 146/61(82) {87/42(53) - 152/87(98)} mmHg\n RR: 23 (19 - 36) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 3,692 mL\n 1,252 mL\n PO:\n TF:\n 116 mL\n 116 mL\n IVF:\n 2,175 mL\n 775 mL\n Blood products:\n Total out:\n 3,790 mL\n 400 mL\n Urine:\n 3,790 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n -98 mL\n 854 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 95%\n ABG: ///32/\n Physical Examination\n Gen: Alert, NAD, lying in bed, comfortable, mouthing words, less\n sedated than yest.\n HEENT: No pallor in conjunctiva, MMM, TM in place\n Resp: Transmitted upper airway sounds/coarse breath sounds.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, decreased bowel sounds, G-Tube in\n place with no erythema/induration\n Exte: No edema, DP 2+ bil\n NEURO: Alert, difficult to assess orientation due to poor voice. MAE\n Labs / Radiology\n 203 K/uL\n 7.5 g/dL\n 149 mg/dL\n 0.5 mg/dL\n 27 mEq/L\n 4.1 mEq/L\n 14 mg/dL\n 108 mEq/L\n 143 mEq/L\n 23.7 %\n 5.8 K/uL\n [image002.jpg] Ca 8.6, Mg 2.0, P 3.7; PT/PTT/INR: 13.3/32.4/1.1\n 03:20 PM\n 03:23 AM\n 03:00 AM\n 04:00 AM\n 05:45 AM\n 03:51 AM\n 04:45 PM\n 04:00 AM\n 07:37 PM\n 04:05 AM\n WBC\n 5.7\n 7.3\n 8.0\n 8.7\n 5.5\n 5.7\n 5.8\n Hct\n 30.0\n 26.9\n 27.3\n 27.0\n 28.7\n 24.7\n 25.2\n 25.3\n 23.7\n Plt\n 356\n 346\n 316\n 271\n 249\n 231\n 203\n Cr\n 0.7\n 0.7\n 0.7\n 0.7\n 0.5\n 0.4\n 0.5\n Glucose\n 129\n 123\n 114\n 112\n 122\n 145\n 137\n Other labs: PT / PTT / INR:13.3/32.4/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.9 mg/dL, Mg++:2.1 mg/dL, PO4:3.6\n mg/dL\n Assessment and Plan\n 56yoF s/p mechanical fall and traumatic T spine fracture with resolving\n respiratory failure and HAP s/p trach with complicating TBM and s/p\n PEG.\n .\n # Respiratory: s/p intubation/extubation, now on trach mask, FiO2 50%.\n Tolerating well with good O2 sat in mid-high 90\ns. Pt continues to be\n at risk for aspiration given new IP finding of opening defect in\n posterior vocal cord space and given recent history of vomiting with\n tube feed trials.\n - Appreciate ENT and S&S input.\n - will follow ENT recs; awaiting input for possible intervention.\n - ppi for aspiration prophylaxis, PMV precautions: \nt use w/o\n supervision, frequent suctioning\n - TM as tolerated.\n - continue scopolamine patch q72hrs for secretions\n - Holding sedation with exception of Risperidal 0.5mg PRN\n - F/u CXR tomorrow\n # Sedation/Anxiolysis/AlteredMS: Resolved O/N with risperdal. Previous\n delirium and agitation most likely secondary to long hospital course\n and multiple psychotropic medications as well as hx of EtOH abuse.\n - started Risperdal 0.5mg PO BID PRN.\n - continue to hold all benzos. opiates, and antihistamines\n - Appreciate psych. Will call and f/u psych recs.\n -Obtain EKG to assess for QTc prolongation.\n #Anemia: HCT low compared to b/l at 23.7. No known etiology of blood\n loss.\n -Will continue to follow HCT daily.\n - Guaiac stools.\n -f/u HCT this afternoon\n -T&S\n # Atrial Tachycardia: Improved HR max of 120\ns versus 160s previously.\n Pt now on PO Amiodarone 200 TID and PO metoprolol 37.5mg TID\n - Will continue amiodarone 200 TID for three weeks and then switch to\n qday for 1week and then d/c amiodarone.\n - Will need to schedule f/u in 4wks with Dr. upon d/c/transfer.\n # Hypernatremia/Fluid Status: Mild hypernatramia resolving with free\n water administration. On TPN/TF. Good UOP.\n - providing D5W IVFx 1L at 150cc/hr, free water flushes with TF\n -Will f/u lytes in afternoon (5pm)\n # UE DVT and h/o labile INR: Decision made to d/c Coumadin given her\n labile INR, and start Lovenox . INR at 1.9\n - Will flush L PICC with TPA if does not flush\n - Daily coags\n .\n # Spine fracture: Stable. T5-T8.\n - Brace for OOB, need to discuss with Neurosurgery before d/c if\n current brace is optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in .\n .\n # Tracheomalacia. Reevaluation bronchoscopy by IP as written above;\n patient not a candidate for stent; pt to follow up as outpatient. No\n new issues.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # FEN: Currently receiving TPN, restarted TF yest, currently at\n 20cc/hr, w/o issue.\n - Appreciate GI input and S&S eval\n -Cont Reglan 20mg IV Q 8 hours for emesis precaution; meds via G-J\n tube,\n -D/w GI; rec: continue bowel regimen if no BM\n .\n # ACCESS: PIV x 1, L PICC\n # Ppx: Lovenox, PPi , Bowel Regimen PRN\n # Communication:\n - (brother) is primary contact\n - Boyfriend of 10 , but minimal contact has been maintained at\n this point\n - Social Work and Case management involved; have discussed situation\n w/ brother and boyfriend.\n # Code: Full\n # Dispo: ICU, Will d/w case management re rehab facilities, likely d/c\n tomorrow if insurance/bed confirmed\n MSIV\n PGY2 addendum: , \n Agree with assessment and plan in excellent MSIV note as detailed\n above. Briefly, 56 F s/p fall with T spine fracture (T5-T8),\n respiratory failure now s/p trach/PEG. Now on trach mask. Patient s/p\n bronch with IP yesterday. Nutrition issues continue; have discontinued\n TPN today and will continue tubefeeding to goal of 60cc/hr per\n Nutrition. Will continue reglan until at goal feedings, and decrease\n and d/c as able given potential for delirium. Appreciate psych recs;\n continuing risperidone for agitation. Etiology of delirium/agitation\n still unclear but likely prolonged hospital course, illness and\n multiple medications. Currently discussing with CM about potential\n placement to rehab tomorrow.\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-30 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 640328,
"text": "Chief Complaint: Delerium, respiratory failure (chronic)\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n STOOL CULTURE - At 06:33 AM\n Remains delerious, confused. Remains somewhat paranoid, but able to\n reorient. Much less agitated.\n Up in chair with brace.\n History obtained from Medical records\n Patient unable to provide history: Encephalopathy\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 PM\n Enoxaparin (Lovenox) - 06:00 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, Tube feeds, No(t) Parenteral nutrition\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation, PEG\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, No(t) Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: No(t) Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 12:02 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.1\nC (96.9\n HR: 70 (66 - 112) bpm\n BP: 96/52(61) {90/37(31) - 164/75(87)} mmHg\n RR: 22 (16 - 29) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,726 mL\n 901 mL\n PO:\n TF:\n 1,388 mL\n 301 mL\n IVF:\n 249 mL\n 330 mL\n Blood products:\n Total out:\n 1,666 mL\n 282 mL\n Urine:\n 836 mL\n 282 mL\n NG:\n Stool:\n Drains:\n Balance:\n 60 mL\n 619 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 100%\n ABG: ///34/\n Physical Examination\n General Appearance: No(t) Well nourished, No acute distress, Overweight\n / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic,\n No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: No(t) Clear : , No(t) Crackles : , No(t) Bronchial: ,\n No(t) Wheezes : , No(t) Diminished: , No(t) Absent : , Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): , Movement: Purposeful, No(t) Sedated, No(t)\n Paralyzed, Tone: Normal\n Labs / Radiology\n 7.1 g/dL\n 183 K/uL\n 115 mg/dL\n 0.5 mg/dL\n 34 mEq/L\n 3.6 mEq/L\n 13 mg/dL\n 106 mEq/L\n 145 mEq/L\n 22.8 %\n 5.4 K/uL\n [image002.jpg]\n 04:00 AM\n 05:45 AM\n 03:51 AM\n 04:45 PM\n 04:00 AM\n 07:37 PM\n 04:05 AM\n 06:05 PM\n 03:23 AM\n 02:54 AM\n WBC\n 8.0\n 8.7\n 5.5\n 5.7\n 5.8\n 5.1\n 5.4\n Hct\n 27.0\n 28.7\n 24.7\n 25.2\n 25.3\n 23.7\n 24.7\n 23.7\n 22.8\n Plt\n \n 183\n Cr\n 0.7\n 0.7\n 0.5\n 0.4\n 0.5\n 0.5\n 0.5\n 0.5\n Glucose\n 114\n 112\n 122\n 145\n 137\n 149\n 105\n 115\n Other labs: PT / PTT / INR:13.3/32.4/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.4 mg/dL, Mg++:1.9 mg/dL, PO4:3.6\n mg/dL\n Assessment and Plan\n Delerium.\n DELERIUM -- likely multifactorial. EtOH withdrawl-related,\n medications, ICU psychosis.\n RESPIRATORY FUNCTION -- stable with trach. Remains on trach collar.\n T-SPINE Fx\n will likely need new fitted brace (as pt. experienced much\n weight loss since admission). Continue PT rehab.\n TRACHEOBRONCHOMALACIA\n no further immediate plans. Will need F/U with\n IP service in future.\n VOCAL CORD DYSFUNCTION -- adduction problem. need ENT f/u in\n future.\n NUTRITIONAL SUPPORT -- TF via PEG\n FLUIDS -- euvolemic. Monitor I/O.\n REHABILITATION placement in progress.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 55 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 639073,
"text": "56 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\n with prolonged hospital course c/b by PNA, anxiety/altered mental\n status, R&LUE DVT .Pt found to have small non occlusive Clot on her\n right axial vein via Ultrasound.Yesterday. She has had problems with\n vomiting tube feedings, feeding tube passed through g-tube (g-tube in\n place with mushroom on inside so cannot pull out) to her jejunenum but\n continues vomit.\n Tachycardia, Other\n Assessment:\n HR better but still 110-130. Receiving 7.5mg lopressor IV Q4h\n Action:\n Heart rate better on lopressor. Lopressor increased to 10mg IV Q4h.\n Response:\n HR still up but is due to her agitation .\n Plan:\n Continue to monitor B/P and HR, do not hold lopressor but decrease the\n dose (ask HO)\n Assessment:\n Pt had tube studies today, contrast injected into feeding tube, it\n went into her jejuneum and went no furtere. Pt has had 2 xrayes to\n see if it has advanced at all.\n Action:\n Pt has been restarted on raglan, narcotics and other meds that slow GI\n motility have been D/C\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Hypernatremia (high sodium)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-27 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 639745,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Aggitation, remains delerious.\n Bedside bronchoscopy by IP service revealed inability of posterior\n portion of vocal cords to adduct. Unclear etiology.\n Sedated for bronchoscopy.\n 24 Hour Events:\n More awake this afternoon, less agitated, but remains confused.\n Tolerating Passe-Muir valve -> speaking but not coherent.\n History obtained from Medical records\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Enoxaparin (Lovenox) - 06:48 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG\n tube, Tracheotomy tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, Tube feeds, No(t) Parenteral nutrition\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, No(t) Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: No(t) Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 11:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.1\nC (96.9\n HR: 62 (62 - 123) bpm\n BP: 87/42(53) {87/42(53) - 179/121(130)} mmHg\n RR: 20 (18 - 31) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 4,004 mL\n 2,070 mL\n PO:\n TF:\n 137 mL\n 51 mL\n IVF:\n 2,544 mL\n 1,423 mL\n Blood products:\n Total out:\n 3,813 mL\n 1,380 mL\n Urine:\n 3,813 mL\n 1,380 mL\n NG:\n Stool:\n Drains:\n Balance:\n 191 mL\n 690 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 98%\n ABG: ///33/\n Physical Examination\n General Appearance: No(t) Well nourished, No(t) No acute distress,\n No(t) Overweight / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic,\n Sedated\n Eyes / Conjunctiva: No(t) PERRL, No(t) Pupils dilated, No(t)\n Conjunctiva pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: No(t) Normocephalic, No(t) Poor dentition,\n No(t) Endotracheal tube, No(t) NG tube, No(t) OG tube, Tracheotomy tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic,\n No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: No(t) Resonant : , No(t) Hyperresonant: , No(t) Dullness :\n ), (Breath Sounds: Clear : , No(t) Crackles : , Bronchial: Right base,\n No(t) Wheezes : , No(t) Diminished: , No(t) Absent : , No(t)\n Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended, No(t)\n Tender: , No(t) Obese, PEG\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Verbal stimuli, No(t) Oriented (to): , Movement: Purposeful, No(t)\n Sedated, No(t) Paralyzed, Tone: Normal\n Labs / Radiology\n 7.7 g/dL\n 231 K/uL\n 145 mg/dL\n 0.4 mg/dL\n 33 mEq/L\n 3.5 mEq/L\n 11 mg/dL\n 109 mEq/L\n 146 mEq/L\n 25.3 %\n 5.7 K/uL\n [image002.jpg]\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n 03:00 AM\n 04:00 AM\n 05:45 AM\n 03:51 AM\n 04:45 PM\n 04:00 AM\n WBC\n 9.5\n 5.7\n 7.3\n 8.0\n 8.7\n 5.5\n 5.7\n Hct\n 28.6\n 28.9\n 30.0\n 26.9\n 27.3\n 27.0\n 28.7\n 24.7\n 25.2\n 25.3\n Plt\n 528\n 356\n 346\n \n 231\n Cr\n 1.0\n 0.7\n 0.7\n 0.7\n 0.7\n 0.5\n 0.4\n Glucose\n 121\n 129\n 123\n 114\n 112\n 122\n 145\n Other labs: PT / PTT / INR:13.6/31.1/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.6 mg/dL, Mg++:2.0 mg/dL, PO4:3.6\n mg/dL\n Assessment and Plan\n Respiratory failure, delerium.\n RESPIRATORY FAILURE -- chronic, s/p trach. Underlying\n tracheobronchomalacia. Possible elevated right hemidiaphragm.\n Continue current care, including aspiration precautions. Maintain\n trach, monitor SaO2 --> maintain >90%.\n TRACHEOBRONCOMALACIA -- no immediate plans for IP intervention.\n VOCAL CORD dysfunction -- ENT to evaluate limited ability of posterior\n portion of cords to adduct. consult ENT service.\n RUE DVT -- anticoagulation with lovenox.\n HYPERNATREMIA -- improved with free H2O repletion. Monitor.\n A-FIB -- rate controlled on amioderone. Monitor HR.\n DELERIUM -- currently sedated from procedure. Unclear etiology.\n Concerns include medications and ICU psychosis. Psychiatry consulted.\n Respiradol dose being adjusted.\n NUTRITIONAL SUPPORT -- hope to transition TPN to TF via PEG.\n T4-T8 VETEBRAL Fx -- suportive care. Will require rehabilitation.\n ICU Care\n Nutrition:\n TPN without Lipids - 05:44 PM 43. mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n 18 Gauge - 10:14 AM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 55 minutes\n Patient is critically ill\n"
},
{
"category": "Rehab Services",
"chartdate": "2167-10-28 00:00:00.000",
"description": "Physical Therapy Evaluation Note",
"row_id": 639900,
"text": "Attending Physician:\n date: \n Medical Diagnosis / ICD 9: /\n Reason of :\n History of Present Illness / Subjective Complaint: 55 yo F originally\n admitted for questionable\n alcohol-related fall from stairs sustaining T4-8 fracture. She\n developed respiratory failure, aspiration, sepsis, ARDS, RUE DVT,\n intubated then trached on . She has been in the MICU over a\n month requiring ventilation, and has now been generally weaned to\n trach mask. She has had recurrent aspiration and emesis even with\n J-tube feeding, now requiring TPN\n Past Medical / Surgical History:\n Medications:\n Radiology:\n Labs:\n 23.7\n 7.5\n 203\n 5.8\n [image002.jpg]\n Other labs:\n Activity Orders:\n Social / Occupational History:\n Living Environment:\n Prior Functional Status / Activity Level:\n Objective Test\n Arousal / Attention / Cognition / Communication:\n Hemodynamic Response\n Aerobic Capacity\n HR\n BP\n RR\n O[2 ]sat\n HR\n BP\n RR\n O[2] sat\n RPE\n Supine\n /\n Rest\n /\n Sit\n /\n Activity\n /\n Stand\n /\n Recovery\n /\n Total distance walked:\n Minutes:\n Pulmonary Status:\n Integumentary / Vascular:\n Sensory Integrity:\n Pain / Limiting Symptoms:\n Posture:\n Range of Motion\n Muscle Performance\n Motor Function:\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion:\n Rolling:\n\n\n\n\n\n\n Supine /\n Sidelying to Sit:\n\n\n\n\n\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n\n\n\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Balance:\n Education / Communication:\n Intervention:\n Other:\n Diagnosis:\n 1.\n Airway Clearance, Impaired\n 2.\n Arousal, Attention, and Cognition, Impaired\n 3.\n Balance, Impaired\n 4.\n Knowledge, Impaired\n 5.\n Respiration / Gas Exchange, Impaired\n Clinical impression / Prognosis:\n Goals\n Time frame:\n 1.\n 2.\n 3.\n 4.\n 5.\n 6.\n Anticipated Discharge: Rehab\n Treatment Plan:\n Frequency / Duration:\n Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n"
},
{
"category": "Rehab Services",
"chartdate": "2167-10-28 00:00:00.000",
"description": "Physical Therapy Evaluation Note",
"row_id": 639905,
"text": "Attending Physician:\n date: \n Medical Diagnosis / ICD 9: /\n Reason of :\n History of Present Illness / Subjective Complaint: 55 yo F originally\n admitted from OSH c fall from stairs sustaining T8 compression fx. She\n developed respiratory failure, aspiration, sepsis, ARDS, RUE DVT,\n required prolonged intubatation and then was trached on . She has\n been in the MICU over a month requiring ventilation, and has weaned to\n trach mask. She has had recurrent aspiration and emesis with J-tube\n feeding, now requiring TPN. Pts mental status has waxed and waned since\n sedation was lifted. Pt had recent broncoscopy which revealed TBM\n Past Medical / Surgical History: See initial eval\n Medications: Risperidone, TPN, midazolam, metoprolol\n Radiology: Extensive basal atelectasis\n Labs:\n 23.7\n 7.5\n 203\n 5.8\n [image002.jpg]\n Other labs:\n Activity Orders: TLSO for OOB\n Social / Occupational History: Has boyfriend\n Environment: Lives in private home\n Prior Functional Status / Activity Level: I PTA\n Objective Test\n Arousal / Attention / Cognition / Communication: Pt very lethargic,\n eyes closed t/o 80% of evaluation. Pt following approx 50% of commands.\n Hemodynamic Response\n Aerobic Capacity\n HR\n BP\n RR\n O[2 ]sat\n HR\n BP\n RR\n O[2] sat\n RPE\n Supine\n 68\n 122/72\n 24\n 98% 50% TM\n Rest\n /\n Sit\n /\n Activity\n 78\n /\n 38\n 87-98% 50% TM\n Stand\n /\n Recovery\n /\n Total distance walked:\n Minutes:\n Pulmonary Status: Coarse upper airways, strong cough. Pt was suctioned\n via trach with moderate amounts of thin white sputum.\n Integumentary / Vascular: Trach, peg, foley, PICC\n Sensory Integrity: withdraws to pain t/o\n Pain / Limiting Symptoms: Pts mental status limited extent of\n evaluation\n Posture:\n Range of Motion\n Muscle Performance\n B UE and LE \n Pt actively moving B UE and LE in bed against gravity\n Motor Function:\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion:\n Rolling:\n\n\n\n\n X 2\n\n Supine /\n Sidelying to Sit:\n NA\n\n\n\n\n\n\n Transfer:\n NA\n\n\n\n\n\n\n Sit to Stand:\n NA\n\n\n\n\n\n\n Ambulation:\n NA\n\n\n\n\n\n\n Stairs:\n NA\n\n\n\n\n\n\n Balance: Unable to assess 2/2 pts mental status\n Education / Communication: Pt status discussed with RN\n Intervention:\n Other:\n Diagnosis:\n 55 yo f s/p fall with resultant T8 fx, with hospital course significant\n for respiratory failure and prolonged ICU stay requiring trach and peg.\n Pt presents with above impairments c/w impaired gas exchange and\n deconditioning. In comparison to prior treatment on pt shows a\n decline in function and mental status, likely related to initiation of\n new medications to treat delirium, however in this instance they have\n sedated her to the point where she is unable to participate with PT.\n Feel pt has good potential based on prior treatments to participate and\n make gains with continued PT in rehab setting, as long as sedation from\n current medications improves.\n 1.\n Airway Clearance, Impaired\n 2.\n Arousal, Attention, and Cognition, Impaired\n 3.\n Balance, Impaired\n 4.\n Knowledge, Impaired\n 5.\n Respiration / Gas Exchange, Impaired\n Clinical impression / Prognosis:\n Goals\n Time frame:\n 1.\n Follow 100% of commands\n 2.\n Maintain eyes open t/o treatment\n 3.\n Sit at EOB c CG\n 4.\n CG for bed mobility\n 5.\n 6.\n Anticipated Discharge: Rehab\n Treatment Plan: f/u mobility, balance, cognitive training, pulm\n hygiene.\n Frequency / Duration:\n 3-5xw/k\n Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-28 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 639928,
"text": "Chief Complaint: Respriatory failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n BRONCHOSCOPY - At 09:43 AM\n More wake.\n Less aggitated today.\n Up in chair with back brace this afternoon.\n Requiring more frequent suctioning, now every 1-2 hrs. Sputum thin,\n slight yellow color.\n History obtained from Medical records\n Patient unable to provide history: Encephalopathy\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:05 PM\n Enoxaparin (Lovenox) - 06:33 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, No(t) Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: No(t) Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 12:33 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.9\nC (98.5\n HR: 71 (70 - 122) bpm\n BP: 122/84(94) {115/48(66) - 167/87(98)} mmHg\n RR: 10 (10 - 36) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 3,692 mL\n 1,980 mL\n PO:\n TF:\n 116 mL\n 244 mL\n IVF:\n 2,175 mL\n 832 mL\n Blood products:\n Total out:\n 3,790 mL\n 1,180 mL\n Urine:\n 3,790 mL\n 1,180 mL\n NG:\n Stool:\n Drains:\n Balance:\n -98 mL\n 800 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 98%\n ABG: ///27/\n Physical Examination\n General Appearance: No(t) Well nourished, No acute distress, No(t)\n Overweight / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic,\n No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: Clear : , No(t) Crackles : , No(t) Bronchial: , No(t)\n Wheezes : , No(t) Diminished: , No(t) Absent : , No(t) Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese, PEG\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, No(t) Oriented (to): , Movement: Purposeful, No(t) Sedated,\n No(t) Paralyzed, Tone: Normal\n Labs / Radiology\n 7.5 g/dL\n 203 K/uL\n 149 mg/dL\n 0.5 mg/dL\n 27 mEq/L\n 4.1 mEq/L\n 14 mg/dL\n 108 mEq/L\n 143 mEq/L\n 23.7 %\n 5.8 K/uL\n [image002.jpg]\n 03:20 PM\n 03:23 AM\n 03:00 AM\n 04:00 AM\n 05:45 AM\n 03:51 AM\n 04:45 PM\n 04:00 AM\n 07:37 PM\n 04:05 AM\n WBC\n 5.7\n 7.3\n 8.0\n 8.7\n 5.5\n 5.7\n 5.8\n Hct\n 30.0\n 26.9\n 27.3\n 27.0\n 28.7\n 24.7\n 25.2\n 25.3\n 23.7\n Plt\n 356\n 346\n 316\n 271\n 249\n 231\n 203\n Cr\n 0.7\n 0.7\n 0.7\n 0.7\n 0.5\n 0.4\n 0.5\n 0.5\n Glucose\n 129\n 123\n 114\n 112\n 122\n 145\n 137\n 149\n Other labs: PT / PTT / INR:13.3/32.4/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.6 mg/dL, Mg++:2.0 mg/dL, PO4:3.7\n mg/dL\n Assessment and Plan\n Delerium.\n RESPIRATORY FAILURE -- chronic, persistent. Tracheotomy tube in place,\n with tach collar/mask. Use Passe-Muir valve as tolerated.\n INCREASED SPUTUM production -- concern for evolving LLL pneumonia.\n Monitor closely. COntinue frequent suctioning.\n T-SPINE Fx -- Back brace. Up in chair as tolerated. Ortho to F/U.\n TRACHEOBRONCHOMALAcIA -- no immediate plans for intervention at this\n time.\n VOCAL CORD DYSFUNCTION -- poor adduction of posterior portions of vocal\n cords --> ENT to further assess.\n NUTRITIONAL SUPPORT -- TF via PEG at low rate. ALso receiving TPN.\n DELERIUM -- likely due to medications and ICU. Possible contribution\n of EtOH withdraw/DT. Improved on Respiradol.\n DVT\n continue lovenox\n REHABILITATION evaluation for transfer.\n ICU Care\n Nutrition:\n Replete with Fiber () - 06:00 PM 20 mL/hour\n TPN w/ Lipids - 06:02 PM 62.5 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer:\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 55 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 639934,
"text": "Chief Complaint:\n 24 Hour Events:\n BRONCHOSCOPY by IP- At 09:43 AM. Severe diffuse\n Tracheobronchomalacia, large gap posterior commisure above true vocal\n cords resulting in possible etiology of recurrent aspiration\n Seen by ENT, no note from attg (Dr. re possible posterior\n augmentation.\nWill require better exam in clinic with stroboscopic\n video\n S&S PMV Eval: Pt not to have PMV without supervision and only for short\n periods of time aspiration risk and vocal cord edema with freq\n suctioning when PMV in place. Per nursing had increased secretions\n requiring deep suctioning overnight, otherwise pt is able to clear with\n productive cough.\n Restarted TF yest: 10\n20cc/hr, no issues.\n Changed PPI to per IP recs\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:05 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.1\nC (97\n HR: 86 (62 - 122) bpm\n BP: 146/61(82) {87/42(53) - 152/87(98)} mmHg\n RR: 23 (19 - 36) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 3,692 mL\n 1,252 mL\n PO:\n TF:\n 116 mL\n 116 mL\n IVF:\n 2,175 mL\n 775 mL\n Blood products:\n Total out:\n 3,790 mL\n 400 mL\n Urine:\n 3,790 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n -98 mL\n 854 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 95%\n ABG: ///32/\n Physical Examination\n Gen: Alert, NAD, lying in bed, comfortable, mouthing words, less\n sedated than yest.\n HEENT: No pallor in conjunctiva, MMM, TM in place\n Resp: Transmitted upper airway sounds/coarse breath sounds.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, decreased bowel sounds, G-Tube in\n place with no erythema/induration\n Exte: No edema, DP 2+ bil\n NEURO: Alert, difficult to assess orientation due to poor voice. MAE\n Labs / Radiology\n 203 K/uL\n 7.5 g/dL\n 149 mg/dL\n 0.5 mg/dL\n 27 mEq/L\n 4.1 mEq/L\n 14 mg/dL\n 108 mEq/L\n 143 mEq/L\n 23.7 %\n 5.8 K/uL\n [image002.jpg] Ca 8.6, Mg 2.0, P 3.7; PT/PTT/INR: 13.3/32.4/1.1\n 03:20 PM\n 03:23 AM\n 03:00 AM\n 04:00 AM\n 05:45 AM\n 03:51 AM\n 04:45 PM\n 04:00 AM\n 07:37 PM\n 04:05 AM\n WBC\n 5.7\n 7.3\n 8.0\n 8.7\n 5.5\n 5.7\n 5.8\n Hct\n 30.0\n 26.9\n 27.3\n 27.0\n 28.7\n 24.7\n 25.2\n 25.3\n 23.7\n Plt\n 356\n 346\n 316\n 271\n 249\n 231\n 203\n Cr\n 0.7\n 0.7\n 0.7\n 0.7\n 0.5\n 0.4\n 0.5\n Glucose\n 129\n 123\n 114\n 112\n 122\n 145\n 137\n Other labs: PT / PTT / INR:13.3/32.4/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.9 mg/dL, Mg++:2.1 mg/dL, PO4:3.6\n mg/dL\n Assessment and Plan\n 56yoF s/p mechanical fall and traumatic T spine fracture with resolving\n respiratory failure and HAP s/p trach with complicating TBM and s/p\n PEG.\n .\n # Respiratory: s/p intubation/extubation, now on trach mask, FiO2 50%.\n Tolerating well with good O2 sat in mid-high 90\ns. Pt continues to be\n at risk for aspiration given new IP finding of opening defect in\n posterior vocal cord space and given recent history of vomiting with\n tube feed trials.\n - Appreciate ENT and S&S input.\n - will follow ENT recs; awaiting input for possible intervention.\n - ppi for aspiration prophylaxis, PMV precautions: \nt use w/o\n supervision, frequent suctioning\n - TM as tolerated.\n - continue scopolamine patch q72hrs for secretions\n - Holding sedation with exception of Risperidal 0.5mg PRN\n - F/u CXR tomorrow\n .\n # FEN: Currently receiving TPN, restarted TF yest, currently at\n 20cc/hr, w/o issue.\n - Appreciate GI input and S&S eval\n -Cont Reglan 20mg IV Q 8 hours for emesis precaution; meds via G-J\n tube,\n -D/w GI; rec: continue bowel regimen if no BM\n # Sedation/Anxiolysis/AlteredMS: Resolved O/N with risperdal. Previous\n delirium and agitation most likely secondary to long hospital course\n and multiple psychotropic medications as well as hx of EtOH abuse.\n - started Risperdal 0.5mg PO BID PRN.\n - continue to hold all benzos. opiates, and antihistamines\n - Appreciate psych. Will call and f/u psych recs.\n -Obtain EKG to assess for QTc prolongation.\n #Anemia: HCT low compared to b/l at 23.7. No known etiology of blood\n loss.\n -Will continue to follow HCT daily.\n - Guaiac stools.\n -f/u HCT this afternoon\n -T&S\n # Tachycardia: Improved HR max of 120\ns versus 160s previously. Pt now\n on PO Amiodarone 200 TID and PO metoprolol 37.5mg TID\n - Will continue amiodarone 200 TID for three weeks and then switch to\n qday for 1week and then d/c amiodarone.\n - Will need to schedule f/u in 4wks with Dr. upon d/c/transfer.\n # Hypernatremia/Fluid Status: Mild hypernatramia resolving with free\n water administration. On TPN/TF. Good UOP.\n - providing D5W IVFx 1L at 150cc/hr, free water flushes with TF\n -Will f/u lytes in afternoon (5pm)\n # UE DVT and h/o labile INR: Decision made to d/c Coumadin given her\n labile INR, and start Lovenox . INR at 1.9\n - Will flush L PICC with TPA if does not flush\n - Daily coags\n .\n # Spine fracture: Stable\n - Brace for OOB, need to discuss with Neurosurgery before d/c if\n current brace is optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in .\n .\n # Tracheomalacia. Reevaluation bronchoscopy by IP as written above;\n patient not a candidate for stent; pt to follow up as outpatient. No\n new issues.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # ACCESS: PIV x 1, L PICC\n # Ppx: Lovenox, PPi , Bowel Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n - Social Work and Case management involved; have discussed situation\n w/ brother and boyfriend.\n # Code: Full\n # Dispo: ICU, Will d/w case management re rehab facilities. Need to\n complete d/c summary.\n MSIV\n PGY2 addendum:\n Agree with assessment and plan in MSIV note as detailed above.\n Briefly, 56 F s/p fall with T spine fracture, respiratory failure now\n s/p trach/PEG. Now on trach mask. Patient s/p bronch with IP today;\n ENT to see and follow for ?intervention. Nutrition issues continue;\n will receive TPN today plus possible restart of tube feeds as tolerated\n (later today), continue reglan. Appreciate psych recs; continuing\n risperidone for agitation. Etiology of delirium/agitation still\n unclear. Likely eventual dispo to rehab facility directly from ICU\n given high nursing requirements.\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-29 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 640059,
"text": "Chief Complaint:\n 24 Hour Events:\n Tube Feed goals increased from 30cc to 60cc/hr. No issues O/N with\n regard to vomiting.\n Calm overnight. Risperdal decreased from 0.5mg to 0.25mg qam.\n 3 runs of SVT peaking in 110-120\ns, metoprolol 37.5mg changed from\n TID\nQID; given with decrease of HR to 80\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Enoxaparin (Lovenox) - 06:33 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.5\nC (97.7\n HR: 114 (61 - 122) bpm\n BP: 119/54(75) {91/36(50) - 167/84(101)} mmHg\n RR: 19 (10 - 30) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,952 mL\n 429 mL\n PO:\n TF:\n 646 mL\n 376 mL\n IVF:\n 950 mL\n 54 mL\n Blood products:\n Total out:\n 2,430 mL\n 470 mL\n Urine:\n 2,430 mL\n 240 mL\n NG:\n Stool:\n Drains:\n Balance:\n 522 mL\n -41 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 100%\n ABG: ///35/\n Physical Examination\n Gen: Alert, NAD, lying in bed, comfortable, mouthing words, less\n sedated than yest.\n HEENT: No pallor in conjunctiva, MMM, TM in place\n Resp: Transmitted upper airway sounds/coarse breath sounds.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, decreased bowel sounds, G-Tube in\n place with no erythema/induration\n Exte: No edema, DP 2+ bil\n NEURO: Alert, difficult to assess orientation due to poor voice. MAE\n Labs / Radiology\n 187 K/uL\n 7.2 g/dL\n 105 mg/dL\n 0.5 mg/dL\n 35 mEq/L\n 3.8 mEq/L\n 17 mg/dL\n 108 mEq/L\n 147 mEq/L\n 23.7 %\n 5.1 K/uL\n [image002.jpg]\n 03:00 AM\n 04:00 AM\n 05:45 AM\n 03:51 AM\n 04:45 PM\n 04:00 AM\n 07:37 PM\n 04:05 AM\n 06:05 PM\n 03:23 AM\n WBC\n 7.3\n 8.0\n 8.7\n 5.5\n 5.7\n 5.8\n 5.1\n Hct\n 27.3\n 27.0\n 28.7\n 24.7\n 25.2\n 25.3\n 23.7\n 24.7\n 23.7\n Plt\n 346\n 316\n 271\n 249\n 231\n 203\n 187\n Cr\n 0.7\n 0.7\n 0.7\n 0.5\n 0.4\n 0.5\n 0.5\n 0.5\n Glucose\n 123\n 114\n 112\n 122\n 145\n 137\n 149\n 105\n Other labs: PT / PTT / INR:13.3/32.4/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.8 mg/dL, Mg++:2.1 mg/dL, PO4:3.5\n mg/dL\n Assessment and Plan\n 56yoF s/p mechanical fall and traumatic T spine fracture with resolving\n respiratory failure and HAP s/p trach with complicating TBM and s/p\n PEG.\n .\n # Respiratory: s/p intubation/extubation, now on trach mask, FiO2 50%.\n Tolerating well with good O2 sat in mid-high 90\ns. Pt continues to be\n at risk for aspiration given new IP finding of opening defect in\n posterior vocal cord space and given recent history of vomiting with\n tube feed trials.\n - Appreciate ENT and S&S input.\n - will follow ENT recs; awaiting input for possible intervention.\n - ppi for aspiration prophylaxis, PMV precautions: \nt use w/o\n supervision, frequent suctioning\n - TM as tolerated.\n - continue scopolamine patch q72hrs for secretions\n - Holding sedation with exception of Risperidal 0.25mg qam PRN\n # Atrial Tachycardia: Compared to recent b/l, HR increased to max of\n 120\ns. Pt now on PO Amiodarone 200 TID and PO increased metoprolol\n 37.5mg QID.\n - Will continue amiodarone 200 TID for three weeks and then switch to\n qday for 1week and then d/c amiodarone.\n - Will need to schedule f/u in 4wks with Dr. upon d/c/transfer.\n # Sedation/Anxiolysis/AlteredMS: Resolving. Previous delirium and\n agitation most likely secondary to long hospital course and multiple\n psychotropic medications as well as hx of EtOH abuse.\n - Risperdal 0.25mg PO qam PRN.\n - continue to hold all benzos. opiates, and antihistamines\n - Appreciate psych. Will call and f/u psych recs.\n -Follow EKG to assess for QTc prolongation (last EKG ; QTc 457).\n #Anemia: HCT low compared to b/l at 23.7. No known etiology of blood\n loss.\n -Will continue to follow HCT daily.\n - Guaiac stools.\n -f/u HCT this afternoon\n -T&S\n # Hypernatremia/Fluid Status: Mild hypernatramia resolving with free\n water administration. On TPN/TF. Good UOP.\n - increase D5W IVFx 1L from 10cc/hr to 150cc/hr, free water flushes\n with TF\n -Will f/u lytes in afternoon (5pm)\n # UE DVT and h/o labile INR: Decision made to d/c Coumadin given her\n labile INR, and start Lovenox . INR at 1.1\n - Will flush L PICC with TPA if does not flush\n - Daily coags\n .\n # Spine fracture: Stable. T5-T8.\n - Brace for OOB, need to discuss with Neurosurgery before d/c if\n current brace is optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in .\n .\n # Tracheomalacia. Reevaluation bronchoscopy by IP as written above;\n patient not a candidate for stent; pt to follow up as outpatient. No\n new issues.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # FEN: Currently receiving TPN, restarted TF yest, currently at\n 20cc/hr, w/o issue.\n - Appreciate GI input and S&S eval\n -Cont Reglan 20mg IV Q 8 hours for emesis precaution; meds via G-J\n tube,\n -D/w GI; rec: continue bowel regimen if no BM\n .\n # ACCESS: PIV x 1, L PICC\n # Ppx: Lovenox, PPi , Bowel Regimen PRN\n # Communication:\n - (brother) is primary contact\n - Boyfriend of 10 , but minimal contact has been maintained at\n this point\n - Social Work and Case management involved; have discussed situation\n w/ brother and boyfriend.\n # Code: Full\n # Dispo: ICU, Will d/w case management re rehab facilities, likely d/c\n tomorrow if insurance/bed confirmed\n MSIV\n PGY2 addendum: , \n Agree with assessment and plan in excellent MSIV note as detailed\n above. Briefly, 56 F s/p fall with T spine fracture (T5-T8),\n respiratory failure now s/p trach/PEG. Now on trach mask. Patient s/p\n bronch with IP yesterday. Nutrition issues continue; have discontinued\n TPN today and will continue tubefeeding to goal of 60cc/hr per\n Nutrition. Will continue reglan until at goal feedings, and decrease\n and d/c as able given potential for delirium. Appreciate psych recs;\n continuing risperidone for agitation. Etiology of delirium/agitation\n still unclear but likely prolonged hospital course, illness and\n multiple medications. Currently discussing with CM about potential\n placement to rehab tomorrow.\n ICU Care\n Nutrition:\n Replete with Fiber () - 09:45 PM 40 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 639874,
"text": "Chief Complaint:\n 24 Hour Events:\n BRONCHOSCOPY by IP- At 09:43 AM. Severe diffuse\n Tracheobronchomalacia, large gap posterior commisure above true vocal\n cords resulting in possible etiology of recurrent aspiration\n Seen by ENT, no note from attg (Dr. re possible posterior\n augmentation.\nWill require better exam in clinic with stroboscopic\n video\n S&S PMV Eval: Pt not to have PMV without supervision and only for short\n periods of time aspiration risk and vocal cord edema with freq\n suctioning when PMV in place. Per nursing had increased secretions\n requiring deep suctioning overnight, otherwise pt is able to clear with\n productive cough.\n Restarted TF yest: 10\n20cc/hr, no issues.\n Changed PPI to per IP recs\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:05 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.1\nC (97\n HR: 86 (62 - 122) bpm\n BP: 146/61(82) {87/42(53) - 152/87(98)} mmHg\n RR: 23 (19 - 36) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 3,692 mL\n 1,252 mL\n PO:\n TF:\n 116 mL\n 116 mL\n IVF:\n 2,175 mL\n 775 mL\n Blood products:\n Total out:\n 3,790 mL\n 400 mL\n Urine:\n 3,790 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n -98 mL\n 854 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 95%\n ABG: ///32/\n Physical Examination\n Gen: Alert, NAD, lying in bed, comfortable, mouthing words, less\n sedated than yest.\n HEENT: No pallor in conjunctiva, MMM, TM in place\n Resp: Transmitted upper airway sounds/coarse breath sounds.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, decreased bowel sounds, G-Tube in\n place with no erythema/induration\n Exte: No edema, DP 2+ bil\n NEURO: Alert, difficult to assess orientation due to poor voice.\n Labs / Radiology\n 203 K/uL\n 7.5 g/dL\n 149 mg/dL\n 0.5 mg/dL\n 27 mEq/L\n 4.1 mEq/L\n 14 mg/dL\n 108 mEq/L\n 143 mEq/L\n 23.7 %\n 5.8 K/uL\n [image002.jpg] Ca 8.6, Mg 2.0, P 3.7; PT/PTT/INR: 13.3/32.4/1.1\n 03:20 PM\n 03:23 AM\n 03:00 AM\n 04:00 AM\n 05:45 AM\n 03:51 AM\n 04:45 PM\n 04:00 AM\n 07:37 PM\n 04:05 AM\n WBC\n 5.7\n 7.3\n 8.0\n 8.7\n 5.5\n 5.7\n 5.8\n Hct\n 30.0\n 26.9\n 27.3\n 27.0\n 28.7\n 24.7\n 25.2\n 25.3\n 23.7\n Plt\n 356\n 346\n 316\n 271\n 249\n 231\n 203\n Cr\n 0.7\n 0.7\n 0.7\n 0.7\n 0.5\n 0.4\n 0.5\n Glucose\n 129\n 123\n 114\n 112\n 122\n 145\n 137\n Other labs: PT / PTT / INR:13.3/32.4/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.9 mg/dL, Mg++:2.1 mg/dL, PO4:3.6\n mg/dL\n Assessment and Plan\n 56yoF s/p mechanical fall and traumatic T spine fracture with resolving\n respiratory failure and HAP s/p trach with complicating TBM and s/p\n PEG.\n .\n # Respiratory: s/p intubation/extubation, now on trach mask, FiO2 50%.\n Tolerating well with good O2 sat in mid-high 90\ns. Pt continues to be\n at risk for aspiration given new IP finding of opening defect in\n posterior vocal cord space and given recent history of vomiting with\n tube feed trials.\n - Appreciate ENT and S&S input.\n - will follow ENT recs; awaiting input for possible intervention.\n - ppi for aspiration prophylaxis\n - Trach mask as tolerated.\n - scopolamine patch q72hrs for secretions\n - Holding sedation with exception of Risperidal 0.5mg PRN\n - F/u CXR tomorrow\n - PMV precautions: \nt use w/o supervision, frequent suctioning\n .\n # FEN: Currently receiving TPN, restarted TF yest, currently at\n 20cc/hr, w/o issue.\n - Appreciate S&S eval\n - Cont Reglan 20mg IV Q 8 hours for emesis precaution; meds via G-J\n tube,\n - Will f/u GI recs\n .\n # Tachycardia: Improved HR max of 120\ns versus 160s previously. Pt now\n on PO Amiodarone 200 TID and PO metoprolol 37.5mg TID\n - Will continue amiodarone 200 TID for three weeks and then switch to\n qday for 1week and then d/c amiodarone.\n - Will need to schedule f/u in 4wks with Dr. upon d/c/transfer.\n # Sedation/Anxiolysis/AlteredMS: Resolved O/N with risperdal. Previous\n delirium and agitation most likely secondary to long hospital course\n and multiple psychotropic medications as well as hx of EtOH abuse.\n - started Risperdal 0.5mg PO BID PRN.\n - continue to hold all benzos. opiates, and antihistamines\n - Appreciate psych. Will call and f/u psych recs.\n -Obtain EKG to assess for QTc prolongation.\n #Anemia: HCT low compared to b/l at 23.7. No known etiology of blood\n loss.\n -Will continue to follow HCT daily.\n # Hypernatremia/Fluid Status: Mild hypernatramia resolving with free\n water administration. On TPN/TF. Good UOP.\n - providing D5W IVFx 1L at 150cc/hr, free water flushes with TF\n -Will f/u lytes in afternoon (5pm)\n # UE DVT and h/o labile INR: Decision made to d/c Coumadin given her\n labile INR, and start Lovenox . INR at 1.9\n - Will flush L PICC with TPA if does not flush\n - Daily coags\n .\n # Spine fracture: Stable\n - Brace for OOB, need to discuss with Neurosurgery before d/c if\n current brace is optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in .\n .\n # Tracheomalacia. Reevaluation bronchoscopy by IP as written above;\n patient not a candidate for stent; pt to follow up as outpatient. No\n new issues.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # ACCESS: PIV x 1, L PICC\n # Ppx: Lovenox, PPi , Bowel Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n - Social Work and Case management involved; have discussed situation\n w/ brother and boyfriend.\n # Code: Full\n # Dispo: ICU, Will d/w case management re rehab facilities.\n MSIV\n PGY2 addendum:\n Agree with assessment and plan in MSIV note as detailed above.\n Briefly, 56 F s/p fall with T spine fracture, respiratory failure now\n s/p trach/PEG. Now on trach mask. Patient s/p bronch with IP today;\n ENT to see and follow for ?intervention. Nutrition issues continue;\n will receive TPN today plus possible restart of tube feeds as tolerated\n (later today), continue reglan. Appreciate psych recs; continuing\n risperidone for agitation. Etiology of delirium/agitation still\n unclear. Likely eventual dispo to rehab facility directly from ICU\n given high nursing requirements.\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-28 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 639909,
"text": "Chief Complaint: Respriatory failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n BRONCHOSCOPY - At 09:43 AM\n More wake.\n Less aggitated today.\n Up in chair with back brace this afternoon.\n Requiring more frequent suctioning, now every 1-2 hrs. Sputum thin,\n slight yellow color.\n History obtained from Medical records\n Patient unable to provide history: Encephalopathy\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:05 PM\n Enoxaparin (Lovenox) - 06:33 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, No(t) Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: No(t) Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 12:33 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.9\nC (98.5\n HR: 71 (70 - 122) bpm\n BP: 122/84(94) {115/48(66) - 167/87(98)} mmHg\n RR: 10 (10 - 36) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 3,692 mL\n 1,980 mL\n PO:\n TF:\n 116 mL\n 244 mL\n IVF:\n 2,175 mL\n 832 mL\n Blood products:\n Total out:\n 3,790 mL\n 1,180 mL\n Urine:\n 3,790 mL\n 1,180 mL\n NG:\n Stool:\n Drains:\n Balance:\n -98 mL\n 800 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 98%\n ABG: ///27/\n Physical Examination\n General Appearance: No(t) Well nourished, No acute distress, No(t)\n Overweight / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic,\n No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: Clear : , No(t) Crackles : , No(t) Bronchial: , No(t)\n Wheezes : , No(t) Diminished: , No(t) Absent : , No(t) Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese, PEG\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, No(t) Oriented (to): , Movement: Purposeful, No(t) Sedated,\n No(t) Paralyzed, Tone: Normal\n Labs / Radiology\n 7.5 g/dL\n 203 K/uL\n 149 mg/dL\n 0.5 mg/dL\n 27 mEq/L\n 4.1 mEq/L\n 14 mg/dL\n 108 mEq/L\n 143 mEq/L\n 23.7 %\n 5.8 K/uL\n [image002.jpg]\n 03:20 PM\n 03:23 AM\n 03:00 AM\n 04:00 AM\n 05:45 AM\n 03:51 AM\n 04:45 PM\n 04:00 AM\n 07:37 PM\n 04:05 AM\n WBC\n 5.7\n 7.3\n 8.0\n 8.7\n 5.5\n 5.7\n 5.8\n Hct\n 30.0\n 26.9\n 27.3\n 27.0\n 28.7\n 24.7\n 25.2\n 25.3\n 23.7\n Plt\n 356\n 346\n 316\n 271\n 249\n 231\n 203\n Cr\n 0.7\n 0.7\n 0.7\n 0.7\n 0.5\n 0.4\n 0.5\n 0.5\n Glucose\n 129\n 123\n 114\n 112\n 122\n 145\n 137\n 149\n Other labs: PT / PTT / INR:13.3/32.4/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.6 mg/dL, Mg++:2.0 mg/dL, PO4:3.7\n mg/dL\n Assessment and Plan\n Delerium.\n RESPIRATORY FAILURE -- chronic, persistent. Tracheotomy tube in place,\n with tach collar/mask. Use Passe-Muir valve as tolerated.\n INCREASED SPUTUM production -- concern for evolving LLL pneumonia.\n Monitor closely. COntinue frequent suctioning.\n T-SPINE Fx -- Back brace. Up in chair as tolerated. Ortho to F/U.\n TRACHEOBRONCHOMALAcIA -- no immediate plans for intervention at this\n time.\n VOCAL CORD DYSFUNCTION -- poor adduction of posterior portions of vocal\n cords --> ENT to further assess.\n NUTRITIONAL SUPPORT -- TF via PEG at low rate. ALso receiving TPN.\n DELERIUM -- likely due to medications and ICU. Possible contribution\n Improved on Respiradol.\n DVT -- lovenox\n REHABILITATION evaluation for transfer.\n ICU Care\n Nutrition:\n Replete with Fiber () - 06:00 PM 20 mL/hour\n TPN w/ Lipids - 06:02 PM 62.5 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer:\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 55 minutes\n Patient is critically ill\n"
},
{
"category": "Nutrition",
"chartdate": "2167-10-28 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 639931,
"text": "Subjective\n Pt sitting in chair, appears comfortable\n Objective\n Pertinent medications: noted\n Labs:\n Value\n Date\n Glucose\n 149 mg/dL\n 04:05 AM\n Glucose Finger Stick\n 134\n 10:00 AM\n BUN\n 14 mg/dL\n 04:05 AM\n Creatinine\n 0.5 mg/dL\n 04:05 AM\n Sodium\n 143 mEq/L\n 04:05 AM\n Potassium\n 4.1 mEq/L\n 04:05 AM\n Chloride\n 108 mEq/L\n 04:05 AM\n Albumin\n 3.1 g/dL\n 03:23 AM\n Calcium non-ionized\n 8.6 mg/dL\n 04:05 AM\n Phosphorus\n 3.7 mg/dL\n 04:05 AM\n Ionized Calcium\n 1.24 mmol/L\n 02:51 AM\n Magnesium\n 2.0 mg/dL\n 04:05 AM\n ALT\n 25 IU/L\n 07:34 AM\n Alkaline Phosphate\n 106 IU/L\n 07:34 AM\n AST\n 19 IU/L\n 07:34 AM\n Amylase\n 10 IU/L\n 03:59 AM\n Total Bilirubin\n 0.2 mg/dL\n 07:34 AM\n Triglyceride\n 109 mg/dL\n 03:51 AM\n WBC\n 5.8 K/uL\n 04:05 AM\n Hgb\n 7.5 g/dL\n 04:05 AM\n Hematocrit\n 23.7 %\n 04:05 AM\n Current diet order / nutrition support: i/2 strength Replte c/ Fiber\n @30mL/hr\n GI: Abd obese/hypo bs\n Assessment of Nutritional Status\n Estimation of current intake: Adequate until TPN off at 6 pm\n Specifics:\n TF\ns retrialed, were tolerated up to 20mL/hr-now off cannot infuse\n c/ apparatus needed around torso while in chair. TPN rec were paged\n this am as pt c/ long h/o intolerance to TF\ns, to continue until TF\n tolerance established. TPN ordered then d/c\nd. Will need to change TF\n goal rate to better meet needs and have low threshold for resuming TPN\n if intolerance to TF occurs.\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: TF\n Tube feeding recommendations: Change TF to Replete c/ Fiber @60mL/hr\n (1440 kcals/89 gr aa)\n MOnitor tolerance via abd exam/pt complaints/BM's\n BG management as you are\n If pt does not tolerateTF's will need to resume TPN\n Will follow- please call c/ ?\ns #\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 639932,
"text": "Chief Complaint:\n 24 Hour Events:\n BRONCHOSCOPY by IP- At 09:43 AM. Severe diffuse\n Tracheobronchomalacia, large gap posterior commisure above true vocal\n cords resulting in possible etiology of recurrent aspiration\n Seen by ENT, no note from attg (Dr. re possible posterior\n augmentation.\nWill require better exam in clinic with stroboscopic\n video\n S&S PMV Eval: Pt not to have PMV without supervision and only for short\n periods of time aspiration risk and vocal cord edema with freq\n suctioning when PMV in place. Per nursing had increased secretions\n requiring deep suctioning overnight, otherwise pt is able to clear with\n productive cough.\n Restarted TF yest: 10\n20cc/hr, no issues.\n Changed PPI to per IP recs\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:05 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.1\nC (97\n HR: 86 (62 - 122) bpm\n BP: 146/61(82) {87/42(53) - 152/87(98)} mmHg\n RR: 23 (19 - 36) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 3,692 mL\n 1,252 mL\n PO:\n TF:\n 116 mL\n 116 mL\n IVF:\n 2,175 mL\n 775 mL\n Blood products:\n Total out:\n 3,790 mL\n 400 mL\n Urine:\n 3,790 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n -98 mL\n 854 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 95%\n ABG: ///32/\n Physical Examination\n Gen: Alert, NAD, lying in bed, comfortable, mouthing words, less\n sedated than yest.\n HEENT: No pallor in conjunctiva, MMM, TM in place\n Resp: Transmitted upper airway sounds/coarse breath sounds.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, decreased bowel sounds, G-Tube in\n place with no erythema/induration\n Exte: No edema, DP 2+ bil\n NEURO: Alert, difficult to assess orientation due to poor voice. MAE\n Labs / Radiology\n 203 K/uL\n 7.5 g/dL\n 149 mg/dL\n 0.5 mg/dL\n 27 mEq/L\n 4.1 mEq/L\n 14 mg/dL\n 108 mEq/L\n 143 mEq/L\n 23.7 %\n 5.8 K/uL\n [image002.jpg] Ca 8.6, Mg 2.0, P 3.7; PT/PTT/INR: 13.3/32.4/1.1\n 03:20 PM\n 03:23 AM\n 03:00 AM\n 04:00 AM\n 05:45 AM\n 03:51 AM\n 04:45 PM\n 04:00 AM\n 07:37 PM\n 04:05 AM\n WBC\n 5.7\n 7.3\n 8.0\n 8.7\n 5.5\n 5.7\n 5.8\n Hct\n 30.0\n 26.9\n 27.3\n 27.0\n 28.7\n 24.7\n 25.2\n 25.3\n 23.7\n Plt\n 356\n 346\n 316\n 271\n 249\n 231\n 203\n Cr\n 0.7\n 0.7\n 0.7\n 0.7\n 0.5\n 0.4\n 0.5\n Glucose\n 129\n 123\n 114\n 112\n 122\n 145\n 137\n Other labs: PT / PTT / INR:13.3/32.4/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.9 mg/dL, Mg++:2.1 mg/dL, PO4:3.6\n mg/dL\n Assessment and Plan\n 56yoF s/p mechanical fall and traumatic T spine fracture with resolving\n respiratory failure and HAP s/p trach with complicating TBM and s/p\n PEG.\n .\n # Respiratory: s/p intubation/extubation, now on trach mask, FiO2 50%.\n Tolerating well with good O2 sat in mid-high 90\ns. Pt continues to be\n at risk for aspiration given new IP finding of opening defect in\n posterior vocal cord space and given recent history of vomiting with\n tube feed trials.\n - Appreciate ENT and S&S input.\n - will follow ENT recs; awaiting input for possible intervention.\n - ppi for aspiration prophylaxis\n - Trach mask as tolerated.\n - scopolamine patch q72hrs for secretions\n - Holding sedation with exception of Risperidal 0.5mg PRN\n - F/u CXR tomorrow\n - PMV precautions: \nt use w/o supervision, frequent suctioning\n .\n # FEN: Currently receiving TPN, restarted TF yest, currently at\n 20cc/hr, w/o issue.\n - Appreciate S&S eval\n - Cont Reglan 20mg IV Q 8 hours for emesis precaution; meds via G-J\n tube,\n - Will f/u GI recs\n -D/w GI 00\n .\n # Tachycardia: Improved HR max of 120\ns versus 160s previously. Pt now\n on PO Amiodarone 200 TID and PO metoprolol 37.5mg TID\n - Will continue amiodarone 200 TID for three weeks and then switch to\n qday for 1week and then d/c amiodarone.\n - Will need to schedule f/u in 4wks with Dr. upon d/c/transfer.\n # Sedation/Anxiolysis/AlteredMS: Resolved O/N with risperdal. Previous\n delirium and agitation most likely secondary to long hospital course\n and multiple psychotropic medications as well as hx of EtOH abuse.\n - started Risperdal 0.5mg PO BID PRN.\n - continue to hold all benzos. opiates, and antihistamines\n - Appreciate psych. Will call and f/u psych recs.\n -Obtain EKG to assess for QTc prolongation.\n #Anemia: HCT low compared to b/l at 23.7. No known etiology of blood\n loss.\n -Will continue to follow HCT daily.\n # Hypernatremia/Fluid Status: Mild hypernatramia resolving with free\n water administration. On TPN/TF. Good UOP.\n - providing D5W IVFx 1L at 150cc/hr, free water flushes with TF\n -Will f/u lytes in afternoon (5pm)\n # UE DVT and h/o labile INR: Decision made to d/c Coumadin given her\n labile INR, and start Lovenox . INR at 1.9\n - Will flush L PICC with TPA if does not flush\n - Daily coags\n .\n # Spine fracture: Stable\n - Brace for OOB, need to discuss with Neurosurgery before d/c if\n current brace is optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in .\n .\n # Tracheomalacia. Reevaluation bronchoscopy by IP as written above;\n patient not a candidate for stent; pt to follow up as outpatient. No\n new issues.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # ACCESS: PIV x 1, L PICC\n # Ppx: Lovenox, PPi , Bowel Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n - Social Work and Case management involved; have discussed situation\n w/ brother and boyfriend.\n # Code: Full\n # Dispo: ICU, Will d/w case management re rehab facilities.\n MSIV\n PGY2 addendum:\n Agree with assessment and plan in MSIV note as detailed above.\n Briefly, 56 F s/p fall with T spine fracture, respiratory failure now\n s/p trach/PEG. Now on trach mask. Patient s/p bronch with IP today;\n ENT to see and follow for ?intervention. Nutrition issues continue;\n will receive TPN today plus possible restart of tube feeds as tolerated\n (later today), continue reglan. Appreciate psych recs; continuing\n risperidone for agitation. Etiology of delirium/agitation still\n unclear. Likely eventual dispo to rehab facility directly from ICU\n given high nursing requirements.\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 639980,
"text": "56 yr old woman, who was transferred from osh for evaluation of\n tracheal bronchial malacia on .Pt presented to Medical\n Center on s/p fall down a flight of stairs fracturing, t5-t8 with\n propulsion treated conservatively with pain meds and back brace. She\n developed resp distress requiring intubation on . Trach/PEG done\n . Now with prolonged hospital course c/b by PNA, anxiety/altered\n mental status, R&LUE DVT .Pt found to have small non occlusive clot on\n her right axial vein via Ultrasound, now rec\ning Lovenox. She has had\n problems with vomiting tube feedings, so feeding tube passed through\n g-tube to her jejunenum. However, she continued to intermit raise\n gastric contents assoc with bronchospasm. Has not required ventilation\n since , on humidified TM @ 50%. Presently on TPN and restarted on\n TF\nings at low rate via J-tube.\n BRONCHOSCOPY by IP- At 09:43 AM. Severe diffuse\n Tracheobronchomalacia, large gap posterior commisure above true vocal\n cords resulting in possible etiology of recurrent aspiration\n Airway Clearance, Impaired\n Assessment:\n Patients lung sounds are course bilat. O2 sat 95-100 on 50% trach\n collar. She has a productive cough. Yellow , clear white sputum in\n small to mod amounts.\n Action:\n Suctioned every one hour, in increase in secretion. She also has\n scolpolamine patch on.\n Response:\n Sx every 1- 11/2 hours.\n Plan:\n to monitor and clear airway as needed.\n Alteration in Nutrition\n Assessment:\n She did start promote 1/2 strength w/ fiber. Advance by 10ml q6 hours.\n Flush w/ 50 ml hour every 4 hurs.\n Action:\n She has a J tube in place, so we are unable to check resuduals. Patient\n had liquid brown stool over night.\n Response:\n colace and senna held. Mushroom cath placed.\n Plan:\n to advance to goal rate.\n Fracture, other\n Assessment:\n Patient has a fracture of t5-t8. she c/o of pain. She was not able to\n tell me where the pain was located.\n Action:\n Changed the position.\n Response:\n She did fall asleep for a few hours.\n Plan:\n Given Tylenol if she to c/o pain.\n Altered mental status (not Delirium)\n Assessment:\n He is trached and appears confused at times. She will follow commands.\n But she makes attempt to pull out her mushroom tube and iv line. In the\n past she has pulled out her trach x2. she is also throwing her legs\n over the side of the bed.\n Action:\n w/ soft wrist restraints.\n Response:\n Patient remains safe.\n Plan:\n current safety plan.\n 02:34\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 639400,
"text": "Airway Clearance, Impaired\n Assessment:\n Action:\n Response:\n Plan:\n Tachycardia, Other\n Assessment:\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n Hypernatremia (high sodium)\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 639401,
"text": "56 yr old woman, who was transferred from osh for evaluation of\n tracheal bronchial malacia on .Pt presented to Medical\n Center on s/p fall down a flight of stairs fracturing, t5-t8 with\n propulsion treated conservatively with pain meds and back brace. She\n developed resp distress requiring intubation on . Trach/PEG done\n . Now with prolonged hospital course c/b by PNA, anxiety/altered\n mental status, R&LUE DVT .Pt found to have small non occlusive Clot on\n her right axial vein via Ultrasound. She has had problems with\n vomiting tube feedings, feeding tube passed through g-tube to her\n jejunenum but she continues to vomit. Trach mask, has not required\n ventilation since . Has also required 1:1 sitters since\n decanulating herself twice, despite restraints.\n Airway Clearance, Impaired\n Assessment:\n Action:\n Response:\n Plan:\n Tachycardia, Other\n Assessment:\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n Hypernatremia (high sodium)\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 639975,
"text": "56 yr old woman, who was transferred from osh for evaluation of\n tracheal bronchial malacia on .Pt presented to Medical\n Center on s/p fall down a flight of stairs fracturing, t5-t8 with\n propulsion treated conservatively with pain meds and back brace. She\n developed resp distress requiring intubation on . Trach/PEG done\n . Now with prolonged hospital course c/b by PNA, anxiety/altered\n mental status, R&LUE DVT .Pt found to have small non occlusive clot on\n her right axial vein via Ultrasound, now rec\ning Lovenox. She has had\n problems with vomiting tube feedings, so feeding tube passed through\n g-tube to her jejunenum. However, she continued to intermit raise\n gastric contents assoc with bronchospasm. Has not required ventilation\n since , on humidified TM @ 50%. Presently on TPN and restarted on\n TF\nings at low rate via J-tube.\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 640038,
"text": "56 yr old woman, who was transferred from osh for evaluation of\n tracheal bronchial malacia on .Pt presented to Medical\n Center on s/p fall down a flight of stairs fracturing, t5-t8 with\n propulsion treated conservatively with pain meds and back brace. She\n developed resp distress requiring intubation on . Trach/PEG done\n . Now with prolonged hospital course c/b by PNA, anxiety/altered\n mental status, R&LUE DVT .Pt found to have small non occlusive clot on\n her right axial vein via Ultrasound, now rec\ning Lovenox. She has had\n problems with vomiting tube feedings, so feeding tube passed through\n g-tube to her jejunenum. However, she continued to intermit raise\n gastric contents assoc with bronchospasm. Has not required ventilation\n since , on humidified TM @ 50%. Presently on TPN and restarted on\n TF\nings at low rate via J-tube.\n BRONCHOSCOPY by IP- At 09:43 AM. Severe diffuse\n Tracheobronchomalacia, large gap posterior commisure above true vocal\n cords resulting in possible etiology of recurrent aspiration\n Airway Clearance, Impaired\n Assessment:\n Patients lung sounds are course bilat. O2 sat 95-100 on 50% trach\n collar. She has a productive cough. Yellow , clear white sputum in\n small to mod amounts.\n Action:\n Suctioned every one hour, in increase in secretion. She also has\n scolpolamine patch on.\n Response:\n Sx every 1- 11/2 hours.\n Plan:\n to monitor and clear airway as needed.\n Alteration in Nutrition\n Assessment:\n She did start promote 1/2 strength w/ fiber. Advance by 10ml q6 hours.\n Flush w/ 50 ml hour every 4 hurs.\n Action:\n She has a J tube in place, so we are unable to check resuduals. Patient\n had liquid brown stool over night.\n Response:\n colace and senna held. Mushroom cath placed.\n Plan:\n to advance to goal rate.\n Fracture, other\n Assessment:\n Patient has a fracture of t5-t8. she c/o of pain. She was not able to\n tell me where the pain was located.\n Action:\n Changed the position.\n Response:\n She did fall asleep for a few hours.\n Plan:\n Given Tylenol if she to c/o pain.\n Altered mental status (not Delirium)\n Assessment:\n He is trached and appears confused at times. She will follow commands.\n But she makes attempt to pull out her mushroom tube and iv line. In the\n past she has pulled out her trach x2. she is also throwing her legs\n over the side of the bed.\n Action:\n w/ soft wrist restraints.\n Response:\n Patient remains safe.\n Plan:\n current safety plan.\n 02:34\n ------ Protected Section ------\n Patient put out 230ml of brown/gold colored liquid foul smelling\n stool. The stool was sent for c diff. All Bowel meds held.\n ------ Protected Section Addendum Entered By: ,\n RN on: 06:13 ------\n 06:13\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 640142,
"text": "Synopsis per prior nursing note:\n 56 yr old woman, who was transferred from osh for evaluation of\n tracheal bronchial malacia on .Pt presented to Medical\n Center on s/p fall down a flight of stairs fracturing, t5-t8 with\n propulsion treated conservatively with pain meds and back brace. She\n developed resp distress requiring intubation on . Trach/PEG done\n . Now with prolonged hospital course c/b by PNA, anxiety/altered\n mental status, R&LUE DVT .Pt found to have small non occlusive clot on\n her right axial vein via Ultrasound, now rec\ning Lovenox. She has had\n problems with vomiting tube feedings, so feeding tube passed through\n g-tube to her jejunenum. However, she continued to intermit raise\n gastric contents assoc with bronchospasm. Has not required ventilation\n since , on humidified TM @ 50%. Presently on TPN and restarted on\n TF\nings at low rate via J-tube.\n BRONCHOSCOPY by IP- At 09:43 AM. Severe diffuse\n Tracheobronchomalacia, large gap posterior commisure above true vocal\n cords resulting in possible etiology of recurrent aspiration\n Airway Clearance, Impaired\n Assessment:\n LS-bilat rhonchi. O2 sat >95% on 50% trach collar. Suctioned large amts\n of thick, white secretions. Passy-muir valve in only while being\n evaluated by Psych d/t large amt of secretions.\n Action:\n Suctioned every one hour. Scolpolamine patch d/c\nd d/t mental status.\n Response:\n Needed suctioning every 1hour.\n Plan:\n to monitor and clear airway as needed.\n Alteration in Nutrition\n Assessment:\n Continues on replete w/fiber full strength.. Advance by 10ml q6 hours.\n Flush w/ 100 ml hour every 4 hours. Denies nausea. No vomiting.\n Mushroom cath in place.\n Action:\n J tube in place, unable to check resuduals. Increased TF as tolerated.\n Reglan d/c\nd d/t to mental status. Colace/senna/polyethylene glycol\n held.\n Response:\n Continues to have liquid stool. Currently tolerating TF.\n Plan:\n Advance TF to goal as tolerated.\n Fracture, other\n Assessment:\n Patient has a fracture of t5-t8. Denied pain. Brace on while OOB in\n chair.\n Action:\n Changed position. Brace on while OOB.\n Response:\n Continued to deny pain.\n Plan:\n Assess/treat pain. Brace on while OOB.\n Altered mental status (not Delirium)\n Assessment:\n When passy-muir valve on, patient had +VH and +AH. She was paranoid\n about her brother in hallway (brother was not at hospital). Stated that\n she will be driving her car home tomorrow. Stated that she is scared.\n Follows commands. Continues to try to pull out lines/tubes. Continues\n to throw her legs over the side of the bed.\n Action:\n w/ soft wrist restraints. Reoriented frequently. Assured patient\n that she is safe in hospital.\n Response:\n Patient remains safe. Able to be calmed when told she is safe in\n hospital.\n Plan:\n current safety plan. Reorient frequently. Psych will continue to\n follow.\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 640378,
"text": "Synopsis per prior nursing note:\n 56 yr old woman, who was transferred from osh for evaluation of\n tracheal bronchial malacia on .Pt presented to Medical\n Center on s/p fall down a flight of stairs fracturing, t5-t8 with\n propulsion treated conservatively with pain meds and back brace. She\n developed resp distress requiring intubation on . Trach/PEG done\n . Now with prolonged hospital course c/b by PNA, anxiety/altered\n mental status, R&LUE DVT .Pt found to have small non occlusive clot on\n her right axial vein via Ultrasound, now rec\ning Lovenox. She has had\n problems with vomiting tube feedings, so feeding tube passed through\n g-tube to her jejunenum. However, she continued to intermit raise\n gastric contents assoc with bronchospasm. Has not required ventilation\n since , on humidified TM @ 50%. Presently on TPN and restarted on\n TF\nings at low rate via J-tube.\n BRONCHOSCOPY by IP- At 09:43 AM. Severe diffuse\n Tracheobronchomalacia, large gap posterior commisure above true vocal\n cords resulting in possible etiology of recurrent aspiration\n Airway Clearance, Impaired\n Assessment:\n LS-bilat rhonchi. O2 sat >95% on 50% trach collar. Suctioned small to\n moderate amts of thick, white/dark yellow secretions. Passy-muir valve\n on during day/while in chair. Able to cough secretions into tissue\n when passy-muir valve on.\n Action:\n Suctioned every 2 hour. Encouraged to CDB.\n Response:\n Able to cough secretions into tissue. Need for suctioning decreased\n throughout shift.\n Plan:\n to monitor and clear airway as needed. Encourage CDB.\n Alteration in Nutrition\n Assessment:\n Continues on replete w/fiber full strength. Restarted @30cc/hr. Flush\n w/ 100 ml hour every 4 hours. Denies nausea. No vomiting. Small loose\n stool in am.\n Action:\n J tube in place, unable to check residuals. Colace/senna/polyethylene\n glycol held.\n Response:\n Continues to have loose stool. Currently tolerating TF.\n Plan:\n Advance TF to goal as tolerated.\n Fracture, other\n Assessment:\n Patient has a fracture of t5-t8. Denied pain. Brace on while OOB in\n chair.\n Action:\n Changed position. Brace on while OOB.\n Response:\n Continued to deny pain.\n Plan:\n Assess/treat pain. Brace on while OOB. ? transfer to \n @ Medical Center tomorrow @ 10am.\n Altered mental status (not Delirium)\n Assessment:\n When passy-muir valve on, patient had +VH and +AH. Stated paranoid\n thoughts. Stated that she is scared. She is starting to acknowledge\n that hallucinations may not be real. Acknowledges that even though she\n her friend die, she knows that her friend is alive. Follows\n commands. Not pulling at lines/tubes very often.\n Action:\n w/ soft wrist restraints. Reoriented frequently. Assured patient\n that she is safe in hospital. Feels more calm when told that she is\n safe.\n Response:\n Patient remains safe. Able to be calmed when told she is safe in\n hospital.\n Plan:\n current safety plan. Reorient frequently. Psych will continue to\n follow.\n"
},
{
"category": "Respiratory ",
"chartdate": "2167-10-24 00:00:00.000",
"description": "Generic Note",
"row_id": 639299,
"text": "TITLE:\n Respiratory Care:\n Pt has #7 portex perc trach on 40% trach collar for the night and\n tolerated well. Cuff is deflated. PMV removed. BS are coarse\n bilaterally which clear when suctioned. Pt is being suctioned\n frequently. MDI\ns ald/atr being administered with no adverse\n reactions. Sitter in room. Pt continues to be agitated. PMV worn\n during the day. Pt not requiring the vent this night. Vent pulled.\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 639302,
"text": "Chief Complaint:\n 24 Hour Events:\n Pt decannulated herself x2 yesterday, the 1st episode she desatted to\n the 80s, the second episode she desated and her heart rate decreased to\n 39-40, before the trach could be replaced.\n PICC line placed by IR, called to notify that there was clot in both\n arms, placed in L arm more proximally than small Bacillis vein clot.\n Coumadin restarted after PICC placement with 2mg\n Per GI Recs: Reglan restarted at 20mg IV q 8 hours, and meds were\n restarted via tube. No vomitting.\n Per PSYCH recs: d/c'd all benzoes, (also requested d/c reglan if GI\n ok), added Risperdal 0.5mg (and can add 0.5mg PRN, and titrate up\n to total daily dose of 2-3mg if helping)\n Per Cards recs: after 18hr of amiodaron drip. Start PO amiodarone 200mg\n TID, which was done at 1am.\n Brother visited\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 37.4\nC (99.4\n HR: 90 (73 - 121) bpm\n BP: 155/49(75) {103/47(66) - 175/98(111)} mmHg\n RR: 32 (14 - 32) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,151 mL\n 293 mL\n PO:\n TF:\n IVF:\n 1,852 mL\n 13 mL\n Blood products:\n Total out:\n 2,460 mL\n 820 mL\n Urine:\n 2,460 mL\n 820 mL\n NG:\n Stool:\n Drains:\n Balance:\n -309 mL\n -527 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Set): 0 (0 - 0) mL\n Vt (Spontaneous): 360 (360 - 360) mL\n PS : 10 cmH2O\n RR (Set): 0\n RR (Spontaneous): 21\n FiO2: 40%\n SpO2: 98%\n ABG: ///33/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 316 K/uL\n 8.3 g/dL\n 114 mg/dL\n 0.7 mg/dL\n 33 mEq/L\n 4.0 mEq/L\n 7 mg/dL\n 111 mEq/L\n 149 mEq/L\n 27.0 %\n 8.0 K/uL\n [image002.jpg]\n 03:43 AM\n 05:02 PM\n 03:36 AM\n 02:30 AM\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n 03:00 AM\n 04:00 AM\n WBC\n 7.1\n 6.9\n 7.6\n 9.5\n 5.7\n 7.3\n 8.0\n Hct\n 29.2\n 27.8\n 32.7\n 28.6\n 28.9\n 30.0\n 26.9\n 27.3\n 27.0\n Plt\n 452\n 467\n 548\n 528\n 356\n 346\n 316\n Cr\n 0.7\n 0.8\n 0.7\n 0.8\n 1.0\n 0.7\n 0.7\n 0.7\n Glucose\n 104\n 108\n 131\n 128\n 121\n 129\n 123\n 114\n Other labs: PT / PTT / INR:13.2/22.4/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:9.0 mg/dL, Mg++:2.3 mg/dL, PO4:4.1\n mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n TPN without Lipids - 06:00 PM 41. mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n PICC Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 639304,
"text": "Chief Complaint:\n 24 Hour Events:\n Pt decannulated herself x2 yesterday, the 1st episode she desatted to\n the 80s, the second episode she desated and her heart rate decreased to\n 39-40, before the trach could be replaced.\n PICC line placed by IR, called to notify that there was clot in both\n arms, placed in L arm more proximally than small Bacillis vein clot.\n Coumadin restarted after PICC placement with 2mg\n Per GI Recs: Reglan restarted at 20mg IV q 8 hours, and meds were\n restarted via tube. No vomitting.\n Per PSYCH recs: d/c'd all benzoes, (also requested d/c reglan if GI\n ok), added Risperdal 0.5mg (and can add 0.5mg PRN, and titrate up\n to total daily dose of 2-3mg if helping)\n Per Cards recs: after 18hr of amiodaron drip. Start PO amiodarone 200mg\n TID, which was done at 1am.\n Brother visited\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 37.4\nC (99.4\n HR: 90 (73 - 121) bpm\n BP: 155/49(75) {103/47(66) - 175/98(111)} mmHg\n RR: 32 (14 - 32) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,151 mL\n 293 mL\n PO:\n TF:\n IVF:\n 1,852 mL\n 13 mL\n Blood products:\n Total out:\n 2,460 mL\n 820 mL\n Urine:\n 2,460 mL\n 820 mL\n NG:\n Stool:\n Drains:\n Balance:\n -309 mL\n -527 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Set): 0 (0 - 0) mL\n Vt (Spontaneous): 360 (360 - 360) mL\n PS : 10 cmH2O\n RR (Set): 0\n RR (Spontaneous): 21\n FiO2: 40%\n SpO2: 98%\n ABG: ///33/\n Physical Examination\n Gen: Awake and alert this am, following commands, mildly agitated,\n stated that she\n wanted to get out of here\n HEENT: PERRL, MMM\n Resp: Diffuse rhonchi and transmitted airway sounds.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, BS+\n Exte: No edema, DP 2+ bil\n NEURO: CNII\nXII intact, reflexes 2+ bilaterally.\n Labs / Radiology\n 316 K/uL\n 8.3 g/dL\n 114 mg/dL\n 0.7 mg/dL\n 33 mEq/L\n 4.0 mEq/L\n 7 mg/dL\n 111 mEq/L\n 149 mEq/L\n 27.0 %\n 8.0 K/uL\n [image002.jpg]\n 03:43 AM\n 05:02 PM\n 03:36 AM\n 02:30 AM\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n 03:00 AM\n 04:00 AM\n WBC\n 7.1\n 6.9\n 7.6\n 9.5\n 5.7\n 7.3\n 8.0\n Hct\n 29.2\n 27.8\n 32.7\n 28.6\n 28.9\n 30.0\n 26.9\n 27.3\n 27.0\n Plt\n 452\n 467\n 548\n 528\n 356\n 346\n 316\n Cr\n 0.7\n 0.8\n 0.7\n 0.8\n 1.0\n 0.7\n 0.7\n 0.7\n Glucose\n 104\n 108\n 131\n 128\n 121\n 129\n 123\n 114\n Other labs: PT / PTT / INR:13.2/22.4/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:9.0 mg/dL, Mg++:2.3 mg/dL, PO4:4.1\n mg/dL\n Assessment and Plan\n 55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach, PEG placement now with respiratory failure secondary to\n tracheomalacia , resolved HAP.\n .\n # Respiratory failure: Slowly improving, spending most of the day on\n trach mask with short periods of rest on PSV at night and setbacks\n from increased secretions to vomiting/aspiration events and her\n self-decanulations.\n - Continue to increase time on trach mask as tolerated.\n - Discontinue all orders for sedation except for Zyprexa QHS.\n - PMV with suctioning as tolerated\n # Nutrition/Vomiting: Normal CT-abdomen, had FT placed via peg into\n jejunum, but continued to vomit. Tube study yesterday showed\n dysmotility in small bowel, but no obstruction, no retrograde flow.\n Awaiting GI recs.\n - Hold TFs\n - GI consult, appreciate recs\n - PICC line placement for parenteral nutrition this am\n - Nutrition recs to start TPN today\n # HAP vs Aspiration PNA: Had been afebrile for last several days, now\n with new fever last night after having decanulated herself. Likely had\n some aspiration. Chemical pneumonitis versus new aspiration PNA.\n - CXR today\n - F/u cx data\n - If remains febrile, send sputum cx.\n .\n # Tachycardia: Pt in and out of SVT and sinus, increased BB seems to\n help, but pt does not stay in sinus. Cards rec to start Amiodarone IV\n drip, and then convert to PO, 200mg TID. Would consider EPS if\n amiodarone not successful, though would wait until pt more stable for\n GA.\n - Changed to IV metoprolol to 10mg IV q4hr during the day and 7.5mg q4\n hours at night.\n - Amiodarone 0.5mg/min IV drip x 18 hours.\n - Cards c/s, appreciate recs\n # Sedation/Anxiolysis/AlteredMS: unclear etiology of her confusion and\n agitation. Has had long hospital course and multiple psychotropic\n medications as well as hx of EtOH abuse.\n - Continue w Olanzapine QHS\n - d/c all benzos, d/c all opiates given GI dysmotlitiy\n - Psychiatry consulted, appreciate recs\n # Adrenal Insufficency: Endocrine following. Pt does not appear to be\n adrenally insufficient at baseline. Suggesting if the patient under\n goes major stressors such as major surgery, sepsis, she may need stress\n dosed steroids.\n .\n # Fluid Status: Likely approaching euvolemia, though still has mild\n hypernatramia which may suggest is still intravascularly depleated.\n - Monitoring urine output\n - will provide D5W IVF as need for hypernatremia and follow lytes\n # UE DVT and elevated INR: DVT in right UE has resolved, new\n non-occlusive in left axillary vein. INR had risen quickly on coumadin,\n likely to poor nutrition, resonded quickly to Vitamin K IV, but now\n subtherapeutic again. Kept subtherapeutic today for PICC line placement\n (for TPN), will restart w/ 2mg Coumadin after line placement.\n - Restart coumadin after PICC line placement today\n - Continue to follow INR closely to reach therapeutic INR.\n .\n #Hematemesis: Pt had small amt Hematemesis, after vomiting, 2 days ago.\n None today. HCT stable.\n -Will follow HCT.\n - Guaiac stools\n # Spine fracture: Stable\n - Brace for OOB, will discuss with Neurosurgery if current brace is\n optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n .\n # Tracheomalacia. Was initially addressed with IP and they wanted to\n follow up as outpatient. IP reevaluated and does not believe that a\n stent would be feasible.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # ACCESS: PIV x 1, PICC placement\n today.\n # Ppx: subtherapeutic INR restarting coumadin today, Ranitidine, Bowel\n Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n - Social Work and Case management involved, have discussed situation\n w/ brother and boyfriend.\n # Code: Full\n # Dispo: ICU, Screening for vent facilities\n ICU Care\n Nutrition:\n TPN without Lipids - 06:00 PM 41. mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n PICC Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 639305,
"text": "Airway Clearance, Impaired\n Assessment:\n Secretions thick, white. LS coarse, diminished at bases.\n Action:\n Requiring frequent suctioning, at times q 30 minutes, clearing\n initially and within minutes, pt rattling with secretions once again.\n Response:\n Secretions con\nt to accumulate despite frequent suctioning.\n Plan:\n Con\nt to pulmonary toilet , clear secretions as appropriate. Maintain\n O2 Sat of greater than 94%.\n Tachycardia, Other\n Assessment:\n HR maintained in the 80\ns and 90\ns for the most part. Up to110\n immediately prior to receiving the lopressor.\n Action:\n Receiving lopressor 10 mg IV a4hr.\n Response:\n Maintaining HR below 100 successfully.\n Plan:\n Attempt to keep HR at 100 or lower.\n Alteration in Nutrition\n Assessment:\n Hypoactive BS, TF\ns on hold. J-tube intact, 2 small liquid stools.\n Action:\n TF\ns on hold due to vomiting, Reglan increased to 20mg TID\n Response:\n No vomiting this shift.\n Plan:\n Monitor GI status,\n Altered mental status (not Delirium)\n Assessment:\n Alert but confused, asking for boyfriend. Seems to be concerned about\n some insurance. Encouraged to rest and get some sleep. 1:1 sitter in\n at bedside all night. Pt very active, attempting to swing legs over\n side rails at times. At one point, pt attempted to kick this RN.\n Begun on resperidone 0.5 mg \n Action:\n Frequent re-orientation\n Response:\n Remains confused, poor STM\n Plan:\n Con\nt with 1:1 sitters to maintain safety of pt, she will attempt to\n grab tubes if unrestrained, Monitor effect to meds.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Tmax 99.4 po\n Action:\n Receiving Tylenol 650 PR TID\n Response:\n Stable no change\n Plan:\n Pt to become normalize temp\n"
},
{
"category": "Respiratory ",
"chartdate": "2167-10-17 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 638039,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 29\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Tracheostomy tube:\n Type: Standard, Cuffed\n Manufacturer: Portex\n Size: 7.0mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Copious\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support:\n Note: On trach collar for most of shift, then placed on vent to rest.\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 638536,
"text": "55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach, PEG, placement no with respiratory failure secondary to\n tracheomalacia , resolving HAP.\n Arousal, Attention, and Cognition, Impaired\n Assessment:\n Alert, mouthing words but very difficult to understand. Follows\n commands. MAE on bed, attempting to get up. Restless last evening, did\n eventually fall off to sleep this AM.\n Action:\n Zyprexa x 1 . Frequent re-orientation to place, situation. Soft wrist\n restraints for patient safety.\n Response:\n Pt did eventually fall asleep. Re-orientation does have calming effect\n however it is short term.\n Plan:\n No valium or benadryl per psych as this exacerbates delirium. Zyprexa\n for agitation. pt prn.\n Hypernatremia (high sodium)\n Assessment:\n Na 145 last night, 148 this AM.\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Trach collar @ 50% O2 overnight until 4AM, Sats 90-97%. RR 17-20s.\n Around 4AM RR in low 30s, sats low 90s while sleeping--? Fatiguing.\n Strong cough, able to cough thick white ->tan secretions out of trach.\n Occ suctioned for same. Lungs are rhonchorous throughout. Impaired gag.\n Action:\n Suctioned prn for copious secretions. MDIs. Placed back on vent @ 4AM\n d/t fatigue.\n Response:\n Tolerated trach collar most of night, back on vent this AM d/t fatigue\n with RR in teens, Sats 98%.\n Plan:\n Wean from vent as tolerated. MDIs, suction as needed.\n Alteration in Nutrition\n Assessment:\n Tube feeds off overnight d/t constant vomiting. No vomiting overnight.\n Action:\n NPO. Reglan q 6 hrs.\n Response:\n No vomiting. Small brown stool x 1.\n Plan:\n NPO. ? may go to IR today to change Gtube to Jtube. Reglan. Meds via\n Gtube.\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-22 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 639041,
"text": "Chief Complaint:\n 24 Hour Events:\n Increased Metoprolol to 7.5 IV q 4\n Getting tube study in am\n had J tube placed by IR via PEG, then had tube feeds at 10/hr which she\n proceeded to vomit, TF held\n Agitated so given Haldol, put back on pressure support\n Na 148 but had not received D5W yet.\n INR 2.3 after 10 IV Vit K\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:30 AM\n Diazepam (Valium) - 02:24 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:35 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 35.7\nC (96.2\n HR: 107 (93 - 140) bpm\n BP: 85/45(55) {83/40(51) - 148/101(105)} mmHg\n RR: 23 (11 - 37) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 3,808 mL\n 557 mL\n PO:\n TF:\n 4 mL\n IVF:\n 3,804 mL\n 557 mL\n Blood products:\n Total out:\n 1,650 mL\n 385 mL\n Urine:\n 1,590 mL\n 385 mL\n NG:\n 60 mL\n Stool:\n Drains:\n Balance:\n 2,158 mL\n 172 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 169 (169 - 438) mL\n PS : 5 cmH2O\n RR (Spontaneous): 23\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 67\n PIP: 10 cmH2O\n SpO2: 100%\n ABG: ///33/\n Ve: 3.7 L/min\n Physical Examination\n Gen: Mildly obtunded in am, responsive to noxious stimuli, on MMV\n through trach tube, but later in alert, responding normally.\n HEENT: PERRL, MMM\n Resp: Coarse BS anteriorly, no focal rales, rhonchi, or wheezing with\n some referred upper airway noises from secretions.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, BS+\n Exte: No edema, DP 2+ bil.\n NEURO: Toes downgoing bilaterally,\n Labs / Radiology\n 356 K/uL\n 8.2 g/dL\n 129 mg/dL\n 0.7 mg/dL\n 33 mEq/L\n 3.6 mEq/L\n 4 mg/dL\n 110 mEq/L\n 148 mEq/L\n 26.9 %\n 5.7 K/uL\n [image002.jpg]\n 06:22 AM\n 02:58 AM\n 03:43 AM\n 05:02 PM\n 03:36 AM\n 02:30 AM\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n WBC\n 7.0\n 7.1\n 7.1\n 6.9\n 7.6\n 9.5\n 5.7\n Hct\n 29.7\n 28.9\n 29.2\n 27.8\n 32.7\n 28.6\n 28.9\n 30.0\n 26.9\n Plt\n 395\n 462\n 452\n 467\n 548\n 528\n 356\n Cr\n 0.7\n 0.6\n 0.7\n 0.8\n 0.7\n 0.8\n 1.0\n 0.7\n Glucose\n 126\n 137\n 104\n 108\n 131\n 128\n 121\n 129\n Other labs: PT / PTT / INR:15.2/24.6/1.3, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:8.7 mg/dL, Mg++:2.1 mg/dL, PO4:4.1\n mg/dL\n CXR: no sig change from previous. R hemidiaphragm remains elevated, L\n hemidiaphragm remains obscured, some patchy opacities in L lobe,\n ?atelectasis\n Assessment and Plan\n 55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach, PEG placement now with respiratory failure secondary to\n tracheomalacia , resolved HAP.\n .\n # Respiratory failure: Slowly Improving. Intermittently on trach mask\n for most of the day, with periods of pressure support of over night.\n This am on MMV. Previously likely oversedated but Benadryl, Morhpine,\n and Valium held now. Pt awake and alert at rounds, interactive, and\n breathing comfortably on trach mask\n - Continue to increase time on trach mask as tolerated.\n - Decrease sedation and valium use\n - PMV with suctioning\n # Nutrition/Vomiting: Has had several days of vomiting up TFs but had\n a normal CT abdoment. Yesterday she had a pediatric feeding tube placed\n by GI through her PEG tube into her jejunum, and was given TFs last\n night, which she vomited. Pt had a tube study this am that showed\n dysmotility of her jejunum. GI continuing to follow study during the\n day with KUBs. Unclear etiology of her ileus; pt has hx of GI problems\n and chronic N/V and this may be her chronic baseline. Alternatively pt\n has had long course of opiates during MICU stay, however, her opiates\n have been decreased steady for the past week and she has had periods\n where she tolerated TFs. Will need to provide parenteral nutrition at\n this point.\n - Hold TFs\n - GI consulted\n - F/u results of Tube study\n - PICC line placement for parenteral nutrition\n -.\n # HAP vs Aspiration PNA: Afebrile without leukocytosis\n - Completed course of ceftriaxone\n - good O2 saturation on trach mask\n .\n # Tachycardia: Previously was assessed as sinus tach with occasional\n runs of SVT and sources such as hypovolemia, PE, infection, and pain\n were assessed as possibly etiologies. Per Cardiology, most likely AT\n given transient response to Adenosine. HR occasionally decreases to\n 70s-80s w/ stable BPs at times that might be associated with\n administration of her BB and valium. Cards recommended titrating up her\n beta blocker as tolerated. Dose increased to 50 yesterday and\n intermittently responded but then had to hold PO meds given need to\n hold PO. Changed PO to IV lopressor.\n - EP consulted for SVT, appreciate recs, will change metoprololt o IV\n and hopefully will be able to restart PO meds soon once able to\n tolerate\n - Changed to IV metoprolol 10mg q4hr during the day and 7.5mg q4 hours\n at night.\n - Per EP, after good trial on PO BB and recovery from current\n hospitalization, would consider EP study or short course of\n amiodarone..\n .\n # Sedation: Inconsistent response to sedation, unclear what is best\n regime. Will continue to wean overall.\n - Continue w Olanzapine QHS\n - d/c all opiates given GI dysmotlitiy\n .\n # Adrenal Insufficency: Endocrine following. Pt does not appear to be\n adrenally insufficient at baseline. Suggesting if the patient under\n goes major stressors such as major surgery, sepsis, she may need stress\n dosed steroids.\n .\n # Fluid Status: Likely approaching euvolemia, though still has mild\n hypernatramia which may suggest is still intravascularly depleated.\n - Monitoring urine output\n - will provide D5W IVF as need for hypernatremia and follow lytes\n .\n # UE DVT and elevated INR: DVT in right UE has resolved, new\n non-occlusive in left axillary vein. INR supratherapeutic yesterday at\n 10.5 despite having stopped coumadin the day before. INR increase is\n most likely continuing to rise nutritional deficiencies given\n continued lack of PO intake. Pt was given Vitamin K IV yesterday, and\n today INR is 1.3.\n - Restart coumadin after PICC line placement today\n - Continue to follow INR closely to reach therapeutic INR.\n .\n #Hematemesis: Pt had small amt Hematemesis, after vomiting, yesterday.\n None today.\n -Will follow HCT.\n - Guaiac stools\n # Spine fracture: Stable\n - Brace for OOB, will discuss with Neurosurgery if current brace is\n optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n .\n # Tracheomalacia. Was initially addressed with IP and they wanted to\n follow up as outpatient. IP reevaluated and does not believe that a\n stent would be feasible.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # ACCESS: PIV x 1, PICC placement\n today.\n # Ppx: supratherapeutic INR, Ranitidine, Bowel Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n - Social Work and Case management involved, have discussed situation\n w/ brother and boyfriend.\n # Code: Full\n # Dispo: ICU, Screening for vent facilities\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 04:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 639131,
"text": "56 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\n with prolonged hospital course c/b by PNA, anxiety/altered mental\n status, R&LUE DVT .Pt found to have small non occlusive Clot on her\n right axial vein via Ultrasound.Yesterday. She has had problems with\n vomiting tube feedings, feeding tube passed through g-tube (g-tube in\n place with mushroom on inside so cannot pull out) to her jejunenum but\n continues vomit.\n Tachycardia, Other\n Assessment:\n HR continued to be 110-140, ST w/ rare PVC\n Action:\n Amiordarone 75mg bolus given, and drip started at 1mg/min\n Response:\n HR at rest now 100-120\n Plan:\n Will continue drip for 18 hr then titrate down to 0.5mg/min\n Altered mental status (not Delirium)\n Assessment:\n Pt very restless and agitated throughout night\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 639387,
"text": "56 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\n with prolonged hospital course c/b by PNA, anxiety/altered mental\n status, R&LUE DVT .Pt found to have small non occlusive Clot on her\n right axial vein via Ultrasound . She has had problems with\n vomiting tube feedings, feeding tube passed through g-tube (g-tube in\n place with mushroom on inside so cannot pull out) to her jejunenum but\n continued vomit.\n At 7:30 pt pulled out her trach tube with staff 6feet away. Her\n HR initially was 120\ns, before an airway could be re-established her HR\n had blocked down to 38 and she had lost consciousness. She returned as\n soon as her airway was re-established. Sitter now @ bedside RTC.\n Altered mental status (not Delirium)\n Assessment:\n Pt very somulent most of shift, awake only from 1500-1700 when she\n opened eyes spont and mouthed words as @ baseline. MAEE with good\n strength. Gag and cough impaired while sleeping.\n Action:\n Pt stimulated with painful stimuli, and sitting upright in\n bed-as-chair. AM Risperidone held. PRN Olanzipine D/C\n Response:\n Pt cont to be difficult to waken.\n Plan:\n Cont Risperidine when pt awake. Sitter and bilat wrist restraints\n remain as pt mental status labile.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt has remained on humidified TM @ 50% all shift. RR 23-31 and regular\n but occas shallow. Lung snds rhonchorous in upper lobes but clearing\n after sxn\ning. LL snds diminished. Trach site clean, well healed.\n Action:\n Pt suctioned freq for mod-copious amts thick white tenacious sputum.\n Response:\n O2 sat bouncing up to 100% after sxn\ning.\n Plan:\n Cont aggressive pulm toilet.\n Alteration in Nutrition\n Assessment:\n Rec\nd pt on TPN via PICC line. J tube site clean/dry, tube clamped\n except for meds. BS present, abd soft/obese.\n Action:\n Shortly after pt rec\nd scheduled dose Reglan she was incont of lg amt\n golden loose stool.\n Response:\n TF of\n strength Promote with fiber restarted @ 10ml/hr, with goal\n 40ml/hr. Water flush of 50ml Q4hrs.\n Plan:\n Cont to increase TF to goal as tolerated. Pt to receive TF only when\n she is in sitting position with strict aspiration precautions.\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 639533,
"text": "Chief Complaint:\n 24 Hour Events:\n Pt agitated overnight given extra Risperidone 0.5 mg x 2 overnight.\n (1.5mg total)\n 1000 mL D5W for Hypernatremia\n Changed B-Blocker from IV to PO, Metoprolol Tartrate 25 mg PO TID\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:17 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.7\nC (98\n HR: 120 (67 - 120) bpm\n BP: 110/64(76) {109/47(60) - 141/115(118)} mmHg\n RR: 26 (18 - 30) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 3,820 mL\n 856 mL\n PO:\n TF:\n 117 mL\n 20 mL\n IVF:\n 2,612 mL\n 572 mL\n Blood products:\n Total out:\n 2,460 mL\n 1,180 mL\n Urine:\n 2,460 mL\n 1,180 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,360 mL\n -324 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 100%\n ABG: ///33/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 249 K/uL\n 8.0 g/dL\n 122 mg/dL\n 0.5 mg/dL\n 33 mEq/L\n 3.7 mEq/L\n 13 mg/dL\n 108 mEq/L\n 146 mEq/L\n 24.7 %\n 5.5 K/uL\n [image002.jpg]\n 03:36 AM\n 02:30 AM\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n 03:00 AM\n 04:00 AM\n 05:45 AM\n 03:51 AM\n WBC\n 6.9\n 7.6\n 9.5\n 5.7\n 7.3\n 8.0\n 8.7\n 5.5\n Hct\n 27.8\n 32.7\n 28.6\n 28.9\n 30.0\n 26.9\n 27.3\n 27.0\n 28.7\n 24.7\n Plt\n 467\n 548\n 528\n 356\n 346\n 316\n 271\n 249\n Cr\n 0.7\n 0.8\n 1.0\n 0.7\n 0.7\n 0.7\n 0.7\n 0.5\n Glucose\n 131\n 128\n 121\n 129\n 123\n 114\n 112\n 122\n Other labs: PT / PTT / INR:13.6/31.1/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:9.0 mg/dL, Mg++:2.2 mg/dL, PO4:3.1\n mg/dL\n Assessment and Plan\n 55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach, PEG with resolving respiratory failure and HAP.\n .\n # Respiratory failure: 36hrs off vent, now on trach mask. No further\n self-decanulations overnight.\n - Tach mask as tolerated.\n - Holding sedation with exception of Risperidal 0.5mg .\n - PMV with suctioning as tolerated\n .\n # Nutrition/Vomiting: TFs restarted yesterday while patient was not in\n optimal positioning. One large BM in past 24 hrs to indicate potential\n improvement in ileus.\n - Cont Reglan 20mg IV Q 8 hours and restart meds via G-J tube,\n - Slowly restarting TFs and will increase as tolerated.\n - PICC line in place with TPN given when pt not tolerating.\n - GI consult, appreciate recs\n .\n # Tachycardia: One episode of SVT overnight with improved HR max of\n 100\ns versus 160s previously. Pt now on PO Amiodarone 200 TID, and IV\n metoprolol\n - Will change IV metoprolol to metoprolol 25mg PO TID\n - f/u Cards recs\n # Sedation/Anxiolysis/AlteredMS: Improved alertness. Long hospital\n course and multiple psychotropic medications as well as hx of EtOH\n abuse.\n - - started Risperdal 0.5mg PO BID\n - continue to hold all benzos. opiates, and antihistamines\n - f/u psych recs.\n .\n # Fluid Status: Mild hypernatramia with good UOP.\n - providing D5W IVF PRN and follow lytes\n # UE DVT and elevated INR: Decision made to d/c Coumadin given her\n labile INR, and start Lovenox . L Picc difficult to flush this AM.\n - Will flush L PICC with TPA\n .\n # Spine fracture: Stable\n - Brace for OOB, will discuss with Neurosurgery if current brace is\n optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n .\n # Tracheomalacia. Was initially addressed with IP and they wanted to\n follow up as outpatient. IP reevaluated and does not believe that a\n stent would be feasible.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # ACCESS: PIV x 1, L PICC\n # Ppx: Lovenox, PPi, Bowel Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n - Social Work and Case management involved, have discussed situation\n w/ brother and boyfriend.\n # Code: Full\n # Dispo: ICU, Screening for vent facilities\n ICU Care\n Nutrition:\n TPN without Lipids - 07:10 PM 43. mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n PICC Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 639546,
"text": "Chief Complaint:\n 24 Hour Events:\n Pt agitated overnight given extra Risperidone 0.5 mg x 2 overnight.\n (1.5mg total)\n 1000 mL D5W for Hypernatremia\n Changed B-Blocker from IV to PO, Metoprolol Tartrate 25 mg PO TID\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:17 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.7\nC (98\n HR: 120 (67 - 120) bpm\n BP: 110/64(76) {109/47(60) - 141/115(118)} mmHg\n RR: 26 (18 - 30) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 3,820 mL\n 856 mL\n PO:\n TF:\n 117 mL\n 20 mL\n IVF:\n 2,612 mL\n 572 mL\n Blood products:\n Total out:\n 2,460 mL\n 1,180 mL\n Urine:\n 2,460 mL\n 1,180 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,360 mL\n -324 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 100%\n ABG: ///33/\n Physical Examination\n Gen: Awake, Mouthing words, More agitated compared to previous\n mornings.\n HEENT: EOMI, No pallor in conjunctiva, MMM\n Resp: CTA bilaterally, no rales, rhonchi, or wheezing, good airway\n movement.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, decreased bowel sounds,, G-Tube in\n place with no erythema/induration\n Exte: No edema, DP 2+ bil\n NEURO: Gross Motor and Sensation in 4 extremities\n Labs / Radiology\n 249 K/uL\n 8.0 g/dL\n 122 mg/dL\n 0.5 mg/dL\n 33 mEq/L\n 3.7 mEq/L\n 13 mg/dL\n 108 mEq/L\n 146 mEq/L\n 24.7 %\n 5.5 K/uL\n [image002.jpg]\n 03:36 AM\n 02:30 AM\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n 03:00 AM\n 04:00 AM\n 05:45 AM\n 03:51 AM\n WBC\n 6.9\n 7.6\n 9.5\n 5.7\n 7.3\n 8.0\n 8.7\n 5.5\n Hct\n 27.8\n 32.7\n 28.6\n 28.9\n 30.0\n 26.9\n 27.3\n 27.0\n 28.7\n 24.7\n Plt\n 467\n 548\n 528\n 356\n 346\n 316\n 271\n 249\n Cr\n 0.7\n 0.8\n 1.0\n 0.7\n 0.7\n 0.7\n 0.7\n 0.5\n Glucose\n 131\n 128\n 121\n 129\n 123\n 114\n 112\n 122\n Other labs: PT / PTT / INR:13.6/31.1/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:9.0 mg/dL, Mg++:2.2 mg/dL, PO4:3.1\n mg/dL\n Assessment and Plan\n 55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach, PEG with resolving respiratory failure and HAP.\n .\n # Respiratory failure: 36hrs off vent, now on trach mask, FiO2 70%. No\n further self-decanulations overnight.\n - Tach mask as tolerated.\n - Holding sedation with exception of Risperidal 0.5mg .\n - PMV with suctioning as tolerated\n .\n # Nutrition/Vomiting: TFs restarted yesterday while patient was not in\n optimal positioning. One large BM in past 24 hrs to indicate potential\n improvement in ileus.\n - Cont Reglan 20mg IV Q 8 hours and restart meds via G-J tube,\n - Increase TF as tolerated\n - PICC line in place with TPN given when pt not tolerating TF\n - GI consult, appreciate recs\n .\n # Tachycardia: One episode of SVT overnight with improved HR max of\n 100\ns versus 160s previously. Pt now on PO Amiodarone 200 TID, and IV\n metoprolol\n - Will change IV metoprolol to metoprolol 25mg PO TID\n - f/u Cards recs\n # Sedation/Anxiolysis/AlteredMS: Improved alertness. Long hospital\n course and multiple psychotropic medications as well as hx of EtOH\n abuse.\n - - started Risperdal 0.5mg PO BID\n - continue to hold all benzos. opiates, and antihistamines\n - f/u psych recs.\n .\n # Fluid Status: Mild hypernatramia with good UOP.\n - providing D5W IVF PRN and follow lytes\n # UE DVT and elevated INR: Decision made to d/c Coumadin given her\n labile INR, and start Lovenox . L Picc difficult to flush this AM.\n - Will flush L PICC with TPA\n .\n # Spine fracture: Stable\n - Brace for OOB, will discuss with Neurosurgery if current brace is\n optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n .\n # Tracheomalacia. Was initially addressed with IP and they wanted to\n follow up as outpatient. IP reevaluated and does not believe that a\n stent would be feasible.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # ACCESS: PIV x 1, L PICC\n # Ppx: Lovenox, PPi, Bowel Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n - Social Work and Case management involved, have discussed situation\n w/ brother and boyfriend.\n # Code: Full\n # Dispo: ICU, Screening for vent facilities\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 639547,
"text": "TITLE:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt on TM @ 70% with O2 sat mid 90\ns-100%. Requiring tracheal\n sxn\ning approx Q1hr for mod-copious amts thick white tenacious\n secretions. Pt with strong cough, but freq unable to clear secretions\n herself. Lung snds rhonchorous in upper lobes, diminished in bases.\n Action:\n Freq sxn\ning per above. Pt encouraged to C&DB. Pt in\nchair\n position\n in bed with head @ 45-90degree angle.\n Response:\n Pt cont to have lg amt secretions requiring assist to clear.\n Plan:\n Cont aggressive pulm toilet.\n Arousal, Attention, and Cognition, Impaired\n Assessment:\n Pt has been awake and alert . Pt chatty, but difficult to read her lips\n and she has trouble writing clearly. Slept for ~ 2 hrs .Pt very\n agitated since ~ 2am. Tryming to climb out of bed\n Action:\n BUE & lt LE restrained with soft restraints. Emotional support\n provided, Risperidone 0.5 x 2 extra doses given.\n Response:\n Little effect with Med. Team aware.\n Plan:\n Speech/swallow consult needed re valve, ? if it is damaged. Cont\n Risperidone. Cont soft wrist restraints and sitter @ bedside for pt\n safety.\n Alteration in Nutrition\n Assessment:\n Abd soft/obese with + BS. On J-tube feeds in upright position.\n Action:\n Pt on colace and senna, held the evening dose as pt had 2 BM\ns during\n the day.\n Response:\n Pt with lg loose yellow BM in am. TF started in afternoon @ 10ml/hr as\n well as 50ml water Q4hrs, with HOB @ 45-90degree angle. Tolerated well.\n Feeds stopped as she became agitated & had to be repositioned multiple\n times to help her maintain a comfortable position, tried bed as chair,\n tolerated for few minutes.\n Plan:\n Currently feed held. Cont to gently advance TF per order. Strict\n aspiration orders, with pt rec\ning TF ONLY when in sitting position.\n Hypernatremia (high sodium)\n Assessment:\n Na 146 , K+ 3.7in am labs\n Action:\n Continued on D5 W@ 100 mls/hr for 1000 mls.\n Response:\n Awaiting order from team for K+ repletion.\n Plan:\n Replete As per orders & Monitor Lytes.\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 639644,
"text": "56 yr old woman, who was transferred from osh for evaluation of\n tracheal bronchial malacia on .Pt presented to Medical\n Center on s/p fall down a flight of stairs fracturing, t5-t8 with\n propulsion treated conservatively with pain meds and back brace. She\n developed resp distress requiring intubation on . Trach/PEG done\n . Now with prolonged hospital course c/b by PNA, anxiety/altered\n mental status, R&LUE DVT .Pt found to have small non occlusive clot on\n her right axial vein via Ultrasound, now rec\ning Lovenox. She has had\n problems with vomiting tube feedings, so feeding tube passed through\n g-tube to her jejunenum. However, she continues to intermit raise\n gastric contents assoc with bronchospasm. Has not required ventilation\n since , on humidified TM @ 50%. Has required 1:1 sitters since\n decanulating herself, twice, despite restraints.\n Airway Clearance, Impaired\n Assessment:\n Pt cont on TM 50%, bilat rhonchi, diminished in bases. 02 SATS 94-95%\n Action:\n Pt requiring frequent suction, copious loose white secretions noted,\n scolopamine patch applied to help with secretions\n Response:\n Cont to suction for copious secretions\n Plan:\n Cont to resp. status, suction as needed, s/swallow to re-evaluate\n for bigger PMV in am\n Alteration in Nutrition\n Assessment:\n Pt cont with restlessness, TF off 00 due to pts restlessness, BS\n positive bilat, loose BM\ns x 2\n Action:\n Pt placed on chair positin in bed, pt recvd scheduled Reglan, colace\n Response:\n Pt had two loose bm\ns x 2,\n Plan:\n Re-start TF when pt more relaxed, cont with TPN 43.6 as ordered, cont\n strict asp precautions :holding TF when pt not in upright position and\n turning TF off for 15 mins before turning\n Arousal, Attention, and Cognition, Impaired\n Assessment:\n Pt cont to be very restless in bed, cont with bilat wrist restraints\n and 1:1 sitter @ bedside\n Action:\n Pt seen by psych @, Risperadol dosing increased\n Response:\n Pt cont to be restless despite increase in HS risperadol and prn dose\n Plan:\n Psych to re-evaluate in am, EKG to be taken in am\n"
},
{
"category": "Nutrition",
"chartdate": "2167-10-20 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 638616,
"text": "Subjective\n Objective\n Pertinent medications: noted\n Labs:\n Value\n Date\n Glucose\n 128 mg/dL\n 02:30 AM\n Glucose Finger Stick\n 142\n 10:00 AM\n BUN\n 6 mg/dL\n 02:30 AM\n Creatinine\n 0.8 mg/dL\n 02:30 AM\n Sodium\n 148 mEq/L\n 02:30 AM\n Potassium\n 4.1 mEq/L\n 02:30 AM\n Chloride\n 105 mEq/L\n 02:30 AM\n TCO2\n 36 mEq/L\n 02:30 AM\n Albumin\n 3.5 g/dL\n 03:00 AM\n Calcium non-ionized\n 10.0 mg/dL\n 02:30 AM\n Phosphorus\n 4.3 mg/dL\n 02:30 AM\n Ionized Calcium\n 1.24 mmol/L\n 02:51 AM\n Magnesium\n 2.5 mg/dL\n 02:30 AM\n ALT\n 25 IU/L\n 07:34 AM\n Alkaline Phosphate\n 106 IU/L\n 07:34 AM\n AST\n 19 IU/L\n 07:34 AM\n WBC\n 7.6 K/uL\n 02:30 AM\n Hgb\n 10.0 g/dL\n 02:30 AM\n Hematocrit\n 32.7 %\n 02:30 AM\n Current diet order / nutrition support: NPO\n GI: Abd soft/obese/hypo bs\n Assessment of Nutritional Status\n Estimation of previous intake: Adequate\n Estimation of current intake: Inadequate\n Specifics:\n 55 y/o female c/ long hospital course,\n Medical Nutrition Therapy Plan - Recommend the Following\n Other: Will follow POC- access for resuming feeds, If unable to resume\n enteral feeds in next 2-3 days, will need to consider PPN/TPN to avoid\n nutritional decline\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-23 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 639120,
"text": "Chief Complaint:\n 24 Hour Events:\n Pt pulled out her trach tube, tube replaced\n PICC Line Placed\n Seen By EP and started on Amiodarone Drip\n Fever - 101.4\nF Cultures sent\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Amiodarone - 1 mg/min\n Other ICU medications:\n Metoprolol - 01:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.4\n Tcurrent: 36.9\nC (98.5\n HR: 107 (107 - 142) bpm\n BP: 86/44(54) {82/39(49) - 181/113(122)} mmHg\n RR: 22 (13 - 25) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,127 mL\n 537 mL\n PO:\n TF:\n IVF:\n 2,127 mL\n 537 mL\n Blood products:\n Total out:\n 995 mL\n 400 mL\n Urine:\n 995 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,132 mL\n 137 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Spontaneous): 208 (208 - 243) mL\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 0 cmH2O\n SpO2: 97%\n ABG: ///31/\n Ve: 4.1 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 346 K/uL\n 8.4 g/dL\n 123 mg/dL\n 0.7 mg/dL\n 31 mEq/L\n 3.8 mEq/L\n 4 mg/dL\n 107 mEq/L\n 144 mEq/L\n 27.3 %\n 7.3 K/uL\n [image002.jpg]\n 02:58 AM\n 03:43 AM\n 05:02 PM\n 03:36 AM\n 02:30 AM\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n 03:00 AM\n WBC\n 7.1\n 7.1\n 6.9\n 7.6\n 9.5\n 5.7\n 7.3\n Hct\n 28.9\n 29.2\n 27.8\n 32.7\n 28.6\n 28.9\n 30.0\n 26.9\n 27.3\n Plt\n 462\n 452\n 467\n 548\n 528\n 356\n 346\n Cr\n 0.6\n 0.7\n 0.8\n 0.7\n 0.8\n 1.0\n 0.7\n 0.7\n Glucose\n 137\n 104\n 108\n 131\n 128\n 121\n 129\n 123\n Other labs: PT / PTT / INR:14.1/23.7/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.8 mg/dL, Mg++:1.9 mg/dL, PO4:3.7\n mg/dL\n Assessment and Plan\n 55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach, PEG placement now with respiratory failure secondary to\n tracheomalacia , resolved HAP.\n .\n # Respiratory failure: Slowly Improving. Intermittently on trach mask\n for most of the day, with periods of pressure support of over night.\n This am on MMV. Previously likely oversedated but Benadryl, Morhpine,\n and Valium held now. Pt awake and alert at rounds, interactive, and\n breathing comfortably on trach mask\n - Continue to increase time on trach mask as tolerated.\n - Decrease sedation and valium use\n - PMV with suctioning\n # Nutrition/Vomiting: Has had several days of vomiting up TFs but had\n a normal CT abdoment. Yesterday she had a pediatric feeding tube placed\n by GI through her PEG tube into her jejunum, and was given TFs last\n night, which she vomited. Pt had a tube study this am that showed\n dysmotility of her jejunum. GI continuing to follow study during the\n day with KUBs. Unclear etiology of her ileus; pt has hx of GI problems\n and chronic N/V and this may be her chronic baseline. Alternatively pt\n has had long course of opiates during MICU stay, however, her opiates\n have been decreased steady for the past week and she has had periods\n where she tolerated TFs. Will need to provide parenteral nutrition at\n this point.\n - Hold TFs\n - GI consulted\n - F/u results of Tube study\n - PICC line placement for parenteral nutrition\n -.\n # HAP vs Aspiration PNA: Afebrile without leukocytosis\n - Completed course of ceftriaxone\n - good O2 saturation on trach mask\n .\n # Tachycardia: Previously was assessed as sinus tach with occasional\n runs of SVT and sources such as hypovolemia, PE, infection, and pain\n were assessed as possibly etiologies. Per Cardiology, most likely AT\n given transient response to Adenosine. HR occasionally decreases to\n 70s-80s w/ stable BPs at times that might be associated with\n administration of her BB and valium. Cards recommended titrating up her\n beta blocker as tolerated. Dose increased to 50 yesterday and\n intermittently responded but then had to hold PO meds given need to\n hold PO. Changed PO to IV lopressor.\n - EP consulted for SVT, appreciate recs, will change metoprololt o IV\n and hopefully will be able to restart PO meds soon once able to\n tolerate\n - Changed to IV metoprolol 10mg q4hr during the day and 7.5mg q4 hours\n at night.\n - Per EP, after good trial on PO BB and recovery from current\n hospitalization, would consider EP study or short course of\n amiodarone..\n # Sedation: Inconsistent response to sedation, unclear what is best\n regime. Will continue to wean overall.\n - Continue w Olanzapine QHS\n - d/c all opiates given GI dysmotlitiy\n # Adrenal Insufficency: Endocrine following. Pt does not appear to be\n adrenally insufficient at baseline. Suggesting if the patient under\n goes major stressors such as major surgery, sepsis, she may need stress\n dosed steroids.\n .\n # Fluid Status: Likely approaching euvolemia, though still has mild\n hypernatramia which may suggest is still intravascularly depleated.\n - Monitoring urine output\n - will provide D5W IVF as need for hypernatremia and follow lytes\n # UE DVT and elevated INR: DVT in right UE has resolved, new\n non-occlusive in left axillary vein. INR supratherapeutic yesterday at\n 10.5 despite having stopped coumadin the day before. INR increase is\n most likely continuing to rise nutritional deficiencies given\n continued lack of PO intake. Pt was given Vitamin K IV yesterday, and\n today INR is 1.3.\n - Restart coumadin after PICC line placement today\n - Continue to follow INR closely to reach therapeutic INR.\n .\n #Hematemesis: Pt had small amt Hematemesis, after vomiting, yesterday.\n None today.\n -Will follow HCT.\n - Guaiac stools\n # Spine fracture: Stable\n - Brace for OOB, will discuss with Neurosurgery if current brace is\n optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n .\n # Tracheomalacia. Was initially addressed with IP and they wanted to\n follow up as outpatient. IP reevaluated and does not believe that a\n stent would be feasible.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # ACCESS: PIV x 1, PICC placement today.\n # Ppx: supratherapeutic INR, Ranitidine, Bowel Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n - Social Work and Case management involved, have discussed situation\n w/ brother and boyfriend.\n # Code: Full\n # Dispo: ICU, Screening for vent facilities\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 04:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 638175,
"text": "Airway Clearance, Impaired\n Assessment:\n Pt placed on trach mask this am (on vent o/n). She continues to have\n moderate amts of thick secretions, requiring frequent sxn. Pt does have\n a strong/productive cough.\n Action:\n Sxn prn; chest pt; pt repositioned frequently (including OOB to chair)\n to help mobilize secretions.\n Response:\n Unchanged at this time.\n Plan:\n Continue to sxn prn; chest pt prn; OOB as tolerated.\n Altered mental status (not Delirium)\n Assessment:\n Pt extremely restless/agitated today. Attempting to get OOB/chair. Very\n difficult to redirect.\n Action:\n Pt reoriented frequently; Valium given prn; Morphine given per presumed\n pain.\n Response:\n Pt had no improvement after Valium; however, she appeared more\n calm/comfortable after Morphine administration.\n Plan:\n Medicate for agitation prn; continue to follow exam.\n Alteration in Nutrition\n Assessment:\n Pt NPO for past few days ( recurrent aspiration/risk for). Pt with\n one episode of emesis today (mod amt) after coughing episode.\n Action:\n Reglan given per orders; TFs restarted this am.\n Response:\n No residuals noted. No further emesis.\n Plan:\n Increase TFs to goal as tolerated; continue with Reglan.\n Tachycardia, Other\n Assessment:\n HR 120\ns-140\ns today (baseline for ~ 1 week).\n Action:\n Lopressor given per orders.\n Response:\n HR in low 120\ns after Morphine, but otherwise unchanged.\n Plan:\n Continue Lopressor; ? need to increase dose.\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 638715,
"text": "Nausea / vomiting\n Assessment:\n NPO. Vomitted meds ~10\n after given via gtube. Coughing same emesis\n from tracheostomy. Later found to have vomited coffee ground emesis,\n guiac +. Denies nausea every time although continues to dry heave,\n vomit small amts clear emesis. BRB suctioned from back of throat also,\n d/t irritation from frequent vomiting. Abd soft, hypoactive BS.\n Action:\n Tube feeds on hold. No residual aspirated from gtube, gtube\n placed->>gravity. Stat Hct, coags T&S sent. Zofran x 1. HOB^^ 30. 2^nd\n PIV placed.\n Response:\n On/off vomiting, coffee grounds x 1, with no c/o nausea. Hct 28.6,\n baseline. INR 10.5 .\n Plan:\n Recheck Hct, FDP @ 7AM. Zofran. NPO. IV meds only. Needs gtube changed\n to jtube.\n Tachycardia, Other\n Assessment:\n ST 109-114, NSR 70s briefly. No lopressor given d/t BP<100 most of\n night when pt sleeping.\n Action:\n Lopressor changed from PO->>IV prn d/t vomiting after meds.\n Response:\n ST 110s most of night.\n Plan:\n IV lopressor prn for HR>130.\n Alteration in Nutrition\n Assessment:\n NPO. Na 146 x 2. D5W per orders. UOP decreased 10-20cc/hr with lower\n BP.\n Action:\n D5W now @ 150cc/hr x 1 liter.\n Response:\n Na 146.\n Plan:\n Recheck Na @ 7AM. D5W x 1 liter.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n On 50% trach mask all day. RR ^^40 after first episode of vomiting last\n night. Copious thick tan, dark brown secretions.\n Action:\n Placed on Vent MMV mode when tachypneic. Frequent suctioning.\n Response:\n Comfortable on vent, RR 12 (set), no spontaneous btreaths when asleep.\n Apneic for a full minute during RSBI. Sats 100%.\n Plan:\n Wean from vent as tolerated. Suction as needed, MDIs.\n Altered mental status (not Delirium)\n Assessment:\n Occaisionally restless, less so than night before. Slept most of night,\n sometimes difficult to arouse. No zyprexa given. Opens eyes to voice,\n follows commands. Mouthing words although difficult to understand.\n Action:\n Reorient pt prn. Emotional support.\n Response:\n Slept most of night, calmer than previous nights.\n Plan:\n No valium or benadryl per psych recommendations. Zyprexa HS prn for\n agitation. Reorient prn. Emotional support.\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-22 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 638903,
"text": "Chief Complaint:\n 24 Hour Events:\n Increased Metoprolol to 7.5 IV q 4\n Getting tube study in am\n had J tube placed by IR via PEG, then had tube feeds at 10/hr which she\n proceeded to vomit, TF held\n Agitated so given Haldol, put back on pressure support\n Na 148 but had not received D5W yet.\n INR 2.3 after 10 IV Vit K\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:30 AM\n Diazepam (Valium) - 02:24 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:35 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 35.7\nC (96.2\n HR: 107 (93 - 140) bpm\n BP: 85/45(55) {83/40(51) - 148/101(105)} mmHg\n RR: 23 (11 - 37) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 3,808 mL\n 557 mL\n PO:\n TF:\n 4 mL\n IVF:\n 3,804 mL\n 557 mL\n Blood products:\n Total out:\n 1,650 mL\n 385 mL\n Urine:\n 1,590 mL\n 385 mL\n NG:\n 60 mL\n Stool:\n Drains:\n Balance:\n 2,158 mL\n 172 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 169 (169 - 438) mL\n PS : 5 cmH2O\n RR (Spontaneous): 23\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 67\n PIP: 10 cmH2O\n SpO2: 100%\n ABG: ///33/\n Ve: 3.7 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 356 K/uL\n 8.2 g/dL\n 129 mg/dL\n 0.7 mg/dL\n 33 mEq/L\n 3.6 mEq/L\n 4 mg/dL\n 110 mEq/L\n 148 mEq/L\n 26.9 %\n 5.7 K/uL\n [image002.jpg]\n 06:22 AM\n 02:58 AM\n 03:43 AM\n 05:02 PM\n 03:36 AM\n 02:30 AM\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n WBC\n 7.0\n 7.1\n 7.1\n 6.9\n 7.6\n 9.5\n 5.7\n Hct\n 29.7\n 28.9\n 29.2\n 27.8\n 32.7\n 28.6\n 28.9\n 30.0\n 26.9\n Plt\n 395\n 462\n 452\n 467\n 548\n 528\n 356\n Cr\n 0.7\n 0.6\n 0.7\n 0.8\n 0.7\n 0.8\n 1.0\n 0.7\n Glucose\n 126\n 137\n 104\n 108\n 131\n 128\n 121\n 129\n Other labs: PT / PTT / INR:15.2/24.6/1.3, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:8.7 mg/dL, Mg++:2.1 mg/dL, PO4:4.1\n mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 04:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-22 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 638904,
"text": "Chief Complaint:\n 24 Hour Events:\n Increased Metoprolol to 7.5 IV q 4\n Getting tube study in am\n had J tube placed by IR via PEG, then had tube feeds at 10/hr which she\n proceeded to vomit, TF held\n Agitated so given Haldol, put back on pressure support\n Na 148 but had not received D5W yet.\n INR 2.3 after 10 IV Vit K\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:30 AM\n Diazepam (Valium) - 02:24 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:35 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 35.7\nC (96.2\n HR: 107 (93 - 140) bpm\n BP: 85/45(55) {83/40(51) - 148/101(105)} mmHg\n RR: 23 (11 - 37) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 3,808 mL\n 557 mL\n PO:\n TF:\n 4 mL\n IVF:\n 3,804 mL\n 557 mL\n Blood products:\n Total out:\n 1,650 mL\n 385 mL\n Urine:\n 1,590 mL\n 385 mL\n NG:\n 60 mL\n Stool:\n Drains:\n Balance:\n 2,158 mL\n 172 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 169 (169 - 438) mL\n PS : 5 cmH2O\n RR (Spontaneous): 23\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 67\n PIP: 10 cmH2O\n SpO2: 100%\n ABG: ///33/\n Ve: 3.7 L/min\n Physical Examination\n Gen: Mildly obtunded in am, responsive to noxious stimuli, on MMV\n through trach tube, but later in am responsive to voice, appropriate,\n asking questions,\n HEENT: PERRL, MMM\n Resp: Coarse BS anteriorly, no focal rales, rhonchi, or wheezing with\n some referred upper airway noises from secretions.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, hypoactive BS\n Exte: No edema, DP 2+ bil.\n NEURO: Toes downgoing bilaterally,\n Labs / Radiology\n 356 K/uL\n 8.2 g/dL\n 129 mg/dL\n 0.7 mg/dL\n 33 mEq/L\n 3.6 mEq/L\n 4 mg/dL\n 110 mEq/L\n 148 mEq/L\n 26.9 %\n 5.7 K/uL\n [image002.jpg]\n 06:22 AM\n 02:58 AM\n 03:43 AM\n 05:02 PM\n 03:36 AM\n 02:30 AM\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n WBC\n 7.0\n 7.1\n 7.1\n 6.9\n 7.6\n 9.5\n 5.7\n Hct\n 29.7\n 28.9\n 29.2\n 27.8\n 32.7\n 28.6\n 28.9\n 30.0\n 26.9\n Plt\n 395\n 462\n 452\n 467\n 548\n 528\n 356\n Cr\n 0.7\n 0.6\n 0.7\n 0.8\n 0.7\n 0.8\n 1.0\n 0.7\n Glucose\n 126\n 137\n 104\n 108\n 131\n 128\n 121\n 129\n Other labs: PT / PTT / INR:15.2/24.6/1.3, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:8.7 mg/dL, Mg++:2.1 mg/dL, PO4:4.1\n mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 04:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-22 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 638905,
"text": "Chief Complaint:\n 24 Hour Events:\n Increased Metoprolol to 7.5 IV q 4\n Getting tube study in am\n had J tube placed by IR via PEG, then had tube feeds at 10/hr which she\n proceeded to vomit, TF held\n Agitated so given Haldol, put back on pressure support\n Na 148 but had not received D5W yet.\n INR 2.3 after 10 IV Vit K\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:30 AM\n Diazepam (Valium) - 02:24 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:35 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 35.7\nC (96.2\n HR: 107 (93 - 140) bpm\n BP: 85/45(55) {83/40(51) - 148/101(105)} mmHg\n RR: 23 (11 - 37) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 3,808 mL\n 557 mL\n PO:\n TF:\n 4 mL\n IVF:\n 3,804 mL\n 557 mL\n Blood products:\n Total out:\n 1,650 mL\n 385 mL\n Urine:\n 1,590 mL\n 385 mL\n NG:\n 60 mL\n Stool:\n Drains:\n Balance:\n 2,158 mL\n 172 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 169 (169 - 438) mL\n PS : 5 cmH2O\n RR (Spontaneous): 23\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 67\n PIP: 10 cmH2O\n SpO2: 100%\n ABG: ///33/\n Ve: 3.7 L/min\n Physical Examination\n Gen: Mildly obtunded in am, responsive to noxious stimuli, on MMV\n through trach tube, but later in am responsive to voice, appropriate,\n asking questions,\n HEENT: PERRL, MMM\n Resp: Coarse BS anteriorly, no focal rales, rhonchi, or wheezing with\n some referred upper airway noises from secretions.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, hypoactive BS\n Exte: No edema, DP 2+ bil.\n NEURO: Toes downgoing bilaterally,\n Labs / Radiology\n 356 K/uL\n 8.2 g/dL\n 129 mg/dL\n 0.7 mg/dL\n 33 mEq/L\n 3.6 mEq/L\n 4 mg/dL\n 110 mEq/L\n 148 mEq/L\n 26.9 %\n 5.7 K/uL\n [image002.jpg]\n 06:22 AM\n 02:58 AM\n 03:43 AM\n 05:02 PM\n 03:36 AM\n 02:30 AM\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n WBC\n 7.0\n 7.1\n 7.1\n 6.9\n 7.6\n 9.5\n 5.7\n Hct\n 29.7\n 28.9\n 29.2\n 27.8\n 32.7\n 28.6\n 28.9\n 30.0\n 26.9\n Plt\n 395\n 462\n 452\n 467\n 548\n 528\n 356\n Cr\n 0.7\n 0.6\n 0.7\n 0.8\n 0.7\n 0.8\n 1.0\n 0.7\n Glucose\n 126\n 137\n 104\n 108\n 131\n 128\n 121\n 129\n Other labs: PT / PTT / INR:15.2/24.6/1.3, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:8.7 mg/dL, Mg++:2.1 mg/dL, PO4:4.1\n mg/dL\n Assessment and Plan\n 55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach, PEG placement now with respiratory failure secondary to\n tracheomalacia , resolved HAP.\n .\n # Respiratory failure: Slowly Improving. Intermittently on trach mask\n for most of the day, with periods of pressure support of over\n night. This am on MMV. Previously likely oversedated but Benadryl,\n Morhpine, and Valium held now. Pt awake and alert at rounds,\n interactive, and breathing comfortably on trach mask\n - Continue to increase time on trach mask as tolerated.\n - Decrease sedation and valium use\n - PMV with suctioning\n .\n # HAP vs Aspiration PNA: Afebrile without leukocytosis\n - Completed course of ceftriaxone\n - good O2 saturation on trach mask\n .\n # Tachycardia: Previously was assessed as sinus tach with occasional\n runs of SVT and sources such as hypovolemia, PE, infection, and pain\n were assessed as possibly etiologies. Per Cardiology, most likely AT\n given transient response to Adenosine. HR occasionally decreases to\n 70s-80s w/ stable BPs at times that might be associated with\n administration of her BB and valium. Cards recommended titrating up her\n beta blocker as tolerated. Dose increased to 50 yesterday and\n intermittently responded but then had to hold PO meds given need to\n hold PO. Changed PO to IV lopressor.\n - EP consulted for SVT, appreciate recs, will change metoprololt o IV\n and hopefully will be able to restart PO meds soon once able to\n tolerate\n - IV metoprolol 5 mg IV q 4\n .\n # Sedation: Inconsistent response to sedation, unclear what is best\n regime. Will continue to wean overall.\n - Continue w Olanzapine QHS\n - Just valium 2.5 mg PRN.\n # Nutrition/Vomiting: Pt has had several episodes of vomiting up her\n TFs, reglan started to increase GI motility, but pt had another episode\n of vomiting this am, not improved with zofran or reglan. Patient also\n had hypoactive BS on exam, concern for obstruction given persistent\n vomiting, inability to tolerate tube feeds.\n - Hold TFs\n - Thoracic surgery recs: 1) oral/nasal tube in post-piloric position,\n or 2) IR to place a pediatric feeding tube through her PEG site to a\n post-piloric position.\n - Will attempt to coordinate thoracic surgery and IR for tube placement\n ; will d/w thoracics\n - CT scan did not reveal evidence of obstruction. Attempted to\n coordinate tube study or UGI btu per Radiology would not be useful\n studies since no obstruction or dysmotility evident on CT\n - Reglan DCd since not helping\n - Will decrease narcotics for possible cause of decreased motility\n .\n # Adrenal Insufficency: Endocrine following. Pt does not appear to be\n adrenally insufficient at baseline. Suggesting if the patient under\n goes major stressors such as major surgery, sepsis, she may need stress\n dosed steroids.\n .\n # Fluid Status: Likely approaching euvolemia, though still has mild\n hypernatramia which may suggest is still intravascularly depleated.\n - Monitoring urine output\n - will provide D5W IVF as need for hypernatremia and follow lytes\n .\n # UE DVT and elevated INR: DVT in right UE has resolved, new\n non-occlusive in left axillary vein. INR supratherapeutic today and\n trending upward. INR most likely continuing to rise nutritional\n deficiencies given continued lack of PO intake\n - Cumadin stopped.\n - INR 10.5 today, up from 5.5, will give Vitamin K IV and reassess will\n check PM coags and follow\n - vitamin K IV x 1. Will likely need to continue with SC, follow coags\n .\n #Hematemesis: Pt had small amt Hematemesis this am. Concerning in\n setting of elevated INR. Will give IV Vitamin K and may need continued\n dosing\n - Vit K IV x 1\n -\n # Spine fracture: Stable\n - Brace for OOB, will discuss with Neurosurgery if current brace is\n optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n .\n # Tracheomalacia. Was initially addressed with IP and they wanted to\n follow up as outpatient. IP reevaluated and does not believe that a\n stent would be feasible.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # PIV x 1\n # Ppx: supratherapeutic INR, Ranitidine, Bowel Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n - Will contact Social and Case management today\n # Code: Full\n # Dispo: ICU, Screening for vent facilities\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 04:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Social Work",
"chartdate": "2167-10-22 00:00:00.000",
"description": "Social Work Progress Note",
"row_id": 639036,
"text": "Social Work:\n Discussed with legal department brother\ns questions re whether the\n hospital should pursue guardianship for pt. Also discussed with MICU\n attending, resident, and RNCM. Per discussion with all of the above,\n shared with pt\ns brother that it does not appear necessary for the\n hospital to pursue guardianship at this time given that, as pt\ns legal\n , brother has been available, communicating regularly with team, and\n making decisions re her healthcare on her behalf\n decisions that also\n appear to be aligned with what pt\ns boyfriend understands pt would\n want. Per RNCM, there is also no indication at this time that, with\n pt\ns legal acting on pt\ns behalf, guardianship would be necessary\n for her for disposition/placement purposes. Reminded brother that he\n can address any further questions or concerns about disposition-related\n issues with RNCM. Brother states he agrees that communication re pt\n medical care is going smoothly. He reiterates from our phone\n conversation yesterday that his questions about guardianship \n largely from his concern about how pt\ns finances are being managed or\n will be managed should she remain unable to attend to them herself.\n Encouraged him to discuss this with pt\ns boyfriend, as it seems\n boyfriend has been trying to manage these matters in recent weeks.\n Brother states he plans to fly in from tomorrow and will come\n to the hospital in the afternoon to visit pt and meet with MICU team.\n Arranged family meeting with MICU team for 3:30 Friday. ,\n , be available to attend along with team. Discussed with\n RN. Please page as needed.\n , LCSW, #\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 639727,
"text": "Chief Complaint:\n 24 Hour Events:\n -hypernatremia: Repeat Na 148-->146 (this am), continuing D5W at\n 125cc/hr\n -TF up to 30cc/hr; tolerated O/N; stopped at 12am\n -Psych recs: Gave risperidone m-tab 1mg PO x1 HS last night and will\n continue risperdone 0.5mg qam and 0.5 PRN; f/u EKG in am;\n -Changed Metoprolol 25 to 37.5mg TID given tach to 110-120\ns; gave 5mg\n x1\n -GI recs: pending\n -IP: seen by IP this am for eval of possible stent placement, pt not a\n candidate as she is at risk of aspiration given opening defect\n posterior to vocal cords; recommended d/w ENT and increase ppi to .\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:30 AM\n Enoxaparin (Lovenox) - 06:48 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.7\nC (98.1\n HR: 79 (68 - 124) bpm\n BP: 134/57(75) {124/52(70) - 179/121(130)} mmHg\n RR: 27 (18 - 31) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 4,004 mL\n 1,084 mL\n PO:\n TF:\n 137 mL\n 51 mL\n IVF:\n 2,544 mL\n 729 mL\n Blood products:\n Total out:\n 3,813 mL\n 1,000 mL\n Urine:\n 3,813 mL\n 1,000 mL\n NG:\n Stool:\n Drains:\n Balance:\n 191 mL\n 84 mL\n Respiratory support\n O2 Delivery Device: Trach mask 40-50%\n SpO2: 99%\n ABG: ///33/\n Physical Examination\n Gen: Sedating post-bronchoscopy; Sleeping; pt would not wake for exam.\n HEENT: No pallor in conjunctiva, MMM\n Resp: Course breath sounds anteriorly, mild exp wheeze.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, decreased bowel sounds, G-Tube in\n place with no erythema/induration\n Exte: No edema, DP 2+ bil\n NEURO: Sedated\n Labs / Radiology\n 231 K/uL\n 7.7 g/dL\n 145 mg/dL\n 0.4 mg/dL\n 33 mEq/L\n 3.5 mEq/L\n 11 mg/dL\n 109 mEq/L\n 146 mEq/L\n 25.3 %\n 5.7 K/uL\n [image002.jpg]\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n 03:00 AM\n 04:00 AM\n 05:45 AM\n 03:51 AM\n 04:45 PM\n 04:00 AM\n WBC\n 9.5\n 5.7\n 7.3\n 8.0\n 8.7\n 5.5\n 5.7\n Hct\n 28.6\n 28.9\n 30.0\n 26.9\n 27.3\n 27.0\n 28.7\n 24.7\n 25.2\n 25.3\n Plt\n 528\n 356\n 346\n \n 231\n Cr\n 1.0\n 0.7\n 0.7\n 0.7\n 0.7\n 0.5\n 0.4\n Glucose\n 121\n 129\n 123\n 114\n 112\n 122\n 145\n Other labs: PT / PTT / INR:13.6/31.1/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.6 mg/dL, Mg++:2.0 mg/dL, PO4:3.6\n mg/dL\n Assessment and Plan\n 56yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach/PEG with resolving respiratory failure and HAP.\n .\n # Respiratory failure/Aspiration Risk: s/p intubation/extubation, now\n on trach mask, FiO2 50%. Tolerating well with good O2 sat. No further\n self-decanulations overnight. Pt continues to be at risk for aspiration\n given new IP finding of opening defect in posterior vocal cord space\n and given recent history of vomiting with tube feed trials.\n - ENT consulted for evaluation of larynx and possible intervention;\n will follow ENT recs\n - increase ppi from qday to for aspiration prophylaxis\n - Trach mask as tolerated.\n - scopolamine patch q72hrs for secretions\n - Holding sedation with exception of Risperidal 0.5mg PRN\n - F/u CXR tomorrow\n .\n # Nutrition/Vomiting: Currently receiving TPN; BMx2 in past 24 hrs to\n indicate possible improvement in ileus. TF tolerated during trial O/N\n without emesis.\n - Cont Reglan 20mg IV Q 8 hours; meds via G-J tube,\n - Will obtain recommendations from Nutrition re TPN today and will\n provide TF as tolerated\n - Speech and Swallow eval today for Passy Muir valve eval;\n - GI consult, will f/u recs\n .\n # Tachycardia: Improved HR max of 120\ns versus 160s previously. Pt now\n on PO Amiodarone 200 TID and PO metoprolol 37.5mg TID\n - Continue current med regimen. Will continue amiodarone 200 TID for\n three weeks and then switch to qday for 1week and then d/c amiodarone.\n - Will need to schedule f/u in 4wks with Dr. upon d/c/transfer.\n - f/u Cards recs\n # Sedation/Anxiolysis/AlteredMS: Resolved O/N with risperdal. Previous\n delirium and agitation most likely secondary to long hospital course\n and multiple psychotropic medications as well as hx of EtOH abuse.\n - started Risperdal 0.5mg PO BID PRN.\n - continue to hold all benzos. opiates, and antihistamines\n - Appreciate psych. Will call and f/u psych recs.\n -Obtain EKG to assess for QTc prolongation.\n #Anemia: HCT stable at 25. No known etiology of blood loss.\n -Will repeat HCT in am .\n # Hypernatremia/Fluid Status: Mild hypernatramia resolving with free\n water administration. On TPN/TF. Good UOP.\n - providing D5W IVFx 1L at 125cc/hr, free water flushes with TF\n -Will f/u lytes in afternoon (5pm)\n # UE DVT and elevated INR: Decision made to d/c Coumadin given her\n labile INR, and start Lovenox .\n - Will flush L PICC with TPA if does not flush\n - Add coags to am labs\n .\n # Spine fracture: Stable\n - Brace for OOB, need to discuss with Neurosurgery before d/c if\n current brace is optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n .\n # Tracheomalacia. Reevaluation bronchoscopy by IP as written above;\n patient not a candidate for stent; pt to follow up as outpatient. No\n new issues.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # ACCESS: PIV x 1, L PICC\n # Ppx: Lovenox, PPi-to increase to , Bowel Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n - Social Work and Case management involved; have discussed situation\n w/ brother and boyfriend.\n # Code: Full\n # Dispo: ICU, Will d/w case management re rehab facilities.\n MSIV\n PGY2 addendum:\n Agree with assessment and plan in MSIV note as detailed above.\n Briefly, 56 F s/p fall with T spine fracture, respiratory failure now\n s/p trach/PEG. Now on trach mask. Patient s/p bronch with IP today;\n ENT to see and follow for ?intervention. Nutrition issues continue;\n will receive TPN today plus possible restart of tube feeds as tolerated\n (later today), continue reglan. Appreciate psych recs; continuing\n risperidone for agitation. Etiology of delirium/agitation still\n unclear. Likely eventual dispo to rehab facility directly from ICU\n given high nursing requirements.\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-20 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 638599,
"text": "Chief Complaint: resp failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n CARDIOVERSION/DEFIBRILLATION - At 11:50 AM\n aqdenosine 6mg given X 1 by cardiologist to assess pt's rhythm. Pt\n tolerated well.\n Held Valium ansd Benedryl and has done well without\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.5\nC (97.7\n HR: 118 (76 - 144) bpm\n BP: 131/72(85) {93/43(0) - 154/134(138)} mmHg\n RR: 26 (12 - 36) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,945 mL\n 680 mL\n PO:\n TF:\n IVF:\n 1,800 mL\n 560 mL\n Blood products:\n Total out:\n 2,300 mL\n 680 mL\n Urine:\n 2,245 mL\n 680 mL\n NG:\n 55 mL\n Stool:\n Drains:\n Balance:\n -355 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: High flow neb, Tracheostomy tube\n Ventilator mode: MMV/PSV/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 319 (319 - 319) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 15\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 15 cmH2O\n SpO2: 94%\n ABG: ///36/\n Ve: 5.5 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 10.0 g/dL\n 548 K/uL\n 128 mg/dL\n 0.8 mg/dL\n 36 mEq/L\n 4.1 mEq/L\n 6 mg/dL\n 105 mEq/L\n 148 mEq/L\n 32.7 %\n 7.6 K/uL\n [image002.jpg]\n 05:00 AM\n 02:06 AM\n 07:34 AM\n 03:50 AM\n 06:22 AM\n 02:58 AM\n 03:43 AM\n 05:02 PM\n 03:36 AM\n 02:30 AM\n WBC\n 5.9\n 7.5\n 5.6\n 6.1\n 7.0\n 7.1\n 7.1\n 6.9\n 7.6\n Hct\n 27.2\n 26.8\n 27.0\n 27.0\n 29.7\n 28.9\n 29.2\n 27.8\n 32.7\n Plt\n 296\n 306\n 335\n \n 452\n 467\n 548\n Cr\n 0.7\n 0.6\n 0.5\n 0.7\n 0.7\n 0.6\n 0.7\n 0.8\n 0.7\n 0.8\n Glucose\n 134\n 134\n 121\n \n 104\n 108\n 131\n 128\n Other labs: PT / PTT / INR:48.3/33.3/5.5, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:10.0 mg/dL, Mg++:2.5 mg/dL,\n PO4:4.3 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-20 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 638600,
"text": "Chief Complaint: resp failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n CARDIOVERSION/DEFIBRILLATION - At 11:50 AM\n aqdenosine 6mg given X 1 by cardiologist to assess pt's rhythm. Pt\n tolerated well.\n Held Valium ansd Benedryl and has done well without\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.5\nC (97.7\n HR: 118 (76 - 144) bpm\n BP: 131/72(85) {93/43(0) - 154/134(138)} mmHg\n RR: 26 (12 - 36) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,945 mL\n 680 mL\n PO:\n TF:\n IVF:\n 1,800 mL\n 560 mL\n Blood products:\n Total out:\n 2,300 mL\n 680 mL\n Urine:\n 2,245 mL\n 680 mL\n NG:\n 55 mL\n Stool:\n Drains:\n Balance:\n -355 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: High flow neb, Tracheostomy tube\n Ventilator mode: MMV/PSV/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 319 (319 - 319) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 15\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 15 cmH2O\n SpO2: 94%\n ABG: ///36/\n Ve: 5.5 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 10.0 g/dL\n 548 K/uL\n 128 mg/dL\n 0.8 mg/dL\n 36 mEq/L\n 4.1 mEq/L\n 6 mg/dL\n 105 mEq/L\n 148 mEq/L\n 32.7 %\n 7.6 K/uL\n [image002.jpg]\n 05:00 AM\n 02:06 AM\n 07:34 AM\n 03:50 AM\n 06:22 AM\n 02:58 AM\n 03:43 AM\n 05:02 PM\n 03:36 AM\n 02:30 AM\n WBC\n 5.9\n 7.5\n 5.6\n 6.1\n 7.0\n 7.1\n 7.1\n 6.9\n 7.6\n Hct\n 27.2\n 26.8\n 27.0\n 27.0\n 29.7\n 28.9\n 29.2\n 27.8\n 32.7\n Plt\n 296\n 306\n 335\n \n 452\n 467\n 548\n Cr\n 0.7\n 0.6\n 0.5\n 0.7\n 0.7\n 0.6\n 0.7\n 0.8\n 0.7\n 0.8\n Glucose\n 134\n 134\n 121\n \n 104\n 108\n 131\n 128\n Other labs: PT / PTT / INR:48.3/33.3/5.5, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:10.0 mg/dL, Mg++:2.5 mg/dL,\n PO4:4.3 mg/dL\n Assessment and Plan\n 1. Tachycardia: runs of atach versus AVNRT. On bblocker be not very\n effective- EP consult for ? is there an ablatable focus.\n 2. Resp Failure\n Trach mask trials as tolerating (needing QHS support at\n present)\n PMV trials\n S/P rx for pan Klebs PNA.\n Per IP not stent planned as technically not possible to\n place into her airway\n 3. DVT and coagulopathy On warfarin but high inr. Hold warfarin until\n inr 2-2.5 range or bridge with loveox if may get procedures\n 4. Feeding tube Getting reglan trial but still with emesis. Need to\n coordinate IR advance of G to J tube with Thoracics\n 5. Hypernatremia Replete free water.\n Please see today\ns ICU team note for other issues.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-20 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 638602,
"text": "Chief Complaint: resp failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n CARDIOVERSION/DEFIBRILLATION - At 11:50 AM\n aqdenosine 6mg given X 1 by cardiologist to assess pt's rhythm. Pt\n tolerated well.\n Held Valium ansd Benedryl and has done well without\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.5\nC (97.7\n HR: 118 (76 - 144) bpm\n BP: 131/72(85) {93/43(0) - 154/134(138)} mmHg\n RR: 26 (12 - 36) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,945 mL\n 680 mL\n PO:\n TF:\n IVF:\n 1,800 mL\n 560 mL\n Blood products:\n Total out:\n 2,300 mL\n 680 mL\n Urine:\n 2,245 mL\n 680 mL\n NG:\n 55 mL\n Stool:\n Drains:\n Balance:\n -355 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: High flow neb, Tracheostomy tube\n Ventilator mode: MMV/PSV/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 319 (319 - 319) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 15\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 15 cmH2O\n SpO2: 94%\n ABG: ///36/\n Ve: 5.5 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 10.0 g/dL\n 548 K/uL\n 128 mg/dL\n 0.8 mg/dL\n 36 mEq/L\n 4.1 mEq/L\n 6 mg/dL\n 105 mEq/L\n 148 mEq/L\n 32.7 %\n 7.6 K/uL\n [image002.jpg]\n 05:00 AM\n 02:06 AM\n 07:34 AM\n 03:50 AM\n 06:22 AM\n 02:58 AM\n 03:43 AM\n 05:02 PM\n 03:36 AM\n 02:30 AM\n WBC\n 5.9\n 7.5\n 5.6\n 6.1\n 7.0\n 7.1\n 7.1\n 6.9\n 7.6\n Hct\n 27.2\n 26.8\n 27.0\n 27.0\n 29.7\n 28.9\n 29.2\n 27.8\n 32.7\n Plt\n 296\n 306\n 335\n \n 452\n 467\n 548\n Cr\n 0.7\n 0.6\n 0.5\n 0.7\n 0.7\n 0.6\n 0.7\n 0.8\n 0.7\n 0.8\n Glucose\n 134\n 134\n 121\n \n 104\n 108\n 131\n 128\n Other labs: PT / PTT / INR:48.3/33.3/5.5, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:10.0 mg/dL, Mg++:2.5 mg/dL,\n PO4:4.3 mg/dL\n Assessment and Plan\n 1. Tachycardia: runs of attach Appreciate EP consult\n will increase\n bblocker. If fails may need EP study for further study and ? ablatable\n focus.\n 2. Persistent Nausea/Vomiting: very poor bowel sounds, get ABD ct to\n look for SBO, talk with GI about EGD or tube study to look for more\n proximal gastric outlet obstruction.\n 2. Resp Failure\n Trach mask trials all day, PSV\n PMV trials\n S/P rx for pan Klebs PNA.\n Per IP not stent planned as technically not possible to\n place into her airway\n 3. DVT and coagulopathy: On warfarin but high inr. Hold warfarin until\n inr 2-2.5 range or bridge with loveox if may get procedures\n 4. Feeding tube Getting reglan trial but still with emesis. Need to\n coordinate IR advance of G to J tube with Thoracics\n 5. Hypernatremia Replete free water.\n Please see today\ns ICU team note for other issues.\n ICU Care\n Nutrition: NPPO while sorting out gi obstruction issues\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n Prophylaxis:\n DVT: coumadin\n Stress ulcer: PPI\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent:\n"
},
{
"category": "Rehab Services",
"chartdate": "2167-10-22 00:00:00.000",
"description": "Physical Therapy Progress Note",
"row_id": 639038,
"text": "Subjective:\n \"I think they are trying to kill me here\"\n Objective:\n Follow up PT visit to address goals of: .\n Updated medical status: PMV\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Rolling:\n T\n\n\n\n\n\n Supine/\n Sidelying to Sit:\n\n\n T\n\n\n Transfer:\n\n\n\n T\n\n Sit to Stand:\n\n\n\n T\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Aerobic Activity Response:\n Position\n HR\n BP\n RR\n O[2] sat\n RPE\n Rest\n Supine\n 110-125\n 142/80\n 99% 50% TM\n Activity\n /\n Recovery\n Sit\n 110-130s\n 138/80\n 96-99% TM\n Total distance walked:\n Minutes:\n Gait: Attempted ambulation, pt unable to advance LEs, was mod x 2 to\n take 2 small steps forward, and Max A to take 2 steps back. Mod A x 1\n to stand pivot to chair.\n Balance: Pt has fair sitting balance. Retropulsive in standing.\n Education / Communication: Pt status discussed with RN\n Other: Pt making nonsensical statements t/o treatment. A and O x 2,\n person and year not month, date or place.\n Pulm: Pt with strong productive cough, thick yellow sputum. Tolerated\n PMV t/o treatment.\n Pt performed sit to stand x 3 with mod A x 2\n Assessment: 56 yo f s/p fall with T8 fx and complicated hospital course\n due to resp distress. Pt continues to be functioning below baseline,\n from both cognitive and mobility stand points. Pt would benefit from OT\n consult and continue PT in rehab setting upon d/c to optimize function\n and independence\n Anticipated Discharge: Rehab\n Plan: f/u progress mobility, advance ambulation.\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 639111,
"text": "Tachycardia, Other\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 639114,
"text": "56 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\n with prolonged hospital course c/b by PNA, anxiety/altered mental\n status, R&LUE DVT .Pt found to have small non occlusive Clot on her\n right axial vein via Ultrasound.Yesterday. She has had problems with\n vomiting tube feedings, feeding tube passed through g-tube (g-tube in\n place with mushroom on inside so cannot pull out) to her jejunenum but\n continues vomit.\n Tachycardia, Other\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 639639,
"text": "Airway Clearance, Impaired\n Assessment:\n Pt cont on TM 50%, bilat rhonchi, diminished in bases. 02 SATS 94-95%\n Action:\n Pt requiring frequent suction, copious loose white secretions noted,\n scolopamine patch applied to help with secretions\n Response:\n Cont to suction for copious secretions\n Plan:\n Cont to resp. status, suction as needed, s/swallow to re-evaluate\n for bigger PMV in am\n Alteration in Nutrition\n Assessment:\n Pt cont with restlessness, TF off 00 due to pts restlessness, BS\n positive bilat, loose BM\ns x 2\n Action:\n Pt placed on chair positin in bed, pt recvd scheduled Reglan, colace\n Response:\n Pt had two loose bm\ns x 2,\n Plan:\n Re-start TF when pt more relaxed, cont with TPN 43.6 as ordered, cont\n strict asp precautions :holding TF when pt not in upright position and\n turning TF off for 15 mins before turning\n Arousal, Attention, and Cognition, Impaired\n Assessment:\n Pt cont to be very restless in bed, cont with bilat wrist restraints\n and 1:1 sitter @ bedside\n Action:\n Pt seen by psych @, Risperadol dosing increased\n Response:\n Pt cont to be restless despite increase in HS risperadol and prn dose\n Plan:\n Psych to re-evaluate in am, EKG to be taken in am\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-27 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 639709,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Aggitation, remains delerious.\n Bedside bronchoscopy by IP service revealed inability of posterior\n portion of vocal cords to adduct. Unclear etiology.\n Sedated for bronchoscopy.\n 24 Hour Events:\n History obtained from Medical records\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Enoxaparin (Lovenox) - 06:48 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG\n tube, Tracheotomy tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, Tube feeds, No(t) Parenteral nutrition\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, No(t) Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: No(t) Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 11:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.1\nC (96.9\n HR: 62 (62 - 123) bpm\n BP: 87/42(53) {87/42(53) - 179/121(130)} mmHg\n RR: 20 (18 - 31) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 4,004 mL\n 2,070 mL\n PO:\n TF:\n 137 mL\n 51 mL\n IVF:\n 2,544 mL\n 1,423 mL\n Blood products:\n Total out:\n 3,813 mL\n 1,380 mL\n Urine:\n 3,813 mL\n 1,380 mL\n NG:\n Stool:\n Drains:\n Balance:\n 191 mL\n 690 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 98%\n ABG: ///33/\n Physical Examination\n General Appearance: No(t) Well nourished, No(t) No acute distress,\n No(t) Overweight / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic,\n Sedated\n Eyes / Conjunctiva: No(t) PERRL, No(t) Pupils dilated, No(t)\n Conjunctiva pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: No(t) Normocephalic, No(t) Poor dentition,\n No(t) Endotracheal tube, No(t) NG tube, No(t) OG tube, Tracheotomy tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic,\n No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: No(t) Resonant : , No(t) Hyperresonant: , No(t) Dullness :\n ), (Breath Sounds: Clear : , No(t) Crackles : , Bronchial: Right base,\n No(t) Wheezes : , No(t) Diminished: , No(t) Absent : , No(t)\n Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended, No(t)\n Tender: , No(t) Obese, PEG\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Verbal stimuli, No(t) Oriented (to): , Movement: Purposeful, No(t)\n Sedated, No(t) Paralyzed, Tone: Normal\n Labs / Radiology\n 7.7 g/dL\n 231 K/uL\n 145 mg/dL\n 0.4 mg/dL\n 33 mEq/L\n 3.5 mEq/L\n 11 mg/dL\n 109 mEq/L\n 146 mEq/L\n 25.3 %\n 5.7 K/uL\n [image002.jpg]\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n 03:00 AM\n 04:00 AM\n 05:45 AM\n 03:51 AM\n 04:45 PM\n 04:00 AM\n WBC\n 9.5\n 5.7\n 7.3\n 8.0\n 8.7\n 5.5\n 5.7\n Hct\n 28.6\n 28.9\n 30.0\n 26.9\n 27.3\n 27.0\n 28.7\n 24.7\n 25.2\n 25.3\n Plt\n 528\n 356\n 346\n \n 231\n Cr\n 1.0\n 0.7\n 0.7\n 0.7\n 0.7\n 0.5\n 0.4\n Glucose\n 121\n 129\n 123\n 114\n 112\n 122\n 145\n Other labs: PT / PTT / INR:13.6/31.1/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.6 mg/dL, Mg++:2.0 mg/dL, PO4:3.6\n mg/dL\n Assessment and Plan\n Respiratory failure, delerium.\n RESPIRATORY FAILURE -- chronic, s/p trach. Underlying\n tracheobronchomalacia. Possible elevated right hemidiaphragm.\n Continue current care, including aspiration precautions. Maintain\n trach, monitor SaO2 --> maintain >90%.\n TRACHEOBRONCOMALACIA -- no immediate plans for IP intervention.\n VOCAL CORD dysfunction -- ENT to evaluate limited ability of posterior\n portion of cords to adduct. consult ENT service.\n RUE DVT -- anticoagulation with lovenox.\n HYPERNATREMIA -- improved with free H2O repletion. Monitor.\n A-FIB -- rate controlled on amioderone.\n DELERIUM -- currently sedated from procedure. Unclear etiology.\n Concerns include medications and ICU psychosis. Psychiatry consulted.\n Respiradol dose being adjusted.\n NUTRITIONAL SUPPORT -- hope to transition TPN to TF via PEG.\n T4-T8 VETEBRAL Fx -- suportive care. Will require rehabilitation.\n ICU Care\n Nutrition:\n TPN without Lipids - 05:44 PM 43. mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n 18 Gauge - 10:14 AM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 55 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 639711,
"text": "Chief Complaint:\n 24 Hour Events:\n -hypernatremia: Repeat Na 148-->146 (this am), continuing D5W at\n 125cc/hr\n -TF up to 30cc/hr; tolerated O/N; stopped at 12am\n -Psych recs: Gave risperidone m-tab 1mg PO x1 HS last night and will\n continue risperdone 0.5mg qam and 0.5 PRN; f/u EKG in am;\n -Changed Metoprolol 25 to 37.5mg TID given tach to 110-120\ns; gave 5mg\n x1\n -GI recs: pending\n -IP: seen by IP this am for eval of possible stent placement, pt not a\n candidate as she is at risk of aspiration given opening defect\n posterior to vocal cords; recommended d/w ENT and increase ppi to .\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:30 AM\n Enoxaparin (Lovenox) - 06:48 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.7\nC (98.1\n HR: 79 (68 - 124) bpm\n BP: 134/57(75) {124/52(70) - 179/121(130)} mmHg\n RR: 27 (18 - 31) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 4,004 mL\n 1,084 mL\n PO:\n TF:\n 137 mL\n 51 mL\n IVF:\n 2,544 mL\n 729 mL\n Blood products:\n Total out:\n 3,813 mL\n 1,000 mL\n Urine:\n 3,813 mL\n 1,000 mL\n NG:\n Stool:\n Drains:\n Balance:\n 191 mL\n 84 mL\n Respiratory support\n O2 Delivery Device: Trach mask 40-50%\n SpO2: 99%\n ABG: ///33/\n Physical Examination\n Gen: Sedating post-bronchoscopy; Sleeping; pt would not wake for exam.\n HEENT: No pallor in conjunctiva, MMM\n Resp: Course breath sounds anteriorly, mild exp wheeze.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, decreased bowel sounds, G-Tube in\n place with no erythema/induration\n Exte: No edema, DP 2+ bil\n NEURO: Sedated\n Labs / Radiology\n 231 K/uL\n 7.7 g/dL\n 145 mg/dL\n 0.4 mg/dL\n 33 mEq/L\n 3.5 mEq/L\n 11 mg/dL\n 109 mEq/L\n 146 mEq/L\n 25.3 %\n 5.7 K/uL\n [image002.jpg]\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n 03:00 AM\n 04:00 AM\n 05:45 AM\n 03:51 AM\n 04:45 PM\n 04:00 AM\n WBC\n 9.5\n 5.7\n 7.3\n 8.0\n 8.7\n 5.5\n 5.7\n Hct\n 28.6\n 28.9\n 30.0\n 26.9\n 27.3\n 27.0\n 28.7\n 24.7\n 25.2\n 25.3\n Plt\n 528\n 356\n 346\n \n 231\n Cr\n 1.0\n 0.7\n 0.7\n 0.7\n 0.7\n 0.5\n 0.4\n Glucose\n 121\n 129\n 123\n 114\n 112\n 122\n 145\n Other labs: PT / PTT / INR:13.6/31.1/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.6 mg/dL, Mg++:2.0 mg/dL, PO4:3.6\n mg/dL\n Assessment and Plan\n 56yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach/PEG with resolving respiratory failure and HAP.\n .\n # Respiratory failure/Aspiration Risk: s/p intubation/extubation, now\n on trach mask, FiO2 50%. Tolerating well with good O2 sat. No further\n self-decanulations overnight. Pt continues to be at risk for aspiration\n given new IP finding of opening defect in posterior vocal cord space\n and given recent history of vomiting with tube feed trials.\n - ENT consulted for evaluation of larynx and possible intervention;\n will follow ENT recs\n - increase ppi from qday to for aspiration prophylaxis\n - Trach mask as tolerated.\n - scopolamine patch q72hrs for secretions\n - Holding sedation with exception of Risperidal 0.5mg PRN\n - F/u CXR tomorrow\n .\n # Nutrition/Vomiting: Currently receiving TPN; BMx2 in past 24 hrs to\n indicate possible improvement in ileus. TF tolerated during trial O/N\n without emesis.\n - Cont Reglan 20mg IV Q 8 hours; meds via G-J tube,\n - Will obtain recommendations from Nutrition re TPN today and will\n provide TF as tolerated\n - Speech and Swallow eval today for Passy Muir valve eval;\n - GI consult, will f/u recs\n .\n # Tachycardia: Improved HR max of 120\ns versus 160s previously. Pt now\n on PO Amiodarone 200 TID and PO metoprolol 25mg TID\n - Continue current med regimen. Will continue amiodarone 200 TID for\n three weeks and then switch to qday.\n - Will need to schedule f/u in 4wks with Dr. upon d/c/transfer.\n - f/u Cards recs\n # Sedation/Anxiolysis/AlteredMS: Resolved O/N. Previous delirium and\n agitation most likely secondary to long hospital course and multiple\n psychotropic medications as well as hx of EtOH abuse. Risperdal given\n O/N per Psych recs.\n - started Risperdal 0.5mg PO BID PRN.\n - continue to hold all benzos. opiates, and antihistamines\n - Appreciate psych. Will call and f/u psych recs.\n #Anemia: HCT stable at 25. No known etiology of blood loss.\n -Will repeat HCT in am .\n # Hypernatremia/Fluid Status: Mild hypernatramia resolving with free\n water administration. On TPN/TF. Good UOP.\n - providing D5W IVF, free water flushes with TF\n -Will f/u lytes in afternoon (5pm)\n # UE DVT and elevated INR: Decision made to d/c Coumadin given her\n labile INR, and start Lovenox .\n - Will flush L PICC with TPA if does not flush\n - Add coags to am labs\n .\n # Spine fracture: Stable\n - Brace for OOB, need to discuss with Neurosurgery before d/c if\n current brace is optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n .\n # Tracheomalacia. Was initially addressed with IP and they wanted to\n follow up as outpatient. IP reevaluated and does not believe that a\n stent would be feasible. No new issues.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # ACCESS: PIV x 1, L PICC\n # Ppx: Lovenox, PPi, Bowel Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n - Social Work and Case management involved, have discussed situation\n w/ brother and boyfriend.\n # Code: Full\n # Dispo: ICU, Will d/w case management re rehab facilities.\n ICU Care\n Nutrition:\n TPN without Lipids - 05:44 PM 43. mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n PICC Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 639715,
"text": "Chief Complaint:\n 24 Hour Events:\n -hypernatremia: Repeat Na 148-->146 (this am), continuing D5W at\n 125cc/hr\n -TF up to 30cc/hr; tolerated O/N; stopped at 12am\n -Psych recs: Gave risperidone m-tab 1mg PO x1 HS last night and will\n continue risperdone 0.5mg qam and 0.5 PRN; f/u EKG in am;\n -Changed Metoprolol 25 to 37.5mg TID given tach to 110-120\ns; gave 5mg\n x1\n -GI recs: pending\n -IP: seen by IP this am for eval of possible stent placement, pt not a\n candidate as she is at risk of aspiration given opening defect\n posterior to vocal cords; recommended d/w ENT and increase ppi to .\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:30 AM\n Enoxaparin (Lovenox) - 06:48 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.7\nC (98.1\n HR: 79 (68 - 124) bpm\n BP: 134/57(75) {124/52(70) - 179/121(130)} mmHg\n RR: 27 (18 - 31) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 4,004 mL\n 1,084 mL\n PO:\n TF:\n 137 mL\n 51 mL\n IVF:\n 2,544 mL\n 729 mL\n Blood products:\n Total out:\n 3,813 mL\n 1,000 mL\n Urine:\n 3,813 mL\n 1,000 mL\n NG:\n Stool:\n Drains:\n Balance:\n 191 mL\n 84 mL\n Respiratory support\n O2 Delivery Device: Trach mask 40-50%\n SpO2: 99%\n ABG: ///33/\n Physical Examination\n Gen: Sedating post-bronchoscopy; Sleeping; pt would not wake for exam.\n HEENT: No pallor in conjunctiva, MMM\n Resp: Course breath sounds anteriorly, mild exp wheeze.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, decreased bowel sounds, G-Tube in\n place with no erythema/induration\n Exte: No edema, DP 2+ bil\n NEURO: Sedated\n Labs / Radiology\n 231 K/uL\n 7.7 g/dL\n 145 mg/dL\n 0.4 mg/dL\n 33 mEq/L\n 3.5 mEq/L\n 11 mg/dL\n 109 mEq/L\n 146 mEq/L\n 25.3 %\n 5.7 K/uL\n [image002.jpg]\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n 03:00 AM\n 04:00 AM\n 05:45 AM\n 03:51 AM\n 04:45 PM\n 04:00 AM\n WBC\n 9.5\n 5.7\n 7.3\n 8.0\n 8.7\n 5.5\n 5.7\n Hct\n 28.6\n 28.9\n 30.0\n 26.9\n 27.3\n 27.0\n 28.7\n 24.7\n 25.2\n 25.3\n Plt\n 528\n 356\n 346\n \n 231\n Cr\n 1.0\n 0.7\n 0.7\n 0.7\n 0.7\n 0.5\n 0.4\n Glucose\n 121\n 129\n 123\n 114\n 112\n 122\n 145\n Other labs: PT / PTT / INR:13.6/31.1/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.6 mg/dL, Mg++:2.0 mg/dL, PO4:3.6\n mg/dL\n Assessment and Plan\n 56yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach/PEG with resolving respiratory failure and HAP.\n .\n # Respiratory failure/Aspiration Risk: s/p intubation/extubation, now\n on trach mask, FiO2 50%. Tolerating well with good O2 sat. No further\n self-decanulations overnight. Pt continues to be at risk for aspiration\n given new IP finding of opening defect in posterior vocal cord space\n and given recent history of vomiting with tube feed trials.\n - ENT consulted for evaluation of larynx and possible intervention;\n will follow ENT recs\n - increase ppi from qday to for aspiration prophylaxis\n - Trach mask as tolerated.\n - scopolamine patch q72hrs for secretions\n - Holding sedation with exception of Risperidal 0.5mg PRN\n - F/u CXR tomorrow\n .\n # Nutrition/Vomiting: Currently receiving TPN; BMx2 in past 24 hrs to\n indicate possible improvement in ileus. TF tolerated during trial O/N\n without emesis.\n - Cont Reglan 20mg IV Q 8 hours; meds via G-J tube,\n - Will obtain recommendations from Nutrition re TPN today and will\n provide TF as tolerated\n - Speech and Swallow eval today for Passy Muir valve eval;\n - GI consult, will f/u recs\n .\n # Tachycardia: Improved HR max of 120\ns versus 160s previously. Pt now\n on PO Amiodarone 200 TID and PO metoprolol 37.5mg TID\n - Continue current med regimen. Will continue amiodarone 200 TID for\n three weeks and then switch to qday for 1week and then d/c amiodarone.\n - Will need to schedule f/u in 4wks with Dr. upon d/c/transfer.\n - f/u Cards recs\n # Sedation/Anxiolysis/AlteredMS: Resolved O/N with risperdal. Previous\n delirium and agitation most likely secondary to long hospital course\n and multiple psychotropic medications as well as hx of EtOH abuse.\n - started Risperdal 0.5mg PO BID PRN.\n - continue to hold all benzos. opiates, and antihistamines\n - Appreciate psych. Will call and f/u psych recs.\n -Obtain EKG to assess for QTc prolongation.\n #Anemia: HCT stable at 25. No known etiology of blood loss.\n -Will repeat HCT in am .\n # Hypernatremia/Fluid Status: Mild hypernatramia resolving with free\n water administration. On TPN/TF. Good UOP.\n - providing D5W IVFx 1L at 125cc/hr, free water flushes with TF\n -Will f/u lytes in afternoon (5pm)\n # UE DVT and elevated INR: Decision made to d/c Coumadin given her\n labile INR, and start Lovenox .\n - Will flush L PICC with TPA if does not flush\n - Add coags to am labs\n .\n # Spine fracture: Stable\n - Brace for OOB, need to discuss with Neurosurgery before d/c if\n current brace is optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n .\n # Tracheomalacia. Reevaluation bronchoscopy by IP as written above;\n patient not a candidate for stent; pt to follow up as outpatient. No\n new issues.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # ACCESS: PIV x 1, L PICC\n # Ppx: Lovenox, PPi-to increase to , Bowel Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n - Social Work and Case management involved; have discussed situation\n w/ brother and boyfriend.\n # Code: Full\n # Dispo: ICU, Will d/w case management re rehab facilities.\n MSIV\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 638525,
"text": "55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach, PEG, placement no with respiratory failure secondary to\n tracheomalacia , resolving HAP.\n Arousal, Attention, and Cognition, Impaired\n Assessment:\n Alert, mouthing words but very difficult to understand. Follows\n commands. MAE on bed, attempting to get up. Restless last evening, did\n eventually fall off to sleep this AM.\n Action:\n Zyprexa x 1 . Frequent re-orientation to place, situation. Soft wrist\n restraints for patient safety.\n Response:\n Pt did eventually fall asleep. Re-orientation does have calming effect\n however it is short term.\n Plan:\n No valium or benadryl per psych as this exacerbates delirium. Zyprexa\n for agitation. pt prn.\n Hypernatremia (high sodium)\n Assessment:\n Na 145 last night, 148 this AM.\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Trach collar @ 50% O2 overnight. Sats 90-97%. RR 17-20s. Strong cough,\n able to cough thick white ->tan secretions out of trach. Occ suctioned\n for same. Lungs are rhonchorous throughout. Impaired gag.\n Action:\n Suctioned prn for copious secretions. MDIs.\n Response:\n Trach collar overnight.\n Plan:\n Wean from vent as tolerated. MDIs, suction as needed.\n Alteration in Nutrition\n Assessment:\n NPO overnight d/t constant vomiting. No vomiting overnight.\n Action:\n NPO. Reglan q 6 hrs.\n Response:\n No vomiting. Small brown stool x 1.\n Plan:\n NPO. ? may go to IR today to change Gtube to Jtube.\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 638657,
"text": "Tachycardia, Other\n Assessment:\n Pt has remained in ST , with HR 90-140. B/P has remained 110-140/\n 50-70\n Action:\n Lopressor increased to 50mg 4x/day\n Response:\n Pt has been vomiting throughout day, ? amt of lopressor absorbed.\n Lopressor 5mg IV given\n Plan:\n Alteration in Nutrition\n Assessment:\n ABD soft, not distended, very hypoactive bowel sounds, TF on hold.\n NA 148\n Action:\n D5W infusing at 125cc/hr then decreased to 75cc/hr. Abd CT done,\n poorly prepped , vomited Bari-kat. reconsulted, ? placement of\n Jtube\nif CT negative for SBO/illeus.\n Response:\n NA level at 1600 =>146, CT scan results pending\n Plan:\n Continue to monitor lytes, continue D5W\n Altered mental status (not Delirium)\n Assessment:\n Pt has been very restless thru the day despite frequent reorientation.\n Pt attempting to mouth words but difficult to interpret. Unable to PMV\n secondary to increased secretions. Pt follows commands, but unable to\n use call light appropriately\n.needs verbal cueing.\n Action:\n Pt OOB to chair , but remained restless.\n Response:\n Pt remains confused and restless\n Plan:\n Continue to reorient\n Nausea / vomiting\n Assessment:\n During am assessment pt was found to be gagging and vomited about\n 50-75cc/hr. Pt pre-medicated w/ Zofran 8mg IV prior to am meds. Pt\n given 60cc fluids w/ am via PEG. Pt vomited about 15 minutes after\n meds. Abd as noted above is soft, NO BM >24hr and BS very distant and\n hypoactive.\n Action:\n Team into assess, CT of abd ordered. Pt was unable to tolerate prep\n and vomited prep. Zofran 4mg given.\n Response:\n Awaiting CT results\n Plan:\n Airway Clearance, Impaired\n Assessment:\n Pt has a very congested cough, w/ bronchial and rhonchi noted in upper\n airway. Sat\ns on trach collar 95-100%\n Action:\n Trach care done and suctioned Q\n-1hr for sm-moderate amts of thin\n yellow sectretions\n Response:\n Sat\ns have remained stable on 50% trach mask 95-100%\n Plan:\n Continue to monitor\n"
},
{
"category": "Respiratory ",
"chartdate": "2167-10-23 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 639217,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 35\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 7.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 23 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Unassisted spontaneous breathing\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Patient decannulated herself at approximately 0730. New tracheostomy\n tube placed in a timley manner. Placed on mechanical ventilation for\n several hours during recover period. Then placed on trach collar.\n"
},
{
"category": "Respiratory ",
"chartdate": "2167-10-21 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 638708,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 33\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Tube Type\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 8.0mm\n PMV: No\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Back to MMV last eve for ?aspiration & increased WOB.\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: No spont resp this morning/ Back to Tc as tolerated.\n Reason for continuing current ventilatory support:\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 639281,
"text": "Airway Clearance, Impaired\n Assessment:\n Secretions thick, white. LS coarse, diminished at bases.\n Action:\n Requiring frequent suctioning, at times q 30 minutes, clearing\n initially and within minutes, pt rattling with secretions once again.\n Response:\n Secretions con\nt to accumulate despite frequent suctioning.\n Plan:\n Con\nt to pulmonary toilet , clear secretions as appropriate. Maintain\n O2 Sat of greater than 94%.\n Tachycardia, Other\n Assessment:\n HR maintained in the 80\ns and 90\ns for the most part. Up to110\n immediately prior to receiving the lopressor.\n Action:\n Rec\n Response:\n Maintaining HR below 100 successfully.\n Plan:\n Alteration in Nutrition\n Assessment:\n Hypoactive BS, TF\ns on hold. J-tube ind\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Alert but confused, re\n Action:\n Frequent re-orientation\n Response:\n Plan:\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Tmax 99.4 po\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 639434,
"text": "56 yr old woman, who was transferred from osh for evaluation of\n tracheal bronchial malacia on .Pt presented to Medical\n Center on s/p fall down a flight of stairs fracturing, t5-t8 with\n propulsion treated conservatively with pain meds and back brace. She\n developed resp distress requiring intubation on . Trach/PEG done\n . Now with prolonged hospital course c/b by PNA, anxiety/altered\n mental status, R&LUE DVT .Pt found to have small non occlusive Clot on\n her right axial vein via Ultrasound. She has had problems with\n vomiting tube feedings, feeding tube passed through g-tube to her\n jejunenum but she continues to vomit. Trach mask, has not required\n ventilation since . Has also required 1:1 sitters since\n decanulating herself twice, despite restraints. Events of the last\n 12hrs include, restarted TF\ns, however, infused for ~7 hrs, then began\n suctioning bile-like fluid from trach after pt experienced a prolonged\n coughing jag. TF\ns placed on hold.\n Airway Clearance, Impaired\n Assessment:\n Requiring frequent suctioning ~q15 minutes to 1hr. Secretions\n initially white, changing to greenish and back to whitish yellow. LS\n coarse, diminished at bases\n Action:\n CPT, frequent suctioning,\n Response:\n CXR, maintain patent airway\n Plan:\n F/U with CXR results, CPT\n Tachycardia, Other\n Assessment:\n Becoming tachy in the 110\ns approx 30 minutes prior receiving standard\n lopressor dose. HR basically in the 70\ns the entire shift.\n Action:\n Lopressor 10 mg IV q4hr, amiodarone\n Response:\n Tolerating meds\n Plan:\n Monitor VS,\n Alteration in Nutrition\n Assessment:\n TF\ns infusing at rate of 10cc/hr. ~2240, pt began coughing. Required\n suctioning. Pt noted to have thin greenish secretions from trach tube.\n Action:\n TF\ns placed on hold.\n Response:\n Not tolerating feedings\n Plan:\n Con\nt to administer bowel meds as ordered, reglan as ordered.\n Hypernatremia (high sodium)\n Assessment:\n Na+ elevated at 148\n Action:\n Receiving an additional 1L of D5W at 150cc/hr\n Response:\n F/U with am lab levels\n Plan:\n Con\nt to monitor Na+ levels, Attempt free H2O bolus\n this am.\n Altered mental status (not Delirium)\n Assessment:\n Some agitation noted in the beginning of the shift. Settling down by\n ~2100. At times attempting to mouth full conversations, but since pt\n has so many secretions, PMV was not placed. She is confused, asking\n for the phone, requiring frequent re-orientation, 1:1 sitter at\n bedside, soft wrist restraints intact.\n Action:\n Re-orient as appropriate\n Response:\n Remains confused, requiring sitters for safety.\n Plan:\n Assess MS\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-20 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 638568,
"text": "Chief Complaint:\n 24 Hour Events:\n CARDIOVERSION/DEFIBRILLATION - At 11:50 AM\n aqdenosine 6mg given X 1 by cardiologist to assess pt's rhythm. Pt\n tolerated well.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:24 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36\nC (96.8\n HR: 114 (85 - 144) bpm\n BP: 111/59(69) {84/42(0) - 154/134(138)} mmHg\n RR: 12 (12 - 36) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,945 mL\n 274 mL\n PO:\n TF:\n IVF:\n 1,800 mL\n 154 mL\n Blood products:\n Total out:\n 2,300 mL\n 500 mL\n Urine:\n 2,245 mL\n 500 mL\n NG:\n 55 mL\n Stool:\n Drains:\n Balance:\n -355 mL\n -226 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: MMV/PSV/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 319 (319 - 319) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 15\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 15 cmH2O\n SpO2: 100%\n ABG: ///36/\n Ve: 5.5 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 548 K/uL\n 10.0 g/dL\n 128 mg/dL\n 0.8 mg/dL\n 36 mEq/L\n 4.1 mEq/L\n 6 mg/dL\n 105 mEq/L\n 148 mEq/L\n 32.7 %\n 7.6 K/uL\n [image002.jpg]\n 05:00 AM\n 02:06 AM\n 07:34 AM\n 03:50 AM\n 06:22 AM\n 02:58 AM\n 03:43 AM\n 05:02 PM\n 03:36 AM\n 02:30 AM\n WBC\n 5.9\n 7.5\n 5.6\n 6.1\n 7.0\n 7.1\n 7.1\n 6.9\n 7.6\n Hct\n 27.2\n 26.8\n 27.0\n 27.0\n 29.7\n 28.9\n 29.2\n 27.8\n 32.7\n Plt\n 296\n 306\n 335\n \n 452\n 467\n 548\n Cr\n 0.7\n 0.6\n 0.5\n 0.7\n 0.7\n 0.6\n 0.7\n 0.8\n 0.7\n 0.8\n Glucose\n 134\n 134\n 121\n \n 104\n 108\n 131\n 128\n Other labs: PT / PTT / INR:48.3/33.3/5.5, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:10.0 mg/dL, Mg++:2.5 mg/dL,\n PO4:4.3 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-20 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 638569,
"text": "Chief Complaint:\n 24 Hour Events:\n CARDIOVERSION/DEFIBRILLATION - At 11:50 AM\n aqdenosine 6mg given X 1 by cardiologist to assess pt's rhythm. Pt\n tolerated well.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:24 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36\nC (96.8\n HR: 114 (85 - 144) bpm\n BP: 111/59(69) {84/42(0) - 154/134(138)} mmHg\n RR: 12 (12 - 36) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,945 mL\n 274 mL\n PO:\n TF:\n IVF:\n 1,800 mL\n 154 mL\n Blood products:\n Total out:\n 2,300 mL\n 500 mL\n Urine:\n 2,245 mL\n 500 mL\n NG:\n 55 mL\n Stool:\n Drains:\n Balance:\n -355 mL\n -226 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: MMV/PSV/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 319 (319 - 319) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 15\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 15 cmH2O\n SpO2: 100%\n ABG: ///36/\n Ve: 5.5 L/min\n Physical Examination\n Gen: Obtunded this am, not responsive to voice, minimally responsive to\n noxious stimuli, on MMV through trach tube\n HEENT: PERRL, MMM,\n Resp: Limited by patients mobility, but CTA anteriorly and laterally,\n no rales, rhonchi, or wheezing, some referred upper airway noises from\n secretions.\n Card: S1S2 tachicardic, no m/r/g\n Abd: Obese, soft, Non-distended, BS+\n Exte: No edema, DP 2+, RP2+ bil.\n NEURO: Toes downgoing bilaterally, patellar reflexs 2+ bil, biceps 2+\n bil,\n Labs / Radiology\n 548 K/uL\n 10.0 g/dL\n 128 mg/dL\n 0.8 mg/dL\n 36 mEq/L\n 4.1 mEq/L\n 6 mg/dL\n 105 mEq/L\n 148 mEq/L\n 32.7 %\n 7.6 K/uL\n [image002.jpg]\n 05:00 AM\n 02:06 AM\n 07:34 AM\n 03:50 AM\n 06:22 AM\n 02:58 AM\n 03:43 AM\n 05:02 PM\n 03:36 AM\n 02:30 AM\n WBC\n 5.9\n 7.5\n 5.6\n 6.1\n 7.0\n 7.1\n 7.1\n 6.9\n 7.6\n Hct\n 27.2\n 26.8\n 27.0\n 27.0\n 29.7\n 28.9\n 29.2\n 27.8\n 32.7\n Plt\n 296\n 306\n 335\n \n 452\n 467\n 548\n Cr\n 0.7\n 0.6\n 0.5\n 0.7\n 0.7\n 0.6\n 0.7\n 0.8\n 0.7\n 0.8\n Glucose\n 134\n 134\n 121\n \n 104\n 108\n 131\n 128\n Other labs: PT / PTT / INR:48.3/33.3/5.5, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:10.0 mg/dL, Mg++:2.5 mg/dL,\n PO4:4.3 mg/dL\n Assessment and Plan\n 55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach, PEG, placement no with respiratory failure secondary to\n tracheomalacia , resolving HAP.\n .\n # Respiratory failure: Slowly Improving. Now remaining on trach mask\n for most of the day and night, with periods of pressure support of \n over night. Last night required MMV and was not breathing well while\n asleep, likely oversedated with Benadryl, Morhpine, and Valium\n administered in the early morning. Pt awake and alert at rounds,\n interactive, and breathing comfortably on trach mask\n - Continue to increase time on trach mask as tolerated.\n - Decrease sedation and valium use see Sedation below\n - PMV with suctioning again today.\n .\n # HAP vs Aspiration PNA: Afebrile without leukocytosis\n - Completed course of ceftriaxone\n - good O2 saturation on trach mask\n - Continue to f/u cultures\n .\n # Tachycardia: Previously was assessed as sinus tach with occasional\n runs of SVT and sources such as hypovolemia, PE, infection, and pain\n were assessed as possibly etiologies. But, now appears to be SVT for\n much of time, rhythm/rate nonresponsive to carotid massage. HR\n occaisonaly decreases to 70s-80s w/ stable BPs at times that might be\n associated with administration of her BB and valium. Rhythm strip shows\n conversion from a narrow complex SVT to normal sinus rhythm and then\n back. Metroprolol was increased from 25mg TID to QID yesterday, without\n any affect on the SVT.\n - EP consulted for conversion of SVT, appreciate recs\n .\n # Sedation: Inconsistent response to sedation, unclear what is best\n regime. Will continue to wean overall.\n - Continue w Olanzapine QHS\n - D/d valium to 2.5 mg TID and leave just valium 2.5 mg PRN.\n # Nutrition: Pt has had several episodes of vomiting up her TFs,\n reglan started to increase GI motility, but pt had another episode of\n vomiting last night.\n - Hold TFs\n - Thoracic surgery recs: 1) oral/nasal tube in post-piloric position,\n or 2) IR to place a pediatric feeding tube through her PEG site to a\n post-piloric position.\n - Will attempt to coordinate thoracic surgery and IR for tube placement\n tomorrow.\n .\n # Adrenal Insufficency: Endocrine following. Pt does not appear to be\n adrenally insufficient at baseline. Suggesting if the patient under\n goes major stressors such as major surgery, sepsis, she may need stress\n dosed steroids.\n .\n # Fluid Status: Likely approaching euvolemia, though still has mild\n hypernatramia which may suggest is still intravascularly depleated.\n - Monitoring urine output\n - FW flushes w/ tube feeds held due to vomitting\n - will provide D5W IVF as need for hypernatremia and follow lytes\n .\n # UE DVT and elevated INR: DVT in right UE has resolved, new\n non-occlusive in left axillary vein. INR supratherapeutic today\n - COumadin held, will restart at low dose when INR approaches\n therapeutic range.\n - INR 4.2 today, will check PM coags and consider restarting at a low\n dose tonight or tomorrow morning.\n .\n # Spine fracture: Stable\n - Brace for OOB, will discuss with Neurosurgery if current brace is\n optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n .\n # Tracheomalacia. Was initially addressed with IP and they wanted to\n follow up as outpatient. IP reevaluated and does not believe that a\n stent would be feasible.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # PIV x 1\n # Ppx: Coumadin, Ranitidine, Bowel Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n - Will contact Social and Case management today\n # Code: Full\n # Dispo: ICU, Screening for vent facilities\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Respiratory ",
"chartdate": "2167-10-22 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 638899,
"text": "Demographics\n Day of mechanical ventilation: 34\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 7.0mm\n Cuff Management:\n Cuff pressure: 23 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Brown / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Pt tolerated t/c all day and then placed on psv 5/5/50% to\n rest noc. RSBI=67. Will continue with t/c trials in am\n Assessment of breathing comfort: comfortable\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment: none\n :\n Plan\n Next 24-48 hours: continue with t/c trials\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 639504,
"text": "TITLE:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt on TM @ 70% with O2 sat mid 90\ns-100%. Requiring tracheal\n sxn\ning approx Q1hr for mod-copious amts thick white tenacious\n secretions. Pt with strong cough, but freq unable to clear secretions\n herself. Lung snds rhonchorous in upper lobes, diminished in bases.\n Action:\n Freq sxn\ning per above. Pt encouraged to C&DB. Pt in\nchair\n position\n in bed with head @ 45-90degree angle.\n Response:\n Pt cont to have lg amt secretions requiring assist to clear.\n Plan:\n Cont aggressive pulm toilet.\n Arousal, Attention, and Cognition, Impaired\n Assessment:\n Pt has been awake and alert . Pt chatty, but difficult to read her lips\n and she has trouble writing clearly.\n Action:\n Emotional support provided, Pt was able to yes as to feeling cold\n & nodded yes for warm blanket & was comfortable after she had the warm\n blanket.\n Response:\n Pt slept for couple of hours , until awakened for care & assessment.\n Plan:\n Speech/swallow consult needed re valve, ? if it is damaged. Cont\n Risperidone. Cont soft wrist restraints and sitter @ bedside for pt\n safety.\n Alteration in Nutrition\n Assessment:\n Abd soft/obese with + BS. On J-tube feeds in upright position.\n Action:\n Pt on colace and senna, held the night dose as pt had 2 BM\ns during the\n day.\n Response:\n Pt with lg loose yellow BM in am. TF started in afternoon @ 10ml/hr as\n well as 50ml water Q4hrs, with HOB @ 45-90degree angle. Tolerated well.\n Plan:\n Cont to gently advance TF per order. Strict aspiration orders, with pt\n rec\ning TF ONLY when in sitting position.\n Hypernatremia (high sodium)\n Assessment:\n Na 147 in pm labs.\n Action:\n Continued on D5 W@ 100 mls/hr for 1000 mls.\n Response:\n AM labs pending.\n Plan:\n Follow up on am labs.\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 639615,
"text": "56 yr old woman, who was transferred from osh for evaluation of\n tracheal bronchial malacia on .Pt presented to Medical\n Center on s/p fall down a flight of stairs fracturing, t5-t8 with\n propulsion treated conservatively with pain meds and back brace. She\n developed resp distress requiring intubation on . Trach/PEG done\n . Now with prolonged hospital course c/b by PNA, anxiety/altered\n mental status, R&LUE DVT .Pt found to have small non occlusive clot on\n her right axial vein via Ultrasound, now rec\ning Lovenox. She has had\n problems with vomiting tube feedings, so feeding tube passed through\n g-tube to her jejunenum. However, she continues to intermit raise\n gastric contents assoc with bronchospasm. Has not required ventilation\n since , on humidified TM @ 50%. Has required 1:1 sitters since\n decanulating herself, twice, despite restraints.\n Airway Clearance, Impaired\n Assessment:\n Rec\nd pt on humidified TM @ 70% with O2 sat 97-100%. RR 22-31 and\n regular. Lung snds rhonchorous in upper lobes, clearing with sxn\ning.\n Lower lobe snds diminished bilat.\n Action:\n FiO2 \nd to 50%. Pt requiring tracheal sxn\ning Q30-60mins, producing\n mod-copious amts thick white tenacious secretions. Pt generally unable\n to fully raise and expectorate secretions.\n Response:\n O2 sat has remained 99-100%, but drops to high 80\ns when requires\n sxn\ning.\n Plan:\n Cont to encourage pt to deep breathe and cough. Cont aggressive pulm\n toilet.\n Alteration in Nutrition\n Assessment:\n Per noc shift nurse, TF off overnight as pt too restless to maintain in\n upright position per strict aspiration precautions. BS +, abd\n soft/obese.\n Action:\n Pt placed on chair position in bed and TF restarted @ 0830 @\n 10ml/hr+50ml free water Q4hrs. She rec\nd her scheduled doses Reglan\n 20mg and colace, senna.\n Response:\n Pt tolerated TF well (but unable to check residuals), so TF inc\nd to\n 20ml/hr @ 1230. Small loose yellow BM today X1.\n Plan:\n Cont strict aspiration prec, holding TF when pt not in upright position\n and turning TF off for 15mins before turning.\n Arousal, Attention, and Cognition, Impaired\n Assessment:\n Pt rec\nd very restless in bed, attempting to exit despite bilat soft\n wrist restraints and sitter @ bedside. When PMV in place pt\n disoriented X 2, and reported she had been in a hotel and could pay\n $3000 cash to leave. When told she was in a hospital bed, she asked,\nWhere\ns the bed\n, unconvinced that she was lying in bed.\n Action:\n Pt rec\nd scheduled 0800 dose Resperadine. EKG taken.\n Response:\n Pt slept for 90mins until woken by team for am rounds. She has appeared\n sleepy since but resistant to falling asleep. Intermit attempting to\n exit bed. QT interval WNL.\n Plan:\n Psych to consult and eval pt/meds.\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 639684,
"text": "Chief Complaint:\n 24 Hour Events:\n -hypernatremia: Repeat Na 148-->146 (this am), continuing D5W at\n 125cc/hr\n -TF up to 30cc/hr; tolerated O/N\n -Per psych recs: Gave risperidone m-tab 1mg PO x1 HS and will continue\n risperdone 0.5mg qam and 0.5 PRN; gave scopolamine patch q72hrs;\n f/u EKG in am\n -Changed Metoprolol 25 to 37.5mg TID; gave 5mg x1\n -GI recs: pending\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:30 AM\n Enoxaparin (Lovenox) - 06:48 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.7\nC (98.1\n HR: 79 (68 - 124) bpm\n BP: 134/57(75) {124/52(70) - 179/121(130)} mmHg\n RR: 27 (18 - 31) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 4,004 mL\n 1,084 mL\n PO:\n TF:\n 137 mL\n 51 mL\n IVF:\n 2,544 mL\n 729 mL\n Blood products:\n Total out:\n 3,813 mL\n 1,000 mL\n Urine:\n 3,813 mL\n 1,000 mL\n NG:\n Stool:\n Drains:\n Balance:\n 191 mL\n 84 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 99%\n ABG: ///33/\n Physical Examination\n Gen: Awake, Mouthing words, More agitated compared to previous\n mornings.\n HEENT: EOMI, No pallor in conjunctiva, MMM\n Resp: CTAB, no rales, rhonchi, or wheezing, good airway movement.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, decreased bowel sounds,, G-Tube in\n place with no erythema/induration\n Exte: No edema, DP 2+ bil\n NEURO: Gross Motor and Sensation in 4 extremities\n Labs / Radiology\n 231 K/uL\n 7.7 g/dL\n 145 mg/dL\n 0.4 mg/dL\n 33 mEq/L\n 3.5 mEq/L\n 11 mg/dL\n 109 mEq/L\n 146 mEq/L\n 25.3 %\n 5.7 K/uL\n [image002.jpg]\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n 03:00 AM\n 04:00 AM\n 05:45 AM\n 03:51 AM\n 04:45 PM\n 04:00 AM\n WBC\n 9.5\n 5.7\n 7.3\n 8.0\n 8.7\n 5.5\n 5.7\n Hct\n 28.6\n 28.9\n 30.0\n 26.9\n 27.3\n 27.0\n 28.7\n 24.7\n 25.2\n 25.3\n Plt\n 528\n 356\n 346\n \n 231\n Cr\n 1.0\n 0.7\n 0.7\n 0.7\n 0.7\n 0.5\n 0.4\n Glucose\n 121\n 129\n 123\n 114\n 112\n 122\n 145\n Other labs: PT / PTT / INR:13.6/31.1/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.6 mg/dL, Mg++:2.0 mg/dL, PO4:3.6\n mg/dL\n Assessment and Plan\n 56yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach/PEG with resolving respiratory failure and HAP.\n .\n # Respiratory failure: s/p intubation/extubation, now on trach mask,\n FiO2 50%. Tolerating well with good O2 sat. No further\n self-decanulations overnight.\n - Trach mask as tolerated.\n - Holding sedation with exception of Risperidal 0.5mg PRN\n - F/u CXR tomorrow\n .\n # Nutrition/Vomiting: Currently receiving TPN;. One large BM in past\n 24 hrs to indicate potential improvement in ileus.\n - Cont Reglan 20mg IV Q 8 hours; meds via G-J tube,\n - Will obtain recommendations from Nutrition re TPN today\n - TF as tolerated\n - Speech and Swallow eval today for Passy Muir valve eval;\n - PICC line in place with TPN given when pt not tolerating TF\n - GI consult, will f/u recs\n .\n # Tachycardia: Improved HR max of 120\ns versus 160s previously. Pt now\n on PO Amiodarone 200 TID and PO metoprolol 25mg TID\n - Continue current med regimen. Will continue amiodarone 200 TID for\n three weeks and then switch to qday.\n - Will need to schedule f/u in 4wks with Dr. upon d/c/transfer.\n - f/u Cards recs\n # Sedation/Anxiolysis/AlteredMS: Resolved O/N. Previous delirium and\n agitation most likely secondary to long hospital course and multiple\n psychotropic medications as well as hx of EtOH abuse. Risperdal given\n O/N per Psych recs.\n - started Risperdal 0.5mg PO BID PRN.\n - continue to hold all benzos. opiates, and antihistamines\n - Appreciate psych. Will call and f/u psych recs.\n #Anemia: HCT stable at 25. No known etiology of blood loss.\n -Will repeat HCT in am .\n # Hypernatremia/Fluid Status: Mild hypernatramia resolving with free\n water administration. On TPN/TF. Good UOP.\n - providing D5W IVF, free water flushes with TF\n -Will f/u lytes in afternoon (5pm)\n # UE DVT and elevated INR: Decision made to d/c Coumadin given her\n labile INR, and start Lovenox .\n - Will flush L PICC with TPA if does not flush\n - Add coags to am labs\n .\n # Spine fracture: Stable\n - Brace for OOB, need to discuss with Neurosurgery before d/c if\n current brace is optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n .\n # Tracheomalacia. Was initially addressed with IP and they wanted to\n follow up as outpatient. IP reevaluated and does not believe that a\n stent would be feasible. No new issues.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # ACCESS: PIV x 1, L PICC\n # Ppx: Lovenox, PPi, Bowel Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n - Social Work and Case management involved, have discussed situation\n w/ brother and boyfriend.\n # Code: Full\n # Dispo: ICU, Will d/w case management re rehab facilities.\n ICU Care\n Nutrition:\n TPN without Lipids - 05:44 PM 43. mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n PICC Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 639686,
"text": "Chief Complaint:\n 24 Hour Events:\n -hypernatremia: Repeat Na 148-->146 (this am), continuing D5W at\n 125cc/hr\n -TF up to 30cc/hr; tolerated O/N\n -Per psych recs: Gave risperidone m-tab 1mg PO x1 HS and will continue\n risperdone 0.5mg qam and 0.5 PRN; f/u EKG in am\n -Changed Metoprolol 25 to 37.5mg TID; gave 5mg x1\n -GI recs: pending\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:30 AM\n Enoxaparin (Lovenox) - 06:48 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.7\nC (98.1\n HR: 79 (68 - 124) bpm\n BP: 134/57(75) {124/52(70) - 179/121(130)} mmHg\n RR: 27 (18 - 31) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 4,004 mL\n 1,084 mL\n PO:\n TF:\n 137 mL\n 51 mL\n IVF:\n 2,544 mL\n 729 mL\n Blood products:\n Total out:\n 3,813 mL\n 1,000 mL\n Urine:\n 3,813 mL\n 1,000 mL\n NG:\n Stool:\n Drains:\n Balance:\n 191 mL\n 84 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 99%\n ABG: ///33/\n Physical Examination\n Gen: Awake, Mouthing words, More agitated compared to previous\n mornings.\n HEENT: EOMI, No pallor in conjunctiva, MMM\n Resp: CTAB, no rales, rhonchi, or wheezing, good airway movement.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, decreased bowel sounds,, G-Tube in\n place with no erythema/induration\n Exte: No edema, DP 2+ bil\n NEURO: Gross Motor and Sensation in 4 extremities\n Labs / Radiology\n 231 K/uL\n 7.7 g/dL\n 145 mg/dL\n 0.4 mg/dL\n 33 mEq/L\n 3.5 mEq/L\n 11 mg/dL\n 109 mEq/L\n 146 mEq/L\n 25.3 %\n 5.7 K/uL\n [image002.jpg]\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n 03:00 AM\n 04:00 AM\n 05:45 AM\n 03:51 AM\n 04:45 PM\n 04:00 AM\n WBC\n 9.5\n 5.7\n 7.3\n 8.0\n 8.7\n 5.5\n 5.7\n Hct\n 28.6\n 28.9\n 30.0\n 26.9\n 27.3\n 27.0\n 28.7\n 24.7\n 25.2\n 25.3\n Plt\n 528\n 356\n 346\n \n 231\n Cr\n 1.0\n 0.7\n 0.7\n 0.7\n 0.7\n 0.5\n 0.4\n Glucose\n 121\n 129\n 123\n 114\n 112\n 122\n 145\n Other labs: PT / PTT / INR:13.6/31.1/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.6 mg/dL, Mg++:2.0 mg/dL, PO4:3.6\n mg/dL\n Assessment and Plan\n 56yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach/PEG with resolving respiratory failure and HAP.\n .\n # Respiratory failure: s/p intubation/extubation, now on trach mask,\n FiO2 50%. Tolerating well with good O2 sat. No further\n self-decanulations overnight.\n - Trach mask as tolerated.\n - gave scopolamine patch q72hrs for secretions\n - Holding sedation with exception of Risperidal 0.5mg PRN\n - F/u CXR tomorrow\n .\n # Nutrition/Vomiting: Currently receiving TPN;. One large BM in past\n 24 hrs to indicate potential improvement in ileus.\n - Cont Reglan 20mg IV Q 8 hours; meds via G-J tube,\n - Will obtain recommendations from Nutrition re TPN today\n - TF as tolerated\n - Speech and Swallow eval today for Passy Muir valve eval;\n - PICC line in place with TPN given when pt not tolerating TF\n - GI consult, will f/u recs\n .\n # Tachycardia: Improved HR max of 120\ns versus 160s previously. Pt now\n on PO Amiodarone 200 TID and PO metoprolol 25mg TID\n - Continue current med regimen. Will continue amiodarone 200 TID for\n three weeks and then switch to qday.\n - Will need to schedule f/u in 4wks with Dr. upon d/c/transfer.\n - f/u Cards recs\n # Sedation/Anxiolysis/AlteredMS: Resolved O/N. Previous delirium and\n agitation most likely secondary to long hospital course and multiple\n psychotropic medications as well as hx of EtOH abuse. Risperdal given\n O/N per Psych recs.\n - started Risperdal 0.5mg PO BID PRN.\n - continue to hold all benzos. opiates, and antihistamines\n - Appreciate psych. Will call and f/u psych recs.\n #Anemia: HCT stable at 25. No known etiology of blood loss.\n -Will repeat HCT in am .\n # Hypernatremia/Fluid Status: Mild hypernatramia resolving with free\n water administration. On TPN/TF. Good UOP.\n - providing D5W IVF, free water flushes with TF\n -Will f/u lytes in afternoon (5pm)\n # UE DVT and elevated INR: Decision made to d/c Coumadin given her\n labile INR, and start Lovenox .\n - Will flush L PICC with TPA if does not flush\n - Add coags to am labs\n .\n # Spine fracture: Stable\n - Brace for OOB, need to discuss with Neurosurgery before d/c if\n current brace is optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n .\n # Tracheomalacia. Was initially addressed with IP and they wanted to\n follow up as outpatient. IP reevaluated and does not believe that a\n stent would be feasible. No new issues.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # ACCESS: PIV x 1, L PICC\n # Ppx: Lovenox, PPi, Bowel Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n - Social Work and Case management involved, have discussed situation\n w/ brother and boyfriend.\n # Code: Full\n # Dispo: ICU, Will d/w case management re rehab facilities.\n ICU Care\n Nutrition:\n TPN without Lipids - 05:44 PM 43. mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n PICC Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 638556,
"text": "55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach, PEG, placement no with respiratory failure secondary to\n tracheomalacia , resolving HAP.\n Arousal, Attention, and Cognition, Impaired\n Assessment:\n Alert, mouthing words but very difficult to understand. Follows\n commands. MAE on bed, attempting to get up. Restless last evening, did\n eventually fall off to sleep this AM.\n Action:\n Zyprexa x 1 . Frequent re-orientation to place, situation. Soft wrist\n restraints for patient safety.\n Response:\n Pt did eventually fall asleep. Re-orientation does have calming effect\n however it is short term.\n Plan:\n No valium or benadryl per psych as this exacerbates delirium. Zyprexa\n for agitation. pt prn.\n Hypernatremia (high sodium)\n Assessment:\n Na 145 last night, 148 this AM.\n Action:\n D5W x 500cc @ 125/hr\n Response:\n Not known yet, will need to recheck Na later today.\n Plan:\n Follow lytes.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Trach collar @ 50% O2 overnight until 4AM, Sats 90-97%. RR 17-20s.\n Around 4AM RR in low 30s, sats low 90s while sleeping--? Fatiguing.\n Strong cough, able to cough thick white ->tan secretions out of trach.\n Occ suctioned for same. Lungs are rhonchorous throughout. Impaired gag.\n Action:\n Suctioned prn for copious secretions. MDIs. Placed back on vent @ 4AM\n d/t fatigue.\n Response:\n Tolerated trach collar most of night, back on vent this AM d/t fatigue\n with RR in teens, Sats 98-100%.\n Plan:\n Wean from vent as tolerated. MDIs, suction as needed.\n Alteration in Nutrition\n Assessment:\n Tube feeds off overnight d/t constant vomiting. No vomiting overnight.\n Action:\n NPO. Reglan q 6 hrs.\n Response:\n No vomiting. Small brown stool x 1.\n Plan:\n NPO. ? may go to IR today to change Gtube to Jtube. Reglan. Meds via\n Gtube.\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 638648,
"text": "Tachycardia, Other\n Assessment:\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 638896,
"text": "Nausea / vomiting\n Assessment:\n Tube feeds started Promote\n @ 10cc/hr. via new jtube. Pt vomited ~ 1\n hr after TF started ->>coffee grounds, TF, H2O(flush). Also\n expectorating same from trach.\n Action:\n Tube feeds stopped. Zofran 4 mg.\n Response:\n No further vomiting, although pt coughing with copious thick tan\n secretions after vomiting episode.\n Plan:\n NPO. Meds given IV for now. Pt to have tube study today.\n Altered mental status (not Delirium)\n Assessment:\n Pt very agitated attempting to get OOB, legs through side rails.\n Mouthing words but difficlt to understand.\n Action:\n Frequent re-orientation. Zyprexa 5 mg x 2. MSO4 2 mg. Valium 2.5 mg.\n Response:\n 1^st dose Zyprexa seemed to have transient calming effect but then pt\n agitated again, 2^nd dose with no effect. Valium with very good effect,\n pt is sleeping but arouseable to voice.\n Plan:\n Zyprexa @ hs (usually effective). Valium 2.5 IV prn, please use\n sparingly d/t ongoing delerium. Re-orientation, emotional support.\n Hypernatremia (high sodium)\n Assessment:\n Na 148 last evening.\n Action:\n D5W c 40 KCL @ 100/hr x 1 liter. Repeat labs sent this AM.\n Response:\n AM Na 148\n Plan:\n Continue to monitor lytes. Free H2O.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Coughing frequently with copious thick tan/brown secretions after\n vomiting. Asking to be suctioned, also coughing secretions to end of\n trach.\n Action:\n Frequent suctioning. Placed on CPAP 5/5 this AM to rest.\n Response:\n RR 22 on vent when sedated. Sats 100%\n Plan:\n Wean from vent as tolerated. Pulmonary hygiene.\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 638502,
"text": "56yo woman admitted 1 month ago with unstentable tracheal malacia,\n failure to wean.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt on MMV settings, no spont resp. Pt unarousable per below until\n 0830 when she woke and was placed on TM with high flow neb@ 50%. RR\n 16-25 and regular, with O2 sat 96-99%. Afebrile.Very bronchospastic\n upon awakening, vomiting mod amt clear/thick X 1 after cuff let down to\n try PMV. Lung snds rhonchorous in upper lobes, diminished in bases. Pt\n with congested/productive cough of mod-copious amts thick white\n secretions.\n Action:\n Pt encouraged to freq C&DB. Suctionned PRN for mod-copious amts thick\n white secretions which pt was unable to fully raise.\n Response:\n Pt cont to intermit require ET sxn\ning. She remains on TM @ this time,\n denies SOB.\n Plan:\n Cont TM, but may return to vent support overnight if again becomes\n somulent with apneic periods.\n Tachycardia, Other\n Assessment:\n Rec\nd pt unresponsive to pain in am with HR 80\ns SR. However, when\n woken HR returned to 130\ns without VEA. BP 92/46-151/78.\n Action:\n At 1140 cardiologists used Adenosine 6mg to eval her heart rhythm,\n which appeared to be AT per attending.\n Response:\n Pt\ns rate slowed to 80\ns but without extended pause, and pt responsive\n throughout administration of Adenosine.\n Plan:\n Lopressor inc\nd to 37.5mg Q6hrs.\n Arousal, Attention, and Cognition, Impaired\n Assessment:\n Rec\nd pt very difficult to rouse after rec\ning Benadryl, Morphine,\n Zyprexa, and Valium overnight. Pt woke @ 0830 and instantly alert and\n restless. Pt has required presence of nurse most of shift to keep her\n safe, despite bilat soft wrist restraints and waist restraint. Pt\n putting legs over/between siderail. Pt not cooperative with\n redirecting. However, she is mouthing words more approp: requesting\n bedpan for BM, that she is afraid she is dying, and wants to go home.\n She did appear to have visual hallucinations, asking who the man\n outside the window was, and smiling @ blank wall.\n Action:\n Restraints and bedside sitter when available from MICU staff. Pt\n constantly reoriented. Psych nurse consulted and eval done.\n Response:\n Psych nurse recommended D/C\ning Valium and Benadryl as they may\n aggravate her delirium.\n Plan:\n Sitter may be available if pt cont to put self @ risk. Zyprexa @ HS.\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-22 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 638998,
"text": "Chief Complaint: resp failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n increased bblocker\n J tube placed by IR through PEG- restarted TF and vomiting\n Went for tube study - dysmotility - contrast sat in stomach\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Diazepam (Valium) - 02:24 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 12:17 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 35.6\nC (96.1\n HR: 118 (93 - 140) bpm\n BP: 153/58(79) {82/39(49) - 153/101(105)} mmHg\n RR: 23 (14 - 37) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 3,808 mL\n 1,119 mL\n PO:\n TF:\n 4 mL\n IVF:\n 3,804 mL\n 1,119 mL\n Blood products:\n Total out:\n 1,650 mL\n 520 mL\n Urine:\n 1,590 mL\n 520 mL\n NG:\n 60 mL\n Stool:\n Drains:\n Balance:\n 2,158 mL\n 599 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 243 (169 - 281) mL\n PS : 5 cmH2O\n RR (Spontaneous): 17\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 67\n PIP: 11 cmH2O\n SpO2: 99%\n ABG: ///33/\n Ve: 4.1 L/min\n Physical Examination\n Labs / Radiology\n 8.2 g/dL\n 356 K/uL\n 129 mg/dL\n 0.7 mg/dL\n 33 mEq/L\n 3.6 mEq/L\n 4 mg/dL\n 110 mEq/L\n 148 mEq/L\n 26.9 %\n 5.7 K/uL\n [image002.jpg]\n 06:22 AM\n 02:58 AM\n 03:43 AM\n 05:02 PM\n 03:36 AM\n 02:30 AM\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n WBC\n 7.0\n 7.1\n 7.1\n 6.9\n 7.6\n 9.5\n 5.7\n Hct\n 29.7\n 28.9\n 29.2\n 27.8\n 32.7\n 28.6\n 28.9\n 30.0\n 26.9\n Plt\n 395\n 462\n 452\n 467\n 548\n 528\n 356\n Cr\n 0.7\n 0.6\n 0.7\n 0.8\n 0.7\n 0.8\n 1.0\n 0.7\n Glucose\n 126\n 137\n 104\n 108\n 131\n 128\n 121\n 129\n Other labs: PT / PTT / INR:15.2/24.6/1.3, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.7 mg/dL, Mg++:2.1 mg/dL, PO4:4.1\n mg/dL\n Assessment and Plan\n 1. Tachycardia: runs of attach Appreciate EP consult\n will increase\n bblocker. Have to convert to metoprolol 7.5mg IV Q4 because unable to\n take pos.\n 2. Persistent Nausea/Vomiting: we have ruled out\n pSBO/SBO, very poor\n bowel sounds, tube study this AM shows contrast not moving out of the\n jejunum. get emptying study and if unrevealing consult GI to discuss\n EGD. Place PICC for TPN as she has not had nurtrition.\n 2. Resp Failure\n Trach mask trials all day, PSV\n PMV trials\n Per IP not stent planned as technically not possible to\n place into her airway\n 3. DVT and coagulopathy: reversed with IV Vit k\n hold coumadin today\n 4. Hypernatremia Replete free water.\n Please see today\ns ICU team note for other issues.\n ICU Care\n Nutrition: plan for TPN\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 04:00 AM\n Prophylaxis:\n DVT: plan for coumadin\n Stress ulcer: ppi\n Communication: spoke with son and\n status: Full code\n Disposition : ICU\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 639361,
"text": "Chief Complaint:\n 24 Hour Events:\n Pt decannulated herself x2 yesterday, the 1st episode she desatted to\n the 80s, the second episode she desated and her heart rate decreased to\n 39-40, before the trach could be replaced.\n PICC line placed by IR, called to notify that there was clot in both\n arms, placed in L arm more proximally than small Bacillis vein clot.\n Coumadin restarted after PICC placement with 2mg\n Per GI Recs: Reglan restarted at 20mg IV q 8 hours, and meds were\n restarted via tube. No vomitting.\n Per PSYCH recs: d/c'd all benzoes, (also requested d/c reglan if GI\n ok), added Risperdal 0.5mg (and can add 0.5mg PRN, and titrate up\n to total daily dose of 2-3mg if helping)\n Per Cards recs: after 18hr of amiodaron drip. Start PO amiodarone 200mg\n TID, which was done at 1am.\n Brother visited\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 37.4\nC (99.4\n HR: 90 (73 - 121) bpm\n BP: 155/49(75) {103/47(66) - 175/98(111)} mmHg\n RR: 32 (14 - 32) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,151 mL\n 293 mL\n PO:\n TF:\n IVF:\n 1,852 mL\n 13 mL\n Blood products:\n Total out:\n 2,460 mL\n 820 mL\n Urine:\n 2,460 mL\n 820 mL\n NG:\n Stool:\n Drains:\n Balance:\n -309 mL\n -527 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Set): 0 (0 - 0) mL\n Vt (Spontaneous): 360 (360 - 360) mL\n PS : 10 cmH2O\n RR (Set): 0\n RR (Spontaneous): 21\n FiO2: 40%\n SpO2: 98%\n ABG: ///33/\n Physical Examination\n Gen: Asleep, unarousable, responds minimally to noxious stimuli\n HEENT: PERRL, MMM\n Resp: CTA bilaterally, no rales, rhonchi, or wheezing, small\n inspirations.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, BS+\n Exte: No edema, DP 2+ bil\n NEURO: reflexes 2+ bilaterally.\n Labs / Radiology\n 316 K/uL\n 8.3 g/dL\n 114 mg/dL\n 0.7 mg/dL\n 33 mEq/L\n 4.0 mEq/L\n 7 mg/dL\n 111 mEq/L\n 149 mEq/L\n 27.0 %\n 8.0 K/uL\n [image002.jpg]\n 03:43 AM\n 05:02 PM\n 03:36 AM\n 02:30 AM\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n 03:00 AM\n 04:00 AM\n WBC\n 7.1\n 6.9\n 7.6\n 9.5\n 5.7\n 7.3\n 8.0\n Hct\n 29.2\n 27.8\n 32.7\n 28.6\n 28.9\n 30.0\n 26.9\n 27.3\n 27.0\n Plt\n 452\n 467\n 548\n 528\n 356\n 346\n 316\n Cr\n 0.7\n 0.8\n 0.7\n 0.8\n 1.0\n 0.7\n 0.7\n 0.7\n Glucose\n 104\n 108\n 131\n 128\n 121\n 129\n 123\n 114\n Other labs: PT / PTT / INR:13.2/22.4/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:9.0 mg/dL, Mg++:2.3 mg/dL, PO4:4.1\n mg/dL\n Assessment and Plan\n 55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach, PEG placement now with respiratory failure secondary to\n tracheomalacia , resolved HAP.\n .\n # Respiratory failure: Slowly improving, spending most of the day on\n trach mask with short periods of rest on PSV at night and setbacks\n from increased secretions to vomiting/aspiration events and her\n self-decanulations.\n - Continue to increase time on trach mask as tolerated.\n - Discontinue all orders for sedation except for Risperdal QHS.\n - PMV with suctioning as tolerated\n # Nutrition/Vomiting: Normal CT-abdomen, had FT placed via peg into\n jejunum, but continued to vomit. Tube study showed dysmotility in small\n bowel, but no obstruction, no retrograde flow. GI recs Reglan 20mg IV Q\n 8 hours and restart meds via G-J tube, if tolerated slowly restart TFs.\n PICC line placed yesterday and TPN started.\n - GI consult, appreciate recs\n - Small volume TFs start today\n - Continue TPN today\n # HAP vs Aspiration PNA: Had been afebrile for last several days, now\n with new fever two nights ago after having decanulated herself. Likely\n had some aspiration. Chemical pneumonitis versus new aspiration PNA.\n Now Afebrile for past 24 hours.\n - f/u daily CXR\n - F/u cx data\n - If remains febrile, send sputum cx, otherwise hold on abx.\n .\n # Tachycardia: Pt in and out of SVT and sinus, increased BB seems to\n help, but pt does not stay in sinus. Cards rec to start Amiodarone IV\n drip, and then convert to PO, 200mg TID. Would consider EPS if\n amiodarone not successful, though would wait until pt more stable for\n general anesthesia.\n - Changed to IV metoprolol to 10mg IV q4hr.\n - Completed amiodarone 0.5mg/min IV drip x 18 hours, and converted to\n 200mg PO TID..\n - Cards c/s, appreciate recs\n # Sedation/Anxiolysis/AlteredMS: unclear etiology of her confusion and\n agitation. Has had long hospital course and multiple psychotropic\n medications as well as hx of EtOH abuse.\n - d/c all benzos. opiates, and antihistamines\n - Psychiatry consulted, appreciate recs\n - started Risperdal 0.5mg PO BID, d/c zyprexa.\n # Adrenal Insufficency: Endocrine following. Pt does not appear to be\n adrenally insufficient at baseline. Suggesting if the patient under\n goes major stressors such as major surgery, sepsis, she may need stress\n dosed steroids.\n .\n # Fluid Status: Likely approaching euvolemia, though still has mild\n hypernatramia which may suggest is still intravascularly depleated.\n - Monitoring urine output\n - will provide D5W IVF as need for hypernatremia and follow lytes\n # UE DVT and elevated INR: DVT in right UE has resolved, new\n non-occlusive in left axillary vein. INR has been volatile, likely from\n drug interactions and poor nutritional status. Have been unable to keep\n her appropariately therapeutic.\n - d/c coumadin\n - start Lovenox, maintain until GI issues resolved and can restart\n coumadin\n .\n #Hematemesis: Pt had small amt Hematemesis, after vomiting, last week.\n None today. HCT stable.\n -Will follow HCT.\n - Guaiac stools\n # Spine fracture: Stable\n - Brace for OOB, will discuss with Neurosurgery if current brace is\n optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n .\n # Tracheomalacia. Was initially addressed with IP and they wanted to\n follow up as outpatient. IP reevaluated and does not believe that a\n stent would be feasible.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # ACCESS: PIV x 1, PICC placement\n yesterday.\n # Ppx: subtherapeutic INR restarting coumadin today, Ranitidine, Bowel\n Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n - Social Work and Case management involved, have discussed situation\n w/ brother and boyfriend.\n # Code: Full\n # Dispo: ICU, Screening for vent facilities\n ICU Care\n Nutrition:\n TPN without Lipids - 06:00 PM 41. mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n PICC Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n MICU Attending Addendum:\n On this day I examined the patient and was present for the key portions\n of the services provided. I have reviewed Dr \ns note above and I\n agree with the findings and plan of care. I would only add/emphasize\n the following: Ms has done well of late on a trache collar,\n able to go all night without the vent. The active issues now are\n chiefly GI, cardiac, and pychiatric. Her hypomotility may be a bit\n better now that she is on high dose Reglan, and we will gingerly start\n feedings via her J in G tube, while continuing TPN for the present. Her\n SVT has for now converted to NSR on Amiodarone and Metoprolol. Her\n delirium is being addressed with the help of psychiatry, and we\n started Risperdal at their suggestion. Once these issues are stable\n she should be able to move to a resp rehab facility.\n , MD\n 30 min spent in the care of this critically ill patient\n ------ Protected Section Addendum Entered By: , MD\n on: 16:43 ------\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 639502,
"text": "56 yr old woman, who was transferred from osh for evaluation of\n tracheal bronchial malacia on .Pt presented to Medical\n Center on s/p fall down a flight of stairs fracturing, t5-t8 with\n propulsion treated conservatively with pain meds and back brace. She\n developed resp distress requiring intubation on . Trach/PEG done\n . Now with prolonged hospital course c/b by PNA, anxiety/altered\n mental status, R&LUE DVT .Pt found to have small non occlusive Clot on\n her right axial vein via Ultrasound. She has had problems with\n vomiting tube feedings, so feeding tube passed through g-tube to her\n jejunenum but she continues to vomit. Trach mask, has not required\n ventilation since . Has also required 1:1 sitters since\n decanulating herself twice, despite restraints. Overnight ,\n restarted TF\ns, however, infused for ~7 hrs, then began suctioning\n bile-like fluid from trach after pt experienced a prolonged coughing\n jag. TF\ns placed on hold.\n Tachycardia, Other\n Assessment:\n HR 67-118ST without VEA. BP 110/59-140/58. Pt rec\ning lopressor 10mg IV\n Q4hrs, as well as Amio via GT.\n Action:\n Lopressor changes to po TiD.\n Response:\n VSS.\n Plan:\n Cont present course of cardiac meds.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt on TM @ 70% with O2 sat 99-100%. Rare desat to 80\ns related to\n inc\nd secretions. Requiring tracheal sxn\ning approx Q1hr for\n mod-copious amts thick white tenacious secretions. Pt with strong\n cough, but freq unable to clear secretions herself. Lung snds\n rhonchorous in upper lobes, diminished in bases.\n Action:\n Freq sxn\ning per above. Pt encouraged to C&DB. Pt in\nchair\n position\n in bed with head @ 45-90degree angle.\n Response:\n Pt cont to have lg amt secretions requiring assist to clear.\n Plan:\n Cont aggressive pulm toilet.\n Arousal, Attention, and Cognition, Impaired\n Assessment:\n Pt very somulent in am, but has been awake and alert since approx 1100.\n Pt chatty, but difficult to read her lips and she has trouble writing\n clearly. Pt intermit very angry, with ? confusion re nurse\ns identity.\n Friend from visited () and pt recognized her.\n Action:\n Passy Muir Valve tried several times.\n Response:\n Pt not able to speak clearly with valve on. Also, D/T lg amt secretions\n could not leave valve on for more than a few minutes.\n Plan:\n Speech/swallow consult needed re valve, ? if it is damaged. Cont\n Risperidone. Cont soft wrist restraints and sitter @ bedside for pt\n safety.\n Alteration in Nutrition\n Assessment:\n Abd soft/obese with + BS. J tube clamped except for meds.\n Action:\n Pt rec\ning reglan, as well as colace and senna. Miralx held in am.\n Response:\n Pt with lg loose yellow BM in am. TF started in afternoon @ 10ml/hr as\n well as 50ml water Q4hrs, with HOB @ 45-90degree angle. Tolerated well.\n Plan:\n Cont to gently advance TF per order. Strict aspiration orders, with pt\n rec\ning TF ONLY when in sitting position.\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 638549,
"text": "55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach, PEG, placement no with respiratory failure secondary to\n tracheomalacia , resolving HAP.\n Arousal, Attention, and Cognition, Impaired\n Assessment:\n Alert, mouthing words but very difficult to understand. Follows\n commands. MAE on bed, attempting to get up. Restless last evening, did\n eventually fall off to sleep this AM.\n Action:\n Zyprexa x 1 . Frequent re-orientation to place, situation. Soft wrist\n restraints for patient safety.\n Response:\n Pt did eventually fall asleep. Re-orientation does have calming effect\n however it is short term.\n Plan:\n No valium or benadryl per psych as this exacerbates delirium. Zyprexa\n for agitation. pt prn.\n Hypernatremia (high sodium)\n Assessment:\n Na 145 last night, 148 this AM.\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Trach collar @ 50% O2 overnight until 4AM, Sats 90-97%. RR 17-20s.\n Around 4AM RR in low 30s, sats low 90s while sleeping--? Fatiguing.\n Strong cough, able to cough thick white ->tan secretions out of trach.\n Occ suctioned for same. Lungs are rhonchorous throughout. Impaired gag.\n Action:\n Suctioned prn for copious secretions. MDIs. Placed back on vent @ 4AM\n d/t fatigue.\n Response:\n Tolerated trach collar most of night, back on vent this AM d/t fatigue\n with RR in teens, Sats 98%.\n Plan:\n Wean from vent as tolerated. MDIs, suction as needed.\n Alteration in Nutrition\n Assessment:\n Tube feeds off overnight d/t constant vomiting. No vomiting overnight.\n Action:\n NPO. Reglan q 6 hrs.\n Response:\n No vomiting. Small brown stool x 1.\n Plan:\n NPO. ? may go to IR today to change Gtube to Jtube. Reglan. Meds via\n Gtube.\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-20 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 638643,
"text": "Chief Complaint: resp failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n CARDIOVERSION/DEFIBRILLATION - At 11:50 AM\n aqdenosine 6mg given X 1 by cardiologist to assess pt's rhythm. Pt\n tolerated well.\n Held Valium ansd Benedryl and has done well without\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.5\nC (97.7\n HR: 118 (76 - 144) bpm\n BP: 131/72(85) {93/43(0) - 154/134(138)} mmHg\n RR: 26 (12 - 36) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,945 mL\n 680 mL\n PO:\n TF:\n IVF:\n 1,800 mL\n 560 mL\n Blood products:\n Total out:\n 2,300 mL\n 680 mL\n Urine:\n 2,245 mL\n 680 mL\n NG:\n 55 mL\n Stool:\n Drains:\n Balance:\n -355 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: High flow neb, Tracheostomy tube\n Ventilator mode: MMV/PSV/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 319 (319 - 319) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 15\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 15 cmH2O\n SpO2: 94%\n ABG: ///36/\n Ve: 5.5 L/min\n Physical Examination\n Gen: lying in bed, alert, responding to questions\n CV; tachy RR\n Chest: bibasilar decreased BS, faint exo wheeze\n Abd: soft NT\n Ext: no edema:\n Labs / Radiology\n 10.0 g/dL\n 548 K/uL\n 128 mg/dL\n 0.8 mg/dL\n 36 mEq/L\n 4.1 mEq/L\n 6 mg/dL\n 105 mEq/L\n 148 mEq/L\n 32.7 %\n 7.6 K/uL\n [image002.jpg]\n 05:00 AM\n 02:06 AM\n 07:34 AM\n 03:50 AM\n 06:22 AM\n 02:58 AM\n 03:43 AM\n 05:02 PM\n 03:36 AM\n 02:30 AM\n WBC\n 5.9\n 7.5\n 5.6\n 6.1\n 7.0\n 7.1\n 7.1\n 6.9\n 7.6\n Hct\n 27.2\n 26.8\n 27.0\n 27.0\n 29.7\n 28.9\n 29.2\n 27.8\n 32.7\n Plt\n 296\n 306\n 335\n \n 452\n 467\n 548\n Cr\n 0.7\n 0.6\n 0.5\n 0.7\n 0.7\n 0.6\n 0.7\n 0.8\n 0.7\n 0.8\n Glucose\n 134\n 134\n 121\n \n 104\n 108\n 131\n 128\n Other labs: PT / PTT / INR:48.3/33.3/5.5, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:10.0 mg/dL, Mg++:2.5 mg/dL,\n PO4:4.3 mg/dL\n Assessment and Plan\n 1. Tachycardia: runs of attach Appreciate EP consult\n will increase\n bblocker. If fails may need EP study for further study and ? ablatable\n focus.\n 2. Persistent Nausea/Vomiting: very poor bowel sounds, get ABD ct to\n look for SBO, talk with GI about EGD or tube study to look for more\n proximal gastric outlet obstruction.\n 2. Resp Failure\n Trach mask trials all day, PSV\n PMV trials\n S/P rx for pan Klebs PNA.\n Per IP not stent planned as technically not possible to\n place into her airway\n 3. DVT and coagulopathy: On warfarin but high inr. Hold warfarin until\n inr 2-2.5 range or bridge with loveonx if may get procedures\n 4. Hypernatremia Replete free water.\n Please see today\ns ICU team note for other issues.\n ICU Care\n Nutrition: NPO while sorting out gi obstruction issues\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n Prophylaxis:\n DVT: coumadin\n Stress ulcer: PPI\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 637600,
"text": "Tachycardia, Other\n Assessment:\n Hr has been in sinus tachycardia all day at 130-140\ns, Hr noted to also\n stay elevated in the 130\ns while at rest also. SBP has been elevated\n throughout the day at 150-170\ns while awake and 120-130\ns while at\n rest. Pt also very restless.\n Action:\n No med to be given for tachycardia or BP MD. Pt given Morphine and\n haldol for restlessness w/o effect. Pt also on valium ATC w/little\n effect. CTA done to r/o pe as a source of tachycardia.\n Response:\n Results pending on CTA.\n Plan:\n Continue to evaluate HR and BP for need of treatment.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt has a known DVT to RUE. Today pt had a US of LUE to R/O DVT as a\n source of tachycardia.\n Action:\n After DVT found, IVF stopped.\n Response:\n Pt found to have a clot to Lt ax vein and MD notified.\n Plan:\n Pt to cont coumadin tonight, awaiting dosage for inr 1.4 . ? Access now\n that Lt arm has a DVT.\n Altered mental status (not Delirium)\n Assessment:\n Pt has been restless most of the day. Pt only follow direct commands.\n When asked to keep her hand off the TC, she will for only 3sec, and\n then she will reach for it again.\n Action:\n Pt given valium, morphine and haldol prn.\n Response:\n Little effect noted from sedations.\n Plan:\n Continue to eval MS.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt placed on TC this am at 8am and was placed back on CPAP at 3pm after\n pt became tachypnic and tachycardic (150\ns). Pt has had a strong prod\n cough with mod amounts of thick yellow secretions. LS coarse before sx\n and CTA after sx. Pt found several times disconnecting herself from the\n vent (even though she is in restraints), and she will desat to 80%\n within seconds.\n Action:\n Cont pulm toilet as needed. Pt in need of freq oral care.\n Response:\n Plan:\n Continue to wean pt off vent and place on TC once pt can tol it again.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Temp 99.1 this am and now 99.5 .\n Action:\n Pt continues on IV ABx.\n Response:\n Awaiting effect from IV ABXs.\n Plan:\n Follow up cultures.\n"
},
{
"category": "Respiratory ",
"chartdate": "2167-10-21 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 638813,
"text": "Demographics\n Day of mechanical ventilation: 33\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Tracheostomy tube:\n Type: Standard, Cuffed, Inner Cannula\n Manufacturer: Portex\n Size: 8.0mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Scant\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Pt weaned to trach collar,\n tolerating well.\n Assessment of breathing comfort: No claim of dyspnea\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: stay on trach collar as tolerated.\n Reason for continuing current ventilatory support:\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-21 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 638816,
"text": "Chief Complaint: resp failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n rising INR to 10.5\n small volume hemetemesis\n abd CT\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:30 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.9\nC (98.4\n HR: 114 (88 - 136) bpm\n BP: 120/65(80) {80/40(49) - 149/88(92)} mmHg\n RR: 11 (11 - 33) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,241 mL\n 1,802 mL\n PO:\n TF:\n IVF:\n 1,941 mL\n 1,802 mL\n Blood products:\n Total out:\n 1,860 mL\n 260 mL\n Urine:\n 1,830 mL\n 210 mL\n NG:\n 30 mL\n 50 mL\n Stool:\n Drains:\n Balance:\n 381 mL\n 1,542 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 438 (300 - 1,054) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 13\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 16 cmH2O\n Plateau: 15 cmH2O\n SpO2: 100%\n ABG: ///35/\n Ve: 5.4 L/min\n Physical Examination\n Gen: lying in bed, alert, responding to questions\n CV; tachy RR\n Chest: bibasilar decreased BS, faint exp wheeze\n Abd: soft NT+BS\n Ext: no edema\n Labs / Radiology\n 9.2 g/dL\n 528 K/uL\n 121 mg/dL\n 1.0 mg/dL\n 35 mEq/L\n 3.4 mEq/L\n 6 mg/dL\n 103 mEq/L\n 144 mEq/L\n 28.9 %\n 9.5 K/uL\n [image002.jpg]\n 07:34 AM\n 03:50 AM\n 06:22 AM\n 02:58 AM\n 03:43 AM\n 05:02 PM\n 03:36 AM\n 02:30 AM\n 01:30 AM\n 06:41 AM\n WBC\n 5.6\n 6.1\n 7.0\n 7.1\n 7.1\n 6.9\n 7.6\n 9.5\n Hct\n 27.0\n 27.0\n 29.7\n 28.9\n 29.2\n 27.8\n 32.7\n 28.6\n 28.9\n Plt\n 335\n 321\n 395\n 462\n 452\n 467\n 548\n 528\n Cr\n 0.5\n 0.7\n 0.7\n 0.6\n 0.7\n 0.8\n 0.7\n 0.8\n 1.0\n Glucose\n 121\n 619\n 126\n 137\n 104\n 108\n 131\n 128\n 121\n Other labs: PT / PTT / INR:82.1/35.9/10.5, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:9.7 mg/dL, Mg++:2.4 mg/dL, PO4:2.9\n mg/dL\n Assessment and Plan\n 1. Tachycardia: runs of attach Appreciate EP consult\n will increase\n bblocker. Have to convert to metoprolol 5mg IV Q4 because unable to\n take pos\n 2. Persistent Nausea/Vomiting: we have ruled out\n pSBO/SBO, very poor\n bowel sounds, get emptying study and if unrevealing consult GI to\n discuss EGD. We will need to pursue NG dophoff by IR if cannot snake\n pedi tube into existing g tube. Was guiac + but in setting of high INR\n HCT stable. Will will reverse inr.\n 2. Resp Failure\n Trach mask trials all day, PSV\n PMV trials\n Per IP not stent planned as technically not possible to\n place into her airway\n 3. DVT and coagulopathy: reverre with IV VIt K today, then maintain\n daily SC Vit K until Inr less than 2\n 4. Hypernatremia Replete free water.\n Please see today\ns ICU team note for other issues.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 04:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n Communication: with pt and spoke at length with brother who would like\n to possibily become her guardian or power of atty to facilitate her\n care and finances. Her partner is alos interested in guardianship.\n We may need ot refer to legal for clarification.\n Code status: Full code\n Disposition : ICU\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 639604,
"text": "Chief Complaint:\n 24 Hour Events:\n Pt agitated overnight given extra Risperidone 0.5 mg x 2 overnight.\n (1.5mg total)\n 1000 mL D5W for Hypernatremia\n Changed B-Blocker from IV to PO, Metoprolol Tartrate 25 mg PO TID\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:17 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.7\nC (98\n HR: 120 (67 - 120) bpm\n BP: 110/64(76) {109/47(60) - 141/115(118)} mmHg\n RR: 26 (18 - 30) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 3,820 mL\n 856 mL\n PO:\n TF:\n 117 mL\n 20 mL\n IVF:\n 2,612 mL\n 572 mL\n Blood products:\n Total out:\n 2,460 mL\n 1,180 mL\n Urine:\n 2,460 mL\n 1,180 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,360 mL\n -324 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 100%\n ABG: ///33/\n Physical Examination\n Gen: Awake, Mouthing words, More agitated compared to previous\n mornings.\n HEENT: EOMI, No pallor in conjunctiva, MMM\n Resp: CTAB, no rales, rhonchi, or wheezing, good airway movement.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, decreased bowel sounds,, G-Tube in\n place with no erythema/induration\n Exte: No edema, DP 2+ bil\n NEURO: Gross Motor and Sensation in 4 extremities\n Labs / Radiology\n 249 K/uL\n 8.0 g/dL\n 122 mg/dL\n 0.5 mg/dL\n 33 mEq/L\n 3.7 mEq/L\n 13 mg/dL\n 108 mEq/L\n 146 mEq/L\n 24.7 %\n 5.5 K/uL\n [image002.jpg] CXR: L Picc, trach tip at midline, bibasilar\n opacities, low lung volumes, Bil pleural effusions.\n 03:36 AM\n 02:30 AM\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n 03:00 AM\n 04:00 AM\n 05:45 AM\n 03:51 AM\n WBC\n 6.9\n 7.6\n 9.5\n 5.7\n 7.3\n 8.0\n 8.7\n 5.5\n Hct\n 27.8\n 32.7\n 28.6\n 28.9\n 30.0\n 26.9\n 27.3\n 27.0\n 28.7\n 24.7\n Plt\n 467\n 548\n 528\n 356\n 346\n 316\n 271\n 249\n Cr\n 0.7\n 0.8\n 1.0\n 0.7\n 0.7\n 0.7\n 0.7\n 0.5\n Glucose\n 131\n 128\n 121\n 129\n 123\n 114\n 112\n 122\n Other labs: PT / PTT / INR:13.6/31.1/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:9.0 mg/dL, Mg++:2.2 mg/dL, PO4:3.1\n mg/dL\n Assessment and Plan\n 56yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach/PEG with resolving respiratory failure and HAP.\n .\n # Respiratory failure: s/p intubation/extubation, now on trach mask,\n FiO2 70%. Tolerating well with good O2 sat. No further\n self-decanulations overnight.\n - Tach mask as tolerated.\n - Holding sedation with exception of Risperidal 0.5mg .\n - F/u CXR tomorrow\n .\n # Nutrition/Vomiting: Currently receiving TPN;. One large BM in past\n 24 hrs to indicate potential improvement in ileus.\n - Cont Reglan 20mg IV Q 8 hours; meds via G-J tube,\n - Will obtain recommendations from Nutrition re TPN before starting TPN\n tomorrow\n - TF as tolerated\n - Speech and Swallow eval\n - PICC line in place with TPN given when pt not tolerating TF\n - GI consult, appreciate recs\n .\n # Tachycardia: Improved HR max of 120\ns versus 160s previously;\n elevated this am secondary to agitation. Pt now on PO Amiodarone 200\n TID and PO metoprolol 25mg TID\n - Continue current med regimen. Will continue amiodarone 200 TID for\n three weeks and then switch to qday.\n - Will schedule f/u in 4wks with Dr. upon d/c/transfer.\n - f/u Cards recs\n # Sedation/Anxiolysis/AlteredMS: Agitation O/N, continues to be\n agitated most likely secondary to long hospital course and multiple\n psychotropic medications as well as hx of EtOH abuse. Risperdal given\n O/N.\n - started Risperdal 0.5mg PO BID\n - continue to hold all benzos. opiates, and antihistamines\n - Appreciate psych. Will call and f/u psych recs.\n #Anemia: Decrease in HCT from 28\n24; tachycardia. No known etiology of\n blood loss, most likely related to variaton\n -Will repeat HCT check this afternoon.\n # Hypernatremia/Fluid Status: Mild hypernatramia with good UOP\n (hypervolemic hypernatremia). On TPN/TF.\n - providing D5W IVF, free water flushes with TF\n -Will f/u lytes (Na) this afternoon at 5pm.\n # UE DVT and elevated INR: Decision made to d/c Coumadin given her\n labile INR, and start Lovenox . Current INR 1.2.\n - Will flush L PICC with TPA if does not flush\n .\n # Spine fracture: Stable\n - Brace for OOB, need to discuss with Neurosurgery before d/c if\n current brace is optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n .\n # Tracheomalacia. Was initially addressed with IP and they wanted to\n follow up as outpatient. IP reevaluated and does not believe that a\n stent would be feasible. No new issues.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # ACCESS: PIV x 1, L PICC\n # Ppx: Lovenox, PPi, Bowel Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n - Social Work and Case management involved, have discussed situation\n w/ brother and boyfriend.\n # Code: Full\n # Dispo: ICU, Will d/w case management re rehab facilities.\n PGY2 Addendum\n Agree with excellent MS4 PN. Will touch base with psychiatry re:\n sedating meds and EP re: atrial tachycardia. Will obtain EKG to\n reassess QTc. Ordered for TPN. Giving d5W for hypernatremia. Re-consult\n S/S for PMV re-fitting. transfer to LTAC.\n \n PGY2\n ------ Protected Section ------\n MICU Attending Addendum:\n ------ Protected Section Addendum Entered By: , MD\n on: 16:21 ------\n MICU ATTENDING ADDENDUM:\n On this day I examined the patient and was present for the key portions\n of the services provided. I have reviewed the note above and agree with\n the findings and plan of care. I would add the following:\n Ms remains stable, on her trache mask, off the vent for 3 days.\n Secretions improved and she is using the PMV to talk in short spells.\n Her ileus seems better, with a good BM and good bowel sounds and no\n clear cut emesis. So TFs will be restarted and advanced. She remains\n on high dose raglan.\n We will rediscuss her case with psychiatry as her mentation varies from\n very alert to more somnolent and she is still confused.\n All in all, however, she is close to being able to go to resp rehab\n facility and we\nll talk to case manager tomorrow.\n , MD\n ------ Protected Section Addendum Entered By: , MD\n on: 17:10 ------\n"
},
{
"category": "Respiratory ",
"chartdate": "2167-10-26 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 639607,
"text": "Demographics\n Day of mechanical ventilation: 38\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Tube Type\n Tracheostomy tube:\n Type: Cuffed, Perc Trach\n Manufacturer: Portex\n Size: 7.0mm\n PMV: Yes\n Cuff Management:\n Vol/Press:\n Cuff pressure: 23 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Moderate\n Pt on 50% cool aerosol, SpO2 97-99%.\n"
},
{
"category": "Social Work",
"chartdate": "2167-10-21 00:00:00.000",
"description": "Social Work Progress Note",
"row_id": 638808,
"text": "Social Work:\n Received phone message from pt\ns brother, (c: ),\n and called back to discuss his questions and concerns re pt\ns prolonged\n hospitalization. He is in on business at this time, but has\n been calling regularly to speak with MICU team for updates. He\ndefinitely\n plans on coming into the hospital next Thursday and Friday\n ( and ) and is also trying to come earlier on his way back\n from , perhaps this weekend. He will call to inform MICU team\n of whether this will be possible, and if it is, he hopes to be able to\n meet with pt\ns doctors at that time to discuss prognosis and plan of\n care. He also raises questions re whether it makes sense to pursue\n temporary guardianship for pt. SW discussed with MICU Attending, and\n further assessment of pt\ns medical condition and mental status is\n needed before a clear recommendation can be made. Of note, brother\n expresses his wish to become temporary guardian for pt, if necessary,\n and he expresses some concern about the possibility of pt\ns boyfriend\n taking this role.\n At this time, pt is unable to communicate clearly. SW met with her in\n MICU, and she presents as sitting up in a chair, awake and alert.\n While she is mouthing words, it is very difficult to discern what she\n is trying to say. SW provided her with paper and pen, and she tried to\n write with a loose grip, but her words are mostly incomprehensible in\n writing as well. She appears frustrated and agitated. SW attempted\n to offer emotional support, though it is unclear how much she\n understands.\n SW also called pt\ns boyfriend, (), to assess\n and support coping. He states he is doing well,\nin better spirits\n than when we last talked,\n as he reports he has been able to\nmake ends\n meat\n more easily than he had anticipated. He states he has gotten a\n 90 day reprieve on pt\ns car loan, has gotten an extension on her car\n insurance payments, and has managed to pay her other bills. He also\n raises the question of pursuing temporary guardianship, stating he has\n looked into this online and talked about it with friends and\n . states that he is\nnot in a rush\n to do this now, as he\n has been able to attend to pt\ns financial affairs as needed, but he\n wonders if it might be useful in the future if pt remains unable to\n communicate for herself. SW informed him that pt\ns brother has also\n raised this question and that team will be continuing to assess pt\n condition with this in mind. Of note, boyfriend states he still has\n not been able to visit pt in the hospital due to his own health\n problems (PVD, having surgery in a week and a half). He states he has\n been calling periodically to get updates from RN\ns re pt\ns care. SW\n put him in touch with MICU resident today for update.\n Plan:\n - SW will plan to discuss with legal department the question\n of pursuing temporary guardianship for pt.\n - Will remain available to both brother and boyfriend for\n continued emotional support and facilitation re team communication.\n Please page with any questions or concerns.\n , LCSW, #\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-22 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 638991,
"text": "Chief Complaint: resp failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n increased bblocker\n J tube placed by IR through PEG- restarted TF and vomiting\n Went for tube study - dysmotility - contrast sat in stomach\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Diazepam (Valium) - 02:24 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 12:17 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 35.6\nC (96.1\n HR: 118 (93 - 140) bpm\n BP: 153/58(79) {82/39(49) - 153/101(105)} mmHg\n RR: 23 (14 - 37) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 3,808 mL\n 1,119 mL\n PO:\n TF:\n 4 mL\n IVF:\n 3,804 mL\n 1,119 mL\n Blood products:\n Total out:\n 1,650 mL\n 520 mL\n Urine:\n 1,590 mL\n 520 mL\n NG:\n 60 mL\n Stool:\n Drains:\n Balance:\n 2,158 mL\n 599 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 243 (169 - 281) mL\n PS : 5 cmH2O\n RR (Spontaneous): 17\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 67\n PIP: 11 cmH2O\n SpO2: 99%\n ABG: ///33/\n Ve: 4.1 L/min\n Physical Examination\n Labs / Radiology\n 8.2 g/dL\n 356 K/uL\n 129 mg/dL\n 0.7 mg/dL\n 33 mEq/L\n 3.6 mEq/L\n 4 mg/dL\n 110 mEq/L\n 148 mEq/L\n 26.9 %\n 5.7 K/uL\n [image002.jpg]\n 06:22 AM\n 02:58 AM\n 03:43 AM\n 05:02 PM\n 03:36 AM\n 02:30 AM\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n WBC\n 7.0\n 7.1\n 7.1\n 6.9\n 7.6\n 9.5\n 5.7\n Hct\n 29.7\n 28.9\n 29.2\n 27.8\n 32.7\n 28.6\n 28.9\n 30.0\n 26.9\n Plt\n 395\n 462\n 452\n 467\n 548\n 528\n 356\n Cr\n 0.7\n 0.6\n 0.7\n 0.8\n 0.7\n 0.8\n 1.0\n 0.7\n Glucose\n 126\n 137\n 104\n 108\n 131\n 128\n 121\n 129\n Other labs: PT / PTT / INR:15.2/24.6/1.3, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.7 mg/dL, Mg++:2.1 mg/dL, PO4:4.1\n mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 04:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-23 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 639210,
"text": "Chief Complaint:\n 24 Hour Events:\n Pt pulled out her trach tube, tube replaced\n Seen By EP and started on Amiodarone Drip\n Fever - 101.4\nF Cultures sent\n Self-decanulated again this am during rounds, bradycardia down to\n 39-40, desated, tube was replaced and vitals normalized. Pt placed in\n 8-point restraints.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Amiodarone - 1 mg/min\n Other ICU medications:\n Metoprolol - 01:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.4\n Tcurrent: 36.9\nC (98.5\n HR: 107 (107 - 142) bpm\n BP: 86/44(54) {82/39(49) - 181/113(122)} mmHg\n RR: 22 (13 - 25) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,127 mL\n 537 mL\n PO:\n TF:\n IVF:\n 2,127 mL\n 537 mL\n Blood products:\n Total out:\n 995 mL\n 400 mL\n Urine:\n 995 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,132 mL\n 137 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Spontaneous): 208 (208 - 243) mL\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 0 cmH2O\n SpO2: 97%\n ABG: ///31/\n Ve: 4.1 L/min\n Physical Examination\n Gen: Awake and alert this am, following commands, mildly agitated,\n stated that she\n wanted to get out of here\n HEENT: PERRL, MMM\n Resp: Diffuse rhonchi and transmitted airway sounds.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, BS+\n Exte: No edema, DP 2+ bil\n NEURO: CNII\nXII intact, reflexes 2+ bilaterally.\n Labs / Radiology\n 346 K/uL\n 8.4 g/dL\n 123 mg/dL\n 0.7 mg/dL\n 31 mEq/L\n 3.8 mEq/L\n 4 mg/dL\n 107 mEq/L\n 144 mEq/L\n 27.3 %\n 7.3 K/uL\n [image002.jpg]\n 02:58 AM\n 03:43 AM\n 05:02 PM\n 03:36 AM\n 02:30 AM\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n 03:00 AM\n WBC\n 7.1\n 7.1\n 6.9\n 7.6\n 9.5\n 5.7\n 7.3\n Hct\n 28.9\n 29.2\n 27.8\n 32.7\n 28.6\n 28.9\n 30.0\n 26.9\n 27.3\n Plt\n 462\n 452\n 467\n 548\n 528\n 356\n 346\n Cr\n 0.6\n 0.7\n 0.8\n 0.7\n 0.8\n 1.0\n 0.7\n 0.7\n Glucose\n 137\n 104\n 108\n 131\n 128\n 121\n 129\n 123\n Other labs: PT / PTT / INR:14.1/23.7/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.8 mg/dL, Mg++:1.9 mg/dL, PO4:3.7\n mg/dL\n Assessment and Plan\n 55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach, PEG placement now with respiratory failure secondary to\n tracheomalacia , resolved HAP.\n .\n # Respiratory failure: Slowly improving, spending most of the day on\n trach mask with short periods of rest on PSV at night and setbacks\n from increased secretions to vomiting/aspiration events and her\n self-decanulations.\n - Continue to increase time on trach mask as tolerated.\n - Discontinue all orders for sedation except for Zyprexa QHS.\n - PMV with suctioning as tolerated\n # Nutrition/Vomiting: Normal CT-abdomen, had FT placed via peg into\n jejunum, but continued to vomit. Tube study yesterday showed\n dysmotility in small bowel, but no obstruction, no retrograde flow.\n Awaiting GI recs.\n - Hold TFs\n - GI consult, appreciate recs\n - PICC line placement for parenteral nutrition this am\n - Nutrition recs to start TPN today\n # HAP vs Aspiration PNA: Had been afebrile for last several days, now\n with new fever last night after having decanulated herself. Likely had\n some aspiration. Chemical pneumonitis versus new aspiration PNA.\n - CXR today\n - F/u cx data\n - If remains febrile, send sputum cx.\n .\n # Tachycardia: Pt in and out of SVT and sinus, increased BB seems to\n help, but pt does not stay in sinus. Cards rec to start Amiodarone IV\n drip, and then convert to PO, 200mg TID. Would consider EPS if\n amiodarone not successful, though would wait until pt more stable for\n GA.\n - Changed to IV metoprolol to 10mg IV q4hr during the day and 7.5mg q4\n hours at night.\n - Amiodarone 0.5mg/min IV drip x 18 hours.\n - Cards c/s, appreciate recs\n # Sedation/Anxiolysis/AlteredMS: unclear etiology of her confusion and\n agitation. Has had long hospital course and multiple psychotropic\n medications as well as hx of EtOH abuse.\n - Continue w Olanzapine QHS\n - d/c all benzos, d/c all opiates given GI dysmotlitiy\n - Psychiatry consulted, appreciate recs\n # Adrenal Insufficency: Endocrine following. Pt does not appear to be\n adrenally insufficient at baseline. Suggesting if the patient under\n goes major stressors such as major surgery, sepsis, she may need stress\n dosed steroids.\n .\n # Fluid Status: Likely approaching euvolemia, though still has mild\n hypernatramia which may suggest is still intravascularly depleated.\n - Monitoring urine output\n - will provide D5W IVF as need for hypernatremia and follow lytes\n # UE DVT and elevated INR: DVT in right UE has resolved, new\n non-occlusive in left axillary vein. INR had risen quickly on coumadin,\n likely to poor nutrition, resonded quickly to Vitamin K IV, but now\n subtherapeutic again. Kept subtherapeutic today for PICC line placement\n (for TPN), will restart w/ 2mg Coumadin after line placement.\n - Restart coumadin after PICC line placement today\n - Continue to follow INR closely to reach therapeutic INR.\n .\n #Hematemesis: Pt had small amt Hematemesis, after vomiting, 2 days ago.\n None today. HCT stable.\n -Will follow HCT.\n - Guaiac stools\n # Spine fracture: Stable\n - Brace for OOB, will discuss with Neurosurgery if current brace is\n optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n .\n # Tracheomalacia. Was initially addressed with IP and they wanted to\n follow up as outpatient. IP reevaluated and does not believe that a\n stent would be feasible.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # ACCESS: PIV x 1, PICC placement\n today.\n # Ppx: subtherapeutic INR restarting coumadin today, Ranitidine, Bowel\n Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n - Social Work and Case management involved, have discussed situation\n w/ brother and boyfriend.\n # Code: Full\n # Dispo: ICU, Screening for vent facilities\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 04:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 639661,
"text": "Chief Complaint:\n 24 Hour Events:\n -hypernatremia: Repeat Na 148-->146 (this am), continuing D5W at\n 125cc/hr\n -TF up to 30cc/hr; tolerated O/N\n -Per psych recs: Gave risperidone m-tab 1mg PO x1 HS and will continue\n risperdone 0.5mg qam and 0.5 PRN; gave scopolamine patch q72hrs;\n f/u EKG in am\n -Changed Metoprolol 25 to 37.5mg TID; gave 5mg x1\n -GI recs: pending\n -S&S re-eval: for Passy Muir valve eval;\n -Call case management \n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:30 AM\n Enoxaparin (Lovenox) - 06:48 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.7\nC (98.1\n HR: 79 (68 - 124) bpm\n BP: 134/57(75) {124/52(70) - 179/121(130)} mmHg\n RR: 27 (18 - 31) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 4,004 mL\n 1,084 mL\n PO:\n TF:\n 137 mL\n 51 mL\n IVF:\n 2,544 mL\n 729 mL\n Blood products:\n Total out:\n 3,813 mL\n 1,000 mL\n Urine:\n 3,813 mL\n 1,000 mL\n NG:\n Stool:\n Drains:\n Balance:\n 191 mL\n 84 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 99%\n ABG: ///33/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 231 K/uL\n 7.7 g/dL\n 145 mg/dL\n 0.4 mg/dL\n 33 mEq/L\n 3.5 mEq/L\n 11 mg/dL\n 109 mEq/L\n 146 mEq/L\n 25.3 %\n 5.7 K/uL\n [image002.jpg]\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n 03:00 AM\n 04:00 AM\n 05:45 AM\n 03:51 AM\n 04:45 PM\n 04:00 AM\n WBC\n 9.5\n 5.7\n 7.3\n 8.0\n 8.7\n 5.5\n 5.7\n Hct\n 28.6\n 28.9\n 30.0\n 26.9\n 27.3\n 27.0\n 28.7\n 24.7\n 25.2\n 25.3\n Plt\n 528\n 356\n 346\n \n 231\n Cr\n 1.0\n 0.7\n 0.7\n 0.7\n 0.7\n 0.5\n 0.4\n Glucose\n 121\n 129\n 123\n 114\n 112\n 122\n 145\n Other labs: PT / PTT / INR:13.6/31.1/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.6 mg/dL, Mg++:2.0 mg/dL, PO4:3.6\n mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n TPN without Lipids - 05:44 PM 43. mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n PICC Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 639662,
"text": "Chief Complaint:\n 24 Hour Events:\n -hypernatremia: Repeat Na 148-->146 (this am), continuing D5W at\n 125cc/hr\n -TF up to 30cc/hr; tolerated O/N\n -Per psych recs: Gave risperidone m-tab 1mg PO x1 HS and will continue\n risperdone 0.5mg qam and 0.5 PRN; gave scopolamine patch q72hrs;\n f/u EKG in am\n -Changed Metoprolol 25 to 37.5mg TID; gave 5mg x1\n -GI recs: pending\n -S&S re-eval: for Passy Muir valve eval;\n -Call case management \n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:30 AM\n Enoxaparin (Lovenox) - 06:48 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.7\nC (98.1\n HR: 79 (68 - 124) bpm\n BP: 134/57(75) {124/52(70) - 179/121(130)} mmHg\n RR: 27 (18 - 31) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 4,004 mL\n 1,084 mL\n PO:\n TF:\n 137 mL\n 51 mL\n IVF:\n 2,544 mL\n 729 mL\n Blood products:\n Total out:\n 3,813 mL\n 1,000 mL\n Urine:\n 3,813 mL\n 1,000 mL\n NG:\n Stool:\n Drains:\n Balance:\n 191 mL\n 84 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 99%\n ABG: ///33/\n Physical Examination\n Gen: Awake, Mouthing words, More agitated compared to previous\n mornings.\n HEENT: EOMI, No pallor in conjunctiva, MMM\n Resp: CTAB, no rales, rhonchi, or wheezing, good airway movement.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, decreased bowel sounds,, G-Tube in\n place with no erythema/induration\n Exte: No edema, DP 2+ bil\n NEURO: Gross Motor and Sensation in 4 extremities\n Labs / Radiology\n 231 K/uL\n 7.7 g/dL\n 145 mg/dL\n 0.4 mg/dL\n 33 mEq/L\n 3.5 mEq/L\n 11 mg/dL\n 109 mEq/L\n 146 mEq/L\n 25.3 %\n 5.7 K/uL\n [image002.jpg]\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n 03:00 AM\n 04:00 AM\n 05:45 AM\n 03:51 AM\n 04:45 PM\n 04:00 AM\n WBC\n 9.5\n 5.7\n 7.3\n 8.0\n 8.7\n 5.5\n 5.7\n Hct\n 28.6\n 28.9\n 30.0\n 26.9\n 27.3\n 27.0\n 28.7\n 24.7\n 25.2\n 25.3\n Plt\n 528\n 356\n 346\n \n 231\n Cr\n 1.0\n 0.7\n 0.7\n 0.7\n 0.7\n 0.5\n 0.4\n Glucose\n 121\n 129\n 123\n 114\n 112\n 122\n 145\n Other labs: PT / PTT / INR:13.6/31.1/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.6 mg/dL, Mg++:2.0 mg/dL, PO4:3.6\n mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n TPN without Lipids - 05:44 PM 43. mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n PICC Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 639663,
"text": "Chief Complaint:\n 24 Hour Events:\n -hypernatremia: Repeat Na 148-->146 (this am), continuing D5W at\n 125cc/hr\n -TF up to 30cc/hr; tolerated O/N\n -Per psych recs: Gave risperidone m-tab 1mg PO x1 HS and will continue\n risperdone 0.5mg qam and 0.5 PRN; gave scopolamine patch q72hrs;\n f/u EKG in am\n -Changed Metoprolol 25 to 37.5mg TID; gave 5mg x1\n -GI recs: pending\n -S&S re-eval: for Passy Muir valve eval;\n -Call case management \n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:30 AM\n Enoxaparin (Lovenox) - 06:48 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.7\nC (98.1\n HR: 79 (68 - 124) bpm\n BP: 134/57(75) {124/52(70) - 179/121(130)} mmHg\n RR: 27 (18 - 31) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 4,004 mL\n 1,084 mL\n PO:\n TF:\n 137 mL\n 51 mL\n IVF:\n 2,544 mL\n 729 mL\n Blood products:\n Total out:\n 3,813 mL\n 1,000 mL\n Urine:\n 3,813 mL\n 1,000 mL\n NG:\n Stool:\n Drains:\n Balance:\n 191 mL\n 84 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 99%\n ABG: ///33/\n Physical Examination\n Gen: Awake, Mouthing words, More agitated compared to previous\n mornings.\n HEENT: EOMI, No pallor in conjunctiva, MMM\n Resp: CTAB, no rales, rhonchi, or wheezing, good airway movement.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, decreased bowel sounds,, G-Tube in\n place with no erythema/induration\n Exte: No edema, DP 2+ bil\n NEURO: Gross Motor and Sensation in 4 extremities\n Labs / Radiology\n 231 K/uL\n 7.7 g/dL\n 145 mg/dL\n 0.4 mg/dL\n 33 mEq/L\n 3.5 mEq/L\n 11 mg/dL\n 109 mEq/L\n 146 mEq/L\n 25.3 %\n 5.7 K/uL\n [image002.jpg]\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n 03:00 AM\n 04:00 AM\n 05:45 AM\n 03:51 AM\n 04:45 PM\n 04:00 AM\n WBC\n 9.5\n 5.7\n 7.3\n 8.0\n 8.7\n 5.5\n 5.7\n Hct\n 28.6\n 28.9\n 30.0\n 26.9\n 27.3\n 27.0\n 28.7\n 24.7\n 25.2\n 25.3\n Plt\n 528\n 356\n 346\n \n 231\n Cr\n 1.0\n 0.7\n 0.7\n 0.7\n 0.7\n 0.5\n 0.4\n Glucose\n 121\n 129\n 123\n 114\n 112\n 122\n 145\n Other labs: PT / PTT / INR:13.6/31.1/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.6 mg/dL, Mg++:2.0 mg/dL, PO4:3.6\n mg/dL\n Assessment and Plan\n 56yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach/PEG with resolving respiratory failure and HAP.\n .\n # Respiratory failure: s/p intubation/extubation, now on trach mask,\n FiO2 70%. Tolerating well with good O2 sat. No further\n self-decanulations overnight.\n - Tach mask as tolerated.\n - Holding sedation with exception of Risperidal 0.5mg .\n - F/u CXR tomorrow\n .\n # Nutrition/Vomiting: Currently receiving TPN;. One large BM in past\n 24 hrs to indicate potential improvement in ileus.\n - Cont Reglan 20mg IV Q 8 hours; meds via G-J tube,\n - Will obtain recommendations from Nutrition re TPN before starting TPN\n tomorrow\n - TF as tolerated\n - Speech and Swallow eval\n - PICC line in place with TPN given when pt not tolerating TF\n - GI consult, appreciate recs\n .\n # Tachycardia: Improved HR max of 120\ns versus 160s previously;\n elevated this am secondary to agitation. Pt now on PO Amiodarone 200\n TID and PO metoprolol 25mg TID\n - Continue current med regimen. Will continue amiodarone 200 TID for\n three weeks and then switch to qday.\n - Will schedule f/u in 4wks with Dr. upon d/c/transfer.\n - f/u Cards recs\n # Sedation/Anxiolysis/AlteredMS: Agitation O/N, continues to be\n agitated most likely secondary to long hospital course and multiple\n psychotropic medications as well as hx of EtOH abuse. Risperdal given\n O/N.\n - started Risperdal 0.5mg PO BID\n - continue to hold all benzos. opiates, and antihistamines\n - Appreciate psych. Will call and f/u psych recs.\n #Anemia: Decrease in HCT from 28\n24; tachycardia. No known etiology of\n blood loss, most likely related to variaton\n -Will repeat HCT check this afternoon.\n # Hypernatremia/Fluid Status: Mild hypernatramia with good UOP\n (hypervolemic hypernatremia). On TPN/TF.\n - providing D5W IVF, free water flushes with TF\n -Will f/u lytes (Na) this afternoon at 5pm.\n # UE DVT and elevated INR: Decision made to d/c Coumadin given her\n labile INR, and start Lovenox . Current INR 1.2.\n - Will flush L PICC with TPA if does not flush\n .\n # Spine fracture: Stable\n - Brace for OOB, need to discuss with Neurosurgery before d/c if\n current brace is optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n .\n # Tracheomalacia. Was initially addressed with IP and they wanted to\n follow up as outpatient. IP reevaluated and does not believe that a\n stent would be feasible. No new issues.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # ACCESS: PIV x 1, L PICC\n # Ppx: Lovenox, PPi, Bowel Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n - Social Work and Case management involved, have discussed situation\n w/ brother and boyfriend.\n # Code: Full\n # Dispo: ICU, Will d/w case management re rehab facilities.\n ICU Care\n Nutrition:\n TPN without Lipids - 05:44 PM 43. mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n PICC Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-20 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 638634,
"text": "Chief Complaint:\n 24 Hour Events:\n CARDIOVERSION/DEFIBRILLATION - At 11:50 AM\n aqdenosine 6mg given X 1 by cardiologist to assess pt's rhythm. Pt\n tolerated well, transiently converted.\n Valium, Benadryl held overnight which pt tolerated.\n Emesis again this am so TF held.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:24 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36\nC (96.8\n HR: 114 (85 - 144) bpm\n BP: 111/59(69) {84/42(0) - 154/134(138)} mmHg\n RR: 12 (12 - 36) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 1,945 mL\n 274 mL\n PO:\n TF:\n IVF:\n 1,800 mL\n 154 mL\n Blood products:\n Total out:\n 2,300 mL\n 500 mL\n Urine:\n 2,245 mL\n 500 mL\n NG:\n 55 mL\n Stool:\n Drains:\n Balance:\n -355 mL\n -226 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: MMV/PSV/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 319 (319 - 319) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 15\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 15 cmH2O\n SpO2: 100%\n ABG: ///36/\n Ve: 5.5 L/min\n Physical Examination\n Gen: Obtunded this am, not responsive to voice, minimally responsive to\n noxious stimuli, on MMV through trach tube, but later responsive to\n voice, appropriate, asking questions, mouthing responses\n HEENT: PERRL, MMM,\n Resp: Coarse BS anteriorly, no focal rales, rhonchi, or wheezing with\n some referred upper airway noises from secretions.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, hypoactive BS\n Exte: No edema, DP 2+ bil.\n NEURO: Toes downgoing bilaterally,\n Labs / Radiology\n 548 K/uL\n 10.0 g/dL\n 128 mg/dL\n 0.8 mg/dL\n 36 mEq/L\n 4.1 mEq/L\n 6 mg/dL\n 105 mEq/L\n 148 mEq/L\n 32.7 %\n 7.6 K/uL\n [image002.jpg]\n , 10/2 blood cx NGTD\n 05:00 AM\n 02:06 AM\n 07:34 AM\n 03:50 AM\n 06:22 AM\n 02:58 AM\n 03:43 AM\n 05:02 PM\n 03:36 AM\n 02:30 AM\n WBC\n 5.9\n 7.5\n 5.6\n 6.1\n 7.0\n 7.1\n 7.1\n 6.9\n 7.6\n Hct\n 27.2\n 26.8\n 27.0\n 27.0\n 29.7\n 28.9\n 29.2\n 27.8\n 32.7\n Plt\n 296\n 306\n 335\n \n 452\n 467\n 548\n Cr\n 0.7\n 0.6\n 0.5\n 0.7\n 0.7\n 0.6\n 0.7\n 0.8\n 0.7\n 0.8\n Glucose\n 134\n 134\n 121\n \n 104\n 108\n 131\n 128\n Other labs: PT / PTT / INR:48.3/33.3/5.5, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:10.0 mg/dL, Mg++:2.5 mg/dL,\n PO4:4.3 mg/dL\n Assessment and Plan\n 55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach, PEG placement now with respiratory failure secondary to\n tracheomalacia , resolved HAP.\n .\n # Respiratory failure: Slowly Improving. Now remaining on trach mask\n for most of the day, with periods of pressure support of over\n night. This am on MMV. Previously likely oversedated with Benadryl,\n Morhpine, and Valium which were held overnight. Pt awake and alert at\n rounds, interactive, and breathing comfortably on trach mask\n - Continue to increase time on trach mask as tolerated.\n - Decrease sedation and valium use\n - PMV with suctioning\n .\n # HAP vs Aspiration PNA: Afebrile without leukocytosis\n - Completed course of ceftriaxone\n - good O2 saturation on trach mask\n - Continue to f/u cultures\n .\n # Tachycardia: Previously was assessed as sinus tach with occasional\n runs of SVT and sources such as hypovolemia, PE, infection, and pain\n were assessed as possibly etiologies. Per Cardiology, most likely AT\n given transient response to Adenosine. HR occasionally decreases to\n 70s-80s w/ stable BPs at times that might be associated with\n administration of her BB and valium. Cards recommended titating up her\n beta blocker as tolerated. Dose increased to 37.5 yesterday but still\n tachycardic.\n - EP consulted for conversion of SVT, appreciate recs\n - Increase metoprolol to 50 PO QID with holding parameters\n .\n # Sedation: Inconsistent response to sedation, unclear what is best\n regime. Will continue to wean overall.\n - Continue w Olanzapine QHS\n - Just valium 2.5 mg PRN.\n # Nutrition/Vomiting: Pt has had several episodes of vomiting up her\n TFs, reglan started to increase GI motility, but pt had another episode\n of vomiting this am, not improved with zofran or reglan. Pateint also\n had hypoactive BS on exam, concern for obstruction given persistent\n vomiting, inability to tolerate tube feeds.\n - Hold TFs\n - Thoracic surgery recs: 1) oral/nasal tube in post-piloric position,\n or 2) IR to place a pediatric feeding tube through her PEG site to a\n post-piloric position.\n - Will attempt to coordinate thoracic surgery and IR for tube placement\n ; will d/w thoracics. IR will not do further intervention due to disk\n on G tube\n - CT scan to evaluate for obstruction, etiology of persistent emesis,\n consider tube study as well\n .\n # Adrenal Insufficency: Endocrine following. Pt does not appear to be\n adrenally insufficient at baseline. Suggesting if the patient under\n goes major stressors such as major surgery, sepsis, she may need stress\n dosed steroids.\n .\n # Fluid Status: Likely approaching euvolemia, though still has mild\n hypernatramia which may suggest is still intravascularly depleated.\n - Monitoring urine output\n - FW flushes w/ tube feeds held due to vomitting\n - will provide D5W IVF as need for hypernatremia and follow lytes\n .\n # UE DVT and elevated INR: DVT in right UE has resolved, new\n non-occlusive in left axillary vein. INR supratherapeutic today and\n trending upward. INR most likely continuing to rise nutritional\n deficiencies given lack of PO intake\n - Cumadin held, will restart at low dose when INR approaches\n therapeutic range.\n - INR 5.5 today, will check PM coags and follow\n .\n # Spine fracture: Stable\n - Brace for OOB, will discuss with Neurosurgery if current brace is\n optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n .\n # Tracheomalacia. Was initially addressed with IP and they wanted to\n follow up as outpatient. IP reevaluated and does not believe that a\n stent would be feasible.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # PIV x 1\n # Ppx: supratherapeutic INR, Ranitidine, Bowel Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n - Will contact Social and Case management today\n # Code: Full\n # Dispo: ICU, Screening for vent facilities\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-21 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 638760,
"text": "Chief Complaint: resp failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n rising INR to 10.5\n small volume hemetemesis\n abd CT\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:30 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.9\nC (98.4\n HR: 114 (88 - 136) bpm\n BP: 120/65(80) {80/40(49) - 149/88(92)} mmHg\n RR: 11 (11 - 33) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,241 mL\n 1,802 mL\n PO:\n TF:\n IVF:\n 1,941 mL\n 1,802 mL\n Blood products:\n Total out:\n 1,860 mL\n 260 mL\n Urine:\n 1,830 mL\n 210 mL\n NG:\n 30 mL\n 50 mL\n Stool:\n Drains:\n Balance:\n 381 mL\n 1,542 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 438 (300 - 1,054) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 13\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 16 cmH2O\n Plateau: 15 cmH2O\n SpO2: 100%\n ABG: ///35/\n Ve: 5.4 L/min\n Physical Examination\n Gen\n HEENt\n CV\n Chest\n Abd\n Ext\n Labs / Radiology\n 9.2 g/dL\n 528 K/uL\n 121 mg/dL\n 1.0 mg/dL\n 35 mEq/L\n 3.4 mEq/L\n 6 mg/dL\n 103 mEq/L\n 144 mEq/L\n 28.9 %\n 9.5 K/uL\n [image002.jpg]\n 07:34 AM\n 03:50 AM\n 06:22 AM\n 02:58 AM\n 03:43 AM\n 05:02 PM\n 03:36 AM\n 02:30 AM\n 01:30 AM\n 06:41 AM\n WBC\n 5.6\n 6.1\n 7.0\n 7.1\n 7.1\n 6.9\n 7.6\n 9.5\n Hct\n 27.0\n 27.0\n 29.7\n 28.9\n 29.2\n 27.8\n 32.7\n 28.6\n 28.9\n Plt\n 335\n 321\n 395\n 462\n 452\n 467\n 548\n 528\n Cr\n 0.5\n 0.7\n 0.7\n 0.6\n 0.7\n 0.8\n 0.7\n 0.8\n 1.0\n Glucose\n 121\n 619\n 126\n 137\n 104\n 108\n 131\n 128\n 121\n Other labs: PT / PTT / INR:82.1/35.9/10.5, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:9.7 mg/dL, Mg++:2.4 mg/dL, PO4:2.9\n mg/dL\n Assessment and Plan\n 1. Tachycardia: runs of attach Appreciate EP consult\n will increase\n bblocker. Have to convert to metoprolol 5mg IV Q4.\n 2. Persistent Nausea/Vomiting: we have ruled out\n pSBO/SBO, very poor\n bowel sounds, get emptying study and if unrevealing consult GI to\n discuss EGD. We will need to pursue NG dophoff by IR\n 2. Resp Failure\n Trach mask trials all day, PSV\n PMV trials\n S/P rx for pan Klebs PNA.\n Per IP not stent planned as technically not possible to\n place into her airway\n 3. DVT and coagulopathy: revsre with IV VIt K today, then maintain\n daily SC Vit K until Inr less than 2\n 4. Hypernatremia Replete free water.\n Please see today\ns ICU team note for other issues.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 04:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n Communication: with pt and spoke at length with brother who would like\n to possibily become her guardian or power of atty to facilitate her\n care and finances\n Code status: Full code\n Disposition : ICU\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-21 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 638800,
"text": "Chief Complaint:\n 24 Hour Events:\n Multiple vomitting episodes, not improved much w/ zofran.\n Unable to tolerate anything through her PEG\n Had an Abdominal CT w/contrast, but vomitted up most of the constrast.\n limited study. Prelim read: no obstruction, PEG in place\n Nurse positive coffe-grounds emesis and w/ a later\n episode, clear emesis with some small blood when she suctioned the\n posterior pharynx. HCT stable\n TFs were held\n Dr. had a conversation with the pt\ns brother.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.7\nC (98\n HR: 110 (76 - 136) bpm\n BP: 98/63(60) {80/40(49) - 149/88(92)} mmHg\n RR: 12 (12 - 33) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,241 mL\n 1,335 mL\n PO:\n TF:\n IVF:\n 1,941 mL\n 1,335 mL\n Blood products:\n Total out:\n 1,860 mL\n 140 mL\n Urine:\n 1,830 mL\n 90 mL\n NG:\n 30 mL\n 50 mL\n Stool:\n Drains:\n Balance:\n 381 mL\n 1,195 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: MMV/PSV/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 809 (300 - 1,054) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 21 cmH2O\n Plateau: 15 cmH2O\n SpO2: 100%\n ABG: ///35/\n Ve: 5.8 L/min\n Physical Examination\n Gen: Mildly obtunded in am, responsive to noxious stimuli, on MMV\n through trach tube, but later in am responsive to voice, appropriate,\n asking questions,\n HEENT: PERRL, MMM\n Resp: Coarse BS anteriorly, no focal rales, rhonchi, or wheezing with\n some referred upper airway noises from secretions.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, hypoactive BS\n Exte: No edema, DP 2+ bil.\n NEURO: Toes downgoing bilaterally,\n Labs / Radiology\n 528 K/uL\n 9.2 g/dL\n 121 mg/dL\n 1.0 mg/dL\n 35 mEq/L\n 3.4 mEq/L\n 6 mg/dL\n 103 mEq/L\n 146 mEq/L\n 28.6 %\n 9.5 K/uL\n [image002.jpg]\n CT: No evidence of obstruction or acute intraabdominal process\n 02:06 AM\n 07:34 AM\n 03:50 AM\n 06:22 AM\n 02:58 AM\n 03:43 AM\n 05:02 PM\n 03:36 AM\n 02:30 AM\n 01:30 AM\n WBC\n 7.5\n 5.6\n 6.1\n 7.0\n 7.1\n 7.1\n 6.9\n 7.6\n 9.5\n Hct\n 26.8\n 27.0\n 27.0\n 29.7\n 28.9\n 29.2\n 27.8\n 32.7\n 28.6\n Plt\n 95\n 462\n 452\n 467\n 548\n 528\n Cr\n 0.6\n 0.5\n 0.7\n 0.7\n 0.6\n 0.7\n 0.8\n 0.7\n 0.8\n 1.0\n Glucose\n 134\n 121\n 619\n 126\n 137\n 104\n 108\n 131\n 128\n 121\n Other labs: PT / PTT / INR:82.1/35.9/10.5, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:9.7 mg/dL, Mg++:2.4 mg/dL, PO4:2.9\n mg/dL\n Assessment and Plan\n 55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach, PEG placement now with respiratory failure secondary to\n tracheomalacia , resolved HAP.\n .\n # Respiratory failure: Slowly Improving. Intermittently on trach mask\n for most of the day, with periods of pressure support of over\n night. This am on MMV. Previously likely oversedated but Benadryl,\n Morhpine, and Valium held now. Pt awake and alert at rounds,\n interactive, and breathing comfortably on trach mask\n - Continue to increase time on trach mask as tolerated.\n - Decrease sedation and valium use\n - PMV with suctioning\n .\n # HAP vs Aspiration PNA: Afebrile without leukocytosis\n - Completed course of ceftriaxone\n - good O2 saturation on trach mask\n .\n # Tachycardia: Previously was assessed as sinus tach with occasional\n runs of SVT and sources such as hypovolemia, PE, infection, and pain\n were assessed as possibly etiologies. Per Cardiology, most likely AT\n given transient response to Adenosine. HR occasionally decreases to\n 70s-80s w/ stable BPs at times that might be associated with\n administration of her BB and valium. Cards recommended titrating up her\n beta blocker as tolerated. Dose increased to 50 yesterday and\n intermittently responded but then had to hold PO meds given need to\n hold PO. Changed PO to IV lopressor.\n - EP consulted for SVT, appreciate recs, will change metoprololt o IV\n and hopefully will be able to restart PO meds soon once able to\n tolerate\n - IV metoprolol 5 mg IV q 4\n .\n # Sedation: Inconsistent response to sedation, unclear what is best\n regime. Will continue to wean overall.\n - Continue w Olanzapine QHS\n - Just valium 2.5 mg PRN.\n # Nutrition/Vomiting: Pt has had several episodes of vomiting up her\n TFs, reglan started to increase GI motility, but pt had another episode\n of vomiting this am, not improved with zofran or reglan. Patient also\n had hypoactive BS on exam, concern for obstruction given persistent\n vomiting, inability to tolerate tube feeds.\n - Hold TFs\n - Thoracic surgery recs: 1) oral/nasal tube in post-piloric position,\n or 2) IR to place a pediatric feeding tube through her PEG site to a\n post-piloric position.\n - Will attempt to coordinate thoracic surgery and IR for tube placement\n ; will d/w thoracics\n - CT scan did not reveal evidence of obstruction. Attempted to\n coordinate tube study or UGI btu per Radiology would not be useful\n studies since no obstruction or dysmotility evident on CT\n - Reglan DCd since not helping\n - Will decrease narcotics for possible cause of decreased motility\n .\n # Adrenal Insufficency: Endocrine following. Pt does not appear to be\n adrenally insufficient at baseline. Suggesting if the patient under\n goes major stressors such as major surgery, sepsis, she may need stress\n dosed steroids.\n .\n # Fluid Status: Likely approaching euvolemia, though still has mild\n hypernatramia which may suggest is still intravascularly depleated.\n - Monitoring urine output\n - will provide D5W IVF as need for hypernatremia and follow lytes\n .\n # UE DVT and elevated INR: DVT in right UE has resolved, new\n non-occlusive in left axillary vein. INR supratherapeutic today and\n trending upward. INR most likely continuing to rise nutritional\n deficiencies given continued lack of PO intake\n - Cumadin stopped.\n - INR 10.5 today, up from 5.5, will give Vitamin K IV and reassess will\n check PM coags and follow\n - vitamin K IV x 1. Will likely need to continue with SC, follow coags\n .\n #Hematemesis: Pt had small amt Hematemesis this am. Concerning in\n setting of elevated INR. Will give IV Vitamin K and may need continued\n dosing\n - Vit K IV x 1\n -\n # Spine fracture: Stable\n - Brace for OOB, will discuss with Neurosurgery if current brace is\n optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n .\n # Tracheomalacia. Was initially addressed with IP and they wanted to\n follow up as outpatient. IP reevaluated and does not believe that a\n stent would be feasible.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # PIV x 1\n # Ppx: supratherapeutic INR, Ranitidine, Bowel Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n - Will contact Social and Case management today\n # Code: Full\n # Dispo: ICU, Screening for vent facilities\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 04:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 638870,
"text": "Nausea / vomiting\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Hypernatremia (high sodium)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 639078,
"text": "56 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\n with prolonged hospital course c/b by PNA, anxiety/altered mental\n status, R&LUE DVT .Pt found to have small non occlusive Clot on her\n right axial vein via Ultrasound.Yesterday. She has had problems with\n vomiting tube feedings, feeding tube passed through g-tube (g-tube in\n place with mushroom on inside so cannot pull out) to her jejunenum but\n continues vomit.\n Tachycardia, Other\n Assessment:\n HR better but still 110-130. Receiving 7.5mg lopressor IV Q4h\n Action:\n Heart rate better on lopressor. Lopressor increased to 10mg IV Q4h.\n Response:\n HR still up but is due to her agitation .\n Plan:\n Continue to monitor B/P and HR, do not hold lopressor but decrease the\n dose (ask HO)\n Assessment:\n Pt had tube studies today, contrast injected into feeding tube, it\n went into her jejuneum and went no furtere. Pt has had 2 xrayes to\n see if it has advanced at all.\n Action:\n Pt has been restarted on raglan, narcotics and other meds that slow GI\n motility have been D/C\n Response:\n Pt has not had a stool .\n Plan:\n Continue to monitor for movement of of monelity\n Altered mental status (not Delirium)\n Assessment:\n Pt was OOB to the chair most of the day and has been on the trach mask\n since 9am. She had the passey-muir valve place. She was pleasantly\n confused and stated that she is not in any pain. She stated that she\n was in Boson and in , and was not making any sense most of the\n time. She has no short term memory so needs constant reinforcement to\n stay safe. At 1550 she was found to have pulled out her trach tube and\n pulled apart her trach .\n Action:\n A new trach tube was placed, she is restrained so that she cannot pull\n anything.\n Response:\n She is able to move and all tubes, wires and catheters are out of her\n reach, under sheets and out of sight. She remains restraint so she\n cannot harm herself.\n Plan:\n Hypernatremia (high sodium)\n Assessment:\n Na down to 146, K+ 4.3.\n Action:\n IV D5w with 20meq Kcl at 100cc/hr stopped and D5W started at 75cc/hr\n Response:\n Na down, K+ better\n Plan:\n Continue to monitor.\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 639079,
"text": "56 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\n with prolonged hospital course c/b by PNA, anxiety/altered mental\n status, R&LUE DVT .Pt found to have small non occlusive Clot on her\n right axial vein via Ultrasound.Yesterday. She has had problems with\n vomiting tube feedings, feeding tube passed through g-tube (g-tube in\n place with mushroom on inside so cannot pull out) to her jejunenum but\n continues vomit.\n Tachycardia, Other\n Assessment:\n HR better but still 110-130. Receiving 7.5mg lopressor IV Q4h\n Action:\n Heart rate better on lopressor. Lopressor increased to 10mg IV Q4h.\n Response:\n HR still up but is due to her agitation .\n Plan:\n Continue to monitor B/P and HR, do not hold lopressor but decrease the\n dose (ask HO)\n Assessment:\n Pt had tube studies today, contrast injected into feeding tube, it\n went into her jejuneum and went no furtere. Pt has had 2 xrayes to\n see if it has advanced at all.\n Action:\n Pt has been restarted on raglan, narcotics and other meds that slow GI\n motility have been D/C\n Response:\n Pt has not had a stool .\n Plan:\n Continue to monitor for movement of of monelity\n Altered mental status (not Delirium)\n Assessment:\n Pt was OOB to the chair most of the day and has been on the trach mask\n since 9am. She had the passey-muir valve place. She was pleasantly\n confused and stated that she is not in any pain. She stated that she\n was in Boson and in , and was not making any sense most of the\n time. She has no short term memory so needs constant reinforcement to\n stay safe. At 1550 she was found to have pulled out her trach tube and\n pulled apart her trach .\n Action:\n A new trach tube was placed, she is restrained so that she cannot pull\n anything.\n Response:\n She is able to move and all tubes, wires and catheters are out of her\n reach, under sheets and out of sight. She remains restraint so she\n cannot harm herself.\n Plan:\n Hypernatremia (high sodium)\n Assessment:\n Na down to 146, K+ 4.3.\n Action:\n IV D5w with 20meq Kcl at 100cc/hr stopped and D5W started at 75cc/hr\n Response:\n Na down, K+ better\n Plan:\n Continue to monitor.\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-23 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 639168,
"text": "Chief Complaint: resp failure\n HPI:\n 24 Hour Events:\n UNPLANNED EXTUBATION (PATIENT-INITIATED) - At 03:50 PM\n Pt pulled out her trach tube, tube replaced\n FEVER - 101.4\nF - 12:00 AM\n 7 AM pulled out trach again , bradycardia, replaced.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Amiodarone - 0.5 mg/min\n Other ICU medications:\n Metoprolol - 01:00 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fever\n Flowsheet Data as of 10:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.4\n Tcurrent: 36.8\nC (98.2\n HR: 116 (84 - 142) bpm\n BP: 147/84(96) {86/39(53) - 181/113(137)} mmHg\n RR: 23 (13 - 27) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,127 mL\n 988 mL\n PO:\n TF:\n IVF:\n 2,127 mL\n 988 mL\n Blood products:\n Total out:\n 995 mL\n 900 mL\n Urine:\n 995 mL\n 900 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,132 mL\n 88 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: CPAP/PPS\n Vt (Set): 0 (0 - 0) mL\n Vt (Spontaneous): 360 (208 - 360) mL\n PS : 10 cmH2O\n RR (Set): 0\n RR (Spontaneous): 21\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 0 cmH2O\n SpO2: 99%\n ABG: ///31/\n Physical Examination\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, g tube\n Skin: warm\n Neurologic: Responds to voice\n Labs / Radiology\n 8.4 g/dL\n 346 K/uL\n 123 mg/dL\n 0.7 mg/dL\n 31 mEq/L\n 3.8 mEq/L\n 4 mg/dL\n 107 mEq/L\n 144 mEq/L\n 27.3 %\n 7.3 K/uL\n [image002.jpg]\n 02:58 AM\n 03:43 AM\n 05:02 PM\n 03:36 AM\n 02:30 AM\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n 03:00 AM\n WBC\n 7.1\n 7.1\n 6.9\n 7.6\n 9.5\n 5.7\n 7.3\n Hct\n 28.9\n 29.2\n 27.8\n 32.7\n 28.6\n 28.9\n 30.0\n 26.9\n 27.3\n Plt\n 462\n 452\n 467\n 548\n 528\n 356\n 346\n Cr\n 0.6\n 0.7\n 0.8\n 0.7\n 0.8\n 1.0\n 0.7\n 0.7\n Glucose\n 137\n 104\n 108\n 131\n 128\n 121\n 129\n 123\n Other labs: PT / PTT / INR:14.1/23.7/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.8 mg/dL, Mg++:1.9 mg/dL, PO4:3.7\n mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 06:31 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 40 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-23 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 639170,
"text": "Chief Complaint: resp failure\n HPI:\n 24 Hour Events:\n UNPLANNED EXTUBATION (PATIENT-INITIATED) - At 03:50 PM\n Pt pulled out her trach tube, tube replaced\n FEVER - 101.4\nF - 12:00 AM\n 7 AM pulled out trach again , bradycardia, replaced.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Amiodarone - 0.5 mg/min\n Other ICU medications:\n Metoprolol - 01:00 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fever\n Flowsheet Data as of 10:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.4\n Tcurrent: 36.8\nC (98.2\n HR: 116 (84 - 142) bpm\n BP: 147/84(96) {86/39(53) - 181/113(137)} mmHg\n RR: 23 (13 - 27) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,127 mL\n 988 mL\n PO:\n TF:\n IVF:\n 2,127 mL\n 988 mL\n Blood products:\n Total out:\n 995 mL\n 900 mL\n Urine:\n 995 mL\n 900 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,132 mL\n 88 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: CPAP/PPS\n Vt (Set): 0 (0 - 0) mL\n Vt (Spontaneous): 360 (208 - 360) mL\n PS : 10 cmH2O\n RR (Set): 0\n RR (Spontaneous): 21\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 0 cmH2O\n SpO2: 99%\n ABG: ///31/\n Physical Examination\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, g tube\n Skin: warm\n Neurologic: Responds to voice\n Labs / Radiology\n 8.4 g/dL\n 346 K/uL\n 123 mg/dL\n 0.7 mg/dL\n 31 mEq/L\n 3.8 mEq/L\n 4 mg/dL\n 107 mEq/L\n 144 mEq/L\n 27.3 %\n 7.3 K/uL\n [image002.jpg]\n 02:58 AM\n 03:43 AM\n 05:02 PM\n 03:36 AM\n 02:30 AM\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n 03:00 AM\n WBC\n 7.1\n 7.1\n 6.9\n 7.6\n 9.5\n 5.7\n 7.3\n Hct\n 28.9\n 29.2\n 27.8\n 32.7\n 28.6\n 28.9\n 30.0\n 26.9\n 27.3\n Plt\n 462\n 452\n 467\n 548\n 528\n 356\n 346\n Cr\n 0.6\n 0.7\n 0.8\n 0.7\n 0.8\n 1.0\n 0.7\n 0.7\n Glucose\n 137\n 104\n 108\n 131\n 128\n 121\n 129\n 123\n Other labs: PT / PTT / INR:14.1/23.7/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.8 mg/dL, Mg++:1.9 mg/dL, PO4:3.7\n mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 06:31 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 40 minutes\n ------ Protected Section------\n ------ Protected Section Error Entered By: , MD\n on: 10:46 ------\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 639260,
"text": "56 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\n with prolonged hospital course c/b by PNA, anxiety/altered mental\n status, R&LUE DVT .Pt found to have small non occlusive Clot on her\n right axial vein via Ultrasound.Yesterday. She has had problems with\n vomiting tube feedings, feeding tube passed through g-tube (g-tube in\n place with mushroom on inside so cannot pull out) to her jejunenum but\n continues vomit.\n At 7:30 this am pt pulled out her trach tube with staff 6feet away.\n Her HR initially was 120\ns, before an airway could be re-established\n her HR had blocked down to 38 and she had lost consciousness. She\n returned as soon as her airway was re-established.\n Tachycardia, Other\n Assessment:\n Pt amiodarone gtt decreased to .5mg/min as ordered at 8am. Following\n incident described above her HR returned to 80\ns SR. She remains\n hemodynamically stable.\n Action:\n Continued the amiodarone at .5mg.min for the next 18h\n Response:\n Her HR has been 80-94, B/P 138-154/70\n Plan:\n Transition her to PO amiodarone at midnight.\n Alteration in Nutrition\n Assessment:\n Pt still has hypoactive bowel sounds. She did have a small loose\n golden stool at 8am. She remains NPO except for meds\n Action:\n Pt on raglan, dose increased to 20mg q6h.\n Response:\n Pt still has hypoactive bowel sounds.\n Plan:\n Give raglan 20mg as ordered, give dose of lactulose.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt has DVT\ns in both upper extremities.\n Action:\n PICC place in left upper arm, for TPN.\n Response:\n Pt restarted on coumadin 2mg as ordered\n Plan:\n Monitor INR, given coumadin as ordered\n Altered mental status (not Delirium)\n Assessment:\n Pt continues to be very delirious pulling at everything. She has no\n memory and will continue to pull at tubes even when standing right next\n to her.\n Action:\n Pt in restraints, with bilateral soft wrist, mitts, and sheet to\n protect her brace when up in chair.\n Response:\n Pt started on 1:1 sitters for her safety, Psych consult done and\n risperidone ordered.\n Plan:\n Given risperidone as ordered with use of zyprexia and safety\n restraints.\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 639412,
"text": "Chief Complaint:\n 24 Hour Events:\n TF held for vomiting\n Given D5W x 2 liters for hypernatremia\n Lovenox 100mg SC BID for DVTs started rather than trying to titrate\n coumadin, follow INR\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:17 AM\n Enoxaparin (Lovenox) - 06:00 PM\n Metoprolol - 06:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.3\nC (97.4\n HR: 68 (64 - 104) bpm\n BP: 116/51(66) {105/45(44) - 151/74(89)} mmHg\n RR: 24 (21 - 38) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,676 mL\n 776 mL\n PO:\n TF:\n 61 mL\n IVF:\n 1,418 mL\n 540 mL\n Blood products:\n Total out:\n 1,910 mL\n 195 mL\n Urine:\n 1,910 mL\n 195 mL\n NG:\n Stool:\n Drains:\n Balance:\n 766 mL\n 581 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 96%\n ABG: ////\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 316 K/uL\n 8.3 g/dL\n 114 mg/dL\n 0.7 mg/dL\n 33 mEq/L\n 4.0 mEq/L\n 7 mg/dL\n 110 mEq/L\n 148 mEq/L\n 27.0 %\n 8.0 K/uL\n [image002.jpg]\n 03:43 AM\n 05:02 PM\n 03:36 AM\n 02:30 AM\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n 03:00 AM\n 04:00 AM\n WBC\n 7.1\n 6.9\n 7.6\n 9.5\n 5.7\n 7.3\n 8.0\n Hct\n 29.2\n 27.8\n 32.7\n 28.6\n 28.9\n 30.0\n 26.9\n 27.3\n 27.0\n Plt\n 452\n 467\n 548\n 528\n 356\n 346\n 316\n Cr\n 0.7\n 0.8\n 0.7\n 0.8\n 1.0\n 0.7\n 0.7\n 0.7\n Glucose\n 104\n 108\n 131\n 128\n 121\n 129\n 123\n 114\n Other labs: PT / PTT / INR:13.2/22.4/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:9.0 mg/dL, Mg++:2.3 mg/dL, PO4:4.1\n mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n TPN without Lipids - 06:10 PM 43. mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n PICC Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 639599,
"text": "Chief Complaint:\n 24 Hour Events:\n Pt agitated overnight given extra Risperidone 0.5 mg x 2 overnight.\n (1.5mg total)\n 1000 mL D5W for Hypernatremia\n Changed B-Blocker from IV to PO, Metoprolol Tartrate 25 mg PO TID\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:17 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.7\nC (98\n HR: 120 (67 - 120) bpm\n BP: 110/64(76) {109/47(60) - 141/115(118)} mmHg\n RR: 26 (18 - 30) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 3,820 mL\n 856 mL\n PO:\n TF:\n 117 mL\n 20 mL\n IVF:\n 2,612 mL\n 572 mL\n Blood products:\n Total out:\n 2,460 mL\n 1,180 mL\n Urine:\n 2,460 mL\n 1,180 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,360 mL\n -324 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 100%\n ABG: ///33/\n Physical Examination\n Gen: Awake, Mouthing words, More agitated compared to previous\n mornings.\n HEENT: EOMI, No pallor in conjunctiva, MMM\n Resp: CTAB, no rales, rhonchi, or wheezing, good airway movement.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, decreased bowel sounds,, G-Tube in\n place with no erythema/induration\n Exte: No edema, DP 2+ bil\n NEURO: Gross Motor and Sensation in 4 extremities\n Labs / Radiology\n 249 K/uL\n 8.0 g/dL\n 122 mg/dL\n 0.5 mg/dL\n 33 mEq/L\n 3.7 mEq/L\n 13 mg/dL\n 108 mEq/L\n 146 mEq/L\n 24.7 %\n 5.5 K/uL\n [image002.jpg] CXR: L Picc, trach tip at midline, bibasilar\n opacities, low lung volumes, Bil pleural effusions.\n 03:36 AM\n 02:30 AM\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n 03:00 AM\n 04:00 AM\n 05:45 AM\n 03:51 AM\n WBC\n 6.9\n 7.6\n 9.5\n 5.7\n 7.3\n 8.0\n 8.7\n 5.5\n Hct\n 27.8\n 32.7\n 28.6\n 28.9\n 30.0\n 26.9\n 27.3\n 27.0\n 28.7\n 24.7\n Plt\n 467\n 548\n 528\n 356\n 346\n 316\n 271\n 249\n Cr\n 0.7\n 0.8\n 1.0\n 0.7\n 0.7\n 0.7\n 0.7\n 0.5\n Glucose\n 131\n 128\n 121\n 129\n 123\n 114\n 112\n 122\n Other labs: PT / PTT / INR:13.6/31.1/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:9.0 mg/dL, Mg++:2.2 mg/dL, PO4:3.1\n mg/dL\n Assessment and Plan\n 56yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach/PEG with resolving respiratory failure and HAP.\n .\n # Respiratory failure: s/p intubation/extubation, now on trach mask,\n FiO2 70%. Tolerating well with good O2 sat. No further\n self-decanulations overnight.\n - Tach mask as tolerated.\n - Holding sedation with exception of Risperidal 0.5mg .\n - F/u CXR tomorrow\n .\n # Nutrition/Vomiting: Currently receiving TPN;. One large BM in past\n 24 hrs to indicate potential improvement in ileus.\n - Cont Reglan 20mg IV Q 8 hours; meds via G-J tube,\n - Will obtain recommendations from Nutrition re TPN before starting TPN\n tomorrow\n - TF as tolerated\n - Speech and Swallow eval\n - PICC line in place with TPN given when pt not tolerating TF\n - GI consult, appreciate recs\n .\n # Tachycardia: Improved HR max of 120\ns versus 160s previously;\n elevated this am secondary to agitation. Pt now on PO Amiodarone 200\n TID and PO metoprolol 25mg TID\n - Continue current med regimen. Will continue amiodarone 200 TID for\n three weeks and then switch to qday.\n - Will schedule f/u in 4wks with Dr. upon d/c/transfer.\n - f/u Cards recs\n # Sedation/Anxiolysis/AlteredMS: Agitation O/N, continues to be\n agitated most likely secondary to long hospital course and multiple\n psychotropic medications as well as hx of EtOH abuse. Risperdal given\n O/N.\n - started Risperdal 0.5mg PO BID\n - continue to hold all benzos. opiates, and antihistamines\n - Appreciate psych. Will call and f/u psych recs.\n #Anemia: Decrease in HCT from 28\n24; tachycardia. No known etiology of\n blood loss, most likely related to variaton\n -Will repeat HCT check this afternoon.\n # Hypernatremia/Fluid Status: Mild hypernatramia with good UOP\n (hypervolemic hypernatremia). On TPN/TF.\n - providing D5W IVF, free water flushes with TF\n -Will f/u lytes (Na) this afternoon at 5pm.\n # UE DVT and elevated INR: Decision made to d/c Coumadin given her\n labile INR, and start Lovenox . Current INR 1.2.\n - Will flush L PICC with TPA if does not flush\n .\n # Spine fracture: Stable\n - Brace for OOB, need to discuss with Neurosurgery before d/c if\n current brace is optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n .\n # Tracheomalacia. Was initially addressed with IP and they wanted to\n follow up as outpatient. IP reevaluated and does not believe that a\n stent would be feasible. No new issues.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # ACCESS: PIV x 1, L PICC\n # Ppx: Lovenox, PPi, Bowel Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n - Social Work and Case management involved, have discussed situation\n w/ brother and boyfriend.\n # Code: Full\n # Dispo: ICU, Will d/w case management re rehab facilities.\n PGY2 Addendum\n Agree with excellent MS4 PN. Will touch base with psychiatry re:\n sedating meds and EP re: atrial tachycardia. Will obtain EKG to\n reassess QTc. Ordered for TPN. Giving d5W for hypernatremia. Re-consult\n S/S for PMV re-fitting. transfer to LTAC.\n \n PGY2\n ------ Protected Section ------\n MICU Attending Addendum:\n ------ Protected Section Addendum Entered By: , MD\n on: 16:21 ------\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 638487,
"text": "56yo woman admitted 1 month ago with unstentable tracheal malacia,\n failure to wean.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt on MMV settings, no spont resp. Pt unarousable per below until\n 0830 when she woke and was placed on TM with high flow neb@ 50%.\n Action:\n Response:\n Plan:\n Tachycardia, Other\n Assessment:\n Action:\n Response:\n Plan:\n Arousal, Attention, and Cognition, Impaired\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 638680,
"text": "Nausea / vomiting\n Assessment:\n NPO. Vomitted meds ~10\n after given via gtube. Coughing same emesis\n from tracheostomy. Later found to have vomited coffee ground emesis,\n guiac +. Denies nausea every time although continues to dry heave,\n vomit small amts clear emesis. BRB suctioned from back of throat also,\n d/t irritation from frequent vomiting. Abd soft, hypoactive BS.\n Action:\n Tube feeds on hold. No residual aspirated from gtube, gtube\n placed->>gravity. Stat Hct, coags T&S sent. Zofran x 1. HOB^^ 30. 2^nd\n PIV placed.\n Response:\n On/off vomiting, coffee grounds x 1, with no c/o nausea. Hct 28.6,\n baseline. INR 10.5 .\n Plan:\n Recheck Hct, FDP @ 7AM. Zofran. NPO. IV meds only. Needs gtube changed\n to jtube.\n Tachycardia, Other\n Assessment:\n ST 109-114, NSR 70s briefly. No lopressor given d/t BP<100 most of\n night when pt sleeping.\n Action:\n Lopressor changed from PO->>IV prn d/t vomiting after meds.\n Response:\n ST 110s most of night.\n Plan:\n IV lopressor prn for HR>130.\n Alteration in Nutrition\n Assessment:\n NPO. Na 146 x 2. D5W per orders. UOP decreased 10-20cc/hr with lower\n BP.\n Action:\n D5W now @ 150cc/hr x 1 liter.\n Response:\n Na 146.\n Plan:\n Recheck Na @ 7AM. D5W x 1 liter.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n On 50% trach mask all day. RR ^^40 after first episode of vomiting last\n night. Copious thick tan, dark brown secretions.\n Action:\n Placed on Vent MMV mode when tachypneic. Frequent suctioning.\n Response:\n Comfortable on vent, RR 12 (set), Sats 100%.\n Plan:\n Wean from vent as tolerated. Suction as needed, MDIs.\n Altered mental status (not Delirium)\n Assessment:\n Occaisionally restless, less so than night before. Slept most of night,\n sometimes difficult to arouse. No zyprexa given. Opens eyes to voice,\n follows commands. Mouthing words although difficult to understand.\n Action:\n Reorient pt prn. Emotional support.\n Response:\n Slept most of night, calmer than previous nights.\n Plan:\n No valium or benadryl per psych recommendations. Zyprexa HS prn for\n agitation. Reorient prn. Emotional support.\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 638681,
"text": "Nausea / vomiting\n Assessment:\n NPO. Vomitted meds ~10\n after given via gtube. Coughing same emesis\n from tracheostomy. Later found to have vomited coffee ground emesis,\n guiac +. Denies nausea every time although continues to dry heave,\n vomit small amts clear emesis. BRB suctioned from back of throat also,\n d/t irritation from frequent vomiting. Abd soft, hypoactive BS.\n Action:\n Tube feeds on hold. No residual aspirated from gtube, gtube\n placed->>gravity. Stat Hct, coags T&S sent. Zofran x 1. HOB^^ 30. 2^nd\n PIV placed.\n Response:\n On/off vomiting, coffee grounds x 1, with no c/o nausea. Hct 28.6,\n baseline. INR 10.5 .\n Plan:\n Recheck Hct, FDP @ 7AM. Zofran. NPO. IV meds only. Needs gtube changed\n to jtube.\n Tachycardia, Other\n Assessment:\n ST 109-114, NSR 70s briefly. No lopressor given d/t BP<100 most of\n night when pt sleeping.\n Action:\n Lopressor changed from PO->>IV prn d/t vomiting after meds.\n Response:\n ST 110s most of night.\n Plan:\n IV lopressor prn for HR>130.\n Alteration in Nutrition\n Assessment:\n NPO. Na 146 x 2. D5W per orders. UOP decreased 10-20cc/hr with lower\n BP.\n Action:\n D5W now @ 150cc/hr x 1 liter.\n Response:\n Na 146.\n Plan:\n Recheck Na @ 7AM. D5W x 1 liter.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n On 50% trach mask all day. RR ^^40 after first episode of vomiting last\n night. Copious thick tan, dark brown secretions.\n Action:\n Placed on Vent MMV mode when tachypneic. Frequent suctioning.\n Response:\n Comfortable on vent, RR 12 (set), Sats 100%.\n Plan:\n Wean from vent as tolerated. Suction as needed, MDIs.\n Altered mental status (not Delirium)\n Assessment:\n Occaisionally restless, less so than night before. Slept most of night,\n sometimes difficult to arouse. No zyprexa given. Opens eyes to voice,\n follows commands. Mouthing words although difficult to understand.\n Action:\n Reorient pt prn. Emotional support.\n Response:\n Slept most of night, calmer than previous nights.\n Plan:\n No valium or benadryl per psych recommendations. Zyprexa HS prn for\n agitation. Reorient prn. Emotional support.\n"
},
{
"category": "Nutrition",
"chartdate": "2167-10-23 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 639158,
"text": "Objective\n Pertinent medications: thiamine, folic acid, hep, protonix, colace,\n senna, reglan, D5w at 75ml/hr, others noted\n Labs:\n Value\n Date\n Glucose\n 123 mg/dL\n 03:00 AM\n Glucose Finger Stick\n 121\n 04:00 AM\n BUN\n 4 mg/dL\n 03:00 AM\n Creatinine\n 0.7 mg/dL\n 03:00 AM\n Sodium\n 144 mEq/L\n 03:00 AM\n Potassium\n 3.8 mEq/L\n 03:00 AM\n Chloride\n 107 mEq/L\n 03:00 AM\n TCO2\n 31 mEq/L\n 03:00 AM\n PO2 (arterial)\n 120 mm Hg\n 03:36 AM\n PO2 (venous)\n 62 mm Hg\n 02:35 AM\n PCO2 (arterial)\n 44 mm Hg\n 03:36 AM\n PCO2 (venous)\n 58 mm Hg\n 02:35 AM\n pH (arterial)\n 7.37 units\n 03:36 AM\n pH (venous)\n 7.37 units\n 02:35 AM\n pH (urine)\n 5.0 units\n 03:05 AM\n CO2 (Calc) arterial\n 26 mEq/L\n 03:36 AM\n CO2 (Calc) venous\n 35 mEq/L\n 02:35 AM\n Albumin\n 3.1 g/dL\n 03:23 AM\n Calcium non-ionized\n 8.8 mg/dL\n 03:00 AM\n Phosphorus\n 3.7 mg/dL\n 03:00 AM\n Ionized Calcium\n 1.24 mmol/L\n 02:51 AM\n Magnesium\n 1.9 mg/dL\n 03:00 AM\n ALT\n 25 IU/L\n 07:34 AM\n Alkaline Phosphate\n 106 IU/L\n 07:34 AM\n AST\n 19 IU/L\n 07:34 AM\n Amylase\n 10 IU/L\n 03:59 AM\n Total Bilirubin\n 0.2 mg/dL\n 07:34 AM\n WBC\n 7.3 K/uL\n 03:00 AM\n Hgb\n 8.4 g/dL\n 03:00 AM\n Hematocrit\n 27.3 %\n 03:00 AM\n Current diet order / nutrition support: NPO\n GI:\n Assessment of Nutritional Status\n Estimation of previous intake: Inadequate\n Estimation of current intake: Inadequate\n Specifics:\n 55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach, PEG placement now with respiratory failure secondary to\n tracheomalacia. Pt has not been tol TF since last wk, pt s/p\n pediatric feeding tube placed by GI through her PEG tube into her\n jejunum, and was given TFs last night, which pt vomited. Pt also s/p\n tube study this am that showed dysmotility of her jejunum, etiology of\n ileus unclear and ? pt' s chronic baseline or d/t long course of\n opiates during MICU stay. PICC line ordered to place and will need to\n start TPN today.\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: in NS, d/c outside folic acid and\n thiamine\n TPN recommendations: start day 1 (150dex/70aa), 70NaCl, 10KCl, 30KPhos,\n 10Mg, 10Ca, thiamine and folic acid in tpn\n Check chemistry 10 panel daily, replete prn\n Check triglycerides\n Start regular insulin sliding scale if serum glucose >150 mg/dL\n Change to non-dextrose IV fluids once TPN starts\n Provided BG < 150 and Trig < 400, can cont to adv TPN to goal of 60kg\n 3-in-1 to provide 1500kcal/day in the next few days\n Retrial TF with Vivonex ( low fat, elemental formula) at 10ml/hr if\n medically allowed\n Please page if has ?\n"
},
{
"category": "Nutrition",
"chartdate": "2167-10-23 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 639159,
"text": "Objective\n Pertinent medications: thiamine, folic acid, hep, protonix, colace,\n senna, reglan, D5w at 75ml/hr, others noted\n Labs:\n Value\n Date\n Glucose\n 123 mg/dL\n 03:00 AM\n Glucose Finger Stick\n 121\n 04:00 AM\n BUN\n 4 mg/dL\n 03:00 AM\n Creatinine\n 0.7 mg/dL\n 03:00 AM\n Sodium\n 144 mEq/L\n 03:00 AM\n Potassium\n 3.8 mEq/L\n 03:00 AM\n Chloride\n 107 mEq/L\n 03:00 AM\n TCO2\n 31 mEq/L\n 03:00 AM\n PO2 (arterial)\n 120 mm Hg\n 03:36 AM\n PO2 (venous)\n 62 mm Hg\n 02:35 AM\n PCO2 (arterial)\n 44 mm Hg\n 03:36 AM\n PCO2 (venous)\n 58 mm Hg\n 02:35 AM\n pH (arterial)\n 7.37 units\n 03:36 AM\n pH (venous)\n 7.37 units\n 02:35 AM\n pH (urine)\n 5.0 units\n 03:05 AM\n CO2 (Calc) arterial\n 26 mEq/L\n 03:36 AM\n CO2 (Calc) venous\n 35 mEq/L\n 02:35 AM\n Albumin\n 3.1 g/dL\n 03:23 AM\n Calcium non-ionized\n 8.8 mg/dL\n 03:00 AM\n Phosphorus\n 3.7 mg/dL\n 03:00 AM\n Ionized Calcium\n 1.24 mmol/L\n 02:51 AM\n Magnesium\n 1.9 mg/dL\n 03:00 AM\n ALT\n 25 IU/L\n 07:34 AM\n Alkaline Phosphate\n 106 IU/L\n 07:34 AM\n AST\n 19 IU/L\n 07:34 AM\n Amylase\n 10 IU/L\n 03:59 AM\n Total Bilirubin\n 0.2 mg/dL\n 07:34 AM\n WBC\n 7.3 K/uL\n 03:00 AM\n Hgb\n 8.4 g/dL\n 03:00 AM\n Hematocrit\n 27.3 %\n 03:00 AM\n Current diet order / nutrition support: NPO\n Assessment of Nutritional Status\n Estimation of previous intake: Inadequate\n Estimation of current intake: Inadequate\n Specifics:\n 55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach, PEG placement now with respiratory failure secondary to\n tracheomalacia. Pt has not been tol TF since last wk, pt s/p\n pediatric feeding tube placed by GI through her PEG tube into her\n jejunum, and was given TFs last night, which pt vomited. Pt also s/p\n tube study this am that showed dysmotility of her jejunum, etiology of\n ileus unclear and ? pt' s chronic baseline or d/t long course of\n opiates during MICU stay. PICC line ordered to place and will need to\n start TPN today. Noted pt with elevated Na, currently on D5w, need to\n monitor BG closely.\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: in NS, d/c outside folic acid and\n thiamine\n TPN recommendations: start day 1 (150dex/70aa), 50NaCl, 10KCl, 30KPhos,\n 10Mg, 10Ca, thiamine and folic acid in tpn\n Check chemistry 10 panel daily, replete prn\n Check triglycerides\n Cont bg management\n Change to non-dextrose IV fluids once TPN starts if Na comes down,\n Provided BG < 150 and Trig < 400, can cont to adv TPN to goal of 60kg\n 3-in-1 to provide 1500kcal/day in the next few days\n Retrial TF with Vivonex ( low fat, elemental formula) at 10ml/hr if\n medically allowed\n Please page if has ?\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 639414,
"text": "Chief Complaint:\n 24 Hour Events:\n TF held for vomiting\n Given D5W x 2 liters for hypernatremia\n Lovenox 100mg SC BID for DVTs started rather than trying to titrate\n coumadin, follow INR\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:17 AM\n Enoxaparin (Lovenox) - 06:00 PM\n Metoprolol - 06:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.3\nC (97.4\n HR: 68 (64 - 104) bpm\n BP: 116/51(66) {105/45(44) - 151/74(89)} mmHg\n RR: 24 (21 - 38) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,676 mL\n 776 mL\n PO:\n TF:\n 61 mL\n IVF:\n 1,418 mL\n 540 mL\n Blood products:\n Total out:\n 1,910 mL\n 195 mL\n Urine:\n 1,910 mL\n 195 mL\n NG:\n Stool:\n Drains:\n Balance:\n 766 mL\n 581 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 96%\n ABG: ////\n Physical Examination\n Gen: Asleep, unarousable, responds minimally to noxious stimuli\n HEENT: PERRL, MMM\n Resp: CTA bilaterally, no rales, rhonchi, or wheezing, small\n inspirations.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, BS+\n Exte: No edema, DP 2+ bil\n NEURO: reflexes 2+ bilaterally.\n Labs / Radiology\n 316 K/uL\n 8.3 g/dL\n 114 mg/dL\n 0.7 mg/dL\n 33 mEq/L\n 4.0 mEq/L\n 7 mg/dL\n 110 mEq/L\n 148 mEq/L\n 27.0 %\n 8.0 K/uL\n [image002.jpg]\n 03:43 AM\n 05:02 PM\n 03:36 AM\n 02:30 AM\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n 03:00 AM\n 04:00 AM\n WBC\n 7.1\n 6.9\n 7.6\n 9.5\n 5.7\n 7.3\n 8.0\n Hct\n 29.2\n 27.8\n 32.7\n 28.6\n 28.9\n 30.0\n 26.9\n 27.3\n 27.0\n Plt\n 452\n 467\n 548\n 528\n 356\n 346\n 316\n Cr\n 0.7\n 0.8\n 0.7\n 0.8\n 1.0\n 0.7\n 0.7\n 0.7\n Glucose\n 104\n 108\n 131\n 128\n 121\n 129\n 123\n 114\n Other labs: PT / PTT / INR:13.2/22.4/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:9.0 mg/dL, Mg++:2.3 mg/dL, PO4:4.1\n mg/dL\n Assessment and Plan\n 55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach, PEG placement now with respiratory failure secondary to\n tracheomalacia , resolved HAP.\n .\n # Respiratory failure: Slowly improving, spending most of the day on\n trach mask with short periods of rest on PSV at night and setbacks\n from increased secretions to vomiting/aspiration events and her\n self-decanulations.\n - Continue to increase time on trach mask as tolerated.\n - Discontinue all orders for sedation except for Risperdal QHS.\n - PMV with suctioning as tolerated\n # Nutrition/Vomiting: Normal CT-abdomen, had FT placed via peg into\n jejunum, but continued to vomit. Tube study showed dysmotility in small\n bowel, but no obstruction, no retrograde flow. GI recs Reglan 20mg IV Q\n 8 hours and restart meds via G-J tube, if tolerated slowly restart TFs.\n PICC line placed yesterday and TPN started.\n - GI consult, appreciate recs\n - Small volume TFs start today\n - Continue TPN today\n # HAP vs Aspiration PNA: Had been afebrile for last several days, now\n with new fever two nights ago after having decanulated herself. Likely\n had some aspiration. Chemical pneumonitis versus new aspiration PNA.\n Now Afebrile for past 24 hours.\n - f/u daily CXR\n - F/u cx data\n - If remains febrile, send sputum cx, otherwise hold on abx.\n .\n # Tachycardia: Pt in and out of SVT and sinus, increased BB seems to\n help, but pt does not stay in sinus. Cards rec to start Amiodarone IV\n drip, and then convert to PO, 200mg TID. Would consider EPS if\n amiodarone not successful, though would wait until pt more stable for\n general anesthesia.\n - Changed to IV metoprolol to 10mg IV q4hr.\n - Completed amiodarone 0.5mg/min IV drip x 18 hours, and converted to\n 200mg PO TID..\n - Cards c/s, appreciate recs\n # Sedation/Anxiolysis/AlteredMS: unclear etiology of her confusion and\n agitation. Has had long hospital course and multiple psychotropic\n medications as well as hx of EtOH abuse.\n - d/c all benzos. opiates, and antihistamines\n - Psychiatry consulted, appreciate recs\n - started Risperdal 0.5mg PO BID, d/c zyprexa.\n # Adrenal Insufficency: Endocrine following. Pt does not appear to be\n adrenally insufficient at baseline. Suggesting if the patient under\n goes major stressors such as major surgery, sepsis, she may need stress\n dosed steroids.\n .\n # Fluid Status: Likely approaching euvolemia, though still has mild\n hypernatramia which may suggest is still intravascularly depleated.\n - Monitoring urine output\n - will provide D5W IVF as need for hypernatremia and follow lytes\n # UE DVT and elevated INR: DVT in right UE has resolved, new\n non-occlusive in left axillary vein. INR has been volatile, likely from\n drug interactions and poor nutritional status. Have been unable to keep\n her appropariately therapeutic.\n - d/c coumadin\n - start Lovenox, maintain until GI issues resolved and can restart\n coumadin\n .\n #Hematemesis: Pt had small amt Hematemesis, after vomiting, last week.\n None today. HCT stable.\n -Will follow HCT.\n - Guaiac stools\n # Spine fracture: Stable\n - Brace for OOB, will discuss with Neurosurgery if current brace is\n optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n .\n # Tracheomalacia. Was initially addressed with IP and they wanted to\n follow up as outpatient. IP reevaluated and does not believe that a\n stent would be feasible.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # ACCESS: PIV x 1, PICC placement yesterday.\n # Ppx: subtherapeutic INR restarting coumadin today, Ranitidine, Bowel\n Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n - Social Work and Case management involved, have discussed situation\n w/ brother and boyfriend.\n # Code: Full\n # Dispo: ICU, Screening for vent facilities\n ICU Care\n Nutrition:\n TPN without Lipids - 06:10 PM 43. mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n PICC Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Respiratory ",
"chartdate": "2167-10-20 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 638539,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 32\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Tracheostomy tube:\n Type: Standard, Cuffed, Inner Cannula\n Manufacturer: Portex\n Size: 8.0mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea); Comments: Pt on\n trach collar for most of the night. Dipping sats and high RR, pt then\n placed on vent to \"rest\"\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Periodic SBT's for conditioning; Comments: Continue with trach trials\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-21 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 638738,
"text": "Chief Complaint:\n 24 Hour Events:\n Multiple vomitting episodes, not improved much w/ zofran.\n Unable to tolerate anything through her PEG\n Had an Abdominal CT w/contrast, but vomitted up most of the constrast.\n limited study. Prelim read: no obstruction, PEG in place\n Nurse positive coffe-grounds emesis and w/ a later\n episode, clear emesis with some small blood when she suctioned the\n posterior pharynx.\n TFs were held\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.7\nC (98\n HR: 110 (76 - 136) bpm\n BP: 98/63(60) {80/40(49) - 149/88(92)} mmHg\n RR: 12 (12 - 33) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,241 mL\n 1,335 mL\n PO:\n TF:\n IVF:\n 1,941 mL\n 1,335 mL\n Blood products:\n Total out:\n 1,860 mL\n 140 mL\n Urine:\n 1,830 mL\n 90 mL\n NG:\n 30 mL\n 50 mL\n Stool:\n Drains:\n Balance:\n 381 mL\n 1,195 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: MMV/PSV/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 809 (300 - 1,054) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 21 cmH2O\n Plateau: 15 cmH2O\n SpO2: 100%\n ABG: ///35/\n Ve: 5.8 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 528 K/uL\n 9.2 g/dL\n 121 mg/dL\n 1.0 mg/dL\n 35 mEq/L\n 3.4 mEq/L\n 6 mg/dL\n 103 mEq/L\n 146 mEq/L\n 28.6 %\n 9.5 K/uL\n [image002.jpg]\n 02:06 AM\n 07:34 AM\n 03:50 AM\n 06:22 AM\n 02:58 AM\n 03:43 AM\n 05:02 PM\n 03:36 AM\n 02:30 AM\n 01:30 AM\n WBC\n 7.5\n 5.6\n 6.1\n 7.0\n 7.1\n 7.1\n 6.9\n 7.6\n 9.5\n Hct\n 26.8\n 27.0\n 27.0\n 29.7\n 28.9\n 29.2\n 27.8\n 32.7\n 28.6\n Plt\n 95\n 462\n 452\n 467\n 548\n 528\n Cr\n 0.6\n 0.5\n 0.7\n 0.7\n 0.6\n 0.7\n 0.8\n 0.7\n 0.8\n 1.0\n Glucose\n 134\n 121\n 619\n 126\n 137\n 104\n 108\n 131\n 128\n 121\n Other labs: PT / PTT / INR:82.1/35.9/10.5, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:9.7 mg/dL, Mg++:2.4 mg/dL, PO4:2.9\n mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 04:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-21 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 638740,
"text": "Chief Complaint:\n 24 Hour Events:\n Multiple vomitting episodes, not improved much w/ zofran.\n Unable to tolerate anything through her PEG\n Had an Abdominal CT w/contrast, but vomitted up most of the constrast.\n limited study. Prelim read: no obstruction, PEG in place\n Nurse positive coffe-grounds emesis and w/ a later\n episode, clear emesis with some small blood when she suctioned the\n posterior pharynx.\n TFs were held\n Dr. had a conversation with the pt\ns brother.\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.7\nC (98\n HR: 110 (76 - 136) bpm\n BP: 98/63(60) {80/40(49) - 149/88(92)} mmHg\n RR: 12 (12 - 33) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,241 mL\n 1,335 mL\n PO:\n TF:\n IVF:\n 1,941 mL\n 1,335 mL\n Blood products:\n Total out:\n 1,860 mL\n 140 mL\n Urine:\n 1,830 mL\n 90 mL\n NG:\n 30 mL\n 50 mL\n Stool:\n Drains:\n Balance:\n 381 mL\n 1,195 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: MMV/PSV/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 809 (300 - 1,054) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 21 cmH2O\n Plateau: 15 cmH2O\n SpO2: 100%\n ABG: ///35/\n Ve: 5.8 L/min\n Physical Examination\n Gen: Obtunded this am, not responsive to voice, minimally responsive to\n noxious stimuli, on MMV through trach tube, but later responsive to\n voice, appropriate, asking questions, mouthing responses\n HEENT: PERRL, MMM,\n Resp: Coarse BS anteriorly, no focal rales, rhonchi, or wheezing with\n some referred upper airway noises from secretions.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, hypoactive BS\n Exte: No edema, DP 2+ bil.\n NEURO: Toes downgoing bilaterally,\n Labs / Radiology\n 528 K/uL\n 9.2 g/dL\n 121 mg/dL\n 1.0 mg/dL\n 35 mEq/L\n 3.4 mEq/L\n 6 mg/dL\n 103 mEq/L\n 146 mEq/L\n 28.6 %\n 9.5 K/uL\n [image002.jpg]\n 02:06 AM\n 07:34 AM\n 03:50 AM\n 06:22 AM\n 02:58 AM\n 03:43 AM\n 05:02 PM\n 03:36 AM\n 02:30 AM\n 01:30 AM\n WBC\n 7.5\n 5.6\n 6.1\n 7.0\n 7.1\n 7.1\n 6.9\n 7.6\n 9.5\n Hct\n 26.8\n 27.0\n 27.0\n 29.7\n 28.9\n 29.2\n 27.8\n 32.7\n 28.6\n Plt\n 95\n 462\n 452\n 467\n 548\n 528\n Cr\n 0.6\n 0.5\n 0.7\n 0.7\n 0.6\n 0.7\n 0.8\n 0.7\n 0.8\n 1.0\n Glucose\n 134\n 121\n 619\n 126\n 137\n 104\n 108\n 131\n 128\n 121\n Other labs: PT / PTT / INR:82.1/35.9/10.5, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:9.7 mg/dL, Mg++:2.4 mg/dL, PO4:2.9\n mg/dL\n Assessment and Plan\n 55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach, PEG placement now with respiratory failure secondary to\n tracheomalacia , resolved HAP.\n .\n # Respiratory failure: Slowly Improving. Now remaining on trach mask\n for most of the day, with periods of pressure support of over\n night. This am on MMV. Previously likely oversedated with Benadryl,\n Morhpine, and Valium which were held overnight. Pt awake and alert at\n rounds, interactive, and breathing comfortably on trach mask\n - Continue to increase time on trach mask as tolerated.\n - Decrease sedation and valium use\n - PMV with suctioning\n .\n # HAP vs Aspiration PNA: Afebrile without leukocytosis\n - Completed course of ceftriaxone\n - good O2 saturation on trach mask\n - Continue to f/u cultures\n .\n # Tachycardia: Previously was assessed as sinus tach with occasional\n runs of SVT and sources such as hypovolemia, PE, infection, and pain\n were assessed as possibly etiologies. Per Cardiology, most likely AT\n given transient response to Adenosine. HR occasionally decreases to\n 70s-80s w/ stable BPs at times that might be associated with\n administration of her BB and valium. Cards recommended titating up her\n beta blocker as tolerated. Dose increased to 37.5 yesterday but still\n tachycardic.\n - EP consulted for conversion of SVT, appreciate recs\n - Increase metoprolol to 50 PO QID with holding parameters\n .\n # Sedation: Inconsistent response to sedation, unclear what is best\n regime. Will continue to wean overall.\n - Continue w Olanzapine QHS\n - Just valium 2.5 mg PRN.\n # Nutrition/Vomiting: Pt has had several episodes of vomiting up her\n TFs, reglan started to increase GI motility, but pt had another episode\n of vomiting this am, not improved with zofran or reglan. Pateint also\n had hypoactive BS on exam, concern for obstruction given persistent\n vomiting, inability to tolerate tube feeds.\n - Hold TFs\n - Thoracic surgery recs: 1) oral/nasal tube in post-piloric position,\n or 2) IR to place a pediatric feeding tube through her PEG site to a\n post-piloric position.\n - Will attempt to coordinate thoracic surgery and IR for tube placement\n ; will d/w thoracics. IR will not do further intervention due to disk\n on G tube\n - CT scan to evaluate for obstruction, etiology of persistent emesis,\n consider tube study as well\n .\n # Adrenal Insufficency: Endocrine following. Pt does not appear to be\n adrenally insufficient at baseline. Suggesting if the patient under\n goes major stressors such as major surgery, sepsis, she may need stress\n dosed steroids.\n .\n # Fluid Status: Likely approaching euvolemia, though still has mild\n hypernatramia which may suggest is still intravascularly depleated.\n - Monitoring urine output\n - FW flushes w/ tube feeds held due to vomitting\n - will provide D5W IVF as need for hypernatremia and follow lytes\n .\n # UE DVT and elevated INR: DVT in right UE has resolved, new\n non-occlusive in left axillary vein. INR supratherapeutic today and\n trending upward. INR most likely continuing to rise nutritional\n deficiencies given lack of PO intake\n - Cumadin held, will restart at low dose when INR approaches\n therapeutic range.\n - INR 5.5 today, will check PM coags and follow\n .\n # Spine fracture: Stable\n - Brace for OOB, will discuss with Neurosurgery if current brace is\n optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n .\n # Tracheomalacia. Was initially addressed with IP and they wanted to\n follow up as outpatient. IP reevaluated and does not believe that a\n stent would be feasible.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # PIV x 1\n # Ppx: supratherapeutic INR, Ranitidine, Bowel Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n - Will contact Social and Case management today\n # Code: Full\n # Dispo: ICU, Screening for vent facilities\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 04:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-21 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 638755,
"text": "Chief Complaint: resp failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n rising INR to 10.5\n small volume hemetemesis\n abd CT\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:30 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.9\nC (98.4\n HR: 114 (88 - 136) bpm\n BP: 120/65(80) {80/40(49) - 149/88(92)} mmHg\n RR: 11 (11 - 33) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,241 mL\n 1,802 mL\n PO:\n TF:\n IVF:\n 1,941 mL\n 1,802 mL\n Blood products:\n Total out:\n 1,860 mL\n 260 mL\n Urine:\n 1,830 mL\n 210 mL\n NG:\n 30 mL\n 50 mL\n Stool:\n Drains:\n Balance:\n 381 mL\n 1,542 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 438 (300 - 1,054) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 13\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 16 cmH2O\n Plateau: 15 cmH2O\n SpO2: 100%\n ABG: ///35/\n Ve: 5.4 L/min\n Physical Examination\n Gen\n HEENt\n CV\n Chest\n Abd\n Ext\n Labs / Radiology\n 9.2 g/dL\n 528 K/uL\n 121 mg/dL\n 1.0 mg/dL\n 35 mEq/L\n 3.4 mEq/L\n 6 mg/dL\n 103 mEq/L\n 144 mEq/L\n 28.9 %\n 9.5 K/uL\n [image002.jpg]\n 07:34 AM\n 03:50 AM\n 06:22 AM\n 02:58 AM\n 03:43 AM\n 05:02 PM\n 03:36 AM\n 02:30 AM\n 01:30 AM\n 06:41 AM\n WBC\n 5.6\n 6.1\n 7.0\n 7.1\n 7.1\n 6.9\n 7.6\n 9.5\n Hct\n 27.0\n 27.0\n 29.7\n 28.9\n 29.2\n 27.8\n 32.7\n 28.6\n 28.9\n Plt\n 335\n 321\n 395\n 462\n 452\n 467\n 548\n 528\n Cr\n 0.5\n 0.7\n 0.7\n 0.6\n 0.7\n 0.8\n 0.7\n 0.8\n 1.0\n Glucose\n 121\n 619\n 126\n 137\n 104\n 108\n 131\n 128\n 121\n Other labs: PT / PTT / INR:82.1/35.9/10.5, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:9.7 mg/dL, Mg++:2.4 mg/dL, PO4:2.9\n mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 04:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 638862,
"text": "Tachycardia, Other\n Assessment:\n ST120-140 with anxiety, BP stayed in 120- 140 systoli8caly.No Ectopy\n noted\n Action:\n Lopressor changed from PO->>IV prn d/t vomiting after meds.\n Response:\n Given lopressor 5mg IV evening, cont ST most of the time.\n Plan:\n IV lopressor 7.5 mg Q4H for Tachycardia.\n Alteration in Nutrition\n Assessment:\n Pt was until went for procedure . Na 144 this morning,^ this evening\n 148. K was low this morning 3.4,Pt also started autodiuresing this\n morning.\n Action:\n D5 with 40 K at 50cc/hr . x1000cc.Pt went down and had New feeding tube\n inside Peg tube,sutured securely with 150 fentanyl and 4mg Versed.\n Response:\n Will follow up with Labs,TF?.HCt stayed stable\n Plan:\n Recheck K and NA later tonight. Start TF and titrate as tol,erate\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Put On 50% trach mask most of the day.. Copious thick tan, dark brown\n secretions.\n Action:\n Placed on Vent onetime MMV mode when tachypneic. Frequent suctioning.\n Response:\n Cont be same, got breathing rx.\n Plan:\n Cont monitor resp status. Suction as needed, MDIs.\n Altered mental status (not Delirium)\n Assessment:\n Restless all day,follow commands intermittently,Mouthing words although\n difficult to understand.\n Action:\n Gave her Haldol and vaslium IV as per order , Reorient pt prn.\n Emotional support.Soft restraints still on.Her brother called this\n evening,will here Friday .\n Response:\n Cont same.\n Plan:\n Valium and Haldol PRN?. Zyprexa HS prn for agitation. Reorient prn.\n Emotional support to pt and family.\n"
},
{
"category": "Respiratory ",
"chartdate": "2167-10-22 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 639062,
"text": "Demographics\n Day of mechanical ventilation: 34\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Tracheostomy tube:\n Type: Standard, Cuffed\n Manufacturer: Portex\n Size: 7.0mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 23 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Pt on Trach collar this am,\n after 2 hrs pt desating to 87%, suctioned for copious thick brownish\n secretions, did not recover on 100% O2, needed to go back on Vent.\n Currently pt on Trach collar.\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: Trach collar as tolerated.\n Reason for continuing current ventilatory support: Cannot protect\n airway, Cannot manage secretions, pt desaturates and does not recover\n with O2 only.\n Respiratory Care Shift Procedures\n Bedside Procedures:\n 1550\n Comments: Pt decannulated herself, desated to 87%, Trach tube portex #\n 7 re-inserted by this RRT, no complication, Easy cap good color change\n to yellow, Good bilateral lung sounds, no bleeding from trach.\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 639138,
"text": "56 yr old lady who was transferred from osh for evaluation of tracheal\n bronchial malacia on .Pt presented to medical centre on\n s/p fall down stairs fracturing t5-t8 with propulsion treated\n conservatively with pain meds and back brace. Developed resp distress\n requiring intubation on . CT neg for PE CXR showed PNA. Pt continue\n to fail to wean from vent and was transferred for evaluation and poss\n tracheal stent but was r/o for malacia by IP. Trach/PEG done . Now\n with prolonged hospital course c/b by PNA, anxiety/altered mental\n status, R&LUE DVT .Pt found to have small non occlusive Clot on her\n right axial vein via Ultrasound.Yesterday. She has had problems with\n vomiting tube feedings, feeding tube passed through g-tube (g-tube in\n place with mushroom on inside so cannot pull out) to her jejunenum but\n continues vomit.\n Tachycardia, Other\n Assessment:\n HR continued to be 110-140, ST w/ rare PVC\n Action:\n Amiordarone 75mg bolus given, and drip started at 1mg/min\n Response:\n HR at rest now 100-120\n Plan:\n Will continue drip for 18 hr then titrate down to 0.5mg/min\n Altered mental status (not Delirium)\n Assessment:\n Pt very restless and agitated throughout night, pt has slept less than\n 2 hours. Zyprexa given w/ minimal effect. Pt seems very disoriented\n despite frequent reorientation. Pt has short term menmory deficits.\n Pt continues to grab at lines if hand are not restrained.\n Action:\n Zyprexa given and frequent reorientation and 1:1 time\n Response:\n Pt continues to be agitated\n Plan:\n Alteration in Nutrition\n Assessment:\n Remains NPO, IVF at 75cc/hr. Abd soft, distant hYPOactive BS. No\n vomiting noted\n Action:\n Continue to monitor for nausea\n Response:\n Plan:\n ? start PPN today if KUB + illeus\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Tmax this shift 101.4 rectally\n Action:\n BC x2 sent and U/A C+S sent . Tylenol supp given\n Response:\n Temp down to 98.5\n Plan:\n Await BC results and urine culture results\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 639065,
"text": "Tachycardia, Other\n Assessment:\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Hypernatremia (high sodium)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 637887,
"text": "Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Left hand to elbow area with edema 2mm\nknown DVT to left axillary vein;\n US of right arm\n Action:\n DL PICC d/c\nd; left arm elevated on pillow; US results pnd for right\n arm\n Response:\n PIV placed for access issues to right arm; edema unchanged;\n Plan:\n Cont to monitor left arm status; no BP/blood draws left arm. NIBP cuff\n to right calf. F/U w/ team Re: right arm status\n Hypernatremia (high sodium)\n Assessment:\n hypernatremic\n Action:\n Free water boluses cont; bloused with D5W/500cc\n Response:\n Remains hypernatremic with min improvement\n Plan:\n Cont with free water boluses; check labs am\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Restless, anxious am\n Action:\n Trach collar placed 70% early am--\n Response:\n Brief episode of desaturation to mid 80\ns requiring increase of Fi02 to\n 100% briefly (approx 20min); placed on 70% remainder of shift with\n adequate o2 sats in low 90\ns;NOTE: pt vomited approx 50cc clear liquid\n prior to going to IR also had some clear lix come from trach\npossible\n aspiration\nteam notified. Placed on PSV at 1840 to rest\n Plan:\n Rest overnight; ?aspiration. Hold TF for now\nf/u team re: free water\n boluses. CXR am. Monitor resp status closely.\n Tachycardia, Other\n Assessment:\n Tachy to 130-140\ns continuous while awake; Hr stayed 90- 120 sound\n asleep\n Action:\n Standing valium decreased; cont with fent patch; morphine and haldol\n prn.Bilateral restraints on\n Response:\n No significant change in level of restlessness/anxiety; freq pulling at\n any objects/lines with short term memory issues. She keeps\n disconnecting from vent,desat to low 80s within seconds.\n Plan:\n Cont to closely monitor mental status; maintain safety w/use of\n restraints, soft wrist restraints and bed alarm. PRN Haldol or\n Morphine.\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 639594,
"text": "Chief Complaint:\n 24 Hour Events:\n Pt agitated overnight given extra Risperidone 0.5 mg x 2 overnight.\n (1.5mg total)\n 1000 mL D5W for Hypernatremia\n Changed B-Blocker from IV to PO, Metoprolol Tartrate 25 mg PO TID\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:17 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.7\nC (98\n HR: 120 (67 - 120) bpm\n BP: 110/64(76) {109/47(60) - 141/115(118)} mmHg\n RR: 26 (18 - 30) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 3,820 mL\n 856 mL\n PO:\n TF:\n 117 mL\n 20 mL\n IVF:\n 2,612 mL\n 572 mL\n Blood products:\n Total out:\n 2,460 mL\n 1,180 mL\n Urine:\n 2,460 mL\n 1,180 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,360 mL\n -324 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 100%\n ABG: ///33/\n Physical Examination\n Gen: Awake, Mouthing words, More agitated compared to previous\n mornings.\n HEENT: EOMI, No pallor in conjunctiva, MMM\n Resp: CTAB, no rales, rhonchi, or wheezing, good airway movement.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, decreased bowel sounds,, G-Tube in\n place with no erythema/induration\n Exte: No edema, DP 2+ bil\n NEURO: Gross Motor and Sensation in 4 extremities\n Labs / Radiology\n 249 K/uL\n 8.0 g/dL\n 122 mg/dL\n 0.5 mg/dL\n 33 mEq/L\n 3.7 mEq/L\n 13 mg/dL\n 108 mEq/L\n 146 mEq/L\n 24.7 %\n 5.5 K/uL\n [image002.jpg] CXR: L Picc, trach tip at midline, bibasilar\n opacities, low lung volumes, Bil pleural effusions.\n 03:36 AM\n 02:30 AM\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n 03:00 AM\n 04:00 AM\n 05:45 AM\n 03:51 AM\n WBC\n 6.9\n 7.6\n 9.5\n 5.7\n 7.3\n 8.0\n 8.7\n 5.5\n Hct\n 27.8\n 32.7\n 28.6\n 28.9\n 30.0\n 26.9\n 27.3\n 27.0\n 28.7\n 24.7\n Plt\n 467\n 548\n 528\n 356\n 346\n 316\n 271\n 249\n Cr\n 0.7\n 0.8\n 1.0\n 0.7\n 0.7\n 0.7\n 0.7\n 0.5\n Glucose\n 131\n 128\n 121\n 129\n 123\n 114\n 112\n 122\n Other labs: PT / PTT / INR:13.6/31.1/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:9.0 mg/dL, Mg++:2.2 mg/dL, PO4:3.1\n mg/dL\n Assessment and Plan\n 56yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach/PEG with resolving respiratory failure and HAP.\n .\n # Respiratory failure: s/p intubation/extubation, now on trach mask,\n FiO2 70%. Tolerating well with good O2 sat. No further\n self-decanulations overnight.\n - Tach mask as tolerated.\n - Holding sedation with exception of Risperidal 0.5mg .\n - F/u CXR tomorrow\n .\n # Nutrition/Vomiting: Currently receiving TPN;. One large BM in past\n 24 hrs to indicate potential improvement in ileus.\n - Cont Reglan 20mg IV Q 8 hours; meds via G-J tube,\n - Will obtain recommendations from Nutrition re TPN before starting TPN\n tomorrow\n - TF as tolerated\n - Speech and Swallow eval\n - PICC line in place with TPN given when pt not tolerating TF\n - GI consult, appreciate recs\n .\n # Tachycardia: Improved HR max of 120\ns versus 160s previously;\n elevated this am secondary to agitation. Pt now on PO Amiodarone 200\n TID and PO metoprolol 25mg TID\n - Continue current med regimen. Will continue amiodarone 200 TID for\n three weeks and then switch to qday.\n - Will schedule f/u in 4wks with Dr. upon d/c/transfer.\n - f/u Cards recs\n # Sedation/Anxiolysis/AlteredMS: Agitation O/N, continues to be\n agitated most likely secondary to long hospital course and multiple\n psychotropic medications as well as hx of EtOH abuse. Risperdal given\n O/N.\n - started Risperdal 0.5mg PO BID\n - continue to hold all benzos. opiates, and antihistamines\n - Appreciate psych. Will call and f/u psych recs.\n #Anemia: Decrease in HCT from 28\n24; tachycardia. No known etiology of\n blood loss, most likely related to variaton\n -Will repeat HCT check this afternoon.\n # Hypernatremia/Fluid Status: Mild hypernatramia with good UOP\n (hypervolemic hypernatremia). On TPN/TF.\n - providing D5W IVF, free water flushes with TF\n -Will f/u lytes (Na) this afternoon at 5pm.\n # UE DVT and elevated INR: Decision made to d/c Coumadin given her\n labile INR, and start Lovenox . Current INR 1.2.\n - Will flush L PICC with TPA if does not flush\n .\n # Spine fracture: Stable\n - Brace for OOB, need to discuss with Neurosurgery before d/c if\n current brace is optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n .\n # Tracheomalacia. Was initially addressed with IP and they wanted to\n follow up as outpatient. IP reevaluated and does not believe that a\n stent would be feasible. No new issues.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # ACCESS: PIV x 1, L PICC\n # Ppx: Lovenox, PPi, Bowel Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n - Social Work and Case management involved, have discussed situation\n w/ brother and boyfriend.\n # Code: Full\n # Dispo: ICU, Will d/w case management re rehab facilities.\n PGY2 Addendum\n Agree with excellent MS4 PN. Will touch base with psychiatry re:\n sedating meds and EP re: atrial tachycardia. Will obtain EKG to\n reassess QTc. Ordered for TPN. Giving d5W for hypernatremia. Re-consult\n S/S for PMV re-fitting. transfer to LTAC.\n \n PGY2\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 639597,
"text": "56 yr old woman, who was transferred from osh for evaluation of\n tracheal bronchial malacia on .Pt presented to Medical\n Center on s/p fall down a flight of stairs fracturing, t5-t8 with\n propulsion treated conservatively with pain meds and back brace. She\n developed resp distress requiring intubation on . Trach/PEG done\n . Now with prolonged hospital course c/b by PNA, anxiety/altered\n mental status, R&LUE DVT .Pt found to have small non occlusive clot on\n her right axial vein via Ultrasound, now rec\ning Lovenox. She has had\n problems with vomiting tube feedings, so feeding tube passed through\n g-tube to her jejunenum. However, she continues to intermit raise\n gastric contents assoc with bronchospasm. Has not required ventilation\n since , on humidified TM @ 50%. Has required 1:1 sitters since\n decanulating herself, twice, despite restraints.\n Airway Clearance, Impaired\n Assessment:\n Rec\nd pt on humidified TM @ 70% with O2 sat 97-100%. RR 22-31 and\n regular. Lung snds rhonchorous in upper lobes, clearing with sxn\ning.\n Lower lobe snds diminished bilat.\n Action:\n FiO2 \nd to 50%. Pt requiring tracheal sxn\ning Q30-60mins, producing\n mod-copious amts thick white tenacious secretions. Pt generally unable\n to fully raise and expectorate secretions.\n Response:\n O2 sat has remained 99-100%, but drops to high 80\ns when requires\n sxn\ning.\n Plan:\n Cont to encourage pt to deep breathe and cough. Cont aggressive pulm\n toilet.\n Alteration in Nutrition\n Assessment:\n Per noc shift nurse, TF off overnight as pt too restless to maintain in\n upright position per strict aspiration precautions. BS +, abd\n soft/obese.\n Action:\n Pt placed on chair position in bed and TF restarted @ 0830 @\n 10ml/hr+50ml free water Q4hrs. She rec\nd her scheduled doses Reglan\n 20mg and colace, senna.\n Response:\n Pt tolerated TF well with no residuals, so TF inc\nd to 20ml/hr @ 1230.\n No BM yet today, but pt having flatus.\n Plan:\n Cont strict aspiration prec, holding TF when pt not in upright position\n and turning TF off for 15mins before turning.\n Arousal, Attention, and Cognition, Impaired\n Assessment:\n Pt rec\nd very restless in bed, attempting to exit despite bilat soft\n wrist restraints and sitter @ bedside. When PMV in place pt\n disoriented X 2, and reported she had been in a hotel and could pay\n $3000 cash to leave. When told she was in a hospital bed, she asked,\nWhere\ns the bed\n, unconvinced that she was lying in bed.\n Action:\n Pt rec\nd scheduled 0800 dose Resperadine. EKG taken.\n Response:\n Pt slept for 90mins until woken by team for am rounds. She has appeared\n sleepy since but resistant to falling asleep. QT interval WNL.\n Plan:\n Psych to consult and eval meds.\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-22 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 639058,
"text": "Chief Complaint: resp failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n increased bblocker\n J tube placed by IR through PEG- restarted TF and vomiting\n Went for tube study - dysmotility - contrast sat in stomach\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Diazepam (Valium) - 02:24 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 12:17 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 35.6\nC (96.1\n HR: 118 (93 - 140) bpm\n BP: 153/58(79) {82/39(49) - 153/101(105)} mmHg\n RR: 23 (14 - 37) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 3,808 mL\n 1,119 mL\n PO:\n TF:\n 4 mL\n IVF:\n 3,804 mL\n 1,119 mL\n Blood products:\n Total out:\n 1,650 mL\n 520 mL\n Urine:\n 1,590 mL\n 520 mL\n NG:\n 60 mL\n Stool:\n Drains:\n Balance:\n 2,158 mL\n 599 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 243 (169 - 281) mL\n PS : 5 cmH2O\n RR (Spontaneous): 17\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 67\n PIP: 11 cmH2O\n SpO2: 99%\n ABG: ///33/\n Ve: 4.1 L/min\n Physical Examination\n Gen: lying in bed, alert, responding to questions\n CV; tachy RR\n Chest: bibasilar decreased BS, faint exp wheeze\n Abd: soft NT+BS\n Ext: no edema\n Labs / Radiology\n 8.2 g/dL\n 356 K/uL\n 129 mg/dL\n 0.7 mg/dL\n 33 mEq/L\n 3.6 mEq/L\n 4 mg/dL\n 110 mEq/L\n 148 mEq/L\n 26.9 %\n 5.7 K/uL\n [image002.jpg]\n 06:22 AM\n 02:58 AM\n 03:43 AM\n 05:02 PM\n 03:36 AM\n 02:30 AM\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n WBC\n 7.0\n 7.1\n 7.1\n 6.9\n 7.6\n 9.5\n 5.7\n Hct\n 29.7\n 28.9\n 29.2\n 27.8\n 32.7\n 28.6\n 28.9\n 30.0\n 26.9\n Plt\n 395\n 462\n 452\n 467\n 548\n 528\n 356\n Cr\n 0.7\n 0.6\n 0.7\n 0.8\n 0.7\n 0.8\n 1.0\n 0.7\n Glucose\n 126\n 137\n 104\n 108\n 131\n 128\n 121\n 129\n Other labs: PT / PTT / INR:15.2/24.6/1.3, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.7 mg/dL, Mg++:2.1 mg/dL, PO4:4.1\n mg/dL\n Assessment and Plan\n 1. Tachycardia: runs of attach Appreciate EP consult\n will increase\n bblocker. Have to convert to metoprolol 7.5mg IV Q4 because unable to\n take pos.\n 2. Persistent Nausea/Vomiting: we have ruled out\n pSBO/SBO, very poor\n bowel sounds, tube study this AM shows contrast not moving out of the\n jejunum. GI consult to discuss any role for EGD. Place PICC for TPN as\n she has not had nutrition.\n 2. Resp Failure\n Trach mask trials all day, PSV\n PMV trials\n Per IP not stent planned as technically not possible to\n place into her airway\n 3. DVT and coagulopathy: reversed with IV Vit k\n hold coumadin today\n 4. Hypernatremia Replete free water.\n Please see today\ns ICU team note for other issues.\n ICU Care\n Nutrition: plan for TPN\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 04:00 AM\n Prophylaxis:\n DVT: plan for coumadin\n Stress ulcer: ppi\n Communication: spoke with son and\n status: Full code\n Disposition : ICU\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 639334,
"text": "Chief Complaint:\n 24 Hour Events:\n Pt decannulated herself x2 yesterday, the 1st episode she desatted to\n the 80s, the second episode she desated and her heart rate decreased to\n 39-40, before the trach could be replaced.\n PICC line placed by IR, called to notify that there was clot in both\n arms, placed in L arm more proximally than small Bacillis vein clot.\n Coumadin restarted after PICC placement with 2mg\n Per GI Recs: Reglan restarted at 20mg IV q 8 hours, and meds were\n restarted via tube. No vomitting.\n Per PSYCH recs: d/c'd all benzoes, (also requested d/c reglan if GI\n ok), added Risperdal 0.5mg (and can add 0.5mg PRN, and titrate up\n to total daily dose of 2-3mg if helping)\n Per Cards recs: after 18hr of amiodaron drip. Start PO amiodarone 200mg\n TID, which was done at 1am.\n Brother visited\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 37.4\nC (99.4\n HR: 90 (73 - 121) bpm\n BP: 155/49(75) {103/47(66) - 175/98(111)} mmHg\n RR: 32 (14 - 32) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,151 mL\n 293 mL\n PO:\n TF:\n IVF:\n 1,852 mL\n 13 mL\n Blood products:\n Total out:\n 2,460 mL\n 820 mL\n Urine:\n 2,460 mL\n 820 mL\n NG:\n Stool:\n Drains:\n Balance:\n -309 mL\n -527 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Set): 0 (0 - 0) mL\n Vt (Spontaneous): 360 (360 - 360) mL\n PS : 10 cmH2O\n RR (Set): 0\n RR (Spontaneous): 21\n FiO2: 40%\n SpO2: 98%\n ABG: ///33/\n Physical Examination\n Gen: Asleep, unarousable, responds minimally to noxious stimuli\n HEENT: PERRL, MMM\n Resp: CTA bilaterally, no rales, rhonchi, or wheezing, small\n inspirations.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, BS+\n Exte: No edema, DP 2+ bil\n NEURO: reflexes 2+ bilaterally.\n Labs / Radiology\n 316 K/uL\n 8.3 g/dL\n 114 mg/dL\n 0.7 mg/dL\n 33 mEq/L\n 4.0 mEq/L\n 7 mg/dL\n 111 mEq/L\n 149 mEq/L\n 27.0 %\n 8.0 K/uL\n [image002.jpg]\n 03:43 AM\n 05:02 PM\n 03:36 AM\n 02:30 AM\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n 03:00 AM\n 04:00 AM\n WBC\n 7.1\n 6.9\n 7.6\n 9.5\n 5.7\n 7.3\n 8.0\n Hct\n 29.2\n 27.8\n 32.7\n 28.6\n 28.9\n 30.0\n 26.9\n 27.3\n 27.0\n Plt\n 452\n 467\n 548\n 528\n 356\n 346\n 316\n Cr\n 0.7\n 0.8\n 0.7\n 0.8\n 1.0\n 0.7\n 0.7\n 0.7\n Glucose\n 104\n 108\n 131\n 128\n 121\n 129\n 123\n 114\n Other labs: PT / PTT / INR:13.2/22.4/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:9.0 mg/dL, Mg++:2.3 mg/dL, PO4:4.1\n mg/dL\n Assessment and Plan\n 55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach, PEG placement now with respiratory failure secondary to\n tracheomalacia , resolved HAP.\n .\n # Respiratory failure: Slowly improving, spending most of the day on\n trach mask with short periods of rest on PSV at night and setbacks\n from increased secretions to vomiting/aspiration events and her\n self-decanulations.\n - Continue to increase time on trach mask as tolerated.\n - Discontinue all orders for sedation except for Risperdal QHS.\n - PMV with suctioning as tolerated\n # Nutrition/Vomiting: Normal CT-abdomen, had FT placed via peg into\n jejunum, but continued to vomit. Tube study showed dysmotility in small\n bowel, but no obstruction, no retrograde flow. GI recs Reglan 20mg IV Q\n 8 hours and restart meds via G-J tube, if tolerated slowly restart TFs.\n PICC line placed yesterday and TPN started.\n - GI consult, appreciate recs\n - Small volume TFs start today\n - Continue TPN today\n # HAP vs Aspiration PNA: Had been afebrile for last several days, now\n with new fever two nights ago after having decanulated herself. Likely\n had some aspiration. Chemical pneumonitis versus new aspiration PNA.\n Now Afebrile for past 24 hours.\n - f/u daily CXR\n - F/u cx data\n - If remains febrile, send sputum cx, otherwise hold on abx.\n .\n # Tachycardia: Pt in and out of SVT and sinus, increased BB seems to\n help, but pt does not stay in sinus. Cards rec to start Amiodarone IV\n drip, and then convert to PO, 200mg TID. Would consider EPS if\n amiodarone not successful, though would wait until pt more stable for\n general anesthesia.\n - Changed to IV metoprolol to 10mg IV q4hr.\n - Completed amiodarone 0.5mg/min IV drip x 18 hours, and converted to\n 200mg PO TID..\n - Cards c/s, appreciate recs\n # Sedation/Anxiolysis/AlteredMS: unclear etiology of her confusion and\n agitation. Has had long hospital course and multiple psychotropic\n medications as well as hx of EtOH abuse.\n - d/c all benzos. opiates, and antihistamines\n - Psychiatry consulted, appreciate recs\n - started Risperdal 0.5mg PO BID, d/c zyprexa.\n # Adrenal Insufficency: Endocrine following. Pt does not appear to be\n adrenally insufficient at baseline. Suggesting if the patient under\n goes major stressors such as major surgery, sepsis, she may need stress\n dosed steroids.\n .\n # Fluid Status: Likely approaching euvolemia, though still has mild\n hypernatramia which may suggest is still intravascularly depleated.\n - Monitoring urine output\n - will provide D5W IVF as need for hypernatremia and follow lytes\n # UE DVT and elevated INR: DVT in right UE has resolved, new\n non-occlusive in left axillary vein. INR has been volatile, likely from\n drug interactions and poor nutritional status. Have been unable to keep\n her appropariately therapeutic.\n - d/c coumadin\n - start Lovenox, maintain until GI issues resolved and can restart\n coumadin\n .\n #Hematemesis: Pt had small amt Hematemesis, after vomiting, last week.\n None today. HCT stable.\n -Will follow HCT.\n - Guaiac stools\n # Spine fracture: Stable\n - Brace for OOB, will discuss with Neurosurgery if current brace is\n optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n .\n # Tracheomalacia. Was initially addressed with IP and they wanted to\n follow up as outpatient. IP reevaluated and does not believe that a\n stent would be feasible.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # ACCESS: PIV x 1, PICC placement\n yesterday.\n # Ppx: subtherapeutic INR restarting coumadin today, Ranitidine, Bowel\n Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n - Social Work and Case management involved, have discussed situation\n w/ brother and boyfriend.\n # Code: Full\n # Dispo: ICU, Screening for vent facilities\n ICU Care\n Nutrition:\n TPN without Lipids - 06:00 PM 41. mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n PICC Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 638537,
"text": "55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach, PEG, placement no with respiratory failure secondary to\n tracheomalacia , resolving HAP.\n Arousal, Attention, and Cognition, Impaired\n Assessment:\n Alert, mouthing words but very difficult to understand. Follows\n commands. MAE on bed, attempting to get up. Restless last evening, did\n eventually fall off to sleep this AM.\n Action:\n Zyprexa x 1 . Frequent re-orientation to place, situation. Soft wrist\n restraints for patient safety.\n Response:\n Pt did eventually fall asleep. Re-orientation does have calming effect\n however it is short term.\n Plan:\n No valium or benadryl per psych as this exacerbates delirium. Zyprexa\n for agitation. pt prn.\n Hypernatremia (high sodium)\n Assessment:\n Na 145 last night, 148 this AM.\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Trach collar @ 50% O2 overnight until 4AM, Sats 90-97%. RR 17-20s.\n Around 4AM RR in low 30s, sats low 90s while sleeping--? Fatiguing.\n Strong cough, able to cough thick white ->tan secretions out of trach.\n Occ suctioned for same. Lungs are rhonchorous throughout. Impaired gag.\n Action:\n Suctioned prn for copious secretions. MDIs. Placed back on vent @ 4AM\n d/t fatigue.\n Response:\n Tolerated trach collar most of night, back on vent this AM d/t fatigue\n with RR in teens, Sats 98%.\n Plan:\n Wean from vent as tolerated. MDIs, suction as needed.\n Alteration in Nutrition\n Assessment:\n Tube feeds off overnight d/t constant vomiting. No vomiting overnight.\n Action:\n NPO. Reglan q 6 hrs.\n Response:\n No vomiting. Small brown stool x 1.\n Plan:\n NPO. ? may go to IR today to change Gtube to Jtube. Reglan. Meds via\n Gtube.\n"
},
{
"category": "Respiratory ",
"chartdate": "2167-10-23 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 639134,
"text": "Demographics\n Day of mechanical ventilation: 35\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Tube Type\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 7.0mm\n PMV:\n Cuff Management:\n Cuff pressure: 23 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments: pt has spc can expectorate secretions as well\n Ventilation Assessment\n Level of breathing assistance: Unassisted spontaneous breathing\n Visual assessment of breathing pattern: pt remained on t/c noc as\n tolerated.\n Plan\n Next 24-48 hours: continue with t/c as tolerates, has periods of ^ wob\n then return to vent. Remain on t/c noc.\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-23 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 639232,
"text": "Chief Complaint: resp distress\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n UNPLANNED EXTUBATION (PATIENT-INITIATED) - At 03:50 PM\n Pt pulled out her trach tube, tube replaced\n POulled out trach again at 7:15 AM complicated by bradycardia and\n profound desaturation\n FEVER - 101.4\nF - 12:00 AM\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Amiodarone - 0.5 mg/min\n Other ICU medications:\n Metoprolol - 01:00 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.4\n Tcurrent: 36.8\nC (98.2\n HR: 116 (84 - 142) bpm\n BP: 147/84(96) {86/39(53) - 181/113(137)} mmHg\n RR: 23 (13 - 27) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,127 mL\n 994 mL\n PO:\n TF:\n IVF:\n 2,127 mL\n 994 mL\n Blood products:\n Total out:\n 995 mL\n 900 mL\n Urine:\n 995 mL\n 900 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,132 mL\n 94 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: CPAP/PPS\n Vt (Set): 0 (0 - 0) mL\n Vt (Spontaneous): 360 (208 - 360) mL\n PS : 10 cmH2O\n RR (Set): 0\n RR (Spontaneous): 21\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 0 cmH2O\n SpO2: 99%\n ABG: ///31/\n Physical Examination\n Gen: lying in bed, alert, responding to questions, PMV placed\n CV; tachy RR\n Chest: bibasilar decreased BS, faint exp wheeze\n Abd: soft NT+BS\n Ext: no edema\n Skin: warm\n Neurologic: confused, stating that p[eople are trying to kill her\n Labs / Radiology\n 8.4 g/dL\n 346 K/uL\n 123 mg/dL\n 0.7 mg/dL\n 31 mEq/L\n 3.8 mEq/L\n 4 mg/dL\n 107 mEq/L\n 144 mEq/L\n 27.3 %\n 7.3 K/uL\n [image002.jpg]\n 02:58 AM\n 03:43 AM\n 05:02 PM\n 03:36 AM\n 02:30 AM\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n 03:00 AM\n WBC\n 7.1\n 7.1\n 6.9\n 7.6\n 9.5\n 5.7\n 7.3\n Hct\n 28.9\n 29.2\n 27.8\n 32.7\n 28.6\n 28.9\n 30.0\n 26.9\n 27.3\n Plt\n 462\n 452\n 467\n 548\n 528\n 356\n 346\n Cr\n 0.6\n 0.7\n 0.8\n 0.7\n 0.8\n 1.0\n 0.7\n 0.7\n Glucose\n 137\n 104\n 108\n 131\n 128\n 121\n 129\n 123\n Other labs: PT / PTT / INR:14.1/23.7/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:8.8 mg/dL, Mg++:1.9 mg/dL, PO4:3.7\n mg/dL\n Assessment and Plan\n 1. Tachycardia: runs of attach Appreciate EP consult\n trying IV Amio.\n will increase bblocker. Have to convert to metoprolol 10 mg IV Q4\n because unable to take pos.\n 2. Persistent Nausea/Vomiting: we have ruled out\n pSBO/SBO, very poor\n bowel sounds, tube study this AM shows contrast not moving out of the\n jejunum. GI consult to discuss any role for EGD. Place PICC for TPN as\n she has not had nutrition.\n 3. Agitation: delirium- trying to wean off narcotics- Will call psych\n as she is no harmful to self with pulling out trach x 2 and very\n paranoid. 1:1 sitter for safety\n 2. Resp Failure\n Trach mask trials all day, PSV\n PMV trials\n Per IP not stent planned as technically not possible to\n place into her airway\n 3. DVT and coagulopathy: reversed with IV Vit k\n hold coumadin today\n 4. Hypernatremia Replete free water.\n Please see today\ns ICU team note for other issues.\n ICU Care\n Nutrition: start TPN after PICC\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 06:31 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n Communication: met with brother for 30 minutes this afternoon and\n reviewed medical and social issues\n Code status: Full code\n Disposition :ICU\n Total time spent: 45\n"
},
{
"category": "Nursing",
"chartdate": "2167-10-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 639244,
"text": "Tachycardia, Other\n Assessment:\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 639475,
"text": "Chief Complaint:\n 24 Hour Events:\n TF were restarted in afternoon and held after one episode of a coughing\n fit in the evening. Pt was suctioned, CXR unchanged. AVSS.\n One episode of SVT to the low 100\ns overnight from 2:30 to 3:15am.\n Given D5W x 2 liters for hypernatremia\n Lovenox 100mg SC BID for prior UE DVT\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:17 AM\n Enoxaparin (Lovenox) - 06:00 PM\n Metoprolol - 06:00 PM\n Other medications:\n Changes to medical and family history: No additional\n Review of systems is unchanged from admission except as noted below\n Review of systems: Pt mouthing words but team unable to understand.\n Flowsheet Data as of 05:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.3\nC (97.4\n HR: 68 (64 - 104) bpm\n BP: 116/51(66) {105/45(44) - 151/74(89)} mmHg\n RR: 24 (21 - 38) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,676 mL\n 776 mL\n PO:\n TF:\n 61 mL\n IVF:\n 1,418 mL\n 540 mL\n Blood products:\n Total out:\n 1,910 mL\n 195 mL\n Urine:\n 1,910 mL\n 195 mL\n NG:\n Stool:\n Drains:\n Balance:\n 766 mL\n 581 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 96%\n ABG: ////\n Physical Examination\n Gen: Awake, Mouthing words\n HEENT: PERRL, MMM\n Resp: CTA bilaterally, no rales, rhonchi, or wheezing, small\n inspirations.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, BS+\n Exte: No edema, DP 2+ bil\n NEURO: Gross Motor and Sensation in 4 extremities\n Labs / Radiology\n 316 K/uL\n 8.3 g/dL\n 114 mg/dL\n 0.7 mg/dL\n 33 mEq/L\n 4.0 mEq/L\n 7 mg/dL\n 110 mEq/L\n 148 mEq/L\n 27.0 %\n 8.0 K/uL\n [image002.jpg]\n 03:43 AM\n 05:02 PM\n 03:36 AM\n 02:30 AM\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n 03:00 AM\n 04:00 AM\n WBC\n 7.1\n 6.9\n 7.6\n 9.5\n 5.7\n 7.3\n 8.0\n Hct\n 29.2\n 27.8\n 32.7\n 28.6\n 28.9\n 30.0\n 26.9\n 27.3\n 27.0\n Plt\n 452\n 467\n 548\n 528\n 356\n 346\n 316\n Cr\n 0.7\n 0.8\n 0.7\n 0.8\n 1.0\n 0.7\n 0.7\n 0.7\n Glucose\n 104\n 108\n 131\n 128\n 121\n 129\n 123\n 114\n Other labs: PT / PTT / INR:13.2/22.4/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:9.0 mg/dL, Mg++:2.3 mg/dL, PO4:4.1\n mg/dL\n Assessment and Plan\n 55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach, PEG with resolving respiratory failure and HAP.\n .\n # Respiratory failure: 36hrs off vent, now on trach mask. No further\n self-decanulations overnight.\n - Tach mask as tolerated.\n - Holding sedation with exception of Risperidal 0.5mg .\n - PMV with suctioning as tolerated\n .\n # Nutrition/Vomiting: TFs restarted yesterday while patient was not in\n optimal positioning. One large BM in past 24 hrs to indicate potential\n improvement in ileus.\n - Cont Reglan 20mg IV Q 8 hours and restart meds via G-J tube,\n - Slowly restarting TFs and will increase as tolerated.\n - PICC line in place with TPN given when pt not tolerating.\n - GI consult, appreciate recs\n .\n # Tachycardia: One episode of SVT overnight with improved HR max of\n 100\ns versus 160s previously. Pt now on PO Amiodarone 200 TID, and IV\n metoprolol\n - Will change IV metoprolol to metoprolol 25mg PO TID\n - f/u Cards recs\n # Sedation/Anxiolysis/AlteredMS: Improved alertness. Long hospital\n course and multiple psychotropic medications as well as hx of EtOH\n abuse.\n - - started Risperdal 0.5mg PO BID\n - continue to hold all benzos. opiates, and antihistamines\n - f/u psych recs.\n .\n # Fluid Status: Mild hypernatramia with good UOP.\n - providing D5W IVF PRN and follow lytes\n # UE DVT and elevated INR: Decision made to d/c Coumadin given her\n labile INR, and start Lovenox . L Picc difficult to flush this AM.\n - Will flush L PICC with TPA\n .\n # Spine fracture: Stable\n - Brace for OOB, will discuss with Neurosurgery if current brace is\n optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n .\n # Tracheomalacia. Was initially addressed with IP and they wanted to\n follow up as outpatient. IP reevaluated and does not believe that a\n stent would be feasible.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # ACCESS: PIV x 1, L PICC\n # Ppx: Lovenox, PPi, Bowel Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n - Social Work and Case management involved, have discussed situation\n w/ brother and boyfriend.\n # Code: Full\n # Dispo: ICU, Screening for vent facilities\n ICU Care\n Nutrition:\n TPN without Lipids - 06:10 PM 43. mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n PICC Line - 01:30 PM\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 639476,
"text": "Chief Complaint:\n 24 Hour Events:\n TF were restarted in afternoon and held after one episode of a coughing\n fit in the evening. Pt was suctioned, CXR unchanged. AVSS.\n One episode of SVT to the low 100\ns overnight from 2:30 to 3:15am.\n Given D5W x 2 liters for hypernatremia\n Lovenox 100mg SC BID for prior UE DVT\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:17 AM\n Enoxaparin (Lovenox) - 06:00 PM\n Metoprolol - 06:00 PM\n Other medications:\n Changes to medical and family history: No additional\n Review of systems is unchanged from admission except as noted below\n Review of systems: Pt mouthing words but team unable to understand.\n Flowsheet Data as of 05:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.3\nC (97.4\n HR: 68 (64 - 104) bpm\n BP: 116/51(66) {105/45(44) - 151/74(89)} mmHg\n RR: 24 (21 - 38) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 2,676 mL\n 776 mL\n PO:\n TF:\n 61 mL\n IVF:\n 1,418 mL\n 540 mL\n Blood products:\n Total out:\n 1,910 mL\n 195 mL\n Urine:\n 1,910 mL\n 195 mL\n NG:\n Stool:\n Drains:\n Balance:\n 766 mL\n 581 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 96%\n ABG: ////\n Physical Examination\n Gen: Awake, Mouthing words\n HEENT: PERRL, MMM\n Resp: CTA bilaterally, no rales, rhonchi, or wheezing, small\n inspirations.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, BS+\n Exte: No edema, DP 2+ bil\n NEURO: Gross Motor and Sensation in 4 extremities\n Labs / Radiology\n 316 K/uL\n 8.3 g/dL\n 114 mg/dL\n 0.7 mg/dL\n 33 mEq/L\n 4.0 mEq/L\n 7 mg/dL\n 110 mEq/L\n 148 mEq/L\n 27.0 %\n 8.0 K/uL\n [image002.jpg]\n 03:43 AM\n 05:02 PM\n 03:36 AM\n 02:30 AM\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n 03:00 AM\n 04:00 AM\n WBC\n 7.1\n 6.9\n 7.6\n 9.5\n 5.7\n 7.3\n 8.0\n Hct\n 29.2\n 27.8\n 32.7\n 28.6\n 28.9\n 30.0\n 26.9\n 27.3\n 27.0\n Plt\n 452\n 467\n 548\n 528\n 356\n 346\n 316\n Cr\n 0.7\n 0.8\n 0.7\n 0.8\n 1.0\n 0.7\n 0.7\n 0.7\n Glucose\n 104\n 108\n 131\n 128\n 121\n 129\n 123\n 114\n Other labs: PT / PTT / INR:13.2/22.4/1.1, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:9.0 mg/dL, Mg++:2.3 mg/dL, PO4:4.1\n mg/dL\n Assessment and Plan\n 55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach, PEG with resolving respiratory failure and HAP.\n .\n # Respiratory failure: 36hrs off vent, now on trach mask. No further\n self-decanulations overnight.\n - Tach mask as tolerated.\n - Holding sedation with exception of Risperidal 0.5mg .\n - PMV with suctioning as tolerated\n .\n # Nutrition/Vomiting: TFs restarted yesterday while patient was not in\n optimal positioning. One large BM in past 24 hrs to indicate potential\n improvement in ileus.\n - Cont Reglan 20mg IV Q 8 hours and restart meds via G-J tube,\n - Slowly restarting TFs and will increase as tolerated.\n - PICC line in place with TPN given when pt not tolerating.\n - GI consult, appreciate recs\n .\n # Tachycardia: One episode of SVT overnight with improved HR max of\n 100\ns versus 160s previously. Pt now on PO Amiodarone 200 TID, and IV\n metoprolol\n - Will change IV metoprolol to metoprolol 25mg PO TID\n - f/u Cards recs\n # Sedation/Anxiolysis/AlteredMS: Improved alertness. Long hospital\n course and multiple psychotropic medications as well as hx of EtOH\n abuse.\n - - started Risperdal 0.5mg PO BID\n - continue to hold all benzos. opiates, and antihistamines\n - f/u psych recs.\n .\n # Fluid Status: Mild hypernatramia with good UOP.\n - providing D5W IVF PRN and follow lytes\n # UE DVT and elevated INR: Decision made to d/c Coumadin given her\n labile INR, and start Lovenox . L Picc difficult to flush this AM.\n - Will flush L PICC with TPA\n .\n # Spine fracture: Stable\n - Brace for OOB, will discuss with Neurosurgery if current brace is\n optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n .\n # Tracheomalacia. Was initially addressed with IP and they wanted to\n follow up as outpatient. IP reevaluated and does not believe that a\n stent would be feasible.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # ACCESS: PIV x 1, L PICC\n # Ppx: Lovenox, PPi, Bowel Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n - Social Work and Case management involved, have discussed situation\n w/ brother and boyfriend.\n # Code: Full\n # Dispo: ICU, Screening for vent facilities\n ICU Care\n Nutrition:\n TPN without Lipids - 06:10 PM 43. mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n PICC Line - 01:30 PM\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM:\n On this day I examined the patient and was present for the key portions\n of the services provided. I have reviewed Dr \ns note above and\n agree with the findings and plan of care. I would emphasize that Ms\n has done well, and is off the ventilator now for over 36\n straight hours. Today she is awake, animated, but unable to talk as\n PMV is not in place due to secretions. Tube feeds had been held due to\n possible aspiration, but without clear cut evidence of such. So with\n the need for enteral nutrition and good bowel sounds, we will restart\n TFs today. For her emotional benefit, we will keep her well suctioned\n and allow her short periods on the PMV so that she can communicate and\n be less frustrated. The goal will be to have her remain stable so\n that transfer to pulm rehab can occur early this work week.\n , MD\n ------ Protected Section Addendum Entered By: , MD\n on: 14:29 ------\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 639550,
"text": "Chief Complaint:\n 24 Hour Events:\n Pt agitated overnight given extra Risperidone 0.5 mg x 2 overnight.\n (1.5mg total)\n 1000 mL D5W for Hypernatremia\n Changed B-Blocker from IV to PO, Metoprolol Tartrate 25 mg PO TID\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:17 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.7\nC (98\n HR: 120 (67 - 120) bpm\n BP: 110/64(76) {109/47(60) - 141/115(118)} mmHg\n RR: 26 (18 - 30) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 3,820 mL\n 856 mL\n PO:\n TF:\n 117 mL\n 20 mL\n IVF:\n 2,612 mL\n 572 mL\n Blood products:\n Total out:\n 2,460 mL\n 1,180 mL\n Urine:\n 2,460 mL\n 1,180 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,360 mL\n -324 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 100%\n ABG: ///33/\n Physical Examination\n Gen: Awake, Mouthing words, More agitated compared to previous\n mornings.\n HEENT: EOMI, No pallor in conjunctiva, MMM\n Resp: CTA bilaterally, no rales, rhonchi, or wheezing, good airway\n movement.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, decreased bowel sounds,, G-Tube in\n place with no erythema/induration\n Exte: No edema, DP 2+ bil\n NEURO: Gross Motor and Sensation in 4 extremities\n Labs / Radiology\n 249 K/uL\n 8.0 g/dL\n 122 mg/dL\n 0.5 mg/dL\n 33 mEq/L\n 3.7 mEq/L\n 13 mg/dL\n 108 mEq/L\n 146 mEq/L\n 24.7 %\n 5.5 K/uL\n [image002.jpg] CXR: L Picc, trach tip at midline, bibasilar\n opacities, low lung volumes, Bil pleural effusions.\n 03:36 AM\n 02:30 AM\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n 03:00 AM\n 04:00 AM\n 05:45 AM\n 03:51 AM\n WBC\n 6.9\n 7.6\n 9.5\n 5.7\n 7.3\n 8.0\n 8.7\n 5.5\n Hct\n 27.8\n 32.7\n 28.6\n 28.9\n 30.0\n 26.9\n 27.3\n 27.0\n 28.7\n 24.7\n Plt\n 467\n 548\n 528\n 356\n 346\n 316\n 271\n 249\n Cr\n 0.7\n 0.8\n 1.0\n 0.7\n 0.7\n 0.7\n 0.7\n 0.5\n Glucose\n 131\n 128\n 121\n 129\n 123\n 114\n 112\n 122\n Other labs: PT / PTT / INR:13.6/31.1/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:9.0 mg/dL, Mg++:2.2 mg/dL, PO4:3.1\n mg/dL\n Assessment and Plan\n 55yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach, PEG with resolving respiratory failure and HAP.\n .\n # Respiratory failure: 36hrs off vent, now on trach mask, FiO2 70%. No\n further self-decanulations overnight.\n - Tach mask as tolerated.\n - Holding sedation with exception of Risperidal 0.5mg .\n - PMV with suctioning as tolerated\n - F/u CXR tomorrow\n .\n # Nutrition/Vomiting: TFs restarted yesterday while patient was not in\n optimal positioning. One large BM in past 24 hrs to indicate potential\n improvement in ileus.\n - Cont Reglan 20mg IV Q 8 hours and restart meds via G-J tube,\n - Increase TF as tolerated\n - PICC line in place with TPN given when pt not tolerating TF\n - GI consult, appreciate recs\n .\n # Tachycardia: Improved HR max of 120\ns versus 160s previously;\n elevated this am secondary to agitation. Pt now on PO Amiodarone 200\n TID and PO metoprolol 25mg TID\n - Continue current med regimen. Will continue amiodarone 200 TID for\n three weeks and then switch to qday.\n - Will schedule f/u in 4wks with Dr. upon d/c.\n - f/u Cards recs\n # Sedation/Anxiolysis/AlteredMS: Agitation O/N, continues to be\n agitated most likely secondary to long hospital course and multiple\n psychotropic medications as well as hx of EtOH abuse. Risperdal given\n O/N.\n - started Risperdal 0.5mg PO BID\n - continue to hold all benzos. opiates, and antihistamines\n - Appreciate psych. Will f/u psych recs.\n .\n # Hypernatremia/Fluid Status: Mild hypernatramia with good UOP\n (hypervolemic hypernatremia). On TPN/TF.\n - providing D5W IVF PRN and follow lytes (check Na this afternoon).\n # UE DVT and elevated INR: Decision made to d/c Coumadin given her\n labile INR, and start Lovenox . Current INR 1.2.\n - Will flush L PICC with TPA\n .\n # Spine fracture: Stable\n - Brace for OOB, will discuss with Neurosurgery if current brace is\n optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n .\n # Tracheomalacia. Was initially addressed with IP and they wanted to\n follow up as outpatient. IP reevaluated and does not believe that a\n stent would be feasible.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # ACCESS: PIV x 1, L PICC\n # Ppx: Lovenox, PPi, Bowel Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n - Social Work and Case management involved, have discussed situation\n w/ brother and boyfriend.\n # Code: Full\n # Dispo: ICU, Screening for vent facilities\n"
},
{
"category": "Physician ",
"chartdate": "2167-10-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 639588,
"text": "Chief Complaint:\n 24 Hour Events:\n Pt agitated overnight given extra Risperidone 0.5 mg x 2 overnight.\n (1.5mg total)\n 1000 mL D5W for Hypernatremia\n Changed B-Blocker from IV to PO, Metoprolol Tartrate 25 mg PO TID\n Allergies:\n Penicillins\n Rash; blisters;\n Tetracycline\n Rash;\n Sulfa (Sulfonamides)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:17 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.7\nC (98\n HR: 120 (67 - 120) bpm\n BP: 110/64(76) {109/47(60) - 141/115(118)} mmHg\n RR: 26 (18 - 30) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 106 kg (admission): 94.2 kg\n Height: 67 Inch\n Total In:\n 3,820 mL\n 856 mL\n PO:\n TF:\n 117 mL\n 20 mL\n IVF:\n 2,612 mL\n 572 mL\n Blood products:\n Total out:\n 2,460 mL\n 1,180 mL\n Urine:\n 2,460 mL\n 1,180 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,360 mL\n -324 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 100%\n ABG: ///33/\n Physical Examination\n Gen: Awake, Mouthing words, More agitated compared to previous\n mornings.\n HEENT: EOMI, No pallor in conjunctiva, MMM\n Resp: CTAB, no rales, rhonchi, or wheezing, good airway movement.\n Card: S1S2 tachycardic, no m/r/g\n Abd: Obese, soft, mildly distended, decreased bowel sounds,, G-Tube in\n place with no erythema/induration\n Exte: No edema, DP 2+ bil\n NEURO: Gross Motor and Sensation in 4 extremities\n Labs / Radiology\n 249 K/uL\n 8.0 g/dL\n 122 mg/dL\n 0.5 mg/dL\n 33 mEq/L\n 3.7 mEq/L\n 13 mg/dL\n 108 mEq/L\n 146 mEq/L\n 24.7 %\n 5.5 K/uL\n [image002.jpg] CXR: L Picc, trach tip at midline, bibasilar\n opacities, low lung volumes, Bil pleural effusions.\n 03:36 AM\n 02:30 AM\n 01:30 AM\n 06:41 AM\n 03:20 PM\n 03:23 AM\n 03:00 AM\n 04:00 AM\n 05:45 AM\n 03:51 AM\n WBC\n 6.9\n 7.6\n 9.5\n 5.7\n 7.3\n 8.0\n 8.7\n 5.5\n Hct\n 27.8\n 32.7\n 28.6\n 28.9\n 30.0\n 26.9\n 27.3\n 27.0\n 28.7\n 24.7\n Plt\n 467\n 548\n 528\n 356\n 346\n 316\n 271\n 249\n Cr\n 0.7\n 0.8\n 1.0\n 0.7\n 0.7\n 0.7\n 0.7\n 0.5\n Glucose\n 131\n 128\n 121\n 129\n 123\n 114\n 112\n 122\n Other labs: PT / PTT / INR:13.6/31.1/1.2, CK / CKMB /\n Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,\n Amylase / Lipase:, Differential-Neuts:83.4 %, Lymph:10.4 %,\n Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, LDH:192 IU/L, Ca++:9.0 mg/dL, Mg++:2.2 mg/dL, PO4:3.1\n mg/dL\n Assessment and Plan\n 56yoF s/p mechanical fall and traumatic T spine fracture, now s/p\n trach/PEG with resolving respiratory failure and HAP.\n .\n # Respiratory failure: s/p intubation/extubation, now on trach mask,\n FiO2 70%. Tolerating well with good O2 sat. No further\n self-decanulations overnight.\n - Tach mask as tolerated.\n - Holding sedation with exception of Risperidal 0.5mg .\n - F/u CXR tomorrow\n .\n # Nutrition/Vomiting: Currently receiving TPN;. One large BM in past\n 24 hrs to indicate potential improvement in ileus.\n - Cont Reglan 20mg IV Q 8 hours; meds via G-J tube,\n - Will obtain recommendations from Nutrition re TPN before starting TPN\n tomorrow\n - TF as tolerated\n - Speech and Swallow eval\n - PICC line in place with TPN given when pt not tolerating TF\n - GI consult, appreciate recs\n .\n # Tachycardia: Improved HR max of 120\ns versus 160s previously;\n elevated this am secondary to agitation. Pt now on PO Amiodarone 200\n TID and PO metoprolol 25mg TID\n - Continue current med regimen. Will continue amiodarone 200 TID for\n three weeks and then switch to qday.\n - Will schedule f/u in 4wks with Dr. upon d/c/transfer.\n - f/u Cards recs\n # Sedation/Anxiolysis/AlteredMS: Agitation O/N, continues to be\n agitated most likely secondary to long hospital course and multiple\n psychotropic medications as well as hx of EtOH abuse. Risperdal given\n O/N.\n - started Risperdal 0.5mg PO BID\n - continue to hold all benzos. opiates, and antihistamines\n - Appreciate psych. Will call and f/u psych recs.\n #Anemia: Decrease in HCT from 28\n24; tachycardia. No known etiology of\n blood loss, most likely related to variaton\n -Will repeat HCT check this afternoon.\n # Hypernatremia/Fluid Status: Mild hypernatramia with good UOP\n (hypervolemic hypernatremia). On TPN/TF.\n - providing D5W IVF, free water flushes with TF\n -Will f/u lytes (Na) this afternoon at 5pm.\n # UE DVT and elevated INR: Decision made to d/c Coumadin given her\n labile INR, and start Lovenox . Current INR 1.2.\n - Will flush L PICC with TPA if does not flush\n .\n # Spine fracture: Stable\n - Brace for OOB, need to discuss with Neurosurgery before d/c if\n current brace is optimal for stabilization given her mobility.\n - Pt to follow up with Dr. in weeks\n .\n # Tracheomalacia. Was initially addressed with IP and they wanted to\n follow up as outpatient. IP reevaluated and does not believe that a\n stent would be feasible. No new issues.\n .\n #. Thyroid Nodule on CT\n - Outpatient follow up\n .\n # Glycemic control: SSI, well controlled\n # ACCESS: PIV x 1, L PICC\n # Ppx: Lovenox, PPi, Bowel Regimen PRN\n # Communication:\n - Boyfriend of 10 \n - Brother also involved\n - Social Work and Case management involved, have discussed situation\n w/ brother and boyfriend.\n # Code: Full\n # Dispo: ICU, Will d/w case management re rehab facilities.\n"
},
{
"category": "Nutrition",
"chartdate": "2167-10-20 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 638618,
"text": "Objective\n Pertinent medications: noted\n Labs:\n Value\n Date\n Glucose\n 128 mg/dL\n 02:30 AM\n Glucose Finger Stick\n 142\n 10:00 AM\n BUN\n 6 mg/dL\n 02:30 AM\n Creatinine\n 0.8 mg/dL\n 02:30 AM\n Sodium\n 148 mEq/L\n 02:30 AM\n Potassium\n 4.1 mEq/L\n 02:30 AM\n Chloride\n 105 mEq/L\n 02:30 AM\n TCO2\n 36 mEq/L\n 02:30 AM\n Albumin\n 3.5 g/dL\n 03:00 AM\n Calcium non-ionized\n 10.0 mg/dL\n 02:30 AM\n Phosphorus\n 4.3 mg/dL\n 02:30 AM\n Ionized Calcium\n 1.24 mmol/L\n 02:51 AM\n Magnesium\n 2.5 mg/dL\n 02:30 AM\n ALT\n 25 IU/L\n 07:34 AM\n Alkaline Phosphate\n 106 IU/L\n 07:34 AM\n AST\n 19 IU/L\n 07:34 AM\n WBC\n 7.6 K/uL\n 02:30 AM\n Hgb\n 10.0 g/dL\n 02:30 AM\n Hematocrit\n 32.7 %\n 02:30 AM\n Current diet order / nutrition support: NPO\n GI: Abd soft/obese/hypo bs\n Assessment of Nutritional Status\n Estimation of previous intake: Adequate\n Estimation of current intake: Inadequate\n Specifics:\n 55 y/o female s/p mechanical fall c/ T5-T8 fx c/ long hospital course,\n now s/p trach and PEG. Pt currently not receiving TF\ns development\n of N/V while TF\ns were infusing, despite addition of reglan. Ongoing\n discussion re changing FT to post-pyloric/JT, and the best way to do\n this. Hypernatremia since feeds/flushes held. Noted 500mL D5W\n given.\n Medical Nutrition Therapy Plan - Recommend the Following\n Will follow POC- ability to obtain access for resuming feeds, If unable\n to resume enteral feeds in next 2-3 days, will need to consider PPN/TPN\n to avoid nutritional decline\n Continue to monitor hydration status and give fluid prn\n Please page c/ ?\ns #\n"
}
] |
30,725 | 137,529 | 1) Hypertension Patient had ran out of her medication 2 weeks prior to presentation. No chest pain or dyspnea. Initially started on nitro-drip, could quickly wean off and change to PO medication. BPs hard to control after that, several dose increases were necessary to achieve goal of systolic BP around 150-170. Renal service was consulted to rule out secondary causes of hypertension. They did not feel a CT scan for renal artery stenosis was necessary at this point. Serum cortisol was normal with 28.1. Per patient's PCP, workup for pheochromocytoma had been negative. Patient wanted to leave the hospital before her BPs were stable with the new regimen (amlodipine, lisinopril, HCTZ, labetalol). She will need to be seen very soon as outpatient. Also, she was hypokalemic to 3.2 and was repleted on day of discharge (likely in setting of new diuretics). Her K+ should be rechecked soon. . 2) Hemoptysis Unclear etiology, patient with one episode of hemopytsis/spitting up blood. No more episodes during hospital course. Hct was stable. CTA was unremarkable, PPD had been negative in the past. Stools were OB negative, no melena. If necessary, will need outpatient work-up. . 3) Renal failure. Creatinine stable at 1.3. Unclear baseline. Likely renal insufficiency in setting of uncontrolled hypertension. Will need outpatient follow-up. | c/o nausea x 1, resolved with no intervention. Nurisng Note MICU-7 7A-7P:Neuro: Patient is withdrawn, flat affect. VOIDED 250CC THIS SHIFT, OOB TO COMMODE TIMES ONE.GI: TAKING PO'S WELL, NO C/O'S PAIN, NO STOOL. Informed pt of the request for nasal CPAP. 12:41 AM CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # Reason: HEMOPTYSIS, SOB Contrast: OPTIRAY Amt: 90 MEDICAL CONDITION: 27 yo f with hemoptysis and sob REASON FOR THIS EXAMINATION: eval for pe No contraindications for IV contrast WET READ: MPtb MON 2:31 AM No PE, essentially unremarkable study. Zofran given with good effect.Skin: w/d/iA/P: HTN- PO meds titrated up. no need for breakthrough meds o/n.. had sbp 180 x 1, repeate check was 150's. Team cosidering bronch on outpatient basis, once bp better controlled. Quiet, soft spoken.CV: NSR-ST. 82-110. PT STATES THAT SHE HAS HER PERIOD.GU: PT VOIDED IN THE ED BUT HAS NOT VOIDED HERE IN THE MICU.SKIN: PT'S SKIN IS INTACT.ACCESS: PT HAS 2 # 18 PIV'S, THE ONE ON THE LEFT HAND IS CLOTTED.SOCIAL: PT IS A FULL CODE. Respiratory TherapyPt presents left lat High position soft snorous respirations. No cough or sob noted.GI/GU: abd obese, soft, +BS. GU: voiding via bsc. 'ING SLEEP APNEA. PT IS AFEBRILE.GI: PT C/O NAUSEA SHORTLY AFTER ARRIVAL TO THE UNIT. AT THIS TIME GOAL IS TO GET BP DOWN WITH PO MEDS. to start labetolol in am and lopressor was dc'd. Complained of difficulty breathing @ 1600, upon examination lungs clear, breathing 12-15 bpm, unlabored. PT HAD CTA DONE WHICH R/O PE. Patient received PO anti-hypertensives this AM, IVP hydralizine Q6hrs PRN. CV: sbp 150's-160's, HR 70's -80's nsr. Afeb.Resp: LS CTA. unclear who told her this.Hemoptysis- No further hemoptysis, CT negative for PE. BP VERY HYPERTENSIVE 170-190'S AT THIS TIME. NPN MICU- 7AM-7PM28 YO FEMALE WITH HTN.S/O: RESPIR: ON RA O2 SATS 93-97%, RR 16-22, L/S CLEAR TO DIMINISHED @ BASES, BUT WHEN ASLEEP DOES DESATS TO 88-90%, ? most likely c/o to floor today. REsP: trialed on nasal bipap. Respiratory TherapyIntermittent use of nasal CPAP. trialed nasal bipap o/n. The heart size and mediastinal contours are within normal limits. NO SOB.C/V: BP IN THE AM 180-190'S/90'S, WAS DUE FOR HER AM MEDS, AND LOPRESSOR WAS INCREASED TO 100MG, NOW BP 160-178'S/70, HR- 70-80'S SR NO ECTOPY NOTED.RENAL: LOW U/O WITH CRE UP TO 1.6 ? The lungs are essentially clear excepting for mild basilar atelectasis on the left. NTG DRIP D/C'D ON ARRIVAL TO THE MICU.RESP: PT ARRIVED FROM THE ED WITH 3LNC WITH O2 SAT'S IN THE HIGH 90'S. Long acting Toprol changed to Lopressor TID for ease of titration. PT 4MG ZOFRAN IVP. Independently transfers to commode and back to bed without problem. Sinus rhythmLeft ventricular hypertrophy with ST-T abnormalitiesThe ST-T changes are diffuse - clinical correlation is suggestedNo previous tracing available for comparison LUNG SOUNDS CLEAR AND HAS NOT COUGH UP ANY BLOOD SINCE ARRIVAL.CV: PT IN NSR WITH HR IN THE 80'S. PT VOMITED AMT OF CLEAR WITH SOME DK MATERIAL. Given Hydralazine as above with fair effect. then fell asleep without it.. overall wore mask sporadically and for brief intervals. no gross motor defecits noted. no c/o sob. IMPRESSION: No acute cardiopulmonary process. Essentially unremarkable study. PT C/O HA WHICH WAS PROBABLY CAUSED BY THE NTG DRIP. No stool this shift.GU: Voiding clear yellow urine per commode.Plan: Called out for floor, awaiting bed. PT HAS A JOB AND LIVES ALONE.REVIEW OF SYSTEMS:NEURO: PT ALERT AND ORIENTED X 3. UNABLE TO DO SO D/T HER NAUSEA. PT STARTED ON NTG DRIP AND NTG PASTE AND LABETOLOL IVP WHICH BROUGHT HER BP DOWN TO 150'S. +BS. GI: ab obese, bs +. CHECK LYTES. Patient has received no sedating medication this shift.Resp: SAT 96-99% on room air. NPN 7p-7a: Nuero: pt A+O x 3. continues with HA, treated with 650mg po tylenol, then 5mg oxycodone po with relief. No c/o HA or pain. No ectopy noted. NPN 1900-0700:Neuro: alert, oriented x3, pleasant and cooperative with care, c/o headache received Tylenol as PRN with good effect, c/o nausea, received antiemetic PRN with good effect, following commands consistently.Resp: breathing regularly on NC 3 LPM, sat 91-96, yet desats to 80s when pulling the O2 out, LS CTA, RR 14-20.CV: NSR-ST HR 80-102, BP was 183/90 when received at 1900, received a dose of lopressor po as ordered and BP has stable for the rest of the night, hydralazine was ordered PRN but not needed, with 2 PIV lines, palpable peripheral pulses.GI/GU: eating with very good appetite, BS present, voiding freely (in bed-pan) and adequately.Integ: intact skin integrity, T max 98.7.Social: full code, mother and cousin visited and updated on .Plan: monitor and control BP, HO will contact where the pt use to receive tx, yet she came this time to because is full. Lung sounds clear but diminished due to size. Sbp 164-198. Oriented pt to purpose of mask and how it might feel.Pt then acclimated well to silicone med nasal mask CPAP 5/5. So far has tol mask for 2 hrs.,however has off and on to use the commode. NPN 7a-7pFull CodePlease see carevue and FHP for additional data.NKDANeuro: AOx3. a/P: pt now within goal bp range. Then noted to have continued nausea. PT IS VERY OBESE, ABD SOFT DISTENDED WITH POS BOWEL SOUNDS. PT THEN FELL ASLEEP AND IS QUIET AT THIS TIME. pt was not very compliant.. removing mask and leaving it on bed frequently. RR teens, O2 sats low to mid 90's. stated patient kept closing eyes and drifting off during conversation. CT OF THE CHEST WITH IV CONTRAST: The pulmonary arterial tree opacifies well without evidence of pulmonary embolism. | 13 | [
{
"category": "Radiology",
"chartdate": "2180-07-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 975649,
"text": " 11:02 PM\n CHEST (PORTABLE AP) Clip # \n Reason: STAT CXR, eval asp, acute process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old woman with hematemesis\n REASON FOR THIS EXAMINATION:\n STAT CXR, eval asp, acute process\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 27-year-old female with hematemesis.\n\n COMPARISON: No prior study available.\n\n CHEST, PORTABLE UPRIGHT AP VIEW: This study is limited by underpenetration\n due to the patient's large body habitus. The heart size and mediastinal\n contours are within normal limits. There is normal pulmonary vascularity.\n The lungs are grossly clear. No pleural effusion or pneumothorax is seen.\n\n IMPRESSION: No acute cardiopulmonary process.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-07-24 00:00:00.000",
"description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY",
"row_id": 975652,
"text": " 12:41 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: HEMOPTYSIS, SOB\n Contrast: OPTIRAY Amt: 90\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 yo f with hemoptysis and sob\n REASON FOR THIS EXAMINATION:\n eval for pe\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MPtb MON 2:31 AM\n No PE, essentially unremarkable study.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 27-year-old female with hemoptysis and difficulty breathing and\n concern for pulmonary embolism.\n\n COMPARISON: No prior study available.\n\n TECHNIQUE: MDCT continuously acquired axial images of the chest were obtained\n after a rapid bolus of 100 mL Optiray IV contrast per the chest pain protocol.\n Multiplanar reformations were obtained.\n\n CT OF THE CHEST WITH IV CONTRAST: The pulmonary arterial tree opacifies well\n without evidence of pulmonary embolism. The abdominal aorta is normal in\n caliber without traumatic injury. There is no pathologic mediastinal, hilar\n or axillary lymphadenopathy. The lungs are essentially clear excepting for\n mild basilar atelectasis on the left. There is no focal consolidation,\n pleural effusion, or pneumothorax. Limited evaluation of the upper abdomen\n demonstrates no significant abnormality.\n\n BONE WINDOWS: No suspicious osteoblastic or osteolytic lesions are seen.\n\n IMPRESSION: No evidence of pulmonary embolism. Essentially unremarkable\n study.\n\n ER dashboard wet read placed at 2:30 a.m. on .\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-07-24 00:00:00.000",
"description": "Report",
"row_id": 1656878,
"text": "NURSING PROGRESS NOTE:\nCODE STATUS: FULL CODE.\n\nALLERGY: NKDA\n\nPRECAUTION: UNIVERSAL\n\nCHIEF COMPL: HEMOPTOSIS, SOB.\n\nTHIS IS A 28 YO FEMALE WHO WAS ADM WITH HEMOPTOSIS AND WAS FOUND TO BE IN HYPERTENSIVE CRISIS IN THE ED WITH BP GREATER THAN 250. IN THE PT FILLED BOX OF TISSUE WITH APPOX 100CC BRB. PT STARTED ON NTG DRIP AND NTG PASTE AND LABETOLOL IVP WHICH BROUGHT HER BP DOWN TO 150'S. PT HAD CTA DONE WHICH R/O PE. PT STATED THAT SHE HAD RUN OUT OF HER BP MEDICATIONS FOR OVER A WEEK. PT HAS A JOB AND LIVES ALONE.\n\nREVIEW OF SYSTEMS:\n\nNEURO: PT ALERT AND ORIENTED X 3. VERY SOFT SPOKEN AND SHY. PT ABLE TO MOVE ALL EXTREMETIES. PT C/O HA WHICH WAS PROBABLY CAUSED BY THE NTG DRIP. NTG DRIP D/C'D ON ARRIVAL TO THE MICU.\n\nRESP: PT ARRIVED FROM THE ED WITH 3LNC WITH O2 SAT'S IN THE HIGH 90'S. LUNG SOUNDS CLEAR AND HAS NOT COUGH UP ANY BLOOD SINCE ARRIVAL.\n\nCV: PT IN NSR WITH HR IN THE 80'S. BP VERY HYPERTENSIVE 170-190'S AT THIS TIME. PT GIVEN LOPRESSOR 5MG IVP. PT IS AFEBRILE.\n\nGI: PT C/O NAUSEA SHORTLY AFTER ARRIVAL TO THE UNIT. PT 4MG ZOFRAN IVP. PT VOMITED AMT OF CLEAR WITH SOME DK MATERIAL. PT THEN FELL ASLEEP AND IS QUIET AT THIS TIME. PT IS VERY OBESE, ABD SOFT DISTENDED WITH POS BOWEL SOUNDS. PT STATES THAT SHE HAS HER PERIOD.\n\nGU: PT VOIDED IN THE ED BUT HAS NOT VOIDED HERE IN THE MICU.\n\nSKIN: PT'S SKIN IS INTACT.\n\nACCESS: PT HAS 2 # 18 PIV'S, THE ONE ON THE LEFT HAND IS CLOTTED.\n\nSOCIAL: PT IS A FULL CODE. NO CONTACT WITH FAMILY MEMBERS. PT NEEDS TEACHING ABOUT THE IMPORTANCE OF TAKING HER MEDS. NOT SURE WHY SHE COULDN'T GET THEM. ALSO SHOULD HAVE A NUTRITIONIST SPEAK WITH HER. AT THIS TIME GOAL IS TO GET BP DOWN WITH PO MEDS. UNABLE TO DO SO D/T HER NAUSEA.\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-07-27 00:00:00.000",
"description": "Report",
"row_id": 1656887,
"text": "Discharge note\n28 yo with HTN, who wanted to go home today, was d/c'd to home with PCP f/u appt already made date- Monday-, date printed on D/C papers, along with medication scripts and medication infomation, was reviewed with pt with handouts on each med. Stated that she understood the importance of follow-up with PCP and the importance of taking her meds as directed. Was d/c'd home with mother.\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-07-26 00:00:00.000",
"description": "Report",
"row_id": 1656883,
"text": "Nurisng Note MICU-7 7A-7P:\n\nNeuro: Patient is withdrawn, flat affect. Sleeping most of shift, or lying in bed with eyes closed. C/o headache @ 1600, Tylenol 650mg PO. Independently transfers to commode and back to bed without problem. Initially refused to speak with Social Worker because of \"pain\". When questioned by RN, stated her IV in her hand hurt. Encouraged pt. to speak with social worker; patient agreed, but then cut meeting short after only a couple minutes stating she could not go on. stated patient kept closing eyes and drifting off during conversation. Patient has received no sedating medication this shift.\n\nResp: SAT 96-99% on room air. Sleeping much of shift with head elevated without drop in SAT. Renal consult recommends CPAP at night for probable sleep apnea. Lung sounds clear but diminished due to size. No cough. Complained of difficulty breathing @ 1600, upon examination lungs clear, breathing 12-15 bpm, unlabored. SAT 99% on room air.\n\nCV: NSR 70's. Skin warm, dry, intact. Palp. pedal pulses. Patient received PO anti-hypertensives this AM, IVP hydralizine Q6hrs PRN. SBP 135-175. IV R hand painful flush, unable to place now peripheral, IV team called, unable to find vein for new IV.\n\nGI: Patient complained of nausea this morning, Compazine IV given @1000. Patient ate 100% of breakfast and lunch. Nutrition consult to speak with patient regarding low sodium diet, food choices. Abdomen obese, soft. +BS. No stool this shift.\n\nGU: Voiding clear yellow urine per commode.\n\nPlan: Called out for floor, awaiting bed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-07-26 00:00:00.000",
"description": "Report",
"row_id": 1656884,
"text": "Respiratory Therapy\nPt presents left lat High position soft snorous respirations. Informed pt of the request for nasal CPAP. Oriented pt to purpose of mask and how it might feel.Pt then acclimated well to silicone med nasal mask CPAP 5/5. So far has tol mask for 2 hrs.,however has off and on to use the commode. Suggest formal sleep study to titrate pressures and provide the best appliance for optimal pt compliance.\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-07-27 00:00:00.000",
"description": "Report",
"row_id": 1656885,
"text": "NPN 7p-7a:\n Nuero: pt A+O x 3. continues with HA, treated with 650mg po tylenol, then 5mg oxycodone po with relief. pt reporting hands have been trembling lately, and she is having trouble doing things like holding a pen/silverware, etc. no gross motor defecits noted. team made aware.\n CV: sbp 150's-160's, HR 70's -80's nsr. to start labetolol in am and lopressor was dc'd. no need for breakthrough meds o/n.. had sbp 180 x 1, repeate check was 150's.\n REsP: trialed on nasal bipap. pt was not very compliant.. removing mask and leaving it on bed frequently. then fell asleep without it.. overall wore mask sporadically and for brief intervals. RR teens, O2 sats low to mid 90's. no c/o sob.\n GI: ab obese, bs +. tolerated dinner. c/o nausea x 1, resolved with no intervention.\n GU: voiding via bsc. urine sent for protein.\n no iv access. team aware. am bloods drawn by phlebotomy.\n integ; intact.\n social: pt's mom called and spoke to pt.\n a/P: pt now within goal bp range. trialed nasal bipap o/n. most likely c/o to floor today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-07-27 00:00:00.000",
"description": "Report",
"row_id": 1656886,
"text": "Respiratory Therapy\nIntermittent use of nasal CPAP. fragmented sleep. Suggest Pulmonary consult and formal sleep study.\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-07-25 00:00:00.000",
"description": "Report",
"row_id": 1656881,
"text": "NPN MICU- 7AM-7PM\n28 YO FEMALE WITH HTN.\n\nS/O: RESPIR: ON RA O2 SATS 93-97%, RR 16-22, L/S CLEAR TO DIMINISHED @ BASES, BUT WHEN ASLEEP DOES DESATS TO 88-90%, ?'ING SLEEP APNEA. NO SOB.\n\nC/V: BP IN THE AM 180-190'S/90'S, WAS DUE FOR HER AM MEDS, AND LOPRESSOR WAS INCREASED TO 100MG, NOW BP 160-178'S/70, HR- 70-80'S SR NO ECTOPY NOTED.\n\nRENAL: LOW U/O WITH CRE UP TO 1.6 ?'ING BASELINE LEVEL. BUN-16. TAKING PO'S WELL BUT HAD A CTA YESTERDAY SO REC'D 500CC NS. VOIDED 250CC THIS SHIFT, OOB TO COMMODE TIMES ONE.\n\nGI: TAKING PO'S WELL, NO C/O'S PAIN, NO STOOL. HCT-36.9.\n\nNEURO: A&OX3. OOB TO CHAIR TIMES ONE FOR 3HRS.\n\nAWAITING BED ON THE FLOOR.\n\nA/P: CONTINUE TO MONITOR BP, ADMINISTER ANTI-HYPERTENSIVES, ASSESS I&OS'S. CHECK LYTES.\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-07-26 00:00:00.000",
"description": "Report",
"row_id": 1656882,
"text": "NPN 1900-0700:\nNeuro: alert, oriented x3, c/o headache given Tylenol with no relief then Oxycodone with good effect, vomited about 600cc, given zofran, then c/o nauses given compazine, going out of bed to the commode without assistance.\n\nResp: breathing regularly on RA, sating well, however she desated to high 80s, O2 NC applied at 3 LPM raised sat to high 90s, but pt pulled it out immediately, RR 11-23, sat 92-100%, LS CTA.\n\nCV: NSR HR 68-82, BP 150-191/85-129, with one PIV line, BP increased to 201 systolic responded to Hydralazine 20 mg IV, started on PO captopril, still on Lopressor Po too.\n\nGI/GU: pt is eating with excellent appetite, obese, BS present, voiding freely and adequately in the commode independently.\n\nInteg: T max 98.5, intact skin integrity.\n\nSocial: full code, asking to be discharged tomorrow and to come back to work next Tuesday because she's not paid by her employer if she's not working, needs a paper from physician proving she's been in hospital, social worker consulted, pt needs a ride or a ticket for a cab due to financial issues.\n\nPlan: continue monitoring BP, control BP, headache, nausea, and vomiting, urine is to be sent for VMA to R/O pheocromocytoma.\n\nN.B: pt is called out, transfer note written.\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-07-24 00:00:00.000",
"description": "Report",
"row_id": 1656879,
"text": "NPN 7a-7p\nFull Code\nPlease see carevue and FHP for additional data.\nNKDA\n\nNeuro: AOx3. Pleasant, cooperative with care. MAE. No c/o HA or pain. Quiet, soft spoken.\nCV: NSR-ST. 82-110. No ectopy noted. Sbp 164-198. Received 10mg total of 40mg iv Hydralazine in divided doses for bp control. Also received one time order of 5mg of Amlodipine. Fair effect noted. Long acting Toprol changed to Lopressor TID for ease of titration. Goal sbp 150-160's. Afeb.\nResp: LS CTA. Sats 89-98%. Noted to drop to 89% when sleeping, ? OSA. No cough or sob noted.\nGI/GU: abd obese, soft, +BS. No stool. Diet advanced, pt ordered hamburger, salad, corn, and ice cream. Then noted to have continued nausea. Zofran given with good effect.\nSkin: w/d/i\nA/P: HTN- PO meds titrated up. Given Hydralazine as above with fair effect. Goal sbp 150-160's. Patient stated that she was told that she had to see her doctor before she could refill her bp med. script. unclear who told her this.\nHemoptysis- No further hemoptysis, CT negative for PE. Team cosidering bronch on outpatient basis, once bp better controlled. ? nutrition consult.\nCont. providing supportive care.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-07-25 00:00:00.000",
"description": "Report",
"row_id": 1656880,
"text": "NPN 1900-0700:\nNeuro: alert, oriented x3, pleasant and cooperative with care, c/o headache received Tylenol as PRN with good effect, c/o nausea, received antiemetic PRN with good effect, following commands consistently.\n\nResp: breathing regularly on NC 3 LPM, sat 91-96, yet desats to 80s when pulling the O2 out, LS CTA, RR 14-20.\n\nCV: NSR-ST HR 80-102, BP was 183/90 when received at 1900, received a dose of lopressor po as ordered and BP has stable for the rest of the night, hydralazine was ordered PRN but not needed, with 2 PIV lines, palpable peripheral pulses.\n\nGI/GU: eating with very good appetite, BS present, voiding freely (in bed-pan) and adequately.\n\nInteg: intact skin integrity, T max 98.7.\n\nSocial: full code, mother and cousin visited and updated on .\n\nPlan: monitor and control BP, HO will contact where the pt use to receive tx, yet she came this time to because is full. Pt ran out of meds for 2 weeks the reason her BP raised so high, HO will f/U on what work has been done at and continue tx from there, R/O pheocromocytoma, hyperaldosteronism, and other conditions leading to hypertensive crisis.\n"
},
{
"category": "ECG",
"chartdate": "2180-07-24 00:00:00.000",
"description": "Report",
"row_id": 181390,
"text": "Sinus rhythm\nLeft ventricular hypertrophy with ST-T abnormalities\nThe ST-T changes are diffuse - clinical correlation is suggested\nNo previous tracing available for comparison\n\n"
}
] |
45,319 | 194,809 | # Cardiac arrest: based on history most likely etiology was aspiration event resulting in likely PEA arrest. Evidence of bilateral multifocal pneumonia on CTA is consistent with this possibility. Patient without evidence of cardiac ischemia by ECG or cardiac biomarkers. CPR initiated in the field with return of pulses. Reportedly, in the emergency room a family member said the patient was full code. Therefore, hypothermia protocol was initiated in the ED, and patient remained intubated. In the morning, the patient's power of attorney (Mr. ) called to report patient was DNr/DNI. The paperwork making him POA were faxed to the MICU. Mr. was spoken to over the phone (he resides out of state) and confirmed the patient was DNR/DNI prior to her arrest. The patient was thus rewarmed using the re-warming protocol. according to the patient's prior wishes she was extubated and died at 5:24pm. The family declined autopsy but the medical examiner accepted the case. The NEOB was contact but did not deem her a candidate for organ donation. | Unchanged retrocardiac atelectasis. Increased small right pleural effusion and decreased small left pleural effusion. The Q-T interval is prolonged.There is minimal ST segment elevation in the inferior leads. The aorta contains moderate atherosclerotic calcification. The retrocardiac atelectasis is unchanged. Non-specificST-T wave changes. There is a small increased right pleural effusion and small decreased left effusion. Right IJ catheter was presumably removed. TECHNIQUE: Non-contrast head CT with axial, coronal, sagittal reformations. There is mitral annular calcification. Compared to the previous tracing of sinus rhythm has been restored and right bundle-branch block and left anteriorfascicular block have resolved. The endotracheal tube ends 1.2 cm above the carina. Left axis deviation.Right bundle-branch block with left anterior fascicular block. Bilateral lower lobe opacity with prominence of the right hilum. ONE VIEW OF THE CHEST: The lungs are low in volume and show bilateral lower lobe and right middle lobe opacity. There is persistent pulmonary edema that is in a different distribution, although the degree of pulmonary edema is unchanged. The heart is borderline enlarged but unchanged in size. Sinus rhythm. Sinus bradycardia. An ET tube terminates 1.8 cm above the carina. Minimal mucosal thickening within the ethmoid sinus as well. IMPRESSION: 1. IMPRESSION: 1. IMPRESSION: 1. Probable junctional rhythm versus a rhythm originating in the posteriorfascicle of the left-sided conduction system. The cardiac silhouette shows mitral annular calcifications. FINDINGS: There is relatively little overall change in the appearance of the heart and lungs. Status post cardiac arrest. The imaged paranasal sinuses are notable for a small fluid level within the left sphenoid sinus. The hilar contours show prominence of the right hilum. Low voltage in the limb leads. ETT tip positioned 1.5 cm above the carina, recommend slight retraction. The mastoid air cells and middle ear cavities are well aerated. No pleural effusions. Vascular calcifications along the carotid siphon noted. There is persistent bilateral perihilar haze. Motion artifact limits evaluation. Coronary artery calcification also noted. There is relatively little overall change in the appearance of the lungs. Clinicalcorrelation is suggested. TECHNIQUE: MDCT helical images were acquired through the chest with and without IV contrast: Multiplanar reformations were obtained and reviewed. In addition, scattered opacities in the lungs anteriorly are noted likely reflecting additional aspiration. Question ICH. An NG tube terminates within the stomach. Could be secondary to aspiration. ET tube terminates 1.8 cm above the carina and should be retracted by about 1 cm. FINDINGS: Motion artifact limits evaluation. No intracranial hemorrhage. IMPRESSION: Chronic microvascular ischemic disease, no hemorrhage, left sphenoid sinus disease. Extensive bilateral predominantly posterior pulmonary consolidations, likely the sequela of aspiration. The NG tube extends into the stomach and out of the field of view. Bony calvarium appears intact. Lung volumes remain low, but are slightly increased. REASON FOR THIS EXAMINATION: Any interval change? There is no associated retrosternal hematoma. Involutional changes are age-appropriate. Apparent sternal fracture for which clinical correlation is advised to determine acuity. (Over) 7:27 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # Reason: r/o PE Field of view: 36 Contrast: OPTIRAY Amt: FINAL REPORT (Cont) 3. No pleural effusions are present. Heart size appears normal and there is no pericardial effusion. No other acute intracranial process. COMPARISON: Chest radiograph from . OSSEOUS STRUCTURES: The osseous structures show no suspicious lytic or blastic lesions. OGT positioned appropriately. No previous tracing availablefor comparison.TRACING #1 No PE. No PE. COMPARISON: None available. COMPARISON: None available. 3. S/p cardiac arrest. ST segment elevation is new.TRACING #3 2. 2. 2. CT OF THE CHEST WITH IV CONTRAST: An ET tube is noted with tip 1.5 cm above the carina. Although this examination was not intended for subdiaphragmatic evaluation, the partially imaged abdomen appears unremarkable. 4. There is no pulmonary arterial filling defect to suggest PE. FINAL REPORT INDICATION: Multifocal pneumonia versus ARDS. Periventricular white matter hypodensities are compatible with chronic microvascular ischemic disease. 3:23 AM CHEST (PORTABLE AP) Clip # Reason: Any interval change? Extensive consolidation in the posterior lungs, primary the lower lobes is suggestive of aspiration sequelae. There are decreased opacities in the right mid and lower lungs but increased opacities in the left mid and lower lungs, consistent with redistribution of edema. Allowing for this, there is no intracranial hemorrhage, edema, shift of normally midline structures, or hydrocephalus. If the outside hospital report was definitive, please provide location. Increased bronchial cuffing is noted. Compared to the previous tracing these findings are new.TRACING #2 There is no lymphadenopathy. OGT extends into the stomach. Artifact is present. ICH on OSH study limited by artifact REASON FOR THIS EXAMINATION: r/o ICH No contraindications for IV contrast WET READ: ASpf WED 8:18 PM Motion degrades study. Multifocal pneumonia is not likely given the rapid decrease in the right lung opacities. A sternal deformity is noted on the sagittal reformats, image 27, possibly a fracture related to CPR though clinical correlation advised. Also noted are healed nondisplaced fractures of the right seventh and sixth ribs. Please refer to subsequent chest CT for further details. There is no pneumothorax identified. FINAL REPORT INDICATION: 84-year-old woman with status post arrest with low sats despite intubation. 7:27 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # Reason: r/o PE Field of view: 36 Contrast: OPTIRAY Amt: MEDICAL CONDITION: 84 year old woman with s/p arrest w/ low sat despite intubation and neg CXR at OSH REASON FOR THIS EXAMINATION: r/o PE No contraindications for IV contrast WET READ: ASpf WED 8:17 PM Bilateral multifocal consolidations worse in the lung bases representing pneumonia. | 7 | [
{
"category": "Radiology",
"chartdate": "2119-12-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1171146,
"text": " 3:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Any interval change?\n Admitting Diagnosis: PNEUMONIA;S/P CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with multifocal pneumonia vs. ARDS. S/p cardiac arrest.\n REASON FOR THIS EXAMINATION:\n Any interval change?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Multifocal pneumonia versus ARDS. Status post cardiac arrest.\n\n COMPARISON: Chest radiograph from .\n\n FINDINGS: There is relatively little overall change in the appearance of the\n heart and lungs. The endotracheal tube ends 1.2 cm above the carina. The NG\n tube extends into the stomach and out of the field of view. The heart is\n borderline enlarged but unchanged in size. There is a small increased right\n pleural effusion and small decreased left effusion. Increased bronchial\n cuffing is noted. There is persistent bilateral perihilar haze. There are\n decreased opacities in the right mid and lower lungs but increased opacities\n in the left mid and lower lungs, consistent with redistribution of edema.\n Lung volumes remain low, but are slightly increased. There is no pneumothorax\n identified. The retrocardiac atelectasis is unchanged.\n\n IMPRESSION:\n 1. There is relatively little overall change in the appearance of the lungs.\n There is persistent pulmonary edema that is in a different distribution,\n although the degree of pulmonary edema is unchanged. Multifocal pneumonia is\n not likely given the rapid decrease in the right lung opacities.\n 2. Unchanged retrocardiac atelectasis.\n 3. Increased small right pleural effusion and decreased small left pleural\n effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-12-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1171119,
"text": " 7:17 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ETT placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with intubation and low O2 sat\n REASON FOR THIS EXAMINATION:\n ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 84-year-old woman with intubation and low O2 sat.\n\n COMPARISON: None available.\n\n ONE VIEW OF THE CHEST: The lungs are low in volume and show bilateral lower\n lobe and right middle lobe opacity. The cardiac silhouette shows mitral\n annular calcifications. The hilar contours show prominence of the right\n hilum. No pleural effusions are present. An NG tube terminates within the\n stomach. An ET tube terminates 1.8 cm above the carina.\n\n IMPRESSION:\n 1. Bilateral lower lobe opacity with prominence of the right hilum. Please\n refer to subsequent chest CT for further details.\n 2. ET tube terminates 1.8 cm above the carina and should be retracted by\n about 1 cm.\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-12-13 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1171120,
"text": " 7:26 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o ICH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with s/p arrest ? ICH on OSH study limited by artifact\n REASON FOR THIS EXAMINATION:\n r/o ICH\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ASpf WED 8:18 PM\n Motion degrades study. No intracranial hemorrhage. If the outside hospital\n report was definitive, please provide location. No other acute intracranial\n process.\n ______________________________________________________________________________\n FINAL REPORT\n NON-CONTRAST HEAD CT PERFORMED ON \n\n CLINICAL HISTORY: 84-year-old woman status post arrest, question outside\n hospital study ICH, artifact limited. Question ICH.\n\n TECHNIQUE: Non-contrast head CT with axial, coronal, sagittal reformations.\n\n FINDINGS: Motion artifact limits evaluation. Allowing for this, there is no\n intracranial hemorrhage, edema, shift of normally midline structures, or\n hydrocephalus. Periventricular white matter hypodensities are compatible with\n chronic microvascular ischemic disease. Vascular calcifications along the\n carotid siphon noted. Involutional changes are age-appropriate. The imaged\n paranasal sinuses are notable for a small fluid level within the left sphenoid\n sinus. Minimal mucosal thickening within the ethmoid sinus as well. The\n mastoid air cells and middle ear cavities are well aerated. Bony calvarium\n appears intact.\n\n IMPRESSION: Chronic microvascular ischemic disease, no hemorrhage, left\n sphenoid sinus disease. Motion artifact limits evaluation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-12-13 00:00:00.000",
"description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY",
"row_id": 1171121,
"text": " 7:27 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: r/o PE\n Field of view: 36 Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with s/p arrest w/ low sat despite intubation and neg CXR at\n OSH\n REASON FOR THIS EXAMINATION:\n r/o PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ASpf WED 8:17 PM\n Bilateral multifocal consolidations worse in the lung bases representing\n pneumonia. Could be secondary to aspiration. No PE. Right IJ catheter was\n presumably removed.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 84-year-old woman with status post arrest with low sats despite\n intubation.\n\n COMPARISON: None available.\n\n TECHNIQUE: MDCT helical images were acquired through the chest with and\n without IV contrast: Multiplanar reformations were obtained and reviewed.\n\n CT OF THE CHEST WITH IV CONTRAST: An ET tube is noted with tip 1.5 cm above\n the carina. OGT extends into the stomach. There is no pulmonary arterial\n filling defect to suggest PE. The aorta contains moderate atherosclerotic\n calcification. Coronary artery calcification also noted. There is mitral\n annular calcification. Heart size appears normal and there is no pericardial\n effusion. There is no lymphadenopathy.\n\n Extensive consolidation in the posterior lungs, primary the lower lobes is\n suggestive of aspiration sequelae. In addition, scattered opacities in the\n lungs anteriorly are noted likely reflecting additional aspiration. No pleural\n effusions.\n\n Although this examination was not intended for subdiaphragmatic evaluation,\n the partially imaged abdomen appears unremarkable.\n\n OSSEOUS STRUCTURES: The osseous structures show no suspicious lytic or blastic\n lesions. A sternal deformity is noted on the sagittal reformats, image 27,\n possibly a fracture related to CPR though clinical correlation advised. There\n is no associated retrosternal hematoma. Also noted are healed nondisplaced\n fractures of the right seventh and sixth ribs.\n\n IMPRESSION:\n\n 1. Extensive bilateral predominantly posterior pulmonary consolidations,\n likely the sequela of aspiration.\n\n 2. No PE.\n (Over)\n\n 7:27 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: r/o PE\n Field of view: 36 Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 3. Apparent sternal fracture for which clinical correlation is advised to\n determine acuity.\n\n 4. ETT tip positioned 1.5 cm above the carina, recommend slight retraction.\n OGT positioned appropriately.\n\n"
},
{
"category": "ECG",
"chartdate": "2119-12-14 00:00:00.000",
"description": "Report",
"row_id": 261469,
"text": "Artifact is present. Sinus bradycardia. The Q-T interval is prolonged.\nThere is minimal ST segment elevation in the inferior leads. Clinical\ncorrelation is suggested. Compared to the previous tracing of \nsinus rhythm has been restored and right bundle-branch block and left anterior\nfascicular block have resolved. ST segment elevation is new.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2119-12-14 00:00:00.000",
"description": "Report",
"row_id": 261470,
"text": "Probable junctional rhythm versus a rhythm originating in the posterior\nfascicle of the left-sided conduction system. Left axis deviation.\nRight bundle-branch block with left anterior fascicular block. Non-specific\nST-T wave changes. Compared to the previous tracing these findings are new.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2119-12-13 00:00:00.000",
"description": "Report",
"row_id": 261471,
"text": "Sinus rhythm. Low voltage in the limb leads. No previous tracing available\nfor comparison.\nTRACING #1\n\n"
}
] |
24,586 | 194,720 | 23 yo female with a history of depression, PTSD, and borderline personality disorder who was admitted with an aspirin overdose, c/b metabolic acidosis and respiratory acidosis. . Patient had an aspirin overdose of approximately 200 pills, with peak aspirin level of 127. Patient was emergently hemodialyzed for her aspirin overdose to which she responded well. She also received charcoal and was started on a bicarbonate drip. Patient was followed by toxicology. Her metabolic acidosis and respiratory alkalosis was monitored closely by serial ABGs and normalized over the course of 24 hours. Patient's aspirin level was negative. . Patient had a femoral line placed for dialysis. Patient had a groin hematoma at the site. She was also noted to have a >10 point hematocrit drop. Patient had a CT scan performed for RP bleed which was negative. She had a hematocrit that then stabilized, and had no further drops over the next 72 hours. Patient was also noted to have an elevated amylase and lipase, thought to be secondary to a salicylate induced pancreatitis. She complained of nausea. She had no epigastric tenderness to palpation. Patient was tolerating pos and did not require pain medications. Her amylase and lipase trended downward. . Patient was seen by psychiatry as an inpatient, and was recommended to have a 1:1 sitter. She was restarted on Lamictal for mood stabilization. She was also placed on antidepressants with fluoxetine and Klonopin. Patient refused all her doses of her medications, stating that she could not tolerate pills. She was felt to be severely depressed, and patient was transferred to inpatient psychiatry for further management. | Head CT completed and reported as neg. still suicidal risk and needs 1:1 sitterResp: RA w/ lungs CTA and stable sats. No cough noted.CV: SR-ST w/ HR 90-120's. for bleed, Hct sent and unchanged from am= 26. HR=86-93 NSR no ectopy noted. No SOBCV: A-line/Quinton cath d/c. TECHNIQUE: Non-contrast head CT. and WNL.Cardiac: HR= 70-80's SR with no ecotpy noted. Sinus rhythmDiffuse nonspecific T wave abnormalitiesSince previous tracing of , diffuse T wave changes present No obvious skin breakdown.LABS: Please see flowsheet for latest labs as pt. SINGLE PORTABLE AP UPRIGHT CHEST RADIOGRAPH: The cardiac, mediastinal, and hilar contours are within normal limits. 12:31 AM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: HCT DROP S/P RT GROIN LINE PLACEMENT. Visualized heart and pericardium appear unremarkable. Will obtain non-contrast CT (? SBP 90-100, HR 80-100, NSR--no ectopy. The uterus, adnexa, and rectum appear unremarkable. IMPRESSION: No acute cardiopulmonary process. peripherial pulses x 4.GI/GU: + BS noted. IMPRESSION: No intracranial hemorrhage. 7a-7p nursing notePt. No SOB of dyspnea noted. "B" Nsg Progress Note:CVS: Afebrile. PEARL, moves all extremities, no acute neuro changes. Fluid boluses given via HD. No cardiac c/o. Appears depressed and withdrawn.RESP: LS CTA bil. Foley in place w/ adequate UO (decreasing this afternoon).Skin: Numerous self mutilations to arms and left heel w/ the word 'FAT' self carved into heel. TECHNIQUE: Non-contrast CT of the abdomen and pelvis. The bowel gas pattern in the upper abdomen is nonspecific. IMPRESSION: No evidence of retroperitoneal hematoma. #18 LUE, RH, sites WNL--NS KVO. Pt with sig. The kidneys appear symmetric without evidence of hydronephrosis. No dilated loops of bowel are identified. No edema noted. No hx of HAs. Not needed for clinical questions. RR regular and shallow. +DP/PT bil. 1:1 sitter as pt. Initial salicyate level 127 and now, 23. Psych in for eval. 1:1 sitter at bedside.Cardiac: HR= 60-80's SR with no ectopy noted. Continue 1:1 Sitter on floor. Cont'd w/ hypotension requiring a total of 4.8 liter of NS given during HD.Review of Systems:Neuro: lethargic, but arousable to voice. SINGLE PORTABLE AP SUPINE ABDOMINAL RADIOGRAPH: No radiopaque foreign bodies are identified. to be hypotensive w/ IVF at NS w/ 20mequ KCL at 125/hr. MICU Nursing Note 2300-0700Events: Please refer to previous note. bleed from ASA ingestion) and repeat hct. HD x 6hrs for ASA removal. ICa=1.07, given 2amps CaGluconate IV also. Lack of intravenous contrast limits assessment of intraabdominal organs. scars LUE and abd. No BM. Hemodynamically stable.Neuro: A+Ox3, cooperative, flat affect, follows all commands, C/O H/A and medicated with 650mg. The osseous structures demonstrate no concerning lytic or sclerotic lesions. No dilated loops of small or large bowel are identified. Right groin site dressing D/ISocial: No contact from family or friendsPlan: Monitor for bleeding, Monitor HCT Q 4hr---next due at 0830, Continue 1:1 sitter at bedside, Transfuse prn, ? T-max 98.4GI: Tol. is soft, NT, ND. N/V prior to my arrive, but none since. Monitor per protocol:--cont. of transferring to medical floor if no further bleeding, Support pt. called out--Please see transfer note for hx and current assessment.GCS: 15, calm & cooperative. PIV's x 2 (#20) and R groin HD cath. IMPRESSION: Air and stool throughout the colon. Psych evaluated and pt. The osseous and soft tissue structures appear unremarkable. No pathologic mesenteric or retroperitoneal lymphadenopathy is identified. for sudden c/o severe HA. c/o severe frontal "migraine" HA relieved temporarily with Tylenol/morphine x 1. No other breakdown noted. The liver, gallbladder, adrenal glands, spleen, and pancreas appear unremarkable. No pleural effusions or pneumothoraces are identified. Conts. No dilated loops of small or large bowel. COMPARISON: None. COMPARISON: None. MICU Intern placed R rad A-line. There is no free intraperitoneal air. The osseous structures appear unremarkable. No free air or free fluid is seen in the abdomen. BP= 89-109/40-50. Afebrile. Stable evening.Neuro: A+OX3, moves all extremities, follows all commands, OOB to w/c with minimal assist, PEARl, c/o H/A---HO aware---medicated with an additional 325mg. Palp. There is no acute major vascular territorial infarct. Oriented x 2 w/ slurred speech and pupils slightly unequal. U/A sent to lab this am.Neuro: No deficits noted.Skin: areas of self mutilation as previously noted, no new areas.Safety: Pt has 1:1 sitter, is calm and cooperative but did awaken twice suddenly with a nightmare.Plan: Continue to monitor labs and replete electrolytes as needed. Denies SOB.GI: Abd soft with + bowel sounds all quads, No BM, taking sips without difficulty.GU: Foley to CD draining clear yellow urine, U/O > 30 ml/hr.Skin: unchanged from previous note.Social: no contact from family and friends during evening.Safety: Siderails up while in bed, 1:1 Sitter at bedside.Plan: Transfer to CC7- for further medical management. There is no intracranial hemorrhage, shift of normally midline structures, mass effect, or hydrocephalus. There is no evidence of retroperitoneal hematoma. Mult. COMPARISON: Chest x-ray from . addendum to 7a-7p shiftDr. 4pm K=3.4 Mg=1.4,phos=0.7, pt given 3GMs MgSO4 IV, 33mmol KPhos IV over 6hrs. Pt again travelled to CT scan of pelvis to rule out RP bleed...negative. BP= 80-100's/40-50's, PIV flushed and patent.Resp: Lungs clear to bases bilat, RA Sat= 98-100%. RA Sats= 98-100%. for bleed. A pressure dressing appears to overlie the right groin. CT OF THE ABDOMEN: The lung bases are clear. po well--. (2) PIV sites--both patent. FINDINGS: There are no studies for comparison. Tylenol as ordered with fair relief. appetite, one episode of nausea--self limitingNo BM.GU: Foley cath draining clear yellow urine QSLABS: NA-140, K-3.6, BUN-19, Cr- .7, mg 1.9, alb-1.7SOCIAL: Mother unaware of pt's admission per pt request. and feels pt not ready medically to transfer to psych facility.PLAN: Continue to monitor labs, behavior, psych needs, transfer out when bed available. | 11 | [
{
"category": "Nursing/other",
"chartdate": "2149-06-20 00:00:00.000",
"description": "Report",
"row_id": 1581682,
"text": "MICU NURSING Note 1900-2300\nEvents: Head CT completed and reported as neg. for bleed, Hct sent and unchanged from am= 26. Stable evening.\n\nNeuro: A+OX3, moves all extremities, follows all commands, OOB to w/c with minimal assist, PEARl, c/o H/A---HO aware---medicated with an additional 325mg. Tylenol as ordered with fair relief. Head CT completed and reported as neg. for bleed. and WNL.\n\nCardiac: HR= 70-80's SR with no ecotpy noted. BP= 80-100's/40-50's, PIV flushed and patent.\n\nResp: Lungs clear to bases bilat, RA Sat= 98-100%. Denies SOB.\n\nGI: Abd soft with + bowel sounds all quads, No BM, taking sips without difficulty.\n\nGU: Foley to CD draining clear yellow urine, U/O > 30 ml/hr.\n\nSkin: unchanged from previous note.\n\nSocial: no contact from family and friends during evening.\n\nSafety: Siderails up while in bed, 1:1 Sitter at bedside.\n\nPlan: Transfer to CC7- for further medical management. Continue 1:1 Sitter on floor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2149-06-21 00:00:00.000",
"description": "Report",
"row_id": 1581683,
"text": "MICU Nursing Note 2300-0700\nEvents: Please refer to previous note. Pt was scheduled for transfer to floor and critical care fellow was assessing pt prior to writing transfer orders when pt started to bleed from old Quinton cath site that had been discontinued yesterday afternoon---pt with moderate-sized bleed requiring 15 minutes of manual pressure followed by pressure dressing and application of IV bag placed over site to add pressure with no further episodes of bleeding. Pt again travelled to CT scan of pelvis to rule out RP bleed...negative. Transfer to floor placed on hold overnight. Hemodynamically stable.\n\nNeuro: A+Ox3, cooperative, flat affect, follows all commands, C/O H/A and medicated with 650mg. Tylenol with good effect. PEARL, moves all extremities, no acute neuro changes. 1:1 sitter at bedside.\n\nCardiac: HR= 60-80's SR with no ectopy noted. BP= 89-109/40-50. (2) PIV sites--both patent. Pt with sig. bleed from right groin quinton cath site---required 15 minutes of manual pressure followed by a pressure dressing and pt with reminders to keep RLL straight overnight, No further bleeding from site. HCT=26.9 at 12:30 am and current HCT= 25.2. Blood products available in blood bank.\n\nResp: Lungs clear to bases bilat. RA Sats= 98-100%. No SOB\n\nGI: Abd soft with + bowel sounds all quads, no BM, tolerating house diet.\n\nGU: Foley to CD draining clear yellow urine > 30 ml/hr\n\nSkin: Pt with numerous scars on bilat forearms due to prior \"cutting\" incidents. No other breakdown noted. Right groin site dressing D/I\n\nSocial: No contact from family or friends\n\nPlan: Monitor for bleeding, Monitor HCT Q 4hr---next due at 0830, Continue 1:1 sitter at bedside, Transfuse prn, ? of transferring to medical floor if no further bleeding, Support pt.\n"
},
{
"category": "Nursing/other",
"chartdate": "2149-06-19 00:00:00.000",
"description": "Report",
"row_id": 1581678,
"text": "Admitting and Nursing Progress Notes for 7a-7p: Full Code NKDA\n\nThis is a 23 y/o lady who lives at a group home who presented to EW after ingesting approx. 200 tablets of Aspirin in an attempted suicide. She has extensive past psych. issues since childhood with previous suicidal ideations and attempts requiring numerous hospital admissions. Being admitted to MICU 6 for further management and closer monitor of this ASA OD.\n\n Please See carevue flowsheet for more obejctive data\n\nEvents: Rec'd report from night nurse and assumed care of pt. Initially, pt. found to be agitated and tearful requesting po fluids. Renal fellow in early this AM for HD evaluation and placed a R groin HD catheter. MICU Intern placed R rad A-line. HD x 6hrs for ASA removal. Initial salicyate level 127 and now, 23. Cont'd w/ hypotension requiring a total of 4.8 liter of NS given during HD.\n\nReview of Systems:\n\nNeuro: lethargic, but arousable to voice. Oriented x 2 w/ slurred speech and pupils slightly unequal. Psych evaluated and pt. still suicidal risk and needs 1:1 sitter\n\nResp: RA w/ lungs CTA and stable sats. RR regular and shallow. No cough noted.\n\nCV: SR-ST w/ HR 90-120's. Afebrile. No edema noted. PIV's x 2 (#20) and R groin HD cath. at noted above. Conts. to be hypotensive w/ IVF at NS w/ 20mequ KCL at 125/hr. Fluid boluses given via HD. Palp. peripherial pulses x 4.\n\nGI/GU: + BS noted. N/V prior to my arrive, but none since. NPO except for ice chips. Abd. is soft, NT, ND. No BM. Foley in place w/ adequate UO (decreasing this afternoon).\n\nSkin: Numerous self mutilations to arms and left heel w/ the word 'FAT' self carved into heel. No obvious skin breakdown.\n\nLABS: Please see flowsheet for latest labs as pt. had q1hr abg's and frequents draws throughout the day.\n\nPlan: Cont. to monitor pH via ABG's and salicylate levels. Monitor per protocol:\n--cont. 1:1 sitter as pt. is still marked suicide risk as she verbally makes clear that she wants to die.\n--Address need for central line if hypotension persists.\n--TEAM tolerating MAP > 55.\n--Social Work consult\n--Case management needs to be involved for placement\n"
},
{
"category": "Nursing/other",
"chartdate": "2149-06-20 00:00:00.000",
"description": "Report",
"row_id": 1581679,
"text": " \"B\" Nsg Progress Note:\n\nCVS: Afebrile. HR=86-93 NSR no ectopy noted. SBP=83-96 with MAP>64 but aline is somewhat positional. 4pm K=3.4 Mg=1.4,phos=0.7, pt given 3GMs MgSO4 IV, 33mmol KPhos IV over 6hrs. ICa=1.07, given 2amps CaGluconate IV also. Salicylate level=16. amylase/lipase elevated.\n\nResp: Sats=98-100% on room air. No SOB of dyspnea noted. Lung sounds clear.\n\nGI: Tolerating ice chips, +bowel sounds, no c/o distress, abdomen soft nontender.\n\nGU: u/o was brownish at first is now clear yellow, 40-120ml/hr. U/A sent to lab this am.\n\nNeuro: No deficits noted.\n\nSkin: areas of self mutilation as previously noted, no new areas.\n\nSafety: Pt has 1:1 sitter, is calm and cooperative but did awaken twice suddenly with a nightmare.\n\nPlan: Continue to monitor labs and replete electrolytes as needed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2149-06-20 00:00:00.000",
"description": "Report",
"row_id": 1581680,
"text": "7a-7p nursing note\nPt. called out--Please see transfer note for hx and current assessment.\n\nGCS: 15, calm & cooperative. c/o severe frontal \"migraine\" HA relieved temporarily with Tylenol/morphine x 1. No hx of HAs. Appears depressed and withdrawn.\n\nRESP: LS CTA bil. on RA pox 95-98%. No SOB\n\nCV: A-line/Quinton cath d/c. SBP 90-100, HR 80-100, NSR--no ectopy. No cardiac c/o. #18 LUE, RH, sites WNL--NS KVO. Mult. scars LUE and abd. from previous cutting. +DP/PT bil. T-max 98.4\n\nGI: Tol. po well--. appetite, one episode of nausea--self limiting\nNo BM.\n\nGU: Foley cath draining clear yellow urine QS\n\nLABS: NA-140, K-3.6, BUN-19, Cr- .7, mg 1.9, alb-1.7\n\nSOCIAL: Mother unaware of pt's admission per pt request. Psych in for eval. and feels pt not ready medically to transfer to psych facility.\n\nPLAN: Continue to monitor labs, behavior, psych needs, transfer out when bed available.\n"
},
{
"category": "Nursing/other",
"chartdate": "2149-06-20 00:00:00.000",
"description": "Report",
"row_id": 1581681,
"text": "addendum to 7a-7p shift\nDr. in to evaluate pt. for sudden c/o severe HA. Will obtain non-contrast CT (? bleed from ASA ingestion) and repeat hct. Tylenol 650 mg. given po at 1835\n\n"
},
{
"category": "ECG",
"chartdate": "2149-06-19 00:00:00.000",
"description": "Report",
"row_id": 126856,
"text": "Sinus rhythm\nDiffuse nonspecific T wave abnormalities\nSince previous tracing of , diffuse T wave changes present\n\n"
},
{
"category": "Radiology",
"chartdate": "2149-06-18 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 915977,
"text": " 11:42 PM\n PORTABLE ABDOMEN Clip # \n Reason: assess for concretion\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old woman with s/p polysubstance ingestion\n REASON FOR THIS EXAMINATION:\n assess for concretion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Polysubstance ingestion.\n\n COMPARISON: None.\n\n SINGLE PORTABLE AP SUPINE ABDOMINAL RADIOGRAPH: No radiopaque foreign bodies\n are identified. Air and stool is seen throughout the colon. There is a\n tampon in the vagina, and a foley catheter is seen. No dilated loops of small\n or large bowel are identified. The osseous structures appear unremarkable.\n\n IMPRESSION: Air and stool throughout the colon. No dilated loops of small or\n large bowel.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2149-06-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 915981,
"text": " 12:32 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for lung injury - ASA OD\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old woman with ASA ingestion\n REASON FOR THIS EXAMINATION:\n eval for lung injury - ASA OD\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Aspirin ingestion.\n\n COMPARISON: Chest x-ray from .\n\n SINGLE PORTABLE AP UPRIGHT CHEST RADIOGRAPH: The cardiac, mediastinal, and\n hilar contours are within normal limits. The lungs are clear. No pleural\n effusions or pneumothoraces are identified. There is no free intraperitoneal\n air. The bowel gas pattern in the upper abdomen is nonspecific. The osseous\n and soft tissue structures appear unremarkable.\n\n IMPRESSION: No acute cardiopulmonary process.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2149-06-21 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 916286,
"text": " 12:31 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: HCT DROP S/P RT GROIN LINE PLACEMENT. R/O RP BLEED\n Admitting Diagnosis: ASPIRIN OVERDOSE\n Field of view: 36\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old woman with recent HD line on right groin after ASA overdose now\n with acute hct drop and bleeding from HD catheter site, assess for RP bleed\n REASON FOR THIS EXAMINATION:\n rule out RP bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KLMn SAT 4:11 AM\n no retroperitoneal hematoma.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Recent right groin hemodialysis line, now with bleeding from the\n site, assess for retroperitoneal hematoma.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast CT of the abdomen and pelvis.\n\n CT OF THE ABDOMEN: The lung bases are clear. Visualized heart and\n pericardium appear unremarkable. Lack of intravenous contrast limits\n assessment of intraabdominal organs. The liver, gallbladder, adrenal glands,\n spleen, and pancreas appear unremarkable. The kidneys appear symmetric\n without evidence of hydronephrosis. No dilated loops of bowel are identified.\n No pathologic mesenteric or retroperitoneal lymphadenopathy is identified. No\n free air or free fluid is seen in the abdomen.\n\n CT OF THE PELVIS: A Foley catheter is seen within the bladder lumen, as well\n as non-dependent air. The uterus, adnexa, and rectum appear unremarkable.\n There is no evidence of retroperitoneal hematoma. There is a small amount of\n stranding in the right groin. A pressure dressing appears to overlie the\n right groin.\n\n The osseous structures demonstrate no concerning lytic or sclerotic lesions.\n\n IMPRESSION: No evidence of retroperitoneal hematoma.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2149-06-20 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 916257,
"text": " 7:29 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ASPIRIN OD.R/O BLEED\n Admitting Diagnosis: ASPIRIN OVERDOSE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old woman with severe headache following aspirin overdose.\n REASON FOR THIS EXAMINATION:\n evaluate for hemorrhage\n CONTRAINDICATIONS for IV CONTRAST:\n ASA overdose, recently dialyzed. Not needed for clinical questions.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Severe headache following aspirin overdose.\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: There are no studies for comparison. There is no intracranial\n hemorrhage, shift of normally midline structures, mass effect, or\n hydrocephalus. The -white matter differentiation is preserved. There is\n no acute major vascular territorial infarct. The osseous structures are\n normal. The paranasal sinuses are well aerated.\n\n IMPRESSION: No intracranial hemorrhage.\n\n\n"
}
] |
15,243 | 190,128 | 71F CAD s/p 3v-Cabg, CHF EF 50%, 3+MR/MS, DM2, CRI, HTN presented with respiratory failure likely CHF and PNA . # CAD: Pt with known CAD s/p 3VD s/p CABG. Found to have troponin leak in setting of CHF and renal failure. Patient remained chest pain free during hospitalization. She underwent cardiac catheterization on without intervention (see cath report above). Continued aspirin, statin, and nitrates. Clopidogreal was continued until after CT surgeon's requested it be held prior to surgery. This was discussed with Dr. and it was felt to be okay to hold/stop this medication for now as > 1year since most recent stent. . # PUMP: volume overloaded on admission, and diuresed. She had episodes post op of overload requiring reintubation once and mask ventilation the second time. She has had no further episodes and continues to be diuresised aggressively and blood pressure control goal SBP <125. Monitored ins and outs and daily weights. . #Complete heart block - after receiving lopressor went into complete heart block that did not resolving requiring insertion of permanent pacemaker. . # VALVES: severe mitral degenerative dz with MS and MR. 1.0-1.5cm2 on echo (1.3cm2 on cath). Mitral disease felt to be contributing to recurrent bouts of CHF requiring hospitalization. CT surgery was consulted for consideration of mitral valve replacement. She had a panorex film and and dental consult for pre-operative assessment. They recommended oral surgery consult and teeth extraction on . She received ampicillin prior to oral surgery. There was concern that she also had a lesion on her right hand middle finger and Rheumatology was consulted. It was felt most likely to be either resolving gout/pseudogout(with tophi) vs resolving infection. Her uric acid was elevated at 10.2. Mitral Valve replacement was performed on . . # PNA: Felt to contribute to her respiratory failure and MICU hospitalization. Resolved leukocytosis, now afebrile and breathing comfortably on room air. Completed 10 day levofloxacin course. . # Anemia: Guaiac negative. Hematocrit stable. She did receive 2 units pRBC blood transfusion for Hct > 30. . # DM: Continued RISS and home regimen of NPH 22 in AM and 8 in PM and regular insulin 8 in AM and 8 in PM. Glipizide held while an inpatient. . # Acute on CRI: recent baseline 1.1 to 1.3. Creatinine did increase to highest 1.9. Prequired natrecor and lasix for diuresis. . # Social: history of abuse in past. Report was filed. Social work following. | The patient is status post median sternotomy, as before. Patient is status post sternotomy and CABG, and moderate cardiomegaly is unchanged. Right internal jugular vascular sheath has been removed and a right PICC line has been placed with tip terminating in the upper superior vena cava. REASON FOR THIS EXAMINATION: eval inf FINAL REPORT PORTABLE CHEST OF COMPARISON: INDICATION: Status post mitral valve replacement. REASON FOR THIS EXAMINATION: assess for infiltrate, effusions, edema FINAL REPORT REASON FOR EXAM: CHF SINGLE AP PORTABLE VIEW CHEST. The patient is post-CABG, with sternotomy wires unchanged. Swan-Ganz catheter has been removed with residual internal jugular vascular sheath terminating in the superior vena cava. Abnormal septalmotion/position.AORTA: Normal aortic diameter at the sinus level. Simple atheroma in ascending aorta. The ascending aorta is mildlydilated. Overall left ventricular systolic functionis mildly depresed with inferior hypokinesis (views suboptimal). Moderatelydepressed LVEF.LV WALL MOTION: Regional LV wall motion abnormalities include: basalanteroseptal - hypo; mid anteroseptal - hypo; septal apex - hypo; apex - hypo;RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level. Mild (1+)mitral regurgitation is seen. Moderatelydepressed EF with inferior akinesis and abnormal septal motion (post-op). Atrial fibrillation with a regular ventricular response suggesting anindependent junctional or idioventricular rhythm with right bundle branchblock/left posterior fascicular block configurationSince previous tracing of , sinus bradycardia and left bundle branchblock now absent There are simple atheromain the aortic arch. Normal sinus rhythm with marked A-V conduction delay. Normal ascending aortadiameter. Normal aortic arch diameter.Simple atheroma in aortic arch. Normal descending aorta diameter. Normal PAsystolic pressure.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor echo windows.Conclusions:The left atrium is mildly dilated. Albuterol/atrovent nebs started. + PERIPHERAL EDEMA. COUMADIN GIVEN. Left bundle-branch block and secondary ST-T waveabnormalities. pt has distant hrt sounds S1S2 w/ systolic murmur. at present sr60s bp 110s/60s ntg off. lactate 4.3, pt received vanco, ceftriaxone, and flagyl. DOSE DISCUSSED WITH MD, WILL CONTINUE TO FOLLOW PT/PTT/INRRESP BREATH SOUNDS CLEAR, DIMINISHED IN BASES. NATRECOR CONTINUOUS AT 0.01MCG. Left anteriorfascicular block. Regular rhythm, mechanism uncertain, may be sinus or ectopic atrial rhythm withfirst degree A-V delay. Resp. Sinus rhythmLeft atrial abnormalityLeft bundle branch blockSince previous tracing of , ST-T wave changes less prominent and Q-Tcinterval appears shorter Probable sinus rhythm. Sinus rhythm. Sinus rhythm. Sinus rhythm. Sinus rhythm. Compared to the previous tracing of atrial fibrillationis no longer present.TRACING #1 Respiratory Care:Pt. ls rhonchi to coarse bs. ABG's WNL. Occasional atrial premature beats. LASIX OR DOSE FOR DIURESIS. A-V conduction delay. Left atrial abnormality. Q-T interval prolongation.Since the previous tracing of the precordial T wave inversions are moreprominent. HR = 69 BP = 128/41 RR = 17 O2 Sat. On fixed dosing of NPH and regular along with sliding scale of humulog.ID: Tmax= 99.1. Resp Care: Pt continues intubated #7.5 oett secured @ 22 @ lip and on ventilatory support, changed to a/c for overnoc rest d/t agitation/bucking vent, currently back on cpap with minimal psv maintaining abg wnl; bs clear to coarse, sxn thick brown/blood tinged secretions, rx with mdi albuterol/atrovent, rsbi 61, will attempt wean to extubate this am. Right fem line d/c'd.GI - Tolerating PO clears, Abd soft, +BS. WBC-14.5CV: 90-110 ST then converted to aflutter/fib with V pacing-rate 60-70's. Cr 1.5.GI: Abd soft, NT, ND with hypo BS. BUN/cr cont to increase 27/1.3.Skin - Bruised areas on back (2) unchanged.ID - Afebrile. COUMADIN DOSING PER INR. Neuro: A&O x3; calm & cooperative; MAE's, following commands consistentlyCV: AV paced/V-paced @ 60; afebrile; SBP 110's-130's, hydralazine given x1; K & Ca repleted; +2 general edema on LE bilat, TEDs on; palpable pulses x4Resp: Lung sound clear, fine crackles @ bases; non-productive cough; 2L NC, sat 98%GI: Tolerating PO diet; abd soft, non-tender, +bowel sound; +flatusGU: Foley draining clear yellow urine; good diuresis with metolazone & lasixInteg: see carevuePain: denies painSocial: no calls from familyPlan: monitor hemodynamics & resp status; pulm toilet; monitor I&O, keep -; transfer to 2 in AM CXR done.Resp: Extub in am. + EDEMA NOTED. + palpable pulses.Resp: LS clear diminished. EKG done. +diuresis. +2 BILAT LE PITTING EDEMA. NPO p midnoc. DIURESIS. Sternal dsg cdi. Type I DM. SBP 130-140s/ 20-30s, NP aware of diastolic, see carevue. IV LASIX, PO METOLAZONE WITH (+)DIURESIS. Min-mod serosang CT output. pp by doppler. Monitor resp. MD UPDATED BY NP. LYTES PRN. TOLERATING PO METOPROLOL, CAPTOPRIL, AMIO. using ISgi/gu: pt with + bs. ABD SNT (+)HYPOACTIVE BS. CONTINUE DIURESING. CT dc'd. NESIRITIDE CONTINUES @ 0.010MCG/KG/MIN. NPNPT W/ RESP DISTRESS AND INTUBATION ON 2. U/O CURRENTLY IS MARGINAL-PA NILLSON NOTIFIED. Cont afib. Perrla. PERRLA. Epi gtt weaned off with CI>2, svo2s 60s- swan dc'd. 2 FFP admin by anesthesia for INR 3.1. neuro intact, 1 assist to getting oob. CRI (baseline 1.2). ABGs stable on SIMV; sedation off switched to PSV; will repeat ABG. CI remained <2, 1 prbcs ordered. Hydralazine to continue NP . HCT stable. Neuro) Pt. Cont wean PSV and extub today. Last ABG WNL with adequate oxygenation on present settings. LUNGS DIMINSIHED BASES, SX'D FOR SCANT AMT THIN WHITE SECRETIONS.CV: NSR WITH OCC PVC'S, HR 65-80'S. HR UP TO MAX OF 61 WHILE AMB, OTHERWISE 40'S-50'S, CHB.RESP: LUNGS CLEAR, DIMINISHED @ BASES. CONTINUE DIURESIS. BP 136/40.Pulm: 2Lnc in place, lungs clear, decreased at bases. Wean sedation and plan to extubate in am. cdb done.GI/GU: abd soft, +bowel sounds. REMAINS HYPERTENSIVE DESPITE PO & IV PRN HYDRALAZINE. o2sats>96%/RAgi/gu: abd soft, +bowel sounds. BS essentially clear sxing for minimal secretions. Continue on natrecor/lasix/milrinone as ordered. IS to 750 with direction.GI: Abd soft,NT,ND with +BS. v-wires pace and sense, remain set at v-demand at 30; a-wires sense but don't capture.resp: ls clear bilat, uses is, coughs and deep breathes. LUNGS CLEAR W/DIM BASES. ls clear->rhonchorous-> clear. Lopressor iv q4hr. Albumin TID. foley reinserted per . Remains on natrecor at 0.01mcg, no change.Resp: Lungs clear, slightly dim at base. continue pulm hygiene. Received extra sedation for TEE, Versed 2mg , morphine 2mg, and propfol boluses.CV: HR 70-90's nsr with prolonged PR>.32. | 106 | [
{
"category": "Radiology",
"chartdate": "2155-05-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 956978,
"text": " 10:42 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval. for interval change\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman s/p Redo-Sternotomy, MVR.\n\n REASON FOR THIS EXAMINATION:\n Eval. for interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST\n\n HISTORY: MVR, sternotomy.\n\n One view. Comparison with the previous study done . There is\n continued evidence of mild pulmonary edema and a moderate right and small left\n pleural effusion. Pleural effusions appeared to have increased somewhat in\n the interval. The heart appears large as demonstrated previously. The\n patient is status post median sternotomy, as before. The patient has been\n extubated and a nasogastric tube has been removed. A bipolar transvenous\n pacemaker and Swan-Ganz catheter remain in place.\n\n IMPRESSION: Mild pulmonary edema. Interval increase in bilateral pleural\n effusions. No other definite change.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2155-05-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 957167,
"text": " 7:46 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval inf\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman s/p Redo-Sternotomy, MVR.\n\n REASON FOR THIS EXAMINATION:\n eval inf\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST OF \n\n COMPARISON: \n\n INDICATION: Status post mitral valve replacement.\n\n Swan-Ganz catheter has been removed with residual internal jugular vascular\n sheath terminating in the superior vena cava. Cardiac silhouette is enlarged,\n but has decreased in size from a recent study. Previously reported pulmonary\n edema has nearly resolved with mild residual interstitial edema remaining. A\n moderate right and small left pleural effusions are present. Middle and lower\n lobe opacities adjacent to right effusion probably reflect atelectasis, but\n underlying infection should also be considered in the appropriate clinical\n setting.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2155-05-23 00:00:00.000",
"description": "PICC W/O PORT",
"row_id": 957646,
"text": " 10:01 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: pt. needs double lumen PICC IV RN\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;SEPSIS\n Contrast: OPTIRAY Amt: 15\n ********************************* CPT Codes ********************************\n * PICC W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with s/p cabg/mvr\n REASON FOR THIS EXAMINATION:\n pt. needs double lumen PICC IV RN\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Needs double lumen PICC for access.\n\n The procedure was explained to the patient. A timeout was performed.\n\n RADIOLOGISTS: Drs. and Dr. , the attending radiologist,\n was present and supervising throughout.\n\n TECHNIQUE/PROCEDURE: Using sterile technique and local anesthesia, the right\n brachial vein was punctured under direct ultrasound guidance using\n micropuncture set. Hard copies of ultrasound images were obtained before and\n immediately after establishing intravenous access. Peel-away sheath was then\n placed over a guide wire and a 37 cm double lumen PICC line was then placed\n through the peel-away sheath with its tip positioned in the SVC under\n fluoroscopic guidance. Position of the catheter was confirmed by fluoroscopic\n spot film of the chest. Peel-away sheath and guide wire were removed.\n Catheter was secured to the skin, flushed, and sterile dressing applied.\n Patient tolerated the procedure well with no immediate complications.\n\n IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided 37 cm double\n lumen PICC line placement via right brachial approach. Tip positioned in the\n SVC, line ready for use.\n\n"
},
{
"category": "Radiology",
"chartdate": "2155-05-26 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 958012,
"text": " 1:59 PM\n CHEST (PA & LAT) Clip # \n Reason: evaluate for effusion\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with s/p MVR\n REASON FOR THIS EXAMINATION:\n evaluate for effusion\n ______________________________________________________________________________\n FINAL REPORT\n TWO VIEW CHEST of .\n\n COMPARISON: .\n\n INDICATION: Evaluate for pleural effusion following mitral valve surgery.\n\n Right internal jugular vascular sheath has been removed and a right PICC line\n has been placed with tip terminating in the upper superior vena cava. A\n permanent pacemaker is unchanged in position, and cardiac and mediastinal\n contours are stable. Small-to-moderate right pleural effusion has decreased\n in size, and small left pleural effusion is unchanged. Interstitial edema has\n nearly resolved.\n\n IMPRESSION: Resolving interstitial edema and improving right pleural\n effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2155-04-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 953056,
"text": " 10:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: acute cardiopulmonary process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with sob\n REASON FOR THIS EXAMINATION:\n acute cardiopulmonary process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Shortness of breath. Evaluate for acute cardiopulmonary process.\n\n COMPARISON: .\n\n SUPINE AP CHEST: An endotracheal tube is in place, with the tip approximately\n 2.9 cm from the carina. The patient is post-CABG, with sternotomy wires\n unchanged. The superiormost wire is discontinued, as seen on multiple prior\n exams. There is mild cardiomegaly, which is slightly more apparent than seen\n on the prior study. There is severe pulmonary edema. There is no pleural\n effusion or evidence of pneumothorax in this supine patient.\n\n IMPRESSION:\n\n Severe pulmonary edema. Endotracheal tube in place.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2155-04-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 953494,
"text": " 7:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for infiltrate, effusions\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with CHF, CAD, intubated for resp distress, extubated\n yesterday, now with chest pain\n REASON FOR THIS EXAMINATION:\n assess for infiltrate, effusions\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: CAD and CHF with chest pain.\n\n AP BEDSIDE CHEST. The heart is borderline enlarged with previous CABG. No\n vascular congestion, consolidations, or effusions. Allowing for technical\n differences, there is little change from supine exam one day ago.\n\n IMPRESSION: No CHF or other acute process.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2155-04-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 953333,
"text": " 1:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for infiltrate, effusions, edema\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with CHF, CAD, intubated for resp distress, extubated\n yesterday.\n REASON FOR THIS EXAMINATION:\n assess for infiltrate, effusions, edema\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: CHF\n\n SINGLE AP PORTABLE VIEW CHEST. Compared to prior study performed the day\n before, mild pulmonary edema has almost completely resolved. There is no\n pneumothorax or sizable pleural effusion. Cardiac size is top normal. Patient\n is post median sternotomy and CABG.\n\n"
},
{
"category": "Radiology",
"chartdate": "2155-04-25 00:00:00.000",
"description": "R HAND (AP, LAT & OBLIQUE) RIGHT",
"row_id": 953856,
"text": " 5:46 PM\n HAND (AP, LAT & OBLIQUE) RIGHT Clip # \n Reason: evaluate for changes suggestive of osteomyelitis\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with right middle finger DIP swelling\n REASON FOR THIS EXAMINATION:\n evaluate for changes suggestive of osteomyelitis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Right middle finger DIP swelling, evaluate for osteomyelitis.\n\n No prior examinations.\n\n RIGHT HAND, THREE VIEWS: Extensive osteoarthritic changes are seen at the\n second, third, fourth and fifth DIP as well as the fifth PIP, with joint space\n narrowing, osteophyte formation and subchondral sclerosis. On the lateral\n view, it appears there is near fusion of the second and fourth DIPs. At the\n third DIP, in the region of the patient's swelling, there is no evidence of\n cortical destruction or periosteal reaction to suggest osteomyelitis. A tiny\n soft tissue calcification is noted dorsal to the third distal phalanyx . No\n radiopaque foreign body identified.\n\n IMPRESSION: Osteoarthritic changes of the DIPs and fifth PIP. No\n radiographic evidence of osteomyelitis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2155-04-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 953115,
"text": " 3:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for edema, infiltrate\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with CHF, CAD, here with resp failure.\n\n REASON FOR THIS EXAMINATION:\n evaluate for edema, infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE SEMI-UPRIGHT CHEST, \n\n COMPARISON: .\n\n INDICATION: Respiratory failure.\n\n Endotracheal tube and nasogastric tube remain in standard position. Allowing\n for differences in technique, there has not been a substantial change in the\n appearance of the chest with persistent CHF, bibasilar atelectasis, and small\n pleural effusions. However, as compared to the earlier radiograph of \n at 10 a.m., there has been interval improvement in the severity of edema.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2155-04-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 953099,
"text": " 6:30 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: interval change\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with CHF, CAD, here with resp failure.\n\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST ON AT 18:45\n\n INDICATION: Respiratory failure.\n\n COMPARISON: \n\n FINDINGS: The ETT remains in place. There is much better aeration compared\n to the prior film and less distension of pulmonary vasculature and diminished\n interstitial markings. No new focal consolidations are seen. Cardiomegaly\n persists, and ETT remains in place. There is an NGT with the tip extending\n below the confines of the film, but clearly below the left hemidiaphragm.\n\n IMPRESSION: Improving CHF with some persistence.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2155-04-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 953196,
"text": " 3:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess for infiltrates.\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with CHF, CAD, here with resp failure.\n\n REASON FOR THIS EXAMINATION:\n Please assess for infiltrates.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: CHF, CAD, and SOB.\n\n AP BEDSIDE CHEST. The heart is enlarged with previous sternotomy and apparent\n CABG. ET and NG tubes are satisfactorily positioned (tip of NG tube not\n visualized). No overt vascular congestion and no consolidations. Equivocal\n subsegmental atelectasis at the left base. I doubt the presence of effusions.\n Since exam one day previous, the vascular congestion and layering pleural\n effusions have improved and possibly resolved. Lungs remain well inflated and\n I suspect this patient has underlying emphysema.\n\n IMPRESSION: Short interval improvement/resolution of CHF.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2155-05-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 955285,
"text": " 11:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o ptx\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman s/p Redo-Sternotomy, MVR. and ct removal\n REASON FOR THIS EXAMINATION:\n r/o ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old woman status post redo-sternotomy and chest tube\n removal.\n\n COMPARISON: Study from .\n\n PORTABLE AP CHEST RADIOGRAPH: Multiple lines and tubes have been removed.\n There is a right IJ sheath with the tip in the upper SVC. No pneumothorax is\n seen. There is stable cardiomegaly. There is mild pulmonary vascular\n congestion. There is small left pleural effusion and left retrocardiac\n opacity representing areas of atelectasis and/or consolidation. No\n pneumothorax.\n\n IMPRESSION: Small left pleural effusion and left retrocardiac opacity\n representing atelectasis and/or consolidation. No pneumothorax. Mild\n pulmonary vascular congestion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2155-05-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 956726,
"text": " 10:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate effusion\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman s/p Redo-Sternotomy, MVR.\n\n REASON FOR THIS EXAMINATION:\n evaluate effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post mitral valve repair.\n\n PORTABLE CHEST: Multiple lines and tubes are unchanged in position. Dual\n lead pacemaker overlying the left hemithorax is unchanged in position.\n Patient is status post sternotomy and valve replacement.\n\n Compared to a day prior, there is mild improvement in the degree of pulmonary\n edema. Layering moderate right pleural effusion appears unchanged. Moderate\n cardiomegaly again noted.\n\n IMPRESSION: Mild improvement in pulmonary edema with persistent moderate\n layering right pleural effusion and associated atelectasis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2155-05-15 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 956646,
"text": " 6:42 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: line and ETT placement\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman s/p Redo-Sternotomy, MVR.\n\n REASON FOR THIS EXAMINATION:\n line and ETT placement\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION: 71-year-old female status post sternotomy revision and mitral\n valve replacement. Please evaluate line and endotracheal tube placement.\n\n FINDINGS: Single portable AP supine radiograph is reviewed and compared to\n . There has been interval placement of endotracheal tube, which lies\n 5.5 cm above the carina. There has also been placement of Swan-Ganz catheter,\n with catheter tip overlying the distal main pulmonary artery. There is no\n pneumothorax. Moderate cardiomegaly is unchanged. There is perihilar\n haziness, upper-zone redistribution, and Kerley B lines consistent with mild\n pulmonary edema. There are small left and moderate right pleural effusions.\n Note is again made of sternotomy wires and clips representing prior cardiac\n surgery. There is also a prosthetic mitral valve.\n\n IMPRESSION:\n\n 1. Status post placement of endotracheal tube and Swan-Ganz catheter. No\n pneumothorax.\n\n 2. Moderate cardiomegaly, with mild pulmonary edema, and small left and\n moderate right pleural effusions.\n\n"
},
{
"category": "Radiology",
"chartdate": "2155-05-15 00:00:00.000",
"description": "R UNILAT LOWER EXT VEINS RIGHT",
"row_id": 956605,
"text": " 2:50 PM\n UNILAT LOWER EXT VEINS RIGHT Clip # \n Reason: eval for DVT in pt with new LE edema and new pacer\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman s/p mitral valve\n REASON FOR THIS EXAMINATION:\n eval for DVT in pt with new LE edema and new pacer\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old woman with new lower extremity edema.\n\n Grayscale and color-flow Doppler images of the right lower extremity were\n obtained. The right common femoral vein, right superficial vein, right\n popliteal vein, and greater saphenous vein demonstrate normal compressibility,\n respiratory varaiation in venous flow, and venous segmentation. The left\n lower extremity was not assessed since the patient developed severe shortness\n of breath.\n\n IMPRESSION: No deep vein thrombosis in the right lower extremity. The left\n lower extremity was not assessed due to the patient's severe shortness of\n breath.\n\n These findings were discussed with Dr. at the time of dictation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2155-04-30 00:00:00.000",
"description": "L RIB UNILAT, W/ AP CHEST LEFT",
"row_id": 954429,
"text": " 2:14 PM\n RIB UNILAT, W/ AP CHEST LEFT Clip # \n Reason: evaluate for rib fracture\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with left sided rib pain after trauma to this area\n REASON FOR THIS EXAMINATION:\n evaluate for rib fracture\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pain.\n\n Three radiographs of the chest and left ribs demonstrate displaced fracture\n involving the lateral left seventh rib. There is equivocal evidence of a\n nondisplaced fracture involving the lateral left eighth rib. The patient is\n status post CABG. No pneumothorax is detected. There is a moderate\n left-sided effusion. No consolidation is identified. Trachea is midline.\n The rib fractures are not evident on the chest radiograph dated ,\n although assessment is limited by technique of the prior study.\n\n IMPRESSION:\n\n Left lateral seventh and eighth rib fractures. No pneumothorax.\n\n Moderate left-sided pleural effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2155-05-14 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 956373,
"text": " 9:05 AM\n CHEST (PA & LAT) Clip # \n Reason: s/p pacer insertion-check lead placement\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with s/p dualc chamber pacemaker implantation\n\n REASON FOR THIS EXAMINATION:\n s/p pacer insertion-check lead placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate pacemaker lead placement.\n\n PA AND LATERAL CHEST: Compared to , a pacemaker has been placed\n with dual leads appropriately positioned in the right atrium and right\n ventricle. Patient is status post sternotomy and CABG, and moderate\n cardiomegaly is unchanged. Pulmonary vasculature is normal. Small bilateral\n pleural effusions persist and retrocardiac atelectasis continues to resolve.\n No definite pneumothorax.\n\n IMPRESSION: Satisfactory placement of dual lead pacemaker with small\n bilateral pleural effusions.\n\n"
},
{
"category": "Radiology",
"chartdate": "2155-05-05 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 955180,
"text": " 6:21 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: r/o PTX/Effusion/Tamponade\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman s/p Redo-Sternotomy, MVR. Please page at \n with abnormalities. Pt still in the OR, please perform when in the CSRU.\n REASON FOR THIS EXAMINATION:\n r/o PTX/Effusion/Tamponade\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old woman with recent surgery. Please rule out\n pneumothorax, excisional component.\n\n Comparisons available from the prior study done on .\n\n SINGLE AP VIEW OF THE CHEST:\n Since the prior study there has been interval placement of the right-sided\n Swan-Ganz catheter with its tip projecting in the main pulmonary artery. The\n endotracheal tube tip is projecting at least 5 cm above the carina, in\n satisfactory position. The NG tube side-port projecs within the stomach. The\n right-sided chest tube is in the proper position. The heart and mediastinal\n contours are mildly enlarged which is not an uncommon finding after recent\n surgery. Note is made of bibasilar increased opacities suggestive of\n bibasilar atelectasis. Increased interstitial markings likely pulmonary\n edema.\n\n IMPRESSION:\n 1. Status post placement of endotracheal tube, Swan-Ganz catheter, NG tube\n and right-sided chest tube in proper position.\n 2. Mild enlargement in the size of the cardiomediastinal silhouette which is\n not an uncommon finding after recent thoracic surgery and is suggestive of\n postsurgical changes.\n 3. Increased interstitial markings reaching the lung periphery suggestive of\n pulmonary edema.\n\n"
},
{
"category": "Radiology",
"chartdate": "2155-05-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 955714,
"text": " 7:39 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate effusion\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman s/p Redo-Sternotomy, MVR.\n REASON FOR THIS EXAMINATION:\n evaluate effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old status post redo sternotomy for MVR.\n\n COMPARISONS: .\n\n PORTABLE AP CHEST RADIOGRAPH: There is stable change related to prior CABG\n and stable cardiomegaly. There has been interval removal of a right IJ\n sheath. There is bibasilar atelectasis. There is partial improvement in left\n retrocardiac opacity, consistent with improved aeration left lower lobe.\n There may be small pleural effusion.\n\n IMPRESSION: Improved aeration in comparison to prior study. Possible small\n left pleural effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2155-05-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 956862,
"text": " 7:58 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval. for interval change\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman s/p Redo-Sternotomy, MVR.\n\n REASON FOR THIS EXAMINATION:\n Eval. for interval change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: ST redo sternotomy, MVR.\n\n SINGLE AP PORTABLE VIEW OF THE CHEST:.\n ET tube is in standard position. Swan- Ganz catheter remains in the main\n pulmonary artery. NG tube tip is out of view below the diaphragm. Left-sided\n pacemaker leads terminate in standard position in the right atrium and right\n ventricle. Patient is post median sternotomy and MVR. Compared to prior study\n moderate right pleural effusion is unchanged. Moderate cardiomegaly is\n stable. Mild pulmonary edema is stable. Small left pleural effusion is new.\n\n"
},
{
"category": "Echo",
"chartdate": "2155-05-21 00:00:00.000",
"description": "Report",
"row_id": 94889,
"text": "PATIENT/TEST INFORMATION:\nIndication: Mitral valve replacement\nHeight: (in) 64\nWeight (lb): 163\nBSA (m2): 1.79 m2\nBP (mm Hg): 131/32\nHR (bpm): 63\nStatus: Inpatient\nDate/Time: at 15:38\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. A catheter or pacing\nwire is seen in the RA and extending into the RV.\n\nLEFT VENTRICLE: Normal LV wall thicknesses and cavity size. Suboptimal\ntechnical quality, a focal LV wall motion abnormality cannot be fully\nexcluded.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion. Abnormal septal\nmotion/position.\n\nAORTA: Normal aortic diameter at the sinus level. Mildly dilated ascending\naorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Bioprosthetic mitral valve prosthesis (MVR). MVR well seated,\nwith normal leaflet/disc motion and transvalvular gradients. No MR. [Due to\nacoustic shadowing, the severity of MR may be significantly UNDERestimated.]\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\nIndeterminate PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: The patient is in a ventricularly paced rhythm.\n\nConclusions:\nThe left atrium is elongated. The right atrium is moderately dilated. Left\nventricular wall thicknesses and cavity size are normal. Septal motion is\ndysnchronous, but the remaining segments appear to contract well. Due to\nsuboptimal technical quality, a focal wall motion abnormality cannot be fully\nexcluded. Right ventricular chamber size and free wall motion are normal.\nThere is abnormal septal motion/position. The ascending aorta is mildly\ndilated. The aortic valve leaflets (3) are mildly thickened. No aortic valve\nstenosis is seen. Trace aortic regurgitation is seen. A bioprosthetic mitral\nvalve prosthesis is present with normal gradient and mobile leaflets. No\nmitral regurgitation is seen. [Due to acoustic shadowing, the severity of\nmitral regurgitation may be significantly UNDERestimated.] The pulmonary\nartery systolic pressure could not be determined. There is no pericardial\neffusion.\n\nCompared with the prior study (images reviewed) of , biventricular\nsystolic function is improved. The heart rate is also much lower on the\ncurrent study.\n\nCLINICAL IMPLICATIONS:\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate a high risk (prophylaxis strongly recommended). Clinical decisions\nregarding the need for prophylaxis should be based on clinical and\nechocardiographic data.\"\n\n\n"
},
{
"category": "Echo",
"chartdate": "2155-05-16 00:00:00.000",
"description": "Report",
"row_id": 94890,
"text": "PATIENT/TEST INFORMATION:\nIndication: Mitral valve disease. valve function.\nHeight: (in) 64\nWeight (lb): 163\nBSA (m2): 1.79 m2\nBP (mm Hg): 105/37\nHR (bpm): 71\nStatus: Inpatient\nDate/Time: at 18:10\nTest: Portable TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nICU nursing staff monitored the patient during the procedure. The patient was\non a propofol drip and was given an additional 40 mcg of propofol.\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA\nand extending into the RV.\n\nLEFT VENTRICLE: Mild-moderate regional LV systolic dysfunction. Mildly\ndepressed LVEF.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior\n- akinetic; mid inferior - akinetic;\n\nRIGHT VENTRICLE: Paradoxic septal motion consistent with prior cardiac\nsurgery.\n\nAORTA: Complex (>4mm) atheroma in the aortic arch. Complex (>4mm) atheroma in\nthe descending thoracic aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Bioprosthetic mitral valve prosthesis (MVR). Normal MVR\nleaflets. No mass or vegetation on mitral valve. No MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was monitored\nby a nurse throughout the procedure. The patient appears to be\nin sinus rhythm.\n\nConclusions:\nThere is mild to moderate regional left ventricular systolic dysfunction with\ninferior akinesis and abnormal septal motion (post-op) (ejection fraction\n?45%). Overall left ventricular systolic function is mildly depressed. There\nare complex (>4mm) atheroma in the aortic arch. There are complex (>4mm)\natheroma in the descending thoracic aorta. The aortic valve leaflets (3) are\nmildly thickened. There is no aortic valve stenosis. Trace aortic\nregurgitation is seen. A bioprosthetic mitral valve prosthesis is present. The\n mitral leaflets appear with upper normal gradientsl. No\nobstruction, mass or vegetation is seen on the mitral valve. No mitral\nregurgitation is seen.\n\n\nIMPRESSION: Normally functioning bioprosthetic mitral valve. Moderately\ndepressed EF with inferior akinesis and abnormal septal motion (post-op).\n\n\n"
},
{
"category": "Echo",
"chartdate": "2155-05-15 00:00:00.000",
"description": "Report",
"row_id": 94961,
"text": "PATIENT/TEST INFORMATION:\nIndication: New pulmonary edema and peripheral edema. Recent MVR and pacer.\nHeight: (in) 64\nWeight (lb): 186\nBSA (m2): 1.90 m2\nBP (mm Hg): 136/50\nHR (bpm): 60\nStatus: Inpatient\nDate/Time: at 16:44\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA\nand extending into the RV.\n\nLEFT VENTRICLE: Severe global LV hypokinesis.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion. Paradoxic septal\nmotion consistent with conduction abnormality/ventricular pacing.\n\nAORTIC VALVE: Aortic valve not well seen.\n\nMITRAL VALVE: Bioprosthetic mitral valve prosthesis (MVR). Increased MVR\ngradient. MR present but cannot be quantified.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion. There is an anterior\nspace which most likely represents a fat pad, though a loculated anterior\npericardial effusion cannot be excluded.\n\nConclusions:\nThere is severe global left ventricular hypokinesis (ejection fraction 20-30\npercent) (at least partly due to intraventricular contractile dysynchrony).\nRight ventricular chamber size and free wall motion are normal. The aortic\nvalve is not well seen. A bioprosthetic mitral valve prosthesis is present.\nThe gradients are higher than expected for this type of prosthesis. Mitral\nregurgitation is present but cannot be quantified. There is a\ntrivial/physiologic pericardial effusion. There is an anterior space which\nmost likely represents a fat pad.\n\nCompared with the findings of the prior study (images reviewed) of , a right ventricular pacing wire is now present, and the left ventricular\nejection fraction is markedly reduced, with evidence of intraventricular\nmechanical dysynchrony; consider biventricular pacing to address this problem.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2155-05-09 00:00:00.000",
"description": "Report",
"row_id": 94962,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. H/O cardiac surgery. S/p MVR.\nHeight: (in) 64\nWeight (lb): 186\nBSA (m2): 1.90 m2\nBP (mm Hg): 157/58\nHR (bpm): 60\nStatus: Inpatient\nDate/Time: at 16:42\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nLEFT VENTRICLE: Mild regional LV systolic dysfunction. Mildly depressed LVEF.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior\n- akinetic; mid inferior - akinetic;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion. Paradoxic septal\nmotion consistent with prior cardiac surgery.\n\nAORTA: Mildly dilated aortic sinus. Mildly dilated ascending aorta.\n\nAORTIC VALVE: Aortic valve not well seen.\n\nMITRAL VALVE: Bioprosthetic mitral valve prosthesis (MVR). Increased MVR\ngradient.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal PA\nsystolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nThe left atrium is mildly dilated. Overall left ventricular systolic function\nis mildly depresed with inferior hypokinesis (views suboptimal). Right\nventricular chamber size and free wall motion are normal. The aortic root is\nmildly dilated at the sinus level. The ascending aorta is mildly dilated. The\naortic valve is not well seen. There is a mild left ventricular/aortic outflow\ngradient which is likely due to mild outflow obstruction from the mitral valve\nprosthesis (outflow gradient was not fully assessed in this study). A\nbioprosthetic mitral valve prosthesis is present and appears well seated. The\ngradients are slightly higher than expected for this type of prosthesis. The\nestimated pulmonary artery systolic pressure is normal. There is no\npericardial effusion.\n\nCompared with the prior study (images reviewed) of , mitral valve has\nnow been replaced. Elevated aortic/left ventricular outflow velocities are\nnew. Ventricular function appears similar.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2155-05-05 00:00:00.000",
"description": "Report",
"row_id": 94963,
"text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure. Coronary artery disease. Mitral valve disease. Shortness of breath. Intraop TEE for MVR\nHeight: (in) 64\nWeight (lb): 150\nBSA (m2): 1.73 m2\nBP (mm Hg): 108/45\nHR (bpm): 77\nStatus: Inpatient\nDate/Time: at 14:01\nTest: TEE (Complete)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA\nand extending into the RV. No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Mild-moderate regional LV systolic dysfunction. Moderately\ndepressed LVEF.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal\nanteroseptal - hypo; mid anteroseptal - hypo; septal apex - hypo; apex - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter. Simple atheroma in ascending aorta. Normal aortic arch diameter.\nSimple atheroma in aortic arch. Normal descending aorta diameter. Simple\natheroma in descending aorta.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. Mildly thickened\naortic valve leaflets (3). No AS. No AS. No AR.\n\nMITRAL VALVE: Moderately thickened mitral valve leaflets. Moderate mitral\nannular calcification. Moderate MS (MVA 1.0-1.5cm2) Moderate to severe (3+)\nMR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. No TEE related\ncomplications. The patient was under general anesthesia throughout the\nprocedure. The patient appears to be in sinus rhythm. Results were personally\nreviewed with the MD caring for the patient.\n\nConclusions:\nPRE-BYPASS:\n\n1. No atrial septal defect is seen by 2D or color Doppler.\n\n2.There is mild to moderate regional left ventricular systolic dysfunction\nwith mild to moderate hypokinesia of the mid and apical portions of the septum\nand anterior septum.. Overall left ventricular systolic function is moderately\ndepressed.\n\n3.Right ventricular chamber size and free wall motion are normal.\n\n4.There are simple atheroma in the ascending aorta. There are simple atheroma\nin the aortic arch. There are simple atheroma in the descending thoracic\naorta.\n\n5.The aortic valve leaflets (3) appear structurally normal with good leaflet\nexcursion and no aortic regurgitation. The aortic valve leaflets (3) are\nmildly thickened but aortic stenosis is not present. No aortic regurgitation\nis seen.\n\n6.The mitral valve leaflets are moderately thickened. There is moderate mitral\nstenosis (area 1.0-1.5cm2). Moderate to severe (3+) mitral regurgitation is\nseen. The posterior leaflet is very restricted. MR jet is posteriorly\ndirected.\n\n7.There is no pericardial effusion.\n\nPOST BYPASS\n\n1. Patient is being AV paced and receiving an infusion of epinephrine and\nphenylephrine.\n\n2. RV systolic function is moderately depressed.\n\n3. LV systolic function is moderately depressed. Anterior wall,septum and\nanterior septum are moderately depressed.\n\n4. Bioprosthetic valve seen in the mitral position. Leaflets open well and the\nvalve appears well seated. Trace mitral regurgitation present. Mean gradient\nacross the mitral valve is 5 mm Hg. Prominent struts seen in the LVOT. No\nsignificant gradient across the LVOT.\n\n5. Aorta intact post decannulation.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2155-04-21 00:00:00.000",
"description": "Report",
"row_id": 94964,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Mitral valve disease. Shortness of breath.\nWeight (lb): 176\nBP (mm Hg): 162/52\nHR (bpm): 71\nStatus: Inpatient\nDate/Time: at 11:59\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Suboptimal\ntechnical quality, a focal LV wall motion abnormality cannot be fully\nexcluded. Overall normal LVEF (>55%).\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior\n- hypo; mid inferior - hypo; basal inferolateral - hypo; mid inferolateral -\nhypo; inferior apex - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets. No AS. No AR.\n\nMITRAL VALVE: Severely thickened/deformed mitral valve leaflets. Severe mitral\nannular calcification. Moderate MS (MVA 1.0-1.5cm2) Mild (1+) MR. [Due to\nacoustic shadowing, the severity of MR may be significantly UNDERestimated.]\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nThe left atrium is moderately dilated. There is mild symmetric left\nventricular hypertrophy. The left ventricular cavity size is normal. Overall\nleft ventricular systolic function is normal (LVEF>55%). Cannot exclude\ninferior hypokinesis (views suboptimal). Right ventricular chamber size and\nfree wall motion are normal. The aortic valve leaflets are mildly thickened.\nThere is no aortic valve stenosis. No aortic regurgitation is seen. The mitral\nvalve leaflets are severely thickened/deformed. There is severe mitral annular\ncalcification. There is moderate mitral stenosis (area 1.0-1.5cm2). Mild (1+)\nmitral regurgitation is seen. [Due to acoustic shadowing, the severity of\nmitral regurgitation may be significantly UNDERestimated.] There is no\npericardial effusion.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2155-05-13 00:00:00.000",
"description": "Report",
"row_id": 270168,
"text": "Atrial fibrillation with ventricular rhythm\nSince previous tracing of , ventricular paced rhythm present\n\n"
},
{
"category": "ECG",
"chartdate": "2155-05-12 00:00:00.000",
"description": "Report",
"row_id": 270169,
"text": "Atrial fibrillation with slow ventricular response\nLeft bundle branch block\nSince previous tracing of , ventricular response is now irregular with\nleft bundle branch block configuration\n\n"
},
{
"category": "ECG",
"chartdate": "2155-05-10 00:00:00.000",
"description": "Report",
"row_id": 270170,
"text": "Atrial fibrillation with a regular ventricular response suggesting an\nindependent junctional or idioventricular rhythm with right bundle branch\nblock/left posterior fascicular block configuration\nSince previous tracing of , sinus bradycardia and left bundle branch\nblock now absent\n\n"
},
{
"category": "ECG",
"chartdate": "2155-05-09 00:00:00.000",
"description": "Report",
"row_id": 270171,
"text": "Sinus bradycardia. Intraventricular conduction delay of the left bundle-branch\nblock variety. Secondary ST-T wave abnormalities. Compared to the previous\ntracing of no change.\n\n"
},
{
"category": "ECG",
"chartdate": "2155-05-08 00:00:00.000",
"description": "Report",
"row_id": 270172,
"text": "Sinus bradycardia. P-R interval 0.18. Since the previous tracing of the\nrate has slowed and T waves are inverted in leads III and aVF, which may be\nconsistent with inferior myocardial infarction in the presence of left\nbundle-branch block. One ventricular premature beat is noted.\n\n"
},
{
"category": "ECG",
"chartdate": "2155-05-05 00:00:00.000",
"description": "Report",
"row_id": 270173,
"text": "Sinus rhythm with first degree A-V block. Left bundle-branch block. Since the\nprevious tracing of the rate is increased but no other changes have\noccurred.\n\n"
},
{
"category": "ECG",
"chartdate": "2155-04-27 00:00:00.000",
"description": "Report",
"row_id": 270174,
"text": "Sinus rhythm. Consider left atrial abnormality. Left bundle-branch block.\nCompared to the previous tracing no change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2155-05-16 00:00:00.000",
"description": "Report",
"row_id": 270166,
"text": "Normal sinus rhythm with marked A-V conduction delay. Left bundle-branch block.\nLeft atrial abnormality. Occasional premature ventricular contractions.\nCompared to tracing #1 no diagnostic interim change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2155-05-14 00:00:00.000",
"description": "Report",
"row_id": 270167,
"text": "Atrial fibrillation\nIntermittent ventricular premature beats\nLeft bundle branch block\nSince previous tracing of , ventricular pacing intermittent\n\n"
},
{
"category": "ECG",
"chartdate": "2155-04-26 00:00:00.000",
"description": "Report",
"row_id": 270175,
"text": "Sinus bradycardia. Consider left atrial abnormality. Left bundle-branch block.\nSince the previous tracing no change.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2155-04-24 00:00:00.000",
"description": "Report",
"row_id": 270176,
"text": "Baseline artifact. Sinus rhythm. Leftward axis. Left bundle-branch block. Since\nthe previous tracing of the rate has decreased. ST-T wave abnormalities\nare less.\n\n"
},
{
"category": "ECG",
"chartdate": "2155-04-22 00:00:00.000",
"description": "Report",
"row_id": 270177,
"text": "Sinus rhythm\nLeft atrial abnormality\nLeft bundle branch block\nSince previous tracing of , ST-T wave changes less prominent and Q-Tc\ninterval appears shorter\n\n"
},
{
"category": "ECG",
"chartdate": "2155-04-21 00:00:00.000",
"description": "Report",
"row_id": 270178,
"text": "Baseline artifact. Probable sinus rhythm. Left axis deviation. Left anterior\nfascicular block. Left bundle-branch block type. Q-T interval prolongation.\nSince the previous tracing of the precordial T wave inversions are more\nprominent. Clinical correlation is suggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2155-04-20 00:00:00.000",
"description": "Report",
"row_id": 270179,
"text": "Sinus rhythm. Sinus rhythm. Compared to tracing #2 the heart rate has\nsignificantly normalized.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2155-04-19 00:00:00.000",
"description": "Report",
"row_id": 270180,
"text": "Sinus tachycardia. Occasional atrial premature beats. Compared to tracing #1\nthe heart rate hias decreased but significant tachycardia persists. Clinical\ncorrelation is suggested.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2155-04-19 00:00:00.000",
"description": "Report",
"row_id": 270181,
"text": "Sinus tachycardia. Left atrial abnormality. Left axis deviation. Left\nbundle-branch block. Compared to the previous tracing of the heart rate\nhas significantly increased. Clinical correlation is suggested.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2155-05-27 00:00:00.000",
"description": "Report",
"row_id": 273792,
"text": "Right may be sinus with marked left atrial abnormality and first degree\nA-V delay. Consider ectopic atrial rhythm. Left bundle-branch block. Since the\nprevious tracing of the rate is slower and the intraventricular\nconduction delay and ST-T wave abnormalities are less prominent.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2155-05-27 00:00:00.000",
"description": "Report",
"row_id": 273793,
"text": "Regular rhythm, mechanism uncertain, may be sinus or ectopic atrial rhythm with\nfirst degree A-V delay. Left bundle-branch block. Since the previous tracing\nof the rate is faster.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2155-05-20 00:00:00.000",
"description": "Report",
"row_id": 273794,
"text": "Sinus rhythm. A-V conduction delay. Left bundle-branch block. Compared to the\nprevious tracing of ventricular ectopy is absent and the rate has\nslowed. Otherwise, no diagnostic interim change.\n\n"
},
{
"category": "ECG",
"chartdate": "2155-05-14 00:00:00.000",
"description": "Report",
"row_id": 273795,
"text": "Sinus tachycardia. Left bundle-branch block and secondary ST-T wave\nabnormalities. Compared to the previous tracing of atrial fibrillation\nis no longer present.\nTRACING #1\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2155-05-18 00:00:00.000",
"description": "Report",
"row_id": 1460561,
"text": "Neuro: A&O x3; sleepy @ beginning of shift, dozing on & off, more awake in PM; MAE's; follow commands consistently\n\nCV: Underlying atrial flutter with V-paced beats @ 60 by perm pacer; SBP 100's-130's; tolerating captopril & lopressor; SvO2 >65, CO decreased from 3.9 to 3.3 in PM, MD , CCO recaled, mixed venous 70 per careweb, fick CI 2.99, OK to pulled swan per Dr ; natrecor infusing @ 0.01 mcg/kg/min; changed to 750 units/hr @ 1100, evening PTT result pending; R fem a line DC'd, pressure applied for 15 minutes until hemostasis attained; new 20g placed on R wrist\n\nResp: Lung clear, slight crackles @ bases; 2L NC sat 98%; non-productive cough\n\nGI: Tolerating clear liquids & pills; +bowel sound\n\nGU: Foley draining clear yellow urine, 30-45 ml/hr; will not start MD and will let pt self diurese first, pt is \"dry\" MD \n\nInteg: Intact\n\nPain: Denies pain\n\nEndo: Cover per humalog sliding scale; q4h BG\n\nSocial: Multiple calls from daughter, stating needs to talk about extremely important issues with patient, explained patient is in intesive care unit and needed rest & phone is not accessible in room; ex-husband in for visit withoout calling @ door; only voisitor allowed is daughter per patient\n\nPlan: moniotr hemodynamics, resp status & labs; get OOB/sit up in bed after 6 hrs (2300) post fem a line removal; monitor renal status & UO; advanced diet as tol; inc activity as tol; social services follow up\n"
},
{
"category": "Nursing/other",
"chartdate": "2155-05-19 00:00:00.000",
"description": "Report",
"row_id": 1460562,
"text": "NEURO: A&O X 3, MAE, FOLLOWS COMMANDS, COOPERATIVE WITH CARE.\n\nPULM: N/C AT 2L, SATS > 98%. LUNGS CRACKLEY IN BASES.\n\nCV: V PACED AT 60 ALL SHIFT, UNDERLYING RHYTHM ATRIAL FLUTTER. AT 750 UNITS/HR UNTIL 0630 WHEN PTT 91.4, PT 22.0/INR 2.2. NATRECOR CONTINUOUS AT 0.01MCG. PEDAL PULSES PALPATED. + PERIPHERAL EDEMA. TOLERATING LOPRESSOR AND CAPTOPRIL.\n\nENDO: Q4H BS WITH HUMALOG INSULIN SLIDING SCALE COVERAGE.\n\nGI: ABDOMEN SOFT, + BS. NO BM.\n\nGU: FOLEY TO CD DRAINING MARGINAL HOURLY AMBER URINE. MD AWARE. WEIGHT UP 0.5KG.\n\nSOCIAL: NO VISITORS OR PHONE INQUIRIES.\n\nPLAN: ? PICC LINE FOR ACCESS THEN DC RIJ. ? DC NATRECOR TODAY. ? LASIX OR DOSE FOR DIURESIS. OOB TO CHAIR THIS AM.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2155-05-19 00:00:00.000",
"description": "Report",
"row_id": 1460563,
"text": "NEURO ALERT ORIENTED GENERALIZED WEAKNESS NO NEURO DEFECITS NOTED\n\nC/V VPACED B/P STABLE PALP PULSES GENERALIZED EDEMA EXTREMTIES HEP DC/ MD. COUMADIN GIVEN. DOSE DISCUSSED WITH MD, WILL CONTINUE TO FOLLOW PT/PTT/INR\n\nRESP BREATH SOUNDS CLEAR, DIMINISHED IN BASES. USING IS WITH MODERATE VOLUMES. NONPRODUCTIVE COUGH. NC 2L TOL WELL SATS 98-100%\n\nGU/GI ABD SOFT INCREASED DIET TO CARDIAC/2GM NA TOL WELL. MODERATE URINE 40CC HOUR NATRECOR DC/ MD LASIX IV BID STARTED WITH GOOD OUTPUT.\n\nPLAN CONTINUE TO CLOSELY MONITOR I/O AND RESP STATUS. INCREASED ACTIVITY\n"
},
{
"category": "Nursing/other",
"chartdate": "2155-04-21 00:00:00.000",
"description": "Report",
"row_id": 1460523,
"text": "Respiratory Care:\nPt. successfully extubated to a 40% cool mist mask. Appears to be doing well. MDI's given prior to extubation. HR = 69 BP = 128/41 RR = 17 O2 Sat. = 100%. Was OET suctioned for a large plug just before the tube was removed; chest sounds were clear after suctioning.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2155-04-19 00:00:00.000",
"description": "Report",
"row_id": 1460515,
"text": "Nursing progress notes\n71 yr old pt w/ long hx (please see fhp) sob x 1 week w/ worsening. daughter called ems, to intubated d/t rr<6 and obtunded. pcxr shows chf lasix given 60mg ivp w/ approx 500cc out this shift. placed on ntg gtt at 3mcq/min for hypertension of sbp 200, given asa and tylenol for temp 103 rectal. lactate 4.3, pt received vanco, ceftriaxone, and flagyl. bs 500 and urine glucose 1000 pt received 6 units of regular insulin iv. to micu. bs 450 insulin gtt started. pt intubated 7.5 orally at 22cm lip line. on ac16/400/100%/5 o2 decreased to 50% sats cont at 100% abg attempted but team and resp therapist unable to obtain.\n\nNeuro: pt sedated on diprivan gtt 40mcq/kg/min able to mae follow commands nods to simple questions.\n\nresp: intubated as above. team to attempt aline later this evening. ls rhonchi to coarse bs. suctioned up thick tan secretions sent for c/s pt on droplet precautions to r/o influenza. pcxr in ed shows pul edema, 2nd pcxr obtain at present.\n\ncv: tele upon arrival to unit hrt rate 90-100 st w/ lbbb. at present sr60s bp 110s/60s ntg off. pt has distant hrt sounds S1S2 w/ systolic murmur. labs ordered for 1800. ck 52 w/ troponin .03, cont to cycle enzymes. cardiac cath on shows ef 60% w/ 2+ mr was stented.\nall cardiac meds on hold for now ? sepsis. uop dropped off x 2 hrs bolus of 500cc ns given at 1730\n\ngi ogt in place tube feeding order needed. abd soft bs+\n\ngu: foley put out yellow urine, ua lytes obtained.\n\nskin: pt has several bruises noted one on her left upper back, one on her right buttock and right shoulder blade. micu team aware\n\nendo: pt on insulin gtt titrate bs for 120\n\nid: pan cx in ed. on vanco levofloxacin and flagyl, lactate 3.4, svo2 74 now afebrile\n\ncode: full\n\nsocial: lives w/ daughter and grandson. daughter called this afternoon and was updated.\n\nprecautions: droplet\n\nPlan:\ncont to monitor uop\nlab pending\ncont to sedate w/ diprivan gtt\n? tube feedings\naline\n"
},
{
"category": "Nursing/other",
"chartdate": "2155-04-20 00:00:00.000",
"description": "Report",
"row_id": 1460516,
"text": "MICU Nursing Note 1900-0700\nEvents: Pt R/I for MI with Trop= 0.39---started on IV Heparin gtt, hypertensive---started on IV Labetolol gtt as per cardiology, remains on droplet precautions. IV Insulin gtt weaned to off.\n\nNeuro: Mildly sedated on IV Propofol at 40mcgs/kg/min, pt easily arouseable, follows all commands, moving all extremities when stimulated, denies pain when asked, c/o fear and anxiety when asked, calm and sleeping when not stimulated. Bilat soft wrist restraints to prevent pt from pulling at lines and tubes.\n\nCardiac: HR= 60-96 SR with no ectopy noted, new right radial Aline placed by MICU team with good waveform and correlation, BP= 102-162/30-50's, Started on IV Labetolol gtt at 0.5mg/min at Midnight and weaned to off at 4am for BP down to 103/39--restarted at 5am for BP trending back up to 140's. #2 set of cardiac enzymes with positive troponin= 0.39, CPK= 146 with MB= 16 and index= 11%. # 3 set pending. Started on IV Heparin weight based protocol at MN with am PTT pending.\n\nResp: Remains intubated with current vent settings: AC 400-40%-16 with PEEP= 5. Overbreathing vent by 3-4 breaths, MV= , Sats= 98-100%, lungs coarse at bases, good ABG= 7.38-40-137-25. Remains on Droplet precautions to r/o flu---specimen obtained by RT and sent this am. Pt with epitaxis this am ---pressure applied to both nares with bleeding subsiding. Hct= 30.\n\nGI: Abd soft with +bowel sounds, med brown BM x 1, OGtube placement checked by ausculatation and clamped at present, tube feedings held d/t possible extubation this am.\n\nGU: Foley to CD draining clear yellow urine, 20-40ml/hr\n\nEndo: insulin gtt d/c'd, 10pm fingerstick= 117---no coverage required, am fingerstick pending.\n\nID: Tmax= 99.8, WBC= 10.1, continues on Levofloxacin, vanco, and Flagyl\n\nSocial: No contact from family or friends overnight\n\nPlan: Wean sedation as tolerated,Possible wean and extubate this am, If remains intubated then start tube feedings as ordered, monitor for bleeding, wean labetolol as tolerated, continue sliding scale insulin,Support pt and family\n"
},
{
"category": "Nursing/other",
"chartdate": "2155-04-20 00:00:00.000",
"description": "Report",
"row_id": 1460517,
"text": "Respiratory care:\nPatient remains intubated and mechanically vented. Vent checked and alarms functioning per respiratory department protocol. Fio2 weaned this eve to 40%. Current settings: A/C 400*16 5 peep 40%. RSBI this am 42. Breathsounds are coarse. Albuterol/atrovent nebs started. Please see respiratory care section of carevue for further data.\nPlan: Continue mechanical ventilation. Wean as tolerated. RSBI 42.\n"
},
{
"category": "Nursing/other",
"chartdate": "2155-04-20 00:00:00.000",
"description": "Report",
"row_id": 1460518,
"text": "Resp. Care Note\nPt received intubated and vented on AC settings as charted on resp flowsheet. RSBI 42 today. Changed to PSV and is currently on 10 of PSV with TV 400's and RR <20. ABG's WNL. ruled out for flu today. Cont current support, reassess in AM for rediness to wean and extubate.\n"
},
{
"category": "Nursing/other",
"chartdate": "2155-04-22 00:00:00.000",
"description": "Report",
"row_id": 1460524,
"text": "MICU nursing progress note 7P-7A\nEvents - Pt c/o mid-sternal chest pressure. Denies nausea, a little SOB. O2 placed, EKG unchanged. VSS. SL Ntg x 1 with some decrease in pain , Maalox resulted with total pain relief. CKs drawn -troponin .2, CKs flat. CXR showed slight ^^ pulm edema. Lasix 60 mg with fair diuresis-UOP had tapered off to<8cc/hr prior to lasix.\n\nNeuro - A&Ox3, MAE, assists with turns in bed. Transient discomfort over left lower rib cage, refused tylenol.\n\nResp - Lungs clear, diminished at bases. O2 weaned 40% FT-->NC 2L. No resp distress, Sats 95-100%, RR teens.\n\nCV - ABP 95-140/39-49. NSR 70s-80s, rare PVC. Tolerating BP med regime, Ntg gtt remains off. BP was in low 90s for awhile after captopril then increased to 120s. Trace edema in LE. Hct 26.6 (30.6). Right fem line d/c'd.\n\nGI - Tolerating PO clears, Abd soft, +BS. + flatus, no stool. Insulin gtt titrated to FSBS- BS 64, gtt off, OJ given with BS^^ 200, gtt restarted.\n\nGU -- UOP 80->8cc/hr. Now ^^ after 60 lasix IVP. Pt was ~300cc neg at midnite, now a little positive. BUN/cr cont to increase 27/1.3.\n\nSkin - Bruised areas on back (2) unchanged.\n\nID - Afebrile. On vanco, levoflox.\n\nPlan - Monitor response BP med regime, goal SBP 120s. Diuresis prn. Replete lytes prn. Cyckle CKs, 2nd set due 8:30AM. Titrate insulin to BS. Cardiology following, will address whether needs tranfusion with them. ? cath lab to evaluate pulmomary edema.\n"
},
{
"category": "Nursing/other",
"chartdate": "2155-04-22 00:00:00.000",
"description": "Report",
"row_id": 1460525,
"text": "NURSING NOTE 0700HRS - 1700HRS\n\n\nNEURO...A/O X3, NO FURTHER CHEST PAIN BUT IS C/O SOME DISCOMFORT RT SIDE OF RIB CAGE, PATEINT REFUSES PO ANLAGESIA ? REALTED TO BRUISING NEAR THAT AREA..PATIENT APPEARS MORE COMFORTABLE THIS PM IN THE CHAIR\n\n\nRESP..RECEIVED ON 2 L SATS @ 100%..N/C REMOVED SATS @ 98% GOOD COUGH/DEEP BREATH, SOME CRACKLES AND CXR SHOWS CHF [ LASIX GIVEN AS BELOW]..EXPECTORATING SMALL AMOUNT OF SPUTUM\n\n\n\n\nCVS...B/P STABLE 110-120 SYSTOLC ON REDUCE DOSE OF ACE, BBLOCKERS CONTINUE TO HOLD FOR PARAMETERS...HR 62-68BPM..K STABLE THIS PM @ 4.1..REPEAT HCT @ 27 [ DOWN FROM 30 YESTERDAY BUT TEAM AWARE] CONTINUE TO OBSERVE....CK'S CONTINUE TO BE CYCLED POST CENTRAL CHEST PAIN LAST PM [ STABLE], TROP @ 0.3 TEAM AWARE... PATIENT HAS R/I FOR NSTEMI ON THIS ADMISSION CONTINUES ASPRIN/PLAVIX/SC HEPARIN..\nAFEBRILE..VANC D/C BUT LEVO CONTINUES..\n\n\nENDO...INSULIN DRIP CONTINUED THIS AM BUT D/C POST COMMENCEMENT OF NPH WITH S/S..CONTINUING TO MONITOR CLOSELY...STABLE AT PRESENT...\n\n\nGI..TAKEN DIET VERY WELL..BOWEL SOUNDS PRESENT NO BOWEL MOTION SINCE ADMISSION\n\n\nGU...GIVEN PO LASIX/SPIROLACTONE THIS AM WITH LITTLE EFFECT..AIM FOR NEG BALANCE 500-1L NEG..RECEIVED IV LASIX THIS PM BUT CONTINUES MINIMAL EFFECT AND WILL RE-REVIEW WITH TEAM...\n\n\n\nSKIN..BRUISES [ X3 AREAS MARKED], BUT SKIN INTACT\n\n\nLINES..ART REMIANS IN PLACE, NEW PIV PLACED...\n\n\n\n\nSOCIAL...SOCIAL WORKER SPOKE WITH TODAY RE CONCERNS ..PATIENT ADMITS TO VERBAL ABUSE BY DAUGHTER IN THE HOME AND GRANDSON ALSO HAVING ANGER MANAGEMENT ISSUES [ RECENTLY THREW A BOTTLE OF CLEANING FLUID AT PATIENT]..DAUGHTER PRESENTLY ADHERING TO REHAB PROGRAMME AND GRANDSON IS TO SEE COUNSELLOR FOR ANGER MANAGEMENT...SOCILA WORKER INFORMED ELDER SERVICES WHO WILL COME AND INTERVIEW PATEINT...THE PATIENT WISHES ARE AT PRESENT FOR THE DAUGHTER NOT TO BE INFORMED OF ANY OF THE ABOVE ACTION AND THAT SHE WISHES FOR HER TO VISIT...PATEINT AWARE TO INFORM OF ANY CONCERNS RE: SECURITY WHILST IN THE HOSPITAL...AWAIT ELDER SERVICES VISIT\n\n\n\n\nPLAN...MONIOTOR RESP STATUS/B/P HR///U/O...AIM FOR NEG BALANCE...AWAIT ELDER SERVICES, OFFER SUPPORT TO PATIENT/FAMILY AT THIS DIFFICULT TIME....CALL OUT TO FLOOR\n"
},
{
"category": "Nursing/other",
"chartdate": "2155-04-22 00:00:00.000",
"description": "Report",
"row_id": 1460526,
"text": "Micu Nursing Transfer Addendum\nEvents: Pt with 7 beat run VT---self-limiting and asymptomatic, no further ectopy noted. Hemodynamically stable at present, Diuresing from earlier dose IV Lasix.\n\nNeuro: A+OX3 pleasant and cooperative, moving all extremities and following all commands, somewhat weepy when discussing her plan of care and potential need for heart surgery in future.\n\nCardiac: HR= 70's SR with 7 beat run VT at 1900---asymptomatic and no further ectopy noted, BP= 140's/40's, given lopressor at 7pm---dose was held at 4pm d/t borderline BP. Denies CP\n\nResp: Lungs clear bilat but diminished at bases, RA Sats= 97-100%, denies SOB, nonprod. cough noted.\n\nGI: Abd soft with + bowel sounds all quads, no BM, + flatus, good po intake\n\nGU: Foley to CD draining clear yellow urine---diuresing from earlier IV dose of lasix, 8pm po dose of lasix held\n\nSkin: intact, ecchymotic areas on back unchanged.\n\nSocial: Pt has been in contact with daughter and grandson via phone this evening. No visitors this .\n\nPlan: Transfer to 6 for further medical and cardiology workup, Monitor closely for CHF and diurese prn, Increase activity as tolerated, replace lytes prn, due at 12 am for cardiac enzymes, Elder Services to come and speak with pt regarding abuse at home---pt requests strict confidentiality and that daughter and grandson are not informed of this, Support pt and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2155-05-17 00:00:00.000",
"description": "Report",
"row_id": 1460557,
"text": "Respiratory Care:\n\nPatient intubated on PSV. Vent settings initially PSV 10, Peep 5, Fio2 40%. PSV weaned to 5cm this morning. Spont vols 500's with RR mid teens. O2 sat 100%. BS clear bilaterally. Sx'd for sm amounts of thick white secretions. RSBI 28. Pt. appear comfortable on PSV 5.\nPlan: Will repeat ABG. ? Extubation later this morning.\n"
},
{
"category": "Nursing/other",
"chartdate": "2155-05-17 00:00:00.000",
"description": "Report",
"row_id": 1460558,
"text": "Resp Care\nPt extubated this morning to 40% cool aerosol face tent. BLBS post extubation clear though slightly diminished. Pt had audible cuff leak and no stridor post extubation. Pt was weaned to 2L after several hours and is currently satting >96% on NC.\n"
},
{
"category": "Nursing/other",
"chartdate": "2155-05-17 00:00:00.000",
"description": "Report",
"row_id": 1460559,
"text": "NPN:\n\nNeuro: Awake and following commands in am. After extubation pt cooperative but sleepy and lethargic. At 17pm pt with increased alertness. Asking questions about what happened to her-remembers going to US and having trouble breathing. MAE and follows commands. Continues with 2+ edema.\nSocial: HCP- called to check on patient-He will be away a few days and can be reached by cell phone-. Daughter called requesting to speak on phone with patient stating she had a serious issue. Request denied-encouraged daughter that patient was not able to speak on phone and if needed to see her she should visit. Also recieved call from -stating he was patients ex husband.\nID: Afebrile. Last dose of Vancomycin given. WBC-14.5\nCV: 90-110 ST then converted to aflutter/fib with V pacing-rate 60-70's. Rare PVC seen. K repleted. Continues on Amio 400mg , lopressor inreased to 37.5 mg tid and captopril increased to 12.5 tid. BP labile at times-hypertensive to 160-190's/ then 90-100's/. Natrecor continues at .01. at 900u/hr with stable PTT 71. Coumadin 4mg given at 16pm. Has L fem aline. Feet with 2-3+ pitting edema. Skin warm and dry. Pulses by doppler.\nResp: Extubated at 9am to 40% FTN with good ABG's-weaned to 2L nc with sats > 97%. Cough fair-productive of thick pale yellow secretions. CXR done today. Lungs -diminished in bases.\nGU: Foley. Diuresing on lasix at 10mg/hr-UO-decreased requiring diuril. Cr 1.5.\nGI: Abd soft, NT, ND with hypo BS. OGT dc'd with extubation. Tolerating small amounts water and diet gingerale.\nEndo: Glucoses high-190-220's. Changed to humalog sliding scale q 4 hrs. ? to restart standing insulin doses.\nComfort: C/o back pain -treated with morphine X1.\nActivity: Turned side to side in bed.\nIncisions: Sternum and L shoulder with DSD-D/I.\nA: Extubated but sleepy most of day. Social service notified\nP: Reorient prn, social work following ptient and family, Continue diuresis with lasix and natrecor-diuril prn-discuss weaning gtts in am, Swan remains in for IV access. Replete lytes prn. /coumadin. ? stop in am to dc fem aline. Restart rehab\n"
},
{
"category": "Nursing/other",
"chartdate": "2155-04-20 00:00:00.000",
"description": "Report",
"row_id": 1460519,
"text": "Nursing progress notes\nReview of systems:\n\nNeuro: pt sedated on 50mcq/kg/min of diprivan increased from 40mcq for vent adaption and comfort. pt awakens to voice and nods to simple questions. mae.\n\nREsp: orally intubated 7.5 22 at lip line retaped to right side of mouth. vent settings psv 10/5 40% abg on these settings 7.41/42/163/29/99% LS clear to coarse w/ diminished bases. suctioning thick tan secretions from ett. pt had copious bldy oral secretions this am w/ multyple med size clots probably induced by nasal influenza spec. pressure applied to nares and heparin gtt stopped and dc'd. one med size clot removed at 1800, but no further bleeding. probable extubation in am.\n\ncv: tele sb 50s - sr60s w/ LBBB. abp 108-150s/60s hrt sounds distant s1s2 w/ systolic murmur. hct stable 30 this am then rechecked at 0830 after bleeding 31.6. heparin gtt dc'd ptt this afternoon 25 inr 1.1, ck cycled at 1300 85 w/ troponin .31 next set at 2100. pt now on heparin sq. pt's own cardiologist in to see her today and will f/u w/ her in am. bb and ace inhibitor added this am.\n\ngi: abd soft bs+ tube feeds at 40cc/hr residual 10cc. no stool this shift.\n\ngu: uop via foley poor this am <20cc/hr lasix 40mg ivp given pt uop picked up to >50cc/hr goal to have pt -500cc at midnight at present pt +700cc and 1500 for los.\n\nendo: insulin gtt on for short time this am d/t bs 300 now on own home regiment. nph 22 am and 8 units at pm w/ reg insulin 8 units am and pm w/ additional humalog sliding scale\n\nid: vanco and levo cont flagyl dc'd bc pending, urine, sputum neg influenza neg pt off of droplet precautions.\n\nsocial: daughter and grandson for a short time and was updated emotional support given\n\ncode full\n\nPlan:\ncont to wean vent as tolerated\nmonitor for nasal and oral bleeding\nmonitor bs x 24 hrs on this regiment and team will reassess in am\nextubate in am.\nnext labs at 2100\n"
},
{
"category": "Nursing/other",
"chartdate": "2155-04-21 00:00:00.000",
"description": "Report",
"row_id": 1460520,
"text": "MICU Nursing Note 1900-0700\nEvents: Bleeding subsiding from nose and mouth, Didn't tolerate CPAP+PS during late evening and rested on CMV overnight, mild diuresis, BP up--required IV Hydralazine\n\nNeuro: Sedated on IV Propofol, mild restlessness with BP elevated during evening---propofol increased to 60 mcg/kg/min with good effect and titrated back to 50mcg/kg/min this am, With propofol off for 10 minutes pt awake and moving all extremities and following commands, otherwise pt arouses briefly to voice and increased stimulation. Bilat soft wrist restraints to prevent pt from pulling at lines and tubes.\n\nCardiac: HR= 57-70's SB/SR with rare PVC, BP 130-188/40-70's. Received 20 mg. IV Hydralazine for BP 180's with good effect and BP down to 140's. Again BP up to 170's this am---Captopril dose increased to 25 mg. TID and first dose given with BP slowly trending down. #4 set cardiac enzymes with CPK down to 71 and Troponin down to 0.24. Receiving SC Heparin. Lasix 40 mg. x 1. Right radial Aline with good waveform and correlation and site WNL. Right Femoral TLC site C/D/I and all ports patent\n\nResp: Remains intubated. Tolerated CPAP+PS until 8pm and then tachypneic and hypertensive with low MV ---placed back on CMV overnight with ABG this am=7.45-44-170 and RSBI= 62. Lungs coarse bilat to bases, ETtube suctioned for mod amts thick whitish sputum and occasionally suctioned for brown plugs, Orally suctioned for small old bloody clots and serous fluid at back of throat.\n\nGI: OGtube placement checked by auscultation, tube feedings infusing at 40 ml/hr until MN and then off for high residuals, pt with increasing bilous residuals during night and OGtube placed to LSW for total of 200ml. green bile. OGtube clamped at present and feedings held both for high resids and for potential extubation this am. Abd softly distended with + hypoactive bowel sounds.\n\nGU: Foley to CD draining clear yellow urine. Mild diuresis from 40 mg. IV Lasix. Pt neg. 100ml at MN and another 300 ml since MN. Remains > 1 liter positive for LOS.\n\nSkin: Grossly intact. No change in ecchymotic areas over back.\n\nEndo: Fingesticks remains elevated 178-304 overnight. On fixed dosing of NPH and regular along with sliding scale of humulog.\n\nID: Tmax= 99.1. WBC= 11.4. All antibx d/c'd\n\nSocial: Pt's daughter called during evening and was updated on pt's condition and plan of care.\n\nPlan: Wean Propofol gtt as tolerated and Attempt to wean vent and extubate, ? if need to diurese pt further prior to extubation attempt, If does not extubate consider restarting tube feeds at slower rate and monitor for high residuals, ? of need to change femoral line soon?, Continue aggressive pulmonary toiletting, Support pt and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2155-04-21 00:00:00.000",
"description": "Report",
"row_id": 1460521,
"text": "Resp Care: Pt continues intubated #7.5 oett secured @ 22 @ lip and on ventilatory support, changed to a/c for overnoc rest d/t agitation/bucking vent, currently back on cpap with minimal psv maintaining abg wnl; bs clear to coarse, sxn thick brown/blood tinged secretions, rx with mdi albuterol/atrovent, rsbi 61, will attempt wean to extubate this am.\n"
},
{
"category": "Nursing/other",
"chartdate": "2155-04-21 00:00:00.000",
"description": "Report",
"row_id": 1460522,
"text": "NURSING NOTE 0700HRS - 1700HRS\n\nPATIENT HAS EXTENSIVE CARDIAC HISTORY AND FREQUENT EPISODES OF FLASH PULOMARY OEDEMA [ WELL KNOWN TO CARDIOLOGISTS HERE]..PATIENT ADMIT WITH FOR PULMONARY OEDEAM ? SECONDARY TO HIGH B/P AND LLL PNEUMONIA\n\nEVENTS..REQUIRED FURTHER LASIX X2 DOSES FOR LOW URINE OUTPUT AND PENDING EXTUBATION...RECEIVED INCREASED PO MEDS FOR B/P CONTROL..HIGH BILIUOS RESIDUALS PLUS ABSENT BOWEL SOUNDS IMPROVED OVER THE COURSE OF THE DAY..PATIENT EXTUBATED WITH NITRO DRIP FOR B/P CONTROL @ 17.15HRS\n\n\n\n\n\nNEURO...RECEIVED ON PROPOFOL DRIP THIS AM AND DRIP TITRATED DOWN TO WHERE PATIENT WAS AWAKE BUT COMFORTABLE...SWITCHED OF FOR EXTUBATION..SINCE EXTUBATION LETHARGIC BUT ORIENATATED X3..MOVEMENT IN ALL 4 LIMBS, NO COMPLAINTS OF PAIN BUT THROAT SORE AND ICE CHIPS GIVEN...\n\n\n\n\nRESP...RECEIVED ON CPAP/PS..PATIENT WEANED AND EXTUBATED AT 17.15HRS WITH GOOD AB'S..PATIENT HAS COUGH...OLD BLOOD TINGED SECRETIONS EXPECTOATED [ FROM PREVIUOS NOSE BLEED WHILST INTUBATED]..ABLE TO COUGH DEEP BREATH WELL..SATS @ 100% AND LUNGS SOUND CLEAR..FOR CHECK ABG...\n\n\nCVS..PATIENT HAD ELEVATED TROP ON THIS ADMISSION ? NSTEMI AND INIITLLY COMMENCED ON IV HEPARIN, HEP D/C SECONDARY TO PREVIUOS EPISTAXIS NOW ON S/C HEP/ASPRIN/PLAVIX...HR SINUS RHTHM 68-75BPM WITH RARE PVC'S K THIS AM REPETED AND AGAIN PM CHECK K @ 3.6 AND REPLETED WITH 40 IV, WILL REQUIRE CHECK K PM....PATIENT IS IN L BBB ON EKG, ECHO PERFOMED THIS AM AND CARDIOLOGY FOLLOWING...\nB/P HAS BEEN ONGOING ISSUE FOR CONTROL AIM < 140..RECEIVED @ 160 THIS AM DESPITE PO MEDS THEREFORE PATIENT RECEIVED STAT DOSE OF HYDRAL..AGAIN MEDS TITRATED UP FOR ACE AND BBLOCKER..PATIENT HAD IV NITRO IN PROGRESS FOR EXTUBATION NO STOPPED AS SYSTOLIC < 140...\n\n\nENDO..B/S ^^^ THIS AM ..PATEINT COMMENCED ON HOME REGIME LAST PM BUT NOT COVERING B/S THEREFORE INSULIN DRIP RE-COMMENCED TODAY AND IS IMPROVING..\n\n\nID..WBC @ 11 THIS AM..PATEINT LOOKS FLUSHED BUT NOT FEBRILE..AB'S CONTINUE FOR LLL PNEUMONIA..? REQIURES VANC LEVEL TOMORROW\n\n\nGI...FEED STOPPED DURING THE NIGHT DUE TO HIGH BILIOUS RESIDUALS..UPON RECEIVING PATIENT THIS AM NO B/S PRESENT BUT BELLY SOFT..BILIUOS SECRETIONS IMPROVED OVER THE COURSE OF THE DAY AND PATIENT NOW HAS HYPOACTIVE B/S..CONTINUE TO MONITOR..ICE CHIPS TAKEN POST EXTUBATION\n\n\nGU....RECEIVED X2 DOSES OF LASIX FOR LOW U/O AND PENDING EXTUBATION WITH SOME RESPONSE [ PATEINT NORMALLY ON LASIX AND SPIROLACTONE AT HOME]...CONTINUE TO MONITOR .. ? EXPECTATION FOR FLUID BALANCE NOW EXTUABATED...\n\n\nSKIN..BRUISING NOTED ON HER BACK AND AREAS MARKED ?? CAUSE BUT TEAM AEA AWARE\n\n\nLINES...SECOND PERIPHERAL PLACED TODAY ? FOR GROIN CENTRAL LINE REMOVAL THIS EVE...\n\n\nSOCIAL..DAUGHTER HAS VISITED THIS AM..SOCIAL WORKER WILL TALK TO HER TOMORROW\n\n\nPLAN...FOLLOW RESP STATUS..MONITOR B/S WITH INSULIN DRIP ? SWITCH TO HOME REGIME..MONITOR K POST DIURESIS...MONITOR BOWEL SOUNDS.? COMMENCE PO'S THIS EVE..MONITOR B/P GIVE PO MEDS\n"
},
{
"category": "Nursing/other",
"chartdate": "2155-05-18 00:00:00.000",
"description": "Report",
"row_id": 1460560,
"text": "NEURO: ALERT, LETHARGIC/WEAK. ORIENTED X 3, MAE, FOLLOWS COMMANDS. VOICE STRONGER MORE FACIAL ANIMATION AFTER SLEEPING. NO SEDATIVES OR NARCOTICS GIVEN.\n\nPULM: N/C AT 2L, SATS > 97%. LUNGS DIMINISHED BASES ? CRACKLES LLL. EUPNEIC.\n\nCV: ATRIAL FLUTTER TO PACED RATE 60-65. CCO SWAN VIA RIJ CORDIS, CI 1.8-2.4, SVO2 65-70, MV02 67. BP'S MONITORED VIA L FEM ALINE, GOOD WAVE FORM. PEDAL PULSES DOPPLED. DECREASED TO 850 UNITS/HR AT 0430 FOR PTT 89.7. NATRECOR AT 0.01MCG.\n\nENDO: Q4H FSBS WITH HUMALOG INSULIN COVERAGE.\n\nGI: ABDOMEN SOFT, + BS. TAKNG CLEAR LIQUIDS, COUGHS SOMETIMES WITH DRINKING.\n\nGU: FOLEY TO CD DRAINING QS AMTS URINE. LASIX DC'D AT 2100. DIURIL 500MG IV AT 2400.\n\nSOCIAL: DAUGHTER CALLED IN FOR UPDATE. ASKING TO TALK ON THE PHONE WITH HER MOTHER ABOUT SOME \"EXTREMELY IMPORTANT LEGAL ISSUES.\". THAT PT IS TOO WEAK TO TALK AT THIS TIME.\n\nPLAN: VENOUS ACCESS TO PLACE PERIHERAL LINE OR PICC TODAY THEN DC CORDIS. COUMADIN DOSING PER INR. WEAN OFF WHEN INR THERAPEUTIC. OOB TO CHAIR. PHYSICAL THERAPY. ? DC NATRECOR TODAY. SOCIAL SERVICE TO FOLLOW PT CLOSELY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2155-04-19 00:00:00.000",
"description": "Report",
"row_id": 1460514,
"text": "Respiratory Therapy\n\nPt received from ER orally intubated, on full mechanical support. Continues on A/C ventilation 400*16 +5PEEP 50%. ABG by RRT and MD w/out success. SpO2 90s. ETT #7.5 secure/patent. See resp flowsheet for specific vent settings/data/changes.\n\nPlan: maintain support\n"
},
{
"category": "Nursing/other",
"chartdate": "2155-05-22 00:00:00.000",
"description": "Report",
"row_id": 1460571,
"text": "NEURO: PT. ALERT, ORIENT X3, OOB TO CHAIR WITH PT, OBEYS COMMANDS.\n\nCV: PT. AV PACED AT RATE OF 60, SBP 120-130, NO ECTOPY NOTED.\n\nRESP: PT. OXYGENATION >95% ON 2LNC. PT. OXYGENATION DECREASE TO 88% WITH REMOVAL OF O2 DURING PIVOT TURN FROM BED TO CHAIR. OXYGENATION IMMEDIATELY PLACED WITH RECOVERY IN O2 SATS.\n\nGI/GU/ENDO: PT. ABD SOFT, +BS, TOLERATING REGULAR DIET, ONE LARGE LOOSE, BROWN BM, +FLATUS, FOLEY DRAINING CLEAR, YELLOW URINE- GOOD U/O. NPH GIVEN THIS AM (20 UNITS)- BLOOD SUGARS TREATED PER PERSONAL SLIDING SCALE.\n\nPAIN: PT. DENIES PAIN.\n\nSOCIAL: PT. DAUGHTER CALLED TODAY- UPDATED.\nPLAN: CONTINUE TO MONITOR RESPIRATORY STATUS, MONITOR FLUID STATUS AND KEEP ON A NEGATIVE FLUID BALANCE, POSSIBLE 2 TOMORROW.\n"
},
{
"category": "Nursing/other",
"chartdate": "2155-05-22 00:00:00.000",
"description": "Report",
"row_id": 1460572,
"text": " 11a-7p\nneuro: a+o x3, mae, follows commands, up to chair with assist x1, ambulated once around unit without c/o cp, mild sob recovered with rest, perrlaa\n\ncv: v paced/av paced 60-70 no ectopy, sbp 100-134, afeb\n\nresp: lungs clear to upper lobes, fine crackles to bases, is 205-500ml, moderate strength nonproductive cough, 02 sats >95% on 2L nc, 86-88% on RA\n\ngi: positive bowel sounds, tolerating small amounts regular diet, fingersticks ssri, large bm this am\n\ngu: foley to gravity draining uop>30ml/hr, good reaction to lasix\n\nassess: stable\n\nplan: pulmonary toilet, increase activity, continue diuresis, transfer to 2 tomorrow\n"
},
{
"category": "Nursing/other",
"chartdate": "2155-05-23 00:00:00.000",
"description": "Report",
"row_id": 1460573,
"text": "Neuro: A&O x3; calm & cooperative; MAE's, following commands consistently\n\nCV: AV paced/V-paced @ 60; afebrile; SBP 110's-130's, hydralazine given x1; K & Ca repleted; +2 general edema on LE bilat, TEDs on; palpable pulses x4\n\nResp: Lung sound clear, fine crackles @ bases; non-productive cough; 2L NC, sat 98%\n\nGI: Tolerating PO diet; abd soft, non-tender, +bowel sound; +flatus\n\nGU: Foley draining clear yellow urine; good diuresis with metolazone & lasix\n\nInteg: see carevue\n\nPain: denies pain\n\nSocial: no calls from family\n\nPlan: monitor hemodynamics & resp status; pulm toilet; monitor I&O, keep -; transfer to 2 in AM\n"
},
{
"category": "Nursing/other",
"chartdate": "2155-05-21 00:00:00.000",
"description": "Report",
"row_id": 1460568,
"text": "Neuro: alert and oriented, pleasant\nCV: NSR, PR .28 60's. NTG weaned off. BP <130. Palp pulses. Cont on Natrecor. Pitting pedal edema, teds on. COumadin on hold due to high INR\nResp: Lungs decreased bases rt>lt. Scattered crackles. Sats>97% , O2 decreased to 2l. Pt denies SOB\nGI: +BS, no bm. No nausea. Tolerating reg diet.\nGU: DIuresisng 100-200cc/hr after zaroxyln, lasix, and aldactone. foley patent\nEndo: Bs elevated. Covered with ssr, NPH this am\nAct: OOB to ch without difficulty\nPlan: Cont assess cardio/resp status. Cont aggressive diuresis. Increase activity and wean o2 as tol\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2155-05-21 00:00:00.000",
"description": "Report",
"row_id": 1460569,
"text": " 7a-7p\nneuro: pleasant, a+o x3, mae, follows commands, up to chair with assist x2, steady on feet, very drowsy today, fell asleep in chair, fell asleep once returned to bed, good assist with turns, no c/o pain\n\ncv: sr/av paced intermittently, sbp 112-131, captopril dose 50mg tid now 75mg tid (tell team if sbp drops below 110, goal sbp 110-120), afeb\n\nresp: crackles to bases bilaterally, clear uppers, 02 sats >94% on 2l nc, is 250-500ml, moderate strength cough productive of thick yellow sputum\n\ngi: positive bowel sounds, tolerating small amounts regular diet, ssri and fixed dose increased today for fingersticks in the 200s, restarted glyburide\n\ngu: foley to gravity draining light amber urine, good uop on bnp with lasix ivp and metolazone po, (bnp now d/ced)\n\nassess: stable\n\nplan: goal sbp 112-131, transfer to 2 tomorrow if bp and respiratory stable overnight, increase activity, pulmonary toilet\n"
},
{
"category": "Nursing/other",
"chartdate": "2155-05-22 00:00:00.000",
"description": "Report",
"row_id": 1460570,
"text": " nursing update\nsystolic elevated to high 140s despite increase in captopril to 75 tid, lopressor 5mg iv given md with minimal response, hydralazine 10mg iv given with good effect. AVpaced 60/NSR low 60s, no ectopy seen. INR remained elevated to 4, medics aware. saturating >95% on 2l/nc, desats to low 90s on air. no signs of resp distress, lungs clear, with scattered crackles at both bases. non productive cough, still unable to raise IS for >500mls. neuro intact, turns independently/ or minimal support. pleasant and cooperative, no complaints of pain, slept well overnight. no problems swallowing, glucose dropped to 57, and improved to 121 after o.j. ~200cc. on lasix and spironolactone for diuresis, no bowel movements. rashes at perineal areas and inner thighs improving, miconazole continued. all procedures explained, no phone calls from rels. overnight\n\nplan: keep sbp 100-120mmhg, ? increase captopril further\n ^diets and activity as tolerated\n cont plan of care\n ?transfer to \n"
},
{
"category": "Nursing/other",
"chartdate": "2155-05-06 00:00:00.000",
"description": "Report",
"row_id": 1460530,
"text": "Nursing\nNeuro: A&Ox3. OOB to chair x3hrs w/2 assist. IVP morphine and po percocet for c/o incisional pain.\n\nCV: Initally nsr w/freq pacs- ivb mag admin. Nitro gtt for hypertension. PO lopressor & IV hydralazine started, nitro gtt off. Goal sbp <130. bradycardic to 50s. NP aware. HCT stable. A's wires don't sense. Pacer box set @ VVI 40. Epi gtt weaned off with CI>2, svo2s 60s- swan dc'd. CT dc'd. CXR done.\n\nResp: Extub in am. Weaned from FT to 2L NC. Sat 98-100%. Lungs cta, dim in bases. Expectorated lg amts thick sputum. Uses IS to 500cc with encouragement.\n\nGi: Tol clear liqs. Hypo bowel sounds. No c/o n/v.\nGu: Started ivp lasix. +diuresis. adequate huo.\nEndo: Titrating insulin gtt. Pt type I DM, not taking adequate POs.\nSkin: Intact. See carevue for incisions.\n\nSocial: SW has long history following pt for concerns at home- see SW note. informed of pt and is collaborating w/SW from previous unit. Daughter called and updated by RN w/pt's permission. Daughter stated on phone she would visit this afternoon.\n\nPlan: BP management. Pulm toilet. Pain management. Advance diet & exercise. ?F2 in am. F/U w/social work.\n"
},
{
"category": "Nursing/other",
"chartdate": "2155-05-07 00:00:00.000",
"description": "Report",
"row_id": 1460531,
"text": "NEURO: PT. ALERT, ORIENT X3, MAE, OBEYS COMMANDS.\n\nCV: PT. NSR, RARE PAC'S NOTED, RARE PVC'S NOTED, HR 70'S, SBP 95-120, PACER CHECKED AND V WIRES SENSE/CAPTURE. PACER ON VDEMAND RATE OF 40. PT. HR DIPS INTO LOW 50'S-TEAM AWARE. PO LOPRESSOR GIVEN AND TOLERATED BY PATIENT.\n\nRESP: PT. LUNGS CTA, DIMINISHED IN LOWER LOBES, OXYGENATION 98-100% ON 2LNC, +COUGH, NO EXPECTORATION.\n\nGI/GU/ENDO: PT. ABD SOFT, HYPOACTIVE BOWEL SOUNDS, TOLERATING CLEAR LIQUIDS, FOLEY DRAINING CLEAR, YELLOW URINE- 20MG IV LASIX GIVEN AT 2400 WITH SMALL RESPONSE IN U/O. LYTES REPLETED. U/O CURRENTLY IS MARGINAL-PA NILLSON NOTIFIED. INSULIN GTT DC/D IN AM- BLOOD SUGARS TREATED PER RISS.\n\nPAIN: PT. C/O INCISIONAL PAIN- 2 PERCOCET GIVEN AND TOLERATED.\n\nPLAN: 2?, MONITOR SBP AND HR, CONTINUE VDEMAND, ANTICOAGULATION?, PULMONARY HYGIENE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2155-05-05 00:00:00.000",
"description": "Report",
"row_id": 1460527,
"text": "Nursing\nPMH: MI, CABG w/occluded vein grafts, PCTA, stents. Type I DM. CRI (baseline 1.2). S/P Redo sternotomy & MVR, mechanical valve. Report received from anesthesia. Post EF 30%, ^RV hypokinesis, epi gtt was started coming off pump, increased in OR. 2 FFP admin by anesthesia for INR 3.1. Poor PIV access, trouble placing PA line pre-op, able to place CCO swan post-op. Fem a-line. Arrived in csru AV paced, hypothermic-> bair hugger applied.\n\nReceived on epi, prop, insulin & neo gtt. Neo switched to nitro in CSRU. Reverse T- and increase in prop gtt to keep SBP <110 MD . IVP morphine & increased nitro for ^SBP. CI 1.8, fluid bolus admin- PADs and CVPs low 20s. CI remained <2, 1 prbcs ordered. Mixed venous O2 sat 77%, fluid infusing. ACT 150, 50mg protamine. Peep increased to 10 NP . Min-mod serosang CT output. Slight serosang oozing on sternal dsd. AV asychronous pacing paused. Underlying rhythm afib 70-90s. Amio bolus ordered, held d/t brief spontaneous junctional 50s. Cont afib. A wires don't capture per anesthesia, Vs work. Received on 100% fio2, weaned to 50%. Peep remains 10. Vent RR increased for resp acidosis. Insulin gtt increased for blood sugars 130s. Creat 0.8, will replete K+.\n\nPlan: Keep sedated MD . Attempt neuro check & resedate. Maintain SBP <110.\n"
},
{
"category": "Nursing/other",
"chartdate": "2155-05-06 00:00:00.000",
"description": "Report",
"row_id": 1460528,
"text": "Resp Care Note:\n\nPt cont intub with OETT and on mech vent as per Carevue. Lung sounds coarse improve with suct mod th off white sput. ABGs stable on SIMV; sedation off switched to PSV; will repeat ABG. Cont wean PSV and extub today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2155-05-20 00:00:00.000",
"description": "Report",
"row_id": 1460564,
"text": " nursing update\nVpaced overnight, continued on captopril and lopressor. distal pulses palpable, +2 edema to both LE. verbalized laboured breathing, crackles to both lower bases, extra dose of lasix 40mg given with good effect, pt verbalized breathing much better. coughing out thick tan secretions, but pt only able to raise IS up to <500 even with much encouragement. sats 97% and better allthroughout, RR eupnic. neuro intact, 1 assist to getting oob. bld glucose covered with s/s humalog, not on lantus, medics aware. on lasix 80mg iv bid, diuresis adequate but not excessive, kcl 20meqs given. no bowel movement but passing gas. pressure areas unchanged, rashes to perineal areas and both inner thighs kept dry, miconazole applied\n\nplan: ? lantus fixed dose\n pulmonary toilet\n ^diets/activity as tolerated\n monitor uop\n cont plan of care\n"
},
{
"category": "Nursing/other",
"chartdate": "2155-05-20 00:00:00.000",
"description": "Report",
"row_id": 1460565,
"text": "Resp Care\n\nPt was placed on NIV while in pulmonary edema. Tolerated well. While on NIV rr and wob decreased\n"
},
{
"category": "Nursing/other",
"chartdate": "2155-05-20 00:00:00.000",
"description": "Report",
"row_id": 1460566,
"text": "NEURO: Alert, awake, oriented x3, transfer to chair/commode/bed with 2 person assist, denies any pain\n\nRESP: Pt had SOB with RR in 40s at 1300, lung sounds crackles throughout, Sats low 90s, placed ventilator with mask, diuresed with 100mg Lasix/5mg Metolazone, also given 2mg Morphine, restarted 0.01mcg/kg Nesiritide at 1700 with 75mcg bolus\n\nCV: Vpaced to NSR, Cardiology consulted to reeval pacer, EKG done shows p waves, HR in 60s, during SOB episode, SBP rose to 170s, started on Nitro drip (currently at 2.0mcg), increased Captopril, Lasix, restarted Nesiritide, pedal pulses palpable, +3 pitting edema on lower EXTs, INR was 4.3 this AM, no Coumadin given\n\nGI/GU: Tolerating reg diet & PO meds, abd soft, + BS, large formed/brown stools, along with SOB episode c/o nausea which resolved itself; Foley in place draining yellow/clear urine, on increased Lasix/Nesiritide, repleted K.\n\nENDO: Started on NPH (breakfast/bedtime) & SSRI\n\nSOCIAL: Daughter/sister called and updated on status/plan of care\n\nPLAN: Continue to monitor resp, cv, urine outputs, LABS, increase activity as tolerated, monitor I/Os\n"
},
{
"category": "Nursing/other",
"chartdate": "2155-05-21 00:00:00.000",
"description": "Report",
"row_id": 1460567,
"text": "7P-7A\nNEURO: A/OX3. PERRLA. MAE. PLEASANT AND COOPERATIVE WITH NURSING CARE. NO C/O PAIN. AFEBRILE.\n\nCV: NSR 60-70S. NO ECTOPY NOTED. LYTES PRN. NTG CONTINUES TO MAINTAIN SBP<140. TOLERATING PO METOPROLOL, CAPTOPRIL, AMIO. PALPABLE PULSES BILAT. +2 BILAT LE PITTING EDEMA. NESIRITIDE CONTINUES @ 0.010MCG/KG/MIN. INR 5.4 PA AWARE.\n\nRESP: FAINT CRACKLES AT BASE, CLEAR OTHERWISE. 02SAT >96% 3L NC.\n\nGU/GI: FOLEY TO GRAVITY WITH MARGINAL HUO. IV LASIX, PO METOLAZONE WITH (+)DIURESIS. ABD SNT (+)HYPOACTIVE BS. PPI FOR GI PROPHYLAXIS.\n\nSEE CAREVUE FOR SKIN ASSESSMENT\n\nENDO: ELEVATED GLUCOSE LEVELS CONTINUE. COVERAGE PER ORDERED RISS AND NPH QAM/QPM.\n\nPLAN: CONTINUE BP MANAGEMENT. MONITOR INR. CONTINUE DIURESING. PULMONARY TOILET. ? START LANTUS\n"
},
{
"category": "Nursing/other",
"chartdate": "2155-05-06 00:00:00.000",
"description": "Report",
"row_id": 1460529,
"text": "Neuro) Pt. kept lightly sedated overnight with one attempt at waking pt. at 2330 whereby pt. opened eyes but then became hypertensive to SBP 140-160's. Pt. did not have a gag or cough at that time. Re-sedated with Propofol until ~ 0400 when pt. awakend calmly off Propofol and able to follow commands and MAE.\n\nCV)Nitroglycerin titrated to keep SBP 110 although lower Syst kept MAP in the 50's. Allowed SBP in the 110-120 range as to maintain renal perfusion in view of huo 25cc x1 hour and baseline creat > 1.0.\nEpi weaned as CI maintained >2.0. SvO2 71% when machine recal.Apaced due to infrequent episodes of nodal rhtyhm.\n\nPulm) vent weaned to CPAP this morning with slow IPS wean from 15. All ABG's wnl.\n\nGI) bile from OGT. Tol clamping well.\n\nGU) adequate HUO.\n\nEndocrine) insulin on and titrated to protocol.\n\nHeme) stable HCT after one prbc given for CI <2.0.\n\nPlan) extubate this morning. Monitor SBP ~110. Insulin protocol and wean epi as tol by hemodynamics.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2155-05-08 00:00:00.000",
"description": "Report",
"row_id": 1460535,
"text": "Shift update\nNeuro: Pt alert and oriented x3, c/o being tired, NP aware. Perrla. MAE. Denies the need for pain med at this time, see carevue.\n\nCV: HR 48-50s CHB, NP aware, keep pt w/ own intrisinic rate. Backup V pace 40s, sense and capture appropriately. SBP 130-140s/ 20-30s, NP aware of diastolic, see carevue. Hydralazine to continue NP . Sternal dsg cdi. + palpable pulses.\n\nResp: LS clear diminished. Sats >98%. Encouraged IS and coughing and deep breathing. Denies CP/SOB.\n\nGI/GU: Abd soft, +flatus per pt. +BS. Tolerating po's ate 3/4th of breakfast. Foley draining clear yellow 20-80cc/hr. Lasix 80mg ivp given at 0830. ? increase pm dose per team during am rounds.\n\nEndo: BS 91 this am, ok to give NPH 20units sc and glipizide 10mg po NP , pt ate 3/4th of breakfast (corn muffin, yogurt,hot cocoa and coffee). Continue monitor BS.\n\nPlan: Monitor hemodynamics. Monitor resp. status. Pain control. Follow BS.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2155-05-08 00:00:00.000",
"description": "Report",
"row_id": 1460536,
"text": "Neuro: A&O x3, calm & cooperative, MAE's, following commands consistently; anxious with activities, calm with instructions & reassurance\n\nCV: Afebrile; CHB 50's, pacer set @ back-up VVI @ 30 NP ; SBP 140, NP awared, tolerating PO hydralazine 25 mg q6 hours; Am hct 26, type and screeen sent, will trnasfuse 1 unit PRBC when product is ready, only have 2 22g , one is due to change , do not pull NP, will get new by NP ; EP following\n\nResp: Lung sound clear, fine crackles @ bases; non-productive cough; O2 weaned to RA, sat 94%\n\nGI: Abd soft, non-tender, bowel sound x4, +flatus; tolerating diet\n\nGU: Foley drainig clear yellow/amber urine; UO tapering off, NP awared, give lasix after transfusion\n\nInteg: Intact, c/o itciness on back & arms, sarna lotion applied with good efect\n\nPain: denies pain\n\nEndo: 1200 BG BG 291, NP awared, revised sliding scale and AM NPH regimen\n\nSocial: family in for visit\n\nPlan: monitor hemodynamics, resp status & lab; get new access tomorrow; pulm toilet; monitor BG\n"
},
{
"category": "Nursing/other",
"chartdate": "2155-05-12 00:00:00.000",
"description": "Report",
"row_id": 1460545,
"text": "NEURO: alert, oriented. following commands. moves well- transfered chair to bed with x1 assist. very fatigued with minimal exertion. no pain control issues.\nCV: complete heart block 40's-50. period of nsr 60's. hypertensive at all times. SBP 150's. with exertion sbp up to 170's, resolved with 5 min. rest. ntg paste applied with good result. epicardial wires v wires sense and pace. set to v demand 35.\nRESP:lungs clear bilat. no O2 requirement. some exertional wheezes, resolve on own.\nGI/GU: abd soft, +bowel sounds. tolerating PB and crackers snack. NPO p midnoc. foley with clear yellow urine.\nENDO: blood glucose wnl. no RISS/PO coverage d/t NPO.\nSKIN: sternal incision approximated, small amount old apearing sang drainage from incision. dsd changed. chest tube site cdi, dsd changed. pressure points intact. sarna lotion to back.\nA/P: continue to monitor cv, resp, lytes and blood glucose. NPO for pacer today. ?transfer to floor p pacer.\n"
},
{
"category": "Nursing/other",
"chartdate": "2155-05-12 00:00:00.000",
"description": "Report",
"row_id": 1460546,
"text": "See transfer note for details.\n\nPlan: perm pacer placement tomorrow AM, 1/2 dose NPH in AM, NPO after midnight; ambulated ~30ft x1, brief episodes of DOE, resolved with rest\n"
},
{
"category": "Nursing/other",
"chartdate": "2155-05-12 00:00:00.000",
"description": "Report",
"row_id": 1460547,
"text": "Foley DC'd @ 1800, DTV 0200\n"
},
{
"category": "Nursing/other",
"chartdate": "2155-05-13 00:00:00.000",
"description": "Report",
"row_id": 1460548,
"text": "NEURO- A&O X3. PLEASANT &COOPERATIVE WITH CARE.MINIMAL ASSIST WITH CARE.\n\nCV- CONTINUES IN CHB WITH PAC'S RATE CONTROLLED. INCREASING AMOUNT OF PVC'S THIS AM WITH NO CHANGE IN RATE. UNABLE TO DRAW LABS TO DIFFICULTY WITH VENOUS STATUS. DEFIB PADS IN PLACE.EPICARDIAL WIRES SENSE AND CAPTURE. DOE BUT TOLERABLE IF TASKS TAKEN IN STEPS.\n\nRESP- LSC. RA=96%. DOE.\n\nGI- ABD SOFT. +BS.MEDIUM LOOSE STOOL THIS AM. NPO AFTER MN FOR PROCEDURE IN AM.\n\nGU-VOIDED X2 AFTER FOLEY DCD. URINE VERY ODIFEROUS. PERI AREA RED WITH YEAST PRESENT.\n\nNO LABS DRAWN THIS AM. NO C/O PAIN.\n\n PT TO HAVE PPM PLACED TODAY. KEEP NPO UNTIL THEN. CONTINUE TO MONITOR CHB. BEGIN P/O TEACHING WITH DISCHARGE PLANNING.\n"
},
{
"category": "Nursing/other",
"chartdate": "2155-05-15 00:00:00.000",
"description": "Report",
"row_id": 1460549,
"text": " NPN\nPT W/ RESP DISTRESS AND INTUBATION ON 2. FAMILY UPDATED BY PA. IN , PT SEDATE ON PROPOFOL. TEAM AT BEDSIDE. SWAN LINE PLACED AND AT PRESENT FEM ART LINE ATTEMPTS. VSS/HEMOS STABLE AS PER FLOWSHEET. + EDEMA NOTED. MD UPDATED BY NP. NO NEW ISSUES, AWAITING ABG RESULTS. GLUCOSE ELEVATED.\nASSESS: STABLE POST INTUBATION.\nPLAN: ART LINE INSERT, OBTAIN LABS. INSULIN GTT. DIURESIS. BEGIN NATRECOR.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2155-05-15 00:00:00.000",
"description": "Report",
"row_id": 1460550,
"text": "Resp CAre\nPt intubated on floor for resp distress then transfered to . Pt has #7.5 ETT 21@lip. BLBS course, suctioned for mod amt of thick pale yellow secretions. Pt currently on A/C, no abgs since intubation MDs currently placing a-line. Plan to obtain abg and wean vent settings as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2155-05-07 00:00:00.000",
"description": "Report",
"row_id": 1460532,
"text": "7am-7pm update\nneuro: pt alert and orientated x3. MAE and able to follow commands.\n\nCV: pt initally 1st degree AV block with occasional PAC's noted. around 9 am the pt had 1 breif episode of CHB -> BP stable -> team aware -> lopressor dc'd. pt went back into 1st degree av block. around 1pm the pt went back into CHB and has stayed in CBH since. ventricular rate in the 60's. EKG done. BP stable. BP 100-130's/20-30's. pt continues on hydralazine for BP control. cardiology following -> ?? need for PPM in future. temp pacer on VVI at 40 (A wires do not capture - team aware). pp by doppler. plavix restarted today.\n\nresp: LS clear, fine crackles noted in RLL this afternoon. pt on 2 L nc, o2 sats > 95%. pt with non productive cough. using IS\n\ngi/gu: pt with + bs. no stool. poor appetite. foley dc'd at 11 am - pt has not voided since. pt on lasix. creatinine 1.2 this am (pt with history of chronic renal failure)\n\nendo: pt on insulin gtt at 3 u/hr this am -> pt given 6 units of reg insulin + 12 NPH (as ordered and gtt was dc'd 1 hr later). glusoce 2 hrs later was 275 -> pt given 12 units reg insulin and 5 mg glipizide PO. glucose 2 hrs later was 237 -> pt given 9 units reg insulin SC. bs 2 hrs later was 288 -> pt restarted on insulin gtt per team. plan to continue on insulin gtt and given NPH and glipizide in addition to inuslin gtt. team increasing NPH dose\n\nactivity/comfort: pt given percocets for pain control. pt oob to chair with 2 assist.\n\nsocial: social work following d/t safety issues at home.\n\nplan: monitor rhythm and BP, ?? need for PPM in future, pulm toleit, pain control, monitor glucose levels -> continue insulin gtt, NHP and glipizide, social work continue to follow\n"
},
{
"category": "Nursing/other",
"chartdate": "2155-05-07 00:00:00.000",
"description": "Report",
"row_id": 1460533,
"text": "update at 1900\n pt had not voided since 11 am (when foley was removed). foley reinserted per . foley re inserted without any issues -> pt put of 150 cc's yellow urine with sediment when catheter inserted. pt also c/o \"itchiness\" on trunk and bil arms -> no rash noted, skin pink in color - team aware -> sarna lotion ordered.\n"
},
{
"category": "Nursing/other",
"chartdate": "2155-05-08 00:00:00.000",
"description": "Report",
"row_id": 1460534,
"text": "NPN:\n\nNeuro: Alert and oriented X3, MAE with equal strength. Very pleasant and cooperative.\nCV: 50's CHB with stable BP-117-140's/40-60's. Hydralazine for HTN. Pedal pulses palp. Ca repleted.\nResp: Lungs diminished in bases. O2 sats> 98% on 2l nc O2. IS to 750 with direction.\nGI: Abd soft,NT,ND with +BS. No N/V. Tolerating liquids.\nGU: Foley reinserted at 1900pm for 150cc uo. Diuresed with lasix 40 mg IV minimal response so dose increased to 80mg IV bid-given additional 40mg at 22pm with marginal response. Dr aware. Will cont to monitor.\nEndo: Glucoses improved to 126-60. Insulin gtt off and low sugar treated with OJ.\nComfort: Percocet 1 po at 22pm with good effect.\nActivity: Turned side to side with 2 assists.\nIncisions: Sternum and CT -clean and dry-DSD's changed.\nA: With stable CHB -adequate ventricular rate and BP\nP: EPS following, Cont to diurese and observe for return of SR. Replete lytes prn. Pulmonary toilet. Cardiac rehab\n"
},
{
"category": "Nursing/other",
"chartdate": "2155-05-16 00:00:00.000",
"description": "Report",
"row_id": 1460551,
"text": "NEURO-Sedated on propofol @ 70mcgkgmin but decreased to 50mcgkgmin due to\ndecreasing bp.Continued to be adequately sedated with no hypertensive episodes with stimulation. pt is able to nod head \"yes\" to her name when asked if she can hear us,but is unable to follow any more commands.\n\n Pt has PPM which is a-sensing/v-pacing at rate between 65-75, rare ventricular ectopy. K=3.7-> 20meq kcl iv x1.Hemodynamically unstable with core temp=95.7 ,co/ci=3.5/1.8,hypotensive bp=94/35(53).Bair huggar applied,milrinone bolus with gtt,natrecor bolus with gtt and levophed gtts started. Pt improved hemodynamically but u/o remained scant.Lasix 140mg iv x1 given with minimal oputput. Lasix gtt started @5mg/hr. u/o =45cc/hr.Pt given another 40mg IVP lasix which she diuresed 100cc x1 and continued to have steady u/o.Core temp/Mvo2/co/ci all improved with gtts. (see carevue)\n\nResp-Remained on CMV 40% x00x12x5. Overbreathing by 6-8bpm. sats=99%. ls clear->rhonchorous-> clear. sxing small amt clear thick sputum.\n\nGI-Abd soft with hyperactive bs. ogt-> lcwsx drg thin bilious secretions.\n\nGU/LAB-stated above in CV.\n\nEndo- insulin gtt titrated to glucose levels and protocol. Glucose level decrased to 84, gtt dcd.\n\nI.D.-Pan Cx for hypothermia with poor cardiac function. wbc=11.0 Pt has 2 more days (1dose qd x2d)of vancomycin post pacemaker placement.\n\nPain- No s/s pain seen, pt sedated on propofol gtt.\n\nPlan- TEE TODAY. wean vent settings after. Titrated gtts for maximum support with minimal infusion. monitor cardiac/resp/renal functions.\n\n\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2155-05-16 00:00:00.000",
"description": "Report",
"row_id": 1460552,
"text": "RESP CARE: Pt remains intubated/on vent on settings per carevue flowsheet. No changes overnight. ABGs acceptable with excellent oxygenation.Lungs ess. clear. Sxd early in shift for thick clear secretions. RSBI-31. Wean as tol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2155-05-16 00:00:00.000",
"description": "Report",
"row_id": 1460553,
"text": "ADDENDUM:\n\nPT 2UPRBC FOR HCT=23.0 POST TRANSFUSION HCT=29.0\n\nTYPOGRAPHICAL ERROR MADE IN RESP SECTION OF NOTE: PT 2 SETTING IS 50%. NOT 00%.\n"
},
{
"category": "Nursing/other",
"chartdate": "2155-05-16 00:00:00.000",
"description": "Report",
"row_id": 1460554,
"text": "Neuro: Pt sedated on propofol, but arousable. Follows commands and moves all extrem to command. PERRLA. Received extra sedation for TEE, Versed 2mg , morphine 2mg, and propfol boluses.\nCV: HR 70-90's nsr with prolonged PR>.32. EP interrogated pacer, confirmed SR. This am pt with rare AV pacing this am at 60 followed by vpacing now sr with rare PVC. Lopressor iv q4hr. INcreased VEA with faster rate. Milrinone weaned to 0.125mcg to remain there overnight per and to start on ace inhibitor. SVO2>70, CI >2. PA systolic low 50's, CVP low teens. BP 110-150, stable. dopplerable pedal pulses. Temp >36. TEE done showed improved EF of ~40% ( milrinone 0.2mcg) up from yesterday will no MR. started at 1400 at 1000units/hour. Albumin TID. Remains on natrecor at 0.01mcg, no change.\nResp: Lungs clear, slightly dim at base. Sx scant white thick secretions. Weaned vent to CPAP Fio2 40%, sats>98%, abg wnl. To remain intubated overnight per Dr. and may extubate in am if appropriate.\nGI: OGT to LCWS, mod bilious drng. Abd soft, hypoactive BS. Pt denies nausea. OGT replaced post TEE, placement confirmed by auscultation\nGU: Foley patent, urine clear yellow. Adequate uop but not great on lasix 10mg/hr, ranging 30cc-200cc/hr. Team aware. Plan is for pt to be negative as much as possible.\nEndo: BS stable this am off , but now elevate post antibiotics. Attempting SC sliding scale, if necessary will restart .\nSocial: Daughter into see pt, very emotional \"They took my son away from me, and now I am losing my mother\" Emotional support provided. SW who has been following up to see family, spoke with her for 15minutes. Will continue to follow\nPlan: CHeck PTT at , continue assess cardio/resp status. Wean sedation and plan to extubate in am. Continue on natrecor/lasix/milrinone as ordered. Start captoril tonight.\n"
},
{
"category": "Nursing/other",
"chartdate": "2155-05-16 00:00:00.000",
"description": "Report",
"row_id": 1460555,
"text": "Resp Care\n\nPt remains intubated and currently vented on PSV 10/5 tol well with Vt around 400-500cc and RR in the mid to low 20s. BS essentially clear sxing for minimal secretions. Last ABG WNL with adequate oxygenation on present settings. Will cont with vent support and reassess for further wean with extubation tomorrow morning.\n"
},
{
"category": "Nursing/other",
"chartdate": "2155-05-17 00:00:00.000",
"description": "Report",
"row_id": 1460556,
"text": "NEURO: SEDATED ON PROPOFOL , AROUSED TO STIMULATION, SQUEEZED MY HANDS AND WIGGLED HER TOES ON COMMAND. EASILY HYPERTENSIVE.\n\nPULM: INTUBATED TO CPAP MODE 40%, PS 10/5 PEEP ALL SHIFT. WILL WEAN PS TO 5 AND WEAN OFF PROPOFOL FOR PLANNED EXTUBATION THIS AM. LUNGS DIMINSIHED BASES, SX'D FOR SCANT AMT THIN WHITE SECRETIONS.\n\nCV: NSR WITH OCC PVC'S, HR 65-80'S. SBP UP TO 160'S AT TIMES, METOPROLOL 5MG IV Q4H, CAPTOPRIL 6.25MG PO Q6H, HYDRALAZINE 2.5MG IV X 2. PEDAL PULSES DOPPLED. CCO SWAN VIA RIJ CORDIS, SVO2'S 70'S-80'S, CI 2.1-3.0. L FEMORAL ALINE WNL. + PERIPHERAL EDEMA.\n\nENDO: BS 152 A 2400, 6 UNITS REGULAR INSULIN SC AT 0030.\n\nGI: ABDOMEN SOFT, HYPOACTIVE BS. OGT TO LCS DRAINING BILIOUS FLUID.\n\nGU: LOW UO AT ONSET OF SHIFT, 500MG IV DIURIL AT WITH GOOD DIURESIS. NEGATIVE ~1.2 LITERS AT 2400.\n\nSOCIAL: DAUGHTER CALLED AT 2200 FOR UPDATE.\n\nPLAN: WEAN AND EXTUBATE THIS AM. CONTINUE DIURESIS. AGGRESSIVE MANAGEMENT OF BP. SOCIAL SERVICE FOLLOWING.\n"
},
{
"category": "Nursing/other",
"chartdate": "2155-05-08 00:00:00.000",
"description": "Report",
"row_id": 1460537,
"text": "BS CTAB. Remains on 35% trach collar with NAD. Suctioned for moderate amount white secretions with some plugging. Inner cannula changed. Continue to monitor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2155-05-10 00:00:00.000",
"description": "Report",
"row_id": 1460542,
"text": "See data, MD notes/orders.\nNeuro: A&O x3, follows commands and communicates appropriately. No pain voice when asked.\nCV: Afib with ventricular rate in 50's, VVI temporary pacer wires intact, rate set at 30. BP 136/40.\nPulm: 2Lnc in place, lungs clear, decreased at bases. Pt uses IS q2-3hrs with good effort. 02 sat 99%.\nGU: Uo 5-45cc/hr clear yellow. Furosesemide changed to po dose taken at home with little change in uo.\nGI: Abd soft, bs presetn, formed stool on bsc this afternoon, appetite improving.\nEndo: Ssc with regular insulin along with NPH and glipizide.\nSkin: Surfaces grossly intact. Right index finger with red,inflamed joint, pt states is \"tender to touch\" and has been ongoing x 1 month. MD aware of same. Peripheral pulses palpable.\nAct: Oob several times today, some exertional wheezes audible resolving with rest.\nSoc: No visitors today.\nP: Keep in ICU over weekend with ?of PPM placement on Monday. Keep pt up to date on poc, incr activity as tolerated.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2155-05-11 00:00:00.000",
"description": "Report",
"row_id": 1460543,
"text": "NEURO: alert, Ox3. MAE, following commands. moves well in bed. no pain control issues.\nCV: CHB with Vpacing and pvc's. epicardial wires set to VVI 35. SBP 130's-150's. tolerating hydral. and lasix PO. skin warm, dry. DP/PT palp- differ in strength between feet.\nRESP: lungs clear with diminished bases. sats 98-99% 2L nasal cannula. some exertional wheezing on turning in bed, resolves on own no drop in sats. good effort on I/S. cdb done.\nGI/GU: abd soft, +bowel sounds. tolerated PB toast and juice. foley with clear yellow urine, output borderline 30cc/hr most of shift.\nENDO: no glucose coverage with RISS . 2300 blood glucose 51. pt able to take PO's. following snack blood glucose 115.\nSKIN: sternal incision approximated no drainage, mediastinal chest tube site approximated with scant amount of serosang drainage. dsd changed.\nA/P: continue to monitor cv, resp, blood glucose and lytes. continue to advance diet and activity. continue pulm hygiene. plan permanent pacer monday.\n"
},
{
"category": "Nursing/other",
"chartdate": "2155-05-11 00:00:00.000",
"description": "Report",
"row_id": 1460544,
"text": "UPDATE\nNEURO: PLEASANT, COOPERATIVE. STATES SHE FEELS TIRED EVEN THOUGH SHE SLEPT WELL LAST NIGHT. DENIES PAIN.\n\nACTIVITY: OOB TO CHAIR. AMB APPROX 70 FT USING W/C FOR BALANCE. STARTED OUT @ BRISK PACE BUT SOON TIRED AND HAD TO STOP X 3 TO REST.\n\nCV: SBP @ REST BREAK WHILE STANDING 225. DENIED ANY SX OTHER THAN SOB. BACK TO CHAIR TO REST, SBP DOWN TO 170 AFTER 10 MIN. BP CONT TO REMAIN >160. DR. NOTIFIED AND 1 IN NTP GIVEN IN ADDITION TO USUAL HYDRALAZINE DOSE (LITTLE EFFECT FROM A.M. DOSE). LATEST SBP DOWN TO 155. HR UP TO MAX OF 61 WHILE AMB, OTHERWISE 40'S-50'S, CHB.\n\nRESP: LUNGS CLEAR, DIMINISHED @ BASES. NONPRODUCTIVE COUGH. SPO2 96-97% ON RA.\n\nG.I.: EATING MEALS W/ GD APPETITE. HAD LG, FORMED B.M. ON COMMODE THIS AFTERNOON.\n\nG.U.: ADEQ HUO VIA FOLEY.\n\nENDO: AFTERNOON GLUCOSE DOWN TO 70, PT ASYMPTOMATIC. OJ GIVEN. EVENING NPH AND GLYBURIDE DOSES HELD SINCE PT TO BE NPO AFTER MN FOR PROCEDURE.\n\nSOCIAL: FAMILY IN TO VISIT THIS .\n\nA/P: DOE W/ AMBULATION AFTER MOD DISTANCE. WENT FURTHER THAN YESTERDAY. HYPERTENSION PERSISTS AFTER SUPPLEMENTAL HYDRALAZINE BUT IMPROVED AFTER NTP. NPO AFTER MN FOR PACER PLCMT TOMORROW. PT TO GET IV VANCO ON CALL. CATH LAB TO PLACE LUE IV IF NEEDED.\n"
},
{
"category": "Nursing/other",
"chartdate": "2155-05-09 00:00:00.000",
"description": "Report",
"row_id": 1460538,
"text": "7p-7a\nneuro: pt alert, oriented x3, acting appropriately, MAE with equal strength, follows commands. speech clear. po percocet given x1 with good effect.\n\ncv: had run of 8 beat v-tach then converted to SR from the complete heart block. remains hypertensive 140-160, prn iv hydralazine added with minimal effect. palpable pulses. v-wires pace and sense, remain set at v-demand at 30; a-wires sense but don't capture.\n\nresp: ls clear bilat, uses is, coughs and deep breathes. o2sats>96%/RA\n\ngi/gu: abd soft, +bowel sounds. no BM, +flatulance. indwelling cath draining clear yellow urine to gravity, diurese with lasix.\n\nendo: pt's sliding scale and fixed dose nph\n\nplan: continue to monitor cv; blood pressure management. continue to advance diet and activity as tolerating.\n"
},
{
"category": "Nursing/other",
"chartdate": "2155-05-09 00:00:00.000",
"description": "Report",
"row_id": 1460539,
"text": "Neuro: A&O x3, calm & cooperative, MAE's, following commands consistently\n\nCV: T max 100.2, SB 50's till ~1000, back into CHB 50's, SBP 130's-150's, team awared, getting PO hydralazine and IV hydralazine with minimal effect; palpable pulses x4; cardiac echo done, plan to have perm pacer on Mon; 2A 2V wires, pacer set @ back-up VVI 30, V wires sensing & capturing; 500 ml NS bolus given; atrial tracing done\n\nResp: Lung sound clear, dim @ bases, IS ~750, non-productive cough; RA sat 93-95%; c/o SOB @ ~1810, put on 2L NC, sit pt up with improvement\n\nGI: Tolerating diet; abd soft, non-tender, bowel sound x4; +flatus, LBM \n\nGU: Foley draining minimal clear yellow urine, poor diuresis after AM lasix\n\nInteg: Intact\n\nEndo: Cover per sliding scale & fixed dose with oral agents\n\nSocial: Family in for visit\n\nActivity: OOB to chair, ambulated ~25 ft x1\n\nPlan: monitor hemodynamics, resp status; pulm toilet; inc activity as tol; encouraged PO intake\n"
},
{
"category": "Nursing/other",
"chartdate": "2155-05-09 00:00:00.000",
"description": "Report",
"row_id": 1460540,
"text": "PO hydralazine increased to 50 mg, held PM dose lasix for tonight\n"
},
{
"category": "Nursing/other",
"chartdate": "2155-05-10 00:00:00.000",
"description": "Report",
"row_id": 1460541,
"text": "CSRU NPN\nSEE CAREVUE FOR DETAILED VS/ASSESSMENTS/INTERVENTIONS.\n\nNEURO: A/O X 3. VERY ANXIOUS/UPSET AT BEGINNING OF SHIFT DURING/AFTER VISIT FROM DAUGHTER & GRANDSON. GIVEN ATIVAN 0.5MG PO W/EFFECT. MAE, REPOSITIONS SELF IN BED.\n\nCV: GOES BETWEEN CHB & 1ST DEGREE AVB W/RATE IN 50S. REMAINS HYPERTENSIVE DESPITE PO & IV PRN HYDRALAZINE. PACER SET TO VVI.\n\nRESP: ON 2LNC, SPO2 AS DOCUMENTED. LUNGS CLEAR W/DIM BASES. BEGINNING TO COUGH UP SECRETIONS.\n\nGI: TOLERATING LIQUIDS/PILLS W/O NAUSEA. PT STATES \"I HAVE NO APPETITE.\" + BS, NO STOOL.\n\nGU: FOLEY PATENT, HUO MARGINAL. SEE CAREVUE.\n\nENDO: HAS OWN ORDERS FOR INSULIN COVERAGE.\n\nSOCIAL: VISITED BY DAUGHTER/GRANDSON AS STATED ABOVE. BECAME ANXIOUS/UPSET DURING AND AFTER VISIT. SOCIAL SERVICES ALREADY INVOLVED.\n\nPLAN: PPM ON MONDAY. B/P MANAGEMENT. PULMONARY HYGEINE. INCREASE ACTIVITY. CONTINUE WITH CSRU PLAN OF CARE.\n"
}
] |
30,277 | 198,836 | 27 yoM with multiple lumbar spinous processes and transverse process fractures with disc herniation at L5-S1. He was placed in a brace for concern of ligamentous injury. Upon follow-up slip was noted to progress radiographically and patient was admitted following scheduled/elective procedure listed above. Post-operative course was without complication. He received routine perioperative antibiotics and DVT prophylaxis throughout hospitilization with teds/pneumoboots. He was noted to have no change in neurologic examination post-operatively. Pain was controlled with IV and then po narcotics. Hemovac was d/c'ed when output was <30cc/8 hours. Incisions were noted to be clean/dry/intact upon discharge. Physical therapy evaluated the patient during hospitilization. He was made activity as tolerated, warm and form brace for comfort with no bending/twisting or lifting >5 lbs. He was discharged to home in stable condition when cleared by PT and medically stable. | An anterior interbody fusion device is seen at L4-L5. Transitional anatomy is again noted, with sacralization of the L5 vertebral body. Laminectomies have been performed at L4 and L5. FINDINGS: A series of 11 intraoperative radiographs of the lumbar spine demonstrate posterior fusion at L4-L5 in progress. Bilateral pedicle screws are inserted at L4 and L5; the L5 pedicle screws approach the superior endplate but do not appear to transgress the endplate. ; SPINAL FLUORO WITHOUT RADIOLOGIST IN O.R.Clip # Reason: L4-L5-S1 POSTERIOR SPINE FUSION Admitting Diagnosis: TRAUMATIC SPONDYLOLISTHESIS/SDA FINAL REPORT LUMBAR SPINE, 11 VIEWS INDICATION: L5-S1 posterior fusion. 7:51 PM L-SPINE (AP & LAT) IN O.R. | 1 | [
{
"category": "Radiology",
"chartdate": "2156-10-06 00:00:00.000",
"description": "O L-SPINE (AP & LAT) IN O.R.",
"row_id": 1038810,
"text": " 7:51 PM\n L-SPINE (AP & LAT) IN O.R.; SPINAL FLUORO WITHOUT RADIOLOGIST IN O.R.Clip # \n Reason: L4-L5-S1 POSTERIOR SPINE FUSION\n Admitting Diagnosis: TRAUMATIC SPONDYLOLISTHESIS/SDA\n ______________________________________________________________________________\n FINAL REPORT\n LUMBAR SPINE, 11 VIEWS\n\n INDICATION: L5-S1 posterior fusion.\n\n FINDINGS: A series of 11 intraoperative radiographs of the lumbar spine\n demonstrate posterior fusion at L4-L5 in progress. Transitional anatomy is\n again noted, with sacralization of the L5 vertebral body. Laminectomies have\n been performed at L4 and L5. Bilateral pedicle screws are inserted at L4 and\n L5; the L5 pedicle screws approach the superior endplate but do not appear to\n transgress the endplate. An anterior interbody fusion device is seen at\n L4-L5. Please refer to operative report for full details.\n\n\n"
}
] |
7,358 | 170,121 | The patient is an 83 yo woman with a h/o DM, HTN, chol, CAD, CHF, afib on coumadin, who was found in her apt on bed, with left hemiplegia and right gaze deviation. As she was minimally responsive whe was intubated. A head CT showed a right ACA/superior division MCA stroke with hemorrhagic transformation. CXR suggested LLL atelectasis vs consolidation. . Neuro: Exam upon dishcarge: the patient can be woken up. She has an eye opening aparaxia, which makes it impossible for her to open her eyes to command. She is able to wiggle her R-toes and squeeze her R-hand/show her R thumb when asked. She has hemiplegia in her L-arm and leg, with only minimal movement in her L-leg to noxious stimuli and no movement in her L-arm. The patient is non-verbal. The patient underwent a R-hemicraniotomy as a 1cm midline shift was noted shortly after presentation. The skull is currently preserved in her abdominal wall. Repositing of the skull by neurosurgery should be planned for in wks after the craniotomy (see follow up appointment). To protect her brain, she should wear a helmet. In addition, she is on seizure prophylaxis (dilantin; goal 15-20; please follow level regularly taking into account her albumin level). She will need to be on prophylaxis for a few years. An MRI/MRA should be scheduled in weeks to look for a possible underlying cause of the stroke. Repeat CT's of the head ( and (/8) showed no interval change apart from progressive reduction of the edema. CTA of carotids showed no stenosis and a TTE did not show a thromboembolic source or wall motion abnormalities. . Respiratory: The patient remained dependent on ventilator support. She tolerated CPAP well, but has episode of apnea (30sec) that might be central of origin. She was trached on . Please continue tracheotomy care. . Cardiovascular: The patient has a history of Afibb. She was in NSR during most of the hospitalization but returned to on . At this point the metoprolol was increased. Amiodarone was not give as her rate remained well controled. Coumadin should be kept on hold given the large intracranial hemorrhages. Aspirin may be restarted for secondary stroke prophylaxix in 4 weeks. . Endocrine: The patient has DM. She was maintained on a ISS and NPH 18 units in AM and 18 units PM. Her FSBS were reasonably controlled. Further adjustments to the NPH should be made depending on her FSBS. . Infectious disease: The patient received cefazolin peri-operative. She was started on levaquin for a LLL PNA. She developed a fever on after which her CVL was discontinued (bacteremia). Final results of the cultures are pending. A PICC line was inserted and other lines d/c-ed at that point. Levaquin to be continued for 4 more days. . Haematology: The patient's Hct dropped to 26.6 on . There were no signs of GI bleed and this drop might have been related to the bacteremia that was noted that day. Her Hct has remained stable otherwise around 30. She received GI prophylaxis. . Renal: Upon admission her creatinin and sodium were markedly elevated secondary to dehydration. Creatinin and sodium normalized slowly after sufficient rehydration. The patient needs diuresis PRN, based on her daily weigth. . Prophylaxis: Please continue penumo boots, PPI, heparin sc TID and a bowel regimen (including senna, dulcolax and colace). . FEN: Tube feeds per PEG tube at goal rate. PEG placed . PICC placed . . Code: full; HCP is nephew cell , home | ABG's showing resolving alkolosis. Lungs clear to diminished at the bases. Lungs clear.Plan: Cont. Diuresing. Resp CarePt remains on PSV-parameters noted. Lung sounds clear and equal / diminished at bases. Mild mitralannular calcification. Cont on dilantin. Will continue on CPAP as tol. Remains in afib rate of 95-118. CARE: PT. RESP. Cont PSV. CONTINUE TO MONITER NEURO AND MENTAL STATUS. Mild [1+] TR.Normal PA systolic pressure.PERICARDIUM: Small pericardial effusion. Resp: Trach #9 portex, simv PS 14/ Vt 600/ fi02 .40/ peep 5. BP stable.GI: Abdomen obese with present BS. CONTINUE TO MONITER HEMODYNAMICS, NEURO STATUS. Mild to moderate (+) mitral regurgitation is seen. Pt had stable shift , plan to cont with current tx. bowel sounds hypoactive.Resp: cont .on vent. Tolerates FS Probalance at goal. Pt becomes HTN with stimuli and then settles on her own w/o and intervention. + BS No BM this shift. Resp CarePt remains on mech vent-parameters noted. PLACED ON SIMV WITH A RATE OF 10, PS AND PEEP UNCHANGED. Reg. Pt remains afebrile pulses are dopplerable. REMAINS ON VENT.SUPPORT. Pt in NARD; no vent changes required overnoc. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Will continue mech vent and wean as tol. On phenytoin (gtube) and level on = 11.5. NPH . BP stable and systolic between 110-130's. Covered with RISS. with current nursing care. HR remains SB-NSR with PAC's. SICU nursing progress notePlease refer to flowsheet for specific info.NEuro: Unchanged from previous assessment. Resp Care Note:Pt cont intub with OETT and on mech vent as per Carevue. s/p Right hemicraniotomy. Report given to at # . Wean from vent. Mild to moderate (+) MR.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. (proxy)called. BP 128/68. PERL. There is a small pericardial effusion. Resp Care, cont on settings as noted, no vent changes. Multiple doses of lopressor given as ordered with fair effect. Follows commands intermittently. LS clear and equal bilaterally, decreased at bases. Continues to follow commands as previously noted. CONTINUE WITH DIURESIS. Cont PSV. resp. Resp. Resp. PT WITH MET ALKOLIS THIS AM. MANNITOL STARTED. 2 U FFP GIVEN AND 1 U PRBC'S GIVEN. PERRL. HEPARIN SC/CLS.RESP: LS-CLEAR-DIMISHED BIBASILER. SKIN W+D. lungs clear to diminished at the bases.GI/GU: OGT clamped. HEAD DSG C/D/I. CONDITION UPDATEVSS. HAD ECHO TODAY.RESP-REMAINS VENTED ON CMV. DISCHARGE PLANNING. Cont support. +RADIAL/PT/DP X2. WHEN IN SINUS, PT HAS PACS. PBOOTS ON. Cont PSV ? MONITOR LYTES/HCT/ABG'S PRN. FOLLOW HCT/COAGS/ABG. transported to ctscan and then to O.r. +PP. WEAN FROM VENT AS TOLERATES. MIN MOVEMENT NOTED LFOOT - NO MOVEMENT LARM. Afebrile. Pt with met. + BOWEL SOUNDS. Cont. vent. HEAD INCSION APRROXIMATED AND SUTURES CDI.CV: PT WITH GENERALIZED EDEMA. REMAINS ON KEFZOL.A-STABLE S/P CRANIECTOMY.P-CON'T WITH CURRENT PLAN. WEAN VENT SETTINGS AS TOLERATED. PERLA. U/O QS VIA FOLEY. TRACH/PEG IN AM GU: MARGINAL UO. +BS. AS PER ORDERS. Diuressing after lasix. trach today. HAD CAROTID FLOW STUDY TODAY.CV-REMAINS IN/OUT OF AFIB. Cont with current plan of care carept continues with mech. Will continue mech vent and wean as tol. OGT IN PLACE, CLAMPED. RATE DECREASED, WILL FOLLOW ABG. Resp Care Note:Pt cont intub with OETT and on mech vent as per carevue. Resp Care Note:Pt cont intub with OETT and on mech vent as per Carevue. Resp Care Note:Pt cont intub with OETT and on mech vent as per Carevue. Pt traveled to CT and then directly to OR. Respiratory CarePt remains on CPAP/PSV, bilateral breath sounds diminished with scattered rhonchi. Cont with ICU care. Resp CarePt remains on mech vent-parameters noted. pt cool temp 95.9 hugger on. TMAX 103 - PAN CULTURED. HCT-STABLE. KEEP SBP <140. continue to wean to trach mask when awake. TEMP 99.6. LUNGS CLEAR TO COARSE. CONT CURRENT ICU CARE AND ASSESSMENTS. Corneal reflex intact.CV: Parameter SBP 100-140. placed on full vent support for trach/sedation. + gag. OGT-PLACEMENT CONFIRMED AND TOLERATING PROBALANCE AT GOAL. DILANTIN LEVEL LOW, BOLUS GIVEN. CONTINUNES ON LOPRESSOR. PALP PP RESP: VENT SETTINGS AND ABGT PER FLOW , HO AWARE AND NO CHANGE.SX FOR A SMALL AMOUNT OF THICK TO THIN TAN TO WHITE SPUTUM. Compared to the previous tracing of sinus rhythm andfrequent atrial ectopy have appeared. There is again demonstrated an endotracheal tube in stable position. Returned to baseline and Dr. notified. Respiratory CarePt remains on present careview settings, suction for small amount thick white secreations. Compared to theprevious tracing of atrial bigeminy is no longer present.TRACING #1 There is unchanged mucosal thickening in the maxillary sinuses, left greater than right. TECHNIQUE: Noncontrast head CT. Urine output adequate.GI: bowel sounds hypoactive. MORMOTENSIVE, NIPRIDE GTTS REMAIN OFF. An opacity at the left lung base is again demonstrated, which is unchanged in the short interval. Persistent left lung base opacity, which again could represent atelectasis or consolidation. ABGs metabolic alkalosis worsening ventilation and oxygenation stable. Resp Care Note:Pt cont intub with OETT and on mech vent as per Careevue. SAme vent settings, A.M. blood gases pending.Plan: Cont. Sinus rhythm and atrial bigeminy. Lung sounds ess clear after suct sm th white sput. Tube feeds continue at goal.REsp: Lungs clear. There is extensive surrounding edema with resulting shift of the septum pellucidum and third ventricle to the left, unchanged compared to 6 hours earlier. Resp Care Note:Pt cont intub with OETT and on mech vent as per Carevue. IMPRESSION: Stable appearance of right-sided parenchymal hemorrhage with extensive associated edema. Sinus rhythm. REASON FOR THIS EXAMINATION: PTX FINAL REPORT INDICATION: Unresponsive. Right axis deviation. Slight right axis deviation. FINDINGS: Multiple right frontal parenchymal hematomas appear unchanged. Cont PSV. The scout image reveals an endotracheal tube and an orogastric tube. Atrial fibrillationInferior T wave changes are nonspecificRepolarization changes may be partly due to rhythmSince previous tracing, supraventricular tachycardia rhythm now atrialfibrillation Atrial ectopy. Left lower lobe atelectasis and consolidation is still present. HR NSR W/ PAC'S. | 55 | [
{
"category": "Echo",
"chartdate": "2131-09-19 00:00:00.000",
"description": "Report",
"row_id": 105266,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 62\nWeight (lb): 187\nBSA (m2): 1.86 m2\nBP (mm Hg): 107/57\nHR (bpm): 64\nStatus: Inpatient\nDate/Time: at 11:14\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: Saline\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. No ASD or PFO by 2D,\ncolor Doppler or saline contrast with maneuvers.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and systolic\nfunction (LVEF>55%). No resting LVOT gradient. No LV mass/thrombus.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter. Normal ascending aorta diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Mild to moderate (+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR.\nNormal PA systolic pressure.\n\nPERICARDIUM: Small pericardial effusion. No echocardiographic signs of\ntamponade.\n\nGENERAL COMMENTS: Contrast study was performed with 1 iv injection of 8 ccs of\nagitated normal saline at rest.\n\nConclusions:\nThe left atrium is elongated. The right atrium is moderately dilated. No\natrial septal defect or patent foramen ovale is seen by 2D, color Doppler or\nsaline contrast with maneuvers. There is mild symmetric left ventricular\nhypertrophy with normal cavity size and systolic function (LVEF>55%). No\nmasses or thrombi are seen in the left ventricle. Right ventricular chamber\nsize and free wall motion are normal. The aortic valve leaflets (3) are mildly\nthickened but aortic stenosis is not present. No aortic regurgitation is seen.\nThe mitral valve leaflets are mildly thickened. There is no mitral valve\nprolapse. Mild to moderate (+) mitral regurgitation is seen. The tricuspid\nvalve leaflets are mildly thickened. The estimated pulmonary artery systolic\npressure is normal. There is a small pericardial effusion. There are no\nechocardiographic signs of tamponade.\n\nCompared with the findings of the prior report (tape unavailable for review)\nof , significant pulmonary hypertension is no longer detected.\nOtherwise, probably no change.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-10-02 00:00:00.000",
"description": "Report",
"row_id": 1360472,
"text": "SICU\nPlease refer to flowsheet and page 2 for specific info. Patient being transfered to Rehab. facility. Neuro status remains unchanged from previous assessment and continues to follow commands and move extremeties as noted. Helmut on for moving patient. s/p Right hemicraniotomy. Do not position on right side. On phenytoin (gtube) and level on = 11.5. Cont to be in atrial fibrillation with rate 85-110/ min. BP 128/68. Aline and TLC d/c'd, left arm and hand with good perfusion brisk cap refill <2 sec. Resp: Trach #9 portex, simv PS 14/ Vt 600/ fi02 .40/ peep 5. Lung sounds clear and equal / diminished at bases. Sxn via trach for thick tan secretions q 2-4 hours. Oral secretions clear, nares draining thick yellow at times overnight. Gtube with probalance at 55cc/hour. glucose level at 10am 205 NPH 18 units. Reg. 15 units SQ. No further changes from previous assessment. Transfer with ALS / paramedic ambulance. Report given to at # .\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-22 00:00:00.000",
"description": "Report",
"row_id": 1360438,
"text": "Nursing Note 7p-7a:\nNursing Assessment:\n\nNeuro: Pt attempts to open eyes to voice, at times opens Right eye to pain. Pupils continue unequal and sluggish. Moves right extremities only, strong grasp on right hand. Occasionally follows commands. Afebrile.\n\nCV/GU: urine output adequate, bp and hr stable.\n\nGI: tube feeds continue, tolerating well. bowel sounds hypoactive.\n\nResp: cont .on vent. am labs alkalotic ph co2 36, Dr. notified and rate decreased. New ABG pending. Lungs clear.\n\nPlan: Cont. with current nursing care. Monitor urine output and resp on vent.\n\nPlease refer to carevue for details.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-22 00:00:00.000",
"description": "Report",
"row_id": 1360439,
"text": "focus data update\nsee careview for details\n\nNEURO: neuro exam unchanged, decreased periorbital edema noted, morphine given for comfort\n\nRESP: Vent changed to CPAP, tol well, abg's done post vent change, suctioned for mod amt of thick white secretions both orally and ett\n\nCV: HR NSR, sys b/p < 160, off gtt's, a-line patent, multi-lumen central line patent, NA decreased 151, serum osmo 317, labs redrawn @ 1600 awaiting results\n\nGI: tol TF @ goal, no BM\n\nGU: adequate hourly u/o\n\nA/P: continue to assess and treat, continue both emotional and education support to both patient and family\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-23 00:00:00.000",
"description": "Report",
"row_id": 1360440,
"text": "Resp Care Note:\n\nPt cont intub with OETT and on mech vent as per Carevue. Lung sounds coarse suct sm th white sput. Pt in NARD; no vent changes required overnoc. Cont PSV.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-30 00:00:00.000",
"description": "Report",
"row_id": 1360466,
"text": "Resp Care\nPt remains on PSV-parameters noted. Pt continues to have periods of apnea. Blood gas shows metabolic alkalosis and vitals are stable. Will continue on CPAP as tol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-10-01 00:00:00.000",
"description": "Report",
"row_id": 1360467,
"text": "NURSING\n SEE CARE VUE FOR SPECIFICS. INCREASED DOSE OF LOPRESSOR VIA G TUBE HAS DECREASED RATE BUT CONTINUES IN A-FIBB.MAGNESIUM REPLETED THIS AM, OTHER LYTES WNL. DAY 2 OF ACETAZOLIMIDE, CONTINUES WITH LASIX .\n NEURO SIGNS UNCHANGED WITH THE EXCEPTION OF PERIODS OF APNEA WHICH INCREASED OVER THE DAY AND NIGHT TO >30 SECONDS. PLACED ON SIMV WITH A RATE OF 10, PS AND PEEP UNCHANGED. ABG AFTER SIMV CHANGE WNL.\n CONTINUE TO MONITER NEURO AND MENTAL STATUS. FOLLOW LABS, CONINTUE WITH NPH INSULIN AND SLIDING SCALE. ATTEMPT TO BEGIN TO WEAN OFF VENT AGAIN TODAY\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-10-01 00:00:00.000",
"description": "Report",
"row_id": 1360468,
"text": "Resp Care, cont on settings as noted, no vent changes. Pt had stable shift , plan to cont with current tx.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-10-01 00:00:00.000",
"description": "Report",
"row_id": 1360469,
"text": "SICU nursing progress note\nPlease refer to flowsheet for specific info.\n\nNEuro: Unchanged from previous assessment. Continues to follow commands as previously noted. Cont on dilantin. Level 11.7 today. Helmut on for positioning, turning only to left and supine r/t right hemi- craniotomy.\n\nResp: Sxned via trach for thick tan secretions. LS clear and equal bilaterally, decreased at bases. Sat's >98%/ ABG this morning wnl.\n\nCV: Cont to be in Afib. BP stable and systolic between 110-130's. Lopressor 50mg given via gtube and approx. 1 hour afterwards had a pause with HR to 20/min. Returned to baseline hr of 80 quickly without immediate intervention. Lopressor decreased to 37.5mg q 12.\n\nLytes/ Endo: glucose continues to be treated by sliding scale coverage. Lytes: K+ replenished with 40 meq KCL x 1. Other labs wnl.\n\nGI: On goal tube feedings through Gtube, probalance formula. Medium formed stool today x 1, yellow brown in color.\n\nGU: 20 mg cont to be given with good effect. UOP >30 / hour, and after lasix ^120cc/ hour.\n\nSocial: Spokesperson called and updated and verbalizing understanding. Family meeting may be scheduled for tomorrow/ Tuesday. Social Services updated. Meeting time not set at this time.\n\nPlan: Cont to check neuro status q 2 hours and prn, Follow glucose/ fingerstick's for sliding scale regular insulin coverage q 6 hours. NPH . Cont to update, support spokesperson. D/c plan is ongoing.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-10-02 00:00:00.000",
"description": "Report",
"row_id": 1360470,
"text": "assessment as noted\n\nRES: CLEAR/DIM LS WITH THICK TAN SPUTUM SUCTIONED Q 4H, +STRONG COUGH-CONGESTED, NO VENT CHANGES, ABG WNL, CONSISTENT NASAL DRAINAGE-YELLOW THICK FROM BOTH NOSTRILS-?SINUSITIS\n\nCV: IN AFIB, +WEAK PEDAL PULSES, BP STABLE\n\nNEURO: NO EYE OPENING, INCONSISTANTLY FOLLOWS SIMPLE COMMANDS, PERL, L.ARM FLACCID, NO SEZURE ACTIVITY NOTED, ON DILANTIN AS ORDERED\n\nGU: 20/H MOST OF THE NIGHT, 200+ WITH LASIX\n\nGI: HAD BM X 1(SENT TO OB), TOLERATES TF WELL\n\nLABD: RISS INUSE, MAG WAS REPLETED\n\nPLAN: SYMPTOMSTIC TREATMENT, TRY TO WEAN VENT DOWN\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-10-02 00:00:00.000",
"description": "Report",
"row_id": 1360471,
"text": "resp care\npt remained on imv 600x10 40% 5peep with 0-10 spont breaths. BS coarse bil. Suct for thick yellow sput.ABG acceptable this am.Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-28 00:00:00.000",
"description": "Report",
"row_id": 1360460,
"text": "STATUS\nD: NEURO UNCHANGED..MOVES RT SIDE & SL MOVEMENT OF LF LEG..NO MOVEMENT OF MLF ARM..WILL FOLLOW SOME SIMPLE COMMANDS BUT ON OCCASSION NEEDS MUCH ENCOURAGEMENT\nA: VENT WEANED TO C-PAP..SUCTIONED FOR MOD AMT THICK RUST COLORED.. LF SUBCLAVIAN LINE CHANGED OVER WIRE & TIP SENT FOR CULT..X-RAY DONE.. TF'S WELL..INCREASED HUO AFTER LASIX..PT PLACED ON LF SIDE>>RAPID A FIB 140-150'S>>ABG/LAB'S SENT>>EKG DONE>>5MGM LOPRESSOR GIVEN>>SR WITH PAC'S & OCC BURST'S A FIB..HELMET ON\nR: AWAITING LAB RESULTS\nP: WILL REPLETE ALL LOW LAB'S..CONTINUE TO MONITOR VS CLOSELY\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-29 00:00:00.000",
"description": "Report",
"row_id": 1360461,
"text": "RESP. CARE:\n PT. REMAINS ON VENT.SUPPORT. PLEASE SEE FLOW SHEET. NO CHANGES IN RESP. STATUS OVERNIGHT. =159.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-29 00:00:00.000",
"description": "Report",
"row_id": 1360462,
"text": "Resp Care\nPt remains on mech vent-parameters noted. Attempted wean to PS, but 12, but pt did not tol. Returned to 14 of PS. Suction for thick tan secretions. Will continue mech vent and wean as tol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-29 00:00:00.000",
"description": "Report",
"row_id": 1360463,
"text": "Nursing care note\nSee careview for specifics\n\nNeuro: Follows commands intermittenly by moving right side. Purposeful RUE. PERL. Does not open eyes. No movement with LUE.\nResp: Remains on CPAP+PS mode of ventilation. Attempted to decrease PS to 12. RR increased to 40's and TV's decreased to 200's. Returned to PS 14. O2 sats 100%.\nCV: Low grade temp. NSR no ectopy. Normotensive.\nGI: Tolerating TF at goal via PEG tube. No stool.\nGU: Foley. Diuresing with lasix and diamox.\nSkin: Neurosurg at the bedside to remove head sutures and abdominal sutures. All incisions approximated.\nPlan: Pulmonary toilet. Turning pt to left side only.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-20 00:00:00.000",
"description": "Report",
"row_id": 1360431,
"text": "Nursing Progress Note\nPlease See carvue for specifics:\nNeuro: Pt mostly arouses to voice. Eyes have open spontaneously and to speech. Moves only Right side. Only withdraws to pain on right side. Does follow commands. Gag reflex impaired. Pupils equal and brisk.\nCV: BP 90-140. Maintaining well. Pt becomes HTN with stimuli and then settles on her own w/o and intervention. CVP ^^ at start of shift. IVF stopped and pt given 10mg of lasix with results. CVP currently 17 MD aware. No new orders at this time. HR remains SB-NSR with PAC's. Pt remains afebrile pulses are dopplerable. NA ^^ 153 given 250 D5W bolus\nResp: vent settings unchanged remains on CMV 600X10 5/PEEP. Lungs clear to diminished at the bases. ABG's showing resolving alkolosis. Sats remai >95%.\nGI/GU: Abd soft NT. + BS No BM this shift. OGT remains clamped. Foley patent drng clear yellow urine.\nID: Remains of Kefzol\nEndo: RISS\nPlan: Cont with Q1hr neuro exam. ? Wean from vent. ? Tube feedings.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-20 00:00:00.000",
"description": "Report",
"row_id": 1360432,
"text": "Respiratory Care\nPt remaiins on mechanical ventilation, attempting CPAP/PSV with poor inspiratory efforts. Remaining on AC. Tube rotated. To CT for scan of the head planned for this afternoon.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-30 00:00:00.000",
"description": "Report",
"row_id": 1360464,
"text": "NURSING\n SEE CARE VUE FOR SPECIFICS.VSS, LOW GRADE TEMPS OVERNIGHT, 99.6 MAX. NO CHANGES OVERNIGHT IN NEURO STATUS. NO EVENTS.\n CONTINUE TO MONITER HEMODYNAMICS, NEURO STATUS. FOLLOW LABS. CONTINUE ATTEMPT TO WEAN TO TRACH MASK.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-30 00:00:00.000",
"description": "Report",
"row_id": 1360465,
"text": "Nursing care note\nSee careview for specifics.\nNeuro: PERL. Follows commands intermittently. Remains unable to move LUE.\nResp: No vent changes. Has periods of apnea inbetween periods of tacchypnea that are lasting 2-4 seconds. ABG remains acceptable. O2 sats stable at 100% on CPAP +14PS mode of ventilation. Suctioning for small amounts of thick yellow material. NT suctioned for small amounts thick yellow material.\nCV: Low grade temps. Remains in afib rate of 95-118. Multiple doses of lopressor given as ordered with fair effect. PO dose increased. BP stable.\nGI: Abdomen obese with present BS. Tolerates FS Probalance at goal. Scant amount of stool.\nGU: Foley. Diuresing. Rec's lasix and diamox.\nEndo: Glucoses elevated. Covered with RISS. NPH dose increased this am\nActivity: Pt's bed put in chair position. Pt became tacchycardic, tacchypnic (rate in the 40's). Tolerated <1 hour.\nSocial: Daughter and cousin at the bedside. (proxy)called. Updated on all information. Family requesting a family meeting for possibly Tuesday . Email sent to Dr , Dr , and .\nAll above events/information reported to Dr .\nPlan: Pulmonary toilet. Reposition pt to left side and back only. ?Family meeting.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-20 00:00:00.000",
"description": "Report",
"row_id": 1360433,
"text": "focus update note\nafebrile t max 97.4 warm blankets applied to pt and room temperature increased, EKG perfromed, nsr- sb with pacs, no a fib today seen, sbp goal libralized per neurosurg/icu team to 100-160, nipride gtt weaned off at 1200, currently heartrate 70s nsr, with pacs, SBP 120/60\n\nresp: vent weaning attempted pt exhibited poor effort, making some small breaths on own, poor gag, thick white secretions, pt bites on tube and mouth care is difficult to provide, ETT rotated, lsc to coarse, o2sat 100%\n\nneuro: opens eyes to voice at times spontaneously, pupils slugish bilaterally, neurosurgery/icu team aware, right hand exhibits purposeful movement, reaching for abdomen incision, follows commands consistently on right side, performs \"thumbs up \"sign when asked, moves toes on bed, unable to illicit response from left UE or LE and no spontaneous movement seen, mannitol on hold, free h2o bolus per ogt q 6 hours initiated for increased na 156, serum osmoalities taken q 6 hours last 337,\n\nplan: wean ventilation as tolerated , monitor neuro status closely, head ct this shift, monitor INR, HCT, serum osmoality, na and lytes q 6 hours, goal inr 1.4, goal hct above 30\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-21 00:00:00.000",
"description": "Report",
"row_id": 1360434,
"text": "Resp Care Note:\n\nPt cont intub with OETT and on mech vent as per Carevue. Lung counds scat rhonchi improve with suct sm=>mod th pale yellow sput. Pt in NARD on present vent settings; no vent changes required overnoc. Cont mech vent support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-19 00:00:00.000",
"description": "Report",
"row_id": 1360428,
"text": "Nursing Progress Note\nPlease see carvue for specifics:\nPt received on call to OR for hemi-craniectomy. Central line and aline placed and pt given 2units of FFP prior to OR. Pt traveled to CT and then directly to OR. Pt received from OR approx 0310 am.\nNEURO: Pt received from OR paralyzed not reversed on prop gtt at 15mcg. No skull on right side. Skull placed in abd. Pupils pinpoint. No movement/response to pain. Prop gtt off at 4am. Pt opening eyes to voice. Pupils 2-3mm brisk on right. Sluggish on left. Slightly withdraws to pain on right side only. Otherwise no noted spontaneous movement. Pt does not follow commands. + gag. Corneal reflex intact.\nCV: Parameter SBP 100-140. HR NSR with frequent PAC's. pt cool temp 95.9 hugger on. BP slowing dropping to high 80's neuro made aware and MD with high 80's to low 90's. MAP remains >60. Pt S/p total of 4units FFP. total since 7p .\nREsp: Remains intubated on A/C TV 600/18 5-peep. Fio2 decreased to 50%. ABG's-met alkolosis Team is aware no intervention. lungs clear to diminished at the bases.\nGI/GU: OGT clamped. + BS + BM in OR. Foley patent drng yellow urine\nID: IV abx\nEndo: RISS\nPlan: Cont with Q1hr neuro checks. Cont with current plan of care\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-26 00:00:00.000",
"description": "Report",
"row_id": 1360453,
"text": "Condition Update B:\nPlease refer to careview and remarks for details.\n\nNeuro exam remains unchanged, following commands with RE's, flacid and no response to painful stimuli LE's. Does not open ou, even to noxius stimuli. PERL 3mm/3mm brisk. Morphine 2mg amdin x2 for resp/pain comfort with effect.\n\nLS dim. Suctioned for small/mod amounts yeelow thick secretions. RR cont in low 30's. Morphine IV amdin xone for RR 35-40 with effect.\n\nPassed large hard stool gauaic neg. Tol TF at goal. No residuals. Diuressing after lasix. -1L at 0700.\n\nMonitoring glucose levels, using RISS and NPH.\n\nDaughter, , is requesting Family meeting with Neuro Med and NSURG. Email sent to SW, , to facilitate meeting.\n\nPLAN: Trach/PEG this week. Glucose levels and effect of NPH and RISS. Neuro checks. Family meeting. Cont with ICU care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-26 00:00:00.000",
"description": "Report",
"row_id": 1360454,
"text": "Resp. Care Note\nPt remains intubated and vented on settings as per resp flowsheet. No vent changes made this shift. No ABG's, sats 100%. Plan to cont vent support, ?trache soon.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-26 00:00:00.000",
"description": "Report",
"row_id": 1360455,
"text": "STATUS\nD: FOLLOWS SIMPLE COMMANDS..NO MOVEMENT OF LF SIDE..DOESN'T OPEN EYES..P=RL\nA: NO VENT CHANGES..SUCTIONED FOR MOD AMT THICK WHITE..ET TUBE MOVED TO LF SIDE..SUCTIONED ORALLY FOR MOD AMT..INCISIONS C&D..LASIX X1 WITH GOOD DIURESES\nR: STABLE\nP: ? TRACH/PEG IN AM\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-27 00:00:00.000",
"description": "Report",
"row_id": 1360456,
"text": "resp. care\npt continues with mech. vent. 9.0 portex placed at bedside. placed on full vent support for trach/sedation. continue to wean to trach mask when awake. see rt flowsheet for more.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-27 00:00:00.000",
"description": "Report",
"row_id": 1360457,
"text": "STATUS\nD: FOLLOWS SOME SIMPLE COMMANDS MOVES RT SIDE & MIN MOVEMENT OF LF FOOT..P=RL\nA: TF'S ON HOLD..#9 PERC TRACH/PEG PLACED WITHOUT PROB..VEC/FENT/PROP GIVEN FOR PROCEDURE..X-RAY DONE.. PLACED ON AC AFTER UNTIL MEDS WEAR OFF..LASIX GIVEN WITH GOOD EFFECT..STARTING TO WAKE & FOLLOW SOME SIMPLE COMMANDS WITH MUCH ENCOURAGEMENT\nR: STABLE\nP: WILL PLACE BACK ON C-PAP WHEN MORE AWAKE\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-19 00:00:00.000",
"description": "Report",
"row_id": 1360429,
"text": "nsg note\nSEE FLOWSHEET FOR SPECIFICS.\n\nNEURO-PT OPENS EYES TO VOICE. PERRL, RIGHT BRISKER THAN LEFT. PT WIGGLES RIGHT TOES TO COMMAND AND OCC RIGHT FINGERS TO COMMAND. MOVES SL ON BED SPONT ON RIGHT SIDE. NO RESPONSE/MOVEMENT ON LEFT, EVEN TO PAIN. DILANTIN LEVEL LOW, BOLUS GIVEN. MANNITOL STARTED. HEAD DSG C/D/I. HAD CAROTID FLOW STUDY TODAY.\n\nCV-REMAINS IN/OUT OF AFIB. WHEN IN SINUS, PT HAS PACS. SBP MAINTAINED <140. SKIN W+D. +PP. PBOOTS ON. 2 U FFP GIVEN AND 1 U PRBC'S GIVEN. REPEAT LABS PENDING. HAD ECHO TODAY.\n\nRESP-REMAINS VENTED ON CMV. PT WITH MET ALKOLIS THIS AM. RATE DECREASED, WILL FOLLOW ABG. LS CLEAR, DECREASED AT BASES. SXN PRN FOR SM AMT THICK YELLOW SPUTUM.\n\nGI-ABD SOFT, NT/ND. +BS. OGT IN PLACE, CLAMPED. ABD DSG C/D/I.\n\nGU-VOIDING VIA FOLEY ADEQ AMTS CL YELLOW URINE.\n\nENDO-SSRI.\n\nID-AFEB. REMAINS ON KEFZOL.\n\nA-STABLE S/P CRANIECTOMY.\n\nP-CON'T WITH CURRENT PLAN. KEEP SBP <140. FOLLOW HCT/COAGS/ABG. NEURO CHECKS. SUPPORT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-19 00:00:00.000",
"description": "Report",
"row_id": 1360430,
"text": "Resp. Care Note\nPt remains intubated and vented on settings as charted on resp flowsheet. Pt with met. alkalosis on ABG's. FiO2 decreased from 50-40% and rate decreased from 15-10 this shift. No oother changes made. Cont support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-28 00:00:00.000",
"description": "Report",
"row_id": 1360458,
"text": "CONDITION UPDATE\nVSS. TMAX 103 - PAN CULTURED. NEURO UNCHANGED COMPARED TO PREVIOUS DOCUMENTATION. FOLLOWS COMMANDS INCONSISTENTLY ON RSIDE. MIN MOVEMENT NOTED LFOOT - NO MOVEMENT LARM. PUPILS EQUAL AND BRISKLY REACTIVE. LUNGS CLEAR TO COARSE. OCC SUCTIONING FOR THICK TAN/BLD TINGED SPUTUM. ABD SOFT. NO STOOL THIS SHIFT. U/O QS VIA FOLEY. CTSCAN DONE OF MD'S ORDERS.\nCONT CLOSE NEURO ASSESSMENT. WEAN FROM VENT AS TOLERATES. DISCHARGE PLANNING. FAMILY TEACHING AND SUPPORT. CONT CURRENT ICU CARE AND ASSESSMENTS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-28 00:00:00.000",
"description": "Report",
"row_id": 1360459,
"text": "Resp Care\nPt remains on mech vent-parameters noted. Pt has metabolic alkalosis. Suction for thick white secretions. Coarse breath sounds bilat. Will continue mech vent and wean as tol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-24 00:00:00.000",
"description": "Report",
"row_id": 1360447,
"text": "ALTERED NEURO STATUS\nO: NEURO : PERL, NO MOVEMENT OF LEFT SIDE, MORE EDEMATOUS THAN RIGHT. RIGHT GRASP STRONG , MOVES RIGHT TOES UPON COMMAND, WILL NOT/CAN NOT OPEN EYES. ABD DSG REMOVED BY NEURO ATTENDING TO LEAVE OTA, NO DRAINAGE. SMALL AMOUNT OF SEROSANG DRAINAGE FROM SKULL INCISION. NO FURTHER DRAINAGE NOTED. SUTURES INTACT. CT NO CHANGE PER HO.\n CARDIAC: SR 70-80'S WITHOUT ATRIAL OR VENTRICULAR TACHYCARDIAS, SBP WITH SX WOULD RISE 180'S RECIEVED LOPRESSOR AS PER ORDERS. SBP 120-140'S. EXTREMITIES WARM. TEMP 99.6. PALP PP\n RESP: VENT SETTINGS AND ABGT PER FLOW , HO AWARE AND NO CHANGE.\nSX FOR A SMALL AMOUNT OF THICK TO THIN TAN TO WHITE SPUTUM. RR TWENTIES TO LOW THIRTIES. O2 SAT> 97%.\n GI: TOLERATING TF AT GOAL. NO STOOL. ABD SOFT. + BOWEL SOUNDS.\n GU: MARGINAL UO.\n ENDO: INSULIN GTT\n PAIN: NO GRIMACING NOTED\n SEIZURE: NO SEIZURE ACTIVITY NOTED, DILANTIN TO BE CHECKED PRIOR TO NEXT DOSE.\n SOCIAL: NEPHEW AND DAUGHTER TO ARRIVE AT 1600 FOR A FAMILY MEETING .\nA: STABLE\nP: MONITOR COMFORT, HR AND RYTHYM, SBP, RESP STATUS, NEURO STATUS- CHECK DILANTIN LEVEL, I+O-UO,LABS. AS PER ORDERS.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-25 00:00:00.000",
"description": "Report",
"row_id": 1360448,
"text": "Resp Care Note:\n\nPt cont intub with OETT and on mech vent as per Carevue. Lung sounds ess clear after suct for sm th off white sput. ABGs stable; no vent changes made overnoc. Cont PSV.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-25 00:00:00.000",
"description": "Report",
"row_id": 1360449,
"text": "Nursing Note 7p-7a:\nNursing Assessment:\n\nPt stable overnight. Moving right side only. Afebrile. PERLA. Tube feeds at goal. Cont. same vent settings. Plan: family meeting at 4pm discuss plan of care and prognosis.\n\nPlease refer to carevue for details/specifics.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-25 00:00:00.000",
"description": "Report",
"row_id": 1360450,
"text": "Respiratory Care\nPt remains on CPAP/PSV, bilateral breath sounds diminished with scattered rhonchi. Improved aeration after suctioning. Spontaneous respiratory rate upper 20's to mid 30's.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-25 00:00:00.000",
"description": "Report",
"row_id": 1360451,
"text": "CONDITION UPDATE: SE CARE VUE FOR OJECTIVE DATA AND TRENDS\n\nNEURO: PT UNABLE TO OPEN EYES. PERRL. ABLE TO FOLLOW A FEW SIMPLE COMMANDS. STRONG RIGHT HAND GRASP AND RIGHT FOOT PUSH. NO MOVEMET OF LEFT SIDE. HEAD INCSION APRROXIMATED AND SUTURES CDI.\n\nCV: PT WITH GENERALIZED EDEMA. L-ARM EDEMA GREATER THAN RIGHT. NSR-NO ECTOPY. HR-80-90'S. SBP-150'S/60'S. CONTINUNES ON LOPRESSOR. CVP'S-16-18. PT STARTED ON LASIX . +RADIAL/PT/DP X2. HCT-STABLE. HEPARIN SC/CLS.\n\nRESP: LS-CLEAR-DIMISHED BIBASILER. CONTINUES ON CPAP 5/5. ABD SHOWING GOOD OXGENATION. SAT'S: >95%. SX FOR MODERATE AMTS OF WHITE/YELLOW THICK SPUTUMN.\n\nGI: SD, +BS,S,NT. OGT-PLACEMENT CONFIRMED AND TOLERATING PROBALANCE AT GOAL. R-ABD INCISION APPROXIMATED AND CDI.\n\nGU: FOLEY WITH QS URINE.\n\nENDO: FS QID-COVERAGE PER RISS. STARTED ON NPH .\n\nSKIN: WDI.\n\nSOCIAL: HCP AND DAUGHTER IN TO VISIT. MET WITH SICU TEAM TO DICUSS TRACH AND PEG PLACEMENT-CONSENT GIVEN. BOTH, WOULD LIKE TO SCHEDULE A MEETING OR PHONE CONVERSTAION WITH NEURO .\n\nPLAN: CONTINUE TO MONITOR HEMODYNAMICS AND MANTAIN SBP<160. WEAN VENT SETTINGS AS TOLERATED. CONTINUE WITH DIURESIS. MONITOR LYTES/HCT/ABG'S PRN. PROVIDE EMTOITONAL SUPPORT TO FAMILY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-26 00:00:00.000",
"description": "Report",
"row_id": 1360452,
"text": "Resp Care Note:\n\nPt cont intub with OETT and on mech vent as per carevue. Lung sounds ess clear after suct sm th off white sput. ABGs compensated resp acidosis with good oxygenation. Cont PSV ? trach today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-19 00:00:00.000",
"description": "Report",
"row_id": 1360427,
"text": "resp care\nremains intub/vented in ac mode. transported to ctscan and then to O.r. s/p hemicraniotomy/evacuation of bleed. presently off sedation but not yet awake enough for , reassess. abg with metabolic alkalosis,pco2 35. c/w airway mgmt/vent support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-23 00:00:00.000",
"description": "Report",
"row_id": 1360441,
"text": "Nursing Note 7p-7a:\nNursing assessment:\n\nNeuro: No neuro changes. No movement on left side, no eye opening except to pain, sqeezes eyes shut to voice. Afebrile. Strong right hand grasp. Edema to left upper extremity, elevated on pillows.\n\nCV/GU: On turning and washing, pt began to cough and had Sustained Vtach of 170 for a few minutes and elevated SBP of 230. Returned to baseline and Dr. notified. NO further episodes during night. BP to 170s with coughing and suctioning. Urine output adequate.\n\nGI: bowel sounds hypoactive. Abd. DSD Clean and dry. Tube feeds continue at goal.\n\nREsp: Lungs clear. Suctioned infrequently for thick white secretions. SAme vent settings, A.M. blood gases pending.\n\nPlan: Cont. to monitor neuro exam and CV status. FAmily meeting to be planned tommorrow with neuro to discuss trach/peg and pt's prognosis.\n\nPlease refer to carevue for details.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-23 00:00:00.000",
"description": "Report",
"row_id": 1360442,
"text": "Respiratory Care\nPt remains on present careview settings, suction for small amount thick white secreations. No changes noted to patient status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-23 00:00:00.000",
"description": "Report",
"row_id": 1360443,
"text": "SEE CAREVIEW FOR DETAILS\nFOCUS DATA UPDATE\n\nNEURO: PT ABLE TO OPEN EYES ONCE TODAY, STILL UNABLE TO MOVE LEFT SIDE, MORPHINE GIVEN FOR COMFORT\n\nRESP: ROUTINE CXR TODAY, REMAINS ON CPAP VENT SETTINGS UNCHANGED\n\nCV: AFEBRILE SYS B/P 170, LOPRESSOR 5MG'S GIVEN IVP, LABS SODIUM DECREASED TO 146, SERUM OSMO 303, NEURO- RESIDENT CALLED DOES NOT WANT TO RESTART MANITOL AT THIS TIME CVP INCREASED , MAG AND KCL REPLACEMENT GIVEN\n\nGI: TOL TF'S @ GOAL, NO BM, ABD DSG CLEAN DRY AND INTACT\n\nGU: ADEQUATE HOURLY U/O\n\nA/P: CONTINUE WITH CURRENT PLAN OF CARE\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-24 00:00:00.000",
"description": "Report",
"row_id": 1360444,
"text": "Resp Care Note:\n\nPt cont intub with OETT and on mech vent as per Careevue. Lung sounds coarse improve with suct sm th off white sput. ABGs compensated resp acidosis with good oxygenation. Cont PSV.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-24 00:00:00.000",
"description": "Report",
"row_id": 1360445,
"text": "Nursing nOTe 7p-7a:\nNursing Assessment:\n\nPt is unchanged neurologically and continues to have no movement on left side. Afebrile. Vent no changes, blood gas pending. Suctioned for thick white secretions infrequently. Bp and hr stable tonight. ? Discuss tighter blood sugar control with team, sugars tonight 200-234. ? Insulin gtt. cont. to monitor urine output, dwindling at times. Monitor neuro status.\n\nPlease refer to carevue for specifics.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-24 00:00:00.000",
"description": "Report",
"row_id": 1360446,
"text": "Respiratory Care\nPt remains on CPAP/PSV, current careview settings throughout the shift. Transported to CT for head scan without incident. Suction for small amounts of thick pale tan secreations.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-21 00:00:00.000",
"description": "Report",
"row_id": 1360435,
"text": "NURSING UPDATE\nCV:\n TMAX 98.6. MORMOTENSIVE, NIPRIDE GTTS REMAIN OFF. HR NSR W/ PAC'S. FFP 2U TO CORRECT INR 1.5, FOLLOW UP INR PENDING.\n\nRESP:\n SATS 100% CONSISTENTLY. SXN FOR MOD THICK YELLOW SECRETIONS, BREATH SOUNDS CLEAR AFTER SUCTION. NO VENT CHANGES OVERNOC.\n\nNEURO:\n NO NEURO CHANGES. SERUM OSMOLALITY AND SODIUM LEVELS REMAIN ELEVATED...FREE WATER BOLUSES INEFFECTIVE.\n\nGI:\n TUBE FEED AND H2O BOLUS TOLERATED WELL WITH ZERO GASSTRIC RESIDUALS. TUBE FEED UP TO 50CC/H AT THIS TIME. GLUCOSE LEVELS ELEVATED AND TREATED WITH SLIDING SCALE REGULAR INSULIN AS PER ORDER.\n\nPLAN:\nREEVAL SLIDING SCALE TO BETTER CONTROL GLUCOSE.\nCONTINUE ATTEMPTS TO DECREASE SERUM SODIUM AND OSMOLALITY.\nCHANGE TUBE FEED TO LOW SODIUM FORMULA.\n\nDR PRESENT ON UNIT THROUGHOUT SHIFT AND NOTIFIED OF ALL PATIENT DATA.\nSEE CAREVUE FLOWSHEETS FOR DETAILED DATA.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-21 00:00:00.000",
"description": "Report",
"row_id": 1360436,
"text": "focus data update\nsee careview for details\n\nNEURO: ATTEMPTING TO OPEN EYES UNABLE R/T PERIORBITAL EDEMA, MORPHINE GIVEN FOR COMFORT, RIGHT CRANIAL INCISION CLEAN DRY AND INTACT, MOVING EXT'S ON RIGHT SIDE, UNABLE TO MOVE EXT'S ON LEFT SIDE\n\nRESP: PCO2 GOAL 35, VENT RATE INCREASED, REPEAT ABG'S PENDING\n\nCV: AFEBRILE, NA 156, SERUM OSMO 328, K 3.4 REPLACEMENT K GIVEN,\nSYS GOAL B/P 100-160, NIPRIDE OFF\n\nGI: TF CHANGED TO PROBALANCE, 250CC'S FREE H2O GIVEN Q6, NO BM\n\nGU: ADEQUATE HOURLY U/O\n\nA/P: CONTINUE TO MONITOR, ASSESS AND RX\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-22 00:00:00.000",
"description": "Report",
"row_id": 1360437,
"text": "Resp Care Note:\n\nPt cont intub with OETT and on mech vent as per Carevue. Lung sounds ess clear after suct sm th white sput. ABGs metabolic alkalosis worsening ventilation and oxygenation stable. Cont mech vent support.\n"
},
{
"category": "Radiology",
"chartdate": "2131-09-18 00:00:00.000",
"description": "BY SAME PHYSICIAN",
"row_id": 879367,
"text": " 9:34 PM\n CT HEAD W/O CONTRAST; -76 BY SAME PHYSICIAN # \n Reason: interval change.\n Admitting Diagnosis: RIGHT FRONTAL LOBE STROKE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with bleed.\n REASON FOR THIS EXAMINATION:\n interval change.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Intracranial hemorrhage. Assess interval change.\n\n COMPARISON: Six hours prior on .\n\n TECHNIQUE: Noncontrast head CT.\n\n FINDINGS: Multiple right frontal parenchymal hematomas appear unchanged.\n There is extensive surrounding edema with resulting shift of the septum\n pellucidum and third ventricle to the left, unchanged compared to 6 hours\n earlier. There is persistent compression of the right frontal and occipital\n horns of the lateral ventricle. There is no evidence of new hemorrhage since\n the previous study. The visualized osseous structures appear unremarkable.\n There is unchanged mucosal thickening in the maxillary sinuses, left greater\n than right. The scout image reveals an endotracheal tube and an orogastric\n tube.\n\n IMPRESSION: Stable appearance of right-sided parenchymal hemorrhage with\n extensive associated edema.\n\n DFDkq\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-09-18 00:00:00.000",
"description": "BY DIFFERENT PHYSICIAN",
"row_id": 879366,
"text": " 9:16 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: PTX\n Admitting Diagnosis: RIGHT FRONTAL LOBE STROKE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with unresponsive s/p Left CVL placement.\n\n REASON FOR THIS EXAMINATION:\n PTX\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Unresponsive.\n\n Comparison made to the chest x-ray obtained earlier on the same day.\n\n FINDINGS: AP supine portal view of the chest was obtained. There is again\n demonstrated an endotracheal tube in stable position. There has been interval\n placement of a left subclavian central venous catheter with the tip\n terminating at the entrance of the SVC. There is no evidence of pneumothorax.\n There is stable cardiomegaly and prominence of the pulmonary arteries. An\n opacity at the left lung base is again demonstrated, which is unchanged in the\n short interval. A left breast prosthesis is also noted.\n\n IMPRESSION:\n 1. Interval placement of left subclavian central venous catheter without\n evidence of pneumothorax.\n 2. Persistent left lung base opacity, which again could represent atelectasis\n or consolidation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-09-24 00:00:00.000",
"description": "BY SAME PHYSICIAN",
"row_id": 879998,
"text": " 3:57 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: CHF lung congestion\n Admitting Diagnosis: RIGHT FRONTAL LOBE STROKE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with hemmorhagic stroke. Now with pressors and fever.\n\n REASON FOR THIS EXAMINATION:\n CHF lung congestion\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Hemorrhagic stroke, now on pressors.\n\n CHEST: The heart remains enlarged. No failure is seen. The left\n hemidiaphragm is obscured suggesting the presence of consolidation or\n atelectasis in the left lower lobe. The position of the various support lines\n and tubes is unchanged since the prior chest x-ray of 8 hours before.\n\n IMPRESSION: No significant change. Left lower lobe atelectasis and\n consolidation is still present.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2131-09-28 00:00:00.000",
"description": "Report",
"row_id": 308556,
"text": "Supraventricular tachycardia, rate 145, with one failure of P wave conduction\nwithout apparent warning. P-R interval is slightly prolonged. The P wave is on\nthe T wave. With history of atrial bigeminy and atrial premature beats, there\nhas been predisposition to sustained atrial arrhythmia.\nTRACING 32\n\n"
},
{
"category": "ECG",
"chartdate": "2131-09-28 00:00:00.000",
"description": "Report",
"row_id": 308557,
"text": "Sinus rhythm. Atrial ectopy. Slight right axis deviation. Compared to the\nprevious tracing of atrial bigeminy is no longer present.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2131-09-20 00:00:00.000",
"description": "Report",
"row_id": 308558,
"text": "Sinus rhythm and atrial bigeminy. Right axis deviation. Diffuse ST-T wave\nflattening. Compared to the previous tracing of sinus rhythm and\nfrequent atrial ectopy have appeared. The previously recorded ST segment\ndepression has diminished. Clinical correlation is suggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2131-09-18 00:00:00.000",
"description": "Report",
"row_id": 308559,
"text": "Atrial fibrillation with rapid ventricular response\nDiffuse nonspecific ST-T wave abnormalities\nClinical correlation is suggested\nSince previous tracing of , ventricular rate faster and further ST-T\nwave changes present\n\n"
},
{
"category": "ECG",
"chartdate": "2131-10-01 00:00:00.000",
"description": "Report",
"row_id": 308555,
"text": "Atrial fibrillation\nInferior T wave changes are nonspecific\nRepolarization changes may be partly due to rhythm\nSince previous tracing, supraventricular tachycardia rhythm now atrial\nfibrillation\n\n"
}
] |
88,180 | 106,166 | This is an 84 y.o woman with a history of HTN who presents with multiple falls of unknown etiology, orbital/facial fractures, found to have a small SDH and hyponatremia. She is also confirmed to have bilateral brain calcifications in the basal ganglia and cerebellum seen on her recent admission, which are concerning for Fahr's disease and could at least partially explain the patient's reported gait abnormalities and recurrent falls. Decreased oral intake in the setting of her recent facial fracture, as well as now-discontinued HCTZ likely contributed to the fall leading to this admission, as well. . # Falls: As noted, there is a strong suspicion that the patient's falls may be related to the calcifications noted on imaging, and the clarification of the diagnosis will require close neurology follow-up. We discussed with the patient and her HCP that we do not yet have a prognosis associated with the possible diagnosis, but that this should be forthcoming as her outpatient work-up continues. Per the patient's and her daughter's story of the falls, they appear to be due to a worsening unsteady gait leading to mechanical falls. The patient has little recollection of the falls, but per her daughter she does not lose consciousness prior to falling. The unsteady gait may be associated with the significant basal ganglia and cerebellum calcifications, likely representing Fahr's disease, as noted below. She was evaluated by neurology who did not note a clear movement disorder or ataxia. While inpatient, cardiac causes for falls were ruled out with a normal EKG and no events on telemetry. She had an EEG which did not have evidence of epilepsy; however, given her daughter's descriptions of "spacing out" seizures remain possible. While inpatient, she was maintained on largely due to the subdural hematoma (see below), but will continue this until her outpatient neurology follow up in a month. While inpatient she also worked with physical therapy to build up her strength and was given a walker to use at home; she will continue with outpatient physical therapy at home and will be re-evaluated by neurology in one month to reassess her gait. . # Calcifications in basal ganglia and cerebellum: Noted on CT, likely Fahr's disease. She had a metabolic work up to determine other causes of calcification, which revealed a mildly elevated PTH determined to be due to vitamin D deficiency, but this was not felt adequate to explain the degree of calcifications. She was started on vitamin D repletion, per below. Per neurology, if the calcifications do represent Fahr's disease, there may not be a specific treatment to reverse this condition. . # Vitamin D deficiency: Normal Ca and Phos, mildly elevated PTH, consistent with secondary hyperparathyroidism due to vitamin D deficiency, will likely resolve with repletion of vitamin D. Started on vitamin D units daily, to be continued on discharge. . # Hyponatremia: Given urine electrolytes and euvolemia, likely secondary to SIADH associated with the SDH, in the setting of recently-started HCTZ. Improved from 125 to 135 with a 1200 cc fluid restriction, which was then stable on the last day despite liberalizing the restriction to cc daily. Her HCTZ was also held, as this was likely contributing to the hyponatremia, and we suggested that this not be restarted in the future to the patient and family. . # SDH: Right occipital SDH and right parietal SDH initially visualized at an OSH. Most recent head CT on showed that "the right occipital subdural hematoma is now barely visible and the larger right parietal subdural hematoma has also decreased in size, with a maximum depth of 7 mm." She had no focal deficits or evidence of seizure. She was started on 750 mg for seizure ppx and will continue for one month after discharge. . # Right eye injury: The patient had a recent facial/orbital fracture with repair and plate placement by plastic surgery on . She was seen by plastic surgery on this admission, who noted no new fractures and confirmed that the plate remained in place. She was also seen by ophthalmology in the ED. She was continued on dorzolamide eye drops throughout her admission, and her right eye improved significantly, with improvement both in swelling and in vision. . # HTN: Has been on atenolol and more recently added losartan and HCTZ at home. In hospital, HCTZ stopped due to hyponatremia. Losartan was continued on her home dose. Her atenolol was also decreased to 12.5 mg daily because her blood pressure had been running low; now with SBP in the 120s-130s on day of discharge. . # Hyperlipidemia: Stable, continued home atorvastatin. . # GERD: Stable, continued home omeprazole. . # RUL pulmonary nodule: Incidental finding on CT at last admission; patient reminded of this finding and encouraged to follow up with PCP. . # Left breast mass (incidental finding): Incidental finding on CT at last admission; patient reminded of this finding and encouraged to follow up with PCP. . # Goals of care: Confirmed full code. Primary contact is daughter or cell ; second contact is (ok to leave messages) . # Transitions 1) Sodium to be rechecked outpatient 2) Home PT, new assistive device (walker) 3) Follow up with neurology in 1 month for further discussion of potential diagnosis and prognosis. 4) Now on , likely will be able to discontinue this medication in 1 month at neurology follow up 5) Blood pressure medications decreased to continue home losartan, continue atenolol but at lower dose (12.5 mg daily), and stop HCTZ given hyponatremia 6) On continued fluid restriction at cc daily; will need to be monitored by PCP 7) Incidental findings on CT at last admission that need follow up: left breast mass and RUL pulmonary nodule | There is persistent minimal mass effect from the subdural hematoma in the form of regional sulcal effacement. interval change from this AM No contraindications for IV contrast WET READ: TXPb TUE 9:47 PM Interval resorption/redistribution of right SDH. TECHNIQUE: MDCT acquired contiguous axial images were obtained through the head without contrast. Bilateral corona radiata, basal ganglionic and cerebellar dentate nuclear mineralization is most consistent with underlying Fahr disease or, less likely, hyper- or hypoparathyroidism, as before. Multiple fractures of the right orbit, maxilla, and zygomatic process appear stable. FINDINGS: The right occipital subdural hematoma is now barely visible and the larger right parietal subdural hematoma has also decreased in size, with a maximum depth of 7 mm. Left axis deviation, likely due to left anterior fascicularblock. The ventricles and sulci are otherwise normal in size and configuration. Sinus rhythm. There is no shift of normally midline structures. Interval decrease in size of right convexity subdural hematoma due to redistribution/resorption. No new hemorrhage or acute process. IMPRESSION: 1. Coronal and sagittal images reviewed. Compared to the previous tracing of the axis is more leftward.The other findings are similar. WET READ VERSION #1 FINAL REPORT INDICATION: New mental status decline in the patient status post trauma with right subdural hematoma. No new acute intracranial process to explain patient's clinical decline is identified. 8:27 PM CT HEAD W/O CONTRAST; -77 BY DIFFERENT PHYSICIAN # Reason: ? The mastoid air cells and middle ear cavities are clear. There is no evidence of acute vascular territorial infarction. Likely underlying Fahr disease; correlate with clinical evidence of movement disorder. 3. 2. COMPARISON: NECT of the head from at 7:30 a.m. | 2 | [
{
"category": "Radiology",
"chartdate": "2191-08-16 00:00:00.000",
"description": "BY DIFFERENT PHYSICIAN",
"row_id": 1247589,
"text": " 8:27 PM\n CT HEAD W/O CONTRAST; -77 BY DIFFERENT PHYSICIAN # \n Reason: ? interval change from this AM\n Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with R SDH, new mental status decline\n REASON FOR THIS EXAMINATION:\n ? interval change from this AM\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: TXPb TUE 9:47 PM\n Interval resorption/redistribution of right SDH. No new hemorrhage or acute\n process.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: New mental status decline in the patient status post trauma with\n right subdural hematoma.\n\n COMPARISON: NECT of the head from at 7:30 a.m.\n\n TECHNIQUE: MDCT acquired contiguous axial images were obtained through the\n head without contrast. Coronal and sagittal images reviewed.\n\n FINDINGS: The right occipital subdural hematoma is now barely visible and the\n larger right parietal subdural hematoma has also decreased in size, with a\n maximum depth of 7 mm. There is persistent minimal mass effect from the\n subdural hematoma in the form of regional sulcal effacement. There is no\n shift of normally midline structures. The ventricles and sulci are otherwise\n normal in size and configuration. Bilateral corona radiata, basal ganglionic\n and cerebellar dentate nuclear mineralization is most consistent with\n underlying Fahr disease or, less likely, hyper- or hypoparathyroidism, as\n before. There is no evidence of acute vascular territorial infarction.\n Multiple fractures of the right orbit, maxilla, and zygomatic process appear\n stable. The mastoid air cells and middle ear cavities are clear.\n\n IMPRESSION:\n 1. Interval decrease in size of right convexity subdural hematoma due to\n redistribution/resorption.\n 2. No new acute intracranial process to explain patient's clinical decline is\n identified.\n 3. Likely underlying Fahr disease; correlate with clinical evidence of\n movement disorder.\n\n"
},
{
"category": "ECG",
"chartdate": "2191-08-18 00:00:00.000",
"description": "Report",
"row_id": 306552,
"text": "Sinus rhythm. Left axis deviation, likely due to left anterior fascicular\nblock. Compared to the previous tracing of the axis is more leftward.\nThe other findings are similar.\n\n"
}
] |
25,475 | 104,621 | As noted above, the patient was initially admitted to the Neurology . After being transferred to the Neurology floor on , he was continued on Mannitol with an osmolality of 308. The patient's mental status did not improve on Mannitol. His edema did not resolve on CT. He was therefore tried on an empiric course of Decadron, a 10 mg bolus followed by 4 mg p.o. q.6 hours. The patient's alertness improved on the Decadron, and follow-up head CT demonstrated somewhat less edema with decreased flattening of the ventricle. The patient became more alert, and the Decadron was tapered over two weeks. The patient's Oxacillin was discontinued after a ten-day course. He has had no further issues with pneumonia. The patient continue to make progress. He was more alert, although still not moving the left side of his body which has remained hemiplegic. He was not taking adequate oral intake, so he was evaluated by Gastroenterology for placement of PEG tube. The PEG tube could not be placed because of his ascites which was noted on ultrasound, and gastroesophageal varices which was seen on EGD. His current examination shows that he is awake and alert. He does not know the date but knows that he was in . His eye movements are full to both sides. His pupil are equal. He has a left facial droop, and his head was turned to the right. He is hemiplegic on the left side. His toes are upgoing in the left. The patient will be discharged to rehabilitation on . | There is a 1cm focal area of polypoid mucosal thickening within the left lateral aspect of the sphenoid sinus, unchanged from the prior study. There is a large right-sided basal ganglia hemorrhage, with minimal surrounding edema, and mild shift of the normally mid-line structures to the left. REASON FOR THIS EXAMINATION: please evaluate for hydrocephalus/expansion of bleed No contraindications for IV contrast FINAL REPORT INDICATION: Right basal ganglia hemorrhage. FINDINGS: There is marked, but stable polychamber cardiac enlargement. No contraindications for IV contrast FINAL REPORT HEAD CT, INDICATION: Right basal ganglia hemorrhage, please assess progression TECHNIQUE: Non-contrast head CT FINDINGS: Comparison is made to a prior head CT from . Of notice there is a mild stenosis of the bulb of the right internal carotid artery in both AP and lateral projections. IMPRESSION: There is a mild stenosis of the right ICA at the bifurcation. TECHNIQUE: Noncontrast head CT. There is still a mild amount of surrounding edema, slight shift of the midline structures to the left and blood within the dependent portions of both lateral ventricles. TECHNIQUE: Non-contrast head CT. TECHNIQUE: Noncontrast CT of the head. Otherwise normal cerebral angiogram in particular of the right internal and external carotid artery branches, of the left internal and external carotid artery branches and of both vertebral and basilar artery complex and their branches. Since no suitable superficial veins were visible, ultrasound was used for localization of a suitable vein. There is a right-sided IJ central venous line in place with its distal tip in the SVC. REASON FOR THIS EXAMINATION: please evaluate for infiltrate FINAL REPORT INDICATION: History of intracranial hemorrhage, now with shortness of breath and gurgling. IMPRESSION: Right middle lobe atelectasis, prominent pulmonary vasculature may be related to positioning, but slight LV failure cannot be excluded. IMPRESSION: Worsening surrounding edema involving the large right basal ganglia hemorrhage with further effacement of the right lateral ventricle and minimal worsening of the midline shift to the left as indicated. Injection of contrast in the right common carotid artery demonstrates normal opacification of the intracranial portions of the internal carotid artery with normal visualization of the lacerum, petrous, cavernous and supraclinoid portion or internal carotid artery and its branches. FINDINGS: There has been interval decrease in size of the hypedense region large right basal ganglia hemorrhage, compatible with partial resorption of the acute hemorrhagic components.. No new areas of hemorrhage are identified. O2SATS AND ABG STABLE.CV: AFEBRILE. Cont w/ generalized non pit edema. Resp Care,Pt. Resp Care,Pt. MD INFORMED.GI: ABD SOFT. TF cont. TO TOLERATE EXTUBATION. suction prn. PERRLA. PERRLA. for extubation ?. sputum cx sent. Plan to extubate. MD INFORMED.RESP: LS CLEAR, BUT OCCASIONALLY COASRE AT UPPER AIRWAY. CONT PER CURRENT MGMT. R fem. WITHDRAWS TO NAILBED PRESSURE W/LE. LOPRESSOR HELD. angio site C&D w/ + doppler pulses in RLE. RSR' pattern inlead V1. MANNITOL STARTED. NG - +placement, minimal residual. SAID "" ONCE OTHERWISE . cont. cont. +corneal reflex. tube fdg held due to ?extubation today. Murble words. MOD. Move RLE and RUE. ABD S/NT. BS sl. NPN UPDATEPT . Abd lg round, soft w/ hypoactive BS. Move RUE - strong. +gag reflex. U/O QS VIA FOLEY. BM THIS AM. MAINTAIN BP PER PARAMETERS. update to signaificant other. focus hemodynmicsdata: vss. FAINT BS. Sx'd for mod. ABD SOFT, NT. NEURO: PT . Arouse to voice. Foley patent. Chest PT and vibration. neuro updatept cont. Eyes - PERL, reddish - MD notify. soft abd, +BS X4. 7p-7a: Full assessment in flow sheet.Lethargic. ET SUCTIONED FOR MODERATE TO LARGE AMT TAN SPUTUM. LUNGS CLEAR TO COARSE, DIMINISHED AT BASES. TOLERATING TUBE FEEDS, W/ NO SIGNIFICANT RESIDUAL. CPT/DB/COUGH DONE TO MAINT. ON RARE OCCASSION. FOLLOWS COMMANDS. Inc BP when turn and position. OPENS EYES SPONT. bp 130-140's., hr 50-80's, remains on a labetatolol gtt. Pt at (R) upper extremity attempting to pull at ETT. SBP 120-150/45-60. Cont w/ current plan of care. Afib 70-110. Warm, dry, general edema +1. Atrial fibrillation with a moderate ventricular response. Afib without ectopy. RECEIVED 1 UNIT FFP FPR INR 1.4. Lytes replenish.Plan; Continue to monitor. See vent flowsheet. LS OCCASIONALLY COARSE @ BASES, PT NEEDS ASSIST WITH PULM HYGEINE. Mannitol given for Osmality less than 310. LS COARSE. Answer inconsistent verbally appropriately - able to say last name (). MOVING RSIDE W/ NL STRENGTH - NO MOVEMENT NOTED LEFT. MAINTAIN BP 140 OR LESS. REPEAT INR 1.5. 7P-7A: Full assessment in flow sheet.neuro: Arouse to voice. normal strength on the right. Right pedal and femoral pulses palpable. TRANSFER TO FLOOR WHEN STABLE, MD'S ORDERS. to hold per team. Weak RLE. W/ L-SIDED WEAKNESS. Maintain SBP <140 with Hydralazine ivpX2. cont on labetolol drip to keep sbp 140.Resp. CURRENTLY IN AFIB W/ RATE 70-90'S & SBP 130-150'S. Monitor sbp and labetalol gtt. CVP 21-24. PUPILS EQUAL AND REACTIVE. PUPILS EQUAL AND REACTIVE. CONTINUE WITH CURRENT CLOSE MONITORING. Please see carrevue for further vent inqueries. Condition Update A:ROS - Please refer to careview for specifics.NEURO: Cont w/ somulance, arouse to voice, attempts to open eyes. Move left feet to stimuli in LLE. FOLLOWING COMMANDS. Plan to extubate today. neuro statusD: pt is lethargic but . Garble and mumble of words. Right side normal - strong. Follow commands. Follow directions. palpable fem pulse. Continue to monitor. Continue to monitor. HYDRALAZINE PRN TO MAINTAIN SBP<150. ABGS: 7.43/29/120/20/96% MINIMAL MOVEMENT OF LEFT EXTREMTIES TO COMMAND. | 40 | [
{
"category": "Radiology",
"chartdate": "2124-11-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 773091,
"text": " 7:52 PM\n CHEST (PORTABLE AP) Clip # \n Reason: NG tube replaced - check position\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with IC hemorrhage now with shortness of breath and gurgling\n on exam.\n REASON FOR THIS EXAMINATION:\n NG tube replaced - check position\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST AT 19:44\n\n INDICATION: Shortness of breath. Nasogastric tube replaced.\n\n FINDINGS: The current study has cut off the apices from view. The visualized\n lung fields are clear. While I can see parts of the nasogastric tube, the tip\n cannot be definitely visualized due to underpenetration nature of the film\n however, the tube does distend below the level of the diaphragm. A left sided\n central venous catheter is seen with tip in the SVC. The heart size appears\n mildly prominent but the shallow level of inspiration could exaggerate that.\n\n IMPRESSION:\n\n 1. Nasogastric tube below the diaphragm. No acute airspace disease in the\n visualized portions of the lungs.\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-10-30 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 772679,
"text": " 5:35 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: please evaluate for worsening shift\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with putaminal hemorrhage and shift noted yesterday.\n REASON FOR THIS EXAMINATION:\n please evaluate for worsening shift\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HEAD CT WITHOUT CONTRAST:\n\n INDICATION: Question worsening basal ganglia hemorrhage.\n\n Multiple axial images were obtained from base to vertex without IV contrast\n administration. Comparison is made to the prior exam of . There is\n worsening surrounding edema involving the large right-sided basal ganglia\n hemorrhage with mass effect on the anterior and posterior limbs of the\n internal capsule. There is worsening mass effect on the right lateral\n ventricle with an estimated 9 mm midline shift to the left. There is also\n effacement of the superior aspect of the perimesencephalic cistern. No\n hydrocephalus is seen. No new areas of hemorrhage could be identified.\n\n IMPRESSION: Worsening surrounding edema involving the large right basal\n ganglia hemorrhage with further effacement of the right lateral ventricle and\n minimal worsening of the midline shift to the left as indicated. Further\n clinical correlation and follow up are recommended.\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-10-29 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 772566,
"text": " 11:29 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: please evaluate for hydrocephalus/expansion of bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with right putaminal hemorrhage transferred from intensive care\n unit.\n REASON FOR THIS EXAMINATION:\n please evaluate for hydrocephalus/expansion of bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Right basal ganglia hemorrhage. Please assess for progression.\n\n TECHNIQUE: Noncontrast head CT.\n\n FINDINGS: Comparison is made to the prior head CT from . There has\n been slight decrease in the size of the large right basal ganglia hemorrhage.\n However, surrounding edema has slightly increased with obliteration of right\n ambient cistern. without evidence of significant change in the mass effect and\n leftward shift. There is no evidence of a hydrocephalus. There is no new area\n of hemorrhage.\n\n IMPRESSION: There is slight decrease in the size of the large right basal\n ganglia hemorrhage and slight increase in edema when compared to the prior\n study.\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-11-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 772829,
"text": " 7:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with IC hemorrhage now with shortness of breath and gurgling\n on exam.\n REASON FOR THIS EXAMINATION:\n please evaluate for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of intracranial hemorrhage, now with shortness of breath\n and gurgling. Please evaluate for infiltrate.\n\n COMPARISONS: AP chest radiograph .\n\n FINDINGS: There is marked, but stable polychamber cardiac enlargement. There\n is minimal evidence for upper lung zone redistribution which may be postural\n in nature but which could also represent mild failure. The aorta is unfolded\n and tortuous. No focal lung opacities are present to suggest aspiration or\n pneumonia. No pleural effusions are present. The osseous structures are\n unremarkable.\n\n IMPRESSION: Stable cardiomegaly, no acute cardiopulmonary changes.\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-11-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 773242,
"text": " 4:48 AM\n CHEST (PORTABLE AP) Clip # \n Reason: check position of NG tube on patient, who is difficult to tr\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with IC hemorrhage now with shortness of breath and gurgling\n REASON FOR THIS EXAMINATION:\n check position of NG tube on patient, who is difficult to transport s/p stroke\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Check position of NG tube.\n\n COMPARISONS: AP chest radiograph from .\n\n SUPINE AP CHEST RADIOGRAPH: An NG tube is demonstrated, with the tip below the\n diaphragm, but not visualized on today's study. Stable, marked biventricular\n cardiomegaly is again demonstrated. The aorta is unfolded. Allowing for the\n supine positioning, the pulmonary vasculature is difficult to assess, but\n slight left ventricular failure cannot be excluded. There is a focal opacity\n within the right middle lobe which likely represents atelectasis. No pleural\n effusions are present. The osseous structures are unremarkable.\n\n IMPRESSION: Right middle lobe atelectasis, prominent pulmonary vasculature may\n be related to positioning, but slight LV failure cannot be excluded.\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-11-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 773327,
"text": " 9:16 PM\n CHEST (PORTABLE AP) Clip # \n Reason: NG tube placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with IC hemorrhage\n REASON FOR THIS EXAMINATION:\n NG tube placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: NG tube placement.\n\n COMPARISON: @ 5:46 A.M.\n\n PORTABLE UPRIGHT CHEST @ 9 P.M.: The tip of the NG tube is difficult\n to visualize but appears to be within the stomach. There is a left PICC with\n tip in the SVC. There is mild cardiomegaly. The aorta is tortuous. There is no\n evidence of vascular congestion or pleural effusions. There are patchy\n opacities at the lung bases which probably represent atelectasis vs.\n aspiration. No pneumothorax.\n\n IMPRESSION: 1) Tip of the NG tube difficult to visualize but appears to be\n within the stomach. If clinically indicated, a dedicated abdominal film\n is suggested to confirm.\n\n 2) Patchy bibasilar opacities, probably atelectasis, however, aspiration\n should also be considered.\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-11-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 773530,
"text": " 7:51 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate ngt placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with IC hemorrhage no w s/p new ngt placement.\n\n REASON FOR THIS EXAMINATION:\n please evaluate ngt placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Intracranial hemorrhage. New NG tube placement.\n\n PORTABLE SUPINE CHEST, 1 VIEW: Comparison . There is an NG tube\n extending below the diaphragm, tip not visualized. The heart is enlarged. The\n left lateral CP angle is not included on this exam. Allowing for technique,\n there is no CHF, focal consolidation, or large pleural effusion.\n\n IMPRESSION: NG tube extending below the diaphragm, tip not visualized.\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-10-31 00:00:00.000",
"description": "CVL/PICC",
"row_id": 772805,
"text": " 4:06 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: please place picc line\n ********************************* CPT Codes ********************************\n * CVL/PICC UD GUID FOR NEEDLE PLACMENT *\n * C1751 CATH ,/CENT/MID(NOT D C1894 INT.SHTH NOT/GUID,EP,NONLASER *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with right putaminal hemorrhage requires picc line for iv meds.\n IV service has tried but unsuccessful.\n REASON FOR THIS EXAMINATION:\n please place picc line\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Right putaminal hemorrhage, requires access for IV medications.\n The IV access team was unsuccessful in placing a PICC line.\n\n PHYSICIANS: Drs. and . Dr. , the attending\n radiologist, was present and supervising. Dr. reviewed the case.\n\n PROCEDURE: The left upper arm was prepped in a sterile fashion. Since no\n suitable superficial veins were visible, ultrasound was used for localization\n of a suitable vein. The basilic vein was patent and compressible. After\n local anesthesia with 1% Lidocaine, the basilic vein was entered under\n ultrasonographic guidance with a 21 g. needle. A .018 guidewire was advanced\n under fluoroscopy into the superior vena cava. Based on the markers on the\n guidewire it was determined that a length of 57.5 cm would be suitable. The\n PICC line was trimmed to line and advanced over a 4 French introducer sheath\n under fluoroscopic guidance into the superior vena cava. The sheath was\n removed. The catheter was flushed. A final chest x-ray was obtained. This\n film demonstrates the tip to be in the superior vena cava, just above the\n atrium. The line is ready for use.\n\n A stat-lock was applied and the line was hep-locked.\n\n IMPRESSION: Successful placement of a 4 French, single lumen, 57.5 cm total\n length PICC line with tip at the superior vena cava/RA junction. The line is\n ready for use.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-10-23 00:00:00.000",
"description": "SEL CATH 2ND ORDER",
"row_id": 772010,
"text": " 8:11 AM\n CAROT/CEREB Clip # \n Reason: CEREBRAL HEMORRHAGE\n Contrast: OPTIRAY Amt: 90\n ********************************* CPT Codes ********************************\n * SEL CATH 3RD ORDER SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE CAROTID/CEREBRAL BILAT *\n * EXT CAROTID BILAT VERT/CAROTID A-GRAM *\n ****************************************************************************\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Mr. is a 58-year-old man who developed a right\n putaminal hemorrhage. The hemorrhage was felt to be due to hypertension.\n However, while the patient has been normotensive on intravenous\n antihypertensive medication, the hemorrhage significantly enlarged and the\n patient developed seizures. After consultation with Neurosurgery it was\n decided to proceed with a cerebral angiogram to rule out an underlying\n vascular malformation or an aneurysm. The assessment and plan were thoroughly\n discussed with the Neurosurgery staff as well as with the Neurology staff.\n\n PROCEDURE: Informed consent was obtained from the patient's significant other\n after explanation of risks, benefits, indication and alternative management.\n The patient's significant other read the consent form, asked appropriate\n questions, understood and signed. The patient was already intubated in the\n SICU. He was thereofre transported from the Surgical Intensive Care Unit to\n the Neurointerventional Suite and placed under general anesthesia. The\n patient had an arterial line and vital parameters were constantly monitored by\n the Anesthesia staff.\n\n The patient was placed supine on the table. Both groins were prepped and\n draped in usual sterile fashion. The right femoral artery was accessed by a\n single wall puncture needle. After visualization of bright pulsatile blood a\n .035 J-wire was inserted into the femoral artery and advanced into the\n abdominal aorta. At this point a 4 Fr short sheath was inserted into the right\n femoral artery using the J wire as a guide.\n\n Under fluoroscopic guidance, a 4 Fr Barenstein catheter in conjunction with\n Terumo guidewire was advanced into the aortic arch and subsequently used to\n select the right common carotid artery. Injection of contrast at this level\n demonstrates normal opacification of the origin of the right internal and\n right external carotid artery and their branches. Of notice there is a mild\n stenosis of the bulb of the right internal carotid artery in both AP and\n lateral projections.\n\n Subsequently, attention was paid to the intracranial branches of the right\n internal carotid artery. Injection of contrast in the right common carotid\n artery demonstrates normal opacification of the intracranial portions of the\n internal carotid artery with normal visualization of the lacerum, petrous,\n cavernous and supraclinoid portion or internal carotid artery and its\n branches. A magnified view of the intracranial circulation demonstrated normal\n opacification of the anterior cerebral, middle cerebral and posterior\n communicating artery and their branches in both AP and lateral projections.\n (Over)\n\n 8:11 AM\n CAROT/CEREB Clip # \n Reason: CEREBRAL HEMORRHAGE\n Contrast: OPTIRAY Amt: 90\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Subsequently, the catheter was advanced into the external carotid artery and\n attention was paid to the branches of the external carotid artery. Injection\n of contrast shows normal opacification of the branches of both superficial and\n deep of the external carotid artery in particular the temporal, occipital\n arteries and their branches as well as the internal maxillary with no evidence\n of arteriovenous malformations.\n\n Subsequently the 4 Fr Barenstein catheter in conjunction with a Terumo\n glidewire was slowly advanced to select the left common carotid artery.\n Particular attention at this level was paid to the intracranial branches.\n Injection of contrast via the left common carotid artery shows normal\n opacification intracranial branches and all the segments of the intracranial\n internal carotid artery. There was also normal opacification of the anterior\n cerebral artery and middle cerebral artery and their branches. Of note, the\n contralateral anterior cerebral artery is also opacified with this injection\n as well. There is also normal parenchymal venous phase in both AP and lateral\n projections.\n\n At this level particular attention was also paid to the branches of the\n external carotid artery. Injection of contrast in the left external carotid\n artery also shows normal opacifications of the external and the superficial\n and the branches of the external carotid artery with no evidence of vascular\n malformations.\n\n Subsequently the 4 Fr Barenstein catheter in conjunction with Terumo glidewire\n was withdrawn to select the left vertebral artery. Injection of contrast in\n the left vertebral artery demonstrates normal opacification of the\n intracranial segment of the left vertebral artery basilar artery and \n branches in both AP and lateral projections. The contralateral right vertebral\n artery is also opacified with this injection. There is normal parenchymal and\n venous phase in both AP and lateral projection at this level.\n\n Dr. reviewed the case with Dr. and Dr. .\n\n IMPRESSION: There is a mild stenosis of the right ICA at the bifurcation.\n Otherwise normal cerebral angiogram in particular of the right internal and\n external carotid artery branches, of the left internal and external carotid\n artery branches and of both vertebral and basilar artery complex and their\n branches. There is no evidence of vascular malformations or cerebral\n aneurysms.\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-10-24 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 772130,
"text": " 10:55 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: assess for progression of bleed/ shift?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with ?ICH\n\n REASON FOR THIS EXAMINATION:\n assess for progression of bleed/ shift?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HEAD CT, \n\n INDICATION: Right basal ganglia hemorrhage, please assess progression\n\n TECHNIQUE: Non-contrast head CT\n\n FINDINGS: Comparison is made to a prior head CT from . Since that\n time there has been no change in the size of the large right basal ganglia\n hemorrhage, but there has been slight increase in the mass effect and leftward\n shift. Perihemorrhage edema is slightly more prominent now. There is no\n hydrocephalus, but blood is still seen in the dependent portions of the\n lateral ventricles bilaterally. No new areas of hemorrhage are seen. Again\n seen is fluid within the right maxillary sinus, consistent with patient's\n intubation.\n\n IMPRESSION: Slight increase in mass effect and leftward shift from right\n basal ganglia hemorrhage. These findings were communicated to ,\n MD, at the time of the exam.\n\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-10-21 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 771891,
"text": " 2:39 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: status of bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with ?ICH\n\n REASON FOR THIS EXAMINATION:\n status of bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Reassess intracranial hemorrhage.\n\n TECHNIQUE: Noncontrast CT of the head.\n\n COMPARISON: Head CT .\n\n FINDINGS: There has been no significant interval change in the previously\n described large hemorrhage in the region of the right basal ganglia. There is\n still a mild amount of surrounding edema, slight shift of the midline\n structures to the left and blood within the dependent portions of both lateral\n ventricles. There is no evidence of new intra/extra-axial hemorrhages or mass\n affect. The ventricles, cisterns and sulci are stable in appearance. Again\n noted is thickening of the ethmoid air cells and a probable retention cyst\n within the left sphenoid sinus. There is a new small air fluid level within\n the right maxillary sinus, which may be secondary to the patient's intubated\n state.\n\n IMPRESSION: No significant interval change in the size/appearance of the\n previously described right basal ganglia hemorrhage. No new intra/extra-axial\n hemorrhages or mass affect.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-10-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 771773,
"text": " 8:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: New right IJ CVL placed, r/o pneumo/hemothorax.Thanks\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with IC hemorrhage\n REASON FOR THIS EXAMINATION:\n New right IJ CVL placed, r/o pneumo/hemothorax.Thanks\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 58 year old male with intracranial hemorrhage and line placement.\n Evaluate for pneumothorax/hemothorax.\n\n FINDINGS: There are no studies available for comparison.\n\n There is an endotracheal tube in good position. There is a right-sided IJ\n central venous line in place with its distal tip in the SVC. There is a\n nasogastric tube in place that passes beneath the diaphragm. The distal tip\n of this nasogastric tube is not visualized. There is no evidence of failure,\n focal infiltrate, or pleural effusion. The heart size is increased. There is\n no pneumothorax.\n\n IMPRESSION:\n\n 1. Placement of right IJ central venous line with no evidence of pneumothorax\n or other acute cardiopulmonary process.\n\n 2. Increased heart size without evidence of heart failure.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-10-20 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 771786,
"text": " 9:47 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: ICH ASSESS BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with ?ICH\n REASON FOR THIS EXAMINATION:\n r/o hemorrhage\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Intracranial hemorrhage, please assess bleed.\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: There are no prior studies for comparison, so it is not possible to\n assess the progression of this patient's intracranial hemorrhage. There is a\n large right-sided basal ganglia hemorrhage, with minimal surrounding edema,\n and mild shift of the normally mid-line structures to the left. Hemorrhage is\n also seen within the occipital of both lateral ventricles, right greater\n than left. No extra-axial collections are seen. There is atrophy of the\n frontal lobes bilaterally. No hydrocephalus.\n\n There is mucosal thickening within the ethmoid sinuses as well as a polyp\n versus mucus retention cyst within the left sphenoid sinus. The visualized\n osseous structures are unremarkable.\n\n IMPRESSION: Large right-sided basal ganglia hemorrhage with smaller amounts\n of hemorrhage within both occipital horns of the lateral ventricles. These\n findings were communicated directly to Dr. , one of the SICU fellows, on\n the morning of .\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-11-15 00:00:00.000",
"description": "P ABDOMEN U.S. (COMPLETE STUDY) PORT",
"row_id": 774096,
"text": " 2:34 PM\n ABDOMEN U.S. (COMPLETE STUDY) PORT Clip # \n Reason: ABNORMAL LFT,S ,EVAL FOR LIVER PATHOLOGY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n As above.\n REASON FOR THIS EXAMINATION:\n Patient is a 58 year-old man s/p right putaminal hemorrhage, h/o\n alcoholism--now has elevated LFTs, palpably enlarged spleen and liver, please\n eval for ascites prior to PEG placement.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Alcoholism, elevated liver function tests.\n\n FINDINGS: A small nodular liver that is increased in echogenicity is\n identified. This is consistent with cirrhosis. There is normal hepatopetal\n flow within the patent portal vein. There is no intrahepatic or extrahepatic\n biliary dilatation. Multiple gallstones and a nondistended gallbladder are\n identified. There is gallbladder wall thickening, probably related to the\n ascites and hypoalbuminemia. The pancreas is not well visualized. There is\n enlargement of the spleen, with no focal lesions. The right kidney measures\n 12.6 cm and the left kidney measures 12.8 cm. There is no hydronephrosis or\n nephrolithiasis. There are small amounts of ascites. A patent portal vein is\n identified.\n\n IMPRESSION:\n\n 1. Cirrhotic liver.\n\n 2. Cholelithiasis.\n\n 3. Small amounts of ascites.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-11-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 773963,
"text": " 12:00 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Infectious (lung) process underlying waxing and (wani\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year-old man 3wks s/p R-putaminal bleed.\n REASON FOR THIS EXAMINATION:\n Infectious (lung) process underlying waxing and ( today) mental\n status?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Mental status changes.\n\n COMPARISON: .\n\n SINGLE VIEW CHEST: There is a left PICC with tip in the SVC. There are low\n lung volumes. There is mild cardiomegaly. The aorta is tortuous. There is\n no evidence of vascular congestion, pleural effusion, or focal consolidation.\n Discoid atelectasis is seen at the right base. The right CP angle is not\n included on this film.\n\n IMPRESSION: Right lower lobe atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-11-14 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 774001,
"text": " 5:00 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Is there further edema and/or are we able to better visualiz\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with R-putaminal hemorrhage--failing to improve 3 weeks after\n event.\n REASON FOR THIS EXAMINATION:\n Is there further edema and/or are we able to better visualize the etiology of\n the patient's significant edema (is there a tumor underlying this hemorrhage?)?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION: 58 year old man with right putamenal hemorrhage failing to improve\n after 3 weeks.\n\n CT OF THE HEAD WITHOUT CONTRAST\n\n COMPARISON: Comparison is made with prior study performed .\n\n TECHNIQUE: CT of the head without contrast.\n\n FINDINGS: There has been interval decrease in size of the hypedense region\n large right basal ganglia hemorrhage, compatible with partial resorption of\n the acute hemorrhagic components.. No new areas of hemorrhage are identified.\n However, there is still considerable surrounding edema, with compression\n of the right lateral ventricle. No hydrocephalus is seen.\n\n There is a 1cm focal area of polypoid mucosal thickening within the left\n lateral aspect of the sphenoid sinus, unchanged from the prior study. The\n visualized paranasal sinuses and mastoid air cells are otherwise well aerated.\n\n IMPRESSION: Interval decrease in size in the large right basal ganglia\n hemorrhage with only minor interval decrease in mass effect. There is\n prominent, persistent edema surrounding the hemorrhage.\n\n COMMNENT: Both studies show a moderate degree of bifrontal peripheral\n cerebral atrophy.\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-11-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 774186,
"text": " 9:53 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess for GT placement.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year-old man 3wks s/p R-putaminal bleed.\n\n REASON FOR THIS EXAMINATION:\n Please assess for GT placement.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Assess gastric tube placement.\n\n COMPARISON: AP chest radiograph from .\n\n SEMI-UPRIGHT AP CHEST RADIOGRAPH: This study is limited by motion. The tip\n of the NG tube is not clearly visualized for technical reasons, but is likely\n within the stomach. Again identified is a left sided subclavian PICC line\n with the tip in the superior vena cava. There is cardiomegaly without\n evidence of left ventricular failure. No focal lung opacities are identified.\n The osseous structures are unchanged.\n\n IMPRESSION: Feeding tube tip likely within the stomach, but not visualized\n secondary to technical reasons. Cardiomegaly without evidence of failure.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-11-17 00:00:00.000",
"description": "VIDEO OROPHARYNGEAL SWALLOW",
"row_id": 774223,
"text": " 10:28 AM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: ASPIRATION\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Aspiration.\n\n VIDEO OROPHARYNGEAL SWALLOW: The demonstrated frank aspiration of thin\n liquids with spontaneous but weak cough and inaffective clearing. No\n structural abnormalities are seen.\n\n IMPRESSION: Please see the full report of the speech and swallowing division\n for full details and recommendations.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-10-20 00:00:00.000",
"description": "Report",
"row_id": 1594560,
"text": "ADMIT NOTE\n58 Y.O. MALE WITH HX CVA, ASTHMA, AFIB, APPENDECTOMY, ETOH- ALLERGY TO SULFA- PRESENTED TO HOSPITAL WITH LEFT SIDED WEAKNESSWAS FOUND TO HAVE RIGHT POST FRONTAL PARIETAL THALMIC BLEED ON HEAD CT- WAS ADMITTED TO FLOOR AT BH- WAS PLACED ON BED REST- FOUND ON FLOOR IN PRONE POSITION AT 1230AM WITH LEFT BROW LACERATION 1.5CM AND RIGHT HAND INFILTRATE- WENT TO HEAD CT - REVEALED EXTENDED PT CAME BACK FROM CT WITH FOLLOWING SYMPTOMS. LEFT LOWER LEG WEAKNESS. FLACID LEFT ARM, SLURRED SPEECH, INCREASED BP 150-180/90-100, PT CYCLED FOR CARDIAC ENZYMES. PT ADMITTED DIRECTLY TO UNIT FROM HOSPITAL AT 0545 AM.\n\nON ADMIT, PT AFIB 100S- SBP 170/58- LABETALOL DRIP STARTED TO KEEP SBP BELOW 140- 2 INCHES NITRO PLACED TO CW- ALINE PLACED/ PERIPERAL IV STARTED.\n\nNEURO: INITIALLY PT RESPONDING TO QUESTIONS- ALERT TO NAME ONLY NOT TO PLACE OR TIME, FULL STRENGTH NOTED ON RIGHT SIDE- NO MOVEMENT OF LEFT ARM AND SLIGHT MOVEMENT NOTED AT LEFT LEG- NO SENSATION NOTED ON LEFT SIDE PER PT, PT DENIES VISUAL DIFFICULTY ALTHOUGH WHEN 5 FINGERS ARE HELD IN FRONT OF PT- HE STATES THERE IS ONLY ONE. PT UNABLE TO PERFORM LATERAL MOVMENT OF EYES TO LEFT- EXHIBITING SLURRED SPEECH.\n\nAT 0600 PT HAD GENERALIZED SEIZURE LASTING MINITES AND CONTINUED TO HAVE 3 MORE SIEZURES OVER THE NEXT PT WAS GIVEN 4 MG ATIVAN WITH NO EFFECT PT CONTINUES TO HAVE SIEZURES TO HAVE LOADING DOSE OF DILANTIN. PT LETHARGIC AND UNRESPONSIVE TO QUESTIONS FOLLOWING SEIZURE.\n\nRESP: PT TO BE INTUBATED SHORTLY\n\nGU/GI: FOLEY CATH PLACED FOR CLEAR YELLOW URINE- BS POSITIVE- OBESE ABDOMEN- NGT PLACED TO LWS\n\nPLAN: PT TO HAVE EMERGENT HEAD CT, TO BE INTUBATED, TO HAVE LINE PLACED, AND HAVE EEG\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-10-20 00:00:00.000",
"description": "Report",
"row_id": 1594561,
"text": "NEURO; MOVES RT HAND AND LEG RANDOMLY AND WITHDRAWS TO STIMULATION, MOVES LEFT HAND SLIGHTLY TOWARD TORSO WHEN NAILBED PRESSURE APPLIED, OCCAS MOVES LEFT FOOT BUT ONLY SLIGHTLY AND NOT TO NAILBED PRESSURE, NEURO AND SICU MD'S INFORMED, PERL #6, BRISKK, POSITIVE CORNEAL, POSITIVE GAG, PT HAS BECOME MORE RESTLESS SINCE LATE PM AND MOVING RT SIDE MORE FREQUENTLY, NEURO TEAM IN TO EVALUATE AND PT DID DISPLAY TWO FINGERS WITH RT HAND, AND WIGGLED TOES RT FOOT TO COMMAND, DOES NOT DO SO WITH LEFT, PT DOES NOT SPONT OPEN EYES, IS LOCALIZING MORE WITH RT ARM, CAT SCAN THIS AM, VERBAL REPORT WAS LEFT BASAL GANGLION HEMORRHAGE, L VENTRICLE-MASS EFFECT, REPORTED TO SICU H.O. AND NEUROLOGY, SEEN BY NEUROSURGERY TODAY FOR ? VENT DRAIN PLACEMENT, BUT WILL BE DEFERRED\nWITNESSED SEIZURE AT 0745 THIS AM, SPASTIC TREMORS OF LEFT ARM AND LEG, LASTED 3-4 MINUTES, MEDIC WITH ATIVAN 2 MGM AND RT LEG BECAME SPASTIC FOR 2 MINUTES AND THEN SUBSIDED.\nCARDIOVASCULAR; HR 70'S-80'S A FIB, LABETOLOL ON THIS AM FOR SYS GOAL OF < 140, HAS BEEN OFF SINCE 9 AM SINCE BP SYS HAS BEEN LOW L110'S-140, (GOAL ACCORDING TO NEUROLOGY IS SYS > 100 AND < 140), LEFT FOOT SL COOLER THAN RT BUT PEDAL AND PT PULSES WEAKLY PALPABLE, THIS PM PEDAL PULSE STRONGER THAN RT,\n\nRESPIR; ON CMV MODE, ABGS REFLECT METAB ALKALOSIS, SUCTIONED FOR SMALL THIN CLEAR SECRETIONS\n\nLABS; K 3.4, REPLETED WITH 40 MEQ KCL, MG REPLETED, ION CA 1.11-NO REPLETION ORDERED, SLIDING SCALE INSULIN BS 207-COVERED WITH 2 UNITS REGULAR, LAST BS 149 AT 1800\n\nGI: BLOOD-TINED BILIOUS DGE FROM NG TUBE, PT WILL START ON PROTONIX TONOC\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-10-21 00:00:00.000",
"description": "Report",
"row_id": 1594562,
"text": "Respiratory care\nPt remains intubated and tolerating wean to CPAP/PSV 5/5. Please see carevue flowsheet for further info. Pt traveled to Ct scan this afternoon and placed back on vent with current settings. Pt sx for thick yellow throughout day, plan to continue with current settings and wean to extubate.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-10-21 00:00:00.000",
"description": "Report",
"row_id": 1594563,
"text": "NEURO; PERL # , BOTH REACT BRISKLY TO LIGHT, POSITVE CORNEALS, STRONGER GAG REFLEX THAN YESTERDAY, ATTEMPTS TO OPEN EYES AT TIMES, ABLE TO SHOW TWO FINGERS ON RT HAND, LIFTS AND HOLDS RT ARM AND RT LEG, LEFT SIDE WEAKER, MOVES LEFT FOOT ONLY SLIGHTLY IN BED, AND MOVES FINGERS OF LEFT HAND VERY SLIGHTLY,\n\nCARDIOVASCULAR; HR 70'S-80'S A FIB, STARTED BACK ON LABETOLOL TO KEEP SYS 140 OR LESS SYS, LABETOLOL PRESENTLY AT 0.8 MGM/MIN, LEFT FOOT WARMER THAN YESTERDAY, PEDAL AND PT PULSES PALPABLE,\n\nRESPIR; WEANED TO C-PAP MODE, 5 OF PRESSURE SUPPORT AND PEEP, SPON TV 520-550, ABG'S STABLE WITH PH 7.44, PC02 45, P02 95, AND BICARB 35, SHOWN TO DR. , PT TO 90% SHORTLY AFTER ABGS DRAWN, SUCTIONED FOR THICK TAN-DEEP YELLOW SECRETIONS, 02 SAT PRESENTLY 96%\n\nLABS: CA AND K REPLETIONS TODAY, BS 142-NOT COVERED WITH SLIDING SCALE\n\n; U/O 30-40/HR, CONCENTRATED, NEED TO KEEP MONITORING\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-10-22 00:00:00.000",
"description": "Report",
"row_id": 1594564,
"text": "Resp Care,\nPt. remains intubated on CPAP IPS5/.4/5peep. VT400-500, RR18. Plan to extubate. See vent flowsheet.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-10-22 00:00:00.000",
"description": "Report",
"row_id": 1594565,
"text": "NEURO: PT . AROUSABLE TO VOICE, BUT DOES NOT OPEN EYES. FOLLOWS COMMANDS. MOVES RIGHT EXTREMTITIES PURPOSEFULLY. MINIMAL MOVEMENT OF LEFT EXTREMTIES TO COMMAND. PUPILS BRISK AND REACTIVE LEFT LARGER THAN RIGHT. RIGHT PUPIL 3-4MM, LEFT 5-7MM. MD INFORMED.\nRESP: LS CLEAR, BUT OCCASIONALLY COASRE AT UPPER AIRWAY. ET SUCTIONED FOR MODERATE TO LARGE AMT TAN SPUTUM. O2SATS AND ABG STABLE.\nCV: AFEBRILE. AFIB CONTINUES 70S TO 80S. LABETOLOL GTT TITRATED UP TO 1MG/MIN TO MAINTAINE SBP <140. RECEIVED 1 UNIT FFP FPR INR 1.4. REPEAT INR 1.5. MD INFORMED.\nGI: ABD SOFT. FAINT BS. TF'S OF IMPACT WITH FIBER STARTED AT 10CC/HOUR WITH MINIMAL RESIDUALS. NOT ADVANCED PER ORDER.\nGU: FOLEY INTACT AND PATENT FOR MINIMAL U/O 30-50CC/HOUR, AMBER IN COLOR.\nPLAN: CONT TO MONITOR NEURO STATUS CLOSELY. CONT PER CURRENT MGMT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-10-22 00:00:00.000",
"description": "Report",
"row_id": 1594566,
"text": "Condition Update A:\nROS - Please refer to careview for specifics.\nNEURO: Cont w/ somulance, arouse to voice, attempts to open eyes. PERL 4-5/4-5 brisk. Displays two fingers to command. No spontanous mvmnt of (L) extremities. Pt at (R) upper extremity attempting to pull at ETT. No seizure activity. Sitter present at bedside.\nCV: Afebrile. Cont a-fib no PVC or PAC seen. Cont w/ generalized non pit edema. CVP 21-24. Cont on labetalol to keep SBP <140.\nRESP: Ambu/lavage/sx x2 for tan plugs, as well as prn for thick tan secretions.\nGI: TF via NGT remains clamped, reviewed w/ Dr. . ABD S/NT. No stool.\nGU: u/o amber clear 25-45cc/h. Dr. of decreased u/o.\nSKIN: Laceration to os C/D/I.\n\nPLAN: Monitor resp status w/ possible extubation . Monitor sbp and labetalol gtt. Monitor MS and for seizure activity. Cont w/ current plan of care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-10-23 00:00:00.000",
"description": "Report",
"row_id": 1594567,
"text": "Resp Care,\nPt. remains intubated on CPAP IPS5/.4/5peep. VT 600's, RR18. Plan to extubate today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-10-23 00:00:00.000",
"description": "Report",
"row_id": 1594568,
"text": "focus hemodynmics\ndata: vss. bp 130-140's., hr 50-80's, remains on a labetatolol gtt. u.o 25-50cc amber colored urine. suctioned for copius amts of tan thick sputum. pt does not move l side. moves r side off the bed. show 2 fingers upon command. tube fdg held due to ?extubation today. incontinent of lg amt of stool. sitter at the bedside.\naction: labs prn. suction prn. neuro signs q1-2hrs. labetolol gtt for bp control. update to signaificant other. sitters cont at the bedside.\nresponse: monitor closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-10-23 00:00:00.000",
"description": "Report",
"row_id": 1594569,
"text": "Resp Care: Pt remains intubated via #8 ETT secured 24cm at lip. BS sl. coarse bilat. Sx'd for mod. amt thick yellow sputum. No vent changes made this shift. Please see carrevue for further vent inqueries.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-10-23 00:00:00.000",
"description": "Report",
"row_id": 1594570,
"text": "neuro update\npt cont. to follow commands w/ RE's, but is not opening eyes spont. PERRLA. +corneal reflex. +gag reflex. no movement w/ LUE & slight movement w/ painful stimulus to LLE. s/p angio this afternoon which pt ruled out for AVM/aneurysm per Dr. . R fem. angio site C&D w/ + doppler pulses in RLE. palpable fem pulse. HR 50 - 90's Afib w/ occ episodes of flutter. cont on labetolol drip to keep sbp 140.Resp. coarse & diminished in bases. sxn'd for thick tan secretions in moderate amounts. sputum cx sent. cont. on CPAP w/ PSV 5/5. Abd lg round, soft w/ hypoactive BS. TF cont. to hold per team. wife @ bedside for part of afternoon.\n\nplan is for EEG in am for further neuro w/u. cont. to monitor ABG's, resp status, & neuro status in prep. for extubation ?.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-10-24 00:00:00.000",
"description": "Report",
"row_id": 1594571,
"text": "Nursing update - See carevue for patient assessment throughout the shift. Right femoral angio site clean with no ecchymosis. Right pedal and femoral pulses palpable. Does not open eyes. Purposeful movements with right hand. Restart tube feedings and advanced to 20 cc/hr. Labetolol infusion titrated to keep systolic bp less than 140. No family contact.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-10-24 00:00:00.000",
"description": "Report",
"row_id": 1594572,
"text": "NPN UPDATE\nPT . W/ L-SIDED WEAKNESS. RUE/RLE 5/5 STRENGTH. LUE/LLE SLIGHT WITHDRAWAL FROM PAINFUL STIMULUS ONLY. PERRLA. FOLLOWING COMMANDS. NONVERBAL. OPENS EYES SPONT. ON RARE OCCASSION. HEAD CT THIS AM SHOWED NO FURTHER BLEED, BUT INC. EDEMA PER SICU TEAM. PT @ 1430. SPO2 98% ON FT @ 35%/10L. LS COARSE. SXN FOR THICK TAN SPUTUM. STARTED ON VANCO FOR GRAM+ SPUTUM CX. CPT/DB/COUGH DONE TO MAINT. SATS>92%. HR IN 50'S AFIB W/ SBP 100-117 THIS AM. LOPRESSOR HELD. LABETOLOL GTT D/C'd HYDRALAZINE PRN GIVEN FOR BRIEF EPISODES OF SBP >150 W/ GOOD EFFECT. CURRENTLY IN AFIB W/ RATE 70-90'S & SBP 130-150'S. MOD. BM THIS AM. PT TO RESTART TF IMPACT W/ FIBER @ GOAL OF 60CC/HR VIA NGT IF . TO TOLERATE EXTUBATION. WIFE @ BEDSIDE WITH PT FOR MOST OF DAY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-10-24 00:00:00.000",
"description": "Report",
"row_id": 1594573,
"text": "Pt place on 50% cool mist. ABGS: 7.43/29/120/20/96%\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-10-25 00:00:00.000",
"description": "Report",
"row_id": 1594574,
"text": "7P-7A: Full assessment in flow sheet.\n\nneuro: Arouse to voice. Open eyes inconsistently. PERL - 3 - 4 mm brisk. Follow directions. Right side normal - strong. Left arm and leg - slight movement to verbal and stimuli (leg stronger than arm). Good gag and cough reflex.\n\ncv: Afib 50-90. SBP 120-150/45-60. Nipride ivp X2 given for SBP 150. Warm, dry, general edema +1, +2 edema bilateral lower extremeties.\n\nresp; Lung sound coarse. RR 16-24, SaO2-94-100%. Encourage to cough and deep breath. Chest percussion and vibration done.\n\ngu/gi; large, soft abd. +BS X4, large bowel movement (negative guiac). TF- +placement, 10-15 cc residual, tolerate goal 60 cc/hr. Foley patent - >40 cc/hr.\n\nint; Skin intact.\n\nAM lab done. Lytes replenish.\n\nPlan; Continue to monitor. Respiratory toileting done.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-10-25 00:00:00.000",
"description": "Report",
"row_id": 1594575,
"text": "FOCUS: STATUS UPDATE\nDATA:\nPT TO VOICE BUT ONLY OPENS EYES TO STRONG STIMULI--ATTEMPTED TO OPEN TO VOICEX1. LETHARGIC. MOVING RUE FREELY IN BED, LIFTING AND HOLDING RLE. NO MOVEMENT NOTED LE'S. WITHDRAWS TO NAILBED PRESSURE W/LE. PERL, HIPPUS NOTED ON SEVERAL OCCASIONS. SAID \"\" ONCE OTHERWISE . NON-VERBAL. MANNITOL STARTED. ON DILATIN W/INCREASED DOSAGE FOR 8.3 DILANTIN LEVEL.\n\nBP MAINTAINED 140 AND BELOW W/PRN HYDRALAZINE WHICH HAS BEEN INCREASED TO 10MG.\n\nLUNGS CLEAR TO COARSE BILAT BASES. STRONG PRODUCTIVE COUGH. SATS 95-100. REMAINS ON HUMIDIFIED FM AT 40%.\n\nABD SOFT, NON-TENDER, POSITIVE BS, OBESE. TOLERATING TF AT NEW GOAL OF 75ML/HR.\n\nURINE OUTPUT ADEQUATE, LASIX X1 GIVEN. CONTINUES TO BE POSITIVE I/O.\n\nPLAN:\nCONTINUE TO MONITOR I/O, NEURO. MAINTAIN BP 140 OR LESS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-10-26 00:00:00.000",
"description": "Report",
"row_id": 1594576,
"text": "7p-7a; Full assessment in flow sheet.\n\nSleep most of night. Follow commands. Open eyes to painful stimuli only. Move RUE - strong. Weak RLE. Withdrawal slightly to pain in LUE. Move left feet to stimuli in LLE. Strong gag and cough. PERL - 3mm brisk. Murble words. Yes and no not appropriate to questions. Afib without ectopy. SBP maintain under 140 with hydralazine ivp. Lung sound coarse in lower lobes - suction tan/thick secretions. Deep breath and cough. Chest PT and vibration. soft abd, +BS X4. no bm. Foley patent. Lasix 40 ivp given - diuresis well - >100 cc/hr. Skin intact. Continue to monitor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-10-26 00:00:00.000",
"description": "Report",
"row_id": 1594577,
"text": "CONDITION UPDATE\nASSESSMENT:\n PT TO VOICE, ATTEMPTS TO OPEN EYES, BUT UNABLE TO COMMUNICATE BY SPEECH. PUPILS EQUAL AND REACTIVE. PT STILL WITHOUT MOVEMENT OF LEFT EXTREMITIES AND NORMAL STRENGTH OF RIGHT EXTREMITIES.\nCONTINUED WITH MANNITOL, NO EVIDENCE OF NEURO CHANGES.\n ABP ELEVATED THIS AM TO 160'S/80'S WITH HR 100-110 AFIB. HR 70-80'S AFTER AM LOPRESSOR AND IV HYDRALAZINE GIVEN WITH +EFFECT. ABP WAS MAINTAINED 140'S/70'S (GOAL TO KEEP SBP<150). CVP SLIGHTLY INCREASED , PT CONTINUES WITH LG HRLY OUTPUT (>120CC/HR).\n PT WITH STRONG COUGH, OCCASIONALLY PRODUCTIVE (THICK, TAN SPUTUM). SP02 > 97% WITH 40% FT, AND BREATHING APPEARS UNLABORED. LS OCCASIONALLY COARSE @ BASES, PT NEEDS ASSIST WITH PULM HYGEINE.\n PLAN:\n CONTINUE TO FOLLOW NEURO STATUS CLOSELY. HYDRALAZINE PRN TO MAINTAIN SBP<150. CONTINUE WITH CURRENT CLOSE MONITORING.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-10-27 00:00:00.000",
"description": "Report",
"row_id": 1594578,
"text": "7p-7a: Full assessment in flow sheet.\n\nLethargic. Arouse to voice. Answer inconsistent verbally appropriately - able to say last name (). Garble and mumble of words. Good cough and gag reflex. Very hard for pt to open eyes - painful stimuli only. Eyes - PERL, reddish - MD notify. Move RLE and RUE. Only withdrawal slight to pain LUE and LLE. Pt slept most of night. Afib 70-110. Inc BP when turn and position. Maintain SBP <140 with Hydralazine ivpX2. Chest PT and vibration, deep breath and cough for coarse lung sound - thick/tan small secretion. Large abd, +BS X4. no BM. Foley patent >40 cc/hr. NG - +placement, minimal residual. Mannitol given for Osmality less than 310. Warm, dry, general edema +1. AM lab done. Continue to monitor.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-10-27 00:00:00.000",
"description": "Report",
"row_id": 1594579,
"text": "CONDITION UPDATE\nS/O: LETHARGIC THIS AM, MORE ALERT AS SHIFT PROGRESSED. AT TIMES ANSWERING ONE WORD QUESTIONS APPROPRIATELY - SPEECH SOMEWHAT GARBLED. PUPILS EQUAL AND REACTIVE. MOVING RSIDE W/ NL STRENGTH - NO MOVEMENT NOTED LEFT. VSS - W/ EXCEPTION OF HIGH BLOOD PRESSURE. HYDRALAZINE AND LOPRESSOR DOSES INCREASED W/ EFFECT. LUNGS CLEAR TO COARSE, DIMINISHED AT BASES. ORALLY SUCTIONED - FOR THICK, TAN SPUTUM. ABD SOFT, NT. TOLERATING TUBE FEEDS, W/ NO SIGNIFICANT RESIDUAL. U/O QS VIA FOLEY. NO STOOL THIS SHIFT.\nA/P: CLOSE NEURO ASSESSMENT. MAINTAIN BP PER PARAMETERS. TRANSFER TO FLOOR WHEN STABLE, MD'S ORDERS. ICU CARE AND TREATMENTS.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-10-28 00:00:00.000",
"description": "Report",
"row_id": 1594580,
"text": "neuro status\nD: pt is lethargic but . pupils are equal and reactive to light. no movement of the left side. normal strength on the right. pt unable to state date or place but continuously follows commands. urine output remains adequate. pt coughing and raising to back of throat. suctioned for thick tan sputum from the back of throat. pt tolerating tube feeds of impact with fiber at 75cc/hr.\na: pt treated with ntp for sabp greater than 140. s\nr: sbp 140-160. pt continues on current antihypertenssive medication. neuro status is unchanged. no further desating and pt remains on 3l and 50% face tent.\n"
},
{
"category": "ECG",
"chartdate": "2124-10-21 00:00:00.000",
"description": "Report",
"row_id": 170579,
"text": "Atrial fibrillation with a moderate ventricular response. RSR' pattern in\nlead V1. Slight ST segment depressions noted in leads V1-V6 suggest possible\nlateral ischemia. Clinical correlation is suggested. No previous tracing\navailable for comparison.\n\n"
}
] |
20,172 | 129,844 | Given the above, the patient was hydrated and her hypotension was thought to be secondary to the verapamil she received the morning she was transferred to the CCU. She was given two units of blood with improvement in her hematocrit. A rectal exam was performed which showed that she was guaiac negative, and with this chronic history of anemia which subsequently stabilized, the patient was deemed stable for discharge. She was discharged to home and will follow-up with Dr. in one week's time, and follow-up with her PCP. was given copies of her catheterization report, and she was continued all of her previous medications except lasix, hydrochlorothiazide, lisinopril, and her Imdur dose was halved to 30 mg po qd. The other medications would be restarted by her PCP as her blood pressure was monitored. The patient was discharged in stable condition. , M.D. Dictated By: MEDQUIST36 D: 21:00 T: 09:29 JOB#: | Sinus rhythm- first degree A-V blockLateral ST-T changes are nonspecificLeft atrial abnormalitySince previous tracing of : ST-T wave changes slightly less prominent CONTRAINDICATIONS for IV CONTRAST: s/p renal artrery stent;s/p renal artery stent FINAL REPORT INDICATION: Status post right renal artery stenting. Dopamine d/c. wheeze.left groin site D/I. CT PELVIS WITH INTRAVENOUS CONTRAST: The distal ureters, urinary bladder, and rectum are unremarkable. IMPRESSION: Unremarkable abdominal and pelvic CT. No evidence of retroperitoneal bleed. sbp 70. given 1lns w/ no change in bp. TECHNIQUE: Helically acquired axial images were obtained from the lung bases to the pubic symphysis without intravenous contrast. Visualized small and large bowel loops are unremarkable. LS diminished bases. started on dopamine. extrem. There is a tiny nonobstructing renal stone within the pelvis of the right kidney. foley draining cl yellow urine qs.A: hypotensive, w/ hct drop s/p l renal artery stent hemodynamically stable at this time.P: monitor BP, follow HCT. CCU NPN 1900-0700S: " I feel achy all over "O: pt. monitor responce to isordil. BP since has been 101/36-124/49. The liver, gallbladder, pancreas, spleen, adrenals, and kidneys are unremarkable. Nausea with hypotension. There is evidence of minimal atelectasis at the base bilaterally without evidence of pulmonary nodules or infiltrate. 3:06 PM CT PELVIS W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # Reason: RT RENAL ARTERY STENT NOW HYPOTENSIVE Field of view: 36 MEDICAL CONDITION: 68 year old woman s/p R renal artery stenting now c hypotension, nausea, and hct drop. audible exp. took all meds except lactulose in eve.isordil to start in AM.PLAN: follow am labs, d/c foley in Am. Pt given one unit prbc and transferred to CCU.Pt arrived ~ 1330 awake, alert cooperative in NAD. cath for dyspnea/CHF: LM 30%, LAD 30-40% prox, D1 ostial 40%, RCA w/ widely open stents, mod pulmonary hypertension, EF 75%,severe left ventricular diastolic dysfunction,labile HTN, PVD, Hyperlipidemiaallergies: full dose asa, codine, percocet, betablockers-> bronchospasmPt underwent stent to l renal artery , plan to d/c today. Hct stable at 30.2.She was discharged home w/ VNA following her. c/o generalized body ache/discomfort ~ 0300. given tylenol and ambien with good relief. Pt getting up this am -> dizzy, lightheaded. There is a stent placement of the right renal artery. warm.foley draining 100-200cc/hr. CCU NSG D/C NOTEPt has remained hemodynamically stable. occas. hr 70-80's sr. 2nd unit PRBC currently being administered. Pt went to CT scan for abd/pelvic scan to r/o bleeding.Lungs cta, o2 2lnc-> sats 95%. able to fall asleep.afeb. There is no significant retroperitoneal or mesenteric lymphadenopathy. There is no pelvic free fluid or pelvic lymphadenopathy. No evidence of hydronephrosis. OOB. HCT noted to be 22, down from 28. pulses 2+. There is no free air or free fluid within the abdomen. Dopamine infusing at 5 mcg/kg/min, bp 119/34. CCU NSG ADMIT NOTEPt is 68 yo woman admitted to for renal artery angiogram and stent to l renal artery.PMH: cad, "90 RCA PTCA, mid RCA ISR rx w/ PTCA, 80% mid RCA which was PTCA'd and stented. There is no evidence of retroperitoneal bleeding. HR 80's SR. BP 101-117/40's.sats 95% on 2lnc. anticipate transfer to floor if stable. Bone windows demonstrate no evidence of suspicious lytic or blastic lesions. REASON FOR THIS EXAMINATION: Signs of bleeding? There is extensive vascular calcification involving the aorta. (-) 1liter at 12am.post transfusion HCT 30.1.ate for late dinner. | 5 | [
{
"category": "Radiology",
"chartdate": "2183-10-08 00:00:00.000",
"description": "CT PELVIS W/O CONTRAST",
"row_id": 772273,
"text": " 3:06 PM\n CT PELVIS W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n Reason: RT RENAL ARTERY STENT NOW HYPOTENSIVE\n Field of view: 36\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman s/p R renal artery stenting now c hypotension, nausea, and\n hct drop.\n REASON FOR THIS EXAMINATION:\n Signs of bleeding?\n CONTRAINDICATIONS for IV CONTRAST:\n s/p renal artrery stent;s/p renal artery stent\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post right renal artery stenting. Nausea with\n hypotension.\n\n TECHNIQUE: Helically acquired axial images were obtained from the lung bases\n to the pubic symphysis without intravenous contrast. There is evidence of\n minimal atelectasis at the base bilaterally without evidence of pulmonary\n nodules or infiltrate. The liver, gallbladder, pancreas, spleen, adrenals,\n and kidneys are unremarkable. There is a tiny nonobstructing renal stone\n within the pelvis of the right kidney. There is a stent placement of the\n right renal artery. No evidence of hydronephrosis. There is extensive\n vascular calcification involving the aorta. There is no evidence of\n retroperitoneal bleeding. There is no free air or free fluid within the\n abdomen. Visualized small and large bowel loops are unremarkable. There is\n no significant retroperitoneal or mesenteric lymphadenopathy.\n\n CT PELVIS WITH INTRAVENOUS CONTRAST: The distal ureters, urinary bladder, and\n rectum are unremarkable. There is no pelvic free fluid or pelvic\n lymphadenopathy.\n\n Bone windows demonstrate no evidence of suspicious lytic or blastic lesions.\n\n IMPRESSION: Unremarkable abdominal and pelvic CT. No evidence of\n retroperitoneal bleed.\n\n"
},
{
"category": "ECG",
"chartdate": "2183-10-08 00:00:00.000",
"description": "Report",
"row_id": 269974,
"text": "Sinus rhythm\n- first degree A-V block\nLateral ST-T changes are nonspecific\nLeft atrial abnormality\nSince previous tracing of : ST-T wave changes slightly less prominent\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2183-10-08 00:00:00.000",
"description": "Report",
"row_id": 1527405,
"text": "CCU NSG ADMIT NOTE\nPt is 68 yo woman admitted to for renal artery angiogram and stent to l renal artery.\n\nPMH: cad, \"90 RCA PTCA, mid RCA ISR rx w/ PTCA, 80% mid RCA which was PTCA'd and stented. cath for dyspnea/CHF: LM 30%, LAD 30-40% prox, D1 ostial 40%, RCA w/ widely open stents, mod pulmonary hypertension, EF 75%,severe left ventricular diastolic dysfunction,\nlabile HTN, PVD, Hyperlipidemia\n\nallergies: full dose asa, codine, percocet, betablockers-> bronchospasm\n\nPt underwent stent to l renal artery , plan to d/c today. Pt getting up this am -> dizzy, lightheaded. sbp 70. given 1lns w/ no change in bp. started on dopamine. HCT noted to be 22, down from 28. Pt given one unit prbc and transferred to CCU.\nPt arrived ~ 1330 awake, alert cooperative in NAD. Dopamine infusing at 5 mcg/kg/min, bp 119/34. Dopamine d/c. BP since has been 101/36-124/49. hr 70-80's sr. 2nd unit PRBC currently being administered. Pt went to CT scan for abd/pelvic scan to r/o bleeding.\nLungs cta, o2 2lnc-> sats 95%. foley draining cl yellow urine qs.\n\nA: hypotensive, w/ hct drop s/p l renal artery stent\n hemodynamically stable at this time.\nP: monitor BP, follow HCT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2183-10-09 00:00:00.000",
"description": "Report",
"row_id": 1527406,
"text": "CCU NPN 1900-0700\nS: \" I feel achy all over \"\nO: pt. c/o generalized body ache/discomfort ~ 0300. given tylenol and ambien with good relief. able to fall asleep.\n\nafeb. HR 80's SR. BP 101-117/40's.\nsats 95% on 2lnc. LS diminished bases. occas. audible exp. wheeze.\n\nleft groin site D/I. pulses 2+. extrem. warm.\n\nfoley draining 100-200cc/hr. (-) 1liter at 12am.\n\npost transfusion HCT 30.1.\n\nate for late dinner. took all meds except lactulose in eve.\n\nisordil to start in AM.\n\nPLAN: follow am labs, d/c foley in Am. OOB. anticipate transfer to floor if stable. monitor responce to isordil.\n"
},
{
"category": "Nursing/other",
"chartdate": "2183-10-09 00:00:00.000",
"description": "Report",
"row_id": 1527407,
"text": "CCU NSG D/C NOTE\nPt has remained hemodynamically stable. Hct stable at 30.2.She was discharged home w/ VNA following her. She was given scripts and instructions re: taking meds, she will see her primary care ms in 1 wk, and f/u w/ Dr in 6 weeks, She will also get a sma7 prior to seeing Dr. .\n"
}
] |
44,064 | 126,583 | 84 year-old M with high-grade cardiac lymphoma (left atrial mass), currently receiving treatment (cycle 4,day 15) with R- who presented from home with low-grade fevers and progressive dyspnea. | Caridiac ischemia also a possibility as pt has alleed hx of a silent inferior MI in . likewise deferred ICU consent until acute anxiety has resolved Prophylaxis: DVT: SQ UF Heparin, IVC filter Stress ulcer: PPI VAP: Comments: Communication: Comments: Code status: Full code Disposition: ICU ------ Protected Section ------ ADDENDUM TO PLAN: Assessment and plan initially changed this am as cardiac enzymes positive and ECHO showing significant new focal wall motion abnormaiilities. likewise deferred ICU consent until acute anxiety has resolved Prophylaxis: DVT: SQ UF Heparin, IVC filter Stress ulcer: PPI VAP: Comments: Communication: Comments: Code status: Full code Disposition: ICU likewise deferred ICU consent until acute anxiety has resolved Prophylaxis: DVT: SQ UF Heparin, IVC filter Stress ulcer: PPI VAP: Comments: Communication: Comments: Code status: Full code Disposition: ICU - will d/w pt and BMT # Hx of DVT: Per previous DC summary, pt has had a recent DVT in setting of ongoing malignancy and has IVC filter in place--by report has contraindication to systemic anticoagulation. - will d/w pt and BMT # Hx of DVT: Per previous DC summary, pt has had a recent DVT in setting of ongoing malignancy and has IVC filter in place--by report has contraindication to systemic anticoagulation. - will d/w pt and BMT # Hx of DVT: Per previous DC summary, pt has had a recent DVT in setting of ongoing malignancy and has IVC filter in place--by report has contraindication to systemic anticoagulation. - will d/w pt and BMT # Hx of DVT: Per previous DC summary, pt has had a recent DVT in setting of ongoing malignancy and has IVC filter in place--by report has contraindication to systemic anticoagulation. Caridiac ischemia also a possibility as pt has reported hx of a silent inferior MI in , curently not on ASA, BB, statin. Caridiac ischemia also a possibility as pt has reported hx of a silent inferior MI in , curently not on ASA, BB, statin. Caridiac ischemia also a possibility as pt has reported hx of a silent inferior MI in , curently not on ASA, BB, statin. He has had a substantial worsening of cardiac fxn w/o clear ECG changes and echo read sounds c/w takasubo He has paraflu on nasal wash which seems consistent with his presentation. Albuterol MDI, and neb treatments given . Moderate [2+] tricuspid regurgitation is seen.There is no pericardial effusion.Compared with the prior study (images reviewed) of , biventrricularsystolic function is now depressed with regionality. Caridiac ischemia also a possibility as pt has reported hx of a silent inferior MI in , curently not on ASA, BB, statin. Mild tomoderate (+) MR.TRICUSPID VALVE: Tricuspid valve not well visualized. Mild tomoderate (+) mitral regurgitation is seen. Indeterminate PAsystolic pressure.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor echo windows.Conclusions:The left atrium is elongated. PATIENT/TEST INFORMATION:Indication: Left ventricular function.Height: (in) 68Weight (lb): 144BSA (m2): 1.78 m2BP (mm Hg): 155/70HR (bpm): 93Status: InpatientDate/Time: at 12:30Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Elongated LA.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Pericardial effusion.Height: (in) 68Weight (lb): 139BSA (m2): 1.75 m2BP (mm Hg): 124/79HR (bpm): 100Status: InpatientDate/Time: at 13:20Test: Portable TTE (Complete)Doppler: Limited Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .LEFT VENTRICLE: Moderately depressed LVEF.RIGHT VENTRICLE: RV function depressed.MITRAL VALVE: Mildly thickened mitral valve leaflets. Narrowing of the superior vena cava by this mass is unchanged. Normal interatrial septum.No ASD by 2D or color Doppler.LEFT VENTRICLE: Mild symmetric LVH. Myocardial infarction, acute (AMI, STEMI, NSTEMI) Assessment: Pt ruled in for NSTEMI with positive triponins. Denies any pain.received ativan from ER. Moderate (2+) MR.TRICUSPID VALVE: Moderate [2+] TR.PERICARDIUM: No pericardial effusion.Conclusions:Overall left ventricular systolic function is moderately depressed (LVEF=30-35 %) with akinesis of the distal LV/apex. There is mild symmetric left ventricular hypertrophy. Atherosclerotic calcifications involve the thoracic aorta and its branches, though the thoracic aorta is of normal caliber. likewise deferred ICU consent until acute anxiety has resolved Prophylaxis: DVT: SQ UF Heparin, IVC filter Stress ulcer: PPI VAP: Comments: Communication: Comments: Code status: Full code Disposition: ICU ------ Protected Section ------ ADDENDUM TO PLAN: Assessment and plan initially changed this am as cardiac enzymes positive and ECHO showing significant new focal wall motion abnormaiilities. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Perhaps slight decrease in size of cardiac mass compared to CT from , with persistent mass effect on superior vena cava. RV with depressed free wallcontractility. Elevation of right hemidiaphragm unchanged since at least . IMPRESSION: AP chest compared to : Mild vascular congestion has developed in the right lung base. - will d/w pt and BMT # Hx of DVT: Per previous DC summary, pt has had a recent DVT in setting of ongoing malignancy and has IVC filter in place--by report has contraindication to systemic anticoagulation. The aortic valve leaflets (3) are mildly thickened but aorticstenosis is not present. Moderate (2+)mitral regurgitation is seen. | 28 | [
{
"category": "General",
"chartdate": "2200-04-22 00:00:00.000",
"description": "Generic Note",
"row_id": 678967,
"text": "TITLE: Critical Care\n Present for the key portions of the resident\ns history and exam. Agree\n substantially with assessment and plan as outlined on multidisciplinary\n rounds this morning. Much more comfortable\n breathless with talking\n or minimal movement but substantially better than yesterday.\n 97.6 102 95/50\n Chest\n prolonged exhalation, mid insp crackles\n Abd\n soft\n WBC 8.7\n Trop down to 0.17\n Much improved. Still somewhat unclear what has happened but it appears\n he has a parainfluenza inf c/b some cardiac event\n unclear if this is\n demand ischemia or Takasubo\ns. We are stopping iv heparin and starting\n sq heparin. Continues to get nebs with some relief. No evidence of\n bacterial inf so we are d/cing abx.\n Time spent 30 min\n"
},
{
"category": "Physician ",
"chartdate": "2200-04-21 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 678697,
"text": "Chief Complaint: worsening shortness of breath over past 2-3 days, low\n grade fevers at home\n HPI:\n Mr. is an 84 yo man with a high-grade cardiac B-cell\n lymphoma for which he is now undergoing R- chemotherapy and a\n history of COPD, DVT s/p IVC filter, and pneumonia with\n respiratory failure requiring endotracheal intubation in . Today is\n Day 15 of Cycle 4 or R-, which he received during his hospital\n admission from . He received Neulasta on . following\n his discharge, he has been feeling generally well; however, he admits\n to increasing exertional dyspnea overthe past 2-3 days. He explains\n that very light activity, such as changing his clothes or walking short\n distances, has resulted in significant shortness of breath. He denies\n cough, sputum production, orthopnea, paroxysmal nocturnal dyspnea, and\n swelling/pain of the arms or legs. He admits to low-grade fevers today;\n while visiting, his daughter noted that he had a temperature of 100.4\n degrees. For this reason, he was advised to report to the Emergency\n Room for evaluation.\n Upon arrival in the Emergency Department, had temperature of 99.6\n degrees. He was tachycardic to 118 and tachypneic (RR 30-40) with\n oxygen saturations of 95% on room air. During the first several\n minutesof is Emergency Department course, he developed rapidly\n increasing work of breathing. A CXR demonstrated no evidence\n ofpneumonia or effusion; furthermore, an echocardiogram showed no\n pericardial effusion. He was noted to have a WBC of 8.8 with 26%\n neutrophils and 36% bands. Due to progressive respiratorydistress\n without hypoxia, he was started on BiPAP. In addition, he was given IV\n solumderol 125mg, ASA 325mg, bronchodilators, piperacillin-tazobactam,\n and vancomycin. Also received total of 1.25mg of ativan in ED.\n Despite a fairly normal blood gas and presumbaly secondary to worsening\n dyspnea and tachynpnea, pt was started on BIPAP which he tolerated\n during his transfer to the . On arrival, he insisted that it be\n removed and then resumed. He was agitated and extremely anxious\n repeating \"I need air,\" peripheral sats were in the 93-100% range on\n room air. Seemed to be more comfortable leaning forward and placing\n his weight on his upper ext's. His HR rose in propotion to his\n tachypnea and gitation to a rate of 140's transiently. Agitation/anxiey\n waxed and waned with pt sleeping intermittently.\n ONCOLOGIC HISTORY (Per recent note by Dr : \n initially presented on , with anewly identified 8\n cm right atrial soft tissue mass. He underwent biopsy of this on\n , and pathology showed high-grade aggressive diffuse large\n B-cell lymphoma, staining positive for CD20, bcl-2, and bcl-6 in a\n small subset. Cells were negative for cytokeratins, CD138, bcl-1, and\n bcl-6. MIB fraction was 95-100%. Bcl-2 co-expression and lack of CD10\n argued against Burkitt's lymphoma; however, FISH studies were positive\n for c-myc rearrangement. He was diagnosed with high-grade cardiac\n lymphoma on the spectrum of diffuse large B-cell to Burkitt's\n lymphoma. No other sites of disease were identified by torso CT and\n bone marrow biopsy. He has begun R- chemotherapy on .\n Treatment course has been complicated by a DVT status post IVC filter\n in and pneumonia requiring intubation for hypoxia in .\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Terazosin\n Mental status c\n Last dose of Antibiotics:\n Vancomycin - 03:31 AM\n Piperacillin/Tazobactam (Zosyn) - 03:31 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n 1. cardiac lymphoma as above\n 2. Left Peroneal DVT s/p IVC filter placement \n 3. COPD\n 4. Hyperlipidemia\n 5. Hypertension\n 6. History of anxiety\n 7. History of rib fracture\n 8. History of silent MI \n 9. Left Shoulder Weakness\n 10. External Hemorrhoids\n 11. Benign Prostatic Hypertrophy\n nc\n Occupation: retired\n Drugs:\n Tobacco: 60 pk yr hx, quit 6 years ago\n Alcohol:\n Other: currently in rehab, living independently up until recent\n admission\n Review of systems:\n Constitutional: Fever\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n Tachycardia, No(t) Orthopnea\n Respiratory: No(t) Cough, Dyspnea, Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Diarrhea\n Genitourinary: No(t) Dysuria\n Neurologic: No(t) Headache\n Flowsheet Data as of 06:28 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.9\nC (96.6\n Tcurrent: 35.9\nC (96.6\n HR: 121 (121 - 121) bpm\n BP: 128/77(89) {128/75(89) - 155/77(96)} mmHg\n RR: 32 (25 - 32) insp/min\n SpO2: 95%\n Total In:\n 2,300 mL\n PO:\n TF:\n IVF:\n 300 mL\n Blood products:\n Total out:\n 0 mL\n 800 mL\n Urine:\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,500 mL\n Respiratory\n O2 Delivery Device: Other\n SpO2: 95%\n Physical Examination\n General Appearance: Thin, Anxious\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), tachycardic\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: dull BS bilaterally with prolonged expiratory\n pahse and use of abdominal muscles during expiration\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis\n Musculoskeletal: Muscle wasting\n Skin: Not assessed, No(t) Rash:\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): , Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n [image002.jpg]\n Imaging: ADMISSION CXR: The right hemidiaphragm remains persistently\n elevated. The\n cardiomediastinal silhouette is stable. There is no focal pulmonary\n consolidation. An IVC filter is seen in the upper abdomen.\n CONCLUSION: No acute cardiopulmonary process.\n CTA (ADMISSION):PRELIM: No PE. New focal right basilar consolidation-?\n pneumonia though may represent\n aspiration with ariway secretions seen on right. Perhaps slight\n dcecrease in\n size of cardiac mass.\n Microbiology: Bcx x2 and Ucx NGTD\n ECG: sinus tachycadia, left axis deviation, low voltages diffusely, old\n inferior infarct, no stt changes from previous\n Assessment and Plan\n ASSESSMENT AND PLAN:\n 84 year-old M with high-grade cardiac lymphoma (left atrial mass),\n currently receiving treatment (cycle 4,day 15) with R- presents\n from home with low-grade fevers and progressive dyspnea; despite\n marked tachypnea and dyspnea, pt's images and blood gas look\n remarkably good suggesting a strong contribution from anxiety. That\n said, he has an atypical WBC diff and is s/p recent chemotherapy and\n thus in a relatively immunocompromised state demanding empiric broad\n coverage with Abx. Physical Exam is most suggestive of COPD\n exacerbation, but dyspnea is out of proportion to boreline (if any)\n hypoxia.\n # Dyspnea / Tachypnea: From what can be gathered of his ED course, it\n seems that it was similar to how he has been in the . Dyspnea is\n out of proportion to hypoxia. Have been thus far unable to repeat\n blood gas secondary to agitation, but peripheral sats in mid to high\n 90s even on room air. When he has used Bipap, settings hve been 17/5\n on room air--he intermittently prefers this to face mask. Bedside echo\n in the ED notable for absence of effusion/tamponade. LV function\n grossly intact. CXR without pulmonary edema. CTA ruled out PE and\n showed ONLY Opacity in RLL which may represent early bacterial PNA vs\n aspiration. Pt does have Hx of DVT, but IVC filter is in place and no\n exam finding to suggest current DVT. Overall, it seems that anxiety\n may be contributing strongly to this presentation--although does not\n seem to be on home anxiolytics other than low dose ativan for nausea.\n His positional preference and prolonged expiratory phase are suggestive\n of COPD exacerbation (FVC 50%, FEV1 40% Predicted), but again dyspnea\n out of proportion to hypoxia. Caridiac ischemia also a possibility as\n pt has alleed hx of a silent inferior MI in .\n - add BNP to admission labs; may be elevated in setting of atrial mass,\n but if negative still useful to r/o failure\n - repeat CXR this am\n - formal ECHO by tech ordered\n - repeat blood gas when tolerats\n - Trend cardiac enzymes\n - albuterol/ipratropium nebs (holding home spiriva); continuing advair;\n will d/w BMT regarding +/- of systemic steroids in this lymphoma pt\n undergoing tx\n - NIPPV on RA vs 2L face-mask per pt preference; O2 sats adeqquate on\n either\n # Low-Grade Fevers / Bandemia: Bandemia present on , but not to\n the prounced degree that it is now. Pt's fevers at home were\n low-grade, was afebrile in ED and on floor. There is a concern for\n relative immunocompromise as he is currently receiving tx for lymphoma.\n Pt is s/p PNA requiring intubation during a recent hospitalization.\n Some concern for infectious process on admission CTA, but RLL findings\n not particulary striking. UA clean.\n - Blood cultures x2 pending, Urine Cx pending, Sputum ordered. Repaet\n Cx if spikes.\n - Nasal aspirate for respiratory viruses: (influenza,paraninfluenza,\n RSV)\n - D/w BMT whether atypical Diff is expected with pt's recent treatemnts\n or whether it is more concerning for infxn. Smear ordered.\n - Empiric therapy for HAP Vanco/Zosyn per BMT\n # Cardiac lymphoma: The patient appears to have had an excellent\n response to therapy to date, with a decline in his LDH and shrinkage of\n his cardiac mass on cardiac MRI. He will be due for his 5th cycle of\n next week, and his ability to receive his chemotherapy safelywill\n be determined by his recover from his present illness.\n - d/w BMT\n # Hx of CAD: Alleged silent MI in . Not in our records and pt\n currently unbale to discuss. EKG suggestive of prior infarct, but ECHO\n is not. Unusual that he is not on home ASA, BB, or statin.\n - will d/w pt and BMT\n # Hx of DVT: Per previous DC summary, pt has had a recent DVT in\n setting of ongoing malignancy and has IVC filter in place--by report\n has contraindication to systemic anticoagulation.\n - d/w BMT\n ICU Care\n Nutrition: npo currently\n Glycemic Control:\n Lines:\n 18 Gauge - 03:37 AM\n 20 Gauge - 03:37 AM\n Comments: code status confirmed by onc fellow in ED. deferred currently\n as acutely agitated/anxious. likewise deferred ICU consent until acute\n anxiety has resolved\n Prophylaxis:\n DVT: SQ UF Heparin, IVC filter\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2200-04-21 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 678698,
"text": "Chief Complaint: worsening shortness of breath over past 2-3 days, low\n grade fevers at home\n HPI:\n Mr. is an 84 yo man with a high-grade cardiac B-cell\n lymphoma for which he is now undergoing R- chemotherapy and a\n history of COPD, DVT s/p IVC filter, and pneumonia with\n respiratory failure requiring endotracheal intubation in . Today is\n Day 15 of Cycle 4 or R-, which he received during his hospital\n admission from . He received Neulasta on . following\n his discharge, he has been feeling generally well; however, he admits\n to increasing exertional dyspnea overthe past 2-3 days. He explains\n that very light activity, such as changing his clothes or walking short\n distances, has resulted in significant shortness of breath. He denies\n cough, sputum production, orthopnea, paroxysmal nocturnal dyspnea, and\n swelling/pain of the arms or legs. He admits to low-grade fevers today;\n while visiting, his daughter noted that he had a temperature of 100.4\n degrees. For this reason, he was advised to report to the Emergency\n Room for evaluation.\n Upon arrival in the Emergency Department, had temperature of 99.6\n degrees. He was tachycardic to 118 and tachypneic (RR 30-40) with\n oxygen saturations of 95% on room air. During the first several\n minutesof is Emergency Department course, he developed rapidly\n increasing work of breathing. A CXR demonstrated no evidence\n ofpneumonia or effusion; furthermore, an echocardiogram showed no\n pericardial effusion. He was noted to have a WBC of 8.8 with 26%\n neutrophils and 36% bands. Due to progressive respiratorydistress\n without hypoxia, he was started on BiPAP. In addition, he was given IV\n solumderol 125mg, ASA 325mg, bronchodilators, piperacillin-tazobactam,\n and vancomycin. Also received total of 1.25mg of ativan in ED.\n Despite a fairly normal blood gas and presumbaly secondary to worsening\n dyspnea and tachynpnea, pt was started on BIPAP which he tolerated\n during his transfer to the . On arrival, he insisted that it be\n removed and then resumed. He was agitated and extremely anxious\n repeating \"I need air,\" peripheral sats were in the 93-100% range on\n room air. Seemed to be more comfortable leaning forward and placing\n his weight on his upper ext's. His HR rose in propotion to his\n tachypnea and gitation to a rate of 140's transiently. Agitation/anxiey\n waxed and waned with pt sleeping intermittently.\n ONCOLOGIC HISTORY (Per recent note by Dr : \n initially presented on , with anewly identified 8\n cm right atrial soft tissue mass. He underwent biopsy of this on\n , and pathology showed high-grade aggressive diffuse large\n B-cell lymphoma, staining positive for CD20, bcl-2, and bcl-6 in a\n small subset. Cells were negative for cytokeratins, CD138, bcl-1, and\n bcl-6. MIB fraction was 95-100%. Bcl-2 co-expression and lack of CD10\n argued against Burkitt's lymphoma; however, FISH studies were positive\n for c-myc rearrangement. He was diagnosed with high-grade cardiac\n lymphoma on the spectrum of diffuse large B-cell to Burkitt's\n lymphoma. No other sites of disease were identified by torso CT and\n bone marrow biopsy. He has begun R- chemotherapy on .\n Treatment course has been complicated by a DVT status post IVC filter\n in and pneumonia requiring intubation for hypoxia in .\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Terazosin\n Mental status c\n Last dose of Antibiotics:\n Vancomycin - 03:31 AM\n Piperacillin/Tazobactam (Zosyn) - 03:31 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n 1. cardiac lymphoma as above\n 2. Left Peroneal DVT s/p IVC filter placement \n 3. COPD\n 4. Hyperlipidemia\n 5. Hypertension\n 6. History of anxiety\n 7. History of rib fracture\n 8. History of silent MI \n 9. Left Shoulder Weakness\n 10. External Hemorrhoids\n 11. Benign Prostatic Hypertrophy\n nc\n Occupation: retired\n Drugs:\n Tobacco: 60 pk yr hx, quit 6 years ago\n Alcohol:\n Other: currently in rehab, living independently up until recent\n admission\n Review of systems:\n Constitutional: Fever\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n Tachycardia, No(t) Orthopnea\n Respiratory: No(t) Cough, Dyspnea, Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Diarrhea\n Genitourinary: No(t) Dysuria\n Neurologic: No(t) Headache\n Flowsheet Data as of 06:28 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.9\nC (96.6\n Tcurrent: 35.9\nC (96.6\n HR: 121 (121 - 121) bpm\n BP: 128/77(89) {128/75(89) - 155/77(96)} mmHg\n RR: 32 (25 - 32) insp/min\n SpO2: 95%\n Total In:\n 2,300 mL\n PO:\n TF:\n IVF:\n 300 mL\n Blood products:\n Total out:\n 0 mL\n 800 mL\n Urine:\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,500 mL\n Respiratory\n O2 Delivery Device: Other\n SpO2: 95%\n Physical Examination\n General Appearance: Thin, Anxious\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), tachycardic\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: dull BS bilaterally with prolonged expiratory\n pahse and use of abdominal muscles during expiration\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis\n Musculoskeletal: Muscle wasting\n Skin: Not assessed, No(t) Rash:\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): , Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n [image002.jpg]\n Imaging: ADMISSION CXR: The right hemidiaphragm remains persistently\n elevated. The\n cardiomediastinal silhouette is stable. There is no focal pulmonary\n consolidation. An IVC filter is seen in the upper abdomen.\n CONCLUSION: No acute cardiopulmonary process.\n CTA (ADMISSION):PRELIM: No PE. New focal right basilar consolidation-?\n pneumonia though may represent\n aspiration with ariway secretions seen on right. Perhaps slight\n dcecrease in\n size of cardiac mass.\n Microbiology: Bcx x2 and Ucx NGTD\n ECG: sinus tachycadia, left axis deviation, low voltages diffusely, old\n inferior infarct, no stt changes from previous\n Assessment and Plan\n ASSESSMENT AND PLAN:\n 84 year-old M with high-grade cardiac lymphoma (left atrial mass),\n currently receiving treatment (cycle 4,day 15) with R- presents\n from home with low-grade fevers and progressive dyspnea; despite\n marked tachypnea and dyspnea, pt's images and blood gas look\n remarkably good suggesting a strong contribution from anxiety. That\n said, he has an atypical WBC diff and is s/p recent chemotherapy and\n thus in a relatively immunocompromised state demanding empiric broad\n coverage with Abx. Physical Exam is most suggestive of COPD\n exacerbation, but dyspnea is out of proportion to boreline (if any)\n hypoxia.\n # Dyspnea / Tachypnea: From what can be gathered of his ED course, it\n seems that it was similar to how he has been in the . Dyspnea is\n out of proportion to hypoxia. Have been thus far unable to repeat\n blood gas secondary to agitation, but peripheral sats in mid to high\n 90s even on room air. When he has used Bipap, settings hve been 17/5\n on room air--he intermittently prefers this to face mask. Bedside echo\n in the ED notable for absence of effusion/tamponade. LV function\n grossly intact. CXR without pulmonary edema. CTA ruled out PE and\n showed ONLY Opacity in RLL which may represent early bacterial PNA vs\n aspiration. Pt does have Hx of DVT, but IVC filter is in place and no\n exam finding to suggest current DVT. Overall, it seems that anxiety\n may be contributing strongly to this presentation--although does not\n seem to be on home anxiolytics other than low dose ativan for nausea.\n His positional preference and prolonged expiratory phase are suggestive\n of COPD exacerbation (FVC 50%, FEV1 40% Predicted), but again dyspnea\n out of proportion to hypoxia. Caridiac ischemia also a possibility as\n pt has reported hx of a silent inferior MI in , curently not on\n ASA, BB, statin.\n - add BNP to admission labs; may be elevated in setting of atrial mass,\n but if negative still useful to r/o failure\n - repeat CXR this am\n - formal ECHO by tech ordered\n - repeat blood gas when tolerats\n - Trend cardiac enzymes\n - albuterol/ipratropium nebs (holding home spiriva); continuing advair;\n will d/w BMT regarding +/- of systemic steroids in this lymphoma pt\n undergoing tx\n - NIPPV on RA vs 2L face-mask per pt preference; O2 sats adeqquate on\n either\n # Low-Grade Fevers / Bandemia: Bandemia present on , but not to\n the prounced degree that it is now. Pt's fevers at home were\n low-grade, was afebrile in ED and on floor. There is a concern for\n relative immunocompromise as he is currently receiving tx for lymphoma.\n Pt is s/p PNA requiring intubation during a recent hospitalization.\n Some concern for infectious process on admission CTA, but RLL findings\n not particulary striking. UA clean.\n - Blood cultures x2 pending, Urine Cx pending, Sputum ordered. Repaet\n Cx if spikes.\n - Nasal aspirate for respiratory viruses: (influenza,paraninfluenza,\n RSV)\n - D/w BMT whether atypical Diff is expected with pt's recent treatemnts\n or whether it is more concerning for infxn. Smear ordered.\n - Empiric therapy for HAP Vanco/Zosyn per BMT\n # Cardiac lymphoma: The patient appears to have had an excellent\n response to therapy to date, with a decline in his LDH and shrinkage of\n his cardiac mass on cardiac MRI. He will be due for his 5th cycle of\n next week, and his ability to receive his chemotherapy safelywill\n be determined by his recover from his present illness.\n - d/w BMT\n # Hx of CAD: Alleged silent MI in . Not in our records and pt\n currently unbale to discuss. EKG suggestive of prior infarct, but ECHO\n is not. Unusual that he is not on home ASA, BB, or statin.\n - will d/w pt and BMT\n # Hx of DVT: Per previous DC summary, pt has had a recent DVT in\n setting of ongoing malignancy and has IVC filter in place--by report\n has contraindication to systemic anticoagulation.\n - d/w BMT\n ICU Care\n Nutrition: npo currently\n Glycemic Control:\n Lines:\n 18 Gauge - 03:37 AM\n 20 Gauge - 03:37 AM\n Comments: code status confirmed by onc fellow in ED. deferred currently\n as acutely agitated/anxious. likewise deferred ICU consent until acute\n anxiety has resolved\n Prophylaxis:\n DVT: SQ UF Heparin, IVC filter\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2200-04-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 678822,
"text": "84 yo male pt with PMH ,Rt atrial tumour , lyphoma , recent\n chemotherapy ,PNA, presented to ER with SOB, N/V anxious, ?\n neutropenic. pt with worsening SOB, received vanco, zosyn ,solumedrol\n ,ativan and aspirin from ER, 2litres of fluid in. ? PE . CT done. neg\n for PE, ? PNA, slight decrease in the size of cardiac mass. put on\n BIPAP .tolerated well. transfered to for further monitoring and\n management.\n Pt is alert and oriented but has very little patience and is easily\n agitated, becoming SOB with activity. He is not comfortable in bed and\n has been OOB to chair most of the shift. Was in bed for cardiac echo,\n then back to chair. Ambulates with assist of one to chair. Family\n calling in frequently for updates. is spokesperson.\n He denies complaints of chest pain or pressure but is ruling in for MI\n by enzymes with elevated triponin to 2.23 at noon today. He has been\n started on lopressor for rate control, heparin drip and aspirin. He was\n also started on simvastatin. Cardiac consult in place.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt with severe complaints of dyspnea and becomes tachypneic when in\n bed. Maintains O2 sat but becomes agitated and feels like he is\n trapped in a cage.\n Once in the chair he was calmer and less anxious\n with improved Resp rate and agitation.\n Action:\n Weaned O2 from 100% down to 3L N/C with good O2 sat. RT sent specimens\n for viral antigens. Pt is positive for parainfluenza. He is on droplet\n precautions but team is not sure if we need them for this diagnosis.\n Response:\n Remains in the chair but still becomes anxious and restless at times\n and is on the call light frequently for small things.\n Plan:\n Provide support and reassurance for this pt who is easily agitated.\n Ordered for small doses morphine or ativan can be used PRN. Has an\n order for 1mg IV haldol on one time sheet which was never given yet.\n Altered mental status (not Delirium)\n Assessment:\n Pt with periods of agitation and anxiety refused to stay in bed,\n becoming acutely agitated, restless and tachypneic.\n Action:\n Given .5mg iV morphine, assisted to chair and pt reassured.\n Response:\n Improved agitation but continues to ask the same questions about his\n illness andhis care.\n Plan:\n Follow mental status, continue to provide emotional support. Use PRN\n morphine, ativan as needed.\n .H/O lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n Pt is currently undergoing chemo treatment for lymphoma\n Action:\n Heme/onc service consulted and will not give chemo while he is being\n treated for an acute MI\n Response:\n Will reassess need for chemo once pt is stable.\n Plan:\n Continue to follow-up with heme/onc for recommendations. Next set of\n enzymes due at 1800.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Pt ruled in for NSTEMI with positive triponins. No EKG changes were\n noted. Echo done at bedside today showed some new wall abnormalities\n but full report is yet to follow. He denies chest pain and pressure.\n Action:\n Pt given one aspirin tablet and was started on metoprolol 12.5mg then\n increased to 25mg PO. Pt also started on heparin drip at 11:45 at\n 750Units/hr. He was also started on simvastatin and remains on O2 3L.\n Stat echo and EKG was done. Pt given morphine for acute anxiety\n episode.\n Response:\n Vital signs remain stable with improved resp status in chair. Family\n have been updated and remain informed of plan of care. Pt started to\n have hematuria at 1600 and small pool of blood noted on pink pad under\n pt. Pt found to have some bleeding from around urethral meatus. Seen\n and noted by team.\n Plan:\n Follow labs, PTT Q6hrs to titrate heparin drip. Follow pt for further\n signs of bleeding.\n"
},
{
"category": "Nursing",
"chartdate": "2200-04-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 678873,
"text": "84 yo male pt with PMH ,Rt atrial tumour , lyphoma , recent\n chemotherapy ,PNA, presented to ER with SOB, N/V anxious, pt with\n worsening SOB, received vanco, zosyn ,solumedrol ,ativan and aspirin\n from ER, 2litres of fluid in. CT done. neg for PE, ? PNA, slight\n decrease in the size of cardiac mass. put on BIPAP .tolerated well.\n transfered to for further monitoring and management. He denies\n complaints of chest pain or pressure but is ruling in for MI by enzymes\n with elevated triponin to 2.23 yesterday. He has been started on\n lopressor for rate control, heparin drip aspirin and simvastatin.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n r/o MI from Elevated cardiac enzymes from yesterday.\n Action:\n Pt on heparin gtt and po aspirin. Lopressor for rate control. PTT q6hr.\n cardiac echo done yesterday. Cardiology consult.\n Response:\n f/u with cardiology, continue heparin per protocol. PTT q 6hrs.\n Plan:\n Continue with heparin per protocol. PTT q 6hrs.\n Altered mental status (not Delirium)\n Assessment:\n Pt alert oriented x 3, calm and quiet most of the time, but get\n restless and anxious very quickly. Slept during the night. Pt states\n he can\nt breath while he is anxious.\n Action:\n Ativan 0.5mg po/iv PRN. Stayed on bed during the night. On NC O2\n 3lit/min. LS Diminished. Neb treatments /MDI as ordered.\n Response:\n Good effect with ativan. Sats > 96%\n Plan:\n Continue with ativan /morphine PRN. Monitor mental status.\n Foley to gravity, urine clear,pink in colout.? Traumatic vs heparin\n gtt.\n"
},
{
"category": "Physician ",
"chartdate": "2200-04-22 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 678935,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 09:39 AM\n EKG - At 11:25 AM\n Allergies:\n Terazosin\n Mental status c\n Last dose of Antibiotics:\n Vancomycin - 08:18 PM\n Piperacillin/Tazobactam (Zosyn) - 06:33 AM\n Infusions:\n Heparin Sodium - 750 units/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:31 AM\n Heparin Sodium (Prophylaxis) - 08:31 AM\n Morphine Sulfate - 10:28 AM\n Heparin Sodium - 11:23 AM\n Lorazepam (Ativan) - 12:15 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.7\nC (98.1\n HR: 103 (88 - 104) bpm\n BP: 136/68(89) {91/43(51) - 139/79(94)} mmHg\n RR: 39 (17 - 39) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,446 mL\n 233 mL\n PO:\n 120 mL\n TF:\n IVF:\n 1,326 mL\n 233 mL\n Blood products:\n Total out:\n 2,690 mL\n 580 mL\n Urine:\n 2,090 mL\n 580 mL\n NG:\n Stool:\n Drains:\n Balance:\n 756 mL\n -347 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///27/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 161 K/uL\n 8.5 g/dL\n 100 mg/dL\n 0.7 mg/dL\n 27 mEq/L\n 3.4 mEq/L\n 11 mg/dL\n 104 mEq/L\n 140 mEq/L\n 24.1 %\n 8.7 K/uL\n [image002.jpg]\n 04:18 AM\n 11:11 AM\n 05:48 PM\n 05:46 AM\n WBC\n 12.3\n 8.7\n Hct\n 29.2\n 24.1\n Plt\n 182\n 161\n Cr\n 0.8\n 0.7\n TropT\n 0.27\n 0.23\n 0.17\n Glucose\n 152\n 100\n Other labs: PT / PTT / INR:12.2/76.2/1.0, CK / CKMB /\n Troponin-T:136/14/0.17, ALT / AST:20/28, Alk Phos / T Bili:90/0.2,\n Differential-Neuts:82.0 %, Band:6.0 %, Lymph:3.0 %, Mono:4.0 %, Eos:0.0\n %, Albumin:3.5 g/dL, LDH:250 IU/L, Ca++:8.6 mg/dL, Mg++:2.2 mg/dL,\n PO4:3.5 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, NSTEMI)\n .H/O LYMPHOMA (CANCER, MALIGNANT NEOPLASM, LYMPHOID)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n ASSESSMENT AND PLAN:\n 84 year-old M with high-grade cardiac lymphoma (left atrial mass),\n currently receiving treatment (cycle 4,day 15) with R- presents\n from home with low-grade fevers and progressive dyspnea; despite\n marked tachypnea and dyspnea, pt's images and blood gas look\n remarkably good suggesting a strong contribution from anxiety. That\n said, he has an atypical WBC diff and is s/p recent chemotherapy and\n thus in a relatively immunocompromised state demanding empiric broad\n coverage with Abx. Physical Exam is most suggestive of COPD\n exacerbation, but dyspnea is out of proportion to boreline (if any)\n hypoxia.\n # Dyspnea / Tachypnea: From what can be gathered of his ED course, it\n seems that it was similar to how he has been in the . Dyspnea is\n out of proportion to hypoxia. Have been thus far unable to repeat\n blood gas secondary to agitation, but peripheral sats in mid to high\n 90s even on room air. When he has used Bipap, settings hve been 17/5\n on room air--he intermittently prefers this to face mask. Bedside echo\n in the ED notable for absence of effusion/tamponade. LV function\n grossly intact. CXR without pulmonary edema. CTA ruled out PE and\n showed ONLY Opacity in RLL which may represent early bacterial PNA vs\n aspiration. Pt does have Hx of DVT, but IVC filter is in place and no\n exam finding to suggest current DVT. Overall, it seems that anxiety\n may be contributing strongly to this presentation--although does not\n seem to be on home anxiolytics other than low dose ativan for nausea.\n His positional preference and prolonged expiratory phase are suggestive\n of COPD exacerbation (FVC 50%, FEV1 40% Predicted), but again dyspnea\n out of proportion to hypoxia. Caridiac ischemia also a possibility as\n pt has reported hx of a silent inferior MI in , curently not on\n ASA, BB, statin.\n - add BNP to admission labs; may be elevated in setting of atrial mass,\n but if negative still useful to r/o failure\n - repeat CXR this am\n - formal ECHO by tech ordered\n - repeat blood gas when tolerats\n - Trend cardiac enzymes\n - albuterol/ipratropium nebs (holding home spiriva); continuing advair;\n will d/w BMT regarding +/- of systemic steroids in this lymphoma pt\n undergoing tx\n - NIPPV on RA vs 2L face-mask per pt preference; O2 sats adeqquate on\n either\n # Low-Grade Fevers / Bandemia: Bandemia present on , but not to\n the prounced degree that it is now. Pt's fevers at home were\n low-grade, was afebrile in ED and on floor. There is a concern for\n relative immunocompromise as he is currently receiving tx for lymphoma.\n Pt is s/p PNA requiring intubation during a recent hospitalization.\n Some concern for infectious process on admission CTA, but RLL findings\n not particulary striking. UA clean.\n - Blood cultures x2 pending, Urine Cx pending, Sputum ordered. Repaet\n Cx if spikes.\n - Nasal aspirate for respiratory viruses: (influenza,paraninfluenza,\n RSV)\n - D/w BMT whether atypical Diff is expected with pt's recent treatemnts\n or whether it is more concerning for infxn. Smear ordered.\n - Empiric therapy for HAP Vanco/Zosyn per BMT\n # Cardiac lymphoma: The patient appears to have had an excellent\n response to therapy to date, with a decline in his LDH and shrinkage of\n his cardiac mass on cardiac MRI. He will be due for his 5th cycle of\n next week, and his ability to receive his chemotherapy safelywill\n be determined by his recover from his present illness.\n - d/w BMT\n # Hx of CAD: Alleged silent MI in . Not in our records and pt\n currently unbale to discuss. EKG suggestive of prior infarct, but ECHO\n is not. Unusual that he is not on home ASA, BB, or statin.\n - will d/w pt and BMT\n # Hx of DVT: Per previous DC summary, pt has had a recent DVT in\n setting of ongoing malignancy and has IVC filter in place--by report\n has contraindication to systemic anticoagulation.\n - d/w BMT\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:54 AM\n 18 Gauge - 05:57 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2200-04-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 678689,
"text": "84 yo male pt with PMH ,Rt atrial tumour , lyphoma , recent\n chemotherapy ,PNA, presented to ER with SOB, N/V anxious, ?\n neutropenic. pt with worsening SOB, received vanco, zosyn ,solumedrol\n ,ativan and aspirin from ER, 2litres of fluid in. ? PE . CT done. neg\n for PE, ? PNA, slight decrease in the size of cardiac mass. put on\n BIPAP .tolerated well. transfered to for further monitoring and\n management.\n Neuro: alert and oriented , restless initially . following commands.\n Denies any pain.received ativan from ER. Very restless and says\n can\nt breath\n and likes to sit with legs dangling down . so made him\n to sit on the cardiac chair. Slept after morphine 1mg and 0.5mg\n ativan iv.\n CVS: HR ,with occasional PVC\ns. BP stable. bilateral pedal\n pulse palpable.\n Resp: Tachypoenic, RR high 20\ns ,initially with BIPAP mask ,then\n changed to 100% face mask.sats 100%. LS with insp/ exp wheeze.\n Albuterol MDI, and neb treatments given . ABG to do later on.\n GU/GI: abd soft ,BS present. Foley to gravity,adequate urine output.\n Skin; intact.\n Social; no family contact after admission . remains full code.\n Plan; follow up with am labs. Monitor resp /neuro status. f/u with\n blood gas. O2 as needed.\n"
},
{
"category": "Nursing",
"chartdate": "2200-04-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 678874,
"text": "84 yo male pt with PMH ,Rt atrial tumour , lyphoma , recent\n chemotherapy ,PNA, presented to ER with SOB, N/V anxious, pt with\n worsening SOB, received vanco, zosyn ,solumedrol ,ativan and aspirin\n from ER, 2litres of fluid in. CT done. neg for PE, ? PNA, slight\n decrease in the size of cardiac mass. put on BIPAP .tolerated well.\n transfered to for further monitoring and management. He denies\n complaints of chest pain or pressure but is ruling in for MI by enzymes\n with elevated triponin to 2.23 yesterday. He has been started on\n lopressor for rate control, heparin drip aspirin and simvastatin.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n r/o MI from Elevated cardiac enzymes from yesterday.\n Action:\n Pt on heparin gtt and po aspirin. Lopressor for rate control. PTT q6hr.\n cardiac echo done yesterday. Cardiology consult.\n Response:\n f/u with cardiology, continue heparin per protocol. PTT q 6hrs. last\n 2two consecutive PTT\ns 66.5 and 61, both within therapeutic level.\n Plan:\n Continue with heparin per protocol. need PTT daily now.\n Altered mental status (not Delirium)\n Assessment:\n Pt alert oriented x 3, calm and quiet most of the time, but get\n restless and anxious very quickly. Slept during the night. Pt states\n he can\nt breath while he is anxious.\n Action:\n Ativan 0.5mg po/iv PRN. Stayed on bed during the night. On NC O2\n 3lit/min. LS Diminished. Neb treatments /MDI as ordered.\n Response:\n Good effect with ativan. Sats > 96%\n Plan:\n Continue with ativan /morphine PRN. Monitor mental status.\n Foley to gravity, urine clear,pink in colout.? Traumatic vs heparin\n gtt.\n"
},
{
"category": "General",
"chartdate": "2200-04-21 00:00:00.000",
"description": "Generic Note",
"row_id": 678684,
"text": "TITLE:\n Respiratory Care:\n Pt arrives from ED with SOB, pneumonia, fever, lymphoma (now undergoing\n chemo), cardiac tumor. PMH of COPD DVT (filter placed), MI ,\n intubated for pneumonia . Placed on bipap\n 17/5 and tolerating\n well, but very anxious. Has nebs ordered.\n"
},
{
"category": "Nursing",
"chartdate": "2200-04-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 678811,
"text": "84 yo male pt with PMH ,Rt atrial tumour , lyphoma , recent\n chemotherapy ,PNA, presented to ER with SOB, N/V anxious, ?\n neutropenic. pt with worsening SOB, received vanco, zosyn ,solumedrol\n ,ativan and aspirin from ER, 2litres of fluid in. ? PE . CT done. neg\n for PE, ? PNA, slight decrease in the size of cardiac mass. put on\n BIPAP .tolerated well. transfered to for further monitoring and\n management.\n Pt is alert and oriented but has very little patience and is easily\n agitated, becoming SOB with activity. He is not comfortable in bed and\n has been OOB to chair most of the shift. Was in bed for cardiac echo,\n then back to chair. Ambulates with assist of one to chair.\n He denies complaints of chest pain or pressure but is ruling in for MI\n by enzymes with elevated triponin to 2.23 at noon today. He has been\n started on lopressor for rate control, heparin drip and aspirain. He\n was also started on simvastatin. Cardiac consult in place.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt with severe complaints of dyspnea and becomes tachypneic when in\n bed. Maintains O2 sat but becomes agitated and feels like he is\n trapped in a cage.\n Once in the chair he was calmer and less anxious\n with improved Resp rate and agitation.\n Action:\n Weaned O2 from 100% down to 3L N/C with good O2 sat.\n Response:\n Remains in the chair but still becomes anxious and restless at times\n and is on the call light frequently for small things.\n Plan:\n Provide support and reassurance for this pt who is easily agitated.\n Ordered for small doses morphine or ativan can be used PRN\n Altered mental status (not Delirium)\n Assessment:\n Pt with periods of agitation and anxiety refused to stay in bed,\n becoming acutely agitated, restless and tachypneic.\n Action:\n Given .5mg iV morphine, assisted to chair and pt reassured.\n Response:\n Improved agitation but continues to ask the same questions about his\n illness andhis care.\n Plan:\n Follow mental status, continue to provide emotional support.\n .H/O lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n Pt is currently undergoing chemo treatment for lymphoma\n Action:\n Heme/onc service consulted and will not give chemo while he is being\n treated for an acute MI\n Response:\n Will reassess need for chemo once pt is stable.\n Plan:\n Continue to follow-up with heme/onc for recommendations.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2200-04-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 678798,
"text": "84 yo male pt with PMH ,Rt atrial tumour , lyphoma , recent\n chemotherapy ,PNA, presented to ER with SOB, N/V anxious, ?\n neutropenic. pt with worsening SOB, received vanco, zosyn ,solumedrol\n ,ativan and aspirin from ER, 2litres of fluid in. ? PE . CT done. neg\n for PE, ? PNA, slight decrease in the size of cardiac mass. put on\n BIPAP .tolerated well. transfered to for further monitoring and\n management.\n Pt is alert and oriented but has very little patience and is easily\n agitated, becoming SOB with activity. He is not comfortable in bed and\n has been OOB to chair most of the shift. Was in bed for cardiac echo,\n then back to chair. Ambulates with assist of one to chair.\n He denies complaints of chest pain or pressure but is ruling in for MI\n by enzymes with elevated triponin to 2.23 at noon today. He has been\n started on lopressor for rate control, heparin drip and aspirain. He\n was also started on simvastatin. Cardiac consult in place.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt with severe complaints of dyspnea and becomes tachypneic when in\n bed. Maintains O2 sat but becomes agitated and feels like he is trapped\n in a cage. Once in the chair he was calmer and less anxious with\n improved\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n Action:\n Response:\n Plan:\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2200-04-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 678861,
"text": "84 yo male pt with PMH ,Rt atrial tumour , lyphoma , recent\n chemotherapy ,PNA, presented to ER with SOB, N/V anxious, ?\n neutropenic. pt with worsening SOB, received vanco, zosyn ,solumedrol\n ,ativan and aspirin from ER, 2litres of fluid in. ? PE . CT done. neg\n for PE, ? PNA, slight decrease in the size of cardiac mass. put on\n BIPAP .tolerated well. transfered to for further monitoring and\n management.\n Pt is alert and oriented but has very little patience and is easily\n agitated, becoming SOB with activity. He is not comfortable in bed and\n has been OOB to chair most of the shift. Was in bed for cardiac echo,\n then back to chair. Ambulates with assist of one to chair. Family\n calling in frequently for updates. is spokesperson.\n He denies complaints of chest pain or pressure but is ruling in for MI\n by enzymes with elevated triponin to 2.23 at noon today. He has been\n started on lopressor for rate control, heparin drip and aspirin. He was\n also started on simvastatin. Cardiac consult in place.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt with severe complaints of dyspnea and becomes tachypneic when in\n bed. Maintains O2 sat but becomes agitated and feels like he is\n trapped in a cage.\n Once in the chair he was calmer and less anxious\n with improved Resp rate and agitation.\n Action:\n Weaned O2 from 100% down to 3L N/C with good O2 sat. RT sent specimens\n for viral antigens. Pt is positive for parainfluenza. He is on droplet\n precautions but team is not sure if we need them for this diagnosis.\n Response:\n Remains in the chair but still becomes anxious and restless at times\n and is on the call light frequently for small things.\n Plan:\n Provide support and reassurance for this pt who is easily agitated.\n Ordered for small doses morphine or ativan can be used PRN. Has an\n order for 1mg IV haldol on one time sheet which was never given yet.\n Altered mental status (not Delirium)\n Assessment:\n Pt with periods of agitation and anxiety refused to stay in bed,\n becoming acutely agitated, restless and tachypneic.\n Action:\n Given .5mg iV morphine, assisted to chair and pt reassured.\n Response:\n Improved agitation but continues to ask the same questions about his\n illness andhis care.\n Plan:\n Follow mental status, continue to provide emotional support. Use PRN\n morphine, ativan as needed.\n .H/O lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n Pt is currently undergoing chemo treatment for lymphoma\n Action:\n Heme/onc service consulted and will not give chemo while he is being\n treated for an acute MI\n Response:\n Will reassess need for chemo once pt is stable.\n Plan:\n Continue to follow-up with heme/onc for recommendations. Next set of\n enzymes due at 1800.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Pt ruled in for NSTEMI with positive triponins. No EKG changes were\n noted. Echo done at bedside today showed some new wall abnormalities\n but full report is yet to follow. He denies chest pain and pressure.\n Action:\n Pt given one aspirin tablet and was started on metoprolol 12.5mg then\n increased to 25mg PO. Pt also started on heparin drip at 11:45 at\n 750Units/hr. He was also started on simvastatin and remains on O2 3L.\n Stat echo and EKG was done. Pt given morphine for acute anxiety\n episode.\n Response:\n Vital signs remain stable with improved resp status in chair. Family\n have been updated and remain informed of plan of care. Pt started to\n have hematuria at 1600 and small pool of blood noted on pink pad under\n pt. Pt found to have some bleeding from around urethral meatus. Seen\n and noted by team.\n Plan:\n Follow labs, PTT Q6hrs to titrate heparin drip. Follow pt for further\n signs of bleeding.\n Assisted back to bed at 1800. Pt looks a little more distressed in bed\n but asked for some ativan to see if it could help him relax. Pt remains\n in bed at present.\n"
},
{
"category": "Physician ",
"chartdate": "2200-04-21 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 678862,
"text": "Chief Complaint: worsening shortness of breath over past 2-3 days, low\n grade fevers at home\n HPI:\n Mr. is an 84 yo man with a high-grade cardiac B-cell\n lymphoma for which he is now undergoing R- chemotherapy and a\n history of COPD, DVT s/p IVC filter, and pneumonia with\n respiratory failure requiring endotracheal intubation in . Today is\n Day 15 of Cycle 4 or R-, which he received during his hospital\n admission from . He received Neulasta on . following\n his discharge, he has been feeling generally well; however, he admits\n to increasing exertional dyspnea overthe past 2-3 days. He explains\n that very light activity, such as changing his clothes or walking short\n distances, has resulted in significant shortness of breath. He denies\n cough, sputum production, orthopnea, paroxysmal nocturnal dyspnea, and\n swelling/pain of the arms or legs. He admits to low-grade fevers today;\n while visiting, his daughter noted that he had a temperature of 100.4\n degrees. For this reason, he was advised to report to the Emergency\n Room for evaluation.\n Upon arrival in the Emergency Department, had temperature of 99.6\n degrees. He was tachycardic to 118 and tachypneic (RR 30-40) with\n oxygen saturations of 95% on room air. During the first several\n minutesof is Emergency Department course, he developed rapidly\n increasing work of breathing. A CXR demonstrated no evidence\n ofpneumonia or effusion; furthermore, an echocardiogram showed no\n pericardial effusion. He was noted to have a WBC of 8.8 with 26%\n neutrophils and 36% bands. Due to progressive respiratorydistress\n without hypoxia, he was started on BiPAP. In addition, he was given IV\n solumderol 125mg, ASA 325mg, bronchodilators, piperacillin-tazobactam,\n and vancomycin. Also received total of 1.25mg of ativan in ED.\n Despite a fairly normal blood gas and presumbaly secondary to worsening\n dyspnea and tachynpnea, pt was started on BIPAP which he tolerated\n during his transfer to the . On arrival, he insisted that it be\n removed and then resumed. He was agitated and extremely anxious\n repeating \"I need air,\" peripheral sats were in the 93-100% range on\n room air. Seemed to be more comfortable leaning forward and placing\n his weight on his upper ext's. His HR rose in propotion to his\n tachypnea and gitation to a rate of 140's transiently. Agitation/anxiey\n waxed and waned with pt sleeping intermittently.\n ONCOLOGIC HISTORY (Per recent note by Dr : \n initially presented on , with anewly identified 8\n cm right atrial soft tissue mass. He underwent biopsy of this on\n , and pathology showed high-grade aggressive diffuse large\n B-cell lymphoma, staining positive for CD20, bcl-2, and bcl-6 in a\n small subset. Cells were negative for cytokeratins, CD138, bcl-1, and\n bcl-6. MIB fraction was 95-100%. Bcl-2 co-expression and lack of CD10\n argued against Burkitt's lymphoma; however, FISH studies were positive\n for c-myc rearrangement. He was diagnosed with high-grade cardiac\n lymphoma on the spectrum of diffuse large B-cell to Burkitt's\n lymphoma. No other sites of disease were identified by torso CT and\n bone marrow biopsy. He has begun R- chemotherapy on .\n Treatment course has been complicated by a DVT status post IVC filter\n in and pneumonia requiring intubation for hypoxia in .\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Terazosin\n Mental status c\n Last dose of Antibiotics:\n Vancomycin - 03:31 AM\n Piperacillin/Tazobactam (Zosyn) - 03:31 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n 1. cardiac lymphoma as above\n 2. Left Peroneal DVT s/p IVC filter placement \n 3. COPD\n 4. Hyperlipidemia\n 5. Hypertension\n 6. History of anxiety\n 7. History of rib fracture\n 8. History of silent MI \n 9. Left Shoulder Weakness\n 10. External Hemorrhoids\n 11. Benign Prostatic Hypertrophy\n nc\n Occupation: retired\n Drugs:\n Tobacco: 60 pk yr hx, quit 6 years ago\n Alcohol:\n Other: currently in rehab, living independently up until recent\n admission\n Review of systems:\n Constitutional: Fever\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n Tachycardia, No(t) Orthopnea\n Respiratory: No(t) Cough, Dyspnea, Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Diarrhea\n Genitourinary: No(t) Dysuria\n Neurologic: No(t) Headache\n Flowsheet Data as of 06:28 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.9\nC (96.6\n Tcurrent: 35.9\nC (96.6\n HR: 121 (121 - 121) bpm\n BP: 128/77(89) {128/75(89) - 155/77(96)} mmHg\n RR: 32 (25 - 32) insp/min\n SpO2: 95%\n Total In:\n 2,300 mL\n PO:\n TF:\n IVF:\n 300 mL\n Blood products:\n Total out:\n 0 mL\n 800 mL\n Urine:\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,500 mL\n Respiratory\n O2 Delivery Device: Other\n SpO2: 95%\n Physical Examination\n General Appearance: Thin, Anxious\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), tachycardic\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: dull BS bilaterally with prolonged expiratory\n pahse and use of abdominal muscles during expiration\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis\n Musculoskeletal: Muscle wasting\n Skin: Not assessed, No(t) Rash:\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): , Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n [image002.jpg]\n Imaging: ADMISSION CXR: The right hemidiaphragm remains persistently\n elevated. The\n cardiomediastinal silhouette is stable. There is no focal pulmonary\n consolidation. An IVC filter is seen in the upper abdomen.\n CONCLUSION: No acute cardiopulmonary process.\n CTA (ADMISSION):PRELIM: No PE. New focal right basilar consolidation-?\n pneumonia though may represent\n aspiration with ariway secretions seen on right. Perhaps slight\n dcecrease in\n size of cardiac mass.\n Microbiology: Bcx x2 and Ucx NGTD\n ECG: sinus tachycadia, left axis deviation, low voltages diffusely, old\n inferior infarct, no stt changes from previous\n Assessment and Plan\n ASSESSMENT AND PLAN:\n 84 year-old M with high-grade cardiac lymphoma (left atrial mass),\n currently receiving treatment (cycle 4,day 15) with R- presents\n from home with low-grade fevers and progressive dyspnea; despite\n marked tachypnea and dyspnea, pt's images and blood gas look\n remarkably good suggesting a strong contribution from anxiety. That\n said, he has an atypical WBC diff and is s/p recent chemotherapy and\n thus in a relatively immunocompromised state demanding empiric broad\n coverage with Abx. Physical Exam is most suggestive of COPD\n exacerbation, but dyspnea is out of proportion to boreline (if any)\n hypoxia.\n # Dyspnea / Tachypnea: From what can be gathered of his ED course, it\n seems that it was similar to how he has been in the . Dyspnea is\n out of proportion to hypoxia. Have been thus far unable to repeat\n blood gas secondary to agitation, but peripheral sats in mid to high\n 90s even on room air. When he has used Bipap, settings hve been 17/5\n on room air--he intermittently prefers this to face mask. Bedside echo\n in the ED notable for absence of effusion/tamponade. LV function\n grossly intact. CXR without pulmonary edema. CTA ruled out PE and\n showed ONLY Opacity in RLL which may represent early bacterial PNA vs\n aspiration. Pt does have Hx of DVT, but IVC filter is in place and no\n exam finding to suggest current DVT. Overall, it seems that anxiety\n may be contributing strongly to this presentation--although does not\n seem to be on home anxiolytics other than low dose ativan for nausea.\n His positional preference and prolonged expiratory phase are suggestive\n of COPD exacerbation (FVC 50%, FEV1 40% Predicted), but again dyspnea\n out of proportion to hypoxia. Caridiac ischemia also a possibility as\n pt has reported hx of a silent inferior MI in , curently not on\n ASA, BB, statin.\n - add BNP to admission labs; may be elevated in setting of atrial mass,\n but if negative still useful to r/o failure\n - repeat CXR this am\n - formal ECHO by tech ordered\n - repeat blood gas when tolerats\n - Trend cardiac enzymes\n - albuterol/ipratropium nebs (holding home spiriva); continuing advair;\n will d/w BMT regarding +/- of systemic steroids in this lymphoma pt\n undergoing tx\n - NIPPV on RA vs 2L face-mask per pt preference; O2 sats adeqquate on\n either\n # Low-Grade Fevers / Bandemia: Bandemia present on , but not to\n the prounced degree that it is now. Pt's fevers at home were\n low-grade, was afebrile in ED and on floor. There is a concern for\n relative immunocompromise as he is currently receiving tx for lymphoma.\n Pt is s/p PNA requiring intubation during a recent hospitalization.\n Some concern for infectious process on admission CTA, but RLL findings\n not particulary striking. UA clean.\n - Blood cultures x2 pending, Urine Cx pending, Sputum ordered. Repaet\n Cx if spikes.\n - Nasal aspirate for respiratory viruses: (influenza,paraninfluenza,\n RSV)\n - D/w BMT whether atypical Diff is expected with pt's recent treatemnts\n or whether it is more concerning for infxn. Smear ordered.\n - Empiric therapy for HAP Vanco/Zosyn per BMT\n # Cardiac lymphoma: The patient appears to have had an excellent\n response to therapy to date, with a decline in his LDH and shrinkage of\n his cardiac mass on cardiac MRI. He will be due for his 5th cycle of\n next week, and his ability to receive his chemotherapy safelywill\n be determined by his recover from his present illness.\n - d/w BMT\n # Hx of CAD: Alleged silent MI in . Not in our records and pt\n currently unbale to discuss. EKG suggestive of prior infarct, but ECHO\n is not. Unusual that he is not on home ASA, BB, or statin.\n - will d/w pt and BMT\n # Hx of DVT: Per previous DC summary, pt has had a recent DVT in\n setting of ongoing malignancy and has IVC filter in place--by report\n has contraindication to systemic anticoagulation.\n - d/w BMT\n ICU Care\n Nutrition: npo currently\n Glycemic Control:\n Lines:\n 18 Gauge - 03:37 AM\n 20 Gauge - 03:37 AM\n Comments: code status confirmed by onc fellow in ED. deferred currently\n as acutely agitated/anxious. likewise deferred ICU consent until acute\n anxiety has resolved\n Prophylaxis:\n DVT: SQ UF Heparin, IVC filter\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n ------ Protected Section ------\n ADDENDUM TO PLAN:\n Assessment and plan initially changed this am as cardiac enzymes\n positive and ECHO showing significant new focal wall motion\n abnormaiilities. These findings are c/w either ACS (plaque rupture) vs\n very significant demand ischemia secondary to a poorly defined acute\n stressor (see above differential). Pt now on ASA, BB (with goal\n HR~60), Statin (declined lipitor given hx of muscle pains, given\n simvastatin 80). Heparin drip started w/o bolus. Per BMT, seems that\n only contraindication to anticoag (unclear this am) has been concern\n that this right atrial mass would bleed into pericardial space. Still\n believe that pt\ns resp status compromised by COPD given exam, but heart\n failure secondary to active ischemia likely also contributing.\n -- cardiology consulted, f/u recommendations\n -- remainder of plan largely as outlined above: treat COPD, cont broad\n Abx coverage\n ------ Protected Section Addendum Entered By: , MD\n on: 14:05 ------\n Critical Care\n Present for the key portions of the resident\ns history and exam. Agree\n substantially with assessment and plan that was elaborated on\n multidisciplinary rounds this morning. He has been agitated, unable to\n get comfortable. Tolerating O2 but not able to use mask vent.\n Describes breathlessness as different from prior episodes of\n bronchitis.\n 121 128/77 26\n Chest is quiet with insp and exp wheezing\n HS distant w/ holosyst m\n Tr edema\n Troponin 0.26\n Echo apical dyskinesis EF 35% down from 55% with 2+ MR from 1+ MR\n Very difficult presentation. He has had a substantial worsening of\n cardiac fxn w/o clear ECG changes and echo read sounds c/w takasubo\n He has paraflu on nasal wash which seems consistent with his\n presentation. We are supporting oxygen, trying to manage his\n agitation, starting beta blockade given rapid HR and poor syst fxn. He\n does not seem to be in signif CHF on exam or CXR. We are monitoring\n closely\n is at signif risk for resp decomp. Not clear how to explain\n rising LD and nl but still LFTs.\n Time spent 65 min\n Critically ill\n ------ Protected Section Addendum Entered By: , MD\n on: 18:36 ------\n"
},
{
"category": "Nursing",
"chartdate": "2200-04-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 678914,
"text": "84 yo male pt with PMH ,Rt atrial tumour , lyphoma , recent\n chemotherapy ,PNA, presented to ER with SOB, N/V anxious, pt with\n worsening SOB, received vanco, zosyn ,solumedrol ,ativan and aspirin\n from ER, 2litres of fluid in. CT done. neg for PE, ? PNA, slight\n decrease in the size of cardiac mass. put on BIPAP .tolerated well.\n transfered to for further monitoring and management. He denies\n complaints of chest pain or pressure but is ruling in for MI by enzymes\n with elevated triponin to 2.23 yesterday. He has been started on\n lopressor for rate control, heparin drip aspirin and simvastatin.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n r/o MI from Elevated cardiac enzymes from yesterday.\n Action:\n Pt on heparin gtt and po aspirin. Lopressor for rate control. PTT q6hr.\n cardiac echo done yesterday. Cardiology consult.\n Response:\n f/u with cardiology, continue heparin per protocol. PTT q 6hrs. last\n 2two consecutive PTT\ns 66.5 and 61, both within therapeutic level.\n Plan:\n Continue with heparin per protocol. need PTT daily now.\n Altered mental status (not Delirium)\n Assessment:\n Pt alert oriented x 3, calm and quiet most of the time, but get\n restless and anxious very quickly. Slept during the night. Pt states\n he can\nt breath while he is anxious.\n Action:\n Ativan 0.5mg po/iv PRN. Stayed on bed during the night. On NC O2\n 3lit/min. LS Diminished. Neb treatments /MDI as ordered.\n Response:\n Good effect with ativan. Sats > 96% .slept well .pt feels better .\n Plan:\n Continue with ativan /morphine PRN. Monitor mental status.\n Foley to gravity, urine clear,pink in colout.? Traumatic vs due to\n heparin gtt.\n Skin intact except bruises on both hands.\n"
},
{
"category": "Nursing",
"chartdate": "2200-04-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 678984,
"text": "84 year-old M with high-grade cardiac lymphoma (left atrial mass),\n currently receiving treatment (cycle 4,day 15) with R- presents\n from home with low-grade fevers and progressive dyspnea; despite\n marked tachypnea and dyspnea, pt's images and blood gas look\n remarkably good suggesting a strong contribution from anxiety.\n"
},
{
"category": "Nursing",
"chartdate": "2200-04-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 678662,
"text": "84 yo male pt with PMH ,Rt atrial tumour , lyphoma , recent\n chemotherapy ,PNA, presented to ER with SOB, N/V anxious, ?\n neutropenic. pt with worsening SOB, received vanco, zosyn ,solumedrol\n ,ativan and aspirin from ER, 2litres of fluid in. ? PE . CT done. neg\n for PE, ? PNA, slight decrease in the size of cardiac mass. put on\n BIPAP .tolerated well. transfered to for further monitoring and\n management.\n Neuro: alert and oriented , restless initially . following commands.\n Denies any pain.received ativan from ER. Slept after sometime.\n CVS: HR ,with occasional PVC\ns. BP stable.\n"
},
{
"category": "Physician ",
"chartdate": "2200-04-21 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 678786,
"text": "Chief Complaint: worsening shortness of breath over past 2-3 days, low\n grade fevers at home\n HPI:\n Mr. is an 84 yo man with a high-grade cardiac B-cell\n lymphoma for which he is now undergoing R- chemotherapy and a\n history of COPD, DVT s/p IVC filter, and pneumonia with\n respiratory failure requiring endotracheal intubation in . Today is\n Day 15 of Cycle 4 or R-, which he received during his hospital\n admission from . He received Neulasta on . following\n his discharge, he has been feeling generally well; however, he admits\n to increasing exertional dyspnea overthe past 2-3 days. He explains\n that very light activity, such as changing his clothes or walking short\n distances, has resulted in significant shortness of breath. He denies\n cough, sputum production, orthopnea, paroxysmal nocturnal dyspnea, and\n swelling/pain of the arms or legs. He admits to low-grade fevers today;\n while visiting, his daughter noted that he had a temperature of 100.4\n degrees. For this reason, he was advised to report to the Emergency\n Room for evaluation.\n Upon arrival in the Emergency Department, had temperature of 99.6\n degrees. He was tachycardic to 118 and tachypneic (RR 30-40) with\n oxygen saturations of 95% on room air. During the first several\n minutesof is Emergency Department course, he developed rapidly\n increasing work of breathing. A CXR demonstrated no evidence\n ofpneumonia or effusion; furthermore, an echocardiogram showed no\n pericardial effusion. He was noted to have a WBC of 8.8 with 26%\n neutrophils and 36% bands. Due to progressive respiratorydistress\n without hypoxia, he was started on BiPAP. In addition, he was given IV\n solumderol 125mg, ASA 325mg, bronchodilators, piperacillin-tazobactam,\n and vancomycin. Also received total of 1.25mg of ativan in ED.\n Despite a fairly normal blood gas and presumbaly secondary to worsening\n dyspnea and tachynpnea, pt was started on BIPAP which he tolerated\n during his transfer to the . On arrival, he insisted that it be\n removed and then resumed. He was agitated and extremely anxious\n repeating \"I need air,\" peripheral sats were in the 93-100% range on\n room air. Seemed to be more comfortable leaning forward and placing\n his weight on his upper ext's. His HR rose in propotion to his\n tachypnea and gitation to a rate of 140's transiently. Agitation/anxiey\n waxed and waned with pt sleeping intermittently.\n ONCOLOGIC HISTORY (Per recent note by Dr : \n initially presented on , with anewly identified 8\n cm right atrial soft tissue mass. He underwent biopsy of this on\n , and pathology showed high-grade aggressive diffuse large\n B-cell lymphoma, staining positive for CD20, bcl-2, and bcl-6 in a\n small subset. Cells were negative for cytokeratins, CD138, bcl-1, and\n bcl-6. MIB fraction was 95-100%. Bcl-2 co-expression and lack of CD10\n argued against Burkitt's lymphoma; however, FISH studies were positive\n for c-myc rearrangement. He was diagnosed with high-grade cardiac\n lymphoma on the spectrum of diffuse large B-cell to Burkitt's\n lymphoma. No other sites of disease were identified by torso CT and\n bone marrow biopsy. He has begun R- chemotherapy on .\n Treatment course has been complicated by a DVT status post IVC filter\n in and pneumonia requiring intubation for hypoxia in .\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Terazosin\n Mental status c\n Last dose of Antibiotics:\n Vancomycin - 03:31 AM\n Piperacillin/Tazobactam (Zosyn) - 03:31 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n 1. cardiac lymphoma as above\n 2. Left Peroneal DVT s/p IVC filter placement \n 3. COPD\n 4. Hyperlipidemia\n 5. Hypertension\n 6. History of anxiety\n 7. History of rib fracture\n 8. History of silent MI \n 9. Left Shoulder Weakness\n 10. External Hemorrhoids\n 11. Benign Prostatic Hypertrophy\n nc\n Occupation: retired\n Drugs:\n Tobacco: 60 pk yr hx, quit 6 years ago\n Alcohol:\n Other: currently in rehab, living independently up until recent\n admission\n Review of systems:\n Constitutional: Fever\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n Tachycardia, No(t) Orthopnea\n Respiratory: No(t) Cough, Dyspnea, Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Diarrhea\n Genitourinary: No(t) Dysuria\n Neurologic: No(t) Headache\n Flowsheet Data as of 06:28 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.9\nC (96.6\n Tcurrent: 35.9\nC (96.6\n HR: 121 (121 - 121) bpm\n BP: 128/77(89) {128/75(89) - 155/77(96)} mmHg\n RR: 32 (25 - 32) insp/min\n SpO2: 95%\n Total In:\n 2,300 mL\n PO:\n TF:\n IVF:\n 300 mL\n Blood products:\n Total out:\n 0 mL\n 800 mL\n Urine:\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,500 mL\n Respiratory\n O2 Delivery Device: Other\n SpO2: 95%\n Physical Examination\n General Appearance: Thin, Anxious\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), tachycardic\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: dull BS bilaterally with prolonged expiratory\n pahse and use of abdominal muscles during expiration\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis\n Musculoskeletal: Muscle wasting\n Skin: Not assessed, No(t) Rash:\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): , Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n [image002.jpg]\n Imaging: ADMISSION CXR: The right hemidiaphragm remains persistently\n elevated. The\n cardiomediastinal silhouette is stable. There is no focal pulmonary\n consolidation. An IVC filter is seen in the upper abdomen.\n CONCLUSION: No acute cardiopulmonary process.\n CTA (ADMISSION):PRELIM: No PE. New focal right basilar consolidation-?\n pneumonia though may represent\n aspiration with ariway secretions seen on right. Perhaps slight\n dcecrease in\n size of cardiac mass.\n Microbiology: Bcx x2 and Ucx NGTD\n ECG: sinus tachycadia, left axis deviation, low voltages diffusely, old\n inferior infarct, no stt changes from previous\n Assessment and Plan\n ASSESSMENT AND PLAN:\n 84 year-old M with high-grade cardiac lymphoma (left atrial mass),\n currently receiving treatment (cycle 4,day 15) with R- presents\n from home with low-grade fevers and progressive dyspnea; despite\n marked tachypnea and dyspnea, pt's images and blood gas look\n remarkably good suggesting a strong contribution from anxiety. That\n said, he has an atypical WBC diff and is s/p recent chemotherapy and\n thus in a relatively immunocompromised state demanding empiric broad\n coverage with Abx. Physical Exam is most suggestive of COPD\n exacerbation, but dyspnea is out of proportion to boreline (if any)\n hypoxia.\n # Dyspnea / Tachypnea: From what can be gathered of his ED course, it\n seems that it was similar to how he has been in the . Dyspnea is\n out of proportion to hypoxia. Have been thus far unable to repeat\n blood gas secondary to agitation, but peripheral sats in mid to high\n 90s even on room air. When he has used Bipap, settings hve been 17/5\n on room air--he intermittently prefers this to face mask. Bedside echo\n in the ED notable for absence of effusion/tamponade. LV function\n grossly intact. CXR without pulmonary edema. CTA ruled out PE and\n showed ONLY Opacity in RLL which may represent early bacterial PNA vs\n aspiration. Pt does have Hx of DVT, but IVC filter is in place and no\n exam finding to suggest current DVT. Overall, it seems that anxiety\n may be contributing strongly to this presentation--although does not\n seem to be on home anxiolytics other than low dose ativan for nausea.\n His positional preference and prolonged expiratory phase are suggestive\n of COPD exacerbation (FVC 50%, FEV1 40% Predicted), but again dyspnea\n out of proportion to hypoxia. Caridiac ischemia also a possibility as\n pt has reported hx of a silent inferior MI in , curently not on\n ASA, BB, statin.\n - add BNP to admission labs; may be elevated in setting of atrial mass,\n but if negative still useful to r/o failure\n - repeat CXR this am\n - formal ECHO by tech ordered\n - repeat blood gas when tolerats\n - Trend cardiac enzymes\n - albuterol/ipratropium nebs (holding home spiriva); continuing advair;\n will d/w BMT regarding +/- of systemic steroids in this lymphoma pt\n undergoing tx\n - NIPPV on RA vs 2L face-mask per pt preference; O2 sats adeqquate on\n either\n # Low-Grade Fevers / Bandemia: Bandemia present on , but not to\n the prounced degree that it is now. Pt's fevers at home were\n low-grade, was afebrile in ED and on floor. There is a concern for\n relative immunocompromise as he is currently receiving tx for lymphoma.\n Pt is s/p PNA requiring intubation during a recent hospitalization.\n Some concern for infectious process on admission CTA, but RLL findings\n not particulary striking. UA clean.\n - Blood cultures x2 pending, Urine Cx pending, Sputum ordered. Repaet\n Cx if spikes.\n - Nasal aspirate for respiratory viruses: (influenza,paraninfluenza,\n RSV)\n - D/w BMT whether atypical Diff is expected with pt's recent treatemnts\n or whether it is more concerning for infxn. Smear ordered.\n - Empiric therapy for HAP Vanco/Zosyn per BMT\n # Cardiac lymphoma: The patient appears to have had an excellent\n response to therapy to date, with a decline in his LDH and shrinkage of\n his cardiac mass on cardiac MRI. He will be due for his 5th cycle of\n next week, and his ability to receive his chemotherapy safelywill\n be determined by his recover from his present illness.\n - d/w BMT\n # Hx of CAD: Alleged silent MI in . Not in our records and pt\n currently unbale to discuss. EKG suggestive of prior infarct, but ECHO\n is not. Unusual that he is not on home ASA, BB, or statin.\n - will d/w pt and BMT\n # Hx of DVT: Per previous DC summary, pt has had a recent DVT in\n setting of ongoing malignancy and has IVC filter in place--by report\n has contraindication to systemic anticoagulation.\n - d/w BMT\n ICU Care\n Nutrition: npo currently\n Glycemic Control:\n Lines:\n 18 Gauge - 03:37 AM\n 20 Gauge - 03:37 AM\n Comments: code status confirmed by onc fellow in ED. deferred currently\n as acutely agitated/anxious. likewise deferred ICU consent until acute\n anxiety has resolved\n Prophylaxis:\n DVT: SQ UF Heparin, IVC filter\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n ------ Protected Section ------\n ADDENDUM TO PLAN:\n Assessment and plan initially changed this am as cardiac enzymes\n positive and ECHO showing significant new focal wall motion\n abnormaiilities. These findings are c/w either ACS (plaque rupture) vs\n very significant demand ischemia secondary to a poorly defined acute\n stressor (see above differential). Pt now on ASA, BB (with goal\n HR~60), Statin (declined lipitor given hx of muscle pains, given\n simvastatin 80). Heparin drip started w/o bolus. Per BMT, seems that\n only contraindication to anticoag (unclear this am) has been concern\n that this right atrial mass would bleed into pericardial space. Still\n believe that pt\ns resp status compromised by COPD given exam, but heart\n failure secondary to active ischemia likely also contributing.\n -- cardiology consulted, f/u recommendations\n -- remainder of plan largely as outlined above: treat COPD, cont broad\n Abx coverage\n ------ Protected Section Addendum Entered By: , MD\n on: 14:05 ------\n"
},
{
"category": "Social Work",
"chartdate": "2200-04-21 00:00:00.000",
"description": "Social Work Admission Note",
"row_id": 678764,
"text": "Family Information\n Next of :\n Health Care Proxy appointed:\n Family Spokesperson designated:\n Communication or visitation restriction:\n Patient Information:\n Previous living situation:\n Previous level of functioning: Required assistance with care\n Previous or other hospital admissions:\n Past psychiatric history: anxiety\n Past addictions history:\n Employment status: Retired\n Legal involvement:\n Mandated Reporting Information:\n Additional Information:\n Patient / Family Assessment:\n Clergy Contact:\n Communication with Team:\n Plan / Follow up:\n Pt is a pleasant 84 yo widowed male who lives alone in . His\n wife died from breast cancer when his children were young and he raised\n them as a single working father. His adult children are very devoted to\n him. Since initial diagnosis of Lymphoma pt has been in the hospital or\n rehab until his last hospitalization when pt returned home. He was very\n nervous about being home, but was quite happy to be there. He tells me\n he had RN, PT and home health aide. His children visited daily and\n provided meals.\n I will follow for emotional support and am available for questions or\n concerns.\n , LICSW\n X73442/ #\n"
},
{
"category": "Nursing",
"chartdate": "2200-04-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 678782,
"text": "84 yo male pt with PMH ,Rt atrial tumour , lyphoma , recent\n chemotherapy ,PNA, presented to ER with SOB, N/V anxious, ?\n neutropenic. pt with worsening SOB, received vanco, zosyn ,solumedrol\n ,ativan and aspirin from ER, 2litres of fluid in. ? PE . CT done. neg\n for PE, ? PNA, slight decrease in the size of cardiac mass. put on\n BIPAP .tolerated well. transfered to for further monitoring and\n management.\n Pt is alert and oriented but has very little patience and is easily\n agitated, becoming SOB with activity. He is not comfortable in bed and\n has been OOB to chair most of the shift. Was in bed for cardiac echo,\n then back to chair. Ambulates with assist of one to chair.\n He denies complaints of chest pain or pressure but is ruling in for MI\n by enzymes with elevated triponin to 2.23 at noon today. He has been\n started on lopressor for rate control, heparin drip and aspirain. He\n was also started on simvastatin. Cardiac consult in place.\n"
},
{
"category": "Nursing",
"chartdate": "2200-04-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 679000,
"text": "84 year-old M with high-grade cardiac lymphoma (left atrial mass),\n currently receiving treatment (cycle 4,day 15) with R- presents\n from home with low-grade fevers and progressive dyspnea; despite\n marked tachypnea and dyspnea, pt's images and blood gas look\n remarkably good suggesting a strong contribution from anxiety.\n .H/O lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n Pt is currently undergoing chemo treatment for lymphoma\n Action:\n Heme/onc service consulted and will not give chemo while he is being\n treated for an acute MI\n Response:\n Will reassess need for chemo once pt is stable.\n Plan:\n Continue to follow-up with heme/onc for recommendations. Next set of\n enzymes due at 1800.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Pt ruled in for NSTEMI with positive triponins. No EKG changes were\n noted. Echo done at bedside showed some new wall abnormalities but\n full report is yet to follow. He denies chest pain and pressure. On\n Heparin gtt this morning with positive hematuria.\n Action:\n Aspirin and on metoprolol 25mg PO. He was also started on simvastatin\n and remains on O2.\n Response:\n Vital signs remain stable. Heparin d/c\ned due to hematuria.\n Plan:\n Cont. to monitor followed by cardiology.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n FEVER\n Code status:\n Full code\n Height:\n Admission weight:\n 60 kg\n Daily weight:\n Allergies/Reactions:\n Terazosin\n Mental status c\n Precautions: Contact\n PMH:\n CV-PMH:\n Additional history: Lymphoma, L atrial tumour ,recent chemotherapy ,\n PNA. s/p IVC filter .\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:114\n D:64\n Temperature:\n 97.6\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 26 insp/min\n Heart Rate:\n 107 bpm\n Heart rhythm:\n ST (Sinus Tachycardia)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 99% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 793 mL\n 24h total out:\n 905 mL\n Pertinent Lab Results:\n Sodium:\n 140 mEq/L\n 05:46 AM\n Potassium:\n 3.4 mEq/L\n 05:46 AM\n Chloride:\n 104 mEq/L\n 05:46 AM\n CO2:\n 27 mEq/L\n 05:46 AM\n BUN:\n 11 mg/dL\n 05:46 AM\n Creatinine:\n 0.7 mg/dL\n 05:46 AM\n Glucose:\n 100 mg/dL\n 05:46 AM\n Hematocrit:\n 24.1 %\n 05:46 AM\n Additional pertinent labs:\n Lines / Tubes / Drains:\n 2 PIVs\n Valuables / Signature\n Patient valuables: Glasses\n Other valuables:\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: 412\n Transferred to: 1281\n Date & time of Transfer: 12:00 AM\n"
},
{
"category": "Echo",
"chartdate": "2200-04-23 00:00:00.000",
"description": "Report",
"row_id": 102037,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 68\nWeight (lb): 144\nBSA (m2): 1.78 m2\nBP (mm Hg): 155/70\nHR (bpm): 93\nStatus: Inpatient\nDate/Time: at 12:30\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal interatrial septum.\nNo ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Suboptimal\ntechnical quality, a focal LV wall motion abnormality cannot be fully\nexcluded. Low normal LVEF. No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal aortic arch diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Mild thickening of mitral valve chordae. No MS. Mild to\nmoderate (+) MR.\n\nTRICUSPID VALVE: Tricuspid valve not well visualized. Indeterminate PA\nsystolic pressure.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nThe left atrium is elongated. No atrial septal defect is seen by 2D or color\nDoppler. There is mild symmetric left ventricular hypertrophy. The left\nventricular cavity size is normal. Due to suboptimal technical quality, a\nfocal wall motion abnormality cannot be fully excluded. Overall left\nventricular systolic function is probably normal (LVEF 50-55%). There is no\nventricular septal defect. Right ventricular chamber size and free wall motion\nare normal. The aortic valve leaflets (3) are mildly thickened but aortic\nstenosis is not present. No aortic regurgitation is seen. The mitral valve\nleaflets are mildly thickened. There is no mitral valve prolapse. Mild to\nmoderate (+) mitral regurgitation is seen. The pulmonary artery systolic\npressure could not be determined. There is no pericardial effusion.\n\nCompared with the prior study (images reviewed) of , the LVEF has\nprobably improved (suboptimal image quality and distal LV/apex porrly seen on\ncurrent study). If clinically indicated, a repeat study with echo contrast\n(dDefinity) may help evaluate regional and global LV systolic function.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2200-04-21 00:00:00.000",
"description": "Report",
"row_id": 102038,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function/wall motion abnormalities. Pericardial effusion.\nHeight: (in) 68\nWeight (lb): 139\nBSA (m2): 1.75 m2\nBP (mm Hg): 124/79\nHR (bpm): 100\nStatus: Inpatient\nDate/Time: at 13:20\nTest: Portable TTE (Complete)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT VENTRICLE: Moderately depressed LVEF.\n\nRIGHT VENTRICLE: RV function depressed.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate (2+) MR.\n\nTRICUSPID VALVE: Moderate [2+] TR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nOverall left ventricular systolic function is moderately depressed (LVEF=\n30-35 %) with akinesis of the distal LV/apex. RV with depressed free wall\ncontractility. The mitral valve leaflets are mildly thickened. Moderate (2+)\nmitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen.\nThere is no pericardial effusion.\n\nCompared with the prior study (images reviewed) of , biventrricular\nsystolic function is now depressed with regionality. The degree of MR \nhave increased.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2200-04-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1081500,
"text": " 5:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: worsening effusions\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old man with high grade lymphoma, pleural effusions\n REASON FOR THIS EXAMINATION:\n worsening effusions\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 84-year-old man with high-grade lymphoma, pleural effusions.\n\n COMPARISON: , .\n\n SINGLE PORTABLE SUPINE CHEST RADIOGRAPH: Positioning limits evaluation of the\n apices. There is persistent elevation of the right hemidiaphragm. There is\n again bibasilar atelectasis but no effusion. Within the limitations of the\n film there is no pneumothorax. The cardiomediastinal silhouette is unchanged.\n The aorta is calcified.\n\n IMPRESSION: No pleural effusion. Bibasilar atelectasis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2200-04-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1081277,
"text": " 8:43 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old man with hx of lymphoma, pneumonia. Low grade fever today and\n increased fatigue.\n REASON FOR THIS EXAMINATION:\n r/o infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 84-year-old male with history of lymphoma, pneumonia and low-grade\n fever, to assess for a cardiopulmonary process.\n\n TECHNIQUE: Single portable AP radiograph of the chest was performed.\n Comparison is made with prior radiograph of .\n\n FINDINGS: The right hemidiaphragm remains persistently elevated. The\n cardiomediastinal silhouette is stable. There is no focal pulmonary\n consolidation. An IVC filter is seen in the upper abdomen.\n\n CONCLUSION: No acute cardiopulmonary process.\n\n"
},
{
"category": "Radiology",
"chartdate": "2200-04-20 00:00:00.000",
"description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY",
"row_id": 1081284,
"text": " 11:13 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: DYSPNEA\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old man with acute onset dyspnea, maintaining good O2 sats but w/ air\n hunger. on BiPap. history of cardiac lymphoma. has IVC filter\n REASON FOR THIS EXAMINATION:\n concern for PE, early pneumonia\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ARHb MON 12:35 AM\n No PE. New focal right basilar consolidation-? pneumonia though may represent\n aspiration with ariway secretions seen on right. Perhaps slight dcecrease in\n size of cardiac mass.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 84-year-old male with acute onset of dyspnea with history of\n cardiac lymphoma.\n\n COMPARISON: CT chest .\n\n TECHNIQUE: Non-contrast and contrast-enhanced axial images of the chest are\n obtained with multiplanar reformatted images.\n\n CTA CHEST: Although respiratory motion of the lower lobes limits evaluation\n of subsegmental vessels, there is no evidence for central main lobar or\n segmental pulmonary emboli. Additionally, there are no secondary signs of\n emboli including no evidence of right-sided heart strain. Atherosclerotic\n calcifications involve the thoracic aorta and its branches, though the\n thoracic aorta is of normal caliber. Several partially calcified mediastinal\n and left hilar lymph nodes represent prior granulomatous exposure. There is\n no pericardial or pleural effusion. The known soft tissue mass with epicenter\n at the level of the right atrium measures approximately 4.4 x 1.8 cm (3:72)\n compared to 4.3 x 2.4 cm on . Narrowing of the superior vena cava\n by this mass is unchanged.\n\n A new small focal consolidation is noted at the right lung base medially. The\n left lung remains clear. A 4-mm right lower lobe lung nodule (3:65) is not\n significantly changed. A small amount of secretions are noted in the right\n mainstem bronchus. Otherwise, the airways appear patent to the subsegmental\n level.\n\n Although this exam is not tailored to evaluate subdiaphragmatic structures,\n limited evaluation of the upper abdomen reveals multiple stones within the\n kidney. A left upper pole renal cyst is partially imaged, with a smaller\n cysts noted in the right interpolar region. 1.8 cm right adrenal mass is\n unchanged in size.\n\n Bone windows again reveal high-grade compression deformity in the mid thoracic\n spine, unchanged. Old healed left posterolateral fracture deformity of the\n tenth rib is unchanged.\n (Over)\n\n 11:13 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: DYSPNEA\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n IMPRESSION:\n 1. No pulmonary embolism.\n 2. New small consolidation at right lung base may represent pneumonic\n consolidation or, in the setting of airway secretions, aspiration.\n 3. Perhaps slight decrease in size of cardiac mass compared to CT from , with persistent mass effect on superior vena cava.\n 4. No change in size of right adrenal mass and right lower lobe lung nodule.\n\n"
},
{
"category": "Radiology",
"chartdate": "2200-04-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1081300,
"text": " 4:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: now more tachypneic, interval change?, any sign of plum vasc\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old man with cardiac (atrial) lymphoma presents with 2-3 days of\n worsening SOB\n REASON FOR THIS EXAMINATION:\n now more tachypneic, interval change?, any sign of plum vasc congestion?\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 6:22 \n\n HISTORY: Cardiac lymphoma. Worsening shortness of breath.\n\n IMPRESSION: AP chest compared to :\n\n Mild vascular congestion has developed in the right lung base. Lungs are\n otherwise clear. Heart size is normal. Elevation of right hemidiaphragm\n unchanged since at least .\n\n"
},
{
"category": "ECG",
"chartdate": "2200-04-21 00:00:00.000",
"description": "Report",
"row_id": 296684,
"text": "Sinus tachycardia\nLow limb lead QRS voltages\nLeft axis deviation may be due to left anterior fascicular block\nModest T wave changes\nDelayed R wave progression with late precordial QRS transition\nThese findings are nonspecific but clinical correlation is suggested\nSince previous tracing of the same date, further T waves changes present\n\n"
},
{
"category": "ECG",
"chartdate": "2200-04-21 00:00:00.000",
"description": "Report",
"row_id": 296685,
"text": "Sinus tachycardia\nLow limb lead QRS voltages\nLeft axis deviation may be due to left anterior fascicular block\nModest T wave changes\nDelayed R wave progression with late precordial QRS transition\nThese findings are nonspecific but clinical correlation is suggested\n\n"
}
] |
11,638 | 155,878 | 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial fibrillation, CKD, with past history of DVT and PE on Coumadin who was recently discharged from the CCU () for CHF exacerbation c/b C.diff infection and on for septic joint washout c/b failure to extubate CHF exacerbation, who was admitted from clinic with total body fluid overload. . # Acute on Chronic Systolic Heart Failure: Patient has endstage systolic heart failure ischemic , 10%, s/p BiV ICD ( Concerto C154DWK) with EF 10%, presenting with significant fluid overload. She was diuresed 9L of fluid during her stay in the CCU with symptomatic improvement. Her blood pressure and forward cardiac flow were maintained initially with neosynephrine, then with a milrinone drip for two days. After a trial of stopping the milrinone drip, systolic blood pressures dropped from 90s to 70s, so milrinone was restarted for one more day. Milrinone was again stopped after the primary goal of care became comfort measures only. Patient had been made aware of her endstage condition by her primary cardiologist, Dr. , during past hospitalizations; on presentation at this admission, her long term goals were comfort. Her ICD was turned off during her stay in the CCU. The primary CCU team and Dr. held a family meeting, at which the goals of care were made clear to be comfort measures only. Palliative Care was also consulted to help with the transition to comfort measures. After milrinone was discontinued the second time, patient's blood pressures were maintained in the 90s systolic. The patient should not be hospitalized further for congestive heart failure. Her anticoagulation was stopped, and she will remain on po antibiotics for her septic joints to prevent pain associated with worsening infection which would cause further pain. Her pain medications may be uptitrated as necessary. She is maintained currently on 20mg torsemide once daily. If she develops shortness of breath, she may be given morphine for comfort. . # Septic Joints: Patient with history +staph aureus in left shoulder treated by washout and vancomycin, 4 weeks of monotherapy by the time of this admission. She has had no positive blood cultures since before . Her pain was controled on ultram, standing tylenol, and long-acting morphine. On , the vancomycin course finished, and she was switched to oral doxycycline for indefinite prophylaxis. . # Sacral Decubitus Ulcer: Patient has unstageable decubitus ulcer, which she had prior to admission. Her pain is being controlled with standing ultram, standing tylenol, MS Contin, and immediate release morphine. Her pain worsens significantly when moved. These pain medications may be uptitrated as necessary. . # Hx of CAD: Patient has right dominant system, hx of mild instent re-stenois of the LAD BM stent and occluded RCA. Patient's blood pressures could not tolerate beta blocker, and beta blocker was discontinued after she was made comfort measures only. . # Hx Atrial Fibrillation: Patient with h/o atrial fibrillation, s/p BiV ICD ( Concerto C154DWK) , on coumadin. Her amiodarone and metoprolol have been stopped, but she has been continued on her digoxin. Her coumadin has been stopped as well so that she will not have to get frequent blood draws to follow INR. . # Hx of DVT/PE: Patient has hx of DVT/PE and was on coumadin with filter in place. Her coumadin was stopped after she was made comfort measures only in order to prevent frequent INR draws. . # Hypothyroidism: Levothyroxine was discontinued after patient was made comfort measures only. . # Gout: Allopurinol was discontinued after patient was made comfort measures only. . # ACCESS: Patient had Right midline, Right IJ central line, and Left EJ during this hospitalization, which were removed prior to discharge. . # PROPHYLAXIS: on coumadin . # CODE: DNR/DNI, made Comfort Measures Only GOALS OF CARE: Patient should not be hospitalized further for heart failure. Her pain should be kept under control by uptitrating the morphine as needed. She is now on comfort measures. She will continue on the medications as listed. Medications on Admission: #. Aspirin 81 mg Tablet daily #. Allopurinol 100 mg daily #. Amiodarone 200 mg daily #. Levothyroxine 150 mcg daily #. Digoxin 62.5 mcg qOD #. Simvastatin 20 mg daily #. Nexium 40 mg daily #. Metoprolol SR 25 daily #. Warfarin 2 mg daily #. Torsemide 20 mg #. Lasix 20mg daily #. Tylenol 975 mg q8 #. Ultram 50 mg QID # Vancomycin 500 mg q24 # MVI w/Minerals # Zinc 200mg Daily # Vitamin C 500 mg Discharge Medications: 1. Morphine 10 mg/5 mL Solution Sig: Five (5) mg PO every 2 hours as needed for mild pain. 2. Morphine 10 mg/5 mL Solution Sig: Ten (10) mg PO every 2 hours as needed for moderate pain. 3. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO every eight (8) hours. 4. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical (2 times a day) as needed for dry skin. 5. Morphine Concentrate 20 mg/mL Solution Sig: 5-20 mg PO q 2 hours as needed for severe pain or respiratory distress: For terminal care, may give sublingual if needed. 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 7. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) as needed for fever or pain. 8. Digoxin 125 mcg Tablet Sig: 0.5 Tablet PO EVERY OTHER DAY (Every Other Day). 9. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours) as needed for itching. 10. Torsemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours): to be given indefinitely. Discharge Disposition: Extended Care Facility: House Nursing & Rehabilitation Center - Discharge Diagnosis: Primary Diagnosis: Acute on Chronic Systolic Heart Failure Secondary Diagnoses: Septic Arthritis Sacral Decubitus Ulcer Urinary Tract Infection Discharge Condition: Stable. Alert and oriented x3 Activity Status:Out of Bed with assistance to chair or wheelchair Level of Consciousness:Alert and interactive Mental Status:Clear and coherent Discharge Instructions: Dear Ms. , You were admitted to the hospital because you were fluid overloaded, having an exacerbation of your heart failure. You were given medicines to urinate out a significant amount of fluid which helped your breathing. You were also given more pain medications to help control the pain in your joints and from your pressure ulcer. You were found to have a urinary tract infection, for which you were also treated with antibiotics. After discussion with Dr. , and our Palliative care team, you have chosen to be treated with comfort measures only. You will continue on your torsemide and digoxin to help your heart work better but most of your other scheduled medicines have been discontinued. You will get morphine as needed for pain and trouble breathing and it was decided that you would not return to for aggressive treatment of your heart disease. The following changes were made to your medications: 1. We have discontinued Allopurinol, amiodarone, aspirin, levothyroxine, Lisinopril, Metoprolol, omeprazole, simvastatin, tramadol and warfarin. 2. Vancomycin course was finished, you were started on doxycycline pills to prevent the MRSA from coming back. 3. We changed the oxycodone to morphine long and short acting. . Pt is DNR/DNI as per attending Dr. Followup Instructions: none | # CORONARIES: Patient with h/o CAD w/ right dominant system, mild instent re-stenois of the LAD BM stent and occluded RCA. # CORONARIES: Patient with h/o CAD w/ right dominant system, mild instent re-stenois of the LAD BM stent and occluded RCA. # CORONARIES: Patient with h/o CAD w/ right dominant system, mild instent re-stenois of the LAD BM stent and occluded RCA. # CORONARIES: Patient with h/o CAD w/ right dominant system, mild instent re-stenois of the LAD BM stent and occluded RCA. 71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention, Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on coumadin, hypothyroidism, CKD, OA. 71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention, Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on coumadin, hypothyroidism, CKD, OA. 71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention, Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on coumadin, hypothyroidism, CKD, OA. 71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention, Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on coumadin, hypothyroidism, CKD, OA. # Hx CAD: Patient with h/o CAD w/ right dominant system, mild instent re-stenois of the LAD BM stent and occluded RCA. # PROPHYLAXIS: on coumadin . Trace aortic regurgitation is seen. Response: Excellent effect Plan: .H/O heart failure (CHF), Systolic, Acute on Chronic Assessment: Off lasix gtt since . # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a filter in place. # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a filter in place. # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a filter in place. # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a filter in place. # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a filter in place. # CODE: DNR, can intubate, briefly . Milrinone restarted d/t BP and U/O decrease. INR mildly subtherapeutic despite Cipro - continue Coumadin - monitor INR ICU Care Nutrition: Glycemic Control: Lines: Multi Lumen - 05:34 PM Midline - 05:34 PM Prophylaxis: DVT: coumadin Stress ulcer: lansoprazole VAP: Comments: Communication: Comments: Code status: DNR / DNI Disposition: # Hx CAD: Patient with h/o CAD w/ right dominant system, mild instent re-stenois of the LAD BM stent and occluded RCA. # Hx CAD: Patient with h/o CAD w/ right dominant system, mild instent re-stenois of the LAD BM stent and occluded RCA. # PROPHYLAXIS: on coumadin . # PROPHYLAXIS: on coumadin . # PROPHYLAXIS: on coumadin . Patient is currently on milrinone and phenylephrine. # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a filter in place. # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a filter in place. # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a filter in place. # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a filter in place. # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a filter in place. # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a filter in place. # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a filter in place. INR mildly subtherapeutic despite Cipro - continue Coumadin - monitor INR ICU Care Nutrition: Glycemic Control: Lines: midline, right IJ Multi Lumen - 05:34 PM Midline - 05:34 PM Prophylaxis: DVT: coumadin Stress ulcer: lansoprazole VAP: Comments: Communication: Comments: Code status: DNR / DNI Disposition: INR mildly subtherapeutic despite Cipro - continue Coumadin - monitor INR ICU Care Nutrition: Glycemic Control: Lines: midline, right IJ Multi Lumen - 05:34 PM Midline - 05:34 PM Prophylaxis: DVT: coumadin Stress ulcer: lansoprazole VAP: Comments: Communication: Comments: Code status: DNR / DNI Disposition: Right IJ catheter terminates in lower SVC. **** Impaired Skin Integrity Assessment: Pt. LS clear to diminished. Admit to CCU for aggressive diuresis. Out to rehab . Out to rehab . Out to rehab . Out to rehab . Out to rehab . Out to rehab . Out to rehab . Out to rehab . Out to rehab . tolerating medication. tolerating medication. 71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention, Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on coumadin, hypothyroidism, CKD, OA. 71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention, Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on coumadin, hypothyroidism, CKD, OA. 71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention, Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on coumadin, hypothyroidism, CKD, OA. 71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention, Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on coumadin, hypothyroidism, CKD, OA. | 98 | [
{
"category": "ECG",
"chartdate": "2180-01-12 00:00:00.000",
"description": "Report",
"row_id": 173437,
"text": "Ventricular paced rhythm with intermittent intrinsic A-V conduction as\ncompared with prior tracing of .\n\n"
},
{
"category": "Nursing",
"chartdate": "2180-01-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 399681,
"text": "Pt is a 71 yo female with PMH: BM stent to LAD ', Occluded RCA\n without intervention, Ischemic CM (EF 10-25%), BiV ICD, AF, PVD, DVT\n s/p IVC filter, coumadin, hypothyroidism, CKD, OA. adm for HF\n (milrinone/lasix) MRSA in L shoulder, L hip and R knuckle. Out to\n rehab . Today went from rehab to see Dr. , sent to EW with\n hypotension. SBP 70 in EW, transiently on dopa, but cardiology d/c'd.\n Rxd with NS 250 cc with SBP 92. Pt has been in rehab since d/c from\n with septic arthritis in L shoulder, hip and R knuckle.\n On Vanco followed by ID.\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n SBP 90-100, HR 80-100 V paced, with VEA, lungs clear, sats >95% on \n Rehab called for date and time of last medications\n Plan:\n To begin on milrinone with bolus/ neo on stand by. Then to begin lasix\n gtt. Once hemodynamically stable on milrinone, can add morphine to\n pain control as needed\n Impaired Skin Integrity\n Assessment:\n 5X 7 cm stage 3 decube on coccyx, surrounded by yellow slough.\n Surrounding tissue macerated. Heels pink, boggy\n Action:\n Intern in to assess wound.\n Offered kinair bed to patient but she refused\n Wound cleansed with wound spray, covered by mepilex dsg\n Multipodous boots ordered\n Turned off of back\n Pt refusing dinner\n Plan:\n Please obtain wound consult for wound care recommendations and\n suggestions on pressure reducing mattress, enc po\ns, have nutritionist\n consult.\n Pain control (acute pain, chronic pain)\n Assessment:\n pain over coccyx, given Tylenol in EW without relief\n Action/Response:\n Ultram 50 mg qid\n Plan:\n Once milrinone bolus finished, can begin IV morphine. Ultram qid and\n Tylenol tid as ordered\n"
},
{
"category": "Nursing",
"chartdate": "2180-01-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 400111,
"text": "71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\n : Sent to ED from clinic w/ hypotension\n transiently on\n dopa, Tx\nd w/ NS 250 cc w/ SBP ^ 92.\n Admit to CCU for aggressive diuresis.She was started on Milrinone\n and lasix gtt. And has been diuresing well. She has lg coccyx decub\n that is a source of chronic pain. She is DNR/DNI and defibrillator has\n been shut off.\n GI: Pt had a few episode of nausea yesterday and one today. It was very\n transient with no vomiting. She ate very well today. She received\n lactalose but no bM. Foley changed today.\n SOCIAL: Family in to visit. Pts HCP, her 38y old neice is very ill\n creating problem for this stressed family.\n Pain control (acute pain, chronic pain)\n Assessment:\n Plan is to transition to oral forms of pain control in preparation for\n pt going to rehab. She had received MS contin at 0600, but pill was\n ground and pt had nausea. She received 4mg IV morphine at 6am as well.\n She continues on standing acetominofen and ultram\n Action:\n MS contin will be given in to 15mg pills, which are smaller and can\n take them without having them crushed. Morphine immediate release has\n been ordered for breakthrough pain. It is also a small pill that she\n can take without crushing. She had 15mg immediate release at 1300 . She\n has had no IV morphine sulfate since 1030.\n Response:\n Pt has been pain free except when turned since then. She will have\n acute pain with position change, but it will settle down and go away\n within a few minutes. She received MS contin at 1800 and was able to\n swallow them without problem\n :\n Continue to try to control pain with oral medications. Give immediate\n release morphine for breakthrough pain.\n Impaired Skin Integrity\n Assessment:\n Sacral wound getting worse and remains very painful. Mepilex dsg oozing\n through. Acuacel added. Know MRSA infection on R knuckle and R elbow\n appear to be much more reddened than last week. Over all skin is dry\n and itchy.\n Action:\n Wound care nurse came to evaluate wound. Area is now cleansed with\n wound cleanser and dried. Criticade antifungal is applied to wound\n edges and peri-wound area. The wound is covered with aquacel AG and\n then small soft-sorb pad. It is secured with medipore tape on skin that\n has been prepped with barrier wipe. Finger and elbow are washed with\n soap and water. Area kept lubricated. oil used in water. Moisture\n barrier clean applied to body. Heels elevated off bed.\n Response:\n Skin less itchy. No further worsening of skin condition.\n Plan:\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Pt being transition for transfer back to rehab. Milrinone and lasix\n drips stopped at 1030. Pt was V-paced with wide complex and blood\n pressure prior to stopping meds was mid 90s with maps in mid 60s. She\n received KCL 20meq in AM She received torsemide 40mg and metolazone\n 5mg with urine output ~ 30-40cc/hr. Blood pressure dropped to the high\n 70s to mid 80s with maps in the low 50s.\n Action:\n After discussions with Dr she was restarted on Milrinone\n .5mic/kilo with bolus of 25mic/kilo given. Labs drawn in afternoon.\n Response:\n Blood pressure more stable with maps in low 60s after Milrinone\n restarted. She is ~400cc neg for the day. BUN creat 33/1.1, stable.\n Plan:\n Family deciding if pt will now be CMO and go to extended care facility\n with hospice.\n"
},
{
"category": "Nursing",
"chartdate": "2180-01-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 400112,
"text": "Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2180-01-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 399678,
"text": "Pt is a 71 yo female with PMH: BM stent to LAD ', Occluded RCA\n without intervention, Ischemic CM (EF 10-25%), BiV ICD, AF, PVD, DVT\n s/p IVC filter, coumadin, hypothyroidism, CKD, OA. adm for HF\n (milrinone/lasix) MRSA in L shoulder, L hip and R knuckle. Out to\n rehab . Today went from rehab to see Dr. , sent to EW with\n hypotension. SBP 70 in EW, transiently on dopa, but cardiology d/c'd.\n Rxd with NS 250 cc with SBP 92. Pt has been in rehab since d/c from\n with septic arthritis in L shoulder, hip and R knuckle.\n On Vanco followed by ID.\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n SBP 90-100, HR 80-100 V paced, lungs clear, sats >95% on RA\n Action:\n Response:\n Plan:\n To begin on milrinone with bolus/ neo on stand by. Then to begin lasix\n gtt. Once hemodynamically stable on milrinone, can add morphine to\n pain control as needed\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2180-01-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 399679,
"text": "Pt is a 71 yo female with PMH: BM stent to LAD ', Occluded RCA\n without intervention, Ischemic CM (EF 10-25%), BiV ICD, AF, PVD, DVT\n s/p IVC filter, coumadin, hypothyroidism, CKD, OA. adm for HF\n (milrinone/lasix) MRSA in L shoulder, L hip and R knuckle. Out to\n rehab . Today went from rehab to see Dr. , sent to EW with\n hypotension. SBP 70 in EW, transiently on dopa, but cardiology d/c'd.\n Rxd with NS 250 cc with SBP 92. Pt has been in rehab since d/c from\n with septic arthritis in L shoulder, hip and R knuckle.\n On Vanco followed by ID.\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n SBP 90-100, HR 80-100 V paced, with VEA, lungs clear, sats >95% on RA\n Plan:\n To begin on milrinone with bolus/ neo on stand by. Then to begin lasix\n gtt. Once hemodynamically stable on milrinone, can add morphine to\n pain control as needed\n Impaired Skin Integrity\n Assessment:\n 5X 7 cm stage 3 decube on coccyx, surrounded by yellow slough.\n Surrounding tissue macerated. Heels pink, boggy\n Action:\n Intern in to assess wound.\n Offered kinair bed to patient but she refused\n Wound cleansed with wound spray, covered by mepilex dsg\n Multipodous boots ordered\n Turned off of back\n Pt refusing dinner\n Plan:\n Please obtain wound consult for wound care recommendations and\n suggestions on pressure reducing mattress, enc po\ns, have nutritionist\n consult.\n Pain control (acute pain, chronic pain)\n Assessment:\n pain over coccyx, given Tylenol in EW without relief\n Action/Response:\n Ultram 50 mg qid\n Plan:\n Once milrinone bolus finished, can begin IV morphine\n"
},
{
"category": "Nursing",
"chartdate": "2180-01-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 400113,
"text": "71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\n : Sent to ED from clinic w/ hypotension\n transiently on\n dopa, Tx\nd w/ NS 250 cc w/ SBP ^ 92.\n Admit to CCU for aggressive diuresis.She was started on Milrinone\n and lasix gtt. And has been diuresing well. She has lg coccyx decub\n that is a source of chronic pain. She is DNR/DNI and defibrillator has\n been shut off.\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2180-01-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 399802,
"text": "Pt is a 71 yo female with PMH: BM stent to LAD ', Occluded RCA\n without intervention, Ischemic CM (EF 10-25%), BiV ICD, AF, PVD, DVT\n s/p IVC filter, coumadin, hypothyroidism, CKD, OA. adm for HF\n (milrinone/lasix) MRSA in L shoulder, L hip and R knuckle. Out to\n rehab . went from rehab to see Dr. , sent to EW with\n hypotension. SBP 70 in EW, transiently on dopa, but cardiology d/c'd.\n Rxd with NS 250 cc with SBP 92. Pt has been in rehab since d/c from\n with septic arthritis in L shoulder, hip and R knuckle.\n On Vanco followed by ID.\n She was started on milrinone .375 after bolus and lasix drip also begun\n at 2.5mg/hr. The lasix dose was increased to 5mg overnight, but urine\n output has remained poor, though she is negative.\n GI: Pt has poor apetite and eats very little.\n SOCIAL: Family in the visit in afternoon. Pt in good spirits, visiting\n with brother and his family.\n CODE STATUS: Dr had discussion with both patient and health care\n proxy and all are in agreement that she be DNR/DNI. Additionally the\n defibrillator part of AICD/pacer was shut off.\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2180-01-14 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 399815,
"text": "Chief Complaint:\n 24 Hour Events:\n - confirmed DNR, acemaker turned off\n - despite lasix gtt, diuresis poor yesterday\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Ciprofloxacin - 08:00 AM\n Infusions:\n Other ICU medications:\n Coumadin (Warfarin) - 04:00 PM\n Lansoprazole (Prevacid) - 04:00 PM\n Morphine Sulfate - 05:05 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.4\nC (97.5\n HR: 99 (66 - 104) bpm\n BP: 91/50(60) {82/42(45) - 101/67(120)} mmHg\n RR: 12 (11 - 23) insp/min\n SpO2: 99%\n Heart rhythm: V Paced\n Wgt (current): 82.2 kg (admission): 82.2 kg\n Total In:\n 1,554 mL\n 456 mL\n PO:\n 900 mL\n 60 mL\n TF:\n IVF:\n 654 mL\n 396 mL\n Blood products:\n Total out:\n 1,628 mL\n 1,505 mL\n Urine:\n 1,628 mL\n 1,505 mL\n NG:\n Stool:\n Drains:\n Balance:\n -74 mL\n -1,049 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///27/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 159 K/uL\n 10.0 g/dL\n 104 mg/dL\n 1.4 mg/dL\n 27 mEq/L\n 3.8 mEq/L\n 42 mg/dL\n 98 mEq/L\n 134 mEq/L\n 31.9 %\n 4.7 K/uL\n [image002.jpg]\n 05:44 AM\n 04:46 AM\n WBC\n 6.1\n 4.7\n Hct\n 32.1\n 31.9\n Plt\n 156\n 159\n Cr\n 1.3\n 1.4\n Glucose\n 83\n 104\n Other labs: PT / PTT / INR:16.8/29.3/1.5, Ca++:8.0 mg/dL, Mg++:2.1\n mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 05:34 PM\n Midline - 05:34 PM\n 18 Gauge - 05:35 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2180-01-14 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 399816,
"text": "Chief Complaint:\n 24 Hour Events:\n - confirmed DNR, acemaker turned off\n - despite lasix gtt, diuresis poor yesterday\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Ciprofloxacin - 08:00 AM\n Infusions:\n Other ICU medications:\n Coumadin (Warfarin) - 04:00 PM\n Lansoprazole (Prevacid) - 04:00 PM\n Morphine Sulfate - 05:05 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.4\nC (97.5\n HR: 99 (66 - 104) bpm\n BP: 91/50(60) {82/42(45) - 101/67(120)} mmHg\n RR: 12 (11 - 23) insp/min\n SpO2: 99%\n Heart rhythm: V Paced\n Wgt (current): 82.2 kg (admission): 82.2 kg\n Total In:\n 1,554 mL\n 456 mL\n PO:\n 900 mL\n 60 mL\n TF:\n IVF:\n 654 mL\n 396 mL\n Blood products:\n Total out:\n 1,628 mL\n 1,505 mL\n Urine:\n 1,628 mL\n 1,505 mL\n NG:\n Stool:\n Drains:\n Balance:\n -74 mL\n -1,049 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///27/\n Physical Examination\n General Appearance: No acute distress, thin, cachectic\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: II/VI systolic murmur best at apex. MI is laterally\n displaced\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Breath Sounds: Clear : anteriorly)\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+\n Skin: Not assessed, Stage 3 sacral decubitus ulcer\n Neurologic: Attentive, Responds to: Not assessed, Oriented (to): x3\n Labs / Radiology\n 159 K/uL\n 10.0 g/dL\n 104 mg/dL\n 1.4 mg/dL\n 27 mEq/L\n 3.8 mEq/L\n 42 mg/dL\n 98 mEq/L\n 134 mEq/L\n 31.9 %\n 4.7 K/uL\n [image002.jpg]\n 05:44 AM\n 04:46 AM\n WBC\n 6.1\n 4.7\n Hct\n 32.1\n 31.9\n Plt\n 156\n 159\n Cr\n 1.3\n 1.4\n Glucose\n 83\n 104\n Other labs: PT / PTT / INR:16.8/29.3/1.5, Ca++:8.0 mg/dL, Mg++:2.1\n mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 05:34 PM\n Midline - 05:34 PM\n 18 Gauge - 05:35 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2180-01-14 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 399817,
"text": "Chief Complaint:\n 24 Hour Events:\n - confirmed DNR, acemaker turned off\n - despite lasix gtt, diuresis poor yesterday\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Ciprofloxacin - 08:00 AM\n Infusions:\n Other ICU medications:\n Coumadin (Warfarin) - 04:00 PM\n Lansoprazole (Prevacid) - 04:00 PM\n Morphine Sulfate - 05:05 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.4\nC (97.5\n HR: 99 (66 - 104) bpm\n BP: 91/50(60) {82/42(45) - 101/67(120)} mmHg\n RR: 12 (11 - 23) insp/min\n SpO2: 99%\n Heart rhythm: V Paced\n Wgt (current): 82.2 kg (admission): 82.2 kg\n Total In:\n 1,554 mL\n 456 mL\n PO:\n 900 mL\n 60 mL\n TF:\n IVF:\n 654 mL\n 396 mL\n Blood products:\n Total out:\n 1,628 mL\n 1,505 mL\n Urine:\n 1,628 mL\n 1,505 mL\n NG:\n Stool:\n Drains:\n Balance:\n -74 mL\n -1,049 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///27/\n Physical Examination\n General Appearance: No acute distress, thin, cachectic\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: II/VI systolic murmur best at apex. MI is laterally\n displaced\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Breath Sounds: Clear : anteriorly)\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+\n Skin: Not assessed, Stage 3 sacral decubitus ulcer\n Neurologic: Attentive, Responds to: Not assessed, Oriented (to): x3\n Labs / Radiology\n 159 K/uL\n 10.0 g/dL\n 104 mg/dL\n 1.4 mg/dL\n 27 mEq/L\n 3.8 mEq/L\n 42 mg/dL\n 98 mEq/L\n 134 mEq/L\n 31.9 %\n 4.7 K/uL\n [image002.jpg]\n 05:44 AM\n 04:46 AM\n WBC\n 6.1\n 4.7\n Hct\n 32.1\n 31.9\n Plt\n 156\n 159\n Cr\n 1.3\n 1.4\n Glucose\n 83\n 104\n Other labs: PT / PTT / INR:16.8/29.3/1.5, Ca++:8.0 mg/dL, Mg++:2.1\n mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\n recently discharged from the CCU () for CHF exacerbation c/b\n C.diff infection and on for septic joint washout c/b failure to\n extubate CHF exacerbation, who is now being admitted from \n clinic with total body fluid overload.\n .\n # Anasarca: Patient has history of CHF ischemic , 10%, s/p\n BiV ICD ( Concerto C154DWK) 1/08with EF 10% which is the\n likely cause of her fluid overload. Her rapid accumulation underpins\n the severity of her condition and her severely unfavourable\n hemodynamics. Her long term goals are comfort, though she still wishes\n to participate in rehab. Her family recognizes that she is dying. Our\n goal is diuresis which we will attempt aggressively, reassessing our\n progress dynamically. She put out very little o/n on lasix gtt. This\n could reflect limitatin of diuresis or the importance of a bolus (we\n withheld bolus to avoid instability)\n -- milrinone with bolus\n -- neosynephrine for pressure support, goal MAP of > 60\n -- slow uptitration of lasix with goal near-continuous diuresis while\n avoiding MAP < 60\n -- strict i/o's with foley\n -- can switch to levophed if low UOP on Neo with need for pressor\n support\n -- family meeting with HCP to assess goals in AM after diuresis\n attempted\n .\n # Septic Joints: Patient with history +staph aureus in left shoulder\n treated by washout and vancomycin, thus far 4 weeks of monotherapy. No\n + blood cx since before . Major issue now is pain control.\n -- send Vanco level in AM, was recently on 500 mg q12 and switched to\n q24 for high troughs\n -- ultram q6, Tylenol q8, Morphine for breakthrough (1-3 mg).\n - Will consider ms contin if no control\n .\n # Sacral Decub - stage 3-4.\n - wound care\n - pain control.\n .\n # UTI: positive UA, no history of culture positive UA's in system\n - treating empirically with cipro\n - watch INR on abx\n .\n # CORONARIES: Patient with h/o CAD w/ right dominant system, mild\n instent re-stenois of the LAD BM stent and occluded RCA.\n - bb as tolerated\n .\n # RHYTHM: Patient with h/o atrial fibrillation, s/p BiV ICD (\n Concerto C154DWK) , on coumadin. Now in paced rhythm\n - cont home dose meds (amio, metoprolol)\n - cont coumadin\n - f/u INR\n .\n # Chronic Kidney Disease: Baseline 1.3 creatinine. At baseline\n - trend\n .\n # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a\n filter in place.\n - cont coumadin\n - f/u INR\n .\n # Hypothyroidism: Continue Levothyroxine.\n .\n # Gout: continue allopurinol\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 05:34 PM\n Midline - 05:34 PM\n 18 Gauge - 05:35 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2180-01-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 400035,
"text": "Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Ineffective Coping\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2180-01-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 400036,
"text": "71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\n : Sent to ED from clinic w/ hypotension\n transiently on\n dopa, Tx\nd w/ NS 250 cc w/ SBP ^ 92. Admit to CCU for aggressive\n diuresis.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt needing less doses IV Morphine since MS Contin increased to 30mg \n this morning\n Pt consistently states pain is at coccyx\n immediate area of pressure\n ulcer and nowhere else\n Action:\n Received MS Contin 15mg x 2 this AM\n Continues on Tylenol 1000mg po TID, Ultram 50mg QID\n Received Morphine IV 4mg approx every 2 hours this am x total 4 doses\n none since approx 1245\n Response:\n Pt appears more comfortable this PM\n able to turn w/o premedicating with IV Morphine\n Pt states pain is which she states is good for her\n Plan:\n Cont assess pain, cont ATC meds and supplement with IV Morphine as\n needed\n ? etiology of severe pain\n ESR ordered to r/o osteo\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Pt asystomatic\n no SOB with stable VS\n Action:\n Milrinone remains at 0,5mcgs/kg/min\n Lasix increased from 5 to 10mg/hr\n Response:\n Initial urine output ~ 200cc/hr in AM\n now decreased to 20-40cc/hr,\n Lasix gtt titrated back to 10mg/hr with slight increase output\n Plan:\n Cont IV Lasix/Mirinone overnight and D/C in AM\n Transition to oral regimen, Assess response\n Impaired Skin Integrity\n Assessment:\n Large unstageable pressur ulcer on coccyx unchanged\n Bilat heels remain reddened but blanchble\n Old abrasion to r elbow\n Action:\n dressing coming off\n cleansed and redressed this AM-duoderm\n gel/Mepilex,\n mod amt sero-sanguinous drainage; redness/maceration to surrounding\n tissue\n severe pain at site\n see above\n Response:\n Site remains unchanged\n Plan:\n Cont keep PU clean with intact dressing, frequent turns avoiding back\n except when pt sitting upright for meals\n Wound care RN consult in AM\n Roho cushion ordered from PT\n unavailable today\n Ineffective Coping\n Assessment:\n Pt continues to have periods in day when she has difficulty coping with\n plan to return to rehab\n Action:\n Pt allowed to verbalize feelings about rehab, realizes she is unable to\n return home\n Response:\n Pt appears to have periods of\nmeltdown\n with periods of rational\n thought regarding needs and abilities going forward\n Plan:\n Case Manager consult in AM\n Social Service consult in AM.\n Cont to provide emotional support for patient.\n"
},
{
"category": "Nursing",
"chartdate": "2180-01-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 400187,
"text": "Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2180-01-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 399880,
"text": "Pt is a 71 yo female with PMH: BM stent to LAD ', Occluded RCA\n without intervention, Ischemic CM (EF 10-25%), BiV ICD, AF, PVD, DVT\n s/p IVC filter, coumadin, hypothyroidism, CKD, OA. adm for HF\n (milrinone/lasix) MRSA in L shoulder, L hip and R knuckle. Out to\n rehab . went from rehab to see Dr. , sent to EW with\n hypotension. SBP 70 in EW, transiently on dopa, but cardiology d/c'd.\n Rxd with NS 250 cc with SBP 92. Pt has been in rehab since d/c from\n with septic arthritis in L shoulder, hip and R knuckle.\n On Vanco followed by ID.\n She was started on milrinone .375 after bolus and lasix drip also begun\n at 2.5mg/hr. The lasix dose was increased to 10 but urine output\n has remained poor, though she is negative.\n GI: Pt has good apetite and has been eating well, but still no BM. She\n has pills ground up in applesauce.\n SOCIAL: Family in the visit in the am and early afternoon. She slept\n most of the afternoon.\n CODE STATUS: Dr had discussion with both patient and health care\n proxy and all are in agreement that she be DNR/DNI. Additionally the\n defibrillator part of AICD/pacer was shut off.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pain is much better contolled now that she can receive prn morphine in\n addition to standing ultram and Tylenol. The coccyx decubitis is what\n causes the most discomfort. She is most uncomfortable on her L side and\n cannot sleep or rest on that side.\n Action:\n She required more morphine in the am and received 7 2mg doses between\n 8am and 1500. She has not been turned on L side except for dsg and bed\n change. She goes from back to R side and is doing better with this.\n Response:\n She was awake and conversant with family all morning, able to eat and\n interact. She has slept most of the afternoon since 1500. She awoke at\n 1800 and was pain free and ready to eat.\n Plan:\n Continue standing ultram and give morphine prn. Change position as\n tolerated.\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n She has her lasix drip increased to 15mg overnight and remains on\n milrinone .5mic/kilo. She has a once a day metolazone 5mg po added. She\n has no audible rales, just decresed breath sounds at the bases. Her\n blood pressure has been adequate with maps over the 60s. She has no\n c/o of cp or acute SOB. Her bilateral leg edema is decreasing. She\n received 20 meq KCL IV this am.\n Action:\n She continues on above medications and is now responding with excellent\n diuresis. She is over 2 liters negative for the day! Lopressor was\n increased to 25mg .\n Response:\n Lytes within nl limits. Goal to to continue pushing diuresis for over\n 10 liters negative.\n Plan:\n Keep careful I & O. Monitor lytes\n Impaired Skin Integrity\n Assessment:\n Pt has large stage 3 decubitus ulcer on coccyx. This is covered with\n mepilex. Her heels are reddened, but . Her skin is very dry and\n thin with a number of discolored areas. She has almost no abilty to\n change her position on her own.\n Action:\n Mepilex dsg had drainage oozing through and was changed. Area has white\n slough covering most of it. The surrounding tissue is red. There is a\n lateral area that looks like granulation tissue. The edges are rounded.\n Area was sprayed with wound cleanser and dried. Peri-wound area had\n aloevesta moisture barrier applied and mepilex applied and remains in\n tact. It is draining enough it needs to be changed daily. Her heels\n have been kept elevated on pillows and she has been well lubricated.\n Her position is changed from R to upright as often as she tolerates.\n Response:\n No new lesions noted. The ducub is no worse than yesterday.\n Plan:\n Monitor wound and change dsg as needed. Add aquacel if draining\n increases. Change position as tolerated.\n"
},
{
"category": "Nursing",
"chartdate": "2180-01-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 400105,
"text": "71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\n : Sent to ED from clinic w/ hypotension\n transiently on\n dopa, Tx\nd w/ NS 250 cc w/ SBP ^ 92.\n Admit to CCU for aggressive diuresis.She was started on Milrinone\n and lasix gtt. And has been diuresing well. She has lg coccyx decub\n that is a source of chronic pain. She is DNR/DNI and defibrillator has\n been shut off. She has excellent apetite.\n Pain control (acute pain, chronic pain)\n Assessment:\n Plan is to transition to oral forms of pain control in preparation for\n pt going to rehab. She had received MS contin at 0600, but pill was\n ground and pt had nausea. She received 4mg IV morphine at 6am as well.\n She continues on standing acetominofen and ultram\n Action:\n MS contin will be given in to 15mg pills, which are smaller and can\n take them without having them crushed. Morphine immediate release has\n been ordered for breakthrough pain. It is also a small pill that she\n can take without crushing. She had 15mg immediate release at 1300 . She\n has had no IV morphine sulfate since 1030.\n Response:\n Pt has been pain free except when turned since then. She will have\n acute pain with position change, but it will settle down and go away\n within a few minutes. She received MS contin at 1800 and was able to\n swallow them without problem\n :\n Continue to try to control pain with oral medications. Give immediate\n release morphine for breakthrough pain.\n Impaired Skin Integrity\n Assessment:\n Sacral wound getting worse and remains very painful. Mepilex dsg oozing\n through. Acuacel added. Know MRSA infection on R knuckle and R elbow\n appear to be much more reddened than last week. Over all skin is dry\n and itchy.\n Action:\n Wound care nurse came to evaluate wound. Area is now cleansed with\n wound cleanser and dried. Criticade antifungal is applied to wound\n edges and peri-wound area. The wound is covered with aquacel AG and\n then small soft-sorb pad. It is secured with medipore tape on skin that\n has been prepped with barrier wipe. Finger and elbow are washed with\n soap and water. Area kept lubricated. oil used in water. Moisture\n barrier clean applied to body. Heels elevated off bed.\n Response:\n Skin less itchy. No further worsening of skin condition.\n Plan:\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Pt being transition for transfer back to rehab. Milrinone and lasix\n drips stopped at 1030. Pt was V-paced with wide complex and blood\n pressure prior to stopping meds was mid 90s with maps in mid 60s. She\n received KCL 20meq in AM She received torsemide 40mg and metolazone\n 5mg with urine output ~ 30-40cc/hr. Blood pressure dropped to the high\n 70s to mid 80s with maps in the low 50s.\n Action:\n After discussions with Dr she was restarted on Milrinone\n .5mic/kilo with bolus of 25mic/kilo given.\n Response:\n Blood pressure more stable with maps in low 60s after Milrinone\n restarted.\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2180-01-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 400106,
"text": "71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\n : Sent to ED from clinic w/ hypotension\n transiently on\n dopa, Tx\nd w/ NS 250 cc w/ SBP ^ 92.\n Admit to CCU for aggressive diuresis.She was started on Milrinone\n and lasix gtt. And has been diuresing well. She has lg coccyx decub\n that is a source of chronic pain. She is DNR/DNI and defibrillator has\n been shut off.\n GI: Pt had a few episode of nausea yesterday and one today. It was very\n transient with no vomiting. She ate very well today. She received\n lactalose but no bM. Foley changed today.\n SOCIAL: Family in to visit. Pts HCP, her 38y old neice is very ill\n creating problem for this stressed family.\n Pain control (acute pain, chronic pain)\n Assessment:\n Plan is to transition to oral forms of pain control in preparation for\n pt going to rehab. She had received MS contin at 0600, but pill was\n ground and pt had nausea. She received 4mg IV morphine at 6am as well.\n She continues on standing acetominofen and ultram\n Action:\n MS contin will be given in to 15mg pills, which are smaller and can\n take them without having them crushed. Morphine immediate release has\n been ordered for breakthrough pain. It is also a small pill that she\n can take without crushing. She had 15mg immediate release at 1300 . She\n has had no IV morphine sulfate since 1030.\n Response:\n Pt has been pain free except when turned since then. She will have\n acute pain with position change, but it will settle down and go away\n within a few minutes. She received MS contin at 1800 and was able to\n swallow them without problem\n :\n Continue to try to control pain with oral medications. Give immediate\n release morphine for breakthrough pain.\n Impaired Skin Integrity\n Assessment:\n Sacral wound getting worse and remains very painful. Mepilex dsg oozing\n through. Acuacel added. Know MRSA infection on R knuckle and R elbow\n appear to be much more reddened than last week. Over all skin is dry\n and itchy.\n Action:\n Wound care nurse came to evaluate wound. Area is now cleansed with\n wound cleanser and dried. Criticade antifungal is applied to wound\n edges and peri-wound area. The wound is covered with aquacel AG and\n then small soft-sorb pad. It is secured with medipore tape on skin that\n has been prepped with barrier wipe. Finger and elbow are washed with\n soap and water. Area kept lubricated. oil used in water. Moisture\n barrier clean applied to body. Heels elevated off bed.\n Response:\n Skin less itchy. No further worsening of skin condition.\n Plan:\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Pt being transition for transfer back to rehab. Milrinone and lasix\n drips stopped at 1030. Pt was V-paced with wide complex and blood\n pressure prior to stopping meds was mid 90s with maps in mid 60s. She\n received KCL 20meq in AM She received torsemide 40mg and metolazone\n 5mg with urine output ~ 30-40cc/hr. Blood pressure dropped to the high\n 70s to mid 80s with maps in the low 50s.\n Action:\n After discussions with Dr she was restarted on Milrinone\n .5mic/kilo with bolus of 25mic/kilo given. Labs drawn in afternoon.\n Response:\n Blood pressure more stable with maps in low 60s after Milrinone\n restarted. She is ~400cc neg for the day. BUN creat 33/1.1, stable.\n Plan:\n Family deciding if pt will now be CMO and go to extended care facility\n with hospice.\n"
},
{
"category": "Physician ",
"chartdate": "2180-01-16 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 400013,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - MS Contin 15 , was getting 22 mg IV morph qday\n - pulled EJ\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 08:00 AM\n Vancomycin - 09:36 AM\n Infusions:\n Furosemide (Lasix) - 5 mg/hour\n Milrinone - 0.5 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 06:40 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.8\n HR: 70 (62 - 75) bpm\n BP: 88/57(63) {78/43(52) - 106/66(76)} mmHg\n RR: 23 (9 - 35) insp/min\n SpO2: 97%\n Heart rhythm: AV Paced\n Wgt (current): 77.3 kg (admission): 82.2 kg\n Total In:\n 1,335 mL\n 121 mL\n PO:\n 420 mL\n TF:\n IVF:\n 915 mL\n 121 mL\n Blood products:\n Total out:\n 5,565 mL\n 880 mL\n Urine:\n 5,565 mL\n 880 mL\n NG:\n Stool:\n Drains:\n Balance:\n -4,230 mL\n -759 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///33/\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Diminished: )\n Abdominal: Soft, Obese\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 146 K/uL\n 10.7 g/dL\n 115 mg/dL\n 1.1 mg/dL\n 33 mEq/L\n 3.8 mEq/L\n 39 mg/dL\n 92 mEq/L\n 133 mEq/L\n 33.1 %\n 5.1 K/uL\n [image002.jpg]\n 05:44 AM\n 04:46 AM\n 04:00 PM\n 03:05 AM\n 03:17 PM\n WBC\n 6.1\n 4.7\n 5.1\n Hct\n 32.1\n 31.9\n 33.1\n Plt\n 156\n 159\n 146\n Cr\n 1.3\n 1.4\n 1.3\n 1.2\n 1.1\n Glucose\n 83\n 104\n 155\n 115\n Other labs:\n PT / PTT / INR:18.4/29.1/1.7,\n Ca++:8.3 mg/dL, Mg++:2.0 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\n recently discharged from the CCU () for CHF exacerbation c/b\n C.diff infection and on for septic joint washout c/b failure to\n extubate CHF exacerbation, who is now being admitted from \n clinic with total body fluid overload.\n .\n # sCHF exacerbation: Patient has history of CHF ischemic , \n 10%, s/p BiV ICD ( Concerto C154DWK) 1/08with EF 10% which is\n the likely cause of her fluid overload. Her rapid accumulation\n underpins the severity of her condition and her severely unfavourable\n hemodynamics. Her long term goals are comfort, though she still wishes\n to participate in rehab. Her family recognizes that she is dying. Our\n goal is diuresis which we will attempt aggressively, reassessing our\n progress dynamically. She diuresed well on Lasix gtt on with net\n neg 4L balance. LOS fluid balance -5L.\n -- goal diuresis 5 to 10L total\n -- continue milrinone\n -- continue metoprolol tartrate 12.5mg PO BID\n -- slow uptitration of lasix gtt with goal near-continuous diuresis\n while avoiding MAP < 60\n -- strict i/o's with foley\n -- replete K to 5\n -- PM electrolytes\n -- family meeting with HCP prn\n .\n # Septic Joints: Patient with history +staph aureus in left shoulder\n treated by washout and vancomycin, thus far 4 weeks of monotherapy. No\n + blood cx since before . Major issue now is pain control.\n -- continue vanc, was recently on 500 mg q12 and switched to q24 for\n high troughs\n -- continue MS contin 15mg \n -- ultram q6, Tylenol q8, Morphine for breakthrough (2-4 mg).\n .\n # Sacral Decub - stage 3-4.\n - wound care\n - pain control\n .\n # UTI: positive UA, no history of culture positive UA's in system\n - treating empirically with cipro day 1 was . Last dose tomorrow\n morning (Morning of ^st)\n - watch INR on abx\n .\n # CORONARIES: Patient with h/o CAD w/ right dominant system, mild\n instent re-stenois of the LAD BM stent and occluded RCA.\n - bb as tolerated\n .\n # RHYTHM: Patient with h/o atrial fibrillation, s/p BiV ICD (\n Concerto C154DWK) , on coumadin. Now in paced rhythm\n - cont home dose meds (amio, metoprolol)\n - cont coumadin\n .\n # Chronic Kidney Disease: Baseline Creatinine 1.3. Creatinine 1.1\n today.\n - trend\n .\n # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a\n filter in place.\n - continue Coumadin\n .\n # Hypothyroidism: Continue Levothyroxine\n .\n # Gout: continue Allopurinol\n ICU Care\n Nutrition:\n Low Na diet\n Glycemic Control: not on insulin\n Lines:\n Multi Lumen - 05:34 PM\n Midline - 05:34 PM\n 18 Gauge - 05:35 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: DNR / DNI\n Disposition:ICU\n"
},
{
"category": "Physician ",
"chartdate": "2180-01-16 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 400015,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - MS Contin 15 , was getting 22 mg IV morph qday\n - pulled EJ\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 08:00 AM\n Vancomycin - 09:36 AM\n Infusions:\n Furosemide (Lasix) - 5 mg/hour\n Milrinone - 0.5 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 06:40 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.8\n HR: 70 (62 - 75) bpm\n BP: 88/57(63) {78/43(52) - 106/66(76)} mmHg\n RR: 23 (9 - 35) insp/min\n SpO2: 97%\n Heart rhythm: AV Paced\n Wgt (current): 77.3 kg (admission): 82.2 kg\n Total In:\n 1,335 mL\n 121 mL\n PO:\n 420 mL\n TF:\n IVF:\n 915 mL\n 121 mL\n Blood products:\n Total out:\n 5,565 mL\n 880 mL\n Urine:\n 5,565 mL\n 880 mL\n NG:\n Stool:\n Drains:\n Balance:\n -4,230 mL\n -759 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///33/\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Diminished: )\n Abdominal: Soft, Obese\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 146 K/uL\n 10.7 g/dL\n 115 mg/dL\n 1.1 mg/dL\n 33 mEq/L\n 3.8 mEq/L\n 39 mg/dL\n 92 mEq/L\n 133 mEq/L\n 33.1 %\n 5.1 K/uL\n [image002.jpg]\n 05:44 AM\n 04:46 AM\n 04:00 PM\n 03:05 AM\n 03:17 PM\n WBC\n 6.1\n 4.7\n 5.1\n Hct\n 32.1\n 31.9\n 33.1\n Plt\n 156\n 159\n 146\n Cr\n 1.3\n 1.4\n 1.3\n 1.2\n 1.1\n Glucose\n 83\n 104\n 155\n 115\n Other labs:\n PT / PTT / INR:18.4/29.1/1.7,\n Ca++:8.3 mg/dL, Mg++:2.0 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\n recently discharged from the CCU () for CHF exacerbation c/b\n C.diff infection and on for septic joint washout c/b failure to\n extubate CHF exacerbation, who is now being admitted from \n clinic with total body fluid overload.\n .\n # sCHF exacerbation: Patient has history of CHF ischemic , \n 10%, s/p BiV ICD ( Concerto C154DWK) 1/08with EF 10% which is\n the likely cause of her fluid overload. Her rapid accumulation\n underpins the severity of her condition and her severely unfavourable\n hemodynamics. Her long term goals are comfort, though she still wishes\n to participate in rehab. Her family recognizes that she is dying. Our\n goal is diuresis which we will attempt aggressively, reassessing our\n progress dynamically. She diuresed well on Lasix gtt on with net\n neg 4L balance. LOS fluid balance -5L.\n -- goal diuresis 5 to 10L total\n -- continue milrinone\n -- continue metoprolol tartrate 12.5mg PO BID\n -- slow uptitration of lasix gtt with goal near-continuous diuresis\n while avoiding MAP < 60\n -- strict i/o's with foley\n -- replete K to 5\n -- PM electrolytes\n -- family meeting with HCP prn\n .\n # Septic Joints: Patient with history +staph aureus in left shoulder\n treated by washout and vancomycin, thus far 4 weeks of monotherapy. No\n + blood cx since before . Major issue now is pain control.\n -- continue vanc, was recently on 500 mg q12 and switched to q24 for\n high troughs\n -- continue cipro\n -- continue MS contin 15mg \n -- ultram q6, Tylenol q8, Morphine for breakthrough (2-4 mg).\n .\n # Sacral Decub - stage 3-4.\n - wound care\n - pain control\n .\n # UTI: positive UA, no history of culture positive UA's in system\n - treating empirically with cipro day 1 was . Last dose tomorrow\n morning (Morning of ^st)\n - watch INR on abx\n .\n # CORONARIES: Patient with h/o CAD w/ right dominant system, mild\n instent re-stenois of the LAD BM stent and occluded RCA.\n - bb as tolerated\n .\n # RHYTHM: Patient with h/o atrial fibrillation, s/p BiV ICD (\n Concerto C154DWK) , on coumadin. Now in paced rhythm\n - cont home dose meds (amio, metoprolol)\n - cont coumadin\n .\n # Chronic Kidney Disease: Baseline Creatinine 1.3. Creatinine 1.1\n today.\n - trend\n .\n # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a\n filter in place.\n - continue Coumadin\n .\n # Hypothyroidism: Continue Levothyroxine\n .\n # Gout: continue Allopurinol\n ICU Care\n Nutrition:\n Low Na diet\n Glycemic Control: not on insulin\n Lines:\n Multi Lumen - 05:34 PM\n Midline - 05:34 PM\n 18 Gauge - 05:35 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: DNR / DNI\n Disposition:ICU\n"
},
{
"category": "Physician ",
"chartdate": "2180-01-16 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 400016,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - MS Contin 15 , was getting 22 mg IV morph qday\n - pulled EJ\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 08:00 AM\n Vancomycin - 09:36 AM\n Infusions:\n Furosemide (Lasix) - 5 mg/hour\n Milrinone - 0.5 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 06:40 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.8\n HR: 70 (62 - 75) bpm\n BP: 88/57(63) {78/43(52) - 106/66(76)} mmHg\n RR: 23 (9 - 35) insp/min\n SpO2: 97%\n Heart rhythm: AV Paced\n Wgt (current): 77.3 kg (admission): 82.2 kg\n Total In:\n 1,335 mL\n 121 mL\n PO:\n 420 mL\n TF:\n IVF:\n 915 mL\n 121 mL\n Blood products:\n Total out:\n 5,565 mL\n 880 mL\n Urine:\n 5,565 mL\n 880 mL\n NG:\n Stool:\n Drains:\n Balance:\n -4,230 mL\n -759 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///33/\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Diminished: )\n Abdominal: Soft, Obese\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 146 K/uL\n 10.7 g/dL\n 115 mg/dL\n 1.1 mg/dL\n 33 mEq/L\n 3.8 mEq/L\n 39 mg/dL\n 92 mEq/L\n 133 mEq/L\n 33.1 %\n 5.1 K/uL\n [image002.jpg]\n 05:44 AM\n 04:46 AM\n 04:00 PM\n 03:05 AM\n 03:17 PM\n WBC\n 6.1\n 4.7\n 5.1\n Hct\n 32.1\n 31.9\n 33.1\n Plt\n 156\n 159\n 146\n Cr\n 1.3\n 1.4\n 1.3\n 1.2\n 1.1\n Glucose\n 83\n 104\n 155\n 115\n Other labs:\n PT / PTT / INR:18.4/29.1/1.7,\n Ca++:8.3 mg/dL, Mg++:2.0 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\n recently discharged from the CCU () for CHF exacerbation c/b\n C.diff infection and on for septic joint washout c/b failure to\n extubate CHF exacerbation, who is now being admitted from \n clinic with total body fluid overload.\n .\n # sCHF exacerbation: Patient has history of CHF ischemic , \n 10%, s/p BiV ICD ( Concerto C154DWK) 1/08with EF 10% which is\n the likely cause of her fluid overload. Her rapid accumulation\n underpins the severity of her condition and her severely unfavourable\n hemodynamics. Her long term goals are comfort, though she still wishes\n to participate in rehab. Her family recognizes that she is dying. Our\n goal is diuresis which we will attempt aggressively, reassessing our\n progress dynamically. She diuresed well on Lasix gtt on with net\n neg 4L balance. LOS fluid balance -5L.\n -- goal diuresis 5 to 10L total\n -- continue milrinone\n -- continue metolazone 5mg daily\n -- continue metoprolol tartrate 12.5mg PO BID\n -- slow uptitration of lasix gtt with goal near-continuous diuresis\n while avoiding MAP < 60\n -- strict i/o's with foley\n -- replete K to 5\n -- PM electrolytes\n -- family meeting with HCP prn\n .\n # Septic Joints: Patient with history +staph aureus in left shoulder\n treated by washout and vancomycin, thus far 4 weeks of monotherapy. No\n + blood cx since before . Major issue now is pain control.\n -- continue vanc, was recently on 500 mg q12 and switched to q24 for\n high troughs\n -- continue cipro\n -- continue MS contin 15mg \n -- ultram q6, Tylenol q8, Morphine for breakthrough (2-4 mg).\n .\n # Sacral Decub - stage 3-4.\n - wound care\n - pain control\n .\n # UTI: positive UA, no history of culture positive UA's in system\n - treating empirically with cipro day 1 was . Last dose tomorrow\n morning (Morning of ^st)\n - watch INR on abx\n .\n # CORONARIES: Patient with h/o CAD w/ right dominant system, mild\n instent re-stenois of the LAD BM stent and occluded RCA.\n - bb as tolerated\n .\n # RHYTHM: Patient with h/o atrial fibrillation, s/p BiV ICD (\n Concerto C154DWK) , on coumadin. Now in paced rhythm\n - cont home dose meds (amio, metoprolol)\n - cont coumadin\n .\n # Chronic Kidney Disease: Baseline Creatinine 1.3. Creatinine 1.1\n today.\n - trend\n .\n # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a\n filter in place.\n - continue Coumadin\n .\n # Hypothyroidism: Continue Levothyroxine\n .\n # Gout: continue Allopurinol\n ICU Care\n Nutrition:\n Low Na diet\n Glycemic Control: not on insulin\n Lines:\n Multi Lumen - 05:34 PM\n Midline - 05:34 PM\n 18 Gauge - 05:35 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: DNR / DNI\n Disposition:ICU\n"
},
{
"category": "Nursing",
"chartdate": "2180-01-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 400098,
"text": "71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\n : Sent to ED from clinic w/ hypotension\n transiently on\n dopa, Tx\nd w/ NS 250 cc w/ SBP ^ 92.\n Admit to CCU for aggressive diuresis.She was started on Milrinone\n and lasix gtt. And has been diuresing well. She has lg coccyx decub\n that is a source of chronic pain. She is DNR/DNI and defibrillator has\n been shut off. She has excellent apetite.\n Pain control (acute pain, chronic pain)\n Assessment:\n Plan is to transition to oral forms of pain control in preparation for\n pt going to rehab. She had received MS contin at 0600, but pill was\n ground and pt had nausea. She received 4mg IV morphine at 6am as well.\n She continues on standing acetominofen and ultram\n Action:\n MS contin will be given in to 15mg pills, which are smaller and can\n take them without having them crushed. Morphine immediate release has\n been ordered for breakthrough pain. It is also a small pill that she\n can take without crushing. She had 15mg immediate release at 1300 . She\n has had no IV morphine sulfate since 1030.\n Response:\n Pt has been pain free except when turned since then. She will have\n acute pain with position change, but it will settle down and go away\n within a few minutes. She received MS contin at 1800\n Plan:\n Continue to try to control pain with oral medications. Give immediate\n release morphine for breakthrough pain.\n Impaired Skin Integrity\n Assessment:\n Sacral wound getting worse and remains very painful. Mepilex dsg oozing\n through. Acuacel added. Know MRSA infection on R knuckle and R elbow\n appear to be much more reddened than last week. Over all skin is dry\n and itchy.\n Action:\n Wound care nurse came to evaluate wound. Area is now cleansed with\n wound cleanser and dried. Criticade antifungal is applied to wound\n edges and peri-wound area. The wound is covered with aquacel AG and\n then small soft-sorb pad. It is secured with medipore tape on skin that\n has been prepped with barrier wipe. Finger and elbow are washed with\n soap and water. Area kept lubricated. oil used in water. Moisture\n barrier clean applied to body. Heels elevated off bed.\n Response:\n Skin less itchy. No further worsening of skin condition.\n Plan:\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Pt being transition for transfer back to rehab. Milrinone and lasix\n drips stopped at 1030.\n Action:\n At noon she received dose of torsemide 40mg po and metolazone 5mg po.\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2180-01-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 400017,
"text": "71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\n recently discharged from the CCU () for CHF exacerbation c/b\n C.diff infection and on for septic joint washout c/b failure to\n extubate CHF exacerbation, who is now being admitted from \n clinic with total body fluid overload.\n .\n Pain control (acute pain, chronic pain)\n Assessment:\n Patent\ns primary wish is her comfort. Continues to favor her DNR/DNI\n status.\n Action:\n Premedicated with 4 mg of MSO4 prior to all positon changes. Pain\n med has been increased to 2-4 mg q1 hour if needed. Ms contin 15 mg q12\n Response:\n Moaning with position changes especially to the left side\n Plan:\n Discussions on going with patient and Dr regarding plan of care\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n HR 70 AVP ..SBP 80\ns/40\n Action:\n Lasix decreased to 5 mg/hr as urine output >200 cc q1 hour\n Response:\n 4200 cc negative at mdnight\n Plan:\n Continue on milrinone and lasix for fluid over load\n"
},
{
"category": "Physician ",
"chartdate": "2180-01-16 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 400027,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - MS Contin 15 , was getting 22 mg IV morph qday\n - pulled EJ\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 08:00 AM\n Vancomycin - 09:36 AM\n Infusions:\n Furosemide (Lasix) - 5 mg/hour\n Milrinone - 0.5 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 06:40 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.8\n HR: 70 (62 - 75) bpm\n BP: 88/57(63) {78/43(52) - 106/66(76)} mmHg\n RR: 23 (9 - 35) insp/min\n SpO2: 97%\n Heart rhythm: AV Paced\n Wgt (current): 77.3 kg (admission): 82.2 kg\n Total In:\n 1,335 mL\n 121 mL\n PO:\n 420 mL\n TF:\n IVF:\n 915 mL\n 121 mL\n Blood products:\n Total out:\n 5,565 mL\n 880 mL\n Urine:\n 5,565 mL\n 880 mL\n NG:\n Stool:\n Drains:\n Balance:\n -4,230 mL\n -759 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///33/\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Diminished: )\n Abdominal: Soft, Obese\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 146 K/uL\n 10.7 g/dL\n 115 mg/dL\n 1.1 mg/dL\n 33 mEq/L\n 3.8 mEq/L\n 39 mg/dL\n 92 mEq/L\n 133 mEq/L\n 33.1 %\n 5.1 K/uL\n [image002.jpg]\n 05:44 AM\n 04:46 AM\n 04:00 PM\n 03:05 AM\n 03:17 PM\n WBC\n 6.1\n 4.7\n 5.1\n Hct\n 32.1\n 31.9\n 33.1\n Plt\n 156\n 159\n 146\n Cr\n 1.3\n 1.4\n 1.3\n 1.2\n 1.1\n Glucose\n 83\n 104\n 155\n 115\n Other labs:\n PT / PTT / INR:18.4/29.1/1.7,\n Ca++:8.3 mg/dL, Mg++:2.0 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\n recently discharged from the CCU () for CHF exacerbation c/b\n C.diff infection and on for septic joint washout c/b failure to\n extubate CHF exacerbation, who is now being admitted from \n clinic with total body fluid overload.\n .\n # sCHF exacerbation: Patient has history of CHF ischemic , \n 10%, s/p BiV ICD ( Concerto C154DWK) 1/08with EF 10% which is\n the likely cause of her fluid overload. Her rapid accumulation\n underpins the severity of her condition and her severely unfavourable\n hemodynamics. Her long term goals are comfort, though she still wishes\n to participate in rehab. Her family recognizes that she is dying. Our\n goal is diuresis which we will attempt aggressively, reassessing our\n progress dynamically. She diuresed well on Lasix gtt on with net\n neg 4L balance. LOS fluid balance -5L.\n -- goal diuresis 1L negative today with lasix gtt\n -- continue milrinone\n -- continue metolazone 5mg daily\n -- continue metoprolol tartrate 12.5mg PO BID\n -- strict i/o's with foley\n -- replete K to 5\n -- PM electrolytes\n -- family meeting with HCP prn\n .\n # Septic Joints: Patient with history +staph aureus in left shoulder\n treated by washout and vancomycin, thus far 4 weeks of monotherapy. No\n + blood cx since before . Major issue now is pain control.\n -- continue vanc, was recently on 500 mg q12 and switched to q24 for\n high troughs\n -- continue cipro\n -- increase MS contin to 30mg \n -- ultram q6, Tylenol q8, Morphine for breakthrough (2-4 mg).\n .\n # Sacral Decub - stage 3-4.\n - wound care\n - increase MS contin to 30mg \n - pain control\n .\n # UTI: positive UA, no history of culture positive UA's in system\n - treating empirically with cipro day 1 was . Last dose tomorrow\n morning (Morning of ^st)\n - watch INR on abx\n .\n # CORONARIES: Patient with h/o CAD w/ right dominant system, mild\n instent re-stenois of the LAD BM stent and occluded RCA.\n - bb as tolerated\n .\n # RHYTHM: Patient with h/o atrial fibrillation, s/p BiV ICD (\n Concerto C154DWK) , on coumadin. Now in paced rhythm\n - cont home dose meds (amio, metoprolol)\n - cont coumadin\n .\n # Chronic Kidney Disease: Baseline Creatinine 1.3. Creatinine 1.1\n today.\n - trend\n .\n # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a\n filter in place.\n - continue Coumadin\n .\n # Hypothyroidism: Continue Levothyroxine\n .\n # Gout: continue Allopurinol\n ICU Care\n Nutrition:\n Low Na diet\n Glycemic Control: not on insulin\n Lines:\n Multi Lumen - 05:34 PM\n Midline - 05:34 PM\n 18 Gauge - 05:35 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: DNR / DNI\n Disposition:ICU\n"
},
{
"category": "Physician ",
"chartdate": "2180-01-16 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 400029,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - MS Contin 15 , was getting 22 mg IV morph qday\n - pulled EJ\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 08:00 AM\n Vancomycin - 09:36 AM\n Infusions:\n Furosemide (Lasix) - 5 mg/hour\n Milrinone - 0.5 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 06:40 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.8\n HR: 70 (62 - 75) bpm\n BP: 88/57(63) {78/43(52) - 106/66(76)} mmHg\n RR: 23 (9 - 35) insp/min\n SpO2: 97%\n Heart rhythm: AV Paced\n Wgt (current): 77.3 kg (admission): 82.2 kg\n Total In:\n 1,335 mL\n 121 mL\n PO:\n 420 mL\n TF:\n IVF:\n 915 mL\n 121 mL\n Blood products:\n Total out:\n 5,565 mL\n 880 mL\n Urine:\n 5,565 mL\n 880 mL\n NG:\n Stool:\n Drains:\n Balance:\n -4,230 mL\n -759 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///33/\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Diminished: )\n Abdominal: Soft, Obese\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 146 K/uL\n 10.7 g/dL\n 115 mg/dL\n 1.1 mg/dL\n 33 mEq/L\n 3.8 mEq/L\n 39 mg/dL\n 92 mEq/L\n 133 mEq/L\n 33.1 %\n 5.1 K/uL\n [image002.jpg]\n 05:44 AM\n 04:46 AM\n 04:00 PM\n 03:05 AM\n 03:17 PM\n WBC\n 6.1\n 4.7\n 5.1\n Hct\n 32.1\n 31.9\n 33.1\n Plt\n 156\n 159\n 146\n Cr\n 1.3\n 1.4\n 1.3\n 1.2\n 1.1\n Glucose\n 83\n 104\n 155\n 115\n Other labs:\n PT / PTT / INR:18.4/29.1/1.7,\n Ca++:8.3 mg/dL, Mg++:2.0 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\n recently discharged from the CCU () for CHF exacerbation c/b\n C.diff infection and on for septic joint washout c/b failure to\n extubate CHF exacerbation, who is now being admitted from \n clinic with total body fluid overload.\n .\n # sCHF exacerbation: Patient has history of CHF ischemic , \n 10%, s/p BiV ICD ( Concerto C154DWK) 1/08with EF 10% which is\n the likely cause of her fluid overload. Her rapid accumulation\n underpins the severity of her condition and her severely unfavourable\n hemodynamics. Her long term goals are comfort, though she still wishes\n to participate in rehab. Her family recognizes that she is dying. Our\n goal is diuresis which we will attempt aggressively, reassessing our\n progress dynamically. She diuresed well on Lasix gtt on with net\n neg 4L balance. LOS fluid balance -5L.\n -- goal diuresis 1L negative today with lasix gtt\n -- continue milrinone\n -- continue metolazone 5mg daily\n -- continue metoprolol tartrate 12.5mg PO BID\n -- strict i/o's with foley\n -- replete K to 5\n -- PM electrolytes\n -- family meeting with HCP prn\n .\n # Septic Joints: Patient with history +staph aureus in left shoulder\n treated by washout and vancomycin, thus far 4 weeks of monotherapy. No\n + blood cx since before . Major issue now is pain control.\n -- continue vanc, was recently on 500 mg q12 and switched to q24 for\n high troughs\n -- continue cipro\n -- increase MS contin to 30mg \n -- ultram q6, Tylenol q8, Morphine for breakthrough (2-4 mg).\n .\n # Sacral Decub - stage 3-4.\n - wound care\n - increase MS contin to 30mg \n - pain control\n .\n # UTI: positive UA, no history of culture positive UA's in system\n - treating empirically with cipro day 1 was . Last dose tomorrow\n morning (Morning of ^st)\n - watch INR on abx\n .\n # CORONARIES: Patient with h/o CAD w/ right dominant system, mild\n instent re-stenois of the LAD BM stent and occluded RCA.\n - bb as tolerated\n .\n # RHYTHM: Patient with h/o atrial fibrillation, s/p BiV ICD (\n Concerto C154DWK) , on coumadin. Now in paced rhythm\n - cont home dose meds (amio, metoprolol)\n - cont coumadin\n .\n # Chronic Kidney Disease: Baseline Creatinine 1.3. Creatinine 1.1\n today.\n - trend\n .\n # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a\n filter in place.\n - continue Coumadin\n .\n # Hypothyroidism: Continue Levothyroxine\n .\n # Gout: continue Allopurinol\n ICU Care\n Nutrition:\n Low Na diet\n Glycemic Control: not on insulin\n Lines:\n Multi Lumen - 05:34 PM\n Midline - 05:34 PM\n 18 Gauge - 05:35 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: DNR / DNI\n Disposition:ICU\n ------ Protected Section ------\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I would add the following remarks:\n Above discussed extensively with patient.\n DNR status discussed. DNR.\n Total time spent on patient care: 45 minutes.\n Additional comments:\n Approaching 10 liters net negative fluid balance, which was our goal.\n She is remarkably better in terms of appetite, breathing, and general\n comfort level. Plan is for another 24 h milrinone plus Lasix gtt.\n Then shut off milrinone and switch to torsemide 40 mg po bid plus\n metolazone 2.5 mg qam. Anticipate discharge to rehab on Tuesday\n ------ Protected Section Addendum Entered By: on:\n 11:28 ------\n"
},
{
"category": "Social Work",
"chartdate": "2180-01-17 00:00:00.000",
"description": "Social Work Progress Note",
"row_id": 400096,
"text": "SOCIAL WORK: Following pt for coping with hospitalization and illness.\n Pt know to this writer from previous admission in . Spoke with\n pt's nurse . RN reports pt has had palliative care consult today.\n Met w/ pt in her room on the CCU. niece was also\n present. Pt was alert and oriented x3, made good eye contact. Pt\n repeatedly states that she is very pleased with care at and\n regrets that she cannot return to rehab. Pt gave limited\n responses around her understanding of palliative care approach. She\n deferred questions to her family members who help her with medical\n decisions. Pt concerned about dispo plan. SW reassured pt that case\n management will work with her family to make acceptable plan and SW\n will communicate family's wishes.\n Obtained contact numbers for all decision makers, HCP is \n (pt's niece) ( (H), (\n (C). Sister (, sister P. ( and niece . Family expressed wish that pt\n go to House in .\n Plan: -SW to provide emotional support for pt coping with the\n transition from the hospital\n -SW to further explore and provide support around palliative\n care approach presented today\n , MSW Intern\n Pager \n 05:36 PM\n"
},
{
"category": "Nursing",
"chartdate": "2180-01-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 400171,
"text": "71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\n : Sent to ED from clinic admit to CCU for aggressive\n diuresis. She was started on Milrinone and lasix gtt, lasix and\n milrinone gtts turned to off . Milrinone restarted d/t BP and U/O\n decrease. Large Stage III decube on coccyx decub that is a source of\n chronic pain. She is DNR/DNI and defibrillator has been shut off. Able\n to swallow pills whole, with either applesauce or custard.\n SOCIAL: Family in to visit. Pts HCP is in and intubated,\n pt\ns sister is alternate HCP.\n control (acute pain, chronic pain)\n Assessment:\n On standing dose of morphine SR, ultram and Tylenol.\n Action/Response:\n Pain rated to be this am, then later in day .\n Given supplemental IR morphine once and 2mg IV morphine once with\n relief of pain.\n Repositioned for comfort\n Plan:\n Continue pain control with oral medications. Give immediate release\n morphine for breakthrough pain.\n Impaired Skin Integrity\n Assessment:\n Stage III PU on coccyx, foul smelling, yellow sanguinous drainage,\n edges of wound yellow with areas of necrosis. Surrounding skin\n macerated. Pt. refusing kinair bed\n Action/Response:\n Dressing changed according to wound care RN\ns recs:\n anti-fungal barrier criticaid to macerated skin surrounding wound,\n acqua cell-AG to coccyx, covered in soft sorb dsg, medipore tape.\n Aloe Vesta to skin\n Offered repositioning q 2 hours, often times refusing as she\n is comfortable\n Po\ns encouraged, patient drinking hot chocolate, custard,\n applesauce.\n Plan:\n QD dressing change as above. Aloe vesta to skin. Reposition q2 hours\n or according to pt\ns wishes.\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Pt DNR/DNI. SBP 90\ns. Milrinone @ 0.5mcg/kg/min. U/O ~ 100cc q\n 2hours.\n Action/Response:\n Dr. in to talk with patient and family extensively.\n Milrinone turned to off. Torsemide and metzolone d/c\n Palliative care MD in to talk with pt and\n family.\n Patient\ns sisters at bedside most of afternoon.\n SBP decreasing to low 80\ns and then 70\ns off milrinone, U/O\n also tapering off. CCU resident notified, will hold off on IV fluids\n unless pt c/o dizziness. Did c/o nausea X1\nzofran with relief\n Plan:\n To remain in hospital for now. Will monitor off of milrinone with plan\n to give IV NS 250 cc for hypotension as per Dr. . No other changes\n in medications for now. Focus on comfort. Continue to support patient\n and family.\n"
},
{
"category": "Nursing",
"chartdate": "2180-01-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 399691,
"text": "Pt is a 71 yo female with PMH: BM stent to LAD ', Occluded RCA\n without intervention, Ischemic CM (EF 10-25%), BiV ICD, AF, PVD, DVT\n s/p IVC filter, coumadin, hypothyroidism, CKD, OA. adm for HF\n (milrinone/lasix) MRSA in L shoulder, L hip and R knuckle. Out to\n rehab . Today went from rehab to see Dr. , sent to EW with\n hypotension. SBP 70 in EW, transiently on dopa, but cardiology d/c'd.\n Rxd with NS 250 cc with SBP 92. Pt has been in rehab since d/c from\n with septic arthritis in L shoulder, hip and R knuckle.\n On Vanco followed by ID.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt given ultram/Tylenol at bedtime for overall pain and pain at coccyx\n wound site. Appears comfortable and sleeping most of nite.\n Action:\n Given ultram and Tylenol as ordered- no prn MSO4 this shift.\n Response:\n Sleeping comfortably. Easy to fall back asleep, comfortable, even after\n changing postion frequently throughout nite.\n Plan:\n Continue to closely monitor pain level. Medicate, reposition, emotional\n support. Attempt to keep pt free of pain.\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Pt w long standing ESHD currently admitted from PCP office for LE\n edema/hypotension for inotropy/diuresis.\n Action:\n Pt started on milrinone 0.375 gtt after 50 mcg/kg bolus- started on low\n dose lasix gtt for diuresis once established that hemodynamics remained\n stable w initiaton of milrinone gtt.\n Response:\n Pt\ns hemodynamics remaining stable after milrinone gtt started- HR-\n 70\ns V paced, no significant VEA. BP 90/40\n goal MAP > 60 met this\n shift. Fair uo from lasix- increased from 2.5-5 mg/hr per team ordered.\n Plan:\n Continue to closely monitor hemodynamics, level of edema/volume\n overload and attempt to diurese w lasix gtt. Consider bolus? Of lasix\n as well as increasing gtt and/or adding zaroxylin to augment response\n to lasix gtt. Keep pt and family aware of plan of care, current\n progress.\n Impaired Skin Integrity\n Assessment:\n Pt admitted to CCU w stage 3 coccyx wound. Currently dressed w mepiplex\n after cleaning site. Dressing remains dry/intact.\n Action:\n Frequent turning side to side w 2 assist- fair tolerance of turning,\n not assisting w turning, and wanting to be\nleft alone and let me\n sleep\n. Applied aloe vesta to back/hips/bony prominences. Applied\n waffle boots to bilateral feet to prevent edematous heels from breaking\n down.\n Response:\n Dressing remains dry/intact.\n Plan:\n Continue to protect skin at risk. Continue to treat current wound w\n dressing as currently are doing. Consult w skin care RN. Of note- pt\n refuses kinair bed.\n"
},
{
"category": "Nursing",
"chartdate": "2180-01-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 399764,
"text": "Pt is a 71 yo female with PMH: BM stent to LAD ', Occluded RCA\n without intervention, Ischemic CM (EF 10-25%), BiV ICD, AF, PVD, DVT\n s/p IVC filter, coumadin, hypothyroidism, CKD, OA. adm for HF\n (milrinone/lasix) MRSA in L shoulder, L hip and R knuckle. Out to\n rehab . went from rehab to see Dr. , sent to EW with\n hypotension. SBP 70 in EW, transiently on dopa, but cardiology d/c'd.\n Rxd with NS 250 cc with SBP 92. Pt has been in rehab since d/c from\n with septic arthritis in L shoulder, hip and R knuckle.\n On Vanco followed by ID.\n She was started on milrinone .375 after bolus and lasix drip also begun\n at 2.5mg/hr. The lasix dose was increased to 5mg overnight, but urine\n output has remained poor, though she is negative.\n GI: Pt has poor apetite and eats very little.\n SOCIAL: Family in the visit in afternoon. Pt in good spirits, visiting\n with brother and his family.\n CODE STATUS: Dr had discussion with both patient and health care\n proxy and all are in agreement that she be DNR/DNI. Additionally the\n defibrillator part of AICD/pacer was shut off.\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2180-01-12 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 399684,
"text": "Chief Complaint: Fluid overload\n HPI:\n 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\n recently discharged from the CCU () for CHF exacerbation c/b\n C.diff infection and on for septic joint washout c/b failure to\n extubate CHF exacerbation, who is now being admitted from \n clinic with total body fluid overload.\n .\n Ms. is a resident at NE where she is convalescing from a\n polyarticular MRSA septic arthritis. She has NYHA IV CHF at baseline\n but over the last 4 days has developed 4+ LE edema and ascites where\n there was previously none. She was presented with the choice to pursue\n cardiac transplantation more than 12 years ago when given the diagnosis\n of end-stage CHF. She opted against that.\n .\n Per her recent visit note at clinic, she continues to have L\n shoulder pain, though significantly improved from a few weks ago. She\n continues to work with PT to improve her ROM. She has no pain at her R\n 3rd MCP, though has difficulty extending her finger at that joint. She\n continues to have mild pain and significant weakness at her L\n hip, though improved since hospital discharge. She has had no\n F/C/NS, and no problems with her midline. She has had progression\n of a sacral decub, which gives her the majority of her pain.\n There has not been concern on the part of her rehab for\n superinfection, and it is being treated with local wound care and\n frequent turning. Her sister is hoping to transfer her to \n within the next several days.\n Patient admitted from: ER\n History obtained from Patient, Family / Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Milrinone - 0.375 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension\n 2. CARDIAC HISTORY:\n -CABG: None\n -PERCUTANEOUS CORONARY INTERVENTIONS: BM stent to the LAD in ,\n Occluded RCA/no intervention\n -PACING/ICD: Ischemic cardiomyopathy (EF 10%) s/p BiV ICD and atrial\n fibrillation\n 3. H/o PE secondary to DVT s/p IVC filter on Coumadin\n 4. PVD\n 5. Small VSD\n OTHER\n # Septic Polyarticular Arthritis s/p irrigation and debridement left\n shoulder via anterolateral deltopectoral miniarthrotomy, aspiration\n left hip joint and irrigation and debridement of 3rd\n metacarpophalangeal joint\n 6. Hypothyroidism\n 7. CKD\n 8. Osteoarthritis\n Mother had MI at age 50, maternal uncle died of MI in his 50's.\n No family history of arrhythmia, cardiomyopathies, or sudden cardiac\n death; otherwise non-contributory.\n Occupation: retired\n Drugs: none\n Tobacco: 20 pack year history, however she quit 30 yrs ago\n Alcohol: none\n Other: Pt lives alone but currently resides at NE . She is not\n married. She is cared for primarily by her Niece and sister, both\n nurses.\n Review of systems:\n Constitutional: Fatigue\n Integumentary (skin): painful decub's\n Flowsheet Data as of 08:40 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 35.4\nC (95.8\n Tcurrent: 35.4\nC (95.8\n HR: 70 (70 - 108) bpm\n BP: 83/50(58) {83/50(58) - 109/76(84)} mmHg\n RR: 12 (11 - 18) insp/min\n SpO2: 100%\n Heart rhythm: V Paced\n Wgt (current): 82.2 kg (admission): 82.2 kg\n Total In:\n 284 mL\n PO:\n 30 mL\n TF:\n IVF:\n 4 mL\n Blood products:\n Total out:\n 0 mL\n 350 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -66 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 100%\n Physical Examination\n General Appearance: Thin, Anxious, Cachectic, tearful\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic), II/VI\n systolic murmur best at apex. PMI is laterally displaced\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear :\n anteriorly)\n Abdominal: Soft, Non-tender, Distended, +fluid wave\n Extremities: Right lower extremity edema: 4+, Left lower extremity\n edema: 4+, cool, dry\n Skin: Cool, Stage 3+ sacral decub\n Neurologic: Attentive, Responds to: Not assessed, Oriented (to): x3,\n Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n [image002.jpg]\n Imaging: TTE :\n The left atrium is elongated. The right atrium is markedly dilated. The\n interatrial septum is aneurysmal. The estimated right atrial pressure\n is 10-20mmHg. Left ventricular wall thicknesses are normal. The left\n ventricular cavity is moderately dilated with severe global\n hypokinesis. The basal inferolateral wall contracts best (LVEF = 20 %).\n The estimated cardiac index is borderline low (2.0-2.5L/min/m2). No\n masses or thrombi are seen in the left ventricle. The right ventricular\n cavity is moderately dilated with severe global free wall hypokinesis.\n [Intrinsic right ventricular systolic function is likely more depressed\n given the severity of tricuspid regurgitation.] The ascending aorta is\n mildly dilated. The aortic valve leaflets (3) are mildly thickened but\n aortic stenosis is not present. Trace aortic regurgitation is seen. The\n mitral valve leaflets are mildly thickened. There is no mitral valve\n prolapse. Mild to moderate (+) mitral regurgitation is seen.\n Moderate to severe [3+] tricuspid regurgitation is seen. There is\n moderate pulmonary artery systolic hypertension. Significant pulmonic\n regurgitation is seen. There is a very small circumferential\n pericardial effusion without echocardiographic signs of tamponade.\n Compared with the prior study (images reviewed) of ,\n estimated pulmonary artery systolic pressure is now higher.\n .\n ETT: \n INTERPRETATION: This 64 year old woman with a history of CAD, atrial\n fibrillation and CHF was referred to the lab for evaluation. The\n patient exercised for 4.25 minutes of a modified protocol and\n requested the test be stopped for nausea. The resting oxygen\n consumption was 3.2 ml/kg/min with a respiratory exchange ratio of\n 0.75. At peak exercise, her oxygen consumption increased to 11.0\n ml/kg/min with an expiratory exchange ratio of 0.86. The peak oxygen\n consumption was 45 % of predicted. The oxygen consumption at the onset\n of the anerobic threshold was 9.9 ml/kg/min. This test was not limited\n by muscle fatigue. No arm, neck, back or chest discomfort was reported\n by the patient throughout the study. The ST segments are\n uninterpretable for ischemia in the setting of the baseline LBBB. The\n rhythm was atrial fibrillation with several isolated vpbs and 2\n ventricular couplets. Blunted systolic BP response to exercise.\n IMPRESSION: Very limited physical working capacity in the absence of\n angina.\n .\n CARDIAC CATH:\n LHC/RHC :\n 1. Selective coronary angiography of this right dominant system\n revealed one vessel coronary artery disease. The LMCA had no\n angiographically apparent disease. The LAD had mild instent restenosis\n of the prior stent. The LCx had no angiographically apparent disease.\n The RCA was occluded and similar to prior.\n 2. Resting hemodynamics on milrinone therapy revealed moderately\n elevated right and left sided filling pressures with an RVEDP of\n 15 mmHg and PCWP of 20 mmHg. There was moderate pulmonary hypertension\n with a PASP of 42/20 mmHg. There was normal systemic blood pressure\n with central pressure of 108/63 mmHg. There was a low-normal cardiac\n index of 2.1 L/min/m2. There was no transaortic valve gradient on\n careful pullback from LV to aorta.\n 3. Peripheral angiography revealed patent renal arteries bilaterally.\n .\n MYOCARDIAL VIABILITY STUDY :\n Within limitation of current study, fixed defects in distal anterior\n and apical walls are consistent with scarring. Improvement of inferior\n wall defect with correction is suggestive of myocardial viability.\n Microbiology: Hx of MRSA bacteremia, septic arthritis\n Assessment and Plan\n ASSESSMENT AND PLAN\n 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\n recently discharged from the CCU () for CHF exacerbation c/b\n C.diff infection and on for septic joint washout c/b failure to\n extubate CHF exacerbation, who is now being admitted from \n clinic with total body fluid overload.\n .\n # Anasarca: Patient has history of CHF ischemic , 10%, s/p\n BiV ICD ( Concerto C154DWK) 1/08with EF 10% which is the\n likely cause of her fluid overload. Her rapid accumulation underpins\n the severity of her condition and her severely unfavourable\n hemodynamics. Her long term goals are comfort, though she still wishes\n to participate in rehab. Her family recognizes that she is dying. Our\n goal is diuresis which we will attempt aggressively, reassessing our\n progress dynamically.\n -- milrinone with bolus\n -- neosynephrine for pressure support, goal MAP of > 60\n -- slow uptitration of lasix with goal near-continuous diuresis while\n avoiding MAP < 60\n -- strict i/o's with foley\n -- can switch to levophed if low UOP on Neo with need for pressor\n support\n -- family meeting with HCP to assess goals in AM after diuresis\n attempted\n .\n # Septic Joints: Patient with history +staph aureus in left shoulder\n treated by washout and vancomycin, thus far 4 weeks of monotherapy. No\n + blood cx since before . Major issue now is pain control.\n -- send Vanco level in AM, was recently on 500 mg q12 and switched to\n q24 for high troughs\n -- ultram q6, Tylenol q8, Morphine for breakthrough (1-3 mg).\n - Will consider ms contin if no control\n .\n # CORONARIES: Patient with h/o CAD w/ right dominant system, mild\n instent re-stenois of the LAD BM stent and occluded RCA.\n - bb as tolerated\n .\n # RHYTHM: Patient with h/o atrial fibrillation, s/p BiV ICD (\n Concerto C154DWK) , on coumadin. Now in paced rhythm\n - cont home dose meds (amio, metoprolol)\n - cont coumadin\n - f/u INR\n .\n # Chronic Kidney Disease: Baseline 1.3 creatinine. At baseline\n - trend\n .\n # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a\n filter in place.\n - cont coumadin\n - f/u INR\n .\n # Hypothyroidism: Continue Levothyroxine.\n .\n # Gout: continue allopurionl\n .\n # FEN: low sodium diet\n .\n # ACCESS: Right PICC, right IJ, Left EJ\n .\n # PROPHYLAXIS: on coumadin\n .\n # CODE: DNR, can intubate, briefly\n .\n # DISPO: CCU for now.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 05:34 PM\n Midline - 05:34 PM\n 18 Gauge - 05:35 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2180-01-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 399685,
"text": "Pt is a 71 yo female with PMH: BM stent to LAD ', Occluded RCA\n without intervention, Ischemic CM (EF 10-25%), BiV ICD, AF, PVD, DVT\n s/p IVC filter, coumadin, hypothyroidism, CKD, OA. adm for HF\n (milrinone/lasix) MRSA in L shoulder, L hip and R knuckle. Out to\n rehab . Today went from rehab to see Dr. , sent to EW with\n hypotension. SBP 70 in EW, transiently on dopa, but cardiology d/c'd.\n Rxd with NS 250 cc with SBP 92. Pt has been in rehab since d/c from\n with septic arthritis in L shoulder, hip and R knuckle.\n On Vanco followed by ID.\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2180-01-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 400114,
"text": "71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\n : Sent to ED from clinic w/ hypotension\n transiently on\n dopa, Tx\nd w/ NS 250 cc w/ SBP ^ 92.\n Admit to CCU for aggressive diuresis.She was started on Milrinone\n and lasix gtt. And has been diuresing well. She has lg coccyx decub\n that is a source of chronic pain. She is DNR/DNI and defibrillator has\n been shut off.\n Pain control (acute pain, chronic pain)\n Assessment:\n Family deciding if pt will now be CMO and go to extended care facility\n with hospice.\n Action:\n Response:\n Plan:\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2180-01-14 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 399833,
"text": "Chief Complaint:\n 24 Hour Events:\n - confirmed DNR, acemaker turned off\n - despite lasix gtt, diuresis poor yesterday\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Ciprofloxacin - 08:00 AM\n Infusions:\n Other ICU medications:\n Coumadin (Warfarin) - 04:00 PM\n Lansoprazole (Prevacid) - 04:00 PM\n Morphine Sulfate - 05:05 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.4\nC (97.5\n HR: 99 (66 - 104) bpm\n BP: 91/50(60) {82/42(45) - 101/67(120)} mmHg\n RR: 12 (11 - 23) insp/min\n SpO2: 99%\n Heart rhythm: V Paced\n Wgt (current): 82.2 kg (admission): 82.2 kg\n Total In:\n 1,554 mL\n 456 mL\n PO:\n 900 mL\n 60 mL\n TF:\n IVF:\n 654 mL\n 396 mL\n Blood products:\n Total out:\n 1,628 mL\n 1,505 mL\n Urine:\n 1,628 mL\n 1,505 mL\n NG:\n Stool:\n Drains:\n Balance:\n -74 mL\n -1,049 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///27/\n Physical Examination\n General Appearance: No acute distress, thin, cachectic\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: II/VI systolic murmur best at apex. MI is laterally\n displaced\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Breath Sounds: Clear : anteriorly)\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+\n Skin: Not assessed, Stage 3 sacral decubitus ulcer\n Neurologic: Attentive, Responds to: Not assessed, Oriented (to): x3\n Labs / Radiology\n 159 K/uL\n 10.0 g/dL\n 104 mg/dL\n 1.4 mg/dL\n 27 mEq/L\n 3.8 mEq/L\n 42 mg/dL\n 98 mEq/L\n 134 mEq/L\n 31.9 %\n 4.7 K/uL\n [image002.jpg]\n 05:44 AM\n 04:46 AM\n WBC\n 6.1\n 4.7\n Hct\n 32.1\n 31.9\n Plt\n 156\n 159\n Cr\n 1.3\n 1.4\n Glucose\n 83\n 104\n Other labs: PT / PTT / INR:16.8/29.3/1.5, Ca++:8.0 mg/dL, Mg++:2.1\n mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\n recently discharged from the CCU () for CHF exacerbation c/b\n C.diff infection and on for septic joint washout c/b failure to\n extubate CHF exacerbation, who is now being admitted from \n clinic with total body fluid overload.\n .\n # sCHF exacerbation: Patient has history of CHF ischemic , \n 10%, s/p BiV ICD ( Concerto C154DWK) 1/08with EF 10% which is\n the likely cause of her fluid overload. Her rapid accumulation\n underpins the severity of her condition and her severely unfavourable\n hemodynamics. Her long term goals are comfort, though she still wishes\n to participate in rehab. Her family recognizes that she is dying. Our\n goal is diuresis which we will attempt aggressively, reassessing our\n progress dynamically. She put out very little o/n on lasix gtt. This\n could reflect limitatin of diuresis or the importance of a bolus (we\n withheld bolus to avoid instability)\n -- goal diuresis 5 to 10L total\n -- milrinone with bolus\n -- metoprolol tartrate 12.5mg PO BID\n -- slow uptitration of lasix gtt with goal near-continuous diuresis\n while avoiding MAP < 60\n -- strict i/o's with foley\n -- replete K to 5\n -- PM electrolytes\n -- can switch to levophed if low UOP on Neo with need for pressor\n support\n -- family meeting with HCP to assess goals in AM after diuresis\n attempted\n .\n # Septic Joints: Patient with history +staph aureus in left shoulder\n treated by washout and vancomycin, thus far 4 weeks of monotherapy. No\n + blood cx since before . Major issue now is pain control.\n -- send Vanco level in AM, was recently on 500 mg q12 and switched to\n q24 for high troughs\n -- ultram q6, Tylenol q8, Morphine for breakthrough (2-4 mg).\n - Will consider ms contin if no control\n .\n # Sacral Decub - stage 3-4.\n - wound care\n - pain control.\n .\n # UTI: positive UA, no history of culture positive UA's in system\n - treating empirically with cipro\n - watch INR on abx\n .\n # CORONARIES: Patient with h/o CAD w/ right dominant system, mild\n instent re-stenois of the LAD BM stent and occluded RCA.\n - bb as tolerated\n .\n # RHYTHM: Patient with h/o atrial fibrillation, s/p BiV ICD (\n Concerto C154DWK) , on coumadin. Now in paced rhythm\n - cont home dose meds (amio, metoprolol)\n - cont coumadin\n - f/u INR\n .\n # Chronic Kidney Disease: Baseline 1.3 creatinine. At baseline\n - trend\n .\n # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a\n filter in place.\n - continue Coumadin\n - f/u INR\n .\n # Hypothyroidism: Continue Levothyroxine\n .\n # Gout: continue Allopurinol\n ICU Care\n Nutrition: cardiac diet\n Glycemic Control: None\n Lines:\n Multi Lumen - 05:34 PM\n Midline - 05:34 PM\n 18 Gauge - 05:35 PM\n Prophylaxis:\n DVT: Coumadin\n Stress ulcer: Lansoprazole\n VAP:\n Comments:\n Communication: patient\n Code status: DNR/DNI\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2180-01-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 400046,
"text": "71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\n : Sent to ED from clinic w/ hypotension\n transiently on\n dopa, Tx\nd w/ NS 250 cc w/ SBP ^ 92. Admit to CCU for aggressive\n diuresis.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt needing less doses IV Morphine since MS Contin increased to 30mg \n this morning\n Pt consistently states pain is at coccyx\n immediate area of pressure\n ulcer and nowhere else\n Action:\n Received MS Contin 15mg x 2 this AM\n Continues on Tylenol 1000mg po TID, Ultram 50mg QID\n Received Morphine IV 4mg approx every 2 hours this am x total 4 doses\n none since approx 1245\n Response:\n Pt appears more comfortable this PM\n able to turn w/o premedicating with IV Morphine\n Pt states pain is which she states is good for her\n Plan:\n Cont assess pain, cont ATC meds and supplement with IV Morphine as\n needed\n ? etiology of severe pain\n ESR ordered to r/o osteo\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Pt asystomatic\n no SOB with stable VS\n Action:\n Milrinone remains at 0,5mcgs/kg/min\n Lasix increased from 5 to 10mg/hr\n Response:\n Initial urine output ~ 200cc/hr in AM\n now decreased to 20-40cc/hr,\n Lasix gtt titrated back to 10mg/hr with slight increase output\n Plan:\n Cont IV Lasix/Mirinone overnight and D/C in AM\n Transition to oral regimen, Assess response\n Impaired Skin Integrity\n Assessment:\n Large unstageable pressur ulcer on coccyx unchanged\n Bilat heels remain reddened but blanchble\n Old abrasion to r elbow\n Action:\n dressing coming off\n cleansed and redressed this AM-duoderm\n gel/Mepilex,\n mod amt sero-sanguinous drainage; redness/maceration to surrounding\n tissue\n severe pain at site\n see above\n Response:\n Site remains unchanged\n Plan:\n Cont keep PU clean with intact dressing, frequent turns avoiding back\n except when pt sitting upright for meals\n Wound care RN consult in AM\n Roho cushion ordered from PT\n unavailable today\n Ineffective Coping\n Assessment:\n Pt continues to have periods in day when she has difficulty coping with\n plan to return to rehab\n Action:\n Pt allowed to verbalize feelings about rehab, realizes she is unable to\n return home\n Response:\n Pt appears to have periods of\nmeltdown\n with periods of rational\n thought regarding needs and abilities going forward\n Plan:\n Case Manager consult in AM\n Social Service consult in AM.\n Cont to provide emotional support for patient.\n Of note, pt w/o bowel movement x 4 days, appetite good, abdomen soft,\n non-tender with + BS, lots of belching at dinner, Senna given 3x since\n yesterday; Plan: increase bowel regimen given ^ nacotics; cont to\n follow.\n"
},
{
"category": "Nursing",
"chartdate": "2180-01-19 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 400237,
"text": "71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\n coumadin, hypothyroidism, CKD, OA. admitted for septic joint\n washout- MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\n On pt. was sent to ED from clinic w/ hypotension\n transiently on dopa, Tx\nd w/ NS 250 cc w/ SBP ^ 92.\n Admit to CCU for aggressive diuresis. She was started on\n Milrinone and lasix gtt. She has large coccyx decub that is a source\n of chronic pain. She is DNR/DNI and defibrillator has been shut off.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt. with history of pain in left shoulder, left hip (septic joints) and\n coccyx (decub.).\n Action:\n MS , morphine IR 15mg for breakthrough pain, given this x2\n today. Pt. also given 2mg IV morphine prior to all activity/turning\n today. Pt. receiving ultram qid.\n Response:\n Pt. has denied pain today until 1500\n she reported pain after turning\n despite premedicating. Tolerating above with no ill-effects.\n Plan:\n Continue present around-the-clock and prn regimen.\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Off lasix gtt since , and milrinone since . AV paced at 70 with\n BP 90\ns/60\ns today. LS essentially clear, some fine ?dependent\n crackles noted at bases. Skin warm, dry. UO approximately 20cc/hr.\n Action:\n Given all meds this a.m. Assessment ongoing.\n Response:\n Pt. tolerating medication. Assessment unchanged.\n Plan:\n Continue to monitor and treat as indicated. Transfer to floor today.\n Impaired Skin Integrity\n Assessment:\n Pt. with sacral decub as documented in metavision.\n Action:\n Dressing changed today at noon per skin care recs. Pt. turned side to\n side as documented.\n Response:\n Pt. tolerated dressing change, premedicated with morphine IV.\n Moderated amt. yellow-white slough noted. Small amounts drainage\n noted.\n Plan:\n Continue daily dressing changes skin RN. Continue turning as pt.\n tolerates, avoid pressure points.\n"
},
{
"category": "Nursing",
"chartdate": "2180-01-19 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 400224,
"text": "71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\n coumadin, hypothyroidism, CKD, OA. admitted for septic joint\n washout- MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\n On pt. was sent to ED from clinic w/ hypotension\n transiently on dopa, Tx\nd w/ NS 250 cc w/ SBP ^ 92.\n Admit to CCU for aggressive diuresis. She was started on\n Milrinone and lasix gtt. She has large coccyx decub that is a source\n of chronic pain. She is DNR/DNI and defibrillator has been shut off.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt. with history of pain in left shoulder, left hip (septic joints) and\n coccyx (decub.).\n Action:\n MS , morphine IR 15mg for breakthrough pain, given this\n a.m. Pt. also given 2mg IV morphine prior to all activity/turning\n today. Pt. receiving ultram qid.\n Response:\n Pt. has denied pain today, tolerating above with no ill-effects.\n Plan:\n Continue present around-the-clock and prn regimen.\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Off lasix gtt since , and milrinone since . AV paced at 70 with\n BP 90\ns/60\ns today. LS essentially clear, some fine dependent crackles\n noted at bases. Skin warm, dry.\n Action:\n P\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2180-01-19 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 400225,
"text": "Chief Complaint: Congestive heart failure\n 24 Hour Events:\n - DCed milrinone and diuretics 11:30am\n - Family mtg held with patient's 3 sisters and multiple other family\n members, Dr. , then (P&PC) Dr. --> everybody in\n agreement w plan to DC milrinone, to give small 250cc boluses as needed\n if BP drops and morphine for symptoms if lungs become overloaded w\n fluid ; Hold on Rehab for now\n - Likely transfer pt to floor tomorrow w PPC following\n - BPs still stable 88-96 SBP (maps>60) at 1am, though family had been\n concerned occasionally that she looked like she had more difficulty\n breathing or increased apneic episodes, though nursing does not feel\n that she has had any difficulty breathing (pt has not needed any 250cc\n boluses at this point)\n - 0430am systolic BPs low 70s, but mentating well, not symptomatic -->\n 1 bag 250ccs NS\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Ciprofloxacin - 10:00 AM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 06:31 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 35.6\nC (96\n HR: 71 (68 - 101) bpm\n BP: 79/58(62) {73/42(51) - 107/73(77)} mmHg\n RR: 11 (9 - 23) insp/min\n SpO2: 92%\n Heart rhythm: V Paced\n Wgt (current): 73.6 kg (admission): 82.2 kg\n Height: 60 Inch\n Total In:\n 743 mL\n 370 mL\n PO:\n 600 mL\n 120 mL\n TF:\n IVF:\n 143 mL\n 250 mL\n Blood products:\n Total out:\n 1,190 mL\n 200 mL\n Urine:\n 1,190 mL\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n -447 mL\n 170 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 92%\n ABG: ////\n Physical Examination\n Gen: alert, oriented x3, pleasant, cachectic chronically ill appearing\n woman. In no acute distress.\n HEENT: dry mucus membranes\n NECK: JVP unable to be assessed secondary to line\n CHEST: clear to auscultation bilaterally\n ABD: mildly distended, soft, nontender\n EXT: + pitting edema lower extremity edema bilaterally\n Labs / Radiology\n 116 K/uL\n 10.2 g/dL\n 93 mg/dL\n 1.0 mg/dL\n 35 mEq/L\n 3.8 mEq/L\n 32 mg/dL\n 91 mEq/L\n 132 mEq/L\n 31.2 %\n 4.6 K/uL\n [image002.jpg]\n 05:44 AM\n 04:46 AM\n 04:00 PM\n 03:05 AM\n 03:17 PM\n 03:05 AM\n 05:03 PM\n 05:22 AM\n 05:25 PM\n 05:40 AM\n WBC\n 6.1\n 4.7\n 5.1\n 4.4\n 4.2\n 4.6\n Hct\n 32.1\n 31.9\n 33.1\n 32.2\n 30.9\n 31.2\n Plt\n 156\n 159\n 146\n 134\n 106\n 116\n Cr\n 1.3\n 1.4\n 1.3\n 1.2\n 1.1\n 1.0\n 1.0\n 1.0\n 1.1\n 1.0\n Glucose\n 83\n 104\n 155\n 115\n 98\n 107\n 86\n 93\n Other labs: PT / PTT / INR:19.1/29.7/1.7, Ca++:8.1 mg/dL, Mg++:2.1\n mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\n recently discharged from the CCU () for CHF exacerbation c/b\n C.diff infection and on for septic joint washout c/b failure to\n extubate CHF exacerbation, who was admitted from clinic with\n total body fluid overload.\n .\n # sCHF Exacerbation:\n Patient has history of CHF ischemic , 10%, s/p BiV ICD\n ( Concerto C154DWK) with EF 10% which was the likely\n cause of her fluid overload. Appears euvolemic currently. Has\n diuresed well -9L on length of stay. Responding well to torsemide with\n metolazone while on milrinone, but urine output had dropped without\n milrinone on . Diuresed net -500cc over last day. Breathing\n comfortably currently.\n - blood pressure maintained without milrinone, will continue to support\n with IV fluids as needed\n - will start on 20mg torsemide daily for maintenance of volume status.\n .\n # Goals of Care:\n End-stage CHF with long term goals are comfort, though she still wishes\n to participate in rehab. Her family recognizes that she is dying. Pain\n and Palliative Care consulted on for pain control and goals of\n care.\n - appreciate palliative care recommendations\n - call-out to floor on for continued comfort measures. Current\n status remains to continue interventions for acute treatable problems,\n but not to re-escalate treatment for CHF with milrinone.\n - will consider disconnecting IJ for comfort\n .\n # Septic Joints: Patient with history +staph aureus in left shoulder\n treated by washout and vancomycin, thus far 4 weeks of monotherapy. No\n + blood cx since before . Major issue now is pain control.\n - continue vancomycin until , then suppression with doxycycline\n - appreciate ID recommendations.\n -- continue MS contin 30mg and reassess pain med needs\n -- standing ultram q6, Tylenol q8\n .\n # Sacral Decub - stage 3-4. Focusing on Pain control. Pain and\n Palliative Care following with patient. Switched to oral breakthrough\n Morphine with IV as backup. Patient required IV morphine this morning\n while moving.\n - wound care\n - standing ultram Q6h, Tylenol Q8h\n - reassess patient\ns pain requirements\n - continue with oral morphine, will use IV as needed now that patient\n primary goal is comfort.\n .\n # UTI: positive UA, no history of culture positive UA's in system.\n Will do 10day course because of chronic foley.\n - treating empirically with cipro ; day 1 of 10 day course was \n - watch INR on abx\n .\n # Hx CAD:\n Patient with h/o CAD w/ right dominant system, mild instent re-stenois\n of the LAD BM stent and occluded RCA.\n - continue metoprolol 25mg \n .\n # Hx Afib:\n Patient with h/o atrial fibrillation, s/p BiV ICD ( Concerto\n C154DWK) , on coumadin. Now in paced rhythm\n - cont home dose meds (amio, metoprolol)\n - cont coumadin, at current dose.\n - trend INR\n .\n # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a\n filter in place. INR mildly subtherapeutic despite Cipro\n - continue Coumadin\n - monitor INR\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 05:34 PM\n Midline - 05:34 PM\n Prophylaxis:\n DVT: coumadin\n Stress ulcer: lansoprazole\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2180-01-19 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 400226,
"text": "71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\n coumadin, hypothyroidism, CKD, OA. admitted for septic joint\n washout- MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\n On pt. was sent to ED from clinic w/ hypotension\n transiently on dopa, Tx\nd w/ NS 250 cc w/ SBP ^ 92.\n Admit to CCU for aggressive diuresis. She was started on\n Milrinone and lasix gtt. She has large coccyx decub that is a source\n of chronic pain. She is DNR/DNI and defibrillator has been shut off.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt. with history of pain in left shoulder, left hip (septic joints) and\n coccyx (decub.).\n Action:\n MS , morphine IR 15mg for breakthrough pain, given this\n a.m. Pt. also given 2mg IV morphine prior to all activity/turning\n today. Pt. receiving ultram qid.\n Response:\n Pt. has denied pain today, tolerating above with no ill-effects.\n Plan:\n Continue present around-the-clock and prn regimen.\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Off lasix gtt since , and milrinone since . AV paced at 70 with\n BP 90\ns/60\ns today. LS essentially clear, some fine dependent crackles\n noted at bases. Skin warm, dry.\n Action:\n Given all meds this a.m. Assessment ongoing.\n Response:\n Pt. tolerating medication. Assessment unchanged.\n Plan:\n Continue to monitor and treat as indicated. Transfer to floor today.\n Impaired Skin Integrity\n Assessment:\n Pt. with sacral decub as documented in metavision.\n Action:\n Dressing changed today at noon per skin care recs. Pt. turned side to\n side as documented.\n Response:\n Pt. tolerated dressing change, premedicated with morphine IV.\n Moderated amt. yellow-white slough noted. Small amounts drainage\n noted.\n Plan:\n Continue daily dressing changes skin RN. Continue turning as pt.\n tolerates, avoid pressure points.\n"
},
{
"category": "Nursing",
"chartdate": "2180-01-19 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 400223,
"text": "71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\n coumadin, hypothyroidism, CKD, OA. admitted for septic joint\n washout- MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\n On pt. was sent to ED from clinic w/ hypotension\n transiently on dopa, Tx\nd w/ NS 250 cc w/ SBP ^ 92.\n Admit to CCU for aggressive diuresis. She was started on\n Milrinone and lasix gtt. She has large coccyx decub that is a source\n of chronic pain. She is DNR/DNI and defibrillator has been shut off.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt. with history of pain in left shoulder, left hip (septic joints) and\n coccyx (decub.).\n Action:\n MS . Morphine IR 15mg for breakthrough pain, given this\n a.m. Pt. given 2mg IV morphine prior to all activity/turning today.\n Pt. receiving ultram qid.\n Response:\n Excellent effect\n Plan:\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Off lasix gtt since . restarted on milrinone at .5mcq/k/min. for\n low u/o.\n HR 60-70 Vpaced. Occas. PVC. BP 80\ns-90\ns/ MAP 55-60.\n Action:\n Lopressor held for SBP<80.\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2180-01-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 400205,
"text": "71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\n : Sent to ED from clinic w/ hypotension\n transiently on\n dopa, Tx\nd w/ NS 250 cc w/ SBP ^ 92.\n Admit to CCU for aggressive diuresis.She was started on Milrinone\n and lasix gtt. And has been diuresing well. She has lg coccyx decub\n that is a source of chronic pain. She is DNR/DNI and defibrillator has\n been shut off.\n Family meeting with Dr. . Decision made to d/c milrinone,\n torsimide and metalazone. Feeling that pt. intravas. Dry. Focus is on\n comfort. Palliative care following.\n Pain control (acute pain, chronic pain)\n Assessment:\n Currently on SR morphine , ultram QID and Tylenol RTC.\n Supplementing with IR morphine 15mg as needed as well as IV morphine as\n needed for breakthrough pain.\n c/o pain in back d/t sacral decub wound. Grimaces with turning\n /position change. Generally pain subsides once repositioned but\n occas. requires additional pain medication.\n 0600: after turning. Pt. stating pain- not relieved after 10mn.\n Action:\n IR morphine 15mg x1. repositioned q3-4 hours or as needed/requested by\n pt.\n 0600: med with 2mg IV morphine followed by additional 2mg IV at 0630 w\n Response:\n Pt. reports good pain control. Sleeping when left alone. Wakes easily\n and is lucid.\n Able to take pills whole with applesause.\n Plan:\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n HR 70\ns Vpaced. Occas. PVC. BP 80\ns-90/50\ns. dipping to 73-79/\n maps 50 when asleep.\n Action:\n Gave NSB 250cc at 0500 x1 (this treatment plan was discussed on rounds\n with Dr. \n Held PM lopressor dose\n Response:\n Good response\n BP BP 86/56 map 64.\n u/o 20-30cc/hr.\n LS diminished bases. Sats 94-96% when awake. Dipping to 80\ns when\n asleep. Noted for periods of apnea.\n Plan:\n Monitor u/o, sats. Monitor for worsening heart failure symptoms.\n Impaired Skin Integrity\n Assessment:\n Stage 3 decub on coccyx. Followed by wound care RN. Dsg changed QD.\n Not visualized .\n DSD remains intact. No drainage.\n c/o some itching but states not as bad as last night.\n Action:\n Barrier cream to all areas.\n Response:Plan\n Change dsg daily. Sarana lotion prn.\n"
},
{
"category": "Nursing",
"chartdate": "2180-01-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 400207,
"text": "71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\n : Sent to ED from clinic w/ hypotension\n transiently on\n dopa, Tx\nd w/ NS 250 cc w/ SBP ^ 92.\n Admit to CCU for aggressive diuresis.She was started on Milrinone\n and lasix gtt. And has been diuresing well. She has lg coccyx decub\n that is a source of chronic pain. She is DNR/DNI and defibrillator has\n been shut off.\n Family meeting with Dr. . Decision made to d/c milrinone,\n torsimide and metalazone. Feeling that pt. intravas. Dry. Focus is on\n comfort. Palliative care following.\n Pain control (acute pain, chronic pain)\n Assessment:\n Currently on SR morphine , ultram QID and Tylenol RTC.\n Supplementing with IR morphine 15mg as needed as well as IV morphine as\n needed for breakthrough pain.\n c/o pain in back d/t sacral decub wound. Grimaces with turning\n /position change. Generally pain subsides once repositioned but\n occas. requires additional pain medication.\n 0600: after turning. Pt. stating pain- not relieved after 10mn.\n Action:\n IR morphine 15mg x1. repositioned q3-4 hours or as needed/requested by\n pt.\n 0600: med with 2mg IV morphine followed by additional 2mg IV at 0630\n Response:\n Pt. reports good pain control. Sleeping when left alone. Wakes easily\n and is lucid.\n Able to take pills whole with applesause.\n 0645: reports pain . reposttioned\n Plan:\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n HR 70\ns Vpaced. Occas. PVC. BP 80\ns-90/50\ns. dipping to 73-79/\n maps 50 when asleep.\n Action:\n Gave NSB 250cc at 0500 x1 (this treatment plan was discussed on rounds\n with Dr. \n Held PM lopressor dose\n Response:\n Good response\n BP BP 86/56 map 64.\n u/o 20-30cc/hr.\n LS diminished bases. Sats 94-96% when awake. Dipping to 80\ns when\n asleep. Noted for periods of apnea.\n Plan:\n Monitor u/o, sats. Monitor for worsening heart failure symptoms.\n Impaired Skin Integrity\n Assessment:\n Stage 3 decub on coccyx. Followed by wound care RN. Dsg changed QD.\n Not visualized .\n DSD remains intact. No drainage.\n c/o some itching but states not as bad as last night.\n Action:\n Barrier cream to all areas.\n Response:Plan\n Change dsg daily. Sarana lotion prn.\n"
},
{
"category": "Physician ",
"chartdate": "2180-01-19 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 400208,
"text": "Chief Complaint: Congestive heart failure\n 24 Hour Events:\n - DCed milrinone and diuretics 11:30am\n - Family mtg held with patient's 3 sisters and multiple other family\n members, Dr. , then (P&PC) Dr. --> everybody in\n agreement w plan to DC milrinone, to give small 250cc boluses as needed\n if BP drops and morphine for symptoms if lungs become overloaded w\n fluid ; Hold on Rehab for now\n - Likely transfer pt to floor tomorrow w PPC following\n - BPs still stable 88-96 SBP (maps>60) at 1am, though family had been\n concerned occasionally that she looked like she had more difficulty\n breathing or increased apneic episodes, though nursing does not feel\n that she has had any difficulty breathing (pt has not needed any 250cc\n boluses at this point)\n - 0430am systolic BPs low 70s, but mentating well, not symptomatic -->\n 1 bag 250ccs NS\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Ciprofloxacin - 10:00 AM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 06:31 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 35.6\nC (96\n HR: 71 (68 - 101) bpm\n BP: 79/58(62) {73/42(51) - 107/73(77)} mmHg\n RR: 11 (9 - 23) insp/min\n SpO2: 92%\n Heart rhythm: V Paced\n Wgt (current): 73.6 kg (admission): 82.2 kg\n Height: 60 Inch\n Total In:\n 743 mL\n 370 mL\n PO:\n 600 mL\n 120 mL\n TF:\n IVF:\n 143 mL\n 250 mL\n Blood products:\n Total out:\n 1,190 mL\n 200 mL\n Urine:\n 1,190 mL\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n -447 mL\n 170 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 92%\n ABG: ////\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 116 K/uL\n 10.2 g/dL\n 93 mg/dL\n 1.0 mg/dL\n 35 mEq/L\n 3.8 mEq/L\n 32 mg/dL\n 91 mEq/L\n 132 mEq/L\n 31.2 %\n 4.6 K/uL\n [image002.jpg]\n 05:44 AM\n 04:46 AM\n 04:00 PM\n 03:05 AM\n 03:17 PM\n 03:05 AM\n 05:03 PM\n 05:22 AM\n 05:25 PM\n 05:40 AM\n WBC\n 6.1\n 4.7\n 5.1\n 4.4\n 4.2\n 4.6\n Hct\n 32.1\n 31.9\n 33.1\n 32.2\n 30.9\n 31.2\n Plt\n 156\n 159\n 146\n 134\n 106\n 116\n Cr\n 1.3\n 1.4\n 1.3\n 1.2\n 1.1\n 1.0\n 1.0\n 1.0\n 1.1\n 1.0\n Glucose\n 83\n 104\n 155\n 115\n 98\n 107\n 86\n 93\n Other labs: PT / PTT / INR:19.1/29.7/1.7, Ca++:8.1 mg/dL, Mg++:2.1\n mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\n recently discharged from the CCU () for CHF exacerbation c/b\n C.diff infection and on for septic joint washout c/b failure to\n extubate CHF exacerbation, who was admitted from clinic with\n total body fluid overload.\n .\n # sCHF Exacerbation:\n Patient has history of CHF ischemic , 10%, s/p BiV ICD\n ( Concerto C154DWK) with EF 10% which was the likely\n cause of her fluid overload. Appears intravascularly dry on exam. Has\n diuresed well -9L on length of stay. Responding well to torsemide with\n metolazone while on milrinone, but urine output had dropped without\n milrinone yesterday. Diuresed net -500cc over last day. Milrinone is\n keeping her blood pressures up.\n - DC milrinone\n - With no milrinone, she needs help with filling pressures, so\n will DC diuretics b/c appears dry on exam\n - If blood pressure drops without milrinone,, she may benefit\n from 250cc IVF boluses as needed\n - Continue strict I/Os\n - Continue to replete K\n .\n # Goals of Care:\n End-stage CHF with long term goals are comfort, though she still wishes\n to participate in rehab. Her family recognizes that she is dying. Pain\n and Palliative Care consulted yesterday for pain control and goals of\n care.\n - family meeting at 1pm today\n .\n # Septic Joints: Patient with history +staph aureus in left shoulder\n treated by washout and vancomycin, thus far 4 weeks of monotherapy. No\n + blood cx since before . Major issue now is pain control.\n - continue vancomycin until , then suppression with doxycycline\n -- continue MS contin 30mg and reassess pain med needs\n -- standing ultram q6, Tylenol q8\n .\n # Sacral Decub - stage 3-4. Focusing on Pain control. Pain and\n Palliative Care following with patient. Switched to oral breakthrough\n Morphine with IV as backup, but patient was not requiring IV backup.\n - wound care\n - standing ultram Q6h, Tylenol Q8h\n - reassess patient\ns pain requirements\n - goals of care family meeting 1pm today\n .\n # UTI: positive UA, no history of culture positive UA's in system.\n Will do 10day course because of chronic foley.\n - treating empirically with cipro ; day 1 of 10 day course was \n - watch INR on abx\n .\n # Hx CAD:\n Patient with h/o CAD w/ right dominant system, mild instent re-stenois\n of the LAD BM stent and occluded RCA.\n - continue metoprolol 25mg \n .\n # Hx Afib:\n Patient with h/o atrial fibrillation, s/p BiV ICD ( Concerto\n C154DWK) , on coumadin. Now in paced rhythm\n - cont home dose meds (amio, metoprolol)\n - cont coumadin\n - trend INR\n .\n # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a\n filter in place. INR mildly subtherapeutic despite Cipro\n - continue Coumadin\n - monitor INR\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 05:34 PM\n Midline - 05:34 PM\n Prophylaxis:\n DVT: coumadin\n Stress ulcer: lansoprazole\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2180-01-19 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 400214,
"text": "Chief Complaint: Congestive heart failure\n 24 Hour Events:\n - DCed milrinone and diuretics 11:30am\n - Family mtg held with patient's 3 sisters and multiple other family\n members, Dr. , then (P&PC) Dr. --> everybody in\n agreement w plan to DC milrinone, to give small 250cc boluses as needed\n if BP drops and morphine for symptoms if lungs become overloaded w\n fluid ; Hold on Rehab for now\n - Likely transfer pt to floor tomorrow w PPC following\n - BPs still stable 88-96 SBP (maps>60) at 1am, though family had been\n concerned occasionally that she looked like she had more difficulty\n breathing or increased apneic episodes, though nursing does not feel\n that she has had any difficulty breathing (pt has not needed any 250cc\n boluses at this point)\n - 0430am systolic BPs low 70s, but mentating well, not symptomatic -->\n 1 bag 250ccs NS\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Ciprofloxacin - 10:00 AM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 06:31 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 35.6\nC (96\n HR: 71 (68 - 101) bpm\n BP: 79/58(62) {73/42(51) - 107/73(77)} mmHg\n RR: 11 (9 - 23) insp/min\n SpO2: 92%\n Heart rhythm: V Paced\n Wgt (current): 73.6 kg (admission): 82.2 kg\n Height: 60 Inch\n Total In:\n 743 mL\n 370 mL\n PO:\n 600 mL\n 120 mL\n TF:\n IVF:\n 143 mL\n 250 mL\n Blood products:\n Total out:\n 1,190 mL\n 200 mL\n Urine:\n 1,190 mL\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n -447 mL\n 170 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 92%\n ABG: ////\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 116 K/uL\n 10.2 g/dL\n 93 mg/dL\n 1.0 mg/dL\n 35 mEq/L\n 3.8 mEq/L\n 32 mg/dL\n 91 mEq/L\n 132 mEq/L\n 31.2 %\n 4.6 K/uL\n [image002.jpg]\n 05:44 AM\n 04:46 AM\n 04:00 PM\n 03:05 AM\n 03:17 PM\n 03:05 AM\n 05:03 PM\n 05:22 AM\n 05:25 PM\n 05:40 AM\n WBC\n 6.1\n 4.7\n 5.1\n 4.4\n 4.2\n 4.6\n Hct\n 32.1\n 31.9\n 33.1\n 32.2\n 30.9\n 31.2\n Plt\n 156\n 159\n 146\n 134\n 106\n 116\n Cr\n 1.3\n 1.4\n 1.3\n 1.2\n 1.1\n 1.0\n 1.0\n 1.0\n 1.1\n 1.0\n Glucose\n 83\n 104\n 155\n 115\n 98\n 107\n 86\n 93\n Other labs: PT / PTT / INR:19.1/29.7/1.7, Ca++:8.1 mg/dL, Mg++:2.1\n mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\n recently discharged from the CCU () for CHF exacerbation c/b\n C.diff infection and on for septic joint washout c/b failure to\n extubate CHF exacerbation, who was admitted from clinic with\n total body fluid overload.\n .\n # sCHF Exacerbation:\n Patient has history of CHF ischemic , 10%, s/p BiV ICD\n ( Concerto C154DWK) with EF 10% which was the likely\n cause of her fluid overload. Appears euvolemic currently. Has\n diuresed well -9L on length of stay. Responding well to torsemide with\n metolazone while on milrinone, but urine output had dropped without\n milrinone on . Diuresed net -500cc over last day. Breathing\n comfortably currently.\n - blood pressure maintained without milrinone, will continue to support\n with IV fluids as needed\n - no diuretics currently, although will re-assess if she becomes\n dyspneic. More likely will use morphine though for comfort.\n .\n # Goals of Care:\n End-stage CHF with long term goals are comfort, though she still wishes\n to participate in rehab. Her family recognizes that she is dying. Pain\n and Palliative Care consulted on for pain control and goals of\n care.\n - appreciate palliative care recommendations\n - likely call-out to floor on for continued comfort measures.\n - will consider disconnecting IJ for comfort\n .\n # Septic Joints: Patient with history +staph aureus in left shoulder\n treated by washout and vancomycin, thus far 4 weeks of monotherapy. No\n + blood cx since before . Major issue now is pain control.\n - continue vancomycin until , then suppression with doxycycline\n -- continue MS contin 30mg and reassess pain med needs\n -- standing ultram q6, Tylenol q8\n .\n # Sacral Decub - stage 3-4. Focusing on Pain control. Pain and\n Palliative Care following with patient. Switched to oral breakthrough\n Morphine with IV as backup. Patient required IV morphine this morning\n while moving.\n - wound care\n - standing ultram Q6h, Tylenol Q8h\n - reassess patient\ns pain requirements\n - continue with oral morphine, will use IV as needed now that patient\n primary goal is comfort.\n .\n # UTI: positive UA, no history of culture positive UA's in system.\n Will do 10day course because of chronic foley.\n - treating empirically with cipro ; day 1 of 10 day course was \n - watch INR on abx\n .\n # Hx CAD:\n Patient with h/o CAD w/ right dominant system, mild instent re-stenois\n of the LAD BM stent and occluded RCA.\n - continue metoprolol 25mg \n .\n # Hx Afib:\n Patient with h/o atrial fibrillation, s/p BiV ICD ( Concerto\n C154DWK) , on coumadin. Now in paced rhythm\n - cont home dose meds (amio, metoprolol)\n - cont coumadin, at current dose.\n - trend INR\n .\n # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a\n filter in place. INR mildly subtherapeutic despite Cipro\n - continue Coumadin\n - monitor INR\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 05:34 PM\n Midline - 05:34 PM\n Prophylaxis:\n DVT: coumadin\n Stress ulcer: lansoprazole\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2180-01-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 400199,
"text": "71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\n : Sent to ED from clinic w/ hypotension\n transiently on\n dopa, Tx\nd w/ NS 250 cc w/ SBP ^ 92.\n Admit to CCU for aggressive diuresis.She was started on Milrinone\n and lasix gtt. And has been diuresing well. She has lg coccyx decub\n that is a source of chronic pain. She is DNR/DNI and defibrillator has\n been shut off.\n Family meeting with Dr. . Decision made to d/c milrinone,\n torsimide and metalazone. Feeling that pt. intravas. Dry. Focus is on\n comfort. Palliative care following.\n Pain control (acute pain, chronic pain)\n Assessment:\n Currently on SR morphine , ultram QID and Tylenol RTC.\n Supplementing with IR morphine 15mg as needed as well as IV morphine as\n needed for breakthrough pain.\n c/o pain in back d/t sacral decub wound. Grimaces with turning\n /position change. Generally pain subsides once repositioned but\n occas. requires additional pain medication.\n Action:\n IR morphine 15mg x1. repositioned q3-4 hours or as needed/requested by\n pt.\n Response:\n Pt. reports good pain control. Sleeping when left alone. Wakes easily\n and is lucid.\n Able to take pills whole with applesause.\n Plan:\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n HR 70\ns Vpaced. Occas. PVC. BP 80\ns-90/50\ns. dipping to 73-79/\n maps 50 when asleep.\n Action:\n Gave NSB 250cc at 0500 x1 (this treatment plan was discussed on rounds\n with Dr. \n Held PM lopressor dose\n Response:\n Good response\n BP BP 86/56 map 64.\n u/o 20-30cc/hr.\n LS diminished bases. Sats 94-96% when awake. Dipping to 80\ns when\n asleep. Noted for periods of apnea.\n Plan:\n Monitor u/o, sats. Monitor for worsening heart failure symptoms.\n Impaired Skin Integrity\n Assessment:\n Stage 3 decub on coccyx. Followed by wound care RN. Dsg changed QD.\n Not visualized .\n DSD remains intact. No drainage.\n c/o some itching but states not as bad as last night.\n Action:\n Barrier cream to all areas.\n Response:Plan\n Change dsg daily. Sarana lotion prn.\n"
},
{
"category": "Nursing",
"chartdate": "2180-01-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 400197,
"text": "71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\n : Sent to ED from clinic w/ hypotension\n transiently on\n dopa, Tx\nd w/ NS 250 cc w/ SBP ^ 92.\n Admit to CCU for aggressive diuresis.She was started on Milrinone\n and lasix gtt. And has been diuresing well. She has lg coccyx decub\n that is a source of chronic pain. She is DNR/DNI and defibrillator has\n been shut off.\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2180-01-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 399736,
"text": "Pt is a 71 yo female with PMH: BM stent to LAD ', Occluded RCA\n without intervention, Ischemic CM (EF 10-25%), BiV ICD, AF, PVD, DVT\n s/p IVC filter, coumadin, hypothyroidism, CKD, OA. adm for HF\n (milrinone/lasix) MRSA in L shoulder, L hip and R knuckle. Out to\n rehab . went from rehab to see Dr. , sent to EW with\n hypotension. SBP 70 in EW, transiently on dopa, but cardiology d/c'd.\n Rxd with NS 250 cc with SBP 92. Pt has been in rehab since d/c from\n with septic arthritis in L shoulder, hip and R knuckle.\n On Vanco followed by ID.\n She was started on milrinone .375 after bolus and lasix drip also begun\n at 2.5mg/hr. The lasix dose was increased to 5mg overnight, but urine\n output has remained poor, though she is negative.\n GI: Pt has poor apetite and eats very little.\n CODE STATUS: Dr had discussion with both patient and health care\n proxy and all are in agreement that she be DNR/DNI. Additionally the\n defibrillator part of AICD/pacer was shut off.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt has a number of sources of pain. She has joint pain in shoulders and\n especially R elbow from septic arthritis. The most uncomfortable area\n is the decubitus ulcer on her coccyx area. She receive standing ultran\n for that. She requires frequent position changes, but seems most\n uncomfortable on L side. By 1000 she was very uncomfortable.\n Action:\n She received 2mg IV morpnine sulfate at 1230 and had shift in position\n and was comfortable until noon when pain recurred. She received another\n 2mg morphine sulfate and position change.\n Response:\n She slept until\n Plan:\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Pt on Milrinone .375mic/kilo and lasix 5mg/hr. Urine output\n ~30-50cc/hr. Hr in 70s AV paced with rare PVCs . BP 85-100/50-60s,\n lower after morphine. Pt sating 98-100% on 3L NP and lungs are mostly\n clear. She has no c/o of SOB. She has 2+ edema in legs.\n Action:\n At 1030 lasix was increased to 10mg/hr and at 1100 milrinone was\n increased to .5mic/kilo. Legs are kept elevated.\n Response:\n She is ~800cc negative for the day. The skin on her legs show signs\n Plan:\n Impaired Skin Integrity\n Assessment:\n Pt has multiple skin lesions. Most prominent is coccyx decub. It has\n mepelix on it that was leaking through and pulling loose in am. Both\n heels are reddened, though they . She has dry skin on all\n extremities with some small abraded areas.\n Action:\n Coccyx dsg changed. Area primarily covered with slough. The edges are\n rounded and pink. Area cleansed with wound cleaner, dried and new\n mepelix applied. All limbs were lubricated frequently. Her position was\n changed, at times only slightly throughout the day. She does become\n uncomfortable if she is in the same position for too long,but also has\n difficulty on the L side. She finds the waffle boots uncomfortable and\n prefers having her legs elevated on pillows.\n Response:\n No new skin lesions have developed.\n Plan:\n Continue with turning, lubricating and keeping heels elevated. Monitor\n mepilex to ensure it is in place.\n"
},
{
"category": "Social Work",
"chartdate": "2180-01-19 00:00:00.000",
"description": "Social Work Progress Note",
"row_id": 400241,
"text": "SOCIAL WORK: Following pt for emotional support around pt\ncoping. Reviewed notes from palliative care service and\ndiscussed pt's progress with RN . A family meeting was\nheld yesterday with the attending physician and palliative care\nservice to review pt's progress and goals of care.\nPt is sitting up in bed finishing her breakfast at present. Pt\nis somnolent; her eyes closing at times. Pt speech is slow and\nmeasured, as are her movements. She engages readily with SW, but\nstops herself when speaking, easily losing her concentration. Pt\npresents today with the same sad affect from prior\nhospitalization in . Pt's mood is congruent: \"worried.\"\nPt reports she is very concerned about her niece (primary HCP)\nwho is currently hospitalized in the MICU. Pt states, \"I wish it\nwas me, if anything bad was going to happen, it wouldn't matter.\"\nPt reports that her discussion with the doctors yesterday was\n\"not entirely unexpected\". Pt understands that doctors 't\nknow what is going to happen and if her present medication\nregimen is going to work. Pt elaborates, \"But, I am not in a\nhurry to leave tomorrow.\"\nPt is comforted most by her family being close to her, especially\nnow due to her niece's illness. Pt is looking forward to seeing\nthem later today. Pt gave permission to contact family members.\nMessages left for (sister/Alt. HCP) and (niece) whom\nSW met Monday .\nA/P: Pt is exhibiting normative distress over her niece and\nshows signs of fatigue and discouragement over lengthy\nhospitalization and course of illness. Pt appears to have some\ninsight into her prognosis , but cannot recall specific details\nat this point.\n-SW will continue to follow the pt to provide opportunity to talk\nabout not only death and dying, but provide opportunity to make\nmeaning through life review.\n-SW will continue to provide emotional support around pt's\nconcerns over her own illness and her niece's condition.\n-SW will build rapport with family to provide emotional support\nthrough this process.\n , MSW Intern\nPager \n"
},
{
"category": "Nursing",
"chartdate": "2180-01-19 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 400242,
"text": "71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\n coumadin, hypothyroidism, CKD, OA. admitted for septic joint\n washout- MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\n On pt. was sent to ED from clinic w/ hypotension\n transiently on dopa, Tx\nd w/ NS 250 cc w/ SBP ^ 92.\n Admit to CCU for aggressive diuresis. She was started on\n Milrinone and lasix gtt. She has large coccyx decub that is a source\n of chronic pain. She is DNR/DNI and defibrillator has been shut off.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt. with history of pain in left shoulder, left hip (septic joints) and\n coccyx (decub.).\n Action:\n MS , morphine IR 15mg for breakthrough pain, given this x2\n today. Pt. also given 2mg IV morphine prior to all activity/turning\n today. Pt. receiving ultram qid.\n Response:\n Pt. has denied pain today until 1500\n she reported pain after turning\n despite premedicating. Tolerating above with no ill-effects. Pt.\n painfree by 1600.\n Plan:\n Continue present around-the-clock and aggressive prn regimen.\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Off lasix gtt since , and milrinone since . AV paced at 70 with\n BP 90\ns/60\ns today. LS essentially clear, some fine ?dependent\n crackles noted at bases. Skin warm, dry. UO approximately 20cc/hr.\n Pt. slightly confused this afternoon per family.\n Action:\n Assessment ongoing. Torsemide started.\n Response:\n Pt. tolerating medication. Assessment largely unchanged.\n Plan:\n Continue to monitor and treat as indicated. Transfer to floor today.\n Impaired Skin Integrity\n Assessment:\n Pt. with sacral decub as documented in metavision.\n Action:\n Dressing changed today at noon per skin care recs. Pt. turned side to\n side as documented.\n Response:\n Pt. tolerated dressing change, premedicated with morphine IV.\n Moderated amt. yellow-white slough noted. Small amounts drainage\n noted.\n Plan:\n Continue daily dressing changes skin RN. Continue turning as pt.\n tolerates, avoid pressure points.\n"
},
{
"category": "Nursing",
"chartdate": "2180-01-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 400243,
"text": "71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\n coumadin, hypothyroidism, CKD, OA. admitted for septic joint\n washout- MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\n On pt. was sent to ED from clinic w/ hypotension\n transiently on dopa, Tx\nd w/ NS 250 cc w/ SBP ^ 92.\n Admit to CCU for aggressive diuresis. She was started on\n Milrinone and lasix gtt. She has large coccyx decub that is a source\n of chronic pain. She is DNR/DNI and defibrillator has been shut off.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt. with history of pain in left shoulder, left hip (septic joints) and\n coccyx (decub.).\n Action:\n MS , morphine IR 15mg for breakthrough pain, given this x2\n today. Pt. also given 2mg IV morphine prior to all activity/turning\n today. Pt. receiving ultram qid.\n Response:\n Pt. has denied pain today until 1500\n she reported pain after turning\n despite premedicating. Tolerating above with no ill-effects. Pt.\n painfree by 1600.\n Plan:\n Continue present around-the-clock and aggressive prn regimen.\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Off lasix gtt since , and milrinone since . AV paced at 70 with\n BP 85-90\ns/50-60\ns today. LS essentially clear, some fine crackles\n noted at bases this afternoon. Skin warm, dry. UO approximately\n 20cc/hr. Pt. slightly confused this afternoon per family.\n Action:\n Assessment ongoing. Torsemide started.\n Response:\n Pt. tolerating medication. Assessment largely unchanged.\n Plan:\n Continue to monitor and treat as indicated. Transfer to floor today.\n Impaired Skin Integrity\n Assessment:\n Pt. with sacral decub as documented in metavision.\n Action:\n Dressing changed today at noon per skin care recs. Pt. turned side to\n side as documented.\n Response:\n Pt. tolerated dressing change, premedicated with morphine IV.\n Moderated amt. yellow-white slough noted. Small amounts drainage\n noted.\n Plan:\n Continue daily dressing changes skin RN. Continue turning as pt.\n tolerates, avoid pressure points.\n"
},
{
"category": "Social Work",
"chartdate": "2180-01-19 00:00:00.000",
"description": "Social Work Progress Note",
"row_id": 400244,
"text": "SOCIAL WORK: Following pt for emotional support around pt\ncoping. Reviewed notes from palliative care service and\ndiscussed pt's progress with RN . A family meeting was\nheld yesterday with the attending physician and palliative care\nservice to review pt's progress and goals of care.\nPt is sitting up in bed finishing her breakfast at present. Pt\nis somnolent; her eyes closing at times. Pt speech is slow and\nmeasured, as are her movements. She engages readily with SW, but\nstops herself when speaking, easily losing her concentration. Pt\npresents today with the same sad affect from prior\nhospitalization in . Pt's mood is congruent: \"worried.\"\nPt reports she is very concerned about her niece (primary HCP)\nwho is currently hospitalized in the MICU. Pt states, \"I wish it\nwas me, if anything bad was going to happen, it wouldn't matter.\"\nPt reports that her discussion with the doctors yesterday was\n\"not entirely unexpected\". Pt understands that doctors 't\nknow what is going to happen and if her present medication\nregimen is going to work. Pt elaborates, \"But, I am not in a\nhurry to leave tomorrow.\"\nPt is comforted most by her family being close to her, especially\nnow due to her niece's illness. Pt is looking forward to seeing\nthem later today. Pt gave permission to contact family members.\nMessages left for (sister/Alt. HCP) and (niece) whom\nSW met Monday .\nA/P: Pt is exhibiting normative distress over her niece and\nshows signs of fatigue and discouragement over lengthy\nhospitalization and course of illness. Pt appears to have some\ninsight into her prognosis , but cannot recall specific details\nat this point.\n-SW will continue to follow the pt to provide opportunity to talk\nabout not only death and dying, but provide opportunity to make\nmeaning through life review.\n-SW will continue to provide emotional support around pt's\nconcerns over her own illness and her niece's condition.\n-SW will build rapport with family to provide emotional support\nthrough this process.\n , MSW Intern\nPager \n 05:11 PM\n"
},
{
"category": "Physician ",
"chartdate": "2180-01-13 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 399713,
"text": "Chief Complaint: Fluid overload\n HPI:\n 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\n recently discharged from the CCU () for CHF exacerbation c/b\n C.diff infection and on for septic joint washout c/b failure to\n extubate CHF exacerbation, who is now being admitted from \n clinic with total body fluid overload.\n .\n Ms. is a resident at NE where she is convalescing from a\n polyarticular MRSA septic arthritis. She has NYHA IV CHF at baseline\n but over the last 4 days has developed 4+ LE edema and ascites where\n there was previously none. She was presented with the choice to pursue\n cardiac transplantation more than 12 years ago when given the diagnosis\n of end-stage CHF. She opted against that.\n .\n Per her recent visit note at clinic, she continues to have L\n shoulder pain, though significantly improved from a few weks ago. She\n continues to work with PT to improve her ROM. She has no pain at her R\n 3rd MCP, though has difficulty extending her finger at that joint. She\n continues to have mild pain and significant weakness at her L\n hip, though improved since hospital discharge. She has had no\n F/C/NS, and no problems with her midline. She has had progression\n of a sacral decub, which gives her the majority of her pain.\n There has not been concern on the part of her rehab for\n superinfection, and it is being treated with local wound care and\n frequent turning. Her sister is hoping to transfer her to \n within the next several days.\n Patient admitted from: ER\n History obtained from Patient, Family / Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Milrinone - 0.375 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension\n 2. CARDIAC HISTORY:\n -CABG: None\n -PERCUTANEOUS CORONARY INTERVENTIONS: BM stent to the LAD in ,\n Occluded RCA/no intervention\n -PACING/ICD: Ischemic cardiomyopathy (EF 10%) s/p BiV ICD and atrial\n fibrillation\n 3. H/o PE secondary to DVT s/p IVC filter on Coumadin\n 4. PVD\n 5. Small VSD\n OTHER\n # Septic Polyarticular Arthritis s/p irrigation and debridement left\n shoulder via anterolateral deltopectoral miniarthrotomy, aspiration\n left hip joint and irrigation and debridement of 3rd\n metacarpophalangeal joint\n 6. Hypothyroidism\n 7. CKD\n 8. Osteoarthritis\n Mother had MI at age 50, maternal uncle died of MI in his 50's.\n No family history of arrhythmia, cardiomyopathies, or sudden cardiac\n death; otherwise non-contributory.\n Occupation: retired\n Drugs: none\n Tobacco: 20 pack year history, however she quit 30 yrs ago\n Alcohol: none\n Other: Pt lives alone but currently resides at NE . She is not\n married. She is cared for primarily by her Niece and sister, both\n nurses.\n Review of systems:\n Constitutional: Fatigue\n Integumentary (skin): painful decub's\n Flowsheet Data as of 08:40 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 35.4\nC (95.8\n Tcurrent: 35.4\nC (95.8\n HR: 70 (70 - 108) bpm\n BP: 83/50(58) {83/50(58) - 109/76(84)} mmHg\n RR: 12 (11 - 18) insp/min\n SpO2: 100%\n Heart rhythm: V Paced\n Wgt (current): 82.2 kg (admission): 82.2 kg\n Total In:\n 284 mL\n PO:\n 30 mL\n TF:\n IVF:\n 4 mL\n Blood products:\n Total out:\n 0 mL\n 350 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -66 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 100%\n Physical Examination\n General Appearance: Thin, Anxious, Cachectic, tearful\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic), II/VI\n systolic murmur best at apex. PMI is laterally displaced\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear :\n anteriorly)\n Abdominal: Soft, Non-tender, Distended, +fluid wave\n Extremities: Right lower extremity edema: 4+, Left lower extremity\n edema: 4+, cool, dry\n Skin: Cool, Stage 3+ sacral decub\n Neurologic: Attentive, Responds to: Not assessed, Oriented (to): x3,\n Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n [image002.jpg]\n Imaging: TTE :\n The left atrium is elongated. The right atrium is markedly dilated. The\n interatrial septum is aneurysmal. The estimated right atrial pressure\n is 10-20mmHg. Left ventricular wall thicknesses are normal. The left\n ventricular cavity is moderately dilated with severe global\n hypokinesis. The basal inferolateral wall contracts best (LVEF = 20 %).\n The estimated cardiac index is borderline low (2.0-2.5L/min/m2). No\n masses or thrombi are seen in the left ventricle. The right ventricular\n cavity is moderately dilated with severe global free wall hypokinesis.\n [Intrinsic right ventricular systolic function is likely more depressed\n given the severity of tricuspid regurgitation.] The ascending aorta is\n mildly dilated. The aortic valve leaflets (3) are mildly thickened but\n aortic stenosis is not present. Trace aortic regurgitation is seen. The\n mitral valve leaflets are mildly thickened. There is no mitral valve\n prolapse. Mild to moderate (+) mitral regurgitation is seen.\n Moderate to severe [3+] tricuspid regurgitation is seen. There is\n moderate pulmonary artery systolic hypertension. Significant pulmonic\n regurgitation is seen. There is a very small circumferential\n pericardial effusion without echocardiographic signs of tamponade.\n Compared with the prior study (images reviewed) of ,\n estimated pulmonary artery systolic pressure is now higher.\n .\n ETT: \n INTERPRETATION: This 64 year old woman with a history of CAD, atrial\n fibrillation and CHF was referred to the lab for evaluation. The\n patient exercised for 4.25 minutes of a modified protocol and\n requested the test be stopped for nausea. The resting oxygen\n consumption was 3.2 ml/kg/min with a respiratory exchange ratio of\n 0.75. At peak exercise, her oxygen consumption increased to 11.0\n ml/kg/min with an expiratory exchange ratio of 0.86. The peak oxygen\n consumption was 45 % of predicted. The oxygen consumption at the onset\n of the anerobic threshold was 9.9 ml/kg/min. This test was not limited\n by muscle fatigue. No arm, neck, back or chest discomfort was reported\n by the patient throughout the study. The ST segments are\n uninterpretable for ischemia in the setting of the baseline LBBB. The\n rhythm was atrial fibrillation with several isolated vpbs and 2\n ventricular couplets. Blunted systolic BP response to exercise.\n IMPRESSION: Very limited physical working capacity in the absence of\n angina.\n .\n CARDIAC CATH:\n LHC/RHC :\n 1. Selective coronary angiography of this right dominant system\n revealed one vessel coronary artery disease. The LMCA had no\n angiographically apparent disease. The LAD had mild instent restenosis\n of the prior stent. The LCx had no angiographically apparent disease.\n The RCA was occluded and similar to prior.\n 2. Resting hemodynamics on milrinone therapy revealed moderately\n elevated right and left sided filling pressures with an RVEDP of\n 15 mmHg and PCWP of 20 mmHg. There was moderate pulmonary hypertension\n with a PASP of 42/20 mmHg. There was normal systemic blood pressure\n with central pressure of 108/63 mmHg. There was a low-normal cardiac\n index of 2.1 L/min/m2. There was no transaortic valve gradient on\n careful pullback from LV to aorta.\n 3. Peripheral angiography revealed patent renal arteries bilaterally.\n .\n MYOCARDIAL VIABILITY STUDY :\n Within limitation of current study, fixed defects in distal anterior\n and apical walls are consistent with scarring. Improvement of inferior\n wall defect with correction is suggestive of myocardial viability.\n Microbiology: Hx of MRSA bacteremia, septic arthritis\n Assessment and Plan\n ASSESSMENT AND PLAN\n 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\n recently discharged from the CCU () for CHF exacerbation c/b\n C.diff infection and on for septic joint washout c/b failure to\n extubate CHF exacerbation, who is now being admitted from \n clinic with total body fluid overload.\n .\n # Anasarca: Patient has history of CHF ischemic , 10%, s/p\n BiV ICD ( Concerto C154DWK) 1/08with EF 10% which is the\n likely cause of her fluid overload. Her rapid accumulation underpins\n the severity of her condition and her severely unfavourable\n hemodynamics. Her long term goals are comfort, though she still wishes\n to participate in rehab. Her family recognizes that she is dying. Our\n goal is diuresis which we will attempt aggressively, reassessing our\n progress dynamically.\n -- milrinone with bolus\n -- neosynephrine for pressure support, goal MAP of > 60\n -- slow uptitration of lasix with goal near-continuous diuresis while\n avoiding MAP < 60\n -- strict i/o's with foley\n -- can switch to levophed if low UOP on Neo with need for pressor\n support\n -- family meeting with HCP to assess goals in AM after diuresis\n attempted\n .\n # Septic Joints: Patient with history +staph aureus in left shoulder\n treated by washout and vancomycin, thus far 4 weeks of monotherapy. No\n + blood cx since before . Major issue now is pain control.\n -- send Vanco level in AM, was recently on 500 mg q12 and switched to\n q24 for high troughs\n -- ultram q6, Tylenol q8, Morphine for breakthrough (1-3 mg).\n - Will consider ms contin if no control\n .\n # CORONARIES: Patient with h/o CAD w/ right dominant system, mild\n instent re-stenois of the LAD BM stent and occluded RCA.\n - bb as tolerated\n .\n # RHYTHM: Patient with h/o atrial fibrillation, s/p BiV ICD (\n Concerto C154DWK) , on coumadin. Now in paced rhythm\n - cont home dose meds (amio, metoprolol)\n - cont coumadin\n - f/u INR\n .\n # Chronic Kidney Disease: Baseline 1.3 creatinine. At baseline\n - trend\n .\n # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a\n filter in place.\n - cont coumadin\n - f/u INR\n .\n # Hypothyroidism: Continue Levothyroxine.\n .\n # Gout: continue allopurionl\n .\n # FEN: low sodium diet\n .\n # ACCESS: Right PICC, right IJ, Left EJ\n .\n # PROPHYLAXIS: on coumadin\n .\n # CODE: DNR, can intubate, briefly\n .\n # DISPO: CCU for now.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 05:34 PM\n Midline - 05:34 PM\n 18 Gauge - 05:35 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition: ICU\n ------ Protected Section ------\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I would add the following remarks:\n Above discussed extensively with patient.\n DNR status discussed. DNR.\n Total time spent on patient care: 45 minutes.\n Additional comments:\n Patient with end-stage ischemic cmp admitted for milrinone and Lasix\n gtt in setting of severe volume overload and hypotension; prognosis is\n end-stage\n Signed on for service provided \n ------ Protected Section Addendum Entered By: on:\n 11:18 ------\n"
},
{
"category": "Physician ",
"chartdate": "2180-01-13 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 399714,
"text": "Chief Complaint: anasarca\n 24 Hour Events:\n MULTI LUMEN - START 05:34 PM\n MIDLINE - START 05:34 PM\n - poor UOP to 2.5 and 5mg/hr lasix drip.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Milrinone - 0.375 mcg/Kg/min\n Furosemide (Lasix) - 5 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue\n Flowsheet Data as of 06:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.1\nC (97\n Tcurrent: 36\nC (96.8\n HR: 72 (70 - 108) bpm\n BP: 97/52(64) {77/44(52) - 113/76(84)} mmHg\n RR: 13 (11 - 18) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 82.2 kg (admission): 82.2 kg\n Total In:\n 417 mL\n 156 mL\n PO:\n 120 mL\n 60 mL\n TF:\n IVF:\n 47 mL\n 96 mL\n Blood products:\n Total out:\n 550 mL\n 410 mL\n Urine:\n 200 mL\n 410 mL\n NG:\n Stool:\n Drains:\n Balance:\n -133 mL\n -254 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ///26/\n Physical Examination\n General Appearance: No acute distress, Thin, cachectic\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: II/VI systolic murmur best at apex. PMI is laterally\n displaces\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Breath Sounds: Clear : anteriors)\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended, fluid\n wave\n Extremities: Right lower extremity edema: 4+, Left lower extremity\n edema: 4+\n Skin: Not assessed, Stage 3 sacral decub\n Neurologic: Attentive, Responds to: Not assessed, Oriented (to): x3,\n Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 156 K/uL\n 10.0 g/dL\n 83 mg/dL\n 1.3 mg/dL\n 26 mEq/L\n 4.3 mEq/L\n 46 mg/dL\n 99 mEq/L\n 137 mEq/L\n 32.1 %\n 6.1 K/uL\n [image002.jpg]\n 05:44 AM\n WBC\n 6.1\n Hct\n 32.1\n Plt\n 156\n Cr\n 1.3\n Glucose\n 83\n Other labs: PT / PTT / INR:15.7/36.8/1.4, Mg++:2.1 mg/dL\n Fluid analysis / Other labs: UA = WBC + clumps. Mod Bacteria\n Assessment and Plan\n 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\n recently discharged from the CCU () for CHF exacerbation c/b\n C.diff infection and on for septic joint washout c/b failure to\n extubate CHF exacerbation, who is now being admitted from \n clinic with total body fluid overload.\n .\n # Anasarca: Patient has history of CHF ischemic , 10%, s/p\n BiV ICD ( Concerto C154DWK) 1/08with EF 10% which is the\n likely cause of her fluid overload. Her rapid accumulation underpins\n the severity of her condition and her severely unfavourable\n hemodynamics. Her long term goals are comfort, though she still wishes\n to participate in rehab. Her family recognizes that she is dying. Our\n goal is diuresis which we will attempt aggressively, reassessing our\n progress dynamically. She put out very little o/n on lasix gtt. This\n could reflect limitatin of diuresis or the importance of a bolus (we\n withheld bolus to avoid instability)\n -- milrinone with bolus\n -- neosynephrine for pressure support, goal MAP of > 60\n -- slow uptitration of lasix with goal near-continuous diuresis while\n avoiding MAP < 60\n -- strict i/o's with foley\n -- can switch to levophed if low UOP on Neo with need for pressor\n support\n -- family meeting with HCP to assess goals in AM after diuresis\n attempted\n .\n # Septic Joints: Patient with history +staph aureus in left shoulder\n treated by washout and vancomycin, thus far 4 weeks of monotherapy. No\n + blood cx since before . Major issue now is pain control.\n -- send Vanco level in AM, was recently on 500 mg q12 and switched to\n q24 for high troughs\n -- ultram q6, Tylenol q8, Morphine for breakthrough (1-3 mg).\n - Will consider ms contin if no control\n .\n # Sacral Decub - stage 3-4.\n - wound care\n - pain control.\n .\n # UTI: positive UA, no history of culture positive UA's in system\n - treating empirically with cipro\n - watch INR on abx\n .\n # CORONARIES: Patient with h/o CAD w/ right dominant system, mild\n instent re-stenois of the LAD BM stent and occluded RCA.\n - bb as tolerated\n .\n # RHYTHM: Patient with h/o atrial fibrillation, s/p BiV ICD (\n Concerto C154DWK) , on coumadin. Now in paced rhythm\n - cont home dose meds (amio, metoprolol)\n - cont coumadin\n - f/u INR\n .\n # Chronic Kidney Disease: Baseline 1.3 creatinine. At baseline\n - trend\n .\n # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a\n filter in place.\n - cont coumadin\n - f/u INR\n .\n # Hypothyroidism: Continue Levothyroxine.\n .\n # Gout: continue allopurionl\n .\n # FEN: low sodium diet\n .\n # ACCESS: Right PICC, right IJ, Left EJ\n .\n # PROPHYLAXIS: on coumadin\n .\n # CODE: DNR/DNI\n .\n # DISPO: CCU for now.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 05:34 PM\n Midline - 05:34 PM\n 18 Gauge - 05:35 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:ICU\n ------ Protected Section ------\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I would add the following remarks:\n Above discussed extensively with patient.\n DNR status discussed: DNR/DNI/defibrillator deactivated. DNR.\n Total time spent on patient care: 60 minutes.\n Additional comments:\n although we have madee some minimal progress in diuresis, the outlook\n is poor\n after 20 min discussion with pt we have reaffirmed DNR/DNI status\n In addition, as per patient's wish we will deactivate the defibrillator\n shocking function of her ICD\n ------ Protected Section Addendum Entered By: on:\n 11:20 ------\n"
},
{
"category": "Nursing",
"chartdate": "2180-01-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 399730,
"text": "Pt is a 71 yo female with PMH: BM stent to LAD ', Occluded RCA\n without intervention, Ischemic CM (EF 10-25%), BiV ICD, AF, PVD, DVT\n s/p IVC filter, coumadin, hypothyroidism, CKD, OA. adm for HF\n (milrinone/lasix) MRSA in L shoulder, L hip and R knuckle. Out to\n rehab . went from rehab to see Dr. , sent to EW with\n hypotension. SBP 70 in EW, transiently on dopa, but cardiology d/c'd.\n Rxd with NS 250 cc with SBP 92. Pt has been in rehab since d/c from\n with septic arthritis in L shoulder, hip and R knuckle.\n On Vanco followed by ID.\n She was started on milrinone .375 after bolus and lasix drip also begun\n at 2.5mg/hr. The lasix dose was increased to 5mg overnight, but urine\n output has remained poor, though she is negative.\n GI: Pt has poor apetite and eats very little.\n CODE STATUS: Dr had discussion with both patient and health care\n proxy and all are in agreement that she be DNR/DNI. Additionally the\n defibrillator part of AICD/pacer was shut off.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt has a number of sources of pain. She has joint pain in shoulders and\n especially R elbow from septic arthritis. The most uncomfortable area\n is the decubitus ulcer on her coccyx area. She receive standing ultran\n for that. She requires frequent position changes, but seems most\n uncomfortable on L side. By 1000 she was very uncomfortable.\n Action:\n She received 2mg IV morpnine sulfate at 1230 and had shift in position\n and was comfortable until noon when pain recurred. She received another\n 2mg morphine sulfate and position change.\n Response:\n She slept until\n Plan:\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Pt on Milrinone .375mic/kilo and lasix 5mg/hr. Urine output\n ~30-50cc/hr. Hr in 70s AV paced with rare PVCs . BP 85-100/50-60s,\n lower after morphine. Pt sating 98-100% on 3L NP and lungs are mostly\n clear. She has no c/o of SOB. She has 2+ edema in legs.\n Action:\n At 1030 lasix was increased to 10mg/hr and at 1100 milrinone was\n increased to .5mic/kilo. Legs are kept elevated.\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Pt has multiple skin lesions. Most prominent is coccyx decub. It has\n mepelix on it that was sloughing off in am\n Action:\n Coccyx dsg changed. Area primarily covered with slough. The edges are\n rounded and pink. Area cleansed with wound cleaner, dried and new\n mepelix applied.\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2180-01-15 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 399948,
"text": "Chief Complaint:\n 24 Hour Events:\n - confirmed DNR, acemaker turned off\n - despite lasix gtt, diuresis poor yesterday\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Ciprofloxacin - 08:00 AM\n Infusions:\n Other ICU medications:\n Coumadin (Warfarin) - 04:00 PM\n Lansoprazole (Prevacid) - 04:00 PM\n Morphine Sulfate - 05:05 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.4\nC (97.5\n HR: 99 (66 - 104) bpm\n BP: 91/50(60) {82/42(45) - 101/67(120)} mmHg\n RR: 12 (11 - 23) insp/min\n SpO2: 99%\n Heart rhythm: V Paced\n Wgt (current): 82.2 kg (admission): 82.2 kg\n Total In:\n 1,554 mL\n 456 mL\n PO:\n 900 mL\n 60 mL\n TF:\n IVF:\n 654 mL\n 396 mL\n Blood products:\n Total out:\n 1,628 mL\n 1,505 mL\n Urine:\n 1,628 mL\n 1,505 mL\n NG:\n Stool:\n Drains:\n Balance:\n -74 mL\n -1,049 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///27/\n Physical Examination\n General Appearance: No acute distress, thin, cachectic\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: II/VI systolic murmur best at apex. MI is laterally\n displaced\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Breath Sounds: Clear : anteriorly)\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+\n Skin: Not assessed, Stage 3 sacral decubitus ulcer\n Neurologic: Attentive, Responds to: Not assessed, Oriented (to): x3\n Labs / Radiology\n 159 K/uL\n 10.0 g/dL\n 104 mg/dL\n 1.4 mg/dL\n 27 mEq/L\n 3.8 mEq/L\n 42 mg/dL\n 98 mEq/L\n 134 mEq/L\n 31.9 %\n 4.7 K/uL\n [image002.jpg]\n 05:44 AM\n 04:46 AM\n WBC\n 6.1\n 4.7\n Hct\n 32.1\n 31.9\n Plt\n 156\n 159\n Cr\n 1.3\n 1.4\n Glucose\n 83\n 104\n Other labs: PT / PTT / INR:16.8/29.3/1.5, Ca++:8.0 mg/dL, Mg++:2.1\n mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\n recently discharged from the CCU () for CHF exacerbation c/b\n C.diff infection and on for septic joint washout c/b failure to\n extubate CHF exacerbation, who is now being admitted from \n clinic with total body fluid overload.\n .\n # sCHF exacerbation: Patient has history of CHF ischemic , \n 10%, s/p BiV ICD ( Concerto C154DWK) 1/08with EF 10% which is\n the likely cause of her fluid overload. Her rapid accumulation\n underpins the severity of her condition and her severely unfavourable\n hemodynamics. Her long term goals are comfort, though she still wishes\n to participate in rehab. Her family recognizes that she is dying. Our\n goal is diuresis which we will attempt aggressively, reassessing our\n progress dynamically. She put out very little o/n on lasix gtt. This\n could reflect limitatin of diuresis or the importance of a bolus (we\n withheld bolus to avoid instability)\n -- goal diuresis 5 to 10L total\n -- milrinone with bolus\n -- metoprolol tartrate 12.5mg PO BID\n -- slow uptitration of lasix gtt with goal near-continuous diuresis\n while avoiding MAP < 60\n -- strict i/o's with foley\n -- replete K to 5\n -- PM electrolytes\n -- can switch to levophed if low UOP on Neo with need for pressor\n support\n -- family meeting with HCP to assess goals in AM after diuresis\n attempted\n .\n # Septic Joints: Patient with history +staph aureus in left shoulder\n treated by washout and vancomycin, thus far 4 weeks of monotherapy. No\n + blood cx since before . Major issue now is pain control.\n -- send Vanco level in AM, was recently on 500 mg q12 and switched to\n q24 for high troughs\n -- ultram q6, Tylenol q8, Morphine for breakthrough (2-4 mg).\n - Will consider ms contin if no control\n .\n # Sacral Decub - stage 3-4.\n - wound care\n - pain control.\n .\n # UTI: positive UA, no history of culture positive UA's in system\n - treating empirically with cipro\n - watch INR on abx\n .\n # CORONARIES: Patient with h/o CAD w/ right dominant system, mild\n instent re-stenois of the LAD BM stent and occluded RCA.\n - bb as tolerated\n .\n # RHYTHM: Patient with h/o atrial fibrillation, s/p BiV ICD (\n Concerto C154DWK) , on coumadin. Now in paced rhythm\n - cont home dose meds (amio, metoprolol)\n - cont coumadin\n - f/u INR\n .\n # Chronic Kidney Disease: Baseline 1.3 creatinine. At baseline\n - trend\n .\n # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a\n filter in place.\n - continue Coumadin\n - f/u INR\n .\n # Hypothyroidism: Continue Levothyroxine\n .\n # Gout: continue Allopurinol\n ICU Care\n Nutrition: cardiac diet\n Glycemic Control: None\n Lines:\n Multi Lumen - 05:34 PM\n Midline - 05:34 PM\n 18 Gauge - 05:35 PM\n Prophylaxis:\n DVT: Coumadin\n Stress ulcer: Lansoprazole\n VAP:\n Comments:\n Communication: patient\n Code status: DNR/DNI\n Disposition:\n ------ Protected Section ------\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I would add the following remarks:\n Above discussed extensively with patient. Above discussed extensively\n with family member, next of or health care proxy. Progress reviewed\n extensively during family meeting.\n DNR status discussed. DNR.\n Total time spent on patient care: 60 minutes.\n Additional comments:\n diuresing well\n DNR/DNI/defibrillator off\n anticipate return to rehab in days\n signed on for service performed on \n ------ Protected Section Addendum Entered By: on:\n 11:05 ------\n"
},
{
"category": "Physician ",
"chartdate": "2180-01-15 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 399949,
"text": "Chief Complaint:\n 24 Hour Events:\n :\n - diuresed ~2L over the day\n - PM lytes & Cr solid\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Ciprofloxacin - 08:00 AM\n Infusions:\n Milrinone - 0.5 mcg/Kg/min\n Other ICU medications:\n Coumadin (Warfarin) - 04:00 PM\n Lansoprazole (Prevacid) - 04:00 PM\n Morphine Sulfate - 03:25 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.4\nC (97.5\n HR: 65 (63 - 99) bpm\n BP: 94/54(65) {76/49(56) - 100/62(70)} mmHg\n RR: 13 (10 - 26) insp/min\n SpO2: 98%\n Heart rhythm: AV Paced\n Wgt (current): 82.2 kg (admission): 82.2 kg\n Total In:\n 2,299 mL\n 162 mL\n PO:\n 1,340 mL\n TF:\n IVF:\n 959 mL\n 162 mL\n Blood products:\n Total out:\n 5,030 mL\n 1,760 mL\n Urine:\n 5,030 mL\n 1,760 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,731 mL\n -1,598 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///28/\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Diminished: )\n Abdominal: Soft, Obese\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 146 K/uL\n 10.7 g/dL\n 115 mg/dL\n 1.2 mg/dL\n 28 mEq/L\n 3.7 mEq/L\n 38 mg/dL\n 94 mEq/L\n 132 mEq/L\n 33.1 %\n 5.1 K/uL\n [image002.jpg]\n 05:44 AM\n 04:46 AM\n 04:00 PM\n 03:05 AM\n WBC\n 6.1\n 4.7\n 5.1\n Hct\n 32.1\n 31.9\n 33.1\n Plt\n 156\n 159\n 146\n Cr\n 1.3\n 1.4\n 1.3\n 1.2\n Glucose\n 83\n 104\n 155\n 115\n Other labs: PT / PTT / INR:18.4/29.1/1.7, Ca++:8.3 mg/dL, Mg++:2.1\n mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\n recently discharged from the CCU () for CHF exacerbation c/b\n C.diff infection and on for septic joint washout c/b failure to\n extubate CHF exacerbation, who is now being admitted from \n clinic with total body fluid overload.\n .\n # sCHF exacerbation: Patient has history of CHF ischemic , \n 10%, s/p BiV ICD ( Concerto C154DWK) 1/08with EF 10% which is\n the likely cause of her fluid overload. Her rapid accumulation\n underpins the severity of her condition and her severely unfavourable\n hemodynamics. Her long term goals are comfort, though she still wishes\n to participate in rehab. Her family recognizes that she is dying. Our\n goal is diuresis which we will attempt aggressively, reassessing our\n progress dynamically. She put out very little o/n on lasix gtt. This\n could reflect limitatin of diuresis or the importance of a bolus (we\n withheld bolus to avoid instability)\n -- goal diuresis 5 to 10L total\n -- continue milrinone\n -- metoprolol tartrate 12.5mg PO BID\n -- slow uptitration of lasix gtt with goal near-continuous diuresis\n while avoiding MAP < 60\n -- strict i/o's with foley\n -- replete K to 5\n -- PM electrolytes\n -- can switch to levophed if low UOP on Neo with need for pressor\n support\n -- family meeting with HCP prn\n .\n # Septic Joints: Patient with history +staph aureus in left shoulder\n treated by washout and vancomycin, thus far 4 weeks of monotherapy. No\n + blood cx since before . Major issue now is pain control.\n -- send Vanco level in AM, was recently on 500 mg q12 and switched to\n q24 for high troughs\n -- ultram q6, Tylenol q8, Morphine for breakthrough (2-4 mg).\n - Will consider ms contin if no control\n .\n # Sacral Decub - stage 3-4.\n - wound care\n - pain control.\n .\n # UTI: positive UA, no history of culture positive UA's in system\n - treating empirically with cipro day 1 was . Last dose Morning of\n \n - watch INR on abx\n .\n # CORONARIES: Patient with h/o CAD w/ right dominant system, mild\n instent re-stenois of the LAD BM stent and occluded RCA.\n - bb as tolerated\n .\n # RHYTHM: Patient with h/o atrial fibrillation, s/p BiV ICD (\n Concerto C154DWK) , on coumadin. Now in paced rhythm\n - cont home dose meds (amio, metoprolol)\n - cont coumadin\n .\n # Chronic Kidney Disease: Baseline 1.3 creatinine. At baseline (1.2)\n - trend\n .\n # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a\n filter in place.\n - continue Coumadin\n .\n # Hypothyroidism: Continue Levothyroxine\n .\n # Gout: continue Allopurinol\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 05:34 PM\n Midline - 05:34 PM\n 18 Gauge - 05:35 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: DNR / DNI\n Disposition:ICU\n ------ Protected Section ------\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I would add the following remarks:\n Above discussed extensively with patient.\n DNR status discussed. DNR.\n Total time spent on patient care: 45 minutes.\n Additional comments:\n diuresing very well; > 5 liters off net los\n anticipate 24-48 hours more volume unloading (until creat shows rise)\n plan to return to rehab\n ------ Protected Section Addendum Entered By: on:\n 11:06 ------\n"
},
{
"category": "General",
"chartdate": "2180-01-13 00:00:00.000",
"description": "Code Discussion",
"row_id": 399725,
"text": "TITLE:\n Discussion of code status:\n Dr. discussed patient\ns code status with her this morning.\n Code status was confirmed with the patient to be DNR/DNI. In addition,\n after discussing with the patient, we will deactivate the defibrillator\n shocking function of her ICD.\n Furthermore, we have confirmed with the patient that, moving forward,\n no escalation of care will be initiated. Patient is currently on\n milrinone and phenylephrine. If patient has increased pain requiring\n more morphine which results in more pressor requirements, or if patient\n clinically worsens requiring more pressor support, will transition\n patient to CMO.\n This discussion was undertaken between the patient and Dr. ,\n in the presence of the CCU fellow and house staff.\n"
},
{
"category": "Physician ",
"chartdate": "2180-01-15 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 399922,
"text": "Chief Complaint:\n 24 Hour Events:\n :\n - diuresed ~2L over the day\n - PM lytes & Cr solid\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Ciprofloxacin - 08:00 AM\n Infusions:\n Milrinone - 0.5 mcg/Kg/min\n Other ICU medications:\n Coumadin (Warfarin) - 04:00 PM\n Lansoprazole (Prevacid) - 04:00 PM\n Morphine Sulfate - 03:25 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.4\nC (97.5\n HR: 65 (63 - 99) bpm\n BP: 94/54(65) {76/49(56) - 100/62(70)} mmHg\n RR: 13 (10 - 26) insp/min\n SpO2: 98%\n Heart rhythm: AV Paced\n Wgt (current): 82.2 kg (admission): 82.2 kg\n Total In:\n 2,299 mL\n 162 mL\n PO:\n 1,340 mL\n TF:\n IVF:\n 959 mL\n 162 mL\n Blood products:\n Total out:\n 5,030 mL\n 1,760 mL\n Urine:\n 5,030 mL\n 1,760 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,731 mL\n -1,598 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///28/\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Diminished: )\n Abdominal: Soft, Obese\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 146 K/uL\n 10.7 g/dL\n 115 mg/dL\n 1.2 mg/dL\n 28 mEq/L\n 3.7 mEq/L\n 38 mg/dL\n 94 mEq/L\n 132 mEq/L\n 33.1 %\n 5.1 K/uL\n [image002.jpg]\n 05:44 AM\n 04:46 AM\n 04:00 PM\n 03:05 AM\n WBC\n 6.1\n 4.7\n 5.1\n Hct\n 32.1\n 31.9\n 33.1\n Plt\n 156\n 159\n 146\n Cr\n 1.3\n 1.4\n 1.3\n 1.2\n Glucose\n 83\n 104\n 155\n 115\n Other labs: PT / PTT / INR:18.4/29.1/1.7, Ca++:8.3 mg/dL, Mg++:2.1\n mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\n recently discharged from the CCU () for CHF exacerbation c/b\n C.diff infection and on for septic joint washout c/b failure to\n extubate CHF exacerbation, who is now being admitted from \n clinic with total body fluid overload.\n .\n # sCHF exacerbation: Patient has history of CHF ischemic , \n 10%, s/p BiV ICD ( Concerto C154DWK) 1/08with EF 10% which is\n the likely cause of her fluid overload. Her rapid accumulation\n underpins the severity of her condition and her severely unfavourable\n hemodynamics. Her long term goals are comfort, though she still wishes\n to participate in rehab. Her family recognizes that she is dying. Our\n goal is diuresis which we will attempt aggressively, reassessing our\n progress dynamically. She put out very little o/n on lasix gtt. This\n could reflect limitatin of diuresis or the importance of a bolus (we\n withheld bolus to avoid instability)\n -- goal diuresis 5 to 10L total\n -- continue milrinone\n -- metoprolol tartrate 12.5mg PO BID\n -- slow uptitration of lasix gtt with goal near-continuous diuresis\n while avoiding MAP < 60\n -- strict i/o's with foley\n -- replete K to 5\n -- PM electrolytes\n -- can switch to levophed if low UOP on Neo with need for pressor\n support\n -- family meeting with HCP prn\n .\n # Septic Joints: Patient with history +staph aureus in left shoulder\n treated by washout and vancomycin, thus far 4 weeks of monotherapy. No\n + blood cx since before . Major issue now is pain control.\n -- send Vanco level in AM, was recently on 500 mg q12 and switched to\n q24 for high troughs\n -- ultram q6, Tylenol q8, Morphine for breakthrough (2-4 mg).\n - Will consider ms contin if no control\n .\n # Sacral Decub - stage 3-4.\n - wound care\n - pain control.\n .\n # UTI: positive UA, no history of culture positive UA's in system\n - treating empirically with cipro day 1 was . Last dose Morning of\n \n - watch INR on abx\n .\n # CORONARIES: Patient with h/o CAD w/ right dominant system, mild\n instent re-stenois of the LAD BM stent and occluded RCA.\n - bb as tolerated\n .\n # RHYTHM: Patient with h/o atrial fibrillation, s/p BiV ICD (\n Concerto C154DWK) , on coumadin. Now in paced rhythm\n - cont home dose meds (amio, metoprolol)\n - cont coumadin\n .\n # Chronic Kidney Disease: Baseline 1.3 creatinine. At baseline (1.2)\n - trend\n .\n # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a\n filter in place.\n - continue Coumadin\n .\n # Hypothyroidism: Continue Levothyroxine\n .\n # Gout: continue Allopurinol\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 05:34 PM\n Midline - 05:34 PM\n 18 Gauge - 05:35 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: DNR / DNI\n Disposition:ICU\n"
},
{
"category": "Nursing",
"chartdate": "2180-01-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 399992,
"text": "71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\n : Sent to ED from clinic w/ hypotension\n transiently on\n dopa, Tx\nd w/ NS 250 cc w/ SBP ^ 92. Admit to CCU for aggressive\n diuresis.\n Ineffective Coping\n Assessment:\n Pt having difficulty coping with chronicity of illness and inevitable\n return to rehab/nursing home\n Action:\n Pt very weepy today after Cardiology team talked to pt about returning\n to rehab once she is better\n RN allowed pt to voice feelings about illness\n conversation about hospice with RN after it was brought up by CHF\n attending\n Response:\n less weepy, visiting with family members, interactive\n :\n Social service, Case Management consults on Monday AM\n Cont encourage pt to vent feelings, Cont to provide emotional support\n for patient.\n Pain control (acute pain, chronic pain)\n Assessment:\n pt with acute pain at wound site on coccyx, increases when pt sitting\n up in bed for meals\n of note, pt states pain is tolerable at 8/10\n severe at \n Action:\n receiving Ultram, Acetaminophen ATC, MSO4 2mg IV prn, MS Contin 15mg po\n added\n Response:\n pt in most pain while sitting upright for meals; sleeping well in naps\n while lying on right side\n Plan:\n Assess response to MS Contin; Assess/Re-assess pain;\n ? pressure reducing cushion for periods when pt sits upright\n refusing to wear waffle boots; does not want kinair bed.\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n diuresing well on Lasiv 10mg iv and Milrinone 0.5mcgs/kg/min\n Action:\n Lasix decreased to 10mg/hr secondary to u/o > 300/hr\n Response:\n remains with urine > 100ml/hr\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2180-01-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 399993,
"text": "71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\n : Sent to ED from clinic w/ hypotension\n transiently on\n dopa, Tx\nd w/ NS 250 cc w/ SBP ^ 92. Admit to CCU for aggressive\n diuresis.\n Ineffective Coping\n Assessment:\n Pt having difficulty coping with chronicity of illness and inevitable\n return to rehab/nursing home\n Action:\n Pt very weepy today after Cardiology team talked to pt about returning\n to rehab once she is better\n RN allowed pt to voice feelings about illness\n conversation about hospice with RN after it was brought up by CHF\n attending\n Response:\n less weepy, visiting with family members, interactive\n :\n Social service, Case Management consults on Monday AM\n Cont encourage pt to vent feelings, Cont to provide emotional support\n for patient.\n Pain control (acute pain, chronic pain)\n Assessment:\n pt with acute pain at wound site on coccyx, increases when pt sitting\n up in bed for meals\n of note, pt states pain is tolerable at 8/10\n severe at \n Action:\n receiving Ultram, Acetaminophen ATC, MSO4 2mg IV prn, MS Contin 15mg po\n added\n Response:\n pt in most pain while sitting upright for meals; sleeping well in naps\n while lying on right side\n Plan:\n Assess response to MS Contin; Assess/Re-assess pain;\n ? pressure reducing cushion for periods when pt sits upright\n refusing to wear waffle boots; does not want kinair bed.\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n diuresing well on Lasix 10mg iv and Milrinone 0.5mcgs/kg/min\n Action:\n Lasix decreased to 10mg/hr secondary to u/o > 300/hr\n Response:\n remains with urine > 100ml/hr; 6 liters LOS negative\n Plan:\n Cont gentle diuresis until CR bumps or BP drops per Dr \n Replace lytes as needed\n Impaired Skin Integrity\n Assessment:\n large pressure ulcer on coccyx area 5.5X6cm base yellow/black\n Action:\n duoderm gel/Mepilex reapplied today\n Response:\n site unchanged\n Plan:\n Cont frequent turns, keep off back as much as possible however, pt\n needs to sit upright in bed to eat\n pt refusing waffle boots, pressure reducing bed\n Wound care consult on Monday AM.\n"
},
{
"category": "Nursing",
"chartdate": "2180-01-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 399927,
"text": "71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\n : Sent to ED from clinic w/ hypotension\n transiently on\n dopa, Tx\nd w/ NS 250 cc w/ SBP ^ 92. Admit to CCU for aggressive\n diuresis.\n Heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n + pitting edema BLE\non lasix gtt 15mg/hr & milrinone 0.5mcg/k/min.\n LS clr, dim at bases.\n Action:\n 1^st dose 25mg PO lopressor given\n Response:\n BPs lower when asleep and after morphine, MAPs >55 (of note: BPs taken\n on L upper arm, pt mosly positioned on R side). K+ 3.7\nto be repleted,\n and Mg+ 2.1. Neg 2L since MN. Neg 5L LOS. Rare short runs AIVR.\n Plan:\n CHF management, aggressive diuresis w/ lasix & daily\n metolazone-- goal NEG 5-10L overall, strict I/Os, Low Na+ diet, daily\n wts, monitor & replete lytes as indicated\n DNR/DNI-ICD turned off after fam mtg. Both pt and HCP\n are in agreement that pt would like to be comfortable to be able to\n participate in rehab.\n Impaired Skin Integrity\n Assessment:\n *Lg stage 3 vs. unstageable decub to coccyx, covered w/ yellow slough &\n red blanching borders--sm amt serous dsg\n mepilex intact, placed \n *Red, blanching heels.\n *Dry and thin skin w/ discolored areas.\n *Good appetite. Declines Kinair bed/waffle boots\n Action:\n Mepilex dsg peeled to check skin--Duoderm hydroactive gel\n applied per wound care recs .\n Heels elevated on pillows, skin/pressure area well\n lubricated.\n Slight freq position changes avoiding back and L side.\n Response:\n Skin unchanged\n Plan:\n Monitor for changes, prevent further breathdown. Change\n position freq as tolerated as pt mobility/able to turn self is very\n limited.\n Change mepilex w/ duoderm gel daily drainage\n Pain control (chronic pain)\n Assessment:\n Very uncomfortable w/ turning and w/ laying on L side\n Action:\n Standing order ultram & Tylenol Q6hrs, 2mg Morphine sulfate\n IVP for breakthrough pain\n Pt positioned mostly far on R side w/ slight position\n changes, placed supine for short periods only.\n Response:\n Pt allowed to rest in btwn necessary nsg interventions, Slept well all\n night.\n Plan:\n Continue current pain control regimen, medicate w/ morphine\n prior to turning side to side\n GI: NO BM, takes pills crushed in applesauce\n"
},
{
"category": "Physician ",
"chartdate": "2180-01-13 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 399698,
"text": "Chief Complaint: anasarca\n 24 Hour Events:\n MULTI LUMEN - START 05:34 PM\n MIDLINE - START 05:34 PM\n - poor UOP to 2.5 and 5mg/hr lasix drip.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Milrinone - 0.375 mcg/Kg/min\n Furosemide (Lasix) - 5 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue\n Flowsheet Data as of 06:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.1\nC (97\n Tcurrent: 36\nC (96.8\n HR: 72 (70 - 108) bpm\n BP: 97/52(64) {77/44(52) - 113/76(84)} mmHg\n RR: 13 (11 - 18) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 82.2 kg (admission): 82.2 kg\n Total In:\n 417 mL\n 156 mL\n PO:\n 120 mL\n 60 mL\n TF:\n IVF:\n 47 mL\n 96 mL\n Blood products:\n Total out:\n 550 mL\n 410 mL\n Urine:\n 200 mL\n 410 mL\n NG:\n Stool:\n Drains:\n Balance:\n -133 mL\n -254 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ///26/\n Physical Examination\n General Appearance: No acute distress, Thin, cachectic\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: II/VI systolic murmur best at apex. PMI is laterally\n displaces\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Breath Sounds: Clear : anteriors)\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended, fluid\n wave\n Extremities: Right lower extremity edema: 4+, Left lower extremity\n edema: 4+\n Skin: Not assessed, Stage 3 sacral decub\n Neurologic: Attentive, Responds to: Not assessed, Oriented (to): x3,\n Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 156 K/uL\n 10.0 g/dL\n 83 mg/dL\n 1.3 mg/dL\n 26 mEq/L\n 4.3 mEq/L\n 46 mg/dL\n 99 mEq/L\n 137 mEq/L\n 32.1 %\n 6.1 K/uL\n [image002.jpg]\n 05:44 AM\n WBC\n 6.1\n Hct\n 32.1\n Plt\n 156\n Cr\n 1.3\n Glucose\n 83\n Other labs: PT / PTT / INR:15.7/36.8/1.4, Mg++:2.1 mg/dL\n Fluid analysis / Other labs: UA = WBC + clumps. Mod Bacteria\n Assessment and Plan\n 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\n recently discharged from the CCU () for CHF exacerbation c/b\n C.diff infection and on for septic joint washout c/b failure to\n extubate CHF exacerbation, who is now being admitted from \n clinic with total body fluid overload.\n .\n # Anasarca: Patient has history of CHF ischemic , 10%, s/p\n BiV ICD ( Concerto C154DWK) 1/08with EF 10% which is the\n likely cause of her fluid overload. Her rapid accumulation underpins\n the severity of her condition and her severely unfavourable\n hemodynamics. Her long term goals are comfort, though she still wishes\n to participate in rehab. Her family recognizes that she is dying. Our\n goal is diuresis which we will attempt aggressively, reassessing our\n progress dynamically. She put out very little o/n on lasix gtt. This\n could reflect limitatin of diuresis or the importance of a bolus (we\n withheld bolus to avoid instability)\n -- milrinone with bolus\n -- neosynephrine for pressure support, goal MAP of > 60\n -- slow uptitration of lasix with goal near-continuous diuresis while\n avoiding MAP < 60\n -- strict i/o's with foley\n -- can switch to levophed if low UOP on Neo with need for pressor\n support\n -- family meeting with HCP to assess goals in AM after diuresis\n attempted\n .\n # Septic Joints: Patient with history +staph aureus in left shoulder\n treated by washout and vancomycin, thus far 4 weeks of monotherapy. No\n + blood cx since before . Major issue now is pain control.\n -- send Vanco level in AM, was recently on 500 mg q12 and switched to\n q24 for high troughs\n -- ultram q6, Tylenol q8, Morphine for breakthrough (1-3 mg).\n - Will consider ms contin if no control\n .\n # Sacral Decub - stage 3-4.\n - wound care\n - pain control.\n .\n # UTI: positive UA, no history of culture positive UA's in system\n - treating empirically with cipro\n - watch INR on abx\n .\n # CORONARIES: Patient with h/o CAD w/ right dominant system, mild\n instent re-stenois of the LAD BM stent and occluded RCA.\n - bb as tolerated\n .\n # RHYTHM: Patient with h/o atrial fibrillation, s/p BiV ICD (\n Concerto C154DWK) , on coumadin. Now in paced rhythm\n - cont home dose meds (amio, metoprolol)\n - cont coumadin\n - f/u INR\n .\n # Chronic Kidney Disease: Baseline 1.3 creatinine. At baseline\n - trend\n .\n # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a\n filter in place.\n - cont coumadin\n - f/u INR\n .\n # Hypothyroidism: Continue Levothyroxine.\n .\n # Gout: continue allopurionl\n .\n # FEN: low sodium diet\n .\n # ACCESS: Right PICC, right IJ, Left EJ\n .\n # PROPHYLAXIS: on coumadin\n .\n # CODE: DNR/DNI\n .\n # DISPO: CCU for now.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 05:34 PM\n Midline - 05:34 PM\n 18 Gauge - 05:35 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:ICU\n"
},
{
"category": "Nursing",
"chartdate": "2180-01-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 399702,
"text": "Pt is a 71 yo female with PMH: BM stent to LAD ', Occluded RCA\n without intervention, Ischemic CM (EF 10-25%), BiV ICD, AF, PVD, DVT\n s/p IVC filter, coumadin, hypothyroidism, CKD, OA. adm for HF\n (milrinone/lasix) MRSA in L shoulder, L hip and R knuckle. Out to\n rehab . went from rehab to see Dr. , sent to EW with\n hypotension. SBP 70 in EW, transiently on dopa, but cardiology d/c'd.\n Rxd with NS 250 cc with SBP 92. Pt has been in rehab since d/c from\n with septic arthritis in L shoulder, hip and R knuckle.\n On Vanco followed by ID.\n She was started on milrinone .375 after bolus\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2180-01-17 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 400075,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - MS contin increased to 30mg last night, received 2 doses w pills\n crushed, complained of nausea after each\n - Has not had a BM for four days\n - PT ordered yesterday\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 08:00 AM\n Vancomycin - 09:36 AM\n Infusions:\n Furosemide (Lasix) - 10 mg/hour\n Milrinone - 0.5 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 12:45 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.6\nC (97.8\n HR: 68 (63 - 75) bpm\n BP: 91/52(62) {75/44(51) - 98/61(70)} mmHg\n RR: 9 (9 - 29) insp/min\n SpO2: 99%\n Heart rhythm: AV Paced\n Wgt (current): 77.3 kg (admission): 82.2 kg\n Total In:\n 1,004 mL\n 146 mL\n PO:\n 440 mL\n TF:\n IVF:\n 564 mL\n 146 mL\n Blood products:\n Total out:\n 2,410 mL\n 420 mL\n Urine:\n 2,410 mL\n 420 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,406 mL\n -274 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///34/\n Physical Examination\n Gen: alert, oriented x3 but appears to have psychomotor retardation and\n easily confused\n HEENT: slightly dry mucus membranes\n CHEST: regular rhythm ; dry basilar crackles\n ABD: mildly distended, soft, nontender\n EXT: + pitting edema bilaterally\n Labs / Radiology\n 106 K/uL\n 10.0 g/dL\n 86 mg/dL\n 1.0 mg/dL\n 34 mEq/L\n 3.7 mEq/L\n 33 mg/dL\n 92 mEq/L\n 134 mEq/L\n 30.9 %\n 4.2 K/uL\n [image002.jpg]\n 05:44 AM\n 04:46 AM\n 04:00 PM\n 03:05 AM\n 03:17 PM\n 03:05 AM\n 05:03 PM\n 05:22 AM\n WBC\n 6.1\n 4.7\n 5.1\n 4.4\n 4.2\n Hct\n 32.1\n 31.9\n 33.1\n 32.2\n 30.9\n Plt\n 156\n 159\n 146\n 134\n 106\n Cr\n 1.3\n 1.4\n 1.3\n 1.2\n 1.1\n 1.0\n 1.0\n 1.0\n Glucose\n 83\n 104\n 155\n 115\n 98\n 107\n 86\n Other labs: PT / PTT / INR:20.2/33.1/1.9, Ca++:8.1 mg/dL, Mg++:2.1\n mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\n recently discharged from the CCU () for CHF exacerbation c/b\n C.diff infection and on for septic joint washout c/b failure to\n extubate CHF exacerbation, who is now being admitted from \n clinic with total body fluid overload.\n .\n # sCHF exacerbation:\n Patient has history of CHF ischemic , 10%, s/p BiV ICD\n ( Concerto C154DWK) with EF 10% which is the likely cause\n of her fluid overload. Her rapid accumulation underpins the severity of\n her condition and her severely unfavourable hemodynamics. Her long term\n goals are comfort, though she still wishes to participate in rehab. Her\n family recognizes that she is dying. Our goal is diuresis which we will\n attempt aggressively, reassessing our progress dynamically. She\n diuresed well on Lasix gtt on with net neg 4L balance. LOS fluid\n balance -5L.\n -- goal diuresis 1L negative today with lasix gtt\n -- continue milrinone\n -- continue metolazone 5mg daily\n -- continue metoprolol tartrate 12.5mg PO BID\n -- strict i/o's with foley\n -- replete K to 5\n -- PM electrolytes\n -- family meeting with HCP prn\n .\n # Septic Joints: Patient with history +staph aureus in left shoulder\n treated by washout and vancomycin, thus far 4 weeks of monotherapy. No\n + blood cx since before . Major issue now is pain control.\n -- continue vanc, was recently on 500 mg q12 and switched to q24 for\n high troughs\n -- continue cipro\n -- increase MS contin to 30mg \n -- ultram q6, Tylenol q8, Morphine for breakthrough (2-4 mg).\n .\n # Sacral Decub - stage 3-4.\n - wound care\n - increase MS contin to 30mg \n - pain control\n .\n # UTI: positive UA, no history of culture positive UA's in system\n - treating empirically with cipro day 1 was . Last dose tomorrow\n morning (Morning of ^st)\n - watch INR on abx\n .\n # CORONARIES: Patient with h/o CAD w/ right dominant system, mild\n instent re-stenois of the LAD BM stent and occluded RCA.\n - bb as tolerated\n .\n # RHYTHM: Patient with h/o atrial fibrillation, s/p BiV ICD (\n Concerto C154DWK) , on coumadin. Now in paced rhythm\n - cont home dose meds (amio, metoprolol)\n - cont coumadin\n .\n # Chronic Kidney Disease: Baseline Creatinine 1.3. Creatinine 1.1\n today.\n - trend\n .\n # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a\n filter in place.\n - continue Coumadin\n .\n # Hypothyroidism: Continue Levothyroxine\n .\n # Gout: continue Allopurinol\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 05:34 PM\n Midline - 05:34 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2180-01-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 400083,
"text": "71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\n : Sent to ED from clinic w/ hypotension\n transiently on\n dopa, Tx\nd w/ NS 250 cc w/ SBP ^ 92.\n Admit to CCU for aggressive diuresis.She was started on Milrinone\n and lasix gtt. And has been diuresing well. She has lg coccyx decub\n that is a source of chronic pain. She is DNR/DNI and defibrillator has\n been shut off. She has excellent apetite.\n Pain control (acute pain, chronic pain)\n Assessment:\n Plan is to transition to oral forms of pain control in preparation for\n pt going to rehab. She had received MS contin at 0600, but pill was\n ground and pt had nausea. She received 4mg IV morphine at 6am as well.\n Action:\n MS contin will be given in to 15mg pills, which are smaller and can\n take them without having them crushed. Morphine immediate release has\n been ordered for breakthrough pain. It is also a small pill that she\n can take without crushing..\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Pt being transition for transfer back to rehab. Milrinone and lasix\n drips stopped at 1030.\n Action:\n At noon she received dose of torsemide 40mg po and metolazone 5mg po.\n Response:\n Plan:\n"
},
{
"category": "General",
"chartdate": "2180-01-18 00:00:00.000",
"description": "Generic Note",
"row_id": 400135,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - lasix gtt stopped and pt started on torsemide 40mg + metolazone\n 5mg daily (needs to drop to 2.5mg daily metolazone tomorrow)\n - started IR morphine po for breakthrough 15mg 4h prn (w IV as backup)\n - Pain and Palliative Care consulted -- leave pain regimen as is for\n now, will reassess 24hr needs tomorrow; MD had discussion w patient\n about Do-Not-Hospitalize, and pt would like HCP/family to be a part of\n that discussion rather than herself--> need to discuss w dr. also\n - milrinone stopped in AM, but restarted milrinone bc blood pressures\n not maintained otherwise (dropped to 70s systolic without) and urine\n output decreased.\n - family meeting scheduled for at 1pm - will need Dr. and\n palliative care present.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Ciprofloxacin - 10:00 AM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 10:32 AM\n Coumadin (Warfarin) - 04:00 PM\n Omeprazole (Prilosec) - 04:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.9\nC (98.4\n HR: 69 (55 - 71) bpm\n BP: 85/56(63) {74/43(53) - 97/62(69)} mmHg\n RR: 13 (9 - 20) insp/min\n SpO2: 96%\n Heart rhythm: V Paced\n Wgt (current): 74 kg (admission): 82.2 kg\n Height: 60 Inch\n Total In:\n 1,052 mL\n 201 mL\n PO:\n 450 mL\n 120 mL\n TF:\n IVF:\n 602 mL\n 81 mL\n Blood products:\n Total out:\n 1,571 mL\n 320 mL\n Urine:\n 1,571 mL\n 320 mL\n NG:\n Stool:\n Drains:\n Balance:\n -519 mL\n -119 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ///35/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 116 K/uL\n 10.2 g/dL\n 93 mg/dL\n 1.0 mg/dL\n 35 mEq/L\n 3.8 mEq/L\n 32 mg/dL\n 91 mEq/L\n 132 mEq/L\n 31.2 %\n 4.6 K/uL\n [image002.jpg]\n 05:44 AM\n 04:46 AM\n 04:00 PM\n 03:05 AM\n 03:17 PM\n 03:05 AM\n 05:03 PM\n 05:22 AM\n 05:25 PM\n 05:40 AM\n WBC\n 6.1\n 4.7\n 5.1\n 4.4\n 4.2\n 4.6\n Hct\n 32.1\n 31.9\n 33.1\n 32.2\n 30.9\n 31.2\n Plt\n 156\n 159\n 146\n 134\n 106\n 116\n Cr\n 1.3\n 1.4\n 1.3\n 1.2\n 1.1\n 1.0\n 1.0\n 1.0\n 1.1\n 1.0\n Glucose\n 83\n 104\n 155\n 115\n 98\n 107\n 86\n 93\n Other labs: PT / PTT / INR:19.1/29.7/1.7, Ca++:8.1 mg/dL, Mg++:2.1\n mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\n recently discharged from the CCU () for CHF exacerbation c/b\n C.diff infection and on for septic joint washout c/b failure to\n extubate CHF exacerbation, who was admitted from clinic with\n total body fluid overload.\n .\n # sCHF Exacerbation:\n Patient has history of CHF ischemic , 10%, s/p BiV ICD\n ( Concerto C154DWK) with EF 10% which was the likely\n cause of her fluid overload. Appears intravascularly euvolemic on\n exam, no need to continue lasix gtt. Has diuresed well -9L on length\n of stay. Responding well to torsemide with metolazone while on\n milrinone, but urine output had dropped without milrinone yesterday.\n Diuresed net -500cc over last day.\n - Continue milrinone for now\n - Continue torsemide 40mg with metolazone 5mg for now\n - Continue strict I/Os\n - Continue to replete K\n .\n # Goals of Care:\n End-stage CHF with long term goals are comfort, though she still wishes\n to participate in rehab. Her family recognizes that she is dying. Pain\n and Palliative Care consulted yesterday for pain control and goals of\n care.\n - family meeting at 1pm today\n .\n # Septic Joints: Patient with history +staph aureus in left shoulder\n treated by washout and vancomycin, thus far 4 weeks of monotherapy. No\n + blood cx since before . Major issue now is pain control.\n - continue vancomycin until , then suppression with doxycycline\n -- continue MS contin 30mg and reassess pain med needs\n -- standing ultram q6, Tylenol q8\n .\n # Sacral Decub - stage 3-4. Focusing on Pain control. Pain and\n Palliative Care following with patient. Switched to oral breakthrough\n Morphine with IV as backup, but patient was not requiring IV backup.\n - wound care\n - standing ultram Q6h, Tylenol Q8h\n - reassess patient\ns pain requirements\n - goals of care family meeting 1pm today\n .\n # UTI: positive UA, no history of culture positive UA's in system.\n Will do 10day course because of chronic foley.\n - treating empirically with cipro ; day 1 of 10 day course was \n - watch INR on abx\n .\n # Hx CAD:\n Patient with h/o CAD w/ right dominant system, mild instent re-stenois\n of the LAD BM stent and occluded RCA.\n - continue metoprolol 25mg \n .\n # Hx Afib:\n Patient with h/o atrial fibrillation, s/p BiV ICD ( Concerto\n C154DWK) , on coumadin. Now in paced rhythm\n - cont home dose meds (amio, metoprolol)\n - cont coumadin\n - trend INR\n .\n # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a\n filter in place. INR mildly subtherapeutic despite Cipro\n - continue Coumadin\n - monitor INR\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines: midline, right IJ\n Multi Lumen - 05:34 PM\n Midline - 05:34 PM\n Prophylaxis:\n DVT: coumadin\n Stress ulcer: lansoprazole\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"
},
{
"category": "General",
"chartdate": "2180-01-18 00:00:00.000",
"description": "Generic Note",
"row_id": 400139,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - lasix gtt stopped and pt started on torsemide 40mg + metolazone\n 5mg daily\n - started IR morphine po for breakthrough 15mg 4h prn (w IV as backup)\n yesterday, and patient did not require IV backup\n - Pain and Palliative Care consulted\n - milrinone stopped yesterday AM, but restarted milrinone bc blood\n pressures not maintained otherwise (dropped to 70s systolic without)\n and urine output decreased.\n - family meeting scheduled for at 1pm - will need Dr. and\n palliative care present\n - does not have any complaints of pain or sob this AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Ciprofloxacin - 10:00 AM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 10:32 AM\n Coumadin (Warfarin) - 04:00 PM\n Omeprazole (Prilosec) - 04:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.9\nC (98.4\n HR: 69 (55 - 71) bpm\n BP: 85/56(63) {74/43(53) - 97/62(69)} mmHg\n RR: 13 (9 - 20) insp/min\n SpO2: 96%\n Heart rhythm: V Paced\n Wgt (current): 74 kg (admission): 82.2 kg\n Height: 60 Inch\n Total In:\n 1,052 mL\n 201 mL\n PO:\n 450 mL\n 120 mL\n TF:\n IVF:\n 602 mL\n 81 mL\n Blood products:\n Total out:\n 1,571 mL\n 320 mL\n Urine:\n 1,571 mL\n 320 mL\n NG:\n Stool:\n Drains:\n Balance:\n -519 mL\n -119 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ///35/\n Physical Examination\n Gen: sleepy but easily awakened, oriented x3, easily confused, appears\n to have psychomotor slowing\n HEENT: dry mucus membranes\n NECK: JVP not elevated\n CHEST: regular rhythm ; mild dry basilar crackles laterally\n ABD: mildly distended, soft, nontender\n EXT: + pitting edema bilaterally\n Labs / Radiology\n 116 K/uL\n 10.2 g/dL\n 93 mg/dL\n 1.0 mg/dL\n 35 mEq/L\n 3.8 mEq/L\n 32 mg/dL\n 91 mEq/L\n 132 mEq/L\n 31.2 %\n 4.6 K/uL\n [image002.jpg]\n 05:44 AM\n 04:46 AM\n 04:00 PM\n 03:05 AM\n 03:17 PM\n 03:05 AM\n 05:03 PM\n 05:22 AM\n 05:25 PM\n 05:40 AM\n WBC\n 6.1\n 4.7\n 5.1\n 4.4\n 4.2\n 4.6\n Hct\n 32.1\n 31.9\n 33.1\n 32.2\n 30.9\n 31.2\n Plt\n 156\n 159\n 146\n 134\n 106\n 116\n Cr\n 1.3\n 1.4\n 1.3\n 1.2\n 1.1\n 1.0\n 1.0\n 1.0\n 1.1\n 1.0\n Glucose\n 83\n 104\n 155\n 115\n 98\n 107\n 86\n 93\n Other labs: PT / PTT / INR:19.1/29.7/1.7, Ca++:8.1 mg/dL, Mg++:2.1\n mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\n recently discharged from the CCU () for CHF exacerbation c/b\n C.diff infection and on for septic joint washout c/b failure to\n extubate CHF exacerbation, who was admitted from clinic with\n total body fluid overload.\n .\n # sCHF Exacerbation:\n Patient has history of CHF ischemic , 10%, s/p BiV ICD\n ( Concerto C154DWK) with EF 10% which was the likely\n cause of her fluid overload. Appears intravascularly euvolemic on\n exam, no need to continue lasix gtt. Has diuresed well -9L on length\n of stay. Responding well to torsemide with metolazone while on\n milrinone, but urine output had dropped without milrinone yesterday.\n Diuresed net -500cc over last day.\n - Continue milrinone for now\n - Continue torsemide 40mg with metolazone 5mg for now\n - Continue strict I/Os\n - Continue to replete K\n .\n # Goals of Care:\n End-stage CHF with long term goals are comfort, though she still wishes\n to participate in rehab. Her family recognizes that she is dying. Pain\n and Palliative Care consulted yesterday for pain control and goals of\n care.\n - family meeting at 1pm today\n .\n # Septic Joints: Patient with history +staph aureus in left shoulder\n treated by washout and vancomycin, thus far 4 weeks of monotherapy. No\n + blood cx since before . Major issue now is pain control.\n - continue vancomycin until , then suppression with doxycycline\n -- continue MS contin 30mg and reassess pain med needs\n -- standing ultram q6, Tylenol q8\n .\n # Sacral Decub - stage 3-4. Focusing on Pain control. Pain and\n Palliative Care following with patient. Switched to oral breakthrough\n Morphine with IV as backup, but patient was not requiring IV backup.\n - wound care\n - standing ultram Q6h, Tylenol Q8h\n - reassess patient\ns pain requirements\n - goals of care family meeting 1pm today\n .\n # UTI: positive UA, no history of culture positive UA's in system.\n Will do 10day course because of chronic foley.\n - treating empirically with cipro ; day 1 of 10 day course was \n - watch INR on abx\n .\n # Hx CAD:\n Patient with h/o CAD w/ right dominant system, mild instent re-stenois\n of the LAD BM stent and occluded RCA.\n - continue metoprolol 25mg \n .\n # Hx Afib:\n Patient with h/o atrial fibrillation, s/p BiV ICD ( Concerto\n C154DWK) , on coumadin. Now in paced rhythm\n - cont home dose meds (amio, metoprolol)\n - cont coumadin\n - trend INR\n .\n # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a\n filter in place. INR mildly subtherapeutic despite Cipro\n - continue Coumadin\n - monitor INR\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines: midline, right IJ\n Multi Lumen - 05:34 PM\n Midline - 05:34 PM\n Prophylaxis:\n DVT: coumadin\n Stress ulcer: lansoprazole\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2180-01-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 400147,
"text": "71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\n : Sent to ED from clinic w/ hypotension\n transiently on\n dopa, Tx\nd w/ NS 250 cc w/ SBP ^ 92.\n Admit to CCU for aggressive diuresis.She was started on Milrinone\n and lasix gtt. And has been diuresing well. She has lg coccyx decub\n that is a source of chronic pain. She is DNR/DNI and defibrillator has\n been shut off.\n GI: Pt had a few episode of nausea yesterday and one today. It was very\n transient with no vomiting. She ate very well today. She received\n lactalose but no bM. Foley changed today.\n SOCIAL: Family in to visit. Pts HCP, her 38y old neice is very ill\n creating problem for this stressed family.\n Pain control (acute pain, chronic pain)\n Assessment:\n Plan is to transition to oral forms of pain control in preparation for\n pt going to rehab. She had received MS contin at 0600, but pill was\n ground and pt had nausea. She received 4mg IV morphine at 6am as well.\n She continues on standing acetominofen and ultram\n Action:\n MS contin will be given in to 15mg pills, which are smaller and can\n take them without having them crushed. Morphine immediate release has\n been ordered for breakthrough pain. It is also a small pill that she\n can take without crushing. She had 15mg immediate release at 1300 . She\n has had no IV morphine sulfate since 1030.\n Response:\n Pt has been pain free except when turned since then. She will have\n acute pain with position change, but it will settle down and go away\n within a few minutes. She received MS contin at 1800 and was able to\n swallow them without problem\n :\n Continue to try to control pain with oral medications. Give immediate\n release morphine for breakthrough pain.\n Impaired Skin Integrity\n Assessment:\n Sacral wound getting worse and remains very painful. Mepilex dsg oozing\n through. Acuacel added. Know MRSA infection on R knuckle and R elbow\n appear to be much more reddened than last week. Over all skin is dry\n and itchy.\n Action:\n Wound care nurse came to evaluate wound. Area is now cleansed with\n wound cleanser and dried. Criticade antifungal is applied to wound\n edges and peri-wound area. The wound is covered with aquacel AG and\n then small soft-sorb pad. It is secured with medipore tape on skin that\n has been prepped with barrier wipe. Finger and elbow are washed with\n soap and water. Area kept lubricated. oil used in water. Moisture\n barrier clean applied to body. Heels elevated off bed.\n Response:\n Skin less itchy. No further worsening of skin condition.\n Plan:\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Pt being transition for transfer back to rehab. Milrinone and lasix\n drips stopped at 1030. Pt was V-paced with wide complex and blood\n pressure prior to stopping meds was mid 90s with maps in mid 60s. She\n received KCL 20meq in AM She received torsemide 40mg and metolazone\n 5mg with urine output ~ 30-40cc/hr. Blood pressure dropped to the high\n 70s to mid 80s with maps in the low 50s.\n Action:\n After discussions with Dr she was restarted on Milrinone\n .5mic/kilo with bolus of 25mic/kilo given. Labs drawn in afternoon.\n Response:\n Blood pressure more stable with maps in low 60s after Milrinone\n restarted. She is ~400cc neg for the day. BUN creat 33/1.1, stable.\n Plan:\n Family deciding if pt will now be CMO and go to extended care facility\n with hospice.\n"
},
{
"category": "General",
"chartdate": "2180-01-18 00:00:00.000",
"description": "Generic Note",
"row_id": 400148,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - lasix gtt stopped and pt started on torsemide 40mg + metolazone\n 5mg daily\n - started IR morphine po for breakthrough 15mg 4h prn (w IV as backup)\n yesterday, and patient did not require IV backup\n - Pain and Palliative Care consulted\n - milrinone stopped yesterday AM, but restarted milrinone bc blood\n pressures not maintained otherwise (dropped to 70s systolic without)\n and urine output decreased.\n - family meeting scheduled for at 1pm - will need Dr. and\n palliative care present\n - does not have any complaints of pain or sob this AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Ciprofloxacin - 10:00 AM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 10:32 AM\n Coumadin (Warfarin) - 04:00 PM\n Omeprazole (Prilosec) - 04:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.9\nC (98.4\n HR: 69 (55 - 71) bpm\n BP: 85/56(63) {74/43(53) - 97/62(69)} mmHg\n RR: 13 (9 - 20) insp/min\n SpO2: 96%\n Heart rhythm: V Paced\n Wgt (current): 74 kg (admission): 82.2 kg\n Height: 60 Inch\n Total In:\n 1,052 mL\n 201 mL\n PO:\n 450 mL\n 120 mL\n TF:\n IVF:\n 602 mL\n 81 mL\n Blood products:\n Total out:\n 1,571 mL\n 320 mL\n Urine:\n 1,571 mL\n 320 mL\n NG:\n Stool:\n Drains:\n Balance:\n -519 mL\n -119 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ///35/\n Physical Examination\n Gen: sleepy but easily awakened, oriented x3, easily confused, appears\n to have psychomotor slowing\n HEENT: dry mucus membranes\n NECK: JVP not elevated\n CHEST: regular rhythm ; mild dry basilar crackles laterally\n ABD: mildly distended, soft, nontender\n EXT: + pitting edema bilaterally\n Labs / Radiology\n 116 K/uL\n 10.2 g/dL\n 93 mg/dL\n 1.0 mg/dL\n 35 mEq/L\n 3.8 mEq/L\n 32 mg/dL\n 91 mEq/L\n 132 mEq/L\n 31.2 %\n 4.6 K/uL\n [image002.jpg]\n 05:44 AM\n 04:46 AM\n 04:00 PM\n 03:05 AM\n 03:17 PM\n 03:05 AM\n 05:03 PM\n 05:22 AM\n 05:25 PM\n 05:40 AM\n WBC\n 6.1\n 4.7\n 5.1\n 4.4\n 4.2\n 4.6\n Hct\n 32.1\n 31.9\n 33.1\n 32.2\n 30.9\n 31.2\n Plt\n 156\n 159\n 146\n 134\n 106\n 116\n Cr\n 1.3\n 1.4\n 1.3\n 1.2\n 1.1\n 1.0\n 1.0\n 1.0\n 1.1\n 1.0\n Glucose\n 83\n 104\n 155\n 115\n 98\n 107\n 86\n 93\n Other labs: PT / PTT / INR:19.1/29.7/1.7, Ca++:8.1 mg/dL, Mg++:2.1\n mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\n recently discharged from the CCU () for CHF exacerbation c/b\n C.diff infection and on for septic joint washout c/b failure to\n extubate CHF exacerbation, who was admitted from clinic with\n total body fluid overload.\n .\n # sCHF Exacerbation:\n Patient has history of CHF ischemic , 10%, s/p BiV ICD\n ( Concerto C154DWK) with EF 10% which was the likely\n cause of her fluid overload. Appears intravascularly dry on exam. Has\n diuresed well -9L on length of stay. Responding well to torsemide with\n metolazone while on milrinone, but urine output had dropped without\n milrinone yesterday. Diuresed net -500cc over last day. Milrinone is\n keeping her blood pressures up.\n - DC milrinone\n - With no milrinone, she needs help with filling pressures, so\n will DC diuretics b/c appears dry on exam\n - If blood pressure drops without milrinone,, she may benefit\n from 250cc IVF boluses as needed\n - Continue strict I/Os\n - Continue to replete K\n .\n # Goals of Care:\n End-stage CHF with long term goals are comfort, though she still wishes\n to participate in rehab. Her family recognizes that she is dying. Pain\n and Palliative Care consulted yesterday for pain control and goals of\n care.\n - family meeting at 1pm today\n .\n # Septic Joints: Patient with history +staph aureus in left shoulder\n treated by washout and vancomycin, thus far 4 weeks of monotherapy. No\n + blood cx since before . Major issue now is pain control.\n - continue vancomycin until , then suppression with doxycycline\n -- continue MS contin 30mg and reassess pain med needs\n -- standing ultram q6, Tylenol q8\n .\n # Sacral Decub - stage 3-4. Focusing on Pain control. Pain and\n Palliative Care following with patient. Switched to oral breakthrough\n Morphine with IV as backup, but patient was not requiring IV backup.\n - wound care\n - standing ultram Q6h, Tylenol Q8h\n - reassess patient\ns pain requirements\n - goals of care family meeting 1pm today\n .\n # UTI: positive UA, no history of culture positive UA's in system.\n Will do 10day course because of chronic foley.\n - treating empirically with cipro ; day 1 of 10 day course was \n - watch INR on abx\n .\n # Hx CAD:\n Patient with h/o CAD w/ right dominant system, mild instent re-stenois\n of the LAD BM stent and occluded RCA.\n - continue metoprolol 25mg \n .\n # Hx Afib:\n Patient with h/o atrial fibrillation, s/p BiV ICD ( Concerto\n C154DWK) , on coumadin. Now in paced rhythm\n - cont home dose meds (amio, metoprolol)\n - cont coumadin\n - trend INR\n .\n # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a\n filter in place. INR mildly subtherapeutic despite Cipro\n - continue Coumadin\n - monitor INR\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines: midline, right IJ\n Multi Lumen - 05:34 PM\n Midline - 05:34 PM\n Prophylaxis:\n DVT: coumadin\n Stress ulcer: lansoprazole\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2180-01-18 00:00:00.000",
"description": "progress note",
"row_id": 400149,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - lasix gtt stopped and pt started on torsemide 40mg + metolazone\n 5mg daily\n - started IR morphine po for breakthrough 15mg 4h prn (w IV as backup)\n yesterday, and patient did not require IV backup\n - Pain and Palliative Care consulted\n - milrinone stopped yesterday AM, but restarted milrinone bc blood\n pressures not maintained otherwise (dropped to 70s systolic without)\n and urine output decreased.\n - family meeting scheduled for at 1pm - will need Dr. and\n palliative care present\n - does not have any complaints of pain or sob this AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Ciprofloxacin - 10:00 AM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 10:32 AM\n Coumadin (Warfarin) - 04:00 PM\n Omeprazole (Prilosec) - 04:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.9\nC (98.4\n HR: 69 (55 - 71) bpm\n BP: 85/56(63) {74/43(53) - 97/62(69)} mmHg\n RR: 13 (9 - 20) insp/min\n SpO2: 96%\n Heart rhythm: V Paced\n Wgt (current): 74 kg (admission): 82.2 kg\n Height: 60 Inch\n Total In:\n 1,052 mL\n 201 mL\n PO:\n 450 mL\n 120 mL\n TF:\n IVF:\n 602 mL\n 81 mL\n Blood products:\n Total out:\n 1,571 mL\n 320 mL\n Urine:\n 1,571 mL\n 320 mL\n NG:\n Stool:\n Drains:\n Balance:\n -519 mL\n -119 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ///35/\n Physical Examination\n Gen: sleepy but easily awakened, oriented x3, easily confused, appears\n to have psychomotor slowing\n HEENT: dry mucus membranes\n NECK: JVP not elevated\n CHEST: regular rhythm ; mild dry basilar crackles laterally\n ABD: mildly distended, soft, nontender\n EXT: + pitting edema bilaterally\n Labs / Radiology\n 116 K/uL\n 10.2 g/dL\n 93 mg/dL\n 1.0 mg/dL\n 35 mEq/L\n 3.8 mEq/L\n 32 mg/dL\n 91 mEq/L\n 132 mEq/L\n 31.2 %\n 4.6 K/uL\n [image002.jpg]\n 05:44 AM\n 04:46 AM\n 04:00 PM\n 03:05 AM\n 03:17 PM\n 03:05 AM\n 05:03 PM\n 05:22 AM\n 05:25 PM\n 05:40 AM\n WBC\n 6.1\n 4.7\n 5.1\n 4.4\n 4.2\n 4.6\n Hct\n 32.1\n 31.9\n 33.1\n 32.2\n 30.9\n 31.2\n Plt\n 156\n 159\n 146\n 134\n 106\n 116\n Cr\n 1.3\n 1.4\n 1.3\n 1.2\n 1.1\n 1.0\n 1.0\n 1.0\n 1.1\n 1.0\n Glucose\n 83\n 104\n 155\n 115\n 98\n 107\n 86\n 93\n Other labs: PT / PTT / INR:19.1/29.7/1.7, Ca++:8.1 mg/dL, Mg++:2.1\n mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\n recently discharged from the CCU () for CHF exacerbation c/b\n C.diff infection and on for septic joint washout c/b failure to\n extubate CHF exacerbation, who was admitted from clinic with\n total body fluid overload.\n .\n # sCHF Exacerbation:\n Patient has history of CHF ischemic , 10%, s/p BiV ICD\n ( Concerto C154DWK) with EF 10% which was the likely\n cause of her fluid overload. Appears intravascularly dry on exam. Has\n diuresed well -9L on length of stay. Responding well to torsemide with\n metolazone while on milrinone, but urine output had dropped without\n milrinone yesterday. Diuresed net -500cc over last day. Milrinone is\n keeping her blood pressures up.\n - DC milrinone\n - With no milrinone, she needs help with filling pressures, so\n will DC diuretics b/c appears dry on exam\n - If blood pressure drops without milrinone,, she may benefit\n from 250cc IVF boluses as needed\n - Continue strict I/Os\n - Continue to replete K\n .\n # Goals of Care:\n End-stage CHF with long term goals are comfort, though she still wishes\n to participate in rehab. Her family recognizes that she is dying. Pain\n and Palliative Care consulted yesterday for pain control and goals of\n care.\n - family meeting at 1pm today\n .\n # Septic Joints: Patient with history +staph aureus in left shoulder\n treated by washout and vancomycin, thus far 4 weeks of monotherapy. No\n + blood cx since before . Major issue now is pain control.\n - continue vancomycin until , then suppression with doxycycline\n -- continue MS contin 30mg and reassess pain med needs\n -- standing ultram q6, Tylenol q8\n .\n # Sacral Decub - stage 3-4. Focusing on Pain control. Pain and\n Palliative Care following with patient. Switched to oral breakthrough\n Morphine with IV as backup, but patient was not requiring IV backup.\n - wound care\n - standing ultram Q6h, Tylenol Q8h\n - reassess patient\ns pain requirements\n - goals of care family meeting 1pm today\n .\n # UTI: positive UA, no history of culture positive UA's in system.\n Will do 10day course because of chronic foley.\n - treating empirically with cipro ; day 1 of 10 day course was \n - watch INR on abx\n .\n # Hx CAD:\n Patient with h/o CAD w/ right dominant system, mild instent re-stenois\n of the LAD BM stent and occluded RCA.\n - continue metoprolol 25mg \n .\n # Hx Afib:\n Patient with h/o atrial fibrillation, s/p BiV ICD ( Concerto\n C154DWK) , on coumadin. Now in paced rhythm\n - cont home dose meds (amio, metoprolol)\n - cont coumadin\n - trend INR\n .\n # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a\n filter in place. INR mildly subtherapeutic despite Cipro\n - continue Coumadin\n - monitor INR\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines: midline, right IJ\n Multi Lumen - 05:34 PM\n Midline - 05:34 PM\n Prophylaxis:\n DVT: coumadin\n Stress ulcer: lansoprazole\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n ------ Protected Section ------\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I would add the following remarks:\n Above discussed extensively with patient. Above discussed extensively\n with family member, next of or health care proxy. Progress reviewed\n extensively during family meeting.\n DNR status discussed: comfort measures. DNR.\n Total time spent on patient care: 90 minutes.\n Additional comments:\n 45 minutes (13:00 - 13:45) spent in family meeting discussing end-stage\n nature of the heart condition and lack of further treatment options.\n Pt will now be CMO. All family in agreement.\n ------ Protected Section Addendum Entered By: on:\n 13:44 ------\n"
},
{
"category": "Nursing",
"chartdate": "2180-01-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 400153,
"text": "71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\n : Sent to ED from clinic admit to CCU for aggressive\n diuresis. She was started on Milrinone and lasix gtt, lasix and\n milrinone gtts turned to off . Milrinone restarted d/t BP and U/O\n decrease. Large Stage III decube on coccyx decub that is a source of\n chronic pain. She is DNR/DNI and defibrillator has been shut off. Able\n to swallow pills whole, with either applesauce or custard.\n SOCIAL: Family in to visit. Pts HCP is in and intubated,\n pt\ns sister is alternate HCP.\n control (acute pain, chronic pain)\n Assessment:\n On standing dose of morphine SR, ultram and Tylenol. Also receiving\n supplemental morpine IR and IV.\n Action/Response:\n Pain rated to be this am, then later in day \n Repositioned for comfort\n Plan:\n Continue pain control with oral medications. Give immediate release\n morphine for breakthrough pain.\n Impaired Skin Integrity\n Assessment:\n Stage III PU on coccyx, foul smelling, yellow sanguinous drainage,\n edges of wound yellow with areas of necrosis. Surrounding skin\n macerated. Pt. refusing kinair bed\n Action/Response:\n Dressing changed according to wound care RN\ns recs:\n anti-fungal barrier criticaid to macerated skin surrounding wound,\n acqua cell-AG to coccyx, covered in soft sorb dsg, medipore tape.\n Aloe Vesta to skin\n Repositioned\n Po\ns encouraged, patient drinking hot chocolate, custard,\n applesauce.\n Plan:\n QD dressing change as above. Aloe vesta to skin. Reposition q2 hours\n or according to pt\ns wishes.\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Pt DNR/DNI. SBP 90\ns. Milrinone @ 0.5mcg/kg/min. U/O ~ 100cc q\n 2hours.\n Action/Response:\n Dr. in to talk with patient and family extensively.\n Milrinone turned to off. Torsemide and metzolone d/c\n Palliative care MD in to talk with pt and family.\n Plan:\n To remain in hospital for now. Will monitor off of milrinone with plan\n to give IV NS 250 cc for hypotension as per Dr. . Focus on\n comfort.\n"
},
{
"category": "Nursing",
"chartdate": "2180-01-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 400162,
"text": "71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\n : Sent to ED from clinic admit to CCU for aggressive\n diuresis. She was started on Milrinone and lasix gtt, lasix and\n milrinone gtts turned to off . Milrinone restarted d/t BP and U/O\n decrease. Large Stage III decube on coccyx decub that is a source of\n chronic pain. She is DNR/DNI and defibrillator has been shut off. Able\n to swallow pills whole, with either applesauce or custard.\n SOCIAL: Family in to visit. Pts HCP is in and intubated,\n pt\ns sister is alternate HCP.\n control (acute pain, chronic pain)\n Assessment:\n On standing dose of morphine SR, ultram and Tylenol.\n Action/Response:\n Pain rated to be this am, then later in day .\n Given supplemental IR morphine and 2mg IV morphine with relief of pain.\n Repositioned for comfort\n Plan:\n Continue pain control with oral medications. Give immediate release\n morphine for breakthrough pain.\n Impaired Skin Integrity\n Assessment:\n Stage III PU on coccyx, foul smelling, yellow sanguinous drainage,\n edges of wound yellow with areas of necrosis. Surrounding skin\n macerated. Pt. refusing kinair bed\n Action/Response:\n Dressing changed according to wound care RN\ns recs:\n anti-fungal barrier criticaid to macerated skin surrounding wound,\n acqua cell-AG to coccyx, covered in soft sorb dsg, medipore tape.\n Aloe Vesta to skin\n Repositioned\n Po\ns encouraged, patient drinking hot chocolate, custard,\n applesauce.\n Plan:\n QD dressing change as above. Aloe vesta to skin. Reposition q2 hours\n or according to pt\ns wishes.\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Pt DNR/DNI. SBP 90\ns. Milrinone @ 0.5mcg/kg/min. U/O ~ 100cc q\n 2hours.\n Action/Response:\n Dr. in to talk with patient and family extensively.\n Milrinone turned to off. Torsemide and metzolone d/c\n Palliative care MD in to talk with pt and family.\n SBP decreasing to low 80\ns and then 76 off mirinone, U/O\n also tapering off. CCU resident notified, will hold off on IV fluids\n unless pt c/o dizziness.\n Plan:\n To remain in hospital for now. Will monitor off of milrinone with plan\n to give IV NS 250 cc for hypotension as per Dr. . No other changes\n in medications for now. Focus on comfort.\n"
},
{
"category": "Nursing",
"chartdate": "2180-01-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 399906,
"text": "71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\n : Sent to ED from clinic w/ hypotension\n transiently on\n dopa, Tx\nd w/ NS 250 cc w/ SBP ^ 92. Admit to CCU for aggressive\n diuresis.\n Heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n + pitting edema BLE\non lasix gtt 15mg/hr & milrinone 0.5mcg/k/min.\n LS clr, dim at bases.\n Action:\n 1^st dose 25mg PO lopressor given\n Response:\n BPs lower when asleep and after morphine, MAPs >55. Lytes. Rare short\n runs AIVR.\n Plan:\n CHF management, aggressive diuresis w/ lasix & daily\n metolazone-- goal NEG 5-10L overall, strict I/Os, Low Na+ diet, daily\n wts, monitor & replete lytes as indicated\n DNR/DNI-ICD turned off after fam mtg. Both pt and HCP\n are in agreement that pt would like to be comfortable to be able to\n participate in rehab.\n Impaired Skin Integrity\n Assessment:\n *Lg stage 3 vs. unstageable decub to coccyx, covered w/ yellow slough &\n red blanching borders--sm amt serous dsg\n mepilex intact, placed \n *Red, blanching heels.\n *Dry and thin skin w/ discolored areas.\n *Good appetite. Declines Kinair bed/waffle boots\n Action:\n Mepilex dsg peeled to check skin--Duoderm hydroactive gel\n applied per wound care recs .\n Heels elevated on pillows, skin/pressure area well\n lubricated.\n Slight freq position changes avoiding back and L side.\n Response:\n Skin unchanged\n Plan:\n Monitor for changes, prevent further breathdown. Change\n position freq as tolerated as pt mobility/able to turn self is very\n limited.\n Change mepilex w/ duoderm gel daily drainage\n Pain control (chronic pain)\n Assessment:\n Very uncomfortable w/ turning and w/ laying on L side\n Action:\n Standing order ultram & Tylenol Q6hrs, 2mg Morphine sulfate\n IVP for breakthrough pain\n Pt positioned mostly far on R side w/ slight position\n changes, placed supine for short periods only.\n Response:\n Pt allowed to rest in btwn necessary nsg interventions, Slept well all\n night.\n Plan:\n Continue current pain control regimen, medicate w/ morphine\n prior to turning side to side\n GI: NO BM, takes pills crushed in applesauce\n"
},
{
"category": "Nursing",
"chartdate": "2180-01-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 400071,
"text": "71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\n : Sent to ED from clinic w/ hypotension\n transiently on\n dopa, Tx\nd w/ NS 250 cc w/ SBP ^ 92.\n Admit to CCU for aggressive diuresis.She was started on Milrinone\n and lasix gtt. And has been diuresing well. She has lg coccyx decub\n that is a source of chronic pain. She is DNR/DNI and defibrillator has\n been shut off. She has excellent apetite.\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nutrition",
"chartdate": "2180-01-17 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 400081,
"text": "Ht: 60\n Admit wt: 82.2kg\n Current wt: 74kg\n Diet: Low sodium, 3 gram\n PMHx: 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension\n 2. CARDIAC HISTORY:\n -CABG: None\n -PERCUTANEOUS CORONARY INTERVENTIONS: BM stent to the LAD in ,\n Occluded RCA/no intervention\n -PACING/ICD: Ischemic cardiomyopathy (EF 10%) s/p BiV ICD and atrial\n fibrillation\n 3. H/o PE secondary to DVT s/p IVC filter on Coumadin\n 4. PVD\n 5. Small VSD\n OTHER\n # Septic Polyarticular Arthritis s/p irrigation and debridement left\n shoulder via anterolateral deltopectoral miniarthrotomy, aspiration\n left hip joint and irrigation and debridement of 3rd\n metacarpophalangeal joint\n 6. Hypothyroidism\n 7. CKD\n 8. Osteoarthritis\n Meds: Lasix drip, Milrinone drip, ABX, Potassium Chloride (20mEq\n repletion), bowel regimen\n Potential for nutrition risk. Patient being monitored. Current\n intervention if any, listed below:\n 71 YO female admitted from rehab with volume overload consistent with\n CHF exacerbation. Noted code status changed to DNR/ DNI, pacemaker\n turned off. Reports eating Rice Krispies with milk at breakfast and\n improved appetite here compared to at rehab. Liked po shake from last\n admit, but does not recall the name of it. Question accuracy of\n weights, patient looks thin. Noted unstageable pressure ulcer.\n Recommendations:\n 1. Encourage po\n 2. Will send Carnation Instant Breakfast shakes with milk/ice\n cream\n 3. Lytes and BS management\n 4. Will follow, page if questions *\n 5. Electronically signed by , RD, LDN\n 10:26\n 6.\n 7.\n"
},
{
"category": "Physician ",
"chartdate": "2180-01-17 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 400082,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - MS contin increased to 30mg last night, received 2 doses w pills\n crushed, complained of nausea after each\n - complains of pain at 8/10\n - Has not had a BM for four days\n - PT ordered yesterday\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 08:00 AM\n Vancomycin - 09:36 AM\n Infusions:\n Furosemide (Lasix) - 10 mg/hour\n Milrinone - 0.5 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 12:45 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.6\nC (97.8\n HR: 68 (63 - 75) bpm\n BP: 91/52(62) {75/44(51) - 98/61(70)} mmHg\n RR: 9 (9 - 29) insp/min\n SpO2: 99%\n Heart rhythm: AV Paced\n Wgt (current): 77.3 kg (admission): 82.2 kg\n Total In:\n 1,004 mL\n 146 mL\n PO:\n 440 mL\n TF:\n IVF:\n 564 mL\n 146 mL\n Blood products:\n Total out:\n 2,410 mL\n 420 mL\n Urine:\n 2,410 mL\n 420 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,406 mL\n -274 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///34/\n Physical Examination\n Gen: alert, oriented x3 but appears to have psychomotor retardation and\n easily confused\n HEENT: slightly dry mucus membranes\n CHEST: regular rhythm ; dry basilar crackles\n ABD: mildly distended, soft, nontender\n EXT: + pitting edema bilaterally\n Labs / Radiology\n 106 K/uL\n 10.0 g/dL\n 86 mg/dL\n 1.0 mg/dL\n 34 mEq/L\n 3.7 mEq/L\n 33 mg/dL\n 92 mEq/L\n 134 mEq/L\n 30.9 %\n 4.2 K/uL\n [image002.jpg]\n 05:44 AM\n 04:46 AM\n 04:00 PM\n 03:05 AM\n 03:17 PM\n 03:05 AM\n 05:03 PM\n 05:22 AM\n WBC\n 6.1\n 4.7\n 5.1\n 4.4\n 4.2\n Hct\n 32.1\n 31.9\n 33.1\n 32.2\n 30.9\n Plt\n 156\n 159\n 146\n 134\n 106\n Cr\n 1.3\n 1.4\n 1.3\n 1.2\n 1.1\n 1.0\n 1.0\n 1.0\n Glucose\n 83\n 104\n 155\n 115\n 98\n 107\n 86\n Other labs: PT / PTT / INR:20.2/33.1/1.9, Ca++:8.1 mg/dL, Mg++:2.1\n mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\n recently discharged from the CCU () for CHF exacerbation c/b\n C.diff infection and on for septic joint washout c/b failure to\n extubate CHF exacerbation, who was admitted from clinic with\n total body fluid overload.\n .\n # sCHF exacerbation:\n Patient has history of CHF ischemic , 10%, s/p BiV ICD\n ( Concerto C154DWK) with EF 10% which was the likely\n cause of her fluid overload. Appears intravascularly euvolemic on\n exam, no need to continue lasix gtt. Has diuresed well -9L on length\n of stay. Diuresed -1.5L over last day.\n - DC lasix gtt\n - DC milrinone\n - Start torsemide 40mg , on which she will be discharged\n - Metolazone 5mg once today, then switch to metolazone 2.5mg\n daily w first dose of torsemide tomorrow\n - Continue strict I/Os\n - Continue to replete K\n .\n # Goals of Care:\n End-stage CHF with long term goals are comfort, though she still wishes\n to participate in rehab. Her family recognizes that she is dying.\n - Consult Pain and Palliative Care\n .\n # Septic Joints: Patient with history +staph aureus in left shoulder\n treated by washout and vancomycin, thus far 4 weeks of monotherapy. No\n + blood cx since before . Major issue now is pain control.\n -- continue vanc 500 mg q24 ; will need to monitor vanc troughs on\n discharge\n -- MS contin increased to 30mg yesterday\n -- standing ultram q6, Tylenol q8\n .\n # Sacral Decub - stage 3-4.\n Pain control very important\n - switch to oral breakthrough Morphine , but leave IV as backup\n - wound care\n - standing ultram Q6h, Tylenol Q8h\n - continue MS contin to 30mg (with smaller 15mg pills x2 so she can\n swallow)\n - Consulting Pain and Palliative Care\n .\n # UTI: positive UA, no history of culture positive UA's in system.\n Will do 10day course because of chronic foley.\n - treating empirically with cipro ; day 1 of 10 day course was \n - watch INR on abx\n .\n # Hx CAD:\n Patient with h/o CAD w/ right dominant system, mild instent re-stenois\n of the LAD BM stent and occluded RCA.\n - continue metoprolol 25mg \n .\n # Hx Afib:\n Patient with h/o atrial fibrillation, s/p BiV ICD ( Concerto\n C154DWK) , on coumadin. Now in paced rhythm\n - cont home dose meds (amio, metoprolol)\n - cont coumadin\n - trend INR\n .\n # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a\n filter in place. INR mildly subtherapeutic despite Cipro\n - continue Coumadin and monitor INR\n .\n # Hypothyroidism: Continue Levothyroxine\n .\n # Gout: continue Allopurinol\n ICU Care\n Nutrition: tolerating po well\n Glycemic Control:\n Lines: midline, right IJ (will consider taking out RIJ tomorrow\n if does not need milrinone again)\n Multi Lumen - 05:34 PM\n Midline - 05:34 PM\n Prophylaxis:\n DVT: coumadin\n Stress ulcer: lansoprazole\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2180-01-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 400129,
"text": "71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\n : Sent to ED from clinic w/ hypotension\n transiently on\n dopa, Tx\nd w/ NS 250 cc w/ SBP ^ 92.\n Admit to CCU for aggressive diuresis.She was started on Milrinone\n and lasix gtt. And has been diuresing well. She has lg coccyx decub\n that is a source of chronic pain. She is DNR/DNI and defibrillator has\n been shut off.\n Pain control (acute pain, chronic pain)\n Assessment:\n Contin. with acute pain with turning. Pain is at decub site/coccyx.\n Pt. also has severe arthritis in legs/hips/shoulders\n Action:\n MS . Supplemented with morphine IR 15mg x2 overnight-\n both times with turning.\n Tylenol and ultram RTC.\n Response:\n Acute pain resolves and pt. able to be comfortable and sleep.\n Plan:\n Family deciding if pt will now be CMO and go to extended care facility\n with hospice- speaking with MD \n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Started on milrinone 0.5mcq\n restarted after u/o dropped to 0cc .\n HR 60-70\ns Vpaced, wide complex. BP maps 53-60. SBP 80-90\n Action:\n Milrinone 0.5mcq/,\n Po amio, metalazone, torsemide po.\n Response:\n u/o 30-60cc/hr. LS clear to diminished. Sats 95-99% on RA. Denies\n SOB.\n Plan:\n Contin. meds as ordered. Monitor u/o.\n Impaired Skin Integrity\n Assessment:\n Skin care plan changed . see wound care note.\n DSD intact over coccyx. Wound not visualized. No drainage or\n saturation.\n Action:\n Maintained integrity of DSD. Turn/position q3hr as tolerated. Barrier\n cream to all other areas.\n Response:\n Pt. states itchy skin is improved.\n Plan:\n Wound care per current plan. See orders\n"
},
{
"category": "Physician ",
"chartdate": "2180-01-18 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 400142,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - MS contin increased to 30mg last night, received 2 doses w pills\n crushed, complained of nausea after each\n - complains of pain at 8/10\n - Has not had a BM for four days\n - PT ordered yesterday\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 08:00 AM\n Vancomycin - 09:36 AM\n Infusions:\n Furosemide (Lasix) - 10 mg/hour\n Milrinone - 0.5 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 12:45 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.6\nC (97.8\n HR: 68 (63 - 75) bpm\n BP: 91/52(62) {75/44(51) - 98/61(70)} mmHg\n RR: 9 (9 - 29) insp/min\n SpO2: 99%\n Heart rhythm: AV Paced\n Wgt (current): 77.3 kg (admission): 82.2 kg\n Total In:\n 1,004 mL\n 146 mL\n PO:\n 440 mL\n TF:\n IVF:\n 564 mL\n 146 mL\n Blood products:\n Total out:\n 2,410 mL\n 420 mL\n Urine:\n 2,410 mL\n 420 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,406 mL\n -274 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///34/\n Physical Examination\n Gen: alert, oriented x3 but appears to have psychomotor retardation and\n easily confused\n HEENT: slightly dry mucus membranes\n CHEST: regular rhythm ; dry basilar crackles\n ABD: mildly distended, soft, nontender\n EXT: + pitting edema bilaterally\n Labs / Radiology\n 106 K/uL\n 10.0 g/dL\n 86 mg/dL\n 1.0 mg/dL\n 34 mEq/L\n 3.7 mEq/L\n 33 mg/dL\n 92 mEq/L\n 134 mEq/L\n 30.9 %\n 4.2 K/uL\n [image002.jpg]\n 05:44 AM\n 04:46 AM\n 04:00 PM\n 03:05 AM\n 03:17 PM\n 03:05 AM\n 05:03 PM\n 05:22 AM\n WBC\n 6.1\n 4.7\n 5.1\n 4.4\n 4.2\n Hct\n 32.1\n 31.9\n 33.1\n 32.2\n 30.9\n Plt\n 156\n 159\n 146\n 134\n 106\n Cr\n 1.3\n 1.4\n 1.3\n 1.2\n 1.1\n 1.0\n 1.0\n 1.0\n Glucose\n 83\n 104\n 155\n 115\n 98\n 107\n 86\n Other labs: PT / PTT / INR:20.2/33.1/1.9, Ca++:8.1 mg/dL, Mg++:2.1\n mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n 71 yo F w/ CAD, ischemic (EF 10%) s/p -V ICD, atrial\n fibrillation, CKD, with past history of DVT and PE on Coumadin who was\n recently discharged from the CCU () for CHF exacerbation c/b\n C.diff infection and on for septic joint washout c/b failure to\n extubate CHF exacerbation, who was admitted from clinic with\n total body fluid overload.\n .\n # sCHF exacerbation:\n Patient has history of CHF ischemic , 10%, s/p BiV ICD\n ( Concerto C154DWK) with EF 10% which was the likely\n cause of her fluid overload. Appears intravascularly euvolemic on\n exam, no need to continue lasix gtt. Has diuresed well -9L on length\n of stay. Diuresed -1.5L over last day.\n - DC lasix gtt\n - DC milrinone\n - Start torsemide 40mg , on which she will be discharged\n - Metolazone 5mg once today, then switch to metolazone 2.5mg\n daily w first dose of torsemide tomorrow\n - Continue strict I/Os\n - Continue to replete K\n .\n # Goals of Care:\n End-stage CHF with long term goals are comfort, though she still wishes\n to participate in rehab. Her family recognizes that she is dying.\n - Consult Pain and Palliative Care\n .\n # Septic Joints: Patient with history +staph aureus in left shoulder\n treated by washout and vancomycin, thus far 4 weeks of monotherapy. No\n + blood cx since before . Major issue now is pain control.\n -- continue vanc 500 mg q24 ; will need to monitor vanc troughs on\n discharge\n -- MS contin increased to 30mg yesterday\n -- standing ultram q6, Tylenol q8\n .\n # Sacral Decub - stage 3-4.\n Pain control very important\n - switch to oral breakthrough Morphine , but leave IV as backup\n - wound care\n - standing ultram Q6h, Tylenol Q8h\n - continue MS contin to 30mg (with smaller 15mg pills x2 so she can\n swallow)\n - Consulting Pain and Palliative Care\n .\n # UTI: positive UA, no history of culture positive UA's in system.\n Will do 10day course because of chronic foley.\n - treating empirically with cipro ; day 1 of 10 day course was \n - watch INR on abx\n .\n # Hx CAD:\n Patient with h/o CAD w/ right dominant system, mild instent re-stenois\n of the LAD BM stent and occluded RCA.\n - continue metoprolol 25mg \n .\n # Hx Afib:\n Patient with h/o atrial fibrillation, s/p BiV ICD ( Concerto\n C154DWK) , on coumadin. Now in paced rhythm\n - cont home dose meds (amio, metoprolol)\n - cont coumadin\n - trend INR\n .\n # H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has a\n filter in place. INR mildly subtherapeutic despite Cipro\n - continue Coumadin and monitor INR\n .\n # Hypothyroidism: Continue Levothyroxine\n .\n # Gout: continue Allopurinol\n ICU Care\n Nutrition: tolerating po well\n Glycemic Control:\n Lines: midline, right IJ (will consider taking out RIJ tomorrow\n if does not need milrinone again)\n Multi Lumen - 05:34 PM\n Midline - 05:34 PM\n Prophylaxis:\n DVT: coumadin\n Stress ulcer: lansoprazole\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n ------ Protected Section ------\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I would add the following remarks:\n Above discussed extensively with patient. Above discussed extensively\n with family member, next of or health care proxy.\n DNR status discussed. DNR.\n Total time spent on patient care: 45 minutes.\n Additional comments:\n signed on for service provided on \n plan to shut off milrinone and furosemide drips and switch to po\n ------ Protected Section Addendum Entered By: on:\n 09:59 ------\n"
},
{
"category": "Nursing",
"chartdate": "2180-01-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 400158,
"text": "71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\n : Sent to ED from clinic admit to CCU for aggressive\n diuresis. She was started on Milrinone and lasix gtt, lasix and\n milrinone gtts turned to off . Milrinone restarted d/t BP and U/O\n decrease. Large Stage III decube on coccyx decub that is a source of\n chronic pain. She is DNR/DNI and defibrillator has been shut off. Able\n to swallow pills whole, with either applesauce or custard.\n SOCIAL: Family in to visit. Pts HCP is in and intubated,\n pt\ns sister is alternate HCP.\n control (acute pain, chronic pain)\n Assessment:\n On standing dose of morphine SR, ultram and Tylenol.\n Action/Response:\n Pain rated to be this am, then later in day .\n Given supplemental IR morphine and 2mg IV morphine with relief of pain.\n Repositioned for comfort\n Plan:\n Continue pain control with oral medications. Give immediate release\n morphine for breakthrough pain.\n Impaired Skin Integrity\n Assessment:\n Stage III PU on coccyx, foul smelling, yellow sanguinous drainage,\n edges of wound yellow with areas of necrosis. Surrounding skin\n macerated. Pt. refusing kinair bed\n Action/Response:\n Dressing changed according to wound care RN\ns recs:\n anti-fungal barrier criticaid to macerated skin surrounding wound,\n acqua cell-AG to coccyx, covered in soft sorb dsg, medipore tape.\n Aloe Vesta to skin\n Repositioned\n Po\ns encouraged, patient drinking hot chocolate, custard,\n applesauce.\n Plan:\n QD dressing change as above. Aloe vesta to skin. Reposition q2 hours\n or according to pt\ns wishes.\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Pt DNR/DNI. SBP 90\ns. Milrinone @ 0.5mcg/kg/min. U/O ~ 100cc q\n 2hours.\n Action/Response:\n Dr. in to talk with patient and family extensively.\n Milrinone turned to off. Torsemide and metzolone d/c\n Palliative care MD in to talk with pt and family.\n SBP decreasing to low 80\ns off mirinone, U/O also tapering\n off.\n Plan:\n To remain in hospital for now. Will monitor off of milrinone with plan\n to give IV NS 250 cc for hypotension as per Dr. . No other changes\n in medications for now. Focus on comfort.\n"
},
{
"category": "Nursing",
"chartdate": "2180-01-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 399911,
"text": "71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\n : Sent to ED from clinic w/ hypotension\n transiently on\n dopa, Tx\nd w/ NS 250 cc w/ SBP ^ 92. Admit to CCU for aggressive\n diuresis.\n Heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n + pitting edema BLE\non lasix gtt 15mg/hr & milrinone 0.5mcg/k/min.\n LS clr, dim at bases.\n Action:\n 1^st dose 25mg PO lopressor given\n Response:\n BPs lower when asleep and after morphine, MAPs >55 (of note: BPs taken\n on L upper arm, pt mosly positioned on R side). Lytes. Rare short runs\n AIVR.\n Plan:\n CHF management, aggressive diuresis w/ lasix & daily\n metolazone-- goal NEG 5-10L overall, strict I/Os, Low Na+ diet, daily\n wts, monitor & replete lytes as indicated\n DNR/DNI-ICD turned off after fam mtg. Both pt and HCP\n are in agreement that pt would like to be comfortable to be able to\n participate in rehab.\n Impaired Skin Integrity\n Assessment:\n *Lg stage 3 vs. unstageable decub to coccyx, covered w/ yellow slough &\n red blanching borders--sm amt serous dsg\n mepilex intact, placed \n *Red, blanching heels.\n *Dry and thin skin w/ discolored areas.\n *Good appetite. Declines Kinair bed/waffle boots\n Action:\n Mepilex dsg peeled to check skin--Duoderm hydroactive gel\n applied per wound care recs .\n Heels elevated on pillows, skin/pressure area well\n lubricated.\n Slight freq position changes avoiding back and L side.\n Response:\n Skin unchanged\n Plan:\n Monitor for changes, prevent further breathdown. Change\n position freq as tolerated as pt mobility/able to turn self is very\n limited.\n Change mepilex w/ duoderm gel daily drainage\n Pain control (chronic pain)\n Assessment:\n Very uncomfortable w/ turning and w/ laying on L side\n Action:\n Standing order ultram & Tylenol Q6hrs, 2mg Morphine sulfate\n IVP for breakthrough pain\n Pt positioned mostly far on R side w/ slight position\n changes, placed supine for short periods only.\n Response:\n Pt allowed to rest in btwn necessary nsg interventions, Slept well all\n night.\n Plan:\n Continue current pain control regimen, medicate w/ morphine\n prior to turning side to side\n GI: NO BM, takes pills crushed in applesauce\n"
},
{
"category": "Nursing",
"chartdate": "2180-01-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 400072,
"text": "71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\n : Sent to ED from clinic w/ hypotension\n transiently on\n dopa, Tx\nd w/ NS 250 cc w/ SBP ^ 92. Admit to CCU for aggressive\n diuresis.\n Pain control (acute pain, chronic pain)\n Assessment:\n Remains on 30 mg of ms contin for coccyx pain associated with turning.\n Although, hips/lower back disarticulating with side to side activity.\n Action:\n Pre-mediated with 4 mg of iv ms04 prior to turning\n Continues on Tylenol 1000mg po TID, Ultram 50mg QID\n Response:\n Pre-medication decreases pain with turning per patient\n Plan:\n Cont assess pain, cont ATC meds and supplement with IV Morphine as\n needed\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Pt asystomatic\n no SOB with stable VS\n Action:\n Milrinone remains at 0,5mcgs/kg/min\n Lasix increased from 5 to 10mg/hr\n Response:\n 1.8 liters negative at midnight\n Plan:\n Plan to transition heart failure meds to po route\n Impaired Skin Integrity\n Assessment:\n Large unstageable pressur ulcer on coccyx unchanged\n Bilat heels remain reddened but blanchble\n Action:\n duoderm gel/Mepilex, changed on \n mod amt sero-sanguinous drainage; redness/maceration to surrounding\n tissue\n severe pain at site\n see above\n Response:\n Site remains unchanged\n Plan:\n Cont with frequent turns\n Wound care RN .. social work, case manager and palliative consult to\n assist with rehab destination\n"
},
{
"category": "Physician ",
"chartdate": "2180-01-17 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 400065,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 08:00 AM\n Vancomycin - 09:36 AM\n Infusions:\n Furosemide (Lasix) - 10 mg/hour\n Milrinone - 0.5 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 12:45 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.6\nC (97.8\n HR: 68 (63 - 75) bpm\n BP: 91/52(62) {75/44(51) - 98/61(70)} mmHg\n RR: 9 (9 - 29) insp/min\n SpO2: 99%\n Heart rhythm: AV Paced\n Wgt (current): 77.3 kg (admission): 82.2 kg\n Total In:\n 1,004 mL\n 146 mL\n PO:\n 440 mL\n TF:\n IVF:\n 564 mL\n 146 mL\n Blood products:\n Total out:\n 2,410 mL\n 420 mL\n Urine:\n 2,410 mL\n 420 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,406 mL\n -274 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///34/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 106 K/uL\n 10.0 g/dL\n 86 mg/dL\n 1.0 mg/dL\n 34 mEq/L\n 3.7 mEq/L\n 33 mg/dL\n 92 mEq/L\n 134 mEq/L\n 30.9 %\n 4.2 K/uL\n [image002.jpg]\n 05:44 AM\n 04:46 AM\n 04:00 PM\n 03:05 AM\n 03:17 PM\n 03:05 AM\n 05:03 PM\n 05:22 AM\n WBC\n 6.1\n 4.7\n 5.1\n 4.4\n 4.2\n Hct\n 32.1\n 31.9\n 33.1\n 32.2\n 30.9\n Plt\n 156\n 159\n 146\n 134\n 106\n Cr\n 1.3\n 1.4\n 1.3\n 1.2\n 1.1\n 1.0\n 1.0\n 1.0\n Glucose\n 83\n 104\n 155\n 115\n 98\n 107\n 86\n Other labs: PT / PTT / INR:20.2/33.1/1.9, Ca++:8.1 mg/dL, Mg++:2.1\n mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n INEFFECTIVE COPING\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n .H/O HEART FAILURE (CHF), SYSTOLIC, ACUTE ON CHRONIC\n IMPAIRED SKIN INTEGRITY\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 05:34 PM\n Midline - 05:34 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2180-01-17 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 400066,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 08:00 AM\n Vancomycin - 09:36 AM\n Infusions:\n Furosemide (Lasix) - 10 mg/hour\n Milrinone - 0.5 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 12:45 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.6\nC (97.8\n HR: 68 (63 - 75) bpm\n BP: 91/52(62) {75/44(51) - 98/61(70)} mmHg\n RR: 9 (9 - 29) insp/min\n SpO2: 99%\n Heart rhythm: AV Paced\n Wgt (current): 77.3 kg (admission): 82.2 kg\n Total In:\n 1,004 mL\n 146 mL\n PO:\n 440 mL\n TF:\n IVF:\n 564 mL\n 146 mL\n Blood products:\n Total out:\n 2,410 mL\n 420 mL\n Urine:\n 2,410 mL\n 420 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,406 mL\n -274 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///34/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 106 K/uL\n 10.0 g/dL\n 86 mg/dL\n 1.0 mg/dL\n 34 mEq/L\n 3.7 mEq/L\n 33 mg/dL\n 92 mEq/L\n 134 mEq/L\n 30.9 %\n 4.2 K/uL\n [image002.jpg]\n 05:44 AM\n 04:46 AM\n 04:00 PM\n 03:05 AM\n 03:17 PM\n 03:05 AM\n 05:03 PM\n 05:22 AM\n WBC\n 6.1\n 4.7\n 5.1\n 4.4\n 4.2\n Hct\n 32.1\n 31.9\n 33.1\n 32.2\n 30.9\n Plt\n 156\n 159\n 146\n 134\n 106\n Cr\n 1.3\n 1.4\n 1.3\n 1.2\n 1.1\n 1.0\n 1.0\n 1.0\n Glucose\n 83\n 104\n 155\n 115\n 98\n 107\n 86\n Other labs: PT / PTT / INR:20.2/33.1/1.9, Ca++:8.1 mg/dL, Mg++:2.1\n mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n INEFFECTIVE COPING\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n .H/O HEART FAILURE (CHF), SYSTOLIC, ACUTE ON CHRONIC\n IMPAIRED SKIN INTEGRITY\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 05:34 PM\n Midline - 05:34 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2180-01-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 400070,
"text": "71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\n : Sent to ED from clinic w/ hypotension\n transiently on\n dopa, Tx\nd w/ NS 250 cc w/ SBP ^ 92. Admit to CCU for aggressive\n diuresis.She was started on Milrinone and lasix gtt. And has been\n diuresing well. She has lg coccyx decub that is a source of chronic\n pain.\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2180-01-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 400119,
"text": "71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\n coumadin, hypothyroidism, CKD, OA. adm for septic joint washout-\n MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\n : Sent to ED from clinic w/ hypotension\n transiently on\n dopa, Tx\nd w/ NS 250 cc w/ SBP ^ 92.\n Admit to CCU for aggressive diuresis.She was started on Milrinone\n and lasix gtt. And has been diuresing well. She has lg coccyx decub\n that is a source of chronic pain. She is DNR/DNI and defibrillator has\n been shut off.\n Pain control (acute pain, chronic pain)\n Assessment:\n Contin. with acute pain with turning. Pain is at decub site/coccyx.\n Action:\n MS . Supplemented with morphine IR 15mg x2 overnight-\n both times with turning.\n Tylenol and ultram RTC.\n Response:\n Acute pain resolves and pt. able to be comfortable and sleep.\n Plan:\n Family deciding if pt will now be CMO and go to extended care facility\n with hospice- speaking with MD \n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Started on milrinone 0.5mcq\n restarted after u/o dropped to 0cc .\n HR 60-70\ns Vpaced, wide complex. BP maps 53-60. SBP 80-90\n Action:\n Milrinone 0.5mcq/,\n Po amio, metalazone, torsemide po.\n Response:\n u/o 30-50cc/hr. LS clear to diminished. Sats 95-99% on RA. Denies\n SOB.\n Plan:\n Contin. meds as ordered. Monitor u/o.\n Impaired Skin Integrity\n Assessment:\n Skin care plan changed . see wound care note.\n DSD intact over coccyx. Wound not visualized. No drainage or\n saturation.\n Action:\n Maintained integrity of DSD. Turn/position q3hr as tolerated. Barrier\n cream to all other areas.\n Response:\n Pt. states itchy skin is improved.\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2180-01-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 399675,
"text": "Pt is a 71 yo female with PMH: BM stent to LAD ', Occluded RCA\n without intervention, Ischemic CM (EF 10-25%), BiV ICD, AF, PVD, DVT\n s/p IVC filter, coumadin, hypothyroidism, CKD, OA. adm for HF\n (milrinone/lasix) MRSA in L shoulder, L hip and R knuckle. Out to\n rehab . Today went from rehab to see Dr. , sent to EW with\n hypotension. SBP 70 in EW, transiently on dopa, but cardiology d/c'd.\n Rxd with NS 250 cc with SBP 92. Pt has been in rehab since d/c from\n with septic arthritis in L shoulder, hip and R knuckle.\n On Vanco followed by ID.\n"
},
{
"category": "Nursing",
"chartdate": "2180-01-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 399676,
"text": "Pt is a 71 yo female with PMH: BM stent to LAD ', Occluded RCA\n without intervention, Ischemic CM (EF 10-25%), BiV ICD, AF, PVD, DVT\n s/p IVC filter, coumadin, hypothyroidism, CKD, OA. adm for HF\n (milrinone/lasix) MRSA in L shoulder, L hip and R knuckle. Out to\n rehab . Today went from rehab to see Dr. , sent to EW with\n hypotension. SBP 70 in EW, transiently on dopa, but cardiology d/c'd.\n Rxd with NS 250 cc with SBP 92. Pt has been in rehab since d/c from\n with septic arthritis in L shoulder, hip and R knuckle.\n On Vanco followed by ID.\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2180-01-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 399746,
"text": "Pt is a 71 yo female with PMH: BM stent to LAD ', Occluded RCA\n without intervention, Ischemic CM (EF 10-25%), BiV ICD, AF, PVD, DVT\n s/p IVC filter, coumadin, hypothyroidism, CKD, OA. adm for HF\n (milrinone/lasix) MRSA in L shoulder, L hip and R knuckle. Out to\n rehab . went from rehab to see Dr. , sent to EW with\n hypotension. SBP 70 in EW, transiently on dopa, but cardiology d/c'd.\n Rxd with NS 250 cc with SBP 92. Pt has been in rehab since d/c from\n with septic arthritis in L shoulder, hip and R knuckle.\n On Vanco followed by ID.\n She was started on milrinone .375 after bolus and lasix drip also begun\n at 2.5mg/hr. The lasix dose was increased to 5mg overnight, but urine\n output has remained poor, though she is negative.\n GI: Pt has poor apetite and eats very little.\n SOCIAL: Family in the visit in afternoon. Pt in good spirits, visiting\n with brother and his family.\n CODE STATUS: Dr had discussion with both patient and health care\n proxy and all are in agreement that she be DNR/DNI. Additionally the\n defibrillator part of AICD/pacer was shut off.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt has a number of sources of pain. She has joint pain in shoulders and\n especially R elbow from septic arthritis. The most uncomfortable area\n is the decubitus ulcer on her coccyx area. She receive standing ultran\n for that. She requires frequent position changes, but seems most\n uncomfortable on L side. By 1000 she was very uncomfortable.\n Action:\n She received 2mg IV morpnine sulfate at 1230 and had shift in position\n and was comfortable until noon when pain recurred. She received another\n 2mg morphine sulfate and position change.\n Response:\n She slept until\n Plan:\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Pt on Milrinone .375mic/kilo and lasix 5mg/hr. Urine output\n ~30-50cc/hr. Hr in 70s AV paced with rare PVCs . BP 85-100/50-60s,\n lower after morphine. Pt sating 98-100% on 3L NP and lungs are mostly\n clear. She has no c/o of SOB. She has 2+ edema in legs.\n Action:\n At 1030 lasix was increased to 10mg/hr and at 1100 milrinone was\n increased to .5mic/kilo. Legs are kept elevated. 02 has been off most\n of the day and she is sating 96-98% on RA.\n Response:\n She is ~280cc negative for the day. The skin on her legs show signs\n that they have lost fluid.\n Plan:\n Continue with Milrinone and lasix. Keep careful I & O\n Impaired Skin Integrity\n Assessment:\n Pt has multiple skin lesions. Most prominent is coccyx decub. It has\n mepelix on it that was leaking through and pulling loose in am. Both\n heels are reddened, though they . She has dry skin on all\n extremities with some small abraded areas.\n Action:\n Coccyx dsg changed. Area primarily covered with slough. The edges are\n rounded and pink. Area cleansed with wound cleaner, dried and new\n mepelix applied. All limbs were lubricated frequently. Her position was\n changed, at times only slightly throughout the day. She does become\n uncomfortable if she is in the same position for too long,but also has\n difficulty on the L side. She finds the waffle boots uncomfortable and\n prefers having her legs elevated on pillows.\n Response:\n No new skin lesions have developed.\n Plan:\n Continue with turning, lubricating and keeping heels elevated. Monitor\n mepilex to ensure it is in place.\n"
},
{
"category": "Nursing",
"chartdate": "2180-01-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 399747,
"text": "Pt is a 71 yo female with PMH: BM stent to LAD ', Occluded RCA\n without intervention, Ischemic CM (EF 10-25%), BiV ICD, AF, PVD, DVT\n s/p IVC filter, coumadin, hypothyroidism, CKD, OA. adm for HF\n (milrinone/lasix) MRSA in L shoulder, L hip and R knuckle. Out to\n rehab . went from rehab to see Dr. , sent to EW with\n hypotension. SBP 70 in EW, transiently on dopa, but cardiology d/c'd.\n Rxd with NS 250 cc with SBP 92. Pt has been in rehab since d/c from\n with septic arthritis in L shoulder, hip and R knuckle.\n On Vanco followed by ID.\n She was started on milrinone .375 after bolus and lasix drip also begun\n at 2.5mg/hr. The lasix dose was increased to 5mg overnight, but urine\n output has remained poor, though she is negative.\n GI: Pt has poor apetite and eats very little.\n SOCIAL: Family in the visit in afternoon. Pt in good spirits, visiting\n with brother and his family.\n CODE STATUS: Dr had discussion with both patient and health care\n proxy and all are in agreement that she be DNR/DNI. Additionally the\n defibrillator part of AICD/pacer was shut off.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt has a number of sources of pain. She has joint pain in shoulders and\n especially R elbow from septic arthritis. The most uncomfortable area\n is the decubitus ulcer on her coccyx area. She receive standing ultran\n for that. She requires frequent position changes, but seems most\n uncomfortable on L side. By 1000 she was very uncomfortable.\n Action:\n She received 2mg IV morpnine sulfate at 1230 and had shift in position\n and was comfortable until noon when pain recurred. She received another\n 2mg morphine sulfate and position change.\n Response:\n She slept until\n Plan:\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Pt on Milrinone .375mic/kilo and lasix 5mg/hr. Urine output\n ~30-50cc/hr. Hr in 70s AV paced with rare PVCs . BP 85-100/50-60s,\n lower after morphine. Pt sating 98-100% on 3L NP and lungs are mostly\n clear. She has no c/o of SOB. She has 2+ edema in legs.\n Action:\n At 1030 lasix was increased to 10mg/hr and at 1100 milrinone was\n increased to .5mic/kilo. Legs are kept elevated. 02 has been off most\n of the day and she is sating 96-98% on RA.\n Response:\n She is ~280cc negative for the day. The skin on her legs show signs\n that they have lost fluid.\n Plan:\n Continue with Milrinone and lasix. Keep careful I & O\n Impaired Skin Integrity\n Assessment:\n Pt has multiple skin lesions. Most prominent is coccyx decub. It has\n mepelix on it that was leaking through and pulling loose in am. Both\n heels are reddened, though they . She has dry skin on all\n extremities with some small abraded areas.\n Action:\n Coccyx dsg changed. Area primarily covered with slough. The edges are\n rounded and pink. Area cleansed with wound cleaner, dried and new\n mepelix applied. All limbs were lubricated frequently. Her position was\n changed, at times only slightly throughout the day. She does become\n uncomfortable if she is in the same position for too long,but also has\n difficulty on the L side. She finds the waffle boots uncomfortable and\n prefers having her legs elevated on pillows.\n Response:\n No new skin lesions have developed.\n Plan:\n Continue with turning, lubricating and keeping heels elevated. Monitor\n mepilex to ensure it is in place.\n"
},
{
"category": "Physician ",
"chartdate": "2180-01-12 00:00:00.000",
"description": "CCU Fellow Addendum",
"row_id": 399668,
"text": "TITLE: CCU Fellow Addendum\n Patient seen and plan discussed with CCU housestaff. For details, see\n CCU resident H&P. Briefly, the patient is a 71 year old woman with PMH\n of CAD, ischemic CMY (EF 10%) s/p -V ICD, atrial fibrillation, CKD,\n with past history of DVT and PE on Coumadin, sacral decubitus ulcers\n and R shoulder sepsis s/p washout, who returns from rehab with volume\n overload consistent with her prior CHF exacerbations. The patient has\n had some chest burning consistent with her angina in the days up to\n today, but none currently. Her primary complaint has been severe\n sacral and shoulder pains, which continue to cause her significant\n agitation. On exam, she is hypotensive with cool extremities and\n slightly dyspneic, consistent with cardiogenic etiology. Plan will be\n for aggressive diuresis, with milrinone and neosynephrine for BP\n support, as well as aggressive pain control. Plan discussed with Dr.\n .\n"
},
{
"category": "Nursing",
"chartdate": "2180-01-19 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 400261,
"text": "71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\n coumadin, hypothyroidism, CKD, OA. admitted for septic joint\n washout- MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\n On pt. was sent to ED from clinic w/ hypotension\n transiently on dopa, Tx\nd w/ NS 250 cc w/ SBP ^ 92.\n Admit to CCU for aggressive diuresis. She was started on\n Milrinone and lasix gtt. She has large coccyx decub that is a source\n of chronic pain. She is DNR/DNI and defibrillator has been shut off.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt. with history of pain in left shoulder, left hip (septic joints) and\n coccyx (decub.).\n Action:\n MS , morphine IR 15mg for breakthrough pain, given this x2\n today. Pt. also given 2mg IV morphine prior to all activity/turning\n today. Pt. receiving ultram qid.\n Response:\n Pt. has denied pain today until 1500\n she reported pain after turning\n despite premedicating. Tolerating above with no ill-effects. Pt.\n painfree by 1600.\n Plan:\n Continue present around-the-clock and aggressive prn regimen.\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Off lasix gtt since , and milrinone since . AV paced at 70 with\n BP 90\ns/60\ns today. LS essentially clear, some fine ?dependent\n crackles noted at bases. Skin warm, dry. UO approximately 20cc/hr.\n Pt. slightly confused this afternoon per family.\n Action:\n Assessment ongoing. Torsemide started.\n Response:\n Pt. tolerating medication. Assessment largely unchanged.\n Plan:\n Continue to monitor and treat as indicated. Transfer to floor today.\n **** Goals towards comfort.****\n Impaired Skin Integrity\n Assessment:\n Pt. with sacral decub as documented in metavision.\n Action:\n Dressing changed today at noon per skin care recs. Pt. turned side to\n side as documented.\n Response:\n Pt. tolerated dressing change, premedicated with morphine IV.\n Moderated amt. yellow-white slough noted. Small amounts drainage\n noted.\n Plan:\n Continue daily dressing changes skin RN. Continue turning as pt.\n tolerates, avoid pressure points.\n"
},
{
"category": "Nursing",
"chartdate": "2180-01-19 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 400262,
"text": "71 F with PMH: BM stent to LAD ', Occluded RCA w/o intervention,\n Ischemic CM (EF <20%), BiV ICD, AF, PVD, DVT s/p IVC filter-on\n coumadin, hypothyroidism, CKD, OA. admitted for septic joint\n washout- MRSA L shoulder, L hip & R knuckle c/b CHF exacerbation\n milrinone/lasix, DCd to rehab w/ septic arthritis on vanco.\n On pt. was sent to ED from clinic w/ hypotension\n transiently on dopa, Tx\nd w/ NS 250 cc w/ SBP ^ 92.\n Admit to CCU for aggressive diuresis w/ Milrinone and lasix gtt.\n She has large coccyx decub that is a source of chronic pain. She is\n DNR/DNI--defibrillator has been shut off \n Pain control (acute pain, chronic pain)\n Assessment:\n Pt. with history of pain in left shoulder, left hip (septic joints) and\n coccyx (decub.).\n Action:\n MS ,\n morphine IR 15mg for breakthrough pain--2mg IV morphine\n prior to all activity/turning today.\n ultram QID, Tylenol TID\n Response:\n Pt. has denied pain today until 1500\n she reported pain after turning\n despite premedicating. Tolerating above with no ill-effects. Pt.\n painfree by 1600.\n Plan:\n Continue present around-the-clock and aggressive prn regimen.\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Off lasix gtt since , and milrinone since . AV paced at 70 with\n BP 85-90\ns/50-60\ns today. LS essentially clear, some fine crackles\n noted at bases this afternoon. Skin warm, dry. UO approximately\n 20cc/hr. Pt. slightly confused this afternoon per family.\n Action:\n Assessment ongoing. Torsemide started.\n Response:\n Pt. tolerating medication. Assessment largely unchanged.\n Plan:\n Continue to monitor and treat as indicated. Transfer to floor today.\n Impaired Skin Integrity\n Assessment:\n Pt. with sacral decub as documented in metavision.\n Action:\n Dressing changed today at noon per skin care recs ( critic-aid\n anti-fungal to peri-wound, covered w/ aquacel AG & sm soft soft pads\n secured w/ soft tape w/ skin barrier wipe). Pt. turned side to side\n as documented.\n Response:\n Pt. tolerated dressing change, premedicated with morphine IV.\n Moderated amt. yellow-white slough noted. Small amounts drainage\n noted.\n Plan:\n Continue daily dressing changes skin RN. Continue turning as pt.\n tolerates, avoid pressure points.\n 19:00-20:30\n Sleepy, a&Ox3. RR 8-12 w/ some periods of apnea ? r/t to\n pain meds. 20:00 dose of MS contin HELD. Currently comfortable and\n pain-free. SBPs generally mid 70s-90s\nASYMPTOMATIC.\n ACCESS: R brachial midline (previously PICC placd )\n RIJ TLC placed : Medial port clotted\n CIPRO for UTI\n Demographics\n Attending MD:\n \n Admit diagnosis:\n CONGESTIVE HEART FAILURE\n Code status:\n DNR / DNI\n Height:\n 60 Inch\n Admission weight:\n 82.2 kg\n Daily weight:\n 73.6 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: Contact (+ CDiff ; MRSA L shoulder, L hip and R\n knuckle )\n PMH:\n CV-PMH: Arrhythmias, CAD, CHF, Hypertension, MI, Pacemaker, PVD\n Additional history: BM stent to LAD ', Occluded RCA without\n intervention, Ischemic CM (EF 10-25%), BiV ICD, AF, PVD, DVT s/p IVC\n filter, coumadin, hypothyroidism, CKD, OA. adm for MRSA in L\n shoulder, L hip and R knuckle.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:99\n D:64\n Temperature:\n 96.6\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 16 insp/min\n Heart Rate:\n 70 bpm\n Heart rhythm:\n AV Paced\n O2 delivery device:\n None\n O2 saturation:\n 90%\n O2 flow:\n 3 L/min\n FiO2 set:\n 24h total in:\n 670 mL\n 24h total out:\n 500 mL\n Pertinent Lab Results:\n Sodium:\n 132 mEq/L\n 05:40 AM\n Potassium:\n 3.8 mEq/L\n 05:40 AM\n Chloride:\n 91 mEq/L\n 05:40 AM\n CO2:\n 35 mEq/L\n 05:40 AM\n BUN:\n 32 mg/dL\n 05:40 AM\n Creatinine:\n 1.0 mg/dL\n 05:40 AM\n Glucose:\n 93 mg/dL\n 05:40 AM\n Hematocrit:\n 31.2 %\n 05:40 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: w/ dtr\n / :\n No money / \n Cash / Credit cards sent home with:\n Jewelry: watch on pt R wrist\n Transferred from: CCU \n Transferred to: 3\n Date & time of Transfer: 21:00\n"
},
{
"category": "Nursing",
"chartdate": "2180-01-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 399738,
"text": "Pt is a 71 yo female with PMH: BM stent to LAD ', Occluded RCA\n without intervention, Ischemic CM (EF 10-25%), BiV ICD, AF, PVD, DVT\n s/p IVC filter, coumadin, hypothyroidism, CKD, OA. adm for HF\n (milrinone/lasix) MRSA in L shoulder, L hip and R knuckle. Out to\n rehab . went from rehab to see Dr. , sent to EW with\n hypotension. SBP 70 in EW, transiently on dopa, but cardiology d/c'd.\n Rxd with NS 250 cc with SBP 92. Pt has been in rehab since d/c from\n with septic arthritis in L shoulder, hip and R knuckle.\n On Vanco followed by ID.\n She was started on milrinone .375 after bolus and lasix drip also begun\n at 2.5mg/hr. The lasix dose was increased to 5mg overnight, but urine\n output has remained poor, though she is negative.\n GI: Pt has poor apetite and eats very little.\n SOCIAL: Family in the visit in afternoon. Pt in good spirits, visiting\n with brother and his family.\n CODE STATUS: Dr had discussion with both patient and health care\n proxy and all are in agreement that she be DNR/DNI. Additionally the\n defibrillator part of AICD/pacer was shut off.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt has a number of sources of pain. She has joint pain in shoulders and\n especially R elbow from septic arthritis. The most uncomfortable area\n is the decubitus ulcer on her coccyx area. She receive standing ultran\n for that. She requires frequent position changes, but seems most\n uncomfortable on L side. By 1000 she was very uncomfortable.\n Action:\n She received 2mg IV morpnine sulfate at 1230 and had shift in position\n and was comfortable until noon when pain recurred. She received another\n 2mg morphine sulfate and position change.\n Response:\n She slept until\n Plan:\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Pt on Milrinone .375mic/kilo and lasix 5mg/hr. Urine output\n ~30-50cc/hr. Hr in 70s AV paced with rare PVCs . BP 85-100/50-60s,\n lower after morphine. Pt sating 98-100% on 3L NP and lungs are mostly\n clear. She has no c/o of SOB. She has 2+ edema in legs.\n Action:\n At 1030 lasix was increased to 10mg/hr and at 1100 milrinone was\n increased to .5mic/kilo. Legs are kept elevated. 02 has been off most\n of the day and she is sating 96-98% on RA.\n Response:\n She is ~800cc negative for the day. The skin on her legs show signs\n that they have lost fluid.\n Plan:\n Continue with Milrinone and lasix. Keep careful I & O\n Impaired Skin Integrity\n Assessment:\n Pt has multiple skin lesions. Most prominent is coccyx decub. It has\n mepelix on it that was leaking through and pulling loose in am. Both\n heels are reddened, though they . She has dry skin on all\n extremities with some small abraded areas.\n Action:\n Coccyx dsg changed. Area primarily covered with slough. The edges are\n rounded and pink. Area cleansed with wound cleaner, dried and new\n mepelix applied. All limbs were lubricated frequently. Her position was\n changed, at times only slightly throughout the day. She does become\n uncomfortable if she is in the same position for too long,but also has\n difficulty on the L side. She finds the waffle boots uncomfortable and\n prefers having her legs elevated on pillows.\n Response:\n No new skin lesions have developed.\n Plan:\n Continue with turning, lubricating and keeping heels elevated. Monitor\n mepilex to ensure it is in place.\n"
},
{
"category": "Nursing",
"chartdate": "2180-01-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 399793,
"text": "Pt is a 71 yo female with PMH: BM stent to LAD ', Occluded RCA\n without intervention, Ischemic CM (EF 10-25%), BiV ICD, AF, PVD, DVT\n s/p IVC filter, coumadin, hypothyroidism, CKD, OA. adm for HF\n (milrinone/lasix) MRSA in L shoulder, L hip and R knuckle. Out to\n rehab . went from rehab to see Dr. , sent to EW with\n hypotension. SBP 70 in EW, transiently on dopa, but cardiology d/c'd.\n Rxd with NS 250 cc with SBP 92. Pt has been in rehab since d/c from\n with septic arthritis in L shoulder, hip and R knuckle.\n On Vanco followed by ID.\n She was started on milrinone .375 after bolus and lasix drip also begun\n at 2.5mg/hr. The lasix dose was increased to 5mg overnight, but urine\n output has remained poor, though she is negative.\n GI: Pt has poor apetite and eats very little.\n SOCIAL: Family in the visit in afternoon. Pt in good spirits, visiting\n with brother and his family.\n CODE STATUS: Dr had discussion with both patient and health care\n proxy and all are in agreement that she be DNR/DNI. Additionally the\n defibrillator part of AICD/pacer was shut off.\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Action:\n Response:\n Plan:\n ------ Protected Section ------\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt w large\n Action:\n Response:\n Plan:\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n ------ Protected Section Addendum Entered By: , RN\n on: 06:13 AM ------\n"
},
{
"category": "Nursing",
"chartdate": "2180-01-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 399794,
"text": "Pt is a 71 yo female with PMH: BM stent to LAD ', Occluded RCA\n without intervention, Ischemic CM (EF 10-25%), BiV ICD, AF, PVD, DVT\n s/p IVC filter, coumadin, hypothyroidism, CKD, OA. adm for HF\n (milrinone/lasix) MRSA in L shoulder, L hip and R knuckle. Out to\n rehab . went from rehab to see Dr. , sent to EW with\n hypotension. SBP 70 in EW, transiently on dopa, but cardiology d/c'd.\n Rxd with NS 250 cc with SBP 92. Pt has been in rehab since d/c from\n with septic arthritis in L shoulder, hip and R knuckle.\n On Vanco followed by ID.\n She was started on milrinone .375 after bolus and lasix drip also begun\n at 2.5mg/hr. The lasix dose was increased to 5mg overnight, but urine\n output has remained poor, though she is negative.\n GI: Pt has poor apetite and eats very little.\n SOCIAL: Family in the visit in afternoon. Pt in good spirits, visiting\n with brother and his family.\n CODE STATUS: Dr had discussion with both patient and health care\n proxy and all are in agreement that she be DNR/DNI. Additionally the\n defibrillator part of AICD/pacer was shut off.\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Action:\n Response:\n Plan:\n ------ Protected Section ------\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt w large\n Action:\n Response:\n Plan:\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n ------ Protected Section Addendum Entered By: , RN\n on: 06:13 AM ------\n ------ Protected Section Error Entered By: , RN\n on: 06:17 AM ------\n"
},
{
"category": "Nursing",
"chartdate": "2180-01-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 399797,
"text": "Pt is a 71 yo female with PMH: BM stent to LAD ', Occluded RCA\n without intervention, Ischemic CM (EF 10-25%), BiV ICD, AF, PVD, DVT\n s/p IVC filter, coumadin, hypothyroidism, CKD, OA. adm for HF\n (milrinone/lasix) MRSA in L shoulder, L hip and R knuckle. Out to\n rehab . went from rehab to see Dr. , sent to EW with\n hypotension. SBP 70 in EW, transiently on dopa, but cardiology d/c'd.\n Rxd with NS 250 cc with SBP 92. Pt has been in rehab since d/c from\n with septic arthritis in L shoulder, hip and R knuckle.\n On Vanco followed by ID.\n She was started on milrinone .375 after bolus and lasix drip also begun\n at 2.5mg/hr. The lasix dose was increased to 5mg overnight, but urine\n output has remained poor, though she is negative.\n GI: Pt has poor apetite and eats very little.\n SOCIAL: Family in the visit in afternoon. Pt in good spirits, visiting\n with brother and his family.\n CODE STATUS: Dr had discussion with both patient and health care\n proxy and all are in agreement that she be DNR/DNI. Additionally the\n defibrillator part of AICD/pacer was shut off.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt w large painful coccyx wound given ultram/Tylenol as ordered as well\n as prn MSO4 for pain control.\n Action:\n See above- QHS Tylenol 1 GM, ultram. MSO4 2 mg x 3 doses this shift.\n Turning side to side and repositioning w less discomfort. Unable to\n tolerate being on left side for very long- describes increased coccyx\n pain/hp pain.\n Response:\n Pt sleeping well, more comfortable w MS IVP.\n Plan:\n Continue to make pt as comfortable as possible. Medicate, reposition,\n emotional support as needed.\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Pt w longstanding ESHD- currently on Mlrinone 0.5 and lasix gtt up to\n 15 mg in attempts to maximize heart function /unloading.\n Action:\n Given 5 metalozone PO x 1 and increased lasix to 15 mg for I/O\n unchanged, even as of MN. No changes to milrinone gtt.\n Response:\n Better diuresis w increased lasix. (-) 800cc as of 6am. HR remains\n 70-100 AVP. Minimal VEA. No runs. Of note defib fx of ICD has been\n turned off. BP- 90-100/50\ns. No hypotension this shift.\n Plan:\n Continue to attempt to duirese without dropping BP, affecting\n hemodynamics. Continue milrinone gtt as ordered. Continue plan of care,\n DNR, keep pt comfortable. Keep pt aware of plan of care as well as\n family .\n Impaired Skin Integrity\n Assessment:\n Pt admitted from rehab for hypotension, heart failure\n admitted w\n large coccyx decubitus. Pain at site.\n Action:\n Pt remains on medications to keep comfortable currently- MS, ultram,\n Tylenol. Repositioning frequently to keep pt off coccyx. Changed dsg x\n 1\n cleaned wound w wound spray- see flow for details. No drainage\n apparent.\n Response:\n Changed coccyx wound dressing. Appears to be clean without drainage.\n Plan:\n Continue wound care per plan. Keep pt off wound site w repositioning as\n able. Comfort/pain control.\n"
},
{
"category": "Nursing",
"chartdate": "2180-01-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 399877,
"text": "Pt is a 71 yo female with PMH: BM stent to LAD ', Occluded RCA\n without intervention, Ischemic CM (EF 10-25%), BiV ICD, AF, PVD, DVT\n s/p IVC filter, coumadin, hypothyroidism, CKD, OA. adm for HF\n (milrinone/lasix) MRSA in L shoulder, L hip and R knuckle. Out to\n rehab . went from rehab to see Dr. , sent to EW with\n hypotension. SBP 70 in EW, transiently on dopa, but cardiology d/c'd.\n Rxd with NS 250 cc with SBP 92. Pt has been in rehab since d/c from\n with septic arthritis in L shoulder, hip and R knuckle.\n On Vanco followed by ID.\n She was started on milrinone .375 after bolus and lasix drip also begun\n at 2.5mg/hr. The lasix dose was increased to 10 but urine output\n has remained poor, though she is negative.\n GI: Pt has good apetite and has been eating well, but still no BM. She\n has pills ground up in applesauce.\n SOCIAL: Family in the visit in the am and early afternoon. She slept\n most of the afternoon.\n CODE STATUS: Dr had discussion with both patient and health care\n proxy and all are in agreement that she be DNR/DNI. Additionally the\n defibrillator part of AICD/pacer was shut off.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pain is much better contolled now that she can receive prn morphine in\n addition to standing ultram and Tylenol. The coccyx decubitis is what\n causes the most discomfort. She is most uncomfortable on her L side and\n cannot sleep or rest on that side.\n Action:\n She required more morphine in the am and received 7 2mg doses between\n 8am and 1500. She has not been turned on L side except for dsg and bed\n change. She goes from back to R side and is doing better with this.\n Response:\n She was awake and conversant with family all morning, able to eat and\n interact. She has slept most of the afternoon since 1500. She awoke at\n 1800 and was pain free and ready to eat.\n Plan:\n Continue standing ultram and give morphine prn. Change position as\n tolerated.\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n She has her lasix drip increased to 15mg overnight and remains on\n milrinone .5mic/kilo. She has a once a day metolazone 5mg po added. She\n has no audible rales, just decresed breath sounds at the bases. Her\n blood pressure has been adequate with maps over the 60s. She has no\n c/o of cp or acute SOB. Her bilateral leg edema is decreasing. She\n received 20 meq KCL IV this am.\n Action:\n She continues on above medications and is now responding with excellent\n diuresis. She is over 2 liters negative for the day! Lopressor was\n increased to 25mg .\n Response:\n Lytes within nl limits. Goal to to continue pushing diuresis for over\n 10 liters negative.\n Plan:\n Keep careful I & O. Monitor lytes\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Radiology",
"chartdate": "2180-01-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1118390,
"text": " 1:08 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for acute process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with chf\n REASON FOR THIS EXAMINATION:\n eval for acute process\n ______________________________________________________________________________\n WET READ: RBLd WED 2:35 PM\n high riding right PICC line, terminates in right subclavian vein. recommend\n repositioning or removal.\n\n persistent severe cdm. small left effusion + atelect. possible trace right\n effusion.\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: Chest, single AP upright portable view.\n\n CLINICAL INFORMATION: 71-year-old female with history of CHF.\n\n COMPARISON: .\n\n FINDINGS: A dual-lead left-sided AICD is seen with leads extending to the\n expected positions of the right atrium and right ventricle. A right-sided\n PICC findings seen, high in position, terminating in the region of the right\n subclavian vein. Recommend repositioning or removal. The cardiac silhouette\n is markedly enlarged without significant interval change from the prior study.\n The aorta is calcified and tortuous. There is blunting of the left\n costophrenic angle and obscuration of the left hemidiaphragm suggesting left\n pleural effusion with overlying atelectasis. Minimal blunting of the right\n costophrenic angle also suggests a trace right pleural effusion and/or\n thickening.\n\n IMPRESSION:\n 1. High lying right PICC line, terminating in the region of the right\n subclavian vein. Recommend repositioning or removal.\n 2. Persistent severe cardiomegaly.\n 3. Small left pleural effusion with overlying atelectasis.\n 4. Mild blunting of the right costophrenic angle, may be due to a trace\n effusion and/or thickening.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-01-12 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1118410,
"text": " 2:22 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: eval for placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with new R IJ\n REASON FOR THIS EXAMINATION:\n eval for placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 71-year-old woman with new right IJ line.\n\n COMPARISON: Chest radiograph one hour prior.\n\n CHEST, UPRIGHT AP PORTABLE VIEW: A right IJ catheter has been placed,\n terminating in the lower SVC. The right PICC line is unchanged, terminating\n at the expected location of the right subclavian vein. The left-sided ICD\n device is unchanged. The cardiac silhouette remains enlarged. Small\n bilateral pleural effusions are unchanged. Perihilar interstitial prominence\n is indicating mild interstitial edema, unchanged. There is no pneumothorax.\n Retrocardiac opacity persists.\n\n IMPRESSION:\n 1. Right IJ catheter terminates in lower SVC.\n\n 2. Unchanged high riding right PICC line terminating in the expected location\n of the right subclavian vein. Recommend repositioning or removal.\n\n 3. Otherwise unchanged from one hour prior.\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-01-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1118513,
"text": " 7:49 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval improvement\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with CHF\n REASON FOR THIS EXAMINATION:\n interval improvement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71 year-old woman with CHF.\n\n COMPARISON: Multiple prior chest radiographs, the most recent performed 12\n hours prior.\n\n AP UPRIGHT CHEST RADIOGRAPH: Marked cardiomegaly is stable. A right internal\n jugular catheter with its tip in the low SVC, a right-sided venous catheter\n with its tip in the subclavian vein and left-sided AICD with its leads\n overlying the right atrium and right ventricle are unchanged. Small bilateral\n effusions are stable. There is slight increase in vascular engorgement since\n hours prior. There is no consolidation or pneumothorax.\n\n IMPRESSION: Mild increase in vascular engorgement, otherwise no change since\n hours prior.\n\n"
}
] |
96,260 | 131,106 | 50 y.o woman with history of adult onset still's disease with HIV who presented to the hospital with signs and symptoms consistent with a flare of her disease, as evidenced by fever, pharyngitis, rash, arthralgias, and facial swelling. She appears to have quite brittle disease as this flare seems to have flared due to her recent decrease in her Anakaria. It is a quite fulminant flare causing hypotension which required pressor support and ICU admission. . Still's disease: The patient received 10mg of dexamethasone in the ED, as well as a dose of her anakinra. Rheumatology was consulted. IV fluid boluses of Normal Saline, and eventually LR to help maintain pressure. She was started on vasopression and norepinephrine for further pressure support and an arterial-line, and triple lumen internal jugular catheter were placed for monitoring. ESR and CRP were ordered, which were 56 and 53.7 (which have both been higher in the past). She was started on prednisone 60mg/day, Anakinra was given on a daily basis, and her fevers were managed with Tyelnol prn. Her fibrin split products were negative. Her ferritin levels were also monitored. Over the course of her hospitalization, her Still's symptoms improved with gradual resolution of the rash, dimished swelling, reduced arthralgias and minimal pain. Pt will continue with a long course of Prednisone 60mg and Anakaria daily until Rheum follow up. Pt was ambulating on her own, comfortable, afebrile, tolerating regular diet by the time of discharge. . Hypotension: The patient's Still's flares appear to manifest in this fulminant manner on a regular basis that appears in many ways like sepsis. While it appears to be that a medication change that triggered this current attack, occult infection was considered given the patient's recent decrease in WBC count and HIV status. Vancomycin and Cefepime were started for broad coverage and completed a 7 day course (end on ). Additionally a CT of her neck was obtained to rule out an abscess, given that she had submandibular swelling. This CT was negative for signs of infection (as was an ultrasound). As mentioned above her pressure was supported with vasopressin and norepi for approximately two days, and then she was able to be weaned off the pressors with fluid support only and then eventually she was able to maintain her own pressures. . Thrombocytopenia: Concern was raised for general cell line suppression from her bactrim PCP prophylaxis, so this was changed to atovaquone which she tolerated well. Additionally, given that her platelets dropped 50% in the setting of heparin use, heparin was stopped and HIT labs were sent off. Hematology was consulted for advice. PF4 was positive with serotonin release assay pending. The PF4 study had low optical density, making HIT less likely. Pt did have suspicious filling defect of jugular vein on CT, however follow up Ultrasound showed no signs of clot. It was reccomended by the hematology service that patient avoid Heparin products in the future given this one episode of questionable HIT. . Diarrhea: Pt had diahrea early during hospitalization. Given that she is immunosuppressed and has been on antibiotics recently, concern was high for cdiff, however tests were negative. Additionally, stool for O&P were also negative and ecoli. Her electrolytes were monitored and repleted as needed with sliding scales. As pts diet advanced to solids, her diahrea resolved. . HIV: recent CD4 count was 444, although has been lower than 200 in the past per records. Her atripla was continued. As mentioned above, bactrim was discontinued and changed to atovaquone. . Hypothyroidism: Pt has history of sp ablation and was on levothyroxine 150 mcg daily supplementation. Now with TSH <0.02 in the MICU. Free T4 1.8. Pt was continued on levothyroxine 150mcg. She should fu outpatient to check her TSH and free T4. If TSH still low, would benefit from endocrinology opionion about possible relapse of . . Pending Labs/Studies: -Serotonin release assay - cultures | IMPRESSION: Fluid-filled loops of small and large bowel with no dilation or wall thickening is nonspecific, may represent a component of enteritis. There are multiple level 1 lymph nodes visualized, none of which appear enlarged by CT size criteria. FINDINGS: The parotid glands are symmetric, without evidence of lymphadenopathy. The more distal portion of the brachiocephalic vein are not evaluated. IMPRESSION: Normal left subclavian, internal jugular and origin of brachiocephalic veins. CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST Other than dependent atelectasis, the lung bases are clear with no focal consolidations, pleural effusions, or pulmonary nodules. Overlying EKG leads noted. The cardiomediastinal silhouette is unchanged. T wave abnormalities. Lungs are clear bilaterally without focal consolidation, effusion, or pneumothorax. ST-T wave abnormalities are less prominent. Fluid within small bowel and colon is non-specific may represent a component of enteritis. Sinus tachycardia. Sinus tachycardia. COMPARISON: CT from . This, as well as the distal luminal narrowing of the left brachiocephalic vein suggests partial occlusion of that vein. IMPRESSION: No acute intrathoracic process. These veins are followed to their confluence, namely the origin of the brachiocephalic vein which also appears normal. CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The rectum, sigmoid colon, uterus, bilateral adnexa and bladder with Foley catheter and air within it are unremarkable. No evidence of abnormal focus of enhancement, or fluid collection. The cardiomediastinal silhouette is normal. The internal jugular and subclavian veins are widely patent, with normal wall-to-wall flow on color Doppler analysis. The visualized osseous structures are unremarkable. Osseous structures reveal no suspicious sclerotic or lytic lesions. Imaged portions of the lung apices are normal. FRONTAL CHEST RADIOGRAPH: There has been placement of a right internal jugular central venous line with tip in the distal SVC. No evidence of lymphadenopathy by CT size criteria. Note that the medial and distal portions of the left brachiocephalic vein are not visible by son and were seen to better effect on the comparison CT from the same day. Sinus rhythm. Note is made of a significant amount of fluid within the colon that may indicate a component of nonspecific fluid within the small bowel and colon that may indicate a component of enteritis. The thyroid is not visualized. The aerodigestive tract appears symmetric. No evidence of colitis. There are multiple scattered retroperitoneal lymph nodes numerous in quantity, though none that meet size criteria for pathologic enlargement. This appears related to a luminal narrowing of the distal left brachiocephalic vein near the confluence of the brachiocephalic veins. No pleural effusion or pneumothorax is seen. There is no pelvic free fluid. FINDINGS: Targeted son of the left internal jugular vein, subclavian vein and brachiocephalic veins were performed. The imaged paranasal sinuses reveal trace mucosal thickening of the maxillary sinuses bilaterally. Subtle detail through the left neck is limited by extensive streak artifact. Since the previous tracing of therate is slower. TECHNIQUE: Helically acquired axial images were obtained from the lung bases to the pubic symphysis after the uneventful administration of 100 mL of Optiray intravenous contrast. FINDINGS: AP upright portable chest radiograph is obtained. TECHNIQUE: Axial CT images were acquired through the neck following the uneventful administration of 90 cc of intravenous Optiray contrast. The liver, gallbladder, spleen, pancreas, both adrenal glands, both kidneys, both ureters, and visualized portions of intra-abdominal small and large bowel are unremarkable. Overall, there is no abnormal focus of enhancement. There is no pelvic or inguinal lymphadenopathy. There is no intra-abdominal free air or free fluid. Clinical correlationis suggested. There is no pneumothorax. There is no focal consolidation, pneumothorax, or effusion. Extensive reflux of injected contrast from the left brachiocephalic vein into the left jugular vein. EXAMINATION: CT of the abdomen and pelvis with intravenous contrast. (Over) 9:53 PM CT ABD & PELVIS WITH CONTRAST Clip # Reason: please eval r/o colitis Contrast: OPTIRAY Amt: 130 FINAL REPORT (Cont) BONE WINDOWS: There are no suspicious lytic or sclerotic foci. There are also numerous cervical level 2 through 4 lymph nodes, again none of which appear enlarged by size criteria. This artifact is related to extensive reflux of injected contrast material from the brachiocephalic vein into the left internal jugular vein. The imaged osseous structures are intact. Coronal and sagittal reformations are provided for review. The submandibular and sublingual glands are also symmetric. Coronal and sagittal reformats are also reviewed. IMPRESSION: 1. The imaged mastoid air cells are clear. Evaluate for colitis. DFDdp COMPARISONS: . 10:22 AM CT NECK W/CONTRAST (EG:PAROTIDS) Clip # Reason: r/o abscess,deep neck space infection Admitting Diagnosis: FEVER Contrast: OPTIRAY Amt: 90 MEDICAL CONDITION: 50 F w/ Stills dz, HIV here w/ fevers, hypotension w/ submandibular LAD and odynophagia REASON FOR THIS EXAMINATION: r/o abscess,deep neck space infection No contraindications for IV contrast FINAL REPORT INDICATION: Fever, hypotension, as well as submandibular lymphadenopathy and odynophagia in a patient with a history of HIV. Compared to the previous tracing of the rate hasincreased. COMPARISON: . | 8 | [
{
"category": "Radiology",
"chartdate": "2195-03-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1178715,
"text": " 8:28 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval r/o acute process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old woman with fever\n REASON FOR THIS EXAMINATION:\n please eval r/o acute process\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH PERFORMED ON \n\n Comparison is made with a prior chest radiograph from as well as a\n prior chest CT from .\n\n CLINICAL HISTORY: Fever, question pneumonia.\n\n FINDINGS: AP upright portable chest radiograph is obtained. Overlying EKG\n leads noted. Lungs are clear bilaterally without focal consolidation,\n effusion, or pneumothorax. The cardiomediastinal silhouette is normal. No\n pleural effusion or pneumothorax is seen. The imaged osseous structures are\n intact.\n\n IMPRESSION: No acute intrathoracic process.\n SESHa\n\n"
},
{
"category": "Radiology",
"chartdate": "2195-03-06 00:00:00.000",
"description": "CT ABD & PELVIS WITH CONTRAST",
"row_id": 1178724,
"text": " 9:53 PM\n CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: please eval r/o colitis\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old woman with abd pain\n REASON FOR THIS EXAMINATION:\n please eval r/o colitis\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DLrc SAT 12:01 AM\n No evidence of colitis. Fluid within small bowel and colon is non-specific may\n represent a component of enteritis.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: The patient is a 50-year-old female with abdominal pain.\n Evaluate for colitis.\n\n EXAMINATION: CT of the abdomen and pelvis with intravenous contrast.\n\n COMPARISONS: .\n\n TECHNIQUE: Helically acquired axial images were obtained from the lung bases\n to the pubic symphysis after the uneventful administration of 100 mL of\n Optiray intravenous contrast. Coronal and sagittal reformations are provided\n for review.\n\n FINDINGS:\n\n Upon additional review of patient's record, the patient is also noted to be\n HIV positive.\n\n CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST\n\n Other than dependent atelectasis, the lung bases are clear with no focal\n consolidations, pleural effusions, or pulmonary nodules.\n\n The liver, gallbladder, spleen, pancreas, both adrenal glands, both kidneys,\n both ureters, and visualized portions of intra-abdominal small and large bowel\n are unremarkable. There is no intra-abdominal free air or free fluid. Note\n is made of a significant amount of fluid within the colon that may indicate a\n component of nonspecific fluid within the small bowel and colon that may\n indicate a component of enteritis. There are multiple scattered\n retroperitoneal lymph nodes numerous in quantity, though none that meet size\n criteria for pathologic enlargement.\n\n CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The rectum, sigmoid colon,\n uterus, bilateral adnexa and bladder with Foley catheter and air within it are\n unremarkable. There is no pelvic free fluid. There is no pelvic or inguinal\n lymphadenopathy.\n (Over)\n\n 9:53 PM\n CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: please eval r/o colitis\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n BONE WINDOWS: There are no suspicious lytic or sclerotic foci. The\n visualized osseous structures are unremarkable.\n\n IMPRESSION: Fluid-filled loops of small and large bowel with no dilation or\n wall thickening is nonspecific, may represent a component of enteritis. No\n evidence of colitis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2195-03-08 00:00:00.000",
"description": "CT NECK W/CONTRAST (EG:PAROTIDS)",
"row_id": 1178933,
"text": " 10:22 AM\n CT NECK W/CONTRAST (EG:PAROTIDS) Clip # \n Reason: r/o abscess,deep neck space infection\n Admitting Diagnosis: FEVER\n Contrast: OPTIRAY Amt: 90\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 F w/ Stills dz, HIV here w/ fevers, hypotension w/ submandibular LAD and\n odynophagia\n REASON FOR THIS EXAMINATION:\n r/o abscess,deep neck space infection\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fever, hypotension, as well as submandibular lymphadenopathy and\n odynophagia in a patient with a history of HIV.\n\n COMPARISON: .\n\n TECHNIQUE: Axial CT images were acquired through the neck following the\n uneventful administration of 90 cc of intravenous Optiray contrast. Coronal\n and sagittal reformats are also reviewed.\n\n FINDINGS: The parotid glands are symmetric, without evidence of\n lymphadenopathy. The submandibular and sublingual glands are also symmetric.\n There are multiple level 1 lymph nodes visualized, none of which appear\n enlarged by CT size criteria. There are also numerous cervical level 2\n through 4 lymph nodes, again none of which appear enlarged by size criteria.\n Subtle detail through the left neck is limited by extensive streak artifact.\n This artifact is related to extensive reflux of injected contrast material\n from the brachiocephalic vein into the left internal jugular vein. This\n appears related to a luminal narrowing of the distal left brachiocephalic vein\n near the confluence of the brachiocephalic veins. Overall, there is no\n abnormal focus of enhancement. The aerodigestive tract appears symmetric.\n The thyroid is not visualized. Imaged portions of the lung apices are normal.\n Osseous structures reveal no suspicious sclerotic or lytic lesions. The\n imaged paranasal sinuses reveal trace mucosal thickening of the maxillary\n sinuses bilaterally. Note is also made of a right bullosa. The imaged\n mastoid air cells are clear.\n\n IMPRESSION:\n 1. No evidence of abnormal focus of enhancement, or fluid collection.\n 2. No evidence of lymphadenopathy by CT size criteria.\n 3. Extensive reflux of injected contrast from the left brachiocephalic vein\n into the left jugular vein. This, as well as the distal luminal narrowing of\n the left brachiocephalic vein suggests partial occlusion of that vein.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2195-03-07 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1178740,
"text": " 1:36 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: please eval placement\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old woman with line placement\n REASON FOR THIS EXAMINATION:\n please eval placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Line placement.\n\n COMPARISON: .\n\n FRONTAL CHEST RADIOGRAPH: There has been placement of a right internal\n jugular central venous line with tip in the distal SVC. There is no\n pneumothorax. The cardiomediastinal silhouette is unchanged. There is no\n focal consolidation, pneumothorax, or effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2195-03-08 00:00:00.000",
"description": "L UNILAT UP EXT VEINS US LEFT",
"row_id": 1178981,
"text": " 6:00 PM\n UNILAT UP EXT VEINS US LEFT Clip # \n Reason: EVAL LT IJV AND LT BRACHIOCEPHALIC V FOR THROMBUS SEEN IN CT SCAN\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year-old female with Stills, currently on pressors via right IJ; CT neck\n today, ordered for neck pain, with concern for occluded left brachiocephalic to\n jugular\n REASON FOR THIS EXAMINATION:\n Please evaluate for DVT; please include in imaging left brachiocephalic,\n jugular\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Question of obstruction of the left brachiocephalic vein.\n\n COMPARISON: CT from .\n\n FINDINGS: Targeted son of the left internal jugular vein, subclavian\n vein and brachiocephalic veins were performed. The internal jugular and\n subclavian veins are widely patent, with normal wall-to-wall flow on color\n Doppler analysis. These veins are followed to their confluence, namely the\n origin of the brachiocephalic vein which also appears normal. The more distal\n portion of the brachiocephalic vein are not evaluated.\n\n IMPRESSION: Normal left subclavian, internal jugular and origin of\n brachiocephalic veins. Note that the medial and distal portions of the left\n brachiocephalic vein are not visible by son and were seen to better\n effect on the comparison CT from the same day.\n DFDdp\n\n"
},
{
"category": "ECG",
"chartdate": "2195-03-12 00:00:00.000",
"description": "Report",
"row_id": 195293,
"text": "Sinus tachycardia. Compared to the previous tracing of the rate has\nincreased.\n\n"
},
{
"category": "ECG",
"chartdate": "2195-03-07 00:00:00.000",
"description": "Report",
"row_id": 195294,
"text": "Sinus rhythm. T wave abnormalities. Since the previous tracing of the\nrate is slower. ST-T wave abnormalities are less prominent.\n\n"
},
{
"category": "ECG",
"chartdate": "2195-03-06 00:00:00.000",
"description": "Report",
"row_id": 195295,
"text": "Sinus tachycardia. T wave inversions in the inferolateral leads raising\nconsideration of possible ischemia, likely rate-related. Clinical correlation\nis suggested. Compared to the previous tracing of the ventricular rate\nhas increased and the ST segment changes are new.\n\n"
}
] |
64,619 | 191,726 | ICU Course: Patient was transferred to the ICU on with respiratory distress and tachycardia in the setting of known MDS and squamous cell malignancy involving the bone marrow and overall poor prognosis. He was intubated for hypoxic respiratory failure. He developed a septic picture. Patient with known C.dif colitis, so, since no other source of infection was found, presumed to have fulminant C.dif colitis. Patient was on Vancomycin PO, IV and PR for C.dif colitis as well as broad spectrum antibiotics to cover essentially any infectious source. Despite this, patient's blood pressure continued to decline. He was started on pressors, and maxxed out on Levophed, Neo, Vasopressin. Despite agressive treatment, he was unable to maintain adequate blood pressures and passed away on . . This is a 74 yo M with PMHx of HTN, HLD, DM-2 and MDS-RAEB-II s/p 6 cycles of vidaza who presents with 3 days of lethargy, subjective fevers and diarrhea. . #Clostridium difficile colitis: Pt was admitted with diarrhea and subjective fevers and fatigue following recent discharge during which he was treated with vancomycin/cefepime for neutropenic fevers and sent home with lovenox for CAP and fluconazole and acyclovir for prophylaxis. On admission he was found to be febrile with and Cdiff stool toxin assay was positive so he was started on PO flagyl. He began to describe pain in his throat making it difficult for him to swallow so his antibiotics were switched to IV. He then began spiking fevers to 102 despite IV flagyl and was started on IV vanc and cefepime. He then triggered on for tachypnea, labored breathing, tachycardia to the 130's and hypotension as low as the high 80's systolically. He was treated with bolused fluids and his pressures improved, he desatted to 88 on RA and was started on O2 and began satting well but remained tachycardic and continued to have labored respirations. He was also started on PO vancomycin. CXR demonstrated worsening of a left pleural effusion and ABG demonstrated mixed respiratory alkalosis and non-gap metabolic acidosis which we assessed as a combination of sepsis and diarrhea. We had mild concern for PE but felt he was too unstable for CT scanner. Abdominal XR showed no free air and was not concerning. He was transferred to the overnight. . #RLE weakness: Pt was admitted complaining of RLE weakness but had equivalent strength on exam but continued R hip pain which has been a chronic issue following a hip replacement ~20 years ago. He had a bone marrow biopsy at the right pelvis during his recent admission and had mild tenderness at the site but no signs or symptoms otherwise concerning for infection. XR of the R hip was normal and our clinical suspicion wasn't high enough to perform MRI to look for osteomyelitis. His CRP and ESR were severely elevated but this was felt to be related to his Cdiff colitis as above. . Worsening Pancytopenia: Pt with poor production from severe MDS and new diagnosis of invasive squamous carcinoma (presumably from lung primary but primary unknown) infiltrating his bone marrow rendering him transfusion dependent over the past several months. Hemolysis labs negative, reticulocyte index low, iron studies suggestive of anemia of chronic disease. He was transfused RBC's and platelets with the threshold of plt >10 and Hct >21 to maintain perfusion and hemostasis. During blood transfusion he spiked fevers likely related to his Cdiff or other underlying infectious processes and blood transfusions were held pending resolution of fevers. Pt also severely neutropenic and was maintained on acyclovir and fluconazole prophylaxis, started on IV Vanc/Cefepime as described above. . #: Pt admitted in , likely prerenal from diarrheal losses and poor PO intake which resolved with IV fluids and blood. . #Elevated D-dimer: Pt with elevated D-Dimer on admission, possibly due to MDS vs. solid carcinoma activity. We also considered possibility of DVT yet patient did not have si/sx concerning for DVT or PE by history or exam. During his trigger on we had suspicion for possible PE but felt he was unstable for CT imaging. . Hyperbilirubinemia: Likely gradual RBC breakdown. Stable and down from prior hospitalization. . | Sinus tachycardia with atrial premature beats. Small right and moderate left pleural effusions are unchanged associated with adjacent bibasilar opacities likely atelectasis. The right internal jugular line terminates at upper SVC. FINDINGS: Supine abdominal radiographs were obtained. Non-specificdilated loop of likely large bowel in the left mid abdomen, though non-specific. FINDINGS: A portable supine abdominal radiograph was obtained. FINDINGS: Again noted is left lower lobe atelectasis with likely at least the subpulmonic component of the previously noted left pleural effusion remaining in place. Worsened moderate-large effusion and right lower lung atelectasis. FINDINGS: There are bilateral pleural effusions, left greater than right with atelectasis both in the left lower and right lower lungs. Multifocal atrial tachycardia. A left lower lobe opacification was described in prior chest radiograph. Multifocal atrialtachycardia is now seen. IMPRESSION: Centralized bowel which may be seen potentially with ascites. Mildly dilated loops of small bowel and large bowel suggestive of ileus. IMPRESSION: Mildly dilated loops of small and large bowel suggestive of ileus. Endotracheal tube, right jugular catheter and esophageal catheter with tip out of view of the radiograph appear similar. New right IJ catheter tip is in the mid SVC. There are mildly dilated loops of small bowel, with presence of a loop of bowel of 7.3 cm of diameter in the lower abdomen that it is unclear whether it is small or large bowel given absence of folds but is probably colonic. Comparisons were made with prior chest radiographs through , with the most recent from . Mediastinal lymphadenopathy is better seen in prior CT from . The right intermediate bronchus cannot be traced beyond its origin and this in conjunction with loss of right heart border and increased density in the right paramediastinal region sugest middle lobe collapse. COMPARISON: Multiple prior examinations, most recent radiograph dated , and correlation with CT of the chest dated . COMPARISON: Portable abdominal radiograph . FINDINGS: An upright abdominal radiograph was obtained. Degenerative changes are seen throughout the thoracic spine and in the included right shoulder. Small lung nodules in the right lung are better seen in prior CT from . Centralization of the bowel may suggest ascites. Quality of the film is compromised by bliurriness and the exclusion from the image of nearly the totality of the right hemi-abdomen. IMPRESSION: Left lower lobe atelectasis with a persistent left pleural effusion likely subpulmonic. Left lower lobe opacification can be better assessed in prior chest radiographs. TECHNIQUE: Single frontal radiograph of the chest. Non-specific bowel gas pattern. COMPARISON: Portable chest radiographs from and . There are borderline dilated loops of small bowel in the mid abdomen, with a loop of bowel adjacent to it of approximately 7.5 cm that is likely colon. 4:53 PM CHEST (PORTABLE AP) Clip # Reason: infiltrates, other? Degenerative changes of the left hip is seen with spur in the superolateral acetabula. Diffuse small lung nodules located mainly in the right lung are better seen also on prior CT. There is a normal bowel gas pattern without evidence of dilatation. FINAL REPORT INDICATION: 74-year-old man with Clostridium difficile worsening shortness of breath. Right pleural effusion and right lower lobe atelectasis have also worsened since . TECHNIQUE: Portable semi-upright radiograph of the chest. The cardiac silhouette is within normal limits for size. Right middle lobe collapse is new since . Endotracheal tube is approximately 3.4 cm above the carina with the neck in flexed position and is appropriate. A small right and moderate left pleural effusions have increased with increasing adjacent atelectasis. Short-term follow-up radiographs may be helpful if clinically indicated. Patient with squamous cell CA, intubated, to look for interval changes. The mediastinum is otherwise unremarkable. IMPRESSION: Large left pleural effusion has worsened with increased lung atelectasis. Assessment of the cardiomediastinum was limited because of large effusions and collapse leading to loss of the cardiac silhouette margins. Baseline artifact makesST-T wave interpretation difficult. The distal tip is out of view below the diaphragm. 8:24 PM CHEST (PORTABLE AP) Clip # Reason: cardioplum process? FINDINGS: Since the prior chest radiograph dated , left pleural effusion has significantly increased and is severe. There is a right total hip arthroplasty. COMPARISON: Multiple priors, the most recent dated . No abnormally dilated bowel loops. Assess ET tube and NG tube. This study is essentially unchanged from prior abdominal radiograph performed approximately 24 hours ago. Suggest repeat ECG. Admitting Diagnosis: THROMBOCYTOPENIA;NEUTROPENIA MEDICAL CONDITION: 74 year old man with MDS and possible metastatic lung CA, and Cdiff with fevers and hypotension and labored respirations REASON FOR THIS EXAMINATION: cardioplum process? If concern for obstruction CT is recommended for further evaluation. LINE PLACEMENT; -76 BY SAME PHYSICIAN # Reason: verification of positioning of RIJ central line Admitting Diagnosis: THROMBOCYTOPENIA;NEUTROPENIA MEDICAL CONDITION: 74 year old man with MDS and new pleural effusion REASON FOR THIS EXAMINATION: verification of positioning of RIJ central line FINAL REPORT SINGLE AP PORTABLE VIEW OF THE CHEST REASON FOR EXAM: Assess line. | 12 | [
{
"category": "Radiology",
"chartdate": "2149-10-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1204146,
"text": " 12:45 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ETT and NGT placement verification\n Admitting Diagnosis: THROMBOCYTOPENIA;NEUTROPENIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with MDS and new pleural effusion per recent cxr\n REASON FOR THIS EXAMINATION:\n ETT and NGT placement verification\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: MDS, new pleural effusion. Assess ET tube and NG tube.\n\n ET tube is in standard position. The tip is 4.1 cm above the carina. The\n distal tip is out of view below the diaphragm. Cardiac size is normal. Small\n right and moderate left pleural effusions are unchanged associated with\n adjacent bibasilar opacities likely atelectasis. Small lung nodules in the\n right lung are better seen in prior CT from . There is no\n pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2149-10-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1203722,
"text": " 4:53 PM\n CHEST (PORTABLE AP) Clip # \n Reason: infiltrates, other?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with MDS s/p BM trasplant, in with dfever\n REASON FOR THIS EXAMINATION:\n infiltrates, other?\n ______________________________________________________________________________\n FINAL REPORT\n AP PORTABLE CHEST, AT 17:00 HOURS.\n\n HISTORY: Myelodysplastic syndrome post bone marrow transplant with fever.\n\n COMPARISON: Multiple priors, the most recent dated .\n\n FINDINGS: Again noted is left lower lobe atelectasis with likely at least the\n subpulmonic component of the previously noted left pleural effusion remaining\n in place. No focal consolidation or superimposed edema is noted. The\n mediastinum is otherwise unremarkable. The cardiac silhouette is within\n normal limits for size. Degenerative changes are seen throughout the thoracic\n spine and in the included right shoulder.\n\n IMPRESSION: Left lower lobe atelectasis with a persistent left pleural\n effusion likely subpulmonic. No definite focal consolidation identified.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2149-10-05 00:00:00.000",
"description": "PELVIS (AP ONLY)",
"row_id": 1203781,
"text": " 10:12 AM\n PELVIS (AP ONLY) Clip # \n Reason: r/o pelvic osteo\n Admitting Diagnosis: THROMBOCYTOPENIA;NEUTROPENIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with mds and possible osteo from bmb\n REASON FOR THIS EXAMINATION:\n r/o pelvic osteo\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP pelvis, .\n\n CLINICAL HISTORY: 74-year-old man with possible pelvic osteomyelitis.\n\n FINDINGS: No previous studies for comparison.\n\n There is a right total hip arthroplasty. There are no signs for\n hardware-related complications. Heterotopic bone formation is seen laterally.\n There are no acute fractures or dislocations. Degenerative changes of the\n left hip is seen with spur in the superolateral acetabula. Degenerative\n changes of lower lumbar spine are also identified.\n\n"
},
{
"category": "Radiology",
"chartdate": "2149-10-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1204139,
"text": " 8:24 PM\n CHEST (PORTABLE AP) Clip # \n Reason: cardioplum process?\n Admitting Diagnosis: THROMBOCYTOPENIA;NEUTROPENIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with MDS and possible metastatic lung CA, and Cdiff with fevers\n and hypotension and labored respirations\n REASON FOR THIS EXAMINATION:\n cardioplum process?\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: MDS and possible metastatic lung cancer, assess lungs.\n\n Comparison is made with prior study .\n\n Cardiac size is normal. Mediastinal lymphadenopathy is better seen in prior\n CT from . A small right and moderate left pleural effusions have\n increased with increasing adjacent atelectasis. Diffuse small lung nodules\n located mainly in the right lung are better seen also on prior CT. There is\n no evident pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2149-10-08 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1204160,
"text": " 4:41 AM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: verification of positioning of RIJ central line\n Admitting Diagnosis: THROMBOCYTOPENIA;NEUTROPENIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with MDS and new pleural effusion\n REASON FOR THIS EXAMINATION:\n verification of positioning of RIJ central line\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Assess line.\n\n Comparison is made with prior study performed a day earlier.\n\n New right IJ catheter tip is in the mid SVC. There is no evident\n pneumothorax. There are no other interval changes.\n\n"
},
{
"category": "Radiology",
"chartdate": "2149-10-07 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1204141,
"text": " 9:31 PM\n PORTABLE ABDOMEN Clip # \n Reason: Please assess for free air for megacolon\n Admitting Diagnosis: THROMBOCYTOPENIA;NEUTROPENIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with C. diff and worsening SOB\n REASON FOR THIS EXAMINATION:\n Please assess for free air for megacolon\n ______________________________________________________________________________\n WET READ: SJBj WED 3:20 AM\n No free air. Air filled stomach. No abnormally dilated bowel loops.\n limited study. Non-specific bowel gas pattern.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 74-year-old man with Clostridium difficile worsening shortness of\n breath. Please assess for free air or megacolon.\n\n COMPARISON: Portable chest radiographs from and .\n\n FINDINGS: An upright abdominal radiograph was obtained. Quality of the film\n is compromised by bliurriness and the exclusion from the image of nearly the\n totality of the right hemi-abdomen. There is a normal bowel gas pattern\n without evidence of dilatation. No evidence of free air or abnormal\n calcifications. A left lower lobe opacification was described in prior chest\n radiograph.\n\n IMPRESSION: No evidence of megacolon or free air.\n\n"
},
{
"category": "Radiology",
"chartdate": "2149-10-09 00:00:00.000",
"description": "P ABDOMEN (SUPINE ONLY) PORT",
"row_id": 1204402,
"text": " 1:34 PM\n ABDOMEN (SUPINE ONLY) PORT Clip # \n Reason: ?interval change\n Admitting Diagnosis: THROMBOCYTOPENIA;NEUTROPENIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with MDS, squamous cell ca, septic, intubated, with c.dif\n REASON FOR THIS EXAMINATION:\n ?interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 74-year-old man with squamous cell carcinoma, septic, intubated,\n with Clostridium difficile. Please evaluate for interval change.\n\n COMPARISON: Portable abdominal radiograph .\n\n FINDINGS: A portable supine abdominal radiograph was obtained. There are\n borderline dilated loops of small bowel in the mid abdomen, with a loop of\n bowel adjacent to it of approximately 7.5 cm that is likely colon. No\n evidence of free air, no abnormal calcifications.\n\n IMPRESSION: Mildly dilated loops of small and large bowel suggestive of\n ileus. This study is essentially unchanged from prior abdominal radiograph\n performed approximately 24 hours ago.\n\n"
},
{
"category": "Radiology",
"chartdate": "2149-10-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1204484,
"text": " 5:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess for megacolon, interval change\n Admitting Diagnosis: THROMBOCYTOPENIA;NEUTROPENIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with MDS, squamous cell ca, c.dif, sepsis, intubated on\n pressors\n REASON FOR THIS EXAMINATION:\n please assess for megacolon, interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST X-RAY\n\n INDICATION: Please assess for the megacolon interval changes. Patient with\n squamous cell CA, intubated, to look for interval changes.\n\n TECHNIQUE: Portable semi-upright radiograph of the chest.\n\n Comparisons were made with prior chest radiographs through ,\n with the most recent from .\n\n FINDINGS: Since the prior chest radiograph dated , left\n pleural effusion has significantly increased and is severe. The right\n intermediate bronchus cannot be traced beyond its origin and this in\n conjunction with loss of right heart border and increased density in the right\n paramediastinal region sugest middle lobe collapse. Right pleural effusion\n and right lower lobe atelectasis have also worsened since .\n Endotracheal tube is approximately 3.4 cm above the carina with the neck in\n flexed position and is appropriate. The right internal jugular line\n terminates at upper SVC. Assessment of the cardiomediastinum was limited\n because of large effusions and collapse leading to loss of the cardiac\n silhouette margins.\n\n IMPRESSION: Large left pleural effusion has worsened with increased lung\n atelectasis. Right middle lobe collapse is new since .\n Worsened moderate-large effusion and right lower lung atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2149-10-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1204364,
"text": " 10:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for interval change\n Admitting Diagnosis: THROMBOCYTOPENIA;NEUTROPENIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with MDS and metastatic squamous cell carcinoma, now intubated\n with hypoxic respiratory failure\n REASON FOR THIS EXAMINATION:\n evaluate for interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 74-year-old male with known metastatic squamous cell carcinoma\n and myelodysplastic syndrome. Interval evaluation.\n\n TECHNIQUE: Single frontal radiograph of the chest.\n\n COMPARISON: Multiple prior examinations, most recent radiograph dated , and correlation with CT of the chest dated .\n\n FINDINGS: There are bilateral pleural effusions, left greater than right with\n atelectasis both in the left lower and right lower lungs. Accounting for\n differences in position, these do not appear significantly changed from the\n prior examination though the presence of infection would be difficult to\n exclude. No pneumothorax is seen. Endotracheal tube, right jugular catheter\n and esophageal catheter with tip out of view of the radiograph appear similar.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2149-10-08 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1204285,
"text": " 7:20 PM\n PORTABLE ABDOMEN Clip # \n Reason: please assess for interval change, megacolon\n Admitting Diagnosis: THROMBOCYTOPENIA;NEUTROPENIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with MDS, squamous cell ca, c.dif, sepsis, intubated on\n pressors\n REASON FOR THIS EXAMINATION:\n please assess for interval change, megacolon\n ______________________________________________________________________________\n WET READ: DLrc WED 11:01 PM\n Centralized bowel indicative of ascites. Non-specificdilated loop of likely\n large bowel in the left mid abdomen, though non-specific. If concern for\n obstruction CT is recommended for further evaluation.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 74-year-old man with squamous cell carcinoma, Clostridium\n difficile, sepsis, intubated, and on pressors, please assess for interval\n change.\n\n COMPARISON: .\n\n FINDINGS: Supine abdominal radiographs were obtained. There are mildly\n dilated loops of small bowel, with presence of a loop of bowel of 7.3 cm of\n diameter in the lower abdomen that it is unclear whether it is small or large\n bowel given absence of folds but is probably colonic. Centralization of the\n bowel may suggest ascites. Otherwise, no evidence of free air. Left lower\n lobe opacification can be better assessed in prior chest radiographs.\n\n IMPRESSION: Centralized bowel which may be seen potentially with ascites.\n Mildly dilated loops of small bowel and large bowel suggestive of ileus.\n Short-term follow-up radiographs may be helpful if clinically indicated.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2149-10-07 00:00:00.000",
"description": "Report",
"row_id": 236974,
"text": "Multifocal atrial tachycardia. Low voltage. ST-T wave abnormalities.\nSince the previous tracing of the rate is faster. Multifocal atrial\ntachycardia is now seen. Clinical correlation is suggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2149-10-04 00:00:00.000",
"description": "Report",
"row_id": 236975,
"text": "Sinus tachycardia with atrial premature beats. Baseline artifact makes\nST-T wave interpretation difficult. Suggest repeat ECG. No previous tracing\navailable for comparison.\n\n"
}
] |
31,235 | 180,780 | 21-year-old woman with DM1 who presented with severe DKA and unresponsiveness. Hospital course by problem: | FINDINGS: Endotracheal tube is terminating in standard location. A right subclavian catheter is terminating slightly below the anticipated cavoatrial junction, unchanged. Moderate retrocardiac atelectasis, no secure evidence of pleural effusions. Unchanged retrocardiac atelectasis is again noted. On the axial susceptibility images, there is a small focus of susceptibility, in the right anteroinferior frontal or subcortical in location (series 5, image 16), which corresponds to a punctate hyperdense focus on the CT, and can represent early calcification or microhemorrhage. Bilateral moderate pleural effusions. FINDINGS: Endotracheal tube is in standard position, nasogastric tube passes into the stomach and out of the field of view, and a right jugular line ends in the upper right atrium. FINDINGS: There are bilateral pleural effusions and associated atelectasis, right more so than left. Unchanged small bilateral pleural effusions. This collection appears separate from the bladder, which is collapsed and contains a foley catheter. Again seen are patchy bilateral alveolar infiltrates, some of which have a rounded configuration and could represent septic emboli. The right subclavian catheter is terminating in the distal SVC. In the absence of intravenous contrast enhancement, measurement of central lymph nodes is difficult, but range up to 17 mm in the left hilus, smaller in the right hilus, and insignificant in the mediastinum. Small non-hemorrhagic pleural effusions layer posteriorly. Visualized pancreas is unremarkable. Contrast has passed to the level of the right colon. Again are noted multifocal peribronchial nodular consolidations, some in subpleural distribution and others more central, worse than the recent CT. RSBI this am 160. remains on CPAP+PS tol well.CVS: NSR w/ no ectopy ABP 140-160's/ 70-90's. Mild(1+) mitral regurgitation is seen. Normal ascending aortadiameter. R rad aline and R s/c CVL intact w/ good BR.GI: abd soft/ nontender, +BS x 4quads, TF at goal rate via OGT tol well. sedation restarted r/t pt not extubating today.Pulm
: LS coarse bilat. no vent changes ordered.GI: abd soft, bs+, tf @ goal w/ min resid. Normal interatrial septum. There are filamentousstrands on the aortic leaflets consistent with Lambl's excrescences (normalvariant; seen on clips 113 and 114). Nephrology is following pt.GI) Abd soft with + BS. Mild mitral and tricuspid regurgitation. Mild (1+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets. ABP's ~20pts higher, K+ repleted as above.GI: OGT removed w/ extubation, abd soft nontender +BS x 4quads. R subclavian quad lumen line intact.RESP: No vent changes overnight. EEG done, non-specific secondary to propofol. remains on IV Vanc/ Cefepime for multifocal pna. Mild [1+] TR. PT became hypertensive w/ SBP 160's and tachycardic w/ HR 140's. Recieved pt on Propofol and stopped for brief time as noted above. Mild [1+] TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. PATIENT/TEST INFORMATION:Indication: Endocarditis.Height: (in) 66Weight (lb): 198BSA (m2): 1.99 m2BP (mm Hg): 129/76HR (bpm): 115Status: InpatientDate/Time: at 15:03Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. L femoral a-line dampened and NIBP started. B/P 120-150/70-90.Resp- Remains orally intubated, see care-vue for trended ABG's. ABGs as noted in care vue.GI) Abd soft with + BS. Head CT done -> prelim wet read unremarkable. + bilat DP/PTResp: remains intubated, ETtube advanced 3 cm and now at lip 23cm---awaiting am CXR, ETtube suctioned for mod. Pt was acidotic on admission and given Bicarb....continues to be slightly acidotic @7.27. Follow up Na level.GU) Goal diuresing (-) 1-2 liters q day with lasix gtt. K level has been replaced multiple times, and needs follow up 2/2 lasix gtt.Resp) LS coarse and clear after deep sx. Pt continues to have gen edema. Bilat soft wrist restraints to prevent pt from pulling at lines and tubes upon awakening.Cardiac: HR= 120-130's ST with no ecotpy noted, Left femoral Aline intact and with good waveform and correlation to NBP, BP= 100-125/80's with MAP's >70's, IV Vasopressin and IV Levophed weaned to off, episode of sBP 80's with Map= 60 following turning and repositioning once off of vasopressors---Levophed restarted at 0.03 mcgs/kg/min with good effect and able to wean off after 1 hour and currently remains off, new right SC multi-lumen central line placed and confirmed by Xray---right femoral TLC d/c'd and tip sent for cx, CVP= . Stool lgr amts of loose stool guiac +. A-line continues dampened but with good blood return.RESP: No vent changes and adequate abg. If need to restart insulin gtt take note that pt has Lantus on board.ID: WBC= 11.5, low grade temp with Tmax= 99, continues on IV Cipro. Lasix gtt weaned off. Diurese and replete lytes as indicated. Keep NPO after midnoc.I/D- Tmax 100.3. BUN 98 and Creatine slight down to 5.7 (peaked ).ID) Pt on IV ABxs for multifocal pna. Pt given diflucan po. Last ABG 7.22/24/121/10. Pt's RR 49 at end of - pt placed back on with slowing of RR. NS, dopa, levo, and vasopressin infusing. CXR done this am. A-line and CVL d/c'd. Vanco level pending. K replaced as noted. ETT repositioned and retaped. Levophed gtt weaning down. + palp peripheral pulses. Begun on vasopressin and dopa. Continue to wean pt off vent as tolerated.GI) Abd soft with + BS. HD on hold for now.Skin) see care vue for details. MICU NPN 0700-1900Events: Dopamine gtt titrated off. Bs cl;aer to coarse. Continues on +10PSV/+5PEEP w/ Vt 600s RR 20s Ve 14-16L/M. Ceftriaxone and vanco given at OSH. CVP 11-14.GI - Abd soft. ABP 1409-160/80-92. Receiving multiple IVABX. LS rhonchorus. Lungs coarse, w/ rhonchi..suctioned for increased oral and deep secretions as compared w/ yesterday. Please refer to carevue for FS results. Full Code.CV) Pt is in ST (100-110) w/o ectopy noted. PM chemistries pnding. A-line wave form remains dampened and following NIBP for BP readings. Shut off for ~1hr and restarted ~0500. Pt has ^RR with desats when sedation off, resp distress-biting ett. b/p stable 130's-150's/ 60's-70's. Flatus +. Hourly BS. A-line and CVL removed, PIV x1 in L A/C patent flushed. Rectal tube placed after episode of liq/loose brown stool. | 65 | [
{
"category": "Radiology",
"chartdate": "2173-05-30 00:00:00.000",
"description": "P ABDOMEN U.S. (COMPLETE STUDY) PORT",
"row_id": 1015801,
"text": " 1:25 PM\n ABDOMEN U.S. (COMPLETE STUDY) PORT Clip # \n Reason: r/o intrabdominal source of sepsis,\n Admitting Diagnosis: DIABETIC KETOACIDOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old woman with dka, sepsis of unknown source\n REASON FOR THIS EXAMINATION:\n r/o intrabdominal source of sepsis,\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 21-year-old female with DKA, sepsis of unknown source. Rule out\n intra-abdominal source.\n\n No prior studies for comparison.\n\n FINDINGS: The liver demonstrates normal echogenicity, without a focal lesion.\n The portal vein is patent with hepatopetal flow. Gallbladder is normal,\n without evidence of gallstones. There is no intra- or extra-hepatic biliary\n ductal dilatation, with the CBD measuring 5 mm. The right kidney measures 13\n cm. The left kidney measures 10 cm. No stones, hydronephrosis, or mass is\n identified. The spleen is unremarkable. Visualized pancreas is unremarkable.\n\n Within the pelvis, there is a large fluid collection, of unknown source. This\n collection appears separate from the bladder, which is collapsed and contains\n a foley catheter.\n\n IMPRESSION: Fluid collection within the pelvis, of unknown source. A CT is\n recommended for further evaluation to exclude the presence of an abscess.\n\n Dr. was paged at the time of this dictation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2173-05-31 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1015930,
"text": " 3:02 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? anoxic brain injury, cerebral edema?\n Admitting Diagnosis: DIABETIC KETOACIDOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old woman with DKA, found down\n REASON FOR THIS EXAMINATION:\n ? anoxic brain injury, cerebral edema?\n CONTRAINDICATIONS for IV CONTRAST:\n renal failure\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 21-year-old female with diabetic ketoacidosis who was \"found down.\"\n\n COMPARISON: No prior exam is available for comparison.\n\n TECHNIQUE: Contiguous axial imaging was performed through the brain without\n administration of IV contrast.\n\n CT HEAD: There is no evidence of acute intracranial hemorrhage, edema, mass,\n mass effect, hydrocephalus, or of large vascular territory infarction. In\n particular, the -white matter differentiation appears to be preserved. The\n basal cisterns are also preserved. Fluid is seen within the mastoid air\n cells. A small amount of mucosal thickening and layering fluid is also noted\n in the sphenoid sinuses. These likely relate to recent intubation.\n\n IMPRESSION: No CT evidence of acute intracranial process. However, as CT\n would not be sensitive to early or less extensive anoxic brain injury,\n followup would be recommended as clinically indicated.\n\n"
},
{
"category": "Radiology",
"chartdate": "2173-06-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1016585,
"text": " 11:25 AM\n CHEST (PORTABLE AP) Clip # \n Reason: check ett placement\n Admitting Diagnosis: DIABETIC KETOACIDOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old woman with dka, resp failure, intubated\n REASON FOR THIS EXAMINATION:\n check ett placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE VIEW ON \n\n HISTORY: Respiratory failure.\n\n REFERENCE EXAM: .\n\n FINDINGS: The ET tube is 3 cm above the carina. Right subclavian line tip is\n in the right atrium. The heart is mildly enlarged and is increased in size\n compared to prior. There are patchy alveolar infiltrates that have progressed\n compared to the film from two days ago. Some of these have a rounded\n appearance and septic emboli cannot be totally excluded. The NG tube has been\n removed.\n\n IMPRESSION: Worsening bilateral infiltrates some of which have a rounded\n appearance.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2173-06-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1016718,
"text": " 3:15 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval changes\n Admitting Diagnosis: DIABETIC KETOACIDOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old woman with respiratory failure, DKA, multifocal pna\n REASON FOR THIS EXAMINATION:\n interval changes\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Single portable AP chest radiograph.\n\n INDICATION: 21-year-old female with respiratory failure, and multifocal\n pneumonia.\n\n COMPARISON: .\n\n FINDINGS: Endotracheal tube is approximately 2 cm from the carina. NG tube\n courses through the mediastinum below the diaphragm with tip out of the field\n of view. Lung volumes are again low. Multifocal opacities demonstrate mild\n improvement from recent comparison. No significant pleural effusion or\n pneumothorax appreciated.\n\n IMPRESSION: Mild improvement in multifocal opacities. No new opacities\n appreciated.\n\n"
},
{
"category": "Radiology",
"chartdate": "2173-06-01 00:00:00.000",
"description": "MR HEAD W/O CONTRAST",
"row_id": 1016101,
"text": " 8:13 PM\n MR HEAD W/O CONTRAST Clip # \n Reason: please eval for ?anoxic brain injury, edema\n Admitting Diagnosis: DIABETIC KETOACIDOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old woman with DKA, renal failure, respiratory failure,\n unresponsiveness\n REASON FOR THIS EXAMINATION:\n please eval for ?anoxic brain injury, edema\n CONTRAINDICATIONS for IV CONTRAST:\n renal failure\n\n Yes to Choyke questions.\n ______________________________________________________________________________\n WET READ: YMf TUE 11:45 PM\n No intraparenchymal lesions or areas of restricted diffusion. No mass, edema\n or hydrocephalus.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 21-year-old female patient, with DKA, renal failure, respiratory\n failure, unresponsiveness, to evaluate for anoxic brain injury, edema.\n\n COMPARISON: CT of the head done on .\n\n TECHNIQUE: Multiplanar T1- and T2-weighted imaging of the brain was performed\n without IV contrast.\n\n FINDINGS:\n\n On the sagittal T1-weighted sequence, the nasopharyngeal soft tissues, likely\n related to the lymphoid tissue (adenoids), were prominent (series 2, image\n 12), which may be appropriate in a patient of this age. However, these are\n not adequately evaluated on the present study. There are no focal lesions,\n noted on the axial FLAIR. On the axial susceptibility images, there is a\n small focus of susceptibility, in the right anteroinferior frontal or\n subcortical in location (series 5, image 16), which corresponds to a punctate\n hyperdense focus on the CT, and can represent early calcification or\n microhemorrhage. There is no restricted diffusion, to suggest acute\n infarction. The ventricles and extra-axial CSF spaces are unremarkable. There\n is moderate increased signal, in the mastoid air cells on both sides, likely\n related to fluid versus mucosal thickening. There is also moderate amount of\n mucosal thickening, along with fluid in the sphenoid sinus and minimal in the\n right maxillary sinus.\n\n No major vascular flow voids are noted.\n\n IMPRESSION:\n 1. No acute infarction.\n 2. Punctate focus of susceptibility in the right anteroinferior frontal lobe,\n which can represent small focus of early calcification or microhemorrhage.\n (Subcortical in location).\n 3. Moderate amount of fluid versus mucosal thickening in the mastoid air\n (Over)\n\n 8:13 PM\n MR HEAD W/O CONTRAST Clip # \n Reason: please eval for ?anoxic brain injury, edema\n Admitting Diagnosis: DIABETIC KETOACIDOSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n cells on both sides, sphenoid sinus and minimal in the right maxillary sinus.\n\n Additional details:\n\n The study was reviewed with Dr. by Dr. on at 4pm as\n the clinical team was concerned about possible diffuse cortical hyperintensity\n on DWI related to hypoxic injury. Apparently, the areas that were of concern\n appear to be related to artifacts from brain-bone interface in the left\n inferior frontal lobe (series 6, im 72) and as a continuous rim in the\n peripheral cortex, which is not hyperintense enough on DWI to be called as\n abnormal and does not have associated corresponding abnormality on ADC and\n FLAIR hyperintensity. Opinion was also sought from 2 senior radiologists of\n the section who agreed that these were artifacts and do not represent acute\n infarction. So, based on the present study, there is no evidence of acute\n infarction. If there is continued concern about encephalopathic changes or\n infarction, a follow-up study can be considered at clinical discretion.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2173-06-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1015974,
"text": " 2:48 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? line placements, change\n Admitting Diagnosis: DIABETIC KETOACIDOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old woman with intubation\n REASON FOR THIS EXAMINATION:\n ? line placements, change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 21-year-old woman with intubation, question line placement and\n change.\n\n COMPARISON: .\n\n SEMI-UPRIGHT BEDSIDE RADIOGRAPH OF THE CHEST: The ET tube is terminating 2.2\n cm above the carina. The right subclavian catheter is terminating below the\n anticipated cavoatrial junction, could be partly explained by low lung\n volumes. NG tube is extending into the pyloric end of stomach, unchanged.\n\n Focal opacities in the left mid and lower lung are more confluent today, could\n reflect interval aspiration however pneumonia cannot be excluded. There is\n mild volume overload. The main pulmonary trunk is distended indicating\n pulmonary hypertension. Dense retrocardiac atelectasis is worse. Small\n bilateral pleural effusions are unchanged.\n\n IMPRESSION:\n 1. Worsening confluent left mid and lower lobe opacities could represent\n interval aspiration however pneumonia cannot be excluded. Unchanged small\n bilateral pleural effusions.\n 2. Prominent main pulmonary artery trunk suggesting pulmonary hypertension\n which in the right clinical settings could reflect pulmonary embolism.\n\n In discussion with patient's referring physician . , a non-\n contrast chest CT to further evaluate the above changes will be considered,\n given patient's acute renal failure limits contrast administration.\n\n"
},
{
"category": "Radiology",
"chartdate": "2173-06-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1016273,
"text": " 3:12 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o interval change\n Admitting Diagnosis: DIABETIC KETOACIDOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old woman with ards, ? pna, intubation\n REASON FOR THIS EXAMINATION:\n r/o interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 21-year-old woman with ARDS, questionable pneumonia; evaluate for\n interval change.\n\n COMPARISON: .\n\n SEMI-UPRIGHT BEDSIDE RADIOGRAPH OF THE CHEST AT 3:45 A.M.: Endotracheal tube\n is terminating 2.3 cm above the carina. NG tube is extending into the stomach\n and out of the field of view. A right subclavian catheter is terminating\n slightly below the anticipated cavoatrial junction, unchanged.\n\n There is interval improvement in the multifocal consolidations with persistent\n retrocardiac atelectasis. Small bilateral pleural effusions are unchanged.\n There are no new consolidations. There is mild interstitial edema which is\n also improved. Heart size is normal. Previously noted prominence of the\n pulmonary trunk has also improved.\n\n IMPRESSION: Mild pulmonary edema with marked interval improvement in the\n multifocal consolidations with persistent small bilateral pleural effusions.\n\n"
},
{
"category": "Radiology",
"chartdate": "2173-06-11 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1017428,
"text": " 2:42 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: s/p right 48cm picc\n Admitting Diagnosis: DIABETIC KETOACIDOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old woman with\n REASON FOR THIS EXAMINATION:\n s/p right 48cm picc\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Line placement.\n\n FINDINGS: Bedside frontal chest radiograph is compared to . The\n right PICC tip terminates in the lower SVC. The patient has been extubated.\n Prior pulmonary consolidations have markedly improved.\n\n IMPRESSION: PICC tip terminating in the lower SVC.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2173-05-30 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1015769,
"text": " 8:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Tube placements\n Admitting Diagnosis: DIABETIC KETOACIDOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old woman with NG tube placed\n REASON FOR THIS EXAMINATION:\n Tube placements\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST ON AT 8:12\n\n INDICATION: Tube placements.\n\n COMPARISON: at 0058.\n\n FINDINGS:\n\n The tip of the ETT is 4.9 cm above the carina. An NGT is visualized below the\n diaphragm with its tip in the body of the stomach. Compared to the prior\n study, there is continued distention of pulmonary vessels. The latter appear\n more prominent but positioning differences could be contributory. No definite\n new consolidations.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2173-05-30 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1015826,
"text": " 7:56 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: eval R subclavian line placement\n Admitting Diagnosis: DIABETIC KETOACIDOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old woman with DKA, respiratory failure, ventilated, s/p R subclavian\n line placement\n REASON FOR THIS EXAMINATION:\n eval R subclavian line placement\n ______________________________________________________________________________\n WET READ: CXWc SUN 8:56 PM\n Right SCC terminates in the lower SVC. No pneumothorax. ETT 6.9 cm from\n carina, at thoracic inlet - advance by 2-3 cm for standard positioning.\n Persistent bilateral pleural effusions, pulmonary vascular engorgement and\n cardiomegaly, indicating heart failure, unchanged.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 21-year-old woman with diabetic ketoacidosis, respiratory\n failure, ventilated status post right subclavian line placement. Evaluate for\n line placement.\n\n COMPARISON: , (8:12 a.m.).\n\n SINGLE SUPINE BEDSIDE RADIOGRAPH AT 8:19 P.M.: Endotracheal tube is\n terminating 6.9 cm above the carina higher than the prior radiograph. There\n are bilateral pleural effusions associated with bilateral mild vascular\n congestion, slightly worse than prior study. Unchanged retrocardiac\n atelectasis is again noted. There are no new focal consolidations. There is\n mild atelectasis at the right lung base.\n\n The right subclavian catheter is terminating in the distal SVC. There is no\n pneumothorax. NG tube is extending into the stomach and out of the field of\n view.\n\n IMPRESSION:\n 1. Mild vascular congestion with small bilateral pleural effusions and\n bibasilar atelectasis, slightly worse than this morning.\n 2. ET tube terminating 6.9 cm above the carina. Position of the ET tube was\n communicated to Dr. .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2173-05-30 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 1015833,
"text": " 10:16 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: r/o fluid collection\n Admitting Diagnosis: DIABETIC KETOACIDOSIS\n Field of view: 42\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old woman with sepsis, dka, free fluid in pelvis seen on u/s\n REASON FOR THIS EXAMINATION:\n r/o fluid collection\n CONTRAINDICATIONS for IV CONTRAST:\n arf\n ______________________________________________________________________________\n FINAL REPORT\n CT ABDOMEN AND PELVIS\n\n CLINICAL HISTORY: Recent hypotensive episode secondary to DKA with subsequent\n sepsis. Abnormal fluid seen in pelvis on recent ultrasound.\n\n TECHNIQUE: Helical acquisition of CT images performed from the lung\n bases through the ischial tuberosities following administration of oral\n contrast only, decreased renal function precludes use of IV contrast.\n\n No prior studies available for comparison.\n\n FINDINGS: There are bilateral pleural effusions and associated atelectasis,\n right more so than left. There are scattered nodular opacities seen\n throughout both lung bases, and more focal consolidation seen at the right\n lung base, all of which may represent aspiration and subsequent developing\n pneumonia. There is a nasogastric tube which terminates in the gastric antrum.\n Central venous line tip terminates in the right atrium. Additionally a left\n femoral venous line is present with its tip in the external iliac vein.\n\n Non-contrast evaluation of the liver, spleen, pancreas and adrenal glands is\n unremarkable. Gallbladder is present, there may be biliary sludge, as there\n is increased attenuation within the decompressed gallbladder. No biliary\n dilatation.\n\n There are no dilated loops of bowel. There is a moderate amount of free fluid\n tracking along the right paracolic gutter extending to the deep pelvis, with\n thickening of the circumferential bowel wall thickening involving the right\n colon and proximal transverse colon. Contrast has passed to the level of the\n right colon. There is no abscess or organizing fluid collection. No\n pneumatosis is evident.\n\n There is a Foley catheter within decompressed bladder. Uterus and adnexal\n structures are unremarkable.\n\n Bony structures are unremarkable.\n\n IMPRESSION:\n\n 1. Bilateral pleural effusions with likely aspiration and developing\n (Over)\n\n 10:16 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: r/o fluid collection\n Admitting Diagnosis: DIABETIC KETOACIDOSIS\n Field of view: 42\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n consolidation at the right lung base.\n\n 2. Free fluid tracking along the paracolic gutter with associated bowel wall\n thickening, the possibility of ischemic bowel is raised given the recent\n hypotensive episode. Infectious and inflammatory etiologies also should be\n considered. No dilated loops or pneumatosis.\n\n 3. Likely biliary sludge.\n\n"
},
{
"category": "Radiology",
"chartdate": "2173-05-30 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1015746,
"text": " 1:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval tube. r/o effusions or PNA\n Admitting Diagnosis: DIABETIC KETOACIDOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old woman with DKA s/p intubation\n REASON FOR THIS EXAMINATION:\n eval tube. r/o effusions or PNA\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, , 00:58\n\n\n INDICATION: Recent intubation.\n\n FINDINGS:\n\n Tip of the ETT is 4.3 cm above the carina. The pulmonary vasculature appears\n somewhat prominent and there is bilateral blunting of the costophrenic sulci\n consistent with effusions. Heart size is top normal and there is no evidence\n of focal consolidation. No pneumothorax.\n\n IMPRESSION: Intubation with an element of fluid overload.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2173-06-04 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 1016526,
"text": " 6:07 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: pls eval interval changes\n Admitting Diagnosis: DIABETIC KETOACIDOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old woman with DKA, respiratory failure, unresponsiveness and recent CT\n showing diffuse nodular opacities\n REASON FOR THIS EXAMINATION:\n pls eval interval changes\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 21-year-old woman with DKA, respiratory failure, unresponsiveness\n and recent CT showing diffuse nodular opacities, evaluate for interval\n changes.\n\n COMPARISON: .\n\n TECHNIQUE: Volumetric axial CT acquisition of the lungs without intravenous\n contrast. 5- and 1.25-mm thick axial slices were obtained. Multiplanar\n reformations were generated.\n\n FINDINGS: Endotracheal tube is terminating in standard location. NG tube is\n extending into the stomach. Right jugular venous catheter is terminating\n within the right atrium, all of these are unchanged.\n\n No mediastinal or axillary adenopathy. Evaluation of hilar structures is\n limited in the non-contrast setting. Heart and the great vessels are grossly\n unremarkable.\n\n Lung windows demonstrate large bilateral pleural effusions, worse than prior\n study. Again are noted multifocal peribronchial nodular consolidations, some\n in subpleural distribution and others more central, worse than the recent CT.\n There is also worsening bibasilar atelectasis.\n\n The study is not designed for subdiaphragmatic diagnosis and limited non-\n contrast evaluation of the imaged portions of the abdomen is grossly\n unremarkable.\n\n No suspicious lytic or sclerotic osseous lesions are noted.\n\n IMPRESSION: Worse multifocal peribronchial nodular opacities with\n increasing large bilateral pleural effusions and bibasilar atelectasis.\n Multifocal pneumonia remains the likely etiology. The distribution and\n morphology are not typical for pulmonary infarction or septic emboli, which\n are differential considerations.\n\n"
},
{
"category": "Radiology",
"chartdate": "2173-06-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1016611,
"text": " 3:58 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for OG tube placement\n Admitting Diagnosis: DIABETIC KETOACIDOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old woman admitted w/DKA, AMS, intubated w/OG tube\n REASON FOR THIS EXAMINATION:\n please eval for OG tube placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE VIEW ON \n\n HISTORY: New OG tube.\n\n FINDINGS: There is a new OG tube with tip in the stomach. The endotracheal\n tube tip is 5 cm above the carina. There is a right subclavian line with tip\n in the right atrium. Again seen are patchy bilateral alveolar infiltrates,\n some of which have a rounded configuration and could represent septic emboli.\n There is small right pleural effusion. Motion artifact limits this\n assessment.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2173-06-01 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 1016108,
"text": " 9:10 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: characterize pulmonary process--ARDS? Radiology concerned r\n Admitting Diagnosis: DIABETIC KETOACIDOSIS\n Field of view: 36\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old woman with DKA, obtunded, ventilated, left infiltrate, pulmonary\n infiltration on CXR\n REASON FOR THIS EXAMINATION:\n characterize pulmonary process--ARDS? Radiology concerned regarding PE\n CONTRAINDICATIONS for IV CONTRAST:\n renal failure\n ______________________________________________________________________________\n WET READ: YMf TUE 10:40 PM\n Bilateral multifocal air space process, the appearance is non-specific and\n likely reflect presence of multifocal infection or aspiration, differential\n diagnosis includes pulmonary hemorrhage or ARDS. Bilateral moderate pleural\n effusions. Not able to evaluate for pulmonary embolism given lack of\n intravenous contrast.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST CT, \n\n HISTORY: DKA. Obtunded. Lung infiltrates and large hila and pulmonary\n arteries.\n\n TECHNIQUE: Multidetector helical scanning of the chest was performed without\n intravenous contrast because of patient's renal insufficiency, reconstructed\n as contiguous 5 and 1.25 mm thick axial and 5 mm thick coronal images.\n\n There are no prior chest CTs for comparison, but the study is read in\n conjunction with chest radiographs, through .\n\n FINDINGS:\n\n Endotracheal tube is in standard position, nasogastric tube passes into the\n stomach and out of the field of view, and a right jugular line ends in the\n upper right atrium.\n\n Multifocal, nodular areas of peribronchial consolidation is all lobes of both\n lungs, and extensive lobar consolidation in the left lower lobe, superior and\n posterior and anterior basal segments are probably infectious; a smaller\n region of posterior consolidation in the right lower lobe is probably\n atelectasis.\n\n In the absence of intravenous contrast enhancement, measurement of central\n lymph nodes is difficult, but range up to 17 mm in the left hilus, smaller in\n the right hilus, and insignificant in the mediastinum. Small non-hemorrhagic\n pleural effusions layer posteriorly. There is no pericardial effusion. Main\n pulmonary artery is equivalent in diameter to the aorta, 31 mm, probably\n larger than baseline, but not so large as to raise concern for pulmonary\n hypertension.\n (Over)\n\n 9:10 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: characterize pulmonary process--ARDS? Radiology concerned r\n Admitting Diagnosis: DIABETIC KETOACIDOSIS\n Field of view: 36\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n IMPRESSION:\n 1. Multifocal pneumonia. No evidence of ARDS. Pulmonary embolism cannot be\n excluded by this non-contrast examination, but findings do not suggest\n pulmonary infarctions.\n\n 2. Hilar adenopathy, small bilateral pleural effusions, probably reactive to\n pulmonary infection.\n\n Findings were discussed by telephone with the house officer caring for this\n patient at the time of this dictation.\n\n\n\n\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2173-06-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1016861,
"text": " 3:07 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: DIABETIC KETOACIDOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old woman with intubation, PNA\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Status post intubation, evaluation for interval change.\n\n As compared to the previous radiograph, there is no relevant change. The\n monitoring and support devices are in unchanged position. The multifocal\n areas of opacities are unmodified. Moderate retrocardiac atelectasis, no\n secure evidence of pleural effusions.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2173-06-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1016648,
"text": " 3:41 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess interval change\n Admitting Diagnosis: DIABETIC KETOACIDOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old woman with resp failure, dka\n REASON FOR THIS EXAMINATION:\n assess interval change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Diabetic ketoacidosis and respiratory failure in a\n 21-year-old woman.\n\n Portable AP chest radiograph was compared to a chest CT from and chest\n radiographs from till .\n\n Multiple parenchymal consolidations some of them rounded in shape did not\n significantly change over period of last three days, but did\n slightly progress since . The current radiograph demonstrate a\n bilateral perihilar opacities which are most likely consistent with pulmonary\n edema and are unchanged since . There is bilateral pleural\n effusion and bibasal retrocardiac atelectasis which are also stable.\n\n The ET tube tip, the NG tube, the right subclavian line are in standard\n position.\n\n IMPRESSION: Multiple consolidations some of them rounded consistent with\n infectious process.\n\n Superimposed pulmonary edema.\n\n Pleural effusions and retrocardiac atelectasis.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2173-06-05 00:00:00.000",
"description": "Report",
"row_id": 85254,
"text": "PATIENT/TEST INFORMATION:\nIndication: ?Septic pulmonary emboli.\nBP (mm Hg): 200/100\nHR (bpm): 120\nStatus: Inpatient\nDate/Time: at 09:14\nTest: Portable TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: No spontaneous echo contrast or thrombus in the LA/LAA or the\nRA/RAA. Good (>20 cm/s) LAA ejection velocity.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA.\nNormal interatrial septum. No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal ascending, transverse and descending thoracic aorta with no\natherosclerotic plaque.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. No masses or\nvegetations on aortic valve. Filamentous strands on the aortic leaflets c/with\nLambl's excresences (normal variant).\n\nMITRAL VALVE: Normal mitral valve leaflets. No mass or vegetation on mitral\nvalve. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. No mass or vegetation on\ntricuspid valve. Mild [1+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR. No vegetation/mass on pulmonic valve.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was monitored\nby a nurse throughout the procedure. The patient was monitored\nby a nurse throughout the procedure. Local anesthesia was\nprovided by benzocaine topical spray. The patient was sedated for the TEE.\nMedications and dosages are listed above (see Test Information section). 0.2\nmg of IV glycopyrrolate was given as an antisialogogue prior to TEE probe\ninsertion. No TEE related complications. Ascites.\n\nConclusions:\nNo spontaneous echo contrast or thrombus is seen in the body of the left\natrium/left atrial appendage or the body of the right atrium/right atrial\nappendage. No atrial septal defect is seen by 2D or color Doppler. Overall\nleft ventricular systolic function is normal (LVEF>55%). Right ventricular\nchamber size and free wall motion are normal. The ascending, transverse and\ndescending thoracic aorta are normal in diameter and free of atherosclerotic\nplaque to 40 cm from the incisors. The aortic valve leaflets (3) appear\nstructurally normal with good leaflet excursion and no aortic regurgitation.\nNo masses or vegetations are seen on the aortic valve. There are filamentous\nstrands on the aortic leaflets consistent with Lambl's excrescences (normal\nvariant; seen on clips 113 and 114). The mitral valve leaflets are\nstructurally normal. No mass or vegetation is seen on the mitral valve. Mild\n(1+) mitral regurgitation is seen. No vegetation/mass is seen on the pulmonic\nvalve. There is no pericardial effusion.\n\nIMPRESSION: No echocardiographic evidence of endocarditis, abscess or valvular\nmass. Normal biventricular function. Mild mitral and tricuspid regurgitation.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2173-06-02 00:00:00.000",
"description": "Report",
"row_id": 85255,
"text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis.\nHeight: (in) 66\nWeight (lb): 198\nBSA (m2): 1.99 m2\nBP (mm Hg): 129/76\nHR (bpm): 115\nStatus: Inpatient\nDate/Time: at 15:03\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal interatrial septum. No\nASD by 2D or color Doppler. Normal IVC diameter (<2.1cm) with >55% decrease\nduring respiration (estimated RAP (0-5mmHg).\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Suboptimal technical\nquality, a focal LV wall motion abnormality cannot be fully excluded. Low\nnormal LVEF. No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter. No 2D or Doppler evidence of distal arch coarctation.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. No masses or\nvegetations on aortic valve.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. mass or\nvegetation on mitral valve.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. No mass or vegetation on\ntricuspid valve. Mild [1+] TR. Normal PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR. No vegetation/mass on pulmonic valve.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Resting tachycardia (HR>100bpm).\n\nConclusions:\nThe left atrium is normal in size. No atrial septal defect is seen by 2D or\ncolor Doppler. The estimated right atrial pressure is 0-5 mmHg. Left\nventricular wall thicknesses and cavity size are normal. Due to suboptimal\ntechnical quality, a focal wall motion abnormality cannot be fully excluded.\nOverall left ventricular systolic function is low normal (LVEF 55%). There is\nno ventricular septal defect. Right ventricular chamber size and free wall\nmotion are normal. The aortic valve leaflets (3) appear structurally normal\nwith good leaflet excursion and no aortic regurgitation. No masses or\nvegetations are seen on the aortic valve. The mitral valve appears\nstructurally normal with trivial mitral regurgitation. No mass or vegetation\nis seen on the mitral valve. The estimated pulmonary artery systolic pressure\nis normal. No vegetation/mass is seen on the pulmonic valve. There is no\npericardial effusion.\n\nIMPRESSION: No valvular vegetations seen.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2173-06-08 00:00:00.000",
"description": "Report",
"row_id": 1661558,
"text": "7pm to 7am:\n\nROS:\n\nNeuro) Pt remains intubated with propofol gtt for sedtion with good efffect. Pt found in the beginning of the shift to be VERY somulent and sedation decreased. Pt became awake and following commands, but agitated at times, and sedation increased again. MD aware of current neuro status. While awake, pt was following simple commands, had = hand grips, MAE and able to answer yes and no by non-verbal ques. Neuro is following pt. No contact from family on this shift. Full Code.\n\nID) Afebrile. WBC 10 this am. On IV ABxs for multifocal pna. Pt has had large amounts of liq stool and stool sample sent for C-diff R/O. Needs 2 more sent off and . Vanco level this am 12.5 .\n\nCV) Pt is in NSR while at sleep and ST (100-110) while awake. No ectopy noted. A-line VERY positional and is now using NIBP for readings. A-line with very poor blood return. MD aware. Gen edema continues. K level has been aggressivly replaced throughout the shift, and is now NL at 4.3. Please follow closely diuresis and diarrhea. Hct dropping. ? need for blood transfusion or epogen RF. Na level now NL after H2O flushes. ? decrease amounts of flushes.\n\nGU) Good respond from lasix gtt. Goal net (-) 100 cc/hr. Pt is currently (+) 14 liters for LOS. Pt currently on bicarb gtt for RF, with now corrected PH and Co2...? Creatine and BUN decreasing. DC gtt. Nephrology is following pt.\n\nGI) Abd soft with + BS. TF at goal at 25 cc/hr. Pt continues to have lg amounts of liq brown stool via rectal tube. Insulin gtt as noted with still very labile BS results. D10 gtt as noted.\n\nResp) LS coarse throughout the shift, but improved after deep sx. No changes made to vent settings. ABGs WNLs.\n\nSkin) body rash improved. See care vue for details.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2173-06-08 00:00:00.000",
"description": "Report",
"row_id": 1661559,
"text": "resp care\npt extubated after successful . strong cough prod mostly whitish/lt yellow secretions. abg acceptable on face tent. refer to flow sheet for further documentation.\n"
},
{
"category": "Nursing/other",
"chartdate": "2173-06-08 00:00:00.000",
"description": "Report",
"row_id": 1661560,
"text": "MICU nurse progress note 0700-1900\nEvents: pt cont to diurese well, lasix gtt now at 12mg/hr. K+ repleted w/ a total of 60meq today. last K+ at 15:30 was 4.3... propofol and TF off, pt extubated today at 13:00, tol well, 02 sat now 95-100% on R/A... insulin gtt at 2units/hr, D10 at 100ml/hr, FSBS 104-137.\n\nROS:\nNeuro: A/O x 2 MS clearing, weepy at times, following commands. all ext strong/= PERRLS. no c/o pain.\n\nPulm: extubated as above, was initially on 40% face tent, now on R/A tol well 02 sat 95-100%. LS remain coarse throughout, strong/ productive cough. remains on IV Vanc/ Cefepime for multifocal pna. day 10 of 14.\n\nCVS: NSR/ST w/ no ectopy HR 80's-110's. b/p stable 120's-140's/ 70's. ABP's ~20pts higher, K+ repleted as above.\n\nGI: OGT removed w/ extubation, abd soft nontender +BS x 4quads. pt NPO post extubation. Speech eval in am. mushroom cath intact draining liq brown stool.\n\nGU: foley cath patent draining clear yellow urine. lasix gtt at 12mg/hr. UOP 250-400ml/hr. goal UOP is net neg ~100ml/hr. BUN/CR improving.\n\nsocial: family at bedside, updated r/t POC/ pt cond by RN and MD.\n"
},
{
"category": "Nursing/other",
"chartdate": "2173-06-05 00:00:00.000",
"description": "Report",
"row_id": 1661549,
"text": "Micu Nursing note \n\nNeuro: Propofol drip stopped at 2 pm. pt more resposive following simple commands, nodding head, try to go for ett, was able to keeppt off propofol for and hour and a half, then palced her back on drip because of ^ rr and acidosis\nCv pt hemodynamcally stable aline and cuff more accurate now that tranduced is taped to pt leg, BP 120-150/60-80 hr 89-113\npulses in leg by doppler\nResp pt changed form ac-ps now on 40%/14/5peeps tv 400-700, rr 20-2g while on propofol off propofol rr ^ 32, pt suctioned for small -mad amount of white secreations, lung course, sats 100%\nGi and soft non tender will restate tube feeds at 10 cc/hr retal tube in place passing small amount of brown liquid\nGU foley in place, pt started on lasix drip which is now at 10mg/hr. goal to make pt a liter neg today so far only 400 neg\npt also started on a bicarb drip which is at 150 /hr, they will change consintration so that we can lower volume about and hopefully get to neg goal, ph slighly better( see objective data ) pt will also start on po bicarb tabs this evening\nid t max 99.7 pt cultured blood x2 urine and sputum, added flagyl for more coverage\nendo Blood sugars difficult to control at one point bs down to 71 given amp of d5 and repeat bs 140, held insulin drip until this afternoon when bs > 300 and was restarted on drip now at 5 units and hour\nA/P\nNeuro status much improved and pt able to folllow commands off propofol\nacidosis r/t renal failer now on bicarb drip and lasix drip\n attempt to correct ph, renal following if over next 2 days no improvement in acidosis, will consider hd line\nblood sugars difficult to control remains on insulin drip will start tube feeds follow bs q1 hr.\n"
},
{
"category": "Nursing/other",
"chartdate": "2173-06-05 00:00:00.000",
"description": "Report",
"row_id": 1661546,
"text": "7pm to 7am:\n\nEvents: Pt has had an uneventful night. Plan for a TEE today and continue to wean pt off vent as tolerated.\n\nROS:\n\nNeuro) Pt remains intubated with propofol gtt for sedation with good effect. When stimulated HR and BP has improved today. When doing oral care, pt will slightly open eyes, have facial grimaces and noted to have decerebrate movements to upper EXTs. Although, pt will not respond to painful touch (nail bed pinch). Neuro exam as noted in care vue. No contact from family at this time. ? need for family meeting in near future regarding pt's progress. Full code.\n\nCV) Pt in SR (80-90's) while at rest and ST (100-110) with stimulation. Aline to Lt Fem with dampened wave form, and using NIBP for BP readings. SBP 120-130's with MAP >65. CVP 14->12. Am labs pending. NPO for TEE this am at 8am.\n\nENDO) Pt remains on insuling gtt with D5W at KVO.\n\nResp) Pt has been deep sx'd for sml-mod amounts of white secretions. Ls has improved throughout the night, now CTA. Pt in AC mode with worsening ABGs as noted in care vue (met acidosis..awaiting am labs for renal function).\n\nGI) Abd obese with + BS. Pt continues to have liq brown stool via rectal tube. NPO. OGT w/o residuals and clamped.\n\nGU) Good U/O via foley catheter. Pt is now +16.6 liters for LOS.\n\nSkin) see care vue for details.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2173-06-05 00:00:00.000",
"description": "Report",
"row_id": 1661547,
"text": "Resp Care\nRemains intubated and ventilated on a/c with no remarkable changes overnight. ABGs with continued metaboloic acidosis, good oxygenation. Lungs clear to auscultation. RSBI this morning = 103.\n"
},
{
"category": "Nursing/other",
"chartdate": "2173-06-05 00:00:00.000",
"description": "Report",
"row_id": 1661548,
"text": "Respiratory Care Note\nPt received on AC as noted. BS slightly coarse with expiratory wheezes in LUL which clears with suctioning. Pt suctioned for small amt thick, tan secretions. Pt weaned to PSV 14/5 as noted. Pt tolerating fairly well with VT ranges in 500's and RR mid to high 20's. Pt becomes tachypneic 35-40 with care. Plan to continue on PSV as tolerated at this time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2173-06-07 00:00:00.000",
"description": "Report",
"row_id": 1661555,
"text": "Respiratory Care\nPatient remains intubated, and on mechanical ventilatory support, breath sounds bilaterally clear throughout shift, suctioned intermittently for moderate to small amounts of thick white secretions, SPO2 remains in the upper 90s, patient did no tolerate tried for few minutes by MD, became tachypneic, put back on previous settings, no ABGs nor vent changes made up to the present, will continue to be followed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2173-06-07 00:00:00.000",
"description": "Report",
"row_id": 1661556,
"text": "MICU Nurse Progress Note 0700-1900\nEvents: pt cont on lasix gtt at 14mg/hr, diuresing well. started on D10 at 100ml/hr x 2L for DKA/ hypernatremia. insulin gtt increased to 8units/hr per protocol. propofol increased r/t agitation. Neuro f/u done today. Aline resited to R wrist.\n\nROS\r:\nNeuro: pt resp to verb stim, able to follow commands. MAE, PERRLS. sedation turned off for Neuro f/u consult/ exam. pt able tro consistently follow commands. sedation restarted r/t pt not extubating today.\n\nPulm\r: LS coarse bilat. suctioned for msm-mod amt thick whitee secretions. RSBI this am 160. remains on CPAP+PS tol well.\n\nCVS: NSR w/ no ectopy ABP 140-160's/ 70-90's. repeat K+ 3.8 pt repleted w/ 20meq KCL IVPB. needs f/u this eve. R rad aline and R s/c CVL intact w/ good BR.\n\nGI: abd soft/ nontender, +BS x 4quads, TF at goal rate via OGT tol well. Mush cath intact draining liq brown stool.\n\nGU: foley cath patent draining clear yellow urine, UOP 200-350ml/hr, net neg ~1.5L since midnight. lasix gtt 14mg/hr.\n\nID: cont on cefepime r/t multifocal PNA\n\nsocial: pt father called, updated r/t pt cond/ POC.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2173-06-08 00:00:00.000",
"description": "Report",
"row_id": 1661557,
"text": "Respiratory Therapy\nPt device: Pt remained on CPAP+PS 14/5 t/o the night and tol well. Pt would get tachypnic with RR up to 40 when sedation was lightened. RSBI was 91.7 this AM.\n\nLungs: BBS clear but coarse at times. Sx for large amount of thick white secretioins.\n\nGas Exchange: ABG normal\n\nPlan: wean as tolerated and extubate.\n"
},
{
"category": "Nursing/other",
"chartdate": "2173-06-01 00:00:00.000",
"description": "Report",
"row_id": 1661533,
"text": "Nursing note 7a-7p\nEvents: pt in resp distress on cpap, after being on cpap for over 24 hrs. placed on CMV. cxr worse on Left, requiring CT chest. EEG done, non-specific secondary to propofol. MRI rx'd, however unable to do on day shift, due to pt needing 2 IV pumps while down in MRI dept.\n\nNeuro: pt opens eyes off propofol for ~20 min. unclear as to if pt is following, because she is unable to repeat commands consistently; however, pt was able to turn her head towards my voice on command and move her legs x2 on command. + gag, + cough, no focus, no upper ext movement noted today(purposeful or non-purposeful).\n\nCV: ST, no ectopy. S1, S2. 2+ gen edema. Pt is up almost 20 kg since admission. palp pulses x4 ext. L fem Aline over damp. SBP correlating w/ NIBP. CVP continues to be elevated around 14.\n\nPulm: Pt on CMV 18/TV 550/Fio2 .40/PEEP5. lungs coarse bilat after suctioning for small-mod amt thin white secretions. Last abg consistent. no vent changes ordered.\n\nGI: abd soft, bs+, tf @ goal w/ min resid. incont small loose, brown stool x3.\n\nGU: foley draining marginal amts cloudy, pale yellow urine. pt on menses.\n\ninteg: L flank & abd ecchymosis, peri redness, however, no longer cottage cheese-like drng. tape burn to RAC, ear spacer holes scabbed-bacitracin applied. L chest bar piercing site scabbed.\n\nIV: RSC TLC patent. no redness. old sang drng.\n\nendocrine: pt remains on insulin gtt 2-3 units/hr all shift.\n\npain: no s/sx of pain. grimaces only with sternal rub and oral care.\n\nSocial: pt's parents home for the day to shower and nap. no other phone inquiries.\n\nID: urine, sputum and wond cxs neg. bc x2 pending.\n\nPlan: MRI of brain, CT chest tonight. daily wake-ups. Neuro consult. monitor neuro status, resp and renal functions.\n"
},
{
"category": "Nursing/other",
"chartdate": "2173-06-02 00:00:00.000",
"description": "Report",
"row_id": 1661534,
"text": "MICU 6 NPN:\nNEURO: PERL 3-4mm and sluggish. Taken off propofol to assess neuro status and pt. noted to move only LEs and head. No following commands. Opens eyes but no tracking or focusing. Becomes very agitated off propofol. Agitated throughout night with tachypnea, biting tube and hypertension- propofol increased to 50mcg/kg/min with good effect. Pt. received head MRI and chest CT overnight with results pending.\nCV: Afeb. HR 90s-110s SR/ST, no ectopy noted. L femoral a-line dampened and NIBP started. BP wnl. R subclavian quad lumen line intact.\nRESP: No vent changes overnight. O2 Sat >95% and acceptable abgs. Sx'd for scant secretions. LS coarse and diminished at bases.\nGI/GU: Abd. soft with positive bowel sounds. Large loose BM - trace guiac positive. TF continue at goal. Insulin gtt currently at 1unit/hour and monitoring blood glucose q1/2-1hr. Glucose dropped to 54 overnight and given amp d50. Foley with cloudy yellow urine 20-30cc/hr. BUN/Cr rising.\nSKIN: Peri area with yeast rash- antifungal cream applied. Backside intact. Generalized edema. Would benefit from kinair air mattress.\nOTHER: Plan for read of MRI/chest CT. Daily wake-up to assess neuro exam. Would benefit from neuro consult.\n"
},
{
"category": "Nursing/other",
"chartdate": "2173-06-02 00:00:00.000",
"description": "Report",
"row_id": 1661535,
"text": "RESP CARE NOTE\n21 YO F ADMITTED FOR DKA NOW BEING SEEN FOR INCREASING SEPSIS. SX MODERATE AMOUNT THICK WHITE. BS DECREASED AT BASES WITH FINE CRACKLES @ L BASE. ETT REPOSITIONED AND TAPED @ 23. RSBI 150\n"
},
{
"category": "Nursing/other",
"chartdate": "2173-06-02 00:00:00.000",
"description": "Report",
"row_id": 1661536,
"text": "resp care - Pt remains intubated and on full vent support. No changes were made in vent settings this shift. Coarse BS cleared somewhat on suctioning of small amounts of thick, white secretions. Bronch was done for BAL. Sample of secretions were sent to the lab. Plan is to continue resp support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2173-06-02 00:00:00.000",
"description": "Report",
"row_id": 1661537,
"text": "0700-1900 MICU PROGRESS NOTE\n\n21yo female admitted from , admitted on after being found down for unknown length of time. PT was intubated at OSH and blood sugar >600. At OSH pupils were fixed and dilated and rectal temp was 88. Pt required pressors and >5L IVF, for hyPOtension intially. Anion Gap 21 and blood sugars >400 intially and placed on insulin gtt. Pt was very acidotic on admission and given several doses of Bicarb. PMH IDDM and alopecia.\n\n\nEvents- Propofol was shut off at 11:45 today and by noon pt agitated. Pt was coughing and on ETT. Sat's dropped to 88-90% when biting tube. PT became hypertensive w/ SBP 160's and tachycardic w/ HR 140's. Dr into eval neuro status, pt UNresponsive to painful or verbal stimuli. Pt NOT following commands. Propofol restarted per team. Bronch completed and BAL sent. Echo completed.\n\n Recieved pt on Propofol and stopped for brief time as noted above. Pt would NOT withdraw to painful stimuli or turn head to verbal stimuli. Pt did bite on ETT and cause sat's to drop. Pt moves legs slightly on bed. Pupils 4cm and sluggish to lights.\n\nC/V- Tmax 99.7 rectally. HR 90-120, NSR/ST w/o ectopy. Pt has 2+ pitting edema. Aline wave dampened and does not correlate well w/ NIBP. Team aware. B/P 120-150/70-90.\n\nResp- Remains orally intubated, see care-vue for trended ABG's. pH 7.30-7.35 and team aware...will monitor. No vent changes made. Sat's remain 97-100% on current vent settings. Lungs coarse w/ rhonchi at bases, suctioned for small amts of thick white sputum. Ct chest last night showed new nodules probable infectious in nature and antibiotic coverage changed.\n\nG/U- Bun/Creat elevated 74/5.4, renal following. Will monitor..dialysis not indicated at this time. Foley clear yellow but decreased amounts...15-50cc/hr.\n\nG/ Pt at goal for TF 25cc/hr. Remains on insulin drip. Blood sugars have been 130-200. Pt has had 2 loose liquid brown stool.\n\nPLAN-\nAWAITING ECHO RESULTS\nBAL AND SPUTUM SPEC SENT , FOLLOW-UP RESULTS\nCONTINUE TO TREND ABG'S, GOAL pH 7.30-7.35\nFUNGAL CULTURES SENT\nSTOP PROPOFOL TONIGHT TO ASSESS NEURO STATUS\nMONITOR ELECTROLTES AND REPLETE AS NEEDED\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2173-06-03 00:00:00.000",
"description": "Report",
"row_id": 1661538,
"text": "MICU 6 NPN:\nNEURO: Taken off propofol x 15min for neuro exam. Pt. does not open eyes to painful stimuli. No following of commands. Withdraws LEs to painful stimuli but not UEs. Moving head back and forth in bed but no movement of UEs noted. PERL 3-4mm and sluggish. Positive cough and gag but no corneal reflexes noted.\nCV: Afeb. Received 1G vanco last pm for level of 20. HR 90s-110s SR/ST, no ectopy noted. BP stable via cuff pressures. A-line continues dampened but with good blood return.\nRESP: No vent changes and adequate abg. TCo2 14. LS coarse and diminished at bases. Minimal secretions.\nGI/GU: Abd. soft with positive bowel sounds, loose BM x1. TF continue at goal with minimal residuals. Continues on insulin gtt at 2units/hour. Foley draining clear yellow urine >50cc/hr.\nSKIN: Multiple blisters to UEs and reddened areas around tape. Will try to minimize tape due to pt's sensitivity. Peri-area red with yeast rash- criticaid antifungal cream applied. Scant blood vaginal drainage from menses.\nOTHER: No calls or visitors this shift.\n"
},
{
"category": "Nursing/other",
"chartdate": "2173-06-03 00:00:00.000",
"description": "Report",
"row_id": 1661539,
"text": "RESP CARE NOTE\nPT REMAINED ON SAME AC SETTINGS OF 18/550/+5/40%. ABG 7.34/24/175/14. BS CS AND DIMINISHED AT BASES. SX'D SMALL AMTS OF THICK YELLOW SECRETIONS. ROTATED AND RETAPED OETT @23CMS. MORNING RSBI 130\nPLAN: CONT FULL VENTILATORY SUPPORT\n"
},
{
"category": "Nursing/other",
"chartdate": "2173-06-03 00:00:00.000",
"description": "Report",
"row_id": 1661540,
"text": "0700-1900 MICU Progress Note\n\n\n21 yo female admitted from on after being found down for unknown length of time. Only PMH is alopecia and IDDM since 7yo. Pt was intubated at OSH and blood sugar found to be greater than 600. Neuro exam at OSH ..pupils fixed and dilated, rectal temp 88 and unresponsive to painful stimuli. Pt was transferred to Tox screen negative for drugs/ETOH B/P 70 palp and required pressors and greater than 5L IVF. Intial anion Gap 21, now 12. Pt continues on insulin gtt and blood sugars have been 100-200, on 1-2units per/hr. Pt was acidotic on admission and given Bicarb....continues to be slightly acidotic @7.27. Team aware and no treatment at this time. Renal function has been worsening slightly(BUN/Creat 81/5.5), renal following...probable ATN and will monitor.continue to follow up with labs. MRI intially read by radiology as normal, but was reviewed by neuro service today and probable anoxic injury noted, awaiting official neuro note. Family NOT aware of new findings, team will address tomorrow. Pt had \"wake-up\" 2x today and was eval by neuro service.\n\nNeuro- As stated above, propofol off 2x today and evaluated by Neuro. Off propofol for 30-1hr and pt became tachycardic w/ HR 120-140 and hYPERtensive. Pt thrashing in bed, gagging and coughing. PT LIFTING BOTH LEGS AND ARMS OFF BED, BUT NO PURPOSEFUL MOVEMENT. Pt does not withdraw from painful stimuli. Pt not opening eyes, or moving head to voice. Pt will bite on ETT off propofol, and sat's drop tp the 80's. Pt place back on propofol..will continue to attempt wake-up and follow neuro rec's when available. Pupils 4cm and sluggish.\n\nI/D- CT chest 2 days ago showed nodules, ? septic emboli. ECHO WNL..PLAN TTE IN AM, WILL KEEP NPO after midnoc. Continues on daily dosed vanco and cefepime. Tmax 100. BAL and sputum spec pending.\n\nC/V- Remains ST/NSR, no ectopy. >17L pos for LOS, +2 edema noted in all extremities and peri-orbital. Aline wave dampened and does not correlate w/ NIBP, team aware. Will keep as access for lab/ABG's. B/P 120-140/60-70. TTE in am.\n\nResp- Vent changed to pressure support and tolerated well. RR 20-30(RR increases to 40's off propofol) and sat's have remained 95-100% on PS. See care-vue for ABG's . Suctionedfor large amount of clear oral secretions and thin white sputum via ETT. Lungs coarse rhonchi,which clears somewhat w/ suctioning.\n\nG/U- Foley draining clear yellow urine and has somewhat increased as compared to yesterday. U/O 50-70cc/hr.\n\nG/I- TF, Nutren Pulm at goal 25cc/hr, tolerated well, no residuals. Pt had 2 loose stool today, hypoactive bowel sounds. NPO after midnoc for TTE. Remains on Insulin GTT at 1unit/hr.\n\n Pt is very sensitive to tape and has multi small fluid filled blisters and arms, and small abrasions. A+D oint applied to open area. Peri-rectal and groin area reddened, criticaid w/ nystatin applied.\n\nPLAN-\nCONTINUE TO MONITOR ABG'S AND ACIDOSIS...GOA\n"
},
{
"category": "Nursing/other",
"chartdate": "2173-06-03 00:00:00.000",
"description": "Report",
"row_id": 1661541,
"text": "(Continued)\nL 7.28-7.35\nMONITOR NEURO STATUS AND CONTINUE TRIALS OFF PROPOFOL\nTTE IN AM\nAWAITING NEURO REC'S\nFUNGAL, BAL AND SPUTUM SPEC PENDING\nMONITOR ELECTROLYTES\n"
},
{
"category": "Nursing/other",
"chartdate": "2173-06-06 00:00:00.000",
"description": "Report",
"row_id": 1661552,
"text": "Micu Nursing note \n\nNeuro: Propofol drip off this am, pt able to follow simple commands grasp hands, and move legs on bed, seems to understand questions and nods. pt placed back on propofol drip because at present no plans to\nextubate.\n\nCv Pt hemodynamically stable BP 120-150/ 60-80 hr 80-110 st, pulses present and palpable,\nResp pt remains on ps14/5 peep/ rr 23-40. fio240%, sats 100% lungs course, pt scutioned s4 for thick tan secreations needing n/s lavage first, secreations are very thick because she is dry.\nattempted to go to 0/5 and pt rr ^ 50, only lasted 5 min and was placed back to previous setting.\n\nGi abd soft non tender, still passing brown liquid stool, tube feeds at goal of 25/hr on nutran plum, residuals 35 cc,\n pt continues to have good urine output, however, we at present are not reaching our negative goal becayse of replacement of free water,\nlytes pending na this am 150, may need to restart lasix drip this eveing, it was stopped early this am because of ^ na level\nid tmax 99.1\naccess, R tlc, and L fent aline\nskin L fa area small blisters drying area cleaned with n/s and dsd applies, R ankle area cleaned and left open to air\nrash improving on body less reddened back and buttock much better\nA/P\nimproving mental status\nat present no plans to extubate until we imporove fluid balance and correct sodium level\nrenal following no plans for hd line, dicarb drip decreased to 12.5 cc/hr, improving ph\nfollow lytes, free water added, may need lasix restarted at the same time as giving free water to reach negative fluid goal.\n"
},
{
"category": "Nursing/other",
"chartdate": "2173-06-06 00:00:00.000",
"description": "Report",
"row_id": 1661553,
"text": "Respiratory Care Note\nPt received on PSV 14/5 as noted. BS coarse bilaterally. Pt suctioned for small amt thick secretions. Pt placed on trial 5/0. Pt became tachypneic with RR 40-45 after 5 min - pt placed back on PSV 14/5. Plan to continue on current settings at this time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2173-06-07 00:00:00.000",
"description": "Report",
"row_id": 1661554,
"text": "7pm to 7am:\n\nEvents:\n Pt has had an uneventful night.\n\nROS:\n\nNeuro) Pt remains intubated with propofol gtt for sedation with good effect. Pt will open eyes and will follow simple commands. Sometimes it takes her a few seconds to respond. Pt has = hand grip. Pupils=and reactive. Pt's neuro status has improved greatly over the last few days. See care vue for further neuro evaluation. No contact from family on this shift.\n\nID) Pt is afebrile. Pt on IV ABXs for multi focal pna. CXR done this am. Pt continues to have a body rash, but improved since .\n\nCV) Pt is in SR(80-90's) at rest and ST (100-106) with activity. SBP stable and a-line and NIBP correlate as noted. Pt continues to have gen edema. Am labs as noted. K level has been replaced multiple times, and needs follow up 2/2 lasix gtt.\n\nResp) LS coarse and clear after deep sx. Pt on CPAP+PS and is tolerating it well. Plan to diurese pt further before extubation takes place. ABGs as noted in care vue.\n\nGI) Abd soft with + BS. Pt continues to have liq brown stool via rectal tube. TF at goal at 25 cc/hr w/o residuals. Pt given H2O fluses for NA level with some effect. Follow up Na level.\n\nGU) Goal diuresing (-) 1-2 liters q day with lasix gtt. . Pt is now + 5.6 liters for LOS (1 liter - for the last 24 hrs). Sodium bicarb gtt as noted. Wean off as tolerating. PH NL and Co2 improved.\n\nSkin) skin as noted in care vue.\n\nSoc) ? family meeting soon.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2173-06-10 00:00:00.000",
"description": "Report",
"row_id": 1661563,
"text": "MICU Nursing Note 1900-0700\nEvents: Transfer to floor cancelled d/t high sugars and anion gap at 2200, gap now closed this am, received 500ml IVF bolus x 110-120's, mild anxiety at times\n\nNeuro: A+O x 3, pleasant and cooperative, anxious with care at times, weepy at other times, moving all extremities, following all commands, asking appropriate questions, OOB til 11pm last night, PEARL, denies pain\n\nCardiac: Pt with HR up 110-120's ST at shift change---received 500ml IV NS bolus with fair effect, second IV NS 500 ml infused with fair effect with HR down to 100-110's ST, BP stable 130-150's/60-70's, pt with (2) PIV's\n\nResp: Denies SOB, RR= 13-20. Lungs clear bilat upper lobes and diminished at bilat lower lobes, occasional scattered rhonchi noted, junky sounding productive cough of thick white sputum, room air Sats with trend down to 90-92%---encouraged to TCDB, placed on 2 L NC with Sats up to 94-97%.\n\nGI: Abd soft with + bowel sounds all quads, poor PO appetite and needs encouragement, taking po fluids well, Mushroom cath draining mod. amts liquid brown stool. C/O nausea at 11pm when BS elevated---resolved after insulin administration.\n\nGU: Foley to CD draining clear yellow urine > 50ml/hr. Creat down to 2.6 this am. Pt currently positive 10.3 L for LOS.\n\nSkin: intact\n\nEndo: Blood sugar up to 401 at 2200----med. with 12 units regular insulin and 25 units Lantus as ordered, team aware and chem panel sent which revealed Gap=16. Fingersticks checked Q 1 hour overnight and 3am Chem panel revealed Gap=10. Blood sugars trending down all night and now currently under 200. If need to restart insulin gtt take note that pt has Lantus on board.\n\nID: WBC= 11.5, low grade temp with Tmax= 99, continues on IV Cipro. random vanco level=16 this am.\n\nSocial: Pt's parents in to visit during evening hours and were updated on pt's care. No further contact overnight.\n\nPlan: Call out to medicine if blood sugars remain under 200, continue freq. glucose checks, increase lantus dose to pt's pre-hospital dose as her po intake improves, increase activity as tolerated---pt is a 2 person max. assist to chair, await PT eval, start pt with incentive spirometer and wean 02 as tolerated, pulmonary toiletting, support pt and family\n"
},
{
"category": "Nursing/other",
"chartdate": "2173-06-10 00:00:00.000",
"description": "Report",
"row_id": 1661564,
"text": "Nursing MICU note addendum\no2 d/c'd and pt with Sats > 95%, using incentive spirometer x 1000ml,\nincontinent of stool---mushroom d/c'd, Fingerstick=182---covered with 2 units SC insulin\n"
},
{
"category": "Nursing/other",
"chartdate": "2173-06-10 00:00:00.000",
"description": "Report",
"row_id": 1661565,
"text": "0700-1800 MICU transfer note\n\n21yo female admitted with DKA on .Pt had been intubated/sedated on Propofol gtt. Pt previously on an insulin gtt/ which has since then been dc'd. Pt is /Oriented x3, pt is weepy at times. Lung sounds coarse, with occassional congestive cough producing thick white secretions, encourged to Pt compliant with using incentive spirometer. O2 sats 95% on room air. Pts appetite remains poor, with about 25% of meals eaten. Pt has been incontient of loose green stools today times 3. Pt OOB to chair for most of the day, pt worked with physical therapy and tolerated it well. Pt continues to complain of headaches, receiving tylenol with minimal effect; team aware. Blood sugars have been between 150-200's covered with ssi. Hct 22, pt to be transfused with 1UPRBC when available. Pt has been called out, due to be transferred to CC7.\n"
},
{
"category": "Nursing/other",
"chartdate": "2173-05-31 00:00:00.000",
"description": "Report",
"row_id": 1661525,
"text": "Resp Care: Pt continues intubated #7 oett, advanced & secured @ 23 @ lip per cxr, on ventilatory support with psv maintaining Vt 5-600 ml with Ve 9-12 L, improving metabolic acidosis with good oxygenation; bs clear to coarse, sxn thick yell secretions, rsbi 51, will cont support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2173-05-31 00:00:00.000",
"description": "Report",
"row_id": 1661526,
"text": "MICU Nursing Note 1900-0700\nEvents: Abd CT scan completed and preliminary report is scan was WNL with fluid collections d/t previous fluid resuscitation, Acidosis slowly correcting, NaHC03 gtt infusing, vasopressin and levophed both weaned to off overnight, remains on IV insulin gtt, sedated with versed and fentanyl.\n\nNeuro: moving lower extremities with stimulation, turns head side to side, responds to painful stimuli, attempts to open eyes with stimulation---unable d/t periorbital edema, + gag, + cough reflex, does not follow commands, swallowing and tongue-ing tube with increased stimulation, IV Versed gtt infusing at 5mg/hr, required a few bolus doses of 2mg for travel to CT scan, IV Fentanyl infusing at 50mcgs/hr. PEARL. Bilat soft wrist restraints to prevent pt from pulling at lines and tubes upon awakening.\n\nCardiac: HR= 120-130's ST with no ecotpy noted, Left femoral Aline intact and with good waveform and correlation to NBP, BP= 100-125/80's with MAP's >70's, IV Vasopressin and IV Levophed weaned to off, episode of sBP 80's with Map= 60 following turning and repositioning once off of vasopressors---Levophed restarted at 0.03 mcgs/kg/min with good effect and able to wean off after 1 hour and currently remains off, new right SC multi-lumen central line placed and confirmed by Xray---right femoral TLC d/c'd and tip sent for cx, CVP= . IV D5W with 3 amps NaHCO3- infusing at 150ml/hr. Last CO2=11. + bilat DP/PT\n\nResp: remains intubated, ETtube advanced 3 cm and now at lip 23cm---awaiting am CXR, ETtube suctioned for mod. amts thick yellow sputum Q1-2hr, tolerated CPAP+PS at 40% with PS=10 and Peep=5. TV=600's, MV= , Sats= 96-100%. ABG improving throughout night with last ABG= 7.30-24-124. Lungs clear bilat upper lobes and with rhonchi at bilat bases.\n\nGI: Abd soft, intially not able to auscultate bowel sounds---now with distant hypoactive bowel sounds, no BM, OGtube placement checked by ausculation, OGtube with 140ml of green bile removed prior to instillation of baricat, after CT scan OGtube placed to LWS for total of 450 ml of baricat removal. Currently OGtube clamped. NPO\n\nGU: Foley to CD draining cloudy yellow urine 10-30ml/hr, Cr up to 3.3 this am, positive 13.7 liters for LOS\n\nEndo: Remains on insulin gtt---currently at 7 units/hr with fingersticks ranging 87-149. Requiring higher dose of insulin while bicarb gtt infusing---will need to titrate insulin closely once off bicarb gtt. Gap closed....last level=13.\n\nID: afebrile, WBC down to 13.3, lactate = 1.3, continues on aztreonam, fluconazole, vanco.\n\nSkin: pt with multiple ecchymotic areas noted over various parts of her body such as thigh, side, rib area---MICU team aware and assessed. Perineum exoriated and red raw---cream and protective barrier applied. continues with menses---no tampon in place.\n\nSocial: No contact from family or friends overnight.\n\nPlan: Continue fingersticks Q1hr, ABG's Q4hr, replace lytes prn, aggressive pulmonary toiletting, blood sugar dropped quickly whe\n"
},
{
"category": "Nursing/other",
"chartdate": "2173-05-31 00:00:00.000",
"description": "Report",
"row_id": 1661527,
"text": "MICU Nursing Note 1900-0700\n(Continued)\nn D5W with bicarb gtt stopped earlier---will need to half insulin dose at that time, need CXR to check repositioning of ETtube, Wean sedation as tolerated, Support pt and family\n"
},
{
"category": "Nursing/other",
"chartdate": "2173-05-31 00:00:00.000",
"description": "Report",
"row_id": 1661528,
"text": "Resp Care\nPt remains intubated. Current vent settings: PSV 10/5 40%. PS increased to 15 due to increased WOB and then decreased back to 10. Pt tolerating change well. Pt taken to CT for head scan. No other changes noted.\n"
},
{
"category": "Nursing/other",
"chartdate": "2173-05-31 00:00:00.000",
"description": "Report",
"row_id": 1661529,
"text": "Micu 6 Nursing Progress Note 0700-1900\nNEURO--Midaz and Fent off. Started on propofol gtt now at 30 mcg/kg/min. When light, MAE. Did not follow commands. Did not track with eyes or make eye contact. purposeful movement. Head CT done -> prelim wet read unremarkable. Initially pupils did not respond. They now are 2-3 mm and respond sluggishly.\n\nCARDIAC-- HR 120's all day. SBP 110-120's/70's. No observed ectopy. Not on any gtts.\n\nRESP--Lungs are coarse in upper airways and diminished in bases bilaterally. SaO2 >97%. Presently on CPAP/IPS . Sx q2hrs for moderate amts of thick tan sputum.\n\nGI--to start tube feeds after mn. Plan was to attempt extubation but that is not happening tonight so start tube feeds. Stool lgr amts of loose stool guiac +. B owelS present.\n\nGU--CR rising. UO decreasing to 5-10 cc hr via foley cath.\n\nENDO--remains on insulin gtt. BS all over the place with insulin gtt changing. bs 70-150 with insulin gtt .5-6units/hr. K+ repleted with 40 meq. CA++ repleted with 2 gms cal. gluconate.\n\nSKIN--Several areas of eccymoisis on torso. Knees are warm and blanched. Buttocks without breakdown. Site on chest from piercing look purulent. Pt with menses. Very edematous.\n\nCOPING--Family in all day and have been updated by this RN and attending. They are aware that kidneys are injured with possibility of permanent damage. They are also aware that further w/u needs to be done on brain. i.e. eeg and maybe MRI. They are grieving. Per pts' mom and dad, pt is non-compliant with her insulin needs.\n\nPAIN--Does not appear to be in pain. Of note, pt is not on any pain medication at present, only propofol.\n\nA--Remains unresponsive,not following commands. No purposeful movements. Holding own RR and BP.\n\nP--COn't to monitor. Wake up to assess neuro status. Offer support to pt and family. Plan for EEG and ? whether MRI is needed. Start tube feeds after mn.\n"
},
{
"category": "Nursing/other",
"chartdate": "2173-06-01 00:00:00.000",
"description": "Report",
"row_id": 1661530,
"text": "MICU Nursing Note 1900-0700\nEvents: Started on Tube feeds and tolerating, low grade temps, Tachypneic on CPAP+PS but ABG good, urine output remains poor and creatinine continues to rise, sedated on propofol with minimal response after propofol off x 30 minutes.\n\nNeuro: PEARL, sedated on 30mcgs/kg/min of propofol, propofol off x 30 minutes and pt moving LE/not opening eyes/not following commands, biting tube with stimulation, Head CT reported as WNL as per MICU team.\n\nCardiac: HR= 110-126 ST with no ectopy noted, Left femoral Aline with good waveform and correlation to NBP, BP= 120-150's/90's, right SC multi-lumen line patent and CVP= , remains off vasopressors.\n\nResp: remains intubated and tolerating CPAP+PS with good ABG, tachypneic overnight, biting tube with stimulation, lungs coarse bilat upper lobes and diminished at bilat bases, + cough reflex, ETtube suctioned for mod. amts thick whitish/yellowish/tan sputum, Current vent settings include CPAP+PS with PS=10 and Peep=5 at 40%. Sats= 97-100%, ABG= 7.34-27-129. RSBI this am > 100\n\nGI: ABd soft with + bowel sounds all quads, small brown BM x 1, OGtube placement checked by auscultation, Started on tube feedings FS Pulmonary Nutren at 10ml/hr---tolerating with minimal residuals and rate increased to 20ml/hr.\n\nGU: Foley to CD draining cloudy yellow urine in scant amts 5-15ml/hr, Creatinine continues to rise =4.3 this am, positive 15.5 L for LOS\n\nSkin: Perineum rash less red today. Ecchymotic areas unchanged. No further breakdown noted.\n\nEndo: Insulin gtt continues and infusing between 0.5-2.0 units/hr and titrated to fingersticks and scale, Fingersticks 97-149.\n\nID: Low grade temp with Tmax=99.2, WBC= 12.7, continues on IV aztreonam and acyclovir.\n\nSocial: Pt's parents in to visit all evening and both are staying at hospital overnight in ICU waiting area.\n\nPlan: Await Neuro consult, possible EEG, possible MRI, wean sedation and vent as tolerated, increase tube feeds as tolerated, replace lytes prn, renal failure---high potential for HD, support pt and family\n"
},
{
"category": "Nursing/other",
"chartdate": "2173-06-01 00:00:00.000",
"description": "Report",
"row_id": 1661531,
"text": "RESP CARE NOTE\nPT REMAINED ON SAME SETTINGS OF PSV 10/5/40%. ABG SHOWING COMPENSATED METABOLIC ACIDOSIS. BS ESSENTIALLY CLEAR BILATERALLY. SUCTIONED SMALL AMTS OF THICK YELL/WHITE SECRETIONS. OETT ROTATED AND RETAPED AT 23CMS. MORNING RSBI 106.3.\nPLAN: WEAN AS TOLERATED.\n"
},
{
"category": "Nursing/other",
"chartdate": "2173-06-01 00:00:00.000",
"description": "Report",
"row_id": 1661532,
"text": "Resp Care\nPt remains intubated, currently on CMV. Pt has ^RR with desats when sedation off, resp distress-biting ett. Sx for mod thick white, plan to monitor nuero status and travel for Head CT/MRI.\n"
},
{
"category": "Nursing/other",
"chartdate": "2173-06-04 00:00:00.000",
"description": "Report",
"row_id": 1661542,
"text": "7pm to 7am:\n\nEvents:\nPt has had an uneventful shift. NPO for TEE today.\n\nROS:\n\nNeuro) Pt remains intubated with propofol gtt for sedation with good effect. Pt has been keeping eyes closed, even when stimulated. Pupils = and reactive to light (brisk). Pt will move head back and forth with oral care and move all ext's with non-purposeful movements. Pt does NOT respond to any painful stimuli accept oral care. Pt does not follow any commands. Pt noted to become tachycardic and tachypnic with stimulation, which has minimized after headphones with music placed. Neuro team is following pt. No contact from family.\n\nID) Tmax 99.2 as of 4am. No changes done to IV ABxs. Vanco level pending. Urine cx negatve. Wound culture negative. Sputum culture with NGTD and gram stain negative.\n\nCV) Pt in sr while at rest and ST with minor stimulation(100-117). SBP stable at 120-130's with MAP >65. A-line with dampened wave form and using NIBP for BP readings. CVP 10-13. Am labs pending. Pt is NPO for TEE today.\n\nResp) Pt placed back on AC mode after pt becoming more and more tachypnic at 4am, with good effect. Pt has been deep sx'd for moderate amounts of thick white secretions.\n\nGI) Abd obese with + BS x 4. Flatus +. Rectal tube placed after episode of liq/loose brown stool. NPO for TEE today. Pt remains on insulin gtt as noted, with now stable BS.\n\nGU) Good U/O via foley catheter at 50-75 cc/hr. Pt is now +17 liters for LOS. Renal team is following pt regarding RF. HD on hold for now.\n\nSkin) see care vue for details. Air bed ordered for pt due to skin break down noted around rectum.\n"
},
{
"category": "Nursing/other",
"chartdate": "2173-06-04 00:00:00.000",
"description": "Report",
"row_id": 1661543,
"text": "Respiratory Care:\n\nPt remain orally intubated & sedated on PSV. WE switched to vent support o/n for tacypnea r>40pm & tachycardis, responded well. Bs cl;aer to coarse. RSBI ~97. WE ARE SXTN FOR MOD AMT OF THICK WHITE SECRETIONS FROM ETT. PLAN: AWAITING FAMILY MREETING THIS NORNING, DE CAREVIEW FOR FUTHER DETAILS. A\n"
},
{
"category": "Nursing/other",
"chartdate": "2173-06-04 00:00:00.000",
"description": "Report",
"row_id": 1661544,
"text": "0700-1900 MICU PROGRESS NOTE\n\n21 yo female admitted from OSH on after being found down, unresponsive at home. Please see nursing noted on for detailed past events while in MICU.\n\nEvents- Attempted to wean down propofol gtt, pt unable to tolerate.. on ETT, RR increased to the 40-50's, and HR increased to the 120-130's. Pt moving extremities more while on propofol. Pt has required several small boluses of propofol and dose increased to 60mcg. Wake-up performed this morning and mental status assessed by team. Pt noted to have increased response to painful stimuli, pt now able to cross legs past midline. Pt opening eyes to painful stimuli but unable to track. Pt noted to have purposeful movement towards ETT with hands. Off sedation pt has increased secretions, cough and seems to Gag on ETT. Pt not grasping with hands or following commands. Pt will respond to sternal rub, by withdrawing. Pt did not have TEE today, will have tomorrow at 8:30a. Keep NPO after midnoc.\n\nI/D- Tmax 100.3. Vanco random yester 33.2, continues on Cefepime daily. Repeat chest CT today f/u pulm nodules, results pending.\n\nC/V- Remains ST/NSR w/ no ectopy. remains >16L pos LOS, but U/O increasing slightly. Extremities remain edematous and swelling noted peri-orbital. Aline continues to be dampened, w/ good blood return. Team aware, site WNL...no plans to re-site at this time. Pt was very difficult to obtain. TEE in am.\n\nResp- SBT attempted today, 5/0..tolerated for @ 15 min and became tachypnec w/ RR in the 50's. Sat's dropped to 87-90's and breathing became labored. ABG's drawn thru day, continues to be acidotic secondary to impaired kidney function. Will monitor and no treatment at this time. Lungs coarse, w/ rhonchi..suctioned for increased oral and deep secretions as compared w/ yesterday. Thin white sputum.\n\nGU/Renal- Bun/creat rising but U/O also increasing. Seen by renal, no dialysis at this time..will continue to monitor..? large 1X lasix dose as test. U/O 50-70cc/hr.\n\nG/ Pt has been NPO thru day, KVO changed to D5W to support insulin gtt while NPO. BS 100-200. Will restart TF and D/C at midnight. Rectal tube draining minimal amts of liquid brown stool.\n\nSkin- ? yeast infection groins and buttocks..pink non-raised rash. team aware and nystatin cream ordered. Multi small blister and broke blisters draining serous fluid..A+D oint applied.\n\nPlan-\nTEE in am, keep NPO after midnoc\nContinue trial off propofol and wean down as tolerated\nMonitor MS closely\nMonitor ABG's and acidosis\n?F/U MRI prior to extubation\n"
},
{
"category": "Nursing/other",
"chartdate": "2173-06-04 00:00:00.000",
"description": "Report",
"row_id": 1661545,
"text": "Respiratory Care Note\nPt received on PSV 8/5 as noted. BS coarse bilaterally. RSBI was 80 with a VT 437 and RR 35. started at 3:50p and ended at 4:20p secondary to tachypnea. Pt's RR 49 at end of - pt placed back on with slowing of RR. Plan to continue on current settings at this time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2173-06-06 00:00:00.000",
"description": "Report",
"row_id": 1661550,
"text": "7pm to 7am:\n\nEvents: Uneventful night. Pt on Bicarb gtt and lasix gtt in order to correct renal status with little changes. Renal team following pt.\n\nROS:\n\nNeuro) Pt remains intubated with propofol gtt for sedation. Pt occ in need of sedation boluses before turns due to being very bronchospastic. Pt will occ open eyes to voice and will follow directions inconsistantly. Pt will squeeze hands when asked to. Pt also noted to MAE. No contact from family on this shift. Neuro is following pt. Full Code.\n\nCV) Pt is in ST (100-110) w/o ectopy noted. Hr will increase to 115 with stimulation. SBP stable at 120-130's. A-line wave form remains dampened and following NIBP for BP readings. CVP14->12. Pt has gen edema and exts elevated on pillows. K replaced as noted. Follow K level lasix gtt for diuresis.\n\nGU) Pt is being diuresed with lasix gtt for goal of (-) 2 liters q day or (-) 100 cc/hr. Pt is now + 16.6 liters for LOS (No change since ). Pt is also on bicarb gtt and Sodium bicarbonate PO to correct met acidosis RF with minimal effect. ? need for HD sooner than thought. BUN 98 and Creatine slight down to 5.7 (peaked ).\n\nID) Pt on IV ABxs for multifocal pna. Pt was started on flagyl, but noted to have developed a body rash at 8pm and flagyl DC'd. Tmax 99.1 as of 4am. Vanco level this am 20. Needs another sputum sample.\n\nResp) Pt intubated on CPAP+PS at 40%/. Pt has been deep sx'd for scant amounts white thick secretions. CXR done this am. No vent changes made. Hard time advancing sx catheter with sx, RT to eval, but unable to improve. Continue to wean pt off vent as tolerated.\n\nGI) Abd soft with + BS. TF at goal at 25 cc/hr w/o residuals as noted. Insulin gtt as noted. rectal tube in place for liq brown stool.\n\nSkin) see care vue for details.\n"
},
{
"category": "Nursing/other",
"chartdate": "2173-06-09 00:00:00.000",
"description": "Report",
"row_id": 1661561,
"text": "7p to 7a Micu Progress Note\n\nNeuro - Pt alert, oriented to person and place, occasionally year. Confused and tearful at times. MAE. Able to raise and hold upper and lower exts. PERL. Impaired gag reflex. No restraints utilized. Denies pain.\n\nResp - LS coarse to clear, diminished at bases. Strong cough. Expectorated sm amt thick white sputum. RR 17-23. 02 sat > 93 on RA. ABG on RA 7.44/41/83/3/29.\n\nC-V- HR 84-105 ST, no ectopy noted. ABP 1409-160/80-92. + palp peripheral pulses. Hct low but stable at 22.9. CVP 11-14.\n\nGI - Abd soft. +BS. NPO. Passing mod amt liquid brown stool via mushroom catheter. Plan is for speech and swallow eval today.\n\nF/E - TFB neg ~2200ccs yest. Diuresed with lasix gtt, currently infusing at 8 mg/hr to obtain goal net neg 100ccs/hr. Repleted with 60 meq kcl iv overnight. K 4.2 this am. BUN and Cr improving at 73/3.4 respectively. IV d5w infusing at 100ccs/hr.\n\nID - Afeb. WBC 10.9. PNA covered with IV cipro.\n\nEndo - Remains on insulin gtt, currently infusing at 2.5 units/hr. FSBS labile at 110-167.\n\nSocial - Parents visiting at bedside last eve.\n\nA+P - Continue to monitor neuro status. Diurese and replete lytes as indicated. Speech and swallow eval today. Monitor FSBS q1hr while pt remains on insulin gtt. Emotional support to pt and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2173-06-09 00:00:00.000",
"description": "Report",
"row_id": 1661562,
"text": "MICU Nurse Progress Note 0700-1900\nEvents: pt cont to improve, MS cleared now A/Ox3, OOB->x6hrs, tol well. insulin and lasix gtt off. cleared by speech therapy, taking PO's well, appetitie fair. A-line and CVL d/c'd. pt to be c/o to floor.\n\nROS:\nNeuro: A/O x3 follows commands, all ext strong/=. OOB->chair as above. PERRLS. No c/o pain at this time.\n\nPulm: LS remain coarse bilat w/ dim bases, pt 02sat 95-100% on RA, strong prod cough noted.\n\nCVS: NSR/ST w/ no ectopy. b/p stable 130's-150's/ 60's-70's. A-line and CVL removed, PIV x1 in L A/C patent flushed. afternoon K+ 3.7 repleted w/ 20meq KCL.\n\nGI: PO intake tol well, appetite fair. Abd soft distended w/ +BSx4quads, pt started on /Gluten free diet. Mushroom cath intact draining liq brown stool. C-Diff neg.\n\nGU: foley cath patent draining clear light yellow urine. Lasix gtt weaned off. UOP 75-150ml/hr since off lasix. pt neg ~3.5L since midnight still +8.5L for LOS.\n\nEndo: insulin gtt and D10 stopped, pt given 10 units NPH at 1300 and started on SS w/ lantus consult.\n\nsocial: family at bedside, updated r/t pt cond/ by RN.\n\nPlan: lytes, replete as needed\nlantus and Reg insulin per SS.\nc/o to floor pendin g bed availability.\n"
},
{
"category": "Nursing/other",
"chartdate": "2173-05-30 00:00:00.000",
"description": "Report",
"row_id": 1661522,
"text": "MICU Nursing Admission Note 0300-0700\n PMH: IDDM since age 7, alopecia, multiple piercings\n\n Pt is a 21yo female who had been out with friends the night of the . she wasn't feeling well and left to go home ~0130 . A friend came by her home ~12 noon on the 31st, to check on her and found the door locked and someone moaning. Police were called and pt was found down without a palpable pulse. Arrived to in DKA, with a SBP of 72/. Over the next few hours, pt received ~5 liters IVF, IVABX: vanco and ceftrixone. She was found to be hypothermic with a core temp of 88. Her pupils were ~6mm, fixed and dialated. Tox screen was neg. CAT scan with no intercranial hemorrhage and an LP was done. She was then transferred to ~12am. Begun on vasopressin and dopa. She became tachycardic and levo was initiated with hopes of titrating dopa.\n\n Arrived to MICU ~0300. Pt was immediately placed on PS ventilation. NS, dopa, levo, and vasopressin infusing. Right groin line intact, as well as (2) add'l peripherals. A third peripheral was placed as well as a left groin arterial line. Both radial pulses were weak.\n\n Systems Review:\n\nResp: LS CTA, Intubated and ventilated, placed on PSV with improved ventilation. PSV 40%/ 5 Peep/ 10 PS. RR 20-24 with TV's 570-580.\n\nNeuro: Pt was normo-thermic upon arrival. Pupils were ~2-3mm,equal in size and responsive to light. She was moving all extremities, but not purposefully. Not following commands. +Gag and + cough.\n\nCV: Hypotensive on vasopressin 2.4 units/hr, levophed 0.30 mcg/kg/min\nand dopa 2.2 mcg/kg/min. Attempting to wean dopa off due to pt's tachycardia, (into the 130's) However, her BP has only been in the 90's-low 100's, with MAP's in the 40's. Recieved an additional 5 liters of IV NS since 0300-0700.\n\nGI: NGT placed, auscultated and +GI aspirates. Awaiting X-ray confirmation. Hypoactive BS, no stool.\n\nGU: Urine specs sent off for cultures. Only 20cc's from 0330-0600. Urine cloudy. +yeast infection in perianal area. Meds to be ordered. Pt + for menses, peri pad intact.\n\nEndo: Pt arrived with insulin gtt of 12 units/hr. Shut off for ~1hr and restarted ~0500. Please refer to carevue for FS results. Currently infusing at 6 units per hr. Will con't to check Q1hr FS and titrate as appropriate. Anion Gap originally 25, down to 18 by 0600.\n\nID: WBC initially 30, down to 18 by am. Receiving multiple IVABX. Ceftriaxone and vanco given at OSH. Sputum and urine cultures sent.\n\nF/E: K+ 2.7, Ca 6.2. Receiving electrolyte replacement as appropriate. 60 meq KCL and 4 gms Ca+ thus far.\n\nSocial: Pt lives between her parents who are divorced. They both reside in . The pt was at the father's home when she became ill. He was out of town and flew in from to be with the pt. Both her parents are here at the hospital and are appropriately concerned.\n"
},
{
"category": "Nursing/other",
"chartdate": "2173-05-30 00:00:00.000",
"description": "Report",
"row_id": 1661523,
"text": "Respiratory Therapy\n\nPt remains orally intubated on PSV. No vent changes made this shift. Continues on +10PSV/+5PEEP w/ Vt 600s RR 20s Ve 14-16L/M. ABG shows continues metabolic acidosis. SpO2 90s, suctioned for small amounts of thick pale yellow secretions. ETT secure/patent. See resp flowsheet for specific vent settings/data.\n\nPlan: maintain support\n"
},
{
"category": "Nursing/other",
"chartdate": "2173-05-30 00:00:00.000",
"description": "Report",
"row_id": 1661524,
"text": "MICU NPN 0700-1900\n\nEvents: Dopamine gtt titrated off. Levophed gtt weaning down. Acidosis slowly resolving. Please see carevue for all objective data.\n\nNeuro: Pt sedated on fentanyl and versed. PERRL. Pt has non purposeful movement to stimuli. Pt did not open eyes or follow commands today.\n\nResp: Pt remains vented on CPAP/PS 10/5. Last ABG 7.22/24/121/10. LS rhonchorus. Sxned for thick yellow secretions.\n\nCV: Levophed and vasopressin infusing. Able to slowly wean down levophed. Multiple lyte repletion throughout the day. PM chemistries pnding. HR 130's-140's. BP 105-140/86-58. MAP goals >60. Team is placing a SC CVL currently. Left groin a-line remains in. Unable to place radial.\n\nGI: US of abdomen showed free air in the belly. Pt needs CT abdomentonight without contrast (but please give 2 bottles of baricet). Abdomen soft. Pt grimaces with abdomen palpation. No BM today.\n\nGU: Minimal u/o via foley 10-30cc/hr. Pt is net pos. approx. 11 liters since admission.\n\nID: vaginal yeast infection noted. Pt given diflucan po. Pt on broad coverage antibx. Cultures pnding. afebrile.\n\nEndo: Pt on insulin gtt. Hourly BS. Titrating s/s.\n\nSocial: mother and father at bedside most of the day. Appropriately tearful and concerned. Pt had many friends/family visiting.\n\nDispO: Remain in Micu. FUll Code.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2173-06-06 00:00:00.000",
"description": "Report",
"row_id": 1661551,
"text": "Resp Care\nRemains intubated and ventilated on cpap/psv with no remarkable changes overnight. Breath sounds coarse, suctioning small amounts of white sputum. Suction cateter sometimes difficult to advance. ETT repositioned and retaped. ABGS still with severe met. acicosis.\n"
},
{
"category": "ECG",
"chartdate": "2173-05-30 00:00:00.000",
"description": "Report",
"row_id": 214207,
"text": "Sinus tachycardia\nNonspecific ST-T wave changes - baseline artifact makes assessment difficult\nSince previous tracing of the same date, tachycardia rate faster\n\n"
},
{
"category": "ECG",
"chartdate": "2173-05-30 00:00:00.000",
"description": "Report",
"row_id": 214208,
"text": "Sinus tachycardia. Diffuse non-specific ST-T wave changes. No previous\ntracing available for comparison.\n\n"
}
] |
15,012 | 175,711 | 1. Neurologic: The patient was initially on the Neurology Service. Head CT scan showed a right medial thalamic, subacute, small lacunar infarct. MRA showed mild stenosis on the left vertebral and mid basilar system. Etiology was thought to be either cardiac embolus or arterial embolus. The patient was initially managed conservatively with aspirin and Aggrenox. The patient's neurological deficits improved slowly throughout the course of his stay in the hospital. 2. Cardiovascular: The patient was hypertensive with systolic blood pressure up to 200 during his initial presentation in the hospital. His blood pressure remained elevated despite being on a Nipride drip and multiple other anti-hypertensives, including hydralazine, hydrochlorothiazide, and Aldomet. Additionally, the patient was found to be bradycardic to the 30s. Despite these cardiovascular abnormalities, the patient was completely asymptomatic. He was seen by Electrophysiology who recommended putting a pacer in and a pacer was placed subsequently. He was eventually weaned off the Nipride drip and his blood pressure slowly decreased on oral medications. The patient was seen by the Renal Service and a gadolinium MRI showed equal sized kidneys with no hydronephrosis or renal artery stenosis. | with uncontrolled HTN on multiple anti-hypetensives. with uncontrolled HTN on multiple anti-hypetensives. WILL RECHECK K+ THIS PM.RESP-LS ESSENTIALLY CTA. attempts to get oob as sedation wears off. EKG SHOWS A-FIB. PT ALERT AND ORIENTED X3 ALTHOUGH LETHARGIC. BR MAINTAINED.COMFORT-DENIES PAIN.A-SEIZURE THIS AM. TECHNIQUE: T1 axial in and out of phase. Norvasc and clonidine added to regimen. (+ CIGS/ETOH )PLAN: PER NEURO. AFTER EPISODE RESOLVED PT A+OX3. team made aware.GI:ABd softly distended, +BM x2, soft formed. Coronal HASTE, pre and post injection of contrast VIBE sequences were performed. Resp CarePt. Slow rise in Creatinine also noted. LAST K 3.9--WILL RECHECK AFTER DIURESIS. LABILE BP.P-CON'T WITH CURRENT PLAN. Irregularities of the iliacs was noted. Continuing with scheduled oral agents and Nipride. Atrial fibrillation with ventricular response of 60Since last ECG, ST-T changes less evidentAbnormal ECG Nipride changed to nitro to keep sys <180. CHIEF C/O DROWSINESS.NEURO: A+O X3 BUT NEEDS PRODING. ho aware, pt remains in fib flutter. SERAX STARTED FOR DT PREVENTION. NIPRIDE GTT. IMPRESSION: 1) There is a subacute lacune in the medial aspect of the right thalamus inferiorly. for albuterol nebs which wre given with good effect. Stroke.Height: (in) 71Weight (lb): 197BSA (m2): 2.10 m2BP (mm Hg): 179/91Status: InpatientDate/Time: at 15:32Test: Portable TTE(Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is mildly dilated.LEFT VENTRICLE: There is mild symmetric left ventricular hypertrophy. There is mild symmetric left ventricularhypertrophy. The aortic valve leaflets are mildlythickened. GLYCOPYRROLATE GIVEN BY DR. . Views are technicallysuboptimal for assessment of ventricular systolic function. The left, right and main portal veins are patent with appropriate hepatopetal flow. LAST B/P 132/59. haldol given, pt calmer after several minutes, but a-line had been dislodged, as well as periph iv. Continues to be medicated with schedule Serax with associated lethargy. There is irregularity of the distal left vertebral artery and the mid basilar artery suggesting mild stenoses. The appearance is consistent with a subacute lacune. Atrial fibrillation with a slow ventricular response. TECHNIQUE: Multiplanar T1-weighted images, axial T2-weighted, proton density, FLAIR, susceptibility and diffusion-weighted images were obtained. UA sent with lytes per rec's. RECHECK K+. DENIED NEURO COMPLAINTS. Evaluation for secondary causes of hypertension. Punctate hemosiderin is noted near the left MCA infarct and in the left thalamus. NPN-Condition updateSee ICU flowsheet. FOLEY CATH PATENT. There is nosignificant aortic valve stenosis. The diffusion- weighted images show a small area of impaired diffusion in the anterior medial right thalamus. NIPRIDE GTT TITRATED ACCORDINGLY TO KEEP SBP 150-170. There is an old lacune in the left corona radiata and old lacunes in both thalami dorsally. cuff bp's are lower than a-line bp's, ntg drip is off. HO NOTIFIED TO EVALUATE. Pt reamins on serax for etoh withdrawal. +PP. DENIES CARDIAC COMPLAINTS. PUPILS EQUAL, 1MM, REACTIVE. Compared to the previoustracing of the axis is now leftward. renal follwoing-proable u/s tomorrow.Pain:none.Endo: borderline BS-covered per s.s. given albuterol 2.5mg/atrovent5cc neb x3 on noc. HTN CONTINUES DESPITE AGENTS. MONITOR FOR DT. Hydralazine and adamet increased.RESP:periodic wheezing noted with act. Sleepy but easily arousable.CV:Remains hypertensive to 240's over 120's. +BS. Mild (1+) mitralregurgitation is seen.TRICUSPID VALVE: The pulmonary artery systolic pressure could not bedetermined.PULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appearstructurally normal with physiologic pulmonic regurgitation.GENERAL COMMENTS: Suboptimal image quality due to poor echo windows.Suboptimal image quality as the patient was difficult to position.Conclusions:The left atrium is mildly dilated. NEEDS PT CONSULT. Bs: diminished to audible exp wheezes, with sats 94-100% on ra.Has gd. STARTED ON PO MEDS WITH MUCH EFFORT. HO AND NEURO MED SERVICE AWARE OF INABILITY TO WEAN SNP.A: WILL CONTINUE TO INCREASE HYDRALAZINE. ARRIVED IN ED WITH SLURRED SPEECH, DROWSINESS, UNSTEADY GAIT. neb given x1. b lower by cuff, ntg remains off . Being worked up for secondary causes of HTN. REASON FOR THIS EXAMINATION: Pt. PLAN ABD MRI IN AM CHECKLIST HAS BEEN SENT, ORDER ON FILE. Admitted for sub acute R thalamic lacunar infarct; has had uncontrolled HTN on multiple meds. IMPRESSION: 1. IMPRESSION: 1. Pt. O2 SAT 98% 2LNC.GI-ABD ROUND, SOFTLY DISTENDED, NT. DENIES HA OR PAIN. Please perform RUQ US as well. SERAX AS ORDERED. GOAL IS TO TRANSFER TO FLOOR AFTER BLOOD PRESSURE IS BETTER CONTROLLED. The hepatic veins are patent with appropriate flow. THEN MRI DONE SHOWED NEW INFARCT R MEDIAL THALAMIC. Probable new dx of DM per team. B/P WAS AN ISSUE AND PT WAS MEDICATED FISRT LINE NIPRIDE WHICH HAD MINIMAL EFFECT ON B/P AND IT WAS THOUGHT PATIENT WOULD DO BETTER ON NITRO DRIP. Hypertensionremains extremely labile with systolics >200. No aortic regurgitation is seen.MITRAL VALVE: The mitral valve leaflets are mildly thickened. WILL NEED NEW PIV FOR CONTRAST. K+ 3.3 THIS AM. NARD, RR 10'S. K+ THEN 3.7. MRA OF THE HEAD CLINICAL HISTORY: CVA. PERLA. Appropriate portal blood flow. Breath sounds sl course at rest but does become dyspneic with audible insp/exp wheezes. IV SITE WNL. AT THAT TIME HE MAINTAINED A B/P SYSTOLICALLY 150'S TO 200'S AND THAT WAS ACCEPTABLE BY MDS. N.O. MONITOR NEURO STATUS. MRA of the abdominal aorta and the renal arteries demonstrated irregularities of the aorta intrarenally. HR AND SBP IMPROVED. HAD HEAD CT WHICH WAS WITHOUT CHANGES. 1:1 SITTER FOR SAFETY. There is variation in precordiallead placement and a generalized decrease in voltage which may be due to thelatter. CONDITION UPDATE PATIENT CONTINUES ON ATC SERAX FOR WITHDRAWAL WITH GOOD EFFECT. Evaluate for ascites and portal blood flow. WILL R/O WITH SERIAL CK'S AND CHECK TROPONIN LEVELNO MAJOR RESP ISSUES SAO2 ON 4L NP ~ 98-100%; CTA BILGU/GI: ELEVATED BUN/CR 32/2.5. TOL PO'S WITHOUT N/V. CUFF COMPRABLE TO A LINE. IMPRESSION: There is slight motion artifact. Mild(1+) mitral regurgitation is seen.No cardiac source of embolus identified but cannot exclude. PATIENT/TEST INFORMATION:Indication: Left ventricular function. ADMITTED TO SICU FROM ER ON ON SNP FOR BLOOD PRESSURE CONTROL. The leftventricular cavity size is normal.AORTA: The aortic root is normal in diameter.AORTIC VALVE: The aortic valve leaflets are mildly thickened. | 17 | [
{
"category": "Echo",
"chartdate": "2114-08-22 00:00:00.000",
"description": "Report",
"row_id": 100732,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Stroke.\nHeight: (in) 71\nWeight (lb): 197\nBSA (m2): 2.10 m2\nBP (mm Hg): 179/91\nStatus: Inpatient\nDate/Time: at 15:32\nTest: Portable TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is mildly dilated.\n\nLEFT VENTRICLE: There is mild symmetric left ventricular hypertrophy. The left\nventricular cavity size is normal.\n\nAORTA: The aortic root is normal in diameter.\n\nAORTIC VALVE: The aortic valve leaflets are mildly thickened. There is no\nsignificant aortic valve stenosis. No aortic regurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. Mild (1+) mitral\nregurgitation is seen.\n\nTRICUSPID VALVE: The pulmonary artery systolic pressure could not be\ndetermined.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appear\nstructurally normal with physiologic pulmonic regurgitation.\n\nGENERAL COMMENTS: Suboptimal image quality due to poor echo windows.\nSuboptimal image quality as the patient was difficult to position.\n\nConclusions:\nThe left atrium is mildly dilated. There is mild symmetric left ventricular\nhypertrophy. The left ventricular cavity size is normal. Views are technically\nsuboptimal for assessment of ventricular systolic function. There may be\ninferior/inferolateral hypokinesis but segments are not well visualized\n(estimated ejection fraction ?45-50%). The aortic valve leaflets are mildly\nthickened. There is no significant aortic valve stenosis. No aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. Mild\n(1+) mitral regurgitation is seen.\nNo cardiac source of embolus identified but cannot exclude.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2114-08-23 00:00:00.000",
"description": "Report",
"row_id": 293302,
"text": "Atrial fibrillation with ventricular response of 60\nSince last ECG, ST-T changes less evident\nAbnormal ECG\n\n"
},
{
"category": "ECG",
"chartdate": "2114-08-21 00:00:00.000",
"description": "Report",
"row_id": 293303,
"text": "Atrial fibrillation with a slow ventricular response. Compared to the previous\ntracing of the axis is now leftward. There is variation in precordial\nlead placement and a generalized decrease in voltage which may be due to the\nlatter. No diagnostic change.\n\n"
},
{
"category": "Radiology",
"chartdate": "2114-08-23 00:00:00.000",
"description": "DUPLEX DOPP ABD/PEL",
"row_id": 741468,
"text": " 8:20 AM\n US ABD LIMIT, SINGLE ORGAN; DUPLEX DOPP ABD/PEL Clip # \n Reason: H/O ESOPHAGEAL VARICES ,ETOH,CIRRHOSIS ,EVAL FOR ASCITES ,PV PATENCY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with h/o varices and etoh abuse\n REASON FOR THIS EXAMINATION:\n Patient with h/o esophageal varices and etoh abuse. Please evaluate for\n ascities and portal blood flow. Please perform RUQ US as well.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of esophageal varices and alcohol abuse. Evaluate for\n ascites and portal blood flow.\n\n FINDINGS: A limited ultrasound examination of the liver was performed with\n Doppler flow studies. The parenchyma of the liver has increased echogenicity\n consistent with fatty infiltration. The left, right and main portal veins are\n patent with appropriate hepatopetal flow. The hepatic veins are patent with\n appropriate flow. There is no ascites present.\n\n IMPRESSION:\n\n 1. Appropriate portal blood flow.\n\n 2. No ascites.\n\n 3. Echogenic liver consistent with fatty infiltration. Other forms of liver\n disease and more advanced liver disease, including significant hepatic\n fibrosis/cirrhosis, cannot be excluded on this study.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2114-08-21 00:00:00.000",
"description": "MR HEAD NEURO",
"row_id": 741378,
"text": " 4:08 PM\n MR-ANGIO HEAD; MR HEAD NEURO Clip # \n MR RECONSTRUCTION IMAGING\n Reason: r/o acute stroke...3 hours of slurred speech, left facial dr\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with ?stroke\n REASON FOR THIS EXAMINATION:\n r/o acute stroke...3 hours of slurred speech, left facial droop, left upper\n extremity weakness..drowsiness..\n\n needs MRI with DWI and MRA\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Acute onset of slurred speech, left facial droop and left\n upper extremity weakness.\n\n TECHNIQUE: Multiplanar T1-weighted images, axial T2-weighted, proton density,\n FLAIR, susceptibility and diffusion-weighted images were obtained.\n\n FINDINGS: There is slight motion on several of the images. The diffusion-\n weighted images show a small area of impaired diffusion in the anterior medial\n right thalamus. Only faint hyperintensity is seen in this region on the FLAIR\n images and no T2 hyperintensities seen. The appearance is consistent with a\n subacute lacune.\n\n No acute cerebral cortical infarct is seen. As seen on the CT there are old\n infarcts within both MCA territories, more extensive on the right than the\n left. Punctate hemosiderin is noted near the left MCA infarct and in the left\n thalamus. There is an old lacune in the left corona radiata and old lacunes in\n both thalami dorsally.\n\n IMPRESSION:\n 1) There is a subacute lacune in the medial aspect of the right thalamus\n inferiorly.\n 2) There are old infarcts in both MCA territories as well as old bilateral\n lacunes.\n\n MRA OF THE HEAD\n\n CLINICAL HISTORY: CVA.\n\n TECHNIQUE: A 3D time of flight study was derived from overlapping axial slabs\n through the inferior cranium. There is slight motion artifact.\n\n Allowing for the artifact there is good flow in the distal internal carotid\n arteries, the distal vertebral arteries, and the basilar artery. There is\n irregularity of the distal left vertebral artery and the mid basilar artery\n suggesting mild stenoses. There is symmetric flow in the proximal cerebral\n arteries.\n\n IMPRESSION: There is slight motion artifact. There is probably a mild\n mid basilar stenosis and possible stenosis in the distal left vertebral\n (Over)\n\n 4:08 PM\n MR-ANGIO HEAD; MR HEAD NEURO Clip # \n MR RECONSTRUCTION IMAGING\n Reason: r/o acute stroke...3 hours of slurred speech, left facial dr\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n artery.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2114-08-27 00:00:00.000",
"description": "MR KIDNEY W &W/O CONTRAST",
"row_id": 741669,
"text": " 10:16 AM\n MR KIDNEY ANGIOGRAM; MR KIDNEY W &W/O CONTRAST Clip # \n MR RECONSTRUCTION IMAGING\n Reason: Pt. with uncontrolled HTN on multiple anti-hypetensives. \n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with s/p CVA, A-fib, and HTN. Admitted for sub acute R thalamic\n lacunar infarct; has had uncontrolled HTN on multiple meds. Slow rise in\n Creatinine also noted. Being worked up for secondary causes of HTN.\n REASON FOR THIS EXAMINATION:\n Pt. with uncontrolled HTN on multiple anti-hypetensives. Need to get gadolinium\n MRA to assess for renal artery stenosis.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72 year old man status post CVA, atrial fibrillation and\n hypertension. Admitted for acute right lacunar infarct with uncontrolled\n hypertension on multiple medications. Evaluation for secondary causes of\n hypertension.\n\n TECHNIQUE: T1 axial in and out of phase. Coronal HASTE, pre and post injection\n of contrast VIBE sequences were performed. Reformatted images of the renal\n arteries were obtained using MPR and MIP.\n\n Findings: The left kidney measures 10.2 cm without hydronephrosis. The right\n kidney measures 10 cm in its sagittal length without hydronephrosis. MRA of\n the abdominal aorta and the renal arteries demonstrated irregularities of the\n aorta intrarenally. Irregularities of the iliacs was noted. Single renal\n arteries were found on both sides without evidence of narrowing of the renal\n arteries. At the lower pole of the left kidney a wedge shaped region was found\n without evidence of enhancement corresponding presumably To an old infarct. In\n the left kidney on the posterior medial and at the upper pole an hypointense\n lesion relative to the renal parenchyma was found on the HASTE sequence\n measuring about 1 cm. This area showed early\n arterial enhancement. This was evident also on the venous phase. The liver\n pancreas and spleen are unremarkable.\n\n IMPRESSION: 1. Atheromatous changes in the infrarenal portion of the abdominal\n aorta without evidence of renal artery stenosis.\n 2. 1 cm lesion with hypointense signal on the HASTE sequence in the medial\n upper posterior part of the left kidney. This lesion shows early enhancement\n - 6 month follow up is recommended.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2114-08-25 00:00:00.000",
"description": "Report",
"row_id": 1457492,
"text": "focus: neuro\ndaata: pt becoming confused, staating thaaat he was being kidnapped and kept in the hospital against his will. pt tried to get oob in repeated attempts. posey belt applied. pt actually untied the belt and continued to attempt to get oob. nursing co-worker sitting in room witgh pt, when he began to pull out his aline and become combative. five nurses, resp therapist in room, ho called. attempt to med pt with haldol difficult due to tenuous iv. haldol given, pt calmer after several minutes, but a-line had been dislodged, as well as periph iv. cuff bp's are lower than a-line bp's, ntg drip is off. pt is sedate now, sleeping soundly. he awakens with stimulation, but remains quite sleepy.\n"
},
{
"category": "Nursing/other",
"chartdate": "2114-08-25 00:00:00.000",
"description": "Report",
"row_id": 1457493,
"text": "Resp Care\nPt. given albuterol 2.5mg/atrovent5cc neb x3 on noc. Bs: diminished to audible exp wheezes, with sats 94-100% on ra.Has gd. responce to tx, will follow. Pt. attempts to get oob as sedation wears off.\n"
},
{
"category": "Nursing/other",
"chartdate": "2114-08-25 00:00:00.000",
"description": "Report",
"row_id": 1457494,
"text": "cardiovascular\ndata: hr drops into the 20's at times. ho aware, pt remains in fib flutter. b lower by cuff, ntg remains off . pt continues to be confused.\n"
},
{
"category": "Nursing/other",
"chartdate": "2114-08-25 00:00:00.000",
"description": "Report",
"row_id": 1457495,
"text": "CONDITION UPDATE\n PATIENT CONTINUES ON ATC SERAX FOR WITHDRAWAL WITH GOOD EFFECT. 1:1 SITTER FOR SAFETY. DENIES HA OR PAIN. EQUAL STRENGTH BILATERALLY.\n B/P WITH BETTER CONTROL TAKING PO MEDS WITH ENCOURAGEMENT.\n TRANSFER TO FLOOR WHEN BED AVAILABLE\n CONTINUE TO MONITOR ALL PARAMETERS\n"
},
{
"category": "Nursing/other",
"chartdate": "2114-08-26 00:00:00.000",
"description": "Report",
"row_id": 1457496,
"text": "CONTINUES WITH LOW HEART RATE ( HIGH TEENS, LOW 20'S AND UP TO 40'S) IN AFIB PER MP AND EKG. HO NOTIFIED TO EVALUATE. PADS PLACED AND CODE MASTER SET IN THE EVENT OF PACER NEED. ATROPINE AT THE BEDSIDE. HTN CONTINUES DESPITE AGENTS. PT ALERT AND ORIENTED X3 ALTHOUGH LETHARGIC. SAO2 98-100% URINE OUTS SUFFICIENT\n"
},
{
"category": "Nursing/other",
"chartdate": "2114-08-26 00:00:00.000",
"description": "Report",
"row_id": 1457497,
"text": "TRANSFER NOTE\n PATIENT A 72 YO MAN WITH HISTORY OF CVA ,HTN, ETOH ABUSE, AFIB , AND ESOPH VARICES. ARRIVED IN ED WITH SLURRED SPEECH, DROWSINESS, UNSTEADY GAIT. BECAUSE OF DROWSINESS HE HAD HEAD CT WHICH SHOWED OLD CVA AND ATROPHY. NO NEW EVENT NOTED. THEN MRI DONE SHOWED NEW INFARCT R MEDIAL THALAMIC. HOWEVER EXAM SHOWED MINIMAL DEFICITS.\n B/P WAS AN ISSUE AND PT WAS MEDICATED FISRT LINE NIPRIDE WHICH HAD MINIMAL EFFECT ON B/P AND IT WAS THOUGHT PATIENT WOULD DO BETTER ON NITRO DRIP. HE CONTINUED ON DRIP UNTIL MIDNOC FRIDAY WHEN HE BECAME UNRULY AND PULLED OUT HIS IV AND A-LINE. AT THAT TIME HE MAINTAINED A B/P SYSTOLICALLY 150'S TO 200'S AND THAT WAS ACCEPTABLE BY MDS. STARTED ON PO MEDS WITH MUCH EFFORT. DOSES CHANGED AND AFTER A TROUBLE SOME DAY SATURDAY WITH PRESSURES TO 200'S/ 90'S AND HEART RATE TO THE TEENS TODAY HE SEEMS MUCH BETTER BOTH PHYSICALLY AND MENTALLY.\n COOP WITH ALL CARE TODAY TAKING MEDS AND FOOD TOLERATING BOTH WELL.\nCLEARER WITH SPEECH AND THOUGHTS. A&OX3 PERLA EQUAL STRENGTH BIL.\n PLAN ABD MRI IN AM CHECKLIST HAS BEEN SENT, ORDER ON FILE. WILL NEED NEW PIV FOR CONTRAST. NEEDS PT CONSULT. 24 HOUR URINE COLLECTION NEEDS TO BE DONE. HE WAS UP TO CHAIR ALL DAY HEART RATE IN 30'S TO 40'S . LAST B/P 132/59. AFEBRILE SAT 100 % RA. NO C/O PAI. FOLEY CATH PATENT. IF HE DOES AN INCIDENT OF BRADYCARDIA TO TEENS AND TWENTYS HE NEED PACEMAKER. HOWEVER HIS PRIMARY CARE MD WANTS TO GIVE HIM 48-72 HOURS TO BOUNCE BACK HIMSELF.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2114-08-23 00:00:00.000",
"description": "Report",
"row_id": 1457489,
"text": "NSG PROGRESS NOTE\nSEE FLOWSHEET FOR SPECIFICS\n\nNEURO-PT HAD SEIZURE THIS AM LASTING APPROX 30 SECS. NO CLONIC/TONIC MOVEMENT NOTED. TEAM AWARE AND IN TO WITNESS. HR DOWN TO 30'S, SBP FELL TO 60. GLYCOPYRROLATE GIVEN BY DR. . HR AND SBP IMPROVED. AFTER EPISODE RESOLVED PT A+OX3. MAE. NORMAL EQUAL STRENGTH. PUPILS EQUAL, 1MM, REACTIVE. DENIED NEURO COMPLAINTS. HAD HEAD CT WHICH WAS WITHOUT CHANGES. NO FURTHER EPISODES NOTED. SERAX STARTED FOR DT PREVENTION. TCD DONE.\n\nCV-PT IN AFLUTTER, RATE 50-60'S. SBP VERY LABILE, DOWN TO 90 WHEN ASLEEP THEN UP TO 200'S AT TIMES. NIPRIDE GTT TITRATED ACCORDINGLY TO KEEP SBP 150-170. DENIES CARDIAC COMPLAINTS. +PP. IV SITE WNL. K+ 3.3 THIS AM. 40 MEQ PO KCL GIVEN. K+ THEN 3.7. ADDITIONAL 40MEQ KCL GIVEN. WILL RECHECK K+ THIS PM.\n\nRESP-LS ESSENTIALLY CTA. NARD, RR 10'S. O2 SAT 98% 2LNC.\n\nGI-ABD ROUND, SOFTLY DISTENDED, NT. +BS. TOL PO'S WITHOUT N/V. HAD ABD U/S TODAY.\n\nGU-VOIDED SPONT VIA URINAL ADEQ AMT CL YELLOW URINE.\n\nACT-MAE. MOVES I IN BED. BR MAINTAINED.\n\nCOMFORT-DENIES PAIN.\n\nA-SEIZURE THIS AM. CON'T IN AFIB. LABILE BP.\n\nP-CON'T WITH CURRENT PLAN. MONITOR FOR CHANGES. MONITOR NEURO STATUS. NIPRIDE GTT. RECHECK K+. MONITOR FOR DT. SERAX AS ORDERED.\n"
},
{
"category": "Nursing/other",
"chartdate": "2114-08-24 00:00:00.000",
"description": "Report",
"row_id": 1457490,
"text": "NPN-Condition update\nSee ICU flowsheet. No seizure activity noted. Continues to be medicated with schedule Serax with associated lethargy. Does become irritated at staff while providing necessary cares. Hypertensionremains extremely labile with systolics >200. Continuing with scheduled oral agents and Nipride. Plan is to increase oral agents today. Breath sounds sl course at rest but does become dyspneic with audible insp/exp wheezes. N.O. for albuterol nebs which wre given with good effect. NPO tonight for possible upper GI today. Voiding clear light amber urine.\n"
},
{
"category": "Nursing/other",
"chartdate": "2114-08-24 00:00:00.000",
"description": "Report",
"row_id": 1457491,
"text": "nursing update\nNeuro:remains neurologically intact. PERLA. no weakness or numbness noted. No seizure activy noted. no withdrawal symotoms notes. Pt reamins on serax for etoh withdrawal. Sleepy but easily arousable.\nCV:Remains hypertensive to 240's over 120's. Nipride changed to nitro to keep sys <180. Norvasc and clonidine added to regimen. Hydralazine and adamet increased.\nRESP:periodic wheezing noted with act. neb given x1. lasix 20 mg po for +crackles at bases. Mod prod cough of thick white sputum. ? of aspiration noted during lunch and dinner- Pt coughing on food. WIfe states he does this at home sometimes-coughs up food in bathroom after eating. team made aware.\nGI:ABd softly distended, +BM x2, soft formed. Tol 1800 diet. no nausea/vomiting.\nGU:voided x1 today. pt feeling urge but unable to void. foley placed for 200cc dark yellow urine. UA sent with lytes per rec's. renal follwoing-proable u/s tomorrow.\nPain:none.\nEndo: borderline BS-covered per s.s. Probable new dx of DM per team.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2114-08-22 00:00:00.000",
"description": "Report",
"row_id": 1457487,
"text": "PT ADMITTED TO SICU IN NAD ACCOMPANIED WITH WIFE. CHIEF C/O DROWSINESS.\nNEURO: A+O X3 BUT NEEDS PRODING. SPEECH IMPROVED. PERL BRISKLY, EQUAL STRENGTH BIL. MOVES SIDE TO SIDE INDEPENDANT.\n\nCARDIO/PULM: PER MP A-FLUTTER WITH RATE DROPS TO 35 RANGE. NO CHANGE IN BP. EKG SHOWS A-FIB. WILL R/O WITH SERIAL CK'S AND CHECK TROPONIN LEVEL\nNO MAJOR RESP ISSUES SAO2 ON 4L NP ~ 98-100%; CTA BIL\n\nGU/GI: ELEVATED BUN/CR 32/2.5. WILL NEED TO EVALUATE H/O ESPHAGEAL VARICES AND CHECK IF PT IS COUMADIN CANDIDATE IN VIEW OF HIS KNOW ALCOHOL ABUSE\n\nSHX: RETIRED POLICE, LIVES WITH WIFE. (+ CIGS/ETOH )\n\nPLAN: PER NEURO. WILL MONITOR NEURO STATUS CLOSELY AND CONTINUE NIPRIDE FOR BP CONTROL.\n"
},
{
"category": "Nursing/other",
"chartdate": "2114-08-22 00:00:00.000",
"description": "Report",
"row_id": 1457488,
"text": "FOCUS: CONDITION UPDATE\nD: PATIENT S/P EMBOLIC STROKE (SEEN ON MRI). ADMITTED TO SICU FROM ER ON ON SNP FOR BLOOD PRESSURE CONTROL. ON NEURO-MED SERVICE. TODAY PATIENT HAS BEEN ALERT AND ORIENTED TIMES THREE. HAS REMAINED ON SNP FROM 0.4-0.8 MCG/KG/MIN. UNABLE TO WEAN OFF. GOAL IS TO KEEP SBP<180, YET BP GOES AS HIGH AS 225/ WHEN WEANING SNP. CURRENTLY ON HYDRALAZINE (30 MG PO Q 6)/ALDOMET/COSAR AND RECEIVED LASIX 20 MG IVP AT 1800. CUFF COMPRABLE TO A LINE. HO AND NEURO MED SERVICE AWARE OF INABILITY TO WEAN SNP.\nA: WILL CONTINUE TO INCREASE HYDRALAZINE. MONITOR URINE OUTPUT. LAST K 3.9--WILL RECHECK AFTER DIURESIS. NEUROLOGICALY STABLE. GOAL IS TO TRANSFER TO FLOOR AFTER BLOOD PRESSURE IS BETTER CONTROLLED.\n"
}
] |